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JAN.-JUNE, 1928] 


f Tax Bamia 
L UxotcLiL Jocxxit 


KEY TO DATES AND PAGES. 


The following table, giving a key to the dates of issue and 
the page numbers of the British Medicai. Journal and 
SupPLESiENT in tho first volume for 1928, may prove 
convenient to readers in search of a reference. 


Serial 

Date of 

Journal 

Supplement 

No. 

Issue. 

Paces. 

Pages. 

3496 

Jan. 7th 

1 - 

38 

1 - 8 

3497 

„ 14th 

39 - 

82 

9-12 

3498 

H 21&t 

83 - 

120 

13 - 24 

3499 

28th 

121 - 

164 

25 - 32 

3500 

Feb. 4th 

165 - 

204 

33 - 40 

3501 

„ nth 

205 - 

244 

41 - 44 

3502 

„ 18th 

245 - 

292 

45 - 56 

3503 

„ 25th 

293 - 

334 

57 - 68 

3504 

11 arch 3ra 

335 - 

382 

69 - 76 

3505 

„ 10th 

383 - 

430 


3506 

„ 17th 

431 - 

480 

85 - 92 

3507 

„ 24th 

..... 481 - 

534 

93-100 

3508 

„ 31st 

..... 535 - 

582 

101 - 112 

3509 

April 7th 

..... 583 - 

618 

113 - 120 

3510 

„ 14th 

619 - 

650 

121 - 124 

3511 

„ 21st 

..... 651 - 

700 

125 - 136 

3512 

„ 28th 

..... 701 - 

742 

137 - 180 

3513 

May 5th 

743 - 

788 

181 - 204 

3514 

„ 12th 

789 - 

832 

205 - 212 

3515 

„ 19th 

835 - 

884 

213 - 220 

3516 

„ 26th 

885 - 

930 

.... 221 - 228 

3517 

Juue 2nd 

..... 931 - 

966 

.... 229 - 236 

3518 

„ 9th 

.... 967 - 

1008 

.... 237 - 248 

3519 

„ 16th 

.... 1009 - 

1054 

.... 249 - 264 

3520 

„ 23ra 

.... 1055 - 

1098 

.... 265 - 276 

3521 

30tli 

.... 1099 - 

1134 

.... 277 - 288 




INDEX TO VOLUME I FOE 1928 


Headers in search of a particular subject will find it useful to bear in mind that the references are in several cases 
distributed under two or more separate but nearly synonymous headings— such, for instance, as Brain and Cerebral ; 
Heart and Cardiac; Liver and Hepatic; Renal and Kidney; Cancer and Carcinoma, Epithelioma, Malignant Disease, New 
Growth, Sarcoma, etc. ; Child and Infant; Bronchocele, Goitre, and Th>Toid ; Diabetes, Glycosuria, and Sugar; Light, 
Rooiitgon, Radium, X Rays; Status Lymphaticus and Thymus; Eye, Ophthalmia, and Vision; Bicycle and Cycle; Motor 
and Automobile ; Association, Institution, and Society, etc. Subjects dealt with under various main headings in the 
Journal have been set out in alphabolical order under their respective headings — for example, “Correspondence," 
" Leading Articles," " The Week," " Reviews," etc. Original Articles are indicated by the letter (O). 


A. 


Aaron, Charles D. : Diseases of ihe Digestive 
Organs, with Special liejerenee to their 
Diagnosis and Treatment, fourth edition, 
rev., 806 

Aradik, Dr., appointed nn officer of tbo Iicalon 
of Honour, 243,291 

Abbreviations, use of. 5;2 

ADDEnnALi>r.N, Emil, nominated an honorair 
member of the Chinese PliTsioloaical Society 
at Pekin, 1096 

Abdomen, acute (E. R. Flint), 203 (0)— Corre- 
spondence on, 284. 325, 377, 411, 470 

Abdomen, acute, dinGnosis of (John Marnochl, 
13^Roview of books on, 223, 1069—“ Rising 
tost” for, 788 

Abdomen, foreign bodies in the, 199. See also 
Foreign body 

Abdominal pain as exemplified in acute appendic- 
itis (John Morley), M7 (01— Koto on, 90€^ 
Correspondence on. 1025 

Abdominal wall, gynaecological involvements of 
the (Frederick Roqaos). M 
‘ *■. r r . . • ' tbo spine 

‘ ; ■ . *(01 


Abortion, criminal, medico-lcgal aspects of 
(O. Roebo Ijyncb).452 


471,524 

' 1 , . Ity of Kew York, 

81 

Abraham, Karl, Selected Papers of, 225 
Abrahaubon, Leonard : Tbo over-sensitive 

Ann Tt.,..* t 

C • * . . ' I 

r I , 

At ■ . . 

f • ■ . 

633 

Abscess, renal, following gonorrhoea (T. K. G, 
Way). 716 

Abt, L A.; Legion of Honour conferred npon, 
291 

Acad6mie do M^docine : The bacillus Calmette- 
G^uerln^ (B.C.G.J, 230, lO'^-Serum treatment 

"* 1* Classes malonal-urea 

• > as dangerous sub- 

ind non-tuborculous 


A 

awarded, 29 


je grandprix Leconte 


Acapesit, Rotab, of Medicine in Ireland; 

0/ MeJtctne.-- The oversensitive 
disease, 452— Narcolepsy, 
Congenital pyloric stonosis. 945— Pitui- 
tary infantilism, 946 

SeeftOM of Obstefnes,— Two cases of twisted 

fistulae ^8-pinIcal report on the Rotunda 
Hospital, Dublin. 771 

Fracture of cervical 
long and liver, 

finir agglutina- 

imfi' 102S-New growths, 

test meals, 1026 

of Surgery.— ConserratiTO treatment 

caries, 55— Treatment of fractures. 55 
*° typhoid fever. 56- 
frSSref if m toxic goitre, 35J-Obstetrioal 

the nrir.™ .25'*— TubercnloaiB ol 

carcinoTnft^RM^**o* — keletal metastases in 

inoma, 899— Surgical uses of radium, 899 

Acddent JB™=a1em. 865 

foresee Psychology of. 191; con- 

Accident servicea in industry 1077 

Accld^tfin^c?.”,'"'’’?'*®- Haemorrhage 
830 mines (parliamentarj- note), 

AMWents’in the SlT “w®' 

Aecide'Sts: St ^ 

A®^-, Gas g^gr^e "' 

Plef as’(A.“ Raklf 985^‘‘““ Auerbach's 
6M.'?7T <*ardiospasm), 


Aciiard. Ch.: diniaue Medicale 'de VH6pital 
Dealt Jon, rev., 635 
Acne, ultra-violet rays for, 966, 1C07 
Acrlflavlno in wound treatment (J, G. Graham), 
'173 

Acta Mediea Neftm2inaptco;‘6upp)emontum six : 
Der Oehalt des Ulutes nn Cfllct«m «rid Kalinm 
(Eskll Kylin). 6()— Memoir of Karl Petrfin, 119 
Acta Paediatrica : Possible dangers of cod-llvor 
oil(E Agdubr). 639 

Acta Psuchiatrica et Neurologica : VIggo 
Christiansen number. 291 
Acta 2'ubercutote't Srandinnvica : The HdU 
san*' Institute in Xorrbotten (Gustaf Neander). 
638 

Actinomycosis of tbo lung, prlmaiy (Herbert 
SUarpo), 1107 (O) 

Actinomycosis pulmonary (P. M. Johns). 404 
Actlnothorapy, review of books on. 356 
Acute abdomen. See Abdomen 
Adam, James: Peptone treatment of asthma, 
'328-Laryngoal myxoedoma, 594— Five genera- 
tions attended byonodoctor,832— Otoscloiosis, 
983 

Adams, S. (and H.C. Weston): On f7ie J?eh>/o/ 
Kyeatrain among Persons Per/om»'ni7 very 
Pine irorfc, 1119 

Addisos, o. L.t Treatment of hare-lip, 1025 

/ • ‘.452 

, , - for (parlia- 


Adoloscenco. review of book on, 806 
Adrenaline in medical and surgical practice 
(W. M. Beaumont). IIM (O) 

Africa, South. Union op: 

Asbestosis. pulmonary in (F. W. Simson). 885 
( 0 ) 

Food, Drugs, and Disinfectants Bill, 1043 

Health lusurance, National, in. 673 

Health legislation, 370 

Medical Association’s Congress, 684, 742 

Medical, Dental, and Pharmacy Bill, 516. 1042 

Mtdwives. supervision of, 1C43 

Native infantile mortality, 370 

Official visit to (H. B. Brackenbury). 726 

Pretoria, health of, 370 

Public Health Amendment Bill, 1042 

South African Field Hospital. 232 

Typhoid immuoizatioQ by the month io. 159 

Vaccinatioa problems, 1042 

Venereal diseases campaign, 517 

Venereal diseases notification. 1043 

Africa, tropical, birth and death rates in (patlie- 
mentary note). 532 

Africa, West; West African Medical Staff, 
revised list, 78T — Yellow fever in, 86 > 

African Congress. See Congress 
Agar serum, peptooed, an improvement in 
(A. Gunn Auld).171 (O)— Correspondence on, 328 
Agassiz, Dr. : Non-tuberculoue fibrosis of the 
luffg in children. 815 

Agduhr, E.: Possible dangers of cod-liver oil, 
639 

Age at death and the birthrate. See Birth rate 
Age, prolongation of, in Scotland (William 
Robertson), 728 

Air Force. Royal : Report on the health of the 
force in 1926. 18G— Estimates, 472, 529— Parlia- 
montarj' notes, 472. 474, £97, 830— Hospitals of, 
474— Accidents in, 830 

Air navigation: Medical requirements for 
aviators (civil fiying), 20— M^tcol Examina- 
tion of Civilian Aviators 991 
Aitken, McCrae: Scope of surgeiy* in chronic 
arthritis, 348 

Aitkin, C. J. Hill : Case of somatic taemasls,943 - 
Alabama, a Listerian in, 582 
Alberta. Government travelling clinics in. 516— 
Sterilization of the feeble-minded in. 680, 823, 
878 ‘ 

Albnminuria during pregnancy (G. F. Gibberd). 
219 

Alcohol in relation to business life (Sir Maurice 
Craig), 408 

Alcohol and longevity (Raymond Pearl and 
Agnes L. Bacon). 148 
Alcohol problem, review of book on, 1114 
Alcohol, revenue from the sale of, in India 
(parliamentary note), 381 * 

Alcoholic inebriety, causes f, 691, 774,876. See 
also Drunkenness 


Alcoholism, etiology of : Discussion at the Ro3'al 
Society of Medicine, 591— Correspondence on, 
691 

Aldridge, E. A. : Appreciation of Basil Thorn 
Lang. 201 
’• Alepol.” 225 - 

Alexander. A.: Treatment of ulcers of the 
mouth, 2?3 

Alexander. Browning : Liver diet in perniciou=? 
aDaomia. 179 

Alexander. F. Matthias: Body and mind, 788 
Alexander. Sir Sidney : Intravenous treatment 
of varicose ulcers, 89S 

Alford, Henry James, obituap’ notice of, 882 
Alkaline treatment of gastric and duodenal 
ulcer (Hugh MacLean). 619 (0) 

Alka’oids. the production of (T. A. Henr^-), 638 
Alkalosis and ketosis. 402 
Allan. P.J.: Painless first labour. 480 
Allan, Geo. A.: The early detection and super- 
vision of rheumatic infection in children, 39 
- (O) 

Allan, James Cyril Dalmahovi a memoir, rev., 
139 

Allbutt [Sir Clifford] memorial atPapworth. 
See Papworth 

Allen, Geo. P. F. : The Meinicke syphilitic 
reaction. 1049— Heat cramp Rnd beat hyper- 
pyrexia, 1C98 

Altodntan, E. n. R.: Blood group percentages 
for Arabs. Armenians, and Jews. 546 
Altrock, Hermann: Kleine SportsJmnde,^ 

** Ambldex “ wrist splint, 1115 
Ambulance Service : Home Service Ambulance 
Committee report, 603, 1053— First-aid service 
on the roads, ^3 

Ambulatory treatment of varicose ulcer. See 
Ulcer 

America. Sfc United States 
American tour of the Surgical Section of the 
Royal Society of Medicine, 186 
American universities, impressions of. 366 
Amerv, Mr. : Health of the Colonies, 1118 
Amoebae, intestinal, of man (E. Brumpt). 1110 
Anaemia, acute aplastic. 918, 1048. 1129 
Anaemia associated with dj’Spbagia (A. Mason 
Jones and Robert D. Owen). 256 (O) — Corre- 
spondence on, 375, 467. 521, 610— (Sidney Elisa- 
beth CroskerjO. 434— Leading article. 6^ 
Anaemia of malignant disease (leading article), 
721 

Anaemia, pernicious, treated with liver diet « 
(F. A. Phillipps), 93(0)— (H. P. Brewer, A. Q. 
Wells, and F. R. Fraser), i65 (OJ— Discussion 
on, 178— Leading article, 188— Report by the 
^ledical Research Council. 398, 4W— (C. F. T. 
East), 491(0) 

Anaemia, pernicious: Becipes for Drs, Minot and 
Muipliy'a Liver Diet for, rev., 102 — Messrs. 
Armour’s booklet of recipes, 243— Wellcome 
liver extract, 502— B.D.H. liver extract, 806 
Anaemia, review of book on. 918, 1113 
Annemia, secondary, liver treatment of, 244 
Anaesthesia, general, h^’perglycaemia in. an 
atypical case (R. L. MackajO, 892 (O) 

Anaesthesia, inhalation, prize for research on. 
381 

Anaesthesia, local, deaths from. 81 
Anaesthesia, rectal oil-etber (Robert A. Hatcher), 
769 

Anaesthetic, general, a new tj-pe of— tetrabrom- 
etbyl alcohol, “ avertin " (W. E. Dixon), 836 
Anaesthetics and diabetes, 1127 
Anaesthetics, local, activitj' of. 68 
Anaesthetics in obstetrics (Eardley Holland). 

394 — Discussion. 395 
Anapbydaxis, severe, 480, 582 

Anastomosis between the recurrent laryngeal 
and phrenic nerves. See Nerve 
Anastomosis, nephro-ureteral, after complete 
avnlsion of the ureter, 1091 
Anatomy, value of (M. B. Drennan), 109 
Ancient Scottish surgeon— John Naesmyth,570 
Anderson, Adelaide Mar>*: Sumanity and 
Labour in Giitua, rev., 1029 
Anderson, J. : Wire bristle in the bowel. 14 
Anderson, John : The effect on the tissues 
of the arc electrode in surgical diathermy, 
222 

Anderson, Robert : Fatality rates of small-pox. 
156 

Anderson, William: Chronic pulmonary sup- 
puration ,597 



4 JAN.-JUNE, I'gjB] 


INDEX, 


r Tuz CRtTiBn 
L Medicai. JotmNJX 


Andhewb, .T. a. : Cytology of Jensen’s rat sar- 
coma, 274 

Aneurysm, innominate, ligature of the innomi- 
nate artery for (E. R. Flint), 979 
Angostura bitters, composition of, 965 
Anhydrous hydrocyanic acid exempted from key 
industry duty, 741 

Animal organisms, revieTy of books on, 762 
Animals, experiments on (parliamentary note), 
474. 1096. 1131— Debate in Edinburgh, 518, 1119— 
Note on, 1111. See also Vivisection 
. Animals, Slaughter of (Scotland) Bill, 289, 380, 
1131. See also Slaughter 
Announcements of forthcoming events, etc., 37, 
80, 119, 163. 202, 242, 290. 333, 381, 428, 478, 532, 
580. 617, 649. 698, 741, 786, 830. 882, 928, 965, 1006, 
1053. 1096. 1132 

Annual Charities liegister and Dipest, rev., 806 
Anrep : The coronary circulation, 404 
Ante-natal clinics in Liverpool, 741 
Antheaume, a., death of, 695 
Anthrax ^parliamentary notes). 474 

- Anthrax, sernm treatment of (G. C. E. Simpson), 

135 

* ' the science of (Arthur 

■ lushine, 272. See also 

Rickets 

Antiseptics, fixation of by dressings and tissues : 
its importance in ■wound treatment, with 
special reference to acriflaviue (J.G. Graham), 
173 (O) 

Antiseptics in 'ophthalmic surgery, 32 
Antistreptococcal action of ceriain arsenical 
preparations (Leonard Colebrooki, 367 
Antivivisoction, early days of (W. W, Keen), 291 
Antrum, maxillary, foreign body in (8. Bubba 
Rao),546 

Anus, imperforate (J. W. Burns), 981 
Anxiety neurosis. See Neurosis 
Apothecaries’ Society of London : Livery dinner, 
37— Degrees and pass lists, 200, 378, 580, 740, 
1002, 1132 — Mastery of midwifery, new diploma, 
1050 

Appendiceotomy during herniotomy under local 
anaesthesia (D, Mackenzie), 445— Correspond- 
ence on, 618 

Appendicitis, acute, abdominal pain as ex- 
emplified in (John Morley),887 (0)— Note on,9C6 
— Correspondence on, 1025 ' 

Appendicitis, acute, treatmehtof(H. H.Bayner), 
706 (O) 

Appendicitis, acute, following typhoid fever 
(V. L. Ferguson), 979 

Appendicitis, chronic, in chi1di*6n (Robert 
ButobiBon), 348~Discuss!oD, 349 
Appendicitis, chronic, x rays in the diagnosis of. 
76, 468 

Appendicitis and cyclical vomiting, 823 
Appendicitis and hepatic abscess (William 
George), 633 

Appendicitis complicated by suppurative pyle- 
phlebitis and hepatic abscesses, a case of 
recoveiy (W. A. Barnes and L. V. Pearson), 
390 (O) 

Appendicitis, review of book on, 806 
Appert, B. M. : Bequest to the Pasteur In- 
btitute, Paris, 291 

Arabs. Armenians, and Jews, blood group per- 
centages for (E, H. B. Altounyan), 546 
Archer, B. W. Crowhurst: Dyspifcuitarism, 717 
ARCHiBAiiH, Robert George, C.&I.G. conferred 
on, 24 

Archives of Neurology and Psychiatry (edited 
by Frederick L. Golla), vol. ix, rev., 59 
Archivjilr Verdauungslcranhheiten. forty-third 
# volume dedicated to Professor I. Boas, 1133 
Archivjiir Yerdauungs- vnd Stoffwechselkranl:- 
heiten: Special number dedicated to Professor 
H. Strauss, 1133 

Ardin-DeltheiIi, Professor, nominated dean 
of the medical faculty of Algiers, 429 
Armenians, Arabs, and Jews, blood group per- 
centages for (B H. B. Altounyan), 546 
ARiriTAGE. George : Three perforations of the 
ileum cau'^ed by fish-bones, 307 
Armstrong, Charles Wicksteed • The Survival 
of the UuMtest, rev., 603 

- AnsrsTRONG, Hubert: The etiology of Mon- 

golism, with a case of a Mongol twin, 1106 (O) 
Armstrong. J. R. ; Complete transverse rupture 
of the jejunum without external rupture, 1064 
(O’ 

Armstrong-Jones, Sir Robert: Neurosis in the 
tropics. ^49 

Army, British : 

Commissions in the R.A.M.C., 1132 
Dispensers in the R.A.M.C., 1095 
Dispensers in the Territorial Army, 1C95 
Estimates, 473. 529 
Health of : Annual report. 268 

“95 

1095 


United States: Medical report (1926-27), 

Aron, Dr. (of Strasbourg), title of professor con- 
ferred on. 243 
Arsenic in suear, 1002 

Arsenical preparations, anti-streptococcal action 
of certain ♦Leonard Colebrook). 367 
f ® neutral and alkaline solution 

(Wilham H. Miller). 407 
Art. medicine in (Sir Berkeley Moynihan), 1W4 
Arterj-. deep epigastric, haemorrhage from into 
the rectus abdominis (Donald MacLennan),895 


Artery, innominate, ligature of for innominate 
aneurysm (E. R. Flint). 979 
Artery, euporior mesenteric, embolus of (Harold 
J. Selby), 757 

Artery, pulmonary, discaeo of the, 604 
Artery, central retinal, bilateral embolism of 
the (T. G. Wynne Parry) 178— Corrospondouco 
on. 286 

Arthritis, chronic, etiology of (J. B. Burt), 309 

' ' ‘ balance and its 

751 (O) 

■ report on (J. 

Arthritis, infective, acidopbilous milk in (E. 
Biddle). 519 

Arthritis, chronic rheumatoid, tho scope of 
surgery in the treatment of (C. Max Pago), 343 
(O)— Discussion on, 347— Calcium and carbonic 
acid content of the eorum In (D. Macmillan', 
519 

Arthritis, rheumatoid, minimal rises of tem- 
perature in (Cl. Schmidt). 493 (O) — Correspon- 
dence on. 610. See also Rheumatoid 
Arthropathy. Charcot’s, of both wrists (C. 

W'orater-Drought), 717 
Artificial light. Light 
Artificial silk factories. Factories 
Asbestosia, puinionary, in South Africa (F. W. 
Simson), 885 (O) 

Ash. W. M. (and W. Gordon): Rain- bearing 
winds and early phthisis in Dorbysbiro, 337 10) 
Ashby, Hugh T. (and James Robrutson)* Ergot 
poisoning among rj'o bread consumers, 302 (0) 
Aslimolean Rocictv. Sec Society of Friends 
Abhton, Robert Johnston: Kaisar-i-Bind medal 
conferred on, 988 
Assam, health progress in. 283 
Association, American Larjmgolocical : Somi- 
ceotennlal meeting. 743— Intrinsic cancer of 
tho larynx operated upon by laryngo-fissure, 
>743 

Association. British, Annual Meeting. Glasgow 
(1928), 1039 

Association. British Medical: Ninety-sixth 


Association, British Medical: Annual Meeting 
at Edinburgh (1927), 235— Presentation to 
certain officials, 235 

Association, Britibh MRDicAD.-*Piocecdlng8 
of Branches and Divisions : 

Ayrshire Division.— Some aspects of gall- 
bladder disease. 48t 

Bath and Bristol Brnncli.— Nasal and oral 
focal sepsis in the etiology of gastro-intestioal 
and pulmonary infective diseases, 931 

Belfast Division — Prognosis in pulmonary 
tuberculosis. 436 

Blachbum Dtvfsfoii.— Puerperal sopsis, 971 

Bradford DivtsioM.— Tho treatment of 
pneumonia, 444 


t 14- 

Fibro8iti8.758 

Dewsbury Division . — Tho acute abdomen, 
209 

Eastbourne Division.— The treatment of 
exophthalmic goitre, 83 
Gloucestershire Branch . — High blood pres- 
sure, 802— Congenital torticollis, 802— Sui'ra- 
condylar fracture of humerus. 802— Spastic 
paraplegia, 802-^ci8Bor-leg deformity of tho 
limbs, 803— Equinne deformity of the feet, 803 
Guthl/ord Diviston.— Clinical pathology and 
general practice. 897 

Hampstead Division . — Treatment of gnstrio 
ulcer, 168 

Harrogate Division . — Immunization against 
diphtheria, scarlet fever, and measles, 833 
Hendon Division .— and its treat- 
ment, 656 

Hong-Kong Branch . — The cause and treat- 
ment of the crisis in lobar pneumonia, 651 
Kensington Diviswn . — Debatable aspects of 
the surgery of gastro -duodenal ulceration, 
623 

Kent Branch . — The early detection and 
supervision of rboumatio infection in children, 
39— The intensive alkaline treatment of gastric 
and duodenal ulcer, 619 
Lancashire and Cheshire Br<inc7i,— Volvulus 
of the sigmoid, 712 — Ambulatory treatment of 
varicose ulcer, 978-8ome problems of glycos- 
uria, 1016 

Leeds Division . — Difficulties in cardiac dia- 
gnosis, 347 

Leicester and Bntlnnd Division . — New 
developments in pharmacology, 895— A new 
type of general anaesthetic, 895— Specific 
therapy in septicaemia. 895 
Middlesex, South, Division . — The use of 
hypertonic solutions in the treatment of 
increased intracranial pressure, 86 
Monmouthshire Division . — Recent changes 
in obstetrical practice. 495 — Treatment of 
puerperal sepsis, 495— Concealed accidental 
haemorrhage, 495 

St. Pancras Division , — Experiments in mal- 
nutrition, 88 

Shejffield Division. — Practical applications 
of recent views on the menstrual function, 
651 


Association, Bnixisn Medical,— P roccodings 
of Branches and Divisions (conCfni/^Z) : 

Southport Division. — Chr'^nic muscular 
rheumatism and panniculitis, 293 

Tunbridge Wells Division.— Some notes on 
diagnoBis. 709 

Ulster Branch . — Cancer campaign, 72' 

Association, British Medical: Masonic Lodge, 
proposed formation of a, 681 
Association, British Medical: Scholarships and 
grants, 640. 675 

AsBociation, Canadian Medical: Annual meet- 
ing, 601— Maternal mortality in Canada. 601 
Association for tho Development of Medical 
Relations: Annual meeting. 28 
Association, Forfarshire 31cdlcal: Malignant 
complications ot utcrino fibromata, 803 
Association. Glasgow-Abcrdeen University: 
Annual luncheon, 463— Progress in public 
health in Scotland, 463 

Association of Health Visitors, Scottish: Con- 
ference, 917 

Association, Hong-Kong Medical; Dinner to 
European practitioners, 1053 


532 

Association, Lausanne Medical Graduates': 

Medical men approved for the M.D. degree, 37 
Association, London, of the Medical Women’s 


Instructions for Missionaries in the Trojnes, 
1133 

Association, Medical Offlcer.s of Schools’; The 
future of tho school medical officer. 262 
Association. Medical, of South Africa: First 
annual scientific meeting. 684— Papers read. 
681 — Distingnished visitors, 6?5 — Entertain- 
ments, 685— Trades e.xhibltion, 685 
Association. Medical Women’s International : 

Council meeting at Bologna, 766 
Association for Mental Welfare, Scottish: Con- 

» . ■ - 0..2 

• ' .• First: Accident 

Association. New' Zealand Medical: Genital dis- 
placements, 431 

~ — 4 ,^ 

• , I 


gicHl Hciiolarsuip. ii^ 

AsBociatioD, University of London Graduates: 
Resolution re support of E. Graham Little as 

represontativo of * ati 

Association, Victor: ' , ' 

Asthma Research C • • ' ' 

Asthma, treatment of, and an improvement of 
tho poptonod agar sernm (A. Gunn Anld), 171 

„ ...l.,..-. .. -*11 -<^5 

> > nt8,568 

^1 .761 


le. 323 . 

Atkin bon-Adam. M.: Appreciation of Basil 
Thorn Lang, 201 

Atophan, administration of followed by yellow 
atrophy of liver (L. J. A. Loewentbal, W. A. 
Maokay, and B. Cronin Lowe), 592 (0) 

Atresia, vaginal, dystocia due to (K. V. Bailey), 
263 , ^ , 

Atrophy, progressive muscular, treated by 
thyroid, ca'clum, and vitamin D (Captain T. H. 
Thomas). 978 (O) ^ , 

Atrophy, progressive muscular of the peroneal 
typo (Qcoige Parker), 1062 (O) 

Atropine treatment of morphinism, 34. bee also 
Morphinism , . . 

Attlee, Wilfred : Periostitis of the metatarsus. 

Auden, G. A. : The borderlands of feeble- 
mindedness, 872 m T» » \ 

Auerbach’s plexus and achalasia (A. T. Raue), 
933 

AuLP, A. Gunn: Tho treatment of asthma, and 
an improvement of tho poptoned agar serum. 

Auricular llutter (C. E. K. Herapath), 213 (O) 


ubtralia: . 04 4 t 

British dentists, regulations for in the State oi 
Victoria, 291 , ^ , a 

Diphtheria immunization: tho Queenslana 
fatalities, 193, 1076 
Hospital problem in Victoria. 630 
Plague in, history of (J. H. L. Cumpston and 
F. McCallum).1036 . 

Victorian Bush Nursing ABSocintion.b/ 

ustralia, tropical, 30, 772, 875 

ustrallan Inland Mission of tho Presbyterian 

— ' * — -'ll aeroplane to be at tiio 

officer, 203 
book on, 1133 

new motorists’ numberj333 
utogonouB residual vaccines (C. E. jenKinay. 
340(0) 

utographs. medical, 825 

utomobile. See Motor - 

VELiNG. Francis: Directing Mental Lneiov, 

vent.^M. : Duration of a positive Widal re- 



INDEX, 


r tbe nRmss « 

L 3fxorcAt, JorairiX j 


JAX.-JlJNH. 192S] 


■*' Avcrtin.’' a now Koneral anacstbotlo (W. 13. 
DixoQ>, 896 

Aviators. Kff Air nnd FlytnR 

Atlwaud, R. D. : ConRonital hoart-bloclc. 913 


R. 


Baby ^Voek, National: Astor OhallonRO Shield, 
215. 555-Report of Council. 9:9 
Raolllus ^ ’ (Professor 

Calmett ■ ' 364— (H .1. 

Parish), ' ■ ■ ‘ statistical 

study o‘ ' Irocnwood), 

793 (0)— And non-luborculouB Infants (,T. 
tiUniorea), 909— Tlio present position of pro- 

! ’ ‘ . t system. 82 

nn of in sputum 
'( 0 ) 

, ' monty present in 

tuberculous bones and joints (Tjouis CobbotO. 
626 (O). Scenls:^ Tubercle bacillus 
B. Tvithfisiis, Isolation of from sowaRo and shell- 
fish (CT. James Wilson). 1061 (0» 

Back, Ivor: Etoction to the Council of the 
Royal College of Surgeons, 691 
Bacon*, Agnes L. : Alcohol and longevity, 148 
Bacon*. Rev. Francis, sentenced 10 imprison- 
ment, 329 

Bacterial ngglutination 6T. W. BigRcr), 633 
Bacteriological nomenclature. Sice Komonclaluro 
Bacteriology, review of books on, 670. 850 
Bacteriophages, cholera (F. d’Hcrollo and Major 
R. R. Malone). 365 

B^DUkuow. G. W., honour of knightbood con- 
ferred on. 23 

Bail, Oskar: Death of, 785 
Bailkt, Hamilton: DeuwnstmtiMi of Bhvsunt 
tn Clinical Snroeriit rov„ 137— Diagnosis 
of branchial cyst. 940(0) 

BAiLr.T. H. C. (and R. \V, Dodesstike): Pre- 
Uflfnl Core, rev., 1U3 

Bailet. K. V. : Mn’tiplo nterinc fibroid tumours, 
265— Dystocia doe lo vaginal atresia. 263— 
Abdominal haematoma. 668 
Baikprioge, C. F.: Malarial treatment of 
general paralysis, 1024 

Baker. H. B.* Dangers of ethyl petrol, 363.1033 
Baker. rjieut. 'Col. Richard John, obItuar>' notice 
of, 965 

Gakqbii. Khan Bahadur Ahmed, Imperial 
Serrico Order conferred on, 9S8 

r„.vTT-T.^- T . r :»-..piorn(iou dc 

* • ralia, 30. 875— 

' i malaria, 114 

' 4'17— Address 

* ‘ Health and 

* ■■ *. he Honorary 

r ellowship of the Roj'al College of Physicians 
of Loudon. 866 

BAEiiAN'CE, Sir Charles: Appreciation of Sir 
David Perrier, 574— (And Lionel Colledge); 
Anastomosis between the recurrent laryngeal 
Md phrenic nerves, 746 (O)— War Emergency 
Fund, 1045 

Bali^aktike, B.: A disclaimer, 120 
BAI.T.ARD. P. B.: The “problem child.'* 28 
B,^qE, F. : The thermo-can terj' for septic 
lesions, 678 
Bangor sewerage, 60S 

Bakkart,^ a. S Blundell; The origin of 


-adiated erg( 




BauKs Lecture. See Lecture 
Bar. calls to the. 203. 1133 
Barbados, infection of with malaria, 66. 114. IS"; 
B^ber. Hu^ : A form of senile seizure, 492 (O 
barber, H. w. : Asthma Research Council, 4S( 
Barber, T. Henry Treves: Injection treatmei 
of varicose veins. 412. 594, 644, 1090 

^ scarlet red dry dressing. 38: 
thwapy’i'zso Ultra-Violet radiatio 

expectant mothe 

^Barley, sulphur dioxide in the milling of (parlii 
mentiry note), 830 

Ucalins of perforate 

Sir Thomas: John Tbomson. 15G 
^preoiatlon of Sir Dawson WlUiama. 117- 
War Em^gency Fund, 1045 
Barnard, Dr. : Cancer of the cervix. 548 
^^rmofd 55 Recurrent endotheliomatou 


►rporated Asso- 


^ eating a^e^dicltis : a case of recoverv, 39 
~ " ■ 3a-8ickness. 1089 

• ' ■ ' , e in the treatment 

, 86— Appreciation o: 

, -Appreciation of Jf 

784— Appreciatio 

*> T Harris, 962 

Barrett. Jaums W. : Tropical Australia. 77 
Barrington- Ward, L. E. : Chronic appendi 
m children, 349-7 ke Ahaominal Siirpe, 
Children^ rev.. 554 

^^arrt. D. T. : The Meinicke syphilitic reac 


JOURN. 2 


Bartlett, Adelaide* trial of (edtied by *^ir John 
Hall), 266 

Bartlett* P. C. : Tsvcholoou and the Soldier, 
rov., 310 

Barton, E.R.: Tho physiology of defaocation, 
77 

Barton, James W. : That Body of Yours, rev. 
18 

Bauton* Mrs., appointodnn additional member 
of the Departmootal Gommittco to consider 
tho Mldwivos Acta, 1G96 

lURwr.LTi. Harold: Dineasea of the Larynx, 
third edition, rev.* 1027 
Basal metabolism. See MotaboMsm 
BASKr.TT, B. Q. M. : Causes of tho decline in 
tuberculosis mortality, 922 
BARSETT-BMiTn, Surgcoii Rear-Admiral. obituary 
notice of, 35 

Bath, balneological meeting at, 859 
Bath, Bernard E. A., presentation to, 999 
Batti-n, G. B. : Diathermy in relation to ciren- 
Jatory disturbances, 134— Tho pulpless tooth, 
549 

Battle, C. J.; Haemoptysis in infants, 382 
Bauer: Experimental transmission of yellow 
fever, 723 

Bauwens. P. : Ergostorol, vitamin D, and 
rickets. 78 

BxYLtsa. Sir WilUam M.. memorial to, 605 
Bazhtt, Henry Cuthbert (and George William 
Nonnisl:— Blood Pressure: Tie Clinical ApvlicU’ 
lima, fourth edition, rev.. 804 
Rr.ADLES. Cecil F.: Tho now* portrait of John 
Hunter, 571 

Beadnell. Surgeon Rear-Admiral Charles 
Marsh : ReminiacencesoftheAmerienn-Fittpino 
TTur. 1899, 68— Gland grafting and inheriiance, 
570, 690 

Beattie. J. M. : Streptococci and puerperal 
sepsis. 642— Pathological report on a mixed 
tumour of tiio nasopliarynx. 654 
Beatty, J.; Treatment of lupus vulgaris, 47 (O) 
Beaumont* O. E. (and E. C. Dodds): Recent 
Advances in Medtcni*. fourth edition, rev.. t51 
Beaumont. W. M.: The use of adrenaUno in 
medical and surgical practice, 1104 (0) 
Beudinoton* E. F. : Winter motoring. 480 
Becrterev, Vladimir von, death of. 240 
Ueckktt-Overt. Dr. : Anaesthetics in obstetrics. 
395— Intravenous treatment of varicose ulcers. 
899 

BficLiiRE, Henri : Elected President of the 
Acaddmio de Uddecioo. 165— (Pierre Duval 
and Jcan-Charlcs Rouse): Badtolo0fe Clinique 
df< Tube Diijeatif: 1, Eatomac et Buodeitum, 
rov., 500 

Bod : an adjustable board-bed (Leonard Hearn), 
1101(0) 

Bepale, E.M. : The economics of menstruation, 
603 

Beds in hospitals for abnormally tall patients 
(parllamcntati' noto), 380 
Beds and personnel in naval hospitals (parlla- 
mcnt‘\rj’ note), 428 

Bkgg. R. Campbell: Kephro-ureteral anasto- 
mosis after complete avulsion of tbe ureter, 
1091 

Bogging letter pest, 430 

Beggs, 8. T. : Chance’s filter for ultra-violet 
rays, 582 

Behrend. Moses; Surgical Diseases of the Gall 
Bladder, Liver, and Pancrens, autt their 
Treatment, rev,, 265 

Belak, Dr., appointed professor of public 
health at Dcbreczin.617 
Belfast. See Ireland 

Bixl. W. Blair (and others); Metabolism and 
acidity of the foetal tissues and fluidn. 126(0) 
—Malignant functions of tbe chorionic epi- 
thelium, 803— Treatment of malignant disease 
by colloidal lead. 958. 1087 
Bellocq. Dr. (of Strasbourg), title of professor 
conferred on, 243 

Belt for use in suprapubic drainage, 556 
Bengal, medical education in, 283— Tuborcu’osis 
in, 1082 

Bennett, Cliarfes ; The acute abdomen, 411 
Bennett. Francis Dillon, obituary notice of, 377 
Bennett, Frailcis G. ; Primula rash, 439 
Bennett, R. Allan: Sea-sickuess and its treat- 
ment, 752 (O) 

Bennett, T. Izod : Pulmonary and gastro- 
intestinal sequels of naso-oral sepsis, 97— 
Treatmentofgastricnlcer, 168(0)— Goulstonian 
Lectures: Some problems of nephritis, 513 
Bequests to hospitals and medical charities, 81. 
119, 381, 957 

Bemespord. G. W. : Gastric ulcer, 99— (And 
B alter Broadbekt) ; Paralysis of all four 
hmbs cured by removal of a spinal tumour. 
1053 (0) 

H^'kqmark, Professor: Memoir of Karl Petren, 

BERKELEr, Comyns; Treatment of eclampsia, 
1066 

Berkelet-Hill, Lieut.-Col. O. A.R.: Neuroses 
in the tropics. 448 

Bermuda, health lessons from(Andrew Balfour), 
^^^^ard, Albert Victor, O.B.R, conterred on 


.ui,usARx>,A;iauae : .in introduction to the Studn 
of Ejrperimental Medicine, rev., 900 
Burnard, L^on: Appointed to the chair ol 
tuberculosis at the Paris Faculty of Medi- 
^055— (And Robert DEimfc) : Coura 
d Jlygthie, rev., 669 


Berry, F. May Dickinson: Medical co-educa- 
tion, 99) 

Berry. R. J. A. ; Plea for a national laboratory 
for tbe study of mental abnormality, 46 (O.— 
The hospital problem in Victoria, 680 

BERTnELOT, Marcellin. centenary of tbe birth 
of. 68 

Bertrand, L. ; Tho causation of rheumatism 
856 

Br.RTWiRTLE, A. P.; Tho role of dead and 
infected teeth in aiUogeuons infections 589(0*. 
700 

Bezanqon, Fernand : The cardiac problem in 
rheumatism, 855 

J)ibItO{7rap7<tn Medica Chirurgicn, first issue, 
119 

JJibliOffrnphj/ of Industrial Hi/gipne: Hygiene, 
jihysiology, pathology, etc., number, 535 

Biddle, E.: Acidophilous milk in infective 
arthritis, 519 

Bier: The thermocautery for septic lesions, 
678 

Bigger. Sir Edward Coey: The need for hos- 
pital co-o dination, 822 

Bigger, J.W.: Bacterial agglutination, 633 

Bilbarzla, vesical, double infection with 
S. haematobium and S. maiisoni(K. Fairbairn), 
52— (Robert B. Coleman), 177— (M. Kbalil). 546. 


(Sir 

”* * ’ ‘ ’ * ■ ooks on, 634, 805 

' Huxley). 1084 

. . lent (N. L, 3Jaxwell 

Reader). 892 (O) 

Birch, John: Fatal poisoning by bora. v. 177 
Birkett, G E.; Treatment of cancer by radium, 
75 

Birmingham, Cancer research in, 372— Guardians 
and the mentally unfit (parliamentary note), 
423 

Birth control: International Medical Group’s 
first report, 515 

Birth Control Clinics, annual report of the 
Society for, 37 

Birth ra*© for London (parliamentary note), 830 
Bbtb rate, effect of on the average age at death, 
644, 775 

Birth and death rates in tropical Africa (parlia- 
mentary note). 532 
Birthday houours. See Honours 
Births registration. See Reslstration Bill! 
Bismuth, metallic, in the treatment of psoriasis. 
204 

Bites and wheals, 275 
Black races, shock in. See Shock 
BLArKALL-MonisoN. Alexander, obltuary notice 
of, 36, 79 

Blacklock, j. W. S. (and G. H. EriNGTox): 
Duplication or subdivision of tbe testicle, 937 
( 0 ) 

Blackwood, William, appointed an officer of 
the Order of the Hospital of St. John of 
Jerusalem, 1133 

Bladder calculus. See Calculus 
Bladder, forei-'n body in the (A. Ralph 
Thompson). 51— 'E, Scott), 216— (Harry D 
Christie), 307— (J. McFadzean), 665 
Bladder, solitary ulcer of (Guy Chambers), 1019 
(O) 

Blair, Patrick: An epidemic of syphilis 
insontium, 151 

Bland-Sutton, Sir John; AppreciaVon of Sir 
Dawson Williams, 418— Hon. M.Ch. Dublin con- 
ferred on. 529 

Blandy, Mary, trial of (L. A. Pairy). 254 
Blanesburgh, Lord, appointed chairman of the 
Advisory Committee on the Welfare of the 
Blind, 1095 

Blastomycosis of eye and face secondary to lung 
infection (Arnold S. Ferguson), 442 (O) 
Blepharitis, chronic, cure of, 650 
Blezabd, Thoina*?: Infection among children 
in casualty departments. 930 
Bhn^d children, numbers (parliamentary note). 

Blind Persons Bill, 289 

Blind^ persons receiving pensions, numbers 
financial position 
new home for in. 

Blind, special schools for, 929 
Blind, tiaining of. memorandum from the 
Scottish Education Department and the 
Scottish Board of Health, 113 
Blind, welfare of: Advisory Committee, 26 — 
Report of committee, 813 
Blind, welfare of. in Scotland, annual conference 
of Scottish national societies for the. 1045 — 
Ncottish Advisory Committee reappointed 
1C06 

Blome, Walter H. (and Homer C. Washbourn), 
Rliarmacognosy and Materia Medtcn, rev., 356 . 
Blomeield, Joseph : Anaesthetics in obstetrics, 

B'ood coagulation time, loop for measu ing. 672 
Blood, estimfltion of glucose in (Francis Tenio e 
Grey). 215(0) 

Blood film, a method of mahing a (Surgeon- 
Commande- ^ =» u 

Blood group , 
and Jews 
spondence ou, 'i62 





Jan.-June, 1928] 


INDEX, 


t Tn Bsmsx m 

KbDIIIU. JotrAXlXi / 


noctloo in n fnlMorni ootopio costa- 
tion (St. Qoorco \Vll8on). 49S 
<3ftcsarcan Boction in proRnanoy complicated by 
tuborculoalB,«180 

Caioeu. Foord : Dipbtborla carriers, 180 
•Caikb, William : Pis7», Fishino, and Finhermen, 
rov.. 902 

(“/■ - -• -ledlclno at, 291— 

( ■ *■ *. ' lodicino, 291 

• . of (Oscar lioow), 

8M(0) 

•Calcium therapy, intravenous, danfior of 
(W. D. M. Lloyd). 652 (O) 

Calculi, urotbral. multiple (0. 11. Pasloy), <143— 
(E.R. Wbooler).445 

Calculus in male bladder duo to a forolRn body 
(E. Scott), 216 

Caloulns. renal, late results of operation for 
(J.P. Dobson). 486(0) 

Calculus, ureteral, largo (John C .TofTcraon), 14 
Calper, J. A.: Life assurance In the tropics. 219 
CALMETTE, Profcssor, elected a momboroftho 
Acaddmio dcs Sciences, 29— The bacillus 
Calmctto<Gu6rin (ll.C.Q.), 250— His statistical 
study of B.C.G. vacciuatlon (M, Grocnvfood), 
793(0) 

Calves used for vaccine lymph (parliamentary 
note), 532.1095: 

Cameros, a. T.: a Texlbooh of Bioeheiniilrv, 
805 

Oamerok. CbarlOB : Report on the East Fottuno 
Sanatorium, 728— The typo of tuberculous 
lesions in bones and joints, 731 
Cameron, .T. a, M. : Dysphagia associated ^rltb 
anaemia, 521 

Cameron prize. See Prize 

Cameron, Samuel J. : Treatment of cancer by 
radinm, 286 

Casiprell, Andrew (Andrew Watt and R. C. J. 
Meter): Operation for pltuitarj* tumour, 747 
( 0 ) 

Campbell, John Archibald, obituary notice of, 
695 

Campbell. Colonel Sir Robert Noil, obitaarj* 
notice of, 474 

Campbell, Walter R. : Intravenous glucose in 
diabetic coma, 197 

Casipbell. W. S.; Value of marine health 
resorts, 450 ^ 

Canada : 


Government travelling clinics in Alberta, 616 

‘ . 'al.569 

. *16 
*' . MncMnrcby), 604 

Medical examination of intending settlers in 


Sch9larships for tuberculosis workers. 369 
Sterilization of the feeble-minded in Alberta. 

680.825, 878 
Tours in, 6:0 

Cancer, anaemia in, 721 
Cancer of the breast, familial, 164 
Cancer of the breast, radium treatment of 
(Duncan C. L. Fitzwdliams). 451 
Cancer campaign in Northern Ireland. 72— Meet- 
ing at Limerick, 235 — In the North-West of 
England, 465 

Cancer campaign, British Empire: Quarterly 
meeting of the Grand Counc 1, 80, 693 — Inter- 
national Convention. 640, 815, 1076 
Cancer cases, records of, 117, 334 
Cancer of the cervix, cystoscopy in (A. A 
Gemmell), 667 

Cancer of the cervix: exhibition of specimens, 
57 

Cancer of the cervix, treatment of (Herbert B. 

Spencer), 535(0)— Discussion, 547 
Cancer of the cervix, treatment of by irradiation 
(Max Cheval).557 (0) 

•Cancer, chimney-sweep’s, first case of reported 
in Scandinavia, 81 

of the colon (Sir George Lenthal Cheatle). 
5|;---Early diagnosis of (Sir William do Courcy 
Wheeler), 846 

Cancer conference. See Cancer campaign 
Cancer, death of a radi-jgrapher from (parlia- 
mentary note). 1131 

Cancer, etiologs' of, a request to general practi- 
tioners, 1W9 

Cancer of the larynx, intrinsic, operated upon 
py laryngo-fissure (Sir StOlair Thomson), 743 
lU), 983— Leading article, 764 
C^cer, lead (colloidal} treatment of (Stanley 

IW? 

Cancer of lung, primary ( Dr. Lait). 1026 

mouth, radium treatment of 
(B. T. Rose). 936 (O) 

®^®®^P0*^itoneal fluid injections in treatment 

Cancer, radium treatment of, 75. 159, 197, 286 
C^cer of the rectum: Ministry of Health 
resnltsof opetations, 
correction, 3S4 — Early diagnosis of (Sir 
William de Courcy Wheeler). 846— Leading 
article on, 905 — ^Radium treatment of (B. T, 
Eose),93S(0) 

Cancer research in Manchester, 282— In Birming- 
In Sweden, 6I7 — By medical women 
(M. Chadburn). 6U — Expenditure on (parJia 
Anentary note), 926 


Cancer, review of books on, 16. 453 
Cancer, skeletal motaatasGs in (F. J. Ilonry), 899 
Cancer of tongue, radium treatment of (Duncan 
C. L. Fltzwilliams), 451 

Cancer, troatmont of, fusion of hospitals 
(Ireland), 29 

Cancor of uterus: Ministry of Health’s memo- 
randum on, 24— Report on. 69 
Cancer of uterus following operation ( W. Gough), 
498 

Cancer of uterus, an occasional symptom of 
(Miles PhilUps), 498 

ANDrXR, A. L.: Tuberculosis of the skin and 
tendon sheaths, 2GS— Surgical troatmont of 
chronic gastric ulcer, 451— Streptococcal collu- 
llUs. 946 

Cann, R.J.: Diphtheria cairiors, 181 
Cannon. Alexander: Thocausoand treatmontof 
tlio crisis in lobar pneumonia. 651 (0) * 

Cannon, D. J. : Congonital pyloric stenosis. 946 
Cantacdzenk, J.: The present position of pro- 
immunization with B.C.G. . 1077 
Canctt. George: Deaths from local anacsthosia, 
81 

Capillary circulation and glancoma, 1127. See 
also Glaucoma 
Carcinoma. See Cancer 
Card hinge, the transparent. 832 
Cardia, achalasia of, 692. 773. SeeoUo Achalasia 
Cardiac diagnosis, diinctiUios in (John Parkin- 
son). 347 

Cardiac disease, tho mental state in (Carey 
Coombs). 352 

Cardiac infarction, two cases of. one followed by 
calcification of tho heart, the other by mpturo 
(T. Wishart Davidson), 212 (O) 

Cardiac malformations and endocarditis, 953 
Cardiac tonics (R. Bodo), 603 
Cardiac. See also Heart 

(iardlfr, Annual Meeting of tho British Medical 
Association at. 142. 509. See also Association 
Cardiospasm. See Cardia and Achalasia 
Carditis and lime-doQcient food. 618 
Caries, spinal, conservative treatment of (Sir 
William do Courcy Wheeler). S5 
CARtiLL. lltldrcd: An egg-cup in the rectum, 
120 

Oarunq. E. L.: Clinical opportunity for mid- 
wiferj*. 693 

Carlsbad, post graduate courses at. 381 
CARONtA, Giuseppe, appointed to the chair of 
infectious diseases of children at Naples, 1036 
Carrier problem (J. E. McCartney)^ 180, 445— 
Discussion, 180, 446— (Adrianus Pljporand B. 
Davidlne PuBlngcr), 587. Seea'so Diphtheria 
and Fever, enteric 
Carroll, John Donal, obituary notice of. 826 
Carr-Sadnders. a M. (and D. Caradog Jones): 
A Survey of the Social Structure of Fnplancl 
and TVales as tUustrated by Statistics, rev., 
598— Pro/e5s(onsr their Orpanisation and 
Place trt Society, 951 
CARROTuens. Vincent Theodore, obituary notice 
of. 1092 

Carson, Herbert W. : Chronic appendicitis in 
children, 349 

Carsos, Joseph Thompson, obituary notice 
of. 10:5 

Carswell, John: Morison Lectures on psycho- 
logy and medicine, 872 

Carswell, Robert: Appreciation of Alexander 
Blackhalt-Morison, 79— Collective investiga- 
tion and tuberculin. 375. 523— The ** cure ” of 
pulmon — 

Carter. * * * oholism, 596— 

Causes * . 4 

Cassidy, L. L. : Vesico vaginal fistulae, 308 
Castellani, Aldo, Grand Cross of the Order of 
Civil Merit (Spain) conferred on, 81— Honorary 
K.C.5LG, conferred on. 120 — Mycoses, 958 
Castiolioni, Arturo; Storia della medicina, 
rev,, 266 

Casual wards at Thamo (parliamentary note), 
1006 

Casuals, small-pox ^ among, 154 , 609, 644 — 
Detained for medical examination (parlia- 
mentarj' notek 428 — Beds for in unions (parlia- 
mentary note), 474— Fitness for labour of 
(narliamentary note), 551 — Medical inspection 
of (parliamentary note). 1095 
Cataract and ultra-violet light, 31, 116 
Catarrh, nasopharyngeal, chronic, treatment 
for. 930 

Cathcart, Charles W. : Portable low-pressure 
sterilizer, 18 _ 

Chronic appendicitis in 


Cawadiab, a. P, 
children, 349^T ■ 

Oawston. F. G.: , , )1. 

proof guttering a* ' 

infection, 1098 

Orllan-Joneb. Katherine (and C. J. Cellan- 
Jones): Syringe for injecting varicose veins, 
763 

Cellulitis, streptococcal (Wayland Smith), 945 
Cemeteries in England and Wales, 273 
Census of the Union of Soviet Bepublics. 831 
Cerebral hemispheres, physiology of the (I. P. 
Pavlov), 809 

Cerehro-spinal fluid, estimation of glucose in 
(Francis Temple Grey), 215 (O) 

Certified persons, procedure regarding discharge 
of (parliamentary' note), 829 
Chadburn. Maud: Cancer research by medical 
women, 641 

Chadwick Lecture. See Lecture 
Ghalam, B. S. (and j. A.Crawpord): — Mosquito 
Brduction and Malarial Prevention ; a Precis, 
second edition, rev., 1029 


Challis, H, T., promoted a Commanderof tho 
Order of the Hospital of St. John of Jerusalem, 
1133 

CniLifERB, R. : Etiology of tho common cold 
244— Pneumonia after operation for gastric and 
duodenal ulcers, 1134 

Chambers, E. R. : Metastatic ophthalmia, 546 
Chambers, Guy: Solitary ulcer of tho bladder 
1019 (O) 

Champnets, Sir Francis: Appreciation of Sir 
Dyco Duckworth, 161— The protection of 
maternity, 465 

Chambt, Dr., nominated professor of histology 
in tho Paris Faculty of Meiicine, 163 
Chance. Arthur: Bone complications in typhoid 
fever, 56 

Chance's filter for ultra-violet rays, 682 
Chandleb, F. G.: Importance of sputum ex- 
amination in pulmonary tuberculosis, 469 — 
Early detection of tubercle bacilli, 731 
Chapltn, Arnold: Appreciation of Sir Dawson 
Williams. 421 

Chapman, R. B.: An unusual type of vicarious 
menstruation. 1065 

Character formation, the effect of illness on 
(David Forsyth), 62 
Character, review of hook on, 138 
Charcot’s arthropathy'. See Arthropathy 
Charities Itepisier and Bioest, A7inual, rev., 806 
Chables, Sir Richard Havelock: Baronetcy con- 
ferred on, 23— Appointed Honorary Serjeant- 
Surgeon to the King, 460 

Charslet, Gilbert W. (and George Richardson) : 

Case of volvulus neonatorum, 494 
Chaddhri. Bai Bahadur Dr. Ivishori Lai, O.B.E. 
conferred on, 988 

Chaddhuri, S. K.: Chloroform poisoning by 
ingestion, 82— Lobar pneumonia with diph- 
theria and malaria, 292 

Chaufpard. Professor : Eulogy of William 
Harvey, 8^ 

Chatasse, Bernard : Pathogenesis of acute 
primary glaucoma, 1(X)1 

CuEAL, P.: An English hospital in Formosa, 151 
Cheatle, Sir George Lenthal: Carcinoma of 
the colon, 55— Pathology of mammary con- 
nective tissues. 550—Appreciatioa of Hugh 
James Moore Playfair, 613 
Chemistry, review of books on. 902 
Chesser, Elizabeth Sloan : Infant welfare in 
India, 1082 

r ’f^rolopi/and 

’ • . ' 'the cervix 


Child guidance clinic, proposed, for London. S57 
Child, tho “ problem '* (P. B. Ballard), 28 . 

Child, the over-sensitive iB. Crichton), 227— 
Discussion. 220 

Obildbirih mortality. See Mortality, maternal 
Child welfare. See Maternity and child welfare 
Children boarded out by the West Ham 
Guardians parliamentaify note), 381 
Children, defective, the teaching of, 62— Educa- 
tion of, 822. See also Mentally defective 
Children’s diseases, review of books on, 15, 454. 

805. See also Pediatrics 
China: Pekin ilTfdtcnl Guide, 741 
CfliRAT. M. 1 1, Pavel and A. Lomon) : La v^siciile 
hiliaire, rev., 255 
Chiropodists’ conference, D25 
Chiropractors in Quebec, 516 
Chisholm, Catherine : Medical co-education, 9S9 
CmsHOLM, J. D. (and Arnold Renshaw) : Tetanus 
in a boy, recovery. 175 (0) 

Chloride, neutral, gastric secretion of, 325, 374, 
411. 469, 521. 729, 1128 

Chloroform for convulsions (report of an 
inquest', 118 

Chloroform, intratracheal inhalation and in- 
sufflation of by means of a flexible metal 
catheter (W. Dakin Mart), 942 (0) 

Chloroform poisoning by ingestion, 82 
Chloroma in a child (J. 8. Y. Rogers), 222 
Cholecystography by the oral method without 
the use of capsules (Hugh Morris). 305 (O) 
Cholecystography, the process of (G. Dyas), 1066 
Cholera bacteriophages (P. d’Herelle and Major 
B. H- MaloDo). 365 

Cholera bilivaccin (Colonel A. J. H. Rnssell), 274 
Cholera in India (Sir Leonard Rogers), 1053 
Cholera and Iraq dates (parliamentary note), 428 
Cholera in the Punjab, 568 
Chorion-epithelioma (Maslen Jones), 181 
(Chorionic epithelium, malignant functions of 
the(W. Blair Bell), 803 

Christiansen, Yiggo ; Sixtieth birthday of, 291— 
Special number of the Acta psychiatHca et 
nettrolopzca dedicated to,29t 
Christif.. Ham’ D. : Foreign body in the 
bladder, 307 

Ohribtopherson, Dr. : Life assurance in the 
tropics, 219 

Church. Sir William Selby, obituary notice of, 
778 

Cigarettes, Rhodesian, 1003 
Cigarettes and snckllng, 966 
Circnlation, coronary, 404 
Circulatory disorders, review of books on, 266 
Circulatory disturbances, diathermy in relation 
to. discussion at the Royal Society of Medicine, 
134 

Cirrhosis, portal (V. M. Synge), 633 
Citobaryum.949 

Olaou 6, Charles-^ Oreille Interne: Etude 
Anatomo-vatholoffique et clinique. TeehniQue 
microscopique et cxpcrimentale.rev., 184 


6 JAN.-JUNE, 1928] 


INDEX. 


Blood pressure, high ( J. Crighton Bramwell and 
R. Ellis), 352— (H. Cairns Terry), 802 
Blood pressure, review of boobs on, 804 
Blood stains, examination of (John Glaister), 67 
Blood transfusion, arm-to-arm, simplified 
method of (E. F. Skinner), 492 (O) 

Blood transfusion, whole, 1054 
Bloxsome, Charles Harold, obituary notice of. 
476 

Blum, E6on, Legion of Honour conferred on, 
291 

Bltth, Alexander Wynter (and Meredith Wynter 
Bltth): Poods, their Oom-position and, 

' Analysis, seventh edition, rev., 947 
Board, Central Midwives, 155, 282, 466, 687, 874 
Board, Central Midwives (Scotland). 236. 957 
Board of Control: Retirement of Sir Frederick 
Willis, 282— Appointment of L. G. Brock as 
chairman, 282 — Pamphlet on the Mental 
Deficiency Act (1927), 372 

Board of Education : Issues a HandbooTc of Sug- 
gestions on Health Education for the Considera- 
tion of Teachers and Olliers concerned tn the 
Work of Tuhlic Elementary Schools, 192— 
Medical Branch transferred to Whitehall, 581 
— ^Estimates, 879— List of special schools for 
blind and defective children, 829 
Board of Trade: re certain imported goo^s, 
medical, surgical, dental, etc., to bear indica- 
tion of origin, 381, 429, 581— Estimates. 1051 
Board-bed, an adjustable (Leonard Hearn). 1108 
(O) 

Boarded-out children. See Children 
Boas L: Forty-third volume of the .4rc7ita/iir 
Verdauungskranliheiten dedicated to, 1133 
Bodman, Frank: Pneumoccal peritonitis, 1023 
Bodo. B. : Cardiac tonics, 603 
Body and mind. 788. See also Delusions 
Bogus doctor, 239 

Boiget, Maurice: Exercise as a therapeutic 
agent. 680 

Bolam, Sir Robert: Appreciation of Sir Dawson 
Williams, 423 — Appreciation of James 
Alexander Macdonald, 783 
BoLr.iNG, R. W. : Surgery of Childhood, rev.. 
1113 

Bolton, Charles : Croonian Lectures on the 
interpretation of gastric symptoms, 1030 
Bolton, E, Richards fand Cecil Revis): Oils 
Fats, and Fatty Foods, second edition, rev. 
&47 

Bombay Medical Council, 283 
Bonar, B. E. (and C. G. Grulee) : The Newborn, 
rev.. 1113 

Bond. C. J : Galton Lecture on natural capacity 
in the population, 3i5— Irradiated ergosterol as 
a dressing for wounds, 339 (O). 642 
Bone complications in typhoid fever (F. J. 
Henry), 55 

Bones and joints, tuberculous: Type of tubercle 
bacillus commonly present in (Louis Cobbett), 
626 (O)— Correspondence on, 731 
Bonhoeffer, E. : Slxty-elgbtb volume of the 
MonatsschrUt filr Fsychiatrieund Neurologic 
dedicated to. 1133 

Bonnet, Victor: Genital displacements. 431 (0) 
— A disclaimer, 1C08 

Booce : Activity of local anaesthetics. 68 
Books, some seventeenth century commonplace, 
190— Some old medical, 884 
Boothbt, Lieut.-Col. Robert Basil, obituary 
notice of, 80 

Borax poisoning, fatil (John Birch). 177 
Borchekds, W. M. : Injection treatment of 
varicose veins, 412,960 

Boric acid in cream, prohibition of (parlia- 
mentary note), 220 

Borrino, Angiola, appointed professor of 
clinical pediatrics at Sassari, Sardinia, 1097 
Bosheb. a. B., bequests of 81 
Botet, Ricardo, death of, 696, 1005 
Bothriocephalus infection IH. T. Leiper), 848 
Bottle, hot-water, " Charlotte ” cover for, 480 1 

Bottles, medicine, return of empty, 919 I 

Bouckaurt, J.-P.: La Pathog^me et le Tralle- ' 
nient dti Diabele, rey.,n 
Boulton, Colonel Harold, C.B. conferred on, 
988 

Bouskield. Paul (and W. R. Boubpield) : The 
Miyid and its Mechanism, rev., 224 
Bovee, John Wesley, death of. 240 
Bowel, wire bristle in the (H. A. Graham), 13 
Bowie, J. 1^1.: Maternal mortality due to puer- 
peral sepsis, 980 

Bowlbt, Sir Anthony: Appreciation of Sir I 
Dawson Williams, 424— Appreciation of Sir 
Robert Porter, 476 

Box, Charles R.: The use of abbreviations, 582 
Boyd, J. J. : Typhoid immunization by the 
mouth in South Africa. 159 
Botle, H. E, G. : Anaesthetics in obstetrics, 
395 

Br\a 6CH, William F. (and Benjamin H. Hager) : 

Urography, second edition, rev , £49 1 

Brachet, Albert, elected a foreign member of ^ 
the Royal Society. 1122 

Brackenburt, H. B.: AnofBcial visit to South 
Africa. 727 — Appreciation of James Alexander 
Macdonald. 783— Organization of medical treat- 
ment of industrial rheumatism, 852 — Apprecia- 
tion of William James Howarth, 1091 
Bradfield, Lieut.-Col. Ernest William Charles, 
C.I.E. conferred on. 938 

RADFORD. Sir John Rose: The history of the 
Physiological Society. 313— Appreciation of Sir 
Dawson Williams. 416— Hon. LL D. conferred 
on, 569— Re-elected President of the Royal 
College of Physicians, 605 


Bradley, O. Charnock: Topographical Anatomy 
of the Dog, rev., 18— Veterinary science in 
Scotland, 195 

Bratlsford, F. j. : The pulploss tooth, 549 
Brailbford, James P. (and Guy Branson) : 
Fracture of the neck of a rib by indirect 
violence, 346— Xray diagnosis of pathological 
conditions of fcho gall-bladder, 484 (O)— Tho 
value of radiography in obscure dental sepsis, 
1013 (O) 

Brain, new methods of surgical access to the 
(H, S. Souttar), 295 (O)— Leading article on. 317 
Brain tumours. See Tumours 
Brain, W. Russell: The use of hypertonic solu- 
tions in the treatment of increased intracranial 
pressure, 86 (O)— Galaiea. or the Future of 
Earivhiism, rev., 1029 

Braine-Hartnell, Mr.: Hydatidiform mole, 
552 

Bramwell, Edwin ; Ocular complications of 
encephalitis lethargica, 261 
Bramwell, J. Crighlon: High blood pressure, 
352 

Branoati, Professor, awarded tho Marchiafava 
Foundation Prize, 163 

Branchial cyst, diagnosis of (Hamilton Bailey), 
&40(O) 

Brander, j. : Etiology of alcoholism, 596 
Brandy flask, an emergency, 672 
Branson, Guy (and James F. BRAiLsroRP): 
Fracture of the nock of a rib by indirect 
violence, 346 

Braunbchweig, B., death of, 79 
Bread, ergotized rye. gangrene following the use 
of (Walter J. Dilling and U. E. Kelly), 540 (O). 
See also Ergot and Poisoning 
Breast-feeding Heading article). 602 
Brebner: Artificial production of a fowl 
tumour, 909 

Brewer, H. P.(A.Q. W'ells and P.R. FraSer) : 
Treatment of pernicious anaemia by liver. 
165(0) 

Bride, Dr.: Cancer of tho cervix, 57— Largo 
ovarian fibroma. 57 

Bridge, Dr.: Tetra-etbyllead in motor spirit, 770 
Briggs, Isaac G. : How to Start in General 
Practice, rev., 1028 

Brimblecomre, Stapley L- : Mechanical medi- 
cine, 158 

Brims, Donald : Treatment of rhenmatism, 858 
Brincker. j. A. H.: The future school medical 
officer, 262 

Bristle, wire, in the bowel (H. A. Graham), 13 
British Army. See Army 
British Association. Association 
British Columbia, convalescent sernm for treat- 
ment of anterior poliomyelitis In, 369 
British doctors in Madeira. See Madeira 
British Empire Cancer Campaign. See Cancer 
British Guiana Act. 615 
British Guiana Medical Aimualfor J9?5, 617 
British Industries Pair. 242 
British Journal of Inebriety completes its 
twenty-fifth year of publication. 741 
British lanmgology (leading article), 764 
British Medical Association. See Association 
British Social Hygiene Council, See Hygiene 
Council 

British spas. 878 

British Spas Federation : Annual meeting, 465 
British spas and health resorts, guide to, pub- 
lished in pamphlet form, 531. See also Bpns 
Broad ligament. See Ligament 
Broadbent, Sir John : The carrier problem, 446 
Broadbent, Walter: Liver diet in pernicious 
anaemia, 179— (And G. W. Beresfobd) : Para- 
lysis of all four limbs cured by removal of 
a spinal tumour, 1053 (O) 

Brock, Laurence George ; Appointed chairman 
of the Board of Control, 282 — Appointed a 
Commissioner under the Mental Deficiency 
Act (1913), 649 

Brocq. Dr„ Legion of Honour conferred on. 
243 

Broderick. Daniel, called to tbe Bar, 203 
Brodhead, George L. : Jpnroaching Mother- 
hood, third edition, rev., 455 
Bronchitis, chronic, afror gas poisoning, 618 
Broncho-pneumonia in children treated by 
injections of emetine hydrochloride (C. 
Robertson Wilson), 844 (O)— Correspondence 
on, 966 

Brooks, J. (and others): Metabolism and acidity 
of tbe foetal tissues and fluids, 126 (O) 

Brown, A. Forbes: Typhoid mastitis. 82 
Brown, Alan: Antirachitic effect of sunshine, 
272 

Brown, A. Samler (editor): South and East 
African Year Book and Guide, rev.. 672 
Brown, Frederick Gordon, obituary notice of, 
118 

Brown, G. Gordon (editor) : South and East 
African Year Book and Guide, rev,, 672 
Brown, Haydn : Theories of euggestion, 53 
Brown, James Godfrey Lyon, O.B.E. conferred 
on. 988 

Brown, K. Paterson : Fracture of the navicular. 
591 (O) 

Brown, B. Dods: Beport on Aberdeen Boyal 
Mental Hospital. 281 

Brown, Lient.-Col. Robert Tilbury, obituary 
notice of, 241 

Brown, Sanger, obituary notice of, 826 
Brown, W. Langdon: Liver diet in pernicious 
anaemia, 179 — The endocrine factor in rheu- 
matism, 855 

Brown, William : Tbeorics of suggestion, 53, 
251 (0) 


Brown, W. M. : Ubcb of tho ophthalmoscope, 
1066 

Browne, Bnckston. prize, 290. See also Prize 
Browne, F.J.; Advice to the Expectant Mother 
on the Care of Her Health, second edition, 
rev.. 1069 

Browne, G. Bnckston : Tho now portraitof John 
Hunter, 325, G43 

Browne, Honry William Langloy, obituary 
notico of. 475 

Browne, Sir John Walton, memorial to. 113 
Browne, Osborne: Whole blood transfusion. 
1054 

Browne, P.J.: Advice to tho expectant mother 
on the care of her health, second edition, rev.. 
1069. 

Browne, Sir Thomas, back to. 742 
Browning, Carl Hamilton, elected a Fellow of 
the Royal Society, 320 

! Bruoe, G. R.: Value of marine health resorts, 
450 

Brumft, E. : The intestinal amoebae of man, 
1110 

Bruntate, Thomas Tombleson, obituary notice 
of. 79 

BmxeUes-Midical annual cruise, 883 
Bryan, 0. W. Q. : Treatment of hare-lip, 1025 
Bryant, E. G. : Recent work on tho glucosides, 
407 

BOden, Iwan von: Die Klinische Anivenduny 
der Diaihermie, rev., 60 

Buchanan, Sir George: Health work of the 
League of Nations. 615 

Buchanan, James: Unsuspected valvular 
disease in children, 287 

Buchanan, Robert MacNcll.oppointed J.P. for 
tho county of tho city of Glasgow. 37 
Buckley, Albert Coulson: Nursing and 

Nervous Diseases, rev., 671 
Buckley. C. W. : Scope of surgery in chronic 
arthritis. 348— Treatment of rhenmatism. 858 
Budge, Sir E. A, Wallis : The Divine Origin of 
the Craft of the Herbalist, rev., 851 
Budget, The '‘Producers,’” 724, 755. See also 
Finance Act 

BOdingen, Theodor, death of. 79 
Buist, Henry: Puerperal sepsis, 1127 
Bulleid, Arthur : Pulmonarj' and gastro-intes- 
tinal sequels of naso-oral sepsis, 97— Apical 
infection of teeth. 135 

Bulletin of Hygiene, 150, 787— ’Bacteriological 
nomenclature, 787 

Bulletin of the Ophthalmological Society of 
Egypt, 1007 

Bullous eruption after phenyl-cincboninic acid, 

38 

Bunje.F. : Complete obliteration of tbe vagina, , 
1054 

BuBDETT. Sir Honry: How to Become a Nurse, 
eleventh edition, rev., 1029 
Bnrdett's Hospitals and Charities, 19SS, rev., 22S 
Burke, B. Tytler : Vaccines In tho troitment of 
gonorrhoea. 920 

Burke, W. B. ; Gas gangrene following a road 
accident. 534 

Burke, Licut.-Col. William Henry, obituary 
notico of, 740 

Burn, A. : Painless natural labour, 120 
Burn, J. H. ; Methods of Biological Assay, rev.^ 
454 

Burns. J. W. ; An uncommon foetal attitude, 
668— Imperforate auus. 981 
Burrell, L. 8. T. : Asthma Research Council 
468 

Burroughs Wellcosir* and Co.: Chemistry 
aod pharmacology of ergot,.4l0 
Burrows, Harold; The origin of iscbaemiu 
contracture, 1047 

Burrows, Roland : The medical practitioner in 
relation to tbe administration of justice, 136 

* ' ' by a scorbutic swells 

, " isurement of Mental 


^ -r- »TT . » -jpi-eciation of Richard 

of puerperal sepsis, 
55— Puerperal sepsis and sensitiveness to- 
streptococcal toxins, 974 'O) 

Bush disease, 568. See also Iron and Ruminants: 
Bush nursing, 67 

Butler. Josephine : Centenary tributes, 606 
Buxton, research at, 519 

Buxton, P. A : Depopulation of Melanesia. 364 
Buzzard, Sir E. Farquhar: Tho Tavistock: 
Clinic— a correction, 287 — The treatment ot 
rheumatism. 857 — Elected to an honorary 

— College, 964 

• iss,1008 

' Massive dosage with- 

insnlin, 801 


CABANks, Dr, : Esculape chez les Artistes, rev., 
719 

Cabot, Richard 0. : Physical Diagnosis, ninth 
edition, rev., 310 

Caesarean Fection, abn^e of, 30 — ^Ten cases ot 
(Chatteris Graham). 980 



JAN.-JUNB, 1928] 


INDEX, 


[ Tax Sxmu 

V>Dt(UX. JpUBWAX. / 


Cftosaroan Rcctlon in a fulMorm ootopic noHta* 
tlon (St. GoorRo WUson), 498 
CRCsfttoan section In proRnancy complicated by 
tuberculosis, 480 

Caioeu. Fooi*d : Dipbtborla carriers, 180 
•Oaine, William ; P»s7i, Fishino. flud Fishermen, 
rev., 902 

r •ucdicino at. 291— 

« : * . ' lodiclno, 291 

\ . of (Oscar lioovr), 

Ity4 w; 

'Calcium therapy, intravenous, dauRor of 
(W. D. M. Lloyd). 652(0) 

Calculi, urotUral, multiple (C. B. Pnsloy), 443— 
IR. R. Wheeler), 445 

Calculus in male bladder duo to a forciRn body 
IE. Scott), 216 

Calculns, renal, late results of operation for 
(J.F, Dobson), 486(0) 

Calculus, ureteral, larRo (John C .Tcllorson), 14 
CAiiDEn, J. A,: Xilfo assurance In the tropics, 219 
Caemette, Professor, ©looted a member of t)io 
Academic dos Sciences, 29— The bacillus 
Calmctte-Gu^rin (B.O.G.), 2^— His statistical 
Btndy of B.O.G. vaccination (M. Oroenwood), 
795 (0) 

Calves used for vaccine huiipb (parliamentary 
note). 532 ,1096; 

Camero.s. a. T. : A Texlhonl: of BiochemiBtrv, 
805 

Ca^ierok, Charles : Report on the East Fortune 
Sanatorium, 728— The typo of tuborculouB 
lesions In bones and joints, 731 
Casieron, J. A. M.: Dysphagia associated with 
anaemia, 521 

Cameron prize. See Prize 
Cameron, Samuel J.: Treatment of cancer by 
radinm, 286 

CAsrPDELii, Andrew (Andrew Watt and R. C..T. 
Meter) : Operation for pituitarj’ tumour, 747 
(O) 

CA^CPDEiJi, John Archibald, ohitnary notice of, 
695 

CAiirnELL. Colonel Sir Robert Nell, obituary 
notice of, 474 

•CampbelIj, Walter R.j Intravenous glucose in 
diabetic coma, 197 

CAifPDELTi. W, S,: Value of marine health 
resorts, 450 

Canada: 

British Columbia, 5S9 
Chiropractors in Oaobcc. 516 
Collip, Professor L B., 569 
Government tmvolling clinics in Alberta, 516 
Hospital campaign in Montreal, 369 
Macallum. Professor A. B., 516 
Maternal mortality in (Helen UacMurcliy), 604 
Medical examination of intending settlors in 
(parliamentary note), 423. 881. 1095 
Karcotics. the law regarding, 369 
"National Dairy Council's report, 854 
Scholarships for tuberculosis workers. 369 
Sterilization of the feeble minded in Alberta. 

680, 825, 878 
Tours in, 650 


Cancer, anaemia in, 721 
Cancer of the breast, familial, 164 
Cancer of the breast, radium treatment of 
(Duncan C. h. Fitzwilliams).451 
Cancer campaign in Northern Ireland, 72— Meet- 
mg at LimericU. 235— In tlio North-West of 
England. 465 

Cancer campaign, British Empire: Quarterly 
meeting of tbo Grand Couno I, 80, 693— Inter- 
national Convention. 640. 815. 1076 
Cancer cases, records of, 117, 554 
C^cer of the cervix, cystoscopy in (A. A. 
Qemmell), 667 

Cancer of the cervix: exhibition of specimens, 
57 • 

Cancer of tjie^cervix. treatment of (Herbert B, 
* . * by irradiation 


•Can(^r, chimney-sweep’s, first case of reporte 
m Scandinavia, 81 

(Sir George licnthal Cheatle 
S^Early diagnosis of (Sir William de Courc 
Wheeler), 846 

Cancer conference. See Cancer campaign 

cancer, death of a radi-jgrapher from (parlii 
mentary note), 1131 

Cancer, etiology of, a request to general pract 
tioners. 1043 

C^cer of the larynx, intrinsic, operated upo 
fni ‘-^/y»fo*fiBsure (Sir BtClair Thomson). 7^ 
(O), 983— Leading article. 7S4 

*CMC8r, lead [colloidal] treatment of (Stanle 

primary ( Or. Lait), 1026 
iriEo4^93?'<Sr’^' treatment . 

injections in treatmei 

Cancer, radium treatment of. 75. 159, 197, 286 

Ministry of Heall 
11??° A ^^^~J:^a-ly8is of results of operation 
^^^Early diagnosis of (S 
■'^heeler), 846-Leadii 

of (B- ' 

Cancer research in Manchester, 282— In Birmin 
Sweden, 617— By medical wom( 
Chadburn). 611 — Expenditure on (parli 
caentary note), 926 


Cancor, reviow of hooks on, 16, 453 
Cancer. Bkolotal motastaBCd in (P. J. Henry), 899 
Caucor of tonguo, radinm treatment of (Duncan 
C. L. FItzwiUiams). 451 

Cancor, troatmont of, fusion of hospitals 
(Ireland). 29 

Cancor of uterus: Mfnistn' of Health’s memo- 
randum on. 24— Report on. 69 
Cancor of utorue following operation (W.Gough), 
498 

Cancor of utorus. an occasional symptom of 
(Milea rhllUpa), 498 

Candler, A. L.t Tuberculosis of tbo skin and 
tondon shoathR, 263— Surgical troatmont of 
chronic gastric ulcer, 451— Stroptocoocal cellu- 
litis. 9^46 

Cann, R. j, : Diphtheria carriers, 181 
Cannon, Alexander: Tbo cause and treatment'of 
the crlBis in lobar pneumonia, 661 (0 ) ‘ 
Cannon, D. J. : Congonitat pyloric stonosls, 946 
CANTAcozi'.SE, J.: The prosont position of pro- 
immunization with B.C.G., 1077 
CANim, George: Deaths from local anaesthesia, 
81 

Capillary circulation and glaucoma, 1127. See 
nlAO Glaucoma 
Carcinoma. See Caucor 
Card hinge, the transparent, 832 
Cardia. achalasia of, 692.773. .Srcnlio Achalasia 
Cardiac diagnosis, difflcuUtes in (John Parkin- 
son), 347 

Cardiac dlsoaeo, the mental state in (Carey 

tCf, 

I * os of, one followed by 

.* • * the other by rupture 

(T. Wishart Davidson). 212 (O) 


•* iical 
• on 


Carlos, spinal, conservative treatment of (Bit 
IVilliatu de Courcy Wheeler). 55 
Cahlill, Hildrcd: An egg-cup in the rectum, 
120 

Oarltng. E. L. : Clinical opportunity for mid- 
wifery, 693 

Carlsbad, post graduate courses at, 381 
Caronma, Qmsoppe, appointed to the chair of 
infectious discae- » 

Carrier problem < 

Discussion, 180. ** 

Davidlno Puliinf 
and Fever, enteric 

Carroll, John Donal, obituary notice of. 826 
Carr-Saunders. a M. (and D. Caradog Jones); 
A Survey of the Social Structure of Englancl 
and Wales as illustrated by Statistics, rev., 
598— Pre/easfons : their Organisation arid 
Place t'n SoctXv. 951 

CAnuuTUERB.VincentTheodore, obituary notice 
of, 1092 

Carson, Herbert W.: Chronic appendicitis in 
children. 319 

Carson, Joseph Thompson, obltuan' notice 
of, 1035 

Carswell, Jobn: Morison Lectures on psycho- 
logy and medicine, 872 

Carswe.ll, Robert: Appreciation of Alexander 
Dlackball-Morison. 79— Coltoctivo investiga- 
tion and tuberculin. 375. 523— 'Tho ’’cure” of 
pulmonary tuberculosis, 692. 875 
Car^'ER. Alfred: Etiology of alcoholism, 596— 
Causes of alcoholic inobrioty, 774 
Carbidy, L. L. : Vesico vaginal fistulae, 308 
Oastellani, Aldo, Grand Cross of the Order of 
Civil Merit (Spain) conferred on, 81— Honorary 
K.C.M.Q. conferred on. 120— Mycoses, 958 
Cabtiolioni, Arturo: Sfonta della mediciiia, 
rev,, 266 

Casual wards at Tbaiuo (parliamentary note). 
1006 

Casuals, small-pox among, 154. 609. 644 — 
Detained for medical examination (parlia- 
mentary note). 428— Bede for in unions (parlia- 
mentary note), 474— Fitness for labour of 
\ *■'’ y’ inspection 


Catarrh, nasopharyngeal, chronic, treatmer 
for, 930 

Cathcart, Charles W. : Portable low-pressux 
sterilizer, 18 

Cawadias, a. P. : Chronic appendicitis i 
children, 349— Treatment of rheumatism, 858 
Cawston. F. G.: Mosquito breeding and poo 
proof guttering. 38, 354 -Mixed schistosom 
infection. 1093 

Cellan-Joneb. Katherine (and C. J. Oellai 
Jones); Syringe for injecting varicose veim 
763 

CelUilitis, streptococcal (Wayland Smith), 945 
Cemeteries in England and Wales, 273 
Census of the Union of Soviet Republics, 831 
Cerebral hemispheres, physiology of the (I. ] 
Pavlov), 809 

Cerebro-apinal fiuid, estimation of glucose i 
(Francis Temple Grey), 215 (O) 

Certified persons, procedure regarding dischan 
of (parliamentarj' note). 829 
Chadburn, Maud; Cancer research by medic 
women, 641 

Chadwick Lecture. See Lecture 
C^LAM, B. S. (and J. A.Crawtord):— afosqut 
it^auefton and Malarial Prevention : a Prici 
second edition, rev., 1029 


Challis, H, T.. promoted a Commander of tho 
Order of the Hospital of St. John of Jernsalem. 
1153 

CnALiTERS, R. : Etiology of tho common cold 
244— Pneumonia after operation for gastric and 
duodenal ulcers, 1134 

Chambers, E. R. : iretastatfe ophthalmia, 546 
Chasoierb, Guy: Solitary ulcer of tho bladder 
1019 (O) 

Champneyb, Sir Francis; Appreciation of Sir 
Dyce Duckworth, 161— The protection of 
maternity, 463 

CuAirPY, Dr., nominated professor of histology 
in the Paris Faculty of Medicine, 163 
Chance, Arthur: Bone complications in typhoid 
fever, 56 

Chance’s filter for ultra-violet rays, 682 
Chandler, F. G.: Importance of sputum ex- 
amination in pulmonari’ tuberculosis, 469— 
Early detection of tubercle bacilli, 731 
Chaplin, Arnold: Appreciation of Bir Dawson 
WiJliftms, 421 

Chapman, R. B.: An unusual type of vicarious 
menstruation, 1965 

Character formation, the effect of illness on 
(David Forsyth), 62 
Character, review of book on, 138 
Charcot’s arthropathy. See Arthropathy 
Charities Pegister anti Digest, Anmial,Tev., 806 
Charles, Bir Richard Havelock; Baronetcy con- 
ferred on. 23— Appointed Honorary Berjeant- 
Surgeon to the King, 460 

Charsley. Gilbert W. (and George Richardson) : 

Case of volvulus neonatorum, 494 
Chaudhri, Rai Bahadur Dr. Kishori Lai, O.B.E. 
conferred on, 988 

Chaddhubi, S. K.; Chloroform poisoning by- 
ingestion, 82— Lobar pneumonia with diph- 
theria and malaria, 292 

Chauepard, Professor : Eulogy of William 
Harvey, 868 

Chatasse, Bernard: Pathogenesis of acute 
primoTi' 

Cheal, P.: • . Formosa, 151 

Cheatle, . ' Jarcinoma of 

the colon. 58— Pathology of mammary con- 
nective tissues, 559— Appreciation of Hugh 
James Moore Playfair, 613 
Chemistry, review of books on. 902 
Chesser. Elizabeth Sloan: Infant welfare in 
India, 1082 

• f^rology and 

. . i 

* ■ * ■. ' ' the cervix 

5 

’ . . ' jondon, 957 

I . . 28 

Child, the over-sensitive (B. Crichton), 229— 
Discussion, 220 

Obildbirlh mortality. See Mortality', maternal 
Child welfare. See Maternity and child welfare 
Children boarded out by the West Ham 
Guardians parliamentary note), 381 
Children, defective, tho teaching of, 62— Educa- 
tion of, 822- See also Mentally defective 
Children’s diseases, review of books on, 15, 454, 
805. See also Pediatrics 
China: Pekin Medical Guide, 741 
CriiRAT, M. (I. Patel and A. Lomon) : La visicule 
hiliaire. rev., 265 
Chiropodists’ conference, 1125 
Chiropractors in Quebec, 516 
Chisholm, Catherine: Medical co-education, 9S9 
Chisholm, J. D. (and Arnold Benshaw) : Tetanus 
in a hoy, recoverj’, 175 (O) 

Chloride, neutral, gastric secretion of, 325. 374, 
411, 469, 521, 7^9, 1128 

Chloroform for convulsions (report of an 
inqaest', 118 

Chloroform, intratracheal inhalation and in- 
Bufflation of by means of a flexible metal 
catheter ( W. Dakin Mart), 942 (O) 

Chloroform poisoning by ingestion, 82 
Chloroma in a child (J. B. Y. Rogers), 222 
Cholecystography by the oral method without 
the USB of capsules (Hugh Morris). 305 (O) 
Cholecystography, the process of (G. Dyas), 1066 
Cholera bacteriophages (F. d’Herelle and Major 
R. H. MaloDQ), 365 

Cholera bilivaccin (Colonel A. J. H. Bussell), 274 
Cholera in India (Sir Leonard Rogers), 1053 
Cholera and Iraq dates (parliamentary note), 428 
Cholera in the Punjab, 568 
Chorion-epithelioma (Maslen Jones), 181 
Chorionic epithelium, malignant functions of 
the(W. Blair Bell), 803 

Christiansen, Viggo ; Sixtieth birthday of, 291 — 
Special number of the Acta psychiatrica et 
neurologica dedicated to.29l 
Christie, Harrj’ D. : Foreign body in the 
bladder, 307 

Christopherson, Dr. : Life assurance in the 
tropics, 219 

Church, Sir William Selby, obituary notice of. 
778 

Cigarettes, Rhodesian, 1003 
Cigarettes and suckling. 956 
Circulation, coronary’, 404 
Circulatory disorders, review of books on, 266 
Circulatory disturbances, diathermy in relation 
to. discussion at tho Royal Society of Medicine, 

I 134 

Cirrhosis, portal (V, M. Synge). ^ 

Citobaryum, 949 

I OiiAOufi, Charles — Oreille rnfemc; Etude 
Anatomo-vatholootque et Clinique. Technique 
mtcroscopique et experimentale, rev., 184 



8 JAN.-JONE, 1928] 


INDEX, 


r Tiir JlnmwH 
1. UKcicii. Jouhmal 


Clare Board of Health: DispeuBavy <3o3tor8 and j 
midwives, 1085 1 

Clark, ti. H. (Bidney I^ss and B. D. H. Wattors): i 
Physics 

Clarke : 604 

Clarke, I 595 

Clarke, B. R.r Prognostic significanco of large 
nnmbers of tubercle bacilli in pus, 788 
Clarke, Ernest; The election to the Council of ' 
the Royal College of Surgeons, 753 
Clarke, J. Tortius ; Rheumatic infection in the 
3 ’oung, 350 

Clarke, T, A. : Pulmonary and gastro-intestinal 
sequels of naso-oral sepsis, 98 I 

Clavicle, fracture of, treated ^vith displacement 

- (G. W. Milroy), 664 (O)-(H. Earle Conwell). 723 
— (H. H. Greenwood), 1021 (0) — Correspondence 
on. 878 

Clayton, 'Williara: The Theoi'y of Emulsions 
and their Technical Treatnitnt^Becond edition, 
rev., 224 

Clegg, J, Gray: Ophthalmology and ge'eral 
medicine, 56 — Fine work and eyestrain, 1119 
Cleland. J. B. : DiCQcult labour in an aboriginal, 
219 

Clero : Cardiac malformations and endo* 

- carditis, 953 

Clerical abortion-monger (Rev. Francis Bacon), 
329 

Climate and epidemic disease (Sir Leonard 
Rogers), 848 

Clinical teaching in Edinburgh. See Scotland 
Clinical teaching in medicine. See Medicine 
Clow, A. E. Sanderson; Medical co-education, 
999 

Club, United Hospitals, of Bt. Thomas’s and 
Guy’s; Centenary dinner. 320 1 

Club, Wolverbamp’on and District Clinical : 1 
First general meeting, SSl—Clinical demon- 
strations, 761— The process of cb-'lecysto- 
graphy, lOS^Renal tuberculosis, lC66-The 
uses of the ophtba'moscope, 1C66 
Coal dust causing chest diseases among surface 
workers at collieries (parliamentary note), 
1131 

Coal mines, accidents in (parliamentary note), 
830 

Coal-mining districts, heath conditions in 
(parliamentary note), 579— Distress in, 579 
Coal-mining industry bill, 5S9 
Coates, Vincent: Treatment of rheumatism, 
858 

Corbett, Louis : The tyne of tubei'cle baci’lua 
commonly present in tubercalous bones and 
joints, 626 (0) 

Cocaine in carter oil with mercuric chloride for 
eye injuries on steam fishing vessels. 119 
Cocaine manufactuiein England (parliamentary 
note), 1006 

Cc ■ • * . . Hagnosis of from 

. ■ 715 

Cc , ' , osu in Europe, the 

Middle and Near East, and Africa, 1071 
Cock, Surgeon Commander Frederick : A method 
of making a blood film, 306 (0), 480 
Cock, F. William: The Harvey Chapel at 
Hempstead, 922 

Cock, Reginald: Polydactylism and reversion, 
413 

Cockayne, R. A. : Familial hypertrophic pyloric 
stenosis, 563 

Cod-liver oil, possible dangers of (E. Agdubr), 
639 , , . 

Cohen, Dr.: Bargical treatment of chronic 
gastric ulcer, 451 
Cohen. H.: Narcolersj’, 447 
Cohen, Jacob Solis, obituary notice of. 79 
Coincidence, a, 534 

Coke, Frank; Peptone treatmint of asthma, 
468 

Cold, common, gift to Johns Hopkins University 
and Hospital for investigation into the pre- 
vention and jiossjble cure of, 119 
Cold, common, etiology of the, 244 
Cole, Estelle : A disclaimer. 38 
CoLEBROOK. Leonard : A Study of Some Orpanic 
Arsenical Compounds loith a Vteiv to tJieir Use 
in Certain Stfeptoroccal Infections, 567 
Coleman, Frank : The pnlp’ess tooth, 548 
Coleman, Robert B. : Vesical bilharzia, double 
infection, 177 

Coleridge, Stephen : Experiments on'animals, 
1119 

Collapse and shock, £4. See also Shock 
Collective research. See Research 
CoLLEDGE. D'onel (and SirChar'es Pat.lance); 
Anastomosis I etwpcn the recurrent larj-ngeal 
and phrenic nerves, 746 (O) — Election to the 
Council of Ihe Rojal College of .-urgeons, 
775 

College, Anderson, of Medicine, Glasgow, last 
meeting of session. 517 

r " 1120 

i , day, 1C96 

■■ ec'td Con- 

College, Prince of Wales Medical, Patna: Report, 
569 

College, Royal, of Physicians of Edinburgh: 
Elec'ions of Fellows and Membo*"®, 289. 830 
— Election of representativo.s 830— Fellows 
admitted. 289 85 — ^ister Fellowcb'p, 830— 
Quarterlr meeting, 830 

College. Royal, of Physician'? of Ireland: 
Degrees and pass lists 241. 697— Licentiates. 
241.697-Members.241,6 7 


College, Royal, or Phybicians or London : 
Appointments. 200 
Comitia, 199, 649»7£6 
Degrees and iiass lists, 199. 649. 786 
De 5Iotn Cordis, tercentenary of the publica- 
tion of, 27.0 
Diplomas, 199. 643 
Exhibition at. 870 
Fellowship, 786 
Harvey film, 870 
Honorary Fellows, 866 
Licences. 199, 786 

Licentiato no longer (Vernon Joseph do 
Boissiere), 649 
Membership. 199, 7 6 
President re-elected. 619 
President's address, 649 
Reports, 200 
Resignations. 649 

College, Royal, of Surgeons of Edinburgh: 
Baihgate memorial prize, 928— Degrees and 
pass lists, 928 

College. Royal, of Buroeovs or England: 
Cancer Convention. International, 289 
Central Midwives Hoard, 472 
Council election. 289. 413, 529. 691. 733. 775 
Council meeting. 118, 289. 472. 695 882. 3093 
Court of Examiners, 472 
Degrees and pass lists, 118,289. 472, 882, 1093 
Diplomas, 118.289.472,882 


Hunter (John) bicentenary, 119 
Hunter medal, 696, 882 
Hunterian festival dinner. 277 
Hunterian Oration. 245, 277 
Jacksonian prize, 6-6 
Lecture arrangements, 79, 289 
Licences, 472 
Membership, 882, 1C93 

Museum demonstrations, 413 — Report of Con- 
sei vator, 1121 
• Presentations, 119 

Primary Fellowship examination in Canada, 
289. 696 

Regulations. 697 
Surgical portrait group. 1134 

College, Royal, of Burgeons in Ireland: Appoint- 
ments, 160— Charter Day dinner, 956— Degrees 
a^nd pass lists, 928— Election of ofiicers, 998— 

. ; ‘ for rebuilding 

College of Burgeons. American : Replica of the 
Lister collection at the Wellcome Historical 
Medical Museum presented to. 81 
College, Trinity. Dublin : Degrees and pass lists, 
IW, 539, 580, 830. See also University of Dublin 
College, University, London : Centenary 
Addresses Bound Tooether in One Volume, 
rev., 59 — Primary Pellowsbin Conrse.®, 289— 
Lectures, 740. 830— Bncknill Scholarship. 965 
College, University, of South Wales and Mon- 
mouthshire: Appointments, 34 
College. W'omen’B Medical. PeDn«ylVQDia, to 
endow a chair of surgery in honour of W. W. 
Keen. 203 

Collier. James* Ocular complications of en- 
ceplialitis lethargica. 261— Lumleian Lectures 
on epilepsj', 557 

Collier, William Tregonwell (and Alexander 
George Gibson): The Methods of Clinical 
Eiaonosis, rev., &19 

Collin, E. : Radium treatment in Denmark, 
358 

Collins, E. G. : Ruptured ectopic gestation 
occurring on both sides. 134 
CoLLiF. J. B., appointed to the chair of bio- 
chemistry at McGill University, 369 
Colloidal lead. See Lend 
Colon, review of books on, 356 
Colon, segmental resection of the (Dr. de 
Martel), 459 

Colonial medica' staffs, strength of (parlia- 
mentary note’, 479 
Colonies, health of the, 1118 
Colour blindness, review of book on, 985 
Colqdhodn, W. ; Vitaglass, 884 
Colt. G. H.: Pseudo-pancreatic cyst, renal cyst, 
or haematoma ? 597 
Commonplace books. Books. 

Compositors, rules for, 460. See also Typo- 
graphical usage 

Conception, control of, 515. See also Birth 
control 

Co\DY, Robert : School medical services 
Hreland), 1126 

Congestion, venous, review of book on, 670 
Congress aramst Alcoholism, iDternational. 
Antwerp fl928». 699 

Congress of American Physicians and Surgeons, 
767 

Congre'^s. Anstralasian Medical. Transactions, 
rev.. 763 

Congress of Cbil'^hood Protection, luternational, 
Paris 11928’. 203 

Congress, Czecbos'ovak Meiical* Prucliiioners, 
Naturalists, and Engineers, Prague (39^81. 6'9 
Congress, Dairy, the World’s. London (1928). 965 
Congress of Dermatology and Syphilology, Inter- 
national, Copenhagen (19301,617,929 
Congress, Dutch, of Natural Science and Medi- 
cine, Rotterdam (1528), 203 


Congress of tho Far EaRtorn ARsociaiion of 
Tropical Medicine, 69— I’rcsldent'n address, 70 
— Work of tho soctiouH, 70— tlialth refienrch In 
India, 70— Congress excursions. 70— Dii-eaRes 
of faulty nutrition, 92— Co ordination in com- 
bating malaria. 429 

Congress of Iho French League against Vtncrcal 
Poril, Nancy (1928), 929 

Conflrcsa of Fronch-speal.ing Alienists and 
Neurologists, Antwerp (1923). 650 
Congress of tlio Frencli-epeaking Association of 
tho .Medical Profession of North America, 
Quebec (1928), 693 

Congress of the French Society of Ophthalmo- 
logy. Paris (19.8), 429 

Congress of tlio French Societies of Oto-i euro- 
ophthalmology, Marseilles (1923). 4.9 
Congress, Gorman Balneological, Buden (1928), 
333 

Congress of tho Gorman Socletv for Hepenrehes 
on tho Circulation. Cologne (1928), 333. G£0 
Congress of the Gorman Pathological Society, 
Wiesbaden (1928), 429 

Congress of tho Gorman Society of Pfijehiatry^ 
Kissengen (19?8). 429 

Congress of tho Gorman Rdntgen Society. Berlin 
11923). 429 

Congress of the German Society of Internal 
Medicino, Wiesbaden (1928), 12J. 4 9 
Congress of tho German Society for ComiMiting 
Quackery, 81 

Congress of the Incorporated Association of 
Hospital Odeers. 928 
Congress. Indian Bcenco il928\ 203 
Congress for Industrial Accidents nnd Occu- 
pational Disease'?, International Medical, 
Budapest >1928), 203, 2i2 

Congress. Industrial Safety, London (1923), 1077 
—Accident services in industry. 1077 
Congress of tho Italian Society of Medical 
Radiology. Florence (1928), 479 
Congress, Journ^esM^dlcales Beiges (April, 1928), 
163 

Congress. Journdcs M^dicales de Bruxelles 
(April, 1928), 429— Report of meeting cf June, 
1927. in the BruxelUs^Mhlieal, 617 
Congress, Jonm^es M^dicales de Paris (1919). 81 
Congress on Light, International, Lausanne and 
Leysin (1928). 699 
CongreRS fo“ 

Internatioi 
Congress for 
Paris (1923), 242 


Congress of Neurology, International. Paris 
(1928), 787 

Congress of Open-air Schools. Paris (1928), 883 
C( » z'. - ' - torDHiional, 

C( . ‘ . 460, 1121 

Congress of Photography. InternatioDnl, London 
(1928). 617 

Congress of Psychology (Applied). Paris (1928),. 
883 

Congress of Public Health, Dublin (1928), 113 
Congress of Radiology, Internailonal, Stockholm 
(1928). 242 

Congress of Radiology, Italian, Florence (1928), 
831 

Congress on Respiratory Tract Diseases. 

Clermont-Ferrand (1928), 787 
Congress of the Royal Sanitai y Institute, 473 609- 
Congress of Stomatology, Polish, Cracow (1928)^ 
650 

Congress of Thalassotherapy, International, 
Bucarest and Constantza (1928), 163. 429. 581, 
787 

Congress of Tropical Medicine, International, 
Cairo (1928). 291 

Congress for Combating Tuberculosis. Inter- 
national, Rome (192^), 883 
Congress of Urology, Hispano-Portuguese, 
Madrid (1928), 381 

Congresses of Ophthalmology, International, to 
be resumed, 533 

Conjoint scheme in Ireland: Pass lists and 
degrees, 928 

Conjoint Board in Scotland: Pass lists and 
degrees, 160, 7-10 

Conn, Harold J. ; An Elementary Lah'ratory 
Guide in General Bacteriology, rev., 670 

:h In'uraT’ce 
Insurance 

Consumplion. See Tuberculosis 
Convulsions, chloroform for (report of an 
inquest), 118 

Conwell, H. Earle:— Fracture'; of the clavicle: 

a simple fixation dressing. 723 
Cook, Captain James, R.N. (R. T. Williamson), 
243 

Cook. James : The preventive frame of mind in 
midwifery, 117 

Cook, Lieut.-Col. Lewis, C.I.E. confeired on, 
988 

Cooke, W B. (and Eric Pondeu): The Poly- 
nuclear Count, rev., 139 

Coo.MB*-. Russell; Appreciation of Wi’liam 
Britain Morton, 201 

Coombs: Disease of the pulmonary artery. 604 
Coombs. Carey: The mental state in cnrdiac 
disease. 352 — The bact-rial origin of ilieuni- 
atism, 855— Heart attacks, 1009 (O) 



JAN.-JUNK, igjS] 


INDEX. 


[ TncPRmtn 

MeDICAI. JODRNAD 


CoorF.ii, G. O.: Unusual pigmentation of scalp, 
852 

Coornu.J. W, Aslloy: The enusos of alcoliolic 
iuobriotv, 876 

Corn, V. Zaclmry: Cnn’ont views of sliock nml 
collapse, 51— r/ivor diet in pernicious anaemia, 
lid ^The irlv of thf Actiie Ahih)ute7i, 

fourth oclitlon, rov., 223; fifth odltlou, 1069— 
The Trentmeut tf the Acute Ahdoineu, rev,, 
223; second eilitlou, 1059— OfimVnl lic^eurches 
tn JcHfe AhiJoviiual Dineitse, second edition, 
rev., 223-UUva-violot radiation therapy, 261— 
Tho carrier problem, 416 
CoPF.M’AN. Dr.: Rbouniatio infection in tho 
young. 350 

Corr.M w. S. ^^oncl;ton : Diphtheria carriers. 180 
— Immuoinatlon against diphtboria, scarlet 
fever, and measles. 833 (O) 

CopLAN’S. Mvor: Totra-cthyl load, 74— Kvidouco 
on tetra-ethyl lead before the Coinmltlco of 
Inouiry, 871— Tctra-othyl lead in motor spirit, 
1001 

CorPl-Kso.v. Victor M. (editor) : Cliuicul Ilnul’ 
hoohjor ItesUleutf, 2v'i<rsrs, aiul Sfmieuts, rov., 
1115 

Cork clip, a captive, 455 
COBNKLt., Beaumont S.; Prnitcfcws 
rev., 1113 

ConNUB, Matthew Cureham, obituary notice of. 

m 

Cornwall, health conditions in tho tin mines 
(parliamentary note), 697 
Coronary circulation. See Circulation 
Coroner again. 1078 

Coroner’s discretion (rcinarka by Dr. Whitc- 
bousok 864, 1078 

Coroners’ inquests In London In 1927, 612 
Coroner's jury. See Jury 
Corrections, 38, 161, 214, 287, 618, 879, 930 

Corrospondcnce : 

Abdomen, acute. 284, 325, 377, 411. 470 
Abdominal pain ns exvinplillcd in acute 
Appondiciifs, loss 
Abortion and sepsis, 1C49 
Achalasia of tho cardia (so-called cardio- 
spasm), 690. 773 

771, 875 



Australia, tropical, 30, 772, 875 
Barbados, infection of with ninlnrla, Il4. 157 
Birth rate, etTect of on the average ago at 
death, 644 , 775 

Blood group percentages, 732 

British doctors in Uaclolra, 571 

British spas, 878 

Caesarean section, abuse of, 30 

Cancer cases, records of. 117 

Cancer, etiology of. 1049 

Cancer treated by radinm, 75. 159, 197, 285 

Cardiospasm. See Achala-sla 

Cataract an '’ n nc 

Clinical tea 

Collective 37<; 

469, 522 

Cyclical vomiting and appendicitis, 823 
Cyst of ovary, large, 32 
nefaecation. physiology of, 77, 199 
piscusflions, oreanization of, 877 
■ Drunk in charge,” 774 

Dysphagia associated with anaemia, 375, 457, 
521, 610 

Edinburgh Corporation Hill, 376 
Ergosterol, radiated, as a dressing-for wounds. 
642 

Ergosterol. vitamin D. and rickets, 73. 237, 
See also Kickets 

Ergot, chemistry and pharmacology of, 410 
Er'iot ixiisoniog among rye bread consumers. 


stomach. 198. 239 
Fracture problem, 730 

^^^®tures ot tbo clavicle with displacemex 
878 

Qjj^Jl 

Gas 74 

• Gasi ' 

Gastric and duodenal ulceration, treatme 
oi. 683, 729 

secretion ot neutral chloride, 325. 3' 
til. 469. 521, 729, 1123 

General .Medical Council, direef represenl 
tionon,999 

Gland grafting and inheritance. 570, 610 690 
'*1000°10m'’°'**° Plimary.nathoKoneBis'of.S: 
Glaucotna find capillary circulation, 1127 

intravoiiously in diabetic coma. 197 
‘0 tho treatment of. 92 
‘ ‘I'l'-icg insulin admlnistratic 

I 

1 

B ealiu and choice of a cai eer 524 
Heat cramp, 609 ' 

^1089 ky immunily, 875. 9 

Historical exhibition nt Cardiff, 520 


CorrospondoncQ (conftnurd): 

)f, 325, 571, 613 
• )tty, 328 

Indigo-carmiuo, inlravonouB InjecUon of, 921, 
1002 

InfoctiouB disease in schools, 878 

Iodine in tho treatment and prevention of 
goitre. 938, 286 

Ischaemic contracture, tho origin of, 921. ICOI, 
1C46 

Litholapasy, a plea forlho operation of. 1089, 
1128 

Malignant dtscaRO treated by colloidal load, 
958. 999. 1017, 1037. See alsa Cancer in General 
Index 

Jfatornal mortality, investigation of, 775 

Maternity, protection of, 572 

Jloaales, isolation for, 35. 75, 114, 156 


Medical examination for life assuranco, 378,411 
Medical freedom, 961 

Medical officers of heaUh, superannuation 
of, 612. 775 

Medical registration in New Zealand, 77, 159. 
1016 

Med ical responsibility for lunacy certification , 
921 

Medical women, salaries of. 512 

• * C.921 

• • 775, 1019 


* . . ' ' liud in, 

117 

Midwifery mortality, 1126 

Midwives and ante-natal work, 463, 520, 571, 612 

Miners' nystagmus. 520 

Morphiniem. a treatment for, 34 

Mother, tho expectant. 571, 689. 733 

Mycoses, 953 

Nophro ureteral anastomosis afttr complete 
avulsion of tho ureter. 3091 
Obstetrics, future of, 284. 32S. 412, 1086 
Occlusion of tho central retinal artery, 285 
Orgunization of dtscuBsions. See Discussions 
Ovarian cyst. See t .yst 
Oxygon, thornpoulic uses of, 774 
Pancreatic preparations in dlab tes, oral 
admlnif tratioD of, 875, 1050 
Peptone treatment of asthma, 328. 411. 463 
Fhnryngo oesophageal sphincter, 879. 922.959 
Physical trentment in London, clinic for. 33 
Pneumonia, acute, treatment of, 159, 238 285. 
376. 512.613. 689 

Poisoning by volatile lead salts, 114 
Volydactylism and reversion, 413 
Post graduate work in Vienna, 77 
Prccnancy. duration of, 75 
Professional (.-xuininations. condilionn of, 76 
ProsUtIc enlargement, treatment of, 31,74,116, 
691.732.958 

Puerperal sepsis. 10S7. 1127 
Quiniiio in obstetric practice, 157, 218 
lUieuuiatio luyocarditis, car.y, 193 
Rheumatoid arthritis, minimal rises of tem- 
perature in. 610 

Uicl;ets, Irradiated ergosterol. and ultra-violet 
light. 78. 237, See also Ergosterol 
Ro>al College of Surgeons, election to the 
council of, 691, 733. 775 

Salaries of medical women. See Medical 
women 

Rca-eicKnc88, 877, 959. 1C89 
Shock and abortion. 2 9. 327. 375, 471, 524 
Shock in black races, 524 
Small-pox and ” casuals.” 644 
Small-pox in the vaccinated and unvaccinat^d, 
fatality rates of. 74. 1 5, 156. 297, 237, 285 
Sociological formula, 413 
Specia'ist public health services, 317, 376 
Sputum examiontiOD in pulmonary diaguosis, 
importance of, 469. 572 
Sterilization of the feeble-minded, 878 
Streptococci and puerperal sepsis, W2, 750. 879 
Suggestion, theories of, 158 
Tavistock Clinic : a correctioD. 287 
Teotb. dead and infected, 731, 823, 876. 959 


Thomson, John, 156 

Tbrombo-phlebitis migrans, 690, 824, 960 
TonsiLsiiction for diagnosis and treatment. 
1018 

Tubevclo bacilli, early detection of, 731 
Tuberculin, efficacy of, 611, 731. 824 
Tuberculosis, early signs of. 31 
Tuberculosis mortality, causes iu tbo decline 
of, 922 ‘ 

Tuberculosis notification, delayed. 692, 775 
Tuberculosis, pulmonarj', the “cine” of 611 
632. 773. 875. 9C0 

Tubercnlosis, pulmonary, diagnosis and treat- 
ment, 5?3 

Tubernalous lesions in bones and joints, type 
TyndfiB v Alcork. 961 


Cosus, 4Jl 

Underfeeding and overfeeding in infancy. 34 


Correspondence 'continued): 

Uterus, draining tho septic, 117, 193 
Vaccination of the newborn against tuber- 
culosis, preventive, 523 

Valvular disease in children, unsnspected, 287 
Yaricoce veins, Injections for, 33,117,157,412, 
522. 644. 960. 1090 

' ' ■' npti\e. 76 


X ravs in the diagnosis of chronic appendicitis, 
76, 468 

Corrigenda. See Corrections 
COBSON, James Fredeiick, M.B.E. confeiTed 
on, 938 

Coryza, ijaroxysmal, 650, 703 
CoTTB, Gaston: Les Ttoubles FtniciiriuneJs dc 
I’Ajypareil Gdnital de la Femme, rev.. 900 
CoTioN. T. F. ; Diathermy in relation to circula- 
tory disturbances, 134 

Cotton cloth factories, artificial humidity in, 765 
Cotton weavers’ health and humidity. 65 
Council, General Ue-lical: Direct representation 
on the, 999— Income tax, case of, 604— fo 
Z[inut*e, rev , 357 — Minutes, rev., 357 — Session, 
May 11928), 953 

Council. Lonpon County: 

Artificial light treatment, 466 

' ' 676 


Medical officers of tho. 821 
Mental hospitals, women medical officers at, 
236 

“Rhenmatic” children, supervisoiy centres 
for, 373 

Ringworm infection in school children, types 
of. 195 

Tempoiary school medical staff’s remunera- 
tion. 325 

'luborcuh us persons, employment of. 1S6 
Tubercnlnsis schemes, wnrkiog of, 4C9 
Vaccination, compnlsory. 874 
Venereal diseases treatment scheme, 519 

Court etiquette as a cause of madness, 82 
CouBTAULD, S. A. : Gift to Middlesex Hospital 
for an Institute of Biochemistry. 1044, I0S3, 
1099 

CovA. Felix : ^ffns Thoracoseopicon, rev., 719 
Cowan. Alfred: Introductory Course fn 

Ophthalmic Oi tics, rev., 1114 
Cowan. George A. : Dead and infected teeth. 875 
Cowdray. B V. (and J. Bront? GAT]:NBr, 
editors): Bolles Lee's Mir.rotomisVs Vade- 
Menim, ninth edition, lev.. 672 
CowHLL. B. M : Current views of shock and 
collapse, 54— Hcniia oiid SetnioplastVt rev., 
266 

Cox, Alfred t Appreciation of Sir Dawson 
Williams, 423 — .Appreciation of ^Yi^iam 
Muir Biuith, 614 — Appreciation of James 
Alexander Macdonald, 784 
Cox, G. Lissant: SpecialUt public health 
services, 327— Delayed notification of tuber- 
culosis, 773 

Craig. J. G. : X-ray diagnosis of chronic appen- 
dicitis. 468 

Craio, Bir Maurice: Alcohol in relation to 
business life 4:8— The prevention of nervous 
breakdown, 1116 

Cramp, fireman s, 291. 334, 383, 546, 6 9 
Cramp, heat (Rayner Thrower), 546— Correspon- 
dence on, 609, 616, 1098. See also Houses, 
heating of 

Cramp after sciatica, 430, 480, 534, 930. 1C54 
Cranial incisions (leading article), 317. See also 
Brain 

CRAWTOno, A. Muir : Materia Medicafor Nurses, 
rev., S49 

Crawi'ord, Lieut.-Col. D. G.: Appreciation of 
Bir Dawson Williams, 424 
Crawford. J. A. (and B. S. Chalam) Mosquito 
liediiction and Malarial Prevention : a Piecis, 
second edition, rev., 1023 
CnAWFURD. Raymond: Appreciation of Sir 
David Ferrier. 526 

Cream, prohibition of boric acid in (parlia- 
mentary note), 290— Preservatives in (p%rlia- 
mentriry note). 474, 926— Synthetic iparJia- 
mentary note). 616, 826 

Crkasy, Rolf: Treatment of prostatic enlarge- 
ment, 732 

Cremation Society. See Society 
Crematorium for Edinburgh, proposed, 153. 1124 
Cressy. a. Z. C. : The future of obstetrics. 412 
Chew, F. a. E. (and others): Ueport on J)r. 
Seroe Voroiwif's Experiments on the Improve^ 
ment cf Zitre.^fock, 505— Debate on animal 
experimeut<,518— Orpantc Inheritance in A/on, 
rev.. 718— Appointed to the chair of genetics at 
Edinburgh Univtrsity. 917 
Crew spaces on British merchant vessels 
'parliamentary note), 649 
Crichton. Brian: The sensitive child, 220— 
Narcolepsy, 945— Congenital pyloric stenosis. 
945 

Crichton Royal Institution : Annual report. 464 
Crile, G. W., Hon. LL.D.Glasg. conferred on. . 
1132 

Crime and encephalitis letlmrpica, 390 
Clime, influence of parturition npon (A. Louise 
Mcllioy), 203 (O 



10 JAN.-JUNB, 1928] 


INDEX, 


[ Tax Bamra 

Hxoicu. Joraaix 


Criminal^ Indian hereditary (F. C. Daly), 67 
Criminal poisoninK. See Poisoning 
Criminology, review of books on, 266 
Crippled Children, ScoUish Hospital .for, 873, 
1124 

CritchIiET, Macdonald : Post - encephalitic 
' respiratory disorders, 148 
- Crocket, James, presentation to, 641 
Crofton, "W. M. : The “cure” of pulmonary 
tuberculosis, 611. 773, 960 
Crookshank, F. G. : Diaonosis and Spiritual 
Mealing, rev,, 185— Shock aud abortion, 375 — 
Appreciation of Charles Greene Ciimston, 754 
Croonian Lecture. See Lecture 
Crobbt, Thomas Villiers, obituary notice of, 825 
Crobkery, Sidney Elisabeth: Dysphagia asso- 
ciated with anaemia, 494 
Crossen, Harry Sturgeon: Q^vnaecologv for 
Nurses, rev., 805 

Crothers, Bronson (Frank R. Ford and Tklavian 
C. Putnam): Hirth Injuries of the Central 
Nervous System, rev., 396 — Disorders of the 
Nervous System in Childhood, rev., 1113 
Croton oil, use of in mental insUtutions (parlia- 
mentarj' note), 1095 

Crowden, Guy P.: Measurement of muscular 
work, 62 

Crowe, H. Warren : Bacteriology and Surgery 
of. Chronic Arthritis and Bheumatism with 
Mnd-resvlts of Treatment, rev,, 183— Scope of 
surgers' in chronic arthritis, 348— Minimal 
rises of temperature in rheumatoid arthritis. 
610 — Treatment of rheumatism, 858 
Crowley, R. H.: Health in relation to educa- 
tion, 149 

Crdickshank: The coronary circulation, 404 
CuLLiB, Winifred: Health teaching in schools, 
28 

CuDFiN, Millais:^ Neuroses in the tropics, 419— 

( ■ . ■ I 

its Production and Uses t« Mirdtctnc and 
Surgery, second edition, rev., 454 
CcmaNG, H. Lovett, obituary notice of, 425 
CrrMMiNG, Burgeon-General H. S.: Aftermath 
of the Mississippi flood, 231 
CuMMiKS. S. Lyle : Clinical differences in tuber- 
culosis, 147 

CoMBTON, Charles Greene, obituary notice of, 
734 

Cdmpston. J. H. L. (and F. McC ALLuat) : Htsfo >1/ 
of the Plague in Austrahn. 1900-‘102'i, 1036 
CuNKis'GHAii, Lieut.-Gol. John, C.I.B. conferred 
on. 988 

t. «+her8) : Metabolism and 
•ues and fluids, 126 (O) 

■ ■ Bill, 879. 923 

• se of erythroedema or 

Cushing, Harvey: The ISTeningiomas, rev.. 16 
Cyst, branchial, diagnosis of (Hamilton Bailey). 
940(0) 

'Cyst, hydatid, dystocia due to (Maslen Jones), 
552— In the heart (H. L. Hcimann). 801 
Cyst of omentum in an inguinal hernia (Fanny 
Howe), 716 

Cyst of ovary, large, 32 — Chocola.te (Alfred 
r '3. Stacey). 980 

C’ ■ • Gough). 981 

Ci cervix (A. A. 

Gemmell), 667 

Cystotomy, suprapubic, a tube for. 61 


Dain, H. Guy ; Direct representation on the 
General Medical Council, 999 
Dairy Congress, the World's, London (1928), 9S5 
Dairy Council of Canada. National : Report, 864 
Dalby prize. See Prize 

Daly, F.O. : The Indian hereditary criminal, 67 
Damages (£I.0D0) for a medical man, 881 
Damon, S. R.; Food Infections and Food Intoxu 
cations, XGW., 1113 

Dana, Charles L. • The Peaksof Medical History: 
An Outline of the Evolution of Medicine for the 
Use of Medical Students and Practitioners, 
second edition, rev., 555 

Danby, Alfred: Chocolate cyst of the ovary, 551 
Danybz, Jean, death of, 785 
Dauier, J. : Precis de Dermatologie, fourth 
edition, rev., 948 

Darwinism, implications of (Sir Arthur Keith), 
full text published in the English Beview for 
June. 1C07 

Davidson, A. H. : Vesico-vaginal fistulae, 303 
Davidson, George S. : Naegele pelvis, 597 
Davidson, Thomas Augustus, obituary noticeof. 
696 

Davidson, T. Wishart: Two cases of cardiac 
infarction, one followed by calcification of the 
heart, the other by mpture. 212 (O) 

Davies, A. Vernon : Edinburgh Corporation Bill, 
376 

Davies, D. S. : Inheritance of mental defect, 823 
— Presentation to, 955 

Davies, H. Whitiddge : Therapeutic uses of 
oxygen, 774 

Davis, Edward D. D. : Pulmonary and gastro- 
intestinal sequels of nasooral sepsis. 96 
Davis. R. : The haemorrhagic diathesis. 692 


Davison, James, obituary notice of, 577 
Davison. W. H., prosontatiou to, 163 
Dawson op Penn, Lord: Voluntary hospitals 
and public authorities, 279—“ Those other 


D 

Daylight in buildings, 681 

Dead bodies found in the Metropolitan area 
(parliamentary note). 423 
Deaf and dumb, training of (parliamentary 
note), 1094 

Deaf, higher education of the. conference on, 
1053 

De Aikaral, Africano, awarded the John Bcott 
prize, 37 

Deane, A.: Appreciation of William Muir'Smith, 
615 

Dearden, Harold, play of on the stage — ” Two 
"White Arms,” 244 

Death certificate, forgery' of (Charles Forbes), 
923 

Death cortifleation. the values of (leading article). 
227 

Death, partial (E. Llbman), 865 
De Ballin, Dr., 152 

Debeyre, Dr., appointed to the chair of histo- 
logy at Lille. 581 

De Boibbiere. Vernon Joseph, no longer a licen- 
tiate of the Royal College of Physicians, 649 
Dedre. Robert (and Ldon BernaRP); Cours 
d^llygihie, rev., 669 
Deck, E. J. : Migraine. 1007 
Defaecatlon. phyaiology of. 77, 199, 292, 382, 480 
Defective children. See Children 
Degenerative diseases, Lasker Foundation for 
medical research to investigate, 81 
d’Herelle, F. : Cholera bacteriophages, 365 
Deity of medicine. See Medicine 
Delafield, M. E., appointed to the chair of 
chemistry at the London School of Hygiene 
and Tropical Medicine. 199 
Deller. Edwin: — Universities in the United 
States: Somelnipressimis,^ 

Deltoid shelf, 986 

Delusions, the reality of (leading atticlo), 457. 
Se-i also Body and mind 

De Martel. Dr.: Segmental resection of the 
colon, 459 

De Meillon, Botha (and Alexander Ingram) : 
A Mosquito Survey of Certain Parts of South 
Africa (Part I), rev.. 919 

Dengue epidemic in Egypt in 1927 (B. Kamal), 
1104 (O) 

Deneer, Alfred, elected a corresponding member 
of the Otological Section of the Royal Society 
of Medicine, 650 

Denmark, radium treatment in (E. Collin), 358 
Dennis, Charles E,: Treatment of prostatic 
enlargement, 691 

Dental companies on the statutory list (parlia- 
mentary note), 532 
Dental officers, R.N.. 1132 

Dental sepsis, obscure, value of radiography in 
(James F. Braiisford). 1013(0)— Loading article 
on. 1036. See also Focal sepsis 
Dentists Bill, Irish Free State, AW. 608 
Dentists. British, registration regulations in the 
State of Victoria (Australia), 291 
Dentists Beaister (1®28), rev., 502 
Dentistry, review of book on. 1069 
Dentures, cleaning of, 164, 204, 243. 291, 334 
Derby, post-graduate conrses at, 741 
Derbyshire, rain-bearing winds and early 

*sh). 537(0) 

• *. ougal), 407 

' Wigoder), 


Dermatitis after ultra-violet radiation, 742 
Dermatologia, first issue. 1007 
Demia(oioatsc7ie Zeitschrift, special volume 
dedicated to Professor Eric Hoffmann, 1133 
Dermatology, review of books on, 17, 599, 948. 
See also Skin 

Dermoid, recurrent endotheliomatous (W, G. 
Barnard). 55 

Deutsche Zeitschrift fiir Ohirurgiei February’ 
issue dedic.ited to Alexander Fraenlcel. 429 
Devine, Henry: Long Fox Memorial Lecture on 
tbe reality of delusions. 457 
Dewey, E.W.: Injection treatment of varicose 
veins, 522 

Diabetes and anaesthetics, 1127 
Diabetes, oral administration of pancreatic and 
other preoarations in tbe treatmentof (C, B. S. 
Fuller), 798 (O)— Correspondence on, 875, 1050. 
1098 

Diabetes, review of books on. 16 
Diabetic coma, intravenous glucose in, 197 
Diabetics, food balance for, 267 
Diagnosis, laboratory methods in (leading 
article), 361 

Diagnosis, notes on (Claude Wilson), 709 (0) 
Diagnosis, the principles of (Robert Hutchison), 
335 (0>— Leading article, 361 
Diagnosis, review of books on, 310, 849 
Dial, importation of (parliamentary note), 474 
Diarrhoea, chronic, caused by a feather ouill. 
788 

Diathermy in relation to circulatory disturb- 
ances: Discussion at tbe Royal Society of 
Medicine, 134 

Diathermy, review of book on, 60, 454 
Diathermy, surgical, effect on the tissues of the 
arc electrode in (John Anderson), 222 
Diathesis, the haemorrhagic (H.Letheby Tidy) 
583 (0)— Correspondence on, 692 ’ 


Dible, James Henry, appointed professor of 
• • ’ ‘ Welsh 

. ’ T.Lclpcr), 

848 

Dick, ‘J. Stavoly; Treatment of acute pneu- 
monia, 285 


Dickson, W. E. Carnegie: Foreign bodies in the 
stomach. 239 

Dictionary, Black's Veterinary, rev., 672 

Dictionary, Oxford English: Completion of, 311 
—Note on. 311 

Digestive system, B. colt infection of the, 82 

“DIgitruss.” 186 

Billing, Walter J. (and R. E. Kelly): Gan- 
grene following the use of ergotized rye bread. 
MO (0)— Colloidal lead, 551— Treatment of 
malignant disease of colloidal load, 999 

Dimol snufT, 672 

Diphtheria carriers (J. E. McCartney). 180, 445— 
Discussion. 180. 445 

Diphtheria among elementary school children 
(parliamentary note). 580 


] . 

fatalities, 193. 1076 

Diphtheria, laryngeal, in old age (J. D. Rollos- 
ton), 1020(0) 

Diphtheria with lobar pneumonia and malaria, 
292 

Diphtheria notifications (parliamentary’ note), 
532 

Diphtheria in tho United States: Cases and 
deaths. 581 

Disclaimers, 38. 120, 1008 
Discussions, organization of, 877 
Disease treated by electrical methods by un- 
qualified practitioners (parliamentary note), 
381 

Disease, epidemic, climate and (Sir Leonard 
Rogers), 848 

Disease. Investigation of new discoveries in con- 
nexion with (parliamentary note), 880 
Disease, tho resistance factor In (Jeffrey 
Ramsay). 628 (O) 

Disease, seasonal variations of (C. O. Stally- 
brass). 563 

Diseases, notifiable (parliamentary note), 380 
Diseases, rare, tho lesson of (Sir Archibald 
Garrod), 914 

Dispensary, Edinburgh Eye: Annual meeting 
and report, 464 

Dispensary medical officers (Irish Free State), 
appointment of, 918— And mldwlves. 1083 
Dispensers in tho R. A. M.C. (parliamentary note). 
1095 

Dispensers in the Territorial Army (parlia- 
mentary note). 1095 
District nursing. .SVe Nursing 
DiverlicuHtis(T. T. O’Parrell), 1025 
Diverticulitis, surgical treatment of (K. W, 
Monsarrat), 309 

DWerlicuUMB , Meckel’s, In atrangulated inguinal 
hernia (Hugh Reid). 394 

DixoN : Passage of substances from the cerebro- 
spinal fluid into the blood, 228 
Dixon, Surgeon Commander T. B.. awarded the 
Royal Naval Volunteer Reserve Officers’ 
Decoration, 825 

Dixon. W. E. : Appreciation of Sir Dawson 
WilIiamB,42l— Tho trend of thought in thera- 
peutics. 896— Tribrom-ethylalcohol,“avertin,” 
896— Specific therapy in septicaemia. 896 — 
Narcotic plants, 1038 

Dobbie. Nairn: Tho future school medical 
officer. 262— Rheumatic infection in the young, 
551 

DoBiE, David Robertson, presentation to, 291— 
Obituary notice of, 478 

Dodson, J. F. : Late results of operation for 
renal calculus, 486 (O) 

Doctor, a bogus (“ Dr. Boyd Faulkner ”), 239 
Doctors, sports, 365 

Dodd, J. Theodore : Small-pox and " casuals.” 
644 

Dodds, E. C. : Asthma Research Council, 468— 
(And G. E. Beaumont): Becent Advances in 
Medicine, fourth edition, rev., 851 
Dodds, Gladys: The Wassermann reaction in 
pregnancy, 272 

Dogs Act Amendment Bill. 289, 332, 1094 
Dogs Protection Hill. 289. 740, 778 
Dogs and vivisection (parbamentary note). 289 
Donald, Professor: Dystocia due to vaginal 
atresia, 263 

Donaldson, ^falcolm : Midwives and anto-natal 
work, 520— Treatment of cancer of tbe cervix. 
547 

DonnAn, F. G., hon, LL.D. Edinburgh conferred 
on. 569 

Donovan, Daniel M. : Complete inversion of the 
uterus, recovery, 756 (O) 

Doolin, William : Treatment of fractures. 55 
Dougal, J. Wilson ; Dermatitis caused by furs. 
407 


Dougal, Samuel Merbert, Trial of, rev., 1029 
Douglas, D.; Haematometra and tuberculosis, 
99 

H. ; Injection treatment of 

COO_rTTt.. T...- — i.-... 


Douthwaite, A 
varicose vein** 
of Varicose V 
Dowling, G. . 
tropics, 180 


n the ■ 



.TAK.-JUKE, 1928] 


INDEX, 


f Tux BsmsB • « • 

LMidicai. JoimHAX. * 


Powi^iNo: Tbo coYonaty okcnlaUon. ^04 
Draininf; tbo bppUo \itcnis. Sfe Utorns 
Dnxun.C. .T.: Modical rofilstrallon in Now Zoa- 
lami, 1W6 
Proams, 105 

pnr.NNAN, M. R.: Intracranial capacity, 106— 
Tho value of anatomy, 109 
ProsainK, scarlet rod dry, 382 
prosslnR of wounds, orgostorol as a. 339. See 
F.rRostcrol 

pjiKVjm, Dr.: Basal principles in mental test- 
ing. 872 

Pixr.vriTT, F. Da\Ytrj’: Latin Names 0/ CommMi 
J^lauts, rev,, 986 

Drug troatmont of pneumonia. Sec Pneumonia 
Drugs, action of. review of book on, 1027 
Drugs of addiction, international control of. 
907 

p;.T.. to register 

' V > T ' ■ \'i*V : • .! ; f< :• tbe use of 


Di. 


451 


rf books on. 


DnxJMirosD, Lieut. Commander G. H., awarded 
damages against a mental nursing home, 287 

“Drunk in ebargo,” 774 

Drunk and incapablea in Glasgow (parliamentary 
note), 428 

Drnnkenness and civil and criminal responsi- 
bility (U. Llowellyn-Jones). 217 

Drunkenness, degrees in (Sir Robert Wallace), 
288 

Drunkenness, stindards of, 288. 573, 693— Jforo 
magisterial dicta. 693 • 

Diunkonness, See uljo Intoxication oiid 
Alcoholism 

Duput. Liout.-Colonel Robert, obituary notice 


of. 963 

Dublin. See Ireland 

Du Bojfl. Eugene F.: BasnlJfefnboWsmtnHtfuUii 
aiul second edition, rev.. lOl 

DunosT, Jean : Les Sates Thvsiaues de la Sndio- 
iliirapie, rev., 635 

DtjcKWomn, Sir Dyco, obituary notice of, 161 
Dodgeos. J, H. : Fumes of tar. 231 
Dddlev, Geoffrey : Isolation for measles, 75 
Dudley’s ntirsing scheme. See Nursing 
Duggan. N. : Delayed intracranial bacinorrhagc, 
666 

Duhcm, X’aul: i4ccfdenfs et Daugers de VEUc- 
trieiU^, rev., 918 

Duke, H. L.: The intestinal amoebae of man, 
1110 

DuKE-EnoEii, W. Stewart: Cataract and ultra- 
violet light. 31— Pathogenesis of acute primary 
glaucoma. 1010 

Dukes, Cuthbert; The examination of urinofor 
pus, 391 (0)— Early diagnosis of cancer of the 
rectum and colon, 816 

Dumas, a. : La Cireulation Sanguine jitVi- 
iiliirique et ses TrouVtes, rev., 266 

* tbof,862 

• • • 1026 
- ■ • ‘ ‘ lonia, 700 

• ' ' . ' obstetrics, 

lasr 

Dundas-Gbant, Sir James: Pulmonary and 
gastro-intestinal sequels of naso-oral sepsds, 
•97— Early detection of tubercle bacilli in 
sputum, 657(0)— Oto-sclerosis, 983 
Dundee. See Scotland 
Dunfermline, health of, 873 
DuNHiLii, T. P.. appointed surgeon to the King’s 
Household, 640 

PuNKEimT, J. S. : Venomous and non-venoraous 
snakes, 899 

Binnio : A sociological formula, 413— 
Effect of the birth rate on the average age at 
death, 775 

Dunlop tyro works : visits to invited, 832 
Dukn. Lient.-Col. Cuthbert Lindsay, C.I E. 
conferred on, 24 

Ddkn, J.Shaw: High blood pressure, 352 — Ulcers 
of oesophagus. 899 

Dokscombe. Nicholas D., called to the Bar, 


g Heaney). 1055 


, , u . ' ■ ' the, 164 

iJnrnam county, infant mortality in (parli: 
mentary note), 333 

Dust carts, covered (parliamentary note). 290 
Diuch Industrial Exhibition, 699. See ah 
Holland 

Dutton, Arthur Stayfc. obituary notice of. 927 
■UuvAij, Pierre; Elected foreign correspondic 
member of the Ro3’al Academy of Medicine < 
Reigium. 429— (Jean-Charles Roux and Hen: 
«ECLBim) : Sa'liologie Clinique du Tul 
^»r7C3tt/; J, Estomac et JDj/oderium, rev., 500 
1066 process of cholecystograph; 

Hydrouepbtosis, MG-Doub«i 
flbroma°MG S’IS — Hotroperitonei 

Boara of Health leaflet o) 

Dv=»n,„., .v- r-... , _ - ^ 

, :i. Masc 

joues aua itobert U. Owen). 25G (O)— Corr 
521, GlO-Heading artiol 
6i6— (Sidney Elisabeth CrOBkery) 191 

’^ilomson) gsl ^ paralysis (W. J 

Dyspituitarism (C. Worster-Drousht and B. T 
Crowhurst Archer), 717 


Dyatocia duo to vaginal atresia (K. V. Bailey), 
263; due to hydatid cyst (Maslcn Jones) 
552; associated with a vaginal hand (W. W’ 
Jeudwine), 660 


E. 


Eadie, Norman M. : A month gag, 902 
Eaqeu, R.: Malarial treatment of general para- 
lysis. 1023 

Eambh. AlcthcaJ.: Herpes zoster and vai'icolla. 
120 

#. ‘'ifty.gix 

E( , ' 

Ear, Internal, vasomotor affections of the (G. 
Portmann), 982 

Ear prosont-itlon, case of (C. G . Walker), 1065 
Ear, review of books on. 181. ^ 

Ear. Sec ulso Otology. Nose, mid Throat 
East, C. F. T. : Pernicious anaemia and the 
liver diet. 491 (O) 

EARTnnimooK. O. C. : Report on the Crichton 
Royal Institution, 464 

EASTyvoon, Sibyl U.: The results of gastric 
secretion and other digestive factors in 
rosacea. 222 

Eclampsia (H. J. Thomson). 2:8— (R. H. Para- 
more), 8?3 

Eclampsia, treatment of (W. Stroganoff), 1065, 
1111— Discussion. 1066 

Ecosoyio, Professor von. appointed professor of 
neurology at Zurich. 1097 
Ectopia vcalcae (Alexander Mitchell), 59? 

Ectopic gestation. See Gestation 
Eden. Thomas Watts (and Cuthbert Lockteb) ; 
yt... ....... « — Pracfiftonerc, 

• . . lead in motor 

spirit, 770 

EnoK, Major P. Granville: European vital 
statistics. 724 

Edinburgh Corporation Bill (Venereal Diseases), 
289. 323. 330 376, 378. 428. 578. 685. 667. See nl*o 
Venereal diseases 

Edinburgh jlfcdtcnt Jbuninl. tuberculosis num- 
ber, 479 

Edinburgh. See nlse Scotland 
Edinqton, George H., appointed J.P. for the 
county of the city of Glasgow, 37— (And J. W, S. 
Blackeocr) : Duplication or subdivision of 
the testicle. 937 (0) 

Edmirton, Major J. F.. Territorial Decoration 
conferred on, 882 

Education committees and salaries of medical 
officers, 952 

Educationists in conference. 28— Some medical 
aspects. 28— Health teaching in schools, 28— 
The “problem child.” 28— Psycho-analysis in 
early childhood. 28— The effect of illness in 
ciiaractcr formation, 62 — School meals, 62 — 
Measurement of muscular work, 62— The 
teaching of defective children. 62— A plea for 
biology, 1084 — Health and education. 149, 192 
—Hamlhook issued by the Board of Educa- 
tion. 192 

Ecl-worm, the vinegar. 1058 
Eobert, 8oneca : A Manual of Eyoiene and 
Sanitation, eighth edition. 58 
Egg cup in rectum. 120 

Egypt, the 1327 epidemic of dengue in (H. 
Ivamal), IKM (O) 

Eichholz. Alfred : School meals, 62 
Einhorn, Max . Le Tube Duodenal, rev., 225 
Eisen, David; Anaemia as a predominating 
symptom in malignant disease, 721 
Elbow, ” tennis,” treatment of (G. Percival 
Mills), 12 (0»— (Correspondence on, 159 
Elbow-joint, treatment of injuries round (J. F. H. 

Stallman), 802— A correction, 930 
EIjBer, WilUam: Sfndies in Psychology, rev., 
185 

Electrical methods in the treatment of disease 
by unqualified practitioners (parliamentary 
note), 381 


tes in 


Euas. Herbert (aud Adolf FeijI.er,) : Stauungs* 
tvpen bei KrieslaufsWrungen, rev,, 670 
Ella Sachs Flotz Foundation. 429 
EniiiOT, A. Macbeth ; Injections for varicose 
veins, 53 

EIjUiot, Walter Chadwick Lecture on sunlight 
in modern medicine: Clinical experience in 
England and Scotland. 859 
EiiiiiOTT. C. C. : Treatment of prostatic enlarge- 
ment. 117 

EniiiOTT, W. A. : Sea sickness. 1089 
EIiUTe, Henry; The causation ol rheumatism, 
856 

EUiia, R. ; High blood pressure, 552 
EntitsoN, J. : Multiple myomas in young 
patients, 351 

Major Cecil Henry, obituary notice of, 

Elton, Charles: Animal Ecology, rev., 1B2 
Embolism, bilateral, of the central retinal 
artery (T. G. Wynne Parry), 378. See also 
Artery 

Embolism of apex of long fW. A. Rees). 494 
Embolism, pulmonary, following delivery 
(Furneaux Jordan). 552 


Embryology, roviow of book on, 985 
Emetine hydrochloride injections in treatment 
Of broncho-pneumonia in children (C. Robert- 
son Wilson), 844 (O) — Correspondence on, 
966 

Emigrants to Canada, prospective medical 
examination of (parliamentary note), 428,881, 
1095 

Emphj'scma and wind instruments, 244 
Emulsions, review of book on, 224 
Encephalitis, epidemic; Pregnancy and 
(Frederick Roques), 351— In the child, life- 
history •''' ' 

Enccpbal by spinal 

curvatu ' . ‘ ' (0)— And 

crime, f: Discus- 

sions at the Royal Society ol Medicine, 261 — 
Provision of treatment for young persons 
suffering from (parliainontary note), 474 — 
Tumour of the brain Fimulating (S. 
McClements). 1061 (O)— Pfiondo-appendicular, 
1093 

Encephalitis, post-encephalitis problems (Allan 
0. Parsons). 759. 1122 
Encyclopaedia of IndusMal Health, 1096 
Endocarditis in young children and lambs, 
1134 

Endocarditis and cardiac ma1formationB,953 
Endocrine imbalance and its relation to chronic 
arthritis (G. L. Kerr Pringle), 751 (0) 
Endocrinology, review of books on, 223, 985. See 
also Secretions, internal 
Endoscopy, 862 

Endotboliomatous dermoid. See Dermoid 
Eng ish Eevieio publishes full text of Implica- 
tions of Darwinism,” 1007 
Ensor, (Colonel Howard, .C.B.E. conferred on, 
988 

Ephedrino, *' vaporole.” 806 
Epidemic disease, climate and (Sir Leonard 
Rogers), 648 

Epidemics in Pepys’s Diary (Colonel W. P. 
MacArthur), 319 

t hundred years (Sir 

• ■ , 557— Leading article, 

(01 

Epilepsy, review of books on, 1027 
Equal Citizenship, National Union of Societies 
for: Conference on women medical students 
and London hospitals. 821 
Equal Franchise Bill, 578. 697, 826. 923. 1094 
Ergosterol, irradiated, as a dressing for wounds 
(C.J. Bond). 339 (01.642 

Ergosterol. irradiated, rickets and ultra-violet 
light, 237 

Ergosterol, irradiated, tabloid form of, 556— 
Liquid form of. 672 
Ergosterol, vitamin D, and rickets, 78 
Ergot, chemistry and pharmacology of, 410 
Ergot poisoning among rye bread consumers 
(James Robertson and Hugh T. Ashby), 302 (O) 
—Note on. 318-(WaUer J. Dilling and B. E. 
KellyJ, 540 (O)— Correspondsnee on, 410, 4D 
Er^'tbema nodosum and acute endocarditis 
following tonsillitis: Recovery after treat- 
ment with antistroptococcus serum (A. Mark- 
son), 715(0) 

Erythema nodosnm and tuberculosis, 824 
Erythroedema or “pink disease,” case of 
(Donald r. Currie), 48 (0). See also Borax 

• Biology for 

• • • \ 

Ethics, medical, review of book on, 984 
Ethyl petrol, dangers of, 363 — Investigations in 
the United States, 36S. Sec also Lead mid Tetra- 
, ethyl 

Etu-'nne, Dr. : Traiteinent des Fractures par le 
PratUien, rev., 396 

Etigem'cs Revteio. to he placed on sale in the 
ordinary way, 761 
” Eukodal,” 1C69 

European child in Malaya, health of (G. A. C. 
Gordon), 37 

European countries, decrease of small-pox in, 
1132 

European vital statistics, 724 
Evans, Geoffrey : Haematuria during insulin 
administration, 1043 

Evans, Howed: Splenomednllary leukaemia in 
an x-ray worker, 135 

Evans. T. Caret: Treatment of prostatic 
enlargement. 74 

Evans. \YilliatQ Owen, appointed an officer of 
the Order of the Hospital of Bt. John of 
Jerusalem, 1133 

Eve, Frank C. : Tetra-ethyl lead in petrol, 409— 
Tonsil-suction for diagnosis and treatment. 
941(0) 

Evolution, review of book on, 1029 
Ewart, James Cossar, Hon. LL.D.Edinhurgb 
conferred on. 569 

Ewing, S A.: Cramp after sciatica. 930 
Ex-America semper aliquid novi, 150 
Examinations, professional, conditions of, 76 
Exercise as a therapeutic agent (Maurice Boigey), 
680 

Exophthalmic goitre. See Goitre 
Expectant mother. See Maternity and Mother 
Experiments on animals. See Animals 
Ex-service men in receipt of hospital treatment 
(parliamentary note), 964 
Bye defects, care of: Report of Departmental 
Committee, 26. 106. See also Optical Practi- 
tioners (Registration) Bill 
By®^iseases in the Navy (parliamentary note). 


12 JAN.-JUNE, 1928] 


INDEX, 


r Titr. Vnmia 
L Medicax. Jovbhai. 


Eye. See also Ophthalmology 
Eyelids, upper, oedema of the (John RobErls), 
307 

Eyes pain in. and chronic headache lelieved 
by a nasal operation (Rosa Ford), 43S (O 
Eyestrain and fine work, 1119 


F. 


Fabre centenary, 119 

Factories, artificial silk, health conditions in 
(parliamentary note), 531, 580, 697— Emission of 
cases from (parliamentary note), 618 
Factories Bill, 289.699 

Factories, cotton cloth, artificial humidity in, 
765 

Factories, hours of work in, 509 
Factories, inspection of (parliamentary note), 
474— In Scotland (parliamentvry note), 474 
Factors in vision. See Vision 
Factory inspectors’ assistants, promotion of 
(parliamentary note), 532 
Factory inspectors in Scotland (parliamentary 
note), 332 

F * ‘ ' ' ’ ' ' on. 763 

F 

]• ‘ relip, 1025 

Fahb, Professor: Non-excretoryfunctions of the 
kidney, 759 

Fairbairn, B.:— Vesical bilbarzia: doub'e in- 
fection with S. haemntohium and S. nmuiont. 
52— The protection of maternity, 462 
Fairbairk, W. R. D. : The study of mental 
abnorroaiity, 566 

Fairs and festivals in India, sanitation measures 
in conneiion with, 569 
Fabkiner, N. : The over-sensitive child, 220 
Falkser. H. G. ; Actiuotheropy for General 
Practitioners, rev., 356 

Fallopian tube and ovary: Congenital absence 
of(.I. Herbert SanderO, 1065— Torsion of during 
pregnancy (•!. E. htacey), 668 
Farmer, Keptimus, obituarj' notice of, 73 
Farrer, Ellen Margaret, Kaisar-i-Hind medal 
conferred on, 24 

F - -—Report on 

ton w'eaving 
3SS rates of 
Hill). 65- 
* tbe radiant 
M. Vernon, 

M. D. Vernon, and Isabel Jjorrain-Smith), 458— 
Ttvo Studies on Honrs of Wo)U . (1) Five-h'iur 
Spells for Wov\en with Reference to Itest 
Pauses (H. M. Vernon. M, D, Vernon, and I. 
Lorrain-Bmith). 509; (2) The Two-shift SysUm 
in Certain Factories (May Smith and M. D. 
Vernon), 509 -Tbe economics of menstruation 
(H. 0. M. SowloD. 0. 8. Myers, and E. M. 
Bedale), 606— Artificial humidity in cotton 
cloth factories (Leons’-d Hill, F. T. Peirce, 
and D. R. Wilson). 765— of Different 
Systems of Lighting on Output and Acairocy 
in Fine Work tTvpe-setting by Hand). 863— 
Report for 1927. 1072 
" Faulkner, Dr. Boyd," case of, 239 
Favue, Dr . appointed professor of morbid 
anatomy at T^yons. 81 

Fawcett, I'j. : Histology of the globus pallidus, 
351 

Fawcett. Millicent G. (and B. M. Terner): 
Josephine Butler: Her Woik and PrincnJles, 
and their Meaning for the Ttuentieth CeuUny. 
606 

Fa^vcUS, Major-General Harold Ben. C.B. con- 
ferred on. 988 

Feather quill causing chronic diarrhoea, 788 
Pedeli, Carlo, death of, 69G 
Feeble-minded, sterilization of in Alberta, 680, 
823.878. Sfe nfsn Mental delect 
Feeding, difficult, in an infant (J. A. Stepben), 
597 

F< ' ■ 'to urgent cases 


F • ' nfectious diseases 

(parliamentrtry note). 4?8 

Feet, fungous infectionsof the hands and (Rupert 
Hallam), 835(0) 

— I - > ,.s_— r.O'T OIH 

complications of en- 
. —Hunterian Or tion 
and treatment, 386 
(0)— The carrier problem. 446 

Fnrx, H. B.: Cytology of Jensen’s rat sarcoma, 
274 

FEiiiiER, Adolf (and Herbert Eetas) : Slauungs- 
typen bn Kiieslavfstdninaen. rev., 670 

Fellowship of MeJicine, 37. See also Post 
Graduate . . r. 

Femur, obstetrical fractures of the (R. A. Stones ), 
354 

Fksn. Joseph Hiorns, obituary notice of. 882 

Fenton, Colonel A ; A surgical emergency in 
tbe mission field. 292 

Ferenczt, SAndor: Further Contributions to 
the Theoi-y and Technique of Psycho-Analysis, 
rev., 61 

Fergus, Freeland: Field vision and near visior, 
42 (0) 

Ferguson, Arnold S. ; Blastomycosis of eye and 
face secondary to lung infection. 442 (O) 

Ferguson. James Haig. Hon. LL.D. Edinburgh 
conferred on. 569— Maternal mortality due to 
puerperal sepsis. 933 


Ferguson, Surgeon Caotain James Herbert, 
(J.B.E. conferred on, 988 

Ferguson, Major N. M., Territorial Decoration 
conferred on, 882 

Ferguson. V. D. : Acute appendicitis following 
typhoid fever. 979 

Ferguson, Captain 'William Haig, obituary 
notice of. 698 

Ferments, review of books on, 454 

Ferrier, Sir David, obituary notice of, 525, 574— 
Memorial to. 1039 

Fever, enteric: Acute appendicitis following 
(V. ii, Ferguson), 979 — Bono complications in 
(F. J. Henry), 56 

Fever, enteric: jCarrier problem (J. E. 
McCartney), ‘ ‘ \drianus 

IMjper and 1 : ' 

Fever, enteric ■noiith in 

South Africa, 259 

Feveri enteric: Pretoria ontbreak of (Adrianns 
l*ijper and B. Davidine Piillincor), 587 (0) 

Fever, paratyphoid, at Galaebiels, 2^36, 281 

Fever, paratyphoid U, an attack presenting novel 
Matures (^ Gmham-Stewart. Philip Manson- 


F •• ■ -nck- 

F , * , ema 

(Herbert E. Marsdeo), 716 
Fever, scarlet, in the tlnitcd States, returns of. 
479 

Fever, yeVow, a new light on, 723— In West 
Africa. 863 

Fever, yellow, preservation of the virnsof (A. W. 
Bollards and Edward Hindlc).7i3 (O)— Note on. 
723 

Fever, yellow, vaccine for (Edward Hindle), 976 
(O) 

Fevers, infectious, immunization against (loading 
artlc e), 861 

Fevers, review of book on, 635 
Fevers, specific, serum prophylaxis and therapy 
in (J. D. Ro’leston). 98 

Ffenneli,. E. B : Tr'*atnQent of vulvitis, 2-4 
Fiuiger, Joh»»uocs. obituary notice of, 200 
Fibroid tumoms of the uterus, multiple (K. V. 
Bailey). 263 

Fibroid tutiiours of the uterus, sarcomatous 
metaplasia of (Leith Murray), 497— (A. A. 
Gemmeil).498 

Fibroma of ovary. largo (J. Eric Stacey). 57 
Fibromata of uterus, malignant complicatioDs 
of(J.A Kynoch),803 

Fibrosis, non-tuberculotis, of tbe lung in child- 
ren (Agasfiz and Gill) 815 
Fibrosis, pulmonary (O. do W. Kitcat and T. 
Holmes Seltors), 1018 (O) 

Fibrositis (T. H. G. bbore and G. T. Lough- 
borough). 718 
Field vision. Vision 
I'lFir.LD, Lionel U.. obituary notice of. 578 
Fight Against Diseahe: Early days of anti- 
vivisection. 291 

Fighting services, coordination of the (parlia- 
mentary note). 579 

Filter for ultra-violet rays. Chance’s, 582 
Finance Act, 724. 735, 10C5. See also Budget- 
Exemptions from key industry duty, 741 
Fisca, G. I. : Evidence before the Commission 
on le^d tetra-ethyl in motor spirit, 1033 
F-ndlat, Leonard : John Tbom«on, 156 
Fine work and ovestrain, 1119 
Fioger-tip removed by a bite, idontification from 
(Sydney Smith), 757 
Fi earms Act (1920), 615 
Fireman’s ci amp. 291, 354, 382, 546. 609 
First-aid treatment for eye injuries at sea, 
cocaine in castor oil with mercuric chloride 
for. 119 

First aid. review of books on, 949 
First-aid service on the ro.ads 633 
** First-class life," an incident in a. 32 

'* ■ 'rforalions in the 

I 

. ‘ be pathology of 

chionic arthritis. 856 — Trea'ment by Manipu- 
lation, second edit on. rev., 397 
Fisher, R. A. : Triplet children in Great Britain 
and Ireland. 93 
Fistula pad, a faecal. 650 
Fistulae, vesico-vaginal (L. L. Cassidy), 308 
Fitzgerald. Gerald, obituary notice of, 240 
FitzQibbon. Gibbon: Twisted broad lii ament 
with cyst, 308— Vesico-vaginal fistnlae, 308 
Fitzwilliasib, Duncan O. L. : Tne role of 
radium in treatment if cancer of the breast 
and tongue, 451 — Treatment of malignant 
disease by colloidal lead. 1047 
Five generations attended by one doctor, 7C0. 
712, 832 

Flatulence, treatment of 38.82 
Flavine in treatment of gonori’boea (R. B. S. 
Statham), 544 (O) 

Fleming, Colonel A N. : Five generations 
attended by one doctor, 742 
Fleming. Robert Alexander, Hoq. LL.D. Edin- 
burgh conferred on, 569 
Fletcher, Cavendish, obitua’-y notice of. 695 
Fletcher, Dr.: Health lessons from Bermuda, 
448 

FiETCHcn, George (and Frank E. Ttlecote)- 
Diagnosis and Treatment in Diseases of the 
Lungs, rev., 985 

Fletcher, H. Morlej': Appreciation of Sir 
William Selby Church, 783 
Fi etcher, John ; Cleaning dentures, 291 
Fletcher, N. Corbet . A Compendium of Aids to 
Home Nursing, third edition, rev.. 555 


Flint, E.R.: The acute abdomen, 209 (0), 325 — 
Ligature of the innominate aricry for in- 
nominate aneurysm, 9i9 
Flood disaster in London, 112, 408— Report of 
committee on, 408— Parliamentary notes on, 
697 

Flood, a great, in 1829 (Moray floods), 350 
Flood, Mississippi, aftermath of the. 2 1 
Florence, G. (and L. Hugodne.vq): Priucipes 
de Pharmneodynaynie, rov., 718 
Flying, civil : Medical requiromenta for aviators, 
20. 6’^e also Air 

Focal sepsis: Discussion at the Rojal Society of 
Medicine, S6 

Focal sepsis, nasal ani oral, in tbe etiology of 
gttStro-intoatinal and pulmonary infective 
diseases (Patrick Watson-Williams and F. A. 
PIckworth), 931 (O) — Correspondence on, 
1049 

Focal sepsis : Value of radiography in the dia- 
gnosis of obscure dental sepsis (James F. 
Rrailsford), 1013 (O)— Leading article on, 
1036 

Foetal attitude, an uncommon (J. W. Burn**) 
6C8 

Footul tissues and fluids : Tbo metabolism and 
acidity of (W. Blair Bell, L. Cunningbam. 
M. Jowott, H. AliBot, and J. Brooks). 126 (0) 
Foggie, W. E.: Hereditary haemorrhagic 

• ‘ title of professor 

' ■ , professor of bio- 

logical chemistry at Strasbourg, 479 
Food balnnco foe diabetics. 267 
Food control in Scotland (Arthur Gofton), 112 
Food and Drugs Act, Sale of (parliamentary 
note), 881. 1095 

Food. Drugs, and Disinfectants Bill (South 
Africa), 1(M3 

Food poisoning, review of book on, 1113 
Food poisoning, unusual case of (F. M. Rowland. 

P. W. Marshall, and J. Menton), 439 (0) 

Food, preservatives in: Midi<itry'Of Health 
circular, 73— Draft regulations of the Irish 
Free State, 687 

Food &ui>ervi8ion in Scotland, 153 
Foods and food analysis, review of books oa 
947 

Foods, tinned (parliamentary note). 333 
Foot clinic, Edinburgh, now premises opened 
997 

Foot- and - mouth disease (19 7). 64— Parlia- 
mentary notes on, 289, 379, 380, 471, 530, 739 778. 
850. 88'', 964, 1095— Alleged remedy lor, 474 — 
Number of animals creumtf^d, 830 
Foot.s’ER, George Rammoll, O B.F. conferred 
on, 988 

Forbes, Cbailes. charged with forging a death 
certificate 923 

Forbe«, Graham: Diphtheria carriers, 181 
Forceps delivery and prophylac ic gynaecology 
(Dr. Lindsay), 353 

Ford, Frank R. (Bronson Orotuprs and Marian 
0. Putnam): Birth Injuries of the Central 
Nervous System, rev., 396 
Ford, Rosa: Chronic headache and pain in the 
eyes relieved by a nasal operation, 431 (0) 

Ford, William W. : Text-book of Bacteriology, 
rov.,8SO _ 

’ —Predisposing 

' • s ‘in ct’ildhood, 

’ ■ to puerperal 


Foreign body in the abdomen, 199 
Foreign body in the antrum (S. Subba Rao), 
546 

Foreign body in the b’ adder (A. Ralph Thomp- 
son), 51— (B Scott), 216— (Harry D. Christie'. 
307— (J. McFadzean). 665 

Foreign body in ear [grain of rice] for tbirty-six 
years ( vViJliam P, Kennedj’), 34 
Foreign body in the oesophagus: Difficult 
removal (Lindley Sewell), 176 (0) 

Foreign bodv in the stomach, 198. 239, 259— Of 
an infant (W. B. R. Monteith), 259 
Foreign body, swaRowed, method of dealing 
with a (S. Gilbert Scott) 133 
Forestxer, Dr. : Intravenous treatment of 
varicose ulcers, 899 

Forgery of a death certificate (Charles Forbes), 
923 

Forgotten swab. See Swab 

Formalin injections in gangrene of the leg: 

recovery(J A. Noble). 216 
Forman, Colonel Robert Hall, obituary notice of 
329 

Formosa, an English hospital in, 151 
Forsdike, Sidney: Treatment of cancer of the 
cervix. 547 

FonsvTH, David : Psycho analysis in early child- 
hood, 28 — The effect of illness on character 
formation. M 

Fortune, R. F. : The Mind in 105 
Forty, A. A'an: Total hepatoptosis. 133 
Foster. Lieut.-Col. W. H. C. : cholera in the 
Punjab, 568 

Foster, William James, obituary notice of, 
963 

Fowl tumour. See Tumour 
Fox, C. Iris, memorial to, 1085 
Fox, E. J. : Accident services in industry. 
1077 

Fox, R. Fortescue: Value of marine health 
resorts, 449 — Rheumatic diseases tieated by 
physical methods in Germany, 815 
Fracture case, alleged negligence in a (Slroud 
V. Bates, Bates, and Wilson), 573 




JAM.-JUNR, tgjS] 


INDEX, 




[ Tn 1 ^ 

JoTTBiru. ^ O 


Frftotnro o( cervical vortobtuo lSlv>VUliain I. clo 
Courcy \VV\cclor), 555 

Frivctnro of clavlolo Iroatod with tllsnlaceinont 
(O. VV. MUroy). 6&1 (01 -'H. F.arlo Oonwolb, 725 
— Oorrospondonco ou. 878 — (H. II. OrconNYOod', 
1021 (OJ 

Fracture followed byRus RatiRreno (U. IVaylaiul 
Smith), 2B3 /T TT 

Fmcture of bnaieriH, supracondylar (J. F. H. 
Stallman), 802 . 

FracUiro of tbo navicular IK. Paterson iJrown), 

FmcUu-o problem (leadinR article). C3G— Dis- 
cussion at tbo Koyal Society of Medicine. 663— 
Corrcsi>ODclencc on. 730 

Fracture reducliou. tbo ritual of (U. IVatson 
.fono'’). 57 

Fraoturoof tlio nock of a rib by indirect violence 
(Guy Branson and .lames F. Brallsford), 346 
Fraotnro of base of skil l followed by acute 
mastoid disease: recovery (W. J. Harrison). 
HOD ! 

Fractures of llio femur, obstetrical (U. A. 
Sloncy*, 354 

Fractures, review of books on, 396, 819 
FracUitos. treatment of (William Doolin), 55 — 
(H. IJ. Staliard). 107 

FiiAt:sKv:t«, Aioxamler, 70tb blrUidav of. 423— 
February Usuo of Urn Dentnehe ZeitszhiiftfUr 
Chiritru«>. dedicated to, 423 

Fuance : 

Association for tbo Dovelopmont of Medical 
Relations. 28 
Calmotto, Professor, 29 
Ijimacy icform in. 402 
Ijvous faculty of Medicine, 29 
Massonr pr so v ted for employinU uUiM*violet 
rays in treatment, 12D 

Medical service in the war. review of book on, 
1112 

Popular promotion, 29 
Professor of therapoutics.a new. 29 
Tuberculosis in. 814 
Yorsin, Dr.. 29 

Fra^ice, 0. F.: Winier motorinc, 38 
Prankau, C. El, S. ; Current views of shock and 
collapse, 54 

Franklim, Lieut.'CoI. George Denno. C.I.C. 
conferred on, 988 

Frakkltn, Kenneth J. : Fovolgn bodies In the 
abdomen. 199— ■iurvival of quadruplets, 700 
Frashling, Herbert: Scope of surgery In chronic 
arthritis. 343 

Fraser. Dr.: Otosclerosis, 933 
Frabeu, F. R.(H. F. Rrkwcr and A.Q.WELiiS): 
Treatment of pernlcioua anaemia by Uver. 
165(0) 

Fraser. John, appointed Honorary Surgeon to 
the Kiog in ScotUnd, 605. 610 
Fraser-Hauris, D. F.; Physiology of defaeca- 
tlon. 199 

Frederick. H. R. : Historical exhibition at 
Cardiff, 520 

Fredet Fierro, Legion of Honour conferred 
on. 291 

FREEUXNr, E. T. : Narcolepsy, 915— Pituitary 
infantilism 916 

Freeman. J. : Tno carrier problem. 446— Asthma 
Research Council, 468 
Free State. S«<» Ireland 

Fremantle. F. B.: Running ns a recreation, 334 
— Appreciation of Rlr Dawson WiMiams, 424 
French, Herbert: Liver diet treatment of per- 
nicious anaemia, 178 

FnEDDENTUAti, Poul : Experimental EicJcetSt 
rev., 762 

Friedlasder, Alfred: Ht/P‘5f«nston, rev., 655 
FRrEND. G. E.: The future school medical 
oEBcer, 262 

Friendly societies See Societies 
“ Friends of ihe Old Ashmolean," 813. See also 
Society 

FRiMODT-MoiiiiBR. Christian Frederick, Kaisar-i- 
Hind medal conferred on, 988 
Froment, Dr., appointed professor of medical 
pathology at Lvons, 81 

Frontal lobe, tumours of the (leading article), 
1071 

FuiiFORD.Miss ; Voluntary hospitals and public 
autboritte8,280 

FuLiiER, C. B. S.: Oral administration of pan- 
creatic and other preparations in the treat- 
ment of diabetei, 798 (O). 1053 
Fullerton, Andrew: Thyroidectomy in toxic 
goitre. 554 

Fund, Kiog Edward's Hospital, 479.532.693,883 
— ApplicatiODB for grants. 479— Educational 
lectures for schools and colleges, 532 — Annual 
meeting. 883. 918— Gift to. 1096 
Fund, Naval Medical Compassionate, 201. 882 

Benevolent 70. 360. 51$. 
564 1077 1077-Annual meet- 

Fund, Royal Medical Benevolent Fund Society of 
^ irela^: ^niial meeting, 1082 


d R, G. McAliley): 

, Sysfeni in Infants 

Furs, poisoning from IJ. Wilson Dougal). 407 
Forth. Otto: Lehrbuch der Phv^iologischen 
wml Eaihologischen Chemie^ rev., 554 




CtADrur.L, W. B.: Early diagnosis of cancer of 
rectum and colon, 847 
Ong, mouth, 902 

Qalasblela. p»iratvpbold fover at, 236, 281 
^ miravonous injec- 

of^tmncocolcl in 

■ D. P. D. 
— Corre- 

Berkeley 




Gall-bladder, T-\ay diagnosis of pathological 
conditions of (James F. Braiisford), 484 (0) 
Gallte, Major-General James Staart, C.B. con- 
ferred on, 24 

QMvano-caiitery In the treatment of Imonior- 
rhoidfl, 1038 

Gangpiio following Iho use of ergotizod ryo 
broad (Walter J. Dllling and R. E Kelly), 540 
( 0 ) 

Gangrene, gas, following fracture (U. Wayland 
Smith). 263 

Gangrene, gas, of sigmoid (R-Sullabury Woods). 
593 

Gangrene, gas, following street accidents 74, 
534 

Gangrene of the small intestine, diagnosis of 
(P V Oharputo).2l7 

Gangrene of leg formalin injections in: recovery 
(J. A. Noble). 216 

GAnDiS»-R-HiLL, H.: The thyroid and menstrua- 
tion. 318 

GAnnsr.R, Frank Gower: Fireman's cramp. 382 
—Elected county director of the Bristol Red 
Cross Society for Oxfordshire. 109S 
Gaudner. T. 1 Procreation after proatatoctomy. 
204 

Garner, Colonel Calhcart, obituary notice of, 
521 

Garrett, J. R.: Effect of tbo blrtb rate on the 

. • • Appreciation of Sir 

• • , 780— The lessons of 

rare maladies. 9_14--The place of biochemistry 

' • . » . rates of small-pox in 

* mvaccinated. 74. 156. 

Gautner. .August, eightieth birthday of, 787 
Garvice. Martha Isabel, M.B.E. conferroJ on. 
988 

Gaa gangrene following fracture (R. Wayland 
Smith). 263 

Gas gangrene of sigmoid (R. Salisbury Woods). 
593 

Gas gangrene following street accidents, 74 
Gas. poison, prohibition of the nse of in warfare 
Ipirliament.iry note), 381— Dangers to the 
civitian population of on escape of (parlia- 
mentary note). 961— Storoge of (parliamentary 
note). 1094 

Gas poisoning, chronic bronchitis after, 618 
Gas poisoning, review of book on, 3K 
Gases from artificial silk works, 648. See also 
Factories, artificial silk 

Gaskell, Burgeon Vice-Admiial : Tbo causation 
of rheumatism. 855 

Gastric juice and meat extractives. 581 
Gastric operations (F. J. Strong Heaney). 105? 

(O)— Correspondence on. 1126 
Gastric secretion of neutral chloride, 325, 374, 
411, 469. 521. 729. 1128 

Gastric symptoms, interpretation of (Charles 
Bolton), 1030— Leading article on, 1075 
Gastric ulcer. See Dlcor 

Gastro-duodenal ulcerations, surgery of (Charles 
A. Panne t), 623<0) also Ulceration 
Gatenby, j, Bronte faud B. V. Cowpoat, 
editors): Bolles Lee's ^^icrotomist's Vade- 
Mecum, ninth edition. 672 
QAULTir.n. Rene; Pricisde Coprologie Clinique, 
rev., 763 

Gauvain, Sir Henry- Present position ofradium 
therapy, 497 

Gaza, Professor voa, appointed professor of 
surgery at Rostock, 1097 

Gazette desHupitaux : Fabre centenary number. 
119 

Gell, H. WilliDgliim: Immunity following 
herpes, 1054 

GemmEll, a. a.: Sarcomatous metaplasia Of a 
uterine fibroma, 498— Cystoscipyin carcinoma 
of the cervix, 667— Spontaneous rupture of 
nterine sarcoma, 931 
General Medical Council. See Council 
General practice and clinical pathology (R. C, 
Matson), 897 

Geneial practice, review of book on, 1023 
General practitioners and the Dawson Williams 
Memorial Fund, 732. »Sceaiso Fund 
Genital displacements (Victor Bonney), 431 
(O) 

Genital organs, review of book on, 909 
George, A. W. ; The causes of alcoholic 
inebriety, 691 

Georgb, William: Appendicitis and hepatic 
abscess, 633 

Gere, Dorothy B.: Underfeeding and over- 
feeding in infancy, 34 

German. B. L. (editor): Handbool: to British 
Malava, J927. rev,. 949 


Gi:rm\nt: 

Appointments in the faculties of medicine 120 
■ German scieniists, scientific war literature 
for. 883 

Rheum itic diseases treated by phj-iical 
methods in, 815 

Society for combating quackery, 81 
Venereal disease, legislation against, 562 

Gi:ny, Dr. (of Strasbourg), title ofiprofessor con- 
ferred on. 243 

Gestation, ectopic, full-term (W. Fletcher Shaw), 
498— Treated by Caesarean section (bt. George 
Wilson), 498 

Gestation, ectopic, ruptured, occurring on both 
sides (B.G. Collins). 131 
Gesiation, See also Pregnancy 
GnARpouE, P. V. : Diagnosis of gangrene of the 
small intestine 217 

Gird, J. Aldington: A series of consecuMve 
operations on the mastoid, 49 (0) 

Gibderd, G. F. ; Albuminuria during pregnancy, 
219 

Gibbs. O. S. ; Loop for measuring blood coagula* 
tlon time, 672 

Gibson, Alexander George (and William 
Tregonwcll CoEEikr) : The Me'hods of Clinic U 
Dtapnosts, rev., 849 

Gibson, C.: Acute intsstinal obstrnction by 
bands in children, 176 

Gibbon. Robert (and Alex. B. Somerford) 
Ambulatory treatment of varicose ulcer, 978 
(O) 

Gibson, R. E. (and P. S. Hichess): Acut 
pneuTnonia treated by sodium nucieinate, 52 
Gibson, Thomas: Cyclical vomiting 
appendicitis, 823 

Qidlev. Dr.: Malarial treatment of general 
paralysis, 1024 

OiEMBA, Gustav, sixtieth birthday of,243 
Gilbert, Professor, bequeaths a raedico- 
hUtorical collection to the Paris I'acully of 
Medicine, 883 

Gilchrist. Thomas Caspar, death of. 240 
Gill, Dr.: Non-tuberculous fibrosis of the lung 
in children. 815 

Gill. F. : Conservative treatment of spinal 
caries. .65 

Gill, Joseph William, ohitnary notice of, 425 
Gillespie, John R.: Prognosis in pulmonary 
tuberculosis, 436 (0) 

Gillespie, R. D. : Theories of suggestion, 53— 
•Asthma Research Council 468 
Gilltatt, W. : Uterine sarcoma, 2:9 — Anaes- 
thetics in obstetrics, 393 — Treatment of 
eclampsia, 1055 

Gilmouu, .\Ddrew, obituary notice of, 927 
Gillson, Edward Henry, M.B B. conferred on, 
988 

Giracd, Di*., appointed to the chair of thera- 
peutic hydrology and climatology at Mont- 
pellier, 617 

Giuel. Georges: La Itoentgenth&rapie ties 
Epitheliomas Cutanes et Cutanco-blnqueux 
par la HHhodedti Dr. J. Coj>fe rev.. 1029 
GirodE. Ch. (and Jacques Leveuf): Le Traite^ 
ment des Prncfwres du Co. du Fimur, rev., 
819 

Githens. Thomas 6‘totesbury (and Solomon 
Solis-Coiien): Pharm icothet aventics , Materia 
Meilica, and Drug Action, rev,, 1027 
Gittings, R. j. ; Preserying the sterility of 
hypodermic syringes, 531 
Glazbter, Joh'; The examination of blood 
stiins and hairs. 67 

Gland rraftiog, 474. 505, 510, 570, 610, 699. 2091. 
See also Voronoff 

Gland crafting and ioheritance, 570, 610, 690. See 
also Inheritance 

Gland, thyroid, and menstruation (H. Gardiner- 
Hill and J. Forest Smith). 318. See also 
Thyroid 

*' Glanoid ” concentrated fluid extract of liver, 
186 

Glasgow. See Scotland 

Glasooio aredicul Jbunial, centenary number 
399 

. k , of 

■ ■ ■ icie, 


Glegg, R. Ashleigb, presentation to, 787 
Globus palUdus. histology of (F. Barton White), 
351 

Gloucester, William Duke of, cause of the 
death of (VV. P. MacArthur).502 
Glover, EJwatd: Etiology of alcoholism, 595 
Glover, J. Alison; Diphtheria carriers, 181 — 
Rheumaticinfection in the young. 356— Report 
on non-specific chronic arthritis. 815, 901 — 
General incidence of rheumatic diseases, 853 
Glucose in the blood and cerebro-spinal fluid, 
estimation of (Francis Temple Grey), 215 (O) 
Glucose, inti*av6nousIy, in diabetic coma, 197 
G ucosides, recent work on the (E. G. Biwant). 
407 

Glycerin injections for draining the septic 
uterus, 117. See also Uterus 
Glycosuria and pregnancy, 82 
Glycosuria, some problems of (George J, 
Langlev). 1016 (0) 

Goadby, sir Kenneth: Diseases'of the Gumsaml 
Oral Mucous Membrane, third edition, rev.. 
357 

Goddard, T. R.(A. GRAnAii-STEWARTandPhilip 
Manson-Bahr) : An outbreak of paratyphoid B 
fever presenting novel featuies. 931 (O) 

Godlee, Sir Rickman, memorial tablet to, 74 



14 JAN.-JUNE, 1928] 


INDEX, 


r The Bamni 
L ICZDICIZ/ JotmiTAl. 


Gofton, Arthur : Food control in Scotland, 
112 , 
Goitre, esonhthalmic, treatment of (A. J, * 
.miton).85 (O) 

Goitre, iodine, and cro^th (Percy Stocks), 24 
Goitre, iodine in the treatment and prevention 
of, 238,286 

Goitre, revie-w of book on, 1067 
Goitre, toxic, thyroidectomy in (D. Kennedy), 
353 

Golbblatt : Alkalosis and ketosis, 402 
GoimsMiTH, Dr.: Intravenous treatment of 
varicose ulcers, 898 

Golf, medical ; Medical Golfing Society, 582. 1134 
— Manchester and District Medical Golfers’ 
Association, 930 

GoiiBA, Frederick D. (editor): Archives of Nenro- 
logy and Psychiat-ry, vol. ix, rev., 59 
Gonorrhoea followed by renal abscess (J. K. G. 
Way). 716 

Gonorrhoea, review of books on, 100 
Gonorrhoea, vaccines in treatment of (E D’Arcy 
McCrea), 755 (O)— Correspondence on. 920 i 

Gonorrhoea in women treated by swabbing with ■ 
mercuroebrome and flavine (R. S. S. Statham), 
544 (O) 

Good, J. P. : A manuscript gone astray, 38 
Goodadd, E. W.: Isolation for measles, 114 — 
Diphtheria carriers. 181— (and Washbourn) : 

A Text-book of Infections Diseases, third 
edition, rev., 310 

Goodhart, Dr. : Diver diet in pernicious j 
anaemia. 179 I 

Goodhart, Gordon W. : Gastric secretion of 
neutral chloride, 325, 411, 521 
Goodwin, A. : Cancer of the cervix, 548 
Goodwin, Dieut.-Gencral Sir John, appointed 
Colonel Commandant of the Army Dental 
Corps, 201 

Goodwin, Colonel W. B. P., appointed honorary 
physician to the King, 201 
Goodyear. R. T. (and H. S. Pf.mberton): 

Measurement of basal metabolism), 395 
Gordon of Aberdeen, 990 

Gordon, Alexander: Treatise of the Eindemic 
Pnerveral F^ver in Aberdeen, 9S0 
Gordon, G. A. C.: Health of the European 
child in Malaya. 37 

Gordon, E. G.: Uses and abuses of hydro- 
therapy, 659 (0>— Etiology of rheumatic 

Gordon, W (and W. Ash): Bain-bearing 
winds and early phthisis in Derbyshire. 337 
<0)*~Surgical treatment of chronic gastric 
ulcer, 451 

Gordon- Watson, Sir Charles : Present position 
of radium therapy. 497 

Gorilla at home (Dient.-Col. Clayton Dane), 7C0 
GosBET, A. : Travauxde la Clinique chirurgicale 
ct du centre anticanctreux de la SalpHrUre, 
rev. , 599 

Gough, A.: Ovarian sarcoma accompanied by 
metrorrhagia, 668— Parovarian and ovarian 
cysts in pregnancy, 981 — Placenta accreta, 
981 

Gough, W. : Abdominal myoma, 57— Uterine 
carcinomafollowing operation, 498 
GouijD, T- Duncan: Dead and infected teeth, 823 
Gout, acute, 430 

Gow. Major Fleming: Treatment of eclampsia. 


Graafian follicle, ripening of the (Wilfred Shaw), 
552 

Grabhah. Michael : British doctors in Madeira, 


Grahast. Cbarteris: Ten cases of Caesarean 
section, 980 

Graham, George: Haematuria during insulin 
administration. 1048 

Graham. H. A. : Wire bristle in the bowel, 13 
Graham. I. C. : Nephrostomy, 650 
Graha^, Colonel J. D. : Public health organiza- 
tion in India, 1082 

Graham. J. G. : The fixation of antiseptics by 
dressings and tissues: its importance in 
wound treatment, with special reference to 
Bcriflavine, 175 (O) 

Graham. R. S.. action against, 328 
Graham-Stewart, a. (Philip Manson-Bahr and 
T. R. Goddard) : An outbreak of paratyphoid 
B fever presenting novel features. 934 (O) 
Granger. E. : Records of cancer cases. 117 
Grant. J. W. Geary: Acute necrosis of the 
pancreas, 1101 (0) 

GRANViEiiE-CHAPMAN, C. D. : Varicose veins in 
the broad ligaments, 665 
Gray, A. A.: Otosclerosis, 983 
Gray, J. A. W. Pereira: Surgical treatment of 
chronic gastric ulcer, 451 
Green, George H.: The Terror Dream, 105 
Qreen'ti Maniml of Pathology and T^orbid 
Anatomy, fourteenth edition, rev., 763 
Greenwich Hospital pension, 119 
Greenwood. Alfred: The welfare lOf hop- 
pickers. 678 

Greenwood. H. H. : Treatment of fractures of 
the clavicle, 1021 (O) 

Greenwood, Major: Fatalityrates of small-pox, 
156 — Elects a Fellow of the Royal Society. 
320 — Professor Calmette’s statistical study of 
B.C.G. vaccination. 793 (O) 

Greixter, Norman : The pulpless tooth. 549 
Grey. Francis Temple; Estimation of glucose 
in tho blood and cerebro-spinal fluid. 215 (O) 
Grey, Henry M. : The Land of Tchinorroio, rev., 
671 


Grcer. James : Chemistry and pharmacology of 
ergot, 410 


Griffith, J. P. Crozer (and A. Graomo 
Mitcheli,) : Diseases of Infants and Children , 
second edition, rev., 805 

Griffith, Wardrop: Difficulties in cardiac 
diagnosis, 347 

Griffiths. G. B. : Encephalitis Icthargica and 
crime. 190 

Grocers' Company’s scholarships, 243 
Gross. Professor, death of, 79 
(IROVES, Ernest W. Hey : A Synopsis of Surgery, 
eighth edition, rev., 397— Some comments on 
the case of Tyndall v. Alcock. with remarks 
as to the origin of ischaemic contracture, 807 
Growth and goitre. See Goitre 
Gruber, Georg B., appointed professor of 
pathology at Gottingen. 120 
GruIjEE. C. G. (and B. E. Bonar) : The Newborn , 
rev., 1113 

Gubb. Alfred 6.: Pnonmonia with acute abdo- 
minal symptoms and multiple abscesses, 1109 
Guibe-Moores, Major-General Bir B. G.; Ap- 
preciation of Sidney Maynard Smith, 527 
Guedberg, Gufitav, reports the first case of 
_ chimney-sweep’s cancer in Scandinavia. 81 

r - - ' D*D. Edinburgh 

of from Edin- 

Gunter, F. E. : The efficacy of tuberculin, 824 
Gunzburo. Isidore: Treatment of rheumatism. 
858 

Guthrie, Thomas Clement, obituary.notico of, 
377 

Guthrie. T. M. : Ultra-violet rays for acne, 966 
Gynaecological mvolvcments of the abdominal 


* ■ '634, 

806,918 

Gynaecology. See also Obstetrics 


Habf.rer, Professor von. appointed professor of 
surgery at DUsseldorf. 1097 
Hadfield : Disease of the pulmonary artery, 604 
Hadfield, Arthur: Etiology of alcoholism. 596 
Hadfield. Geoffrey: Histology of the globus 
pallidus, 351— Pathological investigations in 
rheumatic diseases. 855 

Haemagglutinins. latent, fatal suppression of 
urine caused by (Geoffrey Shcra), 754 (O) 


Haematuria caused by insulin treatment (R. D. 
Dawrence and A. S. Hollins), 977 (O)— Corre- 
spondence on, 1048 
Haemoptysis in infante. 382 
Haemorrhage, concealed accidental (Leslie 
Williams). 495 

Haemorrhage, concealed accidental, and un- 
avoidable haemorrhage (F. H. Dacey), 498 
Haemorrhage from tho deep epigastric artery 
into the rectus abdominis (Donald l^IacLennan), 
895 

Haemorrhage, intracranial, delayed (N. Duggan), 
666 

Haemorrhage, post-operative, from unsutured 
wounds (Lowndes Yates). 983 
Haemorrhage, puerperal (Dr. Kennedy), ?22 
Haemorrhagic diathesis (H. Letbeby Tidy), 583 
(0)— Correspondence on. 692 
Haemorrhoids treated by the galvano-cauterj’, 
1098 

Haemostat, a novel (A. Hopkins), 52. 3 See also 
Rectum 

Hager, Benjamin H. (and William F. Braabch) : 

Urography, second edition, rev., 849 
Haggard, Howard W. <and Yandell Henderson): 
Noxious Gases a7td the Principles of Betptra- 
tion Influencing their Action, rev., 355 
Haig. Earl, death of, 193— Memorial to, 1007— 
(parliamentary note), 290 
Hair-balls in the alimentary tract (Charles 
Noon), 342 (O) 

Hair diseases, review of book on, 1028 
Haire. Norman Hymen : or the Future of 
Mnrrtnoe,rcv.,501 — Gland-grafting and inheri- 
tance, 610 

Hairs and blood-stains, examination of (John 
Glaister). 67 

Haldane, J. S. : A new lamp-room photometer, 
112— Heat cramp. 609— Companion of Honour 
conferred on. 988 

Haldin-Davib. H. : Ultra-violet radiation 
therapy, 260— Primula rash, 430— Ultra-violet 
rays for acne. 1007 

Hale-M’hite, Sir William ; Daz^e ovarian cyst, 
32 

Hall. James S. : Sarcoma of the stomach, 393 
(O) — Nasal and oral focal sepsis in disease. 
1049 

Hall, Sir John (editor): Trial of Adelaide 
Bartlett, rev.. 266 

Hall. Percy: Treatment of prostatic enlarge- 
ment, 204 

Ball, S. Barton : Theories of suggestion, 158 
Hallam, Rupert: Fungous infections of the 
hands and feet. 835 (O) 

Ballet prize. See Prize 

Hallett, F. G., honour of knighthood con- 
ferred on, 23 


Halliday, James D. : The relationship between 
housing conditions and the incidence and 
spread of measles, 5£0 

Hallowes, Collis: Value* of marine health 
resorts, 450 

Hamant, Dr., appointed professor of clinical 
surgery at Nancy, 581 

Hamar, Sir William: Voluntary hospitals and 
public authorities. 279— (.hadwick Lecture'?: 
epidemiology in the last hundred years, 359 
IlAMiLL, J. M.: Report on Dutch and Danish 
condensed milk, 319 

Hamilton, C. K. J. (and K. H. Talleiisian) : 
The Principles of Infant Nutrition and their 
Practical Application, rev., 1028 
Hamilton, S. : A medical liternn* chib, 405 
Hampstead Garden Suburb, twenty-first anni- 
versary of, 1133 

Hamzeu. N. A. ; Incision of the uterus. 1003 
Hanbury, Reginald J. ; Physiology of dcfaoca- 
tiOD. 480 

Handkerchief drill, 878. Bee also Infection? 

disease in schools 
Hands, flushing of the, 581 

F ■ ' • » *.• ffectand (Rupert 

■ *■ 50568 

J ■■ , ' ' Barbados with 

malaria, 157— The injection treatment of vari- 
cose veins, 542 (0)— A correction, 618— Tho 
intestinal amoobao of man, 1111 
Hanbman, F. S. : Gastric secretion and neutral 
chlorides, 1128 

Harbinbon, j. a.: Report on the health of 
Kildai 6,282 

Hare, Hobart Aniorv: A Textbook of Practical 
Therapeutics, twentieth edition, rev., 139 
Hare. J, Q. (and P. Tate) : On the fungi 
causing ringworm in children attending 
London County Council schools, 1% 

Hare, Tom: The comparative pathology of 
rheumatic diseases. 855 

Hare-lip, treatment of (Victor Veau), 1025— 
Correspondence on, 1129 
Hareness.A. H. : Lecturers on social hygiene, 
inoniry for. 700 

Harman, V ' ‘ ' ■ . 

seventh * ■ 

Dai^son 

Verses, rev., 671— Appreciation of James 
Aloxandci* Macdonald, 783 
Harries. E. H. R. : Isolation for measles. 
156 

Harris, Alfred Charles Edward, obituary notice 
of. 962 

Harris. I.: Immortality, rev., 672— Syphilis of 
the heart, 840(0) 

Harrison of Iahtham,T&v.,1010 
Harrison, W, J.:— Fractured base of skull 
followed by acute mastoid disease: recover}’, 
11C9 

Hart, Bernard : Etiology of alcoholism. 594 
Hart, Horace: Buies for Compositors rtnd 
Headers at the University Press, Oxford, 
twenty-eighth odition (fourteenth for publica- 
tion), 460 

H ARTY, John Percy Ingham, obituary notice of, 
576 

Harveian festival, at Edinburgh, 997 
Harvey, William : Tercentonarycelebrations of 
the publication of De Motu Cordis, 275, 509, 
e03. 810, 816, 818. 866. 906, 910. 922, 948, 966, 992— 
Leading article, 810, 906 — Harvey chapel at 
Hempstead (Sir Dawson ' Williams), 816 ; 
Correspondence on, 922— Reception of delegates ' 
by the King, 866— Reception at the Royal 
College of Physicians, 866— Admission of 
Honorary Fellows, 866— Eulogies of Harvey, 
868— Banquet by the Grocers Company, 869— 
Tho Harvey film. 870— Exhibition at the Royal 
College of Physicians, 870— Harvey and St. 

- TT 

' rd. 

■ ral 

of 

Harvey, 913 — The Anatomical Exercises of Dr. 
William Harvey: De Motu Cordis, 1638: De 
Circulations Sanpuinis. 1619 (edited by 
Geoffrey Keynes), 948— Celebrations in Paris, 
992 

Harvey, W. C. : Diphtheria carriers, 180 
Haslam, j. F. 0. : Life assurance in the tropics, 
218 — Health lessons from Bermuda, 448 — 
Neuroses in the tropics, 449 
Hastings, Somerville: Otosclerosis, 983 
Hastings Lecture. Lecture 
Hatcher, Robert A. : Anaesthesia by the rectal 
inj* ction of oil, ether, and other drugs, 769 
Haultain, W. T.: Ovarian extract after arti- 
ficial menopause, 1111 
Hawetard, a. : Milroy's disease, 581 
Hawthorne, C. O. : Appreciation of Bir Dawson 
Williams, 422 — Appreciation of George 
Stevenson Middleton, 576 — Appreciation of 
James Alexander Macdonald, 783 
Haydon, Edgar: Present position of radium 
therapy. 497 

Haye, L. B. : Inversion of the uterus. 1(X)8 
Hayes, M. R. J. : Skeletal metastases in carci- 
noma, 899— Surgical uses of radium, 899 
Haynes, Royal Storrs : Clinical Pediatrics, 
vols. viii, ix, x, rev., 138— Vols. i. ii. iii, v, xi. 
xiii, xiv, XV, rev., 1113 

Headache, chronic, anc #•-, • I;”. 

by a nasal operation it- ■'() 

Heald, C. B. : Ultra-v:';!‘ : : ! s; 1 , 

260 

Health administration, review of books on, 224 
Health and choice of a career, 524 






l6 JAN.-JUNE, igiSj 


INDEX. 


Tiir T\Timnn 

JoCBWlt 


Hospital. Mildmay MIsbIoq, HatUnal Green : 

Exteuniona opened* 831, 929 
Hospital. Monkstown : Annual meeting, 822 
Hospital, Morningside. See Hospital, Royal 
Edinburgli 

Hoipital, Norfolk and Norwich: New private 
patients’ home opened,771— Insurance scheme, 
771 

Hospital officers in the prison service (parlia- 
mentary note), 1095 

Hospital orgvnization. review of book on. 183 
Hospital problem: In Victoria, 680— In the 

■ Highlands. 821, 872 

Hospital, Rotunda. Dublin ; Clinical report, 771 
Hospital, Royal Bath, Harrogate: Annual meet- 
ing, 324 

Hospital, Royal Berkshire. Reading : New 
operating theatres opened, 741 
Hospital, Roval BJinburgb, for Mental and 
•Nervous Disoi^ders, Morningside : New title, 
405— Annual Report, 406 

Hospital, Royal Free (liondon School of ^^ed^• 
cine for Women): Centenary of. 236.333,617 — 
Gifts for the new dental clinic, lore 
Hospital, Royal London Ophthalmic (Moovfields 
Eye): Annual dinner, 290 
Hospital, Royal National Orthopaedic: Festival 
dinner, 195 

Hospital, Royal Westminster Ophthalmic: New 
address, 6i7 

Hospital. Bt. Andrew’s, Dollis Hill: Annual 
meeting. 533 

Hospital, St. Bai tbolomew’s : ReporM, vol. lx, 
rev ,16— JfoitPfl the Foiintnuit fourth edition, 
rev., 60— Sf. Bartholcvieto's Journal: 

■ The A B C of vitamins 292— William Harvey 
and. 870 

Hospital. St, George’s • John Hunter bicentenary 
celebrations. 400 

Hospital, Bt. Mark’s. City Road: Annual meet- 
ing. 479 

Hospital, St. Mary’s: Extensions, 73— Prize- 
giving at the Medical School, 1084 
Hospital, St. Ultan’s Infant. Dublin: Annual 
meeting, 1083 

Hospital Saving Association, note on, 243. 699 
Hospital service in North UUt, lack of (parlia- 
mentary note), JC95 

Hospital staffs and contributory schemes. 1039. 

See also Hospitals, voluntary 
Hospital sterilizer. -See Sterilizer 
Hospital system at West Bromwich (Hallam 
Hoipital), 641 

Hospital Tuberculosis Trust. Royal Victoria, 
Edinburgh: Annual report, 607 
Hospital, Ulster, for Women and Children, 
Belfast: Annual meeting, 519 
Hospital, University College : Clinic for mental 
dedciency, 155 

Hospital, Victoria, for Children, Tite Street, 
Chelsea: Annual report, 1085 
Hospital, Victoria Park (City of London Hospital 
for Heart and Lungs): Now surgical and ar-ray 
block opened. 1045 
Hospital, Wembley, opening of, 933 
Hospital, Westminster : Perpetual ward endowed 
in memory of Sir Robert Hudson. 479 
Hospital. Wingfield Orthopaedic (parliamentary 
note). 333 

Hospital, Woolwich War Memorial, visited by 
the King. 617— Appointments. 649 
Hospitals. Admiralty (parliamentary note). 381 
Hospitals, Bridewell and Bethlem Royal, 408. 

See also Hospital. Betblem Royal 
Hospita's of Edinburgh, visit of the Lord High 
Commissioner to, 937 

Hospitals. London, and women medical students, 
821 

Ho’spitals, mental, of London, women medical 
officers at, 236 

Hospitals, military, closing of (parliamentary 
note), 333— Cost of accounts of (Parliamentary 
note), 1095 

Hospitals. Ministry of Pensions (parliamentary 
note), 530, 925 

Hospitals of Montreal, campaign for financial 
support of, 369 

Hospitals, naval, beds and personnel in (parlia- 
mentiry note), 428— No closure of (parlia- 
mentary note), 47 1 

Hospitals and preferential treatment of friendly 
societies (Now Zealand), 564 
Hospitals and road accidents. 192. 232, 237, 925 
Hospitals. Royal Air Force (parliamentary note), 
474 

Hospitals, Scottish, gifts to. 957 
Hospitals, service, and pensions (parliamentary 
note). 427 . . 

Hospitals, small-pox, tuberculosis patients in 
(parliamentary note), 964 , 

Hospitals, voluntary— Public authorities and: 
conference in London, 279 — Report of the 
Commission (parliamentary note), 616. 925 — 
Rating of (parliamentary note). 850,1095 — And 
motor acci'’''-'‘~ pota), 925— 

Final report ; :• inquiry, 934 

— Hospital • •. I , ; ■. schemes, 

1033. : }l : . 

H 

H . ■ . . , 


Housing .Acts, numbers of houses building, 383, 
697 

Housing improvements in rural districts, 
Uiaistr 3 - of Health’s circular re, 81 
Housing, rural (parliamentary note), 645 


Housing statistics (parliamentary notoi, 616 
Howaud, William Ijpo: PI tin Facts on Sex 
Hvaiene, rev., 101— i*’,irfs/or the. Marrinl, rev., 
101— Sea: Problems Solved, rov., 101— Gon- 
iidejifial Chats with Bovs, rev., 101— Con- 
fidential Chats with Qirls, rov.. 101 
Howahtii, Walter: Pliaryngo-oosophagoal 
sphincter, 922 

IIowARTH, AYiUlam Jamos, obltuarj' notice of. 

1091 

HotvK, Fanny: Omental cj'st in an inguinal 
hernia, 716 

Howell, Whitchurch: Treatment of rheuma- 
tism, 858 

Howitt, Alfred BakewoU, Q.V.O. conferred 
on, 988 

Hoy, W. a. : Pure milk progress, 764 
Hubbard, S. Dana: A Treatise on Biseascs of 
the Hatrntid Scalt), row, 1028 
Huber, Max, elected president of the Inter- 
national Red Cross Committee, 1155 
Hudson: Experimental transmission of yellow 
fever, 723 

Hudson. Colonel C., appointed Honorary 
Surgoon to the King. 201 
Hudson, B. : Abortion and sepsis, 1049 
Hudson, Sir Robert, ward endowed in West- 
minster Hospital in memory of, 479 
HUGOUNENO, L. (and G. Florrnoi:): Priucijies 
de Pharmacodynatnie, rev., 718 

‘ ‘ ‘ Dttls. Slanghtor 

■ investigation and j 

Humidity and the cotton weaver’s heallh, 65 
HUMPaREYs, Major F. R. ; Territorial Decora- 
tion conferred on, 119 

HuiiPiiREYS. Lieut.-Col. Humphrey Francis, 
O.U E. conferred on. 988 
Homphri ys. Mr. Justice: Medico-legal aspects 
of criminal abortion, 452 


The now portrait of. 325. 571, 643— The iirogress | 
of surgery from Hunter's day to ours (Sir 
Holburt Waring), 245— Bicentenary of the birth 
of (leading article). 271— Bicentenary celebra- 
tions at St. George’s Hospital, 400— The hom©3 
of (George 0. Peachey). 275 
Hunter, William: Homes of (George C. 
Peachey), 2?6 

Hunterian festival dinner, 277 
Hunterian Lectures. See Lectures 
Hunterian Oiation: The progress of surgery 
from Hunter’s day to ours (Sir Holburt 
Waring), 215 (O), 277— Sciatica : Its varieties 
and treatment (Anthony Feiling), 386(0) 
Hunterian Society. Sec Society 
Hunters, homes of the (George C. Peachey), 276 
Hurd. Henry Mills, death of, 79 
Horry, Jamieson B. :— The tutolarj* deity of 
medicine : the claims of Imhotep, 565— 
Medical autographs. 825 

HURST, Arthur F. : Dysphagia associated with 
anaemia, 375, 521— Asthma Research Council, 
463— Achalasia of the cardia (so-called cardio- 
epism), 690— Early diagnosis of cancer of the 
rectum and colon. 847 

Husban i'6 resiionsibility for wife’s treatment, 
693 

Hutchinson, Creighton, memorial to. 1007 
Hutchison, Robert: John Thomson. 153— The 
principles of diagnosis. 335(0)— Chronic appen- 
dicitis in children. 348 

HuTiNEL. V.: Le Syndrome Maliji dins les 
maladies de VEnfance, rev,, 635 
Huxley, Julian : A plea for biology, 1084 
Huxley, Margaret, hon. M.A.Dublin conferred 
on, 523 

H ' " . - • . - 

n 

H 

Hyde, Lieut.-Col. Dermot Owen, obll»ar 3 ’ notice 
of, 1002 

Hydramnios with uniovular twins (.\Jaslon 
Jones), 182 

Hydrocele, operation of eversion of the sac for 
(Richard L. Spittol), 305 lO) 

Hydronephrosis, treatment of (0. C. Holman), 
543 (0) 

Hydrops tubae profluens (Miles Phillips), 99 
Hydrosalpinx, torsion of a (A. Leyland Robin- 
son), 668 

Hydrotherapy, uses and abuses of (R. G. Gordon), 
659 (O) 

Hvgiene Council, British Social: Aunual report, 
230— Venereal disease problem in India, 250— 
Summer school. Cambridge (1928), 532 — Health 
and Empire, 643 
Hygiene, international. 312 
HS'giene, review of books on. 58. 669 
Hygiene, social: In Bcoiland. annual report on, 
154 — Lecturers on, 700 

Hygiene, teaching of to cbildren, 149, 192— 
Handbooh issued bj'the Board of Education. 
192 

Hygiene and Tropical Medicine, London School 
of: Degrees and pass lists, 238— Courses in 
tropical hygiene for laymen, 479— Microscopes 
for the new laboratories. 553 
Hyoscine hydrobromide, 763 
Hyperglycaemia in general anaesthesia, an 
atypical case of (R L Mackay). 892 (O) 
Hypernephroma (Foyle Seale), 264— The history 
of a (K. V. Trubshaw), 216(0) 


Hyperpyrexia, boat, and boat cramp, 1098. 

See also Houses, heating of 
Hyperpyrexia in terminal chronic nephritis 
(Howel B. Plorco. John F. Scales, and G. L. 
Pierce). 177 

Hypertonic Rolutlons in intracranial pressure 
(W. RuHsell Brain), 86 lO) 

Hypodermic syringe. See Syringe 
Hysterectomy In puerperal sepsis (Bethel 
Solomons), 351 

IlyRtcrcctomy, Wortheim’s.drainngo in (Fletcher 
Shaw), 982 


I. 

IctcruBj hereditary (.7. .S. !Manson), 131(0). See 
’ 'a bite 

tUjuuuj tJiJlibii,, t,/, 

Iloo-cnecal lymphadenitis, simple (C. Jennings 
Marshall), 631(0) 

Tleo-caccal resection (C. L. Isaac), 257 (O) 
ileum, three perforations of caused by fish- 


. (rnrlla- 
■ iprooin 

photometer, 112 

Imhotep’s claims to bo ibo deity of modicico. 
565 

Immunity: Light therapy and (leading nrlicle), 
362— Following herpes zoster, 875, 92), 1054, 
1089. 1127 

Immunization against diphtheria. See Diph- 
theria 

Immunization against infections fevers (leading 
article). 861 

Immunization against measles. See Measles 
Immunization against scarlet fever. • See Fever 

Income Tax: 38. 120. 204. 291, 334 . 382. 430. 480, 
534, 582. 604. 618, 650. 700. 725, 742. 787. 831, 884, 
930. 966. 1008, 1037, 1054. 1098, 1135 
Allowance after marriage, 534 
Appointments: Post-graduate study and, 618— 
New consulting practice, 831 
Assistant becomes a partner, 1134 
Cash basis, 292,334. 787, 1133— For gross income, 
M4— Receipts basis. 1133 
Changes in proprietorship of pvactico, 1037 
Commencement of liability, 582 
Commencement of partnership, 1054 
Deductiblo expenses, 1098 
Deduction for use of house, 788— For residence, 
832 

Depreciation allowance— x-ray apparatus, 1054 
Division of partnership assessment, 1098 
Expenses of assistant’s board, etc., 1003 
Expenses of illness, 650 
General Medical Council's case.604 
Gift of car for professional use. 1133 
Instruments, replacement of. 700 
Liability for board and lodging, 1054 
Locumtonent’s expenses, 480 
Motor cars: Obsolescence of, 38, 430— Repairs 
to. 204— Uenewa’- 

480. 534. 700. M • . ■ . ■ ■ 

action, 700, 742, ' I’v > ■ , 

788— Depreclatiuu, ouJ 
Payments for capital boirowed, 1054 
Purchase of partnership share, 1008 
Purchase of practice. 884 
Repayment of loan, 930 
Keturos for 1928-29, 725 
Salary with house, etc., 742 
Sa'e of practice, 382 
Schedule B. purchase of practice, 430 
Subscriptions to societies, 334 
Succession in a practice, 582 
Surgery expenses, 291 
Three years’ average, claim for, 966 
Value of board and lodging. 832 
Wife commences practice, 1(X)8 

Indexes, half-yearly,f232 

India : 

Alcohol, sale of in (parliamentary note), 3'1 
All-India School of Hygiene, 865 
Bombay Medical Council. 283 
Cholera in the Punjab, 568 
Climate and disease incidence in (Sir Leonard 
Rogers), 333 

Fairs and festivals, sanitation measures in 
connexion with, 569 
Health progress in Assam, 283 
Infant welfare in, 1082 
Medical education in Bengal, 283 
Narcotic drugs, sale of (parliamentary note), 
381 

O -' — '■* ”• 

P 

P 

Tuberculosis increase in Bengal, 1082 
Venereal disease problem in, 230 

Indian hereditary criminal (F. C. Daly). 67 
Indian Medical Service: Permanent com- 
missions. 160— Ratesof pay, 328 —Annual dinner 
in London. 1132 

Indigo-carmine, intravenous injection of, 921, 
1002 

Industrial fatigue. See Fatigue 
Industrial invalidity, prevention of, 403 



, tan. -.TUNE, igaS] 


INDEX, 


C TiiK LumsH 
1. UedicxI. JonftNlL 


Intlustrlal Mocllolno. ConocU of: conforonco on 
tho proveulion of inilUNtrlal Invalidity, 403 

aua Provident SooloUesfiVmondmont) 

Aut.GlS „ , , 

Induntrial ]>'»ycholofjy. _ .SV^ Paycnoiofiy 
Indnstry, accident servlccB in, 1077 
Industry, application of sclonlinc knowlcdfio to, 
7 1 

Inobrioty. Alcobollsm. nruokennoas, anil 
Intoxication 

Infaucv, uaclerfocdinfi and ovorfocdlnn in. 34 
Infant at birtb, pelvic circntnforenco of, 582 
Infant niovtalUy. See Mortality 
Infanticide UiU. 1130 
Infantile paralysis. See Paralysis 
Infantilism, pituitary 112 T. Krooman), 916 
infection an\ou6 clilldron lu casualty doparl- 
inouiB, 930 

Infectlona duo to dead and septic lootb. See 
Teeth 

lofoctlous disease in schools, 873 
Infections diseases, ctiuloKy of, 833 
Jnfeeti<)u.f Gnver7i>nent lustitule for 

tTokyo], .Scirnfi.dc lirporfs, rov.,600 
InfeotiouB diseases, notification of (parlia- 
mentary note), 618 

In^feitious diseases, reviotv of books on, SIO— 
Foes for uoiificatiou of (parliamentary note), 
425 

Infirmary, Aberdeen Royal: Annual report, 236 
Inftriiwry, I2dtnburah Roval: Clinical leaclwnR 
at. 71 -Annual report, 153— Rotlroment of Pro- 
fo'^sor Onlland, 610 

Infirmary, David Elder, Govan, formally handed 
over to tbomanasorsof the Western Infirmary, 
O nsfrotv. 113 

iDllrmary. GlaSRow Royal : Annual social meet* 
ioB.71— .tnnualmcctCufi 372 
Infirmary, GlasRotv Victoria: Annual mcGtlnR 
of the ladies* auxiliary association, 151— 
Annual lUf'ctlnR, 235— Admission of paying 
patients. 323 

Infirmary. GtasRow Woatern: Annual moetlnR, 
407— Appointments, 993 

Infirmary. Ittvcrncss Kortbern: Hospital pro- 
h{em<i in the HiRblmds. 821 
Inflrmarv. Leeds General : Htatisllcal tables, 154 
Infirmary, Leicester Royal : Annnnl report, 8^0 
iNGti.VM, Alexander (and llotba Du Meilt.,on): A 
Mn<quilo Sim'eu of \>rtnii\ Pdrt« of South 
Africa (Part I), rer., 949 
iMltoritanco of acquired ciiaractcristlcs, 742 
loberitanco and eland grafilnfi, 670, 610, 601. See 
aho Gland 

Innsbruck, post*Rr&duate courses at, 163 
Inoculo tinn. duration of a posi ivc Widal reaction 
after, 430 

Inquests in tbo City and Southwark. 1081 
Inquests, coroners’, fa London ia 1927, 642. 1084 
Insanitary premises, compeusation for (parlia- 
mentary note), 926 


fracture reduction, 57— Serum treatment in 
antluMX, 135— SpleoomeduUary leukaemia iu 
an r-ray worker, 135— Influence of statistics on 
medical practice, 219— Detection and care of 
rheumatism in childhood. 220— Surgical treat- 
ment of diverticulitis, 309— .Measurement of 
basal metabolism, 395— Colloidal lead, 551 — 
Gastric and duodenal ulcers, 551— Some sur- 
g'cal conditions of the stomach, 667— 
capacity in heart disease. 795 

Instruments to bear indication of origin, 381, 429, 
5S1._ Board of Trade 

Insulin, massivo dosage with (Harold A. 
By\vorth>, 801 

Insul n treatment causing haematnria (R. D, 
Lawrence and A. S. Hollins), 977 (O)— Corre- 
spondence on, 1048 

Insurance, accident, review of book on, 1068 

Insurance. National Health; 

Amendment Bill. 428 645. 677, 733. 775, 811, 826. 

879. 92 5. 9S3. 1051.1094.1130 
Approved Societies and additional benefits, 
529.739 -Invested funds of, 649 
Certiflcfttion under, 330 

Res against Panel doctors, 330 

iQspectors, 1095 ' 


4 


Aumber ot insured persons. 289. 964 
Dphthaimic benefit, 616 
lane! doctors umi certificate charges 
persons over 65, 530 

PaT Uamentary notes on. 289, 330. 428. 529, 6 
645, 649. 697. 738, 775, 879. 923, 9&4. 1034 
Payment for medical certification (Irish Fi 
.State), 374 

Sickness and diiablement benefits. 428 
omen employees and pregnancy, 529 


Some problems for solution, 673 
Insurance, private patients' home, Norwich 
schema, 771 


Insurance, third party indemnity (parliamentary 
note), 697 

International Labour Office pamphlets. See 
Labour Olllco 

Intestinal obstruction in nn infant (E. A. 0. 
Wilson). 51 

Intestinal obstruction, acute, by bands in 
uhildron (C. Gibson), 176 
Inioslinal obstruction duo to Imir-balls (Charles 
Nooft), 342 lOK See also Obstruction 
Intestinal toxaemia in ohlldron, chronic 
(Reginald JliUor), 383 (0» 

Intestine, small, diagnosis of gangreno of the 
(P. V, Oharpure>.2l7 

Intoxication and its legal conseqnouces (F. 

Tilowellyn-Joims), 217. See also Drunkenness 
Intracranial capacity (M. R. Drennau', 106 
Intracranial pressure, hypertonic solutions in 
(W. Russell Brain), 86(0) 
lutusBUPcoptlon in nn adult duo to a polyp of 
Meckel’s diverticulum (lau Macdonald), 442 
, (O) 


. ' jitro, 

238.286 

Iraq College of Medicine, 229 
Iraq dates and cholera (parliamentary note), 428 
InuMiND. Major-General M. W. : Editor of The 
Metltcal Department of iheOuitedStatesArrnj/ 
in the TTorid R'ar. volume xl. Surgery, ParsI, 
rev,. 137 

Ireland 

Bangor seworago, €08 

BoIfKBt: Hospital amalgamation in, 155 — 
Forster Green Hospital for Consumption, 
235— Board of Guardians end their m\\\i 
supply, 282— Samaritan Hospital. 4C6— 
A|)poiotinout of a new medical oificcr, 406 — 
Census report. 464— Royal Victoria Hospital, 
603— Education of mentally defective chlld- 
ron, 822— A medical officer’s resignation, 822 
Browne, Sir John Walton, memorial to, 113 
Cancer campaign, 72. 235 
C.ancer, treatment of, fusion of hospitals, 29 
Dentists Bill (Free State), 455. 608 
Dispensary doctors and mldwivcs (Free State), 
10S3 

Dispensary medical officers, appointment of 
(Free State), 918 
Dduhn: 

Mccileal inspection of school children. 464 
Fublio health congress in, 113, 770 
Rotunda Hospital, 771 
St. Ultan'8 Infant Hospital, 1083 
Food preservatives in the Free State, 687 
Health Ministry for Northern Ireland. 519 
Health ot Korthern Ireland, 29. See nl&o Vital 
BtatUtlcs 

Hospital amalgamation in Belfast, 155 
Hospital co-ordination, tlio need for, 622 
Irish C)ominittec of the British Medical Asso- 
ciation. 72 

Irish Medical Committee. 72 
Insurance, National Health: In Northern 
Ireland, 829 — Medical benefits. 919— Medical 
referees under in Northern Ireland, 282— 
Payment for medical certification (Free 
Mate). 374 

Kildare Board of Health, 282 
Lindsay. J. A., farewell dinner to, 770 
Local Authorities Bill, 1126 
McKisacb, tUo late Henry* Lawrence, 68S— 
Memorial fund, 822, 998 
Medical inspection of Ecbool children, 464 

•' ‘ Meath. 113 

■ * public, 938 

‘ Insurance Act in 

Northern Ireland. 

Medical Register (F 
Medical services in 

Medicine bottles aud cafies. empty, return of, 
919 

Slenially defective children, education of. 822 
—(In Northern Ireland), 955 
Milk.clean: Report ot Free State Commission, 
728 

Slilk contractor heavily fined. 406 
Nurses, training and examination of. 1C83 
Nursing scheme. Lady Dudley's, 874 
Public health conference in Dublin, 113. 768 
Public health organization in the Free btate. 
519 

Public health works for relief of unemploy- 
ment, 406 

Royal OoHegeoC Surgeons : Charterday dinner, 
956— Annual election of officers, 998 
Royal Afedical Benevolent Fund Society of 
Ireland. 1082 

School children in Northern Ireland, health 
of, 1083 

School medical services, 1126 



Irish Committee of the British Medical Associa- 
tion, meeting of. 72 

Irish Medical C « - * 

Anomalies in 
Certain areas. 

Local Governi * 

under Local 

medical ofneers in the Free State Army, 72— 
School Attendance Act. 72— Supplying medi- 
cines in certain contract practices, 72 


Irish Medical Schools’ and Graduates’ Associa 
tion. See Association 

Iron starvation in rununants (B. 0. Aston), 558. 
See also Bush disease 

InwiN, Florence: Jtecipes for Drs. Minot and 
Mutphy's Liver Diet, rev., 102 
InwiN, S. T. ; Thyroidectomy in toxic goitre, 3S4 
Isaac, C. L. : Five cases of Ueo-caccal resection, 
257 (0) 

Isaac, .S. (and O. von NoonDEK); Die Zneker- 
hrankheit uiid Hire Sehandlung, rev., 17 
Ischaemic contracture, origin of (Hey Groves), 
807— Correspondence on. 921, 1001, 1C46 
Italy: State Tourist Department and special 
study tours for medical practitioners, 787, 929 
IVENS, Frances: Haomatometra and tubercu 
losis, 99 


Jackson, Chevalier: Bronchoscopy and EsopJin- 
ooscopv, 862 

Jackson, Dc. : Tumour of the left cerebello- 
pontine area, 946 

Jacob, Alfons, to establish an institute for the 
studvof the anatomy of the brain at Rio da 
Janeiro, 479 

jAMi'.R, Phillip, obituary notice of. 240 
James, R. R. : Arrival of the Jews in England, 
935 

James, Lleut.-Col. William Mawer, obituary 
notice ot, 625 

Jameson, W. W., appointed to the University 
chair of public health at the London School 
of Hygiene aud Tropical Medicine, 580 
Jamieson, J. U. Hamilton: Operative Dentistry 
(OniltiifS of Dwital Science, \o\. ixl.iev., 1069 
Jansen, Hans: Treatment of rheumatic 
diseases, 853. 858 

Jaundice, familial acholuric (J. B. Manson), 
131 (O) 

Jaundice, Bcotiisb Board of Health leaflet on, 
281 

Jav. Mr.: Voluntary hospitals and public 
authorities. 280 

Jr.ANPELizE, Dr., nominated professor of 
ophthalmology in the Nancy Faculty of Medi- 
cine. 291 

Jeans. Frank: The influence of statistics on 
medical practice. 219— The acute abdomen, 325 
Je.vnb. F. A. G.; Cystoscopy in cancer of the 
cervix, 668 

Jeans, Surgeon Rear-Admiral T. T. : Asthma 
Research Council, 468 
Jeekbribs, I. 31. : Arsenic in sugar, 1C02 
Jevterson, Geoffrey : High blood pressure, 353 
jErrEnsoN, John C. : A large ureteral calculus, 
14 

Joiunum, complete transverse rupture of, with- 
out external wound (J. R. Armstrong), 1()54 (O) 
Jemma, Rocco, nominated director of the Faculty 
of Medicine at Naples. 1096 
Jenkins, C. B.: Autogenous residual vaccines, 
340 (O) 

Jenkins, G. J. : Otosclerosis, 983 
Jensen's rat sarcoma. See Sarcoma 
Jerusalem, Academy of Medicine of. 865 
jESbE, Tennyson F, (editor): Trial of Madeleine 
Smith, rev., 266 — (Editor): Ttial of Samuel 
Herbert Dougal, 1029 

Jeuew NE, W. W. : Dystocia associated with 
a \aginal band. 666 — Tbrombo-phlebitis 
migrai'S. 824 

Jews. Ar^bs, and Armenians, blood group per- 
centages for (B. H. B. Altounyan), 5461 
Jews, arrival of in England IR. R. James), 993 
Johns, F. M. : Pulmonary actinomycosis, 494 
Johnston, J. H. : The P>t’«cti)les o/ PractUaX 
Bfictertoloov, rev., 670 

Johnstone, R. W. : The preventive frame of 
mina in midwifery, 6 (O) 

Joints, creaking in the, 742 

Jolly, Professor, elected a member of the 
Acad^mie de M4decine, 479 
JoNFS, Archibald Mason (and Robert D. Owen) • 
Dysphagia associated with anaemia. 256 (O)— 
Obituary notice of, 1092 

Jones D. Caradog (and A. M, CABR-SAusDEns) : 
A Survey of the .Social Structure of England 
ami TTales as Illustrated by Statistics, rev., 598 
Jones, H. E. : Chronic diarrhoea caused by a 
feather quill, 788 

Jones, H. Wallace: Vital capacity in heart 
disease, 795(0) 

Joses,* Maitland : Chronic appendicitis in 
children, 319 

Jones, Maslen : Three cases of chorion- 
epithelioma, 181— Hydramnios with uniovular 
twins, 182— Dystocia due to hydatid cyst, 552 — 
Sarcoma botryoides, 552— Case of hydramnios, 
761 

Jones, Meyrick: The pnlp’ess tooth, 549 
JoNFs, Sir Robert: Appreciation of Sir Dawson 
Williams, 418 

Jones, u. Watson : The ritual of fracture reduc 
tion, 57 

Jones, William Black, appointed a serving 
brotberof theOrderoftbe Hosp.'talof St- John 
of Jerusalem. 1C53 

Jordan. Alfred C. : Physiology of defaecation, 
292. 382— The pulpless tooth, M9 
Jordan.^ Furneaux: Pulmonary embolism 
following delivery, 552— Hydatidiform mole, 
5)2 

Jordan, Rose: Delayed notification of tuber- 
culosis, 692 


1 8 JAH.-JUNE, 1928] 


INDEX, 


[ Tns XJnmBB 
Meoicai. Jonmii, 


JoTiKowjTZ, Paul : Lelirhuch der Viifallheih 
Itunde, rev., 106S 

Journal of the Egyvtian 7>,Tedical Association 
DOW contains summaries of articles in various 
languages, 617 

JonrnSes M^dicales de Paris. See Congress 
JowETT, (and others) : Metabolism and 
acidity of the foetal tissues and fluids, 126 (O) 
JoTNT, Bichard Jjane, obituary notice of, 693 
JuARRos, OSsar, elected a member of the Spanish 
Royal Academy of Medicine, 203 
Jugoslav provinces, medical tour to the, 333 
JuiiiAN, F. B. : Emphysema and wind instru> 
ments, 244 

Jury, coroner’s, and hospital arrangements, 768 
Jury’s verdict criticized (Tyndall v. Alcock), 
528, 807 


K. 

Kahlmeter, Dr. : The sedimental reaction in 
rheumatic diseases, 856 

Kahn, R. D. : Clinical aspects of the Kahn 
reactions, 848— Test for syphilis, 848 
Kahn, Wassermann, and Sigma tests compared 
(T. E, Osmond). 440(0) 

Kala*azar, review of book on, 1069 
Kajial, H. : The 1927 epidemic of dengue in 
Egypt, n04(O) 

Kark, S ' I -f I 

Karop, ■ ■ 15 

Karsne .. .A 

Texihoo}:. rev., 599 
^^'AUSCH, Walther, death of, 1005 
EEN, W. "W. : Ninety-first birthday of, 203 — 
Chair of surgery to be endowed in the Women’s 
Medical College of Pennsylvania in honour of, 
203—The early days of antivivisection, 291 
Keevtlii. a. J. : Full-time abdominal pregnancy: 

prolonged suppuration : recovery, 801 
Ketbbl, Franz: Eulogy of William Harvey, 866 

le Brain 
„ AvDlieCL 

■ nality of 

of Sir 
of Dar- 
winism published in full in the English Review 
for June, 1007 

KeIiI/T, a. Brown: Dysphagia associated with 
anaemia, 467, 610 — Cardiospasm (so-called 
achalasia of the cardia), 773 
• Kelhv, F, Greene : Sea-sickness, 930 

KEI4I.V, Howard A. :— Hunterian Lecture : John 
Hunter, lOZ— Gynaecology, rev., 634 
Kelhv, B. E. (and Walter J, DiIiLIKg): Gan- 
grene following the use of ergotized rye bread, 
540 (O) I 

Kepser, Raymond A. : Jilanual of Veterinary 
Bacteriology, rev., 60 

Kenx)ai.X/, James, elected professor of chemistry 
at Edinburgh, 371 

Kendalp, j. a. : Precocious menstruation, 534 
Kennawat, E. L.. awarded the William Julius 
Mickle Fellowship, 199 
KI'NNEDT, Dr. : Puerperal haemorrhage, 222 ^ 
Kennedt, D.: Thyroidectomy in toxic goitre, 
353 

Kennedv, J. R., Royal Humane Society’s medal 
presented to, 195 

Kennedy, William P. ; Foreign body in the ear 
for thirty-six years, 14 

Kennon, R. : Cystoscopy in carcinoma of the 
cervix. 668— The origin of ischaemic contrac- 
ture, 1001 

Kensington, deaths from childbirth in (parlia- 
mentary note), 1096 

Kenya: Tsetse fly in, 290— Medical and sanitary 
services in (parliamentary note', 428 
Kenya and East African Medical Journal ; 
Article on differentiating the anopheline mos- 
quitos, 119— Account of the annual meeting of 
the Kenj’a Branch, B.M.A., 617— Contents of 
February issue, 617 

Keogh, Lieut.-Qeneral Sir Alfred : Appreciation 
of Sir Dawson Williams, 424 
Kerh, W., appointed director of the dermato- 
logical clinic at Vienna. 429 
Kerr, Douglas, appointed medical adviser to 
the Edinburgh Corporation, 686 
Kerr, J. M. Munro: Pelvic inflammation in 
women, 98 

Ketosis and alkalosis,'402 

Keynes, Geoffrey : A Bibliography of the 
Writings of William Harvey, M.D.. Discoverer 
of the Circulation of the Blood, 1628-1928, 913 — 
(Editor) The Anatomical Exercises of Dr. 
Williajn Harvey: De Mottt Cordis 1628: De 
Circulatione rev., 948 

Khaetl, M. : — Vesical bilbarzia : double infec- 
tion, 546 

IviDD, Frank: Treatment of urethral stricture 
by excision, 549 

Ktdd, H. Cameron: Severe anaphylaxis. 582 
Kidney, non-excretory functions of the (Pro- 
fessor Snapper). 759 
Kildare Board of Health. 282 
Kiedtjtfe. Robert A. ; The Clinical Inteyrreta- 
tinn of Blood C/ic/ntsfri/, rev.. 556 
Kilner. Henry Goff, obituary notice of. 577 
Kiener, T. Pomfret : Treatment of hare-lip, 
1025. 1129 

King, W. W. : Carcinoma of the cervix, 57 
Kinkead. Richard John, obituary notice of, 

575 


Kinnear, Sir Walter 6.: Social aspects of 
rheumatic diseases, 852 

Kinnersly, George Edward, obituary notice of, 
201 

Kitcat, 0. do W. (and T. Holmes Sereorb): 

pulmonary fibrosis, 1018 (O) 

Klapp, Rudolf, appointed professor of surgery 
at Marburg, 479 

KEnsNEBEROER, Carl: Die Blutmorphologie dir 
Laborotoriumstiere, rev., 455 
Keeinwachter, L.. death of, 785 
Klumfee-Dejerine. Madame, death of, 240 
Knott, F. A. : Gall-bladder infections, 612 
Knox, Colonel R. W., appointed honorary 
surgeon to the King. 201 

Koeberli!:, Eugdno, centenary' of the birth of, 
203 

Kohlrausoh, Arnt. appointed professor of 
physiology at Tilbingen, 479. 617 
Koli-E, W. (and A^^. Wabserjiann): Handhttch 

• . . der 

‘ “ Plata 

to become the director of an experimental 
therapeutic institute, 533 
Kyltn, Eskil : Der Qehalt desBlntesan CalcUim 
nnd Kalitttn, rev., CO— Die HypertonieUronl:- 
heiten, rev., 266 

KvNOOn, J. A.: Malignant complications of 
uterine fibromata, 803 


L. 

Laboratories of tbo Pharmaceutical Society. Sec 
Society 

Laboratory methods in diagnosis. See Diagnosis 
Laboratory, National Physical : Report, 679 
Labour:— Complicated by measles. encophalitiB 
lethargica, and diabetes respectively : three 
cases (0. W. Somerville). 980— Difllcult, in an 
aboriginal (J. B. Cleland). 219— Ear presoota- 
tion, case of (O. G. Walker), 1065 — Painloss 
natural, 120. 164.291.480— Premature, induction 
of in relation to mental disease (R. Percy 
Smith), 9 (O)— Rapid first labour, 382— Rupture 
of uterus early in first stage of (Grace Staple- 
ton). 893 (0) 

' ■ » — • .1 convention on 


Labour Ottice, International : December number 
of its Bibliography of Industrial Hygiene con- 
' * * * '* ’'ysiology.etc., 533 

>h accumulators 
aniline, arseni- 
r aviator’s sick- 
ness, and tetra-ethyl lead, 581— 0& the bakery 
trade, bleaching, breathingapparatus, respira- 
tors and gas masks, cadmium, carbon bisni- 
pbide, carbon tetrachloride, cobalt. 741— Elec- 
tricity, flax and linen industry, phosphuretted 
hydrogen, goggles. hemp manufacture, odours, 
arsenobenzol. artificial flowers and artists, 
liftmen, the stone Industry', sulphate of soda, 
sulphuretted hydrogen, nitrogen, amino- 
phenols, anisidines. anthraquinono. antimoni- 
uretted hydrogen, and apoatropino. 1C96 
Lacey. F. H. : Dystocia due to vaginal atresia, 
263— Combined concealed accidental haemor- 
rhage sod unavoidable beemorrhago, 498 
Lactic acid exempted from key industry duty, 
741 

Ladele. R. Macdonald: The cause of an anxiety 
neurosis. 444 

Laguesse, Edouard, death of, 240 
Lake, Norman O.: Gas gangrene following street 
accidents, 74 

Lake. Richard (and E. A. Peters): Handbook 
of Diseases of the Ear, fifth edition, rev., 184 
Lakin, 0. E. : Liver diet in pernicious anaemia, 
179 

Lambeth Hospital. See Hospital 
Lambie, Charles G., awarded the Lister Fellow- 
ship ot the Royal College of Physicians of 
Edinburgh, 830 

Lamp, radiator heating, 38. 480 
Lancashire, Cheshire, and North Wales Council 
of the British Empire Cancer Campaign: 
Address by Prince Henry, 465 
Landon, Miss: The protection of maternity, 463 
Lane, Lieut.-Col. Clayton : The gorilla at home, 
7C0 

Lang, Basil Thom, obituary notice of, 162, 201 
Lanqeey. George J. : Some problems of glycos- 
uria, 1016 (O) 

Lapwings Protection Act. 615 
Laquer. Fritz: Hormone undinnere Sehretion, 
rev., 985 

Larbert Colony Scheme for Mental Defectives : 

Report, 518 — Meeting and appeal, 1124 
Larj'Dgeal diphtheria. Diphtheria 
Larmgaal m>'xoedema (James Adam), 594 
Laryngeal nerve. Nerve 
Laryngo-fissnre in intrinsic cancer of the larynx 
(Sir StClair Thomson), 743 (O)— Leading article 
on, 764. See also Cancer 
Laryngology, review of book on, 1027 
Lasker, Albert D,, founds the Lasker Founda- 
tion for Medical Research, 81 
Ladder, Sir Thomas Dick: The Great Floods of 
August, 1829, tn the Frovince of Moray nritl 
Adjoining Districts, 360 

Lausanne Medical Graduates’ Association : 
Medical men approved for theM.D. degree, 37 


Lawen, Dr., appointed professor of surgery afe 
KOnigsberg , 163 

Lawrenci:, R. D. ‘.—The Diabetic Dife : Its Con- 
trol by Diet and Insulin, rev.. 16— Non- 
excretory functions of the kidney, 759— Oral 
administration of pancreatic preparations, 
875, 1098— (And A. 8. Hollins); Two cases of 
haomaluria caused by insulin treatment, 977 
(O) 

Lazarus . Barlow. P. : Tbo causation of rheu* 
551 

' . • (eeaso treated by 

, ■ '—Correspondence 

on, 958. 999. 1047, 1087. 1134 

Lead, colloidal, s ' *’ "action 

of on tumours ( 

Lead Paint Act: . (parlia- 

mentary note), 

Lcad saUs, volatilo, poisoning by. 114 

r " ‘ ‘ 74.363.366.380.381.409. 

. ■ . 0, 831, 965. 1001, 1033— 

* to petrol, 61— Leading 

articio, 64— Correspondence on, 74, 409, 1001— 

- , . !• t, 30 ^—. 

. . )7. 830 

. ' . and 

reports of. 619, 741. 770. 871. 965. 1033. 1073— 
Evidence from America, 770, 1073— (F. W. 
Toms and O. P. Money), 831 

Leading Articles : 

Anaemia of malignant disease, 721 

Biochemical products. 188 

Breast-feeding. 602 

British laryngology, 764 

Cancer of rectum, early diagnosis of, 505 

Clinical teaching in medicine, 316 

Collective research, 21 

Consultants and the National Health Insur- 
ance Bill, 811 
Cranial incisions. 317 
Death certification, tbo values of, 227 
Delnsions, reality of. 457 
Dental sepsis, obscure. 1036 * 

Dysphagia associated with anaemia, 636 

Epilepsy, 601 

Factors in vision, 63 

Fracture problem. 635 

Fundamentals of a medical service, 950 

Gall-bladder disease, 508 

Gall-bladder infections. 21 

Gastric symptoms, interpretation of, 1075 

Glaucoma, 812 

Harvey Tercentenary, 810, 906 
Heart symptoms, interpretation of, 1035 
Hunter, John, 271 

* f 


Liver treatment of pernicious anaemia. 188 
London sewage and the River Thames. 676 
Measles, spread of, 560 

Measles treated with convalescent serum, 189 
Medical service, fundamentals of a, 950 
Medicine in the field of life assurance, 401 
Milk (pure) progress, 764 
Milk and the rate of growth of school children* 
146 

Ninety-sixth year, 1034 
Nutrition and malnutrition, 104 
Osteomyelitis, acute, 456 
Pain, diagnostic value of, 561 
Parliamentary session, 22 
Pillars of health, 507 
Public health, a new way in, 228 
Puerperal sepsis. 989 
Rheumatic disea'^es, 860 
Tetia-otbyl lead, 64 

Tuberculosis, clinical differences in, 147 
Tuberculosis, decline of, 721 
Tumours of the frontal lobe, 1074 
Unborn child, tbo right of the, 145 
Wassermann reaction in pregnancy, 272 
Williams, Sir Dawson. 103— Death of, 361 

League op Nations : 

Cholera bilivaccin, 274 

Decrease in number of cases of small-pox in 
European countries. 1132 
Health organization of ; Report. 814 
Health work organized by (Sir George 
Buchanan), 615 

International control of drugs of addiction, 
^ 907 

(1927). 649 
312; and tho 

List of publications of the Health Organiza- 
tion. 883 

Report on human trypanosomiasis, 225 
Special courses in malaviology, 649 

Leahy, Dr. : Theories of suggestion, S3 
Leahy, M. P. : Etiology of alcoholism. 596 
Leake, Chauncey D. (editor) : PercivaVs Medical 
Ethics, rev., 984 

Leake, J. P. : Evidence on lead tetra-ethj’l in 
motor spirit, 1073 

Lecture. Bauks [Mitchell] Memorial ; The gall- 
bladder and its infections (Sir Berkeley 
Moynihan), 1 

Lecture, Boyle [Robert] : Climate and disease 
incidence in India (Sir Leonard Rogers), now 
published in pamphlet form, 333 



JAN.-JTJNK, igiS'J 


IKI>EX. 


[ 


Tn* Bnmsu 

MUDICil. JouK-Kii. 


19' 


lioctnrc. Croonl'vn : Physiology o( tlio corobvol 
hoiulsph *vo8 (1. P. Pftvlov), 8G9 
Tioctnro, Dohmo (102$), 228 

lioclnro. GnUon: Matuml cn\>aclty la the popu- 
lation (0. J. Bond). 315 

I^ccturo, OutUrio, 381 , ,i . 

Iiocuuo, Hftvvoian: Toxicology In inlntion to 
medical practico ’Rlr WIlUaui illcox), 501 
Lcctnro. Hastings [Sic 0 'arlosj. 3GG. 506— Iho 
foundations of lioaith (Sir Goorj^o Nowiuan). 

ti^vuo. Tionil Fox Memorial: Tho reality of 
delusions (Henry Doviuo), 457 
Iiccluro, MacAllslor: Medicine in art (Sir 
Berlxoloy Moyniban).lC44 
Lecture. Mandeloy: Tho now psychiatry (Sir 
John Maephorson). 905 ^ , 

Lecture. Pasot [Stephen! Memorial'. TV\o woth 
and roaponsibililios of tlio pathologist (Sir 
Bernard Spilahury), 1079 

Lecture, Uode: Stimulus in tho economic life 
(Sir Jostah Stamp). 357 

Lecture. Bichardso'i [BoniainlnWard]: Methods 
of slaughtering (Gerald liolghtou), 8(>5 
Lecture, Yioary [Thomasl : The homes of tho 
Hunters (George C. Pcaehoy), 276 

Lectures. ChadNvick: 

Uundtecl years (Sir 
light In modern • 

859 

Lectures, Croonian: Tho iolorprctatlon of 
gastric symptouia (Charles Bolton). 030 
Lectures, Ooulatonian: Some probloms in 
nopbrltls (T. Izod Bennett). 513 
Lectures, Hunterian, 25,108, 291 — .lobu Hunter 
(Howard Kelly), 103— Mow methods of surgical 
access to tho brain (H. S. Souttar), 295 
Loctures. Lumloiau: Epilepsy (James Collier), 
557 

Lectnres. Morlson: Psychology and modicino 
(John Carswell), 872 
Lnh, A.: Flushing of tho hands, $81 
Leeds : School of Dentistry, 72. 518— Post- 
graduate courses in, 333, 531— Maternal mor- 
tality: visitor tho iMinisior of Health. 873 
Lr.EMiKO, A Norman: Correction re treatment 
of prostatie enlargement, 38— Treatment of 
Ij'mpbatic obstruction, 534 
Lr.ns, David ; Vulvo-vagmltls la children, 221 
LkkSi Kconcth A.: Dysphagia associated with 
anaemia. 5.‘1 

Leggett, Bernard J. : The Theory and Traetice 
of Jiaflioififfv.rev., 801 

LeqicakKiK. B (and It O, Neumann) : Baf.itfWo- 
loflic insdrsondere hahteriolootsehe Diignosttk, 
rer.,986 

LEZcEsrnn, Lfeufe.-Coi. J. C.; Report on tho 
working of hospitals and dispensaries in 
Bengal. 285 

LEtomon. Gerald: * 

Loctnro on methods c 
Leiper. R. T. : a 
Dihothriocephalus Int.,.., u lu 
Lrisa^uK, Sir James, appointed chairman of 
the Scottish Board of Health. 640 
Leishhak, Sir William, momorial tablet to, 
865. 991 

Lelean, P. S. : Teeth of the working classes. 
917 

Lenobee. Emile Alexandre, death of, 1005 
Leo, Hans, death of, 79 

Leosard, William Eller>’: The Loccyjtotive-God, 
rev., 501 

Leprosy, campaign against, 1071 
Leprosy in Palestine (parliamentary note), 881 
Leri, Audr6: Etudes sur les affections de ia 
colonne vertfbrale, rev , 901 
IjEroux-Rodert, Dr.: La Haute JF’r^ouencci e« 
(Ho-Rhino-Earynaoloffie, second edition, rev., 
902 

Lesage, A.» elected araemher oi t\ve Acad€m\e 
de M<^decine, 81 


Leuicaem^, etiology of (H, M. VroodmaD). 50 (O) 
Leukaemia, snlenotnedullarj’-in an x-T&y worker 
(Howel Evans), 135 

Levaditi, O.. awarded the Cameron prize, 997 
Leraute MctXico, first issue of. 479 
Levi, David : Intravenous treatment of varicose 
ulcers, 895 

Levioe. G. Murray: The pnlplcsa tooth. 548 

Max: An Introduction to Laboratorv 
Technique in Bacteriology, rev.. 670 
1U5®°^‘ “Ambidex” WTist splint. 

^9^ * Cardiac malformationB and endocarditis, 

Octavia; Infectious disease in schools, 

T ?r* natural variation. 768 

pamphlet on the 

work of the firm. 109$ 

^44^^'^^*^*^^’ marine health resorts, 

^ &IuSch'^429' professor of surgery at 

Libel, damages for, awarded to Dr. W. S. 

Henderson), 831 »* . «. 

Libman, E. : Partial death. 865 
LiosroHBERG. A. (p. VOELCKEB, and H. WiLD- 
BoiiZ) : Handbucii der Urologie, rev 398 

anniversary of the birth of, 


Lieseoano. Raphael Ed. : ir»»»<*n»ehn/llielie 
J'’orsc7Moio.ibc»'ic7i e IfaturwiKsenschaftltche 
Retkr, Band xix. rov., 985 
Life assurance, medical oxamiuatlons for. 376, 
411 

Life a^Burauco, medicine in the field of (leading 
article), 401 

Life nssuranco In the tropics (J. F. 0. Haslam), 
218 

Ligament, broad, two cases of twisted, with 
CYBta (Gibbon Fit7.Glbboti1,318 
Light, artitlclal. treatment by in London. 465 
Light and Heat, Iniornationol Conference on, 
London, October (1923). 1006 • 

Light. Phydcnl, Biological, and Tliorapeutlcal 
Aspects of. Intornational Conference on, 
Lausanne, September (19281. 1C06 
Light therapy awd immunity (leading article), 
362 

Lighting and flno work, report on. 863 
Lighting nows for motorists, new, 700 
LTONihREs. J. : B.C.Q. and non-tuberculous 
infants, 909 

Limo-deficlont food and carditis, 618 
LiumzEU, Karl, appointed professor of oph- 
Ibalmology at Vionna, 1097 
Lindsay, Douglas Marsliall: Trauma and 
Compensation in Obstetric and Gvnnecolooical 
Cost’s, rev.. 918 

Lindsay, Dr.: Forceps doU very and prophylactic 
gynaecology. 353 

Lindsay, James: Tho cause of chronic rheu- 
matism. 856 — Organization of discussions. 
877 

Lindsay, James A., farowoll dinner to. 770 
LipptMfoH’5 Pocket Formulary, rev., 393 
LirscnCTZ, Alexander: Las Secreeionesintemas 
de las QUUnlulas SexuaJes, rev., 139 
Liquor (DialnloresVod Ownership and Manage- 
ment) Bill. 1131 
Lister in Glasgow. 191 

Lister collection at the Wcllcomo Historical 
Medical ^[U6onm : Replica of presented to tbe 
American College of Surgeons. 81 
Lister Institute: Annual general meeting and 
aunnal report, 951 
Liatorian In Alabama. 582 
Lltbolapaxy. a plea for tbe operation of, 3039, 
1128 

Little. E. ' * * and 

public an; . . , 'ora- 
tion Bill, ) re- 

oicction o* sn 

boDorar>' member of tbe Norwegian Medical 
Society, 883 

Liver diet in tbe treatment of pernicious 
anaemia (F. A. Pbillipps), 93 (O) — (H. F, 
Brower. A Q. Wells, and F, R. Fraser), 1^ (O) 
—Discussion. 178*- Loading article, 188— Report 
by tbe Medical Bcsearch Council, 398, 463— 
(C, F. T. East). 491 (O) 

Liver diet for pomicions anaemia, recipes for, 
102,243 

Liver diet for secondary anaomia, 244 
Liver diet: **G1anoid” concentrated fluid ex- 
tract of liver, 186 — The Wellcome liver extract, 
502— B.D.H. liver extract, 806 
Liver, yellow atrophy of following administra- 
tion of atophan (L. J. A. Loewenthal, W, A. 
Mackay, and E. Cronin Lowe), 592 (O) 

Liver. Sre afro Hepatic 
Liverpool, ante-natnl clinics at, 741 
Liverpool Medical Institution. See Institution 
Liverpool Medical Research Organization. See 
Research 

Livestock. Voronoflf's experiments on. See 
Voronoff 

Livingston. A. : The pulpless tooth, 549 
Livingstone College. See College 
LiviNOBTONt:. David: Surgical pocketcaso of 
pte%entedtothe Royal Faculty of PhyBlciaas 
and Surgeons of Glasgow. 281 
Ldeweddtn. R. L. j. : Prevention of chronic 
rheumatism, 857 

Ldewe^ ’ ^ ^ ' and civil 

and c 

I''iOTD Iho tsetse 

fly, 275 

Lloyd, W. D. Sf. : Dangerof intravenous calcium 
therapy, 662(0) 

Lobenstine, R. W. (and H. C. Bailey): Pre- 
natal Care, rev., 1113 

Local Authorities (Emergency Provisions) Act. 
^426, 472 

Local Authorities (Officers and Employees) Bill 
[Irish Free Statel. 1126 

Local Government employees, superannuation 
of : Soport of Departmental Committee, 511 
Local Government. Royal Commission on • 
Report. 242, 830— Minutes of Evidence, Part x] 
now on sale, 699 

Lock, Norman: Surgical treatment of chronic 
gastric ulcer, 451— Case of mastitis, 946 
Lockhart-Mummert, j, P, ; Current views of 
shock and collapse. 54— Early diagnosis of 
cancer of rectum and colon, 847 
Lockyer, Cuthbert (and Thomas Watts Eden) * 
GyuMcoloau for Practitioners and Students. 
third edition, rev., 396 

Lodge. Sir Oliver : Science and Human Progress. 
rev., 671 

Loeb. Jacques, memorial tablet to, 232 
Lo^er, Dr. appointed proles sor of therapeutics 
^I^Faris, 29— Legion of Honour conferred on, 

Loew, The promotion of calcium reteu- 

lion, 894 (O) 


Loewenthal, L. J. A. (W. A. Mackay audB. 
• Cronin Lor'e) : Two cases of yellow atrophy of 
liver following administration of atophan, 
592 (O) 

Lomon, A.(M. Ciiiray and I. Pavel): Lavhicule 
bitinire, rev., 265 

London : 

Birth rate for (parliamentary note), 830 
Child guidance clinic, proposed, 957 
City of, annual report of coroner of, 1084 
Coroners’ inquests in (1927), 642, 1084 
(jounty Council. See Council 
District nursing in. 373 
Flood disaster in, 112, 408 
Lunacy returns, 688 
Physical treatment clinic in. 33 
Rheumatic diseases clinic, proposed, 152. See 
also Rheumatic 

Scottish medical students visit, 533 
Bewago and the river Thames (leading article), 
676 

Small-pox in, 324. See also Small-pox 

London Association of the Medical Women’s 
Federation. See Association 
London Inter-Collegiate Scholarships Board : 

Medical scholarships, 881. 1093 — Rewards, 1093 
Longevity and alcohol, 148 


^lentiil Patients tn Euglanil nnd Wales: A 
Historical Survey, 353 

Loruain-Ssuth, Isabel isnd others) A Physio- 
loaical InvesUoation of the Itadiant Heatin-j of 
Various Butldinos, 458— Tiro Studies of Hour s 
of Work : (1} Ftve-hour Spells for Women unth 
Itejerence to Best Pauses: (11) The Tivo-shift 
System tu Ceriain Factories, 103 
Lodohdorodgh, G. T. : Fibrosiiis, 758 
Lodghnane, F. McG. : Litholapaxy, 1128 
Love, R. J. McNeill : A Shorter Surgery, rev-, 1£5 
Love, W. G., action against, 328 
Low, Q. C. • Health lessons from Bermuda, 443 
Low, R. Cranston; T7ie Common Diseases of the 
Skin, rev., 100 

Low, V. Warren : Chronic appendicitis in 
children, 349 

Lowe, B, Cronin (L. J, A. Lowenthal and W. A. 
Mackay) : Two cases of yellow atrophy of liver 
following adminUtratloD of atophan, 592 (O) 
Lowe, Q. : Recovery from tetanus, 757 
Lubricant for apphiog zinc ionization to the 
male urethra (C. F, Orr White and B. Buck ey 
! bhatp), 9b 

I Lucas. William Palmer: The Modem Practice 
j o/Pedt'nf rtC5, rev., 453 -(And A. H. Washburn) : 
I Diseases of the Blood and BZood-buRdtnff 
> Organs, rev,, 1113 

Luce, Sir Richard H.: Edinburgh Corporation 
Bill. 376 

1 Lumbar puncture, therapeutic value of, 184 
Lunacy certifiCAtion: Medical responsibility for, 
S21— Parliamentary note, S25 
Lunacy reform in France, 402 
Lunacy returns for London, 688 
Lunaej', Royal Commission on, recommenda- 
tions of (parliamentorj’ note). 925. See olso 
Mental 

Lung, embolism of apex of (W. A. Bees). 494 
Lupus erythematosus, ultra-violet light treat- 
ment of, 411 

Lupus vulgaris, treatment of (J. Beatty), 47 (0) 
Lyall, Alexander : Basal metabolism. 717 
Ltcext, John Allen, obituary notice of, 527 
Lymph, vaccine, calves used for (parJiamentarj* 
note), 532 

Lymphadenitis, simple ileo-caecal (C. Jennings 
Marshall), 631 (0) 

Lymphadenoma and relapsing pjTcxia (A. Salus- 
bury MacNalty), 819 

Lymphatic obstruction, treatment of, 534 
Lynch. Edmund IVilliam : Mercury salicylate 
injections in chronic ulceration, 802 
Lynch, G. Roche : Medico-legal aspects of 
criminal abortion, 452 

Lynham, j, E. a.: Present position of radium 
therapy, 457 

Lyons Faculty of Medicine, 29 


51. 


X , X*. Vttuu Jiliam XJ. X UNlUiOusEIl/ : 

Diseases of the Jtesyirator^ System in Infants 
and Children, rev., i38 

MacAlister, Sir Donald : Appreciation of Sir 
Dawson W’illiams, 416 
MacAlister Lecture. Nee Lecture 
Macadlum, a. B., retirement of, 516 
McArdde, John Stephen, death of. 681— Obituary 
notice of, 734 

MacArthur, Colonel W. P.; Epidemics in 
Pepys’s Dian*. 319— The cause of the death of 
William, Duke of Gloucester, son of Queen 
Anne, in 1700, 502 

George Birmingham : The 
Essentials of Otology, rev., £00 

PQ^^onary and gastro- 
intestinal sequels of naso-oral sepsis. 98— 

S” 8®76“ Wg-Dead and infected 

(end J. H. fj. CtJMpsTON) • The 
Btstorv ofTlaaue in Australia, 1900~im.203B 



20 JAN.-JUNE, 1928] 


INDEX, 


[ The nsiTitn 
VeDICAX JoURNit. 


McCaxn, Frederick J.: An operation for tlie 
cure of prolapse of the rectum in the female, 
890(0) 

McCann, J. F.: Treatment of cancer of tbo 
cei vix, 547 

-McCauhibon, Lieut. -Col. Robert: Diseasfs of 
faulty nutrition, 92 {0)—The Simple Qoitres, 
rev., 1067 

MacCartsy, T. : Placenta praevia in four 
successive pregnancies, 95 
McCarthy, Lieut.- Co'. W. H. Leslie, appointed 
assistant coroner for the south - ej-storu. 
clis rict of London, 203 

McCartney, J. E. : Diphtheria carriers. 181— 
The carrier problem, 445 
McOaw, John : Aids to the Diagnosis and Treat- 
ment of Diseases of Children, sixth edition, 
rev., 454 

McClements, S. : Tumour of the brain sitnulal- 
im: encephalitis ethargica, 1061 (O) 

McCi.’DnE. Campbell : Physical treatment of 
rheumatic disease, 857 

McCombs. Carl E.: City Health Administration, 
rev., 224 

McCormick, H. L. : Treatment of acute pneu- 
monia, 376 

McCormick, Sir Wil iam S , elected a Fellow of 
the Royal Society, 1122 

McCracken, G. : Deltoid shelf, 986— An internal 
T-strap, 986 

McOrea, E. D’Arcy : Vaccines in the treatment 
of gonorrhoea, 755(0) 

McCdli,och, R.. resignation of, 822 
McCotcheon, j. G., dinner to, 163 
MAoDoNAiiB, Arthur; The science of Icfiis’ative 
anthropology, 150 

Macdonald, A. D. : Chemistry and pharmaco- 
logy of ergot. 410 

Macdonadd, D. M. ; Drug treatment of pneu- 
monia, 334 

Macdonald, Ian: Intns^-nsception in an aduU 
due to a polyp of Meckel’s diverticulum, 442 
(O) 

Macdonald, James A’exander : Appreciation ^f 
Sir Dawson 'Williaras, 422 — Death of. 725— 
Obituary notice of, 781 

Mac DouGALL, John Aymers. obituary notice of. 
j092 

MoDowall, R. j. S. : Asthma Research Council, 
468— (Editor), The iltTid, rev., 555 
McElligott, M. F.: TheiRi>eutic value of 
lumbar puncture, 164 

Macbwen, John A. C, • Treatment of rectal 
prolapse by injection, 633 — Thirty j'ears’ sur- 
vival after excision of tongue, 884 
McFadden. G. D. P. : a correction re mesenteric 
lymphadenitis, 38 

MoFadzean, j.: Foreign body in the b’addor 
causing calculus formation. 665 
jVfoPARLAND, B. L. T Hemihypertrophy. 345 
Magpie. J. D. : Diagnosis of ’‘pleural shock” 
from cocaine poisoning. 715 
McGibbon. John E G, : Mixed tumour of the 
sasopharynx, 664 10) 

McGrath, J. J. : Fractional test meals, 1026 
MACGREGOR. A. S. M. : Report on the health of 
Glasgow. 194 

MacGregor, Dona'd, obituary notice of, 1129 
MACGREGOR, Malcoim E.: ilosQUtto Surveys, 
rev.. 455 . , 

McIlroy, a. Louise; The influence of parturi- 
tion upon insanity and crime, 303 (O) — Mid- 
wives and ante-natal work, 466— Breast-feeding, 
602— Treatment of eclampsia, 1066 
Mackat, K. L. : An atypical case of hyper- 
gb caemia in gencx*al anaesthesia. 892 (O) 
Mackay, W. a. (D. j. a. L ewenihal and 
E. Cronin Lowe): Two cases of acute yellow 
atrophy of the liver following adrainistratiou 
of Rtophan,592 (O) 

Mack i*E, George M. ; X rays and Radium in the 
Treatment of DUeases of the Slci”, second 
edition, rev., 17 

MagSenna, Robert W. : Diseases of the S'/v.ii, 
second edition, rev , 599 
Mackenj ‘ ' 

tomy u 
McKenz . 

and Ear, second edition, rev., 355 
Mackenzie (James) Research Institute. See 

Mackenzie, Sir W. Leslie : Progress in public 
health in Scotland, 463 — Retirement of, 996 — 
Presentation to. 997 

Mackenzie (William) Memorial medal, 917 
Mackenzie Institute for Research. See Research 
Mackev, Leonard G. J. ; Treatment of acute 
pneumonia. 639 — Pyrexia due to infected dead 
teeth. 1C2 (O) 

Ma KiE, E. Gordon* Occlusion of the central 
retinal artery, 286 

Mackie, T. J.: An Inquiry into FosUoyerattve 
r<*mrius.987 ’ 

McKinlay, Peter L , awarded the Nichols prize 
of the Royal Society of Medicine, 605 
MACKi.sToaa. Aeh’ey W., appointed honorary 
physician to the King in Scotland, 605, 640 
Mackintosh. J, Stewart; Blood group i>er- 
centages, 732 

McKisack, Henry Lawrence, obitaary notice of, 
613. 636— Proposed memorial to, 685, 822, 998 
MACLACHL.\!y, B., appointed principal assist- 
ant secretary to the Ministry of Health, 831 
McLauen. Ada: Treatment of vulvitis. 204 
Maclt.an, Sir Ewen J. : Historical Rxliihitinn at 
Cardiff, 520— Appreciation of James Alexander 
Macdonald, 782 


lilAOLEAN, Colonel Filzroy Beresford, obituary 
notice of, 80 

Maoli;an, George, M.B.E. conferred on, 988 
MacLean. Hugh: Gastric secretion of neutral 
chloride, 374— The inteneivo alkaline treat- 
ment of gastric and duodenal ulcer, 619 (0) 
^IacLennan. Donald’ Haomonliage from the 
deep epigastric artery into the rectus abdo- 
minis, 895 

IiIacLeod, Dr, : Mycological conditions of the 
skin, 180 

Maoleou. John James Rickiu'd, anpoinlod 
Regius professor of physiology at Aberdeen, 
685 

MacLeod, J. M. H. : Ringworm and its treat- 
ment, 656 (0) 

Macmillan, D. : Calcium and carbonic acid 
content of the serum in chronic rhemnatoid 
arthritis, 519 

MacMillan. John, obituary notice of, 36 
MAoMDnenv, Helen: Maternal mortality in 
Canada, 6(>4 — T7ic Canadian Mother's RooU, 
rev.. 949 

MaoNalty, A. Salushury: Report on lymph- 
adenoma and relapsing pyrexia 819 
McNamaua, J.: Lead treatment of malignant 
disease. 1134 

McNe l. ObarlcB’ John Thomson. 156 
MAOPiiEiisoN, Sir John: Maudsley Lecture on 
the new psychiatry, 903 

MgQoeen, James M. : Patbogencsie of acute 
primary glaucoma, 919, 1086 
McReddie. George Dougal, obituary notice of, 
926 

McsuiSE. Arthur Hotton, appointed an un- 
offlcial member of the Legislative Council of 
Trinidad and Tobago, 619 
Madeira, British doctors in. 571 
Madill, D. G. : Veatco-vagioal flstulae, 3^8 
Madness, Court etiquette as a cause of. 82 
Maber, Major-General Sir James, obituary 
notice of. 160 

MaBONY, M. j., obituary notice of. 79 
Matdlow, W. H.: Treatment of acute pneu- 
monia, 238 

Mainot, Ren6 : Tuberculosis In France, 814 
Maitland, T. Qw'ynne: Sea-sickness, 877 
Iilalaila prison camp, dy’seutery at. Dysen- 
tery 

Malaria, infection of Barbados with. 66, 114, 157 
Malaria with lobar pneumonia and diphtheria, 
292 

Malaria. Scottish Board of Health leaflet on, 281 
Malarial treatment of general paralysis (A. 
Eager) 1023 

Malarlology. special study courses in, 649 
Malaya, health of the European child in 
(G. A. C. Gordon), Zl^HandKoh to Ryilish 
Mal iy'^t 2027, rev., 949 

Malcolm, J. D. : Ourreut views of shock and 
collapse, 54 

Malignant disease, the anaemia of (leading 
ai tide). 721 

Malignant dlsea«e treated by colloidal lead 
(sianley Wyard). 858 (O). 1047— Correspondence 
on. 958. 999. 1047. 1087, 1134 
Malignant disease. a/so Cancer 
Malkin, Sydney : Anaesthetics in obstetrics, 395 
Malnutrition, experiments in (V. H. Motlramb 
88 (O), Sec olao Nutrition 
Malonal-urea (barbitone) derivatives classed as 
dangerous substances by the French Academy 
of Medicine, £81 

Malone, Major R. H.: Cholera bacteriophages, 
365 

Malpighi, Marcello, three bnndreth anni- 
versary of the birth of, 741 
Mammary connective tissues, pathology of (Sir 
G. Lenthal Obeatle). 550 
Manasse, Paul, death of. 79 

Manchester: Cancer research in, 282— Post- 
graduate courses in, 333 

Manganese and thyroid treatment of disease 
(Herbert W. Nofct). 94 (O) 

R/akknell, Arthur, obituary notice of, £26 
Manson, j. s. : Poisoning by volatile lead salts, 
1 4— Hereditary icterus or familial acholuric 
jaundice. 131 (O)— Appreciation of Sir Dawson 
Williams, 424 

Manson-Bahr. Philip: Outaneons mycoses in 
thetropics, 180— Health le sons from Bermuda, 
448— (A. Graham-Stew'art and T. R. God- 
dard): An outbreak of paratyphoid B fever 
presenting novel features, 934 (O) 

" ' *■ alcoholism, 595 

■ ■ • case of blasto- 

mycosis of eye and face secondary to lung 
infection, 443 

Mabgolves, j. : The value of localized sina- 
pisms, 82 

Marie. Pierre: Travauxet MJmo/rcs, rev., 762 
Marine health resorts. See Health resort 
Marines, Royal : rejections and acceptances 
I parliamentary note). 290 
Marjoribanks, Lieut.-Col. J. L. : Fractures of 
the clavicle with displacement, 878 
Markson, A.:— Erythema nodosum and acute 
endocarditis following tonsillitis : recovery 
after treatment with autistreptococcus serum, 
715 (O) 

Maulin, Thomas: Treatmentof ’* tennis elbow,” 
159 

Marnoch, John : Diagnosis of the ” acute 
abdomen,” 136— Appointed honorary surgeon 
to the King in Scotland, 605, 640— K.C.V.O con- 
ferred on, 985 


Marr, Dr.: Thom ntal state in cardiac disease 
352 

MAimACE. J. R. (and P. N. Panton): Clinical 
Pathology, second orlltlon, rev., 1068 
Marriage, review of book on, 501 
Marriage with nephews and nieces by marriage 
(parliamentary note), 333, 740 
:\rarriogo of the physically unfit (parliamentary 
note), 290 

Mauriner, William Herbert Lister, obituary 
notice of, 477 

Marsden, a. T. Hopple: Pscudo-appendicular 
encephalitis lolhargica, 1093 
Marsden, Herbert E.:— Scarlet fever: Reinfec- 
tion from empyema, 716 

Marshall, O. Jennings : Simple ilco-caccal 
lymphadeniiis, 631 (0)— Dead and infected 
teeth, 751, 959 

ItlAnsiiALL, F, H. A, (nnd others): Rtport on 
Dr. Serge Vor(inoff'8 Ejrnenments on the 
Improvement 0 / Livestock, 505 
Marshall, F.W (F.M RowLANoandJ. M enton) 
An unusual case of food poisoning. 439 10) 
Marshall, George Balfour, obituary notice of, 
287 

Marshall, R. H. 8. : A hospital stcriHz r. 930 
Mart, W. Uakin: Intratiachcal inhalation and 
insnfllation of chloroform by means of a 
flexible metal calbeter. 942(0) 

Martin, Sir Charles .1.: Appieciation of Sir 
Dawson Williams. 421 

Martin, Christopher: Loucoplakia of the vulva, 
182 

Martin, J. Purdon : Tumours of the frontal lobe 
of the brain, 1058 (0) 

Marx, Professor, appointid professor of otology 
at \\ (Irzburg. 429 
Masonic lodge. Association 
Masseh, A'fred A.: Painless natural Ittbour, 
l&l— Health and choice of a career, 524 
Masseur iwosecuted in France for employing 
ultra-violet light in treatment, 120 
Mastitis, typhoid, 82 

Mastoid oixirations, series of (J. Aldington Gibb). 
49(0) 

Masturbation, treatment for, 533 
Materia medica, review of books on, 901. 949, 
1027 

Maternal mortality. See Mortality 
Maternity and child welfare: Cooferonco in 
Edinburgh, 194 — Proposed now centre at 
Southgate (parhameiitary note), 290— Revision 
course in Yorkshire. 466— Report of the North 
Kensington centre. 535— The expectant mother, 
671. 689. 733— Training of health vlsitor^i, 6C9, 
See also Health visitois — National League for, 
report for 1927, 687— Number of centres (parlia- 
mentary note). 830 

Maternity, protection of, 462, 572. See also 
Mortality, maternal 

MATBisoN.Dr. : Drug treatment of pneumonia, 
334 

Matson, R. C.: Clinical pathology and general 
practice, 897 

Mattick, a. T. B : Pure milk progress. 765 
Madgban, j. : “ Drunk in charge,” 774 
Mabtnf.r, Margaretbe: Treatmentof rheumatic 
diseases by physical methods, 815 
Maxillary antrum. See Antrum 
MAXW’rn., A. M.i Tetra-ethyl lead in motor- 
spirit. 770 

Mater. ^Otto, awarded the Dalby memorial 


. •‘mckton 

— Isola- 
. [leading 

article), 560— Treated with convalescent serum 


13 

id inguinal 


Medical appointment, a new, in Edinburgh 
(medical adviser to the corpoi ation), 686 
Medical appointments in Palestine. See Pales- 
tine . 

Medical aspects of educational problems, 28. 
62 

Medical autographs, 825 ^ 

Medical benefit See Insurance 
Medical books, some old, 884 
Medical co education in London, 561— Corre- 
spondence on, 999 

Medical. Dental, aid Pharmacy Bill (South 
Africa). 516, 1042 

Medical and Dental Students Register, J02S,vgv„ 
502 

Medical Department of the United States Army. 

See United States 
:\Iedical education in Bengal, 283 
Medical education, methods and problems of. 25, 
216 

“ Medical electrician,” conviction of a, 202 
Medical ethics, review of book on, 984 
Medical examination of intending settlers in 
Canada (parliamentary note), 428, 881 
Medical examination for life ussiuance. See 
Life 

Medical freedom. 961 
Medical golf. See Golf 
Medical bagiology, 107 

Medical history, collection on bequeathed to 
the Paris Faculty of Medicine by Piofessoi* 
Gilbert, 883 



JAK.-,1UNi:, 192S] 


INDEX. 


r Tdb DBmstr 
L Ukdicix. Jocbkai. 


21 


:\r<'<a‘cal llistom, of, vol. lx, No. 4, vol. x, 

No. 1 (edllca by Francis U. rncUaul), rev., 139, 

Medical ImipecUou of scbool cbiKlrcu. fice 

MoiUcul luRuranco Afioncy : Antuml ainnor.OiG— 
Note on, 1039 , 

• ■ ‘ i of, 511 

• ■ 'books on, 7Gl 

. ■ on). 405 

^loUciU ninjJlBlrat'.'R, 37 

ModlCftl nmii-of-ftll- work. 430 , . „ 

Medical man’s honour (case of Robert Henry 
MoonMGO 

Mcilical olllccrfor Rclfftst. a novr. 40G 
31e<llcftl oniccJ-s of health roj>ort9. 37 
Medical onicers of health, Buparannuation .of, 
612, 775 

Medical olhcer's resignation (R. McCulloch, 
lie. fust’. 822 

3Iedlcal oiDeors salaricR oflparlmmentary note , 
332; aid *'1ucallou committees. 952 
Mcrical Ofllcors of Schools Association. See 
As.socIntJon 

Medical practice, inlluenco of statistics on 
IFrank Jeans), 519 

Medical practice, toxicology in relation to (Sir 
William \Vii:cox‘, 501 

Molical practitioner and the administration of 
justice. See .Nfedicttl witness 
Medical profession and the public (R. .T. 
Rowlctto). 993 

Medical referees under the Insurance Act in 
Northern Iioland. .SV^ nlso Insurance 
Mi-dical hepiftter* rev., 501 

Medical Register (New Irish Free State), 605, 686, 
874 

Medical registration In New Zealand, 77. 159, 
1M6 

Medical research. See Research 
5iedical Research Council. See Research 
Medical responsibility for lunacy certification. 
See Lunacy 

Medical saints (Jane Walker), 107 
3Iedical service, tundamenta b of a (Icadlue 
article), £50 

Medical services In the Free State, 3-4 
Medical students from Scotland visit Loudon, 
533 

Medical students, women, and London hospitals. 
821 

Medical and surgical preparations and app'.i' 
ances. See Preparations 
Medical witness (Roland llurrows). 136 
Medical women, salaries of, 612. 832. See also 
Salaries 

Medical Women's Federation: Annual dinner, 
873 

Medical Women’s lotcrnaliooal Association. 
See Association 

Medicine in Art: Review of book on, 719— (Sir 
Berkeley Moynihan). 1014 
Medicine, biochemistry in (Sir Archibald 
Garrod), 1099 (O) 

Medicine bottles and causes, return of empty, 919 
Medicine, clinical teaching in (leading article). 
316 

Medicine, Deity of: The claims of Imhotep 
(Jamieson B. Hurry), 565 
Medicine in the field of life assui'ance (leading 
article), 401 

Medicine, A History of (Arturo CastigUoni), rev , 
256 

A Short History of (Charles Singer), 
rev., 947. See also Medical history 
Medicine, law, and the public, 921 
Medicine, mechanical, 158 
3Iedicine, preventive, review of books on, 53 
Medicine, review of book on. 719, 9-0 

MUDICO-LEOAIy : 


287 

Bogus doctor (“ Dr. Boyd Panlkner ") 239 
Chloroform for convulsions, 118 
Clerical abortion monger(Rev. Francis’Bacon), 
329 _ 

Conviction of a “ medical electrician ” (Charles 
Jackson Palmer), 202 

Damages [£1,000] for a medical man (W. S. 
Henderson), 881 

Drunkenness, degrees in, 288. See olso Sobriety 
Forgery of a death certificate (Charles Forbes), 
923 

I^uabaud’a responsibility for wife’s treatment. 

Jury’s verdict criticized (Tyndall u. Alcock), 
528. 837 

Medical man’s honour (case of Robert Henry 
Moon), 160 

“ ... 

• (Cbarles- 

wortti tf. Graham and Love), 323 
Registration of dangerous drug purchases, 528 
Sobriety standard?, 283, 573, 693 

Mehta, Mangaldas Vlibhukhandas, O.B.E. con- 
ferred on. 988 

MeinicKe syphilitic reaction, 775, 1049 
MEi^ER.^Dr., appointed professor of medical 


oociety, 1122 


yal 


MErxANHY, May: Defective fitrncturc of teeth, 
229, 410 

Mni.viiJ.E, Rtauloy: Foreign bodies in the 
stomach, 198 

McuiufUllB. meningococcus: Number of cases 
in tbo United Slates in 1927, 243; in 1918. 965 
3Ioningionin8. review of books on, 16 
MbNNELTi, Z,: Anaesthetics in obstetrics, 395 
MonopauHo, artificial, ovarian extract after* 
IW. T. HauUaln), 1111 

Menstrual function, practical applications of 
recent views on (lleckwitli Whllcjouse), 651(0) 
•— Corro‘»pondoncc on. 1050 
Menstruation, ccdnomlcs of (S. C- M. Sowton, 
C, S. Myers, and K. M. Bcdale), 606 
Monstniatlon, precocious. 534 
Menstruation and tho thyroid (11. Gardiner-Hill 
and J. Forest Smithi. 318 

• ' •' .ual case of (U. S. 

1134 

• liibnratory for tho 

study of (U. ,1. A. Berry). 46 (0}-(SV. R. D. 
]'airhairn),566 

Mental (Icfoct, inheritance of, 823. 878. SfC (lUo 
Sterilization 

Mental dofoclives, Larbort Colony scheme for. 
report, 518— Apiieal, 1124 

Mental Deficiency Act, 1027: Boird of Control 
pamtihiot, 372 

Mental defioioner clinic.*? at University College 
Hospital, 155 

Mental disease, indiicilon of premature labour 
in relation to (U. Percy Smith), 9 (O) 

3lGnlal health, cotiforcoco on at Hdinburgh, 872 
AIcntal hygiene : tho prevention of nervous 
breakdown, 1116 

Mental institutions. Dso of croton oil in (parlia- 
mentary note). 1095 

Mental patients, evolution of reception orders 
for(J. U. Lovd»,363 

Menial state in cardiac disease (Carey Coombs). 
352 

Mental W’tflfaro Association. .See Association 
Mentally defective children, teaching of. 62— 
Education of, 822, 964 (parliamentary note). 964 
— Provision for In Northern Ireland, 956 
Mentally deficient prisoners, treatment of (parlia- 
mentary note), 925 

Mentally deranged persons, certification of 
(pavliamontary note), 925 
Mentally unfit. Birmingham Guardians and 
(parliamentary note), 428 See also Lunacy 
Minion. J. (F. M. Rowland and F, W. 
Mapsiiat.l): An nnnsnal case of food poison- 
ing. 439(0) 

McNZir.fi, F. N. Kay: Employment of tnber- 
culous persons, 196 —Voluntary' hospitals and 
public authorities, 280 
Mercurochrome. maximal doso of, 38 
Mercurochrome in treatment of gonorrhoea 
(it. S. S. Statham). 514 (O) 

Mercurochrome in septicaemia (W. E. Dixon), 
S95 

Mercury salicylate injections In chronic ulcera- 
tion (Edmund William Lynch). 8C2 
Mesenteric artery. See Artery 
Metabo ism and acidity' of the fnctal tissues 
and (luids (W Blair Bell, L Cunningham, 
M. Jowett, H. Millet, and J. Brooks). 126 (O) 
Metabolism, basal (Alexander Lyall). 717 
Metabolism, basal, measumneot of (H. S. 

Pemberton and R. T. Goodyear), 395 
Metabolism, review of books on, 101, 554 
Metaldehyde exempted from key industry duty’, 
741 

” Jletalix ” a-ray tube, 203 
Metatarsus, periostitis of (Wilfred .\ttlee). 66 
Metcalfe, Brian B., returned unopposed as a 
member for the Liskeard Divibion of the 
Cornwall County Council, 479 
Methyl chloride exempted from key industry 
duty. 741 « 

3IET1VIER, M. : Voluntary hospitals and public 
authorities, 280 

Meteu, R. C. j. (Andrew Watt nod Andrew 
CayiPBELL): Operation for pituitary tumour, 
547 (0) 

Micks, R. H,: Sarcoma of tho lung and liver, 
553— Fractional test meals, 1026 
Micro organisms, review of books on, 223 
Microscopes for the London School of Hygiene 
and Tropical Medicine. 533 
Micturition, frequency' of, 82, 243 
Middleton, George Stevenson, obituary notice 
of, 575 

. Midwifery', clinical opportunity for, 693 
Midwifery mortality*. See ifortality 
Midwifery, the preventive frame of mind in 
(R. W. Johnstone), 6 (O)— Note on, 25— Corre- 
spondence, 117 

Midwives Acts: Ministry of Health circular re 
compensation owing to infection, 2:3 — Com- 
mittee appointed to consider the working of. 
1007 

Midwives and ante-natal work, 466. 520, 571, 612 
Midwivos Board. See Board 
Midwives and dispensary medical officers (Irish 
Free State). 1085 

Midwives Institute : Conference on the protection 
of maternity, 462. See also Mortality, maternal 
Midwives, post graduate course for, 729 

th Africa), 1043 
’ of (parliamentary 
. ^ ^ Committee ap- 

pointed, 917 

Mignon, M^decin Inspectenr G^nSral A. : Le 
Service de Santi pendant la Guerre 
rev., 1112 


Migraine, 966, 1007, 1097 

Mihaiesti, Jonescu: The present position of 
prc-imiMunization with B C.G.. 1077 
Miles, Alexander, presentation to 235 
Military hospitals. See Hospitals 

^ .... ary note). 1006 

'■ . note), 269 

" , ' h Free State f'om- 

miSRion on. 728— Lending article on progress 
in. 761— Production of (P. B. Tustin), 82D 
3ink. condensed, Dutch and Danish, report of 
commifi'^ion on. 319 

Milk, condensed skimmed, and rickets (parlia- 
mentary note), 428 

Milk consumption: “ Drink-more-railk ” cam- 
paign in tho United States, 1120 
Milk consumption per head (parliamentary* 
note), 532 

Milk consumption and growthof^cliool children, 
report on (J. Boyd Orr), 14C— Leading article, 
146 

Milk contractor heavily fined (Enniscorihv), 406 
Milk production in England an i Wales (parlia- 
mentary note). 820 

Milk, pure, progress in (leading article), 764 
Milk sunply, Belfast guardians and. 282 
Millard, C. Killick : Fatality rate-» of small-pos 
in the vaccinated and unvacciuated, 115, 285 
Miller, Alexander Cameron, obituary notice 
of. 118 

Miller. Clarence: Treatment of prostatic 
enlargement, 31 

Miller, C. H. : Polypoidal proliferative colitis, 
264— Surgical treatment of cfarojic gastric 
ulcer. 450 

Miller, Dr.: ^faternal mortality due to 
puerperal sepsis, 980 

Miller, H. Crichton: Etiology of alcoholism. 

595— Mental hygiene, 1 16 
Miller. Reginald : Rheumatic infection in the 
young, 3 0— Chronic intestinal toxaemia in 
children, 3S3 (O)— Rheumatic heart disease in 
children, 853 

Miller. William C. (and others): Jteport on Dr. 
Serge Voronof's Experiments o» the Improve- 
meat of Livestock, 505— (Editor) Black's 
Veterinary Dictionary, rev . 672 
Miller. William H.: Ar?enlous oxide in neutral 
and alkaline solution, 407 
Millet H. (and others) : Metabolism and acidity- 
of the foetal tissues and fluids. 126 (O) 
Milligan, E. T. C.: Treatment of urethral 
stricture, 550— Earlv diagnosis of cancer of 
rectum and colon, 847 

311LLIGAN, Robert Arthur, obituary notice of, 
240 

Mills, Arthur: Recurrent spontaneous pneumo* 
thorax, 222 

Mills, G, Percival: The treatment of "tennis 
elbow,” 2 (0) * 

Milrot, G. W.: a method of treating fractures 
of the clavicle with displacement. 664 (O) 
Milroy’s disease, 581. See also Oedema of legs 
MiKCUiN, William C. : A Study in Tubercle 
Virus, JPolymorphism, and the Treatment of 
Tuberculosis and Lupus with Oleum Allii, 
third edition, rev.. 225 
Mind, review of books on, 224. 499. 555 
Miners’ nystagmus. See Nystagmus 
Miners' phthisis. See Tuberculosis 
Mines, coal, accidents in (p.irliamentary note) 
830 

Mines in Cornwall, tin and clav. health condi- 
tions in {parliamentary note', 697 
Mines,, illumination in, 112 — New lamp-room 
photometer, 112 

Mines, night work by boys in (parliamentary 
note), 380 

Minto, Surgeon Lieut.-Col. Alexander, obituary 
notice of, 698 

Mirande, Dr., death of, 696 
Miscarriages to be reported in the City of New 
York, 81 

Misdemeanours and professional discipline 
Pickup V, the Dental Board), 922 
Mission field, a surgical emergency in. 252 
Mississippi flood, aftermath of ihe. 231 
Mitchell, Alexander: Ectopia vesicae, 597 
Mitchell, A. Graeme (and J. P. Crozer 
Griffith): The Diseases of Infants and 
Children, second edition, rev., 805 
Mitchell Banks Lecture. Sec Lecture 
Mitchell, Douglas A.: Quinine in obstetric 
practice, 238 

Mitchell, J. A. : Annual report of the health of 
South Africa, 370 

Mitchell, Richard Blackwell, obituary notice- 
of, 1129 

Mitchell, R. H. : Supernumerary thumbs. 308 
Mitchell, T. W. : Problems in Psyc7iopaf7«oIO£7t/. 
rev.. 902 

Mitchell, Winifred H. : Inversion of the 
uterus, 1008 

Mivagawa, Yoneji (editor): Scientific Jteports 
from the Government InstiMe for Infectious 
Diseases, rev., 600 

Mohammedan pilgrim ships, medical facilities 
on, 930, 1007 

y... -,r w T..1 .v:a- notice of, 740 

M _ ' ' Jordan), 552— 




paralysis, 983 
MonatsschHft filr Psychiatrte nnd Heurologie 
Sixty-eichth volume dedicated to Professor K 
Bonhoeffer, 1133 

Moncbiefp. A.: Familial hypertrophic pylori 
stenosis, 563 



22 JAN.-JUKB, 1928] 


INDEX. 


[ Tnt nrtmsn 
Mxdicai. JotmniL 


Mojtet, 0. P. : Tetra-ethyl lead, 831 
l^OQgoliBin (Edward Walker), 597— Etiology of. 
■withacase of Mongol twin (Hubert Armstrong), 
1106 (O) 

Monod, (j. : Letter from France. 28— Apprecia- 
tion of Sir Dawson Williams, 424— Preventive 
vaccination of tbe newborn against tubercu- 
losis. 520 — British spas, 878 
■M 0 N 8 AUUAT, K. W. : Surgical treatment of 
diverticulitis, 309 

Moktefosco, Alfonso, death of, 210 
ilONTEiTH, W. B. R. : Removal of a foreign body 
from the stomach of an jnfant. 259 
"Montreal, hospital campaign in. 369 
Moon, Robert Henry, case of the honour of, 160 
Moore, Charles Gordon, appointed physjcian- 
in-ordinary to Princess Beatrice, 1053 
Moore, Han*y H. : American JiTeclicine and the 
People's Health, £50 

Moore, Milner: Appreciation of James 
Alesander Macdonald. 784 
MooRHEiVD. T. Gillmau : Addison's disease. 452 
— (And Leonard Abrahamson) : Thrombo- 
phlebitis migrans, 586 (O) 

Moran, H. H. : Familial cancer of the breast, 
164 

Moray floods of 1829, 360 

More, Lieut.-Col. Paxton St. Clair, obituary 
notice of, 211 •• 1 

IMoreno, Jos6, death of, 695 i 

Morgan, Thomas Hunt: Experimeiitol Embryo^ 
Zopi/, rev., 985 

Moreet, John: Abdominal pain as exemplified , 
in aente appendicitis, 887 (O), 1085 
Morphine, output of (parliamentary note), 829 
Morphinism, a treatment of, 34. 244 ; by atropine, 
34 

Mobpht, Owen C : Tbe pnlpless tooth, 543 
MoRRi', Hugh : Cholecystography by the oral 
method without the use of capsules, with a 
report of forty cases. 305 (O) 

Morrison. John T. : The acute abdomen, 284 
Morse, Withrow: Applied Biochtmistry, second 
edition, rev., 634 

Morshead. R. S. : Fireman’s cramp, 334 
MORSON, Clifford : Treatment of urethral stric- 
ture. 550 

Mortalitj*, infantile: In county Darham (parlia- 
mentary note), 333— Of the natives in Sontb 
Africa, 370— Parliamentary note, 530 
Mortality, maternal (parliamentary notel. 333 
530, 777, 1095— Conference on 333.368.462.572— 
In Canada (Helen MacMurchi ), 604— And pelvic 
defordaity, 618— Proposed committee of in- 
vestigation, 729— Investigation of, 775— "Visit of 
the Minister of Health toLeed8,873— AtLeeds, 
873— Appointment of Departmental Committee. 
998 — In childbirth, 1095. 1096 
Mortality, maternal, from puerperal sepsis : an 
analysis of the factors of contagion, trauma, 
and auto-infection (James Young), 967 (0)— 
Discussion, 9i0 

Mortality, midwifery, 1126 • 

Morton. William Britain, obituary notice of. 
200 

Mosanito breeding and pool-proof guttering, 38. 
334 

Mosquito pest (parliamentary note*, 380 
Mosquitos, anopheline, method of differentiating 
(C. B. Byrnes), Il9 
Mosquitos, review of book on, 949 
Moss. Adam: Gall-bladder disease, 582 
Mother, the expectant, 571. See also Maternity 
MoTHEBSOEE, R. D. : Congenital buccal ej'st, 
899 

Motor cars : Brakes and floods, 38—1928 motor 
licences, 82 — Coachwork for the medical pro- 
fession, 226— The white line, 430— Radiator 
heating lamp, 38, 480 — Finish for bodies of 
cars, 533 — Accidents and the voluntary hos- 
pitals (parliamentary note), 925 
Motor spirit, tetra-ethyl lead in. See Tetra- 
ethyl and Lead 
Motor tyre manufactnre. 832 
Victor vehicles and nervous complaints, noise 
of (parliamentarj’ note), 1096 
Motoring, winter, 38,489 
Motorists, new lighting laws for, 709 
Mott, Sir Frederick, memorial to, 275. 929 
MoTTRAM, J. C.: Combined action of colloidal 
lead and radiation on tumours, 132 (C) 
Mottram, V. H. : Experiments in malnutrition, 
88 (O) 

"aiouED, G. E.: Court etiquette as a cause of 
madness, 82 
Moutb, dry. 204, 243 
Mouth gag, 902 

JiIoTNiHAN, Sir Berkeley: Mitchell Banks 
Memorial Lecture on the gall-bladder and its 
infections, 1 (C>— Appreciation of Sir Dawson 
Williams, 417— MacAlister Lecture on medi- 
cine in art, 1044— Gastric and duodenal opera- 
tions. 1126 

Mucocele (L. Stanley Torrance), 258. See also 
Gall-bladder, distension of 
Mucons surfaces, absorption from, 228 
Muib, J. C.: Village settlements for tbe con- 
sumptive. 76 

Muir. Miller: Tnberculosis of tbe skin and 
tendon sheaths, 263 

Mueeock, Richard William, obituary notice of, 
695 

Mumtord. Alfred A. : The future school medical 
officer, 262 

Munro. John M.: Pregnancy and glycosuriB, 82 
MuNsiiT, Jamshyd : Sanitation measures in 
connexion with fairs and festivals in India. 559 


Murphy, O. : Narcolepsy, 915 
Murphy, Edward : Frequency of micturition, 82 
Murphy, Surgeon Commander John St. John, 
obituary notice of, 698 

Murphy, P. Kennedy: Injection treatment of 
varicose veins, 1090 

Murphy, Father Richard J.:— TJie Catholic 
Nurse: Her Spirit otitl Her Duties, rev., 267 
Murray, E. Farquhar: Abuse of Caesarean 
section. 30 

Murray, H. Leith* * ' ** '* 

—Largo ovarian 
and tuberculosis, 

of a uterine fibronm, Hai— apouiancous nipiuro 
of uterine sarcoma, 981 

JIurray. Philip (editor): Th/^ Stranpe Adven- 
tures of F rederiel: Baron Trcnck. rev.. 501 
Murrele, Christine M. : Medical co-cducation, 
99) 

MiiRculnr atrophy, progressive treated by para- 
thyroid, calcium, and vitamin D (Captain T. H. 
Thomas), 978 (O). See also Atrophy 
Musculor atrophy, progressive, of the peroneal 
type iGeorge Parker). 1062 (O) 

Muscular work, measurement of (Guy P. 
Crowden). 62 

Muskenb. L. j. j. : Epilepsy, rev., 1027 
Mycopcs, 958 

Mycoses, cutaneous, in the tropics (J, Rams- 
bottom). 179— Diacuesion, 179 
Myers. G.S.: The economics of menstruation. 
606 

Myers, J. Arthur:— Fipfifcrs 0 / Fate: A Siorv 
of Men and Women who have Achieved Qyenilu 
Despite the Handicap of the Great White 
Plague, rev.. 720 

Myeeb, Sir Thomas, appreciation of Richard 
Lane JojTit. 693 

Myocarditis, rbcumatic, early, 193 
Myoma, abdominal (W. Gough). 57 
Myomas, multiple, in young patients (J.'Ellison), 
351 

^^yopia in childhood (C. G- Schurr), 803 
Myxoedema of larynx (James Adam), 594 


N. 

Nadkarni, K. M. : The Indian Zlateria Medica, 
rev., 901 

Naegele pelvis (George S. Davidson), 597 
Naebmyth. John, the career of, 570 
Napier, L. Everard: Kala-asar, second edition, 
rev.. 1C69 

Narcolepsy (8. A. Kinnier Wilson), 446— Dis- 
cussion, 447— (G. E. Nesbitt). 945 
Narcotic drugs, fevenne from the sale of in 
India (parliamentary note) 381 
Narcotic plants (W. E. Dixon), 1038 
Narcotics, tbe law regarding (in Canada). 369 
Narkose nnd Anaesthesie, first i<58ue of, 381 
Nasal focal sepsis. See Focal sepsis 
Nash, Elwin : Tbe future school medical ofTicer, 
262 

Nash, Colonel L. T.: Appreciation of Basil 
Thorn Lang. 201 

Naso-oral sepsis, pulmonary end gastro-intes- 
tinal sequels of: Discussion at the Royal 
Society of Medicine. 96. See also Focal sepsis 
Nasopharyngeal catarrh. See Catarrh 
Nasopharynx, mixed tumour of (John E. G. 
McGibbon. with a pathological report by J. M. 
Beattie). 664 (O) 

. . , — . - - Dairy 

' Report, 679 

' • for Equal Citizen- 

ship : Women medical students and London 
hospitals, 821 

National Union of Students of tbe Universities 


N 

tion 

Nauheim, springs of (Adolf Schott). 181 
Naval aiedical Compassionate Fund. See Fund 
Navicular, fracture of the (K. Paterson Brown), 
591 (O) 

Navy, Royae: 

Admiralty hospitals : Beds available. 381 

Beds and personnel in naval hospitals, 428 

Dental officers, R.N.. 1132 

Dispensing of medicinesnn, 531 

Disease incidence in, 531 

Estimates, 472. 529 

Eye diseases in, 697 

Greenwich Hospital pension. 119 

Haslar Hospital, 381 

Health of : Annual report. 267. 

Hospitals of: None closed. 474 — Cost of 
accounts. 1095 

Invaliding from, 472, 578 — Suggested re- 
examination of rules. 472 
Parliamentary notes, 290, 381, 428, 472, 474, 530, 
531.578.697.1095 
Rejections and acceptances. 290 
Royal Naval Volunteer Officers* Decoration, 
241.825 

Tnberoulosis in, 530 

Neame. Humphrey (and F. A. Wieeiambon- 
Noble): a Handbook of Ophthalmology, rev., 
15 

Neanper. Gustaf: The “Hdlsnn” Institute in 
Norrl)o((en,658 

Neff, Frank C. : Diseases of the Digestive 
System of Childhood, rev.. 138 


NcgUgcnco, alleged, in a fracture case (Stroud 
V. Bates, Bates, and Wilson), 573 

, ‘ .1 hospital, 287 

• . • _ * ' > 

* ■ ■ icsearch Council, 
4oo— x'liiiiyugo-ouBopuHgcai sphincter, 879— 
Awarded the John Hunter modal. 8S2 

Nophritie. some prohlcms of (T. Izod Bennett). 
513 

Nephritis, terminal chronic, hyperpyrexia in 
(Howol B. Pierce, John F. Scales, and O. L. 
Pierce), 177 
Nephrostomy, 618.650 

Nophro-uretoral anastomoBls after complete 
avulBion of tbe ureter, 1091 
Nerve tractB, review of book on. 554 
Nerves, recurrent laryngeal and- phrenic, ana- 
stomoslR hotweon (Lionel Colledgo.and bir 
Charles Ballanco), 746 (O) 

Nory’ous breakdown, prevention of (Sir Maurice 
Craig), 1116— Discussion. 1116 
Nervous complaints and noise from motor 
vehicles (parliamentary note), 1C96 
Nervous disorders, functional, Tavistock clinic 
for; Seventh anniversary of, 163, 242 — Dinner, 
242— A correction, 287 
Nervous system, review of books on. 396 
Nkhritt, G. E : Tho ovor-sonsitlvc child, 220— 
Psxchonouroscs, 221— Narcolepsy, 915— Con- 
genital pyloric stenosis. 915 
NnTTEii.A.: Serum treatment of poliomyelUis, 

• 403 

Neumann. R. O. (antlK. B. Lehmann): Bakterin. 
logic insbesondereVakteriologischeDidgnostik, 
rev., 956 

Neuritis, optic, and sphenoidal sinusitis (A. C. 
Rees Walton). J3 

Neurology, review of books on, 100 
Neuroses in the tropics (H. B. Day), 448— Dis- 
cussion, 448 

Neurosis, anxiety, cause of an (R. Macdonald 
Ladcll),444 

Neutral chlorides and gastric secretion. See 
Gastric 

Neve, Ernest F. : Antiseptic.s in ophlhalmtc 
sorgory, 32 

New England Journal of Medicine, centenary of, 
511 

Now growths (J. T. Wigbam), 1026 
Newland. Fleet Surg. Charles Francis, obituary 
notice of, 1093 

Neweand. Lient.-Col. Henry Simpson, honour 
of knighthood conferred on, 938 
New^xan, Sir George : Appreciation of Sir Dawson 
Williams. 419— Hastings Lecturoon the founda- 
tions of health, 506— Theproblemofrbcumat c 
diseases. 852 

Newsholmb, H. P., presentation to, 37 
Now Tear hononrs, 23 

Now York: Miscarriages and abortions to be 
reported to the Department of Health, 81 
New Zealand: Hospitals and nreforontial treat- 
ment of friendly i-ocicties, 568— Iron starvation 
in ruminants, 568— Medical Association. 431— 
Medical registration in, 77, 359, 1C46— Post- 
graduate training for narses, 568— Radium 
department of tbe North Canterbury Hospital 
Board, report. 992 

NicnoEt,. li), F. : Shock and abortion, 328 
Nichols prize. See Prize 

Nicboesos, B. S.: Importance of sputum ex-‘ 
amination in pulmonary diagnosis, 572 
NicnoEBos, Thomas Dryden, obituary notice of, 
927 

NicoEAS, professor, elected foreign corresponding 
member of the Royal Academy of Medicine of 
Belgium, 429 

Nicoee, W.: Life assurance in tbe tropics, 219 
Nicolee. C.. commemoration of tbe twenty fifth 
anniversary of his appointment as director of 
tbe Institut Pasteur of Tunis, 429, 864 
Nicolson, W : Appreciation of Sir Dawson 
Williams, 424 

Night work by boys in mines. See Mines 
Ninety-sixth rear [of tbe British Medical Associa- 
tion) (leading article), 1034 
Nitch, C. a. R : Treatment of bare-lip, 1025 
Nitroglycerin in treatment of sea-sickness, 244 
Nobel prize. 787 

NoBEE, J. A.: Formalin injections In gangrene 
of the leg, recovery, 216 — Precocious menstrua- 
tion, 534 

NooHT, Bernhard; Collection of articles on 
tropical diseases in honour of the seventieth 
birthday of, 600 

NooEOEPs, Humphrey : Voluntary hospitals and 
public authorities. 280 

Noguchi, Hideyo, death of, 909— Obituary notice 
of. 961 

Noise in relation to health, 1124 
Noise of motor vehicles and nervous complaints 
(parliamentary note), 1096 
Noean, M. j. ; Addison's disease, 452 
Nomenclature, zoological. 105— Bacteriological. 
787 

Noon, Charles: Hair-balls in the alimentarj* 
trket, with the record of a case of intestinal 
obstruction due to four hair-balls, 342 (0) 
Norburn, Albert Edward, obituary notice of, 
695 

Norbury, L. E. C. : Early diagnosis of cancer of 
rectum and colon, 847 

Norman, Hubert J.: Mental Disorders, rev., 614 
Norris, George William (and Henry Cutbbert 
Bazett) ; Blood Pressure : Its Clinical Applica- 
tions, fourth edition, rev., 894 
North Uist. See Uist 



JAN.-JUNR, igaSj 


INDEX. 


r Tiiz Britihi! o rt 
L Medical JocBHJLi. 


Norwich, private patients' homo ineuranco 
scheme at, 771 

Nose, review of books on, 355. Sfe al«o Kar amt 
Throat 

Kotos, liottors, Answers, oto« : 
Abbreviations, the use of. 582 
Anaemia, secondary, treated by liver, 244 
* — ♦roin, 81 


Appendicoclomy durintt herniotomy in an 
infant, 618 

'* 2J. colt infection of the digestive system, " 
28 

Back to Sir Thomas Browne, 742 
Begging letter I'ost. 430 
Blepharitis, chronic, euro for, 650 
Blood fllm, ft method of mftklng n, 480 
Blood transfusion, whole, 1054 
Body and mind, 758 
Books, old medical, 8S4 
Bronchitis, chronic, after gas poisoning, 618 
Bronchopneumonia in children treated by 
injections of emotino, 9G6 
Bullous eruption after phenybclnchoninic acid, 
38 

Caesarean section in pregnancy complicated by 
pnlmonarj* tubercuIosiB, 480 
Canada, tours in, 650 
Cancer of broa‘-t. familial. 164 
Cancer cases, records of, 

Cancer of rectum, ft correction, 164 
Cancer treated by injections of peritoneal 
fluid. 204 

Card hinge, a '* transparent.” 832 
Cardiology, books on. 884 
Chance’s filter for nltra-violet rays, 582 
‘•“gostion, 82 


Cold, common, etiology of the. 244 
Corrections, 28, 164. 244, 618, 930 
Coryza, paroxysmal, 6M, 7C0 
Court etiquette as a cause of madness. 82 
Cramp after sciatica, 430. 480. 534. 930, IC54 
Creaking in the joints, 742 


DjAirbocft. chronic, caused by a feather quill, 
788 

Disclaimers, 38, 120 
Drags, dangerous, 334 

' ‘ ■ • • 'the, 164 

' reaction after 

Elbow*30int. treatment of Injuries round: a 
correction. 930 

Emphysema and wind instruments, 244 
Endocarditis in young cblidren and lambs, 
1134 

Errata. Corrections 
Faecal fistula pad. 6M 
r*“ ' ' • 4 

y one doctor, 700, 

Flatulence, treatment of, 38, 82 
Forgotten swab, 742 
Gall-bladder disease. 582 
Gas gangrene following a road accident, 534 
Golf medical: Medical Golfing Society. 5S2. 
n34— Manchester and District Medical 
Golfers’ Association, 930 
Gorilla at home, 700 
Gont, acute, 430 
Haemoptysis in infants, 382 
S^^paorrhoids treated by the galvano-cautery, 
1098 

Hands, flashing of the, 581 
Harvey tercentenary banquet, 966 
Heart, books on the, 884 
Heat cramp and heat hyperpjTexia, 1098 
Hemiplegia, home for a sufferer from, 81 
Herpes genitalis, radical cure of. 650, 699 
Herpes followed by immunity, 1054 
Herpes zoster and varicella. 120 
Hirsuties, 120 . 

Home wanted, 430 
Hospital sterilizer, 930 
Hotrwator bottle cover, 480 
• CT? ^20, 204, 291. 334, 382, 430, 480, 

Si’ 700. 742, 787. 831, 884. 930, 

966,1008.1054, 1098,1133 
Allowance after marriage. 534 

consulting practice, 

post-graduate study, 

Ass^tftut becomes a partner, 1134 

IIM-For gross 

lacorue, 3M— Beceipts basis. 1135 
Commencement of liability. 582 
Commencement of partnership. 1054 
Ueduoliblo expenses. 1098 
^aenc6°«2*°' “^® house, 788— For resi- 

^1054°'°^*'°° K-ray apparatus, 

Division of partnership assessment. 1098 
expenses of assistant's board, etc.. 1008 
Expenses of illness, 650 
Ine^ments, replacement of, 7C0 
•• liability for board and lodging. 1054 
Hocumtenent’s expenses. 480 


Notes. Lnttors, Answers, otc.fronftnnrd) : 
Motor cars : ObROlesccnco of, 38, 430, 884— 
nopairs to. 204— Bonewaks, 382. 480, 966 — 
Roplncomont,480, 534, 700, 1133— Allowance, 
618— Transaction, 700, 742, 788, 832, 884, 1098 
— Exponsos. 788— Doproclfttlon, 884— Gift of 
car for professional nso.1133 
I’ftymcnts for capital borrowed, 1054 
rurchaso of partnership sharo, 1008 
Furchaso of prnctlco. 884 
nopayment of loan, 930 
Salary with house, etc., i42 
Sale of practice, 382 
Schedule B, purchase of practice. 430 
Subscriptions to societies. 334 
Succession in a practice, 582 
Surgery expenses, 291 
Three years’ average, claim to, 966 
Value of hoard and lodging. 832 
VJifo commoDcos practice, lOOS 
Infection among children in casualty depart- 
ments, 930 

Labour. paiolCBS natural. 120, 164. 291, 382. 408 
Labour, rapid first. 382 
Tiond treatment of malignant disease, 1134 
Llmc'dollclont food and carditis. 618 
Listorian in Alabama, 582 
Lumbar puncture, thcrapentio value of. 164 
Limiphatic obstruction, treatment of, 534 
I^fanuscript gone astray. 38 
"’Mastnrbation in a child. 533 
Maternal mortality and pelvic deformity, 618 
Meat extractives end gastric jnico, 581 
Medical books, some old, 884 
Medical golf. Sr^Golf 
Medical luan-of-all- work, 430 
Jlonstrnation, precocions, 534 
Menstruation, vicarious, 1134 
Morcurochromo, maximal do.so of. 38 
3ficturition. frequency of, 82. 243 


on. -dM. 

Morphinism, treatment of. 244 
Mosqnito breeding and pool-proof guttering. 
38.334 

Motor cars : Brakes and floods. 38— Licences 
<1928). 82— f-inish for bodies of cars, 553 
Motor tjTo maniifftctnre. 832 
Motoring, winter: paraffin lamps forradiators, 
38,480 

Motorists, now lighting laws for. 700 
Mouth, dry. 204. 243 

Nasopharyngeal catarrh, chronic, treatment 
of. 930, 1097 
Nephrostomy, 618. 650 
Obesity after childbirth, 742 
Omphalology. 1098 
Orthodiagraphy of the heart. 884, 930 
Pancreatic preparation, oral administration 
of, 109S 

Pelvic circumference of infant at birth, 582 
Pigmentation of scalp, unnsual, 243 
Petrol Enpine, 832 

Pneumonia, drug treatment of, 244, 334 
Pneumonia, lobar, with diphtheria and 
malaria, N2 

Pneumonia after operation for gastric and 
duodenal ulcers. 1134 
Pneumonia, treatment of, 700 
Pregnancy and glycosnria, 82 
Primula rash. 430 • 

Procreation after prostatectomy, 204 
Prostatic enlargement, treatment of. 120, 204 
Pseudo-appendicular encephalitis lethargica, 
1098 

Psoriasis treated with metallic bismuth, 204 

Psychotherapy, new, in stageland, 244 

Quadruplets, survival of, 700 

Radiography of viscera, 884, 930 

Radium, commerce in. 832 

” Rising test ” for acute abdomen, 788 

Rnnning as a recreation. 334 

Salaries of medical women. 832 

Scabies, prevention of, 82 

Scalp, unusnal pigmeotation of, 833, 2054 

Scarlet red dry dressing. 3S2 

Schistosome infection, mixed. 1098 

Sea-sickness, treatment of, 244, 884, 930 < 

Shock in black races, 650 

Sinapisms, localized, value of. 82 

Social hygiene, lecturers on, ICO 

South African Medical Congress, 742 

Status epileptiens. 1C97, 1154 

Streptococci and puerperal sepsis, 788 

Surgical emergency in the mission field, 292 

Surgical portrait group, 1134 

Syringes, sterilization of, 81, 534 

Tar fames, 291 

Teeth, wholesale extraction of, 966 
Tongue excision, thirty years* survival after. 
884 

Toneiis, enlarged, conservative treatment of, 

Tooth, the pulpless, 7C0 
Tours in Canada, 6^ 

Train-sickness, treatment of. 884 
Tubercle bacilliin pus.prognostic, significance 
of large numbers of, 788 
Tuberculosis campaign, starting points for a, 

Twins, 'conjoined, 82, 204 
Typhoid mastitis. 82 

Ulcers of the mouth, treatment of, 120, 164, 203 
Ultra-violet rays for acne. 966, 1C07 
Vagina, complete obliteration of the, 1054 
Varicose ulcers, intravenous treatmentof, 966 


Notes, Letters, Answers, etc. (conftnttgd); 
*• Vita " glass, 884, 1008 
Vitamins in verso, 291 
Vulvitis, treatment of, 1G4, 2C4, 244 
Water, distilled, therapeutic injections of, 120 
White lino, 430 

Widal reaction after inocnlation. duration of 
a, 430 

Notifiable diseases (parliamentary note), 380. 
See also Diseases 

Nott, Herbert W. : The thyroid and manganese- 
treatment of disease, 94 (O) 

NounSE, H. E.: Immunity following herpes, 1083 

Nova et Vetera : 

Arrival of the Jews in England (R. R. James),. 
993 

Deity of Medicine : The claims of Imhotep 
(Jamieson B. Hurry), 565 
Harrison of Ightham, 1070 
Medical literary club (H, Hamilton), 405 
Moray floods of 1829, 360 
Venoreological episodes. 151 
Villemin— Pioneer; A chapter in the historjr 
of tuberculosis, 720 

William, Duke of Gloucester, son of Queen 
Anne, cahso of the death of (W, P_ 
MacArtbur), 502 

NovEii, E. (C. PiRQUET and R. Wagner): 
EmilUruno GesumJer wid Kranlier Kinder^ 
rev., 851 

Notes, Arthur P. : A Textbook of Psychiatrv^- 
rev., 671 

Notons, Professor, appointed to the chair of 
physiology at Utrecht, 1096 
Nunak, W. : Frequency of micturition, 243 
Nurses, post-graduate training for (New Zea- 
land). 568 

Nurses, training and examination of (Ireland),. 
1083 

Nursing, bush. 67 
Nursing, district, in London. 373 
Nursinp ZXirror and ZlidvHves Journal com^ 
pletes its fortieth year, 741 
Nursing, review of books on. 556, 671 
Nursing sebeme. Lady Dudley's : Annual reports 
874 

Notrition, diseases of faulty (Lieut.-Col. B, 
McCarnson),92(0) 

Nutrition and malnutrition (leading article), 104» 
See also Malnutrition 

Nntrition, review of books on, 184, 851. 1028 
NuTTAEi/. George B. F., elected a foreign corre-' 
sponding member of the Paris Academy of 
Medicine, 815— Legion of Honour conferred. 
00,1133 

Nystagmus, miners’. 520 


O. 

Obesity after childbirth, 742 
O’Brien, R. A.: Diphtheria carriers, 181 
Obstetric practice, quinine in, 157, 238 
Obstetric practice, recent changes in (Leslie.- 
Williams), 495 

Obstetrics, anaesthetics in (Eardlcy Holland), 
594— Discussion, 395 

Obstetrics, the future of, 284, 326, 412, 1086 
Obstetrics. See also Gynaecology 
Obstruction, intestinal, in an infant (E. A. 0. 
Wilson) 51 

Obstruction, intestinal, acute, by bands in 
children (C. Gibson), 176 
Obstruction, intestinal due to hair-balls 
(Charles Noon), 342 (O). See also Intestinal 
Ocular complications of encephalitis lethargica : 
Discussion at the Royal Society of Medicine. 
261 

O'Donovan, W. J. ; Ultra-violet radiation 
therapy. 260 

Oedema of the upper eyelids (John Roberts), 307 
Oedema of legs [Milroy’s disease], 581 
Oebteii, Horst : Outlines of Patlioloav* rev., 598 
Oesophagus, foreign body in, difficult removal 
(Lindley Sewell). 176 (O) 

O’FAimEiii,, T. T.: Diverticulitis. 1025— Frac- 
tional test meals. 1026 

Offices, regulation of (parliamentary note), 578 
Offices, Reorganization of (Scotland) BUI, 3S0, 
426. 427, 648 

Ogievie, Major-General Walter Holland. K.B.E. 
conferred on, 988 

O’Hea, M. F.: The over-sensitive chUd, 220 — 
Psychoneuroses, 221 

Oil, cod-liver, possible dangers of (B. Agdnhr), 
639 

Oil, croton, nse of in mental institutions (parlia- 
mentary note), 1095 

Oil-ether anaesthesia. See Anaesthesia 
OxmERSHAW.M. H. : Present position of radium 
therapy, 497 

OimiTEiiP. Carlton: Carcinoma corporis uteri, 
57— Fibroids treated by Apostoli’s method. 
57 — Sarcomatous tissue, 57 — Drainage in 
Wertheim’s hysterectomy, 982 
O’Leary, Mary M. : Medical inspectionof school 
children. 464 

Olsen, Otto: Bakteriolopisehes Taschenbuch^ 
twenty-eighth edition, rev.. 670 
Olson, A. A cause of natural variation. 768 
O Meaba, R. a. Q. : Fractional test meals, 1026 
Omental cyst. See Cyst 
Omphalology, 1C98 

Open-air classes, numbers attending (parlia 
mentary note), 881 


24 JAN.-J0NE, 1928 ] 


INDEX. 


r Tnr BRnuK 
L MeDICXI. JOVAKIL 


■6i>erations and risks of actions at law. 328 
Ophtbalmia, metastatic (B. R. Chambers), 546 
■Ophthalmia neonatorum : New amending regula- 
tions, 1005 

Ophthalmic prophylaxis and treatment in 
Palestine, 1008 

Ophthalmic surgery, antiseptics in, 32 
Ophtbalmo'ogical Congress, 533. See also Con- 


gresses 

Ophthalmology and general medicine (J. Gray 
Clegg). 56 , , 

Ophthalmology, qualificationB in of medical 
oflicers (parliamentary note). 379 
Ophthalmology, review of hooks on, 15, 1067 
Ophthalmoscope, an electric slit lamp, <155. See 
also Eje 

Opium Convention: Signatures still lacking 
(parliamentary note), 333 
Opium exported from India (parliamentary 
note), 333 

Opium traffic and the League of Nations, 459, 
1119— International control of, 1119 
OPi’ENHHiiiER, Carl (and Ludwig PiNCOsar.N)' 
Die Ferniente nud ihre Wirhuvoeii, rev., 454 — 
Die Mtthodil: der Fennente, fifth edition, rev., 


454 

Optic neuritis. See Neuritis 
Opticians, registration of: Report of Depart- 
mental Committee. 26. 106 
Optics, review of book on, 1114 
Oral focal sepsis. See Focal sepsis 
Orm&by-Gore. Rt. Hon. W.. appointed a trustee 
of tbo lieit Memorial Fellowships. 741 
Orm. J. Boyd : Report on the influence of 
amount of milk consumption on the rate of 
growth of school children 140^ 
Orthodiagraphy of thu heart : Literature on the 
subject asked for, 884 — Reply, 930 
Osmond. T. E. : A comparison of the Wasser- 
manu, Kahn, and Sigma tests, 440 (0) 
Ostf'O-ai'thritis, scope of surger\^ln the treat- 
ment of ( ‘ 

Osteomye’ 

O’SULLIVA' , 

haemateniesis scccndarj' to aortic and mitral 
incompetence. 944 

Oswald, Landel Rose, obituary notice of, 733 
Oto-larjngology. 1039 

Otology, review of books on, 184. See also Ear 
Otosclerosis (Lowndes Yates), 982 
Ovarian cyst. Sec Cyst . 

Ovarian extract after artificial menopause 
(W. T. Haultain).im , , 

Ovary, congenital absence of one. and the corre- 
sponding Fallopian tube (J. Herbert Sanders), 

Ovary and Fallopian lube, torsion of during 
pregnancy (J. E. Stacey) 663 
Over-sensitiveness. See Child 
Owen, Ambrose ; Thrombo-phlebitis 
mlgrans,690.9^ 

OwKN. D. R. (and G. C. B. Siiipson)j_ Some sur- 


Dys- 


. Con- 

OxLBV^. W. H. F. : The protection of maternity, 
462 

O.xygen administration, comparison of methods 
of (R. Hilton). 441 (0) 

Oxygen, therapeutic uses of, 774 


P. 

Packard, Francis R. (editor) : <i7infiZs of Medical 
HisbiTV. vol. is. No. 4, rev., 139; vol. x. No. 1, 
rev., 1068 

Page, C. Max : American tour of the Surgical 
Section of the Royal Society of Medicine, 186— 
The scope of surgeiT in the treatment of 
chronic rheumatoid arthritis and osteo- 
arthritis, 343 (O , 347, 858 
Page, G. B. : Importance of sputum examination 
in pulmonary diagnosis, 572 
Fain, clinical study of (John A. Ryle), 537 — Lead- 
ing article 561 

Palestine: Medical appointments in (parlia- 
mentary note), 778— Leprosy in (parliamentary 
note), 181 — Ophthalmic prophylaxis and treat- 
ment in. 1008 . ^ 

Palfrey. Francis W.: The SpecialHesin Geiieral 
Pnicftcc, rev., 719 ... , 

Palmer, Charles Jackson, conviction of, 202 
Pancreas, acute necrosis of the (J. "W. Geary 
Grant), 1101 (O) . ^ ^ 

Pancreatic preparations in the treatment ot 
diabetes, oral administration of (C. B. S. 
Fuller). 798 (O)— Correspondence on, 875, 1050. 
1098 

Pancreatitis, acute, with gall-stones, at the age 
of 16 (Basil M. Tracey), 346 
PANNETT,' Charles A. : Debatable aspects of the 
f-ursery of gastro-duodenal ulceration 623 (O), 
729 

Panniculitis and chronic muscular rheumatism 
(Ralph Stockman), 293 lO) 
pj^TON, P. N. (and J. R. Marrack): Clinical 

• • )rd Allbutt 

‘ ‘ , removal of 

a spinal tumour (Walter Broadbent and G. W. 
Peresford), 1063(0) 


Para'ysis, general, malarial treatment of (R. 
Eiiger). 1023 

Paralysis, infantilo: International committco 
for research on, 765 

Paralysis, infantilo: — Appliances for: deltoid 
shelf. 286; an internal T-slrap. 289 

Par ilysis, pharyngeal, dysphagia duo to(\V. M. 
^follison), 983 

Paramorr, R. II. : Shock and ahovtion, 327,524— 
Eclampsia and its treattnont«803—Bea sickness, 
659 -Glaucoma and tbo ca.piilary circulation, 
1127 

Paratyphoid fever. See Fever 

Parrurt, F, D . fails to registor dangerous drug 


purobasos, 528 

Pans * - 

. air 

of 

of 

Me 

ra* 


lion^ in,932— InternationalSocial Welfare fort- 
night in. 1078. St-e also Franco 
Paribii, H. il. : B.C G. vaccino, 59? 

Par sot. JacQUos, nominated jirofcssor of 
cdicino in the Nancy 

F * of morphinism. 244 

Parkp.r, Eric : FUld, Itiver, and Hill, rov . 1069 
Pahkeii, George: Case of progrosaivo muscular 
aiiopby of the peroneal tjpo. 1062 (O) 

Parkes, Lieut.-UoL E dmund ICrncsl, ohitimvy 
notiro of, 1093 

Padkinson, John : Difficulties in cardiac 
diaguosi4,347 

Parliament, Medical Notes In : 

Accidents : In mtnos. 830 — In the Ro3’al Air 
I orce. 830 

Adenoids, death after operation for. 616 
Admiralty bosjj tals, 381. See also Navy 
Air Force. Rojal : A\'ailahlo beds in hospRalo 
of 381— Hospitals of, 474— Estimates, 472, 529 
— Acetdonts in. 830 

Alcohol, revenue from tho sale of in India, 381 
Animals, oxpenmeuta on, 474, 1093, 1131 
Anthrax. 474 

Appioved societies, invested funds of, 649 
Armv, British, estluiat^s, 473. 529 — Dispensors 
in the R.A.M.C., J095— Dispensors in the 
Territorial Armi', 1095— Coat of military 
hospitals, 1095 

Artificial RilK factories: Ilealih conditions in. 

531. 580. t97-Emis8lon of gases from. 648 
Bods for abnormally tall patients. 380 
Beds and personnel in naval hospitals. 42B 
Bellahouston Hospital, fulnro of. 290 
Bothlcm Hospital Bill. 778. 964 
Birmingham Guardians and tho mentally 
unfit, 423 

Birth and death rates in tropica! Africa, 532 
Birth rato in the administi'ative county of 
London. 830 
Blind Persons Bill. 289 

Blind persons: Numbers receiving pensions 
under tbo Blind Persons Act. 381— Financial 
circumstances of tho so-cnlJed unempJo.i- 
able, 532 

Board of Trade estimates, 1051 
Boric acid in cream, prohibition of, 290 
British Guiana Act, 615 
Budget. 735 

Calves used for vaccine lymph. 532, 10;6 
Cancer research, expenditure on, 926 
Casual wards at Thame, improvements in, 
1C06 

Cnsuals: Detained for modical examination, 
428— Beds for in unions, 474— Fitness for 
labour of. 551— Medical inspection of. 1095 
Certified persons, procedure regarding dis- 
charge of, 829 

Children boarded out by tho West Ham 
Guardians. 381 

Coal dust causing chest diseases among sur- 
face workers at collieries, 1131 
Coal mining industry. 52^ 573 


Cream, synthetic, 616. 826 
Crew spaces on British merchant vessels, 
inspection of. 649 

Croton oil. ' ' 

Currencs'i 

Bead bodi. • . ce 

district, 428 

Deaf aud dumb, training of, lOW 

*■ , from cancer (Arthur 

in Kensington and 

Southwark. 1096 

Dental companies on the statutory' list, 532 
Diphtheria among oleuientaryschool children, 
580 

Diphtheria, notification of suspicious cases, 
532 

Diseases, investigation of new discoveries in 
connexion with, 880 

Diseases treated by electrical methods by 
unqualified practitioners, 381 
Disp-nsers in the R.A.M.O., 1095 
Dispensers in the Territorial Army, 1095 
Dogs Act Amendment Bill, 289. 332, 1094 
Dogs, Protection of. Bill. 289, 740, 778 
Drugs, noxious, revenue from the sale of in 
India, 381 

Drunk and iucapables, nnmbers apprehended 
in Glasgow, 428 
Dust carts, savers for, 290 


Parliament. Medical Notes Inieontd.): 
Dysentpry in llio SInaraugo prison camp. 

Cn'T OTA 

■ ■ ■ mercal Di^- 

35 

. . , 

Electrical treatment cf disease by unqualified 
praciitlonors, 381 

Emigrants to Canada, prospective, medical 

provision of treftt- 
■ ' 474 

iMpmi fniucuiBO lUii, oVo, 697. 82G, 923, 1094 
Experlmonls on animals. See Aniuniis 
Ex-sorvico men receiving treatment, numbers 
of, 964 

Factories Bill, 289 
Factory inspection, 474 

Faclori’ inspectors' assistants, promotion of, 
532 

Factory inspectors in Bcolland, 332, 474 
Fops for doctors summoned to urgent cases, 
925 

Fighting serviros, co-ordination of tho. 579 
Finance Bill, 1005 
Floods, Thames, 657 

Food and Drugs Act, Sale of, 881, 1095— Ad- 
ministration of, 1095 
Food and Drugs (Adulteration) Bill. 1C94 
Foot-and-moutli difca‘-p, 289. 379, 380, 474, 530, 
739. 778.830,880,964,1095-AlIogcd remedy for, 
474 

Gas, poison : Brohibltlnn of tlio use of in war, 
381— Uangern to civilian population of an 
^escape of, 964 — Storage of. ItW 

_ _ a * 11 

739 


Hospitals, voluntarj’: Report of Commission, 


H 

697, 881 

Jlongo* inhabited nnd unfit for hAbitallon in 
Glasgow, 830 
Housing, rural, 645 


from the sale of alcohol and noxious drugs, 
381 

Industrial and Provident Societies (Amend- 
ment) Act. 615 

t,. --nnty Durham, 333 


Infectious diseases, notification of, 648— Fee 
for, 428 

Insanitary premises, compeneation for, 926 
Insurance. National Health: 

Amendment Bill. 42^ 6 5, 7.8, 775, 826, 879. 
923. 963. )051. 1094. 1130 

Approved societies and additional benefits, 
529 

• .* ' 'i of, 649 


Disablement benefits, 428 
Funds invested, 289 

Insured persons reaebing the ago of 65, 289 
In Ii eland (Nortlioru), 829 
Inspectors, 1035 

Medical benefit. State grant in aid of, 10S4 
Mileage and drug costs, 697 
Numbers benefiting, 964 
Ophthalmic benefit, 616 
Panel doctors and medical certificates for 
persons over 65, 530 
Pregnant women at work, 529 
Sickness benefits, 428^ 

Insurance, thii'd party indemnity, 69? 

Iraq dates and cholera, 428 
Kenya, medical and sanitary services in, 428 
Labour, hours of, Washington Convention on, 
379 

Labour Ministry, vote, 775 
Lambeth Hospital, provision of separation 
wards, 1096 

Lapwings Protection Act, 615 
Lead Paint Act, 380 

Lengiiecf Nations, health work organized by. 
615 

Leprosy, 380— In Palestine, 881 
Liquor (Disinterested Ownership and Manage- 
ment) Bill, 1131 

Local Authoriiies (Emergency Provisions) Act, 
426. 472 

* the Royal Corn- 

Lunacy. See also Mentally deranged 
Marines, Royal, acceptances and rejections, 
290, 


Dill, HO 

Slaternal mortality, 530, 177, 1095— In child- 
birth. 1095. 1093 

JIaternity and child welfare centres, numbers, 
830 

Medical examination of intending settlers in 
Canada, 428 



INDEX. 


r The British 
L Medtcai. Joimsii. 


JAN.-JUNK, 193S] 


Parliament, Medical Notes InCrou^?,): 
MeutftUy deftcUnit 501 ! tlelicavo chraroii, 
ociacfttiOH of, EGl 

Mentally clonnU'nt prisonprs. troalipont of, 9 5 
.Moetally doniiwiocl persons. cortinpaUonof,925. 
.SV("rti50 Lunacy 

Midwives, iraluinf: nnd supply of, GIG 
Military IjospUals.dosioK ol. 3S0 
Milk adalloratlon. lOOG 
Milk cMiipaiK'n.2^9 

Milk. condcQ'Od skimmed, an-l rlckols, 423 
Milk consmuplion pt'rlioac.552 
Milk production in I'-nRland and Wales, 810 
TMluoa. nldit work hv bovR In. 380 
Minors' phthisis. .See Tuht-rculosia 
*\iorphine.omput o(, 870 
Mos^nito pest, JSO 

Motor accidents and voluntary liospilalfl 925 
Motor rehiclos. nofso of, and nervous com- 
plaints. K9G 

^*avy, Hoyal: Accoptanccn and rojections, 290 
— \dmirally hospitals, beds nvailahlo. ,'8l— 
lirtslar Hospital palicnls, nnmbor of, 331— 
»<cd^ andpcraonnol in naval hospltalR, 428— 
InvalidinR from, 472. 578— HunRost^’d re- 
examination of rules. 472— Closure of naval 
hospUals, 471 — Kstimates. 472, 529. 573 — 
Tuberculosis in, 539— Incidence of dl'.oaso 
in. 531— Disponslnn of medicines in, Gil- 
Eyo di^oasos In, 697— Cost of naval hoapiials, 
1C95 

Night work by boys in mines MlncR 
Nolso of motor vehicles and nervous com- 
\dainls. 10% 

North Ulet 5ceUist 
Notiflablo dlsoHses. 3S0 

Nuraoo* schools recoRuIzed by the Hoard of 
Education. 531 

Olhces. inspection of, 339— UeRulatlon of. 573 
Open-air classes In London area, number of 
children aUendins, 881 
OnouiiiR of DOW Fossion. 2U 
Ophthalmology, q ralidcations in, of mcJlcal 
oniceva,379 

Opium Convention. aiRnaturcs rHU lacUinR. 333 
Opium exports from India, 333 
i*.a cstin-*, medical appointments In, 773 
pArltamentary Medical Oommitteo. 330 1150 
PEKStONS. 290. 332, 380. 427, 428. 473, 579. G37. 

850,881, 925,954,109;, 1095 
Appeal tribunal, decisions of, lOO'i 
Hollahoustou Hospital, future of 250 
UullQRa Street, Westminster, clinic, 697 


' 474 

Disablement and Health Insurance, 473 
Diflabtement and appointment to a tem- 
porary commission in tbo R.A.M.O.. 473 


Ministry not to bo a subordinate department 
of tbe Ministry of Health, 428 
Ministry of Pensions hospitals, 332,925 
Number employed by the Ministry. 3 0 
ScoUisb disabled ex service men, 579 
Service bospitals and, 427 
Stabilization of war pensions rates, 964 
Status of the Ministry. 1131 
Treatment allowances for pensioners suffer- 
ing from tuberculosis, 616 
Treatmout of pensions patient*?, 1094 
Treatment of tubercnlou- pensioners, 1131 
Visits to patient’s home, 380 
Weekly cost of ox-service patients, 380 
Widows and orphans, numbers, 831 
Petrol, dangerous, protective clause in new 
bill. 531 

Petrol fumes in armoured cars, 531 
Petrol tax, 1131 

Petrol, totra-ttbyl lead in. S-c Totra-etbyl 
Petroleum Amendment Bill. 1094 
Plymouth, insanitary areas in, 830 
Poisons, law relatinR to. 474 
Poor Law relief, 645— Numbers in receipt of. 

881— In Scotland, 1095— Lunatic poor, 

^*381 rejected for flat foot. 

Prayer Book, the new. 1051 

Prison Service, hospital officers in the. 1095 

IP the Solomon Islands, health of. 


(Destruction of A'crmin) Bill. 

Rib, 5i2. 5S0 

Public House Iranrovement Bill. 529 
‘ S^m£ 11911). Bill to amend, 773 1095 

N ‘V ■ ■■ ■ I.'. * :.290 


^1005^109”^ 3'aluafiion (Ascertainment) B 
negUtrars of births anS deaths, duties of, i 


fUil. 4V2 

Rdral Veterinary College, grant tor rebuilding. 
Salaries of medical officers, 332 


Parllamont, MocHcal Kotca fn (ronM.) : 
Sanutorimn treatment, cost of, 829— Of tubor- 
culoiiR persons and Tnccloatlon 1095 
Banitutlnn of rural districts, 648 


• . ry 

Sheep dip. 954, 1O.6 
Siiops Bill. 616 

SiliroRis and Workmen's Componsation, 1005, 
1005, 1005 

SlaiiRhtcr of Animals Bill. 572 
siatigUlcr of Animals (Scotland) Bill, 289. 380, 
1131 

RloeplnR Rlcknoss. 778 

Slum cloaranco schemcR, 1120 

Small pox. 379. 427, 474. 530. 616, 618. 777, 829. 

^ 850. 926, t64. 1036, J)30 


■ 'barley. 830 

. . 1006 

*~uuui{niu uu (if iu«iiii(y npiiifuitod. 615 

Tetra ethyl load in petrol, 330. 426,615,697, 830 
Third party losurancc. Sec Insurance 
Tinned food*:, 333 

Totalizator on race conrses Bill, 472 
Tsct^io fiy In Konva Colony, 290 
TuborculORifl in the Navy, 530— In England and 
Wales. 773— Cost of sanatorium troitinont, 
820“Minors’ |)hthiBlfiduetorock-bonnR.829— 
Cost of treattnent, 1095 — And service con- 
dit-ons, 1C95— S.anatoriimi treatment and 
vaccination. 109.5 

Tnborcnlous patients in small-pox hospitals. 
951 

Hist. North, tack of hospital service in, 1095 
Unl\crslty of KcadinR Bill, 778, 1C91 
Vaccination ; Statistics, 1035— And sanatorium 
treatment of tuberculous persons. 1095 
Vaccine lymph, calves used for, 532 
Vacrants In casual ward-*. Gtness for labour 
of. 551 

Venereal dis^'ase: Control of. 352— Clinics in 
Scotland. 697. 773— Treatment of. 829— Spread 
of. 925. See • • 

Vivisection : * 

Voronoffs ox. 

of livestock. 474. 1C94 
Water Board areas survey. 428 
Water supply of schools. 926 
Welfare ceutro, proposed now nt Sonlhgate, 293 
Welsh Board of IleaUb, 11. 0 
West Ham guardians and boarded out children, 
381 

WinRflold Orthopmdic Hospital, 333 
Workshops, insanitary and overcrowded, 926 
" ZinoviolT icUcr,” 529 

Parliaineutarj* representatives. 831 
Parliamentary session (IcadinR article), 22 
I’AunY, L. A. : Fatalltv rates of emall-pox in tbe 
vnccinatoi and unvaccinated, 116 — Tbo trial 
of Mary Blandy, 264 

PAntiT. T. O. Wynne: Bilateral embolism of the 
central retinal arterj’. 178 
Pausonb, Allan C.: Post-encephalitis problems, 
759— Report on the post-encephalitic patient, 
1122 

Parsokb. Arthur Augustus, death of from 
r V. ' 'r-'.H t-.rv -.-‘ O. V,V 

Pa; '. It ' . ‘ 1 - ’ • •• ‘.452 

P.tri.-.*- . ’ tJtabilaiits of 

ioTidon, rev , 138 

Parturition, influence of upon insanity and 
crime (A. Louise Mcllroy), 303 (O) 
pASLi’.T. C. n. : Two cases of multiple urethral 
calculi. 443 

Patella, Vioceneo, death of. 1005 
PATnnsoN, C. P. : Malarial treatment of general 
paralysis, 1024 

Paterson, Donald: Notes on the history of 
Cardiff. 142. 6S2. 1040 

Pateuson. Elizabeth Park Young, obituary 
notice of, 927 

Paterson, Herbert J.: The fracture problem, 
730 

Paterson. Keppio : Maternal mortality dne to 
puerperal sepsis, S80 

Paterson, R. L. : Scorbutic swelling simulating 
an acute bursitis, 666 

Pathologist, work and responsibilities of the 
(Sir Bernard bpilsbury), 1079 
Pathology, clinical, and general practice (R. C. 
Matson), 897 

Pathology, review of bookt on, 593, 1067 
Paton, Major E. L„ Territorial Decoration con- 
ferred on, 119 

Patrick, Dr : Health of school children in 
Northern Ireland, 1085 

Patrick, W. H. C.: Treatment of prostalic 
enlargement, 116 

Patterson, J. : Lead treatment of malignant 
disease. 1134 

Pattison, C. Lee: Tbe type of tuberculous 
lesions in bones and joints. 731 
Patton, A. : Painless natural labour, 164 
Pavel, I. (M.Chiuat and A. Lomon): La v^si>ule 
bih’atre, rev., 265 

Pavlov, I, P.: Croonian Lecture on the physio- 
logy of tbe cerebral hemispheres, 839 — Ad- 
mitted an Honorary Fellow of the Royal 
College of Physicians of Loudon, 856 
Patne. R. T.: Intravenous treatment of varicose 
ulcers, 893 

Peabody, Frances Weld, death of, 240 


PjiACiiELL, G. E. : Histology of the g’obus 
pallidus, 352 

Peachey. Georg*) 'C. : Vicary Lecture on the 
homes of the Hunters, 276 
Pearce. Q. H.t Troatmentof flatulence, 82 
Pearce. II. M. : Tbe future of obstetrics, 325 
Pearl, Raymond: Alcohol and longovitv, 148 
Peau“-e. James : The Co-ordinafion of the Public 
Health Services m the Couutie.'t of Eisex, 
HampsJdre, Gloucester, and West Sussex, 
228. 1045 

Pearson, Karl : The Itight of the Unborn Child, 
145 

Pearson, L. V. (and W. A. Barnes): Suppura- 
tive pylenblcbitis and hepatic abscesses com- 
plicating appendicitis : a case of recovery. 393 
( 0 ) 

Pearson, Re^^inald Spencer, obituary notice of, 
927 

Pearson. William ; Treatment of fractures. 56— 
Congenital pvloric steno-is, 945 
Pediatrics, review of books on, 138. 453, 805, 
1113 

Peirce, F. T. : Artificial humidity in coticn 
cloth factories, 765 
Pekin, ^fe(l^cal Guide, 741 
Peking Union .Medical College. S^e College 
Pellissier, L. : Ij’hvner tension arth-ielle 
soliinire, rev., 8M 

Pelvic circumference of infant at birth. 5S2 

'■ ' I* lal mortality, 618. 

ucn (J. 3r, Munro 

Kerr). 98 

Pelvis, Naegole f^George S. Davidson), 597 
Pemberton. H. (and R. T. Goodyear): 

Measurement of hacal metabolism. 395 
Pemberton, Ralph: The capillary circulation 
in rheumatic disease. 856 
Penny, Francis, obituary notice of. 785 
Penny. W. Sf. ; The prot'>ction of maternity, 572 
—Puerperal sepsis, 1C87 

Pensions ; 

Ar 

Cl Street, 

Disabled officers, nurses, and men in receipt 
of pensions, numbers of, 474 
Disablement and tbe Insurance Act. 473 
Disablement and appointment to a temporary 
commission, B.A.M.C ♦ 473 
Ex service men receiving treatment, weekfy 
cost of, 380 

Ex-service men returning to Scotland for 
treatment, 579 

Medical facilities for pensioners, 473 
Medical officers employed, 320 
Ministry of, not to be a subordinate depart- 
ment of tbe Ministry* of Health, 428 
Orphans, numbers in receipt of, 881 
Panel practitioners and certificates, want of 
conrtesy at the Ministry, 697 
Parliamentary notes, 380, 427, 428. 473, 579, 6i6. 

697, 880, 881, 954. 1094, 1095, 1131 
Service hos- itals and, 427 
Status of the Slinistry, 1131 
Treatment of pensions patients, 1094 
Treatment of tuberculous pensioners, 1131 
Tuberculosis treatment allowances, 616 
War, stabilization of, 964 
Widows, numbers in receipt of, 881 

People’s League of Health: Lectures on nutri- 
tion, 202 

Peptone treatment of asthma,328, 411, 458. See 
also Asthma 

Peptoned agar serum. See Agar 
Pepys's Diary, epidemics in (Colonel W. P. 
MacArthur), 319 

Peroival, a. S. : Miners' nystagmus, 520 
Pebdrau, j. R.: Ocular complications of en- 
cephalitis lethargica,261 
Periostitis of the metatarsus (Wilfred Attlee), 66 
Peritoneal fluid injections iu treatment of 
cancer, 204 

Peritonitis, pneumococcal, during tbe pner- 
perium : recovery (Harold F. Seymour), 8S5— 
(Frank Bodman), 1023 
Pernicious anaemia. See Anaemia 
Peters, B. G. ; The vinegar eel-worm, 103S 
Peters, E. A. (and Richard Lake): Bavdbool: 

0/ Discuses of the Ear, fifth edition, rev., 184 
Petges, Dr., appointed professor of skin dis- 
eases and syphilis at Bordeaux. 81 
Petben, Karl, memoir of, 119 
Petrol, dangerous, protective clause in new bill 
(parliamentary note), 531 
Pcfrol Engine, 832 

Petrol, ethyl. See Ethyl lead and Tetra-ethyl 
Petrol fumes in armoured cars (parliamentary 
note). 531 

* *M.1131 

1094 

Johannes: Issue - 
dedicated to, 883 — 
Elected a foreign memberof the Royal Society, 
1122 

Pharmacognosy, review of books on. 356 
Pharmacology, review of books on. 493. 718. 1027 
Pharmacopoeia, British, revision of : Discussion 
on, 570— Proposals for a standing Commission, 
915 

Pharmacopoeia of the Paddington Green 
Children’s Hospital, revised edition. 243 
Pharyngo-ocsophageal sphincter. 879. 922, 959 
Phpnyl-cinchoninic acid, bulbous eruption after 


26 JAN.-JUNE, 1928] 


INDEX. 


[ The B»rnf» 
MxDtcii, Jouanu, 


Philip, Sir Robert: Presentation to, 235— Appre* 
oiation of Sir Dawson WilliamB, 416— The 
causes of the decline in tuberculosis mortality, 
701 (O)— Awarded the Trudeau medal, 1097 
PhUjIjIP, Alban M.: The Prison Dreaders, rev., 
500 

PhUjIjipps. F. a.: Pernicious anaemia treated 
with liver diet. 93 (O) 

PhUjIjIpb, F. B. Willmer, obituary notice of, 694 
PhUjIiIpb, Miles : Carcinoma of the cervix, 57— 
Daree ovarian fibroma, 57— Hydrops tuboe 
profluenB,99— Haematometraand taborculOBis, 
99— Puerperal ovarian thrombo-phlebitis, 263— 
An occasional symptom of uterine canber, 498 
— Cystoscopy in carcinoma of the cervix, 668 — 
Drainage in Wertheim’s hysterectomy, 982 
•Photometer, new lamp-room (J. S. Haldane and 
R..'V. "Wheeler). 112 
Phrenic nerve. See Nerve 
Phthisis. See Tuberculosis 
Physical signs, review of book on, 137 
Physical treatment clinic in London, 33 
Physically unfit, marriage of (parliamentary 
note), 290 

Pick, Surg. Com. Bryan Pickering, O.B.H. con- 
ferred on, 988 

Pickup V. The Dental Board, 922 
PicKWOHTH, F. A.; Pulmonary and gastro- 
intestinal seqnels of naso oral sepsis, 97— (And 
Patrick WATSON-WHiiiiAiis) : Nasal and oral 
focal sepsis in the etiology of gastro-intestinal 
andpulmon — --‘i 

Pictures, old * 

PlEUCE, Gwil' 1110 — 

(And others) : Hyperpyrexia in terminal chronic 
nephritis, 177 . . 

Pierce, Howel (and others); Hyperpyrexia in 
terminal chronic nephritis, 177 
Ptcrsol’s Normal Histology^ thirteenth edition, 
rev., 397 

Pii:BT, Dr., appointed to the chair of thera- 
peutic hydrology and climatology at Lyons, 
617 

PiETRuSKT. Friedrich, appointed professor ol 
medical jurisprudence at Halle, 120 
Pjjper, Adrianus (and B. Davidine PoiiLiNOEu) : 
Hiatorj’ of an outbreak of typhoid fever in 
Pretoria, with special reference to the detec- 
tion of typhoid carriers, 587 (O) 

Pillars of health (leading article), 507 
Pinch, A. E, Hayward : Treatment of cancer by 
radium, 197— The present position of radium 
therapy. 496 . , , ^ , 

P 1 NGU 68 EN, Ludwig (and Carl OPPENHEisiEn): 
DieFerinente und £/jreTFtrfcu«fje«.rev.,454 — 
X>ieU^eihodiTidcrFennente. fifth edition, rev., 
454 

PiNET, A. (editor): Green’s Manual 0 / Pathology 
and Morhid Anatomy^ fourteenth edition.rev.. 
76^Bcccjif Advances in Haematology, second 
edition, rev., 1114 _ 

“ Pink disease.'* Erythredema - 
PiBiE, Robert Johnson, obituary notice 01 , 1092 
PiRQUET, Clemens; Elected president of the 
International Union of Child "Welfat®* 291— 
(E. Novel and B. "Wagner) i EmUhruiw 
Gesunder und Kranher Kinder, rev. , 861 
PI 8 EL, Howard G. : Painless natural labour, ^91 
Pitres, Albert, death of, 1005 
Pitts, A. T.: The pulpless tooth, 548 
Pituitary extract, dosage of, 273 
Pituitary infantilism (B. T. Freeman), 946 
Pituitary tumour. See Tumour 
Placenta accreta (W. Gough), 981 
Placenta praovia in four successive pregnancies 
(T. MacCartby), 95 

Plague in Australia, history of (J. H. L. 

Cumpston and F. McCallum), 1036 
Plants, narcotic (W. E. Dixon), 1038 
Plasmoqaine, 102 
Platt, Harry : Etiology of chrome arthritis, 309 
— The scope of surgery in chronic arthritis, 

347 

PLATFAiB, Hugh James Moore, death of, 564— 
Obitnarj' notice of. 613 

“Pleural shock,” diagnosis of from cocaine 
poisoning (J. D. Macfie), 715 
Plotz Foundation, Ella Bachs, 429 
PLTjmiEB. E.Cumow: Pulmonary tuberculosis, 
diagnosis and treatment of, 523 
Plymouth, insanitary areas in (parliamentary 
note), 830 ^ 

Pneumococcal peritonitis. See Peritonitis 
Pneumonia, acute, treated with sodium nuclein- 
ate <P. S. Hichens and R. E. Gibson), 52— 
Correspondence on, 159, 238, 285. 376, 643, 689 
Pneumonia with acute abdominal syi^^toms 
and mnltiple abscesses (Alfred B. QubbJ. 
1109 

Pneumonia, unusual complications 01 in. 
Walsh). 394 ,, 

Pneumonia, drug treatment of, 244, 334 , 

Pneumonia, lobar, cause and treatment 01 tne 
crisis in (Alexander Cannon), 661 (O) . 

Pneumonia, lobar, with diphtheria and malaria 
292 * • ;» 

pneumonia after operations for gastric ana 
duodenal ulcers, 11^ 

Pneumonia, Scottish Board ol Health leaflet on, 
281 

Pneumonia, treatment of, 572, 700 
Pneumothorax, recurrent spontaneous (Arthur 
Mills), 222 

Poisoning by borax, fatal (John Birch), 177 
Poisoning, cocaine, diagnosis of from “pleural 
shock” tJ. D. Macfie), 715 
Poisoning, chloroform, by ingestion, 82 
Poisoning, criminal (Sir William Willcox), 67 


Poisoning, ergot, among ry® bread consumers 
(James Robertson and Hugh T. Ashby), 302 (O) 
—Note on, 318— Conrospondcnco on, 410, 471— 
(Walter J. Dilling and K. E. Kelly), 540 (O) 
Poisoning, food, unusual case of (F. M. Rowland, 
F. W. Marshall, and J. Menton), 439 (O) 
Poisoning from furs (J, Wilson Dougal), 407. See 
also Furs 

Poisoning by [volatile] lead salts. 114 
Poisoning, chronic vinegar, 77 
Poisoning by non-arsenical w'eod-killer, fatal 
case of (A. H. D. Smith), 714 (O) 

Poisons, the law relating to (parllauicntarynote). 
474 

Police Journal, 67 

Poliomyelitis, anterior, treatment of by con- 
valescent serum (in British Columbia), 369— 
(A.BeUex).403 

PoLLAK, Bernhard, death of. 1005 
Pollock, J. H. : Psychonetiroscs, 220 
Polydactylism in the foot (A. Ernest Sawday), 
846 

Polydactylism and reversion, 413 
Polymastia (G. B. Richardson), 346 
Polyp of Meckel'sdiverticulnmcnusingintubsus- 
ception in an adult (Ian Macdonald), 442 (0) 
Ponder. Eric (and W. E, Cooke): The Poly- 


‘ *. in receipt of (parlia- 

mentary note), 381. 532, 881, lOS^ln Scotland, 
1096— Lunatic poor, nnmbors. 1036 
Pope, B. A. D.: Medical facilities on Moham- 
medan pilgrim ships, 1007 
Pope. Sir William: Dangers of ethyl petrol, 363 
—Evidence before the Commission on lead 
tetra-ethyl in motor spirit. 1033 
Population Conference, 3Vorld; Proceedings 
(edited by Margaret Sango]r). 639 
Population, natural capacity in the (C. J. Bond), 
315 

Portal cirrhosis. See Cirrhosis 
Porter. Charles (and W. Robertson) : Samian/ 
Law and Practice, sixth edition, rev., 719— 
Appreciation of James Whcatlor. 825 
Porter, Major-General Sir Robert, obituary 
notice of, 413, 476 

Porter, R. L.. appointed dean of the Medical 
Faculty at San Francisco. 1096 
Portmann, G. ; Vasomotor affections of tho 
internal ear. 982 

Pofl^encephalltic respiratory disorders. See 
Respiratory 

Post-encephalitis problems (Allan C. Parsons), 
759 , 1122. See also Encephalitis 
Post-graduate courses: At Carlsbad, 381 — At 
Derby. 741— In Glasgow. 822— At Innsbrnclc, 
163-In Leeds, 333. 381, 581— In London. 37, 75, 
80, 119. 163, 202. 242, 290. 333. 375. 581. 429, 478. 
532. 581. 617. 698. 741. 787. $31. 883, 929. 1006, 1053. 
1096, 1132— In malariology. 965— In Manchester, 
333— For midwives. 729 — For nurses (New 
Zealand), 568— In Paris. 333, 1006 — In Borne, 
c65_^t Strasbourg. 617, 1132— On tuberculosis, 
203. 956-Ia Vienna, 77. 381, 533 
Post-otfice, rejection for flat-foot (parliamentary 
note), 381 

Postmortem tcchniqae, review of books on, 805 
Potaseium chlorate R., exempted from key 
industry duty. 741 

Potts, John; Getting Well and Staying Well, 
rev., 949 

PouLTON, E. P.: Gastric secretion of neutral 
chloride, 469. 729— Non-oxcretory functions of 
the kidney, 759 

Powell, Allman ; High blood pressure, 802 
Power, Sir D’Arcy : Appreciation of Bir Dawson 
Williams. 420 — Appreciation of Charles Greene 
C/umston. 734 

PoTNTON, F. J.: The causation of rheumatic 
disease. 856— Rheumaticinfection in childhood, 
857 

Prayer Book measure aUernetivo, 3051 
Pregnancy, abdominal [full-time] ; prolonged 
suppnration : recovery (A. J. Kcevill), 801 
Pregnancy, albuminuria during (G. F. Gibberd). 
219 

Pregnancy, duration of, 75 

Pregnancy and epidemiceucephalitis (Frederick 
Roques). 351 

Pregnancy and glycosuria. 82 
Pregnancy, parovarian and ovarian cysts In 
(W, Gough). 981 
Pregnancy, test for, 952 

Pregnancy, torsion of Fallopian tube and ovary 
duric g ( J. E. Stacey), 668 
Pregnancy complicated by tuberculosis, 
Caesarean section in, 480 
Pregnancy. Wassermann reaction in (loading 
article), 272 

Pregnancy. Bee also Gestation 
Premature labour. i9ee Labour 
Pbenant, Dr,, death of. 79 

Pbepabations and Appliances : 

“ Alepol,” 225 

'* Ambidex ” wrist splint. 1115 
Belt for use in suprapubic drainage. 556 
Blood coagulation time, loop for measuring, 
672 

Brandy flask, an emergency, 672 

Citobaryum. 949 

Cork clip, a captive, 455 

Cystotomy, suprapubic, a tube for, 61 

Deltoid shelf. S86 

Diabetics, food balance for, 267 

“Digi truss.” 386 

Dimol snuff, 672 


Preparationb and Applianceb iContd.): 
Krgosterol, irradiated, tabloid form of, 556— 
Liquid form of, 672 
“ Enkodal.” 1069 

“ Glanoid “ concentrated fluid extract of liver, 
186 

Hvoscino hydrobromido, 763 
“lodasopUno,” 357 

Liver extract. Wollcomo, 502— B.D.H., 806 
Mouth gag, 902 

Ophtbalnioscono, an electric slit-lamp, 455 
Plasmoquine, 102 
Quinopban. tabloid, 267 
Radiography, dual control unit for, 851 
Radiostoloum (concentrated vitamins A and 
D).502 

“ Sopticomino.” 357 

StoriUxDr, portiblo low-prcsBUre, 18 

“Sulphostab.” 102 

Syringe for injecting varicose veins, 763 
T-strap, an internal, 986 
Tetanus antltoxin-globulinB, concentrated, 357 
Thoosol, 919 

' ■ . •olyt.”556 


Presentations, 37, 81, 163. 195. 235. 291. 403. 641, 
787. 965, 996. 999 

Prerto.v, T. W. ; Treatment of ulcers of the 
mouth, 164— Efficacy of tuberculin therapy, 
731 

Pretoria, health of. 370— History' of an ontbrenk 
of typhoid fovor in (Adrianus Pijpor and 
B. Davidine Pullingor), 587 (O) 

Preventive medicine. See Medicine 
PniRRAM, Richard, death of. 785 
Pridmore. Colonel W. G. ; Dangerous drugs, 
334 

Primula rash. 430 

Pringle, G. L. Kerr: Endocrine imbalance and 
chronic arthritis, 751 (O)— The endocrine factor 
in rheumatic diseases. 856 
Prisoners, mentally deficient, treatment of 
(parliamentary note), 925 
PrisoDcrs in the Solomon Islands, health of 
(parliamentaTy note), 881 
Private patients insurance scheme. See Insur- 
ance 

Prize, Adami, 199 

Prize for anaestbesia inhalation research, 381 

Prize, Bathgate memorial, 928 

Prize, Buckston Browne, 290 

Prize, CamproD, 997 

Prize, Dalby Memorial. 909 

Prize for best work on treatment of dissem! 

nated sclerosis, 787 
Prize, Gifford Edmonds, 37 
Prize, Graham. 1131 
Prize. Hallett, 697 

Prize, Harry Stewart Hutchison. 929 
Prize, Marchiafava Foundation, 163 
Prize, Nichols, 605 
Prize, Nobel, 787 
Prize, Badcliffe, 1131 
Prize, John Scott. 37 
Prize, Swlney, 617 
Prize. Sidney Rawson Wilson, 381 
“ Problem child,” Sea Child 
Procreation after prostatectomy, 204 
Proctor, F. : Pare milk progress. 765 
Professional examinations. See Examinations 
Professional organization. 951 
Prostatectomy, the patient’s comfort after 
(W. Stanley Wildman). 259 
Prostatectomy, procreation after. 204 
Prostatic enlargement, treatment of. 31. 74. 116, 
120. 204, 691, 732, 958 
Protozoology, review of books on, 670 
Prout, Lieut.-Colonel Sir William Thomas, 
K.C.il.G, conferred on, 988 
Pseudo-appendicular encephalitis lethargica. 
1098 

Psoriasis, metallic bismuth in treatment of, 204 
Psychiatry, the new (Sir John Maepherson), 903 
Psychiatry, Research Institute for at Munich, 
120 

Psychiatry, review of books on, 634, 671 
Psycho-analysis in early childhood (David 
Forsyth), 28 

Psychology. Industrial. National Institute for, 
gift to, 381 

Psychology and medicine (John Carswell), 872 
Psychology, review of books on. 185, 265, 310 
Psychoneuroses (J. H. Pollock), 220 
Psychotherapy in stageland.new, 244 
Fnblic Health Amendment Bill (South Africa), 
1042 

Public Health Conference in Dublin, 770 
Public Health (Destruction of Vermin) Bill, 426, 
532, 580 

Public health, a new way in (leading article), 
228 

Public health organization in the Irish Free 
Btate, 519. 770— In India, 1082 
Public health regulations in Scotland, 281. See 
also Scottish Board of Health 
Public health; review of books on, 669 
Public Health, Royal Institute of. See Royal 
Public health in Scotland, progress in (Sir W* 
' Leslie Mackenzie), 463 

Public health services, specialist, 228, 327, 376. 
1045 

Public health works for relief of unemployment 
(Irish Free State), 406 

Public health in the United States : Report, 203 
Public House Improvement Bill, 529 



.TAN.-JUNK.igsS] 


INDEX, 


r Tk* B*m*a 

L MzDicix. Jonxjj. 


I'libllcntlODB, now nnO lorllicomlni:, 2U. 173, 

553, 693,831,929 

ruorporal baomorrbfik'o (Dr. Komipay). 222 
Puprporai Morbidity Rod Mortality, Oonforcuco 
150 ^ ^ . 

rnorporal pyftomlft. Sep P>i\onua 
Puerperal pyrexia. See Pyrexia 
Puerperal Fopsis (A. Uonlln^^lou Hobbp), 971 (O) 
—DoadinR article, 9S9 

Tucrjwral sepsis, etiology of (Mr. lUirt*\Muto), 
bystoroctoniy in (Uctbel 


Puerperal sepsis, 
Solomons), 351 
.Puerperal sepsis, 
(James yonnfi>. 


maternal mortality from 

957 (O)— niscuRslon, 980— 

Correspondence on. 1127 

Puerperal Fopsia and slrcnlococci. 612 . 730. 788, 
879, 974— Apology atid correction. 879-:H. Hurt* 
\tliite),974 (0)— Corro>pon:lcnco. 1037 
Pnorporal sepals, treatment o( (Leslie Williams). 
495 

PcLMKQnu.B, Davidlno (and Adrianua Pi.mr.u): 
History o( an outbreak ot lypumd fever in 
Pretoria, with special reforenco to tbodetoc* 
tion ot typhoid carriers, 587 (O) 

Pulmonary artery. See. Artery 
Pulmonary diagnosis. Importance of sputum 
examination in, 469. See niso Bputum miuZ 
Tuberculosis 

Pulmonary fibrosis. See Fibro^^ls 
Pulmonary suppuration, chronic (William 
Anderson), 597 
Punjab, cholera in, 553 

PnuvF.S'STnvrxnT. Sir James: Karcolcpsy, 447 
Pns, tuberclo bacilli in. Sec Tubercle 
Pus in nrino. See Urine 

Pdtkam. Marian C. (Bronson CnoTitr.ns and 
Frank R. Fonpl: JJirth Injuries cf the Central 
x^ervOHs System, rev., 396 
PcTTA^*^’A, D. S.: Radical euro of herpes 
genitalis. 650 

Prrrr.n, Atignst: Die Drd-Drfhentheorie Her 
Hetmhereituno- rev., 3029 

•. : . •■.bl.264 

' . • .plfit. 770 

citfitlc ah- 
. , ' 'a ca^o of 

I • ' • . • , Pearson). 

390 (0) 

Pyloric stenosis. See Bteuosls 
PyTcxla, puetpcTal, now amending regulations, 
1006 

Pyrexia, relapsing and lympbadonoma, report 
on (A. Salusbury MacNalty). 819 
Pyrexia dno to infected dead tooth (Leonard 
G.J. Mackey). 1021 (0) 


Q. 


tjuackcrj'. German Society for Combating, 81. 

See aUa Congress 
Qaadrnplots. snrvival of, 700 
Qiiartrrlu Journal of Fhartnacu, first number 
of. 831 

Guebec, chiropractors in. 516 
Oueensland. See Australia 
tZtrfiNU, Profe'isor. elected vice president of the 
Academie de 5f<5decine, 165 
Coin. .T. s.: VeaJco-vaginal flstulae. 309 
(Juinine in obstetric practice, 157, 2^ 

(Juinophan. tabloid, 267 

Quiktela, Manuel, nominated an OQlcer of the 
Legion of Hoaoar, 923 


Radiation in treatment of cancer of the cervix 
(Max Cheval), 537 (O) 

Radiation and lead, combined action of on 
tuniours ( J. C. Mottram). 132 (0) 

Radiographer, death of from cancer (parlia- 
mentary note), 1131 _ 

Radiography in the diagnosis of obscure dental 
sepsis (Jhmes F. Brailsford), 1013 (O). See also 
Dental 

Radiography, dual control unit for, 851 
«aaiology, review of books on. 500, 804, 849, 984 

(concentrated vitamins A and D), 

Radiotherapy, review of hooka on. 16. See also 
imaiolocy. Radium, and X rays 
Kadmm, the commerce of, 19. 832 

compounds exempted from key industry 
anty for six months. 883 

of the North Oenterburr 
• ““spital. Christchurch, New Zeelana ; Report, 
JBays'* “‘SO Eadiotherapy, Radiolosy. and 

Eaiutn, surgical uses of (Walter C. Stevenson), 

cancer, 75, 159. 197. 286. 
(mZri (Roy Ward). 123 

the cancer of 

williams) (Duncan O. L. Fitz- 

JB.T.BoU%r«S 

Amendment Bill, 778. 1005 

Reheating winds. S« Winds 
Sbtch^.^U^nfgl? aegoneration of 

i*AiiAnoyi, Vincent, death of, 79 


U^Ms\T, A. MaUlanilt Pathogoneals ot acute 
primary glaucoma, 789 (O)— Awarded the 
William MncUenr.lo Memorial medal. 917 
Ramsay, Jeffrey : The roalstanc© factor in disease, 
with Rpeclal roferonco to septicaemia and 
allied conditions. 628 (O) 

RAiHPOTTTOst, Cutaneous mycoses in the 
tropics, 179 

UAVDr.r*^, W. Brough (and H. Lloyd Hind): 
Jf(indboo); of i^fiofomicraarapbi/, second 
edition, rev.. 949 

Rankin, WllUara: The aento abdomen. 284, 577. 
470 

Uankini:. John Lawson, obituary notice of, 
785 

Rao, 8. Bubba: Foreign body in the maxillary 
anlrnm, 546 

Ravj‘, K. : The ** rtBlog tost “for acute abdomen, 
788 

Rare maladies. See Diseases, taro 
Rash, primula, 430 
llat sarcoma. »SVe Sarcoma 
Rates paid by hospital**, statistics (Parliamentary 
note), 10>3 

Rating (Scotland) Amendment Act. 615 
Rating and Valuation (Ascertainment) Bill, 1005. 
1094, 1130 

Rau: The coronan* circulation. 404 
Raten, Charles L. 77tc Rumblings o/ a Bird 
Dover, rev,, 18— The Creator Spirit : A Surrev 
o/C)«ri«fioM Doctrine tn the Light of Dtology, 
Fsvcholoou, Jfi/*(tci»m. rev., 311 
RAV.'r.iNOS. Isaac D. : The lUse ntul Poll cf 
Disease tn JHinois, 631 

RATNEn. H. H.: Tho treatment of aente 
appcndlciti-*. 706 (O) 

Raynf-S. H. E.. Life assurance in the tropics, 218 
Read. C. D. : Teratomatous ovarian tamonr, 
£03 — Malignant change in the corpus uteri 
demonstrating metaplasia. 80S 
Read. C. Stanford: The Struggles of Male 
Adolescence, rov., 805 

Reader, J\.L. Maxwell: Spirit and Bipp treat- 
ment. 892 (O) 

Reavley. K. : The maximal dose of merciiro- 
chrouio, 33 

Rectal prolapse treated by injection (John A. C. 

Mftcowen), 633 
Rectum, cgg*cnp in, 52. 120 
Rectum, prolapse of in the female, operation for 
the cure ot (Fredorick J. McCann). 890 (O) 

Rod Cross movement, centenary of the birth of 
the founder of the. 862 

Rod Cross Societies. League of: The TTorW’s 
UeaUh.m 

Hod Cross Society. British : Appeal for a London 
clinic for rheumatic diseases, 152— First-aid 
service on the roads. 603— Report, 1125. See 
oiso Society 

RRDw^TZ, Erich Freiherr von, appointed pro- 
fc’jsor of surgerj* at Boon. 10% 

Rees, O . elected a member of tbo Dorset 
County ConncH. 429 

Rees. W. A. : Embolism of apex of lung, 494 
Reford. John Hope. C M G . conferred on , 98S 
Refractories Industries (Silicosis) Scheme. See 
Silicosis 

R^ffisfrar-GetierarsDrcenntal Supplement 11921), 
J54 

Registcar-Genoral'e reports. See A’ital statistics 
l’.« .i* *.* VT' <,f Birth.! I.*' I Deaths, duties of 
.p • V .i-' ,1*! 

R-;* r*'. . D v.: . and ilarriages) 

Bill. 289, 739 

Reucerger. George E.: Lippincoff’a Pochet 
Formula ry, rev., 398 

Reiin, Ednard, nominated to the chair of 
surgery at Bonn, 291 — Appointed professor of 
surgery at Freiburg. 741 

Reid. Hugh: Meckel’s diverticulum in strangu- 
• lated inguinal hernia. 394 

Reiddt Lieut -Col. Edwin William, obituary 
notice of. 740 

Reidy. Major Alexander Tates, obituary notice 
of. 1002 

Renal abscess. See Abscess 
Renal calculus, late results of operation for 
(J. F. D>bsou),484 (O) 

Benshaw, Arnold (and .7. D.Chishomi) : Tetanus 
in a boy, HS (O)— correction, 244 
Representation of the People (Eqnal Franchise) 
Bill. Equal 

Representation of the Peonle (University of 
Reading) Bill. See University of Reading 
Research at Buxton, 619 

Research, collective (leading article), 21 — And 
tuberculin, 375.469, 522— In the West country, 
512 

Research Council, Medical: Annual report, 233, 
268— A study of some organic arsenical com- 
pounds with a view to their use in certain 
streptococcal infections (Leonard Colebrook), 
367— Report on liver extract in the treatment 
of pernicious anaemia. 358, 463 — Fine work and 
eyestrain, 1119 

Research Institute, James Mackenzie : Carci- 
noma of the colon,58 — Diagnosis of the '* acute 
abdomen,” 136— Pathogenesis of acute primarj* 
glaucoma, 789 

Research institute for psychiatry at Munich, 120 
Research, Medical, Laeker Foundation for, to 
investigate the causes, nature, prevention, and 
cure of degenerative diseases, 81 
Research by observation. S06 
Research Organization, Liverpool Medical: The 
metabolism and acidity of Uie foetal tissues 
and fluids (W. Blair Bell, L. Cunningham, 
M. Jowett, H. Millet, and J. Brooks), 126 


Research. Scientific and Industrial, Depart- 
ment of : Penetration of Daylight and Sunlight 
into Buildings, 681 

Resistance factor in disease. See Disease 
Respiratory- disorders, post-encephaTitic (Aldren 
Turner and Macdonald Critchley). 143 
Retinal artery. See Artery 


Revlev/s of Books : 

Abdomen, Acute, the Early Diagnosis of 
(Zacbary Cope), fourth edition, 223— Fifth 
edition, IC69 

Abdomen, Acute, the Treatment of (Zachary 
Cope), 2^— Second edition, 1069 
Abdominal Disease, Acute, Clinical Re- 
searches in (Zachary Cope), second edition, 
223 

Abdominal Surgery of Children (L. E, 
Barrington-Ward), 554 

Abraham. Karl, M.D.. selected papers of 
(translated . by Douglas Bryan and Alix 
Stracbey), 225 

Accident Insurance. See Insurauce 
Acta Mcdica Scaudinavica. Supplementum 
XIX : Der Gebalt des Blutes an Calcium und 
Kalium (Eskil Kylin), 60 
Actinotherapy for GeneralPractitionersCH.G. 
Falkner), 356 

Adolescence: The Struggles of Male Adoles- 
cence (C. Stanford Bead). SOS 
Advice to the Expectant Mother on the Care 
of Her Health (F. J. Browne), second edition. 
1(K9 

African Year Book. See Year Book 
Alcohol Problem (H. M. Vernon), 1114 
Anaemia. Acute Aplastic (A. Hayes Smith), 
948 

Anaemia, Pernicious (Beaumont S. Cornell). 
1113 

Anatomical Exercises of Dr. William Harvey : 
De Motu Cordis, 1628; De Circnlatione 
Sanguinis, 1649 (edited by Geoffrey Keynes). 
948 

Anatomy, Green’s Manual of Pathology and 
Morbid Anatomy (revised by A. Piney),' 
fourteenth edition, 763 
Animal Ecology (Charles Elton), 762 
Annual Charities Register and Digest, thirty- 
sixth edition, 806 

Anophellnes of Tropical and South Africa, a 
Short Illnstrated Guide to the (Alwen ^I. 
Evans), 395 

Appendicitis (Hubert Ashley Royster), 806 
Arthritis, Cbronic. and Rheumatism, Bacterio- 
logy and Surgery of, with End-Results of 
Treatment (H. Warren Crowe), 183 
.Australasian Medical Congress, Transactions, 
753 

Baby’s Daily Exercises (Edward Theodore 
Wilkes). 357 

Bacteriology: Bakteriologie insbesondero 

bakteriologische Diagnostik (K. B. Lehmann 
and R. O. Keumann), 9S6 
Bacteriology : Bakteriologisches Taschenbuch 
(edited by Otto Olsen), twenty-eighth edition. 
670 

Bacteriologj'. General, An Elementary’ Iiabora- 
tory Guide in (Harold J. (3onn), 670 
Bacteriology. An Introduction to Laboratory 
Technique in (Max Levine). 670 

. Descriptive and 
■ . ntary flelmintho- 

Bacteriology, Practical, Principles of (J. H. 

Johnston and R. B. Simpson), 670 
Bacteriology, Practical, Blood Work, and 
Animal Parasitology (E. B. Stitt), eighth 
edition, 851 

Bacteriology aud Snrgery ot Cbronic Arthritis 
and Rheumatism, with End-Results of Treat- 
ment (H. Warren Crowe), 183 
Bacteriology, Text Book of (Hans Zinsser), 
sixth edition. 850 

Bacteriology, Text-Book of (William W. Ford), 
850 

Bacteriology, Veterinary, Manual of (Raymond 
A. Kelser), €0 

Bartlett, Adelaide, Trial of (edited by Sir John 
Hall). 266 

Basal Metabolism in Health and Disease 
(Eugene F. Du Bois), second edition. 101 
Biochemistry, Applied (Withrow Morse), 
second edition). 6^ 

Biochemistry, a Textbook of (A. T. Cameron), 
805 

Biological Assay, Methods of Cj. H. Burn). 
454 

P*-’ — • r r • - 

E ■ / . ' 

18 

Birth Injuries of the Central Nervous System 
(Frank R. Ford. Bronson Crothers, and 
Marian C. Fntnam), 396 

Black’s Veterinary Dictionary, (edited by 
William C. Miller). 672 

Blood Cbomistry’. the Clinical Interpretation 
of (Robert A. Kilduffe), 556 
Blood Formation: Das BlutbUd und seine 
klinische Terwertung (Victor Schilling), 
fifth and sixth editions. 102 
Blood Group Determination : Die Technik 
der Blutgruppenuntersuchung (Fritz Schiff!, 
635 

Blood Morphology: Die Blutmorphologie der 
Imboratoriumstiere (Carl KUeneberger), 


28 JAN.-JUNE, 1928] 


INDEX, 


[ The nnmra 
Medical JotrBKxL 


Rcviewo of Books (continued". 

Blood ■ Preasuie : Its Cliuical Applicdtion'? 
(George William Morris, Henry Ontlibert 
Bazett, and Thomas M. McMillan), fourth 
edition, 804 

Blood Pressure: Ij’hyportension artdriello 
solitaire (L. Pcllissior), 8'4 
Boar’s Head Tavern in Eastclieap (ICennoth 
Rogers), 851 

Bolles Lee’s Microtomist’s Vade-Mecum, ninth 
edition, 672 _ _ 

Bone. Bel ■ 
of (Sir ■' 

Burdett’g 

Canadian Mother’s Book (Helen Macmurchy), 
£49 

Cancer: Surgical Trratment of Malignant 
Disease (Sir Holbnrt J. Waring). 453 
Catering, Aids to (P. E. Findlay Shirras), 902 
Catholic Nurse: Her Spirit and Her Duties 
(Father Richard .1. Murphy), 267 
Centenary Addresses Bound Together in One 
Volume— Univei si ty of London, University 
Colh ge, 59 

Cl’sracter, the Psychology of (A. A. Roback\ 
138 

Charities Register and Digest. 806 
Chemistiy, Colloid and 1 hysiologic, Lectme^ 
on the Biologic Aspects of, S02 
Chemistry, Physiological: Lehrbuch der Phy- 
Rtologischen und Pathologischen Gbemle 
(Otto Ftirtb).554 

ClBld, Everyday Problems of the Everyday 

■ . * . . it Normal 

Childhood, Common Dlsoiders and Diseases 
of (George Frederic Still), fifth edition, 15 
Children, Aids to the Diagnosis and Treatment 
Diseases of (John McCaw). sixth edition, 
454 

Children and Infants, Diseases of (J. P. Crozer 
Grlfilth and A. Graeme Mitchell), second 
edition, 805 

Circulation : La Circulation Sanguine r^ri- 
ph^rique et ses Troubles (A. Dumas) 266 
Circulatory Disorders : Die Hypertoniekrank- 
heiten (Eskil Kylin), 266 
City Health Administration (Carl E 
McCombs), 224 

Clinical Handbook for Residents, Nurses, and 
Students (edited by Victor M Coppleson), 
1115 _ . • , , 

Clinique M4dica’e de I’Hdpital Beaujon (Ch. 
AohBrd),635 

Colon. Tonic Hardening of the (T, Stacey 
Wllfon),356 

Colour Bliodoess Tests : Stillings pseudo- 
isochromatische Tafein zur PrUfung des 
Farbensinnes (G. Heriel), 986— Tafein mit 
Umscblftg-farben zum Nachweis' von rela- 
tiver Rot- und Gifiosichtigkeit (Grnst 
Wa fflin), £86 

Confessions of a Tenderfoot Coaster” 
(Warren Henry), 986 

Confidential Chats with Boys, 101 —With Girls. 
101 

Congestion: Stauungstypen bei Krieslauf- 
stijruugen (Herbert Elias and Adolf Feller), 
670 

Creator Spirit : a Survey of Christian Doctrine 
in the Light of Biology, Psychology, and 
Raven), 311 


Outlines of Dental 
Hamilton Jamieson). 


1069 

Dentists Register (1928), 502 

Dermatology: Pi^cis de Dermatologie (J. 

Darier), fourth edition. 948 
Dermatology. SeeuIsoSkin Diseases 
Diabetes : Die Zuckerkrankheit und ihre 
Bebandlung (C. von Noorden and S. Isaac), 
17 

Diabetes: La Pathotieuie et le Traitement du 


.nd Insulin 


y Methods 
lur Hawley 


(Alexander 

^ Tregouwell 

Collier), 849 

Diagnosis. Physical (Richard C. Cabot), ninth 
edition, 310 

Dingnosis, Physical (W. D Rose), fifth edition, 
902 

Diagnosis and Physical Healing (F. G. Crook- 
shank), 185 

Diathermy : Die Klinische Anwendung der 
'J. v-*' B*”ben),60 

.■ !’,■ and Uses in Medi- 

.■■■ > '.v : - P. Cumberbatch), 


second edition, 454 

Dictionarj’, Black's Veterinary (edited by 
Willi mO. Miller). 672 

Digestive Organs, Diseases of, with Special 
Reference to their Diagnosis and Treatment 
(ChsrJos D. Aaron), fourth edition, 806 
Directing Mental Energy (Francis Aveling), 
499 

Disease : Krankheitslehre der Gegenwart 
(Gotthold Serxbeimer), 555 
Doc, Topographical Anatoms’ of the (O. 

Charoock Bradley), second edition. 18 
Dongal, Samuel Herbert. Trial of (edited by 
F. Tennyson Jesse), 1C2S 


Reviews of Books (continued): 

Drugs, titandurdization of, M^-thods of Bio 
logical Assay (J. H. Burn), 454 
Duodenal Bound; Lo Tube Duodenal (Max 
Einhorn, translated by Gustave Monod), 225 
Ear Diseases, Handbook of (Richard Lake and 
E. A. Potoi b), fifth edition, 184 
Ear: Oreille Interne: Etude anatomo-patbo- 
loglquoetclin que. technique microscoplquo 
et experimentelio (Charles CIaou£). 181. See 
J diseases 

■. • . i2 

do rdloc* 

Electrolytes : Die Elektroiyte: Hire Bedcutung 
fUr Piiysiologio, Pathologie und Thorapte 
(S. G. Zondek), 138 

Embryology, EKiierlmontal (Thomas Hunt 
Morgan). 98S 

Emulsions and their Technical Treatment, 
the Theory of (William Clayton), second 
edit'on, 224 

Endocrinology : WissonscbaftHcho For- 

schuugsbcrichte NaturwiHsonschaftlicho 
Reibe (Raphael Ed. Licsegnng.). Band xix; 
Hormone und Jooero SekretJon (Fritz 
Laquer), 985 

Endocrinology. See also Secretions, Internal 
Bpilep^v (L. J. J. Mu-kens), 1027 
Epitheliomas of tlie Skin: La Roentgen- 
th^rapio des Epitheliomas Cutauds ct 
Cutan^o-Muqueux par la M^thodo du Dr. J. 
Oosto (Georges Gircl). 1029 
Everyday Problems of tbo Evoiyday Child 
(Douglas A. Thom). 511 
Experimental Medicine. See Medicine 
Faeces: Precis de Coprologie Clinique (Rene 
Gaultier). 763 

Feeding and Nutritional Disorders in Infancy 
and Childhood (Julius II. Hess), fifth edition. 
184 

Ferments : Dio Formon*e und ihre Wirkungeu 
(Carl Oppenbeimer), 454 
Ferments: Die Methodik dor Formenio (Carl 
Oppenbeimer and Ludwig Pincussen), fifth 
edition. 454 

Fevers ; Le Sj’ndrome Milin dans )es :Mii)Adjcs 
de l*Enfauce(V. HutincI). 635 
Field, River and Hill (Eric Parker). 1069 
Fighters of Fate: A Story of Men and Women 
who have Achieved Greatly L’espita the 
Handicap of the Great White Plague (J. 
Arthur Myers). 720 

Fit St Aid for India, Manual of (Mtjor Hasiiian 
Suhrawardy), second edition. 9 -9 
Fish, Fishing, and Fishermen (William Calue), 
902 

Food Infections and Food IntoxicntiooB (B. R. 
Damon). 1113 

Foods, their Composition and Analysis (Alex- 
ander Wynter Blyth and Meredith Wyntor 
Blytb), seventh edition. 947 
Foods, Fatty: Oils, Fats, and Patty Foods IE. 
Richards Bolton and Cecil Uevis), second 
edition. 947 

Fractures : Traitement des Fractures par le 
Fracticien (Dr. Etienne), 396 
Fractures: Traitement des Fractures du Col 
de F4mur (Jacques Leveuf and Ch. Girode), 
8(9 

Fractures. Treatment of (Charles Locke 
Scudder). tenth edition, 396 
French Medical Service in the %Ver: La 
Service de Bant4 pendant la Guerre, 1914- 
1918(In8pecteuv-G^n^raIA.MigDon).Tome8l, 
II, III, IV. 1112 

Galatea, or the Future of Darwinism (VV. 
Bussell Br&in). 1029 

Gall Bladder. Liver, and Pancreas, Surgical 
Diseases of, and their Treatment (Moses 
Bohrenl), 265 

Gall Bladder : La v^sicule biliaire (M. Chiray, 


357— Index to Minutes from 19 3 to 1927, 
357 

General Practice, How to Start in (Isaac G. 
Briggs). 1028 

General Practice, the Specialties in (Francis 
W. Palfrey), 7i9 

Genital organs. See Reproductive 

Getting Well and Staying Well (John Potts), 

949 

Goitres, the Simple (Robert UcCarrison), 1067 

Gonococcal Infection in the Male (Abr. L. 
Wolbarst), 100 

Green’s Manual of Pathology and Morbid 
Anatomy (Revised by A. Piney), fourteenth 
edition, 763 

Gums and Oral Mucous Membrane, Diseases 
of the (Sir Kenneth Goadby), third edition, 
357 

Guy’s Hospital Reports Vol, 78 (Vol, 8, fourth 
series), 555 

Gynaecology (Howard A Kelly), 634 

Gynaecology for Nurses (Harry Sturgeon 
Crossen), 806 

Gynaecology for Students and Practitioners 
(Thomas Watts Eden and Cuibbert Lockyer), 
third edition, 396 

Gynaecology, a Textbook of (James Young), 
second edition, 600 

Haematology, Recent Advances in (A. Piney), 
second edition, 1114 


Roviows of Books (continued): 

Hair and Scalp: a Troatlso on Diseases of the 
(6. Dana Hubbard*. 1028 
Harrison of Ighiham, 1070 
Harvey. William, The Anatomical Exercises 
of: Do Motu Cordis, 1628; Do CircnlatioDO 
Sanguinis, 1649 (edited by Geoffrey Keynes), 
948 

Health Administration, City (Carl E. 
JlcCombs). 224 

Health, Towards (J. Arthur Thomson). 102 
Herbalist, The Divine Origin of tbo Graft of 
the (Sir E. A. Wallis Budge), 851 
Hernia and Hcrnioplasty (Ernest M. Cowell), 
266 

Histology, Piersol’s Normal, thirteenth edition, 
397 

History: A Study of Present Tendencies (A. L. 
Rowso), 600 

History of Medicine. S e Medical bistort’ 
Homo Nursing, a Compendium of Aids to 
(N. Corbet FJotchor), tliird edition, 556 
Bdpital Beaujon, Clinical Lectures (Ch. 
Achaid). 635 

Hospital Organization and Management 
(including Planning and Construction), 
(Captain J, E. filono), 183 
Humanity ^and Labour in China (Adelaide 

1' ' , ' 

Hj . Bernard and 

B . . 

Hygiene and Preventive Medicine (Milton J. 

Rofeoau), fifth edition, 58 
Hygiene and Sanitation: Tbo Essentials of 
Modern Health Care(JcBso Feiring Williams), 
59 

Bygiono and Sanitation, a Manual of (Sencca- 
Kgbori), eighth edi.ion 58 
Hymen: or The Future of Marriage (Norman 
Hairo), 501 

Hyperlonsion: L’hyportonsion art6rielIo soli- 
)io Hypertoniekrank- 


.*■ , ni). 901 

‘ ■ ' P. Crozer 

• ■ ■ . " , second 

edition, 805 

Infectious OisoaBos.n Text-book of. the third 
edition of Goodall and Wasbbourn's Manual 
of Infectious Diseases (revised by B. W.. 
Gooda)!). 310 

Institute of Infectious Diseases. Tokyo, 
Scientific Reports from, vol. v, 600 

iDBuranco: Lehrbucb der Unfallbeilknnde 
Paul Jotikowitz), 1068 

Internal Diecases. Patbological Physiology of 
(Albion Walter Hewlett), third edition, ici^ 

Internal Secretions. See Secretions and Endo- 
crinology 

Kala-azar (L. Everard Napier), second edition, 
1069 

Laboratory Methods, Clinical (George L, 
Robdeoburg), 1068 

Labyrinth, Legons sur I’exploration de 
I’anpnreil vesttbulairo (L, Baldenweck), 555 

Laud of To-morrow (Henry Jf. Grey), 671 

Larynx. Diseases of the (Harold Harwell), 
third edition, 1027 

Latin Names of Common Plants (F. Dawtrey 
Drewitt), 986 

Lippincott’s Pocket Formulary (George E. 
Rehberger), 398 


501 

London, the Earlier Inhabitants of IF. G. 
Pat sons), 138 

Lung Diseases. Diagnosis and Treatment in 
(Frank E. Tylocote end George Fletcher), 98S 
Malaya, British, Handbook to (R. L. German), 
^^949 


Manipulation, Treatment by fA. G- Timbrell 
Fisher), second edition, 397 
Mantell. Gideon Algernon, Surgeon and Geo- 
logist (Sydney Spokes). 311 
Marie, Pierre, Trevaux et U^moires, 762 
Materia Medica, the Indian iK. M. Nadkarni), 
9M 

Materia Medica for Nurses (A. Muir Crawford), 
949 

Medical Annual, 850 

Medical and Dental Students Register (1928), 502 
Medical Department of the United States 
Army in the World War. Volume Xl, Part 
One (prepared under the direction of Major- 
General M. W. Ireland), 137 
Medical Ethics, Percival’s (edited by Chauncey 
D. Leake). 984 

Medical History, Annals of. Vol. IX, No. 4 
(edited byFiancis R. Packard), 239; Vol. X. 
No. 1, 1068 

Medical History : a Short History of Medicine, 
introducing Medical Principles to Sfbdents 
and Non-medital Readers (Charles Singer). 947 
Medical History, the Peaks of: an Outline of 
the Evolution of Medicine for the Use of 
Medical Students and Practitioners (Charles 
L. Dana (second edition), 555 



JAN.-JUNE, 1928] 


INDEX. 


r Tr* Britibh 

L SfEtllCAI. JOCRKlt. 


29 


Kovlows of Books (fonffuiird): 

Medical Ilialory: Storla ilelln incalclua 
(Arturo CaQUfiUonl).2&6 

■ ■* Tsylor'8 rrlnclplo'? 

• by Sydney KmltlO. 


• ' ;ryday Uflo (ShloldB 

Warren). 155 

Modlclno and Art: F.sculapo clior. Ion ArtUtoa 

ir\^ rrio 

■ ■. ^ •. , itrodiiction to 

• . tranBlaled by 

■■ , • lal ni‘»tory 

Medicine and the Man (Mlllaln Culnln). <155 
Medlcioo, Heconl Advancon in (G. H. IJcati* 
moat-'*"'’*' «>=’ 

^foainiji ( 

Mental ■ ■ . *>( (Cyril 

Hurt). 

Mental Disorders (Hubert J. Norman), 6M 
Mental Energy, Directing (rinncls AvelinR), 
499 

Micp-organlsma: Handbucli dor patbogenon 
Mibroorganlsmen (W. Kollo and A. v. 
Wassorumun) 225 

Middle Ago and Keeping Young (E. D. Hoi'c 
woU-A8b),2S7 

Midwifery: History of HriU^b Midwifery from 
1E50 to 1800 ( Herbert It. Rpencer), GO 
Mind, tbetby varmxia autbore. edited by U. J. S 
McDowali). 555 

Mind and its Meclmnisin (Paul llonstlcld and 
W. D. HonBflQ d).221 

^losQulto Reduction and JlalarlM Prevention 1 
A Precis (J. A. Crawford and II. 8. Clialam'. 
1023 

Mosquito Survey of Certain Parts of Soutb 
' Ingram and hoiim 

" ' E. Maegregor), 455 
■ , ,, ■ - Expectant Mother 

on the Care of Her HcallU (F. J. Hrownc), 
eocomi edition. 1069 

Mptborbool. Approacblng (George E. Prod. 

bead), third edition. 455 
ctorvo Tracts of ibo Drain and Cord Anatomy: 

ee/ applied Ncurology (William 

4veiIIor)i 554 

Norvous System. Contml, Blrtb laiuric? ot : 

Dirtb Injuries (‘■rank U. 
Ford), Part ll. cord Dlrlb Injurlos (Drotison 
Crotberaaod Marian 0. Putnam). 596 

Textbook of tlsrael B. 

^ t'ecbsicri, loo 

2seuro1ogy and Peyebiatn*. Archives of (edited 
Frederick L. Golla).69 

Discaaes, Handbook of 
v”' * PCCODd edition, 555 

Diseases, for Practl. 
^ " ' " *. by A. Kogan 

5?,* . ' ■ Diseases 

' . Duties 

Henry 

,, t • ‘ids to 

Nervous Diseases (Albert 
Coulson Bucl^ley). 671 

Principles of, and their 
1 ractical Anpljcalion (K. H. Tallormau and 
,, A; HamUton), 1028 

System of: Ernabrung 

Hobert,).Sr‘' •’• 

^'hood‘’FpU^-‘“'^“5f Infancy nnfl Cbiltl- 
eamM IS, “• 

^Boltfn IE- Rloliards 

^ “P'1 Cecil Hevis). Bccnna edit, inn, 3,7 


Surgery. Treatiso on 

D: 

' eorfie I 

en ' 

Rob. 


■ ■ , loratoi 

Artbi 

t ^tory Pn 
58 

' ■ oward 

598 

White) 598 01 iCliarles l*owe 

Peaks of Medical History. s« Medical 


HoviowB of Books (eotifniued) : 

Podlalrics: Alda to tbo Diagnosis and Treat* 
ment of DIboiisor of Gblldron (Jolin McCaw), 
Bixth odltlon, 454 

Pediatrics, Clinical (odilod by Royal Slorrs 
HaynoM : Vol. vlil. Diseases of tbo Digestive 
System of Childhood (Frank C. Nvff), 138; 
vol. ix, Dleoaaos of the Respiratory System 
In Infanta and Children (WIlHam D. Funk- 
bouROi), 138; vol. X, Nutrition and Develop. 
montlDawrcnco T. Royster). 138; vol. i. pro- 
natal Caro lU. W. DobonKtIno and H. 0. 
Dailey. 1113; vola. II and Ui, Tbo Newborn 
(C. G. Orulco and B. E. Bonar), 1113: vol. xli, 
Infant and Child Feeding (H. D. Wilcox), 
1113 : vol. V, Disorders of tboKervouc System 
in CblMhood (Bronson Crotbors). 1113 ; Dis- 
eases of tbo Blood and Blood-building Organs 
(\V, P. Lucas and A. II. Washburn), 1113; 
vol. xlli. Tbo Internal Secretory System and 
MotalioUsm IP. U. Talbot), 1113; vol. xiv. 
Infectious Diseases of Infancy and Cbild- 
boodill. li. K. Shaw). 1113: vol. xv. Surgery 
of Cbiidbood HI. W. Bolling*, 1113 
Pediatrics, the Modern Practice of (William 
Palmer 1 aicas), 453 

Peking Union Medical College, Selected Con- 
trlliutions from. vol. vi, 455 
Porcival'fi Medical Ethics ‘edited by Cbauncoy 
D. Loako), 984 

Pharmacognosy and Materia Medica i Homer 

C. Wasbbourn and Waller H. Blouu*). 35S 
Pbarniacologlcal Action: Princlpeedo Plmrmn- 

codynamlo (L. Hugnuncoq and G. Fioreuce), 
718 

Plmrmaco’ogy.a Manual of (Tor&ld Bollmann), 
third edition. 499 

Pliarmacotlierapeutlc’, Materia Mcdica and 
Drug Acti'>n (Solomon So is-Cobon and 
Tliomas Stolosbury Gitbens), 1027 
P' ”*.*' ' - ;• 'book ol (H. Lloyd 

Randles , socoud 

Physical Di* gnosis (Richard C. Cabot), ninth 
edition. 31G—{W. D. Rose), fifth edition. 902 
Plusical Signs in Clinical Surgery. Demon- 

inonstratic ' * 

Physics in Russ. 

L. n.Clarl . . . 

Piiysics, Practical, for Medical Students (Mary 

D, Waller . 225 

• “ • • Chemistry’ 

• • • . (Sir Edward 

aUion,851 

1 ujsiuiogy. raviioiogicai ol Internal Diseases 
(Albion Walter Hewlett), third edition. 1068 
Plorsors Normal Histology, thirteenth Gdilion, 
397 

Pneumothorax and the Surgical Treatinont of 
Palmonary Tuberculosis (Clive Hiviore), 
second edition. 900 

Polynuclear Count (W. E. Cooke and Eric 
Ponder), 139 

Post-mortem Appearances (Joan ,M. Rocs), 
second edition, 393 

Post-mortems and Morbid Anatomy (Thcodoro 
Bbcouan). second cd'ttoii.805 
Potassium and Calcium in the Blood ; Der 
Qehalt Ocs Dlntes an Calcium nnd Kalinm 
(Eskil Kylinl.GO 

Preventive Medicino and Hygiene (Milton J. 

Rosenau). fifth editioo.SS 
Prison-Breakers (Allan M, Phillip), SCO 
Prot zoology : an Introduction to Medical 
Protozoology (Ciiont.-Col. Robert Koowlesj, 
670 

Psychiatry, Manual of (edited by Aaron J, 
Rosnnoft), sixth edition. 18 
Psychiatry. Text-book of (Arthur P, Koycsl, 671 
Pavcho-Analysls. Further ConlnbntiODs to 
the Theory and Technique of (Sundor 
Feronezt. translated by Jnno Isabel Sutti), 61 
^ ’ *' * and Mental Hygiene, 

: W. S. Taylor), 31X 

• • urement of Mental 
; • 265 

P.‘5ycbo!ogy of the Soldier (F. C. Bartlett), 310 
Psychology. Studios in (William Eider». 185 
Psychopathology, Problems in (T. tV. 
^Mitcbjll,902 ^ 

“ ■' " ygl6 10 (L6on Bernard 

See also Hygiene 
Clinique du Tube 

et Duodenum (Piene 
Duval, Jean-Obarles Roux, and Henri 

BSclSre), SCO 

Radiology, the Theory and Practice of 
(Bernard J. Leggett). 8C4 
Radinthevapy : La Roentgentb^rapie des 
EpithMiomas Cutan^s et CutanSo-Mnqueux 
par la Mt^thode du Dr. J. Coate (Georges 
Girel). 1029 

Radiotherapy: Les Bases Physiques de la 
Radioth^rapie (Joan Dobostl, 635 
Radiotherapy^ Precis d^ RadiothSrapie Pro- 
' e« also X rays 
'in Malnutrition 

^ .901 

Refraction. Applied (Homer Erastus Smith). 
61 

Reproductive Disorders : Les Troubles Func- 
tionnels de PAppareil Genital dela Femme 
(Gaston Cotte),900 

Rickets. Exnerimental (Poul Freudenthal), 762 
Round the Fountain, fourth edition, 60 
St. Bartholomew’s Hospital Reports, ^-ol. lx 
(edited by W. McAdam c « , and others), 


Reviews of Books (continued): 

Sanitary Law and Practice (\V. Robertson and 
Charles Porte* ), sixth edition. 719 
Science and Human Progress (Sir Oliver 
Lodge), 671 

Secretions, Internal, the Comparative Physio- 
logy of (Lancelot T. Hogben), 223 
Secretions, Internal : Las Secreciones Internas 
do Jfts Glandulas Sexualos (Alexander 
LipschlUr), Spanish translation, 139. See also 
Endocrinology 

Sex: Confidential Chats with Boys (William 
Lee Howard), 101 

Sex: Confidential Chats with Girls (William 
Lto Howard). 101 

Sex, tho Education of Boys in the Subject of, 
61 

Sex: Facts for the Married (William Lee 
Howard ).D1 

Sex Hygiene, Plain Facts on (William Lee 
Howard). 101 

Sox Problems Solved (William Lee Howard). 
101 

Skin Diseases (Robert W. MacKenna), second 
edition. 599 

Skin Diseases, Common(R. Cranston Low),100. 
S<'c also Dermato'.ogy 

Buiitb, Madeleine, Trial of (edited by Tennyson 
F. Jesse). 266 

Social Structure of, England and Wales as 
illustrated by Statistics, a Survey of (A. M. 
Carr-Saunders and D. Caradog Jones), 59S 
Btimulns in tbo Economic Life (Sir Josiah 
Stamp), 357 

Strabismus (Oscar Wilkinson), 762 
Siruggles of Male Adolescence (C. Stanford 
Read), 805 

* Surgery. Abdominal, of Children (L. E. 
Barrington-Ward). 554 

Surgery. Olnical, Physical Signs in (Hamilton 
Bailey). 137 

fcnrgery. Ophthalmic: ChirnrgiedePOeil et de 
see Annexes (F. Terrieti), third edition. 1067 
Surgery, Orthopaedic, Treatise on (Royal 
Whitman), eighth e Htion, 102 
Surgery at the Salpetrifere: Travaux de Ja 
Clinique cbirurgicale et du Centre anti- 
cancereux de la Salpetri^re (A. Gosset), 
second scries, 599 

Surgery, a Shorter iR J. McNeill Love), 185 
Surgery, Synopsis of (Ernest W, Hey Groves), 
eighth edition, 397 

Survival of the Unfittest (Charles Wicksteed 
Armstrong), 6t0 

Taylor's P.inciples and Pi-actice of Medical 
Jurisprudence (edited by Sydney Smith), 
elghtP edition. 761 

That Body of Yours (Jnmes W. Birton), 18 ’ 
Therapeutic*, Practical, Textbook of (Hobart 
Aniory’ Hare), twentieth edition. 139 
Therapeutics. Text-bcok of (A. A. Stevens), 
seventh edition, 102 

Thoracoscopy: Atlas Thoracoscopicon (Felix 
Cova), 719 

Thoracoscopy: Lehrbuch und Atlas der 
Laparo- und Tborakoskopie (Roger Korbsch), 
719 

Throit, Nose, and Ear Diseases (Dan 
McKenzie), second edition, 355 
Tliroat. See also Nose anti Ear Diseases 
To-day and other Verses (N. Bishop Harman), 
571 

Trauma and Compensation in Obstetric and 
Gynaecological Cases (Douglas Marshall 
Lindsay), M8 

Trenclt, Frederick Baron, Strange Adventures 
of (edited by Philip Murray), 501 
Tiials, Notable British: Madeleine Smith 
(edited by F, Tennyson Jesse). 266— Adelaide 
Bartlett (edited by Sir John Hall), 266 — 
Samuel Herbert Dougal (edited by F. 
Tennyson Jesse). 1029 

Tropical diseases : Arbeifcen fiber Tropen* 
krankheiten and deren Grenzgebiete (Bern- 
hard Nocht zu seinem 701. 600 
Tropical Medicine, Recent Advances in (Sir 
Leonard Rogers), 137 

Trypanosomiasis, Human, Report of the 
League of Nations Commission on. 225 
Tubercle Yiius, Poljnnorphism.and the Treat- 
ment of Tuberculosis and Lupus with Oleum 
Allii (William C.Minchin), third edition, 225 
Tuberculosis : Overcoming Tuberculosis 

(Gerald B. Webb and Charles T. Ryder), • 
third edition. 61 

Tuberculosis, Pulmonary (G. T. Hebert), 901 
Tnberimlosis, Pulmonary, Pneumothorax and 
the Surgical Treatment of (Clive Riviere), 
second edition, 900 

Tuberculosis Schemes for Great Britain and 
Ireland, Handbook of, fifth edition. 185 
Urography (William F. Braasch and Benjamin 
H. Hager), second edition. 849 
Urinary Secretion: Die Drei-Drfisentheorie 
der Hambereitung (August PUtter), 1029 
Uro'ogy : Handbuch der Urologie lA. v. 
Licbtenberg, F. Voelcker, and H. Wildbolz), 
398 

Urology and Syphilology (Charles H. Chet- 
wooa). fourth edition, 669 
Vade-Mecum, Bolles Lee's IMicrotomist’s 
(edited by J. Bronte Gatenby and E. V. 
Cowdray), ninth edition, 672 
Varicose Veins, the Injection Treatment of 
(A. B. Douthwaite). third edition. 1069 
Venous congestion. Congestion 
Vertebrae : Etudes sur les affections de la 
colonne vert^brale (Andt6 Leri), 901 



•30 JAN.-J0NE, 1928] 


INDEX. 


[ Ttr* Bnmi* 

MkDtCAL JoCMMAK 


Beviews of Books (continued): 

Veterinary bacteriology. See Bacteriology - 
Veterlnarj’ Dictionary. See Dictionary 
Who’s Who in the Nursing World, 672 
.X-Rays and Radium in the Treatment of 
Diseases of the Skin (George M. MacKee), 
second edition, 17. See also Radiotherapy 
Year Book, International Health (1927), 9S6 
Year-Book of the Scientific and Learned 
Societies of Great Britain and Ireland, 
session 1926-27. 556 

Year Book and Guide, South and East African 
(edited by A. Samler Brown and G. Gordon 
Brown), 672 

Year Book of the Universities of the Empire 
(1928). 763 

Rheumatic children, supervisory centres for. in 
London, 373 

Rheumatic diseases clinics in London, the 
proposed, 152. 883 

Rheumatic diseases, conference on at Bath, 25, 
510, 581, 768. 852-Opening meeting. 852— Presi- 
dential introduction: The problem stated, 852— 
Social aspects, 852— The cost to the nation, 852 
—Organization of medical treatment, 852— 
Continental experience, 855— Environment and 
incidence, 853 — The causation of rheumatism, 
854 — Predisposing factors in childhood, 854 — 
The bacterial factor. 855— The cardiac problem, 
8K— Fihrositis and panniculitis, 855— Patho- 
logical investigations, 855 — The endocrine 
factor, 855— Papers taken as read. 856— General 
discussion on causation. 8i6— The treatment of 
rheumatism, 857 — Prevention of chronic rheu- 
matism. 857— Rheumatic infection in child- 
hood, 857— Vaccines: their use and abuse, 857— 
Physical treatment, 857— The scope of surgery,* 
858 — General discussion on treatment, 858 — 
Civic entertainment, 838 — Luncheon by the 
Bath Division, 859— Leading article._860 
Rheumatic diseases in hospitals, clinical con- 
ference on, 381 

Bheumatiediseases treated by phj’sical methods 
in Germany (R.Fortescue Fox and Margarethe 
Mautner). 815 

■ Rheumatic heart infections, collective research, 

512 , , 

Rheumatic infection in children, the early | 
detection and supervision of (Geo. A. Allan), 39 ; 
(O) — Disensaion at the Royal Society of 
Medicine, 350 

Rheumatic myocarditis. See Myocarditis 
Rheumatism in childhood, detection and care of 
(A. Dingwall Fordyce), 220— A study of (A. P. 
Thomson). 459 , . , 

Bhenmatism, chronic muscular, and pannicul- 
itis (Ralph Stockman), 293 (O) 

Rheumatism and tuberculosis, affinities between 
(W, Camac Wilkinson), 749 (O) 

Rheumatoid atthritis, See Arthritis 
Rheumatoid diseases review of books on, 183 
RBonrs, Lleut.-Col. James Havelock Alexander, 
obituary notice of, 1032 , , 

Rib, fracture of the neck of by indirect violence 
(Guy Bransou and James F. Braileford), 346 
‘ RiGHAXiDS, H. A. : Anaesthetic? in obstetrics. 39o 
BioHAUPSOK. Frank Howard: Breast-feeding. 
602— ReftuiWtnp the Child: a Study tn Mai- 
nutrition, rev., 901 . 

RiCHAUPsoN.Geoxgefand Gilbert W. ChabslEt); 

Case of volvulus neonatorum, 494 
Richaupson. G. B. : Polymastia, 346 
RicmioNp, Mrs. Bruce: The protection of 
maternity, 463 

Eichou, Dr., appointed professor of medical 
pathology at Nancy, 581 

Rickets and condensed skimmed milk (parlia- 
mentary note), 428 

Rickets, ergosterol, and vitamin D, 78 
Rickets, irradiated ergosterol, and ultra-violet 
light. 237 

Rickets, review of books on, 762 
Rickets, effects of sunshine on (Alan Brpwn and 
Frederick F. Tisdalb; 272 
Riddeli.. Lord: Voluntary hospitals and public 
authorities. 280 

Riddell, Major William Hunter, obituary 
notice of, 329 

RiDODT, C. A. 6. : Pulmonars' and gastro-intes- 
tinal sequels of naso oral sepsis, 96 
Rigbv. Sir Hugh, appointed sergeant-surgeon to 
the King. 4M 

Rigden, Walter, obituary notice of, 478 
Ringworm infection in London school children, 
types of (J. G. Hare and P. Tate). 196 
Ringworm and its treatment iJ.M. H. MacLeod), 
656(0) 

Rio de Janeiro: Establishment of an institute 
for the study of the anatomy of the brain, 479 
" Rising test ” foracute abdomen. See Abdomen 
Ritchie. W. T., elected professor of medicine at 
Edinburgh, 371 . . - 

Bitteb von Skbamlik, Emil, appointed pro- 
fessor of physiology at Graz, 163 
Rivett, L. C. : Treatment of eclampsia, 1066 
Rivierk. Olive: The P7ieumothorax and Sur- 
. -r,. T Tuberculosis, 


Robace, a. a. : The Psycholoov of Character, 
rev.. 138 

Roberts, Ff. : Radiography of viscera, 930 
Roberts, Hugh Gordon, C.I.E conferred on, 
9S8 

Roberts, John: Oedema of the upper eyelids. 


Roberts, Lydia J. : Nutrition Work with 
Children, rev., 184 

Robertson. George M.: Report on the Royal 
Edinburgh Hospital for Mental and Nervous 
Diseases. 406— Etiology of alcoholism. 596 
Robertson, Lewis S.. appointed superintendent 
of the Pretoria Hospital. 831 
Robertson, W. (and Charles Porter): Sani- 
tary Law and Practice, sixth edition, rev., 719 
Robertson, William: Prolongation of ago in 
Scotland, 728 

Rodertson-Batn, Ian S. : Midwives and ante- 
natal work. 612 

Robinson, A. Leyland: Torsion of a (hydro- 
salpinx, 668 

Robinson, James, knighthood to have been 
conferred on, 24— Obituan* notice of, 36 
Robinson, James (and Hugh T. .Ashby): Ergot 
poisoning among rye bread conBuniors, 302 (O) 
Robinson, Louis, obitnary notice of. 240 
Robson, W. M. : Medical examinations for life 
assurance, 376 

Roche, Alex. E. : The intravenous injection of 
indigo-carmiuo. 921 

Rockefelbr Foundation: Methods and ProhUms 
of Medical JEdncatioii, eighth Borlos. 25, 316 — 
Research Institute for Psychiatry at Munich. 
120— Offers to equip an All-Indian School of 
Hygiene. 865 

Roclcefeller Medical Fellowships. 815 
Roescbmann, Dr., German legislation against 
venereal disease. 562 
Roger, Robert, obituary notice of, 1093 
Rogerb, j. S. Y. : Caso of cbloroma in a child of 
11 months, 222 

Rogers. Kenneth: The Poor's Send Tavern in 
Eastchcap. rev., 851 

Rogers, Sir Leonard : Rccenf Advances in 
Tropical Medicine, rev., 137 — Liver diet in 
pernicious anaemia, 179— Life assurance in the 
tropics, 219— Small-pox and climatoin England 
and Wales, 300 (O)— Robert Boyle Lcctnro on 
climate and disease incidonco in India, now 
published in pamphlet form, 333 — Climate and 
epidemic disease. 848— Incidence and spread of 

cl * * " ' • * .-» 

Roi . . * TV 

p 

Rollerton, Sir Humphry Davy: Appreciation 
of Sir Percy Bassott-Smith. 35 — Appreciation 
of Sir Dawson Williams, 417— Visit to Pliila- 
delphia, 580— Made an Honorary Doctor of 
Laws of Jefferson Medical College, 580 — The 
causation of rheumatisin. 854 
Rolleston, j. D. : Serum prophylaxis and 
therapy in the specific fevers, 98— Diphtheria 
carriers. 181— Etiology of alcoholism, 593— 
Lar^’ngeal diphtheria io old age. 1020 (O) 
Bolston, Cecil Mitchell, appointed an official 
member of the Legislative Council of the 
Presidency of Dominica, 650 
Ropeu, F. a. : Surgical tieatment of chronic 
gastiio ulcer. 451— Case of marked cyanosis, 
946— Case of pylephlebitis, 946 
Roqufs. Frederick :• Gynaecological involve- 
ment of the abdominal wall, 55— Pregnancy 
nud epidemic encephalitis. 351 
Rosacea, digestive factors in (Sibyl R. Eastwood), 
222 

Rosanofe. Aaron J. (editor): Manual of Psy- 
chiatry, sixth edition, rev,, 18 
Rose, B. T. : Treatment of oral and rectal cancer 
by radium. 936 (O) 

Rose, W. D : Physical Diagnosis, fifth edition, 
rev.. 902 

Rosenau, Milton J, : Preventive Medichie and 
Sygicne, fifth edition, rov., 58 
Ross, Joan iVl.: pnst-worfew appearances, second 
edition, rev., 393 

Robs, T. A. : Theories of suggestion. 53— Etiology 
o'f alcoholism. 596— Report on the Cassel Hos- 
pital, 908 

Ross, T. Douglas: Broncho-pneumonia in child* 
ren treated by injection'^ of emetine, 966 
Roth, E. J, H. : Chronic vinegar poisoning, 77 
Roth, Paul Bernard: The origin of ischaemic 
contracture, 921 

Roddopolodlos.P., L egion of Honour conferred 
on, 1133 

Pound the Fountain, fourth edition, rev , 60 
I Rous, Peyton, awarded the John Scott prize, 37 
I Roux, Jean-Charlos (Pierre Duval and Henri 
1 Beclere); Padtologie Clinigue (in Tube 
Digestif : I, Estoniac et Duodenutn, rev., 500 
Rowland, F, M. (F. W. Marshall aud J. 
Menton): An unusual case of food poisoning, 
439 (O) 

Rowlands, R. P. : Gastro-jejunal ulcer, 433 (0) 
Rowlette, R. j. : The over-sensitive child, 220— 
Psychoneuroses, 221 — The medical profession 
and the public, 998 

Bowse, A. L. On History: a Study of Present 
Tendencies, rev., 600 

Rowstron, Noel P. : Ultra-violet light treatment 
of lupus erythematosus. 411 
Roxburgh, A. C. : Ultra-violetradiation therapy, 
260 

Roxburgh, David: Midwifery mortality, 1126 
Royal Academy of Arts, winter exhibition, 119 
Royal Faculty of Physicians and Surgeons of 
Glasgow: Monthly meeting. 882 — Appoint- 
ments, 882— Admission of Fellows, 1093 
Royal Institute of Fubltc Health: Lectures on 
forensic medicine, 73— The medical practi- 
tioner in relation to the administration of 
justice, 136 — Medico-legal aspects of criminal 
abortion, 452— Arranges tours to the Continent. 
699 


Royal Medical Benevolent Fund. Sec Fund 
Royal Sanitary Institute: Lectures and demon- 
strations for smoko inspectors, 119— Congress 
of, 479, 609. See also CongrcBS— The welfare of 
hop-pickers. 678 

Royster, Hubert Ashley : Aimendicitis, rev,, 806 
‘Royster, Lawrence T.: Nutrition and Develop- 
ment, rev., IZB . 

Ruble, W. A.: Post-graduation work in Vienna, 
77 

Rnminants, iron stan’ation in (B. C. Aston), SCS- 
See also Bush disease 
Running as a recreation. 334 
Rusuton, Mr. ; The pulpless tooth, 549 
Russ, Sidney: Diathermy In relation to circu- 
latory disorders, 134 — (L. 11. Clark and 
B. D. II. Walters): Physics in Medical 
Padioloou, rev., 984 

Russell, Colonel A. J. H. : Cholera bilivaccin, 
274 

Russell, M. M. : Rapid first labour, 382 
RuTHniiroRD. Sir Ernest, admitted an honorary 
Follow of the Royal College of Physicians of 
London, 866 

Rutuven. Jane Henderson, obituarj* notice of, 
785 

Ryder. Charles T. (and Gerald B. Webd): Oy«r- 
coniing Tuberculosis, third edition, rev., 61 
Rye bread and ergot poisoning. Bee Ergot aneZ 
Poisoning 

Ryle, John A. : The clinical study of pain : with 
special reference to the pains of visceral 
disease, 537 (0) 


St. Bartholomew's Hospital Gazette: Vitamins 
in verse, 292 

St. John of Jerusalem. Order of. and the British 
Red Cross Society. See Red Cross and Society 
Saberton, Claude William Scott, obituary 
notice of, 239 

Sac, eversion of for bydrocolo. See Hydrocele 
Sachs, B.: TheNorfJtal Child and Hoio to Keep 
it Normal in Jftnd «»id J/ornl.?, rev., 185 
Sadler. Sir Michael : Education, 28 
Salaries of medical officers (parliamentary' 
note). 332 ; and Edncatlon Committees, 952 
Salaries of medical women, 612, 832.’ See also 
Medical women 

Sale of Food and Drugs Acts. See Food 
Salter. Alfred: Edinburgh Corporation Bill, 
376 

Samuel, A. M,: Biochemical products. 168 

^ .* 4 , .mentary 

vaocina- 

Sanatoriums for Consumption :-~KiDg Edward 
VII. Midburst: Uoporfc, 195— East Fortune: 
Report, 728. 822— Otieon EIi«abetb, Budakeszi, 
.... , 'b: Report, 1125 

• • ‘ • \l absence of one 

, Fallopian tube, 

1055 

Sanford, Arthur Hawley (and James Campbell 
Todd): Citntcnl Diapnosts by Laboratory 
Methods, sixth edition, rev.. 1067 
■ . » — dings of the 


. irliamentary 


Santos, Novoa, appointed professor of medical 
pathology at Madrid, 741 
Sarcoma botryoides (Maslen Jones), 552 
Sarcoma. Jensen’s rat, cytology of (H. B. Fell 
and J. A. Andrews), 274 

Sarcoma of the lung and liver (R. H. Micks) 553 
Sarcoma of ovary accompanied by metrorrhagia 
(A. Gough). 668 

Sarcoma of ovary in^ jehild associated with 
Bt ' ■ 


Dc. 

taneouB rupture of (H. Leith Murray and A. A. 
Qemmell). 981 

Sarcomata, inoperable, treated with radium 
(Roy Ward), 123 (O) 

Sarcomatous metaplasia of a uterine fibroma 
(Leith Murray), 497 — (A. A. Gemmoll), 498 

Sargent, Percy, honour of knighihood con- 
ferred on, 23 

Saunders. C. M. : Congenital pyloric stenosis, 
946 

Bavill. Agnes: Diathermy in relation to circu- 
latory disturbances, 134 

Sawday, a. Ernest: Case of polydactylism in 
the foot, 846 

Scabies, prevention of, 82 

Scales, John F. (and others): Hyperpyrexia in 
terminal chronic nephritis, 177 

Scalp, unusual pigmentation of, 243, 832. 1054 

Scandinavia, reporfcbf the first case of chimney- 
sweep’s cancer in, 81 

Scarlet red dry dressing, 382 

SoHARLiEB, Dame Mary, honorary LL.D.Edin- 
bnrgh conferred on, 569 

ScHEELE, Karl, nominated a corresponding 
member of the SocietA Italiana di Urologla, 
1096 

SoHiFF, Fritz: Die Teehnih der Blutgruppen- 
untersuchung, rev., 635 

Schilling, Victor: Das Plutbild U7id seine 
klinisclie Verivertung, rev., 102 

Schistosome infection, mixed, 1098. See also 
Bilbarzia, vesical 



JAN.-JUNE, 1938] 


INDEX. 


[ The BRiTisn 
Mbdicae Joubkax. 


31 


BcnstTBT. Iltxnfl Uolnlmra, ftBl>olnlo<l profoRBor 
of obBlotrlcs ftud KynnocoloKy Rt DUnsoldorf, 
^10 

ScnatiDT, ti.: Mlninml riscR of tomi>orntnro in 
rlioumaioid ftrtUritlB, 493 (O) 

SciTMiNCTtn, A., nppolnlod profcsoor of i>atUoloRy 
at IIoidolborR. 7U 

Bcholarablps for tuberculosis ^rorbcra. See 
TuborculoRlB 

Bcbool cbildrcn. Rrovrlb of, nml milk consumi). 
tlon. SrcMilk 

School cbildron, bcaltb of in Nortborn Ireland 
1C&3 

School children, medical InRPCotlon of in 
Dublin. 4&1I: in Trinidad and Tobaito, 767, 1097 
School meals (Alfred Klchholr.l, 62 
School medical ofllccr, the future (Alfred A. 
Mumford), 262 

School medical Borvices, cost of (parliamentary 
note), 8^ 

School medical services (Irish Froo State), U2G 
School medical staff, tGmi>orary (London), 
remnnoTatlon, 315 

Schools: ilea*.* *. ' ' ■'* 

—Water sui ' ' 

Special, in 1 ' . » 

Special, In * . . 

926— Special, I ■ ' . . 

SenoTT, Adolf : Dfathormy In relation to circu- 
latory disturbances. 135— Tho aprlncs of 
Kanhclm, 181 

ScnRUirrr-Pir.nnoK, riorro: Tohacco atul Pkiy- 
sical Eficiennu 320 

Scnonn. 0. G. t Myopia in childhood, 803 
SetruaxEB, Paul, nominated an honorary member 
of tbo SocloliX Ualiana Oto^Ncuro-Oftalmo- 
loslca.lOOS 

Schwartz, Dr. (of Straabourfi), llllo of professor 
conferred on. 213 

Sciatica, cramp after, 433, 480, 551, 930, 1051 
Sciatica. Its Tariotlcs and treatment (Antbony 
FelUns). 356(0) 

Scientific knou’ledCQ to industry, application of, 
711 

Scientific research. See UcRcarcb 
Sclorosls, disseminated, prlso for test work on 
treatment of, 787 

Scorbutic swolUnR slmulatlnR an acuto bursitis 
(U. h. Paterson). 666 

Scotland: 

Aberdeen: Eoyal Infirmary, 236— Itoyal Mental 
Hospital, 281— Joint hospital eehomo, 463— 
Regius professor of physiology at. 6S5 
Ago, prolongation of in Scotland. 728 
Ancient Scottish surgeon (John Kaesmyth). 
• 570 

Anderson College of Medicine, 517 
Animal experiments, debate on, 518 
JBIind, training of, 115— Wolfaro of, lC'13-Now 
homo at Glasgow for blinded sailors and 
aoldlers, 1121 

Dritish Medical Association, Edinburgh moot- 
ing (1927). 235 

- * 37^ 

’ wu ■ ■ ■ ■ 

Chiropodists' conference. 1125 
Craigloith Hospital, 407. See also Hospital In 
General Index 

Crichton Royal Institution, 454 
^ n21^®^ Children, Scottish Hospital for. 873, 

Crocket. James, presentation to. 641 
David Elder Infirmary. Govan, 113 
Dunfermline, health of. 873 
East Fortune Sanatorium, 728. 822 
EDINBUROn: 


■ ng (1927), 

Cameron Prize, 997 

Chair of forensic medicine. 727 

Chair of genetics, 917 

Child welfare conference, 191 

Clinical teaching in, 71. 158 

Crematorium, proposed. 153, 1124 

^rippled Children’s Hospital, 873. 1121 

Deaconess Hospital. 570 

Dental Hospital, 917 

^^?burgh Corporation Bill (Venereal 
Diseases?, 289. 323, 376, 378, 428. 530, 578, 

GoS ltaaef" diseaeoa in 

Eye Dispensary, 464 
Foot clinic, 997 
Harveian festival at, 997 

Hygiene Exhibition. 191 

Hospita3'accomS'S“i.n’24 

^P^itaiy,'^7 visits the hoa- 

Medieal appointment, a new cur 
Mental health conference 872^^ 

Morison Lectures. 872 ” ^ 

Morningsid© annual report. 406 

Eoyal Medical Society. 323 

Ro^l Victoria Hospital Toberemosis Trust. 

University. . See University 


Bcoilnntl (fonHnti4*(l): 

Vonoroal dtsoneos, proposed compulsory 
troatiUMit of, 323. See also Edinburgh 
Corporation Bill 
Food control In, 112 
Food BUporvInlon in, 153 

Galashiels Iloepltal, proposed oxlonefon of, 
608 

Glaroow: 

Andornon Colloito of Modicino, 517 
Blinded satlore and eoldiorfl, now homo for, 
1121 

Cancor Hospital, 509 
Children's Uospital, 608 
Drunk and incapablo in (parliamentary 
noto), ^28 

Glasgow Corporation Vouereal Diseases Bill, 
727 

GhiAOOie AfrrHcalJbuniai.contonary number, 
399 

IlcaUh of. 191 
Lister In. 101 
Pnoumonia In, 1011 
Post-graduato conrsos, 822 
Royal Asylum. 323 
Royal Infirmary. 71. 372 
Royal Maternity Ilospital. 71 
Venereal DiBcasos Bill, 727 
Victoria Infirmary, 151, 235, 323 — Admission 
of paying patients. 325 
^YoslQr^ Infirmary, 407, 093 
Gultand, Q. Lovoll. rotiromont of from tbo 
EdinbtUT.b Royal Infirmary, 610 
Ilcaltb visltovR* conference, 9 17 
Highland hospital oxtonsions, 872 
Hospital co-operation in iho West ofBcotland, 
686 

Hospital problems in tbo Iligblandfl, 821, 872 
Hospital Borvico In North Ulet. lack of (parlia- 
mentary note), 1095 

Kennedy, J. R. (of Dunbeatb), presentation to, 
195 

Larbort colony schomo for mental defectives, 
518. 1121 

Leith Hospital report. 408 
Liviogfitouo, David, relic of, 281 
Mackonzio. Sir Leslie, retirement of, 896 


Noiflo in relation to health, 1124 
Paratyphoid fever in Qalashiols, 255, 281 
Pharmacopoeia rovlsion, discussion on, 570 


Reorganization of OlDccs Bill, 289, 380, 42$, 427, 
&18 

Scottish Board of Health. See General Index 

Scottish hospitals, gifts to. 957 

Sellar, Thomas A., presentation to, 403 

Social hygiene in. 154 

Teeth of tho working classes, 917 

Tuberculosis in, 607 

Venereal dl«easo clinics in. 697, 778 

Veterinary ‘science in, 195 

Vital statistics (1927), 517, 1013 

Scott. David Wolsoloy, obituary notice of. 
249 

Scott, E.: Bladder calculus in the male due to 
B foreign body, 216 

Scott, G. Laughton: A treatment of mor- 
pblni8m,31 

Scott, H. H.: Health lessons from Bermuda, 
448 

Scott. S. Gilbert: A method of dealing with 
a swallowed object, 135— Asthma Research 
Council, 468 

Scott, William, obituary notice of, 78 

Scottish Board of Health: Joint memorandum 
on the training of the blind, 113 — Pamphlet on 
**The supervision of tho food supply and tho 
handling and storage of food,” 155— Medical 
appointment, 235 — Leaflets on infective 
jaundice and on malaria, dysentery, acute 
primary pneumonia and acute influenzal 
pneumonia, 281 — Supplementary estimates, 
378 — Chairmanship of: Sir James Leishman 
appointed, 640— Hospital problems in the 
Highlands, 821— An inquiry into post-opera- 
tive tetanus (R. J. Mackiel, 987 — Advisory 
Committee on the Welfare of the Blind re- 
appointed, 10^6 — Estimates, 1051 — Annual 
report, 1080 

Bouddbr, Charles Locke: The Treatment of 
Fractures, tenth edition, rev., 396 

Seaoar, E. a. : Infection of Barbados with 
malaria, 66 

SEALE. Payle ; Hypernephroma, 261— Infantilism 
of Mongoloid type, 916 

Sea-sickness, treatment of, 211, 752, 767, 877, 
884, 930, 959— By nitroglycerin, 214-^U. Allan 
Bennett). 752 (O^Noteon, 767— Correspondence 
on. 877, 959, 1089 

Secretions, internal, review of books on, 139. 223. 
See also Endocrines 

Begab, H. Roland: The forgotten swab, 95 

Seidlin, Dr. : The intestinal amoebae of man, 

mi 

Selby, Harold J.: Embolus of the superior 
mesenteric artery, 757 

Sbllab. Thomas, presentation to, 408 


Sellauls, a. W. (and Edward Hindle): Pre- 
servation of yellow fever virus. 713 (O) 
Sellheim, a.: Nitroglycerin in treatment of 
oca-Hlckness, 244 

Sr.LLORs, T. Holmes (and C. de W. Kitcat): 

Pulmonary fibrosis, 1018 (O) 

Selwyk-Olabke, Dr.: Yellow fever in West 
Africa, 863 

- - ' "”ugh Barber). 492(0) 

« 

Abortion 

Sepsis. See Dental. Focal, and Puerperal 
Septicaemia, specific therapy in (W. E. Dixon), 
896 

Bopticomino, 357 

Septic lesions, tbormo-cautery for, 678 
Sepulchral statistics, 273 
Sr' plaque to, 243 

B( _ treatment of 

Serum prophylaxis and therapy in the specific 
fevers (J. D. Rolleston), 98 

* — c;jnjp. 


Seventeenth century commonplace books. 190 
Sewage, isolation of B. tvphosus from (W. James 
Wilson), 1061 (0) 

Sewage. London, and the river Thames (leading 
article), 676 

Sewell, Lindley: Foreign body in the oeso- 
phagus. difficult removal of. 176 (O) 

Sex, Education of Bovs in the Subject of, rev.. 
61 

Sox hormones, female (J. W. Trevan), 596 
Sex. case of mistaken (A. J. Wilson), 564 
Sex, review of books on, 61, 101 
SETiioPR. Harold P.: Pneumococcal peritonitis 
during tho puerperium. recovery, 895 
BnAMi, Yeshua, honorary M.B.E. conferred 
on, 988 

Shantung Christian University. See University 
Sharp, B. Buckley (and C F. Orb White): A 
Inbricant for applying zinc ionization to the 
male urethra. 96 

Sharp, Neville A. Dyce: Life assurance in the 
tropics. 219— Notes on the gorilla, 700 
SEtARPE, Herbert : Collective investigation and 
tuberculin, 4S9— A case of primarj' actino- 
mycosis of tho lung. 1107 (O) 

Sharpe, Salisbury: The influenza ear, 985 
SUARPET-ScHAPEH, Sit Edwardi— The history of 
the Physiological Society (1876-19261 : a record 
of fifty years, 5 5— Appreciation of Sir Dawson 
William^, 418 — Experimental Physiology, 
fourth edition, rev.. 851 

SiiAW', H. L. K.: Infectious diseases of Isifancy 
and ChtUlhood, rev., 1113 
Shaw\ S. C. : Surgical treatment of chronic 
gastric ulcer, 450 

Shaw, Wilfred : Ripening of the Graafian follicle 
552 

Shaw. William Fletcher: Carcinoma of the 
cervix, 57— Treatment of cancer by radium, 
159, 286 — Dystocia due to vaginal atresia, 265 — 
Full-term ectopic gestation, 493— Drainage in 
Wertbeim's hysterectomy, 982 
Sheep dip (parliamentary note), 954,1005 
Bheifield School of Medicine centenary, 956, 
1122 

Bhelpon, W. P. H.: Familial hypertrophic 
pyloric stenosis, 565 

Shellfish, isolation of B. typhosus from (W. 
James Wilson), 1061 (O) 

Bhennan, Theodore: Posf*7norfems and jJIorbtd 
Anatomy, second edition, rev., 805 
Sheba, Geoffrey: Fatal suppression of urine 
caused by latent baemagglulinins, 754 (0) 
Sherrikgton, Sir Charles : Appreciation of Sir 
Dawson Williams, 418— Eulogy of William 
Harvey, 868 

Bhie, Marviil D. : Tattooing and removal of 
tattoo marks, 318 

Ships. Mohammedan pilgrim, medical facilities 
in, 930. 1007 

Sherrab. F. E, Findlay : Aids to Catering, rev 
902 

Shock and abortion, 239. 327, 375, 471, 524 
Shock in black races. 524. 650 
Shock and collapse, current views of (V. Zachary 
Cope), 54 
Shops Bill. 616 

Shore, T. H. G. : Fibrositis. 758 
Bhrubsall, F. C,: Rheumatic infection in the 
young, 350 

Bhute, Mr. : Malarial treatment of general 
paralysis, 1024 

Bhuttlewobth, George Edward, obituary notice 
of, 1C04 

SiOARD, Professor: Intravenous treatment of 
varicose ulcers, 897 

SiCHEL, Gerald, obituary notice of, 477 
Biddall, a. C. : a test for pregnancy, 952 
Bigma. Wassermann, and Kahn tests, com- 
parison of (T. E. Osmond), 440 (0) • 

Sigmoid, gas gangrene of (R. Saliaburj’ Woods), 
593 

Sigmoid, volvulus of (Garnett Wright). 712 (0) 
Sigurd, Dr., appointed to the chair of pharma- 
cology at Berlin, 291 

SiLcocK, F. A. E, : Injections for varicose veins. 
117 

Silicosis, pulmonary (Gwilym L. Pierce). 1110 
Silicosis and workmen's compensation (parlia- 
mentary note). 1005, 1095, 1C96 
SiAffiY, A. T. : The future school medical ofllcer 
262 



32 JAN.-JUNE, 192S] 


INDEX. 


SiJtPSON, G. C. 13. : Porum treatment of anthrax, 
135— (And D. R. Owen); Some siirRJcal con- 
ditions of the stomach. 667 
Simpson, Georse W., appointed a medical oflicer 
to the Scottish Board of Health. 236 
Simpson, S. Levy: Anaesthetics and diabetes, 
1127 

SiMSON, F. W.: Pulmonary asbestosis in South 
Africa. 885 (O) 

Sinapisms, localized, value of, 82 
Sinclair, Arthur Havens, appointed honorary 
surgeon oculist to the King in Scotland. 6 5. 610 
Singer, Charles : A Short Ht«to7t/ of liTedicive, 
wtroducitto Medical Priuciplett to Students 
anti Non-Medical Headers, rev . 917 
Sinusitis, chronic, familial infectivity of (P. 
■Watson-Williams), 983 

Sinusitis, sphenoidal, and optic neuritis (A. 0. 
Rees Walton), 13 

Skeooh, Hugh H.: Tinea interdigitalis pedis, 
895 

Skin diseases, review of books on, 17. 100. See 
also Dermatology 

Skinner, E. F. : A simplified method of arm-to 
arm blood transfusion, 492 (0> 

Skull, fractured base of, followed by acute 
mastoid disease: recovery tW. J. Harrison), 
11C9 

Slaughter of Animals (Scotland) Bill, 2S9, 381, 
1131 

Slaughterof Animals Rill, regulation of methods 
of (parliamentary note), 578 
- ' • • ■ ' - • n),865 

. 8 

• note). 

1130 

Smalij. J. 0. : Investigations on S. cardio- 
arthritidis, 856 

Small-pox: Among casuals, 644 — (Ministry of 
Health circular), 154, 609— Hospitals, tuber- 
culouB patients in, 964— In London. 324 — 
Parliamentary notes on, 379. 427, 474,530.616 
648. 777. 829, 880. 926, 964,1093, 1130— Decrease of 
in European countries, 1132 
Small-pox and climate in England and Wales 
(Sir Leonard Ropers). 300 (O) 

Bmall-pox in the vaccinated and unvaccinated, 
fatality rates of, 74. 115, 156, 197, 237, 285 
Smith, Alexander: Sarcoma of the stomach, 632 
Smith, Annie Caroline: Kaisar-i-Hind medal 
conferred on, 988 

Smith, Arthur B.: Treatment of cancer by 
radium. 1S7 

Smith, A. Hayes: Acu‘e Aplastic Anaemia, rev., 
948, 1048, 1129 

Smith. A. H. D,: Fatal case of poisoning by a 
non-arsenieal weedkiller. 714 (O) 

SmTH, Charles M. : Pneumonia in Glasgow. 1044 
Smith, Edwin : His remarks at an inquest. 961 
Smith, Lieiit.-Col. Henry: Ultra-violet rays and 
calomel. 116 

Smite. Homer Erastus: Applied NefracHon, 
rev., 61 

Smith, J. Forest: The thiToid and menstruation, 
318 

Smith. John: An ancient Scottish surgeon, John 
Naesmyth. 570 

Smith, Mad leine. Trial of (edited by F. Tenny- 
BomJesse). rev. 266 

Smith. May (and oibors) • The Two-ahift Spstem 
ifi Certain Factories, 509 
Smith. R. Percy: Induction of premature labour 
in relation to mental disease, 9 (O) 

SsnxH, R. Wayland: Gss gangrene following 
fracture, 263— Diagnosis of Hodgkin’s di*easp, 
264— Puerperal pj aemia, 264 — Streptococcal 
cellulitis, 946 

Smith, Sidney Maynard, obituary notice of, 526 | 

Smith. Sydney: Inaugural lecture in the ebair 
of forensic medicine at Edinburgh, 727 ; 
Identification from a finger-tip removed by a ' 
bite, 757— (Kditor) Taylor's Principles a' d 
Practice of ^fedical Jurisprudence, eighth 1 
edition, rev., 761 1 

Smith, Sydney M. : Treatment of cancer by 
radium. 197 

Smith, Travers : Theories of sncgestion.53 
SiiiTH, William Muir, obituavv notice of 614 
Smoke abatement (parliamentary note). 531 
Smvth, W. Johnson: Dry mouth 243 
Snapper. Professor: Non-excretory functions of 
the kidney. 759 

Snell, E. H.: Investigation of maternal mor- 
tality, 775 

Snodgrass, William, obituary notice of, 962 
Snuff, dimnl, 672 

Sobriety, standards of. 573. See also Drunken- 
ness 

Rocial bvpiene. Sec Hygiene 
Social Welfare, International, fortnight in Paris, 
1078 

Eoci^te de M^decine of Le Mans and the Depart- 
ment of Snrthe, centenary of, 81 
Soci6te de Nenro’ogie of Paris offers a prize for 
the best work on the treatmentof disseminated 

sclerosis. 787 

Societies, Friendly: Hospitals and preferential 
treatment of (New Zealand), 568— Invested 
funds of, in connexion with the National 

' : hinu’gical ; Pseudo- 

/ -.yst or haematoraa? 

5^7 — Ditficnlt feeding in an infant, 597 — Siig- 
mata of MongoliRm, 597— Ectopia vesicae. 597 
—Xaegele ' * ’sup- 

puration. I 

S »riety% Ab ■ racti- 

rioners, 321 


Society of Apothecaries. See Apolhecarles 
Society, Asiatio, of Bengal: r'oundor's medal 
awarded, 640 

Society, Assurance Medical: Medicine in the 
field of life nssuranco, 401 
Societyfor Birth Control Clinics : Annual report, 
37 

Society, Prigbton and Sussex Medico Ohirur* 
gical • Gastric ulcer, 99— The trial of Mars- 
Blandy, 264 — Radium in cancer of the breast 


Society. British Paychologioal : The etiology of 
alcoholism. 594 

Society, Caledonian Medical: Julilleo of, 371 — 
Festival dinner, 371 — Annual nicntiog, 372— 
Reception by the University of Edinburgh, 372 
Society of Chcmlcnl Industry Cooferunro on 
the application of scientific knowledge to 
industry, 741 

Society of Chiropodists. Incorporated : Con- 
ference of Scottish Branch, 1125 
Society, Cremation, issues a pamphlet on 
CfTneteries in Fnoland and jVale^. 273 
Society. Devon and Exeter Ucdico-Chirurglnal : 
Annual meeting. 263— Gas gangrene following 
fracture. 263— Diagnosis of Hodgkin’s disease, 
264 — Puerperal pyaemia /64— Hypornpnliroma, 
264— Polypo d proliferative colitis, 261 Sur- 
gical treatmentof cbrAuic gastric ulcer, 451 — 
Clinical meeting. 916 — Sticptococcal cellulitis, 
946— Tumour of loft cerebello pontine area, 916 
— Infantilism ofJMongoloid typo. 946— Hydro- 
‘ ““ - - - abdominal 

* * 946— Mastitis, 

46— Pylepbleb- 
* general para- 

Society, Durham University Medical: Visit to 
Denmark, 772 

Society of Economic Biologists: The proluction 
of alkaloid-i, 638 

Society. Edinburgh Cremation: A crematorium 
for * 

Socie The preventive 

frai ‘ -Viilvo vavinit'B 

iu children. 221— Puerperal haemorrhHgo 222 
— Forceps delivery and propl»ylacllc gynneco- 
. r - •. ' *-’.ie.552 

** . -epsis, 

^arean 

Icated 

. . and 

diabetes respectively. 980— Treatment of 
eclampsia. lUl— Ovarian extract nft.r arti- 
ficial meno* ause. nil 

Society, Bdiobureh Royal Medical : Annual 
dinner. 323 

Society. Eugenics:— Dinner, 315— Gallon Lecture: 
Natural capacity in the popnlatfon. 315 — 
Euoenics lievino to be placed on sale in the 
ordinal y way. 761 

Society, Forfarsbiro Medical: Pelvic Infiamma- 
tion in women. 98— Hereditary haemorrhagic 
telangiectasia. 222— Recurrent spontaneous 
pneumothorax, 222— Cbloroma in a child of 
eleven months, 222— The effect on tlie tissues 
of the arc electrode in surgical diathermy, 222 
Society of Friends of the Old Ashmolean, forma- 
tion of, 813 

Society, German, for Combating Quackery, SI 
Society, Glasgow Royal Philosc i)bical : Field 
vision and near vision 42 
Society. Hampstead Medical : Chronic ioteBtinal 
toxaemia in cliildren. 383 
, Society, Harrogate Medical : Endocrine im- 
balance and its relation to chronic aTtbritis, 

I 751 

I Society. Harveian, of London: Clinical meeting 
I at the Royal Waterloo Hospital, 499-Annual 
I dinner, 11078 

! Society, Hunterian — Festival dinner, 278 — 
Hunterian Oration on sciatica: its varieties 
and treatment, 386— John Hunter bicentenary 
celebrations at St. George’s Hoepital, 400 
Society, Industrial Health Education : Annual 
report, 605 

Society, London and Counties ftfe'^ical Protec- 
tion: Annual generol meeting. 1072 
Society, London Jewish Hospital Medical, con- 
stitution of, 649 • 

Society, Manchester Medical: Ophthalmology 
and general medicine. 56— Etiology of chronic 
arthritis. 309— Colloidal lead. 551— Gastric and 
duodenal ulcers, 551 — Results of a series of 
gastric and duodenal operations, 1055 
Society, Manchester Pathological: High blood 


osteoarthropathy, 899 — Congeoital buccal 
cyst, 899— Ulcei’s of oesophagus, 899— Micro- 
photographs illustrating the histology of 
tumours. 899 

Society, Manchester Surgical: The treatment of 
acute appendicitis, 706 

Society of Massage and Medical Gymnastics, 
Chartered : A register of members 965 

Society, Medical Golfing, 582— Spring knock-out 
tournament. 582 

Society of Medical Hj’drologv to organize 
clinical conferences on rheumatic disease in 
hospitals, 381 

Society, Medical, of London: — Programme of 
session. 26 — Treatment of pernicious anaemia 
by liver, 165, 178— To sell the eo-callod diary of 


the Rev. John Ward, 190— The use and abuse 
of ultra-violet radiation therapy, 259— The 
Bcopo of Btirgerv in the treatment of chronic 
rh'=‘U_matoId and ostco-arthritiR, 313, 317— The 
carrier problem, 445— 155th nnnivorsary dinner, 
479— Advance=» in the treatment of cancer of 
the cervix. 535, 547— Annual Oration: The 
lessons of rare inaladlca, 914— Annual meeting, 
915— Election of oflicors, 915 

Society of Jledical OlDcors of Ilcalth : The 
causes of the decline in tuberculosis inorfality, 
701— Prevention of tuberculosis in childhood, 
918 

Bocloty. Jfedico-Legal : Intoxication and its 
legal consequences. 217— The inllu^-nco of 
parturition upon insanity and crime 303 

Society, Midland Medical: The principles of 
diagoosis. 335 

Societj’, Midland Obstetrical and Gynnoco- 
logicnl: Three cases of chorion-cpi'helioTna, 
181— Hydrainnios with uniovular twins, 282— 
Leucoplakia of the vulva, h2—Choco’ate cyst 
of the ovary, 551— Dystocia duo to hydatid 
cyat,552— Sarroniahotryoldes 5' 2— Pulmonary 
embolism foMowing delivery, 552— Hydnlidi- 

CCO 

• • n-Tyne and Northern 

I *■ e clinical study of pain, 

. ' to the poins of visceral 

disease, 537 

Society, North of England Obstetrical and 
Gynaecological: Gyna«>rologlcal tumour**. 57 — 
Alnlomioal myoma. 57— Carcinoma of the 
c®tvix 57— Large ovarian fibroma, 57— Hydrops 
tubac profiuens.SB-Hacmatometra and tuber- 
cnlosis, 99— Multiple uterine fibroid tumonre. 
265— Dystocia due to vacin'il atresm, 263 — 


hnematoma 668— An uncommon foetal atti- 
tude, 668— OvArisn sarcoma accompanied by 
metrorrhagia. £68— Torsion of a hydrosa’pinx, 
668— Torsion during pregnancy of a Fallopian 
tube and ovary. 668— llilaterAl tarry ovaiian 
cysts. 980— Spontaneous rupfure of uterine 
sarcoma, 981 -Parovarian and ovarian cysts 
in pregnancy. 981— Imperforate anus, 981— 
inWertheim's 

• , '• nrgical: Serum 

• specific fevers. 

Focicty, OpbibalmoJogical, of Egypt: Proceed- 
. r .,..#...-*1. — y. index of all 

■ 007 

• of the United 

• ol. xlvil.tev.. 398 

. , >f Great Britain; 

Dermatitis due to wearing furs, 407— Recent 
work on the glucosldes, 407— ^ rsenions oxide 
in neutral and alkaline solution. 407— Note 
on the laboratories of. 45’— Discu'^sion on 

soc ' of (1876-1926): 

a ' 

.Society of Public Analysts: The separation of 
lead tetra-ethyl from solution in petroleum 
snirit, 831 

Society. Red Cro'?B, American, closes its relief 
work for the Mississippi flood victim«, 1133 

„ Appeal of ft DondoD 

■ liseases. 152 — First-aid 
I— And the Order of St. 
John of Jerusalem : report. 1125 

Society for the Relief of Widows and Orphans of 
Medical Men: Annual meeting. 929 

Bociets’, Research Defence* T?ic Fia7it against 
Disease, Janna'V i'^su •. 291 — Annual meeting, 
1079— Stephen Paget ^Temorial Lecture: The 
work and responsibilities of the p'ltbologist. 


Society, -Royal, of Arts : Swiney prize. 617 

BomBTT, Royal, or Medicine : 

Change in by-laws: Associate membership 
for dental and veterLoary practitioners, 787— 
— Clean milk production, 820 
Collection of portraits of Presidents of the 
Bocietv, 81 

Epidemics in Pepys’s diary, 319 
Medical bagiology, 107 
Nichols prize. 6f5 
Social evening, 107, 319, 820 
Section of Anuest/ieiics.— Anaesthetics in 
obstetrics, 394 

Se ction of Balneology and Oliinaioloov . — The 
spi-ings of Nauheim, 181 — Neuroses in the 
tropics. 448 -Value of marine health resorts. 
449— Annual merting at Bath, 859 
Seefton of Children's diseases — Chronic 
appendicitis in children 348— Familial hyper- 
trophic pyloric stenosis, 583 
Section of Comparative JP’dtctne.— Cutaneous 
mycoses in the tropics, 179 — Female sex hor- 
mones. 596— B.O.G. vaccine, 597 


JAK.-JUNI:, 1928] 


SociETV. RovAt., OP SIi;niriNi; (Cniiliiiii/'il); 

Srclion a/ J)f niinloloul;.— CiitnnooiH iiivcokci 
■■ ■ Ircnlnient of 


Pro-'ont po<^Ulouot r 
pnlploHS toolh, 5«8 
SfcMono/ 

— DlpliUicrlR carrittrp, 180— U\»omimilc Infoc- 
tlou in tho yonnv, 350— Seasonal variuUonK In 
Ulsoaso, 503— Post onceiilialltla prnhlo hr, 759 
iS^ch’on 0/ /yarj/ncj^/oiTl/ *** Piiltnonurv and 
KaslrO'lntostlnal Fonne’R of naso-oral Kop*»is. 
96— Snnmior mooting, 9S2— VaRomoior ntT«'c- 
tloiis of Ulo internal ear, 932— Olosclorosl«. 982 
— Dysplmjtia duo lophavyiiRoal rft\*ahHlR, 933— 
Intrinsic cancer of Uio larynx treated by 
laryusi-flssuro, 0S3— Achalasia and doRenoin- 
tion of Auerbach’s plexus, 9S3— Mo hods of 
cstiuintinR the liability to post-oporivtivo 
liaemorrbafio from unsutured vronnds, 933— 
Fanillial infcctlvitv of chronic alnusUls, 933— 
The intlnour.s, car. 935 

SrcIfoM 0/ .Urdicnir.— Pulmonary and fiaslvo* 
intestinal sctiuclB or nasO'Oral S'-psls.So-Tho 
hacmorrhafiic dtatbe''is, 533— Tlio non-cxcro. 
tory functions of Ibo Icldnoy, 759 
Section q/ Xrurolopv.— ProcccdlnKR of tho 
combined lucetlnit with tho American Kouro- 
logical Assoclat'QD, pnbllfthod in Jlrnfn, 
October (1927), 37 — Ocular complications of 
cncephaUtls letharnicn, 2G1— Karcolepsy, diG— 
Nenroses in tlio tropics, *148— OyRpllniiarlRUi, 
717— Oharoot’R arthroivitby of both wrists. 717 
Section of Obntetrie^ aud Oynarcolonu.— 
Uccnrrent ondotholiomfrtous dermoid, 55— 
Qynaocolocical inrolvomonts of tho ubdnininal 
wall, 55— Kliolofty of puerperal 5>cp<‘is. 55 — 
Uterino sarcoma, 219— Oifllcult labour In an 
ri'V duriuij incu- 
, puerperal sepals, 
*' ■ mfi patients, 351— 

Pregnancy and epidemic cncopliaUtls, 351 — 
Anaesthetics in obstetrics. 391-Mallgnnnt 
functions of Iho chorionic epithelium 833- 
Eclainpsia and iu treatment. 803— Tomto- 
inalouB ovarian tumour, 803 — Malignant 
chango in the corpus uteri detnonstralinc 
metaplasia, €03— Treatment of cc auipsia, 1035 
Section 0/ Odonfnlopv. Puiiuonary and 
gantro*intestinal setiucls of naso-oi al rcpsIs, 96 
—Apical infection of teeth, 1^— The pulnlcsa 
tooth, W8 

Section . 

lions of ci 

Seefieii ■ ■ . . 

treatment of 
myelillB.^56 
Seeffou of Ofoloov.— Summer meeting, 98?— 
% asomotor affections of the internal c ir.9S2— 
Otosclerosis, 932— Dysphagia duo to pharyn* 
pal paralysis, 933— Intrinsic cancer of larynx 
treated bylaryngo-nssuro.SSS-Achalasia and 

degeneratloc • 983— 

Liability to . . . . ' f.om 

unsutnred r ■ • -tlvity 

i^chronic E a. ear, 

^Sccfi'on of Pnflicloffi/.— The pulpless tooth, 

Su6l«cffon of Procfolopi/.— Early diagnosis 
ox cancer of rectum and colon, $16 — An opera- 
tion for the cure of prolapse of tho rectum in 
the lemale, 890 

Section 0/ Pjri/chinfry.— Theories of sng- 
^stion, 251— Neuroses in the tropics, 418 — 

ine etiology of alcoholism. 594 
Aeefton of Suruery —Current Tiews of shock 

ana — s — ^ * 

appe 

tlon • . 

hare-lip. 

Trojn’cal Diaeases and Parasito- 
Wffj/.— Cutaneous mycoses in the xropics, 179— 
_ tropics, 218— Health 
roses in the 
fection, 8i8— 

• , of urethral 


acute hacmatogcoous osteo* 


^ Statistical: Vital statistic 

SisVies!™ “^-European 

and Social Inoniry: 
Society , I ■ . I 

HsKi ■ me 

— Tt , . 

Heal ■ 

^Annukl?eM7t°lM5 Benevol 

Society Ulster Medical-^ , ■ - 

Society for Venereal Db 
, of Scottish Branch. 

the Kahn reaction, 848 
sociological formula 415 

feet 884 

monia (P s. Hicheas ana Gibs“on^ 5' 

awarded the Marchia 


Jtotesbury 

Afrtfenn 


INDEX. 


Sor>r,^rAN.v. Torald : A of 2'harmacoloou, 

llilrd edition, rev., 493 

BoMaY, U. V. : Bolypoldftt proUforatlvo colitis, 
c 261- Surgical troatmont of chronic gastric 
nicer, 451 

Solomon, Iscr: Pn'cfs dc Radiotherapie 
Vrofnndf, rev., 17 

Bolouinn Ihlands. health of prisoners in (parlia- 
incnliiry nolo). 881 

Bolomosr, nclhel: lltstcrcctoiny in puerperal 
Rnpais, ^51 — Clinical report on the Rotunda 
Hospital. Dublin, 771 

SoMUnroup, Alex. It. (and Robert GinsoN) : 

Ambulatory treatmontof varicose ulcer, 978(0) 
BoMuuroHP. Anno K. : Vulvo-vaginitis in 
children. 328 

SoMuusr.T. W. U : Inhaler for closed ether 
anaesthosia, 761 

SoMKHViLLU, C. \V. : Three conilnomcnts com- 
plicated by measles, encephalitis lethargica, 
and dlaboloR respectively. 9i0 
Bootau, Dr.: High blood pressure, £02 
Honth Africa. See Africa 

South, Surgeon Captain H. D . awarded a 
Greunwlch ilospital pension. 119 
fiouTiiAM, A. n.: Ovarian sarcoma in a child 
nsRociatod wlllt sexual precocity 661 (O) 
Bonthgato, proposed new welfare conlrc at 
(parliamentary note), 290 
Southwark, ionucsts in, 1094— Deatlis from 
childbirth In (parliamonlary note). 1095 
SooTTAli, If. S. : fluntcrian Lecture on new 
methods of Burgle •! access to the br»fn, 295(0) 
Soviet Republic^, Union of: Censt^s. 831 
SowroN, fi. O. M.: Tho economics of menstrua- 
tlon. GCG 

Si'ACKMAS, C. L. : Renal tuberculoMS. 106S 
Bpatikb. .1. V. . X rays in tho diagnosis of chronic 
appendicitis. 76 

'* * • ' •*» book on. 1113 

. —British Spas Pedera- 

Spaa and health rcsoits of Italy, special study 
tours to. 787 

Specialist public health services. .See Public 
bcallh 

SVENCn. Thomas Fair nolherington. obituary 
notico of, 478 

Si*ENCKlt, Herbert U.: The Uisiory of Tiritisli 
.Vidiuf/ery/rom UljO to j.sOO, rev.. 60— Apprecia- 
tion of Sir Dawson WHllams, 421 —Advances in 
tho treatment of cancer of the cervix uteri, 
535(0) 

Srr.Ncnn, Waller G.: .Appreciation of Sir David 
Fcrrlor. 575 

Sinusitie 

Appreciation of Basil 

SriETiiorr, Dr., appointed professor of dermato* 
logy at Jona, I()33 

Bpilsdcpt, Sir Bernard: Stephen Paget 
Memorial Lecture on the work and rcsponsi- 

Sp . * inent of (Sir 

■■ Caries 

Sp . . * (F. Parkes 

cucr;, iiw 

Spinal curvatures following encephalitis lethar- 
gica (R. G. Abercrombie), 174 (O) 

Spiua, Leo : Treatment of vulvitis. 244 
Spirit and bipp tveatment (N. L. Maxwell 
Reader), 892(0) 

Spittel, Richard L. : The operation of eversion 
of tlio sac for Ixydrocele. 305 (Oi 
Spleen, ruptixrcd malarial: splenectomy: re- 
covery (D. Laurence Tate), 1022 
Splenomedullary leukaemia. S^e Leukaemia 
Splint, wrist, the *’ ambidex,” 1115 
Spokes, Sydney: Gideon Alyernon liJantell, 
LL.D., F Il.C.S.* F.R.S,, Surgeon and Qeo- 
logint, rev , 311 

SPOi.VEniNi. Luigi, appointed d. rector of the 
' iTcdiatric c'iulc at Rome. 1096 
Sports doctors, 365. See also Doctors 
SpniGou, Sir Squire; Appreciation of Sir Dawson 
Williams. 420 

SrrmoiN, P B. ; Liver diet in pernicious 
anaemia. 179 

Sputum, early detection of tubercle bacilli in 
(Sir Jame.s Dundas-Grant), 62f (O). See also 
Tubercle bacilli 

Sputum examination in pnlmonary diagnosis, 
importance of, 469. 525, 572. See also Tnbercu- 
losis 

Bquair, Fiancis W., obiiuary notice of, 1033 
Stacey, J. Eric; Lai*ge ovarian fibronia, 57— 
Dystocia due to vaginal atresia, 263— Torsion 
dixring pregnancy of a Fallopian tube and 
ovary, 658— Bilateral tarry ovarian cysts, 930 
Stageland, new psychotherapy in, 244 
STAiitiARp, H. B. : Treatment of fra;;tures, 107 
Btallman, J. F. H. ; Congenital torticollis. 8D2— 
Supracondylar fracture of humerus, 80: — 
Spastic paraplegia, 802— Treatment of injuries 
round the elbow-joiut : a C'^rrection. 930 
Staelybrass C. O. : Fatality rates of smalbpox, 
237— Seasonal variations in disease. 565 
Stamp, Sir Josiah: On Sfiinidus in the Economic 
Life, rev., 357 

Stannus. Hngh : Life assurance in the tropics, 
219— Neuroses in the tropics, 448 
Stapleton, Grace; Rupture of uterus early in 
the first stage of labour, 893 tO) 

Starling. Ernest H,: Memorial to, 605. See 
also Bayliss-Starling Memorial Funtl. 

Statham, R. S. S : Treatment of gonorrhoea in 
women by swabbing with mercnrochrome and 
flavine, 544 (O)— The expectant mother, 639 


r TiiePiutish 
L Medjcii. Jccknal 


33 


StatlsSicg, influonco of on medical practice 
(Frank deans), 219 
Status opllopticus. 1097, 1134 
Steadman, St. J. ; The xmlplcss tooth, 549 
BTi:iNiuu8r.R.Dr.,nppoinled professor of phyEio- 
logy at Greifswald. 1053 

Stemiousu, Major J. A., Territorial decoration 
conferred on, 882 

- . •! • Crjchton). 945 

' . ypertrophic (E. A. 

. ■ \Y. P H. Sheldon). 

£63 

SxEJ’nr.N, J. A.: Case of diflicuU feeding in an 
infant, 597 

SiEunKN, Lieut -Col. L P. : A plea for the opera- 
tion of litholapaxy, 1089 

SxEpnEXB, G. Arbour: TborapeuUc injections of 
distilled water, 120— Lime-deficient food and 
carditis, 618— Endocarditis in young children 
and lambs, 1131 

Sterilisation of the feeble mlndel in Alberts, 
689, 873, 878. See also Mental defect, inheri- 
tance of 

Sterilization of syringes. 81. 531 
Sterilizer, portiblo low-pressnre, 18— A hospital, 
930 

Stevens, A A.: .A TexthooT: of Therapeutics^ 
seventh edition, rev., 102 
Btbvkssos, E. P. : Public healib organization 
in the Irish Free Slate. 519 
Stevenson, Mary M. : The lifc-bi^tory of epi- 
demic encephalitis in the child. 938 
Stevenson, R. Scoit: Tonsil-suction for di\- 
gnosis and treatment, 1048 
Stevenson. T H. C.: Vital statistics of wealth 
and poverty, 354 

Stevenson, Walter: Skeletal meta«tases in 
carcinoma, 899— Surgical uses of radium, 8 9 
Stewart. D. Stenhouse: An electric slit-lamp 
ophthalmoscope, 455 

Stewart Samuel H.: Fundame-ital factors fn 
the treatment of pulmouary tuberculosis. 842 
( 0 ) 

Stiles, Percy Goldthwaite: Dreams. 106 
Still, George Frederic: Common Disorders and 
Diseases of OiiMIjood, filth edition, rev., 15 — 
John Thomson. 156 

Stitt, E. U.: Pmcfical Bacteriology, B^ood 
Work, and Animal ParasUoloag, eighth e*i» 
tion, rev., 851 

Stobo, j. M.: Traumatic rupture of the duo- 
denum.lM 

Stockman, Ra^ph: Chronic muRcnlar rheu- 
matism and pannicQiitiB, 293 *0)— The cau'^a- 
tion of fibrositis and panniculitis, 855 
Stocks. Percy: Iodine, goitre, and growth, 24 — 
Fatality rates of smHil-pox in the vaccinated 
and unvaccinated. 115, 197— Etiology of cancer : 
a request to general practitioners. 1649 
Btopdart. W. H. B.: Etiology of a'coholism.596 
Stokes, Adrian: Experimental transmission of 
yellow fever 723 

Stokes. H.: Treatment of fractures, £6— Bone- 
complications in typhoid fever, 56 
Btolkind, E.: Pulmonary and gastro-intestinal 
sequels of naso-oral sepsis, 97 
Stomach, foreign bodies in the, 198, 239, 259. See 
also Foreign body 

Stomach, sarcoma of. See Sarcoma 
Stomach, surgical conditions of (G. C. E. 

Simpson and D. R. Owen), 667 
Stoke, Captain J. E.: Hospital Organizati n 
and ilauagement (tncludmp Pfama'ncr and. 
Construelioii),rQ\\, 183 

Stoney. B. a,: Thyroidectomy in toxic goitre, 
354— Obstetrical fractures of the femnr, 354 
StrabiBrnus, review of hook on, 762 
SxixACHAN. Gilbert I.: Historical exhibition at 
Cardiff. 520 

Btrachader, a. C. : Familial hypertrophic 
pyloric stenosis, 563 

Straits Settlements: Medical men and dangerous 
drugs, 1053 

Strasbourg Faculty of Medicine : Title of pro- 
fessor without chairs conferred on various 
medical men, 243— l ost-yraduate course at, 
617,1132 

StrAthearn, Lieut.-Col. John E., C.B.E. con- 
ferred on, 988 

Straub, Hermann, appointed professor of 
internal medicine at Greifswald, 617 
Btrau-b.H. : The endocrine factor iti rheumatic 
disease. 856— Special number of the 4rchiv 
jiirVerdannno^- und StoFivechsellirankhttten 
dedicated to, 1133 

Street, A. F.; Value of marine health resorts, • 
450 

Street accidents. Accident 
Streptococcal infection, action of certain 
arsenical preparations on (Leonard Cole- 
brooke). 367 

Streptococci and puerperal sepsis. See Puer- 
peral sepsis 

Stretton. j. Lionel : Hospitals and road acci- 
dents, 237 

“ Striae atrophicae cutis.” causation of [Verg“- 
tnres] not due to stretching of the skin 
(F. Parkes Weber). 255 (O) 

Btroganoff, W. : The treatment of eclampsia, 
1065, 1111 

Stroud V. Bates, Pates, and Wilson. 573 
Stoart, Alexander, obituary notice of, 478 
Stuart, F. Wilson: Congenital dislocation of 
hip : a method of controlling the pelvis during, 
reduction, 345 (O) 

Stuart, John Alexander Erskine, obituary 
notice of, 78 

Students, foreign, hospitality sought for, 479 


34 JAJf.-JUNE, 1928] 


INDEX. 


[ Tins i^Rmra 
jlEorciX. Jovnnii 


Stumpk, R. : Surgical uses of radium, 899 I 

"Sugar, arsenic in, 1002 

Suggestion, theories of (William Brown), 53, 251 
(O)— Correspondence on. 158 
Suggestion treatment for frequency of micturi- 
tion, 243 

StTHRAWARDY. Major Hassan : A ZTannnl of First 
' Aid for rnflta. second edition, rev., 949 
Sulphostab,” 102 

Sulphur dioxide in the milling of barley (parlia- 
mentary note), 830 

Sun Iiife Assurance Company to provide travel- 
ling scbolarsbins for tuberculosis workers, 369 
Sunlight in modern medicine (Walter El lot), 
859 

Sunshine, antirachitic effect of (Alan Brown and 
Frederick P. Tisdall), 272 
Surgeon, an ancient Scottish— John Naesmyth, 
570 

Surgery, progress of from Hunter’s day to ours 
(Sir Holburt Waring). 245 (O) 

Surgery, review of books on, 102, 137, 18=1, 309, 397, 
554, 599. 1067 

Surgical emergency in the.mission field, 292 
Surgical and dental instruments to bear indica- 
tion of origin, 381, 429, 581. Sec also Board of 
Trade 

Surgical portrait group, 1134 
SusMAK, W. James, appointed deputy coroner 
for South Oxfordshire, 1007 
Sutcliffe, W. Q. : Value of marine health 
resorts, 450 

Sutherland, G. A.: Chronic appendicitis In 
children, 349 

Sutherland, Halliday: Neuroses in the tropics. 
449 

Swab, the forgotten (H. Boland Segar), 95— (N. I. 
Betters), 742 

Swallowed object, method of dealing with a 
S. Gilbert Scott), 133. See also Foreign hods* 
Swan, R. H. Jocelyn : A belt for use in supra- 
pubic drainage. 556 

Sweden: Report of the Society for Combating 
Tuberculosis in, 203— National fund to be pre- 
sented to the King on bis seventieth birthday. 
€17— Social experiment in tuberculosis (G, 
Neander), 638 

Swift, Homer: Rheumatic fever, 856 
Swiney prize. See Prize 

SwiNTON, liieut.-Col. Francis Edward, obituary 
notice of. 160 

Stme, W. S.: ^andboo^ of Diseases of the Nose, 
Throat, and Ear, second edition, rev., 355 
Sykes, C, B. : A simple method of differentiating 
the anopbeiine mosquitos. 119 
Sykes, J. 0. : Erythema nodosum and tubercu- 
losis, 824 

Sykonds, Sir Charters J. : War Emergency 
Fund. 1128 

Synge, V. M. : The over-sensitire child, 220— 
Portal cirrhosis, 633 

Synthalin exempted from key industry duty, 741 

Syphilis, famaof, 151 

Syphilis of the heart (I. Harris). 840 (0) 

Syphilis insontium. epidemic of (Patrick Blair). 
151 

Syphilis, Kahn test for(B. L Kahn). 848 
Syphilitic reaction, the Meinicke. 775, 1049 
Syphilology, review of books on, 669 
Syringe for injecting varicose veins, 763 
Syringe, sterilization of. 81, 534 
SzEEELY, August, death of, 696 


T. 

Taeniasis. See Tapeworm 
Taillens. Dr., nominated Chevalier of the 
Legion of Honour. 929 
Talbot, Bertram; Mental health. 872 
Talbot, P. B. : The Internal Secretoiy System 
and Metabolism, rev., 1113 
Tallerman, K. H. land C. J. K. Hamilton) : The 
Pmnciples of Infant NutiHlion and their 
Practical Application, rev., 1028 
Tanon, Dr., appointed professor of hygiene and 
preventive medicine at Paris. 1053 
Tapeworm infection, generalized (C. J. Hill 
Aitken).943 
Tar, fumes of, 291 

Tarnibr, Etienne, centenaryof the birth of. 1053 
Tate, D. Laurence : —Ruptured malarial spleen : 

splenectomy; recovery, 1022 
Tate, Major-(3eneral G. : Report on hospitals 
and dispensaries in Bengal, 1082 
Tate, P. (and J. G. Hare) : On the Fungi 
causing Eingivorm in Children attending 
Lc/ndon County Council Schools. 196 
Tattooing and removal of tattoo marks (Marvin 
D. Bhie), 318 

■Tavistock Clinic for Nervous Disorders. See 
Nervous 

Taylor, James : Immunity following herpes, 
920 

, Taylor, W. S. (editor): Beadings in Abnormal 
Psychology and Mental Eygiene, rev., 311 
•Tavlor's Principles and Practice of Medical 
Jnri8P7mde7)ce, eighth edition, rev., 761 
Teeth, apical infection of (Arthur Bulleid). 135 
Teeth, dead and infected, pyrexia due to 
(Leonard G. J. Mackey). 1021 (Oi 
Teeth, dead and septic, autogenous infections 
duo to (A. P. Berbwistle), 589 (0)— Corre- 
spondence on, 731, 823. 876, 959 
Teeth, defective, structure of (May Mellanby), 
229.410 

' Teeth, moUipJe extraclions of (Barvey Hilliard), 
863— (R. N. Burton). 966 


Teeth of the working clnssea. 917 
Tegner, H. S.: Tetra-ethyl lead in motor spirit, 
770 

Telangiectasia, hereditary haemorrhagic (W. E.®' 
Foggie), 2>2 

"Tennis elbow.*' See Elbow 
Terrien. F, : Ohirurgie de VOeil ct ses Annexes, 
third edition, rev., 1067 
Tebry, H. Cairns : High blood prosBuro, 802 
Test meals, fractional (J. J. McGrath), 1026 
Testicle, duplication or subdivision of the (G.H. 

Edington and J. W. S. Blacklock). 957 (O) 
Tetanus antitoximglobulins, concentrated. 357 
Tetanus in a boy: recovery (J. D. Chisholm 
and Arnold Bonsbaw), 175 (O)— A correction, 
244— (Q. Lowe), 757 

Tetanus, post-operative (R. J. Macklo), 987— 
Iparliamontary’ note), 1096 
Totrabrom-ethyl alcohol, "avertin'': a new typo 
of general anaesthetic (W. E. Dixon). 896. See 
also Avortin 

Tetra-ethyl load. 61.64.363.366.380,381.409 426. 
581, 615. 697. 741. 770. 830. 872, 965. 1001, 1033— 
The risks of its addition to petrol, Loading 
articlo. 64— Correapondenco on. 74, 409, 1001 — 
Investigations in the United States, 356— 
Parliamoutary notes on. 380, 381, 426, 615, 697, 
830— Committee of Inquiry' appointment and 
reports of. 615, 741. 770, 871. 965. 1033. 1073- 
Evidonce from America, 770, 1073— (F. W. 
Toms and C. P. Money) 831. See also Lead 
Teulier, Dr.. appointed professor of ophthalmo- 
logy at Bordeaux, 81 

Thame, improvement of casual wards at (pai'Ua- 
inentan' note), 1006 
Thames floods. See Floods 
Thames and London sewage. See Bowago 
Theobald, G. W. : The future of obstetrics, 284, 
1086 

Theosol,949 

Thermo-cautery for septic lesions, 678 
Thermometer, aseptic clinical. ^2 
Therapeutics, review of books on, 139 
Thiers, H. : Estimation of hepatic cfDcioncy, 
231 

Third party insurance- See Insurance 
•TnoM, Douglas A.: Everyday Problems of the 
Everyday Child, rev., 501 
Trokas, John Raglan, obituary notlco of, $28 
Thomas. Captain T. H. : Treatment of progres- 
sive muscular atrophy by parathyToid, 
calcium, and vitamin D. 978 (O) 

Thomas, W, S. Russell : IMedical freedom, 961 
Tromayer, Joseph, death of. 79 
Thovtson. a. Ralph: Foreign body in the 
bladder. 51 


of. 735 

Thoms, Herbert : Gordon of Aberdfcn. 990 
THOSfsoN. A. P. : A study of xboumatism in 
children, 459. 857 

Thomson, F G.: The endocrine factor in rheu- 
matic diseases, 855 

Thobison, Gordon: The intestinal amoebae of 
man, 1111 

Thomson. H. J.: Eclampsia. 258 
Thomson, Jobn. memorial to. 156 
Thomson, J. Arthur: Totvnrds Health, rev., 102 
Thomson, Norman G., called to the Bar, 203 
THOiiisoN. Sir StClair: Promoted Officer of the 
Legion of Honour. 29— Appreciation of Rir 
Dawson Williams, 419— Intrinsic cancer of the 
larynx operated upon by larvnCo fi'^suve, 743 
(O). 983 — Elected a corresponding member of 
tbe Boci6t4 de Laryngologie des Hdpitaux de 
Paris, of the American Stomatological Asso- 
ciation, and of the Philadelphia Laryngologjcal 
Society, 909 

Thomson-Walker, Sir John: Urinary obstruc- 
tion, 14 

Thoracoscopy, review of books on. 719 
Thorne, Colonel A., Territorial decoration con- 
ferred on, 882 

Thornhill. Rdnnld: lajectioa treatment of 
varicose veins, 522. 1091 

Thorpe, Surgeon Rear-Admiral V. G.: Treat- 
ment of ulcers of tbe moutb, 164 
"Those other practitioners” (Lord Dawson of 
Penn), 321 

Throat diseases, review of books on, 355. See 
also Nose and Ear 

Thrombo-phlebitis migrans (T. Gillman Moor- 
head and Leonard Abrahamsonl, 586 (O)— 
Correspondence on. 690. 824. 960 
Thrombo phlebitis, puerperal ovarian (S. B. 
Herd). 263- 

Thrower. Rayner : Heat cramp, 546 
Thumbs, supernumerary (R. H. Mitchell), 308 
Thyroid and manganese treatment of disoaso 
(Herbert W. Nott). 94 (O) 

Thyroid and men^stroation (H. Gardiner-Hill 
and J. Forest Smith), 318 
TbjToideetomj'in toxic goitre ^D. Kennedy), S53 
Tibbles, Sydney; Cataract and ultra-violet 
light, 32 

Tibbles, William, obituary notice of. 528 
Tidy, H. Letheby : Tbe haemorrhagic diathesis, 
583 (O) 

Tinea interdigitalis pedis (Hugh H. Skeoch), 895 
Tinned foods. See Foods 

Tippett, Gordon: Collective investigation and 
tubercalin, 469— Starting points fora tubercu- 
losis campaign, 700 


Tibdall. Frederick F. : Antirachitic effect of 
suDshlno, 272 
Tobacco, evils of, 320 

Tobago, medical inspection of schools in, 787. 
1097 

Todd, A. T. : Treatment of malignant disease 
by colloidal lead, 1017 

Todd, James Campbell (and Arthur Hawley 
Sanford) Clinical^ Diagnosis by Laboratory 

T • ■ ■ . . 

T . ' 

gawa), rev., 600 
Tokyo, trachoma in. 929 
Tomb, J. W. : Siorilization of syridges. 81 
Tombleron, J. B. : Treatment of cancor by in- 
jeetionB of peritoneal fluid, 204 
Tosrs. F. W, : Tetra ethyl lead, 831 
Tongue, excision of, thirty years' survival after, 
884 

Tonsillitis followed by erythema nodosum and 
aento. endocarditis : recovery after treatment 
with antistroptococcus serum (A. Markson). 
715 (O) 

Tonsils, enlarged, conservative treatment of, 699 
Tonsil-suction for diagnosis and treatment 
(Frank C. Eve), 941 (O)— Correspondence on, 
1048 

Tooth, tho pulplcBS (Frank Coleman), 548 — Dis- 
cussion, 548— Note on. 637— Correspondence on, 
• 700 

i ■ - ■ . * • * 


Toulouse, Dr. : Lunacy reform in France, 402 
Tours in Canada. 650 

Toxaemia, chronic intestinal, in children 
(Reginald Miller), 383(0) 

Toxicology in relation to medical practice (Sir 
William Willcox), 504 

Tracey, Basil M. ; Gall-stones with acute pan- 
creatitis at the age of sixteen, 346 
Trachoma in Tokyo, 929 
Train-sickness, treatment of, 884 
Trauma, review of book on, WS 
Tredgolu, a. P., appointed physician in charge 
of theclinicformental deflcioncy at University 
College Hospital. 155 

Trethowan, W. H.:— The origin of ischaemic 
contracturo: tho case of Tyndall v. Alcock, 
1001 

Trevan : Activity of local anaesthetics. 68 
TRF.VAN, J. W. : Female sex hormones. 596 
Ti'ial of Adelaide Darllett (edited by Sir John 
Hell), rev., 266 

Trial of Mary Blandy (D. A. Parry), 264 
Ttiol of Samuel Herbert Dougal (edited by 
F. Tennyson Jesse). 1029 

Trial of Madeleine SmtOriodited by F. Tennyson 
Jesse), rev., 266 

Trinidad, medical inspection of schools in. 787, 
1097 . 

Triplet children in Great Britam and Ireland 
(R. A. Fisher). 99 

Tropical diseases: Arbeiten iiher Tropenkravh- 
heitm und deren OrensgehieteiBornarA Nocht 
zn Boinem 70), 600 

Tropical Medicine. Far Eastern Association of : 

Seventh congress, 69, 92, 429. See also Congre'is 
Tropical Medicine. London School of. See 
Hygiene and tropical medicine 
Tropical medicine, review of books on, 137 
Tropics, life assurance in (J. F. C. Haslam), 218. 
See also Life 

Trotter. Wilfred, appointed honorary surgeon 
to the King, 640 

Tbubshaw, K. V. ; The history of a hyper- 
nephroma, 216 (O) 

Truo, Dr., Legion of Honour conferred on, 1135 
Trypanosomiasis: League of Nations report, 225 
Tset'e flies, 275— In Kenya Colony, 290 
'I'-Btrap, an internal, 986 
Tubercle bacilli in faeces, 731 
Tubercle bacilli in pus, prognostic significance 
of. 788 

Tubercle bacilli in sputum, early detection of 
(Sir James Dundas-Grant), 627 (O)— Corre- 
spondence on, 731 

Tubercle bacillus, type of commonly present in 
tuberculous lesions in bones and joints (Louis 
Cobbett), 626 (O)— Correspondence on, 788 
TubercuUu and collective research. 375, 469, 522 
Tuberculin Dispensary Benefit Society : Report 
on, 1085 _ 


►.700 

. i 

1.. ■ , ding 

article), 147 

Tuberculosis, cost of treatment (parliamentary 
note), 1095 

Tuberculosis Council, Joint, arranges post- 
graduate lectures, 203— Election of officers. 242 
— Report, 533— Status of tuberculosis officers 
in certain counties, 1045 

Tuberculosis, decline of. See Tuberculosis 
mortality 

Tuberculosis, early signs of, 31 

Tuberculosis, early, and rain-bearing winds in 
Derbyshire (W. Gordon and W. M. Ash), 337 
(O)— Correspondence on, 470 

Tuberculosis in England and Wales (parlia- 
mentary note), 778 

Tuberculosis and erythema nodosum, 624 

Tuberculosis in Frauce, 814 



JAN.-JUNU, igaS] 


INDEX. 


[ TUE Beitibe 
Medicai, JorE?riX 


Tiiborculosia ami haomaloniotra (O. DouKlaa), 
93 

Tuboronlosls, International Union atjalnal: 

Oonfcrouco In Uomo (19 8). G30 
Tubcroulosla, minors’, duo to rooK«borinf; (par- 
Uaiuontars’ note), 829 , . , 

TuborouloslB mortality: Cau<oa in tbo docllno 
of (Sir Robert Pbllip), 701 (0)— LDadluC ortlclo. 
721 — Corrospondenco on, 922 
Tuborculosla in tlio navy (parliamentary note), 
530 

Tuberculosis notlftcallon. delayed, 692, 773 
Tuberculosis nauiborof the J^tlinhnroh Me licnl 
Journal, 479 

Tuberculosis ofllcers, status of in ccrt\in 
counties, lOtS. Sff also Public hoalUi services, 
Bpcoialist 

“rnv,." of. 611. 692. 

■ ■ ■ ■ tmoni, 523— 

■ t). 436 (O)- 
■ ■ . nco of, 4G9, 

i ■ * 'undainental 

* . . . . ■ (O) 

Tuberculosis, roviow of books on, 900. 935 
Tuberculosis and rhrumatlsin, alTlnltlcs be- 
tween (W. Camac WMklnson). 749 (O) 
Tuberculosis, sanatorium treatment, cost of 
tparliamontary nolo», 829 
Tu6rr£“Mlosi.i Schemfa for Great liritaiu and 
Ireland, Ilamlbook of, fifth edition, rev., 185 
Tuberculosis schomoH, tbo working of, ACO 
Tuborculosls in Scotland, 607 
Tuberculosis and sorvlco conditions (parlia- 
mentary notok 1095 

Tuberculosis of tbo skin and tendont shoatba 
(.\. Ii. Candler). 253 

Tuberculosis. SwchUbIi National Bocloty for 
Combating: Ropor6,203 

Tnborculoais, Swedish social cxporlmont In. 
533 

Tuberculosis of the urinary tract (Henry ^Vado). 
655 

Tuberculosis, vaccination of tho newborn 
against, 920 

Tubarculosls, village seUlomeats for safTorers 
from. 76 

Tuberculosis workers, acholarshlps for (in 
Canada), 359 

Tuberculous lesions in bones and joints: typo 
of tub^olo bacillus commonly present in 
7^^*^ Cobbett), €23 (0)— Corrcsiwndouco on, 

Tuberculous patients iu small-pox hospitals 
(parliamentary note), 931 
Tnborcuious pensioners, treatment of (nirlin- 
mentary note). 1131 

Tuberculous persous, omplojTnent of, 195 

banatorium treatment of and vaccination 
(parliamootan’ note). 1095 
Tularaemia in the United Slates. 291 
Tumour of I:-*.’ ' * • .utiR 

letbarglcalS. 

Tumour, a fc . of 

l»robner).999 ' 

“^sopharynx. mixed (John E. G. 
Befui’etwUO)’ by J. M. 

Tamour ot ovary, teratomatous (C. D. Bead) 805 
Tumour, pituitary, operation for (Andrew Watt, 
¥*”■■■ ““<> Andrew Campbell). 747 (O) 
cansinR paralysis of all lour 

ami r (Walter Broadbont 
and G. W. Baresford), 1053 (O) 

colloidal lead and 
radiition on (J. 0. Mottraml, 132 O) 

{‘■““(“■I lobe of tho brain 
OU.I074 1058 (O)-Leading article 

Trawn®' 9'°'l®“’'>Sical (Carlton Olddold), 57 

4?^“?'’’ = Oiseasrs of the 

Student A?,?’’ •P’-actid'oiiers oncl 

jifUrtenf*, second edition, rev.. .355 

^one^’domo?'" SI™ Kenerations attended by 

Mlllicent G. Fawcett)*— 
ana £hetr 3feanin£7/or (7ie Tioentieth CeiHury, 

Xhumt-tj t n . 

■ 'ntestinal 

T 

• olunteer 

T « ■ ' on, 241 

, respira- 

L'unioi.oH ' ir David 

''Sranfe'.wi' tbo field ot life 

^ophthafmoscopo^Vss eleotrio slit-lamp 

Twins and triplets (R. A. Fisher) 99 

®JMee),"s2'' '■ I'J'd'amoios' with OSIaslen 

Two white arms,” 244 

Lunas, rev., 985 of Ltseases of the 

Tyndall v. Alcock, 528. 807 9fii c«,va,. 
on (Ernest W. Hey GroveVl”"ln7 
ence on. 921, 961. looi & 
contracture * ® Ischaemic 

fever, See Fever, enteric 

~ in south 

4!o“ 


u. 

Uist. North, lack of liospltal sorvlco in (parlia- 
mont'iry nolo). 1035 

Ulcer of tbo bladder, solltarj' (Guy Cbambcra), 
1019 (0) 


{ 


Ulcor, gastrO'jejanal (R. P. Rowlands), 433 (O) 
Ulcorallou : Chronic, morenry saKcylato injec- 
tions In (Edmund IVIlllam Dyoch), 802— 


University of Glasgow: Degrees and pass lists, 
740. 1132— Honorary degrees, 1132— Gradnation 
ceremony, 1132— Hutchison prize, 929— Prizes 
presented, 740 

University of Innsbruck: Calendar, 243 
University of Ireland, National: Degrees and 
pass lists, 241, 928— Examination in physics 
and chemistry, pre'regiitration.241 
University, Johns Hopkins: Gift to, for in- 
vestigation into the causes and possible cure 
of tho common cold, 119 
University of Deeds : Appointments, 329 
University of Liverpool; Adami prize for patho- 
logy. 193— Degrees and pass lists, 118, 530 — 
Resignations, 965 

Univeusity of London : 

Admission to Faculty of Science, S28 
Applications for grants. 288 

— ^--'’ 471.580.928.1132 





ment oi 


742 

vbnao of 


‘ , . * ides in 

Nature, 690 

Ultra-violet rays, Chance's filter for, 582— For 
neno, 966. 1037 

Ultra-violet treatment, masseur prosecuted in 
Franco for using. 120 

Unborn child, right of tho (leading article), 145 

Underfeeding in infanej*. See Infancy 

UNDEuntLE. Arthur Stopford, obituary notice 
of. 477 

Underwood. R. E.: Life assurance in the 
tropics, 219 

Unions and beds for casuals (parliamentary 
note). 474 

United Hospitals Club. See Club 


United States : 

Abortions and miscarriages to bo reported in 
tho city of Now York, 81 
American Lar>'ngologicat Association: Semi- 
centennial meeting. 743— Intrinsic cancer of 
tho larynx operated on by laryngo-fissure, 
743 

American Physicians and Surgeons, Congress 
of. 767 

American Red Cross Society closes its relief 
work for tho Missiesippi flood victims, 1133 
Anthropology, logislative, the sciencoof, 150 
Army raodlcal report, 234 

*- ■’ ’—tbs. 581 

;a in, 1120 
• 429 

* . rtmont (Illinois), 

681 

Lasker Foundation for Medical Research, 81 
2Iedical Department of th^UnitedStates Arm*/ 
in the World TTar. Volume xi. Surgery. 
Part I (prepared under tbo direction of 
Major-General M. W. Ireland). 137 
Meningococens meningitis in 1927, 243 ; in 1928. 
965 


Tetra-ethyl lead as an addition to petrol, 
investigations on. 365 
Tnlaraemia in, 291 

Universities of America, impressions of, 365 
■Women's Medical Collego of Pennsylvania to 
endow a chair of surgery in honour of W. W. 
Keen, 203 

Universities of America, impressions of (Edwin 
Deller), 365 

Universities Bureau of the British Empire : 

Classified list of students, 291 
University of Belfast. Queen's; Degrees and pass 
lists. 1132 

University of Birmingham ; Degrees and pass 
lists. 79 . ' 

University of Bristol; Degrees and pass lists. 
1050 

Universitt of Oambiudge: 

Appointments, 964, 1002, 1050 

Degrees and pass lists, 160, 199, 288,413, 696, 786, 

- 881, 9S4. 1050. 1151 

Diploma in medical radiology and clectrology, 
786 

Graham (A. R.) prize. 1131 
Scholarships awarded, 193 


Chair of biochemistry. 288 
(jbair of chemistri', 193 
Chair of public health, 148 
Degrees and pass lists, 79, 258, 530, 786, 1050^ 
1132 

Dunn exhibitions. 928 
Dnveen lectureship, 471 
Election of ofllcers. 928, 1132 
Examination, first, for medical degrees, 471^ 
928 

Examiners appointed, 34 
Lecturers, 378 

London School of Hygiene and Tropical Medi- 
cine, 34, 288 

Matriculation examination, 413 

Medical education, recent developments in, 881 

Meeting of Senate, 471 

Mental deficiency course. 241 

Mickle (William Jnlius) Fellowship, 199 

Parliamentary candidate, 378 

Presentation day, 471 

Readership in morbid anatomy, 928 

Recognition of teachers, 34, 288, 928 ^ 

Regulations for tbo Faculty of Medicine, 92& 

Report of the Principal Officer. 881 

Resignations. 471 

Titles of Fellow conferred, 378 

Titles of professor conferred, 92$ 

University College. 289, 740, 830, 9^ 

University medal, 288 

University, McGill : Appointment?, 369 
University of Manchester, Victoria: Appoint 
meats, 118— Degrees and pass lists, 580 

USIVEBSITT OF OXFORD *. 

Appointments, 193. 523, 1002 
Degrees and pass lists, 329, 619, 830, 1050 
Hooorery Fellow, 964 

Hunt Travelling Scholarship awarded, 649 
Kadcliffe prize (1929J. 1151 
Radclifle Travelling Fellowship, 529 

University of Reading BUI, 778, 1034 
University, Shantung Christian: Report of the 
School of Medicine, 955 

University of Sheffield: Centenary of the Medical 
School. 1122— Degrees and pass lists, 118, 529^ 
830 

University of "Wales: Degrees and pass lists, 160 
Ureter, complete avulsion of, nephro ureteral 
anastomosis after, 1091 
Ureteral calculus. See Calcnlus 
Urethra, male, lubricant for appis'ing zinc 
ionization to (C. P. Orr White and B. Buckley 
Sharp), 96 

Urethral calculi. See Calculi 
Urethral stricture treated hy excision (Frank- 
Kidd), 549 

Urinary obstruction (Sir JohnThomson-Walker), 
14 

Urinary sepsis, treatment of (R. J. Willan), 121 
(0) 

Urinary tract, tuberculosis of (Henry Wade), 66d 
— Review of book on, 849 
Urine, examination of for pus (Cuthbert Dukes), 
391 (0) 

Urine, fatal suppression of caused by latent 
haemagglutinins (Geoffrey Shera), 754 (O) 
Urine-testing outfit, a portable, 556 
Urology, review of books on, 669 
"Urolyt,"556 

Uterus, cancer of. See Cancer 
Uterus, fibroids of. See Fibroid 
Uterus, complete inversion of: recovery 
(Daniel M. Donovan), 756 (O)— Reports of more 
cases. 1(X)8 ^ 

Uterus, malignant change in tho corpus uten 
demonstrating metaplasia (0. D. Read), 803 
Uterus, rupture of, early in the first stage or 
labour (Grace Stapleton), 893 (O) 

Uterus, septic, draining the, 117, 198 


University of Chicago; Lasker Foundation for 
Medical Research, 81 

University of Dublin : Degrees and pass lists, 
160, 529. 580, 830— Honorary degrees, 529. See 
also College, Trinity 

University of Durham : Degrees and pass lists. 
649 

University of Edinburgh: Appointments, 371 — 
Cameron prize, 937— Chair of forensic medi- 
cine, inaugural lecture, 727 — Chair of genetics, 
917— Clinical teaching, 71 — Degrees and pass 
lists, 569 — Honorary degrees, 569 


V. 

Vaccination (Amendment) Bill, Irish Free State^ 
608. 822, 875 

Vaccination, compulsory, London County 
Council and, 874 

Vaccination problems in South Africa, 1042 
Vaccination and sanatorium treatment of tuber- 
cnlons X)erson8 (parliamentary note), 1095 
Vaccination statistics (parliamentary note), 109S 
Vaccination against tubercnlosis. See Tuber- 
culosis 


36 JAN.-JUKE, 1928] 


INDEX. 


r TiiK Dnmic 

L UflDTCAi. J0UBV1& 


Vaccine. B.O.O. (H. .T. Parieb), 597. See also 
Bacillus Calmette-Qu^rin 
Vaccine, yellow fever (Edward HiDdle),976 (0). 
See also Fever, yellow 

Vaccines, autogenous residual (C. E. Jenkins). 
• 340 O) 

V ' D’Arcy 


Vagrants in casual wards, fitness of labour for 
(parliamentary note), 531 
Valvular disease in clilldren, unsuspected. 287. 
See also Heart 

•Van Brfemen, J. : Treatment of rheumatic 
diseases, 853 

Van KiiEEF, Lambertus Theodorus, death of, 
1C05 

Van MiiiEiNGFN, J. : Treatment of chronic 
nasopharyngeal catarrh, 1097 
Vaporoie ’* ephedrine, 806 
Var’AN. G.: Metallic bismuth in the treatment 
of psoriasis, 204 

Variation, natural, a cause of, 768 
Varicella and herpes. See Herpes 
Varicose ulcers. See Ulcers 
Varicose veins. See Veins 

Vaughan, Kathleen O,: Maternal mortality and 
pelvic deformity, 618 

VEA.U, Victor : Treatment of hare-lip. 1025 
Veins, varicose, in the broad ligaments (C. L. 

Granville-Chapman), 665 
Veins, varicose, injections for, 33, 117, 157. 412, 
522, 542. 594, 618 . 614. 763, 897. 960, 10?0— 
(H. M. Hanschell), 542 (O)--A correction. 618— 
(T. Henry T.eves Barber), 591— Syringe for 
injections, 763-(ProfesBor Sicard). 897 
Veitch, H. C. Craven: Appendicectomy during 
herniotomy in an infant, 618 
Venereal diseases campaign: In South Africa, 
517 — London Counts’ Council’s scbome, 519— lu 
Germany. 562 

Venereal disease clinics in Scotland (parlia- 
mentary note). 697, 778 

Venereal disease, compulsory notification of 
(South Africa). iC43 

Venereal diseases problem in India, 230 
Venereal diseases : (’ompulsory treatment 
proposed in Edinburgh. 323, 376. 578, 685. 697, 
735— Parliamentary notes on, 330, 332. 378 428, 
530. 578, 6^7. 735— Correspondence on, 376— In 
Glasgow, 727. See also Edinburgh Corpora- 
tion Bill 

Venereal diseases, control of (parliamentary 
note), 332 

Venereal diseases, treatment of (parliamentarv 
note), 829— Grants for(parliamentary note), 829 
—Prevalence of (parliamentary note), 925 
Venereological episodes, 151 
Vergetures. See “ Striae atrophicae cutis " 
Vermin, destruction of. See Public Health 
Destruction of Vermin) Bill 
Vernon. H.M.: The Alcohol Prol»l^?n, rev., 1114 
— (M. D. Veiinos and others): A Physwlooical \ 
InvesUnatioii of the liadinnt BeatiHfj in 
Various Buildivas,<]5Z— Two Studies of Hours ' 
of Worh : I, Five-hour Svells for iroiiteu 
with Beferenre to Best Pauses; 11. Die Two- 
shift System in Certain Factories, 509 
VERBALii, Sir Jenner: Appreciation of James 
Alexander Macdonald. 782 
A’ertebrae, cervical frncture of (Sir VTilliam I, 
de Courcy V'beeler), 553 
Vertebrae, review of book on diseases of, 901 
Vesico-vaginal fistulae (D. L. Cassidy), 305 
Veterinary College, Royal. See College 
Veterinary science in Scotland (O. Charnock 
Bradley). 195 

Victoria, hospital problem in. 680, See also 
Australia 

Victorian Bush Nursing Association. See Asso- 
ciation 

ViEOAS, Luiz, death of, 1005 
Vienna, post-graduation work in 77, 381, 533 
Village settlements for the consumptive. 76. See 
also Tuberculosis 

ViLLARET, Dr., appointed to the cbair of thera- 
peutic hydrology and climatology at Paris, 
617 

ViELEMiN, Dr., appointed professor of anatomy 
at Bordeaux, 81 

Villemin— Pioneer: A chapter in the history of 
tuberculosis, 720 

ViliVANDRE, G. 'rnpy, 

261— Present p 497— 

Treatment of 

Vincent, George F, : The causes of alcoholic 
inebriety, 691 
Vinegar eel-worm, 1038 
Vinegar poisoning, cbronic, 77 
ViNlNG, Wilfred: Predisposing factors of rheu- 
matic disease in childhood, 854 
Viscera, radiography of. 9Z0 
Vision. iactors in (leading article), 63 
Vision, field, and near vision (Freeland Fergus), 
42 (O)— Leading article on, 63 
VitAglas's, 884. 1008 

staMstics: Of Northern Ireland, 29—01 
England and AYales. 141 — Registrar-General’s 
Decennial Supplement, '921, Part II. 154— Of 
Scotlona. 517. IMJ - Of Europe (Major P. Gran- 
ville Edge) 724 

Vital statistics of wealth and poverty (T. H. C. 
Stevenson*. 354 

V.'tamin D. ergosterol. and rickets. 78 
^'502^^°^ (radiostoleum), 

Vitamins in verse, 292 
Vivisection : Debate in Edinburgh, 518 


Vivisection of dogs (parliamentary note), 289. 
See also Dogs Protection Bill and Animals, 
experiments on 

Vof.lcker, F. (A. V. Lichtenbero and H. 

WiLDROLz): HandVucJi dcr Urologie, vev., 398 
Volvulus neonatorum, case of (Gilbert W. 

Charsley and George Richardson), 4S4 
Volvulus of the sigmoid (Garnett Wright). 712 
CO) 

Vomiting, cs’clicsl, and appendicitis, 8'3 
Von Gazen, Wilhelm, appointed professor of 
surgery at Rostock, 741 

Von Noordkn, O; (and 8. Isaac): Die Zjicher- 
1:ranl:h 

Voronoff’ * 

livestoc 

Report ‘ • 

Crew, A 

' — - - . •• t^fculso 


Y • - ^cs). 221- 


W. 


Waddt, Sidney H.: The duration of pregnancy, 
75 

Wade. Henry: Tuberculosis of the urinaiy 
tract, 666 

Waoser. Georg August, appointed profesRor of 
obstetrics and gynaecology at Berlin, 120. 429 

Wagner. R. (E. Noved and 0. Pipoukt'; 
A’r«(Y?irH«o Gesunder uml Krauher Ktmler, 
rev.. 851 

Waileing. Donald P.. appointed an ofllcial 
member of the Excculivo Council of the Presi- 
dency of the Virgin Islands. 243 

Waldo, F. J. Conioincd twins. 82— Annual 
report of: Imiuests in the City and Boutbwark. 
1031 


Welsh Board of Health: Arrangomenls for the 
organization and conductor the work of, U85, 
1130— Parliamentary note on, 1130 

Welsh National School of Medicine: Appoint- 
ments, 34 

Walker. C. G : A case of car presentation. 1065 

Walker. D. I.: Votisiial pigmentation of scalp, 
243 

Walker. Edward : Mongolism 597 

Walker, E W Ainley: Streptococci and puer- 
peral sepsis, 730 

Walker, Jane H, : Medical hngiology, 107— 
Medical co education, 999 

Walker..!, T. Alo«1lo: Streptococci and puer- 
peral sepsis, 788, 879— Apology and correction, 
879 

Walker. Kenneth: Treatment of urethral 
stricture. 550 

Wallace, Sir Robert: Degrees in drunkenness, 


288 


W'aller, Harry Mortlock, obituary notice of, 9Z8 
Waller, Mary; Practical Physics for Medical 
Students, rev , 225 

Walloben, a. : A criticism of “B.C Q.,” 3S4 
Walsh, N : Unusual complications of pneu- 
monia. 3^4 

Waltf.rs. F. R.: Collective investigation and 
tubercuUu.523 

Walton, A. (and others): Beport on Dr. Kerpp 
rorono.fT's Experiments on the Improvement 
of Livestock, 5C5 

W' ALTON, A. 0. Rees: OpUo nouriHs and 
sphenoidal sinusitis 

Walton, A. .T.: Current views of si ock and 

11..^.,^ CA m * 


tion, 688 

Wand, S. : Vicarious menstruation. 1134 
Wanless, William James, honour of knighthood 
conferred on. 24 
War. a half-forgotten. (j8 
War emergency fund, 1045, 1128 
W’ar literature wanted for Gorman scientists in 
research, 883 

W’ar pensions. See Pensions 
^YARD, A. Ogier: IVIedical examinations for 
life assurance. 411— Treatment of urollual 
stricture, 550 

W^ard.E. : Specialist publicliealth services, 376 
— Wet winds and early phtiiisis. 470 
W’ARD, Fowler : Treatment of urethral stricture, 
550 

W’ARD, Rev. John : Hie commonplace bonks, 190 
Wabd.Rov: Inoperablo sarcomata treated with 
radium, 125 (O) 

Ward. William John Culhbert, obituary uolico 
of. 478 

Waring, Sir Holburt: Hunterian Oration on the 
progress of surgery from Hunter’s dav to ours. 
2^5tO>—Th’ SuroicalTreatment of RInlionant 
Disease, rev., 453 

Warren, Shields: Medical Science for Everyday 
Uae, rev., 185 

’■ ' ^ ' of Infectious 

' H Blome) ; 

Pharmacogno’^u and Materia Medira, rev.. 356 
W'ashbdrn. A. H. (andW. p. Lucas): Diieo^es 
o^the Blood and Blood~building Organs, tow, 

W'ARRERMANN. A. von (and W'. VON Kollf.)- 
Handbuch der pathogenen Mikro-orgauismen, 
rev., 223 


W'assermnnn. Kahn, and Bigma testa, comparison 
of (T. E. Osmond). 440 (O) 

Wassermann reaction in pregnancy (loading 
nrtice), 272 

W’atcr board areas, survey of (parliamentary 
note). 428 

W'ater, therapeutic injections of distilled, 1,0 

W’ator supply of schools (parliamentary note), 
926 

W’ATERHOusr., Rupert: The causation of rheum- 
atic d}Bca«e, 856 

W'ATKiNS-PiTCBroRD, Wilfred: A medical man- 
of-all-work, 420 

W’ATsoN, David: Draining the septic uterus, 
117 

W’ATSON, Gordon: Cause of chronic rheumatism, 
856 

W’ATSON, Sir ifalcolm, awarded the Founder’s 
Medal of the Asiatic Society of Bengal for his 
antlmalnrial work in Malaya, 610 

W'ATsoN-W'iLLTASis, Patrick: Pulmonary and 
gsstro-into^tlnal seouels of naso-oral sepsis, 
97 — The causation of rheumatic disease. 
856— (And F. A. Pickwortii); Nasal and 
oral focal sepsis in the etiology of gastro- 
intestinal and pulmonnn’ infective diseases, 
931 (O)— Familial infectivity of chronic sinus- 
itis. 983 

W'ATT, Andrew (R. C. J. Meter, and Andrew 
Camprell) : Operation for pituitary tumour, 
747 (O) 

Watters. B. D. H. (Sidney Russ and D. H. 
Clark): Physics in Medical Badiology, rev.. 


954 

W’atts. Thomr ’ ■" BUI 

375_Honour i ‘ * 988 

W’ACOH.G. E.: ' . Idren 

349 

Wav, Surg. Lieut. J- K. G. : Renal abscess 
following gonorrhoea, 7.6 

W’eatherhi'.ad, E.: The efficacy of tuberculin 
611 

Wedd, Gerald R. (and Charles T. Rtder): Over- 
cerming Tuberculosis, third edition, rev , 61 

W’nnu, J. Curtis: Treatment of prostatlc en 
largemcnt.gsa 

W’KRpr.n, H. W.: B. coif infections of the diges 
tlvo system, 82 , . 

W’nnr.R. F. Parkes: Liver diet in p»rn(cions 

• “,** ' “ -•-iae atro' 

stretch 

• • 'ollowing 

, , of the 

spinal cord, 1106 (0) , , ... 

WhnsTnn, Weut.-Col. Charles George, obituary 
notice of, 413 ... , ,, 

W’epstkr, Douglas: Present position of radium 
therapy. 497-Trcatment of cancer of the 

W’r.riiSTER, Israel B.*. A Texthoolc of Clinical 

Nrurolopv, rev., 100 

W'oed klller, non-arRonlcal. fatal care of poison- 
ing by (A. II. D. Hmith). 714 (O) 


ThoWeok: 

Academy of Medicine of Jerusalem, 865 
Accident services in ind^ustry, 1077 


of, i.ui 


lurgeons, Gpngress 
366 

i factories, 


Asthma roscaroh, 458 
Bacillus Calmettp-Guerln 
criticism of, 364 — And 
infants. 909 -Tho^ present 


(B.C.G.). 2!0-A‘ 

non-tuberculouB 

position of pre- 


a. 65 


ittoe, 26, 8’3 
arships and 


udget, luu, u'i 

nllelin of llvni‘ne,l^0 

ush nursing. 67 , _ . ... 

incor campaign, Britieb J’”!"™ 

ancor OonJerenco, International, 815, loib 

anoer of tho uterus, 24 

ardiao malformations andonaocaraitis, S5i 

ardiao tonics. 603 

ftssel Hospital, 908 

holera bacteriophages, 365 

holera bilivaccin. 274 

oa-Uver oil, possible dangers of. 639 

olon. segmental resection of the, 459 

olonieS) bealth of the, 1118 

oronary circulation, 404 

oroner again.T078 
oroner’s discretion, 864 

oroner's jury and hosmtal arrangements. /63 

ytology of Jensen’s rat sarcoma. 274 
laylight in buildings, 681 

I?!!’ufv,£^n^*^inmimization : the Queensland 


^DrlXmcro-milk" campaign in tbe United 
Dr^ms^of’ilaictlon. international control of 
90T 



JAN.-3XJNF., 193S] 


INDEX, 


[ Tnx Bsmra 
Mcoicai. Jorsnu. 


Tho Week 

Dutdi «ml DAniMi rnnacnnctl milk. 310 
KdHCnllon commlltros nml l!i« pnlnrloR of 

' ‘ IsloTy rtf, 003 


■ \ 

(1.318 

* ' lUCJilnl 


Ex AmcrJcA fPiuf'ernHawIfl novl. HO 
Exorclso R3 ft thcrft]>otjlic niJont. 6S0 
Kxrfriiuonts on nnimnls, lUO 
Hro defects, enroof, lOG 
Eyestrain nnd flno vrork, U19 
Fftmlllftl hyjwrlroplilc pyloric Btcnosls, 5G3 
Ferrier. Sir UavkI, inomorlftl to, 1030 
First nld service on llio rondp, C03 
Foot‘Rnd nioiiUi 01sc«.?o |n 1917, G1 
ForniOFfl, nn Enclisb liospitfti In, 151 
Fowl tnmmir, ftrtlflclnl producllon of, 000 
Fractured cttvvicle, 725 
Fractnres, treatment of. 107 
'* Friends of the Old Aslimolean,*' 815 
General Mcdicnl Council’s incomo lax CftPO, 
GM—Hb soPsIoii,955 

German IcRUlalion nKftlnsl venereal dlficaRo, 
562 

Gland KrAftlnr:. 510 
Gordon of Aberdeen, 90C 
Haic. Earl. 195 
llftU-forcoltcn war. CS 
Harvclftn Bociety of London. 1078 
Harvey Tcrcontcnarj' (1525-1928). SCO. €05. 902 : in 
Pali*. 992 

llasUnga f.GCture. 3f0 
HcaUli ntn\ cdncnllrn. I'lO 
HeaUh tn industry, G05 

■HoaU^orGRuirAtion of llio Leairuo of ^Rtions. 
geatinR of larKc houses. ^55 


iiours ol work in factories, 509 
Humidity Rud tbe cotton wearer’s bcaltb, 55 
Hunter, John, 108 
Hunb rian Leclnrca, 26 
Hygienic teaching to cblMron, 192 
. P?J?lic^ 1037^^^''°*^*^* rroprlotorsblp of 

Income lax retnms for 1928-29 715 
Indexes, 

IndustriE ■ . . . #401; 

■■ ■ ’wimnlttco 

HcaUh Services, 990 
Int^cranial capacUy, 106 

Trvftt.n ...a . .• 


3 now, 605 
M120 
flic, 459 


Lister Institute. 951 

®MployceB. superannuation 

Loeb, Jacques, 232 

France. 4C? 


991 


’ <J( London ’ 

766 *^^ ^ooien’s International Associati 

Mott, Si; Fredoriok “I 
Mdcods snr/S .h ‘o. 275 

Mn^enm of th'o HoTaToM!”® 228 
Narcotic plantsflOil* Burgeons, j 

Rational 

National . 864 

Natural ' . ' 

y®ftt iiwuuurs 23 ' 

Sj?','®’ Charles. 664 ^ 

• „ohnare"8l5“" the lung 

1119^ international control of t 

9t“tt5'n^gijogy.l039 

Pathoiogi® al’^mMcum'at 

232 usenm at tho Cardiil meoti 

Pituitary extract. tho 
Pregoaucy, teat for. 952 

Puerpcral'uiUia^H";f„r^™rfSty\'4 


Tbn Week (ronllniird): 

I’nlmouury ncllnnmycosln, 404 
I'lilpleas tomb, C57 

Hid Crosft inovomont.coutenaryof tbofoundor 
of tbo.8G2 

IleRoarch by obRorvalion, 906 
lloHplmtory dlsordorn. iK)Ht'enC('pba1ItIc. 148 
Ulmuiimtlc (IlnenRGR, conforenco on, 510, 
7C8 

Ubounifttlatn In cbltdron, atmly of. 450 
Itockcfollor Medleal Kollowslilpa. 815 
Itoyal College of Phynlctanp. 275 
Uoyal Medical Henevolont Fund, 5G1. 1077 
Hoyal Hocifty convcrpar.iono. 1121 
Hoyal Boolety Foulerton lleficnrcli FrofesROr- 
fhip'i, GG 
HeR'PirknrRP, 7G7 
Fftpulcbral ftlaliBtIcR, 273 
Serum treatment of polloinyelltls, 405 
Seventeenth ctmlnry comuiooplaco booka, 190 
Sex, rRvo of mUtaken, £G1 
Slaughtering, methods of. 8C5 
Social Welfare. Intcmntional. fortnight in 
Parifl. 1073 

South African Field nospltal.252 
FiKirlR dnclorK.5(>5 

Blerillration of tho fcoblo-mlndcd in Alberta. 
650 

Rwodiflh Focial experiment In tnborculosiB, 658 
Tattooing ftnd romovnl of tattoo marks. 518 
'l ecth, dofectlvo Rtructnre of, 229 
Terth, mnUlplo oxtraclIonH of. 885 
Tbermo-ctvntery for septic Je‘‘lons. 678 
Tbjrold ftnd ttieDFtnmtlon.JlS 
Tobacco, the cvila of, 520 
Tuiierculoslfl In France, 814 
Tvpograpbicnl UBftgc, 4G0 
United Ho^pltala Club of 6t. Thomas’s and 
Guy’s. 320 

University of Ijondon : Chair of public bcftlth, 
148 

V. ‘ • * * In India. 250 

724 

V . *150 

Wheals and l>»te',275 

Williams. Sir Duwpon, teslimonial to, 317— 
Meinoriftl fund. 722. 902. 1075 
World population oroblcm<». 659 
Yellow fever, oca light on. 723 
Yellow fever in West Africa. 865 
Zoological nomcnctatorc, 105 

WniL. Mfttblcu-Pierro^^Tbo cardiac problem In 

* von. appointed 

• * * at rieidolbcrg, 

120 

WrLcn. William IL. M.D. : Koto on. ISO-Pre- 
senled with tho Kober medal, 150 
Welfare. Set Motomity and child wolfaro 
Wolfatt;, social. See Social 
Wr.Li.coMn. FlcnryS. : Presents a replica of Ibo 
Lister collection at the Woilcom© Historical 
Medical Museum to tbo American College of 
Furgeons, 81— lion, Ltj.D.Edinbureb conferred 
on, 5G9 

WrLLs. A. Q. in. F. PRP.WEn and F. It. Fbaseb) : 
Treatment of pernicions anaemia with liver, 
16510) 

Wells, C. Alex.: A lube for suprapubic cyst- 
otomy, 61 

AVelsb. See Wales 

WKNcnEBACtT. K. F„ admitted an Honorary 
Fellow of tho Hoyal College of Physicians of 
London, 666 

Weston, O. M.: The intestinal amoebao of 
man. 1111 

West African Jledical Staff, revised list, 787 
WnsTLEY, H. G. : Midwives and ante-natal work, 
571 

WESTiiACOTT, F. H.: Hypertrophic pulmonary 
, osteo-artbropalhy, 899 

Weston, H. C. (and S. Adams): On the Belief of 
Evestrnin among Persons Perfor7n£7ip very 
Fine TFork, ll»g 
Wheals and bites, 275 

Wheatley, James, death of. 405— Obituary 
notice of, 475, 825 

Wheelt n, E . R. ; Two cases of multiple urethral 
calculi, 443 

Wheeler, R. V. : A new lamp-room photometer, 
112 

Wheeler, Fir William I. do Courcy: Con- 
servative treatment of spinal caries. 55— Bone 
complications in typhoid fever, ^—Selected 
Papers on Injuries and Visease-f of Bone, rev., 
309 - Fracture of cervical vertebrae, 553 — Early 
diagnosis of cancer of tho rectum and colon, 
846 

Whitby. Xi. E. H. • — Afcdfcnl Bacteriology: 
Beseripiive a«(i.4j)plicd,tnclM(ltwo£leme7ifary 
Helminthology, rev., 850 

Whitccmbe, W. 6 . : Treatment of haemorrhoids 
by the galvano cautery*, 1098 
White line and motori8ts.430 
White, C. F. Oxr (and B. Buckley Bhabp) : A 
lubricant for applying zinc ionization to the 
male urethra, 95 

White. Charles Powell; T7te Pn'wctpZcs of 
Pathology, rev., 598— The histology of tumours, 
899 

White, E. Barton; Histology of tho globus 
pallidus. 351 

Whit n. Major F. H.. Territorial Decoration con- 
ferred on, 882 

White, S. E. : Medical responsibility for lunacy 
certification, 921 


WmxH, Winsbury: Treatment of urethral 
fltrictnro. 550 

53'jhti:itoust:. Beckwith: Practical applications 
of recent views on the menstrual function. 
651 (0) 

WniTEiiousE, Dr.: Remarks on a doctor's 
prosonco at a post-mortem examination with- 
out his permission, 864— More remarks on 
doctors, 1078 • 

WntTFiKiJ). A.: Cutaneous mycoses in tho 
tropics, 179 

Whitman. Royal; A Treatise on Orthopaedic 
Surgery, eighth edition, rev., 102 
WiiiTV.’KLL, James It.: I?hy8iology of defaeca- 
tioD. 292 

Who's IMio in the Nursing World, rev., 672 
Widal reaction, positive, duration of after inocu- 
lation, 450 

WiooiNs, n. : Drug treatment of pneumonia, 244 
WiGiiAM. J. T. ; New growth, 1026 
Wiqnabaja.G., called to the Bar, 205 
WinoDEB. S.: Dermatitis herpetiformis in a 
cliild, 259 

WlORAM, Loftus E. ; Early rheumatic myo- 
carditis. 19S 

Wti/BEnroncE, OctaTia: Value of marinehealth 
resorts, 450 

Wilcox, H. B. : Infant nnd Child Feeding, rev., 
1113 

WiLDBOLZ, H. (A. V. LiCHTENBEBCr and F. 

Yoelcbeb) : HaTidtueli der Urolog^e, rev., 398 
WiLDMAN, W. Stanley: The patient’s comfort 
after prostatectomy, 259 
Wilkes. Edward Theodore; Baby’s Daily 
Extrexses. rev., 357 

Wilkie, D. P. D.: Some aspects of gall-bladder 
disea-e. 481 (O) 

Wilkinson, Oscar: Strabismus, rev., 762 
Wilkinson. W. Camac: Early signs of tuber- 

' .*■ in and tuber- 

rheumatism 


WiLKB. S. L. B. ; Caesarean section in pregnancy 
complicated by tuberculosis, 480 

WiLiAN, R. J.: Treatment of urinary sepsis. 
121 (O) 

WiLLCox, Sir William;— History of criminal 
poisoning, 67— Liver diet treatment of per- 
nicious anaemia, 178— Harveian Lecture; 
Toxicology in relation to medical practice, 504 
—Vaccine treatment of rheumatism, 857 

Willett, Edgar William, obituary notice of, 735 

Willett. G.: Treatment of secondary anaemia 
by liver, 244 

Willett. John, promoted Commander of the 
Hospital of the (Drder of St. John of Jerusalem, 
1133 

William. Duke of Gloucester, son of Qneen 
Anne, cause of the death of iW. P. MacAtihur), 
502 

William, Chisholm, obituary notice of, 6S4 

■VViLLTAMS, Fir Dawson : Retirement of (leading 
article), 103 — Testimonial to, 317— Sudden 
death of, 361— Obituary notice of. 414— Funeral 
and memorial service, 425 — Appreciations, 416 
—His last signed article, 399— Memorial fund, 
471. See also Fund— The Harvey Chapel at 
Hempstead, 816 

Williams. Jesse Feiring:— Hypicric and Sanita- 
tion: The Essentials o/3fcdeni Healthcare, 
rev., 59 . . 

Williams, Leslie : Recent changes in obstetrical 
practice. 495 — Treatment of puerperal sepsis, 
495— (Concealed accidental haemorrhage, 495 

Wii LIAMS, Richard Tudor, obituary notice of. 


Williams, Stenhouse ; Pure milk progress, 
764 

WiLLiASisoN, Captain H.: A coincidence. 534 

Williamson, R. T, : Captain James Cook, R.K., 
243 

Williamson-Koble, F. a. (and Humphrey 
Keaue): a Haiidboo).' of OphthalmoloDi/, rev., 
15— Ocular complications of encephalitis leth- 
argica, 261 

Willoughby, W. G. ; Value of marine health 


resorts, 449 

Willoughby, W. M., appointed medical officer 
to tho City of London. 9C9 
WiLLSTATTER, Richard, elected a foreign member 
of the Royal Society, 1122 
Wilson, A. J. : Case of mistaken sex. 564 
Wilson, C. Robertson; Bronebo-pnenmonia in 
children treated by injections of emetine 
hydrochloride, 844 (Q) 

Wilson, Claude: Some notes on diagnosis, 709 
(01 

Wilson. D. R.: Artificial humidity in cotton 
cloth factories. 765 

Wilson, E. A. C. ; Intestinal obstruction in an 

infant, 51 ^ , 

Wilson, Major Gordon. O.B.E. conferred on. 
988 

Wilson, Justina : Diathermy in relation to 
circulatory disturbances. 134 
Wilson. S. A. Kinnier: Narcolepsy, 446— Appre- 
ciation of Sir David Ferrier. 526 
Wilson, T. Stacey : Tontc Sardenixig of the 
Colon, rev.. 356 

Wilson, W. James ; Isolation of B, iyphosxis 
from sewage and shellfish, 1061 (O) 

Wind instruments and emphysema, 244 
Winds, rain bearing, and early phthisis in 
Derbyshire (W. Gordon and W. M. Ash), 537 (O) 
— Correspondence on, 470 
Winsley Sanatorium. S#e Sanatorium 
Winter, A. E,: A surgical portrait group, 1134 
Wire bristle in the bowel (H. A. Graham), 13 



38 JAN.-JUNE, 1928J 


Wise, Alfred Thomas Tucker, obituary notice 
of, 696 

Wise, Kenrick Stanton, appointed an ofllclal 
member of the Legislative Council of Trinidad 
and Tobago, 649 

WoIjBABSt, Abr. L. : Gonococcal Infection in the 
Male, rev., 100 

WoLFFLiN, Ernst: Tafeln mit Umschlagfarben 
zum Naohxveis von relativer Hot* und Grj7«- 
sichtiglceit, rev., 986 

Wolverhampton Clinical Club. See Club 
Women medical officers at the London mental^ 
hospitals, 236. See also Hospitals, mental 
Women medical students and London hospitals, 
821. See also Medical 

WooPMAN, H. M. : The etiology of leukaemia, 50 
(O) 

Woods, R. Salisbury: An incident in a first- 
class life.” 32— Gas gangrene of sigmoid, 593 ^ 
Workmen’s compensation and silicosis (parlia- 
mentary note). 1005, 1095, 1096 
Workshops, overcrowded and insanitary (parlia- 
mentary note). 926 
World's Health, 163 

Worster-Drought. C. : Narcolepsy, 447— Dys- 
pituitarism. 717— Charcot’s arthropathy of 
both wrists. 717 

Worth, H. M. : The pulplecs tooth, 548 
Wright, Garnett: Volvulus of the sigmoid, 712 
(O) 

Wright, George A. Pemberton : Sea-sickness, 877 
Wrist splint, ” Ambidex.” 1115 
Wtabd, Stanley: Treatment of malignant dis- 
ease by colloidal lead, 838 (0), 1047, 1088 
Wynne, Fred E. : Fatality rates of small-poz in 
the vaccinated and unvaccinatod, 115 


INDEX. 


X. 

X-ray diagnosis: Of chronic appendicitis, 76, 
468— Of pathological conditions of the gall- 
bladder (James F. Brailsford), 484 (0) 

X-ray tube, ** motalix,” 205 

X rays, review of books on, 17, 984. See also 
Radiology, Radium, etc. 


Yates, Lowndes: Otosclerosis, 982— Methods of 
estimating the Habilitj’ to postoperative 
haemorrhage in onsutured wounds, 983 

Tear-r ’ ' * 

Year- 
0/ < 

1927. rev.. 556 

Year Bool: and Guide, South and East African 
(edited by A. Samlor Brown and G. Gordon 
Brown), rev., 672 

Yearbook of the Universities of the Empire, 192S, 
rev., 165 

Yellow fever. See Fever 

Yersin, Dr., awarded le grand prix Leconte, 
29 

YoFPA. I. V. : Treatment of flatulence. 38 

YoBKE. Warrington: The intestinal amoebae of 
man, 1110 

Yorkabire. maternity and child welfare in : 
revision course. 466 

Young, Lieut.-Col. Andrew Watson Cook, 
obituary notice of, 698 


TusDamix 
Medical Joitbkil 


Young, Archibald : Lister in Glasgow, ISl 
Young, O. J.: Acute aplastic anaemia, 1048. 
1129 

Young, H. G, K., presentation to, 81 
Young, James :— a Text-book of Gynaecology, 
second edition, rev., 600— Maternal mortality 
from puerperal sepsis: an analysis of the 
factors of contagion, trauma, and auto- 
infection, 967 (0) 

Young, James Buchanan, obituary notice of 
614 

Young, R. A.: Pulmonary and gastro-intestinal 
sequels of naso-oral sepsis, 97— Liver diet in 
pernicious anaemia, 179 
Young, Ruth, M.B.E. conferred on, 938 
Y'oung. William Ale.vander, death of, 965— 
Obituary notice of. 1005 

Younoe, Lieut.-Col. G. H. : Diary of a Field 
Hospital during the South African War, 232 


Z. 

ZiMiTERSiANN, Dr., appointed professor of 
anatomy at Berne, 163 

Zinc ionization, lubricant for applying to the 
male urethra (0. P. Orr White and B. Buckley 
Sharp). 96 

Zinovieff letter, 529 

Zinsser, Hans; A Text Book of Bacteriology, 
sixth edition, rev., 850 

Zondek. S. G.: — Die Elektrolyte : Hire Beden- 
tung fiir Physiologic, Pathologic, und Ther 
apie, rev., 138 

Zoological nomenclature. 105 



JAN.-3UNE, igiS] 


r TnKDRmss ' 

L MtDTClX. JOCBITil, 


LIST OF ILLUSTEATIONS. 


Special Plates. 

rAOE 

Anastomoses botvTcen tbc Kecnrront Laryngeal and Phrenic Nerves 

(Sir Charles llallanco and Lionel Colledgo) ... ... (facingl T-IS 

Brain. Now Methods of Surgical Access to tbo (H. S. Souttar) (facing) 296 
Finfior Tip Bemoved by a Bite, Idcntiflcfttlon from a (Sydney Smith) 

(facing) 7'17 

Gall-bladder Biseaso (D P. D. ■Wilkie) ... ... ... (facing) 481 

Gall-bladder and its Infections (Sir Borkoloy Moyniban) 

inset between 2 and 3 

Gall-bladder, X-ray Diagnosis o! (James F. Brailsford) ... (facing) 485 
Pituitary Tumour, -Operation for (A. Watt, R. C. J. Meyer, and 

A. Campbell) ^ ... .. ... ... ... (facing) 717 

Pulmonary Asbestosis in South Africa (F. AV. Simson) 

inset between 883 and 887 

Radiography in Obscure Dental Sepsis (J. F. Brailsford) 

• inset between 1014 ond 1015 

Renal Calculns, Late Results of Operation for (J. F. Dobson) (facing) 485 
Sarcomata, Inoperable. Treated with Radium (Roy Ward).,, (facing) 123 
Swallowed Object, Method of Dealing with a (S. Gilbert Scott) 

(facing) 122 

Drinary Sepsis, Treatment of (R. J, WlHau) ... ... (facing) 122 

Williams, Sir Dawson ... ... ... (facing) 103.414 


iLLDSTtlATIONS IN THE TeXT. 

Abdominal Pain as ErempUfled in Aoate Appandioilis (John Jlorley) 888 
Alkaline Treatment of Gastric and Duodenal Ulcer (Hugh UacLcan) 621 
“Ambldex" Wrist Splint ... ... ... ... ... 1115 

Anricalar Flutter (C. E. K. Herapatb) ... ... ... 213 

Bassett-Smitb, Sir Percy ... ... .. ... ... 35 

Belt for use iti Suprapubic Drainage ... ... ... ... 556 

Blastomycosis of Eye and Face Secondary to Lung Infection (Arnold B. 

Ferguson) ... ... ... ... ... ... 443 

Blood Film, Method of Making a (Surgeon Commander Frederick 

Cock) ... ... ... ... ... ... . . 306 

Blood Transfusion, Arm-to-Arm (E. F. Skinner) ... ... ... 492 

Board-bed. an Adjustable (Leonard Hearn) ... ... ... 1108 

Brain, New Methods of Surgical Access to the (H. 6. Souttar) ... 296 

Branchial Cyst, Diagnosis of (Hamilton Bailey) ... ... 910 

Browne, Henry William Langley ... • . ... ... 475 

Cardiac Infarction (T.Wisbart Davidson) ... ... 212 

Cardiff and District. Views of ... ... ... 142,652,1040 

Chloroform, Intratracheal Inhalation of (W. Dakin Matt) ... ... 942 

Church, Sir William Selby ... ... ... ... 779 

Colloidal Lead and Radiation, Action of on Tumours (J. C. Mottram) 132 
Cystoscope as used by David Newman ... ... ... ... 247 

Cystotomy. Suprapubic, a Tube for ... ... ... ... 61 

Deltoid Shelf ... ... ... ... ... ... 986 

Dengue in Egypt, the 1927 Epidemic (H. Kamal) ... ... ... 1105 

Duckworth, Sir Dyce ... ... ... ... ... 161 

Ferrier, Sir David ... ' ... ... ... ... ... 525 

Foreign Body in Bladder causing Calculus Formation (J. McFadzean) 665 
Foreign Body in Oesophagus : Difficult Removal (Lindley Sewell) ... 176 


PAGE 

Fracture of the Navicular (V. Paterson Brown) — — — S31 

Fractures of the Clavicle treated with Displacement (G. W. Milroy) 665 
(H. H. Greenwood) ... ... 1021 

Fnngons Infootions of Hands and Feet (Rupert Hallato) ... ... 837 

Gastric and Duodenal Operations (F. J. Strong Heaney) ... ... 1056 

Harvey, William, Tercentenary ... ... 810, 816, 867, 911 

Hip. Congenital Dislocation of (F. Wilson Stuart) * ... ... 345 

HodsdoD. Sir James ... ... ... — ... 1033 

Hunter. John ... ... ... ... ... ... 271 

Portraits and Personality of (Sir Arthur Keith) ... ... 205 

Hunters, the Homes of the ... ... ... ... 276' 

Hydatid Cyst in the Heart (H. L. Heimann) ... ... ... 801 

Hydrocele. Operation of Eversion of the Sac for (Richard L. Spittel) 305 
Imhotep as Deity of Medicine ... ... ... ... 565 

Infantile Paralysis, Appliances for ... ... ... ... 986 

Intravenous Calcium Therapy, Dangers of ( W. D. M. Lloyd) ... 663 

Intussusception in an Adult due to a Polyp of Meckel's Diverticulum 

(Ian Macdonald) ... ... ... ... ... ... 442 

Leper Colony, Chiengmai, Siam ... ... ... ... 1071 

Macdonald, James Alexander ... ... ... ... ... 781 

Motor Can Mann Egefton Coup^ Cabriolet ... ... ... 226 

Mouth Gag... ... ... ... ... ... ... 902 

Nasal and Oral Focal Sepsis (Patrick Watson-Williams and'F. A. 

Pickworth) ... ... . . ... ... ... 932 

Papworth Village Settlement; Clifford Allbutt Memorial Cottages ... 2115 
Pituitary Tumour, Operation for (Andrew Watt, R. C. J. Meyer, and 

Andrew Campbell) ... ... • ... ... ... 748 

Polydactylism in the Foot (A. Ernest Sawfley) ... ... 846 

Polymastia (G. B. Richardson) ... ... ••• ... 346 

Pyrexia dne to Infected Dead Teeth (Leonard G, J. Mackey) ... 1021 
Bain-bearing Winds and Early Phthisis in Derbyshire (W. Gordon 

andW.M. Ash) ... ... ... ... ... ... 338 

Rectum. Prolapse of, in the Female (Frederick J. McCann) ... 891 

Sbatpey-Schafer, Sir Edward ... ... ... ... ... 313 

BpinaV Curvature following Encephalitis Lelhargica (R. G. Aber- 
crombie) ... ... ... ... ... 175 

Spleen, Raptured Malarial; Splenectomy: Recoverj' (D. Laurence 

Tate) ... ... ... ... ... ... ... 1023 

Sterilizer, Portable Low-pressure ... ... ... ... 18 

Surgery. Progress of since Hooter’s Day (Sir HolburfVTaring) ... 247 

Syringe for Injecting Varicose Veins ... ... ... ... ?63 

T-8trap. Internal ... ... ... ... ... ... 986 

Testicle. Duplication or Subdivision of (G. H. Edington and J. W. S. 

Bfacklock) ... ... ... ... ... ... 938 

Toneil-suction for Diagnosis and Treatment (Frank G. Eve) ... 941 

Tuberculosis Mortality, Causes of the Decline in (Sir Robert Philip) 701 
Tyndall v. Alcock, with Remarks as to the Origin of Ischaemic Con- 

tractore (E. W. Hey Groves) ... ... ... 807 

Urine Examination for Pus (Cuthbert Dukes) ... ... ... 392 

Urine Testing Outfit, a Portable ... ... ... ... 556 

Vital Capacity in Heart Disease (H. 'Wallace Jones) ... ... 795 

Tellow Fever Virus, Preservation of (A. W. Sellards and Edward 
Hindle) ... ... ... ... ... 7J4 


Printed and published by the British Medical Association, at their Office, Tavistock Square, in the Parish of St. Pancras, in the County of London. 



THE JOURN^VL OF THE BRITISH MEDIC^IE ASSOCIATION. 


LONDON; SATUEDAY, JANUARY 7th, 1928.' 


®^ljc iilitrljrll fOmths ^trniorinl ICrrtitrc 

ON 

THE GALL BLADDER AND ITS 
INFECTIONS. 

D£li-\-eiied at LivEnrooL, NovEJiucn 24 ih, 1927, 

BY 

Sii! BERKELEY MOYNIHAN, Bt., JI.S., 

PEESIDEKT OE THE EOTAI. COLLEGE OF ECEGEOSS OF ESGL4SD. 

(TTR/i Special Plate.) 


The art of tlio surgeon ryhicli strives to rescue tlie life or 
restore the Iicaltli of patients must servo, wlierovor pos- 
sible, as tlio hanjmaicl of soiencc. lYhon, by one device or 
nnotlior, wo remove diseased organs, or parts of organs, or 
niter the njcchauical or physiological processes which they 
fulfil, wo must no longer rest content merely by the means 
by which wo cfToct these changes — wo must seek to know 
by what process tho pathological state has been produced, 
what aro its relations, if any, to other morbid conditions, 
near at hand or far away, and what modulations in func- 
tion or in action aro tho result. Surgery docs not complete 
its high mission by healing tho individual patient, though 
in this must alw.ays lio its chief importance. It now seeks 
to advance the science of Medicino; and it may claim to 
have done so in a manner exclusively its own. 

The application of this general principle to tho particular 
instance of cholelithiasis is interesting. Before tho surgeon 
became competent to inspect tho gall bladder little was 
known of cholelithiasis but its catastio|)hes. Tho symptoms 
caused by stones within the gall bladder were referred to 
tho stomach, and it was among tho descriptions of func- 
tional diseases of this organ that tho clinical histoiy of tho 
earlier stages of this condition was to bo found. In conso- 
guence there started tho fallacy, which is being so reluc- 
tantly abandoned, that gall stones as a rule cause no 
symptoms, and may often be regarded as “ silent ” or 
P innocent.” 

During the last forty years, in consequence of the know- 
ledge gained during operations, there has steadily grown up 
a clear apprehension of tho clinical symptoms caused by 
cholelithiasis. Tho various problems of differential dia- 
gnosis also have engaged attention, and a conception of 
the clinical and pathological relations between this disease 
and other morbid changes within tho abdomen has now 
been established. Of this relationship wo know little .as 
yet; its existence has, however, clearly been established by 
direct research, and it is for analogical research to, pursue 
to their biithplace the individual elements in a veiy 
complex pattern of pathological changes. Though we have 
learnt much as to tho physiological activities of various 
organs within the abdomen, we know little of the correla- 
tion of normal functions as between one of these organs 
and another, or between one organ and many others. We 
know even less of the effect of morbid changes in one organ 
■upon other organs; we aro only beginning to realize their 
exigence and their significance. May I to-day endeavour 
to interest you in some of the problems regarding tho gall 
bladder as they present themselves to the surgeon? 


The Physiology of the Gall Bladdeh. 

[Sir Berkeley Moynihan then discussed the evidence, 
obtained by direct and by analogical, research, upon which 
our knowledge of tho functions of the gall bladder is based; 
and concluded as follows : 

1. The chief function of tho gall bladder is excretory. 

2. Tho .mucosa of the gall bladder absorbs fluid, and other 
Kubstanees,- from tho hepatic bile, which it reduces to one-sixth 
or less of its original bulk. 

3. Fluids and other substances absorbed aro carried off by 
tho lymphatics and by tho capillary circulation. 

4. The mechanism by which the gail bladder is emptied 
is complex; muscular ’ contraction, variations in abdominal 
pressure, milking of tho common duct by duodenal peristalsis, 
tho “ Sprengcl' air pump ” action of bile as it descends from 
tho liver, flowing past the opening- of tho cystic duct, elastic 
recoil, may all play a part in this act. 

5. .The quantity of bile leaving the gall bladder in the course 
of twenty-four hours is very small. 

6. Tho functions of the “all bladder as an adjuvant of 
alimentary digestion arc slight; and operative experience 
suggests that thov arc almost negligible. 

7. Tho part played by the gall bladder in the general 
economy, by virtue of its powers of absorption, is unknown. 
Thero is suggestive evidence that it is concerned with tho 
movements or the metabolism of cholesterol.] 

Ixtectiox of the Gall Bl-mider. 

Infection of tho gall bladder may bo primary or 
secondary. 

Primary infection is rare. The cause is connected with 
tho solitary cliolesterin stone, formed aseptieally, as 
Aschoff* asserts, within tho gall bladder. Such a stone is 
said to own a different origin from all other stones; they 
aro dependent upon infection, this one arises from causes 
other than infection. IVhen once -formed the stone may 
at length becomo temporarily or permanently engaged in 
tho cystic duct, whose obstruction starts a primary 
inflaramatory change both in the walls of the gall bladder 
and in tho contents. Tlie stone, by its constant friction 
against the Walls of tho gall bladder, may in this way also 
initiate inflammatory changes. .' -. 

Secondary infections of tho gall bladder arc far more 
frequent. The paths by which infection may reach the 
gall bladder are many. Organisms .may be carried in the 
blood stream, in the bile, in the lymph stream, or may 
invade the walls of the' viscus by direct extension from 
neighbouring parts — the liver, tho stomach, the duodenum, 
colon, or kidney. 

1. Infection ihrovgh the Blood Stream. 

(a) Arterial Route. — The gall bladder derives its blood 
supply through the cystic arteries from the hepatic artery. 
This route is followed only in cases of general septicaemia. 

(b) Venous Boutc. — ^Tho veins of the gall bladder empty 
directly into the portal vein. Infection arises through this 
channel only by a process of thrombosis or thrombo- 
phlebitis. No example of this has occurred in my series 
of cases. 

We owe our knowledge of hacmatogenous cholecystitis to 
Rosenow.** He found that organisms removed from tho 
gall bladder, from tho bile, from tho centre of gall stones, 
or from the cystic gland of patients treated by cholecyst- 
ectomy, contained organisms, chiefly streptococci, which, 
when injected intravenously into animals, produced lesions 
i of the gall bladder, of the bile ducts, and sometimes of 



2 Jan.,, 7, 1928 ] the GALD BLADDER AND ITS INFEOTIONfl. 


tlie stomach or' duoilenum. Ho suggested that such 
organisms have an “ (ileetivo affinity ” for tissues liko thoso 
from which they were originally derived. Such organisms 
reacli the gall bladder of the animal by tho blood stream, 
and in tho gall bladder produce lesions exactly comparable 
to thoso in tho organs from which they weio taken. 
■\Vhother it is tho micro-organism which selects tho tissue 
in this “ elective affinity,” or whether it is the soil which 
alono provides tho food necessaiy for the growth of tho 
germs — tho soil selecting tho genn—^is not a matter of 
importance. Tho truth is well established by Rosenow’s 
experiments and by clinical and pathological research in 
man that micro-organisms attacking the gall bladder may 
roach it through the blood stream. 

The question has been closolj' studied in connexion with 
typhoid fever, but the results of experimental work appear 
very conflicting. J. Koch,^ in a- patient who died of enteric 
fever, found inflammatory changes in tho mucous and 
submucous layers of the gall bladder. Just beneath tho 
epithelial layer of tho villi ho found masses or clumps 
of organisms, apparently thoso of typhoid fever. No 
organisms were found on tho surface of the mucosa. He 
therefore drew tho conclusion that it was not from tho bilo 
that tho gall bladder was infected, but by a process of 
embolism. In the nests of organisms in tho wall of tho 
"■all bladder propagation took place, liberated organisms 
escaping through the mucosa into tho gall bladder, there to 
infect the bile. Ghiarolanza' injected typhoid bacilli into 
the veins and beneath tho skin of rabbits, and described 
the organisms as foianiiig emboli in tho capillaries of tho 
submucous layer of tho folds of the gall bladder. Other 
observers have, however, recovered organisms injected into 
the veins fi-om tho bile descending from the lir-er. It is 
interesting to note that the injection of Dakin’s fluid into 
tho blood stream is apt to cause acute cholecystitis. 

2. Infection hy the Lymphatic Itovtc. 

From our knowledge of the development of tho gall 
bladder we should expect to find few lymphatic communica- 
tions between it and the liver. In some situations, how- 
ever, and notably at the splenic flexure, it seems possible 
for an organ to appropriate the peritoneal vessels which 
may oomo into relation with it. Professor Jamieson tells 
mo that there is great traffic of vessels, especially from 
the under surface of the right lobe of the liver, xvith thoso 
of tho gall bladder as together they pass inwards on their 
way to the lesser omentum. Winkerden,’' investigating the 
gall bladder of the cat, failed to demonstrate any com- 
munication between its lymphatics and those of the liver. 
This is a contradiction of Sudicr’s' earlier obsciwations, 
adiich showed an intimate connexion between the surface 
lymphatics of the liver and those of the gall bladder in 
man. Dr. A. L. Taylor, examining my cases of cholecystec- 
tomy in which a piece of the livei- was reinoi’ed, found 
evidence of hepatitis, of a thickened liver capsule, of 
dilated lymphatics beneath it, and of dilated lympihatics in 
the outer coat of the gall bladder. 

The “ hepato-lymphatic route ” of invasion of the gall 
bladder, it it exists, would thei’cfore apj)ear to depend 
upon the following series of events: hepatitis — infection of 
intrahepatic lymphatics — extension of infection to the 
freely anastomosing surface lymphatics of the liver — in- 
volvement of communicating lymph vessels in tho outer 
wall of the gall bladder. If this sequence is followed 
then the occurrence of hepatitis should be frequent, and 
invasion of the serosa and subserosa of the gall bladder be 
demonstrable in an early stage of gall-bladder infection. 
Evarts Graham’ was the first to suggest the invariable 
existence of hepatitis in cases of cholecystitis and of cbole- 
•lithiasis. Many surgeons had been familiar with the fact 
that infection of the liver and early and localized cirrhosis 
were observed both in cases in which stones were pi-esent 
in tho gall bladder and in cases where, although calculi 
were not found, the gall bladder showed evidence of chronic 
inflammation. Our observations, carried on since Graham 
indicated the methods of inquiry, fully support his con- 
tention; and no doubt now remains that heijatitis, if not 
tho invariable, is yet the very frequent, antecedent of 
cholecystitis. A further point concerns the condition of the 
gall-hladder wall. As to this the answer is unequivocal. 


Tho outer coats are in a largo proportion of cases mor« 
seriously affected than tho inner. In this scries of 81 cases 
there were only 18 in which inflammatory changes were 
more marked in tho inner coats. 

Tho wall of tho gall bladder contains organisms more 
frequently than tho hilo. In 33 out of 81 cases active 
micro-organisms wore found; in 30 cases in the wall, in 
25 in tho bile. A further observation made in my cases 
is relevant to this issue. The lymphatic vessels in 'the 
outer coat were grossly dilated in 20 cases out of tho 81. 
The vessels wore mostly free of cells, hut some contained 
lymphocytes. In 16 of the 20 cases tho lymphatics of tho 
suhsei'ons coat wore dilated, and thoro was frequently 
evidence of infection in and around them. The lymphatic 
ap])ears, thorefore, to be a very probable route by which 
infection may reach the gall bladder. 

Further ovidenco of the early involvement of the 
lymphatic hystem in eases of cholecystitis is afforded hy 
tho condition of the cystic gland. C. H. Jlayo was tho first 
surgeon to call attention to the significance of this observa- 
tion. Among tho signs which wo now accept as indicating 
early though definite infection of tho gall bladder, proved 
later on hy mieroscoiiic and bacteriological -examination of 
its walls, is the enlargement of tho gland which lies in 
close relation to the cystic duct. Indeed, its enlargeinont 
not only deiiioiislrates tho existence of an infection, hut 
is an indic.-ition of tho necessity for tho removal of tho 
g.all bladder. 

3. Infection through the Bite Stream. 

If infection is to reach the gall bladder tlirongb tho 
bilo stream it may cither descend from the liver or ascend 
from the duodenum. That rctrogrado infection from the 
intestine is possible is clearly indicated hy the ]irosenco, 
as tho nucleus of a stone, of foreign bodies which, in the 
absence of a fistula between tho gall bladder and tho 
iiitcstiuo or tlio surfat'o of tlio body, could reach the 
lumen of tho gall bladder in no other way. Such a 
nucleus as a piece of cotton fibre, or a tiny flake of copper 
from a cooking utensil, must ascend from the duodenum. 
C. J. Bond’s’ experiments lend eouclnsivo support to tins 
view'.' Ho found that coloured fluids introduced into tho 
rectum could ho recognized in tho dischargo from the 
gall bladder after tho operation of cholecystotomy . Me 
know that after tho operation of tj-phlotomy the coloured 
fluids can ho recognized in tho intestinal dischargo a few 
minutes after their introduction into tho rectum. Bond 
showed that retrograde curreuts extend throughout the 
entire length of tho alimentary canal. What alone is 
doubtful is, tlicroforo, the frequency with which this ascend- 
ing path of infection is followed. Tho following facts 
elicited from my eases aro relevant. . . .• 

As 'Stated above, in 35 cases out of 81 active infection 
was present; in 30 cases organisms were cultivated from the 
wall, in 25 eases from tho bile. In 8 cases in this series the 
bile was extracted from tho duodenum hy Lyon’s method. 
In 2 cases only were organisms present which proved 
identical with those found in tho gall bladder. 

HypocHLoiiHr-DRiA AND AcmoimYvmA. 

The influenco of hypoehlorhydria and of achlorhydria lU 
perhaps important. Tho duodenal contents are usually 
sterile, and aro mado and kept so by the antiseptic action 
of the gastric juice, which depends upon tho presence of 
hydrochloric acid. In over 300 of my cases, including this 
series, it was found (hy Dr. Ailcen Wilson) that 22 por cen ■. 
of patients showed complete achlorhydria, the ordinary 
incidence of the condition being not more thnn 5 pei cen 
Ac)doi-)iydrin, in cases in which afterwards gastro-entcro- 
stomy or gastrectomy is done and the nincous niombrano 
examined, is sometimes associated with, and is pci haps 
dependent upon, e)ironic gastritis. ^Ve do not know at \\hr> 
period of life achlorhydria first occurs, whether it is a 
congenital condition, or whether it follows tipou some acn ® 
or sustained infection in early years. Bnt it appears 
probable, and Knott’s'® work would confirm this view, that 
wlion free hydrochloric acid is absent the " gastric 
cidal harrier ” is removed; the pylorus then is relaxed, an 
organisms escape nnliarmed into tho duodenum, whence (i 
there is also relaxation of the sphincter of Oddi, as seems 



SIE BEBKELEY MOTNIHAN : THE GALL 


JAN. 7. 


r Thf. BRiTisn 
I Mkdical Jocrnal 



Fig. 5.— Calculi with calcium nucleus, surrounded by cliolesterin. 



ITS INFECTIONS 


r Tire Bbitibh 
I. MKDICIL JOUBBIL 


IAN. 7 * ^928! 




/. 





JAK. 7, x9»s3 


THE GAr-E BDAUEEU AND ITS INFECTIONS. ' 


C TizxBiut7«3 

llJtOtOAX.JOmNiI. 


8 


probix^ik') tUoy nmy nscond lo t!io pull bladder. It is 
signilicaut also that .acldorliydria is povlmiis responsible for 
Iwions of the appendix, aiiich may, tiirougli flio portal 
syslom, tUcinsolvps bo the pi-ecnr.sora, or possibly tlio canscs, 
of an infection of tbo bilo ns it <Iesconds from tlio liver, 
'„jiily rases Eliowcd that when achlorUydria was present tbo 
gibiio in tbo gall bladder was infected in 06 por cent., ns 
;,ieoinparcd with 28 per coat, in Cinses wbero tbo acid content 
j was norma! or incrc.ascd — tbo incidonco, that is, of biliary 
i, infcclion is nioro than twice ns high. .Indd," in an exam- 
ination of 100 conseenlivo eases, found that tbo gall-bladder 


lent xnicrobos. Tboso wbicb so escape dcscond in -tbo bilo 
to the gall bladder, and contact with bilo may ear.se tbo 
organisms (especially if they nro of tbo Bacillus coli group), 
to clump in tbo concentrated bilo .and so to become- i.. o 
nuclei for stones. If hepatitis is incidentally caused it by 
no means necessarily follows that the gall bladder suffers 
later, whether through the lymphatics or through the bilo 
stream; for multiple or solitary abscesses of tbo liver, or. 
such conditions as syphilitic hepatitis, may be veiy 
advanced, yot the gall bladder remains normal. 


wall showed organisms in 29; in 7 cases only did tbo bilo 
contain them. 

. Hyporcblorbydria was ]>rescnt in 16 of my 81 casc.s, and 
6 of these patients had duodenal nicer ns well ns cbolc- 
cyslitis. Tbo cvidcnco, thcreforo, appears to show that 
infection of tbo bilo tbraugb tbo duodennin docs certainly 
occur, and that it is more likely to develop when achlor- 
hydria is present. IVbon ncblorbydria was found the radio- 
logical examination often sbou'cd a pyloric relaxation and 
a quicker escape of . gastric contents into tbo duodenum. 
Tbo associated relaxation 
of tbo spbiucter of Oddi, 
tbongb possible, is not 
domonstroblc. 


The Livek, PoniAi, SrsicM, 

AND ArrExnix. 

Infection m.ayvalso rcacli 
tbo intci-ior , of tbo gall 
bladder through bilo de- 
scending from tbo liver. 

Tbo scqucuco of events in 
this " hepato-biliary route” 
will tboreforo bo: mfcction 
of liver cell — hepatitis — 
destruction of parenchyma 
— infection of bilo — con'tact 
infeclion of gall-bladder 
mucosa. If this path were 
followed wo should expect 
to find that when n'liieco 
of the liver is taken for 
microscopic examination 
inflnnuimtory changes nro 

•present. In three c.ases in 

this series a dellnito 
hepatitis, most marked in the portal tracts, was found. 
.1110 .number is too small to liavo any value greater than 
tins— that it docs show that this typo of hepatitis definitely 
occurs m association. with c-liolocj'stitis. 

uifectivo agent which roaches tbo gall bladder in 
us way is derived from tbo portal system. In this aro 

• wo streains-^tbo ono derived from tbo alimentary canal, 

• 10 other from tbo sploon. So far as tlio alimontai-y 
s ream is concerned the main source of origin (of any 
infection) is most frequently tbo appendix. AVo know, 

clinical exporicnco of a multitude of observers, 
oat the appendix shows evidence of disease in a largo 
proportion of cases in wbicb cholecystitis or gastric or 
uodcnal ulcers aro present. Indeed, it is rare to find 
■so itary inflammatory affections of the stomach, duodenum, 
paiiercas, liver, gall bladder, or appendix. AATien ono of 
r shows evidence of disease one or more of the others 
.IS ikeiy also to be implicated. Whether the disease starts 
one and spreads tlionco to tbo others, and if so in which 
ono It begins, is doubtful. All of these viscera may possibly 
crivo their infection from an outside source. There is a 
j bacteria from the intestinal lumen into 

■ organisms may be arrested in tbo glands 

R 1 ° or in the endothelium of the liver sinuses. 

• f ,}^ remain within leucocytes no signs of 

Kmurr destruction of organisms by tho 

bv “ filliug of tko perivascular spaces 

uowci- hepatitis. The bactericidal 

cellc to be considerable; the hepatic 

nrrrn, ' ° ”idood formidable “ destructors.” Some few 

escauc'^'ivmwl™ •*' chance for them, 
fs m* ’ their lives, perhaps at a time n-ben tbo bver 
ucu anly overwhelmed by a flood of unusually viru- 


DESCRIPTION OF PLATE. 

Tio. 6.— CaU*Mfl<Wcr wall from ft typical case of chronic chole* 
c.\>tltis. Tlio mucous membrane is relatively intact and the muscular 
coat of hcallhy appearance. The diibscrous coat Is pready thickened. 

Fio. 7.— I'erltoncal and $tibscfo«s coats of a TOll-bladder wall In 
cliroiilc cliolocyBtItls. This rhow'a A/:nin the great flbrotic thickening 
and concesiion and (be «bi<i«Uous infiUratton by chronic Inflammatory 
cells. TIjc large spaces h.uc contained fat. The mucosa ana muscularis 
are almost tutncl. 

no. C.— Section from lb«' Inflammatory fibrous tissue immediately 
beneath the wroiis coat. In the middle of the field is a greatly 
dllrtlcfj lymphatic tcs^el. The mucous membrnne in this case is 
practjcaUy normal. 

Tin, t).— Section of liver from a case of chronic cholecystitis. 
A portal sheath is chowu containing a %'cin. an arteriole, and a small 
bUo duct. The fcheath is con**idcrably fibrosed anti thickened, and con* 
lama numerous chrOnlc inflammatory cells. These are particularly 
iirominent surrounding the bile duct in the large tract ond round 
the fimaUrr ducts In (lie left-hand top corner of the slide. 

rio. 10.— A portion of Uver ineludloc a portal tract, from a case of 
fubaculc cholccihiltls. There is a pood deal of fatly Infiltration of tho 
llvcf parL-nchvma and a wiUe^prcod Infl 

tract bv fiin.afl UmpUocylcs. The situati * ' is 

round the tsmall bile ducts in the bottom 

Fig. ll.— Ccntrifupcd deposit from the bile In chronic cliolccystllls. 
The <kposU runsi'ts almost l utirely of desquamuted m«co*Bl epitnelhim 
with very few infinmmalorv cells. None of thc.<e la seen In this slide, 
in cases cither >vlth or without stones the sconllnc.ss of inflaramatory 
coHs in tho bile is a notcwoithy feature and Is some evidence against 
mucosal infection. 


The Speeen. 

But rcmcrabi-anco sliould also bo given to tbo possibility 
Hint organisms within tbo portal current may be derived 
from tho spleen. Tho association of diseases of tbo liver, 
and of gall stones, with diseases which seem to have their 
origin or their chief dovclopraont in the spleen, has 
recently become clearer. In cases of haemolytic jaundice 
60 per cent, of tbo patients suffer also from cholelithiasis. 
With splenic nnacmia both cirrhosis of the liver and gall 
stones nro associated. Enlargement of the spleen is noticed 

in cases of stones in tho 
gall bladder and the duct, 
but sufficient regard has 
not been paid to tho possi- 
bility that it is from the 
spleen that the infective 
agent is immediately de- 
rived. There are cases in 
which a large number of 
small stones are foxrad 
throughout the substance 
of the liver, not only in 
cases of cin-hosis, but in 
cases whore tbo liver 
appears little if at all 
changed from the normal. 
And every surgeon is 
familiar with cases of re- 
current gall stones in 
which tho common duct 
and all the ducts of tho 
liver within reach aro 
filled with mud and fine 
stones, which may be 
washed down in almost 
unending quantities. In 
such cases I pass several tubes up into the liver, and 
apply tho Carrel method of intermittent irrigation for 
several weeks. Splenectomy for recurrent cholelithiasis 
may bo found necessary in such cases. Ono of the func- 
tions of tho spleen is to filter out micro-organisms and 
toxio substances from the blood stream, and to send them 
to tbo liver for destruction. It may sometimes harbour 
them as well ns transmit them. Its capacity to do so in 
syphilis has been shown by W. J, Mayo. Possibly in other 
infections micro-organisms or toxic materials are held up 
and passed on only from time to' time to the liver, which 
in this way receives the material, chiefly bilirubin and 
calcium, upon which tho gall stones are deposited. It 
seems possible that stones with a bilirubin calcium nucleus 
may owe their origin to increased destt-uetion of red colls 
in tbo spleen. 

Direct Extension. 

Infection may reach the gall bladder from any viscus to 
which it adheres. If, for example, a duodenal ulcer, or 
oven a gastric ulcer, is about to perforate, the gall bladder 
may become adherent to the inflamed area ; and if the wall 
of the intestine is then completely destroyed, the gall- 
bladder wall may form the basis of the ulcer and so prevent 
perforation. Infection in this way may be spread from tho 
outer coats to the lumen of the gall bladder. AVhon so close 
an attacbmont of duodenum and gall bladder occurs it 
almost invariably has its origin in the latter. A stone 
seeks to escape from the gall bladder, which, becoming 
inflamed, adheres to the duodenum. A fistula forms, and a 
large stone escapes, perhaps to become impacted in the 
intestine and to cause acute obstruction. In only , one 
case in my series of 81 did it seem possible that the gall 
bladder was infected in this way. 


4.' Jan. 7, igas]! 


THE GFAEE BLADDEH AND IT3 INFECTIONS, 


r TnnJ^nrnnt 
L Mrsicaz, Jors^AS- 


CoKciirsTONS As to Infection. 

An examination of the gall-braddcr wall in my series of 
81 consecutive cases shows clearly that infection began in 
the outer coats in 63. In 18 cases the inner coats were 
more seriously affected, but in some at least of these it 
appears possible that infection, beginning in the outer 
coats, attacked the inner coats more sevcrclj’^ only because 
impaction of a stone in the cystic duct caused an obstinc- 
tion which was quickly followed by inflammatory' changes' 
which fell upon the mucosa first. Infection may reach the 
outer coat by direct extension from the liver, by lymphatic 
infection from the liver, or by implication of the peritonea] 
surface as a consequence of disease in an adjacent or^n, 
such as the appendix. In those cases in which infection 
begins from ■within, the ascending route appears to bo 
followed more frequently than I had realized. Cholecystitis 
seems as a. rule to be a part only of an infection which 
has its origin elsewhere; hepatitis is very commonly, if not 
always, present, and is almost certainly of earlier origin 
than the inflammation of the gall bladder. 

Pathogenesis of C-m-chm. 

In the series of cases upon which this paper is based 
the blood cholesterol and the blood calcium were measured 
before operation. The gall bladder after removal was at 
once examined by the radiologist as it lay in sterile 
wrappings. Tlie cholesterol and the calcium content of tbo 
bile in the gall bladder was taken and the bile and the 
gall-bladder wall examined for micro-organisms. Sections 
of the wall were taken in order to study the degree of 
inflammation in the several coats. 

AVlien a gall bladder containing stones is removed by- 
operation and examined at once with x ray.s a very 
interesting discovery is made. As a nilo, with few excep- 
tions, the composition of the stone is dependent upon its 
size. The smaller stones are translucent; they consist 
of cholesterin without admixture or addition of any other 
substance. As the stones grow larger a tiiin deiiosit of 
calcium may be found upon the surface; the i-ray picture 
shows a thin crescent, the " new moon ” appearance, or 
a smattering of black spots upon a tiansluecnt stone. 
"When the stone is still larger a complete covering of 
calcium may be found, and the “ wedding ring ” stone 
is seen in the x-ray photograiih. As the calcitim deposit 
becomes heavier the shadow grows increasingly opaque, 
and finally a dense hlack appearance is presented. The 
inference is clear, I tliink, that not only the solitary stone, 
but the multiple stones, are, as a rule, built around a 
nnclens of cholesterol ciystals deposited from coiicentratcil 
bile. 

The deposition of calcium undoubtedly occurs more 
rapidly upon an impacted stone. When, for example, 
there are a number of cholesterin stones of medium size 
ill the gall bladder, and one becomes wedged in tlio opening 
of the cystic duct, or in a pocket at the fuiidus, calcium 
is soon found upon the surface. When the gall bladder is 
opened such a stone may be wrenched from its lodgement 
only with difSculty, and may tear away a piece of the gall 
bladder as it becomes free. In such conditions the mneosa 
is always destroyed, perhaps by pressure, and the stone 
Is then in contact with a fibrosed inuscnlar coat, an 
adventitious inflammatory coat, or the tissue of a neigh- 
bouring organ (liver, omentum, or intestine) in which it 
is buried. Calcium here, as elsewhere, seems to be de- 
posited as the result of a long-continued irritation. When 
the cholesterin stone is becoming coated by calcium we may 
expect to see changes in the mucosa of the gall bladder, 
inflammation, fibrosis, ulceration, and finally complete 
destruction. We must not, however, be betrayed into 
supposing that these are primary changes which in their 
earlier stages have been responsible for the origin of the 
stones. It°seems quite clear, from the examination of my 
cases, that the changes are induced by the stones, and are 
therefore not primaiy hut consequential. 

There are, however, stones which are differently formed. 
From the first the stone is impenetrably opaque, the shadow 
is quite black, and it is obvious that calcium alone or in 
a very largo proportion is present. Other stones show on 
s-ray examination a tiny speck of blackest calcium, doubt- 
less derived from the liver, snnx>unded by a mass of trans- 


lucent cliolostnrin. An examination of tbo interior of 
tho gall bladder.? from which stones have been removed 
shows that during, tho months oi- years when cliolosteria 
alono IS' fomul in the stonc.s tbo changes in tho mneosa of 
tho gall bladder are sliglit. Tlie membrane may bo 
tliickcnctl, coarsened ; it.s rotioulatiou, at first exaggerated, 
may later bo. rliminisbod or destroyed; ulcers may bo found 
here and there, and papillomata may gi-ow from any part-. 
But tho calcium deposit upon stones shows incrca.so, the 
mneosa is fotmd to have changed and soon to bo completely 
destroyed, perhaps together with tbo snbrancosa, until at 
last nothing remains hut a dense wall of fibrous tissue. No 
trace of elastic or imiscular coat remains. This vaiying 
condition of tbo mucosa scorns in some measure to corre- 
spond to tho change in the blood cholesterol, which seems 
to bo high when tho mucosa is active and low when it is 
lacking or fibrosed. It is interesting to note that when 
foicign material forms tbo nucleus of stones (3 cases with 
copper nucleus and 1 with cotton fibre) the calcium 
content of tbo stones is higher than usual — 1 per cent, 
to 6.4 per cent., compared with 0.1 per cent, in tho 
cholesteiol stones. 

Tho conclusion of tho matter as to tho pathogeny of 
stones in the gall bladder appear.? to bo this: 

Infection reaches, the gall bladder, tbo outer coats as a 
mio being first affected. -As a result the activities of this 
intlo visciis an; at fir-st enhanced; tho lymphatics aro 
engorged and tho activit 3 - of tbo excretory or osmotic 
functions of the mucosa augmented. During tlii.s period 
tbo “ cholesterol flood ” Ls at its highest; increased absorp- 
tion of cholesterol and its transmission to tbo general 
circulation can.se bypcrcbolcsterolacmia. If the lyrniibatics 
in a further stage of inflammation become blocked and tho 
mncosal activity continues, a deposit of lipoid or crystals 
of cholesterol occurs in tlie mncosti, oedema being prevented 
or reduced by moans of the activity of tho capillary circula- 
tion. Tiic condition develops which I first described as 
“a disease of the gall bladder requiring cbolecystcctomy.”r* 
To this disease JIacCarty'‘ later gave tho name " straw- 
berry gall blaihlcr.” It is now generally described as 
“ diolestovosis.” This condition, it is interesting to 
ohsci-vo, never ocenrs unless tho cystic duct is patent and 
bile can freelv enter tbo gall bladder. Tho best description 
of it is given bv Boj-d ; tho “ gjacefnl fragile gossamer folds 
of mucosa avo'complotely altered, being weighted down by 
dense yellow opaque masses much ns a delicate birch tree 
might bo wciglitcd down by a load of snow.” Tho yellow 
material is li)M)id in nature, and displays tho properties of 
an ester of cholesterol. Sections of tho gall bladder often 
shov; long bloated villi filled with this material, and 
pendent only by tbo narrow pedicle. If this pedicle is 
torn tbo villus will soon form the nucleus of a stone, and 
ci-jstals of cholesterol will make baste to envelop it. AVbat 
has happoned in ono villus lias perhaps at the same time 
Jjappeiied m manj*. And so a geneiation of stones is 
fonneil. Cholesterosis may, of couree, bo a primary con- 
dition of the gall-bladder mneosa, a too heavy saturation of 
bile by cholesterin resulting in the deposit of lipoid in tho 
villi. Snell a condition existed among some of tbo 18 cases 
in my series in which tho disease probably began in tha 
mneosa. 

When the stones begin to grow, as they may so rapidly 
do, they begin to be themselves the cause of material 
changes in the gall-bladder wall, by reason of tbo ii-ritation 
tlioy cause or when obstruction of the cystic duct occurs, 
Second.ary ’ changes in the entire thickness of the gall 
bladder then result; the muscular coat and tbo elastic 
coats are fibrosed, and disappear; the outer coats becomo 
thickened, a deposit of fat occurs in the walls, adhesions 
form, and all the changes with which wo are so familiar 
in advanced cases make their appearonco. Concomitantly, 
blood changes in respect of cholesterin and calcinm content 
are observed, Wliilo the mucosa is overactive bj-per- 
cliolestcrolaemia is as a rule found; when tbo mneosa 
is destroyed we may expect to find hypocbolesterolaemia. 

Tho importance of all these considerations, both to tbo 
physician and to the surgeon, is obviously considerable. 
If, on tho one hand, infections of the gall bladder begin 
from within then medical treatment in the early stages 
by tlio methods suggested bj- Lyon, and advanced by Hurst, 


JAN. 7, igaS} 


THE GALE BLALDEU ABD ITS INFECTIONS. 


r Iitt HamsK R 

L MEBICAt JOCBNAJ, ^ 


may iinl on\y bring innncdiato relief but may interrupt 
nn impcncliug and otberwiso inevitable scries of changes, 
leading at last to irremediable conditions, in which tho 
aid of the surgeon would be necessary. It is, in iny judg^ 
inent, not tho least of tho functions of the surgeon^ in 
this ])rosent, and I hope passing, phase of his activities, 
to help tho physician to recognise stages in disease earlier 
than those with wliich posi-tnorfem oxporicnco made us 
familiar; and in .this way to do something to prevent 
disease from drifting until tho surgoon alone can offer help. 
.The business of the surgeon is to diminish surgoiy. 

If, on tho other hand, the gall-bladder infections begin 
fiom without, and aro merely part of an infection which 
sprond.s widely, -involving, first tho liver, then a far wider 
view is nece.ssary, and a multitude of other most relevant 
questions arise. Prevention of tho disease of cholelithiasis 
must then ho sought in a study of changes earlier than 
any with which wo are yet familiar. Tho relief of sym- 
ptoms of tho disease, however, when once established in the 
gall bladder, is hardly to be permanently obtained except 
by its removal, for if the outer coats are involved first, 
Lyon's’ method must, I think, lose mucli of its value. 
Our immediate inquiry must accordingly ho directed not 
only to tho clinical manifestations of early infections of 
the liver and gall bladder and their antecedents, but also 
to a study of early pathological changes in the liver and 
gall bladder, as revealed hy inspection during operation. 
The microseopic, chemical, and bacteriological examination 
of any parts removed must ho correlated with the know- 
ledge so obtained. 

Syjipioiis of Eauly CBonr-cvsTiTis. 

The symptoms which my inquiries indicate as being 
those of cholecystitis in its earlier stage are fiuidamcntally 
those which I described some years ago as the “ inaugural 
symptoms of cholelithiasis.”'* Tlioy are as follows: Plntu- 
.lenco and fullness after meals, amounting sometimes to so 
great distress that a woman takes elf her coi-scts or loosens 
them; great epigastric discomfort which may involve the 
right side also or pierce through to tho hack; early satiety 
during a meal, a fpeling that when a small meal is taken 
the stomach is overfull; a sudden unaccountable sensation 
of intolerable nausea, described very often as “ sea- 
sickness,” sometimes accompanied by faintness and often 
by salivation; a feeling of cold associated with slight 
.shuddering, often coming on with great regularity; acidity 
and “ w.iter-brash.” None of these symptoms is severe 
nnd none striking. It is in association and persistence 
mther than in individual character that their importance 
lies. The complexion of patients is often altered, although 
they do not realize it. After removal of the infected gall 
•bladder a patient will often comment upon an impiwc- 
.mcnt in tlie complexion, and remark that it is “ as it used 
to be many years ago.” Now and again in such patients 
.B more acute disturbance of health is noticed; pain and 
distress in tho upper part of tiie abdomen are associated 
with local tenderness, Avitb swelling of tho liver — whose 
edge becomes more easily palpable — and with a slight 
. increase of tenderness. It is as though tho whole liver 
, wore affected by a slight but transient inflammation. Some 
months or years later an attack of hepatic colic occurs, not 
. with the agony associated with tho passage of a calculus, 
but with a rather more subdued but still sufficiently acuto 
ain which radiates to the right side and presses through 

0 the shoulder. In -an intelligent jjalient these several 
, stops m.ay all, he tr aced. . 

IxnicATioNs Fon Opebatiox. 

The criticisms which may properly ho urged against this 
description are that it is vague and that many of the 
fij-mptoms are of great frequency, occurring even in those 
who consider their health quite satisfactory. I am not 
qmte sure that vagueness, kowever applicable as a qu.alitv 
of any individual symptom, can truthfully be made to airnlV 
to ibeu- conjunctior. It is tho presence of all, or most 
of them, over periods of irooks or months, their consistenev 
ns well as their character, which is significant. As to the 
charge concerning their frequency I would say that iiifec- 
hote of the gall bladder are in truth very common. Indeed 

1 think the statement that of all forms of dyspepsia that 


dependent upon tho gall bladder is tho commonest, is un- 
assailable. AVe use the word “ functional ” in connexion 
with dyspepsia far too easily. If wo look back to the 
great tcacliers of medicine two or three centuries ago — ^and 
it is well worth while to do so — ^we shall see that Trousseau, 
Thomas AVatson, and others described many of the 
dyspepsias wo now know to be dependent upon gross 
organic disease as ” functional.” 

The exact description of the clinical manifestations of 
gastric ulcer, tho recognition of duodenal ulcer in its full 
character nnd frequency, tho discovery of “gall-bladder 
dy.spepsia-," tho deinonstratioii of chronic appendicitis and 
of visceral prolapse as causes of indigestion, have all led 
to a diminution in the number of “functional affections of 
the stomach.” A still further contraction, perhaps the 
greatest of all, will occur when we are able fully and clearly 
to recognize the effect upon tho health for which infections 
of the gall bladder, its antecedents and its consequences, 
arc solely responsible. The uncertainty which may attach 
to tho clinical history is relieved or removed hy tho 
Graham-Colo method of cholecystography. The value of 
this method docs not attach itself so much to the diagnosis 
of cholelithiasis, in which tho proportion of errors is 
abva3’B small, but to tho study of normal phAsiology, and 
of pathological changes in the gall bladder. Dr. Rowdeu 
pointed out to me almost at the beginning of our investi- 
gation of cases, by this method, how likel.v it seemed that 
the negative evidence would prove to be most valuable in 
those cnrlj- cases of gall-bladder disease in which our 
interest was then chiefly engaged. In a few cases dia- 
gnosed as carij’ choicej'stitis either no shadow of the gall 
bladder was seen or perhaps only a faint shadow after a 
long interval. AA'hen an operation was performed wc some- 
times hesitated to remove a gall bladder which showed onU- 
a slight degree of structural change. But its subsequent 
examination, and especially the after-histoiy of the patient, 
showed that cholecystectomy had indeed been necessary. 
It soon became evident that one of the main functions of 
t-he gall bladder, concentration of bile, was checked at a 
time when the externa] appearances of the visous were 
only slightly altered; and fnrther, that in this precocious 
stage the “ inaugural sjTnptoms ” wore clearly elicited. 

If, therefore, “ inaugural symptoms ” are' present, and 
if a cholecystographio shadow is absent, diminished in 
opacity, or delnj'cd in appearance, the integrity of the gall 
bladder may safely- be impugned, and operation for its 
removal ho performed. 

Tho , appearances presented hj; tho earl^- pathological 
gall bladder vary. There is often a lack of the usual 
lustre, the walls, normally deep blue in colour, are a little 
paler, and perhaps a little thinner; there is apt to he 
a deposit of fat, especially towards the pelvis or along 
TCssoIs. Adhesions are present, and the cystic gland is 
, enlarged, while in later stages the wall becomes thickened 
and fibrous in texture. The changed appearance is often 
so slight that reluctance to remove the gall bladder maj- 
iiaturally be felt. But the subsequent examination of tb'o 
wall will convince both pathologist and surgeon that the 
extent of the involvement justifies ablation.. In such 
examinations attention has hitherto been chiefly centred 
I on the mucosa; it is, however, the outer coats which will 
call for the most careful scrutinj-. 

I have no doubt that until we are able elearlv to under- 
I stand and to control the earlier symptoms of cholecystitis 
j. and its foregoing conditions, removal of the gaU bladder 
should be performed more frequently than is now the 
custom. In cases of inveterate mild dyspepsia I have many 
times Iiesitated whether to extirpate a gall bladder which 
did not seem much changed. Xet when I have not removed 
I it I have found sj-mptoms unrelieved, and have been com- 
I pelled to operate again, with great satisfaction to ,mv 
patient. I am happy to find this experience corroborated 
hy one of the shrewdest and sanest of my surgical friends, 
Starr Judd of Eochester.” Advance in this direction must 
be slow and wary, and any case dealt -with should receive 
the -most exhaustive inquiry beforehand, and the parts 
removed — ^the gall bladder and perhaps a tinv, fragment of 
tho liver — should be examined with care and completeness • 
examinations of the blood and bile, in respect at least of 
tho cholesterol content, may be made concniTently. I know 


6 Jan. 7 , 1928 ] 


THE PEEVENTIVE FRA.MB OP MIND IN MIDWIFEBT. 


r Tnr. Hfimw 
L Ukdicai. JoCJlNAti 


no department of medicino which so much requires that 
the physician and the surgeon and all laboratory workers 
should he in league together. 

Note. — This address is based upon an experience of many 
hundreds of cases of cholecystitis operated upon in recent years, 
but more particularly upon a series of 81 cases, in which the 
following examinations were made. Before opci'ation the 
cholesterol and calcium contents of tho blood wcrc^ estimated, 
in many cases a Reyfiiss test meal was given, and in a few a 
duodenal intubation was made. The gall bladders removed were 
first examined by Dr. L. A. Rowden and were then opened; 
cultures of the bUc and of the gall-bladder wall were made; the 
calcium and cholesterol content of the bile was estimated; and 
sections were made of the gall-bladder W'all. In some cases the 
blood was examined for cholesterol at varying periods after the 
operation. 

For this work, and for the advantage of many helpful sueges- 
tions, I am much indebted to Dr. A. L. Taylor, Dr. Eminc 
Knowles, Dr. Aileen Wilson, Dr. Fowwcatlicr, and my research 
chemist, Mr. G* Collinson. 

REFEUEXenS. 

* Aschoff : Wien. TcUn. Woch.^ 1911, xxiv, 559. ^ . 

3 Rosenow : Collected Papers of the Mai/o Clinic, 1916, viii, 222. 

® J. Koch : Zeit. f. Ilyg. w. hifections1:rank., 1909, Ixxii, 1. 

* Chiarolanza : Ibid. ^ • 

^ Winkerdon : Bull. Johns Hopkins Hospital, 1927, xli, 226. 

« Sudler ; Ibid., 1901, xii. 126, 

’ Graham : Archives of Surgery, 1921, ii, 92. • 

* 0. J. Bond : Bamsn Medical JonauAi., 1905, ii» 252. 

5 Lyon : Journ. Amer. Med. Assoc., 1919, IxxiiJ, S80. 

*® Knott : Guy's Hospital Reports, 1923, Ixxiii, 429. 

Judd ; Collected Papers of the Mayo Clinic, 1926, xviii, 256. 

Moynihan : -47inajs of Surgery, 1, 1255. 

*3 MucCarty : Ibid., 1910, li, 651. .. 

Moynihan : British Medical Journal, 1908, ii, 1597. 


THE PBEYENTIVE ERAME OE MIND IN 
MIDWIFERY.'' 

BY 

B. W. JOHNSTONE, C.B.E., M.D., F.B.C.S.Ed,, 

PROFESSOR OF MIDWIFERY AND THE DISEASES OF WOMEN IN rUE 
UNIVERSITY OF EDINBURGII, 


Obstetbics has, I think, always siiffei-ed hy hoing unfairly 
compared with tho two groat sister branches of our practical 
work, medicine and surge^, for thoro is really no proper 
basis of comparison. Medicine and surgery are in practice 
conconied with conditions wiiich are wliolly patliological. 
In so far as they deal with the preservation of the physio- 
logical they come under the heading of preventive medicine. 
Tho functions with which the science and art of obstetrics 
deal partake of both physiological and pathological charac- 
ters. Obstetrics is thus in a somewhat equivocal position,' 
and, as Mahomet’s coffin was believed to he suspended 
between heaven and earth, so it lies midway between the 
heaven of the purely physiological and the lower earth of 
the patliologic.al. On the earthly side we have distinguished 
obstetricians — as, for example. Professor De Lee in America 
— who would have us believe that the function of partuid- 
tion is becoming more and more pathological under tho 
influence of the increasing artificiality of modern life. 
Ouv ovm friend Dr. G. E. Douglas had certainly one foot 
firmly on the earth when he propounded the suggestion that 
possibly there was something inherent in the condition of 
pregnancy which made a woman more prone to death — 
some diminished power of resistance to disease, call it what 
von will, some sacrifice which the individual woman offers 
to the race. On tho other side you have the optimists who 
regard parturition as a purely normal physiological func- 
tion, regardless of the false analogy which such an expres- 
sion implies. As has been pointed out again and again, 
parturition differs from all other physiological functions in 
that it is performed in the interests of tho race, while all 
others are performed in the interests of tho individual 
only. The truth is that tho proper place of obstetrics is 
partly on the earth and partly in the heavens, and our 
business is to keep it as far as possible on the higher 
physiological levels. This, I maintain, can only be done 
by "deliberately adopting and practising a preventive frame 
of mind. 

\Yhen wo come to think of it in rather more detail, tho 
functions of the modern obstetrician are most pronouncedly 

• Being part of the valetlictorv DTesidential address to the Edinburgh 
Obstetrical Society. 


bound up with preventive medicino. I submit that these 
functions may ho summed up as follows: 

1. To watch over Iho hc.'illh of the expectant mother, .md, as 
far as may bo possible, of the unborn cliild during the period of 
utcro-gestation. ' 

2. To foresee conditions calciilalcd to create difficulty or danger 
in childbirth, and to take steps oitlier to remove them if possible, 
or to arrange for tho birth to take place in circumstances m whicli 
tho best obstetric skill may bo available. 

3. To conduct tho delivery so that both mother and child aro 
exposed to the minimum of risk and injury. 

4. To restore the mother to licr ordinary vocation in life with 
liealth and vigour as far as possible unimpaired. 

5. To foster her capacity to nui-sc her child. 

6. To SCO to it that the mother’s reproductive organs return to 
a healthy normal condition fit tor further normal functioning. 

7. To watch over tho health of the infant and thus begin the 
ante-natal care of the succeeding generation. 

Could any programme well ho more preventive than this? 

Tho problem of tho persistent maternal mortality rate 
seems to mo to offer three sides upon which it is susceptible 
to attack and to some degree of remedy. Tho first of these 
is in regard to tho methods of practice, tho second is in 
regard to the conditions of practice, and the third is in 
regard to tho teaching of midwifery. 

The Methods or PnACTicn. 

How does tho general principle of prevention apply to 
tho methods of practice? The first part of tho answer is 

obvious to wit, that the routine and universal practice of 

ante-natal examination and supervision promises an imme- 
diate improvement in maternal mortality. To recall in 
detail tho benefits to ho obtained by ante-natal cave would 
bo to go over ground already familiar. But wh.xt wo have 
to keep in view and to emphasize in our advocacy is that 
tho benefits aro not theoretical or merely possible, but 
certain. To* avert difficulties hy foresight and fore- 
knowledge, or to prepare in advance for unavoidable diffi- 
culties, is hound in tho long run to produce better results 
than follow from trusting to one’s ability to treat un- 
expected complications ’ as and when they arise. Tho 
■general public requires education .on this, point, and I 
earnestly suggest that one of tho duties devolving on each 
member of such a society as ours is to preach tliis gospel 
of ante-niit.al supoiwision amongst tho public until it 
becomes universally understood. That the profession also 
needs to ho educated-' on Ihis point is not so generally 
appreciated,- but. it is a fact. In one sense ante-natal care 
is nothing now, but in another sense— in the sense .if the 
' general routine exercise of such supervision— it is a new 
doctrine to tho great majority of present-day practitioners. 
It is only graduates of tiio last dozen years or so who have 
had the doctrine hammered into them as students. To all 
tho older practitioners the teaching that such supervision 
is an integral part of the obstetrician’s duty is new, and it 
i.s always a difficult thing to arrest tho attention of tho 
profession to new teaching except it be accompanied by 
some striking discovery — such as, for example, insulin. 
I am speaking of what I know when I say that our young 
graduates are sometimes actually discouraged iii their 
&orts to practise ante-natal supervision by seniors who 
are not alivo "to its importance. 

The methods of ante-natal supervision aro simple. A very 
little practice will produce a reasonable degree of skill in 
estimating tho relative sizes of tho head and the pelvis, 
and in other respects the ante-natal examination is along 
ordinary medical lines. Another great point is that the 
means to carry out this principle are already to hand. 
Financial assistance is offered by the Government to ejery 
municipality which starts an ante-natal centi e. But it is 
not enough to establish centres. Tlio women must he got 
to go to the centres. Our experience in Edinburgh certainly 
encourages us to believe that, if the centres are established 
and well run, tho patients will be forthcoming in increasing 
numbers. Furthermore, the practice must bo adopted in 
private by the profession throughout the whole country; 
the rural districts are the most difficult in this respect. 
■When this is done we shall bo making a gallant effort, and 
infallibly a fruitful effort, to attack our problem. At 
present in Scotland not more than 9 per cent, of the 




Jan. 7, 1928] 


THE PKEVENTIVE ERAME OF HIND IN HIDWIFERT.' 


r The BRrnsn 
I Medicai. JoCItNA^ 


7 


inotherB attend the ante-natal centres. I venture to think 
that if wo could convert that 9 into 00 or, hotter still, into 
99, we should have in largo nieasuro solved our problem. 

Another avenuo along which the problem may bo attacked 
on the side of the methods of practice is the improvement 
of iutra-natal care. Hero the general principle of pre- 
vention again makes itself manifest in a way which would 
appear, if wo are to judge by' results, to bo not fully appre- 
hended. It is simply that, in the absence of complications, 
a natural unassisted labour is always more favourable to 
both mother and child than an instrumental one. There ia 
no shadow of doubt in my mind that if this wore hold aa 
a guiding principle in the obstetric practice of the country 
the maternal and foetal mortality would bo very markedly 
diminished. That the forceps, used under proper indica- 
tions, is an invaluable instrument is a truism, but will 
anyone deny that it is employed many times where proper 
obstetric indications are wanting? This is a point upon 
which I submit that the specialist is more able to pronounce 
an opinion than the general practitioner. Only those who 
have experience of maternity hospital work can fully appre- 
ciate the horrors of the “ failed forceps case," and only the 
gynaecologist realizes how many of his hospital beds are 
occupied with the so-called " successful ” instrumental cases 
of five, ten, or even twenty years ago. 

In this matter we can see very clearly the effect which 
certain discoveries have had upon midwifery. The work of 
Simpson and of Lister conferred upon the obstetrician a 
much greater liberty of action than ho had previously dared 
to exercise. Immediately thereafter the further improve- 
ments in the axis-traction forceps gave a decided impetus 
to the employment of that instrument^ and to instrumental 
obstetrics generally. Doctors and patients alike found that 
labour could be shortened by the use of instruments, and 
they appreciated this apparent advantage before the loss 
obvious and more remote disadvantages obtruded them- 
selves upon the professional consciousness. As matters 
stand ■to-day, the public, as well as the profession,' have to 
be re-educated to the much greater safetj-, both inunediate 
and remote, of a natural non-instrumental labour — always, 
of course, provided that real obstetrical indications for the 
forceps or other operation arc absent. Until this re-educa- 
tion is accomplished our younger graduates will receive 
discouragement in this respect mainly from their patients. 
The young doctor who, acting up to the teaching which he 
has received at his medical school, gives Nature the pro- 
longed time which she often requires to accomplish the 
descent and rotation of the head in an occipito-posterior 
position, or the moulding of the head through a slightly con- 
tracted pelvic brim, runs the risk of being most unfavour- 
ably compared by his patients and their friends with other 
neighbouring practitioners, who are prompt to interfere 
even, it may be, at the cost of a stillbirth. The 'pendulum 
has swung too far in the direction of instrumental inter- 
ference, and wo must try to bring it back to the greater 
safet}- of the middle line. 


Now, putting aside complications such as ante-partum 
haemorrhage, which in the present state of our knowledge 
must still be labelled as largely unpreventable, and also the 
minor complications which form the proper obstetrical 
indications for forceps delivery, the fact again obtrudes 
itself that ante-natal examination enables us to divide our 
cases in advance into those in which labour is likely to 
be normal and those in which some form of dystocia may 
bo anticipated. That being admitted, all I am really urging 
15 that the cases in the first gronp should be allowed to 
remain normal. A simple application of our preventive 
profoXindly far-reaching in its results, 
fills brings me to the next point. It has been shown 
more than once that the maternal mortality is less in the 
practice of competent midwives than in the hands of general 
practitioners. Granted that the figures adduced in support 
of this claim can be challenged on some points of detail 
and admitting that the nurses’ figures deal with cases in 
the main uncomplicated, yet the comparison is very striking 
n hen one considers that, so far as normal cases are con- 
cerned the main difference between midwives and doctors is 
that the former cannot interfere instrumentally with the 
natural course of labour. Septic infection is easilv the 


greatest cause of maternal mortality, and equally tho 
greatest risk associated with instrumental interference, and 
it soems obv'ious that, as has been laboriously demonstrated 
by Geddes and others, tho doctor engaged in general iirac- 
tico, especially in industrial areas, is in this respect a 
potentially greater danger to tho parturient woman than 
a trained, competent, and properly siipeiwised midwife 
whoso practice does not bring her into frequent contact with 
virulent organisms. 

Experience in some large practices and considerations 
such as we have been discussing suggest that no slight 
advantage might follow tho adoption of tho plan of handing 
ovor a largor proportion of normal cases to the care of 
carefully chosen competent midwives. An essential condi- 
tion of this would bo that evei'j' pregnant woman should see 
a doctor at least once or more during her pregnancy, and 
should receive adequate aiite-natal examination and super- 
vision, ns well as a subsequent post-natal examination. The 
separation of those in whom conditions aro perfectly normal 
throughout pregnancy, and in whom labour may be expected 
to be normal, from those in whom there are existing com- 
plications or conditions likely to lead to difficulty in labour, 
can and ought to be made onlj' by a qualified medical practi- 
tioner. But with this proviso the plan offers certain advan- 
tages. It would avoid tho ever-pi eseiit temptation, to which 
medical men and women aro exjxiscd, of hurrying a delivci-y 
because of other calls upon their time, and would thereby 
secure a considerablj’ larger number of normal spontaneous 
deliveries. In the second place, it would, if our reasoning 
is correct, lead to a diminution in sepsis through the diminu- 
tion in instrumental interference. In the third place, it 
would relieve tho medical practitioner of a great deal of 
work that is often irksome and harassing, as well as 
physically exhausting, and would give him more time and 
leisure to study and to interest himself in the cases which 
present pathological features. 

When we come to consider how best to deal with the 
second group of cases, in which difficulty is to be antici- 
pated, we find ourselves facing one of the complexities 
of any such remedial schemes. Logically and, I believe, 
actually, complicated cases occurring in general practice 
can be much better dealt with if the patient is placed 
either in a maternity hospital or in a nursing home whore 
the conditions are suitable for operative intei-vention. This 
brings us at once to the all-important point that an increase 
in the provision of maternity hospital accommodation is 
an urgent necessity throughout the whole countr 3 -. But, 
if pressed to a logical conclusion, this plan would in main' 
cases mean that the family doctor would have almost no 
midwifery to do. Many doctors would be greatly relieved 
at sucli an outcome, but others who aro interested in 
midwifeiy would feel aggrieved. This is one of the points 
which require careful consideration, but in considering 
it let us not lose sight of the big general principle that 
complicated obstetric cases are in the same categoiy ns 
surgical operations, and obstetric operations are no more 
suited for performance in the average conditions of general 
practice than are such surgical operations. "U'herc cir- 
cumstances permit the family doctor to do his own surgerv, 
then presumably they would also allow of his doing his own 
difficult midwifery, but where either the inclinations, skill, 
and experience of the doctor, or the conditions in whicli 
he practises, are adverse to his undertaking surgery, then 
my contention is that thej’ should be accepted as equally 
adverse to his undertaking difficult midwifery. 

Another proposal, which has received support from Pro- 
fessor Munro Kerr among others, involves again the estab- 
lishment of maternit\' hospitals in all large centres of 
population, and maternity departments in existing hospitals 
ill smaller centres, and also the establishment of an official 
maternity service ramifjing from these centres over the 
whole country. From the point of view of obstetrics alone 
this is merely a further and more complete develojimcnt of 
the plan which we have been considering. The maternity 
service would exercise practical supervision over all mater- 
nity nurses and midwives, and the scheme would include 
sweeping as many as possible of cases, both normal and 
abnormal, into hospitals. It would involve the appoint- 
ment of obstetric specialists in an increased number who. 


• -8 Jan. 7, 1928I 


■THE - PREVENTIVE- EEAilE.-OE MIND. IN .MIDWIFERY. 


t TitK Bnmm 
MkMCAL JOL'K^U* 


in tho larger centres, might well he whole-time salaried 
specialists, while in the smaller centres such work would 
naturally devolve upon doctoi's engaged in other practice 
as well. Such part-time appointments would of themselves 
constitute a formidable difficulty in the harmonious work- 
ing of such a scheme, and, however logical, admirable, 
and desirable it may be, the plan would, in my view, lead 
directly to obstetrics becoming wholly a specialty. I am 
not at all clear that this is a desirable solution, and 
I should personally regard with considerable reluctance any 
scheme which would deprive the doctor, who has a natural 
interest in obstetrics, of the opportunity of midwifery 
•practice unless ho was prepared to specialize wholly in 
obstetrics. Such a separation of obstetrics from the 
practice of medicine and surger3’ would, I think, tend 
still further to degrade the status of tho familj' doctor 
in the ej'es of the public, and, as Dr. Douglas has 
so ably shown in his recent Alexander Black Memorial 
.Lecture,* this is a very real danger. I would suggest that 
an adequate provision of maternity hospitals or maternity 
departments in cottage hospitals, where familj’ doctors 
who wish to attend their own obstetric cases could do so 
under aseptic conditions conducive to the safety of tho 
, patients, provides a possible and suitable compromise; 
and there can be no doubt that tho provision of more 
hospital accommodation and the general encouragement 
of women to enter hospitals for their confinements — 
although, in tho case of small local hospitals, not neces- 
sarily to irlaco themselves in tho hands of specialists — 
would tend to raise tho standard of midwifery among tho 
piofession generally. 

The first scheme — of encouraging tho handing over of 
normal cases in large numbers to tho midwife, with the 
doctor exercising a general supervision and available at 
need — seems pi-acticable, always provided it is associated 
witli regular routine ante-natal and post-natal examina- 
tion by the doctor. In a sense it is a reversal of tho 
great struggle which the profession waged and won in tho 
eighteenth century to remove midwifery practice from the 
control of the midwife. But the diffeience between the 
trained midwife of to-day, practising under the super- 
vision of tho doctor and the legal control of an active 
Central Midwives Board, and tho ignorant, untrained, 
and uncontrolled handywoman of tlio. earlier century, is so 
vast that I do not think such an apparent reversal of the 
evolution aiy process would necessarily bo a retrogression. 
All complicated cases would still come under the care of 
the medical practitioner, either outside or inside hospital, 
and in this way tho profession, with, I am quite sure, 
tlio weight of an enlightened public opinion and tho 
authority of tho State behind it, would continue to hold 
complete control of the whole position. 

These, then, seem to me to be two avenues opening 
before us, and along one or other of them, perchanco in 
some measure along both, the future practice of midwifery 
is, I think, bound to develop, if we are going to make any 
serious effort to improve conditions. I do not think that 
either line of advance is wholly devoid of difficulties and 
clisadvantages, and I do not wish to appear to be advocating 
either to the exclusion of the other. All I want to do 
is to lay the matter before the profession in the hope 
that it will give earnest consideration to it. We cannot 
afford to stand still, nor can we afford to advance blindly. 
AVe must consider the ground carefully from eveiy point 
of view, and then advance along the line which promises 
best. 

The Conditions of Piuctice. ' 

The second side upon which the problem of maternal 
mortalitj- is susceptible of improvement is in the conditions 
of practice. This is mainly a matter for legislative and 
administrative action, but the medical profession outside 
the official medical services must exercise effort to secure 
such action, and be prepared to offer skilled and experienced 
judgement to mould and guide it. As already said, the 
public must bo made to realize thdt for the safety of 
the mother a confinement demands conditions comparable 
onW with those which it is accustomed to associate 

■ Sec Bmiisa Mmiau. Joorxw. June 18lh, 1927, p. 1121 


with a surgical operation. , Nothing has .done more in 
recent j’ears to educate tho public on this point than 
tho economic and domestic conditions during and after 
-the war, which made niatornitj’ nursing homes in many 
cases a necessity. Even from this educational point' of 
view alone wo do well, I think, to encourage patients to 
enter such homes. It is an interesting fact that maternal 
mortality is not necessarilj’ or always at its highest in tho 
poorest slums. The unfortunate denizens of those areas 
seem to bo protected bj’ Providence bj’ a process of 
immunization through constant contact with dirt. But 
that docs not alter the glcat princqjle' involved.' To my 
mind by far tho best solution of this problem is to provide 
tho noecssarj’ increase in maternity hospital accommodation, 
and tlicn to encourage, or if need be seek powei's to 
compel, everj" woman in such slum areas to go into a 
Ij'ing-in hospital for her confinement. If experience proves 
that it is not enough. — to ada])t in all rcvcrenco tho words 
of tho parable recorded b^- the Good Phj-sician — “ to go into 
tho streets and lanes of the city and bring in the poor,” 
then wo must go further, as the Lord in tho parable did, 
and ” send out into the highways and hedges and compel 
them to come in.” 

In tho next place there is the economic factor, as it 
touches tho medical profession. Tho profession is not an 
organized sj’stom of phihinthropj', and, despite the fact 
that our work affords us more opportunities of helping 
our fellows than fall to the lot of other professions — oppor- 
tunities which one is jjroud to think are usually grasped — 
j'ot wo have our full share of human failings. It is futile 
to expect in medicine, any more than in mining, that 
pooi'lj’ paid work will bo done as well as well paid woilc. 
Midwifery in industrial-class practice is not adequately 
paid, and we cannot hope to raise tlio standard of obstefrio 
practice very much unless tho public, individually or 
collectively through tho State, is prepared to pay for it. 
This is an unpalatable statement to make, and it is usually 
for that reason neglected, but I believe it to be a funda- 
mental truth of great importance in this connexion, and 
I am certain that it is an aspect of our problem that must 
bo considered and remedied. 

There arc many other points on which I might touch in 
connexion with the conditions of practice, but I will con- 
clude by saying that a general proposition to keep in view 
here is that we must welcome and not resent tho co-opera- 
tion of the official and administrative section of the pro- 
fession in theso matters,, AVithqut their help we cannot 
press home the attack along this line. 

The TE.4cniNq of Obsietiiics. 

- This forms the third line of attack on our problem, and 
I will dqal with it very brieflj;. If the general practitioner 
has been criticized in the discussions which have been pro- 
ceeding in a more or less desultory way upon our main 
topic, tho teacher of obstetrics has, of a truth, not escaped 
censure. I think and hope that wo have not made tho 
mistake of confusing criticism for abuse, but have, takeii 
tho censure' in the right spirit and have tried to apply it; 
Personally I have yet to meet the teacher of obstetrics who 
is satisfied with tho present position. The main weakness, 
and tho, only one of which I propose to speak, lies in the 
limited opportunities available to. tho student for gaining 
practical clinical experience before he embarks on practice. 
The cause of this lies partly in the number of subjects 
which require to bo cranimod into a curriculum to which 
economic conditions put, in general, a time limit; partly 
in tho fact that most teaching hospitals are engaged in 
training nurses as well as medical students, and a difficulty 
arises in making adequate provision for both. The obvious 
solution is the increase of the number of maternity beds 
available for teaching — a consummation towards which, j'ou 
will observe, we come by all three lines of approach to our 
main problem. But until this consummation is achieved, 
and even afterwards, more stress should, I think, be placed 
upon what has been described as “an obstetric atmo- 
sphere.” The naturally , erratic incidence of deliveries in 
any maternity hospital removes the clinical teaching cf 
practical obstetrics from any vei-y fair or helpf'ul cc:.’.- 
parison with tho teaching of clinical surgery or clinical 




PREONANCT AND MENTAL f)ISEASB. _ [ 9 


Jan. 7, 1928] 


mctliciuo. Tiio main place foi* clinical olistctvic tiainiug 
must be tbo iabonv ward, supplciueuied by tlio ante-natal 
department and tlic puerperal wards. To obtain the full 
advantage of bis time and study tbo student ought to bo • 
free to devote Ips wliolo days, and as mneb as need be of bis 
nigbts, to clinical midwifery along with clinical gynaeco- 
logv. He ought to reside in tbo maternity bos\ntal, so that 
biT may indeed “ live, move, and have bis being ” in an 
obstetric atmospliore. I entirely agree witli Dr, Fairbairn’s j 
recent reinarlrs at Glasgow us to the .supreme educative 
advantage thus obtained. 1 ain glad to say that in Edin- 
buigb wo have advanced towards this ideal as far as our 
present fnadequato maternity hospital ]irovision and* our 
. present curriculum permit. But 1 take this opportunity 
to point out that, if tbo great new obstetric and gynaeco- 
logical department in tbo Royal Infirmary, to which wc are 
' all looking forward, is to jirovo the gain which it ought to 
be, ample provision for students to reside in it is a sine 
qva non. Eurtbernioro, tbo curriculum must bo altered, 
'i’iic conditions of practice at present arc such that a newly 
Hedged graduate is much more likely to be called Upon to 
attend a complicated obstetric case than to perform a major, 
surgical operation, and public opinion expects, though to 
my mind quite unreasonably, that he will be fully equal to 
any obstetric omergoncy. Yot tbo time allotted to the vital 
study of clinical midwifery is approximately only one- 
tliird of that given to clinical surgery, and is practically 
the same as that allotted to venereal diseases, to tuber- 
culosis, to diseases of tbo oyo, or of tbo ear, noso, and 
throat, or even of tbo skin. Opportunities to alter tho 
curriculum are few and far between ; when tho next ono 
will occur I cannot forecast — they are generally preceded 
by volcanic rumblings in tho General Medical Council, and 
of such I hoar nothing at tho moment. Meantime we must 
wait, like tho man at tho pool of Dethosda, ready to seize 
tho chance of tho troubling of tho waters and press for 
tho remedying of this source of weakness. 


•' Conclusion. 

May I, in conclusion, summarize what I liave been 
cndoavouriiig to lay before you? My first point is that the 
whole position requires to bo considered in broad outline 
and freed from quo.stioiis of detail in treatment, wbicli 
often oiilv tend to obscure the big general outline of tho 
situation. My second point is the need to apprehend fully 
the newer doctrine of tho essentially preventive nature 
I of inidivifciy practice. Tin's embraces in the first place 
the doctrine of ante-natal examination and supervision; 
secondly, the supremo advantages of obtaining a natural 
labour wberever possible. As a corollary to tbis tbere is 
tho urgent necessity of increasing maternity hospital 
accommodation for comjilicated cases and for women whose 
houses arc unsuitable for even a normal delivery. In the 
third place, the consideration of midwifery from this 
preventive standpoint stresses the necessity of carrying out 
adequate post-natal caro of tho mother and the linking up 
of the Work of the obstetrician with that of the pediatrician 
so that tho child’s life may ho protected. The intimate 
relation of tho work of venereal clinics with maternity 
work in this connexion needs only to bo mentioned. In 
tbo next place there is an admitted need for fnllor clinical 
teaching of medical students. Lastly I would repeat that 
if wo aro to make any real advance in regard to conditions 
of practice wo must bo prepared to welcome the assistance 
pt the official administrative section of the profession. 
Without their help we shall bo unable to move in these 
matters as we ought to do, and we must be prepared to 
giro them tho advice and guidance of our experience in the 
matter. If I may borrow a sporting metaphor, I would saj' 
that those of us who are engaged in tlie active practice of 
midwifery, and who are, so to speak, in the front line, 
must use our heads as well as our weight in the scrummage, 
and heel the ball out so that the executive back line may 
bo enabled to carry it forw.ird to the goal towards which we 
I aro all striving. 


IJ5DUCTI0N OF PREMATtJEE LABOUR IN 
RELATION TO iMENTAL DISEASE. 

OT 

R. PERCY SMITH, M.D., E.R.C.P., 

COXSUITIXG PUVSICUN, ST. THOMAS’S HOSPITAL, LOHDOS. 

At tho Annual Meeting of the British Medical Association 
at Nottingham in 1S26 a discussion took place on tho 
indications and methods for termination of pregnancy 
before tho viability of tho child. Tho discussion, which 
was opened by Dr. T. IV. Eden, is fully reported in the 
JonixAL of August 7th, 1926 (p. 237).' There is also a 
report in the Jouhnal of January 29th, 1927, of a Joint 
meeting of the Medico-Legal Society and the Section of 
Obstetrics and Gynaecology of the Royal Society of 
Medicine, held on January 21st, to consider the medico- 
legal and ethical aspects of abortion; this discussion was 
opened by Dr. Pairbairn. 

In the course of the last twenty-seven years I have been 
consulted in a certain number of cases in whieli tile ques- 
tion of terminating a pregnancy has arisen in connexion 
irith mental disorder. . I think it will be of interest to 
set out these cases in two groiqis: I, cases in which the 
pregnancy was allowed to continue; II, cases in which the 
pregnancy was terminated before viability of tbo child. 
I have given the cases in considerable detail from mv 
case-books. •’ 


I. Cases in which the Pregnancy teas -Allowed to 
' Continue. 

1?'=° July 1900, with Dr. La vies. 

“nervous” and depressed; sist, 

trouble and strain from illness 
njen T.' ** Hystcrwu} ” tljo day before marr{ap 4 

la? ® ““iJent six w/eks after A cS 

In Ortobe“ isfl ’hid A'A. not nurse chil 

{j.-v j miscarriage. In the winter of 1890 b 

K P'‘'ebifis for throe months; she reS 

pt ’’V” “uch run down. ®'‘ 

esent At fact.— In July, 1900, she was. sleepless and excit 


and gradually developed acute mania. She remained at home vrith 
nurses. On August 12th Dr. Lavics reported a suspicion of 
pregnancy, os she had missed one menstrual period. After a short 
improvement she became much ^vo^se and had to be certified. 
Slio was placed under care at The Priory. In November her 
physical condition had much improved; catamenia still absent and 
so there was a strong suspicion of pregnancy, although, of course, 
cessation of periods is a common s 3 ’mptom in such acute cases. 
In January, 1901, she was still maniacal, but there was no doubt 
as to pregnancy. In April she was advanced in pregnancy, was 
still incoherent and jocular, but was not so excited. 

Sho gave birth to a child on April 9th, while still under care. 
There were no bad symptoms. By August she l)ad steadily 
improved mentally, and in September was quite recovered. 

In this case there were no indications that tho patient’s 
life or recovery was endangered by' the pregnancy, and it 
was left to run a normal course. 

! • Case 2. 

Mrs. B., aged 30; seen December 4th, 1909, in consultation with 
Dr. I*. D. S. Jackson and Dr, (now Sir) M. Craig. 

Family History . — Sister committed suicide. 

Previous History . — Had been married five or six years and had 
had two miscarriages. Had been living apart from her husband for 
i two years, and he was not supporting her, but occasionalfy visited 
I her. Two years before had had right salpingitis ; no operation 
was done. Recently her sister had shot herself just after 
returning from America with -the patient. This was a great 
I upset to her; she was very depressed, said she had nothing to 
Jn'e for, told her doctor she was going to shoot herself, and also 

I that her husband had forced his way into her fiat and had over- 

1 powered her, and that she wps in the family way. She was 

sleeping badly, constantly imagined she saw the future child with 
a wound on its head, the same as she had seen in her sister’s 
forehead. When seen by an obstetric physician, who thought she 
was pregnant, she said, “That decides it.’* She was cr 3 ’ing all 
day and sleeping verj' little; said she w'ould end it and would 
not have the child; could not bear it, and could not go through 
with it. She refused to have her relatives or her husband told. 
The question of premature labour was raised. 

On examination she was agitated and depressed, said sho would 
be an “absolute ass” to live under the circumstances; felt 

certain her child would be marked by a wound; declared that 

her husband, who had not seen her before for two years, “forcible' 
overcame ** her about two months ago. Said if she had a child 
her husband would never leave her alone, as he generally did 
^Vondered wbv’ she had not already committed suicide* thouo’Jit 
herself a sentimental fool not to have done it because of her 
brother and sister. She could not go on with her work 
(journalism). She spoke of having been to a woman for abortion 
but notliing had been done. , » 







Jan. 7, 192S] 


PREGNANCY AND MENTAD DISEASE. 


[ 


TtreBittrisS 
‘Medicaz. Jocbhal 


11 


and bUo \vj\s in uo way dnngoi-ous to herself or others. 
Eventually she was dolivorccl of n stillhorn child at full 
term. 

Case 7 .' — Tbero Ecemod to bo no juBtirmblo reason, 
physically or rnontally, for toriuinating tho pregnancy. 
There was no doubt that “ res angusta domi ” had somo 
Influence in tho dcsiro for nboition, and this could 3iot bo 
held sufficient reason for it. 


II . — Cases in which Pregnancy was Terminated, 

Case 1. 

Atrs. G., aged 30: 'seen November 17Ui, 1903, with Pr. WothcrccL 
Tam'iJj/ History . — Mother insnucu one child idiotic, 

Prcriotis /fiAfory.— Tlirco and a half years ago, and heforo the 
birtli of the fifth child, she had become dcprcsscfd and appre- 
hensive that Iho diild would bo on idiot- Uhfc the other; idler iU 
birtli she was depressed and then excited, ^jo recovered^ but 
was inclined to depression and irritability since at each period. 

Present Attack . — Three weeks previously the period did not 
cemc ou, and before this she was excited and threatened to cut 
her throat. Her mother had broken down and had gone to an 
asylum about two months before, and patient bad visited her 
there and was much upset, and crying. On November 13th she 
tried to get a raxor and to burn her^erf at a gas iirCj .and rushed 
to the dining room to get a knife. On -examination she was : 
depressed, saying that she ** could not face it,” that one child 1 
was imbecile,^ that she could not live if she were pregnant, and I 
threatened suicide. She was also upset about her motlicr’s insanity. | 
In this ease it was evident that if pregnanc>' continued lier -life ! 
would he lu danger from -suicide, and accordingly the pregnancy 1 
was terminated and a two montiis* foetus removed. She made 1 
a good recovery. ' 

Case 2. 

Mrs. H., aged AG; *;ecn May 3lst, 1905, with Pr. Howard Tooth 
and Pr. IValtcr Griffith. 

Previous itfrstory.— The patient and her husband had postponed 
inaiTiage for sorne years, hoping tliat the time would pass adicn 
she might become pregnant, and married hoping she would not 
have cnildren. Two years before she had boon ralhor “queer” 
after infliienra. Had always dreaded pi-egiiancy ” because of the 
^cs an her hand.'* A friend had become insane, and the patient 
dreaded the same in her own case. She married iu December, IbOA, 
and when seen was four months pregnant. Slie had been vomiting, 
and when told she was pregnant said she could not go on -with it. 
She became “ quite uncoalrollable,” constantly speaking about 
the friend’s insanity and dreading the same result. 

When seen she was lying with her eyes sliut clutching at- the 
bcdciothes, wnplainin^ of a creeping sensation in her liead, and 
as if her brain were balanced on a small area and very little would 
^set it. Thinks siie will become imbecile if she has a child. 
Poes not want to hve, but docs not threaten suicide. Later -she 
had three con^nilsivc attacks and hysterical paraplegia. She 
became more depressed and confused, and in view of the physical 
and mental condition it was decided lo termimts tlie pregnancy. 
Slic afterwards recovered. 


Case 3. 

Mrs. I., aged 2i, -first seen April 9Ui, 1908, with Dr. K. J 
v^ aiker- 

Family Ilisforj /, — Brother alcoholic and delirious. 

Previous History . — Always rather unstable. Her first child wa; 
horn ou Maiyh IStli, 1908. During the whole of the pregnancy 
she liad vomiting after every meal and bad constipatjon. Lal>{ 7 ul 
was easy. Had much pain m the breasts, and bo breast feeding 
She began to be sleepless, depressed, a«.< 
BUiciaal, and passed ilirough an attack of puerperal melancholia 
from which she recovered. 

After the former attack she became pregnant again jn 1909 
and premature labour had been induced. A year before she Jiac 
measles, followed by an attack of melancholia which passed off 
I^^*ember 1st, 1911, in consultation with Pr. Bnrke] 
and X»r. Hey. She was now two months pregnant, and sulferec 
trom constant veiling “night and day” associated with errea 
depression and sleeplessness. The vomiting was said to be wors( 
nian m the first prc^ancy; she prays to 'God to take her. am 
hopes she will n^ Uve; dreads breaking down nud beine xtn 
undei* care. Pr. How had been consulted about terminating thi 
pregnancy. In view of former attacl^ of depression and t'n 
return of vomiting, and the probability that more severe menta 
disorder was likely to follow if the present pregnancy wen 


January Tsth. 1911, rvitli Dr. Mackintosh 
•?'*p'”3;'-~ra-ther had melancholia and -shot himsel 
MoUier died of chronic alcoholism. niiusei 

find been married four and a half vean 

a‘ ' 1 rliildren, a boy aged 3t years and a girl lOJ months Tl 
[La ■"’5" she nursed the child fm Three -Week 

ttea bcraino depre^ed and suicidal, but recovered. The secon 

f"*' mmitbs bift recovCTO 

Had only been back at home since- August. recoverei 

Dr confirmed .1 

1 ,; b-rimth.^ fatient mucli upset at the idea of being nre-man 

a^;n “od u-as agitated. Dreads brelkring^ou 

^am -u ith depression, and feels certain it -will occur and ^hat - 
wiU he worse this tune. Has lost 9 lb. in -n-eight. 


Ill view of the previous attaclcs it seemed justifiablo to tcrirrinatc 
the pregnancy, wJiich was done. Pr. GrifTitli removed ihe uterus 
and contents. 

Case 5. 

Mrs. K., aged K; seen in consultation with Pr. (Sir M.) Craig, 
Fehrunrj' 10(h, 1911. 

Preriovs (History . — Manned nt 18. Was ignorant about marriage, 
niid from tho first ” loathed ” it and began to dislike her husband. 
Ono child born in 1908. During that pregnancy had block of left 
uTctcT and was under Pr. NViWiamson and Mv. Pavdoc. Labour 
ums induced nt ihe eighth month. Had albuminuria for months 
after confinoraent. Was physically run down and had periods of 
depression, nnd took a dislike to the child. In^ 1909 she had 
delusions and thought imps nnd devils were sitting round -her-; 
contemplated siucidc, and in the autumn of 1910 made an attempt 
with drugs. She recovered. 

Present Illness . — Became pregnant again two and a half months 
ago. Began to sleep badly and to have ^'ten'ors ”; dreaded the 
pregnancy and threatened suicide; loathed tho idea that there 
^vas Bomething inside her, ■** put -there by someone she haled.'* 
Said she \^s going lo perdition and would nc^'e^ recover; that 
sho was going to ‘‘make her bow and depart,” and that it would 
bo kinder to her husband and everyone else. She dreaded a 
return of the "kidney trouble. Considering her former attack of 
depression, tho kidney trouble, and the present recurrence of 
depression, the opinion was given that the uterus should he 
emptied. 


Case 6. 

Mrs. L., aged 25-; seen January 21st, 191A, in consultation with 
Dr, Chambers and Dr. Comjms Berkeley. 

Fnmily Hfxtorj/.— Father died of some malignant disease; no 
insanity in family. 

1 ‘rcrifms /fisfoT^. — ^Had had two children; tho hvst died aged 2 ^; 
a second child was living aged 1^. Tlie confinements were normal 
and no mental .disorder followed. The first child had died of 
tuberculous meningitis. After the second confinement the patient 
had an abscess in Uie armpit, follow’ed by a succession of abscesses. 
She was seen by Mr. Watson Chevne, and had vaccine treatment. 
She was ill altogether nine months, was much pulfed down, and 
made up her mind she would never have another child. 

Present Condition . — Pregnant two months. Dr. Comyns Berkeley 
did not feel justified in advising termination. In November sho 
had become pregnant, 'and at once became depressed and spoke 
ot suicide, oat all day silent and gloomy, and took little food 
and had little sleep; ftut convinced the child would not be normal; 
said sho did not care what happened In her. 

The opinion was given that if the pregnancy _ continued 5 -hc 
would have a bad mental attack and might commit suicide. The 
pregnancy was terminated and she recovered. 


Case 7. 

Mrs. M., aged 33; seen November 19Ui, 1918, \vith Dr. Stevens. 

Family History . — Four members of her family, includii^ one 
brother, have been insane and three others “nervous.” \Vas a 
Kusslan, and the family Iiad been xmhed by the revolution. 

Prerious History . — She was musical and artistic, and had -dabbled 
with Rosicrucianism and “ magic.” She mavried in November, 
1917; her husband was a widower, aged 46, and was in the navy. 

7 *rc 5 cnt Condition . — -Pregnant two or three months; she dreads 
having n child and wants to commit suicide; feels incapable of 
having -a child ; thinks it is too like an animal or -a frog ; vomits 
when slie thinks about it; feels like a doomed thing and like a 
prisoner who will die, that this is her end, and that she is between 
life and death. 

It was agreed that continuance of the pregnancy would even- 
tuate in a severe attack of melancholia, and that she might commit 
suicide. The pregnancy was terminated. 

■Case 6. 

Mrs. K., a Swede, aged 30; seen February lAth, 1921, with Dr. 
Wyatt. 

Previous HisferTt/.— Has three children, eldest 4^, youngest 1^. 
Last -child horn Ocloher, 1919; after confinement had puerperal 
sepsis. The uterus was scraped >out and she recovered, but al 
Christmas, 1919, had rheumatic fever, after which she became 
depressed, was taken to Sweden, and there passed tlu'DUgh .a bad 
confuslonal attack which had left a blank in her memory. -8110 
returned to England in September, 1920, apparently recovered, but 
was weak and imable to manage her house. In Januaiy, 1921, 
was depressed, but found to be pregnant again. Was jsaid to have 
been for three .weefe “ very ill in her mind,” spoke of going 
awav and never coming back", was irritable and restless and sleep- 
ing badly, .and .sometimes desiring to .commit ^cide. 

Present Condition . — She complained of being “ nervous “ and 
depressed, dreaded another attack, recognized . that in 1920 her 
“ mind was quite away *’ and she had been in a mental home in 
Sweden; %vas emotional and weeping. It was agreed that there 
was great xisk of another mental illness if pregnancy was con- 
tinued, and it was terminated. 

Case 9. 

Mrs. 0., aged 30; -seen June 18th, 1921, with Dr. Bevan. 

Family History.— lister broke down mentally after -h-\-^terectomy 
and eari 3 ’ menopause. ' " . * ^ 

Prerious //tsfori/,— -Ha^had three children; was quite •u'cll-afler 

after 
five 
was 
by a 


uie Dircu 01 me ursr. xue sccona emm was bom in 1916 ' ; 
which there was an attack of melancholia lastin" four or 
months. .The third child was bom in January, 1§19' -there 
much haemorrhage and (?) inversion of the uterus {olloKcd 


12 Jan. 7 , 1928 ] 


r Tnz Unmm 
t Medical JoovjriA • 


TREATMENT OF “TENNIS ELBOW." 


second attack of mental depression associated 'with lactation. Tho 
husband had been warned against further pregnancies. 

Present Illness , — Now pregnant about six weeks. Became de- 
pressed again, spoke of ‘‘ frightful forgetfulness ’* and of having 
a blank spot in her memory. 

In view of the two previous attacks of melancholia, tho compli- 
cation at former confinement, and the apparent beginning of 
another attack of depression, it was decided that tho pregnancy 
should be terminated. 

Case 10. 

Mrs. P., aged 55; seen November 17th, 1924. 

Family History , — ^Two sisters had been under caro for mental 
illness but recovered. 

Previovs History , — Has had two children. Had been much 
concerned about husband's money difficulties. Had been depressed 
since June. Recently had tried to poison herself by gas rn a 
bedroom, but promised not to make further attempts. Had been, 
however, allowed to sleep in a room alone in a friend’s house, an<l 
one morning had precipitated herself from the bedroom window, 
sustaining fracture dislocation of the riglit ankle, dislocation of the 
left elbow, a scalp wound, and concussion. She was treated in a 
nursing. home for tho surgical troubles, concurrently ■with wliicb 
she passed through a severe attack of mental disorder, part of tho 
time being confused and delirious with rise of temperature, and 
part of the time deeply melancholic with thoughts of suicide. Lato 
in December, when she had sufficiently recovered surgically, 
Dr. R, H. Cole and I saw her in consultation with Dr. Hill, 
and camo to the conclusion that sho should be certified. Tho 
husband, however, objected to this, and as tho patient expressed 
her willingness to go under care as a voluntary boarder she 
went thus to a private mental hospital. She was quickly found 
to be unfit for voluntary treatment and was ceitificd. Subse- 
quently sho recovered sufficiently to bo discharged as ** relieved ’* 
at the end of July, 1925. 

In December, 1925, she became pregnant again. In view of 
the previous severe and dangerous attack of mental disorder there 
was no hesitation in giving the opinion that tho pregnancy ought 
not to bo allowed to continue. 

■With regard to the second group, it may ho said that 
in each case the question of tho health of the mother was 
the primary factor, as in all these cases tho child was not 
“ viable,’* 

I agree with the views expressed by Dr. Fairbairn at 
the joint meeting of the Medico-Legal Society and the 
Section of Obstetrics of the Royal Society of Medicine, that 
only purely medical considerations should he allowed to 
weigh in deciding as to termination of pregnancy. 

It is interesting to note the views expressed by legal 
autlioxdties in the discussion of January 21st, 1927,* For 
instance, Lord R-iddell is reported to have said that 
“ induction was not only justifiable, but a duty when the 
pregnancy indicated grave danger to the mother’s health, 
whether the result was likely to be permanent or not.**^ 
Sir Travers Humphreys said tho practitioner “ was not 
entitled to let anything weigh with him except the health 
of his ijatxent — her medical welfare as distinct from her 
social or economic xvelfai’e.**^ Earl Russell is reported as 
leaning to the German view which Lord Riddell had 
quoted, “ in which it was insisted that the foetus was not 
yet an independent human being, and that every woman, 
by vii’tue of the right over her own body, was entitled to 
decide whether it should become one.** Mr. Justice Salter, 
in summing up the debate, is reported as having said that 
if abortion were ever sanctioned outside the medical area — 
in tho interest of eugenics, for example, or for economic, 
social, or personal reasons* — ^he would have great fear that 
within tho medical area there would arise a large class of 
pliant doctors who would be easily persuaded that there 
were sufficient medical reasons in a given case. Ho was 
certain that if it were ever pi'oposed to extend the liberty 
of abortion, the spirit of unswerving opposition would 
arise again as it did in the attitude of the early Christian 
Church towards abortion. 

In the Journal of Mental Science for July, 1927, is 
published a paper by Dr. J. R. Lord, President of the 
Royal Medico-Psychological Association, on the induc- 
tion of abortion in tho treatment and prophylaxis of 
mental disorder. Ho concludes that the only morally sound 
reasons for inducing abortion are medical : (a) to preserve 
life, (6) to alleviate or cure serious physical or mental 
illness, or (c) to prevent serious ill health, physical or 
mental, whether permanent or temporary. 

Tho cases I have recorded seem to me 'to he of importance 
as showing the questions which have to he taken into 
consideration in each case as it arises. 

, _ REriTvENCES, 

p 183^^“ llEDiea Jomi.s-AL, Januarj* 29th, 1927. « ibid., p. 188. * Ibid., 


THE TREATMENT OF “TENNIS ELBOW.” 

BY 

G. PEllCIVAL MILLS, F.R.C.S., 

SURGEON, ROYAL ORTHOPAEDIC AND SPINAL HOSPITAL, BIRJIINOIIAII. 

TnNRE is probably nothing ivliich brings tho surgical pro- 
fession into greater discredit at . the present time than its 
inability to euro a " tennis elbow.” Tho condition is 
extremely common, and so helpless have wo been in its 
treatment that most sulTercrs now never consider con- 
sulting a medical man at all. For while wo have been 
gravely considering what may bo tho pathology of so 
curious a condition tho_ osteopaths and non-medical 
manipulators have been curing the patients in hundreds. 
Lot us neglect pathology and consider Avhat wo really know, 
about it clinically. 

In tho lirst placo it is almost confined to tennis players, 
golfers, and, workers in, certain trades which involve tho 
constant use of a hamhief. 

Secondly, tho onset of tho condition is insidious; thcro 
is seldom a history of any sudden strain or accident. 

Thirdly, tho patient can commonly do anything with his 
arm ivithout pain except tlio particular exorcise with 
which tho pail) is associated. On tho other hand, during 
tho acute stage at any rate, a patient may suddenly bnnglo 
some perfectly simple action owing to his accidentally 
getting his arm into tho position which produces tho pain. 
A favourite trick of this sort is to drop a tea-cup when 
reaching out tho hand to take it from a tray. Indeed, 
tho action of holding a tea-cup will often produce tho pain 
of tennis elbow, and tho fact is of help in making a 
diagnosis. 

Fourthly, in tho ncuto stage, which may come on rather 
suddenly and in which the patient simply cannot hold a 
racket at all, there is a vei^ strong subjective sensation 
that " something is out of place.” 

Fifthly, all those sj-mptoms are present without any 
physical signs adetjuato to explain them. This represents 
only a superficial point' of view and is nob strictly true. 

I shall return to it later. 

Finally, the condition is frequently cured by non-medioal 
manipulators by some form of forcible manipulation. Tho 
test of euro is that tho patient can play tennis without 
pain, or with only a feeling of soreness quite different from 
the incapacitating pain. 

These, 1 think, represent tho generally recognized facts; 
at any rate they were tho facts known to mo when I first 
began to take a special interest in the subject. I happened 
at this period to como across a number of cases in a short 
time. I found in all the recognized tender spot, which 
varied in position but was usually just above or below 
tho external epicondyle, and, as had been described before,* 
that tho pain was often produced by complete flexion of 
tlio wrist and fingers; also That on superficial examination 
all movements wore complete. When, however, I specially 
examined combined movements, this was not tho case. 
Frequently, for example, with full pronation combined with 
complete wrist and finger flexion the elbow would not come 
perfectly straight, or if it did come straight there was a 
distinct feeling of resistance and the process was painful. 
This is, of course, a complicated movement, but a similar 
movement of the opposite limb was free and painless. 
This fact, together with the known frequency of cure by 
forcible manipulation, stronglv suggested that forcing the 
restricted movement might bring about the desired result. 
My fii-st case was rather dramatic. The patient was a big 
strong man, and I insisted on an anaesthetic. Under 
nitrous oxide I wrenched tho arm as follows; with the 
wrist and fingers flexed and the forearm fully pronated 
I forced the elbow into liyperextension, making at tho 
same time firm pressure with my left thumb over the 
tender spot by the external epicondvle. There was a snap 
like a pistol shot and the horrified anaesthetist insisted 
that I had broken the arm. The cure was as dramatic as 
the manipulation. It was a long-standing caso and had 
never been very severe, but tho patient assured me that 
for the first time for many years he was able to take 
a hard back-hand volley without pain. Further experience 
has shown me that there is not always so loud a noise, 



MEMORANDA, 


t TnE Beitish 
Medico Jodxea& 


13 


Jan. 1928] 


l)Ut ill ovi'iy caso I have' felt a click or smi]i wliicli, tlioiigli 
^icrfoctly obvious to tlic hand, was not always audible. 
Ill loceut eases it is little more 111011 the feeling of some- 
thing giving way. 

1 have performed this manipulation both with and 
Avithoiit an anaesthetic, and so far have not had a failure. 
Tills does not mean that 1 have manipulated every patient 
who eanie to mo thinking ho had a tennis elboiv, for in 
some of them I could not satisfy myself of the diagnosis. 
But all those who had the physical signs detailed above 
(and they were by far the greater part) were cured by the 
manipulation I have described. In all cases a short nitrous 
oxide anaesthetic is preferable, and in chronic cases I 
believe it is essential. The manipulation is painful, and 
few jiatients will allow one to u.se the force necessary to 
cure a chronic ease, where presumably the adhesions are 
firm. As regards after-treatment I believe that none is 
necessary. A few days’ lest from tennis may bo indicated 
if the elbow is sore from the manipulation, but otherwise 
the sooner the patient returns to the game the better. 
The need for prolonged after-treatment would suggest to 
me an incomplete manipulation. 

AYliile the hyiiolhesis of " adhesions ” will explain many 
cases it is difficult to fit it in with some acute cases. 
I recently saw a well knoAvn player on the first day of an 
important tournament. He said his elbow had “ gone 
out ’’ ; he could not hold a racket, and he had to compete 
again during the afternoon. I found exactly the physical 
signs described above, and on manipulation, Avhieh caused 
severe jjain, there was a definite click under my thumb. 
He got up, tided his arm, and said it “ had gone in again,” 
and he played through the tournament with a sore but 
useful elbow. 


Now “adhesions” cannot come on suddenly like this, 
and one is compelled to conclude that something is out of 
jilace. If so, may it not be the same thing in the chronic 
cases also, and that the malposition has become fixed by 
adhesions? The whole condition presents many similarities 
to that of a semilunar cartilage in the knee. Here, how- 
ever, we have no semilunar cai-tilage, but we have a very 
unusual type of joint. The head of the radius is neces- 
sarily very loosely attached to the orbicular ligament to 
permit rotation, and it is possible that a part (possibly 
a torn part) of this ligament may occasionally slip between 
the head of the radius and the eapitelluni. This would 
interfere with extension just as displacement of a semilunar 
cartilage interferes with extension of the knee. Another 
curious analogy is that the sueccssfid method of treatment 
which 1 have’ described above is almost exactly similar 
to the method of reducing a displaced semilunar cartilage 
so ably developed by Sir Robert Jones. If we consider 
pronation in the forearm to correspond to internal rotation 
of the log the analogy is almost complete. 

Condusioiis. 

1. The majority of cases of “ tennis elbow ” present 
characteristic symptoms and physical signs. 

2. These cases can be cured bj' the simple manipulation 
described above, preferably carried out under nitrous oxide 
anaesthesia. 

3. The pathologj- of the lesion is uncertain, but it is 
suggested that in acute cases a portion of the orbicular 
ligament may slip between the radial head and the 
capitellum. 

RrjERFXCF. 

’ Fi&lier ; Jlnnijmlatire Svrpprj/. 


MEDICAL, SURGICAL, OBSTETRICAL. 

OPTIC NEURITIS AND SPHENOIDAL SINUSITIS. 
Having read tlie illxijiiinating disciis.sion on optic neuritis 
published in the Bkitisii Medical Joudnal of November 
12th, and having remarked the scepticisni concerning sinus 
infection as a eunse. of optic neuritis, I was ixrompictl to 
record the following ease as an exauijile of a frankly 
rlunogenic optic neuritis. 

Miss X., aged 24, was admitted to tlie General Hospital, 
Birniingliam, on November 27lh, 1926, complaining of morning 
nausea and vertigo of twcnly-one days' duration, frontal head- 
aches of increasing severity and of fourteen days’ dural ion, and 
sudden partial loss of vision in the I'ight eye since tliree days 
previouslv. The latter symptoms coincided ’with a paioxysmal 
increase in concurrent symptoms. Except for measles as a child, 
and a chrcnic nasal catarrh during the past few vears, she liad 
enjoyed quite "ood health. 

Routine clinical examination revealed no abnormality in any 
Bvsteni except the ocular. A leucocyte count, however, showeil 
slight increase — that is, 12,400. Tlie visual acuity was: right 
eye, 6;[8; left eye, 6/6 partly. Perimetry demonstrated slight 
narrowing of the temporal lialf of the right field of vision. The 
lett visual field was normal. Both fundi presented engorged veins 
and very full arteries with a well marked light reflex, Haemor- 
iliages were freely scattered about, some around the disc and 
many extending far out into the fundus; they issued from 
engorged venules. Papilloedema of tlie right disc was remarked 
to the extent of 4 diopters, whilst the left disc exhibited an area 
nasal half. No retinitis was noteA X rays 
could snow no abnormalit}’ of the nasal sinuses, and no evidence 
increased nitracraiiial pressure. 

under expectant treatment the visual acuitv improved almost to 
tlie normal, and the papilloedema subsided. 

w *■ 0 }t Sphcnotdal Sinus. li(Covcri/. 

exacerbations of headache and photophobia 
ccurrea, and each exacerbation was accompanied bv increased 
asal catarrh and fi-csh crops of retinal venous oozing. *At the end 
'v^cks Mr. Musgrave Woodman removed a septal spur on the 
y i’ which prevented good access to the sphenoidal sinus. 
A he left sphenoidal sinus was then found to be enlarged and 
heavily mfecLcd, containing thick flakes of pus. The 
phcnoidal sinus was small and was slightly infected. From the 
pus a leeble growth of pneumococcus was oblaiued and an 
autogenous vaccine made. 

After the radical treatment no frcsli haemorrhages were 
emarken, the headaches cleared up, and in three months, when 
she was oxamnied, the fundi looked quite normah 

I^ouglas Wilkinson for 

pci mission to publish this case. 


In this case of severe optic neuritis a very definite focus 
of infection was demonstrated in the S2>henoidal sinus, and, 
altliough subjective eye symptoms cleared up with expectant 
treatment, objective eye signs still remained, along with 
subjective symptoms due to sinus infection. Operative 
treatment effectually dealt with the infection, and the 
patient was in jierfect health three months afterwards. 
Had she not undergone operation I am very much inclined 
to believe that she would have led a miserable existence 
for yeans, suffering from time to time a recrudescence of 
eye symptoms due to an intermittently recurring flare-uj) 
in the nasal sinuses. 

A. C. Rfxs AValto.v, M.B.Birm., M.R.C.S., 
Goncial Hospital, Birmingham. 


WIRE BRISTLE IN THE BOWEL. 

The early history of this case led to the patient being 
unjustly suspected of bringing his trouble on himself. 

During the night of September 20th-21st, a boy, aged 14, had 
colicky pains reterred to the region of the umbilicus. He con- 
fessed to having feasted on green apples on the previous night ; 
his mother administered castor oil, but without result. On the 
inorniDg of September 22nd, no, movement having taken place and 
no flatus passed, an enema was given. The bowels moved one 
hour later. In the afternoon colicky pains recurred and retching, 
which bad been present durin" tlie ni"ht, gave place to vomiting. 
The vomited material was black and very foul smelling. The 
temperature had risen to 99.8° F. and pulse was 142. The hernial 
openings wore closed, no tumour could be felt, and the rectum 
was clear. There was fluid dullness in both flanks. Laparotomy 
was decided upon. 

The abdomen was opened by a right paramedian incision. 
Distended loops of small intestine presented through the .wound. 
Examination by hand revealed a constriction near the caecum, and 
this portion was delivered. A piece of wire was found piercing 
the ileiim and passing into an appendix epiploica on the caecum, 
pinning 'another loop of ileum between. On removing the wire the 
obstruction was relieved immediately. The bowel and mesentery 
seemed viable. The peritoneal exudate was not evacuated and the 
wound was closed in layers without drainage. 

On September 23rd the abdomen was distended, but flatus was 
passed after the administration of a dessertspoonful of liquid 
paraflin every hour, and 0.25 c.cm. of piluitrin every half-hour, 
for two hoiu*s. ‘ Distension was present on September 24th, but 
the bowels moved after three doses of 0.5 c.cm, of pituilrin given 
liourly. Since then convalescence has been uninterrupted. 

The piece of wire measured 1 5/16 in., and was identical in 
appearance with a wire bristle from a pot cleaner. The patient’s 
mother thinks that the wire must have been swallowed with 
porridge, but the patient has no recollection of havint» done so 



14 Jan. 7, 1928] 


SCTENTIFIO PROCEEDINGS OE BRANCHES. 


t Tne np.TTtf* ' 
ilrbiCAL JocsNAb 


Mr. J, Anderson, D.S.O., F.R.C.S.Ed., of Dundee, gi\'ea 
mo permission to mention the following case. 

“ In 1914, JIi£.s S. was sent for consultation with a diagnosis of 
embacute appendicitis. The pain was confined to Iho right iliac 
foss.a, and clinically, in all respects, resembled lesion of tho 
appendix. Laparotomy was performed two days later. Tho 
appendix was found normal, but, on investigating tho abdomen, 
omental adliesions were found to tho greater curyaturo of Iho 
stomach which, on separation, proved to be protecting a perfora- 
tion in the centre of which was a metal bristle, which was traced 
to a pot-cleaning brush. Convalescence was uneventful, and slic is 
now well,’* 

Criell. H- A. Gn.tH.Mi, B.Sc., M.B., Ch.B. 


A LARGE DRETERAL CALCUT.US. 

A MAN, aged 49, was admitted to hosiiital with a diagnosis 
of left-sided pyonephrosis. Ho gave a history of attacks 
of pain in tho left sido of tho abdomen and left flank 
of two years’ duration. For tho samo period ho had 
suffered from frequency of micturition. There had been 
no haematuria, but tho urine had been foul smelling and 
turbid. 

Tho pyonephrosis was so big that it was readily visible to tho 
eye. The urine was full of pus and smelled strongly of B. colt. 
An a:-ray report of tho urogenital tract stated, “ thcro is a largo 
calculus in the bladder or in a sacculus of the bladder on tho 
left sido.” Rectal examination revealed a hard fixed mass above 
and to the left of the prostate. On cystoscopy thcro was found 
to be no calculus in the bladder and no sacculus leading out of 
it. The right ureteric orifice was normal, but that on the left 
was congested, and a thin stream of pus was issuing from it. 
Immediately above it the bladder waif was seen to bo bulged 
inwards by a mass lying in the terminal portion of tho ureter. 

The bladder was opened, its wall was incised over tho swelling, 
and the calculus levered out of its bed. Immediately there was 
a gush of foul, greenish pus, which filled tho bladder and over- 
flowed on to the table, A finger could easily bo passed up the 
ureter, tho lumen of which was estimated to equal that of the 
small intestine. 

After the operation tho pyonephrosis disappeared entirely. Tho 
patient refused removal of his infected and disorganized kidney, 
and was discharged from hospital with only a trace of pus in tho 
urine. 

The calculus was smooth and regular in outline, and measured 
Si in. in length and 1? in. in diameter. It was very heavy, 
weighing no less than 1,639 grains. 

Though not the greatest in length and diameter, this 
calculus is, so far as I can discover, the heaviest yet 
recorded. 

John C. Jefferson, F.R.C.S., 

Honorary Surgeon, Rochdale Infirmary. 


FOREIGN BODY IN THE EAR FOR THIRTY-SIX 
YEARS. 

I WAS interested in Dr. AVclIs’s account (October 8th, 
p. 637) of a foreign body in the ear for thirty-three years, 
and I feel it may be of interest to record the following 
account of an encapsulated foreign body which remained 
in tho external auditory meatus even longer. 

I treated tho captain of a vessel, in which I sailed to 
Japan as a ship’s surgeon, at Yokohama Hospital (where 
then patients were allowed to have their own medical 
adviser to treat them) for a serious attack of bronchitis, 
and only consented to take him home if he strictly obeyed 
my orders. 

Ho bad a rancous voice, and, sailor like, did not mince 
matters when lie wanted to cough ; his energetic hades 
must have dislodged the foreign body from its bed, which 
allowed it some play, for it caused a superficial ulceration. 

I told him that his bronchitis was well, and that his 
hacking cough must ho due to some reflex irritation. It 
astounded him to conceive that his ear should have any- 
thing to do with the cough ; but on removing tho body, 
which I found to he a grain of old dry rico (encapsuled), 
he proffered tho remark, “ It must have been there since 
the day I got married ” ; his eldest son was then 35 years 
of age. It impressed him greatly that from tho moment of 
its removal tho cough vanished and never returned again. 

I sifted tho matter as well as I could, and had no doubt 
that the foreign body was there for at least thirty-six 
or thirty-seven years. 

AFilliam P. Kennedy, M.D. 


?3nti5lj iitciitcal, ^ssonnttcit. 


CLINICiVL AND SCIENTIFIC PROCEEDINGS. 


CITY DIVISION. 

Urinary Obstruction. 

A MEETING of tho City Division w.as hold on Dcceniher 6th', 
1927, at tho Metropolitan Hospital, Dr. Pnimr Hamili, in 
tho chair, when Sir John TnosisoN-WALKEH read a paper 
on urinary obstruction. Ho began by saying tliat senile 
enlargement of tlie prostate was tho most common form 
of urinary ohstruction and tho one ivhich gave rise to tho 
greatest difficulties in regard to tho proper method of 
treatment. Once this change in tho prostate had become 
definitely established it was progressive. In some cases 
tho early stage, in which little, if any, residual urine was 
present, might last for throe, five, or more years without 
apparent change, and then rapid increase in tho ohstruction 
take place. 

Operation was tho proper treatment in tho majority 
of cases, and early operation was advocated so that tho 
patient was not too old and the stage of sepsis and back 
pressure was avoided. Moreover, thcro were cases where 
malignant disease developed in a simple enlargement of the 
prostate. In 100 consecutive cases of prostatectomy for 
simple onlargement of tho prostate 16 showed microscopio 
areas of malignant change. Tho presence of two or more 
ounces of residual urine was an indication for operation. 
Frequent micturition in old men was not physiological, and 
alwaj-s demanded careful investigation, althougii tliis sjun- 
ptoin was not, apart from residual urine, a ncccssafy 
indication for operation. ... 

In estimating tho fitness of a patient for operation all 
tho systems must bo included in the investigation. Renal 
failure and sepsis were tho two common contraindications 
to operation. Tlic tests of tlie renal function were within 
reach of all practitioners. Tho clinical symptoms wore 
often overlooketl in tlicir early stage. Repeated estimation 
of tho urea percentage of the urine was a valuahlo guide. 
The urea concentration test of IMaclean was a very accurate 
and valuable test when properly used in cases of hack 
pressure kidney. Tho blood urea estimation was a l.ahora- 
toiT test, and might not bo available in proctice. If 
used alone it miglit be fallacious, but it was valuable when 
combined with tho urea concentration test m advanced 
cases. The surgeon must frequently operate on cases wliero 
the renal function was not completely normal, and his 
success would depend on his ability to prevent post-opera- 
tive complications, wliich were specially fatal m such cases. 
In sepsis the tests of fitness for operation wero tho general 
condition and tho condition of tlie urine. Tlio urea tests 
were used in renal sepsis, but only indicated the amount 
of reduction of tlie renal function, not tho extent or 
virulence of the sepsis. The blood cholesterol had been used 
as a test of the resistance of the patient to sepsis. A high 
blood cholesterol content was regarded as f.avourablo, and 
below 0.130 per cent, was abnormal. 

Treatment by radiation, either with radium or the 
hard x rays, was not a reliable method in simple 
enlargement, and had dangers equal to the catheter and 
to operation. In rare eases the hard x rays had produced 
improvement in symptoms, hut usually it failed. Massage 
was useless in true enlargement of the prostate. The 
removal of the obstruction at the neck of the bladder by ■ 
means of punches and electric cauteries had a veiy limited 
application to a small class of case. When the prostate 
showed definite enlargement these methods were dangerous 
and ineffective. Removal of the prostate by operation was 
recommended early in the disease by a single-stage opora7 
tion and by tho operation introduced by the speakci-. His 
operation mortality in hospital was 8.2 per cent., and in 
private cases 4.4 per cent., and there were long series 
of cases without a death. The recent publication of a 
mortality of 13 and 20 per cent, after the blind operation 
showed that prostatectomy should be performed by surgeons 
with special skill, and with tho advantages of a special 
hospital or a special department of a general hospital. 

After an animated discussion the meeting terminated 
with a hearty vote of thanks to the lecturer. 


7, 1928] 


•EE VIEWS. 


t Tn BBmn 

UXSICXI. 3 9CSJ11L 


16 


Ettolus. 

A HANDBOOK OF OPHTHALMOLOGY. 

■Tiie appearance of A Handhooh oj ^ Ophfhohunloyy^ ^ 
addition to the nninbcr of snialler tcxtl)Ooks on tliis svd)jcct 
adiich aro already at tlio disposal of tlio student may at 
fii-st sight appear somcadiat surprising. But it is cert.ainly ; 
true that the majority of these, being written by specialists, 
look ui>on the subject too much from the simcialist’s point 
of view; they fail to take into consideration the fact that 
the entire clinical u'ork of the average medical student 
lasts merely three years, that within the compass of these 
three years a vei'j’ formidable array of subjects has to ho 
mastered, and that the tendency at the present time is 
not towards simplification,' hut rather towards further com- 
plexity; they forget the absorbing claims of practical and 
clinic.al studies; and, most of all, they forget that to the 
average medical student ophthalmology is, and always will 
be, one of the minor or accossor 3 ’ subjects — of secondary 
importance, both from the vioiv of future practice and of 
examinations, to the main interests of medicine, surgery, 
and mida-ifer^'. The tcndcnc)’, therefore, is for the student 
to regard a coiniirchonsivo treatise on ophthalmologj- as 
making an unjustifiable call upon his time — and often upon 
his purse — and to reU' almost exclusively upon the lectures 
of his teachers and the clinical demonstrations at his 
hospital. It is because wo think that the Handhool: of 
Neamk and Wii.liaiisox--Nodle goes a very long way 
towards reducing matters to rcasonahio proportions, with- 
out at the same time having the defects of a cram-book, 
that we think it assured of a ivclcome. It is small, but 
not superficial; it is easy to road, and not overburdened 
with technicalities; and it treats of the essentials of tho 
whole subject without going into too great detail or 
becoming absorbed, after the manner of an eiicj-clopaedia, 
with uncommon affections or pathological rarities. The 
authors, moreover, have both had considerable experience 
of the routine of out-paticiit departments and of tho 
requiremonts-of teaching clinics; and if, as seems probable, 
the voluino is likelj- to be a popular reference work for the 
undergraduate, a reviciv in some detail may not bo out 


teaching. The ■ student will find the summaries of con- 
fusing' subjects 'useful, such as the diagnosis between iritis 
and glaucoma, tbe tvpes of cataract, etc. 

The book continues with a chapter on tho ocular muscles 
— a subject most students find abstruse, hut well presented 
here — and others on the orlut, on operations, on ophthalmic 
signs and sj-mptoms occurring in general diseases, and 
on ■ the -general therapeutic methods commonly used in 
ojihthalmic practice. 

. On tho whole the book will prove useful, and, we think, 
acceptable to the student. It is vei-j- well produced, and a 
feature of it is the uniform excellence and usefulness of tho 
illustrations. It is plentifull.v supplied with coloured blocks 
(tho work of Theodore Hamblin, Limited), which are well 
chosen and well executed. And finally, considering tho 
labour which must have been expended on its production, 
it is remarkably cheap. 


STILL’S “ DISEASES OF CHILDHOOD.” 

The appearance of the fifth edition of Dr. Sini’s Common 
Disorders and Diseases of Childhood- is, as is said in the. 
preface, another birthday in the life of the book. And in 
the case of a book so well known and so well esteemed 
it is the occasion for congratulation rather than for critical 
examination. 

It is a bigger book than it was at its birth in 1909, but 
in its general plan and character, and even in the order 
and titles of its chapters, it has been little changed. 
In tho. present edition three new chapters, on vomiting, 
erythroedema, and cretinism, have been added, making 72 
chapters and over 1,000 pages of text. 

Bcj'ond these statistical facts appropriate to the life story 
of a book, it is enough to say that this is one of the best and 
most practical books on the subject in the English language. 
Although it has grown out of lectures given to students at 
Great Ormond Street and King’s College, it has perhaps 
appealed most strongly to practitioners — ^those who aro 
engaged in the practical and responsible problems of medi- 
cine in childhood. For it is the narration of the personal 
experience of the author with regard to all the common, 
and not a few of the uncommon, diseases of childhood ; 


of place. 

The first chaiitor deals with tho examination of the eye 
and its surroundings, and goes rapidly and concisely over 
the more common clinical methods used in ophthalmologj'. 
If we were to criticize aiiA-thing here it would be to 
remark that tho detection of colour-blindness seems to be 


treated rather cursorilj-, considering the gravitj- of tho issues 
that sometimes hang upon tbe establishment of its presence, 
and to point out that in Holmgren’s wool tost the excel- 
lence of the test lies in the subject not being asked to 
name tbe colours he sees (as is suggested in the text), 
but fn bis being forced to match them with other (con- 
fusion) colours. The second chapter, dealing with the 
theory of lenses, refraction, accommodation, and anomalies 
of muscular balance, is ver.v well done, and explains in a 
readih- comprehensible manner a subject which’ is difficult 
to deal with without relying vei-y largely on the abstrac- 
tions of mathematics. Eefraction cannot be learned from 
reading alone, but onlj' by painstaking and supem-ised 
practical experience. It is an exercise which has to he 
regarded as a post-graduate sirecialtj', and had best bo 
undergraduate student, but it will be 
difficult to find a more readily comprehensible account of 
the^ essentials of the theoiy' involved. 

The remaining chapters of the book deal with the 
diseases of the eve, the eyelids, and lacrv-mal apparatus, 
including a chapter on injuries of the conjunctiva, the 
cornea and sclerotic, tho iris, ciliary body, and choroid, the 
••1^’ ^1 optic nen-e, and tho retina, and 

uitli glaucoma. The more common diseases only are dis- 
cussed, and, as is essential in a book of this nature, in a 
manner essentially dogmatic. Although evervone will not 
agico with the authors on all points, the views expressed 
aro nliyays reasonable , and represent safe and orthodox 

P*A urnifnmc^ "t Humphrey Neame. F.H C S and 

■p-p. iii + 312Tl93 Gled. 8vo, 


and, while there is a good foundation of pathology, 'the 
emphasis is laid on symptoms and clinical features, and 
on diagnosis, prognosis, and treatment. “ Experience is 
uncertain and judgement difficult ” ; but here the experi- 
ence is long and extensive, and is made np of careftd 
obseiwations, diligentlv recorded, sifted, and weighed. 
Take, for example, pyloric stenosis in infants, which is not 
one of the common diseases, but which is yet very imjiortant 
from the point of view of diagnosis. The chapter on this 
subject is ■written from a personal experience and records 
of 312 cases, and there can be no question as to tbe rare 
value and authority of a pronouncement on the subject 
based on first-hand knowledge of this extent. 

The practitioner of medicine has found in this book what 
he desires above everj-thing else — a full and authoritative 
account of sv’mptoms and those clinical aiipearances which 
he can himself observe or elicit, and of the principles and 
the fallacies of diagnosis : guidance in the perplexing 
business of prognosis, wlietber immediate or remote, 
grave, hopeful, or uncertain; and a discussion of treatment 
which goes ber'ond princiides and enters minutely into 
details. 

Another uncommon- thing about tbe book is that it has 
the indefinable but obvious charm of a literarA' stjle. That 
style is neither eloquent nor dogmatic, but is rather con- 
versational and discursive, with the atmosphere of the bed- 
side and the easy talk of the teacher to his students. But 
with this informality it is always clear and quiet and 
refined, and is often enlivened by gleams of humour. With 
these merits it may stand already inside the narrow and 
closely guarded circle of English medical classics; at least, 
on this new anniversai-y we may say to its' author, Esto 
perpetuns. 

- Common Disorders and Diseases of Chiidhood. By Georee Frederic 
Still, M.D.Cantab,, Hon. LL.D.Ed., F.R.C.P.Lond. Fifth edition. O.’cford 
Medical Publications. London : Slilford, 0.xford tJniversitv Press 'l9^ 
(Demy 8eo, pp. xiv -b 1032 ; 89 figures. 30s. net.) 


■16 JAN. 7, 1928] 


BEVIEWS. 


titiSumn. 

L UrnicAt. Jociucift 


HADIOTHERAPV OP CANCER. 

The sixtieth volume of .S'/.' Hartholomcw' s Hospital 
Hcports^ contains a romarkablo jjiece of team work, con- 
sisting of seven articles on the radiotherapy of cancer, 
about which Sir Thomas Horder, in an iiitioduction, saj’S 
that, as far as ho knows, no single centre has in such a 
short time produced a mass of work of equal value to that 
done at St. Bartholomew’s. The majorit}’ of the articles 
deal with radium : thus Dr. F. L. Hopwood treats of tho 
physical aspects of radium and tabulates tho dangers — ^local, 
such as radio-dermatitis, and general, such ns grave 
anaemia. Tho effects of irradiation on tissues is lucidly 
set out by Dr. R. G. Canti, who, like Dr. Hopwood and 
Mr. Malcolm Donaldson, collaborated with the late T. S. P. 
Strangeways at the Experimental Hospital, Cambridge, in 
experiments on tissue cultures ; in tliis article tho direct 
and tho indirect action of irradiations on cells are con- 
sidered in some detail. Some of this experimental work is 
also referred to in Dr. W. M. I.evitt’s account of tho history 
and present position of deep x-ray therapy. Tho practical 
matter of treatment b}’ the gamma raj-s of radium is fully 
considered by Dr. 'N. S. Pinzi, who is followed hy Mr. 
Geoffrey Keynes on the treatment of mammary carcinoma 
by radium. Mr. Malcolm Donaldson, in reviewing the 
ladium treatment of carcinoma of the cervix uteri in the 
Hospital for five and a half years, pleads for tho estab- 
lishment of an institution for the treatment of malignant 
disease by one method. Writing with twelve years’ expe- 
rience on the radium treatment of the larynx and tongue, 
Mr. Douglas Harmer finds that intrinsic cancer of the 
larynx is very susceptible to radium, probably more so 
than cancer elsewhere; lingual cancers are also susceptible, 
birt less so than those of tho vocal cords, and, as glandular 
metaslases present difficirlties, block dissections still gir'C 
the best results. 

Tho same issue of the Reports contains several clinical 
papers, an obituary notice of Dr. T. Clay Shaw, and the 
completion of Sir D’Arcy Power’s account of the rebuild- 
ing of St. Bartholomew's Hospital in the eighteenth 
century. 


MENINGIOMAS. 


The main topic of the Macewcii Memorial Lecture for 
1927, delivered by H.MtvEY Cushing at the University 
of Glasgow in June of that year, and now published in 
a small volume,'* is the ti'eatment of that group of 
meningiomas or tumour's of tbo cerebral membranes which 
arise in the floor of tho anterior fossa of tho skull, and 
more particularly in one or both of the olfactory grooves. 
They are mostly of the endothelioma tons tjqre, being either 
fii'm and slow-growing, witli a tendency to calcification, or 
softer and more cellular, and tending to rapid growth. In 
this situation they produce a train of symptoms by which 
their presence may be recognized, and arc therefore 
amenable to surgical treatment. They may, however, 
attain a largo size, and nothing can well bo more dis- 
concerting in this difficult branch of surgei-y than to turn 
down possibly an insufficiently lai'ge bone flap and come on 
a huge meningioma. What pioinised to be a simple pro- 
cedure may suddenly be transformed into one of excep- 
tional gravity, increased by tho extreme vaserdarity of 
seme of these growths; tho proposition of enucleation is 
converted into that of piecemeal removal, and the surgeon 
who takes a flying leap at one of these operations, ill 
prepared, rides for a fall. 

It is tho loss of blood and the consequent tedious delay 
that occurs in these piecemeal operations which renders 
stage operation so frequently necessary, the bleeding from 
the raw surface needing to be arrested at tho removal of 
each fragment. To meet this difficulty Cushing conceived 
that the employment of electricity might be of service. 
It is known that, in its application to surgery, electricity 
may ho used for cuttirrg or for the coagulatiorr of the 
tissues, in the latter case acting also as a haemostatic. 


^ St. Earttiolomca's Hospital Reports, vot. lx. Edited bv W. McAdam 
Eccica and otlicfs. London : John Murray. 1927. ' (Demy 8vo. 
rp. xxvni-4- 203 ; 21 Ilgures. 21s. net.) \ o r 

rr “V Cu-liing, C.B., D.S.JL, A.)r., Sr.D.Harv., 

”27. (Roy. 


Cloarly, if this double action could bo combined, and in- 
cision nnd'haomo.stasis bo rendered simultaneous or almost 
siiiiultaneous, tho inconveniences attending tho piecemeal 
removal of mcningionias would largely disappear. Pro- 
fessor Bovio, director of tho biochemical laboratories of 
tho Cancer Commission of Harvai'd. University, interested 
himself in tho problem, and succeeded in perfecting an 
oloctro-sui'gical apparatus in which both tho coagulating 
and tho cutting currents were, combined in one machine, 
and in which, through the agency of a pistol grip, tho 
cui'i'cnt could bo lot off and on , by tho pressui-e of a 
trigger. Tho a]iparntus enables tho operator to control 
tho degree to which tho incised tissues are coagulated, and 
tho current is so ))oworful that a loop may be employed 
in place of tho straight needle in common use. Three eases 
in which tho apparatus was successfully employed aro 
described. In tho first tho tumour weighed 60 grams, and 
was situated well back in tho anterior fossa on both sides 
of tho iniddlo lino. Tho usual low frontal bone flap was 
rcflectocl, and tho dura elevated from tho roof of tho orhit. 
An incision was mado in the tenso dur.a ■well, down under 
tho frmital lobe, and tho anterior margin of tho tumour 
disclosed. Loopfuls of tissue woro then scooped out from 
tho body of tho growth in tho right half of tho fossa, and 
tho outer shell drawn forward and removed. Tho largo 
cavity loft made the removal of tho portion of growth lying 
to tho left, of, tho mid-lino comparatively easy, ^lis 
portion blocked tho opening under tho falx, which had to 
bo incised at the upper part of the field and detached from 
the crista galli ; it was removed intact. Tho operation took 
soven hours, and tho removal of a much larger tumour in 
a subsequent case took nine hours; but Cushing states 
that he has no dread of a long session, believing that 
convalescence is shortened by attention to technical details 
on tho operating table. 

llio point to bo emphasized in these operations is that 
they ■wore carried out at a single sitting, instead of 
multiple sittings as under the old method ; and that we no'w 
have at command a device which makes it possible to 
oxtirpiito intracranial tumours hitherto so inaece,s.siblc tL«t 
their attempted remov.al .would have been • regarded ias 
foolhardy in the extreme. 


DIABETES. 

The third edition of L.awiience’s Dinhefic Lifc‘ contains 
a few important additions. Tho mode of insulin action is 
more fully dwelt upon in the light of new knowledge. The 
author explains, how “ insulin will increase the metabolism 
of a diabetic by supplying a fuel which was hitherto lacking 
(for glycogen, not glucose, is the fuel which the muscles 
can use).” He goes on to point out how, after an overdose 
of insulin, and' probably after vigorous exercise in normal 
individuals, adrenaline is secreted and mobilizes available 
glycogen from tho liver. The short chapter on synthalin is 
welcome. If we may judge from the extensive advertising 
of this drug in certain foreign journals, it is likely to be 
pushed in this country before yerj’ long. ' As Dr. Lawrence 
writes, " one was led to believe that an important dis- 
coverj' had been made.” But, he continues, “ To my great 
disappointment I have not been able to confiim them [that 
is, the claims of the discoverers of synthalin], and, from- 
personal communication with other workers in this coimtry, . 
I have found that their experience has been similar to' 
mine.” His cimjccture as to tho reason for tho success - 
of synthalin on the Continent and its failure here is worthy 
of emphasis. “ It would appear,’’ he says, “ that on tho- 
Coiitinent patients' insist on higher carbohydrate diets than 
in this country, and demand, or get, a certain amount of 
broad and even beer! The lack of apjietite caused by 
synthalin and the consequent failure to eat and absorb tho- 
usual amount of food may account for some of tho good 
results obtained in these cases.” Lawrence’s book is im- 
proved by the additions ho has made, and we are par- ' 
ticnlarly impressed by his well considered criticism of- 
synthalin. His Diabetic Life is a good guide to treatment, 
and can be warmly recommended to general practitioners. 

5 The Diahetio Life: Its Control 6 , 1 / Diet and Insulin. By R. D. 
Lawrence, M.A., M.D., ^f.R.C.P. Third edition. London ; .7. and A. 
CliurchilL 1D27. (5^ x 8 i, pp. viii + 185; 11 figures. 8 s. 6 d. net.) 



BEYIEWS. 


r Tn« ORtTisK T 7 
UeniciL Jotmx*!. . ' 


Jan. 7, 19:8] 

Tiik vcaticr wlio turns ‘from Lawrcnco to Botickaeut 
cannot fail to roaliac tliat insnlin is a innro familiar drug 
in England than in Bclginnii Dr. Bouckacrt’s book on tho 
patbogonv and trc'atincnt of diabetes'* provides a complete 
survey of tbo work Avbicli led up to the production ^of 
insulin, and be lias made a good many observations on its 
action, both in animals and in man. Tho wbolo reads as 
tliougb it were intended to servo as an introduction to 
tho medical profession in Belgium of a little known treat-' 
mont. Accepting this, the book apjmars well arranged and 
■\voIl suited for its purpose. 'I'he author comes largely under 
the influence of Professor Marcel Labbe, and consequently, 
divides his cases into tho two groups diahHe sans dcniifri- 
tion and diabefc avee dcniifrlfion, a grouping which is 
obvious to every observer, but is' not really of prime im- 
portance in the application of insulin treatment. Dr. 
Bouckaert refers to synthalin and accepts tho claims of 
its discoverers with loss resen-o than docs Lawrenco. But 
even he is not wholly satisfied that it can do all that is 
claimed for it. Ho mentions also a proprietary article 
named " oxantin," which its manufacturers state is more 
readily utilized than glucose. It is said to bo a sugar- 
tasting compound more readily transformed into glycogen 
in tho liver than glucose. "Wo have no experience of this 
substitute for carbohydrate in the diet. Its discoverers 
call it “ a sugar which docs not need insulin.” Bouckaert, 
however, is careful to remark that he has little personal 
experience of its use. . Ho is a cautious writer, well 
informed, and capable of setting out bis subject clearly 
and succinctly. 

Professor vo.v A'oonnEN’s book on diabetes and its treat- 
ment’ scarcely needs additional commendation; previous 
editions have made it ns well known in Great Britain as 
on tho Continent, and our chief interest in this eighth 
edition is to road what ho has to say about, insulin, for 
ncai'Iy ten years have elapsed since tho seventh edition was 
pid)lishod, and insulin was then unknown. In the prepara- 
tion of this edition von Noorden has had the assistance 
of Professor S. Is.4.tc of Frankfort; and tho section of 
diseases of the eye is contributed by Dr. E. Grafe. The 
tremendous simplification which tho introduction of insulin 
has wrought in tho dietetic handling of diabetes is not 
made obvious in this latest edition of von Noordon’s book, 
and it seems ns though many of the chapters might now be 
relegated to an appendix or historical summary. Insulin 
has replaced most of the jjlans of treatment laboriously 
surveyed in tho hundred and thirty pages which in this 
book immediately precede tbo dcsci'iption of insulin treat- 
ment. 'fen pages devoted to the cui'o of diabetes by means 
of mineral waters or at health resorts is enough to exhaust 
the patience of any reader of to-day. Although the author 
frankly .admits (on page 490) that insidin has wrought 
a revolution, he does not appear to lay' the same stress on 
It that We have done in this country. Von Noorden men- 
tions syntbaliif with the advice that its value must be 
appraised cautiously and critically. Of oxantin he says 
that in mild cases of diabetes it raises the blood sugar much 
less than does sugar; riioreovor, it seems to have anti- 
ketogenic properties, so tliat it has proved a useful 
adjiivaut to insulin in the treatment of coma. The con- 
clusion we have come to is that, with our knowledge of how 
insulin has altered our views of the treatment of diabetes, 
e eighth edition of von Noorden’s book has not changed 
enough to save it from being tedious. 


tho same lines there are so many additions and alterations 
that it may bo considered to be almost a new book. A few 
chapters have been revised, but most have been rewritten : 
174 pages, 104 illustrations, and- 300 literaiy refcronce.s 
have been added, and twelve additional diseases mentioned. 
IVhilst the- letterpress, etc., has undergone this extensive 
revision, tho general construction remains tho same. 

Apparatus and t’ocliniquo are fully’ dealt with, and each 
disease is considered separately and in most instances 
illustrated. Whilst holding that the dermatologist should 
bo his own radiologist, the author is very insistent that 
this- plan can only -work satisfactorily if the dermatologist 
has had a thorough practical training in the use of both 
radium and a rays, and )iossesses modern equipment. Wo 
are fully in agreement with the author in this respect. Wo 
also agree with his observation that radium, while of 
groat value to the dermatologist, is of less importance than 
arc tho Roentgen rays. 

Finally, wo can only repeat what wo wrote in 1922 — ^that 
tho book is one which every skin specialist, should 
thoroughly digest, that it should prove invaluable to all 
radiologists, and that as a reference book for medical 
practitioners generally it should bo of much value. 

A book on x-ray treatment by Dr. Isek Solomon, 
with a preface by Dr. A. Beclere, entitled Precis dc 
Padiothcropic Profondc,^ is important not only to radio- 
logists, but to all who practise medicine or surgeiy, inas- 
much ns it is tho result of many years of highly scientific 
work. We know of no -book in which tho technique of 
treatment is so fully discussed. Tho first part, of some 
290 pages, is divided into eleven chapters dealing with tbo 
physics of x rays, with their biological properties, with 
x-ray' tubes and generating apparatus, and with protective 
devices. Not tho least important of these chapters are 
those on tho various instruments and methods for the 
measurcraout of dosage from the points of view of both 
quality and quantity. The author is a well known autho- 
rity on this part of the subject, and has devised a method 
which is very accurate, by the use of which different 
workers can ensure the same dosage and quality of radia- 
tion. Illustrations, diagrams, and tables to the number 
of 143 are a valuable addition to the text. Tlie second 
part, consisting of thirteen chapters, treats of clinical 
applications. Following a first chapter on general con- 
siderations in the x-ray treatment of malignant neoplasms 
there are chapters on sarcoma, malignant grmvths of tho 
uterus and ovaries, cancer of the breast, malignant disease 
as it affects tho digestive organs, and cancer as it attacks 
various other parts. Following this are two chapters which 
deal with tuberculous disease and the affections of the 
nervous ^-stem; fibroma of tho uterus and affections of the 
blood forming and controlling organs are each discussed 
separately; the final chapters deal ‘.with the glands of 
internal secretion and some other miscellaneous con- 
ditions in which x-ray' treatment is of value. There are 
, not many illustrations in this second part, and we are 
spai-ed the usual “ picture show ” of cases before and after 
treatment which, as a rule, are so very unconvincing and 
theatrical. The author is to be congratulated on his 
discretion in this respect. ’The fact that BMere has 
written the preface and has given his approval to this 
book is in itself a warranty of its value ; we can agree with 
everything he says about it. 


T 1000 I^-^IOLOGV IN DERMATOLOGY. 

W22 we reviewed the first edition of Dr. G j 
Pndivm in the Trcatmc 
f ■ ases of the Shin, and expressed a very favoural 
opinion upon It from all points of view. The author h 
now published a seco nd edition,' but though on exact 

n™'^Le^rL'‘prt'tac»'du'prof“'A'''T'‘ 

Aft'dioalcs No 1 fonv-iJn o ^sf^aire. Colfection de Monojjraph 
Us Secretariat de la SocitH^ ScientifiqueT Par 

6 LslKaO <!<l France. 1927. (64 x lOJ, j,p. 105; lo’figu, 

'‘n't’tirc Ilrlmndlunff. Von Dr. C. von Noort 
. It Kinipton. 1927.- S ^r^PP. 


A BIRD LOVER’S BOOK. 

If any excuse were needed for reviewing a book about 
birds in a medical journal, it would bo that so many 
medical men, in the past and the present, have devoted 
• their leisure to the study of these delightful creatures. It 
is curious that tho members of what is probably the least 
leisured of all callings should be able to find most time 
for their hobbies; and the study of natural histoi-y has 
■ always been the favourite. Possibly the study of botanv, 
i which includes gardening, takes prior place to all other 
i recreations of doctors, particularly those who are fortunate 
'.enough to ply their craft in countiy places. But, after all. 


’ Prcctv <U JiadiotMraptc Profondc. Par Dr. Iscr Solomon. . Preface 
•Dr. Bcclfetc. Paris ; Mas.-on ct Cio. (lied. Bvo * rr'see du 

• 174 figures. 103. or 60 fr.) * 


pp. xvi -f 512 ; 


18 Tan. 7, 1928] 


NOTES ON’ BOdKa.'” 


t Tnr nBiTtf* 
UcQiciz. Joinnii& 


botanj’ is the most natm-al choico when wo reinemher that 
tile medical man of to-day has not hoen divorced for so 
very long a time from the ancient craft of the herbalist. 

The work before us — The llamblings of a Bird Lover '" — 
is by a doctor, but of divinity, not medicine. His appro- 
priate name is already well known to thousands of bird 
lovers in this country. Dr. Haven states in his preface 
that ho makes no apology for this, his fifth book on his 
favourite subject. Why, indeed, should he, since it is a 
hook which will delight every reader who understands the 
thrill that is felt by all true bird lovers when a new or 
rare bird is seen or heard? The author confesses that ho 
was-born “ bird-mad.” After reading this book wo beliove 
him and rejoice that he was. Quito rightly the chapter of 
honour, the first, is devoted to the author’s namesake, the 
raven; and in the index of references this noble and, in 
appearance, somewhat clerical bird outnumbers any other 
by six to one. This also is as it should be. 

The book is one of the most delightful of its kind, and 
the author’s enthusiasm is such that the reader feels that 


skates in his preface, ” tho veterinary surgeon of to-day is 
following as closely as may be the specialist in Imniaii .surgery, 
and there is no obvious reason why liumairand canine surgery 
should not bo even more nearly alike.” There is no reason 
why the human surgeon should not bo able to profit by this 
adv.ance in tho surgeiy of tho most controllable of tho domestid 
mammals. Clearly, however, a fundamental knowledge of 
anatomy must precede the practice of surgery; and tliis volume 
provides such a fundamental and accurate substructure. It 
should prove also of considerable value to tho student of 
compar.ativo anatomy, who is already greatly indebted to (ho 
earlier volume. Notes on the Dissection of the Dog. The scope 
of the new edition has been widened ; new material has been 
added, and new illustrations by kir. J. T. Murray, an artist 
wlioso skill as an illustrator of anatomical works is already 
well known. Dr. Bradley is to be congratulated on a sound 
.and important addition to the standard works on .anatomy, 
one which sliouhl bo of great importance to both human and 
veterinary surgeons as well as to anatomists in general. 


PREPARATIONS AND APPLIANCES. 


he himself is one of tho author’s party on his oxciting 
expeditions. The volume is generously illustrated with 
original photographs. Most of these are excellent, but 
we have examined Plato ii, which is said to show tho nests 
of raven and buzzard with birds complete, in eveiy light, 
perspective, and angle, but have failed utterly to identify 
anything at all in either photograph. Otherwise it is im- 
possible to find anj'thing but praise for the written word 
and illustrations in this fascinating bird book. 


NOTES ON BOOKS. 

Or the making of popular books on health there is no end, 
but there must be a demand for them, or publishers would 
not undertake their issue. Most of them follow well defined 
lines. Differences appear only with the mentality of the 
writer. Some are crisp and some are dull. Some are sound 
and some are cranky. Most aim at giving the reader sonic idea 
of the manner in which his body machine is constructed and 
how that machine works. Dr. Barton, in his book That Body 
of Yours," has followed a different plan. He starts with the 
body working, and takes point after point in which tlie adult 
feels some sense of strain. Just as when the car driver who 
finds a spluttering in the carburettor turns up a book under 
the heading of ” irregular firing ” to find out the cause of the 
trouble, so Dr. Barton in his book takes salient signs and 
crisply deals with them. “ Are you losing your nerve? ” he 
asks in his first chapter, and then discourses thereon in a really 
intelligent and attractive stylo. But there is method besides, 
for the questions which make the subject matter of the 
chapters are on a plan. He begins with brain and nervous 
system, and so through the various functions of the body. His 
style is pleasant and simple. It is a good little book. 

The well known Manual of Psychiatry,'" of which Dr. A. J. 
Eosanoff is the editor, has iioiv reached its sixth edition. To 
the present volume many additions have been made, amongst 
which are sections on disturbances of nutrition in relation to 
mental disorders; psychoses associated with lethargic encephal- 
itis ; psychoses associated with pellagra ; residuals of cerebro- 
spinal meningitis; theory of personality; rest and diet in the 
treatment of mental disorders ; parole system ; prevention by 
eugenic measures ; mental disorders and hygiene of childhood • 
military psychiatry ; intelligence and educational achievement 
tests; and guide to study of personality. The contributors to 
this volume are Drs. Rogues de Eursac, from a translation 
of whose textbook this manual has developed, H. L. Holling- 
worth, Mary C. Jarrett, Clarence A. Neymann, and the editor. 


The Topograjihical Anatomy of the Dog'" is a continuation of 
the series of e.xcellent manuals on veterinary anatomy W’ritten 
by Dr. 0. Ch.vrnock Bradley, principal of the Edinburgh 
A^'etcrinary College. This volume follows (he plan previously 
adopted in the three volumes on the horse. It is written 
primarily for the use of the canine surgeon. As Dr. Bradley 


Tho Jlamblin^s of a Bird Lover. By Charles E. Raven, D.D. London : 
Martin Hopkinson and Co., Ltd. 1927. (Demy 8vo, pp. xvi+186; illus- 
trated. lOa. 6d.) 

“ That Body of Yours. By James W. Barton, M.D. People’s Library 
cdit|on, London ; Hodder and Stoughton, Ltd. 1927. (4^ x 7, pp. 304, 

j/anua? o/ Psychiatry. Edited by Aaron J, Rosanoff, M.D. Sixth 
edition, revised* enlarged, and illustrated. 'Kew York: John Wilev and 
I^ndon: Chapman and Hall, Ltd. 1927. (Med. 8vo. pp. 

4- OS7 ; 07 figures. 303. net.) 

» ropoj.np;,/cot .4,10(010!/ 0 / (7,0 Do,. By O. Cbarnock Bradlev, St.D . 

Boii 1927.''\R%-.iror"rp.'&‘Ta,8f8j"fe^s.“24^ 


Portable Low-Pressure Sterilizer. 

Mr. Charles AV. Cathcart, F.E.C.S. (Edinburgh), has devised 
an improved form of the cubical low-pressure sterilizer which 
was described by him in the Journal, December I9tb, 1914 
(p. 1056). It is, he says, a simple appliance wliich efficiently 
sterilizes the most resistant patliogenic organisms; tlie sporing 
culture of tlie antlirax bacillus was used as the test. 

Tlic apparatus consists of a cylindrical boiler (a). This 
encloses the sterilizing chamber, which measures 10 by 10 inches, 
and has a capacity of 864 cubic inches. In order to make the 
lid (b) steam-tight it is provided with a flange, which lies over 
a groove packed with asbestos. The screw (c), which takes 
its purchase from the curved liandle (o'), can thus be made to 
force llic lid firmly' down. The short handle (g) belongs to a 
three-way stopcock, wliicli is fixed inside the boiler. By mc.ans 
of this stopcock tlic attendant can, by a quarter of a (lircle 
turn, direct the steam from the boiler cither into the sterilizing 
chamber (as in Fig. I), or (as in Fig. II) into the collecting 
box (e), to be described later. In a half-way position of the 
stopcock tho steam will pass both ways. In no position can 
the steam be deprived of an outlet. 



Tho sliding plate (f) closes the water inlet. The short 
handle (h) controls' the stopcock for the exit of water at the 
aperture tii’), near the bottom of A. This arrangement enables 
the nurse to lighten the sterilizer before lifting it off the stand. 
The water escapes in a curved stream, which clears the stand. 
Complete emptying, if required, can be effected later by tilting 
the sterilizer. A suitable cover is provided to economize the 
heat during sterilization. , . , . , , , 

The stand (d) raises the sterilizer to the requisite height above 
the burner of the primus stove (i), which efficiently heats the 
boiler. The hook (j) is required to . attach tho stand to the 
handle of the sterilizer when packed for transport (see Fig. II). 

The collecting box (e) receives all the steam, whether directly 
from the boiler or indirectly, after it -has passed through the 
dressings. A water gauge (m) takes the form of a split metal 
tube, marked to indicate quarts. Into the groove a strip of 
“ rope-brown ” or similar paper is inserted. This grade of 
paper accurately retains the water-mark left by immersion. 
The water gauge, thus provided, runs no risk of injury during 
transport, and has, in this respect, a decided advantage over 
the glass-tube type. 

The condenser (k) consists of an open can, which is filled 
with cold water. It is furnished with a coiled tube (" worm ”), 
which is connected by a rubber tuba with the exit passage (l) 
of -the collecting box (e). The stand for it is similar to that 
for the sterilizer. 


Jan. 7, 10=8] 


COMMERCE IN' RADIUM. 


f Tmc BRinjnJ *! Q 
Medical JorRNAt 


Mode of JnlTod-ucing the Steam . — TIio steam enters the «TOor 
part of the sterilizing chamber and escapes at the bottom, riiis 
mctliod of directing steam has been recommended by Schimmol- 
buscli and Lelean. It has the great advantage of driving out 
nil air from the dressings without the use of any mechanism 
for the purpose. Since steam is lighter than air it accumulates 
at the top of the chamber, and by degrees displaces the air 
and drives it downwards. The air then escapes, first through 
a false bottom of wire gauze, and then through an exit tube, 
■whidi conducts it through tlio boiler to the collecting box (e), 
thus preceding the steam on the way to the condenser. Air 
in the dressings, if it should surround organisms, would, ns 
a non-conductor, effectively protect them from the action of 
steam. 

The “ drums,” which are “ Canton ” cloth bags, are 
cvlindrical in shape, with an arrangement of tapes which allows 
the edges to be folded over and securely closed. This material 
is very closely woven, and is fluffy on one side like swansdown, 
only much stronger. It is dustproof. Similar cloth “ drums,” 
although of a less close texture, have been used in several 
hospitals with quite satisfactory results. 

Test for Steam Permeation . — To ensure that ste.am is .able 
to permeate bags of " Canton ” cloth, tests were made at the 
laboratory of the Royal College of Physicians, Edinburgh, with 
silk threads infected with a sporing culture of anthr.ax. These 
threads were placed in the middle of dressings cont.aincd in 
the “ Canton ” b.ags. They were steamed for an hour in this 
sterilizer, and found to be sterile. The control threads showed 
active growth in culture medium. 

A card giving directions for use is supplied with the sterilizer. 
The m.akers are Messrs. Smith, Hurford and Drysdale ^21, 
Lauriston Place, Edinburgh), hir. Hurford has made applica- 
tion for a patent. 

The price of the sterilizer without the cover or the cloth 
" drums ” is £12 12s. The size and price of these “ drums " 
are as follows : 9^ by 4 by 4 inches, 3s. each; 10^ by 4^ by 
4i inches; 3s. 6d. eaclij 12 by 7 by 7 inches, 4s. each. 


COHniERCE IN RADItrsr. 

The history of the commerce in radium is that of succcs- 
sivo attempts made by one country after another to secure 
a monopoly. Tho original obseiwation of the Curies, 
reported to the Academic dcs Sciences on April 12tli, 1898, 
was that two minerals, pitcliblendo and chalcolite, wero 
more radio-active than could bo accounted for by the 
uranium they contained. They suggested that this was 
probably due to tho presence of some element much more 
active than uranium. A deposit of pitchblende at Joachims- 
.thal in Bohemia was then being worked to supply a small 
commercial demand for tiranium. Using a ton of tho 
Joachimsthal residues the Curies succoedod, with tho 
assistance of Debierne, in isolating a mixturo of radio- 
active substances associated with barium. By progressive 
separation from tho barium they obtained enough of tho 
active substance to enable its character to bo determined 
by the spectroscope, and in 1902 they produced radium 
chloride in a pure state. 

During the course of these experiments much was learnt 
about the properties of tho element radium, including 
tho main facts as to its physiological action, and it was 
soon seen that it might be of value in therapeutics. The 
mine at Joacliimsthal belonged to the Austrian Govern- 
ment, which sought to establish a monopoly, and founded 
an institute in Vienna to investigate the purposes to which 
radium could be applied. But these discoveries of radium 
directed attention to geological strata in other countries 
which were blown to contain uranium, such as the beds 
of autunite in Portugal, and of pitchblende in Cornwall 
and Saxony. Further deposits of pitchblende were found in 
the United States, in Mexico, and in India, but tho liiost 
important discovery was that of very extensive deposits 
of carnotite in Colorado and Utah. Though this mineral 
^ small proportion of radium (about 1 gram 
in 400 tons) it proved profitable to work it owing to the 
case with which the radium could be extracted. Hence 
there arose French and American attempts to obtain the 
monopoly of radium. 

At first most of the carnotite obtained in America went 
to I ranee, where the amount of radium extracted rose 
from about 3 grams in 1912 to 7 or 8 in 1914. But 
Mveral companies were formed in or near Denver in 
Colorado, with capital sufficient not only for the mining 


and transport of tho mineral, but also for constructing 
roads, factories, and settlements for the workers in 
a previously desolate country. Consequently, in 1913. 
10.6 grams of radium were produced on the spot,- and 
22.4 grams in 1914. At tho beginning of the latter year 
the American Government took stops to obtain a monopoly 
of radium, and decreed that, while radium-bearing mines 
already discovered should remain tho property of tho 
concessionaires, any further discoveries would become tho 
property of tho United States. Prospectors would be able 
to exploit them, but on terms fixed bj’ the Government. 

Tho American monopoly lasted until the Belgian society, 
tho Mining Union of High Katanga, which was working 
somo copper concessions in tho Belgian Congo, brought to 
light somo very rich lodes of pitchblende. The first deposits 
were found in 1913, and in 1915 further discoveries wero 
mado at Chinkolobwe. Tho existence of uraniferous lodes 
was confirmed in 1921 by Professor Schoep of Ghent; by 
tho end of the year tho first cargo of mineral reached 
Antwerp, and by July, 1922, the factory at Oolen was in 
working order. From that time the monopoly has passed 
into tho hands of Belgium, and tho American and other 
factories aro now in a state of partially suspended anima- 
tion, unable to compote with the Belgians, who at present 
supply most of tho world’s demand. 

Tho radium salt chiefly in request at present is tho 
sulphate, which is found jnost suitable for the preparation 
of radium applicators. Tho chloride and bromide, which 
aro easily soluble, can also bo obtained, and are considered to 
be preferable when radium emanation is required. Radium 
is now generally sold in tcims of radium clement, and the 
price of either salt is calculated on that basis. According 
to a table given by Professor Matignon in a recent article,' 
tho prico rose from £2 to £5 a milligram in 1904 to twice 
that amount at tho end of 1905, and to £12 in 1906. By 
1910 the price had risen to £27; it went to £30 in 1912, 
and £36 in 1914. This seems to have been the highest 
point over toucliod. Tho rise occurred in spite of compe- 
tition, and seems to havo been greatest at the time when 
the- French were engaged in extracting radium from the 
carnotite imported from Colorado. With the establishment 
of factories in tho United States tho price began to fall, 
and was becoming stabilized at about £22 a milligram in 
1922, when tho Belgian production caused a further fall 
to £14 in 1923, and tho prico is now £11 ICs. 

AVith tho exception of chalk and the quartz sands, which 
aro almost without any trace, nearly all rocks of the earth’s 
crust contain some radio-active material, usually in quan- 
tity so minute- as to be detected only b}- veiy- delicate 
methods. The richest in radium aro the igneous granitic 
rocks; sedimentary rocks havo a smaller content. All 
spring waters which havo been in contact with strata con- 
taining radio-activo material are more or less radio-active. 
This applies to mineral waters so designated, but whether 
their therapeutic effects are on that account increased or 
modified in any way does not seem to be established. The 
chief sources for the extraction of radium are uraniferous 
minerals, and tho processes utilized are all based on the 
original method of the Curies and Debierne. The presence 
of barium is essential, and it is added to minerals which 
contain an insufficient quantity of this element. Insoluble 
sulphates are precipitated in the process, and when the 
residues are sufficiently pure they are submitted to a series 
of crystallizations, generally as radium bromide, until the 
radium has been separated from the barium. 

Professor Matignon estimated that down to the end of 
1924 a little over 300 grams of radium had been produced. 
Of these, 23 came from the Joachimsthal mine, and 
tho total European production before the Belgian factory 
was established was about 60 grams. The Americans 
claimed that about 160 grams wero extracted from carno- 
tite. The rate of production at tho Oolen factory in 
Belgium suggested that by the end of 1924 it had iiroduced 
110 grams. Half the total quantity in the world appeared 
to be in Amei-ica, where the hespitals and medical institutes 
owned over 120 grams. To dispose of these 300 grams of 
radium complicated commercial machinery was necessary. 
Money was spent to educate the medical profession in the 

' Pev. Scientifique, 1925, 15, p. 521. 







GALti-BtiABDER INFECTIONS. 


[ Tm; Urttith 
MrpiciL 


22 Jan. 7, 1928] 


may, and often do, precede any structural changes, 
the organs have so much functional reserve and power 
pf compensation that morbid changes may begin and 
^sidiously advance before producing any outward 
signs and symptoms. Histological examination of 
Organs, especially in an early stage of disease, should 
therefore be the handmaiden of cUnical research, and 
hot, as has sometimes been said, merely an investiga- 
tion of the late or end results. 

“ Tlie pathology of the living ” is the lecturer’s now 
familiar phrase for the morbid changes revealed by 
a biopsy or operation, not only in the organ or struc- 
ture which seemed to be mainly affected, hut also 
;elsewhere. The instance that occurs to mind is a 
diseased appendix found when operating for a diseased 
gaU bladder — that is to say, two coexisting and 
perhaps related infections, the one diagnosed clinically, 
the other and more severe revealed only by the scalpel. 
Study of such associated changes is helping to eluci- 
date the problem of the origin of disease, and of the 
influence that a morbid process in one part has on the 
other parts with which it is physiologically correlated 
in health. Taldng the gall bladder and its infections 
ns his Bubiect, Sir Berkeley Moynihan has provided 
put of a vast experience of this pathology of the living 
— fortified by detailed special investigation by labora- 
tory methods of eighty-one eases of cholecystitis — 
much material for thoughtful criticism and study of 
its bearings on the present and future practice of the 
healing art. 

In view of the fact that in order to prevent grave 
complications cholecystectomy is advocated earlier 
and more frequently than is even now the practice, 
it is clearly important to have more exact know- 
ledge about the functions of the gall bladder. 
Clinical experience — which, after all, is the working 
criterion — does not suggest that the removal of 
the organ is attended by untoward symptoms. 
But it may be wise to recall the cautious attitude 
of Peyton Rous and P. D. McMaster of the 
Kockefeller Institute for Medical Eesearch, New York. 
These workers, in their paper on the concentrating 
activity of the gall bladder, ‘ have pointed out that it 
probably has other functions; that its secretion of 
mucus (which, like the concentration of bile, is a 
function of the gall bladder as distinct from the ducts) 
is unexplained; and that the fact that removal of a 
normal gaU bladder is not followed by bad eSects 
roves, not that the loss is unimportant, but that the 
ody has adapted itself to the loss. On the other 
hand, as the lecturer’s observations attest, an infected 
gall bladder often shows much more change under the 
microscope than naked-eye examination would suggest; 
its removal, therefore, is on quite a different plane, 
and appears to correspond with appendicectomy. 

After considering, on the basis of his carefully 
examined cases, the waj^ in which infection reaches 
the gall bladder. Sir Berkeley Moynihan concludes 
that in 63 out of 81 cases infection began in the 
outer coat, and might arrive directly or hy way of 
the lymphatics from the liver (the hepatitis here 
being almost certainly antecedent to the chole- 
cystitis), or from peritoneal Inflammation of an 
adjacent organ, such as the appendix. Only in 18 
instances was the inflammation more pronounced in 
the inner than in the outer coat of the gall bladder, 
and there was reason to think that the infection 
ascended from the duodenum more often than might 
be anticipated, particularly in the presence of 
achlorhydria, when Oddi’s sphincter at the biliary 

^Journ. Erper. Ued., 1921, jcnlr, 47-73. 


papilla may possibly bo relaxed. • In reviewing the 
evidence the lecturer admits the occurrence of 
haematogenous infection of the gall bladder, but 
chiefly pays attention to infection hy way of the 
lymphatics. He argues (hat, ns the outer coat of 
the gall bladder is usually first inflamed, there is in 
the early stage increased absorption from the cavity 
of the gall bladder with a consequent rise in the 
cholesterol content of the blood; later the lymphatics 
may become blocked, so that, from continued absorp- 
tion by the mucosa (as Chiray and Pavel also have 
staled), the villi become occupied by cholesterol; hence 
arises the condition first described by him, then called 
‘‘ the strawberry' gall bladder,” and later cholestcrosis 
— a condition that never occurs when bile is 
prevented from entering the gall bladder. Detach- 
ment of these lipoid-laden villi may give rise to a 
generation of minute calculi which proceed to grow 
and cause secondary changes in the gall bladder — 
namely, destruction of "the mucosa and the elastic 
and muscular tissues, and fibrosis. 

The conclusion that cholecystitis and the subsequent 
formation of calculi are duo to infection of the gall 
bladder from without rather than to direct infection 
of the mucosa by bacteria-laden bile has an important 
bearing bn the most effective form of treatment. Sir 
Berkeley Moynihan considers that if the infection were 
fr'om within, medical treatment and Lyon’s non- 
surgical drainage of the gall bladder in the early 
stages might be successful; but that if the infection is 
from without and widespread, removal of the gall 
bladder is, in the present state of knowledge and 
pending the discovery of other means of controlling 
the earlier symptoms of cholecystitis, the proper pro- 
cedure. Further, in cases of obstinate dyspepsia he 
has often hesitated to remove a gall bladder which did 
not appear at the time of laparotomy to show much 
change, and when he has refrained from cholecyst- 
ectomy in these circumstances the symptoms have not 
been relieved until this was performed, ilere, then, 
the ideal of “ surgery to end surgery ” has not yet 
been entirely attained, although much progress 
towards it has been made. 


THE PARLIAMENTARY SESSION. 

The parliamentary session of 1927 has gi3en satisfac- 
tion to medical members of Parliament. They have 
seen the gusts of political prejudice against the medical 
profession die down after having blown with occasional 
bitterness in consequence of the controversy about 
the Axham case, and the disposition of trade unionist 
members of Parliament, when charged with intimida- 
tion or restrictive practices in the unions, to seek to 
make analogies reflecting upon the medical profession 
and the General Medical Council. Even the questions 
put down on behalf of the antivaccinators have been 
less pertinacious, in part because the Royal Com- 
mission on Vaccination was in being. Only at the 
close of the session v.'ere questions asked by members 
which conveyed a suggestion that a report from this 
Commission was overdue. The Parliamentary Medical 
Committee projected an open meeting at which lay 
members of Parliament would hear the medical case 
for vaccination, but this proposal was not persevered 
with. There has, too, been cbmparatively little 
agitation on the floor of the House of Commons by 
antivivisectors, and rumours have been heard that the 
less prejudiced of these may yet be persuaded to 
accept a compromise regarding the use of stray dogs 
for experiment. 



Jan. 7, 192S] 


THE PAKLUMENTAKT SESStON. 


r 'Tnr. llr.msH 
LMedical JoUBNAt 


' A growing proiuclico and source' o£ difliculty in 
niodical legislation, though not antiincdical, has been 
maiiifost during the year. It is the prejudice of tho 
minor local authorities against any legislation or 
rearrangement of duties which would increase tho 
powers of county councils and county borough councils. 
Tho Eoyal Commission on Local Government has long 
been preoccupied with these objections, which have 
forced Mr. Chamberlain to modify his scheme of 
centralizing Poor Law administration under county 
councils and county borough councils, and compelled 
him also to accept a last-minute compromise on the 
Nursing Homes Act, which weakened the principle of 
licensing and inspection by county authorities estab- 
lished a year previously in the cognate Midwives Act. 
In expounding his Poor Law scheme to members of 
Parliament and to local authorities Mr. Chamberlain 
has laid most stress on the need for co-ordination and 
economy in public health administration, and in 
particular for making certain little-used ward accom- 
modation in some Poor Law institutions available for 
the relief of other institutions, including voluntary 
hospitals. He has said emphatically that he does 
not propose to bring voluntary hospitals under public 
control, and in recent answers to questions he has 
declared that he cannot contemplate additional grants 
of public money to voluntary hospitals, which, in his 
opinion, have now been put in a secure position by 
the improvement in public support. Jlr. Chamberlain 
still hopes that his Poor Law Bill will be one of the 
features of the Government programme in 1928, but 
though he has practically promised to continue the 
boards of guardians in rural areas, the passage of the 
bill into law is not assured. Still less assured of 
becoming Acts tliis 3 'car are the bills to bo based upon 
the reports of the Iloyal Commission on Lunacy and 
the Eoyal Commission on National Health Insurance. 
The latter at least has a chance, but the Government 
at the close of the session could give no promise 
concerning it. 

It is also accepted by political observers as certain 
that the Factories Bill, to which the Home Secretary 
has given much attention, will, if introduced this 
jear, be reduced to little more than a codifjdng 
measure. The Home Secretary has, however, 
announced that he hopes, by Order in Council, to 
reduce the danger of fires in factories where celluloid 
is handled. The revision of the Factories Bill has 
been forced bj' the wide objection to legislation involving 
increases in public expenditure and in the numbers of 
public officials, but two departments doing work of 
indirect interest to medical men — the Transport 
Ministry and the Mines Department — have been 
icspited from the closing order, to take effect next 
spring, which the Chancellor of the Exchequer had 
pronounced against them. 


teferences to subjects of medical importance havi 
f fhe Home Seeretarj' and the Ministe: 

o ducation during the session, and the pronounce 
men s of the Minister of Agriculture regarding disease 
animals included the important matter of thi 
possi e association of the importation of pig carcassei 
TiHr,' foot-and-mouth disease. Thi 
pvpr* chiefly concerned with health matters, how 
Wnn’rl Chamberlain and Sir Kingsle’ 

Patpo.J, their position in thi 

hiicinopp “embers, have handled departmenta 
Acts nf " 1 - ’ succeeded in guiding severa 

Acts of 1 ^ ^ 

nrivaS responsibility is taken for bills b- 

P ' members, acting in consultation with thi 


Ministry of Health and supported in Committee by 
tho Minister or the Parliamentary Secretary, has 
secured the passage into law of the Mental Deficiency 
Act, providing that tho sequelae of encephalitis 
lethargiea in adolescents can be classed as mental 
deficiency, of the Nursing Homes Eegistration Act, 
and of tho Midwives and Maternity Homes (Scotland) 
Act. An Act, for which Mr. Chamberlain was 
responsible, has been passed to codify the existing 
Poor Law as a preliminary-to its amendment. The 
Dominion Office, aided by the Minister of Health, 
secured the assent of Parliament to the Medical and 
Dentists Acts Amendment Act, removing difficulties 
consequent on the setting up of a separate medical 
register in the Irish Free State. 

■ Both individuallj’ on the floor of the House and in 
Grand Committee, as also when working as a body 
through the Parliamentary IMedical Committee, in 
collaboration with Lord Dawson and wnth certain 
members of Parliament with professional or academic 
associations, medical M.P.’s have done steady work, 
securing the attention of the House of Commons and 
exerting marked influence on their parties and on 
the Government, Dr. I'rernantlc has been an efficient 
and popular chairman of the Parliamentary Medical 
Committee, and has also presided over the Conserva- 
tive and Unionist Party Committee on Health and 
Housing. Dr. Graham Little, till close on the end 
of the session, was the active honorary secretary of 
the Aledical Committee The Medical Practitioners 
Communications Bill which he introduced came before 
the House of Commons too late to make progress, 
but drew the attention of legal and laj' members of 
Parliament to an important question of law and ethics. 


NEW YEAR HONOURS; 

The New Year Honours list, issued on Mondaj-, Januaiy 
2nd, contains names which the medical profession will 
delight to SCO honoured. A baronetcy is conferred on Sir 
Itichiud Havelock Charles (serjeant-surgeon to tho King), 
who lias had a long and very honourable career, first in 
India, and after his return to this country as president 
of the Medical Board of tho India Office, and Medical 
Advisor to the Secretaiy of State for India. In that 
capacitj- he was able to do much for the Indian Medical 
Service at a time of great difficult 3 '. AVhile in India Sir 
Havelock Charles was professor of anatomj’ at Lahore, 
and afterwards professor of surgery at Calcutta. A knight- 
hood has been conferred on another distinguished surgeon, 
Mr. Perej’ Sargent, who was consulting surgeon with the 
British army in France, and is now consultant surgeon to 
the Ministiy of Pensions. He is surgeon to St. Thomas’s 
Hospital and to tho National Hospital, Queen Square. Ho 
is well known to the profession as a general surgeon, and 
also as a specialist in tho surgeiy of the brain and spinal 
cord. Tho honour of knighthood is conferred also on 
Dr. G. AV. Badgerow, honoraiy lieutenant-colonel of tho 
Canadian Army Medical Corps, dean and surgeon to the 
Throat Hospital, Queen Square, London, and consulting 
surgeon to various Dominion hosjiitals in England. Tho 
knighthood received by Mr. F. G. Hallett, who, after fiftj- 
yeara’ service, recently retired from tho office of secretary 
of the Conjoint Examining Board in England of the Royal 
•Colleges of Physicians and Surgeons, is, it will generally 
be recognized, very well deserved. His powers of organiza- 
tion, his long experience in all matters relating to examina- 
tion, and his exceptional knowledge of regulations for 
medical' education in this and other countries, gave his 
services a very special value and caused them to bo held 
in tho highest regard. The same honour has been received 


24 Jan. 7, 1928] 


IODINE, GOrrEE, AND GROWTH. 


[ Tur nr.msa 

MKKICAL JoCRNiL 


by Dr. William James Wanloss, of tlio American Presby- 
terian Mission Hospital,- Miraj, Bombay, and n'ould have 
been received by Alderman James Robinson, L.R.C.P. and 
S.I., who was Lord IMayor of Cardiff in 1913-14, had lie 
survived a few days more; he died on December £7th, as 
recorded elsewhere. Major-General James Stuart Gallic, 
C.M.G., D.S.O., K.H.S., late R.A.M.C., Deputy Director 
of Medical Seiwices, Aldershot Command, receives the C.B. 
(Military); Dr. Robert George Archibald, D.S.O., director 
of the AVellcome Tropical Research Laboratory, Khartum, 
becomes C.M.G.; and Lieut. -Colonel Cuthbert Lindsay 
Dunn, I.M.S., director of public health. United Provinces, 
becomes C.I.E. Miss Ellon Margaret Earrer, M.B., medical 
missionary. Zenana Baptist Mission, Punjab, is awarded 
the Kaisar-i-Hind Medal of tho first class for public 
services in India. 


IODINE, GOITRE, AND GROWTH. 

Dll. Pekcy Stocks, in an article on the influence of iodine 
administration on goitre incidence and physical growth,’ 
brings forward further evidence of tho efficacy of tho 
ticatment. He has found a class of subjects particularly 
f.avourable for statistical treatment in the secondary school 
of Berne. Tho records of treatment of 1,130 girls in that 
school are exceptionally complete and accurate, and have 
enabled Dr. Stocks to plot a series of curves which show 
with great clearness tho continuous reduction of tho gland 
under treatment. The method adopted is to classifj’ the 
girls in a series of age groups differing progressively by 
one year between the ages of 11 and 16; tho size of the 
thyroid is then registered for each group at gradually' 
increasing periods from tho commencement of treatment, 
thus showing flic effect on tho gland in each group at tho 
beginning of treatment and after one, two, and three 
years. It was found that in eveiy' ago group each addi- 
tional year of treatment is as,sociated with a marked fall 
in the size of the gland. In estimating the size of the 
thyroid use is made of the system of categories based on 
that of the Swiss Goitre Commi.ssion — namely, (1) thyroid 
just paljiablo, (2) gland easily felt, but not sufficiently 
enlarged to chango the contour of the neck appreciably, 
and (3) very obvious enlargement, going on to pronounced 
goitre. By a conventional calculation two intermediate 
categories are added to these, making five in all. The five 
categories are regarded as equal divisions on a uniform scale 
of thyroid size, category 1 being taken as origin (0) and 
the remaining categories as deviations from this — namely, 
1, 2, 3, and 4 respectively. The author considei-s that 
there can be no doubt whatever of the significance of the 
decreases exhibited in the cuiwes, and that the efficacy of 
the treatment can bo safely accepted. The main object, 
hoivever, of the research was to examine tho effect of iodine 
treatment on the growth of the body between the ages of 
11 and 16, in girls having diffeient degrees of goitre at 
the commencement of treatment. Those with pronounced 
goitres (categoiy 3 above mentioned) exhibited about 3 cm. 
(height) and 31 kg. (weight) in excess of the mean growth 
after two or three years’ treatment; and the descending 
series of categories showed a gradually diminishing excess, 
that of category 2, for examjile, showing an excess of 11- to 
2 cm. and kg. in two years. It thus appears that the effect 
of iodine treatment increases progressively with the severity 
of the goitre at the commencement of treatment. That a 
retardation of growth goes hand-in-hand with goitre is well 
recognized; that tho increased growth after iodine treat- 
ment is greater in girls with initial goitre is probably' duo 
to the counteraction of this retardation in districts severely 
affected with the disease. A similar effect on the physical 
growth of normal girls in non-goitrous districts cannot 

'Anualt of Eujoiicr, Vol. II, Parts III and IV, p. 382. 


ncco.ssarily bo inferred. In a second paper, written in 
collaboration with Mary N. Karn,f tho relation hetween 
the prcvalenco of thyroid enlargement in children and tho 
mortality from other diseases is statistically examined. The 
more important results of tho research have reference to 
Graves's disease and cancer. It is found th.at of the largo 
towns those which have tho greatest percentages of children 
aged 12 with enlarged thyroids tend to have a gi'cater 
mortality from Graves’s disease. This seems to support 
the suggestion, already made by Dr. Stocks, that Graves’s 
disease has two causal factors — one local and responsible 
for endemic goitre, and tho other a nervous factor. AVith 
regard to cancer, the authors find that a positive relation- 
ship exists botircen the prevalence of thyroid enlargement 
in childien and tho cancer mortality in the largo towns 
of England and AVales, similar to that found from Swiss 
and American statistics, but less pronounced. 


CANCER OF THE UTERUS. 

The Ministry of Health, through its departmental com- 
mittee on cancer, has made a statistical investigation cf 
the various methods of treating cancer of the uterus, as 
was done in the case of cancer of the breast. A memo- 
randum on mammary cancer was published in 1926, and 
was considered at some length in our issue of September 
25tli, 1926 (]). 575). A memorandum on uterine cancer’ 
(Circular 826) has now been issued to local authorities in 
England and AA’alcs, and contains some recommendations 
v.'hich will icquiro careful considei'ation. In an intro- 
duct-ory note it is stated that about one-fifth to one-sixth 
of tho total mortality of cancer among women is duo to 
involvement of tho utoriis, and that this is relatively moro 
eommon among tlio married and widowed than among the 
single; in recent years there has been a tendency for tho 
death rate from uterine eancer to fall. No special evidence 
was found that the disease is associated with the meno- 
pause, and the explanation suggested for tho prevalent 
contrary view is that at this period women liave loss 
hesitation in seeking treatment than later in life. On 
the average rather fewer than half those applying for treat- 
ment were found to be in an operable condition, and the 
average operative mortality is given as 10 t-o 20 per cent., 
with a tendency to decrease. If recurrence follows opera- 
tion it appears to do so in fiO per cent, of patients within 
five ycais, thus rendering survival for this length of timo 
a reliable criterion. Treatment by' radiation results in the 
survival of about 10 to 12 per cent, of inoperable cases for 
a period of five years, and when patients in tho operable 
class are included the rate rises to about 40 per cent. In 
England, however, this treatment has been relatively less 
used than, in ether countries, and the conclusion is reached 
that, pending further developments, the chief reliance 
must be placed on .operative surgery. It is concluded that 
the incidence cf carcinoma of tho cervix may' be definitely 
reduced by improved treatment of local lesions incidental 
to childbirth, and it is possible that radiological procedures 
will become even more effective than they are at present. 
Emiihasis is placed on tho importance of commencing any 
form of treatment early, and it is suggested that health 
authorities and cancer committees should educate women as 
regards the importance of immediate and thorough investi- 
gation of any irregular uterine haemorrhage. Some local 
authorities have established special centres or clinics 
designed to facilitate diagnosis and to give advice; and it 
is thought that in this way, as well as in others, means may 
be found for inducing a larger number of jiatients to 
undergo treatment at a stage where the prospect is hopeful. 

= .-liniof* of Eugenics, Vol. II, Parts III and IV, p. 395. 

* H.M. Stationery Office. Price Id.’ net. 


JjkK. 7, igzS] 


■ PREVENTIVE MIDWIFERY. 


[ Tnc British OR 

SIZDICAL JoCRXAt. 


METHODS OF, MEDICAL EDUCATION.. 

The eighth series of Methods and Prollcms of Medical 
Education has lately boon published by tho Kockefcller 
Foundation.* Liko its forerunners, it has boon arranged 
by tho Division of Slodical Education in accordanco with 
their plan for collecting and issuing from time to tiino 
brief descriptions of clinics, laboratories, and methods of 
teaching in difforent parts 'of tho world. Tho eight 
Toliin:cs, or sopnfato' reprints of any of the articlp.s, will 
bo sent gratis on application to the Eockofeller Founda- 
tion, 61, Jlrendway, Now York. Tho present series, a 
book of nearly 400 pages, well printcil and lavishly illus- 
trated, includes articles by authorities on medical educa- 
tion in Europe and America. Whilo tho arrangement 
under subjects is not strictly followed, tho earlier pages 
aro mainh- concerned with tho teaching of clinical medicino 
and tho lay-out of medical wards. Then follow groups of 
papers on pediatric departments, on cardiology and heart 
clinics, and on tho teaching of general surgery and tho 
organization of surgical departments. Methods of clinical 
instruction in Great Britain ■ aro dealt a-ith in papers 
contributed by Sir Archibald Garrod, Sir G. Lcnthal 
Chcatle, and Professors Francis Fraser, D. P. D. Wilkio, 
and George Cask; an' account of tho new obstetric hospital 
and residents’ quarters at University Collego Hospital, 
London, is given by Sir George Blacker and Professor 
F. J. Browne; and tho electro-cardiograph department of 
the Edinburgh Royal Infirmarj’ is described by Dr. W. T. 
Ritchie. Sfost of tho articles on Continental schools of 
medicine arc printed in tho language of tho country. It 
would make a dull category to namo hero tho thirty-soven 
. separate articles and their authors, but on a future occa- 
sion wo may tiy to pick out somo threads that appear to 
run through a group of papers un related subjects. 


PREVENTIVE MIDWIFERY. 

PnoFESsoR R. V'. Jousston'e’s valedictory address to tho 
Edinburgh Obstetrical Society, which is printed at page 6, 
contains much material for thought. Prevention is a word 
widely used in general medical literature, and he would 
have it henceforth express tho leading idea in obstetrics. 
He a’ould apply it also to ante-natal care, which, as 
ho says, promises immediate improvement in maternal 
mortality, and is thoreforo true prevention. Professor 
Johnstone remarks on tho recent growth of this work, 
hut seems to question whether its importance is even yet 
sufficiently recognized by the older generation of medical 
men. Perhaps tho suggestion hero is too sweeping; the 
nays in which it is now seen that ante-natal caro should be 
exercised have increased, but tho idea existed before, as 
nitness the continuous watch for albuminuria, which has 
gone on for many years in general practice, to tho saving 
lom eclampsia of many patients who would otherwise 
lave developed it. Perhaps, too, he exaggerates when he 
expresses a desire that 99 per cent, of mothers should 
a tend ante-natal clinics; even if this is to bo understood 
° **PP y to working-class mothers only, surely it is not the 
case t lat only 1 per cent, have doctors who can bo trusted 

0 impicsB on them the simple needs of ante-natal care. 
01 po such instruction and advice is given in general 

some may think. Professor Johnstone, in 

1 ( at mg 01 more intra-iiatal care, reminds us how greatly 
10 noi ^ 0 Simpson and Lister has increased tho amount 
. opcia no midwifen-. T),ig jg obviously correct, and an 

os iiiGM able result is that we begin to think of it 

snvJ' 1 ®*'*'Sevy. Instrumental intervention, he 

3 1 las ocome easy; “the pendulum has swung too fai 
aiic u e must tiy to bring it back to the greater safety 

Votkf 


of tho middle lino.” Ho sees another pendulum swingingy 
this- time towards tho supersession of doctors by midwives. 
Much has been heard in iccent years of tho lower moi-tality 
in the midwives’ than in tho doctors’ practice, and the 
comparison,; unless variations in tho conditions aro fully 
recognized, is apt to bo unfair to tho general practitioner. 
If a similar sort of comparison were to bo made between 
tho treatment of simple fractures and complicated frac- 
tures tho unfairness would bo obvious, for tho results in 
the complicated fractures would bo expected by everybody 
to bo less good. The cases seem to bo parallel, or at least 
ccniparablc. Apart from this suggestion of injustice there 
seems to be no reason to object to tho chango from tho 
medical practitioner to midwife, especially as in many 
important areas midwifery is already in the hands of 
trained midwives, tho doctor only being called in where 
help is needed. Apply to this existing situation a closer 
ante-natal supendsion on tho part of tho doctor, and tho 
difficulties should bo largely solved. There will, it is true, 
always bo persons to agree with Mr. Neville Chamberlain 
in hoping for a time when all serious cases will ho dealt 
with in hospitals; but even if this were really practicable 
tho expense would bo enormous and tho expected improve- 
ment by no means certain. It would, moreover, imply tho 
extinction of tho family’ doctor as a factor in tho case, and 
Professor Johnstone is clear that this is not desirable. 
Perhaps tho situation might he helped by a greater uso 
of tho cottage hospitals. Much good surgei-y is already 
done in theso, and the same might occur in obstetric work. 
Another idea of much interest which calls for examination 
is his plea for an " obstetric atmosphere.” Taken too 
literally this conjures up strange visions. But if it is to bo 
accepted as a plea for an enlarged idea of tho importance 
of all the new agencies which make for the guidance of 
tho expectant mother, then it is one to be energetically 
supported. Sir Thomas Clouston used to plead for what he 
was tho first to describe as a “ health conscience,” and 
perhaps a similar “conscience” is what Professor Johnstono 
seeks. Bo that as it may, the idea is full of possibilities. 
On tho question of education in obstetrics, Pi-ofessor John- 
stone deplores tho shortage of practical opportunities for 
tho medical student, and contrasts with this the dispro- 
portionate amount of practical training enjoyed by pupil 
nurses. With tho admitted need for proper training of 
nurses and the restricted amount of clinical material this 
may bo inevitable; but there seems to be somo doubt 
whether tho General Medical Council’s regulation about 
t-wenty cases duly conducted by every medical student is 
regularly' complied with everywhere. The fact appears to 
bo that with an alleged deterioration in the quality of 
midwifery practice by doctors there has been pari passu 
a genera! rise in tho education and the competence of 
midwives, and it might bo a reasonable inference that theso 
stand in relationship. 


CONFERENCE ON RHEUMATIC DISEASES. 

A CONFEREXCE on rhcvimatic diseases is to be held at Bath 
— ^an appropriate setting — on Thursday and Friday, May 
10th and 11th, under the presidency of Sir George 
Newman, Chief Medical GfReor of the 3Iinistry of Health. 
Thero will bo three sessions: (1) social aspects, presided 
over by Lord Dawson of Penn; (2) causation, presided over 
by Sir Humphry Rollcston, Bt., Regius Professor of 
Physio in tho University of Cambridge; and (3) treatment, 
presided over by Sir E. Farqiihar Buzzard, Regius Pro- 
fessor of Medicino in tho University’ of Oxford. The 
chairman of tho organizing committee is Dr. F. 6. 
Thomson, Past President of the British Medical Associa- 
tion, and tho local honorary medical secretary is Dr. 
Vincent Coates, 10, Circus, Bath. Further particulars 
i will bo announced in due course. 


26 Jan. 7, 1928] 


BEGISTEATION OF OPTICIANS. 


[ Tin BRiTif* 
UxoiCAX. JotrBNAX. 


MEDICAL SOCIETY OF LONDON. 

Thk Medical Society of London lias now issued its 
programnie of work for the second half of tlio present 
session, with which one hundred and fifty-five years of 
useful life will ho completed. The ordinary meetings have 
hecn arranged as usual for Mondays at 8.30 p.m. A patho- 
logical evening on January 9th will ho followed a fortnight 
'later by a discussion on the treatment of pernicious 
anaemia, the openers Ixiing Professor F. It. Fraser, Sir 
■\Villiam 'Willcox, and Dr. Herbert French. On February 
13th the subject of ultra-violet light therapy, its 
use and abuse, will bo introduced by Professor Leonard 
Hill, Dr. O’Donovan, and Dr. C. B. Hcald, and on 
Februaiy 27th 'the scope of surgery in the treatment of 
chronic rheumatoid and osteo-arthritis by Mr. Max Pago 
and Mr. Harry Platt. The discussions on JIareh 12th and 
26th will be on the carrier problem, opened by Dr. J. E. 
McCartney and Dr. John Freeman, and on advances in tho 
treatment of cancer of tho cervix uteri, opened by Dr. 
Herbert Spencer and Dr. Max Choval of Brussels. This 
year’s Lettsomian Lectures, on rheumatic heart disease in 
childhood, will be given at 9 p.m., by Dr. F. J. Poynton, 
on February 20th and 29th and March 7th. The annual 
dinner is to be hold at tho Trocadero on March 8th, and 
the se.ssion closes on the evening of May 14th with tho 
delivery of the Annual Oration by Sir Archibald Garrod on 
" Lessons of rare maladies,” and the annual general 
meeting and conversazione. 


WELFARE OF THE BLIND: ADVISORY COMMITTEE. 

I.v view of the continued development in tho work among 
the blind owing to the operation of tho Blind Persons Act, 
1920, and the new problems constantly arising in connexion 
with this service, the Minister of Health has reappointed 
the Advisory Committee on the AVelfarc of the Blind for a 
further period of office. The committee has been consti- 
tuted so as to afford representation to the local authorities 
concerned with tho working of the Blind Persons Act, 
1920, and to voluntary agencies for the blind, as well as to 
organized blind workers. The chairman is the Eight Hon. 
G. H. Eoberts, and the vice-chairman Mr. P. M. Evans, 
LL.D. The medical members are Dr. J. J. Butterworth, 
Dr. Eobert A. Lyster, Dr. H. A. Powell, and Dr. Adeline 
M. Eoberts. The committee will advise the hlinister on 
matters relating to the care and supervision of the blind, 
including any question that may be specially referred to 
them b3- the Minister. Mr. F. M. Chapman of the 
Ministiw of Health will act as secretary. 


HUNTERIAN LECTURES. 

SiK Arthur Keith will give a course of six Hunterian 
Lectures before the Eoj’al College of Surgeons of England, 
on factors concerned in the growth of the human body, 
on blondays, AVednesdaj's, and Fridays during January, 
beginning on Monday, Januaiy 16th, and ending on Friday, 
Januaiy 27th. The first lecture will deal with Hunter’s 
experiments on growth and grafting, and the second with 
the growth of living tissues under experimental con- 
ditions and tho bearing of the knowledge thus obtained 
on abnormal growth of tho human bode". In tho third and 
fourth tho growth-controlling functions of the pituitary 
gland, and the influence exerted by the thyroid and para- 
thyroid glands on the growth of tho bod}-, will be con- 
siilercd; in tho fifth tho manner in which sex glands 
exert their influence on the growth of the body as a rvhole, 
and on its special parts and organs, will be discussed; and 
the last lecture will contain a review of the evidence for 
including the suprarenal and pineal glands among tho 
conti oilers of growth. Tho lectures will be delivered at 
5 o’clock on each day. 


• • •- BEGISTEATION OF OPTICIANS. , 

Eeport of Departsiental Committee. 

In March, 1927, the Minister of Health and the Secretary 
for Scotland appointed a Departmental Committee to con- 
sider the Optical Pi-actitioners (Eegistration) Bill and 
to make recommendations. Tho chairman was Mr. F. B. 
Merriman, K.C., M.P.', and the ' other members were 
Mr. 0. Aves, Mr. W. B. Barker, Dr. H. B. Brackenburv, 
Mr. L. G. Brock, Mr. E. Treacher Collins, F.E.C.S., liirs. 
■W. L. Courtney, Lord Cozens-Hardy, Mr. Ehys Darios, 
AI.P., 3Mr. H. L. F. Fraser, Dr. 0. 0. Hawthorne, Mr. 
G. E. Houghton, and Sir Henry Keith. 

The Committee held fourteen meetings, all in private, 
and its report has now, been issued.' 'This consists of a 
majority report, signed by nine members, including the 
clmirinan, the upshot of which is that tho establishment of 
a State register of sight-testing opticians is not in itself a 
desirable policy. There are also two minority reports, 
both in favour of registration, though on somewhat 
different grounds. One is signed by Messrs. Aves, Barker, 
and Houghton, and tho other by Mr. Ehys Davies, who 
went abroad before the Committee’s report was drafted. 

Among tho bodies which submitted statements to tho 
Committee were tlio General Medical Council (or.al cvidenco 
by Sir Donald MacAlister and Mr. H. L. Eason), tho 
British Medical Association (Mr. Bishop Harman, Dr. 
E. AVallace Henry, and Dr. Alfred Cox), and tho Council of 
British Ophthalmologists; tho Ophthalmic Benefit Com- 
mittee, and representatives of approi-ed society organiza- 
tions; the British Optical Association, the Company of 
Spectacle Makers, and tho As.sociation of Dispensing 
Opticians; and a number of bodies representing sight-test- 
ing opticians of various kinds. As tho written and oral 
evidence was very voluminous tho Committee did not 
think it desirable to have this printed, but tho names of 
.all the bodies and persons whose views camo before it are 
given in- an appendix. 

T!ir lilajorUij iteport. 

At the outset tho Committee interpreted its terms of 
reforonco as in no sense limiting it to a consideration of 
tho registration of opticians under the provisions of tho 
particular bill referred to it, thinking it advisable to 
examine in a comprehensive manner the problems which 
tho subject appeared to raise. 

Part I of the main report deals first with tho history of 
the matter in this country and the chief factors which 
have lately contributed to the necessity for an inquiry at 
the present time. It then gives an account of the pro- 
visions for registration in other countries, and of the 
nature and promotion of the bill under consideration. 
Part JI refers in greater detail to the main problems 
involved. This part is divided into three sections and 
occupies ten pages. The first section sets out the relation- 
ship between the public on the one hand and ophthalmic 
surgeons and opticians on the other, and the kind of 
register which could bo set up, with a note on the need 
for safeguarding the status of dispensing opticians. The 
second section discusses the limitations which would have 
to be placed on the practice of opticians who would be 
included in such a register. The third sums up the con- 
clusions reached in the two preceding sections and states 
the final conclusions reached by the majority of the Com- 
mittee upon tho main issue. We reproduce, substantially 
in full, both sets of conclusions: 

Summary of Conclusions in Sections I and II. 

The functions of even the best qualified opticians should be 
restricted to the use of mechanical means for the correction 
of errors of vision ; and in the best interests of the patient the 
responsibility for any examination of the eyes should be upon 
an oculist, who, in addition to having access to all the resources 
of the skilled optician, can bring to bear the whole of his 
medical experience either in deciding that it is possible to 
determine the absence of disease or, on the other hand, to 
recognize and to treat any diseased condition that ■ may be 

r Report of tlie Committee appointed by the Minister of Health and 
the Secretary of State for Scotland on the Optical Practitioners 
(Registration; Bill, 1927. Cmd. 2999 London : H.M. Stationery Office, 
od. netl 



Jan. 7, 1928] 


BEGISTRATION OF OPTrOIANg. 


[ Tire Bnmsa 
Mcdicil Jov&yUt 


27 


present. Opticians c.annot, therefore, provide more than .at best 
a partial service, bnt in view of tho fact that largo sections 
of the community in present circumst.anccs do not avail them- 
selves of the services of oculists, and that tho public arc 
not in a position to recognize -which arc tho most competent 
optici.ans, there is a prima facie case for setting up a Stale 
register in order to produce some sort of order out of tho 
present ch.aos. 

As, lioivcver, a considerable proportion of cases of dcfeclivo 
vision are not cases of mere refractive error, but require treat- 
ment other than, or in addition to, tho provision of spectacles, 
it follows that tho very prescription of spectacles involves an 
implied decision that no other treatment is required ; and we 
think that this consideration must govern the standard to bo 
set for admission to any register. After a careful review of the 
facts regarding tho training of opticians as a whole, wo have 
been forced to the conclusion that it would not bo in the public 
interest to set up a prohibitive register which would involve 
tho admission of practically all opticians who were able to show 
that they have been conducting bona fide businesses. At the 
same time the setting up of a non-prohibitivo register would 
bo useless, if not dangerous, unless it were made a condition of 
entry that every candidate should prove to the satisfaction of 
tho Board his ability to exclude the possibility of the existence 
of disease before prescribing spectacles. Wo .ire not satisfied 
that even those opticians wlio .are most highly qualified in all 
other respects are siinicicntly trained in this respect. Further, 
tho setting up of a register of sight-testing opticians would 
necessitate tho separate registr.ation of opticians who undertake 
dispensing only. 

Wo find that it would bo necessary not only to impose 
restrictions on registered opticians in the way of treatment, 
of advertising, and of using confusing or misleading titles, but 
that it is impenativo that they should bo prohibited from using 
drugs. Such a restriction would in effect severely limit the 
classes of patients whom the opticians would bo capable of 
treating. 


Filial Conclusion!. 

In view of all these conclusions wo are convinced that the 
setting up of a State register of sight-testing opticians is not 
in itself a desirable policy. There remains, however, tho ques- 
tion ^whether, it is nevertheless necessary, having regard to 
existing circumst.anccs, to adopt this expedient in tho public 
interest. In our opinion tho answer to this question depends 
on how far tho medical profession is likely to bo able to make 
fee services of oculists available for persons in those sections 
of tho community for whom at present they are, for economic 
reasons, not available. 

Prospect of the Extension of the Services of Oculists . — 
\\ hether it is as the result of the establishment by approved 
societies of ophthalmic benefit, or of the question of registra- 
. tion becoming acute, or of the increasing competition of better 
trained opticians, or merely of tho greater public recognition 
of the importance of defects of vision, we are satisfied that 
there exists a movement on the part of the medical profession 
to provide treatment by oculists on terms which will make that 
treatment much more readily accessible to the public. We are 
assured, for example, that so far as insured persons arc con- 
Mrned, negotiations are at present being conducted by tbo 
lintish Medical Association with a view to the establishment 
'"n- u ii? populous districts of clinics or other schemes by 
which the services of oculists would be made available at fees 
within Uie reach of approved societies, having regard to the 
limited funds available for ophthalmic benefit. 

Ocufists Availahle. — Moreover, we are satisfied 
narf*"/T .1 increasing number of medical men, and 

ijf younger men, have been making a special study 

halmology; also, that there is good reason to believe 
oculisls. Sufficiently well distributed to meet 
of 0 cn will be forthcoming. Tho setting up 

miVbi lou ^ register of opticians would not encourage, and 
be\ retard, these movements. We feel that it would 

to diseniir^oi! 11 op the part of the Slate to do anything 
the creaieU” ^ ' m P™''’*-^ion of tho best form of treatment for 
FiUuT^f^Tr? of patients, 

truth tint claimed, probably with 

tho;e\espon3M “ State register would incite 

standard ^nf n. °i-c Iraining of opticians to raise the 
improvement fn Sods' of 

the last ton no - “"OOds of training which has been made in 
no register is years should not be maintained, though 

opticians in numbers of the population will resort to 

we think lint tb H'ey have done in the past, and 

ment on the ^nart nf tb“' ‘^°™pdt-i<'ion engendered by the move- 
referred will of the medical profession to which we have 
classes cf mao ‘“imng t!m standard in both 

opticians wffio aJo' ^“‘'^'mr, in view of the large_ numbers of 
e undoubtedly capable refractionists, we con- 


sider it would bo beneficial in tlic public interest if use could 
bo made of their services in that capacitj' in collaboration with 
and under the control of oculists. 

While 'wo have been forced to conclude that it is not in’ 
the public interest that a Stale register of opticians should bo 
set up, wo desiro to emphasize that one of the principal reasons 
on which wo base this opinion is our view that it is possible 
and probable that tho medical profession will be able to provide 
insured persons entitled to ophthalmic benefit with the services 
of oculists at an early date, and at fees within the limit of tho 
funds from timo to time available to approved societies for this 
purpose. Wo hope, also, that such a service will bo extended 
to tho non-insured population. If, however, these hopes are 
not fulfilled within a reasonable timo wo do not wish our 
Report to preclude tho possibility of a reconsideration of the 
question in tho light of the circumstances then existing. 

il/fnorify Reports, 

In their dissenting report Messrs. Aves, Barker, and 
Houghton say that, according to their reading of the 
terms of reference, tho main issue to bo determined was 
whether some form of Stato registration of sight-testing 
opticians is necessary for the protection of the public. 

From tho public point of view the case for Slate iutervention 
springs from tho unfortunate prevalence of ignorant and incom- 
petent opticians. All tho evidence before us has tended to confirm 
tho danger arising from tho activities of incompetent persons 
setting themselves up to prescribe for defects of vision. There 
seem to bo but two ways of dealing with this evil. Ouc is 
to prohibit entirely any unregulated practice; tho other is to 
provide some form of identification whereby the public may dis- 
tinguish between regulated and unregulated practice. This neces- 
sity is both urgent and obvious, yet wo find a decision evaded on 
tho plea that tho servico even of the qualified sight-testing 
optician is * at best only a partial service,* and that tho State 
should not encourage tho public to have recourse to any form 
of treatment whicli is * not tho best attainable.* Such a deduction 
appears illogical, sinco it is based on a Utopian service which 
is purely hypothetical, as opposed to tho present adequate and 
admittedly efficient organization.** 

They conclude that the case for the regulation of. the 
practice of optometry by means of a State register is well 
supported, and that the Committee incurs a serious 
responsibility in making an indeterminate report. 

** If this issue is shelved at Ibis juncture through reluctance 
to tackle tho problem we foresee as a consequence : (a) the 
creation of further rested interests which will complicate the 
problem on the inevitable reopening of the question ; (&) tho 
creation of an unfair prejudice against the case of tho qualified 
opticians whoso past voluntary efforts have earned the praise of 
the whole Committee that has heard the evidence; and above all 
(c) an encouragement to tho pretensions of incompetent persons 
whoso activities constitute the most serious and obvious danger 
to the public, A non possumxis conclusion now that tho issue has 
been thus prominently raised will certainly give countenance to 
the idea that there is no intention whatever to interfere with 
undisciplined practice, and this in itself would be little short of 
a public disaster.’* 

In his separate statement Mr, Rhys Davies remarks 
that tho business and practice of optometi*y in this country 
is undoubtedly in a state of chaos, 

** No general standard of qualification is attained. Wliilst a 
large number of opticians are well qualified to do sight-testing 
and provide spectacles, there is a considerable proportion of persons 
performing this very delicate and important task without any 
semblance of qualification. In fact, in some cases spectacles aro 
bought like ordinary merchandise, sold over shop counters and in 
the market places, without any regard whatsoever from tho 
vendors* point of view as to whether they meet the requirements 
of the customer or not. ... 

** There is much to say in favour of laying down the principle 
that all persons suffering from any affliction of the eyes should 
proceed direct to an ophthalmic surgeon, the surgeon to mako 
out tho prescription, which the patient would then take to the 
optical practitioner, who would simply carry out tho instructions 
of tho surgeon, and supply the appliance. That, however, is 
an ideal which cannot possibly he achieved for many years to come. 
The present number of ophthalmic surgeons is totally inadequate, 
and there is no doubt that there are optical practitioners already 
in practice whose experience undoubtedly gives them as good a 
title to perform ordina^ sight-testiug as many general medical 
practitioners. The optician should provide spectacles only in cases 
where no disease exists. Where the optician finds that the eye 
is diseased he should send tho case forthwith to tho ophthalmic 
surgeon for treatment. That practice prevails already among a 
large number of tho most qualified optical practitioners. I am 



88 Jan. 7, 1928] 


EDUCATIONISTS IN CONFERENCE. 


r TuitBstTiinf 
L Medical Journal 


Batisficcl Unit optical pr.nclilioners, even with the best qtialifications, 
should not bo allowed to use drugs for sight-testing purposes. . . . 

“ Steps should be taken (o guide, co-ordinate, and develop 
educational facilities for the training of optical piactitioncrs so 
that a proper standard should bo set and the public safeguarded 
against quackery of all kinds.” 

Mr. Rhys Davies concludes that optical practitioners 
should be registered on the general lines of the provisions 
of the hill suhmitted to Parliament, hut subject to certain 
reservations, which he sots out. 


EDUCATIONISTS IN CONFERENCE. 

Some Medical Aspects. 

The beginning of tho year is the chosen time for educa- 
tionists to assemble, and for tho last ten days University 
College, I.ondon, has been given up to almost continuous 
conferences, in which fifty teaching organizations liave 
participated. The discussions have ranged from the 
alleged dullness of writers on education to such questions 
as the nutritional requirements of school children, English 
spelling in tho schools and elsewhere, and education for 
marriage. 

Sir Michael Sadler, in a presidential address at the first of 
the sessions, claimed that Britain now had the pre-eminence in 
the field of education which formerly belonged to Germany or 
to Germany and America both, and that Britain to-day was the 
most considerable exporter of educational ideas. He deplored, 
however, one vestige of the older European traditions which 
was too prominent in English secondary education — namely, 
the importance given at Oxford to Latin in responsions and 
entrance examinations. There was a time when Latin was the 
lingua franca of educated Europe, but that time had gone. 
He fully realized that certain types of mind were enriched 
by the form and colour of classical education, but there was 
'nothing gained by making it a fetish, especially when this 
meant the neglect of the study of living European languages 
and the art of speaking them. 

Health Teaching in Schools. 

The Association of Headmistresses of Private Schools was 
addressed by Professor Winifred Cullis, who pleaded that 
health teaching should be given the same place in school as the 
teaching of writing and reading, and that no school should be 
considered adequately staffed unless it had at least one teacher 
capable of, and specially trained for, this type of instruction. 
She regretted that in at least one training college physiology 
and physical exercises were grouped together, so that a person 
prcficient in the latter might gain sufficient marks for a 
certificate, while having only' the most rudimentary knowledge 
of physiology. Another point made by Professor Cullis was 
that it by no means followed that the children of the profes- 
sional woman were neglected ; some of the happiest liomes she 
knew' were homes in which the mother went out to pursue some 
lirofessional avocation. Far more frequently the neglected 
children belonged to homes in which the mothers were absorbed 
in social pleasures. Professor Cullis made an appeal to head- 
mistresses of schools to which gilds came from homes in which 
there was no financial stringency, to consider whether the 
ambitions of their pupils might not be properly directed to a 
medical career. She believed that there were too few women 
doctors. Women doctors were wanted especially for the care 
of girls and ycung women, where they had a sphere which 
could not be so well filled by men doctors, and the statement 
that women doctors found it difficult to obtain employment 
was not in accordance with the experience of the Royal Free 
Hospital Medical School for Women, which had trained half 
the women doctors in the country. 

The “ Problem Child.’’ 

One event in connexion with the conferences was the first 
public meeting of the Child Guidance Council, a body of which 
some account was given in a recent issue (December 10th, 1927, 
p. 1104). Here the address w'as delivered by Mr. P. B. Ballard, 
hi. A., D.Litt., who spoke Irom the point of view' of a psycho- 
logist on the “ problem ” child, meaning by this term not the 
mental but the temperamental detective, especially the neurotic 
and the ” naughty ” youngster. Mr. Ballard said that there 
was a tendency to regard mental deficiency as hereditary, but 
delinquency as a thing for which the individual w'as respon- 
sible. But mental deficiency might not be entirely hereditary j 


in part it might be due to bad environment, perhaps to bad 
teaching, wliilo as to delinquency there seemed to be no doubt 
that some children were prone to queer complexes tis a result 
of some unforliinate handling in the earlier part of their lives, 
and for which they themselves could not be held to account. 
The curious thing was that, while attempts were made to cure 
the incurable — that is, tlie mentally deficient — little or no 
attempt was made to cure the curable— namely, the neurotic 
and delinquent child. The mental defective was not punished, 
but the delinquent was punished, and punished, too, from a 
purely retributive point of view, whereas the proper w'.ay of 
dc.aling with him W'as by education. Mr. Ballard submitted that 
child guidance clinics offered suitable machinery for de.aling 
with such children through a sympathetic staff of p.sychi.atrists, 
psychologists, and sjiecially trained social workers. The Child 
Guidance Council, ow'ing to an American benefaction, was 
being financed for the present without the necessity of appealing 
for funds, and hoped to establish before long a demonstration 
child guidance clinic which would show that the problem of the 
“ difficult ” child was not insoluble. 

Psycho-analysis in Early Childhood. 

The full gospel of psycho-analysis was proclaimed at a large 
meeting — over which .Sir George Newman was announced to 
preside, but be was detained at the last moment — held under 
the auspices of the British Psychologicail Society. Dr. D<avid 
Forsyth dt.alt from the psychological point of view with the first 
five years of life, and especially with the period of infancy. 
He said that recent investigation has shown that when tho 
fairly complete amnesia which existed prior to the fourth or 
fifth year was broken up by psycho-analysis the causes of 
subsequent nervous disturbance reached back info that period. 
Even so early in life were children swayed by loves and hates 
and jealou.sies as between their two parents and themselves, 
and were frequently the .subjects of the “ Oedipus complex.” 
The attitude which a child of 3 or 5 adopted towards its father 
or mother might presently determine the adult attitude, if a, 
girl, towards men, and, if a youth, tow'ards women. The 
phjsical experiences of birth, sufficiently trying for the mother, 
must be extremely terrifying to the child, and there was a 
pos.sibility that from these experiences dated the dread which 
hovered in the minds of .some young children. The infant 
possessed a mass of strong emotions, not only powerful, but 
uncontrolled, and his earliest emotional reactions, largely to 
external stimulus, might give shape to his later reactions— 
fliGugli qualified perlmps in one or other direction— to similar 
stimuli throughout life. Dr. Forsyth suggested ways in which 
any disturbance of the normal function of feeding and excre- 
tion might show itself in .subsequent character. For example, 
children who learned the habit of retaining the stool, finding 
that to do so enhanced the pleasure of the eventual excretion, 
were likely to be .strong willed. The making of a pessimist 
might i)e "traced back to a maladjustment in breast-feeding 
which left the infant unsatisfied, or to food being given at a 
wrong temperature to the bottle-fed child. The speaker also 
pointed out that the earlier the origin of p.syciiological 
disorders in childhood the more severe was the ultimate result. 

Amonw other subjects for debate at the conforoncos, which 
do* not conclude until the end of this W'eek, w'erc physiology 
and imiscular work, school meals, and the cttects of 
bodily infirmity on character formation ; these must be held 
over for subsequent reference. 


fxanct, 

[FitoM Oun Own Coebespondent.] 


A.D.E.:?!!. 

The Association for the Development of Medical Relations 
has just held its annual meeting at the Paris Faculty of 
Medicine. Your readers have already heard of the work 
cai-ried on by Professor Hartmann and his supporters. 
The idea is to keej) the doors of our medical sanctuaries 
■wide open to our colleagues from abroad, and to give freely 
and readily all information that may prevent loss of time 
and red-tape entanglements. During the 3 'ear just past 
colleagues from no few'er than fiftj'-six different countries 
availed themselves of the opportunities thus afforded. The 
largest number came from South America. Quite a new 


JAN. 7, 1958] 


FEANCE. 


[ TirElJBrnss 00 

lIZDIClI. JOCBSII 


(Icpartuvo was tlio institution, at tlio beginning of tho 
ncatlGtnio voar, of post-graduato Icotiucs and donionstia- 
tions in English. They wuro atlendod ohiolly by Ainoricans, 
uboso sciontilic lioadquarteis wero at tho Ainorican Hosiiital 
in Neuilly. Tlio association also bad tho privilogo of 
greeting over tivo hundred confreres from tho Intcr-Stato 
Fost-Greduato Assembly of North America. 

The Lyons Faculty op hlr.niciNE. 

Tho ancient medical faculty of Lpns is on tho.cvo of 
being transforred to a part of tbo sito on tho outskirts of 
tho town where the erection of tho great hospital grnuii to 
bo called tho Grange Itlanchc has already been begun. 
This schomo is endowing Franco with an institution which 
will probably bo tho most completo centre of instruction 
and treatment in Europe. Its realization has been 
made possible by tho Rockefeller Foundation, which has 
guaranteed two-thirds of tho cost on condition that tho 
city of Lyons collects tho other third. Hero, then, wo aro 
witnessing tho foundation of a cH6 viidicalc, and tho intro-' 
dnetion almost insensihly of collogiato life into Franco; 
but wo must not com]ilain if wo arc being induced to break 
with our oldest traditions in order to follow tho example of 
friendly nations. Iluirication of methods is tho normal 
course for things to take. 

The New PnopEsson or TiiEnArr.UTics. 

Tho amphitheatre of tho Faculty of Medicine of Paris 
has witnessed one more of those great days when it is filled 
to hear tho iiiaugur.al lecture of a new professor. This 
timo it was the tuni of Dr. Loeper, who has been appointed 
professor of therapeutics. It is not easy to take possession 
of a chair made illustrious by such men as Trousseau and 
Diculafoy, but their successor roso to tho occasion in an 
address which was a miracle of simplicity and good taste. 
Those qualities have rendered him one of the most popular 
of our younger masters. Ho has boon a highly valued 
collaborator of Professor Acliard, and in his service' at the 
Hppital Tenon ho has proved himself a pioneer in tho 
scientific investigation and demonstration of affections of 
tho digestive tract. In him wo shall always find an 
intellect alive to every new dovolopnicnt and thoroughly 
well acquainted with tho investigations and the investi- 
gators beyond our bmi frontiers. 


Dn. Yeusin. 

Tho -Acaddmio des Sciences has just awarded one of its 
most important prizes, le grand prix Leconte, to Dr. 
Ycrsiii. It will bo romemborod that ho was associated with 
Dr. Roux in preparing antidiphtherial serum, and that 
later on he discovered tho plague bacillus, and then went 
on to produce antiplaguo serum. - But tho Academio wished 
in Yersin to honour not only a medical benefactor of 
mankind, but also au eminent geographer. Y'ersin has 
explored the Mois country in Indo-China, and was the first 
to produce a map of that region. Moreover, ho it was 
11 10 introduced tho culture of rubber into tho colony^. 


_ PnoFEsson Calmette. 

rofessor Calmette, assistant director of the Institut 
as eui in Paris and a member of tho Academio dc 
'' been elected a meiiibor of tbo Academic 

es ciences. It is not necessai-y for me to recall that Dr. 
i ^ ^ credit a record of scientific rcsoarche: 
^ overburden any ordinaiw man. Ho gave hi; 
^ study of snako venoms and fo the 
^’!*'*7°nomous serum ; next ho attacked the 
Hie 1 infectious diseases, especially tuberculosis 

animals a w ^ 1 ' '^®S'ii'd to vaccination of young bovine 
Sod tuberculosis led to tho discovery of B.C.G. 

culoSs— a T P'^^tect tho newborn infant against tuber- 
seems to'hfi mm ' T+i 'ts practical applications 

of tliG most important made in our epoch, 

■ Afn-i. PopUL-in PnOMOTION. 

is with tho 'm-e and in Great Britain too 1 H 

Freneh r ^ “t®st pleasure that we have seen that th< 
proTo ed Christmas gift, hai 

no7e nln°l „ the Legion of Honom 

ot-e grand ami Anglate Sir StClair - Thomion . 

G. Monod. 


Irdaitir, 


HE.\LTn OF NoitTnniiN Iiieland. 

The fifth annual report of tho Registrar-General relating 
to Northern Ireland contains general summaries of tho 
births, deaths, nnd> marriages registered during 1626, and,- , 
unliko certain other statistical productions, contains some 
iiitercsting information about tho health of tho population 
concerned. A preliminary report of tho census taken in 
1926 gives tho number of inhabitants of Northern Ireland 
as 1,256,322. While tho marriage, birth, and death rates 
for tho year under review are all below tho average for the 
previous ten years, yet, as compared with 1925, tho birth 
rate shows an increase, though the other two rates are 
lower. There has been a steady decline in tho marriage 
rate following tho peak year of 1919, and it is now the 
lowest for tho jiast ten years, with the exception of 1917. 
Tho birth rate fell steadily from 1920, with the exception 
of 1923 and 1926, in which years there were slight ’ 
recoveries. Tho death rato has varied considerably; it was 
high during tho war years, and then fell steadily until, in 
1923, it reached 14.9. In tho following year an epidemic 
of induenza and a high rate for respiratoi-y diseases resulted 
in an increase to 16.1, but since then there has been an 
annual decrease, and tho rato of 15.0 for 1926 is tho lowest 
recorded during tho past ton years, with the exception of 
that registered for 1923. Deaths from tuberculosis con- 
tinued to 'decrease, but still re])resent nearly 10 per cent, 
of tho mortality from all causes. In the ago period 15 to 
25 this disease is responsible for over 54 per cent, of 
deaths, whereas in tho following ten-year period the pro- 
portion falls to 44 per cent. Deaths from influenza in 
1926 totalled 482, being less than half the average for the 
past ten years. Heart disease was the chief cause of death, 
and is followed by tuberculosis and cancer; the death rato 
from this last condition has risen each year from 1622 to 
1925, but was slightly lower in 1926. There was a slight 
increase in the mortality due to encephalitis lethargica 
and cirrhosis of the liver. The number of deaths registered 
as uncertified in consequence of the fact that no medical 
attendant was present during the last illness has dropped 
considerably, from 2,350 in 1925 to 1,785 in 1926. The 
report is published by H.M. Stationery Office, price 
2s. 6d. net. 

Treatment of Cancer: Fusion of Hospit.als. 

At tho annual meeting of the committee of management 
of the Dublin Skin and Cancer Hospital, Lord Glenavy, 
Chairman of Irish Free State Senate, moving a resolution 
that the Dublin Skin and Cancer Hospital was worthy of 
the support of the citizens, said that the report was calcu- 
lated to raise a feeling of very grave anxiety in the minds 
of those interested in that and similar institutions in the 
city. Tho timo had come when their institution would 
have to make up its mind whether it would carry on on the 
same ambitious lines on whicb it had been working with 
such success, or whether it would have to curtail its activi- 
ties, with consequent loss to the citizens and the country. 
As to State aid in tho routine working of ordinary hos- 
pitals, it was a thing not to be hoped for, and in his 
opinion not to be desired, and in this he was expressing 
tho opinion of all concerned in hospital administration 
in Great Britain. The State had no money of its own ; it 
had to get the money out of the pockets of the taxpayers, 
and any contribution towards the upkeep of general hos- 
pitals would impose a very heavy additional burden on 
the already overtaxed citizens of the community. Further, 
State aid would debar voluntary contributions, and there 
was also the consideration that they would not get State 
aid without State control, and State control was not useful 
or helpful in hospital administration. Four thousand 
people died in Ireland yearly from cancer. It was a 
national matter, and required national consideration. This 
had already been given to tuberculosis, and it was difficult 
to see why the same consideration should not bo extended 
to cancer. lYhilo that hospital was devoting itself.' to 
research work it was doing a national work, -and ought 
to receive national recognition. The difficulty was that 


80 Jan. 7, 1928] 


COBREBPONDENCE. 


t Tjtr,r.nm« 
UeDicu:/ JocBK&L 





7 , 1928 ] 


cor. UESPON DENCH. 


E Tht. T^p.msa 
IfrotCAt. JocBMiX . 


31, 


ot British-born settlors which 1ms persisted without clcterio- 
Totion for three or four generations, nnd tho ninlo nicinhers 
of which have carried out ni.amial labour in Iho open? 
Will Sir James Barrett, out of tho wealth of his exporicnco 
nnd knowledge of local conditions, kindly answer this 
(lucry? — I am, etc., 

' London, W.C.l, Jon. 2nd. AximEW BalTOUR. 


TBEATMENT OF BROST^VTIG ERL 2 VRGEIMENT. 

Sir, — Tho comment on suprapubic prostatectomy by Mr. 
G. A. Clarkson (November 26tb, 1927, p. 1006) might he 
termed ultra-pessimistic. There must bo something radically 
, wrong n'itli tho pre-oporativo care, operative technique, 
. and post-operative treatment to rau-.r so much constant 
. leaking after this operation. 1 have ;,,id tho pleasure of 
, working under Sir John Thomson-Walker and Mr. A. 
Clifford Morson, and since returning to Canada have now 
performed dozens of suprapubic prudtatectomies in accord- 
ance with '.their technique, with onij’ one death, in a man, 
aged 76, who had cancer of tho prostate. In all my cases 
tho wounds were healed and drj’ within six weeks, with one 
exception, where I had to drain tho bladder for three 


.months in order to obtain a proper specific gravity of tho 
urine and suiEcicntly high urea content. Young's operation 
is excellent in tho hands of its author or other experts, but 
for tho average surgeon tho suprapjibic route in my opinion 
is the safest. Each operation no doubt has its place in 
.urinary surgery, but from tho standpoint of mortality or 
complie.ations there is nothing to chnoso between them. 

Statistics have bec-n published which show a slightly lower 
death rate for perineal prostatectomy, but wo must take 
into consideration tho fact that certain difficult eases, such 
as those of very largo prostates, or of largo, complicating 
calculi, or of bladder diverticula, can only bo dealt with 
by the suprapubic route, and that as a result of this the 
mortality of this operation is likely to bo increased. From 
tho point of view of convalosccnco tho advantages lio to 
. ® degree with the perineal operation, hut even Y'oung 
admits that in 14 per cent, of his cases fistula existed six 
wecls after operation. Perineal prostatectomy certainly 
eliminates all risk of hernia, but it carries with it a slightly 
greater risk of fistula, imperfect bladder control, impairod 
s^ual function, and certainly more danger of injury to 
. tile rectum. Tho. suprapubic route, moreover, is certainly 

• tlie best for dealing with tho enlarged prostate, and even 

• With tho small multinodular prostate when, after removal, 

ags of mucous membrane arid perivesical tissue may cause 
0 s ruction. I think that Sir J. Thomson-Walkor’s open 
operation, facilitated by his retractor with light attach- 
men , renders the operation just as efficient as by tho 
^'*0 prostate is placed high in the 
Y®ry lergo, or when associated with bladder 

foil ^ really tho only one that can bo success- 

fully earned out.— I am, etc., 

New V Miller, M.D., C.M., F.A.C.S. 

new Llasgow, ^0Ttl Scoti.i, lice. 1927. 


tuberculosis in children exposed to infection in the family 
" may occur in tlio apex in adolescent children,” and there 
may bo also a “ high incidonco of clinically manifest tuber- 
culosis with symptoms and physical signs.'” Ho adds as a 
control that “ no manifest disease has appeared in the non- 
contact families.” His investigations in tho bacteriology 
of latent tuberculous lesions provide tlio clearest proof of 
the truth of tho view I expressed fully twenty years ago, 
that a typical reaction with tuberculin was itself proof 
that there woro living tubercle bacilli somewhere at work 
in tho living tissues. My view was summarily rejected. 
Dr. Opio’s investigations leave little doubt that my view 
was, and is, sound. 

I regret now that I did not attend tho Annual Meeting 
of tho British Medical Association in Edinburgh in order 
to have tho opportunity of suggesting to Dr. Opie that 
tuberculin dispensaries are not only the best means of 
investigating tho prevalence of tuberculosis in tho families 
of tho poor, but simplify tho diagnosis and treatment of tho 
latent cases by means of tuberculin and radiology. 

Moreover, thirty-five years’ experience convinces me that,; 
of all " tho well known measures directed to retard tho 
progress of tuberculosis,” tuberculin treatment at these 
institutions leaves little to bo desired in simple uncom- 
plicated ebronic phthisis, and probably would bo equally 
beneficial in modifying the character and course of tertiary 
lesions in other organs than the lungs. 

Lastly, Dr. Opie and I seem to have always had an 
instinctive dislike to the inapt and shadowy designation 
“ hiUim tuberculosis.” Such a term is an unworthy reflec- 
tion upon our anatomical and physiological knowledge and 
might well be discarded in radiological descriptions. There 
is no need for shadowy designations, when at least wo are 
anxious to know tho actual site of the lesion. This is all 
tho more important if, as Dr. Opie tells us, ” accentuation 
of tho Inlum shadow or thickening of the mediastinum is 
seldom due to tuberculosis of lymph nodes, and does not aid 
in the recognition of the disease,” and if, as Dr. Armand- 
Delillo (Paris) plainly says in the discussion, “ normal 
lungs show x-ray hilum shadows which bear no relation to 
enlarged bronchial glands.” Wo shall certainly avoid pit- 
falls and clarify our conception of tho secondary stage of 
tuberculosis, the essential lesion of which is tuberculosis of 
tho lymphatic tracts of the lungs, including tho important 
terminal Ij-mphatio glands, if we allow this vague and 
indeterminate expression ‘‘ hilum tuberculosis ” to vanisH 
entirely from medical literature. Tliere is so much uncer- 
tainty regarding many features of tuberculosis that it is 
not wise to introduce a term that merely adds to our 
difficulties without helping towards a clear and definite 
perception of the true facts. — I am, etc., • 

W. Cahao Wilkinson, M.D. 

London, Dec. 23rd, 1927. 


CATARACT AND ULTRA-VIOLET LIGHT. 


Sin 0^ tuberculosis. 

Medical address in the Bniiis 

pStboWv Docomber I7th, 1927 (p. 1130) on tb 

on clintLl *'’i'^°''Eulosis of childliood and its bearin 
should bn pnrof*^n ** j- Valuable contribution, .an 
patlioloev of ^ studied by all who are interested in tli 
disoasoF(?A Ho stresses two features of tb 

childho^d.^U ty. infection i 

causo manifest ami i '^‘^"Ser that latent infection nia 
His idnnV perhaps fatal disease.” 
which 1 have been . tuberculosis agree with tho; 

Those who at thn “ fiuarter of a contun 

tad tho privilocc of Tuberculosis at Berlin in 189! 

of latent pulmona^ the demonstration of 32 cas< 

diertortllrparamS' • OP^^'^’^uEly and frankly vii 
nons of tuberculosis. These latent forms i 


Sir, — Dr. Percy Hall’s letter in your issue of December. 
24tli, 1927 (p. 1206) calls for one comment. He suggests 
that my remarks on the causation of cataract by ultra- 
violet light were based on experiments on animals, using 
the excised eye suspended in normal saline. In this there 
is a slight misunderstanding. Tho experiments whiebi 
I have done involved the radiation of the isolated lens 
suspended in various fluids, and, in addition, the 
radiation of the intact eye of the living animal. And if, 
as I take Dr. Hall to mean, experiments on animals cannot 
apply to the human subject, how much of the accepted 
foundations of medical science are to bo left inviolate? 
Certainly Dr. Hall is not of this opinion in other con- 
nexions, for his book on Ultra-Violet Light contains the 
reports of many animal experiments, the lessons of which 
are applied to the case of man. 

Dr. Hall expresses surprise that, in spite of my conten- 
tion, I use ultra-violet light in the treatment of many 
opbthalmological diseases. When doing so, I am quite 
satisfied that I am not causing cataract, as I hope Dr. Hall 
will be assured when be acquaints himself with the tech- 
nique now employed at the Royal London Ophthalmio 
Hospital, Avherein tho lens is absolutely excluded from thq 


COKRESPONDENCB. 


r ToEBnmsH 
X Mkdicai. JocByiL 


82 Jan. 7 , 1928 ] 

incident light.^ Certainly when used in largo doses ultra- 
violet light produces an intense conjunctivitis. But Dr. 
Hall uses the same agent on the skin, where with similar 
incautious dosage it produces an equally intense dermatitis. 

As for the “ sting in the tail ” of my letter, it was not 
necessarily intended for Dr. Hall, but for anyonesoever 
whose practice leads to the results exemplified in the 
letter of Mr. Sydney Tibbies, which appears in the same 
issue of the Journal. Two cases of a like nature have 
come under my notice recently, tho one treated 1 ) 3 ’ a 
qualified practitioner, the other not. — I am, etc., 

London, W.l, Deo. 24th, 1927. W. StEWART Duke-Elber. 


Sir, — I n view of Dr. Percy Hall’s statement in 3 'our issue 
of December 24th, 1927 (p. 1206), that “ certainly removal 
of the lens is not a ‘ cure ’ for cataract,” I foci it is only 
fair to reply that, so far as we know, it is tho onh' cure. 

' The fact that patients who think tho 3 ' are going blind 
•with cataract want to get hotter, if possible, without an 
operation, leads them to tr 3 ' all sorts of treatment, which 
they • can often ill afford. I have known patients half 
staiwo themselves, live on fruit juices, and tiy oveiy' 
form of treatment, including ultra-violet light. Tho effect 
of the latter, in one case, I mentioned in the letter whieh 
follows Dr. Percy Hall’s on page 1206. 

For twenty 3 ’ears I have tried every form of treatment 
for patients with commencing cataract, in tho hope that, 
if the 3 ’ got no better, at least 'the condition would get no 
worse — that is, in cases of incipient cataract, where tho 
patients’ activities were not greatly interfered with by 
the failing vision. I have tried iodides intornall 3 ’, locally, 
by inunction, and by ionization. They «-ere i-ecommendcd 
in textbooks that were written sixty years ago. Tho 
fact that 1 once thought I got tho commencing striae of a 
j-ight lens practically to disappear with a French pro- 
prietar 3 ’ preparation containing calcium iodide has led mo 
in the last eighteen months to try this preparation on 
some two hundred cases that I have re-examined care- 
fully at fixed intervals. With the exception of one case 
• (which has since relapsed) there has been no definite 
improvement. The patients themselves may think thc 3 ’ are 
better, and, unless the surgeon is careful, he, too, may be 
misled by their enthusiasm. 

The so-called “ cures ” are duo to the fact that anA'ono’s 
vision varies from time to time. If tho lighting, the t 3 'po, 
and the distance from tho type are constant factors at each 
examination there are always slight differences in tho 
vision, and I suggest that that is what caused an “ im- 
provement ” from 6/12 to 6/9 and 6/9 to 6/6 in the right 
and left 03 'e respectively of tho case quoted by Dr. PercA’ 
Hall. 

Apparentl 3 ’ the administrators of ultra-r iolot radiation 
cannot quite agree at present as to its real r-alue in 
ophthalmic practice, but Dr. Spiro, in a paper which 30 U 
quoted on page 1194, read in my Section at the recent 
Conferciice on Light and Heat, pretty well covered the 
ground by showing what eye cases Avere improved by tho 
general tonic effect of general radiation. 

Practically all forms of cataract tend to get denser Avith 
increasing years, and this includes congenital forms, and 
Avhen useful A'ision is preA'ented the only cure is to romoA'-e 
the cataractous lens. There are thousands of people all 
over the Avorld Avho have been successfully operated upon, 
and AA’ho are again able to lead a happy existence, as the 
result of Avhat is probablA' the most delicate operation in 
the AA'hole of surgery. I admit one has to remove the 
opaque lens Avhich is preventing visioiir As the patient Avas 
blind before this, surely Dr. Percy Hall might be generous 
enough to admit that as a “ cure ” for the blindness. — 
I am, etc., 

London, AAM, Dec. 24tb, 1927. SydNEV TiBBLES. 


ANTISEPTICS IN OPHTHALMIC SURGERY. 

Sir, — Sir Arnold LaAvson’s paper on this subject, reported 
in your issue of December 17th, draws needed attention to 
an important subject. His teaching, stated briefly, seems 
to be that, although the eye cannot be sterilized, it should, 
for surgical purpose s, be treated exactly as if it could. 

‘Brit. loum. Ophthal., 1927, xl. 67. 


But in my opinion irrigation is of value. My cxiierionco, 
based on over tivo thousand cataract extractions and an 
annual averago of moro than a thousand eye operations, is 
strongly in favour of the use of incicurA' pcrehloride lotion, 
1 to 3,000 or oven 2,000. Before cataract extraction Ave 
irrigate and AA’osh thoroughly AA'ith this solution. The anti- 
septic poAver of Such a lotion is very great, even Avhen 
diluted Avith tears.- MorcoA-er, it is astringent. Since 
adopting this procedure, Avhich avo oaa'o to Colonel Smith, 
panophthalmitis after cataract extraction has been 
banished. 

In the East trachoma is extremely common, and before 
operating great care has to bo exercised. If there is any 
doubt the lids should bo everted for inspection. Tho 
absence of any latent lacryraal obstruction mi/sf be ascef- 
tained. Smears from the conjunctival sac, examined mierq- 
scopicallA’, aro not to be despised; for, although the con- 
junctiva has some inherent poAver of combating infection 
and intracellular micro-organisms may often bo seen (a 
proof of phagocytosis), excess of organisms can usuallA’ bo 
recognized. We linA'e quite abandoned tA'ing up ca'cs to 
SCO if there is discharge. Such procedure, eA'en for a few 
hours, if it demonstrates tho existence of discharge, also 
aggravates tho condition and necessitates longer prepara- 
tory treatment for days or Avecks. Eyelashes cut short, 
and tho stumps Avashed AA'ith tho pcrehloride solution, rarely 
give trouble if after operation Lister’s double cyanide gauze 
is applied under tho pad of Avool or Gamgcc tissue. 

Tho special value of Sir Arnold LaAA'son’s paper is tho 
emphasis laid upon scrupulously careful antiseptic tech- 
nique even Avhore, as in this case, tho actual organ operated 
upon cannot bo absolutely sterilized . — 1 am, etc., 

EnNEST F. Neve, M.D., F.R.C.S.Ed. 

Koslimir Mission Hospital. 


L.MIGE OVjVRIAN CYST. 

Sin ^Tho interesting acoount, in the British Medical 

Journal, December 31st, 1927 (p. 1225), by Dr. H. H. 
Barnett, of an ovarian cyst from Avhich 108 pints of fluid 
wore removed, brings to’ my mind the case recorded by 
Mr. Samuel Glass in the Phil Trans., voI. xIia', Part II, 
for 1747 (p. 337). The patient Avas Mary Nix pf Hampton 
Poylo. She died, and a post-mortem examination AA-as 
made. The circumference of her abdomen Avas six foot four 
inches, from tho xyphoid cartilage to the os pubis Avas 
four feet and half an inch. The base of the heart lay 
under tho right clavicle, the lungs scarcely exceeded in 
magnitude those of a nOAvborii child. There was in the 
abdomen a cyst AA'hich contained fluid, Avhich was found 
to bo not above a pint less than thirty gallons wine 
measure.” Tho author is uncertain as to the origin of 
tho cyst- it may have been ovarian; he suggests that 
perhaps it was renal; but be that as it may, surely few 
abdominal cysts iiave contained more than 239 pints.— 
[ am, etc., 

' „ , W. Hale-AVhiie. 

London, AV.l, Jon. 2nd. 


AN INCIDENT IN A “ FIRST-CLASS LIFE.” 

giu I think tho circumstances of the folloAving case, 

in Avhich a man is certified a “ first-class life ” at 3.30 p.m 
and has a gangrenous appendix at 9 p.m., may be ot 
interest. 


On December 6th, 1927, I Avas asked to go and see Mi- X. 
omDlainin-' of “ stomach ache,” Avith a temperature of lOU.b I . 
'e AA-as a ?ery healthy, Avell built man, just 50 years of ago. In 
uIa' 1927 he had an attack of similar pain for four hours one 
iglit. As’ regards family history, I had operated upon a son 
nd a daughter for acute appendicitis. 1 -nU 

Ho a-wofce on December 6tli Avith a headache (unusual), Avliich 
iolded to asnirin. This Avas succeeded about noon by abdominal 
iscoinfort be?OAV the umbilicus, Avhich persisted, but had not been 
were. He decided to “ v.-alk it off over a distance of tivo miles 
rom his office to his home, Avhich he reached -with difficultv. 

His condition on examination at 7.30 p.m, was noted as fol oavs : 
loes not look A-ery ill. Complains of moder.ate pain in liypo- 
astrium. Bowels open this morning; no nausea and has not 
omited. Temperature 100.8° i'., pulse 78, tongue coated. -Apdo- 
len moA-es poorly on respiration. Right rectus very rigid m 
wer half: maximum tenderness over McBurney s point. Kcctai 
camination negative. . 

I sent him straight off by ambulance to a nursing home as an 
irl^ acute appendix. 


Jan. 


iqjS] 


, COEEESPONDEKCE. 


r Tee IJTsmsn 
"i Medical Jotasil. 


S3 ■ 


At, 9 ii.in. he looked decidedly ill: Uio tompcrntvre lind risen to 
102° P., and tlio pulso to 84. Ilo had not votnilrd. At tlio 
operation, using Battle’s incision, tlio appendix was. found to bo 
rctrocaecal and bound down. Free pus of horrible odour was 
present and Iho . appendix was ' gangrenous, very oedcnmloiia, 
swollen, kinked like a hairpin, and pcrtoraled. I removed it wilh 
diiriculty, having to begin at Iho base, and- loft a diMUiagc tube m 
the wound. . . . . 

There was no vomiting after Iho' .anacslhclic. Tlie patient was 
very ill for the first week, and the odour of Ihe abundanl purulent 
discharge very foul. He made uninterrupted, if slow progress, and 
was out to have his bed made in .sixteen days. Tin re is still soino 
discharge, now inoffensive. The patient is doing well and gela up 
daily (twenty-one days). 

Tlio iiitcrc.st of tins case lies, in the foot that the patient 
had been carefully examined fot’ life iiisiirauco that very 
afternoon (Dcccniber Gth) 192.7) at 3.30, by a very able 
local practitioner of stantling, and pas.sed ns a “ first-class 
life ” 1 

I have since discussed the case with rcy ccllcagtie, who 
E.ays that Hr. X mentioned some abdominal pi. in to him at 
the time, so that the abdomen, being suspcit, received a. 
more than usually thorough examination, hut there were 
no signs of appendicitis to bo made out. I'e, however, 
■suggested that if the pain contiimcd Mr. X .should call n:o 
•ill, and it \vas this precautionary advice rather than tV.o 
-Ecvcrity of his symptoms which led to my being c-onsultcd 
in time. — I am, etc., 

E. S,ti.isnmiY tVoons, 11. D., F.R.C.S. 

Cambridge, Dec. £811], 19£7. 


ISOLATION FOR IIRASLES. 

Sin, — It is perfectly safe for an uucompli; ated case of 
rueaslcs to mix freely in society fourteen days after tho 
fiivst appearance of tho rash, couvalcsconco being satis- 
factorily established. 

My reason for writing tliis letter is that 1 now find myself 
001111)0110x1 to keep a patient at school over Chi istnias 
because the medical man who attends her family asserts 
that it is unsafe for tlio child to return lioiro till threo 
wi-elts have elapsed from tho first appearance of tho rash. 

^ All the periods during which unconipliciitcd cases of 
t.’.e common exanthemata remain infectious are definitely 
known, and it is important that momhcis of tho medical 
profession should realize this fact. Tho data have hocii 
drawn tip aiid printed by tho Medical Officers of Schools 
Association, in. consultation with epidemiologists of repute 
and other loading consulting physicians, and they have 
stood the test of time. I say this without hesitation after 
more than, twenty years’ cxiiericnco as medical officer of 
a public school. 

practilionors are still unacquainted with what 
. .. “y now a matter; of comriion knowledge, it seems 

Jr'^'ir'c'^ rules adopted by all our public schools 

r..,'ii* corrimmiicatcd to tlie profession by some central 
ion y, such as the General Medical Council. — I am, etc., 

Wincbesler, Dec. £6lh, 1927. F. J. Child, SI.D.Caiitab. 


- i^'JECTIONS FOR VARICOSE VEIXS. 

eolfMciicV^^I ^ warning to tlicM) cf my 

trc'itmont "f jmiiped to the conclusion that the 

uii'dei tnl o ° • veins by sclerosing injections can he 

be finlLi" " marrner? Surely th.ere should 

cardiac patient? Has ‘ho 

veiiis or ■ Ki' “ blockage of tho deep 

ficialVdAsIciu r“^p^ -P- 

new treatment .patient was advised to have th'ra 

to the thigh, ra sed " fourniguct 

info' which he iiifcetixl the popliteal sjmee. 



minutes he was told to , - - 

later and found him cipbff ““ 

, I mentioh.'alKHuV feb generally upset, 
surgeon was wron<- • Afv ^ method used by tl 

to get . your vein°esi^rta'!w'“i'^'' ^PP’^ handaf 

, veins have been rc*f ^7’^” 

jour patient walk away untd T f 1' 
y until he has had at least twent 


minutes’ rest. If you employ the new lino of treatment, 
mnko yourself piofieicnt in the administration of it. 
Calamities are thus avoided. — I am, etc., 

London, S.tV.7, Dec. 14tli, 1927. A. AIaCDEth ElLIOT, JI.D. 


A CLINIC FOR PHYSICAL TREATJIENT IN 
LONDON. 

Sin, — .As a member of the London Clinic Subcommittee 
(British Conuuitteo on Rheumatism, International Society 
of Alcdical Hydrology) I am writing-in leferenco to Dr. 
McnncII's letter in your issue of December 10th (p. 1120) 
as there would appear to ho a danger of some misconcep- 
tion as to the aims and objects of tho proposed clinic. 

But first 1 would like to assure Dr. Mcnnell that the 
committee nrc well aware, not only of tho existence of 
ilio Kensington Clinic, but of tho splendid work that is 
being done there under Dr. McnncII’s direction, and any 
failure to mention tho clinic was, I am sure, due to over- 
sight and not to any lack of appreciation. I personally 
have sent a largo numhor of patients to his clinic, and 
can testify both to the benefits that they have received and 
to tho kind manner in which they have been treated, a 
courtesy wliich has been amply extended to tho doctor 
sending them, as, for instance, in the matter of reports 
on progress. 

There nrc other clinics also of a somewhat similar nature 
in London, hut, so far as I am aware, there is' no place in 
I all this huge centre of poiiulation whero a complete physical 
treatment is given, including hydrothorapeiitics, and hydro- 
therapy is a special feature of the proposed clinic. 

Such troatraoiit can, of course, be obtained at the spas; 
hut the spas could take only a small fraction of the insured 
patients requiring hydrothorapeutic treatment, even if it 
wore possible or desirable to dislocate so large a body of 
people from their work for a prolonged stay' away from 
homo at a spa. It is not suggested that precisely the same 
benefit can bo obtained by a course of baths in London as 
by a similar couiso at a spa, ns, apart from tho benefits 
of rest and change and tho powerful psychological element 
involved, there is undoubtedly a specific influence on the 
bather’s skin, and so on tlie wliole organism, immersed in 
certain mineral waters, though by no means in all mineral 
waters. 

TIius tho action of hypertonic brine waters, or. of waters 
with high contents of free gases or mineral acids, on the 
circulation and on tho peripheral blood content, is not a 
matter of conjecture or assertion hut of proof, and easily 
verified by experiment. It has been suggested in certain 
quarters that practically the whole virtue of mineral water 
baths lies in their specific content. Such an attitude is 
even more absurd than the opposite one, whicli would. deny 
all virtue to any mineral water bath beyond that of lipt 
water. Hydrology, though vei-y little studied, is, up to 
a certain point, just as exact a science as any other branch 
of medicirio, though an' enormous ; 'amoUnt_ of u'ork is 
required, to be done in the matter of research before this 
backward branch can take its true place in medicine. 

Briefly, for the treatment of insured patients it is pro- 
posed to use various baths and douches of hot ordinary 
London water, in combination, or not, as may he neces- 
sary, with massage, manipulation and movements, elec- 
tricity, light, di-y heat, and other implements of physical 
treatment^ in such measure that one form of treatment 
shall aid or supplement anotlicr. It is confidently hoped 
that this COUISO will reduce tho long list of rheumatic 
panel patients at present nocessavily inadequately treated 
by bottles of medicine, week after week and month after 
month ; will relieve effects of rheumatism though not 
causes; that so it will reduce the cost to tho societies 
of sickness benefit; and that it will curtail the huge 
wastage of man-lahour power caused by chronic rheumatic 
disablement. In fine, that it will he a relief both to the 
panel patient and tho panel doctor. The points mentioned 
by Dr. Aleuncll will naturally bo obsei-vcd: 

1. Patients will be sent by their panel doctors. 

2. They wiU be examined by a doctor at the clinic before 
treatment- 

3. The staff will be fully qualified. 


34 Tan. 7, 1928] 


ITNIYEESITIES AND COLLEGES. 


t Tnr. Bnms* ‘ 
MeuJcAL Joro5i& 


4 . All patients will report periodically for examination by 
the medical officer. 

5. The fact that they are panel patients will be accepted os 
proof of their financial status. 

6. A charge will be made. It is hoped that the clinic will 
eventually be self-supporting. 

Finally I would point out that it is hoped that this 
will be only the first of many similar clinics throughout 
London and the country generally.' — I am, etc., 

London, tV., Dec. I6th, 1927. AllTHUIt STANLEY HERBERT. 


a lurking resentment which is only too liable to reassert 
itself when- occasion offers. 

Without a doubt recent regulations in the sale of 
dangerous drugs have improved prognosis generally, but 
60 per cent, of my- cases are medical men, with whom 
opportunity remains. — I am, etc., 

London, W., Dec. 21st, 1927. G. LAUCniON ScOTT. 


ttnitwrsxtits attb CDoIlcgcs. 


UNDERFEEDING AND OVERFEEDING IN 
INFANCY. 

Sir, — ^D r. Leo Mandel, in your issue of December 10th 
(p. 1118), says that it is to welfare centres that wo should 
look, rather than to a hospital out-patient department, for 
statistics as to the simpler diseases of nutrition in normal 
infants. I think that medical officers of welfare centres 
will agree that overfeeding is a very frequent cause of 
malnutrition, even in the breast-fed infant. How often 
do we get the case of a baby suffering from diarrhoea and 
vomiting and consequent malnutrition, who is found to be 
having ten or eleven feeds in the twenty-four hours 1 The 
mother is told by her friends, “ Oh, your milk evidently 
disagrees with baby. Y^ou should put him on a bottle.” 
When the feeds are reduced to five or six in the day, with 
no night feed, the baby quickly becomes normal, unless 
the overfeeding is of long duration. In my cxperionco a 
case of malnutrition duo to long-standing overfeeding, 
whether in breast-fed or. bottle-fed babies, is much more 
intractable than one due to underfeeding. 

As to dried milks, the following of the direotions on the 
tin usually involves not only the fallacy of feeding entirely 
by age without consideration for weight, but also the recon- 
stitution of the dried milk almost to the composition of 
undiluted cow’s milk, which few people would think of 
giving to a young infant. At centres with which 
I am associated dried milk is supplied in plain packets 
without directions. Instructions are given to each woman 
individually to dilute the dried milk in such a way 
(for a normal infant) that, with added sugar and cod-liver 
oil in some form, the mixture approximates as nearly as 
possible in composition to breast milk. The quantities are 
adjusted partly according to weight and partly to age. 

Besides the fact that they deal chiefly with the normal 
healthy infant, medical officers of welfare centres have the 
further advantage that they are able to see the results of 
their methods in after years, whereas in the out-patient 
department of a hospital the child is only seen as a rule as 
long as the mother considers it to be abnormal. — I am, etc., 

London, Dec. 11th, 1927. DOROTHT B. GeRE. 


A TREATMENT OF MORPHINISM. 

Sir, — ^I have only to-day read Dr. Stanford Park’s 
criticism (December 3rd, p. 1056) of my note ” A treatment 
of morphinism,” which appeared in your issue of November 
5th (p. 827).. 

“ What use,” he writes, “ is atropine in treatment 
apart from the delirium it produces? ” I do not use it to 
jiroduce delirium, and, indeed, I consider that the produc- 
tion of delirium is painful, unnecessary, and undesirable. 
I am not prepared to say why an exceedingly high tolerance 
of atropine and hyoscine secures the patient against dis- 
comfort, but I did and do state it as a fact. Had I not 
Dr. Stanford Park’s assurance that the same result can bo 
secured by other (and as yet, I believe, unpublished) 
methods, I should have said that such other methods did 
not exist-. 

My suggestion that such easy weaning had its influence 
on prognosis, to judge from a small but accurate series 
of after-histories, depends on no supposition of mine that 
“ a kind of immunity ” (to atropine or to morphine? I do 
not gather which) is conferred. I should rather favour 
some such psychological explanation as has been given me 
by patients as a cause of relapse after other treatments— 
namely, that painful withdrawal is apt to leave behind 


UNIVERSITY OF LONDON. 

Dr. T. W. 51. CA31EE0N has been rccoguized ns a teacher of 
liclmlnthology at the Loudou School of Il.vgieue nud Tropical 
Mediciue. 

The London School of Hygiene and Tropical Medicine (Division 
of Sfedical Zoology) has been admitted ns a school of the Duiversily 
in the Facnlties of Medicine and Science under Statute 74. pending 
consideration of an application for the admission of the school as' 
a whole. 

5Ir. Wilfred Trotter, SI.S.. F.R.C.S., has been np)ioiuted a 
member of the University College Committee for tlie remainder of 
tlie year ending February 29tli, 1928, vice Sir George Blacker, 
resigned. 

The following have been appointed examiners for tlie second 
examination for medical degrees in 1928, the chairmen being 
indicated by an asterisk; 

Jnatemv—G. Elliot Smith (Univ, Coll.), D. M. Blnir fKing's Cqll.), 
lA'. E. Lo Gros Clark (St. Hart’s), ’F. Q. Parsons (St. Thomas’s), W. Wrieht 
(London Ilosnital), T. Yeatca (Middlesex). Mrs, Lnaas Keene (London 
School of Alcdieino (or Women). J. E. S. Frazer (St. Mary’s), together with 
the external examiners. _ 

Pfmrmacotooi;.— 15. 1). Vorney (Dnivers” r-'-- •• ' ’ 

V naniil) (St. liart’s). N. Mutch (Guy’s), ’ 

Swale Vincent tMiddlcse\). ’Miss E. M ' 

Medicine for Women), B. J. Co)lingwoc " 

c-xtoroal examiners. _ , „ „ „ 

Pkvsioleov 


.T. P. Hill (Univ. Cell.). 
St, Bart’s). G. W. de P. 
)af (London Hospita)), 
(Iddlo-ex). ’Miss W. 0. 
on), B. J. CoUingwood 


R. j. S. Me) 

Klcholson, 

E. C. Dodds 
Cullls (Lorn 
(St. Mary’s), 

It has been decided that tlie soliemo for the second examination 
for medical degrees. Parts I and II, for internal students approved 
in Cv 1925? and continued tor tlie session 1926-27, sliall be 
continued for tl)o session 1927-28. 

Tt Ims been resolved to institute, in acoordanca with the 
reonlatious on xmiversity titles, llie following chairs, tenable qt the 
Tmiflmi Soliool of Hygiene and Tropical Medicine: (1) Chemistry, 
L ann ied to hygiene; (2) Public Healtli, salary, £1,300 a year, 
to-'eflfor ’ivith an allowance of £200 a year. Applications for tlie 
latter chair must be sent in by February 16th. 

A course of three lectures on the surgery of the kidney aud 
ureter with lautera illustrations, will be given by 5Ir. Grabaui 
Simpson at Guy’s Hospital Medical School on Febrimry 10tb,’17tii, 

^’fnUow^ng "have been appointed staff examiners in tlie 
subjects of examinations for medical degrees for 1928 : 

Anolonv.— Professor T. H. Bryce and Professor T. B. Johnston. 
JBactei’ioloffv - — Professor J. W. H. Eyre. 

rti —First Medical: P. D. Chattairoy and Miss Sibyl Taito 

wfdd^'s Secoia Medical: Professor O. S. Gibson, O B.E.. and F. D. 

arc Jiciiic and Hyoicnc.— TV. B. Anderton and A. S. MacNalty. 
Oeneral Biolosp.-A. J. Grovo and F. Drabble. 

xr r Bolton (internal). Professor F. R. Fraser, Professor 

jurmwe. • (internal). Associate Examiners: C. M. AVilson. 

A- FnUi, c D H de Souza, and Professor W. E. Hume. 

Aft "(ni '^.sceWs and Psychoieov.-C. H. Bond, C.B.E.. and E.. D. 
Macnamara* ,, 

Nettroloai/.— Goraon M. Holmes and C. ivr. Hinds HoTvell. 

J y^rfflicine^. S. Fairbnirn and Eardloy Holland. Associate 
E^SninSs: Processor F.’ J. Browno and D. W. Roy, 
'oto-rhino-larvnaoloau.-Sir William Milligan and Herbert Tilley. 

■D IT oTnn.i —Professor Stuart McDonald and Professor E. H. Kettle. 
As“e BxaStoe^ : E. Donaldson and J. A. B. Hicks. 
B/.artnnro!oDW.-W. E. Dixon and V. .1. Woolley. 

PJmsfcs.-Profcssor P. H. Newman and Gilbert Stead. 

PJil/stoioBy.— Professor J. B. Leathes and Professor J . MelUuhy. 

Stall ar«Ifciiie.-W. A. Brend and R. A. Lyster. . 

X.irnerw — H B. Souttar, Professor C. A. Pannott (internal), XV. Girling 
TtiUl fmternaD E. C. Hughes ; and ns fifth ex-mmer if reamred. 
C M 'pag™ Associate Examiners: Professor E. D. Telford, N. C. Lalm. 
G. T.'Mutlally, P. H. Mitohiner; and as fifth examiner if renuu-od. L. K. 
Martin. 


UNIVERSITY COLLEGE OF SOUTH WALES AND 
5I0N510UTHSH1EE. 

Welsh National School of Medicine. 

EOFESSOR James Henry Dible has been appointed 

athoiogy and Bacteriology in the Welsh National School of 

[edioine- 


Jan. 7, 1928 ] 


6IR TERCY BASSETT-SMITH. 


I. KlcDtcii. JotniKiA 




*r9'>->-k.-- ' * - •• <% * "• '* \ JI5 


CDltUitnvir. 

SIR PERCY BASSETT-SMITIT, K.C.B., C.M.G., 
F.R'C.P.Lohd., F.R.C.S.Eno., 

SdhGTON REAR-AMtlltAl. R.N.(liET.). 

We hnvo to record with gro.ot regret the do.ith of Surgeon 
Rcnr-Adniir.il Sir Percy Bnssett-Smith, K.C.B., which took 
pl.ico jvt his iiomo .it BInckhe.oth on Eecemher 29th, 1G27, 
after a short illness. As lately as December 14th ho was 
present in his nsnal scat at the meeting of Council of the 
British Medical Association. 

He was born in 1861, the son of the late William Bassett- 
Smith, and was educated at Hurstpierpoint and at the 
Middlesex Hospital, taking the L.S.A. in 1882 and the I 
M.R.C.S.Eng. and L.R.C.P. ■ 

liOnd. diplomas in 1883. In t _ii^iiiMui]iiijiij. ' Li iii n ' u B ju i ir 
1913 ho also became M.R.C.P., 

and H. at Cambridge, and in T'-i 

1916 u’as elected F.R.C.S.Eng. ; 

After serving as senior house- ‘ 

physician at Jliddlcsox Hos- ' ' 

pital ho entered the Royal -rl r 

Nai-y in 1883, was promoioil 

to staff surgeon in 1895, 

attained the rank'of surg«»:i 

captain in 1917, and retired 

with the rank of surgeon 

rear-admiral on April Isl, ' 

1920. During tho Sudan r 

campaign of 1884-8S ho served 
at Suakim ns surgeon ' of , 

H.M.S. liamhlcr, receiving 

tho Egyptian medal and tlio r 

Khedive’s bronzo'star. During 

this commission ho made vain- 

able reports on the geology 

and biology of coral reefs, and 

many of tho specimens collected 

by him were transferred to the 

.Bjit|sh^Mnsouni,^ f^r which Ijo 

valuable and' interesting rc^- 

ports on subjects of natural rhutuoiaiih hy] 

liistory and collected many Sir Percy Bi 

specimens; for this work also 

ho received the thanks of tho trustees of the British JIuseuni. 

In 1899 Bassett-Smith was specially promoted to fleet 
surgeon, and received tho Gilbert Blanc Medal for his 
journal. He was also Gragg’s research prizeman at the 
London School of Tropic-al Medicine. From 1900 to 1912 
M was lecturer on tropic.il medicine and bacteriology at 
Haslar, and from 1912 to 1921 professor of clinical patho- 
ogy at the Royal Naval Hospital, Greenwich. AVhile at 
Lreenwich he did most valuable scientific work of many 
vinos for the n.aval service, and in 1921, on his retirement 
Im received a letter from the Lords of 
' A f 1 fippreciation of his groat attainments. 

TT I ot f y^t'rcment ho practised as a consultant in 
arey btieet, and was on the staff of the Victoria Park 
Lhest Hospital and of St. John’s Hospital, Lewisham. He 
•'^"1 AT work of tho Royal Society of 

^ ^’®1‘1 office as its president. He was 

ftiQ V ° “Y1'''^1'!s on snake bite and poisonous fishes' in 
tl,^ f Wedioa, Vol. XI; on undulant fever in 
Rvom ^^’''^J^^opoedia of Medicine, 1915, and in 

and of*" , 19 Rrocfice of Medicine in the Tropics-, 

rmnri’o y;butions on kala-azar, typhoid fever, AVasser- 
^ medical iouraa" 3 . Pi'evention of scurvy, to various 


Sir Percy Bassett-Smith was a loyal supporter of tho 
British Medical Association. At the Annual Meetings 
in 1903 and 1912 ho served as vice-president of the 
Section of Tropical Diseases, and in 1910 of the Navy, 
Army, and Ambulance Section. Ho became a member 
of the Naval and Alilitary Committee in 1921, and 
was elected to tho Council in the following year, and 
held both offices continuously until the time of his 
death. In 1922 ho was made a member of the com- 
mittco appointed to consider the expansion of the 
Army' Medical Service in time of national emergency. 
Ho was a regular attendant at Council and com- 
mittee meetings, where his quiet but most effective 
services and his kindly personality were valued by all 
with whom ho came in contact. 

He was created C.B. in June, 1911, at tho coronation of 
H.M. King George, and IC.C.B. in June, 1921, after his 
retirement. He married Constance Brightman, daughter 

of the Rev. F. Hastings, who 








At tho funeral seiwice on 
M'ednesday morning, January 
4th, at St. Margaret’s Church, 
Lee, the Council of the 
British Medical Association 
was represented by Major- 
General Sir Alfred Blenkinsop, 
the Naval and Militaiy Com- 
mittee by Dr. F.AV. Goodbody, 
and the headquarters staff of 
the Association by Dr. C. 
Courtenay Lord, Assistant 
Medical Secretaiy. 




A ,>Tr 

'Stm-i'-PVA 


riiotasiai'h hy] 


[EUiott and Fry, London. 
Sir Percy Bassett-Smitii. 


■ The announcement of the 

premature death of Surgeon 
Rear-Admiral Sir Percy W. 
Bassett-Smith while actively 
engaged in the medical life of 
London comes as a sad shock 

vice. ^ For^many years he was 

..... service (from 1900 until his 

[E«io(( arid Fry, London. retirement in 1921) in this 
sett-Smitii. capacity at the Medical School, 

first at Haslar and afterwards 
at Greenwich, desei-vedly gave him a unique position. 
Though specially promoted in 1899 to the rank of fleet- 
surgeon (now surgeon commander), his employment in 
these pathological posts was incompatible with the usual 
sea service, and accordingly his further promotion was 
much delayed, and, indeed, at one time seemed doubtful. 
Eventually, howei'er, the outstanding value of his work 
was fully recognized, and this most able, modest, and 
conscientious man, ever w'illing and anxious to help, and 
therefore extremely popular ■nuth his medical brethren, 
became a surgeon rear-admiral and a K.C.B. ; when retire- 
ment did become necessary he left with a truly enviable 
reputation. AA’hile at Haslar (1900-12) he combined 
clinical instruction in tropical diseases with his patho- 
logical teaching and research, and when transferred with 
tho Aledical School to Greenwich was enabled to utilize 
beds in tho Dreadnought Hospital for the application of 
his laboratory results — for example, those on the vitamin 
content of foods — to tho practice of medicine. In the 
outside medical world his merits were duly recognized by 
election to the Fellowships of both tho Royal Colleges, and 
after his retirement he at once became an authority at the 
various medical societies in London and in consulting 
practice. 


1 


SB JAN. 7, I92S3 


OBITUART. 


f TmiCnmnt 
Wmicu. /onrfxt 


ALEXANDER BLACKHALL-MORTSON, M.D., 
F.R.C.P.Ed. akb Loud., 

Consulting Physician, Eoyal Kortliovn Hospital, Lontlon. 

The death took place suddenly, on Dcceinhor 23rd, 1927, at 
Itis residence in Upper Berkeley Street, London, of Dr. 
Alexander Blackhall-Morison. 

Alexander Morison was horn on Christmas Day, 1850, and 
after receiving his early education at Dollar Academy, 
in those days a celebrated boys’ school, ho proceeded to 
tho University of Edinburgh, whore ho took the degree of 
M.B. in 1872. He came of well known Scottish ancestors, 
and took a great pride in tho exjtloits of his progenitors; 
this was shown particularly by' tho volumo tliat lie pro- 
<luced for the New Spalding Club, dealing with “ The 
Blackhalls of that Ilk and Barra,” as well as by a mann- 
ecript volimio whicli ho had prepared dealing with tho 
life of Ids grandfather. Sir Alexander ktorison. Tho 
BlacldiaUs, as ho points out, wore hereditary coroners and 
foresters of the Garioch from the end of the fourteenth 
century. A member of this family, William Blackhall, urns 
regent and professor of logic at the University of Aberdeen 
in the year 16b2, when he lost his cliair in consequence of 
religious difficulties with tho authorities. Sir Alexander 
Morison, who was descended through tho female lino from 
the Blackhalls, graduated M.D. of Edinburgh Uidversity 
in 1799, and later hocanie President of tho College of 
Physicians. He was best knoum as a pioneer in this 
coimtry in tlie special study of mental dise.oses, having 
been for fifty years visiting physician to Bcthlcin Hospital, 
and prominently associated with tho philanthropic move- 
ment in favour of the more humane treatment of lunatics 
which was introduced in the earlier half of tho nineteenth 
century. In this connexion he founded, in 1864, a Iccturo- 
ship on mental diseases in the Royal College of Physicians 
at Edinburgh, and an endowment to reward meritorious 
attendants of the insane. His two sons were members of 
the medical profession, and of those Uic older, Alexander 
Cushnie Morison, was a surgeon in the service of tlio 
Honourable East India Company, and father of Alexander 
Blackhall-Morison. 

After graduating at tho University of Edinburgh, 
Blackhall-Morison became house-surgeon to Professor 
Spence, and afterwards spent some time in post-graduate 
study at the Universities of Berlin and Wurzburg. 
Returning to England, he settled in general practice in 
the North of London, a type of medical work wliich ho 
continued for some twenty years. In 1878 he graduated 
M.D. at Edinburgh, receiving a gold medal for his thesis, 
and in 1887 he joined the Royal College of Physicians at 
Edinburgh as a member, proceeding to the fcilowsliip in 
1889. At a later period, in 1892, he became a member of 
the R^al College of Physicians of London, and nas elected 
to the fellowship in 1903. Desiring to confine his practice 
to -work as a physician, in 1892 he became physician to the 
.Children’s Hospital at Paddington Green and physician to 
fit. ikrylebone General Disjieusary. Later he became 
physician to the Eoyal Northeim Hospital and physician in 
charge of heart cases at Mount Vernon HospitaL 

His interests as a physician were specially connected with 
cardiology, and a number of articles dealing with angina 
pectoris, heart failure, and cognate subjects were con- 
tributed to tho Lancet over a period of about ten Tears. 
A series of these articles, dealing with cardiac paiii, was 
published in- 1914 under the title of Sensory and Motor 
Diseases of the Heart. As the views expressed in this 
volume tended to support the old ideas in regard to cardio- 
logy, they brought Jiim into a good deal of correspondence 
and conffict with the clinicians who at that time were 
engaged in work upon the muscular and electrical pheno- 
mena connected with cardiac function, and especially witli 
the late Sir -James Mackenzie. In 1897 he -was appointed 
by the Royal College of Physicians, Edinburgh, to deliver 
the Morison Lectures, which had been founded by his 
grandfather, and he chose as his subject the anatomy 
and physiology of tho neivous mechanism of tho viscera. 
For a second time, in 1923, he was appointed Morison 
Lecturer, when he dealt comprehensively with the progress 


of neurology, psychology, and psychiatry during tho last 
century. 

Like his predecessor William Blackhall in 1682, ho was 
a man of deep and unyielding convictions, which took tho 
form of a strong championship of what ho conceived -to bo 
tho dignity of tho medical profession. This led him, after 
tho introduction of tho national health insurance scheme, 
to become one of tho founders of tho National Medical 
Union. For some years ho occupied tho position of presi- 
dent in this union. Li times of relaxation Dr. Morison 
was fond of fishing, sketching, and golfing, and ho was 
doA’Oted to several branches of antiquarian research. ’This 
led to tho collection of many objects of interest connected 
2 >articulnrly ivith tho historical aspect of medicine. For his 
collection ho had obtained a fiiio portrait of William 
Harvey, painted upon a wooden panel and believed to ho 
from the brush of Cornelius Janssen. ’Ihis portrait was 
presented h 3 ' him to tho Royal College of Phj'sicians at 
Edinburgh. 

Dr. Blnckliall-JIorison had long been a member of the 
British Medical Association. He sorved on the Metro- 
politan Counties Branch Council in 1921-22 and again in 
1926, and in 1922 was chairman of the Jlarylcbono Division, 
of which he nns tho representative in 19^24. Ho was a 
member of tho Association’s Nou-Pancl Committee in 
1923-25. 

He was interred in tho ccmclei-y of Currie, six miles out 
of Edinburgh, in the same burial ground as his grandfather. 
Sir Alexander Morison, M.D. ’I’ho funeral was attended 
by Dr. J. Ford Anderson, together with several of his 
old patients from London, and there was a large attendance 
from tho Royal CoUego of Physicians of Edinburgh, in- 
cluding the new president, Dr. R. A, Fleming, and tho 
past-president. Dr. G. M. Roliertson. 


JAMES ROBLXSON, C.I3.E., L.R.C.P..taT) S., 
Forracfly Lord Mayor of Cardiff. 

Dn. James Romnson died at his rcsidonce. Hillside, 
Penylan, Cardiff, on December 27th, 1927, aftiw a -short 
illness. Born at Portadown, co. Armagh, in 1867, he 
received his early education at Grange, ajid studied later 
at Galway and Belfast. He took Gio diplomas of L.R.CJ’. 
and S., and after some experience of practice in South 
Wales removed to Cardiff in 1894. Ho took great interest 
in municiiKil affairs, and became a member of the Cardiff 
Ci^ Council in 19DL He was chairman of the HeaWi 
Committee from 1907 to the time of his death, and was 
also a member of tho Parliamentary, Watch, Waterworks, 
Mental Hospital, and Education Committees. He was made 
an alderman in 1912, and served ns Lord Alayor of Cardiff 
in 1913-14. 

Dr. Robinson was tho roprcscutativo of the City -Conncil 
on tho Council of tho South Wales and Monmou-thshire 
University College, and was -a incmhcr of Die Council of the 
Welsh National Memorial -Association and of the Board of 
Manavoment of the Cardiff Roj-al Infirmary. Ho was 
appointed n justice of the pence for the city in 1908, and 
in 1915 when deiiuty mayor, he ivas elected a member 
of tho advisory eonunitteo for tho appointment of magis- 
trates for the city. During the Avar Dr. Robinson assisted 
in the Avork of medical examination, and was chairman of 
the executive committee of tlie Welsh National Hospital 
and of tho exeentivo of the Welsh Hospital at Nctley. In 
recognition of these services he was aAvarded the O.B.E. 

Dr. Robinson was a member of the Cai-diff Di-rision of 
the British Medical Association. By a sad coincidence his 
name appears among those members of tho medical pro- 
fession upon whom the King proposed -to confer the honour 
of Imighthood in the New Year. 


Tho death took place, on December 20th, 1927, at ids 
residence at Newburgh-on-Tay, of Dr. John 1Macmu.i..\n. 
Ho had been in his usual health till December 16th, when ho 
developed an attack of pneumonia. He was horn in 1875 
and graduated M.B., C.AL at the University of Edinburgh 
in 1896, taking tho M.D. degree throe years later. As a 



JAN. 7, TgaS] 


MEBlCAti NEWS, 


[ Th* Bamsa - 0*7 

itrorcit Jonnrii;* 


Btiidciit ho wns tv well known Rnghy footh.ill player, and 
ho did mtich to foster open-air sports in Newburgh, where 
ho was for scrcval years prcsideirtr of local golf and howling 
efnhs. Ho acted as medical oilicor for a nimibcr of parishes 
in northern Fifeshiro, and was a proniinoiit nicnibcr of the 
loca' education authority. Ho is .survived by a widow, son, 
and daughter. 




In the previous year, it will bo nn ordinary report and not the 
full survey report, wliicli was last retiulred for 1S25 and will 
not again be duo until 1930. 

The proceedings ot tho combined meeting of the Section of 
Neurology of tlio Royal Society ot Medicine and the American 
Neurological A'-sociation, which was held at the end of last 
July, have been published in the October Issue ot Brain. Wa 
gave an account ot this conference on August 13th, 1927 
(p. 276). 

The Jolin Scott prize ot 1,000 dollars has been awarded to 
Dr. Peyton Rons for bts work on cancer, Dr, A- Hess for his 
work ou rickets, and Dr. Afriano de Amaral for his work on 
anlivcnlus. 


Tnu People's Iic.-iguo of Health has aramged two series of 
lectures to bo delivered In the house of the Medical Soctoty 
ot London, 11, Gbaudos Street, Oavondish Stiuarc, at G p.m. 
Eight lectures on tho mind and what ought to bo known about 
It will commonco on January 25tb r tlioy will bo given by 
Drs. Crichton Miller, E. D. Macnamara, R. D. Gillospio, 
T. Beaton, E. Mnpother, W. A. Potts, A. F. Trcdgold, and 
Sir Robert Arrastrohg-Jones. Seven lectures on nutrition In 
bcaitb and disease will commence on February 17tli, and tbo 
lecturers will include Professors LeonardHill, V. H.Mottram, 
Wlnttrod GnUts, and Drs. Harry Gamphcll, L. J. Harris, and 
Enc Holmes. Tickets may be had from Miss Olga Ncthorsolo, 

E. R.O., 12, Stratford Place, W.l. 

The Pharmacentical Society of Groat Britain will bold, an 
evening meeting in tho theatre at 17, Bloomsbury Square, 
W.C.,on Tuesday, January 10th, at 8 o'cloclt, when a lecture 
on colour photography will be given by Sic William J. Popo, 

F. R.S. Tea and coffee will bo served in tho examina- 
tion hail afterwards. Medical friends of members will be 
welcomed. 


The Fellowship ot Medicine announces tliat a clinical 
dcmonstratfon in ophthalmology will be given ou Jann.ary 
11th, at the Royal Eye Hospital, St. George’s Circus, at 3 pjn., 
by Mr. Griffith. Theflrst medical demonstration will bo given 
by Sir Thomas Hordor, at St. Bartholomew’s Hospital, on 
January 26tb, at 1.30 p.m., and tbo llrst surgical demonstra- 
tion by Mr. A, E. Mortimer Woolf at tbo Qneeu Mary’s 
Hospital, Stratford, on January 23rd, at 2 p.m. Lectures 
arranged by tho Followsliip of Medicine will bo delivered in 
the lecture room ot tho Medical Society, 11, Cliandos Street, 
Cavendish Square, on Mondays, at 5 p.m.; the llrst lecture 
will bo given on January 16th -by Sir James Pnrves-Stewart 
on aento drunkenness. Tliose lectures and demonstrations 
are free to medical practitioners. On Jntiuarj^ 9tli a fort- 
night’s course in medicine, surgery, and tho special depart- 
menu will begin at the Prince of Wales’s General Hospital, 
Tottenham. Also on January 9tli a course in diseases of 
children, organized by Dr. Bern.ard MTyers, will commence 
at tbo Children’s Clinic, tho National Heart Hospital, the 
Royal Waterloo Hospital, the Hospital for Consumption, 
Brompton, and tho Royal National Orthopaedic Hospital, and 
will occupy nearly every afternoon and most morningS- 
Other arrangements for January inclnde a whole-day course 
m cardiology at the National Hospital for Diseases of the 
Heart, January 16th to Z7tli, and one in psychological 
medicine at Betblem Royal Hospital, consisting of iectnro 
aamonstrationson Tnesday and Saturday mornings, at 11 a.m,, 
from January 17th to February 11th. Syllabuses and tickets 
may be obtained from tho secretary ot the Fellow.ship of 
iledicine, 1, Wirapole Street, WJ, wlio will al-o supply 
copies ot tho Postgraduate iledicalJ onmal ami particulars 
or the general course of work, which continues throughout 
the year. “ 


MacNeu, Buchanan and Dr. George 
■r.v..,.A and [iresident respectively ot 

^‘*ysicians and Surgeons, Glasgow, h 

rityor&a^ow.^“^‘^'^ county of 

presented by the pn 
nr, borough ot Croydon with a wireless set 

from thf> gootlwill OU his retireir 

the corresnnn'v^* offlcership ot health for Croydon to tak( 

tho corresponding post at Birmingham. 

on a snhSirt ^0° for ®s 

worir will hp with ophthalmology involving orig 

tWs e^sal is December, 1929. The subject 

significance.” Essaw shonl and clin 

fields Eye HospUal, CitfS F P f f “ 

may be obtained. The fabwf 

sentiubyDeceraber i current essay ti 

diagnosU of m?ptosis ” ’-ilp 

sublets. ^ ^ prize is open to all Bri 

health ^ntlmrHlPs ^®“'tb has issued a circular to pn 
wWchmeawi om if the character ot the re 
wmen medical officers of health should, present for 1927. 


The annual report for 1926-27 of the Society tor the Fro- 
vision ot Birtli Control Clinics has been issued from the 
Women’s Welfare Centre {153a, East Street, Walworth Road, 
S.E.17). Besides tliis main centre at Walworth the society 
now has elglit affiliated centres t in Stepney (East Loudon), 
North Kensington, Cambridge, Glasgow, Manchester, Wolver- 
hampton, Birmingham,.and Oxford, the last two having; been 
opened during tlie year under review. Three ot the medical 
officers attaclieil to the centres of the society accepted tho 
invitation of tho National Birth Bate Commission to give 
exidenetj at its mcdicai session. Fot tbs raaintenanee ol its 
work the society is dependent on volnntary benevolence. 

The honorary secretary ot the Lansanne Medical Gradnates’ 
Association informs ns that the following medical men have 
been approved for the M.D. degree at the Dniversity ot 
Lansanne since June, 1927: F. Ellman, J. J, Lnddy, J. R, 
Maleri, D. A. Lmric. 

The hoaltb ot the Enropean child in Malaya is tbo snbjecfc 
ot an article in the i.ssne ot the Journal o[ Tropical Jlcdicine 
aiid Hygiene for December 15th, 1927, by Dr. G. A. C. Gordon, 
late assistant health officer to the mnnioipality of Singapore. 
Full details are given ot the necessary precautions to ba 
adopted with regard to clothing, diet, and habits, and the 
conclusion is reached that the average period ot residence lor 
those cUildreu may, under lavonrable conditions, be extended 
to the age ot puberty. 

At a livery dinner of the Society of Apothecarle.s ol London, 
held in tho Hall at Blacltfriars on Jannsry 3rd, the Lord 
Mayor (Sir Cliarles Batho) and. Mr. Slieriff Davenport, 
attended, as gnests, and the society’s gold medal was pre- 
.sented to Sir Frederick Gowland Hopkins, D.So., F.R.S., 
P.R.C.P., px’ofe.ssor of biochemistry in the University of 
Cambridge. Tho company were received by the Master, Dr. 
R. Whiteside Statham, and the Wardens, Lient.-Colonel 
C. T. Samman and Dr. H. J. Dott. Those present besides 
the atter-diunor speakers inclnded Sir George Miikins, Dr. 
C. O. Hawthorne (Chairman of the Representative Body, 
British Medical Association), Sir Sqnire Sprigge (Editor of 
the Lancet), Mr. H. W. C.arson, President ot the Medical 
Society of Lorn ion,, the Masters ot fi^ve City Companies, and 
Sir Frodericlt Hallett, who was warmly congratulated on his 
knighthood, aunonucetT among the New Tear honours. In 
proposing the health of the Lord Mayor and Sheriffs, tho 
Master, in a graceful speech, spoke of the happy relations 
between the Corporation and the great Guilds of tiic City 
ot London and of the long history of the Apothecaries' 
Society, one ol tho lew guilds still carrj-iiig out the 
objects of its charter. As proof of its response to 
the needs ol tbo time, ho mentioned the establish- 
ment of the new diploma in obstetrics and infant welfare, 
for which the first examination would be held next 
summer. After replies by the Lord Mayor and Sheriff, tbo 
Master presented- the society’s gold medal for therapeutics, 
paying tribute to Professor Hopkins’s nniqne position in bio- 
chemistry and to the profound inflnenco npon therapeutics 
of his pioneer studies in nutrition.; that part of his work 
which had the widest appeal was his discovery of the bodies 
now known as vitamins. Sir Frederick Hopkins, in acknowr 
ledging the award, welcomed Dr. Statham’s emphasis on 
dietetics as a branch of therapeutics. It might seem a pro- 
vocative statement at such a banquet, but in his view no sec- 
tion of the hnmou race, had ever yet been properly nonrisned. 
Alibougb the race had survived, yet this was a relative 
survival. Something was wrong ; there was some deficiency ; 
but science, ho believed, wonld be able to right matters 
without disturbing the amenities of life. The founding of 
this medal proved the society's interest in medical re.search : 
great advances in medicine almost always camefrom re.search 
rather than Irom experience and common sense. The health 
of the gnests was proposed by the senior warden, and 
responded to, in the absence of the vice-chancellor, by Dr. E. 
Graham Little, M.P. for the University of London, and by 
Mr. Lewis Briscoe. Master of the Armourers’ and Braziers, 
Company. Excellent music was provided by the Chaunt^ 
GUiemeu, a mate voice qnartette from the choirs cl Tfest* 
I minster Abbey and St. Paul’s. 



KHEUMATIG INFECTION IN CHIIiDREN. 


t TmZ^xmn On 
Mcoicjlx. Jomxxb 


Jan. 14, 1928] 


55riit5lj ^tcbitnl ^ssociaiion lEcctiirc 

OJT ■ : ; . - . 

THE EAELY DETECTION AND SUPERVISION pE 
RHEUMATIC INFECTION IN CIliLDREN. 

Delivered before the Kent Branch at Bromley on 
Novejiber IOtHj 1927, 

■ ' . . . BY 

GEO. A. ALLAN, M.D.,,.F.R.F.P.S., M.R.C.P., 

ASSISTANT PRYSICIAN, AVESTEHN, INVIRMARY, GLAEGO'W . 

It is noiv over four yonrs since tlio Section of Sledicino , 
at the Annual Meeting of the British Medical Association 
,at Portsmoutli, after a discussion on the etiology and 
treatment of heart disease in early life, sent a recom- 
mendation to the Couneil to appoint a special committee to 
investigate this grave menace to the communitj-, with a 
•viea' to its prevention. -A few months later such a sub- ' 
committee was appointed b3' the Science Committee to 
inquire into the subject of cardiac disease in children, and ^ 
later to advise the' parent committee on the rheumatic 
problem generallj’. 

As j-ou arc doubtless awarej that Committee has pub- 
lished two reports — one in 1926' and one in 1927- — and the 
interest these have awakened augurs well for the future, 
although it must bo remembered that many years’ work 
will be required if any impiossion is to be made on the 
disease throughout the country. 

It is not my intention by the presentation of figures to 
try and impress you with the size of the problem. I under- 
stand from the wording of the invitation I received that 
you wish to come to grips with practical things and to see 
.in what way you yourselves can help. Your secretary 
spoke of “ rheumatic heart disease ” — I have intentionally 
altered the words to “ rheumatic infection.” One principle 
which has guided the subcommittee in all its deliberations 
has been that to prevent rheumatic heart disease the whole 
problem of the rheumatic infection in children must be 
tackled. This is not to say that until the question of 
rheumatism is solved nothing can be done to avoid much 

■ of the cardiac crippling that exists. But when aiming at 
the prevention of cardiac disease we may, with proper 
vision and perspective, hfelp towards solving the larger 
problem. 

Early Detection. 

l\Tiat we have to aim at as an ideal is not the early 
detection of the manifestations of the rheumatic infection, 
but the ability to detect and circumvent the conditions — 
diathesis, environment, or infection — which in combination 
produce the manifestations. That is the true preventive 
ideal. It involves a knowledge of certain factors about ' 
whith our information is still limited. 

What do wo know in a true sense about the rheumatic 
diathesis? There is a tendency to ascribe it to "a 
certain imbalance of the production of hormones bv 
tlie thj-roid, adrenals, and pituitary.” (I am quoting 
from a book recentlj- published.) A consequent want of 
adaptation to environment would lay the child open to 
infection, and active rheumatism might result. It is, if 
anything, an inborn predisposition to a special type of- 
infection. But not all with that predisposition develop 
the disease, and the problem is not materially altered for 
these children,- though there maj' be need for greater care 
along jneyentive lines generally. The difference is one of 
tile quantity rather than the quality of the steps to be 
undertaken. • ■ . 

'Syiien we turn to the question of the environment 
and the factors which generally predispose to rheu- 
matism we are again in the field of unsettled speculation. 

■ I he subcommittee has made an attempt, I think witli a' 
certain measure of success, to verifj- some of the points 
about which there has for long bung a curtain of 
doubt. It is impressed by the importance of the bousing 
factor and the relation of dampness in dwellings to the 
rheumatic infection, arid with the greater liability to the 
infection of the poorer classes, though not of the very 


poorest. - One-might say that it afflicts the poor rather than 
the rich; those who , live in damp rather than those who 
•live in drj-' houses; the J’oiing rather than the old; and 
children with' enlarged tonsils more frequently than those 
with health}' tonsils. 

When we coriie to the question of the infection we can 
only say that tUerd’ is no view Which has been so .widely 
accepted as that it is due to a streptococcus, and that 
many believe that the tonsil is the commonest portal of 
entry. That the intestines may harbour it, and that, when 
"once it gains entrance, many parts may afford it a resting 
■place where it is ready to light up on slight provocation, 
there are sufficient ground's to suggest. More positive 
knowledge regarding these points — diathesis, environment, 
and infection— hns to be acquired if prevention is to bo 
more than a slogan. 

Early Manifestations. 

In tlio meantime, while laying our plans and working 
for the- prevention of the diWasej oiir next best line of 
attack is to recognize it early, treat • it ' efficiently, and 
prevent, relapses. - 

■ What, then, may be. the earliest niariifestations -of , the 
rheumatio. infection for the discovei-y of which we should 
ever.be on the alert? 1 

The. Heart. . ■ 

It is B'oll to remember that the heart itself may present 
the first recognized manifestation." .In quite a large number 
of cases of rheumatic heart disease there is no .history 
of antecedent illness. Thus, in a series of 112 consecutive 
cases of mitral stenosis, and after, making allowance for 
growing pains, muscular rlieiimatisiri, and .other infections 
in addition to typical rheumatic fever, there still remained 
a balance of 18 per cent, in which no history of previous 
illness could be obtained. In some the heart had been 
quietly infected and the invasion unrecognized, as no 
special symptom called for treatment till the heart began 
to fail. Only repeated, systematic examination of appa- 
rently healthy children would have detected these cases 
early. In others, the attack on the heart is primary, 
acute, and abrupt. 

I It is often extremely difficult to be certain whether 
a heart has been definitely attacked in the early stage 
of the disease. While mitral stenosis may be taken as tho 
valvular lesion most constantly rheumatic, this lesion must 
not be expected in the early stage. ■ Before the character- 
istic murmur and tlirill have fully; developed probably 
several years have elapsed. A systolic murmur developing 
at the apex may be the earliest' si^, .but, -on the other 
hand, such a murmur may appear quite apart from valvular 
damage,, and cannot alone be taken as positive evidence. 
Some enlargement of the heart is ' a better guide, but, 
again, one -must be prepared to - firid variations in tho 
position of -tliecapex beat in perfectly healthy children. 
Definite enlargement and a systolic . iriunnur ri'ould he 
presumptive evidence of heart involvement. In some cases 
the aortic i-alve is affected early, and the diastolic aortic 
murmur provides definite evidence of heart invasion. If to 
those is added an unduly rapid qinlse the inference is that a 
lesion is riot, only present, but active. It must be remem- 
bered also -that while valve lesions may speak more clearly 
in physical signs, myocardial lesions are, tbougli moro 
silent, also more important. Pericardial friction is, of 
course, absolute evidence of heart involvement, ‘and ifc 
is certain to be accompanied by damage to the muscle. 

. , Pains. 

Pains in the child, whether recognized as rheumatic 
fever,- growing pains, or muscular rheumatism, call for 
special care. There are still those who need to be reminded 
that rheumatic fever in children is not necessarily a very 
painful affection. There are still many people who have 
got- to be made to recognize that rheumatic fever is pre- 
eminently a disease of childhood. The term “ growing 
pains ” 1 am convinced has been the cause of much nertoct. 
I- recollect- five consecutive cases of active ■ heart disease 
in young people admitted to hospital tiro years ago. In 
no case bad frank rheumatic fever been the primai-y 
manifestation. In the first and second it was “ growing 

[3497J 


40 Jan. 14, 1928] 


KHEUMATIO INFECTION IN OniEDEEN. 


r TifE I3nmsH 
2. Mcdicii:. JocEXAt 


pains ” ; in the third it was “ rhcnmatics ” in the feet, 
cured after one visit to a doctor’s surgery; in tho fourth 
it was, a septic throat; and in the fifth it was hreathlcssncss 
with lio antecedent history. Those having the care of 
children, whether in the. capacity of parents, teachers, 
school medical officers, or general 2 )ractitioncrs, must have 
these facts prominently iji their minds. 

Chorea. 

Chorea should ho accepted, in tho ahscucc of any dchuito 
evidence to tho contrary (for example, lethargic encci>hnl- 
itis), as a rheumatic manifestation in cvciy case. A fright, 
or the strain of school, may ho tho exciting factor, hut is 
seldom if ever tho only one. In two of the eases already 
referred to chorea was recognized heforo heart symptoms. 
Poynton’s figures, published some years ago, arc worth 
repeating. In 217 cases of chorea there was definite heart 
disease (with other rheumatic manifestations) in 122 ; 
arthritis in 28; dilatation of tho heart in 22 ; in 20 there 
was no histoiy, but irf two rheumatism develoi)cd later; 
and in 15 the chorea was ascribed to fright, and two of 
these later were rheumatic. 

Classical Sydenham’s chorea should not he waited for. 
Restlessness, fidgetiness, or change in nature shoidd he 
investigated early. One wonders how many children with 
unrecognized chorea are imnished when they ought to ho 
medicall}’ treated. Thi.s must also he ])reacho<l in the 
projier quarter, and teachers woxdd often he able to 
recognize symptoms which at least call for medical exam- 
ination before classical symjitoius of chorea ajiiiear. 

Tonsillitis. 

There can he no doubt about tho close association of 
recurrent sore throats, or tonsillitis, with rheumatic fever 
and heart disease. Tho frequency of enlarged tonsils in 
children with rheumatic infection is greater than in other 
children of tho same age gi'oup. Tonsillitis, not ncces- 
sai-ily very serious, may bo the first indication of ill health 
in those cases, and may also usher in a relapse. In a case 
recently seen with enlarged 'heart and systolic ajiical 
murmur there was a history of recurrent tonsillitis for five 
winters, and in the last attack, and for the first time, tho 
patient had some pains about the ankles. The sore throat 
of scarlet fever also seems to ho the fact that determines 
rheumatic and heart infection in that disease. Antecedent 
tonsillitis appears to he less common in the choreic than in 
other types. Whether the tonsil is the portal of onti'y 
for the infection, or a coincident manifestation, wo need 
not pause to consider. We do, unfortunately, know that 
with the removal of tonsils freedom from relapse in 
rheumatic cases cannot he guaranteed, though it appears to 
help more in the cardiac and arthritip than in the choreic 
type. 

Tho only practical conclusion at present seems to ho 
that diseased tonsils are a potential source of danger, and 
if they are |>roved to be diseased enucle.Ttion by an expert 
should be advised. 

Kochiles. 

■ The irainless rheumatic nodules found on the extensor 
aspects of joints or tendons, and on the scaljj, are, when 
present, valuable for diagnosis, prognosis, and treatment. 
Thej- are not iircsent in every case, and will often bo over- 
looked unless speciall}- sought for'. Their painlessness 
contr.nsts with the jjainful and tender fibrous nodules of 
so-called muscular rheumatism or fibrositis. They tend to 
come otit in croirs, and are best seen by flexing the joints. 
In doubtful cases their presence clears the diagnosis; in 
Ijrognosis they help by indicating a severe and usually 
visceral type of infection ; in treatment they indicate 
activity of tho infection, even though fever has ceased, and 
call for pirolongation of treatment. 

Other Early Features. 

Other features may bo even earlier, but are less 
certainly rheumatic. Anaemia in a child always indicates 
the need for careful investigation. Primary anaemias are 
less common in the child than anaemia associated with 
other diseases. One of these latter is rheumatic heart 
disease, and it should always be looked for. Pleuriq- is 


a condition which is occasionally rheumatic, though,' of 
course, it is more often tuberculous. Restlessness and 
ncrvousno.ss have already been indicated in their relation 
to chorea. In aty])ical febrile illnc.sscs tho infectious 
fevers, stomach affections, and chest and throat complaints 
arc often thought of. How often is a search made for 
.soiiio rheumatic manifestation? 

SuPEn VISION. 

The time has iinsscd when tho treatment of rheumatism 
can ho di.smisscd after some details about tho dosage of 
salicylate.s, the best kind of local application, and some trite 
remarks about a siiitahlo' fever diet, a blanket hod, and 
some laxative. 

Prc.sont-day ti'catmcnt iirestipposes an acquaintance with 
tho natural history of the disease so far as it is known, 
with tho environmental conditions of tho patient, with tho 
factors that will host promote recovery and prevent collapse, 
and with tho facilities available for sjiccial treatment 
when homo conditions are unsatisfactory. 

Sniu'cying tho treatment in its broader aspects I would 
suggest that our guiding principle should he to destroy 
the infecting agent while removing the causes that encour- 
age its operation, and to resuorc function while protecting 
against relajisc. 

To Destroy the Injecting Agent . — We do not yet know 
of an)' bactericide or specific serum that has a direct action 
on tho organism. Till we know of something better the 
salicylates arc onr main hope. Administered in large doses, 
with donhle tho amount of sodium bicarbonate, while 
ensuring a daily evacuation of the bowels they ore well 
tolerated by children. This treatment should he continued 
for n week or two after all signs of activity have passed. 

Remove the Causes . — ^This heading implies a knowledge 
which wo only partly possess, but if housing conditions, 
defective nutrition, throat, dental, and intestinal infections 
plav a part even in a general lowering of resistance, then 
these should be combated. As some of those cannot be 
dealt with at homo the logical conclusion is that the child 
should be removed to a more suitable place, and this means 
iiosi>ital for tho majority. There, under more hygienic 
conditions the actual treatment of the infection, of dental 
and of intestinal sepsis, and specialist treatment of diseased 
tonsils can ho carried out with greater hope of success. 
Whether tho general part of this can he under the super- 
vision of tho family doctor will depend on the resources 
of the patient, the nature of tho hospital, and its adminis- 
trative rules. , 1 1 i. 1 4 . 1 

Eestore Function.— IXest in bed, and later regulated 
exercise aio tho most potent therapeutic agents at our 
disposal’ for this purpose. With even any suspicion 
of cardiac involvement rest should be prolonged for .a 
few weeks after all evidence of activity of the disease 
has vanished. Pnin. which is often slight, readily passes 
with salicvlic treatment. Actual fever likewise soon 
disappears,' but a subfebrile temperature, rising perhaps 
oiiiV to 99 ° (skin) at some part of the day, and only on 
some daj-s, often persists. It may only be recognized if 
four-hourly records are made, and not infrequently it indi- 
cates activity of tlie heart lesion. Nodules likewise must 
he looked on as evidence that the disease is not fully 
arrested. Lastly, elevation of pulse rate should warn the 
attendant that the heart is still in the grip of an active 
lesion. 

It may ho asked how long tins is going to take. No figure 
of weeks or months can bo stated. In a recent case whose 
treatment I was occasiouall)' called on to supervise in 
private it took nine months. In many cases it may 
be shorter, but it may be longer. It can hardly be con- 
tested that if the heart is unduly exercised during the 
stage of activity dilatation and iiermanent damage will 
ensue. 

Following this period there usually remains much to 
he done. Iron, cod-liver oil, and glucose have a useful 
place in restoring vigour to the cardiac muscle. Regulated 
exercise is also of value. But experience jioints to the 
fact that these will operate more efficiently if convalcBcenco 
can he prolonged under the best hygienic conditions, and 
ivith fresh air, and especially sunshine. 



42 Jan. t^, 1928] 


done at sufficiently short inten'nls to make it of value. 
It cannot bo done haphazard ; a list must bo kept and cases 
noted to attend at suitable intervals. 

The Hospitals. 

When n'o consider children who have como under the 
purview of the hospitals or infinnnries directly, wo find 
that they have been dismissed to their homes and gone 
back to school or chronic invalidism. A hospital register 
would require to he kept of all such cases, and a method 
evolved for their ijeriodic examination. Unless someone 
accepts responsibility for these, anj’ re-examination is apt 
to he perfunctory. Advice sent to the school would, of 
course, allow of a certain control, hut, as we have seen, 
this is apt to bo unsatisfactory. 

We have now various groups of children whose 'treatment 
is being supervised by different people in the same area, 
and if complications arise these children will mostly gravi- 
tate to the hospitals for indoor treatment. 

If vre could ensure co-operation between the school 
service, general practitioners, and hospital authorities, a 
supervisory centre run in conjunction with a hospital 
would appear to he the most appropriate solution. One 
such centre has been in operation for a year and has 
received the blessing and some support from the Rhoximatic 
Heart Disease Subcommittee. I refer to the one at 
, Paddingtoxi Green Children’s Hospital, under tlie charge 
of the secretaiy of the subcommittee, Dr. Reginald Miller. 
In the official report of this centre (Buitisu Medicai, 
Journal, Supplesient, December 10th, 1927, p. 223) certain 
facts should be noted. It is a supervisoiy, not a treat- 
ment, centre; . it works in close association with tho 
hospital, the school medical service, tho public health 
service, and the general practitioner, and it does not 
interfere with the u'ork of the general jjractitioner. 
The value of such a centre is seen in the numbers 
who have been found requiring, .and who have been 
reconunended for, treatment. About a quarter of the 
cases had active infection and about the same number 
required tonsillectomy, and all these wore referred to 
hospital or to their family doctor. Others have been 
referred to heart homes or to schools for physically defec- 
tive children, and of course a large number are still under 
regular supervision. 

Another benefit from such a centre is that it affords an 
opportunity of educating tho parents in tho significance of 
certain signs of ill health. On the reverse of the iiatient’s 
card are printed tho following suggestions on the care orf 
rheumatic children : 

Ox THE Care or Rheumatic Children. 

1. Rheumatism is caused by infection by a germ, and is a 
common disease of children, in whom it often attacks tho heart. 
This is the great danger of the disease. Rheumatism is the 
commonest cause of heart disease in children. 

2. Rheumatic attacks of all sorts often start with a sore throat. 
A sore throat in a rheumatic child is always a dangerous symptom. 

3. Common symptoms of rheumatism in children are : 

Sore throat. 

Pains in muscles. 

Painful joints. 

Paleness. 

Shortness of breath. 

Fidgetiness or nervousness. 

4. Chorea, or St. Vitus’s dance, is rheumatism attacking the 

brain. Its' chief danger is the tendency for the heart to be 
injured at the same time. Unusual nervousness, disturbed sleep, 
fidgety, movements, or a tendency to drop things may bo warnings 
of St. ' Vitus’s dance. _ 

5. Rheumatic heart disease is often painless and may only be 
discoverable by a doctor’s examination. 

6. If tho heart has been injured by rheumatism, its recovery 
is very slow, and permanent harm may be done by letting the 
child resume an ordinary life before recovery is satisfactory. 

7. An occupation in life for a child with heart disease requires 

very careful choice. m, t 

8. Rest is very necessary for rheumatic children. They should 
always be put to bed early, and they should be made to lie down 
during the day if they seem at all tired or if there is any 
aching of the limbs. 

. 9. Damp is bad for rheumatism; basements are dangerous. 
Rheumatic children should sleep in the sunniest and driest room 
available. If they get wet, their clothes Ehould_ be taken off and 
dried at once. Watertight boots are especially important. 

10. Rheumatism tends to i-ecur, especially in the winter months. 

■ Similar suggestions have been iirinted in other parts of 
tho counti'y for tho information of teachers and parents, 
and have proved useful. 


r TnrDnrnsH 
L Mzcicaz* Jocsxal 


It will ho obvious that local conditions regarding density 
of population must dotenuine to a certain extent tho best 
method to ' ho ' adopted in any locality. Further, any 
sehemo to ho efficient implies tlie presence in tho locality 
of Eomo public-spirited medical men. In certain parts it 
might ho found most suitable to staff such a centre from 
a roster of practitioners. In others a hospital physician 
might take charge. By tho class most attacked by the 
disease payment is not going to ho made. Tho public have' 
not yet been educated to tho standard of individual pay- 
ment for professional attondanco when they think they aro 
well. There is, however, much to commend the work, and if 
local hospitals would provide tho facilities no doubt each 
town could provide one or more who would ho willing to 
give the time nece.ssary to this supen’ision. 

Then tho goodwill and co-operation of tho school medical 
SOI vice and tho general practitioners in the district ought 
to be secured. If tho Branch could stimulate interest so 
as to honeycomb the county ■with enthusiastic investigators, 
in addition to tho immediate good of tho children much 
tiscful information would ho accumulated if 'uniform records 
were employed. Such a scheme is at present under con- 
sideration in tho West of England, and a scheme of volun- 
tary notification of rheumatic hoai-t disease has been 
suggested. 

Possible Immediate Action, 

Before closing those remarks, I should like to emphasize 
two lines along which I think immediate practical good will 
follow. Ono is the education of all those coming in contact 
■with children in tho special liability of children to this 
infection, in tho conditions which as far ns wo, know 
predisposo to it, and tho indications of ill health which 
warrant medical attention. Tho other • is the, need for 
prolonged aftcr-caro and tho provision of suitable residen- 
tial hospital schools .or rest homes — call them what you 

will where a healthful environment, modified recreation, 

and general education can ho provided for more or less 
indefinite periods. 

The report of the Medical Research Council on “ Social 
Conditions and Acute Rheumatism,” published this year, 
while not agreeing in all details with the report of. tho 
Association’s suheommittee, closes its preface with this 
sentence, which has our cordial support: “ Tho plain need 
for organized after-care offers an urgent but soluble 
problem of preventive . medicine, too long neglected, ..and 
evei-y motive of humanity and wise economy should impel 
tho community to provide the after-care as rapidly as 
possible.” 

Referexces. • • 

* Britikii Medical Journal, Sufplejient, July 3rd, 1926. = Ibid, April 

1927. 


FIELD YISION AND NEAK YISION.* 

BY 

FEKELANO FEKGUS, M.D., LL.D., 

-HONORARY SURGEON, EVE INFIRMARY, GLASGOW. 


The Royal I’hilosophical Society of Glasgow in 1895 gave 
me an opportunity of publishing my views on the testing 
of tho eyesight of seamen. The subject was discussed at 
that time chieily from two points of view — namely, tho 
testing of the colour sense and the testing of tho light 
sense.*’ Tho communication was largely a criticism of a 
report by a departmental committee of the Board of Trade; 
tho net result of that discussion was that new regulations 
for tho testing of eyesight which were about to be issued 
were withdrawn after the jiaper which I contributed to this 
society was, in groat part, published in the Liverpool 
Journal of Commerce. 

I have HO intention of going hack on that controversy 
further than to say that, so far as I am aware, the testing 
of tho light sense has not yet been introduced in the 
examination of seamen. As a result of that controversy 
coloured lights are now largely used in examining tho eye- 
sight of seamen, as is also Edridge-Greon’s colour testing 
apparatus, and that notu'itlistanding tho strenuous advo- 
cacy of Holmgren’s wools by the late Sir W. de W. Abney 

• An address given to the Hoyol Philosophical Society of Glasgow. 


field vision and near vision. 



Jan. 14, 1928] 


FIELD VISION AND NEAR VISION. 


[ Tin: Bnm« 
Mto tcat. Journax, 


43 


in llio officml -report to ■ wliicli I Imvo referred. ■ Ho 
ol)j('ctcil to coloured Iniiterns being used for testing, on-tlio 
ground tlmt the light emitted by any coloured lamp was 
not a pure light; forgetting all the while that the saino 
objection is applicable— and perhaps more strongly so — to 
the coloured skeins. 

At present 1 desire to discuss some other functions of 
vision which are classed under the designations of field 
vision, visual acuteness, and form sense; perhaps it is 
logitimato to add to these percc])tion of niovoment. ‘ 

-it may materially help to cliicidato my subject if I call 
attention to the diflerenco between visual acuteness and 
■field vision. A siiuplo experiment will at once show the 
•differciice. I am going to ask the learned chairman of the 
meeting to look at. a single word in tho centre of a page of 
print. He- will- find that, so -long as. ho looks steadily at 
the selected word, ■ lio is-qiiito unablo to rend any other 
word on tho page. -The fact that ho can read tho selected 
word depeiUls on the' crrcuiiistnncb that its imago is made 
at tho macula of, tho .retina-, and hence visual acuteness is 
somotiincs spoken of as. macular vision. Such a dcsigna-, 
tion may not bo strictly accurate, but still no serious harm 
can arise from our regarding “macular vision” and 
'."visual acuteness” ns practically .syiionjmious. Tho term 
visual acuteness ” is perhaps more appropriately used 
;as indicating a measurement of tho sharpness of macular 
vision possessed by any eye. 

. To return to the experiment : while the chairnmn dis- 
covers that so long-'as ho looks fixedly at one word he is 
unable to :rc'ad any otber word on tho page, at tho same 
-I'O- ooticos' th.at lie', sees,' although indistinctly, ' that 
there are persons 'sitting on tho benches. Ho cannot, ! 
however, so long as ho gazes at tho selected word, rccog- 
'nizo any of them, and might even experience some difficulty 
in saying whether they were ladies or gentlemen. The 
power of reading^ tho selected word is called visual acuto- 
'ness'or central' vision ;' the power of recognizing objects at 
a distance 'from tho central point of fixation is called 
field or peripheral vision. To some extent the difference 
beW'een the two is comparable to tho difference between the 

- J? i’ 1’®"'®*' the higli power of a microscope, Tho tom 

- ™ ®<^"®o ’’; is often, indefinitely applied to visual sensa- 
tions, and- in several of the older textbooks it is used 
carelessly to mean macular vision. 

' purpose is to call attention to some of tho 

■functions of -peripheral .VJsion which seem to me to have' 
escaped notice, or at any-, rate have not been adequately 
■considered; ■ My proposition is that for ordinary manual 
work visual •acuteness,., in the proper meaning of the 
expression,- is hardly ever emploved; the workman as a 

■ rule uses only his field ,^^Bion. . " 

'l^isuai nciifeness' has' been evaluated; up till now tho 
.same has not been done for field vision, and, so far as 
-■f .op'opinioh,- it is never likely to bo expressed by 

f°™ola- ■- , The ■first' man to give a reliable formula for 
. of visual' acuteness was Professor Hermann 

. j Utrecht, who for many a day was the colleague 

,ot Professor Donders in tho university of that town. 

nas a most foi-tunate combination. Snellen was an 
oplithalmie clinician of the first rank, and Donders was, in 
i.at part of physiology wliich deals with vision, iferhaps 
only second to Hehnholtz himself. His book on tho refrac- 
tion and accommodation of the eye is still a standard 
book of high authority. 

Snellen, after much experimental work, came to the con- 
^ ,'’®^°re any object could be seen by a typicallv 
ealthy and emmetropic eye, it must subtend an angle of 
one minute on the retina; this implies that, before two 
o jects are distinguishable one from the other, they must 
0 separated by a space which subtends an angle of one 
minute on the retina. Ultimately he adopted a 5-minuto 
angle as the standard of macular vision, and arranged lines 
ot letters, the largest of which at 60 metres subtend an 
, angle of 5 minutes, while the smallest subtend the same 
angle at 6 metres. Between these there are lines for tho 
distances of ob metros,-24 metres, 18 metres, 12 metres, and 
• u metres. 

■ . Snellen introduced the formula V = where V is the 

risual acuteness, d the distance between the’nafient and 

'■■•''•'‘'i- ,1 ic ■ -.-i; 01 , = ' 


tho typos, and D tho distance at which tho lowest of the 
lines -which tho patient is able to road should -be read by 
h normal eye. Thus if at tho distance of 6 metres tho 
person being examined is unablo to read, or says that ho 
is unable to read, anything smaller than tho lino which 
shoidd bo read at 18 metres, his vision, or supposed vision, 
is 6/18 according to Snellen’s scale. 

In practico it is found that some persons with normal 
cj'os as regards both structuro and refraction have better 
vision than Snellen’s standard; but such exceirtions, in my 
experience, aro not frequent. Landolt of Paris, who, 
perhaps ns much as anyone, applied the teachings of 
Helmholtz and Donders to clinical work, while accepting 
Snellen’s standard, altered tho test, using instead of 
letters a broken ring. Either test is quite good ; in tho 
main I think Snellen’s is the more generallj' useful, for 
tho break in the ring may correspond with a corneal 
meridian which is emmetropic — that is, of normal refractive 
power — while tho other meridians of the cornea may bo 
short-sighted or long-sighted. 

In tho next place I wish to indicate as clearly as I can 
what I mean bj' “ field of macular vision.” Again I am 
going to take tho liberty of using the chairman for experi- 
mental purposes. I have on this slip of paper a number of 
letters printed in parallel vertical and horizontal rows. 

1 now ask the chairman to look steadily at the letter 
printed at the centre of the slip,, and while doing so to 
draw a line round all tho other letters which he sees dis- 
tinctly while his vision is fixed on the central letter. That 
gives us tho field of binocular macular vision of the person 
being examined for a particular distance. If the'distance 
of tho observer’s eye from tho paper be known, and also tho 
diameters of the figure drawn to include all the letters 
that the examinee has seen are measured, then a simple 
calcidation will give the field of macular vision in degrees. 
So far as I have been able to form an opinion, the field 
of macular vision, when no accommodation is used, does 
not extend to two degrees in the general field of vision. 

As is well known, the aforementioned binocular general 
field of vision, ns distinct from the macular field in what 
may bo called the maximum horizontal direction, measures 
rather more than 180 degrees, say about 184 degrees. That 
means that if the person being examined stands erect and 
looks at a distant object, so that tho axes of vision aro hori- 
zontal, then if the general field of vision be measured in 
the plane which passes through the m.')culae and nodal 
])oints of the eyes, the general field is approximately 184 
degrees. To put it in nautical language, if I were placed 
at the centre of a ship in such a. position that' I could 
look straight ahead over the bows,' keeping the aXes of 
vision horizontal and parallel, I should be able, if. my eyes 
are normal, to have field vision, -as distinguished .from 
macular vision, from 2 degrees abaft the starboard beam, 
- right round over the bows to 2 degrees abaft the port beam. 
The general field of vision is limited in other directions 
by the j)romincnce of the structures at the upper and inner 
aspects of the margin of the orbital cavity. Now in tho 
circular arc measuring about 184. degrees not more than 

2 degrees correspond to macular vision; the remaining 
182 degress are concerned with field vision. 

I shall have something more to say about field vision, but 
meantime I must ask for careful attention to the conditions 
which obtain in myopia. Suppose a man requires to hold 
a book to within a few inches of his face before he is able 
to read its contents, we say that he is short-sighted. For 
macular- vision it is in all cases necessary that the object 
at which a person is looking — say the book which he is 
reading — and the imago of that object on the retina be at 
foci conjugate to each other, else reading is impossible. 
Supposing a man when not using glasses has to bring a 
newspaper to ten inches from his eyes before he is able to 
read it, then we know that his remote point of macular 
vision is ten inches. Cases are not infrequent in which tho 
remote point is much nearer, perhaps only one inch or 
even less from the eye. Now in such a case it is obvious 
that there is no macular vision at a gre,ater distance than 
the farthest distance at which the person- can see the book 
whieli he is rending; the whole field ber-nnd that dfstaiice 
possesses what has already been called-field vision, but does 
not possess macular. 


Tkj: JlniTtSH 
JICDICAL JovnKi^ 


44 Jan. 14, 1928] FIEIiD VISpN AND NEAK VISION. 


TIio next point wliicli I jim going to mention will appeal : 
to those who have no familiarity with optics. It is this : 
that any man who, when reading without glasses, has to ‘ 
bring a book ,to a distance of ton inches, or oven less, fi'oin 
his e 3 'os before he is able to see to read, experiences no 
difficulty in walking about the sti’eets without glasses. For 
example, in that condition such a man does not require to 
approach to within ten inches of a tramcar before he sees 
it; nor has ho to put his eyes to a distance of ten inches 
from the step before ho is able to mount; nor docs he • 
require to go to ten inches from a man walking in the 
street before he secs him sufficient!}' clearly to avoid 
-collision. All such actions depend on ‘field vision, and not 
-on macular vision, or visual acuteness, as it is generally 
called. 

It is this field vision which is employed -for almost all 
manual -work, and a person engaged in such a form of 
cmi)loyment hardly ever uses his macular vision, or only 
incidentally does so.- As above stated, macular vision has 
been expressed by a formiila. So far as I am aware field 
vision has not been thus expressed, and I think that it 
never will be. Nevertheless, it is of the first importance 
-to those engaged in manual labour and, indeed, to everyone 
in daily life. 

Field vision has the following important functions in 
-health : (1) It has light sense, a function which, up to 
a point, gives a certain -form sense. (2) It has colour sense, 
which, however, is modified in some persons by the prcs('ncc 
of colour-blindness. (3) It has the sense of ])roj(>ction. 
(4) The periphery of the I'ctina, as well as its central parts, 
has vision which is very excellent for the perception of 
movements. 

Although a man be very short-sighted ho can readily 
perceive differences in shades, for that is a matter of the 
light sense. To illustrate -my meaning lot me narrate an 
experiment which I made on myself in the month of Sc])- 
tember, 1926. On a clear although moonless night, towards 
the end of that month, I made myself myopic by tlie simple 
process of putting a pair ofT2-inch convex lenses in front of 
my spectacles for distance, and yet with that nrj’angoinent 
I could from Arinagour in the island of Coll sec the 
Treshnish Islands, the neai'cst being eight miles away : they 
would liaT'e pre.sented' no difficulty had I been navigating 
through them. It was not a pitch dark niglit, for 
there was starlight; had it been so nobody, no matter 
what the condition of his visual apparatus, would have 
seen anything, but the feeble amotint of light present 
was differently reflected by the sky and by the islands. 
Yet, with the optical ai'rangement ivhieh 1 was u’enring 
at the time, I could not have read -a book at a greatei- 
distance than twelve inches from ray eyes. Short-sighted- 
ness, even a high -degree of short-sightedness, does not 
per se pi'esent any difficulty in the .seeing of colours. , 
Thus the short-sighted man negotiatijig the tramcar 
would see the vehicle some liundi-eds of yards fi-om 
him; he would do so because, for the most jiart, cars are 
in movement, and, moreover, the reflection from it.s surface 
would affect his light sense differently from the objects sur- 
rounding it. Further, from the differences in the colours 
of tho ears, he wotfld most likely be able to determine if 
it was -the car that was going to suit his purj)ose. A short- 
sighted person is unable to read an illuminated direction 
notice on the front of a car withoTit the aid of glasses, but 
has no difficulty whatever with a coloured light, unless, 
indeed, he is colour-blind. 

Projection is one of the most important functions of 
vision. IVhen the point at which the person is looking is 
straight in front then the principal axis of each eye is 
directed to it, and it is seen in what may be called its 
true position, but in addition to that, in binocular vision, 
not only can the position of the object, the image of which 
is forined on the macula of each eye, be definitely fixed;^ 
but while the per.-on is steadily looking at this object he ' 
can at the same time quite accurately point to other objects 
in the room. Let us suppose that an object is lying fo 
tho right of the observer when he is looking at the point 
of fixation; then its image is formed on the nasal side of 
tho right retina and on the temporal sido of the left j'eti]in, 
and tlieso two stimulations, one on -each retina, give rise 


in health to single binocular vi.sion. Such points are said 
to be homologous. 

But tho' same condition is found to exist in monocular, 
vision. If I were to shut one eye and look steadily at an 
object in front of me, 1 could quite easily point to other 
.objects in tho room. From tho point o'f .view of compensa- 
.tion for tho loss of an eye tliis is. a matter of great 
importance. In tho early days of woilrmen’s compon.sation 
I wa.s much omjiloycd on behalf of certain firnrs to examine 
-persons who had .sustained eye injuries, and tho mention of 
-two casc.s will show the imiiortance of tho subject. One 
of them was that of a man who had lost .an eye in a largo 
factoiy in a town not. far from Glasgow. Tho remaining 
eye wa.s admitted to be good. I caused search to bo made, 
and it transpired that quite a number of men who were 
each possessed of one useful eye had worked in the same 
and other factories in that neighbourhood; their pay sheets 
were quite as good as those of their more fortunate 
brothron. 

Tho same question aro.se in connexion with a miner who 
had lost ah eye at his work. Again tho pay sheets were 
produced of a number of colliers similarly situated ns 
regards vision, and it was found that the amounts earned 
by these men compai ed favourably with the amounts earned 
by their fellow workimei. At the moihcnt 1 cannot name 
any form of manual work nhich cannot bo undertaken by 
a junn who Jias only .one healthy eye. 

.•Vnother que.stion arises, and it is : Given that a work- 
man ha.s lost an eye at a particularly hazardous occupa- 
tion, .should ho bo.co)npollcd to risk .the remaining eye at 
tho same occupation ? Personally I would answer that ques- 
tion in the negative; ho ouglit not to bo forced to do so.' 
At tho same time there would require to bo a careful 
definition of what constitutes hazardous employment. 

Aleiition must bo made of auother important difference 
between macular vision and general. field .vision; it is that 
if errors of refraction exist they must be veiy carefully 
corrected for macular vision, but -do jiot, within wide 
limits, ' require, to be corrected at all for general .field 
vision. Had time permitted 1 would have elaborated -this 
point, but I mm-t content myself by relating a -few 
examples, which relation will, I think, convoy my meaning 
to mv audience. 

1. To return to our .siipposed case of a nian who, owing 
to ins short-.sightedness, cannot vead a hook at a greater 
distance than ten inches, yet who is able, with suitable 
glasses, to read the .smallest of . Snellen’s types at thoiproper 
distance of twenty feet; such a man, although unable to 
read ordinarv tvpe at a greater distance than a Joiv inches 
with the nakcii eye, can without spectacles mr oyoglas.sc.s 
]ierfectlv well make out objects at very considerable dis- 
tances. and ho secs them with sufficient distinctnass to 
enable him to locate them even when they are far off, and 
to avoid them when they are near. In other words, visual 
pflicienev cannot be expressed in teiuus of visual acuteness, 
using the phrase “ visual acuteness ” as synonymous with 
macular vision. It is -quite untrue ±0 say that because .a 
man cannot read all Snellen’s types at twenty feet ho will 
not be able to make .out ;in -object at sea, perhaps miles 
away. As alroailv narraleil, when I made myself so short- 
sighted that I could not read a book at a greater dis- 
tance than twelve inches I could easily make out the 
presence of islands eight miles away. 

As regards road traffic, it does not matter what letters 
I a driver can read in a -consulting room, but it docs matter 
that he can .see other traffic on the road at a sufficient dis- 
tance to enable him to avoid it; the one is not a test of 
tho other. 

The vision required at sea and on the road is field vision, 
and not macular. No doubt a certain amount of macular 
■vision is required at sea for such purposes as reading of 
tide tables and the examining of charts. 

2. Nor docs the presence of an uncorrected defect in the 
\ refraction of the eye make any difference to the individual 

in distinguishing colours. A person with an error of 
‘ refraction can, without glasses, distinguish colour.s quite 
as well as ho can with them; for the recognition of colours 
is for the most part .a .matter of field vision and not of 
■ macular. 



Jan. 14. ’928] 


FIELD VISION AND NEAK VISION. 


t THE CnmaE 
Mkdicaz, JoirsKU 


45 


5 'I'ho sAiHO vomavk holds tnio ahoul (ho light sense ; iho 
tlislim'lu.ii of shades is quile good in poniiheial vision, and 
that wlu'thov tho individnal is or is not wearing glasses. 
Indeed thi' light senso is more active without glasses 
than with them, for ahoiit 15 ]ier cent, of the light that 
is incident on tho surface of a spectaclo lens is ronectod and 
novel' eiders tho eve at all. AVhori' the initial amount of 
light is .small tlio effect of tho lo.ss of siieli a iiercciitage is 
coiisulornhlo. 

1 hope the |)rcceding remarks have iiiade the essential 
dilFereiiee lietweeii. visual aentenoas and field vision quite 
clear. 1 propose to conclude hy giving a few o.ainples in 
snp])ort of the view which 1 have already expressed, that 
inannal work is for the most part a matter of field vision 
and not of inaciilar. 

In the first place take coal miners. At the Annual 
meeting of the. llritish Aledical Association in Toronto, in 
1906, 1 mentioned' the cases of sonic ininei-s who had very 
higli degrees of short-sightedness — some with tho far point 
of maoiilar vision at only two inches from their cye.s — and 
yet their pay sheets slioivod that they were in no way 
handicajiped. Sinco that time I have seen minors whose 
far points of macular vision wore ton inches or under 
who had' no difficulty with their work. I have recorded 
cases ill which-tho far point of rending vision w.as at two 
inches from the eye, and yot the pay sheets showed no 
diminution of earning power. One case I particularly 
rememher, in which a young miner desired to get work 
above ground and applied to he taken on as a stoker hy one 
of the railways. It was then found that he had short- 
sightedness and that his far iioint of reading distance was 
at fifteen inches from his eyes. Till that examination took 
place lie had no idea that there was anything wrong. It 
is needless to say that his sendees were not accepted.* 

A few years ago I made an investigation as to the 
causes of blindness in about twelve hundred cases. The 
results of that • investigation were published under the 
atispices of the medical officer of health for the city of 
Glasgow. I have selected a few of them as illustrative of 
the truth of the view which I have been enunciating — 
namely, that the importance of field vision has not been 
adequately considered. One or two of the case' which 
I am going to mention were seen at the clinic of the 
Glasgow and AVest of Scotland mission to the Outdoor 
Blind. 

1: A m.aii, aged 70, who, at the time of my seeing Iiim, was 
quite blind as a consequence o( injuiy to the back of Iiis liead. 
Thcrefove for souio- years be bad not bad eillicr macular or 
field vision. The interesting point is that he had previously been 
extremely sboi t-sighted, so tliat tiio conjugate of each leliiia was 
at a jess distance than two inches from the front of the corre- 
sponding eye, and yet, in that condition, lie maintained himself 
either as a dock labourey or as a stoker on hoard a steamship 
Tip .to the tune of, the accident which depi'ired him of sight, and 
he did that work' without any correction of his erroi's hy glasses. 

2. -A man. in the _ employment of the Glasgow mission to the 
Outdoor Tltiiid._ This man lost an eye a number of veal's ago. 
A\ iUi the remaining eye lie secs the ty'pe called “ brilliant '* hy 
printers at rather less than two inches from the eye, but not at a 
greater distance. Till he entered his present employment he was. 
regularly at work at the bottom of a coal pit. 

3. .A man whose conjugate to each retina was twelve inches 
irqm tlio cornea, yet he was quite able, till he became iiearJv 
blind from' choroiditis, to work as a carter in the streets of 
Glasgou'. 

4. In this case there- is also high degree of short-sightedness, 
the conjugate of the retina being at tliree inches from the man’s 
nye, yet all through the war he worked steadily in a hangar of 
the Koyal Air Foi-ce. 

5. This workman lias also an extreme degree of short-sighfed- 
pess, the conjugate of his retina being not more than three .inches 
nidron, of liis cornea, yet lie' was, during the war, enlisted in 
U.m. iorccs ami served abroad. 

The above cases show that, altbougli a man’s far point 
of roatling vision may be only a few incites from bis eve — 
than tw’o — ^yet the field vision is quite 
sufficient to enable the person to undertake mniiv forms of 
ordinary work. 

Amongst those 'vliom I have entered in my siiocial note- 
book there are x'ecorded some cases where the coiiiugate of 
tlio retina is negative — ^tbat is, it is sitnated behind the 
letina, and the light leaving the eye from a point source 

* See Dr.msH JtEDic.n. Jonaxn., 1E06, ii, p. 1855. 


on the retina emerge.s from the eye in a divergent ]ionell. 
For this form of refraction error the same condition is 
true — it makes very little or no dilTerence .so far as manual 
work is concerned, but it docs cause much tvoiililc for near- 
at-liand vision, and intorfore.s materially with a ]iersou’s 
ability to read and to write. 

I might bring before your notice many other cases of 
per.sons possessed of refraction errors wbo liad no difficulty 
wbalevor in earning tlicir living and in getting about mticli 
as other people. It is quite certain that for their work 
they did not employ visual acuteness, but only field vision. 

Now I wish to bring to notice a few cases of a differcut 
kind, hut which also support the view that field vision is 
of great importance for most forms of manual work. 

A man w.is operated on in both eyes for congenital cataract. 
He Ims no visual acuteness — that is, h'e cannot see to read at any 
distance with or without glasses, and never will — yot he has 
cxeclicnt field vision and is able, without any attendant, to get 
ahoul quite freely. 

Bilateral congenital cataract — an opacity in each lens 
in infancy, or at any rate in early childhood — if extensive, 
prevents the formation of retinal images and therefore, if 
not remedied bj- suitable treatment, the patient will never 
have tnaculav vision. At the same time ordinary daylight 
reaches the retinas notwithstanding the opaque lenses, and 
a jiorson so affiicted will be found to have useful field 
vision, allbougb destitute of macular vision. 

One of the most extraordinary cases that I have ever 
seen is the following. 

A man, aged 25, had his left eye removed early in life on 
account of -some disease. The right eye has congenital nystagmus, 
and, in addition to that, the Ions of the right is, as the result of 
an injury received a good number of years ago, dislocated. With 
a convex lens of about 7 degrees focal length held close to the eye 
he can make out bourgeois type when that type is held at an 
inch in front of tho lens. He cannot, of course, with any glass 
see even the largest of Snellen’s letters at twenty feet. He lives 
in a town in the South of Scotland, and yet, handicapped as he 
is, he can walk about quite freely. He also says that ho cycles 
a good dcr.l, but he finds cycling increasingly difficult on account 
of motor traffic. ’ * 

One other sot of cases will further illustrate the fact 
that macular vision is not used by working men. AATicn a 
man is driving paling stobs he swings a long-handed mallet 
over his shoulder; that action entirely prevents the imago 
of the ohjoet which he is going to strike being focused on 
the macula. Such work is entirely a matter of projection : 
and the souse of projection is as much a function of field 
vision as it is of macular. 

Another example of the same thing is the swinging of a 
heavy hammer hy a blacksmith. In this instance, as in the 
jirevious one, the action depends upon the sense of pro- 
jection and on tho mental estimation of distance. 

Macular vision, and therefore macular efficiency, can he 
expressed hy mean.s of a formula, and, as already pointed 
. out, it is seriously impaired by errors of refraction. Field 
vision, and therefore field efficiency, cannot he expressed by 
any formula, and for field vision, within, wide limits, it is 
not necessary to correct erroi's of refraction. 

Field vision is largely a matter of projection and of 
mental interpretation. In one of his writings Helmholtz 
plainly .stated that tho eyes merely receive stimuli of 
various kinds, but that it is loft to the mind to interpret 
them. After all, it is the. mind that really sees and not 
the eyes, just as it is a person who heare" when using a 
telephone and not the apparatus.. 

There are other points on which I should have liked to 
say a great deal, hut 1 have only time for one other 
I'emark, and it is tha.t if you test men for work bv letter.s 
you will reject a number who are quite capable of doing a 
great deal. For example, at tho moment I know a gcntlc- 
mau who has a considerable degree of short-sightedness, who 
cannot see to read at a greater distance than eighteen 
inches and certainly would not have anything like .six 
twenty-fourths of Snellen’s types for distant vision, and 
ret he has for many years driven a motor car and has not 
had any accident. Gndonhtedly eyesight can he tested for 
.such oeciqintions as reading and writing by Snellen’s 
letters, but you caunot test efficiouey for manual work hv 
any such contrivance. The oniy test of efficienev is as to 
j whether a man has or has not done the work ; if ho has 
[ done it in the past there is no reason why he should not 



46 Jan. 14, 19.8] 


THE STUDY OP MENTAD ABNORMALITY. 


r Tnr. nnmw 

L MtMCAL JoCK 5 A£ 


do it ill tile fiitiiio, iiiit 110 priiiia facie statcinont ivitlioiit 
such investigations is of any value. If you' l ojcct persons 
who are capable of work because the)’ are not'able to read 
certain letters at a particular distance you are going to 
throw a number of men out of employment who might 
otherwise bo pursuing occupations reniunorativo to 
theinsolves and beneficial to the community, and add 
materially to the number of the unemployed, although not 
unemployable. 


A PLEA FOE A NATIONAL L.^BORATOEY FOE THE 
STUDY OF MENTAL ABNORMALITY. 

BY 

R. J. A. BERRY, M.D., F.R.C.S., E.R.S.En., 

rEOFESSOK or AKkTOMY, 11)0.0111150 lllSTOEOGV, IK THE OSIVERSITY OF 
MELBOURNE; HONORARY FSYCni.VTElST TO THE CHILDREN’S WELFARE 
DEPARTMENT AND THE CHILDREN’S HOSPITAL, MELBOURNE. 


By the publication in 1914 of Dr. Shaw Bolton’s The 
lirain in Health and Disease and of Dr. G. A. Watson’s 
equally important work on cortical stratification and 
cerebral function in horizontal layers, it appears to be 
established that developmental errors in the cellular 
elements of the sevci’al horizontal layers of the cerebral 
cortex underlie many of those antisocial reactions charac- 
teristic of criminality and some of the insanities. 

Almost every branch of study shows that tlio principles 
underlying the structure of tiic iievvous system are the 
same in all vertebrates. Once fertilization is accomplished 
the single-colled ovuiii undergoes a . rapid process of cell 
division, and these colls resolve themselves into throe groat 
typos — somatic, reproductive, and nervous. As rcgards 
the last highly specialized cells (neurons), it is now 
gonerally believed that, though they remain throughout 
life anatomically independent, they cannot function physio- 
logically unless they become combined into chains and arcs. 
A neuronic arc usual!)’ comprises three nerve elomeiit.s — 
a receptor, afferent, or sensory neuron conducting from 
the periphery centrally; an interposed, connecting, or 
internuncial neuron; and an effector, efferent, oi motor 
neuron. 'Medical attention has, perhaps, boon too exclu- 
sively focused on the "long conducting receptor and effector 
neurons, yet it is the internuncial neurons which, when 
present in sufEcieiit numbers, result in the phenomena 

termed “ mind.” , r. i • n i 

The researches and investigations of Golgi, Cajal, Mott, 
Bolton, Watson, and many others suggest, if they do not 
actually prove, that all mental phenomena— speech, reason, 
memory, and the like — are the products of many thousands 
of millions of cerebral neurons linked together in arcs and 
functional units, and that these millions of cerebral cells 
apiiear to be internuncial in type. 

Ill the spinal cord the dorsal spinal iien'e roots are com- 
posed of receptor neurons. The connecting .associational 
and commissural neurons are internuncial in character, 
and the ventral spinal nerve roots transmit the effector 
neurons of the arcs. In the cerebellum the receptor (pro- 
prioceptor) neurons chief))- tr.averse the inferior cerebellar 
peduncles. The internuncial neurons are of the supra- 
scn-mental type— that is, the associational and commissural 
ne'iirons of the spinal cord are replaced by- small granular 
cells strictly confined to. the grey matter and forming the 
bulk of the cerebellar cortex, and greatly outnumbering 
all otber neurons in the cerebellum. The relatively few 
Rurk-inie cells constitute the effector colls of the cerebellar 
neuronic arcs. The cerebellum is thus distinguished by 
a totally different typo of internuncial or connecting 
neuron, and the associational and eoninnssural spinal cord 
types are coniplotelv absent, being replaced, as .stated, by 
the granular cell type. The fact that anatomical nomen- 
clature has differentiated these granular colls as basket, 
stellate, Golgi Type II, and the like, should not bo allowed 
to divert attention from the fact that all are interposed 
between the receptor and effector neurons of tho. cere-- 
helium and are thus iiiternuiicial in character. Cerebellar 
cortical construction thus compels the conclusion that the 
function of those numerous cerebellar internuncial cells 
must be that of storage of iieiwe imjiulse; hence the cere- 


bellum is,' clinically and functionally, a great storehouse 
of iiorvo energy, and this energy is liberated under the 
control of tho cerebral cortex e.xercisod through tho cortico- 
poiito-cerebellar pathway, and comes into action in evci'y 
voluntary muscular movement. 

Tho cerebral cortex fulfils functions so different from 
those of either spinal cord or cerebellum as to suggest that 
a totally different construction must bo employed by 
nature, and )et such is not the case. Tho cerebral cortex, 
ill its structure, simply repeats both spinal cord and cere- 
bellar types, the essential difference being that there are 
far more a.ssociational and commissural internuncial 
(spinal cord type) neurons, and granular (cerebellar typo) 
ones in tho cerebral cortex than in either spinal cord or 
cerebellum. 

Ill tho cerebral cortex tho tlialamo-cortical fibres form 
the receptor limbs of tho neuronic arcs. Tho projection 
systems represent tho effector sides of tho arcs. There 
are thus loft the enormous numbers of granular cells, and 
the even more niiinerons pyramidal and polymorphic colls, 
tho axon's of many of -which form tho a'ssciciatibii'nl and 
commissural systems of the brain, as tho representatives 
of the connecting or interriiincial units of the neuronic 
arcs. It is not, as yet, clear wbotlicr these numerous cere- 
bral neurons are all to be regarded as the internuncial 
neurons of tho primary cerebral neuronic arcs, or whether 
they form secondary neuronic arcs within the primaries. 
All tlie'evidcnce, however, seems to warrant tho conclusion 
that it is tbeso presumably internuncial cortical neurons 
which, bv storing up all tlioso numerous nerve impulses 
which continually bombard tho brain from birth to death, 
act as the physical basis of memory, and therefore of 
speech, reason, judgement, and of all mental phenomena. 

Bccont research, particularly that of Bolton and Watson, 
has shown that tho cell bodies of those cerebral neurons 
which aro almost certainly internuncial in character and 
function tend to arrange themselves in the cerebral cortex 
in definitely stratified layers, and that this horizontal 
stratification has a subtle, but profoundly important, 
functional significance. Excluding the fibre laminae of 
tho cerebral cortex, which aro not germane to the present 
argument, tho human cerebral cortex is composed of throe 
layers of cell bodies — pyramidal cells on the exterior, 
granular cells in the middle, and polymorphic on -the 
interior next the white matter. The polymorphic colls on 
tho interior, termed by Watson the infragranular cortex, 
are present in all mammals, and are believed to be tho 
iierre elements controlling or concerned with the purely, 
animal functions of the body, such as the acquisition of 
food and the activities of sex — that is, the infragranular 
cortex appears to bo the brain of the preservation of the 
individu.ai and the perpetuation of tho species. 

The pyramidal colls on the exterior aro best and most 
largely developed in man, and man is the only anim.al 
who Iiosscsscs a sufficiency of such pyramidal cells to 
give him tho power of voluntarily inhibiting the animal 
functions of tho infragranular cortex. The layer is termed 
by W.atson tho snpragranular cortex, and the cell bodies 
are of the kind commonly and always associated with the 
effector functions of inhibition. When normally developed 
man can, therefore, exercise a voluntary control over the 
animal instincts of sex, acquisition, and self-gi atification ; 
and society, in the interests of all, expects him to do 
s.->. It is illogical and erroneous to attribute mental evils 
to a purely° physiological process like repression, for 
repression is a- human attribute, and the welfare of the 
nation calls for its exercise. If, however, the individual 
possesses a relatively undeveloped supragranular controlling 
cortex it necessarily follows that his powers of control aro 
diminished, and ho is more likely to react to bis environ- 
ment on the more purely animal basis of acquisition, sexual 
gratification, and lack of appreciation of the consequences 
of these reactions. It is a striking fact that at least 
75 per cent, of those .antisocial reactions against which 
society seeks to protect itself, and known as “ crimes,” 
aro directed against the person or the property — that is, 
sex and acquisition. It is equally striking that Bolton and 
others have been able to demonstrate that these antisocial 
personalities are found, after death, to possess a thinner 
supragranular cortex — that is, ono with fewer pyramidal 



Jan. 14, 1928] 


TEEATMEKT OP EEPUS VUEGAETS. 


t THE Bnirrsn 47 

ilEDicAi. Journal ^ ' 


colls tlian normally slionlcl l)o the caso.^^ It is cqnally con- | 
firmatory tliat Bovry anti Portous in \ ictoria, and jMoiris 
Miller in Tasmania, have been able to substantiate the 
fact, from an examination of many tbotisancls of cases, that 
about two-tbircls of tbc known antisocial group possess 
appreciably smaller beads than the normal, which is, of 
course, a macroscopic and clinical confirmation of Eolton’s 
microsco])ic studies. 

This definitely measurable thinning of the cerebral 
cortex occurs chiefly, according to Bolton, in tho frontal 
region, and chiefly alfccts tho pyramidal-ccllod supra- 
granular cortex, and. these observations of Bolton are 
generally confirmatorj' of tho earlier and more primitive 
worlc of Batty Tuko and other alienists. Such a cortical 
thinning denotes, as stated, a diminished number of 
cortical neurons, and a diminished number of cortical 
neurons equally connotes an altered i-caction to the environ- 
ment. Many human individuals pass into tho com]ilcxitics 
of adult life with an undeveloped, partially developed, 
or irregularly developed pyramidal-cellcil supragramilar 
cortex. They possess tho sexual and physical appetites of 
the adult with the brain of control of the child, and 
it is futile to expect from such abnormally constructed 
individuals that normality of conduct as regards sex and 
respect for the property and welfare of others which 
constitutes the ■ essential basis ■ upon which all civilized 
society rests. Tho .bulk of them are aments and will 
remain aments, and their social reactions will be the 
final product of their environment. 'With such an 
undeveloped and unstable mental or cerebral structure 
they may succumb earlier, and in larger numbers, to this 
stresses and strains of a complex civilized life, and thus 
swell the populations of our poorhouses, police courts, 
mental hospitals, gaols, benevolent homos, and tho like. 
They thus add to tho financial burdens of the fit, and 
aided, as they so frequently- are, by a misguided charity, 
may not improbably ' eventually poison and destroy 
civilization itself. 

A minority of this group, those with an apparently 
irregularly developed cerebral cortex, fonn an even more 
dangerous section of society, tho more so because they are 
frequently mistaken for people of ability, and defy most 
of the known or recognized tests for amentia. 

Many forms of abnormal mental reaction are probably 
not so much duo tq disease as to aberrant cerebral develop- 
ment, with a consequent disordered reaction to tho environ- 
ment. Debates on the relative importance of heredity and 
environment are many. The human brain is tho product 
of both. Mentally deficient parents will breed similar 
children, and will do so in larger numbers than is good for 
society, and for obvious reasons. Lacking an adequate 
■brain of control, they obey, like the animal, the dictates of 
nature, and give free rein to the passions of tho body. 
Developmentally, and in the nonnal individual, the neuron 
or brain coll undergoes a series of embryological changes, 
without which it cannot function. At birth the cerebral 
coitex, and particularly the jiyramidal cells of the supra- 
granular cortex, are largely in a iieuroblastic, non-functional 
condition, and hence the mental reactions of the newborn 
child tend to resemble those of the idiot. With the 
mcoming of the exteroceptive stimuli, particularly those 
from light and sound, a necessary factor for the conver- 
sion of the non-fimctional neuroblast into the functional 
neuron is introduced. The environment, therefore, 
materially affects, not only the nature of tliese .stimuli, 
but also brain growth itself. If, for example, the acoustic 
ex eioceptive stimuli be completely cut off, the child 
becomes a deaf-mute, with a thinner acoustic cortex and 
, a correspondingly diminished general intelligence. If both 
} *®ual and acoustic stimuli are arrested the child may 
become .an idiot from deprivation of its senses, because 
stimuli important to the conversion of neuroblasts into 
neurons are lacking — always assuming, of course, that no 
ot lei form of education ” takes the place of these im- 
portant senses.” If, again, the child be in such an 
oniironment as to encounter only obscene words, criminal 
acts, and the expression of peiwerted thoughts durine 
this most important formative stage of cerebral develop- 
ment, there i'" — — ■■ .... r 


at a 


can bo only* one result- 
later stage. Education is 


antisocial reaction 
the establishment 


of neuronic habit, and that, , in its turn, is the result of 
llio environment. Education — that is, the onviroiimont — 
thus plays an important part in brain growth and mental 
development, hut if tho machine he so imperfectly con- 
structed from tliG beginning as to make it incapable of 
receiving the necessary number of stimuli, then some severe 
degree of amentia must persist tlirougliout life. If this 
be vciy pronounced the law will probably demand the 
segregation of the child as an imbecile, but if it be not so 
pronounced, or he obvious only to the adequately trained 
neurological expert, the' child will he passed into the com- 
plexities of a civilization for wiiioli it is quite unfit, there 
to perform those bodily acts regarded as criminal by the 
more noi-mally constructed members of society. All scien- 
tific* evidence thus scorns to show that mental phenomena 
are tho result of an adequate number of exteroceptive 
stimuli being received by an adequately constructed cere- 
bral cortex — environment and heredity. Tlie first jilace to 
seek for mental ahnorniality of all kinds, and certainly 
those which arc commonly classified as antisocial, are the 
cells of the human cerebral cortex, and this study demands 
co-operative national elfort. 

That there has not hitherto been any co-operative effort 
to study the mental abnormalities appears to ho due to 
a lack of appreciation of the simplicity of the great 
principles underlying tho construction of the vertebrate 
nenraxis, and tho present-day somewhat illogical position 
of tho study of the nervous system may not unfairly be 
represented thus : 

Structure. ■ Specialty. 

i.* Receptor neurons Diseases of the nervous system. 


„ - . . , (Normal 

2. Internunciai 

(Abnormal ... 

3. Eltcclor neurons 


Psychology. 

Psychiatry.. 

Diseases of the nervous system. 


To divide a functional entity, like the nouraxis of 
man, into a series of watertight, non-correlated specialties 
appears to bo unscientific and calculated to breed error. 
It is rather unity of study wliicli is so essential; and the 
future integrity of the nation appeal's to demand the 
cstablishiucnt of a national laboratory for the study of 
cerebral and mental abnormality. Even though the critic 
may bo indisposed .to accept the statements herein briefly 
mentioned, he must in fairness admit that there is 
sufficient suggestive evidence to warrant further inquiry, 
and tho magnitude of the problem justifies a national 
effort. 


TEEATMENT OF LTJPCTS YULGARIS. 

BV 

J. BEATTY, M.D., M.E.C.P., 

DEBMATOLOGIST TO THE ROYAL IXTIUilARY, A27D THE ROYAL HAMADEYAD 
HOSPITAL, CAEHirF. 


Dobing the last four years almost exactly 4 per cent, 
of the patients treated at the dermatological clinic of the 
Koyal Infirmary, Cardiff, were cases of lupus vulgaris, the 
proportion of males to females being a little more than 
two to three. The methods of treatment used have been 
pyrogallol ointment, acid nitrate of mcrcui-y (as recom- 
mended by Adamson), salicylic acid and creosote plaster, 
X rays, ultra-violet rays, and alkaline phenol followed by 
a hypertonic dressing as described below. Of these x-ray 
treatment lias been little employed as the results were slow 
and uncertain. Ultra-violet rays applied by the Kromayer 
lamp locally, combined with general irradiation, have been 
disappointing, as cases wliicli did not readily yield to 
other methods failed to respond, and where they would 
doubtless have been efficacious the other methods gave 
quicker results. Salicylic acid and creosote plaster acted 
well in some cases, but was slow. 

Pyrogallic ointment 5 to 10 per cent, proved valuable if 
thoroughly applied for a long period. One case — a girl 
aged 13 — had when fiji'st scon a wide band of lupus on the 
left thigh, a smaller area about tho right gluteal fold, a 
largo area oh tlie left shoulder, and wide areas on the cheeks 
and nose. The treatment was carried out by a friend, who 
described nibbing the areas with the ointment till thev 


48 Jan. 14, 1928] 


ERYTHKOEDEMA, OR “ PINK DISEASE.” 


t XitR BnmsH 
MKDlCAli JODRSA& 


bled. After four yoar.s tho disease lias disappeared, only, 
■superficial scars being left. Some other patients to whom 
this ointment was proscribed only benefited slightly. In 
- these, investigation showed- that, the pain- of ;thc .application 1 
and tho slowness of the rate of- progress'h.ad' caused them ■ 
to neglect its use. ' ' ■ 

Ono merit of the acid nitrate of mercury and the phenol 
methods is that, being applied b 3 ’ tho physician himself or 
under his direction, and only in hospital, , thero is no 
question of'tlie thoroughness of tho. application. t 

Tho' objectiohs to the caustic nitrate' lard considerable. ‘ 
Its application is intensely' painful and the caustic action ■ 
is comparativelj' unselectivc, so' that sound tissue is apt to 
be destroyed as well as diseased tissue. It is applied in • 
this clinic bn cotto'n-wool pencils, or. by. means of pointed 1 
match-sticks dipped iii tho fluid; tho latter are used to 
perforate and destroy' nodules. The value of tho method 
appears to bo limited to areas whore discrete nodules can 
bo distinctly' made out, otherwise destruction is extensive 
and unsightly scars are loft. The pain is , so. great .that it i 
demands considerable fortitude on the part of the patients 
(local anaesthetics applied to tho surface reduce but do not 
abolish the pain), and they are therefore apt to cease 
attending before tho treatment is completed. Never- 
theless tho nitrate or some equivalent caustic seems to bo . 
indispensable for exuberant or deep-seated nodules, and 
for dealing with tho nodules which survive tho phenol 
treatment. 

Tho application found most generally useful is alkaline 
phenol followed by a hypertonic dressing. AVith the 
co-operation of Mr. J. T. Williams, pharmacist to the 
infirmary, the following foimulae have been worked out. 
In a 4 c.cm. wide-mouthed sample bottle stojjpered by a 
rubber cap are placed 2.5 c.cm. of a solution of caustic 
potash (1 part to 2 of water) in which is suspended pi-e- 
cipitated chalk (1 part), and 1.5 c.cm. of acidum carbolicum 
liquef actum. A considerable degree of heat develops. Tho 
preparation is made in small amounts because oxidation 
takes place with ro.sulting brown discoloration after a few 
days’ exposure to the air over tho fluid. When tho phial 
is filled this does not occur to any extent, and there is 
enough of tho preparation to treat several patches. It is 
better, however, to keep tho caustic potash preparation 
separate from the phenol and mix shortly before use. 
Fresh preparations are thus always conveniently available. 

A pencil of cotton-wool wrajqred round tho point of a 
forceps is dipped in tho fluid and the area rubbed. The 
caustic potash dissolves tho epidermis and tho abrasive 
action of the precipitated chalk aids in its removal. As 
the rubbing is continued tho lupus nodules start out as 
purple spots, and nodules not previously noted can bo 
detected. AVhen these purple spots aro well marked the 
application is stopped ; if it is continued the whole area 
will turn a purplish-black. Tho colour appears to bo due 
to haematin formation by the alkali. 

A yriece of unmedicated lint is cut of the size of the 
area of disease, and on this is placed a fairly thick 
coating of a paste consisting of equal yrarts of salicylic 
acid, sodium salicylate, and Cano sugar, with enough 
glycerin to make a soft jraste. This is applied to the 
area treated and the whole covered in with zinc oxide 
adhesive plaster, which overlaps for some distance on all 
sides so as to make an impervious dressing. 

There is a good deal of pain during the application of 
the alkaline phenol, but the anaesthetic action of the 
phenol soon removes this. Later in tho day a fair amount 
of pain is to be expected, and after a day or two exudation 
finds its way out from under the dressing. The application 
is repeated twice a week, in most cases for four w'eeks, 
though not so long for superficial cases. On the removal 
of the first dressing a granulating surface is found, no 
lupus nodules being visible, but if the wound were allowed 
to heal some nodules woidd be found. 'Repetition of the 
treatment is therefore necessary, but after the first treat- 
ment touching with the alkaline phenol or slight rubbing 
only is required. After the last treatment the place is 
allowed to heal up under boric ointment. 

Superficial areas aro often cured in six weeks, approxi- 
mately, but when tho nodules aro deep-seated or the type 
is exuberant complete cure does not occur so soon, A 


great reduction, however, in the amount of the disease 
takes place. It . is usual to repeat tho treatment if the 
nodules deft are .nuinerous, so ns still further to reduce 
them; if. few -and discrete they, are treated at once by 
acid nitrate of- mercury.' , , • ' , . .. , 

In spite of the strength of the carbolic acid and the size 
of the areas treated — in one case both cheeks were under 
ti'catment at the same time — no sign of carbolic acid 
•poisoning has occurred;- this I- attribute to the hypertoilib 
•dressing, causing the • flow, of lymph to bo outward, not 
inward.- • ■ .. ... .. . .. .. . . T. ... 

In. two cases excessive destruction took place, producing 
superficial, sloughs. In one there was no indication that 
-this might occur. . The- other was that of . a woman whoso 
•leg. had -becn. amputated for tuberculosis;-. her., general 
•reaction was poor, and cure has not- been obtained.- Thero 
is, therefore, some risk in tho mcfliod. 

Tho principle . of tho treatment appears to bo , that 
diseased tissues aro less resistant to caustics .than healthy', 
and that thdrefore,.'if the jn-op.er strength, is- found,. healthy 
tissues will not be seriously damaged. I have repeatedly 
seen islands of healthy tissue in the middle of the ulcers 
produced. Caustic potash alone would act, but the anaes- 
thetic action of tho carbolic acid is valuable.- The hyper- ■ 
tonic dressing might be composed of • other - sub.'jtancc.s. 

I have used a boric acid, magnesium sulphate, and glycerin 
paste with success. .... ... 

This is the routine treatment applied in almost’ every 
case in this clinic, and disappearance of the disease has 
been obtained in cases of many years’ standing — up to 
fifteen or more. It fails, however— or at any rate is only 
pai-tially successful-^where the impervious dressing cannot 
be properly applied— for example, on tho nose,’ or closoUo 
tho eye. For these ’, places it must be supplemented .Jiy 
acid nitrate of mercury or other porverful,’ caustic, ‘or 
perhaps by ultra-violet rays. It does, however, prepare 
the wav for these by reducing the number of nodules. 
It has with tho otheis the great merit that its application 
does not depend on the patient’s perseverance, except so far 
os concerns his attendance at the clinic, and in this respect 
there is no difficulty — patients are eager for the treatment. 
For succe.ss personal supervision by the physician himself, 
attention to .details, and experience of the resistance of tho 
skin; which varies-in different parts of the body, all appear 
to bo requisite., A . 


A CASE OP ERTTHROEDEMA OR 
DISEASE.” 


‘PINK 


DONALD I. CURRIE, F.R.C.S., 

nOXORAKV SUnOEOS, COLWYM BAY AHD WEST DE-SBIGHSHIEE HOSPITAI.. 

Since the clinical picture known as erythroedema, ery- 
throedema polyneuritis, or “ pink disease,” is seemingly, 
from the available literature,^ a somewhat rare condition, 
I have taken detailed notes of a case which came under 
my care lately. 

An only child, a boy aged 2 years and 8 months, -was brought 
to Colwvn Bay iu July for a holiday from Lancashn-o. His parents, 
nra both ouile healthy, said that he was an active and 
normally hoalthy child until a fortnight or so heforo they loft 
homo He then seemed to lose appetite, would not play by himself, 
wanted “ petting, a--^ —n "f*"ti asked to be carried. 

He had one or two t there were no marked 

symptoms, and the . he was “ a .ittle run 

down and that the holiday would soon pul him right.” 

On the day of his arrival he asked for an ice-cream; this was 
civen to him*^ and there seemed to be no immediate ill effects. On 
the next day he complained of severe abdominal pain and vomited 
once and when I saw him for the first time he presented tho 
usual picture of intestinal colic in children. He had spasmodic 
abdommal pain, and the temperature and pulse rate were slightly 
raised. Examination of chest and abdomen was negative, but on 
rectal* examination constipated faeces could be detected. He was 
given a small dose of calomel, a small olive oil enema, which had 
a good result, and ordered boiled water only. 

The next morning (July 22nd), after a good night, the abdominal 
pain had gone, the bowels had been moved with a slightly greenish 
stool, the temperature was 101®, and respirations between 40 and 
50: the alae nasi were active, and although on examination the 
chest still seemed healthy, his condition suggested early pneumonia 
without physical signs, as is common in a child. 

A mild diaphoretic mixture was prescribed, and powders contain- 
ing a sixth of a grain each of calomel and Dover’s powder were 



Jan. 14, 1928] 


A SERIES OF MASIOm OPERATIONS. 


[ TeeBuittsb 
Utdicaz. JorEXAS 


49 


given every four liours. He was kept on boiled water with the 
occasional addition of a lilllo brandy. 

The two following days saw him steadily going downhill; there 
were no physical signs in chest or abdomen, no cough, no vomiting; 
the bowels wore opened two or three times daily, and the motion, 
although not offensive, looked like cooked spinach. On. chest and 
abdomen were a few patches of erythema, which I took to be 
“sweat rash,” and there was a ring of erythema round the 
umbilicns. He was passing nrinc normally, and it showed nothing 
Vniisnnl on examination. His temperature ranged from 102° to 
il03°, pulse rale 140, respiration rate 30 to 40. There were photo- 
}}Iiobia and conjunctival injection, and his tongue and lips ^yc^o 
dp’ and sore. Ho was completely hvpotonic and tho tciidon 
'I'cilcxos were absent. Tlic tips of his Angers and toes were now 
slightly reddened, swollen, and painful to touch, and owing to 
general weakness and the condition of tho month he began to 
refuse fluids, which up to tliis time he had taken in large quan- 
tities. These had consisted of sceway, boiled water, brandy and 
water, and a little orange juice. 

On duly 25th he was semi-comatose with a temperature of 103°* 
His flngps and toes and tho greater part of his hands and feet 
were bright red, swollen, ana acutely tender. Tlicy looked as 
if the boy had been playing with a wet coloured toy and the dye 
had come off on to his hands. His motions wore still like cooked 
ipinach, not too frequent and^ not offensive, and, more with the 
idea of increasing his fluid intake than washing away any poisonous 
bowel cpitonls, I commenced giving him regular large bowel irriga- 
tions with normal saline, leaving a few ounces in the colon eacli 
time. He was also given an ounce or two of normal saline with 
,a little brandy by the rectum at regular intervals, and as much 
fluid by the mouth as possible. All other medication was slopped. 

On July 26tli and 27th this treatment was continued, and a 
■slight but definite improvement was noted. He was liaving up 
tlo 2oz. of. brandy daily and ns much fluid as possible. He had 
wasted rapidly in spite of fluid intake, and was and looked very 
ill, taking no interest in his surroundings and occasionally making 
a feeble cry and holding iip his hands for treatment. The}* were 
being wiped with spirit and dusted with powder. His lempcratiire 
ptill ranged bet^rcen 102° and 103° and his mouth required 
constant attention. 

On Julv 28th he was much better; his temperature was 101°, his 
'hands and ^ct were less red and painful, and tho motions a better 
•ijolour. He began to take more by tho month again, and Yalentine’s 
.^cat juice and albumin water were added to the diet. Tlie next 
day his teniperaturo was 99.5°, his motions were formed and a 
greenish-yellow colour, and as he was taking plenty of fluid by 
■ the mouth the rectal washouts and instillations were stopped, 
and a dilute Ncstld's milk mixture was given in addition. 

rrom this time ho improved daily, his temperature fell to normal, 
nis diet was gradually increased, and his hands and feet became 
less red, swollen, and painful, and commenced to pool in large 
patches, complete casts of some of the fiugcrs being shed in one 
piece. ® ® 

. In another week he was up in a chair, and a few days later 
out in a perambulator. His appetite was enormous ; he con- 
called for more, food, and as his tongue was clean 
and Ins bowels normal he was indulged within reason. When last 
• seen, three weeks after the commencement of the .acute stage of 
the iHncss, he was seemingly quite well except for the wasted 
and flabby condition of the leg riiusclos. He had no motor or 
sensorj' paralysis, but the tendon reflexes were still absent, and 
although he^ was pronounced fit to return home his parents were 
warned, against a too rapid convalescence, with special reference 
to the use of his legs. 


Tho featui'es of the case wliicli impressed me most were 
nist, the iirodroraal historj*, whicli made me suspect meniiig 
itis; then the symptoms siiggestiv.e of earlj' pueiimonij 
wuicU did not develop, and later tho complete hypotoni 
state, and the striking condition of the extremities, whicl 
IS a marked feature of the clinical picture. 

Except for the rise in temperature and the aeutenes 
ot the illness this case seems to have been fairlv typical 
and leads me to suggest that the origin of the‘ toxaemi; 
causing the polyneuritis ” is intestinal. 


Kcfehexce. 

^ Medical Anmial, 1924. 


A SERIES OF CONSECUTIYE OPBRATIOXS Oi 
the aiASTOID. 

BY 

J. ALDINGTON GIBB, 51 D C 51 

no^,on,ur svno^on. KEKI.cou^T^ oPHTixEMic hospit 

• MAIDSTONE, 


j-oais I have pei-fornicd close on 
fo™,cd during Iieve have Keen , 
comprise both^^privalrand h„ 

SLS'fn irtSST' SiSi; 

Any case of n+nvrl ^ record— a somewhat difBcult tj 

wS r.aLi”iSs.”' 


The operations may bo classified as follows : (1) for 
primary acute mastoiditis, in vhich the mastoid and the 
otorrhoea are simultaneous, or tho otorrhoea has lasted 
for a fo«' diiys only; (2) for acute secondary mastoiditis, 
an acute condition grafted on to chronic otorrhoea ; (3) for 
chronic otorrhoea, performed for the cure of the discharge 
and to improve hearing and relieve vertigo. Tho type of 
operation adopted for the acute uncomplicated cases was 
a modification of tho Schwartzo operation. 

In m 5 ' early cases after tho ordinary Schwartze operation 
there was a sagging inward of tho posterior couchal portion 
of tho membranous meatus. This caused a blurring in 
hearing power ; to overcome tins I remove a fair amount of 
tho posterior bony wall and place a suture in such a position 
as to make traction. Unless the tissues aie veiy much 
damaged in tho acute cases the wound is partially sutured 
and the antrum drained b 3 - gauze for twent 3 -fonr to fort 3 '- 
eight hotirs. Ojjinion at tho Anmial Electing of the British 
Medical Association at Nottingham was opposed to this 
and favoured tho open granulation metliod. I am un- 
repentant. It sometimes liappcns that an acute case is so 
severe that a more radical operation than the modified 
Schwartze has to ho done. In such' a case a flap is made 
in the membranous mcatiis and the whole of the posterior 
bony wall is removed. In tho chronic cases the modified 
radical operation was invariably done unless there was 
much destruction of the t 3 -mpanic membrane; tho complete 
radical operation was then performed. In the radical 
operation the posterior wall of the t 3 -mpamim was never 
touched. 

Tho modified radical operation, which is based on 
Bondy’s operation, consists in the complete removal of the 
posterior wall and roof of the external meatus and attic. 
It is tedious but well worth while. The aim of tho. con- 
sen’ativo operation is not onl 3 - to cure the discharge hut 
to improve hearing. This is invariably attained; with a 
lai'go resonance chamber and ossicles and membrane un- 
touched tho hearing power should be improved. After 
the acute operation healing was usuall 3 ' complete in a 
fortnight; after the modified acute operation healing 
usuall 3 ’ took a month ; after the modified radical operation 
cpidermisation in my recent cases, blessed h 3 ’ good nursing, 
lias been o.xtraordinarily rapid— frequently a month, some- 
times six or eight weeks. Any undorh-ing constitutional 
disability, such as S3’pliilis or tuberculosis, delays healing, 
as docs eczema occasionallv. “ 

Among the acute primal^’ cases there were one cerebral 
abscess, two lateral sinus infections with thrombosis, and 
two without. In the acute secondary mastoid cases there 
were three instances of cerebral abscesses, eight of lateral 
sinus infection with thrombosis, and three without. Among 
the acute cases was one septic pneumonia and one diagnosed 
as pulmonaiy embolism. Tho age varied from 1 year and 
2 months to 67 years. 

No case of labyrinthitis occurred in this series. Some of 
the cases had lab 3 ’rinthine s 3 -mptoms, which cleared up after 
the mastoid operations. All cases of serous meningitis 
recovered. ° 


There was one case of secondary acute mastoiditis in a patient 
aged 17, admitted with definite signs of ceVebral pressure — that is 
a high temperature (103°), pulse 5$, and marked mental hebetude- 
aiid vpmitmg. M^toid signs were not typical, but the mastoid 
operation was decided upon. On opening up the antrum pus came 
away under pressure. There was a considerable destruction of 
bone, and the dura was exposed. There was a large cholesteatoma 
occupyms the antrum and middle car. I trephined over the 
temporo-sphenoidal lobe. There was no pulsation of the membrane : 
Hie was carefully opened, and pus sought for in vain. Next 

day the symptoms were better, the mind was clearer, and the 
temperature was down, but the pulse was slower. There was i:o 
papilloedema, and no horaolateral hemianopia. I asked Iiim how 
he was. He said, “ Better, nurse.” “ Have you got anv head- 
ache? ” He ans^vered, ** No, nurse.” I said, ‘^Tm not the nui-se, 
I’m the doctor.” He replied, “ Yes, nurse.” This I took to be 
due to my having explored the anterior part of his temporo- 
sphenoidal lobe (Ballance). The following day his pulse was' 46. 
His answers were normal. There was induced nystagmus in the 
left eye — the operated side— of the cerebellar type. I tlicrefore 
decided to trephine over the posterior fossa, and an inch and 
a half of bone was removed above the lateral sinus. There was 
no bulpriug no pulsation. The dura was incised, the brain 

exposed, and the venules were seen to be engorged but silent. 
Pus was sought for in vain. 

After this second operation he made a complete 
recover 3 -, and left the hospital with quite good hearing 


50 Jan. 14, 1928] 


THE etiology OF LEUKAEMIA. 


[ The DBrnf*. 
Medical Jorsnib 


power. This seems to mo to bo one of tlioso cases of 
encephalitis so well described by Symons. 

Furuncle is mentioned, not as being a complication of 
acute mastoid disease, but for the oj)|)ortunity of making 
this assertion — that in all cases of long-standing otorrhoea 
in which a furuncle largo enough to close or partially close 
the meatus occurs a radical mastoid operation should bo 
done, especially if the furuncle bo on the posterior wall of 
tho meatus. In each of three recent cases I was fully justi- 
fied in this line of action. In many of those cases there 
was a cholesteatoma, and this might mean erosion of bone; 
in one case tho pus tracked backwards between tho skull 
and the dura to make its exit by a hole in the- skull in tho 
sub-occipital region, burrowing its way beneath tho peri- 
cranium into the soft tissues of the neck, where 1 ran it to 
ground, after freel 3 ’ removing the bone from tbo mastoid 
to the secondarj- hole in the skidl. Tho dura was covered 
with granulations, as was the lateral sinus, and at the 
completion of the operation tho lateral sinus burst. This 
man has so far made slow progress. His ago is 47, and ho 
has well marked cmph 3 ’sema of both lungs. Tho lateral 
sinus was never opened and tho jugular never tied unless 
there were definite signs of phlebitis, when tho jugrdar was 
tied high up in tho neck and tho lateral sinus exposed ; 
if thrombosis was present it was dealt with in tho usual 
'wa 5 '. If there had been signs of sinus infection, such as 
rigors without definite signs of phlebitis, the sinus was not 
opened, but if there were definite signs of phlebitis with 
or without thrombosis tho sinus was opened, allowed to 
bleed, plugged, and saline given. In a boy with marked 
lateral sinus thrombosis, necessitating wide excision of 
bono for removal of a septic clot which extended very near 
to the torcular, a complete recovciy resulted with good 
hearing power. In all tho acute cases, primary or secon- 
dary uncomplicated, there were no deaths. Skin gi-afting 
was never done. 


THE ETIOLOGY OF LEOKAEMIA. 

BT 

H. M. WOODM-'IN, M.B., B.Cn. 


The key to the ctiolog3- and nature of leukaemia is 
presumably to be found in tho stud3’ of those factors which 
control the leucocyte content of the blood. While the lino 
of investigation necessary is at present rather obscure, the 
constant recording of cases, €Speciali3’ those which do not 
strictly fall into any standard classification, may throw 
some light on the main causatii e factors. For this re.asoit 
I have analysed the histories of twent3--five cases of 
leukaemia observed during the last six years. 

Tho series consisted of 11 patients with m 30 loid 
leukaemia, of whom 7 were males and 4 females, and 8 cases 
of acute and chronic l 3 Trrphatic leukaemia, 5 in males and 
3 in females. The remaining 6 cases were at 3 -pical. Tho 
red blood count was below 1,000,000 in 37 per cent, of the 
series. 

Myelogenous Series. 

In the m 3 ’elogenous series the total number of leucocytes 
ranged from 32,000 to 954,000 per c.mm. and tho l 3 'mpho- 
cyte proportion from 0.8 to 40 per cent. In the case with 
the most marked l 3 -mphoc 3 tosis the pol 3 -morphonuc]ears and 
myeloc 3 ‘tes were both 29.6 per cent, and the l 3 'mphoc 3 'tes 
later fell to 1 per cent. The pol 3 -raorphonuclear count was 
never lower than 29 per eent. and was usually above 40 per 
cent. This latter point may have something to do. with the- 
better prognosis of myelogenous leukaemia as compared 
with the non-granular form, where the pdl 3 ’morphoniiclear 
count was never higher than 18 per eent. and ranged from 
3.7 to IS per cent. 

Bad teeth or p 3 -orrhoea occurred in 7 cases (64 per cent.), 
night sweats in 3 (27 per cent.), and a chronic infective 
septic focus of some kind was present in 82 per cent, of the 
cases. 

There was nothing in any of the family histories to 
support the possibility of contagion from other patients. 
The duration of the disease varied from two to eight years. 


Tho spleen was enlarged in all cases, and other l 3 -mphatio 
glands in 2 cases. The temperature usually ranged between 
tho normal and 100°; in 3 cases there was no jrvrexi.a and 
in one case tho temperaturo reached 102°. Out of the 
11 cases 7 were discharged as “ better.” 

Non-Graniilar Series. 

In tho non-granular series, out of 9 cases 4 were chronic, 
5 acute. Tho total leucoc 3 -tes ranged from 4,800 to 928,000, 
but in one atypical case the figure was as low as 600. The 
l 3 'mphoe 3 -tic percentage vaiicd from 74 to 96. In all cases 
except one it was 80 per cent, or over. 

P 3 -orrhoca or somo chronic primary focus of infection 
was present in the histories of 6 cases (66 per cent.). Night 
sweats were recorded only in one case. The length of 
history was from ono to seven months in the acute and 
five to eighteen months in tho chronic forms. There was 
nothing in any famiU- histoiy to support contagion with 
an 3 ' other ca.se. The spleen and other l 3 ’mphoid glands were 
cniargerl in all cases except two; in cno of these there was 
no splenic enlargement and in tho other tho spleen onl 3 ' was . 
enlarged. Thcro was usualty no pyrexia in tho’ chronic 
cases; tho temperature rose as higli as 105° in the acute. 
Two patients wei’o discharged — these woio of the chronic 
t 3 'po; the remainder died. 

Etiological Theories. 

Of theories as to tho caus.ation of this disease only two 
need bo considered in the light of present knowledge. 

1. The Tumour Theory. 

This theory is tho moist popular one at tho present time. 
It is based mainly on certain changes which appear to bo 
nnalo''bus to tumour formation, such as tbo excessive and 
apparently purposeless proliferation of leucocytes, and 
their tendency to metastasize. Several factors, however, 
indicate that if the nature of the agency instigating the 
condition is similar to that of tumour formation, it behaves 
quite differently from any other kind of malignant lesion. 
So far as is known, in a necropsy of a case of leukaemia, no 
site can bo indicated as the possible primary focus. 

The changes in tho bone marrow and reticulo-endothelial 
system are more or less uniform, but certain areas may 
tend to be more dense thair others. Patches of leucocytic 
deposit or gross infiltration will be relatively more marked 
in iilaces, but these differ microscopically from centres of 
malignani ijroliferation. “ The newly formed cells are not 
in possession of resolving power (of fermentatire nature?) 
which proper tumour cells possess, and by which they 
entirely destroy the organs attached.”' This is a very 
essential difierence; it. practically aniounts to the difference 
between a benign leucocytic infiltration and an invasion by 

malignant cells. . - , 

Patients moreover, have been known to survive tor ten 
years or longer, and the condition may become entirely 
arrested for°as long as seven 5 -ears (Price). These are 
|)oints hardly com])atiblo with our knowledge of carcino- 
matosis and sarcomatosis. 

2. The Injective Theory. 

In the discussion on leukaemia and allied conditions at 
the Annual jMeeting of the British Medical Association at 
Nottingham, Dr. B. Donaldson, after surveying some of 
the arguments against the sarcomatosis theorv, concluded 
that there was more to be said for a possible virus or 
irritant using the latter in its broad sense.= This certainly 
appears to be the most plausible etiological themy, and a 
survey of the present series of cases would seem to bring 
out points' in its favour. Early investigators such as 
Virchow held this view and maintained that leukaemia 
was the result of specific infection. Others believe that it 
is non-specific in origin. In r'ho histories of tho above 
cases, 17 showed varying degrees of irregular tempera- 
ture; in all the acute and at 3 -pical varieties the tempera- 
turo was 103° or. higher, but the chronic lymphatic patients 
had no rise at all. ■ ■ 

There was a histor 3 - of pyorrhoea, tonsillitis, sore throat, 
bronchitis, or somo chronic infective focus in 82 per cent, 
of the classified cases and in all the atypical ones. Tho 


MEMORANDA. 


Jan. 14, 192S] 


t Tnx British ni 
arEOICAI. JOUBJIU, . 


^occurrence of iiiglit swent.s, to wliicli DoniiUlsou drew 
'Epeciiil attention ns being a common feature, was recorded 
in 20 per cent, of cases. The length of Iiistory m chronic 
cases varied from two to eight years. 

In rare instances cases have been recorded where con- 
tact with a lenkaemic iiaticnt has apparently led to trans- 
mission of the condition, and "Weiss and others iiave 
reported instances where several members of the .same 
family were victims of the disease. Such incidents arc, 
'..however, so rare -that they can hardly be employed as 
' evidence of the infective nature of leukaemia. 

Animals grafted with lenkaemic exudate from human 
beings have onlj- in one questionable instance (that of 
.Wiezowsky’s experiment) developed leukaemia. Three 
patients dying from carcinoma wore inoculated by Schnffer 
with lenkaemic blood from another patient ; none of them 
developed leukaemia. 

It could bo argued that if the disease is infective in 
nature it is hardly conceivable that the latter experiment 
could have failed. Nevertheless it may reasonably be 
supposed that a patient suffering from malignant disease is 
not to the same extent susceptible to the virus. In any 
case this experiment would have to bo repeated by other 
obsciTere fo jirovido confirmatory evidence. 

Kllerman has succeeded several times iu inoculating 
healthy fowls with a filtrate from lenkaemic fowls. The 
filtrate used consisted of an emidsion of organs passed 
through the Berkefeld filter and, therefore, cell free and 
microbe free for organisms up to the size of bacteria. 
The condition could thence be transferred from one bird 
to another indefinitely. These experiments go to show 
that at least, so far ns the leukaemia of fowls is concerned, 
I, it is a definitely infective condition. "Whether the disease 
I, iu human beings is of the same nature is still open to 
question, but it would be difficult to imagine that leukaemia 
in human beings with its fundamental resemblances to the 
disease in fowls could bo induced by an entirely different 
process. The following clinical details arc of interest in 
this connexion. 

A man, aged 66, had a two months’ history of pain on the 
right .side of the abdomen spreading up towards llie thorax. Tlie 
liver was large with a smooth, round, hard, and sliarp edge, and 
there was a largo p.alpablc tumour on the left sid<' with some of 
the characters of the spleen. This diminished under rway treat- 
ment. The red cells and colour index wore normal. The Ictico- 
'cytes numbered 32,000 per c.mm,, and the differential count was 
polymorpiionuclcars 64 per cent., lyrapliocytcs 27 per ceiit., largo 
mononuclears 4.4 per cent., mast cells 0.2 per cent., and myelocytc.s 
4.4 per cent. Megaloblasts and normoblasts were present. There 
was very grave oral sepsis, indicating total extraction. The tem- 
perature ranged from 98° to 100°, but after extraction of the 
teeth it was above 100° for a few days. The total leucocytes 
varied from 8,000 to 32,000 during the month he was in hospital. 
No fnrtlier symptoms developed, and he was discharged feelin'*’ 
well. " 

^ .This case was diagnosed as chronic lymphatic leukaemia, though 
it was recognized as not being a typical cirse. 


klany chronic infectious — tuberculosis, for example — sbo 
a relative lymphocytosis, though admittedly the toti 
leucocyte count would not be expected to reach 32,0Q( 
lire lymphocytes varied from 24 to 38 per cent. There wi 
certainly as much a parallel between the course of tlr 
case and that of a chronic infection (there was a ver 
definite chronic septic focus), as between the course of tb 
case and that of a case of “ iiseles.s wiiite cell prolifen 
tion, ’ wbieb leukaemia i.s .supposed to be. 

"We might conclude, then, from the above aualy.sis tlir 
condition which runs a cour,se in man 
respects parallel ivitb that of an acute or chremi 
iiitcctive process, and that while there are clearly some hi 
explained resemblances to tumour formation (particular! 
c ^ 1 cliloromas are included under tho beiidiii 

of lonkaemia). we must await further light on the who" 
problem of tlie etiology of tumours ; this in turn will revoi 
the 1 elation between the two conditions. 

Hi be proved that Gye’s recent dictum is triie- 

tbat agent of malignant disease is a living filterabi 


^ Lctrlrusi’f in Fotilg, 
October 2nd, 1926. p. 595. 


HETtKENCES. 

Ellerman, p. 12. = DniTi.=H 
® Ibid., November 13th, 1926, 


Medjcil 
I> 870. 


JOURXiL, 


MEDICAL, SURGICAL, OBSTETRICAL. 

. FOREIGN BODY IN THE BLADDER. 

Dll. HuNTEii "Woods reports an interesting case of foreign 
body ill the bladder (Bkitish Medical Jouhnal, December 
17tli, 1927, p. 1140). May I mention two cases which came 
under 1113 ' care at Guj'^s Hospital during the summer of 
1926. Both were j'oung females aged about 20. 

The firet case, when examined, showed a metal bar Ij’ing trans- 
vcrsolj' in the bladder. Tlie gentle efforts which were made to 
dislodge it through the urethra failed to move it, so I at once, 
fearing damage to the large pelvic blood vessels, cut down 
through the suprapubic route, and opened the bladder. With some 
difficuitT I removed the foreign body, which was embedded iu 
the right wall of the bladder and touclied the left wall. The 
foreign body was a metal thermometer case, minus the lid, about 
three inches long. The patient afterwards developed left iliac 
tiirombosis, so my fears as regards damage to important blood 
vessels were justified. 

The second patient had caused much trouble at a country 
liospitul, and was considered to have produced an artificial haema- 
lurm. She was cj’stoscopSd during my holiday, and it was thought 
lliat she had a growth on the left wall of the bladder. When 
I ci'stoscoped her I felt certain it w'as not a growth, as I saw 
a similar mass at the base. I removed, through the urethra, two 
fruit stones. I set them in earth, and one produced a seedling 
tree. Unfortunately it siifiered from being covered up and became 
mouldj', but I think it was some form of plum, cultivated, 
I suppose, as the stones were about an inch long— that is, much 
longer ■ than the stone of any sloe, bullace, or wild plum that 
I have seen. 

I tliink that, in the second case, the stones were intro- 
duced deliberately. But in the first case the thermometer 
case nmy have been introduced into the urethra during the 
passage of urine in order to allaj* spasm and pain. 

In this connexion 1 may mention three other cases. 

The firet, a young child, had a vcsico-vaginal fistula and a 
phosphatic stone in the bladder, which was found to have formed 
round a bone collar-stud about seven-eighths of an inch long. The 
second was that of an old man who had been passing bougies 
on himself for many yeai*s. I removed, suprapubicafiy, three 
stones, all surrounding broken fragments of stiff bougies, but thej' 
were not of metal. The stones were phosphatic. 

The third case was that of an elderly man who had been 
operated upon by the late Mr, Dunn for str«angulatcd hernia. He 
suffered from retention afterwards and a coud^ catheter was 
passed. When this was removed it occurred to the patient that 
the catheter did not present quite the same appearance that it 
showed before introduction. When I examined him I found a 
firm mixed phosphate and urate stone, but in view of tlio history 
decided to perform suprapubic lithotomy rather than lithotrity, 
for which the conditions otherwise appeared favourable, and "a 
stone inches long, oval in shape, was removed from the bladder. 
TIic stone was sawn in half, and it was found that the upturnec. 
end of the coude catheter formed the nucleus of the stone. Iri’mj* 
opinion* the mere suspicion of a foreign body in a stone precludes 
lithotrity iu such cases. 

A. Ralph THoaipsoN, Ch.M,, F.R.C.S., 

Surgeon, Genito-Urinary Department, Guy’s nospit.*!!. 


INTESTINAL OBSTRUCTION IN AN INFANT. 

A PEAL\LE infant, aged 3 days, was admitted to Charing 
Cross Hospital on November 27th, 1926, on accoimt of 
vomiting. The pregnancy and birth had been normal and 
tho child appeared well made. She took the breast well 
when put to it for the first time, but vomited soon after. 
Vomiting continued at frequent intervals (on one occasion 
continuously for an hour), though Ihe child did not again 
take the breast. Meconium unusually liglit in colour was 
liassed, 

Ou admission tho child seemed well and cried lustih*. Some 
distended veins were visible in tlie abdominal wall, othei-wise 
nothing abnormal could be detected. Some bile, but no blood, was 
seen in the vomit; the -stools were small, dry, and putty coloured. 
An . occult blood test was positive. A diagnosis of duodenal 
atresia was made. Saline and glucose were given subcutaneously, 
but the child continued to vomit and rapidly went downhill. 

Laparotomy was performed by Mr. N. C. Lake on November 
28Ui. A mid-line incision was made. On opemng the abdomen a 
blind-ended distended piece of small intestine presented, and 
proved to be the upper few inches of the jejunum., Near to’ this 
blind end was found the 'proximal end of the rest of the small 
intestine, also blind, and of very small foetal tj'pe. Tlie cPlon 
was undeveloped, the calibre of^ a lead pencil, whereas llie 
distended small intestine was the size of a normal adult jejunum 
This discrepancy in size made it impossible to perform aii 
anastomosis, even had the condition of the child been good cnouffh 
to justify such a procedure. “ 



62 Jan. i.), 1928 ] 


■MEMORANDA. 


f ' Tnrllpmin 

MrniCAL JornvAi, 


A incdiiirn-sizcd rubber r.illictcr was lied into tbo dislciulcd 
iejuniim and the abdominal wound closed. The ‘child died 
six liours later. 

Tlic site of the lesion would seem to prcohulo a develop- 
mental error. The theory sugge-sted by the surgeon in 
charge of the case is that the condition was caused by 
pressuro atropliy by a band-like adhesion due to intra- 
uterine peritonitis. 

I am indebted to Mr. N. C. Lake for permission to 
l)ublish this case. 

E. A. C. AVilson, M.R., 

Lec-on*Solcnt. ■ Late lloufic-Surpeon, Charing Cross llosintal. 


A NOVEL HAEMOSTAT. 

An attempt to stop intonial Iiaomorrliage bj’ plugging tlio 
recttim in the manner described below seems of sufficient 
interest to be placed on record. 

A six-foot labourer of generous proportions was admitted to 
hospital on November 21st last. He was exceedingly shocked and 
collapsed and was losing blood from the rectum in an obvious 
manner. 

He stated that for the twenty-four hours before admission he 
had been bleedin" from the. bowels, and in order to stop the 
bleeding he had inserted a porcClain cgg-c\ip into tljo rectum. 
This frank statement, told in a rich brogue, seemed rather 
incredible, but on examination his temperaturo was 96.8^ F., his 
pulse 130 a minute, and his appearance grave. The sphiiicicr ani 
was stretched, and the mucosa lacerated and bleeding. The left 
side of tlie abdomen was acutely tender, but not rigid. 

The man was immediately taken to the tlieatrc and sigmoidoscopy 
performed, with neither anaesthetic nor positive result, except 
great quantities of blood clot. He was nc.Yt screened with .m 
excellent x-ray apparatus, but wilb no j'csult. 

Laparotomy was performed after a lapid preparation, and a 
full-sized egg-cup found just below the splenic flexure. The bowel 
was not perforated. A colleague versed in the art of obstetrics 
passed a blunt instrument up the rectum and the operator gui(le<l 
its point into the howl of the egg-cup, which was tlien genlly 
** milked ” down, guided into the rectum and delivered by genth* 
manipulation. 

Recovery was straightforward, and the patient was discliarged 
a fortnight after operation. 

An interesting fact is that ten months previoiislv tiic 
patient sustained a slight accident at work — no broken 
bones, but a few superficial lacerations necessitating ro.st in 
bed for a week. He has not worked since that accident. 

A. Hopkins, H.B., Ch.B.N.2., E.R.C.S.Ed, 

Huddersfield. 


VESICAL BILHARZTA: DOUBLE INFECTION WITH 
S. H.lJCMATOmUM AND S, MAXSOXI. 

The following throe cases of vesical infection witli bilharzia, 
in which lateral spined eggs were found in tho urino along 
with thoso of S. Jiaciiiatohiumy appear to bo worth 
recording, owing to tho rarity of published cases. 

Case 1 . — A boy, aged about T2 years, first seen on March 6th, 
1925, was passing so much blood in liis urine that it was a bright 
pink colour towards the end. Microscopically numerous eggs of 
iS’. h(icm<iiobium were found, and there was also seen in the slide 
examined a single lateral spined egg. >Subsoquent search in other 
slides failed to show any more of the latter eggs. When seen 
again on July 12th, 1926, the urine still contained numerous eggs 
of S. haematobium, and again lateral spined eggs were found, tliis 
time with greater ease, about two eggs being seen per slide, TJic 
urine was re-examined on July 15th, and lateral spined eggs were 
still present; on this occasion his faeces >vci'e examined twice, but 
no ‘infection w’as found. On each occasion he had been' given a 
test tube and told to bring in it the last few cubic centiniotros of 
his urine, so that there woukI have been little chance of con- 
tamination ffom faeces, even if a faecal infection had been present. 

,Cdsc .2 . — Another boy, aged about 12 years, first seen on March 
3th, 1926, was at (he same school as Case 1; he also showed a lateral 
spined -egg amongst a heavy infCcrion of haematobium. His 
urine was re-examined on July 12tli, 1926, but although eggs of 
S', haematobium were still present in_ large numbers, no lateral 
spined ones were seen, and none again on July 15th,. when his 
faeces were also found to be negative. 

The first boy was also examined by Dr, Mac-lean, sleeping 
sickness officer, on July ho confirmed the fact that 

the egg.s were really lateral spined, and not foreshoi-tened 
terminal spined ones. 

These two cases were seen at the Government School, 
Mwamanviri, Tanganyika Territory, on tho southern shore 
of Lake Victoria. Tho children were mostly drawn from 
the surrounding villages, stretching along the lake shore 
on either side, some of them coining from five miles away; 
the few childivu whose parents Hvecl far inland stayed witli 
. relatives living on the lake shore. There was a .staked-off 
-• bathing pool in the lake, where tho boys wero taken to 
- bathe daily. At the time ot iuspcction in March, out of 


sixty boys attending the ficliool tbirty-ninc had blood in 
their urine and thirty-two of those had S. hnrmaiohiuiii 
eggs present. (I have since heard that some more of tlie 
bo 3 'S are now passing • blood), aiul probably ilioy had all 
been infected In’ liathing in the lake, either in tlio school 
bathing ])ool- or at their homes; for cases of vesical bi!- 
harzin infection wore seen from villages on the shore from 
seventeen miles' to the- east of tho scliool to seven miles 
to tlio west. TJio third case gave tho following history: 


Case 3 . — A man, a^cd about 25 years, \iscd to reside in the town 
vaiiza, where he bathed in the lake every day;, his health 


, __ ^ , :u I.U iii iiia; auoia 

of Mwaiiza, where lie bathed in the lake every day;, his health 
liad been good, and ho liad never before passed blood in his 
urine. At tho beginning of October, 1925, ho was sent to Maswa, 
and at the fii-st three camps on tho sliorc road he just washed 
down w'ilh water from a water-jar; but at tho fourth camp, 
Nassa, seven miles cast of the above school at Mw'amanj’iri, ho 
actually onfered the lake and bathed. The next two camps and 
Maswa itself, where he w’as stationed, w’crc inland, water being 
drawn from water-holes, and Iicro there had never been seen any 
cases of bilharzia infection which could bo said to have been 
contracted locally. On March 20lh, 1926, ho paraded sick, cqm- 
plainin"^ of passing blood in his urine, the last portion of which 
was pnik in colour, and there were seen numerous eggs c-f 
.V. havmatohium and a single lateral spined egg. Ihs faeces were 
unfortunate^’ not examined. 

AYliat, made tliis c.iso ’purticularly striking was tliat he 
paraded sick two days after my retnrn from tho safari 
whore I had been examining tho schoolboys, and that tho 
oiilv history given of washing in doubtful water was his' 
bathing in tl'o lake .at a spot near the scliool. Ko live 
snails, for examination for cercariae, wero found on tlio 

lake .shore. ' ^ .... ,... e 

Tlio only other recorded case of a similar condition of 
which I- know is that'roported by Jfaefio,’ who himself refers 
to another case reported. by Baiidi in Egypt in 1912. These 
case, would, how-over, suggest that the double vesical iut 
feetion with -S', hacmaiohhim and S. mansoni is commoner 

than .supposed ^rJ juo to tho director of inodicaI_ and . 

sauitarv services, Tanganyika Territory, for his permission 
publish those cases, and to Dr. an for his advice. 

‘ 11, JU .tIKBAIllN, 

The East Africnn Medical Ofilcer. 

T.’inganyika Tcrnlory^ 

■VrilTE PNEUMONIA TREATED BY SODIUM 

AUUIJ. n-ucdeinate. 

Dn-c of us having read with much interest a paper by 
n f'l,^lner Medh in (BnmsH Medical Jouhn.vl, July 
mi. 192^ ) ^9) aa treatment of acute pneumonia 
hfs’adhmr’nucloin'ate, had obtained a box of -P-loa of 

tho drug, and so wo wero able to uso it at tlio seiy 

commcnccmeut of 18, who insisted on 

p 1 ™^.; a’pmrrfRugbyJn^ wM and J.ard ^ro^t 

w hen he ■"‘‘'cady ^ pneumonia was suspected, but no 

of severe pains ■!' jbo niade' a good tea and dinner and went 

signs ot it were r gg go o The next day be had break- 

to%ed with a emperatu^^^^^^ 1 , 

fct 111 bed; '“S ^ and about tca-timo suddenly began to . 

He was kept ^vas then 104°, and aftcrwaids rose 

feel very ill. respirations 38. He was 

to 105.6°:. tbo poke s coughed up a fair amount of blood. 

violently .sick aid afle developing eaily signs of. 

mixed with t io,vor lobe of the lung. He was removed 

consolidation in the ii„ injections ot sodium 

to hospital that men B /g^npoules of 2 c.cm. containing 
nucleiiiale .every foui ho'js t p j ,f.d,.achni doses of sodium 

0 05 There was a crisis wilhin twenty-four 

bicarbonate and gluco at the end of a week. 

rose we ore convinced that tho youth was 
1* ‘-Tl Sd in for a lifo-and-dcath struggle, but four 
aeutoly alb ^«1 >U produced a remarkable altera- . 

tfon^ “if a s is supposed, sodium nucleiiiate stiuuilates . 
1 10 whUc eo -p "scloVuioro must bo a great field for its uso . 
tho wlutc c 1 infection— such, for example, as puer- ' 

I„ other it is 03 ^^ at Edinburgh in one 

dosf of 1 e'.em of a 5 per cent, solution before abdominal ' 

°*Avf Crider that it should he in the ai-mameularium of 
every practitioner for use at once in pneumonia, and that 
it should bo tried in other forms of bactenal infection. It 
can be obtained from F. H. Mortens, 64, Holborn \ laduct, 
tbo British agents of Clin ot Cie, St. Jacques, 

- P. S. Hichens,' AI;D., E.R.E.P., 

Guernsey. R. E. GiDSON, M.B., Ch.B. 

1 Mnclie : Journal of Iroimal Medicine and Hygiene, February 16lli, 1920. 





Jan. 1928] 


a?HEORIES OF SUGGESTION. 


[ The British 
Meoicxx. JouiuriL 


63 


B-tpnils of Noddies. 

. THEONIES OE SUGGESTION 
At ilio meeting of tlic Section of P.svehintrv of tlie Royal 
Society of Medicine on January lOtli, witli Ur. R. Uanouon- 
Down in the chair, a discourse was delivered by Dr. 
■\Vii,i.i,\5r Brown, readei' in mental iihilosaphy at Oxford, 
on theories of suggestion. 

Dr. AVilliam Brown hegan by remarking that to talk 
iiowadays of theories o^ suggestion might seem to some old 
fashioned and out of date. That was not his view, and lie 
thought that a great deal of very good work done in the 
past was in danger of being overlooked in the enthusiasm — 
in many cases untrained and uneducated enthusiasm — for 
analysis in its various forms. The word “ suggestion ” w.as 
used in educational, scientific, and medical liter.ature in 
slightly ditfereut senses. Among educ.ationists the word 
was used to indicate a general kind of inflnenco bi-oiight 
to bear upon the mind, other than that of ordered and 
logical argument. In popular speech it was used in the 
sense of insinuation, as a counsel might “ suggest ” to a 
witness ; and among pure p.sychologists it had heen given 
the wider connotation of the effect of preformed associa- 
tions on the activity of the mind. In psychological inedi- 
cino the use of suggestion had developed out of the earlier 
use of hypnotic influence. Hypnosis and suggestion were 
not th(' same thing, but in a state of hypnosis, which was 
a state of mental dissociation, a jierson became more' 
suggestible as a result of the dissociation ; on the other 
hand, tlie op}to.sito condition might also hold good, a state 
of liypnosis following upon suggestion. Hypnosis seemed 
to proceed in stages of deeper and deeper degree, but 
nowadays it was not customary to speak of stages of 
hjpnosis because, although they occurred, they did so ih 
no definite order or sequence. 

A arious theories had been devised to account for the 
^sponsiveness of the hypnotized person to suggestion. 
Fioud said that this result followed boc.auso of some bond 
of affection which had sprung up between the hypnotist 
and the hypnotized. McDougall’s thcoiy was that in the 
process of hypnosis the patient was thrust into a state of 
self-abasement, and, the instinct of self-assertion being in 
abeyance, he was I’cady to acco|it orders from another 
person. During the war large numbers of soldiers became 
readily hypnotizable under intense physical shock, such as 
concussion, which probably brought aboiit physical dis- 
sociation of the higher centres of the brain. Alcoholic 
liersons were easily hypnotizable, also persons under anaes- 
^JT^ofism was originally used at operations, and 
if chloroform had not been discovered shortly afterwards, 
no doubt hypnotism or suggestion-treatment would have 
been used more extensively. It still had its uses in pre- 
paring the patient for operations, and it had quite definite 
eltects, such as the-iirevention of nausea after the anaes- 
thetic. Dr. Broyn had himself observed 600 cases of 
anmesia among soldiers in France during the war; nearly 
evciy case was hypnotizable, and memory invariablv 
hypnosis. Charcot defined hypnosis as an 
Bi incial hysteria, while Bernheim’s definition was that of 
an artificially increased suggestibility. The two definitions 
needed to be combined to give an adequate account of 
Hypnosis. Moreover, due allowance should be made for the 
ac 01 s M dissociation and of rapport in hypnotic pheno- 
mena. He drew attention' also to the work of Parlor', 
w 10 ei^lamed both sleep and hypnosis in terras of inhibi- 
lon o the cerebral cortex, spreading in sleep to the 
" 11 °' centres, and in hj'pnosis not so spreading. 

I •'‘’'T" "ciit. considered in more detail the factor of 
central importance in liypiio- 
in terms suggestion or hy'pnotic effect 

«'<Jco-motor action, in which the suggested idea' 

. ise o t le Inactivity of competing ideas, produced its 

neededTirlfefex^'" nof sufficien';, bntitsHf 

terms of the f e^^anation. Freud explained rapport in 

S aid hro^fi,bt"^'"re “ Hi™ ” (tAansfer- 

idell ” distinction of “ ego ” and “ ego- 

super-ego, to supplement the theory. At 


first sight all suggestion seemed to be in essence auto- 
suggestion, since it must be accepted by the patient if it 
was to work at all ; but there w.as the converse possibility 
that suggestion might be hetero-suggestion, the individual 
being unable to accept an)’thing from himself, but always 
from the outer world. Ernest Jones explained auto-sugges- 
tion in terms of narcissism, saying that if the idea of 
narcissism had been formed directly by concentration upon 
the idea of self the process might he termed auto-sugges- 
tion; whereas if this had been preceded by' a stage in which 
the ego-idoal was resolved into the earlier father-ideal the 
process might be termed hetero-suggestion. AAlien a person 
was hypnotized ho placed the hypnotist in the position of 
his ego-ideal. In auto-suggestion, according to Ernest 
Jones, there was a regression to a still earlier p.sychologicaI 
situation — a situation of primary narcissism, the libido 
being fixed upon the ego and supporting the ego-instincts. 
Jones said that therefore auto-suggestion was a bad thing, 
involving an impoverishment of the ego and the with- 
drawal of energy that should be available for getting into 
touch with the world ; but if this iras true it was not easy' 
to explain the improvement in physical health from auto- 
suggestion. " Auto-suggestion ” was an inadequate and 
misleading term in that it did not s.atisfactorily indicate 
the therapeutic value of auto-suggestion in which the will 
was supplemented, not supplanted, and complete volition 
made possible. Those who benefited by' auto-suggestion 
did not become more self-centred ; on the contrary, they' 
became more self-confident. McDougall’s explanation of 
hypnotic suggestion in terms of the instinct of self-abase- 
ment was too limited, for different instincts might supply 
the driving power to produce suggestion effects in different 
circumstances. Such instincts ns self-preservation (fear) 
■-and gregariousness might play tlieii- part. Freud again 
explained the action of the gregarious instinct in terms of 
the libido; in his view there sprang up among members of 
the group libidinal relations — of course inhibited in their 
aim — ^towards one another and towards the leader of the 
group. AAhthout denying all truth to Freud’s theories of 
love hypnosis and gregariousness, Dr. Brown said that his 
own experience, both of the method of suggestion and of 
deep analysis in investigating and treating cases, did nof 
bear out the theory in its entirety, and lent no support 
whatever to Freud’s theoiy of group-consciousness. He 
could not believe that the libido needed to be brought in 
at all ; the self-assertive instinct came .in, no doubt, but 
the growth of the gregarious instinct could be adequately 
explained in terms of natural selection, and Freud's theory' 
of the libidinal relations of members of the group seemed 
far-fetched and ridiculous. 

In some brief discussion Dr. R. D. Gillespie said 
that Dr. Brown’s championship of suggestion-treatment, 
coming from so intelligent a source, rather surprised him. 
The speaker thought it e.xtremely improbable that sugges- 
tion-treatment in its former vogue would ever return, 
seeing that suggestion depended on lack of criticism on 
the part of the person to whom suggestions were made. 
Dr. Leahy expressed his -emphatic belief in suggestion, the 
value of which was not limited to persons of poor or 
unstable intellect. He described a case in which suggestion 
had proved of great value in facial abscess in a university' 
man; a man of strong intellect and a great sportsman". 
Dr. Tea VERS Smith had found suggestion helpful in the 
administration of anaesthetics, to remove the ])atient’s 
fears. He thought that Dr. Brown had dismissed Freud 
too easily. Dr. H.AyDN Brown said that 90 per cent, of the 
favourable results obtained by' osteopaths were duo to the 
suggestibility of the patients". In his own experience he 
was using the word “ suggestion ” less and the word 
“ education ” niore. Patients should bo made to relax 
the muscles, in winch condition they were more teachable. 
Dr. T. A. Ross spoke of the vavi.ahility of response to 
hypnotic treatment on the jiart of jiaticnts suffering from 
different forms of illness. 

Dr. AA’illiam Brown said, in reply, that ho had not 
“ dismissed ’’ Freud. It was possible to accept a great 
deal that Freud wrote, but in his theories -n-itli regard to 
the gregai-ious instinct and to transference, the explanation 
of rapport in terms of inhibited sex instinct, he foiild not 
follow him. 


64 : Jan. 1958] 


CURRENT VIEWS OF SHOCK AND COLDAPSB. 


r Tbt iiBmira 
L ilcoicAL JccrsKis 


CUREENT VIEWS OE SHOCK AND COLLAPSE. 

At a meeting of tho Section of Surgery of tlio Roy.'il 
Society of IMecIiciiie on January 4 tli, v.itli Mr. V. Wakiien 
Low in the chair, Mr. V. Zacuaky Cope offereJ somo 
criticisms on current r'iews of shock and collapse, and a 
discussion followed. 

Mr. Cope said that in spite of much investigation and 
discus.sion tho current teaching about shock and collapse 
was still far < from satisfactory. This was evident alike 
from tho point of view of the definition of terms, the 
pathological factors involved, and, to a less extent, the 
clinical symptoms. Hardly any two writers agreed on a 
definition of shock. Somo discriminated between shock and 
collapse, and others did not. What was called “ shock ’’ 
by one rvritcr was by another called " collapse.” Some said 
that the symptoms were similar, but tho pathological con- 
ditions dissimilar. Manj- limited tho term " shock ” to 
the result of wound or operation, whilst others included 
those states with similar symptoms resulting from any typo 
of harmful stinruhis or from loss of body fluid. Mr. Cope 
irlaced on tho lantern-screen a number of definitions taken 
from textbooks, British, French, and American, and finally- 
put forward his own definition for discussion; 

“ The term ‘ shock ’ signifies a condition following tho applica- 
tion of harmful stimuli, or tho depletion of the body fluids, in 
which thevo is a serious and clinically dcmoustrahlo depression 
of tlie vital processes of tho body, particularly tho circulatiou and 
metabolism. 

“ ‘ Collapse ’ is a term applicable to tho sudden onset or rapid 
aggravation of tho symptoms of shock.” 

He considered that shock should ho defined clinically 
without reference to the condition of tho blood prossuio 
and without any mention of the pathological factors in- 
volved, inasmuch as these were still not agreed upon. 
Views on tho pathology of shock had varied greatly during 
the last two decades. Laboratory exponmonts liad been 
contradictory, and it was now acknowledged that Malcolm’s 
observations, which were made many years ago in tho 
course of clinical work, were more accurate and informative 
than a great deal of the experimental worlt done by others. 
Malcolm pointed out that in shock the pulse often remained 
slow, but the volume of the pulse became gradually smaller, 
whilst the peripheral vessels were coutrnoted, and ho stated 
that fluid must therefore bo leaving tho vessels. As a 
result of tho investigations made in the war by Keith and 
others, it was determined that the essential factor in shock 
and collapse was a deficiency of tho volume of blood in 
circulation. This was clearly stated by tho lato Professor 
Bayli.ss, whonv ho quoted. It was well understood that 
considerable loss of fluid from the blood vessels might occur 
without lowering of blood pressure owing to compensatory 
vaso-constriction. Unless tho vasomotor centre was out 
of action (and Porter had shown that it rvas not), then a 
serious state of shock might exist with no ap}>reciable fall 
in blood pressure. Vi’hen once tho blood pressure began to 
call the descent might be rapid, owing to the limit of vaso- 
jonstvictiou being reached. That shock miglit exist with 
1 high blood pressure was suspected by Rendio Short, 
affirmed by Parsons and Tyrrell Gray, and referred to by 
Bayliss; but so much attention hacl been paid to tho 
tenniual s3-mptoms of the condition in which the blood 
pressure was necessarily lowered that the earlier hut still 
serious stage in which the blood pressure might be higii 
and the pulse slow had been n-idely neglected. Kinnamau 
maintained that tho fall in body temperature was .a better 
indication of shock. Tho symptoms of shock were due 
cither to circulatory failure, depressed metabolism, or 
sympathetic stimulation. They varied greatlj-, and there 
was liardly one constant sjmptoiu, though in demonstrable 
shock there was nearly always either subnormal tempera- 
ture a lowering of blood pressure, or a diminution in 
size of pulse. -Pallor, mental dullness, increased pulse 
rate, and sweating might or might not he obscrA-ed. Tho 
blood pressure might ho Avithiii normal limits, even in 
serious shock. Unless this dissociation of sj-mptoms of 
shock was romemhered the early stages of the condition rvere 
likely to be overlooked. It was likely tliat a clinical esti- 
mation of tbo circulating blood volume would be a better 
guide to tbe onset of shock. Mr. Coije pleaded for a more 


thorough investigation of sliock from tho clinical a.spect, 
for a widening of tho definition so as to include all tin 
similar states re.sulting from various causes, for tho clcaf 
apprehension of the facts Avhich supported the view that th.i 
advent of shock Avas not increlj’ a matter of fall of blood 
pre.ssuro, and for a recognition of tho frequent dissociation 
of the symjitoms. 

Mr. J. I). JIalcoi.ai said that it Avas generally accepted 
that in pj-ofound sliock tho a-ossoIs aa-oio contracted and 
tho blood pre.ssuro was very low. This made it necessary, 
to reconsider tho laAV that contraction of the arteries raised ■ 
tho blood pressure. His own observations, though made' 
many j-ears ago, Avero not tho first Avhich diiccted atten- 
tion to tho need for modifying this laAV; Sir George 
Johnson, in tho middle of tho last century, had pointed 
out tho saino nceessity. Tho speaker believed tliat per- 
sistent contraction of the vessels Avas by far the commonest 
mode of death in shock, and that A-aseiilar contraction 
should liaA-o an important place in any definition. 

Mr. E. JI. CoAVELi. gaA’o somo account of his ohsen-a- 
tions niulertaUcn during tho Avar, as an outcome of Avhich 
ho had suggested a division of shock into primary- and 
secoiidai'A-. In secondary shock tho blood pressuro fell 
gradually. Ho thought there Avas no need to ho pessimistic 
Avith regard to the state of knoAvledgo concerning traumatic^^ 
shock; it was admittedly inadequate, hut a great deal of ; 
useful Avovk had been done, and already th.o effect Avas ' 
seen in tho greatly le.ssenod frcqucncA- of traumatib" 
shock. Ho exhibited somo simple instruetions issued by 
tho Red Cross Society for preventing shock in motor 
injuries, and said that it Avas noAV found that oven in 
accidents involving compound fracturo of the femur shock, 

might ho proveuted. ,, 

Mr, J. P. LociaiAiiT-MuMMEJir thought that traumatic,, 
shock’ Ava's dno to overslinnilation of tho brain centres. In ■ 
all conditions of shock a diminution in A-oIumo of tho Wood 
in circulation n-as observed. Tlio reason why tho fall in 
blood pressure was msed in early experiments for measuring 
shock was nccamsc it was easily taken, and thoro wore no 
means then— and, indeed, there were no moans now— of 
nmllsuring tho circulating blood volnmo But it Avas 
possible now to rceognizo tho onset of shock hetoio definite 
oAVoring of blood ' pressure occurred. One of t'lo earliest 
e^e s was an increased pulse rate; there might ho excep- 
to this hut with anything like a normal heart, 
Avhoii tho blood volume in circulation began to diauiish,. 
tho heart’s activity would shoiv a compensatory increase 
Normally thoro was a fixed ratio hetween pulse rate and 
blond ressnre. If the blood volume in circulation AVas 
diminished at all seriously tho first thing to ho upset was 
that ratio, tho pulse rate tending to mcreaso out of all 

proportion^othohlood^pressm-e^^^ that the outstanding 

siciii'fic.anee of shock as a process of exhaustion ought to 
1 fvc a n laco in any definition; certainly, clinical y that was 
baAc a piaco , ^ all these cases thero was a 

tho fiist f ^Ho was strongly against giving stimu- 

Irthig lug "1-= 1 i" “ U." 

b.ting mug operation, in persuading the 

“'V i at ond-iut to ilhHold such stimulants. For his 
medical ; "a as ” drugs ” only morphine and 

oAvn P“ r,;:aL” ami not saline,” for he found 

to uiulerstaml how the idea arose of giving 
It dilficiilt to mim comparable con- 

!mion Mthirst one might drink alcohol, or, more wisely, 

Avator, said that tho pnlse rate might he 

1 { sliock, and the heart might 

sloAV at the AAust m cas^^ indicated. Ho 

be tin CO ti . ^ number of cases that 

had been a le to proAO q 

“"tollt at the wHrt. He could not agree with the 
the late felt . „scd Mr. Cope to have made [it Avas 

atuo n of' ir Bayliss] that llaemov- 

rhS shock were much the same thing. The quality 
of blood was different; m shock it had a high specifio 
gravity, in haemorrhage a lou-. , i c „ 

Mr. Coi-E devoted his reply to .a fnrther f?\ ^ 

clinical definition of shock. He thought the definition 
should be a broad one, and that qualifying adjectives— such 


Jan. 14, 1928] 


consekvative tkeatment of spinae gabies. 


[ TmiBnmsa 
UrcicAx. JociutiZi 


66 


as tmuniatic, hnomorrlingic, toxic — should ho . affixed to 
iudicato tho particular clinical typo. ,If a pathological 
dofinitiou were awaited it ivould mean postponement to tho 
Greek kalends. . 


RECURRENT ENDOTRELIOMATOES DERMOID. 

At a meeting of tho Section of Obstetrics and Gynaecology 
of tho Royal Society of Medicine on Docemhor 16tli, 1927, 
tho President, Mr. Comyns Br-nKELEY, in the chair. Dr. 
tV. G. B.vit'NAnn showed a specimen of an endotheliomatous 
dermoid of tho ovary, and a recurrence near the cervix 
removed twenty-four years later. 

Dr. Barnard said that the first tumour had been reported 
by Herbert R. Spencer ; in 1917 a tumour tho .size of a , 
pigeon’s egg was removed from the vagina, and a tumour 
the size of a Bjilit pea could just bo felt to tho right 
of tho os uteri. In Juno, 1927, the tumour exhibited was 
removed from tho region of the cervix. Dr. Barnard stated 
that tho nature of these tumours was identical with that 
of the endotheiiomata, and ho believed that tho second and 
third were secondary to tho first. Tlio extraordinarily 
similar microscopic structure, the fact that tho third was 
palpable when the second was removed, and the slight 
increase in cellularity of the tumours seemed to him to 
support this view. 

, Gynaecological Involvements 0 / the Abdominal Wall. 

Mr. Feederick Roques showed a specimen of endometrio- 
myoma of the umbilicus obtained from a patient who, 
thirty-four years previously, had been operated upon for 
an inguinal hernia. Ho exhibited microscopic specimens 
revealing all the characteristics of an endometrioma, and 
he then discussed the question whether this tumour in any 
way Iielped to\yards tho elucidation of the origin of these 
umbilical endometriomata. Ho drew attention to tho occur- 
rence of a sinus at the back of the specimen, and expressed 
the opinion that it was not justifiable to invoke Sampson’s 
theory of causation to explain these tumours growing at the 
umbilicus and in an outward direction. After reviewing 
the evidence, he concluded that this specimen could be 
used to support almost any of the explanations which had 
from time to time been advanced, but that it lent more 
colour to that usually known as tho “ peritoneal theory,” 
Professor Beckwith Whitehoose showed a specimen 
obtained from the abdominal wall of a patient who had 
menstruated through a laparotomy scar for twenty years, 
associated with diffuse eudometriomatosis of tho pelvic 
cavity and the abdominal wall. He detailed the clinical 
istory of the case, and pointed out that after twenty years 
normal menstrual function returned. The patient was sub- 
sequently- treated by radium, and had made good progress. 

Etiology of Pucrpaal Sepsis. 

Ml; Burt-White read a paper entitled “An investiga- 
tion into the etiology of puerperal sepsis,” which described 
le lesults of examinations of swabs taken from tho cervical 
cana s of pregnant women. The oi-gauisms were cultured 
both aerobically and anaerobically, and their effects on 
animals were tested by injection. Mr. Burt-White demon- 
s ed tile rarity of the S. pyogenes, and mentioned that 
in e one case in which this organism had been isolated 
there was a normal puerperium. He reviewed the previous 
resu s of examination on similar though less exhaustive 
ines, and referred to the difficulty of determining the 
ac ua strains of streptococcus responsible for fatal cases 
or puerperal septicaemia. 


CONSERVATIVE TREATMENT OF SPINAL CARIES, 

■A f of Siirgei-y of the Rova: 
Q. ' o nj of Medicine in Ireland on December 16th, 1927 
?«^^,CoriROY WHEELmi, in the absence of tin 
president took the chair, and read a communication or 
the results of the treatment of Pott’s caries by con- 
servativo treatment alone and treatment supplemented bi 
the introduction of a bone-graft. ' * 

MTieeler said that nowadays patients wen 
treated in open-air hospitals by specially skilled assistant 


and trained orthopaedic nurses; it was too early to judge 
tho results. Under the old regime tho sequels of treat- 
ment in city hospitals, without special nursing and with 
inadequato methods of fixation, were far .from satisfactory. 
It appeared that very few patients with advanced Pott’s 
caries ever reached old- ago. Some records showed that 
within a period of twelve j-ears 40 per cent, were dead; 
others gave the percentage of deaths within fifteen years 
at 38.6, ' 75 per cent, of tho deaths occurring . within tho 
first two years. In 1911 fusion operations of tho spine had 
been introduced in tho hope of reducing tho high mortality' 
and of promoting a speedier cure. There w-as general 
anreoment that tho bone-grafting operation was useful to 
the general ns ivoll as to the orthopaedic surgeon. Opera- 
tive treatment in adults had been further encouraged by 
the report of the commission appointed in America to 
investigate the results of these fixation oiierations. Tliere 
was no doubt whatever that both the Hibbs’s and the Albeo 
operations caused fusion of tho laminae. This had been 
■proved by cases in which a second operation had been 
performetl, by necropsies, by clinical observation, and to 
some extent by radiography. Sir AVilliam Wheeler urged 
the necessity of careful and prolonged after-treatment. 
His patients remained on a Thomas’s or Jones’s frame for 
three months, and were then kept in bed for another three 
months without the frame ; during the next three months 
they were allowed to move about carefully, wearing a 
Jones’s posterior spinal support night and day, and after- 
wards tho posterior spinal support w-as continued according 
to tho progress of the case. He had never seen in an adult 
tho absorption or disappearance of a bone-graft after intro- 
duction. He had operated upon several young children 
about twelve years ago, and was satisfied that the method 
was only- justifiable in exceptional cases, though some 
surgooiLs had advocated the operation as part of the con- 
sei-vative treatment in young children, and had proved that 
tho graft did not interfere w-ith grow-th. The presence of 
abscess or paraplegia w-as in his opinion a strong indication 
for the introduction of a graft. He dealt w-ith the treat- 
ment of spinal abscess, and also with the treatment and 
prognosis w-hen paraplegia was present. In his view 
laminectomy did more harm than good, but Frazer’s 
operation to relievo pressure w-as designed on sound 
principles.- After discussing tho various operations for 
spinal fusion he' gave an account of thirty adnlt patients 
treated in the period 1917-27 ; of these six died, and nine- 
teen or twenty- appeared to be cured. 

Mr. F. Gmu said that by bone-gi-afting operations for 
■tuberculous disease of the spine the patient was restored to 
his normal strength in a shorter time than w-itli conserva- 
tive treatment, and he was able to carry on for a number 
of y-ears. The skin and spinal muscles' were anaesthetized 
with novocain and adrenaline, and this lessened the shock, 
reduceil tho loss of blood to a minimum, and rendered 
the operation field almost bloodless. He used an osteotome 
or chisel for cutting the graft in preference to the Albee 
saw, which, he thought, cauterized the bone and was apt 
to destroy- the osteoblastic tissue. 

Trceitment of Fractures. 

Mr. WiLEiAM Doolin showed a man, aged 63, w-ith both 
bones of the forearm broken. Mr. Doolin said that sixteen 
years previously the patient had broken both bones of the 
left forearm. During the nine or ten weeks that he was 
in splints no radiological examination was made. He was 
out of work for twenty--on6 weeks, and since then had 
been continuously at work as a house painter, hut lately 
there had been pain in tho arm. He liad an evident false 
joint, with %-ery- poor grip; both pronation and supination 
"w-ere present, hut only to a limited extent, and he could 
hot lift weights. Ow-ing to his age and the extensive 
sclerosis of the bone ends demonstrated by- x-ray examina- 
tion, hlr. Doolin had decided against operative repair, but 
a celluloid armlet was provided which effectively controlled 
the forearm, abolishing the flail movement. "With this 
gripping pow-er w-as definitely improved, and there was 
ability- to lift a chair held out at arm’s length. Mr. 
Doolin thought it a singular example of pluck that tho 
man had continued to earn his li-ving at rough paintine 


66 Jan. 14, 1928] 


OPHTHALMOLOGY AND 6ENKEAL MEDICINE. 


f TiiK JJniTi*n 
Mkdical JoviixAi. 


with both bones of tho forearm gone, and , with a false 
joint between tho elbow and wrist. 

Mr. WioLiAJi Peabson, exhibiting some intramedullary 
bone pegs of his own design, said that this method of 
treating fractures had boon very fully dealt with by 
Professor Hey Groves in a series, of lectures delivered in 
London several years previously. Tho tiso of ivory or hone 
pegs was confined to transverse fractures of tho shaft 
of tho long bones, witbout comminution, in which operative 
treatment was required. The principle consisted of putting 
tho peg into tho intramedullary canal so as to keep the 
two main fragments in alignment while union was taking 
place. Mr. Pearson claimed that his pegs could easily bo 
altered in size by filing, and that they did less damage 
\6 the endosteal tissue. It was not good, he thought, to 
fxcavato tho medullary canal and endosteal tissue, which 
were concerned in bone formation. Blocking the medullary 
•canal with a solid ivory or bono peg would retard tho 
formation of callus round the fractured surfaces, and 
therefore his pegs had a series of longitudinal grooves on 
tho surface, and in tho larger sizes small central canals, so 
that the callus formation would grow both through and 
round tho pegs. Tho few cases in which Mr. Pearson had 
used those pegs had done very well. The pegs were made 
in six sizes by Messrs. Allen and Hanbuiys. 

Mr. H. Stokes said that he himself had made somo 
bono pegs, but with difficulty and without much success. 
Using an ordinary chisel, however, ho got a bettor result 
by making them, not round, but octagonal. Mr. AiiTntnt 
Chan'CE had found it difficult to alter tho pegs tlioraselvos. 
Ho thought it was easier to make tho bono fit the peg than 
the peg to fit the bone, and was therefore in favour of 
exxavating tho medullary cavity. 

Mr. Pe.\kson, replying, emphasized the fact that his 
bono pegs, were only for temporary use: they wore simply 
ail internal splint to prevent displacement. Tho canals 
which he had made in the larger sizes were for tho purpose 
of vascularization; ho would not use them in tho case of 
non-union, in which event two methods were open — namely, 
a bone-graft or n step-cut operation. The latter was 
feasible in tho case of the humerus. 

Bone Complications in Typhoid Fever. 

Mr. P. J. HENBi" recorded a case of typhoid infection of 
ribs and sternum in a man aged 62. A lump had appeared 
on the front of the chest about five weeks after typhoid 
fever. There was a smooth, rounded, painless swelling 
about the size of a golf ball on the anterior chest wall, 
involving apparently the second, third, and fourth costal 
cartilages and the right border of tho sternum. It was 
stony hard and very fixed to the deeper structures; an 
x-ray examination showed pronounced thickening of the 
body of, the sternum, with osteo-sclerosis. An exploratory 
diicisiou was made, and tho lump was found to consist of 
a fibro-cartilaginous mass, with a central cavity containing 
l)Us,-from which a pure culture of B. typhosus was isolated. 
No other residues of typhoid infection could be found in 
the urine, faeces, or specimens of bile removed by the 
duodenal tube, .Mr. Henry said that the frequency of 
bone complications in typhoid fever was stated to be less 
than • 1 per cent., which was curious in view of the 
probability -of the marrow of most of the bones being 
infected soine time or other during most cases of this 
infection. De Qnervain had drawn attention to the fact 
that typhoid osteitis and chondritis of the ribs might 
be confused with tuberculous disease, and had emphasized 
the chronicity and the difficulty in securing healing. 

- Sir William- Wheeleb referred to the teaching of 
Murphy that each infection had its qwn date for meta- 
stasis- the infection from staphylococci appeared sixteen 
to twenty-one days afterwards, that from streptococci seven 
days afterwards, and in tho case of typhoid fever metastasis 
of the bones occurred from the fourth to the fifth week after 
the infection. Mr. Aethub Ch.ance had had a similar case, 
the patient having an indolent inflammatory swelling in 
the right side of the sternum. On incision a little thickened 
pus was discovered, but no bacteriological proof was 
obtained. Tho rib cartilage was bare, but there was no 


evidence of . necrosis. Healing occurred in six weeks. Mr. 
H.' Stokes quoted two similar cases, one of an abscess in 
the tibia, the other of an abscess in tho back of tho scalp; 
both had healed without difficulty. Ho thought it wise to 
open the bono and scrape it. 

Mr. Henby, replying, said that in a similar case cf 
swelling occurring four to five weeks after tho infection ho 
would leave it alone. Infections in bone other than tlje 
ribs and sternum healed up without much difficidty. If tlio 
cavity did not heal up ho projiosed filling it with a muscle 
graft from the pectoralis major. 


OPHTHALMOLOGY AND GENERAL MEDICINE. 

A jieeti.vc. of tho Manchester Medical Society was held on 
December 7th, 1927, when Dr. J. Gbay Clegg delivered 
his presidential address on ophthalmology in relation to 
general inedicino. 

Dr. Clegg, referring first to embryology, mentioned the 
fourfold relation of tho eye with ectoderm, comprising tho 
neural ectoderm of the retina, tho lens, the' conjunctiva, 
and tho skin of tho lids; tlio uveal tract and the cornqa 
were of niesodcrmio origin. It was not surprising, there- 
fore, that tho eye, with other cctodci-mic and mesodermic 
organs, was liable to disturbances of function and nutri- 
tion. Tho anatomical relations of the organ and its nerves 
and blood vessels, together with the visual patlnr.ays, wore 
most complicated, and most important ocular signs accom- 
panied, therefore, affections of tho brain and- spinal cord. 
Tho ophthalmologist must have a wide knowledge of 
anatomy, physiology, and p.athology, - and tho ' physioian 
should bo familiar with methods of examination of tho 
eye and the visual field. Reference was -made to somo cf 
tho more superficial ocular diseases, and it was strongly 
recommended that all medical practitioners should possess 
a coed lamp, a largo lens of 3 in. focal lengtlb » pocket 
loupe and an electric ophthalmoscope. With the former 
inanv of the superficial affections were easily and clearly 
distincuishod, and keratio deposits could bo recognized; 
with tlio latter the retina and choroid might bo examined, 
at anv rate aftei- dilatation of the pupil. The opinion was 
exnressed that all affections of the uveal tract were the 
result of the direct actions of trauma, micro-organisms, or 
of toxins circulating in the blood, and therefore the oculist 
needed tlio co-operation of a bacteriologist and a physician 
Abnormal conditions of the retina were then described, and 
the appearances of liaemorrliago occurring at varying 
depths Arterio-sclerosis of the retina and its relation to 
trenerai arterio-sclerosis were considered. It was recog- 
nized bv the “ copper wire artery in the early stage 

nd tho “ silver wire artery" when complete occlusion of 
the lumen had supervened. When this retinal condition 
aHiea xd serious cerebral results followed in .about 45 per 
rent of tlio cases. Amaurosis fugax might result from 
Lmnorarv spastic occlusion of the retinal arteries, but if 
the blood stream remained stagnant long, thrombosis set 
in and coagulation necrosis of the retina resulted. Many 
cases that bad formerly been regarded as embolism of the 
central retinal artery or one of its branches were really 
duo to this cause. Thrombosis of the retinal vein brought 
about rapid loss of sight, was evidenced by extensive 
haemorrhages, and was often complicated by a secondary 
trlaucoma Eenal retinitis was next described, with its 
fharactcristic but not pathognomonic appearances. It 
occurred in' one-third to half the cases affected by con- 
tracted kidney. In chronic parenchymatous nephritis the 
retina w-as usually not. affected ; almost always the blood 
pressure was high. Renal retinitis might occur at any 
age whereas arterio-sclerotic retinitis was a disease of old 
age’ The prognosis for life was bad; very few patients 
survived two years after its discovery, whereas the arterio- 
sclerotic type of patient might live much longer. Further,- 
in renal cases both eyes were usually affected, but in 
arterio-sclerosis in nearly one-half the patients one eye only 
showed the signs. Papilloedema might be tho only ocular 
sign when differential diagnosis from -a cerebral tumour 
might be difficult, but the blood pressure was a distinct 
cuide. Mention was made of tho retinitis of pregnancy, in 



GTNAECOLOGICAri TUMOURS. 


^ TttElJRrnsn K7 

L Medicii. JocRsir. * 


Jan. 14, igjS] 

vliicli cli'taclimont of tlid retina not infrequently oecnrrotl. 
It was believed that tlioro wore two ontetaiuling factoM 
producing different types of renal retinitis— namely, toxic 
and vascular ; in parenchymatous nephritis tho toxic 
olomont 2 >rovailcd, whereas in tho small red kidney tho 
vascular was tho liioro important. ' Iiastly, diabetes was 
-dealt with, and tho reasons given for supposing that tho 
''retinitis was really duo to this disease ,aud not to accom- 
"pariying ren.al. conditions; it affected tho Inter half of life. 
"Diabetes also involved-tho pars rotinao iridis, and Harrison 
Butler had stated that ho had diagnosed diabetes from an 
oedomatous condition. of tho mamelons, tho brown knobs 
at the piipillary margin of tho iris.. Tho lens might become 
opaque and rapid with changes in its refractive index; in 
fact, if in an elderly person a form of progressive myo|>ia 
was noted, diabetes was almost always responsible. Refer- 
ence was made to tho so-called retrobulbar neuritis pro- 
duced bj" diabetes, but it was stated that tho central 
scotoma for colour might reall}' bo jirescnt with an effect 
on the ganglion cells of tho maeular region as in tobacco 
amblyof)ia. Hjqmtony of -the globo and lijiaemia retinalis 
wore also obson'cd, the latter when fat was formed in tho 
■’ blood; which might amount to 26 per cent. • • 

at j ^ 


GYNAECOLOGICAL TUMOURS. 

-iAt a meeting of the North of England Obstetrical and 
.(Gynaecological Society at Sheffield on November 2Sth, the 
(.president. Professor IV. Fletcheii Shaw, in tho chair, 
tiMr. Caulton OunriEU) (Leeds) exhibited a specimen of 
ocaroinoma corporis uteri, showing (1) fibroids which had 
l(been treated by Apostoli’s method thirty-five years pre- 
viously, and (2) sarcomatous tissue. 

Mr. Oldfield said that the specimen had been removed 
from an unmarried woman aged 75, who had had slight 
abdominal pain and blood-stained discharge for three 
weeks. The uterus, which ivas slightly enlarged, was first 
explored with the curette, and since tho tissue removed 
was clearly malignant a pan-hysterectomy was performed. 
The patient, in spite of her ago, bore tho operation well, 
and never had a rise of pulse or temperature. Professor 
Stewart had reported that tho uterus contained both an 
. endometrial malignant growth and several fibroids, the 
latter of necrotic aspect. Tlie endometrial tumour was a 
A'cry cellular and active-looking adenocarcinoma, which 
was invading the muscle to a moderate extent. The largest 
fibroid had undergone total necrosis, but without any 
appreciable calcifications. The uterine wall at one point 
close to the large necrotic fibroid showed a form of sarco- 
matous change. Mr. Oldfield stated that Apostoli’s tieat- 
ment (passage of an electric current through tumours) had 
been employed, by Mr. Keith thirty-five years previously for 
fibroids producing menorrhagia in this patient, the current 
being applied three or four times. The bleeding was not 
checked at once, but continued for two or three years; tho 
menstruation became almost normal in amount for a year 
or so before the menopause. The patient had been quite 
since. The chief interest of the specimen was the 
condition of the fibroids, and the question arose whether 
their unusu.al shrunken appearance was due to the Apostoli 
treatment or was only the ordinary atrophic change. Mr. 
Oldfield added that, if the sarcoma-like tissue was a true 
growth of this kind, tho combination of carcinoma and 
sarcoma was remarkable, and the question arose as to 
whether the electrical, treatment had had anything to do 
with the malignant diseases. 

. . Abdominal Myoma. 

Mr. W. Gough showed a specimen of an unusual abdo- 
minal tumour in a married woman aged 60, who had 
suffered for eighteen months from indigestion and heart- 
burn, and recently from severe attacks of abdominal pains, 
with violent vomiting. ■ Examination showed a very hard 
and -movable tumour -extending from the inibes -to -above 
the umbilicus. ' Pelvic examination sbowed no abnorinalitv, 
and a jirovisional diagnosis of solid ovarian tumour with 
torsion or pedicle was made. ' At the operation it was 


found' that the tumour could be pushed up under the ribs ; 
it was situated in tho lesser omentum, with the stomach 
stretched along its lower border. It was removed without 
any great difficultj-, the only strong adhesion being to tho 
stomach ; the bare area on the stomach wall was stitched 
over and tho abdomen closed. Microscopic examination 
showed that tho specimen, which weighed 15 lb., was a 
liuro myoma. 

Carcinoma of the Cervix. 

Mr. W. "W. Kino (Sheffield) showed a specimen of car- 
cinoma of tho cervix with a microscopical structure in 
places so strongly resembling sarcoma as to be misleading; 
when, however, further sections were cut from other parts 
of tho growth the true carcinomatous nature of the growth 
was at once recognized. Mr. King thought it probable 
that some of the so-called “ sarco-carcinomas ” of the 
cervix wore of the same nature. 

The PiiESiDENT said that specimens diagnosed as sarco- 
mata were ver 5 ’ often difficult to prove, especially in the 
case of fibroids. He asked Avhefher fibroids ever ’underwent 
sarcomatous degeneration, or whether the sarcoma arose 
outside the fibroid. Professor Miles Phillips thought 
that sarcoma might arise in a fibroid tumour. ' Professor 
Douglas said that this very rarelj’ happened. Often 
cells were found resembling sarcoma ; they wore due- to 
degeneration in the cells of the fibroid and were not really 
malignant. 

Dr. Bride (Manchester) showed a case of massive car- 
cinoma of tho cervix in a jiatient, aged 35, who had had 
her first child eleven months iireviously. She had bled 
slightly during tho pregnancy, and for the last three 
months continuously. On examination the vagina was 
found to be completely filled with growth, which was 
removed, and two applications of radium were given. She 
died eight months after the operation, with probably 
recurrence of the growth. 

Dr. Leith Murray said that in these cases the operation 
was easy, but recurrence was very likely. Mr. Gough said 
that recurrence was early in the cauliflower growth because 
the glands were easily invaded. Professor Miles Phillips 
drew attention to the importance of the routine examina- 
tion on the tenth day of the puerperium. Mr. W. W. 
King said these growths were relatively less malignant 
than those arising in the cervical canal, which rajiidly 
invaded the pelvic cellular tissue, and the President 
agreed. 

Large Ovarian Fibroma. 

■ Mr. J. Eric Stacey (Sheffield) showed a specimen of 
fibroma of the ovary removed from a 2-iiara, aged 47, who 
had noticed (swelling of the; abdomen -for twenty years; it 
had been worse since the. .last child had been born seven 
years ago, .and had latterly increased rapidly. The circum- 
ference of the abdomen was 57 inches. A - large, smooth 
encapsulated tumour of the right ovary was ■ removed ' at 
operation ; it contained spurious - cysts from hyaline 
degeneration and weighed 26 lb. There was no ascites. 
Microseoiiically it resembled fibroma of the uterus. 

Dr. Bride commented on the absence of ascites, which he 
believed to be the rule. He had removed a tumour weighing 
8 lb. from a woman aged 70. Dr. Leith Murray said that 
these fibromas became enlarged b}' degeneration. Professor 
Miles Phillips said that a tumour of 88 lb. was the biggest 
recorded. He did not think that ascites was present as a 
rule. ■ 


THE RITUAL OF FRACTURE REDUCTION. 

At a meeting of the Livei'iiool Medical Institution on 
December 15th, 1927, the president. Dr. J. C. M. Given, 
in the chair, Mr. R. IVatson Jones read a pa^icr entitled 
“ The ritual of fracture reduction.” 

■ Mr. M'atson Jones said that of the many auxiliaries of 
treatment introduced since the pioneer days of Hugh Ou'cii 
Thomas and Sir Robert Jones, the most .valuable and vet the 
most ignored was ar-r.ay control, now so' ifcrfcct that plaster 
and certain metal splints offered no barrier. The modern 


68 Jan. 14, 1928] 


EEVIEWS. 


[ Tnr. UnmTH 
llEDtcAi< JotinriL 


routine of fracture reduction must include not only maniiiu- 
lation follou-ed by fixation, but an almost immediate x-ray 
examination to determine the position which was being 
fixed. If this was shown to be imperfect the routine 
— manipulation, fixation, x-ray examination — was repeated 
as often as necessary on consecutive daj’s, until the position 
already fixed was shown to be perfect. Fractures must bo 
regarded as emergencies, and the organization of a hospital 
fracture department must provide for the immediate insti- 
tution of treatment, with further daily attention until 
full reduction was secured. The “ twice-weekly ” fractui-e 
clinic was as obsolete as the “ oncc-weeklj' ” operating day. 
The combination of such a routine with x-ray control 
throughout rendered fracture reduction simple and certain, 
and perfect results could be secured in more than 90 per 
cent.'of recent fractures by manipulation alone. The ritual 
was illustrated by combined injuries of the forearm bones, 
where relatively slight anatomical displacements might 
cause serious functional impairment. An analysis of the 
early and delayed functional defects of malunion was 
followed by a demonstration of a series of cases where 
perfect results had been secured by controlled methods. 
'When operative reduction was necessaiy intramedullary 
ivory pegging was regarded as the operation of choice 
because of the perfect apposition, impaction, and alignment 
ensured. The importance of impaction was seen in the 
relatively’ slow union after autogenous bone-pegging. Tho 
results of 20 cases of medullary pegging (including 12 from 
a total of 200 recent and old fractures of the forearm) 
showed that in the absente of infection union was never 
delayed, and disappearance of the peg was complete in 
three to six months. A method of instituting early con- 
trolled movement, a new way of inserting long pegs, and 
a set of drills with a “ cruet-stand ” for drills and pegs 
were described. 


JA3IES 3IACKENZIE IFfSTITUTE. 

Carcinoma of the Colon. 

On December 6th, 1927, Sir Geouge Lenth.4i, Che.\tle 
(King’s College Hospital, London) read a paper on some 
recent views upon carcinoma as applied to the colon. He 
described two types of epithelial hyperplasia which he had 
found in his researches on the breast. The first type, asso- 
ciated w’ith increase in peri-canalicular and peri-acinous con- 
nective tissue, was seen in the breast of the newly born 
infant and at puberty, and, therefore, might be regarded 
as phy’siological. He protested against the use of the term 
chronic mastitis in this connexion, since the condition was 
not inflammatory. He did not agree that this hyper- 
plasia was secondary to increased vascularity, but con- 
sidered that the increased vascularity present was the 
result of the demands of increased functional activity. 
A second type of hypeqjlastic change was described, jn 
which the epithelial cells tended to heap themselves upon 
one another, and by this process led to the formation of 
cysts and papillomata. In the colon he had been unable to 
discover anything comparable to the first type, but tho 
second type of overgrowth was common. In the breast and 
colon such papillomata might be innumerable, and thev 
were commonly associated with carcinoma. The epithelial 
activity was, in the lecturer’s opinion, the essential change 
in all instances. In the colon two such papillomata were 
shown to be carcinomatous. A cell, having taken on the 
malignant character, invaded surrounding tissue, and as 
yet this invasion was the only proof of its malignancy. 
These conditions and the earliest stages and local spread 
of carcinoma were illustrated by numerous slides. The 
follo^ving types of spread in the colon were described, 
(a) Limited spread in the submucous lymphatics; (b) direct 
spread of epithelial cells in the perirectal fat; (e) embolic 
spread (though this was rare) ; (d) diffuse explosive local 
sjDread in all tissues; (c) invasion of radicals of proctal 
vein; this last explaining the frequent invasion of the 
liver in carcinoma of the bowel. In conclusion the lecturer 
expressed his thanks to Drs. Cuthbert Dukes, Archibald 
Xeitch, and Fry for assistance in the preparation of his 
paper- 


Eciikbs. 


THEEE jUIBRIGAN BOOKS ON HYGIENE. 

The fourth edition of’ Professor IlosE.x.iu’s I’rcvcntive 
Alcdicinc and Hygiene Avas revicAvod in tho Journal on 
April 14th, 1925. In tho fifth edition,’ which has now 
appeared, a number of tho subjects treated are either' 
now or fidly dealt with for tho first time. Tho higher 
preA’alence of cancer in the older states of America as 
contrasted with tho ncAA’cr is ascribed to. differences in .ago' 
and sex disti-ibution . Its incidence is greater among 

AA’hitcs than negroes, but has recently increased among the 
latter. The aTithor doe's not commit himself to any of tho 
theories of causation AA-hieh haA’o boon advanced, but ho 
refers to avitaminosis and groAvth control as possible factors 
and quotes tho AA-ork of Gye! A scheme of ocular hygiene 
is outlined. Consen'ation of vision is described as a vital 
jAroblcm, second only to tho conservation of life itrelf. For 
preventing the damage which ensues on glaucoma, early 
recognition — often difficult — and prompt treatment to con- 
trol pressAiro and maintain drainage aro insisted on. Sharp 
or fragile toys, so dangerous to the eyes of children, arq 
deprecated. Tho good example of the sight-saving, class 
for progressive myopia, first set up by Bishop Harman in 
London, is now folloAved by nearly oveiy alert city in tho 
States. Trachoma is iirevalent among tho American, 
Indians, and is endemic among the poorer sections of all^ 
largo American cities. Refereneo is made to tho, optic 
atrophy induced by wood alcohol, a teaspoonful of AA-hich 
may cause loss of A’ision. Periodical general physical' 
examination, on a birthday basis after early childhood, i^ 
commended as a AA’ise and useful innovation wliich iq 
groAving apace. Distoniatosis, common in warm countries 
and occasional in tho Dnitcd States, is discussed, and its 
prophylaxis indicated. The noAv section on tho psycho- 
analytic approacli to sex hygiene is quite unconA’incing. 
That on mental hygiene is good in tone. It applies 
psychiatry to social problems and folloAA's mental doA-elop- 
ment from infancy to adult life, dealing Avith praise and 
blame, reward and punishment, delinquency, discipline, 
and endurance. .The new section on statistical methods 
Avill bo found of scrA'ieo, though possibly not easy reading 
for all. Among other ncAV or expanded topics aro 
granuloma inguinale, balantidial dj-sentery, and resuscita- 
tion after gas poisoning. Tho author, it would appear, 
still looks askance at vaccination by cross-scratching or 

scarification in fact, be says it should bo prohibited. The 

hi"h opinion which avo expressed of Professor Eosenau’s 
fourth edition is more than confirmed by tho fifth. The 
book is a valuable AAork of reference, but it is much too 
live to be a Avork bf reference only. It is cordinll 3 ' recom- 
mended as a comprehensive guide in the routine practice 
of public health and a sound exposition of its princijjles. 

The eighth edition of Professor Egbert’s Manual of 
Hygiene and Sanitation- presents the fundamental prin- 
ciples of the science in the light of recent knoAvledge, 
aA-oiding the exposition of more detail than may properly, 
in the author’s vicAV, be included in a manual. The 
channels by Avhich the infectious diseases are communicated 
are set forth in' a Avay Avhich should make them clear to 
the non-medical reader. It may be noted, howcA-er, that 
the species of mosquito AA-hich cany malaria are consider- 
ably more than two, and that Pcdicidus capitis as Avell 
as Pcdicidus corporis is oapablo of transmitting typhus. 
The- subject of immunitj-, formidable to the uninitiated, is 
handled Avith lucidity. In the discussion of the causes 
of A-itiation of air the author appears unduly tolerant 
of the organic poison tlieorj-. The Avork of Leonard Hill 
on the phj-sical characters of used air might have been 
accorded more than a reference in a footnote. On methods 
of ventilation the sound opinion is quoted that tho best 
system of ventilating schoolrooms is- by means of fresh 

* Prevf.ntite }Uilicine and Uyijienc. Bj* Union J. Kosenaii. Fifth 
edition. New York and London : D. Appleton and Co. (Med. 8vo, 
pp. XXV 4- M58; 157 figures, 1 plate. 42s. net.) 

of Hygiene and Sanitalion. By Sonoca Egbert, A.M., JT.D., 
Dr.F.lI. Eighth edition. Philadelphia and New York : Lea and Febicer. 
(51 X'8, pp. viii + 616 ; 154 figures. 4 dollars.) 





Jan. 14. 1928] 


3EVIEWS. 


r TffiBnmni * Rft 
t JIXDioii Joum*i* 


imheatccl outdoor nir admitted at tlio windows. Tho 
section on social Iiygieno is in good taste and entirely 
to tlio point. . The following excerpt from tlie section on 
water purification is a direct appeal to the financial 
conscience: “Lawrence, Mass., with a population of 
4d,654 in 1890, built a filter at a cost of $67,000, saved 
enough lives at ?5,000 per head to pay for it within tho 
fii-st four months and had a reduction of almost 60 per 
cent, in the typhoid rate within a year.” Professor Egbert 
is a believer in common sense. Ho writes a vigorous 
English style which is pleasant to read. 

To convey to teachers and students of education a 
helpful knowledge of practical hygiene and sanitary 
organi:!ation is tho task attempted by Profc.ssor WiLi.T.\jts 
of Columbia TJnivci'sity in his work’ on tho essentials of 
modern health care. He defines health as a quality of 
life which renders the individual fit to live most fully, 
and to serve best. Ho has no high opinion of the dull 
gymnastics of tho Gorman and Swedish systems, but 
quotes 'Wiliiam James to tho effect that the strength of 
the British Empire lies in tho strength of character of 
tho individual Englishman, perennially nourished by the 
fiational worship, in which all classes meet, of athletic 
outdoor life and sport. Ho hopes and de.sires that it 
may be so in America also, but recognizes the risks there 
of spectacular di.splay and the scmi-])rofossion,al attitude. 
He treats of the care of expectant mothers, infants, young 
children, and school children. Ho places the optimum 
tomporaturo for tho schoolroom at 68° F. He discusses 
the teeth and tonsils as foci of infection, notes tho 
prophylactic value of unimpeded sunlight, and endeavours 
in a few pages, which will put his non-medical readers 
on their mettle, to explain the phenomena of immunity. 
He cites an excellent summary from an American source 
on the control of communicablo disease. Ho is rightly 
not cordial to the hot-air furnace ns a means of warming 
dwc-lliug.s. He gives an account of Oitv, State, and Federal 
lie.alth administration in tho United States, and concludes 
with a chapter on international health as promoted by tho 
Eookefeller Foundation, tho Rod Cross, and the League 
of Nations. Professor William.s’s book, to borfow an 
expression of his own, is worth while. 


THE CENTENARY OF UNIVERSITY COLLEGE. 
The Centenary Addresses, Bound Toejeiticr in One Volume,* 
delivered to celebrate this great occasion at University 
College, naturally arrest attention both from the eminence 
of their authors and the historical interest of their con- 
tents. Of tho twelve addresses all except Sir Gregory 
Foster’s entitled “ These hundred years,” delivered on 
March 26th, 1926, before the Union Societv, were given in 
1927, and it is perhaps a pity that tho valuable aecount of 
the histoiy of University College Sir Philip Magnus gave 
on April 27th, 1926, which was noticed in our columns 
(1927, i, 155), lias Hot also been included. In his survey 
Sir Gregory Foster, like Professor J. Norman Collie in bis 
address on “ A century of chemistry,” touches on the 
famous Professors T. Graham, IVilliamson, and Ramsay, 
and goes on to praise the famous men who begat reputa- 
tion for T7ni\ersity College, not, of course, omitting the 
masters of medicine. The late Professor E. EC. Starling’s 
discourse (Biiitish ]Medical Jouhnal, 1927, i, 438), winch' 
is the first in the volume, shows how much the progress of 
British physiology in this countiy owes to the professors 
in the laboratories of the 'College, especially during the 
last fifty yeai's. In speaking on the relations of ITiiiversitv 
College r.iid medicine Sir John Rose Bradford pointed out 
that tho two original Facilities were law and medicine, 
drew attention to the extraordinary breadth of view mani- 
fested by tlie founders as to the requirements necessary 
for tlie adequate study of medicine, and showed bow tbo 
College had contributed to the development of scientific 
methods and of the scientific type of mind in the general 


^ pl/ffiene ond Sanitation^ The Sencntials of Me^Iern Health Care. 

I'JnlartephIa ani Lo.irlon : W. B. Saui 
Compam. (Po<5t 8vo, pp;^4; 52 fipine*5. 10s. neO 

Centenarjj Bound Together in One Volume. Unlrersifv of 

London, Unn-ersUy Col/e^e. IVieh a Preface bv Dr. R. W. ChamfK'rs 
London: Universitv of London 
pp. Yiii + 350. 12s. 6d. nct.l 


. By 
Saundex^ 


Press, Lttt 1327, (Demy 8vo, 


practice of medicine. Sir Oliver Lodge in his discourse on 
•“ A century’s progress in physics ” also praises Sir W. 
Ramsay and refers to the work of Professor J. A. Fleming, 
who gave tbo address on “ A century of electricrJ 
engineering ” ; Sir Oliver does not confine himself to 
retrospect, and warns his audience about the risk of 
accepting the false doctrine that science has any other aim, 
such as utility, than truth.' In “ Culture and the coming 
2 )cril ” Mr. 6. IC. Chestei-ton, who was once a member 
of the Slado school, writes on what, after some fifteen 
pages of winnowing down the exact nature of the jjeril, ho 
reveals to ho standardization at a low standard. In the 
centenary oration the Right Hon. H. A. L. Fisher, 
Warden of New College, in speaking on tbo subject of 
'• Our universities," compared tbo exclusiveness of the two 
older universities and tbo narrow curriculum they used to 
offer with tbo broader principles inspiring the foundation 
of London University, which have been followed by the 
newer provincial universities. - University College, he 
pointed out, stands for three things — tolerance, academic 
study, and collegiate life. Professor R. “W. Chambers, who 
contributes the preface, also spoke on “ Philologists at 
University College,” and used tbo word in the older, 
broader, and more correct sense as meaning those inter- 
ested in the study of literature ns well as. the study of 
l.mguagc ;■ appreciative notices of Henry Morley, AV. P. 
Ivor, and Platt add to the attractive character of Professor 
Chambors's address. Profe.ssor J. E. G. Do Montmorency 
is responsible for “ A contuiy of jurisprudence,’’ and Dr. 
Mary Broderick’s address entitled “Our inheritance.” 
brings to a close a volume of varied interest. 


THE ARCHIYES OF PSYCHIATRY. 


Tin: ninth volume of the Archives of Neurology and 
Psychiatry^ is edited by Dr. Fuedeiiice L. Goi,l.\, who 
succeeded the Into Sir Frederick Mott as director of the 
laboratory at the Maiulsley Hospital, and as pathologist to 
the London County Mental Hospitals. Since we owe the 
inception of these valuable Archives to Mott, it is only 
fitting that the present volume should include his portrait, 
an obituary, and a bibliography of bis numerous contribu- 
tions to neurology aud psychiatry. His Hnrveinn Oration 
on " Some Developments of Harvey’s Doctrine ‘ Omiio 
Vivnm ox Ovo,’ ” together with three other articles from 
his jicD, arc also included in the twenty-seven pajiers 
publislicd in this volume. 

Tho various contributions cover a wide range. P. K. 
McGowan, J. S. Harris, and S. A. Mann give an account 
of their researches on blood sugar in encephalitis letbargica, 
and also on the clinical effects following the injection of 
lijoscine in the subjects of this disease, with special 
reference to its influence on carhohydrato metaholism. 
A. Hancock urites on the cerobro-spinal fluid in 
encephalitis lethargica. S. A. ^lann is responsible for 
blood sugar studies in mental disorder; tbo investigation 
of a series of cases of early mental disorder by the laevuloso 
test for liver glycogenic efficiency; and a research on the 
lieutral sulphur excretion in dementia praecox following 
sodium thiosulphato ingestion. A preliminary report from 
tho. London County Mental Hospitals Service of tho value 
of malarial therapy in dementia paralytica is given, and 
AA*. S. Dawson records his experience of the treatment of 
this disease by tiy-parsamide. The same writer and MaiyR. 
Barkas give a somewhat unfavourable account of somnifen 
treatment in the psychoses. Dr. Barkas also contributes 
papers on the treatment of psychotic patients in institu- 
tions in tho light of ji-sycbo-analysis ; on tonic spasm of tbo 
eyes in conjugate deviation; and on social conditions as a 
factor in the causation of mental disorders. G. A. Lilly 
and E. L. Hopkins write a note on the AA'asserniann 
reaction in the blood serum of male admissions to Hanwel! - 
klental Hospital; E. G. T. l^oynder and J. Russell record 
an investigation on the cholesterol content of the cerebro- 
spiiial fluid in certain mental diseases; P, K. McGowan 
reports four cases of pellagra, with bistologic.al findings 
in one ca.se, and also writes on tbo pliysico-psycbo-galvanic. 


S Archircs of Keuroloin/ and rtychiatrrj. Edited bv Frederick I.. 
Golla, F.R.C.r., Jl.n.O.von. Vol. l.V. London: V. S. Kin- nnd Son Lti 
1927. (15s.) ’ 


60 Jan. 14, 1928] 


NOTES ON BOOKS. 


t Tnx Bnmn 
SIeoioax, JoxmiriL 


reflex in the neuroses and psyclioscs; E. H. P. Morton 
gives an account of a case of heriJes zoster, apparently dno 
to invasion of the ganglia by ronnd-cell sarcoma. ’Isabella 
M. Eobertson is resijonsible for a research of considerable 
importance on the vasomotor reactions in mental disorders, 
■with special reference to tlie haemoclastic crisis, and 
A. A. "W. Petrie- writes on the same subject. P. K. 
McGowan and S. A. Mann contribute a paper on tj’jihoid 
carriers in mental hospitals. Tlie editor of this i-olume and 
J. Hettwer are together responsible for two researches: the 
first a study of ’the electromyograms of voluntary move- 
ment, the second on the influence of various conditions on 
tho time relations of tendon reflexes in the human subject. 

We should like to congratulate Dr. Gplla on the quality 
and quantity of the research recorded in this ■\’olume. 
It is evident that under his direction investigations are 
being carried out along lines which can scarcely fail to bo 
fruitful in I'esidts. 


DIAT H ERMY. 

The booi on clfat!ierm3'' written hy Dr. Iiv.t.v vo.v BtriiES.’, 
assistant medical officer in the women's clinic attached 
to the Dniversity of Budapest, though it has reached us 
rather a long time after the date on tho title-page, is 
worthy of notice, because it is concise and will sci-ve as 
a useful guide to those acquainted with German who desire 
to learn the principles of the subject and tho therapeutic 
field. After a short introduction to the histoi'y of 
diathermj’, the authoi' describes the high-frequency current 
and the methods of production; some machines of Gcnnan 
make and electrodes of different types are then described. 
Various ways of administering diathermy to the patient 
.are explained in the next section, and the author indicates 
the.rislis that are encountered if attention is not paid to 
details of technique, and gives instructions for tho guidance 
of tho beginner. The effects of diathermy on normal tissues 
and its method of action in the treatment of disease are 
described ; of special interest in this section are the obseiwa- 
tion by means of the cystoscope of vaso-dilatatiou in the 
mucous membrane of tho bladder when tho diathonny 
current is directed through the pelvis. Treatment of tho 
different regions and systems of tho body is dealt with in 
separate sections. The value of diathermy in many of tho 
diseases peculiar to women is emphasized, and the potency 
of diathoimo-therapj' in gonococcal infection in the female 
subject, is pointed out. In the section on diseases of tho 
lungs diathermy is said to be of value in chronic pleurisy 
and bronchitis, but it is not recommended for any stage 
of pulmonary tuberculosis. Surgical diathermj- is briefly 
descinbcd in the last section. The use of the current for 
coagulating abnormal tissue en masse is the form of 
operation which tho author describes. Tlie book is well 
illustrated and there is a good bibliographic index. 


POTASSIUM AND CALCIUM IN THE BLOOD. 

Aefa Medica Scandinavica, in its nineteenth Supplement, 
oft'ere yet one more of those detailed, almost exhaustive, 
reports of clinical and laboratory investigations tho 
publication of which would appear to be the special sei-vice 
it seeks to render to medicine. This .service merits grateful 
acknowledgement. The subject of this Supplement is the 
jiotassium and calcium content of the blood,^ and consists 
of a considered report by Dr. Eskil Kylin on a long series 
of chemical analyses of .the bodj’ fluids of noi-mal and 
diseased subjects. From the data on healthy individuals 
mean values are deduced for tho nonnal concentrations of 
potassium and calcium in the blood and the magnitude of 
physiological variations. Pathological conditions under 
which significant departures from these normal values are 
obsei-ved are classified, and emphasis is placed upon the 
significance of departures from the normal ratio of 
potassium to calcium. The clinical field has been widely- 
sui-vcyed. 


Anirendung der Diathermif. Von Dr. Iwan von Buben 
Alit oincm ECleiiwort von Universitatsprofessor Dr. Beia v. Helen* 
l..-iraiE; J.-.\ Barth. (Boy. Svo, pp. vi -4- 175 ; 82 fionres. SI.11.40.) 

. .Drr Cfftalt SM OTulfj an Calcium und Kalium. Von Eskil Evlin 
Supplementom XIX. JonkBpinn ; TryeSeri 
At.(i.;6otai;ct SmaianU. 1927. (6x95, pp 112 > 


The patient collection and correlation of a great mass 
of analytical data upon .such factors as those hero dis- 
cnssetl may scorn a monstrously tedious labour. Such it is; 
nor docs the assembly of tho residts in print provide 
engaging reading. Nevertheless, it is siiado work which 
must not bo shirked. When, as in this case, it is per- 
formed with discretion in an organized laboratory under 
rigid standards of control it is a service of great value 
both to mcdicino and to physiology. 


NOTES ON BOOKS. - 

Dn. HEimEitT SpENCSn has published his FitzPatrick Lectures 
on The JJistory of British Midwifery from 1650 to 1800' in 
a volume which is rendered the more valuable by the com- 
pleteness of the bibliographical references it contains. In this 
respect it contains information, doubtless necessitating diligent 
rcscarcli, which is not to be found elsewhere, and which would 
alone entitle it to be regarded as a standard work on the 
subject. The volume is illustrated syith reproductions of the 
portraits of some of the leading obstetricians of the period — 
namely, William Harvey, Sir Fielding Quid, William Smcilie, 
William Hunter, John Leake, Charles White, William Perfect, 
William Osborn, and Thomas Denman. These add greatly to 
the interest of the work. The substance of the lectures was 
published in our columns at the time, and iii the same issue 
(November 12th, 1927) rvas a leading article in which some 
of the lessons they had to teach were discussed, so that we need 
not now say more than that. Dr. Spencer is to he congratulated 
on li.aviiig added an import .int and attractive volume to medical 
literature. 

It is more than eighteen years since the idea occurred to 
a Bart’s man (Mr. Basil Lang) to rescue .from “ the decent 
obscurity of office files ” some of the clioiiest flowers of wit 
that had blossomed in the St. Bartholomew's Hospital Journal 
and arrange them in a little paper-covered book entitled Bound 
the Fountain.” This anthology of verse and prose has enjoyed 
a great and deserved popularity, and several editions, eacli 
larger than the last, went quickly out of print'. A fourth 
edition, with all the old favourites and many sparkling new 
pieces from tho same source, has now been prepared for the 
entertainment of Bart’s people, ancieqt and modern, and of 
others who enjoy light literature with a medical flavour and 
do not mind topical touclies in reason. Apart from the added 
matter, two fresh features will be welcomed by many. The 
to.\t is now decorated with sprightly pen-and-ink sketches, some 
of them very good, and there -is .a. frontispiece showing the 
fountain in the square, with patients in bed under the- plane 
trees. The other novelty is a limited issue of copiet printed 
on better paper, in a stiff binding of dark blue, with the 
hospital arms on the back. This should pleaSe those who agree 
with us that Bonnd the Fountain is much too good to lie 
about on tables and sofas like a last month’s magazine, and 
ought to have its own place on the bookshelf. 

The Manual of Veterinary Bacteiiology,'” as its name implies, 
deals only with baeteriology as it affects the domestic animals, 
but as there are remarkably few textbooks in English on this 
subiect it will be a welcome addition to the books of reference 
of the' medical man who is interested in the diseases com- 
municable to man from animals. The chassification of the 
American Society of Bacteriologists has been adopted through- 
out but the more familiar names in general use in this countiy 
arc ’included in- brackets. In addition to surveying the bacteria 
and filterable viruses. Dr. Kelser includes sections on the 
fungi and the protozoa. Incidentally, we must protest against 
the very general tendency to include protozoology under the 
hc.ading'’^ of bacteriology, a tendency by no means confined to 
-America. In addition to these more systematic parts, the 
author discusses infection and immunity— very briefly and not 
too well — and also serology, haematology, preparation of 
vaccines and serums, and tho o.xamination of water and milk. 
These latter chapters are clear and well written. Any textbook 
must of necessity include only a selection of the material 
available, and accordingly a certain amount of information is 
omitted which, although apparently in the opinion of the author' 
unnecessary, would probably be considei^ed' useful in this 
country. There are also a certain number of actual errors 

» The Htetory of British Itidirifery from 1650 to ISOO. By Herbert R. 
Spencer; lU.D., B.S.Lond. London ; J. Bale, Sons, and Danielsson, Ltd. 
19^. (55 X 9, pp. xxiv -1- 185 ; 9 plates. ISs. net.) 

* Bound the Fountain. Publisli^ by tbe Editors at tlie Journal Office, 
St. Bartholomew’s Hospital, London. Fourth edition. 1927. (Post 8vo, 
pp. X -P 201. Price 3s. 6d. in paper cover, post* free 3s. lOd. ; in cloth 
binding — limited to 500 copies — 7s. 6d., post free -Vs., lid.) ■ 

” manual of Veterinary Bacteriology. By Raymond A. Reiser, D.V.3L, 
PJj.D. London : Bailli&re, Tindall and Co.v. 1927- (Demy 8ro, pp. xii 
+ 525 : 86 figures. 25s. net.1 




Jan. 


TETRA-ETHYD IiBAI). 


(for example, equine epizootic lympliangitis is not present in 
Britain, as T)r. Kclser stvates),' but on the whole they are few. 
Tile author lias produced a very creditable hook, which is easily 
read, and ^YiU prove an acceplahle addition to general medical 
literature. 


Dv. Homer Smith of New York has written a monograph on 
A-ppVicd Kcfractiony'^ dealing M’ith the M-ork of the ophthalmq- 
’ legist from the clinical standpoint. He writes as a pracli- 
; tioner to practitioners, and, omitting optics and mathematics, 
confines his attention to tlic actual practice of the art of 
determining the refraction of the human eye and how j 

• such errors as are found .should he treated. His subjective j 
. practice is ortliodox, and he is able to give a clear statement of 

his methods, and to (jjial with difficulties in an explicit manner. 
-'IVe judge the weakest part of the hook to he his method of 
■ determining refraction*; he appears to rely almost exclusively on 
• subjective methods. It is true ho uses the ophtlialmoiucter for 
measuring the curves of the cornea, hut by neglecting the 
i retinoscojiy mirror lie niisse.s the most valuable of all methods 
of examination— one that is more objective than any other, and 

• one that depends upon the skill of the .surgeon and least on 
the wliim of ' the patient. One ohservation of his is worth 

•. noting: “No one can do good refraction work if he is in. a 
hurry. As a preliminary 1 recommend to tlie heginner Sir 
, "William Osier’s essay on * Equanimitas.’ Repose of mind and 
I hbdv are cssenliaks to patient and operator.” But we would 

• qualify the repose of mind of the operator; the repo.se 
' must he of the .sort that gives complete concentration on the 

• work on hand — a concentrated alertness. The caution against 
hurry is opportune, in view of the difficuUies that attend 
clinical work when authorities attempt to crowd the examination 
room with excessive numbers. 

Dr. Gerxld.B. Webb' and Dr. Charles T. Ryder, in bringing 
. out the third edition of their hook, have changed tlie title from 
, JiCCovrr^ Jif'conl to pvercoinhifj Tuhcrcitlo<ii^A‘. Apart from 
this there seems to he little alteration. It is essentially a popular 
hook, intended for the patient himself. As the recommenda- 
tion on the cover-flap says : “ It is written in a bright, clear, 

. and hopeful style which can hardlv fail to he most helpful.. It 
1 points out clearly and comfortingly the way to recovery, and 

• gives .specific instructions all along the line. Anything the 
doctor may' forget to tell the patient will he found in these 
pages. The advice and counsel cheer the reader’s mind and 

. keep him on a high level of optimism.” Quotations from poets 
and others are inter.spcrsed between the charts. Some readers 
• ■ may find the hook not altogctlier to their taste. 

" • Furtlif^r Contributions to the Theory and Technique of 
'• PMJcho^Analt|eh''‘^ includes a great number of .shork conlrihu- 
tions, some only a fow^ lines long, fogetljer with .some more 
lenglliy papers by Dr, Sandou Ferentzi, one of the leading 
Continental exponents of psycho-analysis. The author explains 
_ .in his preface that the present collection is in no way intended 
,\tp; he a systematic .survey of the development of psveho- 
the years' 'which have intervened since his fii^i 

• collection of writings' was publish^ in English, in 1916, Imt 
c.only .the disjointed. papers -which represent his-personal edn^ 

J .tnbulion to this development. He believes these papers "give 

•a true picture of the manifold interests mIucIi conlinua'lly 
1 occupy the pliysician practising psycho analysis and bring him 
mto touch with the most varied fields of the natural and mental 
sciences. .This volume is compiled by Dr. John Rickman, and 

• 1^'^^slated from the German by Dr. Jane Isabel Sutlie and 

- others. - . ■ . . * . • ■ 


Ihe Student Christian Movement has published for private 
circulation a small hook entitled The Education of lioys in 
the Subject of Sex.” It has. been written anonymously, by. a 
public school housemaster, who describes in detail the ordinaiy 
sexual development of boys. The author’s experience has 
? 1 ^? 1 ^ extensive, and his practical suggestions will he 
neiptul to medical practitioners, parents, and .schoolmasters who 
lave Hie responsibility of dealing with this rather difficult 
uoject. Unaue space is, perhaps, given tc what mav he 
ermed the clinical details, and this will render the hook rather 
onotonous and even irritating to som e readers ; hut, in view of 

Homer Eraslus Smith, M.D. EclinhUrsli : 
'lit,'. ' ■. ' ''tpd. 8vo, pp. i.*: -I- 131*; 9 fifjures. 15 j, net.) 

T5. ' ■ ' !* Gerald R, M'cbb, M.D., and Clmrlcs T. 

s ■ ■ 'iJscd. New York: 1’. D. Hoeber, Inc. 1927. 


Ay ‘ Throry and Technique of Veve 

, A..n i' i ■ •. i-' • JI.T). Compiled bv John Rickman. *M 

nnJ German bv Jai'ie If.ibel Suttic, M 

T JnHnn ■ T Internal ioiial Psvclio-anah lioal Librarv, -Ko ‘ 

is" net;) ° ' HOK.Vlh- Press. 1927. (bj x ?3Vpp/'tI 

■ SuJjJfCt of Srx. Londfin : The Sclit 

N^WII Annandale, Noith End Ro 

N.M.ll, 1927. fCr.-8vo, pp. vii +.115. Ss.-post fice.) ” 



r r Thk Bnrn^a - 
t JoZTiHAl, 


'61 


the sound practical advice, both given and imiilied; this may 
)veU he pardoned. Though tlie hook docs not cover all the 
ground indicated by the title, and leaves some difficulties 
alino.st iinmentioned, yet it is certainly a useful contribution 
(o this branch of pediatrics. 


PREPARATIONS AND APPLIANCES. 

■ - A Tube for i^tifnapuhic Cystotomy. 

Mr.. C- Alex. Wells, F.R.C.S. (Liverpool), has devised a tuhe- 
for suprapubic cystostomy, and has found it very effective in 
practice. Tlie tube is fixed by an efficient purse-string suture in 
the bladder opening, v'hich should he no karger than is essential. 

* The. longer portion 

(about 05 inches) lies 
comfortably on the 
abdomen, and ensures 
good drainage by its 
rigidity and gentle 
slope; it is fitted at 
the distal end with 
the light collapsible 
tubing supplied for 
Paul’s tubes. The 
shorter, portion is about 4 inches long, and- the angle between 
•Ijic two parts is about 75 degrees. By leaving the end of Hie 
inc6rporatc*d catheter outside the dressings the bladder can he 
irrigated .witliout disturbing the bandage. The cave of Retzius 
.should he drained ns usual,' though in favourable circumstances 
the patients remain quite “ dry ” for several days. This tube 
is made by the Genito-Urinary Manufacturing Co., Ltd., 28a, 
Devonshire Street, W.l. . . . 



TETEA-ETHYL LEAD. 

The Risks or its JVdditiox to Pf.tkoi,. 

About 1903 it ivas found that the addition to petrol of one 
part in a tlionsand of the siihstniice liuon-n as tctra-ethyl 
load was of great vnlne in preventing “ knocking,” and the 
mixtnro was a great ponimercial sncce.ss, for 300 million 
gallons were .sold in the United States during the two 
following years. It is .said, moreover, tliat the use of this 
mixture will ]iermit the nsc of petrol engines with higher 
compre.ssion. IVo understand (and Dr. Myer Coplans, in 
'the Idttcr piiblishcd at jiage 74, confirms tliis) -that -petrol 
.mixed with tetrn-ethyl lead is already being. sold in this 
Country ,'.nn(l from the facts mentioned it .appears .probable 
that it may -in the near future replace ordinarj- petrol .to 
a large extent. This possibility . raises a jnhlic health 
problem of importance. 

.There is ho doubt that tetra-ethyl lead is a' very active 
, ^and dtingerous poison. As regards its actuiil toxicity it is 
'D'lie tliiit' Kehoe' suggests that it is ho more toxic than 
• inorgahic . le.a'd ;• hut,- oil the. other hand, .Norris and 
Getllcr’s- 'posf-moi fcm analyses' show, that- the ■ compound 
has a specific affinity for the .central nervous system, and 
this iiicficatos a higher toxicity than inorganic lead.. There 
is, .however, lio doubt that tetra-othyl lead is- far more 
dangerous than any inorganic lead compound, because it is 
volatile" and can be absorbed either, by inhalation or even 
through the intact skin. Even supposing that its toxicity 
is the same as that of. other lead compounds the amount 
needed to produce cumulative poisoning would only bo a 
ferv milligrams a.d.iy. . ... 

■In actual practice its possible toxic action is suggested 
by reports that in the chief factory in whicli it was 
prepared five employees died in 1924 and thirty others were 
affected, and that the Standard Oil Companj- of New 
Jersey had already agreed to pay 350,000 dollars to six 
persons." 

The high toxicity of this compound naturally aroused 
.alarm in the United States, and its use was for "a time 
prohibited in the city of New York". The United States 
Bureau of 3Iines tested the effects produced on animals bv 
the exharrst of “ ethyl gasoline,” and concluded that no 
lead poisoning was produced."’ 

More recently a special committee ap))oint«d by Surgeon- 
General Cumniing has reported on the effects of ethyl 
gasoline, on eraiiloyces in garages and motor drivers;” It 
concluded: “There are at present no good . groimds for 

' ' S' ■ ■ - J . ■ ; .11 



' '62 Jan. 14^ 1928] 


MEDICAL ASPECTS OF EDUCATIONAL PROBLEMS. 


t TnUsmitf ■ 
Mxdicax. Jotrwf Aft 


prohibiting tbe nse of ethyl gasoline as a 2 notor fuel, 
provided that its distribution and use arc controlled by 
proper regulations.” This conclusion was qualified, liow-, 
ever, by the statement that it was derived from the study 
of a relatively small number of individuals, wlio rvere 
exposed to the effects of ethyl gasoline for a period of time 
comparatively brief, and the committee urged the need 
of further investigations. 

The evidence available at present, therefore, so far as it 
goes, indicates that the mixture “ ethyl gasoline ” can bo 
used without producing poisoning. 

iSfi/Hipfoias of Tefra-cthiil Lead Poisoning. 

The effects of tetra-ethyl lead poisoning have been sum- 
marized by Ivchoe.' In cases of moderate cumulative 
imisoning the chief symptoms aro as follows; Insomnia; 
nausea and vomiting, which occur jiarticularly in the early 
morning; headache and vertigo, and muscular weakness. 
The chief signs are a uniform pallor, low blood pressure, stib- 
normal temperature, loss of weight, and a well defined 
coarse tremor. Colic is not a feature and the lead lino 
on the gums is rare; the blood picture is inconstant, some- 
times stippling of the red ceils is seen and sometimes tho 
blood is normal. In acute eases cerebral symptoms pre- 
dominate ; the patient is irritable, nervous, and excitable, 
and may even become maniacal. The signs, therefore, are 
quite different from those of ordinary lead poisoning. 

Kehoe recommends the administration of largo quantities 
of alkalis as treatment (20 to 30 grams of a mixture c)f 
sodium bicarbonate and magnesia). He mentions that tho 
use of narcotics for the insomnia is dangerous. 

BerERSNCcs 

1 Kclior : Jonm, Amer. .!s«oc., 85, 108, 1925. 

2 Xorri!, and Gettler : Ibidf, 85, 818, 1925. 

•' Ibid., 88, «1, 1927. 

* Uiiiied States Bureau of 5Iino.s (report) : Ibid., 83, 1511, 1924. 

support by committee appointed by Suiecon-Concral Cumnnne : Ibid. 
86. 370, 1926. - 


MEDICAL ASPECTS OF EDUCATIOJfAL 
PROBLEMS. 

In our last issue (page 28) we gave some account of fhe 
discussions, so far as they had a medical interest, at the 
various educational conferences meeting in London during 
the Christmas vacation. A few of the later events on tho 
programme are worthy of special mention. 

r/ic Effect of Illness on Character Formation. 

To the Child Study Society Dr. David For.syth lectured on 
the effect of physical infirmities upon character formation — .a 
subject, he said, curiously neglected, and not mentioned in 
any medical textbook so far as he was aware. Permanent 
bodily afflictions and temporary illness alike had their influence 
on the behaviour both of adults and children, and the younger 
tbe child the more pronounced the effect. The very young 
child thought of illness as due to some imp within the body, 
and at a later age regarded .it as punishment for xin, thus 
following the course of race evolution from animism to religion 
though the further development to science and a scientific 
explanation of disease did not come in childhood. Illness 
(hat .sent a child to bed arrested its frirther mental development 
for tbe time being, or even put it back. The child tended to 
revert to the infant state, largely because it became again the 
object of special attention on the part of the mother. Children 
who suffered from nervous ills lost them on being put to bed 
for bodily illness, but the relief was only temporary. Surgical 
operations on children had no bad effect in themselves, except 
that in some cases parents were unwise enough to conce.al 
what was intended until the actual operation took place, and 
this gave the child a sense of grievance against the parent. 
The irritability shown by children during convalescence was 
attributable to disappointment at the partial withdrawal of 
maternal solicitude. Deformities or facial defects c.aused the 
child to feel itself different from other children, and to become 
solitary and subject to fantasy. Dr. Forsyth added that the 
initiative of many children was largely paralysed and the 
c laracter was mined by coddling by parents ■ on account of i 


infirmity ; on the other hand, Ihera were children who reacted 
to infirmity in a different way, and who increased in determina- 
tion and perseverance, as they grew up. 

School Meals. 

The .subject of the nutritional requirements of school childien 
was di.sciissed at a meeting of the National League for He.alth, 
Maternity, and Child Welfare. Dr. Alfred Eichholz of the 
Board of Education, who presided, emphasized (he need for 
providing for the feeding of children in the .secondary as well 
as the elementary schools, especially in country areas. Jlc also 
indicated other advantages in the provision of school meals in 
addition to saving the children from hunger — namely, a certain 
amount of instruction in the elementary principles of dietetics, 
especially as to the right proportions and edibility of food, and 
the inciilcsition of good manners and .social qualities. Dr. V. T. 
Thierens, assistant medical officer of health for Bradtord, men- 
tioned that in the abnormal conditions arising from the coal 
deadlock of 1926 a quarter of a million children were fed 
daily by over 170 authorities, instead of tho usual number of 
100,000 children by 135 authorities. What was noted in the 
children from the poorer parts of towns was not so much 
lack of food at home as hick of appefite, arising from Jiome 
conditions, e.siiccially insufficiency of sleep, which helped to 
bring about the well known a.ssembly of defects — anaemia,'- 
debility, and malnutrition. A further speaker. Dr. C!. Chaikin 
of the Public Health Department of the London County 
Council, spoke on the subject of vitamins and the necessity for 
their preservation in the process of cooking. 

Measurement of Muscular M'orh. 

To the British Association for Physical Training Dr. Guy P.i 
f'rowden lectured on the physiology of muscular work, and' 
described some experiments with lads engaged at a brick-making' 
uuiks near Peterborough as to tbe barrows filled with bricks 
Mliich they could handle. Measurements had been taken of 
the oxygen consumed by the lad or man at rest and then 
of the crxce.ss oxygen when engaged in various phases of his 
occupation. One point elicited was that of this excess cost of 
oxygen 30 per cent, was expended in tho labour of starting and 
stopping the barrow and 70 per cent, in pushing it a dist.anco 
of 50 metres; in the labour of starting and stoiiphig something 
like 25 per cent, was consumed in the gravity action of raising 
and lowering the handles, and 75 per cent, in getting the 
necessary acceleration. The investigation had led to the work-' 
ing out of economy loads and other points. 

The Teaching of Vefcctive Children. 

A ten weeks’ course of study for teachers of mentally 
defective and of dull and backward children has been 
arranged by tbe Central Association for Mental Welfare. 
The course, whicli is to be given in London from May to 
July, includes lectures on the psychological and pedagogical, 
the' inedic.al, and the social and legal aspects of the subject. 
The first of these aspects is concerned with normal and 
abnormal psychology, methods of teaching, and speech train- 
ing; the second with the medical .side of mental deficiency, 
and with the epileptic, unstable, and subnormal child ; and 
the third with the legislation covering the subject and the 
social .organizations for defectives. The Board of Education 
has approved the course, and has agreed that le.ave of absence 
from school on full pay given to the teacher for attendance 
at the course shall be treated as contributory service for super- 
annuation to -the extent permitted by the superannuation rules. 
The Board of Control also has recognized the course in con- 
nexion with the staffing of the teaching departments of its 
institutions. It is emphasized that the course is intended 
primarily for teachers with no previous experience of work 
for defective or backward children. It has been found that 
the number of teachers with the necessary training and quali- 
fications for dealing with such cliildren is very limited. On 
the other hand, the ordinary school teacher without some 
special training should not be placed in charge of such classes. 
Defective children are extraordinarily various, some of them 
dull all round, some backward only in one subject, a nuniber 
are positively feeble-minded, and others only temperamentally 
handicapped and lacking in self-control, and teaching has to be 
modified to the individual. The address of the Contr.il Associa- 
i tion is 24,- Buckingham P.alace Boad, S.W.L 


FAOTOKS IN VISION. » 63 


JAN. 14, 1928] 


jEcUtcal f otitnal. 


SATDBDAY, J^VNUAKY 14tii, 1928. 


FACTORS IN VISION. 

Tun address recently delivered by Dr. Freeland Fergus 
at the Royal Philosophical Society of Glasgow, which 
is printed in full at page 42 of this issue of the 
JounxAi., is one that will be a stimulant to thought, 
for it questions our common ways of dealing with 
matters relating to vision in ch’il life. The subject 
is not a now one. It has been the occasion of much 
experimental work during manj- years past, notably 
by the medical officers of the Air Force. Most of the 
points raised are not disputed, but are accepted on the 
basis of a lengthy experience. They are dealt with 
alil;e by textbooks of ophthalmolog}' and of physiology. 
]jut for all that knowledge and record of ascertained 
facts, a restatement of these facts in virile and racy 
language such as will be found in Jh-. Fergus’s paper 
is needed. 

Again and again the laity, and some doctors, fall 
into the habit — some would call it the slovenly habit — 
of supposing that in stating a figure indicative of 
visual acuity under certain conditions the measure of 
the sight' of the person examined has been given. 
Examples of the evils that arise from such slipshod I 
habits are not far to seek. A little while ago an 
attempt was made to qualify the terms of what was | 
meant by “economic blindness, " in regard to the 
provisions of the Blind Persons Act, by introducing 
steieotyped standards of visual acuity. A vigorous 
pi'otest by Mr. Bi.shop Hannan published in our 
columns led to (or at any rate was followed by) 
further directions which materially and advantageously 
varied the criticized proposals, by restoring to the 
certifying doctor his responsibilitv for the judgement 
of the state of the sight in relation to work in each 
individual ease. Again, during the past year a some- 
what lengthy correspondence was published in the 
Times , oh tests of vision for motor drivers, and in 
niost of these letters there was the same haiqiing on 
visual acuity as a possible standard of efficient sight. 
Li the Joup.xAT.'of October Sth, 1927 (p. 646), we 
touched on the many factors other than acuity that 
needed to be .taljen. into account before the quality 
and quantity of a person’s vision could be determined. 
J'urther, it is no unconmion occurrence in countj' 
Gourts, where clauns . made under the Workmen’s 
- Compensation Acts ai’e adjudicated, to hear evidence 
. given -by -medical witnesses that the patient’s vision 
by reason of the accident has been reduced to 6/12, 
and it is almost the rule for the cross-examining 
counsel to describe tliis as “ vision reduced to one- 
naif the normal. ’ ’ T-oo commonly this eiToneous 
statement is allowed to pass unchallenged, since -a 
discussion upon tlie meaning of medical terms is 
rarely advantageous in a court of law. 

Dr. 1 ergus is without doubt right in his insistence 
on lynat -may be alino.st conceded as a paramount asset 
the held of vision. For all general purposes 
of life a good held of vision is imperative. Without 
hat, no matter how -good the visual acuitv may be, 
he subject of the defect is more or less a prisoner 
unless there be some guide at hand whose services 
can mak-e up to him what he. lacks. Extreme cases 
rave been Imown in which visual acuitv has- remained 
nearly full, registering as inueli'as 6/9'; yet with an 


extremely meagre field of vision — a field- restricted, 
perhaps, to no more than five or ten degrees from the 
fixation point. Such, a patient is blind, so blind as to 
need leading about ; he is unable to see a friendly hand 
held out to welcome him ; blind despite Iris ability to 
read small print! The reverse, where there is. no 
macular r-ision but a full .general field of vision up. to 
the normal periphery, gives quite a different picture. 
Such a iierson (showing, for example, a patch' of 
degeneration or choroiditis in each macula) is a free 
man, able to move about at his own pleasure and in 
safety; he can engage successfiilly in manj- of the 
varied occupations of modern life, especialh- in country 
districts, but with less success in great tomis, where 
ability to rend is commonly necessary. 

The value of a good field of vision is very rightly 
stressed by Dr. Fergus. But wo venture to suggest 
that in doing so he has somewhat belitlled the value 
of an intact and efficient macula, one that is capable 
of giving keen vision for detail. His obseiwation that 
he himself, in a condition of focus or out-of-focus eyes 
■which gi-eatly lowered his visual acuity, was still able 
to see distant islands, is not, wc think, conclusive. 
It is probable that he knew these islands and where 
to look for them. Macular vision is exorcised even 
when the- raj s of light falling upon the structure are 
not in focus. The myope whose vision without glasses 
is less, than 6/60 can often tell the time by the church 
clock; a bare hint of the position of the liands, how- 
ever blurred tlie impression may bo, enables him to 
“ place ’’ them, and. in this judgement no doubt ho 
is aided by bis knowledge of what the time ought to 
be. To “ see men as trees walking ’’ is seeing, and 
seeing with the macula, albeit the impression is faultj', 
for the faulty macular impression is coiTected by a 
•swift and unconscious reference to 'stored experience. 
This is less 'true of the blun-ed imprc.ssions of objects 
seen .with the peripheral field of I'ision : with these 
there is a true impression of position and size, but.not 
of recognizable form; for there is an imperative .urge 
for the subject to turn the eyes upon the object seen 
in this bluired peripheral impression so that fhe 
macula may discover its tine form. If field of vision 
alone were the dominant factor, then the rabbit* 
should have splendid sight, for the field of this animal 
must be immensely greater than man’s; but with this 
great general field there is no critical faculty such as 
goes with the possession of a highly developed macula, 
hence the rabbit sees only to flee. . . 

It may be asked, How comes it that in practical 
affairs so much emphasis is laid on visual acuity and 
so little upon the field of idsion? The practice will 
probablj' be found to have arisen. from two experiences. 
First, those with bad fields of "vision eliminate theiii- 
sclves or are eliminated in early life from tlie ranks 
of the normal. Children who stumble over objects 
obvious to others attract attention, as do those whose 
disability becomes more pronounced with failing light. 
Secondly, tests of ■idsion first Came to be regarded as 
necessities in schools. The children must be educated, 
and education in modern times is necessarily related 
to the printed page ; so their ability to see to read, and 
to do this accurately and without undue strain, is a 
sine qna non for the normal school. This is shown by a 
rcA'erse provision : school children are defined as blind 
if they are “ unable to read llio ordinarv school 
books,” a definition which is in contrast to that of 
blindness in adult workers or pensioners — “ so blind as 
to be unable to perform any work for Avhieh ejesi'^ht 
is essential.” When the need for testing the sight for 
occupations other than education beeaiine apparent, it 
was natural to pursue (with certain ' exceptions— ^fer 


B4 JAN. 14 , 1928 ] 


• TETRA-ETHXrj LEAD. 


- , r Thk fJcmsn 
L AIrdical /oubkaxi 


example, colour vision) the same habit of testing 
visual acuiW. This was the more likely 'to happen 
owing to the commonness, of remediable defects of 
yisual acuity as compared with irremediable defects 
of visual field, colour vision, light sense, and binocular 
yision. The tendency in all human affairs is to tackle 
the simple problem first. But there is evident danger 
in being satisfied with this simple and unrelated test 
of visual acuity, as Dr. Fergus shows. It may bo 
stressed too much; it may cause more serious defects 
■to be neglected; and it may lead to hardship in some 
cases. But for all this we can scarcely agree that 
..visual acuity is negligible or even inferior iu value to 
yisual field. A man to be a whole man, of full 
economic value in any walk of life, should have, 
•besides good- visual acuity, a good field of vision, good 
colour vision and projection, and, possessing two eyes, 
should have binocular vision. A man with less than 
these, with a failure in only orie point, is less capable 
-than one who has them all. That does not mean 
He is incapable of work, and of good work, but; given 
an equality of mental equipment, he is less likely to 
• be successful in the performance of fine, mechanical 
work than is- his physically more perfect competitor. . 

One point in Dr. Fergus’s paper appears to need 
further investigation. He insists on the high value of 
the field of vision, but he does not see that there can 
ever be a practical standard for this field. This is 
a point for inquiry. We should have thought that it 
would be possible to devise such a standard. Patients 
suffering from chronic glaucoma recognize the growing 
limitation of their field of vision; in the early stages 
the limitation causes them little or no disability, but 
•when there is a loss of periphery of some thirty degrees 
they are conscious of a real trouble. They note that 
they bump into door-jambs, pieces of furniture, or 
passers-by in the streets. The loss of periphery of 
field they have sustained is such that they are no 
longer aware, of objects close about them. A series 
of observations upon intelligent patients of this order 
might show at what degree of limitation of field of 
vision an element of danger appears. Some- smaller 
limitation than this would mark -the margin, of safety. 

■ If such tests were carried out, .with agreed standards 
of- illumination, of size of test objects, and of working 

. distance, a standard of sufficient accuracy and ease of 
ascertainment iriight be devised. It would seem to be 
, no ' more difficult than the . deterihination of colour 
sense, light sense, and binocular vision — especially 
when the high average of intelligence now shown by 
the general populace is borne in mind. 

■ . This paper by Dr. Fergus is worthy of careful study, 
and the subject of -it might ■well form a topic for dis- 
cussion by ophthalmic surgeons, possibly in the Section 
of Ophthalmology at one of the Annual Meetings of 
the British Medical Association. 


TETEA-ETHYL LEAD. 

Seveuai. readers have called our attention to the 
answer given by the Home Secretary in the House 
of Commons on December 1st, 1927, to a question 
by Mr. Hardie regarding the possibility of poisoning 
due to the use of petrol containing tetra-ethyl lead — 
Pb(C„Il 5 ),. The Home Secretary’s final statement 
(as printed in the Offioial Eeports) was; “It is quite 
clear, unless the hon. member has information which 
I have not, the poisoning does not exist.” 

The chief facts Imomi regni'ding tetra-cthy] lead are 
set out briefly in an article printed in this issue of the 
Jour.xAi, at page 61. They may be summarized in the 


statement that it is a powerful cumulative poi.son, 
peculiarly dangerous on account of the ease with 
which it cr.:), bo absorbed. U'etrn-ethyl load is added 
to-petrol.in the proportion of one pari in a thousand, 
and the mi.xture is termed in America. “ ethyl gasoline.” 
This appears to be such a A'aluable commercial com- 
modity that, if nothing is done to restrict its use, it will 
probably replace ordinary petrol to a very large extent. 
Investigations by two committees in the United States 
liaA’c indicated that there is no evidence for poisoning 
by -ethyl gasoline, but this conclusion must be 
regarded as provisional. The simplest course open to 
this, country is to admit ethyl gasoline freely, and to 
find out by experience whether a significant propor- 
tion of garage workers and car drivers get lead 
poisoning;' and this appears to be . the course that is 
being adopted. ' ' 

We do .no.t wish ,to. oppose on insufficient grounds 
any important invention that may result in a great 
saving of the, national .petrol bill, but we would siigge.st 
that' a pharrnacplogical experiment of this magnitude 
does at least deserve careful watching It is .true that 
the investigations that have been carried out suggest 
that -ethyl gasoline is not dangerous when, c, arc fully 
used. These inquiries, however, do not claim.to.be 
conclusive, and we would suggest that. the. .'possible 
dangers, are .of such .magnitude that as full an investi- 
gation ns possible of. the problem ougbt-lo' be made in 
this country; The Home Secretary’s answer suggests 
that the Government does not feel any particular' 
alai'in, but it is obvious that if the widespread use 
of large quantities of such a powerful and dangerous 
poison does not result in any ill effects, this will be 
a very fortunate and (to us, at least) unexpected 
occurrence. 

There are two chief dangers. The first is the 
poisoning of garage workers and chauffeurs by fumes 
given , off from the combustion of ethyl -gasoline; a 
short account of • the outstanding symptoms of tetra- 
ethyl lend poisoning, will be found -at page 62. The 
second danger , is the . production of ordinary lead 
poisoning in the' general .population owing to the 
spraying of the stre'ets of our crowded towns with lead 
dust from the exhaust pipes of motor, cars. The' whole 
problem is,’ of course,- .one of particular -interest to 
medical -irraotition'ers, from the professional point of 
'view as the guardians of the health of the community, 
and also fr6m' the personal point of view as car drivers. 


- F'o'o.t-AND-MOUTH DISEASE IN 1927. 

So far as fcot-ancl-moiitli disease is concerned, 1927 lias 
been one of the most fortunate of recent years. In 1923 
there wore 1,929 outbreaks recorded in Britain; last year 
there rvero about 120 , tho majority of which occurred in 
tho latter pai't of December. Last year also saw coiisidei'- 
ahlo activity in research into the cause and prevontion of 
tlio disease; but we are still without any scientific method 
of control. The Foot-and-Mouth Disease Committee, 
appointed three years ago, is still contimiing its work, and 
manj- valuable facts have been discovered by its members. 
Much of this has been rendered possible by tho uso of tbo 
guinea-pig as a suitable laboratory animal, and intradormal 
inoculation of the pads of the feet has been foitnd to be a 
sati.sfactoi-y method of infection. It has not yet been found 
possible to cultivate tho virus in vitro^ however. Using 
this animal as a source of infection, it has hoen possible to 
study the properties of tho virus. It has heen ionnd io 
bo very active indeed, lesions being producible .after an 
inoculation with a dilution of over one iu ten millions. 





Jan. 14, 1928] 


OTIinDITY A'ND THE COTTON WEAVEE'S HEAHTH. 


r THEBama -• CPT 

LMrcicii. Joranrj* 


Plitsky and Boez,* by comparing the filtorability of the 
vii*ns tbrongir collodion membranes, liavo estimated tliat 
tlic size of tlio organism lies bota'cen 20 and 100 p/t. The 
viability of the virus lias also been studied, and somo 
smin'ising results have been obtained. In tlio flesh of 
n slaughtered animal it become-s inert tmenty-four lioui-s 
after death, but it may remain alive for forty days in the 
blood and seventy-six days in the bono marroa-. In cold 
storage it can live for over a year, and for a vei-y con- 
siderablo time on hay and bran. The vims is, hoa-ever,. 
easily dcstroyctl by disinfectants such as sunlight and weak 
formol. It has been found that a cert.ain amoiuit of 
immunity may be conferred on animals by the use of a' 
foimolizod virus, a’ith or aithout the addition of a hyper- 
immune serum ; but these experiments on immimit}' have 
not yet reached a stage at which aholesale vaccination is 
possible. Our knoadedga of the possible hosts of the virus 
ha.s also been, extended. Babbits- and white rats -can bo 
infected, and the rabbits may contract the disease spon-, 
tancously, although possibly simple contact alone may be 
inadequate, and a breaclr of the epithelium may be neces- 
sary. No deSnite cases of infection in man have been 
reported in this country during the jircsent series of out- 
breaks, although there is a possibility that slight cases have 
not hcen diagnosed as due to this cause. An epidemic in 
young milk-fed children was reported recently from France, 
where diarrhoea and other digestive symptoms, together 
■ with a skin eruption"(but without any vesicles on the mouth 
or mucous membrane), were found to follow the consump- 
■ tion of milk from cattle which all subsequently displayed 
typical sjTnptoms of foot-and-mouth disease. The milk was 
always most infective in the pro-clinical stages. It is now 
generally recognized that at least two, and possibly thi-ee, 
strains of ' this virus exist, and that there is no cross- 
immunity. Vesicular stomatitis of horses has been shown 
to be very closely allied to foot-and-mouth disease, and it 
seems possible tliat this is still another variety. It ha.s 
been suggested tliat only one of these strains is infective 
to man — the strain originally isolated from Germany and 
called the “ A ’’-strain — and it is of interest to note that 
the great majority of strains isolatcil in Britain were of 
the otlier or “ 0 ” vai'ioty. Professor Greenwood,' as a 
statistical epidemiologist, has examined the operation of the 
slaughter policj- — abandoned since 1918 — in Holland, and 
believes that this policy has had no effect, good or bad, on 
the incidence of the disease in that country. How far this 
policy has affected the incidence of the disease in this 
country, however, is not apparent. He lias 'also expressed 
scepticism as to the continued reintrodnetion of the disease 
from abroad — a claim which, he points out, has always 
hcen made by ofBcialdom in all countries, and has likewise 
been made in the case of Iininan influenza. Jleanwliile the 
6 aughter policy has cost this country, in compensation 
alone, over five niiUion pounds within tho last five years. 


_ HUMIDITY AND THE COTTON WEAVER’S HEALTH. 

Hi. problem of the effect of, artificial humidification npoi 
^ 16 sickness rates of operatives in the cotton weavin) 
in ustn has formed the subject of. an investigation can-ici 
’ . •' ^ Bi’adford Hill on behalf of the Indnstria 

a igiio Besearch Board, and the valuable conclusion 
arriTO .it have now been publislied in a report.” Previoii 
report.s issued by this board and by departmeiita 
TOmnii ees have shown that excessive warmth am 
1 ^ detrimental effect on the weave 

p ijEio ogicallj^ discomfort and fatigue, an* 

iminis ling efficiency, but no definite figures have hithert 

' Jourti. Eip. Ited., 1927, ^ ~ 

October, 0327 . 

upon Vic'sicknm'^KattJ"^ Ir™** Collon Wearinp Imlrntry ^ lit Cffei 
th-D. Tndmtrial fijr™’’.’’’? Operatives. By A. Bradford Hil 

Stationery Office. 1927f^2s Board, Report Xo. 43.^ London: HJ 


been available to support or refute the oft-repeated asser- 
tion that, even under present working conditions, these 
factoi-s exercise an injurious effect on the health -of the 
ojipiativcs concerned. This report is presumably expected 
to fill tho blank, and it will cei-tainly he vei'y interesting 
to note liow it is received hy tho operatives’ unions. It 
may he explained that cotton cloth is woven in sheds of two 
types, “ wet ” and “ dry,” tlie distinction depending on 
whether moisture is introduced into the atmosphere hy 
artificial means or not; the latter preponderate in this 
•country. Tho choice of the typo of shed depends on the 
kind and quality of tho cloth to ho woven. Cotton weaving, 
whatever the variety of cloth, thrives best in a damp 
atmosphere, and, though recognizing that the natui'al 
humidity fonnd in the south-east and east of Lancashire, 
assisted hy a suitable sizing, is quite enough to meet 
ordinary needs, it is contended hy manufacturers that 
certain varieties of cloth cannot he woven satisfactorily, 
and certainly not economically, without a higher percentage 
of humidity than can be supplied naturally. Steam is 
the most effective and extensively used agent, but very fine 
water sprays are also employed. Unfortunately the intro- 
duction of steam, while increasing the humidity, increases 
tho temperature, and, although tliis is good for the process, 
when certain recognized limits are exceeded the weaver 
suffers. Commencing with the Cotton Cloth Factories -Act, 
1889, a succession of statutes and regulations has been 
controlling atmospheric conditions in these “ wet-’-’ sheds, 
and there can be no question abent the progressive improve- 
ment in the health of the weavers during the period of 
operation.' But the weavera have never - been satisfied 
with statirtory regulation of temperature and humidity,' 
and still insist on the total. abolition of artificial iiiti’oduc- 
tioii.- Tlie need for this particular investigation, can there- 
fore be appreciated; The weai-ing sheds of each type to- he 
placed under observation were very carefully chosen, and 
approved by both manufacturers and operatives. They 
were situated in Preston, Burnley, and Accrington, where 
both processes are utilized; in Blackburn, where all the 
sheds demand high hnmidily; and in Nelson, where the 
sheds are “ dry.” The chosen factories employed altogether 
about 20,000 weavers ; cards for all these were made out, 
and; at the end of twelve months, were sent .in to tlie 
various approved societies concerned for the entering up 
of particulars of sickness. ■ Due account was taken of 
workers, leaving during tlie period ■ of observation. In 
assessing the results separate groups of males, single 
females, and 'married females were formed for noii-humid 
and humid factories, and each group was subdivided into 
ago periods of ten years. The general conclusion is to the 
■ effect that sickness incidence shows no selective difference 
between the humid and non-humid groups, either in 
' number of days of sickness experienced, in number of 
claims made, or in number of persons affected. Analysis . 
of the sicluicss tomi by town yielded similar results. Tbo 
mean cliy .and wet bulb readings and the mean relative 
humidities for a period of five months were calculated 
from the records of hotli types of factories, and these latter 
were ■ again classified under temperature and humidity 
headings, but again no significant- difference in the sickness 
incidence could be found. The possible effect of unemploy- 
ment on sickn^s claims was not lost sight of, hut a com- 
parison between tho results from groups of factories of each 
type, which had been very little affected by unemployment 
during tho year, and the general results showed conclusively 
that this factor could be disregarded. The sicknesses tliem- 
sdves have also been classified under general headings 
without affording evidence of any consistent or distinct 
Uiiferences between the two types. All tliese conclusions 
appear to he quite justified when the results are examined 
from so many angles. The only semblance of a weak spot 
j to be found is in comparing tho influenza and respiratory 


66 Jan. 14^ 1928] INFECTION OF BARBADOS WITH MALARIA. [ Mrm'c'i? jo””, 


classes, which cover tho illnesses genorallj’ attributed to 
“ catching cold.” The claim rates for these classes com- 
bined appear to support a greater incidence in humid 
sheds, for most of . tho groups belonged to Burnley and 
Blackburn. 

THE INFECTION OF BARBADOS WITH MALARIA. 
Hiihehto Barbados was able to boast that, unlike any 
other of the West Indian Islands, it was free from malaria. 
Unfortunately it has, during the last few months, lost that 
claim on permanent residents, and on winter tourists who 
are being attracted in increasing numbers to tbo Antilles 
since the dread of yellow fever has been so greatly 
diminished, if not ontirelj’ extinguished. Mosquitos of 
various sorts, including stegomyia as well as culcx, 

• abounded in Barbados, but auophelino mosquitos, though 
carefully sought for, had never been found. The epidemic 
of last autumn dates from October 8th, when seven patients 
suffering from what was believed to be typhoid fever were 
notified. The symptoms were not wholly characteristic of 
malaria, and it is not surprising that in an island where 
the disease had never been known to occur there was 
hesitation in making that diagnosis. Tho epidemic 
develojjed rapidly, and over three hundred cases were 
recorded in three weeks ; most had a fever running 
from seven to ten days, but many apparently cleared up 
without quinine; a few seemed uninfluenced by quinine; 
others showed marked improvement after quinine; but 
some had been ill at homo for a week before they were 
treated in hospital. They were not having chills, but there 
was a good deal of vomiting, and some cases had shown 
earlj’- jaundice. The deaths were mostly in elderly and 
debilitated people. Splenic enlargement was generally 
absent. In these circumstances the services of Dr. E. A. 
Seagar, professor of tropical hygiene. Imperial College of 
Tropical Agriculture, Trinidad, were requisitioned, and tho 
Colonial Office sent out Dr. J. T. C. Johnson from England. 
Dr. Seagar reached Barbados on November 16th, and 
that evening, under the guidance of Dr. Lionel Hutson, 
inspector of public health, he visited two districts and took 
blood films from a number of cases, finding tho paiasites of 
Bubtertian malaria in most of them. Next morning a few 
aiiopheline larvae were found in one of these districts in a 
small grassy swamp above a pool, and in an adjoining 
district great quantities in a “ seepage.” The search was 
continued during the following days, and the conclusion 
eventually reached was that anopheles was breeding fairly 
widely. Hollows in the fields holding water, and with the 
grass growing up from the bottom and entangling green 
algae, were sites of election for heavy breeding in many 
cases, but even large pools containing “ millions ” showed 
an anoiDlieline infection if the edges were grass-grown. 
Several of the gullies were followed up on to tho terraces, 
and in suitable grass-grown holes containing water in the 
beds of the gullies aiiopheline larvae were found. Grass-grown 
ditches holding water at tho roadside were also infected, 
(ill microscopical examination the laiwae proved to be of 
tbo species Anopheles alhimanus Wiedmann, one of the 
carriers of the malignant iiarasite in this part of tbo 
tropical world. Dr. Seagar bred them out to the adult 
mosquitos and also caught adults, and all proved true to 
species. In his report to tbo Governor Dr. Seagar pointed 
out that it was to be expected that tho aiiopheline mosquitos 
will spread over the island in advance of the actual cases 
of malaria, because a female aiiopheline, having had a meal 
of human or animal blood, will look for water to lay eggs, 
and that brood, when hatched, will push on for other water 
to breed in, and if the 3 - encounter and bito a human being 
1 with the malignant crescents circulating in the blood they 
will become infective. It is thought probable that the 
infection has come from Cuba in labourers, but there is a 
possibility that the mosquito may have travelled also in the i 


holds of small schooners carrying fruit from the neigh- 
bouring Antilles. It seems unlikely that they can have 
crossed tho sea independently, ns tbo ordinary flying range 
of an anophelino is about half a mile, tbougb it may 
traverse five or six miles, with the wind, in .special circum- 
stances. Tbo Govornmont of Barbados has volod a small 
sum of money to cover the cost of cmcrgcncj- measures, 
including, it would appear, the provision of quinine for 
prophylaxis. It is proposed to fumigate houses in which 
infected individuals reside, and to undertake a campaign 
of education. Professor Seagar, however, advises the 
Government that it will be a lengtln- business even to keep 
malaria under control. The pros])cct of stamping it out 
does not seem to be ver}' hopeful. 


PERIOSTITIS OF THE METATARSUS. 

In tho December i.ssuo of the Archives of Disease in Child- 
hood' Dr. Wilfred Attlee, a iiieinbcr of tbo Eton College 
Medical Board, writes on a rather puzzling condition of 
the foot to which he thinks the term periostitis of tbo 
metatarsus may best bo applied. Ho relates three cases, all 
in healthy schoolboys, aged 14, 15, and 17, and illustrates 
his reports with skiagrams. In all three cases tlio first 
complaint was of pain in tho dorsum of the foot, accom- 
panied by a little swelling and tenderness over the middle 
of tho metatarsal region. At this .stage skiagrams showed 
notbiii" abnormal except a faint shadow round tbo middle 
of the shaft of a metatarsal bone. The shadow was so 
faint that it was completely overlooked in one instance, at 
anv rate; it becamo more marked as time wont on, and 
after a month or so films showed a fracture with con- 
siderable callus. Tho fractures seem to have been spon- 
taneous. After another two or three months nothing more 
than a slight thickening of the bone was visible. The 
author offers no satisfactory cxiilanation of tbo cause of 
the initial periostitis. He states that these affections of 
tbo feet have been referred to by various authors as 
“ marching fractures,” “ acute motataisal overstrain,” 
and “ chronic oedema of tho feet.” It is, he says, true 
that hcalthv people have boon affected without definite 
cause, and that tho descriptions given convey tbo impres- 
sion that, ill spite of different titles, they all belong to the 
same condition in different stages. 


royal- SOCIETY FOULERTON RESEARCH 
PROFESSORSHIPS. 

In our advertisement pages will be found a notice regarding 
tho regulations drawn up by the President and Council 
of tlic° Royal Society for the appointment of Foulorton 
Research Professors, on the recomniondation of a special 
committee of Fellows. The full text of the regulations 
may bo obtained from the Secretary, at Burlington House, 
London W. A Foulorton professor will be required to 
conduct such original researches in medicine or the con- 
tributory sciences, on lines approved by the committee, as 
are calculated to promote the discovery of the causes of 
disease and tho relief of human suffering. In awarding 
professorships regard will bo had primarily to tho ability 
of the individual rather than to tho subject of his research, 
so long as the subject is one permitted by^ the regulations. 
They will be awarded only to candidates who liav'o shown 
outstanding ability for independent research. Except as 
provided below, a professor must devote his whole time to 
research, though he maj' give a limited course of instruction 
in the subject of his research to advanced students ; and 
any award will depend on suitable arrangeiiiciits being 
made for pursuing the research at a univer.sity or other 

1 Archives of Disease in Childhood. Issued bv the British ticdical 
Association. Yearly subscription (six numbers), 25s.; a Eiiiole number, 
43. 6d 




THE “POLICE JOURNAL." 


r The BfiiTisa 
\ Mssickx. Jonsii. 


67 


JAN. J 4 , 1928! 


approved place. The stipend of a professor, less deduc- 
tion for superannuation, will ho at least £1,400 per 
annum. In special cases a professorship may ho awarded 
to the holder of a paid academic or other scientific post 
if the' duties of that post occupy only a suhsidiary part of 
his time, and its retention would not interfero with tho 
discharge of tho-dutics of tho professorship as essentially 
a wholc-timo appointment. In such cases tho President 
and Council nmy order tho p.aj-mont of such stipend as they 
think fit, provided that tho total annual incomo from such 
paid post, together with tho stipend from tho Foulerton 
Ecscarch Fund, shall ho at least £1,400, less the contri- 
hution towards superannuation. Foulerton professorships 
will he awarded for five years, the appointment being 
renewahlo for further successive periods of five years at 
tho discretion of tho President and Council, except that 
when a professor is over 55 appointment or renewal will 
ho onl}' for tho period until ho attains the age of 60, though 
power is given to extend tho appointment after ho hecomes 
60 for a period not exceeding three years, and so ori 
from time to time. Power is given also in special cases 
to appoint a professor for a limited number of years 
ivithout the opportunity of renewal, hut tho level of ability 
here must not he lower than that demanded from other 
Eoyal Society professors, hlomhers of all nationalities 
and of cither sex are eligible, hut if a member of Council 
or of the Management Committee hecomes a candidate ho 
will, . fpio fneto, vacate that office. The President and 
Council may make grants to a professor towards the 
expenses incurred in his research whore these expenses 
cannot bo met from other sources. Applications (marked 
outside “ Foulerton Professorship ”) must reach the Royal 
Society hj’ May 1st next, and candidates should state their 
ago and the linos of research in which it is proposed to 
engage. 


THE “POLICE JOURNAL." 

A QUAKTEni,T review for tho police forces of the Empir« 
has just made its appearance under official patronage, 
entitled the Police Joxtmal. Tliis in no way resemhlci 
that lurid periodical of former days the Illustrated Polict 
Actes, with its crude pictures of plump ladies in ball dresse: 
lying among chanipagne bottles with their throats cut 01 
their heads battered in. The first issue contains fourteer 
original articles on various subjects, among which are threi 
of interest to medical men and biologists. Dr. John 
Glaister, ,who is lecturer on forensic medicine in tin 
University of Glasgow, contributes a well illustrated anc 
thorough essay on some results of medico-legal research in 
the examination of blood-stains and hairs. In this th« 
precipitin or serolo^cal test for blood is described, by whicl 
a skilled and experienced investigator can arrive at definiti 
conclusions as to tho origin of a minute and long-driec 
diop of blood. But it is only by skilled manipulatior 
and close attention to detail that trustworthy results car 
e secured, as here described. Most remarkable is the faci 
t at experimentally a blood-stain measuring one inch squan 
w ich was excised from the woollen vest of a suicide gav( 
a satisfactory reaction after tho lapse of fourteen and a hall 
jeais, and it is reported that a like result has been obtainec 
lom a mummy 4,000 years old. That part of the essai 
which treats of hairs is of great value. With the aid of th( 
esciiptions and photomicrographs here given and repro 
uce it s ould not be difficult to determine the zoologica 
species of the source of origin of any hair. Such t 
e ermination may obviously be of the first importance ir 
“ Toxicology and crime ” Sii 
1 lam I illcox gives a brief account of the history o: 
ciimina poisoning and of the scientific study and detec 
ion of po.sons a branch of science which is hardly s 
con ury o d,^ and dates from the discovery of Alarsli’s tes 
01 aisenic in 1836. This paper is illustrated 63 - notes 01 


some of the chief poisoning trials of the past hundred years. 
Wo regret to say that of the nine criminals mentioned 
three were medical men and one (Crippen) passed with tho 
public as a doctor. Latel 3 - tho lower branch of the law 
seems inclined to make a bid for pre-eminence in criminal 
poisoning — at least as far as detected cases go. A third 
most interesting article, although its appeal is to anthropo- 
logy rather than to medicine, is that on the Indian 
hereditary criminal, in which Mr. F. C. Daly describes 
some of the tribes or castes which in India live by crime, 
principally theft, either in the form of larcen 3 ' or of 
dacoity — that is, robbeiy b 3 ’ gangs of five or more persons. 
Mr. Dal 3 - has had charge of the Bengal Criminal Investi- 
gation Department, and he writes with a full knowledge 
of his subject. Some of these tribes are fairl 3 ' civilized,' 
but others are in the very lowest stage of barbarism. To 
read of “ a tribe called Juahgs, who when I know them in 
1896 were tho most primitive people I have ever en- 
countered,” reminds one of Kipling’s verses: 

“ A stone’s throw out on either hand 
From that well ordered road we tread. 

And all the world is wild and strange. 

For we have reached the Oldest Land 
Wherein the Powers of Darkness range.” 

For these people are not denizens of the jungles of Assam 
or the wilds of Northern Burma, but of Orissa, a State 
comparatively close to Calcutta. 


BUSH NURSING. 

The Victorian Bush Nursing Association is an admirable 
institution. Founded in 1910 by the Countess of Dudley, 
it renders assistance to patients in what are described 
as “ outback places ” in Victoria, Australia. Originally 
cottage centres with a nurse attached were opened in 
various districts, but in 1921 tho first hospital centre was 
founded at Sngarloaf Reservoir. In the report of the Asso- 
ciation for the 3 -ear ending June 30th, 1927, the opinion is 
■^expressed that these bush nursing hospitals will probably 
furnish tho solution to the problem of medical attendance 
in tho counti-y. Tho hospitals are “ private ” hospitals, 
owned and controlled b 3 ' the centres. They are available to 
all who need them at fixed rates, and as no rent is paid 
and no profit required the charges are ven- low. Their 
inmates are attended b 3 - their own doctors, and make their 
own arrangements with them. By concentrating the 
patients in one building the nurse is able to attend more 
casesj and no time is wasted in travelling. Tho council of 
tho Nursing Association is convinced that in time all the 
biisli nursing cottages will be converted into small hospitals. 
At present there are fifty-five centres, including nine 
hospitals, and the number of country ambulance centres is 
now nineteen. Drs. C. G. Shaw and B. M. Sutherland, 
members of the Victorian Branch of the British Medical 
Association, have seats on the council ; and the treasurer. 
Sir James Barrett, AI.D., shares with Dr. Edith Barreti; 
the secretarial duties. A short additional report published 
by the council gives an analysis by Dr. E. Marshall Allan, 
director of obstetric research in Melbourne Univei-sit 3 -, of 
tho obstetric work carried out from 1922 to the present 
year. It appears that 2,273 mothers have been attended 
.without a single death. IMoreover, the rate of stillbirths 
was only 12.75 per 1,000, and of deaths under one month 
only 5.27, as compared with average rates for the State of 
Victoria of 30 and 31. Tho average maternal mortalitv in 
Victoria is approximatel 3 - 5 per 1,000 deliveries. Dr. 
Allan, while admitting that this relative immimiti- from 
fatalities in the Victoria Bush Nursing Association cannot 
continue indefinitely, attributes it to efficient ante-iiatal 
supervision and medmal aid, the development of bush 
hospitals, and the excellent infant welfare training given 


OB JAN. 14 , 19 ^ 8 ] A HALF-FORGOTTEN WAR. 


to the nurses. Apparently the' only prohlom awaiting 
Eolutidn is tlio provision, in places at a distance from centres 
and with poor means of transport, of waiting accommoda- 
tion for expectant mothers and creche accommodation for 
their young children. In some States there is a Country 
Women’s Association which provides a rest homo with a 
matron in charge. 


■ ACTIVITY OF LOCAL ANAESTHETICS. 

Some interesting points concerning the activity of local 
anaesthetics have been raised in a recent communication 
hy Trevan and Boock.' These authors compared the 
minimum molecular concentrations, at different pH values, 
of various local anaesthetics which arc necessary to pro- 
duce anaesthesia in a rabbit’s cornea after ten minutes’ 
continuous instillation. The substances investigated 
ivere cocaine, novocain, stovaine, fi-eucaine, benzylbenzoyl- 
cegonine, and phenj’lethylbenzoyl-ccgonine. In every case 
it was found that, between pH. 5 and ;)H 8, the activity 
of the anaesthetic increased directly with the alkalinity of 
the solution in which it was dissolved. On the alkaline 
side of pH 8 the curves which illustrate their results tend | 
to flatten out. The authors also constructed titration 
cuiwes with a view to determining the amount of free 
base present at any given pH. It appears that the results 
obtained incline them to accept Gros’s hypothesis — namely, 
that the active constituent of a solution of cocaine is the 
base, not the basic ion or the undissociated salt. This 
view seems to be to some extent at variance with some 
of the current teaching on the subject. In conclusion the 
authors point out that, apart from the considerations to 
which they have applied themselves, it is clear that the 
activity of these substances when compared one with 
another depends upon other factors, of whicli an important 
one must be chemical structure. From the point of view 
of the synthetic chemist it is desirable to effect changes in 
the molecule which will increase the “ molecular anaesthetic 
power ” while at the same time not increasing the basic 
dissociation constant. This woi'k seems to bo of consider- 
able interest in view of the emploj’mont in evoiyday medical 
practice of substances such as borocaine. 


A HALF-FORGOTTEN WAR. 

It would be fairly safe to assume that there has been no war 
of any consequence during the last three or four hundred 
years in which a British subject has not taken some more 
or less active part. Certainly members of the medical pro- 
fession could irot be accused of shirking' their full share of 
adventures of this sort. The great war has so completely 
swamped all previous hostilities that we are apt to forget 
many of the smaller and less important campaigns of recent 
years, esiiecially those in which this country held only a 
watching brief. Surgeon Rear-Admiral C. M. Beadnell 
has helped to i-emind us of one of these almost forgotten 
wars by publishing his Itcminhccnccs of the Avicrican- 
Filipino TF<!r, 1S99,- a fracas which was so soon over- 
.shadowed by our oivn South Afi'ican war that veiy little 
attention was paid to it in this country. ' Admiral Beadnell 
tells how he, then junior surgeon in the' Powerful on the 
China Station, came, to be lent to the American army, 
which at the time was suffering from a shortage of medical 
officers. He certainly made the most of his opportiinities 
to observe what was going on around him and tlie conduct 
of the troops of both belligerents. While praising highly 
tlie spirit and discipline of the American soldiers, ho is 
generous in his appreciation of the fighting qualities of 
the Filipinos, who, though badly anned and without 
artillorj', nevertheless gave Uncle Sam a considerable 

- ^xpeTitncnlal Patholorjy, August, IS27, 

• Reiniuiscencfs of thr Avicrican-FUiphio ']Var, ISOO. Dv Surgeon Rear- 
Ailmiral C. JI. Beadnell, R.K., C.B., Reprinted from the Military 

Surgeon^ 1S27. . p . i a 


deal of trouble, before the rchollion was finally subdued.- 
Another eye-witness has related how, before leaving homo, 
the Yankee doughboy had been exhorted to i-emcmbor 
that the, Filipino was “Jiis little brown brother”; expo- 
I'ienco of the said brother’s prowess with the bolo prompted 
a very different sentiment, thus neatly expressed : 

" Ho may be a brother of Silos P. Taft 
But ho ainl no brother of mine.” 

The Filipinos took full advantage of the geography of 
their country, and displayed vci-j- considerable military skill 
in the construction of their defensive works. A number of 
these are illustrated in a remarkable series of photographs 
which the author himself managed to take. The magnitudo 
of tho operations maj- bo gauged by his statement that 
a hospital ship arrived at Manila from Now York with 
100 nurses and medical supplies for 250,000 patients. Tho 
greater part of this narrative will probably interest tho 
soldier more than tho medical reader, for it is a chronicle 
of purely military events,' b'lit some interesting information 
is given about tho tjqies of weapons and projectiles 
employed by both sides. Tho much greater freedom of 
movement- and opportunity for personal investigation 
accorded tho author by tho official pass with which ho was 
furnished by American H.Q. might very well bo envied by 
those who, in the world war, found their orb decidedly 
limited. Admiral Beadnell is to bo congratulated on 
keeping his valuable notes intact during twenty-five years 
of active service at sea — no moan feat. 


MARCELLIN BERTHELOT. 

Tun centenary of tho birth of Marcellin Borthclot, tho 
famous French chemist, was celebrated not long ago, and 
in a recent issue of La Chronique Midicale wo find some 
notes on his life, beginning with a paper by M. Georges 
Hartmann on tho sites of tho various houses in wliich 
Borthclot lived with his parents until his marriage at tho 
ago of 33. Borthelot, apparently, was under tho impres- 
sion that ho was born at the house of tho Lanterno, wliero 
Foulon and other suspected enemies of tho people were 
hanged during tho revolution. M. Hartmann shows that 
Bertholot’s birthplace was adjacent to this house. Dr. 
Cabanos describes some of tho achievements of Berthelot 
and some of tho traits of his character. He appears to 
have been distant in manner; his only intimate friend was 
Renan ; they met when young, and were both animated by 
a passion for -truth. Berthelot instructed Renan in natural 
science; Reiiai taught -Berchelot Hebrew. A week before 
his ^de'ath the scientist was engaged in translating, from 
Hebrew a book on alchemy which he had , received from 
Morocco. Berthelot graduated M.D. in 1865; but many 
years before this ho had become engaged in tho study of 
organic chemistry, and in 1860 a professorship in this 
subject was created for him. He occupied the ehair for the 
rest of his life. During the Franco-Prussian war he pre- 
sided over the scientific committee for national defence, 
controlled the manufacture of cannon and of dynamite, 
and incidentally studied tho possibilities of improving upon 
the old black gunpowder. As a result of those researches, 
a few years later smokeless, powder was invented, thus 
giving to French armament a superiority which lasted for 
several years. Berthelot was a man of varied culture, 
and would have shone as a philosopher, historian, or man 
of letters no less than as an experimental chemist. He 
retained a love for the classics, read Plato in tho original 
Greek, and took with him on his holidays well thumbed 
copies of Lucretius and Tacitus. IVhile advocating intel- 
lectual and social relations between Franco and Germany, 
iio. deprecated - close intimacy until both nations had 
renounced all claims to intellectual pre-eminence, and until 
Germany had ceased to proclaim the rights of force and 
nniiouest. 


Jan. t 4 , 1928 1 


RESULTS OF TEEATMBNT OF UTERINE CANCER. 


t TmjBsmrt fiP 
iiXEDicii. Jouxxii ^ ^ 


RESULTS OF TREATMENT OF UTERINR 
CANCER. 

A BErouT is publisliecl to-day by tbo ^Ministry of Health* 
supplcnionting tho important statistical report on cancer 
of tbo nterus, which was issued last summer and was con- 
sidered at some longtii in our i.ssuo of August 6th, 1G27 
(p. 228). Tlio main report, prepared by Dr. Janet E. 
Lanc-Claypon, was based on ,a survey of tho literature 
throughout tho world in an attempt to assess tho oper- 
ability of cancer of this organ and tho effect of modern 
treatment. Tlio supplement now published has boon drawn 
up by Dr. Lano-Claypon and iMr. W. McK. H. SIcCuIlagh 
with a view to comparing tho aggregate figures in tho 
report with those of English surgery. 

The records of over 1,000 patients admitted to the wards 
of tho Samaritan Free Hospital, London, during tho period 
1901 to 1926 were examined ; hut those attending from 
1921 to 1926 were not included in tho estimation of the 
results of treatment, fivo years not having elapsed since 
the 3 'oar of operation. The results in this respect are 
based on a total of 895 patients. A small number of 
applicants at tho out-patient department, who were not 
admitted to the wards owing to their obviously inoperable 
condition, have been omitted from the calculation, but it 
is thought that this docs not appreciably falsify the 
operabilitj’ figure. Radium troatraent had scarcely been 
introduced at the hospital by tho end of 1920, and so no 
comparison is attempted between tho numbers of iiationts 
dealt with in this way and tho corresponding ones in 
the former report. Cancer of tho cervix is considered 
separately from cancer of tho body of tho uterus. Out of 
tho total number of. 1,023 eases, in 207 there was cancer 
of the body of tho uterus, and in 816 cancer of the cervix. 
Microscopical reports wore not always available, but no 
case in which thero was any doubt of cancer was accepted 
for tho purpose of this analysis. 

Tho inquiry dealt primarily with operative treatment, 
and abdominal hysterectomy in particular. Other subjects 
considered include vaginal hj'storectomy, the fertility of 
the patients, duration of symptoms, the ago, and the state 
of the disease at tho time of operation. The main con- 
clusions are given as follows (at two places we have 
appended within brackets tho comparable figures in the 
previous report) : 

(1) Tlio “ operability ” — that is, the percentage of patients pre- 
senting themselves for treatment who are deemed operable — is 
practically the same as, although somewhat higher than, the 
average , operability as determined by the mass data from the 
literature. The percentage for cancer of the cervix is 52.8, and 
for cancer of tho body 78.8. [This compares with the mean 
operability figures in the previous report of 48.9 and 80.7.) 

' (2) The ** operative mortality ” — that is, the mortality arising 
as a direct result of the operation — is markedly lower for cancer 
of' the. cervix than that for the massed literature, being 8.6 as 
against 17.3. For cancer of tho body it is 11.9 on a much smaller 
sample, as against 6.4 for the literature. 

(3) The actual pioportiou of survivors in the Samaritan Free 
Hospital series after abdomiual hysterectomy may be given as 
43.8 per. cent, alive after five years, and 36.6 per cent, alive after 
ten years. , These figures are for cancer of the cervix only, , and 
the . peVeentage has been taken upon all patients operated upon, 
excluding, however, those wlb died from causes other than cancer 
within the given perio'd. For cancer of the body of the uterus 
the corresponding ■ proportions of survivors after operation are 
much -highcr-yfil.S per cent, (five years). No death occurred 
after five years in the ten years’ series. [In the massed literature 
the corresponding net figures for cancer of the cervix treated by 
abdominal hysterectomy were 37.6 per cent, alive after five years, 
and 34, per cent.- after ten j'ears. For cancer of the body the 
net, five years’ surVivar figure was 60.] 

(4) ' *111656 results could 'be greatly improved, in cervical cases 
probably nearly doubled, if 'patients would attend for treatment 
in the early stages of the disease. For tho present series, whicli 
corresponds closely with the figures of the literature, tho mean 
a leged duration of the symptoms before application is made is 
about SIX months in those considered still operable. By this 
time, or on . the average slightly later, roughly one-half of all 

become inoperable, whereas the lives of many 
o them could have been saved, as is shown above, by earlier 
operation. For cancer of the body the mean alleged duration cf 
le symptoms before application “or treatment is eighteen months. 

‘ Ministry of Health Eeport No. 47. H.M. Stationery Offlcc. Price 9d. net. 


(5) Youth docs not appear to be a disadvantage in cancer of 
the uterus as is frequently stated. For cancer of the cervix tho 
figures indicating operability are, in fact, higher than those for 
later years, as is also the proportion of survivors after operation. 
The figures have a similar trend for cancer of tlie body, but owing 
to the paucity of tho data are less reliable. 

The first point notice.able in these conclusions is th.at tho 
results of English siirgerj-, as represented bj’ the Samaritan 
Free Hospital, arc, if any-thing, slightly better than those 
indicated by tho analysis of the massed data of many 
countries. The operative mortality' is notably lower and is 
almost certainly one of tho causes of the higher survival 
rate at fivo years from operation. The strongest emphasis 
is laid in this supplementary report on the deplorable 
number of women who delay applying for treatment until 
in an inoperable state, and it is suggested that further 
efforts should bo made to discover and remove tho causes 
of this disastrous delay. 

Another interesting point raised is the possible associa. 
tion of cancer of the uterus with miscarriages. Tho 
■figures leave little room for doubt that the early termina- 
tion of pregnancy before the foetus is viable has a definite 
association w-ith the occurrence of cancer of the cervix. 
The data are, however, insufficient to establish whether the 
miscarriage or the fact of the pregnancy is more closely 
related to this sequel. Further evidence is required as to 
the duration of the pregnancy’ before the miscarriage and 
tho circumstances of tho labours before more definite con- 
clusions can be reached. Detailed obstetrical histories, 
together with notes of careful physical examinations of a 
large number of women, spread over a considerable number 
of years,' would be most valuable if they-could be obtained. 
I The knowledge desired w-ould relate to the state of a large 
number of consecutive non-cancerous cases, their obstet-- 
rical histories, the proportion of injured cervices, the 
damage resulting from unskilful midwifery, and the exist- 
ence of conditions which might have been prevented by 
ante-natal care. 

As Sir George Newman remarks in a prefatory note to 
this supplement, the interval between tho supposed initial 
factor and the final phase of cancer may be one of many 
years’ duration. It thus seems reasonable to suppose that 
abnormal conditions present during this period could bo 
identified, and either prevented by suitable treatment at 
childbirth or removed subsequently’ by’ appropriate meas- 
ures, thus avoiding or delaying the onset of cancer. Ho 
adds that the practicability of special investigations into 
this subject will receive further consideration. 

The importance of this supplementary report depends 
-not only on the information it contains, but on its ability 
to act as an incentive to further investigations. Sir 
George Newman regrets “ the apparent disinclination of 
English surgeons "in general to" publish records, of series of 
cases from which data could be published for analysis.” 
Something might be done to ov’erc'ome this disinclination 
by including in such official reports as this a more graphic 
presentation of the conclusions reached, which “ those who 
run may read ” without expending the large amount of 
time and energy entailed by careful study’ of the' whole. 
The stimulus is present but latent. 


SEYENTH CONGRESS OF THE FAR EASTERN - 
■ ASSOCIATION OF TROPICAL MEDICINE. , ' 

The seventh congress of the Far Eastern Association of 
Tropical Medicine was held at Calcutta, from December 
Sth to 11th, 1927, under the presidency of Major-General 
T: H. - Symons, . C.S.I.-, Director-General of the" Indian 
ifedical- Sei-vice.- .4. large number of delegates attended 
from many: -countries, and among the specially invited 
guests, were Sir MValtef Fletcher, Professor j. • ^Y. W: 
Stephens; Sir. Malcolm Watson, Professor T. Madsen 
(director of. the National Institute of Serotherapy at 
Copenhagen), Lieut.-Colonel S. P. James, l.M.S.(ret.), Dr. 
F. d’Herelle, Dr. K. Shiga, Dr. A. L. Hoops, and Dr. 
J. W.' Schavff of Singapore, and memhcis of the Puhlic 
Health Service .and Medical Research Besid of the United 
States. In-connexion with the congress ti souvenir booklet 
was issued containing, in some 350 page.s, authoritative 


70 Jan. 14 , 19 : 8 ] 


FAR EASTERN ASSOCIATION OF TROPIOAIi MEDICINE, 


[ Tin: Sninn 

UtOIOAL JOUBSAX. 


infonnation about the leading medical and administrative 
problems, a summai’y of Indian history, and chapters on 
indigenous systems of medicine, art, archaeology, racial 
ethnology, and Indian veather conditions. The subjects 
of discussion rvere arranged in six sections as follows. 
Section I included clinical medicine and surgery, ophthalmo- 
logy, dermatology, gynaccologj’ and pregnancy diseases, 
patliolog 3 -, mental hj’giene and psychiatry, radiologj’, and 
dentistrj’; Section II was concerned with State medicine 
and hygiene, and cliild welfare. A group of diseases 
comprising plague, cholera, dj’senterj’, sprue, intestinal 
infections, leprosy, and tuberculosis were considered by 
Section III, which also included bacteriologr’. Section IV 
attracted considerable attention in view of its dealing with 
malaria, kala-azar,. protozoology, tj’phus-like diseases and 
leptospirae, medical entomology, and hclmintholog}'. The 
fifth Section considered nutrition, the deficiency and 
endocrine diseases, immunolog)’, chemico-thorapcutics, 
rabies, and pharmacology; Section VI was restricted to 
veterinaiy conditions. Abstracts of papers were published 
in advance in tho programme of scientific sessions — a matter 
of great convenience to the delegates. 

Tho congress was opened by the Governor of Bengal, Sir 
Stanley Jackson. In his speech he surveyed the history 
of medicine in India from 1500 n.c., and referred to tho 
distinguished work in Calcutta bj- Major Ronald Ross and 
Sir Leonard Rogers. He emphasized tho practical im- 
portance of scientific research. in promoting public health, 
ns illustrated bj' the discoveries made in connexiou with 
kala-azar. 

Presidential Address. 

Major-General Symons, welcoming tho delegates, indi- 
cated how such scientific congresses had a special value 
in extending knowledge of disease and promoting public 
health measures. In the great subcontinent, of India, .with 
its many races, religions, and languages, serious difficulties 
■Ji'ere encountered in all attempted lines of advance in 
public health and sanitation. Nearly all medical relief was 
State aided, and financial restrictions were consequently 
common. Many of tlie inhabitants did not desire any 
improvement in the standard of living which they had in- 
herited, and, therefore, there was considerable obstruction 
to refoi-ms. The president described the work of combating 
epidemic diseases such ns plague, cholera, small-pox, and 
leprosy, and devoted special attention to the progress made 
in treating diseases of the eye. 

Work of the Sections. 

Malaria occupied a prominent place in the scientific 
progi-amme of the congress. "With Sir Walter Fletcher in 
the chair of Section IV, a paper on the future of malaria 
control in the Malay Peninsula was read bj- Lieut.-Colonel 
S. P. James of the Ministry of Health, who described tho 
proposals of the Malaria Commission of the League of 
Nations for dealing with this .affliction in South-east 
Europe. Dr. Scharff reported the results of mosquito 
control methods in rural Singapore, and the ensuing dis- 
cussion turned on the complex nature of the malaria 
problem, the necessity’ of further research, and the different 
methods of control which might bo emploj’ed in various 
areas. During the subsequent session the subject of the 
theory and practice of malaria control was introduced by 
Lieut.-Colonel C. A. Gill, I.M.S., and Colonel Katsuno 
reported on tbe prevalence and control of malaria in 
Japan. The Section of Medicine held discussions on tho 
importance of mixed infections in tho tropics and on 
disseminated sclerosis in India ; Lieut.-Colonel C. A. 
Sprawson, who ojicned the second of these, encountered 
opposition to his statement that this disease was rare in 
Indians. In the vSection of Deficiency Diseases papers on 
epidemic dropsy bj- Lieut.-Colonel Megaw, and on beri-beri 
by Lieut.-Colonel MoCarrison, led to a keen discussion, 
an outstanding question being whether the conditions were 
the same disease or different degrees of one wide disease 
group. Another point contested was whether the cause of 
tbe disease grouir was a vitamin deficiency or due to a 
toxin derived from grain, or whether both factors were 
concerried. Colonel Megaw maintained that insufficient 
j attention had been paid to the way in which food was 
stored. The effect of storage on the nutritive qualities 


of rice was dealt with by Dr. Kessler, and methods of 
standardizing rice were considered by Colonel Vedder. 
Colonel McCarrison, in a paper on goitre, defined throe 
groups, depending respectively on lack of iodine, infection, 
and unbalanced diet. In the Cholera Section Lieut.-Colonel 
Russell, Director of Public Health, Madras Presidency, 
gave a synopsis of tho statistical work in connexion with 
this disease, and criticized the conclusions of Sir, Leonard 
Rogers as to absolute humidity being tho key to tho 
cholera problem. Ho thought that no one climatic con- 
dition could bo thus incriminated, but a combination of 
high temperature with high himiidity and intermittent 
rains faimurcd tho outbreak of epidemic cholera. Lieut.- 
Colonel Russell ..also criticized . as impracticable the mass 
inoculation of pilgrims before their attendance at religious 
festivals. Tho Section of Dysentery was presided over by 
Dr. IC. Shiga, and tho subjects dealt with included tho 
dysenteries of Bengal, sprue, and tho bacteriophage, on 
tho last of which a paper was read by Dr. D’HEninJ.E. 
Professor Nikanorov of Saratov read a paper on plague 
in South-east Russia, which indicated the notable differ- 
ences between tho epidemiology of this infection in that 
country and in India, both as regards the rodents con- 
cerned and the flea carriers. Ophthalmic conditions con- 
sidered included glaucoma — which is very common in 

Bengal ocular tension, and the ocular complications in 

leprosy. Among the other subjects dealt with in various 
Sections wore: vaccination against cholera, the medical 
inspection of Indian school children, tho value of salvarsan, 
the use of gold salts in tuberculosis, enteric infections, and 
diabetes in the East. Sir Jag.adis Chunher Bose demon- 
strated tho influence of drugs on plant life. 


ncalth Pcscarch in India. 

At the concluding session of tho congress Sir Muhamad 
Hadidolla, .a member of the Viceroy’s exccutiye council, 
announced that tho Government had decidwl to -appoint 
a committee to consider the establishment in “ 

central institute for medical research woik. Sir Valter 
Fletcher would preside over tins committee, which lyould 
include Colonel James of the Ministry of Health, Dr. Row 
and Colonel Christopher. Sir Malcolm V atson has been 
invited to give export advice on tho problems of malaiia 
control in^the United Provinces, Punjab, Central Pro- 
rtnees and Bnnna. An appeal has been issued in India 
for increased financial support for the Ross Institute. 

Congress Excursions. 

After the conclusion of the proceedings at C.aleutta the 
delegates visited different parts of India. One party 
travelled through Northern India, i^siting Benaies 
Lucknow, Delhi, Kasauh, Lahore, and Bombay; another 
excursion included Madras and Cconoor. Those who 
trai-elled to Bihar and Orissa visited the ancient religious 
centre of Bodbgaya, the various medical institutions of 
Patna, and tho Radium Institute and mental hospitals at 

T> r.z 


royal MEDICAL BENEVOLENT FUND. 

At the last meeting of the committee forty-tlUee cases were 
considered and £559 voted to thirty-six applicants. The 
following are notes on some of the cases relieved. 

Dauehler. aged 61, of H.R.C.S. who died in 1S95. She is now very deaf 
00,1 llSr lost the sight of one eye. She looks after an elder sister who is 

iSintX dckient lad also takes lO"- 

“ WWow ^a“d“37^°of ‘talltaP. and S." who died "in 1925. Left with six 
ehUdrenL-^lo 18 years of age. Since her hnshand died they have been 
liiloit on the nrocMds of tho sale of the practice, which is now exhausted. 
I'RIF- f". Receives a month from another charity for 


Eldest ffirl 
and case to be 


one*chUd* anSTTs'^a (garter from the Freemasons for another, 
is a tj'pist at 2 ^s a^week. Rent 12s. a week. £10 voted an 

Binffle^*^a^ed 68, who practised in London and abroad and then 
took n'homo for “delicate children, which unfortunately failed. She haa 
an adopted ^lild aped 14. Voted £26, to be paid in quarterly instalments, 
MHUS aeed 72. Through age and inability to obtain locumtenencjes 
and'exhaukion of savings, applied to the Fund for as-sistance. Has Epsom 
Colle«'e pension of £30 and old age pension. Voted £30. Total previous 
reliei given £100. 

Daughter, aged 54, of L.R.C.P. who died in 1883. She lias no income, but 
lootcs after her mother, aged 87, whose income is derived from the old age 
pension, the E.SI.B. Fund annuity of £30, with a supplementarj’ grant ol 
7s. 6d. a week from the Guild. Voted £18. 

Subscriptions may be sent to the Honorary Treasurer, Sii 
Charters Symonds, at 11, Chandos Street, Cavendish Sqaare, 

W.l, 




72 Jan. 14, 1928] 


IllEtiAND, 


t Tnr.tlnmsH 
ilxrzcu. 




IrISU C’oStJIITTEE OF THE BltlTIsn MeDICAE AsHOOIATION. 
At tlio last meeting of the Irish Committee of the British 
’Medical Association the following members were present: 
Dr. John Mills (cimirman), Dr. T. B. CosteOo, Sir James 
Craig, Drs. Pierce Grace, W. AV. Murphy, J. P. Shanley, 
A. B. Stepheiison, and H. T. AVarnock, Sir AA'illiam 
AA’heeler, a 2 id the Irish IMedieal Seci'Ctaiy (Dr, T. 
Hennessy). Apologies were received from Drs. J. Ai’m- 
strong, T. Bennett, R. C. Pcacocke, and J. Power, and 
Mr. C. J. A. A^'^oodside. Votes of condolence wei'e passed 
to Mrs. Darling and Dr. Alfred Cox on their recent 
hereavomeiits. The draft of a circular letter for the 
recruitment of members in the Irish Pree State was con- 
sidered and approved. Tho different mattere ou the agenda 
of the Irish Medical Committee were discussed at some 
length, aiid suggestions were made to those niembers of 
the Irish Committee of the D.^I.A. who are also members 
of the Irish Medical Committee, for their guidance in 
regard to the decisions that might he taken at the 
subsequent meeting of the latter body. 

InisH IMedicai. Committee. 

At tho meeting of the Irish Medical Committee, held in 
the Roj'al College of Surgeons, Dublin, ou December 21st, 
1927, with Dr. R..J. Rowlette in tho chair. Dr. E. T. King 
was appointed to fill the vacancy upon tho Complaints Com- 
mittee caused by the resignation of Dr. P. Grogan. A letter 
was read from tho National Health Commission stating 
that serious anomalies had arisen in tho remuneration for 
certification in the areas included in tlie counties numbered 
(13) to .(39), and attributing these anomalies to tho 
adoption, of the dispensary district as tlje area unit for 
payment in those counties. In connexion with the Com- 
mission’s proposal to change the unit area from tho dis- 
pensary district to the county, Dr. Power (chairman of 
the Free State Irish Medical Committee) wrote protesting 
against the change, and stating that enlai-gqd areas with 
ineffective supervision and a larger poo! xreve not calcu- 
lated to secure efficient certification. Dr. Elliott also wrote 
that the dispensary unit had given satisfaction and should 
not bo changed. After a long discussion it was resolved 
that a deputation should irait upon the National Health 
Commission to request that the committee be supplied with 
further particidars Avhieh, when received, should he for- 
warded to the local medical committees in the areas 
affected for their consideration before arriving at a filial 
decision. An amendment that the Commission’s arrange- 
ment be accepted was not seconded. It was decided to ask 
the Minister for Local Government and Public Health to 
receive a deputation in connexion with (1) the inadequate 
salaries of Poor Law medical officers in Mayo, Longford 
and elsewhere; (2) appointment of locuratenents nominated 
by doctors going on leave ; (3) promotion under tho 
Local Authorities (Officers and Employees) Act, 1926- 
(4) i-einuneration for registrars of births, deaths, and 
marriages; (5) fees for committal of dangerous lunatics- 
(6) arrangements for the treatment of private jiatients in 
district and county hospitals. In regard to medical 
appointments under the Local Authorities Act, it was 
resolved to make representations to tho Appointments Com- 
missioners as follows: (1) That a recurring fee of £1 for 
medical candidates appearing before different selection 
boards is excessive ; (2) that candidates .with no jn-ospect of 
being appointed should not be put to the expense of appear- 
ing before the selection boards unless on the expressed 
desire of the candidates; (3) that the physical examination 
appears unnecessarily severe, and that . it should have a 
direct relation to the physical 'requirements necessary for 
the efficient medical discharge of the duties of the office to 
he filled; (4) that, if required, medical members of selection 
boards slioidd receive reasonable remuneration. In regard 
to the status of medical officers in the Free State Army, 
the committee placed on record its opinion that these 
officers should be on a permaueiit and pensionable basis. 
A discussion on the School Attendance Act led to a resolu- 
tion e.xpr(^ing the view that as this Act provides no 


remuneration for the medical certification of school children 
treated under the Medical Charities Acts, no certificates 
should he issued in these cases with tho exception of 
children hoarded out by the health hoards; and that in 
anj- event tho minimal roinuneration should bo 2s. 6d, for 
each certificate. As a result of a representation from the 
Limerick Borough JModical Committeo with regard to 
medicines in certain contract practices, the com- 
inittco passed a resolution expressing strong disapproval 
of tho practice of requiring doctors holding society and 
Goveriimciit ajijioiiitmaiits to .supply medicine under the 
terms of such appointments in districts where a supply 
could he had reason.ahly from a local chemist, and recom- 
mending that steps ho taken to alter tho conditions of 
such appointments where necessary to conform with tliis 
resolution. 


The Cancer Cajipaicn. 


A raoeting of medical practitioners wa.s held on January 
5th in tho Medical Institute, Belfast, under the auspices of 
the Ulster Medical Society and of tho Ulster Branch of the 
British Medical Association, to consider tho formation 
of a Northern Ireland branch of the National Cancer 
Campaign. Dr. Rankin, jucsidciit of the Ulster Medical 
Society, occupied the chair, and among those present 
were the Marquess of Dufferlii and Ava, president of the 
National Cancer Campaign in Ireland and chairman of 
the board of management of the Royal A’ictoria Hospital; 
the A'ico-Cbanccllor of tbe Queen’s University, and otlicrs. 
Mr. Soton Pringle (Dublin) explained the objects of tho 
cancer campaign. 

The following resolution, proposed by Dr. AA’illiam 
Porter (Portrusli), president of tlio Ulster llranch, B.M.A., 
seconded by Professor A. Fullerton, P.'R.C.S.I., was 
adopted : 

That tlio National Cancer Campaign is worthy of support, 
and that a Northern Ireland hrancli should be established for 
the purposes of informing the public ns to what is already 
known about cancer, and of raising funds fo assist in furflier 
investigation of tho problems still unsolved. 

A further resolution was adopted on the proposal of 
Professor R. J. Johnstone, hl.P., seconded by Mr. J. Brian 
Moore, F.R.C.S.I., chairman of staff, Mater Infirmorura 
Hospital ; 

That this, meeting is of opinion lliat tho plan of the National 
Cancer Carhpaipn is tlio most siiilabtc tliat can be adopted, and 
is that most likely to lead to further progress, as under its 
present scheme those hospitals and laboratories which are 
already engaged in tho treatment and investigation of cases of 
cancer iviri be assi.sted and cncooraged to pursue their 
activities under a central direction, so that Iiilt use will he 
made of the BCrviccs of their stalls of trained research workers, 
and of surgical, radiological, and biochemical exports. 


The concluding resolution was as follows, the proposer 
being Mr. A. B. Mitchell, chairman of staff. Royal A’ictoria 
Hospital, and the seconder Dr. Leonard Kidd (Ennis- 
killen) : 

That- this meeting agrees- with the decision of the Naiional 
Cancer Campaign that it is not expedient to establish new 
special hospitals for the treatment and inv^tigalion of cancer 
and that the results hoped for arc more likely to be attained 
by development of the institutions already established. 

A committee was appointed to take steps for the forma- 
tion of a Northern Ireland branch. 


(^jT^Iantr Wiaks, 

Leeds Senoon of DEXTisTirr. 

The new buildings of the Leeds Dental Hospital and 
School of Dentistry are approaching completion and will 
be formally opened by the Speaker of tbe House of 
Commons in the early spring. In the opening of these new 
and handsome buildings a hope long entertained will come 
to fruition. For many years before it took definite shape 
the formation of a school of dentisti-y was ’an aspiration in 
the minds of many of the dentists of Leeds, and met with 
warm symjmthy from the members of the medical board of 
the school of medicine, among whom should be specially 
mentioned the'nanie of Air. Seattergood, who for so many 
years acted as the dean of the faculty of medicine. It was 
not, however, till twenty-one years ago that the members 
of the Leeds and district section of the British Dental 



Jan, 14, 1928] 


1 - 

ENGIiAND AND WALES. 


[ Tirr Dhttish 
Uedicii. Jocbnak 


Associ.ntion decidotl to start a (V-ntal liospltal for ilio 
tro.-itmont of patipiits wlio coulil not nfford to pay fees 
and f()r the practieal training of dental stinicnts. 

Inispilat rvas ccinippod tlirongli the generosity^ of those 
dental snrgeons and their friends, and was carried on for 
some years in the l’id)Iic Dispensary, in rooms specially 
provided for the purpose in the new huilding just at that 
time being occupied; hut as its work grew, and as the 
demands on the accommodation of the dis])cnsary increased, 
it became necessary to find new promises. This w.as inado 
possible by the generosity of two other pxddic bodies — the 
authorities of the General Infirmary, who made room for 
part of tho work, and the*' board of guardians, who pro- 
vided accommodation in tho East Leeds Infirinaiy for tho 
rest of it. A few years later this latter portion of the 
work was transferred also to the General Infirmary, in 
which , tho whole of the activities of tho dental hospital 
and school have since been carried on. With tho expan- 
sion of the hospital tho training of dental students has also 
increased in volume and importance, and tho institution 
now forms a combined dental hospital and school, which is 
of great value to tho county and compares favourably in 
the quality of its work with similar institutions in other 
places. There are now 53 students undergoing training in 
tho school, and during last year 9,210 patients received 
treatment, entailing 28,350 visits. At an early stage tho 
Dental Committee in charge of tho hospital camo to an 
arrangement with the Univei'sity authorities by which 
students could read for a degree or a diploma in dental 
surgei’y by combining courses in tho University with their 
practical work in the hospital. In 1914 this arrangement 
was developed into a scheme of amalgamation, by which 
the dental school became a department of tho University 
within the faculty of medicine. Tho University now takes 
uni responsibility for the whole of the educational work of 
the school, while tho hospital work forms a department of 
the General Infirmary, • 

For some time it lias boon clear that now promises would 
again have to ho provided for this progressive institution, 
especially as the rooms now used by it in tho Infinnary were 
only lent temporarily and are required for other purposes, 
luloed, it was seen that without new accommodation tho 
invaluable work of the school and hospital would have to 
)o giicn Up. A building for this department had thcre- 
amongst the urgent needs in respect 
1 " orni o ^ University was compelled to issue its appeal 
for ^500, m A site, valued at about £8,000, has been 
provulcd bj- the General Infirmary authorities, tho Dental 
eo'nnri ^ United Kingdom has promised a grant of 
I. ’ll- on tho balance of tho cost of the 

obtained from other sources, tho honorary 
stalf of the dental school have subscribed £2,000, and a 
..( 1 . of contributions have been received from 

'’O'gcoiis. It is hoped that old students of 
- c 100 , together with other dentists in Yorkshire, will 
hell) in providing the balance of tho funds required. 

190 '^ 1 . 1 provide accomniodation foi 

inpfiinnr ^ ni^oupios a site adjacent to the 

sitmtorl^f Uonoral Iiifirniary, and conveniently 
adiacent to +l*° That the Dental Hospital is 

convenio. n'l will not only bo a matter ol 

of merbVi'i'^^’ ' ^ip fact that dentistry is a pari 

The bi I r*’ ^’pifiS Uiat term in its wide and proper sense, 
the walk p'^i '« fireproof construction tliroughout, ant] 
the most ‘ o to, bo finished in accordance with 

imnortant fioU '' practice. Having regard to tin 

with the Tiro' research into problems conncctetl 

made f^ "f , dental caries, provision is bein^ 

such research no Ur facilitation ol 
to tho need f’nv ' i attention has also been pait 

eoiiiniinrl' i.iri., 4 u 1 dentistrv, and a large and wel 
main features oTtt new bui^;"^ 

iiiebvlofl (■...■ *1 i . " ‘luilding. Special rooms are beint 

SSs' “f- 1 " 

warde.pt 1^“". 

rooms lectiiv ’ • •ihd museum, students’ commoi 

I 0 room, and histo-patbological laboratories 


A hospital-type lift is provided for stretcher cases from 
the ground to the first floor. Here are situated the 
waiting hall for patients, pupils’ laboratory (to acconimo- 
dalo 75 pupils), together with plaster room and stoi'e, 
dental ■ iiieehaiiics’ workroom and store, prosthetics room, 
children's- room, and gas roorn (operating theatre) with 
dressing and recovery rooms. An x-ray room with adjacent 
dark robin is also provided on this floor. The whole of the 
second floor, with the exception of a small workroom for 
students, a iinrses’ room, and stores,' is to he used as a 
conservation room with 72 dental chairs. Provision is also 
made for a model dental surgery on this floor for the use 
of senior .students. In tho basement are situated the 
heating cliamhor, fuel stores, staff incss room, and general 
stores. 

St. Mauy’s HosptTAi. Extensions. 

Over .£40,000 has already been .raised towards the 
£60,000 which the present extension of St. Alary’s Hospital, 
London, is expected to require. It is hoped that the two 
new operating theatres and the sixty additional beds will 
ho ready' for iiso by July; u certain number of the beds 
will ho reserved for cases of accident and sudden 
emergency. A ball is to he held at the Alay Fair Hotel, on 
•lannary 18th, in aid of the fund, and Prince and Princess 
Arthur of Connaught have expressed their intention of 
being present. Speaking at a meeting of tho Ladies’ 
Association of tho hospital on Jannai-y 5th, Lard Eustace 
Percy commented on the fact that the hospital last year 
had been obliged to refuse no fewer than 1,000 patients 
requiring in-patient treatment. He hoped that the asso- 
ciation, which had raised .£1,200 for the hospital in 1927, 
•would ho equally successful on the present occasion. 
Madame Adeline Geneo referred to the recent phenomenon 
of streets covered with ice, and said that on one day 
St. Mary’s Hospital had dc.alt with 184 accident cases, of' 
which fifty were broken wrists, and had used ten gallons 
of liniment. 

I Eoyai. Institute op Public He.ilth. 

j Under the ■ auspices of tho Eoyal Institute of Public 
Health a series of lectures on problems of forensic medicine 
will bo delivered at 37, Russell Square, W.C.l, on Wednes- 
day afternoons, at 4.30, from January IBtli to March 
14th inclusive. The course will be opened by Air. Roland 
Burrows, Recorder of Cliiclicster, who will lecture on the 
subject of the medical practitioner in relation to the 
administration of justice. Dr. Godfrey Caiter in the 
following week will deal with tests for drunkenness, with 
particular relation to motor accidents, and on February 
1st Dr, Nathan Raw will discuss m^ieo-legal problems 
associated with lunacy. The subsequent , subjects are: 
problems of forensic psychiatiy, by Dr. Norwood' East; 
mcdico-logal problems of Jewish life, by , Dr. AY. M. 
Feldman ; some aspects of legal live birth, by Professor 
Whitley' AlacFall ; the present legal position as regards 
the treatment of tho insane and the mentally defective, 
which will 1)0 discussed by Sir Robert Armstrong- Jones ; 
problems in medico-legal practice, by' Dr. 6. Roche Lynch; 
and bacteriology in its connexion- with forensic medicine, 
by Dr. Robert Donaldson. These lectures are free to 
members of the medical and legal professions. 

Pkeservatives in Food. 

The Alinister of Health has issued a reminder (Circular 
852) to local authorities that a further stage in the Public 
Health (Preservatives, etc., in Food) Regulations came into 
operation on January' 1st relating to butter, cream, and 
articles of food- containing preservative necessarily intro'- 
duced by the use of preserved bacon, ham, egg yolk, or 
cream in their pre])aratioD. Since it may not have been 
practicable for all stocks of preserved butter to he disposed 
of before the bogiiiiiing of 1928, the Alinister suggests that 
in the case of butter tho council might refrain, during' the 
first few weeks of the year, from instituting legal pro^ 
ceedings in any case where they are satisfied that reason- 
able efforts have been made to clear old stocks, and that 
future consignments will conform with the regulations.. 
Previous roferences to the regulations dealing with pre- 
servatives in food appeared in oiir issues of -August 22nd, 
1925 (p. 349), January' 8tli, 1927 (p. 70), and April 25rd, 
1927 (p. 782). 


74 Jan. 14, 1928] 




FATALITY RATES OF SMALL-POX IX THE 
VACCINATED AND TIN VACCINATED. 

Sin, — ^It is an almost universal medical belief (and I 
share this belief) tliat the fatality rate among persons 
attacked by .small-pox is much greater, age for ago, among 
the unvaccinated than among the vaccinated. 

An interesting contradiction is furnished in the small- 
pox statistics of England and Wales for the four years 
1923-26. The following table furnishes the numbers of 
cases of “ .small-pdx ” in vaceimitcd and unvaccinated 
persons over 15 years of age, together with the numbers of 
deaths and the fatality rates per cent., for each of these 
years and for the whole period. Tlie comparison is con- 
fined to age 15 and over for the simple reason that 
practically all the cases under 15 are among the un- 
vaccinated. 


Year. 

Vaccinateti. 

Unvaccinated. 

, Cases Over 
15 Y’enrs. 

Deaths. 

Case 

ilortnliti’ 
per cent. 

Cases Over 
15 Y'eai's. 

1 

Deaths. 

1 Case 
[ Mortality 
' per cent. 

1923 

369 

2 


1 

734 

2 

1 

OJ 

1924 

635 

2 


. 1,241 

- 

- 

1925 

933 

3 

0.3 I 

1,824 

_ 

- 

1926 

2.073 

6 

0.3 

'3.116 

2 

0.06 

Total? 

4.010 

13 

t 

0.3 

6.915 


0.03 


* lucluding cases “doubtful " as to vaccinatiou state. 


It will be observed that in each year the fatality rate 
was greater among the vaccinated than among the un- 
vaccinated. In a total for these years of 11,019 cases, 
4,010 occurred among the vaccinated, with 13 deaths — a 
fatality rate of 0.3 per cent. — and 6,915 occurred among 
tiio unvaccinated with 4 deaths — a fatality rate of 0.06 i)or 
cent. That is to say, the fatality rate among vaccinated 
cases was Just five times as great as among unvaccinated 
cases. 

It would be interesting to read iiossible explanations of 
this statistical anomaly which your readers may have to 
offer. Clearly some explanation is required, and I suggest 
that, in Justice to vaccination, these figures call urgently 
feu’ ; 

1. A special inquiry into the true cause of death of 
all fatal cases of “ mild small-pox ” in this country. 

2. Revision of the rules of death registration under 
which a dcatli certified by the doctor in attendance 
as due to chronic nephritis, cerebral haemorrhage, or 

. other disease 01 condition unconnected with small-po.x, 
is registered and entered in the vital statistics as a 
death from small-pox. 

A’ofc. — The figures quoted are from the annual reports of the 
Chief Medical Officer, Ministrj’ of Health, 1923 (p. 37), 1924 (p. 37), 
1925 (p. 38), 1926 (p. 39). 

— I am, etc., 

Chesteitleld, Jan. 4th. F. P, G.VEROW. 


GAS GANGRENE FOLLOAVING STREET 
ACCIDENTS. 

Silt, 1 have read with interest the reports of two cases 

of gas gangrene following motor accidents, by Drs. Marshall 
and Ellis, in your issue of December 24th. 1927 (pp. 1183 
and 1184). It is to be. regretted that both these articles 
convoy the impression that gas gangrene i.s very rare in 
civil practice, whereas it is not at all iincomraon. 

Indeed, in two of the hospitals with which I am con- 
nected the house-snrgeons and casualty officers have been 
told to give prophylactic injections of ‘‘ anti-gas ” scrum 
at- the same time as the antitetanie in all rases of street 
accidents with badly lacerated wounds and cnished tissues. 
During the past year I have had to perform three amputa- 
tions and several le.ssei* local operations for such infections. 


t TnElinms* 
UeOICAZ. JOVSKAS, 


Two ijoints of speciar interest are to bo noted, uith 
regard particularly to infections with 11. xvelchii: certain 
districts and roads a])[)car to be imicb more heavily in- 
fected than otber.s (this corrcsjmnds to war-time experience, 
when wounds .sustained in certain very limited districts 
di.splaj-cd a big incidence of gas gangrene, while tbo.se from 
areas two or three bhndrod yards away wore practically 
free); bacteriological inve.stigation of a scries of .street 
accident wounds will reveal the organism in a laige per- 
centage of cases, but in only comparatively few of these aro 
there any of the clinical signs of infection. A latent 
infection of this kind may suddenly “ light up ” after an 
interval of many days if the ibeal resistance bo lowered 
by thrombosis or ligation of the main arterial su|)])ly. 

It is a mistake, frequently committed, to attempt tlie 
early closure of wounds of tin's H-pe; tiiey should be left 
open, perhaps with continuous irrigation, after careful 
excision of all foreign material and dead or damaged tissue. 
Anti-gas scrum, especially the jioKwalont form which 
jirovcd useful during the war, must bo given in fairly large 
doses, both for prophylaxis and treatment . — I am, etc., 

London, 4V., Jim, 3rd. NoRSI.VX C. L.VKL. 


TREATMENT OF PHOSTATIC ENLrVRGEMENT. 

Sill, — I should like to rojily to the several criticisms of 
my previous letter. 

Mr. Lccming might, in all fairness, have quoted the 
statement in my letter correctlj-, as it was not my own but 
taken from tlio Bradshaw Leetnro by Sir Cnthbcrt AVallacc. 
Mr. Hey Groves’s figures did not refer to London hospitals, 
but to “ all the available largo hospitals in tlie kingdom.” 
Sir Cutbbert M’allaco gives figures from' four London hos- 
pitals, and spates that ” the mortality of pro.statcctomy has 
fallen from 20.2 to 14.5 per cent., but that the total ojiora- 
tivo mortality has somewhat lisen.” The figures given by 
Mr. Leoming — of 3 per cent. — and tlioso given by “ Pro- 
vincial Surgeon” of iiU per cent., arc tliose to which all 
surgeons nsiiire, and merely show that the mortality rate of 
nianv other surgeons must be much higher than one had 
imagined if the average mortality is 14.5, taking Sir 
Cuthbert AVollace’s figures, and not considering Mr. Hey 
Groves’s collective one of 40 per cent. 

Mv intontioii was merely to ])oint out that the mortality 
rates quoted in the Bradshaw Lecture are still too high and 
tiiat the chief hojie for improving them was by encouraging 

and not discouraging— specialization in urology. I claim 

no originalitv for this suggestion, asf I find on referring to 
the acco|)tcd translation of the Hippocratic oath tiio follow- 
iiu' sentence, “ I "'*11 "“t cut a person ivlio is suffering 
from stone, but will leave this to he done by practitioners of 
this ivork.’’ This is tlie fir.st mention of specialization in 
the iiistory of medicine— and it is only surprising that so 
few of our large general hospitals have up to the present 
Inutitiitcd snecial urological departments, such as flourish 
iu America iad on the Contiuent.-I am, etc., 

T. C.iREY Evans. 

London, W., Jnn. 5tU. 

TETRA-ETHYL LE.AD. 

gjj^ “Medical Notes in Parliament,” iu the Journal 

of December 3rd, 1927 (p. 1059), included the following 
passage : 

“ One firm in this country has commenced blending telra-cthyl 
lead with petrol on a commercial scale. The Factorj- Department 
of the Home Office is satisfied that adequate precautions aro 
being taken for protecting workers concerned iu the process." 

Following this comes a series of announcements in the 
public press of a special motor spirit well known to 
motorists on the other side of the Atlantic tor its re])nted 
“ anti-knock ” qualities under the terra “ ethyl gasoline.” 

This heralding of a substance with the object of pro- 
moting its common use among a very large section of 
the population raises important and urgent issues a.s to 
its dangers, reputed or real, l)y reason of the ])resonce of 
tetra-ethyl lead in the spirit, to which its principal “ anti- 
knock ” Virtues are due. 

- Reference to this subject has already been- made by you 


CORRESPONDENCE, 


















Jan. 14, 19=31 


COKEESPONDENCE. 


[ T0* BsmsH 
Mkdicil. Jodsxac. 


76 


ill the JouuK.ii. (Fchniaiy 7th, 1925, p. 273) 111 an annota- 
tion entitled “ A new motor danger.” Referenee was 
a-^^lii made in .the JociiN.u. (March 6th, 1926, p. 442) 
to totra-cthyl lead, in whicli emphasis was laid upon tho 
particularly dangerous character of lead by reason of its 
capacity to produce ciiiiuilativo effects, and thereby tho 
very extensive and irreparablo damage which might be 
produced before the fust symptoms of poisoning appeared. 

Switzerland took tho lead in 1925, and boldly forbade tho 
use of motor spirit contaiiiing any compound of lead 
(Ordiiiauco dated April 7th, 1925). In America its use 
is permitted subject to rogiilatioiis which provide for tho 
giving of notice to tho purchasing public and to garages 
that it is a iioison, and must bo handled with appropriate 
precaution; this despite the reports made by the following 
observers: (A) Robert A. Kchoo, oil tetra-cthyl load poison- 
ing Clinical analysis of non-fatal eases.”* (B) Cliarlcs 
Norris and Alexander ■ 0. Qottlcr ■ on poisoning by 
tctra-ethyl lead: " Post-mortem and clic'mical findings.” = 
(C) Frederick Flinn: “ Some of tho potential public health 
hazards from the' use of ethyl' gasoline.” = Report B 
is an independent official record. Tho investigations ami 
findings embodied in Reports A and C were made at 
tho instance of tho manufaeliircrs themselves, who, in 
short, convict “ ethyl gasoline ” out of their own mouths 
whilst giving tho clearest evidcnco of tho grave dangers 
to all individuals concorned who may use this material — 
namely, motorists and workers in garages. 

There are two aspects of this matter to which reforcnco, 
curiously enough, has been omitted by all observers: the 
toxic influence of lead n]ion the gonads in both .sexes, and 
the possibility of criminal misiiso of this material. A third 
point for consideration is tho character of the deposit in 
tlio e.xhaiist system following tho use of totra-ethyl lead 
in conjunction with organic halides, which must give rise 
to the formation of lead halides in tho engino and in tho 
exhaust system. These lead halides (chloride, bromide), 
being comparatively soluble, arc obviously toxic. 

Legislation and regulation upon this subject arc urgently 
called for, to govern not oidy tho concentration of tetra- 
ethyl lead in petrol, but also its distribution. The public 
should be instructed and warned in tho handling of this 
material as in tho case of all other poisonous substances. 
The potential users of this toxic pi'oduct number over a 
.million adult. persons, the thousands of employees in garages 
being specially exposed to danger by continuous handling. 
— I am, etc., 

Hendon. N.W., Jan. 3rd. Myer CopL-AXS. 

V Further - references to this subject will bo found at 
pages 61 and 64 this Aveck. 


' o TREATJIENT of cancer by RADIU3I. 

V yttm’ in your issue of December 17th, 192 

tp. 1 63), raised a definito question — namely, the siiccifi 
gioun s on M Inch Dr. Fletcher Shaw bases his criticism e 
lum m tho treatment of carcinoma of tho cervix uteri. 

(pecember Slst, p. 1244) by giving his ow 
^ statistics, and suggests tiiat British radiolog 
fnr'’i.n.r furnished statistics on similar line 

Dr their achievoraents and sins I hai’e, a 

rieiit Shaw knows, no responsibility', but I have 

suoffp'rt actively engaged in radium work, t 

which Ins'* A'orkers aro not ignorant of a tcchniqu 

thoui'i!^f‘ven results equal to those of surgery, eve 
.Avhich-one is ^ ^ product of tho particular clinic t 

the protapoiiists^of n 'k’? I’^'^t'^^ses I might add tlia 
easily retort to^Dr ' -radiology in tho past coiil 

statistics bv no'intir ^ &>baw’s preference for Britis 

.on abdominS. -hystereet ^ literatui 

preponderating amount ' 

If I have iLilin.i ^ foreign statistics.) 
preferable to oneration original letter that radium i 

correct, it, because mv” oases I should like t 

ciently wide nor oxporienco is neither sufi 

that in criticizing a rtaW ^ ^ 

■ ni ado in a leading article c 

^ /tlTlff lf-,7 j ' " ' 

• Hot.. February. 1926. p. 51. 


a responsible medical journal tho exact grounds of criticism 
should be given, that tho whole weight of evidence — local, 
national, and oven foreign — should be taken into account,- 
and that personal experience bo given its true value in 
relation to tho whole. 

Dr. Fletcher Shaw on a previous occasion* stated that 
■he “ clinically had concluded that radium was not of much 
A'aluo,” and I suggest that this should be taken into account 
ill assessiiig the true value of his criticism. I admit that in 
an analysis of his cases ho softened tho blow by saying that 
41 per cent, of his cases treated by radium before operation 
were alive and well, as compared with 32 per cent. 

Some of us aro not insensiblo to the deficiencies of local 
couditions, but revolutions, such as have occurred in a 
comiiarativciy short space of time, have not as a rule 
resulted in Utopian conditions. 

Finally, I need hardly refer for serious consideration the 
admirable analysis of world statistics on cancer of the 
uterus (Reports on Public Health and Medical Subjects, 
No. 40), in which tho whole of tho evidence for and against 
is discussed. — I am, etc., 

MancUctlcr, Jon. 7th. ' G. E. BlRKETT. 


ISOLATION FOR MEASLES. 

Sir, — Your correspondent Dr. F. J. Child (p. 33) states 
that it is perfectly safe for an uncomplicated case of 
measles to mix in society fourteen, days after the first 
appearance of tho rash. May I state that in the Memo- 
randum issued jointly by the Ministry of Health and tho 
Board of Education in 1927, on the closure of and exclusion 
from school, tho period of exclusion is three weeks from the 
appearance of tho rash. This, I take it, is the official view 
and tho one generally accepted. — I am, etc., 
siourbritigo. Jan. 7th. GEOFFREY Dudley, M.O.H. 


THE DURATION OF PREGNANCY. 

Sir, — T ho following notes, I think, are of interest. The 
case described adds iveight to the idea that the period of 
gestation is ten times tho normal inter-menstrual period, and 
emphasizes the possibility of an unjust verdict being given 
in a case of legitimacy’ or affiliation where the medical 
evidence is that tho child in question is “ full time,” moan- 
ing, presumably, being born after a period of 273 to 
•280 days. 

On April 7tb a patient, aged 30, presented herself at my surgery 
complaining of foul vaginal discharge. I diagnosed a two to three 
months’ pregnancy with a dead ovum. On April 10th I thoroughly 
curetted, removing a quantity of extremely foul pus and fragments 
of necrotic tissue, placenta, membranes, etc. The uterus was 
flushed with a hot solution of lysol and afterwards swabbed with 
tincture of iodine. During the following fortnight daily vaginal 
douches were employed to minimize the foul odour. The patient 
made a rapid and uneventful recovery. 

On August 8th tho patient complained that she had not 
menstruated since the curettage and that the abdomen was 

swelling.” On examination I would have ' diagnosed a five 
mouths’ pregnancy, but, believing that to be impossible, I estimated 
the date of her confinement to be about the beginning of 
February. She gave birth to a daughter, after a perfectly normal 
labour, on November 27th. Tho child cried lustily at birth, had a 
good crop of hair, ivas well coated with vernix caseosa, measured 
twenty inches in length, and iveighcd 7 lb. The finger and toe 
nails were fully developed and the child sucked vigorously on being 
put to the breast. In every way it appeared to be a “ full-time ” 
child. ’ 

The baby was born 231 days after the curettage. Coitus 
W’ould bo -n'eUnigh impossible for the first fortnight; the 
patient thinks it did'’ not occur for at least three weeks. If 
that is true, it would give a gestation period of 210 days — 
ten times the Tiornial menstrual period for this patient, 
who states that before her pregnancy she menstruated 
regularly every three -necks. 

I have looked through a number of midwifery books and 
the shortest period I can find tabulated in arriving at the 
average duration of pregnancy is 253 days. The statutes 
of Scotland, France, and Germany are said to allow a 
minimum period of 180 daj'S. Is the child of 180 days’ 
gestation expected to be normal in size and development, or 
merely viable?— I am, etc., 

Sidney H. 'W.addy, F.R.F.P.S.GIas., 

lluddcrsfield, Dec. 19th, 1927. L.R.C.P. and S.£d. 

1 Report of proceedings of -the Section of Obstetrics and Gynaecology of 
tha Royal Society of Jledicine, JAncct, October 23rd, 1926, p. 856. 


76 Jan. 14, 1928] 


CORBESPONDENCB. 


[ Tnn nurns!! 
MrDicii. JocBsix. 


VILLAGE SETTLEMENTS FOR THE 
CONSUMPTIVE. 

Sib, — I have read with raucli interc-st your report of Dr. 
P. C. Varrier-Jones’s paper on village sottlomcnts for tlio 
consumptive in the Bbitisu Mkdicai. Joubnal of December 
31st, 1927 (p. 1217). With your permission I would like 
to ask Dr. Varrier-Joncs two questions. The first is: Pre- 
cisely what occupations do the consumptives follow? Tlio 
second is : How does a patient obtain admission to the 
settlement, and, if married, do his wife and family also 
enter it? 

I must add that I think to enable individuals thus handi- 
capped to succeed in becoming self-supporting in this way 
is a tiemendous feat, which deseiw^es the very highest praise. 
AVe see in the Poor Law hospitals a great deal of the 
•difficulty a patient has, oven when greatl 3 - improved or 
even, so far as phj-sical examination can detect, healed, in 
resuming a normal self-supporting life. — I am, etc., 

"Whirps Cross Hospital, Lcytonstone, Jan. 1st. J * C. MuiB. 

*f* AVe have referred this letter to Dr. A'arrier-Jones, 
who replies as follows. 

The occupations followed by consumptives in the 
Pajjworth A''illago Settlement are: carpentiw and joineiy ; 
.building, painting, and decorating; cabinet-making ; 
upholstering; leather and fibre travelling goods; printing 
and bookbinding ; sign and showcard writing ; boot repairing 
and surgical bootmaking; gardening and pig-keeping; and 
poultrj'-farming. In addition, many patients, both male 
and female, are employed as clerks, book-keepers, cost 
clerks, and shorthand-tj’pists in the offices of tho Papwortb 
Industries, the organization which controls the worltshops 
of, these various, trades. 

Patients may obtain admission in the following manner. 
Those who are eligible for treatment under tho tuberculosis 
scheme of their local authority (for example, insured 
.persons and ox-seiwico men receiving pensions for tuber- 
culosis) should apply to tho tuberculosis officer at their 
local dispensarj’, or to tho medical officer of health at tho 
public health department of the town or county in which 
.they reside. Private patients should apply direct to the 
medical director. 

. The answer to the second, part of Dr. Muir’s question 
is that the wives and families of married patients are 
admitted to the Village Settlement when tho patients arc 
transferred to cottages. AA’hen this occurs all further 
financial responsibilitj' on the part of the local authoritj' 
sending such cases ceases. 


CONDITIONS OP PROFESSIONAL EXAMINATIONS. 

. . Sib, — In the report of the proceedings of tho General 
Medical Council (Supplement, December 10th, 1927, p. 226) 
reference is made to the suggestion that all parts of the 
final examination should be completed within nineteen 
months. 1 wish to draw attention to a iiossible hardship 
if this regulation be made. 

A man who has qualified by one of tho examinations 
maj', in later years, find that he wishes to obtain an “ addi- 
tional qualification.” If he has to do this while fully occu- 
pied in earning his living in an appointment, or in practice 
it may be impossible to find the time to complete the later 
examinations within the period. I suggest that in such 
a case, where the candidate is already qualified, the time 
limit should not apply. 

I, for example, after doing the London course, qualified 
M.R.C.S., L.R.C.P. in 1914, and I now want to get the 
M.B., B.S.Lond. degree. I have no hope of completing 
this examination within nineteen months, as all the work 
has to be fitted in, a little here and a little there, as other 
more pressing work will allow. 

Another example is that of a friend of mine who took 
the B.S. half of the examination, did two or three j-ears 

R. A.M.C. service in Egypt, and was then able to get the 

AI. B. portion finished on his return to England. 

The regulations should not penalize the old stager who 
wants to make a step forward. — I am, etc., 

M.B.C.S., L.B.C.P., D.P.M., D.M.R.E. 

Lomion, S.W.IO, Dec. 2Slh, 1S27. 


X RAYS IN THE DIAGNOSIS OF CHRONIC 
APPENDICITIS. 

Sib, — I was considerably surprised when reading the 
I'oport of tho discussion on chronic appendicitis (Bbitisii 
Medical Joubnal, Dceomber 10th, 1927) to find so little 
reforcnco to the use of x raj-s ns an aid in the differential 
• diagnosis of this condition. Mr. Flelclicr and Professor 
AA'ilkio referred bricll}' to tho subject at Edinburgh, and 
Dr. Bortwistle in tho same issue of the Joubnal (p. 1117) 
mentioned a few of the radiological signs of disease of the 
aiipondix. 

It scorns to mo that in a disease whore tho differential 
diagnosis is so difficult and of .such importance to the 
patient it is ns well to Imvo a clear idea of tho limits of 
tho value of an a-raj’ examination in such cases. AVhen 
such a subject can be disciLsscd at length hy tho Section of 
Surgery .at tho British Medical Association Meeting at ' 
Edinburgh without reforcnco to the value of x rays in 
diagnosis one can onlj" assume that those who took jiart 
believe tho examination to be of so little use that it is not 
worthy of mention. If this be so, I venture to say that 
tho radiological findings must have been misinterpreted in 
the past and that it would be well to inquire why such 
errors have occurred. 

In naming one of the chief sources of error I should 
sugge.st incomplete examination. The sjanptoms and signs 
of chronic appendicitis have to be distingui-shed from those 
of gastric ulcer, duodenal ulcer, gall-bladder disease, 
disease of tho urinarj- sj-stem, disease of the caecum, and 
disease of the female genit.al sj'stcm ; a complete examina- 
tion must, therefore, include all these organs, and tho 
point is to decide how to carry out such an examimation 
with tho least trouble and discomfort for tho patient. 

In order to judge the condition of tho appendix it is 
necessary to fill it with barium ; tho patient must therefore 
bo prepared thoroughly by a purge (preferably castor oil) 
overnight, followed by a light breakfast in the morning. 
Radiograms are then taken of tho urinaiy tract and 
the gall-bladder region. Light diet is given during the 
remainder of tho day, followed by' one pint of a bread-and- 
milk barium meal next day. The important times for 
cxamin.ation subsequent to the meal are: six, nine, twelve, 
tliirtj', and fiftj-four lioiirs; ordinary food and drink can 
be taken after the six-hour examination. 

At six hours it is only necessary to see if the motility of 
the stomach is unusual. At nine hours the motility of tho 
ileum is tho impoitant point, and it is advisable not to 
make a prolonged search for the' appendix until tho ileiim 
is empt}’ at ■ twelve hours. A, further examination at 
fifteen hours may be reqiured when there is, as often 
happens, delaved emptA-iug of the terminal ileum. At 
twelve houis the position and mobility of tho caecum are 
noted in the erect position ns well as in the supine. The 
position of the appendix in relation to the caecum arid the 
relation of anj- tender points to the filled viscera are 
observed. In this examination the caecum must be lifted 
out of tlio pelvis before judging its mobility, and it is very 
unlikely that the appendix will be seen until this is done. 

It is usuallv possible to make the caecum rise by continued 
manual pressure in the left iliac fossa, or by putting the 
patient in a knee-elbow position. Should these methods 
fail inflation of the rectum with air will probably succeed. 
Inspection of the posterior aspect of the caecum by fluoro- 
scopy in the oblique position is necessaiy before one can be 
certain that the appendix has not filled; it may be lying 
rotrocaecally. The important points are, I consider, the 
mobility of the filled appendix and the question whether 
pressure applied directly over it produces pain ; any kinks, 
constrictions, or dilatations must be permanent to bo of any 
significance. 

The examinations at thirt}’ and fiftj--four hours are in- 
cluded to complete the examination of tho colon, and too 
much emphasis should not be laid on the emptying time of 
the appendix as an indication of disease. AA’hen all the 
barium has been evacuated, examination of the stomach and 
duodenum, to exclude the presence of ulceration, should 
follow as a routine. After this a second or confirmatory 
examination of the caecum can be made if necessaiy. 

Secondary evidence of anj- gall-bladder disease will now 
be available from the original radiogram of the gall 




78 Jan. .14) 1928] 


OBITTJAET. - 


[ Tn* immsrn 

UZDICXI. JoUBRAl. 


countrymen in attendance. The only reason wo could think 
of was that the advantages offered for perfecting oneself 
in any lino of medicine or surgery are not known. 

Some of the largest hospitals in the world arc in Vienna. 
One great institution has 7,000 hods ; another has over 
4,000, and every bed is filled. INIorc than seventy-five 
hospitals and clinics are open for clinical teaching. The 
material, while used ver}- considerately ns far as tlio 
patient is concerned, can he put to better advantage for 
teaching purposes than in many other countries. There 
arc not so many medical students, but tliero is an abun- 
dance of patients for most instructive clinics. Medical and 
surgical instruction can bo said to bo abreast of the most 
advanced scientific learning of the day, if not in advance 
of most of it. 

In one great hospital there are 4,000 necropsies annually. 
Upon visiting the class in patholog}’ of a jiost-graduate 
school held in this laboratorj’ I found about forty medical 
men from man 3 - countries listening for two hours to one 
of the greatest pathologists in the world. He had the 
pathological specimens of twelve bodies as material, and 
this is a dailj’ occurrence. Vienna is probably the best 
place in the world for post-mortem experience, because the 
material is available and the staff of instructors is so well 
prepared for this kind of work. 

. There are more than three hundred instructors listed on 
the faculty of one post-graduate school. On the bulletin 
board I counted over three hundred courses, in overj’ branch 
of medicine and surgerj’, forming and running at one time. 
For a stay of some weeks the expense is verj’ moderate. 
If he must limit his time the visitor can arrange for any 
kind -of private instruction with the best of instructors — 
at, of course, greater expense. While I have seen post- 
graduate work ill manj- places I have never seen bettor 
opportunities than in Vienna. The professors, dozents, and 
doctors are most courteous, obliging, and helpful. All 
instruction maj’ bo arranged in English it desired. — I 
am, etc., 

Watford, Dee. 26lh, 1927. W. A. Ruble, M.D, 


ERGOSTEROL, VITAMIN D, AND RICKETS. 

Sin, — Surely the number of rachitic children found 
among the breast-fed babies living in towns points to a 
deficicnej' of vitamin D in the human milk of town dwellers. 
This may be due to light starvation and absence of anti- 
rachitic substances in the usual diet of the mother. I 
would therefore be inclined to suggest, as a rational 
prophjdactic measure against rickets, irradiation of the 
mother bj- means of ultra-violet raj-s whenever possible, and, 
falling that, ingestion of some activated substance. It 
is my belief that the introduction of the mercury vapour 
lamp into the armamentarium of the ante-natal clinician 
would save manj' a breast-fed child from rickets. — ^I am, etc., 
London, W.l, Dec. 21st, 1927. R- BaUWENS. 


©faituar^. 


Dr. Septimus Fahmeu, who died on December 14th, 1927, 
at his residence in rerr)diill, co. Durham, at the age 
of 73 lears, after a short illness, received his medical 
education at King’s College Hospital, London, where he 
gained the junior and senior medical scholarships and many 
prizes. He obtained the diploma M.R.C.S.Eng, in 1880 
the L.R.C.P. and L.M.Ed. in 1881, and the D.P.H. of the 
English Conjoint Board in 1891. He held the post of house- 
surgeon at King’s College Hospital and for a period was 
assistant medical officer at Parkhurst Prison, later becoming 
house-surgeon to Cborlo}* Dispensaiy and Hospital. Ho 
was for some years medical officer to Shap workhouse and 
district, and vaccination officer; on leaving that neighbour- 
hood bo was presented with an illuminated address. He was 
for a time in general jiractice at Hull, and later on at 
JIarske-by-tbe-Sea. When the South African war broke 
out Dr. Fai-racr obtained a commission as civil surgeon, 
and served cbioflj- in No. 8 General Hospital, Bloem- 


fontein ; ho was awarded the Queen’s medal with four 
clasps. On his return ho continued hi.s militarj' service 
in the Scottish district till he resigned his commission to 
icsiimc general practice, first at Sponnjmoor and later at 
Ecriyhill, where he resided for the last twentj--two j-ears. 
He was surgeon to the Dean and Chapter Collioiy, Eeriy- 
hill, and al.so held the posts of medical officer and public 
v.accinator to Sedgofield union, .as well as that of police 
surgeon. Ho was a keen member of the Briti.sh IMcdical 
As.sociation, and had been the re 2 )roscntative of the Bishop 
Auckland Division since 1G23; ho was chairman of tlio 
Division in 1924. Ho deiotod much time to the St. John 
Ambulance Association ; ho was aiipointcd an honoraiy 
associate of the Order of St. John of Jerusalem in 
December, 1917, and received the long service medal 'of the 
St. John Ambulance Brigade onlj' five daj-s before his 
death. Ho was a prominent Freemason, and was R.W.M. 
of his lodge (Rowlandson Ferryhill), also a P.P.J.G.D.. 
His groat personal jiopulariti' was shown bv- the very 
largo attendance at his funeral. 


Dr. Joux Alexandeh EnsuiN-E Stuaht, who died at 
Mirfield in the last week of December, 1927, at the ago 
of 73, was a lineal descendant of tbs Regent Moraj', and 
received his name Erskino in momoiy of his great-groat- 
grandf.athor, who is described in Scott’s Gi;;/ Monnering 
as having preached at the Old Grcjfriai-s Church, Edin- 
burgh. Dr. Stuart’s great-uncle fought in 1822 one of 
the last duels on British soil, when ho killed Sir Alexander 
Boswell, the son of the famous biographer; this incident 
is said to Imve been used by Scott in the duel in 
St. Jionan’s Well. On his mother’s side ho was descended 
from the socrctaiy of the Old Pretender. Dr. Stuart 
received his medical education at Edinburgh, whore ho-was 
a pupil of tlio late Lord Lister. He obtained the diiiloma 
L.R.C.S. in 1876, and the L.R.C.P. in 1888, After practis- 
ing for a time in the neighbourhood of Berwick and 
Windermere and holding the post of ship’ surgeon,' "ho 
came to Batley in 1881, and for thirty years conducted an 
extensive practice in the district. For about twenty years 
he was medical officer of health for Batley, and performed 
great public service during the small-pox epidemics of 
1903-4. In 1920 ho retired and subsequently lived at 
Mirficid. During his early days at Batley he was medical 
adviser to Miss Ellen Nussey, who was a confidential friend 
of Charlotte Bronte. He acquired an intimate knowledge 
of the life of this author and her sisters, and his uTitings 
on the subject are admittedly authoritative, his best known 
books being The Br.orxfe Country and Literary Shrines of 
Yorkshire. Since his retirement he was engaged in writing 
a third book on the possible identity of certain charactera 
in tho Bronte writings, which ho had hoped to publish in 
the present year. He was one of the founders of the 
Bronte Society and a past president. He took an active 
interest in botanic and antiquarian studies, and was a 
member of tho Spen Valley Literaiy Society and the 
Wakefield Diocesan Conference. He leaves a widow, two 
daughters, and a son. 

The death took place, on December 23rd, 1927, of Dr. 
AVilliam Scott at Ruthwell, Dumfriesshire, where he had 
carried on practice for the past forty years. Ho was a 
native of Banffshire and obtained the M.B. and C.M. degrees 
at Aberdeen Dniversity in 1883. After graduation he joined 
tho Free Church Medical Mission at Livingstonia in Central 
Africa and remained there two years. Returning to this 
country, he acted for a time as assistant in practice at 
Cromarty, and later took up praetice at Ruthwell. At the 
time of his death he was 68 ye.irs of age, and was held in 
high estimation in the locality where ho practised. Ho was 
a justice of the peace for Dumfriesshire, and took a 
prominent part in politics, being a member of the executive 
of tho Dumfriesshire Liberal Association. He is survived by 
a familv of eight, of whom five are doctors and one a 
woman dentist. His eldest son. Dr. William Scott, was for 
a time demonstrator of pathology in the Dniversity of Cam- 
bridge, and is now a medical officer at the Ministry of Health 
in London. 



Jan. I4i 19=81 


TTNIVERSITIES AND GODDEGES. 


[ The nnmsH 
Medical Jocenai, 


79 


On D('ocinbpr23i(l, 1927, Oun e pAKsci! i^v.^y, in Oio person 
of Dr. J. Maiionv, D.S.O., 'I'.D., Stoneycroft, n .lis- 
tiin'iiisliod soldier and doctor and a ivell beloved citizen 
of Liverpool. After taking bis medical degree at tbe Itoyal 
Dniversitv of Ireland Dr. Mabouy settled m praetire m tbe 
Old Swan district of Liverpool in 1892. lie beeame inedieal 
adviser to tbe many nomaii Catbolic ebaritable institutions 
in tiie neigbbonrbood, and by bis ability, ebecrfuincss, and 
svmpatby soon won the devoted admiration of all elas.o.".s 
.and creeds. At the time of tbe' South African war bo 
joined the Volunteer Force as a combatant ofiiecr, anil 
served with the Special Service Company attacbed to tbe 
1st King’s liegiment (Liverpool), being awarded tbo .South 
African medal with four clasps. Sborlly after bis return 
boine be resigned bis combatant rank and became medical 
ofiiccr of bis battalion. At tbe outbreak of tbo great war 
Dr. Jlabony went to France with 'tbe 9tb King’.s ns major 
in the K.A.Jf.C. Later, in l5l5. be was invalided lioine, 
but rejoined for active service with the 5tb King’.s on the 
Somme in 1916. lie was one of the first olficcrs in tbe 
55tb Division to bo awarded tbe D.S.O., and received bi.s 
decoration on the field from Field-Marshal Haig. lie was 
also awarded the Jledaille dc lloconnais.sance Fram^ai.se. 
Dr. Maliony' (a colleague write.') was one of tbe fonnder.s 
of tbe Hosjiice for tbe Dying. Old .Swan, and be never 
spared bimself in connexion with works of a ibaritable 
nature. He was greatly loved in a wide circle, and bis 
funeral service was literally ami obvion.sly a tribute from 
loving friends. 


Dr. TnoMAS ToMntr.soN DnuNVATi'. who ilicd on .Tannaiy 
1st, at bis homo in Woodstock, at tbe age of 61. was a 
scholar of Christ Church, O.xford. and won an entraneo 
scholarship in 'natural science at .St. Marv’.s Hcs|)ital. He 
paduated JI.IL, B.Ch.Oxon. in 1892, and protceded M.D. 
in 1894. After graduation he hold the post of house- 
physician to the hospital, and subscc)ucntly commenced 
practice in Bochester, being appointed phy.siciau to St. 
Bartholomew’s Hospital in that city. About twenty years 
ago he went to Woodstock in order to be nearer to his 
University, where ho associated himself paiticularly with 
post-graduate work in connexion with tbo Ilailclilfc Infir- 
mary. Ho leaves a widow and three children, of whom 
two are destined for the medical profc.ssion. A colleague 
, Drunyato always retained his interest and 
aliihty in the science of mathematic.s, including its teaching. 
Ihroughout his life he was a keen lover of nature. In his 
early days ho was- no mean oar, and later an excellent 
golfer and tennis player. His life wa.s liveil in tbe admira- 
lon and affection of his colleagues, who will long treasure 
ns memory, and his death evoked an extraordinary trilnito 
o respect from the whole neighbotirhood in which he 


t.orium at Constauz, who introduced a method of treating 
heart di.seases by intravenous injection of gluco'o: Dr. Paui. 
Maxasse, profcs.sor of oto-rhino-laryngology in tbo University 
of Wurzburg, aged 62 ; Professor Haxs Lro, formerly 
director of the Bonn Pharmacological Institute, aged 74; 
Professor Clno.ss, honorary dean of the faculty of medicine 
at Nancy', aged 83; Dr. Vin‘ce.\t RAMAnoxi, senior surgeon 
at the civil hospital at Bastia and Commander of the Crown 
of Italy: Dr. Otto Hii.nEDitAXD, emeritus director at the 
Charitd Hospital and professor of surgery at Berlin Univer- 
.sity, aged 69; Professor B. BnAUNScnwEiG, professor of 
ophthalmology at Halle University', aged 68; and Dr. Joseph 
Thoji.wer, prof( r of 'he Prague faculty of 

medicine, and :■ .'ii.":' ■ ".'i- ;■ of the Societe dc 

Ncurologio of Paris. 


Tiin I.ATE Dn, ALEXAS'Dzn Br.AciiHALL-MonisoN. — Dr. Robert 
C.'irswell (Wandswortb) writes : Perusal of the obituary notice 
in.ycur issue of Januarv 7tb leads me to write that "the late 
Dr. Bl.ackhall-Mcrison was the tliird prcsidciil of tbe Xatioiml 
Medical Union, in succe.ssinn to Mr. G. A. W’rigbt of Jlan- 
rbr.sler and Professor Wdliam Russell of Edinburgh. He 
joined tbe Union in 1915 largely as a tribute to tbe memory 
of bis brother. Dr. Basil Gordon Morison of Islington, who 
was an original member. Becoming himself keenly interested 
in tbe work, be imver lo.st an opportunity of diffusing, by' voice 
or pen, a spirit of broadminded, cultured, and kindly inde- 
pendence, as far removed from bigotry' on tbe one band as 
from time-serving e.xpediency' on the other. His general attitude 
towards medical polity is well expressed in an entertaining 
little pamphlet, Af^riilnjiius liour.tl and Unbound, published 
by' the Union in 1921, and obtainable from the .secretary, 
Dr. E. H. W’orlb of Strcatbiim. 


Euibtrsiiiis nnb CoUtnfs. 


UNIVEB.SITT OF LONDON. 

Tnr following camlUiates have been approved at tbe examination 
indiented : 

M.P.— Bn-Wen I : Enid A. CcTJOC-Cadle, Gwendolen G, 

Cotton, \Y. UranR.UimC. Garvin. Alico M. C. Maephor^on, A. t'.. T. 
Perkins Kvelvn N. Popper, T. ^V. Preston, \V. G. Seni-R. H. K. SneP. 
PnAKoii in (P/nj>‘holo(;icnl Mfdtn'nf): 1. Atkin. Florence M. Gamhle. 
BnAN'cn IV (Muhc’ferv nnd n>o»afes of TPomfii) ; R. A. Brews, 
Uorotlica A. C. Himt, R. G. Mnlipbant. 


■ ■ UtslVERSITT OF BIRMIKGIIAM. 

The following? candidates have been approved at tbe examination 
indicated: 

M D — ‘r# C. TTIIT. *A. V Neale. .7. A. Scott. W. Sommers. 

W.B.. Cn.B— Mirv K. A. Allen. C. C. Grokson, Ii. H. Crosskev. J. F. 
Dnc^bnrv.A. 77. Ghaitb. 11. D*A. Gifford, D. V. Hague. S. K. ilansor, 
AV. n. Shilvock, F. hmitb, R. W. W. Watson. 

* With honours. 


nf + 1 , ConKN, nlio dio(] rccontly in Pliilaclolphia 

assistuiit sui'goon in tlie 20th 
to tlm' J^giaicnt in 1861, .nftrr wliic’Ii lio transforred 
Roval l^iipoiit’s rxpcclition to Port 

tbo' Americ.in'^ civif a‘’ti'''>tics during 

niietice 1 ' ■ commenced civilian 

chest in diseases of the throat and 

Medical pinfcssor of laryngology at the Joffersou 

throat in Bluh,loiT-"''*'“ l”'“f‘^ssor of disea.scs of the 
hospital for m'enta? "r pliysicinu in a 

prcsideutoftCx O Bennsylvania. Ho was 

published a nuinbor ^Ivdical Association in 1875, and 
number of treatises on diseases of the throat. 


. following well I-nn. r 

recently died : Dr. HExn™A” medical men Imvo 

of psychiatry at Jobiis H HfUD, emeritus professor 

snperintonde'nt of tlm"? i University, and formerly 
editor of the 7)nUcfin Hopkins Hospital, .md 

Dr. PuENAXT, professor of l Hopllns nospHal- 

medicine; Dr. TnVonon in Hie Paris facultv of 

aEonon Budixcex, director of tbo sana- 


ROTAD COLLEGE OF SURGEONS OF ENGLAND. 

Lecture Arrangemettts. 

Ix addition to Ibe six Hunterian lectures by Sir Artlinr Keith on 
factors coiicenieil iu the growth of the human body, annoniiced 
last week, the following further lectures will he given at the 
Roval College of Surgeons of England on the dates indicated at 
5 li.in.:— Januarv 30th— Professor W. B. M. Wanlill : Certain 
aspects of deft' palate, with observations on the causes of 
defective speech nnd the remedies proposed for their treatment; 
Fchi iinrv 1st— Mr. II. S. Souttar: New methods of surgical access 
to the brain; Feliriiary 3rd— Jlr. K. Aides Atkinson: The 
natliolo"V, diagnosis, and treatment of abscess of tlie brain; 
Eohmnry 6tli— Sir I’ercv Sargent: 'J’lie surgery of the posterior 
craiiiai fossa; Fehrnarv 8tli— Mr. G. Grey Turner : Tl.e treatment 
of con-'ciiitnl defects of tlie hindder and uretlira in- ini|ilantatioii of 
tlie ureters into tlie bowel, witli a record of 14 personal cases; 
Felirimrv lOtii— Air. J. H. Sheldon: An nndesenhed disease of 
hone- Fehrimrv 13tli— Dr. Adolphe Abraliams: Iho physiology 
of voleiit exercise in relation to the possibdity of s.L'm'i ■ 
Fehrnarv IStli— Air. Alexander Fleming : Lysozyiie, a bacteriolytic 
ferment normally present in tissues and secreuons Fehniaiy 17 li 
Or Ida C Mann* The regional differentiation of the vertehrs-le 
Fehrnarv OT h--Mr. C. B. Shattock ; Pathological specimens 
m t l ^nufseii FehrcaiV 22 nd-Alr. C. P. G. Wakeley ; luvestiga- 
Hnni into Die snr'dcal diseases of tlie salivary glands, including 
m r athoogj- and treatment; Fehvuary 24th-Mr. W. D New- 
comh: The ralatioiisliip between peptic ulceration and gastric 
cavcinomai. 




;.W^) .’ll' 1' 

Jaw. 14 , t 9 j 8J 


MEDICAIi -NEWS. 


[ 


3l£I>JCAE JOCXXAX> 


«l 


Tiir. Kiiif! ot Spain lias confcrrca the Grnna Cross of the 
Orclcf ol Civil Merit on Dr. AUlo Castellanl, G.'Sl.G., ilirector 
ot tropical medicine at the Eoss InsUtiito ami Hospital, 
rntiiQvs who has .lately Tislted Madrid to lectnro on. the 
snhject ot malaria. 

The Minister ot Health has Issued n eiroiUar (No. 839) -to 
county councils rcfiuestlng them to accelerate the improve- 
ment ot houses in rural districts in accordance with the 
provision of the Housing Act ot 19ZG, which cnahles Ilnaucial 
grants to be made, in approved cases, for the rop.air of dwell- 
ings in rural areas and tho conversion into dwellings ot buUd- 
in^s not previously used- for that purpose. It is suggested 
that tho opirortunities aftorded by tho Act should bo more 
widely advertised, and that there aliould be more active 
co-oi)eratiou between tho county and county district councils 
in dealing with rural housing. 

Dh. H. G. It. Young, on relintinishing, through ill health, 
his practice at Hrainlrec, which ho carried on for tweutj'- 
two years, has been in-csented by his friends and tjatients 
with a Waterford cut-glass bowl and a cheque for £350, 

Dr. r. 0’Sulii.iVAN ot Cwm has been presented with a gold 
watch in recognition ot tho services rendered by him after 
the Cwm explosion. The watch hears an Inscription record- 
ing that he was tho flrst medical man to descend the Jlnrino 
pits after the explosion on March let, 1927. 

According to tlie weeidy diary card of tlie Royal Society 
ot Medicine portraits of tho prc.sidents ot tho society from 
the foundation of the Modico-Chimtgicnl Society In 1805 up 
to the presentjtime are being collected and framed for hang- 
ing in the president’s room at 1, Wimpole Street. Portraits 
of the following presidents are missing : Edward Stanley, 
P.R.S., .Toseph Hodgson, P.E.S., Caesar Henry Hawkins, 
FHluS., Sir Charles IjOcocI^ UL, M.D., E-R.S., Charles West, 
M.D., Andrew Whyte Barclay, M.D., George D.avid Pollock. 
In order to make tlie historical collootiou complete gifts ot 
engravings -or photographs of tho xiast presidents missing 
from tho scries, or information as to where they can ho 
obtained, will he welcomed hj' tho socletj'. 

Mr. Henry S. WELLCOJin has presented a replica ot the 
Lister oolleotion at the Wellcome Historical Medical Mnsenm 
to the American College ot Surgeons in commemoration of 
tho centenary ot Lister’s birth. The Board ot Regents ot tho 
Collcgo passed a resolution ot thanks to Mr. Wellcome, in 
which it Is mentioned that tills exhibit was tho outstanding 
feature of the Lister centenary celebration ot the College at 
its clinical ooDgres.s in Detroit last October, when tho pi’e- 
fientation wasformallymade. 

Reprints of papers pnfallshed by members of the staff ot 
the Middlesex Hospital Medical School during 1926 and 1927 
have now been bound together in one volume, with an index, 
whioli may he consulted at the Library of the British Medical 
Association, 

Under the will ot the late Mr. A. B. Bosher the City ot 
London Corporation have,aftercarG{ul investigation, awarded 
the sums indicated to tho following hospitals ; £6,000 each 
to Guy’s, London, and St. Thomas’s; £5,000 to Middlesex; 
£4,000 to St. Mary’s ; £3,000 each to Bt.Bartholomew’s, Royal 
HaUonal Orthopaedic, Royal Rorthern Group, St. George’s, 
University College, and "West London; £2,000 each to Charing 
Cross, King’s College, Metropolitan, Royal Free, and West- 
each to City ot London Hospital for Diseases 
m the Heart and Lnngs, East London Hospital for Children. 
Hampstead General and N.TV. London, London Fever, London 
Queen’s Hospital for Children (and branch) ; 
~hU0 each to Belgrave Hospital' for Children, East End 
Hothero’ Lying-in Home, Elizabeth Garrett Anderson, London 
i^CB, ^Uer General, Mother’s Hospital (Salvation Army), 
yueen Charlotte’s Slaternlty, and St. Paul’s Hospital, Endell 
btreet ; £400. each to Central Loudon Tliroat, Nose, and Ear, 
and Chelsea Hospital for Women; £300cach to St. John and 
Lewisham, and South-Eastern 
^250 each to Mildmay Mission and 
Stone, Etc.; £200 each to BrlUsU 

and Babies, the Hospital tor EpRepsy 
Rniu etc., General Hospital, 

rundrelv AVelfare Wards, Paddington Green 

• Hospital for Women, and West 

-Diseases; £100 each to Central 
Skin, and Streattam labS-"''" Diseases of the 

Chimney-sweep’s cancer met tvith in 
U?P ««stav Guldberg ot Oslo in 

a Combating Quackery will hold 

fiftli 28th, on tlic occasion of the twenty- 

held on thp foundatiou, when a discus'don will be 

held on the best method of dealing with chaifatantry; 


The date of the next congress known as Journics Jlcdicalea 
tic Faria is Alay 19tli, 1929. Further information can bo 
obtained from the general secretarj% Dit Tixier, 18, Rueflo 
Verncnil, Paris A'TI‘’. 

According to tho "New York correspondent of the Tiinta, 
Mr; Albert D. Lasker and his wife have'presented to the 
University ot -Ciiicago a million dollars as an initial gift 
towards the setting up of a “Lasker Foundation for Medical 
Research ’’ to Investigate tlie causes, nature, pi-eVentibn,and 
euro of degenerative diseases. 

In a weekly bulletin issued bj- the city of New York 
Department ot Health hospital .superintendents have been 
reminded that all cases of miscarriage or abortion should he 
reported Iramodlatoly by telephone to the department. It is 
stated that there has been some laxity and delay iu reporting 
these cases, thus preventing investigation of any illegal 
operation that may have been performed. 

The following appointments liavc recently been made in 
Frencii medical faculties. Bordeaux ; Dr. Villemin, professor 
ot anatomy iu succession to the late Professor Picque ; Dr. 
Petgea, professor of skin diseases and syphilis in succession 
to Professor Dubreuilh ;and Dr. TenIier,professor of ophthal- 
mology in succession to Profussor Lagrange. Lyons: Dr. 
Favre. jjrofessov of morbid anatomy in snccession to Profe.sBor 
Taviot ; and Dr. FrOJuent, professor of medical patiiology in 
succession to Professor Collet. 

Professor Erich Hoffmann, director of the Skin Clinic 
at Bonn, has been elected an lionorary member ot the 
Medical Academy of Rome. 

Dr. a. Lesage, a well known Paris pediatrist, has been 
elected a member of the Acadfemie deMedeciiie in the place 
of tlie late Dr. Mery. . - 

The Bociete de Medecine ot Lc 5Iaus-aud the Department 
■ot Sarthe recently celebrated its centenary, when an address 
-was given by Dr. Paul Delaimay, tlie well known medical 
historian. 


KtUtvs, mib 


AU coimnuulcatton^ in I'cgard to edrtorinl busincrss should 
addressed to The ED/TOR, British MetHcai Journtxt, British 
Medicai Association House/ Tavistock Scfuare, VV,C.f. 

ORIGINAL ARTICLES mid LETTERS fonvardod for publication 
are undovstood to be ofTcrcH to ’the BaiTisn itoiCAL Journal 
alone unless the contrary be •stated. -Correspondents who wish 
notice' (o -Ikj taiccu of iheir <ronimunicalioiis siiould authontiTOte 
them ■wU)i their names, not nocessaiily for publication. 

Authors desii'ing RERRTNTS of tlieir articles published in -the 
Barnsn AIedical Journal must commumcotc with the Financial 
Sec3*elar>' ^d Business, JIanager, British Medical Association 
House, Tavistock Square, "W.C.!, on rceerpt of proofs. • 

All communications ^Yith refci-ence 'to ADVERTISEMENTS, as w'ell 
as orders for copies of the Journal, should be addressed to ihe 
Financial Sccrclai*y mid Business Manager. 

•Tho TELEPHONE NUrViBERS of tlic Briusli Medical .lUsociaHon - 
and the BRmsn Medical Journal Rve JIVSFl/JI USQI, VSOiy 1)^3, 
and -JSOi (internal c.xchange, four linesl. * 

The ^ELEGRAFHiC ADDRESSES nvQ : 

EDITOR of tJje British AIeoical Jour*cal, Aitiolof/y WcMcait, 
"London, 

FJNANCIAL SECRET.tVRY AND BUSINESS MANAGER 
(Adveriisemcnls, etc.). Articulate "iTcsUcut, LvittLov^ 

MEDICAX SECR^ARY, Medhcci'fi ITcstceui, London. 

The address of tlie Irish Office of the British Medical Association is 
16. South Eredcriak Street,' Dublin' (telegrams t ItacUJnit Dublin; 
tclcpbonci 4737 Dublin), and of the Scottish OfScc. 6, Drurnelicugii 
Gardens. Edinburgh'(tc]egmms A^taeiaie. Edhibzu-nhi telephone ; 
■24561 Xdinhurgh). 


QUBBIBS AND ANSWERS. 


D, F.,’*>a-jnedical man, married, suffering from hemiplegia, 
wislies to hear of a Ijoine or suitable hospital winch offers 
raoderate terms, Tvith efficient nursing. 

, DXATflS FE05I IiOa\i, AiCAfisTnr.srA. • ■ - 

Dn, Grorgk Ganuyt, xirofessor of oto-rhiuo-laryngology at Stras* 
hourg, would be glad to have details sent him of au}* deaths from 
local anhiGstbesia. Uettei’s should be addressed to him at the 
Clinic Oto-rhuio-laiyugologique, Hopital Civil, Gtras'bonrg; 

Sterilization -of Sveikctts. 

In reply tolhe iuq\dry’by IntmTimsctilar** (November 12tb, J927, 
p. 905) as to keeping syringes and needles sterile withoufboiling. 
Dr. J. W. Tomb (A^nsol, Bengal) cites an article hv himself 
entitled-'* Aiiselnl hypodermic ontllt,*’ 'whicb was piihlislied in 
. tlie Indian sVcdfcal -Gazetie of Jannajw, 1925 (p. 32), ami repro- 
duced in the Tropical Biseasci Balletinior October, 193 {p.775). 




82 JAN. 14, 1928] 


LEXTERS, BOTES, AND- ANSWERS. 


t Tiiz nnmn 
MrOtCXI. JOCBNAXi 


Pbequency of Micturition. 

Dr. Edmond Murphy (CovU) writes iu reply to Dr. MoWlilrtor’s 
inquiry (Journal, December 24lli, 1927, p. 1214) : I nilviso 
that iu this case iodine be Rdmiiiistcrcd. lodioine tahloida 
(B. W. and Co.) 0.03 {jram— one to bo taUeii uiybt and moriiini; 
and continued lor Bomo wcoUs— is a conveuiout method of 
ndmiuistration. 

' Prevention op Soadies. 

" P. M. S.” writes iu reply to tlie inquiry published on 
November 12tb, 1927, p. 906: iTlio lady will be able to disinfect 

. her ('arments easily if she follows lliese iustrnctions. Talic 
a lai'Ke more or less nirtiglit box out into tlie (lardeu away from 
buildings. Spriulde in the box Iialf to one |>iut of petrol and 
quickly arrauge her garments loosely in the box. Close llio iid 
and leave for half an liour. If site lias put the clothes in loosely 
this should be enough to kill all acariiia. With tliickcr woollen 

- clothes more time will be required. I have never yet received 
complaints from those who have used this method 'with flimsy 
uative.silk clothes. It must uot bo forgottou that the mixture 

; in the box is au explosive oue. 

Treatment of Flatulence. 

Dr. G. H. Pearce, M.O.H.Batley, writes: In the British Medical 

■ Journal for October 1st, 1927 (p. 620) “ West Country " asked for 

• advice in tlie treatment of recurrent attacks of 'gastrio and 
intestinal flatulence. On page38ot the Journal for January 7th, 

. 1928, tlie subject is again referred to by Dr. I. V. i'offa. I advise 
them to obtain a supply of taka diastase tablets, gr. 2}. 

■ . , Typhoid Mastitis. 

Dr. a. Forbes' Brown (Trinidad) refers to Scliiftmau's case of 
typhoid mastitis (see- Epitome, November 19tli, 1927, para. 468) 
and describes his personal experience of tliis condition. Do 
writes: I went to bed with typliold fever in England in January, 
1927, and did uot recover till tiie oud of April, wlien 1 got up. 
Alter au interval of one montli .my left nipple hec.nne very 
liaiiiful, and it and the areola enlarged. The indurated region 
was about the size of a pigeon’s egg and very tender. The 

• condition subsided in another moutli spontaneously. Since then 
I have developed a violent periostitis of the left tibia, which left 
the membrane thickened to about the size of a walnut. This 
subsided with daily diathermy. The most troublesome com- 
plioatiou I have hauls wliat appears to be'periplieral neuritis. 
My tactile aud hot aud cold sensations are unimpaired, but 
1 have a continual feeling of numbness and tiiigliiig iu my feet, 
accentuate I while walking. 1 have had tiiis now for'cl'dil 
mouths, without the slightest improvement following diathormv, 
massage, strychnine, aud irou. Das any member auy suggestions 
to make 1 


DETTCRS. NOTES, ETC. 


Conjoined Twins. 

Dr. F. J. Waldo, J,P., conducted an iuquest on December 27th 
I" ~ ’ geeu born on December lOth! ‘ 

vertex, the bodies pointing'iii 
, L ■ er would have been able to 

Bit or stand, and hypostatic pneumonia was threatened. An 
attempt was tiierefore made on December 22ud by Mr. L. 
Bromley, surgeon to the neurological department of Guy’s 
Hospital, to separate the heads. There was no partition between 
the two braius, which lay in contact; tlie circulatory systems 
were independent. Dedlirfoilowed the operation, and was attri- 
'■ bnted to the sudden change iu pressure on the brain of oue child 
• as the result of the inevitable displacement. The other child ' 
was very wasted aud 'survivul seemed unlikely. Sir Bernard 
Spilsbury, who iierlormed the necropsy, attributed death in both 
. cases to shook. He said that the iufauts were two individuals 
iu the souse that the essential organs were complete and separate 
. Iu tlieory they were capable of separate existences, and might 
be termed “conjoined twins.” He agreed that the death of the 
smaller child would have endangered the life of the other oue 


The Value of Localized Sinapissis. 

Dr. J, Margolyes (Loudon, N.E.) writes to emphasize the value 
, of local mustard applications to the spinal column. He reports 
the case of a timber porter, aged 43, who suffered severe pain in 
the riglit arm aud baud, which became worse at ui«ht aud 
prevented sleep. No cause was detected, and there "was no 
limitation of movement or pain on deep pressure. Treatment 
by liniment and massage proved iueCfective, aud no ahuormalitv 
was discovered by au z-ray examination. As a last resort 
a s uapism about two by three inches iu size was fixed over the 
seveutii cervical vertebra by strips of adhesive plaster. Two 
such applications, each lasting half au hour, relieved the pain 
entirely, and euab.ed the patient to return to work. * 


Pregnancy and Glycosuria. 



(October ., — ^ * , 

Mrs. C., who had glycosuria, and gave birth to a girl in ht 
first confinement on June 6tli, 1924, but in her second coufini 
raeut she gave birth to a boy, lOJ lb., on Angnst lYtb, 192' 
Glycosuria cleared up a few mouths after pregnancy in eac 
case; and each delivery was also instriinieutal. There wa 
no laceration aud no infection ; rapid recovery of both cbildre 
and mother, all of whom are sugar-free. - ■ 


"B. coLi Infection of the Digestive System.” 

Mr. H. IV. Webiier (West Looe, Cornwall) reports a case which, 
though ohsenro at the time, seems now to liave been duo to 
if. call iiifeotionof the digestive sysiom, a condition descriheil by 
H. Slallid (SCO Epitome, Octolier 15tli, 1927, para. 335j. lii the 
first wceic in September, 1926, a lad, aged 16, complained of 
weakness; ho had been siifferiiig from frontal lieiidaohe and 
constipation for several days. His tongue was thickiv coated 
with a wli.tish-j-ellow fur; the pulse was 90. and the tempera- 
tiiro 103° F. Tlie nbdomoii was moderately distended and rather 
tynip.aiiitlc; no enlargement of the spleen was found. The next 
morning llio temporaturo liad fiilleii to98°l'’., hut it rose iu llio 
evoiiing to 101° F., the puiso ranging from 70 to96 correspondingly; 
the hoiidaclio was now so severe as to cause photopliobia. A soap 
and water enema produced a copious, dry, hiillty, wiiitisli-yellow 
stool of offensive odoiir;-iio rose epols were visible, and tlieio 
, wore no otlier symptoms beyond a slight congli. On the tliird 
day, wliicli w.as porliaps tlie cud of tlio first .week since the 
.illness started, tlio morning an.l afternoon temperatnros .were, 
respectively, 98.4° and 102°. Inspiratory moist somida were 
lieard^ at hotli pulmonary bases, and tlicro was a fairly profuse 
ornptiou of rose-red papules over the buttocks and extensor 
surface of tlio forearms.' The Widal reaction was negative as 
regards B. typhosus and B. par a typhosus B ; tlie blood cultnre was 
negative for B. typhosus, B. p iriityphosus A aud B, aiid B. coli. 
The cvoiiiiig tomperatiiro now began to fall gradnallv and the 
hcadaclio became miicli less, Tlie bronciiial catarrlrcleared.iip, 
but tlie rash peraistoil, as did tlie pale, bnlky, constipated stools. 
At liie end of tlie -first- week, which was probably tlio'teiitii or 
. oloveiitli day of thc. illneas, the morning and evening tempera- 
tures were subnormal, tlie puiso 56 to. 64, and all tlie rasli had 
disappeared. The only remaining symptom .was the pale, c ni- 
slipatcd condition of tlio stools; tii'e iiriue was 'hot bacterio- 
■ logically examined. Tlio patient gradually regained 'flesli nhd 
• strength, and was oouvniesoeut by the cud of the month. 

Chloroform Poisoning by Ingestion. . 

Dr. S. r r — • -■ i ' 'lease of poisoning 

from, . " ■ ■ 48, who'snftered 

from ... ■ pure cliloroform 

Olio morning in mistakeforadose of cough mixture. He immedi- 
ately felt a burning sensation iu tlio throat and stomacli, and 
vomited some mucus mixed witli blood. He did some honseliold 
work for lialf aii'liour and tlien took ids nsual meal of rice, 
pulses, ami vegetables. A few minutes later he became drowsy 
and theu uiicouscious, when Iiis stertorous bceathiug attracted 
attention. Dr. Cliauilhuri found him about an hour after taking 
the dru” in a couditioii like that of deep cliloroform anaesthesia. 
The iiiiplls were moderately dilated, did not respond to light, 
and tlio conjunctival reflex was entirely lost. The pulse was 
frequent, with a poor volume. Trealmeut consisted of gastrio 
lava-'o witliaweiik solutiou'of potassium pernmngauate, liypo- 
dermio injootioiisot stryohiiiue aud oamiilior dissolveil-iu etlier, 
and rectal injections of wliisky- well diluted with' water. The 
stomach could uot he washed out sucoessfully, since rice particles 
i-one.'itodly blocked the eye of the stomach -tube. While this 
olieration was iu progress .copious vomiting, and involuntary 
evaoiritioiis' occurred, aiid soou afterwards improvement was 
sliowii by tlie increased volume of tlie pulse aud- the return of 
coujniistival and pupillary reflexes. Further recovery was 
uuevcutful, 


Court -Etiquette as a Cause of Madness. 

Dr G E. Mould (Kimher'worth, near Rotherham) Avrites in refer- 
■ e'nce to’ tlio review (December 3rJ, 1927, p. 1034) of Dr; Cnbaiijs'a 
lin'dk.Lc Maf lUriilitaire ; Unless I am greatly mistaken'Philip V 

nfSiiain ■’ - - 'emale Hue, of Charles V. 

How els' ■ l-’o tiuci ratlier than to 

enviroun e eccentricities of the 

j3 ui-boii ■ ■■ mtouud the eugoiiists, 

AHousoM- ■ l>y ot Hapshurg 

ancestors, is the most Virde aud commanding figure among the 
rulers of tlie world. , . . - 

♦ Dr. Mould is Correct iu stating the descout iu the female 
liuB of Pliilip Y, who was the greal-graudsou of Philip IV. But 
no doubt Dr. Mould sympathizes with us iu feeling how dis- 
tressingly his insistence on historical accuracy throws doubt on 
Hio imlBulons theory of Dr. CabanCs. 


' 1928 Motor Licences. 

To assist motorists In comiexion with the renewal of car licences 
^ the Automobile Assooiatiou has issued a booklet. Four Motor 
Tax at a Glance, which sliows the various amounts due for 
licences according to horse-power, either for the j-ear or shorter 
periods.’ Information is also given concerning rebates obtainable 
lu respect of old oars, refunds for surrendered licences, and the 
prooednre for reoewiug licences. Copies may be obtained by 
sending a postcard to the Secretary, A. A., Famim House, New 
Coveutry Street, W.l, or to auy of the A.A. area ofiioes. 


Vacancies. 

Notifications of oEfloes vacant in nuiversities, medical colleges, 
and of vacant resident aud other appointments at hospitals, 
will be found at pages 43, 44, 45, 48, and 49 of our advertisement 
colnmns, and advertisements as to partnerships, assistantships, 
aud looumtenencies at pages 46 and 47, 

A short summary of vacant posts notified in the advertisement 
colnm'uB appears in the Supplaiieiit at page 11. ' - 



Jan. 2t, igiS] 


treatment OE EXOPHTHAIiMIC GOITRE. 


r Tns Bnmsn 
L Uedicu. JoniNAL 


83 


: •. ■ ON ■ 

THE TREA-TINIENT OE EXOPHTHALMIC 

goitre.- 

BT 

A. J. -SVALTON, M.S., F.R.C.S., , 

6UEOEON, LONDON HOSPITAL, 


The necessity of a' close association of medicino and surgery 
is nowlicrc I'noro evident than in the treatment of cxoi>h- 
thalmic goitre, and this must he my excuse, if an exenso is 
necessary,, for addressing yon upon a suhject which is so 
largely medical. It is, indeed, only of recent years that 
operative treatment of this disease has been regarded ns 
justifiable, for many cases are cured hy mcdic.al measures, 
and formerly an operation was a dangerous and hazardous 
procedure. Even ^to-day surgeiy is only safe if combined 
with careful observation and jneliminary treatment. It is 
therefore' accepted by all workers in this field that no 
operation for exophthal.mic goitre should he undertaken 
until a course of medical treatment has been given ; to it 
the patient may react so well that no operation may bo 
thought necessary, or she may improve to such a degree 
that the risics of operation are greatly diminished. 

To operate upon a patient admitted to the hospital or 
nursing home tlie night before is to' seek disaster. It may 
seem tinneccssaiy to stress this )ioint, but I am' still 
occasionally asked to go down to- the country to operate 
upon a case of exophthalmic goitre .wiiich I liave never 
seen and which has never been prepared, usually with the 
added statement that the doctor’s iiartner would like to 
give the anaesthetic and proposes to admini.stcr chloroform. 
To Jiavo acceded to such requests would have raised luy 
mortality figures so high that 1 should not have dared to 
address you u]ion the subject. 

A theoretical, consideration. of the views that have been 
Iield as to whether the symptoms are due to dy.sthyroidism 
01 ' hyperthyroidism, and how they maj' best be controlled, 
would be too lengthy to enter into here, and I propose, 
tho.refo.re, . only to discuss with you in detail the methods 
I now employ, in the belief that in the present state of 
, our knowledge they give the best chance of a satisfactori- 
I issue. 

Every patient is admitted to the nursing home or hospital 
for a period of prelimiiiai'j- observation, during which time 
she may or may not bo told that an operation is contem- 
, plated. This is a matter which caii only be decided in the 
individual case. Some patients who have had the disease 
lor a long period and have received but little benefit will 
have heard of the v.alue of operation, and will look 
foinard eagerly to the . passibility of obtaiuing relief 
thereby. A free discussion of the possibilities of the 
operation will generally do most to gain tlioir coii- 
ndence and calm tlieir - fears, IVIany are, however, 
extiemcly nerA’ous, and are. so^ easily distressed that it is 
JO ter not to lot them know that an operation is being 
^nsideied. They, can,. however, onlv bo kept in ignorance 
It there are hear rblalive's with whom all the difRcnlties 
can e discussed. It is my custom to keep every patient in 
^ ^ ,^’^<?k,with u6 treatment other than rest and a 

inocii icd diet. During this time careful observations are 
inac e or the weight and .appetite and of the presence of 
The jHilse is carefiillv observed 
he.irt noted. The state of tins 
• f ”, utmost importance in determining the value 

n minor cases there is usnallv 

imirmoi-s with no dilatation, although 

T otpi- tho haemic in character mav be present, 

heat s St n of dilatation, l3ut tlm 

been spt-or forcible. 'Where the toxaemia lias 

S'cseS and i continued, auricular fibrillntiou mav be 
bo to determine whether it can 

imnnrtoT.f t w l”?t>niinai'}- medical treatment. It is 
Olid -I + ^J^tcrmuio how the patient sleeps .at jiiobt 
and what .s the condition of the nervous Wrtera. In 
certain cases an estimation o f the basal metiholic rate 

* Given to ttie Eastbourne T>ivifion of tlie British Medical .\ssociation. 


may bo of considerable value, but it is not my custom to 
carry out this method of investigation as a routine 
moasuro. . Not unconmionly.it .causes a good deal of nervous 
upset,- and so mav give a false idea of the general con- 
dition. At the end of a week it will bo possible accurately 
to determine what is the patient’s general state, and an 
index will ho obtained whereby the surgeon can readily 
estimate the reaction to preparatory treatment. 

At the end of a week treatment is commenced. The 
patient is still- kept -wholly at rest in bed, a light diet 
containing no stimnliints i.s prescribed, and with stimu- 
lants must be included meat extracts, tea, and coffee; under 
modern, conditions.it is necessary to state that all tobacco 
•must ho. cut out; otherwise the diet should be full and 
nourishing. . At tho same time largo quantities of fluid 
should- he given, and it is my own custom to administer 
daily one pint of rectal saline. This is given at one hour 
before .thcitiine. of. day at which the operation will idti- 
mately.be carried out. Thus, in cases in a private nursing 
home it is usually administered at 8 a.m., while in hospital 
it. is.given at. 12.30 p.m. The reason for this time of 
4xdministrat ion svill ho shown later. 

:-.The. careful employment of ' iodine is now knoim to 
ho of tho greatest value in controlling hyperthyroidism, 
although, its uso at one time-vas the subject of consider- 
able controversy. Tho hala'rice • of . experimental evidence 
seemed -to show that the sj-niptoms of exophthalmic goitre 
were duo to hyperthyroidism, and the late Profe.ssor Kocher 
held tho view that tho administration of iodine would 
increase tho symptoms or might even - lead to hyper- 
thyroidism, in the ease of patients -with-Bimple goitre. De 
Qnervain discovered, however, that in . certain varieties of 
exophthalmic goitre, tho iodine content of the thyroid 
gland was low, and sometime.s, indeed, lower than that 
foiuid with colloid goitre. Plummer and Boothby found 
that in - certain cases of hyperthyroidism there was an 
insufficiency of iodine, and hence advocated the administra- 
tion of some simple form of iodine in the routine treatment 
of. exoplithalmic goitre.' The value: of 'this drug' ha's' dnee 
been investigated by many observers, and we have been 
-using it- for a long period .at the London Hospital. 
Plummer and Boothby advised the use of Lugol’s solution 
— ^that is, 5 per cent, iodine and 10 per cent, potassium 
iodide in water; 10 minims are given daily. All niy cases 
are given 3 minims of this drug three times a day, -with 
re.snlts which are often lemarkable. The pulse after a day 
or two not infrequently falls from 120 to 80, the patient 
becomes much calmer, and the neivous tremor and excite- 
ment may almost entirely disappear. Sleep is regained, 
tho weight increases, and intestinal upsets may disappear. 
These results appear, however, only to be temporai-j', and 
my own experience closely agrees with that of Eraser— 
that if -tho' drug i.s continued the ^-mptoms tend to 
return, and that if tho dose is increased not only may tho 
beneficial rcsidts fail to apjiear, but the sj'inptoms may even 
he exaggerated. This is not in' accordance with the observa- 
tions of all surgeons. Jackson states that ho could often 
increase the dosage -until 30 or even 40 or 50 minims were 
administered daily • with good results. In all my cases 
where These large doses were tried the symptoms wore 
increased. If the smaller dose was continiietl over a period 
of fourteen days the symptonis also began to return, and it 
w.as necessary to stop the drug for a period. 

It is also of interest to note that the different varieties of 
goitre .appear to react differently to the various forms 
of iodine. In my own experience tho colloid goitres have 
been found to react best with the more simple compounds, 
such as iodido of iron, although these may have to be 
combined with an intestinal antiseptic. Rapidly increasing 
or recurring varieties of adenoparenchymatous goitre, on 
the other hand, fail to react to any form of iodine of 
iodides, hut disappear with thyroid extract. It is hardly 
necessary to point out that patients suffering from 
myxoedema - fail to improve with tho administration of 
iodine, for they have no thyroid tissue to convert this into 
thyroxine,' and yet it is not uncommon to meet with such 
cases which have been ticated with collosol iodine, with, 
of course, no benefit. In my experience exophthalmic 
goitre improves only with Lugol’s solution; iodides have 
but -little effect, and thjToid extract has always seemed 

[ 3498 ] 



84 JAN. 21, 1928] 


TREATMENT OP EXOPHTHALMIC GOITRE. 


[ 


Thk Bbitisk 
U xOZCAL JoOBXAfi 


definitely to incroaso tho hyperthyroidism. In n consider- 
ablo number of cases where tlie disease was in a very early 
stage and tho symptoms slight, tho improvement with tho 
administration of 3 minims thrice daily has been so great 
that operation has been postponed and a continuation of 
tho medical treatment tried. In such circumstances tho 
administration of iodine has boon reduced to 1 minim three 
times a day, in tho hopo that a definite balance could bo 
obtained. With such methods other observers have claimed 
satisfactory, results, but my own experience has rarely 
been satisfactory. Such patients have made very con- 
siderable improvement while in hospital, but on returning 
to their home life, even if they have not returned to work, 
there has generally been a gradual relapse, and an opera- 
tion has had to bo undertaken at a later date. 

As a general rule tho administration of Lugol’s solution 
and tho saline is sufficient to relievo all tho symptoms, but 
in certain cases, and especially if there is considerable 
auricular fibrillation, tho condition of tho heart will 
require special treatment. In these severe toxic cases it 
is always my custom to seek tho aid of tho cardiologist. 
Dr. Parkinson has investigated many such by electro- 
cardiograms, and has not uncommon!}’ been able to restore 
tho heart by tho use of digitalis and quinidino. It is a fact 
of very great interest, to which attention has also been 
drawn by other observers, that a heart which is badly 
fibrillating may bo temporarily restored to normal by the 
use of these drugs, and may apparently bo permanently 
restored by operative treatment. 

Occasionally it may bo necessary to give sedative drugs 
in order to improve tho patient’s sleep, but as a general 
rule the nervousness will bo so much reduced by tho 
administration of Lugol’s solution that quiet and easy 
sleep is obtained. , 

Of the value of x-ray treatment as a means of controlling 
hyperthyroidism I speak with some diffidence, as my expe- 
rience appears to differ so considerably from that of many 
a>ray experts, and it is possible that my series includes 
only more severe or more advanced cases; but in all of my 
series where it has been tried it has been of little or no 
value, and has not, as many have claimed, been capable 
of controlling the hyperthyroidism to any required degree. 
Some surgeons have objected to its use, as they believed 
it caused so much fibrosis that if an operation were required 
later tho difficulties would bo considerably increased. If 
this had been my experience I should have regarded it as 
very strong evidence indeed of tho value of x rays in 
controlling tho increased cellular growth of tho gland, but 
I have never found any noticeable change after such 
treatment, although some of my earlier cases had been so 
vigorously treated elsewhere that tho skin had been exten- 
sively burned. Tlie cases in my series include some which 
have been treated elsewhere and have been sent on to me 
for operation as this method had failed; some which I have 
seen very early and have thought not yet suitable for 
operation; and certain cases where an operation has been 
performed but insufficient gland has been removed, and 
tlie improvement has only been partial. Of the two latter 
groups I have sent many cases to our x-ray department at 
tho hospital, and they have been returned to mo after a 
time as making no impi’ovement. Cases of carcinoma, on 
tho other hand, have shown air astonishing improvement. 

I have one or two in my series where tho gland has been 
enlarged, hard, and irregular, where an operation has been 
performed and the nature of the growth proved, and where 
there has been secondary glandular involvement. With 
x-ray treatment the local symptoms have improved enor- 
mously, and some of the patients have lived from three to 
five years. I have come, therefore, to regard tho x rays 
as showing a remarkably selective influence between the 
overgrowth of a simple hyperthyroidism and a carcino- 
matous overgrowth. 

• Selection of the Time of Operation. 

A careful choice of the time at which operation is 
performed is of considerable importance, both as regards 
the immediate risk and the ultimate prognosis. My cases 
are very rarely oiierated upon in tho first six months of the 
disease, for it is in this period that they are most likely to 
react to medical forms of treatment. Some cases show very 


acute symptoms even in this early stage, with rapid loss 
of weight, the presence of diarrhoea and vomiting and 
distinct cardiac changes. An operation perfoimed under 
such conditions is associated with considerable risk but 
careful medical treatment with tho uso of Lugol’s ’solu- 
tion will generally lead to a rapid improvement of tho 
symptoms. If the improvement is %’ery marked it will 
probably bo better to postpone tho operation for a con- 
siderable period, but if, on tho other hand, it is only 
slight, an operation may be considered necess.ary, while the 
improvement will bo such that it can bo safely performed. 

All cases of Graves’s disease tend to show a periodicity 
in^ tho severity of their symptoms. Several observers havo 
laid stress upon tho fact that tho symptoms are severe 
during tho first six months; they then abate for a year or 
more, to become accentuated again later. There is, in 
addition, a shorter periodicity, tho symptoms varying to -a 
lesser degree almost from .week to week. One of these 
shorter periods of severity is nearly always induced by any 
disturbance, such as removal to a nursing home or hospital, 
and it is chiefly for this reason that no operation should 
ci’cr bo performed within a day or two of tho patient’s 
entering such an institution. Both the long and tho short 
periods are to-day to a very largo extent controlled by the 
judicious administr.ation of Lugol’s solution, and hence it 
is less necessary to pay so close an attention to tho time 
period. Before tho introduction of this method of treat- 
ment it was necessary, after the admission of tho patient, 
to watch her carefully until there was a period of abate- 
ment, and then to operate. Sometimes it might have been 
necessary to keep her in hospital three or four weeks 
before an operation was performed, but nowadaysvithe 
reaction to preliminary treatment is so definite that it is 
ne.arly always possible to operate at the end of a fortnight, 
tho time of operation being selected according to the 
patient’s symptoms rather than to any definite time 
period. 

In more advanced cases secondary changes are not infre- 
quently found in the heart and kidneys, and in some 
severe examples in my series there has been a profound 
degree of auricular fibrillation with the signs of cardi.io 
failure. Such cases always carry with them a greatev 
operative risk, but it is remarkable to what a degree their 
symptoms may be improved by a preliminary course of 
medical treatment and by tho use of Lugol’s solution. 

I luivo in my series some very interesting cases of women 
who had severe auricular fibrillation which entirely, dis- 
.appeared with rest and iodine, although it had reacted 
but little to the previous administration of quinidine. The 
auricular fibrillation occurred again immediately after opera- 
tion but it was again soon controlled, and tho patients have 
since remained well. Although such cases are always more 
serious it is well to remember that without operation they 
will probably progress, and that surgical treatment alone 
holds out any hope of definite improvement. It is true 
that even this measure may fail to bring about a complete 
cure in a seriously disorganized heart, but it will nearly 
always prevent tho condition piogressing. 

Another fact upon which I have often laid stress is the 
reaction of these patients to heat, and it is my usu.sl 
custom therefore, to refuse to operate in the hotter periods 
of the summer. Possibly in the future preliminary medical 
treatment may also be able to overcome this difficulty, 
but even yet I do not feel safe in this resiiect, and still 
refuse to operate in the veiy hot periods. 

Prognosis with Different Types of the Disease. 
Clinically three varieties of this disease may bo recog- 
nized. There is the condition which may occur as the end- 
result of a colloid goitre. The patient, usually a young 
girl, has for many years had a simple colloid goitre and 
then begins to develop tho signs of hyperthyroidism. 
such cases the thyroid is relatively big and the evidence 
of hyperthyroidism is often comparatively slight. Suclx 
patients react well to treatment, and tho operation is not 
generally associated with much risk. The second type abo 
occurs in young women, but shows evidence of hypm' 
thyroidism from the beginning. It is characterized again 
by a relatively largo thyroid, by marked exophthalmos^ an 
vascular changes, but the nervous element is comparatively 


TREATMENT OF ESOEHTHALMIO GOITRE. 


t TmtBBtnsa OK 
Medicxi. JoxniJiAL 


JAN. 21, 19*8] 

aiglit. 'Hicso cases, nvo ns a rule imich improvca by pr^ 
liniinnry luedicnl treatment. Ti\cy stand tlio operation well, - 
and make good immediate iiost-oporativo progress. The 
third variety is scon more often in women at or aliont tlie 
age of tiic monopanso. The tliyroid is often smaller, harder, 
bnd moro irregular. The most characteristic symptoms 
-tare seen on tho nervous side, these patients heing oxtrenicly 
Irestlcss, and often sliowing movements that are almost 
■ifchoroic. blontal symptoms arc also very marked. Tliej' 
-arc generally excitable or melancholy, and sometimes even 
suicidal. They always stand operation less well than tho 
last two varieties, and tho post-operative progress is rela- 
tively slow. They also can bo much improved by pre- 
operative treatment, and since the introduction of tho moro 
modern methods ono is able to cari-j' out operative treat- 
ment with a much happier mind. 

Choice of Aiiacsfhcfic. 

In this matter there is considerable divergence of opinion, 
but all are agreed that chloroform must never be used. It 
seems to be almost a specific poison. In former times, 
'when the mortality was extremely high, many of these 
’'patients died in the preliminary stages of anaesthesia, death 
•■Uiciiig entirely due to the use of chloroform. Ilaiiy surgeons 
'prefer a local aiiacbthetie or gas and oxygen. My own 
' prcfclcnce is for general anaesthesia with such highly 
‘iiciTous patients, and a light ether aiiacsthesi.i is always 
"used. To lessen the distress to the patient of the removal 
' to the theatre and of tho early stages of induction, ether 
"is administered by the rectum. On the day of the 0 )>era- 
■■ tion the rectal saline is replaced by a mixture of olive oil 
3 oz. and pure ether 3 oz. It is for this reason that the 
saline is always administered three-quarters of an hour 
before the time at which tho operation will ultimately be 
performed. Generally this umoiint is sutrieient to induce 
a very satisfacton- anne.sthc.sia. Tho patient is taken into 
the theatre either completely under or showing a few 
of the unconscious movements found during the period 
of induction. The anaesthesia is then continued cither with 
a small quantity of ether on' an open mask or by the use 
of warmed other vapoui-. It is usually tound when the 
patient has recovered consciousness that she has had no 
knoivledge whatever of being prepared for the operation, 
or indeed that tho operation has heen performed. It must 
alivdys be remembered, however, that in so inducing anaes- 
thesia the niininium amount must be given, and even- in 
men I have never found it wise to give more than 3 oz. 
of ether in the rectal mixture. 


Post-operaticc. Trro/moif. 

IVIieii tho p.^ticiit has been returned to bod the ether 
and olive oil are washed out from tho rectum. As soon as 
consciousness returns tho patient is given morphine and 
atropine, and 1 have no hesitation in repeating this drug 
sufficiently to control all post-operative restlessness. In 
some severe cases it may bo necessary to give three or four 
injections (J grain) in the first twenty-four hours. The 
other iiiijiortaiit stop is to administer large doses of fluid. 
As soon ns the jiatieiit is conscious, fluid .should be injecteil 
by the rectum. I jirofer plain water to the usual saline, as I 
believe it is more easily absorbed. As soon as possible large 
quantities of fluid should be given by the mouth. With 
such measures the reaction after operation is often quite 
slight. Tho temperature may amount 'to 99° or 100°, but 
usuail}' falls again to normal within a few days. Tlie pnilse, 
which immediately before operation may have fallen to 
80 or 90, generally goes up again on the day of operation 
to 120, but rapidly falls, and is often down again to the 
pre-operative state within tiiree or four days. I liave not 
a.s a rule found it necessaiy to administer Lugol’s solution 
within this period, but if there is a more marked reaction, 
ven' considerable benefit may be gained by its administra- 
tion, and there is no doubt that it is a very useful aid in 
controlling jiost-operative hyperthyroidism. During this 
important post-operative stage the patients should always 
be kept as quiet as possible, and in hospital wards it is 
our custom to have them screened off from the rest of the 
ward, and also kept as cool as possible, electric fans being 
freely utilized. 

Opcrctficc Penuitx. 

In spite of every care in the jireparation there is still 
a very definite mortality which will vary according to the 
surgeon’s method of selecting his cases for treatment. 
Advanced cases, where there are already secondarj- changes 
in the heart and other viscera, will stand operation some- 
what badly, and hence, if a surgeon is prepared to attemjit 
the cure of these serious and distressing cases, his operative 
mortality will be relatively high. Several series have been 
recorded in which the mortality was reduced to some 3 or 
4 per cent., and Pemberton has published a- group of over 
1,000 cases whore operative inoi-tality was under 1 per 
cent. The usually accepted risk is about 5 per cent. In 
my own group there were 189 cases with 10 deaths, a 
mortality of just over 5 per cent., although it is less in tho 
more recent cases. It has always been my custom to offer 
the help of operative treatment to very advanced cases in 
which there is no other hope of cure. With the use of 
Dugol’s solution the outlook is greatly improved, and the 
mortality has been much reduced since its introduction. 
My series included 170 females and 19 males, aiiproximatelv 
1 in 10 males. In 1923, when writing on the same subject, 
I quoted the experience of Murray, that in recent years the 
proportion of. males had been increasing, and stated that 
up to that time my experience had not been in accord 
with this. Since then, ho-wever, there has been a definite 
tendency in this direction, so that in the last 41 cases 
there have been 8 males, a ratio of 1 in 5. 

In estimating the value of any operative procedure the 
end-results, and the progress towards such results, are of 
even more importance than the immediate mortality. Of 
niy 189 cases 7 must be deducted as having been performed 
for too short a period to estimate tho end-results of treat- 
ment. Of the remaining 182, 9 died as the result of 
operation, leaving 173 for investigation of their after- 
results. Of these, 95 (54.8 per cent.) are completely cured. 
They have no physical signs and no symptoms of their 
disease. The 95 have been observed for the following 

periods: for five years 47, for four years 12, for three 

years 8, for two years 14, and for one to two years 14. 

Forty-six (that is, 26.5 per cent.) are sufficiently cured 
to be able to live a normal life, performing their usual 
duties, and in the majority of cases earning their own 
living. They still, however, have a mild degree of tremor 
or some slight exophthalmos, or even a pulse which is casilv 
increased in rapidity. Of the total, therefore, 81 per cent, 
have been converted from a condition of invalidism to people 
I who are able to live normal lives. Some of the fortv-six 


■ilethod of Operaiing. 

In some of the more serious cases it was the custom to 
carry out a preliminary ligation of one or more of the 
arteries before considering resection. I have never per- 
formed this operation, but preferred, even before the intro- 
duction of Lugol’s solution, to watch these cases carefully, 
and by selecting a time of operation to carry out a partial 
resection. With the modern methods of preliminaiy treat- 
nient ligation of the arteries alone aill probably be 
a audoned. inierover possible a considerable portion of 
_ie gland should be removed. My usual procedure is to 
excise one lobe, the isthmus, and the lower portion of the 
ligature the vessels of the superior pole 
o us remaining lobe — ^that is to sav, about three-quartei-s 
or rather less of one lobe is left, 'and even in this tho 
ciieu ation is controlled. Dnlcss the left lobe is the bigger 
+ 1 ,/!^ ^'^uallj more convoniont to remove the right lobe. If 
” l’®cl operative risk, one may have to be 
cni t.?;!, + 1 ^* 4 * "i ^^rooval of only one lobe, but it is almost 
m operation, although followed bv very 

'“’provemeiit, will not lead to a complete cure,- 
Operative steps will he required later. Some 
which is ^ more symmetrical operation, 

cco f "i ^ extensive form of the douhle wedge- 

“"“id goitres. In my 
hnemnrrlnrr'^ operation is more likely to give rise to 
dpserihod ^’'mefore I prefer the removal as 

insortod ' ^ fomll drainage tuhe should alwavs he 

reaction has abated P^^t-operative 


86 Jan. ai, 1928] HTPERTONIO SOLUTIONS IN INTRACRANIAL PRESSUKB. 


who still hiivo symptoms Iiavo been operated upon at a 
relatively short period, and will almost certainly continuo 
to improve until they are completely cured. Three of the 
cases have developed a considerable hypertrophy of tho 
remaining portion of tho thyroid, and have had little or 
110 improvement of their symptoms. It is probable that they 
may yet bo improved by further operation, which is now 
contemplated. In addition to these, 3 others, who had 
apparently passed to a state of complete cure, relapsed 
owing to some severe mental stress, 2 of them as a result 
of having been exposed to air raids. These have since 
improved so much under medical treatment that no opera- 
tion has been contemplated, although they still have some 
evidence of the disease; 8 have died since operation — one 
from pneumonia; one during a confinement; 2 six and four 
years respectively after tho operation, apparently from con- 
ditions not connected with tho thyroid; one developed car- 
cinoma of the skin owing to an x-ray burn and has since 
died from this; 2 were said to have died from heart disease, 
which must bo regarded as being dependent upon their 
Graves’s disease; one developed diabetes and died, and 
although all symptoms of Graves’s had disappeared there 
is so close a relationship between these two conditions that 
this fatality must be included as a post-operative possibility. 
In addition to the patient who died from diabetes, one 
other has diabetes, which is controlled by medical treat- 
ment, and she has no symptoms of exophthalmic goitre. 
She has therefore been included among the group who aro 
relieved. Nineteen have been lost sight of. 

These results may be tabulated thus : 


Quite cured 



... 84 

Greatly relieved 



... 46 

No better 



... 3 

Died after operation... 



... 9 

Late deaths 



... 8 

Lost 



... 19 

Belapsed 



... 3 

lei 


It is justifiable to claim, therefore, that as a result of 
operative treatment there will be an immediate mortality 
of about 5 per cent., a late mortality of under 2 per cent., 
a certainty ,of complete cure in about 55 per cent., and of 
sufiicient relief for the patients to earn their own living 
in comfort in 81 per cent. — results which are unlikely to bo 
obtained by medical treatment alone. 

It is important, however, to realize that there is not an 
immediate cure as a result of operation. I have on several 
occasions pointed out that the post-operative progress passes 
through several stages, which may be classified as follows : 

1. The Stage of Keaetion. — This is tho dangerous post- 
operative period, and it lasts from three to four days after 
operation, the symptoms in the majority of cases being 
due to a definite post-operative hyperthyroidism. With 
modern methods of operation it is much less in evidence. 
If tho symptoms become serious they can generally be 
controlled by the administration of Lugol’s solution, of 
large quantities of fluid, and of'morphinc. 

2. The Stage of Primary Improvement. — Within a fort- 
night from operation a great improvement is nearly always 
manifest. Many patients before leaving hospital have a 
normal pulse with no tremor ; they aro eating and sleeping 
well, the exophthalmos may be much reduced, and the 
improvement from their condition on admission is often 
startling. 

3. The Stage of Primary lietapse. — Nearly always on 
returning to home conditions there is a disappointing 
return of the symptoms. The relapse is slight in degree, 
but it is because of its presence that a rather prolonged 
convalescence is required, and that tho patients must be 
carefully watched and treated for a considerable period. 
As a general rule, it does not last longer than four to six 
weelts, but if the case has been so severe that it has only 
been possible to remove a relatively small portion of the 
thyroid, the patient may permanently remain in this stage, 
and although showing improvement will not pass to a stage 
of complete cure. This is not uncommonly a difficulty with 
such cases. It is evident that further operation is required 
to bring about a cure, but the patient may be so mueli 
relieved that she refuses to go through the discomfort of 
a second operation. 


[ Tin? 

Mxdical Jocn5jLX> 

4. Ihe Stage 0 / Apparent Cure, — After a few months 
tlicso patients lose all their symptoms. There is no cnlar/'c- 
nient of the thyroid, all nervousness disappears, tlie pulse 
IS normal, and tho exophthalmos slowly disappears. TJio 
patients appear to be absolutely cured, and if everything 
is satisfactory they w'ill pass on to a state where they are , 
absolutely cured. It is only by having watched many ca'^es' 
that one realizes that during -this period any severe mental.!^ 
shock or upset may bo followed by an enlargement of the " 
remaining portion of tho thyroid and by recurrence of' 
tho symptoms. It is very difficult to estimate how long 
this pciiod lasts, but it would appear to persist for one 
or two 3 ^ears. At the end of this time the cure is appa- 
rently complete, for not only aro tho patients free from 
all symptoms, but they seem to bo able to face all normal 
distui-bniices and upsets with no fear of a recurrence of 
tho symptoms. 

Litcratutie. 

1. <lc Qiicrv.'xin, F, : Goitre, London, 1924. 

2, Fraser. P. R. : Iodine in. Exophthalmic Goitre, BniTisir 3 Iedic. 4L 
JounNtL, 1925, I, p. 1 . 

3. Jackson. A. S. : Iodine as an Aid to Surgery in the Treatment of 
Exophthalmic Goitre, Lancet, April 11th, 1925. 

4. Murray, G. : Discussion on Exopthalmic Goitre, Bnmsii MEDiaL 
JouiiNAL, 1922, ii^ n. 908. 

5. Plummer, H. S., and Boothby, W. 31. : Journ, loxca State Med. Soc., •- 
1924, p. 1400. • 

6. Pcml)crton, J. ! Slorlality in the Suri»ory of Exophthalmic Goitre. • 
Surg. Uifnecol. and Obtlet., April, 1923, p. 458. .j 

7. Walton, A. J. : The ElTcct of Heat upon Operations for Exophthalmic 
Goitre, British Medical Journal, 1923, i, p. 1045, A Consideration of Some 
Cases of Exopthalmic Goitre Treated by Operation, Lancet, 1914, i, p. 1387. 
Tlic Operative Treatment of Exonhthalmic Goitre, Praclitionfr, October, ’ 
1914. Fifty Cases of Exophthalmic Goitre Treated by Operation, Practu - 
tioner, October, 1917. Discussion on the Medical and Surgical Treatment 
of Graves's Disease, Prnc. Roy. Soc. Med., July ^st, 193, p. 42. Surpery = 
of tho Thyroid Gland, Lancet, July 14th, 1923, p, 53, and August 11th, 
1925, p. 267. I 


^ JCrrtitK 

OX 

THE USE OF HYPERTOOTC SOLUTIONS IN THE 
TREATMENT OF INCREASED INTRA- 
CRANIAL PRESSURE,’!’ 

BY 

W. RUSSELL DRAIN, M.D., M.R.C.P., 

ASSISTANT PHYSICIAN TO THE LONDON HOSPITAL AND TO THE 
HOSPITAL POK EPILEPSY AND PAEALYSIS, MAIDA VALE. 


Two cnrclinnl facts about tbo skull and its contents foim 
tho basis of a true understanding of tbo pathology of tlio 
intracranial pressure. Tlio skull in the adult is a rigid 
case which is incapable of expansion, andithe total volume 
of tho intracranial contents is therefore constant. These 
contents may for practical purposes ho regarded as three — 
tho brain, tho cerebro-spinal fluid, and the blopd in tlie 
blood vessels. Sinco their total volume m constant, an 
increase in tho volume of any one of them can only occur at 
tbo expcnso of tbo volumes of ono or both of the others. 
For example, if tho brain becomes enlarged by tho growth 
of a tumour there miist necessarily be a corresponding 
decrease in tho volume of tho blood or of the cerebro- 
spinal fluid, or of both. Such readjustments can only occur 
to a very limited extent without raising the intracranial 

pressure. , . , ■ ^ • i 

Tho most obvious way to reduce raised intracranial 
pressure is to abolish in part tho rigidity of tho skull— in 
other words, to perform a decompressive operation. This 
was till recently tho only method available, and it is stijl 
tho method of election in certain circumstances. Ihero 
are however, a number of conditions associated with 
increased intracranial pressure in the treatment of wliich 
such a serious operation is unjustifiable, and others again 
in whicli it is to be avoided if possible. My present object 
is to describo another method of lowering the intracranial 
pressure ivhioh has many therapeutic applications, and 
which can be used sometimes as a substitute for, and 
sometimes as an adjuvant to, craniectom}'. 

The Physiological Action of Hypertonic Solutions. 

Wo owe to AVeed tho discovery that hypertonic solutions 
can bo used to lower tho intracranial pressure. \Veed 

•Delivered to tlie South Middlesex Division of tho British Jledical 
Association. 


87 


Jan. 2T, 1928] HYPERTONIC SOCTTIONS IN ISTRACRANIAr. PRESSPEE. 


ir.icctcd inlmvonously into niiimnls n concontrntccl solution 
ot sodium cldorido, iind showed that a pionounccd fall in 
the ni’cssuro of tho spinal fluid occnvrcdj and that if paid, 
of tho shull wore first removed shrinkage of tho brain could 
bo ohsevved to follow tho injection. Further investigations 
d^'hionstrated tho means by which these results wpro brought 
aljout. Tho intravenous injection of hypertonic solutions 
raises tho osmotic tension of tho hlood, and so leads to tho 
passage ot water' from tho brain into tho hlood strc.am. 
There is an actual resorption of cerebro-spina! fluid, which 
passes up tho perivascular spaces into tho cerebral capil- 
laries, and, according to some authorities, also passes hack 
into tho blood through tho choroid plexuses. Tho result is 
a marked fall in tho intracranial pressuro. It was not 
long before other workers demonstrated that tho same 
results could ho achieved Ic.ss directly by administering 
hypertonic solutions by way of tho alimentary canal. These 
raise the osmotic tension of tho blood by withdrawing water 
into tho intestine. 

jl/odcs 0/ Adminisfratinn. 

1. Inirarenovs Injcciion . — Intravenous injection is used 
when it is dosiied to lower tho intracranial pressuro as 
rapidly ns possible. Tho most convenient hyiicrtonic solu- 
tion for intravenous use is a sterile solution of sodium 
chloride in distilled water. Tho maxiinnl dose is lOO c.cm. 
of a 30 per cent, solution, and I have given this amount 
in certain conditions without ill effects. For most jiur- 
poses, however, this is more than is ncoossary, and it is 
sufficient to give 70 to 100 c.cm. of a 15 jior cent, solution, 
or half these amounts of a solution double tho strength. 
Some workers employ concentrated solutions of glucose, 
for which certain advantages aro claimed. It is said that 
after the intravenous injection of glucose the fall of intra- 
cranial pressure is slower and more sustained, and is less 
likely to be followed by a reactionary rise than after 
the use of sodium chloride. Moreover, glucose jiossesses 
■nutritive value, and is of hoi]) in combating shock and 
acidosis. The maximal dose is 100 c.cm. of a 50 per cent, 
solution in normal saline. IVhothcr sodium chloride or 
glucose solution is employed, it should ho administered 
very slowly at a rate not exceeding 3 c.cm. a nuiuito. 

Administratian hj the iloMth , — To obtain comparable 
results by oral administration it is ncoossary to give largo 
arnounts either of sodium chloride or of inagnesinm 
sulphate. The dose of the former is 16 grams, given in 
^-gram capsules with 80 c.cm. of water, and of the latter 
3 ounces of a 50 per cent, solution. Oral administration 
possesses certain disadvantages, and 1 have not employed 
U to obtain a rapid reduction of intracranial pressure. 

epea cd doses of a half to one drachm of magnesium 
EU p la e, however, may be given by tho mouth when a mild 
continuous action is desirable. 

3. IfeefnJ Administration . — This is the most generally 
usetui way of giving hypertonic solutions. Tho dose is 
solution of magnesium sulphate, 
slowly into tlio rectum at body tem- 
lint' Unless it is retained for half an hour it will 

later* ' effect and should be repeated an hour 

fwportance in the use of hypertonic 
hv delivit he mentioned. Since the method operates 
rktricted ""f ti” I^f'ent’s intake of water must be 
mfnnfshl I’® obtained. Solutions of 

travronsK. be given in- 

produce 

The rectal iniertionc respiratory paralysis. 

produce irritation of the reew"*^ frequently, may 

'iVe now come "tT the Contusion. 

are amomhlp t oonsideration of conditions which 
tions We on-^to^T hypertonic sohi- 

ontity of a conditioT,*'’^re'i ’ocognition as a clinical 
• “ pereistent ccrebrel c^m ^ '^,Po’'haps best described as 
tninor head inTurv^;*?’ 

time gives rise tn s!m* i'^’ “ which at the 

iiot asiefated n^tli Sof™""^^ 

OSS of consciousness and produced by a 


fall or a blow. Following such an accident a patient may 
develop a train of symptoms which are only too familiar, 
and which, sinco they aro often extremely disabling, are 
of considorablo medico-legal importance. The principal 
symptom is headacho, which may not appear until the 

f iationt gets up, if ho has been confined to bed following 
lis injury’. Tho headache is paroxysmal and is sometimes 
extremely severe. It is especially liable to be brought on 
by mental excitement, muscular exertion, and stooping — 
activities which often lead also to giddiness. Tlie patient 
is usually nervous and irritable, and may develop a typical 
anxiety neurosis. There aro as a rule no physical signs 
of a gross injury to the brain or of raised intracranial 
pressuro, but in a considerable number of cases brady- 
cardia is present. It is unusual for radiograms of the 
skull to show any abnormality. 

The persistence of the symptoms, which may endure for 
mouths or years after the injury, is explained by refer- 
ence to the pathology of the condition. A blow which does 
not fracture the skull may, owing to the elasticity of the 
calvarium, nevertheless produce a localized contusion of the 
brain. Such a contusion is characterized by’ the extrava- 
sation of blood and plasma from damaged vessels. Owing 
to the rigidity of the skull, the brain, as we have seen, can 
only swell at tho expense of the cerobro-spinal fluid and 
the circulating hlood. The localized area of oedema due 
to tho contusion thus becomes surrounded by an area of 
impaired circulation, which prevents the removal of the 
exudate, a vicious circle being established which it is the 
object of tre.atment to break. 

Tho prevention of persistent cerebral contusion is to bo 
achieved only by the adequate treatment of the case in the 
early stages; but the method of treatment is the same 
whether the case is seen early or late. Rest is the first 
essential, and the patient should be absolutely confined to 
bed and not allowed to get up for any purpose. Hyper- 
tonic solutions are employed to lower the intracranial 
pressure and assist in tho absorption of the exudate. In 
mild cases it may be sufficient to give half to one drachm 
doses of magnesium sulphate thrice daily by the mouth, and 
this may be usefully combined with 10 grains of potassium 
bromide. Intravenous injections of hypertonic saline, how- 
ever, aro more effective and should, if possible, be used in 
all cases. The usual dose is 100 c.cm. of 15 per cent, 
sodium chloride in distilled water, and this may be re- 
peated in four or five days if necessary. In some cases one 
such injection is sufficient to free the patient from head- 
ache, and, since the treatment is curative, he may then 
be allowed to get up. If medical measures fail, a sub- 
temporal decompression can usually be relied upon to relieve 
the symptoms, but it is hardly ever likely to be necessary if 
hypertonic solutions are given a fair trial. Early treat- 
ment of cerebral contusion is of great importance, since 
if the patient is given time to develop, in addition, an 
anxiety neurosis, he presents a much more difficult problem. 

Head Injuries in the Acute Stage. 

Cases of head injury in the acute stage present many 
difficulties, both of diagnosis and • treatment, which’ can 
only be successfully met by the close co-operation of surgeon 
and neurologist. Hypertonic solutions are of definite value’ 
ill treatment, whether or not operative intervention is 
undertaken. They can be used ns an adjuvant to decom- 
pression to aid in the reduction of cerebral oedema. They 
may tide the patient over the difficult period when opera- 
tion hangs in the balance, and so render decompression 
unnecessary; and they undouhtedly promote recover5’ and 
diminish the risk of sequelae in the milder cases of con- ' 
fusion and concussion in which operation is not indicated. 

In all cases of severe injury the intravenous mode of 
administration should be used, and the glucose solution 
would seem to possess the advantage of combating acidosis ’ 
and shock. Hypertonic solutions, however, should not be 
employed in any form if shock is profound, as indicated 
by low temperature and blood pressure, and a rapid or 
rising pulse rate. The treatment of head injuries by 
hypertonic solutions is the rational use of methods which in 
the form of free purgation with calomel and salines have 
been used empirically for many years. 


[ The Bnmra 
UzotCAi. JotnutxL 


88 Jan. zi, 1928] 'EXPERIMENTS IN MALNUTRITION. 


. . Jninicraiiial Titinour. 

To explain liow relief can bo obtained by inoan.s of Iiypor- 
tonic solutions jn cases of intracranial tnmonr it is iioce.s- 
sary to give a brief account of the ivay in rvbich a ri.se of 
intracranial pre.ssnro is brought about in this condition. 
AVo may recognize three factors wliicli eontribnto to this 
result — the direct prossuro of tho tumour, the effect of tlio 
tumour upon the intracranial circulation, and the com- 
bination of both of theso factors to produce internal hydro- 
coplialus. It is easy to understand that the growth of n 
tumour w'ithin tho brain raises tho intracranial pressure in 
its immediate neighbourhood. In addition, by pressure 
upon surrounding veins, it raises the venous pressure locally, 
pnd in many cases tliroughout tho whole cranial cavity. 
Tho local venous congestion leads to oedema of areas of 
brain surrounding tho tumour, and so intensifies the local 
rise of pressure. The main causes of internal hydro- 
cephalus in cases of intracranial tumour are obstruction 
to tho free passage, of fluid from tho ventricles by tho 
tumour, and tho general rise of intracranial venous pres- 
sure, wliich leads to both increased formation and impaired 
absorption of cerebro-sjjinal fluid. Thus an intracranial 
tumour sets up a series of vicious circles whereby the 
intraci'anial pressure, once raised, tends to rise more and 
more. 

Tho value of hypertonic solutions in cases of corobral 
tumour lies in tho fact that they hroak these vicious circles 
and permit a readjustment of tho volumes of the intra- 
cranial contents which may last for a considerable time. 
This thej^ do mainly by reducing the formation and increa.s- 
ing the absoiption of corcbro-spinal fluid, and so tempor- 
arily relieving tho hydrocephalus. Tho following are tho 
chief indications for employing them. 

1 . . 4 « an Aid io Diarjnosis . — Not uncommonly a patient 
with an intracranial tumour is in a semi-comatose condition 
when first seen, and is quite unable to co-operate in tho 
examination of sensibility or tho visual fields. In such 
cases two or three rectal injections of magnesium suljihato 
solution ma}' be sufficient to restore tho iiatient to conscious- 
ness and render a full examination po.ssiblo. 

2 . In Kineryencies . — If a patient with an intracranial 
tumour suddenly becomes comatose, as may occasionally 
hapjion after ventriculogra)fliy or in other circumstances, 
an intravenous injection of hypoitonic saline may reduce 
tho intracranial prossuro sufficiently long to permit 
operation to ho performed. 

3 . dj Pallintii'c Treatment . — In inoperable cases or while 
a patient is awaiting operation it is often possible to relievo 
headaches and vomiting by giving magnesium sulphate 
either by the mouth or by the rectum. 

Cerchral Haemorrhage. 

Both Leonard Hill and Cushing showed a good many 
years ago that the injection of fluids under pressure into 
the subarachnoid space led to a rise of blood pressure. 
This response of tho vasomotor centre to a rapid rise of 
intracranial pressuio is responsible for yet another vicious 
circle in intracranial jiathologj’. Tho majority of cerebral 
haemorrhages occur in- patients whoso blood prossuro is 
already high, but the haemorrhage, by raising tho intra- 
cranial pressure, tends to cause tho blood pressure to rise 
still further, and this in turn favours tho continuanco 
of the bleeding, or may even result in further haemorrhages 
elsewhere. Thus a lising blood jn-essuro in a patient with 
a cerebral haemorrhage may be taken to indicate that tho 
bleeding is still continuing. On tho strength of theso facts 
it has been urged that venesection is contraindicated in 
cerebral haemorih.agc, because tho medulla is already 
threatened with anaemia, and to withdraw' blood from 
circulation is to add to its difficulties. Those who hold 
this view' advocate lumbar puncture as tho correct treat- 
ment, since by this means tho intracranial pressure can 
be directly reduced w ithout restricting tho blood supply to 
tho medulla. When tho intracranial pressure is low'cred 
it is said, the blood pressure will fall, and the bleeding is 
then likely to stop. 

These arguments against venesection and in favour of 
lumbar inmcture do not take account of all the circum- 
stances. I have never seen benefit result from lumbar 


puncture in a patient suiTering from cerebral haemorrhage, 
and I heliei'o it to ho defiiiitely contraindicated in simh 
cases. Thoj-e are two serious risks attaching to it. The 
fall of pre.ssuro in the spinal theca m.ay lead either to the 
rupture of the haemorrhage into one of the ventricles or 
to the downward displacement of the contents of tile 
posterior fossa into tho foramen magnum, in either cy?e 
with rajiidly fatal re.sults. Venesection, on tho other hand, 
could h.ardly have enjoyed so enduring a reputation in the 
past as a mode of treatment of cerebral haemorrhage if its 
results were uniformly harmful. If it merely reduced the 
blood ])rcssurc without at tho same time low'cring the intra- 
cranial jiressuro it would clearly' bo a dangerous procedure. 
Actually, however, since tho intracranial pressure is ulti- 
mately dependent on the blood pressure, a fall in the blood 
pressure leads to a reduction of tho intracranial pressure. 
Moreover, a diminution in the volume of the circulating 
blood also leads to a fall of intracranial pressure. Hence 
tho theoretical risk of increasing the medullai-y anaemia 
is compensated by the relief afforded by a lowered intra- 
cranial prcssiu'c. Further, wo must place to the credit 
side of tlio transaction tho tendency of the lowering of tlfe 
blond pressure to check the haemorrhage, its relief of the 
strain upon the heart, and its influence in increasing the 
coagulability of the blood. Venesection is therefore a 
rational form of treatment for cerebral haemorrhage. 

Hypertonic solutions have only a limited value in this 
condition. Intravenous injections are contraindicated as 
tending to raise the blood pressure, and if is doubtful if 
the rectal mode of administration can influence a haemor- 
rhago which is still in progress. Tho rectal injections, 
however, may be of value ns a means of reducing the intra- 
cranial pre-ssure in patients in whom thoro is reason to 
believe that the haemorrhage has stopped but who show 
no signs of recovering consciousness. Free purgation 
reduces the intracianial pressure in exactly tho same way 
as hypertonic solutions administered by the alimentaryr 
canal, and possesses the same physiological justification. 

Other Conditions. 

There are other conditions associ.ated with increased 
intracranial pressure in the treatment of which hyper- 
tonic solutions are useful. In tho post-operative treatment 
of cerebral abscess they may be used to reduce oedema of 
tho brain around tho abscess cavity, and so diminish a 
tendency to herniation and iiromoto drainage. They are 
also of value for the relief of headache in epidemic 
encephalitis and meningitis. Other applications will 
suggest themselves, but enough has been said to show 
that Wee-d’s discovery has rendered available thorapeutio 
methods of the greatest value in diseases of the nervous 
system. 


EXPEKBIENTS IN MALNUTRITION/' 

BV 

V. H. MOTTRAM, M.A.Camb., 

PnOFBSSOR or PIIVSIOI-OGy ix the university of rondon, and heap 
or THE rnrsioLOGY rabobatory, king’s correge for women 
(IIOUSEUORII AND EOCIAR SCIENCE DEP.IRTMENT) . 

The lines along which a diet may be inadequate so as to 
entail malnutrition arc many. It may bo insufficient in 
quantity or in quality. It may yield too little building 
material (protein mainly), too little fuel materia! (fats, 
carbohydrate, and surplus protein), or too little m the 
wav of catalysts (mineral matter— for example, iron, iodine, 
calcium— and vitamins). The quality of the proteins may 
be poor— cereal proteins not having the biological value 
of meat or milk proteins. Tho diet may be inadequate 
because it has too little (or even perhaps too much) 
roughauc, because tho proportions between the diftereiit 
constituents aro wrong, or because tbe way in which the 

food is presented is wrong. ,.rr , 

It is clear from this that it is extremely difficult to 
work out experimentally the differe nt pc^sibilities ot 


• A lecture delivered to the SI. Pancras Division ot the British Medical 



Jan. i f, ifiss] 


EXPERIMENTS IN MALNUTRITION. 


r Tzir Barnsn OQ 

LilEOICAL JOCRXXL ' ® 


wrongne.ss of diet. Only a fe^v broad hues aro to bo illus- 
trated hero by experiments on animals. It is not main- 
tained that all, or any, of them aro directly applicable to 
the feeding of human beings. But they may point the way 
for observations to bo made on human beings, and that is 
why they aro now being offered. . . 

Bread is an inndequato diet for a nursing mother rat 


■ 



■ 





' 

/ 

i 



■ 







■ 



■ 



t. 

r 



■ 



■ 






/ 

■ 









S 

r--' 

n 


I 

■ 

, 





1 



.•7 









_ A 



/ ^ 







cl'-"' 

[pS-' 









0 




- 








...t- 








i 



i 7 

s r 

7 r 



Fig. 1.— The growth rate o( two eets of suckling rata when 
their mothers are on a poor diet (bread) and a good diet 
(bread and milk) respectively. At the ninth day, when the diets 
were cnnngcd In both coses — In one from good to poor and in 
uie other from p^r to good— a change In the rale of growth 
was almost immediate. - 


and her offspring during the nursing period. Fig. 1, for 
the data for which 1 am indebted to Dr. Gladys Hartwell, 
brings out tbo point very clearly. Suckling rats whose 
mothers are receiving bread grow at but half the rate 
of those whoso mothers are on hre.sd and milk. Moro- 
immediato response to a chaiigo in diet. 
liJtJiin twenty-four hours a chaiigo from a good to a bad 
diet, or from a bad to a good, shows up on the offspring’s 
weight record. * 


Fig. 6, BO ns to bring out more clearly the facts stated 
above, but scientifically it is not quite fair, because 
although the three upper growth rates were obtained from 
most carefully controlled material used simultaneously, the 
growth rate on bread alone was obtained the year before 
at a somowlint later date in the year and on stock slightly 


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Fig. 3.— llaximal rate of Erowlh on a niL\ed diet. 


heavier. (The dotted lino in Fig. 6 shows the actually 
observed growth rate.) 

Tho inadequacy of bread is, apart from possible defects 
in vitamin and salt content, due both to the small quantity 
(8 to 10 per cent.) and poor quality of its protein. If this 
holds true for man— as is likely— there is nothing to be 
gained by using other wheat-flour foods such as macaroni, 
with its slightly higher proportion of gluten. IVhat is 
needed is the addition of proteins which will “ supple- 
ment ” those of bread. Cereal proteins have but small 
amounts of lysine present in their molecules, while animal 


1 i.°"r ^ ■ '’l^^^finacy of broad is not duo maiiilv to its 

° vitamins A and D, to its poverty in vitamin B, nor 
0 1 s lack of mineral matter. Young rats put on a diet 
o 'qad, mineral matter, butter, and inarmite grow voi v 
grams per day. Such a diet is 
kiUq **^Sdi'ds vitamins A, B, and D, and as regards 

npi- rip ■ ® ®kicd diet grow at the rate of 4.7 grams 

B^rl 7 ^ three and a quarter times as fast. (Fig.s. 2 

•) may be that either tho quantity or the quality 


■i 





n 


i 








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/Mrs 





(i) by ^addtn^^ These possibilities can be tested 

“Bd (ii) proteins of white flour, 

as casein ^o i ^ “®tiiowledged first-class protein, such 
the sroir’ih r,e vitamin diet, and observing 

proves the o-rpr, *i '^ke addition of gluten im- 

deficLni L « 

Btill further Jm content. If tbo addition of casein 

see Fi<r Ki +i P™ves the grmvtli rate (which is the case — 

knUrribi’qualhy'orurptteim^ 

einpting to superimpose these four curves, as in 



proteins, even gelatin, have relatively much larger amounts. 
Consequently, the addition of gelatin, which by itself is a 
useless protein,* = to a wheat protein” or to bread* results 
in a mixture which has high food value. AVhite bread 
supplemented with gelatin enables young rats to grow 
better than upon white bread phis gluten.* 

The inadequacy of bread is shown not only' in the growth 
rate of young animals, but in the deficiency of their coats. 
They become bald for a time, though they ultimately grow 
hair again. Their final coats on a bread diet are never 






00 JAH. ai, igaS] 


experiments in malnutrition. 


. r TiirUnmw 

L MADICAL Jorm<r«g. 


so thick as wJien tho animals receive a control mixed diet. 
The fault lies with tho low quantity of protein in the 
bread, for addition of extra gluten j)rcvents tho occurrcncd 
of baldness. So, too, do casein and gelatin,- though addi- 
tion of vitaihin B does not.’ An allied result is tho paling 
of tho pigmented areas of the animals’ coats. Rapid 
growth with poverty of diet loads to groj-ing of tho' hair, 
which darkens again very soon if satisfactory protein, such 
as casein, is supplied.' 

A further interesting and significant fact is that the 
inadequacy of bread shows more clearly with males than 
with females. Normally tho male I'at is larger than tho 
female, but upon an inadequate diet, such as bread, his 
growth rote is smaller. This is partl 3 - due to the nature 
of the -protein, for if an'aninml protein is added to the 
diet tho male regains his normal snperioritj-, while if onl\’ 
gluten bo added ho does better than on bread alone, but 
onlj’ equals the female in weight. (It is interesting to note 
that gelatin supplements the jn'otcins in bread in this 
resjJect too — the combination of two jiroteins, both poor, 
results in a pabulum which, if n'ot quite first rate, is better 
than bread •plus gluten.) 

Tho extra grovrth of the male is dependent on another 



Fig. 5. — Growth rote on n diet of - bread, salt?, and vitamin con- 
taining materials to which casein trom mill; was addei], 

factor as well — vitamin B. The addition of a preparation 
from j-east containing no protein (though amino-acids aro 
present) enables the male to resume his normal coinjiarativo 
stature.’ Perhaps it is the co-operation of these two factors 
(better protein and more vitamin B) which accounts for tho 
slightlj' improved growth when brown bread is used instead 
of white in experiments on malnutrition. 

This raises at once the problem of the relative merits 
of brown and white breads. The main trouble of entering 
such a discussion is that the protagonists on each side have 
an odium for the other almost theological — a sure sign of 
the insecurity of the foundations of their beliefs.* 

There are some fundamental ad hoc exiieriments’ on the 
relative values of brown and white bread which have rarciv 
received attention from either part}- of combatants. Rats 
of highly stable stock were placed on a dietary of bread 
(white or brown), salt mixture, and water. The brown 
bread was baker’s bread made from whole-meal from which 
a poi-tion of the white flour had been removed — that is, 
it was “ super ” brown bread, and had more of the 
materials supplying vitamin B and protein thfin straight 
whole-meal bread. The experiments showed that white and 
brown breads are equally good — or perhaps we had better 
say equally bad — ^for the gi-owth of female rats, for gesta- 
tion and lactation. Only in the growth of the males was 
the broivn bread superior. How bad tlioy both were can 
be seen from the fact that males and females starting at 
about 40 grams would, on a normal diet, be well over 

• S^ an acrimonious correspondence in the Lancet, Xovember 26 lh 
and December lOtli, 1927. 


100 grams in weight at tho end of four weeks, the females 
on brown or white bread weigh only 'about 65, the males 
on wJiito 65 anti on brown 70. Even tho best grown animals 
on either bread grew at only lialf tho rate of those on a 
mixed diet. 

There is thus in these experiments little evidonco except 
as to tho badnc.ss of white and brown bread as tho sofp 
source of proteins and calories. Tho marked superioriiy 
of brown over white bread, claimed by its adherents, can 
bo due only to its greater content of mineral matter — 
2 )oiiit which the above experiments unfortunately do not 
.settle. The i-csults of the exclusive use of brown or white 
bread were so bad that it seemed not worth while to cany 
tho exjicriments further. 

Tho crying need at the iircseut moment is for experiments 
comparable with those on the food value of milk carried out 
by Dr. Cony Mann' under tho au.spices of the Ministry 
of Health and the Medical Research Council. It will be 
remembered that in these experiments the boys in one 
of tho houses of a charitable institution, all fed from tho 
same central kitchen, received in addition to the normal 



lict one pint- of milk per day. It would be easy, thoiigh 
omewhat costly, to cany out a similar experiment on tlie 
acrits of brown bread in the feeding of growing boys.- 
)no house could have the white bread normally served 
ubstituted by brown bread, and the effects, if any, observed 
v er a period of two or'three years. Until such experiments 
lave been carried out,- and until -they show a positive 
esult there seems no reason to act upon the advice 
if the enthusiasts for brown bread and compulsorily upset 
ho fliptotic liabits of the nation. 

A. sido of the experiments on malinitntion of the 

p-^wing animal is, how long does it take " 

he deflective diet is given during the fiist half ot the 
luvsing period the answer is, not during the nursing 
■ i^r iriD- 11 • if after weaning, recovery fiom its 
fleets t-rkes a?i- ulmxpectcdly long tfme.; Thus thirteen 
iSs’ malnutrition, due to a deficit of quahty and quantity 
f m-oteiii hut of nothing else, produces such a retardation 
f growth that it is seven weeks before the animals approxi- 
aafr n wcWit to the controls, though they receiver diet 
ihich iiramotes an optimal gi'owth rate. In this human 
eincs Apparently behave veiy differently from the expen- 
a^tM Ifled ratA the results of five mahiutntion 

aay be obliterated in as little as six 

eason for this difference is that a day is so much greater 
nerceiita-e of a rat’s life than of a human beings, 
'hh-teen da°ys is about one-tenth of a rat’s growing period, 
VG weeks 0110 two-kundrecltli of a chilcl s. , 

It is not only in direct feeding of a young growin„ lat 




JAN. 21, 1928] 


EXPERIMENa'S IN MALNUTRITION. 


t Tn« BamrH- 

UjUICH. JOUBHAi 


91 


tbAt tho iuadcquncv of diet ... .mulo apparel. Iho 
saL is truo, as was stated above .u_ tl.o opoa.nB para- 
graphs, during lactation. If tl.o n..r.s...g n.oti.er rat has 
L Ladequato diet it results ..t oueo ... a s ow...g of tl.o 
R.-owtli of tl.o offspring.'” A cl.ango ... tl.o d.ot from 
adequacy to inadequacy or v.co ve.sa res..lts ,n a cl.ango 
tho rato of tho g.o.vth of (I.o you..g. (F.g 1.) T .0 
ipohlcm nt onco arises: What .5 the best diet during tho 
qiirsiiu- period and after? As regards the brief iieriod of 
nursing, bread and milk is tho best yet iiivosligated, and a 
mixed diet '(kitchen sciaps from tho studciits’ hostel) for 
tho rest of tho nniwnVs e.xistcnco. It is iiossiblo that a 
mixed diet would he equal to tho bread and milk diet for 
tho nursing period, but owing to technical difTiciilties 

that has not yet been 
investigated. Fig. 7 
shows tho growth rates 
of suckling rats when 
their mothers aro on 
different simple diets." 
It will bo noticed that 
broad and meat is 
neai'ly equal in value to 
broad and milk, while 
bread alone, brcad-and- 
biittcr, bread and dex- 
trin aro far behind. 
Mont alono gives a very 
poor growth, which may 
bo duo (1) to tho im- 
po.ssibility of eating 
sufilcicnt bulk of food, 
or (2) to tho lack of 
balance botivccn tho ex- 
cess of protein and tho 
vitamin D in tho diet 
(vide infra). 

An attempt to im- 
prove tho value of tho 
diet of bread alono by 
adding a commercial 
]ii'otcin led to a curious 
result which cannot bo 
without significanco in 
pioblcms of l.unian 
nutrition. IVlicn a mix- 
ture of ono part by 
weight, or even less, of 
protein to three parts 
of bread is given, tho 

about ten davs and .1 . • 

•of, a striking character'" '“'T 

*Rnn«:mc a: ilioro orc violent tetanic 

-exhausted. Should” 

there is a ram'd ^ changed 

tho mother is not mVrt dio, whereas 

-ndif sh:7oertoS.:':^^A“f?'=‘<:''. Slm may lose weight. 



• m part 


froTYi extent tho young are protected 

about the eighteenth'll tho fits aro delayed till 

The animal,°in bet W; ""-cl' 

there were a permanrnr 

supervene dashes violent tbo .fits 

rolls over in convulsions with 

position. Death is til i ^ jan's Joclfcd in an open 
on growth rat© whon sequel. Fig. 8 shows the effect 

se results can ho“ 

‘ties of milk in '.''■o'ded by giving large 


These 

quantities 


^ “ud an extended investiga- 

proved that it is tho vitamin B 


- 

preparation wliioh ''hich obviates tho trouble. Any 
■amount, siich " -“"V'""® ''•'ta ' " • 


Vitamin B in considerable 


.at norm nvt ” t' of potato, tomato, or 

L“>d°ham,en/„“1’„”‘’ “T'" extract, will pro- 


carrot, ’wheat 
■.■ont uutoward°li™ 

•.cing .'P offspriim^s’p'"”S®-'” It lias been shown that, to 
m the diet the nine’ ®®^olIy, when there is much protein 
^ nuich vitamin needs three to four times 

diiction,» A tentaf Ivl for growth ^and ropro- 

trovertod" hut iinw o^Plenation," onco vigorously con- 
cssoatial as a catalvst /“opted," is that vitamin B is 
or excessivo protein metabolism. 


That tracM of such a condition should not make their 
iippoaranco in tho nursing of children is inconceivable, 
though up to tho momoiit of tliis lecture wo arc ima.vare of 
any description of this. Tl.o old-fashioned but still common 
inothod of feeding the nursing mother on plontv of 
“ strengthening food ’’ — that is, a high protein diet — while 
cutting lior off fiom vogotahles and fruits, with the excep- 
tion of tho complotoly useless grape, is surely heading for 
trouhio if nutritional work on animals has any bearing 
upon human nutrition. That they have such a bearing can 
hardly bo denied, as work upon xerophthalmia (kerato- 
malacia), hori-bori, scurvy, and rickets shows. It is truo 
that results obtained upon animals under laboratory con- 
ditions of careful control have to bo confirmed upon human 
beings under tho much moro difficult conditions of private 
piaclico, where tho world is the laboratory and scientific 
conti’ols aro almost impossible. And sometimes the findings 
on human beings conflict with those of the laboratory," 
tboiigb nono tl.o 
loss tl.o labora- 
tory results must 
not bo neglected. 

They may lead 
to the discovery 
of bitborto un- 
recognized syin- 
ptoms of disease, 
may help to cx- 
plain already 
known symptoms, 
and point tho 
way to tho )U’o- 
vontion or cui-e 
of disoaso in 
human beings. 

It is in the hopo 
that the results 
of tl.o experi- 
ments upon 
nutrition briefly 
outlined above 
may bo of value 
ill clinical work 
that they aro 
hero presented. 


Summary. 

1. Tho inade- 
quacy of bread 
as a diet is duo 
mainly to the in- 
adequacy of tho 
quantity and 
quality of its 
protein. 

2. Animal pro- 

t e i n s, c V o n 

gelatins, supplement tho proteins of bread, and the mixture 
has a high biological value. 

3. Males need moro protein of high biological value and 
more vitamin B than females. 

4. Both brown and white breads are, by themselves, poor 
articles of diet. There is as yet no direct evidence that in 
a mixed diet brown bread is supei-ior to white. 

5. There is strong evidence from animal work that for 
successful nui-siiig of young the vitamin B content of tho 
diet must bo high. 



Fio. 8.— Tho cHect oi excess protein in the 
diet of a nurainj: mother on the offspring:, 
and a method of counteracting it. The upper- 
mo'?t curve is a control curve with mothers on 
bread and milk. Tlie cun-e which declines 
sharply after ten days records the weights of 
sucklings whose mothers have a diet of bread and 
excess of protein. The intermediate curve shows 
the effect of adding a source of vitamin B to the 
diet with excess of protein in it. It. almost 
obliterates the evil effect of excess protein. 


Referexces. 

Blartin, C. J., and Robison, R. : Biochem, xyi p 407. 

Robison, R. : Ibid., 1922, xvi. p. 111. and iqi2 5*ii t> 233 

Osborne. T. B., and Mendel, L. B. : 

Hartwell. G, A. : Brit. Jowrn. of Exper. Biol., 19-5, ii, p. 

Idem : lliochem. Journ., 1925, xi-x, p. 75. 

G. A.: Proc. Phys.ol. Soc.. Joan.. 
11 ('-i 1 ifL.i. i924,^^Ux^, ij* Journ., 1921, -xv, p. 1-10, 

«5. 

8 and 825. / 

[ill : Journ. Phf/sioh, 1922, In, p. 413. 

J. C. : Biochevx. Journ., 1926, xx, p. 1256. 
stefinsron,' V. : Journ. A;iier. lied. Aisoc.. 1918. ' ■ . 



-92 Jan. 41 , 1928] ■ DISEASES OP FATILTY NUTKITIOK. f Ti.Minmm 

^ LMjdicadJoubxii, 

lUmarhs 


ON 

DISEASES OF FAULTY NUTRITION.*' 

BY 

R. McCARRlSON, C.I.E., M.D., P.R.C.P., 

Lieut.-Colosel I.M.S. ; 

mEECTOn, DEFICIESCY DISEASES INQUIEV, INDUN KESEAKCll FCXD 
ASSOCIATION. 


[Ai'iEit observing that tlio functions of food ncro to rcliuild 
the living tissues, to supjily energy, and to preserve ii 
proper niedinm in ivhieb the bioclieinical proee.ssc.s of tlie 
bod 5 ' could talce place. Colonel AIcCarrison said that the 
failures of food to subserve these functions were brought 
about in a number of ways; that Avith ivliieh he would 
deal Avas the insulEcient projiortion of one or other of all 
three of the essential constituents of a diet — namely, suit- 
able protein, inorganic salts, and vitamins. The first 
effect of such nnsatisfaciory foods Avas a Ioav standard of 
physical efficiency; this prevailed in many parts of India, 
both in man and his domes-tic animals; minor manifesta- 
tions of ill health might thus he produced AA'liieh might 
escape observation, although, as Hopkins had said over 
twenty years ago, they “ affect the healtli of individuals to 
a degree most important to thennselves.” In animals this 
subnormal nutrition Avas shown by loss of “ condition,” and 
by impainnont of fei-tility and of the poAver to roar their 
young, which were prone to disease and h.ad a high 
mortalitA'. If the deficiency Avas more prononuced distinct 
disease AA'as produced in man, such as keratomalacia, 
night-blindness, dental caries, polyneuritis, beri-beri, 
pellagra, scurvy, rickets, osteoporosis, .slow healing of 
fractures, .sterility, anaemias, some types of goitn', ali- 
mentary d 3 -strophy, gastric atony, diarrhoea, constipation, 
intestinal stasis, colitis, unhealthy skin, disordered action 
of the adrenal glands, stone in the bladder, and ve-ical 
irritabilitj-. In domestic animals likeAvisc there Avas a long 
list of disease conditions attributable to this cause ; they 
Avoro recognized by veterinarians to be duo to deficiency in 
the diet, especially in mineral elements. 

The relation of malnutrition to di.soase had main- aspects, 
and progress in its comprehension depended on the clo.sc.st 
co-operation betAveen students of human, of animal, and of 
plant nutrition. The fact that one of the most important 
means bj’ Avhich disease is brought about, both in man 
and animals, Avas by increasing susceptibility to infectious 
agents Avas illustrated by the folloAving statement:] 

Dming tlic past Iavo and a Iialf roars 2, <163 rats, living in my 
laboratories under conditions of perfect hygiene, have been fed on 
various faulty foods, Avliile Uie daily average of control or AA-clI-fcd 
slock rats Avas 865. The mortality in the ill-fed animals (excluding 
those that Averc killed on the conclusion of certain experiments) 
Avas 31.4 per cent.., AA'hile in the Avcll-fcd animals it Avas Jess tliaij 
1 per cent. Of the former 13.5 per cent, died of lung diseases 
chiefly pHoumonia or hronclio-pneumonia, Avhile only 0.63 per cent' 
of the latter died from the same cause. Of tlie ill-fed animals 
3.3 per cent., died of acute gastro-iiitestinal disease; of the well- 
fed only 0.09 per cent. During the same period 1,252 previonslv 
healthy pigeons Avere fed on A-arious diets deficient in Aitamins 
tlio average number of stock or control Avcll-fod birds beiiw 33l’ 
Of Uie ill-fed birds 5.8 per cent, died of heart disease, riiicflAi 
pericarditis, Avliile of the Avell-fcd birds only 0.06 per ccut. died 
from this cause ; these figures being exclusive of 137 birds Avliicli 
developed true beri-beri Avith iu accompanying heart disease. In 
the course of my own Avork I liavo seen true dysentery arise in 
ill-fed monkeys, Avhile AA'ell-fed monkeys living in the sanio 
animal room escaped; and I have seen ill-fed pigeons become 
infected Avitli BaciJIus suipcxli/cr and with the invisible vims of 
epithelioma contagiosum, Avhile AAell-fecl birds living in their 
immediate vicinity escaped these infections. The bacillus of mouse 
typhoid kills, on injection, over 90 per cent, of ill-fed mice, while 
it kills less than 10 per cent-.-of AA-ell-fed mice; the ill-fed mice 
are likeAvisc less resistant to J). pestis cariac .md to botuHiais 
toxins. Birds are rendered susceptible to infection by antlirax 
Avhen fed on food deficient in vitamin B, and rats to septic 
broncho-pneumonia when fed on food deficient in vitamin A • 
guinea-pigs, A\dieii fed on food deficient in vitamin C, die more’ 
readily from tuberculosis; ill-fed calves develop inlei-stitial 
nephritis due to B, coli infection; SAAnne suffer from tuberculosis, 
Avhich can be eradicated from the liei’ds by Avell-balanccd vitamin- 
rich food ; stock animals develop sarcosporidia from the same mal- 
nutvitional cause. Man himself provides many examples of a like 
kind; I need but mention tAvo : in northern Melanesia the natwe 

from a paper opening .a discussion on the subject at the 
the Far Eastern Association Tropical Medicine in 
'.aicuua, December, 1927. 


diet lias been slioivn (o lie deficient in suitable protein, miners 
clcmciils, and vitamins, and tlio poor physir|ue of (he native 
and their high ilealli rale fl-om respiratory and intestinal disease 
have been correlated Avilh these deficiencies in, the food; outhreak 
of lironcho-pncunioiim in children have been definitely traced t 
the inadocjiiato ingeslion of fat-soluble A, and liavo been cause, 
to disappear by ilie adequate provision of this vitamin. There i 
good reason for tlie assumption that tuberculosis, leprosy' cholera 
dysentery, plague, and malaria liavo often in India a mal 
nutritional element in their genesis and course. 

Tlio foIIoAviiig im.ssages are taken from tlio coiieliidin{ 
.section of tlio iiapcr. 

IVitliin rocTMit joars “ the spectacular results aaIiIcIi liaA’t 
attimiled the exjicrimcutal study of vitamins Inu-e oA-er 
sliadoAA'cd niiicli else in mitrition, both in the minds of the 
profession and the public ” (Mendel, 1923). It maj- not he 
iiiappro'iiriate, tlicrcforo, to refer to a class of disease 
Avliicii results from the lack of balance of Aarions com- 
ponents of the food, each conjponont in itself gooel. One 
example of the kind is afforded by the In-porplastic goitre 
AAliich may result from an excess of butter in the food. 
The exco.ss of Imttcr, or of iinsatAi rated fatty acid, causes 
thyroid liA-])i'iplasia li}' reason of the rolatiA'o deficiency of 
iodine hrmight about hj' this excess; similarlj-, enlai'ge- 
inoiits of the tliAuoicl gland of the colloid ta pe, may bo 
iiidiicod In- an excess of lime; thej' are ])i-eA-ontahlo by 
inercasing the iodine ingested proportionatciA- to this 
excess. -Vnothcr examjile of much the same sort is that of 
stone in the bladdei-, Avliich is brought about in rats by 
ill-balanced diets containing miieli oatmeal; Avhole-Avheat 
flour, or Avhito flour. To avoid “ stone ” the excess of 
these ccioals must he compensated for by the consumption 
of appropriato amounts of milk. Those most excellent 
foods oatmeal and Avhole-Avhont flour — the staple articles 
of diet of SAich vigorous race.s ns the Scots and the Sikhs — 
may likcAA isc prove harmful, by causing distAirhance in the 
iioniial pi-ofcssos of calcification, AA-hcn — hut only Avlien — tho 
diets containing them are poor -in vitamin D. These cereals 
are not in themselves comiilete foods; a fact of Avhich the 
races using them as staiile articles of diet are not Avliolly 
ill iTiioranet. — tho Sikh does not attempt to subsist -on ntia 
(Avliolc-Avhcat flour) alone, nor the Scot on oatmeal. Any 
ill effect wliich these two foods may exorcise is due to the 
failure suitably to combine them Avitli other food materials 
w-hicli compensate for their defect's. They arc not to he 
condemned nor to he disiilaced from their prominent place 
in the dietaries of mankind for this reason. As Avcll might 
Avo condemn tlie good fuel, petrol, for tho OA-erlieating of 
the civdiios of oiir cars AA-hcn we fail to supply them Avitli 
sufficient oil, as to condemn the excellent Avlicat and oats 
Avlion AVO fail to consume Avith them sufficient quantities 
of milk or other A-itarain-rich foods, Avliich are required by 
the hnnmn machine for its smooth and efficient running. 

The same kind of misunderstanding -siiiroiinds the 
controversy Avliich periodically rages over tho relative values 
of Avhito bread and broad made from Avhole-Avhcat flour. 
Both arc excellent foods, though neither is a complete food; 
and since man requires a certain amount of snitahlo pro- 
tein of mineral salts, -and of vitamins as AA-ell as of cavho- 
hydrates, tho superiority of the one bread over tho other, 
as tlio staple article of diet, lies in tho extent to Avhich it 
excels as a source of these essentials. Seeing, therefore, 
that Avhito bread is notably more deficient in suitable pro- 
tein in vitamins (both A and B), aud iu certain essential 
salts’ than bread made from AA-liole-Avlicat flour, or, indeed, 
tliaii’ any other single food entering into the dietaries of 
Western peoples— Avith the exception of sugars, starches, 
.and fats aa Iu'cIi are marketed in the pure state (McCollum) 
—it is iiy this much the poorer foundation upon Avhicli to 
build a well-balanced diet. Those AA-ho can afford to build 
upon it, and Avho jmsscss tho i-cquisite knoAvlodgo to build 
Aviscly, iiave little need to fear nutritional ailments, though 
their building is improvident, Avliile those Avho cannot— aud 
there arc millions of such— arc in grave danger of disease. 
Next then, in importance to tho quality of the various 
iiigi-o’dients of our food is their right combination. _ 

In exporimeuts oil rats I found that tho AvcU-halanccd 
vitamin-rich diet of the Sikhs is superior to any synthetio 
diet I can devise, and to Avhich A-itamin.s in the form ol 
yea,st and cod-liver oil are added. I do not IjelieA-e that 
human beings can have too much vitamins Avhen they 


7 ah . 21, 1938] 


rEBNICIO'US ANAEMIA TBEATED -WITH LIVER DIET. 


[ TnEUBrnsn 09 
JIJEWCAI. JOTBSll. 


*' mo ialtcn in tho form in ■n-liich Nature prbviaos tliem 

’ in wcU-balanced combinations of unsoplusticatccl food 

I materials. Some indmdnals appear to require more vita- 

J mins than othcre’, size being an important factor in deter- 

^ minin"' tbeir requirements; some species of animals require 

' ,.mdre of a particular kind of vitamin than otbers; more .arc 

'• -aiccded for reproduction than for grou-th, and more for 

optimum well-being than for tlio prevention of tbe named 
, deficiency diseases; more nro required by tlic lactating than 
by the lion-lactaling animal, and more for longevity than 
for a shorter life. The amount needed varies with the 
composition of the food, with its balance in other essentials, 
and with its digestibility; more of one vitamin is required 
■ .when the food is verj' rich in another — as, for instance, 

' more vitamin C when the food is rich in vitamin D; there 

^ is for optimum nutrition an ordered balance even amongst 

I the vitamins themselves. In short, the amount of vitamins 

’ needed varies with the mctaholic requirements of the 

' individual; the attainment and maintenance of physical 

perfection, heavy work, reproduction, lactation, digestion, 
exposure to cold, infectious and debilitating diseases, arc 
all indications for tlioir liberal supply. 

, Before bringing this brief survey to an end 1 will refer 

' ■ 1 [to, another aspect of the matter ; the effect of vitamin 
deficiency in increasing the susceptibility to certain poisons, 

, which tiic work of Smith, McCIosky, and Hendrick has 
i! recently brought into prominence. Deficiency of vitamin A 
increases the susceptibility of mice to hotiiUuus toxin, and 
, al=o their susceptibility to mercuric chloride. Deficiency 
of the same vitamin induces in rats an enonnouslv in- 
.. ciyeased susceptibility to morphine, to ergotoxinc. and. in 
lesser degree, to histamine. Deficiency of vitamin B like- 


wise increases greatly the susceptibility of rats to ergo- 
toxinc and to pilocarpine. Stimulants of the central nervous 
system arc all more toxic to rats receiving too little 
•vitamin A than to well-fed animals. 

Observations of this kind suggest that the ability of 
the tissues to detoxify certain poisons — ^both bacterial and 
.other— is reduced by diets deficient in vitamins: while 
indicating that such diets increase the sensitivity of the 
nciTons system and of its autonomic division to toxic 
agents. Not only may this be so, but the disturbances 
of metabolism which result from vitamin insufficiency may 
themselves give rise to toxic metabolites which exercise 
specific effects on certain organs and tissues of the body. 
This I believe to bo the case in beri-beri. Most of us will 
probably agree that there is such a thing as a specific beri- 
beri-producing poison, though disagreeing as to whether 
it be produced in rice before this food is ingested, or in 
the intestine by some bacterial agent introduced with rice, 
or in the course of a disordered metabolism arising out 
of vitamin insufficiency. Our di.sagreements will not greatly 
mattcr so long as we recognize the prime importance of 
a sufficiency of the antincuritic fraction of vitamin B in 
preventing beri-beri. 

The newer knowledge of nutrition is, I am convinced, the 
greatest advance in medical science since the days of Lister. 
iVhen ])hysicia)is, medical officers of health, and the lay 
)niblie learn to a])ply the principles which this newer 
knowledge has to impart, when they know what malnutri- 
tion means, when thej- look upon it as they now look upon 
sepsis, and learn to avoid the one as much as they now 
avoid the othei’, then will this knowledge do for medicine 
what asepsis has done for surgei'y. 


rERNICIOUS ANAEMIA TREATED 'WITH 
LrnjR DniT. 

BY 

E. A. rHILLIPP.?, M.D., B.Cu.C.vxt.mi. 


The following case appears to ho of some interest in view 
of the severity of the symptoms, the age of the patient, 
and the rapidity of the improvement witli liver diet after 
a prolonged course of arsenic had failed to produce appre- 
ciable alteration in the blood count. 

A widow, aged 68, had had no severe illness, thourti alwavs 
clelicato felie had undergone hysterectomy (with ? double ovari'o- 
ffie age of 35, and had taken H grains of thyroid extract 
myxoedema.- Her husband died three 
''<• breakdown ” two years later, and 

'™n, aisenic, and strychnine for anaemia: 
these she took on and off until January, 1926. 

occurred 'and crs'd.'^u'’'^*^ with oedema 

oecunen, ana gradually extended up tlic lees. lu Jamiarv 1927 

c™, plained of mornffig 
ness The diarrhoea, we.xkncss, and brealhless- 

T ■ “'T “™brane.s were pale. 

Public Hoiltli on toI? I'ahoratories of Pathology and 

1 iiwic Health on November 12lh, 1926, -was as follows : 

White cells mononuelcars ... 

Haemoglobin .i! « cervenf Pe'ymorplionuclears ... 

Colour inUev so per cent. Large mononuclears ... 

Eosinophils 

.roilrflocytosis marlredly present. 

ocytosis and polycutomasin present. 

liaemorrliawpt; tiv? v® exaggerated. There -were no rciin 
albumin oi“pn*gnr.^ normal in colour and contained i 

a^lepnc"'p'olar“‘tvas'''*fSo^^a^’u^ »’ 

her clinifTl followed by temporary improvement 

which noccssitaleVTreafm"n^'f"' 

Prom IMnv 4 « o for ten days, 

tablets (er "l/Pn taking arsenious ac 

'condition 'had imnJo after food), but although the clinic 
September intli somewhat, a blood - count done i 

til by the same pathologists showed no improvemeni 


39 per cei 

53 

b 

2 


Red cells ... 
IVliite cell? .. 

Haemoglobin 
Colour iedex 


1,670,000 
2,500 
... per cent. 
... 1.30 


Small mononuclears ... 43 per ce 
Large mononuclears ... 5 

rolyraorphs 50 

Eosinophils 1 ’ 

Hast cells -1 *’ 


'''■“yea moderate rariations in size, large aver; 
ho abnrtnlarwVue edfs.® polyehromasia. a 


She was first soon by me on September 20th, 1927, and was then 
vci*y yellow, weak, and breathless on exertion; she complained of 
palpitation, sore tongue, eructations after foo’d, and tingling and 
numbne<.s of the feet. The tongue was beefy,” dark red, and 
tender, the lips and mucous raembranes pallid. There was a slight 
systolic murmur at the apes. There was no oedema of the feel, 
but cutaneous anaesthesia, both cpicritic and protopathic, of both 
feel and legs up to the thigh. Heat and cold were well appre- 
ciated. The knee-jerks and ankle-jerks were normal, the plantar 
reflexes fle.xor: the skin over the feet was dry and atrophic. 
Vibration was appreciated in the tibiae. 

A blood count by Dr. J. Bamforth of St. Thomas’s Hospital, 
on October lltli, was as follows ; 


Total red cells ... 1,910,000 
Total leucocytes ... 2,080 

Haemoglobin ... 42 per cent. 
Colour index ... 1.1 


Polymorphs ... ... 38 per cent. 

Small lymphocytes ... 44 ,, 

Largo lymphocytes ... 8 „ 

Eosinophils 2 „ 

Large hyalines ... 7 „ 


• There was much poikilocytosis and auisocytosis. Punctate baso- 
philia was present; megaloblasts found. The blood count corre- 
spontled in all particulars with that of a true pernicious anaemia. 

For a fortnight before tlie taking of this blood count the patient 
had been so weak and ill, and comidained so bitterly of persistent 
diarrhoea, that tbe arsenic had been suspended and sbe was 
having only dilute hydrochloric acid (m xv thrice daily). She was 
then extremely weak and ill, and was only capable of leaving a 
sofa for meals, which was a necessity. 

On October 11th a diet containing 7 oz. of calf’s liver per 
'diem was given, partly as raw sicved piilp and partly as cooked 
liver. The raw liver (4 oz. sieved weight) was given mixed with 
half a cupful of orange juice with water added, and taken at 
11 a.m.; the cooked (5^ oz. fried) liver w^ taken as the evening 
meal with a rasher of bacon. Fresh fruit and vegetables were 
recommended and fats other than the bacon and butter were 
forbidden. Ostclin tablets (one thrice daily after food) were 
.proscribed, tbe rest of the diet being to taste. At the end of a 
fortnight from the commencement of treatment improvement 
became evident. The lips were redder and the j’ellow tint paled. 
She was then able to walk' freely about the room. Diarrhoea 
ceased, and she has since continued to improve. The cheeks are 
now no longer pallid. 

On November 22nd a further blood count by Dr. Bamforth gave 
the following result : 


Total red cells ... 5 580,000 Polymorphs 68 per cent. 

Total leucocytes ... 7,200 ' Small lymphoevtes ... 17 ,, 

Ilaemoglolun ... 72 per cent. Large lymphocytes ... 2 ,, 

Colour index ... 0.65 Large hyalines ... 4 „ 

Eosinophits 8 „ 

Hast cells ... ... 1 „ 

No poikilocytosis or anisocytosis. 

At pi-Gsont (December 2ncl, 1927) the patient is apparently 
in good health, though thin; her appetite is not good, the 
lips and nmcotis membranes are no longer pale, the lemon 
tint lias almost entirely disappeared. 




84 £1, 1928 ] THE THTEOID AM) MANGAKESE -TKEATMENT OF DISEASE. 


Slio still complains of a feeling of broatlilcssncss, but 
tliis ivas a featuro of tlio “ nervous breakdown ” two years 
ago. Anaesthesia to pinprick is still present, but is patchy 
in distribution. Epicritic sensibility a]>poars to show 
definite improvement. The feet are bluish in colour and 
the skin is dry and atrophic ; numbness, tingling, and cold- 
ness of the feet are still complained of, though loss so. 
Knee-jerks and ankle-jerks are present and equal; the 
plantiir reflex is flexor. No retinal haemorrhages can bo 
found. 

She is now permitted to replace one portion of the liver 
with underdone steak or kidnej-s on three days a week, .and, 
oddly enough, prefers to replace tho cooked portion rather 
than tho raw. Tho raw liver can also be conveniently given 
in sandwiches or in a jelly, which can be flavoured to taste 
with bovril, lemon, etc. 

It is, of course, too early to make any clahn to permanent 
elfcct, but the rapidity of improvement appears to be 
remarkable in a patient of this age. 

My thanks are due to Dr. H; M. McCrca tor his kindness in 
givino- me full particulars of the patient’s past history and 
treatment, and to Dr. J. Bamforlh tor tho blood counts. 


THE THTROIH AND MANGANESE TREATMENT. 

A Suggestion with hegaud to its Possible Mode 
OF Action. 

BT 

HERBERT W. NOTT, IM.R.C.S., L.R.C.P., 

GUILDfORD. 


Nb.vhlt three years have elapsed since this treatment was 
promulgated ; it has been widely and successfully prac- 
tised, and the time seems to have arrived for a tentative 
investigation as to its possible mode of action. Some good 
will have been gained if such an inquiry helps to dispel 
certain views which are quite misleading. For example, 
the reports of acute pneumonia being rapidly cured by 
rectal injections of a solution of potassium permanganate 
have led some to disagree with the title of the treatment 
and suggest that the thyroid substance may be unnecessaiw, 
the possibility being overlooked that, by using potassium 
permanganate in the way we do, the thyroid gland may 
he relieved of its load and be allowed to function normally, 
Net this was clearly foreshadowed in a paper in this Jooiw.^i. 
in 1925 (vol. i, p. 443), where, under the heading of 
“ goitre,” the following results of treatment were given. 

Parcnchyinatoiis Goitre . — Four cases arc reported to bavo 
quickly responded to the treatment, two of them without the use 
of thyroid extract. One fe inclined to relapse, unless she keeps 
up the treatment occasionally. c j ,, , 

Exophthalmic ffoifre.— Three . mild cases find themselves veiy 
much better, with increased weight, and diminution of symptoms, 
after a few weeks* to a few months’ treatment. Two advanced 
cases describe themselves as ** less nervy, and the swelling of the 
neck has diminished in size. One case of enlarged thyroid gland 
is reported as having been on the point of having the operation 
of thyroidectomy, but shortly after the treatment was used 
operation became unnecessary. In another very severe case no 
relief at all was obtained after five weeks continuous treatment, 
with injections. 

Since then nothing has been more obvious to numerous 
observers than the satisfactory reduction in the size of 
goitres, so that, whether the thyroid substance is produced 
by the’ individual directly, or whether it is necessary to 
.administer it where greater inefficiency exists, the treat- 
ment need not bo looked npon as incorrectly named. 

Some have loosely ascribed its action to the liberated 
oxygen, without explaining how this occurs. That it 
camiot bo due entirely to oxygen seems quite certain, or 
why should we not get similar good results from the use 
of sodium permanganate? 


Basic Principles Vnicrhjing Treaiment. 

In this paper it is suggested that an increase of oxid.a- 
tive processes in the tissues and fluids of the body is 
produced by the interaction of manganese, potassium, 
thyroid gland substance, and the liberated oxygen derived 
from the permanganate on reduction. In support of this 
Iiypothesis, tho more recently acquired knowledge of the 
olonients comprising tho combination will he considered in 
conjunction with the accepted laws of oxidation. An argu- 


ment will be adduced tending to show that a reinforced 
catalytic action must bo set up in tho blood and colls of 
tho organism by which firmly established metabolites aro 
expelled, to tho relief of tho autonomic nervous system 
and the internal secreting glands. 

As biology teaches that life itself depends npon oxidation, 
so also biocliomistry has taught that, when oxidation is 
incomplete or. hampered, disordered function results; and 
as this is tho veiy core of our subject, oxidation will bo 
considered first. 


Oxidation. 

Bayliss summarizes oxidation as follows: 

" Oxidation in the tissues is duo to the presence therein in tho 
first place of an org.inic substance which is readily o.vidizable by 
moiocuiar oxygen. A part of the energy set free in this process 
is made use of to form from other molecules of the substance sn 
unstable peroxide. Bcnzaldehyde undergoing oxidation in air is an 
inslatico of such reaction. The analogous substance present in 
cells coiTCsnonds to what was originally called by Barb an 
‘ oxygenase,’ because it is by its means that molecular oxygen is 
activated. This activation is produced by the agency of an 
enzyme, peroxidase, which is a colloidal hydroxide of iron or 
manganese, kept active, or protected from precipitation or aggre- 
gation, by a stable or hydropliile colloid. This enzyme decomposes 
tho peroxide vyilh the liberation of ‘ active ’ oxygen, with, its 
powerful oxidizing properties.^ We are still in ignorance as to 
what this form of oxygen is, but there seems to be much 
evidence to show that electrical forces play an important part.” — 
W. M. Bayliss: The Eatmc of Eneymt Action. Fourth edition, 
1919, p. 158. 

This quotation reminds us that both manganese and iron 
must ho present in tho tissnes before complete oxidation 
processes can tako place. Now, if somo people are not 
obtaining a sufficiency of cither of these two essentials f to 
oxielation, tho fact that tho consumption of meat has 
increased so much among B^estern peoples in the last few 
years would suggest that it is not the iron content of the 
food which is at fault. 


Potassium. 

Mathews of Chicago, who established the prime impor- 
tance of potassium in the chemistry of the cell, writes : 

'* Another substance which is in somo way concerned in tho 
respiration of tlio cell is the element potassium. It has been 
found that in tho presence of potassium hydrate, pliloroglucin and 
similar substances undergo oxidation better than with the 
eouivalont amount of sodium hydrate. This indicates that the 
potassium salt is more easily oxidized than the sodium. There 
must be somo reason for tho preference cells have for potassium 
over sodium. A general rioliness of potassium in cells of widely 
different character indicates that this element must be concerned 
with some fundamental process or ooiiditiori in the cell, and it 
is possible that that process is respiration. But just why it is 
favourable or what its, real function is, it is imnossiblo to state.” 
—A. P. Mathews : General Cytology, Chicago, 1924, p. 55. 

This then, may account for the moderate success with 
the soAum salt. ■ 

ATcinj^aTicse. 

Manganese has been shown by Bayliss to he essential to 
oxidative processes; it is found in the ash of all enzymes, 
and is a most potent catalytic agent. It increases antibody 
formation > It is essential to growth, not only to tho body 
Eenerally, hut to the thyroid gland.'- Manganese exists 
in deficient quantity in white flour; wholemeal flour is rich 
in it ’ Artificial enzymes have been produced with alkaline 
solutions of manganese in gum arable (Bertrand’s 

“ laccase ”).■* , , . . , 

For some time it was hard to conceive how manganese 
entered the blood stream, seeing that it exists after reduc- 
tion as the insoluble salt Mn,0,. But it has been suggested 
that it probably forms a laccase with the mucus of tho 
bowel or stomach, taking the place of Bertrand’s gum^ 
arabic, and enters the blood stream as colloids do. 

The Thyroid Gland. 

The following appear to be the chief points in the later, 
knowledge of this gland which are applicable to this 

subje^^^ thyroid gland is generally considered to he the 
cliief activator of oxidative processes, and is now given 
pride of place in the control of the endocrine system. 

2. It is intimately concerned in regulating growth; -and 
is profoundly affected by insufficiency in the food of 
growth-promoting factors of all 'kinds. 



Jan. 21, 1928] 


MEMORA.-NDA; 


[ Thi: BnmsH 
llEDICAt. JOLT-SII. 


96 


3. It is siisooptiblo to toxic notion even wlion the diet 
is not at fault, but more so u-hen tho cjiot is wrongly 
balanced. 

4. AVheii affected by toxins or ill-balanced diets it is so 
liaudica25)ied in its work as to be rendered iihysiologieally 
subnormal and still more su.scoi)tibIo to toxic action. 

5. It accordingly attcmi)ts a eomi)en.satory hyiiertrophy, 
sometimes succeeding, more often failing, and suffers from 
the usual effects of overstrain (that is, diffuse fibrosis), 
which induces a slate, of hyi>othyroidism (i>robably unregis- 
trablo by basal metabolic rate methods), of which tho 
clinical signs may be so slight that they are only rendered 
niiparent by tho effects of thyroid thernpy. 

The last four paragraphs contain the gist of 
McCarrison’s importont paper {Lancet, April 30th, 1927, ' 
p. 916), in which ho announced tho origination of a new 
t^-pe of goitre in rats; 63- giving them diets resembling 
tho average diet of 'Western nations ho has caused serious 
changes to occur in their thyroid glands. Such an achieve- 
ment mav’ havo widespread consequences, for human beings 
may bo similarly affected. Need wo wonder at so man}- 
women having uns3-nimetrical necks, and need we ho sur- 
prised if thyroid therapy is found useful to a far-reaching 
degree? 

This completes a short sotting out of the basic pvin- 
cijiles which seem to undcrl)- this treatment. Wo have 
oxygen jirosent in a form which may have great 
potentialities. Potassium is there to help tho cellular 
■ interchange with a quickening of oxidative processes. 
Blanganese, which is deficient in the modern human body, 
apd .which is indispensable, for oxidation, is supiilicd in 
quantity and carries with it other necessary properties. 
Lastly, we have thyroid substance with all that it stands 
for to a generation which apparently is suffering from 
incipient hypothyroidism. 

Hero, then, is a formidable array of oxidizing agents, the 
combined action of which is likely to result in reinforced 
oxidative processes. This action might be compared to 
the fire on the -domestic hearth, by substituting imtassium 
for the iiapor, manganese for tho wood, metabolites for the 
coal, and thyroid substance for the bellows. The i)otnssium, 
or paper, sets up combustion; tho manganese, or wood. 


convc3-s the heat to the metabolites, or coal; if in.sufEcient 
oxygon is j>resent, or if the coal is of the foreign or “ out- 
crop ” qrialitv familiar to all of us during the coal strike, 
the bellows, or thyroid substance, may be required before 
the whole of tho material is consumed. 

CoXCLUSIOX. 

It is the opinion of many who have used this treatment 
oxtensivelv — heightened in the case of those who know 
what has been effected during the last two years in certain 
farms whore domestic animals suffering from sepsis have 
been treated on like princijiles — that when those drugs are 
combined in their action oxidative jnoeo.sses are greatly 
increased, with the following effects, though not neces- 
sarily always in this sequence. 

1. Rajjid reduction of infective agents and of toxic irro- 
ducts in tho blood and tissues. 

2. This is followed by a lessoning of tho load on the 
thyroid gland, which quickly, or slowly, returns to its 
normal action according to the degree of injun- it may 
have received. 

3. The continued administration of thyroid substance 
provides for any deficiency of sujjply of thyroxine when the 
gland is serioush- injured. 

4. A purer blood supply also oases the strain on the 
other internal secreting organs, and more normal secre- 
tions are jirepared. IVhere hormones of good ciuality have 
been secreted, or where vitamins in good quantity havo 
been ingested, only to be neutralized by toxic li’roducts 
in the. blood, this waste is quickly lessened or ceases 
altogether. 

5. By tho removal of the condition of nerve-block, con- 
ceivably brought about by- organic compounds jxist as selec- 
tive in their action, jierhaps, as ore the drugs atropine, 
digitalis, and aconite, the delicate balance of the 
autonomic nervous ^stem is restored in so far as degenera- 
tive changes will allow. - 

nrrrr.rscrs. 

• Walbum ond XIorsli : .tail, rff I’Inst. Pasteur, 37, 1923, 396. = E. 

McCarrison : 'Iiiiliau- Mnt.' -Ite-'earc7i Jouni., January, 1927. “Idem: 
Lancet, April .30tii, . 2927, p. 916. “.Baylis-s: Principles of General 
Phl/noloijy, 1924, p. 585. ‘ i 


^^ntiirEnttra : 

MEDIGAXi, SUEGICAL, OBSTETEICAL. 

PLACENTA PRAEVIA IN FOCIl SUCCESSIVE 
PREGNANCIES. 

The following notes seem to he of sufficient interest to 
Warrant publication. 

In March, _ 1920, I was urgently summoned to an agricultural 
labourer's wife. I found that she was six months pregnant and 
had lost a largo quantity ot blood. She was very blanched, with 
a small, rapid pulse, and was verj' fainfc, but quite conscious, 
Ihxamination showed a central placenta praevia with a lax os the 
Size of a five-shilling piece. A little chloroform was at once 
administered, the hand put into the vagina, and in a couple 
ot minut^ the os was digitally expanded sufficiently to allow the 
edge of the placenta to be reached. The placenta was pushed 
forceps put on, and the child delivered. 

The next time I saw this woman was in response to an urgent 
siimnions m May, 1922. I found exactly the same state of affairs 
save that she was now seven months pregnant. I acted exactly as 
before, with the same result. . 

In April, 1925, there came another urgent summons; everything 
was as on the previous occasions save that she was eight months 
pregnant, I acted as before, and with the same result. 

1 next heard rrom her about the middle of November, 1927, She 
Old me liiat she was expecting to be confined early in December, 
and asked if I would attend her; she had never troubled to 
me on the other occasions. I wrote saying that I would 
prefer not to, and Iicard no more. On December 9lli, 
message at 8 a.m. that she had lost a 
hor 7 ever before. I went at once, and found 

ler lancli-d and fainting; the os was about the size of half a 
b S ^nr ^'^Sina very tightly, put on a tight 

Ioc-i1 maternity ward of tho 

Sic ^ appeared to lose little after this, and two 

tcasions 1 able to do as on the thr<?e previou^ 

I he wonmn is now 40 3-ears of age; her first jAacenta 
praevia was her tenth pregnancy. The durations of tho 

0 


pregnancies were six, seven, eight, and nine months 
respective!}' ; all tho infants were dead. The question of 
performing a Caesarean section never real!}’ arose save 
perhaps in the last pregnane}-, but if she again becomes 
pregnant, and information is given in time, section with 
■removal of the uterus would probably be the best plan. 
I am aware that the classical - method is to turn and 
bring.tlowu a leg, but in this woman's case, and in that of 
two other mnltiparne with central placenta praevia who 
were unconscious when fir.st scon, and in whom the 
placenta was torn through centrally _ and the forceps 
applied, it appeared to me that less blood would he lost 
by the method used than if turning were performed. 

I realize that I have been very fortunate in not having 
to deal with severe haemorrhage with an nndilated os. 

T. iI.rcC.uiTHY, 3I.R.C.S., L.E.C.P. 

Sherborne, Dorset. 


THE FORGOTTEN SWAB. 

The subject of this note is tlio first surgeon^s swab as the 
second surgeon sees it. Case i gives an excellent example 
of the powers of the body in walling off a foreign body 
in the abdomen. Case ii is perhaps unique, and I should 
be interested to bear if a similar case has been reported. 

Case i. 

A married woman, aged 54, was admitted to hospital in May, 
1926. Three days before admission she was seized with sudden 
acute pain in the lower part of the back, and a diagnosis of 
acute lumbago was made. She had been operated on in Calcutta 
a year previously for a ruptured cclopic gestation. There was no 
other histoiy* of note. On examination there was found a fixed, 
fluctuant, tender swelling arising out of the pehns : per vaginam 
the same swelling could be felt and its fixity and fluid nature 
could more easily be demonstrated. 

Operation . — The abdomen was opened by a right paramedian 
incision below the umbilicus, and a cyst the size of a gi-ape fruit 
was found fixed in the pelvis; it extended upwards and wa* 


96 Jan. ar, 1928] 


BEQUEIiS OP NASO-ORAE SEPSIS. 


[ TifR nnmTif 
UrciCAL JocRMU, 


nttached to tlio promontory of tho encrum and fiftli lumbar 
vertebra, Tho swelling was covered anteriorly by adherent 
omentum. The omentum was divided at tho upper limit, and it was 
then seen that the- lower aspect of tho cyst was adherent to tho 
upper surface of the bladder, and that two coils of small intestino 
were lying parallel across and adherent to the upper surface of 
the cyst. Those adherent viscera ■were carefully stripped off and 
the cyst was then separated from its adhesion posteriorly to tho 
peritoneum covering tho posterior abdominal ’wall. Tho cyst w'as 
removed intact, Tno pelvis was drained and tho wound closed 
after considerable dimculty in dealing with oozing from tho 
bare areas of separated viscera. On opening tho cyst it was found 
to be filled -with thick yellow pus, and floating free was a largo 
gauze swab measuring 8 bv 6 inches. There was a perfect fibrous 
wall to tbc cyst. The patient made an uninterrupted recovery. 

Case ir. 

A man, aged 27, admitted in December. 1927, had been kicked 
in the abdomen four years previously while plaj'ing football, and 
was operated on tho same day in a hospiUl In the North of 
England for a ruptured spleen. For four days previous to 
admission to this . hospital he had recurring attacks of colic, 

- becoming more severe and associated "with vomiting of increasing 

^ severity and frequency. On examination thcro was tenderness 

- below and to the loft of tho umbilicus^ and an indefinite soft mass 
was felt. During an attack of colic visible peristalsis was present. 
He vomited dark brown, foul-smelling fluid once after admission. 
There was no distension, but a small amount of freo. fluid in tho 
abdomen. The diagnosis of a high obstruction in the jejunum was 
made, and he was operated on tne samo evening. 

. Operation , — A left paramedian incision below tho umbilicus dis- 
closed free clear fluid in the peritoneal cavity. Lying among coils 

- of^ collapsed^ small intestine was a dusky red dilated coil of 
jejunum; this was delivered and found to contain a foreign body 

. extending 6 inches along its lumen, and movable up and down the 
lumen. The loop was traced upwards for 9 inches and there 
found to be adherent over a considerable area to a fibrous 
nodular mass in the left hj’pochondrium. The intestino was in- 
cised and tho foreign ^ody removed; it was found to bo a rolled^ 
up gauze swab several layers thick, and when spread out measured 

• 12 by 8 inches. The intestine was sutured and tho wound closed. 
Recovery has been uninterrupted. 

Presumably the mass in the left hypochondriura was inflam- 
matory in nature, and "was tho former site of tho swab, which 
had ulcerated through into a coil of small intestino forming part 
of tho wall of tho cavity walling it off. The swab had then 
been gradually^ drawn info the lumen by peristalsis and eventually 
rolled up till it was of sufficient diameter to cause symptoms of 
obstruction. 

In conclusion it is interesting to note : 

1. Both operations wore acute emergencies. 

2. Both swabs were very large. 

3. Neither of the swabs was provided with a tape. 

4. There may he a groat deal in favour of the method 
of incorporating in every sw’ab a small disc of lead, and 
a routine ai-ray examination of every abdomen before the 
patient’s discharge. 

5. It is conceivable in the case of a small swab that 
the patient may be fortunate enough to pass it per anum. 

H. Roland Seoah, M.B., Ch.B., 

Medical Superintendent, Wellliouse Hospital, 
Barnet. 


A LUBRICANT FOB APPLYING ZINC IONIZATION 
TO THE MALE URETHRA. 

In tlio treatment of certain non-specific forms of anterior 
urethritis we wore confronted with the difficulty of finding 
a suitable lubricant (without which tho electrode cannot 
ho introduced) which would not impede tho passage of the 
current or the zinc ions from the positive zinc intraurethral 
electrode to the urethral mucous membrane. 

Experiment by ono of us (B. B. S.) showed that liquid 
paraffin and vegetable oils, such as olive oil, did not con- 
duct. Trial with a lubricant of glycerin and mucilage of 
gum tragacanth with phenol 3 per cent, as a preservative 
demonstrated that a strong current was required to over- 
come tho resistance. Therefore one of ns (C. F. 0. W.) 
tried tho conducting powers of each of the constituents of 
tlio above lubricant. 

Taking a 1 per cent, solution of sodium chloride as a 
standard, and with tho indicator of tho instrument at a fixed 
mark, tlie galvanometer recorded 10 milliamps. With the 
original lubricant only 4 milliamps was recorded ; with tho 
gum tragacanth mucilage 6 milliamps; with the phenol 
3 per cent, solution 8 milliamps; with the glycerin no 
current at all passed. Tho glycerin was therefore omitted, 
and 1 per cent, zinc sulphate added so that the zinc ion in 


tho lubricant would add to tho germicidal action, tho final 
composition being; 

Phenol ’ ; 3% (gr. 131) 

Gum lr.ig.acanlli 2.55^ (1/4 oz.) 

Zinc siilplnato 1% 

Aqua dcslillata ad 100 (10 oz.) 

This lubricant proved satisfactory, and it was found that 
tho galvanometer now recorded 8 milliamps passing through 
tho solution, and wo consider that with this solution no 
buffer action can take place. 

Wo are indebted to 3Ir. Randolph, dispenser at tho Royal 
Northern Hospital, for preparing the various trial sub- 
stanccs and tho final solution selected. 


C. F. Onu White, M.R.C.S., L.R.C.P., 

Sledical onicer In charge of Physiotherapeutics, 

B. Buckley Sharp, M.B., B.S., 

Assistant, Venereal Diseases Department, - 
Iloyal Northern Hospital, London. 


af Gambia. 

PULMONARY AND GASTRO-INTESTINAL SEQUELS 
OP NASO-ORAL SEPSIS. 

The Sections of'Laryngology, Medicine, and Odontology of 
the Roj'al Society of Medicine held a joint discussion on 
January lllh, with Mr. H.arold BAtstER, president of tho 
first-named Section, in tlio chair, tho subject being the 
influenco of naso-oral sepsis on tho lungs and gastro- 
intestinal tract. 

Mr. Edward D. D. Davis, who opened for tho Section 
of Laryngology, said that nasal sepsis could influenco tho 
lungs or lower rospiratoi-y tract: (1) by direct extension 
of tho inflammation to tho larynx, trachea, and bronchi, or 
infection tlirough tho blood and lymphatic streams; (2) by 
aggravating or incieasing an existing pulmonary lesion ; 
and (3) by being part of a general infection in which both 
the upper and tho lower respiratory tract were involved. 
In 100 of his cases of nasal sinus suppuration tho infection 
was confined to tho noso in 90; tho other patients had 
bronchitis, asthma, lung abscess, bronchiectasis, or _ a 
gastro-intestinnr condition. Of 474 cases of definite 
pulmormry tuberculosis which ho had examined as lai^ngo- 
logist at Jlount Voimon Hospital ho had found to his 
surprise tliat only fivo showed nasal sinus suppuration. 
A mironio nasal sinus suppuration should be regarded, ho 
thought as a potential chest case, and general measures 
similar to thoso for tuberculosis should he added to local 
treatment of the nose. Cases of gastro-intestinal infection 
arising from tbo nose had been raro in his experience. 
This was all the more surprising when it was remembered 
what largo quantities of purulent discharge from the noso 
were constantly being swallowed, yet these patients did not 
complain of sickness, gastric pain, diarrhoea, or symptoms 
arising from infection of the gastro-intestinal tract. Loss 
of appetite and general malaise in such patients were 
considered to bo due to tho toxic effects of the suppura- 
tion But cases of duodenal or gastric ulcer had been 
known to coexist with nasal sinus suppuration, and a 
marked improvement in the symptoms had resulted after 

treatment of the nose. . , 

Mr O. A'. S. Bidout quoted cases of children with 
general debility and bronchial signs, hut no tuberclo 
bacilli wore found; these patients invariably had enlarged 
and obviously infected tonsils and adenoids, generally 
marked dental caries, and very often definite infection of 
tho antra of Highmore. Tho cases illustrated the need 
that every tuberculosis clinic should have a consultant 
laryngologist and otologist. The same necessity for team 
work was shown in regard to the relation of gastric nicer 
to nasal and oral sepsis. The speaker had constantly 
noticed the association of oral sepsis with gastric con- 
ditions such as nicer and carcinoma, and more especially 
pharyngeal and oesophageal carcinoma. It would seem 
that a preliminary condition, tho result of naso-oral sepsis, 
preceded tho establishment of gastric or duodenal ulcer, 
innocent or malignant, and the aid of the laryngologist 
might he all-important. Many patients complained ^ of 
vaguo gastric discomfort, dyspepsia, and general malaise. 




Jan. ai, 1928] 


BEQTTELS OF NASO-OBAE SEPSIS. 


r TnEiJRmsn 
i SleDicAi. JontxAb 


97 


anti on examination very severe tonsillar sepsis, com- 
bined with nasal sinusitis, was found; the sjnnptoms 
cleared up after treatment of these conditions. He also 
emphasized the point that those who devoted themselves 
to diseases of the car, throat, and nose sliould ho careful 
to .obtain from their patients a definite past history of 
any otlier inflammatory troubles, such as gastric ulcers and 
appendicitis, since such histories would probably show a 
(Close connexion between these conditions and naso-oral 
sepsis. 

: Dr. R. A. Young said that the chief conditions which 
bad to bo considered in that discussion wore of strepto- 
coccal origin, Tiiero were six ways in which local septic 
disease in the month, nose, aiid pharynx might affect tho 
respiratory mechanism: (1) direct spread of infection 
along mucous or submucous tissues; (2) mechanically by 
nasal obstruction; (3) inhalation of septic organisms from 
nose or mouth might load to infective conditions of the 
bi'onchi or lungs; (4) the effects of tho altered blood and 
immunity conditions induced by the absorption of toxic 
products' from the local disease areas ; (5) naso-oral sepsis 
leading to septicaemia or to infective endocarditis, in 
..which case the lungs naturally became affected directly or 
'indirectly; (6), the -production of painful fibrositis of the 
muscles of tho thoracic wall, loading to pleurodynia. There 
’could be ho doubt. Dr. Y’oung continued, that laryngitis, 

I tracheitis, and bronchitis might bo caused, aggravated, or 
rendered chronic by nasal ob.struction and nasal sepsis. 

■; Tho part played by disease of the nose in the genesis of 
- asthma was a definite one, though it might be e.asily 
exaggerated. ■ Tho fundamental condition in asthma was, 
j-no doubt, the abnormal sensitiveness of the bronchial 
!. hhrvous system. -.The nose was frequently one of the 
utriggers which ■ discharged tho paroxysm, though not always 
the most important. Tho most obvious disease of the 
lungs influoncod by naso-oral sepsis was ingestion or 
inhalation pneumonia. In lobar pneumonia and broncho- 
pneumonia it was difiicult to resist the conclusion that 
septic processes abqut the mouth and nose were likely to 
• increase the severity of the condition and to promote the 
development of secondary or septic complications. Abscess 
and gangrene of tho lungs were so often the result of 
septio processes that it was difficult not to regard naso- 
oral scjisis as taking some part in their development in 
■many cases, while its importance in pulmonary tuberculosis 
ivas now well recognized. Diseases of the pleura were so 
generally secondary to pulmonarj' conditions that it would 
be difficult to establish any direct influence of naso-oral 
disease upon septic conditions of the pleura. 

Hr. T. IzoD Bknnett believed that the opinion of the 
majority of those who had been particidarly interested in 
gastric and intestinal disease during recent years was that 
the swallowing of bacteria and pus from the teeth, nose, 
and mouth w.as by no means so frequent a cause of disease 
as w.as formerly supposed ; in view of the multiplicity of 
organisms ahich were constantly taken into the stomach 
with the food it was hardly surprising that the addition 
of bacteria from other sources should usually have no 
pathological consequences. Following the work of Faber, 
however, ho showed that when achylia gastrica was present 
the elimination of the possibility of swallowing bacteria 
from tcotii, tonsils, adenoid tissues, or nasal sinuses was of 
importance. Naso-oral sepsis might also alfect the lower 
parts of the alimentary canal by the jiassage of bacteria 
fiom tho upper foci of infection along tho blood stream to 
tho wall of the bowel. The work of Bosenow in recent 
} ears had been chiefly responsible for the spread of interest 
m this .subject. Dr. Bennett also mentioned the great 
increase in the number of cases of gastric and duodenal 
_ vecent years; the important question was 
w lether this increase in incidence was to be assumed to be 
duo to ^eater prevalence of sepsis in the mouth . and 
' ® been specially impressed by the frequenev 

nitli nhich patients with gastric and duodenal ulcer showed 
no objective signs of oral or nasopharyngeal sepsis except 
toi the presence in their mouths of teeth which had 
received . considorablo dental treatment. The filling of 
devitalized and artificiall 3 ’ anaesthetized teeth seemed to 
liim contrary to all approved principles governing the 
surgical treatment of hone disease; it might possihlv 


liavo somo direct relation to the increase in the numbers 
of cases of gastric and duodenal ulcer, cholecystitis, and 
appendicitis. 

Mr. J. Ct. Tunxrjt discussed the nature of dental sepsis — . 
a condition in which food debris, chiefly bread, adhering to 
the teeth, was made jiutrid by bacteria. If sticky food 
could bo eliminated, or the teeth properly cleaned, dental 
sepsis and its evil consequences’ would be prevented. The 
germs of dental sepsis wore firmly attached to the surfaces 
of the teeth, and it required considerable violence to effect 
removal. If the teeth were smooth cylinders this violence 
might be applied, but their smallest recesses sufficed to 
harbour many organisms. The threat of sepsis persisted so 
long as teeth remained, oven artificial teeth. The effect 
of early dental sepsis might be permanently impaired diges- 
tion or chronic infection of the lung. Infection might be 
of tho surface or blood-borne ; lie attached greater impor- 
tance than many to surface infection. Constant swallowing 
of the products of naso-oral sepsis might so interfere with 
digestion, perhaps by destroying vitamins, as to make the 
patient become subject practically to a deficiency disease. 

Mr. -AitTnun BuLt.j,iD said that in the oral cavity the 
normal flora made the bacteriological investigation of 
disease much more difficult than in other parts of the 
body. It was difficult to be certain that the bacteriological 
findings in cultures revealed the causal organisms of the 
disease under investigation, because tho micro-organisms 
isolated did not differ to any marked extent from those 
in the healthy mouth. The normal mouth flora consisted 
of two groups— tho first containing easily cultivable 
organisms, and the other those not as a rule isolated if only 
the usual, technique was employed. The most important 
organisms in the first group were the streptococci; in the 
second group tho Lepfoihrix hnrcali.t was of importance 
because of its connexion with tartar formation, and the 
so-called fuso-S])iral organisms were of interest, though 
their share in infection was not well established. Infec- 
I tion of the alimentary tract from tlie naso-oral cavity was 
chiefly brought about by swallowing septio material. In 
course of time the infection became able to witlistand the 
passage of the bydrocbloric acid of the gastric juice, and 
the iute.stinc also became involved. Infection of the 
respiratory tract was usually by inhalation of septio 
material. He urged that bacteriological examination of 
the sputum, and of naso-oral foci of infection, should 
always be made in chronic lung infections, since prophy- 
lactic vaccination, subsequent to the medical treatment of 
the lung condition, was of the greatest importance. 

Dr. F. A. FicKwor.TH sent a description of an interest- 
ing case of diplococcal infection of the sphenoid sinus with 
associated haemorrhages in the stomach. The point of 
iiitere.st in the necropsy was that in tho vessels of the 
mnscnlar layer, the submucosal vessels, and even in the 
stomach epithelium, there had been found a feiv scattered 
but undoubted cocci, resembling those which were remark- 
ably prolific in the .sinus nicnibraue. 

Dr. P. ^V.^TSON-^YlI,l.^A3IS referred to the frequency of 
appendicitis in association with, and ajiparentlj’ due to, 
na.sal sepsis. In a series of . ninety cases of sepsis he 
found in 14 per cent, that there had been not merelv a 
diagnosis of appendicitis, but an ajipendicectomy, and in 
two other cases there was a history of definite gastric 
ulcer treated by operation. The cbronicity of these sepsis 
cases was an important feature. It was also roraarkablo 
that since about 1890 there bad lieen an enormous increase 
in the number of eases of gastric and duodenal ulcer, and 
that at about the same time influenza became epidemic in 
this country. The increase in the cases of appendicitis and 
similar conditions was due to the .same causes as the 
enormous increase in sinusitis, and be thouglit that the 
prevalence of Influenza could not be disregarded in this 
connexion. 

Dr. E. Stoukind mentioned the importance of determin- 
ing whether dental infection was primary or secondary, and 
recalled a number of cases under his obson'ation affecting 
the digestive system and tlio lungs in which all tlio teeth 
had been extracted without benefit to the patient. 

Sir J. Dund.is-Gb.int disagreed witli the opinion ex- 
pressed by Mr. Davis that pus from the nose was unlikolv 
to be inhaled into the larynx. On a close examination of 



HYDROPS TUBAE PROFDUENS. 


f TnEBnm'ta 03 

MmiCXI. JOtTBSAI. ^ ^ 


Jaw. 2 t, 1928 ] 


Dr. Rollcsloii said that scnim pi-opliylaxis was most &uit- 
ahle for cluldroiv iindor tlic ago.' of 3, or those dohilitated. by 
tuhcrcidosis or other discascsi. It was not iiocossaiy iu 
private practice or, in hospital.ii witli a hygienic environ- 
luont, wlion tlie disease nsually ran a mild- conrso. The- 
serum treatment of measles u’as still- in the experimental 
stage. - ■ 


ITYDROPS TUBAE PROFLUENS. 

At :v meeting of the North of England Obstetrical and 
Gynaecological Sociot 3 -- in jManchester on December 16tli, 
W27; the president, Professor W. Fletcher Sn.^w, in the 
chair, Professor Miles Phillips (Sheffield) showed' a 
specimen of hydrops t'ubae proflnens. 

Professor Phillips said' that the patient, a 6-para aged 42',. 
complained of attaelts of pain in the right lower abdomen 
lasting. two to seven daj'S, at intervals of three to six weeks. 
She stated that a sa'elling, about the size of an orange, 
had' formed on the right side when the pain was severe; 
there was then a gush of thin. bluish fluid from the vagina, 
the pain ceased, and the swelling, disappeared. This ocea- 
eionally happened on the left side. Nino months' after- 
the last, con&iement, fomtoen j-ears previously, .she liad- 
had inflammation of the womb and ovaries. Menstruation 
lasted' for two to seven d'aj's, and' occurred eveiy twonty- 
foui' to twenty-six days; there had' been increased^ loss 
tfuriug the last thirteen years. There was constant 
greenish-yellow discharge, but no vulvitis ; indefinite 
adnexal swellings were detected. At an operation bilateral 
hydrosalpinx was found larger on tlie left side ; the uterus 
and' both appendages were displaced. Wlion a piece of 
sillrworm gut was passed through the uterus into the 
tubes clear fluid, escaped. The cavity, of the hydrosalpinges 
did not eoinmunicato with the cystic ovaries. 

Professor Dox'Ald said there might be a valve action at 
the uterine end of the tube ; ho had' never known pus thin 
enough to escape. Dr. K. Bailey had seen a patient with 
a large right hydrosalpinx who had had an intermittent 
discharge for, eighteen months, Professor Blair. Bell said 
that he had- noted- an intermittent discharge as a rule in 
malignant disease of the tube. Dr. Willett suggested that 
the rise of tension could sometimes overcome the retention 
of fluid, and. asked if there wore any adhesions. Professor 
PniELiPS, in ropl}-, said there -nore no adhesions and 
likened the retention to urinarj- retention with overflow. 


Hacmaiomcira and Tuhcrculosis. 

Professor D. Douglas (Manchester) read a note on thret 
cases of hnematometra associated with tuberculosis. 

The first patient was aged 37, and bad been married for sever 
jears. She had. bad primary anienorrboca till the age of 30, ant 
since tben slight loss every five to six weeks. She bad poor health 
and as a cinid had been an in-patient at a children’s hospital foi 
a montli. The uterus was enlarged to about the size of a foul 
months- pregnancy, and the appendages were adherent. Pan 
iiystcmciomv was performed. The uterus contained a single cavitj 
lull of blood, and the left tube tvas also distonded with blood.. N< 
communiealion was made out between the uterine cavity, tin 
cervical canal, and the right tube. Microscopically there was" fount 
an adenomyomalous condition of the- right uterine comii, -n-itl 
“^croliu areas with giant cells. 

- ^^'^^coiid. pi^ient was 31- yeai-s old, and had been marriet 
or two years. There was primary amenorrhoea, and Uiere hat 
tiiberciiloiis enteritis in infancy. She had had pain in tin 
^ years. The uterus was enlarged to tin 
months pregnancy; it was hard and fixed, and then 
etllicsions in the pelvis. Subtotal hysterectomy was per 
iTned,- with removal of both appendages. The uterus containei 
i^’i fbe right side and communicating- will 

closed at its outer end. The left tubi 
mterstitial. portion, and showed chroiii' 
cells were'seen-'^’''^*^'^' ^mroscopically necrotic areas and gian 

ai^e'norrhoeT.- 't 22,. was single, and had primary 

iitprns WTc 'bbVb family history of tuberculosis. Thi 

pai^ white awatfint“? '^^'a.tic. She had had an acute attack ol 

appendiecctomv tIic tTe™s"Vm 

vVs asvmnipfrtnni removed by subtotal hysterectbmj 

It cMlattTd tY -"ebt portion being- ieiger than the left 
tlie left with liov right being filled with blood am 

me lelt iiitli pus, necrotic material, and giant cells. 

10 essoi Douglas said that all specimens sbowed atresii 
r, "'f' .PhPonic. infection. The question 
nnldovN^ chronic infection in eariy life was the cause o 
tlie inclined to conclude that this wa 


I’rofessor Miles Phillips believed that a condition of 
obliterative endometritis occurred- in the region of the 
internal os. He had once reported a hydrometra the size 
of a .seven months prognanty due to tuberculosis. i\Iiss 
IVEXs had had a case of a single woman who dei'eloped 
amenorrhoea after normal monsti'uation. The uterus 
reached the iimhilicus, and- was filled with blood. The 
obstruction was at the external oS, and there was no 
evidence of tuberculosis. She described anotlier case which 
had caseous iiintcrial in the- cav'ity; she curetted this, and 
the patient afterwards- luenstniatcd. Dr. Leith Mtjbr.ay' 
had in two cases: established communication between the 
hnematometra- and the ceifix with a curette. Dr. Douglas 
replied- that none of his specimens showed infection of the 
lower part of the uterine- wall. 

Ax a meeting of the Brighton and Sussex Medico- 
Cltirurgical- Society on Januai-y 5th, with the president, 
Dr. Dox.vld Hill,, in- the chair, Mr. G. AV. Beresford read 
a paper on gastric ulcer, illustrated by diagrams, speci- 
mens,. and microscopical slides. Mr. Beresford said that 
while- duodenal ulcer was nsuaUy dealt with by gastro- 
jejunostomy, gastric ulceration was more serious,, and the 
treatment presented a difficult prohlem-t ' The most, impor- 
tant conti'ibutory causes were imsuitablo and irritating 
foods,, porliaps the increased consumption of sugar leading 
to gastritis, mental overexertion and worry affecting the 
innervation of the stomach, and focal infection from the 
teeth- or intestinal tract. Acute ulceration was less common 
than it was ten or twelve j'oars previously. It tended to 
early healing, and the treatment was entirely medical: 
even sevei-e haemorrhage was not an indication for surgical 
inten-ention-. Probably owing to the presence of IjTnphoid 
follicles along the lessor cuiwe 84 per cent, of chronic 
gastric ulcers (Moynihan) were situated in this region. 
The main symptoms wore periodicity’ of attacks of epi- 
gastric iiain and vomiting, coining one,- -two, or three hours 
after food-. Tlie x .rays wore the onh* certain method of 
diagnosis, Haomatemesis was not u.sual, but when present 
was of serious import; Bulmer’s recent figures showed timt 
the moi’tnlity from liaematemesis was very high. Medical 
treatment should -Bo given for all cases except where there 
was a suspicion of carcinoma, or where a course of medical 
treatment had failed, or where there had been an attack 
of liaematemesis, in perforation or mechanical defoniiity 
of pylorus or stomach; it should consist of Sippy’s diet, 
witli rest in bed. The aim of surgical treatment was to 
I'cinove the chronic infection. Gastro-jejunostomy, with 
excision or cauterization of the ulcer, should he adopted 
for noil-adherent ulcers, and subtotal gastrectomj- for large 
and fixed nlcei’s. 


T'WINS AND TRIPLETS. 

-At a meeting of the Royal Society on January 19th a paper, 
by Mr. R. A. Fisher, on “ Triplet children in Great Britain 
and Ireland,” was communicated by Sir Arthur Kzrm. Exist- 
ing data on twins, Mr. Fisher said, had given rise to much 
difference of opinion on heredity' of tyvinning, tendency ; moreover, 
good measurements yvere exceedingly- scanty. In order to obtain 
data from a fresh source; in the collection of yvhicli adequate 
safeguards could be taken against the chief causes seeming to 
have vitiated twin material, an inquiry yVas commenced on triplet 
cases recorded as recipients of the Royal Bountj-. Results of 
measurements, and- of genealogical inquiries on three years’ data 
from- tliis source; were given. Six physical measurements taken 
on 117 cliildren slioyved correlation hetyveen pairs of unlike sex 
conformable yvith that obtained bj' the author from Lauterbach’s 
measurements on. twins, and yvith that hetyveen adult brothers 
and sisters. Pairs- of like sex were more highly correlated, the 
results being yvell fitted by’ the supposition tiiat about 54 per 
cent, of the surviy’ing like-sex pairs yvere monozygotic in origin, 
anj that these had a correlation 0.94-. Relationship data 
confirmed paternal influence, and sex distribution of related 
tyrins strongly' suggested tliat this was confined to causation 
of di-emhryony. If maternal influence conditions both dizygotism 
and- di-embryony, the slightly higher values obtained from these 
and other data for maternal influence indicated that, contrary 
to Weinberg, di-emhryony yvas the more strongly inherited 
phenomenon — a vieyv in accord yvith tlie large knoyvn effect of the 
mother’s age on dizygotisim 


100 Jan. 21 , 1928] REVIEWS. 




COMMON DISE 2 VSES OF THE SKIN. 

The Common Diseases of the Shin,'^ by Dr. I?. Cr.an’ston 
Low, is olio of tlio host introiUictioiis to its subject for the 
use of stiuloiits that liavo appearod for some time. Dcrninlo- 
Icigy is by 110 iiieaiis an easy subject to teach, as all those 
who liave laboured to impart a knowledge of it to students 
have long since discovered. It does not lend itself to clear 
definition and easy classification. Tlio various pathological 
alterations in tlio skin often merge insensibly inte one 
another, and it may bo difliqult to mark the dividing lino 
between them. .Sometimes their etiology is doubtful and 
even dual, and we have heard dermatologists of deservedly 
gloat reputation and of ovenvlielming o.vperience remark, 
in confidence, that the more eases they see the fewer thej' 
can diagnose. That is a generalization which need not bo 
taken too literalh', but in any caso D'r. Cranston Low lias 
overcome all his difficulties remarkably well. He has made 
the subject as clear and straightforward as is possible, and 
his book, wliicli is founded on the lectures which ho 
periodically delivers to the students of the Royal Infirmary, 
carries on well tho fine teaching tradition that has always 
distingui-slied tho Edinburgh school ; 0110 may justifiably 
exclaim — fortunate arc the students who hear such good 
lectures. There is not much room for originality in an 
clcuientary book of this character, but Dr.- Cranston Low 
1ms left the impress of his personality on most of tho 
chapters, and is skilful in putting forward novel aspects 
of old problems. IVc would particularly direct the reader’s 
attention to the chapters on dermatitis venenata and 
alopecia areata. His theory of tho nervous origin of tho 
latter complaint, although far from proved, at any rate 
affords an attractive working hypothesis. 

• Most of the recent advances in dermatology are 
noted in tlieso pages, but wo are rather surprised 
that there is no mention of tho recently introduced 
method of treating ringworm of tho scalp by moans 
of thallium acetate given internally. It seems probable 
that notwithstanding its drawbacks it will find a 
permanent place in tlio troatmoiit of this disease in 
children who are too young for x-raj' treatment. Wo are 
also rather surprised to find that Df. Low s.ays (p. 184) 
that “ tho local application of the rays (ultra-violet) to the 
lupus lesion has been practically given up now. Daily 
radiation of tho whole body oven in cxteiisivo and long- 
standing cases liokbs out the best hope of cure.” This i.s 
contrai-y to tho experienco of most dermatologists, who, 
while acknowledging that general- irradiation is a most 
valuable help, still find in the Finsoii lamp,- applied locally, 
tlioir mainsta.v in the treatment of lupus. These, however, 
are but slight blemishes in an excellent work, rvdiich is 
clearly written, well printed, easy to handle, and by no 
means too long. The illustrations, also, eight of which aro 
in colour, are good and well reproduced. IVe feel sure that 
Dr. Cranston Low’s book will bo warmly welcomed by 
students and practitioners alike, and wo wish it every 
success. 


A TEXT-BOOK OF CLINICAL NEUROLOGY. 

Ix hi.s Text-honk of Clinical Xeurologi/- Dr. Ish.aei, 
Wecksuer has attempted a presentation of this field of 
medicine based upon “ an anatoniico-pathologieal sub- 
stratum.” In tho present sta.go of our knowledge with 
re"ard to the etiology of nervous diseases such a task is 
bound to bo difficult and far from the possibility of com- 
pletion. From a mass of clinical material jn esenting only 
occasionally clearly cut syndromes, various disease entities 
have been subtracted, relying for their idoutificiition in 
some cases upon their course and characteristic limitations, 

■ T7,e Common Diseases of tho Stein By R. Cranston Low, M.D , 
r R.t'.l*. Eilinbiirsli mul London: Oliver and Bojd. 1927. (Cr. 8vo, 
ri'. Nil + 223; 19 figurps, 49 plalep. 143 net.) 

* .1 Text-huuk of Cttnicol Xcmolotjt/. By Israel B. WeebsTer, Jf.D. 
I’biladvlpliia and Luntion : AV. B. SaunUeis Co. 1927. (Med. 8vo, 
pp. 725; 127 32?. 6d. net.) 


in others upon associated pathological changes in the 
nervous systoni, A.s it must ho admitted that their recogni- 
tion is still based during lifo a]nio.st entirely upoii clinical 
findings it is open to doubt whether anything is to be 
gained - from .a presentation of neurology according to a 
scliomo derived irom post-mortem results.. - 

In his introduction Dr. IVcchsIcr lays stress on the 
opinion that “ it is unwiso to draw conclusions before the 
whole examination is complete”; “diagnostic interpreta- 
tion,” ho writes, “ has no place either in taking a history 
or eliciting objective findings after this excellent advice 
it is disappointing to, find that in his first hundred pages 
“ tho interpretation of signs and symptoms ” to which 
these are devoted is in terms of purely’ clinical concepts ; as 
an oxamplo reference may be made to tho description of tho 
Argyll Robertson phenomenon (p. 74), which is inadequate. 
The order tho author follows is sometimes bafiliiig — wo find 
sections on the " cerebellar syndrome ” and the precise 
anatomy of tho cranial nerves towards tho end of the 
hook, far divorced from his introductoi'y pages on focal 
signs and symptoms and their interpretation. It is sur- 
prising in a manual of clinical neurology that only two 
pagc.s should bo given to progressive muscular atrophy 
when five aro devoted to syringomyelia, twenty-three to 
compression of tlio sjiinal cord, and thirteen even to the 
technique and findings of thecal puncture. 

It is disappointing also to come across tho terms proto- 
pnthic and opicritic sensibility still receiving currency' in, 
cDiiiio.xion with the rogerieration of peripheral nerves 
(p. 240) ; the section on vascular disturbances of the brain 
could have borrowed much that would have been cnlight'eh- 
iiig from Trotter’s description of tho intracranial cired- 
lation. 

The hook is pleasingly p.aragraphed and the illustrations, 
introduced in commoudablo moderation, are very valuable^ 
if occasionally (as on p. 178) atypical. 


. TREATMENT OF GONORRHOEA. 

Most specialists in genito-urinary surgery are only too 
glad to giro up all interest .in gonorrhoea and its treat- 
ment as soon as they, find themselves sufficiently occupied 
u’ith more interesting work, and it is seldom that a surgeon 
of tho calibre of A; L. AVolbabst is stimulated to write 
a textbook on the subject. Far from being depressed with 
his task ho maintains, in his preface to Gonococcal Infec- 
tion in the that considerable advances have been 

made in our knowledge of tho treatment of male gonor- 
rhoca and its couiplicatioiis. Ho considers that those 
advances chiefly lie in “ physical therapy, intravenous and 
local 'medication, protein theiapy, and, most imiiortaut of 
all in the epochal work of Belfield and his associates, on 
the seminal vesicles.” Some of us may harbour doubts as 
to alicther aiiv substantial progress has been achieved in 
the treatment" of chronic goiiorrhoe.e, but whether wo 
share AVoIbafst’-s optimism or not wo cannot do otherwiso 
than weleomo this work. It is only by tho enthusiasm 
and industry of such men as ho that tho present 
insuperablo tlifficurties associated with the treatment of 
chronic'gonorrhoea will eventually he overcome. 

Tho hook is intended primarily for tho general practi- 
tioner and for this reason particular emphasis is laid on 
many ^points in diagnosis and treatment with which the 
specialist is already -familiar. AVhother the general practi- 
tioner will he prepared to provide himself with tho arma- 
moiitarinm that the author considers necessary for the 
treatment of the disease is, of course, another matter. 
But all will agi’ee that if the ravages of goiiorrlioea are to 
he reduced to a minimum the standard of treatnient must 
he matoi-ially raised. Alaiiy p.atients aro not in' a jiosition 
to afford tho fees of the specialist and will dislike the idea 
of attending a clinic. At present patients arc too often 
discharged as cured whilst they are still capable of infect- 
ing other people. The author of this hook has given 
special pi'oininonce, therefore, to such points as tests of 

.s Oonococcal Infection in the Mate. By .\br.' L. Wolbarst, JLD, 
London : Henry Kimpton. 1927. (Roy. 8vo, pp. 237 ; 89 figures, incluit 
j inj; 7 coloured pl.-ites. 25s. net.) 



Jan. 2t, 1928] 


REVIEWS. 


t TnR Bamim 1 HI 

MkDICAI* JOCBWAI. J-v* 


ciuo and tlio identification of tlio gonococcus in films. 
Tlioro is also an excellent clmptcr on diatlicrni’-, a method 
of treatment that has apparently fonnd an even wider field 
of application in America than it has in tliis country. 
Not only .nro such complications ns ejiididymitis .and 
rheumatism dealt with by this means, hut also iinrompli- 
cated anterior urethritis. Two methods of applying the 
current to the anterior urethra nro described, the first by 
means of an intraurothral electrode, and the second through 
the medium of two lateral electrodes fitted to the external 
aspect of the penis. 

The book is well illustrated, and the tost is .sufficiently 
complete and clearly written to bo readily understood by 
those who arc not expertsS. It is certain that every practi- 
tioner who roads Dr. Wolbarst’s book can acquire an up-to- 
date and complete knowledge of the treatment of gonor- 
rhoea, but whether amidst all his other activities he will 
bo able to afford the time, or bo in a position to acquire 
the instruments necessary for handling these cases, is a 
matter of considerable doubt. 


BASAL METABOLISM. 

Dr. Eugene F. Du Bois, whoso reputation as an investi- 
gator in tho subject is well established, has brought out 
a revised edition of Banal Metaholism in Ilculth and 
Disease." His avou'cd object is to bring basal metabolism 
into the domain of clinical medicine, and his hook pro.sents 
tho subject in a manner at once authoritative and easy to 
read. It is divided into two parts. The first, dealing 
wjth metabolism in health, contains much on the methods 
of investigation, tlic general principles of the respiratory 
apparatus, the estimation of tho surface area of the body; 
the estimation of normal standards, and tlio theories of 
basal metabolism. A brief histoiy of the study of respira- 
tory metabolism is followed by an account of the meta- 
bolism of carbohydrates, fat, and protein ; that dealing 
with tho second begins with the sentence “ it is difficult to 
arouse much interest in fats,” but at once proceeds to 
prove the reverse by a clear statement, including a sum- 
mary of Bloor’s review of normal fat metabolism. The 
motaboli.sm of mixtures of protein, fat, and carbohydrates 
in the body is then considered with the help of a triangular 
map of the metabolism, somewhat resembling tho food map 
of. Irving Fisher. The science of metahohsm has been 
built up oil observations made on students and physio- 
logists, who are the best experimental subjects for this 
purpose. In discussing, the factors influencing normal 
metabolism, such as sox, ago, and size, which are con- 
sidered in detail. Dr. Du Bois accepts the view that the 
constancy of the basal metabolism in an individual is 
probably inherited from remote ancestry thousands of 
centuries ago. TJio first closes ivitli a disnission of the 
theories of basal metabolism. 

The second part, dealing with raetaboH.sm iu disease, 
begins with imdernutrition, a subject whicii comes under 
consideration also in connexion with tlie variations of lueta- 
olism presented in different cases of diabetes mellitus. 
Lroing on to discuss obesity Dr. .Du Bois remarks, '' We do 
not jet know why certain individuals grow fat. Perhaps 
^ ^ ^ accurate to say that we do not know why 
a.l he individuals in this overnourished community do 
210 grow fat. In simple or exogenous obesity there is 
not anj endocrine disturbance, and the fault lies either 
in 00 food or too much laziness, and there is not 

any striking abnormality of metabolism. A summary of 
data about the metabolism in diabetes 
me 1 US IS given, and it js concluded that in mild cases it is 
norma , ana that in severe cases it may be low from imder- 
nu Y liigb from, the influence of ketosis or as a 

result of the storage of carbohydrates. 

y discussion of metabolism in thvroid diseases is 
prece ed bj- a useful summai-y of the present state of 
"non e ge, including that about toxic adenoma. There is 

■a rnatl-minded consideration of the diagnostic reliabilitv 

o as.al metabolism, which, though goneially regar ded as 

Bvo'nn wn iau. 0 ')^”^“''= Bailliere, TintlalKiin'd Cox. 1927.-^(MeJ- 
O'o, pp. + TO; 92 %ures; I plate. 22s. Scl^efc)- ' 


the host index of thyroid activity, should, as a laboratory 
method, be checked by clinical observation. The interesting 
question whether hyperthyroidism or dysthyroidism is the 
essential factor in exophthalmic goitre is left in a state 
of philoso2)hic doubt. Tho metabolism in diseases of the 
adrenals, pitiiitari-, gonads, blood, heart, kidneys, and in 
fever is discussed in subsequent chapters, and the conclud- 
ing chapter in this valuable record of personal research, 
wide critical reading, and thought is devoted to the effects 
of drugs on bas.al metabolism. 


SEX PBOBLEMS. 

Aftf.r reading the five books which Dr. W. L. How.iRd has 
simultaneously offered to tlie iiublic the reviewer is left 
with' the feeling, that the floor has been sprinkled with 
disinfectant, that a licw and stiff broom has thoronghly 
swept the corners, and tliat the windows have been opened 
to admit the fresh winds and sunlight. The author has 
courageously tackled the fundamental facts and^ problems 
of eveiyday life. The facts are chiefly from observation of 
American life, yet with just a little less exaggeration they 
would apply with equal force to English life. 

On the rather startlingly yellow paper covers of the 
hooks there appears this sentence : “ There is a tremendous 
power for good and happiness in this hook.” This stated 
niont is true, for the author really gets to the root causes 
of tho sexual unhappiness of our times. In the volume on 
Sex llyfjienc" ho has done his utmost to impress the laity 
with tho inmimorablo iiossibilities of infection, and the 
variety of illnesses directly attributable to x-enereal 
diseases. These xvarnings should have a salutarj- effect on 
tho indiscretions of youth and age, bnt might possibly give 
rise to ungrounded susiiicions in innocent families. In 
Facts for tlic Mmh'icd^ and Sex Prohlcms Solved’’ there is. a 
clear and outspoken discussion of the many and ordinary 
difficulties which every married couple has to face. Some 
pay bitterly for their experience, .some never solve their 
difficulties; for a few, who have knowledge, the path is 
easier. These hooks supply the requisite knowledge. Most 
men and xvomen would he heljied by reading them, not 
only to Control their own sex lii-es and so achieve the 
happiest results, hut- also to give undersfanding advice to 
their childi'cn. Tho Confidential Chats v:ith Boys" is 
interestingly xvritten in colloquial language. Facts about 
the origin of life and about sex are stated clearly, witliout 
prudery, and with an understanding of the hoy’s point of 
X'iew. Tliere is no [loniogiapbic apjieal. The Confidcntiol 
Chats irifh Girts" is not quite so good. Tlie main outlines 
are sound, but all tho “ dou’ts ” for the adolescent xvonld be 
apt to xveary. It n-onid be more desirable for mothers to 
absorb the information, and then use their knowledge 
tactfully to control their growing girls. 

Ail the books suffer fiom the same faults of discursive- 
ness and redundancy. The author considers them “ chats,” 
and iiossibly as siicli they may ■ carry their points more 
effectually to the laity than more concise treatises. There 
is no quackery in them, and many times are readers 
advised to appeal to a reputable doctor nhen faced with 
difficulties, hut imjilored in no circumstances to hax’e 
dealings with quacks. Thronghont there is a strong apjieal 
to all that is highest in humanity. Dr. Hoxvard has made 
an lionest effort to grapple with the fundamental difficulties 
of life as we lix'e it to-day. So many poimlar hooks on 
medicine are now being written that it is incumbent on 
the general practitioner to be himself in a position to 
advise indix-iduals as- to the benefit or otherwise to bo 
derix'ed from reading certain- books. Practitioners can 
advise their patients to read these books, and, indeed, 
the practitioner’s time would not be wasted xverc he himself 
to glance through Facts for the itfarried and Sex Prohlcms 
Solved. So many of the ailments which find their nay to 
the consulting room under the guise of ordinarv medicine 
have their real origin in some sexual trouble. 

■ " plttin Facts on Sex Hngienc. ‘ Fads for the .Varrirtl. ’ Sex Problems 
iSolred, ^Confidential Chats with Boyf. ^Confidential Chate trifh Oirln 
L-se Howaid. M.D. London : Rider and Co. 1927 . (Cr. Sto* 
"Tx Dd^rllet;JEach volume.) 


“'^oouat of to those 

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TiiEBnmsR 

Mr.DICit JOCRKAL 



3AK. 81^-1528] 


SIR DA.WSON WIIiLIAMS, EDITOR, 189S-1S28, 


t lxrsUnTTifa • ino 
Uedicai. Jtjcmsifi 


BvitlsJ ilctrtcal journal. 


SATXJEDAT, JANUABT 21st, 1928. 


SIR DAWSON WILLIAMS, 

Editor of the “ BuiTisti Medical Jovra'al - 
1898-1928. 

“ Rlio, not content that former worth stand fast. 

Looks forward, persevering to flic last, 

Prom well to better, daily self-surpassed,” 

Ia' our issue of December 24111 lust there ttppeared 
a laconic paraEfrapli announcing that Sir Dawson 
Williams, C.B^E., M.D., LL.D., D.LiU., D.Sc., 
woukl shortly relinquish the editorship of the BrilisJi 
Medical Journai on completing thirty years’ service 
id that post. He was appointed Editor by the Council 
of the British Medical Association on January' 19th, 
1898, and before then had been closely connected 
with the Editorial Department for seventeen years. 
His period of service has thus extended over nearly 
half n century .4 

Tile resignation by a great man of an office of great 
influence and responsibility in the world of medicine 
is an event not lightly to be passed over, and 
least of all in the professional organ which he has 
conducted for so many years with such conspicuous 
ability and devotion. Of Sir Dawson Williams it can 
be said truly that for the greater part of his life ho has 
lived for this Journal, and through it for the advance- 
ment of medical Science and practice and the well- 
being of the individual doctor. That is a record of 
which he, and we, may well be proud. In all that 
long time-— as those Imew best who were nearest the 
middle of things;^there was scarcely a single develop- 
ment, whereby the British Medical Association grew 
in strength and numbers and became more useful to 
the profession in its scientific and corporate relations, 
which did not owe much to his foresight, his tact, and 
his sagacity, so that over .and over again it happened 
that when seeming to follow he led, and the event 
proved the soundness of his judgement. Dui'ing the 
Insurance Bill crisis of sixteen years ago no man 
helped more, in circumstances of peculiar difficulty, 
to keep the profession on an even keel througli stormy 
■waters. Again, in the anxious years of the great 
war, with a depicted staff, he did inestimable, work 
for military medicine and surgery, and, by his under- 
standing of their trials and their needs, for the 
medical men risking their lives .and 
livelihood abroad or carrying on against heavv odds 
in civil practice. 

In an issue that is sent to press at the moment of 
leave-taking we will not try to sum up a long career so 
ull of purpose and of achievement, or to do justice to 
a c laractor so strildng. Moreover, though none of its 
leaclers is held in higher general cstenn by our pro- 
essioir, his reticence and self-effaecmeut are such that 
lie tull range of Sir Dawson Williams’s activities and 
mnuonce is known to few, and time is needed to see 
ms lite-work in true perspective. We mav never- 
heless mcail hero the thumbnail sketch of him drawn 
oy another groat and wise man. Speaking at a 
eomphmontary luncheon in 1921, Sir Clifford Allbutt 
said that if one tried to put into a word or into a few 
w oi'f s tile character the Editor set before his friends, 


he thought they would feel that that blend of width 
of view and sympathy and a fine Idnd of under- 
standing and knowledge of the world was summed up 
in a single word— '^'isdom. Dawson Williams, he 
said, was a parlicularly wise man. A just saying,. to 
which we may be allowed to add that with this broad 
and balanced outlook on medicine, on letters, and 
on life, the Editor of the British Medical Journal 
has combined endless care for detail, thus fulfilling 
Dr. .Toiihson’s definition of the true strong and sound 
mind as the mind that can embrace equally great 
things and small. 

Sir Dawson Williams has received many distinc- 
tions, from the Crown and from learned bodies, and 
the British kledical Association has awarded him the 
highest honour in its bestowal — the gold medal of 
merit. In the jiast few weeks high and just tributes 
to himself and his life-work have been paid in the 
columns of our chief contemporaries, notably in 
leading aidicles in the Lancet of December 31st and 
the Times of January 2nd. “ We are in a position 
of peculiar ability,” writes the Editor of the Lanecf, 
'■ to gauge the statesmanship, the patience, and the 
courage displayed by him in many positions of diffi- 
culty and delicacy throughout a period of revolutionary 
changes in our science, our art, and our everyday 
machinery, every one of which changes has been 
reflected in the labours of the British Sledical Asso- 
ciation; and we are expressing the opinion of all when 
we point fo him not only ns the mainstay of the Asso- 
ciation throughout his exdended term of service, but 
ns a great champion of our profession.” And the 
Times says; “ During thirty difficult years Sir 
Dawson has represented all that is best, most sane, 
and most progressive in modern medicine. To his lot 
it fell to mould and foi*m the ideas of the great 
majority of doctors in this country during the time in 
which science entei-ed into partnership with clinical 
study. Many heads were turned in these days and 
false pi’ophets abounded; hut the British Medical 
Joimtal. while welcoming the new, at no time lost 
sight of the value of the old.” 

Now that Sir Dawson Williams has given mp the 
helm, further public acknowledgement wll no doubt 
he made of his long and splendid services to the 
British kledical Association and the profession, to 
medical science and medical literature. His colleagues 
at headquarters, to whom he has been a valued 
counsellor and the most loyal and considerate of 
friends, are confident that in his well-earned leisure 
they may still turn now and then to that ripe juilge- 
ment in moments of doubt or difficulty. As for the 
paper of which he has been the guiding and directing 
head for more than a generation, and to which he has 
dedicated his life, we of the editorial staff will do our 
best to keep it what he has made it ; moving with the 
times, but holding, os far as we can, to the tradition 
built up by one who, in the woi'ds of the leading daily 
newspaper, “ saw the practice of medicine whole and 
upheld his vision, weelv after week, with a constancy 
and a courage which have their reward to-d.ay in the 
gi-eat reputation throughout the world of the journal 
which he served.” It will be difficult to follow him, 
but his successor has had one ad\ antage — clnily and 
hourly work, for eleven years, udth a great editor and 
a great gentleman. 


The portrait reproduced on the plate facing this page is 
from a photograph taken in the Editor’s room at Tavistock 
Square, and presented to Sir Dawson 'Williams bv his 
imniediate colleagues ou Januaiy 19th, the last, dav of his 
editorship. 


J .04 Jan. 2t, 1928] 


NTJTKITION AND MADNUTBIXION. 


■ f - Th* BKimc ■ 

L UfoicAL Jotnuuft' 


NUTRITION AND MALNUTRITION. • ' 

In this week’s issue there appear full reports of two 
lectures, the one on “ Experhnents in malnutrition *’ 
by Professor V. H. Mottram, the other by Colonel 
Robert McCarrison on “ Diseases of faulty nutrition.” 
I'he two articles are in a sense complementary. Pro- 
tessor Mottram ’s standpoint is that of the laboratory 
worker who is in a position to present the clean-cut 
evidence of the carefully controlled laboratory experi- 
ment. Colonel McCarrison speaks, for the most part, 
as a clinician; he views a more extended field, and on 
that account the focus he can faring to bear on any 
individual set of observations is less sharp. Needless 
to say, both standpoints are entirely necessary to 
medical science. 

So much is now being said and written about 
nutrition that it is desirable to try to take stock of 
some of the fundamentals of the present position. 
One very notable point is raised by both lecturers. 
Nutritional defects may be of many kinds; a proper 
diet is necessarily a balanced one. If, therefore, 
attention is concentrated upon one or two factors only 
— upon vitamins, for instance — and the remainder 
are neglected, we defeat our ovm ends just as surely 
as we should do if we clung to Rubner’s teaching 
that an efficient diet need possess only an adequate 
calorie value. It is necessary that we should con- 
stantly remind ourselves that every factor must be 
taken into consideration — calories, a proper carbo- 
hydrate and fat balance, a sufficiency of protein and 
of essential amino-acids, inorganic material, vitamins, 
roughage, and palatability. It seems, perhaps, absurd 
that such elementary considerations should need to 
be stressed. Many factors, however, often operating 
in a subtle way, affect the food supply of a large 
community. Price fluctuations, commercial processes, 
the ignorant or unscrupulous “booming” of products 
for trade purposes, all play a part — a small one for 
those who in any case enjoy a varied diet, a very 
large one for the great majority for whom straiter 
means dictate more or less rigid hmits in choice 
of food. 

In view of the present bread controversy, it is very 
interesting to note that Professor Mottram finds that, 
by themselves, brov/u and white bread are about 
equally bad. His experiments, in fact, throw a new 
light on the traditional -bread-and-water diet as a 
moans of correction. It would appear that the type of 
bread eaten might quite safely be dictated by con- 
venience or by personal preference, provided other 
sources of protein are available. The bread question, 
in fact, need only arise for those who, like Squire 
Western, have to deal with recalcitrant daughters. 

On the occasion of the presentation to him of the 
gold medal of the Society of Apothecaries, Sh Gowland 
Hopkins lately advanced the rather provocative thesis 
that mankind, as a whole, had never been properly 
nourished. Whether the data for the final proof or 
disproof of such a statement will ever be forthcoming 
is doubtful; nevertheless, quite a good case could be 
made out in its favour. It must be conceded at once 
that a certain section of every community has always 
done vei-y well on the whole, because it can take what- 
ever food instinct or caprice may dictate. Probably 
the “ strong man ” of the primitive tribe, certainly 
the mediaeval nobleman and the modern sensible and 
well-to-do citizen, have all they need to eat. But the 
weaker members of the savage tribe may' well have 
often been short of protein. We read in Piers 


Plowman of the struggles of the mediaeval peasant for 
a balanced diet : the labourers 

" Deigned not to dino today on night-old worts. 

May no penny alo please them, nor a piece of bacon 

^ But it be fresh flesh or fish, fried or y-baked.” 

Again, from Huxley’s Life of Hume it is clear that 
scui-vy was very common among the poorer class of 
the Scottish Lowlands during the winter months. 

Colonel McCarrison cites examples to show that 
serious nutritional defects arc the lot of many com- 
munities at the present time; and the same point is 
forcibly brought home by McCay’s admirable mono- 
gmph on the jail dietaries of the United Provinces of 
India, in which he discusses the diets of several Indian 
tribes (apart from jail inmates). Colonel McCarrison 
further develops the thesis that, short of conditions 
which are recognized as “ deficiency diseases,” mal- 
nutrition of any type may lead, both in man and in 
domestic animals, to a lowered resistance to many 
types of infection. Ho quotes some interesting figures, 
dra^vn from the disease and mortality rates of a large 
rut population and a smaller bu-d population, kept on 
a deficient diet. (Unfortunately it is not stated in 
what respects the diet of the former was deficient.) 
He gives, too, a long list of ailments, based evidently 
on clinical observations, which may follow upon mal- 
nutrition of various kinds. Other examples, such as 
the improvement of eases of pyuria in infants fay 
administering largo quantities of vitamin C, may be 
taken from works like Avitaminosen, by Gyorgy. The 
main difficulty- in appraising such evidence is, of 
course, to be sure that the many possible sources of 
error have been eliminated. Such considerations as • 
heredity, immunity, and environmental conditions 
other than diet have a knack of playing havoc with 
the most convincing sets of figures. Should, however, 
this view prove to be substantially correct it is clearly 
of the utmost importance. Prom the point of viev^ 
of the community the worst diseases are those that 
cripple the young adult; he or she then becomes 
a “ passenger,” unproductive, yet not eliminated. 
Should it prove feasible to low-er the_ incidence _ of 
such diseases as tuberculosis or rheumatic myocarditis 
by dietetic adjustments, to neglect to do so w'ould be 
culpable. 

If however, adjustments are to be made on an 
extensive scale they must be thought out in relation to 
the diet as a whole. The haphazard addition of this or 
that factor— be it vitamin, salt, or energy-yielding 
substance— is very likely to be useless, and may be 
quite definitely dangerous. Por example, Hopkins 
has found that excess of vitamin A in a diet causes, 
in rats, cessation of growth and other conditions very 
plainly pathological. Matters may be adjusted by 
increasin'' the amounts of vitamin B. The ill effects 
of partial carbohydrate starvation on children of a 
certein type are well known; again, Mellanby has 
clearly shown the undesirability of excessive amounts 
of oatmeal. The “ booming ” of one or another food 
material is almost certain to prove an ineffective 
measure, and its failure will necessarily bring discredit 
on all concerned. 

Clearly the fundamental steps must be taken — as 
they ate being taken — by the biochemist, who is in 
a position to produce unequivocal evidence based on 
rigidly controlled experiments. The value, too, of- ' 
work such as that dona by Corry Mann on dietaries of 
institutions, and by Mrs. Mellanby on the incidence 
and prevention of dental caries, can hardly be over-' 
estimated. 


Jan. ?i, , 192s] 


DREAMS. ■ 


r Titz Barrm 
Ueoicai. Ooob:ijx 


106 


' ZOOlIOOCAL NOMENCLATURE. 

ZoOLOQioAi, nomonclaturo has alwa 3 ’s bocn a bugbear of 
tcacbors and students of medical zoology. Pcrliaps tlio 
most annoying fcatui*o of this nomonclaturo w'as the 
inflosiblo working of tlio law of priority. As our readers 
kuow, the rules governing nomonclaturo aro framed by 
tlio International Commission on Zoological Nonienclaturo, 
a body appointed by the International Zoological Congress, 
which meets about once in every ten years. The last 
meeting was held at Budapest in September of last year, 
and at this meeting a very important amendment to the 
law of priority was adopted. This law now reads; 

" The valid name of a genus or species can be only that 
name under which it was first designated on the condition : 
(a) that (prior to January 1st, 1931) this name was published 
and accompanied bj- an indication, or a definition, or a de- 
scription; and (h) that the author has applied the principles 
of binary nomenclature, (c) But no generic name nor specific 
name published after December 31st, 1930, shall have any 
status of availability (hence also of validity) under the rules, 
unless and until it is published cither (1) with a summary 
of characters (scu diagnosis ; ecu definition ; fcti condensed 
description) which difierentiate or distinguish the genus or 
species from other genera or species; (2) or with a definite 
bRiliographic reference to such summary of . characters (seu 
dmgnosis, etc.) ; and further (3), in the case of a generic 
name, with the definite unambiguous designation of the type 
species (sen genotj’pe; ecu autogenotj’pe; ecu orthotype).” 

This revision of the law is intended to inhibit two of the 
most important factors which hitherto have produced con- 
fusion in the names of animals; and although several 
years of grace have been granted before it becomes opera- 
tive, it is. to be hoped that authors will give immediate 
effect to it. The congress also rocominendcd that an 
author who publishes a name as now should definitely 
state that it is now, and that this statement should bo 
made in onlj’ one (the first) publication, and that the 
date of publication should not be added to its name on 
first publication. It is also requested that authors -who 
quote a generic or specific name should add at least once 
the author and j'ear of publication of the quoted name, 
or give a. full bibliographic rcferenco. While this revision 
of the law of .prioritj’ and the accompanying recommenda- 
tions should do much to clarify the position in the future, 
it leaves the past untouched, and the confusion whicli 
existed in the names .of the parasites is still much as it 
was. Readers will remember that Professor Leiper last 
J'ear drew attention to tho deplorable state of confusion 
which existed in the nomonclaturo of the commoner 
helminths. This has to a certain extent been corrected 
bj’ the adoption of an ad hoc list of names which shall 
be accepted irrespective of tho law of priority. The subject 
was discussed recently at the annual meeting of British 
zoologists, held at the Zoological Society’s office in Regent’s 
Park, and it was there unanimously agreed that the 
following resolution should be brought to the attention of 
the Nomenclature Committee: “That this meeting of 
British zoologists is in favour, of a substantial extension 
of the lists of nomina conservanda.” It is gratifying to 
find that this meeting has given its influential support to 
a position which the BmiisH Medical Jouiinal advocated 
a rear ago, and we hope that, while the position has been 
regu ated so far as future names are concerned, a similar 
E ate of affairs may soon be in operation for the old 
confusing nomenclature of the past. 


... . DREAMS. 

N interest rn dreams has been manifested by mankind 
torn Dnie immemorial, but it has been much intensified 
since Freud astonished the psychological world with his 
leory that sleeping thought is not, as had been generally 
rel , a ineaningless conglomeration of psychical processes, 
lit that it is, on the contrary, the disguised expression of 
repressed wishes originating, with few exceptions, from 


infantile sexual tendencies. This theory is intimately 
bound up with its author’s conceptions of mental develop- 
ment and of tho causation of tho neuroses and psychoses, 
and it has for this reason stimulated widespread discussion, 
the dcA'clopment of numoi"ons divergent schools of psycho- 
pathology, and a vast output of literature — ^good, bad, 
and indifferent. The problem of dreams itself naturally 
interests not only psycho-pathologists, but academic psj'cho- 
logists and educationists as well, and that this subject 
still attracts tho attention of manj’- psychological writers is 
evidenced from the fact that wo have received three small 
volumes, all by non-medical observers, dealing with it 
from various points of view. Dr. George H. Green, whoso 
interests aro primarily educational, ivritcs on the dream 
with which many of us are personally acquainted— namely, 
The 'SerTor-Dream,^ or what is more commonly known to 
the uninitiated as tho “ nightmare.” It seems curious at 
first sight that the author should regard a dream out of 
whicli we wake up in a state of terrible anguish as a 
wish-fulfilling dream. This, however, is the view he does 
take, and from what he tells us it may in some instances 
be such as ho believes. Briefly, he considers a terror dream 
to be an incomplete dream; ho regards its manifest content 
as a statement of tho condition which makes possible the 
fulfilment of hidden wishes, but considers that it does not 
pass on to fulfilment because the statement of tho condition 
(dream content) evokes an emotional state (fear) which 
results in waking. Wo must confess that when the writer 
cnde.avours to apply this theory to tho battle dreams of 
war-shocked soldiers w'o feel that he is stretching it to 
breaking point. Dr. Green expresses tho hope that the 
study of terror dreams may afford -a clue to the nature pT 
failures of adaptation to tho school and to the home, and 
thus make it possible to discover means of assisting t\ie 
child to better adaptations. In' contrast to this view Mr. 
E. F. Fortune, in his volume on illiiid in Sleep,® maintains 
that the wish-fulfilment hypothesis is only valid for some 
dreams. Having obtained evidence of thirty dreams from 
two children, aged 5 and 6 respectively, he has come to the 
conclusion that the theories of childhood sexuality and 
invariable wish-fulfilment of children’s dreams appear to 
be unfounded. Twenty per cent, were wish-fulfilments, 
27 per cent, were conflicts between wishes and fear, 
mostly with frustration. The remainder were mainly 
concerned with pugnacity, rivalry, and fear. The writer 
does not consider that any of these dreams could possibly 
be interpreted in either the Oedipus or Electra complex 
pattern by any fair-minded observer. He entirely dissents 
from the view that nightmares or terror dreams are wish- 
fulfilments. In concluding his book Mr. Fortune expresses 
the belief that “ it is legitimate to infer the conjunction of 
covert censorship and covert affective selection of sub- 
mergent in cases that share the linguistic symbolism and 
general structural opposition to conscious thought character- 
istic of dreams in which censorship and affective selection 
of submergent appear overtlj- conjoined, and in which 
there can be little doubt of the mechanism involved.” 
We should hesitate to express an opinion as to tho 
validity or otherwise of this hypothesis, but the language 
in which it is formulated reminds us of a remark 
attributed to William James by Dr. F. 0. S. Schiller, 
to the effect that “ the natural enemy of any subject 
is the professor thereof ! ” We do not wish, however, 
to deter those who are interested in dreams from making 
themselves acquainted with this book on account of the 
intricacies of its concluding sentence; apart from this 
unhappy combination of words tho book is readable, and 
contains a number of observations which those who have 
some knowledge of current theories of dreams will find 

i The Terrnr-Vreum. London : Kegnn Paul, Trench, Trubner and Co 
Ltd. 1927. (Cr. 8vo, pp. 126. 5s. net.) ■’ 

- The Mind in Steep. London : Same publishers. (Cr. 8vo, pp. xii + 114 
53. net.) 


INTEACEAUIAL CAPACITY. 


108 Jan. 21, 1928] 


[ 


Tas Camsi 
MzstaL Jouvxifc 


interesting. ^A’’o coino now to the tiiircl boolc;- It certainly 
cannot be said that Dicnins,^ by Mr. Percy GokUhwaito 
Stiles, is enveloped in an atinosplicre of professorial 
obscurity. The author has An engaging stjde, and what ho 
writes makes pleasant reading. He saj-s he is not a trained 
psychologist, and has not made any extended study of 
dream literature, preferring to remain an amateur rather 
than attempt to qualiH as an export in this field. Tho 
present collection of dreams was begun in 1897, and from 
that timo down to tho irrescnt thero have boon no rerj- 
large gaps in the series. Tho writer does not pretend to 
pose as an oracle where tho dreams of others are concerned. 
During .-the last few years ho has made sketches to give 
prominouco to certain features of his dream stories. Many 
of these drawings are included in the text ; they are very 
quaint, and enhance tho' charm of tho book. As the result 
of his studies Mr. Stiles finds tho dreaming personality to 
be egotistical, and the prevailing mood to bo one of self- 
satisfaction. Tho dreamer thinks that he reasons admir- 
ably when his logic is grossly at faidt, and even in those 
exceptional passages in which there is sharp self-ridicule 
there is an underlying conviction of his own importance. 
More commonlj’ ho is impudent and aggressive, displaying 
an excess of self-confidence. The psychology of dreaming, 
says the author, is nearly akin to that of “ yellorv 
journalism.” Ho concludes with the generalization: 
“ To sleep is to contract. To dream is to bo committed 
to crass egotism and to sitting in tho seat of tho 
scornful. We wake to a broader vision, a moro patiens 
philpsophy, a kindlier idealism.” Mo one, whatever parti- 
cular dream theory ho inaj’ hold, will feel that he has 
wasted his time in reading this entertaining book. Perhaps 
it is all the better because the author is unhampered by 
theories. 


INTRACRANIAL CAPACITY. 

Anthhopoiogists find that tho estimation of the cranial 
contents when only a few fragments of the skull are avail- 
able calls for very special skill and judgement. In using 
any one method it will eften ho necessary to make some 
assumption, possibly several, which may seriously affect tho 
residt. It is therefore verj- desirable to have more than 
one method of estimation available, and Professor Drennan 
of tho University of Capetown, whose essay in praise of 
anatomy is published elsewhere in this issue (p. 109), has 
recently contributed to Ncitttvc an ingenious plan which he 
has applied with apparent success to the bones of the 
Piltdown skull. On examining the endocraniul aspect of 
Barlow’s casts of the bones Professor Drennan was stniek 
by the .size and clearness of outline of the grooves for the 
middle meningeal vessels on the parietal fragments, and of 
the transverse sulci — that is to say, the grooves for the 
transverse venous blood sinuses — on the occipital fragment. 
On inspection of the corresponding grooves in the baboon 
and in the gorilla it was seen that in both they were 
narrower than in man, and narrower in the baboon than 
in the gorilla. This afforded evidence that the size of the 
venous sinus grooves (transverse sulci) is related to the 
cairaeity of the cranium, as was to be expected, seeing that 
these sulci lodge the veins which convey practically all 
the venous blood returning from tho brain. Lai-ger 
channels must be needed for the larger amount of blood 
returning from the larger brain. He put this hypothesis 
to a practical test; the relation of the width of the sulci 
to the cranial capacity was ascertained in thirty-two skulls, 
and a regression formula for the calculation of the cranial 
capacit}' in terms of the width obtained. Estimated from 
this formula the cranial capacity of the Piltdown skull 
came out at 1,415 c.cin. ; the latest calculations of tho 
capac ity by other methods are: by Dr. Smith AVoodward 

* UarcTird University Press. London: Jltlfortl. (Post Bvo, 

PP. BO; Illustrated. 7s. net.) 


and Profo.ssor Elliot Smith 1,300 c.cm., and by Sir Arthur 
Keith 1,400 c.cm. Tho agreement, therefore, is fairly close, 
although a table given by Piofcssor Drennan shows that 
there are considci'ablc variations in individual skulls^ so 
that tho value of tho method is not absolute. 


THE CARE pP EYE DEFECTS. 

Tite report of tho depaitmontal committee apjiointed by 
tho Minister of Health and tho Secretaiy of State for 
Scotland on tho Optical Practitioners (llegistration) Bill, 
1927, ‘ was summarized in our issue of January 7th, at page 
26. It consists of three reports — ^the first signed by nine of 
the thirteen members of the committee, a second issued by. 
three members, and a third by a single member dated ten 
weeks earlier than the date of tho other reports. The 
committee has been commendably expeditious, for it was 
I appointed on IMarch Slst and reported on December 17th 
of last year. It took evidence from fifty-five persons 
I and organizations, but tho evidence, described as “ very 
voluminous,” has not been printed. It will be recalled , 
that of the many shopkeeiiers — ^jewellers, pharmacists, and 
opticians — who. hold themselves out as “sight-testers,” 
certain groups combined themselves into trade societies, 
and these societies declaimed against the laxity of the law 
which allowed all and sundry to “ test sight,” and urged 
that for tho sake of the nation’s eyes thej' themselves 
.should be enrolled upon a State register of official sight- 
testers. That was the gist of tho aim of one of these bills — 
tho Optical Practitioners (Registration) Bill, 1927. AA'hen 
this bill was before Parliament tho Minister of Health 
referred the matter to a committee, representative of all 
parties concerned, for a considered opinion on the desir- 
abilitv or otherwise of such new registration. Our concern 
is with the Majority report. It is agreed therein that 
present conditions arc unsatisfactory. The sale of cheap 
spectacles is said to bo enormous. There exist a consider- 
able number of opticians “the reality of whoso qualifica- 
tions docs' not always correspond with the high-sounding 
titles which they assume.” It is therefore concluded 
that “ there is a prima facie case for setting up 
a State register iu order to produce some sort of' 
order out of tlio present chaos.” But for all that 
it is considered that such a register is not desirable 
poliev. To set up a register prohibiting practice to 
anv "but tho registered would be against public interest, 
because at its initiation this wordd involve the inclusion of 
practically all opticians. A limited register that did not 
prohibit unregistered practice would be useless, ' if not 
dangerous, unless it wero made a condition of entry that 
evei-v candidate should prove to the satisfaction of the 
board his ability to exclude the possibility of the existence 
of disease before prescribing spectacles. The committee 
found further “ that it would be necessary not only to 
impose restrictions on registered opticians in their way' 
of treatment, of advertising, and of using confusing or 
misleading titles, but that it is imperative that they should 
be prohibited from using drugs. Such a restriction would 
in effect severely limit the class of patients whom opticians 
wordd be capable of treating.” The report docs not end 
with this conclusion. Tho final paragraph lays great 
emphasis on what is a virtual promise on tho pai't of the 
medical profession that at no distant date thero shall 
be a sufficient service of medical practitioners well trained 
in ophthalmology to meet tho necessities of tho situation. 
The work of the British Medical Association is admittedly 
the ground for this expectation. During the past few 
■years the Association has done much to encourage medical 
practitioners, and particularly the newer generation, to 

* Keport of the Committee appointed by the Jlinister of Health and 
the Secretary of State for Scotland on the Optical Practitioners , 
(Registration) Bill, 1927. Cmd. 2999. London : H.M. Stationery Othce. 

6d. net- 



MEDICAIi ‘.HAGrOIiOGY. 


[ . The Briush 1 (^7 ' 
UeoTCXL JotTESlIi ■ AVI 


Jan. 21, 1928') 

cultivixtc this work ; it lias proimrcd d list, of no mean pro- 
poi lions, containing tlio names of those competent in this 
work ami willing to umlortako it; and at the last meeting 
of the Ropresentative Body the Association agreed' to tho 
provision of. clinics whero insnred persons might receive 
expert attention linder conditions ' economically possible. 
AVe havo published ; in tho SurimraiENT lately some few- 
criticisms of this policy from correspondents. Their con- 
cern appears to arise in part from a fear that clinics may 
destroy private consultations, and in part from a belief 
that . “ clinics ” meant costly central buildings. But tho 
arrangements in view are that tho private consvdtations 
and the clinics should run together; and that whero this 
would bo convenient tho elinics should be worked at tho 
doctor’s orvn house by his ear-marking, by arrangement, 
one evening a week or so for a group of patients. Tho 
evidence given by tho Association as to the existing and 
projected provision of expert treatment of eye conditions 
by medical practitionore without doubt impressed tho 
departmental committee, and it is tho duty of those con- 
cerned to expedite tho arrangements. Economic conditions 
havo swayed many approved societies in favour of arrange- 
ments with opticians. But there is some ground for the 
belief that tho work could bo done by doctors under 
arrangements that would in tho end prove the more 
economical financially (by reason of a more judicious pro- 
scribing of glasses) ; and this irrespective of the advantage 
that will accrue from preventivo measures that may be 
initiated bj- expert eyo examination. There is a growing 
volume of ophthalmic work to bo done. Tho public x-eads 
to-day as it never read before. Slodcrn industry demands 
good eyesight. Bad or poor sight means poor work and 
additional risks of injurj’. It is conceded on all hands 
that tho best for all pei'sons is that tho care of their eyes 
should be undertaken by trained medical practitioners. Let 
it not be said that there is a lack in tho response of our 
profession to this call. 


MEDICAL HAGIOLOGY. 

The Fellows and guests who were received by Sir James 
and Lady Berry at tho social evening of tho Royal Society 
of jMedicine on January 16 th found themselves immediately 
ill a mediaeval atmosphere. The library was adorned with 
representations of saints, in tho shape of statues, frescoes, 
prints, and tokens (tho exhibits having been lent by the 
"U ellcome Historical Medical Museum and by jMiss Marie 
Roche), and in the Barnes Hall Dr. Jane Walker gave an 
address on the surprisingly extensive calendar of medical 
and surgical canonizations. The outstanding patron saint 
of medicine was admittedly St. Luke, though Dr. Walker 
thought that he was now rather discredited as a doctor, 
for his gospel had been examined from tho medical point of 
1 iew and declared to show no signs of the possession of any 
special medical skill or knowledge. At the same time, she 
thought there were professional touches in the narrative; 
for example, the omission of the fact, recorded 63" the other 
Evnoptists, that the woman with the issue of blood had 
spent all her monei- upon physicians and was nothing the 
letter for it, but rather worse. Again, there was the 
ccsciiption of Peter’s wife’s mother as sick of a fever." 
There were people, however, who declared that St. Thomas, 
an lonest and reverent sceptic, would be more appropriate 
as t le pation saint of tho medical profession. Another 
gieat figure was St. Pantaleone, the ph3'sician who suffered 
malt} idem for his faith in the reign of Galerius Maximus, 
n inediaei al representations ho was shown wearing the 
long robes of a physician. The story of St. Cosmo and 
.-t. Damian has Intel}- been recalled by their selection as 
supporters for the arms of the Royal Society of Medicine, 
but Dr. M alker related their curious histoi-v and showed 
equally curious pictures to illustrate it. Tlien came the 


group of virgin martyrs— St. Margaret, St. Barbara, and 
St. Catherine. Tho first of these was tho patron saint of 
progiiancy, for tho reason that she had delivered herself 
successfully out of tho dragon. In the ]>icturo by Van dor 
Goes in the Ufiizi at Florence she was shown in tho 
tiyptich standing at the top of tho dragon, having emerged 
from its head. St. Barbara was invoked against all 
accidents arising from explosions of gunpowder. Tho 
arrows 'which pierced St. Sebastian were always regarded 
as the emblems of pestilence — tho psalmist’s “ arrow that 
llietli at noontide ” — and there was hardly a town in 
Europo which was not reputed to have been spared tho 
horrors of pestilence by the intercessions of this saint. 
Another of tho plague saints was St. ’ Roche, who was 
also tho patron saint of the sick in hospitals because, at 
his birth at Montpellier in tho thirteenth ceiitur}-, he had 
a small red cross on his breast. Next came St. Lucy, tho 
virgin mart}-r of Syracuse in Sicily, and patroness against 
diseases of the eyes. She had plucked out her own eyes 
because her lover had admired them inordinately. St. 
Agatha was tho protectress against diseases of the breast, 
because her own breasts had been cut off by her persecutors 
when they failed to achieve her dishonour. St. Catherine 
of Alexandria, carefully distinguished from the noble lady 
of Siena, was patron saint against diseases of the tongue. 
She, like many of these saints, was subjected to various 
tortures, from which sho was miraculously delivered, but in 
her case, as in that of Cosmo and Damian, beheading was 
apparently final and conclusive. Then there was St. 
Apollonia, potent against toothache, who had her own 
teeth pulled out with pincers for refusing to worshiji a 
statue. St. Erasmus, bishop and martyr, was’ the patron 
saint of sufferers from stomach-ache and allied disorders. 
The method of his martyrdom was peculiar; he was cut 
open, and his entrails were wound oft’ on a sort of wheel. 
Sufferei-s from throat affections sought the intercession of 
St. Blatse of San Biaga^ who had miraculously saved a 
child from the consequences of swallowing a fish-bone; and 
patients with lung diseases had St. Ansano of Siena, 
though it was not known how he got his patronal qualifica- 
tioii. Dr. Walker confessed to some fear lest tho title of 
her address should have led any to infer that it included 
those great practitioners of tho art of medicine who, apart* 
from their .skill in their profession, have been so full of 
grace and holiness as to merit the title of saint. Medicine, 
indeed, had had its real saints, and they had been mostly 
moderns. 


TREATMENT OF FRACTURES. 

■We agree with a writer in the current number of tho 
St. ’Bartholomew’s Hospital -Journal, that it is a pity there 
is not a special ward for tho treatment of fractures in 
that, and indeed in every general, hospital. When -the 
general hospital in question has a medical school attached 
lie think that the need for a special ward for these cases 
is still more crying, for without it the chance of students 
learning the modern treatment of fractures of the lower 
extremities must be very small. The author of the article, 
Mr. H. B. Stallard, whoso remarks are addressed in 
particular to nurses, says that it is not unusual for a 
patient suffering from fracture of tho femur to havo his 
pelvis raised independently of the rest of the extremity, 
so that the nuise may reach the buttocks and lumbar 
region; nor for one whoso spine has been fractured to be 
rolled over for dressing purposes ; and that in these and 
other ways attempts to immobilize a fracture are frustrated. 
A'arious beds and frames have been devised with much 
ingenuity for the purpose of maintaining correction and 
preventing movement between fragments of fractured 
bones while allowing the necessary access to tho other 
jiarts of the patient to secure cleanliness and preservation 



108 JAN. 21, 1928] 


. JOHN .HUNTER. 


Mxdiccl Jomrit 


of. the skin. Tho bod described and illustrated diagram- 
inatically by Mr. Stallard would, with such modifica- 
tions as actual practice is sure to indicate, no doubt 
bo useful. The pattern of tho particular machino em- 
ployed is, however, of much less moment than familiarity 
with its working, and a duo appreciation of tho principles 
ihvolved, on the' part of surgeons and nurses. Attention 
to details and accurate adjustment are of tho first impor- 
tance in securing that restitutio ad integrum which is eo 
necessary for the patient, especially if ho bo a manual 
Worker whose earning power depends upon his physical 
efficiency. Tho advantages of a special “ fracture ward ” 
seem to us so obvious as to bo beyond dispute. Never- 
theless, they are not universally conceded, and may need 
to bo re-stated. They were practically admitted by tho 
speakers in a discussion on this subject at tho Annual 
Sfeeting at Bath in 1926.' Among those speakers wcro 
general surgeons from various parts of tho kingdom as 
well as orthopaedic specialists. Tho experiences of tho war 
were still fresh in all minds, and it was hoped that tho 
lessons learnt and tho hugo exporionco gained in treating 
gunshot fractures might not bo wasted or forgotten, but 
made useful in tho treatment of the injuries of civil life, 
which have been so much increased in number and severity 
by the growth of motor traffic. If a whole ward wcro 
devoted to tbo care of fractures it is only too likely that 
the beds would bo kept full, and then all concerned would 
bocomo expert and assiduous in fracture treatment from 
t.he. moment of admission of a case till its discharge. A case 
qf abdominal section after tbo stitches aro tied generally 
needs ' none but trivial surgical attention until convales- 
cence, but a case of fracture of one or more important 
Ijtthes may need frequent readjustment if tho best result 
is, to bo secured; and house officers and sisters havo to bo 
e.xperienced and alert to perceive when all is not right and 
to. take the necessary steps to remedy tho ill. To insist 
qn the importance of x rays in this connoxion should bo 
unnecessary, but at the risk of tediousness wo would insist 
that no fracture should bo assumed to bo properly “ set ” 
until stereoscopic x rays, or two plates taken at right angles 
to one another, have shown tho position of parts to be 
satisfactory while in tho retentive appliance. 


JOHN HUNTER, 

The Mansion House, the building of which was completed 
at about the time John Hunter settled in London, was the 
scene of the delivery of tho Hunterian Lecture on Monday 
evening, within a month of the bicentenary of Hunter’s 
birth, by Dr. Howard Kelly of Baltimore. The lectuj'e, 
delivered under the auspices of the Hunterian Society, was a 
rapid review of the history of surgei-y leading up to Hunter. 
Dr. Kelly acknowledged his indebtedness to two of tho 
greatest of medical historians — the late Sir Clifford Allbutt 
and Dr. Fielding H. Garrison, editor of tho Index Medicus. 
Ho took as his text three words : rpijS^ (meaning the rub 
and "wear of daily contact with facts) pera Xoyor (meaning 
the spiritual essence, the ideal, the larger conception). Ho 
regarded these master words as significant of the Hunterian 
pl'.ilosophy. A search back through John Hunter’s intel- 
lectual ancestry carried one right away to our Hippocratic 
forefather. To the island of Cos we owed the beginning of 
clinical instruction and the example of the open mind, the 
rejection of superstitious follies, and the alert and highly 
trained use of the senses. Long afterwards came Galen, 
the speculative philosopher, with one of the most encyclo- 
paedic minds of antiquitj-, faciie prineeps as physician, 
biologist, anatomist, and founder of experimental medicine. 
But tho lecturer also pointed out the mischiefs which arose 
out of Galenical doctrine, with its dogmatism and assump- 
tion of infallibility — mischiefs which became most clearly 
apparent long ages afterwards in the treatment meted ont 


to Copernicus, .Tycho Brahe, and Galileo. Not tho wisdom 
of Galon, but his dogmatism, charaeforized for long the 
stupid autocrats of our precious heritage. But shafts of 
light shono through tho dai'knoss, especially from the 
thirtconth century onwards, until tho steady gleam of 
Hunter’s torch rose at length above tho horizon. The fore- 
runners of Hunter wore often Iiumblo and unlettered men, 
and their place in tho revival had boon too rarely sung, 
but they helped to break down the notion that tho Almighty 
had exhausted Himself when Ho created Galon I Tho 
lecturer mentioned tho names- of several of them— Roger 
of Saloi'no, Langfranc, Mondino do Luzzi (who introduced 
dissection into tho teaching of anatomy in place of the more 
dogm.atic statements taken from Galen), and, above all, 
Ambroiso Bard, Two other names, nearer to tho time of 
Hunter, wcro also mentioned — Richard AVisoman (1622-76) 
and William Chcselden (1688-1752). Tho lecturer spoke 
next of what ho called tho spring tide in tbo world of 
thought in tho eighteenth century. Now elements seemed 
to come raining upon tho earth during tho time of Hunter. 
Tho greatest natural philosopher, Isaac Newton, died tho 
year before Huntor was born. Tho beginnings of tho 
science of chemistry belonged to this era, which saw tho 
work of Rriostloy and Lavoisier, to be followed later by 
Humphry Da^•J•. Geology became an oveiyday sciened 
through James Hutton, John Playfair, and others. There 
wore great developments, too, in botany, while in a.stronomy 
Herschol and his gifted sister were riveting attention upon 
tho heavens. There was also stirring a moral regenera- 
tion, beginning in tho revival of religion.' On the work of 
Hunter himself the lecturer did not dwell, but ho spoke of 
his greatness ns an experimentalist, which was revealed 
continually in his numerous letters to his pupils, his almost 
unparalleled avidity for knowledge, his tremendous energy 
and industry, his greatness ns a naturalist, and his many 
important contributions, especially to comparative anatomy 
and pathology. Finally, Dr. Howard Kelly touched upon 
some of tho great men of the post-Hunterinn era, and said 
that tho names of John Hunter and Joseph. Lister, must 
jointly over bo held in greatest honour. Ho concluded 
by delivering a fraternal message from AVilliam Ma3’o, 
and bj- presenting to the society a letter written by' 
Huntor which had been in tho possession of the family of 
one of Dr. Kelly’s pupils in the United States, but which 
it was thought should properly find a ifiace in the Hunter 
collection in this country. The feelings of the large and 
distinguished company towards tho lecturer were expressed 
hy Mr. T. H. Openshaw and Dr. H. A. Ellis, and in his 
roplj' Dr. Kelly repeated a long and charming description, 
furnished him by an American colleague who bad studied 
at Glasgow, of the late Sir AVilliam Macewen’s methods in 
clinical teaching. 


The Morison Lecture before the Royal College of 
Physicians of Edinburgh will be delivered in the Hall of 
file College. Queen Street, Edinburgh, by Dr. George M. 
Robertson on Wednesday, January 25th, at 5 p.m. ; the 
subject will be “ The teaching of psychiatry in Edinburgh 
and Sir Alexander Morison.” 


A SPEOiAE meeting of the Council of tho Charity 
Organization Society to discuss the question of “ The 
voluntaiT hospitals and the public authorities ” . will be 
held at Denison House, 296, Vauxhall Bridge Road, S.AA’'. 
(three minutes from Victoria Station), on Monday, 
February 13th, at 3.30 p.m. Tho chair will be taken by 
Lord Dawson of Penn, and the speakers will bo Sir VTlliam 
Hamer, Dr. E. Gi'aham Little, M.P., and Dr. Humphrey 
Nockolds. It is hoped that representatives of tho voluntary 
hospitals and public authorities of London and Greater 
London will take part in the discussion. ' 



110 Jan. 21, 1928] 


CANCER OF THE RECTUM. 


r " Tnr. Bnm** 

L SIcDictL Jontyix 


doctor or surgeon. Whilst it is ahv.nys dosirahle to intro- 
duce students to the nietliods employed in research, this 
should not he done at the expense of a good technical 
training in the procedures that are known to make efficient 
practitioners. Although the two ideals aro compatible 
and constitute the essence of good teaching, yet there 
are times when one as]>ect is apt to be ovorstressed. There 
is a danger that, in emphasiKing the value of an experi- 
mental training for the surgeon ivith a view to qualifying 
hiin for research, we may neglect to make the good crafts- 
man, which is just as important, at least for the patient. 

It is not as if the experiments undertaken had ahra3-s 
much of intellectual virtue in them. The pedagogic pr.ac- 
tice of shaking two known solutions in a test tube and 
getting some foregone conclusion is of doubtful mine, nor 
is there much to be gained over reading in making an 
aualj'sis by rule of tbumb. There is little training in 
technique and less in judgement in the usual routine 
tissue observations, following as thei' do cut-aud-dried lines. 
There is room, therefore, for much putting of the house in 
order, but there is no need for bolshevistic methods, nor 
are all the defects to be laid at the door of anatomy, nor 
can all the reforms bo made at her cxjionsc. The use of 
living models b3' anatomists is a stop in the right direc- 
tion, but the next stej) must be the rewriting of the 
textbooks of anatomy with a new orientation towards the 
other medical subjects, and" pa3'ing more regard to the 
relative importance of the various details, and to the 
limited time at the student’s disposal. 

Nevertheless, and without feeling undul3- complacent, 
anatomists have every right to review their two thousand 
years of continuous scientific teaching and study with a 
good deal of satisfaction. Although some would hold that 
the golden age is past, there is little need to disparage a 
subject that has for so long been regarded as the basis of 
pure art and the foundation of scientific medicine. Even 
the moderns need not despair of a science that in recent 
times has given birth to the hefty twins raoqihology and 
embryology, which have provided the thunder' for the 
theor3' of evolution that has transformed human thought. 
Na3', more, anatomy is still fertile and jiregnant with the 
new. science of pln'sical anthropology, which if it fulfils its 
promise will revolutionize medicine with the light which 
it may throw on the human constitution and its structural 
predispositions to disc.ase. 

Even if the lean 3'ears appear to have fallen upon some 
countries it is a consolation to know that, in American 
schemes of medical education, anatomical laboratories 
are rightlv dominant and productive, so that the sun of 
traditional anatom3' is apparently not yet set. 


OAK CEE OF THE EECTUM. 

Analtsis of Results of OpEnATiox. 

Of all deaths registered as due to cancer of the digestive 
tract the largest proportion occur within the. rectum. In 
this situation cancer is readily accessible both for diagnosis 
and treatment, 3et surgeons have often comjrlained that 
about half the cases when first brought to their attention 
have advanced too far to warrant an attempt at radical 
removal. Since education seems so necessary on this 
subject it is fortunate that the Ministr3- of Health Depart- 
mental Committee on Cancer decided to choose cancer of 
the rectum for special statistical investigation. The report 
of this committee has now been published.' As with 
previous reports, such as those on cancer of the breast and 
uterus the method adopted has been a comprehensive 
surveA-’of the literature, in this case embracing the public.a- 
tions from ten different countries concerning nearN 6,000 
cases o'f cancer of the rectum. IVe propose to quote briefly 
the conclusions of the report, and then to comment on 
certain important questions which this stati.stical analysis 
raises for discussion. 

Main Deductions. 

The findings of the inquii'y are as follows : 

1. On the average a i>eriod of twelve months elapsed 
between the occurrence of the first s3'mptom of the disease 
and the patient coming to operation. 

’ Ministry of Health. Reports on Public Health and Medical Subjects, 
ho. as. 11 . 11 . stationery onicc. 1927. Price Is. 6d. 


2. Rather less than half the cases when soon 1)3- the 
surgeons were considered to be operable. 

3. About one-sixth of all the patients who underwent a 
radical operation died as the result of such oiicration or 
from causes connected witli it. 

4. There is evidence, though limited, to show that the 
mortality from operations is much' iiighcr than the average 
among those patients who aro in an' advanced .stage of 
the disease. 

5. Two out of five of those submitted to radical operation 
wore alire three 3'cars afterwards. 

To put the whole conclusion in 0110 sentence — patients 
come to ,tho surgeon too late, radical removal is itself 
a serious risk, and ]e.s.s than lialf of those who submit to it 
arc alive three years afterwards. 

The Questions at Issue. 

Faced with this sombro picture wc are entitled to .ask 
if any advantage is gained by surgical treatment. How 
long will a patient with cancer of the rectum survive if 
he receives onlv palliative treatment, and how does his 
expectation of life compare with the average patient who 
enjoi'S the full benefits of surgical skill? 

AVhen the Ministiy- of Health report is searcbed for an 
answer to this question some details aro found which 
seem to be . well worth bringing more cloarl3' into view. 
Thus, an analvsis of 2,543 ca.ses submitted to radical opera- 
tion during the past fift3' to sixt3- 3'ear.s .shows that tlie 
average number of 3'cars of life for each patient up to 
the end of five years after operation was 2.53. This ma3' 
be regarded as the expectation of life for the average 
treated ease destined to die within five ycais. Tiio figure 
for the untreated ease (obtained 1)3- a modification of the stir- 
vivorsliip table in Dr. Greenwood’s “ Natural duration of 
cancer,” Report No. 33) is 1.59; so that, on the average, 
radical opemtion prolongs the life of a patient by 0.9 3-car 
(for i)aticnts dying within five years), or, in other words, 
the patient submitting to radical operation but d3-ing 
within five 3'ears has an advantage of 59 per cent, over 
the nnlreatcd patient. 

Whether or not the treated patient will receive the full 
benefit of this advantage from surgical intervention appeai-s 
to dcjTond to an unexpected degree upon the nationality 
of his surgeon. This fact is strikingly illustrated in 
Tabic 9 which gives the publislred results for six countries 
since 1890. Of 2,344 patients with regard to whom the 
neccs.sai-v information is available 39.9 per cent, are esti- 
mated as Laving been alive three 3'ears after operation, 
but when grouped according to their coiintn- of origin the 
percentage is found to vai-y from 26.9 to 51.4 per cent. 
It is gratifv'ing to find that England heads the list with 
the highest percentage of three-3'ear sui-vivors. But a 
careful studv of other sections of the report will suggest 
manA- reasons for the wide range of variation in the 
opcratii’o results of different countries, two of which — 
the standard of operabilit3' and the t3'pe of operation 
performed are of particular importance in this connexion. 

At present there are no generall3’ accepted ciiteria of 
opci-abilitv in cancer of the rectum, each surgeon being 
guided li>i-gel3' by bis own personal experience and the type 
of operation he practises. Obviousl3- a cautious interpreta- 
tion of the operability standard is likeh' to produce better 
statistical results. The whole question of operabilitA- is dis- 
cussed in the report, and 5,231 cases are reviewed from this 
point of view, but this part of the abstractor’s labour has 
been corapai'ativcl3' barren. It would not be too mucb to 
sav that operability in cancer of the rectum could only 
be' expressed in exact figures when statisticians have found 
a wav of measuring surgical initiative and experience, and 
assessing the operative facilities available in anr- particular 
circumstanees. The t3'pe of operation performed, however, 
is cminentl3- a subject for statistical analysis, and in this 
respect the report offers useful figures, though not peiliaps 
so large as could be v'islied. 

Chief Types of the liadical Operation. 

The radical treatment of cancer of the rectum has come 
to be standardized into three chief types of operation — ■ 
the perineal, the sacral, and the combined or abdomino- 
perineal. Wlicn the results aro considered in relation to 



Jau. at, 19 * 8 ^ 


OANCEE OP THE EECTEM. 


r TffE UBiTTsir 

L StEClCAX, JOVBMAX. 


Ill 


ttio typo of laAical opovation employwl, thoso of tlio 
perineal and sacral operations aro found to bo practically 
tliQ Santo up to llic end of tlto second year, but tbo perineal 
operation lias often an advantage over tbo sacral. Tbo 
disUnction between tbo results of sacral and perineal opera- 
tions is not of uiucb importance, particularly because tbo 
report does not define wbat is to bo included in a “ sacral 
operation,” altbougb it gives a general account of tbo 
perineal and contbinetl operations. Tbo comparison wbich 
is of most interest is tiiat bettvoen tbo combined operation 
(involving both an abdominal and perineal operation) and 
the perineal excision. Unfortunately, tbo figures for tbo 
combined operation aro too small to allow of any final 
deductions, but in so far as they may bo trusted they 
show tliat tbo operative mortality, rate for tbo combined 
operation is much higher than for other operations. In 
'I'ablo IV tbo operative mortality from tbo perineal opera- 
tion is stated ns 17.4 per cent,, from tbo sacral 15,4 per 
cent., and from tbo combined 32 per cent. When tbo 
influence of the typo of operation on survival is compared 
the results of tbo combined operation appear to bo worse 
than, those of the other two types up to tho end of the 
second year after operation. At about this period they 
begin to improve, and at tbo end of the third year they 
aro nearly the same ns those of the perineal operation, and 
hotter than those of the sacral. The figures for tbo com- 
bined operation are, however, voiy small, and the abovo 
deductions must therefore be regarded us merely tentative. 

Before leaving tbo subject of operations attention must 
bo drawn to the useful section of tho report dealing with 
operative mortality, which for 5,240 cases of radical opera- 
tion is shown to be 16.5 per cent. When tho sexes aro 
considered separately tho a[)erativa mortality for 860 males 
is found to bo 18.9 per cent., whilo for 538 females it is 
15 per cent. As already slated, tho operative moi*tality for 
the combined operation is ai)proxiniatoly double that of tbo 
perineal. Sepsis was found to bo much tbo most important 
immediate cause of operative deaths, being responsible for 
nearly half the deaths from operation. Shock and collapse, 
the next cause in order of importance, only account for 
a little more than half tho deatlis duo to sepsis. 


entitled to ask, wbon be comes to the end and seeks a 
placo for the newcomer on bis sbolves, “ Where does this 
book stand in relation to its fellows?” A certain degree 
of dotacbraeiit is necessary; the book must be viewed in 
relation to what has como before and is likely to coma 
after; its limitations as well as its achievements must bo 
considered. Viewed as a whole in this attitude of mind 
wo obsorvo that this report only deals with published 
cases and takes cognizance only of a fraction of that mass 
of unrecorded experience which forma tho daily practice of 
surgeon and physician treating rectal cancer; that during 
tho period surveyed (almost from the beginning of radical 
surgery for rectal cancer) improvements and modifications 
bavo changed surgical technique so rapidly that any system 
of classification of operability or operation must be very 
elastic and conclusions most cautious; and finally, that the 
particular point in time at which this summary has been 
complotcd (though convenient for readers living in 1928) is 
not actually a suitable ono in tbo history of rectal surgery. 
In a few more years, after a wider experience has been 
gained, it will bo possible to assess more accurately the 
relative merit of different surgical practices on which the 
present report is unable to speak with sufficient authority. 

Kow that its position on tho shelf has been decided we 
should remind ourselves, before consigning it to its place of 
reference, of tho main lessons it has to teach us for tbs 
present and immediate future. Turning to the preface 
of this report we find these words by Sir George Newman : 
“ In the meanwhile, there are ample indications as to the 
lines along which progress may be made in the control of 
cancer at this site — namely (a) the recording in future 
cases by tho surgeons concerned of full details, such as are 
indicated in this report, in order to provide them with 
thoso complete data upon which alone the rational treat- 
ment of tho disease may be founded; (b) the education of 
the public and of the medical profession in those already 
established facts which wiU conduce to discovery and treati 
ment of the disease while there is still hope of permanent 
euro; and (c) the development by all suitable means of 
those facilities for diagnosis and treatment which have 
proved effective in the past.” 


_ Siimptomaiology. 

Tho fact that in sucli a high proportion of cases a 
correct diagnosis of cancer of tho rectum is only made when 
the tumour lias passed tho stage of operability indicates tho 
importance of focusing attention on tbo early signs and 
ay.raplonis of malignant disease of tbo bowel. Tor this 
region of the body tiiero is no ono symptom to suggest 
cancer, a decision to proceed to proctoscopic or sigmoido- 
scope examination must bo based upon a grouping of signs 
am symptoms, of which the most important aro irregularity' 
f.. blood in tbo motions. Thoso were found 

nnir,* Ibo 1,244 cases considered from this 

fn-orr 1 ° later indications of tho disease, 

f blood in tbo motions, and pain aro 

^ '='>”™onest in tho order named. These 
inrr ■. ^ ‘Jornonstrato the great importance of perform- 

first opportunity, of all 
siWov those over 30 years old, who 

rWa o “b stool, constipation or diar- 

or abdomen. " The abL"neo‘'“r’’ porineum, sacrum, 

undmiUorii IT ^osonco of peculiar symptoms and signs 
Ste the of dia^gnosis, but (to 

Sin auv the report) “ it does 

from .tbo /tiH-' bbe patient’s medical attendant 
tbo earlicsi- « ” aut a thorougli examination at 

indications 1 ” =‘”3’ blie chief early 

often made that ewem- "of th statement 

at any rate in its earLJ disease, 

the evidence contain opposition to 

grounds for hoptelh* t U? ^ 

disease is not an aim , -In ■, 1 oarlier recognition of tho 
m impossible of acliicvement.” 

IVe have n' - +1 Outlook, ■ 

commented mi' sLe oAbe n 

tions wbich aro raised ‘'oportant practical ques- 

wbo has faithfullv 1 I, bho reader 

J elloived tbe detail of every page is 


sitii 


SociEiT OP Bbitish Neuhoi-ogicai. Surgeons : 

London Meeiino. 

The third meeting of the Society of British Neurological 
Surgeons was held in London last month. Sir Charles 
Ballance, retiring from the presidency, was appointed 
honorary president, and Mr. Wilfred Trotter was elected 
president. It was announced that Dr. W. W. Keen 
(Philadelphia) had been made an emeritus member, and 
Professor Haiwey Cushing (Boston) and Dr. C. H. Frazier 
(Philadelphia) honorary members. In the morning Mr. 
H. S. Souttar operated at the London Hospital, using his 
craniotome, and cut a large frontal flap, under local anaes- 
thesia, in an exploration for a parasagittal cerebral tumour. 
Cases and apparatus were subsequently demonstrated by 
Mr. Souttar. The later proceedings took place at tbo 
Institute of Anatomy, University College. Professor Elliot 
Smith, in a most instructive .address, reviewed some of 
the commonly neglected points in intracranial anatomy of 
interest to tho neurological surgeon, referring to the work 
of Dr. Harris on the developmeirt of the diploe, the course 
of the abducens nerve, and to bis own work on the visual 
area and the relations of the carotid arteries to the optic 
cliiasma. Papers were then read by’ Mr. B roster, on a case 
of suprarenal virility, with operative findings; by Mr. 
H. C. Cairns, on the effect of trauma in disclosing new 
clinical signs in neurological cases ; and by M Julian 
Taylor, on tbo nature of bone invasion and proliferation 
in cases of meuingoal tumour. A discussion on the snigei*y _ 
of head injuries brought to light a very' geneial con- 
servatism with respect to early operation, except in cases 
where a localized haemorrhage could be diagnosed, and m 
cases of penetrating wounds. The following morning was 
devoted to the display of patients by the London memhets. 




112 Jan. 21, 1928] 


BCOTIiANI). 


[ Tut. Ubittsh 
Uedical Jocusifi 


and to a demonstration by Dr. H. A. Harri.s of tlio proparn- 
tions in tlie museum of tho Iiistituto of Anatomy, 
Universitj’ College. 

Tun Flood Di.sasteu in London. 

In tile, absence of Mr. Clmmberlain, Sir Kingsley Wood 
presided over a conferonce at the blinistry of Health on 
January 16th to review tlio situation resulting . from the 
recent flood disaster in London. Sir Kingsley Wood said 
that their inunediato duty was to settle what action should 
be taken to prevent any recurrence of such loss of life and 
widespread damage, and that any question of recon- 
structing the government of London, or erecting new and 
extensive engineering works, was not a present issue. 
Mr. J. M. Gatti, chairman of tho London County Council, 
explained that tho only responsibility of the Council was 
that imposed by tho Metropolis Management Thames River 
(Prevention of Floods) Amendment Act, 1879, under wliicli 
the Council might require owners of riveixide premises to 
construct flood jirevention works in accordance with plans 
prepared or approved by the, Council. Tho height of such 
works had originally been fixed at 17 ft. 6 in. above tho 
datum line, and in January, 1881, in consequoneo of a 
record tide, was raised to 18 ft. The height of the tide 
on January 7th, 1928, had been 18 ft. 5 in., tbo previous 
highest having been reached in 1884 and 1881, when it was 
17 ft. 6 in. on each occasion. Immediate steps were being 
taken to construct emergency works, hut until these were 
completed occupation of basements in low-lying areas 
adjacent to the river would be dangerous at times of spring 
tides. Lord Ritchie, chairman of the Port of London 
Authority, stated that, while normally in the last hour of 
a flood tide a rise of not more than 1 ft. in the river level 
might be anticipated, there was an actual rise of 2 ft. 
in -tho last hour of the tide during tho recent flood: an 
unprecedented occurrence. Ho said he was not aware 
that any height was prescribed for tho banks from tho 
westward boundary of the county of London in Hammer- 
smith and Wandsworth to the Port Authority’s boundary 
at Teddington. These banks wore maiutaiiied by the 
riparian owners, including municipal authorities, the Port 
Authority, Government Departments, and private owners. 
The actual level of tho banks for this portion of tho river 
varied, and was in places considerably below tho limit 
prescribed in the county of I/ondon. The question of the 
desirability of raising the level of the banks required 
consideration in view of the largo expense entailed and 
the improbability of the recurrence of such a tide. Lord 
Desborough, chairman of the Thames Conservancy, stated 
that the height of the tide was not greatly affected by the 
volume of river water coming domi from tho upper 
reaches. He suggested that data relating to North Sea 
tides should be carefully collected and the likelihood of 
recurrence of a similar set of circumstances bo .scientifically 
examined. Evidence was given by the mayors of the 
boroughs most concerned, and Sir King.sley AVood, replying, 
welcomed the assurance by the London County Council that 
a fresh survey woidd be made of the river defences. 

Illumination in Mines. 

At tho annual meeting of the Institution of Mining 
Engineers, held in London on January 10th, Dr. J. S. 

■ Haldane demonstrated with Mr. R. V. Wheeler a noiv 
lamp-room photometer for checking at the colliery the 
amount of illumination actually given by a safety lamp. 
AVith its help he showed the great differences which exist 
between various forms of safety lamps in the illumination 
actually given at the 2 >h''ee where it is needed. Dr. 
Haldaiie said that these differences were partly due to 
variations of the light emanating from the source, partly 
to tho manner in which this light was concentrated in the 
direction required by means of reflectors or glasses, and 
partly to alter.ations in the distance of the lamp from the 
illuminated surface, which last factor, he added, might ho 
very important, seeing that the illumination of a surface 
varied inversely as the square of the distance of the lamp. 
Besides tlie other advantages of a good illumination with 
what was now a practically attainable increase in local 
lighting, the inconvenience's, suffering, and expenditure 
c.aiised bj- miners’ nystagmus, said Dr, Haldane, could he 
avoided completely. This was confirmed by the experience 


with electric cap lamps in American coal mines. These 
lamjis, owing to their noanicss to tho surface requiring 
illumination, and partly also to tho concentr.ation of tho 
light on that surface by a reflector, gave an illumination 
far superior to that of tho Jiand safety lamps still commonly 
used in Eurojican coal mines, and minors’ nystagmus was 
absent from tho coal-mining population of the United 
States. In tho photomotor which ho showed, shadows jiro- 
ducod by a standard candle and by tbo lamp under test 
were projected side by side on an opaque white surface, 
.and by sliding tho lamp along a graduated scale the 
relative illumination w'as measured within a range sufficient 
for all practical mining jnnposos. He .also demonstrated' 
with this photometer tbo improvements in tbo light given 
by the flame safety lainjjs when there was proper selection 
of the oil or sjiirit, the wick, and the burner, and better' 
ventilation of tho flame by increasing tho length of the 
gauze, using a coarser gauze, or directing the air currents, 
in the lamp more suitably. Another point was the iin-' 
satisfactoiy illumination given by ordinary two-volt electric 
hand lamps, and the greatly increased illumination with 
higher voltages. The idea, he said, was to have a photo- 
meter so simfile that the man in charge of tho lamps at 
tho colliery would be able to see c.xactly what standard 
was needed, and so test the efficiency of his lamps. 

Brecon AV.vn Memorial HosriT.tL. 

Tho opening of the Breconshire AA’ar Memorial Hosiiital 
on January 11th was saddened by tho sudden death during 
tho ))rocccdings of Lord Glanusk, to whose efforts this 
hospital in a great measure owes its existence. AVhen it 
was decided that tho memorial to Breconshire men who fell 
in tho war should take this form. Lord Glanusk presided 
over the committee, provided a site for tho hospital, gave 
verv effective lielp in raising the money required for its 
erection, and collected over £7,000 towards the endowment 
fund. Apart from the building expenses, tho cost of conl- 
plctelv equipping tho hospital amounted to £2,500, and 
thirty-six donations, each of £62 10s., have already been . 
received towards tho endowment of its thirty-six hods and 
four cots. In tho course of a deeply moving speech Lord 
Glanusk became soidously ill, and tho la.st words he uttered 
dealt with tho essential, hut often overlooked, importance 
of providing for the continued maintonauco of newly 
erected medical institutions. His final sentences were:; 
“It is not sufficient to set up a cenotaph, a statue; a' 
tablet or oven a hospital. No one caii ‘ seriously look 
at theso buildings here to-day and say, ' There, at last 
it is finished ; we have paid our debt.’ This memorial 
hosjiital is a very small portion of tho debt that we 
owe but, in my mind, a hos]iitaI is so fitting a memorial 
to the fallen because it enables us, day by day and year by 
Year to continue to pay what we owe by seeing tliat the 
'hospital is properly financed.’’ ^ 




Food Control in Scotland. 

An adilrcss on the control of food in tho interests of 
public health was given by Mr. Arthur Goftou, chief 
veterinary inspector for Edinbm-gh, on January 5th. Tho 
lecturer said that the town councils and county councils 
wore responsible for the enforcement of the law relating 
to food, and in Scotland these were supervised by the 
Board of Health. The ijublic health regulations iii Scot- 
land differed somewhat from those in England. In Scotland 
there was a system of insjiection of all carcasses of animals 
slaughtered for human food, and in addition a fixed 
standard had been laid down as a guide for the whole 
coiintrv as regards judging the soundness or fitness of 
meat for human food; this had not, however;' as yet been 
practicable in England. The reason was that in Scotland 
the burghs had the power to erect abattoirs and to pro- 
hibit tho use of jirivato establishments, a 'iioii'er which was 
not enjoyed by local authorities in England, where the 
multiplicity of private establishments prevented the adop- 
tion of_a fixed standard. During 1926 the total amount, 
of meat condemned in slaughter-houses was 146 tons.. 
Speaking of tho milk supply in Edinburgh, ho said. that. 


Jan. ai, 1928] 


IKEIiANB, 


[ Tue Bnmsn 
Medicai. JouhkaIi 


113 


ao per cent, was produced witliin the city’s^ Ijoundarios, 
aiul precautions were, taken to eii.suro tliat it slioiild bo. 
clean and free from disease, and also to iuspeet milk 
produced outside the city. Over a considerable period of 
years approximately 8.5 per cent, of the milk brought 
into, tlio city had been found to bo infected with tuborclo 
bacilli; this fact showed tho very groat need that existed 
for systematic inspection. 

The David Ei.deu iNrinMAUY, Govan. 

' On December 16th last tho David Elder Infirmary in tho 
parish of Govan was formally' handed .over by the trustees 
to tho managers of the 'Western Infirmary, Glasgow’, repre- 
sented by Colonel Roxburgb. Tho forging of this beneficent 
link, which co-ordinates tho general hospital services in 
Western Glasgow north and south of tho River Clyde, is 
fitly commemorated by Dr. David Murray in a brief but 
interesting account of him whoso namo tho Infirmai-y will 
perpetuate in tho place W'horc so mucli of his work was 
done. David Elder was boni in tho noighbourhood of 
Kinross in 1785. Ho learned the trade of a wright, went 
to Edinburgh, and later to Paisley and elsewhere, in pur- 
suit of his avocation, and in 1821 becanio manager of Mr. 
Robert Napier’s engineering works at C.amlaehio. Horo, 
in the early days, ho constructed a marine engine so good 
that it wore out three hulls. In 1840 ho moved with tho 
firm to tho great shipbuilding yard at . Govan, thenceforth 
carried on under thoniame of Robert Napier and Sons. 
He resided at Kingston, close by Govan, during tho rest 
of his life. When the busincss of the finn extended to iron 
shipbuilding Mr. Elder organized tbo w'ork. Ho was tho 
founder of marine engineering on tho Clyde, “ tho father 
of that very solid .work that set tho Clyde thoroughly upon 
its feet.” He contributed materially to tho success of tho 
Cunard Steamship Company. Like James Watt, he was 
mterested in .music and tho organ. An organ which ho 
built for himself is preserved in tho nurses’ dining room of 
the Infirmary’. lUexander Elder, David Elder’s third son, 
became resident engineer in Liverpool of tho Royal .African 
Mail Company, formed one of the partnershiji of Elder, 
Dempster and Company, and established the British and 
Ap'ican Steam Navigation Company. He founded tho David 
Elder Infirmary as a memorial to his father and mother, 
and desired that his. trustees, on its completion, should 
nand it over to any body of trustees whom they might, 
discretion, think proper. The trustees 
decided that- the managers of the Western Infirmary were 
a suitable body. An agreement was accordingly drawn up 
an tlie transfer took place as stated, 'Tho present 
Infirmary contains 42 beds. If the Western managers see 
♦ sl'a'I not bo beyond 300 beds. Addi- 

ct ^ accommodation, so far as possible, is to bo by oiie- 
"i interfere with light and air. 

I ™ounting to upwards of £60,000, 

lincnit*? ^ Western managers, 'along with tho 

tlm’^n “ ti This drawing together of 

this or ' south is of ha])py augury’., especially in 

CO orrlii? r ^.'^'^“Snrned shortage of beds when hospital 
co-ordmation is greatly needed. 

TIio dootf 1 the Blind. 

Board of TTo'Mi ?‘^l'?ntiqn Department and tho Scottish 
in ^taL 1 “r issned n joint memorandum 

eommlteedo o The advisory 

by whicli m ^ consider satisfactory tlio present methods 
to ^-actice .suitable 

coinniondod that -“T" '•«- 

special craft srLr 1 mstructioii should bo given in 

could be devoted "to 'tb"^**^ *^'i® attention of the staff 

good workmanship workmen and 

schools for tile +rn;»- ^ central technical 

in Scotland Thi^ should ho established 

of blind pencils who w i''f «»= teaching 

at borne and do not drJ!. f subsequently 

in a factory. In tfin _ for work only suitable 

certain institutions conlT^™';’ committee thinks that 
needs, including the Afio, ,’”““0 provision to meet these 

KoyarDinideelnstituBn.f^®’!/®^’"” 

Asylum, and School for ' t|,o Br Gla.sgow 

A.syhim and School at Fdf, l “'nt the Royal Blind 

ficiiool at Edinburg],. The advisoiy committeo 


also considers that it would bo well to secure gi-eater 
uniformity in regard to such matters as tlio age of com- 
moiicing training, the means of testing tho capacity of 
trainees and selecting suitable occupations for them, and 
the cost of training'and of maintonance during the period 
of training. It is suggested that towards the end of 
a blind child’s school life the school authorities should 
commuiiicato with training authorities so that no break 
m.ay tako place between the school and training institution. 
Similarly’, it is advised that tho training authorities should, 
abqut six months before the completion of training, get 
into touch w’itli employment agencies in order to provide 
inimcdiato and suitablo employment for the trained blind 
person. 


Hwlaittr. 


Public HEALni Congeess in Dublin. 

The Royal Jnstitiito of Public Health will bold a 
congress in Dublin from August 15tli to 20tb, at the invita- 
tion of tbo Governmont of the Irish Free State and with 
tlio cordial support of tbo University of Dublin, tho 
National University of Ireland, the Royal Colleges of 
Physicians and Surgeons in Ireland, and the Apothecaries 
Hall of Ireland. It is hoped that the congress may assist 
the Government of the Irish- Free State in placing the 
jinblic health of tho community on a good progressive basis, 
and interest those entrusted with executive duties. The 
work of the congress will be conducted in four sections: (1) 
State Jledicine — (n) Municipal, county, and port sanita^; 
(h) Epidemiology; (c) Tuberculosis; and (d) Housing 
of the working classes, including town planning. (2) Bac- 
teriolog.v, Patliology’, and Biochemisti-y. (3) Maternity and 
Child AVclfare, and School Medical Inspection. (4) Pro- 
duction and Control of Milk and Food. Delegates aro 
being invited from Governments, municipalities, and other 
public bodies and universities of England, Scotland, and 
irelaiicl, as well ns from France, Belgium, Italy, and tho 
United States of America. The honorai-y president is His 
Excellency tho Governor-General of the Irish Free State, 
and the jiresident is the Minister for Local Government and 
Public Health, Dublin. 

JlEHoniAL TO Sib John Walton Browne. 

The Bishop of Down and Connor and Dromore dedicated, 
on January 8th, a pillar in Belfast Cathedral, rvliich was 
specially carved in memoi’y of the late Sir John Walton 
Browno, who died in December, 1923. The ceremony was 
attended by many members of the medical profession in 
Belfast and of the Nursing Council of Northern Ireland. 
The Dean of Belfast read an account of the services 
rendered by Sir John Browne, and an address was given 
by Mr. Harold Balrae, F.R.C.S., ex-president of Shantung 
University, on tho contribution of Christian thought to tho 
science and practice of medicine. An obituary notice of 
Sir John Browne appeared in our issue of December 29tb, 
1923 (p. 1278). 

Medic.vl Officer op Health for Mfath. 

.The proposed appointment of a county medical officer 
of health was considered at a recent committee meeting of 
tho Meath County Council, at ivhich Dr. McDonnell, of the 
Department of Local Government and Public Health, 
was present. It was reported that on agreeing to tho 
appointment of a doctor at a salary’ of £500, the county 
council would bo entitled to he recouped £250. Having fully 
considered tho matter the committeo recommended the 
county council to postpone the appointment for six months 
in view of possible changes in the system of Poor Law 
administration following the report of the Poor Law Com- 
mission. A letter was subsequently received from the 
Department of Local Government and Public Health stat- 
ing that it would he seen from the report of the Poor Law 
Commission, now published, that it did not deal with 
public health administration. The question of the appoint- 
ment of a county medical officer of health should, accord- 
ingly, be considered. After discussion the sngge-stion to 
adjourn further consideration for six months was adopted. 





JAH. II, 1928] 


CORREBPONDENOB, 


t Tnr BarnsH 
UcDtCAi. Jomxix 


116 


a fortniglit is viviunlly to dinniiish by oiic-tliircl llio imrnbor 
of beds set apart for tbo disease, and adds to tho cost of 
die maintenaneo of tlio patients. — am, etc., 
lleminglorU Abbots, Hunts, Jnn. 15tli. 


E. W. Goodalh. 


FATALITY RATES OF SSIALL-POX IN THE 
' ' VACCINATED AND UNVACCINATED. 

Sin, — ^In tho Journai. of January 14tb (p. 74) Dr. R. P. 
Garrow dratvs attention to tho fact that tho fatality rate 
among tho vaccinated eases' of small-pox occurring' in 
England and AVales in tho years 1923 to 1926 at ages over 
15 ■n’as apparently higher than among tho unvaccinated 
cases, and ho asks' for a possible explanation. Tho 
explanation can bo found in (1) tho widely different ago 
distributions of the groups compared, ami (2) the smallness 
of tho actual numbers of deaths dealt with. If wo include 
the small groups of tho revacciuatod with tho much larger 
totals who wore vaccinated only in childhood, and add 
together tho returns for tho four years 1225-26, the con- 
trast in age distributions is readily seen in tho following 
table. 



Vaccinated Cases. 

Unvaccinated Cases. 

*go 

Group. 

Ko. of 
cases. 

No. of Deaths, 

No. of ' 
cases. 

No. of Deaths. 

Actual. 

Expected 
in 1 jenr. 

Actual. 

Expected 
in I year. 

Under 15 ' 

1 

46 

B 


10,298 j 

17 


15- 

■ 114 

B 

0,31 • 

2,932 

B 


20— 

165 

B 

053 

1.342 


4.70 

25— 

I'O 

B 

O.M 

821 

B 

3.16 

30- 

' 2;8 


1.15 

462 

B 

2.06 

35- 

3J4 

3 

2.12 

285 

B 

1.54 

40- 

1,301 

3 

9.82 

423 

B 

3.21 

50- 

1.2M 

4 

17.83 

253 

B 

3.80 

60- 

449 

- 

15.02 

78 


I 2.61 

70- 

W 

2 ■ 

7.M 

12 

1 

1 

; 0.98 

■8>- 

5 

- . 

0,91 

- 

- 

- 

Total J 

4,124 




’ " 


oyer 15 f 


55.97 

6,61G 

4 

29.98 


— - v,...,..u,uoiary amorenco between tho distributions of 
these two groups (which can ho still more clearly 
EtrhncrJ<,t^ ° them graphically) provides, perhaps, tho 
of evidence that has as yet been secured 

dispicn t ^‘*®°*"®tion in protecting against tho 

tub hf sinco it is precisely what 

tion io protection afforded hy vaccina- 

believp n-anes with advancing life. It is, I 

If wp it in any other way. 

prev£ilent''i^^'?n'+ that small-pox of tho 

two noDuI-it: never fatal in itself, and that theso 

population ® “t random from tho general 

Sa^",.® Wales, and subject to tho 

in Eii^^ish Life Tabl^N “*" 0 ®®/^ “®® calculated 

estimate th» L No. 9 for 1920-22, we can easily 

in each poniilnt''”' ®^ ®ii which would be expected 

of a ta’r ^ ro„r-’” *'!® 

Garrow has done ”anH to ages over 15, as Dr. 

of equal uumherc’pf ^ assuming the populations to consist 
used\he “ '^t each age, I have 

the life tahlM for n!l®i P''°i^'ii>iiities of dying “ q » from 
of each of the above females at tho central ages 

the numbers in tho ®^® Syoups, and multiplied these by 
the numbers of 460 ^^,’’?*"^® ®®® Si’onps, thus obtaining 
given in the’ above table A®i 

that the expected t these up, it appears 

cases over 15 in ono -u in the vaccinated 

vaccinated over 15 'yould be 56, and in tho un- 

be 30. It follows that deaths in ono year would 

from the onset of small “ period of two months 

ordinary chSLs of dear T 

ueain in the- populatiouj to have 


onc-sixth of theso numbers of' deaths occurring — ^that is, 
9 among the vaccinated and 5 among' the unvaceinated — 
and those would bo subject in the totals dealt with to 
probable errors of ±2.0 and ±1.3 respectively, owing to 
tho mere fact of random sampling. This means that we 
might natuz’ally expect, from pure chance, any number of 
deaths between 4 and 14 in the vaccinated, and between 
2 and 8 in the unvaccinated, to occur within two months of 
tho onset of small-pox. The actual deaths which were attri- 
buted to small-pox in tho two groups were 13 and 4 
■rcspoctivoly, both of which lie within the limits calculated 
above. 

It seems probable that most deaths occurring -within 
two months of the onset of small-pox would be attributed 
to small-pox as primary cause, and if the recorded deaths 
do actually represent all tho deatlis which occurred within 
that period it may bo concluded that the prevalent mild 
typo of small-pox is not really responsible for increasing 
the chances of death in persons affected to any measurable 
degree. This has, I think, an interesting bearing upon 
tho final suggestion in Dr. Garrow’s letter. However 
this may bo, it can bo definitely stated that these figures 
provide no evidence of any significant difference, either 
way, between tbo mortality rates in the vaccinated and 
unvaccinated cases at ages over 15, though satisfactory 
evidence has, I think, been previously obtained for tho 
efficacy of vaccination in reducing fatality in the severer 
forms of the disease, as Dr. Garrow believes. — 1 am, etc.. 

University College, London, Jan. 15th. PeucV Stocks. 

Sin, — Dr. Garrow’s inqniry is very easily answered. 
It is generally knotvn that the immunity conferred by 
vaccination lasts for a limited time only. The period is 
variously estimated ns between ten and thirteen years. 
By selecting cases over 15 Dr. Garrotv is careful to include 
all cases vaccinated in infancy, but no long-w protected. 
His statement, that “ the fatality rate among vaccinated 
cases was just five times as great ns among unvaccinated 
cases,” is, therefore, grossly misleading. 

It is, in my opinion, most regrettable that a medical 
man occxipying a responsible position should broadcast in 
tho medical press such an assertion, which he must be 
aware will be quoted, on his authority and without conte.xt, 
by' the antivaccinist press. This kind of action can do 
nothing but handicap his colleagues who are engaged in 
combating the present epidemic of small-pox, with its 
serious burden on the public funds, the loss of wages 
involved, and the damage to industry, quite apart from tho 
detriment to public health, which in my recent experience 
is becoming more serious as the infection is passed through 
the human medium. — I am, etc., 

Fbed. E. Wtnne, 

January 16tb. U.O.H., SbefHeld. 

Sm, — Dr. Garrow draws attention to the anomalous fact 
that for the four years 1923-26 the fatality of “ small- 
pox,” in the age period “ over 15 years,” has been fix'e 
times greater in the vaccinated class than in the unvac- 
cinated, and he invites explanations. I submit that the 
explanation is as follows : 

The figures for “ smaU-pox,” which he quotes from the 
jVIinistiy- of Health’s report, are: 4,010 vaccinated cases 
with 13 deaths (=case mortality of 0.32 per cent.) and 
6,915 unvaccinated cases with 4 deaths ( = case mortality 
of 0.06 per cent.). 

To begin with, the case mortality is so trifling in either 
group that it at once arouses suspicion of a “ catch ” 
somexvhere. The “ catch ” is, that under the term “ small- 
pox ” we are including two varieties of the disease so 
utterly different as regards their case mortality that, for 
statistical purposes, they are two distinct diseases, and it 
is most misleading to include them together under tho 
same heading. Indeed, to do so can only lead to a definite 
Tcductio ad ahsurdunij and make confusion worse con- 
founded. There should be little practical difficulty in 
keeping the statistics for tho twm varieties separate, because 
I doubt if there has been a single outbreak of small-pox, 
say in the past ten years, where there -n-as any real doubt 
ns to which variety of small-pox was being dealt with. 

If the figures are analysed and sorted out into (1). variola 






















116 JAN. 21, 192S] 


COUBESPONDENOB, 


r TrrirBBrTtsw 
L UcciCil. JOIT&VAfi 


maior and (2) variola minor, wo find. that wo liavo under 
(1) an insignificant minority of, say, under a iiundrcd cases 
of variola major with most of tho 13 deaths, and an over- 
whelming majority of nearly 10,000 cases of variola minor 
with practically no deaths. Tho few deaths that have been 
attributed to variola minor are usually' duo to some intei’- 
current complication, and, if these ho deducted, wo find 
that variola minor is, for practical purposes, a non-fatal 
disease in vaccinated and unvaccinated iJorsons alike. As 
regards the cases and deaths in the small variola major 
group, it so happens that tho few isolated outbreaks which 
have occurred in tho years in fpiestion have been among 
adults rather tlmn among children. But adults in most 
parts of tho country arc still, on the whole, a vaccinated 
class; therefore, it is not very surprising that many of 
these c.ases have been in V'accinated j)crsDn.s. 

If the statisties for variola major and variola minor 
were kept separate and distinct, ns they certainly ought 
to be, 1 have little doubt wo should find that in variola 
major the vaecinated cases would show a definitely lower 
case mortality' than would the unvaccinated cases. But 
so long as these two varieties of small-pox are “ lumped ” 
together the overwhelming m.ajority of non-fatal vaiiola 
minor oases quite invalidates any fatality rates which may 
be based on them. — I am, etc.. 

Health OlTices, Leicester, Jan. 16th. IvILLlCK HflLlAUD. 

Sir, — The letter of Dr. Garrow raises a very interesting 
cjuestion, one of many which have been vexing the minds 
of those who have watched events in connexion witii small- 
pox and vaccination in recent years. I, in oominon with 
all others of our profession, was educated medically in 
the orthodox fashion : small-pox was a disease whieh was 
contracted by unvaccinated jtcrsoiis, and wa.s with them a 
terrible and fatal malady'; in tho rare event of a vac- 
cinated person being attacked, tho disease w.as a trifle 
and of no importance. 

Hei'o are a few of the questions in connexion with vac- 
cination which are worrying me. IVill any of our moinbers 
who have studied tho subject give me answers? 

(1) Tlmt raised by Dr. Garrow : How is it dial small-pox is five 
limes as likely to be fatal in the vaccinated ns in the nnvaecinaled? 

(2) How is it that as the percentage of people vaccinated has 
steadily fallen (from about 85 in 1870 to about 40 in 1925) the 
number of people attacked with v.ar/ola has declined pnri /ki.mk 
and the case mortality percentage has progressively lessened? The 
years of least vaccination have been the yeai's of least small-pox 
and of least mortality. 

(3) How is it that in some of our best vaccinated towns — for 
example, Bombay and Calcutta — small-pox is rife, whilst in some 
of our worst vaccinated towns,' such as Leicester, it is almost 
unknown ? 

(4) How is it that something like 80 per cent, of the cases admitted 
into tho Metropolitan -Asylums Board small-pox hospitals have been 
vaccinated, whilst only 20 per cent, have not been vaccinated? 

(5) How is it that in Germanj*, the best vaccinated country in 
the world, there are more deaths in proportion to the population 
than ill England — for example, in 1919, 28 deaths in England, 
707 in Germany; in 1920, 50 deaths in England, 354 in Germany. 
In Germany in 1919 there were 5,012 cases of small-pox with 707 
deaths; in England in 1925 there were 5,363 cases of small-pox 
with 6 deaths. What is the explanation? 

(6) Is it possible to explain tho lessened incidence and fatality 
of small-pox on the same grounds as the lessened incidence and 
fatality of other infectious fevers — namely, as due to improved 
hygiene and administrative control? 

. These are just a few points in connexion with the subject 
which are puzzling me, and to which I want answers. I am 
in doubt, and I want to know the truth. IViiJ some of the 
experts help me? — am, etc., 

Hove, Jan. 16th. B.'RRV. 

■* * IFe think tliat Dr. Parry, in his desire for enlighten- 
ment, would have been wiser not to introduce assumirtions 
of fact into the framework of his questions. 


ULTRA-VIOLET RAYS AND CATARACT. 

Sir, — T he controversy on this interesting subject is no 
doubt intelligible to the writers, but is by no means clear 
to tlio reader, 

I have no doubt that undve exposure to ultra-violet rays 
will rapidly produce cataract and other serious conditions 


in tho interior of tho eyo. Tlie folloiving caso will explain 
this issue; 

X., aged 35| a Marconi operator at Basra in tho great war, 
came to mo witli a well developed Morgagnian cataract in one eye 
and distant vision reduced to_6/9 in the other. Ho had been 
frequontly examining with the naked eyo tho sparking apparatus 
of Uio generator, which is intenso. At first ho complained of 
imiscae volitanlcs and, later, the development of cataract. In the 
best oyo the vitreous hnd fi largo number of floating bodies; 
nothing else w'as \'isiblc. There was no history of noticeable liyper- 
aemta of tho conjunctiva. 


Assuming, as I do, tliat tho whole condition was duo to 
iinduo cxposiiro to tho ultra-violet rays, it will he seen that 
it is not merely cataract we havo to deal with, hut tho 
equally, if not more, profound changes as indicated by 
the devolopmoiit of tho crowd of floating bodies in tho 
vitreous. This caso would inako mo hc.sitato to use ultra- 
violet rays in tho treatment of any condition of tlie eye. 

As regards the treatment of tlio early stage of cataract 
the controversy is not easily understood, because tho issues 
have not been clcai'cd. First, what is the rationale of 
tho action of remedies? Secondly, what is tho stage of 
development submitted to treatment as indicated (o) by 
what can ho seen with the ophthalmoscope, and (b) by what 
the patient complains of, and tho degree of what he com- 
plains, ns indicated by tho range of his distant vision? If 
tlic.so issue.s arc not clearly stated the controversy cannot 
bo intclligiblo. 

As regards the rationale of treatment (I have done a 
good deal of work on tins subject), if you assume that tho 
satisfactory result is duo to tho bj-poraemia induced and 
tho time it is maintained, no matter by what means it is 
induced and maintained, and that tho rapidity of tho result 
depends on the degree of hyporacmia induced and main- 
tained, in my observation you will he right. Since I wrote 
mv first paper on this subject, close' on twenty years ago, 
all tho methods and prescriptions which have come into 
tho field havo tho same action — namely, the induction of 
hyporacmia. 

1 do not aerce with the pessimists who hold that nothing 
can bo done lor the early stage of cataract. I hold that 
over 95 per cent, of the cases of senile cataract in tho early 

that is, when distant vision has not been reduced 

below 6/12 are curable, that the cure is enduring, and 

that tho iiatient is not submitted to au}’ risks in ' the 
process or to much iiiconvonionco; and that Ibis is the 
greatest triumpli in the whole history of the treatment 
of cataract.— I am, etc., 

Henry Smith, C.I.E., 

Sidciip, Jan. 7lh. Lieut.-Colonel. I.M.S.(rel.). 


treatsient of prostatic enlargement. 

Tq those interested in tlio discussion on prostatec- 

toiiiv’the following figures of St. Peter’s Hospital may 
prove instructive; 

Prostatectomy. 

Cases. Deaths. rcreentage. 

70 4 5.7 

63 5 7.9 

80 5 6.2 

82 8 9.7 


Year. 
1907 ... 
1903 ... 

1909 ... 

1910 ... 


In the year 1910 seventy-nine cases were treated by supra- 
pubic prostatectomy and three by perineal prostatectomy. 
Of the^ former, five were two-stago operations. I have no 
details in regard to the preceding years. 

The above figures' of work done seventeen to twenty years 
a"o are so far ahead- of the modern figures for general 
surgeons, as given by Sir Cuthbert Wallace, that they lend 
some support to the contention of Sir T. Caroy Evans th.at 
the expert genito-urinary surgeon is likely to obtain the 


best results. _ . , j, . i 

There is no doubt in my own mind that those cases wliere 
the operation is done quickly do the best. No more mystery 
is attached to prostatectomy than to any other oporatioii, 
but a surgeon who performs a given operation frequently 
should be more expert than tho one wlio performs 
it occasionally. Again, the actual operation is only part 
of tho story; the pre- and posWperative treatment are 
of vital importance, and it is bj' neglect therein that most 
cases are lost. 

A. distinguished Scottish general surgeon told me that the 




Jan. 2 t, 1928 ] 


CORRESPONDENCE. 


t Tnz Bjimsa 
McoTCIX. JOCBN1& 


117 


difficultv ho exporienceil in regard to all urinarj' cases was 
that wliat ho learnt at ono ho forgot before ho got another. 

In tho cases I have seen, packing the cavity for haemor- 
rhaco has been nccessaiy in less than 1 per cent. Thoro 
docs not seem to bo EnfRcicnt reason for inflicting tho 
discomfort of packing on the other 99 pci cent. 

Spinal anaesthesia combined with niorphino and scopo- 
Inmiiie is most useful, as, apart from tho diminution 
of shock, it enables tho patient to resumo his normal diet, 
and more or less his normal niodo of living, immediately 
after tho operation. 

The figuies I have quoted deal with prostatectomy by tho 
“ blind ” nictliod. I suggest it would bo very helpful in 
this discussion if tho staff of St. Peter’s Hospital would 
give us tho most recent figures, which would incliido thoso 
of tho “ open ” method. 

.■ There is a suggestion in Jlr. Ralphs’s letter that Sir Peter 
Fre3'er removed only easy adenomata. This is quite wrong. 
Ho removed, so far as it was possible, cvei-y form of 
enlargement by the same method of enucleation. — I am, etc., 

Warrington, Jan. 7th. "W . H. C. PatHICK. 


Sin, — I note tliat-in Sir Cuthbort Wallace’s interesting 
address on prostatic enlargement in tho Jouunai. of 
November 19tli, 1927, he states, “ I am unaware, however, 
that a man has ever begotten a child after a prostatec- 
tom}-.” May I relate tho follon’ing instance? In March', 
1917, I removed an oxalate stone and tho prostate in a 
gentleman of 60. In February, 1919, his wife boro him a 
healthy girl. There was no doubt as to tho paternity. — 
I etc-. - C. C. Elliott, 

December Zllh, 1927. Lecturer on Surgery, University ot Capetown. 


INJECTIONS FOR VARICOSE VEINS. 

Slit, — I would like to indicate four points which, so far 
as I can make out, have not been mentioned in connexion 
with this method of treatment by means of sclerosing 
solutions combined, in most cases, with some local 
anaestbotio. 

(1) Where there is an associated varicose dermatitis do not 
make the injection through the skin of such affected area, but 
go _ through healthy superficial skin, if necessary at tho 
of the patch of dermatitis. 

fi ^^1 frequenUy cases that show small, very super- 

ciai, bulgings of the varicose veins, almost without any skin 
between the outside and the wall of the vein, or in some 
e vein itself is similarly placed for a part of its course. It 
s as veil not to make the inj'ection at such points, but choose 
'o'o bes deeper. Jly reason for this caution 
fooie eppoers to be a tendency foi anj- site that 
Jl'y .^opoincial, and is treated by injections, to become 
proximity to the surface predisposing to septic 

by trauma or otherwise. nib F 

rnnrli associated plcer tho injection is best 

ld\ A distance from the former through healthy skin, 
ho regards site of injection, choose one that will not 

.. ® pressure afterwards by clothing, etc. My 

whleh fbe effect of the local anaesthetic, 

off in 1 h “™bined_with tho sclerosing solution, wears 

sensitivo t hours, the site of the injection becomes hyper- 
sensitive to pressnre for some days afterwards. 

rlpnlin^'^.-li^^'^ method of treatment extensively in 
vprv ff varicose dermatitis and varicose ulcers, with 
very favourable results.— I am, etc., 

Deicester. Jan. 9lh. ' ' F. A. E. SlLCOCK, M.D., D.P.H.’ 


Sm — Th SEPTIC UTERUS. 

Diomo’tinn pf 'nuteiino injection of glycerin for the 
the attention “i septic conditions has not received 

welome tCn merits, and therefore I 


in your 


— — ... December 31st, 1527 (n 12231“ 

iin-gatbn hfnuer""**^/ “ intrauterine 

October 31st *1903 ^'^t''^ fev-er,” published in the Lancet of 
of glvcerin pon+o,-,.’- the injection of an ounce 
double-channel tubT^to formalin through the 

when such was nvp,i’- ®“®h intrautormo douche 

"■me H) to “bsis. Tho objects iu view 

and the stimulation oF uT^'“ 

of uterme contraction, and (2) the 


application of an efiicient and unirritating antiseptic. Tho 
need for some method of drying tho uterine cavdty was made 
apparent to mo by tho occurrence of a rise in temperature 
following each intrauterine douche in a case of puerperal 
sepsis. Glycerin or alcoliol injections seemed the only way 
of achieving this, and glycerin was chosen as being prefer- 
able. Tho resiilts were, and have continued to be, excellent 
in suitable cases — that is to say, cases in which the fever 
is a result of absorption of toxins from the uterme cavity 
or its lining membrane. 

In an annotation in the same issue of the Lancet it was 
suggested that this method was not free from risk, as in 
a few cases death, and in some others liaemoglobinuria, bad 
occurred from tho use of intraiiteriiie glycerin injections. 
In a letter in the next issue I maintained that the uterine 
conditions in which I used the glycerin prevented any risk 
of absorption and resulting liaemoglobinuria, but it seems 
that tho editorial wainiiig prevented any further use of 
tho method until the present able advocacy of Dr. 
Remington Hobbs. • 

I hope Dr. Hobbs will be able to show that the use of 
glycerin, as he advocates it, is without any risk of embolism 
or of ill effect on the kidneys, and if so I am sure that this 
method of treating sepsis within the puerperal uterus will 
prove of great value. The addition of an antiseptic — 
either formalin, which in glycerin is unirritating, or acri- 
flavino, which is very soluble in glycerin — would, I believo, 
increase tho value of his treatment. — I am, etc., 

Glasgow, JaD. 6th. D.VVID M ATSON. 


THE PREVENTIVE FRAME OF JHND IN 
MIDWIFERY. 

Sm, — Dr. Johnstone’s paper on tho preventive frame of 
mind in midwifery (January 7th, p. 6) is really a rehash 
of a former outburst by Dr. Mimro Kerr. Its burden is that 
midwifery to bo safe must be, under the compulsion of the 
Board of Health, in the hands of nurses and specialists; 
that tho general practitioner cannot and should not be 
trusted with this work, as his record of sepsis and mutila- 
tion is so bad; the which sepsis and mutilation are due to 
needless interference with normal processes. The people 
who can pay are to bo in nursing homes; those who cannot 
in maternity homes. I gather, however, that the student 
is still to bo instructed, and oven more intensively in- 
structed, in midwifery. He has to “ live, move, and have 
his being ” in maternity hospitals. Why? For it is clear 
that be is not to have any midwifei-y the moment be ceases 
to be a student. 

Now I wish to say that the safest place, it would seem, 
for any midwifery is the East End Lying-in Hospital, 
London. The sepsis and death rate there are practicall3- nil. 
Yet its work is done by general practitioners entirely. 
Again, statistics show that the sepsis and death rates in 
tho country generally are lowest among midwives and 
highest among the specialists. I have repeatedly asked our 
specialist critics for their private sepsis rates after honestly 
giving my own, and never yet have I Jiad a reply. I did 
not think it was so bad as that. I can only say that tho 
published statistics of the hospitals where tlie3- “ live, move, 
and have their being ” are pitiful compared with the 
London home. The root cause of maternal mortality is 
in the housing conditions. The solution is to provide 
proper maternity homes where the patient may have her 
own practitioner to attend her. 

Wo shall never advance one step by unduly exalting 
the specialist or degrading the general practitioner. Tliat 
way lies extinction for both. I am astonished at the 
blindness of the 03-0 that cannot see this. — I am, etc., 

Glasgow, Jan. 7th. JaaIES Cook, M.B. 


RECORDS OF CANCER CASES. 

Sir, — 1 have just filled in a death certificate, and in the 
space for cause of death have written ” carcinoma of 
liver ” ; that is all. It reads like fate, and as though we 
are resigned to onr fate. 

Of course, I know that thousands of industrious people 
are trying to find out tlie meaning of cancer, and why 
some people die of old age, others of sepsis, and some of 
cancer. It seems to me that they are working in the dark. 



118 Jan. 21, 1928] 


MEDICO-LEGAr;. 


don’t they collect more data to rvork on? I Jiato 
'>''t cancor ahoidd Im notifiable, not 
n.th the Idea of preventing infection, bnt in order to 
collect statistics about tlio lives of cancer iiatients It 
slionld bo an c aborato form of notification, recording eveir- 
di '''-''-i'-g .-.bant tlicso pcopl^St 

-“‘.irj.it’o'fSf 

writing „ their record cards " congi, " ' ‘S ’’ a .d 
cough ’ , Records of the lifo-histoiy k cancer snbi;^ s 
nngbt throiv some light on the ctiologv of o'! at 

■o?L!lr’':m!tc.r' circnniBlancis 

liinelmm, Jan. -Itl,. p;. GR.Wcni. ' 


r„ Hnrrmr 

I. aisorcAi, ^ocEim 


iHfbiro-lfgnl. 


CIILOROFORiM FOR COA'VDLSIOFT.S, 

Aeivspapee reports of a recent inquest in the Birmingham .area 
concerning the death of a child .aged 3 vears, leave a rRW 

t ! f H T I a "PPC'-ws, had severe convulsions, arid 

the father fetched a medical man, ivho found the i.atient stiff 

effect"Tlifdoct l)t>t this had no 

effect. The doctor then, alter auscultating the child’s he-irl 

Aftei"'a ''^P "'oH'fd on a piece of linen’ 

Aftei a time the breathing hecame quieter and began to f.ai 
The doctor then tried artificial icspuation and mflLed le 
cart, pursuing Ins efforts, hut vithout success, for someth ng 
like an hour and a half. The father made no suggS„ ff 
tl3 t7T‘’;^ treatment; indeed, he declared liin .self satRfied 
that the doctor did everything in Ins power to save the M 
Medical evidence was given by the local practitioner who per 

ThrLt .assisted him 

Ihe fiist of these two witnes.ses thought that Uio cause of 

death was heart failure due to the inhalation of clilowforn? 
ho second concurred and added that, in his opinion, thfehUd 
had not li.ad an overdose of chloroform, hut had probablv died 
m the early stages of the anaesthetic. Each of these wi^nessec 
avas questioned by the coroner regarding the propriety of 
administering chloroform for severe infantile convulsions ^The 
first said that this treatment «-.is given in tlio nied/c.nl te.vf’bo^-s 
He used to employ the method himself, but IjorJ i i 
It becaiue of an alarming experience he once had. The method 
o administering the chloroform in this case, as described I 
t o child s father, seemed to him a proper one. Answering 

tlnt'Dr“'7l?“"-7’f‘’ w.as in question, he .agreed 

at Hr. Still said that the administr.ation of an 

rs/ijx rr“ xrisj- in 

,r r; ;r,r K ™ inn-i” “ri 

men to criticize the treatment given by one of their colt"'*'*'*'''* 
went a little further in the colrse of" his snmi^^^ 
balanced their opinion— that it is unwise to eivn rU i “ 
to a child in convulsions— ag.ainst the oth.-’r ^uow „ 7l" 

taught in the textbooks and ptit into pracUro bv ^ 

upon to deal with these emergencies. He then Lhvered 7d7 
meiit on this point of therapeutics as follows ■ “ Tl.o 
shown, r think, tliat it is not wise for a medical man 
chloroform to a child in a convulsed condition.” He sngeesfed'’ 
however, that the jury ought to hesitate before decidin| tlmi 
any blame attached to the doctor, and the jm-y, after a w 
minutes deliberation returned a verdict in accordance with thl 
medical evidence adding that the anaesthetic, in their opinion 
W.-IS skilfully and properly administered. It seems to us^ with 
.all respect to the coroner, that an inquest is not an annroni-iof„ 
setting for the discussion of a medical question such^as^lhis 
•and that having elicited from two medical witnesses that they 
refrCc? f ' ' •‘a® ecnerally accepted view, be sliould hav^ 

wero 7bt aTd i“'T ihal in his opinion thev 

is one n’tberfor dX, ^ P‘'“' wrong. The maUeV 

• of a medical jLrnld the columns 


(0bitmiTr. 

j. lew „o otaLd tte f,s 

r,oi"'X s S' "vi” 5" i-erc’s 

ZTiruiS’TM '“r'n" ’■“•'s'-™' oZ." Tz. 

M.„cr of ti,. soo;,5'.;x5.o’oriof„vi':„r,'"',.d"‘ 

former prc.s.donfc of the Huiitori.on Socieiv. ’ 


who died suddenly on 
...fylf ӣe of 66, was horn at Fort 

M illmm nml reeoivod his^mod.cal odiicntion ni Edinburgh, 
uhere he grnduated 1\[.B C.M. iri 1883, and proceeded 
M.IX infh honours in 1888. - After holding appointments 
at Banff ns a.ssmtant visiting surgeon to the .Chalmers 
•ifospital, and n.s.sistnnt physician to the Banff Dispensaiw, 
-he eammcncod practice in Fort 3Villiarn, and soon won high 
esteem. Ho was consulting physician to the Invoniess-sbire 
Sanatoriiiin, surgeon to the Belford Hospital, and a 
Jucinher of the Highlands niid Islands Consultative Council 
of the Scottish Board of- Health.- Ho was also medical 
officer (if hcaltli for the Ai-dgoui; arid Kingairloch, Port 
AVillinm Biirgh and Kilmallio Di'sfrict, parochial medical 
. officer and vaccinator for ' Hilmallio, ' Ardgour, and Kil- 
monivnig, liicdicnl ieferco iiriJcr'the'IVorlanon’s Compensa- 
tion and Teachers’ Super'anriiiatibn Acts, medical officer 
to the Post Office, and cci-tifying^factory siirgobn. He held 
the commission of linutoiarit-colo'ncl 'E.A.M.C.(T.), and 
had fcccivcd the Territorial Decoration. During the war 
ho was tiiairniaii of the district medical hoard. He was a 
Fellow of the Royal Society , of Edinburgh .and of the 
Society of Antiquaries, of Scotland; he was also a justice 
of tlio pence. He took groat interest in Frecmnsoni^, and 
at a recent meeting of the Brethren of Lodge Fort M'illiam 
No. 43 was presented with a Past Master’s jewel on 
vacating thb chair. Dr. Miller was a member of the 
Inverness Division of the British Medical Association, 


Slnifafrfiiti^s mb ©Rllfgfs, 

UNIVERSITY OF LIVERPOOL. 

TnK /oHowing canCiilates have beeu approvetl afc the exammation 
iudicated ; 

D.P.H.-— V. H. Atkinson, Annie T. Deane, Sybil O. Edv?atds, A. N. 
PJalhotra. 

UNIVERSITY OF IMANCHESTER. 

PnoFKSSOK J, S. R* Stopfoiid, M.D,, 1 ms beeu appointed Pro- 
Vice-CImncoIlor in succession to Professor A. S. Peake. 

UNIVERSITY OF SHEPFIEUD. 

The following candidates have been approved at the examination 
indicated: 

r^!^r, rr): IT. Brookes, A. O. Flint, P. B. Iice-Pottor, 

V. E. A. Mrt^•^YDOd. (P'lrf D-. W. Alcock, Doris Butler. Dorothy 
Colver, R. D. Dcwai*. T. E. Gumpert, K. J. G. MiIno(^vith distinction 
in Public Ilcalib), T. K. Owon, G, B. Thomas, "W. A. Timpcrley, 
Joan J. J. V’allace. 




ROYAL GOLtiEGE OF SURGEONS OP ENGLAND. 

A QBAu'iRUi.Y Council meeting was held on January. 12 th, '“'When 
the President, Sir Berkeley ^Moynilmn, was in tiie chair, 
Cougraluiations were given to Sir Percy Sargent and Sir Frederio 
Hnllctt on having received the honour of knighthood from 
Ilis Majest}'. 

Dijilomas. 

Diplomas of Jlembersliip were granted to six candidates who 
have now complied w'ith the regulations. 







t TOTHBITHS 101 
/ociuriXr 


JA^.^,aS, 1918] 


TREATMENT. ,0p..EBINAET. ^EPSIS. 

U . — , ‘.L ^ - 


©Ittucnl 5Cfrfurc 

0:7 

THE TREA.Til*IENT OP URINARY SEPSIS. 

Given- ai the Eoyal Victohia iNrinMNUY, 

NE\\-CASTI.r.-IJl’OK-Ti'N'E, 

■ BY 

E. J. WILI/AN, JI.V.O., F.E.C.S., 

HONORARY SVRCROK AKD UCCTITRER IN SimCERV TO TJIB ROYAL • 
VlCTOm INYIRilARV, KEWCASTLE-UPON-TYKE. . 

(inVA Special Plalc.) 


Acbte iuflammation of t\\c urinary tract is nnytliiiig but a 
rare disease; too often tlio rcsnoiiso to treatment is dis- 
appointing, rvlieroiipon tlie sequel of tlic aeutc stage, 
ebronic urinary sepsis, becomes one of the common ailments 
met rvitU in general practice. 'J'lie treatment of the 
ebronic stage is not an easy problem, and often little is 
done to assist such patients. 

A typical history given by a jiaticnt tolls of an attempt 
made by the doctor to treat the usual symptoms of fre- 
quency of micturition and dysuria that much medicino 
bad been sn-allowcd, and perhaps the bladder had been 
Trashed out, or a vaccine Imd been employed ; that no 
permanent good had accrued, and the sorely disaiipointcd 
patient had gone to another doctor, rvho carried out-' an 
exactly similar programme to his predecessor. 

The condition attacte either sox, and at any age, though 
it predominates in females. It usually' affects both kiclncy.s. 
In my experience the great majority of cases of urinary 
s’^isis are " descending " infectious. The function of the 
kidneys is to eliminato unsto products, including any 
bacteria, whicli may be present in the blood stream. 

That a kidney is able to eliminato micro-organisms n-itb- 
ont any damage being done to that kidney is an estab- 
lished fact. Probably tbo alternative usually bappens, 
when the extruded pyogenic bacteria gain a footing in 
some situation in the urinan- tract — for example, in the 
solid part of the kidney (causing jiyeloncphritis) ; in the 
mucous membrane of the renal pelvis (causing pyelitis); 
in the mucous membrane of tbo ureter (causing ureteritis); 
in the mucous membrane of the bladder (causing cystitis) ; 
or, rarely, in tbo mucous membrane of the urethra (causing 
uretliritis). 

If bacteria are circulating in the blood stream, and have 
oatnaged the patient’s filtering apparatus, it is tlie medical 
man s duty first to endeavour to discover the focus of 
^ of the bacteria, and socoiidl5- to ascertain the extent 
o e damage uliich has already been done. The cora- 
monest ton of .sepsis are found either in the teeth or the 
• ^ *0 loans may be in the ear, tbo air sinuses, 

case of females it may be in the uterus asso- 
ciated or not ivith pregnancy. 

iirinTi!! relate some clinical examples of acute and chronic 
y sepsis, with the treatment employed in encli case. 

Dnriiitr tim Acute Eihn-ahy Sepsi.s. 
iiossilile ”10 oouto stage of the condition it is not alvravs 
must concentrri^ ^ causative focus, because tlie doctor 
the symptoms' t^'catbig 

^-1? invariably li3'peracid, and tlie 

evGii aVkalhiG its reaction is less acid, or 

of poSm 'citSe e^ert? Sfviug 30 grains 

irritration nt tl.l ^ o'-ery two or three hours, and by auto- 
patient drink tract— that is, by making the 

op to two bottles a Contrexeville water, 

are also good barley water or plain water 

■urine reaction is not ^ 
frith the potassium citrate Tl"'" ""‘'m ooutiuuation 

polirmtr down lU.. hyperacid septic nrino 

6 baped"ar:.rof ni,rns"m“^‘^’ 

ftoiit of each ureteric bladder base in 

tion; later, if hiMilv ulcera- 

over these ulcers,"’ tlie vtllVT''' ’"1 
and the terribly d-'etr^^ ^ deposited upon them, 

"®iii'''f^ ®J’®riess,ng condition of “alkaline phos^ 


pliato cy.slilis ” develops. "Whore tbo patient is of ordiiiaiy 
intolligcnce this can be avoided by giving biiii or her a book 
of litnnis paper with instructions to diminish the alkaline 
inixluro dose ivlien the litmus pa]ior indicates that the 
iiriiio lias become neutral. If it can be managed, the urine 
in nil stages of the treatment of uiinary sepsis should bo 
kept faintly acid. 

Some urinary antiseptic should bo given, either salol, 
5 gmiii-s tliroo times a day, when the wine reactron is 
alkiilind, or liexamino, 10 grains throe times a day, when 
the ' reaction is acid. The application of linseed meal 
poultices every six hours to an affected loin seldom fails to 
relieve acute renal jiain. 

If an obvious septic focus — for example, a dental focus — 
can bo easily dealt with, tbo acute stage can often be cut 
■short by dealing with it forthwith. A saline purge should 
also ho given. The. diet should consist of milk, eggs, and 
fish; meat, and irritants to the urinary tract such as coffee, 
condiniciits, pickles, etc., should he ai-oided. 

It is far from easy to demonstrate the causative organism 
of acute uriiiaiy se2isis. Prohahly staphylococci or strepto- 
cocci are the coranioiiest bacteria, but unless a baotei-io- 
logical c.vnniiniition is made in the early .stages of the illne.ss 
the chance of recognition of the actual organism is gone, 
for Iho nhiqnitons Uncilliis coli communis is quickly on the 
scene when the other bacteria disaiipcar or arc masked. 
This is file reason wliy the treatment of urinary sepsis by 
vaccines is so terribly disajqiointing, for only the secondaiy 
infection, not the primaiw infection, is found, the original 
oiganism still being at work, though bacteriologically it is 
masked by tbo U. coli communis. 

Clinical Examples. 

A typical bistoiy of a case of acute urinary sepsis wliioh 
yielded to treatment is as follbivst 

Case i. 

.A. woman, aged £8, aas taken eachlenly ill with shivering and 
acute pain which radiated to both ^oins, accompanied by 
strangury, with blood and pus in the urine. I saw her four 
weeks later, by which time she had recovered ' from the acute 
stage, bub she slill had frequency of micturition, acute pain 
after mlclurUion, and a heaiy deposit of pus in the urine. 

ik routine examination .showed marked follicular tonsillitis, 
iliougli tho patient denied having Iiad any ” sore throat.” 

Cystoscopy showed a fan-shaped area of ulceration in front of 
the ureteric orifices, the apex of tho fan being at each orifice. Tho 
case was referred to a laryngologist, who removed two liighlv offen- 
sive tonsils. TVithin one month not only had the patienPs sj-m- 
ptoms disappeared, but the bladder ulceration had healed, and all 
pus cells had disappeared from the urine. 

I now give a history of two tyjiical cases of alkaline 
jibosjihatic cystitis. The first of these was one of mild 
degree easily cured, while in the other the condition was 
very advanced. 

Case ii. 

A married woman, aged 25, gave a typical history of cystitis 
extending over two years.’ Her doctor’s letter on her 'condition on 
admission to tlic Royal t'ictoria Infirmary, Newcastle-npon-Tyne, in 
September, 1924, is worth quoting ; 

“ This patient appears to have suffered from cystitis ever 
since her confinement of three years ago. 

“ She comjilains to me of pain during and after micturition, 
and of passing 'olood, slime, and gravel. She brought a piece of 
fairly hard material which she said she had passed per 
urctiii'am. It was .appaiently pliosphatic. Effervescence took 
place on the addition of pure nitric acid. She said slie passed 
several pieces, which sometimes stuck in the urethra and 
took a lot of dislodging with the finger. The size of the pieces 
was that of a pea or sjilit pea. Gravel was also passed in 
quantity. On examining the urine I found it was alkaline and 
contained much mucus and a fairly large piece of bladder 
mucous membrane, but little pus. 'Since putting her on to 
hexamine and daily wash-outs with boracic lotion she has 
improved considerably, but still passes an occasional piece of 
phosphate debris. This morning, when the catheter was passed 
on her, I could not feel a stone, but rather think she must have 
one or more." 

Cvstoscopv showed phosphates encrusted upon ulcem on the base 
of tho bladder. These were scraped away under vision, by cysto- 
scopy, bv a "spoon ” introduced through the urethra. The urine 
was kept acid, and the patient was completely well six weeks later, 
by which time all pus cells had disappeared fiom the urine. 

Case hi. 

A spinster, aged £4, came in August, 1924, to the Royal Victoria 
Infirmary, Eewcastle-upon-Tyne, complaining of passing'urine even- 
few minutes night and day; she brought with her a large pill-boi 

l 3499 j 



122 JAN. 28, 1928] 


r Tnt Bfim-pj, 

L Msmcit Jotiwit* 


TREATMENT OP.TJRINARY 6EPSI0.I 


fuU of pieces of pliospliato grit (some of tlicm largo) wliicli slio was 
accustomed to pass daily. Two years previously slio had had a 
typical acute attack of urinary sepsis, and on closo questioning 
1 found she had been taking some medieino, and the samo mcdicino, 
for tho whole of tho two years. Doubtless this medicine conlamcd 
potassium citrate. Sho had dental sepsis; tho urine was alkaline, 
and contained blood and pus; no abnormal shadows were sccti on 
a radiogram of tho urinary tract. 

Tho dental sepsis was first attended to. As tho bladder capacity 
was under one ounce, cystoscopy under a goner, al anacsthetie was 
Sccessary. Tho surface of tho bladder was found to bo studded 
with _ ulcers, upon cnch of which wero encrusted patches of phos- 
phatio deposit— that is, sho had tho condition of alkalino phos- 
phatio cystitis. Tho dopo,sits proved too ealensivo to serapo away 
through tho urethra, so tliis was effected through a suprapubic 
approach. 

Life is now tolerable for her, for her bladder capacity is 
5 ounces, she can work, and sho is only disturbed once at night 
to micturate. Her urine is acid, but still conlaina pus. Cyslo- 
Ecopy shows a small ulcer on tho right lateral wall of tho bladder ; 
this is not covered by phosphates. Tho bladder is being irrigalcd 
twice weekly, and slio is having hoxamino with acid phosphate of 
soda. I have every hope that tho ulcer will eventually heal and 
that sho will bo completely cured. 

Tlioro is a valuablo lesson to bo learnt from tlicso two 
cases, and it is that tbo potassium citrate treatment was 
overdone; had this drug been confined to tho ncuto stngo 
only, the phosphates would almost certainly never have boon 
deposited on tho ulcers formed in tho acute stage, after 
tho hyperacid urine had digested tho bladder mucons 
momhrano. Immediately tho acute stage was over caro 
should have been taken to keep tho urine faintly acid. 

CimoNtc lTniN.i.nr Sr.rsi.s. 

Tho successful treatment of a ease of chronic urinary 
sepsis depends upon a correct appreciation of tho location 
and extent of the inflammation, and such a diagnosis 
cannot bo mado witliout routine cystoscopy and pyclo- 
gi-aphy. 

Cystoscopy will indicate tho condition of tho Madder; 
ureteral catheterization will enable tho urine collected from 
each kidney to bo examined for pus colls ; whilo pyelography 
will prove whether tho sepsis is merely pyelitis or pyelo- 
nephritis, or whether extensive destruction of tho solid part 
of tho kidney has taken place. I invariably make a double 
pyelography, and in no single instance have I soon any ill 
effects from both kidneys being " pyologrammod ” at tho 
same time. 

For tho benefit of tlioso who aro not familiar with tho 
making of a pyelogram I may say that a ureteral catheter 
is passed, under vision, by means of tho cystoscopo up tho 
ureter into tho pelvis of tho kidney. Tho ureters are 
insensitive to tho passage of tho urotcral catheter; thoreforo 
tho only discomfort of catheterization of tho ureters is tho 
introduction of tho cystoscopo into tho bladder. A solution 
opaque to x rays (I employ sodium iodido solution) is 
injected with a syringe through tho hollow ureteral catheter 
into tho pelvis of tho kidney, and tho patient is x-rayed. 
A pyologi'am should only bo taken in a patient who is 
fully conscious; it is a dangerous proceeding to distend tho 
renal pelvis of an unconscious person. Tho radiogram 
shows up tho hollow part of tho kidney, and an interpreta- 
tion can bo made by an estimation of tho shape and size 
of tho renal pelvis and calyces. 

It is essential to watch tho reaction of tho patient’s 
urino, for it should bo kept just faintly acid. I use 
sufficient doses of potassium citrate to reduce tho acidity, 
or, alternatively, use acid phosphate of soda to keep tho 
reaction acid. In addition, salol 5 grains must bo given 
thrice a day if tho urino is alkaline, and altcrnativoly 
hexamino, 8 grains thrice a day, when tho urino is acid; 
of the two I prefer tho hexamino, largely because of tho 
constipating effect of salol. 

A routine general examination of the patient should bo 
undertaken to find a possible focus of sepsis. Tho diet 
should be light, red me.at being taken only seldom. 
Urinary tract irritants such as coffee, condiments, pickles, 
etc., should bo avoided. Cai'o should ho taken to avoid 
constipation. Diuresis is an important factor in treatment, 
and Contrexevillo water is a valuable help. 

Example of Chrome Pyelitis. _ _ 

A married woman, aged 38, had had for three years periodic 
attacks of left-sided renal pain associated with frequency of 
micturition, hacmaturia, and some pain after micturition. In tho 
acute stage there was a continuous temperature of 100°, and she j 


was confined to bed. Bacteriologically a pure culture of n r, 
eommxims ^itained and prolonged , Vaccine treatment b 
proved iiseloss. Her teeth showed, ovitienco of pyorrhoea 

A routine radiogram of tho urinary tract showed norm' 
shadoa-s; tho urine contained pus aiul some blood; cysio°coB 
showed ulceration of tho left ureteric orifico, with a slight deere 
Pycl.Oiiraphy of both 'kidneys shoa'cu tiiat th 
fi°em f <maffcctcd. Urine collecto 

w.irnormnl ^ contained pus; unno from tho right kidnsj 

A _ diagnosis of Irft-sidcd pyelitis was mado and tho deiita 
sepsis attended to. Tho patient’s condition improved: bul'progress 
was slow, so tho left renal pelvis was irrigated with a 1 in lO.CKXl 
solution of. silver nitrate through a ureteral catheter every three 
weeks on six occasions. No anaesthetic was used, for apart trotn 
tho discomfort of passing tlio cysfoscopo. tho Irc-itraent was 
painless. The patient carried on her ordinary life tho day folldwina 
each treatment. . . . 

Now, three months later, the patient is cured of her symptoms, 
and no pus cells can bo found on microscopic examination of hdr 
urino. . Tho silver nitrate effected a euro by dcstroving the 
organisms in tho mucous membrano of tbo pelvis. 

Example of Chronic Pyelonephritis.' , , 

A married woman, aged 55, hod for two years complained of 
ill. health, associated with attacks of . increased ' frequency -of 
micturition, together with smarting pain during tho act. , She 
had occasionally " a mild backache,” but tho vesical 'syniptoms 
predoroinated. 

Tlio’ urino contained pus, and bactcriologically /?. eoli eontmtinis 
in pure culture was found. An autogenous vaccina failed to 
improve matters. 

Cystoscopy showed a mild degree of cystitis, whilo pyelography 
showed certain changes in tho renal calyces, which wero con- 
elusive ovidenco of a chronic pyelonephritis. The urino collected 
from each kidney contained pus cells. 

OTio renal pelves wero irrigated on four occasions with a 
1 in 10,000 solution of silver nitrate; sho has remained quite 
well and free from all abnormal symptoms and signs for the 
hast threo months, aiid a permanent euro seems assured. Nc 
anaesthetic was ever necessary, and tho patient was up and 
about on the following morning after each treatment. 

Forliiiialcly for tho patient tho infection must have been in 
tho apices of the pyramids, and probably it had not penetrated 
deeply into tho solid tissuo. 

Example of Infected Eydronephrosis. 

In March '1924, threo months after a confinement, a married 
woman need 25, had an acute attack of right renal colic, with, 
tho Ivpicai severe pain, vomiting, and strangury. She got over 
fhn nrnlo staec, but sho never recovered her health, and was 
frequently ailing. Sho had an indefinito acho m the right flank; 
thoro waV neither frequency .nor hacmaturia, . but. slip had lost 
weiirht and tho urino contained pus. Bactoriologically, P. eolt 
eommanis was repeatedly found in pure culture; prolonged treat- 
ment by vaccines failed to give any relief. 

rvsfnscoDV showed a basal cystitis, being much worse on the 
rie^ half of the base, of tho bladder. Pyelography (see Kg. 1) 
rigiJL , rmhf kidnev to bo disorgatiized j tho shadows were 
showed the urinl from tho right kidney 

DUS* that collected from the left kidney was free from 
contiuncd p , piicnolsulphonephthaloin excretion from the left 
irnc Dcr cent, (a normal amount). 

^Rtefit nephrectomy was performed ; the removed kidney con- 
taSinfected urine, but thero was no actual pyonephrosis. 

Tho nhotoRraph of tho specinien (Fig. 2) shows that the 
kidney was disorganized and incapable of recovep-. It 13 
nossihlo that if early treatment of tho kidney had been 
undortaken in this case the condition might never have 
nSressed hevond the stage of pycloneplintis, although 
eSny there was never any indication of a very sorions 
eonditioii. The pyelonephritis was the initial stage of the 

‘”Tho'naticnt°hafmade'an uneventful recovery; six months 
Inter sho is fat and well and tho urine is normal, the 
microscope now failing to detect any pus cells, showing 
that tho basal cystitis has healed. 

Example of Pyonephrosis. 

k oninsfcr ared 22, for six years had had incrcMcd frequency, 
.f'tnfr'tMitlon with pain during and after tho act. Two years ago 
to have pain in the back, but more particularly, in the 
Six months before admission she had haematursa. She 

tf^Srrnesf in the right flank, tho urine contained albumm, 
Ifood! and P?s, but X rays disclosed nothing abnormal in the 

'’clstoscoov'^Bhowed a general cystitis, also that, a thiclc 
f DUS w^^extruded from the right ureteric onhee, 
L^appSSmw of toothpaste being squeezed out of a metal tube, 
^hft nrino from the left kidney was free from pus and the ^en^ 
unction tests showed.ifc to be functionally good. 

7 ZS not made. Tho right kidney was removed by operation ana 
he did well. _ . 

Tho removed kidney (Fig. 3) showed the last stage of 
epsis, being disorganized; it is possible that by treatment 
n the early stage it might have been saved. I was unable 
o find the primary focus of the sepsis. 



S. GILEKllT SCOTT; METHOD OF DEALING 
WITH A SWALLOWED OBJECT. 

{See p. 133.) 



I'jc, J.—Kidno < uniplctoly cli-sortranlzml 
y V I'l 'iGniliii;' 





•Jan. 2S, igzSj 


r T(tK IJniTjHU 

I JOLKSAt. 




r Tar Bnmsrr 
L SiKDiCAt Jocnrfjii. 


T 02 S] 


PiimfiM/ or " i*V5^/inj? " Ctjsftih. 

Jiv ihi^ is woant'an innamiiintion of ilu* urinary tract 
ontiVolv confmod to tlio bladder; eitbor it is n primary 
evstitis, or it is secondary to pyelitis, py<‘loneplinUs, ote., 
which has lioeu cured. Cystoscopy shows the cystitis, while 
the xu-iuo obtained from each kidney (hy means of a 
ureteral catheter) is free from pus. If t!ie bladder is 
constnntiy reinfected by septic urine, then the source of 
the sepsis in the kidney must be attacke<l before local 
treatment to the bladder is of any nse. 

Primary or rosidnal cystitis, witli or witliont nicoration, 
<-an bo cared, or at any* rate tiio distre.s.sing symptoms can 
be abated; by treatment with antiseptic omnisions. The 
details of the treatment are ns follows. 

Twice nookly a cathelor is passed and the bladder dis- 
tomlcd under the usual strict aseptic precautions with 
either solution 1 or solution 2. The iodoform emulsion 
(No. 2) is too irritating to use too often. Solution 1 is 
used three times to one of .sobition 2 — that i'*, solution 1 is 
used on the Srd, 6tb, lOtb, 17tb, 20tli, and 24tb days of a 
month, while solution 2 is used on the loth and 27tli clays 
of a month. Tlie solution is allowed to lemain ui the 
bladder for thirty minutes, when it is micturated, i carry 
out the treatment for eight weeks, or longer if a cure has 
not thou boon obtained. The composition of the solutions 
is as follows. 

iiiJ!rcr‘/ofiidt' or Si>futtn)> 1. 

Pota^^sium iodide ... 2hC6 gram*! in 150 c.cui. watn 
Silver nitrato 21.66 prams in 150 c.cm. waica . 

These sohilions are mi.tcd with 150 c.rin. of mncilapr of lri«h 
moss. 

ladofnnn Kwuhtott, or Snfutwn 
Iodoform ... ... ... 45 pram’! 

Glycerin 315 gtam®. 

Aq, dost 00 c.cm. 

The cnnibion*! arc made up for in«' t»v ilowiv. Utady and 
afartin, Newcastle-upon-Tyne. 


123 


Kjrmafihg of J^Hnmru or Ihsidual Cusiith. 

• Cask A, 

A rnaiTicd woman, aped 48, had had for Uveatv voars periodic 
ntlncks of cy*.tilis, obviously cxacerhalioiis of a 'chronic cystiti*:. 
She Jind had three severe ones during the previous twelve months. 
There was increased frequency of micturition day and night accoin> 
piuiicd by puin; she took very little fluid as “she was afraid to.” 
Tlie uiiiie eontained all>iimin and pus cells. 

Mcdiciiu^s, vaccines, and the ordinary bladder inigations had 
alt failed to cure Jier. 

Cystoscopy sliowcd acute ulcerative cystitis in a contracted 
hladder; the pyelogranis were normal, and mine collected from 
each kidney was free from pus cells. 

The view taken w;as that the trouble was now cntirclv in the 
bladder* and that if tlic ulcers could be induced to heal she 
would be cured. She was treated by the emulsions and she 
quickly responded to treatment. 

Cask B. 

j A niariied woman, aged 75, had for some years been troubled 
I with severe attacks of urinary strangury accompanied by pain and 
hacmaturia. So acute was the pain that she was frequently 
reduced to teal's, and life was n misery to hei'solf and hei rela- 
tions. Treatment was of no avail and nothin" could be done to 
relieve her distress, even morphine having no beneficial effect. 

Cystoscopy showed general ulcerative cystitis; the uretci-s wcje 
not* cathcleVized, as the bladder distension occasioned distress to 
the patient. 

AUliougli a diagnosi.s of primary or residual cystitis was not 
dclinitcly cslablislied, treatment by' the emulsions was recom- 
mended and canied on for three months; by the end of that 
time the pain, strangury, and haernaturia had disappeared. Her 
urine contained pus cells, llierefore .she was not cured, but the 
relief of her symploms restored her interest and pleasure in life. 
Her dopioe of relief oan be gauged by a recently I'cceived letter, 
where she states : 

“ I thought I would like you to know how grateful I feel 
for all you did for me. I’ve had no pain for four months — 
before that, I had it pretty badly for over four veal's. Of 
course, 1 know it will probably return, at my age,* but it is 
.sonmthing to be free for a time, and I feel most grateful. 

** riea’*e do not tlnnk it nccc.ssary to answer this note. I just 
I iliougiit I would like you to know how thankful I feel.” 


INOPJGR ABKE SAKCOJbmjf TR^ATmimTlT RADIO 51. 


LNOPKUAIJLE SAECOJIATA TIlKATKI) WITH 
KAl)]U>f. 

BY 

ROY WAiin, B.S., 

issisTiST Mcnic.a SLTt:iiurrE},-oQ?T, nit nAniuM ikstiti rt. Losnos. 
(R’iBi Si>ecinl Pltitc.) 

Thk objoct of this paper is," to giro the oliuieal data of a 
wucs of tuirty cases of sarcomata treated at the Ia>iidoii 
a uun Inslitate. All the groH'ths rocordod were iiiopcr- 
enr’ cases in ’irhicli a histological iiivesti- 

oauon Had be™ made are included. There might he added 
Tn- A or sarcomata diagnosed clinicallv, hy a- rays or 
in';,,! r progress of the disease, ’and’ such cases 

Tf ?,r «0HsUleraWe interest to the less critical. 

tvBiifa V’c got infonnation about many patients 

tbe Radhmrinstitutc!""'’''’'''^ ” 

Old W forms of sarcomata i.s best carried 

facts gonima radiation. Certain known clinical 

toMs are as follows; 

disappear under the effect of 
doses winVh'd t cells being destroyed by 

2 s sdrronnding tissues. 

others T “re more susceptible to the rays than 

iniDortan..^*' I lymphosarcomata too great an 

aiiee of t) ^ dot be attached to the rapid disappear- 
under Pt'roary growth, and the patient should be kept 
anneai aar.ft^'c*'°” some considerable time so that the 

3 Vim o d'ctastases may be jiromiitly dealt with. 

Ijody docs tumour in different parts ♦»'<• 

4 in the same wav. 

. * Haclium ravs ^ 1 .a l " c 


4* react in the same wav. 

iix' 1 ! ^ bare only a local effect. Separate 

^ widely disseminated rccAi 

sent Will eyenrurtll X* rtretixx -iliA xm.-..'... Ixotxrl 


sfa.SGs may 


^vhen urncftx * widely disseminated rccAi 

S rlZT gain the upper i.and. 

viotisb- ,v>. a time when tumours which hai 

even when' ^ longer respond to ra 

6. Eelinf evidence of metastases. 

in niosf . syinptoms and prolongation of life 
Rng poriodr patients remain in good In 

I >e growth becoming shrunken and fil 


Tri;.\tmen-t. 

Comparatively little can be said of the “ dosage ” owing 
to the varieil situations and e.vtent of the growths, but the 
treatment must he vigorou.s. Both needles and surface 
ai>pIicators are employed and n large rpiautity of radium 
should be used. Speaking in general terms, it is best to 
give a maximum dose at the first exposure; if it be neces- 
saiy to repeat the tieatnient the strength of the subsequent 
exposure must be diminished. 

Surface applicatoi-s are rectangular, square, or circular, 
with superficial areas ranging from 1 to 30 sq. cm. Tlie 
applicators used in tliese cases arc of two strengths, con- 
taining either 1.25 or 2.50 mg. of radium clement per 
squarc centimetre. Tliey aie disposed in such fashion as to 
obtain a cross-fire of focal radiation in all parts of the 
growth. All external apj)licators should he screened with 
2 ram. of lead or its equivalent, and covered with rubber. 
These are applied over a thick layer of wool. The needles 
used contain 1, 2.5, 5, 7.5, 10, or 25 mg. of radirim element, 
their Iciiglh.s varying from 1.2 to 4 cm, and the nail of the 
needle varying from 0.3 to 0.5 ram. of ])latinum or 1 nun. 
of- silver. Recently needles n itli a wall of 0.4 mm. of Monel 
metal have also been used. 

The action of large doses is to produce progiessive 
degeneration. It has been suggested That with very small 
doses it is iJossible there may he stimulation of certain 
types of growth, hut there is no certain evidence on this 
point. The time factor lias been much discussed of late. 
At the Eadium Institute the principle underlying the treat- 
ment is to give a large dose for a comparatively short 
time — seldom lunger than forty-eight hours. It seems, 
however, quite possible that weaker doses for a longer 
time would give equally good results. There arc niaiiy 
obvioiis difficulties in keeping needles in some situations for 
perhaps a week; a very common and serious complication 
is that of sepsia. Tissues subjected to radium rays are very 
susceptible to attack by bacteria, and every aseptic pre- 
caution should be taken' when introducing needles into any 
tumours. 

woman, aged 62. On ilay 21sl, 1915, a swelling cf 
tlie riofit claviele was explored and found to be an inoperable 
sarcoma. When seen at the Eadium Institute on June 6tli there 



124 Jan. a8, 1928] INOPERABLE SARCOMATA TRIjATED WITH jRADIUM. ■ 


r TiiREnmn! • 

L Mecjcu- JovByj^ 


vn*? a firm prominent tumour "rowing from tlio superior and 
posterior surfaces of tlio right clavicle, tillinp up Uio outer three- 
cpiartei-s of tho right suprnc)a\icular fosKa, The tumour incnsiircd 
10 by 6 by 2 cm. (sco Fig. 1). Tho tumour rapidly disappeared 
under radium treatment (sec Fig. 2). Her doctor reported on 
Kovember 3rd, 1927, tliut tlio patient was in excellent health. 


Case f. — A man, aged 3-1. In August, 1912, a growth was 
removed from Llio right side of llic neck. In June, 1913, a 
roeiirrcnco wa.s removed at St. liarlJiolomcw’s Hospital. He had 
fiirlhcr operations for recurrence in December, 1913, and March, 
1915. In July, 1916, microscopical section showed mixed spindle- 
and rouiul-celied sarcoma. When seen at the lladium Instituto 
on July 3id, 1916, there was a linrd fixed mass 5 by 6 cm. 
involving the right sterno-mastoid muscle. Ho received radium 
treatment with steady imnrovcincnt until February, 1922, and 
(lien remained in good health until May, 1926, when the growth 
recuri'od and extended deeply until, in January, 1927. infiltration 
of the growth caused gradual paralysis of the tenth, cieventh, and 
twelfth nerves, and tho cervical sympathetic. The patient died 
on March 8th, 1927. 

Case S . — A woman, aged 50. On September 18tli, 1916, an opera- 
tion was performed for the removal of a round-celled sarcoma of 
the ethmoidal region. Tiiis resulted in an apparent cure, but 
on Marcli 19th. 1918, when the patient first came to the Radium 
Institute, she nad a smooth oval fixed swelling 4 by 5 cm. in tho 
in tho right temporal fossa. All threo swellings disappeared under 
treatment, but a second liard mass appeared between tho right 
globe of the eye and orbit, and later a third swelling appeared 
in tlie right temporal fossa. All threo swellings disappeared iindcr 
radium treatment, and sho remained welt until May, 1923, when a 
tumour developed on her head. Since this time there have 
appeared at intervals at least a dozen difTcrent tumours of the 
scalp, which have disappeared rapidly under radium treatment. 
Sho was last seen at the Radium Institute on October 31st, 1927. 
when she was treated for a tumour in the rigl^^suboccipital 
region. Her general health was cxcclltnt. ' “ 

Case — A woman, aged 65. In March, 1920, tho left upper jaw 
was excised for a sarcoma. She first attended the Radium Insti- 
tuto on December 6th, 1920, complaining of diplopia. On examina- 
tion a nodule was seen in tho region of tho inferior turbinate. 
Treatment was continued until June, 1922. In December* 1926, 
she returned. A mass of glands below tho angle of tho left jaw, 
and a swelling of the left side of tho soft palate, were present. 
Treatment was continued. Sho was last examined on October 31st, 
1927. Her general health was excellent. Tho mass of glands in 
the neck had disappeared, but tho tumour in the mouth is still 
present, although much smaller. 

Case 5 . — A woman^ aged 35. A tumour of tho sternum was 
explored and found inoperable. When first seen at tho Radium 
Institute on September 24th. 1921, there was a prominent, diffuse, 
irregular-shaped tender swcllifig over the centre of the sternum 
and extending on tho third and fourtJi costal cartilages. Tho mass 
measured 6 oy 4 cm. and there were palpable glands in both 
axillae. X-ray examination showed an abnormal shadow at tho 
hilum of the right lung. Tlie growth disappeared completely 
under treatment, but in December, 1923, threo secondary meta- 
static growths appeared in the chest wall, and glands were 
palpable in both axillae. All these swellings disappeared under 
treatment. In July, 1924, enlarged glands appeared in both sides 
of the neck. Those glands in the right side responded well to 
treatment, but those in the left side persisted for some months, 
causing much swelling of tlio left arm and forearm. They 
responded to further treatment, and in May, 1925, when tho 
patient was examined, there was no evidence or disease anywhere. 
However, in February, 1926, there were signs of metastatic growth 
both in the mediastinum and spine. After an initial improvement 
the patient began to go downhill in spite of treatment, and died 
on November 11th, 1926. 

Case 6. — A woman, aged 64, first noticed a lump in tho left 
groin in August, 1921. In January, 1922, an attempt was mado 
at the Elizabeth Garrett Anderson Hospital to remove this mass. 
This was found impossible owing to the fact that the femoral 
vessels were involved in the growth. Microscopical report showed 
the growth to be a small round-celled sarcoma. Radium treatment 
w'as commenced on February 13th, 1922, and continued at 
intervals. The patient remained in excellent health until March 
1925, when the growth gained the upper hand in spite of treat^ 
ment, and the patient died on May i7tli, 1925, 

Case 7 . — A youth, aged 17. On November 15th, 1922, a spindle* 
celled sarcoma was removed from the nasopharynx. Rec'urrenco 
speedily took place. Radium treatment was commenced on 
January 19th, 1923. The growth responded well at first, but in 
October, 1923, the growth became so large that it interfered 
with sw’allowing and breathing. Each radium treatment caused 
apparenji disappearance of the growth for a short time. Tho 
growth was tJius kept in check- with repeated applications of 
radium and the boy remained in excellent general health, lu 
October, 1927, he was referred back to the University College 
Hospital with a view to having the growth excised. 


Case 8. — A woman, aged 45. In November, 1922, an operation 
was performed at the Central London Throat and Ear Hospital for 
a sarcoma affecting the left antrum of Highmore and turbinate 
bones. This was followed by a recurrence, and on February 12th, 
1923, she was admitted to the Radium Institute for tre.^tment. 
She improved steadily, and radium treatment kept the growth 
under control until July, 1927, when the tumour began to spread 
27 ^?^ upper alveolar margin. She was last seen on October 
tion " UoS* although there was a little change in the local condi- 
cachectic. health was failing and she looked ill and 


Case man, aged 78. On Juno 9th, 1923, a lymphosarcoma 

fiom the periosteum of the orbit, and infiltrated tho inner and 
JJPPf Ics and periosteum, but not the globe 

tSi.h" iT" Juno 25111, 1923, at the Radium 

Instilulc, there was .n Email vascular nodule at the inner ejlreiuity 
of the upper eyelid. On August 12th, 1925, two metastatic growths 
were present, one growing from the chest wall, and the other from 
tlio abdominal wall. Ihcso disappeared rapidly under trcalmonl. 
In August, 1923, another growth appeared over the left scapula. 
Ihis responded well to treatment, but in December, 1926, there 
w-ere signs of growth in tho cellular tissue between Urn rectum and 
bladder. This caused retoiitioii of urine. Bronchitis followed, and 
the patient died in January, 1927. 

Cate lO.-X woman aged 48. In April, 1923, a mass of glands 
was excised from tho left inguinal region for supposed tuberculous 
adenitis. A recurrence speedily took place and was excised in 
October, 1923 at the Royal Northern Hospital. The microscopical 
section gave the appearance of a sarcoma of high malignancy TJie 
powth recurred again, and when first admitted to the Radium 
Institulc for treatment she had a hard fixed mass in the I-ft 
inguinal region, and oedema of the leg'. Treatment at intervals has 
arrested tho progress of the disease. On examination on October 
23rd, 1927, there was some thickening to be felt. She complained 
of some pain in this region, but there was no evidence of active 
disease and she was in excellent general health. 

Case H.— On Marcli 17th, 1924, an osteosarcoma was removed 
from tho left malar bone of a girl aged 5 at . Walthamstcw 
Hospital. It recurred rapidly, and on June 7th,. when she was 
first seen .at tho Radium Institute, the tumour was much larger 
than it was prior to its removal. She was treated at intervals 
until March, 1925, when treatment was discontinued as there was 
no apparent disease present. She was last examined on October 
26lh, 1927, when there was no evidence of recurrence. 

Case li. — A boy, aged 4. On May 22nd, 1924, a section v.’as 
taken from a tumour, ^vhich appeared to arise from the superior 
maxilla. Microscopical investigation showed it to be a fihro- . 
sarcoma. He was treated at the Radium Institute on July 14ili, 
1924, on account of a local recurrence. Treatment was continued 
at intervals until February, 1925. On November 1st, 1927, ihe 
father reported that the child was now in hospital, having had 
an operation on the nose for a supposed recurrence. 

Case iJ.— A woman, aged 41. In 1917 a sarcoma in the mid-lino 
of tho neck was excised. In 1921 an operation for recurrence was 
performed. On June 2nd, 1924, a further recurrence was removed, 
when examined at tho Radium Institute on September 1st, 1924, 
there was a hard resistance felt in the region of the scar and 
tiiero were palpable glands in both supraclavicular fossae. Under 
treatment the disease was kept in check, but in October, 1927, it 
was reported that the patient had had the skull trephined for a 
secondary sarcoma of the brain, and sho was not expected to 
recover. 

Case IL^A woman, aged 64. On October 1st, 1924, a sarcoma 
of tho SKull was explored and found to be inoperable. X rays 
showed invasion of tho cranial bones by the growth and loss of 
continuity of tho bony outline. She was first treated at tho^ 
Radium Instituto on October 20th, 1924. Over the upper surface’ 
of tho rit^ht parietal bone there was a conical swelling 8 cm. in 
flinmotcr" nulnv to tho touch, and fixed to tlie surrounding 
Sure’s.^ Fig. 3) No glands wero palpable. She 

responded remarkably well. She was last heard of on November 
2nd 1927 when her doctor wrote : “ I have to report very favour- 
ably The crater has taken a long time to granulate over, but is 
now covered with fine granulation tissue, winch occasionally crusts 
over, but licr general condition is excellent." (See Fig. 4.) 

Cato 15— A. woman, aged 34. On September 24th, 1924, a 
tumour of' the cheek 1 inch in diameter and half an inch in thick- 
ness was excised at the Prince of AVales's Hospital Tottenham. 

fiimour recurred, and the patient was admitted to tlie; 
Radium Institute on November lOth, 1924. Tho treatment was 
continued at intervals until October, 1926, when on examination 
no evidence of disease could be detected. This patient was seen 
last on October 26lh. 1927, when she was found to be in excellent 
health and free from recurrence. ^ 

in A eirl, aged 3. On November 4t!i, 1924, a small 

round-celled sareoma was removed from the leg beneath tho 
solcus muscle When seen at tho Radium Institute there was 
a large palpable gland in the groin, although there vp no smn 
of local ^recurrence. This disappeared after treatment, and tho 
natS reSed well untir March, 1925, when recurrences 
appeared in the groin and in the popliteal , yggs 

followed bv improvement, and when examined m June, 
there was no evidence of disease. Recurrences in tho cidf mmchs, 
pXlitell apace, and groin occurred later in the year The child s 
condition became rapidly worse, and she died m August, 1926. 

Case n —A man, aged 44. In February, 1924,- a small 
in the region of the right upper canine fossa was excised at 
St. Bartliolomew’s Hospital. This recurred in June, 1944, ana 
in iumist w^ treated with diathermy. When first treated at 
tho Radium Institute, on December lOth, 1924, the patient rre- 
sented the following appeaVancc. (See Fig. 5, . 

22 needles had been inserted into the palate ‘ 

There was marked swelling of the upper lip aud 

tho left; the swelling was hard to the touch, and had dehnit 

margins; the floor of the nose was bulged upwards; “'“^7 

half of the palate was occupied by a hard nodular growth, ai a 

point corresponding to the foramen incisum 7 

Bequestrum. Both antra were completely dark to transillum 




r.E S,Vn00jif’ATi' TUEATET}' wiTli RADIUM, 


r TitmnmM int 
L W>'DIC*L JoiJUXlL 


UOTI. This responded well to rndimn (realnicnt. (Sco 

i'ie 6) lie was lasi peon on Ocloher ZyIIi, 1927, when ho avns 
in°caceilent health and (hero was no bi'kii of disease. 

Cnie JS. — .K woman, aged 5G. On Jnnnary lllh, 1925, n (umonr 
of tho left patella was exp]orcd nnd fonnd inopernhlo. A pieco 
was excised for micro'copieal exnininnlion nnd fonnd to ho 
Earcoma. It was Ihoiieht that even a high ninpnlatinn would 
ho hopeless; in any c.ase tho patient's jiealth was not Rood 
.enough to stand the operation. Itndinni treatment was thereforo 
advised. .She was first seen at the Itndinm Institute on .Tnnnnry 
2(th, 1925. A prominent pnrpio soft lieniisplierieni swellin,'; was 
present over the left patella. 'ITio skin waa rdoernted nnd lliero w.as 
a discharging wound. (See I’ig. 7.) 'fhere wn.s consider.aldo inrdlrn- 
tion of the soft tissues on the inner aspect of tho knee-joint, nnd 
commencing rarefaction of tho left internal eondvie. 'riieie were no 
glands palp.ihic at this lime, hut in Slay, 1925, a glniid waa 
removed from Scarpa's Iriangio, • and on niicroseopiral cxninina- 
,non prored to ho sarcoma. Kndiimi treatment wn.s continued. 
General imnrovemenl. in flm l/mnl 


^ Avuuiu.n iroaimriu 7vns coiitmucd. Uiscaso.- no was last examined on October 28lli: 1927 ] 

i 46 tl 0 Smour of gIo v-ne fo' “"'Od. In March, been working ns a pcneral labourer for the past twelve t 

wS in eiShcnt hcaUh '' Aeo Vie n f ^ i'®'!'"''' "'I'' Ccneral ^calth is excellent. There are no glands palp 

Oatient wrfUf.'in (1 1 1 ,^'T’lemher, 1927, tho tho axilla. Tho tumour has boeome bony hard, and rn 

patient wrote to Eay llmt her ccneral coTidi iftn rn«4initr/i at z,. •' 


n-Ti-li — tiu yocu riK. o.| in CTopiomhor, lyzY, tho 
patient wrote to say lliat her general eondilion continued to improve, 
and that she was aWo to walk half a mile with the aid of slicks. 
Case 1.9.— A wornnn, aged &1. In Oclohcr. 1921, an iiioncrahin 

anT?onfirmed®b ‘‘"'''um was din%oscd 

much trnlTi ^ microscopical section. In Decemlier. 1921, ns 

sife of' Gm^ncc^'ri'm Xliaso'w ^°n^,ot^^^ 

in tho‘reemn''o?''f’ha°bfi^' .•’“'"“''-.v Znd, 1925, a growth 
explored at St was 

Microscopical section ^hnwr^Tfi'^ i •'<’ inoperahle. 

sarcoma. She was first lres?r/"i ® ® spindlcHielled 

30th, 1925, when she I"'i>'t'dc on March 

raeasaring 12 cm in disSeiA ""'oolh, fixed rotmded mass 
complete disappearance M the j'l? fo'lo^rd by nlmo.st 

m good health for about a vAr s?! '"’.?'''* J”*'''"* remained 

the upper baud in snito ' T” *1° prowth started to g.iin 
August, 1927. ®‘ <rc'>‘“>cnt. Tho patient, dieif in 

celled sarcoma, ^pherohlaf in iP'e ^ 

was removed from the riel ^ in diameter, 

place, and on Mav ffilirSwc"”'''”®- *'"->>mnlo. Recurrence look 
at Guy’s Hospital." .She 'V®' removed for section 

Juno 17tli, and five weeks ^ Radium Institute on 
«ac to such an extent ihst n ^ '® fumour Iind diminished in 
Excision was performed a) pY. ''V®'’ considered operable, 

was readmitted to the Rsdle ^r* Hospital on .Inly 29lh, and slio 
prophylactic treatment ®n August 12th, 1925, for 

waj last examined on OctowVS^ 1927®*^" of di'=onse when sbe 

glands warrenlSved from Gib, 1925, a mass of 

s>peedi!y took place. On Tni^ neck. Recurrence 

and found to be inoporablf* ma’ss was explored, 

growth to be lymphosarprkJr’^^TT^^J*^^^ examination showed the 
Institute on July 15^ loS^* attended (Im Radium 

intervals.^ Radium ii-catmmi? ’ treatment was continued at 

niei^ until the disease was bv a pcncral improvc- 

on October 27 th, 1927 cured, Kc was last examined 

and DO sign of disease conifi i found to be in perfect Iicaitb, 

Case 2? —A detected, 

uuic zj. — A man, ased t ■ 

fnlu ^rc^n ilf ^^24, Syme's amputation 

llowed by secondary proiri) foot. A year later this was 

i P‘ recurrence m 1 popliteal fossa and in the 

. at the Radium Tn region was excised. 'Wlien 

S A "“"'her of gland?nIi"^m'‘S ®n August 24tl., 1925, there 
niTDri^^ ^a'the ponf't^ ^ groin, but there was no 

Alf fossa were irraiiaF groin and the 

quantities of radium. 

• I9th the patient remained quite 

i ^ groin, and ’on ^ solitary hard gland appeared 

sarcomatous. "Microscopical examination proveS to be 


/ BAwiu, and ftn T^: *»■ uuuvary nara gianu appearea 

sarcomatous. ®« “"croscopical examination proveS to be 

■ Case A mnn 

To'tteoL®’®"'’® '^®®’remm-ert’' .9'? J”’? 27th, 1925, a mass of 
to be”a^"’’ ’^hen eiamln.u * Prince of IVales’s Hospital, 

at tho 'ij9?’P^®*®‘’®®nia of under the microscope was foumi 
reVee a?"?!,"” I®Hit“te o„*'£ ™®''-®®'l®a tyne. When first seen 
appeared “Peration he had a recur- 

"April ITOR®'^'" radium Irratm^^r enlarged cervical glands dis- 
Patieiil m j ^^^arvenco took*!!?i®"*'’ *’® remained well until 

died on Januarr Itf J?!?,® ® months later, and tha 
Case 25. \ ^ 

Radium Institute on Octohn ^?h ,®'® patient first attended the 
ethmoida” rSn 192^. She had a sarcoma of 

beneath In AnHI disappeared entirely under 

a reenr,. "o’"* eje aSd ®'’® eomplained of pressure 

reeim .mvolving’ was found to have 

done ®f t^o' sunoiP**^ maxillary sums and ethmoidal 

operat;n^“* ®“f®rtunatelv*°fn^ ^ "a’GRa was advised; this was 
peration. ®reiy the patient died shortly after tho 

Case SG.’—a XT 

‘a?iMnl'’9i°Z®''®^’^'*atthe'Nor1^^‘ii.®" November 3rd, 1925, an 
parable spindle-celled sar/^® ^ Norwich Hospital revealed 
“ ®®r®oma growing from the right orbital 


r"? ^®'’'>'m Imstitutc on December 

wen, and pnejl tk® \.pnorhand in%^p U M 

patient died on August 291 li, 1926. u raiment,, a no 

i“ Novamber lOth, 1925, the rem'on 
naDi ind '™® explored at tlio Royal United HospTt.ul, 

Rath, and an inoperable osteosarcoma of the lower end of the 
Amo"( discovered. This was proved by microscopical section. 
Amput-aiion w.is advised but refused. He first attended the Radium 

flifilMl-if M926; s- rays showed a pathological 

fracluro of the lower third of the radius with dislocation of the 
wrist-joint. There was much nam, and the patient was unablo 
Ip use Ills arm in any way. The circumference of the wrist at 
tho site of the tumour was 95 in. There were no glands palpable 
m the axilla. Amputation was again advised, but operation was 
refused. Radium appears to have arrested the progress of the 
disease.- Ho was last examined on October 28th, 1927. He has 
^cn working ns a pcneral labourer for the past twelve months. 
His general health is excellent. There are no glands palpable in 
llio axilla. The tumour has boeome bony hard, ami measures 
8i in. in circumference. 

Case i?5.— A man, ^cd 45, On April 15th, 1926, the patient had 
1 ftn operation at llio Central London Throat Hospital for a sarcoma 
I of tlio^ left antrum of Highmore. On September 16th, 1926, an 
I operation for recurrence^ was performed at tho same hospital. 
Before attending the Radium Institute he was treated with ladium 
in May and October, 1926. Recurrence speedily look place, and 
when admitted to tlie Radium Institute on November 16th, 19^, 
tho growth filled tlie loft nasal cavity. The whole of the left side 
of iiio check was swollen, and the alveolar margin of the jaw 
was thickened by the growth. The case responded well to treat- 
ment. Ho was last seen on November 3rd, 1^7. His general 
hcaUh was excellent. Radiation appears to be checking the 
progress of the disease, as there arc no definite signs of recurrence 
at present. 

Case SO. — A boy, a^cd 12. This patient was first seen at the 
Radium Institute on September 27th, 1926. He had a sarcoma of 
llic nasal septum, which perforated the hard palate and extended 
into the surrounding tissues. Although he improved to a remark- 
able degree at first, and remained fairly well for about six mouths, 
tho disease started to gain the upper hand, and when seen on 
September 5th, 1927, he was much worse, and it was thought wise 
to discontinue radium treatment owing to the extensive iunllration 
of the growth into tho bony structures. 

CQsSc S0 > — A woman, aged 20. A growth was removed from this 
patient’s left nostril in July, 1926, at the Bolingbroke Hospital. 
Recurrence speedily took place, and in September, 1926, a similar 
operation was again performed. She attended the Radium Institute 
on March 31st, 1927. She then had a firm, well defined mass, 

5 cm. in diameter, continuous with the anterior surface of Iho 
right upper jaw. Growth was also \isible in the right nostril, and 
in the iloor of tho nose. Microscopical section showed the tumour 
to bo a round'ccllcd sarcoma. The growth responded r^idly to 
radium treatment. She was last seen on October 28Lh, 1927. Sho 
was tlicn iu excellent health, and there were no signs or symptoms 
of disease. 

Restjlts. 

The results of radium treatment can only be judged by 
the number of years the patient lives after the first treat- 
ment. This gives some idea of the prolongation of lifo 
to be expected. 

Summary of Cases; showing Period of Survival after First 
Treatment. 






I4,v5 Jan. 28, 1928] metabolism' AND''ACIl)ITY'-6l'’:E'(SiTAL TISStri'^'^AND FLUJDDB._ ' I 

, , : : ~ ~ ~ ~ I Mkwcal JoTT'T*^"’ 


THE METABOLISM AND ACIDITY OF THE 
FOETAL TISSUES AND FLUIDS/'^ 

DY 

AV. BLAIR BICLL, B.S., jM.D.Loxi).. Mon. F.A.C.S., 

rnOYKSSOR of obstetrics and GYNAECOLOnV, UNIVERSITY OfLIVEHrOOL; 
OBSTETRICAL AND GYNAECOLOGICAL .SURGEON, ROYAL INFIRMARY, 

LiVEUrooL; honorary fellow ajierican gy'naeco- 
LOGICAL society J 

L. CUNNINGHAM, M.B.C.vmii., M.R.C.P.Lond., 

HONORARY assistant rllYSICIAN, DAVID LEWIS NORTHERN HOSFITAL, 
LIVERPOOL ; 

'' AND 

M. JOAVETT, Pii.D., H. AIILLET, Pii.I)., and 
J. BROOKS, Pii.D., 

ASSISTANT CHEMISTS TO THE LIVERPOOL MEDICAl'" RESEARCH ORGANIZATION. 


In the conise of our studies on tho nature of nialignaut 
nco|)lasia wo liavo ohtainod and have puhlishcd ‘"h “ 
ovidoiico iu support of our original liypothosis, and in 
particular of that iiart of it whicli assumed that the 
chorionic epithelium of tho ]>Iacenta is a malignant tissue. 

In this paper we present further observations along the 
same lines, Avlncii, naoveovov, avc of consiAevalAc oIislctvieiA 
interest, both from physiological and pathological points 
of view. 

It will he useful first briefly to consider current vicw.s 
concerning the carbohydrate supply of the foetus. 


Vurreni Vicics 0 / the CaiJjohijihafc iS'i'p/Ji/ of the 
Foetua. 

A large number of obscrvcr.s have investigated what is 
called the glycogenic function of tho placenta since Claude 
Bernard’ in 1859 first demonstrated glycogen in ihc 
pregnant uterus of tho rabbit ; and it appears that con- 
siderable confusion has been caused by the inclusion of tho 
maternal decidua hasalis in the term " ]ilaceuta.” The 
placenta should be regarded as an entirely foetal structure, 
and the maternal decidua as auxiliaiy only to the functions 
of tho placenta pro]ier. This is further emphasized by the 
observations of Driessen,'’ who showed that glycogen is 
stored in tho premenstrual endometrium (iu which a 
decidual reaction occurs), as iu tho decidua of pregnancy. 

Chipman,‘“ and Lochhead and Cramer,'’ a little later, 
showed conclusively that glycogen is found only in tho 
maternal decidua and never in tho foetal — that is, the 
true — placenta, 

According to Chipman, whose investigations were iniero- 
ihemical in nature, the quantity of glycogen is greatest 
in the deepest part of the decidua — that is, the part 
adjacent to the uterine musculature — and the maximum 
is reached about the sixteenth day of iirogiianey (approxi- 
mately half-term) iu the rabbit. Subsequently, there is 
gradual diminution until full-term, when only a mere trace 
is to be detected. Chipman observed an iiivei-se relation- 
ship in regard to the quantity of glycogen in tho foetal 
liver, so the accumulation of glycogen in the decidua in 
the first half of gestation came to be called “ the glycogenic 
function of the ‘ placenta.’ ” Lochhead and Craiiier, em- 
ploying chemical methods, obtained results similar to those 
of Chipman, and stated that the maximum glycogen content 
in the decidua is reached on the eighteenth day of preg- 
nanej- in the labbit, when tho glycogen in this tissue 
amounts to 5.5 per cent, of tho total (? dry) weight. 
’I'hese authors believe that tho glycogen stored in tho 
decidua is absorbed by the placenta in the form of simpler 
carbohydrates produced by enzymes. 

It is" clear, then, that carbohydrates are presented to the 
chorionic epithelium of the placenta in two forms: (a) 
glucose contained in the maternal blood that fills the sinuses 
surrounding the villi; (b) glucose derived from glycogen 
contained in the decidua. 

Slemons,-' whose investigations were concerned with a 
quantitatii’e estimate of the glucose in the foetal and 
maternal circulations of the human subject, stated that the 
glucose contents of the maternal and foetal bloods at fulL 


This, i 
Rcsifaicli 

Liverpool 


m-estipaiion was iiiidprtai<Gn on behalf of tlie Liverpool Medical 
Organization : Diicctor, Professor Blair Bell, the University, 


term are iiracticHlIy the same: out of ,24 cases examined, 
III 5 they wore identical, and the mean glucose value foi 
ilie niiitcniiil blood was 0.132 per cent., and for the foetid 
0.115 jicr cent. .Slemons eoiieluded that this fmdine indi- 
cates that glucose is diffu.scd entirely from the maternal 
to the foetal circulation. AA’hilc glucose certaini}' must so 
ilififuse, it is likely that the chorion also derives somi 
glucose from the glycogen of tho decidua, although, oi 
cour.se, this uicchanisiu could not ojierate at the end ol 
jirogimncy, when the glycogen has disajipearcd from the 
decidua. 


The Carbohydrate j\IctahoUsm of iinlirjnant Neoplasms. 

To Otto AA’arhiirg” of Beilin is due the credit ol 
demonstrating fully tho importance of glucolysis in tin 
metabolism of malignant neoplasms. AA’arhurg has shown— 
and his findings have been confirmed by ourselves aiic 
otliens — that this is a process which dilTerentiates betweer 
malignant and non-malignant tissues, and, further, 
between nialignaut neoplasms, benign neoplasms, and 
normal tissues. 

AA’hen the processes which supply energy to the cell are 
considered, glucolysis is found to yield more energv-, with 
the excejition of oxidation reactions, than any other 
jirocess — lor examples, proteolysis and Vipolysis. MeyerhoU’ 
has shown that in muscle there is an equilibrium : 

c.Trbohydrate lactic acid. 

The forward reaction, glucolysis, proceeds freelj-, hut the 
reverse reaction requires a supply of energy, and, tlicrc- 
fore, proceeds only when respiration is taking place 
simultaneously. 

Tho net amount of glucolysis depends on tho amount of 
respiration taking place— one molocnle of oxygen respired 
furnishing enough energy to bring about the resynthesis 
to carbohydrate of lipproximatoly two molecules of lactic 

acid. - . , , 

If the respiration is high in comparison with the gluco- 
Ivtic power, there will be little net glucolysis. If tho 
converse obtain, then appreciable glucolysis will take place 
under aerobic, as well as under anaerobic, conditions. 

Malignant neoplasms, unlike the somatic tissues from 
which they arise, ban ghicolyso oven under aerobic condi- 
tions. Tills is duo to the glucolytic power being large in 
comparison with tho function of respiration. In normal 
tissues the respiration, wliich does not differ greatly from 
that of nialignaut tissues, is sufficient to causo tho rosyii- 
tlicsis of tho limited products of glucolysis,. which can be 
observed under anaerobic conditions. AVarhurg’s findings 
may he siinimarized thus: 

(A) Glucolysis can occur to a considerable extent only in 

growing tissues. ., ,, . . , 

(B) Glucolysis occurs to a considerable extent under 
ooiokic conditions only in malignant tissue, with the 
exception of retina, erythrocytes, and leucocytes. Benign 
tumours show some aerobic glucolysis, hut in a more 
limited degree. 


The Carbohydrate Metabolism of the riaccnta. 

Tho active elements in so far as tlie function of the 
iilaceiita is concerned consist of the various parts of tlie 
‘h'orionic epithelium— Langhaiis’ layer and the. syncytium. 
It is to ho noted in the human subject that the epitheluim, 
Dsnecially the syncytium, is, relatively to the size of the 
Tviim of far greater extent in the early stages of gesta- 
tion than in tho later, when, except for a thin layer of 
ivnevtium, it tends to disappear. In the human subject, 
therefore account must be taken of tho duration of preg- 
nancy at’ the time when experimental investigations are 
'onducted. In some animals, such as the rabbit, the tropho- 
ilastic cells persist throughout the whole of pregnancy. 

The experimental methods of AA’arhurg have been “.J 

lOA-eral workers in tho study of placental and related 
issues. Negelein,“ working m AA’arhiirg’s laboratory, lias 
ixamined the “ aussere Hunt ” of tho fertilization sdf in 
he rat and later” the same investigator re-examined tlie 
netahoiism of this tissue, using rat serum as a medium 
nstcad of the horse serum earlier employed. Ihe stiuc- 
,ure described by Negolein as tlie outer layer ot tn 
ertilization sac has been identified by us from the autlioi s 
ihotomicrograph as resembling maternal mucosa, it sioiis 


METABOIiIS^.AND AGIDIT^ of rOETAI., tissues AND. FLUIDS. 


127 


.JAN. 28, 1928] 


no neiobio glucolysis. Tlio “ iiinoro H.-mt” cxamniod by 
Nc-’clcin’’ consisted, in our opinion, of tlio fused nmnion 
'arid cliorion; in tins caso ,tbo nerobio glucolysis was not 
jneasnrod. Thus Ncgoloin docs not appear to liavo Etudiod 
the invading colls of tho tropboblast. 

Murphy and Hawkins’* worked with rat placenta at 
inid-lcnn and near fulI-torra,_ using Eingov’a solution, 
containing glucose, ns the medium. They concluded that 
tho metabolism of tho placenta rcscmblos that of a frankly 
malignant tumour. In connexion with tho results of 
Jlegclcin, quoted above, it is interesting to note that tho 
wall of a pregnant uterus and tho embryonic membranes 
wero found by Murphy and Hawkins to show tho typo of 
behaviour nsnal to embryonic somatic tissues — that is, 
little or no aerobic glucolysis was observed. Locsor** has 
studied the glucolytic jiowcr of human placenta iu Ringer’s 
solution. Two experiments nro quoted — one with a young 
placenta, and tho other with tho same tissue at full-term. 

■ The results of theso experimonts nro recorded below. 

Orir own investigations wore carried out with tho typo 
of apparatus used hy Warburg, to wliom wo are much 
Indebted for demonstrating his methods to ns The ex|)ori~ 
mental details arc fully described in Warburg's papers. 

■ The method used is a inanomotric one. A slice of tho 
tissue under investigation, thin enongli to allow adequate 
diffusion of tho metabolites throughout, is shaken to and 
fro in a suitable medium, maintained at a temperaturo 
of 37.5° C., and tho gas cxchnngo is observed. Several 
slices, each in its own vessel with mnuomotcr attached, aro 
reqidred for a complete experiment. Tlio gas space in tho 
apparatus is filled with oxygen or nitrogen containing 
5 per cent. CO,. By this moans tho medium is maintained 
at a physiological pH, tlic pH being determined hy tho 
concentration of bicarbonate ions in the liquid and tho 
dissoh'ed carbon dioxido derived from tho gas mixture. 

The results so far obtained with linnian placental tissues 
are given in Table R In throe eases human aniniotio fluid 
•was used as tho medium, and in the remaining two human 
Berum. The nature of tho tissue used was chocked by 
■histological oxamination. . 

The most important value in connexion with tho quanti- 
^tive expression of tho results is the magnitude of 
VJ the corrected aerobic glucolysis which is given bv tbo 
.equation— o . & . 


N, 

r\ • 




where is the anaerobic glucolysis of tho tissue an 

•Qo. the respiration. For tho full significnneo of this rob 
”1 1’"'*'*'^**^’°** of Warburg’* should lie consulted. 

. u ces 0 state that normal and omhrvoiiic somatic tissw 
■ give zeio or negative values for TJ, benign neoplasms gii 
-■®lo. Of sma positive values, and malignant ncoplasn 
.larger positive values. “ 

ealciilatcd on this basis, tl 
value Hawkins on rat placenta give 

voun.. it, n ’ "“I -4.2 for 

placenta ir-hnfhT"’ H=+1.0 for a full-ten 

L the medium ^ Ringer’s solution was use 


— — ^“'”‘*** Place nta coiitainiiip Chorionic EpitiicKum. 


As>; ■ 

Respiration 

Q 02 . 

1 

Aerobic 
Glucolysis ' 

03 

Q 

M. 1 

Anaerobic 

Glucolysis 

Na 

‘'m. 

i 

V. 


1 ^tctliuni— Human b 

crum. 


Full-term ... 





PnU'term ... 

1.0 

1 5.3 

40.7 


■1 

0.0 

1 ' 

40.3 

Twenty-four Weeks 

filedlum— AmnioUc fluid. j 


t.k 1 

1 1 

1 


1.8 

i 

(>1.0) 


TAnLE I (coiUiiincd). — JJniiiun Placculd cuiitaitiiuff no Chorionic 
Epithelium. 

Modiiim— Amniotic fluitl. • 



Qoj. 

03 



Abo, 

Q 

ii. 

* <2 


ElgMoonwookB 

. * 1.1 

0.2 

1 5.5 

-2.7 

Twonly-four ‘\700lc9 ... 

A.O 

0.2 ' 

1 5.5 

[ -2.5 


Experiments wero also conducted with rabbit placental 
tissues at and boforo half-term, using horse serum as tho 
medium, aud similar results wero obtained; that is to say, 
placentae containing chorionic epithelium gave positive 
values of tf ; on the other hand, placentae containing no 
chorionic cpitholium, and likowiso the fused amnion aud 
chorion, gavo negative values. 

Theso observations demonstrate the ability of placenta 
containing cliorionic epithelium to split glucose into lactic 
acid under aorohio conditions; but before a quantitative 
estimate is made as to the malignant character of tho 
metabolism of tho invading tropboblast, it should be pointed 
out that in tho tissue slices used in these experiments the 
chorionio epitheiinm was mixed with foetal mesoderm, 
which shows little or no corrected aerobic glucolysis. 
Probably, approximately only one-fifth of the volume of 
tissue examined was composed of the epithelial cells of tho 
chorion. In theso circumstanoes the evidence obtained is 
in favour of tho view that the chorionic epithelium possesses 
malignant properties in regard to glucolytic behaviour. 

• The Process of Infiltration. 

Tho chorionic epithelium, like malignant neoplasms, has 
tho power of infiltrating tho differentiated tissues with 
which it is in contact; this process has been the subject 
of much speculation, and is still a matter for further 
investigation, 

Tho work of Biorich,’ and of Bierich and Eosenbohm,* 
however, concerning the mode of extension of cancer of 
tho skin, induced in mice by tar, is of considerable interest 
in this respect. These observers found that there ara 
certain characteristic changes in the collagen fibres pre- 
ceding infiltration. 

Experiments with acids and bases and mixtures of theso 
with salts wero made on the dorsal skin of mice, and 
changes in the collagen fibres were produced ; but, according 
to these authors, tho only reagent which produced exactly 
tho same change as that seen in the presence cf 
cancer was lactic acid. Alkalis produce an entirely different 
appearance. 

This work, if confirmed, is highly significant in view of 
tho lactic acid produced by malignant growths, and by tho 
trophohlast, especially in the earlier stages of pregnancy. 

The Hydrogen-ion Concentration of Foetal Tissues. 

The pH Value of the Placenta. — ^Experiments have been 
conducted to obtain information concerning the pH value 
of the placentae of rabbits. In each case the placental 
tissues wero examined by means of the glass electrode, 
employing the technique of Korridge,” after having been 
placed into liquid air immediately on excision. The pH 
measurements of the rabhit’s placenta in different stages 
of pregnancy are shown in Table II. 


Table II. 


Number of days pregnant... 

20 1 

23 1 

26 

29 

pH of placentae 

6.12 

6.59 

6 76 

6.87 

! 6.97 


It will he seen that the placenta has an acid reaction, 
and that over a period of pregnancy from tiveiity to twenty- 
nine days the pH value rises considerably, the placenta 
tending towards a neutral reaction at full-term. In tho 
case of a human placenta obtained at full-term by a 
Caesarean operation tho pH value was found to he 6.99, 
which is practically that of neutrality. One of us (H. M., 
unpublished) has demonstrated that malignant neoplasms 
nlso show a pH value on tho acid side of neutrality. 




















128 JAN.- as;;, 1028] StETABOMSM AND;ACID1TI- OF BOETAti- TISSUEa. AND FDIIIDSI 


■ [HtS'ax 


The j/II I'liliics of Foetid Souiatir Tissues. — The j-cnctioiis 
of focfal tissues of ii luunhcr of vahbits at (lifrercut stages 
of development have hcen examined, and results Imvo been 
obtained similar in extent and variation to those' recorded 
in the case of rabbits’ placentae. Tn every case tl>o pH 
value of the foetal tissues examined was- lower than the 
/jH value of the corresponding uiatcrnal ti'-sue. 

'J'lius far we have considercil tlic pH values of different 
foetal somatic tissues, and wo have .seen that in all cases 
these aro considerably lower than the maternal tissues. 
Wo have also examined the placenta. Moreover, wo have 
shown that tho placental metabolism with regard to the 
luoduction of lactic acid by aerobic glucolysis resembles 
tliat of malignant tissues which aro also acid in nature. 

"Wo now jjass on to tho consideration of the foetal blood 
as compared with tho maternal. Tho pH values of the 
bloods from umbilical veins and arteries and from the 
maternal arteries and veins at full-term have been examined, 
together with their sugar and lactic acid contents. The 
oxygen content and alkali reserve have also been estimated. 
It is to be noted that somatic tissues, whether maternal or 
foetal, exhibit a lower pH value than tho blood supplying 
the tissues concerned. The amniotic fluid, too, has been 
studied. 

The Glucose Content of the Foetal litood and 
Amniotic Fluid. 

It occurred to us that considerable light might bo thrown 
on tho nature of the carbohydrate metabolism of tho foetal 
tissues if tho glucose content of tho blood entering and 
leaving tho foetus were estimated at the same time as the 
corresponding values of maternal arterial and venous blood. 

The earliest work on tho simultaneous determination of 
glucose values in arterial and venous blood in tho adult 
a])pcnrs to have been done by Clamlc Bernard in 1877.” 
Since then many workers, including one of us,"’ have con- 
firmed his findings. W’c have alreadj- drawn attention to 
the investigations of Slcmons,” who found a slightly lower 
value in the foetal than in the maternal circulation. 
Unfortunately it was impossible to obtain s»ifRcient blood 
from tho various sources to i)crform complete chemical 
analyses in any single case, but wo have had enough 
material to calculate a moan vahio for tho glucose content 
of arterial and venous bloods in tho maternal and foetal 
circulations, respectively, from a series of cases; tho results 
are recorded in Table 111. In all cases the glucose was 
estimated at once by Folin and Wu’s method. 


Table 111.— Glucose Values. 


Number of 
Case. 

^Taternal 

Arterj’. 

Maternal 
Vein. 1 

Umbilical 
Vein. 1 

Umbilical 

jirten'. 

11 

132 

217 

72 

66 

12' 

95 

84 

71 

60 

14 

127 

127 

109 

93 

*16 

88 

89 

75 

48 

21 

100 

97 

89 

81 

23 

110 

105 

81 

70 

Mean values .. 

112.6 

106.0 

C4.4 

1 1 

75.2 


" Caesarean section. This case is excluded from the mean. 


It will be seen from these results that tho arterial values 
— the umbilical vein functioning as an artery — in each case 
arc richer in glucose than the corresponding venous values, 
that the difference in artciial and venous values is greater 
and more constant in tho foetal circulation than in the 
maternal circulation, and that the maternal blood contains 
considerably more glucose than the foetal blood. 

It is interesting to note that in tho detennination of 
lactic acid tho opiwsite state of affairs is found ; a low 
glucose value invariablj" accompanies a high lactic acid 
value, and conversely a high glucose value accompanies a 
low lactic acid value. This may bo seen at a glance in 
Table IX. The assumption is that lactic acid is formed at 
the exjjouse of glucose. The sugar content of a series of 
specimens of amniotic fluid from the parturient woman gave 
a mean value of 18 mg. per 100 c.cm. 


The Lactic Aciil Content of Foetal and' Maternal Blood. 

TIio lactic acid content of blood obtained from tho 
umbilical vein and artery in cases of normal labour was 
determined ; and, owing to tho difficulty of obtaining blood 
from the titcrino vessels, except in cases of Caesarean 
section, blood was also collected from the v-ein and aitory 
in tho arm of tho motlior at tlio time of delivery. A modi- 
fication of Clausen’s” thethod, as used by ITarhurg (private 
coramunk-atioii), wn^ employed. TIio method gave a yield 
of 93 per cent, lactic acid when standardized against pure 
zinc lactate. Tho results obtained aro given in Table IV.. 


Table IV . — Lactic Acid in mg. per 100 grams of Blood. 


Number of 
Case. 

jratornol 

Art^iy. 

Maternal 

Vein. 

Umbilical 

Vein. 

Umbilical 

Arterj*. 

1 

— 

42 

74 

87 

2 i 

25 

30 

47.5 

62 

3 

34.5 

— 

35 

42 

1 

4 

33 ' 

42 

65 

75 

5 1 

29.5 

25 

37.5 

63.5 

6 

24 

27 

52 

48 

7 

35 

45 

54 

101 

8 

22 

24.5 

34 

33 

9 

15.S 

25 

40 

41 

10 

25 

' 49 

I 43.5 

65 

11 

32 

1 42 

65 

63 

12 

48.5 

49 

75.5 

97.5 

13 

56 

54 

64 

77 

14 

42 

45.5 

73 

100 

15 

- 

35 

42 

61 

Menu ... 

1 32.5 

33 

54' 

63 


It will ho seen that tho lactic acid concentration in .the 
foetal circulation is considerably higher -than that in the 
nmtcrnal circulation. Fni-ther, tho concentration of lactio 
acid in the blood leaving tho foetus (tho umbilical artery) 
is greater, except in throe cases (6, 9, and 11, where the 
dilforences lie within the limits of experimental error), than 
that entering. It must, liowevor, he remembered that tho 
umbilical arterial blood is venous in function and composi- 
tion and tlint in the general maternal circulation the 
Yono’us blood contains more lactic acid than tho corre- 
siionding arterial blood. 

The i-osults obtained from cases in which Caesarean 
section was performed (Table V) suffice to show that the 
iiigh l.actic acid content in the foetal circulation is not chw 
to special cii-cumstances attending delivciy. Tho pH values 
of the. Woods are also given in Table V. 

Table y.— Lactic Acid in mg. per 100 grams of Blood. 


Cases of Caesarean Section. 


No. of 
Case. 


Maternal 

Arterj*. 

Maternal 

Vein. 

Umbilical 

Vein. 

Umbilical 

Artery. 

Ovarian 

Vein. 

16 

17 

Xtactic acid... 

pH ... .r 

Ijactic acid .. 
pH 

28 

7.44 

28.5 

7.34 

35 

7.34 

29 

7.30 

42 

7.07 

71 

7.12 

50 

7.03 

'36 

7.19 ■ 

34 

7.30 


In connexion with the lactic acid values given above for 
himiaii cases, it is interesting to note that Loesei-,’ em- 
ploying the method of Mendel and Goldseheider,” in two 
cases found the lactic acid content of tho unihilical vein 
to be’ higlier than that of tho mother’s arm vein, and th.at 
of the umbilical artery to he slightly higher tliaii that of 
the vein. All the determinations by Loeser show a lower 
level of lactic acid content than ours. 

Bokeliuann,’ nsin'g Clausen’s method, finds that tiia 
lactic acid content of the blood from the mother’s cubital 
vein imniodiately before and after parturition aveiages 































:8, 1928] 


METABOIiISM AND ACIDITY; OP POETAD TISS0E3 AND PLUIDS. [srrD^jSJSu, 


129 


A5 niR per 100 c.cm. Tho varintions are aimilar to tlioso 
observed by us, altbougb tho values oro for tho most part 
higher than ours. 

jVcasurcmcnlj of the pH Vahies of VmliUcal and 
Maternal Blood. 

bicasuremciits have been mado of tho pH values by 
moans of tho glass olcclrodo. In .order to prevent loss of 
carbon dioxide oadi samplo of blood was kept under liquid 
paraffin. Tho pH values for a number of eases after 
normal labour aro included in Tablo VL 

Tablh YI.— pH of Umhilical and Maltnial Blood at /S’C. 


The Alkali Beserve and the Oxygen Content of 
Foetal Blood, 

Tho hydrogen-ion concentration of a fluid such as the 
.blood, which contains only weak acids and their salts, has 

been shown to bo equal to - _ v K where K is a 

- ^ (NaHCO,) ' tA. 13 a 

constant, and the brackets denote concentrations. Tho 

significanco of this equation is more apparent if it bo 

r 1, T- (NaHCO,) 

written as follows; In = (H) x -T tt v - • If fl'ete is an 

increaso in tho hydrogen ions, which we have shown to bo' 
tho case in foetal blood, there must bo a detreaso in the 


Case No. 

j)ll Yaluos, 

Maternal. 

■Ujnbllical. 


Artorr. 

Vein. 

Vein. 

' Artery, 

G 

7.33 ' 

7.33 

7.17 

i (6,57) 

7 ' 

7.45 

7.'13 

7,19 


M 

7.31 

7.27 

7.14 

7.02 

8 

7.28 

7.28 

7.15 

7.05 

20 

7.25 

7.23 

7.13 

7.00 

15 

- 

7.23 

7.10 

- 

15 

- 

- 

7.1'1 

. 701 

Mean ... 

7.32 

7.31 

7.15 

7.02 


It will bo seen that whilst thero is but a slight diffor- 
euce m the pH values of the blood from tho inatcrnal 
vein and artery — tho vein having a slightly lower pH value 
—theie IS an apprcciahlo difference between these and that 
of the blood from tho umbilical vein and arterv, both of 
wnioh are more acid in this respect than tho blood in tbs 
maternal circulation. 

The lower pH values obsoivcd in the umhilical blood, as 
Mmpared with the maternal blood, ngreo qualitatively with 
estimations; fiirthonnoro, tho 7.H of the 
iimiiiilvol GpprcciaU.v lower tlian that of tho 

laetin n,.; 1''***''*'*°^ “S'ces with tho fact that tho 

is °f the blood from tho umhilical nrteiy 

usually higher than that from tho vein. 


The lactic Acid Content and pH T'ofuc of Amniotic 
Fluid. 


readiion^of 'tbl^ the current teaching in regard to the 
be quoted. He sUw'o^a"'^’ AVilliams=> may 

amiflotic fluid is clear f-''' 

' A fo,v in reaction . . . (italics 

a ^es similar to those described above 


ours). 


have been carried out Lnu described above 

The results oivon u 1^ full-term bumnn amniotic fluid, 
in reS\o® th“,^H findings of Mendelecff- 
acid in reaction! ^ ^ ^ uudoubtedfy 


fraction ■ ■ ■ * sinco tbo valuo of K does not alter. This 

X-lnC<Uj 

can bo effected in two wavs, either by decreasing tho 
amount of NaHCO,, or bv increasing the amount of 
H,CO,. 

Tlio amount of NaHCO, wliicli is prc.sent in the blood 
is termed tbo “ alkali reserve,’'' and it is calculated as 
tho amount' of CO, which can be taken up by Iilood at a 
pressure of dO mm. of CO, — that is, the tension of CO, 
normally existent in tho alveolar air. 

AVo have succeeded in determining tho alkali reserve 
of tho blood in both tho umbilical artery and vein by 
Van Slyko’s method. Onr object has been to determine 
whothor the increase in the hydrogen ions which we have 
ohsorvod is duo to alterations in the numerator or tho 
denominator of tho fraction in question. It might con- 
ceivably bo duo to either, and, if thero were an increase 
in H,CO, only, wo should expect to find a normal or 
relatively high alkali reserve, in response to an attempt by 
nature to increase tho NaHCO, of the blood with high 
tensions of CO,. 

As a matter of fact, wo have found a low alkali reserve 
in tho foetal blood os compared with the maternal 
(Table VIII). This wo consider to he due to neutralization 
of NaHCO, by excess of non-volatile acids, and we know 
that thoro is a higher level of lactic acid in the foetal 
blood (Table IV). AVo therefore conclude that the depletion 
of tlio alkali reserve observed is in whole or in part 
dopondeut on tho presenco of excess of lactic acid. 

It will be noticed that the alkali reserve of the umbilical 
artery is higher than that of tho vein. This is just the 
reverse of tho values found in the maternal circulation, but 
wo must remember that the umbilical vein is really arterial 
in function, and the umbilical artery venous. 

The oxygen contents of foetal bloods have also been 
ostimated by A’^nn Slyke’s method, and they are found to 
approximate corresponding values in the maternal circula- 
tion, ill those cases that have breathed. Here again wa 
must bear in mind the fact that the umbilical vein is 
arterial in function. It will ha noted that although the 
oxygon content of the foetal circulation is much less than 
that of the maternal circulation in the cases in which the 
foetus did not breathe, the difference between the values 
obtained for arterial and venous blood is the same. 


Table Vll—n,. r ,• . 

octic Acid Content and pH Value of 

donnotie Blnid, 


Umbi'lcal 

Vein. 



Umbilical 

Artery. 


64 

7.M 


plete relation there does not seem to be a 

acid contend value of amniotic fluid 

6pcolmeiis of aiDn^nt^r'^o content of a serii 

gave a mean Taluo of parturient wc 

® w 18 mg. per 100 c.cm. 


Table yill.—Alkali Beserve and Oxygen Content of Foetal Blood. 
(Mean Values,) 



Oxygen Content, 
YOls. per cent. ^ 

CO 2 Combining Power, 
Yols. per cent. 

Maternal artery (radial) ... 

18.87 

40.45 

Maternal vein (median 
cephalic) 

15.14 

43.45 

1 

1 

i A. 

B. 

A. 

B. 

Umbilical veiu ... . ! 

18.78 

9.02 

36.9 

37.7 

Umbilical artsry ' 

17.6 

5.85 

37.7 

40.0 


A = Those that have breathed. Those that have not breathed, 
including two cases of Caesarean section in which the blood was obtained, 
before tbe delivery of tho child. 


Table IX summarizes the related findings in the fore- 
going iuvestigations. The connexion of the production of 






























130 .Tan. 2S, 1928] METABOLISM AND ACIDITY OF, FOETAL TISSUES ANd' FLUIDS. 


lactic acid with tlic diiiiiinition of Migar, llio oxygon contont 
and allcali rcsorvo, togothoi’ witli the ydl values, ai'o all of 
linporlanco in drawing final conclusions concerning the 
mechanisms involved. 


TAiil.r, IX. — Summarhiiiy Table of .III Hxiieriiiitnls.* 
irninun caso k— mean valnCR. 



GInco<<o 
mff. rcr 1 
cent. 

TAncllc 

Acid, 

iiiK.Bor 

cent. 

Oxj-Rcn, 
voIb. per 
cent. 

Alkali 
RcEcrx-o, 1 

i-n. 

Maternal artery ... 

112.6 

32.5 

18.87 

40.45 

7.32 

Maternal vein 

106.0 

38.0 

15.44 

43.45 

7.31 




D 

B. 

' A. i 

n. 


Umbilical vein ... 

m.A 

51.0 

’ 18.78 

9.02 

36.9 

37.V 

7.15 

Umbilical artery ... 

75.2 

68.0 

: 17.6 

5 85 

37.7 

40.0 

7.02 


* In all tlio eases pumnmrizctl in tliis talilo iiaitnrition was normal. 



oj IteauJfs. 

Tho&o investigations, desigiictl primarily with tlio idea of 
examining as far as possible the fnnetion of tho placenta 
ii! regard to tho glucose metabolism and tho production of 
lactic acid in aerobic conditions, which has been shown to 
he a special function of malignant neoplasms, have yielded 

intci-csting results. ... , 

First, tho placental tissues have been oxamined in regard 
to aerobic glucolysis in vitro, and the chorionic epithelium 
alone has been found to have an action similar to that 
observed in tho caso of malignant ncoiilasms. 

Secondly, tho pH values obtained in regard to tho 
placenta agree very closely with those obtained by ono of 
us for malignant tissues (unpublished), and, moreover, it 
has been demonstrated that the younger the placenta the 
lower the pH value. 

Thirdly, the blood concerned in the foetal circulation at 
full-terra lias been studied. It is much more diflicult To 
draw final conclusions from observations mado in this 
connexion, for the actual excretion of lactic acid into tho 
maternal circulation cannot be deduced. 

There arc for decision two main issues: tho extent to 
which tho foetal metabolism is responsible for the lactic 
acid in the blood of the umbilical vessels, and the part, if 
any, plaved by metabolism of tho chorionic cpitheliuni in 
tills respect. 

IVitli regard to the first, the view may be held that the 
clion'oiiic cpitheliuni at full-term acts merely as a semi- 
pernieablo membrane (as is suggested, for instaiue, by 
Lochhead),*® and at this period has neither selective 
activities like the renal epithelium, which is capable of coii- 
contrating urea, nor anabolic functions like tho manimary 
epitbelium, which after birth carries on the metabolic 
functions probably possessed by the placenta earlier in the 
gestation period. If, then, it be possible to exclude such 
active processes in regard to the syncytium of tho full-temi 
placenta, we may draw the concliision that tho lactic acid 
content "of the umbilical vessels is then mainly of foetal 
origin. 

The argument to be adduced m such cu-cumstances is as 

The differences between the blood of the umbilical vein 
and artery obtained at dcliveiv allow us to state that from 
each 100 c.cm. of blood passing through tho foetus, the 
foetus on the average abstracts 3.2 c.ciii. of oxygen and 
9 2 m". of sugar; 14 mg. of lactic acid are excreted, and 
the »H i.s lowered from 7.15 to 7.02. 

Diffusion across the chorion is not an instaiitaneons 
process and it must be expected, therefore, that tho level 
in the umbilical circulation of a substance which is being 
actively removed by the foetus should bo lower than its 
level in the niateriial circulation. This is actually found to 
bo the case for oxygen and sugar, while for lactic .acid, which 
is being excreted by the foetus, tho converse holds good. 

regards the 'pH level, this is lowered on .pas.sage 
tbroiigli the foetus, probably mainly owing to the lactic 


acid prixlnction, although tho carbon dioxide rc.sultiiig 
from rc.spiration will ilonbtic.ss contribute to tlm lowering 
The bicarbonate coiieentration (alkali re.serve) is probably 
•slightly lower in the foetal circulation than in the maternal, 
while the y/II is considerably lower; thus the carbon dioxide 
is higher in the foetal circulation, and wo must, tboicfore, 
suppose that carbon dioxido is actively, excreted to the 
iiiatornal cii'culation. 

Tho source of tho lactic acid produced by the foetus at 
full-term i.s difficult to determino, since there is so little 
muscular movement and there is no evidence that at full- 
term foetal somatic epithelial tissues can glucolyse when 
well oxygenated. The chorionic epithelium can, of course, 
gliicolyso, but at full-term in tho human subjei.t this tissue 
is reduced in amount, and theroforo it may bo surmised 
that its contribution of lactic acid is negligible ronipared 
with that of the foetus. If -wo bad been con.sideriiig a 
much earlier stage of pregnancy wo should c.xpect this 
state of affair.s to bo reversed; tho tropboblast would be 
producing a relatively largo amount of lactic acid, although 
at an early .stage tho foetus it.self might show aerobic 
glucolysis in its somatic epithelial tissues. 

There are tiro further points on which eniiihasis may be 
laid before a final conclusion is considered.' First, it will 
ho obsciTcd lliat the difl'erenccs in lactic acid and oxygen 
contents between the fcctal arterial and venous blood are 
of the samo order as those which occur in the arterial and 
venous blood of the arm of tho mother at. full-term. The 
foetus is sufficiently supplied with oxygen, and there is no 
reason to suppose that its epithelial tissues glucdl 5 -se. 
Secondly, there is a period of many weeks’ duration before 
the foetal circulation is e.stabUshed, when the chorioii is 
particularly active, and in all probability shows its highest 
rate of glucolysis. 

It is, however, as already indicated, difficult to arrive 
at a ipiantitativo conclusion in tho matter of the cause of 
tho high lactic acid concentrations in tho umbilical circula- 
tion at full-term, although thcro can bo no doubt as to the 
importance of this finding. 


Sujrsi.iuY .\ND Conclusions. 

1. It has boon shown that the chorionic cpitheliuni 
behaves functionally liko a malignant neoplasm. 

(n) Tho pH value is on the acid side as compared 
with normal tissues, and tho acidity is greatest in the 
earlier periods of pregnanej'. 

(h) Tliis tissue, like cancerous neoplasms, has the 
power of aerobic glucolysis with tho production of 
lactic acid. It has been suggested by Biorich that the 
infiltrating properties of malignant disease are duo to 
tho presence of lactic acid. If this bo so, the saine 
c.xplunation probably obtains in regard to tlio invasive 
power of tbo syncytium. 

2. .A hi"b lactic acid associated with .a low glucose 
content has been found in tho foetal blood; and a reduction 
ill tho pH, together with a diminution in tbo alkali 
reserve, has been demoiistiatcd. 

3 Certain foetal somatic tissues have been examined and 
have been shown to be acid in regard to their pH value. 

*4. Tho ainniotic fluid has a low pH, and this is not 
cntirclv related to the lactic acid content. 

5 There aiipcars to be no deficiency in oxygen consump- 
tion so far as tho, foetus is concerned. 

6 The source of origin of tho lactic acid in the umbilical 

blood has been discussed. , , . , 

7 The connexion between these findings and ))athoIogic.''.i 
states of the foetus and mother (toxaemias) has not yet 
been determined. 


We ivisli to record our gratitude to Professor tV. C. M. 
Lewis in whose laboratories, and under whose directiini, most 
nf I be chemical ivork has been conducted. We are also indebted 
to Air S B. Herd, Mr. M. Datnow, and hou.se-surgeons 
to the obstetrical and gynaecological department at the Royal 
Iiitirmarv, for the collection of material, and for help m 


other ways. 

References. 

' Ri'Il W Rinir: Laitf'ft, 1925, n, 1003. 

■ 1 \V R a r IL F. IVooUtiuloD. W. R. William^. I. CiinninKliam, S. B. 

lleni; ami. J. G. Adami Lancet, 1926. 


» Bell 
• Bell 


n W' Blair - British Mehicil Jovrsal, 1926, i, C87. ^ 

1 W Blair. W. C. M. Lcui.-, W. J. Billinj:, V. Cai tor ood, 
^ivnn and L. Cuiininc'hiim : Bariisn Meihcvl .Ioi rnm., 1926, ii, 


Glvnn, and L. Ctuininghi , « • -.ocn i 

Bernard, Claude : Coiiii\ Kcnd. Acad. Sci., 1859, .\lvin, 77- 


E. E. 
919. 





















:8, 192S] 


’ -.rA 


HBllifiliulY IGTEki^S.'''' 


[ Tnr Bum^iH 

JlrtilC-U. JOVTS'At. 


131 


’"‘Bernard, Claude: f-cfuns fiir I« DIMIr r( In Gl!IC 0 [,n,Hr AniMale. 

■ ^:lrl^, 1B77. . . 

r Biprich, 11.: JAiit, It ocJi., 19-4, , 'frU plii 

•Bicricli, K.. and Rosonbolim : 

. • Bokplmanu, O. : Arrh. f. (r'l/ndl^, 1926, exj, 7^. 

■"Chipman, IV. : Hep. Bnj-. tall- Vii'a 

■■ Claubpn, S. W. : Jovni. fio. 

>=Iiricp.on, I,. F. : Arch. I. Gmnl-., 1907, Kxx , OT. 

1= KerrklCT. r. T. : Joiim. Seu lnst., lS25-26, i". 401; 

'* Lewi-, W. C. Jl. : loi/rn. C '■ 

Locld.p.id, 3., and IV. Craii 9M. 

“Lodilipad, .1.: Jliir-liall’B . Bei-oml Edition, 

London. 1922, 513. . 

Looser, A. : Zridinlii. /. f-'l/in'd-., 1926, 1, 1619. 

“ Jlendol, B., and 1 . ColdscBoider : him. tt och., 1925, iv. 1502. 

Slendeleen, P. : Cmitpl. llcvil. .lor. lUoh, 1923. l.vxxviii, 146. 291. 

. • 'y. •..> ■-..T..*-. ^eirjn Ti oroT lO'Ji .. r«r^o-.>r* ; 


Meyerhof, 0 * Vfitnjcr'f .-Irrfn'r, 1920, clxxxv, II, and 1921, rlxxxviii, 114. 
Mnrphv, J Ih, ami J. A. Ila>\kins ; Jouru. f.VJi. /’/iJ/t/o/., 1925, vlii, 115. 

SIX' — ii„r2 r« . 'r„:t mo?; Mvr. 1?o 


papers). 


245. 



ileviewed by R, K. Cannan, Cavetr Hckh'u. 1927, ii, 289. 
’*lVarbur", O. : 'Arit., 1927,_ clxxviv, 485. 

“^li'arbuf". O., aii'l T. Knbowit?. : ]iiochriii. Aeit., 1927, cl\*?:xLv, 
•‘'William*', Wlntri<lj:c : Oh>-tetrict', 1923, 173. 


UKREDITAKY ICTERUS, OR FAJIILIAL ACHOLURIC 
JAUNDICE. 

EV 

J. S. MANSOX, AI.D., D.P.H., 

IVARRIKCTOK. 


The following ix a description of a family, some memlters of 
wliich show very distinctly an icteric tinge in the skin and 
conjimctivao. The title “ hereditary ieterns ” would seem 
to he more accurate than the alternative “ familial acholuric 
jaundice,” for there w.as no splenic cnlargemeut, and the 
jaimdice does not affect either the duration or enjovment 
of life. 

Attention wn.s first directed to a girl (IV 1), aged 
10 years, about seven years ago. She was brnnght to me 
hy her mother on aceonnt of jaundice. At the time this 
was thought to he au att.ack of catarrhal jaundice. There 
had hceii some slight malai.se, hut no prominent symptoms. 
On a suhsecinent occasion three vears later she was seen 
on account of the same condition.' In May, 1927, she was 
brought again for examination on acconnt of jnnndiee and 
lor an opinion as to her fitness for entry to a training 
college. She had now grown into a well made, strongly 
uilt young woman, full of vigour and with a ze.st for 
games. The skin and conjunctivae showed a distinct icteric 
mge. llie faeces were normal and the urine was free 
"'n® Ho onlargonieut of the spleen, and 
a the other organs rrcre normal. Her mother informed 
me at uhen her daughter was halhiiig in the sea the 
pai s ol tne hodv not covered hy the hathiug dress (iieek, 
loiildors, and legs) hecarao intensely red. It may he 
onjec mod that this showed au abnormal, sensitiveness of 
tue slrin to exposure to sunlight. A diagnosis of Imemo- 
Z'lt ™ade, and a cousnltation was airangetl 

t' ' o *^1 1- H. Oliver of Alanchcstcr. He saw her on 
i"' i *'*^*1 "nth the diagnosis, and arranged to iiave 
Afun I o^amined at the clinical laboratorv of the 

Alanchester Royal Infirmary. 

also .‘'n'"''' tbe girl’s father (III 2), .aged 49, 

Olivpi-'an,” t'Bge in his skin and conjunctivae, Dr. 

tion arrange for a blood exaiHina- 

that tbo 0*l''vr decided 

but in a ll ^ condition as the daughter, 

who has u ^Hthcr h.as a sister, aged 50, 

' stones skin. She liad an operation for gall 

to whetliPR no infonnation is obtainable as 

livlne “ brother (III 4) 

.vellolness' in tlie sH„"'’% 

brothers together i„ tL } examine both 

parison. This wac \ a “ i^Bybgbt and so make a corn- 
man while the ntl ’^^‘■•king; the one was indeed a vellow 

7, e^l 'and interest oT IT “ 

was examinerl at ti aV the pale brother’s blood 

i-esnufTZ il m Royal Infirmary. The 

On makino^ furthe? ’ '^^?™inations arc given in detail. 

thefotte'of nv fi «.e familv, 

tathei of mi first patient informed me that his fatlier! 


who died in 1909, aged 64, had a yellow .skin, but that his 
mollier was pale and clear-skimied. He also remembers 
that bis father'.s mother was yellow-skinned (she died in 
1897, aged 78), and tliat his paternal grand-uncle was 
yellow-.skiuned. He died aged 81. Aly informant cannot 
remember his fatlier’s father. 

A pedigree chart based on this information and on the 
facts observed can be constructed as follows (the members 
of the family who had yellow skins are indicated hy an 
asterisk) : 


II. 


I 

1, Male.’ 


1. Female. 
I 


1 . 
2. Female. 

I 


3. ilale. 
I 


1, Alale.* 
I 


2, Female. 

^1 


3, Female.’ 


2, Male.* 
I 


) 

3, Female. 


4, Male. 


In estimating the value of the father’s (HI 2) ohsen-a 
tioiis on his grand-uncle and grandmother (1 1 and I 2) 
acc-ount of their advanced 3'ears must he taken into con- 
sideration, for they would then show some of the j ellowiug 
due to age, but this factor can he discounted in the other 
affected members in the pedigree. 

Jilood Examiiialiotis for FrartiUty of lied Corpuscie^ and Bilinibin 
Content of Serum. 


IV 1. 


Ill 2. 



Haemo- 

Solution' 

Ilaemo- 

Solution Haemo- 

Sod. Sulphate. 

Ijsis. 

Sod. Sulphate 

lysis. 

Sod. Chloride, lysis. 

2% ... 

... 107b 

2% ... 

.. 5% 

0.46% ... Beginning 

1.75% ... 

... 20% 

1.75'a3 

.. 15% 

0.4% 103% 

l.s:'3 

«. 40% 

1.5,0 ... 

- 25% 


I.4?i ... 

507o 

l.A% ... 

.. 40% 


L3?i „ 

... 70% 

1.5% 

.. 70% 


1.2% 

... 83% 

1.273 ... 

.. 90% 


1.1% ... 

... 90% 

1.17i ... 

.. ico?i 


1.0', ■„ ... 

... IC0?i 





mi. 


"* ' * * ' * *'■' of corpuscles because haemolrsis is not 

equal to .0.75%. Blood serum: 10 units 

' direct reaction. L’rine : No bile salts or 

bilinjbiu. T . . 

Ill 2 sbows increased fragility of corpuscles. Haemolysis is not usuailj* 
complete until solution is equal to 0.75%. Blood serurn : 5.7 units of 
bilirubin — van don Bcrs'b’s indirect reaction. Urine : No bile salts or 
bilirubin. 

HI 4 shows very .slisbt increase in fragility of corpuscles. Blood serum : 
1.4 units of l>ilirubiu. 

Com me nf ary. 

There will bo general agreement that we have here an 
abnormal yellowing of the skin whicli has been transmitted 
tbrougb four generations. This yellowing is due to an 
abnormal increase of bilirubin in the blood serum arising 
from the destruction of abnormally fragile red corpuscles. 
The increase is greatest in IV 1, less in III 2, and almost 
normal in III 4. 

According to van don Bergli the bilirubin content of 
normal human serum varies from 1 in 1,000,000 to 1 in 
400,000, and taking as his unit 1 in 200,000, it uoidd 
appear that the normal physiological limit varies from 
0.2 to 0.5 of a unit, with an average of 0.3. Tims IV 1 has 
thirty times, and III 2 seventeen times, the average amount 
of bilirubin without signs of ill bealtli, except the icteric 
tinge in the skin and conjunctivae. Ill 4 has five times 
the average amount, and in him the skin colour appears 
quite normal. 

In 1905 Gilberf and LcreboulleH estimated the bilirubin 
content ill the blood .serum of 60 persons (31 men and 
29 women), and came to the conclusion that there was a 
condition of simple familial cliolaemia wherein the bili- 
rubin content of the serum eras more tlian double that in 
the normal idivsiological state. Altliongli they used the 
term “ famili.al” they did not show that the condition can 
be transmitted tbroiigb the generations by genetic con- 
tinuitv. Tboj- also remai-kcd that persons so affected 
showed the characteristics of the “ hilietix temperament.” 
These ore commonly supposed to be instability, ill temper. 



132 Jan. 2S, 1918] ACTION OF COLLOIDAEi IiFAD ANp RADIATION ON TUMOtJUS 


clcprcssioN (Uio jaiiiulicod outlook), but in tlic cnsos boro 
closci-ibod tbo tompor.'xnicnt is placid, pleasant, and 
clicorfnl, in spito of tbo bigb blood content of bilirubin. 

I am greatly obliged to Dr. T. IT. Oliver of Manebestor 
for bis kindly bclp and assistance, and Drs. W. M. (Roberts, 
G. F. Langford, and G. S. Smith for tbo laboratory work. 

Unrnnjci:. 

' C. a. Sac. clc DM., Paris, 1905, p. 837. 


OBSERVATIONS ON THE COJIBINED ACTION OF 
COLLOIDAL LEAD AND RADIATION 
ON TUMOURS.* 

BY 

J. C. AIOTTRAM, AI.B.Lond., D.P.H.Cantad. 

(From ttic Research Laboratory, the Rodiura Institute, London.) 

TirERR is evidence that tbo inoculation of colloidal lead into 
the circulation gives riso to thrombosis of the blood vessels 
of tumours.* Radiation also causes interference with the 
blood supply and thrombosis apart from its direct destructive 


Simil.orly, throc-qu.artcrs of tbo letlml dose of radiation 
—that IS, fifteen minutes — never caused tbo tumour to 
disappear, though a temporary slowing of tbo rate of 
growth occurs, as seen by comparing Charts 1 and 3. 

Combining those two treatments two sets of experiments 
were carried out. In one sot the load inoculaticn was given 
fiist and tbo radiation after varying intervals of time. 
In the other set the radiation preceded the inoculation 
of lead. When tbo radiation was given first mice were 
grafted with small pieces of T/63 into both flanks. When 
ono of these had grown to 5 by 5 or 6 by 4 mni. superficial 
area it was radiated for fifteen minutes. After intervals 
of _ 2, 3, 4, and 5 daj's 0.06 c.cm. of lead per gram 
of weight (mouse) was inoculated into the tail vein. The 
tumour on the other sido seiwed as a control. 

In tbo c-xperiments when lead colloid was given first mica 
were grafted as beforo. The lead was inoculated when ono 
of tbo tumours measured 5 by 5 mm. or less, and tho 
radium applied within a few hours, or later,, when tho 
tumour had grown to 5 by 5 mm. Long intervals between 
dead and .radiation were difficult to arrange, because- it was 
not possible to know precisely how long a small nodule 



oQ 

00 

o 

0 


oOi 

oO 

oo( 


Chart 1. — Showing the normal rnte 
of growth of T/o3, measuienients 
being made three times a week, 
(As also in all subsequent charts.) 


OO 
-o( 
O' 



O' 
oc 

j0( 

OO 

oooOOOUOO 

Chart 2.— Showing the rate of growth 
in animals -which have had 0.06 c.cm. of 
lead colloid per gram of mouse inoculated 
into the tail vein at tbo time of tho first 
measurement. 




M 

mM 


OO 

00000 

OO 

OQOO 

OQOOOO 

oooooooo 

OOoooooooO 

■ CnAr.r 3. — Showing the rate of growth of 
tumours exposed to fifteen minutes’ radia- 
tion at the time of the first measurement. 


action on tnmonr cells." ■* Experiments liavo thereforo 
been carried out to seo wliether, by combining tliese two 
therapeutic measures, tumours can bo made to disappear 
by such doses that the toxic effects of lead on Die patient 
would be avoided, and likewise tho destructive action of 
radiation on normal tissues and its other liarmful effects. 

Expehimental Details. 

The mouse tumour T/63 was used. This tumour having 
once grown to a measurable size has never been observed 
to regress. Its disappearance is, therefore, certain evidence 
that it is the experimental conditions which are adversely 
affecting the tumour, and not concomitant immunity. 
The colloidal lead, containing 0.5 per cent, of lead, was 
supplied by British Colloids, Ltd. Radiation was obtained 
from a radium applicator of 110 mg. RaBr, 4H.0, having 
an area of 2 by 2 cm. and screened with 0.15 mm. of 
silver. Preliminar)’ observations showed that 0.08 c.cm. 
of load colloid pci’ gram of weiglit (mouse) was approxi- 
raatelv the lethal dose. Previous work bad sliown that 
twenty minutes in riro exposnro to a T/63 tumour 
measuring 5 by 5 mm. was just sufficient to causo it 
to disappear. It was decided to work with three-quarters 
of these doses in each case. For lead an inoculation 
of 0.06 for each gram of mouse weight never caused 
dcatli. It did, however, affect the general health of the 
animal, as shown by a dccreaso in weight beginning on the 
third or fourth day, with recoveiy on about the tenth day; 
the decrease amounted to about 10 per cent. There was 
also a slight slowing of the rate of growth of the tumour, 
as seen by comparing Charts 1 and 2. 

• A paper read at (lie llritish Institute of Radiology on January I9th. 


' would take to grow to 5 by 5 mm. after lead treatment. 
Tho' results of- all t'leso experiments are given in the. 
following table. Each -f or - represents a treated 


tumour. 

Table of Besulls. 

Radium Exposure before Lead Inoculation. 

Days’ 

Interval. 

Tumours Grew. D^ai™?nSa. 

5 

■+ + 

■1 

+ + + + + + 

3 ' 

+ + + + + 

2 

-l- + + + -l--t-l- + 

1 

+ + 


Lead Inoculation before Radium Exrosnro. 


0 

+ + + + 


1 

+ + + + 


2 

+ + -1- -I- -H -i- 


3 

+ + + + + -^--^--^ + 

— 

4 

+ + + + + 


5 

+ 


7 

+ + + 


12 

- + 



‘ The table shows that- when the radiation .precedes -the 
lead treatment up to an interval of 5 days, no disappear- 




JAN. 28 , i 928 j 


, .memoranda. 


r Thx BnmfR 
L UeDICAZ. JOCBRAt 


133 


aiu-es of tumoiirs occiirrca. 'Wlieii tlic lonil inooulutiou wa.s 
■first Riven ivitli intcvviils of 0, 1, 2, 5, 7, ami 12 days, tlicrc 
were also no disniipcarances; but ivitli mteryals ol 3 and 
4 days, 8 complete disappearhnccs of tlie treated tumours 
occurred out of 22. 



tion this action has been phoivu first to occur about 4 days 
after exposure.^ Since the best effects of the combined 
action are obtained with intervals of 3 and 4 days, it 
follows that lead must begin to act on the blood supply 
of the tumour about 7 to 8 days after inoculation, provided, 
of course, that load acts in this manner. It has also been 
suggested that radiation has greater action after lead 
treatment on account of the secondary radiation arising 
from tho load deposited in the tumour. If this is so, it 
can hardly be due to any increase in density of the tumour, 
as the amount of lead jircsent is too small to alter this 


OOOOooxx 

OOOOox’' E« 

OOOOGOoooo- 

ooOOOQDDOO 

ooooqQQ^,^ 

ooqDpXX)QO 

ooooocr^ 

OO0CX)O( 

Cn\RT 5. — x=DisappcRrancp of tumtmr. 


CnvHT A. — xs=Disappcarancc of tumour 


The growth of these 22 tumours is shown in Charts 
4 and 5. 

CoJtMENT. 

The above results shou' that the combination of these 
two therapeutic measures will cause a tumour to disapiicar, 
using doses which, by themselves, do not produce this 
effedt, but only result in temporary retardation of growth. 

It has been suggested that this elTect may bo due to both 
treatments acting upon tho lilood vessels of the tumour and 
interfering with its siqiply of blood. In the case of radia- 


appreciably. It might, however, be due to the character- 
istic secondary radiation from the lead, as this is a new 
factor with qualitative difference. 'The results support tho 
view that this combination of treatment should be given a 
trial in the case of patients suffering from cancer. The 
radium nsed was on loan from the Medical Research 
Council. 

KrFssnxcEs. 

* \Voo<l, F. C. : Journ. Ainer, 1926, 87, pp, 717-721. 

= Moltrani, J. 0. : Bitmsit JlEDidm .Tiu'rxvl, Februarv 12th, 1927. 

a Strangeways, T. S. P., ami Fell, II. B. : Proc. Roy, Soc., 1927, 102, 
pp. 9-29. 


MEDICAL, SURGICAL, OBSTETRICAL. 

A METHOD pp DEALING MHTH A SWALT.OIVED 
OBJECT. 
t^pccUtJ Plate.) 

The following case is of interest inasmuch ns it indicates 
a pi.actical method of dealing witli oj)aciue obiects that hare 
been accidGiitally swnllowedr * ^ 

^ schoolboy aged 12, was brought to me with 
oKcpf] It ®"'^howed llie key of his luckbox. He bad 

A mouth wliile unpacking the content^ of the box. 


school pal gave him a 


wnnh iLrv 1 *.., . V**/* fnciidlv .slap on the back, and down 

dUnlavpfi label, and all. The r-rav examination clearlv 

UKplayed them m the stomach (Fig. 1). . * 

that I nii^Iit here make use of the method 
stigation after an opaque meal— namely, 
. fom^d that I had full control over the 
coeded to through the abdominal wall. 1 pro- 
of the kev wav j through the pvloi-us. As the handle 

round wai a. complete turning 

the kev fhnf * careful manipulation tlie wards ot 

in tlie* pvlonis ^ ’ end— were persuaded to engage 

llic size rtf a two-shilHn'e'A-^''' ''‘"P 

lie could without anv ^id, 

Sesliou. Ti^tx “uias. .lo him this was a plea'niig sue- 

Maminatiou, some thrS f'™'’®'’ successful, for .-it the second 
the small iulcstine kIL later, the key could be seen in 

Was safelv delivered o'> was ordered, and the key 

‘ ^ day. per via? voturalat (Fig. 2), 

out of pos,sibl€ that it would have passed 

but the anxiltv’of tlm** assistance hero described, 

it is oiiitp mJpo-. , 1 ® P?’’aats was certainly curtailed, and 
obiect is of f ^ cases where the swallowed 

poisl^^liliTv of heiuR ’;';;?* ■‘‘r 

seutalion to eng.aoe^the wvl most suitable pro- 

t, oU rue prloius is of some value. 

S. GiLBEni Scott, M.R.C.S., L.R.C.P., 

Mp,lu.F,infr . ».5r.R.E.Camb., 

. of the Radiological Department, 

Q -London Hospital. 


TOTAL HEPATOPTOSIS. 

r BELIEVE the condition of total hepatoi>tosis is not a 
conmion ono, and this is iny reason for recording .such a 
case in an old woman, aged 76, whom I I'ecently attended 
in a terminal illness for congestion of the lungs. 

I bad this patient under observation for some yeare, and from 
her figure and fullness of the abdomen I suspected she might have 
an ovarian tumour. From time to time I attended her for slight 
malaise and noted that she had some oedema of both feet and 
legs, which, together with the fullness of the abdomen in an other- 
wise Sparc woman, rather suggested an abdominal tumour, but she 
persistently declined a general examination. 

In December, 1927, I was summoned to see her for a chill and a 
chest condition; a general examination disclosed a tumour- which 
appeared to occupy the whole of tho abdominal cavity, tho more 
so as the patient was in the silting posture propped up in bed. 
The tumour was smooth and even in outline and extended upwards 
to the costal margin; laterally it occupied the right fiank, and 
reached the mid-Poupart line on the left. ' In the downward direc- 
tion the tumour 'ended about two inches below the umbilicus, its 
most dependent part being an edge which conformed to the line 
of the liver, with the notch between the lobes. On palpating the 
'mass I could get my Angel's well underneath it, and quite easih* 
and clearly delineate the liver edge acx'oss the hypogaslrium 
through the thin flaccid abdominal wall. The liver could be raised 
upwards to bring the anterior margin in close apposition to' the 
*' * ' ' ■ 'bus its sharp edge and making the inferibr 

' On percussion over the mass the note ‘was 

nobile, allowing considerable range of move- 
ment, and there was no tenderness or pain on examination. The 
right Iiypochondrium had a resonant note, in place of tlie usual 
liver dullness.' 

. Besides the wandering liver, examination of this patient 
sliowed emrature of the spine, a condition which is occa- 
sionally associated with hepatoptosis, also an enlarged 
thyroid gland. The woman had borne six children, and the 
abdominal wall was lax and pendulous — another associated 
condition. 

Apparently the patient was unaware of this unu.siial 
abdominal content ; the only physical sign arising tliercfrom 
appeared to be the oedema of the feet and legs, possibly 
due to interference with the inferior vena cava. Tlie liver 
was in a position of anteversion with slight rotation to the 
right. 

' Shoningfon, Oxon. A. -Aeaa* Forty, M.R.C.S., L.R.C.P. 







•n 


134 JAN. . 78 . 1928 ] DIATHERMY IN KEIiAglON TO’ CmO0i:,ATOKT ^DISTURB ANOES. 


r Titf Urittwi. > 
LiItt)lClLJoCKVl,i» 


RUPTURED ECTOPIC GESTATION OCCURRING 
ON BOTH. SIDES. 

Tjie following case appears to bo of siifficionfc iutorcst to 
■svrtvraut recovdiiig, 

Tlio patient, a married ^vonlan, aped 31, wns admitted to the 
Hull Boynl Infirmary on December 6tJi, 1927. SJio fjavo a liistory 
of having had no children or roiscarriagos, but had been operated 
on for a ruptured ectopic gestation on tho riglit fide six ycai's ago. 
In October sho missed ono period, and seven days later started 
with a discharge of blood and inucUs by Iho vngiim, wliich never 
ceased. During this period sho had a dull acning pain in tho 
left iliac fossa. Three daj's before admission sho experienced a 
rather more acute attack of pain, hut her medical attendant, who 
saw’ her, states that she W’as not collapsed. During theso last 
threo days her doctor noticed asw’clling abovo the symphysis, which 
gradually increased in size, and which ho satisfied himself was 
not related to tho bladder. Tho patient also had some pain, and 
fiequcncy of micturition. 

\Vhen admitted tho patient showed no anaemia, but on exam- 
ination there was a rather lcnd< ’ (enso in 

character, extending up to tfio ' by tho 

vagina revealed a slight fullness tho abdo- 

minal swelling could not be differentiated from tho uterus, Tho 
cervix was soft to tho loucli. Examination was not very tender. 

A tentative diagnosis of ruptured ectopic pregnancy was mado, 
and tho patient was operated on two days after admission. On 
opening the abdomen there w’as a cavity filled W'ith old blood-clot, 
shut 'otr by adhesions caused by tho former operation on tho right 
side, and by omentum extending down over tfio bowel abovo. 
There was an ectopic gestation, tw’o and a half months old, present 
iu the left tube, but no free bleeding point ivas found. 

The interest in this case lies in tho facts that (1) a rup- 
tured gestation occurred in both tubes ; (2) there was con- 
siderablo difficulty in diagnosis, as tho bleeding was very 
slow, and it was not opsy to fix any definite tiino for tho 
rupture. 

I am indebted to ^Ir. Robert Grieve, who operated on 
the case, for his courtesy iu allowing mo to publish it. 

E. G. CoiiLiN.s, M.R., CIt.R., 

Senior House-Surgeon, Hull Royal lufirmary. 


oi Vedettes. 


DIATHERMY IN RELATION TO CIRCULATORY 
DISTURBANCES. 

A JIEETINO of the Section of EIcotro-Tiioiapoutics of the 
Povnl Society of Medicine was held ou Januaiy 20tb, 
with Sir Heney Gattvain in the chair. 

Rrofessor Sida'ey Buss opened a discussion on dia- 
thermy in relation to oircnlatoi'y disturbances, inoi'o par- 
ticularly high blood pi'essuro, from tho point of view 
of the physicist. Ho described the conditions governing 
the action of high-frequency currents, referring especially 
to .some recent observations of d’Arsonval on the way in 
which heat was generated in body fluids by such currents’ 
passage, one conclusion being that the efficiency of heating 
in the dielectric circuit was dependent upon tho voltage. 
The ionic action of a current was of two hinds, oscillatory 
and rotatory; both played thoir part in tho generation of 
heat. Professor Russ showed how infinitesimal was the 
range of these oscillations — equal to a molecular diameter. 
He emphasized the importance, in tho clinical uso of 
diathermy, of maintaining a check on tho voltage employed. 
The question of the distribution of high-frcquenc}' currents 
througliout the tissues was one upon which further investi- 
gation was needed, but one accidental experience appeared 
to prove tliat nerve tissue provided an unusually good con- 
ducting path for weak high-frequency currents. On ono 
occasion in his laboratoiy a higli-frequency current of less 
than 0,2 ampere was passed from hand to hand for less 
than thirty seconds; one of the persons concerned said that 
she felt “ pins and needles,” and next morning a large part 
of the surface of her arm was devoid of sensation. This 
effect could never have been pi'oduced with so small a 
current unless the bulk of the current had followed the 
nerve. 

Dr, T. P. CoiTON dealt with the results of diathermy 
in disturbances of the cardio-vascular system. The value ' 
of the treatment, he said, depended entirely upon the 
production of heat within the body; there was general 
agreement that no other special effect came into play. 
Lewis had lately advanced tho view that the reaction of 
dilatation of the artorioles, venules, and capillaries to 
changes of temperaturo was dual: there was a direct 


influence of hoal evidenced in a lessening of tone of tiia 
walls of the small blood vessels, and also an indirect (and 
predominating) influenco of heat in increasing the con- 
cciitrntion of vaso-dilator substances in tho tissue spaces, 
tins reactive hyporaemia, witli increased blood flow, was 
tlio moebanism of fine adjustment which governed tlio 
nutrition of the tissues. It was probable that tho deetier 
vessc s reacted m a manner similar to tliat of the cutaneous 
vessels, and, tins being tlio case, diatbormy in the treat- 
ment of disturbances of tho cardio-vascular system had 
a direct relation to the physiological facts. It followed 
from this explanation of tho mecliaiiism of re.sponso of the 
blood vessels to heat that when constrictor influences pre- 
dominated and caused alteration in the peripheral circula- 
tion, with eventual pathological changes, the release (,f 
theso vaso-dilator substances, causing the small vessels 
to dilate, brought about tho restoration of tho normal 
circulation and blood supply to the tissues. Diathermy, 
therefore, seemed to hare an appropriate part to play iu 
tho treatment of such conditions. Theoretically, also, in 
such a disturbance as was found in intermittent claudica- 
tion diatlicriny should bo a valuable remedial agent, and 
it was true that in many cases there was symptomatic 
improveiiient, but otheis, for sonio reason, were refractor}', 
and did not benefit. Another condition in which con- 
strictor influences predominated was acrocyanosis, but here 
diatlieimiy failed to relieve tho venous stasis more than 
temporarily. Tlie treatment, spread ov'or a number • of 
W'eolcs, Jiad not proved sufficient to control the constrictor 
influences, wliich miglit be of central origin. AVith regard 
to high blood pressiiro and its treatment by diathermy, 
tlio speaker thought that patients with hypertension miglit 
bo divided into two main groups — namely, those with 
symptoms directly due to tho high blood pressure, and 
those with symptoms due to other causes. Patients in the 
first category were decidedly better when tho blood pressure 
was lowered 20 mm. Hg, or thereabouts, as a result of 
diathermy. The second group — namely, that of patients 
with symptoms duo to other causes — included those with 
signs of renal insufficiency predominating, and it was not 
rational to give them treatment which had as its main object 
tho lowering of tlie blood pressure. Diathermy should not 
bo given in hypm’Iension with renal disease predominating. , 
Tho group also included patients with ' symptoms of 
myocardial exhaustion duo to auricular fibrillation. The 
blood-pressuro level could be affected in these patients by 
slowing or altering tho rate with digitalis, but no good, 
in his opinion, could como from diathermy. Diathermy, 
however, might bo a valuable therapeutic agent in patients 
with high blood piessuio and symptoms of angina. Dr. 
Cotton looked upon angina as itself a symptom of myo- 
cardial oxiiaustion, frequently associated with coronary 
changes; wlien such patients liad higli blood pressure, and 
this was reduced to a lower level or to normal, tho heart 
had probably less work to do and the circulation was more 
easily maintained. Unfortunately, many such patients did 
not do well under diatliermy, and it might be that tho 
group of patients with angina who did not improve were 
patients witli coronary disease, on account of which tho 
vessels were refractory to heat. There was, however, 
another typo of angina, sometimes called secondary, in 
which there was no structural disease, but probably a 
nutritional disturhanco of the heart function which might 
bo of toxic origin, and here diatliermy was likely to ho 
helpful after any foci of infection had been removed. 

Dr. JusTiNA AVilson gave an account of tho symptoms 
and courso of chronic constitutional hypertonia, illus- 
trating it from her experience of various cases. In 
uncomplicated high blood pressure diathermy might be 
valuable and most helpful of all in intermittent claudica- 
tion' blit to he really effectual she thought it should- be com- 
bined with careful treatment of tho lymphatics. Light 
superficial stroking of the lymphatics of the skin, com- 
bined with a thorough vibratory treatment of the deeper 
lymphatics, was a useful adjuvant. In cases of angina 
diathermy should he given only with very careful priv 
cautions, witli treatments certainly not every day, with 
small amounts of current, and with not over-long seances. 

Dr. Agnes Savill described a long-standing case of 
angina in whicb relief bad invariably been afforded by 



^^n:" 28 , igsS] 


rnf. <fAPICAti .INEEOTION OF TEETH.’ 


'f THEJDBrm* - 1.QR 

• t ilRDICJit. JOOSJTlt A w 


.ten to fiftoou minutes’ liigh-frequcncy or coiulciisor couch 
npnlicoliou. The blood luc.ssmc, which was iiigli, dropped 
hv some 5 to ,10 mm. Hg on tho diathermic npphc.ations, 
and tho inilso had an oiiliroly ditToroiit “ ftcl ” after- 
wards. She added tliat she had found diathermy with a 
higli-voltage apparatus of .singular benefit as a tonic in the 
■over-tired state fii a person with model atelj low blood 
■pressure. 

- Dr. Anoi.r Schott (Had Xanheiin) referred to two cases 
.■of arterial hypoiteiision and angina pectoris which showed 
strikingly different I'cactioiis to diathermy. In ono ease 
it did good, and in the other not only failed to benefit, 
hut ajiiicarcd to intensify tho nttaclc.s. His cxi>crience 
showed that there whs extreme individual variation in the 
Tcsponse to diathermy. 

Dr. E. P. CuMDain.iTCU mentioned some experimental 
work at his clinic at St. J?artholonicw’.s Hospital with 
apparatus providing variahle voltage and frcf|iioncy of 
•oscillation; it had been found that changes in the voltage 
and in the frequency did not appear to affect the distribu- 
tion of tho heat. He protested against the continued use 
of the term “high frequency.” High frequencies were 
only used in therapcntic.s in so far ns they produced heat 
.within the body, and therefore “ dinthormy ” was tho 
conect term by which to designate tho treatment. Ho 
■thought the dilatation of vessels producoel by di.athermy 
was of trifling moment, and that tho nio.st important factor 
■was tho accelcr.atioii of the circulation through the heated 
tissues. Possibly tho action of heat upon the hlood was to 
lower its viscosity. 

Dr. G. B. B.\TTr.x spoke as ono who had had experience 
of the Oudin resonator .since 1896, and joined issue with 
Dr. Ciimberbatch with regard to tho claim that tho whole 
of the tlierapentic effect in diathermy wa.s attribiitablo to 
heat, which accounted, no doubt, for tho m.ajor effect, and 
could easily bo measured by physicists and clinicians. But 
ho believed that other effects must follow from the oscil- 
latory action of tho current. 

Profe.ssor Russ, in his leiily, however, ajiiiearcd to agree 
with Dr. Ciimberbatch, and said that heat was undoubtedly 
geuerated by the atomic and molecular oscillations in tho 
current field. . 


APICAL IXFECnON OF TEETH. 

At the meeting of the fsoction of Odontology of the Royal 
Society of Medicine on January 23rd, with Mr. IV. Rusiitox 
in the chair, a paper was read bv Jlr. AiiTimn Bulleii 
on apical infection. 

ill . Bulleid inentioned that some time ago he wa.s preseni 
a an examination when a well known examiner asked the 
camliclate, “ M hat is tho significance of a graimloma tc 
a pa lent. He himself did not know, the candidate did 
110 ‘mu'j and ho r.ather doubted whether the exaniinci 
men, uit it struck him that this was a suitable field foi 
j’"*^'^figation, and through the good offico.s 
la paiticular examiner he was able to obtain a grant 
trom the Jledical Research Council for the work. Apical 
he classified as follows: (1) The rarefied 

(2) tho chronic absce.ss, with or 

enitliplinl ' granuloma, with or without 

epdhehal cell elements: (4) the dental cyst. The “ rarefied 

qlin^'orl Osteitis which, radiographically, 

hone Tl° ' demarcation from the snrroimding 

aran ” appeared radiographically 

the ora'iinl a^tmtis witb rather more demarcation, and 
tissue' win"'" consist almost entirclv of granulation 

uZht connective tissue: it 

no'enithelinl'^.'n contain epithelial cell elements. If 
the ffraniilom-r^* + l>»t‘:sent no stimnlus could convert 

apic.il infectiW was , -o *ype of 

onlv much P'esont, and not merely report osteitis 

logical sio-nifiMiifo be made, boc.oiise the patho- 

of osteitts differed” to these different varieties 

abscess were miicli moro'”! the chronic 

granuloma, in that tl e '’'"‘' “"'^"tal, he thought, than the 
infecting micro-ore,, 7 ’’iralence of the 

of the tissues 1 resistance on the part 

definite tissue rcsist,ncG”f''*’ other hand, iudic,,ted 

- once to infection, the virulence of which 


was lowered hy drainage down the root canals in a vast 
number of cases. After dc.seribing the technique em])Ioyod 
ill his bacteriological investigation, Mr. Bulleid said that 
in only a small proportion of tectli removed in the hope that 
osteitis present at tho .apex would reveal itself as an 
attached granuloma on extraction was this found to be the 
ca.se. Tlie largest number of granulomata were found on 
septic routes in wliicli drainage down tho canal was possible, 
and he was coming to tho conclusion that the actual forma- 
tion of . tho granuloma was largely dependent on this 
question of drainage. The important bacteriological items 
oT interest up to now revealed hy this investigation wore 
as follows: 

(1) In no single case did proteolytic organisms get througli the 
apex into tho sultslance of the granuloma, though they were 
demonslralcd in cultures from the root canals in all the septic 
roots examined. 

(2) Streptococci were present in all the cases, and were of 
all types. 

(3) In two cases //. fiixiformis was isolated in the anaerobic 
cultures. 

(4) In four cases the Lepfothrix huccalis was found in anaerobic 
culture, but never by itself alone. 

(5) In two cases aerobic cultures were sterile, but anaerobic 
cultures revealed the infecting microorganisms — in one case a 
streptococcus and B. jusijormis, in tlie other a streptococcus and 
Lipiottirix huccitlit. 

(6) In eight cases staphylococci were isolated, in addition to 
streptococci, and no other organisms were present. 

Ho had noticed that wlien streptococci and staphylococci 
were found together thero did , not appear to be much 
fibrous tissue in the granuloma. AVhen the Lcptotlnix 
huccalis was isolated in culture the granuloma was extremely 
fibrous, and be wondered whether the presence of this 
organism indicated an attempt at calcification to overcome 
the infection. Jlr. Bnlleid’.s general conclusions were that 
graiinlomata were most commonly found on dead teeth 
when thero was drainage, and ■that their presence was 
evidence of tissue resistance. Of root-filled dead teeth those 
most likely to show apical osteitis were those with root 
filling.s right to the apex, or nearly so, and those most 
likely to show no osteitis were without root fillings, or had 
only partially filled canals. If osteitis was present in 
skiagrams at the apices of dead teeth with no root canal 
fillings, or only ])nrtially filled canals, then, in a certain 
proportion of such cases, extraction would demonstrate an 
adherent granuloma. 


SERUJI TREATMENT IN ANTHRAX. 

At a pathological meeting of the Liverpool Medical Institu- 
tion on November 17tb, 1927, Mr. G. C. E. Simpsox read 
a note on the sernin treatment of anthrax. 

Mr. Simpson recalled that he had previously described 
twelve successive cases of anthrax successfully treated by 
the use of serum (British Medical Jouiin.ai., 1920, vol. ii, 
]>. 821). He advocated the intravenous route in severe 
cases, and stated tlmt in all amenable diseases serum, to 
he successful, .should he given early and in large doses. 
Only in the Oxford System of Medicine and in Osier and 
McC’rae’s Modern Medicine was an adequate dosage of 
serum advocated. Of his five further successful cases one 
was very severe, the pustule being in the neck and laryngeal 
syinjitoms prominent. After 280 c.cm. of serum had been 
administered in thirty hours the pustule was excised freely 
to relieve local congestion. In spite of a further 160 c.cm. 
in the next t.weiity-fonr liom-s (of apyrexia) the infection 
was apparently disseminated and progressed extremely 
r.apidly, but was checked by the administration of 720 c.cm. 
in a period of forty-ciglit hours; 0.6 gram of neokhai'sivan 
had also been administered, and might have pl.nyed a part. 
Mr. Simpson reiterated his belief in the early intravenous 
use of the serum without excision in this disease. 

Siilenomcdnllary Lcuhacmia in an X-rny IT or/.cr. 

Dr. Howel Ev,vns read a note on a case of splcno- 
raedullary leukaemia occurring in an T-ray worker. A man, 
now aged 46, joined the army in 1914 and served as an 
assistant in various militaiw hospitals until 1925. He was 
for the greater part of this time in charge of the T-ray 
apparatus, and performed the routine radiological examina- 
tions in these hospitals. Symptoms of suhsternal pain 
and dyspnoea began in 1924, a period of ton years after 




136 Jan. 28, 1928] 


THE MEDICAL WITiNESS. 


t TiiP. Bbith* - 
SJehICAL JOUB.'fift 


exposure first began. Tlie splenomegaly and blood changes 
wore first observed in 1925, a few weeks after ho ceased 
E-ray work. After temporary improvement by a course 
of E-ray treatment the patient improved, but again 
relapsed, and was now moribund. Dr. Evans summarised 
the literature, stating that this was tho ninth easo of 
leukaemia reported in E-ray and radium workers against 
an exactly equal number of cases of aplastic anaemia — a 
much bettor recognized condition. Of tho nino cases of 
loukaemia five were lymphatic, threo splenomcdullary, and 
in one the tj-po was not stated. Seven of tho nino occurred 
in E-ray workers and two in radium workers. Dr. Evans 
said that in tho present state of knowledge it was impos- 
sible to affirm definitely tho relation of radiations to 
leukaemia, but tho gradually increasing number of reports 
of such cases was suspicious, atul tho question was a matter 
of considerable importanco from tho radiologist’s point 
of view. 


THE MEDICAL WITNESS. 

In a p.aper on “ Tho medical iiractitioner in relation to tho 
administration of justico,” read at tho Royal Institute 
of Public Health on January 18th, Mr. Roland Dunnows, 
LL.D., said that great resentment was often caused by 
cross-examination, not so much by tho manner of counsel 
(though on occasions counsel did seem to have overstepped 
the limits of decorum), but by tho fact that a medical 
witness should bo cross-examined at all. He did not think 
there was strong ground for that feeling. It a witness 
were called by one party tho other side should have tho 
opportunity of checking tho evidence given, and in principle 
there was nothing that dilTcrentiated tho medical witness 
from any other expert. Ho did not see how it would bo 
to the advantage of the administration of justice if experts 
were to give their evidenco in tho form of a report, cither 
written or oral. A written report was never so weighty 
as evidence given by a competent witness, and cross-exam- 
ination was of advantage to tho competent and truthful 
witness. What, asked Sir. Burrows, should a doctor do 
if duty to his patient seemed to conflict with duty to tho 
court P The rule had been laid down that no medical man 
could refuse to answer a relevant question. In other words, 
the cause of justice was paramount. No ono, ho thought, 
would claim that a medical man called as a witness on 
behalf of his patient ought to confine himself to such 
matters as furthered his patient’s interests and refuse 
to answer if cross-examined on matters which might tell 
against his patient. In, for instance, a divorce suit where 
a doctor had attended one party and was subpoenaed by tho 
other, circumstances pressed with peculiar hardship on him. 
Such questions must be regarded in the light of all the 
considerations, and not merely on tho injury that a general 
rule must inflict in particular cases. He did not think 
that there was sufficient cause for amending tho present 
rule — that a medical man must not refuse to answer 
relevant questions. The medical practitioner who was a 
witness should know in outline what tho case was about, 
so as to get some idea of the way in which his evidence 
would assist tho court. Ho should consider how far his 
evidence consisted of observed facts, and how much of 
inference from those facts. Inference easily glided into 
opinion, and opinion into hypothesis. Every expert should 
confine himself, at any rate in the first instance, to facts, 
and to inferences that could certainly be based upon those 
facts, leaving the less certain inferences and his opinions 
to be given if demanded. A witness was in a strong 
position who said, “ I have observed certain facts. It 
follows from those facts that such and such a state of 
affairs exists or that such and such a conclusion must be 
drawn.” He should be prepared to justify those facts both 
positively and negatively— that is, not merely that he had 
observed them, but had established the non-existence of 
other facts which, if they existed, would have affected the 
matter. If his opportunities for observation had not been 
sufficient to enable him to draw one out of several possible 
inferences, then a frank statement on the matter would do 
him no harm — unless he was woefully negligent or unskilful 
—and he should then state his inference, not as a certainty, 
but> as an, opinion. 


Lord Justice Atkin, who presided, said there was no 
class of export whoso cvitlonco was regarded nioro syd- 
pathetically than tho medical practitioner, whether general 
practitioner or specialist. In numerous cases that came 
before tho courts justice could not bo done without tho 
evidenco of tho doctor, and tho actions in which the 
medical evidenco was relied upon seemed to bo increasing 
day by day._ In an extraordinary range of cases tho rights 
and liabilities of tho parties depended upon a true appre- 
ciation of tho medical facts. Ho had often sympathized 
with tho doctor who went into court to give evidenco in 
which ho thoroughly believed, but who had not thoroughly 
equipped himself to face tho cross-examination. Before 
going into tho box a doctor should tako account with 
himself and seo ivhother ho had observed erciything, and 
whether ho was speaking to anj-thing more than ho had 
observed. A golden rulo to observe in tho witness-box was 1 
“ If you aro not sure of a thing, say so.” The court would 
respect a witness for doing this, and tho witness would bo 
ill a firmer position. It was a good thing to say; “ It may 
be so, but I am not sure,” or, “ Th.at is not the inference 
that I draw, but it is an inference that possibly could bo 
drawn.” It was a great mistake to bo too positive. Judges 
trusted tho doctor because they believed him to be a 
witness of truth, and in ninety-nine cases out of ono 
huudred doctors deserved to be trusted. Any doctor who 
obsen'cd these rules could face with equanimity the duty 
of giving evidence. On tho question of observing medical 
confidence, continued Lord Justice Atkin, the law was that 
a doctor was not privileged to maintain his patient's con- 
fidence. There might bo difference of opinion as to whether 
that ought to be the law or not. It was necessary to 
weigh tho claims of justice on the ono side, and on tho 
other tho claims of public health. In some cases, especially 
in connexion with venereal disease, ho was of opinion that 
tho claims of public health far outweighed the claims of 
justice, and ho would be quite glad to see oven the very 
small change in tho law that was sought to be introduced 
by Dr. Graham Little’s bill. 


JAMES MACKENZIE INSTITUTE. 

Diagnosis of the “ Acute Abdomen." 

On December 20tli, 1927, at tho James Mackenzie Institute 
for Clinical Research, St. Andrews, Professor John 
Marnoch Regius Professor of Surgeiy in tho University of 
Aberdeen^ read a paper on some pitfalls in tho diagnosis 

if acuto abdoranial conditions. • i i 1 

So rapid, ho said, had been tho advance of surgical tech- 
aiuue that it had outstripped tho practitioner’s powers of 
Jiaimosis Indeed, if the successful treatment of a case 
depended more on accurate di.'^nosis than upon safe 
mrgical technique, diagnostic skill 111 abdominal disease 
would have developed furthnr than it had to-day. In recent 
rears laboratories had furnished many aids to diagnosis, 
uid it was impossible to overestimate their value; hut they 
ihould never bo made to supersede a good clinical opinion,- 
-vliich should still bo the dominant factor in deciding what 
1 patient was suffering from In acute abdominal disease 
it\va 3 indeed fortunate that the outstanding clinical 
’eaturo was often that of -peritonitis, which was iisiially 
■asv of recognition, and the early recognition of pcriton- 
ti/had been the means of saving more lives than anything 
-Ise Perforation of tho stomach and duodeiuiin illustrated 
his’ in a most striking manner, but in the symptoms of this 
:atastropho there were some fallacies In the earlier stages 
iver dullness and resonance in the flanks were often 
M csent and tho site of greatest tenderness in a number 
i them was the right iliac fossa owing to the irritation , 
■f the Kastrio contents which had been guided by the colon 
o that neighbourhood. Closely simulating perforation was 
euto pancreatitis, but there were certain points of differ- 
■nco udiich, when kept in view, should lead to an accurate 
liagnosis, at any rate in the fulminating type Even con- 
:enital hypertrophic stenosis of the pylorus might be closely 
imulated by • other congenital conditions. The lorturer 
hen discussed pitfalls in tho diagnosis of acuto conditioM 
if tho gall bladder, acuto intestinal obstruction, acuto 
T>r»OTJ/lTnt+.io •f.nTTlOTirS of ill6 COloila 



, _iU!r. iS, 193S] 


BEVrEWS. 


[ The EETTrra 
S^ciizcLX. Jocbxle 


137 


iiibil'ius. 


EECKXT AEVAN'CES IN THOIMCAE JIKMCINE. 
'.The bulk of iUo literature called forth by the rapid strides 
■made ill our knowledge of the diseases of warm climates 
has grown so great that the tropical practitioner finds 
difficultv in keeping pace witli it. An attempt has 
oocordiiigK- liecn made to meet the situation as in perhaps 
no other hVancli of medicine by the summaries published in 
tho Bulletins of the Bureau of Tropical Diseases (now the 
Bureau of Hygieoo and Tropical Diseases). For many, 
however, the volumo of these summaries is becoming almost 
overwhelming, so that tho book entitled Jfcccn/ AdroncfS 
in Tropica} Medicine' by Sir Leos-aiu) Bogeiis will he most 
■welcome. It will bo read not only by those concerned more 
immediately with tropical diseases, but by others who 
merely wish to mako themselves acquainted rvith the present 
position. In twenty-three chapters the author deals in turn 
with each disease upon whicli research has thrown fresh 
light in recent years, bo it in connexion with etiology, 
distribution, diagnosis, or treatment; at tlic end of each 
chapter a list of references to recent authors is given. 

The hook is eminently readable; the historical method 
adopted adds considerably to its interest, while at tlie same 
time, under diagnosis and treatment, it is full of important 
practical points. Tho scope of such a work must, of 
course, have limits, hut some reference to one or two other 
diseases, such as tularaemia and epidemic jaundice, might 
perhaps have added to its value as a handbook. 


THE UNITED STATES SUBGICAL HI-STORY OF THE 
B'OBLD IV.VB. 

The eleventh volume of tho history of Titc Medical Depart- 
inenf of the United .States Army in the IfoiM lEor- con- 
tams in Part Ono sections concerned respectively with 
general surgery, orthopaedic sui'gcry, and neuro-surgery, 
prepared under tho direction of ilajor-Goneral M. IV. 
In^txp, the Surgeon-General. Tho vast scale on which 
■this liistory has been planned and is being written is 
indicated by the fact that tbe 1,324 jiagos now under 
noUce form only Part One of tbe clcvciitb volume. 

Section II, which is devoted to orthopaedic surgery, 
consists of only two hundred pages, in which tho histon- 
of the foiniatioh and training of tiio Orthopaedic Division 
m related. TIio relative brevity of this .section is probably 
be explained by the inclusion in the section of general 
surgpj of the records of injuries and their results, and 
compmmg nearly all. those hone and joint injuries the 
reataent of whidi so largely occupied the surgeons of 
. ® , rthopaedic DiS-jsion, the fonnatioii of which was due 
e aisTOing action of the American Orthopaedic Asso- 
la mn at its meeting in 'Washingtou in 1916. The resolii- 
presented to the Surgeon-General 
.u ■ • ? States Army, and thq suggestions embodied 

thwem were a^tod by him; 

Euited States entered into the war orthopaedic 
TCptr surgeons were started iu Boston, 

Rnn+iiot ^ o, and Washington, and for fUe 

Sontl e n States m Oklahoma City. Mmeover, a number 

in were sent to Groat Britain to be trained 

dircrtmi," "'“•k in tlie hospitals under the 

savs- “ ft - .°kert Jones. Of this training tho hisfoiT 
nrietiml ^ graduate scliool of the most thorougii and 
r:Xrt ti L^"t’ "l training.of men in 

Army hut •efficient work not only for the British 

tranlferrcd.-- " 

It -1— .. _ ^Uiailer Croun of orflionnodio Riirtrorntc 


transferred.” A were 

from the fnitet Sfnti Sroup of orthopaedic snrgeom 

‘'^T'‘'M\nual ^of 1 r ''Stai'and did^exeXnt worS' 


as 


^5‘b'rinp. By Sir Leonnrd Jlo(;er> 


f* -V. Chitrchill Medical Service (ret.). 

123 . 6 a. nct.)_ 1328 . (Six BJ, pp. vni+ 398 ; 11 fi^ires. 

Jl?(A J°bime XU%‘'uTffeZ* plrt^n Slates Army in the World 

Ireland'' ■Wa^^''" Pr<!P“Kid under the direction o! 
ira. (Snp. roy. 8ro. op a aIJJ Govi^rnmenl Printing Office. 

■ : 237 hjurcs. 4 dollars.1 


Robert Jone.s and Hlauviee Sinclair, the types of splints 
were standardized and finally reduced to ten. Largo 
mimhers of these splints were mnnufactiirod. Bv the end 
of October, 1918, tlio United States Army authorities had 
ordered nearly half a milliou^ splints, of which nearly a 
quarter of a million had been supplied. 

In a cliapter on the foot and its relation to military 
sen-icc ibe soldier’s foot is considered. Troubles duo to 
flat-foot and bad jiosturc seem to have hecu more common 
iu tho army of the United States than in tho British 
forces, and called for <|uitc an elaborate organization for 
their relief .and fin e, interesting details are given of the 
.sjicfia! hoots and modifications of solos which were found 
useful for flat-foot and- for pcs eavus. 

The chapter on fractures caused by projectiles is well 
illmstrated and instinctive. The United States, unlike 
other combataiils. had, in considering the later stages of 
treatment, to keep in view the necessity of providing for 
adequate care of fractures, etc., on the voyage home across 
the Atlantic. Therefore orihopaedic surgciy in ombarka- 
lioii bospitaU lias a chapter to itself, in whicli late treat- 
ment is dealt with and some of the weak points in the 
treatment of fractures, between the battlefield and the 
hospital ship, arc pointed out. 

The use of autogenous hone grafts for non-union in 
atrophic long hones and in chronic suppurative osteitis 
fully justified itself, ns is abundantly shown by the excel- 
lent illustrations of Cfliaptcr X, which is worth very careful 
perusal. 

The care of amjnitation case.s anti the provision of 
prostbesos for them came under the Orthopaedic Division. 
As iu other annies, it was found that one of the chief 
causes of difiiculty was the ignorance of, or indifference 
shown by,, militaiy surgeons to the problems of prosllietic 
surgeiy. The conclusions come to on this subject by the 
American orthopaedic surgeons are much the same as those 
reached by our own. Only five cases of cincraatization of 
stumps were recorded: the results were not encouraging. 
The provisional appliances provided by the United States 
authorities apjioar, judging by the illustrations, to have 
been more elaborate than those used in Groat Britain. 
Permanent prostbeses are not described in this volume. 

Tlio name of the oStcer responsible for each chapter of 
the general, surgical, and ncuro-surgical sections of this 
volume is appended to each, hut no authors’ names are 
given in tho orthopaedic section. A list of names, without 
sjiccification of their contributions, is given in tbe preface. 

Colonel Elliott G. Brackett, M.C., of Boston, who edited 
the .section, was chief of the Division of Orthopaedic 
Surgery iu the Surgeon-General’s office during the war. 


PHYSICAL ENAAIINATION IN SUBGERY. 

There are indications, iu more than one direction, of a 
reaction against tho predominant influence of the acc-essory 
means of diagnosis which have become so numerous iu 
clinical ■work during the last few years. Demonstrations of 
Physical Siyns in Clinical Suryery-’ by H.Airii.TOS B.ailev, 
has appaieiitly beeu written, to some extent at least, under 
the influence of this reaction. The old-fashioned clinical 
instinct appears to he dying out and the taciiis eiiidifus 
is nearly extinct. The modern graduate of medicine, when 
called' to an urgent case, has I>ecn pictured as driving up 
to tlie patient’s house, followed by a pantechnicon con- 
taining a fully equipped a:-ray installation and a labora- 
tory witli a staff of assistants, without which lie would be 
unable to fonmilate a diagnosis. The accessory means of 
diagnosis are not to be despised, but tliey have undoubtedly 
diverted the attention of the student from the tiine- 
lidnoured and primarily important methods^ of inspection, 
palpation, and anscidtatiou which he will find inciis- 
pcnsable in actual practice. 3fr. Bailej^s book will sene 
to give prominence to this point of view . ^ It clescrihcs 
tho ordiiiaiy methods of physical examination in their 
numerous inodes of application in the diagnosis of the 
principal diseases and injuries of the several regions of 


Irmanetratlons of rhytieal Signs in ainieal Sergrry. Tly llainilton 
.- TA-pf-.c vaa Brislol : J, TTriplit and Son?, Ltd.; I/ondon : 
[Cfc’m MaialiaU, namilton, Kent and Co., Ltd. 1927. (Bov. 8vo, 
4- 217 ; 261 ficures. 21?. neL) 



138 JAN. 28, 1928] 


REVIEWS.' ■ 


f TMtjinmw 
uUicrcAt Jocssift 


tho body, tlio descriptions being mainly pictorial, by mc.ans 
of numerous excollont photographs of actual patients under- 
going examination. Tho figures are acconi|)nnied by brief 
verbal descriptions and observations on differential dia- 
gnosis, and give a singularly vivid impression of tho 
methods described. Tho student will find this work, which 
is tho outcome of a series of demonstrations on the elicita- 
tion of phj-sical signs, a useful reminder of tho teaching 
ho has received, or should have received, in tho hospital 
and out-patient department. 


CLINICAL PEDIATIIIC.S. 

PnoFESsoa Neff of Kansas University is responsible for 
tho eighth volume of Clinical Pediatrics,* which deals with 
diseases of tho digestive sj'stem of childhood. It is 
intended more as an aid to the general jiractitioner than 
a work of reference, and as such should fulfil its pui-pose. 
There are chapters on typhoid and paratyplioid fevers, on 
acute surgical diseases of tho intestines, and on poisoning 
both by food and other substances. Tho classifications 
adopted are, on tho whole, siinplo and clear. Thero is, 
perhaps, a tendency to bo unduly dogmatic in tho difficult 
field of treatment, particularly of tho dyspeptic disorders 
of infancy, and to minimixo the difficulties and tho uncer- 
tainties of prognosis. There is a chapter on tho liver, 
biliary tract, and pancreas, so brief that such a subject 
as recurrent partial liver atrophy is not mentioned ; perhaps 
this section is to bo fully considered in another volume. 

Tho ninth volume, which is on diseases of tho respiratorj’ 
system, has been written by Drs. PtiNKnouaEn and McAlilev 
of Emory University, Atlanta. Tho first part is devoted 
to diseases of tho noso and tliroat, and tho last to general 
therapeutics. Some subjects aro incompletely described ; 
little, for example, is said of bronchiectasis os a clinical 
entity; the treatment of empyema is not considered, but 
referred to tho surgeon. Thero aro a number of illuslr.n- 
tions, but some aro of little interest; it seems hardly 
necessary to make a picttire of tho taking of rectal 
temperature. 

The tenth volume, on nutrition and dcvolopnient, is by 
Professor Roysteb, who states that his object has been 
to visualize for tho general practitioner tlio processes of 
digestion and metabolism, together with tho phenomena of 
growth and development of all stages of childliood up to 
puberty. Tho several food elements aro oiuimoratcd, and 
tho part played by each explained. Chemical and bio- 
logical processes are described in a simple, straightforward 
way, and the problems of growth and dovelopineut aro 
succinctly set out. Pellagra is included under diseases of 
nutrition, and there is a chapter on erythroedema. Useful 
tables dealing with diet, food values, and tho chemical 
composition of food materials are given, both in tho text 
and in the appendix. Tho volumo may safely bo recom- 
mended as a clear and interesting exposition of a difficult 
subject, and should fulfil tho purpose for which it has 
been written. 

Wlietlier the general practitioner, to whom it is addressed, 
should bo advised to obtain the whole of this largo system, 
is another matter. Ho might do better with 0110 of the 
accepted textbooks on diseases of children. 


the VITAL EUNCTION OP ELECTROLYTES. 

The importance of electrolyte equilibria in the persistence 
and function of tho living cell is acknowledged by every 
student of biology. Much remarkable experimental work 
has contributed to emphasize the importance of this branch 
of physico-chemistry, but at tho same time a great deal 
of plausible argument has been built upon a too loose 
employment of the language of electrolytic dissociation in 
relation to biological problems. Tho subject is essentially 
a quantitative one, towards whose solution exact measure- 
ment rather than qualitative deduction must be applied. 


* Clinical Pediatrieg. Supervising Editor : 

M.D. vol. VIII, Diseases of the Digestive System of Childhood. By 
Frank C. Xeff. M.D. Vol. IX. Diseases of tlie Itespi^tory System in 
Infanta and Children. By William L. Funkhouser, M.D., r.A.C.P, and 
n. o. UoAlIley, B.S., M.D. Vol. X, Nutrition and Development. By 
Bawrence T. lioyster, M.D. New York and London : D. Appleton and 
Cy- 1S27- ,(Roy. Sro, Vol. VIII, p. v:r + 359, 51 figures; Vol. IX, 
+ 31B, 65 figures; Vol. X, pj-. kv + 310, 75 figures. 165. each 


Di-. Zo.vDEK attempts in his book on electrolytes in pliysio- 
patliology, and thoraiieutics’ to define tho biological 
problems witli precision and to throw light on tho practical 
utilization of tho principles defined. It should be directly 
useful to tho stndont of the.so subjects, since tho discussions 
of tho many biological problems which tho chemistry of 
electrolytes has invaded aro prefaced by adequate explana- 
tions of tho purely physico-chemical principles involved,' 
It is not possible in a brief review to indicate tho multi- 
tudo of subjects brought within tho province of theso dis- 
cussions. I’licy range from tho significance of electrolytes 
in colloidal phononiona, in coll function, in acid-baso 
regulation of blood and tlssuc.s, to tho electrical phenomena 
oxliibitod by tissues, and tho inorg.anio changes evidenced 
in many pathological conditions. Tho book is a serious 
attempt to survey tho field. 


WHAT IS CHARACTER? 

It seems to be cbaracteristic of the human being that the 
less he has to say tho greater his length in saying it. On 
this principle Dr. Roback has compiled a nioiiumental 
tome, entitled The Psychology of Character. Ho is rightly 
Anxious to define his tonns and to distinguish between 
fiersoimliS, teinperamont, and character But the reader 
docs not get Dr. Roback’s definition of character until . the 
S nace when ho is dismissed to ponder the statement 
St clfaiLtcr is “ tho psychophysical disposition to inhibit 
Inknctivo teiidciicics in keeping 

uintuo of Action ” It 13 true that Dr, Roback, in tho pre- 
vious 662 pages, sets himself to supply the student, with a 
^mSrcblnsTvo volume showing what contributions have 
I ^ to the field of character in its widest sense , 

been mado to tuo iieiu ^ compressed practically a 

vi^Jmiriibrtvf into tiio conipas's of a Lgle book. But it 
whole , conibiiiiiig his two aims ho shows a 

tendency to , character, ho attempts to criticize 

formultito a sketchily, the views of inniimorablo 

adversely,, but ff*'’ the same time, his per- 

psycliologists or p ) j.gggntntion to the student of the 
sonal vioiis mai h ^ the .field of 

■< contribuV°",^ho^ incomplete, the exposition 

character. / V .. . jio„i,tful whether the social 
too long-inndcdjsoUifR^^ rise refreshed, with a 

norkci a , ^ j, perusal of the volume. They will 

broadened outlook, ^ ®oback is contemptuous 

have learnt, at all events, urn Freudians ns 

of •»<=>;“'^‘°"”j‘®;ed‘wftb special skiinn unearthing yalii- 
oxcavators strangest hazards in explaining 

.able relics, " ’ ° ^ these relies. Those who attribute 

tho i.^teractioii of the endocriiio glands make, 

chayacter to the I statement which scarcely bears 

tLv aro invited first to establish the rela- 
examination. Hmy tocrine secretions and temperament, 

KC'SS'to „».«> V.«. 

refcrenco to charactei jjggggjgte character from ethics 

Dr. Roback time he gives the reader the 

and religion, ^ ; something good in character, and 

impression that t ^ disreputable character. 

seems to doubt P , . philosophers can be divided into 
It may be La whereby they e.xplain 

two classes: tho 0 those who, seeing some 

everything m the discursive that they drown 

darttyhf an teaii’of words. Dr. Roback belongs to tho 
latter class. — 

-nTW earlier INHABITANTS OF LONDON, 
m nei- Tu-ido of a Londoner is responsible for tho title 

F G Pabsons’s hook The Earlier Inhahitants 
of Professoi^F. G^ ^ Londoner ho centres a 

linaUnu stiidY of racial development as pearly 

Braco and Co., Inc. 1927. (Demy 8vo, pp. - v 4- p p B.C.S., F.S.A. 

_ ' The Earlier Jnliabitanis of gg, 



,.Jan. aS, i 928}» 

gt ■ ■■ ■ 


N0TJ23 .ON . BOOKS. 


r TszZ>iimss 
HZDiaii. JotnaiX- 


139 


oil Lomloii nnd its inlmbitanls; and if tlio titlii be .somo- 
wlmt misleading one would gladly be many times misled 
tlirdngb sncli a succession of interesting cliaiitevs as tlio 
antlior provides. . To arrive at bis limit of “ early,” wliicli 
is set at tbo death of Harold, Professor Parsons begins 
with the “ earliest human evidence which wc have about 
London’s site,” part of a female skull found in C'ornliill, 
rivalling, as is thought, in antiquity even tlio famous 
Piltdown skull. But the land .sank, and this scant cvidcnco 
.was followed by a lapse of time geological in its immensity; 
until re-cmergeneo occurred between 3000 and 1800 n.c., 
leaving the level of the Thames some sixty feet higher than 
it now is. A rapid resettlement, leaving a broad shallow 
marsli-liordercd river, brings us to the beginning of history- 
such history as the archaeologist reads in flints and graves 
and the anthropologist reconstructs from bones and from 
biological observation of living peoph'. Palaeolithic and 
Keolithic man, including the “ river-bed race,” “ jiilc 
dwcller.s,” the iMeditorraiiean or Long Barrow race, tho 
, Alpine and the Nordic races; tho Beaker Folk and tho 
Bronze Age jieoplo; the Celt, tho Boman, tho Saxon, and 
the Dane; the Alcn of Kent, and the Kentish Men — all 
these live again in Professor Par.sons’s scholarly review of 
tho anthropology of tho early Londoner, and their inflnonce 
, in shaping his characteristics is weighed with calm dis- 
crimination. No evidence is overlooked — history and legend, 
place names, tribal names, and surnames, old camps and 
. trackways, graves and grave furniture, survival of aucieut 
words, black li.air and hhic eyes, and, hy no means least, 

• the laboriously acquircil evidence of neenrate cranial 
moasurements ; all are taken into account and duly weighed. 

Tiie book is not written for the professed anatomist; it 
is written for the amateur and the historical investigator. 
M c think, with Profc.ssor Parsons, that tlio historian will 
be greatly helped by the anthropological knowledge here so 
clearly put forward. The amateur, the man who already 
lotos his subject and so finds life distractingly full of 
interest, will welcome this short volume with delight in 
tho discnssiuii ns to wlicro Caesar crossed tho Tliainc.s — for 
on that depends the vexed question of the antiquity of 
^ndon ^^and in the author’s high estimate of the Frankish 
' Tho grammarian, however, may n«k for a little 

miJro clarity of cxiircssiou; there are one or two I'athor had 
faults in this re.spcct— for example, on pagc.s 183 and 215. 

_ .For oiii'sclvcs, we have read the hool: with the greatest 
interest, and to anj- who .seek in intellectual pica.suro.s 
relief from the daily round, or to those u ho are horcrl with 
life, wc recommend it strongly. It will open realms of 
research of fascinating interest.' 


KOTES OK BOOKS, 

of tbc Aitnah of Mi dicnl Ilhtory' 
^ illuslratc‘d account of pygmies* dwarfs, and 
1? Warren R. Dawson, wlio 

of pygmies were the normally small races 

rlwiT-fc from the interior of Africa, w}ierea.> the 

of \-nr, achondroplasiacs. jMr. Bruno Meinecke 

to A Ti 400 ^ traces the liistory of tuberculosis from 5000 b.c, 
ditttvncoc evidence that it was one of tlie commonest 

and assical antiquity, and that its infectivity, heredity, 

nished irJf] recognized. The article is fur- 

Hamm ?.'" rt’ferences. Dr. J. G. dc Lint of The 
of ^Im’ president of the Sixth International Congress 
lit Tni? held at Leyden and Amsterdam 

ancient ‘tinm=*^i '^''^Inient of abdominal wounds . from 

" Sure vr sixteenth century, and on the 

bv a semnto Chauliac. following this up 

manuserint of Bie' representations in the IJtrecht 

“n ^f o? a 

medicine with no t scholarly essay on patristic 

interest references, Dr. Stephen DTrsay shows the 

the sendees the*rSd°erad'\^‘''r‘''' I" medical, and 

lore which othe^-f. “ compilations mucli 

. provides ilhistrateT *mve been lost. Dr. Hoy L. Aloodie 

ancient I’era Thfa”rtW mastoiditis in 

interest to fbe ancient history are of specml 

tiumerous reader s who bear the name of Sir 

''v Edited by rranyis. R. 
Tindall and Cov IS’’? /aa Inc. ^ liOndon ; RailliJrrc, 

scriptlon in Great Britain PP* 315-^24; index, illustrated. Sub< 

iiain £2 2s. ^ volume of four numbers.) 


William Osier in grateful memorj' on many accounts, including 
his services to medical history. On the cover of this instalment 
is tho portrait of Richard Burton, and Dr. F. R. Packard writes 
an editorial describing Osier’s interest in the author of The 
Anatomy of Melanclioly,” as manifested by some papers of his 
recently published in the ProceceJings of the Oxford Bihlio- 
graphical Socirtg. Richard Bright appears on the frontis- 
piece, and is tho subject of two addresses given in the spring 
of this year, the centenary of the publication of his classical 
work. Dr. Burton Chance supplies an ophthalmologist’s appre- 
ciation, and Professor H. A. Christian of Boston speaks on 
kidnej* disease as described by Bright in the light of the 
knoirledgc of a century later. In picturing what Bright was 
doing a hundred years ago in the wards and post-mortem 
room he rather pathetically says that his activities were 
probably much the same as those of a present-day hospital 
physician, ** except in so far as autopsies are concerned, for 
the making of post-mortem examinations is a privilege rarely, 
if at all, granted to the visiting plu'sicians of to-day.” TJ>e 
editor writes on Emile Littre (1800-81), of dictionary fame, who 
was a lios 2 )Ual intern and extern for ten years, wrote a 
monograph on cholera, and brought out an edition of Hippo- 
crate.s, hni never passed any examination or obtained' any 
medical degree. 

Dr. H. A. Hare’s Text-Booh of Praclicnl Thcrap/^utir^^ 
one of the oldest of such book.s in America, has now* reached its 
twentieth edition. Its world-wide reputation is evident hy the 
fact that it has passed through four Cliinese editions. It is 
a big book, and deals both with pharmacology and therapeutics. 
It is only about three years since the last edition appeared, and 
no very extensn'e changes have been made in the present 
edition ; among tlie new drugs includetl are tryparsamicle, 
novasmol. and cpliedrine. In both parts the arrangement is 
alpliahetical — a method which, though it may he convenient for 
reference, tends to destroy continuity. Tlie number of drugs 
mentioned seems somewlfat excessive. The account . of the 
treatment of diseases is perhaps the most interesting part of the 
book, and is well illustrated. There is also a section devoted 
to remedial measures other than drugs. This deals with baths, 
massage, and heliotherapy; it is a rather unusual feature in 
textbooks on tberapeiitics. 

Tn 7he Poh/mtehar Cou7it^^ Dr. W. E. Cooke and Professor 
Eric Ponder describe the nucleus of the neutrophil polymorphn- 
nuelear leucocyte in health and disease, continuing a line < f 
medicine familiar to most under the term of the “ Avneth 
count,” and providing a simpler and apparently more effective 
classification. After a chapter on the technique of blood exam- 
ination and cell differentiation the -authors show how their 
simpler classification may be applied to the diagnosis of various 
diseases, and n final chapter is devoted to the macropolyc^'te. 
Professor John Hay contributes an introduction in which he 
refers to Dr. Cooke's book on The Ameth Count, which was 
published in 1914. He believes that tho new classification 
should i>€ of special interest to general practitioners, as well 
as to haemalologists. The hook is clearly written and well 
iUmstrated with plates and diagrams; a useful bibliography is 
appended, and the information contained hqs a definite practical 
value from the point of view of clinical medicine. 

Tlie textbook of Professor Lipsckutz dealing with the internal 
secretions of the sex glands has now been translated into 
Spanish.^* We reviewed the English edition on October 25tii, 
1924 (p. 769). Professor F. H. A, SrAiisHAi-i.’s preface to the 
English edition is also translated, and a special prologue has 
been written for the Spanish ver-sion by Dr. G. Mar-AXOn of 
the Royal Academy of Medicine, Madrid. 


Jamr$‘ Cyril Dabnahoy AUan : A iVcmoiV, by D, F., printed 
privately at the University Press, Edinburgh, has been pro- 
duced — so says the foreword — to satisfy a wish for a reminder 
of one wlio in his day made many friends, a public schoolboy 
and an Edinburgh graduate who. during a short, eventful 
life, seems to have preserved the high ideals of his medical 
calling with which he set out on his journey. The volume con- 
sists largely of extracts from letters written by Dr. Allan in 
Christmas Island, Hong-Kong. and in France, and are descrip- 
tive of life and of conditions of practice in those places. The 


’ A Text-Bool' of Practical Theraiyeiitics. Bv Hobart Amorj- irate, R.Se., 
M.D., LL.D. Twentieth (Hlition, enlarged. London : K. Kimpton. 1927. 
(0 X 94. pp. X + 1034; 158 figures, 8 plates. 36s, net.) 

The PoUfmiclcar Couuf. By W. E. Coohe, M.D.Liverp., and Erie 
Ponder, M.D., D.Sc.Ed, With an introduction by John Hay. D.L., >LI». 
London ; O. Griffin and Co., Ltd. 1927. (Med. Bvo, pp. yi» + • 

25 figures. 6>. net.) 

Las SecrccinufA InfrniOit de lax Glandular Serualex. Por .Mexand.-r 
liipscUutz. Edicjon revisada, aumentada y pucsta al dia por ol antnr. 
TJn prefacio por F. H. .A. Marshall, F.R.S., y un ensayo, para Ui cdicion 
Espaiiola, por el Dr. Gregorio SlaraDon. Traducclon dirocta del Ingh-s 
•por el Dt. r. Martinez Nevot. Madrid: J. Morala'. 1328. (61 x 9i, 

pp. 3 txxiii -r 492; 142 figures. 25 ptas.), 



140 Jan. a8, 1928] 


MiriK CONSUMPTION AND GBO.WTH .OF^ SOHOOD ;,OHIDDREN. . 


t TifiBumsw 
UKOtCAt JOCSNAA 


letters are written in a racy literary stylo, effervesce with good 
spirits, and arc staraired by a broad humanity. These extracts 
have been chosen with a fine discrimination, and show the 
writer to have been a man of varied attainments,' who combined 
a strong sense of his duty to his fellow men with a healthy 
determination to get the very best out of life. liy remaining 
anonymous D. F. has artistically contrived that all the light is 
shed upon the one central arresting figure of this admirable 
memoir. Copies (price 3s. 6d., postage 5d.) may bo obtained 
from Messrs. Douglas and Foulis, 9, Castle Street, Edinburgh, 
or from Messrs. Macniven and 'WaUaco, 138, Princes Street, 
Edinburgh. 


INTLTJENCE OF AMOUNT OF MILK CONSUMPTION 
ON THE KATE OF GROWTH OF SCHOOL 
CHILDREN. 

Preliminahy Report be 
J. BOYD ORR, D.S.O., M.D., D.So., 

dUIBMAR OP TRE RESEABCR COMMITTEE OP THE SCOTTISH UILX AKD 
HEALTH ASSOCIATIOH.* 


Durino tho past few years a number of tests have been 


Owing to unforeseen difficulties tho tests in Glasgow 
had to bo rearranged about tlireo months after they had 
boon begun, and tho wholo milk group was dropped. Tho 
Glasgow . data, therefore, are limited to tho control, 
biscuit, and separated milk groups. 

Weights and Heights. 

It was intended to weigh tho cliildron with only one 
laj-cr of nndcrclotliing. This w.as found to bo impracticable. 
Tho ohildrcn were thorofofo ivoighcd' in indoor clothing, 
without shoes, and there are considorahio fluctuations in 
tbo weight figures, oven those taken on succcssivo days. 
Tho average weight of clothing was ascertained month by 
month and tho ncccssai’y addition or deduction made in 
tho final wciglit figure. Onung to these 'circumstances the 
records of individual weights are not so reliable an indica- 
tion of tho iiifiiieiico of milk as tho figures showing tho 
incrcaso in height. 

The weights wore recorded to tho nearest quarter-pound. 
Tlio heights were recorded to' the nearest quarter-inch, the 
childrcii being measured without shoes'. Tho measurements 
were taken on three consecutive days at, tho beginning and 
ond of tho ■ test, and at intervals of about ono month 


carried out in America' - " to determine tho nutritive valuo 
of milk for children. More recently a test under exact con- 
ditions in a labour colony for boys, where tho wholo diet 
was controlled, was carried out by Dr. Cori-y Mann‘ for 
tho Medical Research Council. Tho results of all theso 
tests, which are in general agreement, have demonstrated 
tho high nutritive valuo of milk for growth. 

In 1926-27 a largo-scalo test was carried out in schools 
in seven cities and towns in Scotland and in Belfast to 
deteiTnine whether the results obtained by Corry Mann 
under tho rather special conditions of an institutional 
school would be obtained in children attending elementary 
schools and receiving tho varied and changing diet of tho 
ordinary working class household. 

Tho tests were conducted under tho auspices of a com- 
mittee appointed by the Scottish Board of Health, with 
Sir Leslie Mackenzie as chairman. Tho committee con- 
sisted of the school medical officers for tho cities and towns 
where the work was carried out. The collootion of data 
was undertaken by four women medical officers. Tho 
clinical examination of tho children was made by tho 
lato Dr. Cruickshauk of tho Scottish Board of Health and 
the school medical officers. A repeat test is at present 
being undertaken under tho supervision of Dr. Gerald 
Leighton, Scottish Board of Health, and a full report will 
be issued wlien tho new tost is completed. Tho results 
obtained to date, however, so strongly confirm thoso of 
Corry Mann and previous workers, wliich are of such 
importance in public health, that it has been thought 
advisable to issue the present interim report. 

Method. 

At each centre four groups of children were taken, each 
numbering from forty to fifty, according to tho size of tho 
classes in the school. One group received wholo milk, a 
second separated milk, and a third a biscuit of the same 
energy-yielding value as the separated milk. The fourth 
group, which acted as control, received no supplementary 
feeding. The test began at tlie end of November and 
finished at the end of June. TIio Belfast test did not begin 
till the end of January; it is, therefore, not included in 
the results of the seven months’ experiment. 

At Peterhead and Greenock the children were between 
5 and 6 years of age, at Dundee and Edinburgh between 
8 and 9 years, and at Aberdeen and Paisley between 13 
and 14 years. Glasgow and Belfast had a series of groups 
of each of the three ages. There were thus under test 
children at the beginning, the middle, and tho end of 
school life. 

Tho 5- to 6-year-old children received three-quarters of 
a pint of milk per school day, the 8 to 9 one pint, and 
the 13 to 14 one and a quarter pints. The milk was given 
at school. 

"The Chairman of the Investigation Committee is Sir Leslie Mackenzie. 
M.r>., of the Scottish Board of Health, to whom wo are Indebted 

for tho report. 


during its progress. 

Bel'oro tlio results wero calculated such cards were 
rejected ns showed absence duo to serious illness, about 
25 por cent, of missed feeds, doubtful increases in weight 
or height, etc. This accounts for tho decreased number 
of children available for tho final analysis. 

Tho average increaso in height and weight has been 
worked out per group at each ago and in each centre, 
giving tho following results. 


Table. J.—.iyerage Increase in Height (Inches). 




’Controls. . 

Biscuit. , 

Soparated 

Milk. 

■Wliole 

Milk. 

Peterhe^u 

Orcfnock 

Glasgow 

Ago 8-9: 

Eainburch 

Duiuleo 

Glasgow 

Ago 13-14: 
Abordeen 
Pnisluy 
Glasgow 

••• 

1.425 

2.470 

1 1.267 

1 

, 1.224 

1 0.972 

1 1.125 

1 1.395 

; 0.8S9 

1 1.14S 

i 

1.392 

2.455 

1.101 

1.286 

0.931 

1.089 

1.263 

0.841 

1.265 

1.568 

1.625 

1.500 

1.457 1 

1.209 

1.297 1 

1.602 

1.292 

1.734 

1.550 

1.543 

1.483 

1.105 

1.622 

1.365 

TABLE n.— Average 

Increase in Weight {Ih.), 



1 

Controls. 

Biscuit. 

Separated 

Milk, 

■Whole 

Milk. 

Ago 5-6: 
Potcrlicna 



1.973 

2.983 

' 2.741 




1.200 

1 1.969 

1.994 

Grconock 
Gla- gow 


2!784 

2.234 

2.407 


Ago 8-9: 



2.972 

3.238 

3.330 

Edinbnrgb 




2.404 

2,659 

2.556 

Hundeo 

Glasgow 


2.292 

2.266 

3.471 


Ago lJ-14 : 



4.939 

4.790 

5.837 

Aberdeen 




3.934 

5 242 

4.821 

Paisley ... 
Glasgow 

■■■ 

3.855 

4.8C9 

5.959 



Tho heieht increases when all the groups at one age* 
•lespeetive of locality, are combined, show very stnk.ngly 
10 influenco of the milk supplement in aiding growth, and 
10 failure of the biscuit supplement. 

At everv ane the increase 111 height of the whole milk 
• the separated milk groups is significantly greater than 
lat of the biscuit or control groups, while tho difference 
1 increase in height between the two milk groops m 
isignificant. The supplementary biscuit on the other 
and, fails to exercise any significant stimulus in the 
-year-old gi'oiip, and m the 13- and S-year-old gioups 
IS an almost significantly retarding effect 
As the milk gioups (whether separated or wliolej, 
lowed a distinct improvement in growth oyer the non- 
ilk (that is, biscuit and control) groups, the figures ot 
















SAN’. IS, 19:6] 




-■ Tin r.RlTl'TT 

MFDICAL JotTCCAC. 


141 


T.Mii.i: III. Sliniriiiii the Ulcan liiereasc (in Inches) in J-.'nc/i Grauj} at Each Ape, tcith the ProhahU Error. 

Age 13. 


(iVOUp I. 

(»roui> 11. 

Moan 1. 

Mean 11. 

M.I-M. n. 

Probable 

Error. 

1 

1 Remarks. 

ri-ciuttt ' 

ConlroN 1 

* 1.1279 

1.2175 

I - 0.08)6 = 

O.MOl 

Biscuits almost significantly ■worse. 

^VilolD milk 

Controls j 

1.5122 1 

1.2175 

- 0.2917 = 

0,0153 

^^^^ole milk significantly better. 

Keparntod milk 

Controls 1 

1 £521 1 

1.2175 

- 0.3319 

0.0117 

Separated milk significantly better. 

Scjiarated milk 

lUaruila 

j 1.552-1 1 

1.1279 

- - 

0.M14 

Separated milk significantly better. 

Who'e milk 

Biscuit> 

i . 1.5122 j 

1.1279 

- 0.3515 = 

0.0493 1 

1 ^\*bole milk significantly better. 

■\Vljole milk 

SepatAted iiillk ' 

; • 1.5122 

. 1.552^ 

- O.MO* - 

0.0507 i 

Xo significant difference. 


Age 8. 


Biscuits 

Couli-ols 

i.iieo 

; 1.1000 

- 0.0150 


0.0278 

Xo significant difference. 

■\Miolc milk 

Controls 

1.3233 

1 1.1000 

1 

- 0.2233 


0.0318 1 

Wliolo milk significantly better. 

Separated milk 

j Controls 

1,3355 

I I.ICOQ 

- 0.2355 


0.0251 1 

Separated milk significantly better. 

Separated milk 

j Bi-seniU 

1.3S55 

1.1160 

- 0.2i95 

1 

= 

0.02S1 

Separated milk significantly better. 

M'bolc milk 

1 BBciills 

1.3233 

j LU60 ■ 

I - 0.2975 


O.OMO 

5Vholc milk significantly better. 

lA'holemilk 

1 

1 Separated milk 

1.3233 1 

[ 1.3K5 

- 0.0122 


0.C321 1 

Xo significant difference. 

Age 5. 

Biscuits 

1 ContTols 

1 1.3113 

i.toas 1 

- 0.te83 

= 

0.0291 

Biscuits almost significantly worse. 

M'liole milk 

1 Co.'.t-.ol- 

1 1.5155 

j 1.4026 j 

- 0.1132 

= 

0.0293 

MTiole milk significantly better. 

St'paratod milk 

Conlr:l-A 

j 1.5697 

1 1.4023 . 1 

- 0.1671 

= 

0.0295 

Separated laiilk significantly better. 

Separated milk 

Bi cnis 

j 1.5697 

i 1.3M5 

- 0.2551 

= 

0.0303 

Separated milk significantly better. 

IVliole milk 


1 1.5158 

1 1.3443 

- 0.2015 

= 

0.0305 

M'bolc milk significantly better. 

Mliole milk i 

Separated milk 

1.5-153 

1 j 

' 1.5697 1 

- 0.0239 

= 

0.0309 

Xo significant difference. 


tlie average increase at all ages were arranged into two 
groups, svith tlic following results. 


Table IV . — Auropr Iticrtttr*. (Alt .I'/'.' ■ 


jlilk N..ii.Milk 

Ori'iir-. t.r(nip>. 

Average increase in Iieiglii ... 1.470 in 1.212 in. 

Average increase in wciglit ... 3.617 2.974 lb. 


This seven months’ ctqieriinent tliiis shows an avorago 
monthly increase of 0.17 in. and 0.42 lb. in tho non-milk 
groups' and of 0.21 in. and 0.52 Hi. in the milk groups. 
In the nmcli lengthier experiment hy Curry Mann the 
corresponding figures were 0.15 in. and 0.32 Hi. for all 
boys on the basal diet, and 0.22 in. and 0.58 lb. for all 
boys receiving the supplement of one pint of pastcuriratd 
milk es'ery day; the milk group increases in height in 
both experiments, thus ajipiviximating veiw closely in spite 
of the Scottish children receiving the supplement only- 
five days a week. 


^ The children in the different gi-oups at the vai-iov 
centres were examined at the end of the experiment an 
clinical obseiTation.s made. Independent repoi-t.s were als 
lianded in by the headmasters' of the schools. Thes 
clinical reports, which cannot he expressed in figures, shoi 
bat at most of the centres the children who had receive 
milk appeared to be in better condition than those receiviii 
no mi k. It was noted that, on tho whole, they had glossic 
mil anti clearer complexions, and held themselves jiioi 
• *r>i eentres this differcnco was less market 

Tkl. t no distinct difference eoiild be detectet 

marked improvement in the children in the mil 
Hit! '^**''‘l'en who had been in poor coi 

Fr^r tb^ 

of 1 Hort'ciilars gathered as to the home dietar 

els, seem that the average mil 
The total milk *mme was 2.5 pints per head per weel 
these homes ‘^‘’"®'""P*''on of the children under test i 
! av^e tha 

which the rbiM ,'^ ’”" P"'' tlm household t 

1 "t cl. d t^ ll the home consumption t 

still nm intTl’f the amount received a 

the avoran-e of of clnldren receiving more tha 

school) wal romplrcd^rPh that 

than the average. ^ ^ children receiving lei 


Tablk V. — Showing the .irernpe Pate of Increase in Height in the 
" Orer Average" and “• Vnder Average" Milk Coiisnmntion 
Groups. 



.Vge 5-S. 

Ase 8-9. 

^ Age 13-14. 

Increase in height of "over average’* 

1,58 in. 

1.37 in. , 

1.51 in. 

Increase in height of *‘ nndcr average’* 
group 

1.14 in. 1 

1.19 in. 

1.21 in. 

Percentage increase of * over average ’* 
to "under average" group 

9.4 

15.5 

24.2 


Con cl H.si'oii.v. 

From this siin-ey of the data it seems pvohahle that, in 
the final report, it will he possible to draw tho following 
conclusions : 

1. Tlie addition of the milk to the diet of school 
children during the seven months' experimental 
period has been accompanied by a rate of growth as 
indicated by an increase in both heiglit and weight 
20 per cent, greater than that in children not receiving 
the extra milk. 

2. This increase in rate of growth has been accom- 
panied by an improvement in the general condition of 
many of tlie children receiving milk. 

3. Separated milk is of gi-eat value for piromoting 
growth. Its nutritive value for children would appear 
to be underestimated. 

The writer wishes to record his indelitcdness to Jli.ss 
AI. L. Clark, who has prepared the above tables, for 
valuable services in connexion with the sniiervision of the 
'.tests during their progress. Dr. Lewis D. Cruickshank, 
who superintended the' investigation from the administra- 
tive side on behalf of the committee, died towards the end 
of the test period, and we can only record onr profound 
regret that wo have not had the contiiuied advantage of 
liis intimate knowledge of school and social conditions. 

Tlic cost of the above tests was defrayed by a grant made by 
the Empire Marketing Board to the Rowett Research Institute, 
Aberdeen. 

RrlTREXCES. 

1 McCollum (1923) : Proc. World's Dairy Congress, p. 43. s Chaney (1923) : 
.tiller. Journ. Die. Child., 26, 337. “ Morgan, Hatfield, and Tanner (1926) : 
ibid.," 32, 839. * Corry Mann (1926) ; Diets for Boys during the School 
.Age, Medical Research Council Special Reports Series, No. 105. 









142 2S, toisj 


. ANNUAD, MEETXNGf AT CARDIFF. 


r TiiRlipmsH 
L MimcAi.JotE'cu, t* 


rSIHETY-SIXTH MEETIHG 


of the 

British Medical Association. 

CARDIFF, l^QS. 

already announcoil. tho ninoty-sixth Annual Meeting of the British Medical Association will bo 
hold in CardifT next slimmer lindor thb presidency of Sir |Ewen Maeloan, M.D„ B.E.C.P., 
Professor of Obstetrics and Gymabcology in. tho Welsh National School of. Medicine, who will 
deliver his address to tho Association on tho evening of Tuesday, July 24th. Tho sectional 
meetings for scientific and- clinical work will bo hold, as usual, on the three following days, 
the morning sessions being given up to discussions and tho reading of papers, and ‘the 
afternoons to demonstrations. The Annual Eepresentativo Meeting, for tho transaction of 
medico-political business, will begin on the previous Brida 3 ', July 20th. The names of the 
Presidents and other officers of tho Scientific Sections were published m last week’s Supple- 
MENT, together with some preliminary notes on the programme for the Annual Meeting; 
further details will bo announced from time to time as the arrangements take shap.e. On the 
last day of tho meeting (Saturday, July 28th) there will be excursions to places of interest in 
the neighbourhood. We publish below the second of a series of historical and descriptive 
articles on the citj^ and its medical institutions, written for the occasion by Dr. Donald'- 
Paterson. The first appeared on December 3rd, 1927. 

CARDIFF: A BRIEF OUTLINE OF ITS HISTORY. 



Tower or-CJfuDirr 
Cm- II (EL. 


capital of the county of Glamorgan, a shire 
of ^ long and ancient time,” part of tho far older terri- 
torial division of the diocese of LlaudafF, which has its 
bishop seated at Llandaff. The district of which Cardiff 
is tho natural centre was pai-t of the old tribal division 
ol Morgauwg, long held under its Welsh rulers in prac- 
tical indopendoiice of 


the rest of Wales, 
largely because 
the mountain harrier 
of its northern limit 
decreed its isolation. 

Archaeology tells us 
that the cultures of 
prehistoric times 
reached it mainly 
from • the opposits 
shore of the Bristol 
Channel and from 
Ireland, rather than 
from the massif of the 
central and northern 
uplands which has 
done much to pre- 
serve the independ-' 
ence and the language 
of Wales. Its lower 
relief, tho 2’ossessjnn 
of rich agricultural 
land and an indented 
coast-line with tidal 
harbours, made the 
plain of .Glamorgan 

from early times a region of immigration from England 
and the sea. 

On the origin of Cardiff history sheds no light. There is 
not even a local tradition to add a salt of human interest 
and to invite criticism from the liistorian. Yet its situa- 
tion with a sheltered roadstead must have proved attractive 
to the early traders who frequented tho coast. It occu- 
pied a Roman site, and its position — not on the sea, but 
on a navigable river a mile from its mouth — presents 
advantages, military and commercial,- generally associated 
with an ancient settlement. 

is known to be the site of a Roman station, 
though its Roman name has not come down to us. The 


spado has brought to light its existence in the first 
contuiy A.D., its occupation being military in character, 
probably dependent on the legionary fortress at Caerleon 
on tho Usk. The Roman Empire was held together by its 
roads, and tho position of Cardiff on the river Taff, in 
tho middle of tho great sheltered plain between tho 

Rhymney and tho Ely 



CAEDiiT CiBTLE : The Keep, 1840. 


rivers, made it a suit- 
able site for one of 
the many forts built 
at strategic points 
throughout Wales in 
the early days of tho 
Roman occupation. It 
was reconstructed and 
enlarged about the end 
of the third century, 
possibly in connexion 
witii Gaelic migrations 
from Ireland to South 
Wales at that period, 
and the site was still 
occupied towards the 
end of the fourtli 
century. 

With the departure 
of tile Romans the . 
fort fell into decay, 
having perhaps 
suffered, - like other 
sites, in the general 
chaos from incursions 
of Irish sea - i-overs. 
Like a haunted spot, it remained unoccupied for several 
conturies, until the practical Norman sot up his castle-mound 
within its walls. 

Written record and the well known Ogham stones 
attest the prescnco of Irish Gaels during and after 
the Roman period, and their speech prevailed into the 
seventh century. In the Ago of tho Saintes, when 
community had been established between the ancient 
British and Irish Churches, when the monastic school 
at Llantwit Major flourished and Celtic missionaries 
wandered far afield, the estuary of the Taff doubtless 
formed a stag© in the Pilgrim's Way to the Continent: 
from Ireland. 



38, igiR] 


CARDIFF: AtT ODTMNE OF ITS' HISTORY. 


r Tnc Bnm'm 
ilEDicAL Journal 


143 



Norti[-West CAr.Dirr nr tiie EionxEEKTH Centdrt. 


The coming of the Nordic peoples hrmight fresh immigra- 
tions to tho shores of Glamorgan. The Saxons probably 
filtered across from tho opposite shore of tho Severn 
■ estuary, as the men of Somerset and Devon have always 
done. Their Viking kinsmen, after establishing themselves 
in the seaports of Ireland, organised their commerce and 
embraced tho Bristol Channel in their wide activities. 
Bristol, the great seaport of the West, owed its rise to 
this trade, and tho same may perhaps bo said of Cardiff. 
Danish ships were frequently seen in tho Severn Sea in 
tho tenth centnry, and in Glamorgan their i)lncc-namcs are 
remarkable alike for their wide adoption and ]iersistence. 
In the saga of Jittrnt Kjall tho slaying of Kol, who was 
finally discovered settled in Brctland (Wales) — the fitting 
close of the famous blood fend — may well have boon staged 
at no great distance from Cardiff. 

Of the arrival of the Norman advenne in Cardiff little 
that is authentic has come down. The fact of Cardiff 
being a bridge-town, with free access to tho sea, made its 
early possession de.sirable. The change perhaps made 
little difference to tho inhabitants and did not involve a 
breach of continuity. It is fairly certain that when 
William the Conqueror himself paid his visit to Wales ho 
ordered the great castle-mound of Cardiff to be built, 
placing it in tho keeping of his kinsman Robort 
Fitzhamon, who subsequently completed tho conquest of 
Glamorgan when the troublous early years of Rufus’s 
reign had passed. In the settlement Fitzhamon retained 
the rich agricultural land of tho low country for his own 
followers, who held it by service of “ castle-guard ” at 
Cardiff; many of them were already holders of fees across 
tlie water in Somerset and Devon. The hill districts, 
mainly forest and pasture, he left on easy terms to Welsh 
chieftains, in whose hands they remained for nearly two 
iiindred years after the Norman conquest. 

\i hen the written record comes in' wo find Cardiff fully 
formed as a town, styled a borough with legal adminis- 
la lye machinery, palisaded for defence, tho seat of trade, 
and in possession of a castle which fired the imagination of 
le UTiters of Arthurian romance. A seigniorial borough, 

. 1 z amon probably conferred its first charter. His son 
an grandson granted it extensive privileges, and the 
a r extended it by founding a new borough outside 
1 independent community was eventually 
a isor e in the larger community, as happened in the case 
of the earlier French “ new boroughs ” at Norwich, 
Shrewsbury, Nottingham, and other places. 

ostablislied in Glamorgan what was later- 
Mai pb in which the law of the 

imucrin 111 1 ^ feudal law of France — an impcritim in 

unc^tn^^d ^kfogsl 

Go “fid ^ lavished Glamorgan, Gilbert de Clale 

Noimafiized i-i^^ Iffarch was the most thoroughly 
alone' we;e sLe forty '’eartw'' 

..... of th. .*T.wE 


to form an attractive feature of the county in the present 
day. 

Cardiff became the caput or head of the lordship, and 
from his castle at Cardiff, where ho held court and lind 
his chancery, the chief lord maintained tho balance in 
-the never-ending struggle between tho agi’iculturist of the 
low countiy and tho Welsh pastoralist of the hills. Risings 
of tho Welsh broke out at intervals, notably at the death 
of a chief lord, perliaps because tho Celt loves to celebrate 
a funeral; sometimes, no doubt, deliberatelj- provoked to 
furnish exenso for conquest. In these upheavals Cardiff 
did not always escape. 

In tho mediaeval period tho history of Cardiff is linked 
up with tho fortunes of tho lordship of Glamorgan. Its 
chief lords held tho castlo and town of Bristol as well as 
Cardiff, and this did mncli to jn’omoto the close relations 
between tho two seaports which remained such an im- 
portant factor in tho social and economic life of Cardiff 
down to modern times. 

Tlio most able of the chief lords was Robert Consul, 
Earl of Gloucester, who married Pitzhamoii’s heiress. A 
natural son of Henry I, his royal father promoted tho 
match, and, according to the old rhymed chronicle, con- 
ducted negotiations with the lady her|elf, who at first 
made some demur. Her scruples were, however, allaj’ed, 
and William of Malmesbury tells us " she was devoted 
to her husband and blest with a numerous and beautiful 
family.” Robert was a man of affairs, a statesman, and 
a soldier in the difficult days of Stephen. By his modera- 
tion ho conciliated the AVelsh and gained their confidence. 
Ho was, moreovei’, a magnificent patron of letters, and did 
much' to promote the intellectual movements of his time. 
Among the men of letters who frequented his court at 
Gloucester and Bristol and Cardiff was Geoffrey of Jlon- 
mouth, who resided at Llandaff for a time and died there. 
Geoffrey dedicated to him his famous Histoi-y of the Kings 
of - Britain, a work which, however little its value as 
history, made the Arthurian legends fashionable and 
revealed the possibilities of Celtic romance. 

-Half a century later Archbishop Baldwin of Canterbury 
passed through Cardiff on his journey through Wales to 
' preach the Third Crusade. He was accompanied by 
. Giraldus Cambrensis, one of the most remarkable men of 
letters of his time, and an entertaining writer of freshness 
and charm, who has left an account in his “ Itinei-aiy 
through Wales.” Giraldus admired the “ noble castle ” 
at Cardiff, and relates of Heniy II that when he spent 
a night there on his "way back from Ireland, and was 
about to resume his journey on Sunday morning, he was 
upbraided by a native for breach of Lord’s Day obser- 
vance and warned of tho grave consequences. Giraldus 
had a great struggle for the See of St. David’s and paid 
visits to Rome, where ho entertained the Pope with the 
Latin “ howlers ” of his archbishop (not Baldwin), which 
are still paraded in modern dress, but he was not made 
bishop. 

Robert’s son William had not the qualities of his father. 
Ho distinguished himself by being captured, along with 
his countess and young son, by Ivor Bach, a neighbouring 



144 JAN. 28 ,\isi 2 Sj VITAIi STATISTICS '.FOB -ENGLAND AND "WAGES, 


■Wel.<ih cliioft.Tiii, ulio sc:i}<‘il Ciii'diff CnsUc Iiv iiiglif iinc'l 
can-icd liis piismicrs to llu' liills. Joliii, oftonvordf. King, 
married )iis lioiress. Tlio iady, iiowovcr, did not jdoaho 
him after a oliilo, and Iio divorced her, though lie stuck 
to, her rereiitics for a time. 

Tlio thirteenth century sa'v the lord.ship in the strong 
hands <if tiie de Clares, who took most of tlio Welsh lord- 
ships into their oivn possession. Gilberl, the “ Red Karl,” 
plaj-ed a prominent part in the harons’ war, and when 
Simon do Montfort crossed the Usk and ravaged his lands 
it is more than likely that Cardiff .suffered in the process. 

The town attained its maximum under the do Clares. 
With the fall of young Gilbert do Clare at Bannockburn 
the lordship wont to the Despcnsers, the arrogant favourites 
of tho incapable Edivard 11, who wandered in tlio neigh- 
bourhood and was captured not far from Cardiff, to end 
his caredi- in the tragedy of Berkeley. Cardiff had fallen 
upon evil das's. There were long and frequent minorities 
in tho lordship in which the guardians looked after their 
own interests rather than the welfare of tho peojde. The 
visitation of the Black Death in 1348-49, followed by lesser 
epidemics in the same centuiw, took heavy toll of tho 
town, and in the rising of Owen Glyndwr in 1403-4, in 
which economic destruction took place on a large scale, 
jiart of it nas laid waste. Froin this it did not recover 
for several centuries. From being a “ Market of the 
Staple ” and a leading port in the kingdom for a period 
in the fourteenth century, it dwindled in the eighteenth 
to being “ a creek ” in the iioit of Bristol, and its popula- 
tion remained not much more tbau 1,500 until the in- 
dirstiial revolution infused now life into it. 

, Under Henry VI J I the lilarcbcr-lordsliips came to an 
end. Latterly they had hut served to perpetuate tho 
wprst form of anarchy. Henry aholislicd the law of the 
March and siibstitutcd English lair, a ehahgo that was 
welcome and productive of tho best results. . 

The effect, liowever, was not immediate. Piriioy had 
long been rife in the Bristol Channel, and in the days of 
Elizabeth Cardiff became a general resort of pir.itcs and 
adventurers who plundered on the high seas. Many of its 
prominent citizens were not ill disposed to tho practices, 
and even a high .sheriff took a hand. It was urged in 
excuse that Cardiff “ had always protected that class.” 
The Government finally had to move. Many siispeoted 
pirates and their accomplices were examined by com- 
missioners, and some of the ringleaders, including the 
high sheriff, were eonvieted and heavily fined, in spifa 
of their plea that there was “ a difference in law in the 
matter ot spoils done on the sea.” Smuggling, however, 
continued to flourish along the coast for a long time in 
the “ creeks ” wliich were “ inemhers of tlie port of 
Cardiff.” 

In the Civil 'War, Cardiff, following ‘the lead of 
the IVest Coimtiy, was, on the whole, on the side of 
the King, though it changed sides more than once. 
Charles in his wanderings visited the town, but he made 
little impression, and ho went on his way to the north. 
The defeat of the Royalists by Horton’s Brigade at 
St. Fagams, near Cardiff, did much to keep the iieiglibonr- 
hood quiet. 

,, Cardiff had little to do with the Church. Most of the 
land in the neighbourhood had been gifted by its early' 
Norman lords to great abbeys which they had founded on 
their English estates. The Bishop of Llandaff continued 
to hold his manor or lordship of Llandaff, with some 
special privileges nhich ivere settled by a concord with 
Robert of Gloucester. 

. Tho long period of eclipse which set in in tlio fifteenth 
century is perhaps responsible for the old town retaining 
much of its early form and many of the streets their 
original names. Its size and shape can readily be made 
out on the modern map, as the section of the canal from 
the Castle to the Monument occuipes practically the site of 
the Town Ditch, its eastern bonudaiy. The area within 
the old town formed roughly a segment of a circle with 
its arc resting on the Taff, its western boundary. Here 
the river bad seriously encroached on the town and 
destroyed tlie old cbiireh of St. Mary, and it was found 
necessary to divert it into the piosent “ straight cut ” 


before the constrnetion of the Great 'Western Railway. 
Except ill a few instances the streets largely retain their 
old lines. Some have changed their names, a few more tliaii 
oiifc, hilt fhero is a persistence of old names wliieli does 
something to recall the atmosphere of mediaeval times. 

The cighlcentli eeiitury saw a new and greater iminigra- 
tioii, which was to change the face of tho eoimty. It 
began by arrivals from the English Midlands to exploit 
the mineral wealth of tho hills. The discovon- of the 
previous century that iron oro could be .smelted by mineral 
fuel led to works being established along the northern 
bonndary of the county, where coal and ironstone cropped 
out and carboniferous Iime.stoiie was abundant. The iron 
tr.a<lc becaino for a time the inijiortant industry of tho 
district. The iron was first carried down on the backs of 
mules to bo shipped from the Taff, wliieh was navigable at 
hfgli wafer as far as the Old Quay. The constnittion of 
a e.-iiial replaced this primitive method of .shipment. With 
the increased demand for coal for .steam-raising pnnioses, 
especially in ships, greater facilities for its export were 
provided by cutting docks on the moors to the oast of the 
river, .and the modern port of Cardiff began to take shape. 

.In 1840 the first cargo of South Wales steam coal was 
cxjiorted from Cardiff. Its c.xfollonce as steam-generating 
fuel and its freedom from smoko marked its superiority 
for steam purposes. Its sale and export is the main 
industry upon which tlio district depends, and the pliono- 
luenal increase in tho volume of trade has led to the rapid 
rise of tlio port and its emergence as the economic capital 
of a province. 

Cardiff’.s e.xport trade has Ijroiiglit it into relation 
with all parts of the globe, and in consequence it has 
drawn its inhabitants from many quarters, and is the 
most cosmopolitan of cities. All its citizens unite in a 
detoniiimitioii to ndvaned the interests of tho city irliich 
they have hripod to make. In 'this they but serve to 
fnriii.sli another illnstration of the old tnith-^that the 
history of this country has been “ largely a histdiy of 
elements absorbed and as-similatcd from without.”- 


VITAE STATISTICS FOR ENGLAND AND 
WALES, 1927. 

We avo indebted to the Registrar-General for the following 
statement regarding the birth rates and death rates and 
the rates of infantile mortality in England and Wales and in 
certain parts of the country during 1927. The statement is 
issued for the information ot medical officers of health. The 
birth rate and infantile mortality rate for London have been 
provisionally corrected for transfers. 


EXGLANn AND WALES. 

n.-r/f, Death Hate, and Infantile mortality during the 

Jiiriu . 1 . , ^Pfgpi^ional Figures!. 



Dirth Hate 
perl, COO 
Total 

Population. 

. Deaths 
per 1,000 
Population 
(OmdD HateJ.j 

Deaths 
under One 
Year per 
1,000 Births. 

Euelana and Wales 

16.7 

12.3 

69 

107 county boroughs anfl great 
towns, incIudiDgX'0““®° 

)7.2 ! 

123 

71 

smaller towns (popula- 
tions from 20,000 to 50,000 Jn 
1921) 

1 16.5 

1 

“ 11.4 

65 

I<oiidon ... «' 

15.1 

li.9 

59 


,e death rate for England and waies reiaies m u.e 
ilation, bat that for London and the two groups of towns to 


England and Wales. 

The hirth rate ia 1.1 per 1,000 below that ot 1926, and is the 
lowLtmte recorded since the establishment ot civil registration. 

death rate is 0.7 per 1,000 above (Imt of 1926, the excess being 
3n"e torhehtb i^orta'lity of the first and fourth quarters of he 
year. The infantile mortality rate is equal to that of 1923, the 
lowest on record ; the rate in 1926 was 70 per l.OCO births. 




14(5 JAN. 28, 1928] MILK AND RATE OI" GROWTU OP SCHOOL CHILDREN. 


The secoiicl objccUon willi whicli Professor Pe.nrson 
deals — ^namely, ihat some very groai men have sufYered 
from gross mental or physical defect; — is not, we think, 
quite adequately discussed b}' him. “ I admit,” ho 
writes, ” that certain men whom the world tenns great 
have had such defects, but 1 deny the inference that 
25hysical iufei'ioriby is the source of genius.” This is 
rather ad citpiandam, for the present-day disciples of 
isoi-dau are not a large percentage of the population. 
It haijpcns to bo a fact that some men of great ability 
lucre w’eaklings. As Macaulay put it; ” At Landen 
two poor sickly beings, who, in a rude state of society, 
w'ould have been regarded as too puny to bear any 
part in combats, were the souls of two great aiTnies. 
In some heathen countries they would h.ave been 
exposed while infants. ... It is probable that, 
among the hundred and twenty thousand soldiers wlio 
■v\-ere marshalled round Ncen\'inden under all the 
standards of Western Europe, the two feeblest in 
body were the hunchbacked dwarf who urged forward 
the fiery onset of Prance, and the asthmatic skeleton 
who covered the slow retreat of England.” It may bo 
argued — we think that Gallon and Profe.ssor Pearson 
have proved it to be a sound argument — that the 
proportion of able men 2 )roduced by physically healthy 
stocks is much gi'eatcr than that produced by un- 
healthj' stocks; but those who believe in the unique 
^■alue of human personality can still retort that the 
2 )ractice of eugenic 2 ^i’*>iciples would in fact have 
deprived the world of some choice spirits. 

We did not, however, sot out to discuss the pros 
and cons of eugenics as a national progi'ammc, bub 
merely to call attention to a masteidy exposition of 
the creed of our greatest living ougonist. We hope 
this pamphlet will be read by all educated men, 
particularly by members of our profession, whose 
advice is often sought upon such matters. 


MILK AND THE BATE OF GROWTH OP 
SCHOOL CHILDREN. 

Milk has been held to be the best single food, con- 
taining as it does all the ingredients of a balanced 
diet. It is rich in vitamins, and its high calcium 
content is in a readily usable form. For sucklings of 
the same species it furnishes a complete dietary. In 
the growing child it promotes nutrition, whether con- 
sumed by itself or as an ingredient of other foods. 
For adults, too, it is beneficial, though to a more 
limited extent. For all ages of life it has been 
generally agreed that milk is, in varying degrees, 
beneficial. 

A substance so approved by cuirent opinion has 
appear-ed to the Legislature to merit protection, and 
also to demand it. Owing to its composition it is 
readily sophisticated; owing to its method of jrroduc- 
tion it is liable to contamination; and, being usually 
consumed raw, it may easily convey infection. 
Further, it is difficult for the consumer to check minor 
^-aiiations in quality, A number of safeguarding 
statutes and regulations, dealing either wholly or 
2 mrtly with milk, have therefore come into force in 
the tlmted Kingdom within recent years. Under the 
Sale of Food and Drugs Act, 1889, several Sale of 
Alilk Regulations were made, covering both England 
and Scotland. Under the Public Health (Regulations 
as to Food) Act, 1907, regulations were made with 
regard to millc and cream, condensed milk, and dried 
milk, also affecting both countries. The Milk and 
Dairies (Scotland) Act, 1914, and the klilk and Dairies 


[ Titi Hums* 
UZOtCAL ■roCBICLC 


(Consolidation) Act, 1915, witli its klilk and Dairies 
Order of 1926, which related to England, iwotccted 
inilk by cnipowering the appointment of vctorinaiy 
iiLspoclors, providing for the inspection of dairies,' 
prescribing the methods of dealing with the milk 
of diseased cows, with infections diseases in daky 
employees, and other matters. The Milk and Dairies 
(Amendmciil) Act of 1922, which applied to both 
countries, was the charter for graded milks, and by 
Orders made under it certified milk. Grade A milk, 
and pasteurized and other milks came into existence. 
The Public lleulth Condensed Milk (Amendment) 
Regulations, and sinular regulations dealing with 
dried milk, made at Edinburgh at the end of Inst year, 
arc devoted to the protection of infants from milks 
wJiich arc not suitable for them. 

While all these administrative measures were excel- 
lent in promoting the supply of milk of good quality, 
in its natural state, and free from infective germs, it 
was felt that some basic things had been taken for 
granted, and that questions remained as to the precise 
infiueneo c.xeieised by milk on growth and milrition, 
and as to its value as a supplemental food substance 
as distinguisliod from a sole diet. The Scottish 
Board o£ Ilcalth, recognizing this, and introducing the 
I experimental method into the administrative field, has 
afqrlicd itself to the first principles involved, and has 
a 2 >pvoached the 25roblem of milk consumirliou at first 
hand. A series of tests had already been carried out 
by Dr. Cony Mann in England under the IMedical 
Research Council, in which it had been shown that of ■ 
j two groups of boys, ono consuming a basal diet and 
: the other a diet supplemented by pasteurized milk, 
(he latter group gi’c^v more rapidly. These findings 
were put to the proof by the Board under a greyer sky 
and on a different racial strain. They appointed a 
committee of experts, under Sir Leslie Mackenzie, to 
carry out an investigation. Croups of children were 
selected at the ages 5 to 6, 8 to 9, and 13 to 14 in 
scroll Scottish towns. In each torvu four groups 
were taken, each consisting of forty to fifty children.- 
Group 1 received an ordinary diet. Group 2 a diet- 
supplemented by biscuit, Group 3 a diet supplemented 
by separated milk, and Group 4 a diet supplemented 
by whole milk. The foods were given to the children 
in school and carefully supervised. The work was 
continued for seven months, ending in June last. 
Each child was weighed to a quarter of a pound and 
its height measured to a quarter of an inoh. A pre- 
liminary report on the work of the committee by Dr. 

J Boyd OiT, chahman of the Research Committee of 
the Scottish' Milk and Health Association, which is 
printed at page 140 of this issue, sets forth the results 
of the inquiry up to the present time. It is being 
can-ied on elsewhere on similar lines, and a repeat test 
is beinc' undertaken, the results of which will be 
announced in due course. 

General tables in Dr. Oit s report, which should 
be consulted, show the average increase in height 
and weight, and the mean increase in height, in 
each gr<mp’ at each age, with the probable error. 
In the group results, as shown in Talile IV, 
where the milk groups are contrasted with the 
non-milk groups, the average increase in height 
of the milk groups for the period of seven months 
was 1.470 inches, as contrasted with 1.212 inches 
for the non-milk groups. Since the milk given 
in school was an accessory article of diet only, it was 
necessary to ascertain also the home milk consump- 
tion. This was done in 626 households, and the total 
milk figure -was airived at for each child. For the age 


JAN. s8, - 19281' CtimiOAt. DEFFEREglOEB- lltT- a.’UBBRbXJLOSI8. 


r. Trar.nijsTi • •)47. 

L ATEDJtiAi, Jomxxx, A** I 


i 


g&Sps 5 to 6.'8"W'9, mid 13.'f'6''ft/tho mci'oas6' ln 
lici^lit of those whose lolnl milk consumption wos.ovcr 
avera"e was 1.58 inches, 1.37 iuclioa, and 1.51 inches, 
as contrasted with 1.44 inches, 1,19 inches, and 1.21 
inches for those whoso total milk consumption was 
under average. 

The conclusions provisionally drawn by Dr. Orr arc 
to the effect that the addition of the milk to the diet 
has been accompanied by a rale of growth 20' per cent, 
greater than that in children not receiving the extra 
milk; that this increase has been accompanied by an 
iiuprovemcut in .the general condition of many of 
the children receiving milk; and that separated milk 
is of great value for promoting growth. These findings 
confirui the current opinion as to the vuluo of milk. 
They bring out, in addition, the novel result that, as 
an accessory, separated milk is in general as good as 
whole milk for producing gi-owth, and sometimes better. 
Biscuits as a food are far behind. The inferiority of 
-the cereal as compared with milk finds an interesting 
commentary in the fact that the aggi'essive and 
dominant races of the world have usually been milk 
consumers, while the docile and subject peoples have 
principally fed on grain. 

. As already noted, the inquiry is still proceeding, 
and it would be proper to reserve a final opinion until 
it is completed. The report, however, though 
described as " preliminary,” rcachc.s conclusions 
which, we think, wiU stand. It should revive the 
consumption of milk in Scotland, where, .along with 
pom'dge, it was in past days the national food of 
the people, and should encourage its use in England 
to a gi'eater extent than is now tho case. 


CLINICAL DIFFERENCES IN TUBERCULOSIS. 
For the prevention- of a disease it is of gi'eater impor- 
tance to have a thorough understanding of its epi- 
demiology Ilian of its bacteriology. It is of more value 
to the practitioner of preventive medicine to know 
how infection is spread and under what conditions the 
disease arises than to be acquainted with the particular 
organism that is the cause of it. There are many 
diseases— of which small-pox and typhus may be cited 
as examples whose etiology is obscure, yet which 
under control with' wonderful success; 

6 others, of which we may cite tuberculosis as 
"'Inch, in spite of our Icnowledge 
baetenology, offer the greatest difficulty to 
(.1 ^'ke truth is, we know too little about 

nWo •'-'ons under which tuberculosis arises to be 
Tn - "T* ^“^dllible measures for its control. 

tlip^BTiisU statement we have merely to consider 
,.,, 1 - . ’■■®^'mtion in the mortality from tuber- 

last eentni. country that has occun-ed during the 
thp cBionn' t '^eduction that commenced long before 
until T fiinv medicine was born. Not 

lonv of flip study has been made of the epidemio- 

0®?ain '‘kle-in man at leash- 

° pm complete control over it. 

Bi'e^ ^Memorhf ' study the Hermann AI 

America bv hinf Lecture delivered in 

is of coksi/eraWe Sest’ Cummins of Cardiff 

by 

troops in E<wp° amongst the Sudanese 

though in theh’ w “ be ascertained that 

tubereuloas as soofa?tr““'^ became 

'vith civilisation thj V 

suscentiliiUt,, 1.1 ®^mted a high degree of 
sceptibihty to the disease. This is not an isolated 


obsorvatioii. J.Ictchnikoff noted a similar relationship 
in tho Kalmuks, BoitcI amongst the Senegalese troops 
brovjght to France, Coleman amongst the American 
Indians, and so on. The whole subject has been ably 
reviewed by Busbnoll in his Studij on the EpiJcinio- 
foffif of Tuberculosis. 

Professor Gurhmins draws attention not only to the 
high mortality from tuberculosis of these primitive 
tribes when brought iuto contact with civilization, but 
to the entirely different clinical type that the disease 
assumes in them. He divides, in fact, human tuber- 
culosis info two main types — “ natural ” tuberculosis 
and " modified ” tuberculosis. “ Natural ” tuber- 
culosis, nbicli is seen in adults of primitive tribes 
brought under civilized conditions and in infants of 
civilized peoples, is characterized by an acute, rapidly 
generalizing disease; pathologically the usual picture 
is one of enormously enlarged caseating glands at the 
portal of infection — ^generally the tracheo-bronchial 
group — miliary tuberculosis, and often diffuse caseous 
pneumonia; there is no fibrous tissue reaction, no 
attempt at localization of the lesions, and no tendency 
towards healing. ” Modified ” tuberculosis, on the 
other hand, which is seen in children and adults of 
peoples that have long been civilized, is characterized 
by a ebrouic, slowly progressing disease; patho- 
logically' the lesions are often confined to one organ 
— generally the apex of tlie lung — they excite a marked 
fibrous tissue reaction, and they may undergo spon- 
taneous healing. “ Natural ” tuberculosis is the 
clinical type seen in persons who have never been in 
contact with tuberculosis, and who have consequently 
never been called on to protect themselves against it; 
‘‘ modified ” tuberculosis is the clinical type seen in 
persons who have long been in contact with tuber- 
culosis, and have learnt to defend themselves more or 
less against it. ” Natural ” tuberculosis is a disease 
of the highly susceptible; ” modified ” tuberculosis is 
a disease of the relatively immune. 

If this teaching is correct it has an important 
bearing on the prevention of this disease. In this 
country both types of tuberculosis are seen, and, 
according to Professor Cummins, the measures taken 
to protect against tho two types are different. 
“Natural” tuberculosis, which affects chiefly infants, 
and less frequently adults living in isolated districts, 
is due to infection for the first time with too large a 
dose of bacilli ; the virgin tissues are overw'helmed and 
put forth no resistance; the disease therefore rapidly 
gains ground, and proves fatal in the course of a few 
weeks or months. ” Modified ” tuberculosis occurs 
in those peoj)le who have been infected previously, 
often on several occasions, who have withstood the 
disease, but who later, from one eause or another — 
generally unfavourable environmental or social con- 
ditions — temporarily lose their resistance; the disease 
spreads slowly, and may not prove fatal for years. 
To protect against “ natural ” tuberculosis there must 
be — in Sheldon Dudley’s phrase — an endeavour to 
lower the “ infective potential ” of the environment; 

I to ensure as far as possible that the amount of 
infective material w'ith which infants are brought 
into contact is minimal; in this way the tissues 
■ are spared an overwhelming dose, and learn to 
' respond to the attack of the bacillus. To protect 
against “ modified ” tuberculosis, on the other hand, 
it is necessary to do everything to raise the standard 
of living, to improvG tiis social and iiousiDg conditioDS, 
to diminish alcohohsm, worry, and overwork, and to 
-keep the resistance of the body at as high a level as 
possible. 


148 Jan. 28, 1928] 


JLtiOOHOIi AKD LOUGEVITY. ' ifo : 


LONDON UNIVERSITY CHAIR OF PUBLIC HEALTH. 

The decision of tho University of London to establish a 
oliair of public health tenable at tho London School of 
Hygiene and Tropical Medicine is an event of conaiderablo 
importance, both ns regards tho University and the school, 
and also from tho point of view of the Empire. Tho 
organization of tho work of tho school in advance of tho 
.building of its house had already gone as far ns tho setting 
up of divisions, each under professorial charge, for bacterio- 
logy and immunology, for epidemiology and vital statistics, 
and for medical zoology, the last named covering much of 
tho piogrammo of n'ork in tropical medicine and hygiene. 
The new public health division will be concerned with such 
teaching and research as is not already envisaged bj* tho 
other divisions, and will bring into ciToct tho recommenda- 
tion of the Athlone Committee in 1921, that all instruction in 
public health subjects should be concentrated in one central 
institution. Although the now professorial appointment 
will not take full effect until the beginning of next year, 
the professor will in the meantime be permitted to take his 
scat on tho council of the school, and advise on tho organiza- 
tion and equipment of the new division. It is proposed 
that the scheme of teaching should comprise tho principles 
and practice of preventive medicine, and general sanita- 
tion and administration in relation to public health. This 
w'ould imply general courses both in the prevention of 
infectious and non-infcctious diseases controllable by 
administrative measures or hygienic safeguards, and also 
in the functions of health authorities and their officers, 
including the relation of medical practitioners to tho 
State. The special courses would relate to such subjects as 
the hygiene of childbirth, infancy, education, mental and 
industrial conditions, tuberculosis, and venereal disease. 
There will also be special courses in tho largo group of 
itibjects dealt with by sanitary authorities: — as, for osample, 
water supplies, sewage disposal, food control, sanitary law 
and administration, applied phj-siology, and the history of 
hj’giene. Tho duties of the new chair will not bo light. 
Its holder will be responsible for training post-graduate 
students from all parts of the Empire, and will be expected 
to suggest, guide, and supervise research. Ho will have 
also a great part to play in developing tho relations of the 
school with local authorities in this country, and in securing 
their co-operation. An important duty will be the organiza- 
tion of the outdoor courses of study forming part of the 
necessary training of a prospective medical officer of health, 
and of refresher courses for those already holding posts in 
the public health service. An announcement about the new 
chair aijpeared in the advertisement columns of our issue 
for January 14th, and is- repeated this week. It is hoped 
to secure for it a man with the breadth of vision to 
recognize it as a great opportunity of service to the world. 

ALCOHOL AND LONGEVITY. 

Eakly last year (March 19th, p. 528) we published a 
leading article on Professor Eaymond Pearl’s book Alcohol 
and Longevity, which we described as n valuable contribu- 
tion to Imowledge, worthy of its author’s high reputation. 
He has now published in Nature of January 7th a paper 
giving the results of n statistical analysis made by himself 
and Miss A“nes L. Bacon of some of the protocols of 
necropsies at Johns Hopkins Hospital. The first 7,500 
records have been extracted, hut of these 3,906 recorded 
no information as to the -habits of the deceased with 
respect to tho use of alcohol. Of the remainder (taking 
only persons of 20 or more at the time of death) 518 were 
reported to be abstainers, l,o09 moderate drinkers, and 
701 heavy drinkers. Tbe authors have worked ont the 
distributions of ages at death, distinguishing between 
whites and coloured persons. The results are these. Among 
white males there is no significant difference between tbe • 


ages at death of abstainers and moderate drinkers, but 
both bad si^iCcantly higher mean ages at death than 
tlio heavy drinkers. Among coloured males tho mean length 
of life was greatest for the heavy drinkeis. Among white 
females tho abstainers and moderato drinkers had an 
advantage over tho heai-y drinkers. Among coloured 
females tho heavy drinkers also had tho lowest average 
length of life, but tbo differences within this group are 
not statistically significant. The authors aro of opinion 
that these results essentially confirm tho main conclusion 
of Pi-ofcssor Pearl’s book mentioned above, which was that 
moderate drinking does not shorten life. The aut.'iors 
recognize, of course, that they are dealing witli very select 
material. Deaths in hospital are not a random sample 
of deaths in general (wholly apart from economic or social 
selection, particular diseases arc over- and others under-, 
represented in a " hospital population ”), and cases sub- 
jee-tod to post-mortem examination are not a random 
sample of all cases in hospital. Finally, in this particular 
series, tho proportion of cases which could not he included 
owing to lack of details as to drinking liabits was large. 
With regard to this last point, the authors state that the 
data used appeared to bo “ a fair sample of the nutopsied 
population.” Wo presume they moan by this that both , 
in ago distribution and in tho classification of tho causes 
of death the sample used did not differ in any statistically 
significant way from tho sample rejected. TJio authors 
will, no doubt, eventually report in greater detail upon 
this analysis. It docs not appear to iis that, in this short 
article, sufficient evidence is adduced to entitle us to 
ondorso tho authors’ conclusion. • For instance, we do not, 
on tbo facts presented, see how such' a criticism as’ the 
following can be met. It has often been said, probably 
with truth, that the relatively high fatality of lobar 
pneumonia in hospital experience— relatively, for instance, 
to that in such data as the Leipzig State Insurance 
experience— is duo to tho piesence in the hospital ))opula- 
tion of alcoholic adults of from 40 to 60 in whom the 
prognosis is extremely unfavourable. If, therefore, we 
took equal numbers of deaths of alcoholics and abstainers 
we should expect to find in tbo former group a relatively 
greater number of persons from 40 to 60, and a relatively 
smaller number of young persons, so that tho mean age 
at death of the alcoholics would tend to he higher. We 
do not see how in such a case the truth could be asceitained 
without a knowledge of the “e.xposed to risk”— that is, the 
whole number of patients. This difficulty must surely 
affect other comparisons. Thus, suppose, for the sake of . 
argument merely, that the regular use of alcohol pr^ 
disposes to tho development of malignant disease. This . 
would presumably result in a larger and larger ” bag ’’ 
of alcoholics with advancing age, so that a comparison of 
the mean ages of dead persons with cancer ought, on the 
hypothesis, to show a higher mean age for the alcoholics. ' 
In sum, we do not see how any analysis of hospital deaths 
can either strengthen or weaken arguments based upon 
a knowledge of whnt the actuary calls the exposed to 
risk So accomplished a statistician as Professor Pearl is, 
of Murse, aware of these difficulties, and, as remarked 
above we sliould welcome a more detailed exposition of 
ids re’asons for attaching importance to the mean ages at 
death of patients upon whom necropsies have been per- 
formed in hospitals. 

POST-ENCEPHALITIC RESPIRATORY DISORDERS. 

Tbe new issue of the Journal of Neurology and Psycho- 
pathology^ contains a paper by Drs. Aldren Turner 
and Macdonald Critchley on post-encephalitic respiratory 
disturbances, regarded especially in tho light of tlio ir 

‘/uumol of KeuTologv and PsucSiopatholoov, Jonuary, 1928. 
q«/rleru by tue Br Medical Asociation. Ta^etoct Square, Loi^^don, 

l trice rliJela nambers, Bs. 6d. net; subscription, 30s. per annum. 

Post freft. 


roST-ENCKrnAUMOlBESPIIlATORX DISORDERS. 


'.S, 1 028^ 

luognostio significance and scqnclae. It is ,,ninte<l out 
that most of the litcialnio ivliicli deals uitli the icsim-atovy 
disoi-dei-s associated with epidemic enceptialitis lias heen 
of a iniiolv descriptive iiatnrc, and Unit no attemiit has 
been made’ to trace tho results in patients .snfreniig from 
such disorders, or to arrive at their prognosti.' .significance. 
In a previous articlo on the siihject, piihlished in 1925, 
the authors modified tho original classiticatioii of Mavic and 
Lew, and made throe catcgorio.s : (1) disordor.s of respira- 
tory rate, (2) disorders of rosiiiratoiy rliytlim, and (2) 
respiratory ties. Tho first group included case.s of taclij-- 
pnoea and of bradypnoea ; the second, case.s of hroath-holding 
spells, apiiocic pauses, and Choync'-Stoivc.s respiration; tho 
third group comprised .such disordor.s as spasmodic cough, 
iiivolinitary yawning, blowing, sniffing, etc. The authors 
have hceu aide to follow up these cases, and to examino 
many others showing similar resiiiratory troubles, tho 
object being to determine the ultimate fate of such patients. 
References to tho subject in the litoratnro are scanty; 0110 
of the most roceiit is in the Jlcdical Research Council’s 
report on tho epidemic of encephalitis in Sheffield in 1924, 
where Hall and Gurney Yates recorded their liolicf that 
respiratory manifestations, occurring not during the acute 
phase blit as an aftcr-etfcct, were not usually preceded by 
anything similar in the primary attack, and that they 
were not of such serious importance to life; th<‘ fato of 
tho patient as regards respiratory disorder was not, how- 
ever, dealt with. The material upon which the authors 
base their present analysis coin]u'iscs primarily the original 
.seven casc.s reported in their first paiier, and twenty-two 
others, most of- which occurred in tlio praitiie of the 
Xational Hospital, Queen Square. The mitconie of those 
eases has been considered under five main beads — namely, 
(o) cases of comploto cure; (b) cases in which respiration 
became normal .although tho mental concomitants wei'c 
unchanged or had become worse (ton casesl (r) c ases in 
which respiration improved, without, honi’i'er, any corra- 
sponding alteration in the associated niaiiif< 'tations ; 
(li) cases in which respiratorv disortlers p^-rsisted un- 
changed; and (c) fatal cases in niiicli death occui'i'ctl during 
the phase of respiratory disorder. Tho authors have only 
met with two cases in which tho cure could bo regarded as 
complete; one of these was actuallv the severest case of 
paioxysiual breathing they ever encountered. The com- 
pleteness of the recovei-y was dramatic. While in a mental 
liospital the patient developed a severe attack of influenza; 
when this passed away his breathing was almost nonnal; 
he rapidly regained weight, tho hallucinations and de- 
usions fiom nhich ho suffered left him entiidy, and lie 
giathially recovered. The authors recall a similar case 
ported by Fiainberti in which breathing bccanie normal 
« ei an attack of paratyphoid fever. In thirteen cases 
le rospiiatory disorder was unchanged. In one such case, 
in^'i'ooa > "I'o had suffered from encephalitis -some time 
niul attacks of dyspnoea 

iinsnlti'i' 1 “''Huioca; fifteen months after leaving 
uaroKYsni imrcolcptic-like attack.s following tho 

The ^ without any preceding fatigue.. 

rescnib'lor'^'^*°''**T°^, suddevUy, was irresistible, 

ill cases ef " / stimuli. Death may supervene 

but 'is less '•^spiratory disorders, 

encephalitis Tl.„ li chronic or subacute 

1 alitis. The authors report two fatal cases. -Hthougli 


t Tnz Bnrrrf* 140 

ilKDtC-U. JoxTBXii - 


the number of eases ^ 
too small to iustifs- , ’jasis of this p'aper is 

rriiosis if +1 , 1 uefiiiito conclusions as regards pro- 

tentative o;,m, of ‘ they constit«rc a repre- 

ia general. In tl” respiratory disorders 

evei-y varietv nf cases investigated almost 

The author: 


ariet,- nC 1 - cases iiivesrigaieii utiiiosn 

itliors are^'of 'wreathing anomaly was represented. 


hrcatliinir ano.'ooi . i that the character of the 

} oes not materially alter the prognosis. 


Tho proportion of roenvories appears to he greater in cases 
with n progrossivo I’arkinsonian state than in those without 
such manifestation. They emphasize also tho fact that 
tlio I’ccovery rate apparently docs not depend upon any 
particular treatment. Improvement, when it occurs, seems 
to bo spontaneous. 

' HEALTH AND EDUCATION. 

In our issues of .laiiimry .7th and 14th last (pp. 28 and 62) 
wo gave a siimiiiary of several of the papers dealing with 
medical aspects of educational matters which were read at 
tho conference of edncatioiial organizations then being 
held at Dniversity College, London. At the same time, 
according to custom, tho North of England Education 
Coiifevenco was taking place at Scarhovongh. At this 
latter conference Dr. R. H. Crowley, Senior Medical Officer 
of the Board of Education, introduced the subject of 
“ Health ill relation to education.” His paper is impor- 
tant in that it draws attention to two matters in this 
connexion which are becoming of more and more immediate 
and practical concern to those engaged in health and 
educational work. One of these is the teaching of hygiene 
in tho schools; tho other is the special attention required 
by the child of stihnormal or abnormal mentality. Each of 
those subjects is worthy of the best thought of the medical 
and the teaching profcs.sions, and must necessarily require 
their coidial co-operation. Tho present position of the 
former snhjcet is reviewed by Sir George Newman in the 
chapter headed “ Health teaching in schools ” of his 
annual report as Chief Mcrlical Officer of the Board of 
Education, issued last November under the title of “ The 
health of tho school child,” and referred to in the is.sues of 
tho JounN.\L of Decemhor lOtli and 17th, 1927 (pp. 1106 
and 1159). The position is not as satisfactoiy as it should 
be. TJnder some local education authorities (notably 
Hornsey, where lessons in pcraonal and domestic hygiene 
have heen given systoinaticnlly to every child in tho 
elementary schools for nearly twenty-five years) effective 
instruction in health matters has been widely given for a 
considerable mimhor of years. Under other authorities 
(unhappily, Lmidon is one) such instruction was at one time 
provided, hut has latterly been neglected or abandoned. 
Under still others no attention has ever been paid to tho 
subject at all, cxcci>t po.ssibly by the good sense of indi- 
vidual teachers, in spite of the fact that it is among the 
subjects pre.seribed by the Education Code, and is held by 
the Board to be of such importance “ that no one would 
propose its omission from the cnrricnliim.” In view of 
theso recent pronouncements, and of the fact that the 
Board of Education is publishing almost immediately a 
special handbook of suggestions to teachers on the teaching 
of hygiene, it is to be expected that fuller attention will ho 
given to training school children in tho art and science of 
health. The other matter to which Dr. Crowley drew 
' attention in his address was the special needs of tlio 
mentallv maladjusted child. Of late yeara the varieties 
of mental defect have become more clearly differentiated 
and understood; it has been realized that the ” difficult 
oc “ nervous ” child, whose conduct in the school or home 
reveals a lack of harmony or stability, needs at least as 
much individual consideration and help as does the child 
who is mentally deficient in the technical sense. Theie 
are two movements now in inogress thiough which such 
consideration and help mac' be forthcoming. Practical 
developments as well as theoretical investigation may he 
expected by tho appointment of psychologists hj local 
authorities, singly or in combination; and we strongly 
commencl such appointments to the consideration of educa- 
tion authorities. London showed their value long ago, hiit- 
. other authorities have been very slow to follow this example. 
Further such activities as those of the Ceutral Association 
for Aleutal lYelfare, and of the more recently, formed Child. 



160 Jan. 28, 1928] 


WIfiLTAM- H. 


TniiBnmn '.C 

Wf DlClt /OCBltU, _ _ 


Guidaiico Council, avo to Lc welcomed. The former deals 
mainly, tlio\igli not exclusively, with the mentally defective 
child, the latter with the “ difficult ” child or adolescent. 
The Child Guidance Council is at present adequately 
financed and is under suitable auspices. The development 
of its action will bo sympathetically watched by the medical 
profession, and it should ho helpful to, and helped by, 
education authorities. 


william h. welch, M.D. 

FniENDs of Professor W. H. Welch in this country — and 
they are those who have met him — may have noticed that 
on May 4th last he was presented with the Kober medal 
for research in scientific medicine of the Association of 
American Physicians by Dr. G. M. Kqbor, the founder of 
the medal, which, first awarded in 1925 to Hideyo Noguchi, 
was given to Theobald Smitli in 1026. The full account of 
the ceremony, with the speeches, lias now become available 
in an advance print from the Transactions of tiie Associa- 
ixou of American Physicians, and it is natural to find some 
items of interesting history in the remarks of the donor 
and recipient, as they have been friends for close on forty 
years. Dr. Kober, who was born in 1850 — tlio samo year 
as Professor AVclcli — is a well known authority on publio 
health, and is believed to have been the first to point out the 
agency of flies in the transmission of typhoid fever (1895), 
and to have published the first record of the use of tincturo 
of iodine in a gunshot wound of the kneo-joint (1876). Ho 
designated Professor Wolcli as tlio “ father of scientific 
medicine in America,” and touched on his services to 
pathologj', publio health, the history of modicino, and 
especially on his labouns, since 1886, to improve medical 
educationj and so to have been instrumental in m.aking 
American medicine wliat it is now. As founder of tho 
Journal of 'Experimental Aledicinc, as constant advisor of 
the Rockefeller Foundation, inspiring teacher, rcscarchor, 
example of culture, and tho instigator of whole-time 
professorships, he had made American modicino his debtor. 
In his reply Professor Welch mentioned tliat ho was 
the sole survivor of tho small group of men— Osier and 
Pepper from Philadelphia, P. Minot and R. Fite from 
Boston, and Draper, Kinnicut, and Dolafiold from New York 
—who, in Januaiy, 1886, founded the Association of American 
Physicians, and referred to its first president, Delafiold, 
as having “in an eminent degree tho gift of multum-in- 
parvo speech.” Ho went on to claim the privilege of years, 
and to give a few words of advice and precept — ^uot, 
bo admitted, conspionously exemplified in liis own career. 
He exhorted his hearers not to allow anything to divert 
them from their professional and scientific work, and while 
maintaining a spirit of co-operation to resist tho call to give 
general addresses, especially at a distance, not to serve on 
committees, not to assume time-consuming administrative 
duties, or to show visitors round laboratories and clinics, 
for “ tlio active scientific investigator should be at least 
as inaccessible to the intrusion of casual visitors as the 
financier or tho railway president.” 


j'BULLETIN OF HYGIENE.- 

The Eulhtin of Hyqiciie, like its elder brother the Tropical 
Diseases Eulletin (now in its twenty-fifth volume), is 
published bv the Bureau of Hygiene and Tropical Diseases, 
which is an institution of the Colonial. Office ; it deals with 
subjects of interest to medical officers at homo as well _ as 
in the tropics. There appears to bo no other publication 
in tho English language wliicli surveys similarly^ tho 
whole field of hvgiene by signed abstracts (with illus- 
trations) of current literature, the abstractors including 
many well known active and retired medical officers of 
eat . The only other journal at all comparable is 'the 


Gorman ZentralhJalt filr die Gesamte Hygiene, which, in 
an attempt to cover an enormous field, including subjects 
only distantly related to hygiciio, is compelled to slioiton 
many of its abstracts, which consequently convoy little 
information. TJio bulletin of Jlyyicne appears once each 
month; it coiicontratcs upon tho literature in tho English, 
French, and Gorman languages, though in 1927 forty-six 
papers in other languages were also noticed; its abstracts 
aro of sufficient length to make thorn of value to those who 
cannot consult tho originals; and it is the practice of the 
abstractors to add helpful remarks indicating where the 
views expressed support or aro at variance with the 
observations of other workers. Tho Bullet in of Hygiene 
is now entering its third year. Tho first tivo volumes 
included sections devoted to In-giono in tho tropics, but 
from the cominencomont of 1928 those aspects .of hygiene 
and sanitation, such as malaria prevention, which are of 
importance solely or chiefly in tho tropics, will be dealt 
with in tho Tropical Diseases Bulletin, the newer journal 
restricting itself to subjects of general interest. TJie 
January number, just published, has sections dealing with 
dental liygleno, milk, light therapy, cancer, epidemic 
neivous diseases, rlicumatic diseases, scarlet fever, and an 
iUustrated article by Dr. Daukes on popular liealtli educa- 
tion in Germany — the fourth of a scries of aiticles on 
health propaganda. The Bulletin has an interest for 
practitioners as well as for specialist health officers; it 
keeps its rcndei-s well posted in current literature, and is a 
useful work of reference when information on a particular 
subject is required. 


EX AMERICA SEMPER ALIQUID NOVI. 

We confess that wo were unacquainted with the science 
of Icgisintivo antliropolog)-. It seems, however, to be a 
fascimitiim study-no less, indeed, than the invest.pt.oii 
of the k-tslativo, political, sociological, psychological, and 
ohvsical "status of members of tho American Congress. 
U Arthur htacDonald, of tho Congressional Apartments, 
Washington, has kindly given us some particulars of the 
Slice- .and ho tells us that the data are not only of 
general importance, but help to show the degi-ce m winch 
the differeut statuses are related or depend upon each 
Ser ”t appears that evei^ member of ^ngress who 
allows his anthropological measurements to be taken for 
wjfin im. noses is entitled to gratuitous examination by 
scientific ® specialists. As Dr. MacDonald 

t o i if Congress be able in this way 

U pZ ido in advance against any latent weaknesses un- 
^ their family practitioners; they will also set an 

known to _ labouring man ” to spehd a nominal sum 

m e supervision. Every hour spent in these 

organ, " . . gjatgd, may add years to the Congress- 

""“Tu c inJiriaving him from pain, suffering, and 
increase liis efficiency in the public seiwice. Each 
o/ tW specialists sends a report te Dr. MacDonald, who 
furnislici a copy to the member if desired. Besides these 
reports and the anthropological measurements, a record is 
the Icnislative activities of the member; the number 
frills he has introduced and carried, the petitions he has 
of bills be h frequency (not length) of the remarks 

?riiafmado1rom tL\oor of the House. The legislative 
status of the member is estimated by the difficulty of the 
bills he has introduced, and particularly by the number 0 
such bills that have passed into law, and vani Jed, pr - 
sumablv into the Umbo where, we have been told, a larg 

amount of American legislation Jsappears t tteChvs cal 
Dr. MacDonald is right m thinking that the 
measurements of members of Omgvcss 
anthropological status of the wbolo country 
than measurements of any other body of men. Some, liow 


JAN. --S, 1928], VENEREOLOGICAIi EPISODES. 


[ 


Tmi B*m*» 
3Ied;caz, JonHi& 


161 


ever, may bo disappointed not to find in bis snmmai-y of 
legislative antbiopology any evidence of provision of psycho- 
analysis for the members. Tlioir subconscious attitude 
towards, say, the Volstead law might do much to elucidate 
American mentality. 


AN ENGLISH HOSPITAL IN FORMOSA. 

So^rE light on medical practice in Formosa is thrown by 
Dr. P. Chcal, medical officer in charge of the English 
Prcsbj-tcrian Mission Hospital at Tainan in that island. 
The hospital contains 150 beds, and tho staff includes 
three medical practitioners (one a Japanese), two trained 
nurses, and nine probationers. There are also si.v student 
dispensers, comparable with diesscrs in a teaching hospital 
in Great Britain, one pathological assistant, and one man 
in charge of ultra-violet ray treatment. Tho student 
dispensers give all anaesthetics, and chloroform is used 
almost exclusively, usually with tho A'crnon-Harcourt 
apparatus; serious difficulties hardlj’ over occur. About 
2,600 in-patients are , treated annually. Since tho local 
therapeutic fashion favouis injections, not a few cases of 
morphine poisoning bavo to bo dealt with. Iiitussuscop- 
tious form a largo portion of acute surgical cases, and 
treatment by rapid^ lateral anastomosis, leaving the mass 
in position for subsequent absorption, has proved satis- 
factoiy. Gastric ulcer and duodenal idcer are common, and 
gastro-entcrostomy is almost invariably satisfactoiy. When 
these patients are left to medical treatment they rccoivo 
such a multiplicity of drugs from their numerous medical 
attendants that tho stomach has very little chance of 
escaping inflammation, oven apart from tho disease. Some 
acute surgical cases received into tho hospital are compli- 
cated by the fact that a Chinese practitioner, without any 
quahaeations, professional or otherwise, has opened tho 
abdomen, decided that the affair was beyond his skill, 
astdy sewn up tho wound, and sent tho patient aw.ay on 
p journey, possibly on a rough baml.oo stretcher. 

a rents uith acute surgical disorders not infrequently 
pass 111 o a chronic condition before entering hospital, 
oiMiig o die custom of inquiring at a temple what would 
0 e most favourable time for tho eventful step; tho 
emp e aut loritics often advise a delay of some weeks, 
aiicei an tuberculosis fom a largo propoitioii of chronic 
cases, pulmonaiy tuberculosis is veiy prevalent, 

. I*** ^ houses give little chanco for tho 

thm 'T ^lulnria is still common in the island, 

though the Japanese. are eradicating it from tho city. 

almost universal among tho islanders, 
but vniri l^'"’i gonorrhoeal variety, is rare, 

is not t'fi asions of tho heart aro very frequent. Measles 
chilrlron°° ^ “"d therefore amiy prevalent; as tho 

freelv 'Jsually untreated and allowed to r un about 

of tho sequels occur, including gross sloughing 

Lenr lv t”’ the faee^ 

are seldorn'^°'^™°M ''' *1°"' tvpe. Eecropsies 

"gainst^7em'’°n\T^^^^ ^ strong 'local prejudice 

for many cases of of syphilis accounts 

growth or rickoi-c i obstructed labour, due to 

uterus— both bod^ is common. Cancer of the 

vaginal hystereetomv7“ is very frequent, and 

Cheal adds that +i P®**imed whenever possible. Dr. 
supporting ■ all tho ”!• “’®P**“i i^as always been self- 
a small suiri P^i'^ats who can afford to do so pay 


daily. 



to attend. 


liffiTa fit !Jfitfira, 


YENEREOLOGICAL EPISODES. 

I. — 21ie Fama of Syphilis, 

Knowledge of s}*pliilis spread rapidly in the late fifteenth* 
century j before its close Aberdeen had civic regulations 
dealing with it, and Edinburgh used Inchkeith as an 
isolation station. Tho following quaint document, trans- 
lated from tho Dundee records, exhibits anotlier aspect. 

In Ulo 3 'car 1527 on the fifteenth day of July, before th® 
Bailies* Court of pundeo, in presenco of William Lowson, John 
Walker and David Alexander and William Cathro, tho two 
sergeants : — that Alexander Blak, junior, carver, has sold to David 
Weddevbnrn his marilagium with the profit thereof for money 
of Scotland, of which sum he acknowledges himself to have 
received xiiii® in pa 3 'ment, and the said David will pay tho 
remainder on completion of tho marriage (maritagii); and tho 
said Alexander will receive in marriage (maritagio) any woman 
offered by tho said David, whomsoever David shall please, lacking 
these diseases viz : — lo bock et cragyngour (Pock and grangore) 
and free from ill reputo, notwithstanding that she maj' be squint 
or lamo : and if the said Alexander shall refuse to accept in 
marriage the person so offered as above by the said David, that 
ho shall pay xl^^ to tho said David for the said sum of xx^^^ 
and for costs, damages and expenses incurred in the suit.*’ 

TIio Latin transcript of this document has been printed 
in The TrcdJcrhu7 n Doohj 1898, vpl. ii, p. 209. 


IT.— i n Epidemic of Si/phiJis Insoniium. 

Patrick Blair, M.D., F.R.S., whose pemonal story must 
wait another occasion, practised in Dundee and then in 
Coupar Angus before, in the “ ’15,” be accompanied the 
Jacobites to Preston; rejirioved on tbs morning set for liis 
execution, bo went to Boston, Lines, where be died in 
1728. On July 6tli, 1713, from Coiipar he wrote to Richard 
Mead a letter “ on some epidemical diseases in Scotland,” 
from which tho following may be extracted. 

*‘ The third distemper is, what I suppose you have got no 
account of, being os yet but little known in this country (wliere 
it took its rise) except in a few corners tliereof. We general 
compute its date to commence at tlie famous battle of Killy- 
chrankie, soon after which it began to appear. It has not as 
yet spread far, but wherever it takes it is very infectious. It 
IS a common received opinion tliat the Lues Vaicrea is not any 
ways propagated but by impure concubitus, and yet this dis- 
temper is the very same with it, except its not being introduced 
by a coitus, nor preceded by a Gonorrhea, neitlier for tlie most 
part accompanied with Buboes nor Chankers. It spares none, 
affects the sucklings, violently seizes those under age, and such 
as can bo no ways suspected to Iiave a Lues Venerea : It is 
generally known four ways. First by nocturnal pains, which 
degenerate into Nods. Secondly, by an Exulccration of the 
throat, landing in a Carious Palate and falling ofi the nose. 
Thirdly, Cacoethes ulcers over all the body. Fourthly, 
Cotylidoncs here and there upon the body, or dry Pustuls 
unequal in the surface, not unlike the fruit of the llubus Idaeus, 
commonly called with us the Sivvans (from which the disease 
takes its name) being much of the same red fleshy colour with 
that fruit when ripe. The Cotylidoncs affect most parts of 
the body except the pudenda in both se.xes, by which alone 
it may bo dislinc lislied from the Lues FcTierea : This distemper 
is so contagious that if any servant labouring under it (as it 
is generally that rank of people that are most affected by it) 
da lake care of cliildren, be in more frequent converse with other 
servants, or in a word, if their bed-cloaths be mixed with those 
of the rest of the family, it seldom goes off without communi- 
cating itself to some one or other of them. This I have knoivn 
by experience, and generally those have been either sucklings, 
or underlings, as I have said, about ten or twelve years of 
age, and sometimes those of betwixt twenty and thirty-, whose 
behaviour could give no ground to suspect its being venereal. 

" . . I can find nothing more reasonable than that after 

the battle of Killy-clirankie, when, the souldiers, being dis- 
persed all over our Highlands, had a greater occasion of 
diffusing their impurities in those parts of the couidry than 
ever before, and of infecting tlie females there. Row Highland 
nurses being always much valued by those m the Lowlands, 
because of the wholesomeness of ‘heir food, had m all prob- 
ability communicated it to the children on their breasts upon 
whom it appeared with that variety of symptoms I vo told 
vou of Aoain, tliose children it seems _ by the effluvia, 
or transpirations from their body, communicated it to their 
dry nurses, as we caU those who take care of them after 


162 Jan. sS, iojSJ 


LONDON CLINIC FORMlHEmrAXIC DISEASES. 


“ It i.s very observable Ibat altbo' tbi.s cli.slein|)cr lias been 
raging among ns these, 24 years past, ycl it lias not imieh 
exceeded the bounds of 4 or 5 parishes to this hour. So favoiir- 
nblo is a good Lrovidence in restraining the l>mgrcss of a 
distemper, which olherway.s might prove very, no.vioiis to a 
whole country, and in .saving the better rnnk*of people from 
its infcelion. 1 have of late been inform’d that it' now ragc.s 
near to Inverne.s.s and Inverlochy. which imi.sl have been 
comnumicated to the inhabitants of those Highland countries 
by the soldiers.’’ — Blair’s .!/iserWfniioii.< Olixrrrntiimf. 1718, 
p. 87. 

111.— Dr. ])e Jbdlin. 

Dr. Dc Bnllin is a name in the Dundee Directory for 
1845, and recently, during a .search in the Advvrtixer of 
1841 for information on a quilo sejmrate subject, tbi.s 
name was noticed in the ndvertisomeut columns, thus: 

" Dr. Do Dallm M.D. Graduate, of the Universities of Copen- 
hagen and Salamanca and late Surgeon to the Napoleon Forces, 
Member of the Legion of Honour .trc. 

“ Begs to intimate to his Friend.s and the Fahlic that he has 
passed the greater part of his professional career with tlic French 
Army during its active exertions mulcr Napoleon, and which 
he accompanied in its various hostile campaigns thronghoul Sp.ain, 
Portugal, Russia, German}’ Ac. and only terminated his connexion 
with it after the sanguinary conflict and final riihi of Ihc Enmeror 
on the Plains of tVatcrIoo. From the above it is evident Dr. De B. 
has enjoyed the most extensive opportunities of acquiring a 
thorough and practical knowledge of his profession and of all 
diseases incident to the huniaii frame— more particularly those 
which altacli tlKiiisclvcs to the libertine b.ibils of a predatory 
army, via : venereal diseases. 

” The gloss ignorance which British practitioners have displayed 
in the cure of this disease has had the otfect of throwing its 
t.reatmciit almost entircdy into the hands of ffimrk tioetorf, who, 
by pretended siirnfira and glib promises of speedy cure, have, less 
liarmlossly, euccoeded in extracting fees from tbc pockets of llicir 
victims, than irrecoverably vuiiiing their health. The cause of 
' ' ■ ner.s is to ho ascribed to their 

■on the riii'ictim of it. They liavo 
only by extent and not in kind. 

“ ITCH OINTMENT wbicli will cli'cct a cure in one r.ighi to ho 
had at 2s. per box, instead of 2s. 9d, & 4s. 6d. 

“ Dl'LLNESS OF HEARING can be cured in most iiisl aiiecs. 
Also SORE LEGS cured if over of so long slanding. 

" Dr. Do B. has practised in Dundee the.so eleven years past and 
may be consulted on the nature and treatment of all diseases, 
with confidence of relief, at his house, Thortcr Row, from ten 
morning till ten at iiighl.’' 


PROPOSED LONDON CLINIC FOR RHEUMATIC 
DISEASES. 


APPEAL BY BRITISH RED CROSS SOCIETY. 


Tni: British Red Cross Society' is iiroposiiig to est.-iblisb in 
tliickly populated centres t'livougliout the eoiintry cliiiic.s 
for the treatment of iheumatisui in adult .siiflercrs. It is 
taking this action on representations made by large indus- 
trial bodies, including friendly societies and trade unions, 
and snppoited by members of the medical jirofession. 
The first clinic is to be in London, wlioro an ojition lias boon 
secured on a suitable building close to Portland Road 
station, and so within easy acce.ss from the great northern 
termini. To adajit and equip the building a .sum of 
£40,000 is necessary, about £15,000 of ivhieh has been 
ahoadv promised, including donations of £5,000 from tlio 
British Rod Cross Society itself, £6,500 as a “ first instal- 
ment ” from an anonymous benefactor, and 500 guineas 
eatli from the London Insurance Comiiiittce and three 
largo approved society organizations. 

It will he recalled that in March of last year a conference 


on the jirovision of spa treatment for insured persons was 
Bnmnioiiod bv the British Medical Association,- and was 
attended not'only by medical men interested in the subject, 
blit by representatives oT industrial workers, when the 
qucstlim of providing increased facilities for the diagnosis 
and troatniont of rheumatic diseases n as closely explored. 
Blun tly afterwards there appeared in the Times a letter, 
signod' by several eminent meylical men, drawing attention 
to the wide prevalence of rheumatism among employed 

pcp.toiis *11 .1 

^ Jinj 


f'ncl the handicaji thus laid upon industry, .and 


'WSH JlEDICVL JOURNUi, SUPPLEMENT, Slapch I2th, ISZf, 


p. 85. 


f Thj: .2 

LMr.DicALJotftNlt 

pleading flmt clinics for -physical treatment should lie 
e.stablishcd in London and elsewhere for the investigation, 
diagnosis,' and tlcafment of rheumatic conditions, espe- 
fially in the early stages. In the late suninicr a numhor of 
medical men and others iiilerestod in the subject attended 
the iimiigiiratiou of a German committee on industrial 
iheuiimtism iii Berlin, and visited varioms citv clinics ami 
sjuis in (icriiiauy.- TJie British Committee on Rbeumatisiii 
a committee of the Tuti-riiatioiial Society of Medical 
Hydrology — i.s.siied in A’oeomber a niomorandiim outlining 
the problem and the opportunity, which’ memorandum w.as 
ptiblishod iti oilr pages',^ and has been reprinted therefrom 
as a leaflet for circulation by the British Red Cio.s,s Society 
ill fiirtlieraiice of its appeal. 

Pwxs Fon THE London Cw.nic. 

The eommittce of the British Red Cross Society, wliith is 
urging file claims of the London clinic upon the public, 
include.s, under the ehaiimaiiship of tho Hon. Sir Arthur 
Stanley, a iiiimher of medical roiireseutative.s. Lord Dawson 
of Pciin, Sir Humphry Rollcstoii, Sir William Hale-White, 
Sir Thomas Holder, and Sir William Willcox; also such 
trade union and approved society leaders as Mr. AV. A. 
Appleton, Mr. C. G. Izard, and 5lr. P. RocklifF, together 
with |•oprpscufativcs of tho Council of the Red Cross, .such 
as Licut.-Coloiiol A. R. Aldridge and Sir Edward Steirart. 

The jiroiiDScd clinic will he under a niaiiagiiig committee, 
apiiQiiitcd by the Red Cross, to which representatives of 
the inedie.'d profisssion and of industrial organizations will 
be eo- 0 ])tcd. All treatment will be given, under tho super- 
vision of a medical director, by a staff having expert know- 
ledge of ph.vsicai methods of therapeutics. There will be 
provision for men and women (in .separate blocks) of baths 
and vapour trentnienl, locally and generally applied, of 
manipulation and exercises, of heat, light, and ultra-violet 
radiation, and of the usual electrical applications, including 
diathermy. The majoritv of the jintionts will be required 
to make from ten to fifteen attendances, spread over penods 
varying up to a montli or six weeks, and it is estimated 
that the total inimhcr of iiulividnal patients treated in a 
year will he approxiniately 12,000. 

It is hoped to make the clinic, when once established, sclf- 
I supporting, for it is believed that a great majority of those 
attendiiig°will he able and willing to jmy a reasonable fee 
* for troatnieiit, while with regard to insured jiersons a 
I definite undertaking lias been given by the Ministry of 
Hcaltli tlmt the insurance regulations will be amended to 
enable approved societies to pay capitation rates on behalf 
of their nicnihers when treatment at such a clinic becomes 
available. Tbc plan of tlie proposed building shows the 
basement 'dvon up to pool and slipper baths, the ground 
floor to accommodation for doiiehos and vapour treatment, 
as well as administration, and the first floor to rooms for 
special electrical and other treatment, ,T-ray work, and a 
In'horatorv. 

SrnECHEs in SurpoitT. 

On AVediicsday of this xveek a press luncheon took place, 
on the invitation of Sir Artlnir Stanley, at tho Royal 
Antomobilo Chib, when speeches in support and exposition 
of the scheme were made. Tlie first was by Sir AYilw.oi 
AA^ imxox who said that the Ministry of Health report in 
1924 on the incidence of rheumatic diseases was one of the 
most vahviblc ever issued by that department. It revealed 
the astounding fact that something like one-sixth of the 
sick-absence in industry was duo to this cause. The 
prox-alence of rhonmatism had never before been statis- 
tically demonstrated. This clinic, he added, was not 
launching out upon an unknown sea, for already a con- 
siderable Continental c-xporience was available to show 
that such clinics did have a large and direct effect on the 
reduction of invalidity. One could prophesy almost ivith 
certaintv th.at when this moveniont had reached its full 
fruition" crippling rheumatism would he almost niiknowii. 

Sir AA’iLi.i.rar Haue-AA^bue mentioned that at Guy’s, in 
the massage department— which, in spite of its restricted 
name, iiielnded all t he treatments proposed to be given at 

= British jrciiiM, .Tourxm- September 17tli, 1927, p. 502. 

3 Ibid., November P. 893. 




164 Jan. 28, 1928] 


ENQEiAND -AND WALES. 


bv®irfm-\®hn T .rl ^^159, 000 has boon collected 

• ^ ,• sum contributed bv oin- 

p ojees m collieries .and oil norks ainoiintod to £10 267 an 
increase of £554 on the fornior vear’s figure wliicli was 

S'r£T55i2i“91 “l """'I”"'’ voar 

£7 lOs^® 2d^ Tf ■’ ;‘Y''='S“ P'>tienl‘w.a.s 

£f 10s. 2(1. It nas reported that the fund for the new 

o.\Y'.‘sioii splenic, winch is eontcniplatcd when the Kiouiid 
adjoining the liospit.al becomes available in tlie ,-ovrTof 
the next fiio years, now amounted to £17,145. 

Glasgow Vutohia iNiiiurAUY. 

. The annual meeting of the ladi.^s’ aiixiliarv •issoci-./;,,,, 

on Janua'iw Tsui' ‘'i-; Victoria Infirmarv w.a^ h;:id 

bad been h-S' in 

ontlf.?He'f^^ wjnor surgical eases which ^vere treated ‘ai 
sTort "o'r'ilf ''’c 'o’' <lina.'y intme 'IrnT faMe:! 

5;o.i.i.etbrrSi;r‘:!;^S(:;L"^fjLt:i^L 

T^e"”r‘' of the new wing of the hos,,if,‘/at 

;i» C.-;;' :;nrc,Si™ ■” ”■ "'"'i-' 


f, Tiirr.ftm»B 

tSfriucg Joinyu 


TI, * ir. 1 HtCIJ;n-e IN SCOTLAND. 

Tn „ r ■■‘'po t '>r the British Social HAeieno 

19?7 ’ ’"6 "'?*•■ the period from June, 1926 to' JI-iv 

■vhn:ti''Tr2Z2V'rwa^T576’ 

bad boon 4.058. including 2,181 males and 1 ST^'V^.X 


fiwecDs irp linJiln + cotton spinners, nnd cliimiicy. 

e "1.*° . '^’bi minors and cutlen’ 


O^itglanir ^ Males. 

Decennial Suitlfmfnt 

with the mortality of men in dfSt Stations wi t f 
their fertility, and with tho mortality of theil infants 
AA as published on Monday.! The first part consisting ef n 
report by the Government Actnan- on^Iifo’ tables bafed on 
n f r"eL°^ England and IValos, and the average 

number of deaths was issued at the end of last Septembof 

1^607 in our issue of October 1 st 

1 . 607. Among other interesting matter beariim upon the 

tbe country the document fssX this 
eek supplies ansAvers to such questions as “ Whicli are 
the most unhealthy occupations? ” and “ In which sections 
of the community ,s the birth rate high or the ilnut 
mortality o,v? ” Mortality by social clats has beL ado 
a specml featiire of the report. This investigation sho, vs 
the differential incidence of the several diseaL upon tl e 
five social groups into AA-Iiich the male working population 
(liA Ided. iniilo giving statistical proif some 
diffeiences of common knowledge it has rcvealor] /\fi 
hitherto unsuspected. Tims the^abiilatL of cKaths W 
cancer, by site, indicates that cancers of certain parts 7f 
tlie body are very much more frequent in tho poorer 
sections of society, Avhile from those of other sito7^n 
classes suffer very much alike. Of these two groups wl.ic 
account for almost equal numbers of deaOis the first 
includes the alimentaiy tract from mouth to stomach fbiit 
not the intestine), the skin, and the larynx, all other 
cancers affecting rich and poor indifferently. Such a 
phenomenon raises the question to what extent this hiirh 
mortality from cancer of tiie upper alimentary tract is 
preA'entable. The higher incidence of mortality 'from high 
living and excessive drinking amongst the more well-to-do 
is shown in the death rates from appendicitis, diabetes fin 
later life), and alcoholism (cirrhosis of the liver), while 
the high rates from tuberculosis known to exist amcJiig the 
poor are clearly demonstrated. The lengthy section d evoted 

Decennial Supplement, 1921, Part II, Occu- 
Offlee. 1828. 7s. ia. neL ■'>■“'>‘■'0 Mortality. H.M. Stationery 


«.,ll.T. "oi'Acrs, almost without exception are 

h£r '=’’‘''”8'^^ ?f «■■= kidneys, Cm "; .ami 

hcalthv hut Inn kr''*”*!” *bown to be e.xccptioiiaily 
litalthj, but barri.stors have a much less favourable mor- 

bSbest'‘or'ni',v"of B appouIieiC is the 

(-ri ; ^ *'1'^ occiijiatioiis dealt Avith, Tlie section 

b Ld cs to'''the"r‘’ V- f^oTZ 

t .Ntv O ‘ko loAvost .1. the .social scale. Infantile inor- 
t..litA, as Avoiild bo ex])ccted, is biglie.st among the poorer 
classes, am 1.1 the Inst ten years this excess hZs somCrh.at 
iiicrp.ised, tlioiigli for all cln.sscs alike remarkable reduc- 
tions iiiv recorded. )\ o hope to di.scuss some of the 
contents of this report on a future occasion. 

SMALT.-POX AMONG CasUALS. 

In view of recoiit reports of tlie occiirrenco of small-pox 
among casuals the Mini.stcr of Health has i.ssued a circular 
(No. 859) to hoards of giiardian.s in England mid Wales 
in order to facilitate the detection of anv c.nso of this 
disease appearing in a casual ward. The Minister directs 
that from now until March 31st all casuals .shall be 
specially examined to onsnro that no case of small-pox is 
oAcrIookod, nnd in A'icAV of the additional work and respon- 
sibility incurred by the medical officer the Minister will be 
prepared to consider any ajiplication bv a board of 
guardians for sanction of the payment' of reasonable 
additional romnnoration. Stripping to the' waist is 
regarded ns an essential p.irt of tho medical examination, 
nnd, in the event of any snsiiicioiis skin eruption being 
discovered, the medical officer of health of tlie district must 
bo (xjnsiiltcd. Any febrile condition, especially if accom- 
panied by .symptoms resembling those of influenza, should 
also bo regarded Avitli suspicion. In the event of a case 
of small-pox being di.scoA-ered, the medic.al officer of health 
for the district should be informed at once, so that prompt 
arrangements may he made for isolation in a small-pox 
hospital ; and all contacts among casuals and the staff j 
should bo offered vaccination or rovaccination, unless 
ahondy protected in this Avay. It is added that only 
circnmbtances of grave urgency j'ustify the admission, or 
the retention, of patients suffering from small-pox in 
a Poor LnAV institution, and in such exceptional cases 
special isolation precautions must bo taken. 

Leeds Genebal Infirm.aiit. 

Tlie statistical tables for the year ending December 
31st, 1927, show an increase in the Avork undertaken in the 
A'arioAis departments of the General Infirmary at Leeds. 
The total number of in-patients treated during the year 
reached the figure of 13,048, as compared Avith 12,688 
during the previous year. Of these, 4,537 were general 
surgical cases, 2,894 medical, 1,170 ophthalmic, 1,682 aural, 
and 626 gynaecological ; in the orthopaedic department tho 
numbers aa oi'O 901, and cases admitted as “ accident cases ” 
amounted to 1,238. It is to be noted that of the total 
of 13,048 cases admitted 2,558 Avero those of children. , The 
daily aA'erage of patients in the Avards of the main institu- 
tion Avas 474, and at the tAvo semi-conA'alescent hospitals 
84, giAung a total of 558 as compared Avith 555 for the 
previous year, the highest figure being 598 and tho . 
lowest 436. The out-^patient department shoAvs in total 
attendances an increase from 298,141 to 306,648. The 
infirmary, in all its departments, is Avorking to the limits 
of its present c.apacity. It is, of course, the only general 
hospital in Leeds, and a substantial increase in accommo- 
dation is a matter of urgent necessity. The only con- 
sideration AA'liich causes the board to (ielay carrying out 
extensions is that of finance. It is hoped that in the near 
future a block for patients Avho can afford to pay for 
attendance may be provided, and this will tend to lessen 
the pressure on the beds to some extent, as it is belieA'ed 
that there are many patients at present admitted to the 
general wards who would be able and willing to meet the 
charges entitling them to admission to the paying block. 




But apart from this aiiotlior ward block is required, and ft 
groat appeal for funds must shortly ho niado. 

The distribution of prizes iu connexion with tho Leeds 
School of Nursing is an annual event always looked for- 
ward to with interest and with plcasuro by all who, cither 
as teachers or as students, aro eonncclcd with it. On this 
occasion tho ceremony was of n particularly pleasing 
character, lor tho prizes were distributed by Damo Sfaud 
JlcCartliy, and an address was given by jVfnjor J. H. 
Boith, df.C., bettor known ns "Inn Hay." Tho chair was 
taken by Sir. T. F. Brnimo, tbo treasurer of tho infirmary, 
who commented with gratitude on tho excellent work of 
those who had instructed tho nurses. Damo Hand 
t McCarthy in a short speech reminded tho meeting that 
tho first nurse to bo decorated on tho field during tho war 
for conspicuous bravery w.as trained in Leeds. AVliilo 
, St. Thomas’s Hospital woidd always bo remembered as tho 

; homo of Florence Nightingnlo, tho General Infirmary at 

Leeds would for all timo bo known ns tho first training 
school in Britain to arrange with a university for a 
diploma of nursing. Major Boith gave a most useful and 
delightful address, characterized by great common souse, 
niuch humour, and by a profound np]ircciation of tho 
fine work which is being carried on bt' nurses all over tho 
. world. 


averted if tho midwives wore instructed to notify to 
tho medical officer of health all cases they hav'O under- 
taken to attend, and to urge the women to visit a pre- 
natal clinic. Tho following reply was agreed on: (1) That 
compulsory notification by midwives to tho local super- 
vising authority of all cases which they had undertaken 
to attend would bo tantamount to compulsory notification 
of pregnancy, a principle which hitherto the Board had 
found itself nnablo to support; (2) that, in tho opinion of 
tho Board, if midwives strictly obseiwe tho Board’s rules 
their patients will receive proper and adequate ante-natal 
attention. Approval as lecturers was granted to Major 
P. C. Field, I{..\.M.C., Dr. G. H. Nolan, and (pro tern.) to 
Dr. C. C. Holman. A letter was received from the Minirtry 
of Health approving tho rules of tho Board until January, 
1929. 


Hospital Amalgamation in Belfast. 

The board of management of the Eoyal Victoria Hos- 
pital, Belfast, decided unanimously on December 19tb, 
1927, to accede to tho proposal of the Maternity Hospital 
for amalgamation ; it was further decided that a joint 
effort should bo made to raise the necessary £100,000 within 
oho year, A general meeting of the^ life governors and 
annual subscribers of the Royal Victoria Hospital was 
held in' the King Edward Memorial Hall on January 16th, 
when the Marquess of Dufferin and Ava, chairman of 
the board of management, presided, and letters wore read 
from tho Bight Hon. J. M. Andrews, Minister of Labour, 
and Dr. B. 'W. Livingstone, Vice-Chancellor of the Queen’s 
University, Belfast, supporting tho scheme. Tlie chairman 
explained that the present Maternity Hospital, with its 
twenty-five beds, could not meet the needs of the popula- 
tion of Ulster; it was necessary to provide a well equipped 
and fairly large hospital with at least a hundred beds, 
and this would entail an expenditure of £100,000. The 
matter was urgent, for in order to obtain the grant from 
the Ministry of Labour it was essentia] that the building 
should bo started in the spring. The Duchess ■ of Abercom 
had promised to become president of the campaign and 
to giv'o her personal support in the task of collecting tho 
money. Professor J. A. Lindsay said that the people did 
not realize that they had only one little maternity hos- 
pital, exclusive of Poor Law accommodation, to meet the 
needs of tho city and province, while Dublin had 250 
materaity beds. The tendency of medical science, perhaps 
more marked in tho United States of America and in 
Canada, was to associate this particular work with the 
great hospitals, and a movement of this kind was pro- 
gressing in Ireland. The amalgamation could also be 
recommended on the score of economy ; a bed cost £130 
per annum in the Boyal Victoria Hospital and £170 in 
the old Maternity Hospital. It was regrettable that at 
present the majority of students had to go elsewhere for 
matemity training. The new hospital would also have 
all tho advantages of their special departments and labora- 
tories. Professor C. G. Lowry stated that the maternity 
death rate could only be reduced by better education, 
proper ante-natal supervision, and more hospital accom- 
modation. Many women were living in lodgings, and 
houses occupied by other families, and in unsuitable sur- 
z'oundings. The greatest toll of death was taken from tho 
working class families, and tho disability rate was also 
serious. The Bov. 'W. A. Watson, B.D., supported the 
proposal from the point of view of students and nurses. 
The chairman, in putting the resolution to the meeting, 
announced that every step taken in connexion with the 
scheme would have the approval of the present board of 
tho Maternity Hospital. The resolution of the board of 
management of the Royal Victoria Hospital was then 
unanimously endorsed by tho meeting. 

A meeting of the Association of the Belfast Jlatemity 
Hospital was held on January 18th. Professor Lindsay, 
chairman of the board of governors of the hospital, pre- 
sided and gave an account of the history of the hospital 
and of tho proposal to amalgamate with the Royal Victoria 


Univehsitv College. Hospital : Clinic ron Mf.ntal 
Deficiency. 

Dr. A. F. Tredgold has heen appointed an associate 
physician of University College Hospital in psychological 
medicine, and will hold a special clinic for conditions of 
delayed and incomplete mental development and for cases 
of mental deficiency, retardation, and allied conditions. 
Iliis will bo tho first clinic for such cases cstahlishcd at 
a hospital wHh a medical school. It is hoped that it will 
not. only, afford . opportuuitics for students to gain a 
knowledge of mental deficiency and allied conditions which 
‘^'■^'ilablo, but will also constitute 
a urtlier step towards bringing psychological medicine 
into touch with general medicine. Dr. Tredgold will hold 
°ht-pationt department of tho hospital on 
Thursdays at 11 aim., commencing on February 2nd. 

• 'Ti,., n- 4 , Hidwives BoAnn. 

In,., '“I ^lulwivcs Board for England and Wales met 

nrilinni. “ poiial scssioii Was followed by the 

Minist,-^ * ?' i letter was read from the 

a stating that it had received a copy of 

Gehcnl Executive Committee of the 

that the r, to tho effect that it was expedient 

restrictino- + 1 ,^^ ^ Board should iiicludo provisions 

in their prfictico'^'’ Th^f 4 ?'”*''“"® niidwives 

to tliR 'Xt'ir,; 4 ' 4 ' V ® Matter stated also that it appeared 

prepared tn^ ''®®‘’'ablo that tho Board should be 

which might^proDMl 

niidwivcTia nom^I ^ 1 ^® administered by 

suceestiTiir 41 . 4 ® in exceptional circumstances, and 

in fn advii^- embodied 

and a copy ordered tn L ® memorandum was approved, 
A letter was read fmm 4 i .*® Ministry of Health. 
Medical Association inb!”^ Secretary of the British 

of the Association had T'”® * 

sider and report on 41 . ®'' “ special committee to con- 

aiid mortalitv an I causation of puerperal morbidity 
that should be administrative action, if any, 

stated also that tlm ” .oonnexion with this matter. It 
up its report to bad decided, before drawing 

at which the varion«® ® ® conference on January lltli, 
cussed, and that the p®®!’®®.*®. of the problem could be dis- 
represeiitativcs fo 41 ,'^''*’®.'* mvited the Board to send tw'o 
Rearson were annoin 4 ^a®"^®*®"®®' ^^'ss Pollard and Miss 
ference, and Dr J • • *^'® ''opecsentatives at this con- 

Board at tho' appointed to represent the 

in July next. A ^ 9’® B-oysl Sanitaiy Institute 

Northampton Matemu!. received from tho 

©xprossing much mnoo •' Infant Welfare Association 
occurring in ennno^-- “*.fho number of maternal deaths 
to the Board t)n 4 " cbildbirtli, and suggesting 
tlmt some of these fatalities miSht bo 


156 Jan. 28, 1928J 


dOKEESPONbENCE.' 


t TnrfccinsH''-^ 
SlPniciL JouBVU, — 


Hospitiil. Ho Paid that the advantages vevo junnerous 
and of many kinds. Tile Maternity ITosjiital n’as the 
second ohle.st eharity in Eelfast, and had done good work; 
many would rememhor the original hnilding in Clifton 
Street, with eight hods. The institution had carried on for 
more than a hundred yoar.s. Lai-gely owing to tho efforts 
of the late Mr. H. Ewart, the hospital had hocn trans- 
ferred from Clifton Street to its present buildings in 
Townsend Street, but it was desired to advanco with tho 
times and to build a now maternitj- hospital in tho 
grounds of the present Itoyal Victoria Hospital, wTiich 
had been made available by the City Council. A resolu- 
tion of approval, moved by Lady Clarke and seconded )>v 
Lady Byers, was carried unanimously. Tho chairman 
intimated that a “ Relations Committee ” was to be 
established and that the ])opition of the iilnteriiitv 
Hospital uas to be- recognized in every respect. 


C0rr£S|ion&cttC£. 


JOHN THOMSON. 

Sin, — Several of tho friends and old pupils of tho lato 
Dr. John Thomson are anxious to establish some perma- 
nent memorial of his groat sen-ices to pediatrics in this 
country and to jicrpetuato tho memorj- of a very lovable 
personality. 

AVe have been asked to servo ns a, committee to give 
effect to this object, and those who arc in sympathy with 
it are invited to send subscriptions to Dr. C. hlcNoil 
(44, Horiot Row, Edinburgh) or to Dr. Robert Hutcliison 
(32, Devonshire Place, AA^.l), who are acting as treasurers. 
The form of tho memorial has not yet been determined, 
and must depend, to some extent, upon tho amount obtained 
in response to this appeal. — AVe arc, etc., 

(Signed) Tiios. Barlow, 

JjEOXAnD FlNW.Ay, 
Root. Hcrcnisox, 
Cjiahles hloNwi., 

January 18th, GeO. F. StiLL. 


claim), B wotdd still increase faster than A because tho 
number of unvaecinated persons is increasing faster than 
the number of vaeein.-ited owing to neglect of vaccination, 
oo that, so long as v.-iriola minor is the reigning type, tho 
more years wo add together tho more shall we relatively 
dimmish the fraction p„.h/B, in comparison with p,.h/A. 
If vaccination does protect against attack by variola minor 
the same result will ho producocl, hut more quickly. Tho 
result is clearly inevitable, provided any vaccinated persons 
dio of variola major, even if is mneb larger than /<,. 

Dr. Slocks’s. valuable letter strongly .supports the con- 
tentions that: (1) Vaccin.ation does protect against atfacl: 
by variola minor, and (2) that the fatality of variola minor 
is negligible. (Tho fact that one or two of tlie cases in his 
series — ^for example, some of tho London deaths — were 
certainly examples of variola major does not weaken his 
case; virtually ho is dealing with statistics of variola minor.) 
It may ho noted in confirmation (the confirmation is not 
of much importance, because of tho small absolute mnnhers 
of deaths) that between January, 1923, and June, 1927,' 
31,484 cases of small-pox were notified in England and 
AA'alcs and 35 in London — that is, 0.11 per cent, of tho 
total. Ill the sarao period 57 deaths were recorded, 5, or 
8.8 per cent., in London, so that if London liad her jiroper 
quota of cases she had eighty times her proper share of the 
deaths ! 

Tho nnswor, then, to Dr. Garrow’s question is, that these 
fatality rales are, statistically speaking, quite worthless. 
— I am, etc., 

Loughton, Jnn. 21st. M.IJOR GkeEXUOOD. 

Sin, — ^Thc smallness of the numbers of fatal cases of- 
small-pox in tlic rcccmt epidemics is such that no useful 
deductions can be made from them. The striking point 
in tho figures given by Dr, Stocks (January 21st, p. 115) 
is tho ago distribution in the two groups, vaccinated and 
unvaecinated. Forty per cent, of tho population are said 
to bo vaccinated. In the age group under 15 ” only 
46 cases have occurred among the vaccinated. Tho remain- 
ing 60 per cont. (unvaecinated) have provided 10,298 cases. 
If^tho proportions had been the same in tho two groups 
the miinbei-s in the first group should have been 6,865 


FATALITY RATES OF SMALL-POX. 

Sin, — Dr. Ivillick Millard (January' 21st, p. 115) seems 
to me to have bit the right nail on the head with bis usual 
neatness and precision. Tlicre arc certain aritlinietical con- 
sequences of the (in my oiiiiiioii and that of Dr. Millard) 
misleading calculatioiLS to which Dr. Garrow seemed to 
attach some imiiortanee which are worth noting. In what 
follows I use the phrase “ variola minor ” to avoid having 
to keep on writing soiuo such phrase .as “ the present non- 
virnlent variety of small-pox wliicli prevails in the North 
and Midlands.” 

Let us suppose for a moment that variola minor is not 
a killing disease and that in “ classical ” small-pox, or 
variola major, the fatality rate i.s p, per cent, for vaccinated 
persons and /)- per cent, for unraceinated pei-sons. Now 
suppose that .there are a and b cases of variola major 
amouesf vaccinated and unvaecinated per.sons respectively, 
and A and B cases of variola minor. Then the fatality 
rate on the vaccinated will bo p,.n./(n + A) and on the 
unvaecinated p„.b/(b + B). If only variola major were in 
question (which' was .substantially the epidemiological .state 
of affairs a generation ago) A= B=0, and if is really 
creater than p, the statistics will (subject to the ordinary 
fluctuations of sampling) show the advantage of the rac- 
cicated But if the amount of variola ninjoi tends to be 
.small and tliat of variola minor tends to be large, ire can 
neglect a in comparison with A and b in comparison with B 
und oiir fatality rates will virtiially become p^afA and 
P.h/B—that is, in words, the fatality rate is the i-atio 
of tlie deaths from one kind of illhess to the cases occurring 
it f suppose a similar ahsurdity might arise 

oil deaths from lobar pneumonia to cases of 

Noir if vaP?®umonia in young children, 
hj -varioiq protect at all against aliaci: 

fas, of course, the antivaccinators' would 


instead of 46. 

The aeo incidence in small-pox among tho unvaecinated 
is tho sa'mc now as in pre-vaccination days, but is reversed 
in tho cn.se of tlie niccinated. AYliat factor is there to 
account for this except vaccination?— -I am, etc., 

Birminsliam, Jan. 22nd. «OBEnT AxDERSOX, M.D. 


gjj, jiy attention has been drawn to a slight error 

in the tabular statement in my letter of -Jaiiuaiy 14tli. 
riic 94 cases in the year 1926 whose vaccination state is 
classified as doubtful are not included in tlie figure 3,116 
is' stated in tlie footnote to tlio table. This means that 
die total number of cases for the four yeara is 10,925, 
instead of 11,019. This slip does not affect the fatality 
igiii-cs in flic vaccinated and unvaecinated.— I am, etc., 

ChcslcrficUl, Jnn. 20111. G-innon , 


ISOLATION FOR MEASLES. 

gjP ^Dehre and Joannou, who, after Nicollc, are the 

leading exponents on the Continent of the prophylaxis of 
measles by modern methods, iriite as follows; 

‘<T-< rnntaeiosite paraifc commencer avec les manifeslalions 
catarehal™ e?le cesse*^ surement lore de la chute tljermique, el e 
narait souvcnl prendre fm plus tot, apres la pleine effloreEceiice dp 
II no semble pas que la conta^iosite survive a 
1-druDtioii’ alors memo qu’existeot des complications. - . • L exis- 
lencc^dc Doilcurs dc gcrmcs convalescents cst improbable. On n a 
nas si-L^l dc convafcscent semant autonr do lui la contagion.” 
(L<t Rovpcotc, Paris, 1926, p. 147.) 

These views are reflected in the recently issued Code of 
tho American Public Health Association. The period of 
commnnicahility of measles is therein laid down as being 
“ duriim- the period of catarrhal symptoms and until tlm 


> Report of Chief Medical Officer of tfie Ministry of HenUh foi 
1S26, p. 26. 


Jan. sS, 1928] 


[ TmsBnmsa 
Medicai. Jocrxasi 


COEllESPONDENCE. 

» t ■ ' ' 


157 


cessation of abnormal mucous niombranc secretions— mini- 
mum period of nine days; from four days hefore to five 
days ajlcr tho apponranco of the I'ash.” (Italics mine.) 
Isolation is enjoined “ during tho period of communi- 
cability.” 

One of tbo main arguments against tho compulsory 
notification of measles is that such notification is commonly 
only feasible in practico when tho rash has appeared — ^that 
is, after tbo most infective pre-exanthom, or Koplik’s spots, 
stage has passed, and when, therefore, most of tho damage 
has been done. 

I liavo released from isolation largo numbers of oases of 
measles from seven to ton days after tho full appearance of 
the rash. I have never scon or heard of a return case as 
a result of this procedure. A careful study over a number 
of years of eases of measles treated under conditions of 

bed isolation ” has shown beyond any reasonable doubt 
that a case of measles has ceased to bo infoctivo certainly 
by the time tho rash has faded. — I am, etc., 

E. H. R. HAnniEs, 

ilcdlcal Siircrinlcnclcnl, Dlrnilnglinm Clly Hospitals. 

January 23rd. 


QUININE IN OBSTETRIC PRACTICE. 

Sin,— I note in your issue of November Sth, 1927 (p. 827), 
a comment on tho use of quinine bihydrochloride in 
obstetrics, which induces mo to givo my oxpcrieuco in a 
country where malaria is fairly prevalent. 

I have practised in three places in Rhodesia during the 
past eighteen years, in all of which malaria (subtertian 
yarirty) occurs, coupled with blackwater fever, in from 
1 too per cent, of tho population. In tho last locality only, 
wliere I have been for tw.elvo years, has there been an appre- 
ciable amount of midwifery work. Tho population is a 
scattered and widely isolated one, and consists principally 
ot tarniers and workers in small mines. I have been singlo- 
handed, and over 80 miles from tho nearest brother practi- 
loner. In case of any emergency during labour such a 
position causes anxiety. = •' ° 

The well known liability of malaria te break out during 

10 pueiperium adds to one’s anxiety. Jlalaria is not easy 
microscope in ordinary cases — 
pioportion of clinically typical malarias giving 
experts. Tho difficulty in 
‘^*ff®*'®btial diagnosis of any rise of temperature 
nn no 4 ■ * P'mrpenuin is theroforo obvious when there is 
* of separating it, and when active measures 

■'’®P°*'tant. Hence, owing to my general 
cedure of mT?' quinine, I early adopted the pro- 

to attend u ^ Prophylactic measure, when engaging 
v^rfsatkf^t of quinine. So 

ture tint T +1, eliminating rises of tempera- 

m-xhino-* if n the advice as a systematic method, 

had oxiriouo putients. Some who 

made a*!l sortq^ f" country took it quite willingly; others 
unless they acceded ' “%^1 used to take care of them 

inquiries later. ’ utlvico was followed up by strict 

wiL'^“omphcaiTcasffi'“ib^‘‘^°° P 

which gave me anv n temperature 

normal ^linerthe^baTH- ne3mr exceeded the 

had not engaged me confinement patients who 

not been so satisfaewTn^’ their puerperium has 
complicated labour case blackwater fever 

patients aT Cd ^ surprise, that such 

sistentlv easier time • ''“® course of quinine had a con- 
dition was better throughout their general con- 

My rule is de noucar “ , lymg-in period, 
previously or not TI ’ “. . or patients have had malaria 
quinine hydrochloride ^ require is 2i grains of 

SIX weeks prior to tl,o general use) daily for 

5 grains for the last ^ute of confinement, and 

knowing their histoiw pre^ancy. With some, 

house site, I may advise malariousness of 

' will be noted tbit 

entirely. We do not 1 ^ prophylactic procedure 

stimulates to throw 4 ™°"'’- Jet what cells the quinine 
M throw off an attack of malaria; but we do 


know, though it is a specific, that the action of quinine is 
not, as w-as bolioved up to about 1917, a direct one on tbo 
parasite in tbo blood. It may be those reticulo-endotlielial 
cells or it may bo some other defensive mechanism which is 
stimulated and reinforced. At any rate, 1 am, after many 
years’ axporience, convinced of its value in cutting out 
malaria] rises of temperature. So satisfied am I of the 
value of the method that it is tempting to suggest that 
quinine is not only a prophylactic against malaria germs,- 
but also against other and bacterial micro-organisms,- 
which may bo latent or adventitiously introduced during the 
exposure to infection in the course of labour. On the other 
hand, this may seem, I am well aware, like egotism, but 
I can nevertheless with confidence recommend experiment 
of such a simple measure, not only in malarial countries, 
but in general obstetric practice. I hope some obstetric 
spcoialist will submit it to comparative test with series 
of cases. — I am, etc., 

Slnola, S. Rhodcsln, Deo. Sth, 1927. W. M. HhwETSON. 


THE INFECTION OP BARBADOS WITH MALARIA. 

Sm, — With reference to Dr. Andrew Balfour’s postscript 
to his letter in your issue of January 21st, I trust you- will 
permit me to record how it came about that I found 
mosquitos in the fore-peak of a schooner alongside tho 
wharf in the careenage at Bridgetown, Barbados, in the 
autumn of 1907. While acting for Dr. Bridger (to whom 
I am still indebted for very much’ kindness and much 
valuable instruction) as port health officer I came often 
into official and friendly relations with those siilendid 
(and charming) British seamen, the white masters of the 
small ” inter-colonial ” schooners. Tliey are natives of 
Saba, and claim descent from tho buccaneers. 

One of them told me, among much that was Interesting 
and exciting, that it was no use looking over so keenly 
for mosquitos in his schooner — they must be roused out. 
Ho took me on board, and after I had peered closely with 
eyes, and felt stealthily with bands, inside the fore-peak 
and found no mosquitos, he thrust a cloth in and flapping 
it around in the dark fore-peak at once roused mosquitos. 
Though a-e then killed some of them I regret that I identi- 
fied them no further than that they were mosquitos, but 
not stegomyia. — ^I am, eto., 

London, W.l, Jin. ElsL H- M. HanSCHELIi.- 


TREATMENT OF VARICOSE VEINS BY 
INJECTION. 

Sm, — Considering that the majority of the surgeons in 
England look with disfavour on the treatment of varicose 
veins by injection, and discourage this treatment, I feel 
that my personal experience of it may bo of use to medical 
men in general, and especially to fellow sufferers. 

I Lave suffered from varicose veins since I was 21 years 
of age, but with great care I managed not to be incon- 
venienced by pain or throbbing till about my 66tb year. 
I am now 59, and have had a good deal of pain for two 
or three years. I have always been a very active man 
and done much walking, and I began -fo think I should 
have to stop this. My father died of embolism from 
phlebitis of varicose veins and one of my relations has had 
embolism twice from the same cause, but has fortunately 
recovered ; another has had phlebitis. 

It will be seen from the above that I have a had family 
history in this respect, and would not, therefore, be an 
ideal patient for the treatment. I have undergone the 
treatment, and have had nine or ten injections in all. 
Beyond tho fact that I had some bearable pain and some 
oedema I have suffered no inconvenience, and have carried 
on a large practice all the time. My varicose veins are 
gone and my legs are absolutely comfortable, and I can 
walk any distance with comfort.^ 

The doctor who gave me the injections told me he had 
given over 2,000 without any embolism or like trouble. 
From my own experience, and his, I am of opinion that, 
the treatment is most efficacious, and that the risk is 
infinitesimal, being much less than if the veins are left’ 
alone or operated on in the nsual.way. Personally, 1 should- 


158 Jak.- aS, 19:8] 


COERESPONpaN.CE. 


[ Tnr DniTint, , 
Mepicii. } oTnavit 1 


always go to an export for tlio troutmont, bnt I sec i\o 
reason nJiy any medical man should not learn the treat- 
ment if lie tahes the tronblo ip siiuly mulor an expert. — 
I am, etc., 

Janunr.v IStli. VkxoVS. 


CLINICAL TEACHING IN EDINBUHGH. 

Sin, — I read with much surprise in the Jotmx.M, of 
January 14tli (p. 71) the remarks under “ Scotland ” 
referring to clinical teaching in Edinburgh. ^Yhil^t the 
report is .substantially correct, I think it is necessary (o 
point out that the “ dissatisfaction ” in the Edinburgh 
Medical School at the moment is not so pronounced. I 
would also point out that, in my opinion, the que.stions are 
questions which concern only Edinburgh, and which need 
not bother much the profes-sion in general. As your corre- 
spondent, however, has thought fit to ventilate the matter 
in tlie JouuNAL it is perhaps advisable, for more than one 
reason, to supplement liis statement. 

The first reason is th.at the Medical School of Edinburgh 
is the largest medical school in the country. Another,stlnit, 
historically and constitutionally, it is peculiar, and differs 
from all the rest. It is perhaps well for your readers to 
know that the plan followed in medical education in 
Edinburgh is a plan determined by (1) the Iloyal College 
of Surgeons; (2) the Royal College of Physicians; (3) the 
Managers of the Royal Infirinary of Edinburgh ; (4) the 
Governing Board of the School of Medicine of the Ro_val 
Colleges ; and (5) the University Court — by the latter to 
a very slight and partial extent, in actual fact. It inaj* 
also ho usefully pointed out for the information of the 
profession at l.argo that the Baard of Management of the 
■Royal Infirmary of Edinburgh cannot appoint anyone to be 
a physician or surgeon to the hospital unless he bo a 
Fellow of one of the Edinburgh Royal Colleges. 

Recently many of those aspects of matters in Edinburgh 
seem to liavo been lost sight of. In some envious and 
inexplicable way the university authorities seem to have 
overlooked the fact that tlio pi'actising profc.ssors of their 
faculty of medicine are clinical officers to the Edinburgh 
Royal Infirmary solely by the grace of it.s managing board, 
provided they are Fellows, by examination or by election, 
of the College of Surgeons or the College of Physicians of 
Edinburgh. 

The matters in dispute'are temporary, aiul will he settled 
very readily fay the governing hodie.s concerned, nilli the 
help, no doubt, of their legal members, if ueeessaiy. Your 
readers, thei'c-fore. Sir, have no i-ca.son to fear that the 
Medical School of Edinburgh has “ lost it.s nerve ” or is 
in any parlous condition from any cause. — I am. etc., 

CiVIS C'NlVEaSIT.VTI.S EDIXm ltuEXsl.s. 


years or so. Wo have to give panel corlificatcs, most 
humorously marked “ confidential,” to women suffcriiig 
fiom dj.snienoi'i’hooa, menorrhagia, advanced pregnancy, 
niiscariiago, and certain intimate diseases. Tlie.se " eon- 
fidontial ” certificates are then handed to the agents of 
the societies, who are nearly always men, and pass after- 
wards into the hands of clerks or office bovs. It roust be 
extremely gratifying to tlicse patients to iiavo to disclose 
tbns information which, in the old days, was regarded as 
secret between doctor and patient. 

Again, untlcr the Midwives Act, 1918, we attend patients 
when called in by a midwife, onr fees for this being paid 
by the connU councils ; but claims have to be .sent in within 
two nionllis fj'om the date upon which the /service i.s 
rendered, otherwise the fees are not paid. Many medical 
men have had fees disallowed because their claims wore made 
outside the two months, though why this period is insisted 
upon nobody .seems to know. T)io usual custom in this 
country is for accounts to be rendered quarterly, and there 
seems to be no reason wliy these claims should not bo sub- 
mitted in , the same way. It is voi-y ' easy for a busy 
practitioner to overlook a claim at the end of sneb an 
nnti.snnl pciiod ns two months. It lias boon held that the 
Minister of Health i.s legally right in refusing to allow 
claims not rendered within the prescribed period, but it 
savours of sbarj) practice to mulct a man of money be has 
honestly earned. 

AVe oeeasionaily give certificates to insured patients 
slating that it is necessary for them to be examined by 
an ophthalmic surgeon. Many of these certificates are 
ignored altogether, or the patient is sent to an oculist; 
or a rnfbcr more favourite method is for the approved 
.society to write and ask upon what grounds we consider 
tlio services of an opbtlialmic surgeon necessary. 

It would be easy to multiply instances of bow compulsion- 
is put upon ns. onr opinions arc flouted, onr bona fidcn are 
questioned, and we ourselves arc held up to ridicule and 
abuse iu the lav press. We accept all this without protest, 
and arc apparently too apatliotic to raise any defence in 
our own behalf. Surely the time lias come wlion the pro- 
fes.sion ns a whole might take a firm stand against these 
ever-increasing burdens, restrictions, and humiliations. 
The prestige of the medical practitioner Is declining rapidly, 
and it i.s not difficult to see that within a few years, unless 
something is done, we shall become automata, banding out 
oertificates, notifying diseases, and diagnosing and treating 
according to orders received.— I am, etc., 

SiANuEv L. Bhijibeecombk, 

Slelw-un.lrr-llnro, Somerset, Jan. loth. 


Edinburgli, Jan. 15th. 


MECHANICAL MEDICINE. 


Sin, — A patient of mine developed pyrexial broiiebiti.s a 
few days before her confinement on January 1st. Chloro- 
form had to be administered during delivery, after wliieli 
she ran a temperature round about 102° F. for tlnee days. 
The loeliia were normal, there was no trace of .sepfic infec- 
tion, and there is no doubt that the pyrexia wa,-, entirely 
due to the bronchitis. However, since it oeenrred during 
the puerperiuui, I asked the county medical officer of health 
to advise whether. the case must be notified. He quoted 
the regulations: “Puerperal ])yrexia means any febrile 
condition . . . occurring in a womau within twenty-one 
davs after childbirth or miscarriage, in which a temperature 
of 100,4° F., or more, has been sustained during a period 
of twentj'-fonr hours, or has recurred during that period,” 
and said that, accordingly, the case must be notified. 
AVheu filling in the notification form I had to pnt the 
date of the° onset of the disea.se as December 29tli, 1927 
(the day on which the bronchitis developed), and tlie date 
of the birth of the child as January 1st, 1928, which really 
means that this case of “ puerperal pyrexia ” began three 


davs before l.abour commeiicod ! 

To TOO it seems monstrous that any medical man .shonl 
be compelled to certify such an absurdity; but it is a 
SrWf intolerable position into which we have parti 

I e , and partly been jmshed, during the last fiftee 


theories op SUGGESTION. 

j ],ave read with great iiitere.st the report of 

Dr^ AVillinra Brown’s discourse to the Royal Society of 
Medicine on theories of suggestion (Jannmw 14th, p. 55). 
] was cspccinllv astonished at the view of suggestion held 
I.v some of those who took part in the discussion which 
ImIoTcI One of the speakers (Dr. . R. D. Gillespie) ox- 
prdssed surprise that the championship of suggestion earoc 
from “ so intelligent a sonree ” as Dr. Brown, and thought 
“ extreiuelv improbable tliat suggestion treatment in its 
former voone would ever return, seeing that siigge.stion 
depended on lack of criticism_on tbe part of the person to 
whom suggestions were made. - , , 

kroelv psvehotherapy has developed hcyoiid the mere 
i-ivalrv'of its individual schools. Suggestion is, of course, 
blit one of the methods of psychotherapy, yet it is a vciy 
Dowerful one AVe have been too tardy in recognizing 
its widespread use— often with considerable effoeb-by im- 
qualified persons in “ quack ” religious, and other 
of treatment, some of wlucli boast a scientific basis. Ye 
rei^ard anah-sis, properly carried out, as being free from the 
elenieiitof suggestion, but tbe very fact of going to consult 
a nsveluAlierapist must liberate an important sngge.=tion 
in the patient^s mind. The physiological effect of sngges- 
Hmf prSs many aspects for ™-'‘f'reme„t and ohserv - 

tiou, such as .sphygmomanometry, changes in hasa mefi. 

bolie rate, changes in secretion or digestive 

more. Indeed, we are hut at the beginning of knowle „ 


[ Tne Bnmi* 
Mkdicu. Jouujl£ 


159 


Jan. jS, 1928 ] 


COHilESPONDENCB. 


about an important tliorapoutio aid which has been applied 
in treatment since the dawn of medicine — one which is 
constantly in use, consciously or subconsciously, by every 
inoraber of our profession. 

It would bo idle to apply' suggestion without regard to 
tbo indications for its uso, as also to postulate that its uso 
is limited to those of poorly developed intellect. Tho co- 
operation of an intelligent patient in a rational form of 
treatment is surely of tho utmost value. — I am, etc., 

Liverpool, Jan. 15th. S* B-^UTON Uall. 


TREATMENT OF “ TENNIS ELBOW.” 

Sir, — I can endorse what Air. Alills has said in his article 
on “ tennis elliow ” in your issue of January 7tli (p. 12) as 
to the efficacy of manipulation of tho clhow. 

Ono manipulation which I find very clfcetivo is to place 
the patient on his back, with his arm just oil tho table. 
His hand, midaay between jironation and supination, is 
held between the operator’s legs. Tho elbow rests in tho 
operator’s hands, and is passively flexed and extended 
several times. Then, when tho muscles are relaxed, tho 
elbow is sharply forced a little further into extension. So 
tar I have not found it necessary to use an anaesthetio. 

The clicking sound can hardly bo duo to a bone going 
back into place, as tho same sound can bo iiroduced in tho 
normal elbow, and is in no w.ay diflorent from that pro- 
duced by many people when they crack their linger or other 
joints.— I am, etc., 

London, W.l, Jan. Ulh. ThoMA.S MaHLIN. 


MEDICAL REGISTRATION IN NEW ZEALAND. 
Sm, — 'To those of us who aro hoping eventually to prac- 
tise medicine in tho most favoured part of tho British 
™piro — Now Zealand — “ Traveller’s ” letter in tho 
BmiisH MEnicAL Journ.cl of Jauuai-y 14th (p. 77) is most 
disqmeting. 

I can hardly think that tho New Zealand Registration 
Board can overlook tho ilcdical Hcgistcr. That, and no 
mmber of diplomas, gives us our charter to pract so. 

No. difficulties are raised about New Zealand graduates 
practising in this country, and they aro met by their 
colleagues hero on equal and healthy coinpotitivo terms. 

1 surest that the whole subject of reciprocity of tho 
New Zealand should bo taken up by 
0 ritish AMical Association, and that tho New Zealand 
eg ration B^rd bo reminded that wo aro all fellow 
citizens of one Empire.-I am, etc., 

January l«h. I.M.S.(llEI.). 


TREATAIENT OF ACUTE PNEUMONIA. 

ycty much interested to read the memo- 
tTnimv., ^ subject by Drs. Hichens and Gibson 
exTiprionn p. 52) as it confirms my own 

wonders ^ that sodium nucleinato often works 

pueumonin the duration of an attack of 

is a previVi!d™'"'v.'^'^v^ reported, there 
ment can Im patient to be dealt with and treat- 

verse holds truest ""fortunately, tho con- 

materirtl „! i ^ ''■y'""ple, that if one has poor 

little uso bni ^ sodium nucleinato is often of very 

(exnectnraTitr oBier usual methods of treatment 

de^ressLg 

I have abandnnni Por cent, mortality. This winter 

7,000 solution of n "ucleinato and have used a 1 in 

four-hourly' will, Permanganate given per rectum 

twenty-five ’ ^ ^ .ffeatment I had three deaths in 


caws of loba: 

they were almost moribS ° ^ 

COCCUS /r% , X have now added pneumo- 


debilitated chTidren "to •’roncbo-pneuiuonia in 


COCCUS vaccine fPorl,-» tv • 

tarium, and have boa ’ ^“'■is and Co.) to my armamen- 
— thirteen in number —I am*^'' t"" amongst my cases 

. Sunderland, M.D., D.P.H., D.T.JI.and H. 


TYPHOID IMAIUNIZATION BY THE MOUTH IN 
SOUTH AFRICA. 

Sin,— In your issue of December 5rd, 1927 (p. 1050), 
thoro is a noto on this subject under the heading ” Union 
of South Africa (from our correspondent in Pretoria).” 
I am a littlo surprised that your correspondent should 
make no reference to tho work which has been done in 
Pretoria itself. In tho annual health report of the 
medical officer of health for Pretoria municipality for the 
years 1925-26 and 1926-27 there are brief references to 
tho uso of this method in tho case of Europeans as well 
as natives. 

In 1925 Dr. Adrianus Pyper, bacteriologist to the 
municipality, at my request prepared the antityphoid 
vaccino in pill form in accordance with the method 
advocated by Besredka, and since that date has furnished 
us with regular supplies. These antityphoid pills have 
been given, together with bile pills, to some 922 Europeans 
and 1,464 coloured persons in this town. "We have observed 
no iU effects following their administration, and we have 
had no instance of a person contracting typhoid to whom 
tho pills had been given within a few days of exposure to 
infection. 

Our present practice is to provide this form of immuniza- 
tion for all persons living in a house in which a case of 
typhoid has occurred ; the pills are sonietinies given also 
to persons living in the immediate vicinity. In certain 
special cases, where sanitary conditions are particularly 
bad, and the conservancy system of sewage disposal is still 
in force, immunization has been offered to all the inhabi- 
tants of the area, and has been generally accepted. 

A further very interesting use of this form of immuniza- 
tion has been in the treatment of typhoid fever carriers. 
Altogether, fonrteen native intestinal carriers have been 
treated, each receiving an antityphoid piU containing 
approximately forty thousand million dead bacilli, together 
with a bile pill on three successive mornings before break- 
fast. In all cases the carrier condition had been proved 
by cultivation of the typhoid bacillus from the faeces. 
After the treatment no tj-plioid bacilli were present in the 
faeces, and in those persons who remained under observa- 
tion they were shown to remain absent by repeated 
oxaminations. 

For all the bacteriological work in these investigations 
Dr. Pyper is responsible. Typhoid fever has been endemic 
in Pretoria for the last forty years, and althoifgh the 
incidence has been greatly reduced in recent years, and the 
death rate even more so, it is still more prevalent than it 
ought to be and in comparison with some of the other large 
towns in the Union. It was on account of this special 
prevalence that I was led to introduce the system of oral 
immunization here. — I am, etc., 

J. J. Botd, AI.D., D.P.H., 

Pretoria, Jan. 3rd. Medical Officer of Health. 


TREATMENT OF CANCER BY RADTUM. 

Sm, — Dr. Birkett (January 14th, p. 75) has, I fear, 
misread my original letter and seems to be under the 
impression that it was written in opposition to tlie use of 
radium. Far from it ; I should he only too thankful if tho 
radium institutes of London and Manchester* could be 
stimulated to record their results, and still more thankful 
if those results confirmed those of Stockholm and New 
York, 

The sole reason for my first letter was to take exception 
to a phrase in one of your leading articles which inferred 
that those surgeons who operated upon cases of carcinoma 
of tho cervix did so because they “ hare not had or not 
taken the opportunity of seeing what is being done in 
London, Manchester, etc.,” when, as a matter of fact, 
neither London nor Manchester give any information about 
the work they are doing. The subsequent correspondence 
has failed to elicit a single fact from either of these centres; 
and it is to be hoped the writer of the article will, in 
future modify his enthusiasm to correspond with the 
facts. — I am, etc., 


Manchester, Jan. 23rd. 


Wir. FiiETCHin Shaw. 




58, 19*8].. 


SIR ’dTCB DUCKWORTH, BT. 


r Tite Br.msn 
L JIzTJXCAi. Jorr.xiii. 


(Dliitititni. 


SIR DYCE DUCKWORTII, Rt., 51. D., LB.D., 
Consulting riiysici.in to St. B.ytlioloincw’s Hospital ; Einoritus 
Treasurer of the Iloyal College of Vliysrcmns ol Lontlon. 

Wi; li.'iro to record tlio death, in Iiis eighty-eighth year, of 
Sir Dyco DneUwortU, who was for many yeais vihysieian 
to St. Bartholomew’s Hospital, and had long been a 
distinguished figure in the medical world of London. 

Dyco Duckworth was the youngest son of Robinson 
Duckworth of Huddersfield, and tho younger brother of 
the Rov. Canon Duckworth, D.D., well known ns the 
Subdean of Westminster. His mother was Elizabeth 
Forbes, daughter of William Eicol, a naval surgeon, of 
Stonehaven, N.B. Dyco Duckworth was horn at Liverpool 
on November 21st,' 18A0, and was educated at the Royal 
Institution School of that town. Ho afterwards iirocecded 
to Edinburgh Dnivorsity, 

. ndiero ho graduatetl 5I.B. in ^ 

; 1862 .'and .proceeded 31. D. in - 
the following year, his thesis 
being awarded tho gold mcclal. 

Coming to London, ho eon- • 
tinned his medical studies at 
St. Bartholomew’s Hospital, 
but as there appeared to bo 
no likelihood of any opening 
for a young physieian ho 
entered tho Royal Nu'w, 
serving as assistant surgeon ' 
in 1864-65, Tho unexpected 
death of Dr. Henry Jcaifreson 
from typhus and tho resigna- 
tion of Dr. JIartin gavo 
opportunities to Dr. Church 
(now Sir William Church) 
and Dr. Duckworth which 
they were not slow to take 
advantage of. Duckworth ■ 
became medical tutor and was 
elected assistant physician in 
1869, full physician in 1883, 
and afterwards lecturer, on 
medioino.. During his tenuro 
of office as assistant physician . 
ho was placed in charge of 
tho department for diseases 
of the skin. He was appointed . 
consulting physician in 1906. 

■In 1870 he was elected a 

cm .°t Royal Collego 
ot I nysicians of London and Photograph ty] 
from 1884 until 1S23 he ’filled Sia Drca D 

tho important and honourablo 


Photograph ty] ’ lElUott and Fry, Ltd. 

Sib Drca Duckworth, Bt. 


Pensions Commutation Board. Sir Dyco Duckworth edited 
Warburton Begbio’s works for the New Sydenham Society: 
wrote a treatise on gout, which was published in 1889 and 
y.-as translated • into Froncli and German; and published 
in 1915 a volumo of collected addresses and papers under 
the title Piems on some Social Subjects. He was formerly 
a nienibcr of tho British Jledical Association, and served 
as President of tho Section of Medicine at the Annual 
Electing in Birmingham in 1850. He also delivered the 
address in medicine when the Association met in Carlisle 
for its Annual Meeting in 1896, his subject on that occasion 
being the prognosis of disease. 

Sir Dyco Duckworth was ono of the last physicians of an 
age which lias passed. Courtly, slow, quiet in manner, 
soft in speech and earnest in gesture, ho was always 
correctly dressed in a frock-coat and top-hat, which would 
have lookcel as much out of place in an open car as it 
was dc rigitcur in a carriage drawn by two fine horses. In 

politics a Tory, by religious 

__ profession an Anglican and 

a good Churchman, he did not 
suffer gladly the trend of 
modern manners. He dis- 
liked tho intrusion of women 
into the medical profession, 
and maintained stoutly that 
the proper place for them was 
at home, or at most as 

nurses. Professionally his 
opinion was greatly valued — 
early in life as a dermato- 
logist and later as a physician, 
especially for tho gout. He 
was a good teacher in the 
wards of St. Bartholomew’s 
Hospital — rather deliberate 
in making his rounds, hut 
very careful in coming to 
an opinion, which generally 
proved to he correct. He 
brought with him to the hos- 
pital the great traditions of 
clinical teaching for which 
tho Edinburgh school has so 
long been famous. His moral 
influence in the school was all 
for good, and by his example 
he set a high standard of pro- 
fessional honesty. He lived 
for many years in Grafton 
Street, Piccadilly, in the 
house which is now Quaritch’s 
lElUott and Fry, Ltd. bookshop, 
twoRTH, Bt. He was twice married, first 

to Annie Alicia, the widow of 


^ce of Treasurer of the College, ivhose representative he John Smith of hlickleham Hall, Dorking, and secondly to 

s on lie General Medical Council from 1886 until 1901, Ada, the younger daughter of Arthur Fuller of The 

T pet, senior Censor in 1S03, Lumleian Rookery, Dorking, having issue by both marriages. He is 

j in 18-6, and Harveian Orator in 1898. In 1S23 he .succeeded in the title by his son Edward Dyce, of the 

Emeritus Treasurer. He acted as nhvsician to Indian Civil Service, a judge in Burma, who -nas bom in 

g Edward VII then Prince of Wales, fr 0111 1850 to 1901. I 1875. 

Vicfnr‘'^'^*^"’icDc ° honour of knighthood from Queen Tho funeral sei-vice took place on January 23rd at- 
Fvam/^ CT 1 occasion of tho opening of the St. Peter’s, Eaton Square, and was attended by the 

a bar ^ Bio Embankment, and he was created President and many Fellows of the Royal Collego of 

Almonp^ Knight of Justice and Physicians, and a large number of representatives of 

an hnti ° of St. John of Jerusalem. He was institutions, medical and other, with which Sir Dyce 

honoris°^^^ A c 5Iedical Collego of Ohio, M.D. Duckworth had been connected during his long career, 

and of ^ Royal University of Ireland A memorial service was held on the same day in the 

Collo'Tp / . . f''®''sity, honoraiy Fellow of tlie Royal church of St. Bartholomew-tlie-Less, within the precincts 

of tlfp n 1 ®f Ii'riaiid (1887), honoraiy member of the hospital he seiwed for so many years; the hospitaler 

the Univm-^V "Wical Society, Ediiihiirgh, and LL.D. of and vicar, the Rev. J. L. Douglas, officiated. The inter- 
snondipp. Edinburgh (1890). He was also a corre- ment took place at Betcliwortli, Surrey. 

X Di?j?^'‘"f^'’°Ac®dJniie.de5IedocineofPai^^^^^ . . . , . 

Societv .served as president of tho Clinical Sir Fm^Ncis Ch.\ 3 ipnets, Bt., has been good enough to 

Edinhurpl. 'u 1 acted as examiner in medicine at send the following personal appreciation : 

at the P ’■ and Victoria Universities, as well as As one who has known Sir Dyce Duckworth -for some 

also nkv • Examining B6ard for England. Ho was fiftv-five years, as a student, as a colleague, as a friend lU 

.Fromiqnnt“in,^",'^''° Seamen’s Hospital at Greenwich. relation to work at St. Bartholomew’s Hospital, and at 

and from medical referee to H.jM. Troasuiy, the Royal College of Physicians, I gladly add a few personal 

ui to 1910 ho was medical adviser to the notes to his memoir, in which his work as a physician will 


Kinir Fd Treasurer. He acted as phvsician to 

ng Edward VII then Prince of M’ales, from 1850 to 1901. 

Vietorii'^Tn'’icPA* ’honour of knighthood from Queen 


the Univer'sitv of F r Eanibiirgli, ami GG.Ei. or 

Eliondinrr m Edinburgh (1890). He was also a corre- 

Sir Dvp ®f fho Academic- do Sledecine of Paris. 

Societv in IRQo .served as president of tho Clinical 

Edinburirli acted as examiner in medicine at 

at the and Victoria Universities, as well as 

also nbvoiV:°* t Board for England. Ho was 

■From VoO to 19 n” 1 ,^^° Seamen’s Hospital at Greenwich, 
and from igna- bo H.M. Troasuiy, 

to 1910 ho was medical adviser to the 



162 Jan. 2S, 1928] 


. -■.y.us.ts [ 3 ,- 

■ OBITUARY. f" TniDums* 

•=n;2::-ljiEDicu.Jooiciii' 


1)C appraised in- otiicrs move eompotont Ihiwi myself. 
^Althoiigh Sir Dyca vas an importation into this country 
from Scotland he (piicldy and thoroughly identified himself 
■with his now surroundings, both at St. Bartholomew’s 
Hospital and at the College of Phy.sicians, and heeame an 
enthusiastic incmher of both hoclics. His presence was 
liandsonic and dignified; ho was always kind, courteons, 
and friendly, thorough and' pjiin.staking in all that ho 
undertook. Had ho occupied the presidential chair of the 
College he would have upheld its stately traditions; and 
indeed, as it was, he .seemed, as treasurer over a very long 
period, to embody its ancient and cultured spirit. He was 
essentially a friendly and kindly man, and I know of no 
enemies of his. His health had been failing for some years, 
'rapidly of late, and the end was a happy release. Ho will 
long be I'emembered as a fine specimen of the cultured 
physician of the last century. 

.“A. C.” writes; Fitting regard has been jvaid to the 
ereat cjualitics of Sir Hyce Hucku'orth both as a man and 
as a physician, but special attention should be drawn to 
his abiding affection for the College of Physicians, of 
which be was treasurer for nearly forty years. Ko man 
over served the College with more unswen-ing loyalty and 
fidelity. He was always at his post, and his dictum, “ The 
best onlv is good enough for the College,” expressed his 
veneratfon for it and what he gave to it in the shape of 
personal service. For many years few figures were beltov 
Icno-ivn at the College, and the many with ■v\-hom he came 
into contact could not fail to be impressed with his 
charming and dignified old-world cotirtcsy. In ai)pearance, 
in manner, aiuf in all his dealings with others he was 
always the “ great gentleman.” 


BASIL 'I'HORN LAKG, M.A., B.Cri., F.R.C.S., 

Surgeon to the Royal London Ophthalmic Hospital. 

IVe have to announce with deep regret the untimely di'ath, 
on January 18th, from pneumonia, of Jfr. Basil Lang, 
a very able’ ophthalmic surgeon and a man of great attain- 
ments and originality of mind, with a singular gift for 
anything mechanical, whether it bore directly upon his 
professional work or not. 

Basil Thorn Laiig was born in London on October 3ril, 
1880. Ho was the only son of Mr. AVilliam Lang, F.B.C.S., 
comsulting ophthalmic surgeon to the Middlesex Hosjrital 
and to the Boval London Ojilithalmic Hosjtital, Jfoorfields. 
whom all oidithalmologists hold in the highest regard. 
From Abbotsholme School in Derby.shire Ba.sil Lang went 
to Trinity College, Cambridge, and graduated B..\. in 
1902, with first-class honours in the Natural Sciences 
Tripos. He then continued bi.s medical studies at St. 
Bartholomew’s Hospital, and having qualified as AI.B^.C .S., 
L.E.C.P.Lond. in 1906, proceeded next year to the M.A. 
and B.Ch. degrees at Cambridge. In 1910, after .sewing as 
house-surgeon and ophthalmic house-surgeon at St. Bartlio- 
lomew’s, he obtained the F.R.C.S.Kng. diploma and spent 
the following years in preparation for his life-work, holding 
at one time in- another clinieal assistantshiiis in the eye 
departments at St. Bartholomew’s and the Middlo.sex Hos- 
pitals, at Moorficlds, and at the Boyal 'Westminster and 
Central London Ophthalmic Hospitals. The varied experi- 
.euee of these jiosts, reinforced hy private juaetiee with his 
father in Cavendish Square, and hy wide reading and visits 
to foreign elinies, made him familiar with every phase of 
eve 'work. No new knowledge or technical imiuovenieiit in 
onhthalmology- escaped him, and his inventive ?uind ivas 
m-er alert for ), edibilities of further advance. But a 
shmle hraneh of medicine was too narrow a field for liis 
abo^nnding energy and fertile brain ; new methods, new 
ideas new contrivances were the breath of his life. In 
particnlar he was an adept with electrical apparatus and 
in colour photography, and during the war, when bolding 
a commission as captain, B.A.M.C., be devisedwaiul fitted 
up a mobile x-ray plant, and invented a most iiigenions 
r«iige-finclor for locating enemy aoroplancs. 

After the war he resumed Iiis practice and heCcamc assis- 
taut surgeon to the AVestern Ophtlialmic Hosjiital and 
ebici assistant in a luimber of eye departments; he acted 
a So as honorary ophtlialmic surgeon to St. Andrew’s Hos- 
pi a , Dollis Hill, and to the Ncw.spaper Press Fund, 


Later be was appointed surgeon to Moorficlds (as bis 
father bad been for thirty years), and quite recently was 
elected to the visiting staff of the Royal Northern Hospital, 
Holloway Road. His occasional writings on ophthalmology 
were marked by care and accuracy of expression, and bis 
book The Ituuiine ICxeniiiiiiitioii of the Kijc (reviewed in 
oiir issue of April 4tb, 1925) is a cle.ar and tnistwortby 
guide inspired by bis fatbcv’.s nietbodical tcacliiiig. 

Basil Lang took . endless tronblo for bis patients, ]ioor 
or rieli, and would go any distance to servo a friend. 
’Those who knew liiiii best looked upon him as a man of 
nstonisbing capacity who, although lie achieved a great 
deal, never quite did full justice to bis powei-s, and sowed 
much with both bauds for others to reap. 


AVe are indebted to Mr. AA’. T. Holmes Si-iCEa, F.R.C.S., 
consulting ophtlialmic surgeon to .St. Bartholomew’s 
Hospital and to the Royal London Opbtbalmie Hospital, 
Moorficlds, for the following tribute to bis old jiiipil ; 

The nows of the death of Basil Lang came to bis friends 
as a groat .shock; lie was known to have bad some wc.ak- 
ness of heart during the war for wbicli be bad been 
invalided borne, and be bad more recently siiifercd from 
arthritis of bis wrists, but it was hoped that be bad 


recovered. , ' . , . , 

Mv association with him began with Ins dressciship and 
bons'c-snvgcoiiev in the eye department at St. Bartbo- 
lomDw’,s, and aitonvards during a long period of years when 
he was my chief assistant. Even at that early tune he was 
obrioiislv' no ordinary man, but one intent on pushing 
inqiiiiw ‘to its fiirtbe.st limits— an iconoclast perhaps, but 
alwavs a searcher after the Truth as Iio saw it. His 
war ’ sen-ice w.ss unfortunately cut short because of 
bis brcnkdoini in licaltli, but be organinod the service of 
the portable giant magnet for use at the front, wliorcliy 
a fragment of iron or steel conid be removed very soon after 

its iicnctration into the eye. _ 

He spent a eood deal of time and tbongbt in the making 
of eaiFets time savers, and devites for tlie lietter working 
of tiiiim.s ill common use, and be often came to bis work 
ill the aftenuion bursting with a new idea ; ho would tak(> 
out bis pencil, and on the fresh wbito blotting-paper on 
the desk would sketch out bis idea Ho was a skilled 
dramditsmaii and engineer, and would not hesitate to take 
to nrcces a new bit of moehanism, .sneb as a Bron-ning 
uNfo to show bow it worked, and would put it togotber 
n<V h,’ His mind was so full of ideas that be never bad the 
time nor the patience to carry them out. The one groat 
exception was a complete and verv elaborate perimeter, 
irbie . wa- no sooner conq.letcd than be was dissatisfied wif b 
it and which for this voasoii missed success. He lead so 
’ I r tlin Siiirit of tlic inventor and engineer that om 
Ji'ften Wt tliat be bad not chosen to follow his instincts m 

opbtSiologist be was more interested in the 
• fLon ill the biological side, and in Ins teaching to 
H 'Ifu dents bis tbeiiie tended generally toward,s the subject 
^^refroctioVand its mimite eorreetiou rather than to the 
1 - • -.1 Tsnect His demonstrations were clear and logical, 
elinic. ‘ iiitelliEcnce of his beftrers. He held very 

■'’uVimeif vows on^ of sepsis and the use of 

adianccd - matters 

;;"pertectlv loval in carrying out my views. Ho would 
divi'iine.nr and would return with a cackle of 
r'"''-nb Ir'vii >' been to the plivsies laboratory or clse- 
TZ' l), rartf' some point or discuss some problem. . H.s 
"*'V . ,:.i ,',t suffer from these absences, as be was a 

I mid aceiiratrlrker. He bad the voice and laugh of 
a ‘'‘ loud speaker ” ; be bad to be quelled occasionally m -a 
f ■ div iViv when bis own voice filled the room and made 
m" -onnl'e difficult to bear; but he never resented it- 
^ J vei-v pleasant and loyal worker, and wlietber 

?t''tbe' hospital' or on the links be was always a good fellow 

'"evcii diirin " the depressing time of his illness, 

wlmii the condition of bis wrists made operating difficult 

ho was not visibly deprassed, and would dismiss “ 

form of vaccination ''''tli obvious pleasmre. His spir t u 

undaunted and be was looking forward to new fields 
work in Ills post at the Royal Northern when the end came. 
He will be missed by a large number of friends. 





-.1 


Feb". 4 , 192 S] 


TKEATMENT OE PERNIOIOES ANAEMIA BY LIYER. 


‘ L-ileOICAL JoUBNAt 


TEEA.TMENT OF PERNICIOUS ANAEMIA 
BY Li™ * 

BT 

H. F. BEEWEB, M.B., B.Cn., A. Q. WELLS, JLB., B.Ch., : 

AND . ‘ 

F. E. FEASEE, JLB., F.B.C.F. 

(From the Jtcdicnl ProtcESorlol Unit, SI. Battholomew's Hospital.) 

In August, 1926, Minot and JInrpliy* roporlcd that thoy 
liad obtained good results in tlio treatment of pernicious 
anaemia by moans of a generous diet rich in animal 
proteins and especially in liver, and a year later they 
published a further report’ on a series of 105 cases. In 
their second report they confinned the good results obtained 
and emphasized the importance of the liver in the diet, 
and they were further able to announce that a non-protoin 



Omni 1.— Case i. 


Anderson and Spriggs* reported that they had successfully 
treated two cases by liver feeding, and Spence,’ at a 
meeting of the Newcastle and Northern Counties Medical 
Society in November, 1927, reported tho results in 20 cases. 

Wo liavo been able to treat 19 cases of pernicious anaemia 
by tho administration of liver, hut in 6 of these tho disease 
was in tho remission stage, and , in 4 others methods of 
treatment other than liver administration were employed 
in addition, or tho observations were incomplete, so that a 
valuation of tho treatment in them is not possible at 
present. Nino cases came under observation in the stage 
of relapse or before the first remission, and in them there 
woro no other methods of treatment that interfere with 
tho estimation of tho value of treatment by liver. 

Sesulfs. 

Case 1 (Chart 1). 

A woman, aged 47. First attack in 1920. Admitted on Aug>mt 
25tb, 1927, in the second relapse. Subjective and objective 



CUAET 2 . — Case 11. j 


tn prepared by Cohn that appeared 

about a .*"*'’Jence as tho whglo liver in bringing 

ment in symptoms and a striking improve- 

hrueneo ^hoy were led to try tho 

number of reason’s 

in maiiTT nf the similarity of pernicious anaemia 

.beri-beri siiggeS^ pellagra, sprue, and 

ananmin n.; pke these diseases, pernicious 

the re>Teneration'"°'f exerted a striking influence on 

anaemia produepd°l, ^“Etnog^obin in severe secondai-y 
to liver ns likel t I ^°P®^ted bleedings in dogs, pointed 
althoueh it i„ n? v v> “ specially faroiir.able influence, 
hells rather .,P™bably a defect in tho development of tho 
pernicious mnF" bacmoglohin that is present in 

Association in Ed?Al “eating of the British Medical 

Murnhv’ v-ac j '”"gb last year a paper by Minot and 
“Id a number o" the results in 125 cases, 

other countries appeared in tho literature of 

— in the last few months. In this country 

diNnission on°'"'tiie'’trpalni'’il.t'' ,P“Pvr by Professor Fraser opening a 

Society of London on Januarf23A‘l9S‘(scrp.^^^^^^ “““ 


evidence of involvement of nervous system. Achlorhydria present, 
InHirr'cfc van' den Bersjh test, 1 unit. Red blood cells numbered 
1,470,000 per c.mm.; haemoglobin 32 per cent.; whilo blood cells 
2,200. MegoIobJnsle present. Price-Jones curve pceitive. 

Treatment : The patient Tvas given ^ lb. cooked liver daily. On 
the tenth day of treatment the percentage of reticulated red cells 
had risen to 18.0, and at the eiid of two months tho blood 
count showed red blood cells 4,410,000; haemoglobin 93 per cent.; 
white blood cells 9,500. 

Case it (Chart 2). 

A woman, aged 37, admitted on July 29th, 1927, in first attack. 
Subjective and objective evidence of involvement of 
Byslem.' Achlorhydria present. Red blood cells numbered 1,320,000; 
haemoglobin 30 per cent. ; white blood cells 4,500. Megaloblasts 

^ Treatment : She was given ^ lb. cooked liver JaUj- On the 
seventh day of treatment the percent.age of reticulated rod cells 
had risen to 13.0, and at the end of ten we^s the blood count 
was, red blood cells 4,850,000; haemoglobin 90 per cent.; white 

blood cells 6,600. _ 

Case in. 

A man, aged 58, admitted on September 16th, 1927, m first 
attack. Subjective and objective evidence of involvement of 
Arhlorhvdria present. Indirect van den Bcrgh 
test'0 7 uml Ecd blood cells 2,160,000; haemoglobin 69 per cent.; 
white blood cells 3,750. Megaloblasts present. Prico-Joncs curve 

^"rSmeiit : Patient was given i lb. cooked liver daily. He had 
been receiving arsenic by tbe mouth for four days before admis- 
sion- this was stopped for nine days before liver was commenced. 
' • [3500] 







1136 Feb, 4, 1928] 


^TEEATMENT OF FERmoIOUS ANAEMIA BY EIVER, 


On the eighth day of treatment the percentage of rcticidatcd red 
cells liad risen to 5.0, and at the end of seven weeks tlio blood 
count was, red blood cells 4,530,000; haemoglobin 98 per cent.: 
wiiitc blood cells 7,000. 

Case iv. 

A woman, aged 45. First attack commenced in 1921. Admitted 
on Juno 10th, 1927, in the fourth relapse. In tho previous re- 
missions there is no note of tho haemoglobin reachin" a higher 
figure than 75 per cent. Tho tonguo showed atrophy of tho 
mucous membrane. There was siibjcclivo and objcclivo evidence 
of involvement of the nervous system. Spleen palpable. Achlor> 
liydria present. Indirect van den Bergh test, 4 units. Mcgalo- 
blasts present. Price-Jones curvo positive. 

On June 23rd sho was given 200 c.cm. of blood intravenously, and 
on July 11th received a further 600 c.cm. On July 12th tho 
blood count showed red blood cells 2,100,000; bacmoglobln 45 per 
cent, ; white cells 3,600. On July 15th tho red cells numbered 
1,700,000; haemoglobin 50 per cent.; white cells 3^000. On July 
20th liver treatment was commenced-^ lb. cooked liver daily. On 
the seventh day of treatment tho percentage of reticulated red 
cells had risen to 5.0, and nt tho end of seven wrecks tho 
blood count was, red cells 4,350,000; haemoglobin 96 per cent.; 
white cells 8,800. * . » b 1 


Treatment: Extract (Lilly) equivalent to 500 grams of livei 
lo?!.?' S” day of treatment tho percentage of reticu- 

lated red cells had risen to 6.8, Tho extract was stopped aftei 
twelve days, and f |b. of liver daily was substitutea. Aftei 
thirteen weeks the blood count was, red cells 4,810,000; haemo- 
globin 95 per cent.; white cells 5,400 » p > o 


A .small quantity of liver extract was prepared in the 
Research CounciPs laboratories by a modification 
of Cohn s process, and the next case illustrates tho effect 
of this extract, '* ' 

j 

Case vn (Chart 5). 

A woman, agea 34, admitted on j^ovember 14th, 1927, in firsl 
relapse, bubjeclive and obiectivo eviddneo of alight involvement ol 
nervous system. Achlorhydria present. Liver enlarged and aplcei 
palpable. Indirect van den Bergh test, 1.2 units. Bed cell; 
1,830,000; haemoglobin 38 per cent.; white cells 3,900. Megalo 
blasts present. rrice-JoneS curve positive. 

Treatment; Ertraet (JI.B.C.) equivalent to 500 grams of Iivei 
daily. On the thirteenth day of treatment the percentage o) 
reticulated red cells had risen to 16.6. Tho extract was stopped 



Chart 3,— Case v. 


Chart Case vi. 


Through the kindness of Dr. Minot and tho committee 
on pernicious anaemia of the Harvard Medical School, who 
woi'e controlling tho preparation of a liver extract, wo 
received a small supply of an extract prepared by Eli Lilly 
and Co., by the method devised by Cohn.* The effect of 
this extract is seen in the next two cases. 

Case v (Chart 3). 

• A man, aged 60, admitted on September 29th, 1927, in the first 
relapse. Mental disturbances pronounced, and subjective and 
objective eridence of involvement of nervous system. Tonguo 
smooth. Achlorhydria present. Indirect van den Bergh test, 0.6 
unit Bed blood cells numbered 1,920,000; haemoglobin 53 per 
cent.; white colls -4,000. Megaloblasts present. Price Jones curve 

^^Treatinent: Extract (Lilly) equivalent to 500 grams of liver 
dailv On tho eighth day of treatment the percentage of reticu- 
lated red cells had increased to 11.2, and the red cells and 
'haemoglobin rose rapidly. The extract was stopped on the nine- 
teenth dav. and 4 lb. of liver daily was substituted Mtcr tlurteen 
weeks of treatment the blood count was, red cells 4,290,000; haemo- 
globin 97 per Cent.;- white cells 7,100. 

Case vi (Chart 4). . 

A woman, aged 56, admitted on Octeber 11th, 1927, in second 
relapse. Subjective and objective evidence^ of * mvolreznent' of 
nervous system. Achlorhydria present. Indirect van den Bergh 
test, 1.5 units. Red cells numbered 2,310,000 haemoglobin 56 per 
cent.j white cells 3,400. Normoblasts present. Price*Jones curve 
positive. 


i.x j ixvn flavs and Ib^ of liver was substituted. After 

after two j- ^ tjio blood count Svas, red blood cells 

^eborewfba^^m 92_per cent.; white cells 11,200. 

' In 0 discussion such as this it is not possible to include 
many observations of interest that have been made n 
thesf cases, but the results m general agree with the 
reports of Minot and Murphy and their colleagues. 
rri^ frtiiTid that in a few days after commencing liver 
SSmnl tl. p.raml.g. of lolioolotod reJ 

imLt of the rise in the nnmher of reticulated cells 

STtotal red cells and haemoglobin began to increase, an 
the tetai re number ot 

reriruHted Cells. The improvement in the general 
tion of the patients has been very striking and "600 j 

h:ir3 'tm SlS ofTeZIsf and^ dT/ressiotqMckly 

Seared and i^m^ppetite returned, bk the more defimto 
B^ptoms, such as dyspnoea, ^ |he 

cramps, and numbness, only gradually , 

red - cdl . count and tho haemoglobin ’^PP^^^^bvement 
In the cases with mental disturbances the t 

that o'cem-red -in a few days, and tha-t amounte 
to a change in temperament, was remarkable. 



rEii. i, 152$] 


TKEAT5IENT OP PERKICIOES ANAEMIA BY EIVER,' 


r Tn7.B7.rnTa 1 R7 
l Medical Jocrnal a U I 


In I'vo cases in vliicli it 1ms not lioen jiosmI.Io to mnko 
any otlicv diaRiiosis tlmu that of pcrmoions anaoniin, 
altiioimh there rvoro reasons for nneortaiiity m inaking this 
"oi, tho treatment hy liver has failed. 

Case viir. 

\ man a"ca 48, ndmittod on October 18th, 1927, in tho first 
f.aUack Tiicrc was marked dental sc^ms, but no hiMory of Foro 
4on"uc, nor did (ho (on^n^ fhow cvnlenco of previous pl^silis, 
'Anai't from some tingUn? i» tlie fmgers there ^vas no suhjcclivo 
or objective cvidcncQ of involvement of Urn nervou.s .fyslcm. 
Achlorhydria present. Inthrcd van den Kergh test, 0.4 unit. Red 
blood cclk mimhcrcfl 930,000 per c.mm.; imemoglolun 19 per cent.; 
•white cells 4,600. Jilegalobla^U present. rnce-.Ionos curve posi- 
tive. Tho teeth were removed and he was treated hy liver extract 
cnuiValont to 500 grams daily, and for n few days 1,000 prams, 
and later whole liver* (A lb. daily) for three months without any 
response. Hydrochloric 'acid was given, and on two occasions ho 
received blood transfu-sions. The red cells and Jiaomoglohin roso 
after c.ach transfusion, but there was no increase in tho reticulated 
red cells. This patient is still under 
observation. 

Case i.x, 

A man, aged 61, admitted on July 
l2tU, 1927, in first, attack. Ko evidence 
ol glossitis. Apart from occasional 
numbness in the fingers there was no 
subjective or objective evidence of in- 
volvement of tho nervous system. 

There was considerable denial* sepsis 
and pyorrhoea. Achlorhydria prc.>cnt. 

Indirect van don Borgh test, 0.7 unit. 

Red^ blood cells 1,000.000*, haemo- 
globin 25 per cent.; •white cells 8,600. 

Alcgaloblasts present. Price -Jones 
curve _ not typical of pernicious 
anaemia. There was a temporary 
response to each of Ihrco blood trans- 
fusions, but no response to Alb. of 
liver daily. The Uver'“trcatmcnt was 
continued for eight weeks and was 
stopped because of a recurrence of 
gout. He died on October 27th. 

1927, and except for (lie absence of 
any degenerative changes in the 
nervous system the autopsy findings 
were^ compatible with a dfagnosis of 
pernicious anaemia. 

Of the remaining ten patients, 
who citlier commenced liver trent- 
ment in tlio remission sta^o or 
received other forms of trcafmoiit 
in addition, seven (lavc remained 
well during tlie tliroo to six 
months tliat tliev have l)Dcn 
under oliservation, and four of 

c of over 

5,000,000, two of over 4,000,000 
ond one of 3,500,000. One na lent 

was not ahlo to take satistae on' 

.'^mounts of liver, but after 
weofe of treatment felt well; tho 

3,140,000 per 



CiuRi 5.— CoEe vn. 


c.niiii., hacnio- 
who responded 


with a f^"''tker patient, 

severe hcaif f reticulated colls, was siilTciing from 
The last treatinont was abandoned, 

mont with under observation when on treat- 

raised percent entering on a remission with a 
n few day's ' reticulated rod cells that dropped in 

commenced ’shortlt i ‘‘•'‘‘’y 

months.- Ho tI,o/ “nd Iio remained well for four 

Oration and "cnera1°no '’■f''- appendicitis with per- 

Ill's reacinufstn “"d died. A blood count 
cells 5 120 non- "\o days before liis death showed red 
’ ’‘“““g'nWuQS per cent.; white cells 13,400. 


In view of t!i t 
disease it is diffi ° “"rnl remissions that occur in this 
aeries of cases prove conclusively from the small 

.ralue, If^ howev*^^°^^'' liver treatment is of 

with the 125 consider these cases in conjunction 

is a rcmarhahlo .’"^Pnrted hy Minot and Murphy, thero 
this treatment n'fnrmity in the improvement following 
reports of Cases, i to vn confirm tho 

mencod in, the fir t :'’*rphy — that if treatment is com- 
pile reticulated red^ eeU. of relapse, 
commencement of ii-,- ^ 'ooreaso in a few days after tho 
or treatment with a striking regn- 


CoMilEXT. 


larity, and this increase is followed hy a steady rise in the 
total red cell count and in tho haomoglohin. This charac- 
teristic response does not occur in patients with secondary 
anaemia or leukaemia. Theso facts seem to point to a 
therapeutic action of great value. The work of Cohn, and 
tho discovery that a non-protoin, iron-free extract of liver 
has tho same action as whole liver, points to a therapeutic 
principle of which wo have hitherto had no knowledgo or 
suggestion. It is obviously too early to form any con- 
clusions on tho value of this treatment in maintaining tho 
patients in this improved state or in preventing relapses, 
but tho results obtained in America arc most encouraging-. 

Tho studies of Peabody'- oir tlio bone marrow in tiio 
stages of relapse and of remission indicate that in the 
relapse stage tho marrow is packed with megaloblasts, and 
that when tho red blood cells increase in tho circulating 
blood diiring the remission tlio 
number of megaloblasts in tho 
marrow decreases, and tho 
marrow approaches tho usual 
normoblastic type. The reticu- 
lated red cells that appear tem- 
porarilj- in the circulation after 
commencing liver treatment are 
young cells,” and aro mainly 
larger than the normal erythro- 
cyte, and Peabody suggests that 
liver acts hy stimulating tho im- 
mature megaloblastic cells that 
pack the marrow to develop to 
maturity. The approach to tho 
normoblastic typo of blood cell 
formation occurs later. 

It is still uncertain what effect 
liver treatment has on the changes 
in tho nervous system. It is not to 
be expected that objective signs 
of degenerative changes should 
disappear, and though in our ex- 
pcricnco evidence of progressive 
degeneration has appeared during 
liver treatment, it is possible that 
the process ceases after the treat- 
ment has been continued for 
some time, as Minot and Murphy 
believe.- There is less doubt as 
to the effect on the achlorhydria 
wliich is constantly present. 
Thero is no evidence that it dis- 
appears as the result of this 
treatment, and thero is evidence 
that it persists in spite of liver 
treatment,' and that it is present 
long before the development of tho anaemia. '■* It 
would appear probable, therefore, that liver treatment 
exerts a specific influence on tho faulty development of 
the red cells, but there is no cvitlence that it affects 
tho underlying abnormality that is present in those 
patients who develop pernicious anaemia, and of which 
tho achlorhydria is a manifestation. 

For this reason it is as important as it was formerly to 
pay attention to tho general condition of the patient, to 
treat septic conditions, and to administer hydrochloric 
acid. Our patients have all been given hydrochloric acid 
after the immediate effects of the liver have been observ'od. 
Following the advice of Minot and Murphy we have given 
the patients a generous, well balanced diet, with plenty of 
vegetables and red meat, in addition to the liver. Con- 
siderable difficulty has been experienced in producing an 
active extract on a commercial scale, and until an emcicnt 
extract can he put on the market in considerable quantity, 
and at a suitably low price, treatment by whole liver must 
be continued. Most of the patients have taken tho rather 
large quantities of liver (I lb. daily) without difficulty, and 
have, L a rule, preferred it stewed, though fried liver and 
liver soup aro agreeable variations The raw yuico mixed 
with orange juice has proved useful, especially in the moro 
seriously ill patients. “Cooked liver, » as Minot and 
Murphy’ state, “ may he served in any way that pleases 




TBEATMENT OF PERNICIOUS ANAEMIA BY LIVER. 


r TnEBamim; 
LMEDICAI.j0ITRJfAL 


11)6 FEn. 4, 1928] 


On llm ciglith day of treatment Uie percentage of reticiilalcd red 
cells had risen to 5.0, and at the end of seven wcclta the blood 
count wiis, red blood cells 4,530,000: liacmoglobin 98 per cent.: 
white hlood cells 7,000. 

Case iv. 

A %voman, aged 45. First attack commenced in 1921. Admitted 
on June lOtli, 1927, in the fourth relapse. In the previous re- 
missions there is no note of the haemoglobin reaching a higher 
figure than 75 per cent. TIio tongue showed atrophy of tho 
mucous membrane. There was subjective and objective evidence 
of involvement of the nervous system. Spleen palpable. Acblor^ 
liydria present. Indirect van den Bergh test, 4 units. STcgalo- 
blasts present, Pricc-Jonos curve positive. 

On Juno 23rd sho was given 200 c.cm. of blood intravenously, and 
on July 11th received a further 600 c.cm. On July 12th tho 
blood count showed red blood cells 2,100,000; haemoglobin 45 per 
cent.; white cells 3,600. On July 15th tho red cells numbered 
1,700,000; haemoglobin 50 per cent.; white cells 5^000. On July 
20th liver treatment was commenced-^ lb. cooked liver daily. On 
tho seventh day of treatment the percentage of reticulated red 
cells had risen to 5.0, • and nt tho end of seven weeks the 
blood count was, red cells 4,350,000; haemoglobin 96 per cent.: 
white cells 8,800. 



CUAKT 3.— Caso V. 


Through tho kindness of Dr. Minot and the conunittco 
on pernicious anaemia of the Harvard Medical School, who 
wore controlling tho preparation of a liver extract, wo 
received a small supply of an extract prepared by Eli Lilly 
and Co., by the method devised by Cohn.' The effect of 
this extract is seen in the next two cases. 


Case v (Chart 3). 

A man, aged 60, admitted on September 29th, 1927, in the first 
relapse. Mental disturbances pronounced, and subjective and 
obiective evidence of involvement of nervous system. Tongue 

' ,1 .1 1...1 Tra «'an "Rov-rTT ‘ * ~ — 

smooth. 


; eviuence oi liivuivciucuM noivwuo sjoi/cui. 
Achlorhydria present. Indirect van den Bergh test, 0.6 
unit. Bed blood cells numbered 1,920,000; haemoglobin S3 per 


u.i.u ' w per 

cent.’- widte cells . 4,000. Megaloblasts present. Price-Jones curve 

^'Treatment: Extract (Lilly) equivalent to 500 grams of liver 
daily On tho eighth day of treatment the percentage of reticu- 
lated red cells had increased to 11.2, and the red cells and 
'haemoglobin. rose rapidly. The extract -was stopned on the,nine- 
teenth dav and i lb. of liver dally was substituted. After thirteen 
weeks of treatment the blood count was, red cells 4,290,000; haemo- 
globin 97 per dent. ;- white cells 7,100. 


tJASE VI ^ouare 

A woman, aged 56, admitted on October 11th, 1927, in second 
relapse. Subjective and- objective -evidence^, of ■ involvement of 
nervous system. Achlorhydria present. Indirect van den Bergh 
test, 1.5 units. Red cells numbered 2,310,000 haemoglobin 56 per 
cent.; white cells 3,400. Normoblasts present. Price-Jones curve 
positive. 


Trealmcnt ; Extract (Ully) equivalent to 500 grams of live; 
daily. (Jn the eighth day of treatment tho percentage of rcticu 
lated red colls had r^cn to 6.8. Tho extract was stopped aftei 
Iwolvo days, and i Ib. of liver daily was substituted. After 
thirteen weeks the blood count was, red cells 4,810,000; haemo- 
globm 95 per cent.; white cells 5,400. 

A .small quantity of liver' extract was prepared in tin 
-Aledical Research CounciPa laboratories by a modificatioi 
of Colin^s process, and the next case illustrates the effee 
of this extract. ' ■ 

Case vn (Chart 5). 

A woman, aged 34, admitted on November 14th, 1927, in firs 
reJapso. Subjective and objective eviddnee of slight involvement o 
nenrous system. Achlorhydria present. Liver enlarged and splec; 
palpable. Indirect van den Bergh test, 1.2 units. Red cell 
1,830,000; haemoglobin 38 per cent.; white cells 3,900. Megalc 
blasts present. Pricc-Jonc.S curve positive. 

Treatment; Extract (M.R.C.) equivalent to 500 grams of live 
daily. On the thirteenth day of treatment the percentage o 
reticulated red cells had risen to 16.6. The extract was stoppei 



o a K BC-TnilUons per c.mm. 

D-..0 ffb'i. 

• f,—m.HBC.thousartaspa‘Cmmr 
RcTtcvtjocms 7<» 



eSAUT 4.-<3aso VI. 

1 twn (lavs and i lb, of liver was substituted. After 

ftcr treatment tho blood count was, red blood cells 

Vooof baemo^obin 92.per cent.; white cells 11,200. 

’in n teenssion such oa this it is not possible to include 
mny observations of interest that have been wade 
hesJ cases, but the results m general agree with ^t 
eports of Minot and Alurpliy and thoir colleagues, 
mow Uind that in a few days after commencing brer 
T nt the percentage of reticulated red cells ■ began 
and tha^irreached a maximum a few days later 
td then declined rapidly, and that a little after the com- 
Inmoiit of the rise in the number of reticulated cells 
hn total red cells and haemoglobin began to increase, an 
he total red cen^^^^^^ after the fall in the number of 

‘’ripulated^ells The improvement in the general condi- 
bn of tilt patients has been very striking, and commenced 
s a rule with the beginning of the rise in the 
ells The feeling of weakness and depression '1’^''=% •{ 

p^e’ared and the'appetite -turned, but he more defimto 

mptoms such as dyspnoea, palpitations, he 
ramps, and numbness, only gradually disappeared 
ed cell , count and tho haemoglobin ^PPr^'^^^rbvement 
n tho cases with mental disturbances the imp 
bat occurred in a few days, and that amounted almost 
» a change in temperament, was remarkable. 



Feb. i, 


192S1 


TREATMENT OF PERNICIOUS ANAEMIA BY LIVER. 


r TnrCnrnsTi 1fi7 

I StEDICAt. JOCANIX. U I 


In two ca.scs in wliich it 1ms not boon, possiblo to inako 
any otbdr diagnosis than that of pornicions anaomin, 
aU'honMi there wero reasons for nncortainty in making this 
diagnosis, tho treatment by liier has failed. 

Cask viii. 

-V man a^od 48, admitted on October 18th, 1927, in tho first 
i.altack. There was marked denial sepsis, but no hisloi-j- of soro 
.toimuc, nor did tho tongue show evidence of previous glossitis. 
Apart from soma tingling in the fingers tliero w.as no subjectivo 
or objective evidence of iiivolveiiieiit of the. nervous S 3 -Etem. 
Achlorlijdria present. Indirect van den Bergh test, 0.4 unit. Red 
blood cells numbered 930,000 per c.niin. ; haemoglobin 19 per cent. ; 
white cells 4,609. ifcgaloblasls prr.scnt. rricc-Joncs curve posi- 
tive. Tlio ieetli were removed and he was treated bj- liver extract 
equivalent to 500 grams daily, and for a few days 1,000 grams, 
and later whole liver' (1 lb. dail}-) for three months without any 
response. Ifydrociiloric 'acid was given, and on two occasions ho 
received blood transfusions. Tlic red cells and haemoglobin roso 
after each transfusion, but there was no increase in tho reticulated 
red cells. Tills patient is still under 
observation. 

Cask ix. 

A man, aged 61, admitted on .Inly 
12tli, 1927, in first attack. No e\idcnco 
of glossitis. Apart from occasional 
numbness in the fingers there was no 
subjective or objective evidence of in- 
volvement of the nervous sj-stem. 

There was considerable dental'scpsis 
and_ pyorrlioea. Achlorhydria prc.scnt. 

Indirect van den Bergh test, 0.7 unit. 

Red blood cells 1,000,000; haemo- 
globin 25 per cent.; rvliito cells 8,600. 

Mcgaloblasts present. Price - Jones 
curve _ not tj-pical of pernicious 
anaemia. There was a tcniporarv 
response to each of three blood trans- 
fusions, but no response to i lb. of 
liver daily. Tho liver*’treatmcnl was 
confmuod for eight weeks and was 
stopped .because of a recurrence of 
a™to gout. Ho died on October 27tli, 

1927, and, except for the absence of 
any degenerative changes in the 
nervous system the autopsv findings 
were_ compatible with a diagnosis of 
pernicious anaemia. 

Of the remaining ten patients, 
wlio cither commenced liver treat- 
ment in -the remission stage or 
recpived other forms of freatmont 
in addition, seven liave remained 
well during the three to sis 
months tliat they have been 
under ohserv.ation, and four of 

6 nim mo® 

0,000, 000, two of over 4,0C0 000 

- Patient 

as not able to take satistaetor'- 
amounts of hver, but after five 
necks of treatment felt well- tlio 

3il40,0q0 P-- l-Tl' 

ivitli a ris ^ cent. rViiotlicr patient, n ho responded 
severe hcaiVf.,:i ® reticulated cells, ivas sulTering from 
The hst troatiiioiit was abandoned, 

mont with came under ohsen-ation ivlicii on treat- 

raised ncreev,*®'"®’ entering on a remission with a 

a few \laT-q ^"m® reticulated red colls that dropped in 

months- Ho ai ^ and ho remained well for four 

foratioii uml o '®" , ''®'“pcd acute appendicitis ivith per- 
on his i-parb, peritonitis, and died. A blood count 

cells 5 120 nnn**i'®” before his deatli sliowed red 

. ‘e,i;uu; haemoglohin 95 per cent. ; white cells 13,400. 



CiLuii 5. — Case vii. 


In view of tl '-.uaiaient. 

disease it is dim® 7“‘''"'al remissions that occur in this 
series of cas r 1° prove conclusively from iho small 
.value. If ijo®^ reported here that liver treatment is of 
with tho 12S 're consider these cases in conjunction 

is a remarkah?^^®® ."ifPerted by Minot and Bliirphy, there 
fills tre<T.'tmont® "“‘rermity in the improvement following 
reports of Mi •' t ■ r f ° '''ir • confirm tho 

aienced in th”® a Murphy — that if treatment is com- 

fho .reticulated rod^^.oif*®-®’^’ relapse, 

commencement t ® increase in a few days after the 
o liver treatment ivith a striking regu- 


CoirxiENT. 


larity, and this increase is followed by a steady rise in tho 
total red cell count and in tlio haomoglohin. This charac- 
toristic response does not occur in patients with secondary 
anaemia or loukaemia. Theso facts seem to point to a 
therapeutic action of groat value. Tlie work of Cohn, and 
tho discovery that a non-protein, iron-free extract of liver 
has tho same action as ivliolo liver, points to a therapeutic 
principio of which wo have hitherto liad no kiiowledgo or 
suggestion. It is obviously too early to form any con- 
clusions on tho value of this trcatinont in maintaining the 
patients in this improved state or in preventing relapses, 
but tho results obtained in America are most encouraging. 

Tho studies of Peabody"- on the bone marrow in tho 
stages of relapso and of remission indicate that in tlie 
relapse stage tho marrow is packed with megaloblasts, and 
that when tlio red blood cells increase in tho circulating 
blood during tlio remission tho 
number of megaloblasts in tho 
marrow decreases, and the 
marrow approaches the usual 
normoblastic type. The reticu- 
lated red colls that appear tem- 
porarily in the circulation after 
commencing liver treatment are 
young cells,'l and are mainly 
larger than the normal erythro- 
cyte, and Peabody suggests tliat 
liver acts by stimulating tlie im- 
mature megaloblastic cells that 
pack the marrow to develop to 
maturity. The approach to the 
normoblastic typo of blood coll 
formation occurs later. 

It is still uncertain Avbat effect 
liver treatment has on tho changes 
in tho neiwous system. It is not to 
be expected that objective signs 
of degenerative changes should 
disappear, and though in our ex- 
perience evidence of progressive 
degeneration has appeared during 
liver treatment, it is possible that 
tho process ceases after the treat- 
ment has been continued for 
some time, as Minot and Murphy 
believe.- There is less doubt as 
to tho effect on the achlorhydria 
wliicli' is constantly present. 
There is no ev'idence that it dis- 
appears as tho result of this 
treatment, and there is evidence 
that it persists in spite of liver 
treatment," and that it is present 
long before the development of tho anaemia."'* It 
would appear probable, therefore, that liver treatment 
exerts a specific influence on the faulty doA-elopment of 
the red cells, but there is no evidence tliat it affects 
the .underlying abnormality that is present in tli’oso 
patients who develop pernicious anaemia, and of Avliich 
tho achlorhydria is a manifestation. 

For this reason it is as important as it was formerly to 
pay attention to the general condition of the patient, to 
treat septic conditions, and to administer hydrochloric 
acid. Our patients have all been given hydrochloric acid 
after the Immediate effects of the liver have been ohsen'ed. 
Following the advice of Minot and Murphy we have given 
the patients a generous, tvell balanced diet, with plenty of 
vegetables and red meat, in addition to the liver.^ Con- 
siderable difficulty has been experienced in producing an 
active extract on a commercial scale, and until an efficient 
extract can he put on tlie market in considerable quantity, 
and at a suitably low price, treatment fay rvlioie liver must 
be continued. Most of tlie patients have taken the rathei 
large quantities of liver (A lb. daily) without difficulty, and 
have, as a rule, preferred it stewed, though fried ^liver ^and 
liver shup are agreeable variations. The raw juice mixed 
with orange juice has proved useful, especially in the more 
seriously ill ' patients. “ Cooked liver,” as Minot and 
Murphy"" state, “ may he served in any way that pleases 




168 Peb. 4, 1928] 


TBEATMKNX OP GASTllIO ULOISB. 


r Tnr BniTiTjj 
I Medic iL Jocwii 


■Un! patient, but prolonged boiling is to bo avoided," Tlicro 
is ovidenc-Q tliat a smaller quantity of liver is siillioibnt to 
maintain tbo improved condition, and that tlic doso sboiild 
bo redneod when tbo blood picture npproaclics tbo jionnal. 

SirjiJHnv. 

Ninotoon patients with pornieious anaemia bavo been 
treated with wbolo liver or a liver extract. Nino of them 
were in tbo first attack or in a relapse, and seven of tbeso 
showed a pronqit response to treatment, with a temporary 
vise in tbo porceiitago of reticulated red cells in tbo circu- 
lating blood, and a steady increase in tbo total red cells 
and tbo baomoglobin. Tbo reason for tbo failure of tbo 
treatment in tbo other two patients is not clear. 

Ten patients commenced treatment during the remission 
stage or received other forms of treatment in addition, so 
that observations on tbo immediate effects of tbo treat- 
ment were not possible. Tbo condition of tbeso patients at 
tbo end of varying periods of treatment (up to six montbs) 
affords confirmatoi’j’ evidence of the value of tins treatment. 

Our thanks are duo to tbo physicians of St. Dartbolomcw’s 
Hospital and others who kindly enabled us to mako these 
obscivations on their patients. 

HrrEncNCcs. 

1 Jlinot, G. B., and Murphy, AV. P. : Joicni: A/nrr. .Mrd. Afeor., 1926, 
87, <170. 

: Idem, ibid., 1927, 89, 759. 

<1 Whipple, o. II., Hooper, C. AV., and Hob.schcit, F. S. : .Inicr. Joiini. 
of VUysiul., 1920, 53, 151-232; and 1925. 72, 395-1135. 

* AVliipiile, G. II., and Robsciicit-Ilobbins, F. S. : Atiicr. Jottin. «/ Pht/gioL. 
1925, 72, 419. 

r Minot, G. R., and Murphv, AV. P. : BniTisa MtoiciL JoiU’.xtL, 1927, ii, 
674. 

® .Anderson, J. 11., and Spripps, E. I. : Lancet, 1927, ii, 958. 

' Spence, J. C. : Ibid., 1927, it, 1026. 

« Cohn, E. J., Minot, O. R., Fulton, J. F., Ulriebs, II. F., Sarccnl, F. C., 
AVeare, J. H., and Murphy, AV. P. ; Joiini. Jlial. Chettu, 192/, 1.v.yiv, 69. 

’ JIurphy, W. P., Monroe, It. T., and Fita, R. : Jonrit. Amcr, Mctl. 

1927, 88, 1211. 

oiMcdcaris, D. N.. and Minot, 0. R. : Journ. riin. Incest., 1927, 3. 541. 
u .Alinot, 0. R., Jlurphy, AV. P., Colin, E. J., Stetson, R. 1’., and I,a«soti, 
II. A. : Trans. Assoc. Amcr. Phys., 1M7, 42, 83. 

Peabody, F, W, : Amcr. Journ. Path., 1927, 3, 179. 

» Key, J. A. : .Arch. 7nl. Med., 1921. 28, 511. 

' Hurst, A, F. : Lancet, 1920, i. 111. 


THE TREATMENT OF GASTRIC ULCER/' 

BY 

T. IZOD BENNETT, Jf.D., F,H.C.P., 

pnYsinm to out-patients, jiiddlesex hospitai,; physician to the 

EOVAI, NATIONAL ORTHOPAEDIC HOSPITAL. 


It is possible to-day to cure tbo majority of cases of gastric 
and duodenal ulcer without having recourse to surgical 
intervention, and since tbo surgical treatment of this 
disease is attended by a definite, if small, iminediato 
mortality, and by an even more dofinito porceiitago of 
subsequent relapses and complications that are often of a 
nature far more serious than those encountered in patients 
treated by purely medical methods, the present position 
is a grave one. The fiequoncy of tbeso cases is greater 
evei'j’ .yeai', and the problem of treatment one upon wliicb 
practitioners as a Avholo remain in considerable doubt. 
I do not propose to bring before you any .statistics, nor 
to go deeply into theories of causation or into experi- 
mental Avork bearing upon the etiology of peptic ulcera- 
tion, but I am going to outline the treatment which ten 
years’ experience has shown mo to yield excellent results 
in a very large proportion of cases. 

Hcmoi-al of Septic Foci. 

The first step in the treatment of gastric ulcer is ono 
Avbich must bo adopted in every case, Avhatever the decision 
may bo as to whether tbo general treatment is to be on 
medical or surgical lines. I refer to tbo eradication of 
septic foci in the mouth and clsoAvhere. 

Oral sepsis is probably the most important cause of 
gastric and duodenal ulcer, bacterial emboli being carried 
from the region of the dental roots by the blood stream 
to the region of the pylorus and lesser curvature. Tbo 
work of RosenoAV, of Haden, of Christopbe, and a score 
of others, m.ay be quoted as supporting this view, which 

•An address to the Hampstead Division of the British Medical Assocla- 
tlon on January 12th, 1928. 


13 very Avidoly hold in all countries at the present day. 
In addition to dental sepsis, or in its absence, chronic 
sepsis of the tonsils, nasopbai 7 nx, and nasal einuscs mast 
ojimitiaicil. Cases bavo been observed by many 
clinicians in wliicb tbo recurrent attacks of pain i 
patient.s with chronic ulcor bavo corresponded with acu 
cxacorbations in chronically infooted tonsils.- In a fe 
cases chronic apjicndicitis and chronic disease of the go 
bladder appear to bo important factors, and I bavo ( 
inoro than ono occasion received the assistance of rr 
surgical colleagues in removing a factor of this tvq 
AVithout ony surgical treatment being applied to tlie nice 
winch has subsequently responded avcII to purely medic 
treatment. It often, perhaps usually, happens that tl 
removal of these septic foci is better effected after a fe 
weeks’ treatment rather than at once. It would, fc 
cxamjde, bo foolisli to subject a patient recovering froi 
a sov’oro -baeniatemesis to tlie risk of extensive denti 
extractions; but in all cases focal sepsis must be eliminate 
at some stage if a permanent successful result is sough! 
and I ]ilaco it in this cai'ly and prominent position i 
order that its importance may not bo OA-erlookoA 

• Choice of Cases acquiring Surgical Treatment. 

In s])itc of my opening Avords concerning the efficacy o 
medical treatment, I do not wish it to bo imagined tba 
such treatment is to bo applied Avitbout restriction. Oi 
the contrary, I fed that in every case seen for the firs 
time the physician slioAild ask himself Avlictbcr surgica 
trciAtmcnt slionkl bo employed immediately. For Avherea 
lo-dny bimdrctls of cases arc sent to the surgeons Avitboir 
any rear attempt at medical treatment over having beei 
made, otbors are alloAVcd to linger in tbo hands o 
pliy.siciiUis Avbcn notliing but surgical treatment can helj 
them. 

Tlio foIIoAving eases call for surgical treatment as sooi 
as it is safe for it to bo undertaken : 

1. All c.Ases Avith .a high degree of pyloric or duodena 

stenosis, or Avith marked hour-glass deformity of i 
permanent nature. _ . _ 

2. All cases Avith deep ulceration involving adherenci 
to or excavation of neighbouring structures, such as tin 
pancreas or liver. 

Ill tlio fir-st of tbeso groups there is mechanical defect 
which can onlv be put right by mechanical means. In the 
second group tlioro is evidence of ulceration so deep that 
iionling can hardly bo expected, and amputation— that is, 
surgical treatment — is called for. , 

AVe now come to four further groups of very different 

typo : 

3. Cases Avliich have relapsed after a thorough course 

of medical treatment. , i 

A. Cases Avbicb Irave recurred in spite of treatment during 

"'s'^Caserin Avhicb there has been recurrent and dangei-ons 
haemorrhage in spite of careful medical treatment. 

To fall into ono of these groups a case must have had 
nrevious and unsuccessful medical -treatment, and it 
requires considerable judgement for a physician to decide 
whether the previous medical treatment has been such as 
^o tmtify the abandonment of all but operative intcr- 
venHon at the time Avhen the patient comes under Ins care. 
If a Tattnt has been properly treated and still relapses, 
a iiea- line of treatment must bo adopted. If a ease has 
iroiio on relapsing for many years the nicer will probably 
be so callous^hat healing is problematical, but 
experience has taught me that it is so rare for these 
^ c +n Invo received what, in nw opinion, can bo 

-ilipil as' thorough treatment that I hesitate more and 
described as « I have satisfied 

rsitS •" of 5"" 

drastic treatment on the lines I shall indicate. ■ 

6 Cases in Avhicb proper medical treatment is impossibl , 
OAAdiig 'to the patient’s habits and economic poshion 

This is an important groAip, 
numerous than I used to believe. , ‘ . .Ug time and 
assume that the working man cannot ™ 

effort necessary for dieting himself on proper hncs 
many such patients, if they can bo go ,. i^‘ ^ment 

seriousness of the position, will carry out medic.al troatm 



Feb. 4, igiS] 


TREATMENT OP GASTRIC ELGER. 


E Tm BRinra 
LIxoiou. JoasoiX 


169 


fully and thoroughly and give results which a few years 
nfro were imiiossiblo. Thero aro, however, certain recldcss 
aud greedy individuals who aro incnpablo in any circum- 
Btauccs of following a siniplo lino of diototio treatment. If 
by chance they have diabetes they die; if, on the other 
hand, they siilfcr from peptic ulceration it is more in their 
interest to endeavour to get them cured by surgical means 
'\ than to waste their time and that of their doctor by giving 
1 instructions which they will not attempt to obey. 

1 Wo are now left with tho cases suitable for medical 
\ treatment— an cnornious grouji constituting jirobably inorb 
than 80 per cent, of all who como under observation. 
Alvarez, in a recent article, stated that ho had never seen 
n case of gastric or duodenal ulcer which had been properly 
treated before coming to him. I cannot personally corro- 
borate this. I know that I have scon at least two cases 
which I considered to have been well treated, and probably 
I have seen half a dozen during tho last ten years, but 
• I doubt whether I have seen more. It is usually so easy 
to point to factors such as injudicious food, or to ali 
amount of alkali which could not possibly have affected tho 
gastric juice, or to residual septic stumps in tho mouth, 
the removal of which no ono had over suggested, that it is 
extremely rare to encounter a case in which it cannot 
immediately bo demonstrated that previous treatment has 
been obviously incomploto and faulty. 


Geneiui, Mr.nic.^L Tnr..vTStENT. 

.The first question which arises in general medical treat- 
ment is whether tho patient is to bo kept in bed or 
allowed to bo up and about. A p.atient in bed requires less 
food, and, by confining these cases to bed for a week or two, 
treatment can bo started on a lower total diet than other- 
wise. Further, it is difficult to mako a patient realize 
that ho is being seriously treated for a very grave disease 
if he is allowed to go about his business from tho start. 
For these reasons — and tho second is probably even moro 
important than tho first — I usually urge patients to 
abandon work for three weeks, of which tho first ten days 
at least are spent in bed, either at homo, or in Iiospital, or 
in a mmsing home, but it must bo admitted that many cases 
selected from amongst tho moro intelligent classes can be 
^Btorruption of their work. 

The two main objects of medical treatment are: (o) to 
secure the most complete rest for tho stomach compatible 
' With sufficient nutrition tor tho body, and (h) tho choice 
and administration - of food and drugs in such a manner 
that contamination of tho ulcer with acid gastric juice is 
^even ed. It is to tho Into Bcrtr.am lY. Sippy of 
haV we owe tho, full recognition of the logical 
factors, and to him must bo given tho 
r successful application. Tho use of alkalis 
j centuries, and tho uso of frequent and 

for fif+T 7 1 ° Eustric ulcer has been going on probably 

of tlipcn during tho last decade the treatment 

was become infinitely more successful than it 

be found in n? though considerable variation wdll 

‘ties evaminof^ °^p'^V®E'uies employed by various authori- 
thev arena bho more successful reveals the fact that 

fuliy advocated Sippy bo strenuously and success- 

foods which T ' ^ uo unique merit for the alkalis and 
from them n.,- f“S56st, nor do I imply that no variation 
be made anti ° Clearly many such variations can 

to the Doinf *hat treatment remains thorough, 

the same. I caution, the result will probably be 

Went which T I u specimen scheme of treat- 

fu the mainnif frequent experience to be effectivo 

uny crava^pnmni- This dons not refer to cases with 

rhago if 'oations, but to patients in whom haemor- 
bleedinn inrl form of slight occult 

deep, ifwithni t ° evidence of ulceration, horvever 

other organs T adhesions to, or penetration into, 

tobe:;:;etro- taWe' aro set out the diets 
in such cases during tlie first tlrreo weeks. 

Peptic VlcRT Diets, 

Citrated milt per j Fit'xt Week. 

Glaxovo, ®enger*o food, arrowroot, ovaltino, 

“cso to be given white vegetable soups. Ono of 

to exceed an oSSd tdl 9 P-™- Amount not 

,to £11 feeds. an ounco and a half. Cream to bo added 


Second Week, 

The same fooda aro to bo used, but tho amount may bo increased 
to ^two, and two and a half ounces. Alternate feeds may bo 
omitted twico in the morning and twice in the afternoon. Ono 
dry rusk to _bo given at 8 _a.m. and 7 p.m. Two tablespoonfuls 
of milk pudding ns an addition to lunch. A lightly cooked egg at 
breakfast and supper gradually. 

Third Week. 

Three liny meals, with two-hourly feeds between. 

Breakfast . — Lightly cooked egg, milky coffee, 3 oz.; one rusk with 
butter. 

Lunch . — ^Milky soup with a beaten egg in it, 4 oz. ; milk pudding 
with cream, 3 oz. 

Supper . — Ono poached egg, one rusk, ovaltine, or junket with 
cream. 

Three 1 oz. feeds of fluids originally used to he given in addi- 
tion to these meals, at intervals of two hours. 

It will bo observed that at first the feeds are entirely 
fluid, and aro given every hour, but that at the end of 
three weeks they have assumed the nature of three very 
small meals, with two-hourly fluid feeds in between. The 
typo of diet indicated in tho third week must be continued 
for months to como — that is, the meals must remain very 
light, and the patient in no circumstances is to go longer 
than two hours without taking either a small milky feed, 
or, if this he impossible, munching a dry biscuit. The hulk 
of tho main meals may be cautiously increased, but reliance 
should bo put on cream and olive oil to increase the 
calorie value, rather than use being made of more bulky 
articles of diet. Pounded fish or minced chicken, in small 
amounts, with potato mashed with milk, are to be added 
once a day from tho fourth week onwards, and a little 
ingenuity makes it easy to add small delicacies to the diet 
without transgressing the rules of safety. Fish, egg, and 
chceso souffles arc valuable additions, aud the patient 
must bo gradually taught to use his knife and fork and his 
teeth ns substitutes for the mincing machine. 

Drug Treatment. 

During the time this dietetic treatment is in progress 
various drugs are employed as a further aid. Of these, the 
first is atropine, either as such, or in the form of tincture 
of belladonna. It is my custom to give seven drops of 
tincture of belladonna in a little water as soon as the 
patient wakes in the morning. At that moment the drug 
can reach a considerable part of the surface of the stomach, 
and a useful effect is achieved as regards diminishing the 
gastric secretion. Once food has been taken it is no use 
giving belladonna, except in such large doses that a central 
effect is obtained, and this will bo accompanied by such 
dryness of the mouth that the treatment will havo to be 
stopped. Apart from this initial dose of belladonna, 
reliance must be placed on the use of alkalis throughout 
the treatment, taken half-way between the feeds, whether 
these aro being given hourly or less often. Tho strongest 
neutralizing salts are those of magnesia, with bismuth 
oxycarbonate as tho next most valuable; the former has 
the disadvantage of being laxative, and the latter is very 
expensive. A useful formula for the early stages is as 
follows: Alagnesii carbonas ponderosus, magnesii carbonas 
levis, bismuth oxycarbonate in equal parts, 1 drachm to he 
taken between feeds. If this proves too relaxing the 
magnesia should he diminished and the bismuth salt 
increased, or sodium hicarhonate, calcium lactate, or pre- 
pared chalk used ns partial substitutes. Various emul- 
sions of magnesium hydroxide, such as the mist, magnesii 
of Parke, Davis and Company, or Martindale’s well known 
emulsion, are useful ; but I find that patients generally 
prefer powder preparations to fluid ones. During tho 
taking of alkalis additional water may be required on 
account of thirst. This may always be conceded, and 
thirst does not become serious if the bowels are not 
relaxed. Caro must be taken to avoid alkalosis. Loss of 
appetite, headache, vomiting, or even general convulsions 
haW been observed in certain cases in which the use of 
alkalis had been pushed to an extreme degree, especially 
in patients where renal deficiency or pyloric stenosis was 
present Such 'complications must be looked for with care, 
and at any suspicion that the absorption of alkalis is pro- 
ducing a ixeneral toxaemia, tke administration skould be 
stopped and neutral phosphates of magnesia and calcium 


170 FED. 4, 193S] 


THEATMJiNtr OF GASTRIC URCEB, 


f 7)iF.I!Erns* 


employed in jirofcrcucii fo tlio nlJoilis, II mu')!; Im> noiwl 
luno t\u\t sodium bicavbounto is protiably tl>« most 
dangci"oii3 of tlio iilkidis ns regards its capacity for pro- 
ducing alkalosis, and ns it is goucrnlly considered tliat, 
after noutraii'/iiig tiio gastric acid, this salt lias a tendency 
to Btiuivdato late secretion, I liare, in common with iiitiiiy 
otber obsoiTors, practically given up its use. I may :id<l 
tliat with this practice, and with tlio furtlicr precaution 
of instructing patients in the later weeks to abstain from 
tho use of alkalis 011 two days in every month, I have 
never observed a case in which these symptoms caused any 
anxiety. 

Duration and Control of 2 'rcalmcnt. 

How long is this rigorons treatment to he continued? 
I-cauuot give a dofuiito answer in weeks, months, or even 
years, hut if in tho firet place tho patient is told that 
for proper medical treatment ho must give up, before 
attempting work, a fraction of the timo which Iio would 
require if a surgical operation was contemplated, the doctor 
will usually within a month ho in the satisfactory position 
of being able to aliow him to resume work under conditions 
which the patient himself will admit arc not intolerable. He 
-will then be on small meals, deprived of second bolpings and 
of all raw fruits and vegetables, and of a certain number 
of cooked foods, such as tough meat aud green vcgetahles 
which are of an indigestible nature, with small two-hourly 
feeds to be taken fiom a pocket flask-, and a certain 
amount of alkaline powder to be taken in addition. 

This lie has got to go on tloing fov a long tiiiic. The 
entire absence of symptoms in such cases is a factor which 
makes carelessness a perpetual temptation, both to the 
patient and to his medical adviser. IVe all know tho 
chronio nature and tendency to relapses of those idcei-s, 
but they are so hidden from our view that again and 
ao-ain wo tend to heconio careless. We should think of 
them in tho same way that wo think of a chronic ulcer on 
the leg, and remember that pennanont healing cannot bo 
expected in either case without months of careful ti-eat- 
ment, in which rest is tlio all-important factor. In tho 
case of tho stomach vest means diminished peristalsis and 
secretion, aucl it can easily ho obtained by the inotbod hero 
outlined, and there is no o-xcuso for allowing patients to 

disregard it. , 

There aro certain means of controlling treatment wliicli 
avo highly important. The first is periodic -r-ray cxainina- 
■bioU, and since its introduction wo have had the cxperi- 
ouco of seeing deeply penetrating nlcors diminmli. and 
finally become compictcly obliterated. Nicholas and Mon- 
crieff havo reported a series of such eases at aliddlcj-cx 
Hospital during tho last twelve months. White, t 'o'n'- 
Moutier and Povchcr, and Slacloau, Jones, and eddes 
have subsequently made communications to a siimlar cUect. 
It must be realized that tho disappcarauco of an ulcer, 
seen by the a: rays, is evidence of healing, but not of cure. 
The best that can havo happened during tUo ew'ly iiiontb .9 
is tliat tho ulcer crater has been bridged over by grauiila- 
tion tissue of a relatively friable nature, and uionths must 
elapse before this bridge is converted into a tough, per- 


manent scar. 

The other form of control which is most necessary is 
ueriodio review of tho case as a whole. The moment which, 
111 my experience, decides whether the patient is to be 
cured or not is at some time at the end of three or four 
weeks, when, free of all symptoms, be i.s made to realize 
tho wave potential danger of his position, and the abso- 
lute necessity for prolonged attcr-care It is, however, a 
mistake to believe that such prolonged after-care involves 
“ny real hardship. Patients of all classes aiu very wil ing 
to continue treatment when once they uiidcrsfaiul then- 
rLl position, and the reason why so many relapses have 
real pos , because tho patients havo not been 

IT to unSand 4 e nature of their disease and the 
o( the precautions which will lead to core, ,f 

thoroughly applied. 


Alcohol and Smoking. 

Patients always require instructions about tho «se of 
Tobol, and it ri difficult to justify extreme rigour in th,.s 
^pect. It would seem that the same rules must he used 
concerning alcohol as are employed when making choice 


' among alher foods — Hint is, highly irritating things such 
as liqueurs or the stronger alcoholic wines must ha for- 
bidden, also alcoholic drinks which in their natiiro are 
bulky. Beer and cider fall into this latter category and 
aro hotter avoided, hut there docs not seem to ho any real 
reason ivhy a glass of light wino should not he allowed, 
at meal limes afler tho early weeks of treatment havo been 
successfully eoiiiplelcd. 

Smoking falls into a very different category. There is 
a growing body of opinion which holds the view that 
nicotine or .soiiio other poisons absorbed from tobacco 
smoke can play a very deleterious part in tbeso eases,- 
Wbctlier cigarettes are worse than pipe tobacco it is 
difficult to say, but it is a strildng fact that duodenal 
ulcer is commoner among cigarette smokers than among 
abstaincis. As an exampio, it may bo pointed out that 
in the hospital class of patient duodenal ulcer is scarcely 
ever seen amongst women, whilst in women in moro a-ell- 
to-do circimistanccs it is becoming very coniraou, and it 
may well ho that cigaretto smoking is the explanation,' 
I always make it a rule to pei-suado my patients to give up 
smoking if they can pos.sibly manage it, and many of tliem 
.say that the very ficquent feeds in the early weeks of 
treatment aro of great assistance towai-ds breaking the 
habit. There is also a strong consensus of opinion amongst 
patients tliat they feel rapid relief when' smoking is 
stopped. Accepting tliis, it must bo admitted that nico- 
tine can be at most a contributory factor in tho disease.. 


TrEATJCEXV of COIIPLIOATIOXS. 

Of complications tlio most frequent is hacniorrliage. 
The treatment of liaeniorvhago is, in my opinion, always 
mcilical, and coii-sists essentially of eompleto starvation by 
the iiioiitb, togotlicv wrtli tho use of sedatives in sufficient 
amount to produce what is practically a ta-ilight sleep. 
Uiiviug sovcv?.l At tlio end of tliat time fecdiu^j 

whicli has hitherto consisted simply of rectal salines, maj> 
he very caiitiou.sly begun with sips of water, albumin 
water, and glucose w.ator by tho mouth, with a slow and 
•n-adual progress towards tho treatment given to ordinary 
maso.s during their first week. Great caution is nepssary 
ill tiieso cases, and when convalescence is reached the fact 
that a dangerous haemorrhage has occurred should always 
Iciid tho doctor to discuss the possible need of surgical 
trc.atnicnt with a greater bias towards excision than if 
there had been no such complication. Operation at a 
ucriod when haciiiovrliage is still threatening tho patients 
fo is in my opinion, not justifiahle. However alaimimg 
those ’case, may bc-and admittedly there are few con- 
ditions so liable to promote panic amongst those snr- 
roiiiidiiig the patient-operative intervention is always an 
irldcd risk in a ' condition which can easily be shown to 
citnirisiiurlv low mortality. Of tho last fifty cases' 
T'T.-o « or melaena which 1 havo seen, only 
Athnit died and he died, not through haenion-hago, 
cerebral thrombosis. I have, however, 
but X .Lomy performed on several such cases 

had been clear that the nicer 

during coin. • ^ Ucaliiig under purely medical 

X ro^d nit reasonably be expected, 

treatmen^ 1 coiiinion eoiiiplication-perforat.on-is one 
The ..,^1,3 ahrays for immediate surgical 

which, ot wuw , y ^ observe that such treat- 

'■"iTatlmramo "^ «ore eonse.wativo .in r^ent 

ment h.as berame nothing moro than tho immediate 

rCrSSii.", ,iu. t,»e. 

mmit of tho case liom’-glass defomity of tho stoma^ 

Pyloric ^ calling for surgical aid. The only 

Avorxrtlmt niaySio added here is that care mint ha used 
woid th.it deformity duo to spasm alone and 

of r riTTatrieial riiaraeter. Repeated x-ray 
Snat'iof i^tei-vari of medical treatment wiU 

tranXTtioii oecuiHng in made 

place. In order to i>igs.-i'c rnneeious 

statement may bo qualified by say ^ 


Feb. 4 , 191 S] 


TREATMENT OF AETHMA. 


[ . Tiir Lnmsn . 
ilcoicix. JorsKii. 


171 


cliaugo in a clironio ulcer is certainly no cominonor than 
is nnmarv cancer of the duodenum. Mo all know that 
rare in.slanccs of tlio latter disease ])nvo been reported, 
but thev aro so raro that pathologists tisuully say that they 
do not ‘occur at all. Tlie fact about tho supposed malig- 
nant degeneration of gastric ulcers is that cancer of tho 
stomach occasionally arises in tho form of a malignant ulcoi. 
These cases are malignant from tho outset, although in 
elderly patients their progress may bo slow. When a caso 
with ‘a short liistoiy is encountered in a middle-aged or 
eldorlv person, who produces an. a:-ray picture showing a 
largo 'ulcer, usually not very deep, on tho lessor curvature 
of tho stomach, tho possibility should alwaj-s ho considered 
of this being malignant, and if there is any doiihl opera- 
tion becomes dcsirablo, 

. Tlie subject of complications is in itself a iiugo one, and 
•any proper discussion of it is bound to bring us to tbo 
problem of wliat may bo called “ tlio nnsucccssful gastro- 
enterostomy.” It is not mj- intention to enter into tbeso 
cases at any length, but it is only right to realize, when one 
is discussing tbo nltornativo lines of treatment in cases of 
peptic ulcer, that there is no group of patients so calculated 
to fill both tbo physician and the surgeon with despair as 
that group in which a gnstro-enterostomy has been per- 
formed and tho operation lias not been a success. Their 
symptoms aro often far more trying than those of any 
ordinniT case. I have seen such patients die of haemor- 
rhage five, eight, fourteen, and even seventeen years after 
their operation. I liavo had cases whieli rcsjiondcd to 
medie.al treatment in a dramatic manner; ] li.-ivo had others 
in which constant relapses occurred; and in all of them 
I have come to realize that further operation is more 
difficult and imccriaiu than in any case where surgers' has 
not previously been undertaken. I read articles by surgeons 
who write of rownstituting tho original state' of affairs, 
*'’y oxiierience this is an exceedingly difficult pro- 
ceeding. I have soon cases wliere excision of" large iiortions 
of the stomach and jejunum was successfully accomplished, 
and in others tho shock of this operation ha^ proved too 
much. Tlioro is IHtlo doubt tliat the position of these 
cases IS a very serious one, and what is even more serious 
is that this oporation is being liglit-hoartcdlv periormod hv 
mexponenced surgeons in all parts of tho t'ountry to-d.a.v. 

10 proliloni, however, is primarily one for discussion 
ien'^lf^ ^mgeoiis, and cannot ho dealt with boro at greater 


. BiSLioor.irjtr. 

HuUtinl k’t; 1325,,.x.x.sv. «7. 



19^,’ r-*9V9.’ A.; Br.msii Medicil Joi'Rjai, June 4lli 

1S27, cl.'c.xih, 629, and Boston Mc<\ 

Montfet?'®;’ and Sri.. 1927, cl.'csiii, 691. 

IxKii, 1091. ^ SlC-dicoJr, September 7th, 192? 

Maclean, 11., joncs, I., and Fildes, G. : Zancct, 1928, i, 14. 


It will ho scon, therefore, how difficult it is to prove that 
astlima may ho acquired. It may ho dormant for many 
years. -As Pc.slikiii^ correctly says, “ the various etiologic 
protein sensitizations are merely the exciting factors, and 
not the basic cause of asthma.” He also says that protein 
sousitization does not cntirelj' explain the various mani- 
festations connected with allergy. For instance, “ 10 per 
cent, of the children with asthma who were skin-sensitive 
to various proteins showed no etiological connexion between 
jirotcin sensitization and asthma.” 

'When it is said that asthma may he due to toxic 
conditions simply, does not tho question arise of how many 
toxic conditions are found without asthma, and how many 
coses of asthma there aro ivitliout any toxic condition ? In 
toxaemia there is iisuallj' liypcrpicsis, hut tho opposite is 
found in asthma. Again, asthma is said to ho neiwous in 
origin, that the parasympathetic overacts. M'iiy should it 
do so? M’^c have the fact brought out by Auer and Lewis’ 
that anaphylaxis in animals occurs after section of the 
vagi, and destruction of the cord and medulla. T. Lewis,* 
in his recent work, says that substances such as egg and 
fi.sh, in susccptihlo persons, cause asthma, urticaria, etc. 
“ That these manifestations are brought about also through 
a mechanism similar to that involved in animal anaphylaxis 
is open to little doubt, though the manner in which 
suscoptihilitj- is acquired remains unknown.” Let us note 
that in both there is eosinopliilia, and that relief is 
obtained through atropine. 

In many asthmatics there are produced in the body sub- 
stances, pathological hut possibly also normal, which pro- 
duce the attacks. Outside tho body, matter or influences of 
all kinds, antigenic and non-antigenic, are swallowed or 
inlialcd, etc., and act in the same way. The non-antigenic 
substances arouse nsthriia by changing the character or 
metabolism of ceitain of tho proteins. Modifications of all 
sorts arc found. Asthma is sometimes divided up into 
“ kinds ” — perhaps ten or more different kinds may he 
given. Tliero is, however, hut one kind, as the conrtitu- 
tions of all persons differ, and thus tlio various exciting 
substances differ, and they vary from time to time. One or 
two instances of tlie latter I may give. 

A lady, aged 43, consulted me in 1925, She said she had very 
bad asthma from hoi'ses end cats, but from no other source. Her 
skiu had never been tested, and in doing so it reacted strongly 
to hoi-se dander and cat hair, but to nothing else. Her statement 
was tliercforc correct, so far. Then sbo went to Fr.ance for a 
month or two, and remained well for a little time. She then 
wrote me that she had contracted bronchitis and a violent attack 
of asllima, though she had not been near either hoi'ses or cats. 
This astonished her verj* much. 

In anoliier case, a boy, aged 12, was brought to me from India, 
and his mother said he never had asthma in the w'arm weather -in 
India, hut on coming to tliis climate it came on, and it was 
solely produced by cold. In the warm days of last August violent 
aslhma came on.' It was the first time in warm weather. 

Many other instances might he given. 

Histamine. 


THE TEEATMENT OE ASTHMA, 

XD AX IsiPnO'VXlIEXI OF THE PsproxED -Agah SsnUJC. 
BT 

A. GUNN AULD, M.D., 

LONDOX. 


of allel'trip condition, being one of a f; 
The faiifilv ™ay he rogardccl as inhei 

IVliatOTer' foi-n ” by a state of sciisitiza 

Krandnai^ent ^stl “ takes in a paver 

offspriiiL' \ eliil,i'”'i result in one or more oi 
' contact with a^forei^''^pr''T-'”'r 

“.nr- 

Saltert niay^ieoppoSnehore;'''''"''"^^'” 

** It is ft curious fapf *» i 

sisters in n farnilr mav “that several brother 

Bd. Tliis would «'CGm ‘isthmatic without the parents 

inth which tho brSdo^ 

l>:nalions produce Certain ^ f“rai''=u' certain 

certain peculiarities “ofi lead to the creafi 

rod-haired children hoti; sometimes sec a fam 

‘he parents of which have black ha 


Lately a good deal of fresh work has been done on 
liistamine. Last March, Best, Dale, Dudley, and Tiiorpe’ 
stated that they had recovered histamine from liver and 
lung, which seemed to justify tho expectation that this 
potent base was widely clistrihiited in the tissues. It was 
found that 1.58 mg. of pure histamine had been isolated 
per kilogram of liver and 27.64 mg. per kilogram of lung. 
For the lungs this is a very, high content. It may be 
released at tho moment of death, but they doubt this. 
‘‘ It is conceivable,” they write, “ that the lung acts as 
an organ of internal secretion with respect to histamine, 
or that it merely captures liistamine which has escaped 
into the venous blood.” T. Lewis' considers that hista- 
mine (or H-snhstance) is released from the cells of the skin 
in local injurv, and from the tissue cells in general 
anaphylaxis^ “ A fundamental fact in the anaphylactic 
reaction is the liberation of H-substaiice.” 

Now histamine in a certain quantity may be released 
from tho cells in anaphylaxis, but that it is held inactive 
111 the normal state is obvious, for, as Dale sai'S, “,if 
suddenlv released into the circulation of an animal, it 
would liave a profound shock-like action.” On May 27th, 
1922, in this JoraxAi. I recalled that it had been foiind- 
hy Hanke and Koessler that peptone which was perfectly 



172 rnn. 1928] 


TREATMENT OP ASTHMA. 


Trrr.Bmw 

Mfoicit JotnsAi. 


liist.iniinc-frco prndurod llio iypicnl pcptono shock. IJista- 
niino sliock is shorn of tlio following chamcteristics of 
poptono shock: o.xtchsivo l:ntnhoIism of body tissues, 
incongulnhility of tho blood, swelling of liver in dog.s, 
pyrexia and despnsitization. I also added I'lp following 
remark, which is anticipatory: “In tho kataholism of tissue 
connected with anaphylactic or anaphylactoid shock it is 
quite possible that histainino may bo produced where coil- 
oxidation ceases.” It is evident that in anaphylactic shock 
histamine may ho produced, but it is only one constituent 
of tho process. 

A'o.soi Disease and Asthma. 

It will bo - found in considting tho works of nasal 
specialists that they' usually agree in advocating treatment 
of all abnormal nasal conditions in asthma. This is 
perhaps only natural. If wo consult tho works of physi- 
cians, much loss nasal treatment is recommended. Brodic 
and Dixon' discovered that the most important reflex is 
from tho nasal mucous membrane. They found that tho 
bronchial muscles wore innervated by two sets of fibres, both 
of which ran in the vagus — a constrictor and a dilator set. 
When tho upper and posterior part of the nasal septum 
was exposed to electrical, mechanical, or chemical excita- 
tion, bronchial spasm resulted. Section of tho vagus en- 
tirely abolished tho results. Francis' showed that on touch- 
ing certain points on tho septum there ensued a consider- 
able reduction of blood pressure, and on touching other 
points tho pressure was raised. Tho higher the septum 
was touched with tho cautery, tho greater was tho reduc- 
tion of prc,s.suro; ho attributes this action to .a stimu- 
lation of tho sympathetic fibres, and inhibition of vaso- 
constrictor action. Salter mentions sneezing, nothing 
more. 

It is evident, however, that normally there is a strong 
reflex connexion between the nose and tho lungs. I have 
known asthma greatly relieved by applying cocaine to tho 
septum and turbinals. Peshkin" states that in chronic 
nasal discharge, mouth-breathing, etc., in 'children, their 
removal does not relievo tho asthma, but may even initiate 
it. The same is true, ho says, of tho removal of tonsils 
and adenoids. I have known tonsils and adenoids, when 
removed, to bo followed by good enough results, when tho 
patients wore under treatment. Benefit may also bo got 
(with the patients under asthma treatment) by freeing tho 
nasal passages from obstruction, such as that caused by tho 
middle turbinal in contact with the septum, and clearing 
the ethmoidal or other sinus, if need bo. With polypi wo 
encounter a more difficult problem. I have several times 
noticed that their removal was followed by asthma. To 
give an instance. 

In 1925 a gentleman, aged 52 , consulted mo. His nose had given 
him great trouble for many years. Polypi were present in both 
nostrils. He told me that he bad never bad astlima, but his 
eister had. I thought he might have the polypi removed, and 
sent him to an eminent nasal man. He then told mo how greatly 
relieved he was. But in about two months ho wrote s.aying thiit 
he had asthma for the first time. It recurred often. 

If the polypi are recent, sometimes removal is advisable. 

The Bole of Fneefnes. 

I'acciues, autogenous and stock, have been in general 
use for many years, as a rule non-specifically. I doubt if 
it is warrantable to use them except in cases which are 
either definitely associated with, or else dependent upon, 
micro-organisms. Organisms in any part of the body may 
excite asthma, which possibly may be relieved by a vaccine, 
but it is gcneially in connexion with bronchitis that wo 
find them. Is it the organism here that excites the 
asthma? A remark by Ponlton'” is noteworthy. He says 

It is more probable that tho inflammation irritates tho 
nerve endings in tho mucous membrane of the bronchi, so 
ns to produce a reflex local contraction in the muscles.” 
However originated, it is necessary to relieve the inflam- 
mation as much as possible, and for this reason vaccines 
aro given, but they do not markedly reduce the inflamma- 
tion. They may be prophylactic, however. It may bo 
mentioned that some asthmatic patients aro very sensitive 
to vaccines, and it has been shown by Warren Crowe” that 


peptone (Armour's Ho. 2) is tho best desensitizer. Ho 
writes: 

** Pimtoao 15 tho method which oilers tho best chanco of success, 
... It IS most gratifying to . . . find patients who for weeks 
pcrliaps have boon only able to take minuto doses, perhaps 50,000 
or 100,000 germs, whoso symptoms constantly trouble them, who 
aro iinivcli and ailing .all tho time with licadaclio and loss of 
.appciito, suddenly and dramatically, after a few doses of peptone, 
improve out of all knowledge. No ono who has not seen it would 
behevo that tho cllect of pcptono treatment would bo so striking.” , 

Loc.al infection of any part of the body should be clc.ared 
if possible. 

Kocsslcr, Lewis, and Walker” found that a mixture of 
micro-organisms from bronchial secretion, when grown 
in .a blood broth, glycorol, amino-acid medium, forms 
substances winch cause bronchial contraction in tho living 
pithed guinea-pig, and arterial constriction in vitro. Hista- 
mine was rarely found, and the poisons are clicmically 
unknown. Eimau and Wilmer” found that many patients 
develop a sensitization to their own respiratory secretions. 
AVIicn the filtrate from tho secretion is used hypodermically 
relief is sometimes experienced, but severe astbmatio 
seizures also occur. 


Specific Treatment. 

Some time ago, after the work of Chandler Walker, what 
may bo termed the specific treatment of asthma began to 
bo practised with much zest by the Americans. A great 
many substances, mostly proteins, were tested on the skin. 
Tho same tiling was done in this country by Coke. Desonsi- 
tization was attempted by the complete withdrawal of thoso 
substances which seemed from the skin tests to affect the 
patient, and also by tho giving of minuto quantities of 
the food by the moiitli, or tlie hypodermic injection of very 
small dilutions of the substance. About SO per cent, of 
tlio cases tested wore said to give positive results. Of these a 
largo proportion occurred in children and young persons, so 
that the majority of adults were negative. It is difficult to 
SCO how the positive cases could usually bo treated by the 
mouth or by hypodermic injection, as they were nearly all 
multiscnsitive, some being positive to a great many su^ 
stances. It is not necessary to go into any detail, but it 
may bo said that the method lias largely broken down. 
Nevertheless, a clear light has been thrown on the modus 
oucrandi of many of these substances, and some excellent 
results have been obtained, so that it is unjust to depreciate 
it. It is a distinct advance in our knowledge, and the 
tiino may come when definitely specific cases can be made 
to respond more to specific tlierapy, though at present a 
considcrablo number do not do so. 


Improvement of Pepfoned Agar Serum. 

As asthma is a sensitization, .any substance wliicli 
desensitizes may bo termed “specific,” just as there aro 
mecifics for tlio exciting substances. Peptone is the best 
desensitizer wo know of at present, though its action is 
much creator in sonic cases than in others. It desensitizes 
the body genorally. apart from antigens.' It is stated by 
McIntosh” that, if one does not use a specific antigen, 
the results “ depend chiefly on the general tissue reaction 
and the leucocyte response.” Peptone produces both these 
factors .and a'lso an unknown change. In certain cases 
which .are irresponsive to any form of treatment (as known) 
i‘ excites speedy improvement, yet there are other cases 
which respond but little. Armour's No. 2 peptone is best, 
1 - it contains no histamine, .and has primary and secondary 
iroteoses Adam,” in the last edition of bis work ott 
isthma says: “I . . . peptone treatment to any 

itlier modo of desensitization.” In some cases the peptone 
s assisted by an iodine mixture. 

As the incubation of the patient's blood with peptone,' 
rhich I recommended in 1924, failed after a time 
,o some cluange in the peptone,* it was recommended last 
darcb” to make the serum of tho patient anaphylactio 
vitli agar, then add powdered peptone, and then pb<'no'- 
:t is unnecessary here to go into the reasons for f 

,hey will bo found in the works of Karsner and LcKer, 
ind Dale and Kellaway, mentioned in the paper. 1 Have 
6und that tho slight precipit^^ which occurs alter 

• Tho peptone may bo better now. I have not tested It rinoo 





174 FED. 192 S] BPINAIi CURVATURE FOLEOWINC IiETnARGIO ENOEPnAUITia. 


[ Titr. 

UtDiciL J0C&5AL - 


inntciial wliicli might iiitcrfcro will ' ■" tho fluid 

to bo tested. Tlio wnslicd tissue in as coalccd 

for a deftnilo lime in lOO c.cnu of ' (mercurio 

cldorido, pijonol, or ncrWiivinc) a _ of drug 

remaining in tho solutions estimated. After soaking 5 grams of 
l.ho treated musclo in 1 in l.OCO mercuric cldorido for twenty-four 
hours tlio nntisentio could not bo detected in tlio fluid. Fivo grams 
uC raiuced musclo after soaking in 100 c.cm. of 4 per cent, phenol 
for twenty-four hours reduced tlio strength to approximately 
3.7 per cent. A solution of acriflavino 1 in 1,000 was reduced in 
si l ength after one hour to 1 in 1,200, and after twenty-four hours 
to 1 in 1,400, and a solution of acriflavino 1 in 5,000 fell in an 
hour to a concentration of 1 in 8,000 and in twenty-four hours to 
1 in 10,000. Thus, as- measured by such methods, tho amount of 
antiseptic which is fixed by tho tissues is in tho case of .acriflavino 
much tho same as that fixed by gauzo; plionol, although not fixed 
by gauze, is markedly fi-xod by tissue, whereas mercuric chlorido 
is very powerfully fixed by tho latter. 


Conclusions. 

1. In tho treatment of wounds with an antiseptic such as 
acriflavino allowanco must bo madb for tho considerable 
affinity of cotton dressings for this class of antiseptic. (On 
tho other hand, phenol and mercurio chlorido havo practi- 
cally no affinity for cotton.) 

2. Tho concentration of tho acriflavino solution should, bo 
such that, after tho gauzo has satisfied its affinity for tho 
antiseptic there- is still a isufficient concentration left free 
to act ini thoftissues.- It follows; therefore, that tho -swab, 
must-bo applied -.'dripping, w;et and not wu-img -tout. . 
Quantitative -experiments havo -been carried out by soaking - 
gauzo swabs’ in approximatoly threo times- the ^amount of 
solution which can bo -taken up, and- estimating tho eon'-' 
centration of .,tUo antiseptic in tho "fluid expressed.- It- 
h'us.been found that after three minutes’ soaking in 1 in' 
1,000 ' acriflavino solution tho fluid expressible from the 
gaiizo contains 1 in 1,600 of tho antiseptic, and oven after 
twouty-four hours’ soaking tho fluid expressed contains 
1 in 1,800. .'When a 1 in 5,000 solution is employed under 
similar conditions the fluid expressed from tho gauzo after 
three minutes’ soaking contains 1 in 9,000 of tho dyo, 
and after twenty-four hours’ soaking tho fluid expressed 
contains 1 in 20,000. 'riio above concentrations employed 
according to this procedure havo been shown to give a 
dressing which is very satisfactory for treating septio 
infections without inhibiting healing.^ 

3. When a lesser proportion of tho solution is used, or 
when swabs are soaked successively in tho fluid, there is 
groat .danger in tho case of tho 1 in 5,000 concentration 
tliat the amount of antiseptic available may bo reduced to 
an ineffective level. 

4. Expen'ments on the fixation of antiseptics by tissues 
havo shown that minced and washed musclo, while it 
absorbs mercuric chlorido very actively, has a definite 
though much less marked affinity for phenol and acriflavino, 
tho last being absorbed to a slightly less extent than by 
gauze. 

I have to thank Dr. C. H. Browning for his criticisms and 
suggestions in the course of the work. 

Reference. 

1 Bennett, Blaoklock, and Browning : BRrnsn Medical Journal, 1922, il, 
p. 305. Graham : Ibid., 1925. ii. p, 826. 


CtJBV'ATURES OF THE SPINE FOLLOTFING 
ENCEPHALITIS LETHAEGICA. 

BT 


R. G. ABERCROMBIE, M.D., 

^wvatCIAS FOR ORTilOPAEDIC DISEASES, SHEFFIELD ROYAL HOSPITAL; 
KEDICAL director. EDOAE ALLEN INSTITUTE, SHEFFIELD. 


In addition to the characteristio attitudes which aro so 
fAquent a sequel of. the disease encephalitis lethargica 
iu vourig patients is occasionally. foUowed by definite 
localizcd^pinal curvatures. Only these definite cu^atures 
are hero cLsidered.- ' They have tboir origin in abnorma 
muscular contraction, and in this respect differ from al 
other forms of spinal deformity ,-for spastic conditions such 
as hemiplegia and spastic diplegia do not give rise to 
spinal curvatures. 

Fivo examples of the condition have como under my 
chservation : in four the symptoms of tho preceding illness 
were characteristic of encephalitis lethargica; in the fifth 


tho initial symptoms, although probably duo to that disease, 
wore of a somowliat anomalous nature. All tho cases were 
in children or young adolescents. 

Antcro-yosterlor Curvatures. 

Perhaps tho most striking and characteristic deformity, 
scon in two cases, is an arched curve of tho cervical 
spino, convex backirards, ivhich carries tho head forwards; , 
tho. arch of tho curve may bo of so higli a grado as to bring | 
tho chin into firm contact with tho front of tho chest. It 
is clearly evident that this posture is not duo to a moro.' 
falling forwards of tho head by its ow-n weight, hut is' 
brought about by a contraction of tho anterior and antero- 
lateral muscles of tho cervical spino, which can bo felt as 
firmly contracted muscular masses on eacli sido of tho neck; 
tho sterno-mastoids remain perfectly lax. On. attempting 
to bond the head still further '.fonrards, and thus increase 
tho curve, tho posterior spinal muscles aro found to con- 
tract. TIius tho head is held in its neiv posture by the^ 
combined action of tlio muscles at tlio front and tho back 
of tho spine. A lateral view of this deformity, with tbo 
strongly arched nock and powerfully contracted muscles, ^ 

. presents so unusual an appoaraiico as to suggest the desig- j 

• nation of “pony neck.’’ - By steady manual pressure the. 
i resistanoo of tbomuscles can. bo pvercomo in a few moments, ^ 
;and tbo deformity partly or completely Toduccd. ThOj 
'passive raising of the head is accompanied, by the appcai-i 

aiico of a deep -dopression in the neighbourhood • of tho^ 
Isev'dntK'corvical-vbftcbra-’this is' duo to -the pivotal ' move-^ ; 

, mont baclnvards.-pf tho -eorvical spino as a whole' upon tho^ 

I rest of the spinal column. - , , ■ 1 ' 

Another type of deformity is a curve convex backwards ; 
in tbo dorsal region— a dorsal kj-pbosis. By this cun-e an _ 
inclination forw'ards of the upper part of the body is- 
brouclit about, somo.what, resembling that seen in tlie 
, cognate. condition of paralysis agitans;.bnt tho curvature is 
of a moro localized character than that seen in paialysis 

agitans. Lateral Curvatures. 

Lateral curvatures' may occur in any region of the spine, 
causing very diverse deformities; they aro associated with 
Sion but m-e not accompanied by regular compensatoiy 
c™ s^ras aro seen in scoliosis. Tho curvature may he - 
- localized to a few vertebrae, but is, never angulai. . 

• - Tho’ deformities produced may be ^treme ; Au one c^e- 
a lateral oui-vo of the cci-vical spine brought the ear into 
firm contact with the top of tho shoulder, the curvature 
being caused by a unilateral contraction of the prcieitebral 
ce’rvfcal fijusdes, ’ tho stcrno-masteid and trapezius remain-, 
ing unaffected. 

General Characters of the Curvatures. 
■NT^+w.-ftistandinw tlieir diverse character, tho curvatures 

rpsent certain features in common. In all of the observed . 
present certa caused. 

fi s,ection of the prevertebral muscles;- 
^bilateral contraction . causing an antero-lateral curve, , 
Ld a unflat’eral-contradtion bringing about a lateral cuive. . 
w *v..oHon and pressure, the curves may bo partly or (xra- 
Skhtenbd out,-’ but a’s tiine goes oil the vertebrae; 
-pletely str g t wedge-shaped and distorted, as- shown by 
skii^ldrSnalon; reduction is thus xendered.mioro; 

‘^*Thetu"vltur““al-o* associated with a hypertonus of the; 
muscles of tbo limbs and the uncurVed portion of tho spmo, . 
muscles o „ ^ j,g jnereasod; clonio movements 

may bT present, and, occasionally, deformities of tbo limbs, . 

The mental condition may bo fairly good. . , . ; 

! 

' Pathology. . . 

Tt, -ill of the observed cases tho contraction of a special 
la o-vniin was found responsible for the curves-* , 
™ ^liat^of the prevertebral muscles.- The explan^ . 

«on pbenomeSn is probably to be. found in the 

trdency of encepharitis lethargica to attack the “A-. 
S /he substantia nigra, and the |enticAar mideu^ . 
tK-xt is +0 sav tlioso regions of the brain that preside ov 
the postnra/’reflexes and automatic ' 

of the bodv Owing to the damage sustained by tnes 
ryot S is an topairment oflbo highest and most 



Feu. 1928 ] 


TETANUS IN A BOY. 


[ Tin: British 
Mzbicaz. Joubkal 


175 


lately acquired reflexes— namely, those subserving the erect 
posture; and there is a consequent release of a moro primi- 
tive or ancestral form of postural reflex— namelj-, that 
approximating to tho quadrupedal typo ; or, moro precisely, 
to a typo intermediato between tho quadrupedal and tho 
eicct^namely, that of tho anthropoid. In tho quadruped 
the action of tho provortohral muscles must ho of great 
importance in preventing hyperoxtension of tho sjiino by 
the weight of tho body, and’thcso muscles must constan% 
be brought into play in such movements ns running and 
jumping; in tho anthropoid in particular tho spine is 
flexed and tho 
head held low. 

The contrac- 
tion of the pre- 
vei'tebral muscles 
in the cases 
under considera- 
tion may ' tlius 
represent a 
turn to a moro 
primitive posture 
of the spine; 
their sectional 
and sometimes 
uni,'atcral con- 
traction corre- 
sponds to the 
scattered nature 
of the lesions iii 
c ii cephalitis 
lethargiea, and 
is thus of a focal 
character. 

It may bo 

assumed that tho primitive postui'al reflexes are relatively 
moro potent in tho young, and tend to become obsolete as 
life advances; this explains the occurrence of tho localized 
ouiTaturcs in young subjects. 

It lies outside tho scope of this paper to discuss tho 
relationsjnp of the lesions in tho lenticular nucleus, tho 
substantia nigra, and tho mid-brain to the luTicrtonus, the 
attitudes,^ and the localized curvatures. Investigation of 
the morbid anatomy of the typo of case bore described 
may perhaps throw light on this question. 

Treatment. 

Treatment is of moro avail than the appearance of tho 
cases uould suggest. Corrective apjiaratus should be em- 
p oyec , having for its object the gradual overcoming of 

'n °f Ihe muscles, the reduction of the curve, 

an le prevention of osseous deformity. For the cervical 


curves a poroplastic or celluloid jacket should be used, 
with a jury-mast and Sayre’s chin-sling; in some cases (as, 
for example, when salivation is present) a frontal band 
passed round a pulley at the top of the jury-mast is better 
tolerated. Eeduction should be by stages, tho straps 
being gradually tightened; at the beginning- it may be 
advisable for tho apparatus to be worn only for a period 
each day. Patience and some ingenuity may bo required, 
but tho results reward the trouble; in two cases in which 
tho carriage of the head had brought the chin into contact 
W'ith tho front of the chest, the children can now hold their 

heads erect un- 
aided. .For the 
Iq-phosis and tho 
lateral cuiwes a 
poroplastic j acket 
should be used, 
applied with 
tho patient sus- 
pended ; as the 
curve improves, 
the jacket should 
bo remodelled. 
The jackets 
should be well 
perforated, as tho 
patients sweat 
freely. 

Prognosis. 
The general 
prognosis appears 
doubtful. In one 
case the condi- 
tion progressed 
in spite of treatment ; the child became bed-ridden and died 
of intercurrent disease. Two cases show improvement, and 
in two the condition remains stationary. 

Several cases have been obseiwed in which, after 
an anomalous acute illne-ss, children have developed 
an extreme lateral curvature, which has disappeared in 
a few weelvs. Such cases are probably examples of 
an aberrant typo of encephalitis lethargiea, but their 
nature .is at present doubtful. 

Conclusions. 

Tho spinal curvatures following encephalitis lethargiea 
aro due to a localized contraction of the prevertebral 
muscles, brought into play by the relea.«e of a primitive 
postural reflex, locally restricted in its operation. Treat-' 
ment by means of corrective apparatus is followed by 
material improvement. 



Fia. 1. — Antcro-postcrior curve 
of cervical Fpine. 




FiCr. 3.— Posture after two 
montlis’ Ireatmont. Retentive 
apparatus is still necessarj'. 


tetanus IN- A BOY ; EECOYERY. 

* BT 

J. D. CHISHOLM, M.B.Totionto, 

OKORAHT SUEOEOX, ALTEISdUM CEXERAL HOSPITAL; 

AKD 

AHNOLD.EENSHA'W m d d p h 

nOXORAEY PATHOLOGIST AVm.- ’ ’ 

applied PATHOinrv HOSPITAL; DIP.ECTOK, LABOEATOET C 

GV AHD PREVENTIVE MEDICINE, MANCHESTER. 

while details of a case of tetanus in a boy win 

accident, appear to '''tb a sligl 

complete reravei-v ^ 

Q 7 attei prolonged treatment. 

fell on ^ ^'’hoolboy, aged 15 years and 10 niontli 

grazing, and receive,! I.” where animals had bei 

This iras cleaned “".tbe hack of the right forearr 

ten davs later ho n ““d tincture of iodine applied, hi 

chewing. On Auli.srSlf™';-? ^ 

next dav Infl ^ stiffness had increased, and by tl 

very littlo L wasThe? 

treated bv Dr iWeP-..,! ' board ship returning home, and w: 
muscles continued the f^SIst oOlli. Stiffness of the ja 

and he becamr^ihL 

unable to chew. Tetanus was diagnosed, and : 


injection of 1,500 units of antitelanic serum was given, this doss 
being repeated two days later. 

On August 25th, the fourteenth day, it was noticed that lie had 
bitten his tongue, and on the 27th he felt stiffness between the 
shoulder .blades. On August 25th tho stiffness of the back 
increased, and on August 30th he received an injection of 5,000 
units of serum.- An extra effort was made to speed up the ship 
to enable larger doses of scrum to be given. 

The boy was seen by one of us (J. O. C.) on August 30th, late 
in the evening, when it was obvious that it -was a case of ictanus, 
but no spasms were noticed that night. On the following morning 
he was seen again and one spasm of the masseters was noted. 
He was then examined by both of us : marked rigidity of the 
masseters was present, and the boy was unable to open the 
mouth moi*e than a quarter to half an inch. He was examined 
for erupting wisdom teeth, but none were seen. He was able to 
flex his neck, but contraction of the facial muscles caused the 
appearance of risus sardonicus. There was some rigidity of the 
spinal muscles, but no spasms were noted round the muscles of 
the arm at any time, e^en on exciting the muscles. The knee- 
jerks were then fairly active. The pulse was slightly increased, 
but the temperature was normal. Active tetanus was diagnosed^ 
and energetic treatment was considered necessary. ... 

A general anaesthetic was administered^ on August 31st, the 
twentieth dav, in order to inject serum inirathocally. On this 
occasion some difficulty was experienced in getting into the 
cerebro-spinal canal. An anaesthetic was given again on the 





ronEIGN BODY IN THE 0ES0PIIAGU3. 


[ Thi n*ms» 
UtmcAL Jocnvir 


176 Fed. 4, 1928] 


following morninp for n Rirnilfir purpose, nnd to excise llio wound 
lij’ rcmoviii" the skin nnd niibcutnncous tissue, Iho wound being 
swnbbcd with nntitctnnic scrum nnd undiluted chlornmino. Tho 
ccrcbro-spinal fluid which was withdrawn showed n few polj- 
inorphonuclcar leucocytes, but no organisms were found in films 
or on culture. This rcnction was ascribed to Iho scrum given tho 
day previously. The fluid withdrawn on this day failed to give 
tetanus to a mouse inoculated with it, so that presumably any 
\oxin was by now neutralized. 


Treatment 

given. 

Day of 

Dlsonso. 

Intra- 

thecal. 

Intra- 

venous. 

Intra- 

muscular. 

Sub- 

cutaucous. 

August 31st 

20th 

1,200 

10,000 

3,000 

— 

Scplombor'lst 

2Ist 

1.500 

6,000 

- 

2.000 

Soptomboi* 2ud 

22nd 

- 

10.000 

- 

i - 

Soptomber 3rd 

23rd 

- 

10.000 

- 

— 

September 4tb 

1 2nh 

- 

■9.500 

- 

EDO* 

September 5tli 

25th 

- 

9,5:0 

- 

500* 

September 6th 

26th 


Forum 

stopped 

— 

— 


• Desensitizing doso. 


Festlessness and vomiting came on after tho anaesthetic on 
August 31st (twentieth day), possibly post-anncsfhclic; this con- 
tinued till - the • twenty-second day, during which ho was still rest- 
less, but tho vomiting ceased in tho morning. Tho pulso rate 
was now very slow but regular: in tho inoi-ning of. this day* 52 
was tho lowest rate. 

From the thirteenth day to tho twenty-fourth day of tho 
discaso chewing was practically impossible, and fluid nourishment 
only was attempted to bo given by tho raoutlu From tho 
twentieth day to tho twenty-third day vomiting was almost 
incessant,, and liquids, such as grape juice and lime water, woro 
not retained completely. 

Medicinal Treatment . — Calomel 1/10 grain was given at intervals 
on the night of September 1st (2 grains in all), but somo of this 
was vomited. To overcome tho restlessness on tho night of 
September 3rd an enema containing 15 grains of chloral hydrate 
and 1/2 drachm of sodium bicarbonate in 4 ounces of water was 
given; this was retained and he passed a good night. A mixture 
of chloral hydrate and potassium bromide (5 grains of each) was 
given subsequently for two days, three times a day. Ho settled 
down well after this, and from this timo lus convalescence became 
assured. 

On tho twenty-fifth day of the disease tho patient began to 
masticate his food fairly freely; he became moro restful, and tho 
tonic spasm of his masseters and abdominal muscles practically 
disappeared. Convalescence now became assured, and within 
five weeks the patient was ablo to return to school. At this timo 
all symptoms had disappeared; the moutli could be opened widely 
and the natural facial expression was present. Tho knee-jerks 
alone showed slightly increased activity. 

This case of tetanus, in which well marked spasms of tho 
masseters and abdominal muscles were associated with per- 
sistent vomiting, w’as cured by repeated doses of scrum 
given chiefly intravenously and intrathocalfy. To accom- 
plish this nearly 100,000 units of antitetanic serum had to 
bo administered before tho symptoms were finally subdued. 


A radiograph taken liio day after admis'iion to tho Tufirmary 
ehowed (ho toothpinto very dearly at about tho level of tho 
sternal notch. Oosopliagoscopy under local anaesthesia failed to 
reveal tlio plate, hut a mass of granulation tissue at the level of 
tho sternal notch was seen, from wljfch J)acmoiThago was brisk 
enough to prevent further examination. 

Five dny.q later, under local anaesthesia, 
tho ocsoplingoscopo was very cautiously 
passed again; tlic plate was felt in tho 
granulations and was removed from tlieir 
lower end with forceps. On attempting 
to remove tho plate from its new position 
it was found to be too large to pass tho 
sito of tho granulations; it was therefore 
released in order that an effort might bo 
made to so place it that its narrowest 
width was crosswise. In attempting this Toothplatc : Half scale, 
tlio plate slipped downwards and was not 

•Been again owing to the blood which was coursing freely from llie 
granular area. 

Tho patient was given a week’s rest and the tube was again 
passed, a radiograph Imving shown the- plate to bo now about 
two inches above (ho diaphragm. To the surprise of the operator 
no foreign body could be seen, although a radiograph ’taken soon 
aftenvards showed the foreign body still- in tho same place. 
After a further week’s rest, -under general :anaesthesia a further 
examination .was' made, and again ended in failure. 

It was now determined to try retrograde - ocsopbagoscopy. One 
week later, therefore, tho .patient, having s^vallowcd aj length of 
silk, n gastrostomy was performed by Mr. Hrj'ce,. the .silk, thread 
brought out, the ocsqphagoscopc passed on it to the cafdia and 
a little over two inclics up the oesophagus, when the plate was 
seen nnd removed at once without any difiiculty. 

Tho gastrostomy wound was kept open for ten days for tho 
purpose of feeding and for giving rest to tho oesophagus. The 
patient was now ablo to swallow any kind of food, and bad 
apparently made a complete recovery. Whether the contraction 
of the granular area will bring about a stricture the future will 
show. 

Tlio caso must bo regarded as a relative failure hecauso 
tho foreign body was not removed per vias .natxiralcSf for 
it would bo supposed that anything which -had got into 
tho gullet from above could also be removed from above. 

I cannot condemn too strongly the use of the bougie. In 
tho caso of an irregularly shaped foreign body it may 
easily drivo tho same into tho ocsoplmgeal wall and cause 
impaction, or even perforation. The bougie should only be 
used under inspection with the oesophagoscopo, and then 
only for treatment of strictures, not of foreign bodies. 

Tho failure to find the plate on tho third and fourth 
examinations was duo to tho facts that its thin upper 
border fitted closely tho posterior oesophageal wall, that 
its colour was exactly that of the gullet, and that possibjy 
a fold may also liave obscured things. 

Tho sillc thread was used to guide tho oesophagoscope 
quickly, because sometimes it is not easy to find the 
cardiac opening from below. 


MEDICAL, SUEGICAL. OBSTETEICAL. 



FOREIGN BODY IN THE OESOPHAGUS; 
DIFFICULT REMOVAL. 

BY 

■ LINDLEY SEWELL, M.B., B.S.Lond., M.R.C.S., 

HONORARY SUEGEOK TO THE EAR AND THROAT DEPARTMENT, HOYAl 
INFIRMARY, MANCHESTER. 


The chief reason for placing tho following caso on record 
is the difficulty experienced in exactly locating tho 
swallowed toothplato, in spito of the fact that a radio- 
graph distinctly showed its presonco, and also in 
removing it. 

A woman, aged 64, was admitted to the Manchester Eoyal 
infirmary on March 5th, 1927, with the following history. Four- 
teen weeks previously she had swallowed a portion of a dental 
plate; since that time she had been an inmate of another institu- 
tion, where on two occasions oesophagoscopy had been performed, 
without, however, revealing the foreign body. A bougie had also 
been passed and met with no obstruction; a radiograph had not 
shown very definitely whether the toothplate -was present or not. 


ACUTE INTESTINAL OBSTRUCTION BY BANDS- 
IN CHILDREN. 

Two cases of acute intestinal obstruction in children were 
admitted to the Worthing Hospital under my caio,^tho 
one in December, 1922, and tho other in June, 1E27. Both 
eases woro sent in by Dr. Thompson of Lancing, with the 
dianiiosis of acute appendicitis, and in each caso I operated 
through a gridiron incision, expecting to find an acutely 
inflaincd appendix. In both patients physical signs pre- 
aominated in tho right iliac fossa, for reasons which will 
be obvious when tho findings at operation nro read. 

Both patients recovered. The condition of Case i was 
aangerous for some twenty-one days after resection at 
orimary operation, owing to hroncho-pneumonia, and Jiis 
stay in hospital was more than three months. Caso n 
spent only fourteen days in hospital. 

A bov a.»ed 8 years, admitted on December 7th, 1922, bad 
ibdommM pain (umbilical and hypogastric) for two days. The 
ihild was obviously ill. There was general rigidity of the 
















178 Feb. tgsS] - IiIYER DIET IN' EERNICIOUS' ANAEMrA. 


I TprUftin** 
UEDICXL JoCKXiA 


BILATERAL EMBOLISM OF TEE CENTRAL 
RETINAL ARTERY. 

BiLATERAii embolism of tlio central retinal artery is a 
suniciontly rare condition to merit tbo mention of tbo 
following case. 

A farm labourer, a-jed 74, was sent lo see mo in February, 
1D27, having lost tbo sight of tbo right eyo Ihrco months earlier, 
and having suddenly lost tho eight in tho left eyo a few days 
proviously. Tho patient hiniBcIf informed mo that up lo Ihrco 
months before ho had alwaj's had exceptionally good sight, hut 
that suddenly ono day ho noticed that there was something wrong 
with his vision on tlio right side, and that on covering his left 
eyo lio found that ho was completely blind in tno right. 
Apparently ho did not think it necessary to seek advjco about 
tbo troubloj and continued with his work until a few days pre- 
viously, when suddenly, whilst In tho house, overything becamo 
black, and ho found himself totally blind. Tho pupils were fixed, 
dilated, regular, and tbero was no reaction to light, nor any per- 
ception of light. Tho media of both eyes were clear, but tho 
fundus of tho right eyo sliow'cd a pallid, clear-edged disc; many 
of tho vessels usually radiating from it were obliterated, while 
tUoso remaining were represented by mere threads. Tlioro was 
some faint brownish pigmentation at tho macula. Tho left eyo 
showed tho typical picture of recent retinal embolism — tho disc 
palo tho vessels diminished in calibre, a general pallor of tho 
fundus, with tho “ cherry-red spot ” at tho macula. 

From tbo bistory of tbe sudden and comploto blindness 
in tbo right oyo tbreo months before, together with tbo 
typical opbthalmoscopio picture in both eyes, thoro is no 
doubt that thoro had been an embolism of tbo central 
retinal artery in tho right oyo, followed about tbreo months 
later by another retinal embolism in tbo left eyo. 

Embolism of tbo central retinal artery is practically 
always nnilater.al, and I note that only tbreo cases of 
bilateral embolism woro observed at tho Tubingen oyo 
clinic in a period of thirty-seven years. 

It is noteworthy that, although this condition might bo 
expected to occur moro commonly in tbo aged, it is found 
most frequently in persons under 60 years of ago, and often 
in quite young people, particularly of tlio fomalo sex. 
Heart lesions, endarteritis, etc., aro given as tbo usual 
causes of this unfortunate condition — in tbo case boro 
recorded there was advanced cardio-vascular trouble — but 
in about 30 per cent, of cases, according to Lobor, no 
doinonstrablo cause can bo found, particularly among tbe 
younger patients. If seen early, attempts can bo made by 
massage, tapping tbo anterior ebarobor, and tbo inhalation 
of amyl nitrite to promote dilatation of tbo retinal vessels 
and a larger blood flow into tbo oyo, in tbo bopo that the 
clot may bo moved from tbo main branch into ono of its 
smaller ramifications, thus limiting the area of retina 
affected. To achieve this, however, tbe cases must bo seen 
very early, and few successful results have been reported. 

Carnarvon. T. G. WyifNE PABIiy, M.R.C.S., D.O.M.S. 


Bx|j0rts 0f 

THE LIVER DIET TREATMENT OF PERNICIODS 
ANAEMIA. 

At a meeting of tho Medical Society of London on January 
23rd, with Mr. H. W. Cabson in tbo chair, a discussion 
took place on the treatment of pernicious anaemia, moro 
especially with liver diet. It was opened by Professor 
F. R. Fbaseb in a paper the substanoo of which appears 
at page 165. _ , 

Sir Willum TVlitCox, continuing tbe discussion, agreed 
that tbe liver treatment of pernicious anaemia had com- 
pletely altered the general view as to the treatment of tbe 
disease, and possibly as to the disease itself. It was extra- 
ordinary that, just as with fasting in glycosuria, this 
simple- observation should have been delayed so long. It 
was not, however, a chance discovery, but the result of a 
gradual evolution, following upon tbe demonstration that 
various protein foods improved tlia blood after liaemor- 
rbago In many cases of pernicious anaemia the yellow 
tint of the solerotics had been obseiwed, the swelling up of 
tbo liver when relapses occurred, and the appearance of 
toxic iaundioe. Therefore, it was not remarkable that liver 
treatment should be of value in pernicious anaemia, seeing 
that tbe liver suffered so much in this disease. • In sprue, 
which very closely resembled pernicious anaemia, successful 
treatment in Ceylon by liver soup bad been m vogue for 


runny years. Tlio speaker, Jiaving now tried liver treat- 
ment in several cases of pernicious anaemia, could agreo 
timt tho way in wJiidi jjationts improved was striking, as 
was also tlio tolcrnnco to liver they o.xhihited. Under tho 
treatment tbo jaundice cleared up and tho icterus index 
quickly fell to nonnal. TJio Jiyor also Ecemed to act 
as an intestinal corrective, obviating tho necessity for 
aperients, llio stools, which in pernicious anaemia wero 
imiially most offensive, became moro or less normal. In 
theso sovero cases of pernicious anaemia tho lymphocytes 
ajiproaclicd tlio polynuclear colls in percentage, sometimes 
oven exceeding thorn, in uhicb case tbero was tho great 
difficulty of distinguishing it from leukaemia, but under 
liver treatmont both tho total leucocytes and tho diffor- 
ontial count became, normal. This was shown in tho 
account of a case by F. A. Phillipps in tho British 
Medical Journal (January fllst, p. 93). Thoro seemed to 
bo no ndequato explanation why liver acted in this way, 
but tbo disoovoiy was of great value, not only in tbe treat- 
ment of this disease, but as opening up a new field of - 
therapeutics. At tho samo time, it was not well to throw 
aside entirely what was learnt about pernicious anaemia 
boforo tbo value of liver was discovered. Pernicious 
anaemia began very insidiously; it was an altered blood 
condition duo to somo toxaemia in tho body, and early 
diagnosis was essential, so that any septio. focus in tbo 
body could bo eradicated. The teotli, nasal sinuses, and 
tonsils particularly should bo examined, and very often, 
wbcii a case was just beginning to show signs, if tbo 
underlying septio infection could bo discovered and 
eradicated, this progressive and previously fatal disease 
could bo nipped in tbe bud. Sir William Willcox tliouglit 
that in a case of pornicioua anaemia with, tho haemoglobin ' 
40 per cent, or lower, transfusion would still have a place 
in treatmont, since it would raise the liaemoglobin perhaps, 
by 5 to 10 per cent., and the patient would then be ablo 
to take advantage of tbe liver treatment.. Hydrochlorio . 
acid was still undoubtedly of value in addition to liver 
treatment. Treatment of pernicious anaemia by arsenic had 
been a sheet anchor for many years, and he, as a toxico- 
logist, had always doubted whether some of tbo nervous 
symptoms which tbo patient presented were tbo result of ■ 
tho disease or of tho treatment. 'Dndoubtedly tbo giving 
of largo dosos of arsenic in the past in these cases did give 
rise to neuritis and other signs of arsenical poisoning. Ho 
thoun-ht tlio discoveiy of liver treatment really raarked tho 
exit "of arsenic and of tho arsenobenzol derivatives wliicli 
had been recommended for pernicious anaemia. Ho had 
never seen these derivatives do any permanent good, though 
cases of temporary improvement had been observed. 

Dr. Herbert French mentioned a case of pernicious 
anaemia treated only with liver ; it showed the same kind 
of result as the cases described by Professor Fraser. 
Thoro Avas a rapid improvement in haomoglobin, from 35 to 
05 per cent in seven weeks. Liver was tried in different 
forms but tho patient preferred it uncooked. Thin slices 
of raw liver were given in sandwiches with lettuce or 
watercress, and of these tbe patient could eat almost any 
quantity The other lines of treatment must not bo 
forirottoii, and probably must be used in addition to liver • 
in certain cases. He strongly advocated transfusion for 
pernicious anaemia, but not merely when the haeiiioglobm 
bad become diminished to 30 per cent. ; it should be used 
much sooner. If thoro was too long a delay before tran^ 
fusinc it wouid bo found that tbe patient merely received 
so much haemoglobin, and did not build upon that haemo- 
elobin for himself. On the other hand, if transfusion wero 
performed in an early stage of pernicious anaemia, with a 
haemoglobin of 55 per cent., the patient, receiving 7 or 3 
per cent, of haemoglobin in this way, was able to build 
thereon, so that in two weeks, instead of having 62 or 63 
per cent., he would have perhaps 68 or 70 per cenL; after a ■ 
Lcond transfusion be would build again to a higher level, 
and so on The haemoglobin with early transfusion was . 
maintained in a way which' was not the case when trans- 
fusion was employed late in the course of the diseime. - 
Disappointments in blood transfusion wero due to demy 
in using it. This transfusion treatment was worth 
whilo, even though it was not curative. Dr. Frenc i a so 
favoured, arsenical treatment; if ho suffered from pernicious 


Feb. 4, 1928] 


[ Thz Betnsx 1 7Q 

JilEorcxi. J0CUCX& J- 1 o 


LIVER DIET IN PERNICIOUS ANAEMIA. 


1)0 treated by transfusion — 
in six wcelv.s — but also by 
tlio usual way, and cert.ainly now by 
lie mentioned ono cxporienco witli tbc 
' -a treatment 


anaemia bo woidd prefer to 
probably three transfusions 
arsenic given in 

liver in addition. — - , 

salvarsan. treatment of pernicious anaemia .. 
wbicb, bo agreed, did not seem to bo of any particular use. 
But 'years ago it was given in tbo case of a patient at 
Guv’s, a woinan who was in her fifth relapse and appeared 
certain to die. The rod cells had fallen to about 600,000 
per c.mm. This was at a time when salvarsan tfcatment 
•was ill vogue; it was given in the old-fashioned way with a 
Y-tubc, and by an error the salvarsan ivas given in tbreo 
places subcutaneously. The oiieration was stopped, liot 
fomentations were applied, and it was felt that the case 
had been bungled. Tlie patient developed three lai-go sores 
on her arm whore there had been collections of salvarsan 
subcutaneousli', and ono of them proceeded to abscess 
formation. But, curiously enougli, the blood count im- 
proved, and presently the patient loft the hospital with a 
total red cell count of 5,000,000. Possibly this was an 
illustration of the value of alternative sepsis 1 

Dr. Walteh BnoADDn.vT reported two cases treated only 
with liver; in both the results had been very good. 
In the first case the red cells at the beginning of the liver 
treatment were 2,800,000 per c.mm. and the haemoglobin 
48 per cent.; in six weeks the red cell count was 5,340,000 
and the haemoglobin 102 per cent. This patient had been 
under treatment since 1924, mainly on hydrocblorie acid 
and very little arsenic; since hydrochloric acid came in 
the speaker had practically abandoned arsenic, except for 
relapses. The other case had been under the same hj'dro- 
chloric acid regime since 1921, witli occasional courses of 
amenic and a few N.A.B. injections. Ho was going down- 
hill when liver treatment began; the rod cells were 
1,760,000 and the haemoglobin 30 per cent. Two months 
was started the red cells were 
4 ,duu, 000 per c.mm. and the haemoglobin 60 per cent. 

ic- patient was a man, aged 60, who had dingy yellowish 
nay, but since the liver treatment bis hair and' ra‘oust.acho 
had changed to a pure white. 

Dr. R. A. Young said that everyone who had used tbo 
liver treatment of pernicious anaemia would bo impressed 
value. He bad had one rather striking 
, in a nmn, aged 44, with a typical Addisonian anaemia, 
who was extremely ill on arrival at the hospital. He was 
bln ? * ^'^•A.B. injections, then two or throe 

™hsfusions, also hydrochloric acid, and arsenic by 
+ f ‘mprovement was very slight. He was 

iWo ^ pound of raw liver daily, and a remark- 

natients"'^^!.?'^."* occurred. This man, like many of these 
him with liver, and it was given 

blood iiictiirB^ or orange juice. The iniproveraont in the 
first a* rather 1 “ad persistent. The man had at 

before the Hvp””t* oosinophil count — 8 per cent. — but this, 
S level it aos started, dropped to 3.5, at 

eivinff Inif nf+^ caused some mis- 

hospital thfi op ** convalescence awav from 

nospitab the eosinophils fell to 5 per cent 

extracts Tom^^f tf'’”''®. i”^ experiences with liver 

not think the niakinc and said that he did 

practicable ^ extracts on a small scale was a 

his experience of liver treatment in 

brought forward by Profesr'®w^ comparable with those 
quite so satisfactorv A h i b^raser, though perhaps not 
with liver extnrtt, ^en cases had been treated 

the red blood count 

globin had risen °''or 4,000,000 ; the haenio- 

leucopenia had remMup^ qinckly m proportion, but the 
liad become extremolr *''™ “'stances patients 

Dr. F. P.iS? w'y "aBseated owing to the liver, 
used in cases of whether liver diet had been 

regard to certain °°° theory with 

were of exactly the siml condition was that they 

without any effort pernicious anaemia, but 

regenerate. These ont: * ““Trow to 

transfusion, and tberefn"*® if “ 

a case be met with f ^ ^as time, should such 

class of cases not co’ vA ^^'^re was also a 

, ^®'^- rare, of chronic aplastic anaemia 


in childi'cn in wliicb tbo blood picture might sometimes 
resemble that of pernicious auaomia. At present ho bad 
one typical case under Iiis care; the patient had been kept 
alive by repeated transfusions, and liver diet was being 
tried, so far without snfficieiitly marked improvement for 
him to bo sure that the case was going to react favourablv. 

Air. Zachiuv Cope asked how far liver treatment bad 
boon tried in'secondary anaemias', and mentioned one case 
of profound secondary anaemia in whicli blood transfusion 
bad bad- no effect, but a remarkable change was brought 
about witliin a fortnight after liver treatment was started. 

Dr. C. E. Lakin mentioned the case of a woman with 
splenic anaemia, in which operation was contraindicated; 
she was put on liver treatment, with marked results so far 
as the blood count was concerned, though the spleen itself 
appeared unaffected. He had also seen a case of a man 
over. 80 years old with pernicious anaemia, who found it 
very dilliciilt at first to take liver ; after tliree weeks of the 
treatment, however, liis red blood count went up by 500,000. 
, Dr. W. Lanodon BnowN mentioned a case of pernicious 
anaemia in a woman in whom, on liver treatment, there 
was improvement in all respects except that the leucopenia 
persisted, so that be could not regard her as a cured case. 
Ho would not bo iiicliiiod to give up hydrochipric acid in 
favour of the treatment by liver extract. 

In the subsequent discussion Sir Leonard Rogers men- 
tioned, witli regard to tbo parallel between iiernicioiis 
anaemia and sprue, that cases of sprue responded generally 
to a single transfusion, and did not require repetitions. 
Dr. Browning Aijs.ander thought that the value of liver 
treatment might be tested in other conditions, notably in 
other anaemias; be urged that research should proceed on 
the lines of liver efficiency tests. Dr. P. B. Spurgin gave 
details of a recipe which lie bad worked out for preparing 
liver soup economically and palatably. 

Professor Fraser, reiilyiiig, said that the answer to the 
question ns to the action of liver extract was simply that 
it stimulated the immature niegaloblasts to proceed to 
maturity. With regard to secondary anaemia, he and 
those associated with him had tested a number of eases, 
and they bad not reacted. Beef, calf, and pig liver seemed 
equally "good ; birds’ liver of various kinds acted, but not 
so well. He advised his patients to exert ingenuity in 
finding new ways "of preparing liver. Several most 
elaborate ways of preparing liver had been quoted in the 
Journal of the American Medical Association during the 
past year — even including liver cocktails. 


CUTAXEOUS 3IYCOSES IX THE TROPICS. 

At a joint meeting of the Section of Tropical Diseases and 
Parasitology- with the Sections of Dermatology and Com- 
parative Alodicine, of the Royal Society of Aledicine, on 
January 25tb, Dr. J. JI. H. MacLeod, president of tlio 
Section" oi^ Dermatology, in the chair, a special discussion 
was held on cutaneous mycoses in the tropics. 

Air. J. Ramsbottoai, opening the discussion, dealt with 
the scientific principles underlying the modern classification 
of the fungi. Alany of tlie systems in use were useless from 
tbo point of. view of the systematic mycologist. Air. 
Ramsbottom discussed these and explained the meaning and 
significance of the various structures seen in cultures. In 
the course of bis address be made the suggestion that it 
was iiossible that some of the parasitic genera of fungi, 
EiicU as trichophyton, might have free-living, non-parasitie 
stages. 

Dr. A. WniTFiELn said tliat so far as he knew only one 
tropical mycosis — dhobi itch — -iiad become thoroughly estab- 
lished in this country. He iiad cultivated the fungus 
epiderniopbvtoii on iiiimeroiis occasions, and bo had 
observed tb’at it was essentially a parasite of clean people. 
It was present in many I’lirkisli baths and public schools 
in Britain, and it attacked the skin of the toes and the 
groin, as a rule. Unlike ringworm of the head, it con- 
duced to the introduction of streptococci with a consequent 
lymphangitis of the leg. Patients who contracted it in 
Turkish baths often mistook it for a sweat rash, and this 
hindered prompt treatment; it could also be spread by 
means of bath towels, bath mats, and similar means. The 



178 Ted. 19:8] 


LIVER DIET IN' PERNICIOUS ANAEMIA, 


TFnBrtmfH 
WepiriT, JOCBKIA 


BILATERAL EMBOLISIM OF THE CENTRAL 
RETINAL ARTERY. 

BiLATraiAi, ombolisni of tlio central retinal artery Is a 
Eufliciontly raro condition to merit tho mention of tlio 
following case. 

A farm labourer, ajed 74, was sent to seo mo in February, 
1927, having lost tho sight of tho riglit oyo threo months earlier, 
and having suddenly lost tho eight in tho left eyo a few days 
previously. Tho patient himself informed mo that up to three 
months before ho had always had exceptionally good sight, but 
that suddenly ono day ho noticed that there was something wrong 
with his vision on tlio right side, and that on covering his left 
eyo ho found that ho was completely blind in tho right. 
Apparently ho did not think it necessary to seek advico about 
Iho troubfoj and continued with his work until a few days pre- 
viously, when suddenly, whilst in tho house, everything bccamo 
black, and ho found himself totally blind.. Tlio pupils were fixed, 
dilated, regular, and thero was no rcaetion to light, nor any per- 
ception of light. Tho media of both eyes were clcarj but tho 
fundus of tho right eyo showed a pallid, clear-edged disc; many 
of tho vessels usually radiating from it wero obliterated, while 
thoso remaining were represented by mere threads. Thero ’ was 
some faint brownish pigmentation at tho macula. Tho left oyo 
showed tho typical picture of recent retinal embolism — tho diso 
pale, tho vessels diminished in calibre, a general pallor of tho 
fundus, with tho ** cherry-red spot *' nt tho macula. 

From tho history of the sudden and complcto blindness 
in the right oyo three months before, together with tho 
typical ophthalmoscopic picture in both eyes, thero is no 
doubt that there had been an embolism of tho central 
retinal artery in tho right eyo, followed about three months 
later by another retinal embolism in the left eye. 

Embolism of tho central retinal artery is practically 
always unilateral, and I note that only three cases of 
bilateral embolism wero observed at tho Tubingen oyo 
clinic in a period of thirty-seven years. 

It is noteworthy that, although this condition might be 
expected to occur more commonly in the aged, it is found 
most frequently in persons fuider 60 years of ago, and often 
in quite young people, particularly of tho female box. 
Heart lesions, endarteritis, etc., are given as tho usual 
causes of this unfortunate condition — in tho case hero 
recorded there was advanced cardio-vascular trouble — but 
in about 30 per cent, of cases, according to Leber, no 
demonstrable cause can bo found, particularly among the 
younger patients. If seen early, attempts can bo made by 
massage, tapping tho anterior chamber, and tho inhalation 
of amyl nitrite to promote dilatation of tho retinal vessels 
and a larger blood flow into the eyo, in tho hope that the 
clot may bo moved from the main branch into one of its 
smaller ramifications, thus limiting the area of retina 
affected. To achieve this, however, the cases must bo seen 
very early, and few successful results have been reported. 

Carnarvon. T. G. WVNNE PaRUY, M.R.C.S., D.O.M.S. 


Ilf 

THE LIVER DIET TREATMENT OF PERNICIOUS 
ANAE3IIA, 

At a meeting of the Medical Society of London on January 
23rd, with Mr. H. W. Carson in the chair, a discussion 
took place on tho treatment of pernicious anaemia, more 
especially with liver diet. It was opened by Professor 
F. R. Fraser in a paper the substance of which appears 
at page 165. 

Sir WiM-iAU "WiLECOX, continuing the discussion, agreed 
that the liver treatment of pernicious anaemia had com- 
pletely altered the general view as to the treatment of the 
disease, and possibly as to the disease itself. It was extra- 
ordinaiV that, just as with fasting in glycosuria, this 
simple- observation should have been delayed so long. It 
was not, however, a chance discovery, but the result of a 
gradual ’evolution, following upon the demonstration that 
various protein foods improved tho blood after baemor- 
rhao-e. In many cases of pernicious anaemia the yellow 
tint°of the scleroties had been obseiwed, tho swelling up of 
tho liver when relapses occurred, and the appearance of 
"toxic jaundice. Therefore, it was not remarkable that liver 
treatment should be of value in pernicious anaemia, seeing 
that tho liver suffered so much iu this disease. • In sprue, 
which vei*y closely resembled pernicious anaemia, successful 
treatment in Ceylon, by liver soup had been in vogue for 


many years. Tlio speaker, having now tried liver treat- 
ment in scvor.al cases of pernicious anaemia, could agree 
that tho way in which patients improved was striking, as 
was also tlio tolerance to liver they o.xliibitcd. Under the 
treatment the jaundice clc.arcd up and tho icterus index 
quickly ^ fell to normal. The liver also seemed to act 
03 an intestinal corrective, obviating tho necessity for 
aperients. The stools, which in pernicious anaemia were 
usually most offensive, bccamo more , or le.ss normal. In 
these severe cases of pernicious anaemia tho lympliocytcs 
aiiproacbcd the polynuclear cells in porcontago, sometimea 
oyon exceeding thorn, in iibich case thero was the great 
difliculty of distinguishing it from ieukaomia, but under 
liver treatment both the total leucocytes and tho differ- 
ential count bccamo, normal. This was shown in the 
account of a case by F. A. Phillipps in tho British 
Mrdioal Journal (January 21st, p. 03). There seemed to 
bo no adequate explanation why liver acted in this way, • 
but the discovery was of great value, not only in the treat- 
ment of this disease, but as opening up a new field of - 
therapeutics. At tho same time, it was not well to throw 
aside entirely what was . learnt about pernicious anaemia 
before the value of liver was discovered. Pernicious 
anaemia began very insidiously; it was an altered Wood 
condition due to some toxaemia in the body, and early 
diagnosis was essential, so that any septic. focus in tho 
body could bo eradicated. The teeth, nasal sinuses, and 
tonsils particularly should be examined, and very often, 
when a case was just beginning to show signs, if tho 
underlying septic infection could bo discovered and 
eradicated, this progressive and previously fatal disease 
could bo nipped in the bud. Sir William Willcox thou^t 
that in a case of pernicious anaemia with, the haemoglobia ‘ 
40 per cent, or lower, transfusion would still have a place 
in treatment, since it would raise the haemoglobin perhaps, 
by 5 to 10 per cent., and the patient would then be able 
to take advantage, of the liver treatment. Hydrocblorio . 
acid was still undoubtedly of value in addition to liver 
treatment. Treatment of pernicious anaemia by arsenic had 
been a sheet anchor for many years, and be, as a toxico- 
logist, had always doubted whether some of the nervous 
symptoms which tho patient presented were the result of • 
tho disease or' of tho treatment. Undoubtedly tho giving 
of largo. doses of arsenic in the past in these cases did give 
rise to neuritis and other signs of arsenical poisoning. Ha 
thought tho discovoiy of liver treatment really marked tho 
exit 'of arsenic and of tho arsenobenzol derivatives which 
had been recommended for pernicious anaemia. He had 
never seen these derivatives do any permanent good, though 
cases of temporary improvement had been observed. 

Dr. Herbhit French mentioned a case of pernicious 
anaemia treated only with liver; it showed the same kind 
of result as tho cases described by Professor Fraser. 
There was a rapid improvement in haemoglobin, from 35 to 
05 per cent, in seven weeks. Liver was tried in different 
forms but the patient preferred it uncooked. Thin slices 
of raw liver were given in sandwiches with lettuce or 
watercress and of these the patient could eat almost any 
quantity. The other lines of treatment must not be 
forgotten, and probably must be used in addition to liver ■ 
in certain cases. He strongly advocated transfusion for ■ 
pernicious anaemia, but not merely when the haemoglobin 
bad become diminished to 30 per cent.; it should be used 
much sooner. If there was too long a delay before trans- ^ 
fusing it would be found that the patient merely received 
so much haemoglobin, and did not build upon that haemo- 
globin for himself. On the other hand, if transfusion were • 
performed in an early stage of pernicious anaemia, with a ' 
haemoglobin of 55 per cent., the patient, receiving 7 or 8 
per cent, of haemoglobin in this way, was able to build ■ 
thereon, so that in two weeks, instead of having 62 or 63 
per cent., he would have perhaps 68 or 70 per cent. ; after a • 
second transfusion he would build again to a higher level, 
and so on. The haemoglobin with early transfusion was ■ 
maintained in a way which was not the case when trans- 
fusion was employed late in the course of the disease. - 
Disappointments in blood transfusion wore due to delay 
ill usin<» it. This transfusion treatment was worth 
while, even though it was not curative. Dr. French also 
favoured arsenical treatment ; if he suffered from pernicious 


Feb. 4, 1928 ] , 


LIVEK DIET IN PERNICIOUS ANAEMIA. 


r THzBsina 
STeoicxi. /oraxu 


179 


an.-iomia lio would prefer to l)o treated by transfusion— 
i)robablv tlirco transfusions in six weeks — ^but also by 
arsenic' given in tho usual way, and certainly now by 
liver in addition. lie lacntioned one exporicnco with the 
salvarsau. treatment of pernicious anaeinia— a treatment 
whicli, bo agreed, did not seem to be of any particidar use. 
But vears ago it was given in the case of n patient at 
Guy’s, a woman who was in her fifth relapse and aiipearod 
certain to die. The red cells had fallen to about 600,000 
per c.inm. Tin's was at a time when .salvarsau treatment 
was in voguo; it was given in the old-fashioned way with a 
Y-tubc, and by an error the salvarsau was given in three 
places subcutaneously. Tho operation was stopped, hot 
fomentations wore applied,' and it was felt that tho case 
had beei'i bungled. Tho patient dovelopotl three large sores 
On Jier arm whore there had been collections of salvarsau 
subcutaneously, and one of them proceeded to abscess 
formation. But, curiously enough, tho blood count im- 
proved, and presently the patient left tho hospital witli a 
total rod cell count of 5,000,000. Possibly this was an 
illustration of tho value of alternative sepsis 1 

Dr. W.\T.TEn ■ BROADni;.VT reported two cases treated only 
with liver; in both tho results had been very good. 
In the first case the rod cells at tho beginning of the liver 
treatment were 2,800,000 per c.mm. and tho haemoglobin 
48 per cent. ; in six weeks the red coll cotmt was 5,340,000 
and the haemoglobin 102 per cent. This patient had been 
under treatment since 1924, mainly on hydrochloric acid 
and very little arecnie ; sinco hydrochloric acid came in 
the speaker had practically abandoned arsenic, except for 
relapses. ^The other case had been under the same hydro- 
chloric acid regime since 1921, witli occasional courses of 
arsenic and a fen’ N.A.B. injections. Ho was going down- 
liLnoo" treatment began; tho red cells wero 

l,7cU,000 and tho haemoglobin 30 per cent. Two months 
"'M started the red cells were 
4,600,000 per c.mm. and tho haemoglobin 60 per cent. 
Jlie patient was a man, aged 60, who had dingj- vellowisli 
lair, nt since tho liver treatinont liis hair and inoustacho 
had changed to a pure whito. 

said that everyone who had used tho 
pernicious anaemia would bo impressed 
Mco • “^^^^^tic value. He had had one rather striking 
Tilin’ i-*' ^ ""'th a typical Addisonian anaeinia, 

4^remely ill on arrival nt tho hospital. He was 
Wnr .,1 f small Is.A.B. injections, then two or three 
Tr, )*ydrochloric acid, and arsenic by 

tlipii *’ Bninovement was verj' slight. He was 

able ^ '' pound of raw liver daily, and a remark- 

natients This man, like many of tliese 

him with ™oked liver, and it was given 

blood uicturn'^r “’.“PSo juice. The improvement in the 
fi St a athp «nd persistent. Tho man had at 

beLe iho "“‘““Phil count-8 per cent.-but this, 

Siti'iri.S.Til’'™ 3:5. 


ment it went un to” Of; 

giving, but aftm- siK^veTh“”*■’ some mis- 

hospital the eosinophils L convalescence away from 

extracts, some of them “““ experiences with liver 

not think the umkine ‘““c-made,” and said that he did 

practicable proposition C". » "'“s « 

his experience had results of liver treatment in 

brought forward hr pt f roughly comparable with those 
quite so satisfacto^ At though perhaps not 

with liver extneto -^bout ten cases had been treated 
the red blood count 00 bhree of these so far had 

glohin had risen nf 4,000,000 ; the haemo- 

lehcopenia had rem^nS proportion, but the 

had become extrcmoi^ cv two instances iiatients 

Dr. F. PAhnis "acseated owing to the liver! 
used in cases of asked whether liver diet had been 

regard to certain cases "'**'•* 
were of exactly the sam * condition was that they, 
without any effort on pernicious anaemia, but 

regenerate. These nn+: ^ P*'*'* bhe bone marrow to 

transfusion, and tlferefore « “'‘T 

a case be met witb there was time, should such 

class of cases, not so ve°-v Arf 1'"*' • Tbcre jvas also a 
7 rare^ of chrome aplastic anaemia 


in children in which the blood picture might sometimes 
resemblo that of pernicious anaemia. At present bo had 
one tj’pical case under bis care; the patient had been kept 
alive by' I'opcatod transfusions, and liver diet was being 
tried, so far without sufficiently marked improvement for 
liiin to be sure that the case was going to react favourablv. 

hlr. Zacitahy Corn asked bow far liver treatment bad 
been tried in secondary’ anaemias, and mentioned one case 
of profound secondary anaemia in wliicli blood transfusion 
had had no effect, hut a rcmarkahle change was brought 
about W’ithiii a fortnight after liver treatment was started. 

Dr. C. E. Bakin mentioned tlie case of a woman with 
splenic anaemia, in which operation was contraindicated; 
she was put on liver treatment, with marked results so far 
as the blood count was concerned, though tho spleen itself 
appeared unaffected. He had also seen a case of a man 
over. 80 years old with pernicious anaemia, who found it 
very difficult at first to take liv'er ; after three woclis of the 
treatment, however, his red blood count went up by’ 500,000. 
, Dr. IV. Bangdon Shown mentioned a case of pernicious 
anaemia in a woman in whom, on liver treatment, there 
was impi’OA’emont in all respects except that the leucopenia 
persisted, so that ho could not regard her as a cured case. 
Ho Avoiild not be inclined to give up hy’drochlpric acid in 
favour of the treatment by’ liver extract. 

In the subsequent discussion Sir Leonard Rogers men- 
tioned, with regard to tho jiarallel between pernicious 
anaemia and sprue, that cases of sprae responded generally 
to a single transfusion, and did not require repetitions. 
Dr. Broavning Alexander thought that the value of liver 
treatment might be tested in other conditions, notably’ in 
other aiiacraias ; he urged that research should proceed on 
the lines of liver cfliciency tests. Dr. P. B. Spurgin gai’e 
details of a recipe which lie had worked out for preparing 
liver soup economically and palatably. 

Professor Fraser, replying, said that the ansa’or to the 
question as to the action of liver extract was simply that 
it Btimulatcd the immature megaloblasts to proceed to 
maturity. B’itli regard to secondary anaemia, he and 
those associated with him had tested a number of cases, 
and they had not reacted. Beef, calf, and pig liver seemed 
equally good; birds’ lii'er of various kinds acted, but not 
so well. He advised his patients to exert ingenuity in 
finding ncir ways 'of preparing liver. Several most 
elaborate ways of preparing liver had been quoted in the 
Joitrnal of the American Medical Association during the 
past A’car — even including liver cocktails. 


CUTANEOUS SrreOSES IN THE TROPICS. 

At a joint meeting of the Section of Tropical Diseases and 
Parasitology’ with the Sections of Dermatology and Com- 
parative hlediciiie, of the Royal Society of Medicine, on 
January 25th, Dr. J. M. H. MacLeod, president of tho 
Section of Dermatology, in the chair, a special discussion 
was held on cutaneous mycoses in the tropics. 

Mr. J. RASrsBOiiojr, opening tho discussion, dealt with 
the scientific principles underlying the modern classification 
of the fungi. IMany of the systems in use wero useless from 
tho point of. view of the sy’Stematic mycologist. Mr. 
Ranisbottom discussed these and explained the meaning and 
significance of the various structures seen in cultures. In 
the course of his address he made the suggestion that it 
was possible that some of the parasitic genera of fungi, 
such as trichophyton, might have free-living, non-parasitic 
stages. 

Dr. A. B'HiTriELD said that so far as he knew only’ one 
tropical mvensis- — dhobi itch — had become tborougbly estali- 
lisbed in this couuti’y. He bad cultivated tbe fungus 
epiderniophvtou on numerous occasions, and bo bad 
observed that it was essentially a parasite of cle.an people. 
It was present in nianv Turkish baths and public schools 
in Britain, and it att.n'ckcd the skin of tbe toes and the 
groin, as a rule. Unlike ringworm of the bead, it con- 
duced' to the introduction of streptococci with a consequent 
lymphangitis of tbe leg. Patients who contracted it m 
Turkish baths often mistook it for a sweat rash, and this 
hindered prompt treatment ; it could also he spread by 
means of bath towels, bath mats, and similar means. Tbe 


180 Feb. 4 , t9j8] 


DirarnERiA oAnniEng, 


t Tm Vitmsg 
SIcDica JocaziL 


disoaso simulated a simpler vesicular eczema, and Jjo had 
coined tlio expression ■" oezomatoid riiiRworm " to dcscribo 
it. Ho had also recovered from the liorny layer of the too 
a species of pcnicillinm which produced a lesion identical 
witli that of ciiidormophyton. Ho recorded a ease of an 
cczematoid infection of the car duo to aspcrgillus, which 
had been contracted by a patient while bathing in stagnant 
water in India. 

Dr. P. MANsoK-BAim agi-ocd with !Mr. Pamsbottoni that 
the present classification in medical mycology was un- 
necessarilj' complicated and .that too many species existed. 
The most imjiortant tropical m3’cosis was inadura foot, a 
disease which closely resembled actinomj'cosis, and which was 
caused by a nearlj' related species of fungus, Discomyccs 
maditrae. A second condition found also on the foot and 
legs, in South America, and termed " mossy foot,” was duo 
to a species of hj'phomyccto. Ulastomycosis was a term 
given to a cutaneous infection duo to 3'oasts which gained 
access to the tissues through some wound; they clinically 
resembled lupus verrucosus, and, as a rule, tho' infection 
remained localized. Closely related to this was sporo- 
trichosis, characterized by gummatous swellings of tho 
skin which break down and cause deep ulcers. Among 
tho cutaneous afflictions of tho tropics, dhobi itch had 
tho claim to prior place. It produced ver3' characteristic 
lesions, which began as rounded papules spreading peri- 
pherally and producing a festooned border covered with 
thick scales. Tho irritation might bo excessive, although 
the lesions often disappeared in cold weather, to reappear 
when sweating became severe. The disease could bo satis- 
factorily relieved, at any rate tomporaril3’, by tho use of 
calcium sulphide (which must bo fresh). Another very 
common condition in tho tropics ivas pityriasis vei'sicolor. 
There was no need for the artificial differentiation, so often 
used, of patches of different colour. Sir Patrick IManson, 
ho recalled, had on ono occasion converted a caso of tinea 
nigra into one of tinea alba by tho xiso of a cake of soap. 
The disease usually occupied a hargo area of tho body and 
was caused by two species of cndodcrnioph3-ton. Other 
m3'cotio conditions which ho briefly' discussed were pinta 
fa disease of South America, spreading from an initial 
focus and becoming hyporpigmented — white, rod, blue, or 
black) ; Hong-Kong foot (a mycotic condition of the feet in 
summer, probably identical with Dr. Whitfield’s cases); and 
prickly heat (a miliary-like eruption, most probably due to 
a small yeast or inouilia). Ho concluded by pleading again 
for a simplification and rationalization of tho nomenclature 
of medical mycology. 

Dr. G. B. Dowcixo drew’ attention to tho experiments 
which the chairman and he had conducted on seborrhoeic 
dermatitis. They had been able to show that this was a 
fungous disease duo to the so-called “ bottle bacillus.” 

Dr. MacLeod demonstrated a series of photograijhs of 
mycological conditions of the shin, including cases of i 
fungous diseases of tho nails. j 


DIPHTHERIA CARRIERS. 

At a meeting of the Section of Epidemiology of tho Royal 
.Society of Medicine on January 27th, xvith Dr. S. 
Monckton Copeman presiding, some observations on diph- 
theria carriers, undertaken at the North-Eastern Hospital 
of the Metropolitan Asylums Board, were described by 
Dr. ' J. E. McCahtnev, with whom was associated in tho 
laboratory work Dr. W. C. Harvey. 

Dr. McCartney said that up to the present observations 
had been made on over 350 carriers. They were examined 
twice weekly ; srvabs were taken from tho tliroat, from each 
nostril, and, xvhen necessary, from the ear. It had been 
found that ordinary over-night incubation in the bacterio- 
logical examination of cultures from carriers was not 
sufficient; some cases, negative when examined after 
tAventy-four hours, had become positive after forty-eight 
hours’ incubation. ’Hie reason was that diphtheria bacilli 
w’cre present in carriers in a ” lag ” state. When swabs 
were made from clinical diphtheria the organisms were 
actively' proliferating, and on transference to a^ culture 
medium immediately began to grow, but this condition did 
not obtain in carriers. In this investigation a carrier was 


taken ns ono who harbouied virulent diphtheria bacilli 
twelve weeks, or longer, after tho commencement of the 
clinical disease-— an arbitrary but a conv’enient period. It 
was considered important to oxaiiiino tho Upper respiratory 
passages of tho carriers to see w’hcther clinical findings 
could bo correlated with bacteriological observations, fu 
this scries 288 carriers were so exniiiincd, and, as controls, 
300 diphtheria cases were examined in tho fourth or fifth 
week of tho disease, and 100 convalescent diphtheria cases 
iinnicdiatcly before discharge, when it might bo presumed, 
haring had tho requisite number of sivabs taken, that they- 
wore free from hacilli. Some recognizable clinical departmo 
from the normal in the iipjicr resjiiratoiy passages was 
found ill 273 of the 288 caniois as follows ; In throat only, 
63 ; in nose only, 67 ; in throat and nose, 141 ; in ear only, 2. 
'Thus in 75 per cent, of these cases there was some' 
ahiiormality in the nose, either alone or associated with 
a throat condition. In the ago groups (leaving out the two 
car cases) six wore under 1 year old, 171 between the ages 
of 1 and 5, seventy bctivcen 5 and 10 years, scvcntMci' 
between 10 and 15 y'cais, and seven over 15. The average 
duration of tho earlier state in relation to tho clinical 
site of tho abiionnality was as follows: 


Nose only .sffccLed 

Both nose ami tbroat 

Throat only 

Ear, nose, ami throat ... 

Ear .and throat 

E,ar and noso 

Nothing abnormal found 




... wee 

... 23.5 „ 



... 19.0 „ 



... 37.0 „ 



... 31.0 „ 



... 27.1 



... 18.0 „ 


Tho 300 diphtheria patients who were examined as' 
controls yielded entirely different results. Here the pro-, 
portion of cases showing abnormal conditions in the nose 
was very much smaller than among the carriers. In 91 the 
throat only was affected, in 41 the nose only', in 87 the 
throat and noso wore affected, and in 81 there was noiliing 
abnormal. These wore cases in tho fourth or fifth week of 
tho disease, when some abnormality might have been -ex- 
pected to bo present on account of the lesion which had 
been observed in the throat. Of these 300 cases 13 subse- 
quently became carriers — that is, continued to h.irbour 
bacilli after the twelfth week from the onset of the clinical 

disoaso and in all these cases there was some abnormality. 

Of the 100 diphtheria convalescents who were examined 
just before discharge, 45 showed an abnormality only of 
the throat, 3 of tho noso only, 4 of the throat and nose, 
and in 48 there was nothing abnormal. Enlarged tonsils, 
in tho speaker’s experience, did’ not interfere with tho 
cliniination of diphtheria bacilli, provided they ivere not 
unhealthy and the crypts not occluded. The carrier state 
in diplithcri.e w.ns due, therefore, to the presence of some 
pathological condition or abnormality ivhereby the organism 
was enabled to survive. If such conditions could bo 
removed or corrected tho carrier state would disappear. 
Previous workers bad recognized that nasal carriers were 
refractory to cure. It seemed as if in such carriers, 
although the iniwuiiological mechanism was in order, and 
they were healthy peojile, all Schick-negative, yet the 
diphtheria organism was able to live in the respiratory 
passages. It did not live directly upon the living tissue, 
but on tho products of the inflammatory reaction and on 
the secretion of rliiiiovrhoca. The speaker added soma 
remarks on the iutermittoncy of diphtheria bacilli in 
carriers. It appeared from his investigations that failure 
to isolate the organisms might extend over long periods of 
time although the patient was still infective. Even three 
negatiA’O culture results were not sufficient to establish 
that a carrier was completely free from infection. 

Dr W. 0. HaB’VEY added some details of the laboratory 
work'in this’ investigation, mentioning that in eacli case the 
diphtheria bacilli were tested for virulence by the intra- 
cutaneous method in tlm guiiie.a-pig. 

The President (Dr. Copeman) said he had not realizea 
that the question of carriers appertained so predomin.antly 
to tho nose, and asked for any specific reasons why this 
should be, also for information as to methods of. tieatiiient 
adopted. ’Dr. Eooiib Caiger said that while no very new 
facts came out in this investigation it did present for the 
first time something of a statistical nature to back up • 
views already held. The difficulty was lo draw the Imo 




THE SPRINGS OF NAUHEIM. 


L SIEDXCAZ. joCRNAX. 


Lotwecn normal and abnormal, especially m the noso .and 
throat. Ur. Gn.mAM Fomms thought that the paper 
irould ho pnrticnlarly nseful to those who had to do with 
the carrier child in scliools. It was significant how preva- 
lent was tho carrier condition among children of pre- 
school aec. iVfter giving some tignics i elating to the 
epideniic°Ycars 1921-22, ho said that a rising carrier rate 
might predict a period of high epidemic prevalence, fol- 
lowed by a period of low carrier rate. Dr. R. A. O’BnrEjr 
had beoli struck in his own work by tlie distinction between 
sparse and profuse carriers. Tho question was wbothbr 
sparse carriers tended to bocomo profuse, and whether tho 
duo carrier was as much a public danger a.s the other. 

Dr, E. IV. Goon.iLi, said that tho great question to 
bo settled was when it was safe to discliargo patients 
from hospital. Was it possible by this widespread — and 
incidentally costly — investigation to lower tho return ease 
rate? Tho return case rate was already not high — under 
2 per cent. Dr. R. J. Ca>'X spoke of tho work at tho 
clinic recently established at Guy’s by tho London Giunty 
Council for the discovery and treatment of child carriers. 
To ]icrform twelve weeks’ conscentivo swabbing in order to 
obtain a carrier definition was a difficult matter with these 
out-patient children, and reliance w.as iilnccd on three 
weeks’ consecutivo positive swabs obtained at tho clinic, 
these being, in most c.ascs, in addition to profuse positive 
sivabs obtained by tho school medical officer earlier. Ono 
abnormal condition met with in tho nose more often than 
might be supposed was tho presence of a foreign body. 
Dr. J. D. Rolmstox said that return cases of diphtheria 
were not very common, and there appeared to bo little 
difference in the return case rate as between hospitals 
which did and hospitals which did not sj-stcmatically take 
throat swabbings before discharge. Dr. J. A. Glovek said 
that in bis work on cercbro-spinal fever he had found that 
the most common nasal defect tvas an obstinate contact 
beRveen tho posterior end of the inferior turbinate and a 
deflected septum; it was almost possible to detect a carrier 
by tho shape of tho noso. There was no doubt that tho 
meningococcus lived firmly entrenched in that obstinate 
contact. Vt itb regard to iiitcrmittoney, bo recollected 
■esannning a man for fifteen wcclis consecutively — fourteen 
negative results being followed by a positive. 

After further discussion Dr. McC.akt.vev, in his reply, 

• gai e some particulars of treatment. Gcncr.al applications 
ot ultra-violet rays had been tried without success upon 
a senes of carriers. In eases of pure throat carriers 
tonsillectomy gave good results. Tho nasal carrier was a 
f imcult problem; but one useful method was to get 
..nnt..''- • rliimtis by using a mild alkaline douche, 
carbonate, common salt, and sodium 
b.borate, winch cleared up the crusts considerably. 


A n ^ springs of natjhedi. 

MeclichiP ^ Section of tho Royal Society 

of a faroilv 1 .^®fb Dr. Adolf Schott, a mom 

of NaiibBirn with researches on the wai 

carbon diovi’flo account of some recent work on 

Dr Sfbnff't ^ springs of this German spa 

mode of action ^ ^udy has been concerned with 
“nsLis whZ t J® on subcutaneous CO, and 
of circ'nlatioi- dependent on the eonditr 

fiod ?orm Z In Ho.had applied in a me 

that after iha method of Campbell, who sho\ 

tfsBue sX ,nTouin -to ’subentane 

between the inioot^^i” tension was estabhsl 
equilibrium boii’ ■ tbo tissues, and that, 1 

Ser.rproSm1iM'''“*“’""''’ 'CO= 0= tensions 

Dr. Schott bn^?f '?-‘^“"®tant;over a considerable tii 
r.abbits the — the subcutaneous tissue 

effervescent and these tensions of the stand 

80-86° F- for .inn J"*""® efferi’escont Nauheim batlis 

results simwed inSbl'’'"’®'’' ' 

tension under the sS''’ ® „'°"s>d°'‘ablc decrease of ( 

observed usmilv “6 minimum tension be 

bath. oC “-"tes to an hour after 

Bpondingly inSeasoii • P” the other band, coi 

ngiy increased m 50 per cent, of the experimei 


nnd in tho remainder w.as unaffected bv the bath. The 
results were interpreted by Dr. Schott as being duo to an 
increase in ventilation and in peripheral blood flow follow- 
'ing tho action of the waters. Ho said that the Nauheim 
waters, like other natural springs, acted in this respect 
quite differently from artificial CO,- baths, although the 
water of these latter might bo of the same composition. 
Blood pressure, plethysmograpliic, and other researches in 
connexion with artificial baths had yielded very different 
results from those obtained with the water fresh from the 
springs. Tho effects of the natural baths were more lasting, 
nnd proved of value in conditions in which the artificial 
batlis were' wholly inefficacious. Ho discussed why these 
special properties should attach to the natural water 
fresh from tho spring', and said that he thought it was 
a question of the crystalline structure of the contained 
s.alts, though it Wiis not clearly understood why, in natural 
mineral waters, salts were present in a peculiarly active, 
labile, and complex form. Baudiseh, who liad been working 
at tho spas in IVestem Germany under the aegis of the 
iRockefollcr Institute, believed that this was due to radio- 
active processes in tho interior of the earth, and Dr. Schott 
said that this view was supported in the case of the 
Nauheim springs by modern geological findings. He added 
that the Nauheim springs were considered to be of radose 
origin — that is to say, tlic water, originally atmospheric, 
was seeped into tho earth. This penetration, in the example 
of Nauheim, took place in mountains far distant from -tiic 
spot where the water again issued from the ground. Thus 
the water travelled far into the earth’s interior, washing 
out tho salts from the subterranean deposits, before it 
was driven up again by tbo hydrostatic pi'essure and the 
carbon dioxide at a spot where a fault in the Devonian 
formation made it possible for it so to rise. It was 
bolievod that the Nauheim water penetrated at least 
1,200 metres below the snrf.ace of the earth. Ha->-ing 
regard to the way in whicli this water must he acted upon 
nt these subterranean levels by thermal and radio-active 
influences, it was not surprising that on emergence nnd 
before ageing takes place the water should exhibit complex 
compounds of unusual structure, and capable of marked 
physiological action. These complex compounds, however, 
were decomposed by outer heat, light, or access of air, and 
thus their special potentiality was lost. This accounted, 
in Dr. Schott’s view, for the marked differences in effects 
as between natural and artificial carbon dioxide baths 
of apparently the same composition. 


CHORION-EPITHELIOMA. 

’Thf. second general meeting of the Midland Obstetneal 
and Gynaecological Society was Ijeld at the "Women’s 
Hospital, Wolverhampton, on December 13tb, 1927, the 
president (Profes.sor D. C. Raxner) in the chair. Mr. 
Maslex Jokes (Wolverhampton) read a communication on 
“ Three cases of chorion-epithelioma.” 

Mr. Jones said that the statistics of the iueideiico of 
lij-datidiform mole varied very widely. Williamson liad 
placed it at 1 in 2,400 cases, while Meyer estimated it 
as low as 1 in 261. The reason for this extreme variance 
was that whereas the former investigator based his obsei-va- 
tions ori macroscopic appearance, Meyer had made a study 
of the microscopic characteristics in a series of cases of early 
abortions, and had found that in many the chorionic villi 
showed evidence of vesicular degeneration. The statistics 
of the occurrence of cliorion-epitlielioma affei’ Iiyda tidiform 
mole varied almost as much. From 33 jwr cent. (Lockyev) 
to 50 per cent. (Wliitridge Williams) of the cases of cborion- 
epitbclioma gave a history of antecedent A'osicular m°‘°> 
while from 5 per cent. (Teacher) to 16 per cent. (FindlcA ) 
of hvdatidiform moles were followed by the development 
of chorionic cancer. It bad been stated by Neumann m 
1897 that two types of mole existed, one only of which was 
followed by cborion-epitbelioma. The tei-ms “ benign 
and “ malignant,” as applied to these moles, referred only ' 
to their tendency to penetrate into the uterine wall, and 
any difference in type, such as bad' been suggested by, 
Neumann, must be biological rather than histological, tlicre 
beino- no microscopic characteristics by which future 



182 Fkb. igiS] 


OHORION-EPITHErilOMA. 


developments iniglifc-bo foretold. .Mr. Jones nddod tlint 
in llio cnso.s now reported, npnrt from tlio coincidcnco of 
their age.s, which wns high for this condition (Teacher gave 
33 ns the average ago in a series of 188 cases), tiio largo 
proliferating typo of mole, with big hydropic vesicles, was 
common to all three. It Ecemod reasonable to suppose, 
from comparison with other tumour formation, that it wns 
this rapidly proliferating typo of molo which was most 
prono to develop malignant clinractoristics. Vinoberg h.ad 
rceonunonded panhystorectomy for all cases in which 
haemorrhage recurred after the thorough removal of a 
hydatid molo by curette, stating that tho chanco of 
metastasis was less by this proceduro than if a diagnostic 
curettage was first performed. Some had oven suggested 
hysterectomy in every’ case of this typo of molo, but this 
was quite unnecessary in view of tho statistics already: 
quoted — namely, that only 5 per cent, of moles were 
followed by chorion-epithelioma. Mr. Jones supplied tho 
following clinical details. 

Case 7.— -V 4-parn, aged 48, whoso last pregnancy had been 
sixteen years previously, was seen in consultation in January, 
1926. Sho had then been losing freely for seven days, after a 


a largo fragment of a hydalidiform molo, tlio earlier hardness 
of tho uterus being thus c.xplained. Under general anaeslbosia 
the uterus was emptied by curette, ^ and microscopic examination 
of tho vesicles removed showed tj'pical hydatidiform iimlo. t^n- 
valcscenco was uneventful iintil-tho third wcclr, when tho patient 
began to- lose blood again. ■This loss porslsted, and on bimanual 
palpation tlio uterus was found to bo still considerably enlarged. 
In view of pronotinood cardiac weakness it was decided to remove 
tho uterus without further exploration, and in Fobruary a total 
hyslorectoiny was performed under spinal anaesthesia, rlio pqst- 
oporativo findings justified this proceauro, the uterine cavity bemg 
filled by a largo, highly vascular tumour, which histologically 
proved to ha a chorion-cpUholioma. Convalescence was normal, 
and tho patient had remained free from any rcourrcnco for 
twenty-two months. . , , j 

Case 2.— An 11-para, aged 48, whoso last pregnancy had occurred 
twelve years previously, attended in Fohtwary, 1926, giving a 
history of ono week’s losing of blood, following three months 
amenorrhoea. The uterus was enlarged to the size of an eighteen 
weeks’ gestation; no foetal parts could bo dislinguishod. Sho 
was admitted at inco with a diagnosis of hydatidiform molo, which 


hnif. years nrovjously,' and sho had last, menstruated In June, 1927. 
Sho notlcou abdominal swelling early in October; at tho becinning 
of November tlio ankles began to swell, and she observed tliat sho 
was passing less urino. Sho was admitted to hospital in November 
in consldcrablo pain, tho abdomen being so tensely distended that 
tho akin was tightly etrctchcd, whito. and shiny, with tho super- 
ficial Tclns flattened and blue. This distension was duo to a cystio 
tumour, there being a well marked fluid thrill, with central dull- 
ness, and resonanco in tho flanks. So tenso was tho abdomen that 
it was impossible to mako out any Intra-abdominal details. On 
vaginal oxaniinallon tho cervical canal was eufijcicnUy open to 
allow tho examining finger to pass, when a small foetal head was 
palpablo. There was no tenseness or protrusion of tho bag of 
membranes. From theso signs it ecemed po'^siblo that the patient 
bad a normal fivo months’ pregnancy concealed by a large ovarian 
cyst, though tlio actual diagnosis made was hydramnios. Her 
general condition was bad. Tho scanty, highly concentrated urine 
contained a largo amount of albumin; she had a large goitre, and 
was flulTcring from considcrablo dyspnoea owing to tho size of the 
abdominal tumour. In view of tho possibility of a dual condition — 
pregnancy and cyst — being .present, induction was attempted by 
means of a rubber bougio. Tlio result was disappointing, the pains 
being few, weak, and irregular, and the cervical dilatation produced 
only slight. The patient wa.9 placed under spinal anaesthesia 
aher morphine-byoscino narcosis; tho presenting’ bag of membranes 
was ruptured and a small quantity of liquor escaped. The cervix 
dilated easily, and on pushing tho foetal head to ono side a tense 
membrano could bo felt higher up in the uterus. .Rupture of this 
was followed by a prolonged rush of fluid, twenty pints in all, 
while tho abdominal swelling subsided. Extraction of tho twins 


examination a wcok iwfcci, vw , 

found to bo very largo, an^ on speculum examination n thickened, 
dirty highly vascular mucous membrano was yisiblq at tlio 
eSernal os. ^Ciirettings wero reported to show chorion-cpitholioma 
and a total hysterectomy was performed. The patient mado an 
uneventful recovery, and had remained free from any signs of 
metastasis for over twenty months. 

Case S. -An 8-para, aged 48, with her last pregnancy eleven years 
previously, repoJted, in January, 1927, continuous losing for seven 
weeks after a period of eight weeks’ amenorrhoea. Tlio uterus was 
Tnlarged to the size of a flvo months’ pregnancy, no foetal parts 
were palpable, and a diagnosis of ^“^,'1’“'',®.; 

Induction by means of a rubber bougio was attempted, but the 
uterine contractions, while resulting in some dilatation of tho 
cervLx, were not able to expel the mole, which was removed 
Manually, the uterus being curetted. When examined before 
Sscharge it was found that the utenis was soft ond bulky; 
exploratory curettage was performed. Histologically the curetting 
proved to be chorion-epithelioma, and total hysterectomy followed 
The convalescence was normal, and there had been no signs of 
recurrence over a period of ten months. 

Ml- Jones said that the lino ofvtreatment advised by 
Vineberg was adopted in tho first case largely owing to 
tho patient’s poor general condition. The proceduro 
adonted in the other two cases would appear to be all that 
was necessary as a practical working plan-namcly, careful 
bimanual examination of the niorns ten to fourteen da^ 
after the removal of tho mole. Diagnostic curettago should 
Cnerformed in all cases in which the uterus had remained 
enlLsed, or in which an unhealthy discharge, saneous or 
^.rlas present. Inconclusive cases might be kept under 
1 Winn and re-examined after a further short period, 
whUo it wonlf p'vo safest, in view of the malignancy of 
While IP w 1 difiSculty of interpreting tho histo- 

“"“'"f’ T* 

cafes as P^itive. and to perform panhysterectomy. 

Hydramnios with Uniovular Twins. 

Mr. Maslon’^Jones also reported o case of hydramnios 
associated with uniovular twins. ■ - . 

A married woman aged 37, had given birth to 
had had four abortions. Her last pregnancy had been two and a 


and tlio output ol urine steaoiiy returning to normui. ^ 
of tho placenta and membranes showed tlicm to consist of a singio 
nlacenta and chorion, but two separate amniotic.sacs were present, 
tho unper ono, which had been tho seal of tho' hydnimnios, having 
contained the larger twin. Tho umbilical cord of tho larger foetus, 
showed a fair degree of oedema towards its placental end, wmen 
had a vclamcntous insertion. Microscopical examination of tlio 
kidnov tissue from each foetus showed normal foetal renal' 
characters. Tho heart and liver were relatively increMed in bulk, 
but tho kidneys In the larger foetus were barely out of proportion. 
Tho full bladder in tho larger foetus might have 
or haw been an indication of mcreased urinary activity as tha^ 
result of an increased circulation. 

Mr Jones said that Kfistner had suggested that in these 
cases what actually happened was that cardiac hypertraphy 
occurred in tiio manner described, and resulted m a further 
Saso of the cireulating fluid. _ A vicious circle was thus 
established, and eventually a point was reached at lUiioh 
the heart was no longer capable of dealing with tho amount 
of blood coming to it, when failure of compensation resulteel. 
Tho effeorof this failure were most evident as a hack 
Tho ctloots umbilical vein. Oedema and 

piossuro followed, with increased secretory 

congestion of the cora ^ ^ 

X Tl of hvdrarios. The condition of the heart and 
r" and that Oflhe cord associated with tho larger twin, 
coil to support theso views. The etiology of this 
would . . Association remained somewhat obscure, 

well “l=°Acepted theory appeared to ho that 

Tho most een W “TrCriated to its own use a steadily 
tho of the joint placenta, and subsequently 

a deVeo of cardiaA hypertrophy. Secondary 
hSnortrophy followed in due course, and the resulting, 
renal hypertrop y tU production of 

incroasod 0 ”"“^ ^gco that tho excess of fluid 

hydromnios. ^ result of some abnormality of tlio 

accumulated a tl some attributed it 

umbilical heart to cope with tho quantity of 

-.'S 

to"lta“Ss ■>' ini-™**™ »■> “”»• t?"*’- ■ 

findings were as follows 1 

A. Large teeteJ. B. Small foetus. Weight Kotlo. 

• ui ■ 675 crams 450 grams 1.5 i 1 

Total weight — | 2 5 ; 3 1 1 

Heart — — ” 14 18 : 1 

Liver ... - » ;;;;;; « 15.8 : 1 

Kidneys ■' 

The bladder in ^?n’'o™c*o minf;™hat oF the^'smaller was 
and contained about ^^3 no appreciable difference 1 

contracted and which were male; the larger weighed 

iTfte, an^tre smaller, which mado attempts at respiration 
delivery, 1 lb. . 

about a fortnight previously. 




■184 Feu. 4, 1928] 


- - KEVIEWS. 


[ TtrrCsmtii 
Hu)tcxi.Jorr.xifc 


it contains n largo , number of illustrations, including 
sovoral coloured plates, gives llio results, of, and tlio pit- 
falls underlying, vaccine treatment, and coiitains a chapter 
on surgical treatment, occupying rather more than a third 
of the volume, by Sir. IlMtuEUT Fkanklino. This Ijook 
contains the grounds, elaborated in published p.apcrs, for 
Dr. Grove’s views ns to the ctiolog}’ and treatment of thc.so 
diseases. Dncteriologically ho boliovc.s that ostco-arthrilis 
and non-articnlnr rheumatism are caused by streptococci, 
the numerous strains of which may account for the varying 
clinical manifestations. Eheumatoid arthriti.s, which is 
regarded as a much more cleanly cut clinical condition, is 
ascribed to the action of staphylococci, which present a 
greater uniformity. In addition to these two clinical forms 
a third, mixed arthritis, is recognized, to include cases 
with the sj-mptoms of both the previous fonns; this may 
happen when a patient’s resistance is so diminished by 
streptococci that staplylococci gain a footing and exert a 
pathogenic effect. It appears, however, that if all cases 
presenting any .symptoms of this double infection aro placed 
under the heading of mixed arthritis, there will ho com- 
parativclj- few for the other two categories. 

Dr. Crowo ascribes rheumatoid arthritis to a special 
typo D of Stnpln/lococcns alhus which he calls Micrococcal a 
.deformans-, this view has met with considor.ablo criticism, 
and accordingly fresh evidence and argument arc now- 
brought forward in its support, such as agglutination 
reactions, cultivation from the joints of p.aticnts with 
rheumatoid arthritis, and Lsolation from the urine of the 
organism, which is not the ordinary staphylococcus (typo A) 
as has been suggested. He expresses “ a hope that even' to 
the mind of the congenital sceptic a case has been mado 
out for — at least further research.” 

On tho grounds of complement deviation, agghitination 
reactions, and specific reactions to vaccines. Dr. Crowo 
argues that streptococci are responsible for ostco-arthritis ‘ 
and non-articular rheumatism. Further as, with a fow 
exceptions, such as highly virulent and haemolytic strains, 
it appears that streptococci generally must bo regarded as • 
causal agents, he recommends a stock vaccine containing tho 
greatest possible number of different streptococci ; for tho 
failure of vaccine treatment, which so often occurs, is in 
his experience more often duo to tho constitution of tho 
streptococcal vaccine than to any other single cause. In 
conclusion, it may bo said that there is much to excito 
thought and critical consideration in these pages; not tho 
least attractive feature of them is tho frank way in 
which tho failures as well as the successes of vaccino 
treatment are sot before the reader. 


OTOLOGY. 

The Handbook of Diseases of the Ear,’ by Mr. ItiCHAnn 
L.ake, achieved great popularity during the first decade of 
the century, and passed through several editions. Tlie last 
appeared some fifteen years ago. Its success was no doubt 1 
due to the reputation of the author and tho fact that all 
the essential facts relating to tho subject were included 
in a volume of moderate size, an achievement rendered 
possible by tho concise stylo of tho uTiter. Dr. Peters has ' 
now completed a fifth edition, and although ho has pro- 
duced a useful book the difficulty of the task which ho has 
undertaken after this interiml is apparent, and it would ' 
have been easier to rewrite the book than to blend tho new 
with the old. There is, however, a sufficient description of 
all the essentials, including a review of tho functions of tho 
labyrinth, ■with reference to recent views on the utricle and 1 
saccule, as well as tho semicircular canals. Nothing has i 
been added about herpes of the ear, and tho chapter on 
intracranial complications might be fuller; but with these i 
exceptions there is an ' adequate account of the subject as ' 
a whole and of all the ovdinarj- diseases of the ear. It ■ 
should certainly continue to prove a, useful handbook for 
tho house-surgeon or busy practitioner who does not require 
a large book. 


» Banilboot of Diseases of the Ear. . By Blchnrcl Late, J'.K.C.S.Enc.. and ,1 
E. A, Petera.M-D.Cantab., F.B-O.S.Eng. Fifth edition. London : BailliSre, .i 
Tindall and Cox. 1927. (Demy 8vo, on. xviii-l-310; 80 figures, 4 plates. 
12s. fid. net.) , i 


Dr. Cntoui; has pio.sontcd in his modest volume entitled 
Oreille Interne* the fruits of an industrious research into 
tho cmbiyologj', anatomy, and pathology of tho internal 
oar. It is naturally a trork that is likely to appeal only to 
tho anatomist or to tho specialist in otolog)'. There is 
scarcely any region of tho body (especially in man, but also 
in animats) tvlicro histological observation and research is 
nltonded with greater difficulties and has given rise to 
more differences of interpretation. Tho author’s careful' 
description of his technique, beginning with tho removal of 
tho tcmjmral bone, whether Jiuman or animal, down to tho 
final eutting and staining of the sections, is therefore a 
valuable record. Even when this is done the orientation 
and interpretation of tho sections require much skill and 
knowledge, and tho difficulties which arise aro carefully 
noted. Dr. Claoud gives a fascinating description of tho 
development of tho internal ear from tho ectoderm, and of 
the malformations and other pathological conditions con- 
tingent thereon. His research is, however, by no means 
purely academic, ami he describes tho clinical symptoms 
associated with the various pathological conditions, of which 
there is an excellent and well illustrated description, such 
as otosclerosis and suppurativo labjTinthitis. There is a 
good but not overweighted bibliography, and tho whole 
forms a welcome addition to this rather dark corner of 
pathology. 


NUTMTION IN CHILDHOOD. ' 

The problems of malnutrition in childhood are of funda- 
mental importanco in relation to the whole question of tho 
physical and mental well-being of tho child, and a vast 
amount of material, widely scattered tliroughout ' riiaiiy 
periodicals, has been brought together by Ltdi.i J. Eobert^ 
in Nutrition Work with Children.’ The book is primarily 
designed as a textbook for university classes, and its' first 
part gives an account of tho laws of growth, and the 
nature, causes, and effects of malnutrition and its identi- 
fication. Tho second part goes into the methods of com- 
bating malnutrition, referring especially to the work that thb 
schools can do. Tliat there is a serious problem confronting 
health workci-s is well illustrated by certain tables, which 
shon- that out of some 17,000 school children in a section of 
New York City only 17.3 per cent, could be accepted as 
being of normal nutrition. The various systems of 
estimating nutrition aro discussed, and in_ particular 
von Firquet’s work receives full consideration. In a 
chapter on the causes of malnutrition, othenviso very good, 
it is surprising to find no reference to the Medical Eesearch 
Council's report on “ Poverty, Nutrition, and Growth,” nor 
to Dr. Corry Mann’s work on the growth-promoting effects 
of milk. Indeed, it is a fault of the book that it deals too 
much with American work. It does not follow that 
nutritional standards in other coimtrics arc tho same, nor 
is tho excellently sketched plan of work in tho schools 
capable of much aiiplication to educational systems other 
than those in the 'United States. As a work of reference, 
however, the book should certainly find a place on tho 
shelves of those concerned with tlie health of the child. 


Professor J. H. Hess’s work on Feeding and 
Nutritional Disorders in Infancy and Childhood’ is too 
well knoivn to require much introduction to its fifth 
edition, largely revised and enlarged. Tho . author has 
incorporated recent work, especially into the sections on 
artificial feeding, where acidified milk and alkalinized milk 
aro thoroughly discussed. It is interesting to see that 
Professor Hess prefers lactic acid milk to bo prepared by 
souring -with cultures rather than by tho addition of acid. 
A now chapter has been included on coeliac disease, which 
is well treated, except for the statement (p. 334) that 
“defective fat splitting plays a prominent role, when- 
it is one of tho many problems of this disorder that tlie 


By ^dia J. Roberta. The Univer^ 
TOlSvrHomo Economic Series. Chioogo : llniyer|ity of Chicago 
em 1927 fDcmy 8vo, pp. xiv+ 394; 14 figures., 17 s. fid. neC) 
'Ficd^' ahd /irtritional Disorders Money an^ ‘’phflade'lphin^ 

Ilua 11 Hpss M.D. Fifth edition, revised and enlarged, /niiauei^n 

r Da”s Vmpnuy. 1927. (Demy 8vo, pp. rtv + 666 ; 44 figures. 
0 dollars.) 



184 ri.n. r«5] 


Jt 


REVIEWS, 


(1 /firgo of )Hit!.frntion.i, iiiduilino 

MAi.ial oil, .III, Hi plnfoi, givos tlio riMilts' of, nml tho nit- 
lallH iliiil.'ihiiig, vnccini- tioadiioiil, iiml ooiilniiis n cJinntor 
on aiirgual tii'.'itiiioiit, ociMijn’iiig r!itiir>i' iikho (Imn n ihinl 
of (ho voliiiii,., Iiy Jlr. lIrniiKiiT J'jaNici.iNo. Tlii.s hiok 
(■ontniio till' gidiiiiij'i, ulnliiiratotl in pulilistiod pajiors for 
JJr. r'ldivo’., x ions ns to thr otiology nrid (roatiiiorit of tlwao 
diM.nsf.s. llactoriologirnlly ho holiovrs tlint ostco-nrUjritis 
niid iion-artiiiilar rliouiiml ism nro riiiiscd liy stroptocm-ci, 
til.' iiiiiiior„ii-. ^llaiIls of wliicli may nccoiiiil for tlio varying 
clinifiil niatiifi's'.ntioiis. Jiliciiiiiatoid nrlliiitis, wliicli is 
rogardi'd n>. a mticli iiioro clomily cut ciiiiictd conditi'mi, is 
ascribi'd to llio nclion of .'•tapliylococoi, liliicli prosont a 
groator uiiiforiility. In addition to llicso tivo clinical forms 
a third, iiii\cd arthritis, is recognized, to incindo cases 
svith the syiigitoms of hntli the previous forms; this nmy 
happen when u patient's re.sistanco is so diminished hy 
streptoroeci Diat .stnphylocofdi gain a footing and esert, a 
pathogenic ofTeet. ll ajiiiears, however, that if all cases 
presenting any symptoms of this doilhiu infection avo placed 
under the heading of mixed arthritis, there will ho com- 
paratively few for tho other two categories. 

/>r. Croieo nscrihes rheumatoid arthritis to a special 
type n of Slnpln/lorpcni^ olhiif wliieh he calls Mtrroi'orrii.i 
dc/oimoiis ; this view has met with coiisider.nhlo criticism, 
and nccordingjy fresh evidence and arjpinieiit are now 
hronght forward in its siiiipml, such ns agglutination 
reactions, cultivntiiiii from the joints of patients with 
rheumatoid arthritis, and isolation from the tiriiio of the 
organism, wliich is not the ordinary staphylocoeciis (type A) 
ns has hcon suggested. Ifc expresves “ a Imiio that even to 
the mind of the congenita! sceptic a case has hecn inailo 
out for — at least further redoireh.'' 

On tho groiiud.s of com[dement deviation, ngglutirmfion 
reactions, and specific leactions to vaccine;, J)r. Crowe 
argiic-s that strejitococci are rcsjiomsihle for ostco-arlhrilis 
and non-articiilar rlieumi.tism. l''urthor as, with a few 
oxts'ptions, sucli ns highly virulent and haemolytic slrainn, 
it nj, pears that .streptococci generally must ho regarded a.s 
cnu.sal agents, ho recommends a stock vaccino eontaiiiing tho 
greatest possihh; numher of different streptoroeci; for the 
failure of vaeciuo treatment, wliich so often oeeur.s, is in 
his experience more often due to tho constitution of the 
streptococcal vaccino than to any other siiiglo cause. In 
conclusion, it nmy ho said that /hero is much to e.vcito 
thoiiglit and critical consideration in tlicso pages; not the 
least nllractivo feature of them is the frank way in 
which tho failures ns well as the successes of vaccino 
treatment arc set hcforc tho render. 


OTOLOGV. 

Tiin Uandhook of Disensrs of the Tmrf' hy Sir. RiomitP 
JjAKr, neliiovcd invent pojnihirily during the first ilM'ado of 
tho conlnry, and passed thmugii several editions. Tlio Inst 
appeared some fifteen years ago. Its success was no douht 
duo to the reputation of the author and tho fact that all 
tho essential facts lolnliiig to tho .suhjw-t wero included 
in n, voliiino of wodoratc size, an nehievemont rendered 
pnssiblo hy tho concise style of tlio writer. Pr. Putkiib lm.s 
now comp’lotod a fifth edition, and nlthoiigli he has pro- 
duced a useful hook tho dilficnlty of tlio task which ho has 
niidortakcn after this interval is apparent, and it would 
Imvo heen easier to rewrite tlie book than to blond tho now 
with tho old. Tlioro is, however, a sufiricient description of 
all the os-scnlinls, including a review of the functions of tho j 
labyrinth, with roforonco to recent vioa-s on tho utricle and " 
saccule, ns svcil ns tho Bomicirculnr canals. Nothing has 
been added about herpes of the oar, and tho chapter on 
intracranial complications might bo fuller; but with those , 
o.xcoptioiis tlicro is an adequate account of the subject as 
a whole and of all the ordinary diseases of tho ear. It 
should certainly continue to prove a useful handbook for 
tho houso-surgeon or busy practitioner who docs not require 
n largo book. 

•IIn,„thnnt of nhrnun of tho Jtor. by Klctonl ^kc, :j 

R. A. golem, M.U.CanInb., F.n.O.S.Eng. 4 j, 1« t"’ • 

'I'lmlnll nnii Oo.v. lozr. (I)cmy Bvo, [ip. xvlil + 310. 00 aAiirts, o pmics. 
ia». Od. net.) ' . 


f TurCjmni 
L MKDtCll. J0VZ5U 


tho emhri- Jn * *' bb industrious research into 

ear. It s Pb^iology of tho internal 

11 . • i' '^^oik f/iat js ii7:o/y to appeal only to 

tho a mtornist or to tho .pccrnlL^ in otoloL^. Thil l 

n'’antal7w??'’"."^''r Sim, but also 

in an inals) i hero histological observation and re=oarcli is 
ntfondeil with greater dimedtios and h.ns 0 ^ 0 ^ fo 
rnoro ditroroncc.s of intorprotation. Tho LE careful 
description oflms tocl.niqiic, beginning with tho removal of 
tho tempornl bone, wbollicr li.m.an ornuimnl, doxTto the 
final ciiltmg and staining of the sections,- is tboiefme -a 
va nnb o record. Even wben this is dono’tl.o oiienttln 
and intcrjiretation of tlio .sections require much skill and 
icnowlcdgc, niul tho difficulties whicii arise aro carefuJlr 
noted, l^r. Clnoiio gives a fascinating description of the 
development of tlio internal car front tho ectoderm, and of 
(ho inalfonnalions and other pathological conditions con- 
liiigeiit thereon. His research is, howovor, by no means 
puioly acadomic, and lio describes tho clinical svmptoins 
nfsociatod with tlio various pathological conditions, of which 
them is an excellent and well illustrated description, such 
ns otosclerosis and .siip|)ur.afiro /abyTinthitis. There is a 
good hut not overweighted bibliography, and tho whole 
forms a welcome addition to this rather dark corner of 
patholiigj-. . . ; 

NDTltlTION IK CHILDHOOD. 

Tin: problems of mnhiiitrition in childhood arb of funda- 
iiiiMitnl import.nnco in relation to the whole question of tbb 
jiliysical and mental wcll-hcing of tho child, and a vasl 
amount of material, widely -Bcattovcd throughout ' many 
periodicals, has been brouglit together by Lrui.i J. Robehts 
ill Xufrition Jl'or/; with Children.^ Tho book is primarily 
designed ns a textbook for university classes, and its firet 
part gives an account of tho laws of growth, and tho 
naliire, causes, and effects of malmitritiou and its identi- 
fication. The second part goes into tho methods of com- 
bating mnluutritioii, referring especially to tho work that thb 
schools can do. That there is a serious problem confronting 
lic.altb ii-orkers is well illustrated by certain tables, which 
show that out of somo 17,000 school children in a section of 
New York City only 17.3 per cent, could be accepted as 
being of normal nutrition. Tho various systems of 
estimating nutrition nro discussed, and in particular 
von i’irquct’s work receives full consideration. In It 
chapter on tlic causes of malnutrition, otherwise vm-y good, 
it is surprising to find uo reference to tho Medical Eesearcl 
Coiincir.s report on " Poverty, Nutrition, and Growth, ’nor 
to Dr Corn- SInnn’s work on the growth-promoting effects 
of milk. Indeed, it is a fault of the book 

\mcrican work. It docs not follon that 


of 
much 


with 


utritionnl standards in other countries aro the same nor 
is tlio excellontlv sketched plan of work- in 

than certainly find a place on tho 

eoneSned with the health of the child. , 

Professor J. H. Hess’s 


on Feeding and 
Childhood^ is too 
much introduction to its fifth 
and enlarged. Tho . author has 


shelves of those concerned 

work 

Nnirit.w 

well kuou-n to require 

edition, largely pciaPy jnto the scctious on 

incorporated recent wor > P , ^ alkalinized milk 

nrtif.oial fooding.yvhoro acidified mA and_alffa^^ 

iSior “f P s ££ 

is well treated. „ prominent role,” when 

<• dofcctivo fat sph^ttmg^p^^y^^ disovderjb^t® 

it IS one oftho_nin_yj -1 - 7 . 


* OrriVIo /nli'ri'^- Paf;Charli;3 CanonC. 

mfcro,ropt,uo '' J. botcrla 






ji,,„rdoro in 


JoUu/rf.?I«a. JEP- pp. xiy + 666.,« 

F, A. Dnvls Company, l-wi. i. 

4.50 dollnrs.) 



Feb. 4, 192 


8] 


NOTES ON BOONS. 


r ' rarBsmjrr 

illlCiaLX. JOUBNAX. 


185 


excess' of fat in the faeces is nsii.ally split. Nor is tliero 
any mention, in the trc.atmcnt of this eoiulition, of tho 
use of bile salts or of panerealic extracts. Tho sections 
on rickets ami tetany arc very veil done, aiul in particular 
the hiocheinical problems are well sot out. It seems a pity 
that in Part VIII of tile book tlie term “ acidosis ” is often 
used vhero “ ketosis ” is ovideully meant. 


A GENERAL VIEW OF PSYCHOLOGY. 

Dn. William Eldeb of Leith has written a volume entitled 
Studies in Pstjcliolomi’ in which ho aims to approach tho 
problems of mental life from tho standpoints of physiology, 
biology, and neurology. Tho first cliapter is concerned 
with the mechanism of the nervous syslein; in the two 
following, tho psychology of memory niul its neurological 
basis are discussed ; and tho fourth is devoted to considera- 
tion of the affective-conativo life — emotion, drive, ])urposo, 
and will. A discussion of consciousness is followed by one 
on sleep. The author, following tho teaching of Claparndo, 
takes tho view that sleep is an instinct wliich by oft repeti- 
tion has become in most people a habit. 

The latter half of this book is taken up with an account 
of dreams and other allied forms of dissociation. The 
author does not accept tho thcorios of the psycho-analytic 
school as to the nature and functions of dreams ; his views 
are, as he observes, more in accord with those which havo 
been recognized as orthodox for a long time. He quite 
rightly stresses the importance of endogenous and other 
stimuli in the instigation of dreams, though we should 
agree with his view that tho most common cause 
of dreaming IS some error in digestion. All kinds of normal 
6 irouh which in waking life fail to reach consciousness are 
probably liable to influence dream thoughts. In this con- 
nexion we should like to have seen some rofcronco to 
r. . j. Ciibborloy’s unique contribution on the effect 
or experimontally induced tensions of tho body surface 
upon the determination of tho dream content.* This 
impor ant research was based upon the study of about 
cont which all but a few wore cxporinieiitally 


f'ident that Dr. Elder has expended much thoug 
rMfioii'* tnattcr; the book is well documented, 

”rS.Lr“ •» *'■« 


Mrmr«T I i ®^OItTER SURGERY. 

n reviewing their knowledge of surgery 

Surnrri/‘‘^l will find much help in A Shorter 

a clear'^^onrl^ ^ Love, which embodies in 

Tho linoL • manner tho more important principles. 

iiwludes tho ^ of ‘view, but 

uurnosps oocessary academic material for examination 

in BurmlT-lnn- '^.1 * 2 as successfully achieved his aim 

a clear' onB student laclcs — ^that is, the need of 
ETStematio method of classification, and of a 

from a few routine clinical examinations. Apart 

wn-anged. Ind'tCiim’i''^ ?" ^40, the book is ^well 

Mr. Love is lo L “^^'‘ttions are good and well chosen, 
teacher anti “ogratulated ; he is evidently a sound 
aeber, and obviously a disciple of Mr. Russell Howard. 


The fiftb A W ON BOOKS. 

for Great Britafn ^,°'^^^°ok of Tuberculosis Schi 

National Association^or published by 

new address is 1 0 ° prevention of Tuberculosis, w 

short accounts of the t ^'0.1. The volume cont 

counties and county schemes in the vai 

the Channel Islands list., of Great Britain, Ireland, 

' I p.-.,,..- — i — ;; L ^ °t residential institutions for tn 


- — 

London r’w? ^Sema'Jfn ^'‘•'r. 

PP. XV + 212. 8s. 6d. net 1 Books), 

* Brit. Journ. _ . 


Jt.D., F.R.C.P.E., F.I 
Ltd. 1927. (Deroy 


London 

09. od. net.) ' uooksj, Lta. I'UZi. 

F^TLci’r"""' January, 1B23. 

F.E.C R En„ London • H ^ a*' J- McNeill Love, H.B., II.S 
^ ^8; 43 figures. IncluHin^'t'I'* C<>- ^td. (Bern; 
^ Handbook of Tuberculori^V'i^ piates.- 12s. 6d. net.) 

a. London; Adlard Great Dritain and 


r;RC,S.Eng:’ Lon'do'n- 
op. yili + 208; 43 fleurei 

”1 l'ubercuioeit‘'k!a^ plates.- 12s. 6d. net.) 

4^*^, edition. London; Adlard 1°^ Great Itritain and Ir 

.;Ua tor the Prevention of TnSn2!?^, J't^ and the National Ai 
*.M. post free.) ruhorculosls. 19271 (Med. 8vo, pp. vii 


culons patients, and charts illustrating comparative death rates.- 
Tho good arrangement of tho subject matter and the clear 
printing render tho mass of information contained in this 
book of considerable value to all interested in the administrative 
side of tho campaign against tuberculosis. 

Dr, F, G. CnooKSHANK, author of the Mongol in our Midst 
and of a number of other published works, always writes in 
an arresting style, and is becoming, as again shown in his small 
book Diagnosis': and Spiritual Healing the medical philosopher 
in our midst. Tho careless reader might overlook the colon 
after the first word in the title and expect to find a discussion 
of tho merits of spiritual healing, with or without diagnosis of 
tho malady; if so, he would soon find out that there are two 
separate addresses, that on diagnosis being the Bradshaw Lecture 
for 1926 on “ The theory of diagnosis,” delivered at the Royal 
College of Physicians of London, the other, “ Spiritual healing 
and medic.al theory,” being a paper read at a meeting of the 
Hunterian Society in the course of a debate opened by the 
Bishop of Kensington in November, 1925, and reprinted from 
Psyche. Tho Bradshaw Lecture occupies three-quarters of the 
booklet, and undoubtedly stimulates thought, while the other 
address may arouse admiration for the breathless sentence, 
extending over more than a page and a half without a stop, 
which is the supposed reply of many doctors when asked their 
opinion of spiritual healing. 


Dr. Shields Wariien, instructor in pathology in the Harvard 
Medical School, has recently gatliered into book form, with 
tho title Medical Science for Everyday Use,*’ a series of 
articles on subjects of medical interest "which he contributed 
to a Boston Sunday newspaper. Dr. Warren peppers his dis- 
courses with racy remarks, as when he calls the Streptococcus 
haemolyticus a “ mean bug,” or states that we have all seen 
" short, chunky ones [that is, youngsters] husky enough to 
eat nails,” or calls the anthrax germ the “ Henry Ford of the 
bacterial world.” The occasional iniquities of the staphylo- 
coccus are illustrated, in an article on blood poisoning, by 
the notoriety the germ received some years ago in killing Calvin 
Coolidge, junr. On the subject of colds in the head we are 
given an account of how Smith, with a nice tame family of the 
“ mean bug ” in his throat, sneezed a few into Jones, who, 
without developing a cold, raised the virulence of tho germ. 
Jones coughed in a crowded subway train, and sprayed Jackson 
and Harris. The latter was immune, so nothing happened. 
Jackson was tired and chilly; the streptococci got the upper 
hand, and Jackson went to ' bed with tonsillitis. Dr. Warren’s 
views are generally sound, and we are interested to note that 
he doubts whether the exhaust fumes from the tetra-ethyl lead 
contained in the' " ethyl gasoline ” now used for motor cars 
are a desirable addition to the atmosphere. 

Many books, articles, and pamphlets are bein" published on the 
ailing child, the nervous child, the wajTvard child, the defective, 
and delinquent, so it is a pleasant relief to come across a book on 
The Normal Child.'’ The author, Dr. B. Sachs, exhibits a deep 
knowledge of the quite ordinary child. Incidentally he remarks 
that every child is, and should be, a problem-child to his 'own 
parents, and says also that although “ the community owes 
and does its duty to the abnormal child, yet it is far more 
important properly to care for the nornial child.” He warns 
his readers against the ” bogy of heredity,” and also against 
the easy path of making heredity an excuse, where, in reality, 
parental and educational rnethods have been at fault. It is 
refreshing also to find him expressing the ojiinion that children 
should not be raised on “ purely scientific methods by mothers 
endowed with a smattering of psychology.” " Let the mother 
exercise her own good common sense, and let nothing supersede 
the maternal instinct tempered by experience and common 
sense.” The paternal responsibility in the upbringing of 
•children is emphasized, a harmonious dual control being the ideal 
for the normal family. In the chapter on the nursery and pre- 
school period we find it said that ” there has been much idle talk 
about the fear of ' repressing ’ a child as though repression 
were a thing to be looked- at askance. Suppression is bad, 
repression beneficial. Wliy not adopt the slogan, both tor 
children and adults, ‘ Repress yourself so that your neighbour 
may express himself? ’ ” In the chapter on the school ago are 
some wise remarks on modern pedagogical methods und tneir 
resMts. All parents would be the wiser for reading the chapter 
on puberty and adolescence, and the book closes with^ another 
on the evils of psycho-analysis. The author criticizes the 
Freudian doctrines, as they may be interpreted by people of 


” Diagnosis: and Spiritual Heating. By F. G. Croakshank, JLD., 
FRCP Psj-che Miniatures, Sledical Series, No. 6. London ; Kepan Paul, 
T'renc'h 'Truhner and Co., Ltd. 1927. (Pott 8vo, pp. 101. 2s. 6d. net.) 

"Sledical Science for Everyday Use. By Shields Warren. A.B., Jt.D. 
Philadelphia : Lea and Fcbiger. 1927. (Post 8vo; pp. lx + 178. 2 dollars.) 

*» The Normal Child and Hotc to Keep It Normal in flind and Horah. 
Bv B Sachs, lE.D. New York ; Paul B. Hoeber. 1926. (Post 8vo, pp. IIL 
1.50 doUars.) 



186 Feb. 4, 1928] 


HEALTH OF THE HOFAL AIR FORCE. 


f Tirz Bgmw 

Sfr.DiCALJocitxu;, 


ni5u/ficieijt education and cxricWcncc, and protests aijahist the 
iiuliscnminato applicalion of ill-coiisiclerod psydio-thcr.apculio 
jiietliods to yontlifiil inintls. Tlio book is jiotcworDjy for ils 
■wisdom and wliolcsomo coimnoii soiiso. 


PREPARATIONS AND APPLIANCES. . 

" GlANOID ” CoN'CENinATED Fl.UlD EXTOACTT OP LlVEn. 
Giieat interest has naturally been aronsed by the recent 
discovery by Slinot tb.at a striking benefit is produced in cases 
of pernicious anaemia by the addition of coiisider.able quantities 
of liver to the diet. 

.Sometimes it is difficult to get the patients to consume an 
adequate quantity of liver, and in such cases liver concentrates 
are very useful. Messrs. Armour and Co. have prepared 
“ Glanoid concentrated fluid extract of liver,” and they slate 
that each ounce of the extract represents eight ounces of fresh 
liver. They state, moreover, that “ Glanoid concentrated fluid 
extract of liver has been demonstrated to be of therapeutic 
value on a large number of patients with striking success by 
Koessler and his associ.ates of the University of Chicago.” 
(Journal American itedical Association, Soptemter 3rd, 1927.) 

The active principle of the liver that produces the remarkable 
curative effects in pernicious and secondary anaemias is at 
pre-sent unknoum, .although rese.ai-d; on this point is in progress. 
Tile preparation of Ale.ssrs. Armour appears, from the evidence 
supplied, to be an active concentrate of liver convenient for 
administration in anaemia. 

The “ Diorrauss.” 

The " digitruss,” an appliance for the trcalnicnt of higuiiial 
hernia, has been patented by Mr. II. E. Cooper of 63, Green 
Lane, Eltham, S.E.9. It presents the following points worthy of 
notice : (1) The pad is made of “ sorbo ” rubber. (2) This is 
held in position by a very ingenious .slip.on red-rubbor facing. 
(3) The pad is thoroforo capable of moulding itself to the contour 
of the body, and avoids undue pressure. (4) For an ordinary 
inguinal hernia undci-straps may thereby be unnecessary. (5) The 
finger projections are easily bent so as to induce some extra 
pressure. 


THE ROTAL AIR FORCE. 

Report on the Health of the Force i.n 1926. 

The report ou the health of tho Royal Air Force for tho 
year 1926 is convoiiiontly arranged in four chaplors, with 
apjiropriate tables and charts. Tho average stron^h of 
tho total forco ivas 32,985, of which 23,958 were sei-ving in 
tho United Kingdom, 3,528 in the Meditorrancaii littoral, 
3,536 in Iraq, and 1,963 in India. 

The case incidence of disease and injury lyas 801.1 per 1,000 
of strength, a diminution of 100 compared with 1925. Cases of 
les.s than forty-eight houi’s’ duration are enumerated separately, 
and, excluding these, the incidence is reduced to 449.1. The 
decrease in case incidence at homo is attributed to tlie .smaller 
number of cases of influenza, and the increase abroad to the 
larger number of cases of malaria in India and Iraq. 

Forty-one deaths fi'ora disease and 112 from injury occurred 
during the year under review, compared with 36 and 102 
respectively in 1925. Tlie chief causes of death from disease 
were pneumonia and tuberculosis (6 cases each), and from 
injury (multiple fractures). In .all 240 cases were invalided, 
the chi.ef causes being chronic suppurative otitis media, psycho- 
neurosis, and tuberculosis. 

The incidence of all types of venereal disease was 17.1 per 
i.OOO of strength, a reduction of 50 per cent, on the 1921 figures 
and a continuation of the yearly reduction which has been 
effected since that year. Tins continued decrease in ineideUce 
is attributed to tlie unabated prosecution of preventive measures 
described in previous reports. There were 36 cases of pul- 
mcnary tuberculosis, with 6 deatlis and 22 invalidings. Tho 
corresponding figures for 1925 were 27, 1, 30 (7 of which were 
1624- c<isGs)» 

"liie case incidence for injuries increased from 67.8 in 1925 
to 76 5 in 1926. Flving accidents accounted for 7.1 per cent, 
of the total injuries' in 1926, compared with 6.9 per cent, in 
1025 the number of sucli deaths for these years being 78 and 
54 respectively. It is stated that ” considering the number of 
11 viii" accidents in relation to the number of hours flown, the 
c.4n.aUv risk during 1926 was lower than in previous years.” 
It is to be regretted that the actual ratio is not stated, as it j 
would be interesting to compare the figures with tiiosa of other 
countries — for example, those given the U.S.A. ^ Arnjy 
3Iedical Jleport- TJiere were no wounds in action during the 
year, but 14 cases of accidental gunshot wounds, with 2 deaths, 
are recorded. Included in the injuries off duty or on leave 
were 7 cases of attempted suicide, resulting in 6 deaths, and 
S cases of self-inflicted wounds. 


In Chapter III, dealing with the health of the B.AF. 
abroad, an account is given of 1 case of heat-stroke, 5 of heat 
T heat exhaustion. I'iierc were 5 deaths, 

?i RTincipal Aledical Officer there reported 

t lat those of the fatal cases wiiicli were treated for many 
days showed symptoms indicative of toxaemia, and it is possible 
t lat l.iioige of the large intestine with the manganates might 
bo beneficial in these cases.” The withdraw-al of ccrehro-spinal 
lluid and the admimsfr.ation of pilocaii.iiie were ineffective in 
nil aises. 

I Ciiapter ly deals with several miscellaneous subjects. The 
Central Medical Board conducted 2,227 examinations, about 
ono-lialt of winch were of candidates for the various branches 
of the fm-ce, for Hie reserves, tho Auxiliary Air Force, Princess 
Alary .s R.A.I'. Nursing Service, and entrants into the B.A.F. 
Cadet College; the remainder were examinations held on 
serving personnel to ascertain their fitness for dnty and medical 
boards on pensioners. The causes of rejection of candidates 
and the average results of the physical efficiency tests and 
nieasmements in each class of accepted candidate are recorded 
in a scries of most instructive tables. As in previous years, 
the chief cause of rejection was defective vision. Only 53 per 
cent, of candidates for flying duties were accepted." ■ 

There is an interesting account of the results obtained from 
the " flying aptitude apparatus,” which agreed in a remarkable 
way with the assessments made by the flying instructors. The 
apparatus was also found to be of considerable help in detecting 
physical and temperamental defects, whereby unsound pilots 
could be eliminated e.irly, and in testing the' ability of pilots 
to resume flying after minor accidents causing slight con- 
cussion. A new type of ear defender, combined with modifica- 
tion of the standard flying cap, appears to diave assisted in 
preventing deafness due to noisy aircraft. 

At the end of 1926 a thorough medical examination of all 
olficers .“iiid airmen pilots was carried out, and the results are 
shown in four tables; 89 per cent, of officers of the general 
dniics branch were found fit for full flying duties, tlie chief 
causes of unfitness (temporary or otherwise) being medical 
defects and defective vision. 

From the remarks on hygiene we learn that a procedure for 
the selection and recording of suitable volunteers for blood 
transfusion was instituted in order that the least possible delay 
may occur in cases requiring such treatment. In Egypt the 
erection of Paterson’s cliloronomes gave good results in pro- 
viding bacteriologically pure drinking svater. In Iraq 82 patients 
were carried in air ambulances and 48 on aircraft carrying out 
duty trips, the miles, flown being 13,848. At tho various 
pathological laboratories 32,252 examinations were carried out, 
and nearly 40,000 c.cm. of stock vaccines svere prepared and 
issued by the laboratory at Halton. 

The report as a whole maintains the liigli standard of its 
predecessors, and the statistical tables are arranged on the most 
useful lines. Similar tables might be adopted with advantage 
in the reports of tlie other services. A few eri'ors somewhat, 
mar the work, notably colics (sic) fracture on page 6, and the 
omission of several commas in the last two lines on page 34. 


A3IERICAN TOUR OP THE SURGICAL SECTION OF 
THE ROYAL SOCIETY OF MEDICINB. 

As announced in these columns last year, the Surgical 
Section of the Royal Society of Medicine recently under- 
took the organization of a tonr in Canada and the United 
States. Tills, the first attempt of the kind made under 
tho aegis of the society, proved such a success as to raise 
the hope of other similar ventures in the future. 

The party consisted of twenty-five members, seven of 
whom were accompanied by their wives. It was found that 
a group of this size was largo enough to obtain a con- 
siderable reduction in railway and hotel rates, and yet 
was not ctimborsomo to manage. In a tour of this kind, 
in which the stops at tho different places averaged less than 
three days, the mere handling of the baggage of a miicli 
larger party would be difficult, quite apart from otlier 
obvious complications. The travel and hotel arrangements 
were made tbrougboxit by the Cnnard Steamship Company 
and the Canadian National Railway Company; their 
organization Avas excellent, and there Avas no hitch of any 
kind, A courier, provided by tho Canadian National 
RailAvaj', facilitated the details of transportation in oA-ery 
way possible. , , • 

JDr. Franklin Martin, Director-General of the American 
College of Surgeons, communicated with the prominent 
surgeons in each place ou the itinerary before our visit, 
in order that pi eparations could bo made. At every centre 


- ■ ... . . - - .. •' ■ 

'feb. 4, lOiS]”"' ' A SURGICAIi TOUR IN AMERICA, 


I Tnx Cams* 
UroicAx; Jo cKxxa 


187 


tlio local surgeons and the hospital organizations afforded 
the "loup a great 'welcome. First-class prograinincs of 
opcr.ativo work and dry clinic.s— to nsl^ a popular 
Americanism— were organized. Tho hospitality surpassed 
all expectations of a countiy already famous in this respect. 
Not only were the members entertniuod in the clinics and 
at clubs, but the hosts were most helpful and kind in pro- 
viding motor car transport and looking after the comfort 
of tho travellers in every way. 

The party crossed in tho s.s. .-lii.'ioiiin, and landed at 
Quebec on August 29th. Six days were spent in Canada. 
At Montreal Dr. Bazin and Professor Archibald acted as 
hosts at the General and Royal Victoria Hospitals res]>ec- 
tively; and at tho latter ivo wore fortunate in seeing a 
thoracoplasty performed b)- Dr. Archibald. In the evening 
tho party dined at the Mount Ro 3 ’nl Club and mot Professor 
Amistrong. At Toronto we were warmly received by Dr. 
Clarence Starr, and saw Drs. Gallic and Lo Jfesnrior at 
work. An afternoon was spent at tho Toi'onto Kxliibition, 
and on tho following evening some members played golf 
with Drs. Starr and Gallie, tho remainder being entertained 
by Dr. Bruce. 

A visit wiis paid to Niagara before proceeding lo 
Chicago, where, despite our arrival during a week-end 
which terminated in Labour Daj- holida)-, a full clinical 
programme had been organized bj" Dr. Kreuscher, in 
addition to various entertainments. On tho .Snndaj- tho 
part)’ was conducted b_v Dr. Franklin Martin over tho fine 
IMurphj’ jMcmorial, which forms a magnificent addition to 
.the home of tho American College of Surgeons. We also 
saw the new North-Wi'.stern Universitj" Jledical School 
and visited the universih- clinic, then nearing completion, 
m its beautiful surrounding.s in the University Park. At 
Chicag;o the partj- had its first experience of tho intensive 
operating progi'nnimes which our American colleagues know 
how to stage so well. Interesting operations, in whieU 
Dr. kelson Percy, Dr. Eisendrath, Dr. Cubbins, and 
otnors took part, were witnessed at tho Augustana, AVesloy, 
and Cook County Hospitals. Dr. Franklin Martin enter- 
tained the party at Exmoor Country Club on Saturday, 

party was given by Dr. Kreuscher 
at the South Shore Club. J 

n night’s journey tho furthest west point of tho 
in lloehestcr, Minn., ams reached. We spent only 
tao days at the world-renowned Mayo Clinic, and they 
Drs. C. and W. Mayo operated, 
liur interesting tallis, in addition to entertain- 

snmo nir homes. Operation lists, which included 

^nTCft Drs. Judd, Balfour, Adson, 

uathnlnir' ’i "P surgical programme. On the 

rleelT forUiuate in being present at 

Lbertl^n conducted by Dr. H. E. 

wXr n ' ‘‘m Dr. Mann and his co- 

Rochester r ^ Tuesday night tho party dined at the 

w.as enterta^cd by Mr®-- "" Chicago, the pai% 

stockyard and factorv 


-Vt Grand p. "'“j”'-' an interesting experience. ■ 

Ferris Smith Programino was arranged by Dr. 

of the fii sf .. 1 - ® particular interest on account 

Ma^’s Clinks Butterworth and St. 

advanced as auv'+r^t structure and equipment as 
tho eveninn- tl.-^ course of the trip. In 

Medical Society entertained bj- the Kent County 

under the'k'imn- ^ I'eeeption was more than hospitable 
devoted to a v^rPt” Dr. Kelly. Sunday was 
morning was sneni uP D“ke St. Clair. The next 
Ford Hosnital ^ ' Di"- MacClure at the beautiful 

factorv- at Roan-)! n 'P afternoon a tour of the Ford 
aiiqiort and a^t - f^S^t'ior with a visit to the Ford 
plane, made the dnl’ Detroit on a( largo passenger 

and his son ma ^ memorahle. The party mot Mr. Ford 
try their new o ^‘7“ opportunity to see and 

Clinic and Re"eKin„ the following day the Hai-per 
ing, and the Toff Hospital were visited in the mom- 
the afternoon Davis works in 


Tho joiirnoy to Cleveland was made by tho night boat, 
and a very full d.ay was spent with Dr. Crile at his new 
clinic — an operation list of twelve was completed by Dr. 
Lower with characteristic vigour and punctuality hy 
11.30. A number of short papers by members of tho 
staff followed a visit to the experimental department. 
After tea and dinner with Dr. Crile the party loft for 
Baltimore in tho. evening. On our arrival in Maryland 
wo experienced a definite change of atmosphere, touched 
with an agreeable southern flavour; this was emphasized 
by tho fact that tho thermometer rose to 97° F. during 
our stay. 

The programme arranged for us was mercifully confined 
to tho Johns Hopkins clinics. Operations by Dr. Hugh 
Voiing, Dr. Finney, Dr. Dean Lewis, and Dr. Dandy- 
were witnessed, and Dr. Bloodgood gave a demonstration 
of hone tumours and discussed their diagnosis. It was 
delightful to meet the doyen of American surgery, Dr. 
Kelly. Dr. Hugh Young entertained the party at a 
country club in the evening. Some members visited 
'Washington on tho following afternoon, while others went 
to an outlying hospital witli Dr. Bloodgood. 

Philadelphia was unfortunately reached on a Saturday, 
but a full programme was staged. Five surgical clinics 
were in action in the morning in different parts of the 
city. Alost of tho party- visited the Jefferson Hospital 
and watched Dr. Clievalier Jackson and Dr. Gibbon at 
work. Dr. A. Ashhnrst was operating at the Episcopal 
Hospital and Dr. Charles Frazier at the University Hos- 
pital; in the afternoon Dr. John B. Dearer undertook a 
long list at tho Lankenau Hospital. The party was 
entertained at tho Penn Athletic Club in the evening and 
at Dr. Jopson’s home on Sunday. 

Now York was reached on the following day, and 
though three days were at our disposal it proved 
more than usually difRcnlt to make a choice of the 
wealth of clinical material available. Most of tho 
party visited the Post-Graduate Hospital and watched 
Dr. Alheo and Dr. Erdmann. On Thursday Dr. William 
Coley was • visited at the Hospital for Ruptured and 
Crippled. Tho afternoon was most pleasantly spent in 
a yaclit trip up tho Hudson with Dr. George Stewart, and 
it must he admitted that at this stage of the tour most of 
tho party wore ready for a half-holiday. On Wednesday 
an interesting symposium on cancer treatment by x rays 
and radium was given at the Memorial Hospital, and after- 
wards an excuroion was made to the amazing new building 
which is to become tho New Columbia Medical Centre. Tho 
visit of the party to the Rockefeller Institute, where Dr. 
Noguchi and Dr. Eberling gave fascin.ating demonstrations, 
was unfortunately, cut short by the necessity of catching 
a train to Boston. 

. Boston was the last centre to he visited, and most of ns 
felt sorry to have a bare two days to spend in a city of 
such historic associations. Professor Harvey Cushing enter- 
tained ns in the morning at the Peter Brent Brigham 
Hospital, and later tho party went to the General Hospital, 
a pleasant old foundation with modern additions. In tho 
evening we were entertained at Brookline Country Club. 
On tho following day Dr. Osgood and Dr. Ladd gave ns a 
firsteclass clinic in their most delightful Children’s Hospital, 
and subsequently Dr, Lahey was seen operating at tho 
Deaconess Hospital. An interesting diagnostic clinic by 
Dr. Josliii, Dr. Fordan, and others concluded our medical 
experiences. 

The party returned to New York by train, and embarked 
direct on the s.s. Lancastria. All members were tired,^ but 
the infectious enthusiasm of our hosts kept us actively- 
interested from the start to the finish of our journey. Mo 
certainly left America with a sense of having completed a 
memorable and inspiring experience. The whole party- was 
strongly impressed by the high standard of surgery- whicli 
is widely attained in the United States, and was filled with 
unbounded admiration for the energy and organization 
everywhere manifest. From a surgical point of view, in 
the short time at our disposal the able management of our 
hosts made it possible for us to see a great deal of interest- 
ing work, and to obtain an insight into some phases of 
American life. 

C. Max Page. 



188 Feb, ipsS] MVEE TEEATMENT 


Britifi!) illctJical ^owtuaL 


SATUEDAT, FEBEUAET <!Tn, 1928. 


LITER TREATMENT OF PERNICIOUS 
ANAEMIA, 

Six montlis have now passed since the discussion on 
the treatment of pernicious anaemia, at the Annual 
Meeting of the British Medical Association at Edin- 
burgh, drew general attention in this country to the 
liver treatment introduced by Minot and Murphy. 
Since that time the method has been given a wide- 
spread trial in all countries, and although six months is 
too short a period to enable any useful conclusions to 
be drawn as to the permanence of the good results 
obtained, the immediate results tend to confirm Minot 
and Murphy’s observations in a most satisfactory 
manner; and there is general agreement that, putting 
it at its lowest, the liver treatment produces effects 
incomparably better than any previous method. At 
the Edinburgh meeting mention was made of a liver 
extract prepared by Cohn of Harvard wliich had 
given very satisfactory results, and several extracts 
have now been made in this country, either by Cohn’s 
original method or by some modification. Unfor- 
tunately, work in this respect is hindered by the fact 
that there is no experimental method of testing the 
potency of an extract other than by giving it to a 
patient with the disease; nevertheless the work goes 
on apace, and we may hope to have an extract 
available for general use before very long. 

It is therefore of great interest to read the detailed 
observations on the use of liver and liver extracts 
which have been carried out at the Medical Unit at 
St. Bartholomew’s Hospital, and described by Pro- 
fessor Francis Fraser in a communication with which 
he opened a discussion on January 23rd at the Medical 
Society of London. The paper by Professor Fraser and 
his colleagues is printed at page 165 this week, and 
the discussion is reported at page 178. The results 
appear to be equally good whether the liver is given 
in the fresh form or as an extract; and this is for- 
tunate, for with the present methods of preparation the 
extract must necessarily be a costly substance, and 
its use will probably be restricted as yet to experi- 
mental work and to special cases in which it is difficult 
to get the patient to take an adequate quantity of 
whole liver. The number of failures so far reported 
is comparatively few; in a series of 19 Professor 
Fraser records two patients w'ho showed no improve- 
ment. In such cases Minot suggests that in all prob- 
ability the diagnosis is at fault, and Professor Fraser 
admits this possibility, although in his cases no alter- 
native diagnosis could be arrived at. In view, how- 
ever, of our complete ignorance of the way in which 
the liver acts it seems unnecessary to demand 100 per 
cent, of cures, and all are agreed that it is desirable 
to combine with the liver diet such other remedial 
measures as past experience has proved useful. 

As was natural in view of the dramatic results with 
pernicious anaemia, fiver diet has also been tried in 
cases of secondary anaemia. Here the results are 
more conflicting and the evidence less satisfactor 3 ’, 
but Professor Fraser reports that his observations con- 
firm the American opinion that no beneficial results 
accrue. This has occasioned some surprise in view of 


OF PEnNicioicr's ANAEArrA, 

■ L MlCMCAt JoCB-Tlt 

the fact that the use of liver was originally suggested 
in p.iit liy Whipple s worJi on dog.s rendered anaeniic 
by bleeding; but it now nppeqrs probable that in these 
experiments the beneficial elTect of the liver is due 
solely io its influence on haemoglobin regeneration, 
w'liereas in pernicious anaemia the effect is on the 
development of the red cells, an entirely different fiver 
product being responsible in the two cases. The work 
of Peabody on the histology of the marrow during 
Ircntmont with liver, talfcn in conjunction with the 
researches of Doan, Cunningham, and Sabin on the 
normal development of the red blood cells in the 
marrow, seems to show conclusively that the megalo- 
blnst of pernicious anaemia is not an embryonic cell 
more or less peculiar in adult life to patients suffering 
from that disease, but that it is n normal progenitor of 
the adult red cell present normally in the marrow; and 
that its appearance in largo numbci's in the marrow, 
and in smaller numbers in tlie blood, in pernicious 
anaemia is due to the absence of some factor neces- 
sary for the proper maturation of the megaloblast into 
normoblast, and that this factor can be supplied by 
liver diet. If this bo so it affords strong support to 
the view, now largely denied, that the haemolysis so 
characteristic of the disease is not the primarj^ blood 
lesion, but a secondary result. 


BIOOHEmCAL PRODUCTS. 

We have often felt obliged to call the attention of our 
readers to the fact that very few synthetic drugs of 
importance have been discovered in this country, and 
that in consequence Britain has contributed very little 
to the advance of chemotherapy. For this reason it 
was particularly pleasant to read the recent tribute 
by Mr. A'. M. Samuel, now Financial Secretary to 
the Treasury, to the distinguished part that British 
research workers and chemical firms have played in 
the development of the newer science of biochemistry.^ 
The contrast between the position our country occu- 
pies in chemotherapy and in biochemical therapeutics 
is indeed remarkable. Germany led the discovery of 
synthetic remedies si.xty years ago, and that lead she 
has maintained ever since, as is evidenced by the 
large series of synthetic drugs of German origin, which 
beoan with chloral hydrate and the coal-tar anti- 
pyretics and is being continued by such recent addi- 
tions as’ Bayer 205 and pjasmoquine. The British 
discoveries in this field are negligible when compared 
with the German list; but, on the other hand, in the 
production of therapeutic agents of biochemical nature 
our country has played a very distinguished part. 
This is particularly true in the case of endocrine secre- 
tions and vitamins. Most of the outstanding pioneer 
work in endocrinology was done in this country— as 
for example, the work of Horsley on the thyroid and 
of Schafer on the pituitary and the adrenals— while 
H"rington’s synthesis of thyroxine is an example of 
an important recent advance. Similarly, the science of 
vitamins (if the phrase may be used) was very largely 
orisinated by the fundamental work of Hopkms, and 
thif science Ls been developed chiefly in Great Britain 
and in the United States. The history of the dis- 
covery and exploitation of synthetic dyes is a remmder,' 
somewhat melancholy for us, that a discovery may be 
made in one country and that another country may 
reap all the benefits accruing from its commercial 
exploitation. Fortunately, this history is not being 
repeated in the case of biochemical products, 

Mr. Samuel pointed out, British chemical industry 

^ rime#, January 26th, 1928. 





190 Feb. 1928] 


FTTERFFRAri MORBICITF' AND MORTALTlTr 


• TirrBnmw - 

itnncAt, JoCT.xii 


America encom-aging results arc reported by Tunnicliff 
and Hoyne^’ in the use of goat’s serum immunized 
with tho gronn-producing measles diplococcus; more 
recently in Italy Pontano and Alba'* have obsei-ved 
that normal horse serum is ns effective ns convalescent 
scrum. Should, therefore, a relinblo animal scrum be- 
come established and be put upon the marlcet, many 
difficulties in tho collection of convalescent serum, 
and some of tho popular prejudices against it, would 
disappear. In tho meantime, however, further expe- 
rience in the efficacy of convalescent serum and of 
the attitude of tho public in this country towards its 
employment seems desirable; for this purpose it is 
necessary that larger supplies of serum should bo 
available than at present seems to be the case. 1 


PUERPERAL MORBIDITY AND MORTALITY. 

Tnn special committeo which was set up hy tho Council of 
tho British Medical Association in July, 1025, to “ consider 
and report on tho causation of puorporal morbidily and 
mortality and on tho administrativo action, if any, that 
should ho taken in connexion with tho matter,” decided 
early in its deliberations that when its inquiries had reached 
a certain stage it would bo very helpful to call a conforcnco 
of various bodies interested in tho question with a view to 
obtaining suggestions as to what should bo done to reduce 
tho maternal mortality and morbidity rates in this country. 
The conference, which is reported at page 33 of tho 
Sotplement this week, took place at tho Association’s 
House in London on January 11th. Tho following bodies 
wore represented: Ministry of Health, Scottish Board of 
Health, Jledical Research Council, Royal College of 
Physicians of London, Roj'al College of Surgeons of 
England, Royal Society of Jlodicino, Central Midwives 
Board, Society of Jlodical Officers of Health. Several 
very interesting papers were read, and a general 
discussion followed. Tho committee’s next step will bo 
to review the suggestions for action which have been 
put forward before it draws up its final report. Tho 
great success of tho conference shows how widespread is 
tho interest in tho important questions at issue, and how 
keen is tho desire on all hands to find some means of 
diminishing the present mortality and morbidity of child- 
bii'th in this country. 


SOME SEVENTEENTH CENTURY COMMONPLACE 
BOOKS. 

A rAn.\onAPH in tho Times recently announced tho intention 
of the Council of the Medical Society of London to sell tho 
so-called diary of the Rev. John Ward, which has been 
in the society’s possession for many years. This curious 
manuscript work is contained in sixteen leather-bound 
duodecimo volumes, and consists of notes on all sorts of sub- 
jects, taken from time to time during tho years 1647 to 1673. 
They would be more accurately described as table books, or 
commonplace books, than diaries. Tho prevenance of these 
volumes is obscure; indeed, nothing is known of their 
history befoi-e the year 1839, when tho then registrar of 
the society. Dr. John Soveni, published an incomplete 
account of them under tho title Diary of the Dev. John 
Ward, A.M., Vicar of Stratford-upon-Avon. The volumes 
were more fully described by Sir D’Arcy Power in 1916, 
when he made them the subject of his presidential 
address to the society, after having read through the 
whole of them. Dr. Severn tells us that they probably 
formed a part of the library of Dr. James Sims, who 
v-as president of the Medical Society for tho long term 
of twenty-three years, to the great dissatisfaction of a 
nnmher of the Fellows, which finally found expression in 
and tho foundation of the Medical and 


11 

S.nnali 


Infect. Die., 1925, xxxTlll, 48. 
nlgxcne, August. 1S27. 


Chirurgical Society, tho parent of tho present Royal Society 
of Medicine. John Ward was tho son of a Northampton- 
shire gentleman, also . named John, who .served on tho 
King's side in tho civil war. Tho notes begin in tho year 
1647, when Ward was an undergraduate at Oxford, 
probably' at Christchurch. Ho seems to have been more 
interested in medicine than in divinity, and besides taking 
an arts degree ho became, as Sir D’Arcy Power thinks, 
a recognized student of medicine in tho University. In 
London ho attended lectures at Barber Surgeons’ Hall, 
and, in fine, his studies wore such as to have fitted him for 
on M.D. degree and tho Membership of tho College of 
Physicians had ho decided to adopt tho medical profession. 
Theological questions do not seem to have had tho same 
interest for Ward as did therapeutical and pharmaceutical. 
It seems probable that, despite his father’s loyalty, he was 
in sympnthy with tho Parliamentarians and with tho anti- 
prolaticnl clergy who were in office in Oxford during his 
residence there. If so, wo can easily understand that he 
was glad to accept a country-town living after the Restora- 
tion, which was to -sot back the clock of scholarship in 
Oxford for a century. It might be hoped that in thecommon- 
placo books of a vicar of Stratford, dating from the year 
1662, less than half a century after Shakespeare’s death, wo 
should find much Information about tho poet. Unfor- 
tunately, Shakespearean notes are remarkably few, the 
only outstanding statement being that which attributes his 
death to a “ feavour,” tho result of a carouse with Drayton' 
and Ben Jonson. This entry is the solo authority for that 
account of tho groat man’s end, which has been so accept- 
able to tho Baconians. There appears to bo scant reference 
to Shakespeare’s son-in-law. Dr. Hall, who practised in 
Stratford. Possibly tho medically minded ■vicar and tho 
orthodox physician did not got on together, for even in 
these enlightened days tho clerical dabbler in medicine is 
not always on good terras with the local medical practi- 
tioner. Ward died at tho age of 52 in 1681. Sir D’Arcy 
Power says ho has ” little doubt that he was ruptured 
and that ho died of phthisis.” For a fuller account of his _ 
life and opinions and e-xpcriences we recommend the 
extremely interesting paper of Sir D’Arcy Power, above 
referred to. It is styled “ Part I,” and professes to deal 
with tho first six books only. We sincerely hope that the 
author may find time and opportunity to complete his 
study. Industrj', judgement, and erudition are never 
lacking in him. The Medical Society hopes to sell these 
books °for a good round sum, which will be spent in 
rebinding and caring for the other 25,000 works in its 
library. °It scorns likely that there will be keen competition 
among buyers when they appear in tho sale-room. 


encephalitis lethargica and crime. 

IE deplorable effects on character and conduct which so 
ten result from an attack of encephalitis lethargica, and 
e especially prone to occur in adolescents, are now widely 
alized. In was, indeed, bn account of such Bufferors, 
lose criminal conduct was clearly the outcome of this 
sense, that thb recent amending bill 
3 fioioncy Act of 1913 was brought forward. With the 
iect of dealing more effectively and more humanely nit 
ung persons who were really irresiionsible because _ they 
,d had this disease, but who were neither technical y 
sane nor technically mentally deficient (“"’"’.S’ i“ 
iter case, to the mental defect not having existed f 
rth or early J^ars), the amending bill f 

0 previous statute so as to there- 

of hlgfinSeStt^^to^^^^^^^^ :;\?:blvLns made on 
i, b. Dr. G. B. 


Fck 4, 1928] 


THE PSi’CnOLOGT OP ACCIDENT PBE7ENTION. 


r Tira Bnmsa 

MZDrOAZ. JCfV^VAX, 


181 


vear 1926.* ■ Careful inquiries,, covering a period - of- two 
jears, wcro niado of tho prison medical officers. In that 
period no instance of tho onset of encephalitis lethargica 
occurred duviug detention in prison or in a Borstal institu- 
tion. Sevonty-tvro cases of encephalitis lethargica woro 
notod, amongst remand and convicted prisoners (65 males 
and 7 females). Tho method of classification adopted was 
tho relegation of cases into throo groups — definite, probable, 
and suspected. Those cases were regarded ns “definite” in 
which tliero was a clear history of an attack of encephalitis 
lothargica, or wlicro tho subsequent condition was typical. 
Tho group of “ probable ” eases comprised those in which 
tho liistory of tho original attack was indefinito, but 
whoso mental -and physical condition left littlo room for 
doubt that an attack of encephalitis lethargica had 
occurred. Tho “ suspected ” cases wore those in which tho 
occurrence of any illness of tho nature of encephalitis 
. lethargica could not bo traced, hut whore tho patient’s 
condition, personal history, and conduct distinctly suggested 
that there had been an attack of tho disease. One-half of 
the 72 cases abovo referred to were “ dcfiuito ” cases. Tho 
“ prob.ablo ” and “ suspected ” eases together made up tho 
other half in ' about equal proportion. Of tho whole 72 
cases 54 showed no harmful effect as tho result of imprison- 
ment; - iudeed, some ;Wcro definitely improvc<l. Ono was 
insane on admission, and ono reported to tho court ns 
insane. Tho remainder either detcriorntod or received no 
benefit from imprisonment. Tho disposal of tho cases is 
interesting. Twenty-fivo woro discharged at tho end of 
sentence, 11 remained in custody, 8 were bound over and 
placed on probation, 8 discharged at court, 7 certified under 
t o Mental Deficiency Act, 1913, 6 sent to parents on 
• ^ certified insane, 1 absconded from a Borstal 

institution, 1 went to tho caro of a Borstal institution, and 
1 rctMcd to his former omploymont. Dr. Griffiths points 
oil at only in 53 out of tho 72 cases did the attack of 
weep la itis occur before tho ago of 18 years, so that about 
® y could possibly have como under the 
6ill of 1927, which proposes to 
, , ® mental defectiveness” as a condition existing 

also insists on tho 
IbH, recognizing that tho nftor-offccts of encephalitis 

of intensity, and that tho 
Bni-iw t? n previous attack of this diseaso is not neccs- 
cr^al acts couscquonces of his 


A Lilop ^ accident prevention. 

on January" wtr" “a "'o® 6eld in Londoi 

Welfare under tho ausijices of tho Industria 

vontion - consider tho subject of accident pro 

phrase “eft f'ho way, that tho well won 

other expression m ^ dropped in favour of somi 

" accitot prevention"”"- 

attended bv r TJ*° conference, which wai 

films in the ' of many of the most importani 

industrial safrt""l"^’ J-J*® whole conception o: 

rimy bo possibW on to a now plane. Just as ii 

to insure too h ""1"^ Porson to over-insuro himself — that is 
-so it seems "rssfbk "S^inst risks which are too remot. 
safeguard its em 1 ^ factory or works to over 

means of nrote t- fiaduo elaboration of raechanica 

proof,” whilo t ““d J;h0 rendering of operations “ fool 
that they conducT ♦ others, ii 

P'hich wio t, ^ ^®ry carelessness in the workei 
'afoguardkn t " ^ The rea 

of tho emnl iv" ™ach in appliances as in the educatioi 
the mechanism"ho bn intelligently appreciat 

— has to dea l with, its relation to the who! 

3003. Loadon : H.U. Stationery ODlca. 1928. 9d. net. 


process - and routine of tho factory, and the risks involve^ 
through inattention or misjudgement. The first line in 
tho prevention of- accidents, as one of the speakers said, hi 
to strive for tho co-operation of everyone in the works. 
A\'hntovor cynics may say, it is often possible to make more 
impression on a man by appealing to him as a member of 
a team than as an individual. There are many who, 
although apparently they gfko no thought to their own 
safety, can be induced to co-operate with their fellows if 
they know that their thoughtlessness or carelessness may 
involve injin-y to others and discredit to their department, 
Tho wlucation which is the basis of safety can be imparted 
by tho direct instruction of apprentices or of men on 
their engagement, and by the safety discipline in the works, 
Something can also be done by pictorial examples and 
warnings, though one speaker at tho conference referred to 
somo lurid posters, making a crude appeal to fear, which 
are used for this purpose in foreign countries, and said 
that in Great Britain such methods would be more likely 
to offend than to instruct. Tho conference itself was an 
evidonco of the strength of this voluntary movement in 
industry, and the view was expressed by tho president, Lord 
Invernairn, that if the Home Sccretai-y were made aivar^ 
of the progress now talcing place he would- hesitate before 
introducing legislative measures, as he ■ had suggested 
doing, which might- jeopardize the ground already won. 
It seems to us that there is a good deal to be said for this 
view. 


LISTER IN GLASGOW. ' 

Duhino tho Lister centenary celebration in London last 
spring many notable addresses were delivered conveying 
profound truths and interesting reflections, but in tho 
rush of such a crowded -week not all these obtained the 
prominence which was their due. In an annotation in the 
Journal of April 16th, 1927 (p. 733), we gave a vei-y short 
report of the address delivered at the opening of the Lister 
exhibition at tho Wellcome Historical Medical Museum in 
London by the Regius Professor of Surgery in the Univer- 
sity of Glasgow, Dr. Ai-chibald Young. The full text has 
recently been published in the pages of our Canadian 
contemporary,* and is worth reading. On tho four 
hundred years old roll of the University of Glasgow, as 
Professor Young said, no name outshines in brilliance that 
of Lister. It is true that he was not an alumnus of 
Glasgow. He stopped straight into the regius chair from 
his comparatively subordinate position in Edinburgh, and 
London will not forget that she nurtured him and gave 
him his early training in science and art. But the rising 
medical generation in Glasgow- who wero his students 
soon recognized what a priceless boon fortune had given 
to them in their professor, and they took him to 
their hearts as warmly as though he had been bred 
and born a Western Scot. Their affection took tho 
practical form of a testimonial in suppiort of Lister’s 
candidature for tho post of surgeon to tho Royal 
Infirmary, and Professor Young is justly proud of the fact 
that among the 161 signatures the names of his uncle and 
of his wife’s uncle can be read to-day. Although Dr. 
Young is able to show that the students at Glasgow warmly 
welcomed his teaching, ho cannot deny that tho lay 
managers of the Royal Infirmary were ignorant of the fact 
that they had entertained an angel unawares, for as late as 
1870 they indignantly denied that tho improvement in the 
healthiness of their wards was due -to Lister s antiseptics, 
attributing it rather to improved ventilation, for which -- 
they took credit to themselves. A comparison between 
Lister’s wards and those of other surgeons tells a very 
different tale. The convincing statistics of the mortality 
after operation in the pre- and post-antiseptio days which 
^ Tha Canadian Jfedical Aisociation Journal, 1927, xvii, 1264*1278 (Part 2). 


192 Feb. 4, 1928] 


a?EACHlNO OF HYGIENE TO CHIEDEEN. 


[ TiicHrmsa 

McbtCXI. JotTBSUt 


iii'o quoted by Profcs'.ov Young nvo, of course, not new, but 
tbo rising sui-gic.il generation needs to bo told and retold 
from wbnt a bondage Lister delivered the surgeon and liis 
patient. In bis oi'ation on Sir ‘William Jfaeewen, bis pits 
decessor in tho regius ebair at Glasgow, I’rofe.sMir Young 
pointe'd out tho great services Macewen rendered to anti- 
septic surgoiy, and, later, in the evolution of aseptic 
Etirgerv. Macovren bad tho* stroug, self-reliant person- 
ality of ono who, himself convinced, takes liltlo heed 
of tho projndices or hesitations of tho unconvinced and 
wavering. As Huxloy was the " bulldog ” of Darwin, 
so was Macowen ipso Listoro Listerior,” as was .said by 
Sir William Gairdncr. That is truo of Lister’s discovery 
or evolution of tho antiseptic principle which is true of 
other discoveries, '\^’hcu their histories como to bo written 
it is found that before tho groat rovclation was made 
various workers have corao near it ■without making it 
known or accepted. It is as though tho wayfarer .should 
notice a precious object by tho roadside, which another 
perhaps might pick up and throw away again, and so on 
until there comes ono who not only jiicks it up, but recog- 
nizes its raluo and usefulness, and devotes it to the use 
or ])1i‘asuro of his fellows. Professor Young reminds tis 
that Semmelwois recognized tho infectiousness of puerperal 
fever (ho might have added that Oliver Wendell Holmes 
did tho liko independently), that Lemairo in 1863 advocated 
tho nso of carbolic acid for tho destruction of germs in 
wounds, and that Bottini did tho liko in 1866. Thus tho 
stage of knowledge had been roacl’od which made tho 
explanation of tho cause of suppuration likely to bo found, 
but Lister alone possessed and used tho training and tho j 
qualities which enabled him to reach tho goal, not by a j 
hnp)n’ accident, but by a coherent process of laborious 
experiment and sound reasoning. The discoveries of 
Pasteur were open to all. Ono man applied them to tho 
service of surgery, and Hint ono was Joseph Lister. 


. Permanent Secrctaiy to tho Board of' Education, says in 
j his prefatory note that “ .1 knowledge of its contents 
^ should bn regarded ns pni-t of the iicccssaiy equipment of 
every teacher”; and Sir George Newman begins bis 
introduction with the statement that “the lioaltli and 
• well-being of the child is the prininn' foimdatioii of its 
education, ’ and goes on to point out that “ the purpose 
and object of hvgicno and jihysienl training in schools aie 
not only to improve the physical condition of the children 
and to secure the full development of their health and 
Rti*ength, but aho to-aid in the dcA'clopmcnt of theii' mental 
powi-rs and in the formation of diameter.” Tlic instruc- 
tion of school children in hygiene is nccessaiy not only 
for adequate individual education, but for the national 
health. “ It is the neglect of hygiene which costs a nation 
dear. It is the inhibitions and restrictions of ignorance 
in a right way of living which impose upon Great Britain 
much of its annual burden of disease, its millions of weeks 
of lost time owing to sickness, its numerous lunatics, 
deficient persons, and dullards, and its vast comjmny of 
those who exist and toil far below norma] health capacity 
and contentment.” Tho main body of tho handtiook is 
divided into two parts, the former being entitled “ Subject 
matter for health practice and health talks for young 
children,” tho latter “ Outlines of hc.alth lessons for older 
children.” This division emphasizes the fact that habit- 
training is of even greater moment than theoretical instruc- 
tion. The syllabus and notes on lessons are not intended 
to be followed slavishly by tho teacher, nor need hygiene 
bo treated as a separate “ subject ” in every time-table. 
Tho requisite instruction can well be associated with that 
given in many other subjects. Tlie essential thing now is 
that in tho areas of all education authorities every child 
in the public oloinentary schools shall, in the course of its 
scliool life, receive instruction in accordance with this, or 
sonic equivalent, syllabus; and wo suggest that such instruc- 
tion is equally important, and often equally lacking, in 
tbo secondary as in tbo primary sciiools. 


THE TEACHING OF HYGIENE TO CHILDREN. 

Tiin handbook of suggestions on health education for the 
consideration of teachers and others concerned in tho aork 
of public elementai'y schools, tho issue of which wa.s 
referred to as imminout in tho note on “ Health and 
education ” in last u'oek's Joujin.\I/ (p. 149), has now been 
published by the Board of Education. The handbook is 
valuable in itself, and is important as marking, ono may 
hope, a further advance, officially encoiu'aged or even 
insisted upon, in the instruction of school children in 
personal and domestic hj-gieno. Such instruction, together 
ivith that in the other subjects of the school curriculum, 
has long been one of tho requirements set out by' tho Board 
of Education in its Code. Many education authorities, 
however, have either neglected it altogether or have not 
given it due emphasis. Sir George Newman, as Chief 
Medical Officer to the Board, is alive to this, and evidently 
has the support of the Board in his lu-esent endeavours to 
remedy such an unsatisfactory state of affairs. In April 
last there was published a revised and enlarged edition of 
tho Board’s Handbook of Suggestions for Teachers, a most 
interesting and valuable handbook for many others besides 
those engaged in teaching. In this was included a chapter 
on “ Physical training,” hut only two short paragraphs 
on “ Health education ” were inserted, in view of the 
early issue of tho supplementary publication now under 
notice. This small handbook’ is intended to indicate, 
not that health education is of minor' importance, hut that 
it is fuudameutal and all-important. Sir Aubrey Symonds, 

• nantJbooJi of Sufjgcstions on Health Education for the Consideration of 
Tf-nchers and others concerned in the JJ’orl of Public Elementary Schools. 
Board of Education- London : H.3I. Statioaerv Office. 1928. 6d. net paper 
covers; Is. net cloth bound. 


hospitals AND ROAD ACCIDENTS. 

Fob some fow years, since tho heavy increase in motor 
traffic on tho roads, a sense of dissatisfaction lias grown uj) 
at the burden tliat the numerous road accidents have 
thrown upon tbo vplimtaiy hospitals all over tho couutiy, 
and especially upon those situated at points of inter- 
communication. However careful and natchful drivers 
mav bo, however skilful they are in handling their cars, 
accidents will happen. Crossings, bends, uncertain lighting, 
a rain shower on a smooth icy surface, an unexpected 
failure of roachineiy— any of these may precipitate a 
situation of omergency from which thoro will not invariably 
be escape. At the timo of the accident there will always 
bo an urgent desire to bring succour to the injured, and 
most Bud this can best ‘be done by tbo speedy tr.ansfor 
of the sufferer to an organized hospital. Usually this is 
tho voluntary hospital, and it is to this that Good 
Samaritans turn at the moment of the accident. These 
hospitals have not been found wanting in tho past, and 
wo are certain they will not be found wanting in the 
future. But if the hospitals and their medical staffs aro 
not behindhand in their response to these omergency calls 
on their resources and skill, there is a definite want of 
response on the part of those who are most directly involved 
in the consequences of these accidents. The sulfoier may, 
as an injured person, be ruled out until he is m.adc whole 
again, but then neither ho. (with honourable exceptions), nor 
his kin, nor tho insurance company that pays for the 
mending of his broken car and meets other liabilitic.s atten- 
dant upon tho accident, make any attempt to shoulder an 
honourable responsibility for tbo cost of tho services 



DIPHTHERIA IMMUNIZATION ; THE QUEENSLAND FATALITIES. 


193 


FEB. 192S] 


rendered by tbo hospitals. They avo not liko tho Good 
Samaritan, who not only put his own beast, his oil, and Ilia 
wino at tho service of tho injured wayfarer, but took him 
to tho shelter of tho inn, and there niado payment of the 
charges for tho caro of tho stranger, with a promise to pay 
what more might bo needed. On tho contrary, they rush 
tho injured to tho hospitable shelter of tho liospital, and 
forget to pay or oven to iiromiso to pay. Truly a strange 
sense of charity 1 Tho costs of these services to aufferora 
from motor accidents aro mounting np seriously. They are 
involving these charities and their geuorpus suppoi-tera in 
exponscs that voluntary hospitals wore never intended to 
bear. Most of them aro purely local institutions, kept up 
to meet tho needs of their districts, and their funds aro 
diverted to tho caro of. strangers from afar, whoso treat- 
ment is lengthy and costly. Tho position of governors of 
theso hospitals has been brought to public notice on many 
occasions of late, but so far no steps have been taken to 
deal justly with tho situation. Tho letter of Sir Duncan 
Kerly, chairman of tho Purlcy War ^Memorial Hospital, 
which appeared in tho Time!: of Monday last, is a proper 
reminder that tho need is urgent for a speedy considera- 
tion of the claims of the hospitals and of their staffs. His 
letter is tho more timely since, but a few woolcs ago, a 
magistrate cast reflections upon tho charge mado by a 
hospital for services rendered that were, to say tho least, 
most unfortunate. Wo do not ])iotond at tho moment to 
enter into any discussion of tho legal position of such 
claims for reimbursement of costs to hospitals and of 
remuneration of their staffs, but in equity thoro can bo 
no manner of doubt that such claims aro in ovei’y way 
justified, and should bo mot. It is high tiino tho insurauco 
companies took stops to amend their policies. 


DIPHTHERIA IMMUNIZATION: THE QUEENSLAND 

• fatalities. 

E ustralian Government has appointed a strong medical 
oormission to inquire at onco into tho causo of tho deaths 
0 children and tho illness of several others which 

oMuue in Bundaberg, Queensland, during an anti- 
ipi leria campaign. It is not quite clear from tho cables 
'"jetted. “ Scrum ” is mentioned, 
ntlio.. Pbraso “ antidiphthoria inoculation ” and 
tinr appears possible that active immuniza- 

anH f'"5 performed with toxin-antitoxin mixture, 
recor(fp^*^r*t’ “ acute toxaemia ” has been 

tint 1 "u tlio victims. One message states 

Jannrr^m Sa 

from +!, . ‘’t "> because on the earlier date material 

If tlm ° f""'® atch had been injected without harm, 
■tt t!io mixtures during ' 


this 


to bo 


frozen and thawp,r“+r‘*^ happened 

toxicity described n 

Mr. A T Glenn "ocurring under these conditions by 
.... _ 1 enny. Active immilnizntinTi n hplTio- emnlnved 


a lareo smU i. immunization is being employed 

Encland „-i, ' n ^ laany medical officers of health in 
keen interest '"ti,”'* c^plan.ation with 

tho uso of toxin ■^"®‘'"P®"blc Substances Act permits 
reduced to a lo ■ i ° toxicity of which has been 

thcria antitoxin^”^ • "bemical substances or by dipli- 
mixture as a'dont d °^'‘®'' "’ords, it allows toxin-antitoxin 
Queensland, toxohl '^f'’'®" ""tl "PP"rc"% m"P'oy®'l i" 

by the action of .-u ]. deprived of all toxicity 

America. 00^ — as used in Europe 

by the Welle ^ ^ toxoid-antitoxin mixture issued 
which, we eatb™”^ bysiological Research Laboratories, 
tho one upnornii ’ Clraliam Forbes’s report,^ 

England. Dr. R.'A. O’BH 


IS 

len® 


^Medicar'’ ^ ' ^’allace : Journ. Path, and Pact., 

‘ Lancet, Eeport Series, No. U5, 1927. 


states that tlio toxicity of English mixtures has always 
been below tho level permitted in tho United States of 
America, and that five times the human dose does not 
kill guinea-pigs within fifteen days. Tho employment of 
toxoid and nob toxin in tho mixture used in England 
appears to afford a wide margin of safety against the 
distribution of toxin in error for toxin-antitoxin mixture, 
a mistake which, it is stated, caused the Austrian accident, ■* 
or tho separation of toxin from tho antitoxin in a toxin- 
antitoxin mixture which camsed paralysis in Concord; 
Massachusetts (1924). Tho exhaustive tests to which 
material employed in England must be submitted are set 
out in detail in tho Regulations under tho Therapoutio 
Substances Act. Wo think that tho confidence of medical 
officers in tho toxoid-antitoxin mixture need in no way be 
disturbed, and that the Queensland experience has provided 
no reason for any abatement of the work in progress here. 


EARL HAIG. 

Tnr. sudden death on January 2t,'tli of Field-Marshal Earl 
Haig is deplored bj* the medical profession in common 
with all classes and sections of the British people. 
Throughout tho war he was a good friend to. the medical 
services under his command, and his devotion then to the 
welfare of the sick and wounded soldier, and later to tho 
men broken by tho war, became almost a byword. Lord 
Haig was present at tho dinner on June 8th, 1920, given 
in appreciation of the services of the Army Medical Depart- 
ment and of the eminent civilians attached to it during 
tho war, and his moving speech has not been forgotten 
by those who heard it. In a few words, spoken with 
obvious sincerity, he thanked the R.A.M.C. and its civilian 
colleagues for all they did to help in winning the war, 
and said it was impossible to exaggerate the country’s debt 
to them. He recalled the work of the attached medical 
units when he commanded tho First Army on the Aisne; 
their conduct, ho said, was perfectly splendid, so unselfish 
and devoted. Some leaders like himself, wdio realized that 
the success of the army depended very much on an efficient 
medical service, viewed with misgiving the difficulties conse- 
quent upon its great expansion, but as the army grew the 
medical service grew with it, and remained throughout its 
multiplication thoroughly efficient. The problem which tho 
Eci-vico had to deal with was huge, but everything worked 
smoothly. All ranks showed devotion and gallantry, alike 
the regimental medical officers, the field ambulances, and 
the medical corps of the Dominions. Tho Field-Marshal 
ended his soldierly speech with a tribute to the good 
feeling and confidence that existed between the fighting 
portion of the army and their medical comrades. As for 
tho civilian doctors, their untiring zeal was, he said,; 
beyond praise — " all alike played the game as men.” 


In celebration of the bicentenary of John Hunter’s birth',; 
the Royal College of Surgeons of England will give an 
afternoon reception at the College on Thursday,, February 
16th, and at 5 o’clock Dr. G. C. Peachey will deliver the 
Thomas Vicary Lecture on “ Tho homes of Hunter.” 


The next social evening of the Royal Society of Medicine 
will be held in the Society’s house, 1, 'Wimpolo Street, 
MM, on AVednesday, February 15th. The guests will bo 
received at 8.30 p.m. by the President and Lady Berry,- 
and at 9.15 p.m. Colonel W. P. Mac.Arthur will give an 
address on “ Some medical references in Pepys.” Tho 
library will be open, and various objects of interest wiU 

bo exhibited. ^ 

* British HTgnir.AL JottrkaL, 1925, October 24tb, p. 757. 



194 Feb. 4, 192S] 


. SGOTJCiAND, 


[ Tre Dfimn 
Medical Jotr*5Afc , 


^rotlnitir. 


HiM.TJi Or Gi.asgoip. 

Tin; ropni't 011 tlio Iii'nllh of Glnsgoir for tlio past year ivas 
suliiiiittod Jnst ivcok by J)r. A. S.' M. Maegregor,* M.O.H. 
for tlio city, to a sulicominittoo of tlio coqioratioii. It is 
aniiounecil that the death rate of 13.7 per 1,000 for lastj’car, 
whicli is tho same as that for 1023, is tlio lowest recorded 
for tho city. Tho miinbcr of doatlis reported was 15,437. 
Tho hiennial epidemic of measles had spread with more 
than ordinniy raiiidity throughout tho cit3’, and tho winter 
provaloiico of acute pneumonia began to he felt during 
October, about six weeks earlier than usual. It is pointed 
out that the principal causes which influence vital statistics 
aro tho diseases which attack the respiratoiy organs, such 
as pneumonia, influcnr.a, measles, and whooping-eongh. 
There had boon no case of tj’phus fever nor of small-pox, 
and no outbreak of encephalitis Icthargica during tho year. 
Scarlet fever also had not been so prevalent as in the 
previous year, and the death rate from this causa had been 
onh' 39 per million of the population, as against 81 in the 
previous j-ear. Diphtheria, on the other hand, had been 
unusuallj' prevalent, but the death rate was onl3’ 99 per 
million, ns compared with 120 in the preceding year, rrhen 
the disease had been of a more serious t3-pc. The do.atli 
rate for whooping-cough had been 323 and for measles 272 
per million. Acute pneumonia had been responsible for 
2,365 per million, or one-sixth of the death rate, and its 
ihief \-ictims were old people and tho very 3-oung. With 
regard to tuberculosis of tho lungs tho death rate had been 
540, compared with the higher figures of 861 and 922 per 
.nillion respectively for the years 1026 and 1925. This 
year’s figure was thus the lowest recorded. Tho infant 
mortality had been 107 per 1,000 births, and child life 
had been adversely affected by the measles and pneumonia 
during the latter part of tho 3'oar, as well as by whooping- 
cough in the earlier montlis. Tlio births registered had 
numbered 23,585, which was equivalent to a birth rate of 
20.9, compared with 22.1 and 23.2 for 1926 and 1925 
respectively. 

Health axd HyoiE.vE ExatatTiON - at Entx-ntmen. 

Lord Provost Stevenson, on January 25th, opened the 
Municipal Health and Hi'gione Exhibition in the Warcrley 
Market, Edinburgh, which had been organised 113- the 
Public Health Department of the city. Sir John Gilinour, 
Sccretaiy of State for Scotland, who was to have performed 
tho opening ceremon3’, was unavoidahl3' absent owing to 
Government business. Councillor Given, convener of the 
Public Health Committee, presided, and said that tho 
purpose of the exhibition was public health propaganda. 
The cult of fresh air, sunlight, and good food, well cooked, 
was being constantly preached, and the resources of the 
Public Health Department had here been massed in oi'der 
to demonstrate these things. Tlio exhibition took in 
practical^ every actii'ity of the Health Department’s 
work, and the corporation expressed its appreciation 
of the help which had been fi'eelj' given by the Scottish 
Board of Health. The Lord Provost remarked that in his 
own time there had been an extraordinary diminution in 
the general death rate, which had fallen from 17.4 per 
1,000 per annum in 1900 to 14.3 in 1927, while tho infantile 
mortality had fallen from 132 per 1,000 births in 1900 to 
80 in 1927. As to the measures {or increasing the publio 
health which were being demonstrated in the hall, one 
of the simplest and most effective had been to give tho 
citizens a constant supply of pure water. Another matter 
which had been of great importance was the activity 
of the Public Health Department in regard to tuberculosis, 
■which took the form, of impressing on tlie citizens the 
benefits of pure milk and of cleanliness in the home; by 
these means the number .of eases of tuberculosis notified 
to the Public Health Department had fallen by almost 
50 per cent, in the past fifteen years. Better housing, 
and the provision of open spaces around tho houses,^ would 
in the future materially raise the level of bodily resistance 
to this disease. The means which the department had 


taken to save the lives of infants wore also demonstrated, 
although miieh rohmiiiod to ho done in this very important 
•splioro of work, which lie believed would produce a still 
further fall in the death rate among children under 
one year of ago. It was notouoVtliy that while the 
infantile mortality figure for the whole of Scotland in 
1825 was 90 per 1,000 births, and for Glasgow 107, that 
of Ediiihurgli was only 80. The whole aim of the exhibi- 
tion had hccii to stress the importance of prevention in 
regard to disease. Tho Lord Provost formall3’ declared the 
exhihition open. Among the things exhibited and demon- 
strated are the following : The Edinburgh Water Departs 
niciit lias an exhibit to show tho method of purification 
of water supply by sand and by mechanical filtration, 
and various taps arc slioivn to demonstrate how a few 
drops of leakage may cause the waste of hundreds of 
gallons of water. The importance of milk as an article 
of diet, and the methods by which clean milk is produced, 
arc demonstrated at two large stands. Stands for pasteur- 
ization and refrigeration aro shown at work, and cows from 
a t\ihorclc-frce herd aro on exliibition. Tho Edinburgh 
and East of Scotland College of' Agriculture lias a stand 
drawing ’attention to the value of eggs as an article of 
food, and a poultry house and small rim are fitted up 
showing how a few hens may he succcssfull3’ kept in limited 
space. Butter-making demonstrations arc also shown in 
progress, ns well as the production of clean milk, in a 
model h3'ro erected by the Daii-ymen's Association. At 
tho Votcriiiar}’ Department stand specimens of unsound 
food arc shou-n, as well as demonstrations of tlic various 
bacteria which aro capable of spreading disease. The 
exhihition includes a small cinema and lecture hall, at 
which films are shown illustrating tho work of child welfare, 
clean milk production, cleanliness in the home, care of the 
teeth, and other matters. Cookery demonstrations are 
also given in tho lecture hall. An important exhibit by 
tho Public Health Department is devo-ted to tho demon- 
stration of foodstuffs and their values. Many articles of 
food are shown, together -with an indication of their food 
values and their cost. Actual dietaries of Edinburgh 
families arc tabulated and their defects indicated. Various 
slogans aro posted up round this stand, such as “ Protein 
poverty produces puny people.” The Housing Department 
demonstrates its work at various stands witli full-sized 
reconstructions of various houses—from a slum house, which 
was built in 1672 and recently demolished, to a house 
recently erected and surrounded by a real garden. The 
Electricity and Gas Departments have also elaborate 
exhibits showing tho most up-to-date methods for the use 
of electricity and gas in the household. As an example 
of the hygienic benefit of gj-innastics, physical drill, dances, 
and games a demonstration is to ho given by some 3,000 
Edinburgh' children, drawn from fifty-four schools, at 
intervals during the niu of the exhibition. 


Child Welfabe Conference. 

A three days’ conference on maternity and child welfavo 
lork was opened in Edinburgh on January 26tli in tho 
How Dniversity Buildings, Dr. B. H. T. Nash, London, 
iresided Dr. Robertson, M.O.H. for Edinburgh, welcomed 
be delegates on behalf of the public health department of 
ho citr' and invited them to attend the health exhibition 
•hich was being held at the time in the Waverley Market, 
•rofessor Leonard Finlay, Glasgow, delivered an address 
n food requirements of infants, in which' he pointed out 
hat breast-fed children seldom suffered from nutritional 
isease although they might he affected by, insufficient 
upply* I” of the bottle-fed child, underfeeding 

■as also the most frequent cause of mischief, and was 
videnced by stationary weight or loss of weight. He con- 
idered that in teinis of nulk during the first two months 
child required 15 to 20 ounces, during the next, two 
lonths 20 to 25 ounces, from four to six months 25 to 30 
iiiices and from si;c to nine months 30 to 35 ounces dail3’. 
ugar ’was frequently added to the milk, aiid consequently 
. was important to remember that a drachm of sugar had 
'ugUiy tho value of 1 ounce of milk. Dr. Charles McNeil, 
h^ician to the Royal Hospital for Sick Children, Edm- 
[irnh. read a paper upon some types of persistent cough 




196 Fed. .j, 1928] 


ENGtiAND AND WADES, 


r TnEBsmai 
1 >Ii.t)icxi,/orMii 


vhnt niitnro IkicI intended it to bo. Tlie liospitnl required 
£40,000 to complete tlio first st.oj^o of its scliemo for 
dealing with tho crippled child by paying for the 200 beds 

1) rovided at tho country branch at Stanniore. 'J'lie «'hildren 
wore sent to tho hospital from public health and education 
authorities all over tho country, and their education was 
ari'angod in tho hospital so that when they loft they were 
able to talco their place on more equal terms in the 
business of life. Dr. Graham Littlo, M.P., seconding the 
toast, said that the hospital was n fine example of 
tho value of tho voluntary system of managemont. ]le 
iustanced tho recent prudent action of Mr. West, chairman 
of tho hospital, who, hearing tliat sixty acres of ground 
surrounding tho hospital at Brockloy Hill wore about to 
bo sold for building purposes, purchased them on his oini 
initiative and out of his own purse. The hospital board 
gratefully took over Mr. West’s purchase, but had he not 
acted with great promptitude the opportunity might have 
been missed and the hospital have been shut in by build- 
ings. It was in such qualities of foresight apd initiativo 
that enterprises compete so successfully with public bodies. 
Tho hospital at Stanmoro occupied tome of tho most 
beautiful country in tho neighbourhood of London, and 
the newly acquired laud would facilitate various necessary 
extensions in tho future. Dr. Littlo also referred to tho 
present-day orthopaedic treatment, which from its nature 
required time for its perfection. Tlio toast iias acknow- 
ledged by Mr. Herbert E. AVost, who stated that since 
Prince Heniy became president of the hospital nearly 
eight years ago it had Mniost trebled its size; this result 
was pre-eminently duo to tho great interest taken by tho 
president. The present extension had entailed a cost of 
£125,000, towards which £85,000 had been I'ccoived. The 
toast of " Tho Guests ” was proposed by Jlr. Beginnld 
McKenna, and responded to by Sir Philip Gibbs. Tho 
Lord Mayor, replying to tho toast of his health and that 
of tho Corporation, proposed by the Dean of AVestminster, 
said ho owed a personal debt to tho hospital, beeauso 
his crippled brother had been restored to health by tho 
doctors of tho hospital in earlier days. Mr. A. H. Campbell 

2 ) roposed the toast of " Tho President,” who, in liis reply, 
announced tho receipt of donations amounting to £10,000. 

Tstes of Einoworm Ixtectiox in London School 
Children. 

Some light has been thrown upon tho origin and mode 
of spread of ringworm in a given community by a careful 
study of tho precise nature of the fungi incsont. An 
investigation of this kind in children attending the 
London County Council schools has recently been undex- 
taken by Drs. J. 6. Hare and P. Tate,’ their object being 
to cultivate and identif 3 ' the fungi present in the cases 
of ringworm among such children, and thus to ascertain 
the relative prevalence of tho various parasites isolated. 
In this way it was to be expected that the character of tho 
fungi obtained would afford evidence of the importance, 
if any, of animals sueli as cats and dogs as carriers of 
infection, or whether the infection occurred chiefly from 
child to child. Cultures were obtained in 69 cases. In 3 
of these direct microscopic examination of the infected 
hairs showed the presence of favus, the parasite in all 
cases being found on culture to bo Achorion sehonlcinii. 
.Twelve large-spored ringworms due to endothrix tricho- 
phytons were obtained b.y direct microscopic examination 
which were found on culture to be Tiichophyton cratcri- 
formc in 5 cases, T. siiifureum in 2 cases, T. acuminatum 
in 4 cases, and T. viotaccum in 1 case. Microscopic exam- 
ination revealed 54 small-spored ringivorms due to micro- 
sporums, and cultures showed Microsporum audottini in 
89 per cent, of tho small-spored ringworms. They found 
this variety much the most prevalent of the ringivorm 
fungi, being responsible for about 70 per cent, of all 
ringworm infections. M. /clincinn and ill. Janosum were 
each found in one case, and represent 2 per cent, of the 
small-spored ringworms and about 1 per cent, of the total 
number of cases. In addition, four microsporiims lyere 
isolated which have not yet been identified with any 

CauBinv Rininvorm in Children Attendine: London 
VOL It Schools. S. a. Hare and P. Tate. Journal of Hygiene, 

VOL 27, No. I, November, 1927, pp. 32-M. 


Iviiown .species. In Pai'is it would appear that the endo- 
ihrix trichoiih^loiis arci resjioiLsihle for most of tho ring- 
worm of tho sealp, having hocn found in about 66 per 
cent, of tlio cases; in London, on tlio other hand, tho 
luicrosporums are most comnion. The figures obtained hv 
I)r.s. Haro .and T.-tte in the present inve-stigation — nanicl.v, 
about 78 ])or cent, of all ringworms — are seen to agree 
faiil^' closol.v with those obtained in London by Pox and 
BInxnll in 1896--nnracly, from 80 to 90 per cent. Adamson 
ill 1895, rcl.ving entirely* on microscopic exnmination of 
tbo liairs, obtained a .still higher percentage of small- 
spored ringworms. ill. audouini constitutes tho com- 
nione.st eiiiise of ringirorm hath in London and Paris. In 
London it was found in about 70 per cent, of all forma 
of ringworm infections, constituting 89 per cent, of the 
.smnll-spored ringworms; wliilo in Paris, according to 
Siihouraiul, it occurs in about 77 per cent, of small-spored 
ringworms. Summing up these results, it will bo noted 
that with the exception of two species, ill. lonesiim and 
ill. fclincum, and possibly of tbo four unidentified micro- 
.spornms, no animal forms were found. Not a single 
eclotbrix tricliopliyton was encountered b.v Hare and Tate, 
and tlioy appear to be jnstifiod in oonchiding that among 
sebool chihlrcu in London tbo infection with animal ring- 
worm is negligible, the children tbemselve.s constituting 
the chief source of infection. 

Ejfi’LovjiE.xr OF Tehercvlovs PmsoNS. 

A report hy the medical officer of health to the London 
County Council was submitted to the council at its meeting 
on Jamiaiy 24tli, on tho subject of tho employment of 
.tuberculous persons. Dr. Menzies points out that every 
3 'oar a considerable number of patients di.scliarged from 
sanatorinms and hospitals are incapable of work or fit 
only for light work. Tbo working capacity of the latter 
is seldom more than SO per cent, of that of tho normal 
worker, and, as their disability varies in dogieis from time 
to time, they aro unreliable .as well as inefiioiont. Many 
of them, however, aro capable of being employed nniler 
special conditions when littlo physical effort is called for, 
tho liours of work- adjusted to the physical capacity, and 
tho environment hygienic. It is pointed out that whenever 
possible a tuberculous person should seek for employment 
for which bis previous experience fits him, which, as a. 
rule will he his previous employment under modified con- 
ditions. In Borao cities a limited number of tuberculous 
persons may be, and aro, employed by public bodies — for 
oxaiiiplo, in parks; while institutions for tho treatment 
of tho tnhorcnlons absorb a number as members of the 
staff. Specially organized schemes of employment may 
take" tbo form of a settlement, as at Papwortli, or tho 
provision of suitably arranged workshops, the employees 
living in their homes, as at the Spero workshops in London 
(organized hy tho Central Fund for the Industrial AA'cIfare 
of Tuberculous Persons) or at the Altro worlcshops, a 
Jewish charity in Non' York. It appears inevitable that 
such enterprises should bo subsidized by tho State or by 
cliaritv in some form. Industrial settlements run in con- 
nexion with a sanatorium aro more easily organized than 
independent workshops, but aro veiy costly to establish. 
Dr. Menzies appears to regard more hopefully tho work 
of ' cart) committees and similar voluntaiy agencies in 
placing tuberculous persons in suitable occupations ; under 
present conditions, he says, they can do more for tho 
patient than any othor agency. Tho Public Health Com- 
mittee also presented a report of its own on tho subject 
to tho London County Council,^ in which it expressed the 
hope that the Minister of Health would seo his way to 
accede to tho request made to him by tho National Asso- 
ciation for the Prevention of Tuborculosis and hy the 
council itself to institute an inquiry into tho working of 
tuberculosis schemes in this country. At such an inqin^ 
tbo emplovraent of tuberculous persons would be thoroughly 
coiisidored, and tho Mini.ster would no doubt indicate the 
attitude of tho Government on tho question of financial 
assistance. The Public Health Committee puts forward tlio 
suggestion, without actually expressing a definite opinion, 
that it would bo more advantageous for enterprises pro- 
viding omplojment for tho tubercufous tp ho financially 
assisted than for such persons to be maintained at tua 
public charge. 


FElB. 4, 19=81 


COlillESPONDENOB. 


[ 


TiTEBr.msH 
MkDICAI. JoCSNlXi ' 


197 


(!i;0m'S|j0ttiicitc£» 


; INTRAVENOUS GLUCOSE IN MABETIC COMA. 

Sir _JIy attention has been called to n statement in an 
article in yonr issue of December ord last (p. 1019), 
relating to tbo use of intravenous glucose solutions in 
file treatment of diabetic coma. Your columns also carried 
tbo sad news of tbo death of tbo writer of tlio article. 
In tbo passing of Professor Petrdn tbo world has lost a 
ripe scholar and an able and indcfatigablo investigator. 
Referring to diet in coma tbo lato Professor Petren said : 

Campbell in Toronto originallj’ spoko in fjivour of largo 
intravenous injections of glucose. I am glad to sco that 
in bis later publication bo has abandoned this treatment 
and says nothing more about it.” I am at a loss to 
discover the origin of this misunderstanding, and can onlj’ 
suppose it aroso from a hurried review of litcraturo on 
■ tho subject, which is now assuming hvigo proportions. 
-.This is hardly tho time or the place to discuss in full tbo 
evidence leading-to tho conclusion that intravenous glucose 
along. with insulin is a valuable procedure in tho trcalinent 
of diabetic coma. Suffice it to say that tho use of glucose 
is indicated on tho following grounds : 

,, (f) It guards against hjiiOglycacmia. Others as well as 
ourselves have had -occasion to" iioto the development of this 
severe and unnecessary complication of coma when insufficient 
glucose has been avail.able, and it is to be suspected that 
it occurs many times when adequate facilities for laboratory 
control of treatment arc lacking. 

(2) It provides energy in readily availablo form. While 
I am not aware that precise calorimetric determinations have 
been done to establish an absolute requirement for this, it is 
significant that non-infected diabetic comas nearly alw.ays have 
grossly subnormal rectal temperatures. It has been said that 
the excess sugar of tho blood in coma would be sufficient, 
bu an easy calculation will show that it is adequate for one 
hour at the most. The tissue sugar level in diabetes is 
decidedly less than blood sugar level. 

(3) It conrerts the metabolism to a carbohydrate type, thus 
protein*"^ ^ production of more ketones from fat and 

combustion of those ketones already 

present in tne body. 

effects have been shown to arise from 
and' it io '^ S'dMse with insulin in truo diabetic coma, 

those whose kboTawlac^m-^* hypoglycaemia for 

reasons monr- lacilitics are meagre, and for other 

methods of “dviso its uso along with other 

severe ReiLsu“^"?""^ “ In those cases of 

agree that tbn’ "i ' “’'"Y msist on calling coma, wo 
seldom necessai7!iTam*™tc°'' intravenously is 

"Walteh R. C.mipbeli,. 




OP CANCER BY RADIUM. 

■ W. Pletcher Shaw nl?- (P- 

relation to tlm h ‘^““rinumg his correspondence 

about tho work thev givo any infom 

■ ^=Meaicarknerinri‘'‘”"e-” 

London I feel it in of the Radium Institi 

statement. The T upon me strongly to refute 

for the treutmnn*'”^^ ° Radium Institute opened its 
1913, a report d v “ J"ly. 1911- I" 

from July ’^ith the work of the Ins 

particulars’ of cases'* published, 

tables. A report ’ of treatment, and stat 

until 1924. ^ °° similar lines was issued each 

practition’ert request of many m 

tipon and co’mMled'*fV'“ Hadium Therapy, 

Institute was^r, actual work of the R; 

4 ilanual of Tnrt, Ih's was followed, in 19! 

ty Superficial Radium V/" ^'"‘*‘’‘”1 Therapy, and, in 
““‘um Therapy. A work on Deep R 


Therapy is in active preparation, and will be issued in a 
fow months’ time. 

All the publications of tho Radium Institute have been 
supplied post freo-to any medical practitioner who cares 
to apply for them, and this fact has been clearly stated in 
tbo advertisements in tho leading medical journals. 

Papers by various members of the staff of tbo Radium 
Institute have appeared in the British Medical Journal 
and Lancet from time to time, and I would venture to 
direct Dr. AV. Fletcher Shaw's attention to the fact tli.at 
in tho_ issue of the British Medical Journal of January 
28th, in which his letter appears, there are two papers 
by my colleagues: “ Inoperable sarcomata treated with 
radium,” by Dr. Roy Ward, and “ The combined action of 
colloidal lead and radiation on tumours,” by Dr. J. 0. 
Mottram. — I am, etc., 

A. E. Hayward Pixch, 

Tlio Hadium Institute, London, W.l, Medical Superintendent. 

Jan. Satli. 


. Sin, — Tho numerous communications which have appeared 
recently on this subject indicate a growing recognition of 
tho importance of radium in the treatment of cancer. 
There is in these communications one point on which there 
is a striking unanimity — namely, the desire for reliable 
long-])eriod statistics in this country. In view of the 
cxpefiehco of certain clinics, and the efforts iTow being 
made along their lines by others, it is fortunate that 
under the auspices of the British Empire Cancer Campaign 
Fund an International Convention on Cancer Research is 
to be held in London in July, on which occasion tho inter- 
change of views on this and allied problems should be 
profitable. Those interested in radium work would do 
well to avail themselves of this special opportunity. — 
Wo are, etc., 

AnTinm B. Smith, M.B.,. F.R.C.S.Ed.- 

Sydney M. Smith, M.B., Ch.B.Ed. 

Loudou, W.l, Jan. 27th. 


FATALITY RATES OF SMALL-POX. 

Sir, — As your other correspondents have not replied to all 
Dr. L. A. Pari-y’s questions (January 21st, p. 116), althougli 
I had no wish to write further on this subject, it has been 
urged upon me that a reply should be made, and I there- 
fore trust that your readers will pardon the tedious 
reiteration of some facts which are well known to many 
of them. I 

In regard to Dr. Parry’s question (2), there is, to 
start with, a confusion between percentages of “ people 
vaccinated ” in the community and infants being 
vaccinated in certain years. As a rough estimate we may 
assume that from 1854 to the first exemption Act in 1898 
about 85 per cent, of infants were being vaccinated, that 
tho rat© then declined at a uniform speed to 75 per cent, 
in 1908, when exemption became easier, and then fell at a 
more rapid rate to 38 per cent, in 1921. By referring 
back each age group of the census populations to the 
respective years of birth, and multiplying by the percentage 
of infants being vaccinated at that time, we obtain tho 
following approximate percentages of all people living at 
various dates who had been vaccinated in infancy: 


1871 ... 

... 40 per cent. 

1911 ... 

... 74 per cent. 

1881 ... 

... 50 „ 

1921 ... 

... 74 „ 

1391 ... 
1901 ... 

- 60 „ 

70 If 

1926 ... 

... 66 „ 

It would. 

tliereforo, te as 

fair to ask. 

‘‘ "Why did tlio 


total deaths from small-pox in England and Wales decrease 
from 23,062 in 1871, when only 40 per cent, of tbo popula- 
tion were vaccinated, to 5 in 1921, when 75 per cent, were 
vaccinated? ” As a matter of fact, the reasoning either 
way is fallacious, for on the same basis of estimation it 
appears that the percentage of tbo population under 
20 years of a<^o who had been vaccinated did not change 
appreciably from 1871 to 1901, though the deaths at those 
ages fell from 14,223 to 127. The truth is, of course, that 
arguments of this kind can prove little or nothing, since 
epidemics come and go according to laws wliicli we do not 
yet understand, and which involve many factors other 
than vaccination. Moreover, it is forgotten by those who' 


198 Feb. 4, 1928] 


GORBESPONDENCE. 


t Tnc PiniTifa 
SfEurcAi. Jovvitis. 


use tin's kind of argument that never at any time since I 
vaccination was introduced have tliero been in this counti'y 
less tlian seven or eight million jici-sons imvaccinatcd, and, 
therefore, as a wholesale preventive measuro vaccination 
has not yet been seriously tried. 

Turning to Dr. Parry’s question (4), I presume tliat hi.s 
{iguro of 80 per cent, is derived from the totals for 1926, 
in which year there wore 5 cases admitted to tlie M.A.B. 
hospital, of which 4 (ail adults) had been vaccinated at 
some time. In the three preceding years 19 out of 29 cases 
admittoil had a record of vaccination — about 65 per cent. 
Xo sound conclusions can, of counso, bo drami from such 
minute samples from tho population of London, but I 
think that if Dr. Parry were to look at the ages of these 
vaccinated ” patients ho would find what is, perhaps, a 
more satisfactory answer, for most of them were over 30. 
From the calculation just referred to it appears that more 
than 80 per cent, of tho population over the age of 30 at 
tho present time must have been vaccinated ' in infancy, 
apart from many who were vaccinated in the army, .so 
that 80 or more is the percentage of vaccination to expect 
at pi-esent in any largo sample of adults at these ages. 

Dr. Parry’s questions (3) and (5) aro simply the old 
arguments of the antivaccinationists served up in a new 
form — for example, tho old question, " M’hy were there 
less cases and a lower fatalitv rate in Leicester in 1891-92 
than in Shcffiold in 1887-88,' in spite of the much lower 
vaccination rate in Leicester than Sheffield? ” It would 
be equally reasonable to ask why there was an infiuenaa 
death rate of 1.6 in Leicester iii the first great epidemic 
wave of influenza in 1918 as compared with an influenza 
death rate of 11.6 in Shcffiold in the second great wave of 
1918, although undoubtedly more people ivere attacked in 
the finst than the second. ' The answer is, that tho .second 
epidemic took everywhere a more fatal form tlian the first, 
and we have got to leave it at that, not deluding our.selvcs 
that it is an explanation, but merely a statement of fact. 
The same kind of answer covers most of these small-pox 
conundrums, as both Dr. Millard and Professor Greenwood 
havo indicated in their letters. In 1919 Germanj , in 
common with most of Eastern Europe, was .swept by a 
great epidemic of variola major which England almost 
escaped; since 1921, however, wo havo become increasingly 
affected by the milder form which seems to have come to us 
from America; at any rate, there were 139,107 cases in 
the United States of America in 1907-12, with a fatality of 

less than 1 per cent. c • 

The only conclitsivc proof of the efficacy ot vaccination 
must consist in comparing the vaccinated u ith the 
imvaccinatcd at the same ages in the same town and 
during the same epidemic. Where ibis has been done in 
epidemics of variola major with large enough numbers the 
results have been definite enough to satisfy most minds as 
to its efficacy. In addition, there is a mass of presumptive 
evidence, relating to botli types, sucli as is furnished by 
the ago distributions reproduced in my letter of January 
21st.— I am, etc.. 

University College, Boailon, Jan. 27th. PebcY ^.TOCK.S. 


foreign bodies in THE STOMACH, 

Sin —An interesting account of successful manipnlarion 
bv Dr ' Gilbert Scott of a key in the stomach (January 
2‘8th li 133) kas unfortunately been broadcast in the daily 
mess I am sure nobody will regret this move than will 
Dr Scott himself, for the impression will be conveyed to 
lav mind that manipulation ot all foreign bodies through 
uvlorns ought to be undertaken by the radiologist, 
and no more dangerous suggestion could possibly be made 
The knowledge coiiimon to all radiologists of the wisdom of 
ine Kuuui bndies to ha dealt with by nature is 

leaving mo tho horrihle possibilities if an 

unquestionable imagine r manipulate an open .safety 

o“. toSi pi.*",,";*'' 

that most of these foreign bodies will be pa^cd tljugh 
tho pj'loins without any assistance on tb 1 . ■ 

radiologist. If I needed any convincing upon this point. 
Dr. Scott has himself supplied it in bis comment upon the 


impossibility of tiyiiig to manipulato the round label 
attacbed to the lioy. How often lias 0110 not liad to wait 
for some dny.s for a coin of the size of a halfpenny to pass; 
indeed, tlic only foreign body which nature appears to find 
difficulty in dealing with is tho rounded flattened body. — 
I am, etc., 

Eomlon, W., Jan, 29lli. ST-lKhEV JlELYIhhE. 

*,* Dr. Gilbert Scott was, of course, in no way respon- 
.sible for the pnblicitj’ given to bis note by tlic daily 
iicw,spapcr.s. "W’e regret that the columns of a iirofcssional 
journal should ho used in this manner, week after week, 
by our conteiiiporaries of tho lay press. 


DRAINING THE SEPTIC UTERUS. , 
j;in , — I was pleased to notico in your issue of January 
21st (p. 117) the favouvahlo criticism of Dr. David Wat^n 
on tho intrauterine injection of glycerin for tho promotion 
of drainage in septic conditions. The reason for my. 
einploviiig pure niidilntod glycerin without the use of anti- 
sept its is the result of yea'rs of cxpcrionco. I am sure 
ovoiyono has noticed that after the use of a hot intrauterine 
donclie .svmptonis and signs of septic ahsorption are apt 
t.i follow’ and entiro cessation of the discharge, cither pus 

or hlood. . . . • , 1 

liitrnuteriiio treatment ivith glycerin is certainly tJie best 
treatment for post-partum liaomorrhage, and has super- 
seded the hot intrauterine douche. It acts as a powerful 
.stimulus to tho uterus, and as much as 120 c.cm., or more, 
iiinv be injected. The hot douche coagulates the tissues 
ami prevents tissue drainage. I havo noticed on many 
occasions tho sanio symptoms bare been produced by tho 
application of strong antiseptics to tho interior ot tho 
uterus. With regard to the use of oven mild antiseptics, 
the results scorn to bo just as good without them. 
Glvccriu has been used extensively in tins liosjutal for tho 
last nine voars, during which time we have given over 
30 000 intrniitcrijio treatments. Patients have received as 
ma’iiy as fifty treatments, and sometimes four injections in 

*^*1 \night mid that in cases of femoral thrombosis the 
natieiits arc treated as usual, but on a special obstetric bed, 
and the legs aro held apart in trough-like splints. In cases 
of nvolitis and cystitis tho ntenis is treatecl as well, also 
in Vnoumonia aiid influenza occurring in tho imoi-penum 
when there arc signs of secondary haemorrhage, etc. 
D r la ^ wkole of the time we have had not a sing e 
?e"tli arising from the injection of glycerin and not a single 

of liaemoi-lobiiinria or albummuria. Rather than any 
toxic effect, the patients say they feel better But one 
should issue a word of warning; m the case of the small 
Suparons uterus, a large injection, given hastily, may 
he followed bv abdominal pam and faintness. In cases 
following labour or miscarriago tlio utoriis is relatively 
inslnsitivo, -and large quantities can lie given without 
prLlucing paki, if injected alo'vK^-I am, etm, 

^ A. Remington Hobbs, 

viv Ho'ipital, Consulting Gynaecologist to the Royal 

B-ooSh ei Kensington. 


early RHEUMATIC MYOCARDITIS. 

Qir— I n accounts of early rheumatic myocarditis I om 
find no mention of what I have learnt in tho 
mTfPW vears to regard as the earliest symptoms. Tins is 
He iStorrHom thf mother, of the child, after apparently 
the histo y in and “ flopping” in a chair in 

enjoying P-. ' . , manner. This is noticeable m a 

a complete } so as a rule, and is frequently the 

child I ‘. ^ ; sought. It leads one to inquire about 

cause of advice being g ^ 

Hef n o" ’’ The cardiac dullness may be 

called , | tlmn the average and the, apex 

ah-eadysusp.ciousb^ini„er^ fre not present, 

if^'the'^'cbild is allowed to continue up and abput for a 
nv two Hey are fairly sure to develop. A systoho 

to ii-?. 

salicylates and alkalis for a few days in these oailiest 


Feb. 4, 1928] 


UNIVERSITIES AND COLLEGES. 


r Tne r>Tim5iT 
HedICAL JoCKNAt. 


199 


work wonders, and tlio mother is willing to earry out this 
treatment and interrupt school life when tho risk of 
permanent heart trouble is jjoinlcd out. — I am, etc., 

Lorms E. WiaiiAJt, hl.B.Cantab. 

London, E.4, Jan. IBtli. 

FOREIGN BODIES IN THE ABDOJIEN. 

Sm, — I read with interest tho account of tho second case 
described by Dr. H. Roland Segar on p. 96 of your issno 
of January 2Ist, bccauso it affords a human parallel with 
an animal experiment performed hy tho Into Professor Paul 
Hoger at the Solray Institute, Brussels, about twenty years 
ago, and described by him to mo in 1925. Ho was working 
on tho functions of tho omentum and similar structures in 
tho abdomen, and related how in ono case a foreign body 
introduced into tho abdominal cavity was carried to tho 
root of tho omentum, excluded from tho abdominal cavity 
hy tho folding over and adhesion of the omentum, and finally 
mado its way through tho wall of the intestine and was 
passed per rectum.' 

I believe tho specimen is still at tho Solvay Institute, 
although I cannot b’o sure. — I am,' etc., 

Kenneth J. Fkanklin, D.M. 

Tie PharinacolO"ical.Lab<iralorr, , ’ ' 

Oxford, Jan. 26Ui. ~ ■ . . . 


THE PHYSIOLOGV o.F DEFAEOATION. 

k physiologist I havo been following tho con 
spondence on the physiology 'of dcfaecation « itli mu 
interest, and I am glad to seo that at last ono of yo 
correspondents. Dr. E. R.' Barton, refers to tho height 
e seats of closets as ono of tho causes of constipation. 

seem that wo aro never going to get a chan 
w the construdion of these seats, whicli apiiccr to hecor 
and higher as each new hotel, club, train, 
hieh 'a bmlt. It is not onlv that they aie far t 
a 5''® '"variably , level, whcrca.s they oug 
assuZfl downwards in order to permit of tl 

of tko natural squatting position, the phvsioloj 

of whioli IS so well understood. 

I knnn- n physiologically correct scat has been mai 
to send Ttio 01 °’ makers of it wero good enou; 

I shownd t ^*^tration of, it many years ago, and th 

I iTw if I '‘“d it beside n 

nble and I fn' f“^ editorial comment, but it is not ava 
ever thl if 7."'® “f fhe makers. I hope, ho^ 

it known tlinf communication they will ma] 

been rthfmarke?""'’'°®'“"^ I' 

level typ^oT^itX'uld^ absurdly high ai 

tion m the nhvsinIo,?'°^1 continue to be made; the explan 
to construct^sJin momentum of tlioso who contini 

Therebre tarfn adequately adapted to its use 

whicli is provided with^ ' °"n“- 
possibly pbrmit a 

■ of course have L “f The makei 

•treating -it merely “ spout is for, and are nc 

.. . ’^“^^“-“inament;— I-am, etc., 

_ Tll° Author- Club- tI,,, , P' FbASER-HaIUIIS. 


attit Megts, 



f T a congre.*a!io^7fP®f^^-°'' .CAJIBUIDGE. 
degrees were^conferred' 27th the following h 

S. Bol^ 

of '■aa”arcb'fu°'So 5?ol°'®”’’'P ‘f"® enconrag 

_ le\ers has been awnraori®**® > pailiolog}', and prev 
Emmanuel. “ awarded to Mr. Leonard K. Jauei. M 


UNIVERSITr OF LONDON. 

Mn. M. E. Delafield, M.C., M.B., B.Ch.Camb., has been 
appointed to the University Chair of Chemistry as applied to 
Ilygicno tenable at the London School of Hvgieue and Tropical 
Medicine. 

Dr. E. L. Konnaway lias been awarded tho William Julius 
Mickle Followsliip for 1928 (value £275) in respect of the work 
carried out by him on cancer research during the past five years. 

Mr. n. L. Eason, C.U., M.S., Ims been reappointed to represent 
tbo University on the General Medical Council. 

Dr. Andrew Balfour, G.13., will be the renresentative of the 
University at tho Congress of the Royal Sanitary Institute to be 
hold in Plymouth in July next. 


UNIVERSITY OP LIVERPOOL. 

Mrs. Adami, the widow of Dr. J. G-. Adami, Vice-Chancellor of 
tbo University, who died in 1926, has presented the sum of £100 
for tho eudo\vineut of a prize in the department of pathology. 


ROYAL COLLEGE OF PHYSICIANS OF LONDON. 

A QUARTERLY coiiiitia 'of tli 0 Royal College of Physicians was held 
on January 26th, with the President, Sir John Rose Bradford, 
in the chair. 


^embgrship. 

The following candidates were admitted to the membership ; 

Roland Gcorso’ Aodct.'ion,' M.B.Lond., Godfrey .William Bambev; 
If.R.Camb.,. DmmM -Campbell, -L.A.H.Dub.*, Clebienfc. Clapton 
. ‘ ‘ Cli6stcrman, O'.B.E.. 'AI.o.Land:, Ronald CoYeJHulith.M3.Camb.,' 
■\ViUiam. HcfinpjT Craib, JJ.B.Camb., Sheldrn Francis Dudley, 
.1 . u.i 5 ’E;,'.iLD.LDnd.;’SUTgoon i ommander, R'N^‘ William Norwood 
East, Al.D.Lond., Abd el Kadcr lIthni",El-Sburba'{ti,'. L.U.C.P., 
W'illiani Evans. M.D.Lond., .John Rex Godsall. M.B. Sydney, Cecil 
rA-r^-'wini. . ’'“r • '* r- • • ^ . ... 

Noel ’ • ■ 

M3.C . . ■ 

Mark* * ’ ‘ ... 

Adam ‘ * , ‘ , , ■ 

Bristol, Rouald .Arthur Phillips, L.R.C.P., John DouKlas Procter, 
L.R.O.P., Reginald Hans Taylor Rea, L.B.C.P., Abd el-Azim Yousif 
Mostafa Salama, L.R.O.P., Sydney Watson Smith, M D.Edln., 
Howard Hilton Stewart. M.D.Bel^a^t, Charles Cady Ungley. M.D. 
Durham, Marion Boyd Wanliss, M.B.Melb., Lawrence StuartAYoolf, . 

ii.E.c.r. 

Licences* 

Licences were granted to tlie following 120 candidates who had 
passed the necessary examinations of the Conjoint Board and 
conformed to the by-laws and regulations of the College; 


B. Anderson, G. D. Augenliebt, L. Bernard, P. G. Booker, G. N. Box, 
M. S. R. Broadbont, J. W, Bromley. C. B. S. Bullen, ‘Eleanor M, 
Oarless, A. M. Chaudhuri, S. S. Chesser. T. L. Cleave. G. A. Coggin, 
O. N. Cohen, C. 0. Cookson, N. Cos, ‘Pera R. C. Crawford, W. S. 
Orecr, D. S. Davies, E. R. L. Davies, ‘Helena M. De Hartog, if. M. 

. Doj'. ‘OUvia F. Digby-Smith, H. Doyle, M. R. Doyle, Cj B. Drew. 

. John St.C. ..ElkLngtod, •Alexandra -G. H. Enelisb. A. G. Ensor, ‘ 

H. Epstein, M. M." Fikri; J. Foster, H; ‘DrF. Ffuser,* ‘Mabel O. C. 

Frccston, T. R. Gaha, P. J. Ganner, ‘Caierlua P. Giles. E. M. 
Goiteln, R. A. P. Gray. 0. R. Greene, C. S. Gross, ’Bridget S. P. 
Gurney, B. Haring. R. M. J. Harper. J. Harris, R. L. Harward, N. F. 
Haslam, J. 0. Hatrick, L. Hennell, ’Margaret A. L. Herbertson, 
•Anna M. Hilliard, E. A. H. Hindhaugh, N. M. Modivala, ’Josephine 
M. Howells. H. Hubert, Vi. L. Horn, A. L. Hyatt, ’Dorothy M. 
James, D. C. R. B. Jenkins, I. J. Jones, R. T. Jones, H. Eaitz, ’A. B. 
Kerridge. A. K. M. Khan, P. Kuhne, T. B. Lamceb. B. A. Lamprell, 
W.J. Lloyd, ’Margaret I. Meacock, A. A. Miles. ’Mary M. Moller, 
O. F, Moore, C, S. Morgan. W. H. Myborgh, J. J. O'Donoghue, 
•Lola J. Ogle, E. N. O’Neill, ’Ella M. Oswald T. N. Parish. 'W. E C. 
Parry', P. I. Peltz, P, P. Peries, 0. D. Politeyan, A. E. Porritt, 

' •Monica M. M. Power. J. C. Preston,- ’Agnes M. Ramsbothara. W. G. 

" Richards, J. H. Rienmond, T. McK. Robb, F. E Roberts, ’Elizabeth 
J, Robinson, ’Florence E. Robinson. R. S. Rudland, ’Margaret M. 
•RnsseU,* B. W. Babouadiere.-W. J. M. Sadler, H. A. Seidenberg, 
-•Doris. G. Sbarvelle, D. C. Shields, ’Clarice. A. Skidmore, -T.-E. 
Skinner, W. D.hteel, G. Steinberg, W.P.-R. Swemmer, B. A. Taj lor,' 
•Dorothy Tims, ’Ruth M. W. l urner, D. R; Tweedie, G. P. A. van 
Bossum, J. A. Vernon, ’Elizabeth H. Waller, H. S. Wntere. K. H. 
Watkins,. I. •Weynik,U..H. C., White, H. 0.*White, ’Hannah E. 

Wilby, E, A.Wood.N. R; W; Wynne-AViltiama. 

•. . . . • Under theMedical Act. 1876. 


Diplomas in Special Siihjrcis. 

Diplomas in the ’subjects indicated were granted jointly with 
the Royal College of Surgeons to the following : 

D.P.H. — ^P. Asker, A. D. Belilios. F, J. Benjamin, W. A. Brown, Isabella 
M. G. Butb r, Dorothy M. Catchpool, N. B. Cha.'lwick, Nancy M. • 
Coutts. Augel V. B. Crawford, ic. N. Curnow, Gweneth M. Daniel, 
Hilda C, Dean, E. L. F. De Mel, Kathleen Dickinson, Christabel S. 

- - Eyre, Nancy K. Gibbs. Gladys (loumt-nt, W. H. Hamilton, R. S. 
Johnsen, M. H. Khan, F. E. R. Laborda, E. R. Lewis. K. h, 
Malhantra. H. L. Malhotra. Ethel W. Morris. G. Napier, H. A. A. 
Pargeler. B. L. Patney'. K. P. PiUai. T A. fceeking^t, S. R. A.^ah, 
Kathleen Shelton, C. H. C. Toussaint, S. N. Vast!, P. L. Whig, • 

PsTCSOL^ic^ Medicine.- W. A. Caldwell. L.C. Cook. I. G- 

Harris, E. J. 0. Hewitt, R. G, B. Marsh. N. B. Phillips, R. P. Rees, . 
H. H. Steadman. „ „ — _ 

Ophthalmic' Medicine and Suhgeby.--^ K. Basn, J. C. Bringan, 
ABF. Chaffer, E.- J- Collins. S. D^yal G. 1. Evans, B. F. Eminson, ' 
E* R* Ja'^ger M S, Katre. B. K^y, R. B. Khare. L. R. Lalwani. G. D, 
Malhontm M A. Mithavala, D. G. PatwHrdhan. "W. -I. B. Riddell, 
Louie A. Rubidge. D. D. S. Stewart. C. R. Verling-Brown. 
t.atitnoology and Otology. — H. Bafagat, B. E. Buckingham, H. S. 
ciibachhi. H. A. Cowan, S. Dayal, E. M. Dearn, H. G. Downer, 

R A Highmoor, Barbara M. Logan, P. MacMurray.J. H. O'Donnell, 
aI MacK. Boss, S. S. Sen, J. J. Stander, P. Subbaramajya, H. L. 
Valdya. 



.200 Peh. 4, 192S] 


OBlTUAnY. 


t 


.‘Ijy/ioinlmrnts. 

1 "■■'s oleotoil lo llio Connoil in tlie plnoo of tlio 

lato Sir roroy IJnssett-Sniitli. Ur. Jtonckton Coiiomnn was 
tlio Collcflo nt the 39ih ConKrcas of the 
Eojnl Sanitary Instltnte. Sir Iiconaril Itogora -svas annolutcil as 


fl^clcgate to the contonary celebration of tlio" Pacultv of lledlclno 
‘''® invitation of tho minister' of Eitncation 
01 tho luutMom of Egypt. 


Jleporis. 

CommnnicaUouB wero receivoil from tlio President of tlio 
University of Toronto and from Ur. K. U. Uudolph with roferonco 
^ tlio recent colobration of tlio contennry ol King’s CoIIol'c 
T oronto. A report was received from the representative of the' 
College on the Goucral Medical Council. Ur. C. O. Hawthorne 
reported on the Uepartnienial Committee of tho Optical Practl- 
tioiiors (Uogistration) Bill. Booits and other donations to tho 
library presoutod during tlio last quarter were received and thanks 
were accorood to the donors. Tho annual rciiort of the Examiners 
for the Licence on tho c.\ainiiiation held in tho year 1927 was 

X CCC1\ OCi. 


SOCIETY OF APOTHECAniES OP LONDON. 

The following candidates have passed in the subjects indicated; 

Sunar.iiv.— O. N. Fox, A W. Lisnowsky. J. R, Jlltchcll. 

INlEDrciVK — G. N. Pox, D. I. Jones. 

Fonr.Nsic .Medicinr -G. N. Rceston. I). 1'. Jones. D. I. Jones. A. W 
Lnsson-skr, J. R. Mitcbcll. u<.s. a. «. 

SlromFiinv.— W. B. Hnllnins, H. T. Inco, E. A. Jolinstonc. n. D. K. 

The diploma of the Society has been granted to Messrs. D. I. 
Jones and A. IV, Lassowskv. 


©Iiiiitftrir. 

JOHANNES FIBIGRn, M.D., 

Professor of Pathology, Univereity of Copenhagen. 

With profound sorrow wo have to record tho death of 
Jolianncs Fibigor, professor of patliolog)- in tho University 
of Copoiihagcn. Professor Fibigor was in his sixtieth year, 
and had lately undergone a serious operation. Whatever 
bo tho triumphs the future holds for cancer research, his 
namo and his work will always have an honoured place, for 
he was tho pioneer of tho cscporimcutal inquiry into tho 
causation of cancer. 

While tho study of malignant diseases remained for 
the most part a matter of observation and conjecture 
littlo or no progress could be made in our knowledge of 
their etiologj’. Theories and ingenious hypotheses led us no 
further to tho heart of tho problom. No one had produced 
eancer experimentally. His was tho first successful attempt, 
and his claims wore at once recognized and welcomed by 
authorities throughout the world. It is a matter of pride 
to us to remember that within a feiv days of the publica- 
tion of his preliminary communication before the war the 
British Medioai, Journal emphasized the importance of 
this first successful direct attack on the central problem. 
When the story was fully unfolded no one could withhold 
admiration for tho brilliant manner in wliich ho developed 
his research from a simple chance observation, and the 
dogged perseverance which enabled him to overcome almost 
insuperable difficulties. Appreciations of this work, as it 
developed, have appeared from time to time in these 
columns, and only a brief summary need now bo given. 

In the course of some experiments in tuberculosis a 
subject on which ho had gained more than a national 
reputation as an investigator, Profe-ssor Fibiger noticed 
that three rats in one batch had tumours of the stomach. 
Knowing that this was a rarity, if not an unheard-of 
occurrence, he attempted, though without success, to trans- i 
mit those tumours by transplantation and feeding experi- 
ments, and by putting fresh rats into the cages previously 
occupied by the infected animals. Prolonged investigation 
of hundreds of serial sections of the tumours, which proved 
to bo squamous epithelioraata, revealed to his observant eye 
minute structures which enabled him to reconstruct tho 
picture of an undescribed nematode threading its way 
tlmough the superficial layers of the epithelium. Careful 
dissection of a preserved tumour afterwards provided him 
with a complete specimen of this worm, to which he gave 
10 name Spiroptcra ncoplasHca. Convinced that the 
occurrence of this parasite in all three tumours was more 


TfreCBrnm 
Mkuicii. JorRxit 


than nn iiccidcnt, ho sot himself td discover tho origin of 


. tu ui&uuvxT xiio on 

spiioplora, hut tho only information ho could'elicit 
of tho literature about nematodes 
uas that Gulch, many years previously, had found nematodes 
in tho s omachs of rats that had been fed on tho commoh 
cockroach (Pcnplartcia oricntalh). This clue was pur- 
sued, though the nematodes described by Caleb were of a 
(lilioreiit .specio.s, and Fibigor examined tho bodies of many 
rnw xn a district of Coponliagcn wLcre the cockroaches 
abounded, nnd ho fed liis laboratory rats on these cock- 
Toaches, hut in no case did ho find parasites in the stomachs, 
nor was there ever any trace of new groirths. But ho did 
not lose heart. Ho found out that in a large sugar factory 
in Copenhagen there were numbers of rats and swaims of 
cockroaches of a large and nniisual type — tho Pcriplancta 
amcricana — which had come from tlio West Indies with the 
consignments of sugar. Several of these rats were. caught 
and killed, and when they were examined they were found 
lo have gastric tumours, and in the tumours tho Spiroptcra 
ncoplasdca was found. His perseverance desen^ed its 
reward. Ho collected some of the cockroaches and fed his 
laboratory rats on them, and demonstrated that tho cancers . 
wore nhv.ays associated with the spiroptorae. Investigation 
showed liim that these cockroaches contained in their 
muscles the larval stage of a worm which, when the cock- 
roach was eaten by the rat, developed into the adult 
spirojitcrn in tlie gastric mucosa of tho rat. Tho worm in 
some wav stimulated tlie gastric epithelium to excessive 
proliferation of an invasive type, and when the mature 
stage of the jiarasitc was attained tho eggs were evacuated 
with tho faeces. This in turn was eaten by the cockroaches, 
and so tho cycle was carried on. Having thus succeeded- 
in infesting tho rats, and being uncertain of his supply 
of American cockioaclics, ho endeavoured to infest tho 
ordinary typo of cockroach from tho eggs evacuated from 
the rat, and in this ho was fortunately successful, for the 
sugar refinery was burned to the ground and his supply of 
American cockroaches ceased. The experiments, as *tho 
research went on, sliowed clearly that ho could produce 
gastric cancer in tho rats at will, that tho opitheliomata 
produced were preceded by more benign proliferations, that 
tbero was a minimum period required before the spiro- 
pterae produced their effects, that metastases were formed 
without tho presence of parasites, that tho ago of tho' 
animals was of no importance in respect of results, that 
wild rats and otlior rodents wero immune to tho action 
of tho worms, th.at mice were relatively insusceptible and' 
that tho production of gastric cancer in them was exceed- ■ 
ingly slow in comparison with rats, that tho spiroptcra 
could lodge in nnd produce epithelioma of the tongue, 
that other parts, of tlio intestinal tract were resistant to 
the action of tho parasites, and numerous other observa- 
tions. In short, he demonstrated that cancer could he 
caused by chronic irritation of peculiar types — in this case 
some toxic secretion from a parasite; hut it was perfectly 
obvious that this cancer-producing agent could not be 
invoked to account for any cancer except the gastric cancer 
of tlicso rats. There must bo other causes operating in 
other cases. 

Inspired by his work, lamagiwa and Ichikawa m Japan 
took up again tho attempts to produce cancer by pro- 
longed applications of coal tar, and showed us onco more 
that patience was tho necessary requisite for success. Tiieir ' 
experiments were welcomed by Fibiger, who introduced 
thorn to the. 'Western world and extended them, and 
furnished investigators tho world over with a ready means 
of inducing cancer and studying its early phenomena. 
Others have carried on the work in other lines, hnt all- 
will an-reo that to Fibiger is due the honour of blazing 
the trail. 


WILLIAM BRITAIN MORTON, M.D., 

Medical Superintendent, Wonford House, Exeter. 

Dr. William Britain Morton, medical superintendent ol 
Wonford House, Exeter, died on January 10th, aged 60. 
He was educated at University College Hospital, London, , 
took the diplomas of the England Conjoint Board in 1890, 
and graduated M.B.Lond. two years later, proceeding to- 


Feb. 1928] 


THE SERVICES. 


r Tin: Ur.iTTni 
L Medic. 1I. Jour.NU. 


201 






202 FEB. 4, 1928] OONYIOTION OF A "MEDIOAI. EtiEOTBIOIAN ” : REX T. PALMER. 


CONVICTION OF A “ MEDICAL ELECTRICIAN.” 
Tni; ancient lulo of our criminal law that a man who, in com- 
mitting a felony, caiisos tlia death of a human heing is guilty 
of the capital oRenco of murder obtains no favour with a 
modern jury. Proof of this was afTorded by the trial at the 
Old Bailey last week of Charles Jackson Palmer, who had been 
committed on charges of murder and manslaughter of a young 
married woman named Goldsmith, three months pregnant, whoso 
death in Palmer’s consulting room followed an attempt to 
procure abortion. 

In the past the abortionist was invari.ably charged with 
murder and .sentenced to death in our rriminal courts, as 
witness the words of Mr. Justice Hawkins in passing sentence 
of death in B. v. Cnlraore, reported in the Times of August 
9 lh, 1881 : “ That the offence amounts to wilful murder is the 
law ns it at present stands, and as in all human probability it 
will exist in time to come.” Juries, however, became unwilling 
to conrnct on the capital charge, and the Crown, towards the 
end of last century, ceased endeavouring to obtain a conviction 
for murder in cases of abortion, relying on the manslaughter 
charge instead. 

Here the Crown reverted to the old rule in charging Palmer 
with murder, but the Grand Jury threw out the bill, and the 
trial proceeded on the lesser charge of manslaughter. Despite 
the brilliant forensic efforts of the defending counsel, Mr. 
Norman Birkett, K.C., the potty jury found the prisoner guilt}' 
upon evidence which the Lord Ghief Justice described as fo 
clear, as to be quite overwhelming — “ it approached the certainty 
of mathematical demonstration.” 

The verdict of guilty meant that the jury accepted the 
evidence of two pathologists. Sir Bernard .Spilsbury and Dr. 
H. B. Weir — whoso post-mortem examination revealed an 
abrasion which suggested the use of a syringe and the presence 
of soapy water recently injected — and that they did not accept 
the defence that tlio young woman died of shock from the 
passing of alternating currents tiirough the body at a low 
voltage and for an innocent purpose. 

The defendant denied all knowledge of the fact that his 
-patient was pregnant. Possessing no medical qualifications, 
ho conducted a practice as a medical electrician, licensed by the 
lasndon County Council, at Upper Brook Street, giving treat- 
ment for muscular weakness and nervous debility. He said that 
jMrs. Goldsmith visited his consulting room five times for 
electrical treatment for nervous debility, and it was during the 
last of these visits that she died. The Lord Chief Justice's 
questions to an electrical engineer called to give evidence for 
the prosecution elicited the comparatively harmless nature of 
the apparatus found in the defendant’s consulting room. It 
was similar to what is in use in hospitals, and the amount of 
current of which it was capable was limited to 80 volts — quite 
insufficient, in his opinion, to cause a serious burn or .shock. 
This evidence the jury accepted, notwithstanding the testimony 
of an electrical engineer called for the defence, who said he 
himself could not withstand the intensity of the full current 
obtainable from the apparatus. The discovery made at the 
post-mortem examination was met by a complete denial — that 
the defendant did nOt give the vaginal injection of soap and 
W'ater, and that this must have been done by the deceased 
herself, or by some third party, before .she came to Ids con- 
sulting room. Dr. F. ■!. Browne, professor of obstetric medicine 
in the University of London, wiio, on the defendant’s behalf, 
attended the post-mortem examination, expressed the opinion 
that death did not follow immediately on the injection, as his 
microscope revealed indications that a miscarriage had been 
going on a few hours. Professor Browne thought it possible 
that the woman could have made the injection herself, and 
agreed witli the possibility of death from shock from electricity 
at low pressure. This was the strongest evidence produced by 
the defence, but it did not explain why, if the deceased or 
some third party gave the injection elsewhere, she went imirae- 
diately to Palmer for further electrical treatment for debility. 
It is not unusital for medical men to find themselves ranged 
on different sides in a court of law, Avith the inevitable com- 
ments by counsel. ” The jury,” said Jlr. Birkett, “ in dealing 
Avitli the medic.al evidence were in a region Avhere an eminent 
man said one thing and an eminent man on the other side said 
' I say tey the contrary.’ Both Avere Iionest men and both Avere 


distinguished men. One .said tliis and one said that.” In lair, 
If tlioro 18 a reasonable doubt in tlio minds of the jury the 
dofondant is entitled to the benefit of it, and an acquittal 
should folloAA-. The Lord Cliief Justice, in tlie final ATords of 
his Slimming up, said to the jury that ” they might think it 
right to ask themselves the question Avhotlier the true cOii- 
elusion Avas not, as it well might ho on this evidence, tliat 
the case for the prosccntion liad been established in every 
vital particular. ’ The jury, after an ab.scnce of an hour and 
tAvcnly-five minutes, brouglit in a verdict of guilty. 

After tlio verdict tliere came tlie police disclosure that for 
mcnitli.s p.ast the defendant’s premises bad been visited fro- 
qnciilly by tlie authorities because of suspicions that tlio 
practice of medical electricity was largely a cloak for running 
n profitable business as an abortionist. ° 

The Lord Cliief Justice, in passing sentence on Palmer, .said : 

"Tlio olTiccr Avho gave Iiis evidence so fairly coiicerning you 
Iiioiilioiicd on Friday certain suspicions that you had for some 
lime past boon carrying on tho trade of abortion. I shall 
deliberately put out of my mind suspicions and rumours of 
suspicions. It is right that I should direct my attention to tho 
CA’ideiice, and to the oAidence in this ca.so alone. 'That ovidoiico 
coiiA-iiiccs mo that you Avore carrying on tho trade of abortion. 
It was as a pci-son carrying on that trade that y'OAi Avero consulted 
by Mrs. Goldsmith. It Avas as a person canying on that frado 
that you treated her. Such persons undoubtedly subject tlicir 
patieiils or clients to very grave risks, and it is right that all 
of them, Avlierovcr they may bo in this country, should understand 
that they incur grave risks lliemscivcs. TIic laAV must IiaAC regard 
to human life, oven though tlio particular life m the imliAidual 
case may not he of the highest coiisoqueiice. In the niiblio 
interest it is necessary that you should go to penal soiritiido for 
seven years and pay the costs of the proseculioii.” 




As already anuonuced a special meeting of the conuoil of 
tUo Charity Organization Society will bo hold at Denison 
House, 296, Vauxlmll Bridge Bead, S.W.l, on Monday, 
February 13tb, when there will bo a disonssion on tho 
voluntary hospitals and the public anthoritlos. The speakers 
will bo Sir ivilliam H. Hamer, Dr. E. Graham Little, M.P., 
and Dr. Humphrey NooUolds. The chair Avill be taken by 
Lord Dawson of Penn at 3.30 p.m. 

AT tbo Mansion House meeting at 3 p.m., on February 8tli, 
in aid of tlio extension fund for the General Lying-in Hospital, 
Lord Dawson Avill take the place of Sir Berkeley Moynihan, 
who is uuablo to attend. 'The other speakers will IncUido 
Lord Birkenhead and Mrs. Stanley BaltlAvin. 

THE Fellowship of Mediciuo announces that Dr. E. M. 
.Stewart AVill lecture on secondary forms of mental deficiency 
at tho Medical Society, 11, Chanefos Street, on February 6th, 
at 5 p m. On the same day, but at 2.30 p.m., Mr. J. P. 
Lockliart-Muiiimory Avill give a clinical demonstration at 
St Mark’s Hospital. On Febrnaiy 10th there Avill be tv'o 
clinical demoDStrations ; the first, on diseases of children, 
will be given by Dr. 6. A. Sutherland, from 2 to 3 p.m., at 
tho Paddington Green Children’s Hospital, and the second, 
on cataract, Avill be given at 5 p.m. at the Royal Westminster 
Onhtbalmio Hospital by Mr. C. L. Glmblett. Tho lecture and 
the demonstrations are free to medical practitioners. From 
February 6tb to 18th there will be a special course in diseases 
of children at the Paddington Green Children’s Hospital and 
the Victoria Hospital for Children. The start of the course 
in venereal disease at the London Lock Hospital has boon 
nostnoned to February 20th. The course will oontiune for 
one month and occupy each afternoon and some evenings 
with clinical work ; lectures will be delivered if there is an 
entry Of six, and early application is therefore requested. 
A course in medicine, surgery, and the specialties "’ill be 
hold at Queen Maiy’s Hospital, Stratford, from February 20th 
vn 3rd: morning and afternoon sessions of leoturos, 

domouetrationa, and operations Avili be arranged. The general 
nnnrspof the Fellowshipconsists of attendance attheordmary 
nracHco of over forty London hospitals ; tickets for any period 
mav be taken out at any time. Syllabuses, tickets, end 
rnnins Of tho Post-graduate Medical Journal may be obtained 
from the secretary of the Fellowship, 1, Wlmpole Street, W.l. 

A ronnsE of lectures on nutrition in health and disease has 
hppn organized by the People’s League of Health, and Avill 
start on F^rnary 17th, at 6 p.m.,°continulug, with one 
exception (March 1st), on the folIOAVing Fridays, until the 
end of March. Professor Leonard Hill AA-ill open the course 
witli a lecture on the nature and purpose of food, and other 
subjects to be dealt with include historical and 
considerations, the siguifleanoe of 
to 

Tho _ 

from the People’s League < 


FEB. 4 , 192 S] 


MEDIOAIi NEWS. 


r The Bcmss 
L ilSDltUX. JoCfiXA& 


203 


Tub flttoontU nminal post-graiiiinto week for iniclwivos, 
srranccfl by tho General Eying-iu Hospital, York Koad, S.E.l, 
■will bo liokl from May 21st to 25tli liicluslvo. Tho names 
of tboso -wisblng to actoncl sbould bo sent ivitbont delay to 
tho secretarj', Toat-gradnato Wcok, caro of General Lying-in 
Hospital. 

THE following niombovs of tho modioal profossiou ■were 
called to the Bar on Jannary 26th : Dr. G. Wignaraja (Lincoln’s 
Inn), Dr. Norman G. Thomson (Middle Temple), and Dr. 
Daniel Broderick (Gray’s Inn). 

Major W. H. WHlTEnooSE, coroner for tho south-e.astcrn 
district of London, has appointed Llont.-Colonol W. H. Leslie 
McCarthy, D.S.O., M.C., M.D., D.D.H., barrister-at-law, to 
not ns his deputy assistant. 

The Minister of Health has issued a circular (No. 857) to 
local snperintendiug authorities under tho Midwivos Acts 
announcing that the reasouablo oxpondituro of those authori- 
ties on compensation of midwivos suspended in order to 
obviate risk of infection will be ellgiblo for grant uiidor tho 
Maternity and Child Welfare Regulations. It is added that 
sncli compensation should normally bo calculated on tho 
basis of the loss of incomo actually sustained by tlio midwife ; 
exceptional cases nro to bo reported to tboMiulstor before the 
authority concerned commits itself to paying compensation. 

At a meeting of the Joint Tnboroulosis Council on January 
21st it was announced that next Juno there would bo a course 
Of post-graduate study at Alton on surgical tuberculosis ; in 
July a post-graduate course at I’apworth and Cambridge ; and 
In October there would probiibiy bo ono in Edinburgh. At 
tho suhsequont luncheon Sir Gcorgo Newman delivered a 
short address emphasizing tho importance of uotifleatiou. tho 
dispensary, the sanatorinin, and after-care in the tubercnlosis 
campaign. Those present at tho luncheon Included Sir 
Robert Philip, President of tho British Medical Association, 
and Dr. C. 0. Hawthorne, Chairman of tho Ropresculative 
Body; Sir St.Clair Thomson, president of the 'i'uhorculosis 
Society; Dr.F. R. Waltois, president of liio Society of Super- 
intendents of Tubercnlosis Institutions; and Mr. G. S. 
Elliston, secretary of tho Society of Medical Olllcors of Health. 

According to the Canberra oorrospondont of tho Times tho 
Australian Inland Mission of tho Presbyteriau Church lias 
arranged with the Queensland and Northcru Territory Aerial 
Services, Ltd., tor an aeroplane to bo at tho constant disposal 
of tho medical officer of tho mission. The niachino will bo 
ntted ivith a stretoher and will acooramodato a nureo in 
addition to the doctor. In this ■way Isolated settlers will 
receive medical attention and may bo transported to hospital. 
Lonsnltations tvIH be arranged also with medical practitioners 
In remote districts. 


10^0 i? the Indian ilcdieal Gazette for -Tanuary, 

iWiJi}, tuat tl^re •will be no medical and veterinary section of 
Boience Congress in 1928. This is becauso tho 
Wnii*.!! ^ee^ress of tho Far Eastern Association of Tropical 
will availalilo papers. Tho section 

Madras in jJnn tto annual Indian Science Congress in 
or to rosfl those who intend to bo present, 

CoioDPi R Rnnwi^’s to communicate with Lieut.- 

Medidno " the Calcutta .School of Tropical 


Medical ®halr of surgery in the Women 

William IV tn honour of Professi 

Slstbirthflav veteran surgeon who celebrated h 

Philadelphia in college was founded 1 

snrS P"- Koon was in ciiarge of tl 

invited towards iha Contributious ai 

they mav be sent to Mrs professorshfi 

at North ColIeteVv^nR an'd 
■Pan flf.n t”. ®®t8 and 21st Street, Philadelphia. 

Accidents andOMupatiofalD®'^’®'^' ludustrii 

from September 2^4 ^ to 

obtained from Farther information can I 

12 , Stratford Piice.W?!?^''’^’ Industrial Medlcln 

MwBoine^’wm'b^eTekfar^R't?®^®®''’® Science ar 

1923, under the Eotterdara from April 2na todtl 

Rotterdam. Presidency of Professor P. E. Verkade > 


After twcuty-flvo years’ active work the Swedisli National 
Society for Combating Tuberculosis has issued a reporfi 
which indicates that tho process of eradication of this disease 
in Sweden is advancing. Over 7,000,000 kronor (abonfl 
£380,000) has been received in voluntary^ contributions, anq 
more than half this sum was raised by co-oporatiou with the 
Post OOlco, telegr.aphic messages being delivered on tastefully 
decorated forms ou payment of a small extra fee, the net 
in-ollt of wliich wont to the funds of the society. In Southern 
and Central Sweden tliero has been a decided decrease in 
tnboroulosis, and fresh eflorts are being prepared to combati 
the disease in the North, where it is still very prevalent. 
Tuberculous children receive special attention, and in ono 
year free treatment ivas provided for no fewer than 4,600. 

In the annual report of the United States Public Health 
.Service for tho year ending June 30th, 1927, the death rate 
from all causes was given as 12.1 per 1,000 of tiie popnlation 
for the year 1928, which Is rather higher than the rate for the 
previous year, tho inorcaso being due priucipallj’ to respira- 
tory nffcctions, excluding influenza, from wblch that country 
for tho most part was free. The diphtheria rate was the 
lowest ou record, both as regards incidence aud mortality ; 
this is attributed to the increasing use of antitoxin and toxin- 
antitoxin immunization. Declining death rates ■wore shown 
by tuberculosis, heart disease, diabetes, and nephritis. 
Small-pox in most parts of tho United States was mild, but 
in some localities severe forms occurred, particularly on tho 
PaciUo coast. The infant death rate continued to decrease. 
Investigation of narcotic drug addiction indicates a reduc- 
tion in the number of cases, and tends to confirm tha 
opinion previously reached that this is a nenro-psyebopathic 
symptom. 

The “ Metalix ” j;-ray tube, wblch embodies its own pro- 
tection, and has already been noticed in these pages (Decem- 
ber 24tli, 1927, page 1192), is the subject of two booklets 
published by the manufacturers (Philips Lamps Limited, 
145, Charing Cross Road, W.C.). One of these illustrates 
many examples of the uso of the tube in connexion with 
couches and screening stands and other outfits of the principal 
makers of z-ray apparatus. Tho other booklet explains in 
clear language the construction of tho tube and tho method 
of its uso, and emphasizes its value in physical research. 


^aUs, mt& 


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under the president ^nd to 5tb, 1928, inclnsr 
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tho'^ffiventOT^'^o^ Professor Eugene Koeber 

celebrated at StmsboaT 

Madrid psychiatrlsfi, 1 
Medicine. tbe Spanish Royal Academy 


QDSRIBS AND ANS'WBRS. 


Treatment of Ulcers of the Mouth. 

DR. A. Alexander (Dodilingtou, near Sittingbonme) writes: 
Empirically it has appe-ireil to me that there is a pliysio- 
logical cause for the mucous ulcers— namely, lack ot potash 
in the tissues. “ X. Y. Z.” might try the effect of, sav, 
5 to 10 groins of potassium bicarbounte in water charged wi£h 
carbou dioxide gas; a sparklet svphou made to contain about 
3 grains to the ounce of aerated water, and a wineglassful 
taken at odd times daring the day. 



204 Fed. 4, 1928] 


t/ETTEES, NOTES, AND ANSWERS. 


t tHxBmnfc 
iltDzcAL Jonxa 


Buy Mouth. 

‘‘B.”nslc3 for sagHostloiis for troatmont of u man, ngoil EG, who, 
for about fifteen years, lias siifforod trom.Yorostomliint iilKlitHino, 
when lie yooj to bod. Jlo Inis to keep small pieces of sugar by 
Ills bedside to induce uoorctiou. He is iu full work, notivo, 
appears much younger than Ills age, and has no adiposity. Ho 
neither smokes' nor drinks, nor has done so. The tongue is 
normal and there is no constipation nor other symptom. 

MuTAiiT.io Bismuth is the 'XuitaTMENT or rBOui.\sis. 

Du. G. Vaumn (Watford) nsks If others have tiled metallic bismuth 
in the treatment of psoriasis. Ho gives Intramuscular iiijcciioiis 
of the melal in doses of 0.1 and 0.2 gram each week, ami states 
that he has obtained compicto removal of these patches in most 
resistant cases. 

CEEANIKO DENTUnl!3. 

" Amicus ” writes: Jlay I suggest to “ T. M."tho simple expedient 
of cleaning the donturc once a week with homely “vim" 

i iowder? When once the carbonized deposit has been removed 
ly fine pumice-stone powder, the iiowder will keep the doiitnro 
ns new in nppoarnuce. I liave had fourteen years' practical 
exporicuco. 

Tueatment or Vulvitis. 

The following information has been received in reply to tho 
inquiry by “ R.” (Jouunal, January 2Slh, p. IGt): 

Dk. Ada McLauen (London) writes ; Has the patient sufforlng 
from vulvitis and cozomatous condition of tho mono veneris 
tried uUra-violot radiation 7 This hos been used with success In 
similar cases. 

Du. E. 13. FrEKN'ELl. (Walton. Olcvodon, Somerset) suggosts 
washing the inflamed part lightly with liikewarin water, drying 
with nhsorhont cotton, and npidyhig immcdlntoly uuguoutura 
cnlaminae (A. P.) once or twice daily. 

Du. Agnes Savill (London) writes: Tho oonditlous demand daily 
paHont care and call for the use of ^a^' cimugea In tM local 
treatment There Is always some iufoctlug cause present, 

usually a vaginal discharge, a“"’°V’^^^ntion b?o th6?soiwU^^^^ 
parts must bo protected con sniu atlon bi oithe^ 

infection during the treatment of “‘o n® foltowil 

will /livo H»q first Imtuilso towards cnrOi out *ousi ue lotio^eu 
■nn bv^lailv liiUb-fi'cnucucy treatnieufc till tho ewclliu^ dmimialios, 
w^iefi urad X iuoreaaing doses of ultra-violet light may be 
rmuioved. As soon as possible tho discharge must be dealt with 
bvffi ioii^alion; till this can bo given, however, a daily mild 
nut sen io douche will be suffloiout 11 niniiy oases o bring about 
S S ThrappUcatiou of mild moroiirial ointments and 
\v\u\ with bor 0 lotion, must be carofully 

soot img croams, and b.ai m diflloult early iierioil of 

Ibe'miro it is of the higheBt"importauoe tliroughout the course 
th inaleiili d^^^^ 

iroXeilCth^ gi^a“ter plirrot the twen'ty-Iour UoL, 

iKCoaiE Tax. 

^epdivs to Cor, 

"AS G” in 1926 sent his car to the makers for a very complete 
overhaul The liiVctor has allowed the oompauys charge, but 
. hlsrelused to allow^be expense of f'-d'j'R ‘o 

and back— two long journeys costing in all izu. 

• * • The cost of sending tlie car and of obtaining It back again 

seems clearly of precisely the same nature as the e.xpei.se of 
overbanl. assuming that the journeys did not serve n private 
purpose ns well as the main one. If a spate part bad to be 
obtained, obviously the cost of carriage would have beeu allowed, 
though it would be similar iu nature to the e.xpeuse which is 
refused. The point seems to ns so clear ns almost to make 
nrgnmeut difficult. Eerbaps our correspoudeut cau draw from 
the inspector some indication ns to the distinction he seeks to 
lay down. — 

letters, notes, etc. 

TUVATMENT OF OANOBR BY INJECTIONS OP PERITONEAL FLUID. 
TreATMLNi " iT,ondon 3V.) describes n method for the 

BE. J. B- T°V®“?er whicli. he states, has been followed by much 

treatment of cAucer ,^^,0 procedure is as follows; When 

' improverneiit m two . patient, and if 

peritoneal fluid In the absence of this fluid, blood 

\.evy thick It may be n™\®‘'',,e^^Hnated. The resulting fluid is 
is taken trom a vem a d ^ tungsten are lamp, without a 
BUbjeoted to and 20 minims of the treated 

reflector, lor ™ , subcutaneously to the patient. The 

material is vals of two to three weeks, according 

process is repeated at utej ' results, seven to ten 

to the amount o', b®'’®')^,,. „„tient begins to express a sense of 

davsbeiugallowedafte the pat ent O b 

well-being. Tbs o lias been no local reaetioii. 

lasts fiom seven to ten , maiTied woman, aged 38, 

Br. Tomb'eson’s 0''st „,„My„aiit growth of 

in whom laparotorav discIO",ed a iatge - butaveac 

nuoartain origin, ahe was discliarged as mcuiaWe, nnea year 
Tatar peritouealfluid was removed aud she was given an injection 


according to tlio procedure described. She was then weak, ani 
distended with a tliiok and tronoly fluid, tlio legs and abdomea 
being very ooilomatoiis. Six suhsoqiioiit Inicotions were given 
and her conililion imiirovcd considorably, tffo tumour decreased 
in size, lliero was very little distension of the abdomen, anil no 
ooiloma of the lungs or abdominal wall. She is now livinj 
a normal life and is nblo to dance. Tlio second patient rraa 
a business man with caroiiioma of tho rcctiiin, colotomy liaviug 
been jierformcd for tho relief of iionto obstrnction. Bmler Ibis 
treatment Iii-s condition improved very considerably; be has 
regained the iiowor of walking, tho pain is much less, and his 
weight has Increased. 

Tue.atment or Prostatio Enlargement. 

" I3Sr/R3rXR ” (London, B'.C.) writes: With regard to tbi 
Biiggcstioii of ‘‘General Pnictitioiier ’’ (Dublin) iu your issue o 
Jnmmry 2lBt (p. 120), siioaldng ns a radiologist of not iucon 
sidorahlc oxporloiico I can say that if on adequate dose of x rayi 
of suitable quality— about 75 per cent, of the unit skin dose— ii 
applied to tho iirostato In cases of simple enlargement, a gooc 
rcHiilt will ho obtained oftcr about eight weeks iu at leas! 
CO )ier cent, of cases ; a largo iiroportiou of the remainder will be 
cured, for all pmctical purposes, after a second application. 
Except for the time gii’Oii to ibe actual treatment the patient s 
ordinary life is not Inlorforod with. I wish it to bo distinctly 
iiiidorstood that iu making the above . statement I am referring 
to cases that come to the radiologist direct from the general 
practitioner- not viii tho siirgoon. 'I’he latter rarely passes on 
cases of any kind that are still iu t.’ie curable stage, and evidenci 
based on Biioli lias little, if any, value. 

Bn PrncY Hall (Loudon) writes: Oases of prostatio enlargeraen 
are not ot nil uuoommoii iu general prootice, and, short b 
oiiorotlon no spooiflo method of treatraeut is available 
Prostatio massage and internal remedies, iuolndiiig orgauo 
tlicrapoutio pre|iaratioiiB, are, as a rule, disappoiiitmg. I bare 
occn.sloiially found, however, that 20 minima of the liquid 
extract of ergot, given, with an equal amoimt of the tincture 
of hyoscvamiis, thrice daily for short periods, oecasiotinlly pro- 
duces iiiiirked relief from the troublesome symptoms, which 
may bo duo toachronio prostatitis cans ng a degree ot iiiflarama 
tiou aud swolliug iu addition to the actual odenomntoiis enlarge- 
' ment It these are removed the |iatbological lemaiiiing per- 
miiuout oniargomont may not bo suffioieiit to cause troublesome 
svmntoms, mid may not Inoroaso m size. When the [irostite 
olaiid is so enlarged that definite mechanical ohstriiotiou renders 
mich remedies useless, much can still be done, iu my ex|ierieiioe, 
^lort ot operation. Three modes ot Ireatmeut which have 
nrovod usotnl iu my hauils may he used iu coujui otiou or sep.a- 
i-alfilv Tlie flrat is tlie diatliermy cm reut by means of a re t.al 
Seotrode, another electrode being placed above tlie piihio regn n ; 
a ourvout ot from 0.5 tol ampere passed daily, or ou alterimta 
davs for a few weeks is frequently suffioieiit to produce marlced 
■relief' socouiUy, ultra-violet radiatiou given by meaus of t ie 
Kvomwor lamp with a suitably curved quartz electrode m the 
■ McTum^ twice weekly for ten to twelve doses, will also coiisidei- 
lialn These doses should ho suffioieiit to produce o mild 
?DCal venctieu. Too large doses may result in slight pam and 
tnuesmuB and possilily sliglit bleeding from the inflamed rectal 
Y^Hresa- they Bhonld be avoided, although, beyond slight dis- 
tl ej'-do not result in any ndveiso effects ; thirdly, small 
fonizhu' or fraotional doses of a: rays, given bi-weekly or weekly 
for ten°or twelve doses, should produce marked diminution u 
' of the prostate gland. The rays.may he directed through 

iiIb rectum perineum, and suprapubic routes. Pmyerlul nppa- 
rnfnalfi ot required; indeed, better results are probably obtained 
pauivolent spark gaps of from 5 to 7 inohes. So many 
w^rits snfforiug from this distressing condition are given to 

patients 6 Iiiori^s „othiug bnt operation is of any avail that 
i'.'ronpial Practitioner’s” inquiry is welcome, since the possi- 
bintv ot other remedial measures should be more gfiaeially 
known to the medical profession. 

Pkoobeation after Prostatectomy. 

TIT, m Rardner (Brighton) writes: Following up Mr. 0. 0. 

' ■■ " ■ ■ Journal of January 21st (p. Up 

Elliotts _ A man, aged 60 or 61. married, 

„ -3 old. She agreed to marriage 

in 1915. fhB 'understauding that there were to be no children. 

hLland whose prostate had been removed two years 
^®UpT\ad be’eii assured by the surgeon that )t was impossib a 
to nrooraate oliiUlreu. but, within a 
Savrik^e,^ she became pregnant. In this case also there was uo 
doubt ns to the paternity. 

Conjoined Twins. 

tick of which appeared in our issue ot Jammiy 14th Qp- S2). 

Vacancies. 

''kXTvacanY 

_i tr. ^iinn7fivie7it B.t V0>n0 Oif, 


Feb. II, 19:8] 


JOHN HUNTER. 


[ Tes iJRrn^ 
UeDicii.-DCBMu: 


205 


^ discourse 

OK 

TEE POETKAITS AND PERSONALITY 
OE JOHN HUNTER. 


Sir AHTHUB KEITH, SI.D., LL.D., 

F.U.C.S., F.K.S., 

COSSIRVATOR OF THE MUSEUM AND IIUNTEniAN TROFESSOR, ROYAL 
COLLEGE or SURGEONS OF ENGLAND. 


pN July 22nd, 1831, tlio Court of Examiners was seated in 
the Council Room of the Collego of Surgeons in London 
cross-questioning young men who appeared before it as 
candidates for mem- 
bership. On the wall 
behind the examiners 
there hung, just as at 
the present time, 

Reynolds’s famous por- 
trait of John Hunter 
(Fig. 1). Haring 
done with bis ean- 
didato, tho senior 
member of the court, 

Sir Anthony Carlisle, 
rose from his scat and 
proceeded to feast his 
■ eyes on tho features 
of the man, who had 
taught him the prin- 
ciples of surgery 
forty years . before. 

Presently he began ' 
to look closely at the 
various objects which 
Reynolds bad intro- 
duced into' the back- 
ground of tho picture, 
and, having satisfied 
himself, resumed his 
seat and wrote on the 
. back of a stray shoot 
of paper the fonowinc 
note* : 

■'oshua 

Reynolds picture of 
John Hunter ; ho 
has intelligiWy ponr- 
trayed his pursuits 
oy the two exposed 
plates; the one dis- 
plays a series of 
forehmbs, from the 
simplest foot to the 
human hand. !„ the 
opposite plate he 
ranges the human 
skull first and de- 
scends to the quad- 

h'n°s'*from’\^\*’°"' ^ ■"’•'‘le paper showing radialing 

under his pSY and terminating at a point 

-■An imots and r-, ^ss books are Xalura! H.stor;; o 

ground is of Vegetahhs. In the back- 

of a spliced ‘’’e g™al Aant, and the example 

j ^Ph-^ad spme by an ossific prop." (See Fig. 1.) 

not°laS!incr'’well!^/-“''® Reynolds’s portrait of Hunter is 
tbo background ’but for details m 

wbicb Slmrn 1 • preserved in the engraving 

trait fF Uli T®,'” from the freshly finished por- 

of HiiiiIaT f,” . Sharp, the friend of Reynolds and 
on thp in’ ™ instigator of the portrait; be prevailed 
artfJ Af i of the time to sit for the master- 

successfiil W ®*Sbteenth century, and was ultimately 
'' e m ay be sure he took pains to get eveiy 

rupil of^John in the cliarv of my predecc'sor William Clift, 

t William Cliit conservator of the museum, 

he seems to he ^I’S.J^ate as 1785, but, as will be explained later, 

” ^rroT. The proper date is 1788. 



Fio 1 Sharp’s eneravmg of Keynolds's picture of John Hunter. In the background 

nre slioiv'n the various objects described in the text. (Photographed by Grove and Boulton 
from Sharp's engraving.) 


detail right in bis engraving, niid henco it is Sharp’s 
rciidoring of tbo background of Hunter’s portrait that 
is reproduced in the illustration given here (Fig. 1). 
But tliero is one other source of information preseiwed 
in tiio’ Royal College of Surgeons — a small but exquisite 
oiiamol done on copper by Henry Bone early in the nine- 
teenth century, when the rich colouring of the original 
Reynolds was still fresh and vivid. The Hunter family 
had' it done, anticipating just what has happened— that 
tho great jiaintcr’s pigments would prove to be not per- 
manent. Hence it is from these two sources, and the 
Hunterian specimens in the museum, that we have to 
reconstruct the objects represented in the background of 
the origlnnl picture. 

IVc may be sure that Hunter, in supplying Reynolds 
with tho materials for a background, picked what he prized 

most— objects or re- 
presentations which 
illustrated his most 
cherished discoveries. 
'The folio of drawings 
which stands open 
upon the table on 
which his left elbow 
rests (Fig. 1) is one 
of many’ which his 
brother - in - law Sir 
Evorard Home com- 
mitted .to the flames. 
The folio has been 
opoiied to show two 
of JTunter’s “ graded 
series ” ; they give us 
his conception of tho 
two structures which 
make -man ■ man — the 
head and the hand. 

In .the !‘ head ” 
series the skull of a 
European' is placed at' 
the top; then follows! 
that of an Australian - 
aborigine; then a' 
young chimpanzee’s ; ■ 
then a monkey’s — a ■ 
macaque; then a 
dog’s; and lastly that, 
of a crocodile.' I had 
a mind to set these 
same skulls up again — ! 
in the Hunterian order . 
— but the drawings 
are’ not given in suffi-- 
cient detail to pevmit 
individual skulls to ' 
he recognized. It is 
strange, too, that ! 
although Hunter cer- 
tainly dissected a 
chimpanzee and also 
a gibbon, and has left 
notes of what he 
observed, their skulls cannot now be traced; they are not 
mentioned in the original catalogues compiled in Hunter’s 
time, nor in those of a later date. 

On looking at such a series, with the most highly 
developed human type at the top and a reptilian form 
at the bottom, with a bridge of intermediate types between 
them, the modern student may jump to tho couclusion 
that Hunter had grasped the idea of man’s evolution. 
Hunter may have suspected the truth, but be was held back 
by just the same obstacle which kept Huxley from giving 
his complete allegiance to Darwin. Until we have pro- 
duced varieties from a common stock which are infertile 
with each other we have not solved tho final crux of 
evolution — tho production of new species. That was 
Huxley’s obstacle, and it was also Hunter’s; but I am 
sure neither the one nor the other would bo surprised if 
they knew that practical students of genetics are now 
removing even this last obstacle, 

[3501] 


206 Feb. ii, 1928] 


THE PORTBAITS AND PERSONALITY OF JOHN: HUNTER, 


r Tbz Eiin«i . 
L Vzoioit, Jonius 


In Ill's “ Imiul ” .sfiics Hniitor shows oven greater pro- 
science. The horse is given tlio highest plaeo and man is 
relegated to tlio bottom of the list. The gap helwoon tho 
extremes — reading tho scale in a descending order — is: ox, 
pig, dog, monkoy. Tho “ hand ” of tho horse is tho most 



Flo. 2.— Porlroit, believed to be that o( Jolin Ilunlcr, recently 

S resented to tho Royal College of Surgeons by Hr. G. Buclietoo 
rowne, F.R.C.S., F.S.A. 


speoializcd, most highly “ evolved,” of tho mammalian 
series, and my friend Professor Wood Jones would support 
Hunter in placing tho human hand at tho bottom of tho 
primato scale. I do not agree; in many respects roan’s 
hand does retain old-world features, hut there aro others 
in Avliich it is highly specialized. However, these personal 
differences are neither hero nor there; tho broad fact 
stands out that Hunter had ranged. his series of “ hands” 
in the order now accepted by students of evolution — an 
order which it is clear his pupil Carlisle had not fathomed 
and which was regarded by Hunter’s contemporaries as 
highly absurd. These “ graded series ” represent two of 
the many ideas which went into tho flames. Wo have to 
thank Reynolds for their proseiwation. 

Sir Anthony Carlisle misread the titles on the two books 
on the table. The title of the upper is Natural History of 
Vegetables, and contained notes which Hunter kept of his 
experiments and observations on plants and trees; tho 
lower. Natural History of Fossils, was tho gleanings of a 
lifetime from geology and from a study of the, fossil 
remains of animals and plants which had come into his 
possession. Hunter bad a dozen such volumes, each dealing 
with a particular line of research, but it was these two 
he wished to accompany him into posterity. They also 
went missing after the conflagration; fortunately Clift 
had made abstracts from them, and, strange to say, years 
afterwards the two original volumes came to light again: 
Sir Everard Home’s son returned them to their rightful 
owners— tho Council of the College. Nor does one wonder, 
when their contents aro known, that Hunter was proud 
of them. Wo find that he ■ had ceased to deal with the 
Mosaic bank of time 'and , had demanded an unlimited 
chronology to account for what he had seen and found. 
Ho had discovered that the secrets of living matter could 
bo wrung from plants more easily than from animals, and 
the experiments ho had performed on seedling beans aro 
only now having their counterpaits in the laboratories of 
the modern experimental embiyologist. 

'"■ns proud of O’Brien’s skeleton; its feet dangle in 
e background of his portrait. In those limbs lav the 


secrets of growth. Tho giant, although his death belongs 
to tho summer of 1783, was not a public exhibit in Hunter’s 
musoum until 1788, when Reynolds was at work on tbe 
inal portrait of Hunter. Tho finishing touches were given 
a year later 1789. Then comes that puzzling specimen 
placed hy tho giant’s right foot (Fig. 1, background). 
Carlislo tolls us it is “ a spliced spiiio by an ossific prop ” j 
. ly , h translated into modern phraseology, must mean I 
a hone-graft introduced cxperimontaJly for tho repair of 1 
a lirokcii dorsaf spinous proccss-^f an ox or horse.” My ! 
cbJieaguo j\Ir. Cecil Beadles and all oiir assistants have 
.hunted- high land lou' for tho original of this specimen; 

It is not ill the muscniii, and there is no mention of it 
in any catalogue. It must represent one of .Hunter’s most 
prized specimens. As to its nature, wo must be guided by 
its representation in Bone’s miniature. It is presei-red in 
spirit; the round hottlo in which it is mounted is about 
■^11 inches lugh and four wide. The "finer arteries of tho 
specimeini'avo bceir'successfully injected with vermilion ; 
it is the shaft of a bone laid open — about the size of tho 
metacarpal of an ass; Hiintor selected tho metacarpal of 
the ass for many of his experimental investigations into 
the repair and living reactions of hone. There is a gap 
in tho hoiic — apparently half an inch or more has been 
sawn out. At one side of the shaft, closely adherent to it 
and crossing the gap, is tho “ ossific prop,” which I take 
to be a bone-graft, covered by patches of granulation 
tissue, introduced experimentallj- to secure the divided 
bone. In the iiiusemii is a serie.s of metacarpals of the 
ass, showing the results which Hunter obtained while 
experimenting on the growth of bone and the exfoliation 
of necrosed areas. Tho specimen wbieli Hunter had placed 
ill bis picture seems to belong to this series; the notes 
which relate to all these preparations wont up Sir Everard 
Home’s chimney in Sackville Street. 

On the table by which Hunter sits is placed a specimen 
protected by a glass shade — one which puzzled my colleagues 
and myself for a long time. It looks like a successful 



5, rortrait of John Hunter by Robert Iloijle. Tbe original 

is in tile rooms of tbe Royal Society, Amndon, 


ijcctioii of the bronchial system of the lungs of Bome 
liiiial, blit no’ trace of such a specimen could be touna 
1 Hunterian catalogues or collection. The puzzle was 
Ived bv Mr. Cecil Beadles; lie recognized it as a 
unteriaii specimen still preserved in the W"®®™ 
SO. 2060.1) the desiccated and dissected hings of a man 



?EB. Ill 1928] 


THE POKTEAITS AND PERSONALITY OF JOHN HUNTER. 


207 


Carlisle describes tiio 


wbo bad an osteosarcoma o{ tbo lower end o£ the nglil 
fomnr, with secondary bony deposits >n tbo lungs-dcposits 
which had infiltrated and picbcd olit all the i.iimfications 
of the bronchial tree. The rcmaimng object in the back- 
ground of the portrait concerns the aboet 011 v.liieli 
Hunter’s elbow vests (Fig. 1). 
diagram on the sheet as “ radiating 
lines from a largo periphery tcrniin- 
ating at a point under the elbow, 
but gives no explanation. M illiain 
Clift docs; on Carlisle’s note bo bas^ 
written: “ The facial angles of tlio" 
skulls shown on tbo ndjaccnl draw- 
ing” — a bad guess; tbo diagram 
has certainly nothing to do with 
facial angles. In Bono’s ininiatnro 
this drawing is reproduced clearly, 
and appears to represent a system 
of vessels — almost certainly arteries 
— arranged so as to show branch- 
ings at various angles, thus illus- 
tratiug a matter to which Hunter 
gave much study-^tho laws which 
regulate the angle at which a 
branch artery separates from its 
parent trunk. 

Thus wo sce that in choosing llio 
materials for the background of his 
portrait Hunter exercised great 
care. In the opened folio, showing 
the graded scries of “ hands ” and 
heads,” we see him os a philo- 
sopher of natural objects; the two 
closed books bound in sheepskin 
represent him as botanist and as 
geologist; the rare jiulmonary 
preparation under tbo glass shade as patliologist ; the 
drawing under his elbow as philosophical anatomist; the 
" wet ” preparation as experimental surgeon ; and the 
giant’s legs as a collector of Naturo's wonders. 

Huuteiy \yas_60 years of ago when ho was painted by 
Reynolds; everyone is familiar, with tho face thoreiu por- 
trayed; reproductions or engravings of tiic original picture 
still hold the, pride of place in the medical consulting 

rooms of the English-speaking world. Let 

me introduce to the reader at this point 
another, picture of Hunter— one still tlic 
Bubjret of hot debate, but whicli I am 
convinced is a portrait^ or represoiitation, 

° u 6’’®^!', surgeon at an earlier date, 

^en be wm _ about 50 yearn of ago 
tl ig. g).-. This -picture made its fust 
on December 

ist, lSa 2 , when a collection of portraits 
and pictures • ‘ tho property of L. M, 

•wf Hertford Street, 

•Mayfar,”160 in number, “.most of 
great names attached to 
r’hvJstJr .' ^0 auction at 
ns catalogued 

V Gainsborough ” — a 
i.’® portrait representing llie 

tb^of r pnt up for sale 

tto auctioneer stated that iio guarantce 

amW®" portrait was “of 

•Sot u 1 -Ganisborougli,” but 
orSt- a picture of bigli 
^'■•.G-Huckstou Browne, 

' ttudent of medical 

bis !ifi ^ coiiector of pictures all 

, made a dose examination of lot 



>rn T5;j t 1 . oAuniination or .. 

Utt 1 ’ ovidoiice of its being a picture done in the 

^'*0 eighteenth century, and satisfied himself 
* 0 genuino representation of John Hunter the 

.Porchased it, and with great generosity jjre- 
P'ofore to tho Royal Collego of Surgeons. The 
^iicge thereupon obtained the expert advice of tho director 
r tlie Aational Portrait Gallery, tho lato Mr. James D. - 
j liner, aud of Mr. W. T. tVhitloy ; they had no doubt about 
ho picture heiug of Hunter’s time, nor that it was painted 


hy an artist of standing, hut rejected it as a genuine work 
by Gainshorougli. A study of the canvas, technique, 
clothes, and details proved that the picture had been 
painted, in all likelihood, between 1765 and 1785; but 
wlioro had it been in the century and a half which had 
elapsed between the date of painting and its first public 
appearance in 1922? . The task of 
tracing its history-was entrusted to 
Jliss M. Tiidesiey, at present en- 
gaged in compiling a catalogue of 
tho craniological collections in the 
museum of the Royal College of 
Surgeons and well known by the 
studies she has published on tho 
portraits of Sir Thomas Browne, 
Sho obtained access to the note- 
books of Reynolds and of 
Gainsborough; she discovered, for 
-example, that in 1788, when John 
Hunter, was giving sittings to 
Reynolds, he was also attending 
Gainsborough professionally in that 
artist’s fatal illness. She searched 
the archives of the Royal Academy, 
tho lists' of -work of cigliteentb- 
century artists, and of all sale cata- 
logues, ancient and modem, but of 
this picture could discover not a 
trace. 

IVe arc driven hack to prove that 
we have now another genuino 
portrait of John Hunter on the 
evidence afforded by the picture 
itself. The .right forefinger is 
pointing to a skull held in the left 
■ hand ; it is the' skull of a monkey — 
almost certainly of the macaque genus— veiy similar to the 
monkey’s skull which occupies the central place in tho 
Hunterian “ graded series.” The artist must have drawn 
from an actual specimen, but, either in a spirit of freakisb- 
ness or to improve the appearance of an object otheiwise 
rendered faithfully, has given a human outline to the 
nasal bones. Who in the eighteenth century besides John 
Hunter made the monlcey’s skull the central subject of a 
discourse? There was, of course, another 
John Hunter — a Dr. John Hunter — ^wlio 
was born in Scotland about 1750, and 
obtained his JiI.D. degree at Edinburgh 
in 1775 by 3 thesis on “ The causes of the 
varieties of mankind,” and afterwards 
gave himself to military medicine. But 
he was neither anatomist nor zoologist. 
He was not tho man to be handed down 
to posterity with a monkey’s skull in his 
hand, for in his thesis he declared that he 
“ looked on the suggestion of ape being 
transformed into man as monstrous.” Ho 
became an eminent Follow of the Royal 
College of Physicians, hut no portrait of 
him has been preserved. 

But what of the features of the man? 
Are they those of John Hunter? We 
know the features which Reynolds gave 
to Hunter at the age of 60, but what do 
we know of them at an earlier age? The 
sources of our knowledge are these : first 
the portrait now in the rooms of tho 
Royal Society, a rejilica of which was 
presented to the Royal Collego of 
by Sir John Bland-Sutton 
That portrait was painted by 
about the time when John 
sister Anne Home, Hunter 
being then about 40 years of age. We are shown 
John in gala attire, debonair, seated in a sylvan glade 
with his dog — half mastiff, half wolf— resting his muzzle 
confidingly on his knee. The coat has no collar but 
long cuffs, and the waistcoat, embroidered, tightly 
buttoned. The features are open ; the face rather clean- 
cut, not puffy or full. Tho next record we liavo of him 




"■K .V c’-r-rs 




"•V-? iV' 


V. 




I*JG. 5.— Life cast of Huoier'e face lalien either 
io 1786 or 1788. (Pholcsraph by S. Steward.) 


Surgeons 
(Fig. 3). 
Robert Home, tbe artist, 
Hunter was courting his 



208 Feb. ii, 1928] .THE PORTRAIXS AND PERSONADITY OP JOHN HUNTER, 


[ 


TnElJMTJf* 
Medical JotsMA 


is tlio ))orl)-nit in oils whitii Jinngs in tlio Jial) of the College 
of Siirgeons (Fig. 4) ; it also was iiainted hy Jiis hrotlier- 
in-la\v Rohpi t Homo, and was done four or six year.s after 
tlin other. Hunter is liero shown in worhing garb; his 
hair, a deep sandy yellow rather than red, is cut .short in 
front, as in the new poi'trait, hut hangs long about tho 
ears.' The colouiing of tlie coat, and indeed tho whole picture, 
<'atches its tone fi-om tho hair. Hunter had 
changed in the year.s which olajjscd between 
those two portraits; his face had lost its 
clean-cut features and become jjuffy and full. 

There are three points in this picture to bo 
uot<-d : (1) Tho long tapering forefinger of 
the left hand^ — exacth’ the same form of 
finger as points at the monkey’s skull in tho 
new ]iorti'ait. (2) Tho .slight twist of the 
soft parts of the nose towards the left side 
of 1110 face and the asjuumetiy of its tip — 
there being a fullness just over the loft ala; 
the same features coiiio out in tho new ]ior- 
trait, which is not a stud}’ in reds and browns, 
blit one carried out in cool gi'cys, the hair 
being powdered and the costume toned to 
match. (3) The well known wart, situated 


demonstration oil a favouriie topic. Hunter was short- 
necked, higli-sliouldcred, and full-clicsted ; the artist has 
been liind to ]iis .sitter in nil of these ro.spcets; he was 
also, as we have Kocii, indulgent to tho nasal features o! 
tlic nionkcy^K skull. 

Another source of infovmntion regarding Hiuiter’s head 
IS the medallion made by Tassic in 1791, two rears before 
the groat surgeon’s death, and iio'w preserved 
in the College collection. This record is of 
yaliie; It gives a true profile of the head 
(1* ig. 6), aj)d from it aijd from the Jtrynolds 
cast of the face wo can make approximato 
estimates of the shape and dimeiisions of 
Hunter’s .skull. Tho length of hi.s skull was 
between 190 and 195 mm., a few millinietres 
above the average Glasgow male of the nine- 
teenth century. Its width was about 142 to 
144 mm., being about 74 or 75 per cent, of the 
length. Hunter falling thus within tho cate- 
goiy of “long-heads.” His skull, as is so often 
the case in the Scot of tlie’sontli-west, was 
low-vaulted, rising not more than 115 mm. 
above the level of the car pa.ssages. These 

dimensions tell ns that Hnntov’s brain snr- 

011 tho right side of the bridge of Hunter’s p,o 6.— Enemving by .tdlanl of I’f'^scd that of the average British iiialo ouly 
nose, is scon in the second “ Home ” portrait T.is5ic’a mcslallion of Jolm Jlimtcr. by a little; its cubic capacity was alront 
and also in the new portrait (sec Figs. 2, 4, S!lic'c?ron' «rthe Boyal Mkge’of ^.cm .H wo turn to the monograph 

and 5). Tho now portrait 1 suppose to have Surgeon-. which my fnend Dr. Matthew T'ornig wrote 

on tho Seottisli skull,’ founded on material 
drawn from the disused graveyards of Glasgow, ac find many 
specimens which in shape and dimensions uiako a near 
approach to the Hunterian tyjic. Physically Hunter ivas in 
no sense an exceptional man; we can recognize Ids great 
inborn gifts only by measuring what lie succeeded in accom- 
plishing. Ho was a man of very short stature, only 5 feet 
2 inches, so Clift lias recorded. People of bis sandy-red 
colouring and short st.atiiro are particularly frequent 
among the people who live in the western counties — 
between Wales and Argyll. 

Perhaps the most reliable of all Hunter’.s portraits is 
the pencil drawing 



been drawn some years after the second one 
by Home — somewhero about 1775-78, when Hunter was 
reaching Ids fiftieth year. The man is ropro.scnted in a 
forceful mood, alert and alive — the work of an artist of 
nndoiihted talent. 

The third source of Hunter’s features — tho most rolinhle 
of all — is tho life c.a.st taken of his face in Reynolds’s 
studio, either in 1786 or 1788, a photograph of which 
is reproduced here (Fig. 5). The cast .shows Hunter’s 
vide month and inohile lips — the upper lip very cxpaiisis’e, 
passing between the deep lateral iiaso-hnccal folds. There 
IS no suispicion of rnbhit month in the cast; tho upper 

dental arch is wide and 
well formed. Tho face 
was not long — about 
123 mill, as we anthropo- 
logists measure faces — 
hut it was exceptionally 
wide and rather Hat; 
the width across at the 
zygomatic arches was 
145 mm. ; it was opc- 
cially wide over the jowls 
or angles of tho jaw.s — 
about 140 imu. — <Iue in 
jiart to tho fatness of the 
checks. The forehead 
wa,s wide hut not high ; 
its width, measured on 
the cast, was 110 iiiiii. 
The supraciliary eniiii- 
ciices were full and strong, 
hut the sujira - orbital 
ridges had nothing of the 
sliar 2 nicss and temporal 
projections seen so often 
in a Scottish tyiio of 
manhood; tho vvidtli of 
tho forehead on a level 
with the' upper margins of the orbits was 115 mm. — 
verv little more than the forehead at its narrowest. Tho 
noiv portrait reproduces the modelling of Hunter’s forehead 
•rs closclv as any of his acknowledged portraits. But tlioro 
is in the new portrait a narrowing or compression of all the 
facial features; tho upper lip, lower lip, and ohm have 
all tho peculiar features which are manifest 111 tho plaster 
cast, there is a feeling of side-to-side compression in 
tho representation of tho face, cspcoiaTly at tlie jowlsj 
this tho new portrait resembles tho second Home 
portiait. One has to remember that the artist has sought 
in the Buckston Browne portrait, a ^[spenk- 
; Hunter is depicted in the act of gnung a 




m a do h y Si r 
Nathaniel Banco 
Holland in 1793— 
tho year in which 
Hunter di6d. It is 
almost a true ]no- 
filo (Fig. 7). Wo 
note in particular 
Hunter’s small, 
deop-siiiikcn eyes 
and his short neck; 
as lie aged, . Ill’s eye 
receded and his 
head sank down 
more between bis 
shoulders. The new 
portrait, while it 
catches a certain 
cuiwatiire, of the 
uiipcr eyelids, gives 
no suggestion of 
the ojes being small, 
but thoy do not 
depart so much in this respect from tho oyos of the second 
“ Home ” portrait. Hunter’s eyes wore light in colour — 
a grey-hluo, with a slight pigmentation near tho margin of 

tho pupil as depicted in tho Bone miniature. This is the 

colour which has been given to them in the new jiortrait. 

There is still another portrait which deserves close atten- 
tion th.at preserved in tho Apothecaries’ Hall (Fig. 8). 

It is said to ho by Ee}Tiolds, and I have no doubt it was 
painted bv him. Miss Tildesley has worked out the details 
of its history. The tradesman who looked nfti’i- Hunter’s 
establishment, and continued to supervise the I>eice.stcr 
Square property for years after Hunter’s death, was James 
Wcatherall, upholsterer in the Haymarket. Mrs. Hunter 
gave him tho picture in question, informing him th.at it 
was Reynolds’s sketch of her husband. 3Ir. 'Wcatherall 
gave it to his nephew, Mr. Thomas Knight, who practised 


l?iu. o.— puoiograph of the Hunter portrait 
in the Apothecaries’ Hall, Lonclou. Its history 
is given in the text. 



Feb It 1528 ] 


THE ACUTE ABDOMeU. 


r TftzBRinss Of]Q 

LilEDIClI. JOCBjrll. 


ill ClicKca. a licentiate of the Apotliccnrios’ Hall, and 
“ one of the lively.” Mr. Knight iircsciitod it to the Hall 
in 1857. Non-, in her researches into the history of 
Beynohls’.s great pietiiro, Mi.ss Tilclesley was pnuzled by this 
curiotts cirenmstnnco: From Reynolds’s notebook she found 
that Hunter gave his first sittings, four in nnmhor, early 
ill 1786: the sketch then done was shown in the Academy 
exhibition of 1786 ns “ the portrait of a gentleman.” On 
jts return from the exhibition Hunter gave Reynolds 
another .sitting— in Septciiiher. Then bomothiiig happened 
—probably a dissati.sfaction with the l esnlt, both on the part 
of artist and of sitter. Nothing was done in 1787, but in 1788 
Hniitov again sat three times to Reynolds; then, in 1789, ho 
sat fire times — in Iho afternoon from 2 o’clock to 4 each time. 
The Apothecaries’ picture represents Hnntor with a thin, 
strac^iiag beard and moiistaehe, hut the poise of the sitter 
is esaetiv that of the acknowledged portrait. I'lie Apothc- 
earies’ portrait cannot be a copy of the finislied one; the 
rough materials for the final picture are there, hut the 
inspiration and the finish, in a iiiiiltitiidc of details, are 
altogether lacking. How are wc to explain all of these 
facts— the two quite seiiarntc sets of sittiiig.s, a sketch by 
Hoynohl-.. whicli Airs. Hunter disliked; " the (lortrait of 
a gentleman ” cxliihitcd at the Royal Ae.odemy in the 
summer of 1786; its coming homo and an attempt' to mend 
it? And, then, why should Reynolds want a plaster cast 
of Hiiiitei'.s face? All those things can he explained if 
we siipjiose that the Apothcoaric.s’ jiortrait is the picture 
done in 1786 — ^tliat it was an admitted failure; that Mrs. 
Hunter disliked it; that a new one, the final portrait, 
was painted in 178^89; that Alr.s. Hiiiitcr was glad to get 
rid of the original picture, and gave it to Air. AVeatherall; 
and that Reynolds succeeded in getting Hunter to .shave 
off lii.s beard and become n fit subject for iii.s art — by the 
subterfuge of proposing a plaster east of bis sitter’s face. 
Tt is a painful process for a bearded man to submit his face 
to the east-maker; it is easier and better to Inivo the beard 
removed. That seems the most feasible exfilanatioii of 
a curious sequence of events. 

Snell, then, is the story of Hniitor’s portraits, so fai- 
ns oiir present evidence will permit us to tell it. Our 
study lias bad the advantage of hriiiging us into close 
touch with the personality of a liiau whoso like tlie world 
will SCO hut seldom'. • 

‘ erideiice of the authenticity of the new 

I'-c' ! bliQ testimony of one who is better 

vr'l I • ( ban any of u.s to recognize a Hunter — Aliss 
Ss^in-' u grnhddaugliter of Alatthew 
nephew, and now the chief living ropro- 
her ■ '' 1 " family. She bor.self i cpi-oduces 

rr.'m..'Iil!i features and mental outlook with 

noVtihiJ ' * familiar with Hiiiitei-iaii 

d n - that the now 

pqit.ait IS that of John Hunter. 

infonii.s 11 s that there is to bo an 
of til., u " Hunterian portraits and relics in the Almsenm 
frnin 'r.'.>i'!.'” °f .Surgeons, Lincohihs Inn Fields, 

and .stiid - fj*. tStli, open to all medical men 
i-.: “i.™ portraiture. Visitors ivill have an oppor- 

ij Qf Hunter with 


t^ity of cnmpai^^g ^ o 

beciT fitm'i portraits. A soi-ics of specimens have 

portrait ' the background of Reynolds’s 

auato'niv nl.vsmi'’ ® chief discoveries in surgery, pathology, 
ewemn/iVe, Y “Sf. zoology, botany, and geology will te 
Vr Preparations chosen from the original 
interest ' !' {“ action. Students of Hunter’s history will be 
Presidoio o^''ihit prepared at the request of the 

Georire f ” ^ Gollege — Sir Berkeley Aloy-iiiban — ^Ijj- Dr. 

iilintnir,. i ^ ^ehey. By means of maps, sketches, and 
m'efme '**c*^T ^cpeliey has succeeded in giv-ing a vivid 
emit.. . . fjoiidon in the latter half of the eighteenth 
nei.; 1 '’ * “homes” of the Hunters during that 
Stti/V ’ what these “homes” look like to-dav. 

ttL n-'i'i''’ Hunterian interest have been loaned bv 
' c Pcllcome Hi.storical Aledical Aluseum, Hniversitv of 
wasgow, .St._ George’s Hospital, Apothecaries’ Societv,' and 
other in,stitntiou.s, to make the present exhibition as com- 
plete as possible.] 

I n.. IT .n « HEFEREKCn. 


^tibrfss 

02f 

THE ACUTE ABDOMEN. 

Given- befoiie the DBWsmiiiv Division- of the Bihti.sh 
AIedical Association- 

BY 

F. R. .FLINT, F.R.C.S.En-g., 

ASSIST.l.VT SUEGEOX, GESBKAL ISFir.MARY, LEEDS. 

Dt'itiNG the years 1924 and 1925 almost one-fifth of the 
patients admitted to the surgical wards of the Leeds 
General Iiifirinan- were cases of one kind or another of 
the acute abdomen, and the total mortality rate of those 
two years is mainly attributable to these lesions. 


The Commoner Coiitliiiotm oecurrintj in Jf)S4-2-j i?i Order 
of y rcijttcncy {rxcltidiue/ Huhueutc Types). 


Acute appendicitis 

Cases. 

1,0S0 ... 

Deatlis- 

58 = 5.7 per cent 

Strangulated herniae of all 
types 

190 ... 

... 43 = 22.6 


IVrforaled ga'^tric and duo- 
dena! ulcers 

150 ... 

.. 34 = 22.6 


Acute obstructions 

139 ... 

.. 55 = 40 


Acute cholccvstitis 

19S ... 

6 = 5.6 


Acute salpingitis 

48 ... 

2 = 4.1 


Ituplured viscera 

29 ... 

.. 16 = 55 


Ruplurcd ectopic gestation 

16 ... 

0 = 0 


Acute pancreatitis 

13 ... 

9 = 69.2 



Though those statistics are not sufficiently large to form 
an accurate index of the order of frequency of these 
diseases as a whole, yet they illustrate the common ty-pcs 
of acute abdomen in an approximately correct order. In 
.some cases the acute lesion is a conqilication of a disease 
which has existed it may ho for months or years, and 
has, therefore, given ample warning of tlie impending 
catastrophe. Perforated gastric and duodenal ulcers afford 
a good e.xaiiiplo, hut the same applies to many of the 
acute obstructions and the .strangulated herniae. Certniiily 
over 90 per cent, of gastric and duodenal ulcers have shown 
their existence by characteristic indigestion over many 
years. 

Further examination of these statistics brings to light 
another iinsatisfactoi-y feature, and to illustrate it I will 
analyse the acute appendicitis figures. Iii 1925 the cases 
of acute appendicitis admitted numbered 612, and of these 
301 (ahiiost Jialf) were complicated by abscess, or diffuse 
or general jieritouitis. AVlien appendicectomy was qier- 
formed before these complications arose there were no 
deaths, so that the mortality is confined to one-half of the 
eases, and these all late ones. It is this “ too late ” 
lactor which is responsible almost entirely for the high 
mortality of the acute abdomen; I wisli to emphasize this 
most .stiiongly, ami at the same time to say that the time 
is brief between the onset of the attack and the “ too 
late ” pei iod ; it does not as a rule exceed forty-eiglit houi-s, 
and after twelve to twenty-four hours the margin, of safety 
is rapidly passing. 

The .surgeon may make his contribution to the mortality 
by perforniiug unsuitable operations, hut I think it is 
fair to say that he has little or no share in the “ too 
late ” episode. There can he no doubt the responsibility 
lies between the medical practitioner and the jiaticiit, or 
perhaps, more correctly, tlie patient’s friends. The more 
I see of acute abdominal conditions the more convinced 
I become that it is the friends ulio waste the time. In no 
disease is this better exemplified than in acute appendicitis. 
Tlioro is too often a meddlesome household therapy as well. 
Tile patient, often a child and so unable to fend for itself, 
complains of had stomaeli-aclie and is promptly given a 
dose of castor oil. There is no mor“ certain way of 
.sin-eading infection to the peritoneum than by stirring up 
the intestines with aperients at the beginning of a local 
inflammation such as appendicitis; when it is seen that 
the pain is worse the doctor is summoned, and by this 
time probably the appendix has perforated, and, of course, 
the doctor or the surgeon receives the blame if the result 
of an ojiei-ation is unsatisfactory. I reeentlv advocated a 
eampaign of public education, properly controlled, in 




Feb. II, 1928] 


THE ACUTE ABDOMEN. 


L UeDICAI. JorBNAX. 


This attitude is quite justified, for, if one aivaits a certain 
diagnosis, peritonitis of haenidriTiage, or both, are usually 
BO advanced that a fatal result is inevitable. The primary 
shock may bo severe, and an operation have to he del.a 3 ’ed 
on this account; but if the patient rallies in two or three 
hours and still the pulse rate does not drop, it is almost 
certain that there is some condition needing operative 
relief. Those cases require repeated examinations, and at 
short intervals. 

Obstructions. 

An carlv diagnosis in intestinal obstruction is, perhaps, 
even more’ important than in the inflammatory conditions. 

It may happen that an inflammatory condition will get 
well of itself; but it is extremely rare for an acute ohstruc- 
tion to do so, and after the obstruction has lasted fort 5 '- 
eiglit hours the operative raortalit}* becomes very heavy; 
in the table' it will be seen that it is about 40 per cent., 
excluding strangulated heraiae. Moreover, it is often 
difficult to differentiate acute obstruction from spreading 
peritonitis after the second or third day, when absolute 
constipation, incessant vomiting, rapid pulse, distension, 
and great prostration may be found in both conditions. 

The three cardinal symptoms of acute obstruction in the 
early stage are pain, absolute constipation, and persistent 
vomiting. Pain is most marked when tliere is strangula- 
tion as well — for example, in volvulus and the various 
binds of hernia. It is at first sharp and colickj-, later 
more or less continuous, until it ceases with the onset of 
paralysis. In obstructions of the large intestine it is felt 
in the lower abdomen. Gradually increasing distension is a 
prominent, sign of obstruction. In the earliest stages it 
may be confined to particular regions of the abdomen — for . 
example, in obstruction of the small intestine it will be 
central, whereas in obstruction of the large intestine it 
may be most marked in the riglit side, across the upper 
abdomen, or along the whole course of the colon, according 
to the site of the lesion. Visible peristalsis may be seen 
at this stage,' if the patient bo not too fat, and periodic 
hardening of the caecum may be felt; this is a very 
useful sign of colon obstruction at the beginning of tlie 
attack. When the acuto attack follows chronic stenosis 
of some duration a tumour may be felt, and it should 
be a rule always to examine the rectum. 

Oonsiipation . — This is absolute for both faeces and fl.atus, 
but there are one or two points to note. Both may be 
passed in sm.all quantities with the first enema, owing to 
the bowel below the obstruction being cleared of its 
contents. Subsequent enemata will produce no result. 
Also, to be a dependable sign the enema must be a high 
one, given with the patient’s hips raised. In acute intus- 
susception frequent liquid stools may be passed, as there 
may be a sufficient lumen in the invaginated gut to allow 
of this, but other signs' clinch' the diagnosis, such as 
haemorrhage from the bowel, a sausage-shaped tumour 
in the abdomen, and a tumour felt in the rectum, and 
also tenesmus; and, of course, it is most often seen in 
children under 2 years of age. 

T omiting , — Faecal vomiting only occurs after the third 
or forirth day, and therefore has no useful place in 
diagnosis. The first vomit is stomach contents, and has a 
more or less innocent appearance; later it becomes bilious, 
and frequently repeated, much more so than in acute 
gastro-entoritis. The oft-repeated vomiting is in strong 
contr.a.st to the vomiting of appendicitis, which occurs once 
or tuice soon after the onset of pain, but is not froqucntlv 
repeated until peritonitis supervenes. 

1 early diagnosis the first question to 

be settled IS whether or no an acute obstruction exists. If 
present, the c.arlier an operation is performed the better. 
Ihe exact position of the actual lesion is not such an 
important m.atter ; of course, an attempt should be made 
to ascertain this, and a good history will be most useful in 
tins respect; If there is a scar of a previous operation, it 
should bo kept in mind that adhesions associated with this 
may bo the cause of the obstruction. The hernial aper- 
tures should always be examined, and also the rectum. A 
history of comparatively recent increasing difficulty with 
the bowels, slight colicky pain at times, possibly a little 
loss of weight and general well-being, and occasional dis- 
tension of the abdomen .in a patient at,- or- over; middle- 


ago, would suggest a growth as the underlying cause. A 
pr-evioiis histofy of gall stones should make one suspect 
that a stone may be impacted in the small intestine. In 
this condition the symptoms may appear rather insidiously, 
and visible peristalsis may bo well marked. I have been 
able to diagnose the condition before operation in the 
last four cases I have seen. 

In the early stages of, acute obstruction repeated exam- 
inations are necessary. It m.ay be impossible to be sure 
of the condition in the first few hours; if the bowels have 
not acted or enemata are unsuccessful, if vomiting con- 
tinues, accompanied by an increasing pulse rate and abdo- 
minal distension, even if a definite diagnosis cannot be 
made, it will be in the best interests of the patient to have 
a laparotomy performed. A delay of forty-eight hours, 
when obstruction is present, may clinch the diagnosis, 
but will usually prove fatal from toxic absorption and the 
shock of the obstruction. 

Sacmor.rhages. 

The liaemqrrhages associated with gastric and duodenal 
ulcers, cholecystitis, appendicitis, and the like, though 
acute abdominal conditions, very seldom indeed require 
urgent operation, and I shall not deal with them 
hero. The pathological lesions responsible for the type of 
haemorrhage in group 4 of my classification are practi- 
cally confined to two — namely, those associated with injury, 
in which case there is a history of accident to guide 
one, and ruptured ectopic gestation, which I will deal 
with later. 

In the presence of shock which the accident initiates it 
is almost impossible to say whether bleeding is going on 
or not. The symptoms are very similar, though with 
haemorrhage alone there is usually an absence of uncon- 
sciousness, cold clammy sweating, and dilated pupils. 
Sometimes shifting dullness may be found, and is sugges- 
tive of haemorrhage; it should be looked for particularly 
in the flanks and above the pubis, and when found in the 
early hours before the onset of distension it is a verj' 
valuable sign. Bleeding may stop as a result of the low 
blood pressure associated with the shock, only to begin 
again as the shock passes off, and one notices an increasing 
pulse rate and pallor, and the respirations become more 
shallow. It is essential to chart the pulse rate every half- 
hour. A slight degree of rigidity is often present, and 
, also localized or diffuse pain. 'There is also tenderness 
coextensive with the rigidity. Increasing pulse rate, dis- 
: tension, and vomiting indicate an advancing peritonitis. 

: If pain is due to injury of the abdominal wall alone it 
may be quite severe, and may be associated with rigidity 
too, but in this case the rigidity is never so marked as 
when there is visceral injury, and it yields to light 
pressure. 

If a hollow viscus has been torn, vomiting, perhaps 
mixed with blood, is a prominent feature, and haemor- 
rhage, tarry or bright red, may be passed by the bowel. 

Injury to the kidney is followed by haematuria, possibly 
a swelling in the loin, and pain radiating into the testis 
or thigh. A diagnosis of rupture of the bladder depends 
upon tho histoiy and location of the injury, small quan- 
tities of bloody urine recovered on catheterization, pain 
in the bladder region, and constant ineffectual desire to 
micturate. The injection of fluid into the bladder as a test 
is unreliable. 

Rupture of solid viscera gives the signs and sjTiiptoms 
of internal haemon-hage, but the maximum of rigidity and 
tenderness will usually be found over tbo injured organ. 
Fracture of tbe lower ribs often accompanies iiijiirv to tho 
liver and spleen, and pain may radiate to tbe shoiddcrs 
when the injury is to the liver. 

In ruptured ectopic gestation there is sudden severe 
abdominal iiain, with collapse and the signs of internal 
haemorrhage; the face and mucous membranes are 
blanched, there is great restlessness and thirst, and attacks 
of syncope, with a rapid, weak pulse. Tho abdomen is 
uniformly tender and there is a degree of rigidity, but 
not so marked as is found in tho inffammatory conditions. 
The abdomen is distended and gives a peculiar doughy 
-sensation to touch, and there is tenderness and fullness in 
Douglas’s pouch. These are diagnostic indications of a 


212 Fed. 11,-1928] 


CABDIAO INFABCTION. 


f Tnr British 

UtDlClLJoCRSiZ, 


niptiiicil cctopio gestation, if they occur .in. a woman who 
has' lintl a- long' period of sterility, of - a history of pelvic i 
^disease, with irregular menstruation, - pud. especially,, if.: 
menstruatimv has. ceased . for six wcelcs' br-so,'.diiririg'whicli , 
tho. early signs of pregnancy may bo seen, and , at tho end > 
of about six weeks tlidro is' a discharge of clots from' tho ! 
'vdginh, 'with colicky 'pain in 'tho lower abdomen. 

Tho .treatment is immediate' opdratioh,' and, it is stir- i 
■prising how well these patients do afterwards, even though ; 
they may bo, and usually are, terribly blanched at tho; 
time.' I -have .occasionally given a. transfusion of blood, • 
and it seems to help. Blood- transfusion may bo of the * 
■greatest value in those cases where the blooding is diio ' 

to injury. - ' 

"'i have not gone into a detailed differential diagnosis of! 
'all the surgical lesions included under the heading" of 1 
the acute -abdomen;, it would make tho paper .much too > 
lohg. 'Id tho early stages there is usually .little difficulty . 
in deciding which organ is responsible. Again, I have ' 
refrained from discussing abscesses-and peritonitis. These I 
-are- complications, and tho acute abdomen should 'hot 
operated. 'on' before they appear. Jf a patient , suddenly 
■'experietices' adufp abdoniinar pain, "follpwed by nausea or; 
yomiting,. or -both,, ap'd this, is ^accompanied by tenderness, 
-and. rigidity,- possibly in .some degree, over , tho whole* 
'abdomen, _but most pronounced, over, the, most painful area, 
'(which , is’ suggestive . of tho site of the , lesion), with or, 
without, shock, or if with tho. pain 'and vomiting there * 
is absolute constipation, there is _ an acute, abdominal' 
condition 'present' which is almost" c'ertainly of a surgical: 
na.ture.- If tho lesion can bo accurately placed so much tho; 
'bett'er';' .biif this docs hot miittor' so much to the surgeon | 
as getting tho case . early, for he sliould, not tackle the . 
■job' at all if ho is. not able to' deal with any surgical' 
■ catastrophe which inay bo exposed bn bpehing the abdomen. ’ 


TWO OASES OF CARDIAC INFARCTION: 

One Followed dy C.ilcification op the Heabt, 

THE Otheh by EopitmB. 

BY 

T. 'WISHART DAVIDSON, M.B., Ch.B., D.P.AI., 

ASSISTANT AICDICAL OFFICER AND PATHOLOGIST, CITF MENTAL HOSPITAL, 
LEICESTER. 


j)uRiNG tliG past two years there has been a considerable 
increase in the literature on coronary occlusion, cardiac 
infarction, and rupture of the heart. The two cases to bo 
described have been put on record owing to certain unusual 
and interesting features. 


, Case i. 

A man, aged 55 (shoe hand), -was admitted m June, 1901, in 
a state of acute excitement with hallucinations. Ho slowly became 
demented, but led an active and useful life as messroom worker, 
vanman, and hospital messenger. In August, 1^25, at tho annual 
nhysical examination, the heart was found to be enlarged to the 
left nipple line; there was a soft mitral systolic murmur and 
occasion^ extra-systoles. The lungs were clear. On November 
13th 1925 he was confined to bed for a few days with bronchitis 
and ’slight oedema of feet and legs; there was no albuminuria. 
He was soon up and about again, working as usual. On tho 
evening of December 12th, 1925, he returned from afternoon leave 
and complained of not feeling well. He went to bed and slept 
for an hour* at 10 p.m. he went to the ward commode, collapsed, 
and died at 10.3. There was no record of the Wassermann 
reaction. 

Post-mortem Examination, 

The heart was greatly hyp.ertrophied and weighed 809 grams 
(28t ozl- length from aortic ring to apex 14 cm.; mid-yentricular 
V. IZ® cm • left ventricular wall, 2.5 cm. thick; right 

^ Time’s wall 09 cm. thick. The pericardium was much 
ventricular wa h ^ around the apex over an a.rea 8 cm. 
tluckened, of blood vessels passed from tho adhereut 

wid.e; There was a small quantity of straw- 

perioardium to the apex^.^^xu.^^ 

coloured fluid out sufficiently to contain a golf ball, 

ventricle was halloo dilatation was fibrous, with scattered 

The anterior ,Va'' andAn^^^^^^ Bub-endo- 

patches of ° rru- -nex and tho left lateral, medial, and 

cardial flaemorrha,j^e. P j^arked calcareous deposit which 

posterior walls were fitoous 'Vjn septum. There was 

extended 7 cm. along tno inte^euvn u , .. . 

formation of fibrin on tho calcareous nodules 
here and there through the endocardium, 

intact, and lined tho irregular inner aspect of the dilatation, ihe 
myocardium was brownish and soft, and the papillary muscles 
much hypertrophied, ATI tho chambers were dilated and hyoer- 


trophied, .Tho aortic ' cusps wero thickened, and tho ^mitral 
thickened and. .incompetent.. Thcro .were .a • few/ small . patches 

of hlhc’roma in tho ascending aorta, . 

-.Tho; .-left /edroonry- aricry •.wns'rhcallhy. afc.'jifs.. origin/: but "-iust 
inside, tho; mouth- there- -was - atheroma ^with 'Carly- calcareous 
'deposit;/ 3/ erri.^ "from Ulid. origin; of-. tho main vessel there wa) 
compjold pccltision pf Ure antorior-dcsccnding branch for a'dhtaheb 
:bf. 2. cm;,, ond .beyond-' that* tho walls were greally-thickehcd', ' with 
na>Toiving of tho lumen.' Tho right coronary, artery; showed slight 

nthcromh. “ • • ■ - 

'Microscopical Ezamintiiion . — The left coronary artG^_ was athero- 
matous and occluded by organized thrombus. •TIicio Was'gfeai 
proliferation of tho iniima, and fibrous tissue w’as arranged ir 
whorls around- small .vessels' formed during- i-ho- canalization of’.th* 
'thrombus. ^Yellow granules, of .'haemosiderin. lay -amongst. Ihi 
•fibrous tissue. Tho muscle 'fibres of .the myocardium were ifrcgula: 



■ '"7- to mu^' fS 

rthe-ipoB tho muscle, fibres -wero very BCBjityj-^aud -^thero^wai 

bundant win • kfdne'ys' wer£ 

[ chronic hr* . . 

’nost^inquiry revealed no history of any illness "or com- 
Close inqmiy nt-s part to point to occlusion of the 

^“!,ntrv artery - yet .:the anterior descending branch had 
hTnoked ' arid extensive infarction of the inferior hali 
rt"ho ?e?t ventHcIe, -including tho septmu, had oocun-ed 
n * -Tifiret had undergone softening and .been leplaoed hj 
t^iu'e Vhich 'had stretched, . pipducing aneuiO'SH 
ibrous ‘Extensive calcareous deposit -had occuirec 

^ ft d^^I.ear^muscIe, and', judging from this the 
“ftt tst have carried .on with', a .damaged heart foi 
latient mu p'ossibly years, until he presented signs 

: coasiderablo time, p from. 'which he appar- 

,f heart failme / ^ followed by sudden death 

:„tly «'=“'^?;AratSat stool. 'Goodall and Weir' repori 
,ossihly whilst of the hear! 

.Viree cases ot coi y j ; r near lavatories 

-p*”™* ■■ 

imilar ws that occlusion may occur so slowii 

Hamman’ considers^tna^ final occlusion. Thayer- quote: 
hot no sympton periods of three years and thirteer 

-- “'/rSc onf td states tlJ ultimate^ deat! 

or from gradual heart failure. The cas< 

^In ^Gibson's' eenectioi 
Calwficafw of^tl ^1 American 

,f j literature there is no example of calcifica 

ind infarct. Scholz' describes a case of calcificatioi 

,,on *ff/i,o^ins coronary occlusion in a male agei 

,t an infarct to J] . hjcally intra vitam and con 
-4, He remarks that where calcium salt 

irmed post moi infarct “ the calcifying pioces 

;re deposited in involving a larg 

rradually takes o It may 

irea and a apparent elimination of so laige- 

vorth f “^/rUselo causes very little d stress t- 

mrtion of the he the conducting system of the hear 

;he i^erfered with by the calcifying process, 

lappens to bo interierou „f„rnrv occlusion, followei 

Burns in 1809 

r1p.scribed by Askanazy in 1901. 



ATJEICDLAR FIiISTTER. 


Feb. .II, 1928] 


E THcBnmsH 015 

JIeuicai. "Aw 


Cask n. 

A woman, aged 65, was admitted in November, 1925, in a state 
ot enilcptic confusion and restlessness. There was a history of 
epilepsy for the previous thirty years. On admission Iho cardiac 
dullness was normal, but the heart sounds were soft and family 
beard ; the action was regular ,in rate and rhythm. On May Mth,. 
1926. she complained of pain in the cliost, vomited, and breafimd 
witli difficulty; the next day the temperature rose to 101® F.. 
pulse 120 respirations 38, the pain m tlio chest was acute, dyspnoea 
marked and the face extremely congested. Fever continued for 
six days, and the pain and dyspnoea slowly passed off. The 
patient' apparently recovered and was up and about from May 25tli 
vmtil June 6th, when she again complained of pain over the heart. 
■From June 24th there was fever ranging from 99° to 100.4° F.. 
pulse 80 to 100, respirations 20 to 40; dyspnoea, cardiac pam, and 
cyanosis until June 27th, when there was sudden syncope and 

Unforlunatelv, there is no record of the character of the pulse, 
cardiac dullness, sounds and action, or of the presence or absence 
of pericardial friction, etc., and the case was not diagnosed during 
life. The lYassermann reaction was negative. 


Post-vi ortem Ejrmn iimiion . 

The heart was hypertrophied and weighed 481 grains (17 02 .) ; 
length from aortic ring to apex, 10 cm.; mid-ventricular diameter, 
B cm.; left ventricular wall, 2 cm.; right ventricular wall, 0.75 cm. 
thick. The pericardial sac was distended and contained over 
two pints of fluid blood; clot was \vrappcd around the licart like 
a cast. The pericardium was adherent around the apex and to 
the anterior surface of the right and left ventricles over an area 
6.5 cm. wide. Blood oozed from, the left ventricle along the edges 
of the pericardial adhesions. There was infarction of the apex of 
the left ventricle involving the 'mj'ocardiuni for a distance of 
4 cm. along the interventricular septum. "A laminated thrombus 
3 cm. thick filled the apex^ The' myocardium appeared healthy; 
the anterior cusp of the' mitral ‘valve and the aortic cusps were 
thick and fibrous-; dhe -valves -were competent. The aorta was 
atheromatous at tho arch. . : ■ • 

The left coronary .artery was Miealthy at its origin, but 1 cm. 
from its mouth the vessel was tlirombosed for a distance of 
2.5. cm. The right coronary artery was health^’. 

• Microscopical Examination . — Tho left coronary showed irregular 
"signet ring” proliferation of tho inlima,* with final occlu- 
sion of the lumen by thrombus which was being organized. 
The infarct showed, .necrotic muscle fibres. Tlicro was active 
phagocytosis by large multiuuclear cells and leucocytes; bands of 
white’ .fibrous tissue replaced the dead muscle fibres, aud the 



Fig. 2.,-— Case 11 . Section through left ventricle ; (a) adherent 
pericardium; (t) infarct; (c) laminated thrombus. 


pericardium adhered by a delicate fibrous tissue meshwork, in 
which there were small haemorrhages. The lungs were heallliy, 
Tlie kidneys were pale and fatty, and the vessels sclerotic. 

TUofe were no marked signs of cardiac tliseasc until 
corouai’y occlusion occurred; then there was sudden acute 
cardiac pain, dyspnoea, vomiting, and fever lasting ten 
days. The patient apparently recovered and was able to 
be up and about for a period of four weeks; meantime 
ischaemic necrosis had occurred. Pericardial adhesions 
formed over the infarct and were apparently efficient for 
foiir weeks, when, presumably, stretching of tlie infarct 
took place with bleeding into and through the softened 
tissue to the pericardial sac along the line of the 
aanesions, resulting in haeniopericardium. Hamman^ 
considers that it is exceptional for a softened infarct to 
iiiptiiio and cause death .soon after occurrence of the 
occlusion. 


’ I 
for 


am indebted to Dr. J. Francis Dixon, medical superinlendcn 
permission to publish particulars of the above cases. 


= JouasAL. 1927. i. p. ew 

Tot '31,1921. "■ !’• ‘Schola: Arch. InU Alcd. 


AURICULAE .FLUTTER." 

BV 

C. E. K. HERAPATH, M.C., M.D., 

' ASSISTANT PHYSICIAK, BKISTOK KOYAL IlrrlKMAr.Y. 

AimicuL.in flutter is an abnormal hoai-t rhythm the 
diagnosis of which is difficult in the absence of instrumental 
methods, but usually possible if certain points are 
considered. 

The fundamental factor of the condition is that the 
auricles start a very rapid rate of contraction, somewhere 
in the neighhourhood of 300 times a minute. The diastolic 
period allowed at that rate is so short that the ventricles 
are not properly filled and their output is diminished. 
The ventricles are usually unable to follow the auricular 



rate owing to the conductivity of the bundle of His being 
unequal to such rapidity of function, and for that reason 
every other stimulus is held up by the bundle and a con- 
dition of 2-1 heart-block is set up ; this is really a protective 
heart-block, which is useful in that it protects the ventri- 
cular muscle from exhaustion following on an extreme 
tachycardia. Exercise, which stimulates the sympathetic, 
is Imown to increase the conductivity of the bundle, and 
sometimes it is found that exorcise may cause tlie ventricles 
to follow exactly tho auricular rate for a short time 
(Fig. 1). . , 

Usually a 2-1 block is present, so that the veiitri- 
enlar rate is about 150 a minute ; and this rate is very 
constant — it remains the same whether lying, standing, or 
even moving about. Sometimes the ventricular rate is 
about 75 — a 4-1 block^ — and this is a'here we are vei-y apt to 
miss the condition on a cursoiy examination, hut rcallv it 
is the best chance for diagnosis. If exercise is given the 
rate, instead of rising slowly, jumps with a sudden bound 
to double the original rate — namely, about 150 — or in some 
cases it may become quadrupled to about 300, This is 
characteristic of flutter, and there are only two conditions 
where this may occur: in a trained athlete on exercise 
tho rate may rise with a jump from about 60 to 120, and 
on rest the same thing may occur in the opposite direction ; 
auricular flutter is the other. It is commonly said tliat this 
may occur in paroxysmal tachycardia, hut, although sudden 
jumps of rate do occur at the onset and offset of the 
attacks, the increase is not a multiple of the former rate. 

In flutter an intermediate rate may occur, for the block 
may vary between 2-1, 3-1, and 4-1; in this case there is 
ventricular irregularity, and the clinical diagnosis then 
becomes still more difficult. The symptoms to be expected 
are some degree of heart failure if the rate he much above 
normal, on iiig to deficient ventricular output, yet, clinically, 
at rest the heart may appear to function properly. The size 
of the heart may he little if at all increased ; tho rate may, 
as we have seen, he about nonnal. Occasionally a constant 
ripplo may he seen in the jugular vein in the neck, corre- 
sponding to the auricular contractions, but this is not often 
present. The chief points for diagnosis are an unvaniiig 
rate over long periods, unless by doubling or quadrupling, 
associated with breathlessness. 

The condition may occur in apjiarently- healthy or in 
obviously diseased hearts: it is essentially a similar con- 
dition to auricular fibrillation, the former being a ro"ular 
tachycardia, whereas the latter is an entirelv irregular 

• Eeceived for puUication June ZOth, 1927. ■ 



214 Fkb. ir, 1928] 


ATJEIOOriAH FIiUXTEB. 


[ TnEnumt* , 

UEDicii. JonniX 


tachjxnrclia. Tiio 0110 condition may very easily pass into 
the other, and, in fact, may ho made to do so by means of 
dings. 

Tlio treatment consists of tlie administration of digitalis 
or quinidinc, or botli at tlio same time; its results will bo 
demonstrated in the eases recorded below. 

Case i. 

A strong, Iicallby-Iooking man, aged 28, was invalided out of 
Ibo army with disorderly action of tlio heart. Ho received a 
pension for fivo years, and then it ceased ns ho was considered 
well. Eighteen months later he developed extreme tachycardia 
on exertion and was sent to my out-patients’ department. The size 
of the heart was doubtful, but a radiogram showed that it was 
very much enlarged. There was a soft systolic murmur at the 


on holiday. On my return I was informed 
urred, and therefore s!ic had been taken, of! 
■ " rfiythm was normal, and 

il till the present time. 


foi , ^ attack of influenza during wdiich he was 

mith tachycardia associated with 

Pigns of lieart failure. The tachycardia 
continued for eight months. I saw him in August, 192l. TIio 

no murmurs. The pulse 
?” this went up to 288 with 

pulsus altcrnans, as shown by ■ AimViiNi. 

K’lfi” ssii “i„ - 

time came on and I went away. On my return I found the 




Fig. 2. — Shows 2*1 block In auricular flutter. 
P, auricular waves; n, s, and t, ventricular waves. 



apex. The rate was 132 at rest, but this rose to 264 on exertion. 
The condition was manifest. A** ’owed 2-1 

flutter at rest (Fig. 2b but 1«1 * 1). Ho 

was admitted and placed on t minims 

lliricQ daily, and in a few days the ventricular rate was slowed 
owing to a mixture of 2-1, 3-1, and 4-1 block (Fig. 3>. Digitalis 
was continued (15 minims thrico daily) for three weeks, with no 
effect but that the block became 4-1. Quinidino was then given.* 
The condition changed from flutter to normal rhythm after tlio 
third capsule, so no more was given; flutter, however, recurred 
the next day. A further course of quinidino was ordered, and 
again ho became normal after the third dose, but this timo ho 
was given two capsules the next day, and then one capsule a day 
for fourteen days. Ho remained at normal rhythm and was dis- 
charged. He continued well for eight months, but was then taken 
ill again after walking up a steep hill. Flutter was again present. 
He Avas once more put on digitalis, and this timo on the third 
day the condition changed to auricular fibrillation (Fig. 4). The 
digitalis was at once stopped— for if one “can force nutter into 
fibrillation the heart often lapses into normal rhythm as the 
effect of the digitalis wears off ; however, ho relapsed into flutter. 
Digitalis was again administered, and quinidino was given, but 



Fig. 3. — Shows a mi.xture of 2*1, 3-1, and 4-1 block, 
p, auricular waves ; n and s, ventricular waves. 


rale at 60, and, judging that the flutter had ceased, the patient 
was allowed up, and. it was found that the tachycardia bad, 
passed off. He was sent up to London to see Dr. Parkinson, 
who reported that the electro-cardiogram was normal and that 
the heart also appeared normal. Since then the boy has never 
looked back; he n.is played Rugby football and gone through his 
course as a medical student. Ho appears to have a normal 
heart. It was unfortunate that I missed tho turn over of both 
these eases, but probably the flutter was followed by fibrillation 
and then reverted to normal rhythm. 

Case iv, 

A man, aged 50, had suffered with emphysema of tho lungs 
with cyanosis for some years, but for the last four months had 
oedema of the legs with a sensation of fluttering in tho chest. 
His heart was enlarged, the sounds were faint, mi there ^Ye^o 
no murmurs. The pulse was irregular, and a tracing showed 
auricular flutter y with a varying block— 3-1 and 4-1. Digitalis 
kept him at a regular 4-1 block, but did nothing further. Ho 
was given quinidine, fivo doses on two consecutive days, with no 
effect, so digitalis was pushed till fibrillation ensued. On stopping 
tho digitalis the flutter returned, but on repeating the process the 



the full five doses had no effect. Digitalis was continued and the 
condition again changed to fibrillation.^ On stopping the drug this 
time he regained normal rhythm; this has remained so till tho 
present time, a matter of four months (Fig. 5). 

The next two cases came on after an attack of influenza. 


Case it. 

A woman, aged 36, was sent to hospital by her doctor, who 
described her as a case of heart failure which was obscure, as 
tlie heart did not appear clinically very bad. She had influenza 
in 1922 and six months later her feet began to swell. A year 
later she had ascites, oedema of tho legs, and palpitation, which 
i?raduallv ffot better, but she remained very breathless., She was 
admitted m June, 1924. The heart was enlarged to a slight 
dc-'ree there were no murmurs, and the pulse rate was 144 per 
minute A tracing showed 2-1 flutter. Digitalis changed the 
block to 4-1, but nothing else happened ; the rate was then 
72 a minute. She was given quinidine, but the second capsule 
mado her feel very ill and it was stopped. She therefore remained 


• . *Tlic method is as follows: a preliminary dose is given of 0.4 gram 

,in a -gelatine capsule, to' see -that there is no^t an idiosyncra sy a gainst 
Uio drug, and the next day the patient is given 0.4 gram every two 
nours for five dosei. 


rhvthm returned to normal and he was discharged. Six week 
later he relapsed and flutter reappeared. 

Case v. 

A man a'^ed 37, had had rheumatic fever at an early age, 
fhrpV ‘recurrences since, the last being in August, 1926. Ho 
ndmitted on September 1st, 1926, sugering from gross heart 
with a very rapid regular pulse of 182 a minute. An 
eWI?rn-Mrdio'’ram showed flutter with 2-1 block. This is a very 
hodirSfwa flutter, for the auricular rate was 364. The next 
.i»v the heart was found to be grossly irregular, and the con- 
bnd changed to fibrillation. As he had advanced mitral 
it was thought he would do better if the fibrillation was 
So nermlnlnt so^he was given digitalis and the rate slowed 
frt 7^ a minute, and was kept at that rate by a dose of 

K m^^tas of tiMlure of digitalis thrice daily. He did very well, 
and has since gone back to work, which is luckily not of an 
arduous nature. i i • 

The number of cases here reported is too few upon wnicii 
to base any remarks, but it is interesting to noto that tho 
two influenzal cases are tho only- ones which have not 
recurred-^no over -.a • period- of three and tho other or 
six years’ Tho probability is that they will not now recur. 




Teb. II, 1928] 


ESTIMATION OF GLUCOSE IN THE BLOOD. 


[ 3irr. EnmsH 
MzDICAI. JOCBNAL 


215 


ESTDIATIOlf OF GLUCOSE Ils THE BLOOD AXD 
CEKEBBO-SPINAL FLUID. 

BV 


FR.-V^'CIS TEMPLE GREY, M.A.Oxon., 

M.B., Cn.M.SypNEY, 

r.^TIIOLOCIST, EAST LOXI>ON HOSPITAL FOR CniLDREN. 


ILiyi.vg Fail excellent results v.-itli IMacIcan’s inctliod' in 
a large nuiuber of determinations of glucose in the blood 
and eeiobro-siiinal fluid, it lias occurred to me that my 
experience migbt bo of interest. To ensure success certain 
points must be attended to ivliicb, although doubtless veiy 
elementaiy, liave been foiuid to bo neglected in some cases 
Tvhere I have becai consulted. The difficulties appear to 
be of three orders; personal, physical, and chemical. 

The most frequent mistakes common to all methods are 
those of arithmetic, careless reading of the burette, and the 
use of odd slips of paper instead of a xnoperly kept note- 
book. Not the least advantage of tlie well kept notebook 
is that the titrator may leave his entries to be afterwards 
dealt with by another; indeed, one might go so far as to 
saj’ that a notebook of which another worker cannot make 
head or tail has not been properly kept. 

Next to mistakes in arithmetic come errors which arise 
from an absence of the proper physical conditions. On one 
occasion a flask awaiting titration, the iodine having been 
libei-ated, was left standing in the sun : in othoi-s the jiropcr 
heating conditions had not been obtained ; thus on one 
occasion a wire gauze of another mesh than that with which 
the flame had been standardized was used. 

'Last, but not least, the reagents may be at fault. In 
one laboratory, for instance, after exhausting every other 
possible source of ci'ror, the sodium suljihate siipjilied by 
a reputable firm was found to contain sulphite. More often 
the “ dialysed " iron is found to be at fault and to contain 
free hydrochloric acid. If the worker does not make up 
his own volumetric solutions it is as well to have the titre 
of the thin — supplied by commercial houses as decinormal — 
checked. 

! Professor Maclean’s method mav’ be divided into sLiges 
as follows ; 


.Star/c I (Dcprotcinhalion ). — Into a 50 c.cm. Erlemneyer 
fl.isk lake 23.8 c.cm. -of 15 per cent, sodium sulphate acididated 
to the e.vtent of 0.1 per cent, with glacial acetic acid. (Sodium 
sulphate solution which has lost its acidity may be reacidulaied.) 
Add 0.2 c.cm. blood ; raise just to the boil ; add 1 c.cm. dialysed 
iron; filter through starch-free filter paper, whose diameter is 
about 4 inches, into a small Erlenmever flask. 

atttQc ,/ [Hedvciion). The filtr.-ite, or 20 c.cm. of it, is 
transferred to a liwger flask and allowed to cool either aulo- 
matiMliy as it waits its turn, or under the tap; add 2 c.cm. 
standard copper solution and reduce under standard conditions 
that is. raise to the boil in one and a lialf to two minutes 
and keep hoiling for another six minutes. 

— Cool as above, and when ready to 
Htiate, but not before, liberate the iodine with 2 c.cm. 75 pei 
cent, Add a few drops of starch solution and titrate 

against- N/400 sodium thiosulphate. 


Modifications of methods are in general to be deprecate 
milcss tlioy make for simplicity and give constant result; 
To take these modifications in turn. 

I. There is no need for a reflux condenser at this stag! 
as scarcely a^- fluid is lost bj- bringing the lysed blood jus 
to the boil. The dialysed iron may be added immediately ; i 
a good sam|)Ic and poor samples of dialv-scd iron must o 
no account be used — its effect is instantaneous and tli 
m filteiYd hot; in fact, it filters more quickly ho 
ilie fiitiate, measured before anv evaporation has take 
place on standing, is very constantly 21 c.cm., so that, 
ono hkra, the whole filtrate may be taken, inultiplving tl 
resu bv 0.-5. Obviously, if evaporation has occurred 1 
any extent, as may happen when large nnmbei-s are beiii 
QTOlt nith, it IS even more accurate to take the who 
filHate than to imagine that 20 c.cm. obtained with difl 
cidty represent 4/5ths of the siigiir in the blood takei 
?! roc.V represents slightly more— that is, np 1 

uiust take jilaco under tlio standai 
coiiditions laid down by Professor Maclean. I find 


convenient, but not essential, to use a reflux condenser 
at this stage in order to avoid over-concentration. The 
condeii.ser need not even be reflux. ' Clamp a large test tube 
filled with cold water, and ndjiisi it immediately over the 
flask; the cohiiiin of water will eventually become heated 
up, but not before it has prevented the over-concentration 
ill tile flask. The standardization of the flame by a 
nianonieter is unnecessary and unreliahle — unnecessary 
because the observer’s car soon becomes accustomed to 
the sound from a given Bunsen burner at a given gas 
pre.s.stire; unreliable because heat supplied does not vary 
exactly as tlie pressure, but depends on the gas quality 
(tberinie value). It is better, therefore, to find by trial the 
size of flame wiiieh will bring materials to the boil in from 
due and a iialf to two minutes, and reckon six minutes more 
(preferably by an inten-al alann clock).. This procedure 
gives more freedom as to the kind of flask, used, for if the 
manoinotor is depended on it will make a difference 
whether, for instance, Bohemian or Swedish flasks are used. 

III. It IS not necessary, when liberating the iodine with 
strong acid, to wait for the effervescence to pass off, as 
tills will occur duririg'tlie shaking in fhe titration. A blank 
titration of the standard should be done with every batch 
of blood .sugars — say ivi-ica a day. This is especially neces- 
sary if the standard is made np in bulk, for the solution 
ripens on keeping, and its value may rise so that 2 c.cm. 
are equivalent to 13 c.cm. of N/400 thio, IVhen filling up 
the bench bottle (which is preferably of brown glass) 
titrate and correct, if necessary, as follows : 

Suppose ilie value to be 11.7, take 110 c.cm. of the stock solution 
and add 7 c.cm. H-O, and so on ; or the correction may he made 
aritimielically.' Make up the N/400 sodium thiosulphate as follows : 
lake 2( c.cm. N/10 sodium thiosulphate into a 100 c.cm. volumetric 
flask — a graduated glass cylinder is not accurate enough — add dis- 
tilled water to the mark; empty out, shaking the while, into a 
larger flask and shake thoroughly. Volumetric flasks arc for 
measuring, not for mixing. 

Finally, the technique should he checked by seeing that 
reasonable lesnlts are obtained with normal bloods — that is 
to say, a figure around 0.085 per cent, in tlic case of a 
healthy person during the last hour before lunch — or with 
a known solution of glucose, say 1/4 per cent:, which will 
keep if a little toluol be added. 

Until everything is going well ono should be prepared to do 
two or three tihalions on any one particular case. For this pur- 
pose 1 or 2 c.cm. of blood should be taken either from the car or 
from a vein, and the blood collected in a small tube which has been 
rinsed out with 20 per cent, potassium oxalate solution and dried; 

When everj-thing is going well, 0.2 c.cm. of blood is drawn into 
a pipette liaving preferably a capillary mouth subdivided, if 
possible, to 0.05 c.cm.. A small length of rubber tubing (1/8 to 
1/4 in. bore) makes a useful tourniquet; wind one turn just past 
the last joint of the thumb, leaving a small space on the dorsal 
aspect of the thumb between the joint and the naik The advantage 
of Ibis little plateau is that the blood is, not so likely to run off it. 
Stab boldly; have a watch-glass (with a trace of potassium oxalate 
on it) in' readiness to catch any overflow in case the bleeding is 
unexpectedly energetic. Tlie pipette after use is washed out with 
water and tiien in potassium oxalate solution and set aside to dry ; 
more than one should be at hand. 

The time at which the blood is taken slioiild he noted. 
If many hours elapse between tlie-taking of the blood and 
its titration m misleadingly low reading may be obtained, 
even if the blood has been kept on ice. This seems to be 
duo to ferment action, and may be inhibited by adding 
a trace of formalin. It is often convenient, however, to do 
Stage I (which destroys the blood enzymes) in the con- 
snltiug room, the filtrate being reserved for reduction and 
titration at leisure. 

Cerchro-Spinal Fluid. 

■ Here the estimation is as for blood, except that wliero 
globulin is not increased the first stage (deproteinization) 
may safely be omitted, as the eerebro-spinal fluid contains 
iioniially si hundred times as little protein as the blood. 
When, however, globulin is increased, 0.1 c.cm. dialysed iron 
may be used — ^that is, ton times as little as for blood. The 
iioimal glucose content of tho eerebro-spinal fluid is some- 
ndiat lower than that of tho blood, and is fairly cou.stantly 
aboiit 60 mg. per 100 c.cm. Tlierc may bo none in acute 
meningitis. 

I » SiUfhods in the Diagi and tTealment of Glycothfia and 

1 Diahetes. Constable 



216 Feb. ii, 1928] 


MEMORANDA. 


[ TlIEURmsS . 
UZDICAL JotR51& 


THE HISTORY OF A HYPERNEPHROJIA. 

BY 

K. V. TRUBSHAW, F.R.C.S.Ed., 

SUBGEON, CHESTtn nOVAL ictibsiahy. 

^ViiTnoBon tlio vagaries of liyijoniephroraata arc well known, 
llio following caso is so unusual tliat it is worth recording. 

In August, 1924, a girl, aged 15, was admitted to llio Clicslcr 
Koj’al Inurmary aviLIi a nara, firm, roiindcil mn«s occupying Uio 
left loin. The urine had a spceific gravity of 1020, and contained 
a trace of .albumin, but no blood or pus. She slated that tbo bad 
had attacks of vomiting and of pain in the left side for somo 
years and that, shortly before admission, sho had noticed a 
swelling in tho flank. She was extremely cmacialcd, with a 
remarkable growth of hair over all tho limbs and abdomen. Tbo 
skin had a dusky tint, but there was no premature development 
of the sexual organs; in fact, menstruation did not start until 
(ho following year. 

Exploratory Operation, 

A tentative diagnosis of hypcrncphrbma was made, and tbo 
kidney explored through a lumbar incision. It was found fixed 
and surrounded by .a reddish vascular growth. As iieplirectomy 
seemed to be out of the question a small piece was excised for 
microscopical examination. This was reported to bo a typical 
hypernephroma. Sho left the hospital with an uiilicalcd sinus 
and I did not seo her again until about two months later. 
Sho was then a living skeleton, covered with an abundant growth 
of hair, and it seemed impossible that sho could live much longer. 

I heard later, however, that sho remained in this condition for 
about nine months, and then, to everybody’s surprise, began to 
put on weight, tho tumour and tho hairy growth disappearing. 

tfephreetomy, 

Sho was readmitted on September 28th, 1927. Sho was now a 
well developed girl of average height and weight and had been 
going about apparently in the best of health until three weeks 
previously, when tho pain in tho side reappeared. IVo found a 
rounded, tense swelling beneath tho old scar. Tho urine contained 
pus and gave a vigorous growth of 7f. col/. A pyclogram of tho 
left kidnoy showed tho tumour to consist of a greatly distended 

g elvis and main calyces. Radiograms of tho thorax and long 
ones were taken and showed no signs suggestive of raotastases. 
An exploratory operation showed tho kidnoy to be densely 
adherent to tho surrounding tissues and to tho peritoneum. As 
she took tho anaesthetic badly, a drain was inserted and a largo 
quantity of pus evacuated. Three days later tho wound was 
reopened and subcapsular nephrectomy performedr 

Tha wound lias now (November 28tli, 1927) practically 
healed and her general condition has immensely improved. 
The report on the kidnoy by Dr. Grace, pathologist to tho 
Infirmary, was as follows: 

Much chronic inflammatory chango With patches of acute 
inflammation and small abscesses here and there; very littlo renal 
tissue left); no evidenoo of tubercle, new growth, or liyper- 
nephroma.” 

Dr. Grace is also responsible for tbe'origiiial diagnosis, 
and one which was supported by tho nakod-oyo appearance 
of the tumour and tho general condition of tlio patient. 

The dilatation and infection may have been present 
throughout, but it does not alter tho fact that there was a 
growth found at the first operation, and that wo could find 
no evidence of one three years later. It would seem to bo 
a curious instance of tho waxing and waning of malignancy 
to what we hope is a final disappearance. 


MEDICAIi. SURGICAL. OBSTETRICAL. 

formalin injections in gangrene op 

THE LEG: RECOVERY. 

The following caso is unusual in view of the method of 
treatment and the ultimate recovery of the patient after 
having a dead limb attached to him for four months. 

In September, 1925, an outdoor worker, aged 59, of temperate 
habits had a severe attack of enterocolitis lasting eight days, 
whinh' brought him to the drained and shrunken appearance of 
a cholera rase. On September 26tli tho eightli d.ay of tho 
disease, when the temperature had fallen and the bowel evacua- 
tions were normal, ho experienced a sudden feeling of ‘ pms 
and needles ” in the right leg, followed by acute pam of gradual 
onset. His temperature was 97°, and the pulse rate 88. The foot 
W.-1S blanched and the thigh sliglitly hlue; no pulsation could bo 
felt in the femoral artery from a point one inch below Poupart’s 
ligament. Tho specific gravity of tho urino was 1040; no albumin 
or sugar was present. ^ ‘ . 


opp'ia'-ed to bo embolism of tho femoral artery 
th? wctricnmcnt of n thrombus which had probably formed at 
tho^ bifurcation of tho iliac arteries. In two days a demarcation 
• oullino was very pronounced at tho junction of tbo 

middlo and upper thirds of tho thigh. Ho was then seen in 
consultation with my partner, Dr. H. Townscnd-Whitling, and it 
was decided that tho patient was not likely to survive tfio-opera* 
lion of amputation at tho hip-joint, and that, if ho did sunive, 
iio would probably die from gangreno of tho flaps. 

Tho leg was swabbed with spirit- daily, powdered, and com* 
picto/y encased in cotton-wool. On October 3rd, feeling that 
proven lion of decay was tho only hope, I started periodic inicc* 
^ons of formalin, 1/2 to 1 draclim, into tho tissues of the leg. 
Tho injections wero both superficial and deep, and tho strength 
varied from 2 to 40 per cent., according to the distance from tho 
demarcation lino. Tfio courso was perfectly afebrile till October 
17tli, wlion tho temperature reached 99®. It fell to normal on the 
20lh to 22nd, but reached 101® on October 24th and 101.8® tho 
following day. Tlio temneraturo had returned to normal on 
November 1st, after which thcro was only an occasional evening 
rise of one degree. 

Froni October 20th onward thcro was profuse discharge of pus 
from tho demarcation line, and somo gas formation in the thigh. 
Tho occlusion of tho artery spread slowly upwards, and by 
December 2nd tho pulsation, which had been felt above Poupart’s 
ligament, had disappeared. 

On December 25th a rubber tourniquet was applied just below 
tho dcmarcAstion lino to hasten separation. 

On Jtinuarj 7th, 2^6. an incision was made below the tourni- 
quet and tho bono isolated, Tho muscles divided ' were brown, 
with tho exception of part of tho adductor magnus, which was 
pink and was slightly sensitive. Further formalin injections were 
made in and round the sciatic nerve, which was sensitive for 
several inches below tho lino of demarcation. 

On January 18111 tho sciatic nerve was divided, giving rise to 
slight and momentary pain. The next day tho femur was sawn 
through about tho junction of tho middlo and lower thirds. 
Tho medullary cavity was cleared out for a distance of four inches 
and packed with bipp. Tho necrosed tissues, still attached to 
tho stump, wore dissected off daily, and on January' 27th tho 
patient was able to get out of bed and sit in a chair. 

By March 2nd the stump was skinned over with the exception 
of about ono square inch. The muscles had retracted, leaving, 
exposed about four inches or femur, which I left with the idea 
that it would prove a useful lover for an artificial leg, { 

Tho patient was now able to get about tho house rapidly on 
crutches but had becomo depressed and had shown suicidal ten-, 
dencics. Ho was therefor© removed to a local mental hospital,! 
where ho remained for a year, returning homo normal anaj 
cheerful, but with limited backward movement of the stump, in! 
March, 1927. I now fitted him with an artificial leg, made to my 
design by tho local blacksmith and tho saddler, and weighing 2 lb. 
On this ho has been able to walk a distance of a q^uarter of a mile. 
On November 19th ho was shown at a clinical evening of tho Rugby 
Medical Society, when the caso was considered to deserve 
recording. 

Three points are of special interest. (1) The injections of 
fominliu could not bo given nearer than three inches from 
tlio line of separation without causing pain or discomfort. 

(2) Thoro was an almost total absence of decay from above 
tJio knee downwards, the skin being unbroken, illustrating 
tho efficacy of the formalin. The only offensive smell was 
from tho granulation tissue at the line of separation. 

(3) Though gas formation occurred in the thigh, the toxins 
absorbed caused a rise of temperature only on nine con- 
secutive days during tbo eighteen weeks the dead limb was 
attached to the body. . 

The fleshy stump ia six inches long. The bone, which up 
to now has been used as a lever when walking, is being 
eroded by granulations, and will soon separate spon- 
taneously. Forward movement is free. Movement pos- 
teriorly stops short of the vertical. 

I would welcome suggestions as to the best type of 
artificial leg, since his present leg will he useless when the 
hone separates. r . xt t, xr r-i.. 

Husbands Bosworlli, Eugby. J- A. NoDbB, B.AI., .C . 


bladder CALCDLDS in the male due to a 

FOREIGN BODY. 

This case is, I think, sufficiently unusual to be wortlt 
putting on record. 

On May 15lh, 1927, I was called to visit a young unmarried 
man I found iiim suffering from acute epididymitis on the left 
side’ I naturally cuspected gonorrhoea, but the patient denied 
any no^ibffitrof infection, fliere lyas no urethral discharge but 
tiJ Srine contained threads. A eentrifugalised deposit n^hffiited 
numerous Dus ceils and a mixed bacterial fauna, none of whicil 
appeared to correspond precisely with the gonococcus as regards 
arrangement, or staining reactions. The 
more or less completo recovery followmg treatment by rest, bland 


Feb. II, 1928] INTOXICATION AND ITS DEGAL CONSEQUENCES. 217 - 


fluids, and mild urinary nnliscplics. He returned to work in the 
tliird week of June. ' . , 

■ At the end of September he a^ain attended my aurgery 
complaining of pain and difficulty • in micturition. The unne 
was faintly alkaline, and contained blood and pus cells, with 
mixed cocci as before. He did not respond speedily to 
urinary antiseptics, so I decided to take a sterile specimen of 
"urine for examination for evidence of tuberculosis. I endeavoured 
to pass a catheter for the purpose on October 10th, but 
failed owing .to an obstruction in the neck of the bladder. 
.Two days later he told mo that he was passing urine, more 
freely as the result of the instrumentation, and a few days 
later brought a few calcareous fragments that he had passed 
with his urine, with general relief of symptoms. On x-ray ex.am- 
ination the shadow of a laigc calculus was seen to occupy the 
cavity of the bladder; the kidney areas were quite free. He was 
admitted to Ashford Hospital and, oii November 4th, I icmovcd 
a calculus from the bladder by the suprapubic loutc. It was bean- 
shaped, about 1^- inches long, 3/4 inch in breadth, and 1/2 inch 
in thickness. I forwarded it to the county laboratory at Maidstone, 
and received the report that it consisted of a core of hard paraffin 
wax, surrounded by an envelope of phosphatic deposit. It would 
seem that the hard paraffin must have reached the bladder by 
the urethra. The calculus was relumed to me in its divided 
condition, and showed clearly the wax centre with the surrounding 
envelope of phosphates, which is about 1/10 inch in thickness. 
The patient has made an uninterrupted recovery, and tlje calculus 
has been returned to Maidstone for preservation in the museum. 

, I am indebted to Dr. C. Ponder, who is* in charge of 
rtlio county pathological laboratoiy, for the assistance ho 
fhas given and the interest he lias taken in the case. 

Ashford, Kent. E. ScOTT, B.A., B.M., B.Ch. 


J DIAGNOSIS OF GANGRENE OF THE SMALL 
^ INTESTINE. 

The very interesting account and discussion published in 
‘the Bkitish Medical - Journal of May 7tU (p. 856) and 
June 4tli (pp. 1033 and 1034) prompt mo to send the 
following note of. two cases I have come across during 
thei last five years. 


Case r. 

huilt man, aged 35, was admitted to the Jamsetji 
Jijibhoy Hospital, Bombay, in the wards of the senior physician, 
■under ivhom I had charge, on January 1st, 1922, for severe 
pam in the epigastric region, which had been present for five days 
before, admission. Tlio abdomen was soft and thei'e was no 
rwistance to palpation anywhere. An enema resulted in partial 
elimination of the water; the suspected history of syphilis, helped 
by a blood examination in the absence of any loading signs and 
diagnosis of tabetic crisis/’ On Januap’ 
2nd, at 5 p.m., the pain was worse, the abdomen had become dis- 
tended, and the patient had begun to vomit ; there was well 
marked resistance. I do not recollect whether he was parsing flatus. 
Exploratory laparotomy was porfdi-nied ; a thrombosis in the 
superior myenteric artery was found, and gangrene of the small 
.intestine. The patient died on January 3rd in the morning. 
A post-morfem examination could not be obtained. 

The point that I noticed abont this case was the pain, in 
the absence of any definite signs, and a persistent slow 
pulse, varying between 50 and 60 a minute, as recorded by 
repeated observations, till the complicating symptoms just 
before operation, when the rate was faster. 


A t ‘ I f 

Aged 35, came from up country on February 25tli 
^ . as honorary physician, out-patients 

of^min the Jamsetji Jijibhoy Hospital. He complained 

food ind abdomen of fifteen days’ duration, worse afte 

stinatinn ft® Abdomen, •^dthout vomiting or cor 

rptfinn n«d 41 ^ wos slight resistance to palpation in tlic iimbilica 
slow. The general condition, tli 
nnin“in 11 a pulsc rate, and the severe persisten 

the rase as one oTIhroLSs^f 

1 ‘•nromoosis of the superior mesenteric vein o 

dtd 'r performed, but th 

PTfpn«:ivo c It ’**^''* ^ ost-mortcm examination revealed 

Euncrior small intestine, a firm thrombus in th 

hrLches in the liver' ^raisi^/?'’/”® "P “ 

in the liver causing a large infarct (6 inches by 4 inches 

I do not know whether a slow pulse in the presence o 
symptoms referred to bj- writers to th 
^ June may bo of importance in decidiii: 

on le c la^guosis of thrombosis of the superior mesenteri 
vein or artery. ^ 


Department of Patholog.v, Gr.ant Medical 
College, Bombay. 


P. V. Ghaupuue, M 




INTOXICATION AND ITS LEGAL CONSEQUENCES. 

At a meeting of the Medico-Legal Society on January 26th 
a jjaper on drunkenness and civil and criminal respon- 
sibility was read by Mr. F. Lleweli.t>'-Joxes, coroner for 
FJintshire. , 

Mr. Llewellyn-Jones made a general survey of the 
subject of intoxication and its legal. consequences as under- 
stood in English and other law. Dealing first with the effect 
of drunkenness upon civil capacity, he said that a contract 
made by a drunken person was voidable at the person’.s 
option, hut a person who set up a plea of intoxication with 
a view to voiding a contract must satisfj’ the court that the 
other party was aware of his condition at the time the con- 
tract was made. With regard to injuries, if a person was 
so comjrletely intoxicated that he could not appreciate the 
significance of what he was doing, it was reasonable to 
assnnie that he would he regarded in the same position as 
a lunatic. One was perhaps justified in laj-ing down tlie 
rule that when a person was so far out of his mind — 
whether through iusanity or complete intoxication — ^as not 
to know wh.at he was doing, ho could not he regarded as 
acting intentionally, and therefore in torts where inten- 
tion was an essential element lie was not under liability. 
On the other hand, it seemed only equitable that an 
inebriate who had caused injury to another person should 
make reparation, not as a punishment for inebriety, but 
as damages for the wrong done to the innocent, wliieh 
damages, in the case of habitual intoxication, might well 
be exemplary. French juridical opinion took the view that 
a drunken person was not to ho freed from the obligation 
to make good the damage, for it was liis own faidt that 
he had put himself into that state. The German civil code 
also took the view that the drunkard was responsible for 
damage, unless he had been brought into tlio drunken 
condition against his will, in which case the onus of jiroof 
that this had been so rested upon him. 

On the question of the criminal liability of an intoxicated 
person for homicide, the famous case of Beard (House of 
Lords, 1920) was cited. Lord Chancellor Birkenhead, in 
dealing with that case, said that the earlier classical text- 
books sub.sci'ibed to the view that if a person, when drunk, 
killed another, he must suffer the ordinaiy penalty, for 
although he did it in ignorance, the ignorance was occa- 
sioneil by his own act of folly. This view was later some- 
what relaxed, though not according to any single or vei'v 
intelligent principle. Lord Birkenhead laid down the 
following three rules: (1) insanity, whether produced by 
drunkenness or otherwise, was a defence to the crime 
charged; (2) evidence of drunkenness which rendered the 
accused incapable of forming the specific intent essential 
to constitute the crime should he taken into consideration 
with the other facts proved in order to determine whether 
or not he had intent ; (3) evidence of drunkenness falling 
short of a proved incapacity in .the accused to form the 
intent necessary to constitute the crime, and merely 
e.stablishing that his mind was affected by drink so that 
he more readily gave to some violent passion, did 

not rebut the ijresumptiou that the man intended the 
natural consequences of his acts. In the Beard case the 
indielmcnt was wilful murder. The man, while drunk, had 
ravished a young girl, and in trying to stop her from 
screaming had suffocated her. The House of Lords held 
that dninkenncss was no defence unless it coidd bo estab- 
lished that the accused wa.s so drunk as to he incapable of 
forming the intent to commit the rape, and as this was 
not alleged, the defence of drunkenness to the charge 
of murder — the murder having resulted from the rape 
by a succe.ssion of acts which could not ho regarded 
indeiieudcntly — must fail. 

The reader of the paper then reviewed the law in other 
countries. The Britisli colonies followed generally the prin- 
ciple of the English courts. Under the Indian jicnal code 
a person who committed a crime under the influence of 
drunkenness, when the drunkenness was the ro.sult of Ids 
own fault, was in no better position than a perfectly 



218 Feb. ir, 1928] 


'LIFE AS 6 UHAN 0 E IN THE TEOPIOS. 


soboi" person, but tlio textbooks suggested tliat mental 
disease caused by voluntary intoxication would absolve 
fi'om criminal liability. In tlio United States tlio courts 
bad mainly followed principles not dissimilar from those 
laid down in the Beard case. One American- legal writer 
pointed out that in insanity tho law had to deal with a 
disease contracted against tlio will of tlio sufTcror, whereas 
voluntary inebriety, leading to dcrangciucnt of faculties, 
was not a disease, but something which might readily bo 
provonlod by tho person himself. Tho French penal code 
made no rofercnco to drunkenness, aiul French courts had 
formerly maintained tho principle that drunkenness was 
no ground for exculpation; but a milder view had 
gradually prevailed, and some French juries had treated 
complete drunkenness as “ passing dementia.” German 
jurists had distinguished between accidental drunkenness 
produced by tho artifice of another, fraudulent drunken- 
ness, where a man deliberately made himself drunk in 
order to commit a crime or to afford him an excuse, and, 
finally, voluntary drunkenness. They distinguished also 
between stages of intoxication : (1) where consciousness 
was retained; (2) where consciousness remained, but tho 
mind was clouded; (3) where there was coniplcto intoxica- 
tion, depriving a man of his reason and making him no 
longer a free agent. Rarely would a delinquent in tho 
second categoo’ bo treated ns not responsible for his act, 
but almost always a delinquent in tho third category. In 
tho criminal code of tho German Reich there was no 
express reference to drunkenness as a mitigating circum- 
stance, but it miglit bo considered as coming under tho 
definition of a " state of unconsciousness or morbid^ dis- 
turbance of activity of mind, preventing free volition.” 
Under the Austrian criminal code it was definitely laid 
down that no act should bo regarded as a crime when tho 
author was in a state of comploto drunkenness, but tho 
person committing tho act should bo punished for a serious 
police ofFenco — up to three months’ imprisonment, or six 
months’ if ho was aware of his liability to alcoholib 
excess. Tho condition of unconsciousness (Dcicilsstlosigheit) 
contemplated by tho German criminal code and other 
European systems was di/Tcrent from that state of com- 
plete insensibility which was tho general connotation of tho 
English woi-d ; it implied that tho man acted unwittingly 
without conscious knowledge of tlio nature of his acts. Tho 
I'eccnt proposals of the Italian Ministry of Justice were 
interesting. A person wlio, in a state of complete 
drunkenness duo to accident or fovee majan'Cj lost con- 
sciousness of his acts was held not to bo responsible for 
tho offence committed by him; otherwise drunkenness was 
held neither to .aggravate nor extenuate an offence, unless 
a man had made himself intoxicated in preparation for 
his crime, or to furnish an excuse, in which case tho 
drunkenness was an aggravation. One provision of tho 
new code was that chronic delinquents should servo their 
sentence in a speci.al establishment whore they would 
undergo treatment for drunkenness. 

In conclusion Mr. Llewellyn-Jonos touched upon the 
problem of the intoxicated motor driver. One of the 
difficulties of the courts was that Parliament had refrained 
from giving any definition of drunkenness. An attempt 
was made in tho proceedings on tho Criminal Justice Bill, 
1925, to incorporate words which would more clearly 
define the offence of being drunk — namely, ” a state of 
intoxication whereby his capacity to act is. impaired.” 
In a South Australian Act the words wei'e: “ so 
much under the influence of intoxicating liquor as to be 


r Th» Bbittw' 
L siewcAt JocBjriii 


incapable of exercising an effective control of such motor 
vehicle ”; and in a Dutch law, 1924: “ ... so far under 
the influence of alcoholic liquor as not to be able to drive 
in a proper manner.” A good definition was recently 
given by Judge Sturges, K.C. : “ lYhere the skill and 
iudgement normally required in the manipulation of 3 
motor car are obviously diminislied or impaired as a 
direct result of the consumption of alcohol.” Some of the 
usually apiilied tests for drunkenness were often thought 
to be inadequate, particularly in the case of motorists 
who, while showing no signs of gross intoxication, might 
yet be unfit through alcohol to bo in charge of a car. 
Finall 3 ’, ho quoted with approval some remarks from Sir 
James Purves-Stowart’s leoturo before the Society for the 


.Study of Inobriety,* to tho effect ' that ' drunkenness was 
not a simple clinical entity like a broken bone or a coni 
solidatcd lung, and that tho important point- was not 
whether a man could perform certain tests correctly, but 
wlicthor ho was in a fit condition to puisuo his ordinary 
dally avocation. Tho primary duty of tho medical examiner 
ns well ns of tho magistrate was to satisfy himself as to 
nlietlior .there was impairment of tlio power to drive with 
rcasonablo care. 

LIFE A-SSURAKCE IN THE TROPICS. 

At a meeting of tho -Section of Tropical Diseases and 
Parasitology of tho Roj’al Society of Medicine on February 
2ud, at 8.16 p.m., Dr. .-ixuUEW B.i/,Foun in tho cli.air, 
a discussion on life nssnranco in tho tropics was introduced 
by Dr. J, F, C. IlASL.iar, assistant director of tho Bureau 
of llygiciio and Tropical Diseases. 

Dr. H.asinm said that tho chief interest in the subject 
of life nssnranco in tho tropics hay, for him, in tho 
attempts which had been iiiado to dotermine not only tho 
amount of increased risk involved in tropical residence, but 
also tho factors in its prodnctioii, Tiia.so iiifcre.stcd in 
forwarding tho policy of a White Australia had maintained 
that a hot, Ininiid clinmto had no dotrimcntal effect per sc, 
and that tho harmful results arose from disease and faulty 
habits. Ho did not agree with this vieiv, and found the 
arguments of Cilento and others imcoiiviiieing. Attempts 
by Sundstrocm and others to clear up the matter by 
experiment had not holpoel much; tliis work was con- 
sidered ineonclnsivo by Halliburton. Referring to the 
confident claims by Sir James Barret and, others that tin 
actual oxpcricnco of Northern QueohsJand had proved the 
practicability of white settlement there. Dr. Haslam held 
that a much longer period must pass than had yet elapsed 
before it could leally, bo. certain that no deterioration of 
tho stock had taken place. Ho concluded by giving 
examples of tho extra premiums charged by certain London 
insurance offices for various parts of the tropics. Tlio 
great variation between country and country and between 
company and company indicated to him that neither tho 
insurance offices nor their medical advisers had us yet any. 
very clear ideas of tho amount or causo of risk to Hfo 
and health involved in tropical residence. 

Mr. H. E. Bayxes, F.I.A., stated that a constant difil- 
cully confronting actuaries in assessing tropical piemiums 
had been the lack of reliable statistics; crude death rates 
were almost valueless, and tho tendency Jiad been for offices 
to roly on their own very liniitod experience, thus causing 
3 lag botwcoii tho actual mortality cnrient at a iiarticular 
date and the premium charged. Ho favoured the classi- 
fication of tile world into normal, sub-tropical, and tropical 
zones in dealing with the caso of European peoples. A 
mixed racial population presented special difficulties, since 
mortality was a factor of race as well as climate. In 
various West African districts tho mortality was 10.3 per 
cent in 1886; in 1911 it had fallen to just over 1 per 
cent It was uiireasoiiaWo to suppose that this improve- 
ment was confined to West Africa alone; ho had computed 
some figures -for that country during the period 1921 to 
1024 which showed that tho actual death rate was 1.14 
ner rent compared with the English death rate of 0.80 per 


cent (based ou tho No. 8 English table). Tlie mortality 
during tho first few years of tropical residence was higher 
than later Mr. Raynes’s investigations had shown that 
a constant addition of under 0.6 to the percentage rate 
of mortality as shown by the new English life table would 
adenaatelv cover the excess mortality in West Africa. This 
would mean the addition of from 4s. lOd. to 7s. 5d. per 
cent to tho annual premium charged, and a policy from 
a first-class office could bo now obtained with an addition 
of not more than IQs. to cover West African residence In 
East Africa the high lands did not appear to be detri- 
mental to health, but the coastal plains and lake margins 
corresponded to West African conditions. In Mr. Raynes’a 
opinion the factors governing tropical mortality were race, 
Geographical surroundings, political and social administra- 
tion, and occupation. Ho showed graphs illustiatiiig the 
fall in mortality and sickness in West Africa within recent 

1 British Medicu. Joubkai., January 17th, 1925, p. 112. 



Peb. .11,. 1928] 


inr. .. UTERIHE BAHGOMAi " 


..r TeeBriHS* 

' L'McdicIx. Jossxxk 


210 


5-cars, and tables illustrating tlio classification of tlio world 
into zones for insurance purposes. ,, 1 - 

Sir .Leonabd EooeBS compared the results of over 1,600 
necropsies in Calcutta with over -1,000 in London. In 
Calcutta about one-third of tlio deaths wero due to purely 
tropical diseases, such as malaria, kala-azar,- cholera, and 
dysentery. There were relatively few eases of cancer m 
India, because -the normal length of life was much shorter 
than in Britain. Tuberculosis, on the other hand, was 
twice as common, and both respiratory and_ digestive 
diseases were much more frequent. Septicaemio_ diseases 
and tetanus were also very high, although, since the 
introduction of serum' treatment, the latter had been much 
reduced. Typhoid fever' also was voi-y common. It was of 
interest to observe that tuberculosis — especially pulmonary 
tuberculosis— caused a higher mortality than any of the 
pureh’ tropical diseases; Sir Leonard Rogers attributed 
its prevalence to the habits of expectoration and the con- 
tamination of milk in the streets. While lobar pneumonia 
was often seen, broncho-pneumonia was rare. Heart 
diseases were half as common' as in London, and rheumatic 
endocarditis was quite absent, although streptococcal infec- 
tions wero otherwise frequent. Aortic valve disease was 
•‘common, although mitral was rare — ^the reverse of the posi- 
tion in England. Gastric ulcer was unusual in India, but 
cirrhosis of the liver was common.. It was not alcoholic in 
fits origin, and was probably secondarj- to, dysentery. 

' Mr. J. A. Calbeb questioned if heat without humidity 
‘had a very adverse effect on men in the tropics. Ho had 
noticed that in Africa, where the climate was di-y, the 
effects were much less marked than in places where it was 
wet. Dr. W. -Nicoll said that tropical Australia had more 
'tolerable conditions than_olsewhere in the tropics, and that 
-The population included few others than Anglo-Saxons. It 
could not bo compared with other tropical countries, but 
only with Europe and the rest of Australia. Policies were 
not loaded there. Overcrowding was absent, even in the 
towns, and there was only one person to eight square miles. 
The population, moreover, was selected and there was no 
unemployment. Accordingly there was no reason why 
insurance should bo dearer than elsewhere in Australia. 
None of the classical tropical diseases was present, and the 
chief causes of death were diseases like dengue. The 
expectation of life was increasing there, and the effective 
working age period was greater than in any country in 
Europe. Mr. R. E. Uxnrawoon discussed the business 
aspects of insurance, and said that increased premiums 
might be deliberate in order to exclude insurances which 
any particular office considered to be undesirable. 

Dr. H. Staxivos thought that individuals were not always 
acclimatized on residence in the tropics; on the contrary, 
rtere was often a general deterioration throughout service. 
Comparison of tropical countries should not be by latitude 
but by isotherms, humidity, or some such feature, 
^untries could not be classified by lists, and each must 
be considered on its merits. It was necessarj-, however, for 
an insrtrance office to use ■ an average which would deal 
hardly with soine policies and favourably with others. Dr. 
Dycf. . Sharp said that the real reasons for the high death 
rate nr \\ est Africa were still obscure, but he believed that 
^ui asthenia and social conditions were most imiiortant. 

e personally had found that the climate of northern 
i igeria, v ith its great extremes of day and night tem- 
peia ures, was. agreeable, but trying; in the Caraeroons, an 
a mos uninsurable district with a very small range of tem- 
peia iiie and great humidity, life was much less exacting. 

r. uristopiterson thought that both humidity and heat 
wei e 1 cry trying in the tropics, and that frequent holidays 
wero necessaiy for white men employed abroad. 


• UTERINE SARCOMA. 

I ^ mating of the Section of Obstetrics and Gynaecolog 
•n . c’lf °f Medicine on January 20tli, ft 

president, Mr. CoMvxs BERKEi,Er, in the eha’ir, Mr. E 

uSriis^^ ^ mwed a specimen illustrating sarcoma of tl 

Mr. Gilhatt said th.at the specimen was obtained from 

mn .tb ’ 7’ ^Hnptoms had only lasted or 

month. She had a sudden attack of acute abdominal pai 


ten days bofore operation. The physical.- signs wore un- 
usual, in. th.at the swelling was found rising out of- the 
pelvis to within -one- inch of the umbilicus; in the right 
lateral and posterior fornix was another swelling, soft and 
almost cystic. - A subtotal hysterectomy was performed 
and the right tube and ovary were removed. She was 
now in excellent health, and nothing abnormal could be 
detected on examination. The microscopic' sections show 
the characters -of a myosarcoma. • • 

Difficult Labour in an Aboriginal. 

Professor J. B. Oleland (University of Adelaide) sent a 
short communication entitled “ Difficult labour in a pure- 
blooded Australian aboriginal woman.” This was an 
account of the whole process of labour. The first stage 
was noimal, the second was unduly prolonged, the child 
lying in the loft occipito-posterior position. The head 
.descended to the plane of the ischial spine, but further 
progress was impossible. Under anaesthesia the position 
was converted into a left occipito-anterior, and great diffi- 
culty was experienced in delivering the head by axis 
traction forceps. The shoulders were only delivered by 
extreme traction, and there was similar difficulty with the 
breech. The placenta was retained for thirty-five minutes 
and was removed manually. . After labour the pelvis was 
examined, and was thought to be of the funnel variety. It 
was also -slightly generally contracted. The child was un- 
usually large, weighing 121 lb. 

Albuminuria during Pregnancy. 

Mr. G. F. GiBnmiD read a paper on the results of 
albuminuria occurring during pregnancy, with special 
reference to the relation between pregnancy kidney and 
chronic nephritis. This paper was the result of investiga- 
tions of seventy-eight patients at the post-natal clinic 
of the maternity department at Guy’s Hospital, forty-three 
of whom were examined at ’ intervals greater than six 
months from delivery. Mr.' Gibberd concluded that .albu- 
minuria of pregnancy recurred in subsequent pregnancies 
with much greater frequency than was usually stated. He 
considered that this pointed to permanent renal damage 
as a result of the primary albuminuria. The evidence 
showed that chronic nephritis might arise dc novo as a 
sequel to pregnancy kidney, and Mr. Gibberd added that 
he thought the most delicate test of the renal fimction in 
a patient who had had a pregnancy kidney was a subse- 
■quent pregnancy. He had found permanent renal damage 
in over 50 per cent, of his cases. He did not believe it 
possible to say that there was no danger in an albuminuria 
occurring during pregnancy, and he advocated abolishing 
the term “ functional albuminuria of pregnancy.” He 
also concluded that induction for this condition was com- 
monly postponed too long, and that the mere avoidance of 
eclampsia was not an obstetric triumph. As a further 
argument in favour of early induction he instanced the 
frequency with which the foetus was macer.'ited in these 
cases. 


INELUENCE OF STATISTICS ON MEDICAL 
PRACTICE. 

A aiEBTixo of the Liverpool Medical Institution was held 
ou January 14th, when the president, Df. J. C. M. Gia-ex, 
was in the cliair. 

Mr, Jeaxs read a note on statistics, with some 

observations, and remarked that some observations were 
more valuable than statistics — as, for example, Mr. Paulas 
statement that a woman aged 75 was not so old as a man 
of the samo age from the point of view of a major opera- 
tion. The influence of statistics on an operator’s mentality 
was indicated by the subconscious rejection or inclusion of 
certain cases which might affect his mortality rates^ Mr. 
Jeans thought that if a case of appendicitis was treated 
medically and the patient died because the condition was 
really one of internal strangulation, it should he recorded 
as a death from appendicitis treated medically; a death 
from pneimionia treated by operation in mistake for 
appendicitis should figure as a death’ from appendicitis 
treated surgically, because the patient was actually, if not 
statistically, dead. Kow that much surgery was being 
performed by practitioner-surgeons, it iuust he obvious 


220 Peb. xr, 1928] 


THE OVEn-SENSITIVE CHILD, 


T TwtBtmn . 
L VsmeiZr Jcvnit - 


that specializing ' surgeons were getting an increasingly 
liigh porcciitago of difficult eases, and tlioreforo, if tlioir 
mortality ligures were as high as they wore fifteen years ago, 
this was no cause for depression. The iiractitionor-surgcon, 
who often admitted that ho only dealt with the easy cases, 
was more selective than the “ jiuro surgeon ” was allowed to 
bo, and thureforo com]iurisons between the two classes of 
mortality wore impossiblo. The pure surgeon, especially 
when successful, was willing to have tho most difficult eases 
sent to him. 

T/te Detection and Core 0 / llhcumatism in Childhood. 

Dr. A. Dinowam, FoiinrcE, in a pajier on rheumatism 
in childhood, said that detection of tho frank, classical typo 
of acute rheumatism was simple, but active rheumatism, 
endangering the heart, was often present in tho ahscnco 
of striking symptoms. The fundamental inclination towarils 
infection was a diathetic peculiarity which might bo deter- 
mined before or after birth, and lead ultimately to tho 
exhibition of rheumatic symjitoms as a result of ondogonons 
infection by probably varying organisms of a similar group. 
Tho main aim must bo to prevent tho dovolopmont of such 
a constitutional tendency ns would load to a favourable 
field for bacterial infection. During 1927 out of 213 cases 
of rheumatism one child had died from rhouniatio heart 
disease. In 71 coses the heart was permanently injured 
without doubt when tho child was first seen, and at tho 
end of tho year 97 children disclosed permanently damaged 
hearts. In 31 cases tho condition of the heart was doubtful, 
and in 84 eases there was no cardiac otfeclion. Ilhoumntic 
nodules were notic'cd in 3 cases. Tho “ intolligcnco 
quotient,” taken during tho quiescent or convalescent 
stage, was usually well above 80, tho deficiency boing 
mainly scholastic. The essence of correct care was physical 
and mental supervision for a prolonged period. For tho 
poorer classes six months in a county hospital with a 
school such as that at Heswall proved very valuablo after 
the initial condition had been dealt with in the city 
hospital, but for offcctivo results a further prolonged 
period in a residential school was often essential. 


THE OTER-SENSITITE CHILD. 

A jtEETiNO of tho Section of Medicine of tho Royal 
Academy of Aledicino in Ireland was hold in tho Royal 
College of Physicians on January 20th, with the president, 
Dr. G. B. Nesbitt, in the chair. 

Dr. B. CniciiTON, in a paper entitled “ Tho sensitive 
child,” pointed out how' much a very sensitive disposition 
influenced behaviour, and might produce syndromes capable 
of being mistaken for the symptoms of disease. lUich 
depended on tho wisdom of those in charge of such children ; 
for instance, abnormal behaviour in a sensitive child was 
often the result of tho follies or neuroses of the parent or 
nurse. Sympathetic handling was essential, and encourage- 
ment rather than rejiression was the clue to managing 
most of the problems of difficult children. Many children 
laboured under the disadvantage of being forced to attend 
a school where education was carried out in surroundings 
and under conditions prejudicial to good health. He urged 
that medical men in Dublin should unite to make educa- 
tional authorities see the harm done by the present system. 
Hours were long, the lunch interval badly chosen, lavatory 
accommodation defective, medical inspection wanting. 

Dr. M. F. O’Hba agreed that the sensitive child was a 
definite entity. Every child was different, and he felt 
that to try to make children plucky by holding up to them 
the pluck of other children was a great mistake. Tho 
question of giving the cliildren their principal meal at the 
proper time in the middle of the day was vexing the minds 
oi the educational authorities at present; some schools 
insisted that the children should have dinner at 1 o’clock, 
.and stopped school from 1 to 2 o’clock for this purpose. He 
thoimht this was bad for tbe children s digestion, as it 
meant that they had to eat their meal too hurriedly. One 
of tho most important tilings in the management of 
children was being careful ahout the people who looked 
after them. 

Dr. V. jNI. Synge thought children went to school at far 
too early an age, and learnt a lot of things by routine, 


. mstend of reasoning iliom- out. Ho - felt that tho so-called' 
nicrcaso of education in Ireland .by compelling attendance 
at the national schools was not an unmixod -blessing. He 
liad soon eJiildron in quito an advanced stage of tubercu-. 
I 06 IS who wore sent to school every day, as, their parents 
, were afraid that if they did not send them they would 
bo filled. The national schools at present were far too 
crowded; in many of them there were 150 children, in 
ahout throe rooms, with only throe teachers. 

Dr. N. Falkineh asked if most of tho children seen by 
Dr. Crichton woro children who had had some definite 
organic lesion, or in whom diot had been faulty, and if 
tho majority of thorn were children who had not been 
hioasLfod. If they were children wlio wore not breastefed 
ho thought that cases woro more likely to occur in private 
practice than in hospital practice. , , . 

Dr. U. J. Rowlette referred to tho necessity for, an 
■ altered school li 3 -gioiio, and said it was a' pity that tlio 
onforconicnt of attondanco at schools should. have antici-. 
pnted tho cstahlislimont of, a proper, system of medical ini 
spoction of schools. Roforring to the , sensitive child, he 
said that while individual attention was necessary in tho 
diagnosis of tho condition, ho thought it might bo carried 
too far in tho treatment of the child. He felt that the. 
concentration on itself by a child which might take place .if 
individual attention was pressed too far was unhealthy 'for 
tho child. 

Dr. L, AnnAHAJisoN agreed that one of the most difficult 
points in dealing with the nervous child was the compara- 
tively unknown factor represented . by the nurse, who . was 
interposed hoUreon parents and child. In some cases it was 
as necessary to study tho parents and tho nurse as. it 
was to understand the child. He agreed that school 
hours woro too long, and thought it unfair that tho hours 
should bo longer in national schools than in private schools. 

Tho President said that he could not imagine anything 
worse than a child who was not sensitive, or an adult 
either. Ho tliouglit that Dr. Crichton should have entitled 
his paper “ The hj'porsonsitive child.” One of the most 
important influences in the bringing up of children was the 
nurse. Ho referred to the factor of heredity,- which he 
thoimiit plaj'ed a groat part in the sensitiveness of children, 
and said tliat nowadays in cases of extreme naughtiness in 
children tho question of encephalitis lethargica was worth 
going into, for children wlio had over suffered from this 
disease, oven slightly, were very liable for some time 
afterwards to bo naughty purposely. 

Dr Crichton, in replying, said that when talking ahout 
sensitive children, he really had in mind hypersensitive 
children. The ordinary child wanted to he constantly 
doing something, .and he thought that care should be taken 
to study its favourite pastimes and habits. He felt that 
the education of nurses for small children bad not really 
been given enough thought, A person needed to be born 
a nurse- it was really not possible to teach a person to be 
one He .thought that enough interest was not taken in 
the teaching of children, and that the preparatory school 
was more important even than the public school, as in the 
first five years a hoy could ho either made ov marred. He 
bad not found much difference between breast-fed and 
bottle-fed children. By over-treatment a child could, of 
course be made more hypersensitive. He thought that 
the principal meal should be between 1 and 1.30 o clock, 
and not as lata as 2 or 3 o’clock, and that the interval in 
the middle of the morning given in most schools was not 

long onouoh. psychoneuroses. 

Dr J H PoLi-ocK read a paper on a case of psycho- 
neurosis ’ In describing the clinical histoiy he pointed 
out the' importance of the time factor. In the case bo 
described the psychical disturbances came on first some 
considerable time after the shock to which they were due, 
and roused up buried fears dating back to a much earlier 
period Moreover, it was important to remember that 
recove^ was bound to bo slow, and attempts to hurry the 
process were comparable to the “meddlesome midwifery 
of which complaint was made at times. Simple analysis 
mi<>ht help the physician to understand the details of his 
ca^ but it was a grave mistake to interest the patient 
in the process or' present it to him as a means of treatment. 



Feb. ti, 1928] 


YULYO-VAGINITiS IN CHIGDEEN. 


TintPBrnss - 001 

lMxi>TCxi.Jor»3»n 


Tho psychonexirotic tended to bo subjectively minded, and 
tlic object- of treatment Ehould bo to mako him objectively 
minded ; to interest him in his own mental processes was to 
do the reverse. 

The .Puf.sident said that repression was now admitted 
fo be one of tho most important factors in mental upset. 
He thought that tho heredity aspect must also ho present. 
Eeforring to the .endocrine basis of theSo disturbances, he 
felt strongly that these cases were all due to endocrine 
disturbance; even more attention' 'should be focused on 
these glands than was being done at' present. Tho. Olassifi- 
cation of these cases seemed to be quite hopeless, but ho 
did not think that classification would help much unless 
some light was thrown on their etiology. 

Dr. Ann.tawisoN said that he saw a number of p.atients 
rather similar to tho one described by Dr. Pollock, and he 
thought that in cases such as these it was important to 
-work up the details as Dr. Pollock had done, hut in a 
general. practice this was impossible, and ho thought that 
tliey should only be dealt with by a man who had the time 
to go into them thoroughly. He referred to the line of 
demarcation , between, tho ' cjrtremo psychasthenic patient 
and one definitely mental. Ho believed that satisfactory 
classification of these cases would be impossible until more 
light was thro-wn on their etiology. 

• Dr. BowtETTE thought that in these cases the most 
important point was not classification in regard to treat- 
ment, but in. regard to prognosis. The question was. When 
should the line be drawn between a case such as the one 
described by Dr. Pollock and a case which should be certi- 
fied? Many of these patients got seriously depressed, and 
it was in the depressed patient who was not actually insane 
that there was the greatest danger of suicide and the possi- 
bility of not putting the patient under restraint soon 
enough. In a great many of these cases tho condition 
seemed to arise out of a conflict which went on for some 
time, and this conflict was generally between one of the 
primal motives in human beings and that of moral 
restraint. He thought that in most of these people the 
unfortunate subject took refuge in drugs ns a method of 
preventing loss of self-control, which he would do if left 
-to his own exertions. He tho\ight it might bo assumed 
that the endocrine secretions were definitely associated 
with certain emotions. Those conditions had to be looked 
on as having their origin both in the mental substructure 
and in the physical substructure, and it was impossible in 
any case to separate one entirely from the other. 

Dr. M. P. O’Hea did not think that cases of severe 
neurasthenia were nearly so common now as in the previous 
decade. 


TraVO-VAGINITIS IN CHTLDREK, 

At a meeting of the EdinburgJi Obst-etrical Society oi 
January 11th, with Professor R. W. Johnstone in th 
chair, a paper was read by Mr. David Lees on vulvo 
vaginitis, in which. he analysed tho cases which had com 
under his observation in a period of five years— 1922-27. 

Mr. Lees dealt with a total of 146 cases, which wer 
divided into the following age groups ; 

0 to 1 year 7 4 pgr ggnt. 


1 to 5 years 
5 to 10 .. 
10 to 15 


39.2 

44.9 

8.4 


Ho said that the incidence of vulvo-vaginitis in Edinburg 
had been aupnonted by a recent epidemic in a children’ 
ins 1 ution in winch the disease had spread rapidly an 
proved to be very contagious. lii the largest number c 
cases, 40 per cent., tho source of tho infection could nc 
e ascertained. In 13 per cent, of the cases the patient 
were leported to have been assaulted, but in only a ver 
sm.Tll proportion of these basds was this proved; IS pc 
cent, of tho casra were epidemic in origin, and in 32 pc 
con . 10 infection was traced to others in the famiR 

le symiptoms and signs of the disease were described 
^"ii drawn to the frequency (99 per cent, 

uith which the urethral canal was involved in acute cases 
Sir. Lees insisted that every vaginal discharge in childro 
must ho looked on with suspicion, and treated as if c 
gonococcal origin, until at least three bacteriological test' 
performed under conditions favourable for tho dotectio 


of tho gonococcus, had proved negative. In chronic cases 
repeated films and cultures were necessary, and in resistant 
cases direct films or cultures must bo taken from the 
cervix. In 73.7 per cent, of tho cases gonococci were 
found, in 6.6 per cent, gonococci and other organisms, 
and in 19.7 per cent, secondary organisms only. In acute 
cases tho gonococcus was demonstrated in over 98 per cent, 
of cases. Tho more acute signs of disease disappeared 
rapidly with ' treatment, but tho parents should always he 
warned that a long time was required -to eradicate tlie 
disease, and that relapses wera apt to' occur unless the' 
patient was kept under treatment. Hospital treatment . 
and isolation , of . the patient from other children were 
advised wherever possible. The chief therapeutic measures 
recommended were hot' antiseptic and alkaline hip baths 
with daily lavage of the vagina and urethra. In older 
children the vagina was dried by swabbing through a specu- 
lum and the parts were dusted with dermatol powder; iu' 
younger children, when a speculum could not be introduced 
through the hymen, instillations of an antiseptic dissolved 
in glycerin were employed. The antiseptic preparations 
recommended were 1/4 to 1 per cent, picric acid in 
glycerin, 1/4 to 1 per cent, silver nitrate in glycerin, 
and 1/4 to 1/2 per cent. chloraniine-T' in glycerin. The 
instillations were supplemented by the use of small medi- 
cated bougies of those and other substances. If it was 
not possible to irrigate the urethra small urethral bougies, 
with cbloretone added to ease the pain, were inserted 
daily. Repeated changing of the antiseptic was advised, 
and it was recommended that in every case the vulvar 
surface should he left as dry as possible by dusting it 
with a compound dermatol powder. Efficient treatment 
depended more on tho meticulous care with which it was 
applied than on the medicament used. In every case it 
was essential; (Ij to establish good drainage from tho 
urethra, vulva, and vagina ; (2) to produce a' slight liyper- 
aomia of the infected parts by hot hip baths and hot 
vaginal douches; (3) to use a sterile all-glass catheter with 
lateral perforations in douching so as to spread the anti- 
septic over the vaginal wall during tlie doudie and prevent 
the infection being carried to tho cervix; (4) to dry tho 
parts subsequent to douching, or alternatively treat tho 
vagina with instillations of an antiseptic solution in 
glycerin; (5) to treat the urethra in every case; (6) to 
examine and treat the rectum if infected; (7) to prevent 
the child from conveying tlie infection to others and to 
its eyes. Adjuvant methods of treatment were used -in 
both acute and chronic cases, and of these detoxicated and 
autogenous vaccines had proved the most serviceable. TliA 
child -tolerated and responded well to vaccine .therapy.’ 

In the series of cases reviewed, the follbiving complica- 
tions arose : - - 1 . 

Gonococcal infection of tho eye • ... 8.3 per cent. 

Infection of the Fallopian tubes and pelvic 

peritoneum 5.5 ,, 

Infection of the rectum 2.7 „ 

' Non-specific ulceration of the vulva ... 1.8 ,, 

Acquired syphilis of the vulva 1.8 

Cystitis 0.9 „ 

No cases of arthritis were met with, but coincident 
syphilis occurred in 7.5 per cent, of all the cases. In 
making a diagnosis of cure it was essential to observe 
cases over long periods, and to examine repeated films 
during this period of observation. The standard of cure 
aimed at in every case should be : (1) Clinical cure and no 
.sign of clinical relapse after suspending all local tront- 
uiont. Local treatment must be continued for at least 
three weeks after apparent clinical cure. (2) Bacterio- 
logical cure in three successive smears taken at intervals 
of one week during treatment, and in three subsequent 
weekly tests taken after suspending treatment. (3) Clinical 
and bacteriological tests at intervals of one month over 
a period of throe months subsequent to the attainment of 
(1) and (2). (4) If there was any doubt as to the clinic.-il 

condition or as to the bacteriological reports, administra- 
tion of a provocative vaccine and a repetition of the tests 
both by direct film and by culture were indicated. (5) If 
there was neither clinical nor bacteriological evidence of 
disease during a period of three to four months after 
cessation from all treatment the case might be considered 
cured. In trying to attain this standard the following 


222 Feb. ii, 1928] 


DIGESTIVE EACTOliS'TN BOSAOBA. 


r The nnmsnt'p' 

L ilEDlClL J0VBXA6** 


results ii’oi'o obtained in the series o.l ld6 cases reported. 
IIio average duration of trciitmonl and tests for euro of 
gonococcal cases in those completed (87 cases) was seven 
niontlis. Tlie average duration of treatment aTid tests for 
enro of vulvo-vnginitis eases not proi-cd gonocoee.'il (21 
cases) vas tu'o months. Thirteen cases vhicli were still 
under treatment hut presumed cured had hecn under 
treatment and tests for euro for a period of five months; 
eighteen eases wore under active treatment with infection 
still present. Seven patients had defaulted while still 
showing signs of infection. 

Puerperal Ilacmorrliagc^ 

Dr. Kennedv then gave clinical notes ef three cases of 
puerperal haemorrhage. These cases were of interest a.s- 
the bleeding was very severe and did not begin until 
after the tenth day of the puerperium ; the dates of 
occurrence being the tenth day, fourteenth day, and sixth 
week after delivery. There was also no definite caiise 
found for the haemorrhage, even after thorough examina- 
tion under chloroform and curettage. In each of the cases, 
however, a retroversion was present, which was the more 
interesting ns on dismissal from the maternity hospital in 
all cases the uterus was anteverted. In no case was there 
any apparent infection present during the puerperium. 
In two cases the mother was not nursing her hah}', and 
therefore the haemorrhage might ho the return of an 
early menstruation. Dr. Kennedy was doubtful ns to the 
cause of the haemorrhage, but since retroversion was 
common to all, he thought that it must have something to 
do . with the haemorrhage. Ho could, however, find no 
record anywhere of a simple retroversion in the ptierperium 
causing so severe a haemorrhage. 


rORFARSHIRE JIEDICAL ASS0CIATI02f. 

Ar a meeting of the Forfarshire 3Icdical Association on 
December ISth, 1927, at University College, Dundee, the 
president, Dr. T. F. Dewar, in the chair, Dr. IV. E, 
Fogoie road a paper on hereditary haemorrhagic tclangiec- 
tasia, and added a new case to the forty recorded in the 
literature. 

Dr. Foggio said that the essential features of tho 
condition wore an hereditary tendency to epistaxis and 
telangiectasis. His patient, a woman now aged 42, had a 
typical family tree, and ho had been able to trace tho 
condition back through five generations. All tho other 
affected members of tho family had both tho epistaxis and 
the telangiectasis, but in his patient these signs were 
atypical. The only telangiectasis visible was one on tho 
lower lip, which had been ’there for as long as sho could 
remember. An unusual feature, and, so far as ho knen-, 
one never noted before in this condition, was the occur- 
rence of haomaturia, presumably from a telangiectasis in 
the urinary tract; tho urine contained blood and albumin, 
but no casts. The blood film was normal. Before the onset 
of an attack of haematiiria she occasionally had epistaxi-s 
with headache. There was no evidence of renal or cardio- 
vascular disease, and no suspicion of tubercle or tumour. 
Ho suggested that this case might form a link between 
hereditary haemorrhagic telangiectasia and essential 
haematiiria of hereditary t 3 'pe. 

Dr. ARTHim jMii.i.s read notes on a case of recurrent 
spontaneous pneumothorax. A man, aged 21, who appeared 
in perfect health, complained of pain in the loft side of 
the chest and breathlessness on exertion. The pain had 
come on suddenly twelve dajs previous!}-, accompanied by 
a feeling of suffocation and faintness; ho had had several 
similar attacks .before. A diagnosis of pneumothorax on 
tho left side with displacement of tho heart was confirmed 
by a-ray examination. Ho made a complete rocoveiy, but 
one year later a right pneumothorax was found. 'Recovery 
from this was followed in a fen- daj-s by another right 
pneumothorax, from which he again made a complete 
recovery. There was no evidence of disease of the Jungs, no 
indication of pleural adhesions, and no history suggesting 
former tuberculosis. Radiograms of the chest at various 
periods after an attack ivere shown by Dr. G. H. -S. iMrLi>JT. 

Dr. J. S. y. Rogers read notes on a case- of chloroma in 
a female child aged 11 months, wliich came under observa- 
tion because of proptosis of both eyes. The blood picture 


wa.s that of lymphatic loukaomia, tho leucocytes rising 
ovonlually to 65,000 per o.mm. (largo lymphocytes 38 per 
cent small lymphocytes 57 per cent.). Multiple tumours 
of tho skull appeared later. A post-mortcjn. examination 
could not bo obtained. . . 

Mr. .lon.v Anderso.n- gave a lantern demonstration to 
iliustrnto tiio olTcct on tho tissues of tho arc eloctrodo in. 
surgical dintliormy. Ho exhibited photomicrographs from 
sections taken along the lino of incision in amputation of 
the breast and in excision of a part of tho lip. Tho 
sections ^showed on tho surface a discontinuous delicate 
film, which might bo coagulum, and beneath this a narrow 
zone, about 0.1 mm. in depth, where tho cells wore altered 
and desiccated. Mr. Anderson also described briefly Jiis 
tocliniquo in surgical diathermy. 


DIGESTIVE FACTORS IN' ROSACEA. 

At a meeting of tlio London Association of tlio Mcdic.-il 
IVomon’s Federation licld on Januaiv 24tli, with the 
president. Miss Doltox, in tho chair. Dr. Sibyl R. 
Eastwood gave an address on the results of an investi- 
gation into tlio gastric secretion and other digestive factors 
in rosacea. 

Dr. Eastwood defined rosacea ns ossentiallj- a clirouic con- 
gestion of tho facial skin, affecting mainly the central 
two-thirds of tho faco and leading to permanent vascular 
dilation of this area. Papules and pustules, eczematous 
scaling, ocular lesions, hypertrophy of tho subcutaucoiis 
tissues leading to rhinophj-ma, though seen in. vaiying 
degrees in tho clinical picture, were to bo regarded as 
complications of tho iiiKlorljing vascular condition. The 
eyes were affected far more frequenti}- than appeared from 
the literatiiro on skin diseases. Since Arlt described a 
case in 1864 there bad been constant reports' of cases in 
opbthalmologicnl journals, and Dr. Eastwood ' exjilained 
this discrepancy ns being duo in- the first place to rosacea 
keratitis occurring often in mild' forms of facial rosacea, 
and secondly to ' tho greater importanco attached by 
patients to a condition affecting their eyesight than to 
their appearance. It was not until tho recognition, even 
now not general, of tho relationship between the two that 
tho cases had been fieely interchanged between the eyo 
and skin departments of hospitals. Dr. Eastwood said she 
iiad been led to rosacea by her interest in the digestive 
svstom and had hoped to obtain a series of patients with 
achlorhydria or extreme degrees of hypochlorhj-dria to 
ohsorvo as Barber and Ryle had reported this anomaly of 
castric ’secretion as present in 58 per cent, of the rosacea 
cases examined by them. In a series of over 50 cases of 
rosacea 7 of which bad ocular complications, Dr. Eastwood 
found diacstive disturbance present in about 90 per 
cent and that it was nearly alwaj-s “ functional ” in the 
cicwo’ that' no organic lesion of the gastro-mtestinal tract 
could be demonstrated. Fractional test meals bad bwii 
civen to all patients, and '9 per cent, had achlorhydria, 24.5 
i,er cent, hypochlorhydria, and 15.5 per cent, low normal 
curves thus agreeing veiy closely with Brown’s results in a 
birailar series piiblislied in 1925. These results corresponded 
closely with those found in chronic arthritis and chroino 
cliolecTstitis by other observers. Flatulence, constipation, 
flushing after meals, and capneiousnoss m diet had been 
the comiiionest symptoms complained of. From the T-ray 
examinations made in many of these cases it appeared that 
some degree of hypotonicity was common, though by no 
means universal.- Marked dislike of meat bad -not been 


frnd corrernted'with low acid secretion, and had occurred 
,-+i, iiirrli normal and hyperchlorhydric curves — 


of much interest. Focal sepsis had 

* . , • - — nnens D3-sfuiictidn or disease of the 

few cases, ' 


been found in many cases. 


crmiifal'oreans had been found m only 'a 
and’as^these had been cervicitis they fell into the' focal 
sepsis beadine. Tho majority of ■ the patients had- low 
systolic blood pressures. IVhatever the t3qi0 of digostivo 
disturbance, its effective relief had been accompanied by 
+lm rosacea. Hydrocliloi-ic acid in drachm doses 
witb^meals had-Jiad an almost magical effect in the patients 
with low or absent acid secretion, : but it had also prmed 
useful where no deficiency had been shown . Carbo]i3di ate 
excess in diet had been- a fairly constant finding, and its 
correction a strong factor in successful treatment. 


Feb. ir, 1928] 


EEVIEWS, 


If TssBuinf* 005 

I LMECTCJlt, jotmXAt 


Hciibius. 


COMPARATIVE ENDOCRINOLOGY. 

Db. L. T. Hogben’b book The Comparative Physiology of 
Internal Secretion' is n distinguished contribution to, tho 
nerr series of Monographs on Compar.ativo Physiology, 
publislied by tho Cambridge University Press. The subject 
of the chemical co-ordination of function is ono of quite 
recent grou-th in comparison with that of our knowledge 
of the complementary phenomenon — the nervous co-ordina- 
tion of function. Nevertheless, the growth of endocrinology 
has been, rapid, if sometimes impatient. Now, ns the. 
author points out, the practical justification for compara- 
tive physiology resides in the fact that some animals 
provide far more accessible material for the solution of a 
particular problem than others. This has proved very true 
in respect 'of the physiology of tho ductless glands, and it 
has undoubtedly been the comparative point of view which 
has disciplined the less cautious claims in this field. 

• In a field in which terms are apt to be used with little 
discrimination. Dr. Hogben is wise to define his subject 
with precision.. He regards an internal secretion or hor- 
mone as “ a substance liberated into the blood stream by 
the specific activity . of a particular structure, and which 
there is capable of evoking ' response in tissues remotely 
situated.”. .It is no economy, of .hypothesis to extend the 
term, as some writers do, to include any physiologically 
active cell eonstituerit, such as' choline or even carbon 
dioxide. 1 The arguraeht of the monograph, then, is directed 
towards establishing the functional importance of internal 
secretion as a part of the mechanism of co-ordination. The 
various chapters deal with neurb-musciilar co-ordination and 
the suprarenal, with .the chromatic function in relation to 
tho suprarenal and pituitary, with secretory processes and 
the activity .of the intestine and pituitary, with vasomotor 
regulation by the pituitary,- with metabolism as affected by 
the pancreas,- thyroid, and parathyroids, and with develop- 
mental processes in relation to internal secretions of the 
thyroid and pituitary. -Discussion of the internal secre- 
tions of the reproductive organs is omitted with intention. 

that a monograph upon this particular subject 
will shortly be added to the series. It suffices to add that 
the literature of comparative physiology is carefully sifted, 
that the discussion, though severely critical, is considerately 
performed, and that recent work is given generous space 
and careful appraisal. The' book is a contribution of real 
distinction to the literature of endocrinology. 


__ ;'THE “ ACUTE ABDOMEN.” 

vj received' for review ' three books on the “ acutt 
abdomen .’’.by Mr. ZAcminr Cope.” The first deals witl 
dia^osis, the second with .treatment, and the third with 
clinical research- in acute abdominal disease. The booki 
“"'form size and price, aud belong to the Oxforc 
Medical Publications. - . 

^he Early Diagnosis of the Aciife 
• rf fourth edition, and this must not be 
ju ged by the rather forlorn paragraph on mesenteric 
om osis and embolism to which attention is drawn in 
e pre ace as the chief addition to the present issue, 
e VO umo is still the very valuable, lucid, cmmpact 
aocoun o the common abdominal emergencies that must 
appea o eveiy student and young medical man. Probably 
the pages have served , as the basis of many a clinical 
ec ure, and no surgeon, however experienced, will he the 
worse or leading it; few will study it carefully without 
value to them. We are inclined to 
predict that the fourth edition will not be the last. 

The volume on The Treatment of the Acute Abdomen 


Iloff^n ^m"a Contah Irstmal Secrrticn. By Lancelot 

ISefeMa. fl) ."f ^eute Atdomcn Pp. xvl + 2 

iditiM Pn ... ■ ■ AhclominAl n!,cate. Seco 

llllford' - ■ ' Sledicnl Publications. Londo; 

iintord, Oxford 8^0 J03 


must bo appraised according to its intentions, “ to help 
those doctors who are not much practised in abdominal 
surgery, but who may be called in an emergency to 
operate upon an acute abdominal condition.” The claim 
that “ if tho technique advised be followed carefully a 
very largo proportion of successful cases can bo assured ” 
is likely to be made good, for while probably no surgeon 
will agree with every dictum, such criticism as may ha 
offered hero deals with minor matters. Clearly it is 
necessary in such a book to advocate caution, but in the 
matter of dosage of morphine (gr. 1/6) and of medinal 
(gr. 2) the caution seems perhaps excessive. Jejunostomy 
has certainly proved useful in skilled hands, but it must 
be very seldom called for, and it has disadvantages in 
the hands of tho inexperienced. Is it wise to advocate the 
use of intravenous ether by those for whom, avowedly, 
tho author writes? Is it likely that Turkish sponges will 
bo adequately sterilized? Is -it worth while mentioning a 
procedure for which the author (p. 67) “can hardly 
imagine its necessity ” ? The plan of shortening the meso- 
sigmoid by mattress sutures when operating for volvulus 
is hardly to be recommended to the tyro. Half a dozen 
other such comments might be made, • but their trivial 
character bears witness to the essential soundness of the 
teaching and the clari-ty of the directions. This is a 
valuable book, adapted to its purpose; it does not shirk 
difficulties. 

In Mr. Cope’s third volume. Clinical Ecsearches ih _Acute 
Abdominal Disease, is to be found evidence of the pains- 
taking work that has gone to tho successful protluction of 
tho seemingly simple books review'ed above. The most 
important now feature in this, the- second edition, is tho 
study of “shock” embodied in the author’s 'Hunterian 
Lecture. He elaborates . the observation that- shock- may 
be present and manifested by other -signs, with a blood 
pressure still high; so long, that is, as the. fall in circu- 
lating blood volunie can be compensated by ' vaso- 
constriction. His thesis of “ dissociation of symptoms ” 
in shock is amply illustrated by case records, and the 
presentation of it is convincing because it appeals to what 
is common experience. His “ definition ” of shock, how- 
ever, is not much more successful than its predecessors: 
definitions should not need explanation. . 


PATHOGENIC MICRO-ORGANISMS. 

Since the first parts of the third edition of Kolle and 
W.vssebjiann’s handbook of pathogenic -micro-organisms’ 
were reviewed in our issue of Maj' 7th, 1927 (p. 839), 
several fasciculi, forming parts of several volumes, have 
appeared. These contributions, which follow tho lines 
adopted in the earlier fasciculi, are admirable, reviews of 
tho subjects they deal with, and .contain lengthy biblio- 
gr.aphies. A mere enumeration of some . of the .principal 
contents of the various parts is. all that can be attempted 
here;. but this -will, we hope, serve a useful , purpose by 
providing fingerposts for -those to whom the work is 
addressed. ' • . 

Part 12 of volume i contains the final sections of 
Gotschlich’s article on the general morphology and biology 
of pathogenic micro-organisms, a summary of the researches 
carried out on tho bacteriophage by R. Otto and H. 
Munter, and shorter articles on the nature of infection and 
on mixed and secondary infections by A. Seitz. Part 6 of 
volume ii contains four papers . on immunity : on active 
immunity by M. Picker, bn the production of antibodies by 
R. Bieling, on the concentration of antibodies by St. 
Baclier, and bn tho value of antiserums by R. Otto and H. 
Hetsch. Part 5 of volume iii contains articles on serum 
therapy against snake, scorpion, and spider venoms .by 
-R. Kraus, on researches on animal venoms by H. Sachs, 
on plant toxins by M. Jacoby, on hay fever by C. Prausnitz, 
and on the specific treatment of hay fever and asthma by 
G. L. Hoffmann. Part 8 of volume iv contains articles on 
tho pseudo-tuberculosis of rodents by K. Poppe, on tho 
staphylococci by M. Neisser, and on iindulant fc-ver by 
A. Lustig and 6. Terroni; and Part 11 of the same volume 

‘ nandbuch dcr paNiojeant Hil-TOOTganUmrn. Begriindct ron -W. Kollo 
und A. V. Wassermnne. Drttte, erweiterte Aufla^. Jena: G. Fischer; 
Berlin und Wien : Urban und Schwarzenberp, 19^. 



224 - Feb. h, 1928^ 


BEVIEWS, 


r rnsBnmffK* - •- 
L il£oic^ JonyiJt 


conlniiis artiolos on mcniiip;oeoccal infections liy K. W. 
Jotten, on gonococcal infeefions by J. ICocIi and A. C'oliii, 
and on iniinnnity iii gonococcal infections by C. Bnick. 
Part 7 of volume v contains articles on infection by triclio- 
bactcria by O. IJnntcmiillcr, on tbo actinoniyces by R. 
Licskc, on actinomycosis by Jf. Sclilcgcl, on nmdnrn 
foot disease by A. Plebn. and on tlie dcrmalopbj-tes 
(or ringworm fnngi) by H. C. Plant and O. OriitK. 
Part 14 of voinmo v contains an article on tbo yeasts 
by A. Pn.sclike and A. Joseph, one on sporotrichosis 
by A. Bnscliko and E. Langcr, and another on diphtheria 
by H. A. Gins. Part 4 of voinmo vi contains articles on 
glanders by E. Lhhrs, and on 71. pijocyancus by A. Lode. 
Part 13 of volume vii contains a general account of tbo 
5|)iroehactcs by G. Sobernheim and IV. Loewcnthal; various 
ni tielcs on syphilis by G. .Sobcrnhci)n, C. Urnck, P. Priggo, 
and L. Lanbenbeimer, and a concluding one on framboc.siii 
bj' G. Baermann. Part 9 of voinmo viii contains articles 
on tlie i)iroplasmosos by C. Schilling and K. F. Meyer, on 
innnnnity in jn-otozoal infections by C. Schilling, on the 
inorpliology and classification of amoebae b_v W. v. Schnek- 
mann, and on amoebic dysentery by W. Fischer. Pari 10 
of volnine ix contains articles on jdcnro-pnenmoni.a in 
cattle by H. Ilahmcn and M. Eiegicr, on rinderpest by 
B. Albrecht, on African horse sickness by G. Lichtenbcld, 
on infectious anaemia in horses by T. Oppcnnnnn and 
M. Ziegler, on Bornasche Krankheit (meningitis) in horses 
by W. Zwick and 0. Scifried, on distemper in dogs by H. 
Schroeder, and on fowl-pcst by P. Gcriacli. 


HEALTH AIMflNISTRATIOX. 

While public health, alike in theory and practice, is 
based on the application of medical knowledge, the members 
of local authorities responsible for its ailministration 
usually consist for the most part of persons without .special 
medical training. Tho general public, wbicii provides the 
coi'iins vile for tho public honich administrator, and which 
has most to gain or most to lose by the skill or incom- 
])Ctonco of his efforts, is also a lay body, obscivant enough 
of residts achieved, but unfit fully to appreciate the 
methods by which they were ari'ived at. Health propa- 
ganda in this countiy is at present moving along tho lines 
of furnishing tho infoi-matiou on these matters of health 
whieh the laity seems to require. Tho recent issue by tho 
Scottish Board of Health, at a modest price, of pamphlets 
on the Schick and Dick tests, on encephalitis lethargica, 
and on ultra-violet ray therapy, intended for the pcimsal 
of members of local authorities, is an effort towards the 
health education of lay representatives, while tho health 
weeks and other special enterprises, which aro cordially 
aided by’ the press, bring under tho notice of tho general 
lay public the health problems of the day', and suggest 
ways in which the public may co-operate for their solution. 

A volume"* by Dr. Cakl E. McCosins,’ recently issued 
from the National Institute of Public Administration and 
New York Bureau of Municipal Kesearch, aims to provide 
the layman in America with tho same kind of insight 
into public health administration as has been' referred to 
above. Tho book falls naturally into three parts. In the 
first, the health functions of a municipality arc discussed. 
It is pointed out that in America the degree of respon- 
sibility for tho health of their citizens conferred on 
municipal bodies varies greatly in the different States. 
Tlie view is expressed that all health and welfare services 
in administrative areas should be co-ordinated under one 
management. In the second part, referring to vital 
statistics, the author points out the difficulties which arise 
from the differing laws as to the registration of births 
and deaths in different States. The health officer, he 
thinks, shoidd be tho registrar. The third part is con- 
cerned with the treatment of the sick. Dr. McCombs does 
not favour a free public medical service, but he thinks 
that the municipality, while undertaking the caro of 
infectious cases and of the sick poor, ought at the same 
time to provide general hospital accommodation at reduced 
rates for those unable to pay' high chai ges. The educa- 


• Citu Health .idminittration. By Cnrl E. McCombs, JU 
TIic Macmillan Company; London : Macmillan and Co., Ltd. 
8vo, pp. ..c + 524. 24s. net.) 


. New York : 
1927. (Demy 


tioiuil vnliio to, tho general inililic of a good lio.spital and 
nursing servico is emjjlinsizcd. The working of a public 
Jiealth laboratory is described in some detail. The book 
‘ns a_ whole convoys an impression of the sy.stems of health 
administration now current in the American Dnioii. Tho 
instances quoted aro often illuminating. Urging the im- 
portance of registration, tlio author cites the case of an 
American citisicn during the general war who, posso.ssing 
no docinnoiitary evidence of his birth in the United States 
of America, was ctjiiipellod to scivo in a European ai-my. 


EJIULSIONS. 

,Dit. WiLi.tAJi Cl-iyton’s book The Theory of Emuhions 
and their Technical TrcaimcnP first appeared in 1923, and 
the f.'ict tliat a second edition has already been required is 
an indication that this work, which deals with highly 
spccializeil problems, has earned general approval. 
Colloidal I'licmistry' has undergone a rapid development in 
recent yc.srs, but the author has brought tlio present 
volume thoroughly iij) to date, although this has involved 
rewriting a largo proportion of the hook. The laws govern- 
ing the production of emulsions are of peculiar complexity 
ami obscurity'. Tlie niimhcr of important technical pro-. 
cesses which dcjiciid upon these laws is, howcvoi", remarkably 
large. A few of such proccs.ses aro tlio manufacture of ice 
cream and margarine, the cleansing of condenser water;' 
the separation of water from crude oil, and tlio rceovery' 
of ores by the ilotntioii process. The book deals chiefly, 
with the general theories underlying the processes of. 
emulsification and dc-emiilsification, but rofereneo is made 
to ccrUain problems of particular interest to medical 
science. For instance, .the methods used in emulsification ■ 
of drugs are referred to briefly. A good deal of space is 
devoted to the problem of dual emulsions, arid this portion 
will bo found of great interest by those who are concerned 
with tho fundamental properties of protoplasm. There is a 
considcrahlo amount of evidence that indicates that tho 
surface of tlio living cell is composed of n reversible emul- 
sion of lijjoid and protoplasm." The author discusses fully 
the infliiciico of ions on oil-water emulsions, and this," in 
particular, is a problem of great biological interest. ( 


the nature of mind. 

Dn Paul Bousfielp and Mr. W. R.' BonsriEim have 
written a volume on The Mind and its Mechanism’ in 
which they cndeai'our: to ekplriin .the .phrinomena. of mental 
life bv postulating, the ,- existence of • a, real psychic 
rtrncturo or “ psvchoplasm ” which, Jike protoplasm, is an 
Lciitial part of each living cell. As to the possible basis 
of this plychophisiri tho authors take" tlie analogy of the 
etherial pi'otons and electrons which, constitute- matter, 
..nrtulate analogous ethereal units of a finer order 
^ ^ - suggested, that 

tart as protons and electrons arc agp-egated into 
protoplasm so may psychons he aggicgatod into psychio 
rtnicture Electrons and protons arc "both considered to 
bCloiV- to' tho physical i-ealin, and psyclionic substance is 
Considered to ho of mass so small as to he practically 

“’STglCriiis book is highly spccnlatiyo the hypothesis 
wliicli it is intended to elaborate is ingeniously worked out. 
In successive chapters the assumed existence of “ psychonic 
s.ihstaiico” is utilized to explain consciousness, the psychic 
orcan ” memorv, the transformation of ideas the energy 
of kleas emotion, the unconscious' mind, the “ f ’ of 
Freud hypuo.sis, telepathy, and evolution. The writers 
stroiigly favour the Lamarckian theory of evolution, taking 
the view that habits , become ingrained m the mental 
Striictiiro ” of tho organism, and that the psy chic striicturo 
ff thcTe™ cumulatively affected. 

Wo al'C not quite sure whether hypotheses such as those 


Thrnni Of Evinhions ahtl their Teehnieat Treatment. By 
* Tfir Theory or t-oi professor F. G, Donnan, 

rrobnw and cZ ul’; Ncw’To(k: E. P. Dutton anti Co. 1S27. (Demy 
Ivo, pp. vii + 224. 93. net.) 


Teb, ii| 


1928] 


NOTES ON BOOKS. 


I USSTCXZ. 


225 


developed in this book really add to our understanding of 
the phenomena of mind. Memory, “ meaning,” and con- 
sciousness are but manifestations of life ndiich are no more 
and no less mysterious th.an the physiological processes of 
tho living organism. It seems doubtful if it is either 
necessary or desirable to postulate, after the manner of tho 
authors, two kinds of energy in tho living organism — 
physical energy traceable to tho sun, and psychic energy to 
the “ psychic environment.” What can be definitely said 
is that matter infused with life behaves otherwise than 
inert matter, and perhaps this difforehoo is best summed 
up in Kignano’s formula — “ living things remember, inert 
matter does not remember.” (See the review of Jiiologieal 
Memory, Beitish Medicai. Journae, August 20th, 1927, 
p.310.) , . 


NOTES ON BOOKS, 

De. Gustave Moxon has published a French translation' of 
the second , edition .of Professor Max EiijHonN's book on 
the duodenal sound. The volume is well illustrated, and tho 
subject' matter, in Dr. Monod’s lucid style, describes clearly 
-this effective method of duodenal investigation and treatment. 
We published a review of the German edition of Professor 
Einhorn’s book on August 23rd, 1924 (p. 325), and of the first 
American edition on November 6th, 1920 (p. 704). 

True to his faith in the efficacy of oleum allii as a cm-ative 
agent in cases of chronic tuberculosis, Dr. W. C. Minchin has 
issued a third edition of his monograph,* of which the two 
previous editions appeared in 1912 and 1915 respectively. 
Farther experience, he tells ns, lias confirmed his previous 
. views. ■ Tho present; edition, however, contains more than tliis. 
Puzzled, as so many other observers h.ave been, as to the 
significance ^of the^ minute granules end splierical bodies so 
often^noted in association with the tubercle bacillus, he initiated 
_ a series of observations, with expert assistance, and claims to 
have proved that some of these bodies are able to pass the 
Chamoerland filter, to be stained, and to resist acids, alcohol, and 
oil, and to infect guinea-pigs with tuberculosis. Similar minute 
bodies have been studied by other observers. Dr. Minchin 
regards them os yeasts, ana would explain their action as 
fermentative. 


and his study on Amenhotep, for which room could not .he 
found in this volume. The author of these essaj'S died in 
1925, and Dr. Ernest Jones has written a lengthy introductory 
memoir giving a summary and appraisement of his numerous 
contributions to psycho-analysis and a sympathetic appreciation 
of his character. The author was a psychiatrist, and this work 
includes a number of studies of the psychoses from the psyclm- 
analytic standpoint. It is evident that he nourished the hope 
that the application of the psycho-analytic technique in cases 
of manic-depressive insanity, daring the intervals between 
attacks, might prove to be of therapeutic value. How far such 
a hope will be realized time alone will show. Meanwhile,- the 
clinical manifestations of this psychosis are suggestive of 
biogenetic rather than psychogenetio causation. 

■ The thirty-eighth annual edition of Burdett’s Hospitals and 
Ckarities^'^ - contains several new features and improvements 
designed to keep the book abreast of the unending philanthropic 
devmopments in the British Isles and abroad. The chapter 
devoted to tho work of the Hospital Saturday Fund has been 
augmented by a table showing in detail the progress made from 
1898 to 1926 inclusive. More space than hitherto is given to 
the Joint Council of the Order of 8t. John of Jerusalem and 
the British Bed Cross Society, and comments are made on sucli 
important subjects as co-operation between voluntary hospitals 
-and Poor Law infirmaries and the urgent problems created 
by the increasing number of road accidents. .The new develop- 
ments in the London School of Hygiene and Tropical Medicine 
are indicated, and prominence is rightly given also to the 
Liverpool School. A new subsection has been devoted to 
societies for providing legal aid. The names of the medical 
staffs of all (he teaching nospitals in the provinces, Scotland, 
and Ireland have now been added, and much valuable informa- 
tion about the different tuberculosis sanatoriums has been 
incorporated. The section devoted to overseas hospitals has 
been somewhat curtailed, but the directory of British iiospitals 
in Europe, chiefly used by tourists, and the list of nursing 
establishments abroad have been retained. The directory of 
institutions includes universities, colleges, and schools; the 
hospitals in the empire and foreign lands ; educational and 
charitable funds and institutions ; nursing associations throughout 
the world; and periodicals published in Great Britain and 
Ireland dealing , with medicine and allied subjects. It would be 
difficult to praise too highly this indispensable reference book. 


Miss Waller has written a very useful handbook of 

Practical Physics for Medical Students.' As it is intended tor 
use in the laboratory there are no illustrations, but repeated 
injunctions are given to the student to draw a diagram oefore 
atarting an experiment. The book is to be used in dost 
connexion with the lecture course, therefore no textbook 
material is included. In her preface the author states that 
. the ^book is the outcome of some years* experience of the 
particular problems which arise in the teaching of medical 
students. Their time is . limited, and their knowledge oi 
. physics IS not expected to be profound, but it must be adequate 
and accurate, and should be based on sound experimental 
Knowledge, rhe book is so arranged that students who have 

- already had a scientifio training can profitably follow the 
.complete course _ given,- while at the same time students jusi 
. beginning experimental work in physics can perform only the 

experiments indicated- They illustrate general raeasuremenls, 

- mechanics, miscellaneous properties of matter, heat, 
light, sound, magnetism, electrostatics, and current electricity. 

- u intended for medical students certain experi- 
j ^ 'r ®°““*^ .P™ve peculiarly useful to them have beer 

included for example, spectroscopy, surface tension, viscosity, 
psycho-galvanic reflex, and the us( 
of the electricity mams. A list of useful constants aac 

- mathematical tables published by the Board of Education i; 
hPE®?, This little .book is so lucid and concise, and s( 
definitely supplies a want, that we may hope that Miss Wallei 
may presently write a textbook of physics Kir medical students 

; Selected Papers of Karl Abraham, consists of . 

- translation of his more important psyjio-analytic works, c:i 
his Tiaum und Mythus, which has already appeared in Eng 


Mraod.^ Ttntmu d'Sprta S‘deMleme“’ri-"' '^■■''duit par le Dr. Gu'da 

Tubireulo% “"won"' . 

M D Dubl Third pd/firtn j**^*^^ Allti. Bv \Wllfam C. Minclii 

fCr4to PD ^iVlin - .BaiUitre, Tindall and Cox. 19: 

London^' Si + 
by Ernen'jonw ‘^Tr/nSS^d^h’'°^n °i^SFTitroduelarvmeac 

.ivooif, Tha Ho^aJth Press." lag. ' 


The League of Nations Commission on Human Trypano- 
somiasis, consisting of delegates from Britain, Belgium, France, 
Germany, and Portugal, commenced operations at Entebbe in 
the beginning of 1926, and has just issued an interim report 
(CH. 5l6) on its activities. The report consists of an intro- 
duction on the general programme of the Commission (by 
Br. H. L. Duke, the British delegate and chairman), and k 
number of articles written by various individual members. 
These articles include accounts of the commission's epidemio- 
logical, therapeutical, laboratory, diagnostic, and zoological 
studies. Owing to the interim nature of the report few 
definite conclusions are reached, but the lines of research 
contemplated promise to bring results of considerable importance 
in the fight against sleeping sickness. - 


»» BurdeU's Hospftalt and ChariUct, 1V28. Founded by Sir Henry 
Burdett, K.C.V.O. Thlrty-clphth year, London : Faber and Gwyer. 

Ltd. (The Scientific Press). 1S28. (Demy 8vo, pp. xvll -t- 8%. 21s, net.) 


PREPARATIONS AND APPLIANCES. 

. . Alepol,”. 

"Alepol,”. manufactured by Messrs. Burroughs Wellcome and Co., 
* consists of a selected fraction of the sodium salts of the total fatly 
acids of hydnocarpus oil, and' is recommended for subcutaneous or 
intramuscular injection. 

When modern investigations confirmed the traditional value 
of chaulmoogra' oil in the treatment of leprosy, tho chief difficulty 
encountered was the discovery of a method of administration 
suitable for prolonged treatment. This difficulty was due to tlio 
highly irritant nature of the crude oil. Several years ago Messrs. 
Burroughs Wellcome prepared a mixture of esters of acids of tlio 
chaulmoogric series, which has been widely used in leper colonics. 
Hydnocarpus oil contains fatty acids which resemble those of 
chaulmoogra oil and have the same pharmacological actions. Tlio 
former 'oil has, however, the advantage of being more easily 
obtainable. 

** Alepol ** is a selection of the lower melting point sodium salts 
of the fatty acids of hydnocarpus oil, and this selection obviates, 
to a considerable extent, tho old disadvantage of vein blocking 
which tended to occur when these compounds were given intra- 
venously. The makers say that the clinical trials of this pre- 
paration have proved satisfactory. 



226 Ted. ii, 1328] 


MOTOR CAR COACHWORK. 


I Tut Er.mw 

SfKDicju, Joe&sis 


MOTOR CAR GOACnWORK TOR TJIR 3IKDICAI. 
PROFESSIO^f. 

[^FRO^I a COUUESI’O.S’IIENT.J 

So many cUffcroiit styles of bodies for motor cal's are on llic 
market to-day that it has become difficult for tlic medical 
practitioner to decide rvliich will meet bis special ropiiremcnts. 
Particularly docs this apply to the small-))owcrcd loss expensive 
ears. In order to withstand the ordinary wear of a contimioiis 
daily service, year in and year out, for lioth the town and 
country practitioner, workmanship and materials arc iinporlanl 
if heavy repair bills are to he avoided. ^Yith the variable 
climate c.xperienced in this country, the progress that of recent 
years has been made in design, and the aid of new materials 
together -wilh modern methods of construction, the clo.scd body 
with its mechanically adjustable windows and a light pei-manent 
fop, or the cabriolet coup6 with the u[)per .strnctnrc made to 
open when desired, probably stands first. They arc designed 
for all-wcalhcr protection, wliicli an open car, even wlicn fitted 
with a conventional hood and side curtains, cannot give. 

With a large number of medical practitioners self-driving 
is the rule; hence the popularity of the coupe or coiiplollc style. 
A design wliich is preferable is that frequently spoken of as 
a foreshortened saloon. A body of generous dimensions, with 
separate adjustable scats in front and two occasional spring 
seats, staggered for comfortable leg room at rear, fitted parallel 
with the sides, iuto wliich they fold wlien not in u.se, accommo- 
dates four passengers; luggage is carried 111 llic tail-end of 
the. body. The car is easily 
entered; moreover, it is thief- 
proof, ns tho rear o.xteiision has 
no doors or lids to open extern- 
ally. A modification of this 
body is the quarter liglit 
(uiipe. JIann Egcrtoii and Co., 

Limited, of Norwich, Ipswich, 
and London, have for many 
Years specialized in this pai'- 
ticiihir typo of body. It is 
known as the “ all-purpose / 



coupe cflbriolcf,” Jiud it 
ail ideal vehicle for a doctor, 
either for professional or 
pleasure purposes. It . accom- 
modates four persons under the hood, and contains a i-oomy 
hoot for luggage and bags, readily accessible from the iiilerior 
of the ear, this being a great convenience for a doitor. A 
rorafortable detachable dicky seal can be fitted in addition, 
so that the ear will carry from two to six persons, and it can 
he used eitlier as a completely open or closed car. 

But the closed oar of the coupe style, though useful, does 
not po&se.ss to a high degree the points, most essential to 
medical men, of silence, comfort, and roonihiess. To elimiiialo 
all liability to rattle, or drumming noise, .as well .as to prevent 
the chassis frame distortions and vibrations Iieiiig conveyed 
to tlio interior avhen travefling over rough ro.ads, tlie body 
should be practically isolated from the chassis. Tlii*, may 
be done- by some special form of suspension, as in tlie Daimler 
cars or by Iiedding the bottom of the body on tliiek felt or 
rtihher These constructional features are of such importance 
in the production of a silent interior tli.at tlie shell framework 
of many forms of bodies, particularly those fabric-covcicd, 
is built distinct and apart, as in the Weymann fabric flexible 
h dv The body shell framework is developed in .a series 
of ravallelograms, the various components being held together 
!w steel plates with intervening air spaces, so that no noise 
or squeaks are set up by the ends rubbing together. In othcr 
bodies the framework joints are cushioned m rubber or a 
sTmilar resilient material, and the rigid wood framework 
slwarated from the seats and flooring. For the medical man 
laborious day a restful, quiet interior is of impoTt.ance, 

dei-aWe qualfties of silence, comfortab e sealing and Jnra- 
b liU will be found in bodies built with a rigid framewoi^ 
nailed in aluminium for the lower part, and with flexible 
copied upper structure above the waist rad The question 
cushion ‘^comfort depends upon proportional measurameii s 
as to the height of the compressed cushion from .floor, as 
^veU as the slope from the horizontal line, m combination with 


Jtaim L’gei ton t'impe Calirioitt on IWi.p. aix-c.i liiidcr Sunto.sm t.'li.a.va's. 


the slojic of tile hack, sqmihhed deeply and upholstered at 
points that will give support to the back and shoulders. Well 
built cu.'hious arc constructed on a douhlc-dcck princiide, ivilk 
two tiers of coiled .springs of different gauges within a light 
wire frame, aliovc wliich is a squ.ih made of cnrled horse hair. 
The cushions are ventilated to allow of tho escape of air when 
compressed. As a substitute for .springs pneumatic air-filled 
tutics, which c.ati he inflated to the desired resiliency, are 
finding considerable favour. Sorbo rubber sponge is found 
to give .1 particularly soft and easy cushioning on the roughest 
of macadam roads. 

The roomy quarter light coupe will provide good service 
to the medical man, when built on modem lines with all-metal 
front slnictiirc .supporting a windscreen ■ of a .single- deflector 
panel. On a standard cha.ssis from 15 to 20-h.p. the Iiody 
space will permit of a roomy body with extra scats, as previously 
iiieiilioned, and an enclosure in the tail-end, with hinged doors, 
forming a receptacle for carrying instruments, cylinders of 
o.vygcii, and hags for miscellaneous drugs, etc. 

The trend of design in .all motor cars is for a lower overall 
height from ground, high waist, and .sliallow windows; hut as 
long as the road clearance and .st.and.ard head room are provided 
this will not affect the interior roominess for the extra seats 
and a suitable coiivciiicncc for canying tho necessary smgnal 
and other appliances all forward of the rear axle. In the 
interior of the clu.scd car considerable improvement has lieen 
effected in the many appcnd.agcs .and necessary furniture, sucii 
as mechanical lifts' for the fvamelcss glass windows, moving 
in fell and rubber lined cliamicls. 

The prospective owner slionia 
satisfy hini-self that tlie seat- 
ing arrangement and head 
and leg room meet with ins 
approval; he should he eqnall.' 
satisfied that in tlie construc- 
tion every ■eoiifrivuiicc has 
been introduced for alioli.sliing 
sliocks and mill/fying rattles. 
Soft roofs,, composed of leather 
and hiiilt up with an underlay 
of waterproofing material, are 
conducive to a silent interior, 
and are found most durable. 
Jn the construction of tho 
doors spring-loaded hinges 
. . • , 1 . I.i,. im the wear and avoid r.-ittle from 

should be used, so as to ^ ' „„a dovetails should 

lliis source; while o.i the “ pplementary means to 

be fixed, of a Tlirec-way ac , . jlie wings and 

securing perfect rigidity. L 1 . ,hey 

.stepboard l.racket.s no leather; and in case of 

.should lie separated by , tubing slit open at one edge, 
rear wings, at the arches, 

or sheet rnliher »’ ^ before finally fixing. 

Imtwoen the down%n a base of mbber 

Die bonnet .should f ; y,_,;ed portion, if .my, bedded 

with the advmt of vvind- 
m nil.hei , t,,e single-piece screen, adjustable froni 

screeiiwipeis s to d 

the top. F i ^„d lipped to prevent iiot 

• ■■"■'’d fum« fram entering the body. Mats of a material 
.air and si.ould cover the floor hoards, while 

th.al docs material between the cushions and seat 

.a thin, noii-c S ^ entrance of hot air and fumes. Iho 

boards also pra e - lb« P“" 

melliod of ••‘7'='" S p ■ ( extent ,a silent ratenor 

manently is usual to have a rich West o 

V 1 ® I cloth i-eferahly of the plain stretched pattern, of 
Englan j^rnmnize with the painting. _ 

a OTloui to . upisii the improvement m cellulose 

As >'^6® ■ £ bright, lustrous finish appeals strongly 

euamel or from the point of view of dnrability and 

to many ^ . /„ cleaning the car. Small scratches and 

blmrenre C'^ily removed without the expense of a revarnisli- 

ing, as m “®'=’'.P‘'‘'f,ming'”cVstr general op-keep, and garage 
hor economy ^ f ^ediL horse power, i.nd designed 

sp.ace, the coupe wit the 

rddhrr:dv-a"rg^ of the baai 

surgical appliance, is excellent for medical men. 







■Fkb. II, 1918] 


THE VALUES OF DEATH CEBTrPICATION. 


[ Tin: Bp.itish 007 

aiTDlCAI. JOCRSJi 


Bvttis!) jEetitcal foittnal. 


SATUEDAX, FEBEDAEV llTH, 1928. 


THE VALUES OF HEATH CERTIFICATION. 
'J’iJK prnctice of certificfltion of flio cauises of deatli 
iD.-ikes a floubJe appeal to members of the medial 
profession. The immediate call arises when a ccrtifi- ’ 
cate has to be provided in an individual instance. The ' 
wider claim recognizes that from certilieation there 
issues statistical information of high scientific, social, 
and economic importance. ■ Conclnsions regarding the 
frequency of various diseases, the decline or advance 
of each from year to year, and the relations of age, 
occupation, habits, and geogiaphj' to pathological 
processes, are, with seeming iustification, b.ased upon 
the Registrar-General’s returns; and, of course, 
towards these returns each certificate of the cause 
of death is an individual contribution. Clearly, there- 
fore, the aim must be to secure in each contribution 
a maximum of accuracy. It is allowed that there are 
obstacles to this ambition, and that, as a fact, the aim 
is not invariably attained; hence efforts, of which I 
the new form of death certificate recently issued is 
an e.xample, to cultivate and secure accuracy' in 
increasing measure. It is understood that the whole 
subject just now is receiving official consideration, 
and some of its aspects may therefore not inappro- 
priately be submitted to the attention of our readers. 

As a general proposition it may not unfairly bo said 
that the larger values of accurate de.ath certification 
arc not often pressed on the notice of the general body 
of the medical profession. ' The official figures make 
their usual statutory appearance, and offer oppor- 
tunities for passing comment and comparison, but 
they^ have little abiding influence. No practical 
application seems to be attached to them, and they' do 
not secure the attention that is e.vcited by' challenge 
or controversy. Is it not possible to bring them, or 
some of them, into the medical arena as bearing on 
particular points of medical doctrine or opinion? 
Certainly some of the conclusions urged on the basis 
of the official figures are in apparent conflict ■with 
teaching proposed from other sources. Vlierc such 
disparity exists there is obviously opportunity for 
inquiry' and ar^ment and debate, and some of our 
medical societies would surelv provide an appropriate 
platforni. No doubt contributions on the general 
values of accurate death certification have their 
worth, but here we are thinldng rather of limited 
topics chosen as bearing on medical teaching and on 
medical practice. For example, some recent figures 
suggest that the age distribution of cancer and the class 
incidence of this disease may have important relations 
to ttie prevention of cancer. If such conclusions are 
to be made effective the figures on which they are 
based must be brought to the test of debate, and not 
smiply announced as authoritative totals carefully 
registered m appropriate official departments. 

Jlieie IS the more need for such developments as 
are here advocated seeing that, with or without justifi- 
cation, the official returns of the causes of death are 
iceencd with some measure of incredulity'. Their 
general^ appreciation will therefore be promoted if, in 
paiticuiar respects, they' can bo shown to be confirmed 
by other observations. Especially is this true if such 
confirmatory’ observations are supplied by actual post- 


mortem examinations, for here we pass from the 
region of opinion to 'that of demonstration. The 
official figures are naturally impressii e from their bulb 
and from the wide area from which they are collected, 
and ho quotation of the experience of an individual 
practitioner or institution could be set on the same 
level. But post-mortem records, collected from all 
the principal hospitals of the country, would consti- 
tute a body of evidence not to be ignored; and if such 
evidence proved to be in harmony with the official 
figures on any selected issue, the appreciation of the 
official' figures in general lyould certainly bo increa.9ed. 
-The claim; therefore, is that the value of the recorded 
results of death certification will receive wider recog- 
liition when these results ' are presented as topics for 
discussion and debate, and when they can be shown 
to be in harmony with information gathered from 
other sources. 

Ineidentally, we note that in the new form of death 
certificate the performance or non-performance of a 
necropsy must definitely be recorded. Time will there- 
fore bring a body of verified knowledge, valuable in 
itself, and valuable also as a check upon other certifi- 
cates having a somewhat less confident quality. The 
most sure of all bases for death certification is obviously 
post-mortem examination, and possibly the day may 
come when the public ivill recognize the value of such 
examinations, not only to medical science, but also to 
the equipment and efficiency of the individual practi- 
tioner as an adviser of individual patients. Certainly 
the more numerous the death certificates resting on 
this basis the more widespread will be the confidence, 
given to the official returns. 

In. the meantime, and probably for many years, the 
great majority of deaths will not be certified on the 
fact of post-mortem examination, and the returns 
must rest on the care and judgement' with which 
certifying practitioners carry out the duty prescribed 
for them. The question therefore arises whether the 
educatfonal efforts directed to this end are adequate, 
rrcsumably in the medical curriculum the lecturer on 
public health or forensic medicine, in drawing the 
students’ attention to the legal I'esponsibilities of 
medical practice, must speak of medical certificates in 
general, and of the certificates of the cause of death 
in particular. The occasion might well be taken to 
emphasize the wide and important relations of death 
certification, for here is an inspiring motive for the 
cultivation of accuracy in the individual certificate. 
Practical teaching in the actual ivi-iting of the certifi- 
cate has its opportunities in every hospital ward ; were 
such' opportunities utilized the young practitioner 
would surely cease to be embarrassed when he is first 
called upon to sign a certificate of the cause of death. 
A few doctrinal explanations and actual experiences 
would promptly reduce the responsibility to its very 
sunple proportions. Possibly some practitionere fail 
in full attention to the notes and suggestions printed 
■with the books of blank certificates, f’hese are most 
helpful, and they show a very modest set of demands. 
What is desired is not a severely critical c.xcrcise, but 
a broad statement of the disease which has produced 
the patient’s death. Thus, to teke a single example, 
the Registrar- General is concerned to know how many 
persons die from phthisis pulmonali.s, but is relatively 
little interested in knowing how mam' of these die 
from exhaustion and how many from iiaeinopti-sis. 
In many cases a single term fully meets the demand, 
though admittedly there arc experiences which may 
not be so easily satisfied. 

That more accuracy should be attempted in death 
certification is a proposition to which aU will assent. 


A NEW WAY. IN VVBLIO HBAEiTH. , 


r TmfStmn 
L uKJ>ie4I, JoCXirUr 



Feb. it,' 1928 ] 


tois end, wo suggest, will be promoted by bringing 
porno of the official statistics into contact with other 
sources of medical Imowledge, by emphasizing the wide 
bearing of death certification, and by introducing tho 
medical student both to tho certificate itself and to 
.the sanctions on which it rests. 


A NEW WAY IN PUBLIC HEALTH. 


.When tho Local Government Act of 1888 laid donm 
that no person should be appointed tho medical officer 
of health of any county or district having a popula- 
tion of 50,000 or over unless ho held n diploma in 
•sanitaiy science, it made a provision which was greatly 
in the interest of tho beneficiary areas. In drawing the 
, line, of demarcation the Legislature may bo presumed 
to have taken tho view that, while tho health nflairs 
of populations of 50,000 and over were of sufficient 
weight to demand the services of a "specialist'' 
trained In the field of health, those of populations of 
lower dimensions might safely bo entrusted to an 

ordinary " medical man, qualified in general to 
practise medicine, surgery, and midwifery, or, in 
terms of the Act, where tho Local Government Board 
saw fit, to a man without any medical qualifications 
at all. In the present day, wth its wider outlook and 
its Sanitary Officers Order, 1922, such a view may 
seem chcumscribed, yet at that period it was not 
um'easonable. Tho hygiene of the time was largely 
environmental; questions of water supply, drainage, 
and sewage disposal awaited settlement, and the 
problems which arose, while acute in the cities, were 
much less urgent in smaller areas, ndth tho people 
more dispersed or in the open country. 

Tho Act of 1888 notwithstanding, the Local Govern- 
ment Board, as long ago as 1872, had recognized for 
areas of all dimensions, great and small alike, tho 
importance of having a specialist officer in the sense 
of one who devotes his nhole time to public health 
work, and towards this end had urged upon districts 
that they should combine. On this gi'ound, and 
doubtless in some cases on grounds of economy also, 
a number of combinations were made, adjacent areas 
joining together to appoint one common medical officer 
of health. For a time these combinations appeared 
to be adequate; they covered the environmental field. 
Then new issues began to arise as the scope of hygiene 
widened. Since 1907 administration has taken in 
. school medical work, maternity and child welfare, 
tuberculosis, venereal disease, and other subjects, not 
. all supervised by the publio health authority, yet all 
germane to pubfio health. For these new services the 
publio health combinations failed; in. some respects 
they were too narrow, in others they overlapped; 
"a new way had to be found. 

The new way, which goes far t.o solve the problem, 
is to co-ordinate the services of an area in such a 
manner that the medical officer of health of each 
district is also an officer of the county council. It is 
the subject of a report by Dr. James Pearse, lately 
issued by the Ministry of Health,* which deals more 
particularly with the counties of Essex, Hampshire, 
Gloucester, and West Sussex, but at the same time 
treats of the principles involved in a lucid and inter- 
esting manner. Each district has its own medical 
officer of health, and so remains autonomous: but its 
medical officer is also assistant school medical officer 
of the county in his district, or assistant school 


r/ic 

Ez$ex, 

M.D. • ■ 
No. 5S. 


Health Services tn the Counties of 
• West Sussex. By Jamw Pearse, C.B.!!., 
, on Public Health and Medical Subjecta, 
Office. 1928. 6d. net., 


medical _ officer and assistant tuberculosis officer, or 
else ho holds the two last-named posts together with 
that of assistant maternity and child welfare officer. 
Complete co-ordination is . thus effected in the person 
of the district medical officer of health, who holds all 
the reins of district administration, working either in 
concert with, or under tho supervision of, the central 
department of tho county. Tho fact that he works 
under dual control has apparently created no difficulty. 
Tlie opinion of forty-seven authorities in the counties 
concerned, ns expressed to Dr. Pearse, was in general 
favourable to tho new scheme. The most emphatic 
approval was that of the authorities whose sanitary 
standards were highest. Two only, and these not the 
most zealous, evidently thought their new officer too 
energetic. 

Apart from the direct administrative advantages for 
the control of infectious disease, the supervision of 
tuberculosis, tho amelioration of housing conditions, 
and Idndred mailers. Dr. Pearse brings out, as a point 
of importance to the publio health service and the 
medical, profession, tho wider range and interest to 
medical officers of tho co-ordinated soherne, which 
relieves the monotony of the routine e.xaminations 
incidental to school and tuberculosis work, and which, 
if extended in the future, will offer many assistant 
officers an escape from the backwaters of the health 
Bc-rvico into its main cun-ent. 

It is customary to decry the local government 
system of England on account of sundry defects. 
This • report shows that, given goodwdll and enter- 
prise, results can be obtained under existing conditions 
which, for practical purposes, could scarcely be 
bettered by a complete reorganization. 


absorption from mucous surfaces. 

Tjm question of absorption of materials from mucous 
surf.accs is ono of considerable practical interest both to the 
clinician and to the toxicologist, but although a great deal 
of work 1 ms been done by physiologists on questions relating 
to coll permeability in general, the reports of direct 
obsei-vations of the penetration of substances into raucous 
mombranos are comparatively few. General consideration 
of permeability, and Kcperiments on the passage of sub- 
stances from tho corebro-spinal fluid into the blood (Di.xon, 
Dohmo Lecture, 1B26), suggest that one of the detcrmmmg 
factors may he the size of the molecule of the substance 
nmnloved Thiis crystalloids in general pass freely from 
tho^ cerobro-spinal fluid to the blood; insulin, Witte’s 
nentone, and secretin do not; and there are fairly good 
Uunds for Eupppsing .tbat the molecules of 
secretin aro large ones, while we know that the Wrtto 
peptone consists for tho most part of polypeptides, 
difference,' however, between absorption from the cerebro- 
spinal fluid and from the stratified epithelium, of which 
many of tho mucous surfaces of tho body are composed, 
is great Direct experiments by Knaus’ showed that 
oituitrin' was absorbed from tho mouth and the rectum, 
from no other part of the alimentary tract. Ha 
Failed to confirm the results of AVolfe,= Hamill,* and 
Donaldson,* who concluded that pituitrin could Eatisfa<> 
torily bo absorbed from the alimentary canal. In 
Macht reported some very interesting experiments dealing 
rith absorption of drugs from the vagina. The materials 
iOEled consisted of certain inorganio salts, alkaloids, ana 
intiseptics, and were all crystalloids. Ho found that they 
vero, without exception, rapidly absorbed, and produced 


I BRITISH MroiCAi. Journal. Pcbniary 6th, 1926. 
sBert. kUn. ^och., 1921, 5, P. lOL 

• Proo. Hoy. Soc. iZcd., 17, IQZL 

* Ibid., 19, 1921 


FEB. II, igi’S] 


DEFfldTIVE St¥tirdirUBE OP TEETH. 


[ - -The Biimsa ’■ 000 

ITedICAI. JOCBJOI. 


tlioir typical pliysiologicnl and toxic effects to a marked 
tlcgroo. Ho qiioto<l, in ncldition, nmny cases from tlio 
litcrntiiro in nhicli serious — sometimes fatal — effects 
followed tlio introduction into tlic vagina of substances for 
tlierapoutic or, in .a few cases, criminal purposes. At tlio 
moment considerablo interest attacbes to tlio administro- 
tion of insulin In- ’ routes other than the subcutaneous, 
wbicb, if used over long iporiods of time, becomes increas- 
ingly unpleasant to the subject. Notwithstanding reports 
from some German physicians,’ the weight of evidence 
seems to point to the fact that insulin is not absorbed 
from the alimentary tract. IT]) to tho present tho results 
obtained with sj-nthalin and allied substances are not 
sufficiently encouraging to warrant their general adoption, 
and the question arises whether insulin could usefully bo 
given by any other route. In 1923 ri.shor and Noble* 
reported that insulin was absorbed when injected into thq 
vagina. Becently Robinson’ has reported experiments 
which serve to confirm tho work of Macht, quoted above, 
and which, in addition, confirm that of Fisher and Noble 
on tho absorption ■ of insulin.- Robinson found that 
adrenaline, secretin, and Witte’s peptone were not 
absorbed; with pituitary extract the oxytocic, but not tho 
pressor, effect was obtained. This last point, taken in 
conjunction with the similar result obtained by Knaus on 
the absorption of pituitrin from tbo mouth, may perhaps 
be considered as tending to support tho idea that in 
pituitrin we have to deal, not with ono substance, but 
with two. Robinson, unlike jMaeht, took special precautions 
to avoid absorption from tho cervix uteri. 


DEFECTIVE STRUCTURE OF TEETH. 

Fnoii tho Department of Pharmacolog}- of tho University 
of Sheffield comes an essay by JIrs. Mcllanby (reprinted 
from the Brifish BenUil Journal of July 1st, 1927) contain- 
ing a .summary of tho results of .her investigations during 
the last four , years into ' tho prevalence of hjqroplasia in 
the teeth of English, children of tb-day. After prolonged 
research, in tho; course - of which 1,036 deciduous teeth 
and 266 permanent teetli . rvere submitted to mici-oscoiric 
examination, ■ she confronts, iis with figures showing a 
preyalenco of hypoplasia to a degree hitherto quite un- 
expected. She' distinguishes three degrees of hypoplasia. 
,Of temporary incisors-49 per cent, were normal, 14 per cent', 
hypoplasio or sevei'ely; hj-poplasic. Of temporary canines 
8 per ceiit. were normal, 54 jrbr cent.- hypoplasia or sev-erely 
hypoplasic. ■ Of temporary first molar's 7 per cent, "were 
Jioi inal, 73 per cent., hypoplasic or severely hy[)oplasic. Of 
tenipomry second molars 1 per cent, were normal, 92 per 
cent, liypoplasic or 'severely ' hypoplasic. The remainder 
showed slight hypoplasia.- Of tlie penuanent teeth (the 
nisdoin tooth is the only ono not examined) none were 
noimal, and only one tooth, the second premolar (62.5 }>er 
cent.), showed an incidence of hypoplasia or severe 
^OPopl^^sia of under 90 per cent., the second molar reaching 
100 per cent. To emphasize tho tangible nature of tho 
defect tliese figures point to, Mrs. Mellanhy gives tables 
shov ing that hy macroscopic observation in the moutli or in 
tie land (by moans of a somewhat blunt probe to detect 
roug iness, and by visual estimate of hypoplasic enamel) 
practically identical figures wore obtained. Another table 
s loving that the teeth from dental clinics are decidedly 
V 01 so t lan those from private sources, and tho observation 
la 1 10 temporary incisors are the best formed teetb, 
lat malnutrition is the factor responsible for tlio 
vitG sjnead of dental hypoplasia — a theoi'j^ which is 
current view of its origin. Mi’s. 
Mellauby behoves that tho incidence and severity of hyi>o- 


* Lancet, Januarv 21sl, 1928 

‘ Amcr. Joarn. I'hynoL, l.-^vi!, p. 65 

• Joarn Obitcl. and O'jmaeciil., 1925 

Ertter. Therap., .vxxii, 81. ' ■ 


1, and Joarn, Pliarm. 


jilasia' kavo a definito relation to the incidence and 
severity of dental caries. She is careful to define what 
slie means by liypopla.sia, and it is Iiore that a jiossibility 
of error prc.sents itself. It is well known that the dentine 
of the tooth of cotacca, for instance, shows large numbers 
of intorglobidar spaces — are we to expect perfection in 
man only? Again, sbo 8338 .- “It is interesting to unto 
that tbo' intcrglobiilar spaces, especially in the incisors and 
first inolai-s, are usually situated fairly near the amolo- 
dentinal junction, in contrast with tlie deciduous inci,sors, 
where any defects are usually found towards the pulp.’’- 
Tho granular layer of Tomes, situated close to the amelo- 
dentiiial junction, lias always been considered a normal 
structure, and it may bo asked whether this is the lav-er to 
wbicb jMrs. Mcllanby refers-. A.s regards the relationship 
of caries to hypoplasia, Mrs. Mellanhy is rather nnfortnnato 
in Fig. 14, in which the carious area is the onty part free 
of intorglobnlar spaces. The figure seems to suggest that 
environment is the more imiiortant factor in the jiroduc- 
tion of caries.- Importance is attached by the author 
to variations in the rate of calcification, and it is suggested 
that the second temporary molars, for example, are more 
hypoplasic because of more rapid calcification. "We mav' be 
allowed to ask for the proof of this suggestion. Wo may 
ask, too, for proof of the statement that “no doubt . . . 
increased maternal dental decay is due to the sacrifice of 
the motbor to the growing organism of substances essential 
for her own welfare.’’ But these are side issues. Tho 
main point stands. By patient and careful investigation 
Mrs. Mcllanby has demonstrated the existence of dental 
li 3 'poplasia among English children to an extent hitherto 
undreamed of. With a generoiis allowance for Nature’s 
wasteful methods there must still be a large provoiitablo 
residue — and sound teeth will assuredly be the better 
adapted to resist the inroads of decay. AVe ma 3 ' go a step 
further. Children .with well formed teeth are likely to be 
of a healthy constitution — “ dens sana in corpore sano 
aiid Mrs. M^Ianby may have .found a touclistonc for ah 
Al population. She acknowledges her indebtedness to tlie 
Medical Research "Council and the 'Dental.' Board of the 
United Kingdom for the costs of the investigations. ■ 'U’e 
think the whole medical profession will co'rdialh’ agree. 


. IRAQ COLLEGE OF MEDICINE. . . . 

The conclusion of a new treaty, of .alliance between Great 
Britain and Iraq (writes a correspondent), and the prospect 
of tlio early admission of Iraq to. the league of. Nations, 
has-; hroiight , into prominence tho .political and economio 
progre.ss of “ The -Land of Two Rivers ” since the -accession 
of King Faisal.' In educational -matters, too, great-strides 
liavo been made, and the infant. Al-Al-Beit University of 
Baghdad alread 3 ;. iiossesses Faculties .of Religion, Agri- 
culture, and Medicine. Of theso the Facnlt 3 ' of- Medicine, 
is tho most recently instituted.- The doors of tlie Iraq 
College of Medicine were first opened in October last, when, 
following matriculation, twenty selected students began 
their course of studies. The Universit 3 - confers a single 
medical degree — M.D. A high standard of education is 
being required of candidates, and tho curriculum, covering 
fivo 3 'ears, is based on that prescribed for tlio M.B., Cb.B. 
of Edinburgh. Tho dean and the professors aro all British 
graduates of British nnivei sities, and the teaching staff of 
each department includes an Iraqi. The students already 
admitted include Mohammedans, Christians, and Jeu’S. 
Systematic lectures are delivered in English, but practical 
and tutorial instruction is permitted in both English and 
Arabic. Iraq is very poorly provided with doctors in all 
but tho three largest towns, and tho primary purpose of 
the College is to train suitable candidates for Government 
service throughout tho counti' 3 -. AVith diseases such ai 


230 Feb. 'ti, igjB] 


THE BACIDDTJS OAIiMETTB-GUiRrN;i 


[ T/raDsmTs 
MxDICAI. JOCRSAI ^ 


MiJcylostomiasis and billmrziasis rampant among tho 
fcllaliocn, tho necessity of tliis provision is very real. 
Students receive their instruction free on condition that 
they contract to servo tho Government for a period of four 
years folloiving graduation; while so serving, however, 
they will receive tho same rate of pay ns other medical 
pfficors of similar grade in tho health scrvico of Iraq. Tho 
Collcgo is well equipped, and is situated in tho precincts 
of tho Royal Hospital, Baghdad, whero ample opportunities 
exist for clinical instruction of all kinds. There Is great 
competition among young Iraqis for admission to tho 
faculty, and, as tho number of entrants is strictly limited, 
an excellent typo of student is being obtained. Everything 
points to a successful future for tho College, and it remains 
to bo scon whether tho present sons of this romantic 
country, in whoso ancient capital, a thousand years ago, 
dawned tho classical period of Arabian medieino, ' arq 
capable of attaining tbo same heights of erudition and 
professional skill as their distinguished ancestors, among 
whom was Avicenna, “ Prince of physicians.” 


THE BACILLUS CALMETTE-GUERIN (B.C.G.). 
PjiOFEsson Calhettc is a propiiet not without honour in 
liis own country. When he concluded an address at tho 
mooting of tho Academio do Medecino on January 10th, 
tbo president of that body complimented him on being 
raised by tho Government to tho highest grade of tho 
Legion d’Honneur — a small recompense for the' immense 
Eorvieos rendered, not only to Franco, but to tho whole of 
humanity. Professor Calmette’s address dealt with tho 
results wljioh have boon obtained betwoon July 1st, 1924, 
and December 1st, 1927, in tho preventive vaccination of 
.tho uowly born by B.C.6. (bacillus Calmotto-Gudrin). 
During tlio period under review 52,772 infants have boon 
vaccinated; but tho address was only concerned with 5,749 
of those, who wore stated to have been born of tuberculous 
mothers or to bo living in tuberculous surroundings. 
Vaccinated infants under 1 year of ago numbered 3,808; 
of these 118 wore dead, a mortality from all causes of 
3.1 per cent. The mortality at this ago for non-vaccinated 
infants, whether in contact with tubercle or not, through- 
out Franco was stated to bo 8.5 per cent. — a dilforcnco 
sufficiently startling if the former low figure continues to 
be maintained as tho number of vaccinated infants in- 
creases. The mortality from causes presumed to bo tuber- 
culous among tho 3,808 infants was 0.9 per cent., whereas 
tho mortality for such causes amongst non-vaccinated infants 
exposed to tuberculous conditions was variously estimated 
at 24 to 70 or even 80 per cent. Only in Denmark, says 
Professor Calmette, has tho mortality of non-vaccinated 
contact cases under 1 year of age been reduced to 7.7 per 
cent. Amongst 1,941 vaccinated contact children between 
tho ages of 1 and 3J years there have been 21 deaths, of 
which 4 wore from diseases presumed to bo tuberculous. 
The mortality of 1.2 per cent, from all causes compares 
with a mortality of 1.6 among non-vaccinated children with 
or without tuberculous contact. The mortality from tuber- 
culous causes is 0.2 per cent., as compared with 0.14 for 
tho non-vaccinated population of the same age. Professor 
Calmette believes that the immunity conferred by B.C.6. 
lasts longer than was at first thought, and is perhaps 
reinforced by virulent infections which are inoffensive for 
a vaccinated child. He regards this hypothesis as plausible, 
though not irrefutible. It is possible that the immunity 
continues for not less than five years, and so tides the child 
over the period in which it is exposed to severe infection. 
The fact that the bacillus-vaccines can remain so long in 
the human body without producing any other effect than 
resistance to virulent infection removes, adds Professor 
Calmette, any possible anxiety as to danger resulting from 
the vaccine. It appears that with an increase in the 


number of tbo vaccinated a good case can. still bo mailo 
for pro-immunization of tho newly born by B.C.G., at all 
events for those in tuberculous surroundings, and tboro is 
no evidcnco of harm having resulted from the process. 
But wo aro still doubtful whether Professor Calmette’s 
results have boon sufiiciontly submitted to export statistical 
investigation. Wo hopo that as the number of tho vac- 
cinated incroascs tho cases will bo kept in sight,' with tho 
object, ultimately, of a strict statistical review. It -is 
interesting to note that on Januaiy 3rd Dr. Gram 
reported to tho Academio do Medecino observations made 
at Oslo by tho Norwegian doctors Hoimbcck and Schcel 
on tho uso of B.C.6. in persons who gave a negative result 
to tho von Pirquet reaction. Such persons were presumed 
never to have suffered from tuberculosis, and thoreforo to 
bo liable to grave infection from massive doses. Vaccina- 
tion W’ith B.C.G. resulted in a positi'vo von Pirquet reaction, 
but without any sign of disease. ' Tho obsoiwers believed 
that B.C.G. was entirely harmless in such cases, and nn'ght 
be proventivo against tubercle. Professor Calmette con: 
sidered that even if tuberculosis was ' present a sub- 
cutaneous or intramuscular injection of B.C.G. led to 
nothing more serious than a localized cold abscess. ; 


■THE VENEREAL DISEASE PROBLEM IN II^DIA : .. 

The British Social Hygiene Council recently. sent a- delega- 
tion to India, consisting of Dr, David" Lees ; and ; Mrs. 
Ncville-Rolfe, and in tho twelfth annual . import issued by 
tho council some account' is given of the results of the tpur. 
Seven largo towns were visited, and social liygieno 'councils,' 
affiliated to tho .British Social Hygieuo Council, , were 
established in each' place. ' Tbo delegation fo'und evidence 
in the 'Provinces and States Of a high incidence of syjiliilis 
and gonorrhoea, and. it is reported that social cbnditio'ns and 
customs aro such that the diseases aro disseminated among 
tho adolescent as - well as the adult population. Many 
rccommondatiohs' have .been made, and forwarded to the 
Governments concern'ed, dealing n-ith the medical, social, 
and educational aspects of the problem. ' From' tho -medical 
point of view it' is emphasized that there is' need for'mora 
co-ordination of effort, with increased hospital accommo- 
dation and a 'fi'dd supply of pharmaceutical '.material. It 
is' suggested that , there should , bo apiiointed for each 
Proviuco or State, a. specialist in venereal .disease who 
should lie a member of tho surgical teaching- team in the 
university. From, the social and educational standpoint 
tbo impo'rtancotaf biological training is stressed,- and as ah 
emergency measure it is proposed 'that two prominent 
university profesors in biology and p'sycholo^ should 
visit' the uni-versities and educational departments in the 
immediate' futurei The social recommendations' 'are ' far- 
reaching: they include,'' among other point's, ah extohsive 
campaign of public enlightenment, the eventual provision 
of skilled medical treatment for all persons needing it, the 
abolition of commercialized prostitution, and an extension 
of tho cinema censorship. The central Government has been 
asked to co-operate in three wmys : (a) by providing in the 
principal seaports the cost of medical facilities for the 
diagnosis and treatment of venereal disease and ground 
for the erection of institutes affording recreational facilities 
for the members of the mercantile marine; (b) by co- 
operating with the provincial Governments and tho univer- 
sities in the scheme for providing two university professors 
to initiate additional teaching on biology and social hygiene; 
and (c) by taking responsibility, through the British 
Social Hygiene Council, for the Indianization of dramatic 
films for propaganda purposes. In this connexion it should 
be noted that the Government of India 'is considering the 
appointment of a commission of inquiry into the present 
film situation, and the delegation urges that the cinema 
censorship should be extended and that films unsuitable for 


JBB. U, 1928] 


ESTIMATION OE-' HEPATIC EEEICIEN07. 


t THECMTI'?B . Ofil- 
SIedical JoimsAL 


India slionld be banned. Tlio council undertakes anmially 
a vast amount of work, as a glanco at tbc present report 
will show, but it is to bo especially cmnmcnded for the way 
in which its delegation lias tackled a vast problem, and 
the working of the schemes recommended, should they be 
adopted, will bo watched with interest, 

AFTERMATH OF THE MISSISSIPPI FLOOD. 
Stooeos-Geneeal H. S. CiratsiiNC, of tho United States 
Public Health Sendee, has submitted to Congress a report 
dealing with the measures taken to protect the public 
health after the Mississippi flood. It is thought that tho 
economic losses and human suffering in tho flood area have 
exceeded tiiose in an)’ previous disaster in the country. 
Emergency aid was received from tho Federal, Slate, and 
local health authorities, as well as from voluntary agencies, 
including the American Red Cross, and an officer of tho 
Public Health Service was stationed at the national disaster 
relief headquarters of tho American Bod Cross at Memphis, 
Tennessee, to act as liaison officer and to secure tho neces- 
sary assistance required. Such urgently irceded thera- 
peutic agencies as small-pox and antityphoid vaccines and 
antitetanic serum wore supplied in largo qnaiititios. Within 
ten days from the beginning of tho cmergewy fourteen 
trained officers of the Public Health Service, familiar with 
the localities, u’ore actively engaged, and tho response to 
tho demand for other trained help was so generous as to 
meet tlie chief needs of the flood area witliin a very short 
time. With tho recession of the flood a jouit couforenoo of 
tho authorities concerned was held, and a plan was devised 
for the establishment of county health units tliroughout 
the affected area, so as to avert the danger of epidemics of 
various kinds. It was observed that the counties with 
whole-time efficient health services met all emergencies 
promptly and efllectuatly. Surgeon-General Gumming added 
that for a long time the people in tho flooded areas wonld 
bo exposed to adverse health and economic conditions, 
especially owing to tho damage to the water supply and 
waste disposal systems and the curtailment of food supplies. 
Pellagra had increased in certain neighbourhoods, owing to 
tho partial failure of crops as well as to the flood. 


1 per cent, solution of ferric chloride, hut this method of 
estimation gave rise to error. Tliiers therefore proceeds 
as follows. At 8 a.m. the patient is given 0.04 gram of 
sodium salicylate in solution, and all the urine passed 
between 9 a.m. and 1 p.m. is collected in one beaker in 
order to eliminate the possibility of retardation in renal 
excretion. In some cases tho quantity of uriuo is so small 
that its collection has to be continued until 4 p.m. For 
tho estimation of salicylic acid 50 or 100 c.cm. of urine is 
iflaced in a beaker of 200 c.cm. capaciij' graduated at 
intervals of 25 c.cm., and a sufficient quantity of strong 
hydrochloric acid is added to acidify it. Into this mixture 
25 c.cm. of sulphuric ether is poured, and tho fluid is 
shaken energetically three times. The liberated salicylic 
acid is almost insoluble in water, but dissolves in the ether. 
In ten minutes the liquid separates into three layer’s ; the 
urine forms the lowest stratum, the middle layer consists of 
water containing a trace of emulsified ether, and the upper 
frothy A’iscid stratum consists of ether emulsified by the 
mucus of the urine and containing the salicylic acid. 
This fi’othy emulsion is dccajrted, and sufficient alcohol 
{95 por cent.l is added to decompose the emvdsion. The 
mixture is shaken gently and allowed to stand. It then 
separates into two layers ; the upper consists of salicylic 
acid in ethereal solution, while the lower contains mucus 
and organic and inorganic substances which precipitate 
[■ ferric chloride. The upper stratum is decanted; a minimal 
portion of ether is lost in these successive manoeuvres," faiiti 
[ this is fairly constant and produces no appreciable error. 
The ethereal solution is poured iu'to a test tube containing 
10 c.cm. of tho following solution : Liquor ferri porchlofidi 
' fort. 20 drops, concentrated hydrochloric acid 1 c.cm., 
distilled water to 1 litre. Hie contents of the test tube afo 
well shaken three times, and allorved to stand. A positive 

■ reaction is indicated by tho colourless mixture .assuming 
a violet colour; this occurs immediately when, tho reaction 
is strongly positive, and if no colour appears in ton 
minutes tho reaction is negative. Thiers maintains that 
tho test performed in this way is much more reliable than 
the ordinary addition of urine to a ferric chloride solution, 

' because tho insolubility oi salicylic acid in water prevents 
its diffusion in the ferric chloride solution. The test can 
bo applied quantitatively by using a colorimetric scale pre- 
pared by titration of a standard salicylic acid solution. 
Ho claims that this test is not invalidated by circulatoi’y 
failure due to cardiac or renal disease; the majority of his 
patients giving strongly positive reactions had more or less 
damaged kidneys. It should not he employed, however, 
during a period of profuse diuresis, as tho reaction inav 
, then bo negative or feebly positive. Negative reactions 
occurred in all Thiers’s cases in which the liver appeared 
rto he normal. The presence of urobilin interferes slightly 
■with the colour estimation, hut Thiers overcame this 
! difficulty by practice. He thinks that this test, though 

■ empirical, has a definite clinical value, and may be used 
'advantageously until a more systematic ox.amination of 

the hepatic function is made possible by further knonlodgo 
of its physiology and pathology. Epstein, Dolprat, and 
Kerr, who have for some time advocated the intravenous 
■injection of rose hougal for the estimation of liver activity, 
have reviewed the results of investigating over 500 patients 
by this means.= They found that this dye, of which only a 
trace remains in the blood plasma of normal persons after 
sixteen minutes, is not eliminated for a considerable time 
in obstructive jaundice, catarrhal jaundice, or arspheu- 
amino icterus. The test tliereforo appears to bo a valuable 
aid in detecting those conditions and in folloa-ing their 
clinical course. The nephritic toxaemias of pregnancy do 
not delay tho disappearance of this dyo from tho blood 
stream, hut acute hepatic infections were shown by its use 
to canso marked impairment of the liver function. 

Amer. lied, ittoc., Jfay 21st, 1327. 


ESTIMATION OF HEPATIC EFFICIENCY. 

IteE complexity’ of the structure and blood supply of tho 
liver is evidently correlated with multiple function, hut 
tho part taken by this organ in the digestive, glycogenic, 
SDcietoi’y, and eiidocrino activities of tho body is not yet 
fully’ understood. Attempts to estimate hepatic efficiency 
must, therefore, ho beset with .difficulty, and it is not 
sui prising that various tests have been put forward and 
discarded from time to time. Thus, for example, Widal’s 
lacmoclasic test, advocated by some for gauging tho liver 
frmetion, was condemned in our columns by A. F. Bernard 
^ though Maurice Shaw (ibid., 

p. 1020) thought this conclusion a little premature. 
Another lino of .approach was suggested in 1921 by Roch 
employed sodium salicylate to test hepatic 
? S™tmd that this salt is destroyed by a 

lea by bvoi , and tliereforo does not appear in the urine, 
ns test sometimes gave positive resiUts when tbo 
value w’as admittedly doubtful, but 
. "eis las since published' a modified procedure which 
^ ®"'s'deratibn. Ho states that a normal 

a u can assimilate a dosO of 0.04 gram of sodium 
Uace of salicylia acid being found sxibse- 
queii y 111 tlio iirine. ’ If the liver is damaged salicylic 
.acid appeal’s in tho urine passed during tho second to "the 
^ventb liour after tbo ingestion of tho sodium salicylate. 
Roch and Sebiff added tho uriiie, drop by drop, to n 

' ZiSfon Jlidical, May I5th, 1927. 


232 Feb. ti, 19 : 8 ] 


HOSPITALS AND RbAD ACOIDENtrs. 


[ Tff* Hums* * ' 
BlEDICiL JoCBXiL 


HOSPITALS AND ROAD ACCIDENTS. 

L\ a note on page 192 of our last is.suo ivc referred onco 
more to tho lioavy cost of hospital treatment for motor 
c.asualtics, and mentioned tho letter on this subject by 
Sir Duncan Kcrly printed in tho Times of Januaiy 30lh. 
The samo . nemspaper published on February 4th a letter 
by Sir Arthur Stanley stating' that tho British Hospitals 
Association and the Royal Automobile Club had tho matter 
under consideration, and ' on February 7th tho Earl of 
Donoughmoro, as chairman of tho management committoo 
of King Edward’s Hospital Fund for London, wrote sug- 
gesting that the fairest and most oircctivo solution of tho 
j;)roblcm would probably bo found to lie in insurnrico, with 
specific provision in motor policies for agreed payments to 
hospitals in respect of accident eases, and that a com- 
jarativoly small extra premium might ho expected to 
moot a reasonable scale of hospital payment. Lord 
Donoughmoro added that the position was felt to ho so 
serious that tho King’s Fund had decided to tako tho 
responsibility of inviting representatives of tho ho.spitals, 
tho insurance companies, ' and tho leading motorists’ 
organizations to an early confcrcnco on tho subject. Tin's 
wo regard ns an important step in tho right direction, 
and we share his hope that combined effort on tho part 
of all concerned will soon yield an equitable solution. 


PATHOLOGICAL MUSEUM AT THE CARDIFF MEETING. 
The committoo appointed to organize tho Pathological 
Museum in connexion with tho Annual Meeting of tho 
British Medical Association at Cardiff next July proposes 
to arrange tho material under tho following heads: (1) 
Exhibits bearing on discussions and papers in tho various 
Sections. (2) Specimens and illustrations relating to any 
recent research work. (3) Instruments concerned in clinical 
diagnosis and pathological iiivc-stigation. (4) Individual 
specimens of special interest or a series illustrating some 
special subject. (5) Exhibits of general interest. Tho 
committee appeals for the co-operation of the profession 
in making the museum a success. It will bo easy of access, 
being situated in the same building in which tlie Sections 
will meet; it is hoped to make arrangements for exhibitors 
to demonstr.'ite their specimens. Every care will bo taken 
of the exhibits, and tbo contents of the museum will bo 
insured. Tho honorary secretaries (Dr. J. B. Duguid and 
Dr. J. Mills, Department of Pathology and Bacteriology, 
AV^elsh National School of Medicine, Tho Parade, Cardiff) 
ask intending exhibitors to notify them as soon as possible. 


•- A SOUTH AFRICAN FIELD HOSPITAL. 

To many people there is fascination in recalling, or having 
recalled to them, the details of some historical event which 
occurred within their memory. An example of these eclioes 
of tho past is the Dinrxj of a Field Hospital dvring the 
South African IFar, by Lieut.-Colonel G. H. Younge, 
R.A.M.C.fvet.).’ Spion Kop, the Tugela, Colenso, Long 
Tom, Hart’s Hill: what memories these names awaken I 
Tlie author was in charge of the field hospital detailed for 
duty with the Irish Brigade, and so took part in the opera- 
tions which culminated in tho relief of Ladysmith. Of 
particular interest is his comparison between active warfare 
in 1900 and that of only fifteen years later. For tho trans- 
port of his equipment bullock caits were alone available. 
These weio-hed about two tons, were drawn by teams of 
sixteen oxen, and carried a load of at least five tons. By 
how many months would tho campaign have been shortened 
had the modern mechanical tractor been available 1 Colonel 
Younge records the fact that in January, 1900, a steady 
increase in the severity of rifle-bullet wounds uas noted; 
the wounds of entrance had become large, contused, and 
jagged , and those of exit large, funnel-shaped, and 
Journal of tho ILA.JI.C.t December, 1927- , 


lacerated. Tlio inforonco was that expanding bullets wern 
being used. A curious fact, is tho great predominance of 
wounds of tho lower extremities. Tho author recalls for 
U3 some interesting details of Ladysmith on its relief. The 
Genoral Hospital, situated on neutral ground, contained 
some 800 wrecks of humanity; a forest of white headstones 
marked tho graves of 1,600 men who had been killed or had 
died of disease during tho siego; and he notes that most of 
tho Bun'ivors, on return to full diet, developed jaundice. 
Enteric fever was first encountered by him after tho relief 
of Ladysmith, and was traced to the drinking of water from 
pools during tho protracted battle of Pieter’s Hill, when our 
men occupied old Boer trenches at Colenso. From March 
0th, 1899, to July 8th, 1001, this field hospital alone treated 
695 cases with 65 deaths, a mortality of 10.9 per cent. The 
author, however, considers that some of the cases returned 
a.s simple continued fever (972 cases) or ns not yet diagnosed 
(413 cases) were in reality mild or modified cases of enteric. 


JACQUES LOEB. 

At tho Marino Biological Laboratory, IVoods , Hole, 
Massachusetts, a memorial bronze tablet recording his 
achievements under tho headings “ Brain physiology; 
Tropisms; Regeneration; Antagonistic salt action; Dura- 
tion of lifo; Colloidal behavior” was unveiled last suranior 
to Jacques Loch (1859-1924). Among tho “ exercises ” on 
that occasion was an appreciation of his life’s work by Dr. 
Simon Flexner' of tho Rockefeller Institute for Medical 
Research, which Loeb joined in 1910 after being a professor 
at tho University of California. His family, which left 
Portugal to avoid the Inquisition, settled in Amsterdam 
and later in Alsaco; ho was educated at tho Universities of 
Berlin, Strasbourg, and Wiirzburg, and while assistant to 
Fick at tho last named university he came under the 
influence of tho botanist Sachs, who turned his talents into 
tho broad channel of general physiology. Loeb recognized 
that tho tropisms described by Sachs in connexion with plants 
wore applicable to animals, and was led to make ingeniMS 
experiments on animal tropisms and hetei-omorphosis. He 
was thus launched on his life’s work of reducing the so- 
called manifestations of lifo to tho status of physico- 
chemical reactions. Thesd observations were extended to 
psychology, so that he applied his deductions to the 
explanation of certain phenomena of animal behaviour. 
Loeb was. Dr. FJexnor. said, an intensive individual investi- 
gator and though his immedidte piipils were not numerous, 
his wider influence '.reached even the educated lay public. 
Ho organized' tiio Division of General Physiology at the 
Rockefeller Institute, the first department of the kind in 
tho tfnited States, arid in 1018 founded and edited the 
Journal of General Phy siology. 

the HALF-YEARLY INDEXES. 

The usual half-yearly indexes to the Journai. and to the 
Supn-EJIENT and Epitome have been printed; they will, 
however, not be issued with all copies of the Journal, but 
only to those readers who ask for them. Any member or 
subscriber who desires to have one or all of the indexes can 
obtain what be wants, post free, by sending a postcard 
notifying his desire to the Financial Secretary and Business 
Manager, British Medical Association House, Tavistock. 
Square 'iV.C.l. Those wishing to receive the indexes 
re^larly as published should intimate this desire. 


'he title of Sir Holhert 'Waring’s Hunterian OraLon 
ire the Royal College of Surgeons of England is ‘‘ The 
gross of surgery from Hunter’s day to ours The 
tion will be given in the lecture theatre of the College, 
coin’s Inn Fields, on Tuesday next, Februaiy 14th, at 
I’clock. A banquet to celebrate tho bicentenary of 
iter’s birth will be held that evening in the College. 



Tee, it, igaS] 


-HEDICAn KESEABCH COUNCir.. 


r TsB Bsmtx 

I UxviCAX. JotrsjTvU 


233 , 


. . . MEDICAL BBSBAECH COtWCIL. 

AiraiTAL REPOET. 


1. 

The annual report of the Medical Bosoarch Council for the 
year 1926-27 contains in its 150 pages a very condensed 
summary of many investigations- proceeding in various 
parts of tho country. It covers, as usual, a very wide field, 
and we shall follow our customary practice in giving a 
brief outline of some of the work of tho several sections. 
Such a task is rendered especially diflicult on this occasion, 
because tho past year has been notable for many reasons, 
including the bringing forward 'of problems which havo 
emphasized the imperial aspects of the work of tho Council. 
We referred last year to tho discussions at tho Imperial 
Conference. As a result of these, it is remarked, “ steady 
progress has been made towards the linkage of tho research 
organizations in Great Britain with tho equivalent organiza- 
tions, either in being or foreshadowed, in the Indian 
Empire and in the Dominions overseas.” A Colonial 
Medical Research Committee has been njjpointed, and it 
is suggested that as a result of the new opportunities for 
collaboration, and new facilities for intercourse, tliere may 
come about a veritable “ Imperial Research Service.” 
The Empire Marketing Board has shown its interest 
by making financial grants towards research schemes aimed 
at tho improvement of Empire trade in given directions. 


Geneiui, Pkinciples akd PKACiicAt Applicaiioss. 

In the introduction to the report certain aspects of tho 
work are fleeted to illustrate the principles which guide 
the Council. The necessity of standards of reference in 
research work is emphasized; tho Council maintains the 
national collection of type cultures, and at tlie Hampstead 
Institute are 'kept all tlie standard preparations required 
by the regulations under tho Therapeutic Substances Act. 

lufroductiou refers also to the eleven years’ work of 
Sir Thomas Lewis in clinical research and experimental 
medicine, and describes the investigations of tho past years 
on the pliysiology. and disorders of tho heart as “tho 
central stream of progress made in theso subjects any- 
where. The national importance of tho work of the 
Council IS exemplified by tho vitamin researches. The 
molation of the so-called vitamin “ D ” by Dr. O. 
RoseMieim, P.R.S., and Mr. T. A. Webster at the National 
Institute IS traced iu au admirable historical summary of 
tlio aiscorery of the “ antirachitic” vitamiu and tho sub- 
sequent research work ou this substance, culminating in 
the co-operative investigation by tliese workers in this 
Muntry, and in Germany by Professor Wiudaus with Dr. 
-tless of New \ork. The practical importance of this work 
in relation to the food supply of tho nation is emphasized, 
since wo now have at disposal abundant and cheap 
supp les of vitamin D in potent and isolated form,” and 
e search among natural products for tins vitamiu is no 
onger necessary since “ we can produce it artificially by 
ir a la ion of ergosterol.” Arising out of such applica- 
tions of scientific knowledge to the health of tho nation 
floM ^ ulso calls attention to tho entire 

o nu ntional science, which requires careful study ; 
committee has been appointed to frame a 
pre ensive and co-ordinated programme of work. 

T-, .w 1 Haitpstead. 

o next section is summarized the principal work 
during the gar at the National Institute for Medical 
esoarc i “ and in the associated field labora- 

nwf 1 Of biocliemistiy and 

Ti ,.11 'ooluded a large range of subjects. Dr. 

r Thorpe bai-o made a chemical investigation 

iu.se e on a largo scale, undertaken as an extension of 
lor 5 on le nature of vaso-dilator constituents of different 
issues. peculiar peptide “carnosine ” has been isolated, 
an invcs ig^ion of its hitherto unknown functions is 
proceeding. Professor A. N. Richards of Philadelphia has 


been working- with Dr. Dale on the vaso-dilator action of' 
adrenaline. Dr. King and his colleagues have continued 
their syntheses of substances likely to havo chemothera- 
peutic values. In the section of experimental pathology, 
bacteriology, and protistology work during the year has 
proceeded on two main lines. One group of studies has been 
concerned with the infective viruses of various human and 
animal diseases, and the other has been aimed at improv- 
ing methods of precision in immunolog}'. Sir. Dobell and 
Dr.Daidlaw have continued their work upon tho Entamoeba 
histolytica, especially directing their attention to the 
experimental infection of monkeys, and its treatment by 
emetine. In the department of applied optics Mr. J. E. 
Barnard has directed the improvement of niicroscopic.-il 
methods and apiiliaiices likely to assist biological work 
and, in particular, the investigation of filterable viruses. 
The study of tho reactions of the body to various atmo- 
spheric conditions and to tho radiations of light, particu- 
larly in tho ultra-violet region of the s])eetrum, has been 
tho main work of the section of applied physiology. Dr. 
Campbell has completed certain experiments ou the acclima- 
tization of tho body to low and abnormally high oxygen 
pressures in the air, and Dr. Hill, with the assistance of 
Miss Brad, has investigated the effects of diet upon the 
reproductive power and liability to cancer in mice. Tho 
work of the Statistical Committee continues to be of tho 
highest importance, and a fruitful co-operation hetwtn^n 
statistical and psychological investigators upon tele- 
graphist’s cramp has develojmd. The help given by -this 
committee in the general criticism of work of other depart- 
ments, statistical verification of particular points, or in 
tho indication of possible fallacies is emphasized as being 
among the most important of its activities. 

Expemmextato Mebicixi'.. 

At Dniversity College Hospital, London, Sir Thomas 
Lewis and his collaborators have continued tho study of 
tho physiology and pathology of cutaneous blood vessels. 
The director and Dr. Grant have obtained evidence that 
anaphylactic poisons in “ fish poisoning ” act on tho 
vessels of the skin by liberating a histamino-liko substance, 
and tho symptoms of a general anaphylactic rosjmnso aro 
attributed to a similar, altliough more general, i-eleasa. 
Dr. Grant has completed and published his auatoiuioal 
researches uiion tho coronary vessels of the heart, and his 
main work — a systematic examination and comparison of 
tho coroaai-y circulation in representative vortohrate species 
— ^has been completed with the help of Dr. Regnier. At 
St. Thomas’s Hospital, London, work by tho medical unit 
under Professor H. Maclean has been directed to certain 
exjjerimontal and clinical studies of gastric physiology and 
pathology, and the response of gastric and duodenal ulcers 
to treatment by alkalis has been watched by means of 
x-ray examinations. -At the Duiversity, field laboratories, 
and Royal Infirmary, Sheffield, attempts havo been made 
by Professor Mellanby and Dr. Coa-ell to control the 
symptoms of hyperthyroidism, as in Graves’s disease, by 
purely medical means. Professor Mellanby has also con- 
tinued his well knoan inquiries into tho anticalcifying 
action of cereal foods. 

PnoBLEAis OF Child Life. 

Studies of cases of toxaemia in the later months of 
pregnancy have been continued on clinical and biochemic.al 
lines at the Royal Maternity Hospital, Glasgow, and a 
special inquiry is being made into tho carbohydrato meta- 
bolism in normal and abnormal pre^ant women, hliss 
'Widdows, Miss Bond, and others havo continued their 
work ou norma! human colostrum and early milk at tho 
Royal Free Hospital, London. Theso have been investi- 
gated with refeienco to tho racial type of mother, length 
of lactation, method of extraction of milk, and other 
variables. IVork on the metabolism of infants lias been 
carried out at the Royal Hospital for Sick Children, 
Glasgow, under tho direction of Professor Leonard Findlay. 
Dr. Stanley Graham and Dr. Morris havo directed especial 
attention to the acid-baso balance of tho blood in infancy 
and childhood with referoneo to the carbon dioxide dis- 
sociation cuiA’cs in normal and abnormal conditions. Tho 
work of Dr. Leonard Parsons at Birmingham upon the 



234 Feb. iii.1928] 


TJNITBD STATES ARMyrMEDICAE EEPOKT. 


r Ttts U»m« 

•L MxoicAl JoTOTif 


Wood, chemistry and hono chnngos in cooliac disease and 
in renal infantilism has shown that ultra-violet light, whilo 
beneficial in cooliac disease, may aggravate the bone changc.s 
in renal infantilism and . is contraindiratod.. Dr. H. A. 
Harris at University fcollego has studied the tranm-orsc 
striations of long bones whioh occur in non-raebitic children 
who have sulfored from various acute illnesses. This 
investigator holds that the lino of healing rickets of the 
cartilage may have a similar origin — ^namely, slowed growth 
on an inadequate diet — and that the “ lino-tost ” of healing 
rickets therefore presents definite fallacies. 


Human Nutoitiok. 

The Nutrition Committee has under consideration more 
comprehensive schemes for surveying, in the light of the 
latest knowledge, the dietetic needs of dilferent sections 
of an active population and the deficiencies in national 
dietaries, which can bo traced to remediable accidents of 
soil and water supply, or to remediable faults in tho 
treatment and distribution of foods. Professor E. P. 
Catheart has undertaken a study of the dietaries of tho 
population of St. Andrews, whore access to households in 
all grades of society has been possible, so that data of a 
vast economic and scientific interest has been obtained. 
At the Li.stor Institute Dr. S. S. Zilva has investigated 
the improvements of tho methods for isolating vitamin C, 
and tho relation of its antiscorbutic activity to tho 
reducing substances accompanying this vitamin. With 
Captain J. Golding, Dr. Zilva and Hfiss Sonnies li.avo 
co-operated in studies of tho rcintivo values in r-itamins 
A and D of butter obtained from cows fed on diets supple- 
mented by green fodder and cod-livov oil. Cows receiving 
tho oil showed improvement in tho vitamin A and D 
content of tho butter, whilo green fodder imjiroved tho 
vitamin A content only. Miss Hume and Jliss Henderson 
Smith, with Dr. N. S. Lucas, have found that tho inunction 
of irradiated cholesterol into tho skin of rabbits and rats 
fed on a rickets-producing diet will prevent rickets, and 
that tills may represent at least one of tho natural means 
by wliich the body is supplied with vitamin D, since 
activation by light of pro-vitamin on tho surface of tho 
skin is known to take place. Professor J. C. Drummond, 
with his co-workers at University College, London, has boon 
engaged on finding a suitable method for isolating vitamin A 
from material in a large-scale extraction of active fractions 
of cod-liver oil. Further work on the colour vcactiou for 
the estimation of vitamin A in relation to tho disturbances 
produced by natural pigments in butter and milk has been 
proceeding, and means for avoiding this effect have been 
devised. Professor Dnimmond has also continued his work 
on the phj'siological action of vitamin B. Tho only clear- 
cut symptom directly ascribahlo to deficiency in this vitamin 
would seem to be the so-called polyneuritic or “ beri-beri ” 
condition, all other abnormalities being attributable to the 
loss of appetite and resulting inanition which follow the 
withdrawal of the vitamin. With Dr. Hassaa he has shown 
that the physiological action of yeast is complex, duo to at 
least tiro substances; the chemical nature of these two 
components is being further investigated. Mr. H. W. 
Kinnersley has obtained a highly active material, also from 
yeast, by Professor Peters’s charcoal adsorption method. 
Professor V. H. Mottram, Dr. Gladys Hartwell, and Miss 
Clifford have continued their work on nutritional subjects 
at King’s College for Women, London. 

Dental Disease. 

The lymphatic supply of the teeth in the dog and in the 
primate has been investigated • by Dr. E. W, Fish, who 
finds certain fundamental differences which have a bearing 
on the question of dental caries, since the dog, with a 
free irrigation of its dental enamel, appears to escape it. 
Mrs. Mellanby lias continued her work at the field labora- 
tories, Sheffield, with special reference to the control over 
the structure of the teeth by diet and environment, 
anto-natal and post-natal. Miss K. C. Smythe, London, 
has collected measurements in selected children to show, 
by moans of averages, the direction and normal rates of 
growth of the jaws as a basis for study of the abnormal. 


Dise.\8E.s of the Caiiuio-vascueah Svstesi. 

In addition to the work of Sir Tliomas Lewis and hij 
colleagues already mentioned, work on these diseases has 
boon jiroceeding in other centres. Dr. J. C. Bramweli and 
Dr. B. El! is at Manchester' have been studying the form 
of tho pulse wave in the central arteries in man. A 
portable instriimbnt for tho optical record of tlie rapid 
pressure changn.s in tho carotid artery has boon' devised for 
uso at tho hedsido. Dr. Ellis has followed up the results 
of the treatment of cases of anricnlar fihrill.ation with 
qninidino during tlic past live years, and he concludes 
that in the liospitnl class of, patients at lo.ist the results 
are di.sappointing. Dr. G. Anrep at Cambridge has studied 
the blood supply to the' heart muscle under norma! and 
pathological conditions, and the effect of various drugs 
upon tho coronarj- circulation. Changes in the coronary 
blood flow induced by auricular fibrillation, premature 
contractions, heart-block, and other conditions have been 
studied. 

(7*0 l/c condnttcf!.) 


THE UNITED STATES ARMY MEDICAL REPORT. 
Tm: report of tlio Surgeon-General of the United States 
Army for 1926 refers to the fiscal year ending Juno SOth, 
1927, but the vital statistics cover the calendar ye.ir ending 
Dccembor 31st, 1926. 


tilciHcal Pcnnniicl. 

In the rcgul.ir force the Medical Corps comprises 931, Dental 
Corps 158, Veterinary Corps 126, and Jlcdical Administrative 
Corps 72. There are 52 vacancies in the Medical Corps, and 
tho Surgcon-Goncral cniphnsizes, ns in previous years,, the 
numerical inadequacy of tlio medical personnel and (he-difficuily 
in supplying requirements. Tlio proposed increase in the Air 
Corps makes tlio position more acute tlian ever. The Army 
Nurse Corps contains 498 ro,L'ulnrs and 183 reserves, and there 
arc 6,565’ enlisted men — a totally inadcqu.ate number. There 
is a large reserve of about 19,000, of wliicli over 11,000 are 
medical ofTiccrs. It is interesting to note, for comparison, 
that tlio dailv cost per head in hospital is 4.8865 dollars. . 

Tlio medical personnel attached to tho Air ^rps consisted 
of 52 officers and 204 enlisted men, which nnmhers are stated 
to be inadequate. Airplane ambulances are m regular use. 


Statistics, 

The mean annual strength of the arraj' was 132,377 and 
tho rato of admission sick 687.22 per 1,000, an increase com- 
nared with 1925 due chiefly to an epidemic of influenza; 
Bronchitis acain heads the list of admissions, with influenza, 
Sitis, and gonorrhoea occupying the next highest p aces. 
Tlic death rate was 3.94 per 1,000, the chief causes being 
suicide drowning, and tubercnlosis. The dischavga rate 
for disability w.fs 18.35 per 1,000, the chief causes being 
dementia praeco.v, tuberculosis, pneumonia, and automobile 
accidents. Suicide and dementia praecox have now headed 

*^'’The*'uniform”dSinrin the incidence of venereal diseases 
is^aintaineTdropping from 52.25 per 1,000 in 1925 to 49 96. 
Svnhilis 1 577' soft chancre 1,118, and gonorrhoea 3,919, show 
? decreasT of 483 cases. PropTiylactio measures are 

ramnnlsorv and neglect in using them leads to trial by court 
maXl Each soldier undergoes a physical examination 
Urtco a mouth, and pay is stopped should he lose time hy 

“ThrtdmissSn ‘rafnor tuberculosis, 2.71 per 1,000, is 
clmidilv decreasing, while that for alcoholism remains at 
ri oer 1 000 ^ Of the 1,061 cases of .alcoholism recorded, 
749 occun-ed in the United States, and this number does not 
■ 1 lo /-nsps of Doisoning .by wood alcohol, nor the late and 

remote cmidffions'^esultinB iom the .use 'of alcohol. There 
were 42 admissions for drug addiction, a decrease of 13 

”TheTa1-''cst''nnmber of operations were for removal of tunsfls, 
treatment°Tf fractures and appendicitis Ether was the 
.. -ppiUpHp used in 7,634 cases and chloroform in 35. 

Tn the Air Corps 45 deaths occurred from crashes, which 
•enresents one death for every 633 flying hours, and shows 
L reduction of fatalities in relation to the flying time, 

liwins 1926 there were 78 crashing fatalities in the British 
loval^Air Force, but the average number of flying hours per 
irak is not stated in the report of that force. ^ _ 

As visual, tbe report is voluminous, containing a very 
arge number of statistical tables and a coniprebensive 


Feb. II, 1928 ] 


IREI-AND. 


[ Tb 2 Bxirm ' 
ITccxcix. Jocxxxt 


235 


Ifitlatttr. 

Caxcfji CASrPAIGN. 

At a successful meeting in support of tlio cancer cam- 
paign in Ireland, wliich was held recently in Limerick, 
when tho Mayor presided. Professor T. Gilman Moorhead 
said that oho person in every six over 40 years old died 
of cancer. During tho last year thoro had been over 3,000 
deaths from cancer in tho Freo State, which meant that 
1 out of 1,000 in the population died from cancer. This 
represented an addition of 50 persons per year in tho last 
ten years — an increase of 500 altogether. Tho fact had 
a still greater significance when it was realized that the 
general death rate had declined during tho past twenty 
years by 32 per cent., tlio infantile death rate by 45 per 
cent., tho tuberculosis death rate by 38 per cent., while 
cancer mortality 011 tho wliolo was higher by 20 per cent. 
According to Sir Berkeley Moynihan the cancer death 
rate had increased fivefold within the last seventy years. 
There were in the Free' State over 3,000 deaths from 
cancer and other malignant diseases annually ; this probably 
meant that in one year , there were about 9,000 persons 
who suffered from cancer in tho Free State, and 1 in 
every 1,000 died from it annually. The disease tended to 
attack people at tho very best period of their lives, when 
they were useful to the community. The fact that the 
increase was among the civilized races gave rise to hope 
that; the cause would bo discoi'ered before long. It was 
most important that efforts should be made on tho lines 
of research and education. So far tho cause had eluded 
their cffpids, but tho ground was now prepared, and 
Professor Moorhead believed that in time someone, perhaps 
a Limerick practitioner, would immortalize himself by dis- 
covering the secret. It had been calculated that if the 
. public were alive to tho importance of recognizing the early 
symptoms the mortality could be reduced by 25 per cent., 
for undoubtedly cancer, in its early stages, was a local 
disease which could be cured. Jiluch money would bo 
needed if the campaign was to be carried to a successful 
issue, but the speaker felt confident that tho people of the 
Free State would not lag behind other nations in facing 
the situation. Sir W. de Courcy Wheeler expressed the 
belief' that the dread of cancer was to a large extent the 
product of ignorance of what research and investigations 
had already achiei-ed,- and were' likely to provide, and 
failure to realize the number of sufferers who could bo 
rescued with certainty. An eminent surgeon had recently 
published statistics which showed that over 90 per cent, 
of patients afflicted with cancer of tho breast were about 
and well ten years after operation. Tho efforts of scientists 
during the last few decades had been crowned with more 
substantial success than tho total of all the combined 
efforts of past ages. A point had been reached when it 
seemed that nothing could indefinitelv impede progress 
towards the desired goal. Ireland could not compete with 
the great laboratories and vast wealth of other lands, 
but she wanted it known that she was ready to provide 
renuorcements for the army of workers already in the 
field. Dr. M. S. McGrath, medical officer of health, 
inoc 1 report to the Limerick Corporation in 

T^rorded that for the four previous years 
177 persons had died in the city from cancer. A resolution 
declaring tliat the campaign was well worthy of support 
was adopted on the motion of Senator T. W. Bennett, 
seconded by Dr. McGrath. 

The Forster Greex Hospiial for Coxsuiiptiox, 
m , . Buuast. 

The annual meeting of the Forster Green Hospital for 
Consumption, Belfast, was held on January 31st: Mr. 
inr? * tliG chair. It was announced that 

pa len s had been admitted during tho previous year, 
and there was a daily average of 77774 in the hospital; 

twenty-one weeks. Tho committee 
lan -ed 1 rs. J. B. Bryson for her generous offer in respect 
artifici.al light outfit.. It was 
added that a better laboratory was urgently needed. Dr. 
. B. Clarke, the medical superintendent, in his report 


commented on the persistence ef a waiting list and the 
decided disadvantage of patients having to wait several 
weeks, in unsuitable surroundings, before, admission to tho 
hospital. There was a definite improvement in the number 
of early ■ cases ■ admitted, but unfortunately some still 
delayed for many months before applying for admission; 
Medical practitioners were recommending patients to seek 
sanatorium treatment at the earliest possible moment ; 
some of the reluctance encountered might be overcome by 
making it known that there was loss risk of infection in 
a modern hygienic sanatorium than was incurred by enter- 
ing a public building or vehicle. Excellent educational 
work was being done. The principle underlying the treat- 
ment at tho Forster Green Hospital was to help patients 
to cure themselves. Thirty-three open cases of tubercu- 
losis had been discharged during the year after a course 
of sanocrysin ; the results were distinctly' encouraging. 
Tho usefulness of this remedy appeared to be greatest in 
patients who had not been ill for more than a few months. 
Exact information from statistics was being accumulated 
and would prove of great value. 




British Medical Associatiox, Edinburgh 
Meeting, 1927. 

A IIEETINO took place in the hall of the Royal College of 
Physicians, Edinburgh, on February 1st, for the purpose 
of making a presentation to certain of the officials on 
Avhom had devolved the greater share of the organization in 
connexion with the British Medical Association Meeting at 
Edinburgh last July. Dr. A. Logan Turner, chairman of 
a committee which had got up this presentation, presided 
over a company of about a hundred medical men and 
friends, and referred to the great success of the meeting 
and the arduous labours which had been undergone in 
carrying out the arrangements, especially by the individuals 
to whom the presentations were to be made. He then 
tendered to Sir Robert Philip, President of the British 
Medical Association, a silver salver; to Mr, Alexander 
Miles, who had acted as treasurer for the British Medical 
Association Meeting, a silver rose-bowl ; and to Dr. 
A. Fergus Hewat, who had acted as general secretary of 
the meeting, also a silver rose-bowl. Tbe three recipients 
of tho presentations acknowledged their high appreciation 
of the gifts. 

VlCTORLl InFIRAURT, GLASGOW. 

Tho fortieth annual report of the governors of the 
Victoria Infirmary, Glasgow, gives an account of the work 
of that institution from December, 1926, to December, 
1927. During tliis period tho total number of cases 
admitted was 5,130, and tho mortality was 7.7 per cent. 
Excluding deaths within forty-eight hours of admission, 
tho mortality was 5.4 per cent. In addition there were 
[-3,585 minor surgical cases and accidents, and 2,535 
patients received treatment at the infirmary dispensary 
for diseases of the nose and throat. The ai'erago 
daily number of patients was 328, and the average residence 
22.9 days. Patients’ contributions during tho year 
amounted to £904, an increase of £169 as compared with 
last year. The Bellahouston Dispensary, situated in a 
densely populated locality on the south side of the river, 
does valuable work among the poor of tho district, and 
many of the accidents occurring in tho neighbouring docks, 
works, and warehouses received treatment there. Tho 
total number of consultations at tbe dispensary in 1927 
was 41,343. The total expenditure for the year was 
£49,947 4s., being the sum required to maintain tho in- 
firmary, tho dispensary, and tho convalescent homo at 
Largs. Tho total income fell short of that amount by 
£1,931 Is. fid. The new infirmary wing — recently opened — 
will involve an additional annual expenditure of £14,000. 
Employees’ contributions for tho year amounted to £11,062 
7s. Id., and show an increase of £511 2s. 3d. as compared 
with last year. Tho most important er-ent of the year was 
the opening of the new wing by tho Right Hon. Sir John 
GUmour, Bt.^ M.P.j Secretary of State for Scotland, «a 


236 Feb. ii, 1928] 


BCOTLAND. 


l^obniarv 26th. Accommodating 2,000 patients per ainiuui, 
it lias reduced the waiting list from 700 to 230. AVork 
on the auxiliary infirmary at Tliorntonhall wa.s com- 
moiiced in May, and is ])rogrossing .steadily. This huilding, 
when complete, will bo a notabh' addition th an institution 
which already renders valuable service to the community. 


7nr. CnmsH - 
^rOlCAL JoCRSiL 


meeting appointed other conimittcc.s and also c.xamiiiera' 
for tho ensuing year, and approved,, subject to ins|io(tioii 
by tho Hoard, the list of recognized institutions, with tlio 
toacher.s attached thereto, for tho training of midwifery 
nur.scs. ^ 


AiiEUDnr^v Hovai, iKFinji.vnv. 

The 188th annual report of tho Abordeoii Itoyal Infirmary 
lias just been i.ssued. The report .shows that 5,260 patients 
liad been treated in the hospital and 23,208 as nut-patients, 
making a total increase of 1,581 over the figures for 1926. 
The average number of occupied beds had been 349, and 
the average period of residoneo by each patient in liospital 
had been twenty-six days. The ordinary income for the 
past year was £32,884, which showed an increase of £1,028 
over the income of tho previous year. Ileference is made 
to a sum of £96 which had been obtained by the collection 
of tinfoil wrappings. The ordinary expenditure amounted 
to £32,806, an increase of £529 on that of the previous 
year, whicli is attributed to expense's in connexion with 
the opening of new surgical wards. The average cost per 
occupied lied (deducting, however, tho cost of out-patient 
treatment) was £87 7s., compared with £91 3s. 4d. in 1926. 
The average cost of each in-patient treated had been 
£5 15s. lid., as against £6 Is. Id. in the previous year. 
The extraorclinaiy income had amounted to £11,789, and 
of this £4,677 had been expended in extension of buildings 
and provision of new equipment. Tho extraordinaiy income 
and expenditure account showed at tho end of the year 
a credit balance of £50,455, while, taking into account the 
valuable a.ssots comprised in the Infirmary buildings and 
site, the general assets of the Infirmary stood at £145,268. 
The latter figures are, ns it is pointed out, of importance 
in connexion with the Lord Provost’s appeal for a new 
infirmary. 

Scottish Bo.MiD or Hf.m.th: Mkdicai, .‘Vffointmk.xt. 

The Scottish Board of Health has npjiointed Dr. (Jeorgo 
AV. Simpson to be a medical officer in its deiuirtmcnt. 
Dr. Simpson is a graduate of Edinburgh Univorsity and 
holds tho degrees of JI.A., M.D., B.Sc., and the D.P.H. 
Ho ivas for two years senior resident medical iifficer at the 
Edinburgh City Hospital for Infectious Diseases, and was 
appointed assistant medical officer of health to the city of 
Edinburgh and princijial port medical officer, Leith, in 
October, 1926. Since then he has been responsible for the 
immunization of school and other children against diph- 
theria and for the investigation of epidemics of infectious ' 
diseases in Edinburgh .schools. ^ 

PAnATYPHOII) Ef.VEB AT GaLASHFELS. 

Thirty patients suffering from an attack of para- 
t 3 ’phoid-A fever have been admitted to tho Sanderson 
Hospital, Galashiels. It is believed that thirteen j'ears 
have elapsed since a previous case of tj’plioid or para- 
tj’phoid fever was notified in this toivn. Tlie outbreak 
appears to have taken place about tho first week in 
Januaiy. The cases all developed about the same time, 
and as* no cases have been notified recently it appears 
probable that the source of infection, having been intro- 
duced from outside the town, has now disappeared. 

Central Midwivbs Board for Scotlantj. 

At the examination of the Central Midwives Board for 
Scotland, held simultaneously in Edinburgh, Glasgow, and 
Dundee, out of 95 candidates entered 89 passed. Of the 
successful- candidates 20 were trained at the Royal 
Maternity Hospital, Edinburgh ; 27 at the Roj-ai Maternity 
Hospital, Glasgow; 7 at the Queen A’^ictoria Jubilee 
Institute; 8 at the Elsie Inglis Memorial Hospital; 3 at 
the Rovai Infirmaiw, Dundee; 2 at the Maternity Hospital, 
Aberdeen; 3 at the County Hospital, Bellshill; 4 at 
Stobill General Hospital; 1 at the Cottage Nurses’ 
Ti-aining Home, Govan; and the remainder at various 
recognized institutions. - , , . 

At a meeting of the Board lield for the election of the 
offico-hoarors, f>v. James Haig Ferguson was unanimously 
rc-elocteci chairman. Dr. Robert CochraneJBiiist was elected 
deputy chairman, and Sir Arcliibald Buchan-Hepburii, Bt., 
.was ic-olected convener of the Finance Committee. The 


aittr 

Ce.vte.v.irv of tuf. Roval Free Ho.spital. 

A TiiAXKsoivi.vt! service for tiie cciitenarj' of the Royal 
Free Hospital will he held in St. Andrew’s C'luirch, Holhorn, 
on Sunday morning, Fehruary 19th, at 11. The preacher 
will he the Bishop of AYillesden, and tho service will bo 
attended Iw tho Lord Ma^'or of London and the Mai'ors 
of Holhorn, Finsbniy, and Islington. This church has been 
eboseii for tbc .service owing to the fact that the foundation 
of the liosjiital was dne to a pathetic incident whicli liap- 
pened in its luecincts, and is now commemorated by a 
memorial tablet in the nave. On a cold winter night, in' 

1827, I)r. AVilliam Marsdcii discovered a girl dying of tlisease 
and starvation on the clinreb steps. He was nnablo to 
obtain admission for lier to a liosjiital owing to the lack 
of a subscriber’s letter of recoinniendation, and, two days 
later, she snccumbcd. Dr, Alarsdcn determined, therefore, 
to found a hospital wliicli should admit sick persons freely 
and without delay. The work began Ininibly in Febriiarv, 

1828, in a small lion, so in Hatton Garden, and was trans- 
ferred, in 1842, to Gray’s Inn Road. Since tlien the insti- 
tution has grown into a lio.spitnl with 268 beds and a great 
.school of medicine for women. 


CoAIPARISOiV OF TuDERCULO.SIS ReCORDS. 

The Ministry of Health lias published an analj'sis 
(Memo. 131/T) of the rejiorts received from tuberculosis 
oflieors for tho j’car 1926, in order that eomparison may 
bo rendered jiossiblo between different areas as regards 
tlic cfiicieiicy of the various schemes of local authorities — 
namolv, county councils and joint committec.s, county' 
borough coiinci’ls and metropolitan borough councils. TJio 
figures given in the reports have been reduced to a common 
shiiidard, being expressed either as iierccntagos or in 
pnipo'rtio’ii to some common factor of partirnlar significance 
ill connexion with the incidence of tuberculosis — such, for 
example as tlio mimber of deaths from this cause in each 
area dnrinv the year. The suggestion is made that local 
autiiorities'’and their officers should compare the figures in 
tlioir own areas with those relating to others of similar size 
and ebaractcr. This may result in tlie extension or vaiying 
of the 'schemes in certain directions, and may also lead in 
some cases to the recognition of possibilities of effecting 
cconorav. Special points which are elucidated by these 
statistics are; the varying efficiency of notification and of 
tlie revision of notification registers; the jiroportion of tiie 
Inlal tuberculous population in each area dealt with under 
the tuberculosis scheme; the extent of the e.xammat.ons of 
s snected cases and of contacts; tho amount of delay in 
liVrrnosis ■ and the degree of utilization of sputum cxamina- 
f/nns and a-rav investigations. The measure of the 

+ lintwceii tuberculosis officers and general practi- 
Tonet is Mdicaied for the different areasT and also the 
r.f ^Tinervision exorcised over tnhereuloiis iiationts 
■ rthet olX.es. In some areas it is shown that there 
.as heen failure to arrange effectively for the co-ordination 
' tuberculosis officers and insurance practitioners in 
lomicilfarv treatment. The nature and extent of the 
Snihil treatment provided in the different areas is 
iemonstrated, and it is suggested that comparison of tins 
mnvsiidnm with the recommendations in paragraphs 
"^5 of C™ li ar 280, issued on Jannary 17th, 1922, may 
Volitate S'eater economy in making nso of the.ava lab o 
■esidential accommodation, dno regard being paid to the 
tage of the disease and the response to treatment in each 
ndividiial case. 

AA'oaien Medical Officers .vt London Mental Hospitals 
Tlie Mental Hospitals Committee of the London County 
Viuncil from expeiionce gained in tlio cmplymeiit -- 
i^erimeiitallv at one of tlie mental hospitals of -a wom..n 
ssistant medical officer for special duty in connexion vith 



Feb. II, 1928 ] 


COERESPONDENCB. 


r THEBRmsa 
Mzoicix. Jor&xiK 


237 


womon patients, proposes to extend tho employment of 
women medical officers to other mental hospitals where 
thoro aro facilities for their accommodation. TIio recog- 
nii^ed scales of remuneration for junior assistant medical 
officers do not specify that they, aro applicable to men 
alone, but ns they were fixed with only a male staff in 
contemplation, scales of remuneration for women assistant 
medical officers have to bo determined.' It is proposed, 
therefore, that authority should bo given for tho applica- 
tion to women of the scalo of remuneration laid, down for 
assistant medical, officers below tho rank of fourth in tho 
mental hospital sorvico. This at present is £300 a year, 
iiicreasiug by annual increments of £25 to £400. "With 
tho existing temporary additions approved in 1920 this 
means a total remuneration at the minimum of £423, and 
at tho maximum of £547. Tho Finance Committoo of the 
council, before concurring, has inquired what additional 
expenditure in respect of structural alterations and em- 
ployment of domestic staff tho appointment of women as 
assistant medical officers would entail, and has found that 
only at three hospitals (Hanwell, Horton, and Long Grove) 
could women bo employed without additional expendituro 
for thoso purposes, and at each of these hospitals not more 
than two such women. Accordingly the Mental Hospitals 
Committee has agreed not to appoint women medical 
officers except for duty at these three hospitals, and to 
consult the Finance Committee if at any futuie date it 
should be thought advisable to extend tho appointment of 
women at these or other hospitals under circumstances 
which call for additional expendituro. 




HOSPITALS AND ROAD ACCIDENTS. 

SiE, — With reference to your article on hospitals and 
road accidents at p. 192 of the British hlEDic.\L Jourhai. 
of February 4th, I think tho following information may be 
of interest to your, readers. 

On December 6th, 1927, the case of Lewis u. Champkin 
was tried at the Birmingham Assizes before Mr. Justice 
Sankey. The plaintiff Lewis claimed damages for injuries 
sustained as the result of a motor accident. Tho jury 
awarded damages, including the hospital charges and tho 
surgeon’s fees. In his address to tho jury the judge stated 
that both tho hospital charges and the surgeon’s fees were 
fair and . reasonable and not excessive in any way, and 
that tho surgeon and the hospital could not be expected 
to look after the plaintiff and allow the defendant to 
escape, liability if the jury found that tho defendant was 
liable to pay damages.— I am, etc., 

Kidderminster, Feb. Sth. J. Lionel SiRETTON. 


FATALITY RATES OF SMALL-POX. 

Sm,--A3 several persons, notably Dr. Killick Millard, 
lave pointed out, Dr, Garrow^s figures given in his letter oi 
J anuary 14th are based upon tho fallacy of comparing 
s atistmal incommensurables. As Dr. Garrow well knows 

• ave been two distinct types of small-pox occurrinf 
in 'ngand during the last few years: tho vast majority 
lave occurred in the unvaccinated populations of tlu 

01 ern and Midland counties, and were of tho mile 
minor, if bo likes so to term it — whilst a vem 
^ severe tj-po — variola major— hav< 

inti-Ft^ w of England, due to infectioi 

intioduced from Prance, Spain, Itc. 

• .i'® inction 'is not apparent in tho tables publishei 

At;,,: f ef the chief medical officer to thi 

L though doubtless the necessary in 

tlin ut the Ministry. By comparin' 

witi, these tables, from which he quotes 

in TnlilF ■text, and -with the figures givei 

Rpo-ic't n 4.nnual Statistical Reviews of thi 

tin? ®’ 2 eral, I hare been able to identify nearlv al 

f , maimer 1 obtain tho following tab! 

of deaths in England during the years 1R23 to 1926. 


. Ago. 

Vaccinated. 

Unvaccinated. 

Under 15 ... 

0 

17 (prohahly all Northern). 

15 to 30 

1 (? Kortliern) 

2 (1 Northern, 1 Southern). 

Over 30 

12 (3 Northern, 9 South cm) 

2 (1 Northern, 1 not identified). 

Total ... 

13 

21- 


By “ Northern ” is meant the Northern and Midland 
counties as defined by the footnote to Table 4 of the 
Registrar-General’s Statistical Reviews, less Middlesex,- 
Herts, and Essex, the remainder being the Southern 
counties. 

. Assuming, then, that all the deaths in the Southern 
counties were deaths from variola major, wo may deduct 
them from the total deaths; this assumption is quite 
valid, as these deaths can be identified from the text; 
identification of the cases is not easy, but as those occurring 
in the South of England were very few (about 80), they 
may bo neglected statistically. The amended table is as 
follows : 


Agea. 

Vaccinated. 

Unvaccinated. • 

Cases. 

- 

Deaths. 

Fatality 

Rate. 

Cases. 

Deaths. 

Fatality 

Rate. 

0-15 

28 

B 

— 

10,709 


0.158 ±0.026 

15-30 

392 

B 

0.25 ±0.17 

5,296 


0 019 ± 0.013 

30 and over 

3.618 

3 

0.08 ± 0.05 

1,713 

2 

0.117 ± 0.070 

Total ... 

4.035 

n 

0.10 

17.718 

20 

0.112' 


' Ten were under 1 rear old. 


These figures are probably accurate as far as they go, 
except that the small number of cases of variola major 
in tho Southern counties are included. The table gives 
the fatality rates from mild small-pox in the vaccinated 
and unvaccinated, the' advantage being in favour of the 
vaccinated except at ages 15 to 30 years, where, the rates 
being based on a single death in each class, no deduction 
is possible from such meagre data. The probable error 
in all classes except the youngest class of unvaccinated is 
high. Even when corrected there is a further fallacy, as 
two of the three deaths among the vaccinated at ages 
over 30 years were of persons aged over 70, whilst only 
one death at thoso ages occurred among the nnvaccinated. 
It is well known that small-pox fatality rises steeply in 
the later years of life. 

The data do not form a basis of comparison for tho 
fatality rates in variola major among the vaccinated and 
unvaccinated, but this may be ascertained from the data 
of other epidemics — for example, those given in Table II 
of Dr. "W. Hanna’s Studies in Small-pox and Vaccination, 
published in 1913. — ^I am, etc., 

Liverpool, Feb. '1th. 0. .0. StaeLTBR.1SS. 


RICKETS, IRRADIATED ERGOSTEROL, AND 
HLTRA-VIOLET LIGHT. 

Sir, — ^I rradiated orgosterol is now on tho market, and 
great claims have recently been made for it in the lay 
press as to its power of “ stamping out ” rickets. In the 
Times of Jauuai-y 29th it is stated that “ it is recognized 
now that children and expectant mothers should be 
irradiated with ultra-violet light, but this new discovery 
improves upon that treatment." (Italics aro mine.) 

Well, does it? I sincerely hope so, but so far as I know, 
that still remains to be proved. I do not doubt that 
irradiated ergosterol may cure the disease rickets, just as 
cod-liver oil may do, but in its practical application to 
tho masses of rachitic children in tho larger industrial 
areas cod-liver oil has failed to stamp out rickets. Irradiated 
ergosterol may be easier to digest, and therefore may bo 
better, but until this is proved I should bo very doubtful 































238 Feb. ii, 1928] 


CORRESPONDENCE. 


[: 


aboxit iibaudoiiiiig the sure method of idtra-A*iolct treatment 
in its favour. It should he romomhei’od tliai exposure of 
rnehitic ehildrcii to idtra-violct • light not only cures thr 
rickets, but has many other beneficial effi'cts rvhich 
irrndi.atod crgostcrol presumably cannot claim, the most 
important being the groat iniprovoment of the child’s 
general health and its release from the dangerous catarrhal 
state. 

In another respect, however, the Times article is valuable. 
It draws attention to the fact that expectant mol hers 
should bo irradiated. How many maternity hospitals, <ir 
even ante-natal clinics, hnvo installed lamps for the 
purpose? Have maternity hospitals no function beyond 
the mci'o dcliveiy of the child? During the pre-natal stage 
the child’s body is being made or marred, and those who 
undertake the care of this period have surely a responsi 
hility for the future physical condition of the child.— 

I nm, etc., 


Febrnarv let. 


H. Stani.uv Banks, 

McOical Siiporinlcnflrnt, T/'lcp*'ipr I‘-olation 
Ilotipitul and Ranaiorium. 


TBE.VrjIENT OF ACU'l’E PNEUMONIA. 

Silt, — Is not the ])rcsnnt “ curabilitj' [aic] of acute 
pneumonia in adults ” rapidly hocoming farcical? Hardly 
a week passes without some enthusiast writing that h.o 
has not mot with a death since using this or that remedy. 
Is there some factor in common to all these drugs which 
explains the apparent inconsistency, or do they all cure? 
Or does the patient recover in spite of our remedies, as 
Dr. Gee used to saj- of arsenic in chorea? I am old enough 
to remember tlio value of ammonium carbonate; then 
came an infallible mixture of effervescent fpiininc; .some- 
body recently wrote of the great value of sodium 
bicarbonate; another finds calomel in small doses rarcly 
fails, whilst another sedulously keeps the bowels inactive 
or doesn’t bother about them! Now it is injection of 
sodium nucloinatc. Dr. Hearnc puts 1 in 7,000 potaasium 
permanganate into the rectum and believes in a pneumonia 
vaccine 1 A few years ago there was not much chance 
without salicin, and I am told now by a much respected 
physician that few die with a mixture of sodium iodide, 
ipecacuanha wiue, and ammo»ium citrate 1 

It is all very strange, not to say tragi-comic. Meanwhile 
the disease still figures in the death roll. Have such 
fatalities been wrongly treated, or would the patients have 
recovered if one of these specifics had been used? 1 
suggest that with the necessaiy notification, and death 
certificate — if perchance one has to be given--a confidential 
report of the treatment be also given. IVe need skilfid 
logicians to help us with our reasoning. IVith such wealth 
of material some sort of preci.se knowledge .should result. 

Few things in medicine, I A-ontiire to think, are more 
fallacious than the reiiorts of us nieji in general practice. 
They deal so hugely in impressions. The busiest and most 
experienced men find no time for accurate notes — jwee 
the late Sir James Mackenzie; the youngsters are carried 
away by the glamour of their last success (should 
I say bit of luck?); while the hospitals see the worst 
and feeblest cases. It seems to me that, with the 
exception of cei-tain vaccines not dependent on aught 
but hypothetical germs, most of the remedies are harmless, 
provided the hypodermic needles are clean, .shai-]), and 
strong, and they spare the buttoclcs. 

I suppose hoiv most of us would lilce to be treated is 
Eomething like this; in a cosy, well-aired room, with a 
(renial not too officious nurse, peaceful dome.stic siirround- 
higs, and a kind middle-aged, restful, keen-eyed ]jhysician. 

If there were pain, and I could be got at easilv, 

■I woidd submit to a poultice or antiphlogistine, not too hot, 
and expect some morphine, .and some medinal for sleep. 

I should like plenty of lemonade, my mouth cleaned, 
a little champagne or cider, lemon sponge, jelly, 
junket flavoured with rum, and possibly something like 
iionev, glucose, or malt extract to prevent ” acidosis.” 
Seeing how common is this acidosis ” I don’t tliinjv 
I should mind some calomel (if I were promised not to 
be distiuhed too much bj' a bed-pan), and some .sodium 
bicarbonate n-ore or less frequently. 


Tnr IlRmw ■ 
SiriitCAi, JotfcriL 


Mr. Shaw, in one of those valuable gibes of his, sav 3 
how often he ha.s noti<vd the onlv common factor in all 
the pr<scnptions of a imtient who had gone the round 
of Harley Street was .soj. bicarb, gr. x, t.d.s. 1 So let 
us Imvo sodium bicarbonate as a drug by all means; 

mo a littlo oxvgcn if the room got 
.stuffy, and possibly soino strA-ehnino if the doctor looked sad 
at my objection. To Bomo I find strychnine is anathema. 
\Vhnt an intere.sting view of things one. gets at 601— 
I am, etc., 

llmindcr, Somi-r>cl, Jan. 291I1. IV. H. MAimXilV. 


IODINE IN THE TREATMENT AND PREVENTION 
OF GOITRE. 

Sin, — In reference to a note by me (1027, vol. ii, p. 361) 
on the use of iodine in salt, authorized by the New Zealand 
Goi-ornment for the prophylaxis of goitre in children. 
Sir James Barr (1927, vol. ii, p. 470) has avritten to state 
tli.at ho has been unable to detect iodine in iodized salt 
by his method of analysts. This is quite possible, but the 
Department of Health in Now Zealand states that “the 
Dominion analyst, who regularh- examines samjiles of salt 
as sold on the New Zealand market, adopting the method 
recommended by Fallcnbui’g, the ivell known worker, can 
estimate the iodine uith accuracy, and the examination of 
‘ Ceicbos ’ and ‘ Windsor ’ salt, the two well known brands 
on the New Zealand market, shows that the iodide 
is evenly distributed and is present in the requisite 
proportions.” 

A study of the literature shows that the problem of 
"oitre is by no means soh’od, and that there is still doubt 
even ns to the relationship of the disease to iodine de- 
ficiency. At an international conference on goitre held 
recently in SwitzAirland the benefits of iodine prophylaxis 
were questioned by some speakers. On the other hand, 
Swiss and Austrian investigators claim that iodized salt in 
the jiroportion of 5 mg. of potassium iodide to 1 kilo of 
salt (1 in 200,000) has proved of definite value. It can be 
said with certainty that there is no evidence that salt 
(•'outaiiiing iodide in these proportions does any hann, whilo 
there is it certain amount of evidence that it may do good. 
As goitre is prevalent in children in New ’Zealand the 
considerations outlined above are a sufficient justification 
for tbe use of iodized salt in this Dominion. 

The Siviss Goitre Commission recommended that salt 
containing one part of potassium iodido to 200,000 parts 
of salt should be used, but this is stated to contain possibly 
too much iodine. The use of one part of potassium iodide 
to 250 000 parts of salt authorized in New Zealand gives 
a margin of safetv. In this country the recommendation 
of the'’ commission that uncontrolled purchase of iodine 
preparations bv the public should be prohibited was antici- 
pated and niiiinlv for the reason that there is suflicient 
evidence to show that the administration of iodine in com- 
parativelv large doses to patients in adult life sufFeriiig 
from simple goitre may convert simple’ goitre into toxic 
goitre, greatly aggravating the disease.— I am, etc., 

Votm Neav Zealand ComrESPONDENT. 

December 5tli, 1527. 


QIHNINE in OBSTEl’EIC PRACTICE, 
gjji _Tlic letter by Dr. Hewetson on this subject in your 
issue of JanuaiT 28th (p. 157) deserves the careful atten- 
r:,.,, nf all eimaged in this ivork. Tire method was siig- 
cested to me fiim years ago by Dr. Philip Jones of Coleford, 
Somerset, since when it has been used in nearly evciy 
ease in mv practice in which careful ante-natal 

examination permitted a diagnosis of “ normality/’ 
(N B Occipito-posterior positions ivere included as normal.) 
Between us we have used the method in just oi-er 300 cases, 
and have so far failed to discover any disadvantages. The 
details of the quinine administration are not identic.ai with 
Dr' Hewetson’s rontine, hut the principle’ is the same. 
’W’e have aimed at giving li grains of quinine three time.s 
daily for tlie last three Aveeks of pregnancy, though a fciv 
patients complained of cramp-like pain in tile abdomen 
and had to be given half this dosage. 


Feb. ii, igiS] . 


MEDTGO-LEGAn. 


r TirrURtn^s ' OQQ 
I, IfEDieXI. JOCRNAl. 


Ttio following advantages of the ' method have been 
noted : 

• 1. Patients frequently volunteer the information (without 
any leading questions) that their general health has greatly 
improved since starting the medieino. 

2. Labour appears to bo definitely shortened. Tlio average 
duration from tbo onset of "real pains" — as opposed to 
“ niggling pains " — was about six hours for primiparae and 
three hours for multiparac. 

3. Retraction of tho uterus after labour avas uniformly good. 


account of tho '“ affairo Thomas)” in which a woman of 
this namo scorns to have given details of her proceedings, 
from which tho first of theso reports is taken. 

It does not appear from Vibert's book that the intro- 
duction of a sound has, in his experience, been followed 
by sudden death, so that it is likely that something more 
than tho mere introduction of a foreign body such as a 
sound, or fluid such as glycerin, is needed to set up uterine 
shock. — am, etc., 

London, Pcb. 2nQ. Sejtex, M.B., D.P.H. 


Wo c.tu E.ty with conviction that in these cases there was 
no increased tendency to retained placenta, perineal lacera- 
tion, precipitate labour, prematuro labour, or “ after- 
pains.” ■ In its very insistcnco on ante-natal work the- 
method is, surely, deserving of attentiou. — 1 am, etc., 

Douglas A. JIitchixl, JI.D.Lond., 

, Balli, J.iri. oOth. ■■ F.n.C.S.Ed. 


FOREIGN. BODIES. IN THE STOMACH. 

Sin, — Dr. S. Gilbert Scott’s interesting note on a 
method of dealing with a swallowed object (January 28th, 
p. 133), and his instrnction to his patient “ to go out and 
cat as big a lunch as bo.ccnkl without any fluids,” brought 
to my mind another useful " tip ” in dealing with such 
emergencies. 


This was suggested some sixty years ago by my father, 
the lato Dr. George Dickson of Edinburgh, He, when 
a boy, used to keep hawks, and noted how tho bones of tho 
birds and mice which they swallowed were passed neatly 
wrapped up m feathers or fur. Ho had several cases of 
patients who had swallowed their sets of falso tooth, and 
ho ordered them to take largo quantities of wTiat he 
called ''thread-porridge.” A reel of thick thread or wool 
was nvoiscd longitudinally whilst still rolled up, giving a 
large number of short pieces of the thread or wool. This 
was then stirred^ up in thick porridge and administered to 
the patient. A' day or two later tho dentures, some of 
Uem with awkward sharp projections, were passed natur- 
ally from the bowel, wrapped up in tho threads. 

Do comnnmicated this raetliod to a dental journal of the 
’.I ^ exact reference or of the 

. , w icli was, of course, long before the days of x rays. 

successfully treated by 
* thread-porridge method ” were reported 
soon after he recorded his own cases.-I am, etc., 

W. E. Cauxegie Dicksox, M.D., B.Sc., 

> ... .. F.R.C.P.Ed., 

February 5th ethologist to ^Vest End Hospital lor Nervous 
^ ' Diseases, London. 


lUftiiro-ICfgal. 


A BOGUS DOCTOR. 

Theue will ha general agreement with Alderman Sir George 
Truscoll’s view that the maximum fine of £20 which can ba 
inflicted upon any person — to qnote Sec. 40 of the Medical Act, 
1858 — “ who shall wilfully and falsely pretend or take or use 
tho namo or title of a physiciah, doctor of medicine . . . ” 
is totally inadequate to meet so serious an offence. The 
alderman was dealing summarily at the Mansion House with 
a carpenter, twice convicted of fraud, who posed as a medical 
practitioner at Wardrobe Chambers, Queen Victoria Street, 
where his consulting room was fitted op with electrical 
apparatus, his door bearing the inscription " Dr. Boyd Faulkner, 
M.D.” When tho Registrar of the General Medical Council 
wrote in November last inquiring about his qualification, 
Faulkner replied that he was an American subject and was 
registered with the American Medical Association, having taken 
a Federal degree at New York in 1914, and also the degree 
of'D.Sc. at Edinburgh in 1910. He signed himself “ Sydney 
Boyd Faulkner, M.D., U.S.A.” His answers to the magis- 
trate’s questions were distinctly ingenuous. Apparently he had 
no particular wish to practise medicine, but rather " nature 
cure,” 'and he had held himself out as a doctor for the 
purpose of advertising himself as a “ nature cure ’’ specialist. 
As the magistrate said, such an admission showed the necessity 
for protecting the medical profession and the public whom they 
served against such persons as Faulkner, with no recognized 
training or qualifications, and possessing, moreover, so ill a 
character that tho police could find no one willing to act as 
surety. Tho consequence was that a term of two months’ 
imprisonment was fixed in default of payment of the £20 fine 
and 10 guineas costs. Sir George Truscott added that it was 
ridiculous that magistrates were not given more powers in such 
an important matter, where not only the medical profession 
but the public were seriously concerned. 


SHOCK -AND ABORTION. 

int abortion is not of great or genor 
tmee ’t.-i'-? ^ -t of shock is of universal impo 

aintfimv ° pathology is obscure and its morb 
P.a'lmer^ recent case of R. 

Februarv British Medical Journal 

shock cau^he irt un^h ^1® suggests that fat 

an inieetinn f distension of tko uterus 1 

fssuoT n 0“ P«s° 198 

is siRnifinnt''^+l"^t'\i°^ 30,000 intrauterine injections. 
Hobbs of 'KpTici''^ra *“t‘^i’asting report from D 

tte ratfat^Xn^r ^ of warning as 

Is it i Jlyaerin is to be injected. 

of the interfere depends, not on the natu 

auahfrnii^ in ii « ‘ ‘ ■uterus is increased ? Is tl 

angina pectoris blood tension which occurs 

an account of T 

was just hevinnincr tn abortioni 

the n.'ttient'’enir. ,^.1° S'Fe an intrauterine injection wh 

post-mortem ^led in a few minutes. T 

Vibert e vee Was negative. At page 4 

little 0^110 nri.T* on six other cases, all fatal, wi 
P -mortem signs. He published in 1893 


©biiiiar^. 

■ CLAUDE WILLIAM SCOTT SABERTON, M.D., 
D.M.E.E.(Cajib.). 

The death occurred at Bournemouth, on January 16th, of 
Dr. Claude Saherton, who was well known as a radiologist 
both in Bournemouth and Harrogate. The son of the 
lato Dr. Saherton of Manchester, he received his medical 
education at the Manchester University, graduating 
M.B., Ch.B. in 1901, and taking his M.D. four years 
later. Some years after graduation he devoted his atten- 
tion to radiology, and in association with Dr. Fowler 
practised in Bournemouth, where he was on tbo staff of 
tho Royal Victoria and West Hants Hospital. After the 
war he settled at Harrogate and in a few years built up 
a large practice, retiring from active work owing to ill- 
health. 

A Harrogate colleague writes : During the all-too-short 
time that Saberten’s health allowed him to follow in this 
town that branch of practice to which he had for somo 
time devoted himself he gained a deservedly high place 
in the esteem both of the profession and the public. Ho 
brought to his work sound practical and theoretical know- 
ledge, boundless energy, and unfailing optimism, so that 
whether at tho Infirmary and the Royal Bath Hospital (ho 
was appointed to the honoraiy staff of- both Institutions 
soon after coming to the town) or in private ■ practice it 




OBITTJART. 


240 Fed. ii, 1928] 


[ 


TiaDnrm* 
Mepich. Jocnxit 


gained ra])id and ovcr-incrcasing recognition. Ho was 
one of tho first to install at liis private clinic an 
apparatus for deep a:-ray tliera])}', spending a holiday 
in Erlangen so as to gain fii-st-hnnd Icnowledgc of tlio 
method. He wrote a hook on diathermy, contributed 
several papers to tho journals, and took the D.M.Il.E. 
of Cambridge in 1921. Such a record is all tho jnoro 
remarkable when it is remembered that during the latter 
part of his time hero ho was constantly harassed by 
symptoms of the disease which was soon to cause his 
retirement from active work, and in a few years liis 
premature death. Whilst honouring these profe.ssioiml 
acconi])lishmcnts his .friends are glad also to remember 
tho i)crsonality and character which lay behind them. 
His transparent honesty, -wide .sympathy,' generosity, and 
jjcrhaps above all his exemplary courage in a constant 
light against idiysical disability, which tho logic of his 
medical knowledge must at times liavo warned him 
was a sadly unequal one, will make his memory for long 
a happy and in.spiring one to tho.se who knew him best, 
and tlioir sympathy goes out to tho dc\-oted wife and 
.daughter who suiTire him. 


Wo regret to announce tho death, on Januaiy 25th, of 
Dr. RoDEitT Aninim Mh-lican of Northampton, aged 69. 
He was a native of Deonc, and received his carl^' education 
at Clevedon College, situated then in Abingdon Street, 
Northampton, and at tho age of 17 became a pupil at tho 
Northampton Hospital. In 1876 ho entered Guy's Hospital 
Medical School and took tho diplonms of M.R.C.S.Eng. in 
1881 and L.R.C.P.Lond. in 1884; ho became M.D.Durh. in 
1900. After serving as house-surgeon at Guy’s Hospital, 
.registrar and chloroformist at tho Evelina Hospital for 
Children, and as clinical assistant at Dothlcm Hospital, ho 
returned to Northampton in 1884 on being appointed house- 
surgeon to the Northampton General Hospital, and his con- 
nexion with that institution continued for forty-three years 
until he retired in January, 1927. On his retirement from 
the active staff of tho hosjjital ho was presented with a 
cheque of £453 and an album containing tho names of the 
subscribers. He had a largo practice in Northampton and 
the surrounding districts, and won tho esteem and con- 
fidence pf his patients. During tho war lio served at tho 
Military Hospital at Cambridge, and was awarded the 
O.B.E. in recognition of his sendees. Dr. Millig.an was a 
pioneer of the amhulameo movement in Northampton, and 
was for some years ambulance instructor to the Northampton 
division of tho county constabulary. He took a keen 
interest in municipal affairs, and was a member of the 
Northampton Town Council for twenty-three years, and a 
member of tho Public Health Committee, of which he was 
at one time chairman. He was appointed to the magisterial 
bench in 1906. Dr. Milligan was for many years a member 
of the British Medical Association ; from 1892 to 1925 ho'was 
a member of the Committee of Management of tho South 
Midland Branch, was president of the Branch in 1897, and 
treasurer from 1899 to 1922. 


work of tho Life Assurance Medical Officers’ Association. 
During the war ho devoted him.solf to the medical side 
of recruiting. Ho was a member of tho British Medical 
Association and a Fellow of'tbo Royal Society of Medicine. 
Dr. Fitr.gcrald was a man with cxception.ally wide and 
viiricd interests. Ho was a devoted student of Scottish 
folk-lore and history, a keen member of tho Highgate Golf 
Club, and an ardent worker in tho Highg.ato Pre.sbyterian 
Church. His death is regretted in tho City of London 
and es])ccinll_v in Highgate, where ho accomplished 
much quiet and unostentatious social service. He leaves 
a widow and two daughters. 


Dr. David Wolsei-ev .Scott, who died at his residence at 
Bryn, Port Talbot, on January 13th, at tho age of 65, 
received his medical education at Anderson College, 
Glasgow. Ho obtained tho diplomasL.R.C.P., L.R.C.S.Ed., 
L.R.F.P.S.GIns., and L.M. in 1887. Dr. E. AValsli writes: 
Dr. .Scott in his forty years of general jiractice ever 
maintained the highc.st tenets of his profc.ssion. Of a most 
kindly and generous dispo.sition, his relations witii his 
eolleagncs and patients were of tho most friendly nature. 
He was a member of the British Medical .iVssociation. He 
leaves a widow. 


Dr. PiiiLi.ip .Tames of Senghenydd died on January 28fh, 
aged 73. ’ Ho received his medical education at Guy’s 
Hospital Medical School, and took the • diplomas of 
L.R.C.P.Ed. and Jf.R.C.S.Eng. in 1878. He had practised 
at Senghenydd for thirty-five years, and before that at 
Porlhcairl and Pontypridd. It was whilo in practice at 
tho latter place that Dr. James assisted in the j-escue work 
at the eolliciy explosion there in 1877, and he was one 
of tho eight rccijiients of the bronze medal awarded by 
tho British Medical -Association for heroic conduct, self- 
denial, and humanity. 


Dr Louis Ronixsos died at Folkestone on February 5th 
as tho result of an accidental gunshot wound. Ho received 
his medical education at St. Bartholomew’s Hospital and 
took tho diplomas of M.R.C.S.Eng. and L.S.A. 111 1883, 
ho graduated M.B. Dnrh. in 1887 and M.D. with first-class 
Lours and gold medal in 1891. He had seiwed as house- 
surgeon to tho Stockton and Darlin^n Hospitals, and 
subfcnuentlv became surgeon to the rMillor Hospital, F 0.1 
upwards- of thirty years he practised at Streatham, and 
on his retirement some six years ago went to Ine at 
pLni.ifrs near Brighton;- four years later ho removed to 
TP vi-cstoiie Ho was tho author of ^\ild Traits in Diiinh 
A - and contributed articles on “ Reflexes ” to the 

vTcthimn/ of rsycholooical Medicine, 1892, on “ Observa- 
Uicuotm ./ j „ Journal of Anatomy and 

in the san-.e year, and on “ Tho chin in relation 
to artlcuffito speech,” which appeared in the report of the 
Smithsonian Institute, AYashmgton, for 1913. 


Dr. Gehald Fitzgebadd, who died on January 28th, 
received his medical education at Edinburgh, whoro he 
graduated M.B., C.M. with first-class honours in 1890, 
•and obtained the Freeland-Barbour Fellow-ship in the follow- 
ing year. He proceeded M.D. in 1919. He had held the 
posts of assistant to the professor of clinic.al medicine in 
Edinburgh, senior resident physician to the Edinburgh 
Roval Infirmary, and resident surgeon to the Royal Mater- 
nit'v Hospital; ho was also president of the Edinburgh 
Royal Society of Medicine. He abandoned teaching and 
research at what seemed to be the outset of a very promis- 
ing post-graduate university career, and established him- 
self ill the City of London, where he gained a leading 
place in life assurance work. He was medical officer of the 
Scottish Equitable Assurance Society, the Scottish Provi- 
dent Ihstitiite, the Edinburgh Assurance Company and 
other corporations, and also chief medical^ omcor ^ or the 
(Royal Mai] Steam Packet Company. His decisions in 
cases of difficultv were regarded as authoritative in the 
insurance world, and he took a prominent part in the 


The following well known foreign medical men have 
Liw died- Professor Aefonso Moniefusco, director ot 
fospedale Cotugno for infectious diseases at Naples, and 
Lm Ao writer on fevers; Dr. Frances Weed Peabodv, 
oLsor of medicine at Harvard Hniversity, aged 45; Dr. 
lOUARD LaOUESSE, pvofcssor of histology at Lille Hnnei- 
A? Madmno KeRMpke-Dejerine, a promment Pans neiiro- 
ds't and widow of Professor Dejenne; Dr. John At eslei 
of AVashington, .a prolific writer on gynaecology 
’oLier president of the American Gynaecological Societj . 

■ A’dadiJiib roN Bechterev, professor of neurolog} and 
• \ladi3 t : „rad and a pioneer in experimental 

’'^^''livsiolowv a"ed73; Professor Negri, director of the 
titrrte of Neuropathology at Turin TJniversity; Dr. 
mniAM Gilman Thojirson, emeritus professor of medicino 
Cornell Hniversity, New York, and author of a textbook 
medicine aged 70 ; and Dr. Thomas Caspar Gilchrist, 
essor of’defmatology at Maryland Umvcrs.tr f 

dermatologist to Johns Hopkins Hospital, 




242 Feb. ni 1928] 


filEDIOAr, NEWS. 


f TmsBikms* 

L AlEDICJil. JoCSHiX, 




At t1io raeofcing ol tbo OliUcl Stntly Society, Iioniloii, on 
ThuMtiay next, Fobniaiy IGtli, a ioctnro on clilld Ruidanco 
will 1)0 given by Sir Huiujjbry Eolloston, Bt., M.D., with tho 
prosUlent, Sir John Cockburn, M.D,, In the chair. On tho 
following Thursday, February 23rd, Br. Stella Churchill will 
give a lecture, illustrated with lantern slldo.s, on sunlight in 
its efieot upon the dovolopineut and growth of children, tho 
chair being taken by Dr. Erie Brltchard. Tho mootings are 
hold at 6 p.m. at thoBoyal Sanitary Instltnco, 90, BucUlngliam 
Palace Eoad, S.W. (near Victoria Station;. Non-inombers 
may attend tho lectures on ijayment of Is. admission. 

The adjourned meeting of tho Society of Superintendents 
ot Tuberculosis Institutions will bo hold on February 18th at 
122, Harley Street, at 3 p.m. Dr. A. Niven Ilohort.son will 
apeak on open-air treatment and motoorological conditions. 

The meeting of tho Society of Modicni Ofllcors of Health 
for tho discussion of the control of amali-pox has boon post- 
poned from February 17th to March 16th. Tlio next mcoting 
of tho oounoll of this sooioty Is also postponed nntll tho 
latter date. 

The next q^narterly meeting ot tho Royal Medico-Psycho- 
logical Association will bo hold at tho City Mental Hospital, 
Fishponds, Bristol, on February 16th, when papers will bo 
read on the histology of the globus pallidus aud tho mental 
state in cardiac disease. On tho previous day there will bo 
a special meotiug ot tbo council in tho nuatoiiiloal theatre of 
Bristol University, aud al.so meotiugs of tho parliomontary 
and educational committees; these will bo followed by a 
dinner in the evening at the Royal Hotel. Further Informa- 
tion may bo obtained from Dr. R. Worth, Springflold Mental 
Hospital, S.W.17. 

The presidential address before tlio Historian Society ot 
Ring’s College Hospital, London, will ho given on Wednesday, 
February 15th, at 8 p.m., when Mr. Buxtou will spcalc on 
John Hunter, 1728-1793. Visitors will bo wcloomo. 

The Fellowship ot Medicine announces that Mr. Duncan 
Fltzwilliams will give a lecture on hysterical breasts at tho 
Medical Society lecture room, 11, Chaudos Street, Cavendish 
Square, on February 13tb, at 5 p.m. On the same day and 
at the same time there will be a clinical demonstration by 
Dr. 0. Worster-Drougbt at the West End Hospital for Nervous 
Diseases. On February 17tb, ot 5 p.m., tliero will be a 
demonstration in surgery, at St. Peter’s Ho.spltai, by Mr. 
Alban Andrews, and another, in ophtholraologj', at tbo Royal 
Westminster Ophthalmic Hospital, by Mr. M. L. Hino, on 
the clinical application ot perimetry. The lootiira aud tho 
demonstrations are free to medical practitioners. Two special 
courses begin on February 20tb ; one at tho Queen Mary’s 
Hospital, Stratford, in medicine, surgery, aud the specialties 
will continue for a fortnight, occupying tho whole of each 
day with lectures, demonstrations, and operations. The other 
course will be held at the London Lock Hospital aud continue 
for four weeks, with olinioal work and lectures every after- 
noon and some evenings. This course was to have begun on 
February 6th, but was postponed. 'The lectures vvill only be 
given It there is an entry of six, though the clinical course 
will be held in any case. Early application is desirable so 
that the lectures may not be cancelled. There will bo six 
special courses during 'March— namely, one in diseases ot tho 
chest at the Bromptou Hospital, from M.xrcU 19th to 24th ; in 
diseases of children at the Queen’s Hospital for Children, 
from March 5th to 17th, occupying all day ; in gynaecology 
at the Chelsea Hospital for Women, from March 5th to 17th, 
occupying mornings and/or afternoons; in ophthalmology at 
the Roval Eye Hospital, occupying each afternoon ; lu ortho- 
naedics at the Royal National Orthopaedic Hospital, from 
March 19th to March 31st, occupying all day ; and during the 
same period a practitioners’ course m medicine, surger-y, and 
the specialties at the Hampstead General Hospital, for one 
nnd a half hours during the late afternoons. Syllabuses, 
tichets copies of the Post-graduate medical Journal, and 
IrrHoplars of the general course work may be obtained from 
?hfaecreUr¥of the fellowship, 1, Wimpole Street, 3V.1. 
■n«Tvv;-n rhR ansniees of the Chadwick Trust two lectures on 
England during the last 200 years will be 
epidemlol^y Hamer on February 16th ana 23rd, at 

I^^The Mo“s Hallot the House of the British 
Wvistock square; admission will be 
Medical Ass geal with the germ theory and 

eptdfmrn ogy?am7the second is entitled “ The return 
to the mlpocratic method.” During ‘5® 

that other lectures shall be delivered by Dr, Walter EUlot, 
Parliamentary Trader-Secretary of State for Scotland, ana 
Professor W. E. Dixon. 


The British Industries Fair to bo bold at Shepherd’s Bash 
and at Birmingham from February 20th to March 2nd com- 
prlsDS BDino 2,000 exhibitors, and covers a space halt as much 
again as in 1927. 'The catalogue Is really a book ol reference 
for British manufactures; tho description of tho exhibits is 
sot out ill nine languages and tho book goes all over the 
world. At Shojiliord’s Bush there will bo oighteen firms 
exhibiting analytical and research chemicals, and twonty-sis 
showing drugs, phannacoulical chcmloal.s, and preparations, 
Tlio section containing medical and snrglcai instraments and 
appliances Is made up of about thirty llrm,s; soientifio and 
optical in.strunionts also appear likely to bo well displayed. 
Only British manufacturing firms are permitted to exhibit, 
and no exhibitor may Include articles other than those of his 
own manufaciuro. ’The public are to ho admitted daily to 
tho fair, and tho Royal Automobile Club has mado arrange- 
ments for tlic care of vi.sitors’ cars. 

Ak International Medical Congress for Industrial Accidents 
and Diseases will, as wo liavo already announced, be held in 
Budapest from September 2nd to 8th of this year, and 
delegates from all parts ot tho world have been invited. 
.Special pcominoiico will bo given to industrial accidents 
(although industrial diseases will figure in the programme), 
ns in tho following year a congress specially devoted to 
Industrial diseases will bo hold in Lj'ons, under the aaspices 
ot tho Congress for Occnpatlonal Diseases. 'The Conned ot 
Industrial Mcdtclno has been nominated to act as tho British 
national commlttco, and it is hoped that a large number ot 
British practitioners with experience of industrial medicme 
will visit Budapest. Dr. D. A. Coles, Professor Edgar L. 
Collls, Sir 'Thomas Oliver, and Dr. Theodore Thompson 
ropresout the council on the pormauent committee or 
congress. Further information can bo had from the ho^ra^ 
foreign secretary, Dr. H. S. N. Menbo, 12, Stratford Plac , 
W.l. 

AH International Cougcoss for the “f,^“usn?cef 

will bo hold lu Paris from July |tU to gongjatioa lor 

Of tho Rod Cross Society, tho fo“ the 

tho Protcotiou of Infancy, the jn °noy Com® 

‘'cougrcss‘’’wia' bo'^ dRMofmto' fivoYctlons, 
mittco. Tho a— iiy inrancy, childhood, social 

AK - A*? 

Stocitholm medical oleotrology, and radio 

dioguosis, raaiothorai iL meama ^ jjJ lot 

ami a Bplrial exhibition will be arranged in 

tho sessions, ami a p ^ purther infonnation may be 

tho Liljowalch 7 Walker, tho English repre- 

"onmtRo o7 Tl,o swedlu feroBS Bureau, Eim- 

SK»adLano,ChislehurBt. 

n rt onTTnnfh fiTiiiiVBrsEity tU© foiiuclo.tiou, ol 
To celebrate ^ Punotioaal^Nervous Disorders a 

the _ Tavistock ra, mo 10 6th at the Mayfair 

losUval mau Mr. Dougal O. Malcolm, proposing the 

The W^tor's^ appealed as honorary t<^easurer lor 
health of ^ nf the clinic to the extent of an additional 
increasod support announced that T150 had already 

annual sum of Sl.OOO- function. The toast 

been reoeived m con exio^^ Dascelles, who supported the 
was acknowledged y Farquhar Buzzard, who 

treasurer’s appeal, au y an educational 

ompliaslzed the imp ^ boiug collected there 

agency. The scientia tlje 

wonld enable 6^ the young. Sir Farquhar Buzzard 

whole process of ednoat » “ “ft of tbe clinic for tho 

added that the tec ^ complete and instruc- 

years 1920 to 1921 ,, Mina jllnstrating the value of psycho- 

tive „et aopeared, and fully justified the appeal 

analysis that had yet-appearea.anu^ of £300,000. He then 

now of ‘‘The Clinic,” coupled with the name 

proposed ^°\r:l°er to whose pioneer work he relerred 

°\'°'‘T£t7r the’s“eeches the amusingskitonpsycho- 

lelimtously. i t ..Suppressed desires” was presented. R 
analysis ®u«“?S„,.ing^‘tbe evening that further promises ol 
7ver £53“ bsWons and donalons had been renewed 

rtf the Joint Tuberculosis Council on 

T vIlsHt the Uoute of the Society of 

January 2ist, ^ rue ^ j elected chairman for 1928, 

ot Health. Sit Henry Gauyam was eic honorary 

Dr, Lissant C<« Watt honorary treasurer. Sir Hunry . 
Beoretaxy, entertained the council to innnhenn 

ttree7sir"Sg"NewSl7rwi)0 delivered a short address, 

as briefly mentioned in our last issue. _ roealGovem- 

THE first report oi the ^.^rsion o\ 

.ment dealt constitution a d 



Feb. it, 1928] 


LETTERS, NOTES, AND ANSWERS. 


[ Tkl British 

ilEDICil. JOCRXAI. 


243 ' 


In Part II tlic nviclence taken by tbo Commission on tbo 
constitution and e>;tension of comity borougiis was sum- 
marized; and Part III gavo tbo conolnsiouB and rccomuionda- 
tions of the ConimiSBion on this subject. 'Ibo minutes of 
evidence taken before the Commission aro being imblisbed in 
•parts from time to time. The latest to appear is Part IX, 
beinc tho ovitlGUce given on bobalf of tho iVIiuistrj^ of HoaltU 
and other Government deparlments during June and duly, 
1927; it is published by H.M. Stationery Ofilco at Gs. net. 

THE King has appointed Dr. Donald P. Wailling, a medical 
officer of the Leeward Islands Medical Service, to be an 
official member of the Executive Council of tho Presidency 
of the Virgin Islands. 

As announced in our advertisement columns tho Grocers’ 
Company are offering scliolarsiiips of £300, ivith an allowance 
for cost for apparatus and other expenses, for tho encourage- 
ment of original research in sanitary science. Tho scholar- 
ships are teuabio for one year, but renewable for a second 
or third year. Tho next election 11111 be held in May. 
Forms of application andfurtherinformation may be obtained 
from the clerk to tho Grocers’ Company, Grocers' Hall, 
London, B.C.2. 

An interesting article by Dr. E. T. Williamson on Captain 
James Cook, R.N., P.E.S., and his contribution to medical 
science has appeared in the January number of the lonmal 
0/ the Jlajal Naval Medical Seivice. In it Dr. WiliiauiHon points 
out the value of the advances TOndo by the great navi^iator 
in the dieting of sailors. Up to his time scurvy luvariably 
appeared amongst the crews of sliips undertaking long .sea 
voyages. How this remarkable man, self-educated and self- 
made, found the means to prevent this dread tbsease will bo 
read with great interest, as showing bow tlie emiiiricism of 
a sea-captain 150 years ago is jnstifled by tbo biochemistry 
of to-day. . 

Dobing last month the Hospital Saving Association enrolled 
19,424 new members among London wage-earners; its 
membership at the beginning of February had risen to 
400,000, and its income Is now about £275,000 annually. This 
snm, obtained by voluntary contributions of 3d. a week, is 
mstributed, on a pre-arranged scale, toco-operating hospitals. 

A REnsED edition of the Phannacopoeia ot the Paddington 
Green Children's Hospital has now been issued. 

Mmsks. J. and a. Churohill announce for early pnbiica- 
tloa Oils, Fata, and Fatty Foods, by E. Richards Bolton, being 
the second edition ot the book by Bolton and Revis, with 
a chapter on “Vitamins" by Professor J. 0. Drnmniond; 
T 1? edition ot Recent Advances in Biochemistry by 

John Pryde, M.Sc., and a volume entitled Laboratory Manual 
for the Detection of Poisons and Powerful Dinigs by Dr. W. 
Autenrieth, translated from tho fifth German edition. 

T. ^?®^^^hte ot American Meat Packers has recently 
published a recipe book describing forty ■ways ot serving 
, Medical practitioners who desire a copy of tliis booklet 
Miould apply, to Messrs. Armour and Co., Ltd., Queen's 
House, Kmgsway, W.G.fi. > . 

is awarded Iiy the 
KorthamnM^^iw^®®^ Connell, -was won in 1927 by the 

Infant Welfare Voluntary 
Healil, tffirdyear in succession; the Leicester 

wt! am Committee was ’second. The 

was awardefl^t?ino'^r*’”H® shield, reserved for smaller areas, 
h ^““’^f'^gesliire Federation ot Women's 

vnfage^of’iha’i’cL^ty! 

Hainbur?In\um^^f'' obomical section of the 

Of a wS ton vn Diseases and tho inventor 

birthday. stain, has recently celebrated his 60th 

Dra^Aroti'^Bellnnn' ®i*air has been conferred on 
the Strasbourg facukrot l’n^itTn’’"^^ Schwartz, lecturers at 


faculty of medicine, 
years. orates than during tlie previous two 


recently unveiled in tbe Hedical 

discoverer o? morphffie w{;n Sertuvucr. the 

Padeboi-n, in 1783. ^ ®'*' Neuhaus, near 

heen‘mad“acomm'Iude^™and°Dr^^^^^ Paris, has 

of tho Legion of Honour! “ ^ Abadie of Oran an officer, 

contaffis”an ™cOTUuro?‘£{,e*^“v®"'^“ current year 

Information likely to bo usefuTV^^ 
feature is the Insertion of ninsJr,M unusual 

professors at work °°®' including some ot tbe 

ot tho %"u^luo^o/ tho una anniversary 

rounding country, particularly Tyrrf.- ^ of the sur- 


Ktttcvs, Sioks, anit ^ttslurrs. 


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Financial Secretary and Business Manager. 

Tho TELEPHONE NUMBERS of the British Medical Association 
and tho British Medical Journal arc ilUSEUM 9S6I, 0S02, 9SCS, 
and (internal exchange, four lines). 

TliO TELEGRAPHIC ADDRESSES iiVQ i 

EDITOR of tlie British Medical Journal, Aitioiogy ITestccnt, 
London, 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.), ArficuMfe ITestccnt, London, 
MEDICAL SECRETARY, Mcdisccra Westcent, London. 

The address of the Irish OfiicQ of the British Medical Association is 
16, South Frederick Street, Dublin (telegrams: Baeilhix,, DubUn\ 
telephone : 4737 Dublin), and of the Scottish Office, 6, Drumsheugh 
Gardens. Edinburgh (telegrams ; Associate, Edinburgh j telephone ; 
24361 Edinburgh). 


QUERIES AND ANSWERS. 


Unusual Pigmentation of Scalp. 

Dr. D. I. Walker (Banff) reports the case of a boy, aged 9, who has 
ft patch of jet black hair on the right parietal and frontal region 
of the scalp, the hair otherwise being of a sandy fair colour, 

Theh*'*.'*’ “.**'*• ' 6 inches by li inches, find is hori- 

zontc * • . . 6ausage*shaped, tbe upper edge 

being . le lower border Is Irregnlar. It 

stretches from the middle line of the skull posteriorly to within 
an inch of tbe edge of the hairy part in front. There are no 
pigmentation or changes in the colour of tbe hair sucli as follow 
Bii Injury, skin diseases, or special treatment, and the patch has 
been present from infancy. It suggests the coloured areas found 
iu lower animals. 

*,• In regard to this case Dr. H. Haldin-Davfs writes: 
ThU is an extraordinarily rare anomaly ot scalp pigmentation. 
It is not particularly uncommon to find a patch of lencodermia 
Iu the scalp, from which the hair grows white with quite 
a becoming effect. Many will remember the late Maurice 
Ffti'koft, iu bis day a' well known actor, who possessed this 
peculiarity. But a parti-coloured coiffure Is a much rarer 
pheuoraenou. I have seen a man whose occipital hair is several 
shades lighter than that over the crown of his head, but the only 
case I am aware of at all similar to that reported by Dr. Walker 
Is one published by M. Wunseb in the Berl. hlin. TFoch. in 1910 
(vol. xlvii, p. 83Z)— a boy with black hair, but with a number of 
patches of red hair mixed with It, The skin under tbe red hair 
was pink, while that under the black was white. The outlines of 
tbe patches were quite sharply defined, and the general effect 
must have been very odd. 

Dry Mouth. 

Dr. W. Johnson Smyth (Bournemouth) writes: If “B.” (Journal, 
February 4th, p. 204), who is concerned with a patient with 
“dry mouth,** will try tho mountain ash (rowan tree) berries 
I Ihiuk ho will relieve the symptom. I noted their efficacy 
in the British Medical Journal n few years ago. Messrs. 
Martiudale, chemists, Cavendish Street, London, W., keep them 
iu slock, I think, it not, I will gladly send some preserved 
berries4o ** B.*’ if he sends his address. 

Frequency of Micturition. 

Dr. W, Nunan (Bombay), replying to Dr. J. MeWhirter’s inquiry 
(Journal, December 24th, 1927, p. 1214), recommends suggestion 
treatraoiit when other methods have failed to give relief. He has 
known it to be of great value in cases of “ bladder irritability.’* 

Cleaning Dentures. 

“ J, R. R. H.” writes: In farther reply to “T. M.” (Journal, 
January 28th, p. 164) I find that carbonization can he prevented 
by the following method. Take a pencil-shaped piece of wood 
with a blunt point and a little dentifrice on the plate; wot tho 
plate aiul scrub the surface with the point of the ^ncil. If this 
13 done once a week, or when the vulcanite begins to get 
blackened, the discoloration can be mbbed off. • It requires ' 
about ten minutes, and patience. A bard brush and dentifrice 
will also keep the pink gum clean. 1 do not think tbo method 
would be effective in the case of a thick deposit of carbon. 


244 Fbu. II, 1928 ] 


tiETXEBS, NOTES, AND ANSWERS. 


r 


Tfir Briti-W 
Mkdicil ;omyil 


Enoi.ooy of tiih Cojimon Coi.d. 

Dll. R. C ■ • " i to link to;«ollicr Dr. V. S. 

Oheiie; ■ Docombor 3r<l, 1927, p. 1061), 

that n ■ ■ CBiieo ot Uio common colil, 

with Dr. I'k W. Ooodall’s p.apcr on tbo epidemic conslitiitloii, 
read before tiio Section of Kpideniioloj'.v and State kfodiciiio of 
tbo Royai Society of Medicine, of wiiicli a fnli iib'ilinct was piili- 
ligbed in onr iusno of November 5tii, 1927 (p. 830j. Dr. Oinilnicrs 
agrees liiat siioii n motaboiic distnrb.ince exists, and rofera to liia 
ietter (Jouiin.vt,, March 13tii, 1926, p. 507), in wiiioli iio confirmed 
lirovions observations on tiie appe.arancc in tiie urine in aiioii 
catavrhai conditions of icncin crystnis, tiie o.xact nature of wiiicii 
has not yet been cstabiisiied. ' Ho does not boiiove, however, 
that a nliid acidosis is uecessaviiy prc.scnt, aithongh marked 
acetone reactions have freijncntiy been observed In con- 
current cases, bordering on alkalosis, said to bo due to an 
“inward oiiiil.” Investigations for soniu seven years have 
brougiit him to the conoiuaion that tiiere is a doflnito 
disordered inteslinai Iiopalio motaboiism, tending to a 
disturbed btood state, of wiiich tiie altered cnlcinm meta- 
bolism forms an important part. Tliis predisposes to, if it 
does not initiate, a diseased stiitc of tiie tiody, of wliich the 
common cold is only one manifestation. Examination of many 
samples ot urine during tiie catavrhai season results frequently 
in the finding of indican, bile, oxalates, and the Icncin crystalK, 
Dr. Chalmers finds evidence of this disturbed metabolism lilso in 
such concurrent conditions ns the nlbiimimirin of proniinncy, 
eclampsia, nraomio convulsions, acute eczema, and pyelitis, ns 
well as in other conditions traceable, In his opinion, therefore, 
to what he terms an “ epidemic conatltutiou." 


TnuATJtr.NT OF Vor.vtTis. 

Dn. Leo Spira (London) writes: Vulvitis appears to be one of the 
symptoms ot chronic poisoning by a choniical irritant, possildy 
contained in tap water or in food prepared in aluminiimi ntcusils 
cleaned witli soda or proi'arations containing it. The treatment 
suggested is : (1) elimination of tlic Irritant nccimmlatcd in the 
body by taking big doses, say ten heaped teaBjioonfnlB, of a 
high grade olmrcoal and two heaped tcaspoonfiils of a mixture 
ot magnesium and sodium aulpliato a day; (2| strict avoidance of 
local drinking water, eitlicr plain or iii preparing food of any 
kind, substituting it by a natural mineral water; (3) replacing 
aluminium by good enamel utensils. With sucli general treat- 
ment this kiud of vulvitis will improve rapidly, even without any 
local measures. Should it bo necessary, after a fortnight’s or 
three weeks’ treatment (and not before), painting the parts with 
25 per cent, silver nitrate in alisolute alcohol may be very useful. 


TnEATJtENT OF Si:A-siCKxns.s. 

Dit. A. Snr.T.TiF.tM (Leningrad) writes to recommend tlio use of 
nitroglycerin in sea-sickness. He lias treated at different time? 
twenty cases, all witli good results. To bis first patient— 
a woman— be gave one drop ot a 1 per cent, soliitloil of nitre- 
glycerin in some water. Despite a storm In the Blaok 8c.a shs 
reniaiiiod perfectly well and partook of food, bnt, six lioiirs later 
on reacliliig land, slio liad fliisliing ot the face and a Iieadaclie’ 
from wliioli it wonid appear that the nitroglycerin had been 
acting offectivoly for eight lioiirs, tlioiigh tiie rolling ot the shin 
had prevented tlio appearance of the characteristic sj-niptonis. 
Another patient with severe sea-sickness received a tablet ot 
iiltroglycorlii (0.G5 mg.) in water, and twenlv minutes later he 
wan able to talte dinner. Dr. Solllioim subsequently administered 
nitroglycerin to other patients by placing two drops of a 1/2 per 
cent. Boliitioii directly on tiie tongue. All tlio patients, save one, 
speedily recovered ; tlio one exception Imd been taking lemon 
iiilco about tho same time tliat slio received the nitroglycerin, 
and repetition of tlio treatment without this complicating' factor 
produced very good results. Dr. Sellhoim adds that larger 
quantities can ho taken without ttctnal tlnuger, hut lie has had 
no personal experience in tiie use of tliis reinedv in chililreii. 
Ho moiitions tliat one patient was a woman, aged '62 ; there ms 
no coutmiiidication in this case, siiico iiitroglyoorin lowers the 
blood pressure, does not affect the kidneys in small doses, ami 
acts directly on tiie mistrintcd muscle in the arteries and veins 
of the head and neck. 


Drug Treatatent of Fkevaioxia. 

Dr. II. WroGiNS (Worthing) writes to reoommeiid a lino.of treat- 
ment for nncimioiiin wliioli was mentioned in the Britisr 
Mkoical JoVusMj some fifteen years ago. Since emidoying it 
ho cannot recall liaviug lost a single case. The presoripition is 
as follows: 


I) Creosote - * oss 

rot. 31 

Sp. vint root oil 

Ext. glm nb. hit Sib 

Ac si l\-J 

Big. ; Half an ounce to bo taken every four lionrs in water. 

Between each dose he ndmiuisters a saliue mixture containing 
Honor nmmouii acetatis, spiritus aotlieris nitrosi, compound 
tincture of camphor, syrup of toln, and spirit of chloroform. 
In addition bo always prescribes 10 grains ot'the coniponnd 

->> 1 — -"d in most cases uses local 

'poultices. He starts the 
. riioscd, believing that the 

earner me o e speedier the recovety. 


BETTERS. NOTES. ETC. 


New PsvciioTnERArv ik Stagf.i.and. 

A VERY amnsilig piece by a medical playwriglit. Dr. Harold 
Dearden, is now having a considerable success in London at the 
Ambassador’s Theatre. “Two White Arms ’’ is described on 
■■■ ' ' 'I"' 2 , bnt beneath its farcical 

. ' 2ct n current of wholesome 

well-to-do people sufforing 
■ "1 conijdoto lack ot intelli- 

gence,” who want tlieir doctors to make themselves and their 
ailments interesting, and against astute practitiouers ot the 
“ new psychology,” who treat such patients according to thoir 
folly and their means. It is evident that tiie autiior knows botli 
these types well at first hand, and there is probably less exaggera- 
tion abont his character. Dr. Kissaclt Bergherst, than many 
audiences might suppose. Tlie actions and reactions between 
this oyiiioal worldling and his clients should give the medical 
playgoer much laughter and some food for thouglit. Who will 
deny nowadays that there Is a moral for legitimate meiliciiio in 
the success ot the qualified quack? Bergherst, witli all his 
humbug aud greed, has learnt the art ot raaliiug liis treatment 
attriactive. He is a rogue, but a genial rogue wlio knows Iiow 
to handle meu and women ; and fas cst et aU hoHe doceri. 


Treatment op Secondary Anaemia by Liver. 

DR. G. 'WlixETT (Keynsham, Bristol) reports a case of tiie 
successful treatment by liver of anaemia secondary to cliroiiic 
colitis. A woman, aged 62, who was extremely blanched and 
dyspnoeic, was fed with 1/2 Ib. ot lightly cooked liver daily for 
eight weeks, during which period she gained 19S Ib. in weight, 
and her red cell count was restored to the normal. Arsenic was 
tried, but could not be tolerated, and, in view of the success 
foilowini' the use ot liver, no other treatment was atteranted. 
The patient has now fully recovered her health. 


Treatment op Morphinism. 

DR. Stanford Park (Paignton), replying to Dr. Langiiton Soott’s 
reonest for any. published metliod of treatment of drug cases 
which does not involve suffering (Journal. Januaty 7th, p. 34), 
refers him to an article in the November, 1927, issue of the 
Practitioner. Dr. Park adds that sneh patients find it very 
difacult, and at times impossible, to adjnst themselves to tlie 
changed conditions when the morphine is stopped, and the more 
quickly this is effected the greater is the mental auguisb and the 
more likely a relapse. The permanency of the cure is ueterznined 
very largely by the thoroughness of the after-treatment. 


EAirHYSBAU AND WIND INSTRUMENTS. 

TIP F 1) Julian (Liverpool) raises the question whether the 
ailpdcd relation between emphysema and the playing of wind 
i..lrtrnnieiils, to bo found in textbooks, is correct. Two experi- 
,^p,l nlavers of wind instrnments Jiave assured him that this 
^ -Hen 1 ms verv bcueUcial effects, slid one of them, wlio had 
been a violinist lor fifteen years before taking to the clarionet, 
Srod that Ids health, which bad always been iinsatisfactory 
the violin playing period, had improved remarkably wlien 
im adSnted the wind instrument. Dr- Julian remarks that in 
pvnrv wind iustrnment the obstruction of expiration is so 
"imm that the iierformer finds himself short of breath towards 
n S end of a long innaical passage. The oboe provides au excop- 
fion fig mouthpiece being so narrow that the performer has to 

finn, 113 1 1 surplus air subsequently being 

■ long musical passage. He adds 
*1 of ((inssblowers aiso out against great resistance, but, 

• odditioii have the knack of iuapiring tlirongli the nose while 
rnmvi 1 " throiigh tlie mouth; this trick, while adding to their 
Kcuov increases the iutra-alveolar ^ tension. In one case 

fcno“ D- ■ ' ■ ■ ■ lone 

,ivind instrnroeiit. ledtlmtot 

passages could W olarionet- 

Ti',TlnuL'e 3 t He invites the views ot medical practitioners 
pxneri’enoe in this matter, aud asks also whether tliere is 
"'‘ onidonce of functional nervous complaints being nmisnally 
in violinists, in view of the vibrations conveyed from 
fhp mstruinent tliroiigh the lower jaw. HI liealth is said to have 
been caused by such vibrations in the case of saxophone players. 

Correction. 

An ARNOLD Renshaw calls attention loan error in the ropoi't°f 
tetamiB published in the Journal of February 4tli 
? '^1761 The antiseptic used was glanramine (n solution of 
anraniiuo in glycerin aud spirit) and not chloramine ns printed. 

Vacancies. 

rnTTricATioNS of offices vacant in universities, medical colleges, 
of vacant resident and other appointments at hospitals, 
wHlbcfS^pages 45,46,47, 48,49,52and53of onr 
S»IamDs,aDd advertisements as to partnerships, assistantships, 

and locumtenencies at pages 50 and 51. advertisemeii^ 

A short summary of vacant posts notified in the ad\ ertise 
columns appears in the Supplement at page 


[ TcK BnmsH 
MrDioix. Jousxu 


Feb. i8 , 192 


-;■] ■ 

8 ] 


.. ■ -''.i v- 

THE HUNTERIAN ORATION. 


245 


®lji lijuntmnn Oration 

ON 

THE PKOGEESS OF STJKGERY FROM 
HUNTER’S DAT TO OURS. 

Deliveued iiEroiir. the Rovai, Coixioe of Sui;«eon6 
OF Enoland ox EF.riitUAnY 14 tii, 1£28, 
nv 

Sir HOLBURT WARING, iM.S., E.R.C.S., 

SL'nCEO.X TO ST. •BARTIIOLOSir.W’S HOSPITAL. 


To-dat, 3ti-. Prcsiileut aiul Gpiitlomen, wc cclobrato tlip 
two liundrcdth aimivcrsiuy of tlie birth of .John Hunter, 
tlie founder of modern scientific surgery, the creator of 
our jMuseum, aud tlio ])atron saint of our College. Since 
1814 an oration — the Hunterian Oration — lias been gii’en, 
at first annually and tbcn, after 1855, biennially, in tins 
College in bis mcnfoi'j’. A largo proportion of tbcse 
orations have dealt with one or more of the numerous 
brandies of Hunter’s activities; in fact, it bas alrrays 
seemed, to me tliat'tberc is scarcely any part of the rvork 
of Huiiter wliicb bas not been commemorated in one way 
or another at one of these or.ations. ' • 


On examining the conditions as gir’cn in tin' trust deed 
which created this oration it is' stated that “ the Oration 
is to be delivered in the theatre of this College on the 
14th Fcbrnaiw, and such Oration is to be e.xpressivc of 
the merits ■ in Comparative Anatomy, PliAsiology, and 
Siiigery, not only of John Hunter, but also of such persons 
who have become deceased, whoso labours have contributed 
to the iinproyemcnt and extension of surgical knowledge.” 

The provisions of the trust creating this oration being 
so wide 1 have thought it advisable on this occasion — the 
bicentenary of the birth of John Hunter — to devote the 
time allotted to me for the purpose in giving a short 
review of the progress of surgery since Hunter's day to 
ours, in the course of which 1 propose to make reference 
to a few of the most distinguished scientific investigators, 
the results of Avhose Avork liai'e proved to be of the greatest 
lalue to the science and practice of surgery. 

Hunter has been regarded, quite rightly', both in this 
couiitn- and to a lessor extent in foreign countries, as 
the practical founder of modern scientific surgerv. After 
his earliest surgical days (1760-70) he formurated the 
n ea that it was absoliitolv essential for a practising 
surgeoii-who wished to practise his art with the greatest 
prospect of success and benefit to his patients-to have 
.0 Aciy cose and detailed knowledge of the structure and 

unctions of man in health ; that he should also be familiar 
the changes which take place 
(l!. .. onset, course, and deA'clo|imcnt of any 

tliTT " V^'iU °^"od upon to treat; and furthermore 
l-nowledtro +1 ^ compreliensiA’e and detailed 

ticsrc■^ nf processes w'hich take place in the 

disenso eti 1 'luring the period of rccovei-y from 

From thpc r U .Poi'formance of a surgical operation. 
Uiat a dnidP wT'" HunteT fully realized 

the unthnlnirip 'oroughly comprehensive knowledge of 
nrowtlf is f 1.0 occurring in inflammatioi. and 

Ji.tlfcol ra'gor “tiSXu,' t* •>< 

folIowiiiL'- Ho fii- ^ fiiiv subject was the 

minute striictnres'ofai^orgairo tl'o detiiils and 

gated its functions. In makhU +I 

not hesitate to conma re tT investigations he did 

animals with those of man ^‘'iirtures and functions of 
structural and functinimr «=)ving jnade this extended 

and reviewed tl.TTi^X a“d“Tr'"" 

After he had done this he conclusions, 

gated the structure and func 
living bodies in connexio i^^. * 1 ? 

result of disease Tl.:. ■ , o“sot, course, and 

tioii in noiS ^oni Uonr"foir''‘:5' U 

tlio structure and funcUon considerat.pn of 


sui'gei'y a real science. He for one thoroughly understood 
that in order fully to coinprehend the n.ature of a disease 
of an' organ it is absolutely essential to be familiar with 
the structure and functions of such an organ under healthy 
conditions. 

In connexion w'ith the ideas which were formulated bv 
Huiiter concerning the ])ractice of surgery it is verv 
interesting to read his jiliysiblogical w'orks and his siiecnla- 
tioils on the “ basis of life.” The condition of physiology 
ill Hunter’s student days was very little advanced. Hunter 
himself appears to have derived a considerable portion of 
his knowledge of physiological processes occurring in man 
from his direct observation of similar processes occurring 
in animals and even in plants, in addition to the modifica- 
tions', which he observed in man during the treatment of 
his patients. 

Hunter, like every .true physiologist, instead of trying 
to theorize as to what was the exact chemical or physical 
basis of life, investigated all the signs and conditions 
under which life shows itself, and also dissected where 
possible, or examined in minute detail, all structures which 
showed signs of life. By these means he was able to formu- 
late within his own mind what he himself understood by 
life, or “ the vital principle,” or whatever the condition 
may be called. Hunier bclicied that “ life existed in 
CA'cry part of the animal body,” and this life, or “ vital 
principle ” as he called it, iiiade every part of the animal 
body susceptible to tbc impressions which excite action. 

Since Hunter’s day every advance in our knowledge of 
chemistry and physics has been used in attempting to 
explain the onset and course of disease, aud the actual 
biochemical and biophysical processes which occur in living 
matter or matter endowed with the characteristics of life. 
So far, however, these researches have given us more 
enlightened ideas of the chemical and physical conditions 
under which “ life ” may exist and may be destroyed, 
but no ultimate chemical or physical explanation has been 
discovered of the tnie or ri>al chemical or piiystcal basis 
of life. 

I.MJIUXITY AND PRF.VFJs'TION OF DISEASE. 

The first subject which I ivish to discuss as being of 
sujireme importance in the progress of surgery is what 
is now called immunity and prevention of disease. 

During the period of Hunter’s life (1728-1793) little 
or nothing was suspected or known of what we now 
describe as immunity. Edward Jenner (1749-1823), an 
intimate friend and pupil of Hunter, ivas tlie first medical 
practitioner in this country to appreciate the great value 
of inoculation against disease. He noticed in his practice 
that milkmaids ' who had contracted cow-pox from the 
uddei'S of ■ cattle when milking did not take small-pox. 
According to Baron, in his Life of Dr. Jenner, the first 
inoculation was jierformed by Jenner upon a couuti'y boy 
aged 81 years (named James Phipps), in May,. 1796. He 
inoculated the boy with the matter obtained from I'esicles 
upon the skin of a milkmaid suffering from cow'-pox. 
Almost two years later, in a similar manner, ho inoculated 
his own son along with several other children. As a result 
of these’ ini-estigations inoculation of children with the 
exudation from the vesicles of persons suffering from cow- 
pox was used as a protection against the jiossible subsequent 
development of small-pox. 

,A.s we all now know', laity and otherw'i.se, tlie rai-agcs of 
small-pqx liai-e practicallv been set aside in tbis country 
by the systematic practice of vaccination. It is A-ery rare 
■ nowadays in England to meet with anyone who has features 
disfigured AA'ith pits, the result of previous small-pox. 


Biochejiistry. 

The discoA'eries in biochemisti'A', such as those of A'on 
Beliriiig.(1854-1917), Koch (1843-1910), Ehrlicli (1854-1915), 
ami AVassermaiin (1866—1925), have given iis verA* A’aluahlo 
means both of diagnosis and treatment. 

Diphtheria Antitoxin. — Von Behring, in 1890, discoA-ered 
the antitoxin of diphtheria, and found that by injecting 
this antitoxin into patients affected with the disease 
dijihthei'ia could be controlled aud rendered practically 
innocuous. Up to that time a considerable proportion 
of patients suffering from dipbtheria died from one con- 
dition or another, a large number of them having to be 

[3502] 



246 Feb. i8, 1928] 


PROGRESS OF SURGERT SINCE HUNTER'S DAT. ‘ 


L UEQIClL Jocsvii 


submitted to trncliootomy on account of Iniyngcal obstruc- 
tion duo to diphtlicritie membrnno.' In England, at tbo 
present day, owing to tbo general uso of von Behring’s 
diphtheria antitoxin, it is extremely rare to seo a patient 
/sulToring from diphtheria in whom .tracheotomy is ncccs- 
saiy. At St. Bartholomew’s Hospital, in my student d.ays, 
tracheotomy for tracheal obstruction duo to diphtheria 
■w.as a very common operation. Kowadays it is practically 
never scon. In 1890 the number of patients treated in 
this way was 47, and in 1SZ7 there was none. 

Aniitctanic Scriun . — Antitolanic scrum, which was dis- 
covered by von Behring and Kitasato in 1892, was used 
extensively in tho prevention and treatment of tetanus 
during tho great war. Tiic soil of the low-lying lunh of 
Flanders is said to bo almost always infected with tho 
bacillus of tetanus (discovered by Nicolaior in 1884); hcnco 
gunshot wounds sustained by soldiers in this area were 
prone to become infected with tho organism, which caused 
an attack of tetanus. It has been stated that tho death 
rate among inoculated soldiers suffering from tetanus during 
tho great war was 23 ])or cent, as compared with 53.5 per 
cent, in those who had not received preventivo treatment. 

Other diseases which have been treated successfidly, either 
by prevention or euro, in a similar biochemical manner, aro 
hydrophobia, typhoid, and anthrax. 

Many attempts havo been made to render patients 
immune from streptococcus infection by tho injection of 
vaccines, etc. At the present time, however, it does not 
appear that any certain remedial measure, biochemical or 
otherwise, apart from surgical asepsis, has been found 
which can bo relied upon for absolutely preventing tho 
occasional occurrence of a streptococcal or staphylococcal 
infection after an operation. Some success has bc>en claimed 
for tho uso of an nntistreptococcal serum in cennoxion with 
possible infection by tho streptococcus, but tho exact value 
of this is not clear at i)irsent. Certainly, in my experience, 
there is no streptococ< al antitoxin or serum which can bo 
injected into a patient and bo absolutely relied upon to 
pi-event or euro infection nith* virulent pathogenic strepto- 
cocci. 

Insulin . — Tho biochemical researches of Banting and 
Best of Toronto in 1921 and subsequently led to their 
discovery in, and isolation from, tho pancreas of a sub- 
stance which was named “ insulin.” Tho administration 
of this substance .so improved the metabolism of carbo- 
hydrate material by diabetic patients that in many cases 
operations which previously had been thought inadvisable 
and dangerous havo been rendered possible, and tho lives 
of a largo number of patients very considerably prolonged. 
Best has recently stated that, in his opinion, the lives of 
about 200,000 diabetic patients havo been temporarily 
saved by the use of insulin. 

Geneual Anaesthesia. 

Another most important epoch in tho progress of surgery 
was tho discovery of general and local anaesthesia. 
Although a certain amount of anaesthesia — usually induced 
by inhalation or taking internally of narcotic substances 
such as mandragora, hyoscyamus, certain types of hemp, 
opium, etc. — had been practised during surgical operations 
in early days, in Hunter’s time this method of alleviation 
or diminution of pain seems to havo been practically en- 
tirely forgotten, and to have gone out of use. 

As I have already said, every discovery of importance 
in chemistry and physics which has been mado since 
Hunter’s day can truthfully be said to havo beon 
utilized sooner or later by application to surgical dia- 
gnosis and treatment. Thus tbo discovery of hydrogen in 
1766 by Cavendish, of nitrogen in 1772 by Rutherford, and 
of oxygen and nitrous oxide gas in 1774 by Priestley, wero 
the real beginnings of the application of chemic.al sub- 
stances for tho production of anaesthesia in surgical 
operations. Nitrous oxide gas appears to have been made 
use of first as an anaesthetic for tbo diminution of pain 
in tho extraction of teeth. It is stated that Humphry 
X>avy, about 1800, had used this gas for the alleviation of 
pain due to a diseased tooth. He afterwards stated, as a 
result of this experience, that " nitrous oxide seems capable 
of destroying pain. It may be used in surgical operations 
where there is no gieat effusion of blood.”. Unfortunately 


tins suggestion of Davy’s was not mado uso of by surgeoasy 
and it n as not until almost fifty yc.ars later that the valua^ 
aiul USO of nitrous oxido gas for tho induction of anaes- 
thesia wore appreciated and understood. 

ITaraday, another cliomist, seems to havo been one of tlio 
1 anaesthetic properties of ether. In 

lolo ho pointed out that “ when tho vapour of ether is 
mixed uitJi common air and inhaled tho effects aro similar 
to thoso caused by tlio inJialation of nitrous oxide/* 

From tliis^ period onwards a number of observers mado 
uso of tho inhalation of gases to diminish pain during 
surgical procedures. Henry Hill Hickman— a young man 
who bccamo n meraher of this College in 1820, and prac- 
tised in Ludlow, Shropshire, from 1820 to 1828— mado 
o.\-pcrimcnts, in tho autumn of 1820, on tbo possible anaes- 
tlictization of animals, at first with carbonic acid and 
then with nitrous oxido. His proposals concerning the uso 
of nitrous oxide gas for tho production of anaesthesia and 
its utiliz,Ttion in connexion with surgery wero received 
very sceptically and generally condemned by tho surgical 
profession in Ibis country. So much so that be com- 
municated with tbo King of Franco asking that an inquiry 
bo macio by tho physicians and surgeons of that country 
ns regards tho value and correctness of his experiments. 
This communication was sent to tho Academio Royalo da 
Medccino do Paris, which body appointed a committee to 
ini'ostignto tho matter. Nothing, however, came of this, 
although Hickman requested that ho might bo .allowed to 
demonstrate tho result of bis experiments to the Paris 
Academy. Unfortunately, this young and enterprising 
surgeon died from tuberculosis tho following year at tho 
ago of 29. 

Crawford Long, a medical practitioner in Georgia, 
appears to havo been tbo first American surgeon to mako 
uso of other in tho production of anaestbesia during tho 
porformaiico of a surgical operation. On March 30th, 1842, 
lio gave other to a patient for the removal of a tumour 
from tho nock. This caso being so successful. Long con- 
tinued to mako uso of ether for surgical oncrations, and 
norfonned eight such operations between 1842 and 1845. 
Long although ho mado no secret of his discovei-y, did not 
nublisli tho fact to tho world, and it was not until others 
bad mado a similar discoveiy that his experience bccamo 
generally known. Two years later, in 1844, Wells, a dentist 
in Hartford, Conn., made use .f anaesthesia bv nitrons 
oxide" for tbo extraction of teeth. Although Wells bad 
attempted to produce .anaesthesia with ether, ho bad not 
beon .ablo to continuo to do so, owing to the difficulties and 
elmkine sensations which woro produced. jMorton, however, 
who bad been a pupil of Wells, was familiar with tbo 
nropcrtics of ether, and independently discovered its 
anaesthetic qualities four years after tliq discovery by 
1 nnu Apparently the first public exhibition of surgery 
w'tliout pain was given in Mass.achusetts General Hospital 
in October 1846, when a patient was oper.atcd upon by 
Warren for removal of a vascular tumour of the neck, 
after being anaesthetized with sulphuric ether. 

Ether was first used in England for tho induction of 
o-eneral anaesthesia during the perforffianco of an oper.a- 
tmn /removal of a tooth) in December, 1846, and two days 
1 t r' ether was administered to patients at University 
rollcvo Hospital by Squire for Liston, who amputated the 
lower“extremitv through the thigh in one patient, and also 
it, -mother removed an ingrowing toenail. , 

Purin" the following year (1847) Simpson of Edinburgh 
pflmr in obstetric practice, and found that the pains 
''t I hniir could bo abolished thereby, whilst the iiterino 
° vSn^ were not interfered w-itb. The next year 
nnam Simpson, who was somewhat dissatisfied with the 
(1848) Simpsorn irritation which it pro- 

in the lungs and bronchial passages, first made use 
Ini-oform This substance was discovered at about the 
simt too b"two investigators-by Sonbeiran in 1831, and 
bv Liebi"- in 1832; its composition was first accuiately 
dLcribed^by Dumas in 1835. 

lince tbfs period (1847-48) . ^Woroform nitrous 

oxide in many and various combinations, and otliei su 
stanch ha^bLn used for the induction of ^Vgical.anaes- 
tbesia. Recently a most important combination winch 
been, mado use of is that of nitrous oxide, oxygen, and 


Feb. jS, 


PFOGEESS’ OF StrRGER'S: SINCE ITONTER’S DA.Y. 


[ Tnr CR ii ' t'-i i 
SrcWCAL JOURVAI. 


247 


Email amount of other or chloroform. This combina- 
tion is especially useful and safo when admimstcrcd by 
tho intratracheal method. 

Local AN’ALSTirnsiA. 

CocfiiTic — Cocaine as an nlUaloid Teas first isolated, 
apparontlv bv Godcho, about 1855, and some points as 
regards its power of producing loc.al anaesthesia wero 
noticed. No definite advances wero made, however, until 
1374, when Bennett showed that cocaine, applied to living 
tissues, had tho power of causing local anaesthesia. 
V. Anrep, however, in 1878, appears to have been tho first 
to ■ investigate completely tho anaesthetic properties of 
cocaine by injecting a dilute solution (0.003 to 0.5 per 
cent.) underneath tho skin, and in connexion with this 
•made tho suggestion of its possible vnluo for producing 
anaesthesia for surgical opcr.ations. In tho following year 
(1879) its powers of producing local anaesthesia were 
demonstrated in connexion with tho eye. This use of 
cocaine was worked out in coraploto detail by Karl Koller, 
who showed that complete 
anaesthesia of tho eye could 
be produced by tho use of a 
2 per cent, solution. The re- 
sults of Koller’s experiments 
wore fiist published and dis- 
cussed at an ophthalmolegical 
congress in Heidelberg in 
1884. Since then this drug 
has been used increasingly 
for tho production of anaes- 
thesia in all kinds of surgical 
operations. Some difiiculties 
wero mot with at first in con- 
nexion with poisoning by 
absorption, but these wero 
soon overcome. 

A^ofocain. — Considerable 
progress in tho me.thod of in- 
duction of local anaesthesia 
has been made' since that date 
by the discovery of novocain, 
a synthotio product derived 
from coal-tar (para-amido- 
benzoyl-diethyl-amino-ethenol 
hydrochloride) by Alfred 
Einhorn in 1905. So much 
so that at tho present time 
a considerable number of 
major surgical operations, 
such as removal of tumours 
of the thyroid, gastrostomv 
radical operation for hernia’ 



r 






( 6 ) 



M 

Fio 1 -Cystoscoro with electric lightinc as na^d by David Kewman. 
(u) In rcsilion for introduction. 0, Speculum of hollow vulcanite the 
apex of which, ir, is movalilc by handle I. (Ill In position otter it has 
been Introduced into tlie bladder. K, Speculum, the ape.v of whicli, J, 
has been moved bv tlie handle L ko ns to enable the observer to see 
throucli tho class disc wliich closes the end witliin the bladder, 
(c) Electric lamp and handle which is introduced passed along the 
specuium after introduction. 


1,0 doo “"y major and minor operation, can 

tn + 1 , 0 ^ pmnlessly, and in certain cases with greater safety 
adminlFt* \ "f « dilute solution of novocain, 

Store ne ^ J infiltration method. 

-nin-i ' ' nodier variety of anaesthesia, or analgesia 

of stnvomo"; mduced by the injection of a solution 
This form ^ lower portion of tho spinal theca, 
on the nnrHor,''”? especially used in operations 
prostatMtomv l” t below tho diaphragm, such as 

dLat.^nr^i’ etc., when tl.ore are contra- 

3S;5,rJ, :'4S, 

. in'^ctnnexion wHl“^ discoveries’ and improvements 

is such that aim' f’^’S'oal anaesthesia — general and local — 
c.an now be desirable and justifiable operation 

vorv Elicrhf J tecliniqiio, painlessly and Tritb 

n^ministfaLrof 'f'" to\ho 'pationtf when the 

n-ell trained anaesthetist'"““^''‘'^'''' '' 


Pathologv 
tno publicatii 


and ificnoscopicAD Diag.vosis. 


cellular p.athob:f“„?LR''‘‘-"*’°"-’n (1821-1902) work on 
to Etudv the I?it I ■ ''"n® n great incentive to surgeons 

of suritical divo “ "S'cul basis of a considerable number 

From this perfor a8?Rrr"+i growth. 

(1858) to the present time there has 


been a. continuous advance in our knowledge of the 
pathology of surgical affections, one of the latest, perhaps, 
being the recognition of the different histological charac- 
teristics of malignant growths. This has enabled surgeons 
to bo in a much better position as regards giving a correct 
prognosis after an operation for malignant disease. These 
advances liavo been made possible b}’ the improved con- 
struction of the microscope and the knowledge of the 
reactions of human and other tissues to different varieties 
of dyes and stains. 

Tlio improvements which have boon made in the micro- 
scope since Hunter’s day have been very considerable. 
In Hunter’s time the microscope was an instrument which 
was little more than a simple magnifying lens. 

The principles of the compound microscope were dis- 
covered and developed by many physical observers, one 
of whom was Joseph Jackson Lister, the father of Lord 
Lister, in 1830. The discovery of the principle of tho 
homogoncous immersion lens, followed by great improve- 
ments in the construction of lenses which were called 

apocbromatic, bare made 
possible a large number of 
researches in histology and 
bacteriology. As examples of 
the microscope in use in 
Hunter’s day and of that now 
in use I have bad placed on 
the table two — one a micro- 
scope of 1760, and as used 
by Hunter, and the other 
a modern one. I also show 
yon the microscopes used by 
Pasteur and Lister. 

The first surgeon to utilize 
reflected light in the investi- 
g.ation of deep spaces or 
cavities of the body was 
Bozzini of Frankfurt-am- 
Main, who invented, in 1805, 
n form of urethroscope and 
also other forms of “ scopes.” 
Each consisted of a hollow 
tubo along which light was 
reflected by a mirror. No 
practical results, however, 
emanated from this discovery 
at the time, and its use re- 
mained quiescent apparently 
for a considerable period. 
The next observer to make 
use of reflected light in the 
examination of patients was 
Helmholtz, who invented the 
ophthalmoscope in 1851. His original ophthalmoscope 
was, as regards its success in working, dependent 
upon the reflection and concentration of a source of 
light, usually a candle or a lamp. By its use ophthalmo- 
logy became established on a scientific basis. Soon 
afterwards, in 1855, Manuel Garcia invented the 
larj-ngoscope, which was used by Torek of Vienna; then 
followed the rhinoscopo, discovered by Johann Czermak in 
1859. Nitze and Leiter made the most rapid advances in 
the utilization of reflected light for interior investigation 
of the body by combining the principles of the telescope 
and reflected light, and the production of tho cvstoscopo 
in 1877. 

The value of these instruments for investigation of the 
recesses and cavities of the body was enormously increased 
by the invention of incandescent light. Paul Jabloclikov, 
in 1876, invented the electric' candle; Swan and Stearne 
of England and Edison of America improved upon this 
invention and produced incandescent electric lighting in 
1880. David Newman of Gla.sgow improved the crstoscope 
as designed hv Nitze and Leiter, and in 1883 was tho first 
to make use 'of incandescent light in connexion with it. 
With this instrument (Fig. 1) it berame easily possible for 
the practised manipulator to investigate and diagnose the 
various conditions affecting tlie urinary bladder. Tho 
hirvngoscope was also further developed and improved, 
and tho diagnosis of surgical affections of the interior 



248 Feb. i8, 1928] 


PROCnESS OF SURGERY SINCE HUNTER’S D^Vy.- 


r TheKritiSH 
L jIkdical JotTOtit 


of tiio iniTiix «!is iiiiidc |)(i!,.siMo iti (lioii- o.-irly .sfagt's. 
Ollier foi'iiiH (if “ K(i)])cs ” for llie iiivcsligntidii of tlii> 
interior of tlic body wliioli nijiidly follnwod the earlier 
di'cnverif's were tlio .signinidnseopo by Rodeidiamcr in 1863( 
alterwnrds perfected by Kelly of iialtiniore and Slranss 
of Berlin; tlie oi'sopbago'-copo by ICiis-snianl in 1869, ns well 
as the iir.st gastrcscope during the .same year (later per- 
foeled by Jfikniiez in 1881); and the broncboscope b\- 
Gnstav Killian in 1898. 

The latest application of tbe combination of the tolo.scope 
and electric light for clinical and diagnostic piii-jmses is 
the thoracoscope. 2 V similar 
lint much larger instrnmont 
is used for inve.stigation of the 
interior of the .stomach. Tlio 
Iiractical value of tbe gastro- 
scope, however, in diagnosis is 
somewhat ])roblomaticnl, owing 
to tbe difficnlty of correctly 
interpreting the conditions 
seen tbrongb it, and the fact 
that it cannot be used readily 
and with advantage when a 
patient has been anaesthetized. 

One ONample of the applica- 
tion of improved mechanical 
methods to surgery was the 
invention of tlio lithotrito 
and vesical ovaenntor by 
Bigelow in 1878. With this 
snccessfnlly treated and cured 
bladder without any cutting operation. Since Bigelow’s 
day the instrument has been considerably improved 
in' detail, including the addition of an electric light 
attachment, though the essentials are absolutely the 
same. Export operators can obtain excellent results by 
this metliod. In iiot and tropical countries such as 
Egvpt and India, where stone is prevalent and the 
natives are not readily amenable to the discipline, aseptic 
and otherwise, necessary for a successful surgical opera- 
tion, this method in the hands of the skilled operator 
has enormous advantages. 


for me to say that the ..ractice of asepsis and antisepsis 
11 .suigi(,.d (ipei'ation.s, has enabled surgeon.s to submit to 
opoiiition luth .succcis every organ and almost every aart 

of the human bodv. Tbe sorer,.,. eC +i.„ „i..i t * 

fir.st 


. organ and almost every aai.t 
body. ■ The surgery of the abdomen was 
perlectec , es|,ecially by von Billroth of Vienna, 


connexion witii gastio-iiitestinni oiieratioiis, and by Spencer 


Tait as regards operations upon tlio 
an tubes; then that of the 
and moro lately tliat of tlio 



Fjg. 2.^AniputaUons as pcifonncd in the dj\s of Hunter. 




Antisepsis .snd Aski’.si.s, 

Tho next avenue of progress 
in surgery is that branch of 
biology and bioehemistry which 
wo call bacteriology. Hunter, 
of course, was ignorant of 
bacteriology, since bacteria 
liad not been discovered in bis 
day', ft is of interest to note 
that in bis surgical lectures 
given in 1785 bo states, in 
connexion witli fermentation : 

“ Fermentation appears to be 
a jirocess peculiar to dead 
vegetable or animal matter, 
and when we find a tendency 
to fermentation we may con- 
chule that there is a defect of 
the living principle.” The 
modern science of bacteriology 
and its possible application to 
surgery really commenced in 1857, when Pasteur published 
bis paper on lactic fermentation, and subsequently his paiier 
on tlie iiinueiico of oxygt'ii on the development of yeast and 
on alcoholic fermentation, in 1861. 

The adoption by Bister of liis antiseptic doctrine in 
connexion with surgery in 1867, which really followed the 
work of Pasteur, was the commencement of what jimy 
he known as advanced surgery on a scientific basis. The 
ooncral acceptance of Lister’s doctrine and its application 
to luactical surgery was slow in this country. Hoa'ever, 
ill the late eighties and early nineties its practice became 
general, and 11 ms qiiicklv followed by the aseptic doctrine. 
The practice of iiiodorir surgery is really based on a com- 
bination of antisepsis and asepsis, principally .the latter, 
-til the points, however, on tlio subject of Lister were 
discussrd by last year’s Hunterian orator. It is siitScient 


M oils and Lawson 

ovaries, iitern.s, . and Fnllopiair tubc.s;' then tiiat‘ of tiie 

brain and crainai coiitoiils ' ' ■ ■ • - . 

thorax and its contents. 

•file net result of tlio practice of asepsis in operations is 
that infection of and suppura- 
tion in opoiation wounds is 
ahiio.st non-existent in most 
modern hospitals, and the 
mortality, fi.om sin’gical opera- 
tion has been very greatly 
reduced. 

Tii.insfusiox of Blood and its 
. Aim'UCstio.v to SuiiCEIlY. 

'rransfnsion of blood, either 
directly from one individual 
to another or indirectly, was 
fir.st practised, apparently, 011 
animals by Lower in 1655, and 
on man by Denys of Paris in 
1667. No definite progre.ss 
wa.s made, however, in tho 
instrument patients wore I application of this procedure to surgery until the latter 
of stono in tho urinary I part of tho ninetoonth and tho beginning of the twentieth 
I century. 

I Eisonberg, in 1901, discovered that the blood scrnni of 
j both diseased and normal iiidividiuils, when injected into 
another imlividiial of the sniiio race, was liable to liaenin- 
I lyse the blood of the receptor. /Vfter this discovery Jansky, 

! in 1907, divided tho Wood of human beings into four 
; groups, and in 1910 JIoss repeated this investigation and 
I graded individuals according to the character of tlieir 
I blood into four groups. 

' Furtlicr, the advances iiiado possible by our knowledge 

of biochemistry and. bacterio- 
logy have enabled tho indirect 
method of transfusion of blond 
to be very much perfected. So 
much so that at tho present 
time it is quite an easy matter 
for a person who has mastered 
tho tcchiiiquo to obtain blood 
from a suitable selected donor, 
keep it sterile and iincoagn- 
lated by the sodium citrate 
method, and to inject it imme- 
diately into tlio blood vessels 
of tbe recipient. These pni- 
cediiros are now in quite con- 
stant use in bosiiitals .ind 
surgical practice in certain 
tyqies of serious injury or 
disease, especially when a large 
amount of blood lias been lost 
by tlio patient, and have 
proved of great advantage 
111 enabling operations to be 
patients saved thereby wliich 



Fig. 3. — ^Amputation at shoulder-joint, as performed in 1820 after 
introduction of the straight atoinnatioa itmfe. 

done, and the lives of 
' . 1.1 1 1 .., 


otlierivise ivoiild hai e been lost. 

RADIOLOr.Y. 

-Another " milestone ” in the progress of surgery between 
Hniitev’s daj' and onrs is marked by the successive dis- 
coveries of s i-nys and radium. 

Tho discovery of x rays by Wilhelm Roentgen ( 184 a-ladO), 
professor at Wiiizburg, in 1895 was tho commenceinent or 
a series of great advances in surgical diagnosis. -At first 
tbe use of x rays in this direction was mainly coiifinca t” 
injuries to and diseases of the bones. When, however, tiic 
possibilities of this discovery were moro appreciated am 
nuderstood it was found possible to extend the clinicin mn 
of X rays in diagnosis to other conditions. Thus, ns 
the internal organs and viscera, especially portions of 1 1 ■ 





Peb. iS, 1928] 


PEOGKESB ■'^Or' 'STJRGERT SINCE HUNTER’S' EAT. 


t TrrrBsms* 94.Q 

aicDicAi. Joraxi* ^30 



aVim'ontary canal, the oxistonco of diseased conditions Tas 
readily demonstrated by the taking of a skiagram of tho 
diseased, or presumed diseased, region and organ, after 
the administration by the mouth or tho rectum of barium 
sulphate or bismuth nitrate. Thus, the diagnosis of ulcers 
and neoplastic growths of tho stomach and duodenum, 
narrowings in different portions of tho alimentai-y canal, 
such as occur in carcinoma of the oesophagus, or car- 
cinoma of different portions of 
the alimentary canal, especially 
the lower portion of tho largo 
intestine above tho rectum, 'Was 
made possible. Tho determina- 
tion of tho position of_ deep- 
seated fistulous conditions 
between the viscera has also 
been made possible. 

Tho value of x rays in con- 
nexion with tho diagnosis and 
treatment of disease has in 
many cases, and especially by the 
laity, been much exaggerated. 

To tho practising clinician 
X rays, when intclligentlj' and 
scientifically used, can, as wo 
nil know, be of enormous advan- 
tage. They are of great value 
in the detection and localization 

of different forms of calculi, ^„tienflias been 

especially those in the ureters epray Is bein- used, 
and kidney. One of the later 

developments of the use of x rays in diapiosis is tho investi- 
gation of the ureters and pelvis of the kidney by what are 
known as “ ureterography " and “ pyelography.” By these 
means of investigation many obscure cases of disease in tho 
kidneys and ureters have been diagnosed satisfactorily, and 
subsequently operated upon with great prospects of turo. 

' Calculi in the gall bladder for a long time evaded tho 
attempts of the x-ray practitioners definitely to detect 
them. Occasionally when suspected they could bo demon- 
strated on an x-ray plate or film, but often no evidence was 
apparent, although 
the clinical signs and 
symptoms pointed to 
their presence, and 
at operation they were 
found. Improved 
x-ray machinery and 
the intravenous in- 
jection of tetraiodo- 
phcnolphthaloin or 
tetrabromophenol- 
phthalein, and its ex- 
cretion by the liver, 
at the present time, 
however, usually en- 
able definite evidence 
to bo found of the 
presence of chole- 
, cystitis and calculi in 
(these cases. As everj-- 
ona knows, a patient 
I IS much more ready to 
submit to au opera- 
tion for removal of 
u calculus in the 
ureters, kidnevs, 
urinary bladder, 


blende derived from mines in Joachimstal in Bohemia (now 
Czechoslovakia). The salts of this metal were found to possess 
very marked radio-active qualities, and have been used, espe- 
cially of recent years, in the treatment of various diseases, 
and particularly in forms of new growth. Tliere is no doubt 
that certain typos of sarcoma and carcinoma are very sensi- 
tive to tho action of radium, and a number of patients 
have apparently been cured by the use of the salts of 
this metal. Radium has been 
applied in various ways, but 
in the treatment of disease the 
best results have been obtained 
by the implantation of cither 
radium needles or radium seeds 
in the margins of diseased 
tissues. As in the case of x rays, 
tho exact value of radium in the 
treatment of malignant disease 
cannot yet be determined. Un- 
fortunately, a large supply of 
radium is very expensive and 
difficult to obtain. The indica- 
tions, however, appear to be 
that if an increased quantity 
of radium or its salts can he 
obtained and made available for 
clinical use, then considerably 
improved results in the treat- 









I’iU. 5— An buiiij 

P/'*^scnce can be sbomi on an x-ray film 
X nvc! assumed. In a similar manner 

in +bn 'r. ° detecting the presence of stone 

duct or deep-seated calculi in the sub- 

Inrrpni;!? 1 recent great war x-ray diagnosis was 
of detection and localization 

TMPfnii; 1 aones and the presence of bullets and other 

.'vounid Boldtem"^ 

b discovery of x r.ays by Roentgen, Monsieur 

had Madame Cune, in 1898, discovered radium in pitch- 


Fig. 4 .-Operation ns pcrlormcd G^'^jLislenDn disease may 

be made possible. 

CnANTAL Axn Spinal Surgeet. 

In connexion with the surgery of the cranium and its 
contents Broca’s investigations into the localization of 
function, and especially his localization of the centre of 
articulate speech in tho left frontal convolution, enabled 
him to perform the first fixed operation for cerebral abscess, 
which was assisted by localization of function in connexion 
with “ motor aphasia,” in 1861 ; since then numerous 
researches into tho localization of cerebral functions have 
enabled neurologists and neuro-pathologists to determine 
• the site of a large 

number of intra- 
cranial growths. 

Quite a consider- 
able proportion of the 
advances in cerebral 
and spinal surgery 
has been due to two 
Fellows of this College 
— Victor Horsley 
(1857-1916) and 
William Macewen 
(1848-1924), now de- 
ceased. 

Recently much 
assistance has been 
obtained in tho exact 
localization of a 
tumour within the 
spinal canal by the in- 
jection of lipiodol into 
the spinal canal and 
subsequent examina- 
tion with X rays. The 
lipiodol shows as an 
pi-ifuiK.ciI ul the prL tat day. opaque shadow on a‘n 

x-i-ay plate; conse- 
quently any narrowing or encroachment upon the intraspinal 
space by a tumour becomes evident. Similarly injection of 
lipiodol into the trachea, bronchi, and lungs has enabled 
the clinician, on subsequent examination by x rays, to 
demonstrate positively on plate or film the extent and nature 
of abnormal intrathoracic conditions. 







Specializ.ation in SunoEnr. 

The numerous methods — chemical and physical — available 
to the clinician and tho pathologist for the investigation 
of patients suffering from surgical affections are so varied 
that at tho present time it is not usually possible for on* 



.260 Fj2b. i8, i()?S) 


FBOGRESS OF.SDRGERF SINCE. HUNTER’S DAY. 


ff Tn? 


LMturcn. JccJiTit 


iliiignosticimi to. nmlto nil (lio invns(ig;i(i'o!is wliicli aro 
nocvssnvy in tlio oxnminnlion ol' an individual patient. 
Thus, in tlio practice of sui'geiy in Uio present day, wo 
linve skilled spcciali.'.ts in many brnneli(..Sj siich as liistologv, 
biochemistry, cytology', bacteriology, and radiology; ami 
further, • in tho iiso of sjjccial instruments, such as tho 
laiyngoscope, ophthalmoscope, cystoseopo, sigmoidoscope, 
and bronchoscope. This divi.sion of activities has led to 
tho establishment of specialist practitioners, many of whom 
limit their activities, diagnostic and otherwise, to ono 
particular organ. 

From tho point of view of progress in surgery there is 
no doubt that this .specialization, l)oth in diagnosis and in 
treatment, has been a very considerable advantage. This 
trend to specialization has bccomo so marked that at 
tho present timo there is a tendency for specialist prac- 
titioners to work in tcairs, each ono of a team taking 
specialized portions of cither investigation or treatment. 
In practice this method of examination and treatment 
.has been found especially feasible in connexion with hos- 
pitals to which medical schools aro attached. Tho forma- 
tion of private elinics for tho diagnosis and treatment 
of tho non-charity patient on these lines has not been ca.sy 
in this country. JIany 
developments, however, aro 
now taking place which 
will bo of groat advantago 
to tho successful practice 
of surgei-y in the future. 

Ono great difficulty 
often arises in connexion 
with tho progre.'S of 
surgery as regards its 
practical application. This 
is tho inborn dc.siro of tho 
Engli.shman to havo all 
forms of medical and 
surgical treatment carried 
out in his own house. 

Fortunately public 
opinion is gradually being 
educated on this subject, 
and thoro is an increasing 
tendency among educated 
niombers of the community 
of desiring, when ill, to bo 



by superheated steam, or in some cases dry heat produced 
electrically, in a room adjoining tho operation theatre. 

In connexion with this subject tho accompanying illus- 
trations aro of considcrablo interest, both as regards the 
opeia tion room, operation table, and tho equipment and per- 
sonnel of tho surgeon and his assistants. Fig. 2 is an illus- 
ration of an ojieration being performed in tho days of 
imtcr. Fig. 3 represonts tho arrangements for an opera- 
tion in 1820. Fig. 4 represonts an operation being per- 
foinicd in tho early day.s of Li.sterian practice. In it can ha 
seen the carbolic spray which was used for making the atnio- 
spherc 111 tho region of tho operation aseptic. Fig. 5 ia 
an illiisti atioii of an operation being performed under 
modern aseptic methods. 

-dn illustration of tho progress which has been made 
in ensuring surgical cleanliness and asepsis in an opera- 
tion is given in Fig. 6; hero aro shown tho I.ay-out and 
design of ono of tho newest and most modern surgical 
operation tlicatro units in this country. The main point 
in connexion with this lay-out is tho provision made 
for avoiding tho entrnneo into tho operation theatre 
of any individual or material which has not been 
rendered previously as aseptic as possible. 

The progress of surgery, 
espcciallj’ since the aseptio 
.Hid antiseptic eia, • has 
been greatly ass'sted and 
rendered possible by im- 
provements in the educa- 
tion and training of 
nurses. IVitbout these ini- 
provcmeiits it would be 
almost inipossiblo to per- 
form with success a largo 
number of tbo major 
operations which aro now 
regularly done in the prac- 
tice of surgery. 


Fig. 6. — ’* Laj-ouV ** ol one ol lljc latest desigoed operation theatrea and 
accessory rooms. 


treated in an in.stitution built and equipped for scientific 
investigation and treatment. 

Ikixuejjce op .^sepsis and ..Vntisep.sis on the Consthuction 
OF SCItGICAE HosPITAL.S. 

Tho general adoption in surgical practice of tho prin- 
ciples of asepsis and antisepsis was quickly followed by 
oiiormous iniprovemeiits in tho construction of surgical 
hospitals and operation theatres. In Hunter’s day a small 
room, not specially built to fit it for tho purpose, was 
goneially mado use of as an operation room. This 
practice of using any small and otherwise useless room 
for operations was continued until comparatively recently.- 
In my own student days I well remember, in one of tbo 
largo special hospitals in London, that ‘the residents’ sitting 
room and dining room were also used as tho surgeon’s 
operation and instnimeiit rooms. 

Tlio old method of erection of buildings was ill adapted 
for the practice of asepsis owing to the large number of 
angles, corners, crevices, wall and ceiling decorations, etc., 
which formed collectors of dust, dirt, and associated micro- 
organisms. Since the late eighties of the last century 
enormous advances havo been made in the construction of 
surgical wards and rooms used for surgical patients, and 
also operation theatres. In the earlier days of tbo con- 
struction of the modern operation theatre considerable 
difficulty was experienced by architects and builders in 
providing absolutely smooth surfaces for floors, walls, and 
ceilings, which could be readily cleaned without being 
damaged or destroyed. At the present tune the tendency 
in the construction of surgical operation theatres is to 
tn.nko them as simple as possible, and to b.Tve all tbo 
sterilization of equijiuieut, instruments, etc., carried out 


W.tn Suhgehy. 

Tho groat progiess in 
surgei-y during tho lata 
war was duo to tho utiliza- 
tion, in all aspects, of the 
discoveries in connexion 
with (a) immunity and 
prevention, (b) anaesthesia, (c) asepsis and antisepsis, 
and (il) X rays. Tlio utilization .of these discoveries 
in tho recent great war enabled operations of every 
magiiitudo to be carried out in advanced stations and 
hospitals within a short distance of the firing line. 
Ill addition, tho iniprovoinentS' in transport, motor and 
otherwise, contributed greatly to this progress. I have 
already referred to the preveutivo inoculation against 
tvphoid and tetanus. , , . ,, 

'Anotlicr important practice developed during the wai 
in connexion with tho ticatmeiit of recent contaminated 
wounds tho margins of which were lacerated or contuseiL 
was tho' primary excision of all contamimated and contused 
tissues, follower! by immediate or delayed suture. By tba 
practice of these methods and the advantages of improved 
transport it was found possible during tho war, to treat 
patients at the general military hospitals in London within 
twonty-foiir hours after tho wounds bad been received. In 
,a number of cases of wounds tbo margins of which bad 
been excised the cavity was packed with gauze soaked in 
flavine, or after amputation tho stumps were treated in a 

^"A*furtber improvement in war surgery was the recog- 
nition of the fact that in many cases of suppurating 
wniinds' or badly lacerated limbs in which an amputation 
had to 'be performed, the wounds could be left open and 
treated by the Carrel-Dakin irrigation metliod. free 
exudation and associated irrigation enabled *'>0 
surface to become clean, and delayed 
could be carried out afterwards. As a result of 
ment of wav wounds on improved biochemical and biophpiem 
principles tlio mortality from gunshot wounds and injuries 
was enormously decreased. 




rEB. i8, igsS] 


■ "' TflE'OtllES 'OF STiGGESTlblT’. ' 


f Tn* nRmrt 

L UrmcAi. Joubkal 


COKCLTJSIO:^. 

. From the short account u'hich I hare hecn ahlo to give 
you of the progress of surgery from Hunter’s day to ours, 
‘it will he seen that the actual technique employed in the 
performance of surgical operations, and the results which 
can bo obtained thereby, have reached a very high stage 
of perfection. It docs not appear to ino that we can expect 
in the futui’e such great progress to he made in the details 
of the performanco of operations themselves, and tho 
amelioration of the discomforts directly resulting therefrom. 
In my opinion the main direction of advance of surgeiy 
in the future will be along biochemical and biophysical 
lines, both as regards diagnosis and treatment. If this 
assumption be correct, it is essential that tho medical 
student and the medical practitioner of the futnro should 
pay increased attention to all hiochemical and hiophysical 
problems, both in normal and in diseased conditions. 

Owing to the length of the curriculum and the multi- 
plicity of subjects which the student of medicine of the 
present da}- has to pass through, there is a tendency for 
parts of the curriculum to ho forgotten after the examinO/- 
tion in it has been jmssed. Consoquentlj- the application- 
of physiology in the investigation of disease is too often 
neglected, and a student thereby is encouraged to acquire 
surgical knowledge — especially diagnosis — in a somewhat 
empirical manner. At the present time, however, there is 
a tendency in every modern school of medicine to give 
courses of “ applied physiolog)- . and applied anatomy ” 
during the later' and clinical par t of a student’s career. 


THEORIES OF SUGGESTION.'" 


BY 


WILLIAJ\I BROWN, M.A., M.D.Oson., D.Sc., 

WILDE RBASEIt IN MENTAL PIULOSOPUY IN THE DNIVERSITT OF 
OIIFORD; honorary consulting PSYCnOLOGliT, DETHLEM 
ROYAL aO-PiTAL; PSYCHOTHERAPIST, KING’S COLLIGS 
HOSPITAL, LONDON. 


Thk word suggestion ” lias been used in educational, 
ficientiiic, and medical literature in slightly different senses. 
In the Writings of educationists and purely scientific 
psychologists it has been used to indicate a general kind of 
influence brought to bear on the mind, an influence which 
is other than that of logical or rational argument. The 
mind can be influenced rationally and also irrationally, 
Rationally, it is influenced, far example, when a child is 
taught the fifth proposition of Euclidf, in learning to 
understand the steps one by one in the right sequence and 
III tile right connexion ; but the child can be influenced 
non-ratidnally, in its learning of this and other school 
Eubjcits, by virtue of its general mental attitude towards 
tlie teacher, by the views on life of its fellow students, 
men by the beauty or ugliness of the rooms and buildings 
in uhicli it is taught, by the climate, by the fact of the 
Uoather being fine or dull, and in a hundred other ways, 
Jiiesc are non-rational, although not necessarily irrational, 
n uences. They may not be contrary to reason, but they 
are independent of reason so far as the child individuallV 
Is concoined. Me may regard this class of non-rational 
influence as influence by suggestion. 

the chiW may be misled in his reasoning process 

So ; error. Many of the conditions under 

1 Cl lu a s into error can be put under the same heading 
of suggestion. In a general educational way we may use 
. suggestion in a wide sense Avhicli covers all non- 
J!' ^ irrational modes of influencing the 

i”' I 1*^ mdnuliial may be influenced by inanimate 
objects, by social conditions, or by his fellows, not only 
«nir/tfin;7ty_that is, witliout realii- 
e IS being influenced. The weather mav be 

■n • n fundamental mood may fallow .suit 

without bis being explicitly aware of the fact; tlie influence 

Medinneron^jL'n.m'r^'lCth noral S^ioty of 

tlio honorary editor? of (he Society. “ PohUshed by permission of 

tuI'Suve''Secl^iiBon°Uir”rhi)/l P''‘>P'>'"'t''’n may exert n 

fo"K, VemfefnmeSreJ‘o'.<5’;''‘’^’" “f <"» 'vavs 'aocordinff 

mMc Ueleimiacd nttack. ““"““CPaiimt. or ns n chnUenEe to a 


251 


there is an influence of suggestion. It may be considered 
a rational influence if lie observes in the morniug that tlio 
weather is bad, and infers from it (on the basis cl previous 
experience) that he will have a bad day and will not be 
able to work so effectively as usual. But that view is not 
necessarily a true view; he m.ay he mistaken in it. liven 
if it is a true view, so that the result is rational, it is not 
necessarily the work of reason. 

The word suggestion in pure psychology has been used 
in an even wider sense. In Professor G. F. St.mt's Analytic 
Tsyclioloe/ij there is a chapter headed “ Relative Suggc.s- 
tion,” but what lie is referring to there is the Cu'evt of 
pre-formod ' associations on the activity of tlic mind. 
Certain experiences have been passed through and retained 
in memory, and if one experience is repeated it tends to 
call up the memory of another. One experienie “ suggests ” 
the memory of another experience. Suggestion, then, n.ay 
work according to the rules of association, either of con- 
tiguity or of similarity; that is a very wide use of the term. 
An officer’s gesture may suggest a certain moicment to t’l.e 
platoon ' under his command, and they may spnutancously 
move accordingly without haring received a (Lfinite verbal 
order. Tho response to the command may be regarded as 
due to suggestion. It is not necessarily rational — not a 
form of persuasion, which is the word to use iii speaking 
of the process of influencing a person by rational- means. 
Giving a command or making a request may be. hut is net 
neces-sarily, a rational method of influence. In its essence 
a rational method, it may on some particuhii' oe. a h,ii he 
either rational or non-rational. It should pr.bi'hlv he 
classed under the general heading of suggestion, t.ii.iug tlia 
word in its widest sense. 

From these, uses of the term suggestion — a -iiggcsti.,n 
which involves a non-rational influencing of tiie n.fnd — 
we pass to the more medical side of the su’jji'.-.. [n 
psychological medicine the use of snggestien huo ci_'. vi..pcd 
out of the earlier use of hypnotic influence. 

I must first emphasize the fact that hypnotism and 
pggestion are not the same thing. The state of hypno.sis 
is a state of mental dissociation, in which certai,i inUicsts 
of the subject’s mind may be appealed to while other part.s 
of the mind remain in abeyance. 'When a person Is hymi,.- 
tized he is more ready to respond to the iufiuenie of the 
hypnotist because the dissociation of his mind pm ents him 
from being able to call upon liis reserves — to bring uji < t'ler 
considerations. The hypnotic subject receives a cci.nranil 
or request from the hypnotist; and his impulse is to rcc"oi>d 
immediately. Considerations tending towards .o different 
line of action simply do not occur to him ; tliev ci niiot, 
because there is a break in the mind. He caui/ot r. vietv 
the situation and consider alternatives, and certainly dees 
not even begin to consider them. IVe see that iu hvpiio.sis 
he has become more suggestible, and th.ot his inere.iscd 
suggestibility, or increased readiness to resnond to s-ognes- ■ 
tioii, is in part the result of mental dis.socintion. .° 

-But the opposite relationship mav hold pond Ipctcad 
of suggestibility following upon the'state of hrpims'.s, ne 
nmy find .a state .of hypnosis following upon 'sa-ce-stinii. 
Indeed, this is what generally occurs when a rer.s-ni is 
hypnotized. The hypnotist sugge,sts to the person that be 
will become more and more drnwsv, more ami more 
lethargic, but that he will continue to hear and nndor- 
stand what the hypnotist says to him, so that through 
suggestion from the hypnotist dissociation takes place. 
A person is robbed of the power of couti'olling his mind 
as a unitarv system. 

procedure in the case of a patient I'eoniring. 
hypnotic treatment is as follows. After a prcl'in narx’ 
general examination — ^that is, a physical examination aiul 
a psychological investigation of the conditions iindei «';ich 
his illness had set in, which need not take vem- long, 
although a detailed psychological examination fantognoj's) 
would require many hours — after this anatysi.s, if the 
■patient is considered suitable for hypnotic treatment, li'e 
physician asks him to lie down on a couch, to leia.x hi.s 
voluntary muscles,* to fix his gaze on a small minor or 

•The patient may be given rlctniled Instruction In the n-atlei of 
muacular relaxation. If lie directs altention to tlie rnm-l dotal 
muscicv of fiands and feet he xvip find tliat relaxation at tl.*-'i t. ndx 
to spread to the larger muscle? of tlio arms, legs, etc. Ilccii and 
regular brcatiiiag aliU helps iclaxation. 


252 Feb. is, 1928] 


THEORIES OP 


i*' 'i‘ 

SUGGESTION. 


rfi 

f TiirBRmca 
L Medical Jwxn.xit 


otl)cv liiiniiiotis object held about ten inches from his 03-08 
and slightK- above the lioi izonlal jjhino. of vision — so that 
lie has to turn his 03-05 sligiitl3- npivards and inivai-d.s — to 
look steadily' at it, to fix his visual attention on it, and 
to think of sleep. The In-jinotist then proceeds to suggest 
that tho patient is getting more and more drou-.S3; — that 
his 03-eIids are getting .11001-3- ivith sleep — that he n-ill 
soon be asleep, but will continue to hear what the hi-iiiiotist 
sa3-s to him. Tho patient’s 03-68 close and he appeai-s to 
sleep. Tho h3-pnoti.st 11133- then snddenl3- hold his atten- 
tion I13- speaking moi-e iirgentl3’ and more ilrainatfcalh-, 
sa3’iiig, “ Yon iii.av try as hard as 3-011 like, but 3-0U cannot 
open 30111- eyes." The mere fact that he is challenged in 
this 11-33' I'lakes him sudden I3- lose the knack; there arises 
the momentary fear, “ Perhaps I shall not be able to 
open my 63-68,” and that momentar3- fear prevents him 
from opening them. He gets into a slightly emotional 
condition, and is readi- to believe other statements made 
to him. If passes (with or without contact) are made down 
the arm and hand, with suggestions of rigidity and anaes- 
thesia, the arm does become rigid so that the patient is 
unable to bend it, and it also becomes anaesthetic, so 
that a sterilized pin miy- be plunged deep into the flesh 
ivithoiit causing an)- pain. In a deeper stage still the 
patient may become apparently quite unconscious, 
although subsequent investigation 0103- show that he has 
retained an inactive dream-like consciousness throughout 
the experiment. 

H3-pnosis seems to proceed in stages, of deeper and 
deeper degree; but noivadays we do not speak of stages 
of hi-pnosis, because they have no definite order of 
sequence.’ IVe find that the order in which they occur 
depends to a veiy- largo extent upon the way in whicli, 
or the conditions under which, suggestions are given. Tho 
patient falls into a h)-puotic state, and in that state 
becomes more suggestible, more ready to respond to sugges- 
tions, verbal or otherwise, from the h3-pnotist, and these 
siigge.9tions may bo used to increase the depth of the 
h3-piiosis. One stage in a good h3-.pnotic subject is that of 
11-0x3- plJistio flexibiliti-, whei-e the limbs, put in any 
position, remain in that position like the liiiihs of a lay 
figure. This .stage, like those previously described, ia a 
state of dissociation. Indeed, most, if not all, of tlio 
phenomena of hi-pnosis seem to bo phenomena of dis- 
sociation. The simplest is tho patient’s inability to open 
his 63-68; again, if he clasps his hands together and is 
then told by the hypnotist that he will not be able to 
separate them, ho cannot do so. A further result of a 
dissoeiationist nature which it is very eas3- to produce in 
a hipnotic subject is amnesia. If it is suggested to tho 
subject that he cannot recall aiy-thing that happened — for 
exaniple, during the previous da3- — it will be found later 
that he is unable to answer 303- questions about tliis 

period of time. These are all instances of dissociation 

dissociation of the iiower of recalling certain memorie.s, of 
. the power of contracting certain muscles, of experiencing 
certain sensations. 

In a still deeper stage of hypnosis the hypnotist may 
seem to produce positive i-esidts instead of mereli- negativet 
ones. If he suggests to a patient in a dcepl3- hypnotized 
state that the latter will be able to see, say-, a bright red 
light, the suggestion will take effect. AVhat has happened 
is that the patient’s imagination has been sthnulated, has 
been set in motion, and continues working actively in a 
certain direction. You can take a blank card and tel! him 
that you are going to show him 3-our photograph, and he 
will see 3-our photograph and describe it ; and really, so 
far as can be made out, he does actually see something on 
tho card. Ho piojects on the card something that is 
mcrelv in his omi imagination. Here the diffei-cnco 
between tho h3-pnotized subject and the normal poison is 
mainl3- a difforenee in the degree of activity- and control 
of tiio imagination. IVhcn a person fs lu-pnotizcd his 
imagination niay- become iliore active, but is under the 
control of the h3-pnotist ; indeed, all hy-jniotic suggestion 
nmj- be considered as an influencing of the imagination. 
I’be manifestations previousH- described may bo regarded 
merely as the effect of an externally controlled imagina- 


Tht» b.'lir'f 
erronj o 


in a tlennife ordpr of se'juence of such stages >tas one of 
Cunreot aiij the Snlpetriere scliooL 


tion. An individual has been made to imagine that bo 
cannot open his eyes; nothing having arisen to countei- 
that imagination, it takes effect. ’The normal peiton can 
call u]) a fairly accurate picture of another individual, but 
to SCO it at a definite spot and with a cei-tain degree of 
steadiness 111.03- follow upon hypnosis, where tho imagina- 
tion is eontrollod 113- the hypnotist. It is not that tho 
lopnoti.st ha.s any- occ-nlt power (magnetic, telepathic, or 
what not), hnt that Jiis u-ords and gestures call out a 
direct and inevitable response from the patient. Tho 
patient IS ready to boliere and expect that what tho 
113-pnotist snys will come to, jiass. 

Various theories Iiave been devised to account for this, 
and I .shall discuss some of them later on. One well known 
theoiy- is that of Freud — that these results follow because 
some bond of affection has sprung up between the bypno- 
tized patient and tho liA-pnotist. Tho patient responds to 
the suggestioms of tlie h3-pnotist much as a 3-ouiig child 
would respond to tho suggestions of a well loved parent or 
nurse, in primitive crediilit3- without afterthought or other 
consideration. An.-itlier theoi-y is that in the process of 
h3-pnosis the ])atirnt lias been tlini.st into a state of self- 
abascincnt, witli tlie result that ho is iead3- to accept orders 
from another person. This is McHougall’s view: that tho 
patient is specially rcad3- to respond to tho In-pnotist 
liecau.se, under hvimosis, his instinct of self-abasement has 
been aroused to tlie exclusion of other instincts and ten- 
dencies. In ln-|)iiotized jieople JIcDongall assumes that the 
instinct of self-assertion is in ahcyancc. Such a theoiy 
is based on the conception of dissociation — dissociation at 
a very- fiiiidaiiipiital level of the mind — naineh-, dissociation 
of one iiistiiietivo disposition from the others. 

Dissociation may increase suggestibility-, or be increased 
by it. A. person may for the moment “ forget ” how to 
use certain mental (lowers, and tlien through fear become 
permanently incapacitated, or he may succumb to- sugges- 
tions in other directions; or, agitin, ho may fall into a state 
of dissociation, not through mental suggestion from any- 
one but tlirongh some strong mental or jihysical shock. 
During tho war large numbers of soldiers became readily 
Jiypnotizable under the influence of intense (iliv.sical shock, 
either from shell eoncnssion or from blows 011 the head 
received in other nays (falls, etc.). It is often difficult to 
exclude the effect of mental shock in these cases; but 
instances of purelv physical shock, followed by dissociation, 
do occur A person who gets physical concussion is almost 
invariabh- easv to hypnotize. This concussion probably 
bi-iuKS* about phvsical dissociation of the higher centres of 
the brain. The ■harmouions activity of the brain as a unit 
seems to be disturbed by such a general “ sliakiiig up.” 
Di-U"s such as alcobol, may produce a similar effect. 
Alcobo’lic persons are very easy to hypnotize, wliieli is 
fortunate because bypn-Jtism can bo used in ciiniig them. 
An alcoholic person’ may appear to ho absolutely incor- 
riirible but, to his surprise, he finds that he obeys sugges- 
tions under livpnotism. Anaesthetics, such as ether or 
chloroform wifi also make a person more readily bypnotiz- 
abfe and there is good reason for believing that they 
m-od’uee relative dissociation in tho highest cerchral levels. 
Hvimoti-'III was originally used for operations, and if chloro- 
form hid not been discovered shortly aftemyards, no doubt 
kvwiotism would Iiavo been used much more extensively for 
that purpose; it still has its uses to prepare and calm tlio 
natient’s mind for an operation. It is very important that 
a natieut before undergoing an operation, should have Ins 
mind free from fear-, should control his feelings, and not 
sti-uo-<fle against the anaesthetic. One of the best wai-s of 
briiimni this about is to give him suggestion treatment 
beforehand, and I have done this in many cases. It has 
verv definite effects; among others, it may save the patient 
from nausea after the amicsthetic. In many cases where 
tho patients have dreaded the anaesthetic more than the 
operation, suggestion treatment has freed them from this 
loA r 

It" is a fact that in hypnosis the patient falls into a 
.special •kaie in which ho responds readily to suggestions 
from the hypnotist, and to a great extent tho character- 
istics of the hvpnolic state seem to ho explicable m terms 
of sucwcstibili'ty. The patient becomes more siiggestiblo 
to tholiypiiotist, and on this basis Berubefm formulated 


Peb. iS, 1928] 


TIIEOKIES OF SUGGESTION. 


[ 


The Br.rnsT! 
ilflDJClIj JOVZ3UX0 


253 


his delinition of hypnosis as a s’.ato of aitifioially inovoosed 
s\ic.(r(jstihiUty . A hvpnotiacd poison is inado inoie sujxgost- 
ih'Tthan a' noimai' parson. But suoh a dolinitiou is not 
foliv adofjnato to flip facts, ticcaiise it decs not explain 
suffieipntfv how tho incipascd soggostdiiUty is hrougtit 
ahoiit. Although in some cases siiggestnm from the 
plivsician dr hypnotist produces tho hypnotic state, in other 
cak's, as «-e have just scpu, mental shock and physical 
infiupncps — such as jihysical concussion, the iuAuence of 
dings, etc.— may increase snggestihility or hypiiotizahility, 
and certainly it must not he forgotten that dissociation 
itself iucroases suggestibility; that was foiccd upon us by 
the exporieiK-es of the war. Among the thousands of shell- 
shock patients seen just behind the line.s in Franco and else- 
where, 15 per cent, sliowed functional amnesia to a greater 
or less, e.ytent. Tiicse patients were in a di.s.s,K iated .state, 
and in many cases had not only lost the iiowcr of lecalling 
their frightening- experiences, but had also lost the power 
of speaking, hearing, walking, of controlling tremors, and 
of bringing them to an end. There was a sort of general 
dislocation of tin- mind as well as of the nervous system. 
I found that these patients were easily hypnotized, and 
that the more pronounced tho dissociation the more easily 
wore they liypnotized. A man who had lost all his past 
memory could ho hypnotized at once; a wave of the hand 
would effect this mental transformation. If the toss of 
memory referred to hut a brief period of the past, the 
hypnotic state rvonld not sot in quite so readily, but every 
en.se of ainne-in or dissociated memoiw was iu some degree 
hypnotizahle. Amnesia doe.s not mean weaknes- of memory, 
hill a loss of tho power to recall a definite sti<-tch of past 
experience. I observed six liundrcd eases of amnesia in 
Fiance during the war; evciy case was hypnotizahle, and 
memory invariably returned under liypnosis. Patients seen 
i'l Eiighind some months or years later wore not so easy to 
cure; they responded less readily, hut they did so eventu- 
ally, nevertheless. 

1 am iiicrmed to state ns a general rule, admitting of 
no exception,' that a person sliowing functional amnesia, 
uitliout p.syehotic symptoms, is easily liypnotizahle, and 
that in functional amnesia the los.s of memory i-, easily 
cured by hypnotiEin, as well as any accompanying paralysis 
-—mutism, etc — of a functional nature. Facts such as 
the.so make it neccssai-y to u'iden the definition of Beinheim, 
and to recall the earlier definition of Charcot, who used to 
say that hypnosis was an artificial hysteria. We need to 
comhine the two theoric.s (with certain omissions), and .say 
that in the hypnotic state suggestibility is increased, but 
i.at a fuudaincntal factor, to some extent of independent 
Mime, is a state of dissociation which works in Iiarinony 
nith .suggestion; dissociation tends to produce increased 
su^estibihly. The reason of this is obvious. If a person 
IS is.soeiated ho has no power of reviewing the situation 
anti considormg altcriiatire mode.s of tespouse. A certain 
mode ot rcspoitse is stiggc.stod to him, and he makes that 
response, hnt because of his dis.sociatioii ho is unable to 
c nn c o lei powers of tlie mind. The dissociation is not 
n ?? mercased suggestibility, for we can imagine 

rlin'(...rr,ri ■ person, a unified person, showing 

ovei- ->lti s>nggesUbiIity at different timi.s. Moro- 

soom’c t forms of dissociation siiggcatibilitv 

i icr^ses a, t,,c degrbe or extent of cFic^oc iatiou 

■u-i.„.‘ ji'_ i'.*® bo'irtatioii does not hold for extreme rases. 


M lien the dissociation 


IS extreme, or the state of iivpiiosis 


patient may be fonnd to have bccoire less 
ncii siieee=I'!i,'l*'”''' to outside influeiuo, or even 

ncu-suggeslible ,n certain directions. 

(iifii> 7 ir<r ’mpcrt.anl uoik of J. p, Pavlov on Coii- 

cxnhiiis slepif s'miild be referred to here. Pavlov 
.g'.Vi ! 1 .‘'"'^.'Wnosis in terms of infr,,.of inhibition 


lu the cerebral cortex- 


-.spreading; to the siihcoiticnl coutrci 


of the latter^ fmmer, limitcct to the cortex in the ca; 


Me 


II. 


rc//i/w't""w!iieb"; niorc detail the factor of 

andjnaetiee of li.^notj^nn'"'*''’'’ importance in the theory 

bvnnorte'"'’ gone beyond the earlier view of 

a form of T’ "''“"’‘'’5 "I'ibl' 't i^ regarded as 

. foiin.of ideo-motor action, whore, as Piorie Janet savs 


the suggested idea ])rodiices its full or maximum effect 
iinclistuvbccl by conllieting ideas. This theory is not 
sufficient, hnt itself lerjniies further explanation. An idea, 
to iiroduee an effect, needs to ho in relation with some 
source of energy. Such a source of energy is any one of 
tho instinctive “ itrgc.s ” or other coiiative and nffeetivo 
tendencies. According to Freud’s theory, the affective 
tendency couceviied is iif an erotic or sexual nature — not 
the tendency of ordiimry .sexual love, hnt a. .sexual tendency 
iiiliibitcd ill its aim (riclpc/icmiatf), manifesting itself in 
a readiness to rely eomplolely upon the ln])iiotist, to ho 
at one with him, and to grant him vigorous and whole- 
hearted co-operation. Tliis is the well known factor of 
“ transference ” (Fchf r/mr/inic/), so named boeaiise it is 
believed by Freud to he a rcanimatiiig of affectiva 
tendencies felt by the young child towards his olders iu 
the bosom of the family. Freud quotes with approval 
Ferenezi’s observation that there are two main and con- 
trasted methods of hypnotism— namely, the’ method of 
command and tho method of soothing and coaxing. The 
former conespond.s to the attitude of tho father towards 
the child, the latter to the attitude of the mother. [Com- 
pare Pavlov’s purely physiological distinction of {!) mono- 
tonous stimuli of small and medium intensity repeated for 
a long time, producing Inqmosis slowly, and (2) .stimuli of 
considerably greater intensity, producing hypnosis quickly 
(in animals).] 

At fii-st sight all suggestion seems to he in essence auto- 
suggestion, since it must he accepted hy the jmtieiit if it is 
to work at all ; the ))atieiit has to make tho suggestion 
his own. Blit there is the convor.se jmssihility that all 
suggestion may he hetero-suggc.stion — tliat the individual 
may never he able to accept anything from himself, hut 
must always accept it from without, either from peojjle 
or from the books he roads or from jdiy.sical events in the 
outer world : so that even auto-suggestion would ho hetero- 
suggestion. Tho ])crsoii who a]iplies Cone’s method of auto- 
suggestion, and benofits thereby, owes bis success to the 
influence that Cone has had upon him, the lectures lie has 
heard, and the hooks ho has read. How can this he 
brought into line with the Frcndian doctrine of hetero- 
snggestion? Ihuest Jones lia.s recently attem))tcd to solve 
this problem in an important article on ‘‘ Tlie nature of 
auto-suggestion.”’’' He follows Freud in raaiiitaiiiiiig that 
the success of hetero-suggestion is due to the-re-aroiisal of 
early feelings towards the father, iu which tlie liypnotist 
is put in jilace of the ego-ideal or super-ego, which, as 
distinct from the ego, is modelled upon the father. The 
doctrine of Freud is that in earliest years a little hoy 
loves his father according to the narcissistic or identifica- 
tion type of love — he identifies himself with his father ; 
hut he loves his mother according to tho doiiendonce or 
“ aii.aclitic ” type, because his various idiysical wants are 
satisfied tliroiigh lier.t His love for his mother involves 
the desire to have her to himself, whicli arouses, hv 
reaction, a feeling of hostility towards his father. This 
feeling of hostility towards his father is then repressed, 
by virtue of bi-s previous identification with his father, 
and thus is innngiirated tho contrast between the ego aiitl 
the ego-ideal or super-ego. Ho incorporates in his own 
mind the charactov of his father as he .sees him, and if 
he represses this hostile feeling towards his father, and 
develops a had etmscienee about it, that had cxniscieiico 
covi'espoiids to a coiifliel between bis ego and bis ego-idcal. 
The cliild incorporates in himself tho disapproval of himself 
wliieli be must rssiime that his father would feel if bis 
fatlier knew. Thus the ego-ideal in Ins own mind eorre— 
sponds with his ri.eeeption of his father. 'When a jiei'son 
is hypnotized, and accepts suggestions from tho hypnotist, 
he puts the hypnotist lu the place of hi-- ogo-idoal. 

In aiilo-sug"c.stioii, accoiding to Ki iiO‘t ,Ioiu -. there is a 

•‘'If the* primary ujiil 

Uireclly, by cr«nreiirt:\tioti upon tlif* ulra of 4oU, the JIroce^' ji;n> Ik* 
fcnnccl ‘ aiito-s«"g:cs{ioa * ; if ii has? Inn'ii prec«‘ile<l Ii> a vtaiie in vhich 
tho eptv-itleftf rc'^olieil into the earlier failirr-iilenl. the i*roee«'? inny 
bo terinoci * hotcro-suggcetion.' ' — c/ Mcif. rt-ijcholo;;!/^ 1S23, 
vol. iii, p, 209. 

t More accuralelv, l»ceoii«e ‘'in tho fir^t pl)^^c of llic:r .Tlevelopnjcnt 
(he sexual instinct.® IiaNO no jmlcj'ondcnt incnti'^ of fjnilin" ton ; 

thov* <lo so by proppuip tl.cm*elve'i upon or * Jenninp up apaijist ' Ihc 
self’-prcs'erYativc — S. Kreud. ff'rtufp Pftjr/ntlotj!/ an/7 t/<r AjifTlt/irit 

nf H,e Eaa. Enp. Trans., p. 61, Internotional Psycho-nDOlilicnl Tras, 
I^ndon, 1?^. 






Feb. i 8, 1928] 


HjEO-CAEGAIi resection. 


[ The Bnmsir 
IIIXDICAZ. JoxniNAX> 


257 


A married woman, aged 53^ was first seen for general 
loss of appetite, and inability to swalloiv solid foods. Further 
inquirv showed that the dysphagia was occasionally associated 
with ulceration " of the tongue nud had been a source of dis- 
comfort to her for about tln-ec ycai-s. She paid little attention 
to it.until her general weakness forced her to seek advice. 

On admission examination showed : (1) the mucous membranes 
of llic mouth to bo very pale. Slio was edentulous; the teeth 
had been extracted years previously. (2) The tongue was red, 
smootli, glazed, devofd of papillae, with patches of sticky mucus 
present. (3) The tonsils were small and septic. ■ 

Blood examination showed poikilocytosis, anisocytosis, polychrom- 
asia, and punctate basophilia. Haemoglobin 32 per cent.; colour 
index 1.4; red cells 2,200,000, white colls 5,000; polymorphs 57 per 
cent., I^Tnphocytcs 37- per cent., large mononuclears 6 per cent.; 
normoblasts and one or two racgaloblasls seen. 

The spleen was enlarged and could be felt projecting H inches 
below the costal margin. 

Tlie centra! nervous system showed no abnormality. Wasser- 
mann reaction negative. 

The uz*ine contained acetone, bile salts, and pigments. 

Van den Bergh test: direct — delayed positive; indirect — imme- 
diate positive. 

Fractional test meal: achylia with 110 delay. A’ rays showed 
the stomach to be very large and atonic, reaching well 'down into 
the true pelvis. There was no irregularity or tenderness. Six 
hours later the bulk of the meal was in 'a terminal ilcuni. 

A swab from the throat gave pure growths of Htrcptococcin 
ih’idnns and iS’. lonr/us. 

The diagnosis of pernicious anaemia was made and treatment 
carried out accordingly. 

Five months later tonsillectomy was performed and a few weeks 
later the dysphagia became^ much more marked. She was there- 
fore -obliged to exist on liquid diet only. Examination of the 
rood passages showed the usual atrophic clianges. She was r-rai’cd 
again and the report was as follows : ** Heart and vessels normal, 
iostonor mediastinum clear, and opaque food passed down the 
oesophagus into the stomach easily, but showed a temporary 
arrest at the level of the larynx. Oesophagus not dilated.^’ 
jjii-oet oesophagoscopy showed no evidence of a neoplasm present, 
llie hj-popharyngca! mucosa appeared thin and tense. She died 
at Jiomc three weeks later. Unfortunately, no post^morUm 
examination was performed, 

. Treatment. 

There is no doubt that bouofit is obtained bv the passage 
of tli^c ocsophagoscope and dilatation nitli bougies. TJie 
lesnlt IS very often .striking, as after tlie initial soreness 
lolloumg the direct examination patients are able to par- 
a xe ot normal meals and immediately announce themselves 
as being cured. Relajise, honever, will result — some within 
irce neeks, others may go on for years. tVlien relapse 
oes a CO place normal deglutition can he re-estahlished for 
anotlier period by fiirthor dilatation. It may he stated 
la le patient with the primary anaemia showed little 
improi-ement after dilatation. 

One fiirtlicr point may he mentioned— the not infrequent 
upeiien ion in such cases of malignant disease at the 
fhnl +V° I gwllet. Logan Turner and Paterson state 
IS lappens too often to be merely a coincidence. 

ali'mviiW’'^ us* Taterson for Iiis kindness in 

Cardiff°HoyaI InliraaTy. department at the 

ri; R™p"iS"h; ISIS. 1327. 

■ a' Turner : Ibill,, 19^ 


.five cases op ileo-caecal resection. 

DY 

c. L. ISAAC, JI.B., B.Cn., F.R.C.S.Ed., 

SURGEON, SWANSEA HOSPITAL. 

During the last six veart; • i • i *1 

resection has been necessan he T 

O™ f^: “'‘'"--nation ;viih ‘e„..crma"of Or'ea'cem 

luhVt’ioS^rtCc-lnm 

-m^nm^tr o*; ^eem' 

Eliock. O' bred from operation with practically ] 

1921: he ’lin'd 'hacf'abscduie'^iT't*'^'*.-*” ''osP'tol o" December 71 
tor four months with oonsOpati 

lost a deal oFwcieht X " P*'" “f'" '■ 

99° F., pulse 64. An“ enema nrod'^^i mclaena Tempcralt 
0/„mlio„.-Qn Decemb” 8U> e 

over a mass in the otpotI ^ icctus incision was ma 

tended, and there wac small inlcsUne was i 

, ana mere was free ilu,d in the peritoucal cavity. 


irreducible intussusception was found with diffuse thickening of 
the caecum. The lower end of the ileum and the caecum, as far 
as it was mobile, were excised. The ascending colon was closed 
and the proximal end of the ileum anastomosed to the transverse 
colon by the end-to-side method. 

The pathological report was adcno-carcinoma, with -marked 
inflammatoiy reaction and congestion. 

Jtcfuli. — A notable feature was tlie complete absence of- shock 
and rapid convalescence. .Tlie patient left hospital on December 
21st, within a fortnight of operation. 

■ Case ii. 

A woman, aged 47, was first seen as a private case, and a 
diagnosis of caccal tumour was made. She was admitted to 
hospital on Januaiy 20th, 1923, with twelve months’ history of 
pain occurring in attacks over the umbilicus. There was no 
mclacna or hacmatemesis, but she complained of diarrhoea. 

Opemtion. — On January 23rd, through" a ri^ht rectus incision, 
an intussusception was found similar to that in Case i, but -the 
ileum was laterally implanted into the transverse colon. 

On section the resected portion showed columnar-celled adeno- 
carcinoma with intense inflammatory* reaction within the support- 
ing tissues. 

Jicsitlf. — ^Thc patient had an uneventful recovery, leaving hospital 
ton days after operation. 

Case hi. 

■ A woman, aged 54, was admitted to hospital on January* 10th, 
1924, with a history of paiu, vomiting, and constipation, whicli Iiad 
recently become worse. 

Emcrfjciicp OiKration. — There was great distension of the small 
gut, with ring carcinoma near the caecum. The patient collapsed 
somewhat, and no attempt was made to bring the growth out. 
Tlie bowel was short-circuited betweeu the ileum and the left 
end of the transverse colon. 

Resvetion Opemiion. — On January 26th the patient was passed 
on to me for resection. This case showed a typical glandular 
dislribiilion, as described by Dobson, and the resection included 
the transverse colon, as advised by him, the anastomosis being 
carried out as before. 

The specimen was a typical ring carcinoma, and no sections 
were cut. 

Result . — ^Tlie patient left hospital within a fortnight. 

Case iv. 

A woman, aged 49, was admitted to hospital on September 
8th, 1924. 

Operation. — ^Tiirough a right rectus incision a one-stage. Dobson 
resection of the ileo-caecal region with half tlie transa*ei*so colon 
was' performed. 

Section of the portion resected showed large masses of carcino- 
matous cells in the intestinal wall. 

ResuH. — ^The patient left hospital within a fortnight. 

Case v, 

A woman, aged 53, was admitied to hospital in June, 1924. She 
complained of pain, dull in character, in the right iliac fossa of 
five months* duration; she fell distended, but the bowels acted 
well. A fixed tumour was felt in the light iliac fossa. 

Oprrafiosi . — On June 18tl) an operation revealed what appeared 
to be a malignant growth in the caecum, %vith glands in the 
mesentery. The ileum was anastomosed to the trans\*erse colon. 

Reaction Operation. — On July 9th the patient was passed to 
me for i-escction. The mesentery was much thickened, and 
numerous large glands were present, which, on section, were 
obviously breaking-<lowu tuberculous ones. Tlie resection in this 
case was far more difficult than in any of the cases described 
above, as it was deemed advisable to remove the thickened 
mesentery in which the glands lay, and unfortunately the ureter 
was injured. 

Section of the portion of bowel removed showed tuberculosis to 
bepicseiit. 

Result. — Strangely enough, this non-malignant case compares 
very unfavourably with the other cases in the immediate result, 
but possibly the eventual outlook may be better. The patient 
did not leave hospital until November 7th, owing to a faecal 
fistula, which has i.ow almost closed; her general condition is 
vei'y good. 

Case IV returned to hospital on Januaiy 1st, 1925, with 
an implantation groirth in the abdominal wall, Avhich was 
removed and radium introduced. The abdominal cavity 
appeared to be free from recurrence. Tho remaining four 
patients speak enthusiastically of their state of 

health. 

It will be notic-ed that in two of these cases resection 
was preceded by a short-circuit operation, but this is only 
necessaiv in the presence of acute obstruction. The 
presence of carcinoma in both intussusception cases is a 
reminder that a wide resection is advisable in these chronic 
cases, as they arc almost always associated with a malignant 
growth. For the pathological reports I am indelited to 
Dr. A. F. Sladdeii, director of the Beck Pathological 
Laboratory, Swansea Hospital. 

Since writing tho above notes I have had two cases of 
carcinoma of the caecum. One was inoperable, but a short- 
cirouit operation has given relief. The other patient, a 
middle-aged woman, after resection has returned to her 
duties as a school teacher. 



868 Feb. iS, 1928 ] >■ ACUTE DISTENSION OF GAUr, BLADDEK. 


r TnK Bprnnr 
L Mfdicai. Jocaxix 


ACUTE DISTENSION OF THE GALL BLADDER 
(MUCOCELE) IN A CHILD. 

UY 

L. STANLEY TORRANCE, M.B., Cit.B.En., 

LATE HOUSE-SULGLON, ROVAL VICTORIA A:JI> -WEST HAXTS UO&PITAL, 
BOURKCMOUTir. 


As this condition is not n common ouo I think that Iho 
publicatiou of tho following notes is 'Ou tliut ground 
justified. 

A boy, aged 12, was sent into tho noyal Victoria and West 
Hants Hospital, Bournemouth, with tho diagnosis of “ acuto 
appendicitis with the appendix in an abnormal situation.*' Ho was 
admitted on July 12th, 1927, and seemed to bo an intelligent bo 3 '; 
he was fair and freckled, of slight build, and with littlo sub- 
cutaneous fat. The skin had a slight icteric tinge, while the con- 
junctivae were definitely yellow. _Tho pulso was 75 to 80, tempera- 
tui^e’98°F. in the axilla and 99° in the rectum. Ho complaiuod of 
pain in the right upper quadrant of the abdomen. 

The history of tho present illness was as follows : On July 4th ho 
sufiered from gcuerai znaJaise and fevcrJslmess, went to hod, and 
the doctor was summoned. On July 7th clay coloured stools wore 
pa^ed. On July lOlh he had pain in tho upper abdomen, unlike 
colic, and severe flatulence. On July Hth he vomited; pain waa 
becoming localized in the right iliac fossa and a tender swelling 
was felt there by the patient. On July 12th tho temperature was 
subnormal, he had abdominal pain and flatulence, and the right 
rectus ju»;;r3cle was tender and rigid. Tlicre was a yellow tinge 
in the skin and conjunctivac. His appetite was good, and there 
w’ero no subjective phenomena The bowels, whicli had been 
regular, had recently become constipated, and tho motions were i 
cl^ coioui'ed. 

Examination of tho abdomen showed very little movement of tho 
upper part, and none at all' in the right upper quadrant. On 
very ^ lightly stroking the abdomen with the finger-nail very 
definite hyperae&thesia was found over tho galbbladder region, at 
the lower edge of the tenth costal cartilage. The skin of tho 
right upper quadrant could be pinched up between tlmmb and 
forefinger more easily than that on the left fiide, aUhough pain 
was caused^ — proving the right rectus to be contracted. Palpation 
confirmed the contraction and elicited tenderness, especially pro- 
nounced over the gall-bladder region, where pressure caused a 
sudden cessation of respiration, lb was thought that an under- 
lying tumour could be felt here, bub owing to the rigidity it was 
impossible to be certain of this.^ There was a pronounced absence 
of tenderness in every other region of the abdomen, even on deep 

E ressuro, and in the right iliac fossa the vertebral column could 
e palpated without causing pain. Percussion j’ieJded a dull note 
over the gall-bladder region, extending from and continuous with 
the liver dullness for a distance of approximately two inches from 
the costal margin. Kectal examination gave a negative result. 

The patient^ food consisted chiefly of bread, butler, and 
potatoes. He had had measks, chicken-pox, and tonsillitis; for the 
last-named he had undergone tonsillectomy eight yeai*3 ago. 

The urine, which was of a dark amber colour, green on surface, 
gave an alkaline reaction ; specific gravity 1020 ; there was no 
albumin or sugar, but bile pigment was present (Foam, and 
Gmelin’a nitric acid tests). The respiratory system was normal. 

A soft mitral systolic muz*rour was heard. There was a alight 
generalized itching of the skin. 

The diagnosis was; acute gall-bladder lesion; ? appendicitis and 
coexistent catarrhal jaundice. Immediate operation was decided 
upon. 

Operation. 

Mr. W, S. Richardson operated on July 12th. Tlio anaesthetic 
was the chloroform and ether sequence. A paramesial incision 
was made through the upper right rectus. On opening the abdo- 
men an. enlarged, much distended, Out not inflamed, gall bladder 
was found. Tliis was inci'^ed, allowing the escape, under tension, 
of clear mucus. A soft rubber catheter was stitched into the gall 
bladder. No obstruction of the bile ducts could be felt. The 
appendix, in a normal situation, was inflamed; it had a bulbous 
tip, with a constricted part proximal to the swollen extremity, 
Appendiccctomy was pertormed. The other abdominal organs 
were all found to bo healthy, and the abdomen was closed. No 
bacteriological examination was undertaken. 

progress . — Bile drained freely through the^ catheter, which in 
due lime came out’ leaving a biliary fistula which gradually closed, 
while the faeces regained their normal colour. The boy was 
discharged, cured aud well, on August lOlh. 

Jxcmarhs. 

The chief point of interest in this case is the occurrence 
of the condition in a child, following upon w'hat must almost 
certainly have been an attack of catarrhal jaundice com- 
plicated* bv a coucomitant attack of appendicitis. At least, 
in view of the condition of the appendix as found at the 
operation, it is to bo assumed that tho pain and swelling 
ill the right iliac fossa, experienced the day before admis- 
sion, were due to an attack of appendicitis. Aaiother inter- 
esting feature of the case is that this same attack of 
ai>pendicitis should havo completely subsided by the time 


of ndniission, so^ that no tenderness whatsoever could ba 
czimtcd in tho right iliac fossa. It is to bo assumed tiiat 
tins acuto nuicocclo foi'matioii wa.s caused by tho spread of 
tho catarrh to tho cystic duct, whero the swelling of tbo 
mucous incnibrano was such as to occlude the lumen cf the 
duct, thereby preventing tlio escape of the mucus secreted 
by tho miieus-socroting cells of tho lining of the gall 
bladder, thus causing tho rapid distension of the bladder 
aud giving nso to tho referred abdominal pain and rigidit)', 
I am indebted to Mr. llichardsou for very kindly per- 
mitting mo to publish this case. 


jUrntoraitba : 

MEDICAi, SURGICAIi, OBSTETRICAL. 

ECLAMPSIA.- 

I mvn, during the j'car, treated in tho County Maternity 
Hospital, Bellsliill, Lanark, 27 cases of eclampsia, with a 
matei'nal mortality of 7.4 per cent. 

The treatiueui, as carried out at present, is as follows r 
I If tho patient, when admitted, has recovered consciousness 
j tho stomach tubo is passed aud gasti-ic lavage practised 
until tho fluid siphoned off returns clear. A dose of chloial 
hydrato aud potassium bromide, 25 grains of each, is given, 
after whicli a rectal enema containing magnesium sulphate 
1/2 oz. in 10 oz. of sterile water is administered. Tha 
patient is then given 4 oz. of compound senna mixture 
with 1/2 oz. of Epsom salts dissolved in it, which is followed 
by a dose of 2 minims of croton oil in half a drachm of 
olive oil. If tho pulse is full aud bounding oi- orei' 110, 
veratroDO 1/2 c.om. is given hypodermically. If the fits 
recur, or if the patient is unconscious on admission, _ the 
same procedure is carried out, savo that tho croton oil is 
given by the rectum, aud the chloral and bromide in similar 
doses at intervals of one hour until three doses have been 
given. Largo doses of morphine sulphate are undesirable, 
as it appears to me to depress tha heart’s notion (as is 
evidenced by tho early appearance of cyanosis), and .tends 
also to increase intestinal stasis. At the same time I am 
of the opinion that small doses of morphine (1/6 grain) are 
beneficial at the beginning of treatment in severe cases. 

No attempt is made to deliver the patient uule.ss labour 
is wei! advanced in the second singe, and tlien deep ether 
anaesthesia is produced before delivery is attempted 

All cases were treated by the roiitino described, llie 
ante-natal cases numbored 2; one died, the other went 
home at her own risk after treatment, to come in for con- 
finement at full term. The number of neo-uatal cases iras 
20, and of post-natal cases 5. 


Mother 
A or D. 


A 

A 

A 

A 

A 

A 

A 

A 

A 

A 

V 

A 

A 

D 

A 

A 

A 

A 

A 

A 

A 

A 

A 

A 

A 

A 


* TkIh pregnancy. I Macerated. A=Alive. SB— Stillborn. 
i3=»Dead. P^Bostruatal. 

Bellshin, X^aaarksMra. ThoMSOX, M.H. 


1 

2 

3 

4 

5 

6 

7 

8 
9 

10 

H 

12 

IS 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 
27 


Age. 


31 
26 
51 
30 
17 

32 
22 
22 
32 

' 23 
32 
21 

29 

30 
41 
21 
30 
40 

21 
26 
21 

22 
17 
20 
19 
40 
27 


Gravida 


4 

4 

4 
2 
1 
3 
1 
1 
1 

3 
2 
1 

5 
8 

10 

1 

4 

5 
1 
1 
1 
1 
1 
2 
1 

11 

7 


Maturity. 


8 months 

7 .. 
Kull 

8 months 
Full 

7t months 

75 
8 
65 
8 

7 

8 
85 

9 
8 
9 
9 

75 
8 

n 

9 
9 
9 

Full 
FuU 


No. of 

I’ltS. 


1 

2 

5 

3 

5 

12 

3 

4 

4 
1 
2 
3 
8 

13 

5 
16 

1 

2 

11 

5 

6 
2 

20 

7 

10 

2 

5 


Child A 
or SJJ. 


A 

SB 

SB 

A and SB 
A 
A 
A 
A 
SB 
t 
A 
P 
A 
A 
A 
A 
A 
A 
A 
A 
A 
A 
P 
P 
P 
P 
A 


Feb. iS, 1928 ] 


MEMOBANDA. 


r TffE BRmsTt 9 R Q 

Medical Jocbxal ^ w a 


THE PATIENT'S COSIFORT AFTER 
PROSTATECTOMY. 

A Mr.THOD of nursing cases of prostatectomy lias recently 
l)Gon demonstrated to me by the matron of our local 
nursing bomeV Miss A. A. ' Frazer, wliiclr is, I believe, 
original, and ceidainly contributes in no .small measure to 
tlic^ patient’s comfort. It is also a great economy, both as 
regards dressings and the laundry bill. 

For the first fen* days, of course, the patient remains 
practically dry, but, as soon as the sn])rap\ibic drainage 
tube coines away, then tho patient, lying in FowleFs 
p’osition, is placed sitting on a well-inflated rubber bed-pan. 
A piece of gauze is placed over the wound with tho ends 
brought down on each side to a point between the legs. 
Over this comes a piece of wool, about six inches square, 
folded at tho lower end to a point, and lastly, a piece of 
jaconet, about ten inches by eight inches, also folded to a 
point between the legs. A ^rip of bandage is passed round 
the waist and tied in front over the jaconet, tho upper border 
of which is folded over it. The urine will now all drain 
into the rubber bed-pan, which is removed for emptying 
several times in the twenty-four hours, the bed remaining 
di*y. The patient’s scrotum, groins, and perineum are kept 
well smeared with ointment. 

The rubber bed-pan nsed must he kept almost fnllj* 
inflated and well powdered. Tho patient soon learns to sit 
well back on it, and remains on it throughout his con- 
valescence in bed. It can be obtained from Messrs. 
Rolhbaiid and Co., Bent Street, Manchester, price 21s. 

Rotiicrham. W. Stanxt:y AVildytan, F.R.C.S.Eng. 


DERMATITIS HERPETIFORMS IX A CHILD. 
The following unusual case of dermatitis herpetiformis 
seems to be of general interest. 


was passed, and the clip of the pin was sighted. The tube had 
then to be withdrawn to re-establish the child’s airvvaV, and a 
smaller tube was introduced. Examination was made along the 
length of the oesophagus, but the pin could not now be seen; 
the fluorescent screen, however, showed it Ij'ing in the fundus of 
the stomach. It wa-s deemed inadvisable to make further attempts 
at removal that evening. 

Tho next morning an 'r-ray plate revealed the pin in the same 
place at the fundus of the stomach. The child was again Anaes- 
thetized, but look the anaesthetic none too well. A soft rubber 
catheter, size 16 English, was passed down the oesophagus into the 
stomach, and the abdomen was opened through an incision splitting 
the upper part of the left rcclus muscle. The end of the catheter 
and the undipped pin were grasped through the unopened stomach 
wall; the point was passed through the wall of the catheter and ihc 
pin was closed. The stomach wall was then pinched up to make 
sure tliat it was in no way caught. The catheter, bearing the pin, 
was then withdrawn along the oesophagus through the mouth, 
and tlie abdominal wound was closed willi through-and-through 
.sutures. The child was returned to the ward in a satisfactory 
condition and made an iminlerrupted recovery, leaving hospital 
with the wound healed, and quite well. The pin was an inch in 
length. 

There seem to he several points worthy of note in the 
procedure detailed above. Tho additional shock attendant 
on opening a hollow viscus was avoided. In any case this 
is quite a serious undertaking, and would almost certainly 
have killed the child. The method of removal adopted 
might be employed for any object, sharp at one end and 
blunt at the other, which has passed as far as the stomach. 
It is obvious that while this procedure can bo used in tho 
case of an object lodged in the stomach it is advisable not 
to delay until it might pass further. 

I can find no mention in the literature of this method 
having been suggested or attempted. The procedure was 
conceived and executed by Mr. L. R. Broster, to whom 
with Mr. Lees, I am indebted for permission to publish 
this case. 

AV. B. R. Moxteith, H.R.C.S.Ed. 

Queen’s IIospHal for Children, Hackney. 


In December, 1927, I was called to sec a boy, aged 4^ years, 
who had a temperature of S9,4® F., a corresponding increase in 
Uie pulse rate, redness of the throat, and an crytliematous rash. 
Three days later a number of small vesicles ^ 7 Gre seen on the 
forehead and eyelids; these burst and disappeared, leaving the 
skin blotchy. On the following day a bulla about the size of a 
marble developed on the left forearm, accompanied by a larger 
one on the chest, which became haemorrhagic and bui'st, leaving 
a raw surface. This wa^ followed by the appearance of bullae 
covering the body and limbs and attaining, in some cases, quite 
lar^e dimensions. The boy was admitted to Leeds In{irmai”y 
Ingram, who confirmed the diagnosis of 
, . the history at this time of a multiform 

-I' ■ . papular, vesicular, and bullous — with the 

■' V' ■■ ' ! the vesicles, some of which were haemor- 

being characteristic of the condition. The fluid from the 
stenle and showed an excess of the eosinophile cells, 
in the bloocl to tlie extent of 3 per cent, 
io treatm^r^ arsenic in small doses and responded well 


Etprrrts nf 

THE USE AXD ABUSE OF ULTRA-VIOLET 
RADIATION THERAPr. 

At the meeting of tlie Medical Society of London on 
February 13tli the subject for discussion was the rise 
and abuse of ultra-violet radiation therapy. Mr. H. W. 
C.tRSON, the pre.sident, was in the chair. 

Dr. LEON.titn Hinu, in introducing the subject, began 
with a reference to other radiations. Much nonsense, he 
said, was talked about infra-red radiation therapy. The 
infra-red rays were nothing but beat rays sucli as were 
obtained with a hot-water bottle or fomentations. Thev 


le chief point of interest in this case is the occurrence 

0 ermatitis herpetiformis at such an unusual age, since 

1 IS almost exclusively a disease of adult life. Some 
wri ers bat e suggested that the condition results from 

voirj or shock, while others attribute it to a toxin arising 
rsn™.’ u - Metabolism. My observations in this case, 
* onset, when it showed an ervthematous 

voosV.u”"’ ’’'^°™POoied by papules, which later became 
/correlate it with varicella. Such a 
■ f ,• involve a similarity of origin — namely, 

most rit‘ ’’'^''.''■MMroscopic virus. This seems the 

T oxpla^tion to me. 

me with ronort'^ V".?' '> for liis help in furnishing 

P s of the blood and serum from the bullae. 

S. ViGODER, M.B., B.ai., L.M. 


Morlcy, Yorkshire. 


EEMO^ ^ OP A FOREIGN BODA' FEOIM THE 
T - • 1,1 STOMACH OP AN INFANT. 

procedure adontefl'^t^^*''^’^”'^-' novelty of tin 

of an infant Om f if “ safety-pin from the stomaci 

ot an infant ,he following case may hi worthy of record. 

swallowed brought to hospif.al, havin. 

showed the nin VifI, ii* ‘ "" '"nr previously. .T-ray cxahiiiiatioi 

cartilay; an4, ,"S '’f Z’'® 

engagm» ciio and nnint “ the hinge rjowmvnrds, and thi 

not disircfs-A Th/ 1,, directed upwards. The child wa; 

An oesophagoscopc spcciillv'^ dcT" 1'? anaesOictiacd 

o 1 , speciaiij dcjigncd to close an open safclv-pm 


had exceedingly little power of penetration, and were 
absorbed especially by the water in the outer layers of the 
skin. Tho visible rays — light — had greater power of pene- 
tration, esjiecially the rays in the red portion of the 
spectrum. If a powerful source of incandescent rays wore 
used, and the infra-red rays cut off so as to avoid over- 
heating, a penetration of some de 2 >th below the dermis 
might be secured. The energy of the visible rays was 
turned into heat in the blood, and possibly had some other 
action in the blood of which nothing at present was known. 
The ultra-violet radiations might he of long, medium, or 
short wave-length. They covered the region from 4,000 
to 2,000 Angstrom units. There was no need to consider 
radiations beyond the 2,000 limit, Ix-causo these were 
absorbed by the oxv’gen of the air. The sun gave no rays 
shorter than about 2,900 Ang.stibm units, but artificial 
sources like mercury vaiiour lamps or long-flame arcs ex- 
tended tlio siiectrnm right down to the 2,000 limit. Tlie 
biological evidence showed that the region round about 
3,000 had the principal action on the .skin in causing 
sunhiirn and in activating ergosterol and ))rodneing anti- 
rachitic vitamin. Tlie shorter the wave-length the greater 
the killing power for bacteria and infusoria. The long 
ultra-violet radiations, from 4,000 upwards to 5,000, were 
not absorbed to any great extent by living tissues; at 
about 3,000 they passed tliroiigli tlio horny layer of the 
epidermis, being largely retained hy it, and were almost 
completely absorbed by the living cells of the dermis. The 
maximum biological action was at about 2,970, just where 


2 C 0 Feb. iS, 1928] 


' ' t, - • ■ ! 'rr T- '7 

■ULTRA.- VIOLET RADIATION THERAPY. 


[ The nnmetf 
MrDICAL 


tlic high sitn leachocl on a vcr}- cloai- (lay. Artificial sources 
acted mostly with rays shorter than 3,000, and tho sun 
with rays mostly longer. Pigment was not a gi'cat pro- 
tection against ultra-violet, hut it was a defence against 
the visible rays; the pigment was in the deeper cells of 
the epidermis, and its function was to prevent over-heating 
of hlMcl by light. Of all the methods of stimulating tho 
defensive mechanism of tho body none w.as more excellently 
adapted than ultra-violet radiation, which could ho very 
carofnily gradu.ated and distributed over such areas as one 
pleased. Harm was done by over-dosage, jirst in the same 
way as exhaustion was produced by excess of sunlight. 
The temporary discomfort or illness which persons might 
experienco after over-uso of ultra-violet baths was of tho 
same character as that which followed imprudent ex- 
posures at tho seaside ; but in acute disease such as phthisis 
much harm might be dono. 

Dr. W. J. O’Doxovan said that tho fact th.at light- 
treatment had been going on at tho London Hospital sinco 
1900 without a day’s discontinuance — except for tho deplor- 
able behaviour of tho electricians in the general strike — 
was greater proof of its efficiency than any mass statistics 
of therapeutic results, which might rightlj’ ho distrusted. 
FurthoiTaoro, artificial sunlight thorajiy, both bj' arc and 
mercury vapour lamps, was introduced into tho hospital in 
1S22, and there was not tho slightest indication that it was 
failing to produce its cures. Tho speaker then mentioned 
a number of skin conditions in turn.. Light therapy for 
lupus must bo both general and local. The dostructiyo 
work of the tuberclo bacillus was slo'V, and the euro must 
necessarily be tardy also. Nodule after nodulo of lupus 
could be picked out by Finsen light, or by its more destruc- 
tive, less elegant, and loss manageable substitut(>, the 
Kroinayer lamp, and tho time required could bo shortened 
considerably and tho euro made more certain by tho daily 
administration of active light therapy. If light had served 
only to banish a: rays from the therapeutic field of lupus it 
would have justified its phaco. The immediate results of 
X rays wero often gi'atifying, but tho later result? of 
atrophic, vascularized, pigmented, and ugly scars wcio not 
pleasing. As to lupus erythematosus, he could confirm from 
his own experience what was .the traditional teaching of 
tho London Hospital clinic — namely, that light treatment 
for this condition was a waste of time and effort. His 
impression of tho value of actiuothorapy in cases of acne 
was distinctly discouraging. In widespread cases of 
psoriasis he had completely cleared the lesions ancl obtained 
two years’ fieedom from relapse by a steady' daily dosage 
from tile mercury vapour lamp. Nevertheless, each case 
had relapsed to a greater or less extent in the course of 
time. It (vas his practice always to combine light therapy’ 
with vigorous inunctions of ointment" and the use of the rest 
of the dermatologist’s annanientariura. Actinotlierapy had 
proved to bo a most valuable weapon for combating 
pruriginous conditions. It was his opinion that many of 
these, whether accompanied by- cutaneous manifestations 
of lichenization or no, were psychic in origin. In this he 
included cases of pruritus ani, pruritus scroti, pruritus 
capitis, and such conditions as lichen axillaris and lichen 
circumscriptus. All these benefited patently by general 
daily light baths, and where the irritation was intense and 
localized the patients all derived benefit from as large 
a local dose of mercury vapour radiations as could be 
tolerated without acute discomfort. It was with pleasure 
that in this field a dermatologist was able to turn from 
ai-ray treatment to local actinotlieraijy, with results which 
were vratifYing to the patient and a relief to the conscience 
of the operator. He was doubtful as to tho value of light 
therapy in ringworm. In certain cases of eczema, following 
tho exhibition of ultra-violet light, there developed occa- 
sionally a most intractable exfoliative dermatitis. In 
6eborrhoe.a, apart fioin simple lesions wjiich responded 
(juickly to sulphur ointments, x-ray epilation was of 
primary importance, and after that relapse could he pre- 
vented and cure hastened by the general administration 
of very small (loses of ultra-violet radiation, not exceeding 
half a minute to each side of the body daily' in the first 
instance. In three cases of post-herpetic paiu in elderly 
patients tho condition became quite toicrable within a week 
of daily administvaiions of l(,cal ultra-violet radiation baths. 


He had also found actinotlierapy u.seful in dealing with thq 
wide wounds after surgical incision for carhunelo. 

Dr, C. B. Hitvim took some exccjitioji to Di*. HiJI’s remark 
that the rays at tho long end of the spectrum had no effect; 
it was to that region that tho rays used in diathermy 
belonged. With regard to abuses of ultra-violet radiation,- 
lio thought these camo under three heads: extravagant 
claims, injudicious doses, and homo use. To claim cures 
of . cases, unsuppoi’tcd by scientific measurement and 
accurate clinical data, and based on insufficient numbers, 
was in his opinion dangerous, misleading, and liable to 
bring tlio subject into disrepute. Witii regard to inju- 
dicious dosage, this implied a failure to realize the true 
needs of tho patient. Patients miglit be classified as 
those requiring sedative, tonic, and counter-irritant treat- 
ment. It was possible to use ultra-violet radiation in a 
.. sedative way- and also in a counter-irritant way, but tha 
essential preliminary’ before its use was not only accurate 
diagnosis of the disease, hut a careful assessment of the 
condition of the patient; and, further, it was necessary to 
know tho lamp, and what was exactly required of it. 
Ho thought there was no doubt that ultra-violet radiation 
could light up a quiescent phthisis, or give rise to cataract, 
or inercasG a bacterial infection. In a case of chronio 
■long-standing arthritis of tho hip, following a hunting 
injui-y, after the patient had made considerable progress 
with (liathermy the speaker thought he would try ultra- 
violet radiation. The effect was to precipitate a definite 
and acute attack of appendicitis. AVith regard to homo 
use, he was not a party to the general condemnation of 
! the lamp at, home, nor to its general recommendation. 

' Ultra-violet radiation, which was capable of altering the 
lime salts of bones in a very short period, of altering the 
I iint.'ilivo valuo of milk in nursing mothers on tho one 
' hand, and of lighting up phthisis on tlia other, w.as a 
I potent therapeutic agent not to bo lightly installed in 
every room. -But geographical and other reasons miglit 
brill" about a set of circumstances in which, after accurate 
diagnosis and (Ictermiiiation of dosage, and instruction— | 
given an intelligent patient — he might be allowed to usoj 
tho lamp at borne. Any employment of the lamp wliicli went; 
beyond those limits ho would condemn. If the uses of ultra- 
violet radiation wore not to be outweighed by its abuses it 
was necessary that the knowledge with regard to it should 
ho* on firm grounds and the technique capable of accurate 
description. Dr. Heald ventured with some hesitation tO| 
make one ob.scrvation— namely, that in his own experience 
lie was finding a curious difference in clinical results 
obtained, say, with the mercury vapour lamp at^ a great 
distance, at a medium distance, and, with the Krpniayor 
or Fins'en-Bcyn lamp, in close proximity. This was a 
matter which called for more investigation. During tho 
lact five years four thousand fractures, major and minor, 
had passed through his department, and there had not 
been one siimle failure of union. In cases of delayed union, 
sent from infiniiaries , or from tho country, success had 
evoiitually been obtained by the use of light combined! 
with other means. In some of the cases union had been| 
delayed for a long period, the longest being twelve months. 

Dr H, Haldix-D.vvis said that in his department at 
the Royal Free Hospital Dr. Colohrook had made a careful 
investigation of the treatment of varicose ulcers by ultra- 
violet radiation, with regard to which largo claims had 
been made. Slie had foiiiid the radiation practically inert 
in this particular condition. . 

Dr. David Bakcrofi said that lu Vincent’s angina ho, 
had tried ultra-violet radiation in two cases, with good, 
results "in one. In anno his results were distinctly dis-, . 
appointing, and generally, he thought, ultra-violet radia- 
tion was rather like a summer holiday, in that it waa 
a tonic at the time, but its effects evaporated. 

Dr. A. C. Roxburgh spoke of tho detection of ringworm! 
hairs' in' tho scalp by ultra-violet radiation. The patient 
(vas taken into a dark loom and placed underneath a 
mercury va))our lamp, with tho hood closed save for an 
opening about 2 inclies in diameter, across which was a 
piece of AVood’s glass — a dark violet glass containing oxide 
of nickel. This glass allowed to pass certain of tho long 
ultra-violet rays, from 3,600 to 3,300 Angstrom units. If 
the hand wero placed under this emission the skin would 



Feb. i8, 192S] 


OCULAE COJrPLICATIONS OF ENCEPHALITIS LETHAE5ICA. 


[ TnrBr.rtrsn OCT 

HKBICit. JOCRXII. "VX 


l>c seen to fluoresce sliglitly, and the naiU iiuicli more. 
Wieu tlie head of a cflild afflicted with MnalUsporod ring- 
v-onn— M-hicli -was the conuuou kind of ringworm in this 
country — was rxiiosed, the normal hairs looked as though 
they had Jieeu slightly dusted with flour, hut the ringworm 
hairs showed a hrilliant greenish light, which enahled one 
to pick out a single ringworm hair in an otherwise healthy 
seal)). This metliud had heeu found useful in detecting 
early infections in brothers and sisters of patients obviously 
infected. It was as well to rememher that iodine would 
coinpletely j)revent tlie fluorescenee, and silver nitrate 
wmild stop it to a certain extent. 

Dr. G. ^'ILVA^'nRE defended .r-ray therapy from some of 
the critieisms of Dr. O'Donovan. In skilled hands ho 
thmight a* rays as good an agent in the treatment of tuber- 
cnlniis glands of the neck as ultra-violet radiation. He 
emphasized the need foi careful diagnosis of tlie condition 
before patients were treated with the ultra-violet lamp. 

Sir. Zachary Cope commented on the fact that no con- 
, struetive views had been put forward as to the scientific 
ineasnremont of the ladiation emitted by the lamps. He 
liad not ho-^rd a word in that discussion as to the safe 
dosage of u local lesion. It seemed to him that much 
rehiained to he stated with regard to intensity, distance, 
and the area which it was safe to illuminate at one time. 

pr. kEOXAUT) Hirjj, in reply, said that in the measuro- 
nient of nltra-violct radiation biological methods must be 
the^ filial standard. To find out the exact dosage for a 
patient nothing was easier than to put some lund of a 
bandage ou^ the arm or elsewhere, and expo'^e through 
sniull Iioles in the bandage for difFerciit peiiods. Tlie dose 
nhieh produced the smallest amount of erythema should be 
usotl to start with. For estimating the dosage of the lamps 
tlio aeotoiie-blue method was accurate. 

Hr. O’Honov.vx, also in rojilv, said tliat any man who 
wonlo loani to use ultra-violet radiation slionld go to a 
clinic and instruct himself in its tradition.s. These things 
y Cl e only learned hy the ejiperienco of aclnallv seeing eases 
hiindled in the mass. ‘ 


•OCULAR COMPLICATIONS OF ENCEPHALITIS 
LETHARGICA. 

meeting of the Sections of Noiirologv anti 
Uiilitlinlmotogyof the Royal Society of Jlodieineoii Feiiniary 
1 , Miti the president of the Neurological Section, 
1 Bn.istsr^i,^ in the chair, a discussion was 

“yylae complications of encephalitis Icthargica. 

-■ I" OcLLiER, opening for the Neurological Section, 

1 p i.isizcd the difficulties in diagnosis, mentioning 
e pecn, y eases in which no hint ns to the nature of the 
."i'l S‘''cn during the carh- dass of the illness. 
a,\r. ^'1*”°^''® _"’ith rapid onset might closely simulate 

t* speaker maintained that the 

oiistic symjitoms of sleepiness, ojilithalinoplcgia, 
®P‘’"^>'Beons movements, dvsnria, and con- 
1, 'f*' "eie due to the iiosition of the le.sions in the 
1 pH, specific eiualitv of encephalitis 
senuIrrmiT ''t t"o fatal cases with such a 

n’UiPi- p .’.””■'^, 1 '^^ which Was encephalitis lc*thargiea and the 
tiiberri'ilr,,,"^”'^ ' .S‘'?"cng soft tiimonr. Polionivclitis and 
e"amh^ e,,’"r’cl®'*’^ he clistingnishoel, hut 

siclernhiv in +1 ^ r Pniid would help con- 

lelio.?e L i Dr. Collier then dealt with 

Meiitinnimr 'fi mechanism which sul).sen'ed vision, 

ho had lun occipital lobes, the speaker said that 

had Iipen 1 S'] ease in which “ cortical hlindness ” 
l!rii.!nr.,n 'b' « persistent left 

for four i-pors ’'|”‘''".°P*“> per-sistiiig altogether unchanged 
!"na.^ to ti n tlH’ vfsiial path. Wth 

the acute one patient presented during 

Papilb, edema he'’ Inad'' onK- 'ieT‘‘'- ' ‘'Dobulbar neuritis, 

in wi-icb , 1 ; '* ° oaso in any degree 

degrees of siveirm"'’oTthrdN "l^'' 

'Hjo /Hiicoc ^ occur vorv often, 

ill int'ricran!',l'^"r' f“P’^’ocdema might he, firstly a rise 
from local inn'a, '' ossurc, and secondly that the neuritis, 
at the ontle far enough forward to be sceu 

I ISC. Oplitliahuoplegia was met with in two 


forms: paralysis of any of the peri|)horal oculomotor nerves 
might occur, or a nuclear ophthalmoplegia, hardly ever 
complete, affecting both eyes, leaving the optic axes 
tinparallel, might he found. Dr. Collier said that 
ny.stagmus was not common. He had seen it in one ease 
of acute cerchellar encephalitis. Herpes certainly occurred, 
hnt the speaker had not actually seen a case. 

Air. F. A. AVilliausox-Noble', for the Section of 
Ojihthalmology, referred in the fii-st place to recent patho- 
logical work on the disease which had an ophthalmological 
basis, since it began with Griiter’s work in 1910 on 
vateinia of the cornea in rabbits. The outcome was the 
indication of a close relation between the virus of herjics 
simplex and the virus of encephalitis Icthargica, the prin- 
cipal point of difference being the enhanced neurotropic 
activities of the encephalitis virus. Coming to the clinical 
side of the subject, the speaker cnnuicrated the eye lesions 
occurring as a secpiel to encephalitis Icthargica. These' 
comprised jerky eye movements, lack of blinking, hlepharo- 
clonns, partial ptosis, unequal pupils, deficient accom- 
modation, deficient convergence, nystagmoid jerkings, 
diplopia with squint, lid retraction, oculogyric crises, 
sluggisli reaction to light, Argyll Robertson pupil (rare), 
ECjuint (rare), tapping the glohella making the eyes flicker, 
and “ hlinking sign ” (Kinniev AVilson) on lateral devia- 
tion. Of these signs Mr. AVilliamson-Noble emphasized loss 
of power of convergence as being one of the commonest 
associated with the Parkinsonian syndrome : this was also 
one of the commonest eye troubles in jiaralysis agitans. 
He mentioned also the curious tonic eye fits or oculogyral 
crises: these consisted of spasmodic attacks of conjugate 
deviation of the eyes, most frequently vertical, often 
associated with a marked emotional factor. The speaker 
refciTod to the occnirenco of papilloedema, mentiouiug 
four cases, in all of which the diagno.sis of encephalitis 
Icthargica was found to he incorrect at autopsy. 0])tic 
neuritis was also veiy i-are, and the absence of optic disc 
ehunges appeared to be a negative sign of value in the 
diagnosis of encephalitis Icthargica. 

Dr. A. Feilixc: gave some details of his personal expe- 
rience of ocular complications of encephalitis Icthargica. 
He described four cases of ocnlog.vric crises, stating that 
this complication had only ap 2 ieared in this country during 
the last two years. Ho agreed that the presence of papill- 
oedcnia was against the diagnosis of encejihalitis Icthargica. 
AVith regard to the various ocular palsies, during the 
acute stage both the intrinsic and the extrinsic mnscle,. 
were commonly involved. In the sequels or in the ohronie 
form of the clisoase the commonest palsy was one of the 
intrinsic muscles, and consisted of deficient contraction of 
the pupil on accommodation. 

Dr. J. R. Pkiiubau dealt with two jioints in connexion 
with oucephalitis lethargien. He emphasized the high 
])erecntage of wrong diagnoses made among cases of which 
the cerebro-S])inaI fluids or brains had been referred to him 
for examination. He also considered some of the argu- 
ments concerning the relation of the virus of herjies simjilex 
to that of encephalitis lethaigica. 

Air. AI. L. Hixe described a case of a young man, aged 
24, in whom, as a complication of encephalitis lethargica, 
a left heiuianojiia develojied, complete in the lower 
cjnaclrant artel iiartial in the niiper quadrant. This had 
jiersisted unchanged for three years. 

Dr. A\'. J. -Adie emphasized the nitmher of wrongly 
diagnosed cases, and commented oil the difficulty of men- 
tioning definite ocular signs- wliich were distinctive, since 
■so many- ocular comjilications might occur. He thought 
the chief sign was lack of convergence and absence of 
contraction of the pupil on accommodation. 

Dr. Goaoox Holmes cnuntci-ated some of the jiositive 
ocular signs which assisted in the diagnosis of eucciihalitis 
lethargica in the acute and chronic stages. He mentioned 
the '■ reverse -Ai-gyll Robertson ” ]inpil as being common, 
and agreed that papilloedema was rare. 

The PiiESiDEXT added two definite signs which, in his 
opinion, occurred in jiractically no other disease. One 
was the loss of upward movements of the eyes and the 
other was a curious oscillation of the eyeballs when the 
patient attemiitcd to pierform certain inovemonts of the 
eyes. 



Teb. ' 


WUIji;irLE UTERINE. FIBKOID TUMOURS.;'. 


r Twr. EnmsH 
I ilznicki. Jomtii 


263 


MULTIPLE UTERINE FIEROID TU3IOURS. 

At tlie animal mcpting of Uio NoiUi of England Obstetrical 
and Gvnaccologital Society in Manchester on J annary 27tli, 
Dr. H. Lkitb Mi-kkay (Liverpool) ivas elected president for 
the ensiling year. 

Dr.-K. U liAinEY slioircd a specimen of multiple uterine 
fibroids, ivitli torsion of the pedicle of one, and gave the 
folloiving clinical details. 

A woman, aged 36, with a norma) mcnMrnal history and no 
menorrhagia or leiicorrlioca, \\:id definite dysmonorrhoaa of the con- 
gestive t\TQ- She had noticed a “ lump *’ in the right iliac region 
during the last twelve months. This had occasioned no pain or 
other untoward svmpioms until six monllis a"o. when an attack of 
acute abdonimat pain occurrcd-al (ho close of a menstrual period: 
it passed o.T after a few hours,* and there was no recurrence of 
pain until a week before admission, >!ien a similar attack 
occurred, but of greater intensity. During the few days prior lo 
admission the patient had expci'iencod some degree of dysiiria. 
There were no symptoms rclfAtivc to pressure on the rectum. The 
previous medical history contained no points of impoi lance rela- 
tive to tlic prc«:ent co'ndilion. A firm, hard, mobile mass was 
found occupying the right iliac region; its origin from the pelvi.s 
was traceable^ Vaginal examination revealed the covnux to oe of 
a smooth and conical type; the mass, palpable abdominally, was 
continuous with two irregularly rounded, liard, but mobile pelvic 
tumours, which appeared to be situated in front of a somewhat 
bulky uterus and on either side of it. A diagnosis of solid ovarian 
111100111*5, with torsion of the pedicle of one of them, was made. 
On opening the abdomen the uterus was found to be the scat of 
numerous fibroids. The. two masses which had been palpated 
vaginally were two subperitoncal fibroids springing from the 
antero-lateral aspect of the uterus, and possessing definite pedicles. 
Toi-sion of the pedicle of one of them- liad occurred. The uterus 
and its appendages were removed by subtotal liysLercctomy. 

The specimen shown by Dr. Bailey consisted of a rela- 
tively small uterus, which contained iiunievous small inter- 
stitial fibroid tumours, and one larger fibroid, the size of 
n tangerine orange, growing out from its right lateral 
nspoct. The two largo subperitoncal fibroids sprang from 
the antero-lateral asiicct. Torsion of the pedicle of one of 
these had occurred, with resultant haemorrhage into the 
Eubstanco of the fibroid. The other .subperitoneal fibroid, 
the size of a foetal head, had undergone hyaline degenera- 
tion, and there was evidence of calcification in its sub- 
Btance. Dr. Bailey remarked that in this ease there was 
110 history of menorrhagia, and this notwithstanding the 
fact that numerous interstitial fibroids were present. He 
liad operated recently on three other cases of multiple 
titcnne fibroids, exhibiting the tumour in all its situations, 
end in nono had menorrhagia been a sjTnptoni. 


Vtfsfocia clue io Vaginal Atresia. 

Dr. K. Bailey also described a case of atresia ol 
the vaginal vault causing dystocia in a 3-para, aged 33 
who had had two premature stillborn children. She hac 
been operated upon for prolapse twelve years previously 
.and a repair operation, most likely amputation of the 
cemx, Iiad been performed two years before the presenf 
date. The menstrual liistory was nonual, 

when two months pregnant, had suffered fron: 
the urine contained diacetic acid. She gav< 
premature rupture of the membranes in two previoiu 
wn<f st il Ibirtlis. The IVa'^scrmann rcactior 

Rnmft ^ she- was six months pregnant, but there wa-‘ 

■RniioY- CQ, antiseptic treatment wa.s ordered 

and Hin patient first when she was in labour at term 

n^esPDUfini contracting strongly and frequently. Th^ 

Iicad a \crtex left occipito-anterior, but the foeta 

l5-“Ludibr The foetal heart soundi 

rate nf 19R* n, patient was becoming distressed, with a puls( 

Skrnal os“io f flir-the 'T l"” 

n bind cnniT Aty 'apnal vault was entnely closed, ant 

posterior direrlion^^n^v^ souicwhat obliquely in an antero 
The uterus ncrn?Ti' the middle of it. During cxaminatioi 

bnVed under lension'^olf^'^'o'^ ®^.^ongIy, and the vaginal vaull 

ohvTous that there ivarcon^ 'waWe M '* 
the viiilf nF +i,r. • ^""^uierable thickness of tissue composing 

chhd bv CaeUoL d<='ivercd a. health.v mali 

possible and rend^WnS^ ?i ^ vaginal vault m 

vaeinal vviiU n<s olr”” i- space between this line and the 
progressed ilry 'favoOTab'ly!' The patient had sinci 

i^’i 15 t.\cey (SlieffielcI) described a similar casi 
T ""1. /vr 1 V Caesarean section. Dr. F. H 

nnitiiro^ r'lt >cster) recorded a case of this kind in wliicl 
retnml ’’r''"'" ““"’'''‘''I cari.v in labour and liyster 

Bttribntod* Professor Dos.\t.d (Manchester 

ho -presence of excessive scar tissue- in thi 


vagina following* colporrhapliy to the use of strong and 
harmful anti.scptics. Professor Fletcher Shaw (Man- 
chester) mentioned recent cases of sloughing and stenosis 
of tho vagina following the use of methylated spirit as an 
antiseptic. 

Puerperal Ovarian Throinho-phlchitis, 

Dr. S. B. Herd described a case of puerperal ovarian 
thromho-phlebitis. 

A married woman, aged 30, had had four previous confinements, 
all normal except for oedema of legs during the last three 
months of the fourth pregnancy. During the present pregnancy* 
the ankles wore oedematous in the course of the last two weeks. 
She was delivered fairly easilj* at home by high forceps, but she 
was admitted to liospital on the third day after delivery with 
a temperature of 100,4° F. and a pulse of i20. There was slight 
iaundice; she looked ill, and was anaemic. There was oedema in 
botli ankles. The lochia was normal. The uterus was tender but 
well involuted, and no swellings were palpable. The urine con- 
tained no pus, blit there was a feeble growth of staphylococci. 
The temperature fell on the next day, and the uterus continued 
to involute; at this time the blood culture was negative. On the 
eleventh day another rigor occurred, but there were still no 
localizing symptoms; she was given scrum, quinine ergot, and 
pituiti'in. On the twelfth dav there was tenderness in the 
popliteal space and left calf, but no vein was palpable; there 
was tenderness in the left fornix, but no swelling. The uterus 
was normal. On the following day a blood culture showed strepto- 
cocci in chains. On the fourteenth day the abdomen was opened 
and the Icit* ovarian vein was found to bo thrombosed, the 
thrombus extending almost, if not quite, up to the renal vein. 
Ligature and excision of the left ovarian vein was performed, and 
the left ovary was removed; no other abnormality was found in 
the abdomen. The patient suffered severel}* from shock after the 
operation and died fifteen hours later, in spite of blood trans- 
fusion. There were no further rigors. - 

Dr. Herd discussed the literature on the subject, and 
mentioned the difficulty of early diagnosis. The con- 
clusions he drew from the case were: (1) the importance 
of early diagnosis; (2) that complete excision of tho vein 
was preferable to ligature; and (3) laparotomy might be 
perfoimed earlier in obvious cases of pyaemia where the 
patient was rapidly becoming worse in spite of active 
trca-Jtinent. 

Professor Miles Phillips (Sheffield) did not consider 
that laparotomy was justifiable in a serious case of puer- 
peral septicaemia unless tho diagnosis was certain. 


TUBERCULOSIS OF THE SEIX AND TENDON 
SHEATHS. 

The annual meeting of the Devon and Exeter Medico- 
Chirurgical Society was held at tlie Royal Devon and 
Exeter Hosj^ital on January 26th, when Dr. R. Eager 
inducted Mr. A. L. Candler, the newly elected i>resident, 
into the chair. 

Mr. Candler shovred a case of tuberculosis of the skin 
of the finger and of the .synovial sheath of the flexor 
tendons in a man aged 55, a herdsman. The historv 
dated back to July, 1927, wlien lie remembered having 
received a bruise on his right wrist following a blow 
from a cow’s log. He had been unable to work since 
August 20th. Fluid had been present in the anterior 
common synovial sheath since early in September. The 
skin had improved under treatment by ultra-violet rays, 
but the synovial sheath remained swollen and tender. Dr. 
Solly had found tubercle bacilli in the inflamed skin in 
September, and this had added a medico-legal interest 
to the case in that tuberculosis had been prevalent in the 
wrist in question. Mr. Candler concluded that from Jiis 
own experience excision gave bad results owing to the 
risk of subsequent adhesions ; he had in view the possi- 
bility of aspiration followed by an injection of ether into 
the synovial slienth. 

Dr. Miller Muir suggested a prolonged course of ultra- 
violet rays before trying any drastic remedy, but IMr. 
Candler considered that from the wage-earning point of 
view this was undesirable. 

Gas G^onprc7ic FoUorring Fracture, 

Mr. R. Wayland Smith reported a case of gas gangrene 
in a bov, aged 3L '^ho was admitted to hospital on 
Januarv*17th with a compound fracture of the left fore- 
arm, having fallen through the roof of a shed where root.s 
were stored, thus causing contamination of the wound. Tbe 
'Wound was cleaned under a general anaesthetic, irrigated 






266 


Feb. i 8, igrS] 


EEVIEWS. 


arSiL'iSi SSS' „d 


r TiiRUBrnsB 

L JlKOJClL JOCRXAS 


HERNIA AND HERNIOPLASTY 

oporative treatment. Mr. Cowell sft out very Sly t o 
present position, and has, moreover, succoSlod i^n hitr^ 

s?= “-'if ■"Sr.r- fi 
-s&is't ?,rf“ ?/ ss“/ib5 

and 1 ;:e?nfa''P*^^^ Impact of XrniJ 

It must b^dmittn “"'P'eto a laluablo study. 

- s«r;x 

.|3EMXi-jS;.-££ 


1 history of medicine. 

\N e welcome tbo aiipearaiice of a fmo volume on tlie history 

subTeet''^"’I?^V''•• C.isTiGLio.N-r, professor of thaT 

subject m the IJniversity of Padua, to whose liistorical 
contiibutions we have drawn attention on several previous 

lll7Xz29‘r ®24f 1108; 

Although the number of persons intorost-cci in tlio liistorv 
of medicine is undoubtedly as great in Italy as Nowhere 
^ IS more than three-quarters of a century sfucc a complete 

fessni-r" appeared in that country. Pro- 

fessoi Castighoni has made good this defect by uiulCTtakiim 
a work winch deals with the history of niedidne f rom 
prehistoric times down to the present day, hiS.i an 
IiidoM °A ^^aaling art m Mesopotamia, Ancient E^ipt 
a.^^ Z’FaTEast P-^'^l^bian Anm^-fea 

a. i tiie X ar East, classical antiquity-, tho Middle A<»es tho 
Rima.ssance, and subsequent ceiituides. ° 

Professor Castighoni has combined a broad and nbilo 
“astery of an enormous amount of 
detail, which he has so skilfully arransed as never n 
tedious. It IS gratifying to find that the author has done 
ample justice to British medicine, as shown by his app,47a! 
tion of Harvey, Sydenham, the Hunters, Jennei/Lisfer 
and of British medical historians such as Friend T F 
Payne, Osier, and Allbntt, as well as living workers^ in this 
county. The text is liberally interspersed with excellent 
reproductions (some of them in colour) of contempor.a w 
sculpture, buddings, manuscripts, books, pictures and 
portraits relating to the history of medicine A snecial 
bibliography is appended to 'each chapter, and a general 
bibliography of books dealing with the history of medicine 
its special branches, or particular diseases will be 
at the end of the book. 

Professor Castighoni is to be warmly congratulated on 
his work, which deserves to rank among tho most authori- 
tative and readable books on the history of medicine. 


F n c's" n e'!'' Ucrniotitutty. By Ernest M. Cowell. D.S O., M D B S 
Lon', Ion- H * ir introduction by Sir .Arthur Keith. F.U.C.S., F ji <?’ 

IMunce " Unni>s;''-"'i 9 ^'‘’-„,'h''„ Arturo Castlclionl. Mil.m : .Socipta 
'• Wi X “J. PP. li + 959; iS9 fljrures. L.120.) 


In a small ‘^fKCULATORY DISORDERS. 

V ?n hypertensive diseases' Dr Eskh 

S'hdcn/n^r^^ arterial hypertension in the light of recent 
tin T : experimental work. He recogniaef throe main 
t’ ,'S. essential hypertension, insidious in 

svrantoms'^ a'”'" absence of oedema or renal 

S va,a'aHono‘T Pressure, and by abnormally 

laigo laimtions of systolic arterial pressure. This tvpe ho 
believes to bo due to a disturbance of tho vog^tive 
nervous system of unknown origin. Such patients live fl? 
fifteen or twenty years and, if they do not die from 
cerebral luaemorrhago or cardiac failure, end in a condition 
of renal insufficiency. The second type is hypertension 
associated with acuto glomerular nephritis; in this the 
capilhary pressure is raised, oedema is present, and the 
daily blood pressure variations are normal or but slightly 
'^^n.ggei ated. The disease is considered to be dependent on 
a general capillary damage duo to circulatiug toxic sub- 
stances .and associated with a functional arteriolar spasm. 
A\ bile \ cry few of .such patients die in the acute attacks 
and a number are left with permanent kidney damage, tho 
majority recover entirely. Cases of hypertension with 
chronic kidney disease form the third type, called permanent 
hypertension, and this is held to bo a later stage of either 
of the first two classes. Such in outline is the author’s 
working hy])othesis. It is evident that no clear conception 
of arterial hypertension has yet been reached, and that 
almost nothing is known of either its mechanism or 
causation. 

In a book describing tho peripheral circulation and its 
disturbances,' Dr. A. Dumas of Lyons brings together a 
largo series of clinical observations, many of which havo 
been published previously in French medical journals. Tho 
various maladies are described largely in terms of blood 
pressures and of indices obtained by the Paclion oscillo- 
meter, an instrument which has not found much favour in 
this country. Throughout the book there is no departure 
from tho somewhat obscure terminology that is commonly 
associated with descriptions of such vascular disturbances, 
and, as too often happens, the reader is left at the end 
wondering what exactly is meant. It is difficult to avoid, 
tho feeling that much information might havo been 
gathered from all this varied clinical material if different 
methods of study had been adopted. Tho book reveals 
clearly how little is known about the diseased conditions 
affecting the peripheral vessels. 

CRIMINOLOGY. 

Two more volumes have been added to the Notable British 
Trials scries, both dealing with accusations of murder, in 
each of which tho accused was a young woman of pleasing 
aiipearance, involved in the troubles of love affairs. In tho 
Scottish case the verdict was “ not proven ” ; and there is 
littio doubt that, if the law had allowed it, tho samo 
verdict would have taken the place of “ not guilty ” in 
tho English case. The Trial of Madeleine Smifh‘ in 1857 
is interesting for the light it throws on mid-'Victorian 
montalitv apart from the interest of the question how 
lins of arsenic found their way into the stomach of 

Tn 1 * A T’lirtT*rx -Jo oiTTmrtn+. nlcrt 


82 <’’rains ot arsenic lotmu uiicn utij inuu miu ot^uinucii ui 
tho'’lover, Emile I’Angelier. There is entertainment also 

I’n the florid defence by tho Dean of Faculty, John 
ill +l,a T.a.vl 


in the florid detence oy viic uean oi nacuivy, noun 
Ino-lis who, after praising tho moderation of the Lord 
Ad'vocate in his speech for the prosecution, proposed to 
‘‘ tear to tatters that web of sophistry in which tho prose- 
cutor has striven to involve this poor girl and her sad, 
stranee .storv." The Trial of Adelaide Hartletf’’ in 1886 
raisoiT the extraordinaiy’ question whether it was possible 
for a poisoner to get a largo quantity of chloroform down 
tho gullet of her victim ; and if Adelaide Bartlett was 
giiiltv we agree with Sir James Paget that, once it was 
all over, she should have told us, in tho interests of 


• Dir Hvncrliiili‘-lTa”’ ’ieiten. Von Pr. Eakil Kylin. Berlin : J. Springer. 
IHov Svo np viii + 195; 22 figures. R.II.S.IO.) 

^ r 7*(i Circiiietiev Sntiytiiiie jH-riphi-riqiie el see Troubles, Par Dr. A- 
Dunms. Paris : G. Doin et Cle. (6i x,91. PP. iv + 376. 40 fr.) 

* Trial «/ ^latfAcinc St.uth. LaileJ by Tennyson F. Je^so. Notabia 

British Trial-* Dllnbnrtrh anti London: \V. Hod"c and Co., Ltd. 1927. 
fDemv 8\o, pn. xl 10 plate". 10*. 6d. net.) 

® Trial «/ t^leloitlr Tartlrtt. Edited by Sir Jolin Hall. N’otahic British 
Trial". E<linbiirgh and London: \V. ilodge and Co., Ltd. 1927. (Demy, 
Bvo. OD. ^02 ; 8 plates. lOs. 6d. net.) 



PiiB. iS, igsS] 


HEALTH OP THE NAVY. 


r - Tht. nprn«a 
MrnicAL JocR>Ai. 


267 


science, lion- slio did it. In tiiis case Sir Edward Clarke 
enhanced ononnouslv his reputation by the skilful defence 
he put up. Both the trials displayed the difficulties and 
weaknesses of medical evidence. In both the sumining-xip 
was masterly; but we prefer tbc Scottish Lord Justice 
Clerk’s charge in the Madeleine Smith case to that of Mr. 
Justice AVills. The Right Hon. John Hope told the jury 
that they were not to give the slightest weight to the 
personal opinion of tho Lord Advocate in prosecuting, or 
to tho moving declaration of conviction of innoccnco by the 
Dean of Faculty for the defence. Perhaps the saddest 
thing in these trials is to watch tho attempt of counsel 
to instil by rhetoric into tho minds of twelve presumably 
rational beings that black is white or vice versa. 


NOTES ON BOOKS. 

One of the most popular among the Students’ Aids Series 
is the Aii/s to Ophthalmolog!/,'^ the seventh edition of which 
by Mr. Bishop Harman, is to hand. It is more than twenty 
years since the writer of this notice first made the acquaintance 
of the work as a medical student; it gave him the maximum 
of necessary information 'in the minimum space, and he has 
never ceased to advise students preparing for the final ex.amina- 
ticn to^ use* it as it is meant to be used. As an epitome of 
theoretical ophthalmology it would be hard to beat ; the descrip- 
tions are clear and accurate, while tho liberal provision of 
illustrations adds enormously to its value. The present edition 
has _ undergone revision. More .space is now devoted to the 
subject of glaucoma, while two new chapters h.ave been added — 
one on the eye signs of general disease and the other on tho 
blind. Both are excellent, particularly the latter. The author 
IS to be congratulated, and we are sure that his little book will 
conlinue to appeal strongly to students, who, as a rule, resemble 
Mr.s. Gamp in liking their beer drawn mild. If they feel the 
need of audit ale there are plenty of larger textbooks on the 
market which supply it. 


^ t’i;^-AsH's small book On MidtUe A^c and Keeping 
t ”1*^ • y^tten in simple langii.age and contains the laws 
ot physiological righteousness and much common sense for the 
readers the lay public — for whom it is obviously suited. It 
'i- "I popular edition of an earlier book with a 

slightly different title, and contains a new chapter on anto- 
into.yication, which, with nerve strain, the author regards .as the 
greatest factor making for ill health in men and women in 
le prime of life. If complimentary, ho is fortunatelv very 
premature in lu.s reference to “no less .an authoritv than the 
• * *1 ®*^.*‘‘’*‘^''’hiild Garrod,” to whom he ascribes a dictum on 
gout which probably came from his father. Sir Alfred Garrod. 

T Catholic Kiirsc,^- by Father Richard 

■ j vdnsists of twenty chapters dealing with the 

rolmin,,^ . "■“'■h in hospital and private houses, her 

’n'^imlmg bagtlsm of infants and preparation 
aftiind iij® sick and extreme unction, and her 

attitude towards non-Catholic patients. 


r R C ^1* lli*’hop Harman, M.B.Cantab., 

1^23 CFcnn edition. London: Bailliire, Tindall and Cox. 

" On ItZar J + 112 fiw.rea. 3a. Od. net.) 

London - M il, at*'/ n"'‘ By E. L. Hopewell-Asli, JI.D. 

■= rL' Co V ™’ 8vo. pp. 121. 3s. 6d. net.) 

Murnhv SJ 1927 Spirit and Her Duties. By Richard J. 

^Slnlb PnblUliin, 


preparations and appliances. 

Wi- ^ - Tabloid QuixopnAH, 

a specimen ^or''fahi^°T Burroughs Wellcome and Co 

plionyl cinchonimV qu’aophan,” which is a preparation oi 

Kest*^^ (U.S.P,, X), This dm, 

its power to* increase Ibl actions— namely, 

pyretic action. It Tppt4tn“’r“-™ 

steadily. The makers >1,^ i? '““^easing in popularity fairlj 
quiiiophan is exceptional P''’*'*^ ‘“bloic 

Urilish PharmacopoZt CoTci ° ‘ 

A snrinn B*I.ASCi: FOB DiADCTICS. 

by Messrs George Ti’t' 

Eland at the Britisli TaU, . • shown on then 
February 20th to March P Bromwich 

balance,^egistoriugu;t8\"BtJ.‘ " 


THE HEALTH OF THE SEEYICES. 


THE -XAVY. 

Axxttal Report for 1925. 

As usual, the annual report on the health of the navy* 
is a year late as compared with those of the other fighting 
forces. This delay precludes a comparison of statistics, 
and tho out-of-date figures and remarks have ceased to 
be of real interest. It might perhaps be suggested that if 
the present office staff is unable to cope vith the work there 
are several “ unemployed ” officers ■who might thus be 
tiscfully employed.” Besides being out of date the na-^y 
report is also the most expensive of such publications. 

Over seventy pages of the report are devoted to statistical 
tables of vaiwing interest, but no information is given as 
to rejection of recruits. The report as a whole is an 
improvement on previous issues in that the general remarks 
are more informative, but even in its present form it cannot 
be considered entirely satisfactory. Too many pages are 
occupied in putting into words tlie bare numerical facts 
which are later repeated in tables. 

The report for 1925 deals with the health statistics of a 
total force of 89,950, an increase of 2,330 compared -with 1924. 
The ratio of admissions was 464.78 per 1,000, a decrease of 
21.46. The average number of men sick daily was 21.45 per 
1,000, a decrease of 2.18; the death rate was 2.82 per l.COO, 
a decrease' of 0.27, and the number finally invalided, 1,412, 
giving a ratio of 15.69, also shows a decrease. 

The chief causes of admission to the sick list were injuries 
(7,133 cases), catarrh (6,098), gonorrhoea (3,971), and tonsillitis 
(2,746). There is a decrease in nearly all the diseases caused 
by infection. Vaccination, and revaccination everj’ five years, 
probably accounts for the fact that only 2 cases of small-pox 
occurred, both on foreign stations; the total number of vaccin- 
ations amounted to over 21-.000. An epidemic of enteric in the 
Emperor of India accounted for 17 of the 32 cases: the outbreak 
was probably clue to contaminated food supplied by the canteen 
■while at Kavaln, was confined to boys belonging to one mess, 
and was generally mild in type, duo to preventive inoculations 
within five to nine months prior to the outbreak. The routine 
measures taken to prevent enteric diseases include lectures and 
notices, the clilorination of drinking water and sterilization of 
milk, the prohibition of uncooked vegetables, the regular medical 
examination of all ratings engaged in handling food, the 
bacteriological examination of those who have recently had 
enteric fever, and prophylactic inoculation. Influenza shows 
a large decrease, great attention having evidently been paid 
to preventive measures. There is a slight increase in the 
incidence of pneumococcal infection of the lungs, but a decrease 
in that of rheumatic fever. Pulmonary tuberculosis accounts 
for 221 cases, with 197 invalidings and 31 deaths, a slight 
increase in incidence compared wdth the average for tho four 
years 1921-24. The East Indies Station shows the highest 
case ratio and the North America and W^est Indies Station the 
lowest; the ratings mostly affected were Kroomen, the regulating 
staff, telcgraphi.st.s, supply staff, and cooks — -that is, excluding 
coloured ratings, those working between decks. Venereal diseases 
show a case ratio decrease of 10.13 compared with 1924, and of 
27.35 compared with the previous four years’ average. The 
methods adopted for the prevention of these ciseases, in addition 
to lectures, recreation, and physical training, include improve- 
ments in the means of early diagnosis, facilities for returning 
on board at night in foreign ports, and the provision of anti- 
venereal outfits and ablution cabinets. Data are being collected 
as to the relative merits of calomel cream or a 1 per cent, 
mercuric iodide soap as a prophylactic. Diseases of the respira- 
tory system show an increased incidence of 3.59 per 1,000, and 
diseases of the digestive system an increase of 2.48, as compared 
with 1924. Alcoholism accounts for 40 cases, ^Yith 10 invalidings. 

General injuries account for 272 cases, with 111 deaths, 
69 of which were due to suffocation occasioned by the loss 
of Submarine ^11, and 26 from drowning. Local injuries 
amounted to 7,583 cases, with 58 invalidings .and 10 deaths. 
There were 3 cases of wounds in action and 10 of suicide. 

The total number of deaths was 131, the causes being suffoca- 
tion (69 cases), drowning (26), wounds, fractures, etc. (24), 
suicide (10), and burns and scalds (2). Tlie chief causes of 
invaliding were diseases of the eye (256 cases), pulmonary 
tuberculosis (197), and diseases of the ear (144). Sequelae of 
gonococcal infection, which usually head the list of invalidings, 
now take fifth place with only 63 cases. Thirty men were 
invalided on account of having refused surgical operations, 
chiefly for hernia. 

1 Report of the Health of the Navy for the Year 1925. 

London : H-IL Stationery Office. 19?7. Price fls. 6il. net. 



268 Feb. i8, igaS] 


beaijTh of THF AKMX. 


r Tj(k BamsH 
I DiciL Jochsit - 


Witfi reg.ard to (lenlisfry, it is rpcordod Ui.it (Iicrc is 
o general improvement in the quantity of work performed 
and an increasing demand for treatment. Definitely belter 
dentiil condition of pensonnel, with evidence of greater care 
bring taken witli regard to oral cleanliness, is e.speeially 
noticeable among boy.s who have recentlv ’Jeft the training 
cenlre.s and whose dental condition is noted .is veiy .satis- 
factory. Of newly entered recruits about 31 per cent, required 
e.vtensivo and 63.5 per cent, limited dental treatment to 
render them fit for service. 


THE ARjMV. 

Aenuai, Repout Fon 1926. 

The Army Medical Department at the W.ir Office is again 
to be eongratnlatcd on its ('iitlcnvoiiv tr> issue the uiinuat 
reports on the health of the aiiny before their value has 
diminished. 

The report for 1926, which lias just been is.sued,' contains, 
as in previous years, the I'arioiis statistical tables which 
are essential for administrative pnrpuscs and yearly com- 
parison, while the attempts hitherto made to render each 
an instructive volnnio for all medical officers and a 
periodica! contrihntion to scientific literature on the 
diagnosis, research, and tieatnient of disease in the army 
are continued. This finictiun of the report is of much 
importance, and a copy should he in the liamis of every 
medical officer to enable him to obtain np-to-date official 
information connected with diseases in the army. 


.IrfwMsio/i I'atrx. 

In general the health of the troops at home and .ihroad in 
192b W.1S satisfactory, .ilthougli there was a slight increase in 
the admission rate compared with the previous year. The 
death rate remained the same, 'and there were further rcductioiis 
in the invaliding and constantly sick rates. 

The principal causes of admission to hospital, insnltding, and 
inefficiency on account of sickness in hospital, are tahulated, and 
the notes on diseases draw particular attention to the loss to 
the army occasioned by the more oominon ailments. Two 
charts .showing the admissions for prevalent dise.ises at lioiiie 
and abroad, eveept India, are published for the first time, 
with a view to impressing upon all medical officers “the 
necessity for constant and unremitting attention to the research, 
investigation, and treatment of these ailments.” It is pointed 
out that the ratio per 1,000 of men coiistaiitly in hospital for 
the more common diseases was 1,217.79 in 1925 and 1,154.95 in 
1926, while the number of working days lost to the .ii-my at 
home on acooiiiit of these diseases was 444,493 in 1925 and 
421,557 in 1926. 

The admission rate for officers, ivitli an average strength of 
9,835, was 298.4 per 1,000, compared with 296.3 in 1925. The 
death rate fell from 4.44 per 1,000 to 4.27 in 1926, wliile there 
was also a decrease in the constantly sick rate from 13.46 per 
1,000 in 1925 to 12.76 in 1926. The admission rate for other 
ranks, with an average strength of 189,906, was 454.8 per 1,000, 
compared with 446.2 in 1925. 

The chief causes of admission to hospital were similar to 
those of 3925, malaria heading the list ivith 10,159 admissions, 
tile ratio per 1,000 showing an increase from 51.8 to 53-5. 
Venereal di.seases (7,795 cases) come next, with a decrease of 
795 cases on the .1925 ad.missions. The ratio per 1,000 has 
f.illeii to 31.2 for gonorrhoe.i and 3.8 for syphilis. Then follow 
tonsillitis (6,420 casesj, inflammation of areolar tissue (4,434 
c.ise.s), influenza (4.360 cases), bronchitis (3,116 cases), and 
sprains (2,571 case.s). The ratio per 1,000 increased in 
influenza and tonsillitis, and decreased in bronchitis ,ind 
sandfly fever. 

Wliile .some commands show an increased admission rate on 
that for 1925, others show a marked decre.ise, .such as North 
ci'-ina, from 909.4 in 1925 to 698.0 in 1926, and West -Africa, 
fiom 1,016.8 to 881.0. 

The death rate remained the same as in 1925. 

'I'lie ratio per 1,000 of invalids discharged from the army 
fell from 11.12 in 19^ to 10.68 in 1926. The chief causes were 
again iiiFimmation of the middle car, tuberculosis, and valvular 
disease of tbe heart ; the two last causes, however, show a 
Sliebt decrease. Investigations are still proceeding witli a view 
to redneing the wastage caused by middle-ear disease. 


.Sic/.-ncss and of Worhing Day*. 

As .ilreadv pointed out, particular attention is drawn under 
notes on diseases to the part played by the commoner ailracnls 
among troops. -Along with two charts, supplementary figures 
are given showing tfie average constantly sick and tbe total 
wmkiiig Hay,, lost Ijoth at home and .abroad, eiiipbasizing their 


* on 

London : IL5L 


ihr Health vf the Aitny for the Veor Vol. Jxii. 

Slalionerv Office. Price 35. 6d. n<*t. 


iniporl.inco front the point of view of military efficiency. 
ATmere.ll diseases at boine show an average constantly sick of- 
316.61, with 115,563 working d.iys lost, for 1926, ‘ followed 
clo.sely by local injuries, with an average constantly sick of 
276.44 and 100,901 working day.s lost. Diseases of tlio digestive, 
system, other than tonsillitis and dise.ises of the liver, come 
next, with 209.12 constantly sick and 76,329 working days 
lost. Abroad, except India, the order is the same. Venerea! 
diseases show an average constantly sick of 298.50, with 
103,9.52 d.iy.s lost; local injuries 96.87'aiid 35,348 respectively; 
.iiid diseases of the digestive s.vstem, other than tonsillitis and 
■ liver di.seases, 90.84 and 33,157 respectively. The 'cliarts and 
tables wilt repay careful study, 

Di*t'a*cs of tfic Digestive iSggtcm. 

Dysentery aceomifed for 1,048 admissions, of wJiicli 892 were 
reported from India. Of these 692, 230 were diagnosed amoebic, 
303 bacillary, and 359 group dysentery. The increase on the 
1925 figures is largely balanced by a material reduction in the 
imniher of cases diagnosed colitis, wliich fell from 207 in 1^5 
to 45 in 1926. Particular attention must be drawn to the 
reduced incidence in Iraq, which was 7.1 per 1,000 in 1926 
compared with 19.0 and 38.6 in previous years. 

Enteric fever .shows a decrease. Iraq h.id the highest inci- 
dence with 4.4 per 1,000, with India second witJi 2.7. An 
indication of the degree of protection afforded by inoculation 
ill India is seen in the fact that the proportion of cases in the 
unprotected ns compared with the protected was 7.7 to 1, and 
of deaths 10.4 to 1. 

As in last year’s report, diseases of the digestive system 
are dealt with at length, both medically and surgically, and 
the results of some investigations carried out at Aldershot and 
Woolwich are given. 

The work of tfie .special departments— medicine, surgery, 
hygiene, and pathology, together with an account of deiifai 
u'ork ainone troops and the examination of recruits, form 
interesting reading in Section II of the report. Tiie results 
of research and investigations should be helpful to those ~ivho 
are interested in Ihe special subjec'ts. 

A summary of tlie measures adopted by the Government of 
Iiidi.i to combat nialari.i in military stations in India is 
included -in Section HI of the report, which gives detailed 
statistics and notes on the health of tlie troops in all commands 
at home .ind abroad, and of the women and children on the 
strength of the army. 


MEDICAL R ESEARC H . COUNCIL. 

AimUAL REPORT. 

{Concluded from page Hi.) 

II. 

Di.sonnEits of the Exchetohy System.' 

At Guv's Hosiiital, London, Dr. A. A. O.smaii ha,9 coii- 
riiuied'his work oil the prevention of nephritis after 
-carlct fever and he has extended his method of giving 
alkalis to other forms of nephritis. Evidence has been 
obtained that alkalis, used propliylacticallv, can avert the 
of 'aiiuri.i under conditions in which tins symptom 
"r.noulv occurs, and that thi^; can effectively protect 
the kidiicv and prevent nephritis following exjiosnre to 
infection. niet,iHic poisoning, bodily ovcr-cxcrtion and 
witli general anaesthetics. Dr. Dorothy S. 
Rii^ell under Professor Turnbull, at the London Hospital 
Iia- been dcfei'mining the correlations between clinical 
cliemical tests of renal efficiency, .and tlio macroscopic 
ml TnRrotcopic anatomy of the Iridney. At Manchester 
Prefossor Shaw Dimii has been working with cxiicrimental 
Iienliritis studying the changes produced in the tubular 
vHcm of tlie'kidncy. Dr. S. L. Baker, at Middlesex 
Bospital, London, has also been investigating expeninontal 
lepbritis. 

Disom>Eit.s OF THE MEnv'ons System. 
c;.. PI, ..vies Ballaiice’s study of nerve suture at tlio 
National "liistituto has proceeded. Dr. M. Critcliley lia.s 
wen workiiig on cerebral -irterio-sclerosis at the Aational 
Hospital, gSeen Square, London. Ho ,s analysing the 
.■linical sviidronios usually simkeii of as 
lisc-’se Part of the work i.s concerned with the blood 
vi-CKSure variations in cerebral nrtcrio-selero.sis examined 
ivith a view to eliciting points' of prognostic value. Dr. 

I A ilcClnskie is continuing his research at Gia.sgow on 
Ii«erniii.ited sclerosis and neiiiosyphilis. Ho lia.s reeeiitly . 



Feb. - i 8 , 19=81 


■MEDIOAri EESEABCH COUNCrti. 


[ TREBRmrt 
SIedicax. Joirs!rA£ 


'directed liis .attention chiefly to tho conditions required 
for the cultivation of spirochactes. At the Eoyal Hospital, 
Sheflicld, Professor Hall and others aro studying tho 
rigidity and slow movements as sequels of encephalitis 
lethargica. The nitrogenous metabolism, including tho 
creatin excretion, has been followed up by Dr, Imrio and* 
M. Hirst in cases with marked rigidity. 

Mental Disorders. 

At Cambridge Miss L. G. Fildcs continues her inquiry 
into the causes of mental defect in children, with special 
reference to the psychological nature of congenital audi- 
toi*}’ aphasia or word-deafness. Detailed study has also been 
made of certain abilities among the mentally defective, 
especially of their discriminative perception of size and of 
form. Dr. G. W. Pailthorpo is investigating mental con- 
ditions and criminal olfences. She has examined psycho- 
logically one hundred cases in rescue homes, and spent 
a summer vacation in visiting prisons and rescue homes 
on the Continent. Dr. F., E. Reynolds, at tho Scottish 
Asylums Research Laboratory, Edinburgh, has been explor- 
ing the paths of infection of the brain, meninges, and 
VenoUjS blood sinuses from neighbouring foci of inflam- 
mation. 

The Guxns or iNirnxAi, Sechetiox. 

At the Lister Institute, Professor V. Korenchevsky 
with Miss M. Schultess-A'ouiig, lias been endeavouring to 
isolate the active principles of the testes and prostate. 
[Results so far obtained indicate that active substances 
are present in both lipoid and protein-like fractions of 
the sexual glands. Other work on the parathyroids 
seem.s to show that the parathyroid hormones and 
insulin are similar in their action upon nitrogen meta- 
bolism, and antagonistic to that of the thyroid gland. An 
mvostigation on the influence of parathyroid secretion on 
DOTo formation has been in progress at Newcastle-on- 
by Professor D. Burns and Mrs. Burns. Dr. A. S. 
Parkes and a group of workers at University College, 
I^ndon, have studied the internal secretions of the ovary; 
they suggest the hypothesis that there is an alternating 
dominance in the complete reproductive cvcle of oestrus 
producer and oestrus inhibitor, each capable' of being over- 
ridden in its nntur.ally dominant phase by an artificial 
augmentation of the other. At St. Bartholomew’s Hos- 
pital, London, Dr. Scott Williamson and Dr. Pearse have 
con miied their work on Graves’s disease. They believe 

ere is a true secretion by way of lymphatic vessels 
w lie 1 contains no iodine and is the intoxicative factor in 
’rac es s isease, while the stored colloid material contains 
the iodine m thyroxine form. 


■ Tlr r 4 ®'“b=tcs.- Insulin; Synihalin. 

taro ..ooi ’ has shown that inunctions of insulin 

R -n T I;'* for subcutaneous injections. Dr. 

ta ’ j 1 nnd Mr. R. A. McCance have been making 

cornmnn frr!rl' of the carbohydrate content of 

nreseiit A on estimation of the pentose 

s'* s. -i?. s.. in 

aninnls It insulin in human beings and 

stimuhtion nf ^,'}yS®sted that this effect is due to the 
trHir in sefr ^ thyroid and adrenals. The clinical 

known as Tvntlirn^'^^l ‘"'Suanidyl derivative 

Svnthalin cnTinot i* already been reported. 

but is thoufi-ht t 1 as a substitute for insulin, 

but IS thought to deserve further investigation. 


hfost nf tlio r- 1 TeUEIICULOSIS. 
logical or serolop^al”" disease has been of a bacterio- 

bridge. Hrin^sr .^ ^'® tb® field laboratories, Cam- 
the chief cause of tide" * bovine tubercle bacillus is 

the only tvpe of bacilks‘'fl?'a “ ''?™^,®tic mammals, being 

Tho avian' bacillus howp/ i'^ 

of localized tuberculosir' ’ 

supplied from Smithfip 1 ,l"\r^'^i’”®\ bundred pigs 

Toting after beine ppp!? blarket by Colonel T. Dunlop 
bacillus has been found'^™"'^'’ tuberculous, the avian 
Griffiths has ako stL-"a““r" P'^'’ D''* 

Calmette’s “ B C n » the immunizing effect of 

vaccine when given by the mouth. 


and the results so far do not confirm the conclusion of 
Calmette that susceptible animals can be protected 
against infection with virulent tubercle bacilli by feeding 
with “ B.C.G.” Professor S. L. Cummins has continued 
his studies of sanocrysin in tho treatment of selected 
cases and further experiments. By careful selection of 
patients tho results gained with sanociysin appear to 
justify the hopes Trofessor Cummins formed of it during 
his initial tests in 1925. Dr. R. G. Bannemian, at the 
Cripples’ Hospital, Alton, has confirmed Sir Almroth 
Wright’s work that the tubercle bacillus grows more 
luxuriantly in normal plasma than in that of tuberculous 
patients. Ho has also improved upon tho usual method 
of performing tho “ sedimentation ” reaction. The Tuber- 
culin Committee has been active, continuing to advise the 
Ministry of Health upon the tests to be exacted for herds 
producing graded milk. Alost of tho committee’s work 
is given to the examination of particular forms of tuber- 
culin advocated for the treatment of tuberculosis in man. 
In no instance, so far, have these new varieties of tuber- 
culin been found to - have any advantages over the 
tuberculins already in use by tho profession. 

Cele axd Tissue Growth. 

Tho investigations at the Research Hospital, Cambridge, 
aro being extended under the general management of Dr. 
J. A. Andrews, acting in the place of the late Dr. T. S. P. 
Strangeways. The direct and indirect effects of x rays 
upon chick embryos of various ages have been studied. It 
was found that 20 to 25-hour embryos, in which blood circu- 
lation was not yet established, can recover from tho effects 
of X rays, while embryos 6 to 17 days old, with their active 
circulation, cannot recover after similar treatment. It has 
been shown that the death of the older irradiated embryos 
is due to the inhibition of gaseous exchange due to action 
of the rays on the circulatory system itself. At the same 
place Dr. R. G. Canti and Dr. F. G. Spear have investi- 
gated the effects of irradiation of “ gamma ” rays on coll 
division in tissue cultures. The biochemistry of tissue 
growth has been studied under the direction of Sir 
Frederick G. Hopkins. Mrs. B. E. Holmes and Miss E. 
AVatchorn have continued their work on groa-ing kidney 
tissue, and the production of urea and ammonia, already 
studied, it is now suggested is due to protein breakdown, 
by means of which the growing tissue provides itself with 
energy for growth. Other studies have been made of 
nitrogen exchange in the tissues of the brain. 

Malicxaxt Disease and Radiatiox. 

At the Middlesex Hospital, London, Dr. Helen Cliambers 
has proceeded with her investigations of tho substances in 
inoculated tumours which influence tumour growth. She 
has been especially tracing the properties of the substance 
stimulating growth and tho conditions under which it is 
formed or may bo extracted and isolated. It is not a 
living agent, os it is formed under conditions in which 
bacteria cannot grow. The Council has a supply of radium 
entrusted to it by the Government, and distributed to 
five hospitals in London and four institutions elsewhere. 
Radium emanation derived from the portion of this 
element at Middlesex Hospital is available for the general 
scheme of treatment of malignant disease directed by tho 
Radiology Committee, the expenses of the supply being 
largely borne by the British Empire Cancer Campaign. At 
University College, Bangor, Professor E. A. Owen is 
investigating tho effect of x rays of different wave-lengths 
upon living tissues and bacteria. Dr. H. A. Colwell, at 
King’s College Hospital, London, is studying the physio- 
logical actions of secondary radiations. 

✓' 

CHEMOTHEHArV. 

The Department of Scientific and Industrial Research 
and tho Medic.al Research Council have appointed a 
committee to draw up a scheme for joint work on this 
subject. Mention is made of the preparation of new 
organic compounds at Leeds by Professor J . B. Cohen, 
F.R.S., and their biological examination at Glasgow by 
Professor C. H. Browning. A special study has been made 
of trvpanosome infections; aminostyrylquinoline and amino- 
anilquinoline compounds are found to show promising 



270 Teb. i8, 1928] 


•MEDICAIi BESBAROH COENOIEi. 


r TlIE IlMTira 
Slr.ncAL JucRsii. 


ti'ypaiiocidal properties in experimental infections. It is 
found in general that such substances appear to act by 
first killing some of the imrasites, and thereby an immunity 
response is produced, leading to destruction of tho rest. 

General Biociiej[ical IlESEARcnEg. 

Bacterial Chemistry. 

At Cambridge Miss Stephenson has correlated tho 
enzymic activity of bacterial suspensions with tho numbers 
of living and dead organisms present. Further work on 
tho dietary requirements of striet anaerobes has been 
continued, but has not led to tho discovery of an adequato 
synthetic medium. Continued investigation of enzyme 
action by 3Ir. Woolridgo and Dr. J. H. Quastci has 
resulted in tho development of somo striking new views 
of the mechanism of enzyme action connected with surface 
structure. At Leeds Professor J. W. McLeod is examining 
tho propionic acid bacteria which have been described as 
anaerobes capable of producing catalase. 

Colloids, 

At Cambridge Dr. C. G. L. Wolf, with others, is pro- 
ceeding with his consideration of the physico-chemistry of 
precipitin reactions. With Dr. G. S. Haynes ho has com- 
pleted the first part of a study of the diagnosis of cancer, 
using the interferometer for the detection of digestion of 
specific substrates. It has been shown that this method 
fails to reveal any digestion, and the colloidal changes 
taking place are entirely unrelated to any diagnostic 
significance. 

Metabolism. 

Dr. T. Izod Bennett, with Dr. D. T. Davies and Professor 
E. C. Dodds, has studied tho significanco of excess of 
cholesterol in tho blood in various pathological conditions. 
Xepln-itis with oedema has been e.speoially considered in this 
respect. At Cambridge Mr. A. Carruthers has investigated 
the resj-nthesis of glycogen from lactic acid under the 
influence of oxygen by tissues other than muscle. Ho has 
been unable to confirm Meyerhof’s observation that liver 
tissue can synthesize lactic acid to glycogen. At Cardiff 
Dr. J. Piydo and Mr. J. M. Peterson have studied tho 
unknown sugar-phosphate component of animal nucleic acid. 
This has been isolated, and detailed investigation is being 
made by tho wave-length spectrometer of tho striking colour 
reactions given by this compound and the parent nucleic 
acid. 

Anaesthetics. 

Many points of general scientific interest, and of especial 
interest in regard to its anaesthetic action, have been 
revealed by examination of the impurities likely to occur, in 
nitrous oxide by Mr, A. N. C. Bennett at University College, 
London. Professor H. B. Dixon, F.R.S., at Manchester, 
has been investigating the ignition points of various 
anaesthetic agents. Ho has found that both ethylene 
and propylene burn in nitrous oxide and form highly 
explosive gas mixtures. The Anaesthetic Committee has 
been collecting information about “ ether convulsions.” Xo 
adequate explanation of some of the fatalities associated 
with these phenomena has yet been reached. 

Genehal Physiological and Pathological Rese-iiiches. 

Mr. P. Eggleton,' under Professor A. V. Hill, F.R.S. 
i.i London and at tho Marino Biological Laboratories i 
I’lymoiith, has continued liis study of tlio substance 
“ phosphagon,” a constituent of muscle he discovered 
in 1926. Ho has shown that pho.sphagen breaks down 
in a muscle in contraction and is resynthesized during 
the recovery process in tho presence of oxygen. It has 
also been shown that phosphagen is apparently connected 
with the velocity of contraction. Work on immunity' 
by Sir Alinroth Wright has proceeded during the year. 
Xew oxt>eriments have been made on tho ” iutei-traetion ” 
occurring between fluids of different kinds in contact. 
Dr. Colobrook, with Dr. Hare and Dr. Roche Lynch, 
has been investigating compounds of the novai-senobenzol 
typo and their use in tho treatment of imerperal fever 
and other sti'eptococcal infections. By using those found 
least toxic, and by spacing the doses so as to maintain 
adequate concentration in tho blood, it is possible to 
pio ong considerably the acquired potency of 'the blood 


ill its dofenco against streptococci. " Moixiiiutlinimo ” 
lias been found not to confer bactericidal power in animals, 
either upon tho blood or bilo. At tho London Hospital 
Dr. P. G. Fildes and Miss A. Greaves Imve continued 
work on tetanus and tho meclianisni of imnumity .against 
tetanus infection. It has hecii shown by diicct experi- 
mental evidence that tho immunity is due to tlie high 
oxj’gcn tension of tho tissues themselves preventing 
germination of the spores, except in areas in which tissue 
damage has caused a local a.spliyxia. Dr. L. S. P. 
Davidson, at Edinburgh, has devised a method for quanti- 
tative estimation of tho chief groups of intestinal bacteria 
by which tho difforcricos of intestinal flora in health and 
disease can bo shown and tabulated numerically. In cases 
, of pernicious anaemia ho has found a vciy suggestive high 
count of B. welchii. Dr. Katherine J. Guthrie has con- 
tinued tho study of enteric carriers at Glasgow. A chronio 
urinaiy cxcrcfor of B. typhosus has been especially investi- 
gated, and treatment with a vaccine of thcrniostabilo 
antigens of B. iypliosus has been begun. 


Vision. 

Tlireo gioups of work have been in progress on tho 
physiology of vision. Problems of the fighting services 
calling for investigation hayo.been attaclced, such as tho 
visual factors determining proficiency in gunnery and the 
visual factors which distinguish a man who m.ay becomo a 
good riflo shot from one who will never shoot well, where 
tho results obtained by Dr. H. Banister at Cambridge seem 
to indicate tliat visual acuity is of less importanco than 
mi"lit bo expected. A second category of work has been 
concerned with glare and flicker. Dr. D. X. Buchanan has 
investivated tho effects of continuous exposure to flickering 
light OTor a period of months. With tho assistance of 
JIrs. Bk B. CerkiU at University College, London, Dr. 
R j Lrtligoo has studied the rates cf eye movement in 
different directions, with and without glaring sources of 
livht in the' field of vision, which is a contribution to some 
urgent practical problems of motor driving at night. The 
third group of investigations is concerned with the physio- 
j of rcadinv. Study of the effects upon vision of indus- 
trial occnpntimis involving tho risk of eye-strain has been 
continued by Dr. Duke-Elder at tbe_ London School of 
Printing in eo-operatioii with the principal, Mr. J. R. 


UirMclI. 


Ixdpstkul Medicine and Industbul Fatigde. 

■U'nrk on dust inlialation and pulmonary disease has been 
it Oxford hv Dr. J. S. Haldane. Hacmat.te 
has been found to produce reactions not definitely liarmful, 
while it has been established that soluble silica is the most 
deadly of all dusts as yet examined. Further inquu? is 
boing^mado intd the pulmonaiy effects of the fineness of 
the state of division, of tho amount of dust inhaled, and 
nf its solubility. Outbreaks of jaundice, apparently infec- 
e i a me liave been investigated in Scotland by 
P^oVssoi T j’ Maclcio and Dr. d! G. S. McLachlan in 
revard to the question of spirochaetal jaundice in mines. 
Ceimlusivo proof of the nature of these mild caso-s mostly 
hi children, was not obtained, but in two of the outbreaks 
studied the ovidciico suggested a spirochaetol origin. The 
work of tlie Industrial Fatigue Research Board has been 
described in the annual report of the Board, published 
-eivuafelv by tho Council, and a summary only of the 
oroirress of the statistical committee, tho coraniittee on the 
nhvsioioev' of muscular work, tho conimitteo on indiistnal 
[isy-choloK-. ““'1 industrial investigations is 

CoNCLUniNG Notes. 

There is a shoi-t section in the Council’s report dealing 
vith tho Travelling Fellowships. A sumniai-y of Ho investi- 
i-ations of last year’s Fellows is given, together with a list 
>{ tho awards for the academic year 1927-28. The changes 
m the membership of the Council are noted, and the heavy 
osscs sustained during the year by the deaths of Dr. John 
Srowulee, director of the statistical department since 
Or. 'f.. s! P. Strangeways, and Professor E. H. Starling, 
ire' mentioned with sympathetic reference to the inspiring 
vork of these three investigators in different branches ol 
nodical research. 



^ 272 Feb. iS,' 192S] 


THE WASSERMANH BEAOTIOH IN PBEGNANC7. 


r TfiE nr.m« 

l?FTiJCiL jDVn-ftl 


knew, but that the inference he drew that gonorrhoea 
and syphilis were one was false, resting as it did on 
p false premiss. 

John Hunter took a teleological view of the history 
pf living things, assigning' to Nature the role of Provi- 
dence, which made provision for the needs of every 
organism; but when he came to the study of fossils 
his penetration convinced him that such processes 
and changes as he obseiwed or inferred must have 
taken up more than the six thousand years which 
were all that the accepted chronology of Bishop 
"Usher allowed for the 'age of the world on the basis 
of Bible chronology. This unorthodox view was 
expressed in his “ Observations and reflections on 
geology,” which he had intended to contribute to the 
Boyal Society, but refrained on the advice of a friend, 
lest his heterodoxy should give offence. Books had 
little attraction for him, except the great Book of 
Nature, which he studied both closely and fruitfully. 
Indeed, he had little knowledge of the science of his 
day, of chemistry or optics or phj'sics in general, and 
this ignorance of so much that so often forms an 
important part of the equipment of men of great 
intellectual distinction makes almost irresistible the 
conclusion that Hunter’s achievements were the 
outcome of true genius. 


THE WASSERMANN REACTION IN 
PREGNANCY. 

Ik the Winter Number of the Journal of Obstetrics 
and Gynaecology of the British Empire Dr. Gladys 
H. Dodds* records and analyses the results obtained 
by the performance of the Wassermann test on 

2,000 consecutive pregnant women in the Obstetrical 
Unit of University College Hospital Medical School. 
.The purpose of this inquiry was to estimate the value 
of the routine use of the Wassermann test at 

ante-natal clinics. It has sometimes been questioned 
whether the results of the Wassermann test are 

as much to be relied on during pregnancy as in the 

non-pregnant subject. From investigations made in 
Edinburgh on 100 women suffering from syphilis F. J. 
Browne concluded that pregnancy has little or no 
influence in modifying the Wassermann reaction. 
Similarly, Boas, Gammeltoft, and Siecke, investi- 
gating response to the test in 2,200 pregnant 
women in Scandinavia, with 6.7 per cent, of positive 
results, concluded that the Wassermann reaction was 
as trustworthy during pregnancy and childbirth as 
at other times. 

On the strength of the Wassermann report Dr. 
Dodds divides her cases into six groups, which may 
be termed the strongly positive, positive, weakly 
positive, doubtful, anti-complementary, and negative, 
respectively. Of the 73 women with the strongly 
positive reactions either a history of syphilitic infection 
or clinical manifestations were obtained in 47. In 
17 women with "ho history or manifestations of syphilis 
there was a repeated Wassermann reaction, in some 
a suggestive obstetric history, and the babies of four 
showed syphilitic manifestations. Six patients had 
a positive Wassermann reaction as the only sign. Of 
the six cases with a positive reaction, the diagnosis 
was established in four, but the remaining two gave 
no history of infection and showed no specific mani- 
festations. It was in this group that the value of 
the routine use of the Wassermann test was most 


9 of tho Results of tho Wassermann Reactfon obtained fro 

nler,. Pregnant Women. Glndra H. Dodds. Jf.D., D.P.l 

'^vnarcol. of IJ^ EHluh Empire, Winter Number, 132 


clearly indicated. The third gi'dup with weakly posi- 
tive rcactions_ is considered by Dr. Dodds to be the 
most interesting, since most clinicians are reluctant 
to attach importance to a reaction unless it is strongly 
positive; thej' fear a wTong diagnosis and do not wish 
to label their patients as syphilitic. Clinical mani- 
festations were found in six out of nineteen cases in 
this group, which justifies a more careful consideration 
of these cases. Again, .syphilis in pregnant women 
is often latent. Sumrharizing the case’s with weak 
positive reactions, there were 30 in which this finding 
was- obtained at the first examination. In one a 
triple positive was obtained after a provocative injec- 
tion of an arsenical corripound, and six were again 
neg.ativo after a provocative injection. In ten cases the 
reaction was weakly positive more than once — in four 
oven after a provocative dose. In one case the reaction 
became doubtfully positive after such a dose. Nine 
cases were insufficiently investigated. Dr. Dodds con- 
siders that these findings' justify us in regarding the 
weak positive reaction -with suspicion of syphilis. In 
17 cases the reaction was a doubtful positive, and 
12 were still negative after a provocative injection. 
Five were not further investigated. No history of 
infection and no clinical manifestations of syphilis 
were found in any of the cases investigated. Dr. 
Dodds accordingly does not regard the doubtful posi- 
th’e results of any significance. Six cases were 
reported to have anti -complementary serums, a con- 
dition stated to be more frequent in pregnancy than 
at other times. These cases presented no clinical 
significance. There were 15 cases_ with a negative, 
rcoction which presented cliniccl evidence of syphilis. 

There can. therefore, be little doubt as to the 
value of the application of the Wassermann test as 
a routine procedure in pregnancy. Dr. Dodds points 
out "that in the Obstetrical Unit at-Umversity College 
Hospital the urine of the pregnant woman is examined 
for albumin as a routine, and silver nitrate is always 
instilled into the eyes of the newborn infant, and 
tint many tragedies are thereby averted; she con- 
tends that many more could be averted by the routine 
Samination of the blood, with the additional aid of 
rprovocative dose of one of the arsenical compounds, 
if necessary. She insists also on the need for a 
fuller investigation and "iollowing up of cases m 
which an incomplete Wassermann reaction is obtained. 


' antirachitic effect of sunshine. 

„ - by Brs. Alan Brown and Frederick F. Tisdall 

fn the sehsonal' variation of the antirachitic action of 
i,:„a nn'd its effect on resistance to disease, in the 
Wdian Medical Association Journal for December 1927, 
t is remarked that study of the literature dealing with tho 
tioloirv of rickets shows how little has been discovered in 
hi, revard from the time of Glisson until tho past ton 
e!,rs “it remained for Mellanby in 1918 to deiiioiistrate 
ho tiresence of a substance which possessed antiracliitio 
rouOTties and was effective in the prevention of rickets. 
t was at first uncertain whether this substance was somc- 
liing other than vitamin A, but this was definitely cstah- 
^hed bv McCollum and his co-workers, who distinguished 
; by the name of vitamin D. Cod-liver oil is now rocog- 
iaed ns its most concentrated source. Huldschiiisk-y, in 
939 was the first to demonstrate the curative action 
f ultra-violet light in rickets; he employed tho rays 
manating from a mercury vapour quartz amp. tim 
isults have since been abundantly confirmed by many 
orkers. In 1921 it was shown by He^ and Meyer thn 
similar effect could also be obtained by esposuro to mo 


Feb. i8, i9=S] 


ANTIRACHITIC EFFECT OP SUNSHINE. 


t Tirr. British 
S tEDICAt Jo'cnsvAi, 


273 


direct ravs of the sim, and this was coiifinnod experi- 
nicutallv oil animals hy Park and Hess. Thon Rosenheim 
and Wehstor in Eiigl.ind, Hess, Wciiistock and Helniaii, 
and Stoenhock and Black in the United Stales, . working 
indcpeiidoiitly, found that food containing cholesterol and 
allied substances acquired antirachitic properties on being 
exposed to ultra-violet rays. More recent investigations, 
however, have shown that the substance concerned is 
cigosterol, which is nsnally present as an impurity in 
cholesterol in the proportion of 1 in 2,000 iiarts. Brown 
and Tisdall give some indication of the great potency of 
activated ergosterol when they state that the administra- 
tion daily of 1/10,000 mg, of it to a rat on a rachitogenie 
diet cures or prevents the disease, and that 5 mg. of it 
prodneo the same antirachitic effect as one litre of active 
cod-liver oil. The eurativo results of exiiasnre to the rays, 
either from an ultra-violet lamp or from the .siin. are due 
to certain rays present in the ultra-violet iiortion of the 
siiectrnm, experimental work with cholesterol showing that 
the maximum antirachitic potency is possessed by rays of 
302 millimicrons in wave-length ; the most effective rays 
of the sun, both for the prevention and the cure of rickets, 
are those which range from 290 to 313 millimicrons. 
Unfortunately, these short wave-lengths have very fei'ble 
lienetrating powers, and arc thus readily cut off by' the 
smoke, dust, and moisture of the atmosphere; they arc 
thus markedly reduced in winter, and also in the early 
morning and the late afternoon, when they have to pass 
through a thicker layer of the atmosphere than at noon, 
when the sun is high in the heavens. Thus Brown and 
Tisdall found that the sun’s r.ays in Docomhor, January, 
and .February, in the latitude of the city of Toronto, 
produce a slight but definite antirachitic effect on rats 
fed on v\ rachitogenie diet; a very sharp increase occurs in 
the antirachitic effect of sunshine about JIarcli lat, while 
the antirachitic effect of April and jMay sunshine is 
appioximately eight times as great as that of December, 
January, and Fcbruaiy. Further, the antirachitic effect 
of skyshine (reflected rays from the sky and clouds) is 
about one-half to two-thirds of that produced by sunshine 
(lajs from the sun plus the reflected rays from the .vkv). 
It slionld he noted that reddening of the skin is not a 
suitable unit for the measuiement of ultra-violet therapy ; 
1 s lould merely be considered as an accompanying pheno- 
menon. Sunshine wliich has passed through siiecial glass, 
such as corning glass, vitaglass, or vioray, has from 20 to 
per cent, of the antirachitic effect obtained without the 
* S'ass; hence the employnient of this glass is 
Jiu I L( iihen inclement weather prevents the direct 
xposuie o^ patients to sunshine so as to obtain the Irenefit 
^ I properties. Again, experimental data 

• "Inch show that sunshine definitely increa.scs 

•non albino rats to infection with specific 

sunn” '‘ttlo doubt that the 

siibie -t ”t 'I derived from it by the Iinmaii 
' Vr to sunshine was found to increase 

a Id R. "• * ''L'''‘^^tinal tract of exposed rachitic rats, 
that tfi” " Tisdall claim this as additional evidence 
that the sun’s rays definitely aid in digestion. 


Tim Irhehbur OF PITUfTARY EXTRACT, 

which have ^ ®f the Therapeutic Substances Act 

Sit is ^r'r l?r that all pitnitar; 

logical units. Thitigtl content of physio 

fore henceforward ^ 7*^" 

standard .,.,,1 ti • ‘“'^‘•^oied by a uniform Internationa 

o bo diied I? Pennif the dosage of the dm 

hitltto W, " timn ha 

Ciii-ofnl ^ P^'oblem of dosage deserve 

” hecause i„ the' past ther e has bee 


a considerable variation in tho strength of pituitary pre- 
parations. The general tendency of such variations has 
been to encourage overdosage of pituitary extract, 
because failure of the drug to produce an effect is botiiid 
to caiiso delay and may involve danger in childbirtli, and 
hence obstetricians have tended to choose a dose which 
would be certain to be effective, even though the sample 
used rverc considerahly below standard. Bourne and Btira' 
have i-eccntly published a very careful analysis of the action 
of ))itnitary extract. Their findings are based on graphic 
rccoi-ds of tile uterine movements during parturition. Their 
chief concltisions are as follows: “ A dose of two units may 
be expected to produce an effect wlriclr should be useful in 
hastening the course of a sluggish labour, provided that it 
is not administered before tho os is about oric-lialf dilated. 
A dose of two riiiits may he given with safety at any stage, 
provided thcro is no mechanical obstruction. The least 
interval at which any doso can bo usefully repeated i.s one 
hour, but often the effect of two units has lasted longer 
tlmn this.” Tlicy mention that a dose of two units in 
some patients “ produced a very striking increase in 
uterine action, as large, indeed, as it would seem advisable 
for an increase ever to be.” Tlio usual concentration of 
pituitary extract is ten units per cubic centimetre, and 
do.ses of one-half or even one cuhio centimetre of tho extract 
Iiitherto have been in common use. Tho results of thii 
inquiry indicate, therefore, that the dosage hithertc 
employed slionld be reduced considerably. The conclusions 
regarding the dosage of pituitary extract in labour confirm 
those reached by other workers. 


SEPULCHRAL STATISTICS. 


Tun day has long gone by when for the majority of the 
inhabitants of these islands their last resting place is 
the qniot village clnirchynvd beloved of tho poets. Some 
few there are still, almost exclusively among tho land- 
owning classes and tho fast dwindling rural 2 'opulation, 
who may view the prospect of sleeping their last long 
sleep beneath the shadow of the old yew tree ; but for 
the mass of urban dwellers, if they think about the subject 
at all, their thoughts must perforce turn towards some 
Iinge cemetery, where tho headstones are crowded together 
ill almost indecent ])ro.ximity, and the surroundings, as 
likely as not, are gasworks or main lines of raihvav. 
Unless the actual figures .are iirtsented it is almost imjios- 
siblc for tlie ordinary individual to conceive the amount 
of ground required and the cost involved in making jiro- 
visioii for the 600,000 inteiinents which take iilace annually. 
These details have recently been published hv the Cremation 
Society of England in a iiamjihlet entitled “ Cemeteries in 
England and Wales — Statistics to 31st March, 1926, of 
Municipal Undertakings.”" The society lia" gathered 
together the figures relating to 305 cemeteries, owned and 
'managed by 166 miiniciiialitics acting as burial autho- 
rities for their re.siiective areas. This is said to be tbo 
most complete return of the kind issued in recent ycar.s. 
The iiopniation covered by the survey is c.stinuited at 
17,528,548 iiersons, and the average number of interments 
per annum is 173,073. The area of land occupied or 
reserved for cemeteries is over 8.400 acres, or 12J square 
miles, and the total ex^ienclituro on purchasing land or 
laying out burying grounds exceeds five million pounds. 
Assuming that xbose statistics cover about half the iiojnila- 
tion of England and Wales, ,ve arrive at the staggering 
conclusion that 16,000 acres, or 25 square miles, arc set 
apart for no other ^mv^iose than burying tho dead an aica 
wliich,.- otherwise employed, would have housed half a 
.million people, with a consequent increase of rateable 


■I TIio Dov:.<-c anti .Vclion of I’ituitary E.xtjact, etc., Jnt'rn. OI,t!rl. and 

jtTra'wv'u/o. A:"Noble!1i^’el®tav,.n,li.sh Street, Lnatlon, W.l. 
or Mn A. E. Piggolt, 56, Mo>ley Street, Manebrster. 2^. post free. 






Feb. 1 8, 1928] 


WHEALS and bites. 


[ Tre Bftinsn 
Medical Joebnai. 


276 


crawl out from the oxplant. Pseudopodra aro thrown out, 
with surprising rapidity, glide, swell, and .aro withdrawn as 
quickly, to start anew from a fresh site in tho surface of 
tho cytoplasm. The nucleus is often correspondingly dis- 
torted, and lobes, sometimes showing a marked constric- 
tion, bulge into tho bases of tho main psoudopodial 
branches, only to bo drawn back into tho main body of 
tho nucleus as tlie psoudopodia are retracted. Tho authors 
describe graphically how tho restless turmoil of the coll 
is enhanced by tho violent activity of tho cytoplasmic 
inclusions. Mitochondria, small fat globules, and cell 
granules scour to and fro along tho psoudopodia, jostling 
ono another, and showing at tho samo timo a coaseless 
dancing motion resembling Brownian niovomont. These 
differences in form and behaviour aro paralleled also by 
apparent differences in function. Tho wandering cells, 
which aro moro actively phagocytic than tho fibro- 
blasts, aro thought to bo of lymphoid character, for 
by dark-ground illumination they aro indistinguishablo 
in structure and behaviour from tho wandering cells of 
normal embryonic tissue cultivated in vitro, or from tho 
larger lymphoid colls in cultures of adult spleen. On tho 
other hand, the fibroblasWikc cells are similar to cmbi-j-onic 
comiectivo tissue cells, and thoir main function is to pro- 
vide scaffolding for other tissues. Since there is no histo- 
genetic relation between these two colls tho question arises 
as to which of tho two types of cells is tho malignant agent. 
For tho Hous sarcoma of tho fowl Carrel has adduced 
experimental evidence tliat lymphoid clemcirts — so-called 
monocytes — are responsible for tho malignancy of this 
tumour. By analogy it is possible to deduce that tho 
wandering cells may bo tho malignant components of the 
rat sarcoma, while tho flbrOblast-liko cells represent stromal 
elements, but such a hypothesis could only bo r-oriftod by 
further experimental work. 


WHEALS AND BITES. 

THorroH tho bito of a blood-sucking insect and the 
resu ting wheal, with its often intense itching, are so well 
.. ®''’lB'isingly littlo has been really’ understood about 
IS s -in leaction, and especially its purpose in relation to 
0 transmission of tho parasites of which tho insect is the 
caiuer. lany years ago it was suggested that tho salivary 
sccie ion o mosquitos, which (among other insects) produce 

function tho prevention of 
o t e blood on its way to the stomach ; subsequent 
01 - now doubt on this hypothesis. In 1914, however, 
rnwa an Patton were able to demonstrate tho presence 
Riint’ ‘“®gnlin in the salivary glands of various blood- 
'iviTu!''” in some cases at least, a neutral- 

letter enaymo existed in tho stomach. A recent 

Tsetse p. 1.3) by Dr. Lloyd of the 

on this • T Nigeria helps to throw some light 

rLS b " H. M. 0. Lester, he 

coae-ulin ^+ 1 ^ ^sliod that tsetso flies have both an anti- 
coao-nlin i,, of the salivaiy glands and a 

Sinen S digestive tract. vitre 

veL 7^0 ” 

tho looeb " i” “’'^•kinase and. kinaso respectively. (In 
gioup tho ’r ’ to a different zoological 

fhZbin hirudin-is an ^nti- 

and the Lembera oS'‘S ^ 

a delicate operator wMelf^'p® 

thus treated fefd normaut%““^ appreciable shock. Flies 

9«ite lons ;el1,^;irV“"‘‘"^ 

larvae and bchavins? ^n ° “°“ths— producing normal 

g n a normal way. Siaf.er or later, 


however, tho insect chokes or shows symptoms of convulsions 
and cannot feed. Dissections show that tho lumen of tho 
gut has become closed by a blood clot. Further experi- 
ments indicate that tho amount of salivary secretion mixed 
with blood prevents its coagulation for several hours, but 
the secretion of coagulin is so powerful that it is neutralized 
in a few seconds and a clot formed, which is then in a 
position to be digested. In this fly, therefore, tho produc- 
tion of the skin reaction is purely an accident, although 
often a painful and sometimes a dangerous one. Tho 
salivary secretion mixes with tho blood at the voiy tip of 
tho proboscis, and a certain amount always escapes into tho 
skin of tho host. Dr. Lloyd and his colleagues have thus 
solved an interesting problem with important practical 
bearings. 


ROYAL COLLEGE OF PHYSICIANS. 

TnE Eoyal College of Physicians of London is celebrating 
on May 14th next and following days the tercentonaiy 
of tho publication of William Harvey’s book Dc Motu 
Cordis, an event that laid the foundation stone of modern 
physiology and scientific medicino. Delegates and dis- 
tinguished guests from all parts of tho world have been 
invited to participate in an interesting programme of 
scientific and social gatherings. Tho College is reviving 
on this occasion an honour that has been bestowed but 
seldom in tho four centuries of its existence by electing 
to its Honorai-y Fellowship tho Earl of Balfour, Sir 
Ernest Eutherford, and Profossore Ivan Petrovitch 
Pavlov and Karl Friedrich Wenckebach, each of whom 
has rendered signal service, directly or indirectly, to 
tho advancement of medical science. Tlie spring lectures 
at tho College open on March 1st, when Dr. F. A. E. 
Crew will give the first of his threo Milroy Lectures on 
“ Individual, familial, and racial differences in respect 
of immunities and disease resistance ” ; the second and 
third lectures will be delivered on March 6th and 8th. 
Dr. Izod Bennett will give three Goulstonian Lectures on 
“ Some problems of nephritis ” on March 13th, 15th, and 
20th. Tho Lumleian Lectures on “ Epilepsy ” will be 
given by' Dr. James Collier on Alarch 22nd, 27th, 
and 29th. Dr. E. P. Poulton will give tho Olivor-Sharpey 
Lectures on “ An experimental study of certain visceral 
sensations” on May, 1st and 3rd; and tho Croonian Lectures 
on “ Tho intorpiotation of gastric symptoms ” will be 
given by' Dr. Charles Bolton on June Sth, 7th, and 12th. 
All lectures begin at 5 p.m. Jlembers of tho medical 
profession will bo admitted on presentation of card. 


MEMORIAL TO SIR FREDERICK MOTT. 

We aro glad to learn that the council of the Eoyal Medico- 
Psychological Association has decided to commemorate tho 
lifo work of tho late Sir Frederick Mott by publishing 
a memorial book, and for this purpose has appointed a 
committee consisting of Drs. C. Hubert Bond, F. L. Golla, 
Douglas AIcEae, Thomas Beaton, and J. R. Loivl, tho last- 
named acting as honorary secretary. Promises of scientific 
articles havo been received from the leading exponents of 
psychiatry throughout the world; many of these papers will 
embody original work, and will bo important contributions 
to neuiology, psychiatry, and sociology. A fund has been 
opened to defray the cost of publication, and tho committoo 
appeals for donations, which should be sent to the treasurer. 
Dr. Janies Chambers, Tho .Prioiy, Eoehampton, S.W.15. 
In tho course of our obituaiy notice on June 19th, 1926, wo 
indicated the international influence of Mott’s work and 
his great personal popularity. This memorial volume, pre- 
pared in his honour, will register steady progress in the 
branch of medicine which ho did so much to advance, and 
a world-w'ide response to the appeal may be confidently 
expected. 


276 Feb. i8, 1928] 


THE HUNTER mCEHTENAlli-.' 


I ■ 


Tit» Dntms 
L SiztiiCAC. Jcnrati^ 


Urntt^r Dkcnfmarg^ C^Iiilliratinas. 



Fig. 1 .— Lohj' Caklcrwoofl, tlic biitliplncc of B’illiom nnd John Hunter, 


THE HOMES OP THE HUNTERS. 

VicAEY Uectuhe )!v Hk. GEonoE C. Peachey. 

At the Roviil College of Surgeons of Englantl on Fcbniaiy 
16th tlip Thomas Vicary Lecture was delivered by Dr. 
GroiiGE C. Peachei-, who took for Ids subject “ The homes 
of the Hunteis, ’ and illustrated it by many topograpliical 
pictures and j)ortraits. ^ ° 

«mt he proposed to follow tho footsteps 
of \\ ilham and John Hunter in 
the London of tho eighteenth 
centur3’ — the London of 
Hogarth and Gar*, Fielding and 
Smollett, Johnson and Gold- 
smith. But the scene opened at 
Long Calderwood in Lanark- 
shire (Fig. 1), where John 
Hunter was born in 1728, tho 
tenth child of his jjarents. 

Many of the children had died, 
probably all from tuberculosis, 
and onh- four came into 
the story — James, 'William, 

Dorothea (mother of Matthew 
Baillic), and John. It was 
William who bore tho burden 
nnd heat of the day; ho was 
tho architect of his' brothers’ 
success and that of his nephew 
Matthew, and in our admira- 
tion for tho genius of John it 
was only right that U'illiam 
should receive his meed of 
honour. James studied law, M’illiam was designed for 
the ministry but abandoned tho Church for medicine 
and practised surgery at Hamilton. In 1740 he made 
o® I/oiidoii, finding lodging under William 

Smo he’s roof in Pall Mall. Ho was fortunate in h” 
teacher, for .Smellio was described by Dr. Herbert Siioncor 
as the gieatest of British obstetricians. The instruction 
SmelH vecoived during those ten months with 

Smellie laid the foundation of his subsequent success, and 
even the uncouth manners of his teacher were useful in 
suggesting to him the value of a more courtly bearing 
II Inch subsequontlv prociii’ed 
for him his a])pointment to 
Queen Charlotte. Ho next 
became anatomical assistant to 
James Douglas, and tutor to 
Douglas’s son. bh-oni Douglas 
ho learned his love of books, 
acquired his zeal for anatoniv, 
and was inspired to choose 
obstetrics as a means of future 
livelihood. Under Douglas’s 
roof in Red Lion Square he 
lost no opportunity of acquiring 
knowledge. In 1741 he entered 
St. George’s Hospital as a 
.surgical pupil. In that jear he 
lost his father, and not long 
afterwards his brother James, 
who had forsaken tho law and 

had joined William in London, returned to Scotland to die 
■William succeeded on his elder brother’s death to a smali 
estate, but his mother, his two sisters, and his brodier John 
were entireli- dependent on this man of eight-and-twentv 


Dnri.m ^ Dw'glas’.s house in Hatton Garden. 

dissecHne t'’Ti'"‘^ "'f® "‘'tiated into the art of 

dissecting. I,, the summer he went to Chelsea Hospital 
to learn .surgery at the feet of Cheselden, and later was 
P''T'l at St. Bartholomew’s. Soon afterwards 
Milhiim was elected to the staff of the Hospital for Lyinr. 
in Momen, Brownlow Street, Holborn. From his .s'libsl 
qiieiit movements it appeared to tho lecturer that William 
Hunter had gra.s|)ed the important jirinciple that for tho 
salcty of the women he attended bis practice should not 
bo eonducted from iircinises 
which served at the same lime 
for dissecting; therefore he 
took a large house in the Great 
Piazza, Covent Garden, which 
lionccforth became the resi- 
denco of himself, his brother 
John, and their jinpils. At 
the same time he retained 
the apartments in the Little 
Piazza for anatomical purposes. 
This was almost a hundred 
jears before Semnielweis was 
led to attribute jmerperal fever 
to tho carriage of sepsis from 
tho attendant to the patient. 

John llunicr'x Enrh/ Career 
in London. 

John Hunter evidentli- made 
up his mind at this time to 
follow surgery as his pro- 
fession. In 17'64 he entered as 
surgical pupil at St. George’s, 
and in 1756 lor a second course. At St. George’s 
there were no restrictions; the appointments were open, 
subject to votes and influeneo alone. AVhatever tho 
evils of the system — nnd they were many — without it 
surgeri- would not have had its .John Hunter. In 1756 
be was appointed resident bousc-phi-sician at St. George’s, 
a stepping stone to the staff, but he retained the office 
oiilv for five months, being anxious to return to the 
dissecting room anil complete his researches. In the same 
vear Il'illiam Hunter removed to Jermiui Street, and 
the house in the Great Piazza served as the residence 
of John and the pupils and as 



Fjg 


^YiUiom Hunter a Pioneer in .infisepfic Hidirifcrij. 

In 1746 William Hunter announced his first course of 
iectur« on aiiatoini- at the Little Piazza, Covent Garden 

much of William’s success for himself, and finding that his work continued to accumu- 

making hia home with his broilicr'^ r/'*' late, resolved to give up teaching anatomv and to vacate 
his hi other during tho ne.xt twelve the Covent Garden premises. Ho applied' for a grant of 


the school of anatomy. An 
attack of pneumonia brought 
to an end John’s labours in 
the dissecting room, and his 
dolorous family history pointed 
the need for pi'blonged change 
of occupation. In 1761, having 
obtained a commission as army 
surgeon, he sailed on foreign 
service. Beforp leaving Eng- 
land ho had become a sub- 
scriber to St. George’s, and it 
was at a board meeting there 
that ho appeared again in 
histoi*;^’ on liis return from 
abroad after two years’ absence. 
Ho was then, in all probability, 
living in lodgings in Bussell 
Street, Covent Garden. Two years after his return 
he purchased the lease of ground at Earl’s Court, on 
which lie proceeded to huild a residence (Fig. 2), and 
shortly afteiavards ho also became tho occupier of a 
lioiise in Golden Square. 


'"".I 


2.— John Hunter’s home nt Earl’s Court, Kensington, 1V64-1793. 


Wil/iam Hunter's Theatre. 

Mo.mii’liile William Hunter, having acquired competency 

^1* i<» . 1/1 ! •• ■* . 


Feb. i8 , 1928] 


THE HOMES OF THE HUNTERS. 


[ Tbx SBirm 
Ueciciz, JonuriA 


277 


land from the Crown for tbo building of a museum of 
anatomy, but bis offer in that connexion failed of accept- 
ance. Had it materialized tbo name of Scotland Yard, tbo 
ebosen site, would bare been associated in tbe public mind 
with tbo investigation of disease instead of crime. He had 
taken temporary premises in Litclifield Street, until, foiled 
in bis dc.sign, bo purebased a house in Great 'Windmill 
• Street (Fig. 3), and began to build a tbcatro for himself. 
From 1763°until bis deatb in 1783 William Hunter, with 
a successijn of distinguished assistants, continued there his 
courses of anatomy.' After his death the property passed 
to Matthew Baillie until, in 1831, its doors were finally 
closed. Of all tbe homes of William Hunter in London 
this alone, in part, remained. The wall in Great Windmill 
Street, now tbe back of tbo 
Lyric Theatre, was tbo actual 
frontage of tbo old bouse. 

Tbo front portico bad gone, 
tbo area remained, and behind 
tbo railings might be seen tbo 
basement windows. Tbrough 
a side entrance to tbo north 
tbe actors and actresses now 
passed to their dressing rooms 
above, and a flight of steps 
was to bo seen down which 
many a " resurrectionist ” 
must have staggered under 
bis ghastly burden. Tbo stage 
of tbofbeatre, which was sunk 
below tbo level of tbe street, 
formed tbo actual floor of 
William Hunter’s dissecting 


T/ie Estrangnnciii of the 
Brothers. 

When AVilliam Hunter 
vacated Jormyn Street in 1768 he handed over tbo 
remainder of tbo lease to bis brother, who, with his 
suiiport, was elected surgeon to St. George’s Hospital. 
1 s appointment enabled John to take pupils, one of 
10 earliest and certainly tbo greatest of whom was 
Edward Jenner. ’The exact date of tbo termination of 
unnei s lesidence iu Jermyu Stv^efc was conjectural. Ho 
migut or might not have been there in July, 1771, when, 
one tiaturday evening, John wrote .a letter to William 
-leiiing nim tliat be was to be married at eight tbe following 

nnun'''i*’T^w Piccadilly. From his marriage 

' ““'1 Hunter made good use of the house at Earl’s 
tlipvo 1 :.* which was demolished in 1886, 

^ is. of John Hunter’s otherwise 



turbulent life, 
began about 1778 


The estrangement between the brothers 
when, owing to some disagreement, 


Tnlin’o i„„t "ucii, owing to some disagreement, 

wliicli and practice of surgerj', 

miatom ion? delivered at bis brother’s 

at No 28 Great Windmill Street, were given 

done s'o AVilliam Hunter, who had 

done so much for bis brothers, and had secured for John 


tho opportunity of developing bis talents, was no easy 
master. Tbo opposition to bis claims of discovery had 
perhaps embittered him. In 1778, for some reason, their 
ways parted, and tho estrangement lasted to the end. 
John was not mentioned in AA’illiam’s will. 

Triumph and Tragedg. 

The museum, which was the darling object of John 
Hunter’s life, requiring better accommodation, he decided 
to purchase the lease of a bouse in Leicester Square and 
tho premises behind it. On the ground between the two he 
built a lecture theatre and a conversing room, and above 
them a museum and gallery. It was said that he spent 
£6,000 on tbe lease and tbe building. This house was his 

family residence. He had 
by this time been appointed 
surgeon extraordinary to the 
King. Honours were showered 
upon him, and the deatb of 
Percival Pott left him without 
rival in his profession. But two 
troubles assailed him, one 
an alarming malady whose re- 
curring attacks made him in 
constant fear of death, and tho 
other his financial responsi- 
bilities. For although he had 
earned as much as £5,000 a 
year he had saved nothing, and 
his family was unprovided for. 
Everything above his establish- 
ment expenses, tbe purchase of 
tho Earl’s Court freehold, and 
tbe lease in Leicester Squaro 
was swallowed up by his 
museum. These circumstances 
made him irritable and im- 
patient of opposition, and 
worsened the relations, which were never good, between him- 
self and his colleagues at St. George’s. 

'The lecturer recited tbe melancholy history of that 
quarrel, which was terminated by Hunter’s tragically 
sudden death, or perhaps not even terminated then, for at 
tho meeting of tbe board following the tragedy no vote 
of condolence was passed, no official expression of sorrow, 
was forthcoming. John Hunter’s personal property was 
dispersed, the Earl’s Court house was sold, and after debts 
had been paid only a balance of £1,500 remained. In 
1799 the Hunter collections were purchased for £15,000 
for the use of the public, and were entrusted to the keep- 
ing of the College of Surgeons, being moved in 1806 from 
Castle Street to Lincoln’s Inn Fields. 

“ In the brilliant sunshine of modem surgical progress,”- 
added Dr. Peachey, “ begun by Simpson with tho introduc- 
tion of chloroform anaesthesia and culminating in the 
magnificent triumph ’ of Lister, our eyes are apt to bo 
blinded to the debt we owe to the perseverance and the 
genius of John Hunter. ‘ Si monumentum reguiris, 
circumsince.’ 


royal COLLEGE OF SURGEONS. 

,J. , Pestiv.\l Dixneb. 

AVaring oirFebruan. Oration by Sir Holburl 

a festival banquet '1 "“f ^ollo'ted in tbe evening bj 
tbo Royal Collev,. of c™ President and Council al 

of all branches °of nuliK representativt 

dent, Sir Berkelpv were received by tbe Presi- 

Cuibbert AVallaco^anrl” tr* Aricc-Presidents, Sii 

After tbo lovaf to i Steward. 

“ Memory of Tnhn honoured, and tin 

tbo BiiEsinnNT f toasted in silence 

health of the’ man v felicitous speech, proposed th( 

night to do honour te f.f guests assembled that 

sketched in imaphiat- ^ College and its greatest son. H( 
been given hv tlmt ^ t>oBquot that might hav< 

the time who might Great figures ol 

200 years a^o if tl.o,. i entertained within its wall: 

“ ? “ad known then that the child bon 


that day was destined to refound surgery on tho basis of 
science. Tbo claim,- Sir Berkeley Moyniban said, might 
almost be made that science was substantially the only 
thing that had advanced in the last two centuries. In 
painting and sculpture, in architecture and literature, 
tastes and interests had changed, but when they regarded 
tho work of those who lived centuries ago they must remain 
in a position of profound and reverent admiration. 

Tho E.\itL OF BiiiKEXHE.iD, Secretary of State for India, 
responding to the toast, said that he was glad to meet so 
large a company of eminent surgeons on their own ground, 
although any layman must do so with mixed feelings. Ho 
had a great admiration for the surgical profession, without 
wishing to push the acquaintance too close in any individual 
case. Taking as his text tbo claim that tbo illustrious 
-John Hunter was the first to introduce scientific surgery 
to the world, and a recent statement by their President 
that tho highest point of technical achievement in surgery 
had perhaps now been reached^ ho indulged in a little irony 



278 Feb. 18,1928] 


■' JOHN-^ nUNTEE EIOENTENAEY.'r ’ 


' • T/, J 


[ Trnnitmjs 
JItmcAi. Jocftxu “ ' 


at tlio 0X1)01180 of liis hosts and tlioir predecessors. Ho 
hoped that tlio surgeons of to-day were at least as right 
as those ivho wont before them in tho view they took of 
the perfoction and the great resources of their art. His 
definition of surgery as “ dcstruetivc medicine ” was well 
received by the physicians present. Lord Birkenhead, in 
short, proved himself an adept in the branch of nianiiin- 
lativc surgery that has_ been described as leg-pnlling, and 
jio ended, as was fitting", with an apology for the seriousness 
of his remarks on a festive occasion. The De.\n of St. 
FaUl’s, in a short speech, cxiiressed gratitude for tho skill 
and generosity of surgeons at anxious moments in his life. 
It was noted that Dean Inge, when he made jiassing allusion 
to vitamins, adopted a pronunciation of that much-used 
Avord which was non- to many of his audioneo. 

In proposing the health of the Hunterian Orator, 
Sir GEonoE NnwirAX paid ivarm tribute to Sir Holburt 
Waring, describing him as a physiological surgeon and a 
successor in the great line of John Hunter, “the real father 
of prOA'entivo medicine.” In his acknowledgement Sir 
Hoi-BXTiT Waiunc said that in his surgical ivork and study 
it had been his aim to follon- in the footsteps of Hunter. 

The company at dinner included, besides those named 
above, Lord Dawson of Fenn, Lord Stanmorc, Trca.surer 
of iSt. Bartholomew’s Hospital, and Lord Eiddell, Fresident 
of the Ko}'al Free Hospital ; Lord Justice Atkin and M)-. 
Justice Howlatt; Sir George Makins, Sir Anthony Bowlby, 
and Sir John Bla.nd-Sutton, past-Fresidents of the College; 
Sir John Rose Bradford, Fresident of tho Royal College 
of Fhysicians; the Regius Frofessors at tho two aneicut 
universities, Sir Humphry Rolleston and Sir Farrjuhar 
Buzzai’d; tho Treasurere of Lincoln’s Inn and Gray’s Inn; 
the Master of tho Society of Apothecaries, Dr. R. AVhiteside 
Statham, and tho Masters of other City Companies, in- 
cluding the Barbers, n-ho for centuries were united rvith 
the Surgeons; the Presidents of the Royal Academy of 
Arts and tho Royal Institute of Painters in Water Colours, 
the Royal Society of Medicine, the Royal Institute of 
British Architects, and the Institution of Civil Engineers; 
the Directors-Gencral of the Royal Naval Medical Service 
and the Army Medical Service; Sir D’Aicy Porver, Sir 
Charters Symonds, Sir Dan-son "Williams, Sir Frederic 
Hallett, and Mr. H. do Vore Staepoolo; Sir Arthur Keith, 
Conservator of the Museum, Mr. Forrest Cowell, Sccrctaiy', 
and Mr. Victor Flair, Librariau of tho College; and the 
Editors of tho Lancet and tho British Medical Journal. 


HUNTERIAN SOCIETY, 

Festia’-al Dinner. 

The annual dinner of the Hunterian Society nas made an 
event of special imijortance this year, held as it Avas Avithin 
fiA-e days of tho bicentenary of John Hunter’s birth. 
A vei-A- large conijiany gathered at tho Hotel Victoria on 
Febniary Sth under the chairmanship of the societA-’s 
■juesident, Mr. Morthier Woort. 

The princip.Al guests Avere : Sir Douglas Hogg, K.C. (Atlorney- 
General), tlie Lord Mayor and L.ady Slayoress, the Recorder of 
London, the High Commissioner for India, Sir John Rose 
Bradford, P.E.C.P., the Presidents of the Royal Society of 
hledicine and. the other metropolitan medical societies. Sir 
Arthur Keith, and Sir Dawson Williams. 

TJie menu card AA-as a striking production, the work of Mr. 
"W. Thornton Shiells, Avitli the Reynolds portrait of John 
Hunter in the . centre, surrounded by sketches of his birth- 
place at Long Calderwood and of his Aveek-end “ cottage ” 
at Earl’s Court, as Avell as emblems of surgery and com- 
parative anatomy. Sir Ara-hur Keith, after e.vplaining some 
of the devices for the benefit of the uninitiated, mentioned 
that there Avas present that cA-ening one living link with Hunter 
in the person of Miss Hunter Baillie, who, despite her ninety 
A-cors had come to London to attend the celebrations, and u-ho 
inherited her great-grand-unde’s outlook on life and something 

of his physical features. _ , , j ■ 

The toast “ In memory of John Hunter Avas pledged in 

silence. - tt , . 

Sir Dougl-as Hogg, in proposing the-healfh of the Hunterian 
Sctciety, said tliat he had alAvaA's regarded the Church, medicine, 
and law as the three great healing professions,- There AA-as some 


laughter at this, A\-horcupon .Sir Douglas added : “ Well, I 
Mipjiose it is true that you do not always heal your patients, 
but at any rale you try to folloAV onr e.xample ! ” As they liad 
Ibis object in common it AA-as not unnatural that they should 
liaA'o something of the same experiences. Doctors and laAA-yers 
alike suffered fr.om the fad that patients did not come to 
them until too late. Both depended for their success on the 
entire confidence of their patients. LaAV and mfdicine, again, 
Averc progressive professions. Every practitioner learnt some- 
thing from ever}' case he handled, although he Avas supposed 
to knOAV .all about the case before be began to handle it, and 
AA-lien he had once passed his e.vaniinations and been admitted 
to jiractice lie AA-as supposed to be capable of advising on the 
most abstruse problem.s of the science be liad set out to learn. 
LaAV and medicine had this further in common — tliat they both 
demanded on unremitting industry. These professions A-.-ere 
jealous mistresses, and brooked no rivals. There vere, of 
course, diITcrenoe.s hetAA-een the tAv-o. It seldom or ncA-er 
happened that the doctor had to define legal problems, but it 
constantly happened that the lasvyer had to defAne medical 
ailments. Perhaps that AA-as the reason Avliy doctors had so 
much less respect for the laAv- than laAA-yers had for medicine. 
Both professions had their OAA-n standards of ethics, applied 
bv tlicir OAA-n chosen chiefs and recognized by a bay public 
aaIio hoAVCver, did not ahv.ays understand or appreciate them. 
There AA-as forraerlv anoibcr link of resemblance, in that both 
doctors and laAvyc'rs Avrote their prescriptions in a language 
AA-hich no one else could understand, but the laAsyers gave up 
the use of Norman French 2S0 years ago, and he hoped that in 
another 2S0 vears the doctors Avould he Avriting their prescrip- 
tions in inlclligil'le English. But the great distinction of 
these two professions aa-.as the f.act that Avith each the object 
and inspiration Aras the .Attainment of truth. It Avas a mediml 
man Avho said Ihiit there were many more mistake made by 
not looking than by not knoAving, and it Avas a lawyer aa-Iio ■ 
said “ Be sure of your facts before you come to your thrones. 
With botli professions the ascertainuAent of truth AA-as the first 
Essential of successful practice. The members of boBi regarded 
tiieir profession as imposing on- them a responsAbility to the 
public ratlier than as furnishing them Avith a means of liveli- 
bred The cenerositv of the medical profession was AveU known , 
to 1 w^rfd! LaAA-yers, though they lagged behind med.ca 
* * - (bis respect,'^ nevertheless did in the aggregate a great 
o a su e for the poor of this country that expert help 
' ibev could not otlienvise afford. Just as there were 

r ",V Ak for bodily healing in every centre of population, so 
hospitals to see a day %vhen there would be 

^r'rtsDiHl^’^-^entres to Avhich poor people could go for 
legal ho p • j„ conclusion, he referred to the fact 

the advice y^n^^^ in Parliament the greatest medical con- 
*!u'' in the United Kingdom (Marylebone). 

Mr" MonTiMP. Wootr responded in a pleasant speech in 
b- i’ be recited the achievements of the society in recent 
AA-hich . especially its long association AVith tiie 

years, tlie fact that its monthly meetings. 

City of in * the old City, sometimes at the Mansion 
alAvays be ^ (.j(y company, liad an 

House , of one hundred. The traditional asso- 

ayerage ‘ o„torian Society with the City of London Avas 

ciation of . in proposing the health 

“Inb^'^o^MAA^ a;d Corporation. The Lord Mayor, in 
of ‘he Lout 1 . members that during his temporary 

responding,, ess n^re than an 

residence at Hm 

oiduiary P Broaa-n, in proposing “ The Guests, said 

i*u' 1) it was the common idea that they would all be 
that i^nn^red vears’ time, yet, as the present spate, 

lorgotten passage of a century often added to 

ol centena P toast had three respondents, the first 

a mans rep ^ constitutional Labour peer, 

revolutionary” character of recent legislation, 
deplored • compaced ‘be achievements of John Hunter 

S.T Ernest j Howard in penology, the aim 

'r r mL birthe extinction of barbarism. Finally Sir 
of both men bemg^^^ Jolm 

^nnd Wniiam Harvey, describing Hunter's intellect as 
Hunter ceser,-oir and Harvey’s ol the spnng 

perhaps f ^'r oi t ^ notwithstandmg h.s 

type • yet h« of facts, resembled Harvey 

great eminence in me fo-i;Vitv nf idea. " 

in nossessins also a- striking originality and fertility ol 



VOLUNTARY HOSPITALS ATSTD PUBLIC AUTHORITIES. 


"" 07Q 

IfrmcAX. JocMA* “ * ^ 


PEB. i8, igsSl ’^ 


J 

J 

J 

t') 

t, 


J.11 

t? 

iv 


YOLUJITARY HOSPITALS AAD PUBLIC 
au thoriti es. 

CONFERENCE IN LONDON. 

A SPECIAL meeting was heUl, muler tlio auspices of tlio 
Charity Organization Society, at Denison House, v ictoua, 
on February 13tti to tliscuss tbo question of tho voluntary 
liospitals tiiui tliG public autlioritics. Loi'cl D.\u son of 
Penn presided, !ind tlie large .attendance included many 
persons avell knouai in connexion u'ith hospital and public 
liealtb administration in London. 

Lord D.cwson said that tho purpose of the meeting was 
to discuss how best to direct and co-ordinato London 
hospital accommodation. Tho first fact ivhich had to ho 
faced was that increased hospital accommodation was called 
for by the progress of medical treatment of disease, and by 
domestic circumstances and social needs. Tlio demand had 
been met to a large extent by voluntary effort, recently 
reinforced by- tlio utilization of some Poor Law hospitals. 
Tlie work of these Poor Law — or better called niunicipal — 
hospitals was likely to grow in importance and magnitude. 
VTion the Poor Law Reform Bill hccaiiio law tho public 
authority in London would bo responsible for over 100,000 
beds. The question was wlietlier two parallel and compet- 
ing systems of hospitals in London were to ho niaintaincd 
or wlietlier co-operation was possible. The big teaching 
hospitals of London were part and parcel of the national 
li.'o. On them very largely the nation depended for its 
future supply of doctors j in thorn to a great extent now 
hnoujedge was ** tried out ” and made generally available. 
A vise statesman, so far from undermining tlicni, would 
try to lulapt them as leading and guiding elements in a 
la.ge . scheme. It was important to conserve their cliarac- 
tenstics of initiative and freedom from that cramping 
routine winch seemed to bo inseparablo from State-aided 
R‘® embodiment of the voluntary 
P ■. , ' oluntaryism in hospitals ho would describe as 
bodies which didy^not owe their origin to 
wlro Sovernraent. In London these hospitals 

Hesnitef of tho King Edward 
efTorl wbirli ^ oxampio of voluntary 

and in. r intorforeuce, 

keotiiiin^nUrp” several in.stitutions while 

spirit ^IVbnt 1 °^ them a certain independence of 

Should tlip *ii in tho public interest? 

beds and ut control 100,000 

bospi'tals in biii 1 r * experience of existing voluntary 

falling under bureaiicm}- ^ P^“5Pcct of all hospitals 

foninflas and ."’it'* 

the teaching hospitals of Im affirmed that if 

istcred so that all fauaicipally admin- 

wouid meant ati'tSt s'd 

Sir WiLUAii Hiart-T. survey of tho whole position, 
gradual replacement ^“®^orical survey of tho 

system in dealinc with efforts by an organized 

National HeaUWn t Uie community. Tho 

lino of demarcation made it clear that tho 

ciliary medicine was State medicine and domi- 

preventive and cuni: the satne as that between 

small result, the notable To take one relatively 

among children was cleo ® mortality from measles 
between the Mini'strv tl ^ .ascribed to co-operation 
the county and bomnn-i Metropolitan Asylums Board, 
tioner. ^e time InT L™.™”'®- P--»®ti- 

tures in co-operation T ,?°®® make further adven- 
for persons of all a<res nr. 1 ' provision of medical help 
lines, there was work' * preventive and curative 

be brought into flm agencies which could 


• oc nrougut into the fieW % agencies whicli could 

and offici.al institofinr,^ ’ .r^’apetition between roluntaiw 
yolunfary hospital in and should be avoided. Each 
functioning in London should form a nucleus 

agencies, and in tho i;'^T®P®^'“t>on with associated health 
gation of such agencies t^e aggre- 

“'■gauization would <tno n-i^° tnust he no schism. Such an 
and sickness rates nn/ ‘U bring about a fall in de.atli 
capacity, which would open tim “ ®ffi®ifncy and_ working 
P lie eyes of the statisticians. 


The Case for the Voluntanj System. 

Dr. E. Gbaiiaii Little, M.P., pleaded for the mainten- 
anco of the voluntary system unimpaired. The voluntary 
hospital was one supported mainly by voluntary subscrip- 
tions, gifts, or endowments; its pennanent staff consisted 
of honorary physicians and surgeons; patients were freely 
admitted, any contributions they made being voluntai-y 
contributions, and the hospital was managed by an unpaid 
hoard elected by the subscribers. The note of the voluntary 
hospital was independence and charity, and these qualities 
had attracted to its service the best men, lay and medical, 
for generations. Side by side with the voluntary hospitals 
another class of institution had long existed — the Poor Law 
infirmary controlled by boards of guardians. These institu- 
tions were still hedged about with restrictions, the legacy 
of their origin as part of the system of poor relief. Com- 
pared with the voluntary hospitals they lacked individuality, 
and their organization tended to bo stereotyped, inelastic, 
and departmental. But as they were supported by the 
public purse they tended to become more and more com- 
petitors witii tho A'oluntary hospitals in equipment, though 
hot in personnel, for in this latter respect the}- were less 
adequately supplied, on both tho medical and the nursing 
sides, than was the case with the voluntary hospitals. 
(“ No.”) In London there wore thirty of these institu- 
tions, with 19,000 beds, as against 130 voluntary hospitals 
with not quite 14,000 beds; but whereas, owing to their 
popularity, voluntary hospitals had waiting lists, and in 
fact could not deal with more than 70 per cent, of the 
demand upon them, the Poor Law hospitals had very large 
numbers of permanently empty beds — (“ No ”) — a pro- 
portion variously estimated, according to tho district and 
the season, as from one-sixth to one-fourth of the total 
accommodation. Tho impoverished condition of the national 
finances made imperative the most economical use of the 
available resources. It had been estimated by expert local 
committees outside London, and by the King Edward Hos- 
pital Fund in London, that for voluntaiy hospitals in 
England and Wales to overtake the demand upon them 
11,000 extra beds (3,000 of them in London) would be 
required, but tbero were from 20,000 to 30,000 beds empty 
at Poor Law institutions. This reserve of beds would 
enable the I'oluntary hospitals to deal with the calls now 
made upon them. It seemed obvious that the need of the 
moment was redistribution, both of functions and accommo- 
dation. There were several factors which explained why 
the voluntary hospitals had long waiting lists and the Poor 
Law hospitals thousands of empty beds. In the former 
institutions there was the atmosphere of personal sci-vice, 
given, not for money, but for love, a sense of individuality, 
and the ancient traditions. The Poor Law hospital, 
immeasurably improved as it had been during tbe last 
twenty years, suffered from two handicaps easily removable 
— tho legal disqualification of pauperism which attached 
to patients — (A voice: “ That has been removed since 
1918 ”) — and the rule that only patients from the district 
should be admitted. But the hospital had an inherent 
defect more difficult to change. The provision of out- 
patient and special departments, with the necessary medical 
and surgical personnel, would be immensely costly, and it 
was not likely in any case that tbe same quality of personnel 
would be secured by payment as was now fortbeoming at 
tbo voluntary institutions. 

Dr. Graham Little, in conclusion, referred to a method 
of co-ordination of medical services which Jlr. Walter 
Spencer and he had proposed. The idea was to establish' 
an advisory council to deal at first with the hospitab in the 
metropolitan area. It would bo nominated on tbe one side 
by the King Edward Hospital Fund Council,* and on the 
other by the Ministry of Health and the London County 
Council, always provided that the preponderant influence 
on the council should he essentially voluntary. The volun- 
tary hospital in each area should become a nucleus of 
medical services for that area. Tentative efforts at co- 
ordination bad already been carried out with encouraging 
success, but they bad been somewhat haphazard. Tho 
precedent of some modern universities, where advisory 
councils representative of all interests concerned had been 
Ect up, might also be cited. 


280 Feb. i8, 192S] THE VOnTJNTAEY HOSPITALS AND PTJBOIC AHTHOBITIES. 


[ Tite Briths 
lIcDiciL Joca^u. 


The ('rise for a ^hitiiiij.iil Bn rirr. 

Dr. Humi’iiuhy Nockomjs .sivid tluit tlicro were fmir main 
cause's of tlio ])rosout position : tlio difficiiitios of tiio volun- 
tary Imspitals in fiiuling in'onoy; tlio incre.asing jinpnlation, 
more c, specially in tlio areas envorod by largo lionsiiic 
sclieinos; tlic progress of niodicino and .surgery, AYliiob 
required more ox]ionsivo cqnijiraont ; and tlio ineroasing 
desire of tlio general ])nblie for satisfactory aeetimmodation 
and treatment. Tlie fir.st of these was a very sorions dilli- 
cnltv. Resort had to ho made to .such expedients as 
“ golden ballots,” and yet, in spite of intensive elforts to 
obtain money, the dread spectre of the State drew near. 
Already the Voluntaiy hosjiitals maintained eerlain services 
only by State .subsidies. It was admitted that the volun- 
tary hosjiitals in the London area wore unable to cope with 
the number of patients requiring hosiiital treatniont. The 
possible .solutions were : (1) for the State to take over all 
hospitals, which would mean the destruction of the volun- 
tary system, and would bo the worst iiossible coni.se to take; 
(2}'for the local authorities to make grants to the volnntarv 
hospitals, but the.se grants would have to be .“o large that 
no Government would over sanction them without requiring 
popular representation, and, further, the voluntaiw Kiib- 
scribers would quickly dis.a])pear ; (3) for the voluntary 
hospitals to be linked up with and to control the Poor Law 
hospitals, the local authorities finding the money (but as 
the volnntarv ho.spitals had |)ractically no eo-opeiution 
among themselves, even after hundreds of yeans, they 
appeared to have no claim whatever to become the organiz- 
ing authority for a unified hospital service); (4) for the 
local authorities to make a now departure and institute 
municipal geneial and special .services, the Poor Law 
hospitals being the basis of the scheme. This last was, he 
believed, a really practical suggestion, and shotdd, with the 
definite letcntio'n of the voluntary hospitals, form the basis 
of all reform. The unit must be large — for example, the 
county ai'oa. A strong medical representation, the obvious 
nucleus of which would be from the staffs of the volnntai'y 
hospitals and from the direct medical control of the muni- 
cipal hospitals, would prevent ‘‘ the creeping ulcer of 
bureaucracy.” But the icpresentation must be of really 
active working medical men. He thought the Poor Law 
hospitals not unworthy to come into such an organization. 
Tliev had already taken over a part of the burden of the 
voluntary hospitals, and although they suffered under mani- 
fest disa’dvantages in their origin and management, the 
latter being rather too near the “ vote,” and in lack of 
dircctivitv in medical matters from the Poor Law section of 
the Mini’stiv of Health, they had nei-ei theless shown a 
great faculty of adaptation. 

Dr. F. N. Kay IMenzik.s, who said that he was not 
present as medical officer of the London County Council, 
gave some figures to show that financially the position of 
the voluntary hospitals had improved greatly since 1920. 
In 1920 the ordinary ex])enditure of the hospitals of 
England and 'Wales exceeded ordinary income by £500.000, 
and in 1926 ordinary income exceeded ordinary expenditure 
bv £250,000. But it was of no use slnitting one’s eyes to 
the shortage of accommodation, intensified in many areas by 
the housing shortage, and evermvhere by the growth of tho 

hospital habit.” The public authorities were concerned 
now much moi-e than formerly with the treatment of the 
individual. The Poor Law authorities in London, includ- 
itW the Iifetropolitan Asylums Board, had actually got 
between 70,000 and 80,000 beds for the treatment of tho 
sick Ho begged that those interested would get it out of 
their minds that the taking over of a complete municipal 
hoMiital service was too big a job for the London Countv 
Cm noil- it was already doing bigger jobs in other de],art- 
mentB such as education and housing. Not only c-onld it 
u;;,,o’snch a service under a single control, but it could 
do it e^raordinarily well. But if the volunta.-v hospitals 
Infused to co-operate iff such a service it would mean in 
time their extinction. In London there had been for mam- 
x-c" rs complete and liarmonim.s co-operation lietween the 
London County Council and ^ho rohintaiy liospd.aK 
tow.ards the wofk of which the eouiicil iiaid about £150,000 
a year without asking for any voice in the a])j)Ointment of 
tlio metlieal staff. He was tillable to understand .wliy there 


.should he any difficulty in adiijiting tho facilitic.? provided 
Iiy voluiilary hospitals and public authorities to the needs 
of the community. 

The Poor Ijuv Jlosjiitols Ptfciided. 

Aliss Eni.Fiiun (cliairman of the Fulham Giiardiinis) 
declared that in tho Poor Law ho.spital with which she laid 
had to do there had been for the last five years an entire 
absence of empty bed.s. It had been said that the atimi- 
sphere in Poor Law hospitals was different, hut she felt 
that all who had had experience of them must know wliat 
magnificent services were rendered hotli by doctors and 
nnr.ses to the chronic and helpless cases with whieli tliey 
were mostly full. She denied that the guardians were 
swaved hv the vote, and entirely repudiated the r-tatcmcnl 
that they did not receive encouragement from tlie Ministry 

of Health. r. 1 

Mr. MniviEU (Edmonton Guardians) asked Dr. Graliam 
Little what was the difference between a “ Poor Law 
appendix ” and a voluntary hospital appendix. The Poor 
I.aw vacant beds existed only in the fever liospitals of the 
Metropolitan Asylums Board. Dr. Graham Little had .said 
that “ of course ” in any unified system such as he had 
•on'tlincd tho voluntary hospital element must he pre- 
dominant. The siieaker would really like to send to medical 
snokes'men Thackeray’s Pool; of Siiohs. If he went into 
nnv co-operative movement it mn.st he really co-opei-ative 
not theUrt of co-operation uf the lady who wont foi .a 
■■do on a tiger. Ho wanted to know whether medical ^ 
officcr.s changed their skins when they went into a Poor 
law hospital. One of the officers at Edmonton uas also 
St Bartholomew’s; was he animated by a different 
* in cadi of tlie t-vvo places? He thonght the 
ought to have knocked any sneh nonsense out of their 

heads. j, pf the Hospital Pvhscrihcr. 

^ _;j +i'»nf it was evident a new situation 

Lord RinoELii s. He had been reccntlv to 

faced the q ; j the last speaker came, and he' had 

Edmonton, .Lorn ulu^^^ better hospit.al, or one better 

uever m „ tetter spirit. But if tlie Boya 

eqnipi^tl f ®„.],ich he was identified, '''•efo linked 
Free Hosintal. wondered wlicther lie would stdl 

up with Edmon 0 pocket for the benefit 

be P''eP"''^VFrerwhen at Edmonton ho saw jnst as good 
of the Royal Fi ,„„„,e,pal subsidy. 

work being admirer of rate-supported hos- 

Althongh he vas a g institutions run by public 

pitals, it t .e spirit of researeb, diversity, and 

bodies usually lacked 

eom-iictition. * , q n-itbout acrimony, and be tbought 

that ’iiedical men in voluntary hospitals 
it , down upon other institutions., 

rather ,„„a,ulo sccretaiy of the King Edwarf 

Mr. Jsf (1’^°'’ +,,at tlie task ahead was to convince 

Hospital 

the *."nt from others. He suggested n differentia- 

function differ voluntary hospitals with their pcu.d 
tioii IJ be used mainly for specialist treatment, 

equipment nou ^ the Poor Law hospitals 

neuto cases, and cases which, for other 

"■ould special treatment was necessary, could 

said the point 

Lord 1 , 0 th dales of institutions were 

had emerged tin . ,.c.s. But the volniitaiw •'o^T 

in their to oope with their problem Those 

irere no long j others, simply ou n v 

hospitals oo‘^'^A,ov bad gained a certain prestige and had 
to the fact th.at tliey Solent ni the 

attracted oiou highe.st ambition of men 0 

medical ■"'or'^'- q, ; taffs. But the danger of ancient 
ability to got on the , 

institutions va. -i ,vere also doing good work. Mhat 

™"’"7:U’rWendlv c^onlrave to°roview the positmii 
"■as ooeded nas re.a.s.soitnient of dmw • 

and endeavom to g teaching hospitals would rise 

He ^tion woidd 'important, more 

to the occa.sion. Hmu posit on u question of 





FEB. iS, 1928] 


SCOTLAND. 


[ The EniTTfa 
Uedical JoCEXAb 


281 


(ianiin.inco. Almost cvcrytliing in this cotmtry catno ahont 
In* mutual agi'comout. ■ Ho referred to t!io report of tho 
CcnsuUativo Council in nhicli ho had a hand, and declared 
that it still held tho field; if Ihoro had been a proper 
classification of hospitals according to that report thoro 
waukl by now have been much better co-ordination among 
tl:e new communities. Ho believed that popularly elected 
hsdics woidd increasingly hare to nominate, or consent to 
the nomination of, bodies of experts detached from them- 
selves on whom the immediato responsibility of manage- 
raont would rest. Incidentally this wovdd furnish a rejily 
far the elected person when assailed by his constituents; 
ha would bo able to say that, whatever he and his colleagues 
ir.iglit feel, they, must trust tho appointed experts. 
Jfcdicinc, like other professions, was becoming more and 
more technical, and this fact, so far ns hospital provision 
and management were concerned, would have its bearing 
cu the shaping of government. 


^rntlantr. 


Relic of David Livingstone. 

At a meeting of the Boyal Faculty of I’h3slcian3 and 
Suigeniis of Glasgow on Fcbruarj* 6th, Mr. 0. H. Edington, 
tho president, in tho chair, the surgical pocket-case used by 
David Livingstone during his dailj* work in Africa was 
presented to the Faculty by Dr. Freeland Fergus, on behalf 
of Mr. Hilliard, surgical instrument maker in Glasgow, to 
nhom tiie relic belonged, but who was prevented bj* his 
stato of health from attending tho meeting. In tho course 
of a letter from Mr. Hilliard it was recalled that Dr. 
L.ungstane had been born at Blantyro, some seven or 
cig^..t miles distant from tho hall of tho Faculty, and had 
obiaincd his licence to practise from the Faculty of 
1 liysicians-_ and Surgeons at Glasgow. Through Mr. 
imard s influence the instrument case which belonged 

I'h.i •S’^'t'Seou on board the T'icforu at 

le la tie of Trafalgar, had been, somo j ears ago, presented 
to tho Iloyal Faculty of Physicians' and Surgeons. Dr. 

eigiis mentioned that Mr. Hilliard had been tho close 
f I i' son, Mr. W. Oswell Livingstone, 

nrv; * ° College days. This intiinato con- 

iinifn'.* him into contact with Livingstone’s sup- 

Pn../* Tj”'^ patrons, including James Young and Sons, 
S" Henry U. 

tlin 1 • Hilliard had followed tlio stops of 

town districts, including tho flourisliiiig 

Zanibn i and other places hordoiiiig on tho 

wc- th! cr.ll ?•' --^“i'-ed for the ralic from 

Fereiis^nrltio*^^ ti' London, and Scotland. Dr. 
of Urn me li 1 “Itl'oiigh Mr. Hilliard was not a member 
all 1 is hfo h • Im bad been connected with it 

father as Hoyal Infirmary, where bis 

perseveranop in l- ’ it spoke of Hr. Livingstone's 

pciseie.ance and self-denial in sirinountiiig difficMties. 

■ The 127tb Mental Hospital. 

Hosnital Iias'..”+*'l of the Aberdeen Koyal Mental 

dent Dr U physician superinteii- 

19C7* there wpm Decemhei* 31st, 

the luimber of if) patients on the register; 

and of deaths 1^1, of discharges 102, 

patients resident 'bad boon 7g2'’®‘'“f • “rr"'’ “/i 

tarv Datipnfc +i,.^ a -i ^^d including the vokm- 

total Ser o na?.' had been 831. The 

1;025, or 18 more tlnn*; during the year bad been 

to the types of inen^-! pi'cvious year. IVitb regard 
Eufferiiic 56 of tl.o Horn which* patients bad been 

insanitjy’ and in 'vere due to manic-depressive 

Lwonty-ein-iit -c .i ° ° , toose melancholia was present. 
feclion-exhaustJcr. ^ odmissions bad been cases of in- 
tbe physical licnitu^i^ many of these patients 

HghrS bem? unsatisfactory. Tliirty- 

from Ltonlfa dnf VroecL, and 23 

four had been cases of ??."''‘'^y. organic brain disease, 
general paralysis and 3‘of°nn’ ^ e^leptic insanity, 4 of 
J > o of paranoia. One patient admitted 


had heoii found to he not insane. Of the total admissions 
122 had been sent in for tho first time, while 28 had had 
one previous breakdown, and 11 had had more than one 
prior attack. Thirty-seven patients had been received on 
tho voluntary system, constituting 35 per cent, of the 
private admissions. Of the total population in the asylum 
44 were ..voluntary hoarders, of wlioni only 1 was rato 
aided. Attention is again drawn to the desirability of 
voluntary admission at an early stago of the disease, when 
it is presumably in an unconfirmed and still curable state. 
IVith regard to causal conditions, it is pointed out that 
of tho 161 admissions 51 of the patients were suffering 
from some bodily disease, such as disorder of the heart, 
kidneys, and lungs. Alcohol was assigned as the cause in 
15 cases, venereal disease in 9, and epilepsy in 8, ■while 
in 14 cases mental anxiety and worry appeared to bo 
tho canso. Among tho 102 discharges, 51 patients had 
recovered, this being 32 per cent, of tho number admitted. 
Tho 65 deaths constituted 6.8 of the total number under 
treatment,' and included 3 patients -ivho were admitted to 
hospital in a dying condition. This number included 10 
cases of disease of tho nervous system (of which 6 were 
general paralysis), 19 disease of the circulatory system, 
19 lung disease- (including 12 from pulmonary tuberculosis), 
8 disease of the abdominal organs, and 5 cases in which 
exhaustion occurred in the course of ’ acute psychosis. 
Kefercnce is made to tho treatment -of general paralysis by 
tho artificial induction of tertian malaria, which was intro- 
duced in 1917. It is mentioned that the most which can 
be hoped for is that the disease will he arrested and a 
mental and physical improvement brought about. So far 
no patient in this institution could bo considered as having 
improved sufficiently to permit of discharge, although tho 
majority of those so treated had benefited both mentally 
and pliysically. Attention is also drawn to the satisfactory 
results which had been obtained from the " protein 
shock ” treatment. Kiiioty-two patients had been put 
under ultra-violet rnj* treatment, aird in cases which 
were anaemic, poorlj* nourished, and below normal weight, 
benefit had been obtained as regards gain in weight, 
increase of appetite, hotter sleep, and disappearance of 
anaemia. Mental improvement in melancholia had also 
been noticed from this form of treatment. Similar results 
had been obtained bj* natural sunlight therapy during the 
summer months. 

Paratyphoid Fever at Galashiels. 

Tbo outbreak of paratyphoid fever at Galashiels reported 
last week (p. 236) has attained more serious dimensions than 
seemed likely after the check which occurred at an early 
stage. Tip to tbo end of last week tlio number of notified 
cases had been practically 100, of which 70 bad been 
admitted to tbo Sanderson Hospital, where tho maximum 
of acconunodation bad been obtained b ' ' ' 

of other infectious disease to Hawick i 
tho epidemic was generally mild, tbrc( 
by Februarj* 9th. Tbo outbreak had bcconio general over 
the town, and the persons affected wore of all ages, from 
infants to persons over 70 years old. In only two instances, 
however, has more than ono person been affected in a single 
household. The water supplj- of tlio town, which is of com- 
parativclj’ recent installation, has been found to be clear 
of bacteria of tbo pavatjphoid group, and tbo original 
channel of infection has not 3et been discovered. Cases 
bavo also been reported from the neighbouring counties 
of Peeblesshire and Eoxburghsliire. 

Public Health Regulations In Scotiand. 

The Scottish Board of Health has recently issued two 
leaflets dealing with the prevention of epidemic, endemic, 
or infectious disease. B3’ ono of tbeso the regulations 
dealing with infective jaundico issued in 1927 aro 
extended until December 31st, 1932. L’nder these regula- 
tions infectivo jaundico was made a notifiable disease. 
Tbo second leaflet deals 'with malaria, d3'sentery, aento 
primary pneumonia, and acute influenzal pneumonia. 
These disorders aro made notifiable diseases from January 
1st, 1928. Every medical practitioner becoming aware 
that a person upon whom be is in professional attendance 
is suffering from one of these disorders is obliged to trans- 
mit a notification thereof to tbo medical officer of health 




Feb. i8, 192S] 


INDIA. 


[ - TheBritipjt • OQO 
Medical JousNAX. ^Ou 


to lectures was being CoiiVcucd with a view to joint ropre- 
sentation being made, as a result of which' it was hoped 
that tho policy of the Board might bo modified, and asking 
that in tho circumstances Dr. Williamson's approval as 
a lecturer at Tynemouth might bo oxteuded from illarch 
31st next. Tho Board agreed to reply that if it could 
receive assurauco that arrangements for convening the 
conference were actually in progress, and that an early 
presentation to tho Board of tho representations of tho 
conference was likely, tho Board was willing to extend tho 
ap])roval for a short period. Tho sccrct.ary reported 
that tho Nursing Ilomos (Registration) Act, 1127, repeals 
tliat portion of tho Midwives and Maternity Homes Act, 
1926, which deals with the registration of maternity homes, 
and provides for registration and inspection of nursing 
homes generally (including maternity’ homes) by county 
councils (subject to certain powers of delegation) and 
county borough councils. Provision is made for delegation 
by county councils of any of their powers or duties in 
certain circumstances. It was resolved to inform the 
Minister of Health, tho County Councils Association, and 
the county councils : 

That the Board is still of opinion that tho supervision of 
mateniity homes ought to bo in tho same hands as tlio super- 
\ision of midwives; that delegation of powers and duties relating 
lereto under the Act is undesirable, and ventures to express the 
lope thai the Minister and the 'county councils will grant no 
e egation in respect of maternity homes, except in those cases 

*1' -fSi "'^Sation has already taken place under the ilidwives 
Aci, j.y02. * 




. _ Atcdlcal Education in Bengal. 

xiERKiixo details about tho progress of medical educi 
non m Bengal are contained in Lieut.-Colonel J. ( 
0 ici Leicester’s report oji tho working of hospitals an 
dispe^anes during the three years 1923, 1924, aud 1921 
le our Government medical schools of Bengal — namcl; 
amp e Dacca, Ronaldshay, aud Lytton — now accou 
mo a 0 1,300 students, the last named having been foi 
a y opened m July, 1923. A scheme for tho establisl 
aiedical schools in other places is und( 
th!!^ 1 * 1 attempts are being made to enhrr^ 

r-Iininnf r ''“spitals SO as to render them suitable fc 
stondivd bring them up to the nocessar 

sfbnnic h Scbolarsliips tenable in medic: 

denressed available for students of tl 

spmuous n-irr^'^^Vl generosity has played a col 

a npiv *** establishment of medical schools, an 

has named tho “ Calcutta Medical Institute, 

1925 bv tl provisionally for five years froi 

an iustltu^ Council of Medical Registration, 1 

licentiate eva'Jn* students for the Stal 

also been started^'ln schools hav 

has matu.tr V? enterprise, but so far nor 

of Trltal arn v .>'eeiguition. The Scho. 

-uexion with th Hygiene in Calcutta, iu coi 

0115 covers vx. » of instruction, of whic 

of Tropical diploma issued by the FacuH 

instrurtiou foJ 

Calcutta. Hniversitv t? “ P«l)lio health of tl 
three months’ course nf® • organized also 

tropical medicine anu '."stiuction for the licence j 
that the courses nf '‘Jgiene for Bengal. It is state 
and hvgieiio Inv i both in tropical medicir 

mine Board in ’’®oognized by the Conjoint Exan 

at tho School nf” T teaching aud research woi 

Government nf Ti Medicine are controlled by tl 

Medicine and ’ ®®®'®ted by the Faculty of Tropic; 

towards the sni.nnf ^“*'S®°“-General. Generous donatioi 
tea, juto mills ” 1 ”^ I'ospital are provided by the India 
benefactors Vl,n"T associations and by prival 

endowed a ^®=®‘arch Fund Association h: 

a number of special investigatioas of vario, 


tropical diseases and their treatment, some grants for 
medical research being made by the Government of India. 
In 1923 tho Government sanctioned the establishment of 
therapeutical and teaching departments for diseases of tho 
car, uose, and throat in tho medical college and hospitals in 
Calcutta, and' tho payment of two independent medical 
practitioners as honorary physician and surgeon ; two 
senior officers have also been appointed as physician and 
surgeon to the out-patient department. The establishment 
of a dental school in Calcutta is under consideration, and 
an extern maternity department has also been opened. 
During tho three years there has been in Calcutta a net 
addition of eight medical institutions, raising the total 
number to thirty-two, of which nineteen have accommoda- 
tion for in-pationts in over 3,000 beds. 

Health Progress in Assam. 

Tho general decline iu the death rate in Assam con- 
tinues, though there was a slight increase in 1926 owing 
to outbreaks of cholera. The deaths from kala-azar are 
steadily diminishing, although no additional organization 
of treatment and survey has been found necessary ; it 
appears, therefore, that this disease is under control and 
that its further spread has been arrested. Treatment at 
tho special dispensaries is growing in popularity, and the 
work of civil surgeons in infected districts in snpei- 
vizing tho campaign of their subordinates against kala-azar 
is proving very effective. In areas where the disease is 
particularly prevalent special hospitals aud additional dis- 
pensaries have been established, staffed by expert officers. 
Wherever the disease is suspected in other areas trained 
investigators proceed there immediately and provide treat- 
ment for any i-equiring it; the value of such systematic 
progi’ammcs has now become apparent. The cholera death 
rate has risen as the result of an epidemic which spread 
from one locality. Cholera inoculation -was adopted as a 
preventive measure with excellent results, thus limiting 
tho spread, despite the infection of tho rivers. Anticholera 
inoculations are becoming increasingly popular in Assam, 
where very little vaccination was used, except in tea 
gardens, prior to 1924. There is, however, a regrettable 
shortage of fully trained workers for combating epidemics 
in -\ssam, where only threo epidemic units at present exist. 
Major T. D. Murison, director of public health, in his 
annual report for 1926, expresses the hope that the jiublic 
health department will soon be very considerabl}’ strength- 
ened, in order that more effective resistance ma}’ ho made 
to the spread of epidemics. Public health propaganda is 
active, and lectures and demonstrations are given on such 
prevalent diseases as malaria, kala-azar, cholera, and small- 
pox. Lantern slides have been found vei’y effective ; 
gramophone records are employed in Bengali and 
Assamese; nnmorous pamphlets and leaflets, containing 
simple illustrations, have been distributed to the public iu 
general, as well as to the schools, and prizes aro awarded 
to the children and the teachers as the result of examina- 
tions in public health. The local authorities aro widely 
co-operating in this activitj-. 

Bombay Aiedical Council. 

At the last meeting of the Bombay Medical Council an 
application was received from the Mysore University for 
recognition of its L.M.P. examination. The council de- 
clined the application on the ground that, in aceoi dance 
with a communication by the Government of India, any 
institution hot mentioned iu the schedule of tho Indian 
Medical Degrees -Act which desired to have a diploma 
recognized, should become affiliated to one of the institu- 
tions so mentioned. This had not been effected in tho case 
of the Mysore University, and the council did not con- 
sider, therefore, that it had power to accede to the request. 
It was decided that in the case of general practitioners 
the use of the words “ physician and suigeon ” after their 
names might be allowed, and that Rule ^2 of the Code 
of Medical Ethics issued by the council should be amended 
accordingly. The council considered the ease of one practi- 
tioner wffio was alleged to have been guilty of infamous 
conduct in a professional respect; judgement was postponed 
to tlio next session. 





Feb. iSVigiS] - 11 : A '.c ^ i CORRSSPONPENGB'.' ^ ’ ' ■ ' ^ 285 


J^c.iland, drawn up for tlio Govcrnmoit by Dr. Henry 
Jellett. 

.\s tlio solo person responsible for tbo training of medical 
Etndents in midwifery in tins country, I greatly deplore tins 
and similar attempts' to justify “ mcddlesomo midwifery.” — 
I am, etc., 

G. W. TnroBMjD, 

Profcpsor of Ob^totric^ and Gynaccolo^, 
Bangtol:, Siam, Jan. lOlli. Bangkok. 


TREATMENT OF ACUTE PNETUfONIA. 

Sm, — I road Dr. Alaidlow’s letter (Bnirisn Medicai. 
JoenSAL, February lltli, p. 238) with very considerable 
relish. It seems just possible that a few communications 
of. this typo might succeed in arousing tho profession from 
its lethargic self-complacency. At all events, he is entitled 
to our. best thanks for his genial banter, ns underlying it 
thoro aro indisputablo facts which do no great credit to 
anybody; and least of all, I think, to consulting phvsic'ans, 
who sometimes impedo progress by mistaking their own 
impressions and ex-cathedra pronouncements lor realities, 
just like ordinary general practitioners. 

But “ to err is human,” and none of ns is immune. 
Still, I feel able to enjoy Dr. JIaidlow’s little jokes with a 
comparatively clear conscionco, as I have already offered 
tho best solution I could to this very important problem. 
Dealing with one aspect of the problem — the specific treat- 
ment — I wrote as follows two years ago : 

** Material for the final assessment of the value of specific treat- 
ment in early pneumonia can hardly be anticipated from the isolated 
efforts of individual private practitioners under present conditions. 
If pnenmoma were dealt with on similar lines to diphtheria as 
regards diagnosis, specific treatment, and notification, tne owtiooK 
would bo more promising. In connexion with pneumonia, however, 
J suggest that it would be desirable not only to proiido patlioiogical 
facilities and vaccine or serum, but also sonic soi t of clearing house, 
preferably as a department of tho public licaltli seriice, which 
would collate chnical records. Tliis would cventuallv permit of a 
siimciently wide scrutiny of results to settle the matter to tho 
saUsiaction of everyone, except perhaps tlio occasional crank who 
refuses to be luflueiiced by eiideuce,”! 

May I inquiro what ohjcctions thoro aro to an attompt 
nt a solution of this aspect of tho prolilom on these or 
similar lines? I suggest that tho death rate and the 
present chaotic position in regard to treatment demand 
that something should bo done.” — I am, etc., 

Manclicsler, Feb. 11th. ' J. Si WELT DiCK. 


FATALITY RATES OF S3r.\LL-POX. 

Sm, ^Dr. Percy Stocks, in his letter in your issue of 
February 4th (p. 197), makes a statement wiiich embodies 
so profound a truth that I should like to be allowed to 
reiterate it. He says: “ Epidemics come and go according 
to laws which we do not yet understand, and which involve 
many factors other than vaccination.” When, however, 
he states, later on, that “ the only conclusive proof of the 
emcacy of vaccination must consist in comparing the 
vaccinated with the nnvaccinated at the same ages in tlie 
same town and during tho same epidemic,” I feel obliged 
0 ask liim just wliat bo means by’ the expression ” the 
efhcaey of vaccination.” It may mean two entirely 
different things — namely (1) efficacy to protect the indi- 
vidual, and (2) efficacy to protect the community. I quite 
agree that the comparison Dr. Stocks suggests docs prove 
le efficacy of vaccination to protect the individual, but 
submit, with all respect, that such a comparison does not 
prove the efficacy of vaccination to protect the community; 
and I suggest that, vaccination or no vaccination, 
qiideniics will continue to come and go, as Dr. Stocks says, 
according to laws which wo do not yet understand, and 
" I* . many factors other than vaccination.” 

ti 'f because there has been so much confusion of 

. j* between tho efficacy of vaccination to protect the 
im ivi ual and its efficacy to protect the community — so 
m.iiiy people thinking that proof of the former implies 
pnio 0 the latter, whereas in reality it does nothing of 
11 viii --that prophecies as to tho effect of vaccination 
have so often been falsified.— I am, etc., 

^Tlejllli omces, telcrstor. Fob. 8th. C. KrLI.ICE MlXEAnn. 

' Lancet, Xoveniber 28th, 1925, p. Ilia 


Srn, — On January 14tli you published under tlie title 
“ Fatality rates of small-pox in the vaccinated and unvac- 
cinated a letter from me containing a tabular statement 
of sniall-pox cases and deaths in vaccinated and unvac- 
cinated persons over 15 years of age in England and 
AVales during tho four years 1923-26. 

Tlie 13 deaths among 4,010 vaccinated cases gave a enso 
mortality of 0.3 per cent., compared with 4 deaths among 
6,915 unvaccinated cases — a case mortality of 0.06 per cent. 
The fatality among the vaccinated thus appeared to be fivo 
times as great as among the nnvaccinated — something of 
a shock for those who, like myself, believe that vaccination, 
after preventing an attack of small-pox for a number of 
years, subsequently mitigates the severity of the disease 
so as to lessen its fatality. I invited explanations from 
your readers of these obviously absurd statistics, and tho 
answers have been extremely interesting. 

A lucid explanation of the statistical anomaly was fur- 
nished by Dr. Percy Stocks in your issue of January 21st, 
and I wish to thank him for liis exposure of the fallacy 
of these so-called “ small-pox fatality rates.” He shows 
that the sufferere from “ small-pox,” whether vaccinated 
or unx-accinated, were dying at about the same rate as 
those of tho population who were not suffering from 
“ small-pox,” and he concludes that “ the prevalent mild 
tj'pe of small-pox is not really responsible tor increasing the 
chances of death in persons affected to any measiireable 
degree.” This conclusion would be still more obvious and 
inex’itahle if allowance were made for the facts that : 
(a) About half tho 17 deaths recorded occurred in small 
outbreaks of virulent small-pox, and should therefore he 
excluded in calculating tlie fatality rate of “ mild small- 
pox ” (C. 0. Stallybrass, Bniiisn Medical Joubkal, 
February 11th). (b) The number of missed and unrecorded 
cases of “ mild small-pox ” in the four years referred to 
must have been considerable (but if a “ missed case ” 
developed any serious disease or condition and died from 
it, the chames are that the death would be registered as 
a death from “ small-pox ”). (c) Optional vaccination as 

it exists to-day has made small-pox a class disease. The 
fatality rate of this class from all causes is probably higher 
than that of the population as a wliole. 

Dr. Stocks’s interesting analysis of the figures confirms 
statistically the conclusion I had arrived at clinically — that 
so-called “ mild small-pox ” is a non-fatal disease in other- 
wise healthy individuals. To discuss “ small-pox ” fatality 
rates in such figures as 0.3 and 0.06 per cent, is an insult 
to the very name of “ small-pox.” I have seen tipwards 
of two thousand cases of this disease in vaccinated and 
unvaccinated of all rges, with rashes vaiwing from a few 
spots to almost conflnent eruptions, and 1 hax'e never 
observed a patient with such a degree of toxaemia as to 
endanger life, or even to cause the slightest anxiety as to 
the issue of the illness so far as the “ small-pox ” itself 
was concerned. Further, I have had the opportunity of 
obseiwing the disease through every season of the year for 
seven successive years, and I have not observed any altera- 
tions in its characters at any time during that period, or 
any tendency to increase or decrease in virulence. It is tlie 
same disease to-day as it was when it arrived in these 
parts in 1921. I believe it is tho same disease as Edward 
Jenner described about a centm-y and a lialf ago in the 
folloAving passage : 


“ About seven .years ago a species of small-pox spread tbrouph 
itianv of the towns and villages of tliis part of Gloucesterslnre. It 
was "of so mild a nature that a fatal instance was scarcely ever 
heard of, and consequently so little dreaded by tho loi.er orders 
of the community that they scrupled not to liold the same inter- 
coarse with each other as if no infectious disease Iiad been present 
among them. I never saw nor heard of an instance of its being 
confluent. The most accurate manner, perliaps, in whicli I can 
convey an idea of it is bv saying that had fifty iiidiyiduals been 
taken promiscuously and infected by exposure to this cont.apon 
they would have liad as mild and light a disease as if they had 
hecii inoculated with variolous matter in the usual way. Tlio 
harmless manner in which it showed itself could not .ariso-from 
any peciiliaritv either in the season or the we.lther, for I w.atchcd 
ite pro*^ress iip-vrard of a year vrithout perceiving any variation 
;« ife fTPnrvral aDoearance. I consider 


in its general appearance, 
small-pox.” 


it, then, as a variety of tho 


If this ** small-pox ” is so mild as to be incapable of 
causing death, the question naturally arises, “How is it 



286 Ted. i8, 1928] 


COEBESPONDENCE. 


[ Tiir DnmsB 


L Mr.i>icii. Joak**!!, 


tliat a number of deaths have been registered in its 
name? ” The answer is to be found in one woid, “ iioiiien- 
chiture.” According to the rules of death registration, if 
small-j)ox and any local disease are mentioned on the 
death certificate, smnll-])OX is prefcjupd, however the (crti- 
ficate be , framed. So long as this rule is in force, and no 
clear distinction in names is made between the fatal 
disease sraall-pox and the non-fatal disease “ small-pox,” 
it is obvious that deaths from pneumonia, cerebral haemor- 
rhage, nephritis, and many other diseases which happen 
to synchronize with an attack of the nou-fatal “ .small- 
pox” imi.'if be registered as deaths from small-pox. The 
Kegistrar-General’s Department has no choice in the matter 
so long as it continues to follow thi.s rule. And so it 
comes about that the non-fatal “ .small-jiox ” acquire.s a 
purely fictitious fatalitj' rate which is not in any way 
related to small-pox, and therefore cannot he influenced by 
the vaccination state of the patients. 

To the medical profession the Department of the 
Eegistiar-Goneral is one of the greatest .scientific assets 
this country possesses. At the annual autumn dinner of 
the British Medic.al Association in 1925 the Registrar- 
General paid an eloquent tribute to our ))rofe.ssional co- 
operation in the advancement of knowledge, and he 
finished his speech by affirming that : 

" All that the Registrar-General’s ofTice did was inspired by an 
almcst fanatical honesty in the desire to furnish nothing which 
was not trustworthy, nothing capable of misleading, and he 
iliought the profession and the public could rely upon that office 
not to be moved by any controversial aspect of the m.aterial with 
which it dealt.” CApnIause.) (BaiTisn MnniCAc JoeaxAt, Supple- 
MExr, October 31st, 1925, p. 143.) 

Those who have not given tliought to the stipvome scien- 
tific importance of correct certification and registration of 
death should read carefully pages 20 to 33 of the annual 
rep.orl of the chief medical officer of the Ministiy of 
Health for the year 1926. There will he found a briliitint 
dissertation “ on the accuracy of the statement of causes 
of death,” in the last paragraph of which the chief medical 
officer says : 

” These observations have been made lo illustrate the great 
importance of the correct registration of the cause of death. 
Upon the accuracy of such medical certification mucli depends. 
For quite apart from its social and legal value, it is hardfv loo 
much to say that the fabric of the ai't and practice of preventive 
medicine is founded upon it. Tlie jegistration of sickness, as far 
as we can obtain it, i.s r':vnlUBble, but the correct ascertainment 
of the cause of mortality is essential. . . 

The great majority of toilers in the field of ju-eventiA-e 
medicine are inspired by un equal zeal for bouesty and 
accuracy in their svork, but wben it comes to certifying a 
death from, say, chronic nephritis in a peraou .suffering 
from an attack of “ mild small-pox ” all efforts to achicAC 
the truth are baulked by /lomcnclatiirc. 

KoiAienclatui-e iiA siAiall-\>ox tliAAs actpAires a ViAst iuipoA'- 
.tancc. The pi-esout confusion arises from iiotifA'ing under 
the one name ‘‘ small-pox ” tAA-o tliseases Avhieh can he 
distingAiisbed clinically, epidemiologically, iinmiiiiologically, 
and .statistically, Avitli ease and certainty, as .sejiarate 
entitie.s — namely, small-pox. the seA-ere. A'irulent. loatli- 
sonie, and fatal disease, and “ .small-pox,” the relatieely 
trifling, non-fatal disease. This scientific distinction is by 
no means academic, and the suggestion of a distincti\e 
name for “mild small-pox ” is a practical proposition 
urgently required in the interests of notification, apjiro- 
priaio measures of control, correct death, ivgistr.atfoii, and 
accurate .statistics. 

Faihtre to adapt official nomenclature to our incre.asing 
InAOAAledge is bringing discicdit upon the art and practice 
of lAreAmitive medicine in general, and in particninr is 
doin" move harm to the cause of v.accin.atioii than all the 
efforts of the anti-vaccination societies since their foiimla- 

tion.— I nm, etc., tj v 

ijeaith Office, Chesterfield, Reh, tSUi. • - aaAIABOAV. 

lODI^fE IX THE TBEAT-MEXT -AXD PEEVENtiOX 
OF GOITRE.' 

Siti, In XcAV Zealand they seem to he s.atisfied Avitli very 

liomocopathic doses of iodiiAC — one giain of pota^-inin 
ioUitlo in 250,000 grains of t,ahlp .salt. IVe are ttdd 
f.TevAra-.vT,, Febru.ary 11th, p. 238) that this gives *' .a 
margin of safety ” against any r isk of overdosing; Tliis, 


1 .should think, Avoiild be jier/ectly .safe even for a ea.se of 
exAijththalniie goitre. Personally ’] .should have.no hc.sita- 
tion in prescribing a grain of potassium iodide daily for 
a long ])eriod, c.vce|)t in cases of hyperthyroidism, bat 
T .shotild hesitate for a long time before I jircscribed 571 
ounces of .Cerebos or B'iudsor .salt dtiily for anyone. 
HoAvoA'cr,. this i.s the ago of “ .safety first,” and this 
experiment can do no' Iinrm, but I liojro in this country avc 
Aviil not start any such grandmotherly- legislation. *• The 
administration of iodine in compai'ativcly large dosp.s to 
patients in adult life .suffering from simple goitre may 
convert simple goitre into toxic goitre, greatly aggravating 
the disea.se.” Tiicre is no danger of such a eatastroplio 
Avitli iodized salt. — ^1 am, etc., 

Innilon, S.AA'.l, rcli. llUi. J.AJins B.MIU. 

OCCIiDSIOX OP THE CENTRAL EKTIXA.L 
. ARTERY. 

.Silt, — The nipmorandiim on bilateral emboli.sin of the 
centinl retiiml artery (Biiirrsir AIewc.ai. Jouhsal of. 
Februarv 4tb, ]). 178) i.s of great interest, but appears to 
contain no evidence justifying the restrictive Avord 
“ embolism.” The condition described is retinal occlusion, 
Avliicb may be due to embolism or thrombosis, and I AAould - 
siiggc.st that the age of the patient (74), the pre.scnce of 
a<lA-aiiced cardio-cascnlar trouble, and ca-cii the consecutive 
occhisioAAs of the right and left arteries, are much moie 
snggcstiA'c of thrombotic causes than of embolism. 

These causes are gener.ally accepted, and include 
endartei-itis, arterio-sclevosis, spasAAA, and'faiiiiAg cardiac 
effioiencA-. It is clear that these comprise local cleter- 
ininaAAts ns well ns general influences, and it is to be 
remembered that .ai-tcrio-sclcrosis can cause a loAvercd 
pi-cssure in. the retinal arteries eA-en in the presence of a 
raised eenoral blood pressure. Spasm is suggested as the 
likely rouse whore there have been iirecediiig attacks of 

transient blindness, . i • 

H-iviiig regard to all the circimAstnnces pnrnceutcsis 
AA-onhl njiponr less hojAeful aaa thrombotic than in emhoho 
eases but in .the latter. group p.firticu]nrly it. should ncA-cr- 
be omitted if in time to anticipate veliAAnI death. 

I AV!AS once fortunate, ns a bonse-man, in beiiAg associated 
Avitb a'sAicccssfuI (embolism) case, and found the experience 
stimulating to future efforts, remembenng that, l^v the 
Havs of ebmice, we start afresh with each case, unaffected 
liv the general pei-ccntagc considerations which would be— 
for ,,ur.?ceiitesis-so discouraging.-I ani, .ctc., 

' . ,,, E. CoVaDon M.sckiVa. 

SUcftielcl, FeJ». SHi. 

TRE.VTJIENT of caxcer by radium. 

n,. Fletcher Slian ’s experience of the treatment 

f ^nver of the coreix by radium' and by operation 
.. Ill, ,nv oAvn. Consequently 1 restrict the use 

T radidUA to cases in which the disease hpjiears to he so 
nsivc tliat radical operation seems to he impossible. 

pronounced, nncl in somo 
• 't c the lesion is improved to SAieh an extent that 
I'td ~al ^;^wetised inter. Xot one of my cases has 
tot.vl rtiiploving I'adium alone, while many .aie 

’T^ovin" good’ health through having hecn subjected to the 
radiroi operatio’n-sonie as long as fourteen years ago.- 

I am. etc., .Sawcci, J. Gaiif.rox 

C! T bad intended m'v last letter to end ibis eovre- ■ 
spmAaeuoe. but it AA;ould be discourteous not to reply to 

mv'Avoixu'arc too sweeping, and, taken 
VC '■ IK- ‘"draw injustice not only to the RadiAim Institute 
hterollA, ™ to that of Jlanebester ; but, read m 

of Loiulon, j ^.m-i-espoudonce, they can l oicr 

eonjunetiou AAdh of statistics upon the result of radium 
trohuuent of roreiuoma of the ce.A-ix, after a period of 

five, or more years. m pnhli.shed such 

//. i^rould hr^rateful if Mr. Hayward Pinch aa-ou d 
statistAcs I f I .should be only too happy to 

iSir.- « I '»'■« 

—I anA,- etc. 'U'lLi.iAAr Fi.ktcher Shaav. 

JIancIiestcr, Feb. 8tn. 



. . n.nt 

Teb. l 8 , 192 SJ 


OBITUAltT. 


t Tfrr URinsa 
llrDicxi. Jo7sxi£ 


287 


TJNSUSPECTKD VALVULAR DISKASE IN CHILDREN. 

Siit,— A consiclorablo amount of at!*;ntion is now being 
givon’to tlio subject of acute rbcumntism iu children, and 
it would tliercfoic bo interesting to bear from other 
readers to what extent valvular disease of the heart occurs 
without tbo knowledge of the parents or praetitioncys. 

AVitli an experience gained during the inspection of 
20,000 school children I cstiniato roughly that more than 
80 per cent, of the mothers whose children have valvular 
disease are unaware of the fact until it is pointed out at 
school inspection. — I am, etc., 

Walio.d, Herts, Fet. ' J '«tns BuCHAN.lN, 


THE TAVISTOCK CLINIC. 

.1 Correction. 

Slit, — In your issue of Fehruaiw 11th (p. 242) there 
appears a report of a dinner celebrating the .seventh 
anniversary of the foundation of the Tavistock Clinic for 
Functional Nervous Disordois, in which I am stated to 
have expressed myself iu these words: "Sir Farquhar 
Burzard added that tho recently issued report of the clinic 
for the years 1920-27 was one of tho most completo and 
instructive statements of its kind illustrating tho valuo of 
psycho-analysis that had yet appeared.” 

This is not an accurato rc|)rcsentation of my remarks. 
I never used the word “ psycho-analysis ” in the course of 
my speech, and my appreciation ■ of tho clinic’s report 
referred t<t its fair-minded, unbiased, yet convincing expo- 
sition of the benefits derived from jtsychoihcrapy by patients 
suffering from psychoneuroscs. - ■ ■ 

Tho words of your lepoit suggest that tho clinic depends 
on psycho-analysis for its results and its justification — 
a suggestion which is likely to do tho institution and its 
appeal for support moro Iiarm than good. A perusal of 
the clinic s rejiort is sufficient to show that psycho-aiialvsis, 
using the word iu its technical (that is, Freudian) sense, is 
a lorm of therapy never undertaken by tho medical staff, 
u 10 depend on other psychotherapeutic methods for the 
successful relief of their patients.— I am, etc., 

London, w.i, Feb. Pitii. E. F.snquH.sn Buzzabd. 

, Re much regret the slip in our news paragraph. 


©Iiititam 

GEORGE BALFOUR MARSHALL, M.D.Eo., 

Tr_„„ ^ 

Glasgow Royal Infii-mary 
sor (^ Obstetrics and Lecturer lu Gynaecology 
Mungo’s College, Glasgow. 

MnvJw?* .* 1 ” the death of Professor G. Balfour 

on January 31st. Glasgow 

wlioi-r was a native of Edinburgh, 

• itiuniciml been prominent in business and 

Searil From George Watson’s 

graduated M B™*" C V“ University, irtiere he 

obstetric*; mS bis distinguished career in 

of house-surgeSTn'The^Fd^ folding first the appointment 
pital, then imdcrtakina n 1 ^os- 

Rotmida Hospital and on “"v 

yoars in Jeim a.id BeHi.f F."^ subsequently some three 
brought back a most extensive t" 1 ° 1 

Dter -^S^d" wt- thf rk°‘x:h 

foi?owing^“3?ear proceeded^M D 17 

Fll7\fXSr 1 ■ Feilo^^hip Tl^'^R^rai 

nppointed to the sta/nf Glasgow. He was 

of Glasgow Roval Infi.m.. ,gJ'uaecological department 
Dr. Kelly in clmree ef i'® succeeded the. late 

n gloat io;uta .«.1907. He quickly acquired 

School, and for m7, ^ Extra-Mural Medical 

the old 'Western Aten- ioctured to crowded classes in 

logl- at -St. Mnio’s ColW°“'- 

g s Lollege, and succeeded Dr. Robert 


Jardiiie as professor of midwifery there in 1621. His clear, 
witty, and vigorous stylo of expounding his subject, and 
the obvious joy he took in inspiring a like enthusiasm in 
others, rendered him an ideal instructor, whose infinence 
and fame will long survive. 

Professor Marshall rendered yeoman service to his pro- 
fessional colleagues. Ho was for many years a member 
of the council of the Medical and Dental Defence Union 
of Scotland, which he was largely responsible for establish- 
ing. He represented the Royal Faculty of Physicians and 
Surgeons of Glasgow on tho directorate of the Glasgow 
Royal Alateriiity and AVomen’s Hospital. He was a strong 
supporter of tho local Obstetrical and Gynaecological 
Societj", and filled various posts in it, including that of 
president from 1920 to 1922. He held an appointment from 
tho Privj’ Council as one of the Government visitors under 
the Pharmacy Act, and brought to its obligations his 
characteristic accuracj- of observation and whole-hearted 
interest. He made manj* valuable contributions to the 
literature of liis sjieeialtj'. In 1911 he published his well- 
known Manual of Oltstctrics, which was based on liis 
lectures and won high praise from medical students and 
practitioners. His popularitj' as a teacher owed much to 
his scrupulous care in observing and recording, and his 
abilitj’ to set out his conclusions attractivelj- and con- 
vincinglj’. 

A colleague writes: Dr. Marshall was an admirable 
surgeon, with splendid judgement and most careful 
technique. To patients, students, and colleagues he was 
a model of coiirtesj' and helpfulness, enhanced hj' a 
delightful modest}' and a kindl}', if caustic, wit. He was 
a most patriotic Scot, with a great love for the Highlands, 
where he indulged his recreations of fishing and jihoto- 
graph}', in which he excelled. For several years he suffered 
from bronchitis and rheumatism, hut though suffering even 
more than usual he lectured to liis class at St. Mungo’s 
College on Januaiy 20th. On the next day he bocanio 
acutel}' ill. An operation revealed an intestinal perforation, 
and at a lower level there was an inoperable iiialignaiit 
growth. A few hours later he passed peacefully away, 
having completed a wonderfully full and useful life. His 
profession and the citj' where he laboured so devotedh' have 
lost a noble soul. It was onlj- last x-ear that Dr. Marshall 
celebrated his silver wedding. He leaves a widow and 
three children. His daughter is a science student in 
.Glasgow Univereitx'; his elder son has just finished his 
course at Epsom College, where the j'ounger son now is. 
The sjnipath}- of the whole profession goes out to the 
bereaved. 




ALLEGED NEGLIGENCE AT A MENTAL HOSPITAL. 
A SPECIAL jury in the King’s Bench Division, after a three days* 
Iicaring, awarded Lieut. Commander G. H. Drummond, V.C., 
R.N.V.R., £150, and Mrs. Drummond £500 damages for alleged 
negligence and breach of contract against Wonford House 
Hospital (Incorporated), the proprietors of a mental nursing 
home in Exeter, but found for the defendants on a counter- 
claim for £22 10s., the balance of fees. 

The alleged negligence and breach of contract consisted in the 
defendants’ nurses not exercising a continuous watch over Mrs. 
Drummond, who was a patient in the institution. Slie \vas 
watched without cessation until the second night, during which 
only intermittent visits were paid to her, when, in the absence 
of the night nurse, she broke the glass of a window and forced 
herself through an aperture measuring less tlian ten inches 
square and through the bars guarding the window, striking 
an iron balustrade and fracturing her arm and her jaw. After 
the birth of her third child Mrs. Drummond had become 
obsessed w’itli the idea that she had committed an unspeakable 
crime, and had expressed intense dislike for her children and 
her husband. On the advice of Dr. Grant llilson she ^\as 
removed to Wonford House Hospital, and a great deal of 
evidence given in the case was on the question whether Dr. 
Grant Wilson told Dr. W. B. Morton, medical superintendent 
of the hospital, of the suicidal tendencies exhibited by Mrs. 
Drummond Dr. Grant Wilson’s ^'ersion of his telephonic 
communication with Dr. Morton was that he told him Mrs 
Drummond was extremely restless and agdated, and she had 
delusions of persecutions and all the symptoms of acute puerperal 



288 Feb. i 8 , 192S] 


MEDICO-IiEGAti. 


melancholia. He sngrrp.sU^ that ilre. Dniinmoiul .should enter 
the liospital a.s a vohintiir.y patient, hut that if Dr. -Morton 
thought that that was net safe he would certify her ns a 
lunahe. In fact, after the accident, he was n.'-hed to go to 
Exeter and certify Mrs. Drummond, and he did so. Happily. 
Mre Druniniond has since recovered her mental halaiice. 

llie evidence' of Dr, Morion, ^vhD lias since* died, Inlcea 
on co.mmirsmn whilst he was suffering fre.ni c.aiKs-r. Ifc said 
Ineiv was no mention I,y Dr. Grant^ Wilson of any snieidal 
tendencies, or of Mrs. Drummond being insane. 01 .'^iiffeiini'- fio'ii 
puerperal melancholia. She herself told him her only tnnd.le 
was slecple.ssiie.ss. He found no signs of suicidal lemiencies in 
lier; it he had, he would have refu.scd to take her in .as a 
voluntary patient. 

Dr. Grant At ilson attrihuted this lamtradiclorv evideiice to 
•a lapse of memory in Dr. Morton. Mr. Justica- Avorv said 
the tact that the ex.amimition on commis.sion look place a ‘month 
before Dr. Morton s death might afford some eyplaiialioii of 
apse of memory, and. to the oliservation of tlie counsel for 
the defence that cancer did not affect the faculties, the jud^c 
icphed : Poisoned blood affects the hr.ain, and I uiidei-sland 
that nobody can have csanccr without poi.soned blood.” This, 
of course, was ohitri dirtum. since no medical evidence was 
tendered as to the effect of cancer upon the mental faculties 
OT a sunorer from that disciisc. 

Tile defending counsel urged that there wa.s no evidence of 
lack (if care to go to the jury, but the judge ruled olherwi.se. 
and. Ill his summing up to the jury, he pointed out that the 
deiendants owed a duty to take reasonable caie and to e.ytiibil 
reasomable skill in the treatment of all patients admitted to 
their institution. The juiy had to ascertain whether lliere 
was evidence that the defendants, by their agents or servants 
had been guilty of negligence, or whether Dr. iforton. knowiim 
what he did. or knowing what he ought to have known, was 
right in withdrawing the night nurse on the second night - and 
further, the night nurse having been withdrawn, wliellier. not- 
withstanding visits paid eveiy half-hour, tlie patient might Jiave 
lieen prevented from actually throwing Iiei-self out of the 
window. The jury’s verdict was as staled. 


TiiREnmiH 


LWEDicitJociau, 


descrilied 


sli./r,.: 1 vigils which he liad noted in the accused— 

d''-*.'- ” .tongue, and so forth,' He 


had_ stated that the accused wa.s .asked'' at' the police istatkin 

ll.<: JAnen nnrl i i.,* .. 1 • 


I ms( liad put IIS finpr m |„.s eye; also to walk on a clailkcd 
(balked line he walked straiglif acro.ss the room. Uiiforiiiiiatelv 

Hm ft had agreed 

(iial not one of (he signs lie had discovered was in itself (vii- 
elusive of drunkfnne.ss, hut he .affirmed Uiat the comhinalimi 
of them wa.s conclusive. The man, who had been a motdr c.ali 
driver for ten years, had a clean record, hut he 


Imd I'l'pn 


snlijecl to nervous breakdowns, and oil the day in qnestii.ii 


DEGREES IN DRUNKENNESS. 

Some interesting observations on drunkenness were made bv Sir 
Robert Wallace, K.C.. chairman of the County of Lo'ndon 
Sessions, at Newington on Fehruary 9tli in sunim'ing up a case 
in svlnch the driver of a motor call was charged with being 
drunk while driving his vehicle. Tlie evidence, which was 
tendered on the preinous day, was of .i contradi-torv character 
and Sir Robert had intimated that if the pri.soiier 'were found’ 
guilty he would grant leave to appeal so that there would be 
some chance of an authoritative definition bv a higher court of 
what constituted drunkenness within the meaning of the section 
under which the accused person was charged. 

In placing the case before the jury Sir Robert AAkallace said 
tliat there had never yet been any actual definition of drunken- 
ness given by the Court of Criminal Appeal, the final anthoritv 
in tnese matters. If there had been such a definition other 
courts would have felt it tlieir duty loyally to abide bv it. 

1 lie phrase was used ‘'under ttie 'influence of drink,” which 
miglit mean drunkeiine.ss dr niiglit not. No one had any 

<uniculty •with the ,i :i . v 

aiul diso^de^l^ 


had hceii implored by his wife not to drive his ca'h. It'sppmed 
ntiwise that a man m this nervous condition should have charge 
of a vehicle at all. hut that was not the question the jury had 
to consider. The man affirmed that he had taken no iiitox'ic.siits 
that day except two glasses of beer an hour or two hefore tlia 
mishap. 

The jury, after a Iirief dcliheralion. i-etnriied a verdict of 
“ not guilty,” and Sir Robert AA’ali.-ice, in discharging the 
accn.sed, said that he did so with satisfaction, hut he ipgretted 
(hat a proiionnc(|niciit on such a case by the Court of Criminal 
Appeal would still not be forthcoming.' 


BTnilijirsitifs mtit (ERllcjjfs. 


UNtrEllSITr OF C-iMBRIDGE. 

At a congregation lield on February 11th the following 
degrees were conferred : 


medical 


JLD.— F. M. Bmiios. 
IJ.Cnui.— IV. J. Wilkin. 


UNWERSITY OF LONDON. 

It has been . “niversity CIinirorBiochemislr.v 

tenable nltt ' "ygieue nml Ti-opical SlediciuB'; 

salarr £1 30C .. . bf £200 per aminm. Applica- 

tioiis'mns’t bo received by Hie Academic Registrar by April 12tb. 
Annlications for llio Chair of Fatliology tenable at the London 
(Koval Free Hospital) School of Medicine for Women (salary £1,000) 
mnst be received bv the .Academic Registrar by Mnroli 1st. 


AmilicaHons for grants from the Thomas Smytbe Ilnglies 
Medical Research Fund, allocated nnunally for tbo imrpose of 
assisting ori''iual medical research, must be sent in, accompanied 
bv the names of not more than two persons to whom reforenoe 
mav bo made, between May 1st and June IStli. 

Annlications are invited for the Laura de Saliceto Stndentsbip 
for the ndvaiirement of cancer research, value £150 a year. It is a 

■ * ’ "-"y be held in conjunction witli an 

or patliological laboratory, or iritU 
• special opportnnitiesfor tiio study 

ificatioiis, together with tlie names 


one had 

cases commonly described as ” di-imk 
or ” drunk and incapable,” but druiiken- 
ness w.as a question of degree. Many people were atiniulaled 
by taking some drink, were rendered more brilliant or 
acquired more courage. It was not unknov.n for liieli. 
class orators to be indebted to this stimulus Atedical 
men bad seemed unable to arrive at any specific definition 
A new set of circumstances arose, however, wliea a man wiio hail 
been drinking was.m charge of coinpli(ated machiiierv .such as 
a motor car. winch required Hie e.xercise of discrimination and 
other faculties winch into.\icatnig liquoi miglit disturb He 
believed that drunkenness from tliis point of view meant the 
taking of sufficient imo.vicalmg liquor to di.sturb the mental 
lialanee and render it unsafe for the person to be in cliarae 
of a motor c.ar. The evidence m this case showed that ' the 
accused collided slightly with a motor cyclist and disrcjardcd 
the police signr.l. AA’heii liis cab was stopped lie was^fmiiid 
leaning against it for support, .and the police con.stabic’s 
evidence was tliat he avas thick in Ids speech, tliat his eyes were 
lilocidshot, his lips puffed, and that he .smelt stiongly o'f drink. 
He avas taken to the police station, where the divisional surgeon 
certified that he was drunk. Tlie man asked fc,r liis own doctor, 
avho. hoavever, was not available, and aiiotlicr doctor was 
c.aiird. but by this time the man had been one lionr and a 
'lua.-ier at the station. Some argument had taken place diirin' 
'he hearing on the previous dav as to which was the belter Ivo 
<.r ev.Uenee in such ' ■' ” ' ' 


of two persons ns relerees, must bo sent to the Academic Registrar 


,vo iiersDus u 
before July Ziid. 

A Carpeiilc 
£20 ill all, v 

Mulrimenlal psvcbology, including tlie''fnnctious ot'tlie central 
1 rvoiiB sTslem special senses, for winch fi iloctors de'.'ree 


“lone}' prize. of the value of 
mate in 192S for a thesis of 
genetic, comparative, or 


/IffhAi- ihaii tho Ph.D. degree) has been awarded during the three 
(earae ding Mav 31sl. 1928. Applications must be sent in i.ot 

jears e t* oTi. A 


later Hiaii Jiiiie 9tli to Hie.Aiiademic Registrar 


AniitirnHoiis for grants from the Dixon Fniid, allocated nmnially 
_ Eoicntirio investigations, must bo sent in betueon 


'd^st ami May iotli. aooonipauied by the names of tivo persons 
retereiice mav be made. 

WorMier uarticnlara of the varions grants or other awards maybe 
obliiiued from Hie :.\c.ademio Registrar, Hmversdy of London, 

tlmi’ter lias been recognized as a teacher of mediciiio 
ainVeSon nospital Aredioal College. 


rni’? TT^iivPFsitv medal at the M.S. Examitmlion (Branch I, 
j-tenml and external students, December, 1927, hfl^« 


pe 


p 'ii't f cases — that of the police con'-lnhlp. wliose 

dwtor” whJf'J i''‘? **"■ prartic.ll m.iii. or that of the 

. no rehed upon certain tests. The iKilice surgeon liad 


bee'^SnwL^i°odTo Rober'r -Walker ot University College Hospitii 

London School of Hygiene and Tr.oric.VL Medicine. 
JOiviiioii of Tropical Olcdiciiie aad Htjpienc. 
n-'i,„ fnilowin'’ Hissed Hie school examination at tlie terminalic 
of th|e°gbty-third session (October. 1927-February, 1928); 

•n vr °>lmith (Duncan atedaU, 'R. Pierre. "V. E. Whitman, "Jt. SI 
*^ wye“al1. 'D. B. Jandial. ’H. A Fawcett. »M. N Andrews 


i?' AT I. Siimmerhayes. *A. M. Soliman, V. H. 
*G. M. ^ D *T> fZ OlTV-rM *n W T 


*A BearblocU, *B. Al! Johns^ •T. P-JEeatinR. • \V. E.^Dayis./if.^ M 
■Bsirri E. S. havcrie, G. A, ” 

A. xMagraby, E. A. 

nlfrJS^’T^C P Grey, c/r. Amies. M. Merchaot. O. if. Francis, 

S fnrt'nc N ■■ “'ntins. E. FarTS. 

li.VTa'Jk.' j. : ■■ ■ ■ . V-J'-v^H?am 

TT AT willouc. . ■ '' an*. 

A Tiiininn P T. J. Do«s, R. S. JobnstoD, H. J.Eawson 'W.Magowon. 
e! L Connor.G. G. Udeshi. R. U. For^ayeth. 

• With distinction. 



289 


; .isr, 1 

Feb, i8 , 1928 ] 


Univeusitv' College. 

SrrciAL sliovt courses in anatomy niul iJliysiology, desigueil to 
meet tlie lenuivcmeiits of tlic Primary Fellowsliip Examination 
ot the Royal College of Surgeons, arc lielii at University College 
twice ilurmg the session. They arc advanced courses intended to 
supplement°tlie routine instruction, required for the prorossionol 
nnalityiug exaininatioii. Each course extends over a period o( 
three months. The next course will hegiu on Monday, March. 5lh, 
in preparation for the June examination. I’articulara of these 
conrsesmay be obtained from the Secretary ot the College. 


t Tni: BRirrra 

?^frmr-xT. JnT-Tt vtt. 


the Births and Deaths Eegi.str:ition Acts, 1856 to 1926, pre- 
sented by Captain Gunston; the Blind Persons Bril, presented 
by Mr. Naylor; the Dogs Act Amendment Billr to amend the 
Dogs Act, 1906, presented hy Mr. Briggs; and the Slaughter 
of Animals (Scotland) Bill, presented by Brigadier-General 
Charteris and supported bv Dr. Sluels. All these were read 
a first time. Among tlie bills occupying the ten first places 
in the ballot for private members* bills — ^these being the only 
private members’ bills which are likely to become law — none is 
of direct medical interest. 


MEDICAD NOTES IN PARDIAMENT. 


KOTiVL COLLEGE OFSBllGEONS OF ENGEAND. 
ovihuarv ConucU meeting was held oa February 9th, whoa 
the President, Sir Berkeley Moyuihau, was in the chair. 

Diplomas, 

Diplomas of Membership were gmutod to 164 candidates^, nnd the 
Diploma of Fellowship was gmnted to Mr. II, I. Deitch. Diplomas 
were granted jointly with the Royal College of PhysicFans: iu 
Public Health to thirty-six candidates; iu Ophthalmic Medicine 
and Surgery to niueteen candidates. 

Bradslinin Lecture, 

The President appointed Mr. C. 11. Fagge as Bradshaw Lecturer 
for the ensniugyear. 

Conrefition on Caiiecr, 

Sir Berkeley Moynihau and Jlr. Steward will attend the 
Interimtioual Convention on Cancer, to be held in Loudon from 
July 16th to 22ml, as delegates from, the Roj'al College of Surgeons. 


Primanj Examination for Fellowship in Canada. 

A revised scheme for conducting the Primary Examination in 
Anatomy and Physiology foe the Fellowship in Canada wis 
cousideved and approved, and instructions were given for the 
scheme to be forwarded to the Canadian Medical Association for 
tueir comments. 


Couiicii Election, 

T 1 Council will take place on 

July 5th at 11 a.m, to filf the vacancies caused by tlie retiremeut in 
rotation of Sir Anthony Bowlby, Sir D’Arcy Power, and Mr. P. J; 
Steward, and by the deatli of Mr. ThchvuU Thomas. Notice of 
the election will be given to Fellows by advertisement and by 
March 19th will be the last day for tlie 
• • • • sent to every 


. .... ’ • • y celebration 

rtf 9!- . Cairo. and the International Congress 

iQ 9 « « * ' Cairo iu December, 

: irgeous. 


royal COLLEGE OF FHYSICrA'SS OP EDINBURGH. 

lueetiug of the College was lielil ou February 7 
n? nobeft-V Fleming, was iu the chair. 

Gra.' Charles John Shaw, Dr. Ron 
Fellows oUhe CoRe^e^ ‘beir seats 

James Thomsou (Duiul 

were efectefl Fellmvs ot the College. 

(Calcntta^n,- (Edinburgh), Dr. Premaukur 

(Aberdeen), Dr. J. D. Af 
ffiVur limnnfM ^ss(Loehgilpliead). Dr. Chas. A. Has 

Riutoul Jack (Edmhurgli),. aud Dr. Alex. 

( uowaj', Fife) were elected members of the College. 


^trliical ^otfs iit 

[From ock Paeuahentaiiy Cobrespondekt.] 

In this week tl.e debate on the Addres 

House V\ip‘ ® Speech closed on February 14tb, and tli 

On flip ^ motion for the appointment of two new judges 

that rt.'if inght the Prime Minister adduced evidenc 

c]a<^«P« l.e. 7 standaixl of living of tlie worknij 

t United Kingdom. The rest o 

H^timat«<? i Wouse of Commons- A^’as spent on Supplemental*; 
bvalth mil* pnvate memljers* business. Neither iiationn 
On the- AdiWrs^^^^^* topic was discussed in the debat 

and Unionist Party Couunittee on Healtl 

I^tli an,? meeting of the session on Febnmr 

HehruaiA- ^^Umuieutary Medical Committee its first oi 
Dr d" ’ Fremantle presiding over each, 
from Shiels has returned to the House of Common 

JHission. ^ been serving on a .special com 

Bills of ParUfimfiit. 

0?i FebniavAr given in tlie House of Common 

(8ubstitufPf?^p*m ♦ Hie Edinbiagli Corporation Bil 

of the citv .Norther powers, upon the corporatio’ 

Hegistmtion \ I’^^atioii to venereal disease; th 

b iration (Births, Deaths, and Marriages) Bill, to amem 


On February- IQth the Secretaiy for Scotland presented, and 
the House gave a first reading to, the Reorganization of Offices 
(Scotland)- Bill, which had been promised in the King's Speech. 
One of its purposes is. the transfer of the powers and duties of 
tile Scottish Board of Health to a Department of Health for 
Scotland. 

On February 13tl> a bill to prohibit the vivisection of dogs 
was presented by Sir Robert Gower, and w'as read a first time. 
The Dogs Act Amendment Bill, introduced by Mr. Briggs, 
is not an antivivisectiouist measure, but will probably propose*, 
among- other objects, to strengthen the provisions of the law 
against the stealing of dogs. The Protection of Dogs Bill, 
presented by Sir Robert Gower, h.is as its declared object “ to 
pichibit the vivisection of dogs.’* It is supported by Colonel 
Moore, Mr. Bromley, ^Ir. ISIacquisten, Mr. Thurtle, Captain 
A. EvaiLS, Mr. Sexton, and Mr. Radford. The second reading 
is put down formally for April 20th. Before the presentation 
of this bill a suggestion was made to its promoters that 
it might be treated as uncontroversial if a clause were added 
to uutJiovize the police to supply for experimental purposes dogs 
seized as strays and subsequently unclaimed. This . overture 
was flatly rejected. 

Ou February 14th iMr. Tinker presented a bill to consolidate, 
with amendments, the enactments relating to factorie.s, and it 
was read a first time. 


Xational Health Tnsuvance, 

Oil February 9th Mr. Chamberlaiu staled that 355,000 iusured 
persons woro estimated to have reached tlie age of 65 ou January 
2nd. During the month of January the estimated addition to 
that number was 8,000. AU these would cease to pay coutributioua 
under the health insurance scheme and to be entitled to sickness 
and disablement benefits; medical benefit, together with additional 
treatment benefits-, woula remain available to them for life. How 
many were in receipt of sickness or disablement benefits when they 
attained the age of 65 was not known. 

In an answer to Mr. Foiiby, on February 9th, Mr. Chamberlain 
said the- approxliuale amount of funds invested on behalf of 
approved societies mulor the National Health Insurance Act at Iho 
cud of 1925 was £115,000,000, and ab the end of 1927 £111,000,000. 
In a reply ou the same day to Mr. Rhys Davies, Mr. Chamberlain 
said that after meeting out of cuxrent income the cost of schemes 
of additional benefit, amounting to over £8,000,000 yearly, the 
approved societies bad available for investment in 1925 £1,500,000, 
and in 1927 £200,000. 


Foot-cend'Houth Disease, 

On February 13th Mr. Guinness, replying*- to Sir Basil Peto, 
said that in recent yeaj*s no definite proof liad been obtained 
that foot-and-mouth disease outbreaks in this country had been, 
due to infection by meat imported from South America.. Suspi- 
cion had, however, arisen' that certain outbreaks had been due to 
cloths in which imported meat was wrapped, or to bones from 
sucIl meat. To guard against- this danger orders had been 
issued which required meat, bones, or other parts, of a carcass, 
or cloths iu which foreign meat had been wrapped, to bo 
boiled or di^^infected before they were brought into contact with, 
animals. Negotiations had been in progress for some time with 
the South American Governments which should result in the 
adoption in those countries of measures for preventing tho intro- 
duction of infection into Great Britain. 

Mr. Guinness also told Mr. Wardlaw-Milne that he had seen in 
the press reports of the discovery in France of a ne\y cure for 
foot-and-mottlli disease, but he had no official information on tho 
subject. No invitation had been received by the Ministry to 
attend the tests. Our policy was eradication by slaughter, and 
Ihfe discovery seemed to be merely a cure and not a preventive. 

Mr. ‘ Guiniics'!, on February 14th, told Major Davies that do 
experiments to determine the after-effects on animals which had 
had foot-and-mouth disease and had recovered from it had as yet 
been carried out by the Foot-and-Moutli Disease Research Com- 
mittee. Tlioro was considerable evidence from abroad that the after- 
effects of the disease were ■^■al'iabIe. Mortality among unweaned 
stock was very high. The Continental view was that a certain 
proportion of tlie recovered anunals became ** earners of tho 
disease, and were for a long time capable of infecting susceptible 
stock. 


3lUk Campaign. — Mr. Guinness announced, on February 9tb, 
iliakthe Enipii'c Marketing Board, in consuUalioii \\itU the Ministiy 
of Agriculture, proposed to open, in April, a piibTicily campaign 
in favour of the consumption of ficsh milk. Tins campaign will 



200 Feb. i 8, lg^8] 


M:EDICAr.'NEW'3. 


r fri lu-n 
i ’Il.llIC'E JO! 


last for six months, and may be extended. Pr. Drummond Shicis 
esked wliethef Iho Minister would see (liafc lliis advocacy of fresh 
milk discriminated between tubcrciilosis-frco milk and other milk 
which might bo dangerous. Mr. Guinness said tho proportion of 
tuberculous milk was much lower than a few yeai-s r^o. He 
thought nothing moro could* be done than was being aono at 
present to improve tho supply of 'milk and avoid this danger. 
Dr. Fremantle asked whether the Minister of Agriculture pro- 
posed in this publicity campaign to work with the Ministry of 
Health, which was able to use tho medical channels for recom- 
mending milk. Mr. Guinness said they would certainly work in 
conjunction with tho Ministry of Health. 

^Tarrtape of the PhysieaVj; Vnfit.— On Fchriiarv 13th Sir R. 
Thomas asked tho Minister of Health if ho had devoted any 
attention to the report on the marriage of the physically unfit, 
recently issued by the London County Council, and if he proposed 
to introduce legislation on the subject. Sir Kingsley Wood said 
tho Minister- of Health was not aware of tlio adoption of any 
such report by the London County Council. 

• Vroiithitton of Boric Acid in Cream, — Sir J. Gilmour told 
Brigadier-General Charteris, ‘ on February 14lh, that only a few 
creameries in Scotland had made representations against tho 
prohibition of boric acid in cream. There was substantial evidence 
that cream properly produced from clean milk and^ properly 
handled would keep si\'eet for several days. The Scottish Board 
of Health accordingly saw no reason to rescind the regulations so 
far as they applied to cream. 

Bovrs of Hallway DininQ'Car Attendants. — On February 14th 
Mr. Betterton, in reply to Sir R. Thomas, said he was informed 
bf the Great Western, London, Midland, and Scottish, and London 
and North-Eastern railway companies that there was no founda- 
tion for the statement that railway dining-car attendants woro 
habitually required to be on the trains for periods up to forty- 
eight or lifty-three hours, with consequent tuberculosis atid gastric 
disorders. 

Proposed New Welfare Centre at Southgate. — On February 14th 
Mr. R. Morrison asked why the Minister of Health refused to 
approve or make a grant in aid of expenditure by the Southgalo 
Drban District Council of £19, the salary of the medical oflicer, 
In respect of a proposed new maternity and child welfare centre 
to be held on premises belonging to tho council for two hours 
monthly, for medical inspection of children between the ages of 
Z and 0 years. Sir Kingsley Wood, replying, said that sanction to 
this proposal was wilhlield because tho Minister of Health was 
ftdWsed that the facilities already provided by the urban district 
council should be sullicicnt to allow of the medical inspection of 
children between the ages of 2 and 5 years. It was proposed, 
however, to arrange for a further inspection by a medical officer 
of the Ministry of the arrangements made by the council for 
toaternily and child welfare, and the Minister would give further 
consideration to this proposal when he had received a report on 
this inspection. 

Street Accidents. — In the House of Lords, on February 14th, the 
Bishop of Southwark called attention to the statement of the 
education officer of the London County Council that in 1^6 in 
the Metropolitan area 233 children were killed and 9,528 were 
injured by traffic accidents. Lord Peel, First Commissioner of 
Works, in reply, said that the^ Adviso^ Committee on Street 
Accidents, appointed by the Minister of Transport, had presented 
a report about a year ago. The committee was set up because of 
the anxiety of the Ministry of Transport to see what could bo 
done to reduce the dangers of the streets. He understood that* 
the Advisory Committee would report very soon to the Ministry, 
The Minister of Transport was prepared to give a special 
direction t'- r . ; consider particularly the problem 

of accident • ■ c'. . !■■■■:. . ( nsult representatives of the police 

and local ■ ’! } might decide upon definite rules 

to reduce these accidents. 

Memorial to Lord Baig. — On February 8th Mr. Baldwin moved 
that the House, on the following day, go into committee to pass 
an Address for the erection of a monument at the public charge 
to the late Field-Marshal Earl Haig. Mr. Ramsay MacDonald 
moved as an amendment that a select committee be appointed 
to consider the most fitting form of memorial to Earl Haig, in 
view of- his concern for the comfort and welfare of ex-service 
men. Supporting the amendment. Dr. Drummond Shiels said 
there were many tuberculous ci-service men who were gassed 
during the war and whose disease did not make itself known 
for many ycai-s. Many of these cases had been disallowed. The 
House had’ an opportunity to make up for what it had failed to 
do in the past. The amendment was defeated by 220 to 105. and 
later in the week the House unanimously passed the Address in 
favour of a monument. 

Botes in Brief. 

The Minister of Pensions has discussed with a deputation, from 
tho Glasgow Corporation the futui*e of Bellahouston Hospital. 

There is no evidence to show that tho tsetso fly is increasing 
or spreading anywhere in Kenya Colony. 

Local authorities are increasingly making use of dust carts with 
Covers, and ai-e encouraged by tho Ministry of Health to do so. 

During 1927, out of 53,915 men and boys w’ho offered them- 
selves for service in -the Royal Navy and Ro.val Marines, 5,655 
Were accepted and 47,866 rejected for medical, physical, and 
educational undtixess. 




• The aumial dinner of past and present .sludoiils> of tlio 
Boyal London OphtUaUulc (MoorUeldb Bj tj liuU 

at tho Lau^ham Hotel on Februar 3 ^ 8tn, Bir WiliuoE 

Herrin«linni in tho chair. Among tlio "no \rcr S.rJoliu 
lloi-e Hriidlord, Sir 'James Berry, Siiryeuu \‘.eu'-..'-il...iral 
Arthur Gaslioll, Sir Mathe'U’ Pell, rro.'o s rs LI; o.-j.i.itb 
and U. Hiirtrldgo, and Messrs. Ernest Clai Ice a.i J 'i'li-o.luie 
LiiliU''. The toasts were proposed by , the cliai.— -..u. sir 
John Parsons, and Sir William Lister. 'L'uri..y iho o'-cac.;; 
tho dean, Mr. Charles Gouldeu, ann.iiac^d t.'.ai 1-3 sew 
students had enrolled; the number attoseiUn' ll.o piae ico 
of the hospital was 216. .Two students ha.l ieee.\e.l ILa 
diploma of P.B.C.S.Ed. In opUthaliiu-lUry. The 
part of the oxaminaliou for the diploma -m o.yiiljaluix 
medicine and suryery had boeu passe.l by lwauty-oi,;iit 
stiideuls and tho. second part by twcniy-s.-'c. D..r.u" the 
past year Hr. H. M. Traquair of Edmt)ui'"li had aiveo a 
course of lectures on perimetry and PioXis. oi llailii..„e 
two lectuies on the resolving power of the eye. In t.u 
coming term Professor Elliot-Smith woul.l live a coui.so ( f 
six lectures on the optic connexions in the trahi, a;.d Hr. 
Kerr, late' principal school medical offleor of the Lomlou 
County Couticil, two lectures relating to cd..ea.icn. cl -ho 
partially sighted. 

The Council of tho Harveian Society of Loud..u ha-i c.'io.''eu 
for tho Buckstou Browne Prize the subject ‘-Clii ouic strei'io- 
coccal illnesses”; a medal, together w.lh tho .-u a o- £-d.i, 
will he awarded for the best essay’ on this. Toe piizo L o,’i'U 
to any mciuher of the medical profession rogis.eiod m ihj 
British Isles or Dominions under the age of 43. E .'H.v ' 
be sent in by November 1st, 1929. Further ji-U" u a - mav 
bo oblaincd from the honorary treasurer. Hr. G. a- B— ' 
Turtle, 81, Cambridge Terrace, Hyde Park, IV.-’. 

At the next moetiug of the Boyal Statistic..! Seemly on 
February 21st Dr. 1. H. C. Stevenson wul /‘-ad u . l’''i’ ^ 
on tho vital staiislics of wcalUi nud povoitj. iui» aill 
Include a discussion of the social disbrlbubiou o. var.ou-. lo w., 
of uortalitil The meeting will bo held m tho had of ihe 
Royal Society of Arts, John Street, Adelphi,'\\ .L..a. -p.-u. 

the iiibileo of tho Caledonian Medical \‘i-l he 

cetehraiod^ in E.llnburgh ou February 23rd and 2-iai, uuder 

fpmi.^oulhfsame diy the University oIL-inLu.gU is givi-g 
a reception lor the society. 

■T>n A F. Tredgold will lecture for the 
TtT in fche nature of menial deficiency lu tJ.o 

Chandos Street,- CavendisU ou hobLuary 

9 /?/}! ^ai 5 pm.’ On February 21ht, at 3 p.m., tho l-cuu 

V- l^mo’^S hf hlt^i A.° Saf if 

a Climca ‘If' 3 p.^. The leciuic aud doui..U; 

i are free to medical praotilioners. A .our woe-.s 
Btrations j disease will be undertaken by ihc Loi-don 

course la ve ,-rxr pomi tn i\rarc?b IGtti. catwisUng 


r 1 f.omFebVoavy 2Qth to March 3rdf with lecture .uuiiju 

f ‘^Jinnfaud operations throughout the day, aud ouo..-.o-. n 

stratiops, ana optsiuw c V t; a vveek's c-iut>e uni 1 

at the Hofpitkl' from March 19... to 24lU: 

given at the Brorop o, childicu at the Q>me.. s 

a two 5th to 17th ; aud two wceli.,’ cutrsiB m 

Hospital fvom nijelsea Hospital from March 5th to 16ih, 
m ShaLoIogyf t the Boyal Eye Hospital (a.ie.u-o.,a 
to 17th. inOudlug JaHKd..> s. or 


only) tujoners a late afternoon course f4.30 

general praetlt oners a ^ ggu^ral Hos'itt'-^ A" 

Fellowship, 1. Wimpole street, W.l. ■ 

Too Ttoval societv announces in ouradvcrtlscmeul c-lmi ns 

tharap®p°icatfonT for tho Goyernmeut -;r; 'f 

JnvesligationB for 1928, ou pnuted lonns to ho 

the clerk to tho Government Grant Commit cm !■ 

Builington House, W.l. must be received by Maicu Ot-t. 


TEB. i8, .1918] 


IiETTERSi NOTES, AND ANSWERS. 


[ TiteBritito 001 
Medical JocusAZ. -AvA 


THE centenary cotobratlon ot tUo faculty of meclicino at 
Cairo and an international congress of tropical modicluo and 
hvgiono will bo bold in association from Decouibcr 15tb to 
2Znd 1928, in that town. In tbo provlslonat programme, which 
lias i’ustb’eon Issued, It Is stated that various sectional meet- 
InRs^will bo held and that special attention will bo paid to 
anhylostomiasis and bilharziasis. The proceedings ot the 
congress will bo published. In connexion with this celebra- 
tion a medical exhibition is being arranged, and it is possible 
that tho foandaiion stono will bo laid ot a now building to 
replace tho exisiing Kasr-el-Anl Hospital. Enrther informa- 
• tion may bo obtained from tho gener.al secretary, Dr. M. 
Khalil, 1, Sharia Mazlonm Pasha, Cairo. Tho postponed 
congress known as tho Journdes MMicales d’Bgypto will 
be held at Cairo from Dooenibcr 12th to tho 23rd on tho 
lines of tho original programme, which wore meutioued ou 
October 15th. 1927 (p. 711). Further details ot tho congress 
■ and tho excursions to Luxor and Assouan may be obiained 
from the general secretary. Dr. Zoitoun, 32, Rue Gay-Lussac, 
Paris 

Under an Act recently passed in tho State ot Victoria 
(Australia) the registration ot British dentists is restricted ' 
solely to licentiates ot British medical authorities, and tho 
restrictions apply to all dentists who bad not embarked for 
Victoria prior to December 8th, 1927. 

The January issue- ot Tho Fight- Againit Disease, tho 
quarterly journal of tlie Rosearcli Defence Society, contains 
a reprint ot an article in Science on January Idth, 1927, by 
Dr. W. W. Keen, on the early days ot antivivi-seotion. Some 
recent coirespoiideuco in tho l.ay pre-s on small-pox in 
England and autivivisecticn propaganda is reprinted. Sir 
Leonard Rogers contributes a note on the increase of small- 
pox in England since 1920, and illustrates this with a chart. 
It is announced that the membership of the society is steadily 
growing; the 'subsoripLion tor members is 10s., associate 
membeis pay 53., aud nudergr.'iduates and students ot medi- 
cine 2s. 6d. Furlhor ialormatiou may bo obtained from tho 
secretary at the office of thesooiety,ll, Chandos Street, W.l. 

On his retirement, after practising for twenty-seven years 
In Crieff, Dr. .D. Robertson Doblo was pre.sented liy his 
colleagues aud fr.ends with a ptirting gift of a wallet of 
Ireasury notes. Ho w.as honorary medical officer to Crieff 
the n A M twenty -five years' service in 

Bureau of the British Empire, 50, Russell 
^uare,.W.G.l, has published a classified list ot students from 
studying in tho universit-ics and 
4 colleges ot Great Britain and Ireland. A total ot 

1 im ; of those 1,826 come from Asia, 

SfiorU Africa, 887 from America, 693 from Europe, and 
list is Is Zealand, and Fiji. The price of tho 

lo^rnd Pricer ot the Legion ot Honour has been con- 

senior Fredet, a well-known Paris surgeon and 

Eailwav • Faris, Lyons, and Mediterranean 

facultv^nr professor ot therapeutics in the Paris 

menM Professor of nervous aud 

Strasbourg. Bordeaux; and Professor L6ou Blum of 

thaImofo^4™amf nominated professor of oph- 

and nrevpiitiro ,v,„ Parisot professor ot hygiene 

uu preventive mcdiciue, in tUe Nancy fkonlty of medicine. 

heoa dS.licafed^to^n'’^r'^®^'' F»yc7iiafricrt ct neurolo<iica has 
bagen byhh^?enLans®^^°?;^''^ Christiansen of Copen- 
blithdaj’; ®““ Papds on the occasion ot his sixtieth 

presideut^o? PiRQUET ot Vienna has been elected 

succession to Union of ChUd Welfare in 

Dr. I. A. Art 

Universitv iiroriV^,'i pediatrics ot the North-Western 

of pediatrics Chicago, and editor ot a system 

Legioii of Honour ^®®®“^*i' appointed an officer ot the 

Rge of 65 recently died at San Remo at the 

ot 2,000,030 franM Institut Pasteur of Paris a sum 

succe.ssor^or Dusseldorf has been nominated 

University anri n .^°^.U^rr6 in the chair of surgery at Bonn 
fessor Tren’dploni, r'Sord ot Freiburg has succeeded Pro- 

OP *“ Uie chair of pharmacology at Berlin. 

Service ot*thlf reported to the Public Health 

of about 4 Per rpni patients have died, a mortality 

is probably hiehcr number ot cases and deaths 

Japan, tbo Disiripf of®®® have now been reported from 
tho nine -North ^rom thirty-seven States, 

portion of the States being tho only significant 

recognized. states In which cases have not been 


%ttt£xs, Siatts, aittr ^ttslu^rs. 

All commnnications in regard to editorial bu<5iness should be 
. addressed to Tha EDITOR, British Medical dournai, British 
MetiiccI Association House, TaviStock Square, W.C.f*. 
'ORIGINAIj ARTICLES and LETTERS forwarded for publication 
aro understood to bo offered to the British Medical Joursal 
alono unless tbo contrary be stated. Correspondents who wish 
notice bo taken of their communications sliould authenticate 
them with their names, not necessarily for publication. 

Authors desiring REPRINTS of their articles published in 'the 
Brittsii Medical JounyAL must communicate with the Financial 
Secrctai-v and Business -Manager, British Medical Association 
House, Tax'istock Square, W.C.l, on receipt of proofs. 

AH communications with reference to ADVERTISEMENTS, as well 
as orders for copies of the Journal, should be addressed to tho 
Financial Secretary and Business Manager. 

TIio TELEPHONE NUMBERS of the Biitish Medical Association 
and tho British Medical Journal are MC/SEUlt 9861, 9862, 986S, 
and 9S6S (internal exchange, four lines). 

The TELEGRAPHiC ADDRESSES 

EDITOR of the British Medical Journal, Aitiology Westeent, 
London. 

FINANCIAL SECRETARY ANT> BUSINESS ilANAGER 
(Advertisements, etc.), Articulate Kesfeent, London. 

MEDICAL SECRETARY, Mcdhccra Wcstcent, London. 

The address of the Irish Office of the British Medical Association is 
- 16, South Frederick Street, Dublin (telegrams: liaetlhi.^, Dublin; 
telephone : 4737 Dublin), and of the Scottish Office, 6, Dramsheugh 
Gardens. Ediifturgh (telegrams : Associate, Edinburgh \ telephone : 
24361 Edinburg). 


QUERIES AND ANSWERS. 


Fumes op Tae. 

Dr. J.H. Dudgeon (Stainbnni, near Workington) asks for informa- 
lion about the actiou of tlie fumes oti those working with tar. 
He has seen cases of the most acute abdominal pain**, lasting for 
days; relief was only obtained by~larga doses ot aperients; 
x-ray examinations revealed no abnormality. Dr. Dndgeou 
asks also for references to any literature bearing on the subject. 

• , * "We have referred this inquiry to Sir Thomas Oliver, who 
writes ; Tar fumes act particularly npon the skiu, leading to 
acne or the formation of small pnstnles, wil^li considerable 
Irrilalion; they also act upon the respiratory mucous membrane, 
inducing bronchitis. Not an infrequent result is epltbeliomatons 
ulceration of the skiu. Of the effects of tar vapours upon tho 
alioieutary canal, little is known beyond loss of appetite, nausea, 
headache, aud, in some instances, diarrhoea. Nothing of an 
authoritative nature has been published beariug upou the rela- 
tionship of acute abdominal palu and the inhalation of tar fumes. 
Reference to the subject may be obtained by consulting the 
brochures on “ Occupatiou aud health ** which are being issued 
by the Industrial Section of the League of Natious. 

’ • Cleaning Dentures. • • * 

Dr. John Fletcher (Lomlon, S.W.) writes: A strong solution of 
**harpic** will, in one night, remove tlie thickest deposit of 
carbon, with the aid of a stiff brush in the morning. 

Rainless N.atural L.abour. 

Dr. Howard G. Pisel (Maidstone) .writes: I remember having 
a similar case to those describe! by ynur correspondents many 
years ago now. The patient was a young primipara, who assured 
mo that her uterine contractions caused no pain at all. Her 
mother, a mnlbipara, was present at the coufiuemeuL She told 
me that her confinements also were painless, and added that sho 
** would sooner have a baby tlian a ‘poorly time' any day”! 
If true, this certainly seems curious. 

Firemen's Cramp. 

“ Ship ” writes : I should be interested to have your readers' views 
as to the etiology aud treatment of *• lireineu’s cramp." It is ou 
board supposed to be brought on by the drinking of niucb iced 
water. This may account for the cramp, which takes the form 
of abilominal colic, bub is nob necessarily the cause of that which 
affects the somatic muscles. I recently diti several four-hour 
watches in the stokehold in the tropics. I drauk very’ UttJe iced 
water indeed, but though 1 had no ‘‘cramps" while on watch, 
X subsequently suffered from them, bub only iu leg and arm 
muscles, wheu these were* mildly strained in action. Fatigue 
aud loss of fluid by’ sweating, etc., presmiiably accouut in part 
for this form of cramp, which I ha 1 hoped to escape by drinking 
while on watch wcll-sweeteued, iion-iced m:\td. Considering the 
frequency’ with which firemen — and not only novices and beer 
drinkers— are affected with agonizing " cramps," some hints as 
to treatmeut would be very welcome. 

Income Tax. 

Surgery Expeiises, 

•• J. H. S.” has succeeded to a sh.are iu a practice. For a time the 
practice rented surgery accommodation from his predecessor’s 
widow at per auuum — tlie araouut formerly allowed as a 
reasonable proportion of the predecessor’s total expense of rent, 




TEB. 25. 192®]. 


MUSCTJLAK EHEUMATISM AND PANNIOUDITIS. 


t Trry.BnKisH 00 Q 

srEDtCAL JomxAi. «ou 


?Jnti5lj ^ctiiral ^ssaciatioit ICtcliiw 

OS 

OEEORIC lUISClttAE EHEtJMATISM 
AHD PAKRICULITIS. 

Delivered to the Sodiuport Divisiok 

BV . 

EALPH STOCKMAN, M.D., 

PBOFBSSOK OF MiTETJA liEDICA AXD TRERAPECTICS, CXIVEESITT OF 


Cdroxio rhoumatio diseases are, gonorally speaking, of 
niicrobio origin, and can usually l)o traced back to a pre- 
ceding attack of acuto rheumatism, influenza, dysentery, 
or some other infection, and hence they may bo duo to a 
considerable variety of germs. But whatever the original 
infection may bavo been, the basic pathological change 
which is the cause of the sj'inptoms and sufferings of the 
patient once he has become the victim of what wo designate 
“chronic rheumatism” is in all cases the same, and con- 
sists in a lo'.v form of inflammation of the white fibrous 
tissues which constitute so largo and» important a part of 
the locoinotory system of the body — namely, the aponeuroses, 
sheaths and fibrous origins and insertions of muscles, peri- 
o.steum, the innumerable - ligaments of joints and their 
sj-novial membranes, fasciae, nervo' sheaths, and the sub- 
cutaneous areolar tissue. Fibrosis of tlic internal viscera 
and arterial syrtem is not a feature of chronic rhoumatio 
conditions. In acute fhoumatism, on the other hand, 
car^tis and vah-uliti^both inflammations of fibrous tissue 
— very, common, whereas ; in .gonorrhoeal, scarlatinal, 
•iJa ^ fairly bo de- 

Ecnbod .as. rare; although . their occasional oceurrenco is 
quite well ' recognized. ; Those differences in the incidence 
0 infection are difficult to explain, but they are of very 
co^derable clinicaHnWrest 'aiid importanco. 

nqnio rheumatism, then, is essentially a fibrositis of 
10 ocomotory system— the hahitus cxtcrMis of older 


wn ers, as oiiposed; to the internal organs — and, as fibrous 
so ividely spread, it may' affect many regions of 
10 0 y, or may bo' confined to one or a few parts; but 
Uimi. situation or whatever name it may go by — 

I,., P , sciatica, torticollis, coccydynia — it 

In same pathology. ' The fibrositic tissue is a 

tlvin to an irritant, and is therefore a sequel rather 

fiWn; f i^^t.as valvular heart disease or 

riilnnc • “ sequels to an acute rheumatic or a tuber- 

■ hin'no ,ction and onco established tlicv remain i>er- 
' of ultimately give rise to serious troubles 

inf—. -ly. ,'^‘ttorent character long after the original 
, 1 v-lncb caused them has died out. 

i Drnn™° A a survey of the whole ground, 

manifpet'^- remarks to the two commonest 

' rheunntu''”'^ • fi^^sitis— namely, chronic muscular 
E'reat bult' Panniculitis— becauso they furnish the 

Vast -imn,, I seen" in practice’, ' they give rise to a 

tivelv snp-il-- chronic ill health and, disability, and, rela- 
. '"S’ they are fairlv 'amenable to treatment if it 


they are fairly 'amonable to treatment if it 
gently carried of .their pathologj" and intelli 


is founded on 


fill I,- MuscTii.AR Eheujwtism. 

docal^Sp'^f*^ anatomy is simple enough. As the result of 
'widely fp'^ local irritation spreading more or less 

serona oyn'J' centre’ or focus olsewhero in the body 
tissno- tiips place in small patches of fibrous 
tion anfi fn° np and become painful, active prolifera- 
is an oTorio™*^'i''' nnmprons fibroblasts occur, and there 
twim .iT,a “ p"th of the fibrous tissue of the local nerve 
to be of blood vessels. The two last seem to mo 

of chronic rim 'Ictcrmining the typical symptoms 

Bible for tb 'the inflamed nervc.s being respon- 

0 pain, and the inflamed injured vessels for 


tho subsequent great liability of these lesions to exudation 
of serum and swelling from slight causes. 'Vtnien first formed 
the inflamed patches are soft and consist of a good deal of 
undifferentiated matrix, but as time goes on they hecomo 
much harder in consistence and veiy definitelv fibrous. On 
palpation through tho skin they can usually ho readily 
felt, and their tenderness on pressure is a further and 
useful aid to locating them. 

The pathological fibrous tissue differs from the healthy 
normal in being painful on pressure, in being very sensitive 
to irritation, in' a tendency to contract, and in the fact that 
it can bo dispersed by massage or absorbed by the vis 
medicatrix natural:. Its formation is a local reaction to 
the virus of certain infections, among which acute rheu- 
matism, influenza, tonsillitis, rheumatoid arthritis, mucous 
colitis, gonorrhoeal septicaemia, dysentery, and coliform 
infection are common and definitely known, although there 
are probably others not so easily traceable. In many cases 
it starts at an early age in life. Chemical poisons such 
as load, arsenic, and alcohol, which are notorious as 
causes of neuritis, do not give rise to a more general 
fibrositis such os wo aro considering, nor in my experience 
do vaguo streptococci and staphylococci, although they 
liavo often been accused. The original infection may dis- 
appear, leaving behind it a legacy in the shape of tho new 
patliological fibrous tissue, or it may persist in a more 
or less latent condition (as is so fully recognized with 
tubercle and sj^ihilis) and insidiously keep up and in- 
crease the fibrositis, so that with increase of years there is 
continuous increase of rheumatism. Scar tissue formed 
during suppuration, adhesions, and pelvic cellulitis have 
tho same origin and patholo^, and may he equally pro- 
ductive of symptoms. But miorohic infection does not 
seem to be a necessary factor. Sprains of muscles and 
joints, accompanied by tearing of the tissues with exuda- 
tion of serum and blood, are often followed by formation 
of new pathological fibrous tissue, and the consequent pain, 
weakness, and disability may bo very persistent or even 
lifelong. 

As has been previously mentioned tho new inflamed 
fibrous tissue is very . susceptible to many and diverse 
forms of irritation hardly felt by. the healthy individual, 
and hence unwonted muscular exertion, exposure, to cold 
and wet, keen winds, moist heat, changes in barometric 
pressure, slight infections, and intestinal fermentation arc 
apt to cause serous exudation ; tho exudation is not readily 
got rid of by, the thickened capillaries, it exerts pressure 
on tho inflamed nerves, and a “rheumatic attack” is the 
result. In a changeable climate with continual barometric 
I variations some people are thus never free from inoro or 
less rheumatic pain, although an anticyclone with high 
pressure and dryness of the atmosphere, inay' give them 
some temporary relief at times. The disturbing influeneo 
may, have a general effect on all the rheumatic tissue 
throughout the body, or it may he . confined to a single 
area, as is seen in an attack of lumbago after undue use 
of the lumbar muscles or of torticollis after 'exposure to a 
draught. 

Tho morbid anatomy . explains the familiar symptoms. 
Aching, weariness, and pain are all different degrees of the 
same symptom and are due to. the neuritis, while tho 
stiffness is due to stagnation of the circulation and exuded 
serum. Tlius the stiffness so often felt in rheumatic tissues 
after resting arises from the latter cause, and tends to 
disappear as soon as a little active movement has improved 
the local circulation. The sj'mptonis of pain and stiffncs.s 
are most often complained of in parts liable to muscular 
strain and to exposure, such as the small of the hack, 
lower limbs, neck, and shoulders, hut the abdomen and 
inner aspects of the thighs may show equal abundance of 
rheumatic tissue, although they do not suffer so mnch 
owing to being loss exposed to strain and external influ- 
ences. They are often, however, just as tender on pressure 
or if they do happen to be exercised. 

During an acute exacerbation with pains all over tho 
body the patient should remain in bed for two or three 
days and be treated on general principles with mild anal- 
gesics* and diaphoretics — Dover’s pmvder, salicj-Iic com- 
pounds, phenazone and similarly acting substances, hot 
baths and so on. If tho attack he confined to a small 

l3503j 



294 ;- ■ Peb. 25, 1928] 


MtIBCULAR BHEDMATISM • AND -PANNICDDms, 



area — sa3’ a torticollis — inassago is most lielpftil in adtlitiou 
to tlie usual liniments, poultices, and other local applica- 
tions. Its object is to get rid of the exudation and 
improve the cireulation in the inflamed area, and licnco 
is should ho begun as earlj- as possible and given as 
effleurago firmlj- and deeply, but short of increasing tho 
irritation and pain. 

Before starting on a prolonged course of treatment 
designed to i-cduco or get rid of the fibrositic tissue it is 
absolutelj- essential that a strenuous effort should bo made 
to deal as effectively as possible with diseased tonsils, 
gonococcal foci, chronic dj-scntoi^, colitis, and other known 
predecessors of fibrositis. Unfortunately eradication of 
these is not ahvays possible, and as long as they are present 
they remain sources of rheumatic fibrosis, and a permanent 
cure of tho latter is also impossible. In certain of these 
cases protein shock therapy is worth considering. Many 
patients, however, seem to have got rid of tho original infec- 
tion, leaving only the fibrositis to bo treated, and this is a 
very practicable matter. There is no known drug which will 
bring about absorption of fibrous tissue, and hence for relief 
or cure of the chronic thickenings massage is our great 
mainstay, but it nimt be applied iritli a deiinito knotrledgo 
of what it is desired to accomiilish. We wish to get rid 
of the exudation and the neuritis, and, if possible, to 
break up and disperse the little areas of new fibrous tissue, 
which is a much more tedious and difficult matter. A 
lubricant, such as oil, liquid paraffin, or vaseline, should 
be freely used, and the efficac)- of the massage is greatly 
increased by tho previous application of heat and moisture 
or dry hot air. Tor tho first ton days or so gentle but firm 
and eSicient cftleurage should bo given daily for about ton 
minutes to each part which is being treated. At tho end of 
that time the local soft swelling and exudation have- been 
got I'id of, the neuritis is lessoned, and tho fibrou.s thicken- 
ings can usually be felt as more defined, somewhat hard 
and sensitive little masses which giadually become iirscnsi- 
tivo to tho pain of the massage, which should then bo given 
as hard as it can reasonably be borne by tho patient, and 
applied specially to the small thickened painful .areas. 
Light massage is valueless at this stage. Recent indura- 
tions clear up in three to five weeks, but the more fibrous 
and those of long standing take a very much longer time, 
and may never become broken down and absorbed. Theso 
last remain rheumatic subjects, and may require a few 
a-eeks’ treatment once or twice yearly to keep them free, 
or comparativ'ely free, from symptoms. Such patients should 
be taught to massage themselves, or get tho assistance 
of some member of the household to do it. It is not diffi- 
cult to learn. The treatment is ahvaj-s tedious and ospen- 
.sive, but so far it is the only means known of dispersing 
the rheumatic fibrous tissue. Ionization, diathennj’, elec- 
tricit3', radiant heat, and such measures merely relieve the 
exudation and sn-elling, le.-vving the new fibi-oiis tissue 
ill statu quo and liable to become again acutely inflamed 
on the first opportunity. In the same wa3- spa treatment 
1)3' hot baths, purgation, diaphore.sis, and diuresis tem- 
poraril3’ removes the congestion and pain and .stiffness. 

In treating sciatica it should be borne in mind that it 

is most often due to rheumatic thickenings in the hip 

not necessarily on the nerve itself. But involving ono of 
its branches — and in the same way the cause of brachialgia 
is to be sought for in the deltoid, trapezius, and infra- 
spinatus muscles chiefly. Tho pain seems to be reflected 
down the large nerve from pressure on the branch. In 
lumbago and torticollis the fibrositis )n.a3- be widespread 
' locall3', or there nuvy be' only one or two veiy sensitive 
nodules from which the pain radiates widely, and in that 
case treatment should be concentrated on these. Fibrous 
nodules are not uncommon in the heel, and somotinies give 
rise to much pain and consequent lameness. These cannot 
1)0 dispersed by massage owing to tlic thickness of the sole 
and thoir haiduess. The only method of cure is to reflect 
the skin and remove the fibro-fatty tissue cii masse, the 
re.sult being invariabl3- satisfactory. , 

Rheumatic headaches due to perineui-itis of tho temporal 
supraorbital, or occipital nerves are best treated by blisters 
over tile part whore the nerve comes to the surface, and 
V lore )t is usually found to he very tender on pressure. 


Onco tho rheumatic thickenings have been dispersed 
or lessened under treatment an activo ouMoor muscular 
life should bo led as far as is reasonably possiWe 
for tlio individual. Ho thus becomes JiardcnecI, aud 
muscular exercise, drauglits, and other slight causes of 
irritation cease to tronhlo him. 

Pankiccliiis. 

Panniculitis is a fibrositis of the pannieulus adiposus, 
and has the same etiology and pathology as fibrositis goaer- 
ally. Its anatomical distribution, however, confers oil it 
certain clinical , characteristics which mei'it some special 
description. TJio new fibrotie tissue assumes two forms, 
according to its situation. Over the . deltoids, sboiilders, 
hack, flanks, upper abdomen, hips, and outer sides of the 
thighs it is dense and evenly spread, giving the skin a hard 
brawny feel, while on the inner surfaces of the upper arms 
nnd thighs, abdomen, and pectoral regions it is in iiiiiiieroiis 
pea-liko masses lying in the suhciitaneoiis fat and often 
forniiiig veritable fibro-fatty pads at tlie inner sides of the 
knees and elsewhere. The little masses can be easily felt, 
and arc exceedingly tender on pressure, as is likewise tlie 
irhah siihcuiaiiCDUS overgrowth- Sometimes distinct encap- 
sulated lipomata are found, and these have a core of 
inflamed fibrous tissue, as if the local irritation had 
determined their growtli. 

It is an cxtrcmel3’ common condition iii all degrees of 
severity in women of all ages, but is also found not in- 
frequently in men, and in bo3-s and girls. It selcloiii, 
however takes on the same proportions in men as in women, , 
and this seems to be connected wltli the much grcatei' 
development of tho pannionlns adiposus in tho latter. These , 
patients when tho condition has become well advanced, 
complain of a constant sense of fatigue, dull or acute pains, 
.stiffness, numb feelings, neuralgic lieadaches, and very 
often arc distinctly iionrastlienic. The skin bruises veiy 
ro,a<lilv, backache is often i)re.seiit, tlie weight of a coat 
tires tlio shoulders, and oven tho pre.ssuro of lying m bed • 
may be painful. If fiom any cause an acute exacerbation ■ 
of tho whole fibrositio area occurs all the symptoms aro . ■ 
intensified and may remain so for a week or more, often . 
of severe suffcviiig. Some of theso people are not stout, . 
but obesity gicixtly increases tho symptoms and snfferinp,. 

•i d rso many women over 30 , and particularly after... 
uie incnouause, tend to lay on fat, medical advice is usually . 
first fought at this time. Most of thein, however, giro a- 
1 • * , nf Inviiiv been more or less rheumatic foi 

history 0 ^ ,„ay be great incroaso of bulk all 

ycai.s 1 ^ jfjy i,e Qifly round tho lower abdominal ■ 

overtlehod3,m. y a shoulders also - 

regions hut too whole abdomen may be bulky, heavy 

laicly ‘ P ■ ay have several transverse folds of 

‘"'f fftty tifue lying like cables across it. The 

^”^^“t:ssue inay bo cliiefly of tho dense hard kind, or of the . 
fif” f-ittv or^ most commonly, a mixture of the two. In 
fihio-f. >j eases, as time goes on, the irritant, 

it may he, tends to affect at certain places tho 
ineiSaes and the periosteum (both fibrous 
S''° t the former hypertrophies and becomes painful- 

Tons’ Td HeberdeTs nodes, bony swelling at the, 
f“‘^pHrs fii.i.ing of Um femur and tibia at the knee-jomt, 

and W “"y 

Tiffs' Stace has lately been described as a separate clinic.al. 
pnder such names as climacteric, menopausal, hypo- 
entity " ’ endocrine arthritis, and has been attributed 

ff'f of Ihe thyroid, pitnita.y, and ovarian secre- 

i pvPiTisinK a direct effect on the joints. I.tako this, 
f • to be an erroneous interpretation of what happens. 
T°"'Tti.P e cases a history can be obtained of rlienmatm. 
,,ai.m fof yeaT past-oftei very many years_and dating 
from acute^ rheumatism in childhood, or from influenza or 
TtW infection. Whenever such a person lays on 
fat, a.s so frequently occurs at the menopauso,. the rheum- 
atic symptoms become greatly mtcnsified and the m 
creased weight throws a certain strain on the and 

especially on the knees. At this stage many of these 
pationts have no arthritis, but in time some of the s^movial 
membranes and bones (tlirougli tlieir periosteum) ec 


NEW METHODS' ,OF BTTKGIGAE ACCESS TO. THE BKAIN. 


296 



Si i 

tlicro 1 ,vomcn bear cbiltlren iiorinallj . 

“krogard to treatment, the principles affecting aento 

, \MUiiog original nnderlying causes bare 

- 'alrct(ly''kccn discussed, leaving for consulcvation hou; wo 
' rrnt vid of tlio flbro-fattv overgrou tb. In patients 

wiTh aTgo mount of subcutaneous" fat the most sat.s- 
irv results are obtained by moans o diet and massage 
Tho niiantity of tbeir carbobydrato food sbonld bo 
V onthalf or tbree-quarters, exercise B-tab o to the ago 
and condition of eacb .pat'o"* sbould be 
sneciar medical exercises may bo given iii addition, a u 
a' iMy ibse of thyroid gland. Tbo last 
action on tlio fibrosis, but assists in reducing u eight. This 
"should be coi’itiiiiied 

Eometliing like normal ivoigbt for tbo height ‘^"<1 
■ivliieb often means a reduction of several stones. t\ iC. 
loss of fat tho smiptoins lessen and the massage can 
applied much more effectively, as the fibrotic tissue is then 
moro directly reached. Patients of normal stoutiiess-aud 
tlicre are very many such-do not, of course, rcqiuro these 

reducing measures. . , 

The method' of applying tho massage is a >''«ter ot 
the first importanco for successful treatment. It sliouia 
be directed to tho panniciiliis adiposiis, and either I'oiu er 
or a miiiinuim only of lubricant should be used, 
the bare hand the grip is too firm and 
much oil too slippery. Tlid manipulation is a little di 
to describe, but very easy to demonstrate. A mass 077 
pnnnicuUis ndiposus should ho grasped with one oi o 
hands, holding it between tho tlininb' and thenar eminence 
on the one side and tlio rest of the hand on tlie 
side, and then tho two parts of tho hand approxiinatoa 
with adeq^uate pressure and a slow moveniont. The skin is 
usually hound down to the subjacent tissues, and it too 
should' bo grasped and manipulated witli the object or 
•loosening it and making it moro flexible. Such trcatnient 
is paiiiful, often exceedingly so if not carried out gently, 
and bruising is , very - readily produced at first. It may 
-take five or six weeks.before any blit very light pressuio 
•can be borne, but gradually the neuritis is reduced, and 
•then bai'der treatment, caii bo given. It is always, “ou- 
ever, a- painful 'and "disagreeable and tedious process. Tho 
'patient should- always be warned that treatment must be 
•continued -for six of twelve months or even more, ana 
fthal-during that tihie several courses of massage of * 
•weeks of so will be hecessaryj and that if left untreated le 
'ednditipu is certain to go on from bad to worse. Many 
•patients can bo taught to treat themselves to a certain 
. extent. . - ■ 

In cases where'the fibrositis is of the hard brawny JP® 
'dieting often fails to reduce the bulk to a satisfac ly 
dogreb, the new tissue is miicli more resistant to massaging, 
and the prognosis is in consequence not nearly so ’ 

but tbo symptoms can always be greatly amelioia e . 
Such patients usually remain •“ rheumatic ” and requir 
reneiyed courses of treatment from time to time for le le 
of tbeir symptoms. • • t i nl 

Filially, as regards tlie important question of m ly 
I lifive formed tlio opinion that many su 
h'om muscular rheumatism and panniculitis have 
the fibrositis at an early age from an attacU o 
rlieumatisui, and continue to harbour in a latent con i lo 
the specific germ of tlie disease. After recoveiing ro 
-tho acuto attack children should he carefully- exaniin 
I ■ and an}* fibrositic areas massaged while the deposi s ai 
, still soft and easily dispersed. Further, they shou ( o 
given at bedtime for some months a nightly dose of so 
salicylate or ' salicin, with - the object of eradicating t e 
.1 infection. After tonsillitis, influenza, and- othei o 

^ infective causes, all patients should bo similarly examine , 
\\ and, if necessary, treated -by massage. Unfortunately we 
have no specific drugs to help us for most of these cases. 


'guntrrian ICfrfxt'rfi 

ON 

NEW METHODS OE SURGICAL ACCESS 
TO. THE BRAIN. 


H. S. SOUTTAK, C.B.E., D.M., M.Ch., F.E.C.S., 

SURGEON, LONDON HOSPITAL. 

(With Coloured riatc.) 

The problem of obtaining easy access to f 
the skull has become of increasing "£,1 ho 

•modern demand for large openings, m winch ' “ 

nossiblo to replace tho bone without fear of risking its 

w| I A;:- — » -'i 

C f„. .i,„ lp.sscn and tho massage can bo | ^ lastly, the control of linemoiiua e , j , . <= 

ihe operation is of vital importanee to the patient. 

mood Supply of Scalp of an osteo- 

piece. I believe that this is and 

» ‘rt£n»s 

rhrongh^timmusdeswto^^^ The'lrtTorms 

r“os“eal Uidng, ”and as sonreTactnaUy 

enter the bone. Ihe scaip, , ^ layer of loose 

from the periosteum o the ^ 

of the scalp and the calvaria. 

Structure and mood Supply of Senip. ■ 

The scalp consists of three is veiw 

fieW f..™, K.d »• ef” “fS tto. t.Vbo"nj 

IrSAsir..?- s£.r.s:.t. 




■ i’TG. l.-~-JlU5Cie3 auu u«v/w^. 

independent. The galea ^ ^tough membrane^sy-otched 
over the calvaria and roalK foiroin attached to the 

occipito'-frontalis muscle ; anteriorly it 

superior curved line of the o 1 , ijecoines con- 
joins the frontalis -muscle, iLLnp; no direct attach- 

tinuons with the 7 ^f‘^Tl'*Bskull. ’ Laterally it has a weak 
raent to the front of th • ^ dense temporal 

attachment to the tethp®--®! 1* ® h® 

fascia which s ia alm^rt down ■ to the 

Sntit u®se^?atcd from the pericranium by a loose 



296 Feb. 25, 1928] NEW METHODS OF BHEGICAD ACCESS TO THE BEAIH, 


TszBxnac 


ni'colar tissue in -whicli a feiv , small veins may bo found, 
but wliich contains no vessels of practical importance. 

The blood supply of the scalp arises from various sources, 
and all its vessels enter it beyond the limits of the attach- 
ments vhich u’c have described. In front the supraorbital 
and frontal arteries are derived from the ophthalmic branch 
of the internal cai-otid, and I'amify upivards in the forehead. 
Laterally the superficial temporal branch of the external 
carotid extends upwai'ds just in front of the ear, dividing 
at abovit the level of the upper margin of tho lobe into 
anterior and posterior brancbe.s, ivbieh ramify widely- over 
the whole of tho side of the head. Posteriorly the occipital 
and posterior auricular arteries, both derived from tho 
external carotid, s\ipply the whole of the back of the scalp. 
Between these arteries there is the freest po.ssible ana.sto- 
mosis, so that portions of tho scalp can bo raised in 
almost any direction without danger to their vitality. The 
point, however, which I wish to stress is that those flaps 
can bo raised without endangering the vitality of tlie snl> 
jacent bone, since it is in no way dependent upon the scalp 
for its blood supply. 


Blood Svpphj of Sl ull. 

This will become still more obvious if wo consider tho 
blood supply of the skull itself. More tiian half of its 
lateral aspect is covered by the temporal muscle and its 


Eig. 2, — JIuscIes and 




Injc', passing one blade of a soft intestinal clamp throuri 
the tunnel so formed, and with it clamping the In'o of 
the pedicle. If this is done there will be no bferfing 
-uhater-cr from the cut margin of the flap itself, andllie 
attention of the surgeon can thus be directed solely fo 
preventing bleeding from the opposite side of his incision. 
After the iiieisioii has been made and the hleodio^ 
arrested, the whole ffap can be turned down as far as 
the clamp at its root without the division of anything 
except soft areolar tissue, and without bleeding from i 
single point. 

In tho occipital region the scalp can only he turnei 
down as far as the superior curved line of the oecipifa 
hone, since below tin's point it is firmly attached to tin 
muscles. If an attempt is made to raise it beyond fbii 
point tho origin of the occipitalis muscle must first bi 
divided ami the skin must then be dissected away from thf 
muscles fo which it is united by dense and vascular 
fibrous tissue, and bleeding in.ay be considerable. 'Witl; 
the methods of approach which we now adopt we always 
respect this attachment, and never go beyond it. None the 
less wo can turn don-ii osteoplastic flaps in- this region and 
even leiiiovo tlio bone without ever detaching tho scalp 
from the muscles to which it so firmly adheres. 

In tho frontal region superb access to the bone may be 
obtained by very simple means. If an incision is carried 
boldly across the bregma, coming down just in front ol 



fascia, whilst, behind, the broad surface of tlio occipital 
bone below tlie superior curved lino furnislies an origin 
for the large mass of muscle which occupies the nnclml 
region. _ These muscular attachments can be made to furnish 
ideal hinges for osteoplastic flaps in almost any situation, 
they carry a blood supply sufficient to maintain tho vitality 
of the bone, and tliey form, in our opinion, the only 
means by which the blood supply can he maintained. Their 
blood vessels are entirely distinct from those which supply 
the scalp. In the temporal region the chief vessels aro the 
temporal branches of the internal maxillary artery-, whilst 
in the occipital region the most important vessels arise 
from the occipital artei-y as it lies deeply beneath the 
sterno-mastoid and the digastric, actually- grooving the 
occipital hone. 

Scalp Flaps in Different Begions. 

There are three primary- regions from which the brain 

can be approaclied — the temporal^ occipital, and frontal 

and in each instance the scalp flap required presents certain 
peculiarities to which we must non- direct attention. In 
each instance, however, the scalp flap should be so 
lasliioiied, if possible, as to overlap by fully half an iiieb 
the proposed incision in tho skull. 




Fig. 3.— Temporal scalp flap. 


In the temporal region a flap of any dimensions may be 
formed, care being taken that the anterior portion of the 
incision lies well in front of the ear, so to avoid injiiry 
to the superficial temporal artery. In this instance a great 
advantage is gained by- first marking out the pedicle with 
two small incisions, one in front of and one behind the car, 
tunnelling through with a blunt dissector in the areolar 


tho ear it will be found that the whole of tho forehead 
can be turned down without the slightest difficulty, even 
bevond the upper margins of the orbit. It is true that 
the anterior branch of the superficial temporal artery is 
divided hut the forehead has an ample blood supply 
•mart from this. I would again point out that even m 
this region the vitality of the bone is in no way jeopar- 
dired and that an osteoplastic flap consisting of one-half 
f the frontal bone may be formed ivith perfect success on 
the tempera” muscle as a base. . -When the scalp flap is 
reolared^the suture line is entirely out of sight and the 
nei-vo supply of *>‘0 forehead is still intact. I have 
J^cneatedlv cai-ried out all these procedures under local 
anaesthesia with a coiiscions patient; there has been an 
oniirc absence of either shock or pain ; and in the case of 
+1 A frontal the only additional precaution taken was 
to cover the patient’s eyes and face with a sterile bandage. 

Control of Haemorrhage. 

The control of haemorrhage from the scalp is a matter 
f the very first importance to which sufficient attention 
” vnvelv oaid. Any loss of blood at this point is eiitirdy 
I'fiiiustifiable and may prejudice the further stages of the 
nm-ation very seriously. Bleeding from the sraallei 
vLsc”s is best^ controlled by preliminary injection of tho 
whole lino of incision with 1/2 per cent, iiovocam, to 
wliich about 1 per cent, of 1 in 1,000 adronalme 
npil \t the same time it is our custom to infiltiate 
..-hole of the suhapoiiourotic space in the oper.-itioii 
PvL with the same solution. If this is done half an hour 
Lforo the operation tliere wiU he no bleeding at all from 
tbn smaller \WeIs, and only the larger arteries will require 
attention. Tliese may he seized in special forceps, suai 
as those of De Jlartel, which grasp the whole 
of tho scalp, <>'■ compressed by seizin^ 

in artery forceps ai.d drawing it over tho cut area 
The arteries themselves it is impossible to seize onmg t 
tlie density of the tissue in which they iie. P®', { 
I use small steel clips which are crushed with imcei 
L "thetargin of the scalp. They hold it finite firmly 
without injuiy, they are so small that they are not m 
way, and at the end of the operation they arc vci-j- oas y 





UEW HrETHODS OF SURGICAL ACCESS TO THE BRAIN. 


FEB. I5i *9-S] 

— " tlir ti'inpi'inl l\ni> I \\iivo hIvpmIj' 

romoved. In t'n‘ from its in.-irgnis 

dcs.cvib«t the 'f (hij) tlio im-isioii lio.s in a 

■■ ■ ' 10 only 

. of till' 

iilisnlllto Iitoinlto'-'Siio 


r TaEEr.rtua Ort^ 

L SIedical JorESAL * 


dchcvibwl tlK* Vrnnt'il fl»P tho iiu-i.^ion Vws 

" rrtt. *» - ”1, "i. »' 

?:“Sr3icu,« 

o™i 

advmitago. tonsitlorntinil of tlio foriimlioii of 

osteoplastic flaps a 

d%ml In tWtompor.a! region a iinp of nnv ilimonsu.n, 
cau^iio tnnicd donn on t!io temporiil musclf. In tlio 
fiontal region a large flap can V ti.nic<l oulivnrc linsed 
!as a liinlo on tlio tliiek anterior portion of ho .^uuo 
muscle. It is upon this nnisde, .and not upon tho M-nl|., 
that the bone is in any ereiit di'iu'ndont for i s I.lood 
snoolv. In the occipital n'gio" ‘''o \'holo of tho haol; 
of the skull, as ive shall see Inlor, ran ho tnrnod dotti. on 
tho nnehn! nniscles as a hinge, offering supia-h aoross to 
the whole of tho posterior aspect of tho hrain. 

The D'lrifion of ihe Hone. 

IVe must now turn to the tcclmical mot hods at oiir dis- 
posal for the division of tho hone. In gonora! lorms tliroo 
methods arc in common use. In tlve fust a series nf 
trephine hole.s is made through the skull along the intondod 
lino of section, and these arc joined liy means of a saw or 
some variety of cutting forceps; in tho aceond a (tigli 
saw is snhstitnted for the forccjis; for the tiiird metiiod 
a powerful electric motor is necessary, and the procedure 
consists in drilling a series of lioles and joining these tip 
either by means of a circular saw or soine form of hnrr 
electrically driven. The first two methods are certainly 
primitive, and they demand a degveo of exertion on the 
part of the snrgeon which is dotriniental to his mniinal 
skill when ho comes to dc.al with tho hrain itself. Tho 
third method is effective, hut it involves the uso of a 
powerful electric motor and of a somewhat 01111111011,0100 and 
costly apparatus. 

It has long seemed to me that it should he possihlc to 
cut through the skull entirely hy hand if the prolileiii could 
only ho vedneed to the tccius of ordinary eiigineeving. 

succeeded in devising nu appliance liy which 

■ the skull can be divided entirely by hand with great 
facility and so smoothly that the operation can he easily* 
aecompUslied on the conscious patient under a local annc.s- 
thetic. The appliance was specinUy designed for the forma- 

tinn of large osteoplastic flaps, anci it oiuihlcs the surgeon fo 

toiTO these with a facilitv, a rapiditv, and a precision 

■ hitherto unapproached. . 

The instriimcnt (Pig. 5) consists essentially of a stud. A, 
^1 wians of a locking device tlie stud i.s 

securely fix«l ,n a half-inch hole provionslv drilled at tho 

centre ot rtic proposed hone flap. Around this can turn 


with a special hracc. Into this hole is inserted the split 
slu<i, A, rcsemhliup nii expanding mandrel, and into the 
ciiilre of Ihk is .screwed a pin, B, whicli forces it open and 
locks it into place. Tlie lever p is now dropped over the 


iOVKS lllio AUC ICVVt V- lix iiUW uioppt'Ai ovtjr lUtt 

|>h», nml hvh\ iii place by n nut. D, the Csarnage E is adjustetl 
lo (Ilf coiToct radius, and the cutting tool F is advaucecl 



1*10. 5. 




Fic. 7, 


Fw. 6, 


milil it just piojccts from its housing, H. It will now he 
found th.-it oil .swinging tlie lever round its fixed fulcrum 
I he .skull can he cut with astonishing facility*, and without 
the slightest suspicion of violence. The cuts are taken m 
long sweeps, oniiltiiig the base of the flap, which is always 
so arranged that the .skull at this point is thin. After each 
cut the tool is advanced a fraction of a millimetre and another 
cut is taken. In a verv short space of time it will be found 
that tho thimicr parts uf the skull have been penetrated 

and the cuttinc is now limited to the thicker part, ss'here hard 

hone rail still he felt with .a seeker .at the bottom of the slot. 
The form of the tool precludes any possibility of inyurmg 
the dura, but a.s J?oi>n as the seeker shows that the aura has 
hecu reached these parts of the incision will naturaUy he 
left alone. The hone i.s hy this means almost completely 
divided over three-quarters of a circle, and two flat steel 
iescr.s are now inserted into the slot which has been formed. 
Verv slight pressure cii the.se levers is required to crack the 
thill layer of inner table still remaining and the thin base of 

the bonv flap, which is now turned dow*n still attached to 

the sofl‘ parts, u.sua3)y formed by tlie temporal muscle, llio 
tool is set at such an angle Hint the margin of the bone hap 



the Icacr l^v^7' f' » . . 

MrniiiS a c„h! " 'y ‘ nd.iimfi'hle eavringe, E, 

partiiic j„*i F, which closely resomhlcs tho 

from a socket H cliisel can be advanced 
G, so that ’ T, "“* supports it, bv nio.ans of .a screw, 
nicest acciirn,.,. "w! ' 'lo adjusted with the 

A Tcrv i ^ method of procedure is ns follows: 

I' rnist" be^ so*^ r®usisting of scalp oiil.v is turned down, 
mrtliest limit.; nt®,', f® overlap bv fuilv half an inch the 
G'cra is no which is to he formed. As 

and of whatever between tiie vessels of the 


and of jh’e I „ whatever between tiie vessels 
*''’1 intetfere in ih„ "v '* fuming down of the .seal 
hone, v-liikt it ar-Mi ? "-itli tho vitality 
the centre ’ii.. > facilitates access to the latti 


.scalp does 
.,,1.1 ,„u .,„.iity of the 
— - centre of '11.0'^?^'' .’'“i'fatcs access to the latter. At 
eraniam are 'S' flari the muscle and peri- 

‘'weei and drawn asidi, and a hole is drilled 


Fin. 8. 

is hcvellcd and therefore when the latter is replaced it lies 
smiclv in position against tlie corresponding bevel of tho 
.skufi 'itself.^ I know of no other metiiod by means of which 
such accurate and firm coaptation can be obtained. 

A difliciiltv ill using the instrument arose from the im- 
possibiUtv of holding the head steady against such 
leverage.' This lias been overcome by a simple deuce. 
rVfter drilling the hole for the centre pm, another small 
hole is drilled at a distance of one inch from its centie. 
To enable this to be done accurately a i'S .'® 
sisting of a stud, which fits the centre pmho e fiom 
wliiclf a plate e.xtcnds cariyiug a hole through " ‘ 

drill is passed for tiie fomatiou of the secowdavN lolc. 
V lo„*^ iov!^t provided with a pin, which fits t - 
iiolc.lind with a hole through which is f 

pin of tlie instrument. The lever is tlins ii„ y . . ^ 
to the skull, and if it-s extremity is held by an assistant 
it absolutely prevents rotrtion. 

There is no instrumental limit i„ 

flap which c.an be formed, and • ' temporal 

diameter can quite c-asilv however, a flap of from 

region. For most 'y.rili be sufficient. One of 

three to four “'f 7,'® of the in.stniment is the 

the most remarkable featmes formed, tho 

impidity with which these axg^^^ 

,e take minutes. Tho tendency 

experience betweetx to* ^ +lifv l^rnin tbroPEU 


• witii Wiucii varving in my own 

average time taken minutes.' Tho tendency 

,cc betiyeeu * ' » * . explore the brain throngh 

of modern chieliial s ^ purpose that the 

;S™S ■£'='» “ “ “ 



298 Feb. 25, 1918] NEW METHODS OF SHBGICAD ACCESS TO THE BBAIN. 


r The Ttnmn 

L llf-DICjU. JOUBXJX 


any region of the .skull, but it irill find its gre.itost utility 
in tlio formation of largo toinporal flaps. Tho manipula- 
tion of tlio instrument is very easy, but its action i.s 
so unusual that it is absolutely essential that, before 
attempting to uso it on tho living subject, the surgeon 
sboultl familiarize liimself with its uso both on the dried 
skull and on the cadaver. 

The Svrgical Motor. 

Although the craniotomo is so effective there are a few 
cases to which it is not applicable — whore, for example, 
a flap of other than circular outline is rcfiuired, or whore 
it is necessary to enlarge an opening already made. For 
this purpose I have devised a new fornr of surgical motor 
which seems to irrcsent many advantages, (Fig. 9 .) Its 
general arrangement will bo understood from the accom- 
panying illustrations, the siinplo construction being 
rendered possible b}- an entirely now form of universal 
joint. Tile entire weight of the operating end is sup- 
poi ted by that of tho motor, M, which acts as a counter- 
poise, so that tho surgeon has tho advantage of a powerful 
and massive tool, without tho inconvenience of its weight. 




0 




Fio. 9 . 



Into tho nose, N, of the instrument may bo inserted drills, 
burrs, or circular saws, and as these are driven slowly 
and with great power, their action is both safe and rapid. 

Tho saws are provided with guard discs, so that they 
can be adjusted to cut to any depth from 1 to 10 milli- 
metres. Starting with a largo disc and a'shallow cut, tho 
size of tho disc is gradually reduced and tho depth of tho 
cut correspondingly increased until the inner table is all 
but severed. A scries of holes lias already been drilled, 
and as these are joined up by tho saw cuts the depth of 
tho skull between each pair of holes can bo accurately 
gauged. In this way the densest bone can bo cut with 
tho greatest ease and with absolute safety. .As regards 
asepsis, tho two terminal arms of the ap|ilianco can ho 
boiled, after which they aro encased, for convenience in 
handling, iii a sleeve of stockinette. 

Osteoplastic Flaps. 

Having shown tlio iiossibility of obtaining a full exposure 
of tlio bone by first removing the scalp, and having 
described tho apparatus at our disposal for dividing the 
bone, we aro now in a position to discuss tlio actual 
formation of osteoplastic haps. IVo shall consider the.5o 
Beparatel3' as they aro required for apiiroacliing tlie lateral 
posterior, or anterior regions of the skull, ’ 

The Temporal Flap. 

Lateral approach hj' means of a temporal flap is tho 
commonest mode of access to tho brain. Not oulj' is it 
required for tile removal of tumours in the sensorimotor 
region and in tlio temporal lobe, but it is often the niost 
conrenieut and effective method of obtaining decompression. 
A large scalp flap is first turned down, as we have already 
described, bleeding from the flap being controlled by a 
clamp across its base, and from tlio scalp by clips attached 
to its margin. Tlie total loss of blood should be trivial, 
and all bleeding must be absolutely checked before tho next 
step is taken. The scalp flap and tlie exposecl area are 
carefully protected by gauzo pads moist with w.aim saline. 

The b'oiio flap required is now marked out with a com- 
pass, and the bone is divided round tbree-quartors of a 
circle with tlio craniotomc, tho temporal muscle which is 
to form the hinge being carefully preserved. Tho levers 


aro inserted and tho thin bone in tlio temporal fossa is 
cracKoU, ^vhen tlio bono flap can be turned down and out 
of tho way. Tho bone usually cracks at a point half an 
inch or moro from tho base of the skull, and it is coii- 
vonicnt to strip down the temporal muscle as far a.s tho 
temporal crest and to remove the thin bouo witli punch 
forceps. In this way maximum uso is made of tho opening 




Fig, 11.— Temporal osteoplastic llap. 

in tho skull, and if tho hone is, replaced the defect left at 
its base forms a very useful subtemporal decompression. 

Although the opening made for exploration can scarcely 
bo too largo, it may liappen that in tho case of an inoper- 
able tumour tlio opening made for exploration is larger 
than need bo loft for decomiiression. 'When it is suspected 
that this may bo the case tho following plan lias been 
adopted with complete success. After centring the cra'nio- 
tomo a preliminary cut is made half an inch within the 
outline of the proposed flap, the outer table only of the 
bone being cut through. The carriage is now readjusted 
to tho ' full size , of the flap, which is . then formed as 
described. If, after exploration, it is desired to leave a 
iiermaiicnt decompression tlie outer half-inch of tlio bone 
ilan is easily removed with bone forceps. The bone now 
floats as a valve, surrounded by a half-inch gap, across 
which union eaiiiiot occur, whilst the temporal muscle 
which forms its pedicle furnishes ,on entirely adequate 
blood suuplv. Ill a case of vascular tumour on. which we 
Srated our veavs ago, in a boy of 12, this arrangement 
haranswered perfectly, and tho valvular action is still free. 

The Occipital Flap. . ■ 

■n nnmoaeii to tlie brain has usually been obtained 

bv idocem al of tho occipital bone below the lateral 

by Piocama ^ generally regarded os a region 

"‘Tot ,1 Hit d to tho formation of osteoplastic flaps. 
Sio sHuat ltas, however, been . entirely altorod by tho 
which enables huge osteoplastic .flaps to bq 
crauiotoi , leclon with precision and safety, 

an access to the cerehellum, tho brain stem, 
affoidiiig , . ‘ , jgijpj never before achieved. At the same 
and f'^'o 0, „.Uole or in part, can bo replaced with 

^ert accuracy and with absolute security. Tlie cffective- 
^ method can be suffioiently judged from tho 

v/ {■ wUolo of tho hack of the skiih, from tho 

Ida "to tlio foramen magnum, can bo turned iM"'" 
lambda to utmost ease, without the slightest 

:;rr « .uig. .»« » «» ..*• 

r the blood pressure of tlio patient, 
ratooi t io 10 jyrned down, as we have already 

A scab ‘1 .y,e superior curved lino of the occipital 
described, as_fm .^ is attLhed. This flap should overlap 
bone, to ineb. A point is now 

the ^ an inch above tho external occipital 

selected ^ a hole is drilled for tlie centre pm. 

Tho hone . j ju ^ aompletety through; indeed, it is an 
necessaij to dn ^ emissary vein may bo 

advantag gpoiild, however, bleeding occur, it is iiiimc- 
oncountc od. Sh i^^^^rtion of tho centre pm, which 

diately stoPi ;-" 1, The skull is cut as usual, and 

IS then an inch or moro in thickness the 

as It IS heie 1 1 demonstrated. A channel 

power °f ^ thick hone completely and extends 

IS cut on each side. With a spociaily 

below the latcial j j channel are extended 

guarded chisel tlie exiicji found that 

towards the foramen rs+erioi ma^^ 

'^"nlVawfSb- 


Feb. 25, 1928] 


NEW METHODS OF SUUGICAD ACCESS TO THE BEAIN. 


[ THTBauirt 
Meoicai. JorSXAL 


299 



backnaids, so as to avoid injury to the medulla, and it 
is thou turned doivnwards over the nape of the neck, still 
attached, o( course, to the whole of the nuchal muscles. 

The oiilv risk in this procedure is that of haemorrhage 
from the large emissary vein which communicates between 
the torcular Hcrophili and . the vascular diploe of the 
occipital hone. In raising the hone this vein is torn, and 
the finger of an assistant must be immediately applied 
to stop haemorrhage. A small piece of muscle, cut ready 
for the purpose, is now applied and held in place by the 
finger for three minutes, when it will he found to adhere 
firmly and to have stopped the bleeding. Occasionally a 
similar but smaller vein may he torn from the superior 
longitudinal sinus, but it is easily dealt with in a similar 
manner. There would seem to he no risk wliatever of 
injury to the sinuses themselves. 

The field now obtained is veiy remarlcable. In the centre 
lies the toreular, the lateral sinuses spreading outwards 
on each side, whilst above these the occipital lobes are 
exposed to an extent of perhaps two inches. Ideal access 
to the eerebellum is offered, 
and if necessary the posterior 
arch of the atlas can bo re- 
moved. But most important 
of all is the rcla-xation of 
the tentorium, which results 
from the removal of its 
posterior suppoit, so that it 
can now move upwards freely 
and release the pi'essuro on 
the, medulla. .Provided there 
is no undue pressure in the 
upper chamber this may pro- 
vide sufficient decompression 
without any opening of the 
dura, ^nd we have liad a case 
of midbrain tumour witli 
secondary hydiijcephalus in 
which this procedure alone 
was sufficient to secure per- ' 
manent relief. lu anv case 
a combination of this with 
aspiration of the ventricles ■ 
will give all the relief of ten- 
sion that can be desired. 

Two other points must bo 
noted. The exjjosui'o of the 
occipital lobes renders punc- 
ture of the lateral ventricles 
easy, and the .surgeon has at 
ilis disposal a simple means 
of reducing the cerebral 
pressure to any desired 

degieo. In addition, the full oxjiosure of the sinuses enables 
um to introduce ‘fluid into the circulation at the end of 
10 opeiation, often a consideration of the most vital 
importance. The walls of the sinuses arc by no means 
ragi e, and if a fine -needle is used puncture docs not 
itself' at 'a bleeding, for the opening seals 

11' . ^”‘'2 o^'er the ccrelieliuiu it will be 

mobility of tbe lentoriuni is of the gi-eatesf 
smno 1 “f ’ . '^'^P'^'^'ng it upwards the available 

Trlv-iiitn.r''" ''.'*1^ increased. A still further 

fro- -1 gained by freeing the dura 011 each side 

taken imt + from the skull, though care must he 

' jMohlIi7i+° '"JBre the large mastoid emissarv veins. 
Mobilization of the tenW:™,. „ t t’ 



Fig. 12.— Exposure of rigVit 
frontal lobe (1). 


FiC. IS. — Exrvosurc ot ligbl 
frootiil lobe (2). 



Fig. 14. — of right 
frontal lobe (3). 


so far as I am aware, is 
bv the nVeinV+^'i and it is only rendered possible 

AVithoiit tbV ^Icaplastic flap which has been described. 
slarLlv n mcZr‘r" formation of such a flap is 
cutting of tho denSt^p^rfoS’l ‘lemands the clean 

circle. The traimn. fi " oEcr a very large 

altempliiig to do thk b'° 
serious as to prSibit it^ “7 

must he turned down l’®‘'f°‘’“ance. Moreover, the flap 
rhaoo is to ho rapidity if serious haemor- 

whid, wc have referred f 

11 » 


instaiitaiieoiis, and in no ca.se has tho bleeding remained 
uncontrolled for a longer period than two seconils. I am 
so impressed with the value of mobilization of the teiitoriuiii 
that 1 feci th-at this possibility alone justifies the invention 
of tho eraniotoine. 

If removal of the hone is desired it should be peeled off 
the muscles from below upwards, when it will be found 
that they separate from it without any bleeding at all, 
Tho contrast with the haemorrhage which occui-s in the 
usual method of stripping the muscle off the bone is .very 
remarkable. It will, however, be necessary to cut through 
the aponeurotic attachments to the superior curved line 
with a pair of scissors. If the hone is replaced the margin 
of tho foramen magnum and a portion of the thin hone 
above it may with advantage ho removed, as can he done 
with the greatest facility. 

The Frontal Flap. 

■ Anterior approach is rendered much easier by the frontal 
scalp flap which wc have already described. This placw 

the whole of tho frontal 
region at our disposal, and 
allows the foi-mation of osteo- 
plastic flaps on a generous 
scale. The thick anterior 
])ortion of the temporal 
muscle, the origin of which 
extends right up to the 
angular process of the frontal 
hone, furnishes • an ideal 
hinge and preserves an ‘ 
adeejuate blood supply. If 
the cran’iotome is used the 
centre will usually ho placed 
a little above the temporal 
line, and tho line of division 
of the bone will bo just above 
tho superciliary arch and to 
one side of the middle line, 
although the latter may ho 
crossed without risk if a 
rc.ally full exposure is desired. 

This method of approach 
furnishes admirable access to 
tho frontal lobe and, if this 
is displaced, to the falx 
cerebri, in its anterior por- 
tion. It is, however, of 
still greater value in tho 
approach which it offer.s to 
the jjituitary gland. If tho 
bone flap is properly formed 
it will be found that tho 
whole of the hone overlying the frontal lobe has been 
removed, and that tho lobe can therefore be dis- 
placed upwai-ds with quite iiniisual facility. If tho 
hyperextended position of the head is adopted it will 
be found that the frontal lobe actually falls away from 
the orbital plate, so that the route to the pituitary is 
opened up even without mechanical retraction, and all 
contvision of the brain is avoided. ‘ 

In this region, if a very extensive exposure is required, 
or if theie is uncertainty as to the side on which a tumour 
is situated, it is sometimes an advantage to form a large 
angular flap; or indeed to expose both sides of the brain at 
the same time. After the frontal scalp flap has been 
turned dowji this can he done with the greatest facility hv 
means of the surgical motor which wc have described and 
a guai'ded cirenlar saw, after drilling a series of holes as 
guides to depth. One saw cut should bo coronal, ono 
horizontal and just above the superciliary arches, and ono 
sagittal and to one side of the middle line. By this means 
a double exposure is easily obtained with very little 
disturbance. 

The new methods of obtaining access to tbe brain ■which 
I have thus briefly described appear to offer considerable 
advantages over those in general use. They arc exceed- 
ingly precise, they demand very little exertion from tho 
snrgeon, they involve a minimal destruction of the tissues. 



Fic. 15. — Exposure of rirlit frontal 
lobe (4). 



300 Feb. 25, 1928] SMALL-POX AL’D CLIMATE, IN ENGLAND AND WALES. 


r Tnrnr.rn^H 
, I AlKDlClL JOL-Rva 


and they can bo carried out almost bloodlessly and entirely 
witlioiit shock. Having now used thoin in a number, of 
cases of the most varied kind, I can speak confidently of 
their, practical v.aluo and of the facility with which they 
can bo applied to vaiying circumstances. The tendenej’ of 
modern corehral surgery is towards larger and larger 
openings in tho skull, in order that its contents may bo 
handled with a minimum of trauma. To form these largo 
openings with ease and safety is tho first problem which 
tho cerebral surgeon has to face, and a realization of its 
importance has impelled mo to offer these suggestions as 
to its solution. 


SlIALL-POX AXD CLIMATE IJJ ENGLAND 
AND WALES. 

DT 

Sm LEONARD ROGERS, C.I.E., M.D., F.R.C.P., F.R..S., 

Lieut.-Colonel I.M.S.(nCT,). 


Drnixo the last six small-pox seasons — from 1921-22 to 
1926-27 — there has hcen a sixly-six-fold increase of small- 
])ox in England and Wales over tho figures of 1920-21, 
calculating from tho first seasonal rise in September to tho 
minimum incidence in August. According to tho Health 
Committee of tho Leagno of Nations, in 1926 tho countiy 
of Jenner showed the unenviable record of returning 
90 per cent, of the small-pox of Europe, exclusive of .Spain 
and Russia. Data are therefore now .available for .a study 
of tho seasonal incidence of tho disease in this countiy in 
relationship to climate, for tho wocklj- .returns of . tho 
Registrar-General contain all tho necessary data on which 
tho accompanying chart is based. In calculating tho 
monthly figures those of weeks including parts of two 
months have been divided in proportion to tho days in 
each, any pos.siblo errors being too small to affect tho 
variations in the curves on which my conclusions are 
based. 

SmaU-pox and CUmaic in India. 

I was led to undertake this inquiry by tho sncco.ss of 
my previous study of tlio Indian data, which furnished 
the kej* to tho prohlcni and yielded the following results. 
Oil charting out tho average montiily small-pox mortality 
of eight provinces of India, together witli tho monthly 
rainfall, mean temperature, and both tlio relative and the 
absolute humidity or aqueous vapour tension (tho last being 
tho actual amount of inoistnro in tlio air measured by its 
pressure in terms of raorcury, and essentially a measure 
of combined heat and moisture), I found tho closest rela- 
tionship between tlio last-named factor and tlio small-pox 
incidonco. Thus the disease rapidly sank to its minimum 
with tho rise of tho absolute humidity to its maximum of 
fiom 0.800 to 0.950 — far higher than over occurs in 
England — dining tho south-west monsoon from tho middle 
of June to early in October, and rose throughout tho winter 
cold weather of low ahsoluto humidity, and continued high 
through tliG hot season of modcrato degrees of tho same. 
Moreover, so close is this relationship that a failiiro of tho 
monsoon rains, accompanied by lower absolute humidity, 
produces a slighter fall of small-pox, with the result that 
tho disease subsequently becomes epidemic, and a closo 
examination of tho data of over tliirty years enabled mo to 
point out how small-pox epidemics can bo foreseen in 
I'uturo in India before tho actual rise has commenced as 
rcpoi-ied in detail in my paper of 1926 (Special Report 
Series No. 106 of tho Alcdical Research Council). 

Chart of Small-pox and Climate in England and Wales 
1921-27. ' 

In tho present chart tho same .climatic data, together 
with the direction of the prevailing winds, arc shown 
- monthly for tlio past seven years, and it will bo seen at 
oncG that, with the exception of tho unusually Into rise 
in Juno, 1G23, to wliich I shall return, tlio seasonal rise 
of small-pox’ occurred vo^ regiilarl 3 ' in tho winter and 
spring months, and a decline in the summer to a minimum 
in August or Soptemhor. 

In tho upper part of ,tho chart tho montiily relative 
humidity is sliqnm by tho lower, dotted ■.line's, - tho absolufo-- 


liiimidity by tho middle continued lines, and the mean 
temperaturo by tho upper curve of broken linos; and it will 
ho scon at once that tho small-pox inercaso occurs during 
high relativo humidity and low ahsoluto humidity and 
temperature, and tho doelino of tho disoaso with tho 
opposite conditions. Further, tlio.two upper eun-es follow 
almost exactly tho .same course month by month, .although 
this is not the case in India, as shonyi in Diagram 1 of tlio 
paper already referred to, wlicro tho almost total absence 
of rain in tliat continental area during the hot season 
causes tho absolute liumidity to bo mucli lower then than 
in tho cooler monsoon months, and tho relative humidity 
may fall to about 30 in tho hot weatlior; wliereas in sea- 
girt England tlio relative humidity usually varies only 
botwcoii. 65 and 80 in tho .summer, and the absolute 
humidity rises with cacli degree of tomperaturo under such 
conditions. In view of this Indian experionco wo may 
proceed to study tlio rolationsliip between tho absoliifo 
humidity and tho small-pox curves in England more closely. 

The Eclnlionship Ectween the Small-pox and Ahsohite 
Humidity Curves. 

Tnicn allownnco is made for tho incubation period, tho 
development, and notification, tho infliienco of any special 
climatic factor m.ay bo expected to shoiv itself on tho 
incidenco of tlio disease in tho following month, as I 
found to he tho case witli the effect of tho monsoon rains 
and high ahsoluto humidity with the seasonal decline of 
tho disoaso in India; and weekly charts for the last seven 
years I have also worked out for this country confirm this 
relationship. It is therefore very significant that tlio 
present chart shows tliat tho Janu.ary peak' of tho small- 
pox curro in both 1926 and 1927 followed the minimum 
of tho absolute humidity curves the month before, and 
that tho rise in January, 1928, has follmred the. cold 
woathoT and very low absolute humidity of December last. 
Even more striking is tlio fact that the late April maxima • 
ff sma l pox in 1924 and 1925 immediately followed the 
very lato Marcli minimal absolute humidity readings of 
those two years. Wo also find hero tho explanation of tho 
remarkUlo very lato sm:dl-po.x maximum in June and 
TnTv nf 1923 for in May tiio absolute humidity was only • 
n aS an average of 0.557, and in Juno by far ■ 
low figure of tho seven years of 0.372, against 
nraeo of 0 413 favouring tho prevalonco of - tho ■ 
an ],appened to break out in badly vaceiriated 

S t 1 n’nd Wales in that one unfortunate county. Truly 
England and .10 , save in his own country 1 ] 

more rapTd decLo of the disease from the yearly! 

m in July to tho minimnra in August is the most. 
"T^t-'-nrin the whole chart, and it is extremely significant) 
that "t followed immedi.ately on tho highest temper.atuve | 
that It to no of tho seven years, not 

“"^i 'tho very hot 1921. Gloucester, however, would 
Sr well '’advised not to hank on such remarkably good 

fortune “Tie'hst* fivo years of considerable prevalence of 
Rio declinrto tho minimum occurred in August 
sraall-po. w-hich the .absolute humidity 

1 maximum in the previous July, and it is of 
reached its minimum in September 

intercs August maximum absolute humidity m 

followed the only^A, reading whs 0.505 in July and 

nafin^^iu August; in September tho figure was 0.4o4, and 
0.480 1 S great increaso of small-pox occur in 

in 110 ° 

October. average absolute humidity fell to 0.351, 

•If n rJftho “owrtt rfguro of 0.309 of the last five years 

rn mV and tlr was® followed by much the greatest 

November rise of tho disease in that year. In November 
N 01 ember ri o imusually 

m 4 at 0 296, and in 1927. at 0.282, .and in the 
^ vp-iv' there- was-a most exceptional . slight decline 
foimer jea . . latter , year the - considoivahle 

necen bev while m .^^328, was broken by ; 

aT'almriVstSart return in DZeomber; ' 1927, followm.g 
Dm rXthelv hig^^ Immidity-of the .previous . 

mn, fi. On' tlin contrai-y, tho considcrahlo_ increases^ of 



with Noyomher absolute humidities mueh below the 
average. 

In a similar manner an early deeline of the disease may 
be associated with unusually high absolute humidity in 
February, as in 1926, and the second slight rise in May 
and June of that year followed low absolute humidity in 
the former month, and the second sharp fall occurred 
as usual .after the rise in the absolute humidity in Juno 
and July. 

The foregoing data will suffice to demonstrate that the 
mam features of the monthly small-pox curve year by 
year can be explained by the absolute hnmiditv d.ata to a 
remarkable extent in this country, as well as in'lndia. 

Sninfall and Direction of the Tl'iiid. 
n a pie.sidential address, to the- Roval ]Meteorologic<al 
cm^'n ' ®“^"'n Latham pointed out that 

Jr, bio.ee ont in this country after a very dr\ period 

i But Sir' Arthur 

found this relationship to bo by no means 
wnnt nf ’ nttribnted the recurring epidemics, for 

Z or iL, constitution ’’-wl.at- 

relationslnn"rt India I showed a very close 

cnidomir sin iT monsoon rain and subsequent 

whit^rain 

decline "of tl I'roiitier Province a slighter 

raiLs! the tlmro in the winter. Thi^ 

disease in this country J rainfall on the 

in inches al +h« K tV* J given the monthlv data 

studied. ■ ^ ^'^ding wmds, ivliich may next be 

In the first place, low raiuMi • .i ■ * ^ 

months of hi<-h small „ * winter and spring 

panied by low°temnpVn? Pi’cvalenco is usually accora- 
conserpiei'itly low absolute^l “"‘1 

small-i)ox. 'We finrl ^ |i^imidity, favouring increased 
low absolute humidity' remarkably 
sharp Gloucester ontLp' i associated with the 

1624; in So" W tiff i ■" Fehriiaiw and March. 

maximum in that year fob 

J > r, lollowing an unusual decline in 


February after the opposite conditions of south-west winds 
and relatively high absolute humidity in Jannaiy. Again, 
the late April small-pox niaximnm in 1925 followed low 
rainfall, north-west winds, and ven- low absolute humidity 
of the previous month, and the verj’ low rainfall of only 
0.38 of an inch in December, 1926, accompanied by north- 
east winds, was followed by the highest small-pox rate of 
the whole chart in Jnniiaiy, 1927, aided by continued loa" 
rainfall in that month. Once more, the rapid rise of 'the 
disease in Koveraher, 1927, followed low rains and north- 
east winds in Octo1.)er, and the further rise in January, 
1928, followed low temperature and north-east winds, hut 
with high rainfall in tho last two ■ weeks of Dcccmher. 
Tluis low temperature and absolute humidity, followed by 
increased in'evnlence of small-pox, are commonly associated 
in the winter and spring mouths with low rainfall and 
north or east jyinds. 

"When we turn to tho summer period of low small-])ox 
incidence we find totally different conditions, for at this 
season low rainfall is usually accompanied by liigh tempera- 
tures, which i>roduce relatively high absolute linraiditics 
in this counti-y in spite of low rainfall, and so aro 
followed by decreasing small-pox — as, for example, in the 
second week in June, 1925, when in the absence of rain 
even a north-cast, wind was accompanied by very high 
temperature and absolute humidity, and was followed by 
declining disease. This explains Sir Aithur Nowsholnic’s 
experience, for it is now evident that only scanty rains in 
tho winter and spring months are likely to be associated 
with low absolute humidity and increasing small-pox, while 
low rainfall in tho summer will favour high temper.aturcs 
and loa' small-pox. 

The Future Outlool: of Small-pox in England. 

The most striking feature of tho chart is the .steady 
increase in each of the last four seasons at an average rate 
of 160 per cent, over the previous year in geometrical 
progression, and there seems to he no apparent reason why 
this should not continiio in view of the increasing neglect 
of vaccination in tho rising generation. M'ith tho excep- 
tion of. the Gloucester outbreak in 1923 and tlie infection 
of South 'Walos last year, tho great majority have occurred 




302 Feb. 25, 1928] 


EBGOT POISONING AMONG RTE’ BREAD CONSUilERS. 


'[ 


Tn*URmsB ^ 
Mf.Djcii. JticB'ru, - 


in tlio Nortli of Englnnd, no fewer than 615 of tlio highest 
monthly figure of 675 in Januai'y, 1926, having been 
roiiorted from Durham and West Yorkshire. Possibly tho 
lower winter temperaturo and absolute humidity in tho 
North may bo one factor in this distribution. Tho data 
are not yet sufficient to alford soopo for forecasting tho 
probable incidence some months ahead, as in India, biit 
it may ho significant that tho less marked summer dcelino 
in 1924 than in 1923 and 1925 was associated with lower 
summer absolute humidity in 1924, as I should expect a 
cool summer to produce less reduction of tho disease, and 
a cold winter and spring should favour an increase. 

Tho immediate outlook is complicated by twenty-four 
counties repoi-ting cases at tho end of January, 1928, 
against nine at the same period in 1927, but against this is 
tho fact that the groat rise early in 1927 was largely duo 
to small-pox getting out of control in Durham, with nc.arly 
half the total Januai-y cases in that one county, which is 
not tho case this j'ear. The recent very mild January and 
early rebruary is unfavourable to tho rapid increase of 
tho disease, but in view of the maximum occurring as late 
as April in two years xvith especially low spring absolute 
humidit}-, it is too early to say whether tho high small-pox 
rate of last year will bo exceeded this year or not, but a 
cold sjn-ing is likely to result in some increaso on tho 1927 
figures. A few more years of neglected vaccination and 
we are likely to possess better data for forecasting tho 
epidemics hero, as in India. 

Nor should wo forgot that tho present widespread mild 
small-pox is a reliable measure of rvhat is likely to happen 
when tho fatal African and Indian, form onco more gets 
a firm footing in tho country of Jennor, ns it nearly did in 
May, 1927, with five deaths among eleven cases in London, 
when a serious disaster was only staved off by tho fine team 
work of the medical profession in tracing and vaccinating 
contacts. 


Conclusion. 

Tho mild typo of small-pox now endemic in Englnnd 
and Wales has increased each year for tho past four seasons 
at an average rate of 160 per cent, on tho previous year. 
Its seasonal prevalence is closely related to tho absoluto 
humidity, as I havo previously shown to bo tho case in 
India. Low absolute humidity favours and high cliecks 
the disease, and in this country tho mean temperaturo 
curve closely follows the absoluto humidity one, although 
this is not the case in India, whore the yearly epidemics can 
he foreseen several months ahead. In England the probable 
course can only be forecast at present for tho succeed- 
ing month. A cold winter and spring are likely to result 
in increased small-pox. 


ERGOT POISONING AMONG RYE BREAD 
CONSUMERS. 

BY 

JAMES ROBERTSON, M.B., Ch.B., 

AHD 

HDGH T. ASHBY, M.D., F.R.C.P., 

VrsITING pnVSICIAH TO THE ROYAL MAHCHESTEa CIULDREX’S iSD 
SALYORD EOYAL HOSPITALS. 


Attention was first drawn to tho prevalence of symptoms 
suggesting poisoning by ergot by one of us ( J. R.) some 
eighteen months, ago. An increase in the number of cases 
slioiving symptoms has led us to investigate the condition 
thoroughly. 

In the first place it was noticed that the disease is 
confined to the Jewish population of tho city, and it 
is found that the symptoms aro only met with in that 
portion of tho Jewish community which uses rye bread as 
an article of diet. In no case is the condition met with 
among those who eat white bread. 

Wo have carefully collected and recorded cases, and 
havo had analytical and physiological tests made on tho 
rye in order to prove tho cause of the symptoms met with. 


Early in tlio ini-cstigations it was observed that the 
general symptoms complained of were coldness in the 
extremities, numhness and lack of sensation in tlio fingers 
— a sensation like an insect creeping over the skin— 
hoadaclies, depression, gastric disturbances, shooting pains, 
twitchings in tho limbs, and staggering gait. It was 
further obsen'cd that the patients who complained of 
these symptoms were Jews and later that these Jews ate 
-black or ryo bread. On the other liand, iiono of the 
Ej'mptoms complained of wero observed among that portion 
of tlio Jewish population who ato white bread. It was 
then suggested that the ryo bread might bo the source of 
tho trouble. From this it was^ concluded that the symptoms 
.wore duo to .orgot, which, as is lyell known,, so readily 
contaminates the ryo. It was. also noticed that tlio 
symptoms w'cfo much more pronounced in the Russian, 
Polish, and Oerman-borii Jews than in English-born Jews. 
'J'his is explained by the fact that black bread is the bread 
commonly used on the Continent, whereas in this country 
its place is taken by white bread. ’ Further, on account of 
its slightly bitter taste the black bread proves more palat- 
able than the comparatively tasteless , wliito bread. In 
addition to this, black bread is found to be more satisfy- 
ing and is a little cheaper than white bread. 

In some liouscholds it is found that one member may 
show no symptoms of ergotism' whatever, whilst all the 
other members of tlio family are variously affected. Ques- 
tions elicit the information that tlio unaffected member 
does not cat ryo bread. In many of the cases first seen 
ryo bread was stopped ns an articla. of diet; this was 
followed by an early diminution in the symptoms, and a 
comnlcto disappearance of them in most cases. 

Rvo is bv far the most susceptible grain to infection 
bv tho par.asitic fungus Claviceps purpurea. Tho gram, is 
Sfec ed jus ns tlio^’fiowers are opening, and the fungus 
miectea j grain. The infection is only 

enters at j i,ecomes too hard 

possib^at US tin e, a commonly 

* dnrina°a spell of sunshine following a cold, damp 
occurs can more readily bo detected and 

period, and 0 damp raising and harvesting 

domonstra ed a to ^ 1927.- ' Grain that is 

season— foi ex..mi ; i 

infected with eigotm seen^to 

tho cereal has probable that some con- 

signLTts" of rye grain arb ergotised and somo are free 

from tbo gf events precautions aro takbn 

-In tbo fidumiy ^ consumer 

to prevent \ procesA known as “ screening,’ 

bvthe g a u passed tbrougb a sieve and tho large 
li airs are eltoinated. If a sufficient proportic.n 
infected g*' . . , ne.^roted in this manner, then tbo ijo 

lanfinatcd^ is classified as unfit for use. 'This method 
so contaminate inefficient, as it does not prevent 

passing through.- ' Thus all 
the . f f ,[ o-raiiis are passed on as fit ±oi use. A ^ 

the small J Eventually becomes black in colour. It is 

infected r} g ^ify with the naked eye. TIio gram is 

therefore easy to ite y ^ 

then ground and, after bfker for bread-making. 

middlemen IS boi i qualities, and therefore, 

Bye flour In • 7 P ground to meet consumption, 

as far as use- frasW ground ryo deteriorates in 

Old lye is thebe Uor g^nliar fishy odour AVbcn 

twelve hours, invariably takes it as an uidication 

this 13. smelt tho uaKe un quickly; otherv/iso it will 

that rye used is home-grown when avail- 

be unfit for . j^. percentage has been imported 

able, although ' ^-nrm water is added to the 

from Canada 1 .. ,our this takes about 

rye, and it is eighteen hours old 

twelve hours^ ordinary 

b:kero, and no machinery is a the broad 

Samples of the gi am, ^eap^ the Manchester city 

r^Mysrtbf reported that the gkin submitted showed 

"inTutLl sS'oribo infected grain tho fungus 




TEB. 15. 


INFLUENCE OF PARTUBITION UPON INSANITY. AND CRIME. 303 


Clavkcps vurinnra B-as at onco scon invading it, and 
t\ c fi4ns slioivcd lip ivcll after .staining iv.tli iiicthy- 
one bhil and cosin. Sections of gram wore also stained 
with iodine and potassium iodide for .sUreh none of which 
was seen in niaiiv sections, owing to its having been 
replaced hv the fungus. Extracts from the rye were also 
tested phvsiologieally for ergot, and the results were 
positive! Mr. Heap has, moreover, been able to grow the 

fungus from the lyc. . 

The three chief coiistitueuts of ergot are spliacelinic acid, 
cornutinc, and ergotinc. Hotvever. ergot is not as yet 
defiiiitelv’ split up. into , its component parts or active 
constituents, and little is . at . present known of them 
specifieallv. 

It is found that the .average Jewish jicrson consunies 
about 1/2 lb. of rye bread per diem, the flour of which 
contains 1 per cent, of ergot. Now 1/2 lb. of bread will 
contain .about 5 to 6 oz. of flour, the rest being the water, 
which is added before baking; 5 oz. of flour equals 2,285 
grains, of which 1 per cent, is ergotized. Each person 
is thus consuming 22.85 grains of ergot daily. The ordinary 
medicinal dose of ergot, taking the licpiid extract of ergot 
as a sample dose, is 10 to 30 minims, which equals 10 to 
30 grains. Thus each individual is taking rather more 
than the average dose of ergot each day. On account of 
freshness the ergot is also likely to be more potent than 
the inedicinal ergot which has been kept for a time; also 
grain harvested during la.st autumn, if infected by 
ergot, is likely to contain fresher principles than that of 
the ergot from the previous harvest. It is found that rye 
bread takes time to rise before baking, cspeciall 3 - in 
the winter months, when it is colder; and the flour mixed 
witli water is allowed to stand for a time to “ sour,” during 
wbicli time it is likeh- that the fungus ma,v increase in 
quantity. 

The symptonis observed in these Jewish patients corre- 
spond very closely with those produced by chronic ergot 
poisoning. The severity of the .symptoms produced sceiiis to 
increase with age, children being slightlv and elderlv people 
more acutely affected. 'This may be due to the elderly 
people having taken rye bread for manv j-ears. The foreign- 
born Jews, who have always eaten rve bread, are the most 
affected. ' • . ' 

The first simiptoms obseiTcd aie coldness of the ex- 
ticmities eombined with nuinbue.ss. These svmptoms are 
especially observed in tailors, buttonholcrs, etc., who find 
lat their fingers are numb, and they have difficulty in 
.eejnng up inth their work. They often notice that they 
pile, their fingers without feeling it. Ravnaud’.s disca.se 
amoiigs 10 Jews during this winter would appear to be 
1 lieretofore. IVe have also come across 

“ ‘definite dry gangrene of both 
gangrene of this man is not associated with 
no* n o'- °*i condition, and it i.s possible that, 

poisoning ™nsumer, his gangrene is due to ergot 

ca^s' ®®l’®ation, which i.s found in all marked 
This SOT,. nK "h ”'®^at creeping under or over the skin. 
Itchino is lolunteered bj- the patients in most cases, 
nervousness .symptom. They also suffer from 

marked. Pains in ■"‘hilst headaches are well 

of, whilst among the more 00 !'" 

ataxia may be fonnrl T '® '’daggering gait and 

. the blood' prc.ssui-e is 'ong-.staiidiug cases 

r7 AA 1.1 definitely raised — for example, a 


'' U Tas^ilf obs^verilnt" 

when rye broad as an fl"iokly improve 


A lai-irp "“ article of diet is discontinued. 

contr.aeUou of the .arterlL 


probable that if the * fver the bod.v, and it is 

such serious should become move severe 

-ill beemne nmif gangrene 

tracting the promnnt , ! has the power of con- 

eegot poisoning n,av conw”^’ 

nancy, Unfnrtninthi ‘ '’'any abortions in early iireg- 
as the Nofific.a“f.^“;.«“'<>hs available of thes'e easel, 
horn after the expiration children 


pregnanov. 


of tlie twenty-eighth e*eck of 


Treatment consists in stopping the consumption of the 
contaminated bread at once, and it is remarkable how 
quickly patients recover when tliis is done. Tliey slioiild 
be kept warm, and drug treatment is necessarily only 
palliative. 

We are much indebted to Mr. H. Heap, M.Sc., F.I.C., the city 
analyst, for his careful analysis of the samples sent, and for his 
help and ach'ice. 


THE INELXJENCE OF PARTURITION UPON 
INSANITY AND CRIME. 

AnsTit.vcT OF A Pafeu he-cd befoue the jMedico-Eeg.il 
Society ox Febuuaby 23bd, 1928. 

BV 

■ A. LOUISE McIEROY, M.D., D.Sc., 

PROFESSOR or OBSTETRICS AND GYNAECOLOGY, UNIVERSITY OF LONDON 

(royal tree hospital). 

Ix 1922 tho Infanticide Act relieved the courts from the 
painful task of finding a verdict of murder against a 
woman, mentally deranged by childbirth, who kills her 
iieivly born child. 

Tbo records of Broadmoor show that of the total female 
receptions from 1900 to 1924, 42.8 per cent, were in respect 
of child murders duo to insaiiitj’ associated with childbirth, 
tho majority being crimes committed during lactation. To 
escape punishment a woman pleading puerperal insanity 
must prove (o) that she was suffering from the disease 
when she committed the offence ; (h) that she was incapable 
of distinguishing right from wrong, or was under the 
infliieiieo of a delusion which prevented her from under- 
standing at the moment the nature of the act which she 
was about to commit. The law assumes tho delusion to ho 
a fact, and if the fact would justify the act of violence 
then tho prisoner would he entitled to a verdict of “ giiiiy, 
hut insane.” This is provided for by the Criminal Lunatics 
ilct, 1884. As maiij' critics have pointed out, it is difficult 
to see how a person can be both insane and guilt}’. Before 
the Infanticide Act was passed the practice was for the 
jury .to bring in a verdict of “ not guilty, on the. ground 
of insanity,” which seems more logical. It should be borne 
in mind- that a verdict of “guilty, hut insane” can he 
passed upon a person sano at the time of tlie trial. 
A prisoner who is admittedly insane' when about to he 
tried is, of course, unfit to plead, and is therefore detained, 
during His Majesty’s pleasure — that is, until he recover.? 
his reason and becomes fit to plead. 

Eroiii this it is plain that a woman suffering from puer- 
peral insanity who uinrdered her child knowing that she 
was doing wrong would he liable to he convicted and 
sonteneed to de.atli for murder unless she were able to 
avail herself of the Infanticide ’ Act, which makes an 
exception from the general law. On the other hand, if 
she established a defence of insanitj’ she would be found 
guilty of murder, but insane, and locked up during His 
Majesty’s pleasure, so that even in these circumstances 
she would suffer punishment of no light order. 

Tho Infanticide Act provides (Section I) : 

” AVhere a woman by any wilful act or omission causes the 
death of . her newly born child, but at the time of the act or 
omission has not fully recovered from the effects of giving birth 
to sucli child, and by reason thereof the balance of her mind is 
disturbed, she shall, ’notwithstanding that the circumstances were 
such that but for this .\ct the offence would have amounted to 
murder, be guilty of felon.v, to wit, infanticide, and may for sucii 
offence be dealt.' with and punished as if she had been guiiti* 
of tile offence of manslaugliter of sncli cliilci.” 

As a corollary. Section II entitles a jurv’ to find a verdict 
of infanticide where tho charge is one of murder. To put 
tho matter in a nutshell, in respect of a newly born child 
the mother has a period of absolution nndor the Act. M hen 
that period has expired she is dealt with 011 the same 
jirineiples as other persons charged n’ith murder. It is 
obvious that the Act requires two things tho woman niiut 
he mentally unbalanced and tlie cliild niiist be newly born. 
The absence from the Act of any definition of the term 
“ iiewlv horn ” has occasioned some discussion. 

■ In- a case relating to a .young woman named ^Mai-v’ 
Donocime, heard last November (1927), the Court of 


304 


OF PARTPMTIQN TJ Jqn ^NSANITr. AND- CRriTB. 


Criminal Appeal, consisting of tlio Lord Chief Justice Mr 
Just, CO Arory, and Mr. Justice Salter, decided tJmf a 
c aid more than a month old was not newly born within 
tcxtbooli 'vhen correcting a statement in a 

; oUa i T, expressed the opinion that 

the ° ‘>1'° Act. Wo 

'' newr\'*“ constitutes in law a 

newly born child, except that one more than a month 

catego^-!*^ ^ ^ mthin the 

In medicine the definition of a newborn child is sonie 
uhat vapie. Obstetricians look upon the newly boni or 
neo-natal infant as one under ten days, but rcoue tlv 
for purposes of mortality statistics and diso.ssl tlds 
poiiod IS extended to one mouth. Tho convalescent period 

dai-r'^ATtro’enVl eight to ten 

bo noma t^t enn -'‘1 thcrcfo,-o 

no uoimal, but convalescent. Ten days after parturition ;« 

from hos "P'”’ disehaigo of patients 

engaged fo “one "'-e 

—to 1 nionth-witness the tci-ni “monthly nurse” 

In^ni e ?"°‘;'‘cr amLbaby till the end of this period 

In no case is tho infant looked upon as newly born after 
one moiith from birth. A wo.nan ougU to bo Shy 
ecovoied at the end of a month from delivery This 

present'tim Act 'in its 

Iha state of the law is most unsatisfactoiw so far as it 
affects cases of puerperal insanity, a term ulcd to denote 

rsfi;;;srs"‘ 

or mccipitaterbv t cctic.i 

an^hv“th!f P"®^PC''C' insanity it shouid bo impossible to ■ 

insmie. Apparen%,™s“th'^ l«’”'ftandsTrSl“n*Lfe-,^^ ' 

. from puerperal insanity who killed her chilrl rl., . * ® "'8 ' 

Jjio dw no^kfow%mt™slm d'S^g' wmig ZT" T 
the^influcnce of a delusion, she ifight b^o senl^Udlo 


r,, Tn* 

L aHotCXL JoCl*44 


that 


TJio ditestion js further complicated liv +lin r t- 
physical and ineiital exhaustion^ Tt suckling, oiraig to 

Seft- s»."r , r;„s 

tendenr- pationt has suicidal or homicidal 

tendenaos, often on imjiulso. Sho may cut her tCat or 
single or drown her infant. Many patients are d.^cu 
to cure and niay end their days in an asyium. In “any 
criminal asylums a coiisiderahlo number^ of women aro 
oi ‘•‘rts towards their infants 

to dm f , f d ’°i ? This mav bo duo 

cm.tta. f * * during lactation there is less skilled and 

hT ,t I tho pnerperium. It must 
o icco,„iii^od that as the acute maniacal nou-homicidal 


. . - * 7*“ iiiujuiicui nou-jJorD]CJnai 

t 31 )o IS most common within ton days of childbirth, and 
the later niel.aiicliolic, suicidal, homicidal tyjio during lacta- 
tion, no legal distinction should bo made betwera tha 
yarions weeks or months whbn tho symptoms occur. Need- 
less to sai', a woman afflicted in this way has “ not fully 
recovered from tho effect of giving birth ” to her child, to 
use tho i.-inguago of the Infanticide Act. Therefore sho 
should bo entitled to the benefit of its provisions. If the 
law nhsoives tho mother wlio commits infanticide upon her 
toil 11 . 1 } s ojtl child, it should just as readily absolve the 
depressed uiotlier who, worn out by Jactation, puts an eud 
to her infant’s Jifo. 

Iho words “ newly born ” should be deleted from the Act, 
Bufaject to a proviso tliat its operation should ho limited to 
a period of six or nine months from the date of birth. It 
would afford protection for mothers suffering from what 
the medical profession recognizes as puerperal insanitj', 
and it would also cover cases in which a woman, although 
not insane, in a. moment of distraction kills her child shortly 
after its birth. It is important to mark the difference 
between tho two classes of case. Unhappily tho murder of 
infants is only too common, but they are usually killed 
cither at birth or shortly afterwards. Therefore the exten- 
sion of tho period would in practice be limited to cases 
of jiuerporal insanity. It is fully recognized that many 
infants are deliberately made away with, and nothing 
should be done to weaken tho law hi such cases. 

Mothcriiood is a necessity for. the- race; -It .is tho factor 
of motherhood that makes the woman insane and causes 
her, wlien suffering from a disease duo to motherhood, 
to destroy her offspring. Thcro is - a- marked difference 
between a murder committed by a person suffering from 
general paralysis of the insane, or even paranoia, and one 
committed by a mother in the delirium of childbirth or 
exhausted by nursing. 

A debate took place in the House of Lords on tha 
Children Bill, 1008. Lord Loreburii, the Lord Chancellor, 
with tiio concurrence of the Home Secretary, proposed to 
insert a new clause providing that: 


treated with more lenicicv than nno i -i i 

peral insanity wjio kills her chit,! as from pucr- In support of tho clause ho said that the passing 

„ -c.„„ . ^ , ■ “r, saj-, six weeks? death seiiteuce in such cases was a mockery, as s 

-tear of exposure, shame, depression ovn.. - • '--i --i ’ .,.-:..,l .,,.1 m/iQ +1, 

the brcalcing' of the moral law ini^ery following 


of the moral law should J'olJowing^ 


-symptoms arising 

reactions Of tho normal mind— in fact were 
— J. E. Lord, Journal of Mental ScienZ, July “•" 


It may bo said that tho general law concei-ni,„r 7 
insane persons is a sufficient protection for sUffo? 

puerperal insanity, hut this should not apply to n o. 
insane cases. i X j to imeiperal 

Pueijioral insanity is a well-rocognized disease of moii 
hood, just as much as puerperal sepsis and si, 
treated accordingly. A virdii of infaUidc' 
to one of maiislaughter, so that tho offender does w 
escape lightly. If the- prisoner relied upon the ^ 

law, and suaceded tlie verdict would be one of “'’g"ntv 
but insane,” which would for all time brand her^ as ’ 

Ks ss ““ i”,"— p.±iic ; 


Where a woman is convicted of the murder of her infant, and 
tliat child was under tho ago of I year, the court may, in lieu 
of passing a sentence of death, sentence her to penal servitude 
for life 0°r any less punishment. 

of the 

death seiiteuce m suen eases was a moeaery, iis SUcIl a 
soiitciice had not been carried out siiico 1849. Ho thought 
that public opinion was sliocked at the idea of the death 
sentence being jiassed in cases where it was manifestly 
iiihuniaii to carry it out, and on tho other hand it was 
veiy much to bo regretted that the death penalty should bo 
nominally inflicted when tliere was no reality behind it. 
Tim bill was uUiiriately rejected by 42 votc.s to 36. 

Any change in the law should bo limited to women who 
are mentally unhalanced owing to pregnancy, parturition,- 
or lactation. Tiie removal of tho term “ newly born ” 
from tho Infanticide Act, coupled with the proviso 
suggested in the present paper, would meet the difficulties 
lecogiiized by speakers who opposed the danse. 

The following points demand consideration: (1) Tho 
definition of the term “ newly horn ” under the -'let, 
(2) Should the law be altered to give more extended pro- 
tection to the parturient and nursing -mother who, when 
suffering frein puerperal insanity, destroys her child? 



TeB. 15 . 


CHOLllCTSTOGRAPn'E BY THE OKAD METHOD. 


t lrrEBiuTTss 
UZPICXI. J PCBttir 


305 


CHOLECYSTOGKAPHY BY THE ORAL METUOD 
AVITHOUT THE USB OF CAPSULES. 

With a BEroni ox Foiny Ga:;i;s. 

BY 

HUGH MORRIS, M.D., I».:H.R.E., 

r.AOIOLOGlST, SALTOnD ROYAL HOSPITAL, SrAHCIlKSTER. 


Owing to the olijcction wliicli niaiii' nir^oons itill Iiavc to 
the use of tctraiodophcnoli.htlialoin iiUmvciioiisIy, it is 
often nccess.TiT to administer the salt bv flio inoutli. Miicli 
lias heeu written on this snhject, and vari,nus methods have 
been devised to allow capsules containing the salt to jmss 
tbrmigb the stomach with their outer coats intact. In this 
liosjiital, as in others, results were good with the aid of 
capsules which had been freshly coated with keratin, but 
after a short period of storage the capsules jmssed through 
the bowel undissolvcd. Reali/.ing tliat this is a great 
disadvantage, especially in the smaller hospitals, or in 
private practice, where not many cascss' are examined, an 
attempt was made to dispense with the use of capsules 
altogether. 

Sproull' examined a scries of 23 cases, giving the salt 
mixed with cream of wheat, and this method was tried 
hero in several cases. 'Whether the wrong patients were 
selected, or the wrong method of cooking the cream of 
wheat was employed, is not clear, but, at any late, all the 
jmficnts (five) on whom this method was tried developed 
sickness, and one had headache. An alternative vehicle 
Has theveforo sought for, and on the suggestion of Mr. 
Adamson, pharmacist to this hospital, the salt (grains v 
per 10 h. body weight) was first mixed with white of egg 
befoi'e hping added to the cooked cream of wheat (about 
4 ounces). The idea underlying this was to fix, or par- 
tially fix-, the salt until it should luave passed through the 
pylorus, and, whether dr not this effect was produced, the 
method has been satisfactorj-, as is shown bv the following 
table and by the operative findings. 


- ■ 

XoriualJ 

1 

PflUio- 
! logical. 

'“’Vlezeant olTecU were 
^'’liroduoj? Yinnleasant effects irerc 

18 1 
7 1 

! 

^ 2 


ache a') produced were as folloivs : be.od 
‘due to the vases, of which 3 were slight, .and «er< 

^ mixture, u'liich is certainly ai 
cliGvrboea (2 ciises 
and vomitinc fn I>v a carcinoina of the caecum) 

after the idm, a- ^ ®vrero ; i-omitiiig etmse< 

bydvochlor. ms, aq.“ad ss 0 ^“'’“ "“"I’'' 

value of attempt to demonstrate tin 

this method of adminirtertn^^' 

Ibe ■' pathological " cases 12 ^ 1 *’’® f s.otisfactory. Oi 
' ^ oporateci on up t( 

The remaining cas< 


anerema 

c was “ the report o 


show 

this 


this case was “doubtful *cpovt o 

to throw a faint shadow'^^^^Tl'’”'”' 7®?“ 
bladders were examined -it mm" r normal ” ga 

least to palpation and +‘ ,, and were normal, a 

the test was lepesSd ll’ 

salt which was present amount of fre 

e.ises the finding was Iiowel, but in e.ieli of fhes 

first examination. at tho second ns at tli 

bldddcrs; this b^ reprodnee films of ga 

density <;t oft-. .a!.T.ady, but ^tb 

intense <os tliat oKt-.;., i ■ ™.'‘low in this method was a 
i.„,. 1 ' oMamed m any other oral method wbic 


has-been emploj-cd here. 

address of the parent 'wn? ont-patients, .and f 

^•■0 x-ray department. Ut 


form, wbii 


explains the tccliiiiquo employed, was sent, examination 
being arranged on a day to suit the convenience of the 
department, and the form being sent five or six d.ars before 
tlie day of examination. 


Special A'-ray Examikatjox. 

to the ratient. 

(1) Take n <lo«c of uistor ojl on night. 

(2) AUciuI at tile disponsary of liosjiitnl on between 

2.30 aiul 4 p.m. If desired a ineM*-enfrer may bo sent — personal attend- 
ance ib not necessary. 

(5) Take (he mntenat iirovided by the dispenser at 9.30 that niyht, 
as instructed. 


(4) Talio nolhing^ but water after tliis. 

(5) Attend at x-ray department at 9.30 a, in. on havinjj^ 

taken uothtuy but irfltcr since taking: the ^^eci3i meal. 

(6) Stil! liavfng: taken nothing but watox’, attend at the x-ray 
department again at 2.30 the same afternoon, 

(7) Have n meal, with as much fat in it ns possible. 

C8> Aftend for final x-ray examination at 4.30 p.ni. 

(9) Report to the doctor who attends you in out-patient department 
on Jiis next day for seeing patients. 


The lilaulv spaces arc filled with the names of three 
consecutive days — for example, Monday, Tuesday, and 
AVcdiiesday, if the examination is fixed for AVednesday. 

I am indebted to the physicians and surgeons of Salford Royal 
Hospital for so kindly helping by providing cases, and for their 
useful suggestions at various times. I am also indebted to Drs. 
BydicU and Higgins for permission to publish these cases. 

Rtrrp.tJccE. 

^ Amer. Joum. Roentgenol., March, 1927. 


THE OPERATION OF EYERSlOX OF THE SAC 
FOR HYDROCELE, 

BY- 

RICHARD L. SPITTED, F.R.C.S., 

BVRCEON', GEXERAL HOSFITAL, COLONIBO. 

It lins abvays been a puzzle to me ,w-Uy the simple and 
efficient operation of eversion of the sac for Iiydrocelc is 
not practised more frequently in England. Of all opera- 
tions for hydrocele it is perhaps tlie easiest, and acliieves 
its object Yvith least disturbance of tissue. It is, I think, 
much preferable to Rcrgmaim’s operation of excision of 
the sac, which, ajiai-t from the element of time inioli-cd, 
entails inucli ■ stripping of tissue and tying of yessebs, and 
is fairly frcqncntK- followed by post-ojicrativc baenia- 
tomas; whereas eversion of the sac mas- easily be done 
within fiv-e minutes (1 have often done it in two) and 
without tying a single Y-essel, the only buried suture being 
that liolding together the edges of the everted sac. 

One objection fretpiently urged against ei-ersion is tliat 
it is apt to be followed by recurrence; but tin’s need 
never be if the operation is correctly performed. 

I do the operation tinder local anaesthesia as' follow-.s : 
.All injection of moiqiliine is given half an hour before- 
hand. The ingnino-scrota! fold is seized w-ith the fingers 
of the left hand and the cord imprisoned; into the 
substance of the cord 5 c.cm. of a' 1 per cent, novocain- 
adrenaline solution is injected. This renders the testicle 
insensitive to manipulation. The assist.nnt iioiv grasps 
the tumour with both liands, gathering up the loose 
scrotum beneath, in such a way as to make it protuberant 
and tense. Along the line of the proposed scrotal incision 
10 to 20 c.cm. of a 1/2 per cent. nOY-ocain-adrenalinc solu- 
tion is injected. (I prefer the scrotal to the inguinal 
incision, as there are few or no vc.ssels to tic, and access 
is direct to the best jiart of the sac to incise.) An 
incision 2 to 3 inches long is now m.ndc over the tense 
tumour, and deepened later by layer along the full length 
of the cut until the translucent sac becomes evident. 
Dane’s forceps are clipped on to the edges of the scrot.al 
wound on each side. The point of the knife is plunged 
into an avascular part of the tunica and the fluid evacu- 
ated into a tray, but the blade is not remoi-ed from the 
rent tmtil the cut edges are secured with forceps, other- 
wise their retraction makes them difficult to define. Tlie 
assistant now releases his hold of the scrotum and takes 
up one of the forceps on the tunica, the surgeon the other. 


306 Feb. 15, tgiS] 


A. METHOD OP MAKING A BDOOD FIDM. 


C r . T«* Ctm* 

L UrDtcit Jomit 


The opening is enlarged with scissor.s along the anterior 
Burfaco of the sac, avoiding blood vessels. The tc.sticlo 
is drawn through the ample hole and the tunica everted 
like a cuff. The assistant holds np the to.sticlo wliilo tho 
operator, introducing forceps or lingers into the scrotal 
wound, eases it out so as to form a roomy hod in which 
tho testicle may lie when it is returned, without tension 
on the sac. Two pairs of Lane’s forceps are now used on 
either side, one to embrace tho cord (c), tho other tho 
gubcrnaculum (o), or rather what remains of it, which 
is very little. Tho two forceps 
are held apart, displaying a web 
of tissue between them partly 
covered by tho everted sac (Fig. 1). 
To this web tho sac is secured 
by a through-and-through mat- 
tress stitch of catgut, or an open- 
ing is made in it with pointed 
forceps and the edges of the sac 
are approximated and secured 
througli tho rent with a single 
mattress suture. If the sac is 
very redundant an additional 
pleating stitch may bo applied 
to it on tho outer side of tho 
cord, as is done in tho usual 
operation. Tho testiclo is now 
replaced and the scrotal wound closed with an intradermal 
or a running mattress stitch, which, better than any other, 
obviates tho tendency to incurvation of tho edges. A 
scrotal suspender secures a gauze dressing in place. 

Tho whole operation is very quickly performed. Tho 
points I would recommend as safeguards against recur- 
rence are : (1) tho making of a new bed for tho testiclo 
b}' casing, out tho depths of tho .scrotal wound ; (2) tho 
securing the edges of tho sac to tho wob of tissue behind 
the testiclo. 

In the operatiou ns it is usually done tho everted sac 
is merely constricted by a stitch or two besido the cord, 
and no new cavity is made for tho testicle. There is thus 
a tendency — though not as often as is supposed when tho 
technique is careful — for tho sac to retrovert when re- 
turned. Most recurrences, I feel sure, occur at tho timo 
of replacement, or very shortly afterwards, for “ tho endo- 
thelial surface of the serous sac faces tho scrotal fibrous 
and cellular tissues to which it becomes 
adherent in a short time ” (Jacobson). 

Jaboulay in his original operation 
released tho testiclo by ligating and 
dividing tho gubcrnaculum testis, and 
then folded the two sides of tho divided 
sac behind tho testiclo and fixed them 
there with a few sutures (Pig. 2), ono 
of which included tho superficial tissues 
of the cord (Binnie) ; or ho oven cut 
away, in addition, part of tho redundant 
sac before stitching them together 
behind tho testiclo (Thomson-Walker). 
No recurrence can follow such a pro- 
cedure, but I think that in tho usual class 
of case it ini'olves unnecessary interference with structure, 
though when the sac is thick and eversion difficult it is 
best to open it up, and then to peel off the parietal tunica 
from the thickened adventitious coverings, and thus, having 
released tho testicle, to evert round it and the cord tho 
now membranous tunica, as in tho Jaboulay operation. 
In Wyllys Andrews’s “ bottle ” operation a small opening 
is made in the upper pole of the sac and the testicle is 
displaced tbrougli this and tho .sac inverted and di-awn up 
the cord— a procedure which gives no absolute safeguard 
against recurrence. 

Eversion of the sac is, generally speaking, contraindicated 
when the sac is very much thickened and calcified, for 
tho main reason that it does not then reduce tho size of tho 
tumour to anv extent; but in these cases, and oven in tho 
leathery sacs' of infected haematoceles (and incidentally 
in pyoceles), I have often saved testicles that might other- 
wise have been sacrificed by everting tho sacs, swabbing 
out their roughened inner surfaces with zinc chloride 



Fi&, 2. — Jaboulay’s 
operation. 



Fig. 1 — Evoision of sac. 
T, te'^ticie; c, cpidulymia ; 
c, coni; G, gubernneubr 
remains; M, inattresssutiire. 


•solution, packing them with iodofonn gauzo anti leaving 
tho wound piirtially' open, and instituting in a day or 
two Carrol-Dakiu drip until tho cavity gradually obliterated 
itself. It is femarkabio what a degree of pliancy and 
shrinkage the’ sac eventually attains. ■' • •• 


A METHOD OF JIAKIHG A BLOOD FILM. 


FREDERICK COCK, M.R.C.S., L.U.C.P., 
SuncEos Commander, R.N. 



Thk following method of making blood films is ono of several 
tried in an attempt to get a "more even distribution of 
tho red ami wliito blood cells. In an ordinaxy blood Bme.ir 
most of tho leucocytes are found at the niargins of the 
film, but the method about to he described le.aves tlia 
majority of these cells in the centre of tho film. This 
may ho a .step in obtaining tlio rc,sult originally aimed at— 
namely, oven distribution of cells in a film. 

A piece of glass about tho size of a lialf-plato nogativo 
(a in the accompanying diagram) is cleaned, and on oao 
side white paper is gammed so that tho quality of tho film 
can he more readily observed in preparation; h and b aro 
each two glass slides stuck together with Canada b.slsam 
and mounted two inches apart on ct; c is a single glass 
slide moimtcd in tho position shown. ' 

A drop of blood is taken on tho end of a slide and placed 
hetween h and b, and a second slide is made to I'cst on b and 
h at right angles to 
the first, so that 
there is tho tliick- 
ncss of a slide 
scjiarating tho glass 
surfaces between 
which tho droji of 
blood lies. Contact 
of blood between 
upper and lower 
slides is made by 

rai,sing the latter, to fall back on the stage 

Tho Upper* slide is now passed over tho lower, tho 

T t Mood following and leaving a very thin 

f behind tiio timo taken to traverse the slido bping 

nt tl rtv seconds. Tho margins of such a film consist 
about Unity 

mostly or r ^ platelets aro deposited, 

numerous bl<^ocl ^ ^ 

“So^bSti t of the cLtral zone, duo to tho baso- 
eMmeut of tho blood, can bo seen by the naked eye; 
pliil ‘’I®"*?'"® ,fnined pink. Under tho mieroscopo the 
mous white blood cells and blood platelets in tho central 
•^mJ^liatelv arrest attention, and in some spwimcns 
wdllo fiehls whoro not a single red blood cell is o 
tbero ^bor of white blood cells in a given fie U 

,,a,..es I have counted over sixty, 

coranionly obsen , ^ rapidly made, but. since occa- 

■^^luTthrwbito blood cells 'in a field are very nurneroiis 
An is likely to arise at first m counting; after . 
rifi nract CO lai® can be dealt with, or tho 

httlo piactic e using a higher magnification. 

aI" AZ 3X «£ 1 ” 

at the margins. , . for the various white cells to occur 

. for example, numbers of polymorpbonuclears aro 

in groups for - kinds of ccUs._ 

found <-ogetber, and so ^ invariably 

3. In comparing polymorpbonuclears am 



iS. 


(i; eMEMOEANDA. ; ■■' ■■• 


f TnzDnmsH 
irETDICAL Jovr.XJLl. 


307 


•an^l inanv more such -masses must he earned o the end o£ flic 
film in preparation. Ruptured eosinophd eells also .are some- 
times seen, and are very obvions, provided that the granules of 
tlie cells have not been scattered too far apart. It appears that 
the eosinophil is very easily ruptured, and the polymorpho- 
nucle.ar comes nevl in this respect. In .a drop .smear evidence 
of ruptured cells is seldom observed, and, considering that the 
' fdm is made l)v passing a drop of idood over the slide, it is 
not likely that colls will suffer mechanical injury 
' 5. In drop smears the cells of the central 7one are ■vv^ll 
separated one from anotlicr, they suffer little if any distoilion, 
and they take the stain well. Pod blood cells can be studied at 
the margins of the film, hut it is in conditions whore infurma- 
tion regarding tlic white hlood cells is required that the aliove 
method would appear most useful. 


Tho question of the comparative accuracy of olifferential 
counts in tho two methods is nitlior coiiijilicated. For 
instance, in comparing counts of 100 cells from a blood 
iilm made in tlie ordinary way it is not uncommon to find 
a difference of 10 per cent, in the polymorphonucloars, and 
tho final result after counting 300 or 500 can only bo an 
appioximation. For the present .1 am not proiiared to 
make any statement regarding tho comparativo accuracy of 
the two methods. 


Tho following advantages of examination of pathological 
fluids hy the drop smear method arc worth noting : the 
films are thin and evenly spread; tlie results arc far hotter 
than those obtained b}’ using tlio end of a slide or the 
iflatinum loop; the cells suffer no damage; casts are often 
spread out in a beautiful fashion, and, owing to tho thin- 
ness of tho film, micro-orgaiiisins arc readily iccogiiizcd. 
There is no difficultj* in making the films, and 011101*3 may 
be able to devise further useful modifications of the method. 


On admission she complained of intense pain on dcfaecation and 
of pain. in the right biitfock. There was an indurated, red aica 
about li- inches in diameter over xmd just external to ‘the ischio- 
rectal fossa. 

^ On November 11th she was given an anaesthetic and an 
incision was made into tlie inflamed area. About a cupful of 
purulent and necrotic material was evacuated, and then the 
scoop which wa.s being used impinged on something hard and 
sH^hlly mobile. On digital examination this was fell to be a 
spicule of unknown material. A piece about 1 incli long .was 
broken off and turned out to be lead pencil. Slight bleeding 
from file urethra led to investigation there, and on passing a 
finger into tlic bladder — an operation rendered simple bv tlie fact 
that the urethra was dilated so as to admit a finger' easily — it 
was found to hq almost completely filled by a soft, crumbling 
mass of phqsphnlic material. This calculus was broken down, and 
embedded in it was found the remainder of the pencil, wliicli 
had pierced the posterior ^YaU of the bladder just to the right of 
tlio trigone. The pencil was removed, and, with the piece 
removed via the ischiorectal fossa, measured 4^ inches in length. 
The 'bladder and sinus in the buttock were irrigated veiy 
thoroughly with boric lotion, and drainage of the sinus providc'd 
tor. An uninterrupted recovery was made, tho opening in the 
bladder healing up spontaneoiisfy, and the patient was discharged 
on January 1st, 1928. Micturition was normal, and tho urine was 
normal also. 

On being questioned the patient stated that two year.s 
previously she dreamt she was going to have a child, and 
insei'ted the pencil then with the object of preventing this. 

It seems remarkable that the pencil, after penetrating 
the bladder, should reach the ischiorectal fossa witho\it 
doing any damage to the vagina or rectum, alongside both 
of which it lay. 

I qm indebted to Mr. C. J. Pinching, O.B.E., for permission 
to publish this case. 

Hauuy O. Christie, M.B., Ch.B., 

Resident Mwlical Officer, Gravesend and Xorth Kent 
Hospital. 


^cmoraitita : 

MEDIOAIi, SUEGIGAL, OBSTETEIOAL. 

OEDEMA OE THE ITPPEE EYELIDS. 
A^abently trivial symptoms and signs may frequently be 
indication.s of serious disease, and, ronverse'ly, tlie opposite 
occasionally holds good — gi-ave signs and symptoms resulting 
trom comparatively simple conditions. ‘ 

Uedoma of tho upper eyelids is a particularly instructive 
.example of the latter, and requires especial rvariness on 
the part of the practitioner. 

oii^ nr j?,*®'". presenting an alarming oedema of 
are-i ia an eyelids and a raked temperature. The swollen 

is tmSnrirorn'f^'^ suggestivc tliat an exploratory rperation 

is diarnvn.nA" ®“.pP°sed acute frontal sinusitis, hut no disease 
actual can-n nF u the oedema peisists, until the 

of the mfiVnl’n rfin becomes self-evident hy (lie staining 

or abrasinn nn or pillow wliich indicates a septic wound 

days nrnv?n„a?v “S Originally sustained some 

tions D^rodiiri. completely overlooked. Aiitiscptic foraenta- 

failcd to -relieve^ ^ resolution of the oedema, which oper.ation had 

hnv='''"fr cases of this tyiie, botli in voung seliool- 

tlin nth lollowcd the course just depicted, while 

CurinusW ^ resolved after less drastic treatment, 

occinital' ’ oases the wound was found in the 

T ’ of the scalp. 

Sinead ^nf * 1 ^ the upper eyelid is no doubt due to the 

suheutaneoiis fcsue of the *'“1 ••'■'"I’.’';'*"’ “otwork in the 
that in thn Inn. ^ scalp, which is continuous with 

I helifve 'is well The comlition, 

John- Eobeiits, M.B., F.R.C.S. 

O.N ohserWnf f ^faa" THE BLADDER, 

a recent mfmher' of Bm 

p. 11401 I thmirrWi^ Journal (Decemher 17th, 1927, 
inight be worth r^rdilig somewhat similar case 

November gtli, admitted to hospital or 

rwtal abscess diagnosed as a case of ischio- 

about a fortnight nrevimie » medical attoudaut. Foi 

and tenderness in thr* i admission she had had pale 
had been treated for nvn * nnttqck. For about six months she 
the exhibih'on of clearing up or 

was discontinued, Otways recurred when the lioxaminc 


THREE PERFORATIONS OF THE ILEUM CAUSED 
BY FISH-BONES. 

The following is an unusual case of general peritonitis 
resulting from perforations of the ileum due to swallowed 
fish-bones. The patient, being a staunch devotee to 
Christian Science, at first refused admission to hospitfil, 
then relented; she later refused operation, and finally 
consented Only when in extremis. 


During tho ni^ht of April 6th-7th, 1927, an unmarried domestic 
servant, aged 49, was admitted to hospital with a history of 
sudden onset of severe abdominal pain, stabbing in character, on 
April 3i*d, necessitating confinement to bed. There W'as somo 
relief the next day, when she vomited two or three times. Tlie 
bowels were quite normal. In the early morning of April 5th the 
pain was miidi worse, but this passed off, and she was able to 
perform her domestic duties. In the evening of this, day a marked 
increase of the abdominal pain compelled her to return to bed. 
She vomited several times during the night, and was unable lo 
retain food or fluids. In spite of all this she did not consult her 
doctor until the evening of April 6th, when ho ad\'ised immediate 
removal to hospital. To this 'she objected, but when he repeated 
the advice three hours later she consented. 

On admission the abdomen was somewhat distended, there was 
generalized rigidity, particularly in the lower abdomen, and a 
diagnosis of general peritonitis was made with no little assurance, 
but the cause remained obscure. Operation was advised but 
refused, and for four horn's tho patient remained adamant, 
consenting to operation about 3 a.m. on April 7tli. 

02 >craiion . — ^The abdomen was opened through a paramedial 
incision. Free brownish, stinking sero-pus was found in the 
abdomen, the intestines being generally distended and inflamed; 
the appendix and pelvic viscera were nonnal. In the coui-se of 
searching tho pelvis for a cause of the peritonitis a sharp point 
was felt in the wall of the ileum; this proved to bo tbc point 
of a fish-bone pi'ojecting from the wall of the gut, around which 
the intestinal contents had escaped. The hone was removed and 
the perforation sutured. The whole of the gut was then carefully 
examined and two other similar points were found; tlic bones 
were taken out and the wall was repaired. Pelvic drainage was 
instituted and the abdonion closed. 

The patient’s condition was extremely poor at the end of opera- 
tion, but couvalescence proceeded without hindrance to complete 
recovery. 


Questioned as to tlio mode of introduction of these bone«. 
ho patient admitted having hiu'riodly taken a large meal 
f brill on the night of April 1st, and that she had had 
lifficultv M'ith the large coai*sc bones. These have been 
xaniined by Mr. Henry Crou-ther, curator of tho Leeds 
)ity Musonm, who states that the specimens arc probably 
►rill bones, and draws attention to certain characteristics — 
laiuely, the fluting, the elasticity, the hollowness, and 
inalh*, the vei\v sharp point. 






•\r n n\, vr i? i? n c 


Leeds Geneial Infirmary. 



308 Feb. 25, 1928] 


YESlCO-VAGINAIi FlSyULAE. 


SUPEllNUMEBAIlY THUMBS. 

A CASE of bilateral polydactylisni has recently como ■under 
my care, and may bo of sonio general interest. 

The patient is a woman, aged 25, under treatment for bronchitis. 
The deformity consists ot supernumerary thumbs. Tl»o thumb of 
the riglit hand lias two almost parallel proximal phalanges, and 
is nearly twice as thick as the normal from the head of Iho 
carpal to tho inlcrphalangcal joint, which is greatly enlarged; 
hero the thumb is cloven into two perfectly formed terminals, 
inclining at an angle to each other in a forcepsdike fashion. The 
left thumb had also a completely formed but ratlicr small extra 
top, proiecting at a right angle from tho lateral aspect of tho 
interpbalangeal joint. As this had no communication with tho 
joint cavity, and as it seemed to bo a nuisance, I removed it, 
under local anaesthesia, by tlin simple expedient of transfixing it 
through its base, tying a double ligature and cutting away the 
redundant part. Both thumbs function to the full extent, and the 
left one has now a normal appearance. Tlio closest inquiry into 
the family history reveals notliing abnormal on oilbor side, and 
the woman is herself the mother of three normal children. 

Tho evident lack of hercditaiy infliionco and tlio bilatcr.al, 
and almost symmetrical, nature of the deformity make tlio 
case somewhat remarkable. 

Leeds. H. MiTcilELL, M.B., B.Cll.Dub. 


Krpnrts d ^adrtirs. 

YESICO-VAGINAL FISTULAE. 

At 3 meeting of tho Section of Ohstetiics of iho Hoynl 
Academy of Medicine in Irel.-ind, held in the Ko 3 -al CoIIcgo 
of Plij’sicians on February 3rd, tho president, JL)r. Gibbon 
FitzGibbon, read a note on two eases of twisted broad 
ligament with cyst, and showed specimens. Tho interest in 
tho specimens was that both showed necrosis from strangula- 
tion. Both patients had a period of symptoms pointing to 
an “ acuto abdomen,” but these tended to .subside, and 
the condition might have been overlooked in tho first case, 
except that the patient complained of pelvic pressure, 
which it was thought might bo duo to prolajise. In tho 
second ease a history of an acuto attack suggestive of acuto 
abdomen two years before tho present attack was obtained. 
The symptoms, however, subsided, and from tho nature of 
tho adhesions and tlie condition of tho pedicle of tho tumour 
it seemed likely that the a'ttack was duo to twisting of 
the pedicle, while the present attack was most probably 
due to some intermittent and partial intestinal obstruction 
caused by adhesions. Tho president then showed a third 
specimen of an ovarian cyst witii -a twisted pedicle. This 
patient was operated on soon after tho torsion had 
occurred, and while the symptoms wore still acuto; she 
showed haemorrhage infarction, and it was doubtful 
whethev the symptoms would have subsided without opera- 
tion. 

Dr. L. D. Cassidy read a paper on resico-vaginal 
fistulao occurring during labour. Ho said that injuries 
to the urinary tract during labour might bo due either 
to wounds caused by instrumental delivery or to trophic 
disturbances, the result ot prolonged l.abonr. Tho n.atnro 
and extent of the injuries duo to tlic latter cause depended 
upon the amount of pressure and the length of the labour 
resulting in (1) ischuria puerperalis, with puerperal cystitis 
if infection follows ; (2) pressure necrosis ; (3) vesico- 
vaginal fistula, following necrosis. Tho last-named condi- 
tion was more likely to arise in the case of flat pelvis than 
in a generally contracted one, where tho pressure was 
more evenly distributed. He mentioned tho suggestion 
put forward by Fritsch that the frequency with which 
vesico-vaginal fistulae occurred amongst Polish Jews was 
due to the early age at which they married, the immature 
pelvis causing such compression and over-stretching of the 
soft parts that fistulae -followed. ‘Where injuries to tho 
bladder resulted from interference with delivery their 
more common causes were false indications for interfer- 
ence, deficient technique, or both combined. The lesion 
most commonly arose after forceps delivery, especially 
high forceps, and sometimes after perforation. Brow 
presentations, delivered as such, might also cause severe 
bladder injuries. Ureteric fistulae sometimes arose. -Accord- 
ing to Butnm there were thirty-one such cases, eighteen j 


folloiving difTicuIt forceps delivery. Ho attributed sucK 
traiimat.'i to tlio inclusion of a portion of tho cervix iu tlia 
hhido of tho forceps. Continuing, Dr. Cassidy said that 
delivery of an impacted breech by a blunt hook, wliore the 
point of tho hook had been insulficiently guarded, was 
another sottveo of injury. Tho operations of symphysio- 
tomy .and piibiotomy had been known to cause fistuJae, .and 
Sigault’s operation had been abandoned on this account. 
Its modifications by Moris.ani and Zweifel lessened this 
danger. Buinm and Doederlcin each advocated an 
operation for iho closure of such fistulae, but the 
operation of lower uterine segment Caesarean section 
would probably take tho place of tho methods which 
necessitated .splitting of tho pelvic bones. Intraperi- 
tonoal lesions of tho bladder should not ariso during the 
course of gynaecological operations. During vaginal 
Caesarean section tho bladder should ho carefully kept out 
of tho way by mc.nns of an anterior speculum during 
division of tho cervix. Difficulty was sometimes encoun- 
tered in the recognition of fistulao, both by tho patient 
and by the obstetrician. Should such doubt ariso careful 
iiioasuromcnt of tho amount of urine passed in the twenty- 
four hours should bo made, and catheterisation or even 


cystoscopic oxainiiiation carried out if doubt still exist. 

Ill regard to treatmont Dr. Cassidy held that the most 
important point was that no attempt should bo made to 
repair tlio fistul.a until three months had elapsed since 
tho birth of tho child, on tho grounds that safe union 
would not take place, and that spontaneous healing, {hough 
rare, might occur. This was favoured by a normal piier- 
pcriiim. Should there be signs of spontaneous healing a 
retention catheter should bo used. Three important prin- 
ciples wore to bo borno in mind in connexion with tho 
repair of vcsico-vaginal fistulao: (1) Great care must ba 
taken that no trauma of the bladder was occasioned during 
previous cystoscopic examination. (2) There must be 
thorougli exposure of tlio parts and complete separation of 
tlio bladder wall from tho vaginal mucous membrane, so 
that the edges might bo brought together without tension 
nnd tied loosolv. (3) -^ retention catheter should bo left 
i.rLr seviHa^s. Dr. C.assidy cpncUided by bringing to the 
notice of the Section n series of ten oases which had been 
tro-itod in tho Coombo Hospital since 1922, and in which 
tho above principles were observed. In nine of these cases 
iho patients were completely cured; one was considerably 
immoved nnd could retain urine for three hours, but there 
ras still slight leakage. Nine of the women were delivered 
previously by forceps. One fistula followed upon amputa- 

***Tlio^ Pbesident remarked that in some of these cases 
the o wa rsiderablo loss of tissue in the process of 
s oi ghing, and there was practically no cervix left Ho 
t S t th.at tbo question of closing vesico;vaginal fistulao 

* 1 ^ .Ic, .ended on tho amount, of cicatrization, and in 
if ^ ^ nhio to hold tho bladder wall together. If this could 
B^d^no L cSusually healed up very well. Dr. Cassidy 

1 ^ f cred to fistulao occurring following pubiotomy ; he 
Seal? did not think that this often happened. 
wi"i ^ ho wa? Master of the Eotunda he had seen only 
AVhilo J*® had he ever had any bother 

”"tVwlddGr - fistulae. After confinement a patient often 
” ff' d from loss of control for some time, but he thought 
•rttter neavo time-even as long as tlireo months-for 

* Winn to occur before operating. It was important 
‘"‘Tfn odSo in a hurry. Mobility of tho bladder seemed 
+ -di the essential point in closing bladder fistuffie. 

to him the e ^ Suggested that with large fistulao it 

fi ?;rv ffifficult to get tho amount of separation 
tom-der to bring lie bladder wall together. ■ He 
necessaiy in « jarge fistulae, but m some cases 

^'f*^ Ltulao he had had difficulty in getting an absolute 
of .small fistu bladder; when the catheter was taken out 
c osure of ^ operation had to bo 

there was » hMore this cleared up. Ho had 

performed oier ^ operation in three cases, 

recently „,?yccesSully closed straight away. Ha 

and tho operations, such as’^flap splitting, 

hut y^.Ts opinion tt essLtial part of the operation was 
s"paratffi^ of the bladder from the anterior vaginal waU 
for a cocsiderablo area all round. 


-■ 'tztJibbnr, : ' ihnt I , ^ P 

it 

°s^thcr the b/n M ® ”"'«rf the'*' ”'°''W bp °^*‘“''''<>oii ,,.‘'® 


F-'nt'ivol-l !°”°"'- neecnt,'?' ‘■;,r’’'"‘' oi, 

"’®'0 So P„ , F\y,r,^ ’■«ICo v., '?, S'Ont 

°f<«t.0„^“'’/' »'••«? «,ov ‘'-.-.f f),'"'' ''*"*> 

''«<> teefV'"'^ ^■'■^■o, t '',••■ m,,4 •“•'■ «.e 

tt'";'' ^ia/f " ’•■''' t'Vi b '"ar/o 0 • 

Si5;fs^g;S€!s 



--^om,7p. to b— 'ires ft. 

.^‘JiQlCAL TPpa ' ° 

'‘^"uVa ^ ^'*0 ooiufLr ■ ‘"’ton T 'tirert,' 

Xr;;»» fe «;■. Kr¥“- .r 

Pat/o„(s M.ff "■«''■•■>? treo'r 't'’crftpl;,.-'^{onsnrint^ ®%tjtcon 

•■'t'soe.sses /'""‘erf tiejrf th[t n-n” 

f ’'>‘tis l,p°°I>^»ing ‘ jt'o aurg/e". fgard f'® 

n ”t>erot/o,r';“*|®- Rosoctio^<^^^ 

.V bufr tbe 


"O jJossfbJp .'^ oj,erot;„ ‘'’"osis. r„ ‘''‘"'tinen? p"*''9iier 

•i.!,':," s «“*<.»v“s ~>,S” "'gi*;; • " 

" '■'^t’onte;; ;; 0 sbo„" 




"bleb inf ii'it^ '^’‘°"Sl‘ fl/'. “t' Wore • 

°‘'too„,e or/-^''" ^°»ti-ihur^ 

; ««rfer „pi*. P'oofte," ^"’Boon F '""f on tloltf Vf^Ky 

£'! &'•• ^rxirr! ts ao ^ ‘‘^'Poj.ipapp ' to „,,! .V'tyecfs 

rf -"^o of ® «'0 Renl Fn. Benero, '°/:"»o 

^£^“!FsS'SFF 'SF 



310 Feb. as, 1928] 


KEVIKWS. . 



its ai'rival at the 3Ia3’o Hospital in America to its final 
disohargo “cured,!’ is most vivid and convincing, but tlio 
reader is impressed with tho magnitude of tho problem 
which faces those who would try to make such a system 
uni^^ersal. Still, as an advance towards tho ideal of 
surgical treatment the work of tho Mayos may well bo 
set before us as an inspiration to further effort. 

The Dublin school has always been well to tho front in 
tho treatment of fractures, and has contributed largely in 
the past to our knowledge of these injuries. Sir AVilliam 
AVhooler is a worthy representative of that school, and ho 
has well maintained its reputation in tho four lectures 
delivered two or three j'oars ago in London at St. Bartho- 
lomew’s Hospital on fractures of tho lower extremity. 
These remind us of tho great change which has come over 
our knowledge and our treatment of fractures of tho pelvis, 
and of tho important share which radiography has in that 
treatment, as in tho cure of fractures in general ; tho 
section on tho treatment of complications, such ns injuries 
of the bladder and urethra, is particularly valuable. 
His remarks on tho extension treatment of fractured femur 
are full of practical value. “ Mal-union and non-union aro 
duo probably in 80 per cent, of cases to maltreatment. 
They are a reproach to surgorj’, and can always bo avoided.” 
In these words tho author boldly throws down tho glovo 
and challenges those apologists who appeal to constitutional 
peculiarities or the intor])osition of soft parts as excuses. 
Ho follows Sir Robert Jones in discriminating between 
absolute non-union and delayed union, and in reserving 
operative inteiwention for the former condition only, after 
Thomas’s “ hanmiering and damming” method has -had 
a proper trial. The comments on tho treatment of frac- 
tured patella, of Pott’s fracture, and those of tho tarsus 
are all, full of practical good sense. 

The short paper on “ slcevo ” amputations and that on 
tho treatment of Pott’s disease are useful reminders of 
known methods. The same may be said of other articles 
in the volume. Tho work of American surgeons, and espe- 
cially of the Boston school, has lately drawn attention to 
tho sacro-iliac joint and its disorders, and it is interesting 
to read the opinions of a European author, who has 
recently surveyed American sux'gical practice, on this 
subject. Disease of this joint is, in Sir William Wheeler’s 
opinion, far commoner than has been believed, and its 
early sjmrptoms and signs can bo, and ought to be, recog- 
nized more often than has been tho case. Ho describes and 
freely illustrates tho operation for laying open and draining 
this joint, which ho has found practical. His fourteen 
points about bone grafts are of groat value and should 
be noted by any sui-geon who is thinking of perfonning 
a grafting operation anil wishes to avoid disappointment. 

In fine, there is vei-y much in this book of great value 
and nothing that is not worth reading and marking. 


instance,^ find a single reference to the literature of 
diplitheritio paralysis, only one in tho few. pages dealing 
ttitli Vincent’s angina, and only two on the section on 
nephritis, which date from 1S89 and 1894 respectively, 
while fii’st-hand references to Continental literature aio 
particularlj' scanty. 

A drawback to tho publication is its high price, which 
is partly duo to tho largo number of illustrations, some 
of wJiich, as wo remarked in our review of tho second 
edition (JounNAt, 1908, ii, 1813j, might well'li.ave been 
omitted, especially tlioso on scarlet fever, rubella, and tho 
early stages of small-pox. The work, however, will ho 
welcomed alike by epidemiologists and clinicians who desiro 
authoritative information on tho subject of infectious 
diseases. 

PHYSICAL DIAGNOSIS. 

Books on physical diagnosis do not always make attractive 
reading, but tlio appearance of a ninth edition of Profe.ssor 
R. C. Cadot’s Physical Diagnosis,^ first published in 1905, 
shows that an account of wliat an experienced physician 
has found useful is more popular with tlio rank and fAe 
of tho profession for eveiyday practice than a treatise 
containing all tJio described tests available for pathological 
investigation in tho clinical laboratoiy, valuable as sneb a 
work may bo for reference. Copiously illustrated as a book 
of this kind should bo, attention may be specially directed 
to tho admirable series of changes in tho hands in various 
diseases, and to the photograph of twelve students listening 
at once to a chest by means of Bowles's multiple stetho- 
scope, the limitations of which are pointed out. The text 
gains interest from references to the author’s long clinical 
experience and to statistics of the incidence of various 
visceral diseases at the Jlassachiisetts General Hospital; 
thus bo frankly mentions that in two cases with well- 
marked Corrigan’s pulse in life he “ was confronted post 
moriem with a narrowed, rigid aortic valve.” Dogmatism 
is useful for the student, and may be welcomed hy some 
of more advanced age; writing on the supposed effects of 
tobacco on tho heart, he quite definitely lays it down that 
there is not any cardiac abnormality or group of abnor- 
malities that can bo referred to tho effects of tobacco alone, 
fnr almost always some other factor can be discovered in 
£ baeground.^ The sections on the blood, tuberculosis 
and the cardio-vasoular system have undergone a good deal 
of revision, and tl.e aiitlior’s preface mentions particularly 
+L addition of reference numbers corresponding to tho 
Gambie-Cabot diagnosis records, a set of phonograpbio 
reXds taken in 1926 to illustrate the normal and ahiiormal 

^‘^This^^eMon then, fully maintains the reputation of 
•Profossor Cabot as a clear, interesting, and honest-minded 
teTcber of students, whether young or qualified. 


INFECTIOUS DISEASES. 

Dn. E. IV. GoonALi., who recently retired from tho 
fever service of the Metropolitan Asylums Board, has 
employed his leisure in bringing out a third edition, under 
a somewhat different title, of tho work on Infectious 
Diseases,- originally undertaken in collaboration with tho 
late Dr. Washboukn. The considerable additions to our 
knowledge in the nineteen years which have elapsed since 
the appearance of the second edition have called for a very 
complete revision' and enlargement of tho work. The prin- 
cipal changes have been the addition of an introductory 
chapter on epidemiology and two new ones dealing respec- 
tively with epidemic encephalitis (including epidemic 
hiccup) and epidemic poliomyelitis, and the omission of tho 
chapter on plague. , , , , . , , 

The hook is well up to date and is or value, not only 
as representing the long and extensive e.xperience of an 
acute observer, but also the work of one who is more 
familiar with tlie literature of the subject than the biblio- 
graphical references would suggest. Wo do not, for 

Text-ioati of Infectious Diseases. Being the third edition of 
Goociou and Washbourn’s Slanual of Infectious Diseases. Revised and 
SnAY’*’’ rewritten by E. W. Goodall, O.B.B., M.D., B.S.Lond. 

15 S; pewla and Co., Ltd. 1S28. (Demy 8vo, pp. 3cvi + 718 ; 

rnsrams. M charta, 26 plates. 30s. net.) 


MILITARY PSYCHOLOGY.’ 

Mn F C Bartlett, who is reader in experimental psyclio- 
Wv and' director of the psychological laboratory m tbo 
University of Cambridge, has written a book on Psychology 
^ a She Soldier* which consists of selections from lectuies 
cd in coAn^xion with a conrso of mditary studies 
for officers. Ho quite rightly points out that a psycho- 
ior omce i of the i-ecruit is just as essential as 

ohvsioloEical or “medical” examination. Tins was 
^Sdautlv evident in the late war, where the failure 
r'take into account the intelleetual status of the soldier 
I 1 in^nritable consequences. It was surprising, moreovei, 
simple psychiatric examinations were instituted 
^TTiprican recruiting camps, to discover how considcr- 
'w*w-^^ho moportion of recruits who were mentally unfit 
?n. mditarv servffie. Useful as these tests as to. mental 
fo2 m y i,f,,yever, a largo number of recruits uho 
exam nation n them broke down before reaching 

passed the examinat.^^ been well termed “ anticipation 
neuroses.” Most of these were temperamentally unfit to 

S physical Tmdali a’nf Co:?‘" 9V‘'(Be3.* 

8TO,‘“pp.*:Jk> + 5^1"6' plates, K9 figops. 2^^ neU ^ London: Cam- 

(Ow SvV -pp. viil -t 224. 7s. 6d. act.) 



THE OXFOHD' EHGI.TSH DICTIONiLUT. 


r Tnt Brttiss 

Jlr.DTCXl. JnRBVit, 


311 


Feb. 25 , igJ*! 


react to tlie armv situation, and, as Sir. Bartlett observes, 
tlicro is no testV which tho defect of tomporamont c.an 
bo discovered. As bo well puts it, “ By intelligcnco tests 
a man mav be safely ruled out, but by intelligence tests 
alone a man cannot safely be ruled in." It .should bo said 
in this connexion that, in tho experience of tho reviewer, 
nearly all tho men breaking dmyn in tlie manner here 
described had been more or less inadeejuate in civil life j 
but this fact could only bo elicited by full investigation 
of the social history. 

In the development of his themo tho author makes it 
clear that psychology nmy give valuable guidanco in deter- 
mining who is and who is not fit or adapted for tho military 
life, in deciding what tho fit person can justly be expected 
to do well, in training body and mind, in detecting and 
guarding against undue fatigue, and in taking precautions 
against nervous and mental disorders. Mr. Bartlett con- 
siders that training in psychology should bo made part of 
liny general scheme of preparation for a military career. 
He suggests that whether for war or for peace-time 
organiaation tho psychologist who works in tho academic 
laboratory should be asked to train tho officer in methods 
and theory, and tho officer having tho necessary inside 
practical knowledge should then applj’ tho methods and 
theories to his practical problems. This readable book 
affords an interesting instance of tho value of vocational 
psychology as applied to a particular form of employment. 
It is not written for tho medical practitioner, but we can 
recommend it to tho officers of tho army and naval medical 
services, to whom a knowledge of psychology cannot fail to 
bo of considerable servico. 


NOTES ON BOOKS. 

Mr. Sxdxet Spokss’s^ biography of Gideon Algernon MantelP 
contains a syrapathotio account of this pioneer of British 
geology, who started his professional life as a country doctor 
at Lewes, where he w.as bom in 1790. While carrying on an 
extensive practice in this town and the neighbouring country ha 
lound time for cpoclnm,aking geological work, Kls first impor- 
ci" TAc Fossils of the South Downs. 

hiortly afterwards appeared in tho Philosophical Transactions 
e account of the discovery of the iguanodon, in recognition 
of which he was elected F.R.S. at the early ago of S5, when 

by John Aberne%, his 
teacher at St. Bartholomew’s Hospital, and William 
mnv.a ? u ^ 1 ?/ Hunterian Museum. In 1835 Mantell 
"b^ro he continued his practice in com- 
° .W . ,b'® geological researches, and established a 
where hn°fn,f *breo years' stay in that town, 

he profession far from sympathetic, 

next Hlapham Common, where ho remained for tho 

anil wni a “ mnch more congenial atmosphere, 

Athenaenm and highly appreciated lecturer at tho local 

in pTmifee ■ ■■fT»'n>ng eight years of his life were spent 
scientifir wnrl- a occupied by his practice, his 

■ and DaKsnr,! ™‘'‘'“I®ndence with contemporary geologists 
Im Jan Lyell, WrSifon, "and 

- and hemiV ei-„" i b'® professional life was a constant 

tic-donlonrei« anVa^sninal >’* health, including 

been of ths not"'* complaint which appears to have 

b/>rlras?fXlr‘? -.The work is illustrated 

a pliotograph df\is- srij*' perioyls of his career and 

of the Hoyal CoUege;Pf'’|u;g^;* '** 

College, i mu'st^Wo**J**°j’®,P’'of®®®br of psychology in Smith 
compilation of 1 Jwork^enrt? .’““oh time and trouble in the 
logg and llental Hypic"^ " If ’> Abno^al Psycho- 
stndent of nsveholom-— .1. .-too book is intended for the 
As Professor JosenlPr, ",*bcc than for tho psychiatric student, 
a knowledge of tL leiR-'’"' ff^tes in an introductory chapter, 
psychology forms an info "*f ®“d principles of abnormal 

It bas afltal messaw ahf k ‘be psychologist’s training. 

hiimanitari,an, now ronvem-enHv ^'**' ‘be practical-minded 
m whoso field devotion 7nn ^ known as a social worker," 
of authentic information “‘-S.b purpose require the support 
of admirably selected evtr ‘"^'Sht-. The book consists 

ps.vcho-pathologists and n ^ 1 *'°'" ‘be waitings of well-known 
■ gis is and j ^-chologists. It includes a lengthy 


By'*sXey SmS’ F.It.C.S., F.Tt.S.: Surpeon o; 

London : John Bale, Sons, oi 
in H&nopmal 263; illustrated. 123. 6d. ne 

London and H.V';irnc. Edited 

“' 0 , pp. xvu + 783. 16s, net) ^ -APPleton and Co. 1927. (Der 


bibliography.^ It will be useful as a book of reference for those 
for whom it is intended. It is scarcely suitable for consecutive 
includes more than the average student of 
psychology could be reasonably expected to assimilate. 

_ The Creator Spirit; A Survep of Chrisficin Doctrine in the 
of Biologij, Psychology^ and il/yseicism^ is the text of 
Canon 0. E. Raven's Hulsean Lectures at Cambridge (1926-27) 
and the Noble Lectures at Harvard (1926). It contains an 
appendix on “ Biochemistry and mental phenomena *' by Dr. 
Joseph .NEEDHAit, Fellow of Gonville and Cains College, Cam* 
bridge, who, after discussing the question whether any real 
relations between mental and physico-chemical phenomena are 
possible, and whether any are known or not, concludes that, 
though in the future an ever-increasing number of mental 
phenomena will receive satisfactory treatment in physico-chemical 
terms, there is nothing at all in this for the philosopher or the 
theologian to regret. In his eight lectures, the first four being 
based on his Hulsean and the remaining four on his Noble 
Lectures, Canon Raven treats the old problem of the conflict 
between science and religion in the light of modern knowledge 
and phases of thought \yith great skill, wide knowledge, and 
sympathy. 


^ The Creator Spirit: A Survey oj Christian Doctrine in the Light of 
Btologi/^ I'sycholoyg, and Mystfeism, By Cliarles E, Raven, D.D. With an 
Appendix on Biochemistry and Mental Phenomena by Joseph Needham, 
M.A., Pb.D. London : Martin Hopkinson and Co., Ltd. 19^. (Cr. 8vo, 
pp. XT + 310. 8s: 6d. net.) 


THE OXFORD ENGLISH DICTIONARY. 

Op tlio many good things the nineteenth century 
bequeathed to tlie twentieth through its belief in the 
capacity "of individual initiative and enterprise to accom- 
plish big undertakings is tho Oxford English Dictionary. 
Tho first part was published on February 1st, 1884; the 
final sheets were returned for press by Mr. Onions on 
January 5th, 1928, and the last part will he published on 
April i9th. Seventy years ago the Philological Society, 
after considering and rejecting schemes for the production 
of supplements to standard dictionaries, resolved to accept 
the ideal of Trench,' author of the Study of TFords, then 
Dean of Westminster, to prepare and somehow to find 
means to print and publish “ a complotelj' new English 
dictionary.” It was realized that the task would bo very 
big, but no one then had any definite idea of what tho 
cost would be in time and monej’. It proved to he in time 
fifty years of continuous labour by a succession of skilled 
editors, helped by large sub-editorial staffs, and £300,000 
in money. 

From the first it was realized that the kind of complete 
dictionary aimed at could only be produced through the 
co-operation of many voluntaiy contributors, and even in 
1857 Trench had received offers from seventj'-six. When 
the larger scheme was got fully under way the number had 
increased tenfold, and the maximum of over eight hundred, 
reached in 1881, was maintained to the end. They road 
books, copied out passages from them to illustrate 
meanings and shades of meaning,- and verified facts; one 
contributor, Mrs. Moore, who came on an unusual word' 
describing the seeds of a certain plant, procured some of 
the seeds, gummed them on her slip, and pasted trans- 
parent paper over them. Not all the contributors were 
British; there were a few in other European countries, 
and several in the United States. Tlie slips, as prepared, 
were sent to tho scriptorium or dictionary rooms, where 
they were pigeon-holed, with others referring to tho same 
word, ready for tlie editor. Nearly all tho work of editing 
has been done in Oxford. Herbei-t Coleridge, the first 
editor, was of .Balliol, but had barely made a start when 
he died of consumption in 1861. Furnivall, who succeeded 
him, was keenly interested in tho enterprise from tho start, 
and remained a diligent contributor until ho died, at tho 
ago of 85, in 1910. He was a lively writer and an 
exuberant controversialist, who must have been sui-pnscd 
to find himself a lexicographer. He was much concerned 
with the publication of early English texts, and for tins 
purpose founded several societies. His hobhv. if it may ho 
so called, made him a vei-y valuable contributor as long as 
ho lived, and during the eighteen years for which ho was 
editor he not only kept the project alive in its infancy, 
but watched over its adolescence by continuing the 


312 Feb. 25, 1928] 


.INTBRiiTATrONAp; HYGIENE.. 


[ Tjrz Bettiw 
'MeDICII. JOITBJUI. '' 


collection of matori.il (slips) .and org.onizing .siib-cditing. 
Tlje clictioiiai-y readied early jiiaidiood when, in 1878, Dr. 

,T. A. H. Murray, then a master at Sfill Hill School, look 
the matter up, and a year later, acting on behalf of the 
Philological Society, signed an agreeincnt with tho 
Clarendon Press for tho pvdilicatiou of tho dictionary. 
From that time it has been an Oxford enterpri.se, having 
indeed had many connexion.s with that University all 
akmg. Murray began work at Mill Hill, where ho erected 
a fcriptorinm, and was helped by his brother-in-law and 
one assistant. In 1885 he removed to Oxford, and put up - 
another scriptorium in tho garden of his hon.se. There ho 
worked for thirty years, until his death at tho age of 80. 
Ill tho interval he was joined by three other editor.s, who 
took over certain voluines from him; they were Dr. Henry 
Bradley, who was responsible for E, F, G, L, If, and parts 
of S and W (ho died in 1923); Dr. AV. A. Craigie, who 1 
joined tho staff in 1897, and from 1901 until ho went to 
Chicago to ho professor of English in 1925 edited Q, N, 
11, U, y, and parts of S and AV; and Mr. C. T. Onions, 
M.A.Lond., who began to help Drs. Murray and Bradley 
in 1895 and became an independent editor in 1914'. He has 
worked in this capacity ever .since, with the exception of 
two years, when ho was engaged in prodneing the Oxford 
Shnhcspcarc Glossary and editing Shnlrsiicare.'s Englaiu). 
Another valuable by-prodnet of tho great dietionarj- was 
tho Concise Oxford Victioiinnj, a scheme of Fnrnivall’.s, 
carried out later on by H. AA’. and F. G. h'owler; recently 
this was supplemented by tho Foclrt Orford Vietiomry by 
the sanio authors. . ■ .. i 

Tho big Oxford Dictionary is a groat achievement, and 
110 other language posses.ses anything so good.' AA'e do not 
recall oi’er having gone to it witlibnt liiuliiig what wo 
wanted, provided tho word was iii use when tho'voliinio in 
which it would find its proper place was issued. Though 
forty-four years is a short time in tho lifo of a language, 
it is long enough for a good many ‘new words to have' 
come in. Tho Oxford University Press recoguizeis iliis,' 
and aiinonnoes in a special (Febi'uarj') number of its' 
Periodical that a supplement is In' preparation, “ the uiaiii' 
object of which will be to include words” (aeroplane ‘and 
appendieitis are instanced) ” which were born too kite for 
inclusion.”^ It is added, with fine liberallt 3 -, that “ copie's 
of the supplement will be offered fre'o to 'all holders of 
the complete dictionaiy.” ' . 

.Apaz’t from its completenc.ss, duo to tho inclusion of all' 
n'ords in use (not omitting scientific words) and of all' 
words that ever have been used, even though' now ob.solete, 
the feature that gives the Oxford Dictionary its nnifjn'e' 
character is that it is constructed on a historical nlcthod. 
The first use of the word and its meaning at that tiiiie,' 
and subsequent changes in meaning, and expansions andi 
extensions of meaning, are alf indicated and iilu'Str.ated 
tho origin and etymolog)- of tho word also are explained' 
and di.scus.sed, so that the book a's a bdok makes fascinating' 
reading — dangerously fascinating a b'u'sz’ man" ihay soin'c-i 
times find it. As the Periodical notes, a series of articles, 
“ Aledical Tei-ms hi the Hew English Dietionarj- ” (as tho 
book used to be called), was long an established featnro of 
the BaiTiSH Medicai. Jouiixai.. Tliey were written by the 
late Dr. J. A. Ballantj-ne of Edinburgh, who thus enabled 
our readers to keep track of the progress of the dictionary, 
and provided a gauge of its completeness in eveiy direc- 
tion. It may bo too big and too dear (fifty guineas) for 
most private libraries, but no public, university, or collego 
library can afford to be witho.ut it. Its motto might be 

“ Thorough;” 


INTERHATIOHAL HYGIENE. 

The League of Natioxs He.alth Ougaxizatiox. 
AA^HATEATm the progress of the League of Nations in other 
respects its Health Orgauiz.-ition is advancing rapidly, 
and according to the Information Section, may now be 
described as world-wide, ' not only in its membership, but 
in tho range of its sei-vice.s; In addition to the fifty-five 
nations in the League, tho United States and the Union 
of Soviet Socialist Republics hcivo contmuea to tatc part 
in all the principal branches of tho health work, and when 
members and corresponding members of the various com- 


missioits are iiieliidcd it can ho claimed that there is no 
conniiy of importance from tho point of view of public 
health which does not co-operate. Tho information regii- 
larlj- received and di.s.scraiiiatcd hj- tho service of epidemio- 
logical intelligence relates to three-quarters of tho popula- 
tion of the globe. Tho biiroan at Singapore receives 
information from 140 Eastern and Southern ports. It is 
propo.sed to .set nji a snhsidiaiy centre of cpidemiologic.al 
information at Melbourne, and certain preliminary experi- 
nieiits have been made at -Algiers for a similar centre it 
Africa. 


Two geiier.il intcrebanges of public health personnel took 
place last year, one in Great Britain and the other in Germany; 
but only one— in India— is contemplated for this year. The public 
lieallb 'courses organized in Pari,s and London in connexion with 
(be svstem of interchanges are being continued. The Health 
Committee at its recent se.ssion decided to est.ablisli an inter- 
national puhlic liealtli school at Bio de Janeiro, and an inter- 
na'tioiiiil seliool for infant and ciiiid hygiene at Buenos Aire.s. 
Beseareii continued last year, under the League’s encourage- 
ment ill a ntimber of institutes on such subjects as anti- 
dvsenteric and other serums, on tuberculin, and on the diagnosis 
aiid treatment of and immunization against scarlet fever. The 
iiisiiliii stamlard previously adopted has been distributed 
widelv to the appropriate authorities, and a unit of insulin lias 
now 'cverviiliere the. same meaning. Ho difficulty has been 
experienced in producing samples of pituitary extract ot 
uniform strength l>y following the same methods m heir 
m-oduction. Standards for neosalvarsan .and sulfarsenol liaie 
ii.eii menared and samples have been distributed to several 
cViii'iIrms'^for' international -trial ' imd report. The Health Com- 
mittee lias decided to' approach institutes concerned with the 
determination df blood -gronps-in order to the laler- 

*• -f .tlie.-various serums employed and- 

nomenclature. 

v'.^ . poii and vaccination ivas set up by 

A ^ >^^ 25 . and has no>v investigated a 

tbc ' . .s 


il. .'f nvoblems, espedially-^oncerning the preparation and 
Hrilpii; The cancer commission has 
exanmiation ',L^.ti■on^into the differences in the incidence 
completed various countries. It has not 

o.f.ecrtaiii foims of conclusions as regards racial 

ot^ ersidcbtbe term “race” is too league, 
.susceptibility broiight out concerning the efficacy 

but certain facts lia 'PA- ... -gj^tively greater liability to 
Of APPP‘''\’°!’’,’'o,.'b.irren''women and mothers not nursing 

cSncei- of uninarriedo^^ barren,!^ dispatched to 

tlic-ii- h>.!‘ 4uire intb the problems of sleeping sick- 
, in received, and .the- Governments which paiticpa ed 
"''.V'’'biHnl«“ tionrt.sleeping sickness conference m London 
„i the first inlei v-bether thev Avould be prepared to send 

t a 'e:;,:ncl conference, with the object of 
Udmical delegates ^ recommendations. The malaria 

studying "P°”^^bted its second general report, and a 
comm^sion as pieae^ commission is to be held, to which 
special I’lpP tl.- xjnited gtates will be invited, to discuss 

malariologtstsA'om relates to America, 

certain aspects has adopted the report of its opium 

^ describing eucodal and dicodide as | 

cnninussion des«>^ g be controlled by the 

manufactme .and is being communieafed to the Goveni- 

convention, and initiative of the commission, has 

Office Inteniational d-Hygien'e Publ^ue, 
also reported to ^ Health Committee, 

wbicli ads .as ai • ailed esters of morphine, such as 

that dilaud.de and tn jbe convention, 

beiizyl-morphme, sbo l 7 insurance 

A pi-elimin.ary inve S a ioiiit international com- 

in various Eiirope.aii representing both the public health 

mhsibn has fnsurance orgariizatidns, with a view to 

services .and the healt i ^ the , haphazard efforts at 

putting on “ been found in --'...1 insurance 

ni’evention , , 


HnVf* uecll iuuiiw AAA ... — - 

■- fsr as i' has proceeded, and to reduce tlie over- 
inquiry so f--'"' '^b services. An inquiry is also proceeding 

ipping of publw hea r j^atin Americ.a, into 

n certain “"^Aal cLses of stiUbirths and infant deaths 
lie medical and social l—rnsv as to which there aie 

unally, there is tlie question centre in 

roposals for the setting up certain obscure 

IriTzil, particularly for the elucid.alion of certam 

^ueslions concerning' spread and rea m 



Peb. 25, 1928] 


THE PHTSIonOGICATj- SOCIETr,’ 


fr Jgg gg rrr g g QTO 

I LlInucAi. Jorssir. 


THE HISTOET OE THE PHYSIOLOGICAL SOCIETY 
(18T6-192G). 

A Eecord of Fifty Years. 

COMPILED BT 

Sir E. SHARPEY-SCHAFER, P.R.S. 

It is gciicrslly rGCOgnizcd nt. tlio pi oscut time tliut tliG 
British school of physiology occupies u foremost position 
in the biological sciences owing to the outstanding 
character .and varied nature of the notable discovcrie.s that 
have been made by many workers during the last thirty 
years. A very remarkable record of achioveincnt stands to 
the credit of British workers .in many departments of 
physiology', and amongst these may bo mentioned tho great 
advances made in our 
knowledge of the functions 
of the nervous system ; tho 
nature of tho activities of 
ductless glands ; tho physio- 
logy of the circulation, 
both in relation to tho 
central pump and also to 
the part played by tho 
peripheral and caiiillaiy 
circulation ; thophenomcna 
of nutrition, including not 
only tho question of vita- 
mins; but also tho action 
of minute quantities of 
inorganic' salts and the 
action of the sun’s rays; 
and, lastly, fundamental 
researches on muscular 
activity and contractility 
generally, together with 
investigations on the elec- 
trical phenomena accom- 
• panying the activities of 
living matter. 

This great progress 'has 
been _ due not only to 
individual discoveries of 
interest, but has depeudod 
still more on the discoveries 
being of such a character 
as to lead to the enuncia- 
tion of general principles, 
thus tending to remove 
from physiology the re- 
proach sometimes levelled 
at the biologice.1 scicneds, 
that they consist mainly of 
a catalogue of facts' or 
observations. The concep- 
tions we now entertain as 
regards integration in 
system, the 
™.__, correlation of 



Pholograph hi/] [A. Stcan Wateon, Edinburgh. 

Sin EowAnn Sharpev-Sch.uxe, F.K.S., 

Professor of Physiology in the University of Edinburgh. 


chemical 

8tanding''"exampw'’of ™Mns of hormones, uie «uo- 

physiological workers iri^'tl “"‘I® -Vy 

. the last • few years. Such dis- 


are out- 


coveries connote 


record of certain ' '*®‘'** than the mere 

they open up ‘vLa, experimental results, and 

Sir Edward Sln-ir^ev Scl! , promise for the future, 
small part in thl? ^ who has himself played no 

C% years, has coSi^i? physiology during the last 

Physiological Societv-^tl ^ ^ bistory of a society— the 
with this development of ““'Y ^’^''Y closely linked 

but has also exerted a Pysiology in the British Empire, 
wherever it is culti f d ““''““le influence on tliis science 
this society, founded“dnlv 

even wider influence nv 1 ®^*Y years ago, lias had an 

a number of othe ' ' served as the model on which 

been moulded younger societies have 

small influehii nn +1 their turn, have exerted no 

science. ^ progress of biological and medical 

Physiological Society owed its origin not only to the 


awakening, after a long sleep, of physiological studies in 
England, under tho influence of the inspiring teaching of 
AVilliam Sharpey at University College, London, but also, 
and very largely, to the anti-vivisection agitation that 
arose in the early seventies as a sequel to the commencing 
development of physiological investigations at that time. 
In 1875 a Royal Commission was appointed to inquire into 
these matters, and in due course reported, and subse- 
quently an Act of Parliament was passed for the purpose 
of regulating experiments on living animals. In conse- 
quence of tho report of the Roy.al Commission a meeting 
was held at 49, Queen Anne Street on March 31st, 1876, 
at the request of Dr. John Burdon-Sanderson, and was 
attended by nineteen persons interested in physiology, in- 
cluding Sharpoy, Huxley, Michael Foster, George Henry 
Lewes, Francis Galton, G. J. Romanes, Francis Darwin, 

and two who happily are 
still with us, E. A. Schafer 
and David Ferrier. On 
the motion of Dr. Michael 
Foster, seconded by George 
Henry Lewes, it was re- 
solved : 

“ That an association be 
formed, under tlie name 
of the Pliysiological 
Society, for promoting the 
advancement of physiology 
and facilitating the inter- 
course of physiologists.” 

The record of tho work 
of the society during the 
fifty years of its existence, 
as shown by Sir Edward 
Sharpey- Schafer, reveals 
how admirably it has ful- 
filled the objects expressed 
in this resolution. It is 
only necessai-y to allude to 
two facts in proof of 
this. The records of the 
society show that every 
really notable discovery in 
physiology made by workers 
in this counti-y during the 
last fifty years has, in the 
first instance, been brought 
before this society, and 
thus it has undoubtedly 
fulfilled its obligation in . 
promoting the advance- 
ment of physiology. 
Further, the well-known 
spirit of carnarnderic that 
inspires the working 
physiologists of this 
country is proof in itself 
of the good the society 
has done in “ facilitating 
the intercourse of physio- 
logists.” In later years 
this side of the society’s activities was extended, with 
manifest .advantage, far beyond the confines of these 
islands, and international relations were entered into 
and lod to much friendly intercourse between foreign and 
British ph3‘siologists. 

The great success of the society in achieving its aims 
was doubtless due to several causes ; thus many of the 
men who played so large a part in its foundation were 
animated by broad views in biological matters, and were 
concerned in placing physiology on a secure basis as 
an independent science and not merely as a science 
ancillary to medicine. Huxicv, G. H. Lewes, Francis 
Galton, G. J. Romanes, E. Ray Lankester, Tbiscltoii- 
Dyer, are names of men distinguished bj* their work 
for biology, and .all of these took an active pait in 
the foundation and in the early work of the society. In 
Sharpey, Biirdon-Sanderson, and Michael Foster the society 
had the support of tlio three men to whom the develop-, 
mont of pliv-siology in this country, both as regards 
teachino- and" as regards the inspiring of research, was 



314 ITeb. 25, 1928] 


THE PHTSIOLOGICADvSOGrETY. 


r TiTiBRms* 
Mkoical Jera5Ut 


mainly tluo. All tlii-co laid the foimdatioiis of modern 
pliysiology in tills coniitry in 'Dnivei'sitv College, l/ondoii, 
v.hero Sliarpcy was jirofcssor from 1836 until 1874, and 
Biirdon-SiUidorsoii, under Sharjiey’s influenee, liegaiV ox- 
jioiiniontal investigations in 1866 and succeeded Shaiiiey 
in tlio cliair of physiology-, in 1874. Foster, who gave up 
general iiracticc at tho instigatidii of Shar)iey, and hceaii.so, 
as he once told the writer, ho had come to the eoiicliisioii 
that no sane man could make a diagnosis in niediciiie — 
such were tho contradictions of medical teaching in his 
time — hccame the teacher of practical physiology and 
histology in 1867. Subsequently (in 1870) he went to 
Cambridge, and there built up a school of jiliysiology that 
has achieved results of the first importance, and even as 
early as 1876, when tho Physiological Society was founded, 
had already amongst, its workers such men as IV. H. 
Gaskoll and J. N. Langley. 

Although the society was fortunate in having amongst 
its foundei-s men of such ivido outlook, of such outstanding 
intellectual ability, and of such remarkable personality, 
nevertheless this was by no means the oidy factor in 
determining its success. Much of this success is to bo 
attributed to tho rules and remarkable constitution of the 
society. Thus at tho outset the membership was limited, 
and the members -were for the most part active working 
j)hysiologists, but they had tho right to introduce guests. 

It is also interesting to note that the society was 
originally intended to be a dining club, and 0110 rule 
lays down that tho meetings shall commeiico with dinner 
at tho early hour of 6 p.m., later altered to 7. Another 
I'ule of some importance provided that at each meeting 
one member should be elected, on tho motion of the 
secretary, to act as chairman. Hence the .society never 
had an official head or president, and this may have had 
■some influence in making the procoeding.s, oven in later 
yeai's, less formal than is usually the case in .scientific 
societies. It has been the custom to adhere to tho rule 
that all business of a formal nature should he tramsacted at 
the dinner meeting. Tho inaugural meeting, with Dr. 
Michael Foster in the chair, ivas held at the Criterion 
Re.stauraiit on 3Iay 26th, 1876, and twenty-two members 
were present with fourteen guests. Amongst the latter 
were Donders of Utrecht, Marcy and Fran9ois Franck of 
Paris, and Loven of Stockholm, together with’ William 
Bowman, W. B. Carpenter, and William IMarcct. AVilliam 
Sharpey and Charles Darwin were the first two honorai-y 
members of the societ)-, and Francis Galton, George Henry 
Lewe.s, and Francis M, Balfour all attended the first 
meeting. 

In the first few yeai-s of tho life of the society, as is 
seen from Professor Shaiqiey-Schafer’s interesting narra- 
tive, the main business seems to have been to keep a 
watchful eje on the proposed legislation and on tho 
administration of the Act regulating experimental work 
on living animals. Further, the society gave advice with 
regard to the allocation of the Government grants admini.s- 
tered by the Royal Society for tho furtherance of physio- 
logical research. In the records of these awards, preseiwed 
in the minutes of the society, it is interesting to see the 
recommendations as to grants that have enabled workers 
to carry through successfully researches that have become 
famous with the lapse of time. Thus in 1876 there is tho 
record of a recommendation of a grant to Mr. G. J. 
Romanes to carry on “ obsem-ations on the locomotor 
system of the medusae,” and another with reference to 
work by Air. Langley on “ The action of the sympathetic 
oil the Eubmaxillary .gland.” 

The international relations of the society were marked 
even in these the earliest days of its life, as is shown not 
only by the number of foreign guests often present at the 
meetings, but also by the minutes of the year 1878, which 
contain the record of a letter of sympathy addressed to the 
Societe de Biologic on the occasion of the death of Claude 
Bernard. -A. resolution was also passed in thi.s year record- 
ing regret at the death of George Henry Lewe.s, one of the 
original members, and one who took A'Ci-y gieat interest 
i.u the dovclopnient of phv.siofogy in this country, anil 
",’|:'’^':_m9niory tho woll-kno’wn' George Henry Lewes student- 


n-as siib-scquentlv founded, 
too years 1879 Vind 188(1 ji" nolu flovi 


1879 'and 1880 a' nciv development took ' in 


place that ultimately led to the full . realization of tlio 
wishes of tho founders as to tho promotion of the advanco- 
meiit of physiology. In 1679 a spe^-ial afternoon meeting 
was lield at lying’s College to hoar an address by Profesor 
Arthur^ Gaingeo on ” Old and ncir exporiments relating 
to fibrin ferments, with a demonstration of the rapid 
coagulating action of.a .solution made bv extracting washed 
blood clots with 8 per cent. A’^aCI solution.” This meeting 
was attended by oiglit members and one visitor. In 1830 
tho scientific mootings of tlio society were definitely 
commenced; the first was hold on December 9tb, 1880', 
in tho physiological laboratory of University College, 
London, under tho chairmanship of Professor Burdon- 
Sandorson. Eiglitcen members and' three visitors were 
pre.scnt, and amongst the visitors was Sydney Ringer, who 
at that limo was actively engaged in his work on tho 
action of inorganic salts on living tissues, especially tho 
heart-, that has made his name famous. He did not 
becoino a member of the society until 1884. From this 
time onward, scientific meetings wei’e held in the aftornoou 
prior to the dinner, at regular intervals, in the lahoratoriea 
of colleges, medical schools, and at the Universities of 
Oxford ami Cambridge. In later years such meetings 
were held further afield — for example, iu Edinburgh and 
at many jirovincial universities — but wherever they were 
held they retained their fundamental and original charac- 
fcristi(», and it is to these, perhaps, rather than to any- 
thing else, that tho society owes its most remarkable success 
in promoting the advance of physiology and thus fulfilling 
the aims, not only of its founders, but also those of all 
active workers in jiliysiology. 

Tho meetings of the Physiological Society have alway8_ 
been remarkable for the interest awakened in those present' 
in the subjects brought forward for their consideration, and 
also for the freedom and candour of all, discussions tliat- 
fook place. The remarkably ” live ” charn?tor of tho, 
meotiiigs was duo to many .causes, but mainly to tho 
following. Practically all members wove actively engaged 
ill prosocntiiig investigations of ono kind or another, and 
the conimnnications mado to tho society were gcnornlly of 
tlie natnro of actual demonstrations of some .experimental 
result recently obtained by the inve.stigator. In fact, one 
of the rules laid down that demonstrations should always 
have priority over oral communications, .and hence the 
incctiiids often consisted only of a series of demonstrations.; 
Tims uhvsiologi.sts had often the opportunity of witnessing 
tho nroercss of researches and not simply listening to tlio 
recital of a piece of finisl.od work. Inasmuch as there was 
no nnhlished record of any discussion that took place, 
criticism was not only often remarkably free and outspoken, 
l.iit ttill iiioro often it was most benehcial, and many 
workoi-s must look hack with plcasnro and thankfulness to 
+1.0 'iwiqt'iiicc often i-eceived from others moic ex- 

uerieiiccd Vho witnessed and criticized tlieir experimental 
results Snell was the friendly feeling amongst the 
menilmrs that no one hesiUted to bring forward striking 
expe tme, ts obtained, it may he at an early period of 
an h vestigatioii and beforo work had .advanced to an 
miL-ient to justify conclusions. Ino claims of 
.-ly «-p!-p either advanced or allowed on the mere basis 
of experimental 'demonstrations, and it is 

t^m..haU.e tlie vahiahln results that were obtained by 
+1'*^ t ft!lv folIowhi*T of such methods. All the members felfc 
tbov werr ln active contact with the most recent 
that tl y J ] Jgo in the making, and this led to an 
for i n siology that has had much. to do with 
enthusiasm 1 ^’,,„Yast fifty years. At a later stage 

in thd’wsSry of the society the rapid progress of 

led to^ tbo- publication by the society - of short 

of its proceedings, and recently the control of 
a jstiacts r/iffsfo/ooy hec'omo pai-t of its iiork, 

Edwird Shai-pcy-Scliafcv, iu his full and interesting 

and in the case of deceased j’,®.® ' 0 p.ay be 

obtaining their iiortraiis. In fact, 



J" TnEEBinsa Ql 
-LMzOICAI. JOCBXll. . 


BEB. SS, GADTQN. LBGIUKE. , Oil, NATURAL .CAPACITY. 


regarded as a biograpliienl , diclionaiy of tlio pliysiologists 
of this coxintry, for tlic last fifty years, aiid must for tliis 
reason have a real permanent value, quite apart from its 
interest in many other respects. 

• The author has dealt with a subject of no little intcrc.st 
in the history of scicnco and of scientific medicine in this 
country, and has shown in an attractive' manner the pi’o- 
found influence that' a xvorking society, founded and con- 
ducted on sound lines, can exert on the advancement of 
, science and the progress of knowledge. 

John Rose Bn.xDFonn, 

JI.D.. F.n.s., 

President of the Hoval College of Pliysicinn* 
of London. 


NATURAL CAPACITY IN THE POPULATION. 
j Galton Lecture by !Mu. C. J. Bonu. 

The Galton Lecture for this year was clclivcrccl at the 
Rembvandt Hotel; South Kensington, before the Eugenics 
SocifU' hy Mr. C. J, Bond, C.M.G., F.R.C.S., of Leicester, 
on ^’ehrtiary 16th. It was preceded b}’ a dinner, which 
was presided over by Major Leonard Darwin, Sc.D. It 
w<Ti well attended, and tlio audience inclnded many ladies. 
AMiong those present were the Bishop of IVincliestor, Lord 
^awsoii of Peiui, the Dean of . St. Paul’s, Dr. Fremantle, 
M.P., Dr. H. H. Dale, Secretaiy* of the Royal Society; 
Sir Artlmr Keith, F.R.S., President of the British Associa- 
tion; Sir Milliam Beveridge, Director of the London School 
of Economics; Dr. C. S. Myers, F.R.S., Director of the 
Iiidiistrial Institute of Psycholog}* ; and the Right Hon. 
AVilliain Graham, The subject of the lecture was “ The 
distribution of uatimil capacity in the population,” and 
the conclusion to which the lecturer led up was that there 
uas a need for a national stocktaking, or a census of the 
people which would reveal the mental qualitio.s. 


Y .. . Knrjal Decline, 

onrU* r part of liis lecture Mr. Bond contended that 

individuals, passed through suc- 
^ gro\yth, maturity, and decline. Tiie life of a 

mini;!: ^ • expression of herediturilv transmitted racial 

from and body. This national life was renewed 

largely on the mental and bodily 
ITnfTo.. citizens in the large middle section of society. 

was a strong and gi-owing 
iTidrifni ^ ^C'vest social, groups — tliose including the 

® ^ individuals of a low mental grade, the 

irihiifo innately criminal classes — to con- 

o,, 1 j-1* ^ proportion to the numbers of the population. 

aiifi iiifli’n \ as in individual, life was abnormal, 

racial Sn wnimencement of racial decline. Although 
docenerate the direct biological effect of breeding from 

socinlncrif-il * ff ***^^*'*°^ stocks, there was also an indirect 
econoniio siMi^ importance. The burden of the 

bv the ii degenerate groups was largely borne 

bandicannPfl above, who were themselves thus 

ihe-Sv nf their own families. If, in addition, 

also deprecuvted hvVr'^V"^’ biu-den w.as 
injury w.^s Mjeted on'u"ntTi^„'''‘‘'' 

gualiUeToI mental and bodily 

inquiries and nffin* People was to be found in the numerous 
inTecrmyLrs ^^i't which had appeared 

an urgent need e\isi;,m"f drawn was that there was 

of the people which would 1 “ stocktaking, or a census 

Tlic fact lliaf quality as well as numbers, 

and moral, would ‘emperamental 

civilization of the fnxnl!„ ' nnport.ance m the 

qualities in the nronn.oT'’- essential to include these 

of neur.al, .as of ^jsveldp.I ^ixoiigh the ultimate nature 
had been ascertained as t was unknown, yet something 

energy operated. Thai^ a - i x;onditions under which neural 
the neur.al or nlivsid ... , wh was transmitted in heredity was 
tion, through which efr degrees of org.aniza- 

hecame manifest. ’ "htch, the psychical phenomena 

The essenU.al'poi'ntf'jn^‘ ^atr and Conception Control. 
different social gronns in ''^Sard to the relative fertility of 
standpoint were • ni Tl t population to-day from the eugenic 
upper levels of 'societv 'and* - was, lowest in .the 

groups in the Jarcc mi'ddir ’P- professional and salaried 
arge middle section of the population, and that 


™se as a descent avas made to the ranks of uiiskiilcd labour. 
(2) This alteration in the previous normal incidence of fertility 
Iiad grown rajiidly in recent years. (3) It was operating on 
a very large scale, and must, if continued, have a very serious 
.influence on the whole population. The practice of contra- 
'ceptioii Avas to-day more prevalent among the educated upper 
.and middlc classes, and less prevalent in the unskilled labour 
groups, Avhile it was practically absent in the loAvest degenerate 
sections of society. Birth control, tlien. as at present prac- 
tised, Avas undoubtedly exercising a dysgenic influence on 
society. The remedy, howeA'er, did not consist in the curtail- 
ment of knowledge, hnt in its spread, on wise lines, to 
•all sections of the population, poor as well as rich. This 
spread of knowledge in regard to birth control must also include 
; instruction in the duty of adequate parentage in the case of 
married pci*sons of sound stock and healthy constitution. 

T/if! Kind of Ctn^its Xceded, 

An inquiry into the distribution of natural capacity in the 
population should be included in the census schedule for 1931 
. by asking questions of genetic or racial importance as to size 
of family, etc., Avhich were in the schedule for 1911, but Avere 
omitted in that of 1921. Certain data of genetic importance 
should also he added in the system of birth certification and 
registration. In addition to such information as could be 
obtained from a census of the Avhole population a more 
inleiisiA'e inquiry might be carried out into certain representa- 
tive samples taken from the children of school age, and from 
industrial Avorkers, Avho might be examined under tlie Insurance 
Act at the time of entrance into industrial life, and periodically 
afterwai*ds. The object of the inquiry must he to reveal 
quality as well as numbers, and to show in what sections of 
the population civic Avas associated Avith racial Avorth. 

Eugenics and Medicine: Civilization of the Future. 

Much advantage to eugenics (Mr. Bond continued) and to 
medical science would accrue if the interest and active co-opera- 
tion of the medical profession could be enlisted in the study of 
genetic problems. Medical men possessed unrivalled oppor- 
tunities for observing and recording the hereditary transmis- 
sion of mental and bodily characters from parents to offspring 
and from generation to generation, but at present this valuable 
knowledge AA*as largely lost to the nation. Medical science 
Avonld also greatly gain by fnrtlier research into the influence 
of the hereditary factor in disease.’ But in order to bring alxmt 
this actiA'e co-operation between medicine, genetics, and eugenics 
a different outlook must first be established towards genetic 
problems in all bodies and institutions concerned with the 
education of medical students. 

It might bo objected that since no one knew what human 
civilization and human life would be like in the future, any 
attempt to produce, along eugenic lines, mental and bodily 
qualities suited to the future onA'iionmental conditions must 
necessarily fail. It might, however, be predicted that human 
CAolution Avoiild proceed along psychical lines, and that the 
human environment of the future would be one in Avhich brains 
counted for more than muscle. In such an environment intel- 
lectual and moi'al qualities, diameter, personality, and capacity 
for citizenship Avould be A^ery important features in the equip- 
ment of the future citizen, and there would be no ixiom, at any 
rate, for mental deficiency. 

Practical Conchtnont, 

If such an inquhy or national stocktaking as was suggested 
should point to, some deterioration in the population, then, 
among the remedial raeasiues, thq first place must be given to 
education. It Avas only by education along biological lines that 
a sound public opinion could be formed concerning eugenic 
problems, or. that a racial conscience could be aroused. Segre- 
gation along biological lines nUist be brought about between 
the fit and the degenerate sections of society. The mentally 
cUfectiA'e gixmps, including the habitual pauper, the inebriate, 

I and the innately criminal class, must be segregated during the 
: reproductiA'e period of life, while in some cases, after careful 
j inquiry, e.xpert advice, and judicial * sanction, sterilization 
I might be necessary. 

I Aliliough man had grown but little in mental stature during 
historic times, there Avere encOui-aging signs for the future. 
The power to control not only the einuronniental conditions in 
the outside Avorld, but also the quantity and eventually the 
quality of human life produced, would enable ciA’ilizcd man to 
change human nature and to raise mental and moral capacity 
to a higher level. But tins artificial selection under human 
control must be of the right kind, and it must be exercised in 
the right avra- — namely, along lines calculated to promote true 
racial *AveIfare. At the present time much legislation and many 
scciologicar methods for improving the conditions of- life were 
not founded on sound biological principles. The aim of the 
eugenist would he to bring about a wider outlook and a sounder 
public opinion concerning racial problems. 



816 Feb. 25, 1928] 


ClilNIOAIi TEAOHINa IN IIEDIOINB; " . [ir^jSu 


Britts!) JHetJtcal journal. 


SATUBDAY, FEBKFAKY 25TH, 1928. 

• 

CLINICAL TEACHING IN MEDICINE. 
iTnE eighth series of Methods and Problems of Medical 
Education,^ brought out at intervals since the autumn 
pf 1924 by the Division of Medical Education of the 
Dochefeller Foundation, is a mine of information on 
the methods of teaching and equipment of medical 
students in various centres in parts of the world ns 
far asunder as Pekin and Paris. Attention may well 
be drawn to some of the information given in the 
eleven articles on the teaching of medicine and the 
lessons to be learnt from them, leaving those on 
surgery, gynaecology, and pediatrics, and the consider- 
able series on cardiological clinics, for later study. 

The first two articles, by Professor A. Chauffard 
and Sir Archibald Garrod, are of the nature of general 
surveys of the teaching of clinical medicine in France 
and in England, and necessarily touch on the 
historical aspect of clinical teaching in order to show 
how the present plan has been evolved. In France 
the oldest medical faculty is that of Montpellier, where 
from the thirteenth century students followed the 
practice of medical men, though it was not until the 
fifteenth century that it became a university. In Paris 
chairs in clinical medicine were not instituted until 
the end of the eighteenth century, Corvisart giving his 
first clinical lecture at the Charity on May 20th, 1799. 
Professor Chauffard points out that medical students, 
while spending the first two years in woi’king at 
anatomy and physiology, attend the hospitals in order 
that familiarity vdth the symptoms of disease and 
their education as medical men should begin as early 
as possible. Dui’ing the first year they all follow 
the clinical professors’ visits, but in the subsequent 
years they have the advantage of being taught in small 
groups by the “ professeurs agiAg^s ” and the hospital 
physicians, thus, to some extent, resembling the British 
routine. Sir Archibald Garrod outlines the history and 
evolution of clinical teaching in this country from 
the sixteenth century until the establishment of the 
professorial units in 1919. He describes the advantages 
and possible drawbacks of these units with complete 
detachment, as the first dn-ector of the professoria.1 
unit at.St. Bartholomew’s, impartially indicating what 
the students gain from being taught by the ordinary 
physicians, with their various interests and experience. 
He reminds us that the clinical clerks and dressers of 
to dayare the direct successors of the apprentices and 
pupils of the past. Turning to a rather different aspect 
of the . subject, he recalls that the medical schools of 
the new universities have grown out of pre-existing 
medical schools, so that the universities have not had 
the opportunity of establishing and organizing medical 
schools from the start with a new hospital un- 
trammelled by ancient custom and vested interests; 
tbe reverse is very frequently the case in the United 
States. 

It is interesting to contr ast the English and foreign 

onrf Problems of Medical Education. (Eighth series.) 
IS**?' Medical Education, the Rockefeller Foundation, New York. 

PP. 372; illustrated.) 


medical schools as regards the clinical years when' 
students come into intimate contact with patients by 
holding clinical clerkships. In their account of the 
arrangements at the Second (Cornell) Medical Division 
of the Bellevue Hospital, New York, Drs. Eugene F. 
Du Bois and P. Beznikoff state that in American 
medical schools the clerkships are usually reserved 
for the final year, by which time the student has 
almost completed his period of systematic training and 
is about to become his own instructor. Professors 
Henry Christian, J. H. Means, and F. W. Peabody, 
describing the teaching at Harvard, say that after 
one and a half academic years of instruction, intended 
to give the student a knowledge of clinical medicine 
and a drilling in the methods used in its practice, as 
well as information about the more important data of 
medical diseases, the final year sees a complete change 
in the routine; the student is then put in full contact 
with the patients, and applies the methods he has 
previously learnt to the examinati(5n and consecutive 
study of cases in the wards and out-patient depart- 
ments. According to the professor of propaedeutical 
clinical medicine and general pathology in Amsterdam, 
Dr. I. Snapper, the students there, after -passing their 
examination in anatomy and physiology, attend for 
two j’cars demonstrations on cases, and take practical 
courses in the methods used for investigating them; 
after a further examination their practical education 
begins, and they work in the wards and out-patient 
rooms for several months as so-called co-assistants. 
A special feature of medical teaching in Holland is 
that during the two' years devoted to normal anatomy, 
physiology, and histology, a theoretical introduction' 
to the clinical sciences is given by means of a course in 


general pathology. 

it must be admitted that, just as our students con- 
centrate on physiology and anatomy before entering 
the wards and out-patient departments for continual 
contact with the sick, so, on strictly consistent and 
lo-^icol gi-ounds, it might be argued that they should 
acquire a thorough working knowledge of morbid 
physiology and morbid anatomy and of the methods 
of clinical investigation before being turned loose 
among patients. This, however, is completely foreign 
to our system of beginning clinical work directly, after 
the examination in anatomy, and physiology has been 
passed, and picking up while thus occupied a know- 
ledge of pathology and of chmeal methods. Ine 
advantage of the British method— a . continuation, as. 
Sir Archibald Garrod points out, of the old appren- 
ticeship plan— is that the clinical instinct, difficult as 
this important faculty may be to define, but neverthe- 
less invaluable, is' thus engendered. Continued and 
close 'study of patients is an education which, when 
combined with a good knowledge of laboratory work, 
makes the best type of clinical physician. It has long 
been recognized in this country how difficult it is to 
carry out successfully what is a priori the proper plan 
^nahielv, to teach students auscultation and percus- 
sion before they begin to deal with medical patients, 
Professor F. E. Fraser, in giving an account ot tne 
Department of Medicine at St. Bartholomew’s Medical 
College ’ says that a . few years ago an attempt was 
made to set aside a period of three months, imme: 
diately before the clinical appointments, for introduc- 
tory courses in pathology, clinical medicine, an 
surgery, the course in medicine including in^ructiqn 
in historv-taking and physical examination. tin? 

obvious ‘dissociation of the instruction in bedsiae 
methods from the actual responsible clerkship proven 
unsatisfactory, and at the present time this course i 



. CEANIAL INCISIONS. 


r f R* BBmfB 
MeDICAX. JOCSNIL 


317 


Feb. 2Si,'92S]. 


given nt the beginning of the first in-patient clerkship. 
Tlic usual order in which these medical appointments 
at St. Bartholomew’s Hospital arc held is; three 
months’ in-patient clerking under ono of the ordinary 
phvsioians, then three months as pathological clerk 
to a “ firm,” throe months’ out-patient clerking, and 
a further three months’ in-p.'vtient clerking — in the 
last year — in the professorial unit. 

Thus it may bo said that the British plan of picking 
up clinical methods and pathology while in daily and 
hourly contact with patients lacks the advantage of 
coming fully armed to the task of solving a patho- 
logical problem, which should he provided by the 
-American plan of xireparation for clinical clerkships. 
But, on the other hand, the ideal medical man cannot 
be rapidly made out of a well-drilled laboratory pupil ; 
ho requires experience, which develops the intuition 
and human touch that nothing else gives in quite the 
same degree; and certainly it was these quidities that 
made the great clinical physicians of this country in 
the past. 


CEAHIAL INCISIONS. 

There will ever be a certain fascination for the surgeon 
in the problems of surgical approach, and that to the 
skull IS one of the most difficult. In other regions the 
actual approach, the exposure, is made through soft 
tissues, and is a matter of minutes only. None the 
less, surgical technicians have found much to absorb 
their interest, and to exercise their -ingenuity, in the 
mutter, for instance, of opening the abdomen or of 
exposing the hi^i-joint; and it would be not unfair 
o sa) that on occasion some warmth has been 
generated m the defence or the criticism of some 
pai leu ar method. The fundamental issues arc the 
sanii. Ill the case of the skull, hut here the approach to 
the brain is physically more difficult. 

lo before the surgeon in making all incisions 

atraumatic, that they 
nf ti ^ ‘’Pt’edy, that tliey should give good exposure 

be easify and firmly 
operatioii, and, lastlv, that 
v hiVl?^?n The ideal incision ‘is that 

°P®’';dion easy, for what is easy is 
whiVli I'o it is not always true that that 

cn-eatev there must always be a 

gicater element of risk in it. 

fhe ditficulties of the free exposure of 

eerebr il c small amount to the risks of 

looieil whole essence of neuro- 

skull as in much in what is done to the 

think contents. It has, we 

sm-veon that ^ source of wonder to the general 
indfiferent m ti"^ necrological specialist should be so 
H he he cses for opening tlic skull. 

seqLnce%f half a 

methods, all diffemnt P’'ohably see half a dozen 
fact as it coo “eut m some degree; and the plain 
matter Tlio c.cs, is that it does not very much 
to be limcli operator on the skull is apt 

and in tho ■? 'cterested in the boring of the bone 
staU }t l of cutting it than“in the later 

th.at operators nnoTtl^^u’ unkindly perhaps, 

classes sk-nll ths head may be divided into two 

the foiTO«- vasth- hi’ain surgeons, of whom 
out of the skulf u-n latter. To cut a disc 

dura mves -m on .“h “ trephine without opening the 
tance to sonio, '^“nccs pleasure and feeling of impor- 
shouW L so >^°®P‘tnls. Jus't why this 

^ uot Aerj easj’ to understand; perhaps 


it is because they may have very nearly done some- ^ 
thing important without incurring tho risks that 
something really important might have entailed. 

Wo hope there is no need for us to saw that in 
making these few remarks it is very far from our 
intention to belittle the importance ' of klr. H. S. 
Souttar’s new instrument. His craniotome — described 
in the Hunterian 1-ecture, printed with illustrations at 
page 295 this weelj — is the most valuable and most 
rapid bone-flap cutter that has yet been invented. The 
danger is that now he has made the approach to the 
brain a little easier the generalitj’ of surgical folk may 
think that one of themselves phis a craniotome equals 
a neurological surgeon. The circular saw we are less 
impressed \^ith; there is, of course, nothing now in 
the idea of using a saw of this type ; the ingenuity lies 
in the transmission sj'stem, an engineering feat of no 
small magnitude. The less mechanically minded of 
surgeons are grateful to such men as Mr. Souttar for 
solving their problems for them. We have not seen 
Hr. Souttar use the circular saw, but we well recollect 
seeing a New York surgeon take a good hour to cut 
a bone flap with an Albee saw or some modification 
of it. Such constant soundings had to be taken that 
progress was most tedious. The Souttar craniotome, 
on the other hand, seems to be almost fool-proof, and 
will iirobably supersede other implements. Its dis- 
advantage, we think, is that it cuts a circular flap. 
This is not a bad shape in the parietal region if made 
large enough (Hr. Soutfar’s advice that it should be 
three or four inches in diameter is a conservative" 
measurement), but on many occasions the rectangular 
flap is a more useful shape, especially in the frontal 
region. 

Air. Souttar’s recommendations for occipital expo-' 
sure will be read with the greatest interest by all whose 
special hobby this is, and he appears to have made a 
most valuable contribution to the subject. Experience 
is the only tost, and we shall follow the results of 
extended experience with his instrument with lively 
curiosity and appreciation. 


TESTIMONIAL TO SIR DAWSON WILLIAMS. 

SoJiE of our ic.-ulcrs will be awavo that preliminary steps 
are~being taken to promote a testimonial to Sir Dawson 
AVilliams, wlio lately retired from the. Editorship of the 
Bbiti.sh AIedicm. Jouhxwl after thirty yeara in that 
position and nearly fifty years’ close connexion witli the- 

, editorial work of this Jourk.m,. Tiiere is a widespread 
feeling that the occasion .shonld not pass without some 

■ recognition, from the profession as a whole, of his long 
and distinguished services to the science and xifacticc of- 
medicine. Wo understand that it is accordingly proposed 
to issue a general appeal, and to send to tho medical 2 ness 
a first list of suiqiorters for jniblication on JIarcli lOtli. 
Those wishing to he incinded in this list are invited to 
send their eontrihiitions, not later than JIarcli 3rd, to 

I Sir fBtClair Thomson, who has been asked by the provisional 
Executive Committee to act as lionorarj’ treasurer. 
Though the committee does not wish to limit the amount 
of individual donations, it holies that the sum eventually 

' I'oceived will include a large numher of coutrihutious of 

■ two guineas or less, and so represent the profession 
generally. Cheques should he made payable to Sir StCIair 
Thomson and sent to 64, "Wimpolo Street, London, .1, 
and the envelopes luaikod ” Dawson Williams Testimonial.” 

I Wo feel sure that this proposal to honour ono who has 
soi-ved tho British Medical Association with such out- 
standing ability and devotion will commend itself to 
members in every branch of professional life. 


318 Feb. 25, 1928] 


THE THYBOID 'AND MENSTRUATIOH. 


Medical Jouavii 


EPIDEMIC ERGOT POISONING IN ENGLAND. 
EriDEMic eigotism is well known as an affliction of 
mediaeval. Europe, but it lias boon generally assumed 
that this is one of the plagues that the advance of civiliza- 
tion has banished. It will thorefore come ns a surprise 
to many to road the account of a recent epidemic of ergot 
poisoning described by Drs. Hobortson and Ashby in our 
present issue (p. 302). This epidemic has occurred, more- 
over, not in the wilds of Eastern Europe, but in Man- 
chester. Records of epidemic ergotism date back to the 
ninth century, .and all through the Middle Ages terrible 
outbreaks of poisoning occurred amongst rye-eating popula- 
tions after wet summers. Largo numbers were killed in 
those epidemics, and many only survived after losing the 
greater portion of their limbs from gangrene. Before the 
advent of steam transport the unfortunate inhabitants of 
districts which depended on rye often found themselves 
faced, after a wet summer, with the alternative cither of 
starvation or of poisoning from the consumption of 
ergotized rj'o. The improvement of communications due 
to the advent of steam transport naturally reduced the 
frequency and severity of such epidemics, but it did not 
abolish them, for several have been recorded during the 
last half-century in Eastern Europe. Last summer pro- 
vided the optimum conditions for the growth of ergot in 
rye, and no doubt ergot was very prevalent in the grain. 
It is, however, rather a shock to learn from the present 
report that gi-ain containing 1 per cent, of ergot has been 
in use in England as human food. The pharmacology of 
ergotism is somewhat obscure. Ergot contains about one 
part per thousand of two specific alkaloids — namely, ergo- 
toxine and ergotaniine — and those can cause high blood 
pressure, gangrene, and abortion. The symptoms described 
in the present outbreak — namely, disorders of sensation, 
twitchings of the limbs, and staggering gait — are more 
associated with the spasmodic typo of ergot poisoning (as 
opposed to the gangrenous ty]io), and the active principle 
in the former is unknown. Fortunately, tho cases in the 
Manchester epidemic wore relatively mild, but tho event 
is a curious example of tho way in which an obsolete and 
half-forgotten danger, to health may bo revived by some 
change in conditions. Tho fact that tho caters of black 
bread contracted ergotism and tho eaters of white bread 
escaped shows that there is, at any rate, one sound reason 
for the popular ijrejudico in favour of tho latter. 


THE THYROID AND MENSTRUATION. 

An example of the functional relation which exists between 
endocrine glands is afforded by tho thyroid and tho ovaries, 
as evidenced by tho frequency of menstrual irregidarities 
in affections of tho thyroid. Disorders of menstruation are 
also not uncommonly observed in other diseases in which 
metabolism is affected— as, for example, in diabetes and 
tuberciddsis. In these conditions, • however, menstruation 
is usually suppressed, but in diseases of tho thyroid either 
suppression or excess of menstrual activity may be found. 
This was thought to be dependent upon tho degree of 
activity of the thyroid, but a study of the literature 
sliows no general agreement. Thus, either ainenorrhoea or 
menorrhagia has been recorded as being present both in 
myxoedema and in exophthalmic goitre — conditions which 
exhibit tho two extremes of abnormal function of the 
thyroid. Drs. H. Gardiner-Hill and J. Forest Smith have 
recently made an inr estigation in tho Medical Unit of St. 
Thomas’s Hospital, to ascertain the tj-pc of menstruation 
occurring in a large series of cases of diseases of the thyroid 
of different grades. ^ In this investig.ation they examined 
more than 300 patients, including 9 cretins, 100 adolescent 
goitres with vai-jing degrees of thyroid function, 06 
cases of exophthalmic goitre and hyperthyroidism, 41 of 


oum. Obetet, and Gynaecol, of the Britith EmpirCt Winter Number. 


myxoedoma, 24 of parenchymatous goitre, and 22 of sinmls 
adenomatous goitre. In order to provide confirmatory 
ovidence of tho degree of thyroid activity estimations of 
basal metabolism wore also carried out. Turning to tlio 
icstllts obtained, and taking into consideration the whole 
series of cases investigated, it was found that mcnstrimtion 
may or may not bo affected in these diseases, but that 
when menstruatipn is affected tho alteration tends to be in 
n uniform direction. Tho degree of thyroid activity and. 
tho ty’po of menstruation vary inversely, as there is often 
a tendency to monorrhagia in .hypothyroidism' and to 
, amenorrhoca in hyperthyroidism. Tho ob.servations ■ of 
.Gardiner-Hill .and Forest Smith may bo summarized as 
follows: In cretinism tho onset of menstruation is usually 
, delayed, and if not adequately treated may never appear, 

’ but if suitably treated menstruation tends to be regular 
and normal. . In adolescent goitre, with no signs of thyroid 

■ disturbanco .apart from tho goitre, menstruation is usually 
noi-mal; with .hyperthyroidism tho menstrual periods aro 

■ often delayed, scanty, and • irregular, and with hypo- 
, thyroidism monorrhagia occurs. In exophthalmic goitre 

I monstruation may be normal, but in the more severe cases , 
tho periods aro scanty and irregular, and in the most 
Eovero cases amonorrhoea is generally ijresent. In 
myxoedema before the menopause menorrhagia is com- 
monly present. Tho impression that myxoedema is 
sometimes accompanied by amenorrhoca is duo to the fact 
that this disease frequently develops after tho menopause. 
Finallv, in parenchymatous and simple adenomatous 
goitres there is usually no disturbanco of menstruation, but 
in patients with hypothyroidism monorrhagia has been 
observed. 

TATTOOING AND REMOVAL Of TATTOO MARKS. 

The ancioit practico of tattooing, which probably dates 
back to tho prehistoric cave-dwellers, and has reached its 
highest development in tho islands of tho South Pacific and 
in^Japan, presents many points of medical interest. In 
cortain lands it is employed ns a form of preventive 
1 medioino in virtue of special designs warranted to avert 
tho ovil eve, while, on the other hand, in modern 
medicine many examples h.ave been recorded of patients 
infocted with divers diseases at tho hands of those 
who practise this form of decorative art. ■ Dr. Maiwin 
D Shio in an interesting article' on tho subject, 
mentions’ that Bercheron in 1862 was able to report no 
fewer than eight deaths as the direct result of tattooing, 
with m.anv other cases of serious septic infection. Leprosy 
and tuboiclo have several times been transmitted in this 
wav and syphilis quite frequently; a single operator with 
mucous tubercles in his mouth is said to have infected 
■ as many as'nine patients m a single day. Modern anti- 
. se,,tics have much reduced' the risks . of tattooing, as of 
' other and more useful opofations, but sinco the practire is 
peculiarly attractive to the'denizens of the ‘ underworld • 
and is often c.arried out on alcoholic- subjects by. alccholio 
onerators' tho attendant hazards still. remain, considerable.'- 
But the c’ommoncst problem associated with tattooing to bo- 
presented to tho surgeon'is that of the removal of the marks. 

It is a problem which has scarcely yot been satisf.actoiffly 
solved Tattooers have thorefore been in the habit of doing 
what niav be considered the next best thing-naraeh^ the 
bowdlerization of obscene designs or tho concealment of 
some mark of identification by the 

thine new on the same site. Surgical, electrolytic, and 

cheiMc'al methods have all been tried in the effort 

complete removal without a scar. Except in tho 

tivelv rare instances when the design can be excired aiid 

the wound sutured or eyen skin-grafted the 

is always a-serious matter, but Dr Sh.o has been .able to 

obtain good results by t he method of nriot, ^ 

1 Joum. Aincr. Med. Aesoc., vol. SO, p. 94. 



[ The EBmsn 
3Iei>ic.iz. JocayiX 


319 


Feb. 35 ) 19’*] 


EPIDEMICS IN PEPyS’S DIARY. 


consists of tattooing into tlio design a 50 per cent, solution 
of tannio acid in water. Tho area to 1)0 treated is painted 
with tho tannio acid solution and tightly stretched so as 
to minimizo tho pain to tho patient, and tattooed closely 
all over. To acceler.ato tho process several needles — for 
■ example, ten— can ho used simultaneously if niounted in a 
convenient manner. From time to time an assistant adds 
fresh tamiic acid, so that tho tattooing is always dono 
through tho solution.^ When all is complcto tho whole .area 
is grey and swollen "and tho pigment almost obliterated. 
It is then luhhcd over witli a stick of silver nitrate, and 
a hea \7 black deposit of silver tannato is formed, which 
extends right down to tho corium where tho original 
pigment was laid down. After fifteen or sixteen days a 
slough, liko a thin piece of leather, comes away, le.aving 
a thin new layer of epithelium beneath it. This gradually 
assumes tho appearance of the normal skin, and in favour- 
able cases no scarring persists. If, however, tho hair 
follicles havo been destroyed within tho tattoo mark thoro 
will bo some scarring. Dr. Shio considers that tho best field 
for this method lies in the removal of accidental tattoo 
marks such as aro left by powder explosions depositing 
carbon. Rut ho owes his very considerablo experience of 
tattooing and its removal to tho fact that ho has been 
connected with the Marine Hospital of Cleveland, fre- 
quented by sailors — a folk among whom tho practice is 
notoriously popular. 


EPIDEMICS IN PEPYS’S DIARY. 

At tho social evening of tho Royal Society of Medicine on 
February 15th, when Sir James and Lady Berry received 
a large company of Fellows and guests. Colonel W. P. 
MacArthur, just returned from Shanghai, gavo a very 
interesting lecture on tho modical references in Samuel 
I’epys’s diary. It was remarkablo also as a feat of 
memory, for, without tho uso of a single rroto, tho lecturer 
had every name, date, quotation, and reforertco at his 
finger-tips. Ho reminded his audience that tho diary 
egau in 1660 and covered a period of nearly terr years. 
16 medical references are numerous, and, unless our 
rnemory is .at fault. Sir D’Arcy Power otreo wrote a 
charmrrrg pairer on tho medical history of JIrs. Pepys. 

0 one -racArthiir recalled tlio diarist^s account of a 
success id experimerrt in blood trarrsfusion, which “may 
I f marr’s health, for tho ruending of bad 

00 y rorroiiing from a better body.” Pepys had some 
<^otrotis also on his own operation for stone. A storre 
1 ball, accordirrg to Evelyn, was 

ill ^ pathological relic Pepys carried about 

tPTit show his friends. Tho mid-seventeenth 

fearful ravages from small-pox, and Pepys 
yj, j frogic disfiguroment of Frances 

orisriii^l vf '•!’ i^oauty, said to havo been tho 

the coinage. In March, 1668, tho 


iiiifnit,,,,... , , . “ eoinago. in iuaren, looo, xno 

Peiivs -111 1 ^ ' “‘silty full of the small-poc,” which, 

• S “is the greatest inkanco of 

A verv !ipo'v*"+^u°^ beauty which could bo in this age.” 

anl)e^rlt,l +i • i family. Colonel MacArthur 

death of ilm - ^ small-pox wliich caused tlie 

cleared tlio w ivf'wi^w® ^'‘"tcester in 1700, .and so 

Engli^i throne but 71m n ^ 

tays otherwise’ I„ +i °f ^'afionid Biography 

failed to trace an penod Colonel MacArthnr 

-■tt that lime it 'i-^ snmlar record of sm.all-pox virulence, 
a childish affeetm'if ^ I'aekeled with measles and .accounted 
tile mild tvuo f ' interesting to speculate whether 

revert to its Prevailing would again 

tioued in the rlla...-' -^“otlier epidemic was nien- 

^utod bv Pen - 1 summer of 1661, and was attri- 

'^hicb i)ersi^inl?^+i ^ t ° ,*^^^^'^oi'^iuarily warm weather, 
pels, sled through tho autumn and into the winter! 


This strange fever was not pilaguo, small-pox, or typhus, 
with all of which Pepys was too familiar, but it could he 
gathered from the pages of Sydenham to have been malaria, 
or, as Sydenham called it, intermittent fever. Tho most 
extensive of Pepys’s ynedical interests was concerned with 
the London plagiio of 1665. This was an epidemic of 
bubonic plagno affecting tho chief residential district of 
London — tho City — which was at that time filthy and con- 
gestoil. It was tho last of a long scries of epidemics which 
had flared up at intervals; the seventeenth century had 
already seen three great outbreaks. Pepys’s earliest men- 
tion of tho epidemic was in April and May, when lio noted 
tho great fear and dread in the City, several houses being 
shut up and marked with tho plague sign. In liis own 
parish there woro as many burials in four weeks as there 
had boon in tlie whole year before. Entire families were 
wiped out. Tho hills of mortality, to which Popys made 
frequent reference, were originally concerned with plague 
deaths only; but from 1592 they were issued weekly by' 
tho London Company of Parish Clerks, and gave the deaths 
from ail causes. Four principal outward manifestations of 
the plague were noticed — namely, the botch or bubo, the 
carbuncle, the token, and the hlain ; of these only the first 
is now cominonly found in association with plague. A letter 
by Pepys showed tliat the diarist stayed on in London until 
the recoi'ded deaths reached 6,000 in a week, and tho 
nights, although lengthening, were too short to conceal 
tho burials. His household returned to London in 
December. Plague persisted in London for another four- 
teen years, but with the enforcement of cleansing orders 
and a higher standard of sanitation there was no further 
epidemic. In conclusion. Colonel MacArthur said that 
those who had estimated Pepys’s character from the more 
frivolous pages of his journal might do well to recall that 
he was an indefatigable and conscientious worker, a most 
efficient public servant, and an honest man according to the 
ideas of his time. He received many honours, he was 
President of the Royal Society, Master of Trinity House, 
Warden of the Cinque Ports, member of Parliament, friend 
and correspondent of Isaac Newton, John Evelyn, and Hans 
Sloan. But ho had a claim to the goodwill of the medical 
profession because he held the science of medicine in high 
regard — a regard by no means universal in old times, as 
witness a passage from a book almost as intimate and 
revealing as the diary, namely, tbe Paston Letters. In a 
letter written by Margaret Paston to her husband in 1464 
occurred this distressing passage: “ Also for Goddys sake 
be war wbat medesy-ns ye take of any fysissyans in London ; 
I Ecbal never trust to bem be cause of your fadr and myn 
onky], whoys sowlys God assoyle.” 


DUTCH AND DANISH CONDENSED MILK. 

Ix August last year tbe Minister of Health dlspatolicd 
a commission to the Netherlands and Denmark for tho 
purpose of inquiring into the conditions of production of 
the milk used in preparing condensed brands. This visit 
followed ail earlier one to the two countries paid by dele- 
gates from the city of Liverpool; we gavo a short account 
of the report of this deputation on April 2nd, 1927 (p. 635). 
Tho present commission consisted of Dr. J. M. Hamill, 
a medical officer of the Alinistry of Health, together with 
Mr. T. A. Hole, a milk inspector, 'and Mr. J. Mackintosh, 
professor of dairy husbandry at the University of Reading. 
The report of Dr. Hamill and his colleagues has just been 
issued. It is satisfactory to note that neither in Holland 
nor in Denmark did the observers find tho conditions of 
milk production markedly superior to those existing in 
England. In Holland cows aro milked in the fields instead 
of sheds for six months in the year. Any disadvantages 
in the cleansing of utensils are neutralized by the rapidity 
with which the milk is removed to tho condcnseiy or 


320 Feb. 25, 1928] 


THE EVILS ' OP TOBACCO. 



THEHninw 
Medicii. Joraxu — • 


ci'cjimei'y. The floor construction in the cow.sliods is 
gcnei'alh- .snppiior to English construction. This is cliio to 
the sheds having boon built for the specific purpose of 
housing cows, instead of being intonded originally for soino 
other purpose. The commission was .struck by the similarity 
in principle of Dutch Government regulations inul otir 
own for couti'olling the purity and clcanlino,ss of milk. 
■Administration works smoothly. The Dutch authorities 
have not yet adopted official veterinary inspection, hut tho 
matter is now under eonsideratiou. Private organi 2 .atioii 
for controlling the purity of milk and tho health of tho 
cows is good, and in tho co-operative .societies has attained 
considerable efficiency. Conditions in Denmark are similar 
to those in Holland, hut the cowsheds are said to he even 
superior to tho average Dutch type. Government regida- 
tions for tho control of jiurity and cleanliness of milk 
rc.semhlo those of our Milk and Dairies Order for milk 
intonded to he consumed as such. But milk intended for 
conversion into condensed milk is exempt from these 
regulations, though othcr.s of a less specific .and detailed 
character are now in contemplation. The commission con- 
cludes that neither in Holland nor in Denmark are tho 
conditions of production, the rcgul.ations, or the administra- 
tion sufficiently different to wan ant any differentiation, on 
the grounds of danger to health, between dairy produce in 
England and that in the two countries visited. Kor is it 
thought that English regulations i)laco any significant 
burden upon the English farmer which is not already borne 
by tho farmers of Holland. Otherwise tho main interest 
of the report for tho British farmer .should ho the evidence 
it ofFer.5 of tho successful results of co-operation in the 
production, transport, and distribution of milk, and in the 
manufacture of milk products in the two countries investi- 
gated. These points were emphasized also in the report of 
the Liverpool deputation. 


THE EVILS OF TOBACCO. 


PnoiUDiTiox, like drug-taking, whets the appetite for 
further indulgence. It appears that in America there aro 
many people who regaid tobacco as tho next .sid)ject for 
legislative attention. To inform the public on the matter 
there exists a Committee to Study tho Tobacco Problem, 
which includes in its membership not only IMr. Heni-v 
Ford, a cliief executive of tho boy scouts, and a ju-ofessor 
of theological exegesis, but also numerous medical and 
physiological piofessors at universities. The coinmitteo 
has recently issued a book by Dr. Pierre Schrumpf- 
Pierron, professor of clinical medicine in the Universitv of 
Cairo, entitled Tobacco and Physical Pfficiencyd The 
president of tho committee, Dr. Alexander Lambert, in a 
foreword, claims that the object aimed at is an unbia.sed 
presentation of every variety of opinion. Professor Vacpiez 
of Paris bas written a preface, and explains wliy he advises 
the total abandonment of tobacco in patients with cardio- 
vascular lesions, manifest or latent. At the end of the book 
there is a very complete bibliography of the literature of 
tobacco. --Vs regai'ds Professor Schrumpf-Pierron’s con- 
tribution, wo can only say that it is not very illuminating. 
He states tliat tobacco may cause headache, migraine, 
vertigo (how true of the first pipe!), insomnia, and 
amnesia; but in many conditions of a graver nature that 
are mentioned it might bo better to say merely that 
sufferers from' such disorders sometimes smoke tobacco. It is 
=atisfaetorv, however, to learn that the charge timt tobacco 
causes actual lesion of the heart is “not proven,” and 
that in women smoking itself has no ai)imrent influence on 
the functions of the genital system. The author is of 
opiiiioii that further controlled clinical and ].-ifaor.atoi-y 


> Taljacco <tnir Physical Smeirncy. Bv Pierre Schmmrf-Picrron, M.I). 
l.T ;“'S. Henri Vaquez, 5I.D. Witli a foreword b.v -tlciander laimbert, 
1-8S aoUar, Inc. 1927. (5i X Bi, pp, xiii + 134. 


studies are desirable to asccrt.ain tho ultimate effect of 
jirolonged moderate use of tobacco, as wcU as of its free 
use. He wisely adds that tho dangers of e.xecssivo 
indulgence in tobacco should not bo exaggerated, anti that 
tobacco .should not be placed on the same plane as morphine 
and cocaine. Becollcctions of nonagenarians enjoying their 
jiots of beer and pipes of .shag lead us to endorse "this view. 
Our readers will remembci- that on October 22nd, 1927 
(p. 719), we published Piofessor IF. E. Dixon’s Eorman 
Kerr Lecture on tho tobacco habit. The very rea.sonablo 
conclusions at which Professor Dixon anived included a 
pica for fnrthci- investigations, especially into the tpiestion 
how far tho use of tobacco leads to vascular degeneration. 
Profe.s.sor Schrumjif-Picrroii’s hook confirms onr opinion 
that the ellects of this veiy slow poison are not yet i-ipa 
for dogmatic statement. 


THE UNITED HOSPITALS CLUB OF ST. THOMAS'S 
AND GUY’S. 

Tins ancient cliih held its centenary dinner on Fchruarv 
16th last. It was founded on Fehrnary 15th, 1828, hy two 
gf'iicral praclitioiier.s — then called apothecaries — educated 
at tho Borough hosjjitals, St. Thomas’s and Guy’s. Its 
object was to maintain and keep alive the friendship that 
had alwa)-s existed between the two great institutions, le.st 
this should be imperilled by the opening of the independent 
scliool at Guy’s in 1826. The Dnited Hospitals Club is 
proud to remember that its foundation was owing to the 
general practitioner; for at the foundation meeting; held 
at the Izondon Coffee House, twenty apothecaries wero 
prc'cnt ami onlv two members of tho staff of the hospitals. 
The club consists of eight of the staff from each hospital 
and nine gcncr.al practitioners, who by dining together four 
times a vear jenew the dual friendsbip. Tho club enter- 
tains guests, and during the hundred years of its exist- 
ence has welcomed most of the ])rommont members of the 
profession both from home and abroad. It was not until 
1836 that the complete separation of the two .schools took 
iilace in consenncnce of a disagreement as to the attend- 
ance ’of tho students of each hospital on the praetice of 
the other, whilst tho removal of St. Thomas s to Lambeth 
sixty years ago further emphasized the separation. Move 
than ever then did tlio club appreciate its usefulness; not 
tint now it is needed to increase the fneiidsbip between 
Jr H.om.as’s and Guy’s-that is impossible-hut rather 
as a concrete and jicrmanent reminder of past roffitionslup 
ami an earnest of future good foeling. At its 
dinner, under the joint chairman^iip . of two of its old^t 
I »• Qir Gcorce Makins (St. Thomas s) and Mi. C. H. 
rTi |Giiv’a)-it broke one of its most rigid rules, 

'hrie^mis mi’ «->>Aers of the profession as gne.sts. 
iVciitortaincd last week the .treasurers of the two hospitals, 
S . tthu" Stanley and Mr. F. P. IVhithre.ad, hn 
cHi.cr.i.m the m.imi, in public, of twm famous medical 
■ I p tions now removed a distance from one aiiotliei. 
Perhaps Guv’s Hospital reaps the gre.atcr advantage from 
tlul cUih for its fomider, Thomas Guy, was a govcrnoi of 
St Tiiomas’s. In this filial relationship Guy’s niay claim 
4 ^ *1 n full share in the traditions of St. Thomas s, 
.« .. 


Thomas’s has good cause to be proiuU 


At tbe meeting of the President and Council of the Koyal 
• i r n Fehruan- 16 th it was decided to recommend 
’ftoL' candidates for election as Fellows. Among those 
bosen are two members of tbe medical ® „ 

lari Hamilton Browning, professor of bacteriology J 
Iniversitv of, Glasgow, and Dr. Major 
f epidemiology and vital statistics in the IJniie.s.tj 

jOlulon. 


Feb.' 25i '9^8] 


"THOSE OTHER PRACTITIONERS.” 


[ Tn* BBima 
UcsiCAx. JonurjA 


321 


“THOSE OTHEE PEACTITIONEESi” 

Ak Address to tub 

AuEBN-Eini.vN Society of St. BARTnoLOiiEiv’s Hospitae, 
January 26Tn, 1928, 

BY 

LORD DAWSON OF PENN. 


My intention is to refer to those praotitiouers ivho do not 
give allcgianco to the medical profession and are styled 
unqualified. That such should havo existed in past cen- 
turies does not causo us surpriso, hut that their activities 
shoiv little sign of abatement in this ago of scientific 
inquiiy should prompt us to reflection. No doubt the 
desire for gain and notoriety is a partial, and in some 
instances a complete, explanation of their activities, hut 
many of them, however mistaken, havo an honest belief 
in themselves and their work. 


The Unqualified Practitioner. 

A quack may bo described as a man who makes baseless 
and boastful pretensions for a method of treatment. Ho 
may be one who deceives himself beforo deceiving other 
people, or one who deceives other people without deceiving 
himself. It has to be admitted that tho quack may exist 
inside as well as outside tho ranks of tho profession. For 
my present purpose I exclude from this puiwiew thoso 
' who have the intention to bo impostors and whoso methods 
are designedly dishonest. Tho unqualified or irregular 
practitioner need not bo a quack. In some instances his 
methods of treatment are helpful, provided they aro 
applied under the right conditions. 

To keep the art of medicine firmly set on tho rock of 
knowledge and defend it against falso doctrine what 
vantage ground should wo select? I suggest to you that 
we should take our stand on diagnosis. Here our position 
IS unassailable. To attempt to treat disease without 
knowing what is wrong would bo folly. Diagnosis must 
precede treatment, and tho knowledge of diagnosis can only 
com6_ from years of training in tho , sciences of physics, 
cnemistry, biology, anatomy, physiology, pathology, 
bactonolo^, and then in tho study of the bodies and 
of the sick at the bedside. Educational authority 
™d”quate interest, soo that such training is 

However much public opinion might bo carried away by 
t-i? tnat oult or miraculous euro and demand of us to 
tl,™ * exponents into our confidence, it never would give 
mo.lfoni' ®P®ndent practitioners tho rights and duties of 
bnm +1 “'y wore than it would permit a heaven- 

Atlantiriine'r.''"^‘^“‘"“‘* ®"e>neer to drive a train or an 

de?npri°nn!i’ ground; it is a clearly 

on wbict province of medicine and tho sciences 

ment f °ther hand, treat- 

healiniy lipo ’ '® “Pnnage of doctors alone. The art of 
has brcn 'b1p,”l ^ concern of peoples and 

instinctL n W 7 sive. Its 

beast- witnps.! exist in each individual — man and 

licks tho inflamed paw or 
“'Viilage dame “of form of grass. Tho apothecaiy or 
Bide' the Imrbs and V gathered from the country- 

repute' a.non4 the ,7'? 

would gathe? tho ® l ^P'®* "'ero made. The herbalist 
ordination “ I catbprt“l “"®”ou 0 with tho ceremonial 
Similar ceremonv at+n remedy against all disease.” 

called mistletoe 

influence of popular belief ‘ ' ' - ' - - 

ii WO 5urv~- ” 


Nor did surgery escape the 

tho ono handful;!? ^^1^1 °f treatment to-day we find it on 
torics as anaton/'“ 1 defined and ordered terri- 

Ipgy, and in‘othe‘r’rI?,.l'!-'’'°®’’ chemistry, and pharmaco- 
rogions of mind r ,.’®ctaTOs merging into the less defined 
cf which penetAto®f ’'^1 liclief, even superstition, all 
That medicine slmnl,? i^“®^ human history. 

‘‘Tho art of heahiifr ® ‘?s one of its styles. and titles 
main puruoso of ^ lominds us that for the public a 
r existence is to make suffering people 


well. Thus it is that unqualified practitioners centre their 
activities in tho treatment of illness. From the innumer- 
ablo cults and cures, past and present, I will select a few; 
examples. 

Perkins and ilesmer. 

Elisha Perkins (1740-99) was in the earlier part of his 
career a country practitioner. Later he invented the 
“ metallic tractors,” which consisted of two rods of metal 
— ono of gold, copper, and zinc, the other of iron, silver, 
and platinum. These rods were drawn over the affected 
part, and acted by tho electricity they were alleged to pro- 
duce. They cured most things — pain, rheumatism, tumours, 
boils, pleurisy, “and various' nervous diseases. The vogue 
was great — all sorts and conditions of men, including noble- 
men, statesmen, and divines, supported his claims; real 
cures resulted, though how permanent they were is doubtful. 
Then came decline. Finally Dr. Haygarth of Bath showed 
that tractors of wood painted like tho metal ones produced 
even greater cures, and so the bubble burst. 

Mesmer (1734-1815), who took his M.D. at Vienna in 
1766, based his cures on the uso of magnetism. In Vienna 
ho was not accepted, but, moving to Paris, his reputation 
gi-ew and ho hecamo tho rage. At first he was only- mis- 
guided. 'When his influence grew vanity obscured his 
honesty, and one reads of all tho paraphernalia of tho 
charlatan — spacious salons, stained-glass windows, coloured 
lights, fragrant fumes, velvet, and soft music. Let mo 
quote* : 

“ In the middle of the principal salon was deposited an oval 
vessel, about four feet in its major diameter and one foot in 
depth. This receptacle contained a number of wine bottles, filled 
with magnetized water, well corked, and disposed in order, with 
their necks outwards. Tho vessel was filled almost to the brim, 
and iron filings were thrown into it at intervals, to increase, it 
was said, tho magnetic effect. An iron cover, called the haquet, 
perforated with many holes, completed the apparatus — a long 
movable rod of iron issuing from each aperture for the patients 
to apply to tho diseased parts of their bodies. The patients sat 
round the vessel, holding each other’s hands, and pressing their 
knees together as closely as possible, in order to facilitate tho 
circuit of the magnetic fluid. 

“ Tho assistant magnetizers then entered — stalwart and hand- 
some young men, who were supposed to pour into the patients 
from their finger-tips a fresh supply of tho magnetic fluid. They 
embraced tho patients between the knees, rubbed them gently 
down the spine and along tho course of the nen-os, pressed gently 
on the bosoms of tho females, while fixing them with a magnetic 
glance from their eyes — in anticipation of tho Ancient Mariner 
and the Wedding Guest in Coleridge’s ballad.” 

It is difficult to believe how Mesmer took possession 
of public attention. . His methods attracted tho Court 
and tho Government. Tho latter offered n pension of 
20,000 francs and a decoration if he would communicate 
his discovery to physicians nominated by the King. This 
offer he evaded. Later commissioners investigated his pre- 
tensions and reported against them, and finally ho became 
discredited. 

Osteopathy. 

The osteopath is the descendant of tho bone-setter, and 
it is an interesting fact that Barker succeeded to tho 
practice of Hutton, who was a well-known bone-setter of 
the Victorian era. Osteopathy ascribes maladies to mis- 
placements of anatomical parts, and especially to faulty 
arrangements and alignment of the vertebrae. Tho treat- 
ment consists of manipulation of the misplaced parts with 
a view to their correct replacement. It is done with 
vigour and often accompanied by elicks, which provoke 
a strong and confident statement that the malady will 
immediately cease, and so sometimes it does. I have not 
heard of skiagrams being taken before and after the troat- 
mont. One may discern in these treatments (a) physical 
examination and treatment of the body, and (6) influence 
on the patient’s mind. Sometimes there is a dexterous 
manipulation of the part affected, and in other instances 
there is only a ritual handling of the body, and this is 
made the means of exerting forcible impressions on tho 
mind. . 

There is nothing radically unsound in theso methods. 
■When they fail it is because a false diagnosis of tho con- 
dition has been mado. If the manipulation is harmless 
there may remain a beneficial effect duo to suggestion. 
Where tho case is ono unsuitable for manipulation grave 

harm may result. 

1 Tht Bealing Art. By tV. H. Davenport Adorns. • 


.322 Eeb. .25,. 1928] 


“ THOSE OTHER. PKAHTmONERS." 


pj BEmw 


L JlcftrcAt Jdcsxu 


TJiore aro gifts of liaiids often inborn — not acquired — a 
dexterity without a ■ reasoned basis, and tliereforo • not 
teachable to others. .Sucli is so-cnHed.manipuIntivo..surgerr. 
If it were jn-actisod witliin its pjopci' ainl)it, if. it, were 
only apidied after skilled diagnosis had been inndo and 
skilled direction given, how useful it would be I 1 come 
back to what must over ho our undeviating insi.stoncc — 
diagnosis must precede treatment. 

Faith-licalinff. 

- I non' pass to the consideration of methods of treatment 
which do])eud on mental influences and use hut little 
manipulation or other physical mode.s of approach. I will 
select Cou6’,s teaching, and what may bo convenicjitly 
comprised rtuder the term “ faith-healing.” 

M. Cone’s method seeks to take control of the patient’s 
subconscious mind: the constant and rhythmical repetition 
of the phrase “ Qa passe ” for the time .so occupies the 
suhconsciou.s mind that the latter is impervious to the 
influence of reason. IVith periodic repetition of this exer- 
cise the impression remains, and the subconscious mind 
accepts and keeps the idea that this or that .symptom lias 
pa.ssed. 

The merit of M. Cone’s method is that it trains tho 
patient to help himself. But is that all? No; M. Cone’s 
forceful, cheerful personality, his atinosjdiere of sincerity 
and confidence, made a deep impression on Ids patients; lie 
immediately secured followers who passed into di.scijdcs; 
and the fact that ho impressed on his hearers that bis 
personality counted hut little deepened his influence, for is 
it not true that mental influences often reach their best 
when they are incidental rather than intentional, implicit 
rather than explicit? Tho Cone method is, in short, auto- 
suggestion i-cinforccd by suggestion. 

So far, so good. The method, applied to functional dis- 
orders, whether standing alone or as part of organic disease, 
is one of usefulness, and only disadvantageous because of 
its detachment from other treatment and when its claims go 
beyond facts. But when its claims are extended to tho 
curing of developed structural disease then a doctrine is 
being propounded which is not only erroneous, but dan- 
gerous; and a similar false doctrine is found in tho teaching 
of Christian .Science and some forms of faith-healing. There 
is no evidence, for e.xample, that a tumour disapjiears under 
psychical treatment, and such teaching is dangerous because 
it leads patients to postpone physical treatment until too 
late. “ Bender unto Caesar tho things which arc Caesar’s, 
and unto Cod tho things that aro God's.” 

Faith-healing is so large and diffuse a topic that I will 
limit myself to healing by the influence of a personality'. 
Here the he.aling depends on the .'(ttributes of tho per- 
sonality and the reaction of the patient. The attributes 
of the healer are in part inborn, though cultivation may 
do much to enhance them ; whether they can be inspired 
from without — that is, implanted by Divine gift — is a 
question outside our present inquii-y. 

Our daily experience leads us to conclude th.at the 
influence of mind is an integral part of the ai-t of healing. 
Let me give you two examples. A patient, after weeks 
of unconsciousness due to typhoid fever, graduallv emer"os 
and for a fortnight remains on the threshold of conscious- 
ness. AVe all know how painful and enfeebling that phase 
can be — dreams, terrors, cries, restlessness, insomnia — and 
narcotics and hypnotics gave but poor results. Tlicu, by 
good fortune, comes on the scene one nurse who, bv touch 
and voice — or shall I say through touch and voice ?.i—ciuells 
the troubled spirit, gives sleep, and contributes in no small 
measure to recovery. 

Another . example. An aged lady, great in mind and 
character, had fecurreht carcinoma of the breast and 
suffered agonies of pain in her arm. One day she said 
“ AA’ould vou mind if we let a healer try and help niv 
arm?” and she mentioned the best-knmvn heeler of that 
time! I assented, and offered to meet the healer in 
consultation. For several weeks that healer substaiitially 
reduced the pain and brought her peace. One day she 
said to me, “ 1 feel the good Mr. X can do me is over, and 
1 would libe bis visits to cease.” By that time the end 
nearer and morphine carried US through. . 

n both these ' instances' we ‘ Saw mind 'healing at its | 


Jicsfc. Wiy? Beemise it ivas not dissociated from plivsical 
Jiealing, AVJien^ dissociated^ -mind healing loses its sense 
of proportion, its j)reton.sions groiv and groiv, the healer 
falls with linngpj'ous facility into a dependence on tho 
accidentals rather than the. essentials of Iiis art. He thus 
gets on to a basis of falsity' ratiier than truth, and he 
becomes as sounding hra.ss aiul tinkling cymbals. ’I’hero is 
no department of treatment which goes mad so easily as 
psychothe,ra]iy'. 

'riie remedy for these dangers is to secure that all forms 
of ^treatment .should ho guided .and co-ordinated by the 
doctor; hut this supposes a. wide comprehension ' on the 
part of tho medical profession of what treatment includes 
and a rcnclincss - to seepro the help, of ancillaiy' callings. 
Such comprehension is growing apace. I _need only in- 
stance the midwife, the masseur, the elcctrici.an ; and why 
not the mauipulator and healer, provided nlw.ays one essen- 
tial — that diagnosis and direction precede treatment? 

il/facZ aild Body. 

As regards mind treatment, there is danger of it losing 
direction in tho learning of medicine; on the ono hand 
advances in’ pharmacology' rightly' giro prominence to 
.specific remedies like digitalis, insulin, emetine, qiiinidine, 
etc., and on tlie other hand there is a tendency to pash 
tho estimate and treatment of the mind factor into the 
ken and care of tho psychotlierapeutist. Therein lies error : 
body and mind cannot he thus separated either in diagnosis 
or troalmont. In both functional and organic diseases 
there are the reactions of mind and temperament, and we 
liave to study not only tho material disease, but the com- 
pieto fabric or mnkc-np of this or that personal illness. 

^ Moreover, strnctur.al disease may have a psychical as well 
as a physical beginning. Lot me instance Graves’s disease 
and certains forms- of high blood pressure. Inborn 
traits and reactions — impressionability, sensitiveness, oyer- 
coiisciontiousncss— reacting on some varieties of physical 
moko-np will produce, say, increased secretion or vaso- 
constriction. Then develops what may be called physicv 
logical habit, and so gradually tliere evolves full-fledged 

structural disease. ^ r i 

Tims is emphasized the importance of the study or 
medicine by Uio student at the bedside. There ho will 
study first the symptoms and signs of physical discnsc, 
md^at tho same time will be brought in contact with 
clnractcrs, temperaments, and difficulties of patients lives 
which go far to determine tho form of their illnesses. In 
this win- imaginative insight will gradually become one of 
tim niialities of tho student’s mind. 

Tho psychical factor in illness is likely to play a larger, 

. + n Ln-iller part in the future; tho material resources 
of civilization have developed so rapidly that they liavo 
fc+rJmiPfl man’s power of adaptation, and strains and 
will need more careful consideration. That is 
\ in the increase of illnesses duo to ” e.xhau.stmn ” 
^t'^tps which illustrate that the best healing of tho 
states, oljtrusivo and still less exclusive, 

w rathpf aeeo.V'i a sound physical treatment. 

’o pf the latter and the ascribing of the illness to 
“neurasthenia” or erroneous habits of thought arc apt 
, “ the natient. Even if true, the “ sick ” are not 

^4-^^^-nmred for tliis; they cannot get away from iJto 
f**p1inff that what is physical is real and something they 
^ pf bein' whereas- what is p.sychical is unreal and some- 
thev^can help. Tliis misconception is perhajis duo to 
•''Ifl-en\e “chinB about tho doctrine of freewill. 

™From this I am led to suggest tl.at 

I ibniterl to selected cases, and its practice to the tci 
e^,p nre sncciallv trained and possess the needful gifts of 
mind Psrcho-analysis requires tho clinician; it should 
bo eriide and lav hare a patient’s soul. Clumsy qiios- 
ti^nhig, lilm clumsy surgery, can easily produce irreparable 

damage. ii,„,.pforo, that wo .should take a large and 
co^,p?^::f;sivo":io'v’ot ti^atment: that pliysh. - 

each Uiier and that all forms of treatment , 

co-ordinated and directed, though not ’ 

by the doctor and based on sound and accurate diagnosis. 



Eeb. S 5 , 192S] - 


SCOTLAND. 


[ Thk BsmsH 
Medical 'Jocbval 


323 


kntlantr. 


Proposed Compulsory Treatment of Venereal Diseases 
. . in Edinburgh.' 

Tm: Edinburgh Corporation is. at present promoting a 
parliamentary bill* for eonipulsory treatment of venereal 
diseases, and ■ • ■ ' ' ■ ' .j-g of Parliament and 

tbo medical ■ on the subject. Tho 

corporation holds that at present the scheme for treating 
these diseases is not yielding results commonsurato with the 
expondituro involved, and that tho purely voluntary system, 
having received an adequate and exhnnstivo trial, has 
proved Ineffective for tho purpose of preventing infection. 
They thereforo desire to tiy tho methods they propose for 
an experimental period of fivo years. According to a state- 
ment which has been issued over the signatures of Councillor 
Given (convener of tho Public Health Committee), Jlr. 
Andrew Grierson (town clerk), and Dr. W. Kohertson 
(medical ofBccr of health for Edinburgh) tho publication 
of the report of the Eoyal Commission in 1916 led to exten- 
sive propaganda for tbo object of public enlightenment on 
the grave evils of these diseases and to tho establishment of 
facilities for tboir treatment free of cost, witli, so far as 
tho patient was concerned, as little ptiblicit}' as possible. 
As a result, it is stated, local authorities were brought into 
touch with a largo amount of this disease, and many of tho 
patients tieated had been cured. Under tho Edinburgh 
Corporation venereal diseases scheme a total of 19,059 new 
patients had reported for treatment during tho fivo years 
1921 to 1925. During tho period, however, a very consider- 
ablo number of those patients had ceased attendance long 
before they, were' considered cured. During 1925-26, for 
example,, there had been 903 sncli defaulters, wliile tho 
total number of defaulters during tho fivo-year period was 
5,129. It is considered fimt the fact of tlioro being in each 
year an average of over 1,000 cases of possible infective 
disease known to the public health authority, while this 
authority is powerless to deal with them, is far from satis- 
faotory when viewed from tho public health asiiect of pre- 
vontiblo disease. This also loads to tlie local authority 
expending very considerable sums of monec' without an 
adequate return. Tlie expeiiditnro in connexion with tho 
Ldmbin-gh scheme in the past ybar was £21,862, of which 
w , 1^5 a’as recovered in the foi-ni of Government grants. 

le operative clause of tlio bill now to ho submitted to 
1 arliament provides that when tho medical officer of liealth 
as leason to believe that any person is suffering from 
oneieal disease and liable to infect other persons, and 
on sue 1 person neglects or refuses to undergo treatment 
practitioner or at a treatment centre estab- 
iinti'f . ?■ * ™*'P'’''**tion, tho medical officer of health may 

a medical practitioner or attend a 
and tl.o" • ^failure to carrv out such a requisition 

tim. +1 without reasonable cause, of informa- 

^ is suffering from venereal disease are to 

Edinwll The exeontivo committee of the 

As'joci'ifinl I-eith Division of the British Medical 
the r meeting held on February 18th, discussed 

a rcsoliitin*' file Edinburgh Corporation, and passed 
beforn tlm of tliein. Tho matter will come 

ewssed tide "'jsion oil February 28tli. The bill was dis- 
toeether f'*® Parliamentarv Medical Committee, 

p. 330) * ’ ®P*®seiitatives of Edinburgh Corporation (see 

Glasgow Victoria Infirmary : Admission of 
Tbp f f ii Paying Patients, 

of fjlnspl! * annual meeting of the Victoria Infirmary 
■ronort* tl "t^ on February 15th. The annual 

Febiii-i.-,, ill? *''®f*fotion. was noticed in the Joobxai. of 
Coveriinvl ^f*'- William Gray, chairman of tho 

in reend’ ?°'+i important statement at the meeting 
naviiiplif of'mission of patients for treatment on 

LnrZl LT, modified fee. He said that the 

tioii of tl.p vr *0’P*'®ssed by the strong recomnienda- 

^Zinte^b^ Committee, which had been 

tlo ri v thnlol i"*** f'O work- 

_j;^_tl^^,^tary hospitals in Scotland. Mo.st 


wock'ut pTgo'w. ‘='“'‘*'*'^nwrbnn;Tr 


of the 

ill be found in flic ScPrLESIEXT this 


witnesses before this committee liad. urged the need for 
hospital facilities for persons of moderate means who could 
not afford the charges of the ordinary nursing homos.' 
The practice of providing beds for paying patients was 
now spreading, . and the, question of extending it to tho 
wliolo hospital system was one of the definite issues before 
voluntary hosjjitals. After careful examination- a suit- 
able schemo had been formulated by the governors of the 
Victoria Infirmary, and this wonld be put into operation 
as soon as tho necessary accommodation was available. It - 
was proposed to admit patients on payment of an inclusive 
feo of six guineas per week, which would bo sufficient to 
cover maintenance and nursing charges as well as a modi- 
fied feo to the surgeon performing tho operation. The 
speaker expressed indebtedness to the surgical staff of 
tlic institution, who had agreed to carry out the work at a 
scale of fees much below tlie ordinar}' charges. Tlie 
schemo would, however, not interfere with the patients 
for whom the voluntary hospital was intended, and the- 
present accommodation would not be used for fee-paying 
patients, for whom an annexe to tho existing hospital would 
1)0 built, with access to the present operating theatre. Ho 
felt convinced that the decision of the governors to extend 
tlie fielrl of tho Victoria Infirmary in this direction would 
bo welcomed by a largo section of tho citizens, who could 
feel that there was some prospect of treatment being 
carried out under tho most favourable conditions, at a cost 
which it would he within their ability to pay without undue 
anxiety. 

Glasgow Royal Asylum. 

Tho annual meeting of the Glasgow Koyal Asj-liim was 
held on February 16tli, with Professor Glaister in the 
eliair. Dr. D. K. Henderson, niodieal superintendent, in 
his report said that there had been 518 patients in tho 
asylum at tho close of the year, while the total number 
under treatment during tho year had been 671, and the 
average daily number resident 527. There had been 138 
admissions and 153 discliavges, with 59 deaths. All tho 
patients admitted were private cases, and of these 76, or 
over 60 per cent., had been vohmtaiy patients. Attention 
was drown to the fact that this was a record for this 
mental ho.spital, and was an indication of the growing 
tendency in regard to mental hospitals generally. Tho 
voluntary patient made the best and quickest recovery ns 
a rule; indeetl, the great majority of patients who got 
well from mental diseases did so within the first year 
after admission. Thus of tho 51 recoveries 47 took place 
during the first twelve months of residence, and of these 
the great majority had recovered within three months 
after admission. The chairman, in moving the adoption 
of the report, said that many people were going about 
to-day whose mental balance was a very precarious affair, 
but who could not he certified as insane, although they 
were deficient in the power of adapting themselves to their 
social environment, and so did not conform to necessary 
requirements. At tho present time many sexual crimes 
were committed by these people, and he was convinced that 
the only remedial treatment of value to them would be 
confinemont in a place of custody. 

Royal Medical Society of Edinburgh. 

The animal dinner of the Royal Medical Society of 
Edinburgh w.ns hold in the Royal College of Surgeons on 
February' 16th. Dr. W. Mitchell Innes, senior president 
of tho society, presided, and the guest of tho evening was 
Dr. A. Logan Turner. lu proposing the toast of tho 
Royal Aledica! Society Dr. Logan Turner leniarked that 
Charles Darwin, when ho was a student in Edinburgh, 
attended the meetings of the society regularly, and spoke 
of it in his autobiograiihy. Many of tho students who 
were now members woxild in future belong to other socie- 
ties, hut they would always look back with pleasant 
memories to the day’s they had spent in this society.^ The 
society’ for a time had gone down, but since the war it had 
enjoyed increasing prosperity, whicli its friends trusted 
might long contiiiiio. One of its earliest activities had 
bcmi tho founding of a lilirary, which had steadily grown 
until there had now risen tho important question of tho 
accommodation .and proper arrangement of its hooks, and 
he hoped that this matter would bo settled satisfactorily'. 



324 Feb. 25, 1928] 


Ireland; 


Dr. J. A. Bruce, one of ilic .societv’.s presidents, in 
replying, said that in the present year tlio nienihei-sliip 
had showed an increase of 60, which was a reeoi’d for the 
society. Dr. L. B. AVcvill, proposing the toa.st of the 
Kdinbiirgh Medical School, said that the greatest feature 
of the scliool had been its success in turning out good 
general juactitionejs. A medical school must ultimately 
stand or fall by the average of men which it turned out, 
and Edinburgh in the ]>ast had produced ,])rnctitioners of 
great intellectual honesty, of keen observation, and ])os- 
sessed of a capacity to draw logical conclusions from the 
facts which they observed. On this type of man the 
greatness of the Edinburgh Medical School had been ba.sed. 

Attention may be drawn here to the fact 'that an appeal 
has recently been issued by the officers of this .society in 
order to raise an endowment fund of £3,000 for the pur- 
pose of ensuring the proper preservation of the library 
and rooms and of obtaining the .service.s of a full-time 
librarian. The scheme is intended to celebrate the bicen- 
tenary of the .society, which will fall in 1937, and it is 
launched at this early date in order to give membei-s an 
opportunit}- of paying ten annual conti-ibutions — if Ihev 
prefer to do so — instead of giving a liini]) sum. Old 
members who desire to subscribe to this object should 
send subscriptions to the treasurer, Boyal Medical .Society, 
7, Melbourne Place, Edinburgh. 


Ifrdantr, 


TjrtBftmw 
MedICIL J0CT.VAL 

J ho flopartniGut iii tJiis inattc'r iroiild raise no objection 
if its general policy was not transgressed— that is, the 
matron to be ])rimarily responsible for adiniiiistration and 
the medical officer for treatment. The members of the 
deputation expressed general accjuicsccnce with the draft 
regidations relating to juivate wards for ])rivato patients 
issued by the dc]>nrtmcnt, and urged that these regulations 
should be applied to all county hospitals. It was stated 
by members of the deputation that persons who were 
able to p.ay the full cost of niaintename and treatment and 
medical fees nci'e being treated in the Poor Law wards of 
eounty hospitals, and the hospitals were being freely 
utilized’ by persons not eligible for relief. Longford was 
mentioned ns the outstanding example of both forms of 
the.se ahiisrs. A thorough examination of the records of 
this and other hospitals was promised by the Minister. 
As regards the delay in appointing county medical ofliceis 
of health in certain counties, the Minister .said that the 
matter was not being overlooked, and would be pre.ssed 
as opportunity offered. As regards medical research the 
Minister said that he had had the question under con- 
sideration for .some time, and if a suitable .scheme was 
.submitted bv a committee representative of the medical 
schools ho would make representations to the Depart- 
ment of Finance for a grant. The consideration of other 
questions, relating to registration fees for births, deaths, 
and marriages, and fees for the committal of dangerous 
lunatics, was deferred, as the discussion of the previous 
matters had occupied over two houre. 


Medical Services in the Free State. 

The Minister for Local Government and Public Health, 
accompanied by the Secretary of the Department, Sir. T. 
MacArdghail, and Dr. Stephenson, lately I'ocoived a depu- 
tation representing the Irish Medical Committee. The 
deputation consisted of Drs. A. McBride, J. F. O’Connor, 
O’Brien (Wexford), McCann, Conor Maguire, Armstrong, 
and'J. P. Shanley, with Dr. T. Heunessy (Iri.sh Medical 
Secretary), and Mr. C. H. Gick (Secretary, Irish Medical 
Association). The questions raised related to the dis- 
pensary medical service, to county hospitals, to the public 
health service, and to miscellaneous matters. The deputa- 
tion pointed out the inadequate salaries jiaid to dispensary 
medical officers, particularly in Blayo and Longford, and 
asked the Blinister to regulate the salaries in these counties 
on the basis of the scales sanctioned in other counties. 
The Blinister, while fully syra 2 Jathizing with the medical 
officers, statecl that he was not at iircscnt prepared to issue 
sealed orders determining the s.alarics in those counties. 
He jiromised to ex)ilore the situation fully so as to a.scertaiii 
the most desirable way of dealing with it. Dr. Heniiossv 
drew attention to the transfer of medical officers by local 
authorities, and urged that transfer sheudd he regarded 
as iJromotion, not as iiatronage, and that seniority and 
meritorious service, and )>ost-graduate qualifii ations and 
experience, should be the determining factors. He con- 
sidered that such transfers, in the first instance, might 
be restricted to the county areas. It was suggested that 
the local autlioritv seeking to transfer an officer should 
state in the first place if it intended to limit the .selection 
to the county. Attention was drami to certain cases in 
which local authorities had not accepted the locumtcnents 
nominated by the medical officers during holiday and sick 
leave. The policy of the department to afford aU reasonable 
facilities to dispensaiy medical officer.s to enable them to 
avail themselves of their holiday leave, and the legal .aspect 
of the question, were cx])laiucd. During the discussion of 
questions relating to county hospitals the deputation stated 
that the salaries of eounty Surgeons were inadequate, and a 
scale of £800 to £1,200 was suggested. No decision was 
come to, but the Bliiiister stated that individual <-ascs would 
be examined as occasion arose. 'I’he deputation was 
opposed to an inclusive salaiy for countv hosjiital surgeon.s 
in any circumstances. The relationship of the county 
surgeon and the matron in regard to the control of eounty 
liospitals was considered, and a few alterations in the 
general regulations were suggested to strengthen tjie 
nuthority of the medical officer. Dr. O’Connor undertook 
to submit amended regulations raising the jioints at issue. 


antt Mabs. 

Small-pox in London. 

Thf number of cases of smalJ-pox under treatment in 
London on Tuesdav, February 21st, was 19, an increase 
of 3 since FebrnaiT 17tb. All these cases arc being treated 
•at the Lone Ecaeii Hosjiital of the Bletropohtan Asylums 
Board In addition 8 cases of possible infection were under 
M?servMion at the Board’s diagnosis station at Eotlier- 
hUbc as against 7 in the previous week, 3 of these 8 cases 
I J . ,Tnro on tlie point of being -diseliargcd , fi'oni 
'l" cation and of the remaining 5 it was reported that 
S 7 not dim™ as vet anv sigim of small-pox. The j.ro- 
^ 1 ““^ ia for snspcctc'd cases to co first to this Eotherliitbo 
eedme | ® n,.e seen hv the medical snperiiitcndcnt 

"r ’arnall nox smVice, who decides wlietber they should 

of t'‘%^'"‘:^ -’;’“VeTeh (to which they are transported hy 
"" mbnhni- or be returned home as free from tbo 
nver conditifin is doubtful, be kept for 

observation The majority of the eases at Long 
w * I and of the recent siisjieeted cases aro from the 

Sonthuark . < ^ iustitntion of the Southwark 

guardians A" t ^0 , proximate in this re.spect to 

no spool" ^ Uses ‘recorded elsewhere in the country, 
the ^ .^^r7he .small-pox eases in London of recent 

veai?"-lS 

rirnieiit in cliaracter. 

Royal Bath Hospital, Harrogate, 
w nnlal ronsideratioiis were prominent at the annual 
. ccT meeting of the Boyal Bath Hospital, Harrogate, 

1 inarv 15tb. T'bc secretary, in his annual statenieiit, 
m „„n,ber of patients in 1927 was eon- 

,cporlcd that the 1 rcvionsly recorded since the 

’Ld been adojitcd' of keeping the hospital open 
\ 1 D o Sr months. During the past year aecom.no- 

i'V" ^ for electrical treatment and remedial exercises had 
latioi. for oloctnc.al^^ j.ouorai^- treasurer stated that 

” £12 000 asked for in connexion with the centenan 
T ss Dian £8 000 had been received. So far as the 
nnd, % „3 concerned a financial profit had resulted 

irorMng Eawson Convalescent Home 

howed'a' deficit of £189 To complete ^’'^"la'coo' to 
dated in connexion with the centenar,^ ont~th'e very 
a,000 was still required, and for pr. 

ipcG5«nrv imnrovements proposed were at a n 


COEKESBONDENCE. 


[ Tire Britti* 
Uedicac. JoOBIfl^ 


325 


FEB. 25, 192.S] 


G'. L. Kcrr-Pringlo, replying to a vote of tlinnks to tlio 
medical staff, referred to ciirreut exaggeration of tlio cost 
of treatment at Harrogate, and mentioned that the aver- 
age was said to ho about 26s. a week. During tho four 
winter months December to Sfarcli there was accommo- 
dation in tho hospital for those who could not affoi'd the 
charges at tho Royal Baths, with rcsideuco in tho town, 
and who were ablo to pay three guineas a fortnight; many 
patients wore already being admitted each year, and tho 
number was increasing. Ho hoped that a proportion of 
the charges mado might soon bo placed to tho credit of a 
medical fund for research into rbeniuatic diseases. Most 
of tho patients treated in tho hospital woro suffering from 
the rheumatic group of diseases, and tho institution, 
already constituted a rhoumatio clinic. At present the 
.laboratory cost tho hospital £350 annuallj’, towards which 
only a small endowment of about £50 was available. Dr. 
,Kerr-Pringlo urged that more extensive propaganda should 
bo adopted, since many patients came from largo manu- 
facturing towns from tho West ‘Riding which did not 
contribute towards tho support of tho hospital as they 
might. He thought the time had como for tho launching 
of a crusade in Yorkshire against rheumatism ; Harrogate, 
owing to its site and its well-equipped hospital, might well 
be tho centre of an intensive campaign against this 
disease. 


Temporary School Aledlcal Staff’s Remuneration. 

Tho London County Council at its meeting on February 
14th decided to increase tho rate of pay of its temporary 
school medical staff. The staff is divided into two classes, 
those employed on a sessional (that is, a half-day) basis 
and those appointed on a part-time yearly engagement. 
The revised pay for tho first class will bo 30s. a session, 
instead of 27s. 6d. as hitherto, and for tho second class 
-.1 a a ye.ar for duty consisting of three half-day sessions a 
week, instead of £180. Tho first of those classes has at 
present a personnel of 22, fluctuating according to the 
nee s of the work. The second has a personnel of S3, of 
Id servo for six sessions a week (so that their 
cocci'*"'*"^''*"'"' yonr), and 40 for threo 
cxisting engagements of these 
in -n-l, exception of one who has resigned, and 

^ ^ another has been appointed) have been 

_ renewed for a further period of one year. 


C0ms|i0nircnri, 


GASTMC. SECRETION OF NEUTRAL CHLORII 

of review of tho annual r 

itself Biul Research Council I turned to the r 
St. Thniinc’c w summai-y of the work doi 

by" Professor ,g“strio physiology and path 

passage- ^ clean and his colleagues, I fiud this str 

during concentration in tho st< 

of 

tatiou of allnKtv^ J ^ ^ be dependent on re, 

chlorides which rA,-« contents. The increase in n 

acid is duo to the diminution in active hydroc 

itself. This x. ^ chloride actually secrete'’ 

-ith dogf Jied With"'r"^®'7 " 

j chmeal obsei-vatious.** 


cUnical Obsm^ations.^ 

led to this^conru'"™””'^! Professor Maclean hr 
has been known Md a ®'"®® 

of people. Now that apparently by quite a 

ment of conrli, • ''® ^'‘'’0 f*'*® 00; cathedra pro: 

.l>®foro veiwTi^'™ -ay I express the hoj 

l>acn anxiouslv h- ^® S'^en what some of 1 
fog for myself j^'^^S for— to wit, tho evidence? 
talkinc of tt,!, ^ disturbing thought 

duodenal contpntf^T''*““‘^ *'*® regurgitation 
doctrine- but if t ^ daily, teaching an er 
O’o I, am bomiri + fu bo true to the faith tin 
rao not only tbat^ Professor Made; 

lies. If error, but also where m 

for the irutif ff^to of ignorance and imp 

I may ho permitted one mild or 


I would add that I am not particularly attracted by this 
reversal of tho older custom of giving the evidence first 
and the conclusion last. — I am, etc., 

London, W., Feb. 161b. GoKDON W. G 00 DH.UIT. ■ 


THE NEW PORTRAIT OP JOHN HUNTER. 

Sir, — ^I knew nothing of Sir Artliur Keith’s discourse on 
the portraits of John Hunter until I read it in tho 
British Medical Journal of February 11th (p. 205). It 
is perhaps just as well that I did not, for, in consequence. 
Sir Arthur was free to express his individual opinion of tho 
recently discovered portrait which has been accepted and 
hung in the Royal College of Surgeons of England. Sir 
Arthur is sure that the painting represents John Hunter, 
and ho gives his reasons with his usual lucidity and 
punctilious accuracy. 

Tho ■ picture was one of 157, tho collection of Mr. 
McCormick of Hertford Street, sold at Christie’s on 
December 1st, 1922. All were distinctly labelled and bore 
great names, which in the main were not justified by the 
prices' obtained, but some were very- fine, notably Sir 
Joshua Reynolds’s “Captain Bligh," 260 guineas; a beau- 
tiful Th. do Keyser portrait of a lady, 250 guineas; and 
a gentleman by Raeburn, 230 guineas. Picture No., 131 
had been labelled by Mr. McCormick “ John Hunter, 
Esq., F.R.S., by Thomas Gainsborough,’’ but in Christie’s 
catalogue Gainsborough was not mentioned and the picture 
was attributed to one “ Seton,” whose name does not 
appear in any work of reference to which I have access. 

No. 131 hung on Christie’s wall for some days, and I 
wont backwards and forwards to the College of Surgeons 
comparing the portrait carefully with the Reynolds life- 
mask of Hunter in the museum. To my mind the picture 
agreed with tho mask in every particular. Tho wart, tho 
shapo of the nose, the sladl, wore all in tho painting, and 
the colour of the eyes, grey-blue, and the slight squint 
all agreed with what I had read of Hunter’s face. Tho 
painting was entirely in the manner of. Gainsborough, 
the coat was in style and colour exactly what I knew 
Gainsborough was fond of, and so I bought the picture. 
During Gainsborough’s fatal illness, of some months’ dura- 
tion, he Avas closely attended professionally by Hunter, and 
ns wo know that tho artist painted to the very end of his 
life, how likely that ho should ask his wonderful surgeon 
to give him a sitting. He painted Hunter exactly as he 
saw him, so faithfully described by Sir Berkeley Moynihan 
as a little ugly, red-haired, cantankerous Scot.- The truth- 
fulness of tho portrait was probably ■ distasteful to Mrs. 
Hunter, and it may have remained in the studio. 'WHieu 
her husband died Mrs. Gainsborough quickly sold off OA'ory- 
thing, and the picture woidd easily ho lost. 

'We know on the authority of Allan Cunningham that 
Gainsborough never signed his pictures and rarely dated 
them. I bought the portrait because I am convinced that 
it represents John Huntdr, and I believe it was painted 
by Thomas Gainsborough, — I am, etc., 

London, AVM, Feb. 15th. G. BuCKSION BrowXE. 


THE ACUTE ABDOMEN. 

Sir, — ^Tho admirable article by Mr. Flint in tho British 
Medical Journal of February 11th (p. 209) omits, no 
doubt from want of space, reference to one A-ery important 
early sign of a diffuse leak. This is the sign of reversed 
abdominal movements. In tho normal patient, wlien the 
chest comes out tho abdomen comes out (except in tho 
first threo breaths, Avhich are self-conscious). If, hoAveyer, 
tho abdomen goes in when the chest comes out the patient 
has a perforation of some kind and a generalized inAmlvc- 
ment of the peritoneum. It is an earlier sign than rigidity, 
and many lives have been saved by its recognition. 

I am, etc., 

Liverpool, Feb. 20tb. Frank JkaNS. 


Snt, ^In the correspondenco columns of your issuo of 

February 18th appear two letters criticizing my paper on the' 
above subject, published on February 11th. Mr. Morrison- 
takes exception to my use of the word rigidity as an in- 
dication of early mischief in tho abdomen, preferring to- 



326 Feb. 25, 1928] 


COKRESPONDBNOE. 


TrrEUams* 
WncicAt Joraxit 


1 . 


use the word rosistaiice. Ho says this is 110 academic 
quibble. I venture to think it i.s. I grant there are 
degrees of abdominal rigidity both in jespcct of intensity 
and surface extent, but in all cases tlio form rigidity 
is .perfectly correct. If Mr. Morrison will refer to a good 
dictionary he will find rigidity defined as the quality of 
resisting change of form, and I submit that exaetl.v 
expresses tho muscidar stato when an organ beneath is 
inflamed. Mr. Bankin also comments on this matter of 
rigidity. He says “ It is regrettable that so man.v )>rncti- 
tioners think- there can bo no acute lesion in the absence 
of rigidity.” This criticism cannot bo faiily levelled 
against my paper, for I state quite clearly that an acute 
appendix lying in tho pelvis may bo unaccompanied by- 
rigidity of tho anterior abdominal muscles, and also that 
it is not one of tho early signs of acute obstruction of the 
intestine.- 

I would suggest to Mr. Bankin that if he wishes to 
criticize my paper ho should read it again more carefully, 
and perhaps then ho will not accuse me of referring to 
faecal vomiting ns one of tho symptoms with which to 
diagnose an early acute obstruction, for the only occasion 
on which I mention faecal vomiting is when I .s.a*v ‘‘ faecal 
vomiting only occurs after tho third or fourth day, and 
therefore has no useful place in diagnosi.s,” and he may 
also find that I am one of “ those irho h-now what tlicy 
nre talking about.”-— I am, etc., 

Leeds, Feb. 19tli, K. B. Fl.TXT. 


Siu, — Mr. Flint’s intere.sting article on the actitc 
abdomen suggests to me tho value of a cottage hospital 
staffed by local practitioners in the treatment of acute 
abdominal conditions and in tho elimination of tho ” too 
late factoi'.” 

In tho town of 12,000 inhabitants in which I live wo 
have a hospital of this typo; it is staffed by the local 
piactitioncrs, amongst whom thoro is none of outstanding 
surgical ability. In the treatment of tho acute abdomen this 
lack of .special surgical ability seems more than compcn.sated 

by the rapidity with which — beeauso of our lio.sjrital we 

are able to act. Our patients have little fear of accepting 
our advice quickly and of being treated in their homclv 
local hospital by their oivn doctors. Becatiso the town is 
a small one, and surgical results are therefore quicklv 
known, tho population is well educated in the advantage's 
of early operation in acute surgical conditions. 

On our part we brook no delay, and operate at once 
in order to save ourselves unnecessary difficulties. As 
a re.sult of doing our own urgent surgery, we doctors get 
into the Imbit of making a definite diagnosis as quicklv as 
po.ssible, and of acting upon it; this liabit carries itself 
into our, general private work, and greatly increa.ses tho 
efficiency of all our medical work in tho town. 

Our figures during the two years in which the hospital 
has been at work are necessaril)- very small, and to that 
extent are an unreliable guide, but I believe that other 
small cottage hospitals thi oughout the coimtr.v can produce 
similar figures. Our figures are: 


Acute appendicitis 

Pneumococcal peritonitis ... 
Strangulated heniiae 
Perforated duodenal and 

gastric ulcers 

Acute obstructions 

Kupt;u-ed ectopic gestation 
Ruptured ovarian cysts 


Carps. Wortalitr. 

23 ... Xil ■ ... 0 . 0 % 

1 ... A'i/ ... 0.0% 

3 ... Xil 0 . 0 % 

7 ... Xil .. 0 . 0 % 

9 ... 4 ... 44 . 4 % 

2 ... Xil ... 0 . 0 % 

2 ... Xil ... 0 . 0 % 


Of the.se oases three acute ob.struction.5, one ruirtured 
ectojiic gestation, and three perforated duodenal ulcers 
were operated upon by a surgical specialist. The mortality 
of the 47 cases is 8.3 per cent. 

Afv own conviction is tliat the way to eliminate the “ too 


late factor ” in urgent .abdominal surgery is to encourage 
general practitiouoi\s'to undertake this type of vvork, wliich 
fs often considerably le.ss difficult than the eomplicated- 
midwiforv with which general practitioners habitually deal. 
— I am, etc., 

February IStb- 


THK FUTUBE OF OBSTETBICS. 

Sib, — I) r, B. AV. Johustono (Biiitish Mrnrc.w Joimx.u,, 
January 7t]i, p. 6) and previous writers have raised points 
of vital im|)ortanco as to tho part to be played by the 
midwife and by tlio general practitioner in the' conduct of 
ohstetrics. APo have heard the opinions of specialists, wo 
hear mnrnuirings of discontent from some of the older 
e.stablishcd jrraeti tinners, hut we do not hear much from 
those who have hut recently entered upon jiractice fresh 
from a modern training. Now in all matters of progress 
tho future must be given more consideration than the past, 
or oven than the present — often a transitoi-y stato. ' May I, 
therefore, as one of only two years’ experience in practice, 
offer mj- views on this important subject — views shared, I 
believe, by a good many of mj- contemporaries? 

If wo contrast obstetrics as carried on 3-ears ago and at 
present, wo sec that w-o have progressed from: A, an un- 
trained, ignorant, and dirt3- handy-woman, plus B, a 
general practitioner, trajned and experienced np to a point 
but without asejitic surgical and other modern methods, to 
C, a trained and certified midw-ife, plus D, the modern 
general practitioner, who has trained in an atmosphere of 
preventive and aseptic midivifcry. 

AVliat an advance is C over A 1 Equally all will admit 
that B and B hear little comparison. ’ Surely, tlieii, the 
rnoie comjdelolv do wo co-operate the two forces C and B 
tho further and quicker- do we climb up the hill toward 
ideal midwifery. The suggestion of Br. Johnstone and 
olher writers to disiiense lai-gely -with B at the actual con- 
finement in normal cases is, to my mind, a definitely 
rctrbgrado stej). , ■ 

It docs not take much thought to discover why, m yio 
minds of Br. Jolmstono and other obstetrical experts, this 
succostion lias boon fostered. It is, I think they will agree, 
largely owing to the fact that force B is not quite properly- 
fulfilling its work; partly because the whole of force B is 
not at an equal standard of modernization (time alone will 
rectif - >al) TiBt ibbcU more because B has not fully 
Realized tho advantages that tho provision of C aferds, 
him Equally C does not always realize the ndiantage 
'nomnloto co-operation with D, and is too much inclined 
to 2 upon a ease where the help of D has had to be 
called upon, either before, during, or after labour, as some- 

nafaVeSBitiou and supervision of aveij pregnant won ml 
natal ex. ^ inclined to place as the 

f ’"'pifit coudifioB preventive midwifery, 

it rbe i largely overlooked at the present -time, as 
■ 1 b e mimber of cases carried tbrongli by m.dw.ves 

bvB men arc never consulted at any stage. ^ 

"”'4 BiinS stand in our industrial areas at present^ the 
As thing consult her doctor, 111 wliicli 

‘'nse'slm rece”te^uporvisioii throughout (unless her doctor 

‘’ I 1 bif lutvl- (2) apply for' admission to a hospital, 
neglects bis dntyH l.^^^n o„te-imtaI supervision 

winch ease s P^.^ post-natal supervision is more 
consult a ’private midwife, in which ;caso she 
doubt i ; O medical supen-ision at any tiino ; (4) 

usually in chare© Association jnidwives, m 

T-®V -is^sbe niau bo referred to her doctor for examma- 
which cfise sbe « ^ ^ t],o services of a 

^“'ior'aro'quHhmuecokar^^evon sometimes after having 
doctor . 1 j,g,. o„.n doctor to attend her as well.- 

expressed in tho latter two cases is one iiistauco 

fadure^of each to realize the advantages of co-opcr.n- 
of the y It would at once be rectified by all 

t.qu with in charge of midwives, being rciiuircd 

midwives, or m. doctor for consultation, 

to refer cases j i|y clnctor ” should he the first 

"brl the cSctont mother, or tho first penson 

finenient (in all but tiic y 1 rlifFpront from 

•ui \ TTi'c flnties are. now'over, veiy cuucitm' * 


■, Feb. 25, 1928] 


COBEESPONDENCB. 


t Tnc British 
UcDicii. JorsKiA 


327 


ndequtito Iielp :vill bo avnilnblo or makes hospital arrango- 
iiicnts; bo attends at the oonfincmcnt, but purely as a 
bjstandor if labour is normal ; bo carries out ucccssaiy post- 
natal examination and treatment. 

Now this means to say that his midtvifery is not tho bur- 
den to him that it was in tho days beforo there wore com- 
petent midwivos. At tho confinement ho is not compelled to 
waste hoin-s; his patient realises that ho is engaged as a 
responsible overlooker of tho job in hand. Ho has not tho 
sliglilcst incentive or excuse to resort to forceps unneces- 
sarily, and ho quite likely may not bo present at tho actual 
moment of birth. ' During tho puerperium he is not obliged 
to visit as often, knowing that ho can roly on his midwifo. 
His fee is, nnder these conditions, quito adequate at tho 
rate at present usual in industrial districts. 

This, in my opinion, is tho ideal way in which tho mid- 
wifery of our industrial and suburban areas should and 
Cflti bo carried out. I do not consider that tho establish- 
ment of municipal clinics for ante- and post-natal work is 
the right means to carry out tho principle of ante- and 
pcst-natal supervision. Neither do I approve of sweeping 
largo numbers of normal cases into hospitals. Tho ideal 
place for the birth, if normal, of tho children of a family 
is tho homo, and tho right person to supervise that birth 
is tho family doctor. By the first confinement in tho family 
more than all else does ho gain tho parents’ trust, and it 
aiust over be remembered that, by’ tho trust of tlio indi- 
vidual family in their medical practitioner, so grows tho 
trust of tho community in tho profession as a whole. This 
trust of the public in tho medical profession has of recent 
years miQwn signs of weakening, and must bo strengthened 
as it IS of fundamental national importance. — I am, etc., 

Halifax. Feb. Slh. R. JI. PeaUCE. 


SPECLVLIST PUBLIC HEALTH SERVICES, 
fn leading article in your issue of February 11th 

Mbdstvl ‘'P"* Pearso (of the 

lioallh f eo-o>’dination of tho public 

Gloueeefor m “''"ties of Essex, Hampshire, 
BoZ v report raises 

public health issues, particularly' to the specialist 

sanitary di^rictV'^-^-tm' “!"*'‘""tion of two, three, or four 
of hoalL who ef’ 1-’'° county has a medical officer 

councf a, 0 “-of “/"‘f "''e" f"" tl'® county 

culosis officer auTsom T* officer, assistant tuber- 

welfare officer. “ctimes assistant matoruity aud child 

tuberculosis?" ""tipual campaign against 

four countific' bo pointed out that, of the 

and Hampshire ' (anT"p ' °"‘y 

culosis work undertakenT’^ I?" ^ 

Secondly the imoi i i- those “ omnibus specialists/' 
officer ihe" areas covered by tho one 
Buch areas in the mmVt° *'',‘■'‘■"60 population of eleven of 
as outlined in .vour 33,202. The scheme 

mendations of the B "lakes one of tho chief recom- 
culosis (published in ,ln^'„*®C"tal Committee on Tuber- 
Report ”) impossible f . known as the “ Astor 

mended that the +' 1 1 *^. committee definitely recom- 

Bhould bo a whole tin officer of tho dispensan 

“cnt, and sbenhi'i; ° “““‘b 

culosis to 


ment, and shoubl hn'° "fficer, of suitable age and attain 
expert on tho subject of tuber 


culosis to command expert on tho subject of tuber 
tioucrs. Is it possilila % '^'"ffidonce of tho general practi 
IS responsible at the '**' ''."’edical officer of liealtb w'hi 
tioned in Rj. Pgj, “"10 time for all the services men 
tuberculosis? IVilF ^ leport to bo a real specialist ii 
a ^nsultant? ^^y Scneral practitioner treat him a 

district is Jess public health work in a combine! 

tuberculosis. Surd,. specialized work, say, ii 

work is said to b^ * fault in other areas, where thi 
facilities to allow is the lack of prope: 

specialist, if [,g , ‘ ° tuberculosis officer to bo a rea 
be should do ehewlmrm^ 1 " areas in England (and a 
"■■tificial pueumothorn^’.. ='-’'‘''y examinations am 

ci'i better still i- ; ’ ' 1 °'^’ m in close, touch with 

’ of, hospital heds-to sa; 


nothing of noii-pulmoiiary work — surely it is entirely falso 
to Bay that such work can only ho monotonous. 

Much is often made of overlapping in county areas. If 
tho county staff arc real experts at their work tho over- 
lapping vanishes, becanso tho smaller districts within tho 
county accept the reports and work of tho county authority. 
This is what actually occurs in Lancashire, and no doubt 
in many other areas. 

Is it the jiolicy of the Ministry of Health to support the 
Echemo described and commended by’ Dr. Pearse, and to 
split up all tho counties in England into small areas? 
Everyone knows tho splendid tuberculosis work done in, 
say, Biriningliaiu, Bradford, or Sheffield. Are tho patients 
with tuberculosis, or those suspected of having tuber- 
culosis, ill a county area to have no chanco of equal 
Epecialist advice and treatment? 

Should not tho present county dispensary areas he made 
much larger instead of smaller, to bring the general 
standard of county work nearer to the best county 
boroughs? Such areas would provide for a graded specialist 
tuberculosis service with varied work and better prospects, 
facilities for artificial pneumothorax treatment and arti- 
ficial light treatment, the use of x rays for the purposes 
of diagnosis by tho tuberculosis officer, and beds in one or 
more tuberculosis hospitals, under tho care of the senior 
tuberculosis officer and his assistants for each area.— 
I am, etc., 

G. Lissant Cox, 

Preston, Feb. Mth. Central Tuberculosis Officer, Lancashire. 


SHOCK AND ABORTION. 

Sib, — ^There seem to ho two kinds of shock: that in 
which death is immediate or occurs “ in a few minutes,” 
and that in which death is delayed for several houi's, 
twenty-four or more. Shock caused by criminal abortion 
apparently belongs to the former category. “ Seiiex ” in 
his interesting letter (February 11th, p. 239) points out 
that since the passage of a uterine sound is ineffective, 
something more than the mere introduction of a foreign 
body is needed to set up " uterine shock.” 

Two factors are concerned in the production of the first 
variety of shock : (1) the mental state of tho patient and 
(2) the effect of pain. Fright, fear, emotion may produce 
such an unstable state of the nervous system that the heart 
may bo inhibited or stop on the le.ast provocation. Pain, 
which may produce faintness, and in tho case before us 
arises from dilatation of the internal os or distension of 
tho uterus, may he that provocative. Shock caused diy 
criminal abortion seems to be due to these causes, death 
being the result of an abnormal neiToiis reflex, conditioned 
by unstable nervous centres. 

The same factors arc at work in the rise of the other kind 
of shock, of which tho post-opefative'variety is perhaps the 
best example. A patient who has -made up her 'mind to 
die as the result of a fortbeoming operatiou, or one who is 
unduly afraid, is more likely to suffer from and succumb 
to shock than the individual confident in her surgeon. But 
in this case tho whole body becomes changed — there is 
something beyond a mere nervous reflex at work. The 
reaction of the tissue cells becomes abuornial, and the 
effect of these colls on the related capillai-j’ blood flow is 
thereby deranged. 

A primary universal dilatation of the capillaries can 
hardly bo supposed to he tho cause of the sudden death 
in the first variety of shock. It thus seems reasonable to 
infer that the capillaiy dilatation of tho ingravescent 
variety of shock is a Eecoiidaiy phenomenon. It is secondary 
to the deranged activity of the tissue cells — of striated 
muscle cells, of gland cells, of nerve colls. 

• All tho tissue cells presumably are connected with tho 
central nervous s}stem, and their state of being conditioned 
by ” trophic ” impressions. If the mental state of the 
patient can inhibit the heart, fright or despair produced 
by the knowledge of a serious pathological process can pre- 
sumably inhibit or derange the activity of other tissue cells. 
Added to this is tho effect of the operative procedure itself, 
plus that of the anaesthetic. Anaesthetics affect not only 
cerebral cells, but presumably other cells. Morphine, so 


328 Feb. 25 , 1928 ] 


OPERATIONS AND RISKS OF ACTIONS AT DAW. 


[ Tm’BntTM* • 
UXDtCAL JOTTRSiX. 


f.-ivotiiito a remedy for post-operativo restlessness, in iny 
opinion is a not nncoinmon precipitant of an oven f.atal 
shock. Of value in that by it i)ain is dulled, it must bo 
regarded as a most dangerous drug. 

The above view of ingravescent shock differs from the 
orthodox in that it sees as the cnu.se a primary ebange 
in tho tissue colls; the current view regards a capillary 
dilatation ns primary. But man consists of a mas.s of ti.ssuc 
cells, for which tho capillaries exist. The ti.ssue cells are 
the masters of tho capillaries, not the other way round. — 
I am, etc., 

ni.gby, Feb. litb. E. H. PAIl.\MonK, F.E.C.S.Eiig. 


eases were examined by my predecessors and forty-two by 
myself, with those results: Of 58 cases 5 were gonococcal 
= 9 j)cr cent.; of 42 cases of my oun 12 were gonococcal 
= 28.6 per cent. 

TI 16 organism usually found in the non-gonococcal cases 
was a largo Gram-positive diplococcus; in a few cases 
Staphylococcus aitrciis was isolated, and in one case only 
a long chained streptococcus. — I am, etc., 

Anne E. SoMEitronn, M.D., 

rebntarv 20tli, Patbologist to Royal JIanchester Children's 

Hospital. 


Sir, — Some few years ago I was called to a case of 
sudden death in the following circum.staiices. A young 
woman was found h'ing in the doorway of her bedroom, 
fully dressed and death Her follow servants had heard 
a cry of distress, and coming to investigate had found 
tho girl as stated. I was called in, and found a ehambor 
under her bod containing some dirty-looking fluid (a 
disinfectant), and by it a recently used enema syringe. 
The post-inorfciii examination did not reveal any vaginal 
or uterine injuries, and all other organs were ap]>arcntly 
healthy, but a 3 months’ foetus was at home. Shock from 
a self-administered injection was my stiggo.stion to tho 
coroner; but I have not yet satisfied myself where tho 
shock came in. — I am, etc., 

E. E. Nicholi., Bf.E.C.S., L.E.C.P. 

Dun&forcl, nr. Exeter, Feb. 13Ui. 


PEPTONE TREATMENT OF ASTHMA. 

Sir, — ^In tho Journal of February 4tli (p. 171) Dr; 
A. Gunn Auld, in an article on asthma, does mo the honour 
of quoting from my last edition tho sentence “ I prefer 
. . . peptone treatment to any other method of dcsensiti- 
Eation.” To prevent misconception, may I quote the con- 
text and emphasize that the passage refers to a minority 
of asthmatics — those manifesting idiosyncrasy or allergy. 

“ If avoidance of the offending antigen is not easy desensitization 
may bo tried till methods of detoxication get a chance to lell. 
I prefer Auld’s peptone treatment to any oilier method of desenci- 
tization. Sometimes it succeeds; but wlioro the mode of treatment 
advocated in the early pages of this chapter lias failed I have 
usually- found peptone fail. It may be useful where the patient 
is unable or unwilling to carry out other trcatnient. It may bo 
dangerous, and many deaths have been recorded in America after 
its use.” 

As I hope to return to this subject soon I need say no 
more at present, except that I have not used peptone for 
two years. — I am, etc., 

Glasgow, Feb. IStli, JAMES An.tM. 


I.M.S. RATES OF PAY. 

Sir, — In these days of skilled advertising why does not 
the India Office calculate what it spends each year on the 
various ranks of tho I.M.S. in pay, extra pay, and allow- 
ances, divide that by the number jmid, I'educe tho amount 
into .sterling, and publish the result as the average paid 
each year to each rank? This would surely bo a better 
adtoftisement than the rates set out in the memorandum 
which you reproduced in the Scppi.eme.nt to your last 
issue. Unintelligible annas and rupees have kept some 
candidates out of the service. Then, too, the other services 
would have to follow suit. — I am, etc., . 

W. E. Home, 

Naval and Jlllilary Club, W.l, Feb. 20lb. Fleet Surgeon. 


VTJLYO-VAGINITIS IN CHILDREN. 

gj,; I read with interest Dr. Lees’s paper on the 

incidence of gonococcal vulvo-vaginitis in children, reported 
in vour issue of February Uth .(p. 221). 

As very different figures have been obtained in Manchester 
I tluiught it might be of value to give the results of a 
survey of the last lunidred cases examined. . . 

These children were patients of one of the three following 
hospitals: the Royal Manchester Children’s Hospital, tho 
^lanclicster Northern Hospital, and St. Mary’s Hos]>itals, 
The ago limits were from 3 months to 15 3 ’cars. Fifty-eight 


OPEHATIONS AND RISKS OF ACTIONS AT LAM . 

A case licard recently at Chester Assizes^ supplies a painful 
il!nstr.alion of the risks run by surgeons of having actions 
brought against them for the manner in wliieli they face a 
grave emergency suddenly arising during an operation 

Dr B S. Graham, honorary assistant surgeon, and Dr. W. O. 
Love boitse-surgeon, whilst operating for a perforated gastrio 
uker’upon a mm named John Cliarlesworth, 50 ye.ars of age, 
at the Chester Roval Infirmary, were informed by >'« 
tbetist that immediate death would ensue if the patient i ere 
lint at once sewn up, so the operation was concluded as lapidly 

- It t;,r.sKS s 

F " 


-.viclow under ijora ^ — 

followed an .Ldainiine any, suggestion of incompetence 

Her counse, whdst disclaiming^^ contended that the mere 

nn the part of the . pnma facie evidence 

fact of against hr. LoWe broke down before 

of negligence. The ciia g b dismissed from the case 

Ihe weight of t S’tlif jury needed but a few minutes’ 

during the only possible. conclusion— that there 

retirement to arrive at tliemnlj 

was no evidenc „„mnl(>ip vindication of the manner in 


STeirvetrerwas^.'a cJm^lete vindication of the manner in 

which a 8 ^“'^ ’ jobbing gardener right up 
Cliarlesworth vv^a» admitted to the infirmary, and he 

to the evening when ! j;„t pom- 

W.ns on the operati B operating theatre, m 

nl'iHuntr of ibncss. inere j -ia a T) . P. Alexander^ 
Addition gTTe-the •anFesthetic, and the theatre 

the bonsc-phya'C'ani jiie instruments used. Dr. Graham, 

sister, who kept a tally in the course of his evidence, 

who made the me.s.on “ harnot seen so much fluid before, 
that in all '"^.‘^y^ynceeded the anaesthetist observed t*‘at tlie 
As the operation p oceeaea ^ .. to get 

patient yoa will have to sew him up at once, 

him off the Graham quickly finished oR suturing Be 

n tins dOCjBCOoy . j abdomen, whilst both- D ■ 


As 


ind if one Ukc twenty minutes, because of the 

iratracted to fact, the theatre lister’s eyffience 

lecessity for count there were, two ■o®trum 

bowed that on after a long search that one was fo 

:ounsel withdrev. . 'xu fjjg lecnl argument that g 

- content hi^eU -th the leg^^_ g pHma face evKlence 

eavmg of .tn®. -nr Graham, upon v'hom resieu 

If negligence body at o^ce 'before takmg » «’unt 

lecision to close up sbovved by" their ''ocd'ct that tb ) 


Feb. 25, 1928] 


MEDICO-riEGAlj. 


r TnrBnrrrtff 
L SIedicai, JornxAi. 


329 


Oio forceps were left in tlio body from ^v;\nt of care on Dr. 
Graham’s part. But tho mere fact ihat sucli actions at law 
arc possible ^Yhcn surgeons arc called upon to make instant 
decisions in the interests of the patient on the operating table 
is, to say tho least, disquieting. v . , . , , 

A point of some importance, not mentioned in the above 
accouk of tho action at law, is that Dr. Graham himself 
reported tho circumstances to tlio coroner, with tho result that 
an inquest was held, when all the facts came out, and tho 
verdict returned was dc.ath from natural causes — perforated 
gastric ulcer. Tho' defence of tho ease was undertaken by tlio 
Medical Defence Union. 


A CLERICAri ABORTION-MONGER. 

Tin: “Jek>'ll and Hyde” career of the Rev. Francis Bacon, 
aged 70. who, while performing duties as vicar of All Saints, 
Spitalfieicls, was also, ,'is “Howard Barron, LL.D.,” carrying 
on three businesses \Yhich advertised and supplied varieties of 
treatment to pregnant women with tlio object of procuring 
abortion, ended in a sentence at the Old Bailey on February 
20th of fifteen months’ imprisonment in the second division. 

It appeared that Bacon for many years had done good work 
in facilitating emigration among boys in tho East End of 
London, and had taken part in voluntary missionar}^ work and 
lecture tours in America. In 1917, ^Ynilo lecturing on war 
‘films, Bacon met a man named Carlton, who was similarly 
engaged, but who also ran the Powell Manufacturing Company, 
Limited, which gave advice and treatment to women in early 
pregnancy. An agreement was entered into between the two 
men whereby Carlton assigned half flic shares in tlio company 
to Bacon. Apparently the concern proved profitable, for two 
further businesses, adverli«icd as “ Dr. Mary Lane ” and 

Hannah Brown, -Ph.D.,” were started with tho same illicit 
object, the promoters employing a permanent manageress named 
^me Bolton, daughter of a chimney-sweep, who was ivnablo 
to loiiow Jier occupation as a school teacher owing to deafness. 

When the police commenced criminal proceedings Carlton 
reaped to Bermu^, but Bacon and Bolton found themselves 
!!!« 1 Bailey to answer charges of conspiring to 

supply noxious^ things to women knowing 'that they were to 
intent to produce miscarriage. “Dr. Hannali 
** 1 remedies ” lYero variously classified as : 

cmin;.n» «« 2 treatment,” price two 

mef ^0* 3 treatment,” price five guineas — the actual 

pft’pnt nf being but a few shillings. Tho cumulative 

Snv described by Sir William 

Lvneh ^edical adviser to the Home Office, Dr. 

rattg?. .-.s likely to cause illegal 

aJdot Bo'ton showed without 

Bacon and CarU object of the businesses, 

to send tho breaking the law 

time thev drpTO i? pregnant women, but at the same 

and of some month's‘'”A’"tock'V'’H " P‘'®en''ncy of » few weeks 
Etatinn that ♦I,. * ' , awek letter was sent to all customers 

pregna'nt, but "T 

treatment saiel • “f f'’® women who wrote for 

They were all suppLd'^a® I'p u® of pregnancy, 

tho counsel who Holton unhesitatingly agreed witli 

was ‘‘ eyewash " '‘er that the stock letter 

counsel to with'dniv n'”" ‘'“™''ing admissions forced her 
apleaof "TX?- p'®® "f “not guilty” and to enter 

on the shQuUle4 of ♦ 1 °'" P“®f Hacon threw the whole blame 
he s.aid, was not ‘‘ evewiO,°”“''o ‘f®f®"‘f“"‘- The stock letter, 
ment was not for o "’arning that the treat- 

them to take it an,i '"■omen was not an incitement to 

Bolton sent the fcMfmo* contrary to his intentions that 
no medical traininrr w-i '"'omen. He .admitted he had 

Brown was ‘‘ beean.o he chose the name of Hannah 

lor the business. was a good old family name ” suitable 

his use of den-ree.^'^ W*- ®®‘''rching questions by the Eecorder on 
in Canada and Tho said he w*TS given the LL.D. 

tho Recorder Bimn United States. In reply to 

Hannah Brown Ph that he used the business name of 

Mtract OiQ niiMm i deceive the public, but rather to 

SW®lly. he suS h1f™'y. it ^vas‘^a false statement. 

‘‘ Howard' Bkrrtn ^®scription of himself on a pamphlet 
ordinary commercial’ “ f'® fc®' But “ it is the 

plain duly morality. The jury performed their 

in: the second divlslAA i7' Bolton received six months 

®anying on tho frafliT fiecorder felt that she had been 

offender. , BacoTi’. °ng f°c him to treat her as a first 


despicable and"d^pnloI?5i!i'^^ described by tile Eecorder as 

an illicit traffic under 
ppon. tho aconv rf ' made, money by preying 


-fwii. uio ajTojHv maac. money by preying 

health.' A 'pr^^er^f\j5^®^"t-iJolhers,.. jeopardizing their 
e Gospel, h© had pleaded commercial 


mcralitv ^ as an excuse for deceiving the pnblic, and, most 
contemptible of all, be had sought to shield himself behind 
a subordinate. 

The Recorder, in referring to the difficulties of the press, 
seems to have overlooked tho fact that full information as 
to the nature of the traffic in remedies for “ female irregu- 
larities ” has been available to anyone interested in the subject 
since the publication of the report of the Select Committee on 
Patent Medicines in 1914. The committee recommended abso- 
lute prohibition, not only of all advertisements likely to suggest 
that a medicine is an abortifacient, but of all advertisements 
referring to sexual weakness. It also recommended legislation 
to prevent three very general practices of the vendors of these 
nostrums — namely, the enclosure with one remedy of printed 
matter recommending another, the invitation to sufferers to corre- 
spond with the vendor of the remedy, and the use of the name 
of a fictitious person in connexion with a remedy. Any news- 
paper manager sufficiently interested in the source of advertise- 
ment revenue to pursue the subject further might have learnt, 
from tlie evidence tendered to the committee by the repre- 
sentatives of what was held out as legitimate business of 
this nature, that no harm would bo done by its total 
suppression. The report of the Select Committee deals very 
lai'goly with methods of advertisement, and in spite of the 
general preoccupation with other matters at the date of its 
publication (August 4tli, 1914), its existence should not be 
unknown to newspaper proprietors. In face of this fact it is 
difficult fo agree with counsel for the Crown that “ there Yvas 
nothing in the wording of the adv’ertisements to make the 
newspapers suspicions,” or with the Recorder that “ there was 
no blame to be attaclied to the newspapers,” and that “ the 
Press was placed in a very difficult position and did exercise 
a great deal of discretion and tact.” In our opinion advertise- 
ments of this nature (however decently worded), which do not 
now appear in every newspaper, should not appear in any. 


©Iji; ^frliias. 


DEATHS IN THE SEEVICES. 

Colonel Robert Hall Forman, Army Medical Service (retired), 
died in London on February 16th, aged 73. He was born at 
Halifax. Nova Scotia, on November 2nd, 1854, the son of 
J. R. Forman, C.E., of Craigpark, Ratho, Midlothian, and 
was educated at Merchiston School and at Glasgow University, 
w'here he was captain of the University Rugby fifteen. While 
still at college he obtained a commission as surgeon in the 
Imperial Turkish Army, and served in that capacity in tho 
Russo-Turkish war of 1876-77. Returning to Scotland he 
qualified in 1877 as L.R.C.S.Ed. and L.F.P.S.Glas.. and in the , 
following year graduated at Glasgow as M.B. and C.M. , 
Entering the army as surgeon on March 5th, 1880, he attained 
the rank of colonel on January 8th, 1906, and retired on 
November 2nd, 1911. After the great war began he rejoined 
for service on .January 22nd, 1915, and served as inspecting - 
officer on the staff of General Sir Francis Lloyd, commanding ' 
the London Division. He was a keen Freemason, and devoted . 
much of his leisure to work on behalf of the craft. AYheu 
he left India he held the rank therein of Grand Master of 
Scottish Lodges in India. 

Major William Hunter Riddell, M.C., Indian Medical Service 
(retired), was accidentally killed by being knocked down by 
a motor on the Crieff-Miithill road, Perthshire, on December 
27lh, 1927, aged 45. He was born on September 22nd, 1882, and 
educated at Edinburgh University, where he graduated ns 
M.B. and Ch.B. with honours in 1906. After studying in 
Paris, and filling the post of house-surgeon of the Staffordshire 
General Infirmary, he entered the I.M.S. as lieutenant on 
July 27lh, 1907. He attained the rank of major on January . 
27th, 1919, and retired, on account of ill health, on April 4th, 
1919. He served in the recent great war, was mentioned in 
dispatches in the London Gazette of Jul 3 ’' 27th, 1916, and 
received the f^Iilitary Cross on June 24th, 1916. 


StitilTirailiis attJt (EoIIrgrE. 


UNIVERSITY OR OXFORD. 

At a congregation held ou February I8th the following medical 
degrees were conferred : 

B.JL— F. "W. Hobliousc, H. A, Gilkes, D. S. Davies. 

B.M.— U. Oddie. 


UNIVERSITY OF LEEDS. 

Du. A. Massey has beeu appo'mted Honorary Demonstrator in 
Public Health. 


330 Feb. 25, 1928] 


MEDICAr/ NOTES IN PARLIAMENT. 


^ Bninia 


iltiitical llofis in JDaiiinincnt. 

[FkoM OTO PAHUAlIENTAny CotlllESrONDENT.] 

The House of Commons this week gave the Comiiaiiies Bill .and 
minor measures a second reading. In reply to a question, on 
I'cljruary 16th, the Home Secretary said that owing to pressure 
oi business he was not at, present able to introduce legislation 
on juvenile oTenders and on sexual ofleimes against young 
persons; he would see what could he done hy administrative 
action. He hoped that a report would he published this voar 
covering the work of the Children's Branch of the Home dflicc 
mnee publication of the last report in 1895. Supplementary 
Estimates^ were discussed on February 20th and 23rd, and an 
^nipire Settlement Act Amendment Bill on Fehruary 24th 
Hebiites regarding hospitals and medical affairs under the 
National Insurance Act arose on February 20th 


t Medic it jovaint 


Parliamentary Wedical Committee. 

t "^SooD meeting of the Parliamentary Medical Committee 
for 1928, on February Idtli, Dr. Fremantle was rc-cleclcd 
c lairman ; Dr. Vernon Davies (acting honorary sccrclarv during 
the closing weeks of last session) being absent no honorary 
secretary was elected. The committee decided to trv to arraiig*c 
a visit to the army medical establishments at Alder.shot, and 
a so another visit to the Medical Research Council's institutions 
at Mount Vernon and Mill Hill. The committee fiirtlier dis- 
cussed the hill introduced by Sir R. Gower against experiments 
on dogs. A suggestion was made that amendments to the bill 
^loiild be concerted between the committco and the Research 
Defence Association and put down. After a discussion on 
saccmation and small-pox tlie iMedical Committee agreed to 

reno,\’^ ‘o Pi'l'l'sli as soon as possible the 

repoit of the Committee on Vaccination. This report is iindcr- 
slood to have been completed. 

Edinburgh Corporation Bill {Vcncrcni Dhemef). 

♦ ff' Shiels drew the attention of the committee 

to the Edinburgh Corporation’s Bill already laid before Parlia- 
ment. The object of this bill is to secure further compiilsorv 
powers for dealmg with venereal disease. (See this ^iveck’s 
SCPPLEMENT, p. 66.) A letter from Mr. W. Graham relating 
the* fact ILT'T the comniittec. whicli look note of 

Siltfe members Dr. Grahnni Little and Dr. 

Saltei, had Js&ued an invitation for momhors intero.stod in Ihe 
mihject to meet and concert action in the House of Commons 
Jf’tl CpminRtee agreed that the hill raised questions 

.4a 

Tlie town clerk of Edinburgh said that the corporation Teco^' 

n ‘I'® suggested but 

tbouglit that the proposal made by tlie bill wire till best 
which Jiad been siipested to check the spread of venereal 
infection. Edinburgh asked permission to use these 
as- .-in experiment. Certain members of the Medic.al rnmO^ilf 
asked why Edinburgh did not secure colmihon 
of- venereal diseases, as Bradford had done The ansi 
that the corporation thought the proposals of the ‘biirbetleO 
and in accord with the Irevcthm report. The oflieisls ib? i 
that, . as Bradford had secured compiiIso.O po^lrO f.3 
Parliament without debate, Edinburgh was entitled to Ii 
its case heard before a parliamentary committee TW 
reported that at a conference of the large local authorities of 
Scotland all had declared themselves in favour of the Edinburgh 
proposals. The corporation ■ was prepared to give some pro 
tecHon to doctors who reported suspected cases, and was ready 
to add a protective clause to the bill if this were_desired. The 
discussion, which lasted about au hour and a half, showed that 
the Parliamentary Medical Committee was united in support 
of the obj'ects of the bill, but no verdict on its propos.-ils was 
suggested. (The statement for the Edinlnirgh Corporation 
which was the subject of -debate -by the Parliamentary Medical 


Cerlification under the National Insurance Acts. 

w, •, „ vr °!/ainst Panel Doctors. 

iis,'”,”” ■ 

f,.. 1 ?- ' of the Ministry of Health includine 

|,i.irits m aid HI respect of benefits and expenses of administn^ 
Lou under the National Health Insurance Acts. In thrvofi 

ni-dernhv td" 0.3 f dYsaMenilnt 

P'esentiiip the Estimate, explained that 
fho £210,000 was necessitated by the continuing higli exneiidituio 
on benefits by approved societ/es. There had® been a3™crel? 
in the nimbcr of attendances of insured persons for medical treM? 
3" n- for benefit had been made very freely, this state 

of affairs no do-jbt being accentuated in a- time of considerable 
uncmploymont It wag v-rv db.'- ibi-: The Ministry 

ol Health had taken . ly . o; : - -i-u i-;. of reminding 

socieUes of the need of ■ ; ;c- .c-i: im ■ i!. . .... of insurancS 
Claims by .such moans . as improved sickness visitation and tlie 
use of the regional medical services. The matter had been con- 
stantlv discussed with the medical profession at many conferences 
and the British Medical Association had the matter under close 
consideration as a result of a meeting with it on January 19th 
last. New regulations were brought into operation from October 
1st, .1927, whereby a fortnight’s delay was imposed on the transfer 
from one doctor to another, except where both*doctors consented.- 
That miglit have some material effect on these claims. 

Mr, Rhys Davies said that they were informed that 150,000 
pcrson.s Iiad come into the health insurance scheme as voluntary 
contributors under the Widows’ and Orphans’ Contributory Pensions 
Act. This was about 10 jier cent, above the estimate of tho 
actuary. Proceeding to criticize the medical profession, he said 
that what they were failing to do accounted more than an\-thing 
else for this increased expenditure. Three of the approved 
societies in Durham had complained about loose certification. So 
far as he was aware, no approved society declined a genuine claim 
for disablement or sickness benefit* but wlien they were suspicions 
that -a doctor was giving medical certificates merely to increase 
the number, of insured persons on his panel, tho societies were 
entitled fo say that that doctor should be stopped. In the 
course of tlie discussion they would no doubt oe told that 
tho panel doctor could not increase the number on his panel 
merely by granting certificates loosely. Tho Insurance Com- 
mittee for ibo county of Durham had passed a resolution 

asking the Minister of Health' to conduct an inquiry into 

this subject of loose certification. What was tho Minister of 
Health doing about it? As a matter of fact, the Minister was 
afraid of tlie medical profession. When it was' a question of 
dealing with a board of guardians they had heroics, but -when 
the British Medical Association was “ on the job,” then the 

Minister quaked at once. (Laughter.) Was it true that this 
increased expenditure was partly due to the fact that tho stamina, 
of the people liail deteriorated because of poverty and destitution? 
(Cric-s of ‘*’No.’') Was it the experience of the approved societica 
that (he increased sickness was greater, in the distressed areas? 
That could easily be found out. He would give figures to prove 
that where a panel practitioner had a great number of persons 
oil liis panel he was not so careful in prescribing. Where a doctor 
had 2 500 pci*sons on his panel the average frequenc}’ per insured 
pei-son in connexion with prescriptions W'as 0.354 : wlicn he liad 
fewer than 1,000 pei'sons on his panel the average frequency was 
0 237. There had been several allegations in Salford that doctors 
had been ** touting,” and he understood that there had been an 
inquiry into the allegations. He would like to know what was 
the result of that inquiry. He ^Yished to add that the medical 
profession as a whole could not be charged with doing what ho 
had sut'gestcd. Tliey were not guilty of it, but only just a few, 
who ou"ht certainly to be bi-ought to book by the Ministry of 
Health '’and made to do their duly to the State and to tlio 
approved societies. • 

Some approved societies, Mr. Davies .said, had to realize their 
investments to meet the claims for benefit. That was the most 
serious aspect of tho work of the societies, and this was the firet 
lime that' Ihev had been in that position. Wore it not for tlio 
interest on their investments, the approved societies would now be 
headin' 


" tue suujecL -ueuctie iric x aiji<iiiieiiiarv Jlcdical 

omniittoe and representatives of the Corporation is referred 
jn Scottish news^nt page 323 of this issue ) ^ 


on Ihoir investments, tne approved societies would now uc 
straight for bankruptcy. In 1926 the total sum brought 
— •■'*ies* funds in contributions amounted to 
• grant was £7,000,000, and the interest 

; t-a total of £37,000,000. Payments out 

for benefit amounted to ±;30,000,000, and the. cost of administration 
■WHS £5 000.000. That made a total of £35,000,000^ and left a 
balance of only £2,000,000. The interest on' investments of 
snripfics out^ht to be safeguarded by the Minister of Health, but 
he had been browbeaten by the Chancellor of the Exclicnucr. 
Did the extension of the .average age of the insured persons in 
the last decade account for the increase in the average 
sickness^ He wished to ask some questions on the work of tne 
rct'iouar medical officer. Was it a fact that some panel doctors, 
wiio were in practice themselves, were also acting 05 regional 
medical officers? He took it for granted, of course, that a panel 
doctor did not become a judge of his own case. How manr 


doctor did not become a judge 

regional medical officers were there, and were iney siuncitiiii 
How raanv regional dental officers were there? Tlie work o. (hc.so 
officers had been very good; were there sufficient to carrj* out 


MEDlCATj NOTES IN PABEIAMENT. 


t Tm PTimsB 
ZlZDICXl. JoCBKlXt 


331 


Eeb. 45 


, 1958 ] 


llm task? The Minister of Health might consider tho appoint- 
ment of someone to act in tlio same capacity m relation to optical 
^^catment and appliances as ho had done in regard to dontistry. 

Metier said that ho was very glad to find that. in his 
reference to tlio sickness cxpericnco of societies Mr, Davies had 
not alleged that there was malingoring among insured persons. 
Malingering in this country was very rare, and ho hehovpd that 
the malingerer was made, and not horn. If nny malingering had 
occurred 111 conneiion with tho sickness cxponenco of societies 
in this country it had hccii duo very largely to the lax iiiothods 
which had been adopted by tho medical prnctilioiicrs. Ho joined 
■with Mr Davies in saving that, nlthongh the allegations which 
ho had made willi rcganl to doctors were extended only to a few, 
and although a verv largo proportion of them endeavoured to 
carrv on tlicir \York quite fairly and properly, in the best 
interests of their patients, there ^Yc^o unfortunately many 
instances in whicli doctors had not paid that regard to tho 
patient which they ought to havo paid. Tliey liad been freo 
enough to give medicine where mediciuo might not havo been 
required, but slow in giving what ho believed was very much 
better than many bottles of medicine— that was to say, to giro 
B few healthy admonitions and send them about tlieir business. 
The medical profession had said that their difficulty had arisen 
from the fact that they found it extremely hard to maintain 
the patients on their panel with tho competition of other doctors 
In the neighbourhood. Many a man started to-day, not by buying 
his practice, but by putting up his plate and ^ hoping that the 
number of insured persons would bo fairly distributed in tho 
district, and that ho would get his share. It was nob pcriiaps 
unnatural for him, when ho was told that the patient was 
suffering from some complaint which ho could not diagnose and 
which he could not disprove, to give liim his certificate quite 
readily. Tliero had been instances— and a good manj^, unfor* 
tunately — of medical men tbcmsclves saying that patients had 
come to them, and had said, “ If you do not give tlie certificate 
I can get one down the street,” The medical man, in such a case, 
had found himself in the dilemma of either retaining tho patient 
or seeing him go to another doctor down tho street. In that way 
ho might lose not only insured patients, but patients who were not 
insured poRons. It was a difficult position, and unfortunately it 
seemed to be spreading. The best men in the medical profession 
were standing out- against it, and wanted to stop it. Ho believed 
that the Ministry of Hcaltli was anxious to assist tho strong 
doctor m resisting these unfair claims upon him and the unfair 
wmnetmon of certain men in the profession. Ho regretted very 
JDin comparative case of trans.fcr from ono panel doctor to 
another which had been allowed. Under tho old system, when 
1 • or even a year was required, there was 

^ Pcrson, but it gave the doctor the 

Stirr ‘'*5 to act. The present 

niompnf' opportunity of transferring at any 

® proposed 

notice a mnn commou practice that, with a fortnight^s 

SnSr transfer from ono doctor to 

thhiff fhft rinSiir might havo been upset by some* 

Indeed improper and ought to bo stopped. 

B that the medical profession was in favour of 

Tho re/iooH? doctor to another, 

it was some time ago because 

made uno« f^.^^ry large number of claims were being 

Certificates nf grounds to justify them, 

tinuine for somo ^ minor ailments, eucli as dcbilitv, con- 

mcans of cbecl-intr ti’ and there W’as no satisfactory 

regional medical nffif-o ° ^^^'^reupon tlio Ministry set up 

oAhe M^nistf The report 

to the nuUS of "dtU regard 

Some 420 cases were O'^^^^ination in that year, 

regional medical u societies to be examined by the 

■ to tho genuine societies had some doubt as 

There wero 450,000 cases^^referred^ persons concerned. 


persons 

and of that number about 


found to bo before the examination or wero 

tho^ people . who^ bad Wn rof only about 40 per cent, of 
to bo incapable of wort -Tt by the societies were found 

wrong in a method 'of i • there was something 

be issued in resnect nf oidication which allowed certificates to 
havo been issued and +h-»V cent, when they ought not to 
Incapable of work. If if ^ cent, of the cases -were 

further overseeint^ of tlm that further examination, 

request of Mr. l)avip<! men, was needed, he Iioped the 

Bomo reference had be^n acceded to by tho Ministry, 

medical officers were in ^^^t that certain of these 

Maminations as part-timo ^nd -tt’cre conducting these 

bo stated that they did nnf fairness to them it ought to 

be agreed that it would within their own area, but 

medical referees entirelv fro much belter to have these 

ro iho work of examininrT nor i suspicion, devoted only 

Hr^i^®J^P?Iby of the Minis^trv ^°d not having to bring 

Mr.^ Barker said that ViJ; ^ health. 

Bnd m Monmouth eenpr<jiu*^^®dmn of health in liis constituency 
Ibere to-day than boj deplorable. Tliere was more 

nfT«^ui®^®d statistics from il bnown for t-wenty years. Ho 

•health of Brynmawr urhn .^^porls of the medicai officers 
tho medical officer for tbp district and of Nantyglo, and from 
in P^i'.licularly with fim Monmoutli. Mr. Barker dealt 

liA^m ®P^”^on, partly duo small-pox, which was, 

calth of the worl-ino. of sufficient nourishment. Tho 


caiUi of the working cla«;«:*xc i sufficient nourishment. Tho 

Dr'Vernon^’D^ endangered 

Siich^rniM^®f^^®d*attack seemed to be in that debate 


®iobt to a certain tlie medical profession, 

ut havo been justified, or might not. 


Ono of tho fundamental difficulties of the National Health Insurance 
Act w’as the question of certification and the free choice of doctor. 
Tho whole system of medical behaviour between doctor and patient 
liad been altered. In tho old days tho doctor as a rule was the 
friend, helpmeet, and medical adviser of his patients, and his 
patients trusted and obeyed him. But the Insurance Act created 
a new state of affairs, and the medical man, instead of being tho 
master, became the servant, and was now absolutely the servant, 
of tho insured population. They could take him on when they 
liked and dismiss him when they liked. Panel practitioners were 
^hitman beings, and, in tho majority of cases, had their living to 
earn. As a rule panel practitioners were^ as good or as bad as 
ordinary indiriduals, and they could be divided into three sections. 
Thcro was tho man wlio was conscientious, honest, and determined 
to do his best, and, at the other end of the scale, they had the 
man who was perhaps not so particular; he would nob say that 
he was dishonest, but perhaps he was a little lax and careless. 
Between these two extremes was the man who wanted to do what 
was right, and was not ablo to do so. What was the reason? 
A patient came to tho doctor to get a certificate. The doctor, if 
ho was honest, as all doctors W’ould like to be, gave a certificate 
if ho thought that the patient was entitled to it. The difficulty 
did not occur at tho onset of the illness, but tow’ards the end, when 
tho patient should go back to work. The doctor rnight think that 
tho patient wms fit for work, but the patient might think that 
ho was not, and desire to draw benefit a little longer. The 
honest, conscientious doctor would cross tho man off; but the 
doctor -who was not quite so particular said to himself : I might 
as -well please my patient.” The other man perhaps said : ” It is 
my object to bavo as many patients as I can, and if I can please 
my patients it does not matter about the national health 
certificate.” So long as they gave the patient the free choice of 
doctor they would bo up against that difficulty. The difficulty did 
nob always end there, because the man might have a family of 
five or SIX children who were private patients. The man miglit 
leave tho doctor and not allow any of his family to go to him. 
Moreover, tho same man might say to his friends that Dr. So-and-so 
was too particular and signed one off far too quickly, 

TJio doctors undoubtedly were to blame in certain cases, and 
lio had no desire to stick up unnecessarily for the medical pro- 
fession. On tho otlier hand, they must remember that they were 
putting very great temptations in the doctor’s way. The doctor 
was in a very difficult position. He might be deceived by patients 
in certain cases if the patients wished to 'deceive him. On the 
other hand, tho doctor was up against the approved societies, who 
were an extremely foolish body of individuals. An essential 
point in the administration of the Insurance Acts was that the 
medical man, the approved societies, and the chemists should work 
together, because liieir aims wero the same — namely, to keep tho 
insured persons healthy and to administer tho funds to the best 
advantage. The approved societies did not like to pay benefit 
if they could help it, and when benefit was paid they wero 
anxious that tho patient should get off benefit as soon as possible. 
He would not say that they went spying round, but they sent 
their visitors, and if a poor woman happened to be lifting a 
kettle off the fire, or if sbo had a duster in her hand, or if a man 
happened to bo out one minute after six o’clock, there was trouble. 
Instead of working with the medical men societies were too apt 
to send cases to the medical referee. Ho had found, over and over 
again, when ho was in practice, that the majority of cases thus 
sent to tho medical referee were the absolutely genuine case®, 
and the particularly doubtful cases bad never been spotted at all. 
If the approved societies had asked his honest opinion they would 
havo got it, and, in that event, they would have been able 
to send to the referee the proper cases. They had worked against 
the medical men because, in the old days of the club, they had the 
medical men under their thumb, and they had never forgiven the 
Ministry of Health and the Government for deciding that the 
doctors should not be put under the approved societies. It was 
absolutely necessary that they should make tho right of free 
transfer very much more difficult than it was. No patient should 
be allowed to transfer without giving a specific reason. Mr. Rliys 
Davies had said that there had been a lot of over-prescribing. 
That -was true; but again the doctor was in a verj' difficult 
position. If a patient said ho was ill and^ wanted a bottle of 
medicine, and- the medical man refused to give him one and told 
him to go home and do something that would do him good, the 
patient thought tliat he was not being properly treated, and that 
the doctor was no good. Such a doctor might find that a com- 
plaint had been made against him to the Medical Committee or 
tho Insurance Committee, and that might cause him some trouble. 
Therefore, when a doctor had a discontented patient he gave a 
bottle of medicine. Fortunately, people were nowadays getting 
better educated, and recognized that medicine was not always 
necessary. At tlio same time there was in the industrial popula- 
tion the greatest belief in the efficacy of a bottle of medicine, and 
they could not afford altogether to neglect its psychological 
effect. He thought that a panel of 2,500 was far too many for 
any medical man. As a rule, doctors had private patients as well 
as panel patients. The danger was tliat a doctor miglit miss 
sometliint', and then there was a scandal. But what was the 
doctor to do? If a doctor had 2,000 patients on his panel it 
meant about £800 a year. That sum did not go /ar, as tho 
expenses of a doctor -n-cro appallmg. The result was that a doctor 
must have a big panel to make it a paymg proposition, and it 
they gave him a big panel he could not do the work properly. 
At some time or other ho was bound to neglect it, and there would 
bo complaints. "Touting” for patients was ano her curse of 
tho Insurance Act. Since that Act came into force the 
standard of medical men had deteriorated, and there was not 
the same class of men coming into medicine to-day as there was 
fifteen or twenty years ago. Therefore they would get these 



332 Feb. 23, 1928] 


MEDIC&n NOTES IN PAKLIA3IENT. 


r TflJ- EttinsR 

iilriircAL Jocr-SAL 


cases of “ touting -vvlierc a young man nnxiou'^ jo make ft 
practice ^vouM do something or other to get others in. 

Mr. ‘Whitcley said that llierc Iiad been loose cerlificntion in 
Durham. There was a great dc.«;irc in the counl5' Uml tlicro 
should be an inquiry. Something ought to be done. 

Sir K. Wood, repl^dng to the debate, said that the incrcn’?e 
in the level of sickness had been pretty general, and was not 
clmractcristic of any particular industry. He wislied to correct 
the view that had been put forward as to the number of 
insured people who were permitted to go oii llie p.ano! of a 
particular doctor. The maximum number of insiu'cd persons per- 
mitted to a single panel doctor was 2,000. The average number 
ol insured persons on doctors’ lists np and down the country wfts 
not anywhere near 2,500, but about 1,000. It was a matter of 
considerable controvei*sy and anxiety why the very large sum of 
money provided under tlic Insurance Act for sickness benefit 
should have been exceeded. It was true that the influcnta 
epidemic did not wholl}* explain the persistence of high expendi- 
ture, and it might be that insured persons were looking more 
carefully to their rights under the Insurance Act, and that their 
claims for benefit were being made mucli more freely. The 
statements which he had made in that House twelve months ago 
had been very amply confirmed in all parts of the House that 
night. He found that the number of cases referred to the regional 
medical ofRcei-s for a second opinion rose from 201,291 in ifel to 
577,180 in 1926, which was an abnormal year owing to industrial 
troubles, and was actually 313,011 in 1927. Comparing the figures 
of 1927 with those of 19&, he found that the number of poi-sons 
referred to the regional medical officers had increased by 55 per 
cent. These were astonishing results, because tlie proportion of 
persons examined who were found to bo capable of work had 
increased from 24 per cent, to 28.8 ncr cent. Another astonishing 
figure was that 44 per cent, of tlic people wlio were referred 
to the regional medical officci's failed to attend llie cxainination or 
declared off before the dale of their examination, and the pro- 
portion of persons referred for examination who came off tlic fund, 
either by failing to attend or as the result of tlie meilical cxamiiin- 
lion, increased from 57.7 per cent, to 59.8 per cent. He was 
not going to endeavour to say who was responsible, wJicther it 
was the people Avho presented themselves for examination, or who 
failed to attend after notice had been given to them that their, 
case was going before the regional medical officer, or whether it 
was due to faulty certificates by the medical profession. But 
these facts showed that the approved societies and the medical 
profession of the country had seriously to take this matter into 
account, because this excessive sickness was bearing on the 
approved societies, aud the people who liad to stand the racket 
in the end wei’e the insured persons. It was only riglit that the 
greatest care and precaution should be taken in the administration 
of their affaii's. The investigations into sickness ought to be of 
variou.s kinds. In the first place, the Ministry had impressed on the 
approved societies their responsibility in the matter. In the second 
place, the Ministry had had a conference with llie British Medical 
Association, which was engaged in an inquiry into this particular 
matter. Thirdly, the Ministry had advised tlie increased use of 
medical referees. The department was anxious to obtain, as far 
as possible, self-government by llie approved societies, and that 
national insurance should be conducted by the societies themselves. 

Mr, Rlij's Davies: Is the riglit hon. gentleman aware that the 
approved societies have little control over the medical profession? 

Sir K. Wood said that Mr. Davies knew the difficulties and 
delicate matters that obtained in a profession of this kind, but 
ho thought that a very fair balance had been struck belwceu tlie 
representatives of the approved societies on (lie one liand and 
of the great profession on the other, “ You cannot,” Sir K. 
Wood continued, make the medical profession the servant of 
the approved societies, but, administering as they do an Act of 
this kind, they must be prepared to obey certain rules and con- 
ditions which I think are fair and sufficient. This discussion will 
serve a useful purpose in bringing these facts before the country, 
and the House has seen the serious state of affairs as far as 
sickness is concerned. Tlie speech of Dr, Vernon Davies was a 
reasonable one, and did not disguise the seriousness of the 
position or the fact "that there are a large number of people 
obtaining benefits which they ought not to obtain. Everyone who 
values the work of the approved societies must realize that 
these things must stop.” 

Dr. Watts remarked that he held no brief for the panel 
doctor; indeed, his personal opinion was that any man in the 
medical profession who accepted service under ' the National 
Insurance Act deserved what he got. Tlic Act had had nn ill 
effect on the health of the country generally. That Act v.as (he 
greatest fraud ever perpetrated upon the country, and it should 
bo repealed^ In regard to certification, the panel doctor naturally 
took the line of least resistance, and accepted the statements of 
his patients, as it would be manifestly impossible to make a 
thorough and detailed examination in each case. Therefore it 
was unreasonable for membei's to blame panel doctoi's — foolish and 
mU^uided though they might be to take serdco under the 
Insiirance Act. Unquestionably the approved societies had of 
Ia(c*vcai-s been culireiy wrong in their adniinistralion of the Act. i 

The Estimate was agreed to by 189 voles to 96. | 

^iiiisirv of Pevstions Ho'^pUah. 

The Hou«:c of Commo'ns, on Febiatary 20th, went into Com- j 
a^ittoc of Sapplv on a' Supplementary Estimate token vole of £10 
for expenditure* in respect of sundiy public buildings in Great i 
Britain not provided for in other voles. Sir > . Henderson, Lbidcr | 
Secretary to the Home Office (speaking on bc-hali of the First i 
Coinmi^ioncr of AVorks), explained that this token, vole was I 
really in connexion with the provision of hospital accommodation * 


in B ncH- Ministry of Pensions liospitnl at Diinslon Hill, Ncncastle- 
on-rjiic. _ Tlie new Iiospital -ivoulcl deal with genera! medical 
anoo ^*nses. The present liospital had hcen in use since 

IjKU, but (he Bccommodalion there was more than was required. 
IJie jmesent Iiospital accommodated about 4S0 patients wherens the 
actual requirements at present did not c.xceed 120. The nurses 
employed at the liospilal were quartered some dktance away. It 
I M decided to re-houso the patients and the mirecs in one 

building, and arrangements had been made to lake a lease for 
^lU’leoti years of Inc old manor liouse and grounds known as 
Diinston Hill, five miles from Newcastle. The lease was deter- 
minable if necessary at the end of seven vears. The cost of the 
alterations and works services would be "£22,565. The building 
would hoii^c 120 patients and tlic nursing staff. The ic-Iiousing, so 
far as the nurses were concerned, would be complete by July of 
tins year. It was estimated that there would be a saving on (he 
new scheme of £6,800 a year. It was possible to deal with the 
matter by a token vote, the necessary money having been obtained 
from savings on certain other services. 

Licut.-Commander Kenwortliy congratulated the Ministry of 
Pensions on deciding to remove this hospital out into the countiy. 
The lease of the new hospital, he said, was too short; it ought to 
liavc iiccii for ninety ycai-s.^ After the hospital ceased to be neces- 
sary for the use of cx-service men it could be taken over by the 
Slinistrj' of Health and used for the treatment of tuberculosis. 
Tlicre was a tremendous shortage of such hospitals on the North- 
easi coast. He believed that the real solution of the difficulty 
would be to liavc Government hospitals in the future. 

Sir V. Henderson said that it would be out of order for him 
to deal with the question of the futui*e of the hospitals or the 
question of their control by the Ministry of Health. The Office 
of Works considered that a fourteen years’ lease was Bufficienl. 
Tlic new hospital would be well away from the road and the 
liouse stood in its own grounds. The House agreed to the vole. 

Major Tryon Glalcd, on February 16lh, that the three Ministry 
of Pensions hospitals in Scotland— Bellahouston, Craigleith, and 
- Edcnhall— iiold only 226 in-patients on February lOtli, as compared 
^ritll 557 on the same date in 1926. Arrangements had been 
made to close Craigleith liospitnl at an early date. The Ministry 
would retain hospital accommodation of the best quality m 
Scotland under its own control so long as it was nwded. 

Sir L Worthington-Evans infonned Colonel Woodcock that 
3 454 beds were available in the military' hospitals in this 
coiintiT-' the maximum number occupied on any one date last 
yenr was 5,277, and the annual avei-ago occupied was 2,061. 


Control of Venereal rase, 

T fiilmour replying to Mr. Buchanan, on February 21st, said 
ii^t iirB A ieust 1921, resolutions in favour of the general pnn- 
i of comnulsori- nolificalion of venereal disease, in pi^ fora or 
?md been submitted to the Scollisb Board of Hea th by 
renly'ninf burgbel V 

authorities >'eP,';«*«"V'W„vaf§urSi 
bv the Convenliou of Eo>a! Burgh 
ti a deputation about a year ago, 
milW hMification. .In 

rto'pJblic HeaHb'TsoolIandT Aetasgr, lyonld bo an appropriato 
method hf view of the fact that' Certain 

^p™a"^ for powers, it would no 
corporations /aarc app pj.ajited any powers, that full 

be belter, sliould be^instituted V the Department, 

inquiry into ^ . mneli the best way would be to allow the 

Si? J; Gilmour: 'f;’ X House E. Brown asked whether 

matter to be ],nii not also received a number of strong 

the Secretar.y for Scot^nd hay or^a^^ , 

P''?ffl %X'rad «cei'4f communications, both pro and con Mr. 
said that be bad against the best interests of goicrn 

Hardie asked “ , I things by piecemeal, such as 

ment., cither another. wJs it not better to 

dealing and then to legislate? Tlie Sppeber, mte- 

bave a full cc"ev.> , ^ mallei' to bo discussed on the bm 

takls “ or Sver the dog to a police officer of the 

dog to its 1° iho dog was found, and "ifc™ ® nre- 

police area found.’’ A fine not exceeding 403. is P 

Tcribld for faVc to comply with this eubsec 

EdCtorp In^pccto^ i?n.^BS;4®‘tMaY4brslag- 

two m^pectois a^ an inspector, Ydors 

brfillcd''shorn.v. Tlio staff in 1914 consisted of sixteen inspe 

and five assistants. , , n t • Pmokshank, 

.a case. Captain Crooksbank f bed wimty “ « .and Trade 

now modify bis action seeing that the O-'rade uispuit 


Peb. *3. 1928] 


MEDICAIi NEWS. 


L DICAl, JoCnNAI. 


Unions Act, 1927, forbade local Ruthontics to Uj down tho condi- 
tion that (heir employees should bo members of trade unions. 
Mr. Chamberlain said the Act contained such a provision, but ho 
did not think it applied to this ease. 

Wingfidd OrihopanUo ffospital-^n reply to Sir Robert 
Hamilton, on FcbruaiT 16tli; Lord Euslacp Percy said that on 
\pril 7tb, 1927, the medical inspectors of Ibo Ministry of Educa- 
tion at the close of their inspection of the Wingfield Orthopaedio 
Hospital, Hcadington, Oxford, conferred with Uio houso com- 
mittee at the request of that body, and in tho course of tho 
discussion commented advci-scly on tho clhcicncy and suitability of 
the secretai-y of the hospital and of tho manager of tho work- 
shops. The ‘ inspection was under tho Education Act and in 
accordance with the usual practice. Action subsequently taken by 
the niauagci-s was at their own discretion. 


Tinned Foods . — Tho Minister of ncalth is advised that the 
nutritive value of tinned foods is, in general, comparable with 
that of other cooked foods. Ho has no evidence suggesting the 
necessity for him to set on foot expert inquiries into the effect 
of these foods on the public health. 


Infant Death Date in Countp Durham. — Mr. R. Richardson, on 
February 16lh, asked if Mr, Chamberlain’s nllcnlion had been 
called to the report made in December, 1927, by tho medical 
officers for Cbester-le-Strect and lloughton-lc-Spring, and again 
in January for Houghton-lc-Spring, to the effect that the infantile 
mortality rate in Hougbton-le-Spring was over 200 and in Chestcr- 
le-Slrcet 147. Mr. Chamhcrl.'iin .«;aid lie had not officially received 
these reports, but would obtain them. Mr. Richardson asserted 
that medical officers in various parts of Durham had reported 
inci’cases in the infantile mortality rale, and had expressed the 
opinion that it was largely due to lack of nourishment for mothers 
and children. 


in Drivf» 

Three out of Uie neccs«;ary seven signatui*cs by nicnihci’s of the 
Louncil of the I.eaguc of Nations are still lacking to tlie Inter- 
national Opium Convention, signed at Geneva in Fcbniary, 1925. 
On Februan* 20lh Sir Shirley Bonn presented a bill to amend 
le law mlatmg to the marriage of persons with their nephew 
or inece by marriage, and it was read a fii-st time. 

Opium cxportcd from India in 1926, 
opium sent to this country. In 
1 nsp Tnn produce of the ncrcagc, in Hritisli India was 

I,re2,700 lb. Figures for lOT arc not yet available. 

Board” '"'® present recognized by the 

auDroTsd ?''® P‘®™ion of two olirci-a has been 

approved, one of which is now in course of erection. 


avbo intoiul to be present are ashed to inform [he secretary' of 
tho British Euipiro Cancer Campaign, 47, ParkSqnaie, Leeds, 
at least two days before each lecture. The eonrsc is free to 
medical practitioners, and tea will be provided. 

The Fellowship of Jlcdiciiie announces that Dr. Neill 
Hobhonso will give a lecture on amentia in relation to 
cerebral disease and abnormality on Febinary 27tli, at Sp.iii., 
at tho house of the Medical Society of London, 11, Cbaudos 
Street, W. There will bo a deinoustration in surgery by 
Mr. Aleck Bourne at the Samaritan Ilospital for IVonioii on 
February 29th at 2.30 p.m., and Dr. Heald svill demonstrate 
on eases treated by' electro-therapy' on tho same day, at 
5 p.in., at tho Royal Free Hospital. Tlie lecture .and the 
two demonstrations are free to medical practitioners. Frotn 
March Stli to 17th there will bo three comscs as follows: in 
diseases of children at the Queen’s Hospital, talcing np the 
whole of each day ; in gynaecology at the Chelsea Hospital 
for Women, occupying some mornings and some atternoons; 
and in ophthalmology at the Royal Ey'e Hospital during tho 
afternoons only. Prom Marcli IStli to 24lh there will be 
an all-day course in diseases of the chest at the Broinpton 
Hospital. From March 19th to 31sb a course in orthopaedics 
will bo held at the RCyal National Ortliopaedio Ho.spiial in 
the mornings and afternoons, and a praciiliouers’ course iu 
medicine, surgery, and the specialties in the late afternoons 
at the Hampstead General Hospital. The April courses begin 
on the IGth of that month. The general conrso of worlc, 
consisting of attendance at the ordinary' practice of some 
forty London liospitiils, continues without interruption, 'i’he 
programme for this course and the tickets, which may bo 
taken for any period from one week to one year, together with 
the syllabuses of tlie special courses, may' he obtained from 
the secretary of the Fellowship, 1, Wimpole Street, W.l. 

A POST-GRADU.tTE coursB in recent advances in pediatrics 
will be held under the auspices of the Paris Faculty of Medi- 
cine at tho Hopital des Euiauts-Malades, 149, Riie de Sevres, 
from April 2nd to 14th. The fee is 250 francs, and further 
information may be obtained from the secretary of the 
Faculty of Medicine, 12, Rue de I’Eoole do Medecine, Paris. 

The Council of Industrial Medicine hastirranged a meeting 
for Friday’, Srarch 2nd, at 5.30 p.m., at 12, Stratford Place, W., 
to discuss the treatment of industrial accidents and the value 
of adequate treatment of industrial rheumatism. 


HMteriS'°Societv delivered before the 

Monday nevt Pehr,?, Jlansion House on 

Feiling, of ••’soiatka^i^^'’’ ^ F-™-. by Dr. Anthony 

Hunterian Soeiolv fr' 4.® and treatment.” The 

thcHuuterian Society hospital has invited 

of the hiceutenarv of V® commemoration 

accordinRlvbe hplTi !.. t A special meeting will 

on Thmsdav Varpu if St, George’s Hospital 

the nature of a convoV* ® P’™’ '^be meeting will be in 
delivered by Sir lTn.r...u ® „ P®’ '^'id sliort addresses will be 
As a sequel to the coJ “"‘1 Sir Crisp English, 

end of last October °“^®''®®co on maternal mortality at the 
■the Central Hail Woof meeting will ho held at 

when Mr. Arthn’r on Fehru.iry 28th, at 3 p.m,, 

Hon. Mr.s. Alfred Lvnfu'™®^’ w'ill speak, and the 

proposed tliat stees r'*** the chair. It will be 

inquiry into every . taken to obtain a medical 

farther instruction in ^®atli due to childbirth ; that 

the medical curricnlnm®.'®ff‘^®'^y shonld be introduced into 
b° anpointed to conoMe .f'*' olDcial committeo shonld 
midwives; that the m-eef”- training and employment of 
ance Acts should bo uienin °f ® °t the National Health Insur- 
services available for n?.lri®‘^ make medical and midwifery 
during and after oonfl..®'®®^®* both for ante-natal care and 
euen... — ,“®nient; and that local authorities 
Wake tlieir maternity services 


should be enenn,.„''e“f“®“ 
adequate. ®“®°"‘Pg®a to 

at the Manchester l?o^?T^n lectures autl demoustrati'ons 

^na, when Dr. A. be resumed ou March 

^euical cases. On }iive a clemoustration oC 

n? colitis, tiia i^ Howson Ray will lecture 

to members nf and demonstraiious, which 

•10 p.m. each day aufi ff ° Medical profession, will begin at 
A COURSE of three nn \ 3-^5. 

Ani-ii'd^f*'® Hedif lectures on cancer will be 

wni^i^^-’’ 9th nf ffS,®®* Wednesdays, March 7th, 

Will deliver the first P.-™- Berlmley Moynihau 

in ^^^’essorG v will be of au introductory 

m ^^^°**‘®3.tmontof April, on radium 

burner will fleal f th cafeef ff.®®®® ^ Px’ofe.ssor G. Grey 

“cancerof the rectum, in May. Those 


The Irish Medical Schools’ and Graduates’ Association 
will hold its annual Loudon dinner on Saturday, March 17th 
(St. Patrick’s Day), at 7.45 p.m., at the Savoy Hotel, when 
the gnest of honour will ho General Sir Hubert Gough. .The 
lionornry dinner secretary is Dr. F. E. Holmes Mey'riek 
(59, Kensington Court, W.8). 

AIjMO.st sininltaueonsly’ with the appearance of Sir Leonard 
Rogers’s paper on siuall-pox and climate in England and 
Wales in our present issue there has been published by the 
OxfordDiiiverslty Press his Robert Boyie Lecture on “Climate 
and disease incidence in India: forecasting epidemics,” de- 
livered last .Tune. Tho price of the pamphlet is Is. 

This week’s issue of the Autocar is intended especially for 
new motorists ; its contents inclnde notes on learning to drive 
a car and a classified buyer's guide. 

The Bishop of Willesden preached at St. Andrew’s Church, 
Holborn, ou February 19th at the thanksgiving service for 
the centenary of tlie Royal Free Hospital ; the Lord Mayor 
was present, togetlier with the Mayors of Holliorn, Finsbnry, 
and Islington. The Bishop described the origin of the 
hospital, to which we referred on February llth (p. 236), 
•and commented on the valuable work it was now doing, 
particularly in the education of women for medical practice. 

The first congress of the Gtermau Society for Researches on 
the Circulation will be held at Cologne on March 5th and 6th, 
and the.Germau Balneological Congress will be held at Baden, 
near Vienna, from March 28th to the 31st. 

The medical visit to Prague. and the Czechoslovakian spas 
last Easter, of which some account appeared in our issues of 
May 14th, May 28th, aud June 4ih, 1927, is to be followed this 
spi inghy a tour through several J ugoslav provinces. We gather 
that it will he more of a pleasure party than a professional 
expedition, the only place with a special appeal to doctors 
being the Rockefeller Institute at Zagreb. The journey out 
and home wilt be by way of London, Harwich, tho Hook of 
Holland, and Munich ; apart from this all the travelling will 
ho iu motor cars. A most attractive itinerary has been 
arranged, and places in Jugo.slavia will bo visited which 
ordinary tourists rarely see. The party is due to leave on 
April 3rd and return on April 24th ; the charge will be £41 16s., 
to include all travelling expenses, motor cars, hotels, and 
tips. Wives or d.-iughters of medical men joining the tour 
Will be welcomed. Typed partlcnlars of the route, with 
information about passports, postal arrangements, and so 
on, may bo had from Mr. Henry Baerleln (the Bath Club, 
34, Dover Street, London, W.l), who organized BO successfully 
last year's travel in Czechoslovakia. 



334 Feb. 25 , 1928 ] 


liFTfTEES,- NOTES, AND ANSWERS, 


r TBrJlnmw 

L MCblOAD JoCBilit 


%tittvs, antr 

All communications in regard to editorial business sliould bo 
addressed to Tho EDITOR, British Motllcal Journal, British 
Medical Association House, Tavistock Square, W,C,1, 

ORIGINAL ARTICLES and LETTERS forwarded for publication 
are understood to bo offered to the Bnirisn MEnicAi, Journal 
alone unless the contrary be stated. Correspondents who wish 
notice lo bo taken of their communications should autiicniicato 
them with their names, not necessarily for publication. 

Authors desiring RETRINTS of their arlicles published in the 
British Medical Journal must communicate with tho Financiiil 
Secretary and Business Manager, British Medical Association 
House, Tavistock Square, W.C.l, on receipt of proofs. 

All communications with refcrcnco to ADVERTISEMENTS, ns well 
as orders for copies of tho Journal, should bo addressed lo the 
Financial Secretary and Business Manager. 

The TELEPHONE NUMBERS of the British Medical Association 
and the British Medical Journal are MVSIiVM OSGl, VSG2, !)SGS, 
and GSGi (internal exchange, four lines). 

The TELEGRAPHIC ADDRESSES are i 

EDITOR of the British Medical Journal, Aitiotogy Westeent, 
London. 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements-, etc.). Articulate Wrstcent, London. 

MEDICAL SECRETARY, Alcdisccra IVcstccut, London. 

The address of tho Irish Office of the British Medical Association is 
16, South Frederick Street, Dublin (telegrams; UaciUue, Dublin- 
telephoiio ; 4737 Dublin), and of the Scottish Office, 6 , Driimsiieu'»h 
Gardens. Edinburgh (telegrams ; Aseoeiatc, L'dinburoh : Iclcpliono : 
24361 Edinburgh), 


QUERIES AND ANSWERS. 


Firkjhjn’s Champ. 

Dr. R. S. Mohshead (Sliorehain) writes : “ Ship " (February 18tb, 
p. 291) will Ilitd a most interesting aooouut of “ firemen’s crump ” 
ill Possible Worlds, by J. B. S. Haldane. 

“ B. D. M.” writes : An answer to the query of “Ship” will be 
found in an article by Dr. A. Vavasour Elder in tho Medical 
Press and Circular of October 7tli, 1925. The writer advises the 
addition of 3 drachms of common salt to the gallon of water for 
drinking, and the avoidance of iced water as mticli ns possible. 
Tho recoinmendations are based on the researohos of Sir Josinb 
Court and Frofessor K. Neville Moss on minors' fatigue. 

Cleaning Dentures. 

" L. M.” writes: I find that the depisit is all removed by leaving 
the dentures at night in half a tuinbler of water, to which a small 
quantity, say half a teaspooiifiil, of conoentrated eiisol has been 
added ; "miltou” will do as well. Of course, the dentures slionid 
be first washed with soap anil water to remove any grease. With 

• a nightly soak in eiisol and water there will bo no further trouble* 
if the deposit is very thick it will take a few nights to remove it! 

Income Tax. 

Cash Basis for Gross Income. 

“ M. B." has Iiitlierto been assessed for income tax on the basis of 
cash receipts; be lias recently bought a new praotice— the book 
debts have hot been taken over— and the inspector of taxes now 
declines to accept the cash basis. 

! *,• “ M. B.” cannot siiccessfiilly appeal in snob circiim- 

staiioes. The cash bisis is admittedly incorrect in theory, but is 
accepted in viractice where the circumstances are stioli as to ' 

. create the assumption that the value of tho year's bookings 
unpaid is about equal to the cash received for .work done in - 
previous years. He should, however, claim a reasonable amoiiiit 
as a deduotioii from outstanding debts in respect of the amoiiut 
which he will probably not receive, and he should not pay tax on 
cash received for work done in prior years— for example, if he 

• has given np his former practice the cash receipts therefrom no 
longer affect his income tax liability. 

Subscrqytions to Societies. 

“ A. A. C.,”who writes from an inllrmary, and whom wo therefore 
assume to be assessed under Schedule E, inquires as to the 
allowaiioe for subscriptions to the British Medical Association 

and scientific societies. . 

*,* The point was before the High Court in 1925 in the case 

■ of Simpson v. Tate, when Mr. Justice Rowlatt declined to accept 
the argument that siioti expenses were necessary to obtain the 
periodicals requisite for professional work. In that case it was 
not a coudition of Dr. Tate’s employment, ns county medical 
officer that he should be a member of the bodies in question, 
shown to apply to “A. A. C.'s ” eraploy- 
sucU circa" °° stronger ground, and we believe that in 

the olabn to^i!!?'^'^f R°ard of Inland Revenue would admit 
° >l<=>luot the subscriptions. 


Dr. 

Dr 


IiETTERS. NOTES. ETC. 
Drug Treatment of Pneumonia. 


-A. Aii.wjiurtiA. 

In spite of 

_r. Maldlow s clover satire (Journal, February 11th, p. 238) on 
the absence of satisfactory drug treatment in piennioniA 
I endorse tho experience of Dr. Wiggins, which also Appeared hi’ 
Hint issue, with reference to the undoubted emcaev of the 
prescription coiitaiiiiiig creosote and potassium iodide, i cannot 
claim his 100 per cent, successes, and attribute the failure first 
to delay 111 seeing the patient in the early stage of the malady’ 
and, secondly, to the presence of complications. If I remember 
rightly, the prescription was contributed - to your coliiniiis bv 
Dr. Mathisoii, who also fiiriiished me with a modiflcatioii of the 
mixture for the disease in children, as follows: 

A child aged 12 would get onG-bsIf the dose of nu adult. 

,, 6 onc-tliird „ ‘ 

4 ,, one-fourth ,, 

„ 1 .. one-twolfth „ j, ’ ’ 

Dr. Mathisoii opens treatment .with a dose of calomel; I have 
not used the saline mixture given at intervals between, doses of 
the above prescription, but the use of Dover’s powde: at bedtime 
is extremely helpful. 1 have given iuoreasiiig doses of the iodide . 
alone, and creosote by itself, but in my opinion the results 
never equal the two in oombiiiatioii. .1 would suggest that 
Dr. Maidlow give the prescription a fair trial and report the 
results in a future issue of the Journal. 

Running as ,a Recreation. 

Dr. F. E. Fremantle, M.P., contributes to the Febrnary issue of 
the i.d.C’. AVirs,. the official publication of the Loiidon Athletic 
Club, an interesting note on running ns n recreation, in which he ' 
advocates iiopiilarizntion of this iiealtliy and inexpensive form of 
e.xercise. He believes that breakdown in m.ddle life may be 
prevented by cross-country riiniiing, and pleads for the opening 
up of the neglected bridle patlis for this purpose. In the coiirsa 

of n-fi “ ' he— like the late 

Dr. U. ■ in 1895— has found 

that SI u ■ heart niid did not 

interfere with this form of sport. The iiossibility of eiisiiriiig 
the preservation of the heart and circnlatiou in good order by 
oven a short run every day certainly deserves coiisiderntioii in 
these davBasniiecoiioniical form of recreation, and Dr. Freiiiaiitle 
looks upon it ns “one of the surest, menus of enjoying and 

piolongiug life. dixgehous Drugs. ' , . 

PoTDWPi. W. G. Pridmore, I.M.S.(ret.), writes : Is niiylliing being 
done to extend tho utility of the Dangerous Drugs Act? It is 
to obtain opium and its derivatives or 
-’s prescription, and then only with special 
3 it should be, but almost anyone can go 
intonebemist’s shop and buy siilplional, the quantity varying 
with the desire oT tho buyer and respectability of tho, chemist. 
Some will sell twenty-five tablets of 5 grains each without 
Sion some, whose sense of honour is a little h.igi:er..wi 
on-v “()f course, -your doctor knows that you are faking this?.” 
will refuse to sell any. But there are many chemists 

who will sell without a question, aud nU tlie drug addict has to 

■YoTo tovisithalfadozeii chemists to collect the same number 
oMbUles, each containing twenty-five tablets of 5 grains -each. 
Tfiiri know is being done by a young girl palieul of mine, 
w V are not the same precaiitioiis necessary witlrsulphoual aud 
the barbitoue group ns witli morphine aud cocaine ? 

Records of Cancer Cases. 

.. r c ■ A " writes: Dr. Granger’s letter in your issue of January 2l8t 
m mibdigs to mind a contribution by Sir D’Arcy Power to 
■lYo^rLiceh^Number of the Practitioner of April, 1899, p. 418, 

“ ° u wYhans Imay be allowed briefly to epitomize. • In a 
•'•iVn.lp not uiinieil, so many cancer ensea hail occni-reil tliat ii 6 

1 ° down and investigated -the iieighbonrhood ns -well as .bo, 
went dmv a circumstances in such marlted relation lo 

Mfhons^s vhere cancer had occurred.- that he ended- his cora-- 
the houses certainly prove that there is 

"’mn mterme liate host whose chance of, detection will increase 
or^frahdsli with tlie care which is taken to examine ,t,he,fs'”‘“ 
no -Y of the districts where cancer is most prevalent.' Is it 
‘‘■‘‘I'Sim'lv obvious that where the “causa causa.is'; is n 
not J -(.Inn jg the very place. in which to seek for it, aud 

ir^i'Yh'e iireseiice of any accomplice may lead^to discovery? 
wry ihnbt tlds local clne^horongtily followed up ? 


• MosouiTO Breeding and Pool-proof Guttering. 

. -IT r rvAYSTON (Durban) writes in reference to the 

advocated by him in a letter published in our issue o 

guttering a. 'opat ^ ,, eu 

i 1 eeliug at the Colonial Office of the Coloma 
Bhovyu i>t ^ ® ” t Saiiitarj* Committee,' aud ba^e been 

S^wdi^^l^ey wil l be exhibite d.”- ■ , 

Vacancies. 

"t s'h°^rt'^Ji^irm“a1rofvrc“4^%®o\Ke.^^^^ the advertisement 

robimns annears in the Supplement at page 07 . 



MAIiCH 3, i9=8j 


THE f RlN(3rHliliS' 'OE’ 'tftXGNbSfs; ' 


[ 


Tttt: Brimaa 
ME&tCU. JoCPVlXi 


325 


^biJiTSS . 

ox 

THE PRINCIPLES OF DIAGNOSIS.* 

nv 

ROBERT HUTCHISON, M.D., r.R.C.P., ' 

rllVSICIAN TO THE LONDON HOSPITAL. 


It is written that tliero nbidcth Faith, Hope, Charity, 
tlieso tliree, hut the greatest of these is Charity. And so 
ill Sfedicine ' vrc Iiai-e Diagnosis, ivhich . is a matter of 
faith; Prognosis, which is. a quc.stion of hope; and Treat- 
ment, which is Only too often an affair of charity; but 
tlie greatest'of these is Diagnosis. For without accurate 
diagnosis it is im]iossible to forecast tlie course and out- 
■comc of a disease or to treat it satisfactorily. Indeed, as 
someone has truly said, “ The first part of treatment is 
diagnosis, and the second, diagnosis, and the third, 
diagnosis.” I need make no apology, therefore, for. 
directing yoiir attention to some reflections on such an: 
important subject on this occasion.- 
Diagnosis is based on an accurate interpretation of 
symptoms and signs. I am aware that there has been in 
iccent times an attempt to ignore any distinction between 
these and to speak of all the manifestations of disease as 
symptoms. 1 think there is an advantage, however, in 
keeping to the old division and to call “ syniptoiiis ” all the 
.subjective results of disease which' are described to you by 
the patient, and "signs” all the objective phenomena 
vvliicli you discover on physical oxaminatioii. It is true 
fiiat there are .some manifestations of disease which occupy 
an intermediate place between symptoms and signs — 
disorders of sensation, for instance — but this does not 
invalidate the general utility of keeping the subjective and 
the objective separate. 

Symptoms are elicited by taking the historv and bv the 
cioss-oxaniiiiation of the patient upon it. This is .the. 
pa lent s contribution . to the making of the diagnosis, and 
s 1 a ue cannot bo over-estimated. The importance of tho 
*-'“;''hfore of the jiistorv — in the diagnosis 
IPS gicatly 111 different cases, but it is perhaps greatest 
abdominal disease, and least in cutaneous 
diseases pd organic disease of the nervous system. If you 
nna ! ^ ^tiipid, dcaf, or confused patient, or 

von,. ' ° power of expressing himself in words, 

in-'cin,,',.! ol'oiting symptoms may bo very great, 

nniin as the whole diagnosis may depend 

mti'nnor is worth while to exercise great 
^ 'aii “"f much-time in the cross-examination.^ 

i'm equal diagnostic importance. 

iiiHY enf 1 *^ voluble patients a good many of tiiem 

lior-pvpv ^ *oHored. There is usually one symptom, 

^ , u lie 1 tioiiblcs the patient more than any other, 


apd to this the term “ 


presenting sjnnptom ” is sometimes 


Althnnali f^ttention should ahvays be giycn to it. 

ivhou takiiio- AV ask* loading questions 

diagnosis hnq *t is Jegitimate — once a preliminary 

ask for “ presenting symptom — to 

not have spechinroh^'- patient may 

to nioiition ' ^ ’sened or which lie maj- have omitted 

training'^h^dl’nicnf „!*fi"® /Impends upon ohservafion and 
and special. It nmv investigation, both general 

observation of tho s' doubted wbotber ordinary bedside 
a generation or two"* disease is as good now as it was 
mention onlv two the time of such men, to 

Jonathan Hiitobinson* 1'! i'osp'tal. “s 

I believe, a real diinee Juokson. There is, 

tests, K-rav oxaminir ' idorcased use of lahoratoi-y 

should lead to* a ncV'*'t*’ outs to diagnosis 

by the skilful use of tl iiifoi-niation to be obtained 

parative ati-onbv of +l! ''"d'dod senses, and to a C07.1- 
feacliei-.s must be .-u:---- disuse. Blost clinical 


■ TliPi-e arc two .sorts of 


uware of this. 


■Do.ivcrt,! K.foro 7 


error in diagnosis by signs — one 


Society, Oclot'rtlr 27th, '1S27. 


negative, the other positive. Negative errors are perhaps 
commonc.'t, and arise from overlooking signs wliicli avo 
present; they are chiefly made by tliose ill trained iiV 
clinical niotliods. Positive errors consist in detecting signs 
iHiich-have no real existence — the discovery, in short, of 
marcs’ nests. They are chiefly made by those with observa- 
tional zeal blit little knowledge or experience. The apex 
of the right hmg, the pulmonary area of the heart, and 
the right iliac fossa are the regions in which mares’ 
nests are specially common. 

Having elicited the symptoms and signswliich are present, 
hnowledgc is noccssary. in interpreting them, for, without 
: knowledge one, is “.mind-blind.”- I remember well the first 
case of .encephalitis lethargica w-hicliT saw, -just when the' 
disease was beginning-. to appear in ' this country. 'The', 
symptoms and signs were obvious" enoiigli, but' the"assem- 
hlago of them-ineant-nothing: I' could iiot-put a .name to/ 
the disease, and -it ivas only after the publication of cases' 
by Professor Arthur Hall and others that I recognized,, 
retrospective!}-, -ivhat I had been dealing with. Such mind- 
blindness may at times affect one. even as regards. a disease 
which- one -has. seen before, as the result of temporary, 
fatigue; for,- as Dr. Samuel Johnson reniarked, “ Sudden 
fits of -inadvertency will surprise’ vigilance . . . and casual 
eclipses iof tho mind Avill darken learning.” Seen again 
next day, when one is fresh, the whole clinical picture at 
once falls into focus. 

After ohsei”vation and'knowlcdge comes pidgemeni as a 
factor in the making of a diagnosis; indeed, I believe 
it to bo in some respects the most important factor of the 
three. Evei-y doctor must be a judge. He has to weigh 
the evideiicc ol sy mptoms and 'signs, and- allot to each 
its proper v.alue in making the diagnosis. Now we have 
Hippocratic authority for the belief that “ judgement is 
difficult,” and, indeed, medicine has been defined as “ tho 
art "of coming to a conclusion on insufficient evidence,” 
so it need bo no matter for surprise that errors of judge- 
ment so often lead to erroneous diagnosis. 

We can increase onr powers of observation by training 
and practice, and we can extend tligir range by means 
of spbcial iiisti-unients and methods.. We can increase dur 
know-ledge by study and experience, but can we improve 
our powers of judgement? I greatly doubt it. Judgement 
seems to be an inborn faculty, the result of a union of mind 
and character, -ivhieh a. man either has or has not, and 
it is almost as difficult for him to increase it as to add 
a cubit to his stature. As Stephen has said : 

" The one talent which is most worth all other talents put 
together in all -human affairs is the talent of judging light upon 
imperfect materials, the talent if you please of guessing right. 
It - is a talent 'which no rules n-ill ever leach, and which even 
experience - does not 'always give. It often" coexists with a good 
deal of slowness and dullness, and with a very slight power of 
expression. All, that can be said about it is, that, to see things 
as they are, without exaggeration or passion, is essential -to'nt ; hut- 
how can wc sec things- as -they -are? Simply by opening our eyes 
and looking with whatever power we may have. All really impor- 
tant mailers are decided, not- by. a process of-argument worked 
out from adequate premisses to a necessary conclusion, but by 
making- a w-ise- choice between "'several possible ’views.” — Stephen’s 
Liberty, etc., p. 332. 

What is sometimes called “ clinical instinct” is, in truth, 
simply a iiower of rapid instinctive judgement, and it may- 
bo lacking in men of high intellectual .ability- and present 
to a marked degree in those ivlio are in other respects 
mentally their inferiors. It" seems to be nnicli"tbo saino as 
“ common sense ” and closely- allied to a sense of Iiumonr, 
which is the same thing as a sense of propoi-tion. Tlioso 
who lack it are apt, in making a diagnosis, to fail to see the 
wood for the trees. - 

If the natural powers of judgement are to he improved 
it is only, I believe, by general mental cullurc, and not 
'by purelv scientific training, that it can he done. 'Ihe 
study of “ humanism,” 'by 'which is meant the phjlosopliy- 
of knowledge ns opposed to its jiractical application, must 
be the means. -4s someone has said, sanity, humour, 
breadth of view, and powers of criticism are the dis- 
tinguishing marks of the humanist, and it is at those that 
we must aim. It is for this reason that I regret tlie 
modern -tendent-y- to ' make tho scientific studios of the 

[ 3504 ] 



336 ‘ March- 3, ■1928] 


■ TfiE • i?EI^6lPriES"C)F 'tor!4.QNO’BiB.^'’ ■ ■ 


t TnrHnm^ 

MtDZCALJoctSAi 


Medical student licgin at an earlier age and .ivliilst lie is 
Still at school, and to sacrifice to them nnieli of the old 
literary and linguistic .training. It is, I think, not a-itli- 
out • significance in this regard that many of the most 
ilistinguished physicians of the last generation have akso 
/jccn good classical scholars. 

It follows from what has heen .said that erroi-s in 
diagno,sis may arise from bad observation, from ignorance, 
or from want of judgement. It is commonly .said that 
more mistakes are made from not looking (defective obser- 
ration) than from not knowing (ignorance). Hoivevcr 
this may be, I believe that still more mistakes arise from 
bad weighing of evidence (lack of judgement). \ou may 
increase the accuracy of your observations in a ca.se and 
the range of knowledge brought to bear upon it by the 
most skilled “ team work,” but without a good judge of 
evidence as captain of tlie team these things will avail 
nothing in diagnosis. 

I came across, not long ago, a good example of tho 
prevalent under-valuation of judgement and over-valuation 
of observation as factors in the making of a diagnosis. 
A practitioner wrote to a medical journal to say that “ he 
had no use for the consultant whoso only instrument was 
the stethoscope.” This being interpreted means that this 
particular doctor is of opinion that he never need.s any 
help in weighing the evidence in a case; all he wants 
ii help in detecting more signs by instrumental and labora- 
tory metbods. I take leave to doubt, however, whether 
such .self-confidence is ever ju.stified. Cases must arise 
often enough in every practice in which what is wanted to 
c.stablish a diagno.sis is not more facts but a new evaluation 
of tho existing facts by a fresh mind — in other words, a 
revised judgoment. 

On the other hand, it may be granted freely that a bad 
diagnosis due to an error of judgement is more excusable 
than one attributable to want of knowh>dge or even to 
faulty observation. The ghosts of dead paticnf« which at 
the midnight hour haunt tho bedside of every doctor who 
has been some years in practice will not upbraid him 
with such questions as ” Whj- did you not know that 
a ball-valve gall stone may produce symptoms like those 
of malaria? ” or still loss ” Why did you not attach more 
importance to tho raiiidity of my pulse and less to tho 
signs in my abdomen?” No; the unescapablo quc.stions 
they will put to him will be such as these; “ Why did 
yon not examine my fundi for optic neuritis? ” or “ Why 
did you 'not put a finger in my rectum? ” 

It must not be sup])oscd, however, that you will in every 
case coii-icioiislij use observ.ation, knowledge, and judgement 
in eoming to your diagnosis. It is only in the more 
obscure, intricate, and difficult cases that you will be able 
to trace the successive operation of these faculties. In 
the vast majority of cases of disea.se — at least, when you 
have bad some exjicrience — the stages by which you arrive 
at j-our conclusion will be passed through subconsciously, 
and you will recognize the disease, as you do jour friends, 
at a glance. This power of immediate and intuitive 
diagnosis — having j-our knowledge alwaj-s “ on tap,” so 
to speak — cannot be learned from books; prolonged ex- 
perience at the bedside alone can impart it. The descrip- 
tion of a disease in books is like tbo description of a 
person wanted by the police, or the woi-d-painting of 
scenei-v in a novel — it rarely gives us anj- real nieiital 
ima"e”of tho thing described. --Vs Montaigne .says: 


‘f Like him wiio paints Uic sea, rocks, and heavens, and draws 
the model ot a ship as ho sils safe at his table, but send lum to 
sea and he knows not how or where to sleer, so doelors often 
hml-e sucli a description of our maladies as the town ci-icr does 
of' a lost do» or donkcv, of such a colour, such ears, etc., biii 
hriug the lU-V (Oiimid belorc him ami he hmon-s it not for alt 
thut.'" 


Jilost of ns are “ visuals ” and not “ anditives,” and we 
must have once seen a thing, or, at tho least, an image of 
it before we can recognize it again. 

The effect on the doctor’s mind of a mistake in diagnosis 
is of some interest. If the mistake is due to bad obsei-va- 
tion or want of knowledge it should be sahitaiw tbongh 
painful, ill teaching one greater care or gicater diligence 
in future. On .the other hand, I- believe that the effect of 


an error in judgement is wholly bad, as it .shakes tli.it 
self-confidence wbicb is really necessary to the exerc/sp of 
pronijit and accurate decision. If j-ou make a bad driro 
at the first too it often puts you oif your game for \W 
whole round in' undermining j-our sclf-eoufidcncc, and it 
i.s much tho same in diagnosis. For some time after a 
“ howler ” one is afraid to come to a decision in miT 
difliciilt case. Tliat, at ie.ast, has been inj' own experience. 
Fortunately, however, tho diagnostician has a hajipy knack 
of forgetting liis own mistakes whilst remembering those 
of other people. 

Having made your diagnosis, sboiikl you cominuiiicate it 
to the jiatientP Certainly not always, nor in all circiim- 
stancos. Some of you may remember what the Poet at the 
Breakfast Table has to say on this subject: 


“young doctors arc particularly strong,” he says, “on what 
lliey call diat/nunis — an excellent branch of the healing art, full of 
salisfaclion to the curious practitioner who likes to give the right 
Latin name to- one’s complaint; not quite so satisfactory to the 
patient, as it is not so very much pleasanter to be bitten by a 
do" witli a collar round his neck leIJing yon that he is called 
.S’imp or 7 ',., sir, than by a dog without a collar. Sometimes, m 
fact, one would a little rather not know the c.xacl 
complaint, as if be does lie is pretty sure to look t out n a 
medical dictionary, and flien if he reads, T us ^ „ 

athnderl >rith rint auffirinfl and « identabiy moitnl, y 

such slatomenl, it is apt to nlTeet him unplcasanth . 

Timt is tho truth of the matter in a nutshell. If the 
• u- ftnntl llirrc is 110 reason vrhy tlie patient 
T"!';’ ^ -nr tbe I amc of the disease; if bad, a little 
?udicSL:fvag:w;.cAS of statement is wiser. .The .frankness 
^ *.1 1 • I mnet floctors iiowadavs take patients into then 

w.tU winch mos ’ treatment, is 

confidence ^ ..^3 to the pontifical and mysterious 

perhaps to be P ‘predecessors of another 

airs so ‘ f ™p„ssii;,e to overdo it. It is not every 

S’tTeirt is fit to' bo told the whole truth about h.s 

disease. . „ against some common 

In eonelusiou let jf I may, in the 

faults in 'i'«f/“’^„,J/„r DirgRostieia;s.” 
form of some Hon “ * \lcrcr. Jlere clcvcnicss is 

in niLt walks of life, ami cevta.uly 
apt to i''-' make a good diagnostician. Excessive 

it does not bj pr^etting tciujitation of the amatern 
cloverncss is the c- t ]„n,self 

type t i,c is most likely to make a mistake, 

most scientific tl „ patient being sent to mo 

^\s an example 1 tom „.ho rather prided 

some years ago, ‘ to' date,” with a diagnosis of 

,.i.,„alf in .Iming alimentary toxaemia.” He 

" iilbiiniinuna Hi elaborate analysis of the 

sent «iti>tl>o potion Hie^n^^^ 

stools to notice that the patient bad 

but bo bad q aso with commencing heart failure, 

advanced mitra • ^ congestion of the bases 

and that us well as the supposed “toxic” 

of tbo lungs methods, of course, are of ihe 

albnminurny. m ^ but their results have got to 

greatest value ^ S other evidence in the ca=c. 

bo weighed along by imitating 1be 

Another '''‘“I ° gberlock Holmes. It is. always dangorciis 

metbods of Sir. deductions from veiy .small 

in diagnosis Herculem ” is not a safe motm 

indications. 

for the rarifics. Remember the s.sying 

Sceo„dly,H->» “Common tbm^s 

of that wise P«-r® j associated for a tune m 

most commonly ^ pbvsician who liad acquired a 

my early , pdamiosis of unusual and rare eases, 

reputation m Hm oftener wrong than 

allhougb, ns a ^ j „ round the wards with him one 
right. I to f sudden elevation of tempcratiiie 

day when bo point d , „ary disease and inqinred its 

in a ebronie ease of j„e to the patient 

cause. I J"'; iscbio-vcctal abscc.ss, as bo bad a 

having dovolopcd an ^;+,,^+;nn “ 'Woll,” kc rophc*d» 

tondofswelling in the ’ When at a 

“I /.arc, seen an «Xtrb^f“lTncosawacase," 
:tr'’ltZ.U‘rg:iSt‘maL a bad diagnosis. Cases 



March 3 


1, 192S] 


11A.IN-BEARING AVISOS AMD EARLY- PHTHISIS. 


t Tnx Cninsa ^ Q 7 

UrDICAI. JoCBKAfc wO I ; 


BO uncommon as only to bo scon oiico arc not likely to bo 
scon flffftini 

Tliirillv, DonH Ic in a Inirry, AVaifc till you havo all 
tLo facts, remembering that a laboratory report (for 
example) may at tbo last jnonieut upset all your calcula- 
tions. Reseno your decision, tlicrofore, in a Uifficult case; 
take ilj as tUo Scotch lawyers say, “ to avizandum.” If 
you come to a promaturo conclusion it is diilicult to alter 
it aftera-ards, not only because it involves ankward ex- 
planations io tho patient, but bccjiiiso, by tbo mcj-e fact of 
having m.itlo a diagnosis, you bccoiuo insensibly biased 
and more impervious to tho reception of fresh evidence. 
It is for this re.ason that all “ snap-shot ” diagnosis is 
to be condemned. It is impressive hnt perilous. “ Life,” 
as Dr. Johnson said, “ is not to ho sacrificed to an 
affectation of quick discernment, or of crowded praclico, 
but miiy bo required, if trifled itway, at tho hand of tho 
physician.” 

I'ouitbly, Pon’t he faddij. This is the besetting sin of 
the specialist. He sees only wimt ho is alw.ays seeing and 
what be wants to ECO. To tho cardiologist few hearts aro 
healtby; to the tuhorculusis export no lung is sound. Tho 
Eypbilographcr sees disease only in terms of syphilis: tho 
psycho-analyst only in those of sox. Beware, llunofore, 
when you find yourself always diagnosing tho same 
thing; beware also of the “ stunt ” of tho moment — • 
“ avitaminosis,” “ focal sepsis,” “ distnrbancb of endo- 
crine balance,” or what not. Try to soo the case steadily 
and see it whole. 

Fifthly, Don't mistahe a lahcl for a dinqnosis. Such 
‘‘diagnoses” as “gastritis,” “neuritis,” “ intiuenza,” 
“neurasthenia,” aro, more often than riot, mere labels; 
they have no essential relation to reality. It may bo 
necessary in the exigencies of practice, and in order to 
satisfy the patient’s mind, to use such labels for a time, 
but don’t let them deceive you into thinking that you 
understand the natura of tho case. Bo mentally honest. 

Sixthly, Don’t diagnose two diseases simultuncoiisli/ tn 
the same Jioiieni. Kemember the law of “ paucity of 
causa ion. Don t, for example, explain some features of 
^ ^ diagnosis of eaiieur and others bv assuiuiiig 
of tuhcrcnlosis. Tlioro is, of course, no 
tmonnei ''- '^1 should iiot Tuu two disoasos simnl- 

it a rule’ll”^ fbct tliov rai'oly do. JIako 

possibly can, to account for all the 

as^Cromw^i “ Think it possible,” 

bo mistaken'”^ On the otl’ 

between two alternalilo iicsitato too long 

between two bundles of l.av” 

^ V •• '^ock-sureiiess in diagnosis is 
inexperienced ; oxcossivo caution that of 


the vice of the , 

'‘Eighthiy;''“£.r“ • 

Approach every case preconceptions, 

to the opinion of nU * “P®" and don’t listen 

nurse, till von Wo f®'' of the relations or 

reason for 'consiiltati ^'’® nmin 

case, or should do sn°''^ni * 'consultant approaches the 
justification for the ' -‘'“."P®" 

1.3“, 


ail open mind. 

0 for “ 

of one who is approach 


It is also tho 
an independent 


hhoiit any jrrcconceived ideas 


opinion 

'“‘'“I"" 

Finally, Don’t hesitate t ■ 
to time in a chronic r ^ V°tiT diagnosis from time 

may appear which nut n "I?® “’“F change, new signs 
matter, and the orimn , v different complexion on the 
longer bo able to stand^ pcovisional diagnosis may no ■ 
experienced practitioner tl °''®° '’F s'mowd and 

re-examine his patient ^ '® made it a rule always to 

On the one occasion ^*® morning of a consultation, 
badly caiiglit out. ' ”® omitted to do this he was 

In conclusion let mo o 

yon should alwavs bn •? , . is quite impossible that 
the reason that cliseaso'^Ii ^ Four diagnosis, if only foi- 
ls better, however to w “'"-ays play the game. It 

right by chance. ^G,,p '• " on sound ,princi])Ies than 


for if 


--- you once set ^® "voided at all costs; 

diagnostically damned ° ^ guessing you are 


Er\JN-BEAElNG ^YIEDS AKD EABLT PHTHISIS 
IN DEPiBYSHlRE. 

BX 

AV. GORDON, M.D., F.B.C.P., 

BEKIOn PHYSICIAS TO THE nOYAL DEVOS AKD EXETCK HOSPITAL; 

AXD 

AV. 31. ASH, ai.B., B.S., r.K.C.S.E., D.P.H., ■ 

COUNTY MEDICAL OmCER OF HEALTH FOE DEP.BYSHIRE. 


The county of Derby provides a remarkable proof of tho 
effect of strong prevalent lain-bearing winds upon iho 
conrso of early phthisis, amtily confirming the recent 
evidence from Devonshire and AVest Shropshire. Incident- 
ally it also furnishes interesting indications of an effect of 
subsoil on the course of phthisis ivliieh v.ill riot surpriso 
those who have followed the work already published regard- 
ing tho effect of subsoil on the prevalence of the disease. 
AA'o shall set forth onr findings as briefly as we can. 

AVo have dealt with 506 fii'st-stage cases, which had been 
treated at the County Sanatorium (near Chesterfield), and 
followed at their homes for four years after their dis- 
■ charge, as ii-as done with tho cases in Dei-onshire and 
AA'est Shropshire. Tho results for the whole county of 
Dorby, taken as a unit, are as follows: in respect of 
south-west, west, and north-west winds— 

Mortalities. 

Slioltcrcd casc3 6.96% 

Exposed cases 14.13% 

or, confining attention only to the indisputable cases — 
that is, deaths certified as due to phthisis and living 
cases in which tubercle bacilli had been discovered in the 
sputum : 


Sheltered cases 

... ... ... 

14.05% 

Exposed cases ... 

Arrests^ 

28.72% 

SheUcred cases 

... .. ... 

63.69% 

Exposed cases ... 



63.87% 


or, considering only indisputable cases, as above: 

Sheltered cases 61.39% 

Exposed cases 41.49% 

These figures, significant as they are, do not, however, 
shoAV the veal extent of the contrast, because of certain 
peculiarities of the geology, configuration, and rainfall of 
the county, which no shall now explain. 

Arrc.ss of Westerly IViiids. 

Derbj-shire lies a littlo to the north of the centre of 
England, and so receives its westerly (chief rain-bearing) 
winds as follows. 

'The north-west wind arrives directly from the sea, with 
no outside intervening heights to break its force or abstract 
its rain. The west ivind is also a direct sea wind for tho 
extreme north of tho county, hut for the greater part of 
its surface comes across the mountains of AA'ales. Tho 
south-west wind, for the entire county, has crossed tho 
AA’eish mountains. Of these winds the south-west is the 
commonest, and the wind which most often blows as gales. 
Next in frequency, and in gale-frequency, is the nortii-Avest. 
At Buxton the ivest and south-west winds are rainier than 
tho north-west. 

Natural Divisions of the County. 

Tbo geological formations of Derbyshire divide it natur- 
ally into three great areas, indicated on the accompanying 
sk^ch-map, and these areas differ conspicuously in respect 
of altitude, configuration, and rainfall. Tlicj compi me . 

1. A north-western area, of high grounch highest m the 
north (where it culminates lu tho Peak— 2,01,8 feet hign), 
having a main plateau running nearly north and south, 
mostly over 1,000 feet in altitude, tne whole area P'csent- 
in<^ pronounced coutiasts of exposure and shelter. It has 



March 3, 1928] 


BAIN-BEAKING WINDS AND EARDY PHTHISIS, 


r TiipDRiTijm 



Summary I. 

Pcrccntatjcs of Mortalities on Different Subsoils, 


U) AH Cases. 


(2) All Deaths, tot 
only Fosith’o A ani 
. D Cases. 


Sheltered. I Exposed, i Sheltered, f Eairased, 


Millstone grit 

Carbonifcrons limestone 
Fcrics 

Northern coalmeasures ... 
Magnesian limestone 


Eonthem coalmeasures ... 



Note.— TlironghouttheBQ tables A=arrested; I*-living,but notarrested 
and I)=dend, certified from phthisis. 


Summary II. 

Percentages of Arrests on Different Subsoils. 


2. A north-eastern area, of much lotvcr altitude, uith an 
undulating .surface, which slopes from west to cost and 
from north to south, with much less decided shelters (so 
much so, indeed, that the assessment of some of them is 
doubtful), having a considerably lower rainfall than the 
north-western area — namely, gcnei-ally between 30 and 25 
inches. Tho subsoil consists mostly of coalmeasures, but 
there is also a considerable stretch of magnesian limestone 
in tho north-east. 

3. .‘1 southern area, which contrasts strikingly with both 
of the former. Nearly all of it is relatively low-lying, much 
of it below 200 feet above sea-level, and a little of it along 
the Trent even under tho 100 feet level. There is hardly 
any actual shelter, but all winds reaching it do so across much 
higher country. It has a low rainfall, mostly rather over 
25 inches, but, along tho north of the Trent valley, slightly 
under 25 inches. The area consists almost wholly of trias, 
a subsoil which former work by one of us showed to be 
assoeiated with some of tho lowest phthisis death rates in 
England, There is some alluvium along the Trent, a small 
patch of millstone grit at Melbouime, and a larger patch 
of coalmeasures in tho south-east. 

The Elimination of Subsoil as a Conflicting Influence. 

To judge fairly, therefore, of tho relations of phthisis 
and rain-bearing winds we must disentangle the influence 
of subsoil. This can easily be done by considering tho 
effect of the rain-bearing winds over each geological forma- 
tion separatel 3 '. The same procedure also eliminates tho 
influence of differences of rainfall and exposure; for mill- 
stone grit and the carboniferous limestone series (formations 
upon which phthisis mortality in England is relatively 
high) have here the heaviest rainfall, and tho most pro- 
nounced exposure; whilst trias (on which phthisis pre- 
valence in England is relatively low) has here the lowest 
lainfall and lies in 3 sort of hollow. Tho coalmeasures 
have been divided by us into north and south, on account 
of the different heights and rainfalls; we do not think that 
grouping the very small patch of north-western coal- 
measures with the large area of north-eastern can lead to 
any error. Tho trias and coalmeasures of the southern 
area are considered separately. Melbourne, the only mill- 
stone grit localitj’ in the south, must be taken "with millstone 
erit generally, as it must not be confused with localities 
on tho contrasting soil of trias. Most of the cases on 
alluvium are in tho southeni area ; the exceptions are only 
a little to tho north. of it under voiy slightly heavier rains; 
they may therefore fairly be considered together. 

AVe have satisfied ouiselves that no other conflicting 
influences exist. 

Eesults. 

Taking, then, the effect of these winds over each subsoil 
J-paratelv, we reach tho striking results shown in the 

aUowing' tables. 





































IRKADIATED 'EliGOSTEROii AS A 'f)BESkNG' EOB WOUKES. 


mnCH 3 i 1928] 


339 ■ • 


I Tims in Derbyshire, as in Dovonshiro and ^Ycst Slirop- 
Ehiro, there is a‘ remarkable body of evidence showing that 
patients with early phthisis die more often and recover more 
rarely when residing in exposure to strong prevalent rain- 
bearing winds than when residing in shelter from them, 
and this to a degree which cannot bo considered negligible. 

It is obviously important that phthisis sanatoriums should 
be located in shelter from these winds, and even more 
important that phthisis patients, on leaving their sana- 
toriums, should bo advised to reside for some years in 
such shelter. 


Olf IRRADIATED ERGOSTEROL AS A DRESSING 
EOR IVOUNDS : 

"With Stiogesiioxs as to its Mode of Action. 

BY 

C. J. BOND, C.M.G., F.R.C.S., 

nOHOEiEY COSSDLTISG BUEGEON, LEICESTEE BOYAL INFIEJIAEY. 


An inquiry undertaken four years ago into the effect 
exercised by irradiated and nou-irradiated cholesterol and 
some other unsaturated fatty substances on the cellular 
constituents of- the blood (recorded in a communication to 
the Phj'siological Section of the British Association last 
September) had previously demonstrated the fact that 
blood incubated in a closed cell on a film of cholesterol 
crystals ^deposited from' ether on a slide showed increased 
leucocytic activity and also agglutination, followed by 
haemolysis of the red cells, and that tlieso changes W'ero 
ranch more marked in the irradiated than in the non- 
iiTadiated film. - It was this fact which led to the- use of 
cholesterol, dissolved to saturation point (about 3i per 
cent.) in liquid paraffin, as a dressing for ulcers and 
granulating wounds. 

very extensive wound of the upper limb, in 
.inch, as the result of a machine strap accident, the entire 
limb elbow had been stripped from the 

^Tlnch two unsuccessful attempts at auto- 
dX previously made, was dressed 

and^ML cholesterol paraffin mixture, 

tii,, ' b ’ sloughs had separated and granula- 

adiatel^thiouXtr'’ wou^nrwas 

vanour Inmn Aff„. ra-violet i-ays from a morcui-y 

the wound eVentuallv hMl ,!'^ - ^ ^■'^'^tment 

tion and the lad r-aoir- j ^*1 "'ithout cicatricial coutrac- 

EoHowing Vhe SXv 
England, and WiXu? X 

irradiated ergosterol contn" , Germany that 

of antirachitfc or “4rufin "b 

cholesterol, irradiated ergo“terol T“l ' a? '‘■•''‘‘’iated 
in liquid, paraffin, was Jed ■ ‘a same way 

as a dressing for variVnc place of the cholesterol 

granulating wounds Gootf infected and 

the reduction of infection obtained both in 

Latterly “ radiostol ” m promotion of healing, 

and soaked in gauro has b' ’ '"’'I'k liquid paraffin 

form of dressini XX “ convenient 

delayed by B. woeuanen? healing had been 

infective process w'ns a, it was noticed that the 

contact with tliVhradXt'’ in 

it was stiU present the'^ orgosterol dressing, although 

used as a control ^ dressed by liquid iiaraffin, 

applied to wounds°MtXT‘^^ irradiated ergosterol so 
healthy granulations- it “"‘1 promotes 

epithelial cells fmm tu “ the ingrowth of 

jn'oeess. uiargiu, and so favours the healing 

baetel-icM^reWcrof “i^° ca^iad ont to test the 
irradiated ergosterol compared with non- 

tlio under surface 'of of ergosterol wore spread on 

irradiated and tbn. v “ , ^''P®' some of which were 


jelly, and incubated in Petri dishes. The colonies were 
found to bo more numerous and larger on the non- 
irr’adiate'd than on the irradiated films. 

These experiments require, however, to he repeated with 
other types of organisms, both aerobic and anaerobic. 

Mode of Action. 

Tlio first suggestion I wish to make is that the beneficial 
effect of irradiated ergosterol, when used in solution in 
liquid paraffin as a dressing for wounds, may be due to 
a further continued irradiation effect on the wound tissues 
after the primary irradiation of the sterol by the ultra- 
violet rays from the mercui-y .vapour lamp has ceased. 
The question of the ph 5 -sical and chemical action of tho 
irradiated substance still remains. 

In tho British AIedical Journal of October 8th, 1927 
(p. 637), I described a coloui- .test for distinguishing 
irradiated from non-irradiated ergosterol, which depends 
on tho oxidation of potassium iodide by liberated oxygen, 
and the formation of a pink or a blue coloured iodide of 
starch when a solution of boiled starch dissolved in 
potassium iodide solution is applied to such an irradiated 
film. This and similar colour tests with ammonium ferrous 
sulphate and potassium thiocyanate solutions, and the 
haemolytic effect of the irradiated sterol on a suspension 
of washed red cells previouslj- described, and the fact that 
orgosterol can ho activated by ozonized air, all enggest that 
tho taking up of oxygen during irradiation and the subse- 
quent liberation of the ox 3 -gen may ho tho mechanism b^- 
which the irradiated sterol acts upon tho blood and tissue 
cells and epithelial colls in the wound. 

According, ho'wever, to Rosenheim and Webster (Lancet, 
September 17th, 1927) the conversion of ergosterol and the 
formation of vitamin D is brought about equally well in 
an atmosphero of nitrogen, the supposition perhaps being 
that the chaugo consists in n molecular rearrangement 
only. 

Experiments carried out by mj-self, in ■n-hich thinly 
spread ergosterol films were irradiated through water 
covering the film, and also ■with films spread on the under 
surface of quartz slips, placed film downwards on mercurj-, 
and then irradiated through the quartz (atmospheric 
oxygen being thus excluded), showed that no activated 
substance had been formed capable of liberating iodine 
when tested by the starch potassium iodide and other 
colour tests. 

These and other observations suggest the conclusion, 
either that ergosterol when treated by ultra-violet radia- 
tion takes up oxj-gen which can he subsequently liberated 
and is itself vitamin D, or that t-uro substances are formed 
from the sterol during radiation — one a vitamin, whicli 
docs not take up and subsequently liberate oxygen, and 
the other a substance of a peroxide character, which does 
take up oxygen and gives the starch potassium iodide 
colour reaction, and which haemolyses the red cells. If 
two substances are formed then the further question arises 
which of' these substances exercises the stimulating and 
healing effect on wounds. 

The fact that the activated substance which forms 
during irradiation is a fat-soluhle material is of consider- 
able importance; for, unlike a water-soluble material, a 
faf^soluble substance can transmit oxygen through tho 
lipoid coatings of the cell and its nucleus, and if it is also 
an oxygen carrier, soluble in fats, it maj- exert its 
influence on red cells, leucocytes, and tissue cells in tho 
Avay described. 

In support of this view it is interesting to find that 
when large and Avell-formed crvstals of ergosterol, de- 
posited slowly from solution in tetrachlorethane (Westron) 
on a slide, are viewed with polarized light after irradiation 
only the very small crj-stals become complctelj- isotropic 
or non-polarizing. The larger crystals still contain a 
luminous core surrounded hj- a non-luminous non-polarizing 
layer of resinous material, which appears to protect tho 
central core from further change. 

If we assume that only one fatsoluble oxygen-absorbing 
and oxygea-disobarging substance is formed during irradia- 
tion, then such an, assumption seems also to imply that it 
is in virtue of this fat-soluble character, in conjunction with 
its capacity for liberating oxygen, that .vitamin D exerts 


340 ilARGH 3, 1928] 


AUTOGENOUS RESroUAIi VACCmES, 


r Tnr. 

L JjErrc'AL JucavAt 


its physiological effect on both general and local meta- 
bolism. 

Tho further fact that irradiated orgostcrol (“ radio'stol ”) 
after long exposure to atmospheric oxygen (especially in 
a warm temperature) is found to lose its antirachitic 
value, and also its capacity for liberating oxygen, and 
no longer oxidizes potassium iodide, as shown by tbc 
starch test, is also important. It may perhaps be ex- 
plained on tlie assumption that the oxygon additive com- 
pound undergoes rearrangement, in consequence of which 
the oxygen is no longer easily liberated, tlic final jirodiict 
being the inactive resinous material. 

3Iy object in putting forward tbe.se snggc.stions is, first,, 
to point out tbo value of certain irradiated -tcrolswlicn used 
a.s a dressing for wonnds, and secondly, to indicate certain 
directions in which, as it seems to me, further research 
would he very useful in throwing light on tho mode of 
action of vitamin D. 

Put shortly, the present position is this: wo know from 
tliQ hrilliaut work of a number of observers that Irradiation, 
will convert ergosterol and other misatnratcd sterols into 
a suhstance having antirachitic qualities — that is, vitamin 
D. IVe liavo now shown that irradiation will also produce 
from the ergosterol a fat-soluble subst.ance containing 
oxygen, some portion of which can bo readily liberated.. 
We also know that ozonizatioii (and possibly other methods) 
will convert ergosterol into an oxidizing substance, but 
we do not yet know wlictber ozonizahion will ])roducc an 
aiitirv’bitic substance. Neither do wo yet know whether 
the rttamin D and the oxidizing substance are one and 
the same thing. 


cation must be coiisidored in relation to tbo di&ca.so. TJiw 
tlio^ sticccssful trcatihcnfc of furunculosis means a coniplefo 
aiul lasting cure. On the other hand, an advanced 
rheumatoid arthritis cannot he expected to viold sa con- 
plctely to vaccine therapy th.at all bony deformity 
appears j hr this case one looks for fiuodom from pain, 
disappearance of the swelling ofi the soft tissues, increased 
mobility of the affected joints, cessation of periodical acuta 
attacks, and the ]iatieuPs restoi*ation to a more active life. 
An early case may be expected to clear rqr completely. 
Eveiy case, however, is siiscojitibio to analysis In* means of 
a simple question — as tbo vaccine therapy* really* worth 
while considering tho results and tho nature of tiie ease? 

I wish to offer my* thanks to all the medical practitioners 
whose time I have taken np and whose memones I hare 
racked in my efforts to assemble these records. 

Tho results^now published comprise all the autogenous 
residual vacemes made between January 1st, 1924, and 
Decciiibcr 31st, 1926. 


Total vaccines prepared ... ’ ... 

, ' 448 

‘KesuUs not traceable 

55 

Still under observation ... 

35 

Kcswlts non* recorded ' 

... ■ ... 360 


The eases still under- ob.servation will be mainly, but not 
necessarily, the most recent. A vaccine for chronic nasal 
eatarrli. requires some time before its result is- apparent 
so far as prophylaxis is, concerned, whereas the result to 
bo obtained in a case of rheumatoid arthritis may*, and 
frequently does, declare itself after tsvo doses. 

It will be convenient to consider tho results in seven 
groups. 

Group A. 


AUTOGENOUS EESIDUAL VACCINES: 

TjiiJ THER.aPEUTic Re.sults Odt.m.xed IX .\ Series 
OF 360 C.i.SE.s. 

lY 

C, E. JENKINS, 

PATHOLOGIST TO SALTOUD ROYAL ITOSHTAL. 


The method of preparation of those i*uccines was described 
in tliis Jovnx ae six years ago. On tiiat occasion tho results 
obtained by tbo treatment of cases of clironic broneliitis 
in the oukpiitioiit department of Salford Royal Hospital 
wore presented and compared ivitb cases treated by* a 
similar stock vaccine prepared according to the older and 
usual method. The conclusion w*as drawn that the residual 
vaccine was superior.’ 

Tlie original technique for the preparation of residual 
vaccines lias been slightly modified. One washing, combined 
with the use of hydrogen peroxide as introduced by- Dean,' 
is found to be sufficient. This paper contains tho I'esults 
obtained when autogenous vaccines are used, and the whole 
of the cases now described were treated with that type of 
vaccine. 

Detailed comment is best made under tho separate gi*onp 
headings, but it is necessary to draw* particular attention to 
the means employed for asse.ssing the benefit or othonviso 
of the treatment. Almost without exception the result has 
been asses.sed by some other medical practitioner, u.sually 
the patient’s private doctor. A miiioi*ity of the records 
were- upon liospital case sheets, and w*hero 1 have been 
compelled to yiass an opinion upon them myself I have 
classed as successful only those cases wiiich show-ed a 
marked improvement obrtously related to the administra- 
tion of the vaccine; cases which showed a slight improve- 
ment or no ciiangc are failures, and those ca.ses which, 
from inadequacy of note.s or some other reason, show*cd 
an obvious benefit not attributable with certainty* to tlie 
vaccine therapy, are classed .as “ Xot traceable.” Cases 
which slowly improved after vaccine therapy had ceased 
IV month or" so previously are deemed to be failures. The 
remainder of the untraced cases are so owing to disappear- 
ance of tho patient or to my* failuro to establish contact 
with tlio patient’s doctor. 

It will be seen that the standard of assessment is of a 
simple order — .succeeded or failed. Ohi-iously such a classifi- 


Disease. 

Total’ 

Cases. 

1 Success, 1 

FaUitre. | 

Percentage 
of Success. 

Furuiiculosie* «• •- 

45 

mm 

5 

58.9 

Pyofe'ouic abscess 

4 


H 

— 

Sycosis 

S 

■■ 

D 



5 . 

i 1 


83.5 


The failures in furunculosis include a diabetic "Tvlio 
refused to limit his diet in any way, and a p.'rtienl 
ill whom a large carbuncle had already spread to the cord 
,111(1 produced myelitis when I him. The three 

case.s of sycosis barbae show* two-tlnrds of successful results, 
wbich is probably* unduly flattering. 


Group B. 


Disease. 

Total 

Cases* 

Success. 

Failure. 

i perceTTtajJo 

1 of Success. 

: — r"! 

lUicuniaUstaandrbonuiatoid I 

63. 

50 

13 

79J 

affections 1 

Gouococcal axtliTitis ... ... | 


' 3 

0 


Totol of group 

65 1 

ks 1 

i 

80.3 


In the eonococcal e.rses tho organi-sm was isolated 
ntire culture from the affected joint. Tlie rheumatic, gioup 
reoniro explanation and couiment. Before a 

^ ,rprJ a urcOiiniiiary bacteriological examination IS Jxj *7 

ertaken cStures are made from the throat and fnere. 
IS t rontte "viien pvorrhoea or some other i) « 

1 ,iL N m-e rent ilio appropriate cultures are made Tho 
^TeXmTnaCg organis/n" I '’have found to ^ ^’r^ 
?oct«s-lmmaoiyfi>iis, salirorii/s*, or t,,eco 

coccus I have never seen anything to suggest that 
strentacocci concenu'd in the rheumatoid griinp are V ‘ ^ 
ffifleicnt from tho standard types of these varieties, 
H- is of course, quite possible that iii a susceptible 
fer^ain sS do'prodi eo toxins which have rather more 


iffiijtv than nsiia! fov tlie joints and heart valvc.s, 

ThV majority of the wiccines m t.ns -..jbility 

rom the faeces, and an arbitrai*y standard of su * 








Mauch 3 ^ 1928 ] 


ATJTOGENOrrS KESIDirAri TACCINES. 


[ The British 
aiEUICAl. JoCRXil 


for ractine -treatment is tlicrcfore necessary, llie normal 
pi-oportion of .streptococci and enterococci in tlie faeces is 
from nil to 2 per cent.; a i-accine is not prepared unless 
the proportion is greater tlian 20 per cent. A pure culture 
is not nnconiinon. Tiro specimens separated by a tircnty- 
fonr-iiour intciral are obtained, as it is 'found that the 
proportion is apt to ran- a little from day to day. The 
standard raedhim for all routine .examinations in the 
Salford laboratory is nutrient beef broth agar eontaiiiing 
2 per cent, of o.v' scrum. It is possible that a higher per- 
ceutatre of strejitococci is thus found than ivoiild be the 
case on “ plain ” nutrient agar, ivliicli is never used. 

Other organisms that have been found in the faeces in 
high proportions and ivhicli have given .satisfactory results 
in an autogenous vaccine — and therefore prosiiinably have 
a causal relationship to the disease — are Sluithijlococms 
aureus, H, lactis acrogcucs, Friedlandor’s bacillus, 11. pwfeus 
rulgaris, and various diphtheroid bacilli. Approximately 
one-half of the rheumatoid cases examined show these 
bacterial abnormalities or foci of infection. tVhere no 
abnormality is found a vaccine is not administered, and the 
results- of stock vaccines in such cases have not been im- 
pressive. This probably explains why the vaccine treatment 
of the rheumatoid diseases is the subject of such conflicting 
opinions. The cases for which a vaccine is proposed must be 
bacteriologically examined first. 


Group 0. 


Disease. 

Total 

Cases. 

Success. 

Failure. 

Percentage 
of Success. 

Ditestiuol toiaemia ... 

21 j 

’l 6 

5 

75.2 

Eis'tlieiaa and urticaria 

12 

g 

3 

75.0 

Wucoas colitis 

4 

2 

2 

1 

- 

Total of group 

37 

27 

10 , 

73.0 


The cases of iiitestinal toxaemia arc a mixed group that 
showed wide variations of blood pressure, vague skin 
eruptions, dyspepsia and diarrhoea, anaemia, and in a few 
ins anees a mental complex that had been dismissed by 
vaiious obseiTcrs as neurasthenia. The improvement in 
these cases wiis frequently dramatic. It may be thought 
la the i-ffiults obtained were largely produced bv sug- 
.e® 'Oil, but several of the patients had had treatment far 
Vffi! than a bottle of vaccine, and it is 

'Uacult to s^ how suggestion could cure anaemia, 
woi-n ,®'^™j‘^/’®^tioii in this group compri-^es cases which 
or thrw" -nn ’"tootionj usually in the bowel 

vaeeinn ^T'ere no bacterial abnormality was found a 
cases snoT^f prepared, and about, two-thirds of the 
as heinr. ^^ominatioii were rejected on this gi-ound 

os being unsuitable for vaccine tlierapv. 

seemed'sner.V.'^l?? 'solated were varied, and no one organism 
eomnrised li ' l' as a cause. The bacteria found 

streptococci, and o't,, 


Gkoxjp D. 


Disease. 

Total 

Cases. 

Success. 

Failure. 

Percentage 
of Success. 

Cj-stitis ' 

^’/^^erlu'osis. and 
Pjelonephritis “ 

' ngmitis (not venereal) 

33 

13 

27 

9 

6 

4 

81.8 

69.2 

3 

2 i 

1 


Total of group • j 

49 

38 

1 

1 11 

1 

77.5 


TJic rcTiioto . 

to depend upon the age of this group a 

women and most mhn the patient. I 

boon cured, but middle-s"' 
laH.v if ma’rried, Z^tlelcW 'I'”"''?’ 

‘'^ecKted tendenc}* io relapse 


about tu'o year.-s’ freedom from trouble. A further course 
of imccino ti-eatmeiit o-ill put them ri^it again for another 
period of about the same length. 

Group E. 


Disease. 

Total 

Cases, 

Success. 

Failure. 

Percentage 
of Success. 

Septicaemia 

2 

1 

1 

— 

Pynomia 

1 

0 

1 

— 

Osteomyelitis ... ... 

3 

2 

1 

— 

Clironic cellttiitis 

2 


1 

— 

Erysipelas 

1 

1 

0 

_ 

TJlccralive endocarditis 

1 


1 

- 

Total of group 

10 

5 • 

= 

50 


Tlie only inference that one can extract from the above 
figures seems to bo the folly of waiting for an autogenous 
vaccine when a stock one, read)' on the spot, could have 
been given several days earlier for a set of conditions in 
which time is all-important. It is probable that better 
results would have been obtained by the use of one of the 
two special tj'pes of stock residual vaccine, designed for 
tlic purpose, and given the moment the condition was 
diagnosed or even suspected. They could have done no 
possible Imrin. 


Group E. 


Disease. j 

Total 

Cases, 



Percentage 
of Success. 

Chronic and reciuTent acute ' 
catarrh of the respirator}* 
passases,jnclnding bronch- 
itis 

101 


9 

1 

91.1 

Asthma accompanied by 
bronchitis 

15 


3 

83.0 

XHcerative tonsillitis and 
**septic throats” 

10 


2 

£0.0 

Localized infections of nosal 
sinuses and antra 

6 

H 

2 


Total of group 

1 

! 132 

116 j 

16 

8B.0 . 


The first section of this group is the largest and the 
most satisfactory in its results. The average period of 
protection gi^'c^l by the vaccine is about two years — ^two 
complete winters. AH the usual causal organisms have 
been found; the only point of interest is the connexion 
of the pneumococcus aith a certain type of catarrii. In 
the course of routine work it has been observed that cases 
of nasal catarrh with a blood-stained discharge or a 
tendency to catarrhal deafness are move commonly asso- 
ciated with tlie pneumococcus than with any other 
organism. At the same time, tlie association is not ns 
complete as that between bronchitic asthma and the 
streptococcus. 

The asthma cases were interesting inasmuch as they 
showed the clearest division of the disease into two types — 
the purely “ neurotic ” and the type in which the astlima 
is secondary to clironic bronchitisj; that i'^, asthmatic 
attacks occur only during pv immediately after an attack 
of the former disease. The organism invariably present is 
n streptococcus, usualh’ of the salirarius variety. It is 
customary to find this organism forming at least 95 per 
cent, of the total organisms present in the sputum. A 
pure culture is not remarkable. 

It will be seen that the results of treatment of bronchitic 
asthma are gratifying. On the few occasions when 1 have 
been persuaded to supply a stock strcptocoecal vaccine for 
a patient suffering from the other tyjie of asthma I havi- 
never seen any result that could be called succc-ssful. The 
benefit in the' bronchitic type cannot be due to the action 
of a non-specific protein. If it were so. the vaccine sbonhl 
benefit both tvpes indifferently. A survey of tlie facts 
indicates that the role of the strentocnccu.s could liardly 
be more specific. 



















842 March 3, 1928] 


HAIR-BALLS IN THE ALIMENTARY TRACT, 


r TitEBnmsa 

LMedICAL JoCRKil 


Group G. 


Biscaso. 

Total 

Cases. 

Success. 

Failure. 

Pcrcontngo 
of Siicces.s. 

Pyorrhoea 

2 

2 

0 

- 

Chronic septic ulceration ... 

2 


1 


Suppurating sinuses (not 
tuberculous) 

3 

mm 

! 1 


Septic thrombO'Phlebitis ... 

1 


1 0 


Hepatic abscess (not amoebic) , 

1 1 


1 

— 

Acne vulgaris 

3 


1 

1 

— 

Unna*P ulcerating inguinal 
granuloma duo to B. vuo- 
cyaneus 

■ 




Total of group 

13 



61.5 


If this conception of tlio action of these different 
bacterial siiiistancos bo correct, it follows that a mixture of 
bacteria and their aggressins, such as is represented k an 
ordinary “ whole ” vaccine, cannot bo as efficient as asms 
of tho fractional types of vaccine. Purther expericDM 
with many of these fractions may show that they are not 
in opposition to each other as potential remedies, but irill 
perhaps bo tised most effectively at different stages of the 
same disease. 

HrrrnrxCEs. 

> .Tonkins : RniTisir JtEDiCAL JounxAt, June lltli, 1921. -IT. R. Dean: 
Ibid-, April 29lli, 1916. ^ Arkwright : Journ, Path, and Bact., \ol. xxx, 

1927. * Ilordcr and Ferry ; BniTisji JIedicil JoCR.va, 1926. 


HAIR-BALLS IK THE ALIMENTARY TRACT: 

WITH THE 

Rkcord of a Case op Inte.stinal Obstruction due to 
Four Hair-balls. 


This last group does not call for comment at leiigtli. 
The two cases of pyorrhoea were similar — young women 
who wished to save their own teeth. Pj-orrhoca cases 
associated with rheumatism are placed in Group B. 


Orand Total o/ all Cases. 

Total cases 

Success 

Failure 

Percentage of success 


360 

294 

66 

81.5 


CON'CLUSION. 

I would again draw attention to tho fact that tho 
benefit in tho vast majority of these cases has been 
appraised by indoponclent observers, which fact is rendered 
doubly important by tho nature of tlie results. Tlio higli 
proportion of success obtained is attributable to tivo 
factors. In the first place, selection of suitable cascs by 
bacteriological examination provides one witli clinical 
material that offers a rational basis for tlie uso of I'accino 
therapy. The results are influonced accordingly. The 
second* factor is tho residual vaccine itself, which has an 
inherent therapeutic efficiency greatly superior to that of 
the older “ whole ” type of vaccine. 

In recent years tlio production of improved types of 
antigens has engaged the attention of a number of 
workers. The most recent paper on tho subject is by 
Arkivriglit,^ and deals ivith typhoid and paratyphoid 
vaccines. Amongst other facts elucidated ho shows that 
a hoat-stablo antigen is more efficient than a heat-Iabilo 
one obtained from tho samo organism, and notes tlie 
interesting detail that a heat-stablo antigen that bad been 
heated to 100° C. gave slightly better results than the 
identical antigen unheated. Precisely the same result is 
revealed in tlie tables published in my original paper on 
residual vaccines. 

Holder and Ferry* have produced antigens tliat differ 
in tho mode of preparation, and almost certainly in their 
composition, from those of Arkwriglit and myself. At first 
sight such results may appear contradictory, but tliat is 
not necessarily so. The improvement upon heating the 
heat-stable antigens can he explained in one of two ways. 
It may be supposed that the ' antigen itself is actually 
improved by heating, which is iiniirobable. Tlie alterna- 
tive is more feasible: it is that some substance inimical 
to antibody formation is destroyed by the Iieat. 

The aggressins have not received mucii attention in 
recent bacteriological studies, hut it has been shown by 
Bail and subsequent workers that their action is to paralyse 
the tissue resistance against bacterial invasion, althoiigli 
the a""ressins themselves are not toxic, and that immunity 
can ho created against aggressins or against bacteria. 
\\nien a mixture of bacteria and their aggressins is 
administered the host experiences increased difficulty in 
the production of an adequate resistance. 

This cxwerimental evidence indicates two methods of pro- 
ducing immunity, and it is conceivable that the iininunogens 
of Horder and Ferry depend in part at le.ast for their 
efficitnev upon the small quantities of aggressm present in 
Gio washings. The heat-stahle antigens are probably freed 
from tlieir aggressins wlieii heated, and aie therefore 
capable of stimulating to the fullest extent the resistance 
appropriate to them. 


BY 

CHARLES NOON, F.R.C.S., 

ASSISTAXT SOnGEOX, NORFOLK AND HOEWtCH HOSPITAL. 

Hair-balls occurring in the gastro-intestinal tract are not 
often met with. When found the stomach is the commonest 
situation for their development, but they may be rarely 
present in anj- part of the intestinal tract. The literature 
contains a few accounts of masses of hair situated in the 
ileum giving rise to intestinal obstruction, of ivliich tlio 
case here recorded is an example. 

A woman aged 30, was admitted to the Norfolk and Norwich 
Hospital on October 15th, 1925, complaining of abdominal pam. 
She^was married at the age of 24, and liad one clnld, aged 

l„sn. 

" ™ — Ti,"!,', 

Kl Hospital on January 5lh,.1925. On admission her cou- 

diUon was diagnosed as ixcen^^^^^^ 

• dLt ucth^ ’She tiien began to improve menlallj;, 

irritable, and Msuu physical condition deteriorated; sho 

I'nsl wcFlikmid suffered from constipation, followed by 
ibdomnal pain, and distension. The stools became lep 
dmrrliooa, abdomma P , discharged from tlio 

SarbospHal ifd the same day was admitted to the Norfolk 
and Norwicli Hospital. 

Condition on Admission. 

,• t n sallow pale, emaciated woman. Hei mental 
The patient was a Ae could answer questions mtelligonth, 

condition was ? ■][ pain. Temperature 99 , pulse 100, 

although she was y furred and the bre.ath foul, 

respirations 18. Th o disease of the lungs. The abdominal 
Tliere was no / tlie^ abdomen distended, especially below 

wail was very ‘/l-d ^tas tenderness all over the abdomen. A 
the swelling could be felt in the region of Iho 

fairly .‘’“„,faco was smooth and its margins 
caecum. Ita a . ,],ape and measured about 3 by 4 , 

It was if The rectum was ballooned, and a bimanual 

was painful because of the pam and tenderness. 

admission to hospital. Operation. . . ' , 

The abdomen - 

Tlio lower part of U ‘ adherent in the pelvis. On freemg 

and mflamed, and one^^ .1^ intestine was visible The caewn 
tlus small p6 P ileum were dva\7n out of ‘ 'irt.-m 

and tho lower part of ,„,ccr two feet of t 

and “* 1,6 much thickened, and its 

was found to toe m separated one from ”vas 

bodies which c ^ 0 ,^ 0 ] was examined, and a piece of , 

perforation m the o cl intestine was then OP® ^’ 

seen prqiootmo ^pfag offensively, were removed. j_,cs(inc. 
four ban-balls, s on mucous membrane 

very extensive "ffensivo fluid was removed by 

A large collection of offo'>=*'0 g rubber tube stitebed n. pla« 
^^feeifSo^ aflfe ’glestine was then stitched to th 

aSdomin.a} wall. j patient’s mental 

After .tho operat on 0.0 manage, but sj'o f 

.for a time entally and physically. The ootcrostomj i 

improved, both menia y difficult to keep tho skm o ^ 

satisfactorily, al ° y „ opening freo from ^'TO' “ y,c 

abdommal ivaU lomm motions DJ 

'tion- i’rom 

rectum naturally. Operation. operation, 













Mabch 3, -1918] 


SCOPE OE- SURGERY IN CHRONIC- RHETOIATOID ARTHRITIS. r, TmEcm^ 

— ■ LAIfPlCXI. JOCEXll, 


343 


„ n,„ inlcilino bv an tnd-io.oi«l anastoTnosi=;. 
n,?p”rk-!lt'ma<lo a gooa recovery from Ibh scoona operation.- She 
LiiL '“ T. ^ a _jj , recks later wos tliscliargcd from 

lorpha'i!' Ste has been beard from frequently since, .and is now 
injoyiug good health. 

In 1779 Baiidaniant- dcscfi^Jcd ilio first reported ense 
of bair-ball; since then over 100 cases liave beon recorded. 
The condition is fre<inciitlv found in .niiininls iji the season 
wlioh the liair is shed, l)nt r.arely gives rise to symptoms, 
.as the liair-bails are nsimlly ex)>ellcd-by vomiting or passed 
in the baeces. In Iminan beings tlio hair-eating liabit is 
gcncrallv eoiifincd to .vonng females, occurring usually in 
individuals of nervous constitution ivitli ])ciTCi ted appetites, 
or in patients irho liave definitely cxbiliitod symptoms of 
insanity. 

Hair-halls may be multiple or single: those developing 
in the stonmeh arc nsiially single. The hair is gradually 
ivorked np into a mass by the gastric movements until 
at length it entirely fills the organ and forma a cast of the 
stomach, with a prolongation in some cases through the 
pylorus into the duodenum. In the small intestine, in 
which they are very rare, the hair-balls ai-e not infrequently 
multiple; tbey.talce the shape of tlie intestinal tube, and 
may be, when closely pressed together, faceted. 

The clinical symptoms caused by the presence of a hair- 
ball in the gastro-intcstinal tract depend on its position, 
its size, .and the derefopinent of obstructive and inflam- 
matory conditions to which it may giro rise. I.edra- 
Hearlit states that the stomach is exceptionally tolerant 
of' foreign bodies, but eventually rebels when the limit is 
reached. Ultiniatcly symptoms appear, such as )iain, voniit- 
ing, and attacks of diarrlioca alternating with constipation, 
and there is much wasting. The hveath becomes foul, and 
the stools are ofFeusive. In the case boro recorded tbc.se 
typical symptoms n-ere present. The development of 
obstinate constipation was first noticed; this was followed 
bj’ ocr,asioiiai vomiting; later on the constipation alternated 
with attacirs of diarrhoea. There was marked wasting, 
and an abdominal tiimorir was di.scoverod. It has been 
auegetl that the patient’s hair may be deficient in the 
frontal region, but this is unusual in cases in which hair- 
i"® founfi in the stomacli. In cases in which com- 
p icatioiLs have not developed' a marked feature is the 
very sliglit disturbance of nutrition. In the rare cases in 
winch liair-balls have been found in the intestine the lower 
is the site where tliov hare nsnallv lodged. 

fie clinical picture presented has nsnallv been one of 
chroiiio intestinal _ obstruction as.sociated with wasting, 
m and vomiting; in addition, an 
tuniour is tunally present. As the hair-ball 
is enno stomacIi the tiinionr, when pre-ciit, 

extend f” situated in the epigastric region, and may 
is well ^^ochendrinni to the other. Its outline 

usunllv surface is siiiooth and hard. It is 

case characteristics in this 

the rielit ir'** that the tumour was situated in 

ahdomfn n''" reached to the mid-line of the 

seated sensation of crackling, or deep- 

The i-ier n ™ade out on palpating the swelling, 

been carefullT'^Sn'd^”^ 5^ hair-lmlls in the stomacli have 
It has been nbvi described by Tlinrstan Holland, 

meal spreads 00^!^ form^''“ ™oiithfiil of an opaque 
the tumour. The shane 
^hen covered by the opaque 'mlar'"' 

The treatment eonsists^r'”'^'''’. 
operation. A carefnllv th removing the foreign body by 
during the removal of tl.„i teelmiqiie is necessary 

rounding the masfare 0 *1- discharges sur- 

licro rocord^ it ^^is septic. In the ca«e 

a considorahle titne to drain the intestine for 

hater to close the faei.-a nas performed 

of a segarent of smol'l • necessitated resection 

nnd an end-to-end anastomlfs”^’ ® inches in length. 



THE SCOPE OF SUEGERT ES' THE TREATMENT 
OF CHRONHC RHEmiATOID AND 
OSTEO-ARTHRITIS.- . 

EV 

C. ^lAX PAGE, M.S., E.R.C.S., 

EURCEOX TO ST. TIIOJIAS’S HdSPlTAL.O 

Co^tMCXiCATioss 071 the treatment of chronic I'heiiiuatoid 
infections may almost be regarded as chestnuts in the 
programiiios of medical societies. I take it that this 
teiideiicv to discuss the various iirohlems connected with 
these diseases is an index of our failure to arrive at any 
generally accepted solution of them. The subject is 
certainly one of exasperatiug complexity, and the average 
lato results of the more severe examples of jheumatoid 
arthritis mav well discourage tlio most optimistic of 
clinicians, fl’jie issue on this occasion is, at an\' rate, 
clearlv defined, being limited to the surgical aspect. 
1 shall not attempt or consider any classification he\-oud 
that in the title, noi- do 1 propose to consider the 
surgical troatinent of what mav- be tlie primary focus of 
infection. I think the simple subdivision is sufficient to 
guide us in radical local treatment, and the surgery of 
the prosiiincd jirimary focus would carry ns too far afield. 

For the purposes of surgical treatment it will, I think, 
he sufficient to accept the chronic rheumatoid group as 
incliidiug several' infective conditions, the results of which 
oil individual joints may vary within wide limits. This 
statement is as true of the late results in individual joints 
as of the earlier cliujeal course. In the late stages of joint 
change, duo to what has been called rheumatoid arthritis, 
we maj- meet witli extreme capsular fibrosis associated with 
varying degrees of destruction of the articular cartilage. 
Ankylosis may he fibrous or bony. 

Osteo-artliritis mav- be accepted as a change in a joint 
initiated Jocallv- by some biochemical reaction; the associa- 
tion with iiijiuy- is no doubt in many cases an important 
factor in the production of the process, hut it does not 
luatoriallv- affect the question at issue in the treatment 
of the condition. The local changes may he clearly 
separated from the first-mentioned variety by the fact that 
anky-losis nev-er occui-s, although absorption of articular 
cartilage may he complete, nnd that periarticular fibrosis 
is never a jiromineiit feature. 

It must ho admitted at the outset that both consermtiv-o 
and radical treatment of joint disease of the cliaracter 
under coiisider.ation can at the best ameliorate the con- 
dition, and seldom, if ever, restore the state to normal. 

In clironic rhenmatoid arthritis it is generally agreed 
that no drastic treatment to the joints can be apjilied 
while the infective process is still active, on accoiiiit of the 
risk of producing a local or distant extension of the con- 
dition. A fen- authors hav-e advocated sv-novectoniy of several 
of the affected joints at an carlv- stage; hut I think there is 
little support for this method. Evidence of activity is giv en 
by the presence of fever and the signs of local inflammaton- 
reaction about the joints. While this is present surgical 
treatment will he limited to the avoidance of contractures 
and to holding the parts affected in such a iiositioii tliat 
function will he interfered with as little as possible should 
ankylosis of the joint ensue. This is not a dramatic part 
of surgical treatment, but it is, none the less, a v-ciy- im- 
portant one, and one that is perhaps insufficiently recog- 
nized, if vve are to judge by the serious and disabling 
deformities which come to hand for treatment in late 
stages. The reason for this is perhaps partly because tto 
treatment of rheumatoid arthritis in the aetivo period 
is considered a medical mattei-. Tlie comfort of the 
patient is hound ±0 influence the practitioner, and 
attitudes of maximum comfort or minimum discoinfoit 
assumed during periods of aefiv-e inflammation of a 
joint mav he progressiv-cly exaggerated till they lead to 
extreme flexural deformities. I do not propose to 
describe ill detail what may ho regarded as the ideal 
positions which should be maintained for all the impor- 
tant joints during an acute or siihacnto arthritis. Tiiev- 

* .Vlntract of a paper introtlnciop a discuesion at tlie Sledical Society 
ot Loadon oa February ^th. 



844 MAncn 3, 192S] 


SCOPE OF SEfBGERT IN OSTEO-ABTHEITIS. 


r TiteDriti?! 

IMrOICAtJOLTSIt 


nro well I’ocopniKod and hold good for nnj' process liable to 
leave a stiff joint. I should like to' draw attention to a few 
deformities which are too commonly met with, and which 
can, as a rule, bo avoided by siiitablo splintage or support. 
In tho lower extremity an acute and painful effusion into 
the major joints will load to tho adoption of tho flexed 
position of tho Ihig'i and knee in tho first attempt to 
relievo pain. •» Tho hip-joint can ho nnkylo.sed in ilcxion 
to 20 or 30 degrees without interfering seriously with 
function, prorddod thero is no adduction. Fixed flexion 
of tho knee-joint beyond 5 or 10 degrees should bo avoided. 
Extension in a Thomas’s splint of a light weight without 
any splint will prevent this deformity being exce.ssi\'c. 

In the upper extremity ono of the most disabling defor- 
mities often seen after a polyarthritis is flexion at tho 
wrist-joint. Tliis joint can ho kept straight or slightly 
extended in a light plaster casing, which loaves tho fingers 
free without discomfort to tho patient. Tho position of 
the shoulder and elbow should also ho considered. 

Tho next stage of polyarthritis in which surgical 
measures may apply is in tho chronic phase. All signs of tho 
infection should have died out, ankylosis or contr.actures are 
established, and the problem becomes essentially an ortho- 
paedic ono. It is not aJirays oa.sy to sotiio when this time 
has arrived, and it undoubtedly varies with tho nature of 
tho infection. It is most undesirable to operate if in- 
fection is still latent, and the matter may bo tested by 
mobilizing a small joint under anaesthesia, and observing 
the local and general reaction. -Operations undertaken at 
this stage will bo of two typos: first, to correct the dis- 
abling deformity, and secondly, to restore tho movements 
in stiff joints. Tho two conditions may bo dealt with 
at tho same time in some cases. 

In order to correct deformity ono of three methods may 
he employed — namely (1) manipulation under anaesthesia, 
(2) graduated extension, (3) open operation. 

1. Manipulation under anaesthesia is often sufficient to 
correct contracture of short standing. It is clearly value- 
less in those cases in which bony ankj-losis has occurred. 
Against tho use of tho method it must bo admitted that 
tho procedure is more likely than anything else to light 
up any latent infection. I do not think, however, that 
this is sufficient reason to cut tho method out. It should 
be approached with caution, and with due ob.serranco of 
the condition of tho patient. In some cases it will not 
only correct a faulty position, but may restore a consider- 
able degree of movement to a joint previously stiff. 

2. Graduated extension may bo employed on special 
joints, as the knee and hip, for similar purposes. It has 
the merit of involving no risk of causing a flare-up, but it 
must be admitted th.at it is not alone likely to bo effective 
in those cases in which thero has been much destruction of 
articular cartilage or fibrosis in and around the joint. 

3. An operation designed only to correct position will be 
in the nature of an excision of the joint, coupled with tho 
division of contracted capsidar structures and even tendons 
in the neighbourhood. In some instances in which thero is 
bony ank 3 -losis a simple osteotomy may bo sufficient. This 
operation is most often used for ankylosis of tho hip-joint. 
It should, however, be noted that osteotomy is a delusive 
operation in those cases unless the ankjdosis is sound. 
If it is only fibrous thero will bo a tendency for flexion 
and adduction to recur. 

Operations undertaken to restore movement have not 
. much vogue in relation to chronic rheumatoid arthritis, 
but in most instances in which ankjdosis of several major 
joints has occurred it should be considered. Thero is no 
doubt that after many of these infections an arthroplasty, 
though it appears satisfactory in the first month or so, 
tends to stiffen up.- Tho technique of the subject will be 
gond Into further when considering the surgery of osteo- 
arthritis. 

The surgical problem in relation to tho treatment of 
osteo-arthritis is simpler.^ We are dealing here with a 
relatively common disease in which no question of any local 
bacterial infection arises. The chief difficulty is in the 
selection of cases suitable for surgical treatment. Patho- 
logical changes vary in degree in a remarkable way, and 
to an extent unexplained by any recognized etiological 
factor. Though the disease in its advanced form may be 


practically monarticular, cases occur in wliich many jointj 
are involved, and tho problem then presented is not iinliko 
that of chronic rheumatoid arthritis. Tho severity of pain 
expei icnccd by tho patient is usually tho reason ivJiich 
decides him to socle radical treatment. Its degree h 
roinarkahly variable in its incidence, and bears no direct 
relation to tho extent of tho anatomical change. It would 
appear that it is tho result of changes in the capsule of 
tho joint, rather than in the articular surface. In view oi 
tho fact that bony ankj-Iosis does not occur in this disease 
wdicn it is allowed to r un its natural course, freedom from 
pain cannot bo assured at any stage. 

The incidence and chronic nature of the disease naturally 
leads to a trial in sequence of conservative measures, siidi 
as flnigs, vaccines, diet, baths, and various forms of physio- 
therapy'. Tho search for focal infection and attempt io 
eradicate it must bo regarded as essential in all early cases; 
I confess that in tho late stages it does not appear to mo 
to ho of such crucial importance. In tho early stages 
surgical measures will bo limited to the provision of rest 
from weight-bearing for tho affected joint. This is clearly 
of most importance in tlio lower extremity. The weight- 
relieving calliper or ambulatory splint will often be of 
service, and if properly fitted will certainly arrest tho 
progression of the articular change. 

JIanipulation, as in tho case of rheumatoid arthritis, 
is tho simplest surgical procedure which can be applied. 
It aims at breaking down adhesions, or, rather, sfrcfohiiig 
fibrosed or capsular structures which limit movement or 
are the source of pain. When tho disease is advanced and 
associated with gross osteophytic outgroivths, I do not think 
much good can bo obtained by the method. In my expe- 
rience tho henofit received has generally proved only tem- 
porary in nature. I do not wish to suggest that the 
method should not ho employed regularly. _ It is of striking 
value in early cases of chronic arthritis in tho knee and 
shoulder in which the changes are mainly capsular. 

When wo come to tho disease in its .advanced form tho 
direct indications for a radical operation- may he clearly 
defined ns two in number— namely. (1) progressive 
deformity in relation to tho joint affected, (2) peisistent 
pain. These indications hold good whatever anatomical 
form’ tho disease assumes, and wliethor the probable causa- 
tive factor appears to be trauma, toxic absorption, or 

bacterial infection. i 

Tho character of the operation selected will be influenced 
by the number of joints involved and the life expectation 
of tho natient. Tl'.e operation may take the form of uhat 
Ti,-iv bo termed (1) speculative arthrotoiny, (2) an operation 
Mnfin-at " okyloiis: or (3) an arthroplasty, an operation 
nhnn?d to restore movement at the affected joint. Tho 
dwisions as to which of these procedures is suited for any 
pmticular case must, as stated above, depend on, several 

O'" exploratory arthrotomy has its ^ 
.'mnnitmt field in the knee-joint. It will generally ho 
,-tnI-on in tiioso cases in which there is pain without 
rmitv or recurrent attacks of effusion into tho joint 
ed wHh symptoms of internal derangement. Good 

associated with sy ^ j 

action is then taken in accordance with he 

ttato found. Eooso ““T 

bvnortrophic villi may be excised, marginal osteophytes 
^ vpd or^the articular cartilage trimmed or shaved 
T^it app^rs diseased. In ttso cases of so-oallcd 
‘Minoma arborcscens ” a complete synovectomy may bo 
n,W The operation is a conservative ono, and 
T''^l I not materially interfere with the subsequent normal 
should not mat^y the joint; it does not involve a 
range of raoveme . ^ experience the 

reTuUs^^e often much hetter than would be e^pocted /mm 


tr^'v^rt^fnature of tho operation. I do not know 
uhetlmrtch reshlts are to bo attributed ^ Jie mechnmeaj 
measures adopted or to tho period of rest and 
after-treatment usually involved. _ i.-riv is the most 

2. Arthrodesis, if eff^tively *™d and 

ndinl and final operation; it cures the pain tor g™” . 

all, its only drawback being that iH 

entailed bv the stiff yoint. I am inclined to ‘ 

tho operation of choice in tho hip-joint in a potion 



MAncH 3> 19 -S] 


CONGENITAEi DrsiiOCATION OF THE HIP. 


t TBTDarnsT 
Mesicu. JoraxiA 


345 


a good cxpectalioii of life, livovidod that the disease is 
monarticular. It is generally accepted .is heiiig the most 
efTcctivo procedure ulicn the knee is .seriously involved, 
and ivheii deforniitv is developing in relation to that joint. 
Ill many eases the operation undertaken to secure bony 
nnkvlosi's may fail to iirodnce this, leaving in .some cases 
tibrous anlcvJosiSj.and in othere a false joint. This failure 
to secure boiiv union does not seriously prejudice the result 
in the upper extremity, and even in the loner pain irill be 
relieved by the measiire, though some deformity or con- 
tvacture may develop. Failure to secure bony ankylosis 
results from'citlicr an iiicomjilcte operation or inadequate 
or insufficient fixation nftenvards. 

3. Formal arthroplasty, or oiierntioiis designed to leave 
a movable joint, arc naturally in favour if they are 
effective in curing symptoms and in giving a sufficiently 
stable joint. In the case of the iiictatarso-plialniigoal joint 
of the great toe an operation of this character is carried 
out as a routine hy many surgeons for conditions of hallux 
rigulus or valgus. The goad re.siilts obtained in this 
operation cannot, hoirevcr, bo oraployed as an argument 
in favour of a similar procedure for the major ucight- 
beaiing joints, the knee and the Iiip. In these articulations 
it is clear that there is risk of the neu'-formed joint iiiidor- 
going in course of time the same pathological changes that 
were responsible for the primary condition. This risk is 
so definite in the case of the knee that I think an arthro- 
pla.sty .should only be aimed at boie in exceptional circiini- 
staneos. In the hip-joint oporntiona aiming at mobility 
appear to be coming more into vogue, being geiicrallv 
based on 'Wlutmaii’s method of reconstruction. Membrane 
or fascia, after the method of Baer or Putti, is often inter- 
posed to seeiire a movable joint. My own view is that the 
operation should be limited to the elderly and to those 
cases in which, on account of disease in the" opposite hip 
or of othei joints in the same extremity, mobility is 
particiilaily important in order to secure reasonablv good 
function. 

This siiiTev represents a brief sketch of a complicated 
problem. It will be noticed that I have not referred in 
detail to the treatment of osteo-arthritis of the spine and 
sacro-iliao joints; this h.as not been done because the 
technical methods employed in those areas must still bo 
icgarded as on trial. I Imve not entered into the surgical 
tcclmique of the different methods discussed, as a full 
account of these can be found in the literature. My aim 
has been to indicate the importance of surgical super- 
vision froiii an early stage in nil cases of ehi-onic arthritis, 
and to demonstrate the possibilities of radical treatment 
ot the more advanced forms. . " 


Some time ago I was faced with the problem of 
reducing a case of bilateral dislocation in a child aged 6, 
big for her ago, muscular, and with strong femora. The 
femoral heads were unusually high above the acctabiila. 
All atteippt to reduce the left hip failed coiiipleteiv and 
was abandoned till a future date, after a considerable'range 
of telescopic movement liad been obtained bv alternate 
extension and rcla.xatioii. Meanwhile both hips' were to bo 
subjected to daily stretching. 

A fortnight or so later a second attempt was about to 
be abandoned when, on considering wavs and means, it 
occurred to mo to make uso of the roller towel which had 
hoeii employed for 
counter - extension 
purposes, and, pass- 
ing the left limb 
tliroiigli one loop, 
the two strands were 
crossed on tbom- 
selvos and continued 
over bath anterior 
superior iliac spines, 
being well spread 
out .so as to cover 
the whole pelvic 
front ; tbo a,ssistant 
put bis foot ill the 
otiior loop ns it 
hung down towards 
tbo floor. -A. tri- 
angular block was then placed between the pelvis and the 
great trochanter, against which the towel passed. This 
enabled me at once to applj- extension at the femora! con- 
dyles with both hands, the limb being in the abducted position, 
and to lever the iicad into the acetabulum at tlie same time. 

1 have since emjiloyed this method siiceessflilly in three 
other oases — one a child aged 9 years — and have found that 
the adductors stretch easily without any kneading or 
hacking with the hand. The amount of force applied is 
under the complete control of the surgeon, the action of the 
towel converting the pelvis into a very efficient fixed point. 

The aecompanyiiig illustration should make my moaning 
quite clear. 


MEDICAL, SURGICAL, OBSTETRICAL. 



COA^GEAUTAL DISliOGAtiOK OF THE HIP: 

-A Metuou or Coxthollikc the' Pelvis wnixc, 
Keduction. 

• BY 

P. AYILSOH STUAET, Ar.CH., 

CSIPPEES’ UNIOX AND ROYAL ORTHOPAEDIC AND 
S RAL HOSPITAL {AMALGAMATED), .AND TO MAKl’IELD ORTHOPAEDIC 
HOSPITAL, NORTHAMPTON. 

ASiu-geon ivi'th experience of a con- 
. K cia ) c lumibei of cases of congenital dislocation of tlie 
JJ-joni in patients of vatA-ing ages it must be a]»parent 
on in.u cqiia oh contro] of the pelvis can be carried out 
attempts at reduction. The chief 
pressing downwards ou the 
aki-^t-nif pt>lvis in an attempt to fix it, the 

tlu' VfTori- ^ the pelvis into a short-armed lever, 

onnn<;i'tn dowji, IS to misc up the 

vaosiit. from the table, carrying the 

end of In *^^ *^*” 'it.'- The nmniinilator is at the 

located ^‘^^(^r-z^naTncly, the knee of the dis- 

pnsterior lin of ^+1 to lever the liead over tlio 

i'm Vo- ' ^‘r^tabulum. are really aiding the 

a Hi-p'it ^ P^h'is.froin tho table, and therefore 

with thr„‘nc velrlvTaent when dealing 

u ith tho older cases-, uRtients aged 5 years and upwards. 


HEMIHYPERTROPHY. 

The case recorded below is, I think, of sufficient intere.st 
to warrant publication. 

The patient, a bov, was 12 years of age when fii'sfc seen. The 
left leg, it was said, was short, and the right sometimes “pained.” 
The father, mother, and seven other children were healthy. Tlierc 
had. been a suspicion of inequality at the age of three weeks, and 
shoricning of the left leg was definitely noticed when he started 
school at the age of five years; it was’corrected by a boot. For 
the past five years there had been intermittent attacks of 
intense oedema of the right leg extending to .the top of the 
thigh, starting with pain in the groin and accompanied by 
pyrexia, anorexia, and signs indicating toxaemia, but no vomiting. 
During the attack pain in the whole leg was extreme; tlie urine 
was scanty and dark (probably febrile), the face swelled as with 
toothache, and the arm throbbed and swelled. Tlieso attacks 
occurred irregularly and subsided with rest, lasting about ten 
days to a fortnight. 

I’Jie right side of the bodA'. including face, arm, and hand, 
was bigger than the left, but the enlargement was most marked 
in the lower limbs. There was oedema of the soft tissues, which 
increased on standing or walking, but subsided after two or 
tUreo days in bed. The right leg w.as 2 inches longer than tlic 
left, and resulting scoliosis and limp were present. Tho right calf 
was 2 inches greater in circumference than the left, and the right 
ihigii li inches. On r-ray examination the bones were found to 
be normal, but the right was larger than tlie left- The urine uas 
normal, and tho Wassermann reaction negative. 

■ The iiitorest of tliii case centres, I tliiuk. round tlio 
iiitennvttciit attacks. It has hecn sugge.stcd that the 
eiilai'gemciit might he due to a pituitaiy*, a symjiathctic, 
or siqivaieiial anomaly. I think this would he hard to 
reconcile with the condition, and feel that it is in nil 
probahility a diffuse unilateral lymphatic or roticulo- 



346 MAticn 3, 1928] 


' memobanda; ' ' 


iftcrciL Joiaxji 


oiulotlielial . liypertiopliy. ■ The attacks jvoiilcl then, corre- 
spond to tho intermittent inflammation wiiich occurs in 
other lymphatic ovorgiowths, siicli as cystic liygromata. 

B. L. McFAitLAMi), Sr.D., iM.Cli.(Orth.), 

Absi&tant Honorary Orthopaedic Surfjeon, Itoyal Liveipool 
Chilclieii’b Hospital. 


POLYMASTIA. 

AcoEssonr nipples are common enough ; hilatcral accessory 
mammae aro comparatively rare, and still more so when 
normal lactation occvws in tliem. 

Tho subject of tho accompanying illustration, aged 25, 
has just given birth to her lirst-born female child. Below 
each mamma is an accc.ssory organ, that on tho left 

being a complete breast, witli 
prominence, nipple, and small 
areola; whilst on tho right 

side is a full-sized nipple with 
practically no areola and no 
mammaiy prominence — quite 
distinct, however, from tho 

main gland. Tho accessory 
mammao aro not visible ordin- 
arily, being hidden by tho 
overhang of tho main organs. 
All four aro secreting milk 
abundantly, though the acces- 
sory ones aro not being used. 

Is tho condition purely accidental — that is, a congenital 
abnormality? If so, they should occur anywhero on the 
body, whereas they always, in ray experience, appear 
in tho “ mammary lino ” — that is, anterior border of 

axilla, just below tho main breast, or over tho 

rectus sheath, though some authorities state they have 
been found on the outer side of tho thigh. Or has man 
evolved from an originally polymastic typo? If so, why aro 
there so few “ throw-backs ”? The child has not inherited 
the condition. 

Penzance. G- B- Biohabdso.v, F.R.C.S.Eng. ' 



GALL-STONES WITH ACUTE PANCREATITIS 
AT THE AGE OF 16. 


The association of gall-stones and cholecystitis with tho 
great majority of cases of acute pancreatitis has been 
recognized for a good many j'oars, although there is still 
some controversy as to tho method by which theso 
conditions may cause pancreatitis. The principal rivalry 
lies between two views — either that the pancreatitis is due 
to a spread of some infection from the gall-bladder through 
tho lymphatics, or that infected bile regurgitates into the 
pancreatic ducts from the common bile duct, this process 
occasionally being duo to the impaction of a gall-stone at 
their common opening at the ampulla of Voter. The 
following case appears to be a good example of the latter 
sequence of events, and, occurring at the remarkably early 
age of 16, is sufliciently unusual to be recorded. 


A girl, aged 16, was admitted to the Wolverhampton and 
Staffordshire Hospital in October, 1926, with the history that 
thirty-six hours previously there had been a gradual onset of pain 
in the upper abdomen, with nausea, loss of appetite, and, later, 
vomiting. In the last twelve hours the pain had settled to tho 
lower abdomen, and was then more marked on the right side. 
Tho bowels had not been open for three days, but she stated 
that this was not unusual. There was no history of any previous 
abdominal trouble. *1. * . 

. She did not appear to bo very ill ; the temperature was 99°, and 
the pulse 116; there was no cyanosis. All over the abdomen 
ri-iditv and tenderness were present, though not very marked ; the 
noirt of maximum tenderness lay over the upper part of the right 
lower quadrant, while the left lower quadrant was the part least 
affected I made the not unusual diagnosis in such cases of 
“ acute appendicitis,” and operated for this condition. 


OTicration, 

On opening the abdomen through a right pararectal incision 1 
found the peritoneal cavity contained a large amount of straw- 
coloured slightly turbid watery fluid. The appendix was normal, 
Pour or five small spots of fat necrosis were found on the 
mesentery and the omentum, whilst a mass could be felt in tho 
upper part of the abdomen. A drainage lube was placed supra- 
pubically by a stab wound, and tho l&sfc wound was closed. A 


right paramedian incision; made above -tiio umbilicus exposed a 
sojt jiiass^ about 4 by I inclies ‘in size, of a’ daik',' almost 'black 
colour, Jyiu^ between (Iio stoiiiacJi and the transverse colon rntl 
arising Iroin tho head of the pancreas. This mass was incised 
freely, showing necrotic tissue. The gall-bladder was 'felt to be 
slightly distended and to contain a number of small gall-stones. 
J.WO lubc5 were left in to drain the necrotic area, and the wound 
was then partially closed. The gall-bladder was not drained as 
the condition of the patient was not good towards the end of the 
operation. 

Ihe patient survived for five days after the operation, her 
appearance during the last three days being that of a case of 
diliuse post-operative peritonitis. Glycosuria appeared fov-tiie 
Ill's! tiino twenty-four houis after llic operation. There was no 
cy.mqsis except in the last thirty-six hours, when the circulation 
was failing. 


Post-mortem Examination. 

Tho subcutaneous fat was soft and friable. There was peri- 
tonitis with free pus bathing the coils of small intestine in tlio 
lower abdomen. In tho, pancreas all normal tissue had disl 
appeared from the iicad, which was replaced by a sloughing ina'3 
with extensive areas , of fat necrosis around it; Ibis was ateosf 
black in appearance, but had no haemorrhage -of any size. Ihe 
duels in (he pancreas could not be identified in the necrotic area. 
There was no sloughing in- the body and tail of tho pancreas, 
which were firm and cont-ained occasional bright yellow - spots of 
fat necrosis. Considerable fat necrosis was found around the tail 
of tho pancreas and in tho fat around tho left kidney. The'gall 
bladder contained a large' number of small yellow faceted stones, 
but w'iis of normal size, with only a slight degree of iiiflammalioii 
of tho wall. The common bile duct was slightly dilated and 
contained about twelve small gall-stones, whilst one stone about 
I inch in diameter was found in the ampulla of Vatcr. . 

. I am indebted to Mr. W. F.' Cholmeloy, under whoso 
caro the jiaticnt was admitted, for permission to publish 
tlieso notes. 

Bash. M. Tk.\cey, M.B., B.S., F.R.C.S., 

Lute Resident Snrpical Officer. Wnfiprhamjriton 
Norwich. . Staffordshire Hospital. 


FRACTURE OF THE NECK OF A RIB BY lATORECT 
VIOLENCE. 

We aro unahlo to find any lecord of this accident in the 
literature, though, by the coiirtcsy of tho librarian of the 
Royal Society of Medicine, we append referondes to similar 
fractures of tho bodies of ribs by muscular action. 

A man aged 60, but appearing ten years younger than his 
declared age; spare, wiry, and athletic, reported on September 2nd 
Inst that eieht days earlier he had suddenly experienced severe left 
umhar pda whillt driving at golf This had nlrnost disabled him 
if /he timo and had persisted. Examination disclosed a round, 
fift trnrr swening. about the size of a florin, in tho left lumbar 
relkn three induS from the middle line and two inches below 
Twelfth rib. It was unattached to the skin, which moved 
Tnr it and it became more pronounced and Wi« more 
1‘Tinv when tho lumbar muscles were put into action. Support 
LmTdia'rpnHial relief. It was Evidently due to muscular 

herniation tl „ injury, though the- patient, from a pre- 

indicalion o ^ years earlier, of fractured ribs in another 

vionsexpcuenc^^seie™ "gone." Repeated 

situation, P airected to this point failed to elicit any 

external nvestigai™ given at first by 

confirmation. sp ^ Churton’s bandage, the pain con- 

strapping, ana disability, and in course of time became 

tinned to caus yfg area of distribution of the tmith 

more rather than in the lumbar muscles. This 

left dorsal to explain by the muscular injuiy three 

localization bei dimc^.^ ^^^j^P^^^ Brailsford on 

segments bel , disclosed “ a fracture of the neck of the 

September 17tK 1 Arthritis lumbar spine, pe frac- 

tenth.left nb ana between the tubercle and the head, 

■ • 

Tho arthritic changes are probably clue to a marked gouty 

^’mT'^^iLnltaneous production of two such lesions as the 
H nfruseX action is remarkable. The special points 

result of muscular ^ the str.-iii Ml 

,f fouV inches apart; (b) that tho sirongly 

in .. the tenth rib (rather than the body) 

Sdtavrbtn fractured, presumably by torsion. . 

Guy Bhansox, M.D.Loncl. 
Jaites F. Bkailsfokd, M.B. • 

Edgbaston. 

Literature. ^ • iqifi 

)ubs: (Ruvami; of 

■alfrey: Fracture of Bita by Museular Action. Poston 

Vehi”rd’c?trrtTiib'/F-^^^ Cough, learn. Aawr. I/rd. 

Julv. 1923. 


BOIENTinC proceedings of branches; 


r Taz EBm<m 
Medjcu. Jocrnax. 


347 


MARCH 3, 


1928] 


IGritislj ^ssodniion. 

CLIXICAL AXD SCIENTIFIC PROCEEDINGS. 

LEEDS DIVISION. 

Difficulties in Cardiac Diagnosis. 

A MEETING of flic Leeds Division, to wliioh oil menibers of 
the niiHlical profession in Leeds and district ivoro invited, 
was held in the hoard room of tlio Genorol Infirmary at 
Leeds on Febriiaij J7tb. Tiio eliairmaii of tlie Division, 
Dr. A. Hawkt.mid, presided, and a Britisli Medical Asso- 
ciation Lcctnro was given hi' Dr. John Parkinson, 
physician in charge of tho cardiological department at 
the London Hospital, on common difficulties in cardiac 
diagnosis. 

Dr. Parkinson said that the time at his disposal would 
permit of a brief description of only a fow of the numerous 
points in cardiac diagnosis. Palpitation was a clinical 
entity, common to many conditions, but most frequently 
met with apart from organic heart disease. Its basis bad 
often to he looked for in liypci'seii.sibility of tho nervous 
sretem, and in toxic and dyspeptic conditions. In simple 
tachycardia tho heart rate was normal when the patient was 
undisturbed, but tho response ivas excessive on exertion or 
emotional excitement. It was not a heart affection, but 
occuiTed under various conditions, such as pulmonary tuber- 
culosis, exophthalmic goitre, and iicurasthciiia. The attacks 
began and stopped gradually. The trouble might be life- 
long, and might not bo duo to any definite cause ; it miglit 
inlerfcro with tlio amount of exertion passible. In simple 
paroxysmal taeliycardia the attack began and ended quite 
suddenly. Change of posture, exertion, and emotion did 
not alter tlio pulse rate. Tlic condition was compatible 
with long life, and no definite cause might bo obvious. 
In ventricular extra-systoles tlio pulse tracings showed 
intervals lietween -two iiorriial beats of exactly the length 

two normal periods witli tho extra-systole inten-ening. 
The venous pulse showed a normal a wave and an almonnal 
c wave corresponding to the I'entricular c.xtra-systole. 
Extra-si-stoles might disappear; they might be a lifelong 
complaint, and might not always be traceable to any definite 
cause. The pulse tracings in auricular fibrillation never 
s owed a regular pulse; the contractions were entirely 
Jviv®” force. This irregularitv was the real 

1 crenco between the pulse tracings of this and of other 
me lac irregularities. In a tracing, for instance, showing 
rl,,' 1 "^' ^ there were portions of tho tracing quite 
” as applied to pulse tracings 

did not convey definite knowledge. 

of cardiac pain was of tlio utmost impor- 
mnro affretions unattended with pain were the 

inis+^l.- diagnosis was ndmittedlv difficult, and 

term “ cardiac pain, Gie 

nicaiiintr Tif “"'1 conveyed no definite 

andff ^.vJn ^crnhl” was more descriptive, 

or below “thp I sternum. Pain at the apex 

necessarily it, ^'voast and down the left arm did not 
in character pectoris, hut might bo neuralgic 

across the chest oboy!'?i,™i “"S'"'' pectoris commonly ran 
to the left shnympT**^^ the breasts to the right shoulder or 
the area of distrihur**”*^ Z'"'™ inner side of the arms; 
the lower iaw Tf might include tho neck and 

the condition was yo..^' r * f™ affected 

Recently a variety pectoris, 

off due'to coronaiw thiyS“ 1’®'^^''*® separatoil 

this condition there was li“”^ cardiac infarction. In 
from anv stress a e, m’ patient at rest and apart 

o-vtonding to botl, a onset of pain across the sternum 
the patient was 00 ™*’ hack, in which 

suggestive of a'ciito vomiting and sweats, 

liver regions with 1 veferahle to tho stomach or 

ond lasting' for h„„re ol'" dayr^'^'’’ 

11*001 nngina pectori*: ‘ t . oiicli a- seizure clifferecl 
tion, the duration short a ^^^r- 
in which there was n ’ “ . .'■“O patient inimohiliv.ed, but 
tore and blood pressiire'^''™'*'”^ alteration of tempera- 

ailerio-sclorosis thrombosis was nsnallv 

conditions, such as syphilis 


and high blood pressure, caused a .small proportion of the 
cases. In nrtcrio-sclcrosis there was a loud aortic second 
sound. Arterio-sclcrosis might result in angina pectoris, 
or bo n coiiiplication of it. In regard to enlargcinciit of 
the heart, if the heart was really enlarged this nicaiit 
a serious and dreaded condition, and great care should bo 
taken to avoid the use of this expression unless the 
diagnosis was certain. For tlic determination of cardiac 
hypertrophy percussion was only roughly correct; an x-rav 
examination was necessary for definite diagnosis. 

The lecturer showed a large number of lantern slides 
illustrative of his subject, and particularly laid stress on 
the presence, in arterio-sclerosis, of enlargement of the 
ascending aorta and a prominent knuckle in it on the 
left side near the clavicle. 

In the discussion wliicli followed Professor V.aiidrop 
Griffith agreed about the doubtful value of percussion. 
Ho illustrated the point by the tnie stoi-y of two eminent 
professore who, when blindfolded and set to percuss a heart, 
failed ignominiously. He mentioned the value of palpation 
in estimating the size of the heart, and the necessity, in 
the case of a small thorax, of recollecting the relative size 
of the heart and the chest. Dr. B.ihnes inquired , about 
the prognosis in reduplication of heart sounds, and. Dr. 
Parehnson replied that in many cases there was no pro- 
gnostic significance, but that oedema indicated a grave 
prognosis. 

The lecture was listened to with great interest and mneb 
appreciation, and a hearty I'ote of thanks was accorded to 
Dr. Parkinson on the motion of the Chairman, seconded 
bv Professor Griffith. 


B-gpnils trf 

THE SCOPE OP SURGERY IN CHRONIC 
ARTHRITIS. 

A MEETING of the Medical Society of London, with tho 
president, Mr. H. IP. Carson, in the chair, took place on 
February 27th. An interesting ceremony was the bestowal 
of the honorary fellowship of the society upon Sir Thomas 
Barlow. 

Mr. M.ix Page opened a. discussion on the scope of 
surgei'V in tho treatment of chronic rheumatoid and osteo- 
artliritis. A full abstract of his paper is published at 
page 343. 

Mr. Haurt PtATT (Manchester), continuing the discus- 
sion, said that the classification of the various types of 
chronic non-specific arthritis could not be better made than 
under the two headings rheumatoid arthritis and osteo- 
arthritis. This classification offered a sound basis for a 
consideration of the role of surgei’y in such affections. In 
rheumatoid arthritis surgical measures, and more espe- 
cially reconstructive operations, had a limited application. 
It was unnecessary to consider in detail the correction of 
deformities by -such well-recognized methods as gradual 
stretching, cautious manijiulation under anaesthesia, open 
division of contracted joint capsules, osteotomy, or arthro- 
desis. Tile speaker’s experience of the operation of 
synovectomy', occasionally practised in the major joints, 
was disappointing. Pseudarthrosis operations were also 
unsuitable, except for bilateral ankylosis in imjKutaiit 
joints, sucli as hip or elbow. In osteo-arthritis a more 
promising field was available. Osteo-arthritis of the hip- 
joint — a definite clinical entity — ^presented most oppor- 
tunities for surgical inteiwention. The patient sought 
relief, either because of intolerable pain or because of tbe 
disability of lameness due to inci'casing joint stiffness. Four 
methods were worthy of consideration, each having its 
definite indication. The first was forced movemonts niider 
anaesthesia. ^This was often followed bv temporary relief 
from pain and tbe restoration of a fair range of move- 
ment. The procedure could be reconuneiided in younger 
patients where the joint change was in an carly^ stage. 
Tho second method was excision of osteophytes, thickened 
capsule, and other formations. Such operations were based 
on tbe procedure known as cbeilotoniy; their scope was 
verv limited. The third method was arthrodesis, which 
was the pivotal operation in ostco-artbritis of tbe hip. 
This was eminently suitable in the younger and more 



348 Makch 3, 1928] SCOPE OE BERGEET IN CHRONIO ARTHRITIS, -T TmrBRm^a 

; ' • • * ; iMnDiCALJomviir 


robust patients. /Inkylosis was not casj’ to obtain .owing 
to the extreme sclerosis of tbo .ioint surfaces. There were; 
certain cliawbacks to arthrodesis, one being the abnormal 
strain throa-n on the lumbar spine, expressed in terms of 
backache, but that should not dissuade surgeons from 
regarding arthrodesis, a-ith all its limit-ntions, .as the, 
method of choice. The fourth method aas reconstnictivo 
excision of the femoral head, an operation aliich gave good 
results in older patients. A comfortahlo joint a-ith a 
limited range usually resulted. The operation competed to 
a certain extent with arthrodesis. It took a shorter iimo 
to carry out, at least in his cam hands, and it gave tho 
patient perhaps a movablo or at least a comfortable hip. 
Finally, he mentioned that the combination of spondylitis 
deformans a-ith bilateral ankylosis of tho hip-joint 
{S[ionihjlosc rliizoncViquc) aas by no means rare. The con- 
dition took many years to develop, and before tho stage of 
ankylosis a-as reached little could he done. After tho hip- 
joint had fmsed it a-as urgently desirable to mobilize one 
side by carrying out a pscudarthrosis beloa- the level of 
the joint. 

Mr. HrnnFiiT Fr.\nki,ino (Harrogate) said^that tho hip- 
joint cases aliich ho had had to tackle liad been practically 
all of them cases of tho ostco-arthritic variety in clderlj- 
subjects. The three cardinal indications for operation a-erc 
relief of pain, restoration of nnbility, and correction of 
deformity, but it aas the fiist of these almost niu-.ays that 
brought tho patient to tho surgeon. Jlost patients were 
very clever a-itli a hip a-hich a-as merely stiff, but pain 
drove them to seek relief. Tho operation best suited for 
this condition was remodolling or reconstruction of tho 
head of tho femur. Ho had found in practically every 
case on which ho had operated that tho capsule, instead 
of being a thinnish membrane allowing a certain amount 
of movement, was very much thickoued, coutracted, and 
actually adherent to tho articular femoral head. As to tho 
results of this operation, the pain had been removed and 
a few degrees of added mobility secured, but even a small 
amount of extra mobility to these people nas well n-orth 
having. The alternative was arthrodesis, extremely difficult 
to do, requiring a good deal more prolonged after-fixation, 
and offering no advantage in respect to mobility. Certainly 
in the eases he had tackled — mainly these of older people — 
tho operation of arthrodesis would not have been an 
improvement on the one described. With regard to tho 
knee-joint, an arthroplasty had been in somo cases 
sufficiently successful to please tho patient, if not to satisfy 
tho surgeon. 

Mr. MoCn.iE Aiiken said that tho cases in which he had 
seen succe.ssful results had been mainly thoso in which tho 
Ijatient’s disab'lity ivas duo to adduction and external 
rotation. Of theso two ho would place more emphasis on 
the latter as a straining factor in rvalking and in main- 
taining pain in the affected joint, more particularly tho 
low- backache pain from which theso patients suffered. It 
wa.s when tho external rotation got corrected by the freeing 
of adhesions that these jiatients were made comfortable 
for a consideiablo time. More attention should be paid, 
both in the early positional treatment and in tho after- 
treatment, following any operation, whether oxtensivo or 
limited, to the position in which the patient was going to 
balance and carry weight aftora-ards. Postural b.'.laiico 
was .a very important factor to the patient. 

Dr. Wakukx Chowe complained that although the 
announced subject was tho seppe of surgery in arthritis, 
no speaker had defined that scope. In fact, theie was no 
scope for surgeiy (he was not speaking of advanced ortlio- 
qiaedics) in arthritis at all. The disease must be extinct 
before tho surgeon came on tho scene. The surgeon was 
dealing with end-results, and if ho confined himself 
to end-results ho would have a certain proportion of 
successes, but tlie more ho moddied witli the disease when 
it was active tho less successful would his total results 
appear. Tho scopo of snrger3- proper, therefore, was 
limited to deciding at what stage it was safe to operate. 
In tho treatment of arthritis three peojile were involved — 
namely, the general practitioner, the pliysician, and the I 
surgeon. The two latter seldom came into tho picture at 
all; the general practitioner was the man who treated j 


.artliritis, and what it was necessary to do if possible in 
all pnblic -di*nsSions was" to' try ' to "impress' on geiim! 
practitioners tbo early results of simple orthopaedic surgery 
so as to avoid tlic “ wbceled chair ” deformity which was 
so very difficult to deal witli afterwards. 

Mr. GroFriiEY Hoi.jees said that there were some surgeons 
who maintained that no self-respecting phy-sician should 
ever handle a splint. If that was so the surgeon came 
early into d.-mand in tho case of arthritis. Tho point as to 
when snrgic.il treatment should be started was very impor- 
tant. In tbo spa hospitals patients were seen in alt stages 
of arthritis, but the more he saw those cases the mere ho 
.s}-mpathizcd with tlio difficulties tho general practitioner 
hail to contend witii in the early stages. There u-as nothing 
more Ininililing to the man wlio had bandied tiie late stages 
of arthritis n-itli some freedom and success than to be 
called upon to handle the early and most difficult stage, 
and know wlien to splint and when to manipulate. 

Dr. C. W. Buckley (Buxton) quoted the case of a 
patient svbo liad been suffering from arthritis for a period 
of fifteen years. 'Within the last two years one knee — the 
worse of the two — had been artlirodesed, and on operating 
tbo marrow of tbo bone was found to be soft and absolutely 
of tbo consistency of butter. The bone, lioweYer, was 
placed in position, and tho patient kept in plaster-cf-Paris 
for throe montlis. Since the operation tliere had been no 
trace of pain, and tho wliole condition of the patient had 
improved to an extraordinary- extent. That was an indica- 
tion tliat it was somotimes desirable to operate for relief 
of pain even if the disease bad not completely subsided. 
Jinny of the knee-joint cases which were beginning the 
cliair-lifo were doing so through habit which had led 
to a spasm of the hamstrings and a contraction of tbo 
capsule of the joint. Ho was disappointed not to hava 
beard moro of the application of manipiilativo surgery to 

conditions of that kind. _ • i n i *1 

Jlr. Max Baoe, replying to the discussion, said tliat the 
rcmiivks of the varieus spc.-ikers had emphasized the fact 
+1,-1+ nt am- rate, the surgeon could relieve the final stages 
S adtmVeed joint change.” Witli regard to the value ef all 
these oiiorntioiis it must bo a matter of several years before 
the merits of arthroplasty and arthrodesis 011 the m.ijor 
ioints could bo exactly assessed; the results were yet young. 
No inontion bad been made in the course of that discussion 
of tUo very useful part played by surgery Jn relieving 
artln-itic coiulitieiis of the smaller yoints-for example, 0 
the fingers— but that was a field in which much good could 

bo done. 

CHRONIC APPENDICITIS IN CHILDREN. 

^ r. rmiihinc'cl meeting of tho Sections of the Study of 
dLuso in Children and of Surgery of tho Royal Society 
M jiedicino 0,1 February 24tli a 

chronic appendicitis in children. Mi. G. L. Waugh,, 
- Vent nf the first-named Seelion, was m the chan-. 

I’T Boi- Huxchisox, opening for the CliiUli-eu’sj 
c fen raised the question whether tnere Mas such a- 
®‘’‘'dRbn as Cliroiiie appendicitis in childhood. He did not: 
condition ■ statement that in childhood appendicitis! 

oitlipr acute or non-existent; it was, however, rare 
f'^^nipct with the chronic condition. Ho asked wlietlior 
• aoneiidicitis always arose out of an acute attack, 
■"debt it bo chronic from the start. If an acute attack 
" nrilv nrcceded tho chronic disease, then the h.story 
TITreveil some such event; it was not always discern- 
D,nll. it mi-bt have been too mild to h.ave received 
ifaie ti ^ to be no reason whytlie disease 

nu.cl.at e„tmi,.^^W tbronghont, as in tho. case of tons.l- 
did not think “appendix dyspepsia’ occiiiied 
! e'.c^hild it was rather an affection of the colon than, 
' f F c . omach which was apt to be simulated. In the 
cin-h reenn'ino episodes of abdominal pain were mo.o 
with or without vomiting and slight fever, lO 
common n th 01 ni constant. If tho patwni 

nas' iilTseen hotwUn attacks there might be no phys.e^ 
signs. If there was no tenderness cially 

pressing over -McBurney’s point was J to the 

if it was referred to tho epigastrium. Pam conhnea 



March si .^-'CHHONIO J^rPE^biotn^ 'm chilbreit; [siS^5^u 319 


Vi-'lit iliac- fossa was rarelv duo to chronic nppondicitis, but 
if°it came on after exertion rather than after meals it 
simeested that condition. Indamcd glands might give pain 
ou‘^palpation of the right iliac fossa. Kadiography coidd 
not determino the diagnosis; indeed, it might only add 
another clement of doubt. JIany conditions might simulate 
chronic appendicitis in childhood; enlarged glands, kinking 
of the ileum or appendix, a mobile caecum, and an adherent 
aicckers diverticulum could not be certainly distinguished 
from chronic appendicitis, nor from each other, except by 
exploration.- Ureteral obstruction by stone should bo dis- 
tiuguishnble by x rays and by examination of the urine 
and nrinaiy jjassages. Pelvic affections in girls could be 
detected by bimanual rectal examination, if necessary 
under an anaesthetic. Ovarian pain without a discover- 
abio organic basis might occur in girls at about puberty, 
and ceased with the establishment of regidar menstruation. 
It might be impossiblo to distinguish pain arising in tbo 
colon from the pain of appendicular origin ; the former 
was very common in childhood, and was sometimes accom- 
panied- by vomiting. The more frequent the pain and the 
_ closer its relation to meals, however, the less likely was the 
condition to be elironio appendicitis; in intestinal colic a 
long retrocaecal and adherent appendix might be the 
cause. Slight attacks of appendicitis of acute form were 
often mistaken for bilious attacks. Some surgeons seemed 
to believe that appcndicectomj' cordd cure cyclical vomiting ; 
his own view was that true acidosis attacks, with rejjcatod 
vomiting and tlio presence of acetone bodies in the urine, 
were of hepatic origin, but the child with acidosis attacks 
was likelv to have appendicitis. His own practice, when 
hronght into^ contact with a child who had recurrent 
abdominal pain, with or without fever and vomiting, and 
m a bora chronic appendicitis was likdly to be tiie cause. 
Has to advise exploration of tbo right iliac region — not 
appenchccctomy ; this advice was the more readily given if 
le child v as going abroad to school, or if the iiarcuts were 
anxious about tho_ possibility of appendicitis, or if there was 
a strong family history of the disease. He did not promise 
» euro of the symptoms; lie stated morel v that tlio fears of 
an attack of appendicitis might now be set at rest. In the 
within his experience the symptoms 
irnc +? I’y appendicitis, yet in onlv a few cases 

snmo exploration ontii-cly negative. In 

-enlnro.o.1 '^”1' appendix was found, in some there were 
• .fl . ® g ands or a band of some kind; vorv geiierallv 
. cie Y® condition wliich justified the ciploratioii.' 
tP^t from the surgical side, said 

rarelv nr-fiivT i^''* ^ apiieiidicitis iii the adult 

■ from'aii f disease; it resulted usually 

■ appendicitis with so-called chronic 

with viro-i'ml ' + conditions of the caecum associated 

he iiiclmlerl Ir the acute variety of appendicitis 

seriously having gangrenous, perforated, and 

caso?ueJ h' 1" l>!a category of ci.ronic 

condition wss^° wY'®"!- active symptoms, even though the 

-thoro with an acute attack, and also 

external dens “"d stricture formation, or 

showed senile atronhv '" ''s not diseased, but 

l^rane. In 906 c \ ^ ^ involved in a J ackson’s mem- 

' otlier lesion*? fini \ appendicitis uncomplicated . with 

fhero warabott 305 as chrouie; 

patients 186 were uS *'*° sexes. Of the 

into tho present age, and so came 

chronic. In 17 thn only 33 of them were 

attacks which had s^shlS ''“‘I followed acute 

laent. Acute appendicitifstill 1" 

mortality in children 1,1 * ' a" alarmingly high 

with severe pain and vo, -r- '**'-’ associated 

grave suspicion. In his should bo regarded with 

enlarged mesonterio o-i ^ ,^'^'’*^5 there . were five cases with 
angle! In those "®P^ciallv those at the ileo-colie 

Y»ngh sreth“s‘^;u^^Y;?/’’'’i 

hvo cases of ^ acliinp; pain. In 

frequent attacks of p^^n^n^tf 

abdomen ; the attaeK 1 \* "S'd iliac fossa and lower 

■tion, and a sirmiflen^i °nh' a few days’ dura- 

.was no acconipanvintr -‘'*?®*’™^>ating point was that there 
cconipanying inflammatory mass. In four of his 


cases there wero threadworms; the mild attacks had 
ajipendicitis, and at the operation the appendix 
.seemed to bo slightly inflamed. The threadworms were 
found in the lumen. About 33 per cent, of cases of 
aijpondicitis occurred in children iiiidor tho age of 14 , 
and in them it was a more serious condition than in 
adults, prohahly hecanse children wero less likely than 
adults fo notice earlier sniiptoms. Ho did not fiiid any 
cases 111 early life which had been chronic from the 
beginning. 

Mr. HnunKRT It . C.insox referred to a paper which 
appeared five years ago in a medical journal in the United 
States suggesting that chronic appendicitis was a myth. 
Ho did not doubt, from his experience, that chronic 
appendicitis in children did occur, but in certain respects 
it differed materially from the condition in adults. With 
Dr. Hutchison he agreed that “ appendix dyspepsia ” did 
not exist in children, neither did they have tho symptoms 
of visceroptosis, .though occasionally they had a mobile 
caecum. In children it was common to find the appendix 
in the dangerous “ five o’clock position ” — ^that is, hanging 
over the pelvic brim. He agreed with Sir. Walton con- 
cerning the occurrence of threadworms in the appendix; he 
thought they caused chronic appendicitis rather than an 
acute perforative lesion. Enlarged glands in the ileo- 
caccal mesentery ho did not consider were tuherculoiis from 
the outset; rather they were chronically inflamed glands 
upon which tubercle bacilli were easily implanted sub- 
sequently owing to low resistance. In distingnisliing these 
enlarged gland cases from appendicitis he relied more on 
the character of the attacks than on cither temperature or 
tenderness. In the former condition there were many 
attacks, but pain was not continuous between . them, as it 
was in appendicitis. 

Dr. G. A. SuTHEnuAND was still of the opinion that 
chronic appendicitis did not exist in children. He criticized 
one reason given by Dr. Hutchison for advising surgical 
exploration of the right iliac fossa — that, namely, of 
relieving tho parents’ fear lest the condition might bo 
appendicitis; this he regarded as an instance of treating 
tho parents instead of the child — a sort of conspiracy 
against the child’s physical well-being. He would deal 
with such a child on much the same lines as a doubtful 
heart case — by letting it play about and carefully observing 
tho result. • 

Mr. V. W.vRREx Low' deprecated the ideas expressed by 
Dr. Sutherland, and thought that to allow a child with 
such symptoms to run about would invite such a disaster 
as perforation. 

Dr. A. P. Cawadus recommended that the terms 
“ acute ” and “ chronic ” in respect of appendicitis should 
ho abolished; this would lead to a great clarity of con- 
ception, what was now spoken of as the acute disease 
being regarded as a paroxysm. Temporizatious based upon 
tho idea that a case might be only chronic had led to 
many disasters. It was better to risk an occasional opera- 
tion' for which there was proved to be small justification 
than to let a patient die, but the number of unnecessary 
explorations would be much reduced if a thorough examina- 
tion wero made, not only of the abdominal region, hut also 
of the thoracic, and of tho nervous system. 

Mr. L. E. B.rnRixGTOx-WARD did not think there was 
danger of any surgeon mistaking acidosis for appendicitis. 
Many cases showing sr-mptoms such as had been described 
were due to alterations in the relation of the ileum to the 
caecum. 

Mr. Maitlaxd Jones admitted uncertainty as regards 
the diagnosi.s of chronic appendicitis in children, and 
desired more minute guidance as to symptoms. Ho agreed 
with Dr. Hutchison that in some cases it was quite good 
irractice to “ treat the parents.” 

The CnAiRJfAX (Mr. Waugh) said that the pathologist 
could not gU'e much practical help in this condition, it 
was nccessarv to weigh the probabilities in a symptom- 
complex which might be very varied. He drew particular 
attention to the primary tuberculous appendix, more 
common when tho appendix was in a hernial sac than ^len 
in the abdomen, and also to the primary streptothrix 
appendix: he revierved the subject in a general way from 
tho surgical standpoint. 



350 MARcn 3, 1928] 


HHEUMATIC’ 'INFECTION HI ‘THE YOUNC. 


It,r 

• ' • L ii*oiciL JorMij 


EHEUMATIC INFECTION IN THE YOUNG. ■ 
At a meeting of tlio Section of Epidemiology and State 
Medicine of tho Eoyal Society of jModicine on February 
24th, tho president, Dr. S. Monckton Coi'EMan, in tlic 
chair. Dr. Reginald Milleii read a paper on some public 
health aspects of juvenile rhoumatisra. 

Dr, Miller dealt first with tho prevalonco of rheum- 
atism in tho young, and mentioned that in no country 
was rheumatic infection moro common than in Great 
Britain, where it affected tho elementary school children 
most seriously. Heart disease seemed to ho more frequent 
among children leaving school than among new entries, 
and more common in urhan than in rural schools. In 
secondary schools information about tho prevalence of 
rheumatism was scanty, but the speaker quoted some 
figures supplied by Dr. Poarso Williams with regard to 
the Polytechnio Secondary School, which indicated that 
whereas the proportion of boys with rheumatic heart 
disease was 1.53 per cent, this was distributed unevenly, 
so that among scholarship boys from the elementary schools 
tho incidence was 2.67 per cent., and among the fee-pa3’ing 
boj’s only 0.08 per cent. ; this class incidence was an 
important point. Dealing next with mortality Dr. Miller 
mentioned some of the difficulties in estimating tho death 
rate due to rheumatic infection, and after discussing 
various published figures concluded that tho number of 
deaths due to rheumatic heart disease in this country was 
about 20,000 in each year. With regard to tho invalidism 
caused by rheumatic infection in London it had been 
estimated that about one-quarter of tho children absent 
from the elementary schools for long periods were those 
affected by rheumatic infection. Dr. Miller then dealt in 
some detail with tho age and class incidence of tho disease. 
Most of tho first attacks occurred between the ages of 
7 and' 8, while at puberty the type of tho diseaso changed 
to the adult variety. There appeared to bo three reasons 
for the ago incidence: chronic tonsillar infection, tho 
beginning of school life, and tho diminished resistance to 
infection shown during the years of childhood. Dr. Miller 
emphasized the point that rheumatism was a disease of 
the hospital class and was rare in private practice; but 
investigation of tho lower limit of its incidence suggested 
that it was less common among the very poorest. He said 
that this view had been criticized, and he dealt with 
certain pieces of evidence, including some recently pub- 
lished work; a map of Birmingham with the incidence of 
rheumatism marked upon it did not resemble at all closely 
another map defining the areas of poverty. Tho deductions 
from this peculiar class incidence of tho disease were that 
rheumatism was not altogether governed by poverty, nor 
did it spread by infection. Dr. Miller went on to affirm 
that juvenile rheumatism was essentially an environmental 
disease. Ho quoted the report of the Medic.vl Research 
Council, which indicated that in Poor Law residential 
schools rheumatism was very rare, and yet these children 
came from homes where they would certainlj' have con- 
tracted rheumatism had they not been removed. Tho 
absence of overcrowding, the provision of good food the 
short distance necessary to get to school, and tho preven- 
tion of sitting in damp clothes were no doubt important, 
and there was evidence to show that the housing of children 
of this class was an important consideration. Dr. Miller 
mentioned the association between tonsillitis and juvenile 
rheumatism, adding that chronic tonsillar sepsis was present 
in about 85 to 90 per cent, of rheumatic cases. Ho 
. emphasized the importance of damp dwellings in the pro- 
duction of rheumatism, and said that rheumatic infection 
attacked children through the tonsils; cold and damp 
dwellings predisposed children to recurrent attacks of 
catarrhal colds. The disease was commonest in cold, damp 
countries, and some unpublished work by Mrs. F. C. 
Shrubsall showed that the sites of the homes of rheumatic 
children tended to bo in low-lying areas and to follow tho 
watercourses. Other evidence quoted included the report 
of the Committee on Rheumatic Heart Diseaso of tho 
British Jledical Association (Supplement, July 3rd, 1926, 
p. 3), which showed that 62 per cent. ^ of all rheumatic 
children investigated were found to bo living in obviously 
damp homes; a recent series of- cases in West London 


investigated by tho speaker gavo much tho same resnllj 
Tlio reason why tho very poorest families escaped rheum 
atism was that tho overcrowding of many people into on 
room tended to keep it warm and dry. Dr. Miller tliei 

■ dealt with tho organized effort against juvenile rheuit 

■ atism, and said that . tho difficulty of obtaining th 
support of tho public in tho work of prevention ami th 
task of providing dry and warm homes for the poorc 
classes seemed very great. Notification had been tried ii 
Paddington for somo months, and despite the legal limit.! 
tion of tho typo of case which could bo notified tho spe.ike: 
thought this procedure was well worth while. The super 
vision of rheumatic children, especially by tho children’ 
hospitals throughout tho country, was rapidly increasing 
and Dr. Miller mentioned the importance of calling sue) 

.centres " rhouraatio ” rather than “cardiac” if the; 
were to perform their true function of preventing hear; 
disease. He referred also to tho need for further accom- 
modation for cardiac patients requiring prolonged rest in 
bod, and urged that such facilities should not be too iai 
from the metropolitan hospitals. Dr. Miller dealt finall; 
with tho role of the school medical service, which, he urged 
should secure the warming and drying of all childrci 
arriving damp at school; he also asked that certificate 
stating that a child should not attend on wet days or onl; 
for half-days should be allowed. Dr. Miller stated that ii 
liis opinion tho ordinary routine of school medical inspec 
tions failed to discover the rheumatic child or the victin 
of heart disease in the great majority of cases. Treatraeii' 
should bo undert.iken only by those who had the facilitiej 
for dealing with every possible rheumatic emergency; ii 
should not bo conducted at minor ailment centres. 

Dr. J. Tehtius Clahkb, in a paper on the pathogenesii 
of rheumatic fever in its climatological relationship to a 
possible insect carrier, said that during thirty j-ears’ semes 
in the Malay Peninsula he had never seen a case of rheum- 
atic fever, chorea, or subcutaneous nodes, and he had neve 
found mitral stenosis at post-mortem examinations. Rheum 
at 0 diseases appeared to be very much less frequent i 
the troDics, and yet inflamed tonsils were as common ir 
so p^ts’as in "England. He discussed.the gecgraplnca 
JUtrlbntion of rheumatic fever, mentioning first some 0 
tbn difficulties in diagnosis. He quoted figures in support 
? hfsS ^tservatioL that rheumatic fever did not occui 
tbr, trooics Coming next to the question of the rat-flea 
CeZophyUns' fasciatuf, the speaker showed that its ffis 
t -Z7;L was in the temperate clime,s, corresponding closel 

wW Tat 0 rhoumari The flea required a Ing 

Tt not excessive degree of humidity for all its life phases 
^ VTarval and most delicate state a wet skin killed 
nt one Its tost, the brown rat, lived in ont-of-doo, 

burrTr and under dwellings. The flea was es«n iMR ^ 
burrows certain persons, which mighl 

T?-,orexplain the rlLmatio diathesis. Dealing w.tl 
^ •"^mental conditions. Dr. Clarke said that damp tour 
r'^ prTe favourable to rats, and therefore eucouragoc 
Tfleas Since the flea had a very long life sometnue: 

rat-fle . might be tho meteorological coa- 

Ju-ons of tlm earlier months of the year which Produced tk 
^‘Tof rheumatic infection in the late autumn months, 
nr TaT then discussed the similarity between the lesion 
^ rlipumatio fever and those produced by other protozo ■ 
- ThLs and summarized the evidence against the strepto- 
'"T or ein of the disease. He believed that the d.seas 
was oausei T- protozoou or spirechaete which was carried 
hv the flea Ceratophyllus fasciatus. .* 

T>rpsident, ■ Dr. Copeman, mentioned some ot th 
a-ffi RtFps of accepting Dr. Miller’s deductions, remarkinS 
difficul j districts the conditions with regard to 

that in in the towns. Dr. J. A. Gloveu 

f wltrsome of T evidence which Dr. Miller ha 
dealt with thought that the class incidence 

i vfLnFnred in the fignres quoted was due to the fac 
which fiPP ‘ , investication on rheumatism had related 

Sl-S/Srii-V. p;r.. .. 

Shbubsall discussed the question of tho sites of the 


viSARcri 3i I9-*1 


,<HYSTERECTO:\IY'-IN PTIERPERAti SEPSIS. 


r Tgr Pu mra 

Medicxi. JoC1Ufl£ 


351 


from' wliich rlieumatic casps came. It tos a curious fact 
that aliens living under the same conditions appeared to 
escape the vheiimatic infection which afflicted English 
children. He replied vigorously to Dr. hfiller’s criticisms 
of the school medical service. Dr. J. N.vinx DonniE empha- 
sized the very careful nature of the examinations made 
hy the school medical service. He mentioned a special 
investigation he was making on 100 rheumatic children, 
and he^descrihed the type of pre-rhcumatic child for which 
"he was constantly looking aniong the entrant children. 


HYSTERECTOTIX m PUERPERAL SEPSIS. 

At a meeting of the Section of Obstetrics and Gynaecology 
of the Royal Society of Jlediciiie on Pebruary 17th, the 
president, Mr. Cojiyxs BF.nKKi,irv, in the chair. Dr. 
Bethel Solotioxs showed siiecimons of two uteri which had 
been removed for puerperal sepsis. 

Dr. Solomons emphasized the difficulty of determining 
the optimum time at which a hysterectomy should bo 
performed in cases of puerperal sepsis. He regarded a 
continued raised temperature and inilso rate in spite of 
treatment, an arrest of involution, the presence of irregu- 
larities on the surface of the uterus, and an olfensive 
discharge .as cardin.al sign's that this ' treatment might be 
adopted. The first patient had a prolonged illness, and it 
was not until the twenty-fifth day that it was decided to 
remove the iitems. At the ojieration this was hnind to be 
in great jjart necrotic, and Dr. Solomons showed a <lrawing 
of the uterine wall. The patient died soon after operation. 
In tile second case, after a vei-y difficult delivoiw owing to 
a complicated presentation, there was continuons jivrexia. 
A fortnight after the labour bimanual cxanunation 
®^’SS^^ed the fonnatiou of a uterine abscess, and a hvster- 
cctoroy n-.is performed. This patient made an almost 
umntciTupted recoveiy. 

- ^ultipJc Ihjomas in Young Patients. 

i ■ ■ Ettisox read a communication entitled “ Two 

sisters under 25 

fivet ’ 1 patient was 24 vears old, and was 

i e pregnant. 'She was complain- 

Trnre ^ud the utcrus was mucii larger and 

Entrircst™?? duration of pregnauev would 

ref^ the abdomen and 'found a 

surfaeo fibroid growths scattered over the 

foi-moA 1 °rgan. A subtotal hysterectomv was iiei- 
Her sic-ul P‘''tient made an uninterrupted i-ecoverv. 

found tn h I>y ilr. Ellison soon after and was 

sha'nc snneeS'*'” retroverted uterus of inegular 

She had can Presence of multiple fibroid tumours, 

time and P “'“cd of abdominal jmins for a considerable 

Bonnev oneraT 

of the .append doubtful about the coiulition 

multinlo Jl removed ninety-five fibroids bv 

“S:. "etf/vir"' sood 

and hail ua , + "c Edison last saw her she was well 
anu had no return of abdominal pain. 

Jlr. FiiEn^S',!lt'‘u ^P’^emic Encephalitis. 
epidemic encc^aUtirh^ pregnancy and 

Tvhich he had Bill eat “f’”" twenty-one cases, of 
collected from the in '’P°" ®°rne 200 other cases 

.of pregnanev, labmir‘‘''^nd‘’' tl^** considered the influence 
qudomic encephalitis v. i- l^'^rperium upon acute 
ao untoward influenw^ believed that pregnancy exerted 

:tbat the process of driiveiwdffln'r“‘''l 

improvement ia natient. ^ “■ produce any marked 
regard to the inV'uonee of' r"repb"'‘tis. With 
scorned to be no tei f disease upon labour, there 

labour. Tlie 000005 ^ nf T*T miscarriage or premature 

tionallv easy in case itself seemed to be excep- 

cophalitis *T+ oT^a* bv acute epidemic en- 

wore dulled and tl"^‘ ^ senses of such patients 

hbolished or ’diminished P"*"' 

occasionallv occurred i labour retention of urine 
resultino' from tl.o .i’- ®'gbt bo due to central paralysis, 
that the ciicephalit\rhad f-lii suggested 

'though ho thouriit that ctiect upon the child, 

o t epidemic encephalitis neonatorum 


was a i-are but definite clinical entitv. The author then 
considered the question of Parkinsonism and its relation to 
pregnancy. He discussed the diagnosis of encephalitis as 
a complication of pregnancy, and in conclusion drew atten- 
tion to various points in the treatment. 


HISTOLOGY OF THE GLOBUS PALLIDUS. 

The usual quarterly meeting of the Royal Aledico- 
Psycliological Association was held on Eehru'ary 16th at 
the City Alental Hospital, Fishjionds, Bristol, the chair 
being occupied by the president, Dr. Hajiiltox Mahe. 
A resolution of appreciation of the good work done for 
many years by Sir Frederick Willis as chairman of the 
Bo.ard of Control was carried with acclamation. 

Dr. E. B.MtTOX White read a paper entitled “ Some 
points in the histology of the globus i>allidus.” He said 
that among the changes in this body in different diseases 
various authors had referred to striking changes in the 
walls of the blood vessels, manifested as a deposit of an 
amorjihous material in their outer walls which was often 
sufficient to obliterate their muscular and elastic fibres. 
The process simulated calcification. One-half of the 
hundred cases examined "by Dr. Weston Hurst at Queen 
Square Hospital showed this change in the vessels, sharply 
limited to the anterior half of the globus pallidus ; the ages 
of those patients ranged from 20 to 81. Hurst bad shown 
that the material was not calcium, but a large portion of 
it was easily staiiiablo iron ; the material was also detected 
lying free in the corpus striatum. Hurst found that the 
deposit did not represent a senile change, that it was 

not related to arterio-sclcrosis, and that in some of the 

cases no pathological change could be seen in the nerve 
cells of that nucleus. These deposits seemed to indicate, 
in that worker’s view, a proclivity for the globus pallidus 
to degeuomte in the second half of life. Dr. G. Hadfield 
had shown that acute bilateral necrosis might affect the 
part of the globus pallidus in which the vessel change was 
found, and that a rich deposit of iron salts was present 

in the walls of the vessels of the pallidus in half the 

persons examined who liad no chronic ncrvo.us disease, their 
ages being over 50. Dr. Barton Hliite’s figures corre- 
sponded with these. The paper was supported hy tho 
exhibition of a series of very convincing slides, and the 
speaker submitted, as his conclusion, that the deposition 
demonstrated was as frequent in all forms of mental 
disorder as in chronic neurological cases and as in normal 
brains, and that therefore it could not he regarded as 
pathognomonic of .my particular nervous disease, as some 
iiad lueviously contended. 

Dr. ClnoFFEEV Hadfield said tho deposit was not a 
minute microscopical quantity, hut that it could he easily 
detected with the aid of a liaud lens. Alany had con- 
cluded that the change in the vessels was pathological and 
that it caused, or largely contributed to, neurological signs 
and symptoms; it had, for instance, been suggested as a 
cause of post-encephalitic Parkinsonism, also os playing a 
large iiart in the causation of paralysis agitans. The 
change must he related to the fact that the globus pallidus 
Avas verv rich in iron salts, as could be readily seen hy 
putting a slice of brain into potassium fcrrocyanidc and 
Iiydiocliloric acid, when it rapidly became a deep blue. 
An investigation led him to the conclusion that the iron 
which appeared in the vessel wall came from the miclons 
•itself, and was therefore intrinsic iron ; he also con- 
sidered that it was derived from a precursor in the nucleus 
which did not stain. The site of the deposit in the nucleus 
stronglv suggested that the process was octnallc ^ a 
det^enerative one. It was, he said, tempting to think 
that perhaps the globus pallidus was a vestigial strnctnrc 
which was undergoing evolutionary atiophy. There seemed 
to ho no specific association with diseases. It was a possi- 
hilitv that this deposition of iron might predispose to 
disease: it certainly would alter the perme.ahilitv of the 
vessels. Tho condition always seemed to he absent in 
children, hut in old people it w.as frequently found. 

' Professor E Fawcett agreed that tho globus pallidus 
was one of the oldest parts of the encephalon, and thought 
that Dr. Hadfield's suggestion that a degoncrativo process 



362 MAncn 3 , 1028 ] 


HIGH BLOOD PBESSURE. 


r TniDBrnsf 
L JfEmclL JoCRXlS 


resulted in these depositions soemod fairly sotiiuL Dr. 
J. B. Bonn mentioned the importance to psychiatrists of 
the basal gariglion as being probably tbo seat of the 
contra] mechanism of the emotions. Dr. Brandcr at Bexley 
had investigated the presenco of iron in cases of general 
paralysis, and had discovered it in largo quantities. Dr. 
Barton White, however, did not appear to have arrived 
at the same conclusion. The presenco of tho iron in tlio 
globus pallidus might indicate a regression of function, and 
indeed that tho structuro was a dying one. Tho extent of 
regression would vary in individuals. Di’. G. E. BnACiiKi-ii 
asked whether tho author had investigated, tbo brain of 
a patient who died of pernicious anaemia, and, if so, 
whether iron was found in tliat case. ITo inquired also 
whether there was any analogy hotwoon tho reaction found 
in tho globus and tho staining and pigmentation discovered 
in tho brain after haemonhago. 

Dr. Bauto.v White, roplj'ing, said that in ono case of 
four persons dying of general paralysis there was certainly 
no iron deposited. 

Dr. II\T)riEi.D, replying, stated that ho had not examined 
any cases of pernicious anaemia, hut that in that disease 
tho pigment was taken out of tho blood by a phagocyte. 
In tho cases which had been examined there was no reason 
to suppose that there was 003 - e.xccss of iron in the circu- 
lating blood, nor in tho pathological series as contrasted 
with tho normal. Ho believed that tho deposit occurred 
apart from any phagoc 3 tic cell action. He thought haemor- 
rhago could bo eliminated ns a cause of tho pigmentation 
or tho change in tho globus pallidus, since in tho ni.ajorit)' 
of these cases there was no sign of a pathological lesion. 


The hfenial State in Cardiac DUcasc. 

Dr. Cauev CooJtns road some notes on tho mental .state 
in cardiac disease. Ho said ho had reviewed about 
2,000 cases of cardiac diseaso, and from them ho had 
drawn certain inforonces as to the connexion between 
such disease and mental disorder. Ho suggested answers 
to the following questions : (1) Was there cvidonco that 
mental disorder caused cardiac diseaso? (2) Did the circu- 
latorv disturbances arising from cardiac disease often upset 
tho mental functions? (S) How far wero both cardiac 
disease and mental disorder, when they occurred together, 
due to a common cause? In tho war mental disturbance 
was often the chief factor in causing functional tachy- 
cardia, and mental stre.ss and worry woro appreciable 
factors in producing high arterial tension. Ho did not 
believe there was any form of heart diseaso which arose 
out of mental disorder. As to whether cardiac disease 
could bo directly responsible for mental disordei-, he had 
been impressed by tho absence of unimpeachable evidence 
in support of such a view; still, severe cardiac diseaso was 
BO terrible to contemplate that it might well upset tho 
mental equilibrium of the person conceined, and also the 
deficiency in the cerebral circulation might result in mental 
trouble. It was rare to find insanity as a sequel of 
rheumatic heart disease. Tho incidence of insanity in 
uncomplicated heart disease was not higher than that of 
insanity in the general population. There were some con- 
ditions in which mental and cardiac symptoms appeared 
to<^ethor and might bo ascribed to a common cause. In 
poisons with senile heart diseaso, for example, tho failure 
of the heart to supply blood adequately to the periphery 
was only one of many factors concerned. 

The Pkesident (Di-. Marr) thought there would bo 
general agi'eeniont that heart diseaso per $a seldom caused 
mental d'lsorder; when mental disorder followed heart 
disease it could usually bo ascribed not to cardiac con- 
ditions but to the circumstances which brouglit about 
the diseased state— namely, the autotoxin or microbic 
effect on the blood. With regard to heart conditions 
offpcting the mind, it was usually the mental condition 
which caused the f«-tional aber.wt.on 


This was cer- 


tn.-olv so in very many of the cases of shell-shock during 
th^war; tho heart condition usually came on after mental 

exhausrton ^ ^ president; the action of tho 

heart was very much involved in the psvebonenroses and 
tho noiirosci?. Insanity was so closely nssoc.atccl with the 
toxaemias that it was difficult in a given case of acute 


insanity to decide whether tbo heart condition was due io 
tbo montnl state or to tbo accompanying toxaemia. 

Tho readers of both tho papers wero cordially thanked 
and, at tbo invitation of the hospital visiting committeo, 
members and visitors lunched together, Mr. John Cems, 
J.P., mayor of Bristol, presiding. 


HIGH BLOOD PRESSUEE. 

At .a meeting of the M.anchoster Pathological Society held 
on Febnmry 8 th, the president, Mr. E. H. Wrsiii.wOTi, 
in tho chair, communications', on tho subject of high blood 
pressure wero made. 

Dr. J. CniCHTON BnAaiwEM, and Dr. B. Ew,is in a joint 
paper referred to tho difficulty in defining the upper 
normal limit of blood pressure. In common with many 
other physical attributes tbo range of variation follow^ 
tho ordinary typo of normal frequency curve. A systolio 
reading of 1.60 mra.’ Hg should not. bo regarded as neces- 
sarily pathological even in young people. There was little 
tendency for tho systolic pressure to rise between the ages 
of 20 and 40, and even in healthy old people a systolic 
rc.ading of under 150 was common. The high pulse pressure 
in old aeo was a compensatoiy mechanism to overcome the 
loss of elasticity in tho arteries. Even apart from any 
structural change tho elasticity of the arterial walls might 
be greatly impaired by a high diastolic pressure. Henco 
a relatively small rise in diastolic pressure would entail 
a much greater riso in pulse pressure if tho bc.art was 
to maintain its output. In this respect a high diastoho 
pressure was just as important as a stiffened arterial 
Fn determining tho limitation of exorcise to eranco Tb® 
snliygmogram in cases of liyperpiesis resembled taat ot 

stenosis the maximal pressure m the aorta being 

atta nod FeSvcly late in systole. With regard to prog- 
attamco r > condition of tho kidneys was oi 

Frnwtance. In primary hyperpiesia, though the 
the first impu ^^1 o^,tiook was not quite so 
pressure n „^t incidence was 

graio as 1 -pnerally ended in uraemia. Tho diastolio 
lower, an J fpgcial significance in relation to tho ulti- 

PT^’IcuLFs because it represented tbo liability .which 
.mate piognosis, ^ ^ undertake. Tbo systoha 

the boait w. .. g . ],and, was more closely rciated to 
pressure, on indicated the capacity of the 

the jj' liabilities. A falling sy.stolic associated 

’’ul a rWnt diastolic p.-cssuro was always a very baf 

• tbit it signified boart failure. 

omen, in that it sg account of tli£ 

Professor J. ■ ■ hs-pertonus might still very 

morbid anatomy g to the long-cstablisbed faci 

well ^tart.wil a refere^e ^ 

tbatcliron.c nopbe trs,^!) 

commonly P' oduce temporary rise of pressure in acutt 

evidence, including P circulatory change being i 

nephritis, ^nt of e^retort funcO It migbl 

reaction but bitlierto unrecognised pressoi 

he that some P. the body owing to ircpairec 

substanco was vessels, Anotbci 

cxcrotioiiy and ^ Hkely was that in accordance witl 
explanation, n excretory substances were eliminatoc 

Ciisliny-s view filtration under pressure of _tb( 

from tho bloo t filtration was imitec 

blood, ‘’’I „.as required to secure adequate chraina 

a greater Pf terious group of non-renal cases, e 

tion. -tonus many of tbo morbid changes in tbi 

organs wore degenerative phenomena such as cere 

merit. end® cerebral softenings, atherom.a n 

bral .'*■'“^“‘”7 -Imnkage of the kidneys. Local softening 
arteries, and je^atrophy seemed to depend at time 

and patches of tissue auop.y s ^ inadequate h 

on the blood vessels, tbo contraction of which hat 

perfuse .some of degenerative changes vanix 

helped to raise .-^''j^erent instances ; they appearei 

markedly in cases wlmre death occurred frot 

‘Fretanm^^^ cTml’e" ^n’ 



r TnESnmw 
L iiEDicxt, Jorny^ ouo 


^ ’ IMARCH 3 , 1928] 


PEOPHYLACTIC GYNAECOLOGY. 


btnicUiral clinnges ivhicli might bo said to occur in all 
eabcs of essential liipertonus, or at any rate winch were 
found' even in the earliest cases at the jmsi-morfcm 
examination, ivere (1), Jivpertrophy of the loft ventricle of 
tiic heart; (2) hypertrophy of tho middle coats of tlio 
arteries gcnerallj’, in Professor Dunn’s experience in- 
variably accompanied by--fome fibrosis of tho media, a 
degenerative feature, but an . earlier stage of pure hyper- 
trophv might be presumed; and (3) changes in niinuto 
arterioles of the size of tho affereuts to , renal glonieruli. 
All affected vessel shoived thicheniug with fatty degenera- 
tion of its lutimal coat, starting exactly at its origin from 
the parent trunk and extending throughout its length. 
I'rora its distribution and character tliis lesion hardly 
suggested the action of a toxin in the ordinary sense; if 
such was concerned it was difficult to see why the jiarent 
vessel should escape damage so completely as it often did. 
Tho morbid condition seemed on tho whole more likely to 
he due to a poor blooil supply in the smaller ve.ssch result- 
ing from contraction of tlie larger one. Tf this explanation 
of the change could be supposed to bold good then all 
the earliest structural changes in Iiypertonus were mostly 
evidence of the mechanism' for maintaining it, or of defects 
arising from the operation of that meehanism ; the ultimate 
causal agency remained quite obscure. Tf this agency was 
an abnormal pressor substance it had still to be demon- 
strated. Other possibilities might bo imagined on lines of 
analogy with chronic nephritis — such, for exam|)le, as the 
presence in the blood of a substance of low solubility which 
demanded excessive filtration for its elimination even by 
normal kidneys; lead and perhaps uric acid might suggest 
this type of action. Increased osmotic pressure of the 
blood colloids would also require a greater filtration 
pressure. 

Mr. GsoFriiEr Jeffersox dealt with blood pressure read- 
ings in the course of operations, especially on the central 
nervous system. The systolic blood pressure and the pulse 
rate were recorded every five, or in some cases ten, minutes 
regularly, and the curves so obtained gave valuable in- 
formation as to the condition of the patient, and some 
indication, at any stage, of his ability to undergo pro- 
longation of the operation. In more than one instance 
patients whose systolic pressure had fallen as low as 45 or 
t>U mm. of mercury had made uneventful recoveries. 


FOKCEPS DEIIYERr AKD PROPHYLACTIC 
GYNAECOLOGY. 

. aiEiTTiXG of the Edinburgh Obstetrical Societv was held 
In + 1 ^ Gr. Haig Feugc.sox, the president, 

Giims.iv (Glasgow) rea.d a jniiicr on the 
gi'iiaecoloev delivery as a basis for prophylactic 

intnV ‘'^®oribed the various cau-es of inter- 

-tliK M-ol "'fr “Electing the birth canal, and suggested that 
trauma in? I ?'i application of forceps. The 

almost minfn *0 the naked eye, or might be 

over stretrl ' in manv cases was due to tlie 

fascia Z para-ccrvicai tis-sue or pnho-ccrvical 

mmiinize matoriaUv^'jn!” to 
Dr LinUsavV „ ■ ^ "Umber of forceps cases, and in 

foneps deVrvery*’,vrs‘”tlie"' “’‘''i ’'''I"'’''' 

amount of avliere there was a moderate 

of labour. ror2ens"apr^ beginning 

eases of occinito-im.ri«^.^ "'^o be advisable 111 

rotated hv hand * j Presentations which could not he 
was resistance of'+l difficult instances where there 

ness of the i..* Poivic floor, and narrowness or tense 
me ilitroitiis of the 


vagina was marked. 


ji - ““.luitus or 

therefore emphasived +),e -. s’ 

of antc-nahal simei • • ^ "ecessity for the careful teacliiii! 
5.fandnid indicnw‘'"f”" students. tVith regard to tlr 
they could he verv n 1 delivery he thought tlia 

for example, that f since he did not believe 

Caesarean section were warranted in cardiac cases 

of distrer more satisfactory. Foeti 

iiiteneatioii. bi.e Ycrtainly definite indications 
labour liad 


bitenentioii, but ■ 

labour liad progip^^":' ""'y permissible when ... 

of .safety for the ^^'fficiently to make delivery a matte 
n debilitated cliiia nf- “h Irenefit in deliverin 

q iickly wlien such a rapid delivery woul 


entail a degree of maternal injuiy. In his opinion the 
mother should be the first consideration. Iii primarv 
uterine inertia he was opposed to the use of forceps, since 
delivery could often be effected by emptying the bowel 
and the bladder, and by giving a hot vaginal douche. In 
secondary uterine inertia the uterus required a "rest ; 
morphine was indicated in such cases, and not forceps. 
Perineal rigidity should be treated by the administration 
of light anaesthesia, when relaxation usually occurred. If 
rigidity persisted anaesthesia, and such expedients as fiindal 
pressure or administration of pituitary extract, would 
often evoke the necessary power. Until these simple 
methods had been tried forceps should not be emjjloyed for 
this minor indication. If forceps were necessary they 
should be employed in such a way as to prevent serious 
birth injuries; it had been proved that they were safe only 
when applied in the hiparietal diameters. Dr. Lind.say 
considered the axis-traction forceps a dangerous instru- 
ment, for, wlien applied with the head in the oblique 
diameter of the pelvis, the vagina was inilled taut and 
forcibly twisted as rotation -of the -head progressed. This 
often caused extensive vaginal lacerations. In Dr. Lindsay’s 
opinion the best iiistriiiiient to-day was the K.ieIIaiid modi- 
fication, which was a long forceps and practically' straight, 
the pelvic curve being almost negligible. This instrument 
was nlw.ays ajiplied to the hiparietal oephalic diameter, no 
matter what tlie position of the head ; it was smaller than 
tho Miliie-Miirray forceps, and liad no fixation screw or 
axis-traction apparatus. It remained under the control of 
tho oper.ator, who knew the amount of force he was expend- 
ing. There was much les.s compression of the child’s head, 
and, what was more, the compression was always main- 
tained in the safest cephalic diameters. If the high 
foi-ccps ojieratioii was to remain at all in obstetric practice 
then the ICielland forceps was the ideal instrument. Di'. 
Lindsay condemned the use of forceps as a lever and as 
a rotator, and concluded that it should be employed as 
a tractor and considered ns a compi-essor, the latter action 
being only utilized in the planes where it would be most 
efficient and where the compression would least damage 
the child. Ho added that if this line of practice were 
followed it would be realized that the only safe forcejis 
delivery wliicli one could complete in those unfai-ourablo 
surgical circumstances usually found in working-class areas 
was the low forceps operation. 


THYROIDECTOMY IN TOXIC GOITRE. 

-At a meeting of the Section of Surgery of the Royal 
Academy of Jlcdicine in Ireland on Fehruaiy 10th, the 
president, Pi-ofessor A. Fullerton, in the chair, iMr. D. 
IvEXXEDT read a paper on the operation of thyroidectomy 
for toxic goitre. 

Mr. Kennedy advocated the standardization of the opera- 
tion so as to lessen its dangers, shorten the coiivalescoiico 
of the patient, and improve the results. He recommended 
ligature of the vessels before they entered the gland tissue, 
whether the whole or part of a lobe was to be removed ; in 
this way there would bo no haemorrhage, the danger of 
.shock was greatly lessened, and the iiost-operativc condition 
of acute thyroid poisoning would not occur, at all events 
in a degree to endanger the patient’s life. The steps of 
tho oi>eratiou should he thought out beforehand and per- 
formed with deliberation. Open ether well diluted with 
air was the most satisfactory anaesthetic, and 1/4 grain 
of morphine and 1/100 grain of atropine were administered 
about thirty minutes before the operation, the patient 
being always carried to tho operating table. Local anaes- 
thesia was not satisfactory, and combined local and gencial 
anaesthesia was useless and a waste of time. To expose 
tlie tliAToid A'cssels fullv, and to free the reciiiTCnt laryn- 
geal nerve and the parathyroid glands from any danger of 
fiiiurv, the gland should he dealt with inside the capsule 
The cut muscles should be accurately sutured to prevent 
scarriiK^ Limol administered in preparing the patient 
for operation helped to lesson the seventy of the symptoms 
and to improve the condition of tho patient, hut its utility 
ceased after administration for a few weeks. Mr. Kennedy 
said that the results of operation had been gratifying; 
in suitable cases the mortality was nil, and complete 



VJIAL STATISTICS OF. WEALTH AND POVERTT, 


T TnrBnmss 
• UMepIcIC JlICMit 


'354 . March 3, 1928!. 


recover}' wns assured. No- operation was advisaWe if the 
heart muscle was degoucratod or whore a pathological 
c(.iKlition such as kidney disease had developed. 

The President referred to the. difficulties- roof , with in ■ 
operations for toxic goitre in connexion with the recurrent 
laryngeal nerve, wliich was often .surrounded by tlie 
hranehos of the inferior thyroid artery, and thought that | 
tile question, of shock following thi,s operation was not so 
sinijilc as Mr. Kennedy had made out. 

Mr. S. T. luwix suggested that Mr. Kennedy had failed 
to distinguish botacen exophthalmie goitre and toxic goitre; 
he believed that any surgeon who opciatcd indi.scriniinately 
on cases of exophthalmic goitre would encounter fatalities. 
Every case, of exophthalmic goitre .should ho admitted first 
into medical wards, and an operntinn should not he under- 
taken until a physician had recommended both the time 
when it should ho perforniod and its c.xtent. 

Mr. R. A. Stonky agreed that ligature of the ve.s,sels was 
an essential preliminary to thyroidectomy, hut if the 
thyroid wa.s much enlarged the isolation and identification 
of thojvo.ssels were hy no means simple. It wa.s sometiine.s , 
very difficult to reach the inferior thyroid vos-sels, and 
when there had heen prolonged medical treatment, and 
especially i-ray therapy, so many adhesions were formed 
that it was almost impossible to free the gland. It might 
bo hard to invert the lower ]iolo of the gland and expose 
the inferior thyroid artery ; in tho,se case.s he approached 
the inferior thyroid vessels from the inside, and it wa.s thus 
possible to avoid the trachea, which often caused difficulty 
in rcspii'ation. Ho had tried local anaesthesia, hut had 
not found it satisfactory. Ho always used rectal ether 
suppleraonted hy a certain amount of open other on the 
mask, whieli gave rise to no difficulty. 

Mr. Kpn.xfdy, replying, said that lie woidd never hesi- 
tate to operate on any ease of oxoplillmlinic goitre, provided 
tiiat the cardiac muscle was not affected. Ho looked upon 
the difforenco between e.vophthahnic goitre and toxic 
goitre as being one of dogieo. In operating on the.se 
patients difficulties wore encountered with adhesions, hut 
these had to he dealt with as in other operations. Ho did 
not ligature tlic pole, hut tied the vessels directly; after 
ligature lie divided freely and opened the lower pole. 

Ohsteti'ical Vrar.turcs of the Femur. 

Mr. R. A. Stoney read a paper' on two cases of 
ohstoti'ical fractures of the femur'. 

An infant, 2 days old, was admitted to hospital with a fi'.acttirc 
of tho right femur at the junction of the middle and upper thirds, 
which liad been produced in attempting to Iii'ing down one leg 
in a breech presentation. Tiro child was treated by extension of 
Ihe thigh in the vertical position. One month lalvr the extension 
was taken down and the log was x-rayed ; tire photograph showed 
malunion _ with considerable overlapping and backward displace- 
ment of tho lower fragments, both fragments being snri-oundcd 
by a large mass of callus. Two years later the child was again 
.seen; she was able to walk and run perfectly, and the x ray 
showed a femur which appcni'ed perfectly normal except for a 
slight thickening of the compact tissue over tlie outer side of the 
hones in the region of the fractures. Tire medullary canal had 
been perfectly reproduced. 

The second ca-sc was that of an infant, 8 days old, admitted with 
a fracture of the left femur at the same level, produced in the 
same way as in the former case. Tliough the limb was in a 
Thomas splint, the x-ray examination showed mai'ked displace- 
ment. Tiro case was ti'cated with cx'tensioii in the vertical posi- 
lion, and an x-rav photogran’i taken a month later showed union 
with abundant callus in excellent position. 


Mt. -Stoney said that according to some autboi-ities tire 
treatment of these cases wa.s aiinple, merely folding the 
thigh on the abdomen and holding it there by a broad 
snathe. Pla.stei'-of-Paris from the thigh to the ankle, with 
the thigh at right angles to the' abdomen, was also said to 
give good -results. One writer on surgical diseases of 
chlldi'cn had suggested that good lesiiUs were obtainable 
in. all cases bv almost any tr eatment. Fi'om the ex2Jei'ience 
of Ids two cases it -would seem that extension in the 
vertical irosition -was in every way satisfactory ; the results 
were Rood it was easv to uuvse the patient, and the infant 
did not object to the position. Cai'e should be taken to 
npplv the extension plaster to the thigh as well as to the 
le", and to see that the weight was sufficient to keep tho 
hdttoek off tho bed. It was advisable m these small infants 
to sling both legs, since if only tire broken one was slung 
uiid tlfo' other was left on the bed, it was impossible' to 
control tho movements. The probable cause of the' had 


result in the early stage in the first ease was the fact that 
tho sound log was merely tied to the ci'o.ssbai- and was not 
counterpoised with a weight and pulley. It would appear, 
liQwev'cr, that at this early ago a good first result. might he 
confidently expected, even if tho x ray showed that the 
union was not automatically perfect. 


VITAL STATISTICS OF WEALTH AND 
POVERTY. 

At the meeting of tho Royal Statistical Society on 
February 21st Dr. T. H. C. Stevenson of tiro General 
Register Office read a pajicr on vital statistics of wcaltli 
and poverty. 

Many attempts, lie .said, had heen made to estimate the 
iiitliicncc upon health of iii'ospei'ity and the lack of it, but 
the extent of our ignorance of the subject attested the 
difficulties of its investigation. His paper describod a 
iiietliod of dealing with it employed in tlio recently pub- 
lished report of tho Registi-ar-Gcneral on occupational 
moi'tality dur ing 1921-23,* ' and discussed the degree of 
.success attained in the light of the results arrived at. 
The method most commonly emiiloyed had heen tho com- 
|inrisoii of returns for com])letc populations selected as 
lepr'cscnting wealth and poverty; but the samples so 
secured wcio far fi'oin pure or free from influence by 
other factors. If the contrasts in wealth and — what was 
jirohably quite as ' important in its iiifiuenco on health — 
ciiltui'O 'wore to bo obvious the numbers available for 
o.vaminntioii ii'ould he limited; and, on the other hand, 
if the field' of investigation rvere extended the difficulty of 
assessing degree of local wealth and culture became foruud- 
able Classification of individuals by income was not pos- 
sihlo under present conditions in this country,- -thougU 
■it had been employed bn ri very limited-scale in America. 
•Estimation of poverty hy housing conditions was vep- 
unsatisfnctorv, as bad housing was only one of the handi- 
^ onvertv SO that it was inipossiblo to determine 
far the excess of mortality associated with had housing 
r ir e riibverty and how' far to the divert effects of 
„Jrmvdhic etc. Even if full iletails of income wei-e 
available- tlfese in themselves. -would not - jitoyide nu-ideal 
r of ’ classification; as it was I'n-obably- the cultural 
basis of n-ealth which promoted longevity rather 

assoeiaLons ° for. the mo.st part poorly 

tlnm ® i-rjv liealthyT The method advocated for 

wn'ditions to he considered was that of 

■"w iim social iiositioii from occupation. By this means 
infer, ng social ^ ^ to (average) culture as well as 

regard cou d h P foj population could he iii- 

rncome, ai. t i ^ The re.sults attained by a scheme 
I' ef on tl ese linos had been described in the report 
T verl to and the regularity and consrstepey of the 
referred to, “j- mortality from various causes 

graduation s ’i evidence of the success of the 

appe.oiod to ^ Instances of such regu- 

Bocial hy Dr. Stevenson, mortality from many 

larity increasing without interruption from ri 

forms of Pest to a maximum in the lowest socia 

Pi^tely^iseases, including phthisis furnished 
class. Jtespii r ^ of distribution. 


" s:m;w:f ^strnmHon, 

„e most rerei'sed for diseases of the digestive 

'".:fd for diabX in later life, mortality from 

ysteni, and without interruption' . from a 

qipendici . jo,vest to a maximum for the highest- of 
iiiuimura fpi th ^ distinguished. Tho case of cancel' was 
ho fi?"; ting. Mortality from this cause followecj 

.specially J^ial distribution, being lowest in tho 

he usual i„ tpe lowest section of society. But 

ighest **«*!. to auply to cancer of certain 
his from the lemaiuder being much the 

rtes ^ The graded sites, which were respoir- 

" ol^TaTf the tMal deaths (in males, for whorn 
rble for occupational information was available), 

lone the requisite „outh to stomach 

rst have' to be recogn ized. 


r^Tjiin'MEiacu. Jocn.x.ii7 JanunryTstli, P- 154. 



MAKcii 3. 




r Trn: BnTn^fr- 

MeOIC-M- JoCBSAt 


355 


EibittoB. 

. ' GAS POISONING. 

The piibliration in tbo JIoiioi,H-ni)h Series of tlio American - 
Chemical Society of a treatise on a problem in industrial 
liTgicne by two ’wcll-Icnoivii physiologists seems to us to bo 
ail event of real. significance. It is a practical expression 
of that liaison between the laboratory and our social 
organization which many advocate in tbeorv , but too 
seldom are at any great pains to re.alize in practice. , The 
book which occasions this comment is by Professor Yandeli, 
HEXDEasox and Dr. H. 'AIY 111100X110, and is entitled 
2ioxioits Gasexand Hit PrincipJes of Kespiration Influencing 
their Action.} - It will bo agreed at oiico that the authors 
lire well qualified to instruct us in the principles of respira- 
tion, arid, further, that the sympathy towards questions of 
applied pliysiolo^ which is betrayed in much of their work 
wilt incline us to listen to what they have to say on this 
grave problem of industrial gas hazards. 

■ , Headers of the Eniiisn Mebical Jouiinae may recall two 
lectures by Professor Henderson which wo had the privilege 
of pubVishirig during his recent visit to this countiy. Tlie 
substance of those lectures is the foundation of this book, 
and the same lucid argument and forcible persuasion will 
be encountered again. It is surprising that in the enormous 
library of toxicology there does not appear to have heen 
."iiv earlier book dealing specifically with the problem of the 
special nature of poisons which find entrance to the body 
through the lungs. It is well .that the omission is now 
repaired, for, if ,wc accept the statement of the authors, 
it is “ almost the only field in the whole range of modern 
sanitation in which fatalities throughout the civilized 
world are increasing from year to year.” 

Four introductory chapters summarize those princijiles 
of respiration and of the behaviour of gases and vapours 
which arc fnndaniental to the consideration of the absorp- 
tion and elimination of volatile substances. As the authors 
•acknowledge, the discussion goes much further than that 
in any current textbook in representing a vital function 
as a iiiechanisiii. For the practical problem in hand physio- 
ogists will not be inclined to quarrel with this adventure. 

ch.apters are devoted to the classification 
le chief groups of gases of social importance upon the 
pasis ot their physiological action. This leads to the 
•sepaiatc consideration of asphyxiants, irritants, anaes- 
■horgaiiio and organo-metallio gases. The 
®^™P*P™s, and sequelae of each group are 
: ” f a description follows of the special character- 

i' ('nm!',. }" nicnibcrs. The chemical field covered 

•ind .chapter discusses the prevention 

iiiit idon P°*®®“'ng by noxious gases. A selective 

Thf ‘•'■‘■onipaiiies the text, 

more tin n 'riite for chemists and engineers rather 
are in imm a* men, because “ in general chemists 

resnonsiblp ^-f ® and control, and are increasiiigly 

, — . 1 .. •• human portion of the machinery of 


prodncyioii, and for the 


the ‘'^termination and prevention of 

f-actre ” tL which they 

tip. 1 -1 .. that in this subiect nonnl.ar 


manu- 

in this subject popular educa- 


men,’cllctririinKmeiranrh''‘^ instruction that “ police 
that a nhvsician frequently save lives 


profession^are'*fainu'ia”*^’''ti^"'“® members of the medical 

aStme’t. 


the matter of the book under 
for them to challenge this 


merited' success of 'a new edition. From a modest origin 
it has'.devcloped into a* comprehensive textbook, although 
it * retains its previous character. Fach section has been 
expanded, where necessary, so that it is not merely brought 
up to date, but it is scarcely possible to discover anv 
point about which useful information . is lacking. Tli'e 
editor has evidently been a wise guide to his associates, 
and has so arranged the sections that the whole is well 
balanced, while thero is a sober restraint and an abseiice'of 
fads and fanciful ideas. This ]ilain statement of the case, 
howiivcr, in some places is associated with a style so crude 
that improvement is really needed, and frequently soriio 
literary polish would be welcome, though this does not 
apply to all the sections. Opportunity has been taken 'to 
remedy' some minor defects, and the illustrations have be.eri‘ 
improved, but it is sad that such an important group ,as' 
those depicting the stages of the mastoid operations -are 
not more realistic, for as they' are they would give but 
little help to an inexperienced operator. There is, however, 
no other book which includes laryngology and otology with 
such success, for there is no undue stress laid upon any 
particular .section, which is the common failing of such 
books. Although it has reached its -present size it is not 
unwieldy; but is packed with information; and has attained 
the right proportion between an elementary textbook and 
a work' of reference. The present, edition should surpass 
the previous issues in popularity. 

Progress during the seven years which have elapsed 
since Dr. D.ix AIcKexzie produced his Diseases of the 
Throat, Nose, and Dar^ has induced him to enlarge the 
second edition, which is now issued, though time does not 
appear to have modified his views in any important details. 
The size to which this new volume has been expanded 
must give serious concern to the reader, although Dr. 
McKenzie has eluded the vigilance of his publisher; this 
great increase might have been avoided by a judicious selec- 
tion of material and condensation of language, without 
omitting anything the least important. The author, as 
before, freely acknowledges the work of his colleagues and 
many otliei's, although he gives comparatively few refer- 
ences, and these in no systematic fashion ; throughout he 
makes it clear that the hook is based on his own personal 
experience and opinions. The expansion is due, however, 
chiefly to the desire of the author to give acknowledge- 
ment to the observation of others — in such matters, for 
example, as tuberculosis of the larynx and meningitis. 
Valuable as tbe book is as the expression, not only of his 
own matured judgement, but that of the teaching school 
he represents, yet it does not attempt to be the book of 
. reference and authority which a volume of this size 
might well have claimed to be. It must, however, be 
judged bv the standard of the first edition, and the reader 
will certainly fiiid- here full information and advice on 
every point which can possibly be held to come within the 
provinces of otology and laryngology. There arc various 
debatable topics upon which it would be easy to challenge 
the views of the author, and herein there is but little 
change from the first edition ; but he has the courage of his 
opinions, and supports them with sound logic and argu- 
ment. This edition, therefore, more than deserves to 
repeat the success of the previous one — to which it is 
certainly superior in its breadth of view — as a conipro- 
hensive work on tbe subject. It should bo added that the 
book is published in a generous style and is magnificently 
illustrated. 


The welMmS® THHOAT, AND EAR, 

■vvliiclr unflor of the Kosc, Throe 

"'■'V bo taken to ' of Dr. Logax T 

Edinburgh School 01''^!!"''-*’'®."’°’'^' teaching 
— has Tlo^v acliieved th 

Catft 


.. : — lias Tlo^v ai 

1- r SomVu- S Jlowartl W. 


'irafion Influence 
Hap^iird. 
Clienucai Cai 


figures, fl.50 dollars.) 

?“nsM Earner ST PractUion 

and onJar-Pd. :^*Pv F.R.C.S.Ed. 

^jnipkin, MarihnTi • John AVrfrv^f 


ISimnk. ,7 F.R.C.S.Ed. 

I'P Hamrit™' ■"'rislit and Snns, 

I'P. .XMV+ 410; 2 J, E ™'™. bent and Co., Ltd. 1927. 
“ P'ales. 203. net.) 


Dr. State has enlarged the second edition of his Dand~ 
hook of Diseases of the Nose, Throat, and Ear* to some- 
thing like double the size of the first, and be has been 
wise to follow this policy of decompression, for tbe con- 
tents were so tightly packed that their utility nas im- 
paired. Even now the author attempts to cover a wide 
field in such a way that ho is compelled to touch very 


Jnis,- 3 .rs of the Thrnnt, Kose and Ear. Bv Dan McKenzie, 5LD., 
FlLCSEd. Second ednion. London : U illiam lleincmann. 1927. (Slip. 
tAir on VI + 577 ■ £64 figures, 3 plates. 4 ds. net.) 

4 Hoinito?!' of the Xoee, Throat, and Ear. By W. S. Syme, 

” V r r P*and S Clas., F.R.S.Ed. Second edition. Edinliiiryh : 
11 and S. LiiiXgstone. 1927. (Cr. 8vo, pp. .tv + 400!.25 Szurcs'. 21 plates. ' 
12s. 6d. net.) 



366 March 3, 1928] 


EKVlEWS.'^'T-.y.r 


P ., Jiir UnrnjH ■ 


liricfly on many points. The book, liowevor, gives a general 
representation of his oivn practice, vithotit attempting to 
follow any orthodox lines. It is presumably addres.secl 
primarily to the .students and post-giaduatcs of his own 
teaching school, but it will be found a usoful guide to any 
house-surgeon or during a .short courso of post-gradjiato 
instruction. If Dr. Syme has not put . forward the full 
capacity of otology and laryngology at the present time — 
and indeed ho has not attempted this — yet he will be found 
a safe guide in all conditions and maladies that eonniionly 
occur. Ho nearly always writes from o.xpcr'ence, and 
seldom from authoritj', and the whole book is exi)res.sive 
of his own personality. The superficial treatment of some 
subjects rather indicates that ho considers them of minor 
importance, and the book is not one in which to search 
for information on obscure points or rare disea.scs, but 
there are many flashes of wisdom and much jiraetical 
advice. Not only has the text been improved, but also 
the illustrations and the general .style, .so that tho new 
edition deserves a prominent place among the smaller 
books on these subjects. 


TONIC HARDENING OF THE COLON. 

Tonic Uuvdening of flic Colon,^ which forms tho subject 
of a volume by Dr. Sr.rCEy Wilson, is a condition which 
has been well known for several years. It is, however, 
hardly recognised as a well-defined ailment, and referenres 
to it in medical literature are scanty. It leads to a train 
of symptoms, often of a serious nature, which may bo 
puzzling to tho practitioner who is unaware of the under- 
lying cause, and which are I'cadily curable by a simple 
line of treatment if tho true nature of tho ailment has 
been detected in time. Dr. Stacey Wilson has given a full 
account of tho condition from his own long experience, 
and his book will doubtless bo appicciated by general 
practitioners. Tho lesion is usually localized to the region 
of tho caecum or sigmoid colon, and consists in a prolongeil 
over-activity of a segment of tho colon of tin* type described 
by Sherrington a.s “ postural muscular activity.” The 
segment becomes like a hard rubboi' tube and necessarily 
causes increased contractile activity of the colon muscles, 
which in its turn intensifies tho reflexes originated by the 
normal aetivitie.s of tho bowel, producing symptoms having 
a voiy wide range. Tho onlj- certain oi-idence of the 
ailment is tho presence of abnormal hardening and tender- 
ness, and in tho absence of a systematic examination of 
tho colon there is nothing in tho symptoms to demonstrate 
to any medical man tho existence of the ailment. The 
author admits that some may suspect that the disease 
lie describes exists nowhere but in his imagination, and 
these ho advises to palpate the colon in the left iliac fossa 
in a series of a scoro or two of cases, and, where hardening 
is found, look for the symptoms and try the effect of tho 
treatment he describes. 

The reflex circulatory disturbances associated with 
hardening of the colon aro shoirn in such symptoms a.s 
la.ssitudo and inability to work and dcadness of the fingers 
from generalized contraction of tho arterioles; and a 
more local effect occurs as swelling and cyanosis of the 
fingers, such as is seen in Raynaud’s disciise. In a few 
cases vasomotor angina pectoris has been met with. The 
connexion between tonic hardening of the colon and 
mental .symptoms appears to be important, and it is not 
generallj-' recognized. The author states that it is bv no 
means unusual for a degree of mental depression to arise, 
of sufficient severity to induce, suicidal tendencies, and 
cases are cited in which treatment of the colon has 
restored the mental balance in these and other fornrs of 
emotional instabilit}*. The intimate reflex relationship 
between the stomach and the colon explains the frequent 
occurrenco of gastric disturbances, of which the most 
important are pyloric spasm with a certain amount of 
dilatation, reflex’ vomiting, and occasionally hardening of 
the muscles of the stomach, associated with tenderness 
and severe vomiting. As regards tho function of the 
colon itself, no recognizable disturbaneo may be present; 

^ Tonic Ilarticiiitiff of the Colon. By T. Stacey WiI?on, 3I.D. and B.Sc.Ed., 
F.B,C.P.Lon[I. Oxford Medical Publications. London : Jfilford, Oxford 
Ua,ver,it, Press. 1927. (Demy 8vo, pp. xxiii + 210. 8?. 6d. Btt.} 


censlipation, however, is < very liable to occur, and at 
times there may bo con.sidorablo dilatation above the con- 
tractetl sogment. Other symptoms mentioned aro brachial 
neuralgia, giddincs.s, and- jialpitation ; and a ea,so is cited 
in wliit'b tho jiaiii in tho colon appears to have been in- 
tensified at tlio menstrual periods, leading to the diagnosis 
of dysinonorrlioca, relief being obtained by' treatment 
dir(>cted to the colon. I'be prognosis is, as a rule, good 
when tiio condition is recognized early and receives adequate 
tre.atmcnt on tbo simpio lines laid down by the author. 
Where, however, neurasthenia has resulted from the ail- 
ment, tlie outlook may bo far from satisfactory. ' 


ACTlNOTHERAPy. 

Actinotbcrninj for General I'racfitioncrs* by Dr. H. G. 
Falkxei!, hears a strong family resemblanco to a lumiher 
of other works previously published on the same subject. 
There is li semi-tccbnical introduction dealing with tho 
physics and history of tbo medical uses of ultra-violet 
liglit, wbicb is the only de|)artmont of lictinotberapy dealt 
with, and a somcwliat lengthy section describing tho 
various types of njiparatiis put on tbo market by enter-' 
prising ni'annfacturers, and copiously illnstratod from their 
catalogues; further on a considerable portion of the book 
is devoted to an enumeration of tho .various diseases 
treated fortified by cases illustrating tlie wonderful results 
obtained. .Speaking generally, ultra-violet tlicrapeiitists 
are nothing if not optimists. Perhaps the most interest- 
ing and novel parts of the book are the cliaptors in wbicb 
Dr. Falkner describes tho results ho has obtained from 
te.sts of the i-arions sorts of goggles on the market os 
reeards their impermeability to nitra-violct and also infra- 
red radiation, and tbo.se in which be shows hoiy lanqis 
fitted with different electrodes vary enormously in their 
outnut of liltrn-violct rays from time, to time. Tho same 
nail- of electrodes, working apparently under constant con- 
ditions will nt one moment produce a copious supply of 
, trn-violct rnvs, wliile within a' few minutes the outpt 
will* fall off t'o a small fraction of its former quantity. 
TJia }K?si rtutl iDost uniform results, ho finds, arc given by 
rtectmlos made of a substance called ” metallinm, ” but the 
comnosilion of this material is not given. Confidence in 
Dr Falkncr’s clccti-o-pbysical experiments, however, is not 
.mroased bv reading tbo observation which convinced bmi 
D nt ultra-violet light is closely allied to x rnys-tho observa- 
+* flinf his “ hie raving lamp ” (no doubt an extremei) 
we Ld i I mn-nant) CO throw a shadow of the bones of 
li d n ^ on a white wall. It might have been 
dit tiiat .any medical student would have known that 

thought at y^ ^ „ 

*' '-1* 'Ktraiisluccnt, while bones are much less so, and the 

east bv the latter has nothing whatever to do witli 
shadow oa t 1^ t 0 • 

f ’■•'''■';..fahrammmt of eriticTsm, its perusal w 11 enable 
to a ceiti methods and practice 

of empToying ultra-violet radiations in therapeutics. 

PHARM-ACOGNOSY. 

1 Pflicd ^ hv H. C. WASHBOVn?^ 

Phomflcogimsj^a ^ textbook for students in pbaraiacy 

‘■"1 imml^ror practising pharmacists. One of the 
and « liam^beob 1 the other is a 

anthors is ^ l^\®^„,^.,tories of a chemical fii-m and hence 

chrectoi of y>e p knowledge of the needs 

togothei J Ij the practising pliarmacist. 

of both „„e of the most difficult subjects on 

Phavmacog 5 readable textbook, because mo?t of it 
f eeiVaiRv be composed of detailed descriptions of 

must characters of plants and drugs. The 

the appearance a u _ material to 

mit^g^abfe t^e.is ions by eliminating descriptions o^o 

;Snu“ Sokrinc^Vondon"' S and Hall. Ltd. 1927- (Red. 

pp. ix + 585 ; 210 figures. 25.?. nel.) 


MATi-n i, >q-8l 


NOTES ON BOOKS. 


microscopic characters of drags, and also hy making rvhat 
they have to say about the pliTOieal characters of drugs 
fairly short and concise. It is profusely illustrated, and 
contains an account of the history, habitat, properties, and 
uses of e-ach of the vegetable and animal drugs in the 
United States Vharmacoiincia (tenth edition) and in the 
h'atioml FormMhnj (fifth edition), and of a limited number 
of other non-official drugs; the total has thus been restricted 
to a moderate number. 

As a result of these restrictions and limitations the 
authors have been able to produce a very iiitere.sting 
volume, aud one that will serve ns a handy work of 
refeieiire in respect to all tlie' more important drugs. In 
addition to the usu.al information many interesting scraps 
of history and descriptions of the methods of cultivation 
of drugs’ have been inrludcd. Tlio volume concludes with 
two chapters by Jlr. 'V\’. PiTZ, giving a short account of 
the vitamins aud of insulin. 


AN ECONOMIST ON STIMULUS. 

In his Picdo Lecture last year at Cambridge, wbich has 
Tcceutly been publislicd in a small volume. Sir Jostaii 
St.ajip gave bis views on Sfimvhi.i hi the Ecoiinmic if/c’; 
be began by distinguishing stimulus from incentive, and 
went on to ovamine the increment in incentive. After 
describing methods of stimulating capital, and laying 
down a provisional classification of stimulus according to 
its results, the author said that “ the economic life is 
a complex reaction between a physical world, obeying 
tho laws of physics and chemistry, and living organisms 
obeying more elusive biological and" physiological principles, 
the whole relationship being worked upon by individual 
and mass psychological and ‘ spiritual ’ forces.” Various 
rtirauK are tlicn. passed in review, os]K!cially those which 
have been made the subject of physiological and psycho- 
logical investigation in labour tasks. Sir Josiah Stamp 
IS doubtful whether Knoeppel’s view, that an ideal attained 
by a piece-worker is automatically replaced by one still 
higher, is true ns a rule. General experience, he sav.s, 
points to a standard amount of earnings which the worker 
will exert himself greatly to reach, but will not exert 
himself greatly to exceed. It is pointed out that tho 
ciange 111 the value of monev has meant that business 
enterpriso has been imcoiiscioiisly subsidized bv the slow 
unseen rnboery of past accumulations of caliital. Tlie 
tallacy of ^ the standard of life,” “ the living wage,” and 
the motive of adequate profit,” in that thev are all 
pointed out. Sir Josiah Stamp 
in 's lat while a time of depression is a forcing ground 
elimination of non-cssontials, 
*V is the mother of invention, 

fho !.v”f ' apparently, that tlie cash nexus is 

111100^4 hetween the worker and his work; but he 
ho whether a new or substituted incentive may 

Ecn>?n iri an environment with a higher 

an different ethical bias, the response to 

“aybeertirely d“nt.’" 


w 1- l^’OTES ON BOOKS. 

being'ralleT'iTirfofrp^rd'Su^*''™/!’® c-Npefie 

tJte Gums ami edition of his work on Disri 

,its firsT pnMicaHon ThTl ^'’0 yi 

laboratory and rlln' , ^°ck is the outcome of ve 

.of research! auf Us with the 

dental bact’criologj- %otr!!f‘‘^ is a tribute to a pior 
Worker. In fhi^ »ri;i-'^ ' “ clinician and as a labc 

month origin has heo^'T ^ chapter on general disea 
cases have been rccorded^of somi 

in the same region • fh. a- uncommon affections origi 
escaped the aufhnr’; “'sease, indeed, must bo rare w-hi 
,tlie value of the bmk^'r '' “’^^orvation. As might bo ex] 
■-7- lies largely in a constant corr 

!Hon.Sc.aI”S!D.,*VB Josinh Stamp, 

”et.) Cambrid.go ’Onirersitj Press 

J/omSreac. Bv Sir 1 
•M'Wenl. Oitnrd Urtvmiiv p;t“-J^-?.:Cantab. Third edition. I 
ins azotes, 10 platei nelj ' X PP- =^‘ 


r TrirBunTm 

MzDICAI. JOCBNIT. Uw* 


of bacteriology avith clinical symptoms, but the advice on 
actual treatment is often of equal value. The author makes 
an important clinical observation (p. 131) when he says : 
“ Chemical examination of the stomach in cases of chronic 
oral infection invariably gives a large excess of lactic acid 
together with a diminution in the normal hydrochloric acid 
present .and very justly draws attention 'to his observa- 
tion, published in 1911, that slow and progressive joint in- 
fections followed injection into rabbits of a special tj-pe 
of month .streptococcus. Tiie book, however, suffers from 
serious blemishes. Chapter I should be rewritten — or even 
ent out; there is a tendency to redundancy, and often tlie 
author’s style leaves the reader perplexed. Nevertheless, it is 
a avork we can recommend to all interested in mouth 
conditions. 

Why should American babies from the age of 5 months 
require a special manual of graduated exercises ? Most babies 
one secs here arc eager to kick and push and stretch in that 
delightful intera'al between the bath and redressing. Apparently 
Ur. Wilkes of the New York Nursery' and Child’s Hospital 
does consider that a daily course of sy'sterr.atizcd exercises 
would benefit all infants. He has therefore drawn up a series 
of twelve exercises, and collected them into a book called 
Baby's Daily Exercises.'’' They are very clearly set out and 
very' well illustrated. No doubt such exercises, if carefully 
and intelligently performed, would increase the infantile muscu- 
lature. The necessity is a matter of opinion. 'The anther does 
give warning that “ babie.s who have had kidney trouble should 
be exercised very cautiously.” 

The hfiniites of the General Mcelical Council aril of its 
Various Committees" for the year 1927 liai'e now been pnb- 
li.shed, with twenty'-one appendixes, in a volume which includes 
the customary' detailed reports of the two sessions of the 
General Medical Council and its Executive Committee, <ard 
those of the English, Scottish, and Irish Branch Councils. The 
longest of the appendixes comprises the final report (nearly 
200 pages in length) of the Education Commit'ee on the 
progress made throughout the country towards the readjustment 
of the medical cnrricnlum in acccrdanco svith the resolutions 
.adopted by the Council on May' 26fh, 1£22, which came into 
force on the first day of the following year. The General Index 
to the minutes of the General Medical Council and of its 
Executive and Dental Committees, and of its three Br.snch 
Councils, from 1903 to 1927, has also been published. It relates 
to volumes xl to xliv of the Minutes. The plan of previous, 
editions has been followed, and each subject is fnllv indexed, 
the references being arranged chronologically, with appropriate 
sub-headings? 

‘® Babif's Doth/ Excicisr*. By Efh'ard Thoodore Wilku^, B.?., il.D. New 
York niul Lomlon : D. Appleton and Co. 1927. (Sup. roy. lou.o, pp. xi 
4- 14 figures. 4s. 6d. net.'' 

** .i/Zm/tf*. 12s.; Index to Minutcf, 7s. 6d. London: Constable -and 
Co., Ltd. 1928. 


PEEPARATIONS AND APPLIANCES. 

“ SePTICEMIX^ ” AND " lODASEPTUn*.” 

Septireminc (Cortial) has t^’e rhrmical corstitution of iodo-beiizo- 
inelliyl'di-formine and cortpins 33 per cent, of iodine. H also 
contains 45 per cent, of formaldehyde in organic combination. 
This drug is given intravenously; the adult dose is 1 to 2 
ampoules. Favourable results have been obtrined by French 
clinicians with this drug in septicaemias of various forms. Vaucher 
and Uhrig (British Medical Journal, Epitome^ January 21st, 1928, 
para. "stale that the drug causes no toxic symptoms. The drug 
IS also -recommended for a wide variety of acute infectious 
diseases. It is supplied in ampoules of 4 c.cm. 

lodascpfine (Cortial) has the clicmical formula^ of iodo-bcnxo- 
methyl-foi-mine and contains 42 per cent, of iodine. This com- 
pound was discovered in 1910 and has been used extensively by 
French clinicians. The drug can be given by morth in the 
form of tablets and can also be injected intramuscularlv, or, 
preferably, intravenously, Tho intravenous dose is from 0.5 to 
2.0 nrams in the form of a 10 per cent, solution. The drug has 
been favourably reported on in the treatment of chronic rbeuma- 
lUm, pulmonary tuberculosis, and syphilis. It is svpphed in the 
form of tablets (0.2 and 0.3 gram) and in ampoules containing 
5 c.cm. of a 10 per cent, solution. . , „ , _ Tiri 

Both drugs are supplied by the Ando-French Drug Co., Lid.. 
238a, Gray’s Inn. Road, London, W.C.l. 

Concentrated Tetanus AimroxiN-GtOBrLTNS. 

Messrs. Burroughs AVejlcome and Co. in carh 

.nd 

therefore g’„rea at the Wellcome Phy.=iologica! Rc.^carch 

toxm-globnlins la p ^ yg;j bv Burroughs Wellcome and Co., Snow 
Hm^Buildfogs! E.C.1, in phials coiftaining 20,OCO international 
iiTiiiji in 10 c.cnu 



368 


March 3, 1928]-, 


kad'ium teeatment in Denmark. 


RADIUM TREATMENT IN DENMARK 

boEknb, niicl publis hod in VncslvUf //i.. r ^ 

5th, Dr E Pnii;,. , Joy Lueijcr on Januaiy 

stationjn tho fi" pJlrodtp^ 

~p,:s; paJi? 

TI.^ „ SniUiim Thcrami. 

were excelled!” Inq^iiHof i°nto''Tllo“ tumours 

those patients sliou od i , +1.I „ * r fate of 

80 per cent, and marked improvemo"^^ 

Tlie correspondinfi fio-ures for ,rr° 

cent, respectively® AU ti e ease; of I'®*’ 

and 85 per cent, of the warts Tn IS 

treated for warts could not bo ^traced Onh 5o‘” 

of the naticnts tientou ' t*" per cent. 

remainder wm-o much improved" 

treatment of nneionm. ri- p'li;.. the 




treatment of nuRionna Dr ft;!, • *5® 

u‘.ata!''wMciraS3 better"t‘”oat "/'f 

l-and,’ tlfo lU or ejanosed 

angioma of the skin or miienn ^^cep-seated imem- 

faetorily to radium treatment whrcir'fr"*^ ^'''’'^ted satis- 
other methods had failed ' ’''t^h often succeeded after 


ment. It was obseia’od tlm^ 

which had bceonio rc^tta f tl,e skia 

a-ray treatment might well stiirho^'^'*''"^ v- 
dtsappoar as tJ,o result of fsirnd ' r^r 
it was iliis observation Nr),;',) treatment, and 

P^"P~Eii§l 

fi' ? ''"f'""' treatment must bo. in skilled hands k 

tiio host ic&ults aro to bo obtained. 

In the three-year period 1920 ‘to 1922 recovers- was 
effected m _72 per cent of the cases of carcinomnf Ib 
skin. In 13 per cent, the fato of the patient could no-, b 
aseci tamed, and m 16 per cent, failuro to euro the patient 

nofic case in this latter class tb 

patients had already undergone protracted jc-vay rreat- 
meiit, whicli in some cases lind lasted for years. These 
patients cached the radium station in a hopeless state, 
and the lesson to he learnt from them is that when an 
opilhchoma iecnrs after one, or at most two, x-ray treat- 
ments, It should he operated on or given radium treat- 
ment. On the other hand, it cannot be regarded as a 
mistake to give x-rny treatment to a case of cancer of the 
skin bitl.erto untreated, but to give one x-ray exposure 
after another for the same case is a mistake. 

Umlium and X-rny Treatment Compared 
In addition to being successful in cases wbicli bare 
become resistant to the x rays, radium possesses the 


i >, r vw inuiuw possesses the 

Almost all tlio cases of koloid benefited funn, . r advantage of l^nnag, as a rule, liardiy visible scar-a 
lentment, tlie skin becoming flatter and milei- mnttcr of considerable importance in cases of eaueei- of 


relief froin the pain “lilnd ibbing^^^wbicb often 
this condition, was obtained But >. e 1 , “"'P'lcates 
of cases some trace of the I-ebiVl ,• proportion 

-lain, of a eompbte r eovS S 

was given to thj cases of kelo^id of o d r" 
formation of pale, cartilajno.is tbs ,1 the"’®’ " 
and still pink keloid was fnn.iri i ‘n® more recent 

^-ray treatment, uEcrwas " 0 •^’vn'd’.r to 

-ntioii. Tbe.te’nder 

■fref f-. f_ _ . I 


ti-entment, tlie skin bccominfr ^ fi'om radium matter of oonsid< 

and hardly visible scar bofiig Jeft ' At ^t 1 ^ provoke a certain degree at 

relief from th^ nn:,. „_.j . tlie same time cicatrization and retraction of the tissues treated, the 

scar formed under treatment with radium is soft and often 
iiivisiblo, being wvered by normal-looking skin if the 
dosage and technique have been correct. Eelapscs after 
isidium treatment of cancer of the skin are most rare and 
when they do occnr.tiiey are usually to be found in the 
margin of tho original patch, where they are, in most 
cases, amenable to treatment. In the overwhelming 
niajority of cases a single radium treatment was sufficient 
to cui-e cancer of tlie lip locally-, but in this class of facial 
cancer the cosmetically successful results were often 
marred by distant metastases. Eor this reason the prac- 
tice has been adopted at the radium station of giving 
preventive x-ray treatment of the glands in the ncigb- 
bourliood, and this measure appears already to have 
reduced tlie frequency of metastases. Of Die 26 cases of 
cancer of the lip treated in the three-year period under 
review, 19 could be said to be cured, an observation period 
of five yeare having existed in 15 cases, and one of four 
years in 4 cases. ■ Of the i-emaining 7 patients, 2 were not 
traced, and in 5 eases tho treatment failed to arrest the 
disease. Considering that large operation statistics show 
a recovery rate of only- 40 to 50 per cent, in this class of 
case, these results of treatment with radium must bo re- 
garded as encouraging, both from tho cosmetic and the 
functional point of view; it is doubtful whether tliey 
could be achieved by other means. In the case of small, 

I'T.-k. /»OT-ir*01*v? rtf +7vrt 7 ?t. ^4- l-.H -1 t._ -..-At 


losities we.; founr to reae vft- P‘=»*t«r cal- 

and tn a-iay treatment and tJin ^ ^^otli to radium 

class of eas"o m V 

patients had been vnsvcce^shilh- 
-Although ordinary warts of the InnVl 

under skilled x-rly t!-eatment in » rtilo 

radium treatment,^ thn n.-nniiL ...7 ‘';‘"ays under 


laauiiii treatment the n.-,nf;A„ , “'--■‘•y uin.iys under 

on these cases to dormat'ologica/’ diidc?*^' Tho 

station has also paid little attd.^;-,,, , radium 

treatment is apt not only to be ineff f mdiuni 

in.jurioi.s, since a pmdostea] ,-7nt? 7’ 

aljoiit the bono lying immediatelV nn*\ occurs 

if other methods If freatme.it fS s a «, I "" "'T' 

may be given, since it is often benkcial a id'd e 

In a class midwav’ betneen kann. 

new growth Dr. Colli,, place,’ naevifs" vm-,i. 

pigmcntosus, which lie liad found resnon^V 

faetonly- to radium treatment. Ponded most satis- 

Among the 600 cases of maligmmt new o<.o,vths fve-,r -i 
in tue period under review there were 84 duriim tlm 7'"* 
three years in which the disease im-oived the 
and tho subsequent fate of the patient was i?7 7 ’P®’ 
after an observation period of five to seVen 
practically all these 84 cases the diagnosis of bl7 cel/l 
carcinoma was verified by a microscopic examination /pf 
exploratory- excision for which never did harm Ko rT-’ 7 
t.on (sneh as described by French workoi.) eouulTSHt 


COulu oc ac-iutJtckA xjvj-ivi ail tlie case oi siuan, 

strictly limited cancers of the lip it may-, indeed, be just 
as well to excise them ns treat them by- radiotherapy-, but' 
if the growth recurs, it should always he treated with 
radium, supplemented by preventive x-ray treatment of 
the local glands. 

Much less encouraging were the experiences of the 
radium station in tho case of cancer of the mouth, tongue, 
larynx, and oesophagus; none of tlie 8 patients with cancer 
of tlio oesophagus who were treated was still alive. As 
for cancer of the mouth and tongue, local healing, which' 
was apparently complete, was effected in most case.s; but 
in two or three veal's there was a recurrence of the dise.iso 
elsewhere. Dr. Collin gave details of a case of inoperable 
cancer of the tonsil and palate in which four years were 
added to tlie life of a man wlio would othei-wise have 
been preinatuicly doomed. There were only 32 cases of 


March 3, 1918] 


epidemiology,. IN THE LAST ,HTJNDHED. YEA.ES. 


[ THEBBrasH QRQ 
Medical JocBKAi, wUC' 


r 1 tliornx— tlin't 13, cases of reciir- 

cancer ‘ „„ operation for cancor of tlio 

breast^trcatel all rvoro inoperable from tlic outset and 
termi^ted fatally. Dr. Collin st.l recommends combined 
X r™y and radium treatment as a pal .ativo measure ... such 
Isel Of the 6 cases of .cancer of tho pon.s, 2 showed 
freedom from recurronco after an obsoryat.on por.od of 
three years and ono after five years. .1' or such epos, par- 
ticularly when . tho patient .s youp, the bpt method 
would seem to bo radium treatment of tho glans penis, 
and x-ray treatment of tho loc.al glands; x-ray pcatmont 
of the tumour of the glans itself would, on tho other hand, 
seem to be of comparatively little value. 

Dr, Collin' does not detail his gynaecologic.al _ cases, but 
he admits that the results achieved with radium might 
not prove to be ns good ns those in Sweden, where, with 
the inclusion of many operable eases, a recovery rate 
of , up to 50 per cent, after an observation period of five 
years has been claimed. Tho difference between the two 
countries in this respect depends on the fact that in 
Denmark a high proportion of tho cases coming to the 
radium station are already advanced. Dr. Collin ends his 
paper with an appeal for. a systematic and energetic educa- 
tional campaign in favour of early detection of tho disease. 


. EPIDEMIOLOGY IN THE LAST HUNDRED 
TEARS. 

Sia "VYiiLiAii HAirni’s Chadwick Lr-cnniEs. 
EpiDEU.OLOOr in England during the last hundred years 
was the subject of two Cliadwick Lectures delivered by 
Sir IVinLiAii HAirsn at the House of tho British blodical 
Association on February 16th and 23rd. The chai.*mon 
were, respectively. Sir Willlisi Goldins and Sir Jahes 
CnicHTON-BnowNE. 

T Gsrm Theory and the Old Epidemiology. 

In hm first lecture Sir IVilliam Hamer began by 
remarking that in epidemiology, ns i.i all branches of 
con I 0 inquiry, certain periods or “ climates ” of opinion 

u ere successively encountered. Dr. Crookshank had iiidi- 

during the last four and a 
mediVnl marked by different phases of 

Whfch il In the first of these, 

enidemie ni ‘•'"d Sydenham, wide 

whhniit , 0 'rere observed and compared generally 

b into component diseases, and sy-mptomi 

d': rStn Lrnlo"’ ®neephalitis, and myelitis" were 
called teease groZ ' 11 ™?"'“ 

svstems nf 1 period was ono in which 

symptom groups” iZeueZ symptoms, tho 

different elements usually considered as 

third period bevinn: epidemic constitutions. The 

sistent efforts were “^““^.^dddi jcas one in which per- 
tho findings of m distinguish specific diseases by 

from fortf veZ” and the fourth period, 

distinction of man^Qn” characterized by the 

specific orcanisma ^ ® diseases by association with 

middle of the iiinofo lecturer dated from about the 
General Board of TToaUi “ntury — at which time also the 
foundations of a no.- ** established — ^tbe laying of the 

1883 Hirsch could sav t”w country. By 
quite different from tb epidemiology boro a character 
earlier, having filled science twenty or thirty years 

to an oxtraordinnrv a Proportions and acquired finish 
William Collins about then that Sir 

excessive zeal for sno ^u^ion to the dangers of an 
then existing to lav ^ tendency, even 

the soil. Euj n . .ue stress upon the germ and neglect 
and beat upon tlm descended and the floods came 
researches focused .:}pl’*deiuiological) house.” Pasteur’s 
special te'chninue mado upon genus, and Koch’s 

bacteriology ia ♦),„ . uppearance. Those working on 

regarding the comnli^ made frequent announcements 
organisms with Kncl,'- successive newly described 

^ogy, like the silk d ?°®^ulates, until the old epidemio- 
•'':®ro darned with Sir John Cutler, which 

silk remained, almost die. scarcely any of the original 

“f‘cr the openinrof ZTP“r?lfrom vdew. But shoi-tly 
“ twentieth century the fact came 


to bo recognized that bacteriology had sown a reasonable 
allowance of wild oats, and that a halt must be called. It 
was agreed that bacteriologists had by then outgrown 
Koch’s postulates as Koch himself outgrew them, and that 
account must be taken of the results of fifty years’ patient 
examination by epidemiologists of the influence of environ- 
ment, including conditions of cleanliness, space, dryness, 
pure water and food. All this, with the increasing know- 
ledge of protozoology, filter passers, enzymes, and the 
recent demonstration of the mutability of bacilli, made it 
clear that attention must still be concentrated upon the 
systematic development of a discipline as conceived and 
exploited by Hirsch. Progress in k.iowledge of epidemic 
diseases was seen to be dependent on a unity of opposites, 
such as the teaching of Sydenham concerning epidemio 
constitutions, and of Pasteur and Koch concerning the 
germ theory of disease. 

The Ectum to the Ilippocratic Method. 
in his second lecture Sir William Hamer further 
developed his theme under a plea for a return to the 
Hippocratic method, remarking that Hippocrates had 
clearly bee., of opinion that tho soil and surroundings as 
well as tho seed required consideration. The lecturer took 
an illustration from the influenza epidemic of 1918, the 
official description of the “ setting ” of which presented a 
close resemblance to Sydenham’s account of epidemic “ con- 
stitutions ” in 1673-75. Sydenham had reiterated that 
while the bowels, brain, and lungs were successively 
attacked, the accompanying diarrhoea, stupor, and 
pneumonia were all merely symptomatic of one “ stationary 
fever,” with all the characteristics of influenza. Further- 
more, Syde.iham’s view that the fever or influenza worked 
more easily and rapidly near the crests of the pa..demic 
waves, and with .nore diffic.lty a.id more slowly in the 
intervening troughs, had received ample confirmation. One 
interesting conclusion to which the lecturer had been led 
in his study of influenza was the toll which it had levied 
during the last two and a half centuries upon men of 
marked ability; n.id in some conspicuous instances the 
facts were on record that tho influenzas of past times had 
mado havoc of the lifework of notable men and women. 
Influenza, as Daniel Webster had said, was the “ crux of 
epidemiology.” It was not merely, as it had long been 
supjKJsed to be, a pandemic disease, reappearing once or 
twice in a generation, but it was ever present, now 
smouldering, and then, every ten, fifteen, or twenty years, 
bursting into flame. Its great prevalences were specially 
favoured by war, famine, overcrowding, and free com- 
munication with sufferers from the disease in the early 
stages of their illness. Despite tho huge increase in means, 
of communication and traffic during the last one hundred 
years, coupled with the entire absence of systematic 
attempts to limit spread of the disease by sufferers in the 
early stages, the mortality in London from the influenzal 
group of diseases appeared not to_ be appreciably greater, 
in proportion to population, than it was 150 years ago. 
Great influences for good had been better food and housing, 
more cleanliness, and the provision of medical and nursing 
caro in serious cases. To these should now be added care- 
fully considered measures for preventing sufferers from 
coming into contact with others in the early highlj- infec- 
tious stages of the illness. Abor^e all, it should be ajrpro- 
ciated that the most extravagant and bizarre efforts made, 
under the influence of panic, at times of widespread 
prevalence were as nothing compared with the steady and 
continued prosecution of a considered campaign against the 
influenzal group of diseases conducted on epidemiological 
lines. The records of recent years abundantly bore witness 
to the fact that field observations and research should bavo 
their place as well as observations and research in tho 
laboratory, and that the two sets of findings should be 
placed alongside one another and co-ordinated. Given sncli 
a consummation, it might be surmised that in public 
health, as in other scientific vork, an age of professionalism 
and specialism would slowly but surely give place to an ago 
iu which interest was taken in general principles, as well 
as in stubborn and irreducible facts. That was a lesson 
which he who ran might read in the history of 
epidemiology during the past hundred 'jeais.. 


360 Mahoh 3, ifjjS] 


A GREAT ELOOP IX 1829. 


LMKDJCAt JOCB-Tii 


JE-olta tt 


A GREAT FLOOD IN 182'*, 

Exi’EniEN’CEs or a Scottish Doctor. 

Not for many years lias piiUio attention 1)cen so ilirccted 
to tho cntastroiiliic ravages of floods as it has hecn during 
tlio Ia.st twelve months. More than a j-car ago the bursting 
of reseiwoir dams near 'WoHiyss Bay and in North Wales 
gave an inkling of what enormous damage can ho caused 
by tho sudden loosing of a torrent of water upon a pcacefid 
and unsuspecting counti'j'-sido. Since then, apart from 
what might be called in a comparative sense minor visita- 
tions in different parts of tho country, there liavc hceii 
dining recent months tho groat Mississippi floods, tho 
Fleetwood disaster, and lastly, the tragic overflow of tho 
'J’hamcs into many London streets and houses. 

It might be of interest, therefore, to make some refer 
cnee to the tremendous deluge which swept some parts of 
the north-east corner of Scotland almost ono hundred years 
ago, generally referred to as " The Great Sloray Floods “ 
Those who liave visited that part of tho country — and they 
must bo many, as iu these days golf courses and magnificent 
fishing rivers attract largo numbers of holiday makers — will 
recall this district as a particularly favoured one in respect 
of weather. It justl 3 ’ boasts of the finest climate in Scotland 
for dryness and sunshine, claims wliicli are amifly sub 
stantiated by tho wealth of its fruit crops and the almost 
prodigal splendour of its flower gardens. On to this land 
of milk and honoi’, and in tho middle of summer, there 
Euddenlj’ descended one of tho most oxtciisivc and devas- 
tating floods ever recorded. 

A very complete history of all tho circumstances and the 
. widespread damage caused has been liniided down bv Sir 
Thomas Dick Lauder, Bt., in a monogi-aph, first puhlishod 
iu 1830, entitled The Great Flooch of .-liipiisf 1S29 in the 
I’loriiice of Moray and .idjoiiiing Disiricis. From the 
earefullj' prepared meteorological tables contained in tho 
hook it woidd appear that during tho mouths of Maj’, June, 
and Julj', 1829, tho heat was unusually groat. On tho 3rd 
and 4th of August a dolugo of rain fell all over tho 
district; the wind, which previously' had been fioni tho 
Avest, suddenly changed to a strong blow fiom tho north- 
east. Betireon 5 a.m. on August 3rd and 5 n.ni. on August 
4th a rainfall of 3J inches ivas accurately recorded. Tho 
actual fall on the mountain range of the Caii'ugoims, ivbich 
dominates this district, must haio been far greater. Tho 
result Avas that tho riA'ors Nairn, Findhorn, and Lossio, 
tho Spey', the Deveron, the Don, tho Dec, and tho Norfh 
and South Esks broke their bounds and swept all before 
them — houses, bridges, roads, cultivated lands, Aiere simply 
Avlpcd oft tho map. The AA'hoIe aspect of the couAiti'y avos 
cluuigod : neAV ri\'er chaiAnels Avere formeil, ships Avero 
Avrecked, harbours Avere damaged and in some cases irre- 
trievably silted up, so that even at tho present day some of 
tho dire effects of this inundation are still A-isible. 

Tho work of yeai's of steady pj'ogress disappeared in one 
night. Owing to nearly' all the bridges being doAvn and 
to the damaged state of the roads conimimications for 
mails and passengers Avero hopelessly disorganized for a 
long time afterirai'ds. 'Whilst the damage to material Avas 
enormous, and has been faithfully recoi-ded, it is strange 
that the author, aa-Iiosg poAvei's of obseiwation ivero un- 
usually acute, and ayIaoso iAAdustry AA as immense, makes no 
attempt to estimate the total loss of life, Avhich roust have 
been considorahlo. There av.ts another veiy heavy fall of 
rain on the 27t!i and 28th of the same mouth, amounting to 
21 inches, but tlio consequences Avere not nearly so serious, 
possibly because the Avind held in the Avest and north 
instead of backing into the cast as on tho eazlier ocea.sioii. 

Dick Lauder collected tho stories of many eye-witnesses, 
and the following e.-ctracts bearing on the aclA-entiires of 
one of the local doctors seem worthy of repetition. 

“ On MoncbiA-, the 3rd of August, Dr. Brands of Forres Avas 
called professronallv to the Avestern side of the river. He 
forded on horseback, and, ere he had crossed the second branch 
of tlio stream, he saAv the flood coming thnndering doAvn. His 
JJorse was caught by it ; he was compelled to swim ; and he had 
Jong toue/ied dry land ere the river had Z’iseii 6 Sect. 


Whilst at dinner at 3Ioy, ho observed it brantliinc 
numerous streams. manunug 


out into 


iurried doAvn to the offices, ; 

waVtiil . ‘°P'. The pros; 


and 

wic owrftii un r top. j.u(i prospect 

Bit ’''“‘ers Avas only bounded by 

t e h ii"’" about JVrrcs, skirting the flooded plain to 

tie nnri ~ Dalvoy fo the west-whilst, tOAvards 

the 1101 th and east, the Avatery Avorld swept off unialCTraptcdW 
mto the e.™anding Firth and the German Ocean. He fooked 
ari.\iously for the houses of Stripe Side. They were .still 
standing; but the powerful and agitated stream that rolled 
around them, and betAveen them and the offices, seemed to' 
liiveatcn their speedy destruction. , . , 

“ -\11 direct communication Avith 'the counti-y iiorthAvard of 
Moy Acas cut off by the flood of the burn meeting that of the 
river, and floating entirely over the bridge ; they therefore took 
their AA-ay by the avenue on the south side of the house. At 
the gate, about 100 yards in front of it, they found the Avafer 
very deep; but) though their horses Avore frequently sAvimming, 
they managed to get on by keeping tbo line of the road. At 
the distance of a mile from Moy, the Avater became so deep and 
strong that they Avere compelled to make for the rising grounds.' 
The lad now left Dr. Brands Avith the intention of going round 
by Dah'ey, towards Earnhill and Kincortli, Avliilst the doctor 
proceeded towards the Bridge of Findhorn, AA-jth the hope of 
getting one of the fishermen’s cobles. As he Avas approaching 
tJi.i bridge, be learned that the last of the three arches, that 
oil the AA'est, had fallen the instant before ; and, Avhen he got to 
the brink, tlie waters Acere SA'.'eeping on, as if it had neA'er been, 
making the rocks and houses vibrate Avith a distant and 
tremulous motion. At the Turnpike House, at the end of the 
bridge, he Avas told that all' the boats had been SAvept aAvay. 

" Froni the brow of the bank to the north-east of the toll- 
house, Dr. Brands commanded a full vieAv of the flooded 
country from one e.xfrcmify to the other. The mightiness of 
the inundation baffiwl all description. The Avaters, breaking 
out from the pass at Coiilternose, covered JIuridole, and SAvept 
furiously through the estate of Balnagieth, carrying corn, 
trees, hedges, and everything along with them, and rolling oA'tr 
the sti-ong embankment lately constructed along the turnpike . 
road by Mr. Leslie. MeanAvliile the chief current AA;a.s playing 
Kiriously against tlie southern approach of the bridge ; and, 
AA'hilst Dr. Brands Avas looking at it, the Aisnally dry arch, at 
its farther eiul, burst Avith a loud report, its fragment's, mixed 
Avith Avater, being' bloAvn into the air as if by gunpowder. . . . 
The row of fishermen’s houses, on tlie right bank, a little beloAV 
the bridi'e, were already in one mass of ruin, and the scene of 
devastation Avas complete. . . . Looking doAvn on the houses- 
of '\Yatei-side, the liamlet of Broom of Moy, and others,' the 
doctor could see nothing but a foAV roofs peeping from the 
midst of tile inundation, and as there AA-as nOAA- no chance of 
getting a boat he returned towards Moy. In his Avay thither 
his m.ire Avas compelled to sAvim for a great Avay, and she after- 
wartls stuck in the mud where she touched the ground and Avas 
nearly drowned.” 

Perhaps Are may remark in conclusion that Dr. Brands 
.ras fortunate ii\ having a horse to ride on such a perilous 
journey rather than having to trust himself to a motor car. 

royal medical BENBTOLENT FUN’D. 

■kT a recent meeting of the committee forty case.s were con- 
sidered and £630 voted to thirty-two applicants. The following 
is a summary of some of the cases relieved. 

AVirlow aceU 56. of L-R-C.P. who •licil in 1901. Tin to 1914 she i-elicd on 
i.on.-aei-s’lor hei- maintenance, but owing to ill health has had to give up 
m,", \v?rfc and her income is now reduced to about £21 per annum 
lliws with "n aged father, who needs constant attention. Acted £5 

^Avt\otv*a"ed'M,''orjI.K'C.S. who died in 1905. Apart from an onninl.v 
r'Vm ner "annom is dependent on her earnings by needlework. Rf'.'t 
lls.'M. a wS? hut she smhiets two rooms for 10s. a week. Voted £26 in 

‘''V'w'v'n i'nd”’A"'^aged IT. who mostly practised abroad. Sined 1921 has 
w'n'Se to do anj work and lias now come to the end of her 
not been ame m ■’qanrtcrly instalments. 

’^‘^nTiwht'er'aeed 64, ot 1..S.A. who died in 1873. Earned her living for 
.a- rears as govcrnes-s-coinpanion, and on having to give op this 
thirtyflAO ye take pnAing guests in a sraali house. On account 

wyrh ■-j.i, .jjic tiad to ask the last guest to leave, and a friend 

f with several small bills owing. The friend raised 

lonna heA p ininicdiale needs; this was being disbursed at the 

raf^oi* 1^° a week, but was almost e.vliausted. A'oted X'30-in quaitcrly 
iuatalmcnts. rrt _ 

Suiiscriptions mn.v be sent to tho Honorary Trc.a.surer, 

Sir Cliartcrs Symomis, at 11, Chandos Street, Cavcmlish 

^'^Tirn’Rovai ifedic.Al Benevolent Fund Guild still receives 
many applications for clothing, especially for coats and skirls 
for ladies and girls ho ding secretarial posts, 

Avorking boys. The Guild appeals for second-hand 
household article.s. Tile gifts should be sent to tiic Secretary 
of tlia Guild, 58, Great Marlborough Street, -W.l. 


IIAECH- 3." ’ 928 ] 


[ Tiir Bsmsa 
SIsprc.u. JorBiT-U 


. 361 


«r< 


DEATH OE SIB DAWSON lYILLIAMS. 

Editou of the “ BnmSH Medical Journal,” 1898-1928. 


W E have to aiiuounee, with deep regi-ct in 
which all our readers will share, that 
Sir Dawson AVilliams died suddenly on 
. Jionclay, February 27th, at his country home 
near Bourne End, Bucks. It is but a mouth or 
two since he retired after thirty years’ work as 
Editor of the British JIedical Journal, and 
only last week we recorded that a fund had been 
opened lor the purpose of recognizing his long 
and most distinguished services to medical 
science and the medical profession. What was 
to have been a testimonial must now take the 
fomi of a memorial. Supporters of the fund 
will like to know that his own wish, on hearing 
of the proposal, was that the money raised should 
be used in such a way as would link his name 
with some object appropriate to his work. 

Sir Dawson Williams’s health had given con- 
cern to his colleagues and intimates for some 
years past — indeed, ever since the middle of 
1920, when a severe and prolonged heart attack 
incapacitated him for many weeks. Although 
ho continued to shoulder the cares of editorship 
for seven more years, those around him were 
aware that the burden was becoming too heavy 
for his phpical strength, and it often seemed 
that only Ins indomitable will-power and devotion 
to the JouRN.^L kept him going. Nevertheless, 


the parting was a wrench. Wc are thankful to 
know that the sadness he felt at ending his 
lifework was relieved by the countless messages 
of admiration and affection that came to him 
during the past few months from medical men 
and women throughout the world. These public 
and private expressions of regard touched him 
deeply. In a letter to his closest colleague — the 
last of many beautiful letters — he wrote: “ Few 
men can have had such ample opportunities 
as I of Imowing the good things their friends 
could say of them. ...” All his many friends 
had hoped that Sir Dawson Williams would have 
been spared to enjoy a little quiet after long toil. 
His mind was vigorous up to the end, and only 
a week before he died he wrote, at our request, 
the charming note on the Oxford English 
Dictionary which appeared in our last issue. 

A full obituary notice will appear in these 
columns next week. The memoir will include 
a number of personal tributes from leading 
members of the profession. The funeral will 
be at Little Marlow Cemetery' to-day (Friday, 
March 2nd) at 3.30 p.m. A memorial service 
has been arranged for Monday next, March 5th, 
at 1.45 p.m., in St. Pancras Church, near the 
headquarters of the British Medical Association 
in Tavistock Square. 


Brtttslj iRctjtcal fottvnal. 

SATURDAY, AIARCH 3RD, 1928. 


laboratoky jtethods in diagnosis. 

proper effort to establish more 
of in'pfi' ^ scientific basis on which the art 

tho nn lests must inevitably tend to emphasize 
troiKj aspect of medicine, it would be disas- 

oi endpiT-m bring about any slackening 

In an clinical observation. 

335 of thh fs^sn^ pubUshed at page 

as a resull nf Hutchison suggests that 

other invpstmof-'^ “creased facilities for laboratory' and 
to apply thp r"’ " ^re to some extent intended 
^ses,' there is academic medicine to practical 

observation o.. some deterioration in bedside 

indeed be so uith former days. If this 

educational demnni oareful, for modem 

ot time to be sop'nf ■ increasing amount 

(unless familiarity V**! ‘u and presumably, 

attention to 7 „i ^ nreed contempt) an increasing 

■ Tholestii ’“'^thods. 

reason ivhi ]Ii arises, Is there really any 

iar beyond h methods, even if multiplied 

attention to-day, should divert 

answer is certoi , _ . '^iinical study of disease? The 
?f the informiHnp negative if only the nature 

■s clearly repo'm-,:, 1 laboratory methods afford 
i Joeogmzed. On this point, however, there 


appears to be a good deal of misapprehension, and 
even Dr. Hutchison seems perilously near error when 
he speaks of “ laboratory tests and other short cuts 
to diagnosis ” (italics oui-s), though his whole argument 
makes it abundantly clear that for him, at least, 
there can he no such short cuts. Laboratory workers, 
like other specialists, are apt to be over-enthusiastic 
about their oiin branch of work,, and to attach undue 
weight to the information they are able to give; but 
no laboratory method yet devised can pi-ovide a 
short cut anywhere; on the contrary', it can only' 
put another fact at the clinician’s disposal, and so 
increase the number of data, whose value it is his 
business to assess hi coming to a considered opinion. 
But laboratory methods do provide facts; and it is 
here that the clinician is sometimes at fault, for 
if the laboratory finding is not in harmony with his 
clinical conception of the case he is apt, especially 
in his teaching, to draw distinctions between ” clinical 
observation ” and “ laboratory methods ” which are 
by' no means flattering to the latter. This is all 
wrong; there is no real distinction between the two 
types of observation. 

The fact that a patient has an eosinophilia, a raised 
blood urea, or a positive Y asserniann reaction, is 
merely a clinical observntiou which it happens to be 
more convenient to make in the laboratoiy , hut if 
we were to take the necessary apparatus to the bod- 
investigations iiouid in no essential way 
differ from tJiose made, say, n-fth a stethoscope or 
*j tIiei*moiiieter, and the information they giv.o is 
much of the same order. Viewed in this light 
laboratory methods merely give additional clinical 


362 March 3, 1928] 


LIGHT THEBA.TY AND IMMHNm. 


r. .-InxEamn 

LMECtCAX. JOVBXAft ' 


tacts. Occasionally it may bo a fact -which dominates 
nil others, but far more often it is one which, fitting 
into its place with others in the mosaic, helps to 
complete the diagnostic picture. Sometimes, indeed, 
the fact is one for which no place can be found, but 
this should not be made a ground of complaint against 
laboratory methods; it is merely evidence of our 
present ignorance. In the earlj' days of the Widal 
reaction it was sometimes a complaint that the 
reaction was negative in a clinically clear case of 
tyjihoid fever, but the subsequent recognition of the 
paratyphoid organisms proved the accuracy of the 
laboratory work; and doubtless much that seems con- 
tradictory to-day will be made plain by the knowledge 
of the future. 

It is, however, not to be denied that danger lurks 
in too great emphasis upon the importance of the 
laboratory, and it would be an interesting experiment 
if, during some part of their career, students could 
be prevented from access to all reports from special 
departments, and were made to rely entirely on their 
own investigations. For some minds there is a curious 
attraction about facts elicited from a test tube or by 
the microscope, as being more scientific than those 
observed by the unaided senses, and this is a prolific 
source of error. The sensible plan seems to be to 
collect all the facts that are within our reach by what- 
ever means they are obtained, and then, taking Dr. 
Hutchison’s wise words to heart, pray that we may 
be granted the supreme diagnostic gift — a right 
judgement in aU things. 


LIGHT THERAPY AND IMMUNITY. 

The beneficial eSects of light therapy have been so 
clearly defined with regard to growth and nutrition 
that this aspect of the subject has naturally received 
more recognition than has been accorded to the almost 
equally promising efiects of radiation in another pro- 
vince of medicine — namely, resistance to microbic 
infection. Not to explore this field would certainly be 
an example of neglecting the obvious, because there is 
surely no axiom of hygiene to which assent would be 
given with more unanimity than to an acknowledge- 
ment of the invigorating action of sunlight, particularly 
in convalescence from infectious disease. Like many 
other familiar things, however, this recuperating action 
of sunlight is difficult to investigate by quantitative 
scientific methods and to define in scientific language. 
It is generally believed that here, as also with grovvth 
and nutrition, it is the ultra-violet rays which are the 
most effective, but there is little reason to suppose 
that increased resistance to infectious disease is due 
to tlia bactericidal powers of the rays themselves. 

Although the ultra-violet rays are so efiective in 
sterilizing bacterial cultures and protozoa in test tubes, 
the}' do not penetrate sufficiently to exert a lethal 
action on microbes in the body. The good results 
obtained in the treatment of lupus with ultra-violet 
rays are not to be ascribed to a local disinfecting 
action of the light on the tubercle bacilli, as was 
formerly supposed, but rather to a general increase of 
resistance. It would be a ^eat advantage if we could 
define more exactly what is meant by a general in- 
creased resistance, a state apparently analogous to the 
natural immunity acquired on recovery from an infec- 
tious disease such as enteric fever. Since the labours 
of immunologists have reaped such a rich harvest in 
the investigation of the serological reactions of enteric 
fever, with the discover}’ of agglutinins, precipitins, 
complement-fixing antibodies, and so on, it was 


natural that in the study of increased microbic resist- 
ance after radiation the immunity reactions of the 
blood should receive a thorough investigation. Gain 
quickly carne'from this— and so far, we are relieved 
to say, without any addition to immunological 
vocabulary. The test which has proved most useful 
has been the study of the bactei-ieidal power of the 
blood, a test designed to express in quantitative terms 
the property of actually killing or preventing the 
growth of cocci and bacilh when incubated with a 
sample of blood. 

Ultra-violet radiation has an easily determined 
action on the bactericidal power of the blood, but the 
effect of radiation is not necessarily to enhance the 
bactericidal property. In fact, Gonce and Kassowitz* 
have proved that daily quartz lamp treatment over 
a period of two to eleven weeks — avoiding any marked' 

1 erythema, and general, febrile, or focal reactions — does 
not as a rule improve, but actually tends to lower, tbs 
destroying power of the blood for certain test bacteria, 

I such as staphylococci and B. colt. In some of these 
cases, however, the bactericidal power of the blood was 
substantially raised; and, since we may assume that 
it is an advantage to raise and injurious to lower the 
I bactericidal power of the blood, it seems obvious that 
some of their patients were benefited and others injured 
by the radiation. This conclusion is supported by 
their records, and finds its explanation in experimental 
work carried out lately in tins country by Colebrook, 
Fleming, Maitland, and others. 

The increased bactericidal power of the blood found 
in some cases after radiation is not due to. any change 
in the fluids, as proved by the fact that when serum 
has separated from blood knov’n to be powerfully 
bactericidal this serum provides an excellent culture 
medium for bacteria. The bactericidal power of the 
blood appears to depend on the cells and not the 
fluids of the blood; in fact, it bears a direct relation- 
ship to the number of phagocytes per cubic millimetre. 
The actual amount of phagocytosis undertaken by any 
single cell is neither increased nor diminished by 
radiation; the altered property is due 'to increase oi 
decrease in circulating phagocytes. This being so it 
becomes important to consider in greater detail what 
effect radiation has upon the leucocyte count of the 
blood. Some years ago this question was investigated 
by J H. Clark,= who found that ultra-violet rays 
shorter than 3,000 Angstrom units induced a great 
increase of ' lymphocytes, while the polymorphs 
remained constant; on the other hand, the near ultra- 
violet rays, just below the visible portion of the 
spectrum, bad a depressing effect on the lymphocytes 
and gave rise to an increase in neutrophils lasting only 
a few hours and followed by an abnormal decrease. 
Other observers have found that the total white count 
fluctuates a great deal in any individual after exposure 
to ultra-violet rays, but the fluctuation varies m 
different persons, and even in the same person, after 
repeated exposures to light. Gonce and Kassowitz 
found that differential counts made at the seventh 
hour after irradiation showed a relative and absolute 
increase in the polymorphs, and a relative and some- 
times an absolute decrease in the mononuclear cells. 
By the end of twenty-four hours the total and differ- 
ential counts usually returned to the same level as 
had existed before the first exposure. They found 
an improvement in the bactericidal power of the 
sample of blood taken at the height of leucocytosis. 

If this work is confirmed by o ther investigators, it 

*7ourn. Amer. Med. Aesoc., January 28tli, 3928, pp, 280-281. 

•Amer. Joum. of Hygiene^ 1, S9, January, 192L 
* Ijoc. cit. 



Makch 


ETHYL PETKOL. 


f TRE Bsmsu 
tLcniCAI. JOCBXAA 


363 . 


will prove Hint, as fur as the baclencidal power of the 
blood is concerned, the iminodialc died, of ultra-violet 
radiation has a direct relationship to tlio mnnber and 
cliaracter of the leucoeytes of the blood. AVholher or 
not the lowered bactericidal power observed in the 
blood of the majority of their patients after radiation 
was due to a leucop'enia is a question the authors do 
not attempt to answer. But one other practical point 
of importance mentioned in this paper deserves 
emphasis-— namely, that the bactericidal power cannot 
be infen-ed directly from the number of leucocytes 
per cubic millimetre of circulating blood, because the 
phagocytic capacity varies considerably in different 
individuals, although the antibacterial function of a 
single white cell may he constant for one individual. 

In a recent discussion on ultra-violet radiation 
therapy at the Medical Society of London (reported in 
our issue of February 18th at page 259), one speaker, 
referring to the abuses of ultra-violet ray therapy, 
classified these under three heads: “ E.vlravagant 
claims, injudicious doses, and home use.” The study 
of the bactericidal power of the blood has shown how 
hnportant is the question of correct dosage and proper 
control of treatment. Having been reminded of the 
inherent dangers of this valuable remedy, ue arc glad 
to recall here that the attitude of the medical profes- 
sion towards the employment of ultra-v'iolet ray treat- 
ment and other forms of electrotherapy' carried out by' 
unqualified persons has recently been before the 
Council of the British Medical Association, and that 
the matter has been referred to the Science and the 
Ethical Committees for consideration and report. 


ethyl petrou 

Sin UrLLi.iM Pope, professor of choniistry in tho Hniversity 
of Cambridge, in a letter to tho Times on February 22nd, 
bas ealled public attention to tho possible dangers attending 
the use of ethyl petrol. His views have been supi)ortcd 
y Dr. H. B. Baker, president of tho Chemical Society, in 
a letter in the same newspaper of February 25th, and" one 
result lias been a question in tlio House of Commons to 
tho Home Secrotaij, which elicited tho fact that the 
«sponsibility in this matter rested with tlie Ministi’y of 
^ealth and not with the Homo Office, but that the latter 
^ ecn ollo\ung closely the investigations wliich have 
ecu cauiet out in the United States.” We hare already 
cussej e possible dangers of tetra-ethrl lead 


(February 27tb, 1925,' p. 273, am 


addition 

r.^™iuary aytu, lyViS 

arpot'"^ 

to question wc have thought it wel 

to wlib.!*^ elsewhere (p. 367) of the investigation; 

aahot has reined. These hrvesti 

petrol < u ^ conclusion that tlie use of etliv 

'ot given 

however that tl,” Wc would point out 

by tho Cm-o 'Conclusions of the committee appoiutei 

Servte States Public Healtl 

elusions of “^'^orably more weight than do tho con 
oniphasized sTr” T '“ 7 ‘^®*'' 5 ntoi-s,- and that the eommitte. 
The necessity cont° 

‘o he obvious Ti mve.sligation appears to u 

aa excention-dK- i totra-etliyl lead i 

lead is tijg ^ ’^.’'S'^rous volatile compound of lead, am 
medical science°^ ennudative poison known t. 

loaf] rVi \ ®vitlenco available shows that tetra 
used for a com ^ form of ethyl petrol, has beei 

toxic effects ®hort time without any obviou 

occurrence but'^’t ^ Pmduced. This is a very fortunat 
tinned and evt ' "ould bo foolish to assume that the con 
ho free from '^alT'^da'*^'* mixture will of necessit 


Sir William Pope indicat 


some of tho ])ussiblo dangers that may' arise when 
familiarity breeds conteinjrt and carelessness, and wc would 
strongly support his demand that tho Ministry of Health 
should organize an e.xhaiistive official inquiiy. We have 
no reason to distrust the findings of the American com- 
mittees of investigation, but the detection of incipient' 
lead poisoning is a very difficult task. In the case of any 
scientific discovery of importance it is usual to check the 
results by independent investigations, and surely this ought 
to be done when the safety of a large section of the com- 
munity depends on tho soundness of the conclusions. 
Moreover, if it bo assumed that the conclusions in ques- 
tion aro absolutely correct, the need still remains for a 
careful watch to bo kept lest new dangers arise. This is 
particularly necessary because lead is a cumulative poison, 
and, unless the first signs of poisoning aro detected, great 
damage may be done to the liealth of the community before 
the effocts are obvious euougli to arouse public alarm. 


EVOLUTION OF RECEPTION ORDERS FOR 
MENTAL PATIENTS. 


Dn. J. E. Loan, lato president of the Royal Medico- 
Psychological Association, has written an interesting 
liistorical account of tlie evolution of the reception orders 
for mental patients in England and Wales, in which ho 
describes the very important part played by Lord Shaftes- 
bury in huiacy legislation during the middle of tho 
nineteenth century.’ Lord Shaftesbury’s attitude towards 
tho question of judicial inteiwention in the process of 
certification of mentally deranged persons has often been 
misunderstood. Dr. Lord, in the course of his examina- 
tion of tho various lunacy enactments of that time and of 
Lord Shaftesbury’s share in them, is careful to dispel this 
misunderstanding. He shows that only oue motive actuated 
Lord Shaftesbury — the resolve to procure early' and efficient 
treatment for tho mentally afflicted. It was this that 
caused iiim, on the one hand, to pi ess for the intervention 
of tho justice iu late-aided cases — for without such inteq- 
ventioii such cases would be immured in workliouses and be 
deprived of tbo advantages of institutions specially designed 
for tho treatment of tho insane — and, on the other hand, 
to oppose strennously the justice’s inten'entiou iu private 
cases, because this could only result in inducing people to 
keep back the patient as long as they could before they 
submitted him to treatment in a mental hospital. Tho 
value of tlie intervention of the justice iu the process of 
certification of cases of mental disorder has been clialleiiged 
mbny times since Lord Shaftesbury's day, and not solely 
in the case of private patients, but iu rate-aided cases 
too, on tbo ground that it is now an anachronism. Tho 
recent Royal Coimuission on Lunacy came to the conclusion 
that the inten'entiou of the judicial authority is still a 
necessity, even in tlio case of tlie Provisional Treatment 
Order, whoso adoption they recommend. Tho Commission 
took care to point out that tho value of such iiitorveiition 
depended ultimately on the methods pursued; but even so, 
it is difficult to escape from the validity of Lord Shaftes- 
bury’s observations iu his answers to the questions put to 
him at the Dillwyii Select Committee of 1877. These 
observations are most apjiosite to-day. “ Just consider it 
this way,” he said. “ Supiiosiiig you called in tho inter- 
vention of the magistrate, ho must act either ministorinlly 
or judicially'; if he acts ministerially what earthly use is 
he? He merely signs his name to tho documents . . . 
it is a mere ministerial act and affords nO security what- 
ever.' Supposing, on the other hand, he acts judicially 
and is called to sit in judgement on the certificate, and then 
gjoros his name at the foot of tho document and says it is 


■ The Evolution of the RecevUon Orders for Mental Pattenls in England 
ml IVnlcs- A UMoricel Surre’j. Rearinlcd from the Journal of llenUi 
cicnce October. 1927. London : Adlard tnd Son, Ltd. 



864 March 3, 1928] 


A ORITICISM OF “B'GG;" ' ’ 


p-<-TnRBRrTi« 

L MKJ'ICaI, JoCRXAt 


good and sound, lie exonerates tho medical man from liis 
great responsibility: lie exonorates the man wlio signs the 
order: ho exonerates tho man rvho admits tho patient into 
the asylum because he has declared everything to bo good 
and eurrent: however bad it may be it is endorsed by tho 
judicial man who has been called in by Act of Parliament 
to sit in judgement on that certificate.” “ Wo should 
object,” ho says elsewhere, “ to an inexperienced layman 
taking upon himself to reverse the decision of the medical 
man.” Dr. Lord is oonfident that in tho changed circum- 
stances of to-day Lord Shaftesbury, if he were alive, would 
fee! that judicial inteivention in the certification of tho 
poor insane was no longer necessary, but to be condemned 
for tlie same reason as he condemned it in regard to the 
private insane — ^namely, that it dolaj-ed early and effective 
treatment. 

A CRITICISM OF "B.C.G.’N 
The results claimed by Calmette and his co-workers for 
projiliylactic vaccination against tuberculosis b 3 - means of 
tho “ Baeillo Calmette-Guerin ” vaccine (B.C.G.) have 
alreadj' been criticized bj’ certain observers, mainlj’ from 
the statistical point of view, and in reply it has been urged 
that the good results were so obvious to clinicians that 
statistical difficulties could be ignored. A recent paper 
b^- A. Wallgren,* who is in charge of tho medical side of 
tho Children’s Hosiiital at Gbteborg, contains so careful 
an analj'sis of Calmette’s published conclusions that tho 
criticisms in it cannot be so easily' mot by such a generaliza- 
tion. He first deals with the oral route chosen for the 
administration of tho vaccine, casts grave doubts upon 
the amount of absorption likeh- to occur, and remarks that 
Calmette himself prefers the intravenous or subcutaneous 
route for the prophylactic vaccination of animals. The 
next point made is that following the infection of 
children by tho tubercle bacillus which is survived 
a .state of immunity doveloiJs; the sole clinical mode of 
estimating tins immunity at the present time is the tuber- 
culin test. Children who show no reaction to tuberculin 
are regarded as possessing no specific immunitj*, and yet 
according to Calmette’s figures only 6 per cent, of infants 
vaccinated by B.C.G. give a positive reaction with tuber- 
culin. So far Wallgren’s criticisms have been on contro 
ver.sial ground, but he is moro destructive when he gives 
a detailed analj'sis of Calmette’s published work. .As a 
basis for estimating the results of vaccination Calmette 
takes figures which show that of 1,364 infants born of 
tubercidous mothers in France in 1922, 24 per cent, died 
during the first year of life “ from affections presumed 
tuberculous.” A further iiiquiiy in Belgium in regard 
to infants born of tuberculous mothers and brought up in 
contact with them gave the slightly lower mortality rate of 
20 per cent. Again,st these basic figures Calmette brings 
foi'ward a group of children numbering 1,317 who, up to 
Januaiy, 1926, had been vaccinated with B.C.G., and he 
states that only 1.8 per cent, of those childi-en exposed 
to tuberculous infection died of the disease. But when the 
1,317 cases are more closely analysed it appears that 564 
had been protected for over a year, and of these only 231 
had been in contact with tuberculosis. Since among this 
group of 564 infants 45 are dead, it may be argued that if 
this mortality is diatributed among those 231 in contact 
with tuberculosis the rate becomes 20 per cent.— the basic 
figure for comparison. This juggling with the figures is, 
of course, pushing matters to an extreme, but Wallgren’s 
point is rather that tho tables published by Calmette do 
not contain evidence which jiuts such adjustmciiLS out of 
court. Dealing still with these 1,317 cases, Wallgren goes 
on to show that some 96 infants are stated to have died of 
inni-tuberculotis diseases, but no necropsies were iield, and 
in' tiio list of c auses of death in this group, based on clinical 
* Acta PaeJiatrica, ISi?, vli, 120. 


dmgiiosis, tho large.sf mort.ality group is labelled “ coii- 
goiiital weakness.” May not, be asks, tuberculous infection 
cause dentil from congenital weakness or provoke the fatal 
■issue in infants- debilitated for other reasons.^ The other 
caii-scs of death, such as gastro-ontcritis, infiuenzal broncho- 
pneumonia, and athrepsia, may all bo attributed to some 
tuberculous origin unless this is negatived quite definitely 
by necropsy. Tlicso are but some of the questions which 
Wallgren raises, and it is clear that much more detailed 
information is necessaiy, especially of the mort.ality rates 
of vaccinated children brought u]i in contact with tuber- 
culous mothers, before the optimistic claims of Calmette 
can bo completeh' accepted. 


THE DEPOPULATION OF MELANESIA. 

Ix an interc-stiiig study on the depopulation of the New 
Hebrides and other parts of Melanesia, ^ Dr. P. A, Buxton 
points out that remains of vanisb.ed peoples are to be found 
in several parts of, tlie Pacific. Thus, a race of .sculptors, 
now extinct, once flourisbed on Easter Islands, while in tlio' 
Caroline Archipelago tbero wore cyclopean builders of 
irliom even less is known, Who these people wore and how 
tlio}- lived is a mj'sterj'. In other races in tho Pacific, 
however, tho decline in population is of more recent date, 
while in some — such as tho natives of the Now Hebrides — ' 
the decrease is still in progress, and may' he studied to-day. 
It is among these peoplo that Dr. Buxton, while on an' 
expedition of the London School of Hygiene ahd Tropical 
IVfodicine in 1924-25, has made his investigations. He shows 
liow tlie inhabitants of Melanesia in general, and of the 
Now Hebrides in partieulai’, are now dying out, and among 
tlio causes of this he includes constant wars, the practice of 
magic, insanitary bousing, improper infant feeding, tho 
treatment of women under the pi cvailing gerontocracy, and 
tho provalonco of abortion, infanticide and other customs 
which have prevailed from time immemorial. Tlieso 
conditions cannot, therefore, be held directly responsible 
for the depopulation, .since this has only set in during 
the last century. Here it may be noted that it was 
not until the c.arly years of the nineteenth contnry that 
contact with the foreigner became' frequent. Not only 
did constant bloodslied then ensue, but diseases hitherto 
unknown, and against which the natives had acquired no 
immuiiitj', were introduced, and began to decimate them, 
measles alone carrying off thons.ands. Many writers also 
assert that svphilis was introduced by Europeans, and that 
it is lar<Tc]y' to blame for tho dying out of the natives. 
Buxton however, contests this view, and maintains that 
the disease in qnestiori is yaws, or framhoesia, which is very 
prevalent throughout tho islands. The “ hlackbirding ” 
which was among the horrors connected with the sandal- 
wood traffic was an important factor in the depopulation, 
but Buxton considers that the greatest of all the curses 
inflicted on the islands by Europeans was the labour traffic, 
which began about 1860. Eor many years, and often by 
force or fraud, natives were cairied away to work in tho 
plantations of Fiji, Queensland, Samoa, dnd New Caledonia, 
and even in the mines of western South America, many ot 
whom never saw their native country again. That these 
practices were eventually snppi'essed can he placed to the 
^redit of the Pre-shyterian missionaries, who, however, as 
Rivers pointed out,' wore also partly responsible for tlio 
decav of the population, inasmuch as they rapidly destroyed 
tho communal life and interests of tho natives, wliile putting 
next to nothing in the place of what they liad dcsG'oycd. 
Further, the form of government of the New Hebridc^, . 
joint administratihn by Great Britain and France, cstab- 
lisliod in 19C6, is not conducive to the intromiction o 
reforms or even to rapid and decisive administration^ so 
that the suppression of abuses is apt to be ncglcc.o m 


1 Traneaellaiis of the Uoyal Society of Tropical llcdicine and llyyicne, 
voL xix. No. 8. 


CHOIiERA-'EACTERIOPHAGES. 


r Tira British 
Mkdicai Tocbsal 


365 


March 3 , 


igssT' 


Anions the ciulomic diseases nialana, and espooially yaivs, 
and anion-i the imported diseases dysontery, tiihorculosis, 
and othci°indmonan- diseases, aro iiniioitant factors in 
depopulation. -Viiart from tlicso causes, Bnxton.con.sidcrs 
that two Torv disquieting facts arc, fir.st, that though the 
rate of decline of the population is noir loss- tlian it mas half 
a centuiy ago, the race continues to die out, irrespective of 
tho abolition of “ blackhirding ” and the reduction in the 
severitv of epidemics; and secondly, in all iiarts of tho 
islands about 118 males are born per 100 females, this 
disproportion persisting through life. 


CHOLERA BACTERIOPHAGES. 

A piiEumx.AnY report of work carried out by the Cholera 
Bactoiiophage Inquiry under- the Indian Research Fund 
Association in 1927 has recently been submitted by Dr. 
F. d’Hcrelle of the Pasteur Institute, Paris, and Major 
R. H. Malone, I.M.S., of the Central Re.scarch Institute, 
Kasauli.' The authors first studied in detail twenty-three 
cholera patients who were undergoing treatment at tho 
Campbell Hospital, Calcutt.a, during the iieriod April 27th 
to Juno 20th, and they made the folloning obserr.a- 
timis. In three cases no bacteriophage was present on 
admission, and all the cases proved fatal within twenty- 
four hours. Dr. d’HcrclIe recalls that in 1921, while in 
Indo-Cliina, he failed to isolate bacteriophages in 100 fatal 
cases of cholera. In anotlicr three of tlie Calcutta cases 
tho bacteriophage was weak from tho start, became weaker, 
and finall}- disappeared; tlicso eases provetl fatal within 
tneuty-four lionns after disappearance' of the hacterio- 
P mge. In two cases wlierc the hactonophago was strong 
oa admissiou recovery was prompt. In two other casre 
the power of tho bacteriophage fluotnated, hut finally 
ecame potent, and there was delayed recovery in each 
case. In the niajority of tho cases (tliirtocn out of taonty- 
UM) tie \irulence of the bacteriophage towards the 
C O era VI no was feeble at first, hut bocaino e.xaltcd and 
a ainc its maximum potency in tweiitv-four to fortv- 
ght houra after the onset of the disease. The antho'rs 
r^veiy or death from an attack of cholera 
tilncrn ^ * ‘f presence and' behaviour of tho bacterio- 

wein to! r'l^- intravenous saline injections 

nine life and giving the hactcrio- 

S the r ^-^“"tatii in viudenee; 

iniectioii<r tlic bacteriophage was absent the 

different re e attack vibrios varied in 

and the autlior! i’'’" ''’’ ‘'•''i®'''’’ 


wore aWo, by means of passage tlirougli 


strongesr\'trah,s*\/“t?^ 

''Vitli these senes of twciity-threo cases, 

proceeded to treat the investigators thcr 

villages wbei B ^“'“'■i’ar oT cholera patients in foui 

started. Altogetlier’Tu D f "°t long 

were treated w tl h ' villages fortv-dhc patient' 
pm- cent.', of these only’ three, or 7.; 

a-C'-e nntreated witt* u’ ■''■'•ages 107 patient! 

per cent. dieP ^""teriophage, and of these 70, oi 
of cholera in a fiftl . ‘“aipt notification of an outbreal 
an opportji,,;^.. of't*-'^°*^ (^awar) afforded tho author! 
oijolera haeterioubaacs''^^r ® prophylactic powers o1 

I'onsos niainiv occnniel’!, village, consisting of 34f 

flora thirteen publi ? ■ w-ator supply is derived 

eliolera occurred o ^ Private wells. Six cases ol 

fatal, while six fui-H ''S"st 2nd, of which three proved 
'iay. On August AH* w-ith two deaths occurred nexi 
bacteriophaqo^Yere ■> I'l a.cm. of a culture of selected 
tbe eontamii,afo,j ar' i-’™ "’ohs supplyinj 

ii''-® “ sailin', ” nf fresh case was repoited aftei 

yy-— >e Wa ter, and the Jat patients win 

ra'b« 

rS27. I.'oi, No. 11, p, 614.61&. 


drank of these wells rcc-overed. The authors recognize that 
the evidence of this single expcrinieiit is not of imich 
value; but Dr. d’HeroIIe refere to his more extensive experi- 
ments in fowl typhoid, where in each case the epizootic 
ceased immediately after spi-c.ading the bacteriophage in 
the envii'oiiment. It certain!}- seems reasonable to snpqiose, 
with the authors, that greater success should follow when 
anxilian- bacteriophages of proved antieholera virnleuco 
and in sufficient quantity are, so to speak, rushed up to 
the support of exposed persons at tlie very beginning of 
an epidemic, than when, in the natural course of events, 
valuable time is lost before tlie first convalescents begin 
to pass in their stools p.otciit bacteriophages which then 
(like the vibrios themselves) become disseminated bv flies 
and drinking water. Still more reason is there to expect 
that tho use of liighly virulent bacteriophage cnitnres 
should prove helpful in the treatment of these patients 
who, on their own account, piodiicc no bacteriophage, or at 
best only a feeble and evanescent one. The results of 
fnrllier experiment in both directions will therefore he 
awaited with great interest, and should these confijm those 
already rc])orted a rational and practical expedient will be 
available for the control of cholera epidemics and the care 
of cholera patients. 


SPORTS DOCTORS. 

Thkue have been and are in this country surgeons with 
special experience in tho diagnosis and treatment of 
injuries incurred in the pursuit of various sports, but no 
attempt has as yet been made to develop the study of these 
injuries into a specialty. In Gei-many, however, where 
things are apt to be taken more seriously. Professor Dr. 
Hormaiin Altrock of Leipzig has jn-odneed a work' which 
treats systematically of most sports and bodily exercises, 
and of their medical and surgical aspects. His plan is 
to print an article by a specialist in each sport and to 
follow it by another dealing with its medical aspects. 
Tims there is an article on rowing, which goes into a good, 
many details as to boats and the weights of nicmhers of 
crews, etc., written by Dr. Altrock himself. This is 
followed by another on tho tactics of rowing matches by 
Ohmpia blaster Hermann TVilker, and, to complete the 
subject, one on the medical aspects of rowing by Dr. 
Rolf Friedlaciider of Berlin.' Dr. Altrock thinks that a 
“ Sportarzt ” is not properly equipped to treat sportsmen 
unless he jiossesscs at least a theoretical knowledge of 
those games and sports with which they amuse or occupy 
tliemselves. Professor Bier of Berlin, in an introduction, 
supports Dr. Altrock, and urges that evei-y medical man 
wlio wishes to use sports as thei-apciitic measures should 
say to hifiisclf that to do so he must correspondingly have 
exercised his body and have got an insight into the means 
of jihysical exercise. Before the last decade of the nine- 
teenth century Germany timsted to iraplemental gv-mnastics 
as taught in gxmnasiiira.s for exercise, but after that time 
an interest sprang up in games as practised in England 
and, America. The German sport authority (Bohordo) for 
.athletics was founded in 1897, a society analagous to our 
Amateur Athletic -Association. There is a gi-oat deal of 
interest to us in the medical part of the introductory article 
on “ Leichtathletik ” (a convenient term which rnchides 
most of the .sportSsliractiscd here at such meetings as those 
of Oxford and Cambridge). It is interesting to note that 
Dr. Amo Arnold of Leipzig quotes Dr. Parkes IVeber’s 
account of the thrombosis of tho inferior vena cava from 
which the late Dr. Rivers Pollock suffered at the end of 
a hni-dio race. He appends to his article an elaborate foini 
to be used bv surgeons in the examination of athletes and 
would-be athletes, as used by tho German High School for 
Bcdilv Exercises. If this is conscientiously filled up there 
can be little left to be known .-ibou t tlio habits and plivsiqnc 

‘ Ktrinc Sportslumlr. Unter mitarbeit von fachgeno-sen beraofgcgebcn. 
Leipzig: G. Tliicme. 1923. (31.9.50.} 



366 MAncn 3 , tgis] 


TETRA-ETHTD IiEAD IN'PETUOlj. 


of tlio Knbjoct of it. Association football is very shortly 
•Icscnbcd, and Iltigby barely mentioned. Uoxing, wresUin-,- 
monntamcering, skating, slci-ing, cycling, and oven flyiirg 
receive due attention, as ivell as almost every other kind of 
H’lort. Sivimming is dealt vitb at some length, but golf and 
Cl icket get scarcely nioi o notice than do croquet and bowls 
Tlie.so four are liiiiiiied together as “ turf games,” but Mr.' 
Krne.st Gla.ss of Hamburg welcomc.s the spread in Germany' 
of golf. 


' r A. . r 

I JirnjCAL JocRuti 


IMPRESSIONS OF AMERICAN UNIVERSITIES. 

Fon three months in the early jiart of 1926 Dr. Fdwin 
Deller— the academic registrar of the T'niversitv of' London 
—was the guest of the Laura Spclman ' Rockefeller 
Memorial in order that bo might quietly and informally'' 
investigate and di.scuss educational ])roblem.s in the univer- 
sities in various pait.s of America, and noir with a yvinniiiE 
con.scioiisncss of bis “ infirmitic.s ” be has placed liis 
irniire.ssions on record in an interesting iiamplilet.' In tlie 
irst place, be was struck by the keenness of the American 
belief in education, wbicb is shown in the practical yrav 
of the exeirption of universities from national and locaY 
taxation. The ideal of the American university has been 
built up out of the British tradition of “ sound learning,” 
the German sjiirit of re.soareb, and the American conception 
of ovoii broader sorvico to llio eoinmiinity 
lirodiicing good citizens, 
qi'cstion of the danger 


in the nay of 
But li(‘re Dr. Dcllcr raises the 
... making utility rather than 

intHlectual training the object of university education. 
In British medicine instruction lias been mainly ancillary 
to hospital work, whereas in Germany the university has 
for many years lieen the predominant partner in the 
combination with the hospital. In America both tlio 
relations may bo seen, respectively, in the case of the Mayo 
Clinic attached to the Uiiivfrsity of Minne.sota and the 
Kockofellor Institute and Hospital in Xew York. The 
strongest feature of the American university appears to bo 
the provision for post-graduate instruction, and in some 
States the activities of the universities have made them 
the most esteemed governmental organs; this is due in part 
to the relatively undeveloped condition of the other State 
organs and the low opinion in which legislators and 
“ politics ” are bold. Some of the American universities 
are extremely well provided v itb money, but all have their 
difficultio.s, e.speeially in maintaining a high .standard of 
education for the appalling number of students, ofton very 
inadequately prepared, and who, their teachers say, aro 
often without any veiy clear objective, excejit to get on 
in a land where material success is too prone to bo regarded 
as the ultimate good. “ 


ILTRA-LTHYL LEAD AS AK ADDIITON TO 
PETROL. 

LN-vnsTio,\Tioxs IN Tin; L'Nixim Sj.ifr.s. 

■ An American correspondent has .siiggesicd to ns that in 
recent articles in the Bhitish MimicAi. JounN.iL on the' 

gnen to the negative conclusions arrived at bv ccrt.ain 
committees wdio have investigated the effects produced hr 
this substance. The matter is of .such great potential 
imporlni.ee that we think it ,advi.sablo to give on.- readers, 
a somewhat fuller summaiy of the evidence available'. 

Jwo .separate eommittces' in Hie' United States have in- 
ycstig.ated the effects produced by ethyl -petrol. The first 
ini estig.ation , was_ carried out by the Bureau .of Mines',! 
who entered into an a'grecmcint'dn'Ocfobcr; 1923,'. with .tliV 
General Motors. Research .Corporation.. of Dayton, .Ohio,-., 
according to which the corporation jiaid the exiiense.s of 
a research by the 'Bureau into the effects produced by 
exposure to the exhaust fumes of engines using ethyl jK-trol.'- 
The Bureau first invcstig.atcd the effects ■ on animals : of.' 

, exposure. to the exliaiiH of. an. engine using ethyl petrol of 
'normal constitution (.that- is; one part tetra-etliyl lead in 
1,270 jiarts by volinne of petrol). I’bey concluded that 

" llic elTi.'cls of cxpo.sufe to the concentration of lead prevailing 
in the ' air during this campaign wore not manifested by tlio 
storage of lead, pathology, haematology, symptoms, weight, and 
growllj of the animals exposed/’ » 


SIR CHARLES HASTINGS LECTURE. 

Tire second of the Popular Lectures instituted hy the 
Bnti.sh Medical Association, and a.s.soeiatod with the name 
of its founder. Sir Cliarles Hastings, will ho given by Sir 
George Hewman, K.C.B., Cliiof Medical Officer of the 
Ifinistry of Hoaltli and the Board of Education, on the 
evening of ■Wednesday, JIaicb 21.st. Sir George Kewman 
has chosen as the title of his lecture “ Tlie fundamentals 
of bealtli.” It will bo delivered in the Great Hall of tbo 
British Medical A.s.snciation’s Homso in London, and tbo 
chair will' be taken at 8 o’clock by Lord Cozcn.s-Hardy. 
The first Hastings Lecture was given a year ago bv Sir 
Btrkcloy Afoynilian, President of- tbo Royal College of 
Surgeons of England, on “ Cancer and bow to fight it ” 
and it attracted wido.sprcad ])nb!ic interest. Admission is 
free by tickets obtainable from tbo Financial Sccrctam- 
B.M.A. House, Tavistock Square, AV.C.l. .Seats not occii- 

p.m. will bo available for 


pied by ticket liolders by 7.50 
^lior irombcrs of tlie public. 

l,l-D."''unVj'",f" ■‘'t'”'’ - Sniiie Iitii'rrttiortf. Ilv Edwin Dcllcr, i 

university ol London I'rc.'s. 1927. (Demy 8vo, pp. «. Zs. net.) j 


They next investigated the effects of exposure of anim.'ils 
to the exliaii.st of engines using five times tbo conimcfciul 
concentration of totra-ctbyl lead. In this c;ase “ di.stinct 
.storage of lead was found in all species and groups of 
animals c.v])osed during campaign 2,” but “no ebaractei!. 5 tio 
.symptomt of lead poisoning wore obtained, except 16.ss of 
weight in .some animals.” Ujioh the basis of these results 
the Bureau of Jliiies published a preliminary report in the 
autumn of 1924* recording tlie.se neg.ative findings. 

About this time, however, various things happened. 
Eldridge’ jinbli.sbed a report from tbo Chemical Warfare 
Service .showing that daily application to tbo skin of a dog 
of 0.1 e.cm. per kilo of pure tctra-otliyl lead produced 
Ictlia! results. This association of tetra-otliyl lead with gas 
warfare was alarming, and the .alarm was increased by 
the oceiii'icnee of fatalities in the factories making tetia- 
etbvl lead. Hamilton, Reznikoff, and Biirnliam'' in 1G2S 
recorded eleven sncli fatalities in the previous .seventeen 
months. Tiicy also criticized severely tlie experimental 
mctliod-s and conclnsious of the Bureau of Mines. 

In Alay, 1925, tbo Siirgeon-Genornl, U.S.A., appointed 
a stroll"' coinmitteo to investigato tbo toxicity of ethyl 
petrol (“ ctlivl gasoline ” is tlio American name), and the 
production of ethyl petrol was suspended .until tlio eom- 
mittce reported. This committee reported in January,. 
1926 ® after eight months’ work. Meanwhile the Bureau 
of Mines continued tlieir work for another year.* 'riicy 
examined the effects of exposing animals to the vapour' 
of unconsumed ethyl petrol, arid also studied tlie effects 
of ajiplying ethyl petrol to the skin. Wlien animals were 
exposed to the vapour of comniercial ctliyl petrol they 
found no evidence of storage of lead, and also found that 
“ the weight and growtii of the animals were normal, .which 
included those born on tc.st.” With ctlrel gasoline con- 
taining two and a half to five times the normal content 
of tctra-ctliyl lead they found : “ Some of tlio animals 
exposed to 'O.IO per cent, otbyl gasoline vapour showed 
distinct storage of lead,” but also “ no inhibition of growtli 
or lo.s 5 of weight was noted to occur in animals exposed 
to 0.1 and 0.3 per cent. cth 3 -I gasoline va))oiiis.” Wlicn 
otlivl gasoline was applied to the .skin tliev found tliat 

".clhvr gasoline containing the commercial amount of cth}'! fluid 
(1 in "l ’270), applied daily- in-doscs up to 1 c.cm., wlicn it is limited 
to skin ahvorption is apparently no more -injurious than stiaigi't • 
gasoiiiic.*’ 

Tins work was apparently finished in Becombor, 1925, 
but for some reason or other the full report was not piih- 
Jisliod until 1927. The report ronsists of a stout voliimo 
of 447 ■ pages. Meanwhile the report of- the Surgeon- 



, MARCH 3, l92Sl. 


ANTI-STKEPTOCOGCAn .ACriON OF AHSENICAri PKEPAEATIONS. 


367 


Gcneval-s Committee mas pi.bl.shc(l m Jaiutary, 1926. The 
^mmittee examiued transport am gnrago morko.-s wl.o 
Tad been morlcing mitl. etUyl petrol for two years, lu view 
.of tbc importauee of tlicir- conclusions- we reprint- them - 
ill ciicaso. 

“ On tlic basis of tliis investigation llic committee feels that the 
follo-King general conclusions arc iustilicd : 

“ 1 Drivers of cars using ctliyl gasoline ns n fncl, nnd in which 
the concentration of tetm-cthyl lead wns not greater than 1 part 
‘in 1,500 parts by volume of gasoline, showed no denmte signs of 
lead ab'iorption after periods approximating two jears, 

“ 2. Employees of garages engaged in the handling nnd repairing 
of automobiles, and employees of automobile service stations, may 
show evidence of lead absorption and storage, as indicated by the 
lead content of the faeces and the appearance of stippled cells 
in the blood. In garages and stations in which ethyl gasoline 
was used the amount of apparent absorption and storage was 
somewhat increased, but the effect was sliglit in comparison with 
that shown by workers in other industries when there was a severe 
lead hazard (Group E), and for the periods of exposure studied 
was not sufficient to produce detectable symptoms of lead poisoning. 

*‘3. In the regions in which ethyl gasoline has boon used to the 
greatest extent as a motor fuel for a period of between two and 
three years no definite eases have been discovered of recognizable 
lead poisoning or other disease resulting from the use of ethyl 
gasoline. 

“In. view of these conclusions your committee begs to report 
that in their opinion there arc at present no good grounds for 
prohibiting the use of ethyl gasoline of the concentration specified 
as a motor fuel, provided that its distribution and use arc con- 
trolled by proper regulations.'* 

A very important qualification is, lioNvcvcr, appended 
to tliese conclusions : 

“ In coiiclusion we beg to say lliat we arc conscious of the fact 
that the conclusious to which we have come in this report, 
although based upon most careful and conscientious investigations, 
arc subject to the criticism that they have been derived from the 
study of a relatively small number of individuals who were exposed 
to the effects of ethyl gasoline for a period of time comparatively 
brici when we consider the possibilities in connexion with lead 
•poisonmg. A .more extensive study was not po<*siblc on account 
of the limited time.* It remains possible that if the use of leaded 
gasolines becomes widespread conditions may arise \cry flifTcrcnt 
from those studied by us, which would render its use more of a 
hazard, than .would appear .to be the ease -from this investigation. 
Longer experience may. slidw that even such slight storage of lead 
as was observed in these studies may load cvcntiinlly in sus- i 
ceptible individuals to recognizable lead poisoning or to chronic 
degenerative diseases of a less obvious- character. In view of such 
po.«sibihties the committee feel that the investigation begun 
under their direction must not be allowed to lapse.” 

Another piece of evidence is an unpublished paper 
courteously forwarded to .us by X)v. R. A. Kchce.® This 
work was done between October, 1S£6, and April, 1927. 

le examined 143 persons who liad been exposed 

0 ctiiyi petrol as garage mechanics, filling station 
a em an s, oi tank wagon emplov’ces, and 69 persons doing 
MHiilai- work with ordinary petrol. About 40 per cent. 

exposed to ethyl petrol for more 
41 per cent, bad been exposed for more 
sienc 'fkc cases' were examined c.-ircfully for 

'conchIdV^“'^ ««ret.on and for lead poisoning. Tlie .authors 

“f this study it jg possible to state conclusively 
tlou his f. evidence to indicate that appreciable lead absorp- 
■” of. persons who have bad the 

associated irprTi! “P. Present to the hypothetical hazards 

On-the cthei- l' ■ handling' of ethyl gasoline, 

o stndv fou-'d 

•» *»<•'■» •‘.™ 

present "oVn'n''* ? fair summary of the evidence .at 

with ti,„', tke possible dangers associated 
of lwgV“ petrol. The value of the evidence is, 

the ari-nre' to asscss exactly. It depends uiJon 

estimatinn.!^^ "t very delicate teclmiqu'e — for example, the 
excrot, a milligram of lead in the 

of slight deviations from 


-ion. 
Thomas. 


inicxioiis of a 

aweta and the estimati'on 

taii™oiir«f,-^!''' Wood corpuscles. °Furtberraoro, jmpor- 
tion of thp^nv regarding the intensity and ttie dura- 

possihilitv nf aud.also regarding the 

lossibiiitj of individual variations in suseeptibnity to lead 


poisoning. VCo mention thc.se considerations to emphasize 
t)ie point tliat a very largo amount of work over prolonged 
periods will be neccssarv’ before any certain and final 
conclusions can bo reached in this difficult problem. 

REfEK EX CES. 

* Exiierimental Stmlies om the Effect of Ethyl Gafoline anil its Com* 
httslioH Protlitclf. Report of tlie United States Bureau of Mines to 
General Motors Research Corporation arid the Ethyl Gasoline Corporati 
Bv R. R. Savers, A. C. Fieldner, W. P. Yant, *and B. G. H. Thom 
/if 47 pp,) Bepartnient of Commerce, U.S.A. 1927. 

^ Jottrn. Atner. MciL Assoc., 85, 1511, 1924. 

* Eldridgc Report 29. Chemical IVaifatc Service, October 5tb, 1924. 

^A. Hamilton, P. Rcznikotl, nnd G. M. Burnham: Journ. Amcr. l/ed. 

A**oe., 81. 1481, 1925. , , ^ , 

* Report of Committee appointed bv the Surceon-General of the United 
Stalcj*. Health Hazards in Sale and Vse of Ethyl Gasoline. January 17tb, 
1926. (12 pp.) Xames of Committee: W. H. Howell, A. J. Cliesley, D. L. 
Edsall, Reid Hunt, W. S. Leathers, J. Sticclitz, C. E. A. 

Abstract of fin<lingh pubtisJicd in Jouin. Amcr.jled. 86, 3<0, lw,.o. 

* •{ Study of the llenlth Hazards associated icith the JJistnhiinon ana 

Use of Ethyl Gasoline. Bv R. A. Kehoe, K. V. Kittmiller, R. L. Crud^inston, 
\\\ F. Macklc, W. E. Brown, L. Sanders, F. Tiiamann, and J. Cholafc. 
(47 PI>.) — 

ANTI-STREPTOCOCCAL ACTION OF CERTAIN 
ARSENICAL PREPARATIONS. 

Some interesting and possibly important conclusions with 
legard to the .application of chemotherapy to strepto- 
coccal infections arc to be found in a special lepoit 
which is - published this week bj' the Afedical Rescareh 
Council. This contains an account of a study by Oi. 
Leonard Colebrook of the effect of certain organic arsenical 
compounds on streptococci in vitro and in the human 
body. During the uar Captain S. R. Dougl.as, H.A.M.C., 
and" Dr. Colebrook, bath working in connexion with the 
Council, commenced an investigation into the use of diugs 
of the salvarsan and neosalvarsan type in Die treatment 
of wound septicaemia. Aloro recently Dr. Colebrook has 
turned his attention to puerperal infections, and Ims 
attempted to provide data for planning a chemotherapeutic 
attack upon such conditions. He has studied the degree 
and duration of bactericidal power conferred upon the 
blood bv the administration of different doses of various 
arseniciil compounds, nnd has also considered the eompli- 
catiii" factor of coneiinent leucocytic poisoning. It is 
nientfoned that careful cliiiieal trials on similar hues .are 
also pr'ocecdiii'g in London and Alanchestei . 

yuiiiic oj the Bnrpcrimciif.of IVor/.'. 

The starting point of the prcssiit inquiry was the belief 
that the anti-svphilitic arseiiicals, wnon .administered to 
man, might e.xei-t a directly destructive action upon pathc- 
aenie bacteria in the body as well as upon spirochactcs 
and protozoa. The first demonstration of the conferring 
of bactericidal power on the blood serum Hie 
tratioii of a drug was made by Sir Almioth 
1012 in connexion with the quinine derivative ethyl hydro- 
cuprein, or “ optochiii,” which Jlorgenroth and Levy in 
1911 had shown to be cajiable of saving mice e.xpenmentally 
infected with pneuraoco-cci . Douglas and Colebrook in 
1916 demonstrated that similar results followed the use of 
neosalvarsan in the case of staphylococci. AJany other 
chemical agents have since been tried, but on enteiing 
the blood stream they appear to become by Jie 

serum proteins, tbe blood cells, or the tissnes. Aloreove. , 
Fleming’s work in 1924 made it clear that so much 
damage might he done to the normal protective elements 
in tuf hlood, particularly to the leucocytes, that f.ar more 
harm than good might result from the 

in treatment. Tlie ]ireseiit investigation, theiefoie, nas 
directed also to ascertain whether the injection of tncchcm^l 
do "s of certain drugs wonld injure norma prot ot.vc 

mechanism of the body. T^ “rTnc'i^as iTc ’ qulitv to 
tested was accorc^ingly was observed upon tbe 

human blood in rifro, and effect a as o 
phagoeytib ea]iaeity of the blood, tle^^.^pp 
leucocytes, and the piood in vitro had 

that the addition of ars- . other th.an to increase 

little effect upon its compounds incubated with 

1 i Sluilt/ .of So, nr '^lleonanl Colrbrooll. M-Il.. 

H^i. 'Office. lES. Is. 3d. act. 



368 Mabch 3, 1928] 


CONFBIIENCE ON MATERNAL MORTALITY. 


Tur Ijcmw 
MHiICAL JOCRSit 


tiventy-foiir hours oxcrtod .t slowly destructive action, 
chiefly on the pohunorphoinicloar and largo mononuclear 
leucocytes. The next step wa.s to determine whether the 
leucocytes in the body were similarly jillected; and it was 
shown that uherens after a largo dose of novarsonobenzene 
there was a falling off in the activity of the leucocytes in 
three cases out of four, particularly when the patients 
wei'e .suffering from .severe infections, the ndmini.stration 
of kharsulphaii and metai-scnobillon did not api)rcciably 
reduce the leucocytic efiicicncy', even when given in do.se,s 
which maintained bactericidal potency in the serum for 
two to four days. It became likely, mm’covcr, that by 
suitably adjusting the dose of. the arsenical preparation in 
the blood it would be possible to secure bactericidal 
potenc3- without doing anj- apjireciablo harm to the leiico- 
c^'tes. To establish this point cxperiinonts were performed 
upon the blood in ritr.o and also in the living bodj-. 

Sininnarj/ of Expr.rimcntal llcsnUs. 

A small group of triyalent arsenicals comprising salvarsan 
and tv.'o of its derivatives — ^namch-, novarsonobenzene and 
the diniethylene bistdphite (sulfarsenol, mctarscnobillon, 
and kliarsulphan) — were found to exhibit certain properties 
distinguishing them sharph- fiom almost eveiy other known 
compound which it lias been propo.sed to use for the chemo- 
therap}' of bacterial infections; no pcntavalent arsenical 
showed these properties. 'When injected into the living 
bodj- this small group conferred upon the blood the ]>ecnliar 
bactericidal powers characteristic of their simple solutions, 
which powers were retained by the blood for a considerable 
time. It is suggested that, owing to the slowness with 
which these drugs arc excreted and enter into combination 
with the blood or tissue cells, a considerable portion of the 
injected dose is retained for a time in solution in the blood 
plasma. This bactericidal effect is most marked in the case 
of the haemol.vtic streptococci and the jmcumococci ; strepto- 
cocci of the v'lriilans group and staph.vlococci are less 
affected, while there is hardly an\- action on the enterococci 
and certain diphtheroid and coliform bacilli. It was found 
that 1 c.cm. of the serum from a patient who had received 
an injection of one of tho.se arsenical compounds would 
sometimes kill as many as one to two million haemolytic 
streptococci, but somewhat lower figures were more usual. 
The bactericidal power thus acquired by the serum reaches 
its highest point immediateh' after an intravenous injection 
of novarsenobenzol; it then diminishes, somewhat rapid!;', 
at first, and then more slowly, during the following twenty- 
four to forty-eight hours. By the intramuscular or sub- 
cutaneous injection of nietarsenobillon, kliarsulphan, or 
sulfarsenol, repeated at suitable intervals, it has been main- 
tained in several patients for three or four days, and in 
one case, using inetarsenobillon, for four weeks. The 
arsenic compounds tested were found to have the following 
order as regards toxicity for luiman leucocytes. The least 
toxic were mctarscnobillon, kliarsulphan, and sulfarsenol, 
approxim.otely equal ; next came stabilarsaii, salvarsan, and 
neosalvarsan, while the most toxic of all was silver sal- 
varsan. The leucocytes of jiatieuts suffering from ver.r 
severe streptococcal infectious were found to have an in- 
creased sensitivity to this toxic action. It was shown 
experimentally that the dosage could be adjusted so as 
to secure tlie nimimal effect on the leucoc.vtes with a 
maximal bactericidal potency of the blood. In solutions of 
low coucontration or in the scrum of patients it was found 
that the bactericidal effect was reiy slow in developing; 
implanted streptococci often multiplied at fiist, but were 
killed after a period of six to twenty-four hours. 

Lines of Future Iiuvstigation. 

Hr. Colcbrook concludes his report by mentioning a 
number of questions arising out of his results and requiring 
further research. There is, first, the elucidation of tlic 
source of the bactericidal power; is it due to the simple 
solution in serum of the drug, or to the presence of some 
“ alteration product ” formed m the body, or to the 
elaboration of some antibody under the stimulus of the 
fii-«;onic£il ? Afc pr6S6tit tiitt evidence indicates tliat tiie first 
those is concerned. Tlie second question is vhetlier the 
jnetortciclal power is relatctl to one specific feature of the 
structure of tho arsenical preparation; if this 


could bo cstablislied as a fact the wav would lie open t 
le piC]>aratiou of still more effective therapeutic agents 
Jhe nature of the difference in the action between tlics 
-drugs- and other- disinfectants' is -striking, and invite 
research, a.s also tlie question whether the streptococc 
can become I'csistant to them. Another interesting am 
piactical jioiiit is thc po.ssibility tliat both .spirochactes am 
iacicria uhicJi arc not ki/led hy diiution.^ of arsenicals ii 
a shoi t time, such as one or two Jiour.s — ^tlie usual expert 
niental period may siiociimh to ireaker dilutions if exposei 
to them for some days, as has been shown to be possible noi 
•with certain of these in the human bodv. A series o 
doses is suggested for the clinical nse of the three selcctci 
ar-sciiicals by iatramii.sciilar and subcutaneous injections 
and tlie importance of improving the circulation tlirougi 
the infected areas is emphasized. This report wil 
undoubtedly provoke discussion and stimulate research ii 
what may prove to be a very fruitful field. 


COXFEREXCE ON MATERNAL MORTALITY. 


A YEiiY largely attended meeting ■ to discuss materna 
mortality was held at the IVcstminstcr Central Hall oi: 
Echriiary 2 Sth. The gathering consisted almost entir.-l; 
of women, ivho represented county mii'sing associations, 
infant welfare centres, and materiiitv and child welfire 
committees. The chair was taken by tlie Hon. Mi-s. Awftiei 
Lvttelto.v, D.B.E., who was supported bv Sir George 
Newman, Dame Janet Campbell, Ladv Barrett, and others 
whoso names ajipcar in tho list of sj)oakcr.s. A message 
from the Queen was read stating that Her Majesty viewed 
with grave eoncern the contimiecl high rate of maternal 
mortalitv, and felt that a vei'y real endeavour should 69 
made to remove tin's reproach from tho national Iffe. 
“ The Queen trusts this may be achieved through the 
education of mothers themselves in the need for ante-natal 
care through inquiry into the immediate causes of 
mortality in childbirth, and through a wider provisiou 
of first-rate mediral and midwifery services.” 

At the eonclusioii of the meeting the following compre- 
hensive resolution was cairied unanimously: 


That steps should be taken to obtain a medical inquiry into 

even- nialernal death due to cliildbirth : ., , , ,, 

Th'at tho attention of the antliorities responsible for the 
education of medical students sliould be drawn to the need for 
furtlici- training and experience in midwiferj- as a preliminary 
to general practice in medicine; 

That an official committee should be set up to advise upon 

1 r.f ivninint/ finrl r'mnlnvjTH'Tlt OI 


' q'liat action should he taken in every area to induce all 
Ira-al authorities to make tlieir maternity sevrices adequate; 

That tlie provisions of tiie National Hc.nlth Insurance Acts 
-slimild be readjusted and extended so that medical and mid- 
wiferv services should be available for mothers both for 
anle-hatal care and during and after confinement. 

It was luiclerstoocl that tlie resolution would be sent to 
the Ministry of Health. 

T)r J s. Faibb-uen said that maternal mortality tvas lowest 
in those countries, like Holland, which had a well-trained 
-ervice of midwives. In paiticuiav he emphasized tlie impor- 
tance of post-certificate training, mentioning also that Uie 
rinivprsities of Durham and Leeds now assumed a lecture 
'ourse for inidwives as part of their university duties. But m 
wldifion to the training of midwives it was neces.sary to mai-e 
be profession economically and otlicrwise attractive enough 

Foi women ^to^p M.P., formerly Parliamentary 

to the Jlinistiy of Healtli, said that there were tliwe 
ines of' possible advance; the development of national healt 1 
rurmice'^ the Ivelopment of the work of local authorities as 
egrrds maternity and child welfare, and the improvement 0 
hf social environment.. If only the existing powers of loca 
1 . Pie- with re-ard to ante-natal and post-natal -'are rverc 
ulircairied out the stubborn' total of 3,C00 maternal deaths 
xT'r.nlfl to fiecVme. . - 

'After Miss Steek bad .spoken from tlie point of “ 

lira! nursimr. and Airs. Haeeisox Belt., a signatory of he 
linoritv Report'of tlie Royal Commission on National Heal 
nsurance. bad urged additional insurance benefits 
f midwifery, medical e:.-am.nations before ^ „ry. 

and medical attendance at tlie confinement if nece;> 


X 



CANADA, 


.MABcn 3 < ' 928 ] 


[ 


Th* Bnmjs 
Mkoicjlz. Jocbxal 


369 


tho meeting was thrown open to general discussion. Dr. S. G. 
IfooRE said that tlicre was .a town in England where the women 
vho were confined might ho divided into two groups. In one 
group there were three times as many maternal deaths as in 
the other. In the group with tho lory death rate every woman 
was visited during pregnancy by a avonian doctor, who saw 
to it that she was normal, or, if not normal, sent a report to 
her family doctor, whereby tho case was followed up. 

Lady StLEOusE said that tho United States had a higher 
'maternal mortality than Great Britain, and there it avas doctors 
who were employed, not niidavives. She thought that con- 
ditions were better now, but she recalled a time when doctors 
in attendance on lying-in women took extraordinarily few 
precautions. Another speaker, who said that she avas a town 

■ councillor, declared that tho crux of the problem was the 

■ training of tlie medical student. This lady urged that doctors 
should be subjected to tbc same discipline as midwives, and 
suffer tlie equivalent penalty if they neglected to observe any 
proper care. Miss E. M. DonBLED.aY thought that the appoint- 
ment of doctor at tho ante-nat.al ■ cenlro should be given to 
one who was specially qualified for tbo work. Manv of these 
appointments went to persons who had no special exper.eneo 
in obstetrics. 

Dr. Ethel Bextiiam urged that the necessary' research info 
this whole subject should include an economic as tvell as a 
- medical inquiry. Another speaker regretted tho absence tVom 
. the resolution of any referenco to permanent injury and 
, invalidism resulting from childbirth. Tho conclusion of one 
health visitor who spoke was that the death rate was practically' 
level in all classes of society. One sjjeaker, again a woman, 
\entured to plead for good scientific teaching on birth control 
to be given at the ante-natal centres. 


n determination was evident throughout tho 

debate that the total of maternal mortality must by all 
means be reduced; but tho remarks of many’ who spoke 
10 m the side of the social and municipal services seemed 
etray a feeling that, in tlie exact words of Lady 
Selborno, there 13 a danger in tho doctor ” 1 


Cattatra. 

[Fnosi oun SpEcrAi. ConnEsroxPEXi.] 

A , Biitish Columbia, 

eollctfn evolved in British Columbia for tho 

antori t V serum for tho treatment of 

actiQn°nf^ti''”'i;^ mado possible by the 

British ^foviucial Board of Health Laboratories of 

5 dnlHrs f 7'° •tfrioiiuced that tlioy will p.ay 

-end Irurnn of blood (80 to 100 c.cm.), 

at whicli ordi'nV''"H^”’ “"’ounts. This is tlio rate 

The Hboratnr: blood for transfusion auo paid, 

testin'o- ifl yv responsible for collecting the blood, 

sufe to cairr:"? presowinS it on ice, 

. the serum esnon' u cases. It is intended to use 

cases and r treatment of early or advancing 

'arti:;uf„t2P''^7,fnnit, for prophylaxis also. Thil 
"■'til this disease wbw '^ axaniplo of foresight in dealing 
concerting cvfeni i existent in the West to a dis- 
««"ning the nature an 

intercltinl*”**”^''' i" Montreal, 

campaio-n fo,- 7®"® ‘'“s developed out of the last 
One of°the first '’PPai't ef the hospitals in Montreal, 

from the Bank- nf'ivr , ^Sest subscriptions to the fund was 
end other bank “"trcal, to tho extent of 200,OCO dollars, 
Tlie contribution “nf were similarly generous. 

opposed by some Alontreal is now being 

Seek to «: ^ in tlie city of Quebec, 

7 ,'eh donations 0*00 '"l that 

<Iirectors under tl "^oess of the powers of tho board of 
rogarded as a test'^ Bank Act. The action is generally 
corporations to decide the right of directors of 

defence is made P"Blio institutions. The 

"■ork of four'hnsr.ia ' 1 money is being devoted to the' 
*0 oil the ■ inhabitants which aro of sei-rico 

‘ace or religion an^ai a”* *• *® province, irrespective of 
b on, and that many of their patients are unable 


to pay for tho cost of their treatment. It is pointed out 
also that these hospitals render a much more widespread. 
Eervico to tho community at large by their training of 
nurses, besides providing clinical facilities for the medical 
faculties of^ universities. For tho hospitals to cany out 
these functions properly involves a continual and heavy 
outlay, and if such burdens were not borne in part by 
voluntary subscription the cost w'ould have to he met by 
taxation, in which corporations would have to take their 
part. Ihe success of tho campaign, it was shown, depended 
on tho advance pledges of the banks and corporations. 
Aliiny of tho larger subscriptions were secured on the 
express understanding that at least 3,000,000 dollars would 
bo pledged before the opening of the campaign. It has 
been tho custom for many years to raise funds for the 
hospitals by such campaigns, and it has alw.ays been recog- 
nized that contributions by banks and other organizations 
aro a necessary incident in the business conducted by them 
in the community from which they derive their revenues. 
This particular subscription from the Bank of Montreal 
was not at all disproportionate to its position and the value 
of its business in tlie community', quite apart from the 
fact that the business of the bank, as of other corporations, 
is dependent largely on tho growth and welfare of tho 
city and upon the provision mado for the care of the sick, 
including the employees of the customers and depositors, as 
well as of tho banks themselves. One direct interest of the 
Bank of Montreal in the campaign arose from the fact 
that out of the money collected the bank has already 
received substantial repayments on account of advances 
previously made in the form of overdrafts to the hospitals. 


Scholarships for Tubercilosis Workers. 

As evidence of their continued interest in public health 
tho Sun Life Assurance Company have taken steps to 
provide travelling scholarships for salaried tuberculosis 
workers in Canada. It is recognized by the company that 
the grant which they have so generously given towards 
extra-mural teaching of medicine in Canada (which is 
now being renewed for its third successive year) does not 
reach those engaged in the specialization of tuberculosis. 
They tliereforo have offered thirty travelling scholarships, 
to be given to those named by the Canadian Tuberculosis 
Association. Each candidate will receive 500 dollars from 
the company, provided that a similar amount is added by 
the executive of the association, at the same time grant- 
ing leave of absence u-itli continuance of salary. The 
recipients will travel in England, Prance, and Italy, 
visiting research laboratories and institutions for tho 
tuberculous. Perhaps the activity which it is most desired 
that they should study is the sheltered employment schemes 
in England for the families of the tuberculous, especially 
tho Papwortli colony. • 


The Law Regarding Narcotics. 

Tho stringency of the law in Canada regarding tho 
giving of narcotics is illustrated by a recent case in Ontario. 
It happened that a young doctor just beginning in practice 
gave some ground for suspicion that he was violating tho 
law, and a trap was set for him by ihe detective depart- 
ment. As a result of this he was found to give morphine 
and cocaine in considerable quantities, to be carried away 
by the patient. He was accordingly convicted before a 
police magistrate, who, taking the circumstances into 
account, did no more than fine him 200 dollars. This 
sentence was carried to tho Court of Appeal, which not 
only upheld the judgement, hut found that the sentcnco 
had not been in accord with the requirements of tho law, 
which imperatively required imprisonment. Tho upshot 
was a sentenco of threo months in prison (tho sliortcst 
term allowed). The Canadian Medical Association Journal 
has taken this opportunity to remind the medical pro- 
fession generally of the law on the matter. 


Professo*" J» B. CoIHp* 

The Medical Faculty of McGill University annouiice the 
ppointment to the chair of biochemist^' at McGill of 
•lofessor J. B. Collip, at present on the staff of the 
fniversity of Alberta. Professor Cwllip’s brilliant research 
-ork on tho parathyroid glands is noil known, and tho 



TTNION • dP‘- SOUTH APEIOA. 


370 Mauch 3, i9j8] 




ffrtr Bam»a 
Medical JoiTsvAt 


Alonlrcal Univorsitj’ have reason to be proud that lie has 
been added to tlioir staff. He succeed.s Professor A. Jl. 
Macalhim, who has resigned after a more than usually 
long and brilliant career in toaching and research. 


ITnmit uf Africa. 

[Fjioji oun CoitnKsroNDiaT in Piiktoiiia.] 

Health of Pretoria. 

PnnTOKiA, the administrative ca 2 iital of the Union of 
South Africa, lies in the high veld, and its altitude of 
5,000 foot above sea-level iiresoia’os it from a tropical 
climate. A'orth of Pretoria the land. slopes aivaj’ rajiidly 
tc the low veld, and sub-tropical conditions are soon 
oncountei'cd. I'Jevertholess, sultry conditions aro met 
with in the capital, and in very wet summers malaria is 
liable to occur in the district. The year ended la.st Juno 
was iiarticularly dry, there having been only twenty inches of 
rain — apiiroximately half of the previous year’s rainfall. 
Only twelve cases of malaria were notified in the munici- 
pality during the year; eight of the jiatients had either 
come to Pretoria from elsewhere or had been infected 
outside the area. Of the four locally infected persons 
three lived near the railway lines to Uelagoa Bay and 
Pietershurg, regions in which malaria is prev.alent; the 
train transjioit of infected anophelines is not an imcommon 
event. The rainy se.ason, as elsewhere in the Tran.svaal, 
occurs chiefly in the latter half of the summer, and the 
jiresent year has heon ushered in by very heavy rains. 
Conditions favourable for mosquito-breeding are therefore 
being produced in the di.strict, and the he.alth authorities 
are intensifying the iirevcntivo measures. The oppre.ssive 
summer conditions are not entirelj' duo to latitude. The 
town lies in a valley between parallel ranges of quartaite 
hills running east and west. Air movement is therefore 
much I'cstricted, and the cooling power of the atmosphere 
is considerably less than that of Johannesburg on the 
south, which, in addition to being fieely windswept, is 
located a thousand feet higher on the high veld. Privileged 
houses are rapidh' creeping up the slope of the southern 
range of hills. Here are cooler conditions, and the houses 
have the northern aspect which is so much sought after 
in the southern hemisphere. 

In his annual report for the rear ended June, 1927, the 
medical officer of health draws attention to the very 
satisfactory European vital statistics. The European popu- 
lation, exclusive of the inmates of the central jirison, 
mental hospital, and leper institution, is 42,000, and there 
are 23,000 coloured iiersons — Africans, Eur-.4frican.s, and 
Asiatics. The European death rate was 6.99 per 1,000, 
as coiniiared with 7.7 in the previous year. The death 
rate for the coloured races was 16.0 per 1,000. The 
European infantile mortality rate of 48.48 per 1,000 births 
is the lowest on record for Pretoria ; last year’s figure, 
which was considered to bo very low, was 2.5 higher. The 
non-European infantile mortality rate continues, however, 
to he high — 315 per 1,000 registered births. Excluding 
imiiorted cases the infectious , diseases notified among 
Europeans were: typhoid 67, scarlet fever 25, dijjhtheria 
20, measles 209, whooping-cough 100, other infections 33; 
among non-Europeans: typhoid 26, diphtheria 2, measles 
17 whooping-cough 8, tuberculosis 13, other infections 8. 
The high typhoid incidence among Europeans is partly 
to he attributed to the zeal of the local health authorities 
in searching for hidden cases. This is supported by the 
fact that only two of the Europeans died, whereas of the 
twentv-six natives eight died. These figures suggest that 
most of the European cases, even when comparatively 
mild are notified, whereas the hulk of the milder native 
cases escape notification. In diagnosis blood tests are ex- 
tensively used, and many of the clinically doubtful cases 
were dia<rnosed by a positive complement fixation tost. 
Nevertheffiss, the number of cases is high for modern 
conditions, and protective vaccination was extensively 
employed by Besredk.a’s oral method. Tlie vaccine was 
administered, in all, to 1,497 persons — 545 Europeans and 
952 non-Europeans. ^ The individuals so immunized in- 
cluded 830 persons living in houses from which cases 


Imd boon notified, 296 persons employed in dairies, and 
171 natives ircwly 'engaged by the town council and housed 
in the municipal location. TJiis method of ndministerina 
dead cultures of typhoid bacilli by mouth was found to he 
quite effective, and for preventing the contamination of 
milk by' anihulaiit native patients or intestinal carriers 
the method is considered hy the medical officer of health 
to .ifford raucli greater security than docs periodical blood 
te.stiiig of native emiiloyoes. The chief cause of the loc.!! 
primary outbreaks appears to have been contaminated 
milk, which was jirovod to he responsible for at le.ist 
twoiity'-one cases. The continuance of the conservancy 
system in certain parts of the town is also blamed, and is 
undoubtedly a very important cause of spread of intestinal 
diseases. itli its rapidlj' growing population Pretoria is 
Imviiig some difficulty with its water supply, and schemes 
arc under consideration for its increase. ’ In dry spells 
inhabitants aro not iiermitted to use the municipal 
supply for flower gardens. Slight contamination still 
appears to occur at all the sources; of 161 samples taken 
during the year at the various intakes and reservoirs, 
89 showed li. coll in 20 c.cm. or less. The degree of 
contamination is hardly dangerous, hut it is evident that 
some of the springs arc not snfficiently protected. 


Native Infantile Mortality. 

The lay press is giving jirorainence to the high native 
infantile mortality figures appearing in the recently pnh- 
lislied health reports of the larger Transvaal towns. In 
Pretoria the figure ior all colomed races last year was 315 
per 1,000 registered births. The natives (Bantus or Kaffirs) 
suffered most heavily, their rate being 388.5 per 1,000, 
though this figure is an improvement on that of tlie 
previous vear, which was 483 per 1,000. ’ In Benoni the 
rate is quoted as 847 per 1,000, the number of deaths in 
native infants under l.year in Jannai-y, 1927, being equal 
to the number of births during the month. On the West 
Rand conditions, though bad, are better than on the eastern 
end of the Beef; in Krugorsdorp last year the native 
infantile mortality rate was 320.14 per 1,000 births, hut 
those figures undoubtedly exaggerate the state of affairs. 
Notifie.'ition of native deaths is practically complete, biit 
that of births is very defective. The reason for -this is 
probablv that the native parent is .apprehensive of .addi- 
tional taxation following on admission of increased popid.a- 
tion In these circumstances a death rate stated in terras 
of file number of births is clearly misleading. Still, the 
number of native infant deaths in the larger towns has tor 
manv vears been notoriously high. This is to he attributed 
verv lari^elv to the insanitarj- conditions under which these 
ncople' reside in the towns. In the kr.aals where they lire 
simple if exceedingly primitive, lives the mortality woiilO 
annear to he lower, although accurate figures are unobtain- 
able Mniiv of the children in the towns are the offspring 
of nrostitntes: they are often neglected, and in some cases 
dyberatelv allowed to die. With a large native mao 
impnlation living for twelvemonth periods 
olono the Beef, prostitution is almost unavoidable, ton- 
diuoL are, howev'or, being greatly improved hy the Govern- 
moot’s active policy of removing from urban and industiiai 
areas all native women not officially married either by 
European or Bantu custom, and hy limiting the numheis 
of mLried natives in the towns strictly to those that aio 
reauired for labour purposes. The Natives (Urban Areas) 
Act allows individuals from the native territories to 
in towns only long enough to seek employment If at t e 
»iid of that time employment has not been obtauied the 
native returns to his kraal. By these means it is hoped 
to prevent the further detrihaBzation of the Bantu races. 
ExPoHence has abundantly proved the evil resnlt.s of close 
issSon in slum areas of detrihalized natives and 
Europeans. In the industrial compounds the male native 
s weU looked after, and his health in general is 6"°^^ 
t is when he finds his way into the poorer quaiters o 
he towns and has no fixed employment that the worst ev 
+n Pn.nlrh and morals occur. 


Health Leglslntion. 

In the annual report of the Department of Pnhhc Hc.alW 
)r J A. Mitchell, Chief Health Officer for the Union 
eviews the legislation affecting public health passed dm mg 



BOOTIiAND 


Makch 3, 1928] 


r TheBriti^ 

L MfDICAL JOUBVAI, 


371 


tho last parliamentary session. Certain clauses onlj- of tlio 
Public Health Act Amendment Bill rvero passed ns Act 
No. 56 of 1927. Tlmt dealing with tho alluvial diamond 
diffiiugs makes tho Mining Commissioner, acting under the 
authority and instruotions of tho aiinistcr of Public Health, 
tho local authority. Some direct sanitary supervision of 
■ tho diggings had bocomo an urgent necessity. Supporting 
for often quite long periods a largo population who oro 
content to exist in tho most deplorable huts, sanitation is 
considered to bo of secondary importanco, and tho most 
noisome conditions aro tolerated. Typhoid soon makes its 
appearance, and emergency hospitals liavo to ho constructed. 
Another clause makes provision for periodical visits by 
medical officers to places lacking medical aid, tho cost being 
met out of moneys specially voted by Parliament for tho 
purpose. The unfortunate position of tho small farmer or 
settler in remote localities, often forty or more miles from 
tho nearest doctor, and not infrequently in a malarial area, 
liad' attracted public attention. If his cow or horso 
becomes ill a Government veterinary ofiiecr is available on 

• payment of tho bare transport costs of tho officor ; but if the 
farmer or a member of his family is aifocted tho Govern- 

• ment has in the past given no assistance, and ho has had to 
summon a medical practitioner at ordinary r.atcs — which 
the necessary time and transport rates render ruinous or 
prohibitive if repeated visits aro required. To remedy 
such conditions tho Chief Health Officer advises tho co- 
ordination and unification of local and central administra- 

. tions with control of preventive and curative activities, 
coupled with the cautious and gradual building up of a 
S ate-aided medical sorvico, both preventivo and curative, 
or all members of tho public who wish to avail themselves 
o 1 , beginning with the inhabitants of remote and perhaps 
maarial rural areas, and with school children in both 
urban and rural areas throughout tho Union. Tho clause 
It reads^"^^^™* makes a beginning in this direction. 


medical aid nriv.u*'”® ** satisfied that, owing to lack of 
special circu'm?i^n?»°°^ malaria, or other disease, or other 
in proridinr f"' assislaiico from public funds 

of such area is medical treatment of the inliabitants 

bv pfrliaSen Ar of moneys specially voted 

officer.” “7 .? district surgeon or otlier medical 

with!? ^ bring medical aid 

encourave teacb of tlio inhabitants, but will also 

Sns ®t„irT‘‘““. “'^'•nitaiy or unhealthy con- 
50 certified h ’ personal. Indigent patients, 

will bo tret/ f “ngistrate, will bo treated free ; all others 

travelling 1 ^ ; ''l headquarters, and, wliore special 
charged ^the °“'y tho extra mileage will be 

' andfrom the of travelling to 

fair remuneration to*t/'“‘i' ^ ensuring 

tho neonlo 1 * • 1 doctor, does not tend to panpeiize 

advantages net "F" 

concerned but b ^ inhabitants of tho areas 

. development nL t P™”°ting agricultural aud general 
1 ‘i to tho Union as a whole. 


^rntlanb. 

'iAt a meeting Professors, 

•Universitv of Vu: 1 . Curators of Patronage of the 
Ritchie was oleSd“o®^ Fehruary 23rd, Dr. W. T. 

Professor G. Lnvoii Arntaasor of medicine in succession to 
tfio Edinbureh l Hnlland. Dr. Ritchie was educated at 
. Edinburgh Un “"d graduated 5I.B., C.M. at 

tho post of residon***^^ After graduation he held 

and subsequentlv Physician to the late Sir Janies Affleck, 
Vienna. After h P®.tt®d of post-graduate study at 

and assistant mti ' arious positions as clinical tutor 
'^nvgh, ho beemno Royal Infirmary, 'Edin- 

Buring tho lato ’'^^’^tant physician to this institution. 
Egypt, and for bio ■ “rv«l with the R.A.AI.C. in 
ttio p.B.E. Ho ®®rr‘ccs in this connexion was awarded 
0 author, in collaboration with the 


Clraham Brown, of Medical Diagnosis, a manual 
of clinical methods, and, with Dr. John Cowan of Glas^row, 
of a textbook on Diseases of the Heart. He has also mib- 
I lished niinicrous papers dealing with heart-block, the action 
t of tho vagus nervo on tho heart, the action of the heart in 
health and disease, etc. For some years after the war ho 
acted as a lecturer on the practice of medicine in the 
School of Medicine of the Royal Colleges at Edinburgh, and 
ho at present holds tho position of physician to tho Royal 
Infirmary, Edinburgh, and consulting physician to the 
Deaconess Hospital, Edinburgh. 

At tho same meeting of tlio Curators Professor James 
Kendall, professor of chemisti'y in New York University, 
was elected professor of chemistry at Edinburgh Univer- 
sity in succession to Sir James 'Walker. Professor Kendall 
is an Edinburgh graduate, having taken the degrees of 
M.A. and D.Sc. at Ediiibiirgli. After graduating ho 
engaged in research under Professor Arrhenius at 
Stockholm, and became instructor in chemisti-y in Columbia 
Univei-sitj' at New York in 1913. In 1922 he was appointed 
professor of chomisti-y at this University, aud edited and 
• revised tho textbooks on chemistry of his predecessor. 
Professor Smith. Professor Kendall has published many 
original communications dealing with inorganio and 
pli 3 -sical chemistry, and he was elected a Fellow of the 
Royal Society in 1927. 

Jubilee of the Caledonian Afedical Society. 

The jubilee meeting of the Caledonian Medical Society 
was held at Edinburgh on February 23rd and 24tli. It 
may be recalled that this society traces its beginning to 
February 23rd, 1878, when three Highland undergraduates 
attending Edinburgh University decided to found a society 
with the object of promoting the professional knowledge 
of its members by the consideration and discussion of 
medical and surgical subjects. They were afterwards joined 
by four other enthusiastic Celts, and the seven members 
held weekly meetings at their various rooms for the dis- 
cussion of papers contributed by each member in rotation. 
Most of the original members qualified in 1878, and the 
society remained in abej'ance until 1881, when five of the 
seven original members met in Manchester to reconstitute 
it. The membership was then enlarged to fifteen, and a 
manuscript journal was started which was circulated among 
the members. During the next few' years the number of 
members increased to thirty, and annual meetings were held 
in various parts of England and Scotland. In 1891 it was 
resolved to have the journal printed, and it has now become 
a regular quarterly publication. To-day the society has n 
membership of 500, including Scotsmen scattered over 
Britain and the dependencies beyond the seas. 

Festival Dinner. 

The jubilee proceedings began, on February 23rd, with 
a dinner in the hall of the Royal College of Physicians, 
Edinburgh, at which about 120 members and guests were 
present. The chair was taken by Dr. S. Rutherford 
MacPhail, and Dr. "W. A. Macnaugliton acted as croupier. 
These members, who were two of tho original three 
founders, are joint presidents of the society for this year; 
tho third founder. Dr. Donald Maclennan, died twenty- 
three years ago. The toast of “ Caledonia ” was proposed 
by Lord Alness, Lord Justice Clerk, and that of “ Tho 
Universities and Medical Corporations of Scotland ” by 
Dr. David Rorie. The latter toast was acknowledged by 
Professor H. J. C. Grierson of Edinburgh University, who 
referred to the tie which had alwaj's subsisted between 
medicine aud literature, by Dr. R. A. Fleming, president 
of the Royal College of Physicians, and by Mr. Alexander 
Allies, president of the Royal College of Surgeons. 

The Rev. Dr. Norman Alaclean, Moderator of the General 
Assembly of the Church of Scotland, proposed the toast of 
“ The Caledonian Aledical Society,” and in doing so said 
. that the Church was really the mother of the medical pro- 
fession, which had sprung out of the bosom of the Church 
in the Aliddle Ages, when the churchman and the doctor 
were one person. To-day, ho added, the medical profession 
and the Church were two hands of tho one institution, 
and the '’lory of the medical profes-sion kayln the general 
practitioner. The chairman, replying to this toast, recalled 
the history the society, and said that its 500 members 



372 Makch 3, 1028] 


ENGIiAND AND WALES. ' 


<T '-TnEBRnTi* 
uMer- ’ 


uMEPrcAr JoPB!fii 




to-day liad more amljition limn lliose of .most oilier inodieiil 
societies because they bad a special patriotic side to 
presorve— the medical' aspeot of Celtic tradition, Celtic 
litoraUiro, and Celtic follciore, wliioU were in dan.ner of 
Xiassing into oblivion. The toast of “The Cno.vts ” was 
jiroposed by I)r. C. hi. Douglas and acl;nmvlcdgod by the 
Dev. Dr. J, Harry Miller, C.B.K., Afodorator-KIcct of the 
General Assembly of the IJiiitcd Free Church of Scotland. 

Aiiimol Meeting. 

The annual meeting of the society vas held on FebriiaiT 
S4tli in the hall of tlio Itoyal College of Surgeons, Kdin- 
burgh, ivlicn Dr. W. A. Macnaughtou gave a pre.sidenti.al 
address in which ho referred to some of tho changes which 
had taken place in medical life and medical knowledge and 
jn'actice since 1878, when all the medicid classes wore 
taught within the walls of tho old Thiivcrsity, for the new 
medical school had not yet arisen. Speaking of the cost of 
living in 1878, ho said that nliilo 35.s. a week was regarded 
as tho average expenditure of a .student for lioard and 
lodging, ho himself had shared a room with a fellow .student 
who bec.aino ono of the best prnetitioner.s in the North, 
and their landlady’s weekly bill seldom exceeded one-third 
of this figure. Modest as these figures were compai’od with 
X>veEcnt-day charges, ho had been assured by an Aberdeen 
graduate of tho same period that his weekly bill, eked out 
by ’-Ggular parcels from homo, seldom exceeded 6s. The 
medical classes a-* ’ '■ > seventies included a 

lai'ger jiroportioi i : than they did now, 

Iloferring to the ■ sendees in the High- 

lands and Islands, he .said that a groat change had taken 
place sinco 1878 with respect to medical attendance and 
skilled nursing wdtliin tho Highland area. The central 
feature of tho scheme, which had boon introduced in 1912, 
was that no iiatient, however far he might bo from tho 
doctor’s residence, should pay more than Ss. for a first visit 
and 3s. 6d. for a subsequent visit in the same illness, the 
mileage for snnh visits being payable out of a central fund 
subsidised by tlio Government. This was a groat concession 
to the struggling crofter who lived in .some Highland glen 
twenty miles from the nearest doctor. To the doctor the 
advantages of the scliomo were that his payment was 
assured, althongli he had probably far more travelling and 
less leisure now than in the past. Highly qualified 
surgeon-consultants bad been established in such jilneos 
as .Stornoway and Lenvick, where local ho.sjiital facilities 
were available,' and before long a system of other 
specialized services would bo introduced. The last fifty 
ycai-s bad also witnessed the e.stablishinent, by local 
endeavour, of a large number of cottage hospitals in 
various parts of the Highlands, and no doubt the useful- 
ness of these could be still further extended if tliey wore 
linked up with a general hospital such as tliat at Inver- 
.ness. In the near future, too, every jiarish, botli on the 
mainland and in tho Hebrides, would enjoy the advantages 
. of the services of a duly trained nurse. 

Jiccepfion by ihc Vnieersify. 

In the afternoon a reception was given by the Univer- 
sity of Edinburgh to the society. Pi-incijial Sir Alfred 
Ewing received the guests in the Upper Library Hall in 
the Old College, and, in an address of welcome, referred 
to'tbe jubilee of the societj- as a remarkable attribute to 
.the efficiency with which it had fulfilled its intended 
objects. A ' number of niedic.al manuscripts and early 
printed hooks, referring chiefly to Scotli.sb medicine, were 
on exhibition in the ball, and an address dealing with 
~ these was delivered'by Dr. John D. Comrie. Dr. Comrie’s 
survey included Michael Scot’s book- on physiognomy, of 
•which no fewer than eighteen editions had apiiearcd 
• between the early printed copy of 1477 and the year 1660. 
From 1400 onwards there bad been a copious Gaelic 
medical literature in Scotland belonging to the medical 
'attendants of the Highland chieftains, usually members of 
the families of Macbeth or Maeonnaehcr. Tliese sliow^ 
that the Higblnnd physicians were well-educated men, with 
a knowledge of Latin, who had travelled abroad Defer- 
cnco was also made to a ififtcentli ccntiuy Lo'uland Scottish 
practitioner, 'William Sclicvoz, who amassed at St. Andrews 
a notable collection of boohs, and who was foi* many years 
. physician to James HI. Several Latin translations of 


Galen iiiul other ancient writers were also shown, as ivcll 
as more recent niannscripts, iiicliidiiig a small hnok 
bearing the title .4nc Glide Jhhc of Medieines Called the 
frensMTie of Poore Men, Jo!)5, which was trpica! of tlio 
medical treatises upon wliieli the Scottish doctors relied 
nftor ihoinflnonco of tlic Church, wiUi its monastic libraries; 
had jinssod aw.ay. A copv of tho Piseonrae on the Whole 
.in of Chynirgcric by Peter Loire, irlio, in 1597, w.ss the 
first .Scottisli writer on surgerj', was also exhibited. 

■ Qlasgow Royal Infirmary, 

The 133rd annual meeting of the Glasgow Koval 
Infirmary was bold on Febniary 13t)i in the Merclian'ts’ 
House, Gla.sgow. Lord Provo.st Mason presided, and 
referred to tlic iiecc.ssity which at present e.xisted of 
obtaining added subscriptions to meet the inoro.ased 
activity of llio institution. jMr. James Macfariniie, IL.D., 
chairman of tlio. managers, referred to • the proposed 
auxiliary lios|)ital and nursing homo at Cannicsburn, and 
said that tho managers were iraitiiig till they liad collected 
a sum of between £50,000 and £60,000 before proceeding 
rvitli the building. Up to the present £45,000 had been 
received or promi.scd spontniieonsly, and the managers now 
felt that the new scheme might lie begun. The managers 
felt some anxiety about meeting the cost of inainteiiaiico 
at the infinnary, as the rejiort showed this had been 
steadily increasing, and when the new extension was set 
up the cost would bo still further augmented. He was 
confident, however, that the jmblic of Glasgow would pro- 
vide tlio necessary funds. Tlio report shows that in tlie 
year 1927 the number of persons who received treatment 
at tho infinnary was 82,852, a figure wliich represented 
8,7.33 persons in cxces,? of those who received treatment 
during tlie previous year. On the financial side there was 
a shortage . over the year’s working of £12,896. The 
ordinarv expenditure amounted to £119,464, while th« 
average’ cost of each patient under treatment irns 
£7 4s77id., ns compared with £7 16s. 9td. for the previous 
year, . _ 

(ittglstti attti Maks. 

, Atental Deficiency Act, 1927 - _ 

Tnr Board of Control has issued a pamphlet 
7021 dr.iwiiw the attention of local authorities to the 
nrovisbim of the Mental Deficiency Act. 1927 This Act 
removes certain defects in the pnneip.nl Act (the Mental 
DZciency Act of 1913), and also enlarges the power,^ and 
to Line extent the duties, of the local anthonties. Under 
the nriucipnl Act tho condition of mental defectiveness u as 
defi, ed as one which must have existed “ from birth or 
from an early age.’’ Under the new Act mental defective- 
nestis defined L “a coudition of arrested or incomplete 
m aimiment of mind existing before the age of 18 years, 
wlmHier arising from inherent causes or induced by disease 
• 'iivv " The altered definition allows, therefore, cases 
of miiital' defect arising from encephalitis lethargica to bo 
deair dtb under the Act. Indeed, it was the large number 
.,1 aaaps throughout the country that led to the icpeal 
of the* definition of mental defectiveness as stated i" t m 
A„t- The need for providing suitable accommo- 
'I’aimTfor sr eh posueucephalitic cases was urgent. Thc.o 

ir Z- no to their being certified as 

i- iw flpfoctive and so trained and cared foi. Tn 
"uS bfti'tifiabihty, except in tl-e case of foebh. 
m nded children, is whether the individual is so mentadj 
defective that ho requires care, supervision, and control. 

Cancer Research in Birmingham, 
w IIo-vvItict the favourable reports from Liverpod on t m 

Leatmen 6 -ivorkers, a subcommittee w.ns 

TO-U. rfiiu amraWw °'7riima'u«Vu« 

accommodation was obtained, since it The 

treatment could not safely be given to 1927 

report of the committee on tho work accomplished m 



MARRH 3.' 'O’"®] 


EKGLAKD AND' WADES. 


373 


[ 


Jrre Br.msa 
Medicad Jocskal 


has ROW been published .n the Febrnnry issuo of tho 
mrmhgham Medical Itcvicw 'J ho .n.mber of eases of. 
mali-^nant disease treated witli lend was tliirty-fouv; mno- 
tcen°of the patients were women and fifteen men. Iho 
nreparations used were colloidal lend in.twcntj--thrco cases, 
lead glTcine in eight, and both preparations in two eases. 
The lemaining patient received an injeetion of colloidal lead 
prepared in the hospital laboratory with gum arabic. Tho 
questions of toxicity and tho too rapid decomposition of 
the lead preparation were carefully studied, and a colloidal 
lead phosphate was found to bo most suitable, though lead 
glycine proved to bo markedly Ic.ss toxic. Tlic committee 
concludes that, since ten of the thirty-four patients derived 
benefit, lead treatment has a distinct therapeutic value, 
and deseives further investigation. In view of tho very 
small quantities of lead found in tho tumours examined the 
committee doubts whether Blair Bell’s original hypothesis 
of a specific affinity of cancer tissue for lend can ho upheld. 
It is thought more likely that tho action of this metal is 
indirect, and that two explanations are possible ; (1) that 
lead injections stimulate the production of some active 
body in the serum, liver, or elsewhere ; (2) that colloidal 
lead or lead salts, by tl.cir conversion to phosphate after 
injection, must render some of the phosphate of tho blood 
unavailable in its usual form — nuclein synthesis, a 
necessary accompaniment of growth, might thus bo effected. 
It is added that there is reason to believe that the main 
therapei;t!c value of lead lies in its ability' to restrain 
nietastasis or to destroy small ami recent growth deposits. 
A\ith the exception of one case of sarcoma in bone, no 
benefit was obtained by any patient who bad a largo 
malignant mass. It is thought that tho most profitable 
lesults will be obtained by treating patients who have under- 
gone palliative incomploto operations, cither by surgerv 
or radiation. o >? . 

Supervisory Cert-es for >• Rheumatic ” Children, 
he Ldncafion Comraitfeo of the London County Council 
nkia ' ri®"; “"s'Jeratioa a resolution from the Invalid 
Association asking that tho school medical 
rliilhr closer touch with elemoutary school 

•e iddren who are. rheumatic ” and marked for observa- 
iindor - honimitteo records what has already been done 
niade recently by tho jletropolitan 

07een «« set apart at 

children c. ^ Corshalton, and elsewhere for 

chorea TTn t heart disease, and 

admitted undo” children had been 

received an t 'f ®theme, but 535 nominations had been 
Queen 31a, Vs v' i Pr^^sed forward at 

eliildren at places for rheumatic 

failed to obta i d’’ 9‘”'dhcu who have hitherto 
are being assiduousir'f' M accommodation 

seiTice and hv +i ^ up by tho school medical 

with the medha V''''®®‘‘V‘‘’" Co-operation 

also been cst.ablislieT’^^ horonghs has 

rheum.atism in children ^ansnigton and Paddington 
and in cases "-hnr made a notifiable disease, 

with under the srbnm! rheumatic cliild, dealt 

etiology of the di „ ®’ to have a hearing on tho 

with a view to imnr''^*-’ ^ '® medical officer is informed, 
child returns from rl f be home conditions before tho 

is of opuiion tliat i ' hospital. The committee 

along .oj; ([,(, ,.l ■ ° °ndon some progress has been made 
authorities sumnnr;,^ i 1®® action for local education 
Sir George Newman in 27ie 
special atientioii to are paving 

been established sch a register of cases has 

and residential’ lining carried out, 
eases is being ornoniV ^“nation for acute and subacute 
the development’" of " 'at is now chiefly required is 
which parents rniwlit n ’.n''n’atisra supervisory centres to 
requiring obseiyntlnn inspected children or children 

gn'en upon manao-pmor,*’^® ®F®'* eentres advice would bo 
detected, suggestine- tl ’ ^nst symptoms would be 

Three rheumatism sur,'" necessity for special measures, 
established in 3yps(- T pill centres hav-e already been 
'’ene, and Kensington Paddington, Alarvle- 

no attempt should hn" rp i® aenimittee is of opinion that 
ade to organize such centres as 


nd. hoc institutions, hiit that they should bo formed in 
natural relation with tho other remedial activities at 
hospitals and treatment centres already provided under the 
council’s scheme. It is also thought that it would be 
advantageous to have some expcrienco on a limited scale 
before a complete scheme is devised, and endeavours are 
therefore to ho made during the coming year to organize 
five sucli centres on oxiiorimcntal lines— two in North-east 
and East London, to bo formed at hospitals (for which 
purpose tho Queen’s and tho London Hospitals appear to 
bo tho most suitable), and three in South London in asso- 
ciation with treatment centres. Tho two hospitals to he 
invited to co-oporate will receive a grant of £1C0 a year, 
and tho authorities of the centres will be given increased 
provision for medical, nursing, and organizing assistance. 
Tho general administration of tho arrangements for 
rliouniatic children will be in the hands of one of the 
assistant medical officers of the public health department. 

District Nursing in London. 

At tho annual meeting of the Central Council for District 
Nursing in Loudon on February 23rd, under the presidency 
of Sir AVilliam J. Collins, the principal matter brought up 
on tlio report of the executive committee was the recent 
change of policy on the part of the Aletropolitan Asylums 
Board with regard to scarlet fever and measles. Until 
lately the Board’s hospitals were available for all scarlet 
fever patients requiring admission, but only' a limited 
mimber of measles patients were received when accommo- 
dation was available. In view of tho decline in the severity 
of scarlet fever, however, and of tho fact that tho death 
rate from measles in London is now six times as great 
as that fi'om scarlet fever, greater facilities have been 
afforded by .the Board for the treatment of measles, and 
the beds for scarlet fever jiatients have been restricted. 
After a oonfereiice with medical officers of health of the 
metropolitan boroughs and others, the executive of tho 
Central Council lias come to the conclusion that the homo 
nursing of scarlet fever can bo undertaken with careful 
precautions, provided that the nurse is not in attendance 
on any maternity case. A reminder was given, moreover, 
that a similar conference had been held some vears ago to 
discuss the nursing of measles, which was subsequently 
undertaken by the district nursing associations without 
any complaint being made of transference of infection. 
Tho view of the council that scarlet fever nursing could 
he thus arranged has been communicated to the affiliated 
associations. It was also reported to, fhe meeting that 
efforts were being made to establish a district nursing 
service in those parts of the Greater London area within 
tho county of Aliddlesex whicli had hitherto been without 
such provision. The Rev. J. Scott Liclgett announced that 
certain midwifery training bursaries, to wliicli the trustees 
of the London parochial charities made grants, were greatly 
v.aluod, eagerly taken up, and usefully employed. It may 
he added that the function of the Council is to assemble 
the various religious, pliilanthropic, and official interests 
ii' tho systematization of arrangements for district nursing 
throughout tiio metropolis, and to promote its adequacy 
and efficiency. 

Courses in Psychology at the Ataudsley Hospital. 

A new series of lectures and practical courses of instruc- 
tion for the diploma in psychological medicine will com- 
jiienco at tho Alandsley Hospit.al, Denmark Hill, S.E.5, 
on Alarch 6th, at 2.30 p.ni., when Dr. F. C. Shrubsall will 
give the first of six lectures on the practical aspect of 
mental deficiency; they will be continued on succeeding 
Tuesdays, with the exception of April 10th. A course 
of eight lectures on morbid psychology by Dr. E. Alapothcr 
will be given on Wednesdaj's at 2.30 and 4 p.m., from 
Alarch 7tli. Dr. A. A. W. Petrie will deliver three lectures 
on therapeutics on Tuesdays at 4 p.ni., beginning on 
Alarch 20tli. 3Ir. R. Foster Aloore will lecture on abnor- 
malities of tho fundus oculi on April 16th and 23id at 

2.30 p.m. The first of a course of eight lectures by Dr. 
Bernard Hart on the psychoneuroses will he given on 
April 30th, and continued on succeeding Mondays, at 3 and 

4.30 p.m. Dr. 3V. Norwood East will deliver four lectures 
on crime and insanity on Jfay 1st and the three following 
Tuesdaj-s at 3 p.m., and Dr. F. L. Golla will give four 



874 March 3 , 1928 ] 


lEEH/AND. 


r Tirr Cnmnt 
r. L ilxpicAx. Joma 


lectures on tho pathology of inontnl diseases at 2.30 p.m. 
on Fridays, commencing May 4tli, and followed by four 
demonstrations of the pathologj- of tho central iicn’oiia 
system by Mr. Charles Geary. Three leeturea on 
the legal lolatioii of insanity and treatment will bo 
delivered by Dr. C. Hubert Bond on Fridays, May 
4tli and 18tli, and Tuc.sday, Maj- 15th, at 4.30 p.m. 
Six donionstratious in clinical psychiatry will be given by 
Dr. E. Mapother on Wednesday’s at 2.30 p.m., commencing 
on April 18th. Dr. F. M. R. AValsho ■a'ill commcnco a 
series of six clinical demonstrations in neurology on Thurs- 
day, March 8th, at the A^ational Hospital, AV.C.l, at 
2.30 p.m. On Tliursday, April 19th, at 3 jnin., tho first 
of a .series of six demonstrations in neurology by Dr. Golla 
will be given at the Hospital for Paralysis and Epilepsy, 
Maida Vale, W. The fee for the whole course is £10 10s. 
In addition to the special lectures and demonstrations of 
the course opportunity is provided for clinical work at 
the Maudsley Hospital. A certain number of whole- or 
part-time clinical assistantships are also tenable. Further 
information about the courses may be obtained from the 
Director of the Central Pathological Laboratoi'y, Maudsley 
Hospital, Denmark Hill, S.E.5. 


irclantr. 


National Health Commission (Irish Free State) : Payment 
for Atedical Certification. 

Aiiisixo out of tho request of the deputation from the 
Irish Medical Committee to tho National Health Com- 
mission for further information with regard tq tho decision 
of the Commissioners to change the area of tho pool for 
payment fi’om tho dispensary district to tho county, tho 
Commissioners have supplied a largo amount of tabulated 
information. In an accompanying iottor it is stated : 

As explained at liie conference the Commissioners have decided 
that they would not be justified in continuing to use the dis- 
pensary area, as a basis for calculating tlie payments for medical 
certification for the following reasons : (1) As wiil bo seen from 
the figures in the statements enclosed, the results are obviously 
unsatisfactory. In the area whore tlie capitation rate is Zs. 8 d. 
the rates per certificate vary from £I to Sfd. in the March 
quarter. In the area where the capitation rate is 2s. 1 . 6 d. tho 
rates per certificate vary from 10s. IJd. to Zid. in tho Juno 
quarter.^ (2) Apart from the financial results shown above, the 
system is unsatisfactory owing to the fact tliat it is not possible 
to obtain accurate figures of tho number of insured persons in 
the dispensary^ areas without incurring expenso wiiich would be 
very much higher than the results obtained would j.istify. 
(3) The calculations on tlie dispensary basis entail mucb work 
and expense m the department, and it is not possible lo defend 
the _ continuance of expenditure on a sclieme which produces such 
obviously inequitable results. The Commissioners therefore pro- 
pose that the scheme must be altered, and lliat in future the unit 
on which calculations will be based shall be cither (a) the 
administrative county area, or, alternatively, (b) the area in wliich 
the capitation rate is uniform. 

Dr. Power, chairman of the Irish Medical Committee, in 
a letter to the Local Medical Committees urging the 
retention of the dispensary district as the vinit for the 
pool, states that the dispensary medical officer in rural 
areas treats almost all insured persons, and is therefoi-o 
in a position to prevent malingering and unnecessary 
demands on the societies’ funds, at the same time pro- 
tecting his interest in the dispensary pool. Though this 
does not apply so freely to towns, it is yet a very im- 
portant and s.ahitary factor. Dr. Pow^r remarks that 
excessive ceitification on a dispensaiy basis can militate 
only against the interests of those in a small area, and 
could Sisily ho checked if the Commissioners brought the 
fact to the notice of the societies operating in the district 
and to the notice of the Local Medical Committee of the 
countv However, if those w'ho certify in excess are 
allowed to go on they will operate only against tlieir own 
pool Ficures have been presented showing that there has 
been an fnerease in the number of certfficates issued year 
bv year for some time past. The societies also complain 
that as a result the demands on their funds are becoming 
proportionately heavy. Dr. Power agrees that there are 
reasons whv this might he so, hut he thinks that the dis- 
crepaucy betiveeu the cost of certificates in different areas 


ill the same county cannot bo attributable entirely to the 
iiioMcmo of disease, or to the properly growing insistcuco 
by insured persons on tbeir rights. Ho suggests that the 
causes of cheap certification should bo investigated in tho 
areas in which it occurs by the Commissioners (who aro 
cognizant of the localities) and tho societies, so as to 
discover tho real state of affairs, and apply a remedy if 
necessary. Tho certificate values referred to by Dr. Power 
are from figures supplied by the Insurance Commission, 
and be gives au instance of a county whore Dr. H. (tho 
highest) gets 3s, per certificate, Dr. L. (tho lowest) gets Sd. 
per certificate. The contributions from 414 persons make 
a certification pool of £50. Now, H. at 3s. per certificate 
issues 333 certificates annually in respect of 414 insured 
persons to got that amount, while L. at 5d. per certificate 
(in his area) to got that amount must issue 2,400. Tin's I3 
a matter for immediate investigation by tho societies. 
According to Dr. Power the county pool idea is not a 
remedy; it would, if adopted, make things much worse. 
Thus H. is awarded 3s. ])er certificate in his district and 
L. is awarded Sd. per certificate in his district; the county 
b.asis is OJd. Now (he continues) let H. and L., each 
having issued certificates in respect of 414 insured persons, 
and therefore drawing £50 each from their respective 
district, make a common pool equal to £100, and now rc- 
withdraw it on the county basis of 9Jd. As it is assumed 
in the Commis.sioncrs’ circular, each one will issue the 
.same number of certificates as heretofore, the ratio of 
certification being H. — 1, L. — 7.2. In this £100 pool the 
portion of H. is reduce.d to £12 4s., and his loss equals 
£37 16s., while the share of L. becomes £87 l6s., with .a 
gain of £37 I6s. AVhere H. got £50 for adequately certify- 
ing 414 insured persons each year he now gets £12 4s. for 
tho same service; and whore L. certified a similar number 
for £60 ho now gets £87 16s. for tlio same service. A 
distribution on those lines is the inevitable result oi t™ 
adoption of a county scheme. Dr. Power asks: Could the 
medical profession as a whole support such a grossly unm'h 
nroposal? Does it not tend to demoralize those talcing 
part in it? Docs it not offer temptation to increase still 
further tho number of certificates each year, and is wpt 
fair to the societies? Tho cost and diffionlties of 
tration aro tho only objections to dispensary pools winch 
bare anv substance, and when the Commissioners, limit 
themselrw to those points, Dr. Power wmiild 1”'®?"®'^ 
to adviso his colleagues to go into the matter with them. 




R4STB1C SECRETION OF NEUTRAL CHLORIDE, 
In -In reply to tho letter of Dr. Gordon W. Goodhart 
linb’ anneared in your issue of Fchriiary 25th (p. 325) 
ould Hke to state that the evidence which he so muc 
sires has already been fully communicated to Gm J"® ' 
fs of the Biochemical Society at their meeting held as 

Corrected prooS'^of’ two papers dealing with this work 
been returned to the editors of the 
'l,;n/onv some little time ago, and presumably these 

nerallv ohserved among scientific men, of, imt 
rsonal letter before rushing into print. 

Sart written to me directly I would have f 

rnished him with a copy of the 

ler infonnation I could give him on this su J 

b TTroTT MicLeax. 


MARCII 3 , 1528 ] 


CORRESPONDENCE. 


r The British 
L ilCDICAl. JoCBKAli 


375 


. ...dysphagia ASSOCIATED. AVITH AXAEJIIA.’.'' : 

Siii _ln tlicii- iin'portnrit paper 011 dysiiliagiii absoeiatctl 
ivith-anacffiia, published in the Jouii.vAi, of Eobniary IStli 
(n 256), Mr. A. Mason Jones' and Jlr. Robert D. Owon 
refer to a case reported by mo in the 6 ’h;/’s IlospiUil 
■Hepods for October, 1S26. I called llio condition tho 
Plumnier-Vinsan syndrome,” as I u as not then awaro 
0 ! Uk earlier work of Drown Kelly and Paterson on tlio 
subject. .. These authors, however, did not mention .splono- 
me'ailv, and gave no details of tlic nature of tlio anaemia 
pidoiit, but they describe in detail tho glossitis, ^ which 
.appears to have been overlooked by Plumn'cr and Vinson. 
In all of the four cases I have now seen, and in the ono 
described bv Dr. J. A. Ryle in tho Guy’s Jlos])it<il Itcports 
for JainiaiT, 1£27, tho characteristic dysphagia was a.-so- 
ciated with’ glossitis, non-Addisouiaii nnneniia, and spleno- 
megaly. 

It is clear that tho dysphagia is not. caused by any 
gross organic disease, but there is no evidence in favour 
of Phnnnier and Vinson’s vica- that it is hysterical in 
origin. Tho theory that it is duo to reflex .spasm, which 
was first suggested by Drown Kelly and Paterson, and 
which has been followed by Jlason Jonc.s and Onen, has 
much to bo said for it; but, although I adopted it in my 
paper on the subject, I am now inclined to tliink that any 
spasm which is present is secondary, the primary cause 
being achalasia of tlio pharyngo-ocsophageal sphincter 
of. Aegus, the condition being exactly analogous with 
achalasia of the cardiac sphincter, which was formerly 
erroneously described as cardiospasm. Achalasia of tho 
cardia has now boon proved, by tho pathological investiga- 
tions of Stakes and Rake' to be due to inflammatory and de- 
generative changes in Auerbach’s plexus, which prevent tho 
normal relaxation of the sphincter wlfen it is reached by 
peristaltic waves carrying food down the oesophagus. If 
similar changes werq present in Auerbach’s plexus at tho 
upper sphincter, relaxation at the beginning of the act 
0 dcglutination would lie prevented. Such changes could 
ready bo caused by a direct spread of inflammation from 

no mucous membrane to the deepcr-lving iilexus. There 
1 ° -c the atropliic glossitis and iiliaryngo- 

these cases is a result of a strepto- 
nurt , wWch is also responsible for the anaemia 

oesonlif! ^Romegaly Dilatation of the closed pliaryngo- 
mercnri^'f 1 relief, just as the passage of a 

of tlm ^ 'i- ° most effectual treatment of achalasia 
at the cardia.— I am, etc.. 


Kew Lodge Clinic, Windsor 


Forest, Feb. 22nd. 


AnxHUR F. Hurst. 


TUBERCUL: 

last tliirfvtT througbout the course of 

Koch o^mf the first announcement 

develonment agent which would prevent 

coiisistentlv vie- i * Kritish AIedic.al JonitN.tn 
fairly and bnnnf^i reviewed tho available evid. 
iotemst and ' •'j struck by the susta: 

out this long nerh!d^ JR'Jgemont brought to bear, throi 
variations of onininn oL" ^1'® g''?® 

of overj- description P''®j“ 

reports avaiiaMn*°*^*”F critical examination of 
.-k. so d®!®. it still remains for yoi 

of Taluei the ?•’ “ T® "'bat extent is’tu 

losis? ” and tr. “’asnosis and treatment of tube 

ore with'odt guidnncl^ " practitioners feci that 
conditions under \,.i • 1”^ k'm eases in wbicli, and 
to which tliev are value; guidi 

mcnl by tuberculin ■ i ™®re, since systematic ti 
osperionce of its ™®‘ii®Ri ' 

a thoroueb re guidance asked for dem; 

™Mcct; fhat L to^e 

aad results of coses “ 'fivivestigatinn into tbo.co 
ii»a l conclusions ’f. ®®®®rdance with Kc 

p;— l!l!!lijl^^£_£i^ons. Discarding the 


“r « Uospuai SepcTU^ Ixxvii, 141, 1927. 


limiiiary. conceptions of 1890, -except- in relation Jo di.ai 
gnosis, such a rc-examination would involve an inquiry 
into tho action of T.R. (1897) and B.E. (1901) in .such 
c.ases, and .with the observance of such directions, as Koch 
liimsclf laid down, undertaken after a thorough and 
minute oxaininatioii of and acquaintance with the whole 
of Koch’s work 011 the subject. Extraordinary as it may 
apjroar , adequate clinical examination of Koch’s impoidant 
woi'k on this subject has not yet been accomplished; 
certainly it has not been accomplished to such purpose as 
to carry conviction to medical opinion in general, though 
one may note your opinion, stated in 1911, that “ already 
results wore accumulating which should convince everyone 
but the incurable sceptic.” 

Tho recent revival of a former ideal of the Britisli 
Alodical Association — namely, the direction of the collective 
scientific acumen of its members towards the solution of 
important medical questions — together with the failure of 
other bodies to deal adequately with the subject, induces 
me to appeal to the Association to undertake this impoiTant 
work itself. There is sufficient individual initiative and 
knowledge to set on foot here and there, in this Division 
or that, colloetivo research upon a sufficient number of 
suitable cases, under suitable conditions, for a sufficient 
Icngtii of time, and under the scrutiny of competent 
observers, .and so to furnish, or assist m furnishing, within 
a few years, some satisfying answer to the urgent and 
insistent questions which are now being asked. 

In this case collective investigation might well begin aith 
tho Divisions themselves, leaving collation and co-ordination 
to develop from a natural tendency to correlate the work 
as it progresses. No rigid uniformity of procedure need 
ho insisted upon ; tho issue is a fairly simple one. It is to 
demonstrate the effect of rapidly increasing doses of T.R. 
or B.E., administered in accordance with Koch’s methods, 
in simple, early, uncomplicated cases of tuberculosis, espe- 
cially such as present lesions whoso jjrogress is capable of 
being watched by actual inspection. 

Tho obstacles in tlie way of private investigation are 
almost insuperable, owing to the impossibility of inducing 
a sufficient number of suitable cases to undergo a long 
tedious course of treatment, often at tlie mercy of eveiy 
idle opinion. In collective investigation there would bo 
scope for a selection of suitable cases from a wide field, 
observation by trained observers, and the building up of a 
solid body of common knowledge and instructed opinion, 
with aU the weight which such a settled body of opinion 
would exercise. 

Judging from considerable experience, I have very littio 
doubt as to what the verdict would he, and if this im- 
portant woi'k is to bo retained to any extent in tlie hands 
of the general practitioner, instead of those of the specialist 
o." State official, tho method here advocated would form 
an invaluable means of diffusing knowledge on a line of 
work which is far removed from ordinary methods of 
practice. 

In any case, the present range of applicability of tuber- 
culin is already wide, the possibilities of the subject are 
of universal importance, and furtlier demonstration and 
research are of extreme urgency. — I am, etc., 

Wandsworth, Feb. 23rd. Robert CaRSAVELI,. 


SHOCK AND ABORTION. 

Sib, — One kind of shock referred to by Mr. Paramorc in 
his interesting letter in your columns to-day (p. 327) 
appears to be that which Broiiardel in his lectures (trans- 
lated under the name of Death anil Siuhlen Death) calls 
inhibition. 

There is no doubt that death by inhibition is intimately 
related to the mental state of tho patient at the time of 
the reception of the trauma, whatever it may be. Equally 
. — or perhaps it is reallj' the same thing differently stated 
death by inhibition is particularly likely to occur in con- 
nexion with injui-y or offence to particular organs or 
regions. Again, personal idiosyncrasies and vaiietics of 
constitution have to be borne in mind. But one"^s more 
and more convinced of the pai amount importance of tho 
patient’s psychological state at the moment of the trauma. 
Fear shame, and the like count for numh; the unexpected- 
ness’ ol a trauma counts for much; and, singularly but 



COREESPONDENOE. 


376 March 3, 1928] 


[ 


Tffz Bums* 
SIrdical Jocmyii 


indisputably, lie or she vlio is “ keyed np,” to receive an 
if'jRi'y lesion that is feared and dreaded irithout 
(Visplaying emotion in the ordinary way, is very likely to 
suffer from inhibition. Again, associations come into play. 
I know once a very bravo and gallant soldier who fainted 
to disappearance of bis pulse whenever an attempt rvas 
made to vaccinate him. Tliero bad becii 'distre.ssing circniii- 
stances attendant on bis first vaccination. 

Some discussion on those and other aspects of the qne.s- 
tion of shock (inchiding that of delayed shock) took place 
at a meeting of the Aledico-Legal Society in, I think, 
1913, and is duly recorded in tlio Tratisncfions of that 
body. — 1 am, etc., 

Loncicin, W., Fel). 25t!i. F. G. CnoOKSHANR. 


MEDICAL EXAMINATIONS FOR LIFE 
ASSURANCE. 

Sin, — The more cases one examinc.s for life insurance 
the more one becomes convinced that the medical profo.ssion, 
as a whole, nnncce.ssarily wastes probably thousands of 
hours per annum which, with a little help from the insur- 
ance companies, cmdd be easily avoided. 

Everyone who doc.s this work must have been struck by 
the difficulty that practically all proposers for life insur- 
ance have in answering questions concerning family history. 
To be asked .suddenly to give the age of father, mother, 
and perhaps several sisters and brothers, when these are 
living, is often a question requiring time for thought. 
'When, however, several of these pcoiilo have been dead 
many years it becomes increasingly difficult to answer 
correctly their age at death, the year of death, and what 
preciselj' was the cause of death. 

Some companies realize this difficulty and forward these 
details on a printed form, which the piopo.ser has had 
lime to consider previously, thus saving, in .some ease.s, 
Ave to ten minutes’ concentrated thinking and arithmetic 
in the examiner’s consulting room, with a possible negative 
result. 

Tlie other factor which leads to. waste of. time is- the., 
-Jack of knowledge on the 'proposer’s part that lie' will have 
to pass a .specimen of his urine in the presence of the 
i examiner. My experience is that the last act of almost 
‘everyone before presenting himself for medical examination 
- is to empty the bladder, so that if he should be able to pass 
urine there is rarely enough to take the specific, gravity 
„ .without dilution. I have found that the companies for 
, whom one examines manj' cases arc quite willing to have 
the family histoiw details sent with the proposal papers, 

.. or with the medical examiner’s form. It is the siioradic 
..xases which take up so much of one’s time. 

• ■ To overcome these annoyances would be an easy under- j 
taking for the Ceutral Office of the British Medical 
Association, and 1 feel that the profession would be deeply 
obliged to them for doing so. The insurance companies, 

I am convinced, would be willing to help. All that would 
be necessaiy is an undertaking on the part of each company 
to provide the proposer witli a copy of the family liistory 
details, to be filled in before coming for examination, 

■ and to toll luin that ho will need to provide a specimen 

■ of m ine, passed- in the presence of the examiner. AVomen 
would bo told to take a specimen in a bottle. — I am, etc., 

AA’. M. Robsox, M.D., F.R.C.P. 

Northampton, Feb. 20th. 


SPECIALIST PUBLIC HE.ALTH SERA’ICES. 

Sii, A’our leader in the Jonnx.Ai. of Febrnary 11th 

{p. 228) commends the appointment of district medical 
officers of health who are also school medical officers, 
maternity and child welfare officers, and tuberculosis officers 
under the countv council (so-called omnibus appointments). 
AA’hile wo all befieve it is an' advantage to the service that 
these officers should be under the county councils, and 
recognize that the appointment provides, as you suggest, 
air escape from tlie backwaters of the health service,” 
Ihcro is yet another, aspect -of the matter, • where- 'tuber- , 


culosis is concerned, winch deserves attention. Such at 
officer would almost essentially ho a junior, and withoF 
much clinical knowledge of tuberculosis. To diagnosi 
and ahovo all to adviso as, to tlie treatment of tiihcrculosi 
nMe.s.sitate.s prolonged, e.xperionco and training, and a iiiai 
of less capacity could not inspire the confidence of tin 
general - practitioner,- without which the tuberculosis cam 
paigii IS almost impossible; most of the . practitioner 
coiiccincd ■i^oiiUl bo more competent to diagnose and trea’ 
tuberculosis than the officer appointed. 

Surely the solution of the tuberoulosis problem lies.ii 
tbc appointinpnt of consultant officers of wide experience 
coi Cling an area largo enough to a/Ford adequate remiinera 
tioii for whole-time men, together witii modern aids ii 
diagnosis and treatment. The value of the additiona 
appointment of a part-time consultant, as in some districts, 
is small, for he will not obtain the same personal contaci 
with practitioners as the whole-time officer. — I am, etc., 

E. AVatid. 


rxiignton, Pevon, Feb. 22n(l. 


EDINBURGH CORPORATION BILL. 

Sill, — AA'e notice Hint a statement is made in your rcpoi-t 
of tlie iiicctiiig of the Parliainontary Atedical Go’inmittee on 
February 21st that “ Tlio discussion, which lasted about 
an lionr and a balf, showed that tlio ParliamcntaiT Alcdical 
Committee was miiled in support of the objects of tbo 
bill. ...” 

AA'o submit that this is a travesty of what occurred at 
that meeting, if we understand the language your Parlia- 
mentary correspondent uses. The objects of the bill, as 
set out ill the pamphlet convoying tlio case for the. cor- 
poration, are to secure compulsory treatment both of 
defaulters who discontinue treatment befoi-c . official dis- 
charge and of persons who are suspected of infection, -but 
who Jiave not Bought treatment. -A large majority of 
members present spoke against these objects very definitely. 
— AVe are, etc., 

E. Git.iHAM Littlz, 

. , . , Rics-uin H. Luce, • 

. . A; A’shxon Davies, 
Aifued Salter, . 

House of Commons., Feb. 24111. Thomas AA’’.Arrs. ■' 

* * Our ParliamenLary correspondent regrets that: the 
sentence objected to” by tlie signatories to the above. letter 
did not convey clearly tlio idea he wished to cxpress-p;tliat 
is that the .aim of the bill is to secure that persona jrjio 
break off trentmeut at venereal disease clinics shall bo 
induced to rcsiune it till they are innocuous. 


TREAT3IENT OF ACUTE PNEUMONIA. 

gj„ X)r..Maidlow’s letter in tlio Journal of February 

lltb (p. 238) cannot be allowed to pass nncliallenged. It 
breathes the spirit of a bygone age — an ago of frock-coats, 
top-hats. Dundreary whiskers, and ])onderoiis platitudes. 
The davs of adopting a line of expectant treatment and 
hoping "for the best have bad their innings, and must make 
wav for rational treatment. Bulky volumes of therapeutics 
are of verv little help when one gets down to bed-rock facts. 
AA'hero one doe-s receive much help is in the Letters to the 
Editor Notes find Queries, and the small print gciieraliyia 
the British Meuic.il Jour.n.il. . 

Dr. Maidlow sjieaks well of cliani])agne, rum, and cider 
in the treatment of pneumonia — be likes his eoiiiforts^biit 
sodium nucleiiiate is good, potassium permanganato better, 
and collosol manganese best of all, cron tboiigli it docs 
tickle the biittock.s. No man with any initiative can stand 
by and persuade himself that be is doing tlie best for Ins 
patient bv filling him np with expectorants, cardiac stimu- 
lants, and alcohol. I have used potassium perin.aiigniiate . 
for a sufficiently long period to bo convinced of its great 
value in most oi' the commoner constitutional diseases, and 
collosol uiaiiganese lias displaced, in my Jiaiids, iiie.esy 
poultices and foiiientatioiis. . . 

It is A'crv easy for an cxperioiieed practitioner- to jFi 
into a rut, and very -difficult for -liim-to-gct-out' of it. -Ho 


JTAKCn 3. 1928 ] OBITUARY. 


[ 


Tbi BRmsH 
Mcdicix, JotniKit. 


377 


has been treating a cliseaso hr ono method for twonty 
rears, and contimies to nso tho sanio method for the next 
twenty. This sliould bo discouraged, otliorn-ise we should 
still bo treating diphthcri.a with ipecacuanha wino and 
leeches. 

This is an ora of rcstlc.ssness and of research, and wo 
must not rest content until wo hnvo pneumonia under 
control, in much the same way ns wo have, say, diphtheri.a. 
I may be as a voice crying in the wilderness, “ JIako 
straight the curve on the temperature chart ” ; hut we must 
do it, or our labours are in vain. — I am, etc., 

Dennistoun, Glasg’ov, Feb. ISlh. T'* ^IcCoIlMICK. 


THE ACUTE ABDOJIEX. 

Sm, — It is unfortunate when those who know what they 
are talking .about snfEor from an incapacity to impart 
their knowledge. 

I happened on Jlr. Rankin’s letter heforo reading Mr. 
Flint’s lecture. Fiom Mr. Rankin I gathered that Mr. 
Flint depended on tho “ classical symptoms ” (including 
faecal vomiting) for tho diagnosis of intestinal obstruc- 
tion; that Mr. Rankin had knowledge of earlier signs, 
which he kept secret; that a rising pulse rate was tho 
surest indication for laparotomy. 

It was not clear whether ilr. Rankin made his dlagnosi.s 
and waited for tho pulse rate to rise, or operated on all 
patients with rising pulse rates (in tho latter case may tho 
fates protect Mr. Rankin from a diaphragmatic pleurisv 
with pneumonia). I further gathered that Mr. Flint 
recommended high encmata and otlier non-operativo treat- 
ment for intussusception, Richter’s hernia, etc. ; also that 
cases suspected of acuto abdominal conditions may be 
0 sen^ by properly tiained competent surgeons, never bv 
general practitioners, nor, apparently, by Mr. Fhut (in tho 
opinion of Mr. Rankin). ' ^ ' 

^ My curiosity was aroused, and I turned to the paper of 
Mr, Flint. I was puzzled to find no 

.* 1 *"*^^ *1 'r® \ in treatment, tliougli there was 

A. + diagnostio significance of their results, 

it hna vomiting, there was mcrclv tho statement that 
oniiiTO place in diagnosis.” In place of tho 

astonidiirnf that I had expected was the 

tho better^” *'^"*^**’ earlier operation is performed 

Ine .““y find time to read this intcrest- 

deficiencinq care, and to supplement its 

mrn methods'^f'^ “nstructivo manner by divulging his 
diseases from the •'?? ngerous 

abdominal pain that vomiting and 


general mapfi*+‘ tho dailv cxporionco of tho 

Bm^eo^.il "am;"""’ roach tho operating 

Cblnsford, Feb. BiLLIXO. 


caro than I *'^nd my letter with less 

iiijnstice^of tMnK must not do himself 


have not reacbed^'pi"''"^ name and reputation 

sounded in my lett Tho note of disappointment 

given bv one'wbo knn'^"^ . ^ ™ ™ “ paper 

elassicai cbalf slmnlrl SO much 

personal experience raluablo grains of his 

February “ ^-F-” in yonr issue of 

that practitioners' hr "i"‘* amply confirm my thesis 
symptomatolotrv nf tl “P on the classical clinical 

look till it ig ] ,'® 'peribund will continue to look, and 
iho most deceptire' f"’ n" intestinal obstruction — 

Four!;/ ohscTrntion "c lypes of tho acute abdomen, 
temperature ratios a ■ " P'*^®®‘ 2 '®spi 2 'ation and pulse- 
of abdominal discomfnrf exploration in every case 

Vomiting should cert"' i"*" associated with nausea or 
profession as at r...n ^''’’y bo routine practice. Can the 
.1 salute -AH organised do it? 

sions will alwavs pvust that onr abdominal expan- 

I am, etc., ' ^ momzo with our chest expansions. — 

Glarfow, FeV 2£lh. 

IVlLLIAM HaXSTX. 


©liiiiiaru. 

F. D. BEXKETT, AI.R.C.S., L.R.C.P., 

London. 

Dn. FnAX-cis Dillox Bexxett, who recently died, was horn 
in Sydney, Australia. Ho came to England in 1878, and 
after studying medicine at St. Bartholomew’s Hospital 
obtained, in 1800, the diplomas AI.R.C.S., L.R.C.P., and 
L.S.A. In addition to conducting a private ophthalmic 
practice ho was for many years medical officer to the 
Army and Xnvy Co-operative Society. 

Dr. Bennett was associated with the Royal Eye Hospital 
for more than thirty years, being senior clinical assistant 
to Sir M’illiam Collins. His knowledge of ophthalmology 
was very thorough, and both in refraction work and in 
ophthalmoscopic diagnosis his judgement was sound and 
reliable. He served for a considerable period on the hoard 
of management of the hospital, where his sagacious advice 
and equable temper often helped to smooth out difficulties 
and to increase the reputation of the institution. During 
tho war he acted as consulting ophthalmic surgeon to the 
Anglo-French Red Cross Society, and was created a 
Chevalier of tho Legion of Honour and received the 
Aledaillo Reconnaissance F’ranfaise; he was also awarded 
the medal of the British Red Cross. 

Dr. Bennett took an active interest in the work of tho 
British Aledical Association. He was honorary secretary 
of the M'estminster Division from 1918 to 1923, a member 
of the executive committee from 1922 to 1E27, and vice- 
chairman in 1926. He was also a member of the Aletro- 
politan Counties Branch Council from 1918 to 1926. 

A colleague writes : -As one for whom tho death of Dr. 
F. D. Bennett has brought to an end a close friendship 
covering over forty years, I am expressing tho feelings of 
a host of people to whom the end of his well-spent life has 
brought a deep sense of personal loss. He had a positive 
genius for friendship, making friends wherever he went and 
retaining their affection to a remarkable degree. Quiet, 
reserved, and grave in manner, he seemed to most people 
on first acquaintance kindly rather than warm-hearted, hut 
it did not take long for them to realize that he was one of 
those rare spirits for whom the joys and sorrows of others 
are of far greater importance than their own. He shared 
the troubles and anxieties of the many friends who sought 
his advice on every conceivable subject. None was ever 
sent empty away, and his sound judgement rarely failed 
to solve their, special problems. Not often is a man found 
of whom it can honestly be said that he was universally 
respected, at tho same time capable of winning tho affection 
of all with whom he was brought in contact; but it was so 
with “ Ben,” as he was known to his intimates all throngli 
his life. Greatly beloved and deeply mourned by all who 
knew him, his passing leaves a gap in many lives. 

Dr. H.vkvet Hilliaud (formerly chairman of the AYest- 
minstcr Division) writes : By the death of Dr. F. D. 
Bennett the British Aledical Association in "Westminster 
loses a staunch supporter and the medical profession a 
confrere who set the highest professional example. For 
several years ho acted as secretary of the "U’estminster 
Division, and did his best to bring together tho medical men 
in the district in a spirit of friendly co-operation. Bennett 
was a man whoso kindness of heart was one of his chief 
cliaracteristics, and gained for him the affection of all who 
knew him. 


T. C. GUTHRIE, AI.B., C.M., 

Tunbridge Wells. 

"We rec'ret to announce the death, on Febniarv 18th, of 
Thomas Clemext Guibhie of Tunbridge M’clls m h'? 
61st rear. Dr. Gnthrio was horn at Liberton in Alicl- 
lothian, and received his medic.al education at the 
University of Edinburgh and St Thomas’s Hospital He 
graduated AI.B., C.M.Ed. in 1892, and obtained the 
diplomas AI.R.C.S., L.R.C.P. five J^ars ^er. Ho held 
the appointments of house-surgeon at tl.o Edinburgh Royal 
Infirmarv and tho Royal Hospital for Sick Children, and 
was dssistaiit physician to the Victoria Dispensary for. 
Diseases of the Chest. Some thirty years ago ho settled 



MEDICAL NOTES IN TAELIAMENT. 


r Trr npmsH 
I LifKtHCAt. JotTBtu 


378 Mauch 3, 1928] 


in Timlii idgo ‘Wells ninl coinnicnccd a parlnorsliip with Dr. 
Claude ‘Uh'lson, wliieli was aftcrward.s extended. In 1902 
lie was ajipointcd junior Iionorarv surgeon to the T'unhridge 
"Wells and County Gonernl Hospital, and subsequently filled 
tlio .senior post; for many years ho was a inemhor of the 
committee of mauagoinent, and took special interest in the 
jubilee extensions of the institution, which included the 
children’s ward and the x-ray department. He built up a 
largo privato practice, and was held in very high esteem 
over a wide area as a .skilful o]ierntor and a wise con- 
sultant. Ho was also honorary surgeon to Dr. Uarnardo’s 
Home for Crippled Children. ' Free from all ostentation, 
his sympathy and kindne.ss won him many friends. Mr. 
Guthrie rendered valuable services to the British Afedical 
Association ; ho was e member of the Executive Committee 
of the Tunbridge Al'ells Division for many years between 
1904 and 1S23, chairman in 1915, and vice-chairman in 
1916. At the time of bis death he was about to retire 
from his hospital appointment. Ho is survived by his 
widow, one son, and one daughter. His wide popularity 
was shown at his funeral by the lai-ge congregation, whicli 
included many of his collcaguc.s and fiiends. A colle.ague 
writes : Air. Guthrie was an exco|)tionalh- able surgeon, 
and had a largo suigical and consulting practice. He never 
spared himself, and gave his best- services with equal hands 
to rich and jioor. Though suffering fioni a fatal malady 
ho performed many major operations till within a few 
months from the end. Ho was a man of the highest 
integrity and character, tall, cheerful, and posse.ssing the 
best typo of dry Scottish humour and candour. The 
singularly elusive charm of his jicrsonality ivas such that 
even his faults seemed to endear him. In spite of the 
curious fact that he never know the time, and was con- 
sequently often late for his appointments, lie enjoyed the 
friendship, resiioct, and confidence of all his colleagues, and 
any excusable irritation was on such occasions replaced by 
a smile of amusement, in which ho often joined. In his 
hours of leisure he was the keenest of sportsmen, being 
a good golfer and tennis player, a first-rate angler, and 
a good shot. “ He warmed both hands at the fire of life.” 
Nature he loved, and in his a[)proaching retirement he 
looked forward to life in the froli air devoted to country 
pursuits and pastimes. His life indeed was a full one; Id's 
death is an irreparable loss to his medical brethi’en and 
to the public. 


anti ffioUc^es. 


DNIVEBSITY OF LONDON. 

The title of Fellow of Uuiversity College Ims been conferred upon 
Dr. Gleb V. Aiirep, formerly senior assistant, Department of 
physiology, lecturer in physiology, University of Cambridge, 
find Snrgeon Vice-Admiral Arthur Gaskell, C.IJ., R.N., Medical 
Director-General of the Royal Navy. 

The title of Fellow of King’s College has been conferred upon 
Dr. William Blair Bell, professor of obstetrics and gynaecology in 
the University of Diverpool and Director of the Diverpool (Cancer) 
Research Association. 

Sir Holburt Waring has been appointed the representative of the 
Universitynt the centenary celebrations of the Faculty of Medicine 
and International Congress of Tropical Medicine anil Hygiene, to 
be held in Cairo in December next. 

At the auunal general meeting of the University of Dondou 
Conservative and Unionist Association, held on February 23rd, it 
was decided'to adopt Sir John Gilbert, K.B.K,, formerly Chairniau 
of the Dondou County CoaucU and a Member of the Senate of the 
University since 1921, as the prospective Conservative candidate at 
the next General Election. 

The name of Dr. John N. Beadles has been added to the supple- 
mentary list of University extension lecturers in physiology and 
meteorology for the session 1928-29. 


SOCIETY OF APOTHECAKIES OP LONDON . 

The following candidates have passed in the subjects indicated; 
SnaoEBT.— B'. A. A. Collington. B. Elliott. M. Franzler, G. Forniss. 

Beeston. M. Franzler. H. I. Jones. J. B. Mitchell, 
K. J. M. Grab™. 

■W. B. Hallums, H. J. Harconrfc. H. T. Ince, F, M. Iiessing, 
C. Beckitt. ,E.' E. Bowen. M. Franzler. K. J. ir. 

Graham. 

The diploma of the Society has been grantedjo Messrs. G«N. Fox, 
M. Franzler, G. Faruiss, and R. W, Wood. 


iltfitiical plates in ^parliamcnf. 

[FhOM OUH P AIlLIAtrCNTAKy CoitllESPONDEXT.j 

.SraiECTs di.sciisseci in ibe Hoii.se of Commons this wed; have 
mcliKled tlic Briti.sh GovernmenC.s decision not to ratifv the 
Ataslimglon _ Convention on Honrs of Lalioiir, file state of 
trade, tlic railivay companies' apjilieations for power to fransjiort 
goods and pas.sengers by road, and a bill for the icgistratioa 
of arcliifeC'U. 

Tlie Cliairnian of Cominitfce.s will probablv set down the 
Edinlmrgb Corporation Bill for disewssion on second reading 
on an evening during the first forlniglit in Alarcli. As c.vplained 
last week Ibo coriioration seeks by, this bill to .secure greater 
powers for dealing with infectious cases of venereal disease 
where treatment is neglected, refused, or abandoned. A meet- 
ing called by Dr. Graham Little and Dr. Salter on February 
22nd, brought together over thirty members who disapprove 
of (he bill. No re.5oliition was passed. 

Scottish Board of Health. 

Supph-mentary' Estimate. 

Iiitrodiiciiig a nominal Supplementary Esiimale for £10 in tlie 
House of Commons on Februaiy 23rd Sir John Gilmour said it 
was required to meet State grants payable on expendiluro incuiTcd 
by approved societies in Scotland on sickness and disablement 
benclit, and was necessitated, as in England, by the rise in the' 
cost of these seiwiccs. The large increase was a matter of very 
grave anxiety to the approved societies and to the Minister con- 
cerned Expenditure commenced to rise markedly in 1926, and 
continued abnormally high till the end of that year. Expenditure 
on sickness and disablement benefit in 1927, contrary to expecla- 
lioii, was' even higlicr than in 1926. Taking the index figure for 
19^ as 100 the figure for 1926 was 113.5, and for 1927 117.75. It 
was difficult to find any explanation of this excoptioual expendi- 
ture Apart from an epidemic of influenza in Slarch. 1927 was not 
an unhealthy year, wliellier judged by the inorlabty or by the 
number of prescriptions issued by medical practitioners m Scotland 
to insure^d patients. Tlioro was a groat feeling of apprehensian 
among the approved societies that the inedica profession i- as not 
the caVe in giving this relief that might be expected et 
it lircady the Scottish Board of, Healtfi . had called the 
of the approved societies to tins huge increase, and Jiad 
CO .sn cd ropresenutives of the medical profession. The period 
coDsullcci p aoDliciinl’ h'om one medical practitioner to 

beelines, and might have to.lJe still further 
If there were flagrant examples of medical practitioners 
incrc.'ised. if tnere wc R„eh steos as increasing 



not ask as that sum could be found by transferring 

|i"’n.wt'ot*tlifskvmg made Uirougli a reduction by 500 ni the 

Janies SUwarSovod tlie reduction of tlie vote. He noted 
,i^’'’iBo°rLDoration of Glasgow bad decided to have notliuig 
lliat the giecl houses, and ho invited tlic Secretary fo» 

furtlier to do with steel uo^^-^^^ ^ success. The shortago of 

Scotland to s.y had been estimated at 121,000 m 1917, 

bouses in bcouni . increasing medical 

jvas more money in health administration when 

benefit 'o°urce of nearly all tlie troubles wliicli beset 

iMantilc death rate this' year was the second lowest 
tbemP 'Tbe nlami p„,.is of (i.o 

,n Scottish lustoiy, o yfpaical officers ni every mimip- 

ivorld drawn attention, year in veav out, to the 

aality and liealtli. In every part of Glasgow 

-clationship bMwee ^1^^ fhe°infantile mortality rate was llincc Ibo 

vliere '■“V'”’'’,, -;tv The Labour party did not oppose ilus 

"""a^ed grant of £W, 000. They knew that in llie circumstances 

^y^wM^'^dlie was suspicious of the Minister’s i-efereiico to 
Mr. Nidd ...rod through -increased sickness. Last year 

,be B 3 ;Iva host 1 fron, tlie coal .stoppage, and bad the 

Scotland was si .,veatlier, acting on vitalit.v lowered 

vettest . accounted for tlie increased sickness. He asked 

ifter the slovr in assuming tliat medical practitioners 

,he Munster * .j j allowing panel patients medical treatment, 

lad been too facirnm i„jg,f„ed with 

,r loo slow m t ™ loctor, on whom was the supervision 1® 
he discretion ot t ne renresenting tbe Miiiistrv, or should I lie 
X aiiSe oro^ doctors.? Ho had found 

loctor have objected to beiim overruled on the gaalily 

ascs where a doci r j 5 ,,, should not create the 

f the reedicme wWeii n^^P j patients, only one of 

mprcssion , that there gj ; tliougli tliey were equally 

-i s?"= 

»w “ “s,"”e;r.' 7 ; 4 »S pu"-! 

Jampbeil btepuon ^articular in certification. 

£,‘ 4 S”iS 


, 19281 


MEDICAti NOTES IN PAREIAMENT, 


MAECS 3 

were not. ncliiip: properly in this 

that medical men m 8 ™'!“., ; seriously before it allowed the 
matter. The House “ vv conditions on the medical 

Secretary for mitrlit send working people to work 

profession in order ^.-Uy in Glasgow (licro had not 

when they were , f„r Vho medical panel committee. Medical 

been the regular election to election, yet tlio Minister 

men in S®". Gruliam said ho made no charges 

refused to have > 1 - , , (| j,,]; tliev would find an mstaiico 

against t°?‘-T\.lwrc i medical practitiiiicr had signed a " lino ” 
m benefit to a person not. entitled to it. 

^^Sir HeMTSutlCT said the increase in sickness and disabicmcnl 
Sir Henry oauiiei ^ ^ serious. In mimcroiis 

benefit m the last three jws . brought him in 

’"^a-Tlhrifif uitLit The euro was to increase Ins indepen- 
“efc^ In maiiT eases ’a panel doctor was approached by the 
fa h“r of a household and might bo slow m certifying him as unfit 
for work or to receive beneSt. The patient changed to anolher 
panel doctor, and the old panel doe tor who had Veil nttendmg 
the man’s wV and child in his privato practice, bst that con- 
neiion. That ought not to bo allowed to aiise As much ns a 
month should elapse before a patient TOiild chaiigo Ins panel 
doctor. Mr. ^Yestwood alleged that in his coiislituciicy (Peebles 
and Southern Midlothian) medical men were forniing themselves 
into a limited liability company so that they coiild dispcnso tho 
medicines which they themselves liad proscribed. The original 
Health Insurance Act laid down that, save in oxcoplional casc«, 
a medical man should not dispense the medicine lie prescribed, 
but he could instance a case where a doctor Imd started n share 
company, in which his wife took two shares and lie the rest. This 
doctor did not hand prescriptions over to tho patients, but took 
them away to dispense himself. Ho hoped the Secretary for 
Scotland would issue instructions that prescriptions must bo given 
to insured persons so that they might obtain medicine from 
whatever chemist they chose. 

Sir John Gilraour, speaking again, said that in 1925 tho number 
of national health cases in Scotland on which doubt was expressed 
and which were referred to examination was 22,231. It was 24,016 
m 1926 and 35,068 in 1927. Of men’s eases examined bv tho referee 
in 1927 the practitioner’s certificate was upheld in 45 per cent., 
and of women’s cases in 35 per cent. The practitioner’s certificato 
was reversed in 21 per cent, of tho mcn’.s cases and in” 24 per 
cent, of the women’s. Of eases referred but not examined, 15 per 
cent, of the men were declared off the fund and 19 per cent, of the 
women. Of tho men 14 per cent, failed to appear and of the 
women 19 per cent. There were not examined, for various reasons, 
5 per cent, of tho men and 3 per cent, of tho women. If the cases 

WP.rft erf>iiiiina tlio l.-J e..it _j_i • - • • 


r th* BBitisa 

L SfEOlClZ. JOCBMJA 


379 


9 per cent. 01 ino men and 3 per cent, of tho women. If the cases 
were genuine tho doctors had full right to make (heir recom- 
mendations. The Board had issued an order bv which fourteen 
days notice of change must be given. The object was to let tho 
doctor feel that there was a time during which tho fainiess 
tr be considered by himself and the referee. 

found it nc^sary to say quite plainly that some members 
eL.SS were not obsondng os carefully as they 

must recognize the difficulties 
<le«lt witli, but tho f^act 
pn/i fiif CA ‘V medical profession would help tho Board 

concerned, and that they should not be compelled 
methods. He did not think a Select 
Tho fanic required (o inquire into the charges he had made. 

f’u^ and known to the approved societies, to 
nut during medical profession. Replying to questions 

panel election to tho medical 

whether it with as there was a doubt as to 

Royal Comrnksitm^^ ^ recommendation of the 

tions repardinc^ investigate Mr. Westwood’s allega- 

send him infoVatiom Mr fe.|;r 2 ®‘i‘>oners if that niember would 
diversions of rnone^P’fmm i * Adamson protested against the 
was carried by 229\o 89 ™ The Siipplemeiitary Estimate 

Sir JdiiiGHm!\«r*rlritv^^^'^^‘“^'‘’^‘’t^2t of Medical Officers. 
said that 011 appomtfnff^m/r " 2Znd to Sir R. Hamilton, 

Board of Health officers to their staff the Scottish 

qualifications in onKiili require candidates to possess special 
obligatory in the other than the course now 

present stall had had But the majority of the 

view of the sDecial experience in eye work, and in 

medical staff had industrial blindness the whole 

Bultant ophtlialmolopicf \ course of instruction by a con- 

under the Blind Pereons Ae?^Vi° peculiar problems arising 
.aiinculty were reported it 'Vlien cases presenting exceptional 
Rn eye specialist. * Board authorized the employment of 


giving details of small-pox cases the responsible officials should 
state wlictlicr tlio case was vaccinated during tho incubation period. 

On February 27lh Mr. Chamberlain, replying to Mr. Groves, 
said that tho notifications of cases of small-pox in England and 
Wales last year wero as follows, the figures being provisional : 

In tho thirteen weeks ended April 2nd, 1927, 6,153 cases; in the 
thirteen weeks ended August 2nd, 3,753 cases; in the thirteen 
weeks ended September 1st, 1,930 cases; and in tho thirteen weeks 
ended December 31st, 2,928 cases. This made a total for the 
year of 14,764 cases. 

On February 28th Sir Kingsley Wood informed Mr. Groves that 
ho iiad seen a report of the proceedings at the coroner’s inquest 
on tho death of Mr. J. H. Chetter of Warrington, after vaccina- 
tion imposed on liim by his employers as an alternative to 
suspension from w*ork for an indefinite period. Representatives 
of tho Ministry of Health were not present at the post-mortem 
examination or at tho inquest, and tho vaccination was not carried 
out by ft public vaccinator w'ith Government lymph. 

Replying to Dr. Vernon Davies, on February 28tb, Sir Kingsley 
Wood said that during 1927 there were 49 deaths in respect of 
which small-pox was entered on the medical certificate ^ fhe 
cause, or one of the causes, of death; 2,582 cases had been notified 
during the first seven w’eeks of the present year, but no 
particulars on deatlis were available. 

Foot-and-Mouth Disease. -j . 

Mr. Guinness, replying to Mr. Hurd on February 27th, said that 
in March, 1927, the Ministry of Agriculture asked three of the 
Governments of South America which exported meafi <0. 
coiinirv to accept certain proposals designed to intro- 

duction of virus of foot-and-mouth disease into Great Britain. 
Last December Lord Bledisloe, then Parliamentary Secretary, 
conferred with representatives of the Argentine, Uruguayan, and 
Brazilian Governments. As a result, k*'® •^^5®'’^”’,® 
issued ft decree, which took effect on February 1st, the mam 
p'rovision of wliich was that the carcasses of 
and those which had been in immediate contact with them, sliould 
not be exported to Great Britain. The Uruguayan and 
Governments had adopted similar regulations. .Iioid Bledisloe 
renorted that all three Governments were increasing their eftoits 
to’^get foot-and-mouth disease under eont'’®'- A. British inspector, 
who was stationed in the Argentine Republic, repor ed ‘ke 

disease was endemic. In a second progress report the loot-and- 
Mruth Disease Research Committee had reported that >" ti'® 
instances the bone marrow in carcasses of cxpenmentally mtccled 
animals wliich had been frozen or chilled for seventy-six 
refined infective. There was thus experimental evidence tl at 
chilled or frozen carcasses of infected foreign cattle might iimo 
dueniseose to this count.-y, but there was no conclusive evidence 
that this happened under ordinary trade conditions. 

TTashinnlon Conrerttion on Boars of LnBour. _ 

Tn Committee of Supply on the Civil Service Estimates, in the 

rlVs’ ffiJ,; "ts 

Washington Hours^iComenuon^^b^ur. ^^at to accuse this 
'^‘P\s‘’'fin'lf;'’d“ft’’S ^f'^ratlSIdTont 

F’t S^milctlfn 

this momenc a .,, , -.-orkei-.. Those agreements were valuable 

“menls in the maintenance of industrial peace and would be 

Tern^®n DaS‘sa”d that there had been ®ne great feature 

®mrTtempt^to“controvert%hr’S“rg”i"^^^ .them- It 

l "f-i nec?liL tiling that both the Labour party in wishing for 


Answering Mr. Rhvc ti,..- 

that in tho nrespnf Tebrurary 23rd, Mr. Chamberlain 

in the Hindley urban ® cases of small-pox had occurred 

district. Tho sources nf ; in the Aspull urban 

detailed tho preventim had not been ascertained. He 

nnd Echcwls were taken. Absentees from works 

'^silcd. Picture >nlTo health Department weekly, and 
Ino schools, billiard ^ '^erc closed for matinee performances, 
^cro also disinfected XT* ^^Tjoyment exchange, and post office 
Dad sanitation did nn*f ^ advised that overcrowding and 
Anss^ering Gro°es “^® ““tkreaks of small-pox. 
that of the 7,956 De»*<;c!ne° , 23rd, Mr. Chamberlain eaid 

the the report of tlic chief 

^8 Irad been vacciiuateu Hcallb for 1926 as unvaccinafed, 

^ the .age of 20 TT ” incubation period, 72 of whom 

• °“kl justify ijjjjj ■ ® not think the added information 

suing instructions that in filling up forms 


also tho bad habit of not on i... - 

bv their d®'®®®*®®- . ''''S the* fortiSeight hours week was a 

Labour that tins neople of this country. It was the 

very vital one to tk®^“'Vv had concentrated. They held the 
one thing on which they forty-eight hours week only by 

opinion that ,^key had they wefe determined that in 

prolonged and kitter ig -■ necessity would tlicy ever 

no circumstances ®kmt. not quite convinced them 

give it up. M hat Convention was to tho 

of was that the °° tngople of this country. If the Minister 
advantage of the l'°[kP®^Pnnd simplv say that if the Convention 
'^-ere'^rltifiefTt “voSd m?an that the textile workein would be 


380 M/mcn 2, 1928] 


MEDICA.ti NOTES IN PiLlirirA.TMENT< 


f - 

LaiCWCU. 


working’ forty-ciglit haul's a week witli no ovcrlirnc, hul that in 
Gci*niany they Mould he workin", say, fifly hours, or fdxly in 
Czocliosl'orflkia, nud so on, such a slnlemcnL %vould can-j' ’con- 
viction. Up to the present tlic Government had not been ablo to 
prove conclusively to him that ratification M'ould he definitely to 
the detriment qf'the people, and Jio mus compelled for the fourth 
time to speak against his party. He hoped the Minister would be 
able to make a strong case in proof of the statement that 
ratification >voulcl be dolnmonlnl <0 tlie workpeople and industry 
of the country, and that the Government regarded it as Ihcfr 
duly, m looking after the workpeople’^ interests fii'st and fore- 
most, to refuse to ratify the Convention. 

Sii A. Slccl-Maitlnnd cxpres«:cd the hope that the cmploj'ei-s* 
rcprosenUiivos and the Trades Union Council would sit dowm 
with him and help in the revision of the Convention, and work 
out a practicable Bchcme. 

The motion for the reduction of the vote was defeated. 


I^co)v/ani:uf}oii nf 0{Jir(s {Hrofhtitii) liifL 

On February 28th Sir John Gilmour moved the second reading 
of the Kcorganizntion of Offices (Scotland) UiJJ. The bill pj-o^'idcs 
that on the appointed day the Scottish Board of Health, the 
Board of Agriculture for Scotland, and tlie Prison Commissioners 
for Scotland •shall cease to exist. Tlie powers and duties of these 
Boards, including Die Piison Commissioners for Scotland, arc to 
ho transferred to and vc^slcd in a Department of HcaUli for 
Scotland, a Oepartiricnt of Agriculture for Scotland, and a 
Prisons Department for Scotland, under (lie control and direction 
of one of His ifaje-sty’.s Principal Secretaries of State, and con- 
bisLing of a seci’etary and such other officers and servants as the 
Secretary of Stale may determine. Tlio offices of the departments 
are to bo .situated in* Edinburgh. TJic persons employed by the 
Board arc to be transferred and attached to the department, and 
shall bo in no worse position as I'egards tenure of office, salary, 
and .superannuation allowanee than if the bill had not pas<=e*d. 
No vacancy in the ofiice of membei'S of the Scottujh Board of 
Health existing at the passage of the hill or afterwards is to be 
fdled, a.nd that part of Section 3 of (ho Scottish Board of 
Health Act, 1919, requiring that the Board of Health shall at 
all times include certain nieinbci's having the qualifications 
therein set forth, is to cease to have effect. 

Sir John Gilmour said that the bill was practically Identical 
with that of last year. While it abolished patronage, the bill did 
not lessen the possibilities of contact between outside interests 
in Scotland and the departments. Tlie sole motive was one of 
eflicieucy. The bill left intact the same responsibilities, and it 
gave to the Minister in charge in the House of Commons addi- 
tional assistance in that, in future, he would have tlie ^-31110510 
advice of first-class civil servants. Tliero was 110 intention of 
transferring the w'ork of iJie departments to London, and to 
make that clear he had inserted a provision in the bill to the 
effect that the offices should be in Edinburgh. 

Mr. T. Johnston maved the rejection of the bill, and contended 
that although the offices -would be in Edinhurgli, the power that, 
directed the departments would be in London. The Government 
were deliberately attempting to lake away tlie administration of 
public affairs m Scotland from skilled men selected because of 
their specialized knowledge, and transfer it to men m-Iio, M’hntcvcr 
scholastic qualifications they might have acquired at Oxford or 
Cambridge, had not proved their fitness to control the depart- 
menis. Sir. Barr seconded the rejection, Mr. Webb urged the 
Government not to. smother the real experts in tliesc deparlinents 
by administrative chiefs. He admitted that it would be to the 
advantage of the Minister to have au administrative chief in 
each department. Mr. Kidd said that from Ids experience in the 
Board of Health there was probably no better service than that 
v'hich had obtained in Ediiiburgh. There vras, however, a gi*eat 
deal to be said for concentrated aclminislrnfion of the public 
service in the hands of the Civil Sendee. 

Tlie debate on the second reading was adjourned, and M’ill 
.probably be completed on March 5tli. 


— On February 23rd Major Tryon issued figures 
showing tliat during 1927 the Ministry of Pensions emploved 
50 established whole-time inodiea] officens and 190 uncstahlished 
ones, against 50 and 222 respectively in 1926, 50 and 329 in 1925, 
and 3 and 452 in 1924. In 1927 the average number of ex-service 
men receiving treatment was 27,700, against 34,700 in 1926, 
44,600 in 1925, and 56,500 in 1924. The weekly cost of an 
ex-service patient in a Ministry of Pensions institution during 
1027 was £3 Os. 3d., and of similar patients in other hospiUls 
£Z 18s. 7d. each. At the end of January, 1928, 5,3C0 ex-service 
men in England and 800 in Scotland were receiving, at the expense 
of the Minisli'y, treatment in institutions belonging to local 
authorities. Lieut.-Colonel G. F. Stanley, replying to Mr, 
Robinson on February 28tli, said that the occasions nhicli necessi- 
tated a visit bv a medical officer of (he Ministry of Pensions 
to a patient’s home were comparatively few, and it had long 
been the practice of the Ministiy to employ a medical man on 
fl fee ba'sis in the rare cases where the deputy commissioner of 

usance hacrnor^ally Z 

o s of their available to call for pur- 

treatment at home or otlicnvise. ami the Minister of 
Pensions would not be justified in duplicating those arrangements. 


Trtra-rthyl The Home Secretary, in an anp-er on 

I'obruai'v ^rd to Commander Keiiwortiiy, said the ciicct on the 
public health of (lie use of petrol diluted with teiraKiHiyl lead 
was outside the jurisdiction of the Home Office. However, as 


special measures might have to bo taken for liio protection of 
foclorj- -workei-s, that department had followed closelT tin 
inrcsligations made in tho United States. No evidence had beta 
dircovcred (here of any injuiy lo the public. No reguiafions had 
been imposed in the United States on the use of this substance, 
hut inslnielions were issued bj- tlie company supplying it, and 
tho same iva.s done in this country. Tho effect on workers in 
industry wiiere there was .a risk tiiroiigli exposure to Ictra-elhjl 
lead would be carefully walclied. So far no case of lead poisoning 
had occurred. _He Iiad seen a recent warning by Sir tthlliam 
Pope against its use. He would confer with the Ministry of 
Health lo sec whether tho Department of Scicnlilic and Industrial 
Itcscarcli could investigate the matter more fully. Comniandtr 
Kcnworiliy asked whether the Home Secretary would consider Ibe 
effect of this substance in city thoroughfares. Sir tV. Joynson- 
nick.s said the Ministry of Health dealt with public healtli. 
Colonel Howard Biity asked whether the Home Swretary knew 
that lead poi'^oning took a considerable time before it appeared. 
No answer svas rctunied. 


yolifiabtc Vixaxr.s . — Eeplyinu to lord Sandon, on Tcbniary 
23ril, sir. Cliamheilain said the majority of infectious diseases 
were notifiable throughout tho country, hut a few had been made 
notifiable in certain areas only of London and the provinces^ for 
reasons wliich did not cjdst elsewhere. Nothing would he gained 
by uniformity. 

The Moxjiiito 1‘rsf . — In reply to questions about the prevention 
of mosquitos in England, Mr. Chamberlain said ihe indiscriminate 
.spraying of all mai-sli lands svas not necessary and would probably 
he incilcclire. He advised local authorities, when they had any 
particular pest, to apply lo the Ministry of Health, which could 
send an expert to advise, A British Museum pamphlet on 
Vrili.th ilmqviios and Their Control contained advice on the best 
methods lo combat mosquito pests. 


Lrnrosii.— On February 27th Mr, Amery, in reply to a qtiesiion, 
said that hi those parts of the Empire where leprosy existed aelne 
measnres were hciiig taken by medical departments for its eonliel. 

rasi in lo-operation with the British Empire Lepio.sy 
Belief Asmcialion and other agencies. Medical officers tramed iu 
reecnf methods had been detailed for special duty in Nigeria, f be 
P/ilfl Coast Fiji, and other colonies, while in all areas alienlion 
was being given to the possibility of the eradication of the 
hr the Istahliblimcnl of treatment stations, as in Tangmj Aa 
S^va^lanX Hgeiida, or by such other means as the situatm 
appeared lo demand. i • „ i- 

I . 1,11 Bovs in .Vines.— Commodore King, replymg to 

Aio/if ^ '’' 4 „i,^^^, 4 v*^ 2811 i said ho was aware that many of the 
f bmween 14 ’and 16 working underground m the 
28,000. youllis lo work on the night shift, and that youths 

collieries were expect^ to " ora on co 

of pIcii'eMmtaation was t^ie practice at some collieries, 

at night. Mcdmal ex mma Parliament passed 

but was not year, it was decided that the proliihi- 

the by hoys on the surface should not he 

tion against ^ork, and this decision was confirmed 

extended to underg mm Employment 

bv Uie ""persons and Children Act of 1920, He was net 

of Momen, reversing this decision. 

vmiary Bospitals.-Oa February 28th, m reply- I" 
CToxing oj Jl'M" ^ WorUiington-Evaus said that in 1922 
Dr. Vernon D?""?!., cimtham, and the Royal Naval Hospital, 
the Xsed Military patients at Chatham were now 

Gibraltar, neic clo Hospital, Chatham, and naval yieX 

treated m the ““I Military Hospital, Gibraltar. Since 

at Gibraltar were fUl,-,., Hospital at Cosliam and the Military 
1922 the A “"-;t“pS'td^ee?closed and militaiy .patients m 

Hospital at Dm onp^ treated bl naval hospitals, llw 

?oS Me|ral ^rvires^toimiU^^ oo^po, 

Fehraary 17th Genera, 

(Scotland! Bil to pro duly ■ Iramed and 

knackers’ J:?"t®,,‘*’fVall animals except swine, use a .mecliamral 
licensed, and ® ' j jfoore said that orer 2,000,000 Jj c 

insirumen . n Scotland. The bill was read y vcond tn 

slaughtered yea''! , standing committee. On l-elniiaiy 

reply lo i^powers to undertake avstomat.c msn ct 

i"feSed iuspoetion. 

.Totf.s ill Brie/. . 

’X ’of special 

Ledl7o'’r’ a“hnormany tall pa^ients.^^^^^^^ 

iraced le 

"P.l"Jrnrbe‘^^’=una Dead kint Act, 1926. 


Ma-RCH 3. 19^®! 


MBDlCArj NEWS. 


r Tite DnrTMTT 
L UrDtcxi, JouBSll 


381 


domi- 


, .3 --.n,. imcnilaU of llio Uiiilcd Kingdom 1,912 bods 

occtiiiicd on anj- day last 
aro Air Forco iiosiufals tlio figures were d-lO 

vear was i,o0+» 

’“eiSdinc lunatics, casuals, and persons only , receiving 
cal^^Selical rfief, 1 , 203.179 pe^ons ^re rocoiving poor rchef 
in England and Wales on Februarj 4th, 1928. 

On Marcli 51st last 14,663 b ind persons between 50 nnd 70 
of nep were rcceiring pensions under tbo Blind Borsons Act, 
were nnnrosim.itely 30,000 blind old ngo pensioners over 
70.^ On the same ilaio (here ""f »’ ■"'"!!;« 258 blind 
children tinder 5 years of ago nnd 2,554 bclwccit 5 titid 16. 

Mr Chamberlain is advised that the iufonnntion nvaiinble docs 
not iustifr further legLdation on the use, for treatment, of 
disease, of clecfrical methods a.s well ns x rays and ultra-violet 
rays by unqualified practitioners. 

The rerenuo from the sale of alcohol and narcotic drugs in the 
provinces of India in 1925-26 was 1,930.8 lakhs of rupees. 

During 1927 seventeen applic.ants for service in the Tost Offico 
as boy messengers were rejected for flat-foot. 

The ifinistry of Health has received no report from the We«:t 
Sam Board of Guardians on the health of tuo children boarded 
out by them. These children aro regularly inspected. 

Tlie Government think it inexpedient to ratify the Convention 
accepting the prohibition of the use in war of asphyxiating poison 
or gases until all important Powers have i*atificd the Protocol, or 
have signified their mtcnlion to do so. 

Tlic average daily number of eases tinder treatment at ITasIar 
Poyal Kaval Hospital in 1927 was 386, against in 1926 and 
538' in 19S. The pcacc^ accommodation is 88 officci-s and 1,059 
men; the annual cost in the vear ended September last was 
£105,419. 


jUdtJS, 

, A jiRETIA’G of the Harvoian Society of Loutlon will be held 
’at the PaddiBgton Town Hall, W.. ou Thursday, March 15tb, 
at8.Mp.m., when Sir William Willcox, K.C.I.E., will deliver 
toe Harveian Lecturo ou fo.ticology In Its applicutioa to 
medical practice. 

Place of tho Practisiuf? MhUvife ici 
B Protection ot Motherhood will bo held at tho 
urnlnh Street, Adelphi, on W'cdnosdaj', 

SlrErewi?=’ri‘’‘“ ^ will ho taken by 

Midwlrpo chairman ot the Central 

pairbairn speakers will lucludo Dr. John S. 

bairbaitn, Dr. J. A. Willett, and Dr. Oxloy. 

ot^Sns wm'f ■ \^‘‘‘“ey. 3t.P., Speaker of tho House 
■ SoSd on Mareh huildlng of tho Leeds Dental 

Sh o?thf.cLl^“' P-“- Some particulars of the 

In oar Lsae^of°°r buddluf; were published 

rooms, and at 4 n n. ^ opportunity of inspecting the 
upon the Speaker degrees will be conferred 

A DtscnsnoZn ^ distinguished por,soas. 

jointmeetinaof 

Neurology, and 'Propical Diseases, Psychiatry, 

to be held at 1 tvim the Eoyal Society ot Medicine 

at8.30p.m. ’ "““Po'o Street, WM, on Tuesday, March I3tb, 

on elec^ZdSs'^o^s'^'® Neotnre before the Physical Society 
Sir Joseph Thomson no?® fwough gases will he given by 
5 o’clock, at the Inin'eri'afr.n'^-®-’ Friday, March 9th, at 

South Kensington \-nT- ,^686 of Science and Technology, 
The course of th ^S'ln'i^od. 

Leeds Medical lectures on cancer at the 

, IS under the ioint Z ^^•'^oh 7th, April 4th, and May 9tU 
British Empire **'0 Yorkshire Council ot the 

Medico-Chirnrgical sSe“- Hiding 

The Fellowship of Ar.V- . 

Wilson will lecture on announces that Dr. C. M. 

“ P-m., at the Stedioai o„ ®. ®"ronic abdomen on March 5th, at 
girendisii Square W i of London, 11, Chandos Street, 
Heruaman-JohnsoniriilAnu® 6th, at 3 p.m., Dr. F. 

graphs, at the British r lecturo, illustrated by radio- 

Street,lV.l,ona:rav,acZ‘’‘®t.® o' Eadiology, 32, Welbeck 
wfu®^®' March ‘1'*^ diagnosis ot abdominal 

TwH."^ '!><nical o' , “’^5 p.iu., Mr. T. Jefferson Faulder 
^“lipita!. Tho e,*' t'le Golden Square 

bocii.,'® “Wdical practiun®'®'^® ®®d two deinousti'ations are 
begin on March Stli-n^ ®®®- Tli ree two weelts’ courses 
Hospital '"''‘men, in afij’’ gynaecology at the Chelsea 
Eor? p’ "y opbtL7'®®f®®® childreu at tho Queen’s 
Eromn?^® i?°®Pital. An VI? laftemoous only) at tho 
Hromar®® Hospital for on' coarse avill be held at the 
•Roval^f'* fn 21at inoi® )''®ok, beginning March I9th. 
^ * National OrthouZml.®??^® will be a course at tho 
uaeuic Hospital, and from March 19th 


to 30tli a course for the gciioral practitioner at the Hampstead 
General Hospital daily fioiii 4.30 to 6 p.m, Mo special 
courses Will bo hcguii subsequoutiy nntil April 16th, but the 
1 ellowsiUp of Mcclicino jirovicles a general course of instrnc- 
tion at hospitals, for wiiich comprehensive tickets are issued 
for varying periods. Farther information may be obtained 
from the secretary of the Fellowship, 1, IVimpole Street, W.l. 

A POST-GUADUATE Course in neurology and psychiatry will 
bo held, ill English, at Vienna, under the auspices of the 
American Medical Association of Vienna, from June let to 
July 31st. Farther information may be obtained from Dr. E. 
Spiegel, Falkostrasso 3, Vienna I. 

The Central Committee on Bheumatlsm ot the International 
Society of aiedfcal Hydrology has decided to organize clinical 
conferences on cases ot rhenmatio disease in hospitals, with 
the assistance of members of the different national com- 
mittees. In connexion with the inaugural meeting o£ the 
French Committee on Ehenmatism in Paris on April 2nd a 
contorcnco will take place, with tho collaboration ot French 
physicians, at La Pitie Hospital and the Salpetriere. Any 
medical men desiring to attend this conference can obtain 
further information from the secretary of the French Com- 
mittee, Dr. H. Forestier, 10, Bne do Mont Tbabor, Paris (I). 

The tenth international medical post-gradnate course, with 
special reference to balneology and balneotherapy, will be 
held at Carlsbad from September 23rd to 29tb, 1928. Clinicians 
and scientists from tho medical faculties ot Austria, Bulgaria, 
CzccUoslovaltia, Denmark, England, France, Germany, Italy, 
Norway, Poland, Sweden, Switzerland, and the United States 
of Amorica will give addresses. England will be represented 
by Professor Hugh MncLean and Dr. George Graham. An 
Invitation is extended to all medical practitioner-s. Those 
who accept will receive a passport visfi without charge 
and a 33 per cent, reduction on all State railways in 
Czechoslovakia. A programme of entertainments has been 
arranged. Full information may be had from Dr. Edgar 
Ganz, secretary of the medical post-graduate course, Carlsbad, 
Czechoslovakia. 

The Standing Committee appointed by the Board of Trade 
will hold an inquiry on March 5th and 6th as to whether the 
following imported goods should hear an indication of origin; 
surgical, medical, dental, and veterinary instruments and 
appliances, aseptic hospital furniture ot all descriptions, 
dental supplies ot all descriptions other than glassware, 
and dental furnitare of all descriptions. The inquiry will bo 
held at tho Board of Trade Offices, Great George Street, 
S.W.l. Communicatiousshould be addressed to tho secretary, 
Mr. E. W. Eeardou, at that address. 

The second Hispauo-Portuguese Congress of Urology will be 
held at Madrid from May lOtb to 16th. Further information 
can bo obtained from the general secretary, Dr. T. S. Govisa, 
Calle do Alcala 93, Madrid. 

THE National Institute of Industrial Psychology, which 
was founded seven years ago for the application of the hnman 
sciences to the everyday need.s of industry, has received an 
anonymous gift of £4,090 towards the cost of new premises. 

We have received the first issne, dated January 15th, 1923, 
of a new monthly iournal ou anaesthetics entitled NurAoss 
iind Anacsthesic, and published at Berlin nnder the editor- 
ship of Dr. H. Franiten ot the Freiburg University Women’s 
Clinic, assisted by Drs. H. Eppinga and 0. Pankow ot 
Freiburg, E. Rohn of Bonn, and P. Trendelenburg ot Berlin. 
The issue contains an original article by Dr. H. Lindemanu 
of Dusseldorf ou new methods for producing anaesthesia of 
the jaws and face, a review by Dr. Hans Killian ot Dusseldorf 
ou tho results of rectal anaesthesia by avertin, and abstracts 
from current literature. 

It is announced in the January issue of the British 
Journal of Anaesthesia that a prize ot £50 is offered in com- 
memoration of the late Dr. Sidney Eawson Wilson for the 
best research on inhalation anaesthesia between now and 
December 1st. In sending the essay a nom cle plume is to bo 
used; further information maj' be obtained from the editor 
ot that journal “Ainsdale,” Palatine Eoad, Withington, 
Manchester. 


The subject ot tetra-ethyl lead as an addition to motor 
lirit, which is referred to at pages 363 and 366 ot oar present 
sue, was raised in the House ot Lords on B'ednesday by 
ord Buck-master, u ho moved that the Goverumeiit should 
umediately set up a committee to advise as to the ^hho 
luger that might arise from this cause. Lord Salishni^ , in 
inlvin.. for the Govermiient, said that an mterdepptuiental 
^iniiiiM’eG vvoiilcl Dg appoiutecl forthwith, containiiif, repre- 
mtauves 0 °the MinistZ of Health, the Home Office, and 
le JEedical Eesearch Conncil. On this nudertaking 
uckmastor withdrew his motion, after insisting that 
ninent chemists ought to be included m the membership of 
IB cominittee- 


382 March 3, 1928] 


I/ETXEKS, NOTES, iiND ANSWERS. 


[ ■ r TffE Bsmfli ’• 
L Mkdicai. /ocs.'ru 


WtUttSf . JIntcs, mtiT J.itste5. 

All communications in regard to editorial business eliould bo 
addressed to Tho EDITOR, British lYIodlcal Oournal, British 
niodlcal Association House, Tavistock Sifuaro, W.C.I. 

ORIGINAL ARTICLES .and LETTERS forwarded for publication 
aro understood to bo oifered to tlio UaiTisii Medical JounHAL 
alone unless llio contrary bo stated. Corrospondonts wlio Avish 
notice to bo' taken of their communications should nulhcnlicnto 
them uilh their names, not necessarily for publication. 

Authoi-s desiring REPRINTS of their articles published in the 
Bamsii Medical Jouhnal must communicate with tho Financial 
So'erotary and Business Manager, British Medical Association 
House, Tavistock Square, W.C.l, on receipt of proofs. 

All communications with rcforenco to ABVERTISEMENTS, ns well 
ns ordeia for copies of tho Jourhal, should bo addressed to tho 
Financial Secretary and Business ilnnager. 

Tho TELEPHONE NUMBERS of tho British Medical Association 
and tho Bamsn Medical Journal aro MUSVVil OSCl, OSCi, OSCS, 
and OSCi (internal exchange, tour lines). 

Tho TELEGRAPHIC ADDRESSES are ! 

EDITOR of tho Bruise Medical Journal, AitloJoau Westeent, 

■ Loudon. 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.). Articulate JTcsIccut, Loudon. 

MEDICAL SECRETARY, Alcdiaccra rTcstccnt, Loudon. 

The address of tho Irish Office of tho British Medical Association is 
16, South Frederick Street, Dublin (telegrams: Haeiltus, Dublin; 
telephone : 4737 Dublin), and of the Scottish Office, 6, Drumshcugli 
Gardens. Edinburgh (telegrams : Associate, Edinburgh; tcicptiono : 
84361 Edinburgh). 


QUERIES AND ANSWERS. 


ParswiiOav of Defaecatioh. 

Dr. a. 0. Jordan (London, W.) writes: In reply to numerous 
iuqoiries regarding the w.c. fool-rest referred to In my letter of 
February 18tU (p. 2921, tho address of the makers is the F.A.F.R. 
Company, 35, North Gate, Newark, Notts. 


LETTERS, NOTES, ETC. 


Rapid First Labour. 

SunoF.ON Commander G. V. Hobbs, R.N., writes: The booob-.i 
of two cases of painless natural labour (Journal, January 21il 
]>. 120, and 28th, ii. 164) prompt me to mention tlie followieg cm 
iatloiidcd some years ago, which I think must be equally rare, 
I was called one night to nee a young married woman said lots, 
suffering from acute abdominal pain. It was obvious she irai 
in labour, and after exaniinatiou I expressed the opinion that 
tlio cliild would not he born for some fioiirs; I then foituil that 
bIio was unaware of her condition. I was also surprised when a 
perfectly healthy child of 71 fb. was born oufy two hours later, 
three and a ball hours after the first pain. It appeared that 
seven months previously she attended her own doctor lor ths 
nmonorrhoea, who, finding she was Buffering from anaemia, gaia 
that as a probable cause and preaoribed for it. The patieut 
thought this treatment beneficial, causing her to put on weight. 
Tlioro was no evidence of quiokoning, and she felt perfeotlylit 
during tho whole of her preguauoy, playing teiiiiis, aud even 
going for a twelve-mile walk with her husband tlie day belore 
the child was born. Tlie points of interest in tlie case are: 
(1) Tho short period of labour for a primipara — namely, three aud 
a half hours. (2) The lack of distress of tlie patient: she was 
most auxions to get up the next day', as she felt so well. {Jlllis 
abseuco of any reason for couoealmeut of her oonditiou. (4) The 
fact that she was staying, at the time with her motlier-iudaw, 

. who evidently noticed nothing., (5) This case also illustrates ths 
advantage of a pregnant woman leading a uormaf life, iuslead el 
pandering to false modesty by staying indoors and taking very 
little exorcise, a proceeding all too common at the'pr'eseut day. 

Dr M. M. Russell (Sutton) writes; At the risk of lironsing 
incredulity I am prompted by recent letters in the Journal to 
meutiou a case which 1 attended while on extern duty at the 
Rouiiida Hospital, Dublin, in 1915. I was called to see a stalwart 
vouiig primipara in labour who,nftBrIarrivod, had three uterine 
coutmetious without nuy disoomlort, with the head on tba 
noriiieum. She theu declared that the “ baby was coming,” aud 
on the next contraction the head was horn with the membranes 
iulacl aud was tbeu completely witbdrawu witbin tbe vulva 
naaiu ' I ruptuced tlio membranes aud tbe child was born forth- 
"”,1, ■ . ' • tbroiighent. 

It wai . • • ■ 

porloeal laceration. 


Firemen’s Crajip. 

Dr. F. G. Gardner (Oxford) writes : I believe the view now hold 
Is that cramp ooourrlng in firemen and others working in great 
heat is due to a deQoieuoy of eodium ohlorido in the system, as 
the result of excessive sweating. If this is so, proveutidu should 
be n simple matter. A largo quantity of cold water quickly 
swallowed will Induce “cramp” in anyone— as manvof us know 
from experience. A safer drink, aud one more satisfying to the 
thirsty, is oatmeal water. A contributory cause of cramp is 
exposure of tbe abdouieu, eitlierat work or at rest; the rapid 
evaporation of tbe sweat causes “absorptiou of beat," and so the 
blood is " cbilled "over a large aud somewhat euperfioial area. 
Those who “go down to the sea in ships ” — naval surgeons and 
others— have opportnuities of testing the theories I allude to In 
a very simple manner, aud their experiences would be useful aud 
interesting. 

Income Tax. 

Motor Car Snmvals. 

“ H. C. M.” bought au “ H ” saloon (U.4 b.p.) ip 1922 for £750 aud 
has now replaced that car by a “ \V ” ealoou /16 h.p.l for 
£495— £140=f355. He asks what claim lie cau make, “taking 
into consideration the increased horse-power.” He has not made 
any annual claim for wear aud tear. 

Nominal horse-power is ouly oue consideration among 
several indicating tbe capital value of a oar, and seeiug that the 
list price of the second car is £155 below that of the former car, 
we are of opinion that " H, C, M.” may fairly claim the whole of 
the out-of-pocket expeuse — £355 — as au expense of renewal. 

Sale of Practice. 

“ E. A. M. C.” was in partnership from October, 1922, to Sep- 

, tember 30th, 1926, and on his own account to September 30tii 
1927, as from whioii date he sold his practice aud lias been 
unemploved. He has received applications for payment of tax 
“ from tiie inspector’s office, £34 odd, aud from the coUeotor's 
£6 plus £27.” 

His liability will he represented by the tax applicable to 

(1) a hilf-sliare of the practice profits to September 33th, 1926; 

(2) the whole of the profits (as calouUtad on the usual average) 
for the half-year to March Slst (or April 5tb), 1927 ; and (3) tho 
half-.vear to September 30th, 1927, based ou halt the amount ol 
the piofits of the year to September 30th, 1926, or to whatever 
may have been the usual date taken for income tax purposes. 
It the whole of tho caih received for practice debts is brought 
iuto tbe computation of tho practice profits after the dissolution 
of partuership at September 30tU, 1926, tbeu tbe £100 received 
since September 30th, 1927, should be ignored. ^ R. A, M, C.” 
will probably find that tbe applicxtious by tbe inspector and 
collector refer to tbe. same amounts of tax, and should not be 
regarded as iudependeuU 


A Scarlet Red Dry Dressino. 

... _ . . igie of Man) writes: I should like to 

0 ■ ' tiou ot scarlet red incorporated into 

.■ . ent of indolent ulcers. It is prepared 

'“-‘I'nnon is made ot 20 grains ol a Biebrioh red 

ft9 lOuOW® • , ^ ' 

(chemically. 

u't.mArVed iu this solution for two days, ourmg wniuu 
The 'i"uhl be oooasioually compressed, so that the solution 
period It she; d he 0 t>‘e material. Without wringing or 

may heat it is allowed to dry, aud is theu noued 

the use of ai title g details, even if only roughly 

“I,'* Juriuruish a satisfactory dressing, which shon d ba 
lonowcd, V ill f . ^ tbe piece of material employed 

5^‘emg cu?exaaiy to the sixe and shape of the nicer. 

Haemoptysis in Infants. 

„ T Tt.TTiE (Klerksdorp, Transvaal) records the case of a 
OB. C. J. B4TTL ' 3 months, who ivas fouud oua 

male Hood running out ol his mouth. He 

moruiug coughing and coughed up a bluish clot. Later 

thou went blue in the face, and ooughed iipblooil 

he agaiu couR ■ g g^mg uijjht he passed black stools. Tbe 
mixed 'vitb 6 me-^ (g,.gg „a3 rather leaden. In the left luog 
child ‘ oitations, chiefly in the upper lobe ; there was uo 

were niauy orep normal. In tbe afternoon fresh blood 

pyrexia “"d ^ were fouud iu his mouth. It was stated 

aud a small 0101 m ^ j jigg Paeu uo epishixis, 

that ‘‘‘ose had b®eu j , 

aud there apl c . ^ rjij,g jufant was given an injection o! 

acoouut lor i , ggtatio serum, which was repeated ue.xt day: 
about 2c.om- . .g|.gjgj jlig mouth. Two days later the 
calcium was ^j^g j-eotum, and ou tbe fourth day it 

temperature waa „jjgj.g m, more haemorrhage after the 

was normal aoB ■ ggegud day of illness there were signs ol 
first iu both lungs, and this lasted for a week or 

bronclual catar n ^ ^ exception of some stomach trouble, 
two. Smoe tbeu, wvm ^ , ,g. ,j,,,g 

due to case appears to me to lie in the fact that haomor- 

iuterest of the case pp mouth m.mfants is 

rbage from the luuyB of Sau 

exceedingly late, Management of the Sick Infant, is pruoti- 

Prttuoisco in 

_ ..'ll 


VAOA^XIES. 

PiuATlONS of 

'sh±— v^ofvSptM 

: It, the Suovlement at-page /d. 


CHKONIO INTESTINAti TOXAEMIA IN CHIIiBREN. 


[ 


Twr Britts 

^lEuicit. JooRNiL woo 


2,n 




CHKONIO Ev’TESTINAIj TOXAEISIIA IN , 
CHILDREN. 

DmrmD D.:roKE thf. iUMrsiR^vD MfTdicai. SooiriT, ' 
jAXMnt lOin, 1S28, 

PT 

REGINALD MILLER, SI.D., F.R.C.P., 
mrsioiF. P 1 DDISGI 0 .V csta cnit-Dnr.v’s hospital; efkiob rnTEicus 

TO Oirr-PiTIE-VTS, ST. WART S KOSBITAL, LONDON. 

The chief object of this ndilrcss is to direct nftention to 
tho type of child who is persistently out of health owing to 
chronic intestinal toxaemia. I shall deal, first, with tho 
signs and symptoms by which it maybe recognized ; secondly, 
with tho various forms of intestinal derangement respon- 
sible for it, some of which are special to childhood ; nnd 
finally, with tho principles of its treatment. But I have 
also a subsidiary purpose in view, which is to craphasizo 
tho fact that in many of these children tho most con- 
spicuous symptoms arc those pointing, to disorder of the 
noiTous system, so that tliero is a danger that tho causa- 
tive physical condition may bo overlooked nnd tho case 
regarded as a purely psychological problem. In these days, 
when the psychology of tho nursery is so much under dis- 
cussion, this danger is, at least in my opinion, by no 
means remote. 

Becoonitiox or tiie " Intestinal Cnii.n.” 

The “ intestinal child ” — as, for lack of a better term, 
we may call tho typo produced by chronic intestinal 
toxaemia of all sorts— is often easily rccognizablo at sight, 
but it is seldom brought to see the doctor for any one very 
definito sjTuptom. Occasionally it is brought for irregu- 
larity of the bowels, sleeplo.ssness, persistent nocturn.al rise 
of tcmpcimture, or bouts of feverish biliousness. Much 
moro often it is brought that the parents may learn 
whether it is ill or not; and it is notioeablo how often 
oth p.arents accompany the child, so nonplussed aro they 
^out tho whole business. “ Why docs it look like this? 
nay does it behave as it does? Surely there must bo somo- 
taing wrong with tho child.” Tlicso aro the things they 
® “aplication being, of course, that to such parents 
1 • P'“aid but brilliant, and as least as 

ihIidoA 8™d, should have boon vouclisafcd. And 
parent 3 Utth!“\\-^*’ confessed that tho child brings its 
suvirpsto no' credit, for its appearance 

demrtmpnt ' f™™ a spell of dchauchory, and its 

the third '’■sited upon tho fatliers unto 

final child are 

TKn ‘ t “^^10 to bo enried, 

under Srhp”,d' perluaps best summarized 

appeLte S:f unhappiness. In 

times undersize<r- "f ''‘“'■“'■*®>'>stic) it Is thin and somo- 
muddy its pvp. ’ .'oniplexion is pale, sallow, and 
aniged and tlm IowoM'T''^ towards evening, are darkly 
Its breath foul and -t *^“267; its tongue is coated, 

it noticeable that tl. •i”??”'' strong. Especially is 

way feel and balvR-t completely tired out; it 

More often it is f , “ush languid and exhausted, but 
Its appetite is bad^'^^'^'^ active, chiefly in wrongdoing, 
purge, at a nartv ’ perhaps for breakfast, after a 

meals are often a holidays. So had may it be that 
f.amily. Its sle^n ! nait sometimes a horror to tho 
disturbed bv frmhtp^ asnally poor : awake late .at night, 
doing at daivn. dreams, it is agog to be up and 

a poisistent low is common during tlie night, and 

unnaturally adds .discovered. This not 

doctor, who has i,;u, -1® Parents’ alann, and often the 
duo to had aianarrpiap ®r*® regarded .the whole business as 
the idea yiTp-pn spoiling, becomes obsessed with 

to this he will seldom tuberculous mesenteric glands : 

a correct; Ponrersions of appetite. 


such ns dirt-eating, gnawing of bedclothes, and others, are 
not uncommon. 

Tho nervous symptoms aro often more conspicuous than 
those of physical ill health, and I have already mentioiied 
Eomo of them. Taken ns a whole tho child is chiefly 
unhappy, and its misery spreads to those round it. It is 
unreasonable, ill humoured, cantankerous, self-centred, 
emotional, negative— everything, in short, that can make 
a child unpleasant. In milder cases it is shy, frightened, 
occasionally spiteful, and on the whole disappointing; 
but moro often it is actively and aggressively unpleasant. 
Much has been mado of the negativism of neiwous children, 
hut it is tho inevitable expression of noiwous irritation 
and exhaustion. How else can a child show this? It 
cannot go home and bully its wife and family; so it shows 
its ill humour in refusing to do tho ordinary things 
expected of it — ^the child’s method of bullying. 

Tho intestinal child is often in character singularly unlike 
its brothers and sisters. The parents, thinking on psycho- 
logical lines, aro reminded of the neiwous taints and^ pecu- 
liarities in each other’s relations, hut surely in such circum- 
stances n physical cause for the child’s ill health should 

suggest itself. . 

In many cases tho symptoms are altogether milder and 
less harassing, and here we see the difference between the 
normal and the neurotic temperament. Tho placid child, 
poisoned from the intestine, becomes sleepy, tired, 
apathetic, and protects its incapacity by withdrawing its 
interest from its surroundings. The neurotic child, on the 
other hand, heenmes in its fatigue more restless, and so 
enters into the vicious circle so well demonstrated by adults 
who have command of their own course. 

Thus far, then, we have the picture of our too-familiar 
friend the “ nervous child.” How are wo to distinguish 
the group ivliich originates in intestinal toxaemia? It is 
true that in most cases the very appearance of the child s 
face should suggest the presence of a toxaemia quite 
decisively; but there are other signs which point clearly to 
«16 intes^tinal tract, and of these I place re lance chiefly on 
tho following: (o) enlarged abdomen; (b) the occasional or 
persirtfnt ofcuiVence of abnormal stools; (c) the presen^ 
of gross indigestion os shown by microscopical or cjicm 
oLmination of the faeces; (d) the presenee of much 

“‘EXrgLtnt "outlie abdomen is frequently overlooked 
by parents and doctor, and if recognized it is often mis- 
inte%reted. A cliild’s abdomen ought not to swell visibly 
from^timo to time, or to diminish visibly after an action 
S bowels. I always view with 

of which tho mother says it is the child s )cs p . 
Fnlarirement of the abdomen must, then, be looked for, 
S if f^Ld must be explained. InTutestinal toxaemm 
fhe distension is chiefly due .to 8“*^®“®’^^''®.^®",“%:^ 

L“'\”oxa^ia?"1ho "stools- tr A f-queuT undig|ted ^or 

h"times''rJlnd1sVo%e”hf^ 

by microscopical exammation of the stools, i win oea 

^'‘But, it may be said, granted that there is an action 
between disorders of the ^l.ich tho 

toxaemia, who is to say which i there are 

effect? Now. I readily, admit 

•• nervous children withou j jrom develop- 

there.is nothing to Pi;®'’®!!* “ it is clear that in 

ing intestinal toxaemia ; furthc , be produced 

aLuropathio child thlm in^a moro 

by a 'smaller degree ^.-i-ntruisb between such c.auses 
stable subject. Yet to customary tnsk 

and effects in indmdual produce evidence 

of the physician, and I he , j ^ f producing the 

that intestinal. childA’ 

psychological g— first that from the early 


'384 March lo, 1928] 


CHHONIO INTESTlNAri TOXAEMIA IN CHILDREN. 


[ TuECnmsa 
ift'Dicii, Jom’iit. 


J)aiu, has a great ctfcet on tin? iiorrons system ; tefjiiiy and 
convulsions are hnt c'xtrenie example's of this. Eor a 
hahy’s mishehaviour there is .still more, merit in a dose 
of castor oil than in the mo.st modern p.syehologj' of the 
n\irsory. In matters .seientifie the infant remains sadly 
out of date, and even the small child conservative. 
Secondly, as .shoeing tin,; jcossihlo production of nervous, 
sj-mptoras hy intestinal toxaemia, J cvould cite as the; 
clearest proof the child with eoeliac disease. Hero, wo 
have all the eccentricities of tho “ nervous child ” in 
cxcclsis — ^tho negativism, the introspection, tho so-called 
'■ anorexia nervosa,” and tho re.st of them. While p.sj’clio- 
logical treatment aloue i.s here, a complete failure, correct 
dieting brings about gradually such a change for the 
heller that tho child becomes easy, well behaved, and 
lovable. Yet with an extra dose of fat, bringing back 
abdominal distension and ford .stools, there reappear the 
irritability, tho loss of appetite, and the unhappiness. I. 
have seen this so often that I cannot doubt the sequence' 
nf events. Further evidence to the same point might ho; 
given. I could quote the experience of adults with in- 
testiiiarto.xacmia, the effect of Plombieres treatinont, and 
tho alteration in the disposition of the “ intestinal child ” 
when properly treated ; all these show that a toxaemia of 
intcstiiral origin can have a profound elfcet on tho nervous 
sj'stem. 

I uill therefoie conclude irith tuo .sub/ni.s.sions. First, 
that any child who i.s brought to us for marked nervous 
symptoms and pcerdiaritie.s should be examined rvitli 
great care for some possible phy.sical cause, particu- 
larly one originating in the intestine; remembering that 
the nervous symptoms are often so conspicuous that they 
are likely to mask the less evident intestinal .symptoms. 
Secondly, I would urge that whore iute.stinal toxaemia', 
can he proved, a generous nliowaiiec should ho made for tho 
child’s misdoings. I linvc seen such alterations in dis- 
position in these cases that I am convinced that allow- 
ances should he made for those ehildroii on tho ground tliat 
they arc really ill children. I would even go further than 
thin, and .suggest that a like measure of chailty ho extended 
to the mother herself. For her to see her child looking 
often enough like a dissipated drug addict and behaving 
like a fiend is more than likely to make lier morbidly 
anxious and unwise. After all, if our mothers may not be 
” unwise ” with us, who may? 

Forms of Ixteshx.m, HisoanEE rnontrciKC the 
Intestinal Child. 

Let me first exclude two conditions which should not be 
classed as causes of intestinal toxaemia — namely, .simple 
coiistipatioii and abdominal tuberculosis. 

.Simple constipation does not, in my opinion, give rise to 
toxaemia. In a child, if it produces anj' sjinptoms, they 
are those of abdominal distension ; pain, partieidarly after 
food (of which constipation is tho commonest cause in a 
child) ; and perhaps some lack of appetite and disturhed 
.sleep. Where toxaemia develops I class tho case as one of 
toxic coustiiiation or of the other tyjies to be considered in 
a moment. 

Abdominal tuberculosis is often diagnosed in these cases 
because there are chronic ill health, abdominal eiilargement, 
and nocturnal fever with sivcatiiig. As a matter of fact, 
in the richer classes it is by far the least common cause of 
this triad of symptoms. Yet it is diagnosed because tho 
doctor does not appreciate the alternative possibilities, 
and pcibaps has not examined the stools. A child cannot 
bo ill for two or three years from abdominal tuberculosis ■ 
and yet show no abnormal signs in tlio abdomen. Tuber- i 
culous glands are the commonest lesion diagnosed, but there 
is no reason at all why their pro.seiice should be accom- 
panied by foul and undigested stools. Some confirmatorj- 
sign should be elicited before such a diagnosis is made. 

*1 turn now to the various digestive disorders which may 
give rise to intestinal toxaemia in cliildreu. 

Coehac Disease. 

I put this first because it is both common and clearly 
recognized. I have not hero in mind the classical form 
of the disorder, with its large, pale, offen.siro, unformed 


.stools containing a great excess of fat, chieflv in the form 
of fatty acids. Rather I refer to tho milder tvno wliidi 
1 iiavo clsowJiorc dcsjcribccp as tlio non-diarrlioeic type, ia 
winch the stools are largo formed, coloured, and contain 
their excess of fat chiefly in tho form of soaps. This 
pi’h gives rise to abdominal distension and coiisideraWo 
toxaemia, and can. of course, be recognized hy a careful 
analysis of the stools on ordinaiy and on f at-f reo - diets. 
There are, however, a low points which are of aid in 
reaching a diagnosis clinicrdly. Growth in height is 
ictardcd more constantly and more seriously in this group 
than in . .any of tho other forms of intestinal toxaemia. 
I'lattoning or wasting of the buttocks is a suggestix'e sign.^ 
Lastly, eoeliac children are very seldom constipated, and 
in this they differ froni most other cases of. iute.stinal 
■ toxaemia. On the contrary, tho bowels act very regiilarlv, 
and however little the child maj- cat one day it will not 
fail to pass a good-sized stool tho next. How often this 
leads to the erroneous conclusion that there is nothing 
.wrong with tho intestine! Yet it is a noteworthy yioint 
in favour of malabsorption of fat. 

I must not forbear to mention that H. C. Cameron, 
who has written so instructively and delightfully on tlia 
” nervous child,” has repeatedly laid stress on its in- 
ability ill many cases to take fat well. In doing so ho 
"has had, I think, flio tendency to acetoiiaemia chiefly in 
nrind. The intestinal child is not the tyqie which is prone 
to true jnimary acetoiiaemia fcyclical vomiting), although 
it may liave feverish bilious attacks with secondary aceton- 
aemia. In the eoeliac cases the cliild cannot absorb fat 
properly, and to give it induces toxaemia and .perhaps 
a low porsistont fever. In other types of intestinal 
toxaemia cooked fats (of roast meat, sausages, rich 
gravies,- etc.) will upset, just as -they will similar cases in 
adults. 

Starch Indigestion. 

In spite of the amount of attention paid .to it in the 
textbooks I have not found this to bo a common cause of 
intestinal toxaemia. It can be easily locognizod in a 
'microscopical examination of the .stools, anti may be su.s- 
pected where a child passes rather loose acid stools, pitted 
or honeycombed from the evolution of gas. Such indiges- 
tion' sets up a secondai-y colitis. These cases seem chiefly 
to arise from overfeeding with starch, but tbere seems 
little doubt that rarely there is a great intoleranco of 
starch. 

iViif Indigestion. 

In the last three or four years I have met with a dozen 
or more cases of chronic indigestion in which the stools 
-were full of undigested nut cells. The.sc are easily recog- 
nizable as being tho only vegetable cells wliicb contain 
oil ' The amount of tlicsc has been in some instances 
sufficient to make the stool large and fatty. I am not 
satisfied that I have always been able to explain tlio 
nrcseiico of this, and suspect that ernshed nut is being 
used in some foods which I have not yet traced. 

Lamhliasis. 

Infection hy this flagellate protozoon is now very 
common amongst the children of the hospital class in fins 
country. I have published” a study of the effects of it on 
them. It produces an enterocolitis v.'ith some distcn.sion 
of the abdomen and loss of weight. It is, however, moro 
characterized hy intractable diarrhoea than hy an ohsenro 
toxaemia. The stools show all sorts of undigested food, 
mucus but no blood. The flagellate is easily seen under 
the microscope during the diarrhoeic periods. ' 

■ Toxic Constipation. 

Lastly, there is tho group of imclassifiablo forni-s of 
inte.stinal indigestion similar to the nsnnl adnlt 
Their origin is as difficult to dogmatize on in children os 
in adults, Fersonally, I believe that they arise in w''”'” 
ways. Some are the sequel to acute enterocolitis^^ 
example, dysentery. Others are possibly the resnu o 
infection of the intestine from above — for example, m" 
fected tonsils or antra. By far the most common txpe, 



CHKONIC INTESTINAti' TOXAEMIA IN CHILBEEN, 


MARCH 10 , 


192S] 


r THKBRm« QDg 

l.lIr.DTCXI.J 0 CSNXIi 00 U 


'1 is that ivhich foIIoOT prolonged constipation: a 

howoTcr, IS at ^ „ turns into a toxic constipa- 

transformation brought about?' 1 
IXva S ahaomal infective agents Iiavo very little to 
Ao whh It in ordinary cases, but that the sequence of 
ovents is increasing constipation causing faeca decom- 
wsition, ivhich in' its turn produces irritation and catarrh 
1. Tn iliin the chcmica 


of the colon. 


In this the chemical irritants of decom- 


position arc often aided by the use of improper purgatives 
Ld an nnsiiitable diet of “ rough.ago." In my view it is 
the supervention of this mild colitis winch pormits the 
ahsorption of toxins from the hoivcl. A great function of 
the colon is to refuse to ahsorh the poisons which are over 
present within it-at least in quantities gi'cater than can bo 
dealt with by the liver; it is not, tborcforc, unreasonable 
to assume that where the wall of the colon is abnormal its 
impermeability is impaired. 

With the onset of the colitis there is not only toxaemia, 
but pain or discomfort in the hypcracsthctic colon may 
develop. Spasm of the colon (spastic constipation) is rare 
in childhood. 

In such cases of stasis tho stool is usually alknlino in 
reaction, and rather foul and greasy from tho piosonce 
of a little mnciw. Microscopically tho food resitlucs nro 
■found to he finely divided; the muscle fibres small, palo, 
rounded, with their striatioii Inrgely lost. Although there 
is no excess of fat in the stool, many huudlcs of coarse fatty 
crystals can be found by tlio microscope. Oxalate crystals 
are also nnmerons. The benzidine test for occult blood is 
■usually positive. The bacteria may bo normal, but fre- 
quently there is a proportionate excess of streptococci. 
Other and more ahnonnnl organisms arc sometimes present, 
but I have seldom been able to trace 'any significance to 
them. Although tho amount of mucus seen in the stool 
in ordinary circumstances is scanty, on washing out tho 
bowel there is usually plenty, both old and recent. The 
urino contains a largo amount of indienn and many oxalate 
crystals. 

Two conditions eotneiimes associated with toxic con- 
^ipation require mention : parasite.", and appendicitis, 
^ns is the type of case in which threadworm infection 
?s common. Except for loc.al syrajitoms I do not believe 
its presence makes any difference. The so-called symptoms 
of threadworms are, for tho most part, those of toxic 
constipation and colitis. 

Rppiindicitis is common enough in children. 
,.-11 j “ 'R ^'inm a condition similar to the so- 

ed chronic appendix " of adults is questionable. 
nnU ^ I'C-gard riglit-sidcd abdominal pain 

'discesn”;Tf'^^'T-i5* ™ni'® indicativo of appendicular 
tliiris tl,;V “diilt. My reason for saying 

beei reZved ft 
in childWd. 

The tro ( ^R’^'RJwrs or Tnr.ATAtENT. 
to he lonn intestinal toxaemia in children is apt 

■ necessarv tn * Paticnco and attention to detail are 

briefly cnumcrrtr'll,®‘“’'^-'’“'''^®- ^ Tory 

treatment. ^ Pviticiples which should guide the 

Many of tliKP 
ill enough to benefif f 

this is iinnecessarv ^ ^ R’^Rtli’s rest in bed. Where 

exhaustion mnst V "RRHS'" to ensure freedom from 
troublcsoniD sedat" ^ ™nintaine<I, Where restlessness is 
sheet-anchor here ordered; bromide is a 

to promote sleep ^R older children adalin is veiy useful 

Uliere the e Biet. 

lions in tbg in digestion is knomi the altera- 

groiip of cases 1^"^^ nlearly indicated. De.aling with 
diet should ], above “ toxic constipation ” ' — 

quite different fmm the associated colitis. This is 

tor the aim ; i’Rt _ used for simple constipation, 
Amal] smooth rc<:;,l,-il ° R diet wliich will leave a 

' RRd all sorts of “ roughage ” are 


out of place. Fresh fruit, except orange juice and 
squashed ripe banana, shoidd be forbidden, and cooked 
fruit given only sparingly and without pips or skins. Tho 
vegetables allowed should he only such as can be put 
through a siove. Cooked fats of roast and fried food 
and rich gravies often dis.igree. On this diet, although 
tho constipation may bo increased, discomfort and dis- 
tension are lessened, and a ohanco is given to the colitis to 
subside. 

Aperients. 

Much depends upon the .selection of an aperient wliicli, 
when given regularly, is efficient yet harmless. The aim 
sliould bo to produce a stool which is soft but formed, 
avoiding either a constipated or a watery action, liiquid 
stools are far more toxic than are formed ones. 

It is rather characteristic of the cases of toxic con- 
stipation that they are ordered doses of calomel once or 
twice a week. These, although they do temporary good, 
are liable to set up or increase colitis. Even for emer- 
gencies castor oil is safer. 

Paraffin is, perhaps, the drug in most common use. 
IVlicre quite small doses are effective there is small objec- 
tion to its use; in large doses it is quite unsuccessful. 
Stools full of paraffin ferment readily, and a microscopical 
examination of them shows how great is the interference 
with protein digestion. On large doses children remain 
distended and toxic, and their tongues coated. An 
emulsion of paraffin and plienolplithalein has much more 
“.cleansing ” power, and, where it works eflflciently in small 
doses, makes a good aperient for some of these cases. Cocoids 
of plienolplithalein make a very palatable aperient for small 
children, and m.agnesia may be sufficient for others. All 
preparations of senna and cascara are best avoided, if 
possible, for persistent use. 

MHiero tho child is old enough to swallow a tablet we 
have the group of bile preparations of which the pro- 
prietary preparation taxol is a pattern. Tliese, in my 
experience, are extraordinarily successful, and on the whole 
a groat advance on any of the other aperients for daily 
use. Tliey' produce no griping, the liver action is stimu- 
lated, the motions, with a properly adjusted dose, are soft 
but formed. In young children I have often prescribed 
taxol ground up in jam, 

Intestinal Lnvaffe. 

Intestinal wash-outs are very useful in really severe cases,- 
even though they may moan tliat the child wiU require 
more rest than would otherwise be necessary. They should 
be given about twice a week. The fluid used may consist 
of equal parts of Plombieres water and ordinaiy water, or 
of a solution of 2 drachms of salt and 1 drachm of sodium 
bicarbonate to a pint of water; 1 to pints should be run 
into the bowel from a funnel, tlirqugh a soft rubber catheter, 
and evacuated after being held in tho bowel for a minute 
or two. IVliere proper Plombieres treatment is available 
it is more efficient, but in children the wash-outs given at 
homo are often quite successful. After six or eight treat- 
ments at threo-day intervals it is usually possible to lengthen 
the intervals between the treatments. They should not be 
continued too long nor left off too abruptly. 

Blassagc. 

Some massage should be given, if it causes no pain, along 
the colon when cleared out by the wash-out. .An overloaded 
bowel should not, I think, be subjected 
bowel should first be emptied, ilany cases 
dilatation of the stomach, and light mass.sge for this 13 
useful. General massage is rarely advisable, and should 
certainly not he ordered until ail fatigue has p-assed off. 

later Measures. 

As the child improves appetite and sl<>op return, and 
■lUoT, IS nsinllv fairly assured. Additions may now 
progr.^ to the amount of exercise allowed. 

Enxntscxa. 

1 Lancet, 1923, i, 72- * Arch. Die. in Childhood, 1927. ii, 189. Itld-i 

1926, i, si 



386 ' March 10, J928J SCIATICA; ITS VARIETIES AND TREATMENT. 


"b, 


THRBnmw 
EDICAL JOCKNil 


'^uniman C^ration 

ON 

SCIATICA: ITS VARIETIES AND 
TREATMENT. 

Deliveukb before the Hunterian Society on 
Femiuaby 27th 

BV 

ANTHONY FEILING, M.D., F.R.C.P., 

PIIYSICIAS AND PEAS OP THE MEDICAL SCUOOL, ST. GEORGE’S HOSPITAL; 

PHYSICIAN TO THE HOSPITAL FOR EPILEPSY AND PARALYSIS, MAIDA 
VALE, AND TO THE ROYAL NATIONAL OR'niOPAEDIC HOSPITAL. 

With tho roccnt celoliratioiis of Hunter’s bicentenary 
fie.sb in all our inincls it is quite uiinocessary for mo to 
insist on tlio debt ivbicb the medicine and snrgeiy of 
to-day owe to him and bis tradition. 

Tliat Hunter Jiiinseif was fully alive to the interests 
afforded by tlio .subject of my addrcs.s may easily bo seen 
from tlie following quotation from ono of bis lectures:’ 

“ A gentleman complained of a pain in the liip, running down 
the outside of tho leg and foot. Supposing it rheumatism I gavo 
him James’s powder, Dover’s powder, and volatile tincture of 
guaiacum, but with no good effect. A linunont of opium to the leg 
and foot gavo some relief. He at last perceived a tumour by the 
os iscliii, 3ust at the posterior edge of the gluteus ina.\imus. Tlits 
tumour increased and tho pei-son died. Tho tumour was found to 
fill a part of the pelvis, and had made its external appearance at the 
foramen magnum iscliii, being filled with coagulated blood; but the 
pain in tho limb seemed to have been produced by its pressing op 
a great branch of the nerve, but chiefly perhaps from the great 
ischiatio nerve being stretched very tight over tho upper surface 
of the tumour. Here that happened which may often be observed: 
that is, the impression made on the tiuuk of tlio nervo gave a 
sensation as if it had been on the cxlreniilies of tho nerve.” 

I make no apology for tho choice of my subject for this 
Oration, trito though it may at first sight npiioar. The 
aggregate of sufferiug and of disability in the sbnpo of 
work and wages lost through this common disorder is 
sufficient excuse for any attempt to clarify its causes or 
lationalizo its treatment. 

It is unfortiiiiate that the term “ sciatica ” is ono 
of those which have boon accepted by the public and used 
by them to designate almost an3- kind of pain in tho 
i-egion of tho lumbar spine, buttock, hip, and leg. Like 
certain medical terms — “ rheumatism ” or ” anaemia,” for 
example — it covers a multitude of sins ; it sounds sufficiently 
scientific to lull the patient into a belief tlint the real 
nature of his symptoms is known, even allowing him to 
seek various forms of treatment — li^'drotiathic, electrical, 
and so on — entirely on liis own respoiisibiliti'. 

Wo should think of sciatica as merely' signifying sciatic 
paiii — that is, pain in the distribution of the sciatic nervo 
— -without allowing it to connote an}' particular pathogenesis. 
This simple anatomical reminder will at once prevent us 
from lightly labelling as sciatica any case where tlie pain 
affects, for example, the front of tho leg or the groin. It 
i.s hardly possible now' to abandon the uso of the term 
'• sciatica,” which is particularly useful in denoting one 
common variety of the disorder to wbicli further reference 
will, be made. 

Two Tyi'Es of Sci.vtic.i. 

For purposes of convenience wo may speak of (1) a 
secondary or symptomatic sciatica, and (2) a primary or 
essential sciatica. By secondary I mean a sciatica due to 
some gross pressure lesion; by primary or essential I mean 
that lai'go group of .^jases w'hero no gross pressure lesion 
can bo demonstrated, whoso exact etiology is a matter of 
doubt and dispute. Strictly ' speaking, it is, of course, 
inadmisrible to call siicli cases primary or essential— there 
is probably no such condition— but the term is useful and 

difficult to replace. c v ■ . . 

May I remind you very briefly of a few inqiortant 
anatomical points? The great sciatic iicrvo is fqi-med 
in tho sacral plexus from ho anterior primary divisions 
of the fifth lumbar afid the first and second sacral nerves; 
smaller brandies join iij fyott\ tU© fourth lumbar and the 
thii'<j sacral nerves. From its position on tho posterior 
pelvic wall where tho plexus is formed the great sciatic 
“orvo passes into tho buttock through the great sacro- 


sciatio. foramen . between the pyrifomiis and superior, 
pmcllus muscles. It passes down into the thigh in the 
Iiollow between the great trochanter of the femur and lie 
tuberosity of tho ischium. 

_ Tho part played by the fifth lumbar nerve in tho produc- 
tion of symptoms is a point of considei-ahio clinical impor- 
tanco; anatomically this may he in part explained by tha 
longer and more oblique course it has to take to reach tho 
plexus, as well as by other considerations to which I shall 
hare to refer later. 

Before proceeding to consider what I hare called tha 
primary sciatica, s something must be said about tho 
sccoiidaiy or symptomatic forms. 


Seco.vd.iry Sciaticas. 

TJioso may, of course, be duo to a large variety of 
different lesions, 'rumours of tho rectum or of the pelvio 
organs, primary or secoudaiy growths of the bones of the 
pelvis or of the vertebral column, disease of the hip-joint, 
tho sacro-iliac joint, or tho joints of the lumbar I'ertebrae; 
various affections of the actual nei-ve roots of tho cauda 
equina within the theca or outside it, such as syphilitic 
inflammation or pre.ssuro by tumours; the effects of old 
injuries and disease of tho spinal cord such as tabes 
dorsalis. All of tlic.se are possible causes of sciatic, pain. 
Ill practice, liowevor, the great majority of such possible 
causes arc easily ruled out by a careful physical examina- 
tion, Avhicli must in all cases include tho vertebral cohimn 
and hip-joint, the abdomen, including rectal and some- 
times pelvic examination, and tho nervous system. 

Ill niv cxpcricnco it is relatively uncommon to find 
"loss pressure lesions such as that produced by pelvio 
tumours, growths in the rectum, or abdominal disoaso 
overlooked. On tho other liand, osteq-arthritis of the liip- 
ioin't is repeatedly overlooked as a cause of so-called 
sciatica ami mueli valunblo time often wasted thereby on 
methods of tieatmcut which can sen-o no useful purpose. 
Careful movements of the liip-joiut by the ohseiwer should 
not produce pain in the case of true sciatica, nor is there 
anv real limitation of the range of tlio movements of tho 
joint. Tho importance of radiography is so obvious ns 

hardly to call for mention. , ' 

I do not intend to weaiy you with a long discussion on 
tho differential diagnosis of all tho conditions which may 
produce a seconda.y sciatica, hut it may, however, ho of 
some value to remind you that tho piosenco of any of tho 
following signs or symptoms should at onco arouse suspicion 
ami seriously invalidate tho diagnosis of a primary sciatica. 

attribution of tUo pain in any of the tollov;ing areas: 
ailcrior aspect of Uio thigh; (*) the penueum, grom, 


1 . The -w , 

^*'unroreans-”(ri the ahdomcn “■ ’’h'iomiiial Avail. 

iiiolor^paralysis of the leg or thigh or oven a dropped foot. 
3 Loss of the kncc-ierfc. 

4_ Any niarkeil inusculav atrophy._ 


of the 


5 Tim prcsenCQ of the reaction of degeneration in any 
™6*1Sy^sovcro^vSmo^r^disorders, and, of course, any such signs 
as_^o^cina^ or^ tro^phio^ nervous control of micturition, 

defa^tnuit^Aai jjgg,,;gncy jge movements of the spnial 

operation for malignant disoaso 


shouid''i'nimcdfateIy 'rriso doubts as* to tho innocency of .any sciatio 
p.iiiis. 

Tt is sometimes stated that a bilateral sciatica is always 
H ! .-cLinr some gross lesion-that is, a secondaiy sciatica 
r'l-ininlv bilateral sciatic pains should always be'regaidcd 

+1, case that it is possible for an essential or primary 

ScTtraffRc? both sides, as well as for a true pen’ 
neuritis to affect hotli sciatic nerves. 

Pbijiahy Sciaticas. . 

YAr„ now turn to. consider the primary or essential 

f of seiXa Hero it is useful to divide the’ cases 
■ni two eroups' where tho symptoms sugges 

ihat t l oro LTneuritis of the trunk of tho sciatic nervO 
itself a tnie sciatic neuritis; and (2) those where thei 
s no~d“rocrcvTdenco of such a nofiritis, hut ivhcro thqro 
reems iXn to believe that ^ip of tho trouhlo to 

hicher *110 in the region of the lomba-sacral vertebrae. 


UiinCH 10, 1^:8] 


SDTATI0A":'!1TS 'VAEIETIES --AND TEEATMENT. 


r Tif* Enmya 
MxstCJX JOCSXAL 


3C7 


can if wo cliooso call this latter group “ sciatic neuralgia,” 
but in my opinion little is gained in this further suh- 
divisiou in nomenclature. 

Actirifis of the Sciatio Nerve. 

Tliere can ho, I think, no doubt that a true neuritis 
of the sciatio nerve does exist. It is an interstitial neuritis, 
or perhaps rather a perineuritis, not in any sense com- 
parable to the degenerative lesions of the nerves which 
are found in the cases of multiple neuritis or toxic poly- 
neuritis due to such poisons as alcohol or arsenic. The 
great majority, of cases do not afford us an opportunity 
of verifj'ing by sight the exact nature of the lesion, but 
occasionally in cases of very long standing where the nerve 
has been exposed by open operation cicatrization of the 
nerve sheath with adhesions to surrounding structures has 
been demonstrated.. 

The precise etiology of theso cases is generally uncertain. 
Like other forms of fibrositis, neuro-fibrositis, or neuritis it 
is now the custom to attribute them to some focus of 
infection in the body, and it is certainly good practice 
to institute a vigorous search for any such foci, and if 
they be found to vemovo them, if possible. Personally, 
however, I must confess to little success in this respect, 
and I doubt it I can recall a single example out of the many 
cases of sciatica I have seen where the finding of a septic 
focus, followed by its appropriate treatment, seems to have 
affected to any appreciable extent the course of the disease. 
Experience teaches that this form of neuritis occurs in 
diahejic subjects with a greater frequency than can bo 
explained by mere coincidence; this possibility, therefore, 
must always ho carefully borne in mind. 

There are certain features which, I venture to submit, 
are of considerable value in the diagnosis of this particular 
form, of sciatica. I have already mentioned certain dia- 
gnostic criteria which are' of the greatest importance in 
establishing the presence of a gross pressure or secondary 
form of ^sciatica as distinguished from the form we are 
now considering. In the ordinary sciatic neuritis, as indeed 
in the other variety of primary sciatica which I shall 
desoiibe presently, tho sensory functions of tho nerve are 
aueoted not merely out of proportion to the motor functions, 
but practically to their exclusion. A voiy different picture 
IS geneially presented by gross pressure lesions or by 
traumatic lesions of the nerve trunk. In theso latter it 
sj'fflptonis may occur first, but they 
° ^™ptoms on the motor side, muscular 

weakness, dropped foot, gross muscular wasting, and, 

I" tlie ordinaiy f^rm of 
ness of the Hmb exceptional to find motor weak- 

be found lint «*- niuscular wasting, it is true, may 

lomr stnnrfi'n unusual severity or very 

irthffib ^ 

known ''test ^nf ° ^‘“gnosis is afforded by the well- 

thich fiexpil p ®y®*’'^‘"g tbe leg at the knee with the 

pam not only In rtruo““^“t'- .mnnmuvi-o will iause 

other cases i sciatic neuritis, but in numerous 

either bv pressure or T “‘’® 

for the ’nrpcon * r® inflammation. The simplest test 

itsolf is tcnrlrr'^ * ®®^^ neuritis of the nerve trunk 
this tindernossTr direct pressure. The points where 
sacro-seiattn easily elicited are (1) over the 

tliirh midi (2) w-here the nerve enters the 

tho° great irLh ®\''®®’^ *1*® tuberosity of the ischium and 
ness^mav hr “^treme tender- 

external poDlifMi"^-”? popliteal space and over the 

of the xr this winds round the head 

tions is ineffi-:- discomfort on pressure in theso situa- 


neuritis 'ni,' warrant tho assumption of a real 

Eeasatinn pf'- ’■ Present, reacts to such a stimulus by 

disappearanp^^f* t’l'" neuritis is the 
together wltl, ^ nnkle or Achilles jerk. Its absence. 


tremelv pppV,: exaggeration of the L-nee-jerk, is ox- 

typical ,)ipf combination constitutes quite a 

Vp.cal picture of the state of the deep reflexes in tho 


affected limb. It is remarkable with what rapidity tho 
ankle-jerk may he lost; moreover, it is weU to rememhor 
that it may never return, its perpetual absence being as it 
were a scar of the old disease which, many years after 
perhaps, may complicate the diagnosis of a new train of 
symptoms in the same patient. 

Seiatic Neuralgia. 

I pass on now to consider what is in my own view 
perhaps the most common form of sciatica. Ton will, I 
feel sure, all agree that even when the cases duo to gross 
pressure lesions — ^that is, the secondary sciaticas — ^liave been 
weeded out, and when the cases of definite neuritis of the 
nervo have also been excluded, there vet remains a very 
considerable moiety of uncertain nature. In this group 
tho pains may be just ns severe, just as persistent, and just 
as genuinely sciatic in distribution as in the forms I have 
already described. There may he in such cases practically 
no tenderness of the nerve trunk at all ; further, the ankle- 
jerk is by no means invariably lost. A suggestive feature 
of these cases is tho tendency of the pain to radiate, 
especially in the distribution of the fifth lumbar neire 
root. It is quite coramou, for example, for the pain to 
appear first in the region of the outer side of the ankle 
or the outer aspect of the dorsum of the foot, not in- 
frequently also round tho head of the fibula. It is very 
imcoranion, on the other hand, to find the pain referred to 
tho sole of tho foot or the actual calf of tho leg. Tliis so 
to say selective incidence of the pain upon the area 
supplied by the fifth lumbar nerve root, as compared with 
the areas innervated by the other roots constituting the 
groat sciatic nerve, must in my. opinion influence our 
views of the etiology of tho symptoms. 

At this juncture I should like to iuterpellato this ques- 
tion for your consideration. AVhy is sciatica so common? 
The correct answer to this question should provide a 
valuable clue to the problems of diagnosis and treatment. 
But can we find the answer? 

Scoliosis. 

There is one important symptom often associated with 
sciatica to which I have not yet referred — that is, scoliosis. 
In a certain number of the cases which do not yield rapidly 
to treatment and in a very large proportion of tho chronic 
cases a scoliosis may he observed. It may he one of two 
kinds — the contralateral or tlio homolateral typo. Of theso 
the more common is the contralateral form. In this form 
a lateral flexion of the lumbar spine away from tho affected 
side may he seen. Attempts by the patient, or the more 
forcible efforts of tho observer, to correct this deformity 
immediately cause pains in tho distribution of tho affected 
sciatic nerve. Associated with this scoliosis in nearly evorv- 
caso is a rigidity of the lumbar spino, with defective flexion 
and extension as well as impaired lateral movements. Sloro- 
over, it is often possible, especially in thin subjects, to 
palpate an unusually firm and contracted condition of tho 
erector spinae muscle. 

There can he, I think, no doubt that this form of scoliosis 
is duo to a muscular contraction, reflex in nature, exactly 
analogous to that with which we are so familiar in disease 
of joints elsewhere in the body. In this typo of case with 
a contralateral scoliosis it is interesting to find further con- 
firmation of the suggested lumbar vertebral site of tho 
lesion in the not uncommon experience of a prcseiwed ankle- 
jerk in association with sovere sciatic pain; further, as 
Harris- has pointed out, saline injections of tho nerve trunk 
are not as a rule successful in giving relief in those cases 
showing a contralateral scoliosis. This form of scoliosis 
will, as far as tho lumbar articulations aro concerned, pro- 
duce a tendency to a wider separation of the articular sur- 
faces of the intervortcbral joints and enlargement of tho 
intervertebral foramina on tho side of tho sciatic pain. 

Less commonly found is tho homolateral typo of scoliosis, 
wliero there is a lateral flexion of tho spine to the side of 
tho affected neiwe. One effect will be to lessen any possible 
tension on the roots or trunk of the nciwo on that sido. 
Harris^ slates that this form of scoliosis is readily amenable 
to treatment hj’ the injection of saline solution into tho 
trunk of the ner\’o at the sacro-sciatic notch or midway 


888 MAnoil 10, 192S] SCIATICA r ITS VARIETIES AND TREATMENT. 




Ti'r Pnm*if 

JocRsit 


between tlio gleet trocimntcr iiiiil tlic tuberosity of tlio 
ischium, an experience suggesting veiy stronglj' that in 
those cases with a homolateral scoliosis the lesion is probably 
a neuritis or a perineuritis of the nen'e trunk itself. 

Much less common than tlieso two varieties of scoliosis 
is an alternating form, now homolateral and now crossed 
in the same patient. Putti^ believes that these eases are 
fine to a bilateral ai thritis of tho lumbn-.saeial joints, and 
that the varying nature of the dofonnity is- due to the need 
felt by tho patient to rest tho joints first on one side and 
then on the other. 


The CArsATi\m Lnsiox. 

Enough has already been said to make clear my belief 
that in a large number of what I have provisionally called 
tho iirimary or essential sciaticas tho lesion probably lies- 
higher up than is ofteJi .supposed — in the neighbourhood, in 
fact, of tho lumbar vertebrae themselves. Wo grant at 
once the existenco of a true sciatic neuritis affecting the 
ncia-o- trunk or its constituent roots in the plexus, in the 
latter case an intr.apelvic situation. lint there yet remains 
the largo group uhci'a tho .si-npitoms snggesi: .-i vertehral or 
at any rate a jn.xtavertehral lesion. Tiiis group demands 
close atlentien. 

For tho views I am ahoiil to put hofore yon T claim no 
originality. Tlicy are based on tlio.so of the French school, 
notahly tho work of Sicard' and of Pntti, as well as other 
orfhopaedic surgeons. My exenso for .a.sking yon to con- 
sider them carefully is the fact that the.se conceptions have 
as yet found little mention in Kngli.sh textbooks. According 
to Sicard neuralgic pains in tho distrihntion of a .spinal 
nerve rout, nerve plexus, or nerve trunk can ho cla.ssilled 
topograpliually as follows. 

1. iXeuraigias dac to le.siotis of tho poslei-ioi nerve roots within 
tile spinal theca; to such tho torni '* radiculitis " has been applied. 

2. Xcural^ias due to lesions bcinoeii tlie poslci-ior root g.mgli.v 
and the origin of the neido plcxu'. This condition Sicard lias 
called “ fmiicnlitis,” tho funiculus heing tlic iiumo given to that 
pip't of tho iici-vo root between the ganglion and tho plo.xus. (It 
will bo noted that tlie funiculus is that part of the nerve root 
winch is mostly contained in the bony canal fonnod by tbo 
inlerrertebi-al foramina.) 

3. Neuralgias due to lesions either of tho nerve plexus or of the 
nerve tiiiiifc itself. 

.Sicard lays especial stress on the conception of fimicniitis, 
and, since this lesion occurs in tho situation of tho intcr- 
vertehral foramina, has coined tho term “ nenrodocite ” or 
“ nenrodocitis,” indicating thcrohy some inflanimatorj- 
lesion of the hoiiy canal tlirough which tho nen'e root 
pas.ses, and by which tlio root is irritated. 

It will bo noticed that radiculitis is a lesion within tbo 
subaraeliiioid space, where tbo roots arc still bathed by 
the ccrebro-S))inal fluid. Such lesions are not voi'y common, 
if wo exeejit the sypliilitic processes (including tabes), 
herpes zoster, and varions forais of acute spinal meningitis. 

Tlio fiinienhis is a part of the nci-ve roots subjected to 
possibilities of very diverse typos of lesions, tiv-iumatic and , 
artliritic; and the region of the lower lumbar .-pines, 
especially tho articulations between the fourth and fifth 
lumhar v-ertehrae and tho fifth lumbar and tlie sacrum, is 
particularly prone to ho affected, for reasons which I liope 
soon to give you. 

Tho fact that a neuralgia is unilateral is, as Sicard 
points out, an argument in favour of an extra- a.s opj)o.sed 
to an intra-moningeal lesion — of a fimicniitis rather than 
a i-.-idiculitfs. 

It is surely clear that the muscular contractions c.ansing 
tho rigidity of the spine and the scoliosis which wo have 
already considered are powerful arguments in favour of 
such a conception as that of iieuiodocitis. 

An examination of tho eerebro-spinal fluid will provide, 
again according to Sicard, a further distinction between 
radiculitis and funiculitis. He states that in i-acliciilitis 
a lymnhoc-vtosis of the fluid is found, while in fimicniitis 
there is a" characteristic condition of an increase in the 
protein without anv increase in the cells, the “ dissociation 
albuminocvtologiqne ” of the French autliors. Greenfield 
aii.l C.'irm'ichaeF have found this increase in albinnin in 
eases of sciatica up to as mucli as 0.1 per cent. — a very 
great increase. These authors state that in the cases with J 


a Jugli albumin content the pain was severe ami .svniptoms 

marked, .suggesting .an active process. 

Sicard describes three clinical -varieties of sciatica is 
loilou's : 

1 . High _ sciaticas liiat is, tiiosc due to funiculitis -or 
nein-oilocilis. 

2 . Mfildic fciaticas — those due to lesions either of the plexus 
or of tho inittk of the nerve from the mcro~‘*c.ioiic notch 
to its entiT into llic thigh proper. 

3. Low sciolieai— those due to affections of the nerve in tlio 
popliteal space or of its external popliteal division in Uie leg. 

His class of high .sciaticas would iiu-Itido, thcrefoi-c, tlioso 
which I have licre designated as vertebral or jnxf a vertebral; 
tho class of tho middle ,sciatica.s- embraces those common 
forms of sciatic nenritis or perineuritis; xvhilc the low 
variety i.s formed by those cases of a more or less localized 
iicm-itis or perineuritis of a nerve lower down in tbo thigh 
and (lopUteal space, and oven of tho cxtci-iial popliteal 
nci-vc in the leg or just above tlie ankle. 

It is perhaps easier to follow Pntti, who calls the high' 
.sciaticas “ central ” and the middle aud lower fornis “ peri- 
pheral. ” This last dmsioii i.s nsefni, as it fellows wli.nt I 
consider .a difference in the usual etiology- of the cases, tlie 
central foi'iiis heing those due to vortehi-al lesions, while the 
peripheral fomis are those to which the term of nonritis 
or perineuritis is niore properly applied. 

If this coiicejition of the central toi-ins of scialica be 
aecei?fed as due to a vertebra! Ie.sion, probably- of tbo natare 
called by Sicard a neurodoc-itis— a term whose moaning 
I liavo' already discussed — w-e have .still to find tho answer 
to the question, IVhy is .sciatica so eoinmon.=- or, to pvt 
it in another way, IVhy .should the low-ei- lumhar region of 
the spine esiieci.slly suffer iri this respect? 

Tlic anatomical peculiaritie.s of tin's region appear to 
afford a satisfactorv e.\-planation. Hanforth and "Wibon,' 
in an interesting paper, have reported the results of the'ir 
ob-ei-vations on the anatomy of tho himbo-sacrai region 
in relation to sciatic pain. They found' the intervertebral 
foramen between the fifth lumhar ve.-tehrivand the saentm 
to he the smallest, and that between the fourth and fifth 
Iimilwr vertcijrac iho next smallest in tins region. This 

is siirelv' a sicnificant fact. _ 

These authors think that, an.atomically, nerve pain duo 
to ioint lesions might occur, as regards the fourth lumbar 
nerve root, from (1) lesions in tho inteiwenebi-al canal, and 
(21 at the lower margin of the. sacro-iliac joint close to the 
ereit. .sncro-sc-iatic notch; and as regards the fifth lumbar 
nen-o root, from lesions (1) in the inteivci-tobral canal, 
(21 at tlic lateral margin of tho joint, between the body 
of the fiftli lumbar vertebra and the sacrum, and (3) at tjio, 
lower edge of the svcro-iiiac joint. They conclude by, 
expressing the view that sciatic pain of the ty-pe stiulicd 
is a svnmtoni of di,sturhanco in the lower lumbar spine, 
ami tbit the site of the lesion is most frequently the hiinho- 
.sacral junction, and the nerve chiefly involved is tho fitfh 

*'"lbaVo' already pointed ont bow in many cases the paw 
i-idiatcs evpecially, and sometimes solely, in the distribu- 
tion of the fifth lumhar nci-ve i-oot~for example, along tbo 
outer part of tho leg below tho knee and tho outer aspect 
of the region of the ankle. ^ 

Other anatomical considci-ations arc also of importance. 
It is well i-ccognized tliat the fifth lumbar vertebra is 
„ee,iHai-ly liable to congenital variations, of which the most 
rtrikiiw^is that termed “sacralization,” though it is im- 
lilrolv that this sacralization is often of itself ve^ponsihlo 
rni-soi-itiepaiii. I’utti has called attention to the frequency 
af xal^us miomalies in tho articular facets of the lumbar 
rm-tebrae, and especially of the fifth lumbar 

Iip shape of, oi* rothice tbo 

canaci’tY of, tile iiitci-vei-tebral foramen, sometimes on ono 
-ide' oiilv Finallv, the importance of tho fiftli liimhar 
rertchro as tiw foundation ‘stone, as it has been rofled, 
if the whole spinal column must ever be borne 
To Pntti the central sciaticas arc sy-nonymous witH 
ipim-il aiti-iris, which he ,-Iaims can always ^ f, 

>v good lateral oml stereoscopic skiagrams. In 
:‘mns-t .admit tliat my experience ha.s been Irs^ fo u - - 

Enou-h has been said, 1 hope, to convince you tli.it tiier 



March io, 1928] 


BCIATIOA; 1TB VABIETIES ANE TREATMENT. 


I Tnr 

ATHDlCJlI. JorRNlL 


389 


are at least good grounds for supposing ti nt in 1 any cases 
0 sciatica a vertebral lesion e-x.sts, probably of the nature 
of an arthritis, and that the nerve root principally affected 

is the fiftli lumbar root. ... , ,1 , 

But even when ive have satisfied ourselves that our case 
of central sciatica is 'due to a lesion involving the nerve 
root or roots in the intervertebral canals- we have yet to 
find the cause of this particular form of . arthritis. Ihis 
niav be no easv task. Careful search foi^ foci of iiifeetioii 
must be made just as in other forms of infectiic ai-thiitis 
. elsewhere in the body. Teeth, tonsils, acccssoiy sinuses, 
alimentary tract, and genito-iirinary tract niiist all receive 
due coiis’ideration. 1 have already indicated my own 
experience of failure in estahlishiiig cause and effect in 
most cases in this matter of focal iiifeetioii, but neverthe- 
less I believe it is the right practice to make a careful 
search and treat adequately any infective foci found. And 
in this connexion it is well to remember the jiossibilities 
of a gonococcal infection, even of some, nnliquity, as a 
cause of the more chronic forms of iiiflaniiiiatory lesions of 
the spinal column. Such considerations, however, must 
never lead 11 s to neglect the prompt .syiiqitoniatic Ircatiiicnt 
of any case of severe sciatica. 

Prom time to time the vieiv is expressed that disease 
of the sacro-iliac joint is a common cause of sciatica. It 
will be readily appreciated from the brief anatomical 
digressions I have .made , that, theoretically at least, such 
a combination of cause and -effect might easily occur. 

- Actually, however, T believe the event to be rare, although 
I confess it is a possibility difficult to disprove. Certainly . 
cases seldom if ever exhibit the classical symptoms of sacro- 
iliac disease, but these, it must be remcnibcred, are those 
of an advanced disease of the joint, gencialiy of a tuber- 
culous nature. Quite minor intlamniatory affections of the 
joint would certainly be very difficult to detect, both 
.-Unically and radiographically, although they might well 
le associated with sciatic pain. 

There is, however, a considerable body of opinion, 
especially in America, which believes very strongly in the 
relation between sciatic pains and iniiior subluxations or 
strains of the sacro-iliac joint. This belief docs not as a 
rule, 1 think, meet with general acceptance here, but it is 
a li 3 'pothesis well worth careful testing, Hort Cox' has 
rccenth- well summarized certain American views on this 
point. Ho distinguishes two tyqies of sacro-iliac sub- 
luxation: (1) the traumatic form, iisualh', of course, acute, 
^ heavj- lifting strain; and 

(Z) a postural form, usuallj- chronic, duo to loiig-contimicd 
fault} postures. In this form the back is unduly flat, the 
luinb.ar curve obliterated, and the ilium tilted forwards at 
an abnormal angle with the sacrum. The chronic forms 
ma} also result from infections, with subsequent relaxation 
of the ligaments of the joint. 

,!? j" second or chronic trqie that sciatic pains 

form one of the principal svmptoms of a 
clinical picture 111 which the following sigHs may also be 
W undue prominence of tlic sacrum; (2) a 
rigidity of the spinal niiisclcs; (3) an obliteration of tlic 
normal lumbar curve; (4) a lateral curve of the spine 

'll side;. (5) marked tenderness on 

pressure over the affected joint. 

, , Diagnosis. 

diimmsi's'"? /"f a:' ray.s are of little help in 

timf'witi’ ! i perhaps partly exjilaiiis the hesita- 

iirLe s that the “pathological 

Ilium from the taerit "f tl'm"'’' o/ Hie 
product hy oxtrome h^p^^exlmis;^; 

the ihini.” 1'"” the anterior part of 

sacro-ihifc P,';,,”/ ^"’"■p''cr, are not confined to the 

to the bnni .. n obvious possibilities of injuries 

suiiie niul’ " ipanents of the liuiibo-sacral region of the 
fr"ctm; eve^'’n-;''':i‘’^ ''‘'‘tebra, and 

of prodiiHinr cr-lni- ''’''t. 'b-splacciiients, are certainly capable 
• nerve root iisoif involvement of the fifth lumbar 

buttock, referred wnstant pains in the region of the 
i-atci, perhaps, down tlie leg as well. 


from involvement of the posterior primary division of this 
.root. But, holly lesions apart, muscular and ligamentous 
injuries may lead to the formation of scar tissue which may 
implicate nerve fibres, perhaps of the superior or inferior 
gluteal nerves, loading to pain in the buttock and pains 
referred to the .sciatic distribution. Such cases demand 
a clear ajiprccintidii of the site and natiiro of the injury 
hctorc Mikable treatment can he instituted. 

The.it.me.nt. 

It is obvious tliat in this, as in every condition in 
mediciiK', successful treatment depends on an accurate 
diagnosis, although ])alliavivo treatment may, of course, 
temporarily lelieve all the .symptoms. The treatment of 
the seeoiuhiry forms of sciatica is clearly that of the 
causal factor, hut whore that is unfortunately not amon- 
ahlc to direct treatinciit wo must he content with methods 
designed to mitigate discomfort and suffering. 

Let us consider first the treatment of those cases where 
a real neuritis or jieriiiciiritis of the nerve is present. As 
previously iiulicated, a careful scarcli for etiological factors 
will have been made, and any diabetic element in the case 
noted and treated. In the severe and acute cases rest in 
bed is nearly always essential. The application of a splint 
to the afl'ected leg is soiiietinies advised, hut in niy 
expcrienco this can seldom bo tolerated; indeed, the maiii- 
tenaned of any position of the liiiih for long at a time is 
often almost iiiijiossihle.. Undoubtedly the most useful 
local metliod for the relief of pain is the application of 
heat in some form or another, wbetbor this be acliioved 
by -(loultiees, fomentations, radiant boat, or diathermy. 
The last, when available, is a most useful method. Ultra- 
violet rays with the mercury vapour lain]) or the tungsten 
are applied locally arc also of value in the relief of pain. 

Many authorities think highly of the value of electricity, 
cither in the form of the simple constant current or of 
ionization. I must confess to having hcoii little impressed 
by the.se methods of treatniciit, and now seldom cmiiloy 
them. Eor slighter cases some benefit may he derived from 
eonnter-irritatioii, wliethcr this ho effected hy strong 
liniments or ointiiicnts, or hy blisters, or by the old- 
fashioned method of painting with concentrated hydro- 
chloric acid, hut in any severe case such methods are 
generally of doubtful value. In the early stages of an 
acute neuritis massage is definitely contraindicated. 

1 cannot deal in any detail with all the iniiiiiiicrahle 
drugs which have been used in this disease, either as 
supposed cures or ns mere relievers of jiaiii. Any condition 
amenable to medicinal treatment, such ns eoiistiiiatioii or 
urinary infections wbieb may bo a factor in the causation, 
must, of course, receive iiromjit trcatineiit. 'J'lie salicylates 
and the iodides are about the only drugs wliich seem to liai'e 
any direct effect on these cases. The intravenous injection 
of sodium iodide has been advised, hut 1 cannot sav that 
I hai-e found this method to possess any jiarticiilar advan- 
tage OA-er the ordinary form of medication by the nioiitli. 

Analgesic drugs will nearly always bo iiocticd in cases of 
any severity, es])Ocially for the relief of pain at night. 
Aspirin, phciiacetiii, phcnazoiio, may all he tried; “ diala- 
cctin ” is a useful compound, and I have also foiiiiil 
“ allonal ” of value. A mixture of drugs wdiicli I have 
found effective is a cachet containing 5 giaiiis of aspirin, 
5 grains of jiyrainidon or amidopyriii, and a small dose of 
heroin, say oiic-cighth or oiic-qiiartcr of a grain. It need 
hardly be .said that the use of morphine should bo re- 
stricted as much -as possible, although in really had cases 
its U.SC for a time will ho almost imperative. 

Cases of sciatic neuritis which do not yield fairly rapidly 
to troatmeiit along thc.so lines, say in two or three wcek.s 
at most, may be very advantageously treated with in- 
jections of .saline solution into the nerve trunk — a method 
Avliich marks a distinct advance in our therapeutic nrma- 
mcntariuin. This method is particularly indicated in cases 
where there is definite evidence of tho presence of a true 
neuritis, such as marked tenderness on pressure of the 
nerve and loss of tho anklc-jork. The host sites fov tho 
injection arc just below tho sacro-'ciatic notch and at .a 
point on a level with the tuberosity of tho iscliiiini.- Tho 
method is now well known, so that I need not enter into 
all the details, hut it is important to make certain that 




392 MAncH lo; 1938 ] 


EXAMINATION OP URINE FOR FU3. 


i, . r, rJnmw 
'I Medical Jocrxh 



Fio, 1. — lluliTig of Fuchs-Ho^scothnl 
filido moffnifiod nine times. A»ficld of 
\icw witli 8 mm. objective nnd xlO 
eyepiece; B^field of view with 4mm. 
objective and x5 eyepiece; C=field of 
view with 16 mra. objective and xlO 
oj epiece. 


the slide and allowed to run between tho platform and cover- 
glass. A minute or two linving been allowed for llio formed 
elements to settle, tho cells aro counted by moving the ruled 
slido to and fro across tho microscopo stago until tho whole ruled 
area has boon ’surveyed." 

Tho most convenient objcctivo to use for tin's purpose is* an 
8 mm. or 1/3 in, dry lens providing an initial magnification of 
about 20. This objcctivo with a xlO eyepiece includes comfortably 
in its field of view four of tho smallest squares (sco Tig. 1, A), and 
this permits tho whole' field of 16 sq. mm. to bo sun’cyed in eight 

ighb and four from right lo left. 
' 200 diameters) leucocytes and red 

easily. 

Most microscopes in common uso aro provided with only two 
dry lenses, a 16 mm. or 2/3 in., and 4 mm. or 1/6 in. The 6 mm. 

objcctivo recommended for 
^ ^ this lest is intermediate bc- 

, tween tho two; it is well 

worth while lo exchange (ho* 
16 mm. for an 8 mm. objec- 
tive for cell count work. The 
test can bo performed witli 
the 4 mm. or 1/6 in. objcc- 
tivo and a low power eye- 
piece, but, although tho 
magnification is quite satis- 
factorj’, tho microscope field 
is much more restricted than 
with an 8 mm. or 1/3 in., so 
that only ono of tho smallest 
squares is completely en- 
closed in tho field of view. 
^Scc Fig. 1, B.) Thus sixteen 
journeys must bo made- 
eight from left to right and 
eight from right to left — 
before the whole field has 
been survcj'od. Tho 16 mm. 
or 2/3 in. objcctivo, alUiough 
offering a wide microscopo 
field (Fig* 1, C), docs not 
provide sufficient magnifica- 
tion, even when combined 
with a high eyepiece, to per- 
mit distinction helwoen leuco- 
cytes and bodies which closely resemble them in size and shape. It 
may be used for tho rapid e.xamination of a urine almost free from 
cells, but if formed elements are present in the urine it will usually 
1)0 necessary to re-examine tho field with a higher objcctivo to 
determine what should or should not bo counted. A mechanical 
stago is almost indispensable. In an emergency tho count can 
be mado without a movable stago if tho observer has acquired 
sufficient dexterity to movo tho slide by hand, but a mechanical 
sta^o saves time and energy and ensures much greater accuracy. 
Unless pus is present in largo quantities all Uio sixteen largo 
squares must bo counted — that is, the whole ruled area. Tlio 
volume thus surveyed is 16 sq, mm, by 0.2 mm. «= 3.2 cubic milli- 
metres, Tho number of cells observed in tho whole ruled area 
divided by 3.2 gives the number of cells per cubic millimetro. It 
is sufficiently accurate for practical purposes to count all the cells 
in. tho sixteen squares and divide by 3. If pus is present in such 
large quantities that each microscopo field shows several cells, 
then tlio survey of all the 16 sq. mm. may mean counting several 
thousand cells- For such specimens a shorter method is sufficient. 
Only the first four of the sixteen 1 mm. squares need bo counted, 
and the figure obtained is multiplied by 4 and divided by 3 to give 
the cells per cubic millimetre. 

Leucocyte Content of itic Urine in HcaUh, 

A few leucocytes aro often found in tho urino of healthy 
men and women who give non history of any disease 
of the genito-urinary organs. Whether or not such 
colls aro physiological, or represent tho after-effects of some 
morbid lesion too slight to evoho symptoms, is a question 
on which urologists liave held different views. For practical 
purposes it is generally admitted that if only an occasional 
leucocyte or two is found in a centrifuged urino after 
soarching several fields of tho microscopo, tho urino may bo 
regarded as normal-; but the fact that a few leucocytes 
may be present in tho urine of healthy people necessitates 
a definition of the normal limits before a numerical 
definition of pyiirin is possible. 

The cell count method of examining xirino for pus has 
been applied to more than 700 samples of urine; of these 
examinations 411 more of men and women free from genito- 
urinary discaso and 291 were of cases of urinary sepsis. 
Tho siimmary of results obtained with normal men and 
women is recorded in tho following table. 



1 


ilaxiirinm 

Mlnlmuin 

Areraffo 


Counts, j 

dividuals. 

Count. 

Count. 

Count. 

Hoaltliymen 

238 

157 

50 

0 

2.1 

Healthy Women ... 

123 

85 i 

■ 50 

0 

7.1 


Numerical Definition of Pus. 

A total of 291 counts lias been made on patients snfferin" 
from yiirious dismsos of tlio genito-urinary tract, iiichitlinc 
nephritis, pyelitis, cystitis, prostatic abscess, xiretliritis, 
stone in tho ureter, and many undetermined inflammations, 
Insufficient data liavo been collected to pennit any sort ol 
classification of tho pus counts of different patliologic.xl 
conditions; ^for tho present jiurposo they aro grouped 
together as individuals suiforing from some disease of the 
genito-urinary tract in whom the diagnosis of pyuria was 
justified. Tho counts ranged from 100 to 5,000 leucocytes 
per c.mm. In most cases of acute inflammation a leucocyte 
count liiglier than 500 cells per c.nini. was obtained ;* in 
, more quiescent or chronic cases tho figure was less than 
500. • Expericnco has shown that' a count of more than 100 
Icncbcytcs per c.mm.' points to disease of tlio genito- 
urinary tract, and justifies tho designation pyuria. Urine 
should bo described as containing pus when more than 100 
leucocytes aro present per c.mm. This allows of a very 
generous margin ' above tho average' count of 2.1 cells per 
c.mm. for men and 7.1 for women, but such a wide margin 
is advisable because of the normal range of variation. 
lYliat significance, if any, should bo attached to counts 
between 50 and 100 will probably have to bo decided separ- 
ately for each individual case when other sources of 
information have been explored. 

Comparison with Previous Standards for Pus. 

In deciding wlietlicr or not a urine shall be said to 
contain pus reliance is sometimes placed upon tho number, 
of Icncocj-tes seen per field of tlio microscope after the urino 
has been allowed to settle or been centrifuged. Obviously 
no comparison is possible between tho standard now recoin- 
mended of 100 leucocytes per c.mm. and tho number of 
cells per field of the microscopo, because tlio thickness of 
the drops adds yet another variable factor to those already, 
nientioncd ' inherent in tho pj-ocess of centrifuging and 
sedimentation. Comparison was mado with other methods 
by adding leucocytes to normal urine until tho tests became 
positive and then counting tho colls, and by diluting pus- 
rontaining urino with normal urino until tho tests becamo 
negative and again' counting tho cells. These comparisons, 
rcncatcd on many occasions, only served to emphasise how 
crude and full of pitfalls aro all methods for the detection 
of pus other than by tho microscope. These comparisons 
may be summarized in a sentence by saying that urine which 
is' clear from every other possible cause of turbidity must 
contain liioi-o than 400 leucocytes per c.mm. before tho pus 
causes sufficient opacity to ho detected by tho naked eye, 
and tho guaiao test and liquor potassae test aro often 
negative with urine containing more than 500 cells 
per c.mm. 

The Examination of Urine for Blood. 

Tho cell count method of estimating pus is applicable also 
to the study of haematuria. An occasional red blood 
comusclo may bo found in tho urino of healthy people, but 
except after injury or disease of the genito-urinary tract, 
or during menstruation in women, there are always tar 
fewer reel blood corpuscles than leucocytes. Tho discovei-y 
in tho urino of moi'o than 2 or 3 blood cells per c.mm. is 
an important obsoiwation, but the counting of tho cells has 
n^m-actical value except when both red blood cells and 
rencocytos aro found, and tho question is raised whether 
tho Mndition is ono of uncomplicated haematuria or 
whether blood and pus aro both present. 'When both red 
and white corpuscles are enumerated tho cell count method 
will decide this question, thereby showing whether or no* 
tim relationship existing in the blood of ono Icncocjte to 
SOO red blood cells is maintained or exceeded in the urine. 

•r’w,* /.mint tho red cells per cubic millimetre of tho^ 
fattS^suitablo dilution if necessary) and divide by 500 £‘7° * , 

nf leucocvt(» expected to accompany tins ^„ 4 rA 

Then count tho number of leucocytes per cubic 

bi.™ ifprtSa „ ..nribbi„e f 

is made between tins and other methods It jvas n 

during routine testing, and has been frequently vent y 


MAIiCH 10, 1928] 


SARCOMA. OF THE STOMACH. 


t Tirr British 
JIedicai. JorRyjLL 


393 


simnle experiment of adding Wood to urine and tlien 
eoudting the cells, that all methods of testing for h ood 
other tlmn microscopic arb not only valueless hut a positive 
source of deception. The guaiac test for blood is liardly 
ever positive unless the urine m red m colour, and experi- 
ment lias shown that more than 10,000 red Wood corpuscles 
must ho present per c.mm. before tins point is i-eaehed. 
The pvramidoii and benzidine and spectroscopic tests are 
onlv positive when the urine is cither obviously rod or 
has' a- “ smoky ” tint, “ smokiness ” being reached only 
when .the uriii'e contains at least 1,000 red blood coiiiiiscles 
per c.mm. IVlieii less than 1,000 red blood cells are 
present per c.mm. no test other than the microscope will 
show the presence of blood. On the other hand, the cell 
count method may be relied on when such small quantities 
of blood as 10 red blood cells or even less are present per 
c.mm. The delicacy of tho cell count method is revealed 
when these facts are presented in an example. A specimen 
of urine containing about 800 to 900 red blood corpuscles 
per c.mm. would show no smokiness and no trace of blood 
‘to the naked eye, and the guaiac, benzidine, and spectro- 
scopic tests might all he negative, and yet the iiresenco 
of blood would bo indisputably demonstrated by the cell 
count method after the iir/nc had been diluted inorc than 
one hundred times. 

•. • Practical Points. 

Tho specimen of urine to bo examined should be the 
first passed in the morning, and the patient should be 
.instructed to pass the urine direct into a wide-mouthed 
■bottle, or into a clean receptacle from which it is to be 
transferred , at once to a clean bottle. The figures given 
above are based on early morning specimens ; lower counts 
.are obtained if a specimen is collected only an hour or 
two after the bladder has been -emptied and the jiatient 
.has taken a-lot of fluid. Specimens may be accepted if an 
interv.al of more than four hours has passed since the last 
micturition,- but in all doubtful cases the earlv morning 

■ specimen must bo insisted on. Tho urine ‘should be 
examined on the day on which it is passed. 

. Turhid XIrincs. 

■ Urines need not be clear from crvstalline or amorphous 
deposit of inorganic salts, but if these afe dense accurate 
counting becomes impossible.- A cloud of phosphates mav 

1 i®f ^ deposit o'f 

c.annot bo easily removed by any 
t.iiifn ' 1®’ ^”1^ turbid from this cause usuallv becomes 
qmto clear by dilution with an dqual volume 'of warm 


line, and leucocytes usually measure 10 to 12 microns, a 
littlo more than 1/25 of the bonndaiy line. 

Epithelial cells must not be included in tho count. 
These are usually larger, often irregular in outline, with 
a relatively small conspicuous nucleus. Squamous cells are 
easily distinguished and disregarded ; caudate cells with a 
tail-like 2>rolongation of the body, and iiear-shapcd cells, 
usually attributed to the renal pelvis or neck of the 
bladder, must not be included in the count. In judging 
whether or not a cell should be counted as a leucocv-te 
special attention should be [laid to the size, the definite 
rounded outline, and the iiresence of a nucleus. The 
recognition of a leucocyte is an accomirlishmcnt that 
becomes progressively ea.sier with experience. Xo advan- 
-tage is gained by trying to stain tho cells, and the so- 
called differential stains jiiirporting to distinguish cjiithe- 
lium from blood cells are unreliable. Acidifying with 
acetic acid makes the cell nuclei more consiiicuous, but 
with experience in the counting of leucocytes even this 
simple step is usually unnecessary. 

Pccopnition of Bed Blood Cells. 

Red blood corjinscles are more difficult to distinguish 
than leueoeytes, and it is well before atteiniiting to count 
erythrocytes to become familiar with the shapes they may 
assume, whether tho disc is viewed through the centre 
or periphery. Accurate measurements are neecssarv- in 
doubtful cases. 

Stnrinr/ of Apparatus. 

After use tbc slide and cover-glass are conveniently dis- 
infected and stored in methylated spirit. The glass jiipettc 
should be well rinsed out with water and stored standing 
in a test, tube containing 1 iier. cent, formalin. After use 
for a urine containing much pus the pipette should bo 
boiled or thrown away. The pipettes are made by drawing 
out glass tubing in the blowpipe flame, and it is useful to 
have about rfi dozen at hand. 

Summar.i/. 

The most accurate method of determining whether or 
not pus is present in urine is to count the leucocytes in 
a chamber similar to that used for counting the cells in 
cercbro-spiual fluid. The sarajilc to be tested must be the 
first urine iiassed ini the morning or after an interval 
of four hours. The "test can be completed in two or three 
minutes, and jnovides a quantitative record comparable 
from day to day. It is suggested that no urine should be 
said to contain pus unless it contains more than 100 leuco- 
cytes iier c.mm. 


„ , Pccognition of Leucoctitcs. 

■mmf'bn™" of leucoevtes 

must be counted. Until the eye has become trained to 

distinguish such cells 
with confidence it makes 
for accuracy to carry a 
micrometer scale in the 
eyeiiiece of tho micro- 
scope and to measure the 
cells; or to add a drop of 
blood to another jiortion 
of the urine, jirepare a 
slide from this, and make 
a mental note of the size 
of red blood corpuscles 
and leucocytes with the 
particular combination of 
lenses in use. Fig. 2 
shows the field of view 
(reduced to one-fifth) 
obtained with an 8 mm. 
objective and xlO eye- 
piece, including four 
1/4 mm. squares. In the 
red blood cells In,-.. 1 , upper left-hand square 

right-hand 

size of thines cm v, impression of tho relative 

those smallest sonivo °. recollecting that each of 

iength. Red hinna ® n by lines 250 microns in 

9 microns in diamoto v urine usuallv measure 8 to 
0 ‘‘“'““ter. a little less than 1/25 of the boundary 



• SARCOMA OF THE STOMACH. 

BY 

JAMES S. HALL, M.B., B.S.Loxd., F.R.C.S.Ed., 

SURCYO:?, TICTORIA HOSPITAL, DEAL. ' 


following' case presents ■so many features of interest, 
apart from the ’ extreme rarity of the condition, that it 
seems worthy of record. Most of the surgical authorities 
consulted either make no reference .to the incidence of 
this type of growtli or else quote it as a “ rare patho- 
logical curiosity.” Xn this instance the only practitioner 
to diagnose the' case as one of malignancy was the anaes- 
thetist, who was not acquainted with the physical signs or 
the clinical history. 

A man, aged 40, was first admitted to the Victoria Hospital, 
Deal, on. April 14th, 1927, under ray colleague the late Dr. F. M. S. 
Hulke. The diagnosis made on admission was chronic duodenal 
ulcer. The history was typical : pain an hour or two after food, 
slightly relieved by food, melaena. some wasting. A skiagram 
after a barium meal confirmed this diagnosis. There was a rapiilly 
acting stomach with considerable deformity of the duodenal cap, 
no filling defects, no sign of crater in tlie Ic.«cr curvature, and, 
to complete the picture, an apparent duodenal ncus 

Dr Hulke commenced medical treatment and the results nerc 
excellent. The -patient put on weight, a stone or more, icgaincd 
hiriiLlthy appearance, and was discharged fit a month later 
After three months of rather strenuous work he came to consult 
me with a view to operative treatment of Ins condition. His 
previous good health had disappeared, he was emaciated, had 
fremicnt romitinv, and mclacna witli a good deal of pain and 
discomfort He was therefore readmitted to hospitaj on •'August 
15th for a preliminar.v course of rest and diehiig. as his condition 
was too poor to risk immediate operation. During the following 



394 March io, 1928 ] 


■ • ■ ; 1 •IK 1 ; 

memoeanda. 


r The DnmsK 

L MedICAA. JOVBXli 


week Iio had so much tenderness and rigidity In his tpigastrium 
that no tumour eould bo felt. After tlio first week lie was con- 
Biderably_ hotter ; the vomiting and molaona liad censed. 

O^cratiou . — On August 22nd ho rvns taken to tjio theatre with 
a view to removing the appendhe and performing duodeno-iejuno- 
stomy. Under general anaesthesia a movable epigastric tumour, 
about 4 inches in diameter, was felt througli the abdominal wall 
and explored through a right paramedian incision. It proved to 
bo a growth of tho cniddlo of the stomach, slightly adherent to the 
pancreas, with multiple glands in tho gastro-hepatie and gastro- 
colic omenta. I removed tho growth with the enlarged glands 
aud a small portion of pancreas by tho modified Polya method, 
leaving about a quarter of tho cardiac end of the stomach to 
anastomose to tho sido of tho jejunum. Convalescence was 
uneventful. 

Macroscqpically tho stomach showed two largo ulcers about 
2 inches in diameter, facing each other on tho anterior and 
posterior walls, with very thick heapod-up edges and obvious 
neoplasms in their bases. A section of one was sent to a patho- 
logist, who reported as follows : " This is a difficult specimen 
about which I felt doubtful. A second opinion I obtained was 
given as follows : ‘ Tho gastric wall is occupied by small polygonal 
cells of connective tissue typo and oat-shaped form. Being almost 
absolutely miiform in character, without admixture with chronic 
inflammatory colls, tho condition cannot bo related to a hyper- 
plastic gastritis or leather bottle condition. Tho diagnosis would 
bo spindle-colled sarcoma.’ I hesitato to accept this diagnosis as 
the condition would be extremely ra^o^ and I think there are other 
.possibilities. Without knowing anything of tho clinical condition, 

I do not caro to express a definite opinion." 

Having fortunately preserved tho specimen I forwarded a 
section of tho growth from tho other ulcer and an enlarged gland. 
A second report road : " This is evidently a deposit of small round- 
celled sarcoma which has become ulcerated, a very rare condition. 
The gland does not appear to bo affected.” 

Tho patient was seen again four months after tho above account 
was written: ho had then gained 2 st. in weight and all signs of 
malignancy had disappeared. 

Prom a surgical point of view one would certainly say 
from tho specimon that tho sarcoma supervened upon ohronic 
ulceration, but that is a pathological point I am not 
qualified to dispute. 

Tho salient points of tho case aro rather romarkablo—the 
clinical evidence of duodenal ulcer, tho condition found 
at operation, and the points against malignancy, especially 
the considerable improvement after rest and diet. I have 
no information as to tho prognosis of theso cases, if, indeed, 
any have been operated upon before. 

I would like to express my thanks to Dr. Ponder for tho 
pains he has taken to give mo an accui'ato statement of 
tho microscopical condition of the growth. 


^^inuraittra : 

MEDICAIi. SUEGICAL. OBSTETEICAL. 

MECKEL’S DIVERTICULUM IN STRANGULATED 
INGUINAL HERNIA. 

The follow'ing case, in which a Meckel’s diverticulum was 
found in a strangulated inguinal hernia, soems worthy of 
record. 

A married woman, aged 66, was admitted to the Royal 
Infirmary,* Liverpool, in October, 1927, with a history of having 
been acutely ill for three days -n-ith a lump in tho right groin, 
abdominal pain, and vomiting; strangulated inguinal hernia was 
diagnosed. There was a tender, tense, rounded swelling at the 
lower end of the right inguinal canal; tho okin moved freely over 
it, and there -were no signs of inflammation of the cutaneous 
ti^ues. The patient stated that she had had a rupture for some 
years, and that three days before admission, while exerting 
herseif, a sudden severe pam had appeared in tho groin, causing 
her to vomit. . 

On opening the sac some sanguineous fluid escaped, and a tube 
was discovered about three inches long, and intensely congested at 
its dis’al end. This tube had a small mesentery, and at first 
si-'ht I took it to be the appendix. On pulling out tho poHion 
of bowel to which it was attached, however, a loop of small 
intestine presented instead of the caecum, After ligaturing and 
divMinv the mesentery (or meso-diverticalum) the tube was 

“The ^atie“/mado“an“ miUe“upte'‘rrecovery and no compKca- 

tioQS iiave arisen since. 

Pathological examination of tube showed the 
ture to he typical of a hlechePs diverticulum. 

Hugh Reid, M.B., F.E.C.S., 

Honorary Assistant Surgeon. Royal Infirmary, 
llrerpooX. 


TJNT7STJAL COMPLICATION'S OP PNEUMONIA. 

In view of tho ^exceptional symptoms, course, and com- 
plications tho following caso of pneumonia appears to to 
worthy of record. . 

A man, aged wlioii first seen complained of backache, slight 
headache, and “ cold chills.’* Ho had not had a rigor, and did 
very ill His longuo was very dry and red; the pulse vas 
iW, tho respirations 20, and tho temperaturo 101.5° F. Physical 
oxamination was negative. The next day ho had a slight cough, 
vrith a Iittlo yellow sputum. The chest was resonant, with a few 
rales at both bases. Ho had no pain. On tho thhd day the cough 
had almost gone and tho general condition was tho same. 'On tho 
fourth day ho had severe hiccup, which continued almost without 
pauso for two days. Ho also liad slight conjunctival jaundice, 
On tbo fifth day jaundice became very deep over tlie whole body, 
and tho abdomen was greatly distended, though no cause was 
found. Tho patient^ passed a small, soft yellow stool, and tho 
urine was ’ ' * On the sixth day the jaundice 

was much eturned, and there was a sus- 
picion of base of the right lung. The 

ptilso was . . ^ ■ d the temperature 103° F. Tlie 

abdomen was still greatly distended; and on this day a- hard, 
globular swelling about tno size of an orange was noted in the 
jeft iliac fopa. This had a' clear edge below, but -the upper- 
margin was jJJ defined ; there was a resonant note over it, and it 
did not movo on respiration. 

Tho diagnosis up to now had been influenza with mild bronchitis, 
and later early pneumopia, possibly. The .jaundice presented a 
difficulty, but W'Os recognized as occurring rarely in influenza. Tho 
distension was attributed to a condition of paralytic ileus duo 
to profound toxaemia. Tho lump ebuid not be explained, and waa 
tho chief difficulty. 

Dr. J. H. Thornley, honorary surgeon to the Scarborough 
Hospital, saw tlio case in consultation, and agreed to take the 
man into hospital. During the following day the patient became 
gradually much worse, and died that evening with definite signs 
of a right-sided pneumonia. 

At tho necropsy marked pneumonia was found in the lower lobe 
of tho H"ht lung; tho heart contained aatC’inorteni clot. There 
was no lump within Uio abdomen, but a largo hsematoma was 
present in tne abdominal wall. 

Hio unusual points in this case are: (1) Tho Inigo 

haematoina. I cannot find a record of this occurring in 

tho abdominal muscles ' during influenza and pneumonia. 

1 would suggest that tho cause was thrombosis of a vessel 
in the abdominal wall. (2) The marked jaundice. 

I am indebted to Dr. Thornley for tho later liistory of 
tho man, for the necropsy findings, and for helpful sug- 
gestions generally. Walsh, M.B., Ch.B.Leeds. 

Scarborough ' 


anaesthetics in obstetrics. 

At a ioint mooting of the Sections of Anaesthetics and 
Obstetrics of the Royal Society of Medicine on March 2nd, 
with Dr. Cecil Hughes, president of the Section of 
Anaesthetics, in the chair, a discussion was held on 

““alf eI^dlbv Hollaot, opening the disoussion 

standpoint, said that he was glad to see that 
obstotr 0 P ginning to take an interest m a 

of their art wldch hitherto they l.ad almost 
The requirements of tho obstetrician were that 
tbf anae;thet hould be simple and safe in administra- 
and capable of being used by those inexperienced m 
u a of general anaesthetics. Pain must be ahohshed 
^ neefsTary, kept in abeyance for long periods o 
!,,,+ there must ho no interference with the. fqico or 
time, but uterine contractions, or witl. tho 

frequency of the n Chloroform and ether 

safety of the i^nt the latter needed more 

were equally as it was more difficult to ensuvo 

expert h required more elaborate apparatus. 

■ O oaf useful in certain obstetric operations, but was 
Stovame labour.’’ Morphine was a good 

not advised in^^ moUier, but was dangoinus to the foetus, 
analgesic j j e believed ' that intermittent ch.oro- 

“ h,! s.ffbSj s H ^ 

difficult to give an overdose, and so an unskilled po 



March io, 1928] 


ANAESTHETICS IN OBSTETRICS. 


[ Titr Breeisi^ 
MilOIClX. JoCRXJlL 


395 


could bo allowed to adnumstc- It in the pioscnce of the 
obstetrician. Chloroform should not bo given until the 
second stage of labour was beginniug. In the first stage 
tairlv large doses of chloral (30 grains) might he given, 
and 'if. necessary repeated; iiiorpliino and hyoscino in small 
doses were also useful. These ensured relief from pain 
without marked interference with the uterine contractions. 
Mr. Holland pleaded that Simpson’s method should be 
taimht to students. It was difficult to keep patients in the 
. ' first ■ stage of anaesthesia ' without practice. It was a 
reproach to. obstetrics that in hospitals and in the practice 
of midwives common labour should be conducted without 
.the use of elilnioform or some other general anaesthetic. 
The first stage of anaesthesia was ample' to relieve pain 
'for the second stage of labour, and with it there was 
relaxation of the levator aiii muscle, with consequent 
'shortening of the time of labour, ns there was less resist- 
ance to the passage downwards of the head. The anaes- 
thesia needed deepening towards the end of this stage, 
when the head was engaging the cervix and stretching it. 
'.He referred also to the effect of emotion on labour pains. 
Suitable mental treatment was valuable during the last 
months of pregnancy, so ns to ensure the co-operation of 
.the patient by gaining her confidence. Pain was greatly 
increased if • a patient were unduly apprehensive or 
frightened by tales told by her friends. Psychic treatment 
tended to make the ordeal less terrible, and she went 
through it with far less emotion. 

'Dr. Jo.sEPH Blomfield agreed as to the desirability of 
anaestbetics being given in common labour, but denied that 
, anaesthetists had only just coimneuced to take an interest 
in obstetric anaesthesia.- Tlioir opportunities had been 
limited hitherto by lack of invitations to co-operate with 
,the obstetricians. . In his opinion nitrous oxide and oxygen, 
owing to the bulk of the apparatus necessary for their 
effective administration, could not bo used as a routine in 
private houses. Moreover, it was difficult to give these 
gases in a wide bed such as was commonly used for 
.parturition. They caused a condition of excitement in 
many peojile which militated against proper asepsis for 
' ti kelieved chloroform was the anaes- 

hetic of choice. Regarding synergistic analgesia, he was 
surprised at the choiee of this route of anaesthesia. The 
pens was already full, and it was proposed to add several 
ounces of fluid. Ethylene and acetylene, excellent for 
■piotueiiig quick loss of consciousness, wore unsuitable if 
P''o'ongod. Ethyl chloride was 
could be used repeatedly in small doses 
without any .11 effects on the patient. 

'■ . • said there were three tvpes of con- 

.bnements: (1) among the poor and in hospital; (2) in a 
^ practice, where the practitioner gave the anaes- 
TT-onU^ conducted the confinement; and (3) among the 
. a.sses, where an obstetrician and an anaes- 

n employed. In the fii-st group an anaesthetic 
.”®Vally given. Chloroform was the most useful 
tlietisf ^ second group, and where a skilled anaes- 

of third group, the choice 

■certainlv could safely be left to him. Chloroform 

■me of '1^1 ether, and the 

■heing needod"''''on \hp probability of forceps 

patient wliinl, c ii “*'’cr hand, the immobility of the 
coiitamiilatinn f chloroform lessened the chance of 
•PiW oxrn •'> stc’-'ilo field. Probably 

for confinement?^but 'tl'^ anaesthetic 

a skilled anaesthetist “*= 7 ss'tated the presence of 

as the routino „ ’ 7'^ to be ruled out of court 

aPd might lead U°chaZes in‘'tr'° r™ ’'“h 
c^'stmg toxaemia mivhf L liver and kidneys; any 

■a second operation ° ^creased by its use, and if 
form was verx- ri k '*^®®‘t“cntly became necessary cbloro- 
aceoimt. Spinal should not be used on any 

Caesarean section b'nf stovaine was useful for 

tion anaesflietic even ’"''ala- 

tions Were vcrv’lil-pT t aitroiis oxide, as lung complica- 
®''. H. A T1 ^ ^ 

for a xvonian selection of an anaesthetic 

patient, just as in p depended on the state of the 

could. consist of f ' The first , anaesthetic 

J suitable drug, but on no account 


should a second anaesthetic contain any chloroform. 
Nitrous oxide was not suitable when the patient was in 
a state of apprehension of pain, as it only tended to excite 
her, . and chloroform could be dispensed with in cases of 
Caesarean section. If stox’aine were used he recommended 
that a small dose, such as 0.4 eg. in saline solution, 
should bo given. If nitrons oxide were used he preferred 
to give it w-ithout oxygon, but with air, and possibly with 
a little carbon dioxide. 

Df. H. E. 6 . Boyle had been much impressed with what 
lie saxv in the United States, where nitrons oxide and 
oxygen xvere given to a great extent. So far from being 
diminished, ho believed that the uterine contractions were 
increased both in force and frequency, and the length of 
the labour thereby shortened. A little ether should be 
added when the head was being born. This could be cut off 
before the body xvas delivered, and oxygen and carbon 
dioxide substituted. After the birth of the body the 
nitrons oxide and oxygen should be continued until the 
placenta was delivered. 

Dr. Beckett-Overy belicYed that in the hands of the 
unskilled nitrous oxide and oxygen were dangerous; chloro- 
form could be given by the woman herself xvith the help 
of a Junker inhaler. During the first stage he liked 
to give morphine and liyoscine, as it led to calm and quiet. 

Mr. Sydney Malkin said that he had had a limited 
experience with synergistic analgesia and thought it might 
be useful. Of twenty cases analgesia had been entirely' 
successful in twelve; two failed completely; one patient 
showed undue excitement; in one case, with a quick 
second stage, the child was born blue, and the rest were 
not entirely satisfactoiy. Dr. Clarke strongly approved 
chloroform, both in obstetrics and in general surgery. 
'When properly given, according to the Scottish method, 
it was both ' safe and satisfactory. Dr. Z. Mennell 
believed that the method of nitrons oxide and oxygen as 
used in America was excellent in America, where all 
obstetric cases were dealt with in private and public 
hospitals, but that in this country it was impracticable 
because of the drawback of lack of portability of the 
apparatus. 


MEASUREMENT OP BASAL METABOLISM. 

At a meeting of the Liverpool Medical Institution on 
February I6tli, with the president, Dr. John H.ay, in the 
chair. Dr. H. S. Pemberton and Dr. R. T.-6oody'E.vr made 
a communication on the clinical value of basal metabolism 
measurement. 

Dr. Pemberton^, dealing witli the clinical side, compared 
this method of measuring thyroid activit}- with the well- 
established tests of functional efficiency of other tissues, 
and defined it as the measurement of resting heat produc- 
tion or minimal oxygen consumption under basal condi- 
tions. He contended that it now had, or should hare, its 
place in the diagnostic armamentarium of the modern 
general hospital. In discussing the practical value which 
might be obtained from a knowledge of the basal meta- 
bolic rate, lie drew attention to four questions : (1) In the 
case of apparent liypertliyroidism or goitre, xvliat was the 
actual level of thyroid activity? (2) In cases in wTiich 
tlierc xvere no definite signs of altered thyroid actix'ity was 
there, in fact, an alteration in so far as this was expressed 
by an abnormal basal metabolic rate? (3) The success or 
otherwise of treatment as reflected in a movement of the 
basal metabolic rate towards normal ; guidance from this 
movement as to subsequent treatment; and a comparison 
between alternative methods of treatment. (4) The pro- 
gnosis as measured by the basal metabolic rate. 

Dr. Goodyear described in detail the working of the 
modified Benedict instrument in a room especially set aside 
for the inirpose. The production of the basal st.ate, the 
many factors xvhich influenced it, and the difficulties in 
technique were discussed. The standards of Aub and Du 
Bois were those upon which estimations were based. He 
laid stress upon the careful preparation and the handling 
of the patient while undergoing the test, and particularly 
the lighting, decoration, and heating of the basal meta- 
bolism room. The reliability of the results was also dis- 
cussed in detail. 



396 March jo, 19 : 8 ] 


BEVIEWSv 


{d- LMCDICJlLJoCWlil,' 


Ecbkfos, 


EDEN' AND LOCKYER'S “GYNAECOLOGY.” 

The third edition of Eden and Lockyeh’s G-tjnaccology^ will 
roceivo a hearty rrclcomo, for it has already established 
itself as one of the soundest and sanest presentations of 
the subject published in tliis country. From tho first tho 
authors sot themselves tho difficult task of striking an even 
balance between tiio pathological and tho clinical aspects of 
gynaecology, and they are to bo congratulated on having 
maintained that balanco throughout successivo editions. 
From tho standpoint of those specially practising and teach- 
ing this branch of mcdicino the thorough manner in rvliieh 
the pathological side is treated has made it essential for 
them to find a place for this vohimo on their bookshelves. 
It gives in small compass a judicial summary and world- 
wido review of the advances in gynaecological pathology, 
particularly in morbid histology'. 

This edition has called for considcrahlo addition both to 
text and illustrations. The physiology of menstruation — 
both the histology of tho endometrium throughout tho cyclo 
and tho influence of tho corpus Intoum — has been revised 
in the light of recent research, including tho work of 
Wilfred Shaw on the formation and structure of tho yellow 
body. Other new matter calling for niontion is tho full 
account of adenomyoina — or endometrioma, as it is now 
more often termed — and its place in tho causation of tho 
tarry blood cysts of tho ovary, as ivorked out by Sampson 
and Bailey. Tho book has, too, a correspondingly valuable 
practical side, and tho more modern means of diagnosis and 
treatment are fully considered and weighed. Tho section 
on operations is clearly written and well illustrated; the 
attention paid hero to tho after-treatment of both abdominal 
and vaginal operations is particularly U'orthy of notice, 
and must prove of value to those who have tho after-care 
of tho patients as well as those who operate. 

The section on cancer of tho uterus jirovides a good 
example of the authors’ skill in combining tho scientific and 
practical sides of their subject. Tho naked-eye and micro- 
scopic characters and tho mode of spread of tho various 
forms of uterine cancer, together with their features as found 
on clinical oxamination in their early and late stages, aro 
fully' deseribed and illustrated, and possible linos of treat- 
ment, operative and otherwise, and selection of cases are 
carefully' discussed. Treatment by radium is regarded with 
an open mind and optimistic outlook, and the technique 
for its apiilication is exemplified by figures showing a front 
and side view with a tube in tho canal and needles palisading 
tho periphery of tho growth. The dosago advised is, how- 
ever, smaller than that commonly adopted. The difficulty' 
in reaching glandular and cellular-tissue metastases is 
stressed, and deep a;-ray radiation advocated for them. 

The inclusion of puerperal sepsis in the infections is 
greatly to be commended, for it cannot be reasonably 
separated from other infections of the female genital tract, 
although enslomarily it is allocated to obstetrics. Good use 
has been made of the old surgical division of the subject 
into general and regional, but we question whether this 
classification is any less open to the objection tho authors 
make to a jiathologicai classification — that it tends to 
dissociate conditions whicli are in close clinical relation. 

This new edition of a good book deserves all the apprecia- 
tion accorded to its predecessors. 


FRACTURES. 

ScunDER’s Treatment of ’Fractures'^ is recognized ns a 
leading authority wherever the English language is spoken 
or read, and tho issue of the tenth edition will be welcomed 
bv all who have to do with these injuries— that is to say, 
by every medical practitioner— for the spread of the motor 


• Gunaecotnav for StuiUala and Praclttfoncrt. Bv Tliomas Watts 
Edanf W.D., 'CM., F.R.C.P.Lond., F.E.C..S EcL. and Outhbert Eockyer, 
MO its FRnP F.B.G.S. Third edition. London: J. and A. 
Chu'rchil’ **1928 * (Roy 8to, pp. xv + 822 ; 5^ figures, 32 plates. 36s.) 

= r?if rrca(men( o/^rflc/urciT. By Charles Locke Scudder, A.B., Ph.B., 
M.n . v A o <5 nrasrifh prlilioit. revised, riuladelphia and London : 


U.D., F.A.C.S. Tenth edition, revised. PhiJadeipma nna ^ndon : 
W. B. Saunders Company. (Boy, 8vo, pp. 1240; 2,036 figures. Bos, net.) 


car epidemic makes it impossible for any man to foresee 
when or whore ho may ho called upon to treat a fracture, 
■\Vo aro not surprised to learn from Dr. Scudder that tlie 
incidence of fractures is increasing in the United States, 
hut tho figures lio quotes are appalling. Ho tells us that 
in 1924 155,000 cases of fractiiro wore treated in “A 
Grade ” hospitals in that country. How many cases should 
bo added for hospitals of lower grade wo cannot tell, but 
tho figures above quoted signify that ono person in seven 
hundred suffered from fracturo in ono year and was 
fortiinato enough to bo admitted to hospitals of A grade. 
This new edition lias been brought thoroughly up to date, 
tho operativo treatment being especially fully discussed 
and described, including both plating and grafting 
methods. The importance of team w'ork is emphasized. 
For tho first time Dr. Scudder has, in tliis edition, con- 
fided' tho articles on special subjects to sjiecialists. Dr. 
Joseph C. Bloodgood writes on pathological fractures, 
Dr. F. AV. Bancroft on bone repair, Dr. Kurt H. Thom 
on fractures of the maxilla and mandible. Dr. James 
Jloiinoll on massage, Dr. Frank Richardson on anaesthesia 
and anaesthetics, and Dr. Edward Truesdell on birth 
fractures, a subject that ho is peculiarly qualified to deal 
with. Dr. Scudder recognizes that if bettor functional 
results ill fractures are to be attained, treatment, especially 
in difficult and complicated cases, should be carried out 
by specialists, or at least by general surgeons who have had 
special experience, and that such treatment should ha 
initiated as early as possible, if it is to give good results. 


Tho, publishers of Dr. Etienne’s Traitement dcs Frac- 
tures par h Praticten^ say that “ this little book has been 
written for the practitioner who, in the presence of a 
fracture, without radiographer, special apparatus, or 
skilled assistance . . . has to decide on and ajiply treat- 
ment." Any practitioner in such a predicament has out 
sincerost sympathy, for the absence of radiography alone 
presupposes that ho is fighting with one hand tied beriind 
liim and that he may be tho victim of an action for 
malpraxis. This is a handy little guide to the rudiments 
of fracture treatment,' and contains useful hints os to 
first aid Unlike most Continental surgeons, the author 
seems to have some knowledge and some appreciation of 
the merits of Thomas’s splints. The figure which purports 
to roprosoiit the conditions in a fracture of a vei-tebral 
bodv does not show the ordinary compression fracturo, but 
a fracture-dislocation, which is uncommon. In tho case of 
1 fracture of the patella wo are told that there is only 
one ioi'ical method, and that that is open operation and 
“ orcUiEe ” How the practitioner in tho circumstances 
prLipposed by the publisher is to carry tliis out we do 
not Imow. No other method of treatment is so much as 
to. 


birth INJURIES OP THE NERVOUS SYSTEM, 
rmc Foud. Ckotiiebs, and Putnam, in their book on Firth 
U,iur'irs of the Oeatral Nervous System,-' have attempted 
Jarrire at a more exact definition of the group of true 
lirth palsies than has been hitherto attained. The subject 
“^rebral” birth injuries is dealt with by Dr. Fold, 
,. 1 . 1 , Etates that there is convincing evidence that the con- 
rpnital* diplegias which constitute by far the largest group 
r ffifantUo spastic palsies are not to bo attributed to 
:ieniimeal haemorrhage at birth, but are the .result of 
-arioul pathological processes of intrauterine origin. 
Vrebral birth injuries producing lesions of a kind tliat 
' Imrl to conKenital diplegias Iio considers to be raie, 
hi eoncluXs^hat tlm great majority of infantde 
,akiei ern no longer be lightly attributed to fai.Rr 
bstoHical procedures. As regards hydrocephalus, no 
tatpment ^n be made about its relation to birth injury. 
a"enla^^ement of the head may occur, with extensiyo 
leeding into^tlie ventricles or subaraclinoid spaces; bu 


TZ Z n if-a fractures par le Fraiicien. Par 

protosor Jeanbrau. Paris : Maeson et Cie. 1927. (6, x 3. 

i. 194: 115 figures. 16 fr. sans ' _ -ebral Birlh 

'Birth InjurteB of the OrMrlu ^ Bronson 

juries, by Frank. B. Ford P „ .. 

•others and Marian C. Pu , + 

ndon : Bailliere. Tmdall anc 

figures. IBs. net.) 



MkncH 10, igiS] 


BE^aiiws.' 


f TraURirrsH 
UepTci^ JocKxu. 


397 


vsiwllv the blood hocomos absorbed, tbougb j.ossibl.v bydro- 
ceodmius mav Tosult occasionally from plugging of tlu; itor 
The common diffuse meningeal haemorrhago, nhioh la not 
lar-c enough to. cause death, apparently leaves no re.Mdnum 
as a rule The real birth injuries to the hram are eaused 
hv the rarer intracerebral hacinorrliagos and nceroscs, hy 
depressed fractures with lacoration of the brain, and hy 
some eneapsuled Iiacinorrliagcs which conipre.ss and soften 
the corto.';. The true birth palsies arc npparontly rejne- 
sented, not by tbc diplegias, but by tho congenital hemi- 
plegias, the monoplegias, and the asymmetrical and unequal 
bilateral spastic paralyses; asymmetrical congenital defects 
of the brain will, however, be unavoidably included in this 
group sinco they are clinically indi.stingiiishablo. It this 
view is collect it would appear that only aliont 6 per cent, 
of allMiifiuitilc cerebral palsies arc due to birth injury, but 
the group is not well onongli defined to permit of exact 
hmnerical ' estinvition. Keeiirreiit convulsions occur in 
ahoiit onc-tliird or more of these cases, and it is inobable 
that about 2 or 3 per cent, of all epilepsies seen in 
ebiidren are related to birth injury. Severe grado.s of 
nieutal defect are probably not related to birth injury, 
with tbc c.xecption of tliat type which develops in associa- 
tion with frequent convulsions. 

Birth injuries of tho spinal cord arc eonsidored by 
Crothers and Pntnain. The ordinary tyqre of brncbial palsy 
is ucll understood; it is produccel by traction, usually 
lateral, and in general is characterized by paralysis of 
definite groups of muscles. In a number of case.s, however, 
where the disability was paralysis of the arm, tbc aiitbor.s 
found evidence that the spinal cord was also involved, and 
they have come to the conclusion that in most cases where 
tho spinal cord is affected the cause lia.s been trartion 
o.verted during delivery and not congenital or other pre-natal 
inflneiices. The most fragile and least clastic structures, 
they contend, are the spinal cord, the mciuhrancs protecting 
it, and the neiwes, and it is these strueturc.s which arc 
liable to suffer from undue traction. The authors note 
.tlint obstetrical textbooks arc almost completely silent on 
tins iwintj and they consider that until more cmjdiasis is 
placed on the importance of the control of traction as a 
factor m succiissfid deiivei-y, accidents will occur in nn- 
ncccssary niimbors. If no adequate warning i.s given by 
teachers that traction may result in .serious injury to tlie 
spina] cord, tho individual practitioner niav use it to 
the detriment of tho children ho delivers. ‘ 


■ SYNOPSIS OP STjIlGPRY. 

'To S™"' ill bulk with everv 

liv air’ edition of .1 ,V.i/uopsis oj Svry, 

ninincf " o' (^noVESi, is no excoption. It W( 
tint tiT™' *1 has outgrown its original title, 

' rv'.' iT''*’ 1™® 's deserving of a inoro iinpo: 

^ short, concise senteuecs, 
eno'rmmiT*^ i*'"' classified, it covens such 

heomni, increasing field that it is in danger 

"enm'” fTTT gnick and ea.sy reference tha 

examination! O" the threshold of his shiv 

•uiSrts « ‘""“‘{'IT' 1°” T 

but its re-in. * retained in all tbc larger toxtlm 

lop-heavv ®>''i®Pais tends to make tbc I 

svpbilis ' and s the older fonns of treatment 

strotebiue e u \ °P®J'“ti<>ns as nenyeefomy and m 
stretcliiue'io dispensed with, and for facial 

tions. |{pr.anr ' °° mention made of alcohol in 

euloeranliv n- an^b as cholecystography and vev 

fnllv have" lie ° Hpiodol iujeetione could 

cularcements ■ o° segments, rather than 

lioen f, ' nmlat Wnck-and-whito illustrations 1 

a c Sou T te^t. and as an appendix tl 
_J^ciiaptoi on surface nmrkiup-^ ^ ^ 



Ail stiulent.s will find in tliese pages what is necessarv for 
their pass e.xiiinihatioiis, a great deal of practical 'help 
and wisdom to guide them in their period of hospital 
!\pprcnticeshii>, and concise references on most of the im- 
portant points of suigci-y likely to arise in the couv.se of 
husy general piaetiee. 


NORMAL HISTOLOGY. 

The thirteenth edition of '1‘icnoVs yormiil Ilhtoloytj.’^ 
revised, and in pai-t rewritten, by Professor .Yoni.sox of 
the Univei-sity of Pennsylvania, sliows a welcome advance, 
though all tod small, in the phy.siological treatment of the 
subject. Histology is the easiest subject to master in the 
medical curricnhnn, and the easiest to teach. Hence it 
is too often taught in uninteresting fnsb,ion, and the 
student fails to obtain that familiarity with the minute 
anatomy' of tho normal ti.ssues, a.s distinct from the 
" spotting ” of organs, which is so necessary for the later 
stmly of morbid anatomy. The decay of morbid anatomy 
is partly duo to lack of vision in histological teaching. 

As an example of the anatomist's outlook the hook is 
satisfaetorv, and many new illustrations have been added, 
notably those .showing vascular iiijcetious of various organs. 
Con.sidcrahio .space is devoted to those organs which are 
examined in tlie post-mortem room, and tho section deal- 
ing with the blood has been amplified. From the point of 
view of the physiologist the work suffers from an innde- 
fjuatc description of the appearance of freshly exaraiued 
tissues and from a lack of liistorieal c-ouscioii.sne.se of the 
contiiinity and intcn-ulationsliip of form and function in 
the work of all tho masters in thi.s subject. There l.s a 
icseful aiipcndix of routine methods and a list of selected 
lefcreiiee.s based on the reading lists that ai-esuch a feature 
of American .seminars. This list includes about 165 titles, 
of wliieh. 130 are purely American. The student would 
benefit in bis reading if he were made acquainted with 
some of the giants of histology, such ns 'Kollikor, Ranvicr, 
and Virchow among the earlier, and Sohottn, Schaffer, and 
Seliiifcr among the more recent. The description of tho 
Wood vessels is still inadequate, and the statement that 
the iiitinia of the veins sometimes contains miisele is not 
in keeping with the description in Piei-soVs textbook of 
anatomy. IVe find no reference to tlie Ronget cells of the 
capillaries, -or to the work clone thereon by Clark of Phila- 
clclpliia, or to tlie direct examination of the circulation 
of tho blood in the kidney cle.scribcd hv Richards of the 
same schooi, and the masterly Harvey Lecture hy Gideon 
AVclI.s on calcification and ossification is omitted from tho 
rc-acling list. 

The sc‘c-tioii dealing with the nervous sy.stem is in keeping 
with the anatomical tradition, but siiffeis from brevity. 
The histologv of degenerating nerve is .still omitted. The 
c-linic-al and jiathological signific-nnev of AVallerian degenera- 
tion is one of the main weapons of the histologist, and the 
most important of the few that he Jms. The stria of 
Geniiari in the visual cortex is not figured or described. 
■Yt a time when increasing attention is being [laid to 
metaplasia of tissues, senesceneo, and normal decay, it 
seems a pity that tlie histology of the clnetus artcriosns, 
ductus veiiosus, allantois, AVolffiaii duct, aucl foetal oe.so- 
phagus should be omitted, for the student will .snrely liear 
of them cluriiig his later stuclie.s in morbid anatomy. 


NOTES ON BOOKS. 


Tteatmcnt hi/ J/aiii/mtation' is the second edition of Air. 
Tijibuei.t, Fisnca's ilanipiiluliri' S\:r(jir!i, wliich w.ns reviewed 
by ns in our issue of December 26th, 1525 (p. 1231). Me do 
not quarrel with Mr. Fislier's ciiange of title, althongli a 
captious critic might object that all snvgical treatment is treat- 
ment bv manipulation, for the cheirourgos is essentially' -a 
manipul'ator. The .sections on osteopathy, tennis elnov. , 


spivrsotv Xonml llhlnhuni. Tliiriecnth edition, nmy fir't nlitM and 
Jiin TwHCten .V William It. F. .Vddi-on, M-I>. Tliorouclil.c revised 
k"/rierD^doaT.T"B.' mrinneoi.. 1927. {Med. 8v„, rp- vliia-CT; 

By .V. G. Timbrell risl.er -V.G., 
utir^Fn- ' Bein'- Ihe i-eennd edition ot .VnnipulKire •^”rii^/. 
SdilnPlt and Co., ltd. 1928. {Bemy Bve, rP. -vi - 200; 

62 ngures. 9-. nct.3 


398 UAEcn 10, 1928] 


tlVEE EXTEAGT- IN PERNICroUS ANAEMIA. 


!}., r XnRPnmsa 
* ■ L mebicai, Jom'Al 


chronic arthritis, and lesions of the sacro-iliao joint have been 
rewritten and enlarged. As regards the last named, Mr. 
Fisher’s views now approximate to those held by the Boston 
school in America, but in a book on manipulation wo can 
hardly expect to find a recommendation of fixation operations 
in oxlremo cases of subluxation. His diseu.ssion of osteo- 
pathy and chiropractic is timely, and the instances ho quotes 
of damage done by osteopaths and chiropractors should bo 
a warning to those who are inclined to be indulgent towards 
such practices, and will furnish valuable arguments to medical 
practitioners who are trying to guide their patients into safe 
ways. As regards the elusive syndrome known as tennis elbow, 
but not confined to tennis players, wo note that Mr. Fisher 
does not mention the method of treatment which has been 
so successfully used by Mr, G. Percival Mills of Birmingham, 
and which was described in our issue of January 7th (p. 12). 
Mr. Fisher’s remarks on the value of movement and rupture of 
adhesions in various cases of chronic arthritis are worthy of 
notice. 

Under the editorial direction of three distinguished .surgeons 
of Berlin, Hallo, and Berne, a System of Urology* is being 
prepared. The first volume deals with urology generally, and 
in particular with its surgical anatomy. A careful account is 
given of operations on the kidneys, ureter, bladder, and male 
generative organs. The physiology and pathology of the 
urinary secretion are similarly dealt with on an el.iborato 
scale. The book is copiously illustrated, and there is a useful 
inde.x. It is a good example of the characteristic typo of 
German publication which endeavours to combine the textbook 
and the reference volume. 


Dr. Joan Ross, now lecturer in pathology at the London 
School of Medicine for Women, brought out in 1925 a book on 
Post-mortem Appearances,'^ which was favourably noticed in 
these columns (1926, i, 331). It iias now deservedly passed info 
a second edition, which has been revised and enlarged by 
some additions. The book is a little longer, but there is every 
reason to repeat wh'at we said on the previous occasion, except 
those suggestions then made as to slight changes, which have 
been adopted. 


All workers on mosquitos in tropical and South Africa will 
be greatly indebted to Miss .^wen M. Evans for her Guide 
to the Anophelines of Tropical and South Africa,^” which 
appears as one of the Memoirs of the Liverpool School of 
Tropical Medicine. As the author states, " it is not in any 
sense of the word a monograph . . .” but it is all the more 
aseful to the medical and sanitary officers in these countries, 
for whom, in fact, the volume is likely to prove indispensable. 
A key for all adult species and a key for larvae of the six most 
widely distributed species is given, followed by a systematic 
and bionomio account of each, with excellent illustrations in the 
text, and at the end a series of plates of breeding places and 
many very beautiful delineations of arrangements of scales and 
tarsus markings. 

Volume XLVII of the Transactions of the Ophthalmological 
Society of the United Kingdom}^ contains the proceedings 
during the past year of this society, and also of the Midland, 
North of England, and Irish Ophthalmic Societies, and of the 
Oxford Ophthalmological Congress in 1927. Good illustrations 
are provided for the various papers, and the present issue, like 
its predecessors, constitutes a valuable record of progress in 
ophthalmology in Great Britain. 


■Lippincott's Pocket Formulary^^ requires a somewhat capa- 
cious pocket. The volume has been compiled by Dr. Geoege E. 
Rekeergee in order to provide the medical practitioner with 
a ready reference manual. The first sectien gives an alpha- 
betical list of diseases and symptoms, with appropriate treat- 
ment and prescriptions. Some of the conditions may sound 
quaint to English ears, such as caked breasts and milk sickness. 
The latter part of the book contains lists of U.S.P. X drags, 
of drugs in the National Formulary, and of new and non-official 
remedies. Sundry tables of weights, measures, and so on are 
appended. . 


• Uanihuch der VroUgle. Herausgegeben von A v. Mchfenberg, F. 
Yocicker H “vildbolz. Erster Bond. Allgemeino Urologie I. BeJiin : 
Voeloke , 8vo, pp. X - 1 - 754 ; 312 figures. H.31.93.) 

^vvcdrances. By .loan jr. Boss, M.D., B.S.tnnd., 
\Tnrs LRCP With a preface by E. K. Kettle, M.D. Second edition. 
Ox?o‘rd Med'i^a?'Publications. London: Milford, Oxford University Press. 

OuNe to^hf/no^hAin^ of Tropical pnd South 
\trica. By Alffcn M. Evans, M.Se. LwerpMl School of . 


^ TJve aivvati m F.vans il SC. ijiveryowt g>t.-nvwi v* Tropical Medicine* 
vCmotr r^ew leries) and Stoughton. IBV, 

m x lOi, pp! 10 figures, 12 plates. Paper cover, 7s. 6d. net; cloth, 

°';?rr?n1i’cffons of the OpldmmologicalSoci^ot aeV^ 

Vol. XLVII, London : J. and A. Churchill. 1927. (Demy Bvo, pp. xlvill 
•4* ^7 ; 82 figures, 3 plates. oOs. net.) _ _ ■» t> v Tt 

' ** Lippincott's Pocket Formulary, By Georgo E. Rehbergert MeD. 

IiOBdoa 1 J.. B. Lippincott Oempany. 1927. (4 X 81. 155. net.) 


LITER EXTRACT IN THE TREATMENT OE 
PERNICIOUS ANlExMIA, 

Repout by tub Medical 'Beseaiich Council, 

The following preliminary report on tho liver treatment of 
pernicious anaemia has been received for publication from 
tho Medical Research Council. 

Tho treatment of pernicious anaemia by addition of liver lo 
tho diet, introduced in America by Minot and Murphy, has 
already been widely adopted with encouraging results. Aa 
important development of this has recently become possible 
through the successfnl preparation, by Cohn and others, of an 
extract of liver containing in small bulk the unknown factor 
which produces tho ameliorating effect. The treatment is 
thereby made available for patients who cannot tolerate the 
largo daily consumption of liver itself. 

In tho past autumn, through the courtesy of the Pernidons 
Anaemia Committee of Harvard Medical School, the Medical 
Research Council received information about this method ol 
preparing liver extract, and were invited to make trial of it 
with a view to assisting introduction of the treatment in this 
country. On the basis of this information experimental work 
was undertaken in tho Council’s laboratories at the National 
Institute for Medical Research, and a modification of tho 
American process was found, through the co-operation of 
Professor F. R. Fraser of St. Bartholomew’s Hospital, to yield 
a satisfactory extract. To increase tho scope of the work tho 
Council then invited the co-operation of manufacturing firms 
likely to bo interested, and arrangements were made for clinical 
trials of tho preparations thus obtained in adequate quantity. 

Supplies of liver extract made on a manufacturing scale by 
tho modified process were received from the Boots Pure Drag 
Company, from the British Drag Houses, Limited, and from 
Messrs. Burroughs 'Wellcome and Co. , 

It is at present impossible to gauge the therapeutic effects 
of liver exfracts in pernicious anaemia by any other method 
(It>i of direct trial upon human patients.- The extracts 
I mplied by rte three firms were, therefore, distributed widely 
suppheu y . , . clinical reports upon the activity of 

«ie''several preparations have been received from tho following 
nhvsicians t ^Dr. John Cowan, Glasgow j Dr. 8. P. Davidson, 
ultab. Professor B. C. Dodds, Middlesex Hospital, 
'T B Elliott, University College Hospital, London! 
«ov A 'W M, Ellis, London Hospital,- Sir Thomas 
Professo • ' p f^gsor W. E. Hume, Newcaslle-on-Tyno ; 

Praffsrar E. MMlanby, Sheffield. To these, and the 
ZLguTX have been assooiatod with them m this work, 

iha nouncii ai*0 much indebted. 

A 4 I'll of 34 apparently clear cases of the disease came under 

A total of 34 appar n y 

treatment The object ot^ possible, rather than to watch the 

n^'^over a long^per^od of time. For this purpose the early 
results ov g P t;culocytes— the young red cells with 

’"'"•I Steining praperties-was adopted, as it had been found 
special P T the American work. This rise is usually 

to be sat'sfacto y improvement on the part of 

and it is succeeded by a progressive increase in 
red cell count, while the relative proportion of 

'crser’all but 2 showed a good response. In 

ox of these the conditions were sueli that other reason 

f thr^rovement than the administration of the 
^*^4 f were ' clearly excluded. In the remaining 
extract ^ treatment was no less marked, 

response duringatt^^lt influence of olh« 

possibihy previous administration of fresh live, 

treatments, suen . „„tain The daily dose of extract, 

rendered the condu o„ hver, generally 

corresponding to P jesf culminating ^ 

~ W ^ swv. ;■ isys- S; 

These effects are identical with th extract is not 


9 

but 


the 

tho 



,MAECH'io,I928] 


-THE ■ GBa.SG'OW •MEDICATi- JOITKNAIi. 


f Tm Bamsa 
ilEDlCil, JOEEKAZ. 


399 


derived. Time has not yet permitted an estimate of any 
possible deterioration of the c.xtract on kecpin^^ ,■ 1 TJ I 

These preliminary reports enable the Medical Research 
Council to state that the preparations subnnttod have been found 
to lie satisfactorv. The process used in making these extracts 
has not necessarily any peculiar value as compared rvith possible 
alternatives, but it is one capable of ready application on a 
large scale The Council believe that further progress mil be 
best facilitated if extracts of the type which they have 
investigated are now made available, along with any others 
introduced apart from the Council s action, to the medical 
profession in general. 

It is understood that supplies of these liver extracts will at 
once be obtainable, through the usual commercial channels, 
from the firms already nanfed. The Council arc not themselves 
able to deal with any applications for the material. 


THE GLASGOW MEDICAL JOURNAL, 

A CE.N-TEN.\nT Nujintni. 

A HUXDUED years have passed since Dr. William JIackoiizic 
launched the first number of the Glasyow Medical Journal 
upon the waters of Scottish medical life. His name and 
,a list of the appointments which he held occupy such a 
• prominent position on the title-page of the fii-st number 
that it is fair to .assume that even if he did not himself 
build the ship, his at least was the hand that knocked away 
the dog-shores and allowed the vessel to glide down the 
metaphorical ways, as so many tall ships and ocean liners 
have done on the hanks of the actual Clyde. This centenary 
occasion is celebrated by the publication of a commemorative 
number which consists entirely of historical articles and 
notes, and is illustrated by a number of portraits and views. 
It includes also papers on medical journalism by Sir Dawson 
^ illiams and Sir Siiuire Sprigge. 

Sir Dawson Williams’s contribution — which now has a 
•sad interest as being the last of the few articles he 
eiei signed traces-the origin of newspapers to the news- 
business firms, such as the greiit Augsburg house 
0 Migger, whose system, at first intended onlv for their 
own use, was afterwards extended, so that their periodical 
"f''® allowed to be copied and sold to the public, 
tins intewsting article is illustrated by reproductions of the 
ir-j ■ ^ earliest French medical' paper, the Journal 
British one, the Mcdicina 
° 1684, of which latter only two numbers are 
tint'll "c published. Our late Editor recalls 

*+i *ssue a newspaper in the modern 

rpirnln,. •**** ’’ printed sheet jiublished at 

®‘'als--was a Doctor of Medicine, Theophrastus 

ill Paris'' i'n"lKT Noiii-.eUcs Ordinaircs appeared 

would put back the origin of medical 
when nn I? somewhat earlier than 4000 B.c. 

of ineiir..n'' Babylonian physician recorded a case 

realizes tb,it ‘'ropsy on a clay tablet; but he evidently 
one or eve fallow does not make a summer, so 

medical periodi'ea? W constitute a 

first Brit, cl. !•' assigns the honour of being the 

lleriew of 178o'''oH!'pr ^o the Foreign Medical 

Eurrived tlm I journals followed this, some of which 

which in 1 R 9 X " appearance of the Lancet, 

anr^Ler ®°“>plote innovation in the matted 

Sir i^^^alism. It had its rivals, as 

Provincial ilfcdiraf'^Tn '’ ‘'‘“'>“6 ^Bem the 

ancestor ^ Charles Hastings, and our lineal 

Eoino of the''op..i^'^^'^°^ Journal resembles perhaps more 
at no time been publications in that it has 

month. IndooR published at shorter intervals than one 
it Was a quarteHv°*T i'alf the time of its publication 

«S«larlv";u;*;1;J:"t,^“- 1877 it has appeared 
Glasgow and Been produced by the 

which Dr J xv ,|.°l.,^^®°tland Medical Association, of 

■editors to-dav are^ArpT^”^ president, and the two 
1 are Ali. pat^ick and Dr. George A. 


Allan-. The Journal has not been without its local’ rivals 
during its long career, of one of which there is an entertain- 
ing account in the leading article of this centenary number, 
“The Glasgoiv Medical Journal and its Editors.” This 
was the Glasgoiu Medical Examiner, which had a brief 
existence in 1831, and was revived in 1869. It became 
known as the “ Mustard Plaster,” so called partly from 
the colour of its wrapper, but still more on account of the 
blistering cjualities of its- articles. Even so late as 1869 it 
ridiculed Lister, congratulating its readers on his removal 
to Edinburgh and on the hope that “ our Alma Alater will 
no doubt be purified from even the smell of the quackish 
jiuffed nostrum ” (that is, carbolic acid). Gairdner was 
bracketed with Lister as a subject of its denunciation. 
But the Journal itself was not always polite in its reviews 
of books. In 1853 Syme came in for 1-017 rough treatment, 
even being reminded by the reviewer of individual patients 
whom he had failed to cure. 

The principal of the University, Sir Donald MacAlister, 
has contributed a short note on that school as it was a 
hundred years ago, when the professor of botany was Sir 
William Hooker, afterwards director of Kew Gardens, 
whose son and successor. Sir Josejih, the friend of Darwin 
and Huxley, died as recently as 1911. The school was 
flourishing, for at that time the number of matriculated 
students of medicine was 428. The Scottish universities 
at that period, and for some time afterwards, had no 
rivals in Great Britain as regards medical degrees, for 
Oxford and Cambridge scarcely counted as schools of 
medicine, and London University was not. Yet few 
Englislunen seem to have availed themselves of the oppor- 
tunities offered at Glasgow, for of the thii-ty-eight degrees 
granted in 1827 in medicine or surgery, only two were 
conferred upon Englishmen. Probably Edinburgh offered 
greater attractions. Sir Donald JIacAlisfer’s article is 
illustrated by a photograph of the picturesque old college 
in the High Street. 

The old universities did not condescend to meddle with 
the “ base mechanick art ” of surgery, except in so far as 
it was studied by physicians who professed to control the 
practitioners of surgery. Thus in Glasgow, ns in London, 
we find the teaching of surgery in the hands of corpora- 
tions of less dignity than the universities. The Faculty of 
Physicians and Surgeons of Glasgow was established by a 
charter of King James VI in the year 1599, and given 
authority, among other things, to examine all persons 
professing the art of chirurgie. It is noteworthy that in 
tho same charter it is enacted that no one is to practise 
medicine “ without ane testimonial of ane famous univer- 
sitie quhair medicine be taught.” IVlien the University 
took to granting degrees in surgery, as it did in 1816, 
competition between it and the Faculty heeame keen. 
Despite the prestige of the additional title of “ Royal ” 
which was granted by King Edward in 1909, the Faculty 
finds itself handicapped by the action of the Carnegie Trust, 
under which many students’ university fees are paid. 
Although the Faculty had furnished surgical teaching 
to its apprentices, the extramural school realh- dates from 
the year 1744, when William Cullen, a physician, founded 
it by instituting courses of lectures, but Dr. John 
Henderson tells us, in his article on “ The position of 
extramural teaching in Glasgow,” that tho era of con- 
tinuous teaching in Glasgow dates definitely from the 
establishment of the medical school of Anderson’s College 
in 1799. This very flourishing school at one time called 
itself Anderson’s Univei-sity, although it was never incor- 
porated as such. It still continues to contribute largclv to 
tho educational needs of Glasgow medical students, and 
among its teachers have been many distinguished men, 
not the least of whom is the present regius professor of 
surgerv. Dr. Archibald Young. Besides a former school of 
medicine of the AVostern Infirmary, the Royal Infirmary 
has also had its medical school, for which a charter was 
obtained in 1875, and this school is still carried on, not- 
withstanding the competition fi'om which it and Anderson s 
College suffer from the University. , - t 

7his contcii Eir^’ jiiinibcr coiitnins nmen TOorc "tiiji't is oi 
interest, including a paper by Dr. Fergus on the Glasgow 
hospitals, and tho editors, Mr. Patrick and Dr. Allan, 
deserve congratulations on the result of their labours. 




‘March Vo, 1928 ] 


MEDICINE IN THE FIEDD OF LIFE ASSUEANCE. 


L MtOICU. JdC&XAI. 


ISrittsI) iWctiical journal. 


SATUKDAX, MAECH lOTH, 1928. 


MEDICINE -IN THE FIELD OF. LIFE 
ASSURANCE. 

Ix the course of a thoughtful address, delivered lately 
to the Assurance Medical Society, its president, Dr. 
il. G. Turney, found some interesting things to say 
ahout modern developments of life assurance and their 
bearing upon the vorld of medicine. He sketched 
the evolution of the medical examination for assurance 
from a stage .vhen the examining doctor voukl submit 
a laconic “ Good ” or “ Bad ” to his directors on the 
strength of little more in the way of examination than 
the shrewd appraisement of a seeing eye. But he 
might have gone a step further hack j'et, to a daj' 
nhen (in some offices at least) the appraisement was 
a confessedly lay affair, carried out by the directors 
after a personal inspection of the candidate. 

From these beginnings medical selection gi-adually 
won its way, until a day was reached some twenty- 
five years ago when an observer might justifiably have 
assigned the future to the medical profession, so far 
as concerns the selection of lives for assurance. But 
ho xVould have judged amiss; for at about this time 
lay opinion in the insurance world, hitherto trending 
steadily towards the enlargement of medical influence 
m this sphere, evinced a tendency to branch. While 
the great inajority of those concerned were content to 
paj increasing tribute to the claims of medical selection, 
there arose in this country a school of pioneers with 
the unexpected and reactionarv watchword, “ Life 
assurance without medical examination.” It is not 
eas^ at tliis distance to appreciate as it deseiwes the 
lardihood involved in this daring breach of the accept- 
ances of tte day. The scheme, however, was put into 
e ec , at first tentatively and with reservations, and 
a er vith increasing boldness; and it succeeded. 

system has widened its scope and 

interruption, though without speed, 

I maj now be said to be common form in a good 
many institutions. 

Ifie special appeal of " life assurance 

hi Dr. Turnev allots 

lo the large body of semi-invalid 
fexamlnni'"' people who shrink from a medical 

Innnilv' /°a'i I'eveal some sinister but as yet 

tliinl- 'll ■ '^®“,P°^®nt of disaster. We cannot but 
S ml" There are. no doubt, a 

tion wi’f'l, 'ybo approach a medical examiua- 

sureh- • ‘''5P‘^®l!f“*^*nns of the kind he describes, hut 
W 'mnii"- o group-” the average 

of the pvn ’ — which feels the temptation 

a cominolll.”r^'°'^ assurance. Life assurance is 
diate tn-nfm ^ yields no imme- 

So since" a buyer, but rather the reverse. 

Lzv about without it he is hkely to be 

bis' heart that' knows well eno'ugh in 

when the 1 \ foi- bim. Accordinglv, 

strationhis neerl?™^ down and proves to demon- 
contingoneies he bjmself against unforeseeable 

listens under ’m-nt ^ mood to listen, but he 

it comes aboid thTt tlm*^ '"’^'^bout enthusiasm. And so 
the wav which win inl chooses is prone to be 

■ "-b "bl lead him with the least expenditure 


of trouble to the end which his reason — but not his 
indolent habit of mind — has considered and .approved. 

As to the future of this system. Dr. Turney thinks 
it has come to stay under, certain restnetions. at all 
events for .sums of moderate amount, and he deplores 
the injury thus inflicted upon the pockets which, in a 
better-ordered world, would continue to gather the 
honest guineas thus withheld from the medical pro- 
fession. M'o agi-ee that it has come to stav; indeed, 
.we fancy the speaker unden-ated the firmness of its 
footing at this minute. Certain it is that an approved 
life can already obtain cover under this system, 
without limitation of amount and subject to no other 
restriction than a generous limit of age. But as 
regards tlic guineas, we are fain to believe that the 
new order entails less prejudice to our cloth than Dr. 
Turney fears ; . for though it dispenses with medical 
examination it is far from dispensing with medical 
selection. Nay, it leans at eveiw doubt upon medical 
assistance in the shape of reports from medical atten- 
dants. So jierhaps wc may hope, after all, that a good 
proportion of the guineas which used to be ear-marked 
for medical examinations will find a dedication no less 
honourahlc under the new dispensation in the dis- 
charge of fees for medical attendants’ reports. But if 
in “ life assurance without medical examination ” wc 
see our.selves faced by a tendency which is, however 
slightly, uncomplimentary, we may seek consolation 
in tuniing to another and more flattering tendency in 
the opposite direction. This finds its expression in the 
periodic examination of assured lives at the expense of 
the assuring offices. The idea underlying the periodic 
examination is, of course, that under such a scheme 
a double and mutual advantage will accrue to the 
parties concerned : the assured will he warned in 
good time of the errors of addiction or regime into 
which he has been beguiled by the naughtiness of 
appetite or the ” strength of nature in youth ” (as 
Bacon aptly designates the reserve-against-stupidities 
by means of which a merciful heaven tides us over the 
follies of that epoch); while the assuring office is able 
to rest haiipy in the confidence that its clients are 
being maintained in a condition to go on paying their 
premiums punctually up to the very last unescapable 
moment. 

Periodic examination is, it seems, an American 
product, though even in its homeland its vogue is 
strictly limited. Such success as the movement 
has had in the United States Dr. Turney attributes to 
“ the very large class of people of the Babbitt type 
who are extremely well-to-do, who have made a 
fortune in a strenuous business life involving much 
nervous strain, and who have I'etifed in the prime of 
life. They have unlimited leisure, with no outside 
interests to fill it, and it is not long before iaedium 
vitae begins to take its toll of their sense of spiritual 
and bodily well-being.” We are invited, that is to 
say, to believe that the valetudinarian h.abit of mind, 
which drives some men to assure their fives non- 
medicallv for fear of the doctor, will equally drive 
others who belong to the same category into the 
doctor’s consulting room time after time under the 
svstem of periodic exammation ; and it must be 
a'dmilted that the reactions of the human mind arc 
sometimes bizarre enough to bring oven this paradox 
within the hounds of belief. _ 

• j)j.. Turnev’s conclusion is that the periodic 
examination is not desirable because it w ill tend to 
create a race of cranks and hypochondriacs. Wc 
wonder "whether cranks and hypochondriacs are really 
so easily made as this conception implies. The 
deplorable abundance of indifferent health which seems 



402 Mabcr to,- 1978 ] 


AtiKAIiOSIS AND KBTOSrS. 


-f 


Tnx Bfltma 

MtDicii. Jorurii 


to be a corollary of sedentary existcnco may be, as 
Dr. Turney holds, purely an expression of morbid 
states of mind reflecting themselves in misdemeanours 
of the body. But there is an equal likelihood — and 
more hope — in the view that some kind of, physical or 
chemical misdemeanour of the body is needed to 
determine the valetudinarian habit, at its beginning 
at any rate. If this view is the more correct, we 
need not vex ourselves on the subject of morale; and 
since it is certain that a great many people are daily 
running risks of irreparable damage to their bodies 
owing to their innocent disregard of unappreciated but 
avoidable perils, it seems almost a pity to impede 
a movement which is designed to warn them before it 
is too late. 


ALKALOSIS AND KETOSIS. 

The effect of the ingestion of alkali upon carbohydrate 
metabolism has been further discussed by Goldblalt in n 
.recent paper,* and tho subject is perhaps of sufficient 
clinical importance to warrant a brief suminai-y of somo of 
the earlier litoraturo. Davies, Haldano, and Konnaway= 
showed in 1920 that alkalosis, produced experimentally by 
bicarbonate ingestion or ovorbreatbing, caused acetone 
bodies to appear in tho urine. Haldano, AViggIcswortli, 
and Woodrow^ repeated these results, using tbcmsclvcs as 
experimental subjects, and found that after overbroathing 
and after bicaz'bonato ingestion largo amounts of /3-oxy- 
but 3 ’ric acid and small amounts of acotono were excreted. 
Tho iuoroaso of ketosis after alkali administi'ation to 
diabetics had often been obseiTod, but had boon put down 
to a “ Avasliing-out ” effect on tho aooto-aootic acid and 
/3-oxybutyaio acid already present in the body. Tlio ketosis 
produced by alkali administration to normal subjects would 
bo difficult to account for in this way, and Haldano, 
AViggleswortli, and Woodi-ow thought that it might bo duo 
to deranged cai-bohydrato metabolism, and sought further 
evidence of such a derangement. Tho respiratory quotient 
was found to fall voi-y low about three hours after 
bicarbonate had been taken, and remained low for several 
hours. In somo cases tho quotient was well below 0.7, 
this showing that no carbohydrato at all was being oxidized 
during that pci-iod. At tho sarao time tho sugar tolerance 
was very much lowered, and tho blood sugar cinwcs after 
taking glucose resembled those given by diabetic subjects. 
The ketosis, very marked during the experimental period, 
was only partially suppressed by the glucose, and returned 
again as the blood sugar level fell. As such results (except, 
of coui’Se, the altered respiratory quotient, wliich could not 
bo determined in overbreatbing) could bo obtained either by 
overbreathing or by bicarbonato ingestion, both of which 
methods produce alkalosis but othenvise have veiy dissimilar 
effects upon the blood and tissues, tho authors thought it 
safe to assume that their results were indeed duo to tho 
state of alkalinity produced in tho body. They pointed out 
the similarity between tiio conditions of alkalosis and 
diabetes, and suggested that tho administration of largo 
amounts of alkali to diabetics might well prove dangerous. 
Collip and Backus'* bad previously shown that sevei-o over- 
breathing could produce actual byperglycaemia. Pavy in 
1861 had shown, on the other hand, that acidosis was 
often accompanied by glycosuria. Haldane, Wigglesworth, 
and AVoodrow, therefore, compared the effects of acidosis 
produced by ammonium chleride ingestion »with the effects 
of alkalosis previously described. They found that acidosis, 
like alkalosis, lowered very definitely tho glucose tolerance, 
and that the lowering of tolerance much outlasted tho 
acidotio state. On the other band, they found no ketosis 


» Biochem. Joum., xxl, P, 93L 
*Jnurn. 54, 1920. 

• Proc. Boy. Soc., B, 96, 192'^ p. 15. 

* Atner. Jotim. Physiol.^ 61, i920, p. 


568 . 


and no lowering of tlio respiratory quotient, so that thera 
was no sign of interfercnco with the oxidation of carlra- 
hj-dratos. They therefore concluded that alkalosis checked 
the oxidation of carbobjdrate, whereas acidosis only 
hindered its storage. AVigglcswortb in 1624* furllier 
investigated tho effect of alkali administration upon f.it 
metabolism in rats. Ho showed that rats, when fed upon 
a diet consisting wholly of fat, developed a considerable 
ketosis, wiiich, however, was transitoi-y. By about tho fifth 
day of feeding the rats had become acclimatized, and had 
no abnormal ketosis and showed no ill effects. The addition 
to this diet of considerable amounts of bicarbonate caused 
exaggerated and greatly prolonged ketosis, delaying the 
acclimatization almost indefinitely. It also produced ketosis 
in rats on a normal diet, and, as in the case of tho 
human subjects, tho “ acetono body ” excreted iv.'is 
chiefly ^-oxybutyrio acid. If large doses of bicarbonato 
woro given to rats on a fat diet, however, greatly 
increased excretion of acetono and aceto-aoetic acid was 
also demonstrated. It thus appears certain that alkali 
renders more difficult the oxidation of fat in the absence of 
sufficient carbohydrate, and a condition of alkalosis -would 
thus aggravate one of tho difficulties of the diabetio 
organism. Goklblatt tried tho effect of administering 
alkali to a subject with high sugar tolerance, and found 
that the tolerance was Ibwered by tho alkalosis. He found 
also that tho ketosis and intolerance to carbohydrate pro- 
duced by starvation are both definitely increased by the 
ingestion of alkali by the starving subject. The administra- 
tion of 30 grains of bicarbonate to a case of severe glycos- 
uria without any ketosis caused the appearance of ketone 
bodies in tho urine. This case had been obsen-ed inter- 
mittently for twelve months previous to the experiment, 
and had^ never before shown any ketosis. Goldblatt con- 
firmed the results of Hetonyi, which showed that the adminis- 
tration of alkali inhibits to a considerable extent tho action 
of insulin. Goldblatt’s work thus confirms the belief that 
alkalosis causes a derangement of carbohydrate metabolism. 
It siigvcsls, moreover, that the storage as well as the 
oxidation of carbohydrato is interfered with, since he 
f^nd in experiments with rats (which should perhaps be 
roiicated on a larger number of animals) that a very con- 
siderable diminution of the amount of glycogen present m 
the whole carcass was produced by feeding with a diet to, 
which alkali was added. 

lunacy reform in FRANCE. 

bears an honoured name in lunacy reform. It was 
+l,n immortal Pinel who, during the tumult of the levolu- 
imfetterecl the insane from their chains, and ushered 
new era of humanitarian progress. “ Everywhere 
1 + Wiirone until 1794,” said Esquirol, his pupil, 

f more should be done for them.” Pinel’s ideas, 
anything inadequately realized, and although tho 

f°'arv enactments which followed his dramatic stroke were 
‘ Cd S the purpose of mitigating the harshnesses 
'""TtMishiiig the aLses under which the insane laboured, 
and nn^nrstandlng of the problem as one 

they yet - treatment, hut had regard only for 

: hS. safety Such an enactment was tho Act of 

fRAS^’S eh S regulates the procedure with regard to 
1838, f f I, inaane, and is now under review ^ 

the It has frequently been assailed 

the Fnmch Governm 

over since It wa placed “oro numerous and more 

LTtef Ifthe'^equest of a committee fla Co^ 

of the League oPMental Hygiene, has submatt^ . 



MABgH, 10, 1928] 


SEEtru: TREAXMENT- OF.PODTOMXEETTIS, 


[ 


THxBBmsa 

ilEDICAL JotmKU, 


403 


rardum has caused ,v.despread comment Dr. 

Toulouse criticizes freely tho provisions of the 1838 Act, 
and asserts that its spirit is inimical to tlio interests of the 
mentally affected patient. He thinks it should apply only 
to the relatively small number of violent and dangerous 
patients, and be suitably amended accordingly. For the 
great majority of the mentally deranged the thorough 
treatment required can, he maintains, bo attained only 
by the conversion of the present asylums into hospitals. 
;\Vbere it is found necessary that a patient should be kept 
in confinement, tho preliminar)- examination would bo made 
elsewhere than in the infirmary, which, under the Act, is, 
like the asylum, a place of detention. Tlie certificates 
would be signed by specially appointed alienists, who would 
be quite independent of the judicial authority, which would 
then be enabled to render the certificate operative. Dr. 
Toulouse advocates tho provision in evei-y region of France 
of centres tor the prevention and early treatment of mental 
disorder, along the lines' of the Henri-Rousselle Hospital in 
Paris;' this institution is a complete psychiatric unit with 
various activities. It comprises a department for the 
prophylaxis of mental disorder, an out-patient mental 
clinic where patients are examined and, if necessary, the 
services of other specialists utilized, a voluntary treatment 
centre for all binds of mental disorder, an observation 
pavilion in which borderland cases are studied and where, 
if necessary, detention can be enforced for a week, 
quai’ters for dangerous or violent patients, laboratories, and 
instructional classes dealing primarily with tho problems 
of prevention of mental disease. It will bo interesting to 
see what action is taken in regard to these proposed amend- 
ments. It wpuld seom that tho time is ripe for a thorough 
revision of the lunacy laws in France, and the present 
attitude towards reform augurs well for the ultimate success 
of measures which will react beneficially on tho whole life 
of the community. 


SERUM TREATMENT OF POLIOMYELITIS. 

The treatment of acute anterior poliomyelitis by means of 
injections into the spinal canal of serum from patients 
u 0 have suffered from the disease previously has not 
icceivcd an extended trial in this country, although the 
late Dr ,F. E. Batten interested himself in it. Since 1910, 
n len iis procedure was suggested by A, Netter, attention 
1 as given to its possibilities by Professor G. Etienne of 
1 ancy, and on October 22nd, 1927 (p. 743), wo referred at 
. mo engt to flio results which have been obtained. In 
A .'^°™™'iiiication' to the Academie de Medecine 

■ E 1 ^ . auggerts that the reasons for tho relative neglect 
1^ he a valuable therapeutic measure are an 
so of the indications for the use of 

it Tr. ®^aggeration of the difficulties of obtaining 

and outbreaks in 1926 in Great Britain 

the foot reviewed the subjeet, and recalls 

that ho 'Ji=«>V6red, jointly with 'Levaditi,’ 

l)oIiomvpl'f°° ° patients who had suffered from anterior 
lioliomyehtis contained immune bodies which 


virnlarip immune bodies wliicU rendered 

places the uhinfective for monkeys. Netter 

in three ' tr which convalescent serum is indicated 

tbose'with''rani^J'-‘'™'^'^'',-*-“®® pre-paralytic stage, 

acute cases l^itb^ ap^’^ading paralysis (Landry type), and 
tendonnv'+ra .a locent paralysis which is showing no 
liiain difficult^ a" he remarks, the 

epidemic this^pl ’ ij” ‘^‘‘‘Sposis, but in the presence of an 

seven ^ senes of cases in America 

hours of onspt ^^®ated within the first twenty-four 

rapid recoverv Z ^““"aaular injections of serum, with 
■'■ariotv the pe matance. Of the acute spreading 

de I Acad, de SI(d.^ January list, 1928, p, ItL 


personal experience of two cases where the prompt injec- 
tion of convalescent serum not only prevented further para- 
lysis, hut brought about in one the complete disappearance 
of a paraplegia with retention of urine. When paralysis 
is already established the beneficial results of serum treat- 
ment depend largely upon how soon it is employed. Netter 
believes that it is of little efficacy after the fourth day, 
and still less at tho end of a week, although reports from 
South America seem to indicate that small doses may still 
do good as late as the twelfth day after onset. The dose 
of serum employed by Netter varies with the age of the 
patient, tlie gravity of tho symptoms, and tlie duration 
since the onset. Ho usually administers 10 to 30 c.cm. 
intrathecally, although in one case he gave as much as 
66 c.cm. in ten injections. Ho adds that the difficulty of 
obtaining the serum of patients who have suffered from the 
disease lias been largely overcome by keeping a record of 
old patients so as to make use of them when an epidemic 
commences. This was accomplished in 1925 in Melbourne, 
where 110 patients who had previously bad the disease were 
quickly obtained as donors by the help of official registers, 
hospitals, doctors, masseurs, and even orthopaedic instru- 
ment makers. The serum so obtained can apparently be 
stored for short periods in ampoules. The serum of 
immunized horses has also been efficacious in certain 
cases, but its supply at the present time is limited. 


THE PREVENTION OF INDUSTRIAL INVALIDITY. 

The Council of Industrial Aledicine called a number of 
representatives of industry into conference in London on 
March 2nd, at the house of the Federation of Medical and 
Allied Services, with a view to discussing schomes for the 
prevention or amelioration of industrial invalidity. Dr. 
D. A. Coles, the chairman of the council, who presided, 
referred to the millions of weeks wasted annually by dis- 
ablement or illness. A skilfully devised schemo whereby 
this invalidity could be prevented or more expeditiously 
treated would, he said, cast no additional burden upon 
industry, but, on the contrary, would relieve it of a part of 
the burden it already carried. In a pica for works clinics 
Professor E. L. Collis pointed out that the treatment of 
industrial injury included wound healing and restoration 
of function, and, while every surgeon was concerned with 
wound healing, it needed some special acquaintance with 
industrial medicine, and in pai'ticular with the occupation 
to whicli the injured person was returning, to bring about 
restoration of function in the best way. He urged that 
the' setting up of industrial clinics would vastly reduce 
compensation claims. Dr. Alfred Salter, M.P., as a medical 
officer of three largo trade unions, referred to tho acute 
difficulty of men employed on the' industrial fringe of 
London in obtaining suitablo after-treatment in cases 
where traumatic arthritis had developed. They could get 
such treatment only by travelling to a central London 
hospital, wliich often they were not able to do. He said 
that if only after-treatment were available very many of 
these cases, which now dragged on for months, would bo 
restored to full functional activity after a few weeks. 
Somo account was given' of an industrial clinic by Mr. 
Maurice Salmon, of the Lyons catering firm, who said that 
in trying to deal with the slighter kinds of accidents on the 
premises, rather than send them out to the hospitals or 
insurance practitioners, his firm had felt that they wcio 
saving themselves a great deal of lost working time and 
thoir employees a great deal of suffering. Dr. on ar 
Mummery, director of the Lyons clinic, said that during 
the past three months 2,909 new injuries of all kinds liad 
been treated in his clinic, and in 2,730 of tlieso cases tlio 
patients had remained at work; thus in only 6 per cent, 
was there any lost time Involved. The number of ro- 
; dressings during that period was 5,060, of which 4,716 were 



404 March io, 1928] 


PUiMONABY ,ACTINOMIC.OSI8. 


r The Bninsn 
L Mzdical Jocryal 


done during omiiloynient witliout loss of time. The frc.it- 
niciit and dressings uerp given by liospital-trainod nurses 
under close medical supervision, and'llio average time was 
ton minutes to each ease. So far n.s first aid is concerned, 
tho railways uore higlilj- commended. Sir Percy Wilkinson, 
secretary-general of the Order of St. John of Jerusalem, 
said that over 40,000 railway employees had hcen trainocl 
to deal with accidents, and Dr. W. Salisbury Sharpe, chief 
consulting suigeon to tho Groat Western Baihvay, spoko 
of the very large numher of men on that railway wlio not 
only had had training in first aid, hut who kept up their 
training by passing through a course every year. Dr. 
Drummond Shicls, M.P., as one who had a great deal to 
do.witt. railway workers, said hoiv much ho was impressed 
-hy tho skill shown hy numbers of them at various points 
in the railway system in dealing with tho accidents which 
occurred to their fellows in tho course of their employment. 
IMr. Henry Lesser mentioned one interesting cxpcriniont 
in progress at a gas works, whore, after any serious injury, 
a jury of workmen was called together — tho momhers of 
thp jury having had experience of tho work on which tho 
injured man was employed — and tho official rcsponsihlo at tho 
particular depot or station where the accident had occurred 
presided. Witnesses wore summoned, including, if possihlo, 
tho injuicd man himself, and tho jury decided whether 
there was any fault, and, if so, whore it lay, and made 
suggestions as to prevention. Dr. Fortescuo Fox, Dr. 
M. B. Ray, and other speakers mentioned tho movement for 
the establishment of clinics- dealing with rheumatism, in 
particular the venture in London sponsored by tho British 
Red Cross Society. Tho large number of cases of so-called 
rheumatism which were not suitable for the hospitaks, and 
for a-hieh there was at present no provision, accounted for 
a vast sum of industrial invalidity. A resolution from the 
chair was carried aiiproving, in general, co-operation 
beta-cen industry and medicine, and pledging those present 
to suppoi t schemes tending in that direction. It will now 
be for tho Council of Industrial Medicine, in tho light of 
tho expressions of opinion at tho conference, to suggest 
some practical proiwsals. Emploj'oes of labour are to he 
asked what steps the council can take to help them. 


PULMONARY ACTINOMYCOSIS. 

IXFECTiox with the ray fungus, tho causal organism of 
actinomycosis, is said to be fairly frequent in certain 
parts of the a'orld, such as Germany, Russia, and Austria. 
In England and America, though isolated cases are 
reported from time to time, the disease would appear to 
be a comparatively rare one in man. Infection is usually' 
found to occur in those whose occupation entails tho 
handling of sliair and grain and by those in close contact 
\vith vegetable products. It is through tho alimcntaiy 
or respiratory tracts that infection most commonly occurs, 
and statistical considerations indicate that the infection is 
primarily a pulmonary one in from 15 to 18 per cent, of 
the recorded cases. The syin])toms produced in tho lungs 
closely resemble those of tuberculosis, and this diagnosis 
will usually bo made, provided the continued absence of 
tubercle bacilli in the sputum is ignored. This lesson is 
welt brought home by a case reported by Dr. F. M. 
Johns.' This patient had been regarded as tuberculous 
for twelve years, and during that time this diagnosis was 
confirmed by numerous x-ray and sputum examinations, in 
which tubercle bacilli, however, were never found. Expec- 
toration had always been profuse, containing numerous 
largo granules which the patient himself, being a inechanie, 
had found to measure up to three-sixteenths of an 
inch. 'These granules, when compressed under a cover-glass 
atttl exaniinod niicroscopicall}', presented the diaracteristic 

Medical Clinics vf ^orih America for Xoveniber, 1927. 


appearance of actinomycotic granules. Culturetl on 
glueoso agar the organism had grown into long filamentous 
forims, which were partially acid-fast. Both the granules 
in tho sputum and tho oultiiros wore not pathogenic for 
guinea-pigs. A month s treatment with rather large do.sos 
of iodides has resulted in an onconraging reduction in tlie 
amount of tlio sputum. 

THE CORONARY CIRCULATION. 

The physiology of tho blood supply to the heart has 
iiithoi-to been very much a matter for conjecture. That- 
this ..should bo so, and that experimental work on the 
subject has given somewhat conflicting results, is little to bo 
wondered at if the difficulties of such investigations are 
appreciated. It is, bowevei-, becoming moro and more 
obvious that better and fuller knowledge of this branch of 
physiology is essential in viea- of the rapid advances that 
have of recent years been made in the study of coronary 
disease. Fciv of those interested in enrroiit medical thought 
and work can have failed to notice fregnent references to 
the comparatively newly recognized syndrome of coronniy 
infarction. Tiio pathological entity has long been appre- 
ciated, but that the condition is now clinically separable 
from the great group of angina pectoris is shown by several 
recent publications, notably that by Parkinson and 
Bedford,’ who analyse 100 cases, most of them correlated 
with ■post-mortem findings. Clearly, in the present state of 
our knowledge, icsearcb iiito tho vascular supply of the 
heart must bo by animal experiment. Tin's lino has been' 
follon-cd in the past principally by Rebate! in bis investiga- 
tions on tho horse, by Porter, and by Langendorff, but tbs 
value of their work has been called in giicstion by succeeding 
investigators on account 61 the inadequacy of their record- 
ing systems, or tho artificial conditions under which their 
experiments were conducted. Tl.eso earlier atten^ts at 
olucidatiug the problem are reviewed by Anrep, Cnuck- 
shank Downing, and Rau= in their recent work on the 
coronarv circulation in relation to the cardiac cycle. For 
tlicir c.xpcrimonts they employ the denei-vated heart-lung 
nreparation of the dog, and the coronary inflow and out- 
Livarc recorded electrically, both separately and together, 
and arc further correlated with tlio electro-cnrdiogram and 
with "curves of intracardiac pressure. These observers find 
that the cuivo roiiresenting coronary outflow slioits three 
waves the first closely following auricular systole, the 
second at the bcginiiiiig of ventricular systole, and tho 
third during the ejection phase of ventricnlar contraction 
The last wave' is by far the largest, showing that tho 
contraction of' the heart is the principal factor m 
promoting coronary outllow. It might be argued that tins 
increased outflow was the result of systolic increase in the 
a'ortic pressure, but tliis is disproved by taking a curve of 
coronary inflo"'. restricted dm mg 

fltc election phase of ventricular systole. Analysis of 
roi-onavv inflow gives evidence that blood flows into these 
ro^lh dm-h’g vrntricular diastole. Anricnlar contraction 
does not iiifliionce inflow, but contraction of the 
• ncHcs the passage of blood into the vessels, this liiiidiance 

"^1.. ^ - «» 

-.-stole “and presumably being due to compression of tl e, 
cor^a’rr arteLles by the heart mnscle. In these important 
results 4oro is provided at last a clear and precise pictuie 
of' the vascular supply of the heart, and it is necessais to 
consider bow these findings widen onr conception o 
Canary disease and whether they are 
fletcrmiiiing treatment in myocardial ’’’farctipn Corona y 
thrombosis is attended by two dangerous possibilities. Tb 

failure; the second is that as a result of 

haemorriiage and extension of the mQibid_^ 


1 Cardino Infnrclioa and Coronary Thrombosis, Zaocct, 1928, i, ‘I. 
-ffcart, 1927, xiv, HI. 


MaucH io, iQiS] 


A MEr>rCAi:(’ LlIBHARt CLUB. 


f TssBr-rnsir /Irtff 
L ilvDicii, Jonuui “Utl 


may occur.' Trcatiiioiit in tho first ovont must bo directed 
toward the maintenance of adwiuato blood flow through the 
coronary vessels, so that nutrition may bo encouraged and 
tho damage reduced to a minumim; just as we employ 
stimulants with this aim in cerebral tbrombosis, so wo 
should e.vpect them to exert a beneficial influence in 
obstruction of the coronary circulation. On tho other hand, 
in order to avert tho possibility of further damage, 
reduction of blood i)iessuro should bo the aim. Only by 
careful consideration of the individual case can it he 
decided which of these courses should bo followed. Past 
or present evidence of high blood pressure in a patient 
suggests measures for the prevention of a return to tho 
habitual pressure level following tho fall in arterial tension 
which is nearly always a sequel of myocardial infarction. 
In view of the fact that systole occupies a constant 
time whatever tho heart rate, it is clear that with 
increased rate of beat there is in a given period 
less aggregate time for coronary inflow than with 
slower rates; with the aim of slowing the heart and so 
providing better blood supply to this organ Parkinson 
and Bedford recommend the uso of digitalis in cardiac 
infarction, especially where ra])idity of tho heart’s action 
is the result of fibrillation or other abnormal rhytlim, and 
where failure is present or appearing. The tendency for 
digitalis to raise the blood pressure should contraindicate 
its administration in coronary thrombosis when there is 
evidence of hypertension and when tho normal cardiac 
rhythm is preserved. • • 

; Sin HunruRT Roliestom will givo the William Sidney 
Biayer and Susan Road Thayer Lectures on Clinical 
Medicine ou March 20th and 21st at tho Johns Hopkins 
Jlniveisity, Baltimore. 

Dn. T. Izoo Bennett will deliver the Goulstonian 
ures before the Royal College of Physicians of London 
oil March 13th, 16th, and 20th, at 5 p.m., at the College, 

^ I ffis subject is “ Some problems of 

nep iri is. Any member of the medical profession will bo 
admitted on presentation of card. 


As we announced last week, the Sir Charles Hastings 
opu ar ^ure for this year , will bo given by Sir George 
Medical Officer to the Ministiy of Health, 
« ose subject will be “ The fundamentals of health.” 
l ie lecture will be delivered in the Great Hail of 
the ^ edical .Association’s House in London on 

v-ill ° i Wednesday, March 21st, when the chair 

is free U ^ Iiord Cozens-Hardy. Admission 

B M a' n from the Financial Secretary, 

pied bv “^'^Wcls Square, W.C.l. Seats not occu- 

other memberi’'^’ publffi available for 


the ■"’ill give an address on 

for senior studenS ‘Sd especially 

arraiiced bv n “ Joaag practitioners— at a meeting 
British MeA- ‘’°.M"‘^0P0litan Counties Branch of the 

•" '"'I 

22nd, at 5 30 “floaie, London, on Thursday, March 
^ o’clock. All coffee will bo served at 

recentlv omUfioi”^ ” ™edical students and 

Practitioners are cordially invited. 

James WheaBpv^'^'”'"'^'^ death on March 3rd of Dr. 
Shropshire and "nv rncdical officer of health for 

of Health.* ^ osident of the Society of AXedical Officers 




A MEDICAL LITER AET CLUB. 

The doctor who devotes all his time aiid energy to the practice 
of medicine, without any outside interest, may be a very 
successful practitioner, but he must lead a routine life. 
Incessant concentration of thought on one subject promotes 
n narrow outlook on life, limits his point of view, and hastens 
his degeneration into a mere machine. While some form of 
sport proviiles the youthful members of the profession with 
much-needed relaxation, many of middle age interest themselves 
in local government, and do useful work for the community as 
councillors, aldermen, or mayors. There have been exhibitions 
of the works of medical artists. A minority, perhaps, find 
distraction from the sturm ttnd drang of medical practice in 
the cultivation of the literature of their own and other 
countries. • After the daily round, the common task, these men 
find pleasure in some intercourse with the great minds of all 
ages. Let me have books,** said Horace, “ and a contented 
mind.** 

Sit bona librorum et provisae fnigis in annum, 

Copia, neu fluitem dubiae spe pendulus horae, 

Sed satis est orare Jovem quae donat et aufert; 

Det vitam, det opes, aequum mi animum ipse parabo. 

EpistleSf 7, 18, 

A few doctors, filled with these desires and the ambition to 
attain Horace's degree of contentment, founded a literary 
club in Newport (Mon.) some twenty years ago. Now since 
it has run its course and ceased to be, perhaps the brief account 
of it which follows may lay the foundation on which similar 
structures may be raised. Its proceedings were never 
chronicled in. lay or medical-papers, publicity was not one of 
its objects, and this posUmortem report is its only introduction 
to the medical world. 

Now. as to' its pre-natal conditions and the manner of its 
birth. All potential medical members were approached, the 
scheme was explained, and, their consent obtained, a pre- 
liminary meeting was held at which a code of rules was drawn 
up and adopted. As the members numbered ten the club was 
caUed ** The X Club.** 

A meeting was held once a month from October to June at 
each member's bouse in rotation j the host of the evening was 
chairman. Members might be fined for absence without suffi- 
cient cause and for ignorance of the subject under discussion. 
At each meeting the subject for the following one was chosen, 
and it was the duty of every member to procure and read books 
dealing with the matter. The chairman for the evening opened 
the discussion with either (a) a written paper or (6) a verbal 
discourse, and at its conclusion called on each member in turn 
to supplement this with further matter relevant to the subject. 
He might provide light refreshments. Minutes were kept. 
The club displayed great catholicity in its choice of subjects. 
Ruskin*s “ Stones of Venice,** Carlyle’s " French Revolution,** 
Bosweirs ** Johnson,** Keith’s “ Antiquity of Man,” eugenics, 
Prescott’s ” Conquest of Peru,** the dole in ancient Rome, 
glaciers, ** Pepys's Diary,” and many others appear in the 
minute book. Much has happened since Norman Angell’s book 
** The Great Illusion ** was written. It provided the club with 
a subject. 

During the summer one day was devoted to a visit to some 
place of interest — a cathedral, an abbey, or one of the numerous 
Norman castles along the Welsh border. The club continued 
its activities during the war, as all its members were oyer 
military age and were employed at home. Its monthly meeting 
was a welcome diversion from the work and anxiety inseparable 
from the world conflict. 

Tho club achieved its objects. Members were faithful, (ho 
club’s monthly meeting was eagerly anticipated, and penalties 
were seldom inflicted for any breach of the rules. The reading 
habit was encouraged among its members, and they gained that 
aequum animum alluded to above. . i . 

The manner of its exit? No, it did not meet a violent 
end like that other society ever famous in ' ■ -rse of Bret 

Harte It died of asthenia. Three of it, .. .... ..rr, predeceased 
it another left the district, a fifth was m feeble health 
and unable to attend. The time of its passing liad arrived, and 
the survivors, with much regret, sounded a coronach and' 

celebrated its obsequies. ^ Haiuhon. B.A., M.D, 



406 Mahch 10,' 1928] IREEiAND. ’ 


THaEsmss 
L Uciiicii. J0CB51C ’ 


Kr£lait&. 


The Samaritan Hospilal, Belfast. 

TVk L.^y JIayoress jiresidcd at tlio aiiiuial ' meeting of 
the Saniaritnii Hospital, Belfast, in the City Hall, on 
February 29th. The annual report stated that the oxten- 
■sion of the buildings 'vas eoninionced in August, 1926, and 
that the new btiilding would bo ready for occi)])ation on 
May 6th. The senate of the Queen’s IJnivorsity had made 
available, meanwhile, temporary accommodation. Ono now 
ward would bo named after Viscountess Craigavon, and 
another the Florence Hendcrncss ward, in grateful recog- 
nition of the efforts of these two ladies to raise funds. 
The ceremony of laj'ing the foundation stono had tjcen 
l)erformed by Lady Craigavon on December Stii, 1927. TIio 
nmv operating theatre would he named after tlio Northcrii 
branch of the Irish Rugby Football Union, from whom the 
huildiug fund had received help amoi\nting to £1,000 
in the last few years. Tho medical report showed that 
339 patients had been admitted to tho wards during the last 
year, and that 331 operations had been performed, of which 
128 were major ones. In the out-patient dciiartnient 646 
jnitionts were treated. The Right Hon. H, M. Pollock, D.L., 
M.P., Minister of Finance, moving the adoption of the 
annual report, drew attention to tho fact that this hospital 
received patients from all Northern Ii'oland, and even 
beyond its boundaries ; no charge was made unlc.ss tho 
patient could i)ay. He emphasized the concensus of 
opinion favouring the present voluntary system of hos- 
pitals. Tho Lord Bishop, the Right Rev. Dr. Grierson, 
proposing a vote of thanks to tlie sui'gieal staff, referred 
to tho loss the hospital had su.stainod b)' tho resignation 
of its senior surgeon, Mr. John Campbell. 

Appointment of New Medical Officer for Belfast. 

At tho monthly meeting of tho Belfast Corporation on 
March 1st it was decided to advertise for a medical super- 
intendent officer of health at a salary of £2,000 a. year, and 
for a city surveyor and engineer at a .similai' salary. 'The-so 
appointments aro to fill tho vacancies caused by tho 
resignations of Di'. H. W. Bailie and of Mr. 13. S. 
Pinkerton. Aldornian Dr. Williamson, who moved tho 
adoption of the minutes of the Public Health Committee, 
.said that tho committee and corporation were determined 
to appoint candidates of ability and public health experi- 
ence so that Belfast should no longer lag Irehind in matters 
of public health. Tho duties had been increased; tho 
kfinistiy of Horae Affairs had asked them to take over 
all public health services. The man to bo appointed must 
have had not less than ten years’ oxiierience in public 
health work. A sirecial resolution granted a retiring 
allowance of £906 a year to Dr. Bailie. 

Public Health Works for Relief of Unempioyment. 

The committee appointed by the Free .State Government 
to consider and report as to the steps that might be taken 
for the immediate relief of unemployment ha.s included in 
its recommendations the undertaking of public health 
developments such as waterworks, sewerage schemes, im- 
provement of burial grounds, provision of fair and market 
greens, and works of construction in connexion with county 
homos, county hospitals, mental hospitals, and sanatoriums. 
Housing, which is a work of public healtb, has already been 
dealt with in this connexion. Tho committee is satisfied 
that much work has yet to bo done before the position of 
tho Saorstat in the important matter of public health 
services is satisfactory or equivalent to that of other 
countries. It is common knowledge that in many parts 
of the country water supply and sewerago conditions aro 
deplorable and the committee indicates in an appendix 
to the report the various towns and villages in tho Saorstat 
which arc at present without modern or up-to-date water- 
works or sewerago systems. At the same tune tho com- 
mittee feels that the Government is to bo congratulated upon 
tho steps which have been taken to securo^ impioyed con- 
ditions in this respect. .Since the beginning of tho 
great war financial advances for this puiqiose ceased to 
be obtainable, and the banks were reluctant to lend for 


any extended period. Tho action of tbo Government, how- 
ever, in jirovidiiig, in the Local Loans Fund, sinco 1925 for 
loans to local authorities for works of tliis nature lias 
proved most heneficial, and many necessary schemes have 
hecii sanctioned. Tlio committco would, however, like to 
.SCO theso loans made iiso of by local authorities to a very 
iiuich greater extent than has been tho caso up to the 
pre.sont. TIio committee believes that tho appointment of 
comity medical officers of health, whose duty it will be to 
cdiicato public opinion in the matter of public liealtli and 
to eiisuro that tlio chronically bad conditions of tiie various 
towns and villages througbout the whole country are 
speedily remedied, will result in a steady improvement; 
it is added that no timo should be lost in the appoint- 
ment of tlieso officers. A difficulty TV'hicb, the committee 
imdcrstands, is liolding up many urgently needed pnblio 
healtb scliemes is that of cost. The ratoiiayers who are to 
benefit immediately aro often unable to bear the whole of the 
increased rate represented by tho loan charge, and there is 
ilisinclination on tho part of ratepayers in contiguous areas 
to slimihler any part of the burden. IVliilo it may not bo 
unnatural for a ratepayer or taxpayer to bold that he 
should not ho obliged to pay for a service which ho does 
not receive, tbo committee considers that this difficulty 
would .speedily be removed if he could be made to see that 
bo is in fact, paying in other ways a groat deal more; 
l)V reason of the absence of projicr public health systems of 
tiic kind. Tho committee considers that tliis aspect of the 
ca.se should bo brought to tbo notice of tbo local anthontios 
and tbo ccuoral public; if the problem of public healtb wore 
am.roaclied in this way, and a suitably graduated system of 
charge could be devised, tbo question of the area of ebargp 
?vnnld no longer bo a bar to tbo.progrcss of such sobemes. 
It will bo obvious, the committee concludes, tliat tho more 
M I L sdmme bat are put in hand the greater wdl-.be 
tL Xf of uncmplovmcnt, and that the remova of any 
SLSies t Xe way of carrying out such works must 
necessarily result in increased employment. . 

Alllk Contractor Heavily Fined. 

— • Tiwtrict Court the contractor for the 

At Enniscoi j County Homo was prosecuted unclor 
supply of "“J’' ..esnect of milk .supplied for con- 
tho Food and - Having board tbo evidence, tbo 

sumption tbe.nimMos^ Hav^ 

judge said the Z Ho was entitled 

tho worst of Jts kind no n> ‘ J j defendant 

«Xortli“ rrX -XtXX defendant’s 

to prison ® „ot hesitate about awarding 

physical 'maternity homo for the county had at 

this pen.alty. Hio materi y receiving 

least' a hundred infants inflicted a fine of £20, 

this inferior ^ £2 2s. costs. The 

with the , allowed ten days in which to pay, or, 


. has been /"hstitnted^J^ tl^ aesignation 

rgb Asylnm 01 --fleets the gradual alteiatiou 

opriate, and 3 7 j j a„a the increasingly 

itution to "htob 1 ‘ J ^ described as a 


March. 10, 1928] 


SCpiLA.Nl). 


r Tm: BnmsH 

L Medical JonuxiL 


407 


Rlace of datcRtion. Professor Robertson snms up his expe- 
rience of the benefits of voluntary treatment ns follows: 

“tVe find that voluntary patients nro ncimitled for treatment 
sooner than certified patients, that Ihcv come when Ibeir malady 
is moTC recent and less serions, that they are more contented to 
be treated, that thoir residence in tbo hospital is shorter and 
that a larger proportion of them mcover, Ihoiigb many leave 
betoro they ar^nuito recovered. They leave when they feel 
themselves improving, and some, no doubt, comp etc their 
recoveries at home. More than one-half haic been ill foi less 
than three months before coming for trentnicnt and more than 
onc-half who Como snller from melancholia. Jii those cases volun- 
tary treatment leads to earlier recovery and tlio prevention of 
many suicides.*' 

With regard to the certified patients tp-o fe.atiircs in the 
statistics’ call for notice. Tbo first is the small number of 
admissions compared with the large resident population 
—the legacy of the past. Of 812 certified patients treated 
during the year only ono-nintb were heiv admissions. In 
the second place; the number of removals by discliavgo and 
death exceeds the number of admissions, so that the certified 
population in the Royal Hospital is diminishing, and in 
the course of a decade may shrink to a half of what it is 
at present. Professor Robertson suggests that tbo form of 
official statistics should be recast with a view to recognizing 
these changes. In. addition to the two departments of the 
Royal Edinburgh Hospital, Craig House and The West 
Hpiise, there are, under the sanib management, six nursing 
homes to which patients ' may he admitted in exactly the 
same way as they would he to ordinary nursing homes; 
in this respect these' are unique medical institutions. Most 
patients a'dmitted to these nursing homes' Iiavo come for the 
treatment of functional systems, including states of neur- 
asthenia, depression, anxiety, sleeplessness, and nervous 
exhaustion. Woi'k is proceeding in connexion with tho 
completion of the Jordanburn Hospital, which was designed 
for the treatment of cases of nervous and of early 
mental disorder. Accommodation will bo provided for the 
psyeliiatrio and psych^pathological investigations required 
by the publio antboritios of tbo city, its schools, and polico 
courts, and by social agencies in and about Edinburgh, 
as well as for a freo mental out-patibnt clinic. Tho biiild- 
ing IS to mclndo a lecture theatre for tho benefit of students 
attending tha class of psychiatry. The weekly out-patient 
present at tho Royal Infir- 

‘ T' .professor Robertson foresees remarkable develop- 
Psyehiatrio world, and compares tlio new 
t'„ha*n„i”° ’yrth the successful campaign against 

Sir Roher? iu Edinburgh under tho auspices of 

tn hnCT,'t 1 .^erty years ago patients were sent 

to dicoftTOT. +1 Arrangements were tliereforo made 

out^natlpui- pH ^‘sease at an earlier and more hopeful stage; 
the familv an^'fh dispensaries were instituted; finally, 
provSrl ^® home came under review for e^rly and 
adds inusf d h’sychiatrists. Professor Robertson 

recIntXvsI r K^forring to tho report of the 

expresses iii«i f °° Lunacy, Professor Robertson 

inCo t '‘^Sislation in England will, 

Scottish procedure In R seventy years behind 

patient to decide Tvl.»fl7p , °*’?"d no layman over sees ti 
hospital or not “ should be treated in a mental 

difficult medical rirnKi ■ ,^®®P°Psibility of dealing with a 
of the mediS S ' ™ in the hands 

phoed, the nublE. r ^his trust has not been mis- 

xecord in our law j down, for there is no 

anyono heinsr imomnlli the last seventy years of 

oemg improperly detained in a mental hospital.” 

Tlie fiftv-third”'''*^”'^, ""^^tern Infirmary, 
of Glasn-ow Was lipU?”''' meeting of the Western Infirmary 

17th'. Lord Provost Sir 
of the report was^ f b-w ''tn important feature 

aatistactoiw position frp'' p infirmary was in a most 
ordinary revenue was fr^ f hnRucial point of view. Tho 
of last year, ^han that 

hy nearly £2 OOO 'ar,” v expenditure had decreased 
the board of ’manacora’ a' ll°^hurgh, chairman of 

was a deficit! os revfrded out that, although there' 

o ed ordinary income and expenditure 


of £10,042, this was tho smallest during tho last ten years, 
except for Hie exceptional year of 1925, when it was about 
£7,000. As showing the rise in' cost of running the iiifir- 
mai-y, ho mentioned that in 1924 the expenditure had 
been- £44,152, while in 1927 it had been £82,375. Work- 
inen*s contributions, which had been recently depressed, 
wore now again on the up grade, and the speaker referred 
to tho collections h\- students, which had already endowed 
tlireo beds in the hospital at a cost of £1,500 each. The 
important feature of the year had been the opening of the 
David Elder Infirmary at Govan, which was to be carried 
on as an annexe of the Western Infirmary, and was already 
making its influence felt on the waiting list. The annual 
appeal for increased funds must bo renewed, but the 
managers were especially anxious to obtain money to erect 
a new ffi-ray and electrical department, as the present 
department had been built twenty years ago in the early 
days of fl:-ray development, and now proved inadequate to 
the amount of work which had to be done. For this 
purpose the managers had in hand a sum of £5,800, but at 
least £20,000 would be required before they could feel 
justified in beginning the new building. 

Crnlglelth Hospital, 

Some discussion has taken place in regard to the pro- 
posed closing of Craigleitli poorhouse, which has been used 
ns a Ministry of Pensions hospital since tho war, and 
during the war was in use as a military hospital. A letter 
was road by Sir Samuel Chapman at tho annual dinner 
of the Edinburgh Parish Council and District Board of 
Control which he had received from the Minister of Pen- 
sions. Tho letter made it clear that it is not the inten- 
tion of the Ministry of Pensions to remove all pensioners 
in Scottish hospitals to England, as had been rumoured. 
Tha natural decline in the volume of medical work in 
I'espoct of pensioners in Scotland had made it necessary 
to revise the arrangements for their treatment, and ns 
tho number of pensioner patients now under treatment is 
about 100, with a tendency to grow less, it appears 
unreasonable that a hospital accommodating 520 beds 
should be maintained for the small number requiring 
treatment. The alternative accommodation, to which it 
is proposed to remove the pensioner patients, is Edonhall 
Hospital, which was built, equipped, and placed at the 
disposal of tho Government hy the Scottish Red Ci'oss 
during the. war. As this affords sufficient accommoda- 
tion, it is proposed by the Ministry of Pensions to utilize 
it for their future requirements and to hand back the 
building at Craigleith to the iiarish council. 


Poisoning from Furs. 

At a meeting of the North British Branch of the 
Pharmaceutical Society of Great Britain at Edinburgh 
>n February 29th Mr. J. Wilson Dougal, B.Sc., read a 
iommunication upon dermatitis caused by wearing furs, 
rhe lecturer had found that in some cases where dermatitis 
lad been caused an infusion made from the fur worn 
vas poisonous to tadpoles, while antimony could he delected 
>y careful analysis, suggesting that tartar emetic had 
leen used as a mordant in dyeing the fur. The toxic 
lotion of tartar emetic was evident even in so dilute a 
lolutioh as 1 in 50,000. Cases of such dermatitis had not 
leen so frequent of late, sino© dealers in furs had, to a largo 
sxtent, given up employing tartar emetic as a mordant. 
Or. E. G. Bryant read a paper on recent work on tho 
jlucosides, in which he discussed the formation of glucosides 
n plant metabolism. He said that vitamin D, which was 
if great importance in animal nutrition, could bo formed 
ly the action of ultra-violet rays on the glueoside ergostoiol. 
Mr. William H. Millar read a note on arscnious oxide in 
leutral arid alkaline solution, dealing with tho arsenical 
lolutions used in medicine. There were objections to 
Powlei-’s solution of arsenic becanso it was unstaWe and 
ncompatible with medicines containing alkaloids. He had 
ound that a satisfactorj- 1 per cent, neutral solution of 
irsfenious oxide could bo prepared by using just sufficient 
lotassiiim carbonate to dissolve it, and neutralizing tha 
iolution with sulphuric acid. 



408 March lo, 1928 ] 


ENGEiAND AND WADES, 


,,,, Leith Hospital Report. 

Munagmoat' XrS'’s£te;i tImt''tho "{'f""®"*'"*' 
patients treated in "'"‘''s »''<1 om dopuAnient 


111C01I10 )iar? ninr*iT>^fr..1 nic -?/»« ... cj* JilC 0H!)2)}UV 


iiicoiiio had amoiintcil to £16 349 and\hc”m*,Ji 

tnro io £16 854 Thn nvf».o^. r ^ ouhnar^’ 0 X 2 )emJi- 

to £28,067. ’ivliiie ti.f >>a'l nmoimtcd 


to £28,067, ivliilo tlie ovtvZwi; . n>no«iitc<l 

o))K' £4 913 Tim I • <?xpoiitliluv‘c Imil hecu 

th}\,5;Sos i t£‘ v?T’’ '^”t‘-»H<tious hv 

£1,692 to £2,0S7 in Hie j aTveTr ?r 

io ondoiv a bod in the blpdal 
n r,,. Presentation to Dr. T. A. Sellar 

on February 25^tb'«-itlf it Mond ’ ff 'f ‘' "i 

portrait of himself „„ ill l '•»■■ «"<' « 

I'ortv-fom- vears of inedir",) t" "' 01110 . 1 1 after 

Eiovost, Cawn Je K If' 1'^T '^'''o 

rendered by Dr Soli -ir’ in u"T S‘'oat service.^ 

district, and oiontion'^rtbo L' 

tl.e various .social activities of the it, , n tv D. 

i;; i..,i .,..c,i *,ri„sS,j, 

ami \VlIagcs"lmci ctgc/nl 

his Visits irero naid on f/inf i i i hogaji jjrjictieo 

on t’ho JoniiovitT' of fim i *1 i ‘a * 

™.~. “Sf I ;'.;t ■"»'■»> « 

(hy and the second not nuU- +i ' rn 
t).o next .vcar;^“1bTn.^;fUnt4! 


r.Vmaf jSSu 


tlio hos* 


' SiZTTlST 

lias been inndo ivitbin }iri]i^^n!p,°^ bebalf of tbo Iiospital 
obtained it is stated tiiat no^f^H » 

ceneratioo elm.,i,i ?. l"}iber appeal to tbo present 


ficnoration sbonld occu • cLi Tf- ^ 

Eoi-d jrayor at tlio Mansion TTnI '“ ''l”’7 «« 

tlio treasurer,' rit Betbicm Dnva'^i’ °w -I'l P*'®idont, or 
Bridge Street, E.C.4. Eojal Hospital Office, Xteu 


®nglima ^ State. 

T»r..,Trrs™SK-'t. . , 

of an anneal for fion finn /^'-oiii.nj jl/tli, in .support 

”:,i 'sis S“,'v“i'‘v «» S*‘ 

Dady Cooper had presented £^000 1 !? 

ball, in memory of bei lafe I.,?i I'Oereation 

reported iiichidcd an anonymon.s sift 'of 

of 1,000 guineas from tbo^ treasurer Si 

Phillil.s, Bt, The Lord Ma™, l^-nidol- 

of building the new bospita^l ivliieli ”nd^! L*’" **5° soliemo 

the governor.s, and referred to the gS nZ % 

tim Corporation of London. Betblem Rovai HoLh 

ancient foundation of tbo City of London fi... “fP'i‘d, an 

of mental and nervous disoi^lers, it 

je.ar 1247, and some reference to its bi.storv si„ce^tJmt“dat° 

wn.s made in our columns on May 7th, 1927 /„ 'nlo, 

present buildings in the Lambotli Bead, .Soiirli vo. I- ' 

in 1815, are quite unsuitable nmv, more s , ace Jo.! 

treatment and accommodation for the medical and 

staff being urgently required. On the non- site deto T*? 

Iniildings rvill permit better classification of the valient'^ 

ivith pathological, bacteriological, psychological, denfo?’ 

electrical, and radiological departments; fuller fncilitie^ 

for ^search Jill also be available. Tbo governing 

£120 -f, ‘'*PP®''>6«g for .1 .sum of about 

muteut ’deT t* 'V neiv buildings to.be opened 

cbavit.ablo basis^'^ra of tbo present 

oasis, 75 per cent, of the total cost of treatment 


TI, , . Committee on London Floods 

nmy "be KiiSl Horn Tm "srt'"'^“’^ 

House IV. 0 2 mica ll- Office, Ad.i.stral 

elusions, but for tbo evi'deiit 7aerSXrr/T '^iT 
wtiieti tbo members encoimtererrjn fi ■ ‘ ®'’i 

on tbo problem. MeZ Z^ Z J 1 "sbt 

misuro tbo c,,tab!isl,mei^ro1 

ibo committee, m recommending that the statutory dutv 

definitc'ir nln?e?''i''^ "ispocting floods defences should to 
defmitclj placed upon tbo London County Council ivifhii, 

b<)dv'’'tt bow"^”’ v’ « J'«solution of that 

-odi, uboso position was exTiIained in a report of tbo 

proceedings of the coiiforenca of local authorities irJn'cb 

Having carried tbo investigation to this point tile com., 
imtfco suggests that an intensive study of tlm ,vboIo 
subject of tidos w the Thames .should be undertaken bv tbo 
Lnoipool Tidal Institute in co-operation with the b'vdro- 
graphic department of tbo Admiralty and the Meteoro- 
logical Office. It IS furtbor suggested that when tbo 
results of fins mve.stigation arc available tlioy .sboiiltl 
1)0 applied to conditions in tbo tipper part of tbo river 
and that clforfs should mcautimo bo niado to obtain more 
o.xact iiifoniinffon of tbo part played by land floods in 
jiroiliiciag high waters. The committee's references to the 
uusatisfactory bousing conditions brought, to light by tbo 
disastrous events of January are of some interest. Many 
tbonsauds of persons, it is stated, now live in dwellings in 
■low-iyiiig areas near the river, much below liigli-wnter 
level. It is regarded ns impraciicable to proposn their 
displaecmciit, bat it is recommended that the London 
County Connell .should try to obtain power to prohibit, 
on laud within possible flood limits, the erection of iioiv 
dwellings or the re-orcctioii of existing dwellings tbo floors 
of which aro not np to a specified miiiimiim level. A 
nieasmo of fids kind, tbo coiiimittoe holds, would facilitate 
drainage, and apjienvs to bo commendable on grounds of 
licaltJi. Tbo iiso of faasomoiit rooms as sleeping quarters 
was given special coiisidoi'atiou, emphasis being laid upon 
tbo relation of this question to the general bousing problem 
and upon the de.sirability of enforcing, wherever possible, 
tbo existing statutory provisions relating to siicli dw ellings. 

Alcohol in Relation to Business Life. 

An address 011 the relation of alcohol to biisinc.ss lifo 
was given by Sir Maurice Craig at the Mansion House, 
London, oil March 1st; Sir Tbomns Barlow, P.R.S., presi- 
dent of Iho National Temperance League, occupied tbo 
cimir. Sir JIaurico Craig said that medical science was 
tending more and moro to the prevention of disease, and 
jiooplo wero being encouraged to acquire some bnowlcdgo 
of tlieir bodies and their mental reactions. After fifteen 
years in mental hospitals ho had come to the conclusion 
that .at least half of tlioso who broke dovyii need not liave 
doiio so, and for over twenty^ yeai-s his work had been . 
increasingly the teaching of pe"r.son.s to nndcr, stand tbeiii- 
selvo.s and to get the best out of tlicir mental activities. 

A person endowed with a btgbly sensitivp nervous system 
must Hiidorstand bow to use it, and wliat external or 
intonml sires.scs might affect or injure it. The minor 
mental disturbances were important, not only because of 
their maiiifostatioiis, but because of tbo w.ay they might 
develop if uncovrccicd. It was generally agreed that 
alcohol was a .sedative in action and not a stimulant as 
bad been supposed. Its effect on conduct Jed sometimes to 


the idea that it was stimulating, but the bebavionr rcsiiltcd 
from lessened control. Alcohol inhibited the control of tbo 
iiorvou.? system, diminished tbo power of thought, and 
affected judgement and accurate thinking; uiifortiinatclj' 
the drinker was often quite unconscious that it was having 



MARcn 10, •■■1926]' 


COEBESPONDENCB. 


409 


tin's cITect upon him. One of tho grc.-itcst dangers of 
alcohol tvas its potvcr of bcstouing a transitory feeling of 
wol'-being' yet it niight bo lessening the mental values 
ami rcduciim the rcsist.mco to disease. Drug addiction 
ivas treated °very seriously, though rare in this country, 
and yet littlo was done comparatively to control alcoholism, 
which Was infinitely more common. Tho stresses of modern 
life. Sir Jfaurico continued, were many and sovero, and 
no men had a greater share of them ' than those who 
worked amid the industrial difficulties and financial strain 
of our great cities. Tliereforo they must presorvo their 
health in every way in their power. Ho adi’ised them to 
watch their sleep, as this was the only thing that repaired 
fatigued tissue, but never to rely upon alcohol to get 
sleep. It was tho worst form of sedative, for tho doso 
required to bo constantly increased. In tho case of sonio 
jicrsons it might overcome tho early difficulties of defective 
sleep, but in tho end not only failed to produce it, hut 
aggravated the condition by bringing in other symptoms. 

The Working of Tuberculosis Schemes. 

It was reported to tho London County Council on 
February 21st that tho Minister of Health was unable to 
see bis war- to accede to a resolution sujiportod by tho 
council calling for the setting up of a departmental com- 
mittee to inquire into tho working of tuberculosis schemes 
throughout the countiy. The Minister stated that some 
of the matters in conno.vion with the treatment of tubercu- 
losis which tho council thought niight bo the subject of 
inquiry were scarcely appropriate for investigation by a 
departmental committee, and that if iiiqiiirv was needed 
oil the point it should bo undertakon bj* a medical com- 
mittee. llith regard to institutional accommodation for 
advanced cases and the appropriate duration of troatnient 
for intermediate ca.ses, tho Minister stated that his views 
had already been given in circulars issued by his depart- 
inont, Willie ns to the after-care and employment of tuber- 
cnloiis persons ho was now in a position to cnconrngc the 
provision of further workshops on an oxperimeiital basis in 
two or three largo towns. He thought that aiiv inquiry 
on the subject might ho deferred until the result of these 
until further Gsjioiionco was 
ava lable with regard to the village settlements and work- 
shops already established. 




I?n:— PETROL. 
ledo’p’nF A prcteiiil to export knoiv- 

onoa-^li +n I submit that wo already know 

G Pi'ovi.sionally on these three grounds; 

■ poLonbig^ pi’oduce death or severe or mild 

'mrecogidzaSrhyli^^^ 

otlieriricc*^ * 1 ^ motoring advantages can ho attained 
Aornnl^im!!''' /'’eomniehsiirate with the liealtli risks, 
know. ^ different category ; I do not 

ho absorlLd l>eyontl dispute. Tetra-ethyi lead can 

1 in 1 300 w-'U lungs, or skin. Although diluted 

leaving a fi),,, 'p *, the lattev evaporates quickly, 

■thioiigli tlip )-• - toxic tetra-etliyl lead for absorption 

public, wompiV*''.'ii lead-pctrol is let loose on tho 

for cleaning . — innocently and dangerously — 

Point of warnings, 

etiivl lead chief point. Poisoning by totra- 

n doctor rolioJ* “'“"‘led by the old liall-marlcs on which 
lino in g ,„„5 and‘’wri‘,!t°i''’^® poisoning. Colic, blue 

nve: “ Dron of . , " ‘ ^f''l‘op do not occur. TJio symptoms 
veduced niiKo ^ ““‘1 pvessure, drop of body temperature, 
nausea, .sonif.t;,,,!! 1°^ of weight, sometimes 

■leliriiim tremens ^ serious cases, 

but arc not serious.” > symptoms are warnings, 

*’■ * ^oHriul and , Ungintcring Chcmistri/f Aiigu.«t, 1925, 


Now tlicso acuto symptoms may be enough to warn 
a vigilant woiks doctor in a tetra-ethyi lead factory j but 
I submit that mild poisoning, acuto or chronic, of tho 
ordinary citizen^ by tctra-otliyl lead cannot he diagnosed 
. by a doctor. That, in my opinion, is the danger and 
treachery of this stuff. 

Tlio careful expert investigation and report to tho 
American Surgeon-General (January, 1926), with faecal 
analj'sos and blood-stippling tests, discovered “ no good 
grounds for prohibiting tho iiso of ethyl-gasolino ” ; but 
the investigators go on to say that further experiments 
and larger experience may lead to recognizable lead 
poisoning or chronic degenerative diseases. Actually thoj- 
did find slightly increased storage of lead in the employees 
of garages, etc., where lead-petrol was used. 

Mr. Pi-yce- Jones kindly tested lead-petrol with 
sulphuretted hydrogen for mo: no black sulphide was 
produced. Doubtless this is why no blue line is found in 
tho gums with this nou-ionized compound. 

The Government proposes to appoint a strong committco 
to investigate lead-petrol, and meanwhile to permit its 
use. Surely this is the wrong order. A poison should he 
invo.stigatcd before being let loose on tho public. And 
tho coiimiitteo will take a year at least to report 
adequately; tho Anieiicau report took seven months, and 
found it too short a time. 

Another fallacy is that tho problem can be solved hy 
chcmical and medical investigation. 1 feel convinced that 
this is impossible in regard to slight or chronic poisoning 
effects. No investigators can report whether slow slight 
deterioration of arterioles or of iieiTons tissues occui-s in 
tho course of years in human beings. That is the main 
danger to the public, and, speafeing medically, I would 
say’ it is certain to occur to some unknown extent. 
Urbanization and civilization already have sufficient draw- 
backs to licalth — for example, the smoke ]m]l — without 
stupidly allowing another unseen, mirccognizablc, insidious 
horror "ill our garages and iu our streets, polluted with 
exhaust gases containing lead. 

Tlic public expect that an alert and intelligent Govern- 
ment will protect them against this, until investigators 
can assure them positively that there is no risk to public 
health. It can bo said in" advance that no men of wisdom 
who have experienced even tho old form of lead poisoning 
can make such an unscientific statement. The least that 
they could say is that, while finding no positive evidence 
of "danger, there may bo protracted summative ill effects 
on health which baffle experimental investigation. The 
soothing pnrliameiitai-y reply “ no evidence of danger ” is 
not enough, and vet positive elimination of all possiblo 
perils by experimental iiivostigatioii is iiiiattainahle. I have 
read all the Blue Books 011 lead poisoning and know tho 
difficulty of getting evidence. 

Switzeiland— an intelligent, well-educated country — has 
made lead-petrol illegal, and we should do the same pro- 
visionally. .\iiother point is that the stuff should be called 
—compulsorily— by the warning name “ lead-petrol ” and 
not by the pretty euphemism of ethyl-petrol. 

Point (J).— Turning now to the countervailing advan- 
tages for tho motorist, I have inquired of cxiicrts, ^ and 
find that the chief claim is elimination of “ pinking ” m 
Iiigh coni]U'essioii engines. But “ pinking ” may also bo 
eliminated (iii soiuo cases better) by using a benzol iiiix- 
tuio ov hv cloauiiig out carbon or tuning the ignition or 
carburettor. The use of this fuel in aeroplanes may bo m 
a different category, and the public would not mind it it 
were allowed iiiidcr supervision. But, so far as 1 can 
gather, tlic motoring advantages are not iiid^ensable and 
are small compared with the risks to health. ei am 3 

would not use it. . 

Tho problem is a confusing ono to get into proper per- 
snectivc Neither the politician, nor clicniiyt, iioi nioto i.st, 
irth" public is likell- to SCO nil .oniui it Tim medical 
profession alone can envisage its insidions daiigc.s They 
alone are aware of their powcrlessiicss to an.snei a patient 
ivho asks “ A.in 1 suffering from mild poi.sonmg Irom Icnd- 
notroH ” ov “ AVill niv lioalth suffer if I work for months 
or rears in a garage "using lead-petrol? ” Until, at any 
rate, they can answer these questions, doctore must 



410 Ma.I!CH 10, 1 O 2 S] 


COHRESPONDBNGB. n 


t r_ TnEBcmsH 
/ LTiezuciz. JotTnxit • 


condemn tho domestication of a deadly, insidious, and 
cumulative poison, even though it is highly diluted. . . 

Wo should not pander to tho crude mechanism of tho 
motor at tho risk of damaging tho exquisite bodily 
maehincr}' of our citizens and workmen. — am, etc., 

Hull, Mnrch 1st. IfllAKK C. Eve, bl.E., E.R'.C.E. 

P.S. — The Ministerial roplj- (March 1st) that lead-petrol 
la to be allowed because latterly “ no cases of poisoning ” 
have occurred may bo true and yet quite misleading. 
Translated medically, it may mean that in tetra-othyl lead 
factories any man ivith suspicious symptoms is i>rom 2 )tly 
changed to other work, while, outside factories, severe 
poisoning is unlikely to occur, and mild poisoning will not 
bo recognizable. Hence “ no cases of poisoning " are 
reported, though lots of minor poisoning may occur. Tho 
only safe course is to banish a iioison until at least doctors 
can recognize its minor toxic effects, as they could with tho 
old forms of lead poisoning. 

■%* There is no doubt that jjuro tetra-othyl load very 
roadily produces poisoning. Tho whole difficulty of 
tho matter lies in the fact that at present there is not 
sufficient evidence that tho use of load-petrol leads to 
toxic effects. Tho forthcoming appointment by tho Govern- 
ment (announced in our last issuo at page 381) of an 
Interdepartmental Committoo to investigate tho subject is 
0 stop which will be generally welcomed. — ^En., B.M.J. 


DEFECTIVE STRTJCTUIIE OF TEETH. 

Sib,-— W ith regard to tho questions asked in your anno- 
tation' on defective, structure of teeth in the Bniiisn 
Medicai, Joubnal of February 11th (p. 229) may I first say 
how much I appreciate the frank and friendly criticism of 
points which are, as stated in tho articlo, only side issues? 
In reference to ' these points I should liko to mako the 
following observations. 

1. As to tho possibility of error in my definition of hypo- 
plasia. I think that the evidence I have adduced suggests 
very definitely that the normal dentine of both tho dog 
and man does not contain “ interglobular spaces.” The 
lato J. Howard Mummery, in his Anatomy of the Teeth, 
slates that interglobular spaces are usually associated with 
very conspicuous defects in the enamel, and are probably 
occupied by the uncalcified ground substance of the den- 
tine. The small spaces of the granular layer of Tomes are 
usually confined to tho dentine beneath the ecmeni, but 
may occasionally, though very rarely in man, be found 
under the enamel. In comparing interglobular spaces with 
the gi'anular layer of Tomes, Mummery' says : 

“ The fact that the tubes of the dentine communicate with tho 
spaces of the granular layer, while in the larger spaces they form 
no such communication, would apparently point to tho explanation 
that the spaces of the granular layer represent a normal and 
functional structure, while tho larger spaces are due to a defect 
in calcification,” 

The spaces to which I referred resemble interglobular 
spaces, and not those of the granular layer of Tomes. 

You cite cetacea as creatures w'hose teeth show large 
nurabors of interglobular spaces. As far as my knowledge 
goes, these animals are degenerate land animals whose 
teeth, when present, are often greatly modified. Cetacea 
occupy such an exceptional position in nature that argu- 
ments based on the structure of their teeth can be of little 
significance; moreover, the “spaces” in their dentine 
resemble those of the granular layer of Tomes rather than 
interglobular spaces. In some other animals interglobular 
spaces are seen occasionally — for instance, in horses, 
rabbits, and monkeys. Certainly in rabbits and rats they 
are easily produced by diets similar to those used in the 
puppy experiments, and they are equally easily prevented 
by adequate diet's. ' Interglobular spaces are, however, 
rare in animals living under their natural conditions; but 
the teeth of civilized man, who lives under artifici.al con- 
ditions, usually, in my experience, display such spaces. 

2. You suggest that Fig. 14 indicates that environ- 
ment is more important than structure in producing caries. 

is not, I think, a correct interjjretation of the illus- 

a ion. .43 jg usual in the teeth I have examined there , 


is some normal dentine near tho amolo-dentinal junction; 
this is well shown in Fig. 14. When tho dentine is 
decalcified by acids tho “ spaces ” often appear to ba 
obliterated, as might bo expected. This tendency is indi- 
cated in Fig. 14. In this figure tho part of the tooth 
chosen for photographing was that in which caries was 
least extensive, as the object of tho section was to show 
tho structure of tho dentine, and not to indicate tha 
presence of caries. Tlio greater part of the tooth was, in 
fact, carious. 

. 3, From tho evidence I have of calcification in puppies* 
teoth.it seems clear to me that in those regions where 
calcification usually takes place most quickly the dentine 
tends to bo worst calcified. 

; 4. Pat-soluble vitamins have been shown to pl.iy a part 
in tho resistance of teeth to .caries.' Tlie fact that the 
mother sacrifices her tissues to a certain extent for tho 
sake of tho developing offspring needs no comment. Ex- 
periments mentioned in tho paper show that when a bitch 
is' fed during pregnancy and lactation on a diet deficient 
in fat-solublo vitamins the deciduous teeth of the offspring 
are not ns badly calcified as the permanent teeth would bo 
if tho same diet were given to the puppies after weaning. 
(Puppies’ deciduous teeth are all erupted befoie weaning.) 
From this it seems probable that the mother has sacrificed 
Eomo at least of her' store of calcifying vitamin. If, as I 
have indic.ated, faFsoluble vitamins are of importance in 
resistance to caries, then the teeth' of tho pregnant woman 
might be expected to be more liable to caries than those 
of the non-pregnant, other things being equal. — I am, etc., 

Mat Meliandt, • 

Pharmacolosy Depnrlment, Sheffield University, 

March Srd. 


CHEMISTRY AND PHARMACOLOGY OF ERGOT. . 

Sib —In tho articlo on ergot poisoning among rye bread 
consumers (February 25th, p. 302) we noted with surprise 
that tho authors claim that “ extracts from the rye were 
also tested physiologically for ergot, and the results were 

^°On(rof us (J. G.) prepared an extract from 600 grams 
frouEhlv 20 oz.) of the suspect flour, using the approved 
method of the D.S.P. X for “ Fluidextractum^ ergotae 
Tho neutralized extract was tested by the other (A. D. M.) 
on tho isolated virgin guinea-pig and rat uteri, the blood 
pressure of the spina! cat, and also by the more specific 
test of intramuscular injection in the white Leghorn cock. 
Tho extract contained a histamine-like substance, but tliore 
was no evidence of ergotamine. Another extract, supplied 
bv the city analyst, was even less active, so that our 
obsei-vations were diametrically opposed to your authors 

'^"Microscopic'^oi^aniination, while revealing moulds, was 
similarly negative as regards ergot.-We 


Tho Victoria 


Jaitbs Grieb. 


In the interesting article on ergot poisoning 

mniip rve bread consumers hy Drs. Robertson and .Mhby, 
ubli^ed in your issue of February 25th (p. 302), the 

allowing statement occurs : 

••The three chief constituents of ergot are 

(Vo* md eri’otine. However, ergot is not as yet 
fift w 'into its” component parts or active constituents, and 
tile iTat present known of them specifically, 
mis statement does not quite accurately 

nosition of the chemistry and pharmacology of 
i-Kot Fiom 1906 onwards chemical and t 

10 proteins of rye gram, ■■ In 

sing histamine (“ ergammo > ) ""<1 

322 Spiro an d StoU isolated from ergot a _nm v^__ 

' Brillih Dental Journal, October Ist, 1926, and Pcccmber 15tb, 


COBEESPONDENOE. 


MiBCH 10, 


I92§] 


[ 


THEBninsa 
JJeoxcax, JoTnuus 


411 


ei'^otainino, which lias qualitatively and quantitatively the 
same pharmacological action os ergotoxinc. The questions 
that remain to be answered are: Is orgotamino identical 
with ergotoxine, and, if it is not, docs it partially or 
wholly replace the latter alkaloid in certain varieties of 
ergot? From a medical point of view these questions are 
of academic importance only. 

The facts given above are generally accepted; they aro 
quoted, for example, in English, German, and Swiss text- 
books oil alkaloids, and are duly recorded in modern text- 
books on pharmacolog}-. It would in fact appear that 
probably no other natural drug has been so thoroughly 
investigated, both chemically and pharmacologically, as 
ergot, and in no other case can the activity of the crude 
drug and its extracts bo so exactly associated with its 
known active components. — AVo are, etc., 

Buimouc.iis AA'm.LCOJiE .\xd Co. 

London, E»C.l, Feb. 29tli. 


GASTRIC SECRETION' OF N'EFTRAL CHLORIDE. 
Sin,— It is apparent that Professor AlacLoan thinks that 
I was guilty of some discourtesy in inv previous letter, and 
if I really gave him cause I am extrcmelv sorrv, for it was 
far from my mtention. Here, with tho gmod n'cws that his 
work IS shortly to bo published, I would gladly leave the 
matter; but his final paragraph shows such misunder- 
s ‘Tiif nig of my attitude tliat I must add something more. 

un wiV r ^lacLcaii nTodestly 

1 utci estimates the importance of his conclusions. To prove 

fo.™ no? •'>«y 

the unite i T •kvdrod.loric acid is to disprove 

h ni- s twtimony of all the brilliant array of phvsio- 

This is no'inpan° domain in modern times. 

can suitabirhe 

the CQurtesv nt private correspondence. By 

to be nresent at tf Society it was my privilege 

referred and I nmrT to which Professor JIacLean 

which followed his^parer t)'® tl'scussion 

.ductorv remarks on ^tW ol'o'mian, in Ins intro- 

proceedings ,me nritte°“'‘"‘.T’ tl>ot the 

eomnuinieation was^ot ev’ Professor AlacLean’s 

all of us wlio heard it W puklioation, and 

matter from tinf a sealed on the 

aoggest, wRhoiit at this date I may 

AlacLean’s memm-v ^ of coiifidciico, that Professor 

the evidlce iTsJ false when he savs that 

••»<»£; Z »n« 

proof merelv nn tl, i a statement of conclusive 

November 1926 "a-atioiis then made. This was in 

elusions has leal-prl . "’^antime the news of Iiis con- 
asked by membpis nf prettj- widely, and I have been 
view of Professor II n r'^ 'a"' *a.'' wiews are tenable in 

1928, when T wrotfi^Z^ ^ ^ "-s Februaiw, 

months before osf ^®'> ao that I have waited fifteen 
described as “ f*'® evidence; if this is fairly 

pie-eminencc in eDistfl-,r'**‘’|f’""f’” ^ f “‘‘I' 

Lon, epistolary slow motion.— I am, etc., 

™. -M, March 3rd. GoBDOX W. G 00 DH.VKT. 

Sii!,-Ii is -“ICnTE ABDOMEN, 

ra^sioii which has hpi?"— -ft® , soinewliat earnest dis- 
from honest appearing in vour columns arises 

been good hecanso ^tstanding. The result, however, has 
of diagnosis in nr, t ugain the very difflenlt problem 
the flout, ® oodominal disease has been forced to 

The ^Uin^con wl, * *' 

signs, wilf niiss °P®rates early, and on slight 

and again by heeatlviT’a-^''*^ he will be faced every now 
succeed in thrn 5 +:„ vP®ings. He may, in most instances, 
I'o harm has' been latter aside by the claim that 

interested do not ni 'I’t't) unfortunatelv, the parties 

l«uch harvet to 

juent upon the earHo^f ®“®.to„tl“ .way of reaching agree- 
kut things are urnmno of surgical abdominal disease, 

IS being sajj a],out ^ti”° ‘'opl'lly- I think that too much 

There’ aro vci-y few .In wait for late symptoms. 

ners in that respect now in practice. 


One of tho niost impressive improvements in recent 
years is the anxiety of practitioners to refer their patients 
to tho surgeon in the earliest hours of disease. The 
statistics of every hospital prove that. Neither general 
practitioners nor surgeons can bo held responsible for delays 
brought about by patients or their relatives.— I am, etc.,' 
Glasgow, Sfarcli 3r(l. ChaBLES Bexxett. 


PEPTONE TREAT JIENT OF ASTHAIA. 

Sm, — Perhaps 1 may he allowed to refer to a statement 
in the letter of Dr. James Adam in yonr issue of February 
25th (p. 328). Refen'iiig to peptone, iio says, “ It may bo 
dangerous, and many deatlis have been recorded in America 
after its use.” I have often pointed out that certain 
peptones are dangerous to give internally, hnt that I have 
never found the slightest danger with Arnioiir’s No. 2, 
after rising it for many years. I have not, however, heard 
of deaths in -America produced by anj' peptone. Perhaps 
Dr. -Adam would kindly give us tlie references to these 
“ many deaths.” — I am, etc., 

London, W.l. Feb. 25lll. GtlXX AuLD. 


^MEDICAL EXAAHNATIONS FOR. LIFE ASSURANCE. 

Sir, — AV hilo ready to agree with Dr. AV. AI.- Robson 
that time is wasted by applicants being unprepared to 
micturate, I cannot by any means endorse the whole of his 
letter of rchruai-y 20th which appeal's in yonr issue of 
Alarcli 3rd (p. 376). 

No iiistiranco company cares a straw for the riact ages 
of brothers and sisters. AA'hat is wanted is their relation 
to tho ago of tlio applicant; indeed, even the ages of 
parents aro only important for tho same reason. The word 
” about ” may he appended to the figures given, and will 
salvo the conscience of the ultra-scrnpuloiis applicant — and 
there arc such! But my experience is that to ask these 
details gives the examiner a valuable opportuni^ of 
gauging the tnithfiilness, or otherwise, of the applicant, 
and is a useful guide in assessing tho value of his replies 
to more personal queries. . . 

As to permitting women to bring urine in a bottle, let 
me recount one experience. I was once instmeted to visit 
a lady of very exalted title at an hotel. I made the usual 
request for a specimen, and the lady retired to the 
adjoining bedroom in her suite. But I bad taken the 
precaution of hiding a chamber vessel which I had found 
containing urine, and which I had reason to suspect had 
been passed by lier ladyship’s maid. As a result the urine 
passed at my request was found to contain sugar. I never 
allow uriiio to be brought in a bottle, and if the applicant 
has to bo loft to himself or herself I always satisfy myself 
that the uriiio is warm. - 

One further detail : I have in reserve a uriiionieter which 
can give the specific gravity in less than one onneo of fluid. 


— I am, etc., 

London, E.C.2, 3I.trcIi 3rd. 


-A. OgiER AAktBD. 


ULTRA-VIOLET LIGHT TREATAIENT OF LUPUS 
ERYTHEMATOSUS. 

Sib, ^Tho remark of a speaker at tho meeting of the 

Aledical Society of London, recorded on Febniaiy 18th 
i'p.259), to tho effect that treatment of Itipns erytlicmatosus 
by ultra-violet light is " waste of time and effort,” prompts 
me to record a recent experience of mine exactly to 
the contrary. I extract the following notes from my case- 
book. 


larch 9th 1927 —Mrs. , aged il, family histoij unimportant, 

I »■"“"> “ “ 

olved. 

V mask was made for the face to protect the tinaffccted 
■a and treatment was begun on JIarch 6tli. The patient 
eived two local radiations per week from a mercury 
— the time of each exposure gradnallj 



412 Maboh 10, 1928] 


COERBSPONDENCK ‘ 


r TTrEHniTiTfl ‘ ’• 

L Meiecai, Jovasit 


Increasing from two and a lialf to ton minutes, and tlio 
distance diminishing from thirty to six indies. The lesion 
slowly but steadily improved, and on December 9th treat- 
ment was discontinued. 

January 17th, 1928. — The eruption has completely disappeared, 
and the scar is so fine that it is hardly perceptible. Closer 
inspection reveals a small scale on the edge of the pinna. 

I should add that no lotions, ointments, or dressings 
were applied to the affected ni-ea, and that only two 
general radiations wci-e administered, the patient having 
refused any more because of the subsequent irritation of 
the skin. Probably the entire absence of local applications 
of ointments or lotions made the light therapy more effec- 
tive; at any rate, one must agree with Dr. Hcald that 

a curious differouco in clinical results ” calls for more 
investigation. — am, etc., 

Sunderlnud, Feb. 21 st. NoEL F. RoWSTHOM. 


INJECTION TREATMENT OF VARICOSE VEINS. 
Sin, — ^In South Africa, where, as a nation, wo are par- 
ticularly free from syphilis, wo have a great opportunity to 
observe the condition of varicosity of veins as it arises in 
the European and native races; some of the latter aro 
heavily and widely infected, whereas some are not infected 
at all. Among the non-infeoted no varicose veins aro 
found, but among infected persons— especially in heredi- 
tary cases — instances of varicosit}’ occur. 

The standard treatment, either by operation or by pro- 
ducing thrombosis, must in itself appear a crude temporary 
measure unless it cures the cause of the complaint, whicli, 
from a pathological point, is the same as aneurysm — ^in fact, 
it is Inferred from the textbook statements. ' 

I came to use “ 606 ” in tlie treatment of the varicose 
condition because I had to treat a patient who thought he 
had syphilis in a mild form ; the Wassermann reaction of 
his blood was slightly positive. Knowing that he had 
varicose veins in both legs I injected a vein ; to my 
astonishment, a few days later 1 found that the varicose 
condition had entirely disappeared. Since then I have 
always treated all varicose conditions and especially the 
accompanying hard ulcers so common among the poor, by 
arsenical compound injections, with the happiest results, 
as the ulcers heal up in about a fortnight without any 
special treatment except the concomitant mercury pills 
(Hutchinson’s formula). 

No one now suggests that arsenical compound prepara- 
tions form thromboses in the veins, since the same vein 
can bo used for months for the injection, showing that it 
has not become occluded in the course of treatment. The 
groat objection, in my opinion, to the u.se of other drugs 
which do not attack the cause of the disease, but produce 
thrombosis, is the risk of embolism. Moreover, the prin- 
ciple of thrombosis is wrong, inasmuch as it throws a 
■greater burden on the yet uncured veins. I am confident that 
the use of the arsenical compounds will become standard in 
all varicose conditions; I can especially recommend it for 
that intractable condition of varicose ulcer. In the case 
of a sleepwalker, aged 24 years, I used the same treatment 
after finding from the family history that his mother and 
two elder brothers died before the age of 38 from apoplexy. 
The effect of the first injection was complete cessation of 
the sleepwalking. He had in all three injections; inci- 
dentally, his piles were cured as well as a Circe’s girdle of 
veins due to obstruction of the veins of the liver. I saw 
him in 1916 when he was suffering from chronic syphilitic 
rheumatism. — I am, etc., 

trpington, South Africa. W. M. BoitCBBatDS. 

gjjj may not be out of place to give some reasons 

\\hv thrombosis need not be considered as a possible factor 
a<rainst the use of injections for varicose veins. 

“if 20 per cent, strontium bromide is injected into a 
varicose vein and a metal disc is placed oyer the site 
of the needle mark an immediate radioscopy will show that 
not a particis of the opacfus substance goes above the 
metal di.se, but on the contrary falls distally from it 
—that is to say, against what would bo the normal venous 
ow in a Healthy vein. By this same method the theoiy | 


of Troudolenburg, or the reversal of the blood stream in 
varicose veins, is proved to bo correct. This, therefore, is 
one reason wlij’ a blood clot lias no tendency to get into 
the general circulation (Yentzer).' TJie first effect on the 
veins of an injection of certain substances is a* chemical 
in/Iamniation and destruction of the endothelial cells, with 
subsequent sclerosis of tlie vessel walls. The clot which 
forms after the ondotliehura has been destroyed is firmly 
adherent to tho vessel wall. 

The risks attending thrombosis aud emboli are practically 
nil. There is far more danger from errors in technique. 
It must bo borne in mind tliat great care and attentiou to 
asepsis ore necessary wlien injecting the fluid into the vein. 
Not a drop must be allowed to get into the surrounding 
tissues, since great pain, and even a slough, may be caused, 
just as with injections of arsenic or moi’cury. The injections 
well done are painless, except for a cramp that spreads 
along the leg. It lasts only for a short time, and is of 
good omen with regard to the ultimate success of the 
treatment. It is only right to emphasize the fact that 
unless great care is taken in giving these injections com- 
plications may occur which would tend to discredit this 
form of treatment in the eyes of the practitioner and the 
public. W'hen well done no form of treatment for this 
condition gives such rapid, lasting, and gratifying results. 
It is a boon to all classes, since they need not. curtail their 
work nor their pleasure. The thrombus in ligatured 
vessels and in veins treated by injections does not become 
detached unless it is infected. — ^I am, etc., 

London S.W.7. Henhy Tbeves Babbeh,- M.D., B.So. 


THE, FUTURE OF OBSTETRICS. 
gjn_I Was delighted to read -the -comments of Ur. 
G. W.' Theobald of Bangkok (February -ISth, p. .2S4) on iny 
letter' published in your issue of December ICth, 1927 
(n. 1117) and I agree with much he has said. 

'‘The medical practitioner of to-day is- far too often 
uassed into the world of medicine with n scanty -knowledge 
of obstetrics, and it is for the centres of teaching to B«PP‘y 
that deficiency. 1 quite agree that so long ns a midwifery 
Se is pregrlssing'it should be left to Natui;e I-cou- 
Ler an enema a matter of course, but. a catheter as a 
routine practice , is an abomination ; morphine, scopolamine, 
nnd tincture of opium are dangerous expedients that too 
often rask symptoms which are leading up to difficulties. 
These difficulties have to be dealt with after much un 
necessary delay, indicating a want of perception of the 

#»T.ii^6S of tli&ti doloy* ^ • 1 t 

Dr Theobald suggests that strict asepsis is ■unattainable, 
r nriruB that asepsis is the chief and only point to be 
arri^d at, and should be applied in midwifery 
Hm same wav as it is in surgery. Whore should we be 
but for the idvanco in this respect in surgery, and why 
should we fail in the attempt to bring midwifery uP ^o tbe 
mo standard P After forty years* practice, and having 
’tended over 4,000 confinements, I claim that forceps, 
Ti-f and turning can be aseptically applied in mid- 
witery under reasonable conditions, and I have no regrets 

°”M!'dwifery in private practice is not the same as mstitu- 
limial treatoent, and I consider that cases in institution 
left far too long for the good of the patient, 
Wffs would not be tolerated in private practice. ^ 

” -tilrl that private practitioners have no time 0 
'"r noB to give a case decent opportunity to progress 
^f but it not the truth; a general practitioner is a, 

’ as anybody else, and it is high time that 

offensive assertions were dropped and that fair p M 
bS him Axis-traction forceps, being scient.fia 
. mpnts are invaluable in whatever position the head 
" B Biff inlV forceps are out of date. I contend hat 
'tW head hL come to the outlet of the 
:Lron\*erine^^^^^^ time has come rather to take the 

"rhrve1ead”a"nd"dFgested'l?"of 

WftlHnrrfnn. SurrCT. Frf** 


MARCH 10, 1928] 


DEATHS IN THE SEEVICES. 


f The B«msa 
L lIzDicji JorcNii. 


413 


A SOCIOLOGICAL FOBIMULA. 

Sill, -III i-ieiv of yoDi- ivelcomo report of Mr. C. J. Bond’s 
Galton Lecture on eugenics (February 25tli, p. 315) 1 beg 
to submit a sociological formula ivbicli would serve for all 
countries ami for all time. The fundamental consideration 
in sociology is the very strong tendency of population to 
press upon the moans of subsistence. This tendency imist 
bo completely counteracted if a satisfactory standard of 
living is to be maintained, and three factors are necessary 
to counteract it completely— namely, liigli production, a 
low birth rate, and eugenic selection. Thus I arrive at 
mv formula; People must work their best, and also mu.st 
not have iiioro than two children uiilc.ss they are above the 
national average in tho advantages for paronthood. I 
assiiino that if tho less eugenic couples do not have more 
than two children the others will be proud to have larger 
families. — I am, etc., 

London, S.W.7. Feb. 25tb. BlNA’IE Do.VLOr, M.B., Cll.B. 


POLYDACTYLISM AND BEVEESION. 

Sin, — Tho case of supernumerary thumbs reported by Dr. 
E. H. Mitchell (Februaiy 2Sth, p. 308) raises iiitorcsting 
points. Darwin in his work The Descent of chapter 

ii, page 55, says: 


He served throughout the whole South African war of 1899- 
1902, when he took part in operations in Natal, the Transvaal, 
tho Orange Eiver Colony, and Cape Colony, including the 
-actions at Elandslaagte and Lombard’s Nek, and the defence of 
Ladysmith, and received the Queen’s medal with five chasps 
and the King’s medal with two clasps. During the war of 
1914—18 he was D.Al.S. , from 1914 to 1917, of the Second Arniv. 
the army which held Ypres throughout, and which maintained 
the long and bloody struggle of Passchendaele. Towards the 
end of this time this army had grown in strength to 800,000 
men, and lie had under his administration some twelve hundred' 
medieal officers, employed in twentj'-eight Divisions, as well 
as in some thirteen c.asnalfy cle.aring stations, fourteen sanitary 
sections, three mobile laboratories, and five army schools of 
sanitation — a vast organization which he had himself built up. 
He was six times mentioned in dispatches — in the London 
Gazette of October 19th, 1914, February 17th, 1915, June 22nd, 
1915, January' 1st, 1916, Slay 29th, 1917, and December 24tb. 
1917. He was awarded the C.B. in 1916, and the Crown of 
Belgium, as commander, in the same year, tho C’.M.G. on 
June 3rd, 1919, and the K.C.B. on January* 1st, 1921. He 
also had the Belgian Croi.x de Guerre. In 1903 he married 
M.ary', daughter of the late John Johnstone of Barnard Castle, 
aiid leaves a widow and three sons. 


I attributed, though with much hesitation, tho frequent cases 
of polydactylism in men and various animals to reversion. . . . 
I was chiefly^ led to the conclusion that tho presence of super- 
numerary digits might be duo to reversion from the fact that, such 
digits not only are strongly inherited, but, as I then believed, bad 
the power of regrowth after ainpulation, like the normal digits 
of the lower vertebrata. . . . But at present it is the safest 
course to give up altogether tho idea that there is any relation 
bctacen the development of supernumerary digits and reversion 
to some iowly organized progenitor of man.” 


■ As Dr. Mitchell remarks, tho lack of hereditary influence 
m .Ills case makes tho ocourrenco somoivhat rontarkablo. 
• patient underwent an operation it would be 

in cresting to be iiifonned later whether there was evidence 
of any power of regrowth. 

Haeckel asserted that tlie five-toed amphibian foot was 
r, '"•'Hiy-toed fish fm (Evolution of Man, 

'• ^ long way back in tho animal scale for such 

, 'Of®*on to recur in man; even tlio interval between one 
immense. Personally I do not 
mnro „ ™ Dtnnrui realized tho fact tliat polydactvlisni is 
wise bo occurrence of a tail, since other- 

slon Tin?" ™®'*o this statement about rever- 

lonk-od i.r, naturally arises Can a human tail be 

looked upon as a reversion P-I am, etc., 

Loudon, E.. M.R.C.S.Eng., L.H.C.P. 


Lieut. -Colonel Charles George Webster, Madras Medical 
Service (retired), died at Ryde, Isle of Wight, on January 
26th, aged 56. He was born on July 5th, 1871. the sou 
of the late John Hcnrie Webstei*, Government Telegraph 
Department, Cliandanagore, Bengal, and took the Scottish triple 
qualification in 1892, and subsequently the F.R.C.S.Ed. in 1G05. 
Entering the I.M.S. as surgeon lieutenant ‘on July 28th. 1895. 
he became lieutenant-colonel on January 29t]i, 1915, and retired 
a year later on January 29th, 1916. lie served in the China 
war of 1900, receiving the medal. He entered civil employment 
in the Madras Presidency in January, 1902; in 1909-10 he held 
the professorship of medical jurisprudence in Madras Medical 
College, and in June, 1914, was appointed surgeon of flie 
1st District of Madras City. 


ttnilimitus anti (KoIIigts. 


UNIVERSITY OF CAMBRIDGE. 

At a congregation held on March 3rd the following medical 
degrees were conferred : 

M.B., B Cnin.—S, J. P. Gray, M. J. Harker, R. if. B, MacKenna, 
K. H. Uttley. , 

M.B.— J. Dockray, H. K. Goadby, H. B. Stallard. 

B.Chib.— W. J. H. M. Beattie, D. B. Tweedie. 


UNIYERSITT OF LONDON, 

At " ' * ' 'xaminatiou held iu January there were 

197 ■ iu tlie first divi«iiou and 880 iu the second 

<liv' , took the supplementary, certificate for 

l^tiu. 


■ ^frliirts. 

deaths in THE SERVICES. 

„ Sir Robert Porter. 

Senior Robert Porter, K.C.B., Army Aledica 

to Lord Haf • taken ill during the memorial service 

auii pleurkv^-^^ ^Westminster Abbey, and died of pneumoni: 
Kent nn Pi 'v^'^ek later at his residence at Beckenham 

Donegal on t 70. He was born in Connti 

Sorter* anrl ^ 1858, the son of the late Andrev 

Bnivc^itv Y 1**^^ 1 Foyle College, Londonderry, at Glasgov 
in graduated M.B. and C.M. in 1879, am 

51b. 1881. the R.A.M.C. as surgeon on Febroan 

after a f ^ rank of colonel on January 14th, 1910 
an January' 14?]? imf ’ "’as placed on balf-pai 

creat u-ni. * a to duty at the beginning o: 

surgeon-r:enen?" ^^^4, he was appointed temporary 

raanfa "uit November 2nd, 1914, and confirmed in tliai 

general nn i? i ^ was subsequently changed to major 

Marched ^915. He retired afttr the war o. 

before as \vp11 ^ ^ very fine record of war servic( 


His first active servic 
dispatches ■\nA ®f 1895-96, when lie Yvas nientione 

P and received the star given for that campaigr 


royal college of surgeons of ENGLAND* 
Council Election. 

The Secretary of the Royal College of Surgeons has sent out the 
usual election notice, which on this occasion informs the Fellows 
of the College that on Thursday, July 5th, there wiJI take place nn 
election of four Fellows into the CouncIFin the vacancies occa- 
sioned by the retirement in rotation of Sir Anthony Bowlby, 13t., 
Sir D'Arcy Fow’er, and Mr. F. J. Steward, and by the death of 
Mr. W. Thelwall Thomas. 

Blank forms of nomination and of the requisite notice from a 
caudidate may be obtained on application to the Secretary, and 
the same must be received by him, duly fiiled np, not later than 
on Moudftj’, March 19tb. A voting paper will he sent by post on 
April 5rd to each Fellow whose address is ' ’ “ 

The candidate elected by the smalles 
become substitute Member of Council fo 
Thomas until 1935. 


21useinTi Denionstralious» 

The followiiij? denioustrntions of specimeus in the miiscnm will 
a given in the theatre of the Royaj^College of 
y Professor Sir Arthur Keitli. 

Ivauced students and medical 

le dates indicated at 5 p.m. t Ma j • i ' • , 

the sacro-lnmbar regiou of tlte spine and their hearing on 
irAcni practice; March 16tli-Varmtions and anonialies of the 
??iSl and costal series of the vertebral colnmn and their applica- 
'on In <lia“uosis and treatment; Marcli 23rd— A review- of the 
°raeut state of Knowledge regarding the juuervatiou and move- 
leuts of the intestine. 



414 Mmxgh to, 1918 ] 


SIR DAWSON WIDDUMS, ,M V. 


[ Tme Critixs 
Bfeoicxi, JorEVif* 


(©Mtuafij. 


SIR DAWSON WILLIAMS, C.B.E., M.D., 

Hon, liL.D., D.Lwt., D.So.; F.R.C.P., 

Editor of tlio Dritish Htcdical Journal, 1898-1928; Consulting Physician to tho Bast London Hospital 
for Cliikfron ; Pcllov? of University College, London, 


We had to annovnee with sorrow in onr last issue tho 
Euddon death, on Bebrnary S7th, of Sir Dawson Williams, 
who retired from tho Editorship of tho Tiritish Medical 
Journal as lately as Jantiary 19th, after thirty years of 
invaluable sorvico in that position, 

Dawson Williams was born on July 17th, 1854, atUUesfcolf, 
Yorkshire. Like so many other distinguished men, ho was 
tho son of a clergjTnan. His father, tho Rov. John Hack 
Williams, was formerly Rector of Burnhy, in tho East 
Riding, from whom ho inherited Scottish and Welsh blood. 
His mother had been Miss Ellen Monsavrat, on whoso 
account ho could claim Spanish and Huguonot extraction. . 
More than most Englishmen, tlicrcforo, ho had tho advan- 
tage of a mixed origin in which were tlm potentialities of 
many fine racial characl-oristics. Ho was tho eldest of 
seven children, and was sent to Pocklington Grammar 
School, in his native county. It had been his wish, and 
that of his father, who had been a scholar of St. John’s 
Collogo, that ho should bo sent to Cambridge, but circum- 
stances prevented tho fulfilment of his desires, and ho 
proceeded to University Collogo, London, and in duo course 
became a student in its Medical School, at that timo at 
the height of its rcpvitation. Dawson Williams never 
ceased to regret that ho was not a Cambridge man; ho 
always cherislied a warm fooling for that University and 
took great interest in tho success of its medical school. 

In 1878 ho became a Member of tho Royal College of 
Surgeons, and in tlie next year graduated Bachelor of 
Medicine and Bachelor of Surgeiy of the University of 
London, earning tlio Gold Medal in Jlcdicine in tho former 
examination, and when in J.881 ho took the degree of 
Doctor of iledicino ho was adjudged worthy of tho Gold 
Medal. Tho membership of tho Royal College of Physicians 
of London followed in 1885, and ho was elected to tho 
Fellowship ton years later. 

Williams held tho post of house-physician at University 
College Hospital and afterwards served as registrar and 
pathoiogist at tho Victoria Hospital for Children, and as 
resident clinical assistant at tho Hospital for Consumption, 
Brompton. He had entertained thoughts of joining the 
Indian Medical Service, hut gave up tho idea when ho 
decided to devote himself to pediatrics. In tho year 1884 
he was elected assistant physician to tho East London 
Hospital for Children at Shadwcll, where ho soon bccamo 
an outstanding member of tho staff. He was promoted 
full physician in 1894, and on retiring from the active 
staff was elected consulting physician.- In 1902 he gave 
up his whole time- to the duties of Editor of this 
Journal. During tho preceding twenty years Dawson 
Williams worked very hard, and it was only his industry 
and powers of economizing effort, and minimizing waste 
of timo which enabled him to fulfil efficiently the duties 
of physician to a somewhat remote hospital and of private 
consulting practice, and to meet tho ever-increasing claims 
of medical journalism. That he did so with eminent success 
is well known; for ho was one of those rare men rvbo “ can 
fill the unforgiving minute with sixty seconds' worth of 
distance run." But this statement of his activities in 
tho eighties and nineties of last century would bo incom- 
plete -without mention of his scientific contributions to the 
Tranmetions of the Fafholoffical Society and of the Report 
of a Committee of tho Clinical Society on the “ Periods 
of incubation and contagiousness of certain infectious 
diseases ’’ which owed so much -to him. In submitting the 
Report,’ which forms a supplement of 225 pages to the 
Transactions for 1892, the Chaiman of the Committee, 
SiT %YiUiaiii Broadbent, wrote: 

“ Tho Cornmitteo are bound as a sirnp^o mal^r of jvsltca to 
call attention to tho important p.art vliich Dr. Dawson iViiiiaojs 
lia-s taken in collating, sifting, and arranging tho largo amount of 
• material embodied In tho Report. It is duo mainly to tho 


enthusiastic interest ha has taken in tho question, and to tho 
labour ho has devoted to tho investigation, that the Report can 
now bo placed beforo the Society, and the Cornmitteo consider* 
that ho deserves the special thanks of tho Society.'' 

On this work Williams had been occupied for four years, 
nud in later life he referred to it with manifest pride and 
pleasure as his best performance in that line. Meanwhile 
ho had contributed, in 1886, an article on " The, attenua- 
tion of vims and protective vaceination ” to Cheyne's 
Jiacicriaiii Jlclation to Disease, and in' 1898, when he heg.nii 
to give up all private practice and Iiospital work, his 
important book Medical Diseases of Infancy and Childhood 
was published. He also contributed, at the request of his 
friend Clifford Allbutt, several articles to tho System of 
Medicine, and among these was one on glandular fever, 
although he himself was perhaps not entirely convinced 
of tho actual existence of that malady as a disease entity. 
Ho never forgot that pediatrics was his first love as a 
practising jibysician, and it was to his sympathy and 
powerful help that the Archives of Disease in ClMliood 
partly owed its establishmont, and that its publication was 
undertaken by tho British Medical ' Association. It would 
not surprise us to find that his. helping hand has been 
oxtondod to the study of disease m children from beyond 

**DnwsTn Williams’s long connexion with tho TIriihh Medical 
began' in 1881, only tiirec years after ho took his 
first onalificatinn. Ho was appointed hospital reporter m 
1884 Vincipal Sub-Editor in 1886, and Assistant Editor m 
^On the death of Ernest Hart in January, 1898 ho 
^ nnuniuted Editor. Tho position of hospital reporter, 
was PP . , visits to various hospitals in London, brouglit 

ii to tormna r laUons with the leaders of the pro- 
r • nml irtbis way he became well known to many 
fession, and m turn surgeons, an acquaintance 

^ fvh^wns aUoJwLds of much value to him as Editor and to 
which was a served. When ho came to succeed 

Rio J®”"' duties of the post were by no means 

Ernest ™ f 1 ,^ Pad often been left m charge 

the Cv absences of Hart in India and on the 
during tProUKbout which periods he was entuely 

nvibb for t m conduct of tlio paper. rort««®tely bo 
resDonsible tor ^ aolleaguo and 0 d 

had beside Taylor, whoso wide learning, ready 

«< '■*’ 

, to the ^gj.g ujoinentous for the British 

Williams said m reply j£,j,3past was very qmcHy 

?’'''edite^‘" The rccLsti'tutidn 'of the A^odiatlon with aU 
discredited. „nd excitement which it caused, 
the turmoil, a.nu , times of the introduction of the 

the troublous .-ajritical 

Insurance - > _ should be by no means a sinecure, o 

TrlZ' Jn !aU tlfos:%t'ree trials he 1-Pt £ 
bed of unsel to the Association m pejticumr 

tlieVofesslcn m fa^^Ur^n^ 

Hon "wSlc maintaining the rights an . 

on tiroecasion of his roRroment ffgu^tions 

tributes to his firmness, man. That 

bad a high opinion both 






. March lo, 192*] 


Bin DAWSON WIDDIAMS, M.D, 


Tsx Bamt« 
Hxmcjx. JocBNift 


415 


of flio standard of accuracy innintainctl by tlio Journal and 
!cf what is called its " nows vnluo ” may bo inferred from 
■the attention they paid to otir columns. Lord Norlhcliffo, 
who had a sure instinct for such things, is roported to fiavo 
■said that “ the Editor of tho B.MJ. must bo n man who 
knons nows when ho sees it.” Dawson 'Williams, wlxcn bo 
heard this, reniarlced with a qniofc chucido that it was 
rather fun to note how often a good bare started in tbo 
llritiih Medical Journal was lumlcd, first in tho 2’inics, and 
then up and down tho press of tho country. 

In thy scope of this notice it is not pos&iblo to deal wdtb 
all tho activities of thirty fateful years, but wo cannot 
omit mention of Dawson Williams’s action in bringing 
j about tho highly successful scientific and clinical meeting 
! held in London by tho Assordation soon after tho war, or 
the work he did with tho help of Dr. Johson Iloriic, many 
ye.irs c.wlior— in 1904 — in arranging for tho reception and 
entertainment of 150 leading Ercneli physicians and 
surgeons who then paid a formal vi.sit to London. Yet his 
habitual modesty was such tlmt in tlio full reports of 
fboso proceedings in tho Journal no mention of his name 
.IS to bo found. During tho war, when ho worked for 
many months almost single-handed, lio gave unllinching and 
eftcctive support to tlio Naval, Anny, and Indian Medical 
oeniccs, and forwarded witli all means at liis command 
leir best interests in war, as ho had dono in peace, 
eicnng that thpso interests were inseparable from 
ilti*' 1 “Hth blo' of tbo figliting forces, 

n,-.'?-'® I'ci'sonal oxpcrionco of general 

1 t nndcrstaiiding of tho difficulties 

*11 P''Rctitinnor.s .and championed their 

our professbn^^^ those of any other branch of 

soiwo* ho loft to speak for them- 

'vears Journal during tho past forty 

nronrcM in 'I'i'cctiou it was not merely a record of 

oninimi • i* science and an organ of professional 

cared for ^ ^''ut stamped it, for those who 

with a fino c " as tho production of a literary artist 

of each of 'ijiiluos. Ho tlionght of tho scrcral parts 

'over cnirnniiJ** making up a whole, and spent infinite pains 
Paracranh Workmanship, ovon in tho smallest 

the food ■ ®'‘«0'.truo editor ho took more prido in 

from bit nnn™ ^ cliosoii contributor than in aiiytbing 
English—d' bimsolf wrote was always sound 

affeetatinn ■ ’ ^'Sofous, never commoniilace; free from 
to the “onnensin ; a stj-le that fitted itself naturally 
sentence band, witbont waste of words. Tbo last 

^eb'eie on tl.n n”/” , E, P''J’''oation was at tbo end of an 
nppearcrl #, ^ Jinglish Dictionary, in tbo issuo wbich 
‘ Thoroiiffb e'oatli: “Its motto might 
In rpmn-i:*' „ certainly his own motto, 
the wap services to tho Il.A.M.C. during 

tlio honour /af "w C.B.E. in 1919, nnd he received 

of Knighthood on January 1st, 1921. Other 


distinctions, 


receivofl tlm '^®.?®’^'’cd, fell thick upon him. In 1921 he 
J'"ociaf;„„ rT° *1 of tho British Aledical 

the highest honour which tho Association has 


Assoi 

to bestow, 
hom 


lOiart, a J^ocliani University lie received tho 

from Slmifiowlts D So the LL.D., and 

ho Woultf ccuioiistraiicea of some of his medical friends, 
close f'fo more easily and relax the 

tho contpnio which ho had always given to 

held tho ooai th® Journal. As long as he 

~-and inrTona Editor -ho insisted on doing his share 
routine worl- ®®’^® than his full share — of the hard 
absence waa’ during tho spells of illness when his 

handed At last, in December, 1927, ho 

Council witl, ’ which was accepted by tho 

association al E’Ertfclt regret that so long and close an 
»f this stTn for ^ ®*rd. Ho had talked 

to conmle?o 1 months, hut not unnaturally wished 

EdiW whl^l term of thirty years of service as 
m our issue nf t ’^^““hed in January last. As recorded 
editorial office was'on attendance at the 
that day Uo was nroa^ ^onuary 19th, and on tho evening of 
soltoagues at an^infonn portrait by his immediate 

On tbo news of V P'rrty. 

IS re ireinent becoming knon’u it was 


felt very generally that, as stated in a circular signed by 
a gioup of ropresentativo members of tlie profession, “ thia 
occasion sliould not pass without some recognition from tho 
profession ns a whole of his groat services to medical 
journalism and so to the science and practice of medicine.”. 
Stops wore accordingly taken to raise a testimonial fund, 
and a public announcement was made on Febrnaiy 2Sth. 
Uiifoi*tiniately for his friends and admirers, Dawson 
'Williams is beyond tlio reach of such witness to the affec- 
tion and esteem in whicli ho was held, hut ho lived long 
enough to bo awaro of what wms afoot, and to lot it he 
Itnown that ho for his part would wish that any testimonial 
should take the form of an endowment for tho fnrtheranco 
of research by way of scholarship or prize. It will he for 
tho Conunittco of tho Iftind, of wliich Sir StClair Thomson 
is Treasurer, to decide, in consultation with the subscribers, 
on tho prociso object to wdiich the money that may be 
collected had best be devoted in association with his name. 
Tho project has by no means ended with the death of our 
chief, .and wo liojie that in the form of a Dawson 'Vk’illiams 
Memorial Fund it will go forward to fruition a.s a worthy 
monument to ono who did incomparable work for British 
modicino. 

Some cigiitecn years ago Dawson Williams was injured 
in a motor car accident and severely shaken, as well as 
incurring a bad strain of tho wrist, and during the last 
docado he suffered more and more often and more severely 
from bronchitis, attended by a disquieting -inadequacy of 
tho heart’s action. After one of these attacks in 1924 ho 
wrote: “I wish I wasn’t so old; the world is veiy 
interesting.” Despite increased weakness of body, his 
interest in all that went on did not diminish, and just 
after his retirement was decided upon ho wrote to a 
friend : “ How I shall like to have no definite occupation 
1 do not know, but possibly better than I fear.” And in 
another letter to tbo same correspondent ho said that, as 
ho had always had “ ono foot in tho countiy,” he did not 
dread giving up his quarters in London, seeing that ho 
would still bo within easy reach of Town. Fortunately for 
him his newly acquired leisure had not had time to pall; 
ho had just finished ordering his private affairs when he 
was struck down while on tho way to take ti'ain to visit 
a friend in London. 

In person Dawson Williams was an impressive figure. 
'Well above six feet in height, he was of commanding 
presence, until of late years sickiiess and over-anxiety 
wasted his body and ho stooped .somewhat. But up to the 
last no ono could fail to notice liim even in a crowd. 
Strongly marked eyebrow’s and an aquiiino nose gave 
severity to his expression when ho was displeased, or dis- 
gusted with any display of meanness or bad faith; but 
tho frown swiftly melted into a peculiarly sweet smile when 
bis wrath was appeased, and this characteristic smile lit 
up his face at the sight of an old friend. Ho was by nature 
an aristocrat, and tho almost autocratic position he held 
suited his disposition. Democracy did not attract him, for 
ho believed, and could bring forward instances in support of 
his belief, that (in his own words) tho best results wore 
achieved by tho people acting under the direction and 
control of their natural leaders. 

It is not necessary for us to dwell further on tho many- 
sided character of our late Editor, because this is revealed 
in tho large number of appreciations, printed below, which 
have hoen sent to us by leading members of the profession. 
They depict the man and his work from widely different 
aspects, individual or official, and their effect taken as a 
whole is that of a composite portrait. To attempt to fit 
them into a forma! pattern would, we believe, bo a mistake, 
oven if exigencies of timo and space had not mado it im- 
practicable to do so. These tributes, therefore, follow ono 
another very much in tho order in which they seemed to 
group themselves after most of them had come tO'hand. Tho 
same noto of admiration and warm personal feeling runs 
throngh them all, and together they seem to us to bring 
before our readers’ eyes the man as ho was — a great and 
good man wise and far-seeing and true-hearted. Dawson 
Williams was loyal through and through— to his paper, to 
tho Association and tlie profession, and to everyone with 
whom he worked or who worked under him. The Dritish 
Medical Journal, and all that it stood for, was his life. 



March io, 1928] 


SIR DAWSON WIDDIAMS, M:.D. 


[ Thb Baiiisjf 
Ukdicai. Jouslnai. 


417 


recognition ijv tlio profossion of tho sterling clinracter of 
tho man liimself. Beneath a massive, rugged, and some- 
nhat brusquo exterior ho concealed a kindly . heart, and 
no one who had any sort of relations with' him could fail 
to appreciate that his opinions, however bluntly given. 
Mere always determined by the sole consideration of what, 
in his judgement, was right, and to tho honour and dignity 
of the profession of medicine. 

The work of an editor must always bo difficult, even when 
it is limited to the acceptance - or rejection of scientific 
communications for publication, but .when, in addition, it 
involves the consideration of matters that are termed 
“medical politics,’.’ the position is one calling for no 
common ability. The fact that Dawson Williams filled 
such a position for many years- with credit to himself and 
with honour to our profossion is perhaps tho most fitting 
tribute to his memory." 


Sir Thomas Barlow, Bt., K.C.V.O., F.It.S., consulting 
physician to University College Hospital and tho Hospital 
for Sick Children, writes; 

It is just forty-eight years since I first met Dawson 
Williams at University College Hospital. Ho wms then 
house-physician, and I had been recently appointed junior 
assistant physician with regular charge of out-patients and 
occasional charge of in-patients. AVilliams was a square- 
set vigorous, Yorkshireman," rather brusque in his manner, 
. not aggressively argumentative,- indeed a little reserved, 
but teuacious in his opinions, and able to give a good 
account -of himself. He knew his medicine and was keen 
-in every - department. I remember that he took tho gold 
medal in medicine, at, tho London 31. B. examination, and 
.ho was qualified for the gold medal at the 31. D. He was 
an invigorating and stimulating resident. He and Horsley 
were close friends. I recall that at that time he showed 
an immensely practical outlook; he saw the wood as well 
ns the trees. After he had completed his hospital resident 
posts he took some time to settle down to outside work, 
e aid- some pathological investigations for Dr. Wilson 
’ ox, going through some of Dr. Fox’s histological findings 
°*'+i 'j oii^n of tubercle and testing them by recent 
me lods. For a time he was drawn towards medical 
Y^'Ode; after a while he.was appointed assistant physician 
n the Last London Children’s Hospital, Shadwell, and I 
ca a good clinical, study by him on cases of glandular 
■ I ioter years he wrote a small manual 

TT ^ di^ases. Dawsou Williams had a ready pen. 

e lots good English and his views were stated in a fair 
at length he joined the staff 
f ^ • Nodical Journal it was soon obvious that he 

ound his true vocation, though I regretted that ho 
n'm. .i-o relinquish his hospital work. He was 

“y® . “Oenly interested in children’s diseases, and he had 
ue clinical enthusiasm. He maintained throughout his 
ong career enthusiasm for the scientific advance of medi- 
cine, and was, to my personal knowledge, anxious to 
eoognize, and emphasizo original work and to give credit 
ere credit was duo. Ho was loyal to his editorial cora- 
mi ee but as years went on he strove to widen and deepen 
medical education and to maintain general medical policy 
on a lofty and honourable plane in wdiich partisanship and 
personal ambition had no place. 


Sir HuirpHRY Bolleston, Bt., K.C.B., Begins Professor 
of Physio in the University of Cambridge, writes: 

The passing of a great personalitv, even though his life’s 
work has been done, cannot fail to'be a sad break with old 
associations, and the sudden death of Dawson Williams 
recalls his activities tlurty and more rears ago as phvsician 
to the East Lonclon Hospital for Children, Shadwdl, his 
book on Medical Discuses of Infancy and Childhood (1898), 
his early work on the “ Glandular fever of childhood ’’ 
(Lancet, 1897, 1, 160), and articles on that di.sease, measles, 
and rubella m the first edition of Allbutt’s System of 
Medicine (1897), efore he abandoned active practice in 
a branch of medicine in which ho ever rcTTiained keenly 
interested. A man of wide culture and many human 
Intercsts-as shown, among other wavs, bv his dubs- 
ho was exceptionally fitted by critical and ithcr faculties 


for editorial work; his success in a position rendered 
difficult by the changes in the constitution of the British 
3Iedical Association, and by many cross-currents of thought, 
is evidence, if it were needed, of the wisdom and extensive 
acquaintance with human nature, whereby .-he steadily 
maintained his ideals of medical journalism. Probably the 
influence he thus quietly exerted is most clearly shown by com- 
parison of the British Medical Journal as it was when he 
assumed the full editorship in 1898 with its present character. 
Tho power he gradually acquired of forming and directing 
aright medical opinion was very real, and the affectionate 
regard inspired by his upright character enabled him to 
obtain leading articles and signed reviews from prominent 
and busy members of the profession. He was remarkable 
for absolute freedom from egotism and self-seeking, for 
his statesmanlike outlook, intense patriotism and devotion 
to British 3Iedicine, generous help to young men trying to 
get their feet on the first rung of the professional ladder, 
and an open mind willing to give publicity to good work 
from unknown and unlikely quarters, even when departing 
from orthodox doctrines. The great position he established 
for medical journalism was slowly built up, and liis well- 
deserved honours were chiefly of recent date. In one of 
tho very few personal comments that I remember was the 
remark, in response to verbal eongratulation on his knight- 
hood in 1921, that it came too late to be of any use. 
He once admitted that he went into medicine from a desire 
to relieve the sufferings of others, and few men so sore let 
and hindered by family illness and personal disabilities 
have faced life more bravely and unselfishly. It is a satis- 
faction that before crossing the bar he must have realized 
tho profession’s appreciation, and that his labour had not 
been in vain. 

Sir Berhelry hloTuiHAN, Bt., K.C,3I.6., President of 
the Royal College of Surgeons of England, writes : 

Tho sudden death of Sir Dawson Williams will leave a 
gap in many lives, for few men had so great a gift of 
intellectual and emotional friendship for those privileged 
to know him well. 3Iy first contribution to the pages of 
the British Medical Journal was made at tho time he 
became Editor. It was not long before he asked me to 
revieiv works on surgery, and to write leading articles 
dealing with surgical problems. The help he gave me was 
incalculable; and 1 may truthfully claim that his forma- 
tive influence upon my literary methods was greater than 
that of any other man. His comments might be ironical 
or provocative, but his shrewd insight made him see the 
full drift of an argument, and able to demonstrate how It 
might be carried further or presented more cogently dr 
accejitably. A word of praise was never praise only : "it 
was encouragement which gave a new direction to one’s 
mind, and made one eager to do better. "Discussions 
on phrases or on the logical ' and lucid presentation 
of a thesis soon led to references to literature in 
general. We quickly realized a similarity of tasto. 
A devotion to the sonnets of Shakespeare, to hlacaiilay, 
and to Keats was acknowledged on our first encounter. 
It was always a joy to learn from him the books ho 
Jiad recently been reading, and to hear his fresh and 
illuminating comments or exposition. In literature, as in 
politics, .he held tenaciously to opinions; his clarity of 
judgement, intellectual fairness, and wide experience made 
cenversation with him a delight. 

His help was given ' in far larger matters than these. 
AVlien tho National Health insurance Bill was under dis- 
cussion its chief protagonist was not alwa3-s very friendly 
to tho medical profession and its ideals and desires. Tho 
wounding accusation that doctors in pressing their claims 
were “ bickering at tho bedside ’’ did not help to a better 
understanding or to easier discussions. It n'as at a time 
when tempers were roused and passions were ugly that 
I was asked to' see the politician most concerned. Before 
lunching with him I spent over an hour with Dawson 
Williams in sharp discussion on the many points then 
exciting controversy. The result of my verj- prolonged 
interview with tho protagonist of the bill was expressed 
a daj- or two later in the British Medical Journal and other 
newspapers, which recognized in him “ a changed attitude 


•418 March io, 1928] 


■giR D'A^S6N' ''WrE,t/liMS[ M:D, 


fSsr*' 

* LMeDICAX.J017CX1L 


to llio medical jii'ofcssion and afterwards matters moved 
more smoothly. Tho credit for this was due entirely to 
the sagacity of Dawson Williams. 

On other occasions, when ns a member of deputations I 
had to see the Home Secretary, tho Secretary of State for 
India, oi- other high Government officials, I never felt that 
I could he adequately prepared without a fidl discussion 
with Dawson l\hlliams. I am convinced that tho best 
friends of our profession are those members of it who hold 
high permanent position in Government offices; their 
opportunities for service to causes we uphold arc innumer- 
able .and are fully enjoyed. Among others who can help, 
the editors of our medical journals have perhaps the 
greatest power. We hardly realize, I think, how foitunato 
wo have boon in recent years. The influence of Dawson 
Williams on that aspect of medicine which touches public 
questions was of the highest importance; it was exerted 
through many channels, on various occasions, and by 
diverse methods. Ho was a staunch, loyal, upright, and 
most powerful friend of medicine, with the insight and 
imaginatWo grasp of a statesman. It was his own reti- 
cence .alcnc }rhich pro’cnicd the nwld fj'cm learning this. 
Tho cause of medicine has lost in him one of tho greatest 
advocates, and wisest and most powerful friends. To some 
' he seemed austere and aloof ; yet behind tho obvious 
barriers there was a generous and tender heart, full of 
understanding and sympathy, and craving for affection. 

Sir Robert Jones, Bt., K.B.E.,. Emeritus Pi-csident of 
tho British Orthopaedic Society of Great Britain, writes: 

When the heart is full of sorrow.it is not easy to paj’ 
tribute to tho memoi'y of tho dead. Dawson Williams 
was an ideal friend — affectionate, loyal, and full of the 
rare gift of understanding. His acute critic.al faculty 
never dwelt on any defects in those he loved. He was tho 
embodiment of chivalry and the soul of honour. Under a 
cloak sometimes austere and cynical he hid from the out- 
side world a beautiful, gentle, and kindly nature, and a 
mind of refinement and extreme delicacy. What a wise coun- 
sellor to those in trouble and doubt 1 His guidance seemed 
invariably to lead to the light. One always felt safe to 
proceed with any undertaking if it passed his censorship. 
If his help was asked for he gave it whole-heartedlj', and 
was prodigal of time and effort. He spoko his mind with 
no uncertain note on any question submitted to him. 
Friends expected nothing of him but tho truth; he was 
guileless as a child. Nobody will ever know the weight of 
responsibility which ho bore during the war. The Red 
Cross, the War Office, the B.A.M.C., and tho civilian 
medical service at home and abroad all sought his 
help. He was a veritable city of refuge. Often 
very frail in body, his mind never lost its keen 
edge and his sympathy always flowed freely. When 
ho fought, he always fought a straight fight; ho 
never took an unfair advantage nor did an unkind thing. 
His death is a great loss to medicine, and his memory will 
be a great inspiration. For a long time past his friends 
knew the sufferings of his mind and tho frailty of his 
body, but now that he has gone they realize that one of 
the sweetest chapters in their life history is closed for ev^cr. 
Dawson Williams has fulfilled his mission and his death 
ends a glorious life. 

Sir E. Shabpev-Schafer, F.B.S., Professor of Physiology 
in the University of Edinburgh, writes: 

Tho death of Dawson Williams ends for me an uninter- 
rupted friendship of more than half a century. I call him 
clearly to mind as I first knew him in the seventies, a 
student at University College, whore I was then assistant 
professor. Ho was one of a particidarly brilliant coterie, 
all of whom made good — none bettor than Williams. Later 
ho came back as a worker in my laboratory, and wo were 
near neighbours at Elstreo in his early married days, and 
were thus afforded opportunities for greater intimacy. 
1 saw less of him after he had developed into the dis- 
tinguished journalist whose capabilities are everywhere 
recognized. Few who knew him as a student would hav'e 
been prepared to predict that his development would be 
on those lines. But the character of his writings, distin- 
gttishod as tbpi~ aJn-ajw irere by clarity of description and. 


purity pf English, might well have indicated such ■ a 
destination. I have myself Jong been • in the habit of 
submitting doubtful points of literature and etymology to 
his judgement, which was rarely wrong. ' , 

AVhen I wrote to express tho gratification I had expe- 
rienced at seeing tho appreciative leading article in the 
Times on tho occasion of his retirement, I received a 
deprecatory reply exhibiting the modesty and self-efface- 
ment which were so habitual to him. “ The article in the 
Times was a huge surprise to me. I never dreamed that 
they would take any notice of my disappearance, and that 
they should have done it in such a handsome way is 
astonishing.” ' Tho rest of tho letter is equally character- 
istic, but too intimate for rejiroduetion. It will bo one of 
my most treasured possessions. 


Sir Charles Sherrington, O.M., G.B.E., Waynflote 
Professor of Physiology at Oxford and Past-President 
of the Royal Society, writes ; 

- In tho death- of Sir Dawson Williams I feel the loss 
of a friend. In tho nineties' of last century Dawson 
IViJJiams was a fj-cqnent attendant at the meetings of the 
Physiological Society, and it was through them that I came 
to know him. To know him was to like and respect him; 
and although in later years opportunity did not throw lis 
■together often, yet when we met it was upon a footing 
such as if our previous meeting had been but the week 
before. In Canada once we were constant travelling com- 
panions for several days together. Railway journeying was 
irksome to him, and he did not conceal his dislike of it; 
but he was none the less excellent company, I saw him very 
occasionally in Oxford. Ho seemed to retain his interest 
in physiology despite the call of a career which had side- 
tracked him from it. He certainly preserved his symipathy 
vvith physiologists right up to tho end. 

Sir John Bland-Suiton, Bt., Pas(>Prcsident of the Royal 
College of Surgeons of England, writes; 

friendship with Sir Dawson Williams began about . 
fortv years ago, when I was busy making almost daily 
visits to the prosectorium in the Zoological Gardens. At 
Ilmt date bo was regularly reporting the meetings of the 

Pathological SocietySor the IMtish Med> cal Journal. 

i found that rickets was a common disease of monkeys 
X rouuu and as Dawson Williams was 

f'”fvtete!’.^ted irtho’ diseases of children my rickety 
narticularly appealed to him. He arranged with 
Srl^r convenience in ^reporting and for accuracy, that 
T .’hould supply him with an abstract of my paper m 
Lfance' a^d^'g.'^e it to ^m^at tee meeting. J^h.s^^was^an 

excellent arrangement, guidance I mastered the 

odilorW ■■ we,” and acquired mlny other useful tricks 

inddontal hjs interest 

• Zh w 2 e 'ves broad and deep. Sick children have 
,n teen ucll. physicians and 

PZ' biE and little, who eome much in contact with 
surgeons, mg miu , iutimato association of 

ItZfTte dre'B ^spiSl Although; Williams 
tho wards Yu-different -orbits-oiio in joiimabsm 

and "D^olf tiavol « ^ uften m conjunction, 

uud tho oteer^r^'^Yfis ^altitude and his ambition, ho 
AMien be ■ joyab and gonial friend, and, as in the 

remaiiied the days, he published my essays, addresses, 

early Y.uf „ava ^tbem good places and good notices, 

or lectures, amt ga „-,.ii(.uIar cases to intorview the 
He even dllowed m taken .to do justice to 

printer, so J. i Biitterworth^s exquisite 

Hood advice when it uas souglit. Jiclit one; 

L.k ot "S’, 


.MAncn 10 , 19 : 8 ] 


BIR DA^VSON WiriMAMSi M.D. 


r TiiE BniTifK 
Mzdicai, Jotmyii. 


419 


boforo ho had tirao to reply! Williams was a keen 
iudRO of the value of an article, a review, or a report. 
Ho told mo that a weekly issue of the Journal contained 
Eufficicut “stuff” to make an octavo volume. A fow 
days aeo I was Inmting for an article in one of the early 
volumes of the Journal and compared it with the last 
half-yearly volume: it was like a Boole of Common Prayer 
compared to a Family Bible! It requires a god, like tlio 
Esn-ptiaii Toth, to hold' the balance fairly in these days. 
Dawson Williams did it; and ho loaves no small trust to 
his successor. 


" worn to a frazalo.” On one occasion he told me that if 
was no longer " copy ” he wanted, but that he did not 
know whore to turn for printing paper and for compositors. 

Tlio wclcomo task of giving some help in the furtherance 
of a testimonial, which now, alas 1 must change to a 
memorial, has afforded me the opportunity for reading 
many, appreciations of Dawson Williams. They have come 
from far and wddc — Macphail in IMontreal, from Cushing 
in the United States, from that hale and vigorous 
nonagenarian surgeon in Philadelphia W. W. Keen — and 
they are still arriving from further off. A few quotations 
will suffice. 


Sir Anrinin Keith, Jf.D., P.B.S., President of the 
British Association, writes : 

The editor of a great medical journal has many oppor- 
tunities of assisting in the advance of medicine ; there can 
have been few, if any, that Sir Dawson Williams failed 
to utilize during his thirty years, of office. His activities 
covered a period which was besot with editorial difficulties. 
The grorvth of medical knowledge was uniirccodontcd, tlio 
profession became more and more divided by specialization, 
the ancillary subjects became more numerous and more 
clamorous to bo heard, charlatanry in many guises sought 
for a place in legitimate practice, professional policy had 
to be shaped and reshaped, crises had to ho surinountcd. 
Sir Dawson Williams overcame all of these difficulties because 


he was at the core a scientific physician — one who believed 
that medicine could advance only by the accumulation of 
clearly ascertained fact and well-grounded inference. His 
sympathy was altogether with the inquirer and observer, 
the man of science — ^particularly tho young man of science 
— who had something new to say. But ho looked on 
medicine as a whole and realized that tho backbone of 
medicine was, tho practising profession — tho men and 
women who have the health of tho nation in their keeping. 
He gathered the best that hospital ward and scientific 
laboratory could givo him, and placed it at the disposal 
Ho sought for, and obtained, the best 
that the general practitioner could givo him. His wide 
interests in literature, history, science, and art were 
reflected in tho pages of this Journal. The sixty volumes 
wiich appeared under his editorial guidance mako an 
imposing arr.ay on our library shelves; in their pages is 
reflected tho histoiy of medicine of our time ; they are an 
sound judgement and untiring industry 
c a monument as any man might well bo proud of. 
I,,? suceeeded bettor than ho in masking activity 

j a s ow of leisure, but ho was less successful in covering 
a warm heart by a pretence of austerity. 


Bnvifi Thomson, M.D., Past-President of th 

tSn^ writes"^ Medicine and of tho Medical Society < 

many advantages of attending congi-esse; 
fm- Tnoi-’' , ye^ng men, is tho opportunity they affor 
It w'le nf® valuable, and enduring friendship! 

that bv International Congress in Home in 18* 

becanii/:ir.**°^- slight help as an interpreter, I fin 

his Dawson Williams. I there note 

imnresswl “ journalist, and w'as still moi 
■ and above I-nowli^go and interest in pediatrici 

which be TOO 1 1 ®''"*‘^ant appreciation and regard i 

press hJ? colleagues of the medic: 

course sn st,'’v embellishments of facile intei 

Journal Possessed by tho Editor-in-Chief of tli 

warsuie^ a — “ then serving. Ernest Hai 

Iod/a\Twen Z't If f 

Euronean ba ^^mracteristics W'hich tho well-rea 

caeSceri?; the Britis 

a certain W,^’+ honesty, downrightness, an 

TheL imnrfl « accepting and in refusin; 

years whicli b*”^ confirmed during tho thirty-foi 
m various r' elapsed. They re-presented themselv: 
graclfslv nnf Ho could accept a favor 

but without r decline to givo one with firmnes 

opiniM t tho war I formed tl 

on at home bn n ° many other people who had to can 
^onie, he was overworked and, in American parlanc 


“ I am delighted to assist in any way I can in recognizing 
Dawson Williams’s services to the medical profession and to 
science generally ” (Sir Hugh Anderson, Master of Cains 
College, Cambridge). “ I very gladly support an appeal for 
recognition of Dawson Williams’s public services to our pro- 
fession ” (Professor J. S. Haldane, O.vford). ■' I am conscions 
not only of tho great services Sir Dawson Williams rendered 
to the science and practice of Medicine, bnt also to the 
sympathy, help, and encouragement ho has always extended to 
a young anatomist ” (Professor J. S. Stopford, Manchester). 
“ One feels compelled to respect one of the sanest and rarest 
minds in modern medicine ” (Dr. J. S. Manson, Warrington). 
“ Ho is eminently worthy of becoming an immortal ” (Dr. 
Hnrry, Bournomoutb). ’’ I enclose a very small appreciation 
of my regard, and convey with it my great admiration for his 
splendid work, and to me his unfailing kindness and courtesy ” 
(Dr. Lonise Mcllroy). “ It will be a joy to farther and support 
an appeal so happily conceived and so well merited ” (Dr. 
R. M. Buchanan, Glasgow). " No officer of the B.M.A. is 
more worthy of esteem and recognition ” (Sir John Moore, 
Dublin). “ I trust the subscription list will show that the 
appreciation of his work is widespread ” (^Bilton Pollard). 
“ I regard it as a privilege to be allowed to join in. a demon- 
stration of appreciation and affection to Sir Dawson Williams, 
to whose services we, as doctors, owe so much ” (Sir Henry 
Gauvain). 

Similar appreciations aro repeated in hundreds of letters 
I have received. I will therefore finish with the exquisite 
sentence, so descriptive, in the letter of the Paris corre- 
spondent of the Journal. Dr. Gustav Monod, in sending 
his donation, writes : 

“ Quel bon souvenir je garderai de ce bon patron, tonjours 
accueillant derrifere ces lunettes rebarbatives." (What a happy 
remembrance I shall ever treasure of that good Editor-in-Chief, 
always with such a warm welcome behind his rather crabbed 
spectacles.) 

Botli our great medical weeklies have been fortunate in 
their early editors. The fiery Wakley and the scintillating 
Ernest Hart were the type of men to start a new adventure. 
Those who followed them have been the exactly necessary 
typo to consolidate, elevate, and make worthy of apprecia- 
tion those two great voices of our profession. Dawson 
Williams deserved well of his calling. 

Sir George Newman, K.C.B., M.D., Chief Medical Officer 
to tho Alinistiy of Health and the Board of Education,- 
writes : 

Wliat a man really is, in his own complex self ; what he 
is in his home and to his own people; and what he appears 
to be to outsido friends and acquaintances — ^these indeed may 
be three very different things. Some men have a person- 
ality which seems alniost transparent, whilst in others it is 
concealed more than revealed. Dawson Williams belonged 
to the latter. I have known him for thirty years — at first 
at a respectful distance, as a kindly and encouraging editor 
to a junior and inexperienced contributor; then, in later 
years, he became a friend and counsellor, almost a colleague. 
I never saw him in his editorial room, or in his home, but 
wo often met in Whitehall and other places, shared mutual 
fi'iendships with other men, and carried on long and 
intimate correspondences. Only the other day I received 
a beautiful letter, which I shall always treasure, looking 
backwards and forwards, and ending with the words, “ Few 
and obscure the daj’s that remain to me.” Now, in a 
twinkling, he has left us, and his large circle of friends 
all over the world, and tho whole medical profession in 
England, are much the poorer. 

The reason of our poverty is this. Here was a wise, 
competent, straightforward, and experienced man at the 
centre of things; one upon whom was bestowed, in excep- 
tional degree, ability, foresight, and fairmindedness. Ho 



420 MiBOH 10, 1928] 


SIR' toAWSON WILLIATSi's,- iff.!).' 



Trr Bnmw 

MtDlCAI. JorsKA 


J T 


liras austere, hesitant, perhaps a little reticent and taciturn. 
Inclined to aloofness, liable to ho a dark horse; yes, but he 
was also genial and peculiarly attractive — his eyes, 

“ An outdoor sign of all lho_ warmth within, 

Smiled with his lips — a smile beneath a cloud. 

But heaven had meant it for a sunny one." 

And sometimes it became a veiy morr}" one, btdibling 
and dispersive, dissipating all over the place, lighting up 
a handsome face, and dispelling an anxious look which 
betokened mental and physical suffering. Ho knew the deep 
waters, and that knowledge left its trace in his humility 
and gentleness. ■ He had met many men aud reflected on 
the correct meaning of their words and .signs, and this 
developed an inborn and delightful sense of humour. Yet 
it was U2)bringing and occasion which made him a humanist, 
gave him the chance of wielding a mighty influence, and 
left him in the end a single-minded man unusually devoted 
to duty. Wo can now see wliat he did with it all ; he 
subdued it to one task — the editorshiji of the Jotiriia!. It 
lias been suggested that Dawson Williams was knighted 
because of his services to the R.A.M.C. I doubt it. Public 
recognition may be, indeed, mysterious and unequal, but 
my interpretation would be that when he and Sir Squire 
Sprigge together received the accolade in 1921^ it was the 
official and royal sign of a])preciation of their long and 
inestimable services to current medical literature. Com- 
parisons are said to be invidious : but the histoi-y and con- 
tribution to medical science and humanity of the Lnticcf 
and the British ilXcdical Journal are unique among medical 
papers all through the world, and the profession in this 
country owes more than it declares to the dignity, sagacity, 
and power witli which they have been conducted. Their 
influence has been prodigious and immensely beneficial — an 
influence in the ci'eation and maintenance of the jirofession 
comiiarable to the grand effect upon it of the Renaissance in 
the Boventeonth century, to the brilliant work of the jiracti- 
tioners of the eighteenth, and to the Medical Acts and 
social evolution of the nineteenth. Dawson Williams's 
splendid innings of thirty years as Dditor has jilaj'od a 
significant part in a great constructive period. It is this 
nchievoment of his task which is surely the most impressive 
thing about him, 

I think Dawson Williams was a Humanist. Ho believed 
in a sv'nthetic philosophy of knowledge as well as its direct 
application to circumstance; he believed that the aiiplication 
of knowledge must have close regard to the human elements 
in evei-y situation. This dual view he .shared with the 
Humanists of the Renaissance, but be went further, because 
he lived in a time of social reform of which they had never 
dreamed. He had the broad common sense, the critical 
faculty, and the unifying vision belonging to the Humanist, 
which, with experience, gave him his supreme gift — 
judgement. Only last week there was a quotation in 
the British j\Icclical Jovrnal from Fitzjamcs Stejilien’s 
Liberty : 

“ The one talent which is most worth all other talents put 
together in all human affairs is the talent of judging right 
upon imperfect materials ... to see things as they are, 
without exaggeration or passion. . . . All really imporiunt 
matters aio decided, not by a process of argument worked out 
from adequate premisses to a necessary conclusion, but by 
■making a wise choice between several possible views," 


That is what he had — a iiowei- of judgement between pr.ac- 
ticabilitics. Though a philosopher in temperament, he did 
not write Jihilo.sopliy nor did he ]nirsuc a irbilosophic system. 
Ho took his liiohlcms vciy much as they came, but he 
tackled them philosoiiltically, though not always paticntly 
o'r serenely. He sought Reality. His religion was in that 
respect like the Persian Sufi: “ Show mo things as thev 
really are, and not only as they aiipear to ho.” He was 
also an observer of the trend and tendency of events. Ho 
recomtized what the Listorian revolution involved in prac- 
tice^ he held that a study of the disease.s of children wa.s 
hasii- ho foresaw the far-reaching change.s which would 
foUow the Kational Health Insurance Act and a development 
of the public medical services; he laboured for the refom 
of medical education, and particularly for the fnlfdment „f 
newssarv post-graduate facilities : above all. Ins bohef m 
metoarprogress in England found alike its rational basis 


and its confidenco in tlio medical practitioner. Hero 
five visions which he saiv and noted, for ho was not only 
observer, but a recorder. Thus it would seem that 
place of Dawson Williams in modern English mcdicim 
that of humanistic recorder. The last discussion we 1 
together was upon this theme of Doers and Recorders, 
described a certain medical contemporary as a Doer, wh 
ho himself was only a Recorder; one, ho said, makes histc 
the other writes it. Yet for the majority of men hist 
does not become inspiring or directive until it is record 
Dawson Williams knew that from such .record i 
advances spring, a spell of recording being followed b_i 
period of new doing. The doer is, of course, the nr 
creative, the oxiilorer, the thinker, the transmutoi 
Deoiiardo, Harvej', Hunter, Jenner, Pasteur, Lister — I 
the I'ecorder is the transmitter. As the art of jirii 
iiig was an essential implement of the Benaissain 
so great journalism is the active instrument of jirogri 
to-day. 

As Dawson Williams pursued this high road 
fcuiid his journey dusty. But he was a good ai 
coiirngeoits trarelfer, and kneir the dangers of the ira 
Highwaymen had short shrift — doctrinaires, quacks (qua 
fied or otherwise), humbugs, chatterboxes, pretendei 
advertiseix, and downright robbers all “ got it in t 
neck ” .sooner or later. Some he scourged with satire, 
the delight of pas.sers-by ; others were shot dead — to t 
satisfaction of all lioiie.st nicii. There were, again, nio 
subtle dangers which ho also know — the slojipy wori 
without meaning, the nn.sniiported generalization, the t' 
sanguine hope, the fully presented but unproved case, tl 
much announced panacea. Against tliesq allurcnieiits al 
ho had his own defences. When he travelled by dnyligl 
ho was accompanied by a retinue of iiiany devote 
friends, by whom ho was greatly beloved ; when li 
travelled 'in the darkness he found his way by the ligl 
of a lamp within. 


Sir Squinr. Spricoe, M.D., allows us to quote tli 
following pa.ssage from the memoir that appeared in lai 

wc-ok’s Lancet ; . 

“ Austerity and gentleness, ability, and fairness wei 
expressed in' his actions and- words exactly ns each wr 
demaiided. These qualities were- reflected throughout li 
conduct of the British Medical Jovrnal and also in h: 
dealincswith members of the medical profession, a coiiiitlc! 
number of whom iiiiist owe him a debt of gratitude fo 
counsel and assistance. Among such is the present Edito 
of the Ixincct, and ho and all associated with mm 111 tli 
conduct of this paper feel the death of Dawson illianis a 
a peisonal loss. Wo trust that similar feelings, widel 
evoked in the medical profession, will express themselvi 
in the Iiioveineiit .started just before Ins death to creat 
•1 tancible iiieiiiorial to him.” 


Sir D’Anev Power, K.B.E., consulting surgeon to SI 

Snrtliolomew’s Hosiiital, writes : 

To lose one’s early friends is the penalty of age, an 
he circle becomes smaller every day. On Febimary 14 t 
:ir Dawson Williams was taking part in the Himteria 
•estival at the Royal College of Surgeons. AA 0 were speak 
nf before dinner of those early days of struggle wine 
so pleasant in the Tomcmbraiice— days when he nii 
n assistant phvsiciaii and I an assistant .surgeon attache 
o hospitals for sick children; both active members e 
he Pathological Society, to which we brought spccmieii 
od where we had those active discussions winch are 11 
mger common at medical gatherinp. Both of us, ioa,^yea- 
ceping Oiir heads above water by devilling for Ernes 
kart a past master in the art of extracting copy fioi. 
hoL’he was accustomed to call his young men- ro,iv 
0 the form of articles or abstracts often demanded at. 
inTTiPnt’s notice, and criticized by a someivbat cmisti 
oimue At that time Dawson AATlliams was in the fairwa; 
? f Kvess as a consulting physician, and it was som, 
latto of wonder to us that he gave up practice a 
hose journalism as a profession. But rc.ip/rr 
ms primii .1 inter parrs as a medical editor; as a consiiltii , 
hvsieian he would only have been one amongst many. 


r loE Bnmsit 
Mevicai^ JOUCKIX. 


421 


March io, .1928] 


SIR DAIYSON WIRIiTAJIS, M.D. 

» < > ' / ■ I . f . . ■ 


Dr. HERnEiiT SrEN-cnn, Consulting Obstctrio riiysician 

to Dnivci-sitv Collogo Kospitnl, • 

Tho sudden death of Dawson Williams cainn ns n severe 
blow to his friends, who were hoping that ho would live 
for many years to enjoy his well-earned rest. Having had 
his intiniato friendship for thirty years I should like to 
add a few words to those of others; for T think ho was 
known infiinatclv to hut few, and his soiiiowhnt austere 
and troubled countenance and reserved iiiaiinor hid from 
tho niiiltitudo his real worth and nficctioii and his souse 
of humour. Ho had tho true north coiiiitryiiiaii’a desire 
for facts—" chicls that winna ding ” — and for honest state- 
ment. Ho wished everything to ho “ jniinock.” though 
I never heard him use the word. Though fluent with his 
pen, ho was sparing with his voice, except when iiidignntioii 
string him to very effcctivo speech. 

Dawson Williams had tho honour of the profession and 
the welfare of tho Association as his constant interests, 
■ and was always alert to bring new facts before tho pro- 
fession. I may mention that when Werlheim in 1905 wrote 
his great paper on extended ahdoinitial Iiystorcetomy for 
cancer Williams undertook to have tho Corinan MS. trans- 
lated and published in full iii.tlie .lotiniii/, and from that 
time tho operation heeamo widespread in Great Britain. 
Williams also took great interest in tho development of the 
radiation treatment of cancer, and, indeed, in all obstet- 
rical and gynaecological subjects. I have often been 
admitted to his editorial sanctum and watched tho rapid 
and effective wav' in which he conducted the business of tho 
Journal. Ho often spoko to me in terms of praise of his 
■subordinates — behind their backs — and from their attitude 
I could see that they, like all who knew him iiitiniatcly, 
understood, trusted, and admired their old chief. 

Since his retirement Dawson Williams was occupying 
himself in preparing an account of the forthcoming Harvey 
tercwfeiiaiy celebrations. A few weeks ago ho went down 
to Hempstead Church, in Essex, with some friends to 
examine tho Harvey nionunients. He lunched with those 
friends, who arranged to meet him again at dinner on 

, ? of his death. His' sudden death has saddened 

em, but they will retain a • fragrant incmoiy of him as 
a great journalist, a pleasant companion, and a dear friend. 

Harveian Librarian of the Royal 
College of Physicians of London, writes : 

v<..„.'°i work of Dawson Williams during tho manj’ 
nf tlfo u wtli such distinction the editorial chair 

Tiiiin.. il/crfical .Tournal will receive adequate recog- 

Pi-cnt ia" 1 * bmgraphy which appears this week. His 
crief Tni n* I?** P®vforin his duty no matter what tlio 
tbic laJ'i I'o'v much the attempt to accomplish 

with fnir ™i^ II?" during tho last five years of liis life, 
wnvt fn ^'stilth, no one will over know. Although his 
nrcvont'i- was ever his chief care, it Uid not 

Amnnir tl.™ taking jj interest in other matters. 
Collcn-n veneration for the Royal 

tn tlin I? 11 and ho probably valued his election 

Hownen*^ OHS np higher than any of ids other distinctions, 
ami c ®*'^®'^dant at tho meetings of tho Comitia, 

Here ^ ’"'ped the Comitia dinner in tho evening, 
cniovino- ®"‘'>'uundGd by his friends and 

member^ ^ 'uuiiy vears ho was .a 

position *hr Committeo at the College, and this 

CaW^ V,°T * ’T,."'*" with hooks, for which 

read anri ci^lc “ud deep lovo. Ho was a widely 

great moral' n oogoging and interesting. Of his 

honestv bU fi unnecess-ary to speak, for his 
of bea'rt wpro"'"if^^’ porseverance, and his kindliness 
cSS. * oil with whom he came into 

wTtli tbo Y' Y F.R.S., writes: 

bussed awav '"tT" ° Dawson Williams a great man has 
hmS aSl b;a 'vore mainly those of benevo- 

Hs medial out for helping the helpless, and in 

that pertained +0 special sympathies embraced all 

Ids studierwerli'd''*'f = 

and what ho did acquaintance with hooks gre.at, 

"hat he did not immediately know he could at least 


toll whero to find. Most men readily accept tbe praise 
givon theiUj and regard tlio sentence in their fav'our as a 
sign of acumen; but blandishments were entirely wasted iu 
Dawson AVilliams*s office and, bej'ond a twinkle, evoked no 
response. His litoraiy judgement was severe, but, having 
decided to accept a paper, I have known him take infinite 
pains to put the writer’s meaning into understandable 
Hnglish. As a writer Dawson 'Williams had the perspicacity 
and elegance of tho historian ; his precepts were judicious, 
often now, and always happil}^ expressed. 

Dawson Williams was really interested in science; often 
ho would sit through a meeting of tho Physiological or 
other scioiitific Society and afterwards discuss the validity 
of tho ovidoiico of some young man wlio had expressed a 
now idea. I know him very early in my career; lie was 
always open to now ideas and never received suggestions 
from liis juniors with derision or contempt. His sympathy 
lio extended to all, but to Iiold his friendship was a prize; 

110 soomed intuitively to read thoughts and difficulties, whilst 
his knowledge, liot only of literature, hut of men and 
matters, was of tho widest. As his years advanced he 
advanced in reputation, but his mind, always richly 
furnished and adorned, and arranged in the most regular 
order, seemed to become even more alert; in his latter years 
oftentimes ho was distressed at making decisious likely to 
caiiso pain. 

Socially, Dawson MTlliams was delightful; his active and 
inquiring mind showed itself in the vigour of his colloquial 
wit. Nothing ho enjoyed more than to sit after lunch in 
tho Garrick with two or three literary friends, with a good 
glass of wino and a cigarette — for Dawson lYilliams, like 
most of tho great in literaturo, knew how to get tho most 
and best out of lifo. Ho was a man of great liberality and 
dignity of sentiment, with little ambition and no vanity. 
He is gone — this great literary critic, this kindest and most 
lovahio of men, whoso goal in life has been to help those 

111 pain or difficulty. 

Sir C. J. M.VRTrx, C.M.G., F.R.S., Director of the Lister 
Institiito of Preventive Medicine, writes: 

May I add my note to the chorus of appreciation of our 
friend Dawson 'Williams? No one, unless he has served 
on tho Council and sonio of its numerous committees, can 
appreciate what wo owe to Dawson "Williams for his skilful 
conduct of our Journal and the sanity of his influence 
upon the policy of the Association. Ho never failed to 
realize that tho British Jledical Association was sonietliiiig 
greater than a professional coi’poration to safeguard the 
interests of its meinhers, and that its equally imjiortaiit 
function was to encourage medical discovery and spread 
knowledge aniong.st its members. 

I have referred to his conduct of the Journal as skilful. 
Tliat adjective is inadequate to describe his editorship. 
Skilful handling was essential, hut Dawson Williams 
brought greatness of purpose to this, his life’s work. He 
laiew that if the 'B.M.J. was to maintain its reputation as 
a leading organ of medical thought it must he, not merely 
a professional newspaper, hut reflect in its pages the 
progress of medic.al knowledge and scientific discovery. 
Dawson Williams, who was equally interested in the science 
of medicine and its application, and equally capable of 
comprehending both, was especially qualified to make the 
adjustment between science and practice, and eminently 
successful in keeping tlie ship on an even keel. The 
editorial chair of the B.M.J. is, in some resjiects, a 
peculiarly difficult one. All editors have their troubles 
with their proprietors, and in his case there were 33,000 
of them ! It is impossible to please everybody, and if the 
scientific side of medicine has been less emiiliasized than he 
and some of ns desired, that must not be attributed entirely 
to the appetite of the members of the Association for 
records of cases and accounts of successful treatments. 
Original scientific papers are “ bad copy,” as they generally 
describe but bricks in an edifice, and only interest the 
builder. Many are unnecessarily tiresome. I remember on 
one occasion, when urging the devotion of more space to 
dealing with the growing edge of those sciences on which 
the practice of medicine is based, he replied, If you 
would write intelligibly I would publish,” and the remark 
was not intended, I believe, to apply to myself exclusively. 



422 Maeoh 10, 1928] 


SIR DAWSON WILLIAMS, M.D.' 


[ Tkr Barrrai 
XfcnrcjLL Jov&Ktt 


As its Director, I desire to add a few words of grateful 
recognition of -Dawson Williams’s service to tlio Lister 
Institute. By tlio constitution of the Institute, the B.M.A. 
lias a representative on its Council, and although the Council 
has no longer executive rosponsibilitie.s, it has some impor- 
tant duties. For many years the Association was i-epre- 
sentod by Ernest. Hart, who was one of the founders of 
the Institute. Subsequently, when Dawson Williams was 
nominated, the staff were more than pleased, for, reraem- 
bering his keen interest in the work of Pasteur and Lister, 
and the contrihution ho made to the spread of knowledge 
of Pasteur's work hy translating his more impoitant papens, 
they wore sure of his understanding and S3'mpathy. For 
eighteen j-ears Dawson Williams manifested a helpful 
interest in the work of the Lister Institute, and was a 
constant attendant at its meetings. On other occasions, 
too, his advice was sought and ungrudgingly given. His 
fellow councillors will deplore the absence of a colleague on 
whose wisdom they relied, and the staff of the Institute, one 
and all, know that they have lost a very good friend. 

Dr. C. 0. Hawthokne, Chairman of the Representative 
Body of the British Medical Association and Acting Chair- 
man of Council, writes: 

Those of us who for a number of years have had close 
personal and official relations with Sir Dawson Williams 
have difficulty' at this moment in expressing any thought 
other than the sense of loss which has so suddenly fallen 
on us. But a few weeks ago we said regretfully a formal 
farewell to an editor and a colleague, but we said it with 
the full hope that for him time had many restful hours 
in store, and for ourselves opportunities for renewals of 
friendship and of counsel. And now, as it were in a 
moment, all these pleasing anticipations close in darkness 
and, in some sense, in dismay; for, behind his apparent 
severity and aloofness, Dawson Williams had for those who 
seiwed with him a large capacity for comradeship, and 
qualities which stirred and held affection ; not readily 
known perhaps, but well worth knowing, and genuine and 
real and sincere. One might differ from him in opinion, 
but no one questioned his integrity, and these personal 
qualities gave him the secure position which he held in the 
esteem and regard of his colleagues. IVitii his resignation 
of the editorial chair there was a not unnatural conclusion 
that his work was done, but many of us who have been 
close to his stores of knowledge and experience and goodwill 
wore counting with confidence on not a few helpful associa- 
tions in the future. The editorship indeed had ceased, 
hut not, we knew well, the friendship and the readiness 
for service. Now fate has put its seal on both chapters, 
and left us but memories and regrets. 

In this brief note of appreciation I must recall general 
impressions rather than particular incidents. Tliese come 
from associations, enterprises, and responsibilities shared 
in a common, but not an equal, partnership ; for with all 
his knowledge and experience Williams was always ready, 
and indeed anxious, prior to decision and action, to hear 
the other view. He was, too, a good listener, and patient 
of the other view — at least to a point — and he would take it 
from anyone so long as arguments could he quoted in its 
support. But beyond this moment the caller, apparently 
from some mysterious change in the atmosphere, became 
aware that the editorial time was valuable, and that the 
last word had been said. In his own department he refused 
to be hurried in judgement, but he was not afraid of 
decision, and he preached and practised the doctrine of 
editorial responsibility in no uncertain fashion. Not un- 
naturally he took a high view of the function of the 'British 
medical Journal in the scheme of the Association and, 
indeed, in the work of the profession generally, and against 
anythino- which tended to lessen this claim lie was prepared 
to'offer°a strenuous resistance. Here, he would urge, is 
post-n-raduation training brought to the practitioner’s door. 
Nor were his sympathies by any means restricted to the 
editorial chair. On the contrary, he was alert to all the 
interests and enterprises of the Association, and was keen 
to hold these to the highest standards. In council he was 
helpful with information and a certain spaciousness of 
judgement, and though cautious, he would press the bold 
view where his convictions were strong. Perhaps he accepted 


rather grimly an adverse decision, hut he had a high sense^ 
of loyalty- to tlie Association, and happily he cultivated a 
generous measure of humour which leant rather to the 
ironic side. To he associated with him in the work of 
a great organization was to learn with wliat abundance of 
knowledge and .experience liis mind , was equipped, to grow 
an . increasing regard for his high sense of personal and 
professional rectitude, and gradually to recognize that a 
great editor was none the less a man and a brother. ' 


Mr. N. Bisnop Haiim.\n, F.B,C.S., Ticasiwer of the 
British Medical Association, writes: 

To die in harness, time-worn,' tired, hut still striving, 
is given to fow of us. But this has been the lot of 
Dawson IVilliams. The days since his retirement are too 
few to count the interval. The pages of the Journal that 
ho has penned are still- alive; liis words spoken at tho 
committee meeting still ring in oiir eare; and his Last 
letter, written only a few daya ago, still shows that his 
mind turned on new work even in retirement. 

Dawson Williams left his impress upon oveiyone who 
camo into contact with him. There is fresh in my memory 
the first time I met him in person. The “ Editor ” I had 
heard of; it was Dawson Williams I met, and felt. I had 
gone to put a piece of information before an impersonal 
editor: I met a person — a man tall of stature, keen-eyed, 
and-slow of speech. He -took me into an adjoining room, 
introduced me to his shorthand writer with the words: 

“ This member will dictate an article to you.” I, Mt hke 
a small hoy at school before a great, compelling, and all- 
pervasive headmaster. Dawson Williams was like 
he made one feel his mastery of things. Ho combined 
witliin liimself the playful attitude of the fathor of the 
family shrewdness of tho headmaster. Ail ins 

contributors felt they were members of his family, eons 
who could trust his direction, no matter how much tboj 
might bo inclined to rebel against bis mastership. Laoh 
of us felt his breadth and weight of knowledge, sometimes 
with surprise that ho hod his eye upon our 
of medical work. But he was kindness personified. Our 
fflittering gems that we spread before his shrewd eyes were 
annraised with gentleness and fairness, and if their lustre 
sfemed to dim somewhat in our own eyes after his 

rbanee in the setting, at least we saw his 
f^^r and Si Die Ldness® of his dealing. But 
fairness, filled a far larger part than that of a 

Dawson Williams fi led t ye^ars, when, as Treasurer 

great eamrnearer the focus of medical 

of the Associ , to the Association, the 

“^rSs coinsellLhip could be realized, and with 
a better appreciation of the greatm^s of the 
that came ^Pfovotion to duty was manifest. No 

man. His smg J -„bicct for consideration was the 

exposition of tho P negotiation, or tho 

,t related to ^ the fruit of our complex 

solution of one or the other h.s attention 

cvilizatioi -foi edl judgement of worth. He did not 
was 1 J g ^ n-eakened physical strength 

^“■'rimve ixeused'^some relaxation in any man. With 
I ^ ^ jjpfieg or pains, 

him wiU-pov T)awson Williams leaves a sense of groat 

-“r 

memory of the man remains, unforgettable. 

one of the ^ ^ ; many respects. I" Ins 

half-century. He "fl.-foi tJnartial always willing to 

t|hi:^^^ T- 

when his outer shell o ^ -scpntiallv sound senso 

trated there was found a jmrso ...t jn 'his profound 
and a wise counsellor. He was great iu Jus P 


JlARCH 10, 192S] 


SIB PAWSON WiririlAMS, M.P. 


[ Tins Citmra 

ilZDlCXV JOCBKU 


423 


knowled-ro of tho racciicnl litcriitiiro of all nations. Ho 
was great ns a medical jonrn.'ili.st-v-in iny opinion ho was 
the greatest medical journalist of his time. It was in this 
role that ho found his lifo work— tho control and develop- 
ment of tho British Medical Journal. Do gave up his lifo to 
this work and reaped his reward in seeing tho Journal 
attain its present proud position of tho loading medical 
journal in tho world. Ho was porlmirs greatest in tho 
infliieuco ho brought to bear in furthering tho highest 
interests of tho medical profession and of tho British 
lUedical Association. I think very few, even of tho 
moinbcrs of tho B.5I.A., aro nwaro of tho influcnco Dawson 
IVilliams, by his own personality and through tho J oumal, 
exerted in tho development of tho policy of tho Associa- 
tion, particularly in keeping it on sound and dignified lines. 
His influence in all things relating to tho profession w.as 
ahv!)ys on elevated lines; ho had an intense sonso of tho 
dignity of medicine as a profession. 

It is ono of my proudest memories that for twenty-fivo 
years I was 'more or less closely associated with Dawson 
IVilliams in my many official positions in tho British 
Medical Association, and, in later years particularly, 
as Chairman of tho Journal Committee. As a personal 
note may I s.ay that with tho passing of Dawson 
llilliams has p.assed out of mj* lifo tho ono among all 
men for whom I had tho highest respect and esteem. Ho 
has deserved well of tho profession ho loved and adorned. 


BoLAJt, SI.D., LL.D., Chairman of Council 
of the British Medical Association, 1920-27, writes : 

A man must have certain qualities succossfull3' to conduct 
journal, and yet others if his task bo tho 
e 1 mg “^ journal of news and of policy. In rare degreo 
Bawson Williams combined scientific insight and wide 
journalistic intuition and that 
men and alfairs which needs must go 
>>''>'1 » "'Wc field of 
unpvnonfn'i ■within tho profession, and in many 

esnre^sinii , outsido of it. In argument and 

wWIst few m “any styles and slave to none, 

all uerfppf '°°° attained more nearly “ tho chief of 
nnp I 1 ='"'1 brief ' 

to know”* Williams was not an easy man 

but tbn irnrm” ^ i ® maiitlo of rcsorvo, yet it was 
quick Lf rf This cast off, one found a 

of couuspI '®^.®P"'ii'i generously helpful to all seekers 
pationth ^""‘ier to the inexperienced, im- 

triciou tho mere- 
Pnjust. ’ All fiercely in face of things wrong or 

to serve hfo ’“®''Pgent tendencies ho ruthlessly schooled 
■Journal. And°’tho^”h of his beloved 

"on*’'?- J'*'’ '““P is shattered 
Alio light in the dust lies dead,” 

faction ”to”fpo ideals of service — to heed no 

““t in right seeking, to spare not self. 

the BritS^Me'd^al^^A^'^’’ President when 

writes; * Association met in Livorpiool in 1912, 

come as ^prpn^c?^**i Dawson Williams must have 

serious conditmr, .to those who wore not aware of tho 
associates the health; j-et even to his intimate 

flPito nrexnectef ’""^t have been 

■aonial which wo’ anticipated that tlio testi- 

long and vahioKlo *^®°o.otly launched in recognition of his 
hava to be turned to the medical profession would 

downs of life ° “*omorial ; such are the ups and 

forth. It is trim knows what a day may bring 

had just retired from\liP* "^o>’h ” was done; he 

an exacting offirp arduous and onerous duties of 

he had so lone nnU 1 ■?,®PhiO‘i'ts of tho Association which 
the British Medical A f livery member of 

'ieao, good and f aithf urj“5 '°“ truthfully s.ay, » Well 
of thy lord” - bur +1 ” foarant; enter thou into the joy 
, out there is no one who will not shed a tear 


over his departure ; everyone will miss his genial presence, 
and regret that ho has not had an opportunity of viewing 
lifo from a disinterested standpoint. I was on tho Council 
of tlio Association ivlicn he succeeded Ernest Hart, and 
consequently I have known him during tho whole of his 
editorial career. His urbanity endeared him to everyone, 
and ho nlwaj-s retained his popularit3', even with those 
who did not approve of the frequent changes of the policy 
of tho Association. , Death has taken him from us, but in 
tho memory of everyone who know him he wdll long live. 
In lifo ho was a burning fire which kindled many a hearth, 
tho bright offulgcnco of which will not soon be allowed to 
dio out. 

Dr. AurnED Cox, O.B.E., Medical Secretary of the 
British Alodical Association, writes: 

I find it nearly as difficult to write about Dawson W'^ilHams 
as it was for mo to get to know him. I have been in 
contact with him for thirt3' years, and for- the last twent3’ 
have been his colleague; but for a long time I thought 
him unapproacliablo and difficile-, one did not seem to get 
much nearer to him on tho occasions on which we met, 
and it seemed to bo necessary every time to reopen the path 
of approach. It is only in the last eight or ten years that 
I have felt wo wore on easy and companionable terms. 
At first I found him formidable and austere, and (I tliouglit) 
not very’ sympathetic to my special anxieties and diffi- 
culties. This was particularly during the stormy times 
of tlio Insurance Act, when there was so much division 
of opinion inside the Association. I recognized, like every- 
body who came in contact with him, his sound judgement, 
his honesty of purpose, and his unshakable integrity as 
a man and a journalist; but I did not make sufficient 
allowance for tho fact that his duty as an editor compelled 
him to look at things and write about things from all 
angles. But I learnt much from him, and alwa3's admired 
him immensely, and in time his devotion to the Association, 
his gifts of intellect, a certain mellowing of demeanour, 
and the knowledge ono got (but never from him) of his 
great domestic anxieties, broke down the barriers between 
us, and I learnt to love as well as to admire him. He set 
a standard of work- for all of his colleagues which we 
humbly, however unsu(i.essfully, try to attain, and I 
think he was pleased when, on behalf of the rest of us, 
I had the privilege of s.a3’ing so at a little dinner we gave 
him when ho retired. Ho hated an3-thing like gush, but 
on that occasion I believe we did get him to feel our 
absolute sincerity when we told him how much we admired 
him and his w-ork, and how proud wo should feel if, when 
our turn came, tho Association could as truthfull3- and as 
fervently 503-, “ M^ell done, good and faithful servant.” 

In tho various appreciations of our old friend I have 
not seen any reference to his gifts as a speaker. ■ Among 
tho many things ho disliked was having to make a speech 
in public, and ho would do a good deal to avoid it; but 
I have known few men more effective when he did rise to 
speak. His choice of words was, of course, admirable, 
and before bis health failed his manner was eqiiall3- good. 

The Association has lost a great Editor, and we of tho 
staff a colleague of whom we were vei'y proud. Ma3- ho 
rest in peace. 

Mr. W, E. Hexipson, who is retiring at tho end of this 
month from the position of Solicitor to tho British Medical 
Association after thirty 3ears, writes : 

It was a real shock and grief to mo to read of Sir 
Dawson Williams’s death. I have before me a letter from 
him, on which the ink is scarcely dry, in which he writes 
of ** our long collaboration in the work of the B.M.A. 
We have witnessed, and each in our way shared in, its 
development.” My close relationship with him extended 
well over thirty long years without a break on either side. 
I can therefore speak with appreciative knowledge of liis 
sterling qualities as a man, and also as a light in the world 
of literature. To have enjoyed his confidence — which he 
was slow’ to give — ^was a privilege of which one may well 
feel proud, and the lighter side of his character was only 
revealed to those w’ho were thus accepted by him^ 



424 March io, 1928] 


SIR DAWSON WILLIAMS, M.D. 


r TirEBomw 

L MtDICAL JorCNAb 


Sir Anthont Bowmy, Bt., K.C.B., K.C.V.O., Past 
President of the Royal College of Surgeons of England, 
rvlio was Advisory Consulting Surgeon to H.M. Forces 
in Franco througliout tlie war, writes : 

JIaj’ I send a very few lines to I'ccall to mind the very 
great service rendered by Dawson "Williams to tlio'mcdical 
service of the Army and the Navy? Whoever might have 
been responsible for the mobilization of the fighting forces of 
tho Crown, there can be no doubt that the mobilization of 
the medical profession was tho work of Dawson Williams. 
To further this end he laboured without ceasing, and liis 
thorough knowledge of tho members of his profession, and 
his sj'inpathy and common sense, enabled him to do work 
which was of the greatest seiwice to the soldiers and sailors 
of Great Britain. 

Licut.-General Sir Aufred Keogh, G.C.B., G.C.V.O., 
who was Director-General, A.M.S., in 1904-10, and again in 
1914-18, writes: 

May I be permitted to associate myself with the many 
who will have heard of the death of Sir Dawson AVilliams 
with the most profound regret? I have the more reason 
for this regret in that I owed to him at times of great 
difficulty much wise counsel and- an abundant sympathy. 
He was ever gentle in his criticisms and a trustworthy 
guide at all times, ever rcadj' when I had recourse to liim, 
which was often, to smoothc the numerous difficulties which 
frequently arose. I owe to his memory a profound respeetj 
and I sorrow to think he is no longer with us. 

Lieut .-Colonel D. G. Cuawford, I.M.S. (retired), the 
historian of the Indian Medical Service, writes: 

The British Medical Association has always done much 
for the public medical sendees, the Navy, the R.A.M.C., 
and the I.M.S. As regards the last, many of those who 
have spent their lives in the Indian army have always 
realized what a debt of gratitude they owe to the Asso- 
ciation, and in particular to the late Editor. Some of 
them, like Kenneth Macleod and Walter Buchanan, have 
preceded him across the great divide. One of those who 
remain may perhaps be permitted to ex[)ress hero that 
gratitude to one who has just completed a life’s work — 
a long and fidl life’s work, well and thoroughly done; one 
of whojn it may truly bo said Felix opporhinitate mortis. 


Dr. F. E. FnEJiAKinE, F.R.C.P., F.R.C.S., M.P., mutes: 

As Chairman of the Parliamentary Medical Committee ,| 
may I add a tribute of respect for Sir Dawson 'Williams 
on the part of my colleagues and myself? During tho last 
nine years he developed tho parliamentary side of the 
Joxirnnl with great success. The “ Medical Notes in 
Parliament ” — reprints of which are sent weekly to every 
medical member of Parliament — have become more and ■ 
more a sure and useful record of medical events and 
opinion at St. Stephen’s. The editorial work lias always 
exqiressc'd a wise and sober judgement, wide sympathies, 
and a bold imagination. It was but a short time ago that 
he urged me in jierson and by letter to explore further 
'a certain svstem of preventive treatment which had been* 
rejected by a Government department on what seemed to ' 
him insiiffieient grounds. On each question of medical 
intere.^t as it drifted across the public screen, he was , 
rcadv to hear opinions from every quarter; but was not 
slow" to focus them into place and to draw tho proper 
conclusion, leading to effective action. When the interests 
of the medical profession might seem at first sight to clash 
with those of the public. Sir Dawson Williams seiwed both 
with tiie mo.rt convinced loyalty; the loss to the profession 
bv his death is so much - the greater. We mourn the 
passing indeed of a great leader as well as a personal 

friend. 


Dr David NicolsoS, C.B., LL.D., formerly Lord 
"han’cellov’s Visitor iu Lunacy, wntes : 

i " hall be glad if I am permitted to offer my testimony 
o the high regard in which, with many otlievs I hold the 
nemorv of Sir Dawson Williams with respect to h.s work 
md l.-is personality. I always found him jileasant and 
igrce.alile and rc.ailv to oblige, and he stood the pressure 
' * work with wonderful equanimity. 


Dr. J. S. Manson (Warrington) writes: 

As a general practitioner who has occupied from time 
to time .some of the .TournaVs space, let mo pay tribute 
to the patience of the late Sir Dawson Williams and to 
tho kindly help which ho gave to an inexperienced writer. 
I have no doubt that similar help has been given to many 
others, and it would bo a pity if at this time no mention 
were made of this fine trait in his character. He also was 
concerned ■ greatly ■ with tho continued education of the 
general praetitionof, and was proud of his work in im- 
proving the’ Libraiy to help forward that aim. I have e 
letter from him, '• dated December 23rd last, where he 
mentions his ;ihtcrest "in the improvement of the Library 
of the - Associatioiij and expresses satisfaction with its 
present success; It is said that without vision the people 
perish. Sir Da’wsbii "strove to give vision to the ordinary 
practitioner, who 'in his tens of thousands forms the main 
body of tho profession. 


. Our correspondent in France, Gustave Moxod, M.D. 
Paris,' M.R.C.'P .Bond., writes: 

. Dear Sir .'Dawson AVilliams! . Such a loss will be deeply 
felt all over the world, and 'first of all iii France, when 
his influence has lieen far ' beyond rvliat he would evei 
'admit. It was difficult to" find in the Journal the iiaiiu 
of the Editoi-; but -every page w.ab: ihspired by bis gnrit 
and his friends nover hesitated tp recognize la griim rtti 
Lion ” in tho editorial columns. I am told by .a 1 am 
medical librarian that the British Ucdical Journal collection 
is in constant demand by his readers, and no doubt tuc 
indomitable effort of Sir Dawson has gonfe very far tc 
bring British Medicine to its high 

ledgement. He leaves last grateful 

•Xrin'"hfna-"e of .Frencll' medical journalism," to him 

auieu. 111 in Imn Pafron. 


AVe are glad to print the following note from an oW am 
fled contHbntoi' if only because it brings out a side 0 
r Dawson -AVilliams which meant very, much to his 

Ileagnos in the Effitorial „ ]„y 

““'’hst " mSi’eLeoiis ■' copy- ” came under the 
Editor’s nencil for a space of twenty years. In the 
» rtvlo he was an austere man, not the easiest of 
attcr of sty le 1 annoyed him 

He was ntolmant of “ fine writing ’’-writing 
cessivcly . nas ^.,^j^rly and 

’;”^:"conv Tldet^^t was part.' of his general im- 
secntiiely CO y hi rimeal. On reading 

’Inv ” aHev it had loft 'the editorial mill, 1 offer 

sentences had 


” after it bad lott tne euibui.u* — , - - -- 
rmy .copy , . ^ many smooth sentences bad 

occasion to ^ that 'some pictiiresqne 

f nl lustois bad vanished- altogether; but I w.as 
lies and ° Editor’s touch, if it had not 

nd to admit m writim' On the other hand, 

rned, fanerfor unusual words, and liked 

Editor had lathei * ruio. t ,vas rather amazcd'tc 

• the-terse'cingramma m accepted 

some hold r ent ^^y^ exigcnciei 

S' 

s?- si““= » 

astatmg. ^ ^101 ^ ted .1 

art, ; spu gbavp criticism stung, hut it was sa u ai 

’p.y» s'/riS 

ircoMd pardon, H was preton 
it to 

lized how vast a every .accuracy; hu 

microscopic criticis vexation at the necessity o 

Editor -concealed his own vcxati tl, ought Imi 

itiiig errata, upheld his contn evidently 

:ho Lht, and did not ‘‘rub it m if h^ 



Mauch 10 , -JgsS] 


OBITUARY. 


[ TirzURinsH 
IiteDiCAx. 


425 


niclliocl Sir Dawson B'illinms oxorcised a stimiilatiiif; inflii- 
cnco ami wlio will ever hold him, ns a master of their 
craft, in gr.atoful and admiring recollection. 


Ftixratt AXi) Mr.AioniAT, Srnvicr. 

TIio funeral was at Littlo Marlow Cometerr near Sir 
Dawson IVilliams’s country homo at M'cll End, Dourno 
End-on-Thames, on tho afternoon of Frid.ny, Jfarch 2nd. 
TIioso who stood at-tlio graveside with relatives and family 
friends and ncighboms inchulod tho Treasurer of tho 
British Mediciil Association and Jfrs. Bishop Harman, Air. 
IV. JfcAd.mi Ecclcs (Chairman of tho Hospitals Com- 
mittee); Sir Sqniro Spriggo (Editor of tho Lancet) and Bady 
Sprigge, Air. E. Muirlioad Litilo,' Dr. .md Alr.s. Henry 
Devine; Dr. Alfred Cox (Jlcdical , Secretary), Dr. N. G. 
Homer (Editor), and Air. L. Fcrris-Srolt (Financial Secre- 
tary and Business Afanngcr) ; with Afr. Stephen Aforrey 
(Head Clerk of tho Editorial Dcpnrt.mcnt) and Air. Trevor 
Lapworth (Head Printer), who rvero closely associated 
with onr lato Editor in his work, ono for forty-six and tho 
other for forty-four years. 


\ memorial scrvico was held on Afonday afternoon, 
Afarcli Stli, at St. P.ancras parish church, close to tho 
headquarters of tho British Afcelical Association. It w.as 
attended hy a largo gathering, which included many dis- 
tingnished and representativo memhers of tho medical 
profession, somo of whom wero present in an ofHciat 
capacity. 

The President of the British Afcdical Association (Sir Hobert 
Philip), with tho principal ofiicers and ofTicials, and many 
members of Council attended; other members of Council sent 
exjpress'ions of regret for their absence. A group of ropresenta- 
1^050 Bradford, came from University 
College, ^ndon, and University College Hospital Afedical 
School. The Royal Society of Afedicine, tho Medical Society 
of I^ndon, and other protcssion.al bodies joined in tbc 
ri ute through their presidents or other ofTiccrs. From the 
ea quarters of the Association, over which tho flag flew .at 
during the day, came practically tho whole of the 
a , rom the he.ids of the departments down to tho most 
Pfc-cmincntly ,a gathering of tho Into 
or,! ®en .and women avho had served with him 

tn more than a generation, and 

jtin.i / ®‘^aasion brought an added sadness because so 
their cllief'* saparafed it from the official parting from 

ducted Sf.,P.ancras (Prebendary E. L. Afotcalfc) con- 

fine slmnV ■. ™ service, which was marked throughout by a 
desired ' commemorated would have 

familiar ri, ‘"'ddress, no laudatory oration, only tho 

the anth™'^"^^ music — the latter including 

and the Fnr, Lord,” to Alcndelssohn’s setting, 

of the Asa Beethoven. But avlicn the President 

LelW the w n r ••'"d ‘'ead with much 

heginnine " T i passage from tho Book of Ecclcsiasticus 
tentences^in fhaf ^“"’ous' men,” some of the 

significance • “"'“lar encomium seemed to have a startling 

renowned for rulq in their kingdoms and were men 

gi'ung counsel by their understanding, 
„ ,r_- . . . . . . people 

learning for 


Vm' "'S s'T^ *'■' 


acir woi 


Usual l/tTni'ij'i^'/'^ chanted, and then followed the 

givine in ti,- petitions, one of the latter being the Thanks- 

Itemfor peace'tTn others-^no of 

those who rnoi, departed and tho other for comfort to 

Revised Ptavcr'^BooV^'^‘’nw''^" Permissive use of tho 

sixteenth-centurv noHi' concluded with tho fervent 

’opf.thistroSelonsiifo” ""T"' "" day 

hallowed bv’lnn J- he hymns chosen were aiBo those 

good fight ” Memorial occasions—*' Fight the 

P'egation dispersed help in ages past.” The con-- 

the spirit of thft * -was resumed at headquarters in 

had been read • words from the Apocrypha which 

Their bodies aria ^ • 

^venaore.** • - . . peace, hufc their name Hreth for 


Tho following were among those present ; 

Mrs. inn (sifter), Mrs. Arthlir Wllliurn-^ (flftcr-In-law) 

SU nobert Philip (Prcfident of the Dritish Medjcal As.Tocfatfon). Dr. 

0. a nnwthorno (aialrman of Represontative Dodv and actlnp Chairman 
of Council). Mr. Bishop Harman (Treasurer), sir Robert Bolnm, Dr. 
Barcrpft Anderson, Dr. F, W. Goodbody, Mr. ^V. McAdam Eccles, Dr. R, 

1. anffdon.Down, Dr, Ohrlstino Murrell. Licut.-Colonel F. O’Kincaly, Mr. ' 
H. S. SouUar, Mr. E. B. Turner, and Sir .Tenner Verrall (members of 
Council), Mr. Walter O. Spencer (Honorary Librarian), Mr W E 
Hempson (SoHcdor to tho Association), and Mr. W E Warne (lato 
Financial Secretary). 

Sir John Roso Bradford, President of the Roval Colleirc of Physlcirns, 
who also represented Vnlrerslty CoUcffc, London, together with Sir 
Gregory' Foster (ProvostT, Professor Elliot Smith, Mr. Douic (Secretary), 
nnil Mr. Gwynno Williams, representing University College Hospital 
Medical School. 

Sir Outlibeifc WnBneo, mcr^her of Council, and Mr. S. Forrest CoweP, 
Sccrotnr * '^ollcgo of Surgeons of England; Sir 

StClaIr esident, Royol Society of Medicine); 

Mr. He Medical Society of London); Sir 

Charles J.. Sfartin, rcprofcnling .the Council of tlic Lister Institute, and 
Dr. -II.' II. -Dale (Secretary of tho Royal Society), representing the 
. Medical Research Council. 

Sir George Newman (Chief Jlcdical Ofilcer, Ministry of Health), Sir 
Humphry Ilollcston, Sir Charles Balinncc, Sir D’Arcy Power, Sir George 
Jfnkin*?, Dr. F. E. Fremantle, M.P., Dr. ITerbert R. Spencer, Dr. William 
Hunter, Professor W. E. Dixon, Dr. Charlf's Buttar, Major-General J. B. 
Smith, representing the Indian Medical Service, Colonel Battyc, 
and Mr. E. Muirhead Little. 

Sir Squire Sprigge, Editor of flic L(tneH\ Dr. Fiofet Kelrnach and 
Miss Bolton, representing the SIcdicnl Women’s Federation ; 'Sfr. G. S. 
Elliston, roprefcnling tho Society of Medical OfTiccrs of Health; Dr. James 
Neal, rcprc.‘'enting tho Jfcdicnl Defence Union. 

Dr. Arnoh! Chaplin, Dr. Camac Wilkinson, Dr. and Mr?. Bernard E, 
Potter, Dr, Percy Spurgin, Dr. S. Gilbert Scott, Dr. Herhert W. Nott, 
Mr. II. Cuthl)crt*Di.Ton, Dr. and Jlrs. J. W. MoNee, Mr. Bertram Sutton, 
representing the Medical Sickness, Annuity, and Life Assurance Society; 
Major E<lon Paget, representing the Homo Service Ambulance Committeo 
of tho Order oi St. John and the British Red Cross Society ; Mr. J. W. 
Mliarton, representing tho Garrick Club; Dr. Rawlins, Dr. Tiney. 


Dr. H. Lovett CtrjrMixG, who died at Shanghai in 
January, was born in Glasgow in 1878. Ho was educated 
at Alorchiston Castle and Georgo M'^atson’s College, Edin- 
burgh, and subsequently at tho Edinburgh University, 
where ho graduated AI.B., Ch.B. in 1902, proceeding to 
tho AI.D. with commendation in 1905. He obtained the 
D.T.AI.and H.Camb. in 1516 and D.P.H. in 1917. After 
holding several appointments, including those of house- 
physician and pathologist at the Prince of AVales’s Hos- 
pital, Tottenham, and house-physician to the Royal Chest 
Hospit.iJ, London, he practised in South-AVest London 
until his departure in 1910 for the Far East, where for five 
years ho was medical officer to various groups of rubber 
estates in Johore and Alalaya. In 1915 he became a tem- 
porary lieutenant in the R.A.AI.C., and served at the 
Fulham Militai^ Hospital. He went to Hong-lvong in 
1918, and after remaining one year there proceeded to 
Shanghai, where ho set up in general practice and became 
visiting physician to the Shantung Road (Cliinese) Hospital. 
Dr. Gumming w.-is a member of the Alid-China Branch of the 
British Aledical Association. 


By the death, on February 2nd, of Dr. Joseph William 
Gill of Billa Alill, that section of South-East Cornwall has 
lost a man of outstanding personality. Born in 1866 at 
Croydon he received his medical education at the Aliddlesex 
Hospital, obtaining the diplomas AI.R.C.S., L.R.C.P. in 
1888. In 1895 he took the diploma D.P.H.Lond., and in 
1906 he graduated AI.D.Durli. He went as assistant to 
Dr. W. Nettle of Liskeard in 1890, being also appointed 
medical officer to tho Phoenix and other mines. In tho 
Boer war Dr. Gill acted as medical officer at concentration 
camps, but contracted typhoid, and was invalided homo. 
During tho late war ho held a commission as captain in 
tho R.A.AI.C., woi’king on hospital ships travelling across 
the Channel until incapacitated by illness. He served 
under the Local Government Board on a commission to 
inquire into conditions of British workhouses, and was 
' at one time district medical officer to the Liskeard Board 
of Guardians. Dr. Gill took a great interest in the history 
and antiquities of the county where he worked for so many 
years, and was associated with tho Royal Institute of 
Cornwall. Ho had travelled in the Far Ea^ also, and 
had a wide outlook and understanding of questions relating 
to tho Empire. Ho remained a member of the British 
Aledical Association until the end of last year, when his 
- final illness compelled him to give np the greater part of 
his professional, activities. He married in 1897, and if 
survived hy his wife, a son, and a daughter. 





ITARCH ro, igjS] 


MEDICAt) NOTES IN PARLIAMENT. 


r TnE 

Medical Jocrsai. 


427 


Hn was clad to seo tlmt in tlio IIouso of Lords nltcnlioii Iiad been 
drawn to this matter. That was the first opportunity lio 
(Lieutenant Commander Kcnworlhy) had liad of ealliiiB nllenlion 
to tho matter except at qjicslion time, when Ministers could 
always ride oft. Ho lind been told that tlio Govcrmneiit were about 
to srt np an inlerdeparlmcnlal committeo to inquire into tbo 
matter hut it had not yet been sinnmoned. It was ccrlain that 
an inlerdcparlnicntal committeo meant delay, becanso tlio com- 
mittee would tako very great caro over their ovidciico, findings, 
and report. Then tho Government would delay further beforo 
tliey acted on tho report of tho committeo, and in tho iiicantimo 
a great deal of mischief would liavo been done. Tho danger lay 
in two facts, one of wliicli was that tbo spirit itself was poisonous. 
If any of tho liquid got on to tho skin it would bo absorbed and 
bring on lead poisoning. Load poisoning was stow in its clTccts, 
and came on gradually, but it was none tho less deadly when it 
ran its course. This siibstanco should never bad been put on tbo 
market without orders being issued through local authorities and 
tho police to garage proprietors and ^all whojiad to do with its 
sale, to warn tlie public against handling the liquid. Tho question 
of the effect on tho general public in crowded strcels was also of 
great importance. In trafiic blocks tho fumes from the ordinary 
petrol were most objectionable. At present tho cities, and especially 
London, with their ever-increasing motor traffic, wero sutTcring 
from a very foul atmosphere duo to tho exhaust fumes from motor 
cars. Scientific tests had been made by tbo Research Association 
of British Motor and Allied Manufacturers, which was founded 
under the auspices of the Department of Scientific and Industrial 
Research. A distinguished chemist, who carried out the research, 
stated categorically that the exhaust vapour from tho uso of this 
petrol was poisonous. Ho (Lieutenant Commander Kenwortby) 
contended tliat tho Honio Office had been wholly negligent in 
regard to this petrol being placed on tho market. 

No reply was made for tho Government, and tho bill was road 
a second time. 


Reorganization of Offiecs (Scotland) Bill. 

•Oil March 5tli tho debate on tho motion for tho second reading 
of the Rcorgamaation of Offices (Scotland) Dill, which had been 
adjourned from Tebruary 28th, was resumed. Tho bill provides 
lor the transference of tho powers and duties of ccrlain Boards 
“1 .‘K^lodiug tho.l’risoii Commissioners and tho Board 

m Health, to a Department of Hc.ilth for Scotland and a Prisons 
Department for Scotland. 

i nobody had over suggested that tho 
of TToifn* Iioaltli and other things for wfiicli t ho Board 

V was Icss cfficieiit in Scotland than in 

f's. Parliament of 1922 nor in (his Parlia- 
Single question raised as to tho adminis- 
hefiero ff ‘>'0 Board. If tho bill passed, ho did not 

of fim TW havo first-class civil scn'nuls at tlio head 

ho was VI Ho opposed tho bill bccauso 

and that the Gorcrnmeiit were taking an unjustified 

Dr Dj.TTw>,n£;, would not bo of any essential uso at all. 
said ' in bturts opposed tho bill. It was an attempt, ho 

ccon’omv tn ofliciency. and with a timid suggestion of 

the Fnoil 5 i,° tho Scottish system of government to 

form of i”;- srstom\vas a mmo dcmocratio 

of tho one-man system. A great part 

authorities uremi"^ tbo Scottish Boards was to deal with local 
tar,4 a Boards wero not simply secre- 
had ouVsidn P'^oplo wlio, m many cases, had 

actualh training. Some of them had been 

local aulhoriMe^^ u.uthorilies, and they had to deal with 

srere rve.^ P"*?' .■''gotiations with local govornine bodies 
and was' -PfnneVVn element in tho administration in Scotland, 
Civil ServieoTMu”" more suitable for a Board than for a 

in tho Seniiicli^n Department.’ Ho was specially interested- 
Seakhih in tbe ,Healtb.- Tho Secretary for Scotland, 

iL renort of V.'^batc, put a great deal of emphasis on 

the Board Boyal Commission, ssuiicti, ho said, condemned 

dSut aPh on iVr"'. *^«>t>and. But tho Royal Commission was 
uImo 5 t° enitelv Board, and was referring 

Health met Local Government Board. The Board of 

■uinules kent ^ and sometimes oftener, and had 

of tho XJnrtei- iBrooeodinns. It was under tho chairmanship 
Board S“the nn“7 Jcotland, and was a very different 
Board there i!'i ^'°ra*' Government Board. On tho present 
Scotland a renrM^°i 1’-'^“'^ National Health Insurance of 

PeuHons’ and department, and of tho 

the mSicM rlennrt Tho posH^^ head cf 

'recks. Who hkely to be vacant in a very few 

distinguished nrese??*''? appointed to succeed the very 

“ea Sr to'^him b, i’r? departme.it.:> Tbero were 

appointed and JBat department wlio were suitable to bo 

'™re of thosoTo bo^V”'''-". Scottisl. local government, 

to that imnortanl^nns?Ho'’^°'°i®‘’’ ®'' appomted 

Jnowled.-e of Scottisb^lo.V’i requiring a very lutimato 

Hinistry'' of Health? ""''borities, an official from tho English 

ruspicious that snmn 7.1 ^ ®nd see; but be was very 

place. Tho headset tt'V 

junior medical omoore- i i medical department and the 

Radical oKs of heanf''-’^''-” “en who had been 

House, ho thoLbt “ '“Portant towns in Scotland. Tho 

rienco of the work’ of '‘y.roo tKat a man wtio had had expe- 

jargo towns of ScoH->,i.l^ medic.al officer of health in some of the 
head of their natim'.-,! Proper typo of man to bo at tho 

some of tho last deportment. Tho bill took away 

from tho administration f^ti ®.o°l'i‘^b individuality and sentiment 
for burcaucS at ih" “L^^oir country. It was really a triumph 
expense of their national sentiment. 


Mr. James Stewart, wliilo opposing tho bill, said that tho pro- 
posals ot tho Secretary of State for having all the departments 
under oiio head would produce good results. If they took tho 
liealth administration they would find that in Edinburgh it was 
dividca into throo buildings in threo different parts of the city. 
If tlio Government would introduco any proposals for providin*' 
tho buildings wliieli wero clamantly necessary, so that they could 
havo tho Scottish departments under ono roof, there would be 
wiiolc-licartcd support from tho Labour party for the bill. It 
seemed to bo suggested that there was difficulty in getting advice 
from tho heads of tho departments. His experience in ofllicc was 
a very brief one, but it taught him that it was easy to get into 
touch with tlio head of any department. Suppose that it was 
a medical problem relating to tho health administration in any 

E art of tho country, and ho wanted advice. He applied to the 
ead of tho department for his experience and advice. That 
advico was freely tendered and as freely accepted, and was very 
generally acted upon, bccauso ono knew that there were ability and 
experience behind it. There was complete independence on the 
part of tho head of the department and on the part of the pci*son 
who had to supply the Minister with advice. Then again, one had 
tlio benefit, every Friday morning, of a Board of Health meeting 
at which tho heads of tho various departments were present. 
Either tho Secretary or Under Secretary for Scotland took the 
chair, and deliberated on tho problems for discussion. They had 
tho benefit of all tho experience of the members of the Board, 
and, finally, tho Minister had to assume responsibility. It was he 
who came to a conclusion even if, as happened sometimes, the 
whole of the Board was against the Minister. If Iiis experience 
and that of tho Secretary for Scotland had been similar then 
tho changes proposed in tho bill could not be beneficial. It was 
beneficial also for local authorities to meet tho Board of Health 
to discuss tho health administration of the local bodies. For that 
very strong reason they ought not to depart from the Board of 
Health and create new departments. There had been for some 
lime a movement for bringing about unity among local authorities. 
Economy and efficiency could be developed in a way that was not 
possible under tho present system. 

Mr. D. Graham said that tliey had no complaints against the 
various boards. Ho had met the Board of Health and had nothing 
but pleasant recollections of the meeting. Ho regarded cvei*y 
member of tho Board as well <5ualified; they were always 
courteous and willing to hear one, and they always produced 
arguments for any decision they gave^ 

Tho Loan Advocate, replying to tho debate, said that at tho 
present there was no first-class Civil Service position open to 
a Scotsman in Scotland, but the bill would make that possible. In 
reply to Dr. Shiels, there could bo no doubt whatever that the 
men who were appointed would have the same capacity fer 
administration as tho existing’ individual members of the Board 
in their particular department. What was wanted was adminis- 
trative knowledge, tho power of taking a concentrated opinion, as 
an administrator, of all tho expert knowledge available. That was 
the vital thing, and was one of tho reasons why ho said, quite 
frankly, that the Boards were not as efficient as a Department 
would be. Certainly, at tho beginning, and he hoped in 
succession, tho existing members of tho Board of Health would 
remain in office. In fonn their appointment would bo different, 
but they would bo there, and their expert knowledge would be 
continuously available. There would be no change in that aspect 
of the matter, and tho advisory councib would carry on just the 
same as at present. 

The second reading w’as carried by 161 votes to 66, and the bill 
was committed to a standing committee. 


Small-pox, 

- Mr. IsEViLLE Chamberlain furnishes tho following provisional 
: figures for deaths in England and. Wales during .1927 in respect 
of which * small-pox appears oii" the medical certificates as the' 
cause, or one of the causes, of death : Quarter ended March, 1927, 
19; ended Juno 30th, 17; ended September 30th, 7; ended 
December 31st , 6. .* * . 

On March 5th Sir Kingsley Wood informed Mr. C. Edwards 
that tho Minister of Health had received a letter from the 
I Bedwellty Council asking that the law should be amended so 
■ as to provide that in the case of persons who had been in contact 
I with, or were suffering from, small-pox or other infectious disease 
; in casual wards of Boor Law institutions, the medical officer of 
health should bo empowered to have them detained and isolated 
I for such period as ho might deem necessary. Sir Kingsley adde'd 
that there was power under tlie present law to secure the removal 
I to hospital of any person who was suffering from a dangerous 
infectious disease and was without proper lodging or accommoda- 
tion, but, as at present advised, the Minister of HealOi did not 
think it necessary to introduco legislation conferring similar powers 
in regard to persons who had been in, contact with cases of such 
diseases, though not themselves suffering. 


Pensions and Service Hospitals. 

Answering Dr. Drummond Shiels, on March 1st, Major Trton 
laid arrangements had been made, as already annomiced, to close 
Iraigleith Hospital, and the patients remaming m that institution, 
vho occupied less tliau one-fifth of the available accommodation, 
vould bo removed to Edcnhall, which had been placed at the 
lisposal of tho Government by the Scottish Bed Cross, and was 
)cm<' fully equipped as a modern surgical and medical hospital. 
[?ho 'closure of Eellahouston Hospital was not at present iii con- 
omplation. He was anxious to extend tho Ministry’s tenure of 
his^ hospital, and was in communication with the Glasgow 
iorporatiou with that object. He hoped that a satisfactory 



428 Makch 10, 192S] ■ 


aXEDIOAIi NEWS. 


r TH£Bnmr« 

L ^IeDICAL JotrBTfAX 


agreement would be I’cacbed. Ti was iioi possible io esiimafe 
the final requirements of the Ministrj* in Hcolland in lespecl of 
special hospital accommodation 'of its" own, but he inloiidod, as 
beret of ore, to provide such accommodaiion of the best quality 
that could be obtained as long as required. Tlic onlj’ eases iiaving 
Scottish domicile who received in-patient Ircatmcut in England 
were suffering from certain special disabilities, sucli as. diabetes 
and certain types of neurasllienia^ for which treatment was now 
provided by the Ministry in a limited number of centres. It was 
not proposed to alter these aiTangcmcnls, 

On March 6Lh Mr. Durr Cooper informed Dr. Venioii Davies 
that, so far as the War Department was concerned, by the closing 
of the military hospitals at Challiam, Devoiiport, and the 
Alexandra Military Hospital at Coshani, there had been a not 
reduction of 215 equipped beds and of 15 officoi's, 15 nurses of 
the Queen Alexandra's Imperial Military Nursing Service, and 
149 other staff. In addition to economies effected by tin's roduc- 
lion in beds and staff, tbe buildings had been set free for other 
Government purposes, or nltimate disposal. 


Gomlcufcd Skinimtd M'tJk avd liicJcets. 

Oo March 6tli Mr. Neville Chajiberlaij,’, in reply to Mr. 
Evevard, who asked if be had received any report that the 
prevalence of rickets among children in some districts was largely 
caused by tlic fact that Ihej* were being fed on imported skimmed 
milk winch was marked unfit for babies, said that he had seen a 
newspaper report of a statement of a lecturer on agricultural 
economics to that effect. He was advised that the feeding of 
infants on skimmed milk in any form would tend to produce 
rickets, and it was for this reason that he had made regulations 
requiring the words ** unfit for babies " to be displa^'ori on tbe 
tins. Recently he had issued fresh regulations which would have 
the effect of displaying these words more prominently. 

Mr. Everard asked whether, in the public interc.st, the Minister 
of Health would publish figures showing the value of English 
milk as compared with this foreign condensed milk as a dean 
product. Mr. CnAiiBEELAiK said lie did not think it was necessary 
to publish figures showing the difference between skimmed 
milk and full milk. Dr. Verkon Davies asked if Mr. Chamberlain 
knew that a lot of this skimmed milk was sold in such small 
packages that people bought it whether it was maiked “unfit for 
babies” 01 not; and if he would issue regulations to provide that 
this milk should be sold in much larger containers. Mr. 
Chamberlaik replied that he must have notice of that question. 
Mr. Keuer asked if the right hon. gentleman was not aware of 
the growing importation of this skimmed milk, and if he would 
not look fiirtlier into the matter to see whether some other 
steps could not be taken to avoid this increased consumption, 
which must be bad for the people who consumed it. Mr, 
Chauberlaiit said that he could not accept that statement. The 
hon. gentleman seemed to consider that chiUlreu and aduUs were 
in the same position. Though skimmed milk was very bad for 
infants, it might be wholesome foi adults. Colonel Howard-Buri' 
asked if the Ministry of Health could not prohibit, its sale for 
infants. Mr. Chamberlain ; I would do so if I was sure that tho 
prohibition would be adhered to. 


yationa? Health Insurunce Amendment Hill. 

On March 5tli Mr. Chamberlain presented a hill to amend the 
National Health Insurance Act, 1924. and oilier enactments 
relating to health insurance, and it was read the first time 
without debate. 


Edinbiire/h Corporation Bill {I'enercetl Dtstean). 

The second reading of the Edinburgh Corporation Bill was 
moved on March 2nd. Objection being taken, it was put dorni 
again formally for March 16th. 


?luiional Insurance . — In a reply to Mr. L’Estrange Malone, 
on March 1st, Mr. Ne^hlle Chamseflain said he had never 
suggested that the whole of the increase in sickness and disable- 
ment benefits in 1927 compared with 1926 was attributable to 
laxity in certification. Such cvideuce as ivas obtainable suggested 
that the increase in claims to these benefits was general and not 
limited to particular districts. The whole quesMon of certification 
■was being examined witli the Insurance Acts Committee of the 
British Medical Association. 


Fees for liotijicalion of Infectious Diseascs.^On March 5tli Sir 
Kingslev Wood, replying to Mr, Groves, said tliat the Minister 
of Health had no authority to disallow tlie fees payable to 
medical practitioners for the nolificalion of infectious ‘diseases. 
A certain pi*oporlion of cases notified as diphtheria and admitted 
to ho'=pital were subsequently considered by the hospital aulho- 
litics not to be cases of diphtheria. Those who made use of the 
returiw issued by his department for statistical study applied 
in the figures of notified cases the information available for 
correction'’ such as was contained in ilie annual reports of the 
Metropolitan A.syhims Board. 

'Medical and Santtemj Services tv A7;JW.-0a ^farch 5lh Mr. 
Amery replied to Mr. Bavr, who asked if his attention had been 
called to the fact that it had been laid down by the deputy 
dh-ector of sanitarv sendee in a 

large riii*nl native- district, containing 100,000 to 2W,009 people, was 
one district medical officer, one nicoical officer^ of health, one dis- 
pcns.'iry medical officer, two European inmiiig sisters, one European 
sanitary inspector, and pos-^ildy a European hospital assistant and 
a stoi-ekcc]>er, and, in addition, an adequately-trained nafirc 


subordinate staff, n hospital with accommodaiion ' for about 1( 
patieius, and from six to twelve out-dispensaries. Mr. Amor 
said his Jilienlion had been drawn to the address to the Eoyi 
Sociefy of Tropjcal Medicine and Hygiene in wfiicli this statemeii 
occurred, bo lar as ho was aware the standard suggested had no 
been endorsed by any colonial Government, and, ns the raedica 
requirements of the colonies differed, it would he impracticable U 
regard such a suggestion as n general standard. Ovei-sea Govern 
menls were everywhere endeavouring to maintain a medical stal 
adequate io their rcqnii'cments, and in some of the Africa! 
territories a relatively higher standard had already been achieved 
Iraq Dates and Chofero.— Mr. Amerv, replying to >Sir B. Thomas 
on March 5/h, said that stringent measures were taken by th' 
Iraq health authorities during the cholera epidemic of last yea 
to ensure that all dates exported from Iraq wore free fiun 
iiifecliou. He was not awaro_ whether, under novnml conditions 
the Iraq Government required inspection or considered it necessary 
He was asking the High Commissioner for a report on the subject 
There was no evidence of disease being introduced into thh 
coiinli-y ill Iraq dates. 

Dinniiif/hnm Guardians and the Mentally Unfit. — Sir Kingsley 
Wood informed Sir G. Dalrymplc-White^ on .March 5th, that the 
Minister of Health had received a copy of a resolution passed by 
the guardians of the Birmingham Union on February with 
regard to the mentally unfit. The Minister could not undertake, 
al present, to embark on an inquiry which would involve the 
far-reaching and controversial issues inseparable from (Iiis 
question. Dr. Fremantle asked if Sir Kingsley Wood would take 
steps to impress on local authorities the powei-s that they already 
liad, and the necessity of .enlarging them, under the Menial 
Deficiency Acts. No reply was given. 

.Beds ami Personnel in Naval Hospitals. — Lieut.-Coloncl Headlam, 
answering Dr. Vernon Davies, on March 5th, gave a full list 
of naval hospitals at home and abroad, the number of beds 
available in each liospilal, and the number of pei'sonuel attached 
to each hospital. The details .were as follows: Haslar: 625 beds; 
62 salaried and 334 wages staff— total 'staff, 396. Plymouth : 590 
beds* 52 salaried and 272 wages staff— total staff, 324. Chatham : 
490 ’beds: 55 salaried and 279 wages staff— total staff, 334. 
Portland: 104 beds; 12 sab-vied and 37 wages staff— total 49. 
South Queensferry: 103 beds; 8 salaried and, 29 ^vages st.tff— 
frtal 37 Great Yarmouth: 213 beds; 4 salaried and 38 
staff-total 42. Malta: 365 beds; 31 salaried and 131 wages staff 
total 162 Cape of Good Hope: 48 beds; 5 salaried and 21 
wnee? staff-total 26. Bermuda : 77 beds; 6 salaried and 16 wages 
staff— total 22. Hong-Eong ; 107 beds; 11 salaried and 70 wages 
staff— total 81. _ , T»r 

Medical Examination of Intcndinp Settlers v\ Canadei.^m. 
A MPRv Informed Mr. B. Smith, on March 5th, that intending 
iimeis in Canada who were examined and passed by Canadian 
officers were not required to undergo further examination, 
no hable to rejection on medrcal grounds on arrival 
*^?n.rnorl of entry unless essential information had been withheld. 

disease had developed in the interval. The new 

Notes in Brief. . >r. . , . * 

• ■MinkioT docs not propose to make the Mmistiy of 
The ljpj.(linate department of the Ministry of Health. 

Pensions IV. subon Health does not propose a general surrey and 
- The of p,.ofonn.g ll.e 

allofmeDt to local adopted of regional water coninnttces. 

were 707 dead bodies found m lie Moiropoblan 


^^Utri'cr*^_orwliicIi*77''ot* newly born infants and 7+ ollicrs 

police 


*'®Mr'"cbanibevlain ’is not aware of any. 
Mr. viiaiiiuy j - mpdieal exami; 


instance where a casual 


bad been th® day of discharge, 

scribed lion* ® montlis ended October 31st, 1927, 135 

In tbe j fr,. beine drunk and incapaolc m Gla.sgo» 

"hSo*’condtu?n was believed to be due to the drinking of 
:ne°b°lalcd spirits. _ 


medical examination beyond the pie- 


pci’sona 


fiebjs. 


E Irish Medical Schools and Gradoates AssofHon itdU 
Hk fiftieth anniversary dinner at the y. q 

irdeneral Sir Ht^bcrt de^a Jo^ Gong^lb 

to-day (Friday, March 9th), - r-idinm treatment of 

bm-n vviU read a paper oa the ratimm 


MABCn 10, 192S] 


MEDIOAI/ NEWS, 


r TuxUniTtw 
L 31»,0tCAI- 


429 


wr vonret to loam that Dr. W. J. IlowartU lias boon 
-muncUod by ill lioalili to resign tUo anpoiutmout ol wofllcal 


Sr ot \waltb for tlio (Jity ot Lomlon. l5r. W. M. Willouglibj',, 
montcaVofiltor tor tUo Portot Loudon, is noting tciiipoMfllv 
SiWartli’s absence nutll n snecossor is apiiolutca. 


Tiir nnmwl nicoting of tUo Iloya! Urodlcnl Eenovolout Fund 
wnKcld at 11, Chandos Street, W.l, on Tlwvaday, Marcb 
oViiH nt 5 50 P.W., wUen tUo annual report and Unancial 
statement for tbo year ending Doooinbor 31st, 1927, will bo 
presented, and tlio offloors and committoo for the current 
year elected. 

The Pliysical Troatincnt Centro of the Kensington Division 
ot the British Bed Cross Society at Tlio Limes, UoUaiid Parle 
Gardens, W.W, will lie open for luapootlou by medical jiracti- 
tiouera on Tbursday, Jtarcb 22na, at 8.30 p.ni. Dr. .Ininos 
Ifonnell will give a short Icoluro on foot trouble and loot gear. 

A. scsstoSAti meeting ot the Hoynl Sanitary InstUnto wffi 
bo hold In the ConneU Cliambor ot tUo Town Hail, Sear- 
borough, at 5 p.m. on Friday, Jfarcli 16tli, wlion a discussion 
on tbo Scarbotongb water supply and now sclicme will bo 
opened by Mr. Herbert Lapwottli, D.Sc, The ebair will bo' 
taken by Professor A. Bostoelc Hill. 

The next evening meoting of tbo Plmniinccutlcal Society 
ot' Great Britain ivlll be bold in tbo Joofiiro tboatro of the 
Society’s House, 17, Bloomsbury Square, Loudon, IV.C.l, on 
Tuesday, March 13th, when an address will be gii'cii by Dr. 
H. H. Dale, secretary of the Iloyal Society, and iiead ot tbo 
Department of Biochcmisti-y and Pbanuacology, National 
Institute for dledical Rosoarcli, upon some renctloua ot 
pharmacology on pharmacy. 'I’iic president will talto tbo 
cliair at 8 p.m. 

A sPECUt disenssiou on tbo pulplcss tooth will bo held at 
a combined nieeling of tbo Hoottous ot Odontology. Pathology, 
aud Electro therapeutics ot tbo Iloyal .Society oC Medicine at 
“lb Society’s House, 1, tVImpolo Street, W.l, on Monday, 
Marob 26tli, at 8 p.m. Mr. Frank Coleman %Yill open for tbo 
Section of Odoatoiogy aud Dr. H. Jf. Worth tor the Section 
of Eiectro-therapontios. 

Society of Modical Ofilccrs ot Health 
®'* control ot suiail-pox fl.xod for 
td he auuQUUced after 
Vacoination° Departmental Committee on 

I'li'ionucos tliat Dr. .T. L. Biricy 
nraeffei'^.!,? ^ Hi; defective in relation to general 

Medical ® Iccturo room ot the 

bn'the ^baudos Street, Cavciulisli S<iuaro. 

a snerial c •Parsons-Smiil. will give 

DiseaTOs nf ft ^lic National Hospital for 

atthe Cancer sPbo'al clinical demonstration 

annonS fo?Mf P-'”” >-dP'aoinf5 the ono originally 
ate free I n ‘^ctnro and demonstration 

beam on Praotiliouers. 'Phreo speci.al conrses 

las”ts a wed- Hronipton Hospital, 

two ofhrecLr ^ occupies mornings and afternoons. TUo 
National Orthona'* for trvo weeks ; ono, at tlie Iloyal 

operationq Hospital, occapies the whole day with 

pital cominno^'V®’’*'’ *'•'0 Hampstead Hos- 
a lectured n fie™ J’-™' ® P’“” ooioprises 

in sntgorv '^.„^®'“®bstratiou,eaoli day in medioiuo, or 
will be Bosoeolnd cn“° departments. There 

Compreheosivc Hdr , March Slst until April 16th. 

trom oue Sto nn^^^ any period 

1'"— • “■ to o n - courses at various 

' . ■ ■ •' made for practitioners 

I ' ■ ' ■ ■ .information about the 

bost-qyadunfi^“\rT^'- '^^“*’^0805, and speoimon copies ot the 
seci'otarv of the '[‘’.'"’nal may bo obtained from the 
Dn 1, Wimpole Street, W.l. 

British Dorset Division of fcJJO 

of tliG Panel ^ member of the executive 

bisuraneo GoinmilTcc^fc““5 ™a'nbor of tUo Dorset 

Dorset Countv blunted a member ot tbo 

exceeded ?hfMmbTnc"i'\- ^°tes polled for him 

Sm 'pn.v- ^ of the other three candidates. 

General Lvin's-iu M.D„ president of the 

nnuQal conevni iS-E., presided at tlie 

It Was recalled the? fi"® governors on February 29tli. 

beake in-lyfiS tor 'P^i-rlntiou was founded liy Dr, .John 
includes Westmm??^ . -Dbo ont-pationt district 

'rnil Battersea ^“™botb, Sonthwarlr, C3ml)erwel), 

iraiaing of lukiwives*^**^'*'” *'*’® bo.spital’s work is the 

bn international congress 

^onstantr.atvomMa/2lst fo 29tU.“ 


'Tin.; annual congress Iciiowii as Joumees uiedicales do 
Bruxelles will 1)0 bold at Brussels Irom April 21st to 25tb, 
wlien tlie following pajiors among others will bo road : lieo- 
c.'icoal e.xcision in diseases ot the ascending colon, by Mario 
Douati of Torin; arterial ouceplialography, by.Egas Mouiz of 
Lisbon ; cardiac .syncope and ndronalinc, by Emile Bardier ot 
Toulouse; provouttvc inooulationa, by C. Zoellev of Paris; 
cholagoguo function of the liver, by Noel Fiessinger ot Paris; 
carbohydrate metabolism, by Cesaro Serono ot Some; belio- 
tborapy ot surgical tubereniosis, by A. Eollier ot Leysin; 
rlioumntism in tlio inenopanso, by M. P. 'Weil ot Lyons; 
neurology ot tbo abdominal wail, by G. Sodenbergh of 
Goilienburg ; and plastic snrgery of the face, by Sanvenero- 
Eosclli of Genoa. 

'PltE forty-ilrst congress of the French Society ot Ophthalmo- 
logy will bo held at the Faculty of Medicine ot Paris tconi 
May Mth to IGtli, when a paper will be read by Dr. Mawas on 
tbo hiomicroscopy ot the iris in health and disease. Further 
information can be obtained from the general secretary. Dr. 
Benfi Oufray, 6, Avenue do la Motto-Picquet, Paris VXI. 

The Standing Co)))niitteo appointed by the Board of Trade 
to consider whether imported snrgical, jnedical, denial, and 
veterinary instruments, dental supplies aud dental furnitnre, 
shonid hear an indication of origin, aunonuce lhab their 
inquiry lias been postiJoned, and will be now hold on March 
19tU and 20tli. 

Dtmisc, the tonrtli year of the Ella Sachs Plotz Fonndation 
for the Advancement of Scientific Inve.stigation filty-fiva 
applications for grants were received by the trustee.s, Iwonty- 
0110 ot wiiicli c.rine from tlio United States and thirty-four 
from cloven dilTorciit coiintrics in Europe and Asin. ’Twenty- 
four grants were mailo during 1927, including one lo Dr. J. E. 
Dawson of Ediiibiirgli for investigating the pathology of (lie 
breast. Applications for grants for the coming year slionld 
be sent to Dr, .T. C. Auh, Massaclinsetts General Ho.spital, 
Boston M, botoro Alay ISlii. 

’Tin: February issue ot tbo Veiitsche ZtilseUrlJt fiir Chi rwflie 
is dedicated to Professor Alexander Fraenlfel, director of tbo 
snrgical division ot the General Policlinic of Vicuna, on tho 
occasion ot liis 70t1i birthday. 

Jfnssns. W. IlEPTBn .vnd Sons, Ltd., aunouuoo for early 
publication Practical Serolorjij, by Professor Luigi Vigano of 
Milan, translated from tho latest Italian edition by Miss 
E. M. Hoftcr, and edited by Dr. C. G. L. IVolC. 

William Hbinemann (Medical Books) Ltd. announce for 
early publication Tonsils and .lAcnoi/ls anil Their Diseases; 
luchuiing the Pari Tlieg Play in Systemic Disease, by Dr. 
Irwin Moore. 

IlBSOLUTio.xs emphasizing the importance, in combating 
malaria, of co-ordination lietwceu the pnbliobealthantboritres 
and tlio promoters of engineering works were passed by the ■ 
Jfalaria .Section ot tho Far Eastera Association ot 'Tropical 
Stcdiciuc at the seventli congress, Calcutta, in December last, 
oil the proj) 0 sal ot Sir Malcolm Watson, M.D., seconded by 
Licut.-Colonol S. K. Christophers, I.M.S., director of Central 
Ecseavch Institute, Kasauli. Iteterence was made to the 
fact that many cases had oocuri’ed in 'W’blch a great Increase 
in the incidence of malaria had been caused by facilities 
give- • ' ■' ion by engineering works, and 

it W! IS of such works liliely to affect 

tho ■ ■ ■ tlaria shonid be submitted to 

the ■ • . " . before being sanctioned. Tho 

congress coucluded that there was no singio method of 
malaria control applicable to ail conditions and all countries, 
but, whatever other measures might be adopted, control ot 
tho mosquito breeding places should be employed where 
there were large aggregations ot people. 

Tiib following German medical congresses will bo held 
nest month : Eontgen Society, April Hth to 14tb, at Berlin; 
Society for Internal Medicine, April 16ch to 19tb, at IVie.5- 
baden; Pathological Society, April 19th to 21st, at Wiesbaden; 
Society for Psychiatry, April 24th and 25th, at Kissingeu, 

’The following appointments have recently been made in 
foreign faculties of medicine : Dr. Erich Lexer ot Freibni'g, 
professor of surgery at Munich; Professor G. A. Wagner of 
Prague, professor of gynaecology at Berlin ; Professor Marx 
ot Munster, professor ot otology at tVflrzburg ; and Professor 
W. Kerl of Innsbruck, director of the dermatological clinic at 
■Vienna in sncccssion to Professor Finger. 

PnopEssOR AUDIN-Dbltheil has been nominated dean of 
the medical faculty of Algiers. 

Professors Nicolas aud Pierre Duval ot Paris havebcen 
elected foreign corresponding members ot the Boyal Ac.ademy 
of Medicine of Belgium. 

A CoaiMiTTBE lias been formed at Tonis to commemorate 
the twenty-fifth amiiversary ot Dr. G. Nicone’.s appointment 
as director ot the Institnt Pastenr ot that city. Further 
information can be obtained from Di'- F. Geeard, 100, Rno.dp. 
Sefbie, Tunis. 



430 March io, 1928] 


IiETIERS, NOTES, AND ANSWERS, 


j' hriii?* 

L'MiOICAI. JoURVlt f 


Wtttm, $rii U^, att tr 

'All communications in regard to editorial business should bo 
addressed to 77ie EDITOR, British lYJodical Uournal, British 
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The TELEPHONE NUMBERS of the British Medical Association 
and the British Medical Journal are blVSEVU dSQl, VSG2, 
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The address of the Irish OIHco of the British Medical Association is 
16. South Frederick Street, Dublin (telegrams : TiacUlus^ Dublin\ 
telephone : .4737 Dublin), and of the Scottish Ofllco, 6, Drumslieugh 
Gardens, Edinburgh (telegrams : Associate, Edinburgh ; telcphono : 
24361 Edinburgh). 

QUERIES AND AKSYTERS. 

Acute Gout. 

** Hon. Sec.*’ asks for information about any modern treatment 
likely to be useful in a case of acute gout, iu which all the old 
remedies have beeu tried aud failed. 

■\Vakted— A Home. 

Member of Thirty Years’ Standing ” would be glad to beat 
of a home in pleasaut surroundings, where au old lady could be 
placed voluntarily for moderate paymeut, lu some such place as 
Bournemouth. 

•Cramp after Sciatica. 

asks for suggestions for the cure or mitigation of cramp in 
the leg following an attack of sciatica. Tlie trouble is mainly at 
night, and causes loss of sleep. It appears to be increased by any 
esercise. 

Duration of a Positive Widal Reaction after 
Inoculation. 

Dr. M. Avent (Basingstoke) asks how long the effect of inoculation 
with T.A.B. remains as regards aggUitiuatiou powers of the 
serum of the person inoculated. One or two bacteriologists 
hedged, but implied only tw'o or three years. Ho has recently 
seen a case which was diagnosed as being typhoid fever largely 
on the strength of a Widal reaction, which the bacteriologist 
reported as “strongly positive to B. typhosus and negative to 
B. paratyphosits A and B.“ The man biul been inoculated with 
T.A.B. over teu years previously. The diaguosis was eventually 
settled as splenic auaemia. 

Primula Rash. 

Dr. Francis G. Bennett (Bonruemouth) writes: For some time 
I have beeu attending a patient for a rash on the hauls due to 
handling the above-named plant. Applications of various kinds 
have answered fora time, bub the rash still coutiiiues to appear 
at intervals. This obtained also witli respect to the nltra-violet 
rays, wliich were given a good trial. I should be grateful for any 
suggestions as to treatment, as both the reappearance of the rash 
and the irritation which accompanies it are becoming distressful 
to the patient. 

We have referred this inquiry to Dr, H. Haldin-Davis, 
who writes: The first point iu the treatment of this case is to 
ensure that the patient never, on any account, handles Q,2>rimula 
at all.' Unless this precaution has been taken (and Dr, Bennett 
does not make it quite clear that it has), no treatment is likely to 
be successful. If, however, the rash rennius obstinate, even 
aUhoiigli care has been taken that there should be no renewal 
of the harmful contact, one must suppose that the patient is so 
sensitive that the original dermatitis has developed into a true 
eczema— a contingency by no means improbable; the tendency 
of eczema to relapse is notorious. It is difflciiU to give explicit 

direotious withoat soeiog the patient, bat the keynote ol the 
treatment sliould he pcoteetiou, as comp ece as possible, from 
ex.terual irritants of every Uind, however sliglit. 

Income Tax. 

Schedule B : Purchase of Practice. 

<‘Ii. C.” asks whether lie is correctly nssessol in i-espeot of a 
meadow mider both Schedule A and fachedule H, and also as 
to the i^osition arising out of the purchase of the remaining 


hair share in the practice from Iiis former partner ns horn 
Decomher 31st, 1927, Dnriii" the quarter ending April 5tli, IP’S 
luolu 3 lvo^° paying an assistant at the rate of £m pet annum 

' , ' The tax is payable under both Schedule A and Schedule B. 
Oiir correspondent is not entitled to deduct the expense of Ilia 
omployment of the assistant from the share of the 1927-23 
assessment relating to the last quarter. The only relief open lo 
him is to claim under llnle 11 to have the proportion ol tlie 
asscssmont applicablo to the final quarter reduced to the ainonut 
of the profits of the practice for that period. In computing those 
profits lio'would, of course, deduct as au expense of the praolica 
the £100 payable to the assistant for that quarter. 

Motor Car Obsolescence. 

“ 0. A. E. M.” bought a oar for £295 in September, 1925, whicli he 
sold in Septomher, 1927, for £150, buying another car for £255. 
Depreciation iias been allowed, but.tiie claim, for, ohsolesceuca 
(presumably on £145 less £40 depreciation— that is,' £105) has been 
refused on the ground that the 1925 car was not " obsolete.’' 

*.* Apparently the inspector of taxes is relying on the case 
of the Soiitli Metropolitan Gas Company v. Dadd, which was 
decided by Mr. Justice Eoiylatt last November. The decision 
weut iu favour of the Crown ou the ground that the qnesliou 
was one of fact, aud that the Court therefore could not iuterlere. 
But tlio judge went out of liis way to say that this case was not to 
bo taken ns deciding that iu order to be obsolete a thing most ha 
“worn out," and suggested that in that -particular case the 
Commissioners against whose decision the appeal was made had 
In mind the probability that the appellaut company f‘ wauled 
something rather better . . . because it would suit their purpose 
better." The case quoted dealt with the replaoeraeut of a seven: 
year-old ship. It is clear that the life of a medical practitioner's 
car is normally so much shorter than that of a ship that there is 
primn facie less ground for ntlnoklug a claim for a two-year-old 
car than for a seveu-year-old ship. Further, there con bo iio 
Bivueslioa that oiir correspondent was biiyiiig the pew car for 
aurother reason thau tliat the old one Iiad become unsiiitablo 
by one and use tor the purpose for wliioh it was lequieecl. . If tho 
iiisiieotor ol taxes remains obdurate on the merits of the claim 
mreveu r«>« lagal merits are arguable the eqi. table merits 
are not open to dispute-we suggest tliat a ful siatemoiit of tlie 

■ factl be slnl to tlie Secretary, Inland Eevenue, Somerset House, 
W O 2 with a request for au official ruling, Iu that event we 
Bh'ould be glad to see a copy of the reply. 


IiBTTERS. notes, etc. 

A Medical Man-of-all-worl. 

. - — (Bridgnorth) sends us the 

Dr. WieFR ■ ■ jplag (i-oni tlie Bath Chronicle, 

following (pQuu 1,1 the aeiejuid Journal tor Maroli 27th, 1777: 

xvhichma) -...wh-. Imra bad health— a sober steady uei-son 

•• VTantod for a family ^ manmidwife. -Ha 

in the m the cai. of butlor, dress hair and wigs 

• nxuat occasionally nrayers occasioually and a sermon tweii 

Ho will be reqaired ‘a N,B.-He will have 

, Bunday evening. A good y o, ^,3 profession when not 
liberty to tn*” ^ ^ 

wanted in the adils) the omission of the usual 

■ Forlmps ,!°’’'n„foro “^penuy " m iudicative of delicate politeness. 

qualification ooiuio r 

A BegGINQ Letter, Pest. 

Aiwust 13th last we warned onr readers that a 

In our issue o' ^ operating from Cardiff-a woman ' ho 

begging letter oxpei t fatlier, described ns a foimer 

appealed for loa woman is still sending out lier 

"’'’‘'iroh the same^ines, and we hear from tl,e Chi^ 

otCardifitlmtth 

bas already been . ■ ■ 

by talBO pretenco..^ Especially favourable prey, win no on in... 
Been^ to ue t-uu 

the AVhite Dine. . 

... , ug that tke police aiitlionties 

THE ' to liave determined to prose- 

iu ■ . to keep to the 'vhite lines on 

i“ SS fi'cM .".sr a 

corners and loiiuij j 

keep well within them. 

Vacancies. 

will he fo«“‘'“‘.PeftUBra'en\’s as to partnerships, assistants p , 

.AS" •“".■S £SS.-. .t ,»s. «■ 



00 ’ 

il\Rcn 17. 192 


s] 


-b 

GENITAH DISPEACEiirENTS. 


[ 


Tnx BRrTTgff 
Uedica^ • oornal 


431 


^f(llrf55 

ON 

GENITAL DISPLACEMENTS.* 

DY 

VICTOR BONNEY, M.S., B.Sc., F.R.C.S., 

/ssiswsT crxircoiooicAL sohoeon to »iinni.ESr.x iiosmtalj surgeon 
TO CDELSE* HOSPITAL FOR WOMEN. 


The Pelvic Floor akh the Pei.vio Snrur. 
SnccE'tlio ciiro of nil dofoi'mitics and displacomonts must 
be founded on a correct understanding of tho anatomy of 
the parts concerned, I will begin by reminding you of tbo 
structures that keep the fcnialo genital canal in position. 
.They may bo divided into •three groups ns follows : (1) 
The broad ligaments with all tbo structures contained 
within them that are nttnclied to the body of tbo uterus. 
(2) The cardinal ligaments and pubo-cen’ical musculo-fascia, 
which collectively I call tbo “ pelvic shelf.” (3) Tho 
levatores ani and other muscles that close the outlet of tho 
pelvis, together with tho fascial layers in relation to thorn ; 
the whole being named the polvic floor. 

The first of these three groups is tho least important, for 
the broad hVaraents have no gieat fixing power on tho 
uterus, but merely, so to speak, steady it like tho guy- 
ropes steady a tent pole, though its main support is tho 
ground into which it is driven. 

The second group is of far greater importance, for tho 
cardimal ligaments not only keep tho vagina in its normal 
position, but also hold tho cervix. They spring from the 
sides of tho vagina, from its vault down to tho upper 
surface of tho levatores ani, and it is this arrangement 
that makes tho lateral walls so fixed. They spread out 
fan-shaped, to hocomo attached to tho lateral pelvic wail 
on each side along tho so-called “ white line,” like tho wings 
of a butterfly whose body is formed by tlio vagina and tho 
inusculo-fascias which onshoath it, tho whole forming a shelf 
of considerable rigidity, projecting out into tho polvic 

upper and anterior surface of this shelf 
tho bladder and ureters lio, and its posterior .surfaco is 
separated in tho mid-lino from tho rectum by a thin layer 
of loose cellular tissue, whilst at tho sides it is separated 
10m the lateral rectal ligaments and upper surface of the 
ovatores ani by wads of fibro-fatty tissue. Tho reality of 
Ills structure which I have ventured to call tho “ pelvic 
SIC can only he appreciated. by deep dissection such as 
las o be nndertakoii in Wertheim’s operation. It is of 
great importance, for on it tho position and stability of 
10 cety-ix and vagina and bladder depend. Tho plane in 
w nch it normally lies is roughly parallel to, though con- 
Eitoably below, that'o'f tho pelvic brim. 

^ e pelvic floor, on the other hand, lies in a plane which, 
m t o standing posture,' is practically horizontal, and 
lere ore at an angle of about 45 degrees to that of the 
pe vie shelf. ^ Its function is to support and fix tho lower 
en s of the rectum and. vagina respectively, and that part 
w lie supports and fixes the vagina is not only the weaker 
portion, but it is much more liable to be injured in the 
proMss of childbirth. Weakness loading to yielding, either 
o t e pelvic shelf or pelvic floor; or of both together, is the 
1111 amental cause of uterine and vaginal displacement, 
an t lerdfore, in determining the measures to ho employed 
01 loir cure, it behoves us to find out in each individual 
case which of tho two structures I have described is 
primarily at fault. 

^Tech.ixism of Eetroveusion. 

Retroversion may come about in one of three ways. 
! . ^ fault lies solely with the broad ligaments, 

being weak, allow tho body of the uterus to be 




Eealand Aledical 


unduly mobile. - In the second 'there is weakness of thoso 
upper fibres of tho cardinal ligaments which fix tho cervix 
at its jnnctiiro with the vagina. The result is that tho 
ntoriis is loosely set into tho vagina, and in recumbency it 
tends to drop back towards tho hollow of tho sacrum. This 
tondency is no doubt resisted by tho broad ligaments if they 
themselves aro noi-mal; hut just as tho gu3’-ropes would not 
long hold a tent pole once it had come out of the ground, 
so sooner or later the uterus falls back. In this class of 
caso tho Titoriis is not merely retroverted, but is lower in 
tho pelvis than normal. Tho third way in which retro- 
version of tho uterus can come about is bj’ tho whole pelvic 
sliolf rctrovcrtifig. This displacement of the uterus is 
Eomotimes called “ rotroposition,” but the term seems to 
have boon coined without understanding tho processes at 
work, and without noticing that in these cases the vagina is 
retroverted as well. Cases of this deformity aro constantly 
mistaken for cystocolo because, on looking through tho 
vaginal entrance, tho anterior vaginal wall is, seen imme- 
diately behind it, and much lower than normal. On 
straining it may oven partially protrude, but this is not 
because it is bulging abnormally, hut because the axis of 
tho canal is tilted back so far that tho anterior wall. only 
requires a normal degree of bulging to reach the orifice. 

The MECHArrissr or Prolapse. •; 

Prolapse in its essence is the vagina beginning to tuim, 
or actually complctelj- turning inside out. The uterus not 
only plays no active part in this performance, but actually 
passively resists it. In other words, the vagina can turn 
inside out more easily if the uterus is not there, and this 
is tho reason why the greater- degrees of prolapse are 
mostly seen after tho climacteric, when the uterus has 
atrophied. For a hollow visous to turn inside out an initial 
bulge inwards of some area of its wall is necessary, and 
in tho case of tho vagina this bulge practically always 
starts cither on its anterior or its posterior wall, or its 
vault, for tho lateral walls, by reason of the cardinal liga- 
ments attached to them, are too rigid to bulge. The exact 
position of this initial bulge or ” dropping ” depends on 
which part of tho supporting apparatus is yielding under 
the intra-abdominal pressui'e. 

In normal circumstances the axis of direction of the, 
intra-abdominal pressure during straining is downwards 
and backwards behind the uterus into Douglas’s pouch, 
into which coils of small intestine may be forced, just as 
they aro forced into a hernia sac -(yheu tho patient coughs. 
This happening not only compresses the. rectum against the 
sacrum arid forms an important factor in the act of 
defaecatiori, but the pressure being applied behind tho 
uterus and the pelvic' shelf, the uterus, the vagina, and 
the whole shelf tend to bo pushed forwards and slightly 
upwards, so that so long as the posterior vaginal wall is 
eqpal to the strain, no abnormal bulge into the vagina 
occurs. "When, however, the uterus is retroverted, and 
more especially -n-hen the vagina is retroverted as well, the 
axis of direction of tho intra-abdominal pressure is 
forwards of the uterus, and the pressure is chiefly-exercised 
in crowding down coils of intestine on to the back wall 
of the bladder, and on to tbe pubo-cervical musculo-fascia 
and vaginal wall which lie immediately beneath it. The 
result is a tendency for the anterior vaginal wall to bulge 
abiiormallj-, and this is rendered tho more easy if the 
pelvic floor has been so weakened in its anterior jjart that 
tho vagina gapes. Tho point at which the primary bulge 
occurs differs in different cases. Thus it maj' be situated 
at its upper part only, the anterior vaginal vault — that is, 
that portion of the wall which is above the trigone of tho 
bladder — in which case thq protrusion contains no bladder; 
or it may be situated at that portion against whicli tho 
trigone lies, in which case a true cystocele is formed; or 
it may bo situated at its lower end, in wiiich caso tho 

[3506] 



432 March 17, 1928] 


GENITAn DISPCACEMENTS. 


urotlira is displaced, with the result that the patient wets 
herself wlicn she sti'ains. 

I'rolapso' of the anterior vaginal wall ,is not invariably 
accompanied by retroveision of tlie pelvic slielf, or oven by 
simple retroversion of the uterus, hut it is so in tlio 
majority of eases. Moreover, a something additional to 
retroversion is lequired — namely, that stretching and 
weakening of the pclvie shelf, either in whole or in part, 
which labour alone can bring about. Thus jirolapse of the 
anterior vaginal wall is very rai'e in nulliparae. 

' Prolapse of the posterior vaginal wall, on the other 
hand, is not primarily dependent on the j'ielding of tho 
jjelvic shelf, but is chiefly brought about hy post-parturient 
weakness of that part of the pelvic floor whicli supports 
its lower end. As a result, every time the woman strains 
this lower attachment is pidled down by the bulging floor, 
and tho posterior vaginal wall becomes elongated so that 
it droojjs forwards into tho vagina] lumen. At this stage 
tho protrusion is not aceompanied by a protrusion of tho 
rectum, the vagina mei'oly slipping- down' on the front of 
■the rectum. Presently, however, the rectum, deprived of 
its support in front, commences to slijr down tho face of tho 
sacrum and buckle forwards, so that the protrusion becomes 
a tiue vectocele. This buckling forwards of the . rectum 
depends on the posterior part of the pelvic floor .main- 
taining its stability, for if it bulged too, a rectal prolapse, 
and 'iiot a Tcctocele,' iibidd result. The protrusion' is 
rendered the more ea.sy because of the gaping vaginal 
orifice which the absence 'Of tlie perineal bod3' and laxity 
of tho levatores have brought about. ' 

There is a rare form of prolaj)s.o of the posterior vaginal 
wall whicli does not primarily depend on, weakness of tho 
pelvic floor, but is duo to a bulge inwards of that upper 
inch which is in relation to IJouglas’s pouch. This form 
of prolajise is a true hernia of tho pouch. Speaking 
gouerallj', prolapse of the posterior vaginal wall, when 
occurring bj' itself, is commoner with the uterus in ante- 
version ; and this is what would ho e.xpcctcd, for then 
the axis of direction of tho intra-abdominal pressure lies 
posterior to tho uterus, and exercises an effect chiefly on 
the iiosterior wall and rectum. 

Though prolapse, to begin with, is initiated by a bulge 
inwards of some partieular area of tho vaginal wall or 
vault, it is comparative!}' rare for tho clinician to see the 
case until several areas of tho whole of one or both walls 
are bulging, for weakness of one part of the supporting 
apparatus is soon followed by weakness of other parts, 
owing to the increased strain put on them by tho failure 
of the primal'}' defaulter, until in tho end, all of them 
having failed, the vagina turns in.sido out. 


Opeii.vtive Tkeatme.vt. 

In these days, when the operative tieatinont of dis- 
placement has reached so high a pitch of satisfactoriness 
and reliability, no other treatment needs to be considered 
ill the vast majority of cases. The exceptions to tho rule 
are: First, cases of retroversion or jirolapse discoveied so 
soon .after labour that further involution of tho stretched 
.siijiiiorting apiiaratus may be hoped for, if the strain on 
the. parts be temporarily removed or lessened by the wearing 
of a pessary; a pessary worn this way, as a splint, pending 
nature’s leparativo processes, is without objection, but it 
is objectionable when employed as a permanent orthopaeilic 
aiiparatus. Secondly, there ore those cases of prolapse in 
a<'ed persons whose physical condition is too feeble for an 
operation. Age by itself is no contraindication ; I have 
operated several times on women over 80 years of age, 
with prolapse quite incapacitating them, when pe.ssaries 
could not be worn. 

From a consideration of the mcchannon and varieties of 
genital displacement that I have put before you, one fact 
is imniediatelv apparent— namely, that no one operation 
will suffice to' cure tho many varieties of deformity which 
come under this head. As in orthopaedic snrgeiy in 
general, so in that part of it which is epncm-iied with dis- 
placements of tho genital canal* in. piiJ'ticnlar, the opera- 
tions mav ho divided into tAVO categories: those •\viiicii 
have as their object the repair of the faulty siiliporting 


TnEBamat . 

UtnicAL J00BIU& 


apparatus, and those irhich discard it in favour of making 
• a suhstitiite Tims perineorriiaphy witli suture of the 
levatores and the fascia suporflcial to tJiem is a rcp.rir 
operation, heeaiisc it directly mends the parts at faidt:' 
wulst 1 eiitrofixatioii is a substitution operation bocaiiso 
It discards the natural support, s of the vaginal vault and 
^places them with a now ligament made out of the uterus. 
Eotli repair operations and siihstitutioii operations are 
legitimate, and botli Imve their oivii sphere of propriety 
and iisefiiluess, and it is the task of the surgeon to decide 
which amongst them is tho most applicablo to the deformity 
present in the individual case. In the abstract repair is 
superior to substitution, but in practice we often have to 
deal, not with normal tissue, but witli tissues tliat liavo 
pei'inaiiently lost much of their origiimi sti'cngtli ■ and 
rcsilienc}', and in such 'cases repair miiv: be impossible 
altogether, and compel absoliito substitution — or,- being 
possible, ,be insufficient without a degree of substitution. 

Itctrorcision. ■ 

When operating for,, retroversion -of the uterus we have 
to. distinguish between the three classes of case: in the 
first of these the fault lies solely with the lax broad liga- 
ments; in the second it centres round the, point of inser- 
tion .of the uterus into the vaginal vault, the extreme 
upper fihi'cs of tlio cardinal ligaments being deficient; 
whilst in the third the defect is a weakness of the whole 
shelf. The first two varictic,s are oft’oii met with in young 
unmarried girls, and bear no necessary relation to ehild- 
licaring. A congenital defect is often alleged to be the 
critise ill those milliparons cases, but tho term “ growth 
defect” is bettor, for" probably the-, fibres which should 
hold the cervix in its iiorinnl position fail -to keep" pace 
with the enlargement of tho , ntoriis that occurs after 
puberty. Tlie third variety is, I think, always tii'e result 
of child-bearing, and in thc.so cases the vagina is .retro- 
vorted as well as ..the ntcriis. For the first variety tbo 
feling operation is eminently suitable, but for the second 
it is not ideal, because it does not raise tbo ulerus 
siiflicientl}% and the operation of sbortoiiing the round 
ligaments by retroperitoneal plication is to be preferred. 

In tho third variety botli of tlic.so operations are insufficient 
because they do not lift tbo retrovorted pelvic shelf, so that 
tboun-h tho uterus is brought forwards tho entire deformity 
is not eonected, and later on the patient is liable to return 
on account of retroversion or prolapse of the anterior 
vaginal wall. For such cases an operation which pulls np 
tiie uterus much higher and much more stroiigly is needed. 
Ventrofixation effects this object, and to a lesser extent 
so does the modification of round ligament shortening that 
I have cmploved for some years, whieh in effect .seourcs 
strong ventrosuspension from each cornu. Mhich of the 
two should be chosen in any particular case has to bo 
.Ipcided by consirleration of the exact degree of the 
cloformitv tlie character of tlio patient’s physique in 
general, 'and the texture of tho pelvic tissues in particular. 

Prolapse. 

Til the ti'catmont of prolapse a number of o]n'rations 
are at our service, all of whicli have tlieir spliercs of 
' ijiilicabilitv and inappheability. In deciding which of 
bhiiii is suitable to the iiidivithial ca.se, the surgeon has 
„ make ,q. his mind: (n) which part of the vagina pio- 
laiiscs and therefore which part of the supporting 
iXaratiis is at fault; (!>) wliether there is redundancy of 
the tissues or not; (c) the position of the uterus and 

to the site of the hnlge in vault prolapse and 
its uiidorlviii" cause it is the upper fibres of the cardinal 
'f.r.niioiits'tbat are relaxed, and these, to an extent, can 
1?' tautened from tbo vagina by exposing them 
he lateral forniccs after having amputated the vaginal 
;irvix aiM suturing them together, ofer..ni froiU r 
lehind the cervical stump. The .alternatnc is o d. cni 
horn altogether and make a new vault ligament out 01 

lie uterus bv ventrofixing it. nbich 

In cystocele it is the pubo-cei-vical 
s lax and needs repairing, and this can bo accomplisbcd 



MiRon i7i 19**1 


GASa?BO-JEJUNAr. ULOER. 


, r Tub UnmiB 
' L Ucpiojll JotmxiA 


433 


by niiterior colporrimpliy, providing tlint tho mnsculo-fnscia 
tnxitonod by EUturo ns well ns tho vaginal wall. When 
vana priap^ and cystocclo aro both present Fothorgill-B 
oporation is.suitablo, for it tantons both tho pubo-corvicnl 
fascia and tho upper fibres of tho cardinal ligaments. An 
nltonirtivo is to corabino anterior colporrhaiihy with 
ventrofixation. Which of tho two is tho better depends on 
tho individual case, but both, when properly applied, givo 
happy results. Another alteriiativo is tho interposition 
oporation, which eflects some tautening of tho fibres of tho 
cardinal ligaments and inarlcedly streiigthciis tho middlo 
section of tho pelvic shelf. When tho whole shelf has 
retroverted ventrofixation is indicated, for it cannot bo 
lifted except from above. Laxity of tho pelvic floor is 
perfectly corrected by perineorrhaphy proiierly performed — 
that is 'to say, with' suture both of tho Icvatores and tho 
fascia superficial to them. 1 einphasizo this becauso tlio 
latter are sometimes missed. 

For rcctocelo posterior eolpoporincorrhaphy moots tho 
case, but in that rare form of prolapse which is a true 
hernia of Douglas’s pouch colporrhaphy by itself is rarely 
eiEcieiit, becauso tho upper part of tho posterior vaginal 
wall is defective, so that tho vaginal oporation had better 
bo' supplemented by obliterating Douglas’s pouch from 
above by suturing tho rectum to the back of tho uterus. 

■ The question, of redundancy of tissue is important 
bocaiisc, if it exists, tho reparative operation must incliido 
tho rodiiciiig of it by amputation of tho cervix or excising 
largo areas of vaginal wall. On the other hand, it is quite 
conunon to moot with cases of prolapse in elderly women 
in which there is not only no redundancy of tho cervix 
and vagina, but actually a diminution of tissue, and in 
such, if tho surgeon unthinkingly excises more, ho will 
have difSculty in bringing' together tho cut edges of tho 
frail vaginal wall — a most disconcerting o.xpericnco. Sinco 
the ease with which tho vagina can turn inside out depends 
in part on tho relation between tho thickness of its wall 
and tho sizo of its lumen, any variety of prolapse can bo 
prevented by sulEciontly narrowing tho canal. This is tho 
effect of Lo Fort’s oporation, which leaves tho patient 
“ double vagina, each half of which is so narrow that 
in-falling of its wall is impossible. Great narrowing of 
the canal is, howovof, only allowable when tho patient no 
longer has relations with her husband on account of ago. 

iho |)nsition of tho uterus is important, becauso if it is 
ictrovorted the reparative operation must includo tho 
rectification of that part of tho displacement, for if it 
0 lett backwards tho abnormality of tho axis of direction 
o 10 intia-abdominal pressuro remains as before, and 
menaces a further displacement. Tho sizo, or rather 
>, of the utorhs should always bo iiicnsurcd with a 
Eoun 1 ono wishes to escape tho error of opening tho 
a .omen 0 icntrofix a uterus which is too small to bo 
roug it up to tho abdominal wall — a state of affairs quite 
TOmmon in .aged fat women. Finally, tho position of tho 
p l ie E 10 t inust bo ascertained by noting tho direction 

”^^i vagina, and if it is retroverted stops 

must be taken to bring it up. 


Conchtsion. 

ncliicvn'i^T'^*^! by which those various aims ca: 

this 1 1 * intend to discuss, becauso tho objec 

ocnJKii- •’“P®'" 'S to summarizo the basic fad 

imccssU u full appreciation of which 

a scienr^ * ‘he operations for its relief aro to const! 
tlm nn„ "? ‘“’h- surgeon who proclaims 

or Rot ®‘‘‘ldoys for prolapse is Jones’s or Sm 

coiKsifi proclaims himself ns belonging to 

"““'hind who prefer to got som 
tint 1? Fnncy a. tailor who advcri 

Joiips’«° '^”*1 hh " P"''' trousori 

aro alt Goiitlemqn, in tho matter in hanc 

anv nnvt'-' nur aim should bo not to carry 
wo'rds^nf P“’.‘"’""®ived sot operation, but, in 

mako tlio ■'"• 1 ^ immortal l,,ord High Executioner, 
Dmse dk.it""’ '".’Z '"•iiue ” by employing 

wliicb will readjustments, and sutni 

W neVj> ’ ^ P^'ts concerned ■' as 


^ Chlintral 

ON 

GASTRO-JEJUNAIj ulcer.* 

BY 

B. P. ROWLANDS, M.S., F.R.C.S., 

BUIiaEON TO guy’s HOSniAL. 


I AORx:}! with Balfour' that “ rccuvronco of ulceration may 
follow an}' oporation for jjeptic ulcer, including pai*tial 
gftstroctoiny.” Gastro-jojunal tilcor, of wliich two gravo 
oxnniplcs .aro recorded below, is tlio commonest secondary 
ulcor nhd tho most serious complication of gastro** 
jojxmoslomy. It may appear at any time from a fow days 
to twenty or more years after tho primary oporation, Ib 
is goiiorally taught that a now ulcor appears sooner or 
lator at, or near, tho stoma after about 2 por cent, of 
gnstro'jojunostomios performed for non-inalignant disease, 
Balfour found tho percentage to ho 1.6 after 8,600 gastro- 
ontcrostomios at tho Mayo Clinic; hut many patients suffer 
from this complication who do not sock anotlior opoi’ation, 
but do everything possible to avoid one, and I have reasons 
for thinking that it is far commoner than is generally 
bolieved. After seeing and treating many of these difficult 
cases, I have come to tho conclusion that gastro- 
jojuiioslomy should never bo. performed cither without 
gravo consideration beforehand or without tho greatest 
care to mako tho anastomosis a perfect ono. 

Casb I ; — Uccurrent Oastro-jcjtiiial Ulecn Oastro-colic Fistula: 

O^^crations: Jtccovcry. 

In 1915 I performed posterior pastro-jejunostomy for this 
patient (a man) at Guws Hospital for duodenal ulcer with 
stenosis. In March, 19^, 1 excised a small anterior gastro* 
jojunnl ulcor which had nearly pierced tho colon, and at the samo 
limo I enlarged tho stoma, which had contracted. Ho remained 
w'cll until Jiily, 1927, when ho suddenly developed a gastro*colic 
fistula with faecal vomiting. Somo of a barium enema obviously 
passed into tho etomacli, but none of another barium enema, given 
a few dnva Inter, However^ the diarrhoea and tho otlicr symptoms 
continued, Ibcroforo tho diagnosis of gnstro*colic fistula was mndo 
with confidence, and an oporation was advised. .Y-ray examination 
showed that nearly all tho food leaving tho stomach passed out 
through tho pylorus and duodenum; there was uo delay in tho 
stomach. 

At tho operation I found two gastro*colic fistulao; ono of them 
admitted tho index finger, tho other one was smaller; both 
opened from tho front wall of tho stoma, which was of good 
SI 20 and position. As tho duodenum was now patent and 
apparently healthy I excised tho gastro-colic fistulao and tho 
gastro-jejuuostomy, togctlicr with tho engaged loop of jejunum. 
This proved to bo extremely diflicult. Tho gastric wound and the 
distal cut end of tlic jejunum were closed, tho end of Iho 
duodenum being implanted into tlic jejunum, thus restoring tho 
normal anatomy and physiology as far as possible. 

About a month later tlio patient was readmitted for eevero 
haematemesis and mclacna. Tho source of tho bleeding was 
uncertain, but it was later proved to bo a posterior duodenal 
ulcer. Careful medical treatment, with tho patient in bed at 
tho hospital, was tried in vain for three months'. Duodenal 
stenosis gradually developed and increased so that visible peri- 
stalsis beenmo evident in the epigastrium, and vomiting of large 
quantities occurred about once cvciy forty-eight hours. Gastric 
lavage only afforded partial relief. 

On December 8th, 1927. another operation was performed. Tho 
stomach was very dilatca, hypertrophied, and inflamed, owing to 
n large, deep . posterior duodenal ulcer penetrating into tho 
pancreas and stenosing tho duodenum. No other ulcer could bo 
tound. A lateral gastro-duodenostomy was performed well below 
tho duodenal ulcer. The patient made a rapid and excellent 
recovery from tho oporation, but ho is to continue his extremely 
careful after-treatment for at least six months, and to observe 
all tho known precautions against recurrence. 

Case II . — Fccurrcnt Oastrv-jcfunal Ulcer: Partial Gastrectomy, 

This man was referred to mo for tho first lime early in 
December, 1927. with tho folloAving history. In 1908 ho was 
erpJored for gall-stones; none were found, but instead a duodenal 
ulcer with localized peritonitis, indicating an old perforation. 
Tho appendix was removed about a year later. In 1910, tho 
duodoiial ulcer persisting in spite of medical treatment, it bccamo 
necessary* to perform gastro-jejunostomy. Tho anterior operation 
was pci*rorracd, and the patient remained fairly well for nearly 
four Years. 

In/l914 another operation bccamo necessary, when a largo 
gastro-jojunal ulcer was found on tho front and right side of 
Iho stoma. There was also obvious obstruction of tho proximal 
loop of tho jejunum. For these conditions cntcro-anastomosis was 
performed; this relieved tho patient almost, completely for nearly 
eleven years, then symptoms of obslniction of Iho stomacn. 
recurred, and a severe haematemesis with mclacn a developed. 

•Delivered at Guj’s Hospital on December 15tb, 1927. 



434 MAUca 17, 1928] 


GASTRO-JEJUNAri ULCER, 


[ The ntraj* 
HtDlCU. 


Another operation was i)erformecI; tho gastro-jejunostomy had con- 
tracted so iniicli that it was necessary to dctadi it and make 
a new anterior one somewhat to the left of the old one. After 
this* operation the patient wag never weU, and a month Jater 
BuRered pain, and two swellings developed above and to the left, 
of tlie umbilicus. These wore at first thought to be ventral 
herniac/biifc later proved to be abscesses, whicii subsequcnlly dis- 
charged intermittently into tlie gastro-jeiunostomy. In June, 
1927 , several sinuses were excised, and they were found to lead 
down to the anastomosis. Two openings, one at each end 0 / the 
stoma, were closed. There was also an obstruction of a loop of 
jejunum about a foot below the anastomosis. Pbr this an entero- 
anastomosis was performed, and gave great relief, hut ilic pain 
aiui indigestion persisted, and abscesses recun*ed above and to 
the left of the umbilicus. The pain became almost continuous, 
tliQ patient thin, anaemic, and very miserable, praying for a ** kill 
or euro in the way of au operation. 

Oh December 8th, 1927, the operation was perfonned. A large 
elliptical piece of the abdominal wall, containing several abscesses, 
was excised, together with a litLlo more than lialf the stomach, 
the gastro-jejunostomy, the loop of jejunum engaged in the 
anastomosis, and a small piece of the transverse colon around 
a g«astro-coljc fistula. The operation was extremely difficult oiviwg 
•to numerous adhesions and the complicated anatomical condi- 
tions.. As the duodenum was hopelessly stenosed and very 
adherent, partial gastrcctom 3 ’ was the only possible radical opera- 
tion. The anastomosis was made after the Polj’a-Balfour method. 
The patient was so thin, and so nmch of the abdominal wall had 
been sacrificed, that it was difficult to close the parietal wound, 
but by beginning at each end and gradually proceeding towards 
the centre, and by mobilizing the parietal periloneu/n, the closure 
was at last successfully accomplished, and the wound healed per- 
fectly'. Three pints of normal saline were run into tlio axillae 
during the operation. The next day the patient, became very 
restless in spite of axillary infusion, and was transfused {three- 
quarters of a pint); this caused no reaction, hut improved the 
patient’s condilion to a remarkable extent. He is now making a 
slow iDufc satisfactoi^ recovery, although an abscess developed 
three weeks after Iho operation in the right hypochondriurn near 
a stab wound that had been used for drainage. He is now nmch 
better than ho has been for several years. 

Pathology. 

A gastro-jejiinal ulcer is one tliat forms upon the inargin 
of the gastro-jojunostomy and involves Ijotli the stomach 
and tlio jejunum at the lino of union; it ma^' eneirclo the 
stoma, and by fibrosis it tends to narrow the ojiening, which 
mny finall}^ become completely closed, as not infrequently 
happened after the use of the ** Murphy button. '' Jejunal 
ulcers are loss common ; they develop in the jejunum near 
tlj6 anastomosis, usually just below the stoma, or in the 
first four inches of the offerout limb of tlio jejiinunJ, very 
rarely in the afferent limb. The ulcer is generally small, 
but it may be deej) and invade tlie pancreas, the transverse 
colon, or a neighboiii'ing coil of small intestine, into any 
of w'hich it may ultimately perforate. It may also per- 
forate into tlie peritoneum, causing a grave form of 
peritonitis, or even into the abdominal w’all, causing a 
parietal absce.ss or cutaneous fistula. It ulcorato into 
a large artery, siicli as the middle colic, and cause severe, 
or even fatal, iiaemorrhage. 

Etiology and PnorHYL.vxis. 

Tiie causation and prevention of gastro-jejunal ulcer are 
vGiy important; certain facts bearing on these may now 
bo considered. 

Out of 270 cases at tho Ma\'o Clinic 248 ivere males and 
onl^’ 22 were females, a ratio of eleven to one, whereas 
gastro-jejnnostom^" was iierfonned only three times as often 
in men as in women. Secondary iilceration is far more 
likely to follow when the primary peptic ulcer is duodenal 
rather than gasti-ic. Balfouz’^ founct that 
“ of those cases in which gastro-entcrostomy was performed ah 
tliQ clinic, gastro-jcjimal ulcer followed an operation for duodenal 
ulcer in 130, and followed operation for gastric ulcer in only nine. 
While this ratio is 15 : 1, the ratio between the number of cases 
in which gaslro-entcroslomy was performed for duodenal ulcer 
and those m which it was perfoJ*mcd for gastric nicer is 7:1.” 

These facts arc significant, and tend to show that men’s 
habits and occupations iiave some relation to secondary 
ulceration. Men are more prone to excessive smoking and 
drinking, and have moi'o laboiious mental a/icJ physical 
occtipations, anil generally Ijave less leisure, u-jOi Jess 
fieqiient and less regular meals. 

Excess of free hydrocliloric acid in the stomach and in 
the bowel at or near the stom.a lias always been considered 
an important cause, .supported bv the absence of sccondaiT 
ulceration (other thau rare septic instances) gastro- 

jejiuiostomj' for cancov of the stomach, and tho undue 
frequency' after an operation for duodenal ulcer in which 


excess of free hydrocblorie acid is constant before opera- 
tion, and usua ly after it/ as showb by A. R. Hurst’ at 
New Lodge Clinic,' whereas hj^icrclilorbydria is rateW 
associated witli gastric ulcer. Balfouri found tliat in 40 pet 
cent, of his series of eases of gastro-jejunal ulcer 

“ the free IiytlrocbJoric acid was citlior increased or very sliehtly 
reduced by the gastro-cnterosioniy ; but in 40 per cent, there was a 
marked reduction, and in 20 per cent, the free hYdrochloiic add 
was reduced to zero. The fact that there was no free hydrochloric 
flcifi in oiie-fjflli of iho cases of gasiro-jojunal ulcer, in which 
repeated anil 'fraclional e.xaminations of the gastric contents were 
made, disproves tho assumption that achlorhydria following Iho 
pnmary operation affords protection against later ulceration.” 

Tho liyjiertoiiic tyjio of stomach commonly seen in tho 
suhjeets of duodenal ulcer is particularly subject to reciir- 
roni ulceration, but any of the errors of habit or of sepsis 
which may haro coiitrihuted to the causation of tho original 
peptic ulcer, unless tliey. are eliminated, may cause tho 
aiipearancc of a .secondary .nicer. Notable among these 
causes arc imperfect mastication, irregular meals, septic 
teotli, tonsils, sinuses, appendix, or gall-bladdor. Infection 
from an open duodenal or gastric ulcer left behind may be 
grafted iipoa the stoma. ... 

Anatomical and jiliysiological errors at the stoma aro 
important causes of recurrent ulceration. Among tlieso 
may bo mentioned a wu'onglj^ placed stoma, which does not 
drain the stomach well or obstructs tho jejimum by Itinking 
or torsion at or near the stoma ; bruising or laceration of 
tho %-isccra engaged in the anastomosis is to be scrupulously 
- avoided, as aiso are al! unabsovbahle sutures. Drugs, 
especially tobacco and alcohol, have much to ansirer for in 
the pathogenesis of gastvo-jejima! ulcer. 

Errors in tlie after-treatment undoubtedly contributp 
towards tho formation of gastro-jejunal ulcer.' It is 
important for the jiatient to be dieted with the greatest 
care and allowed only soft and non-irritating food at 
revidar and .short intervals, and to have a long restful 
hotiday before lie returns to work and worry. The slightest 
return of symptoms demands rest and a return to medical 
tveatnieut by dieting and administration of alkalis. 

Diagnosis. 

• already said, I believe that gastro-jejunal ulceratioa 
is much commoner than is generally supposed, and tliat it 
should bo- suspected whenever abdominal paiii or “ indiges- 
tioii” follows gastro-jejunostomy. Tho- diagnosis is not 
easy, particularly as radiography rarely gives anj' direct 
evidence of this form of peptic uleeration;j-that is to say, 
irrarelv displavs a shadow of the ulcer. I have only once 
seen such a sh'adow confirmed by operation. But radio- 
Sanbv gives valuable hints-generaiiy delay in emptying 
B,vL' 4 a narrow stoma and uneasy peristalsis in the 
, nut of tho jejunum. The symptoms are moro 
reliable.*^ They aro similar to those of duodenal 

• llv Iiun'>'er pain perhaps relieved by food and 
but com ng on much earlier than the pain of 
S^Si’al Lr gen^crally within an hour after food; latez 
•r Wnmes more severe and almost continuous; morraycr, 

It above and to the left of tho navel instead of m the 
rfeht hpieastric anglA Tenderness and perhaps a tumoni 
uotiwd in same .situation. Melaena or occuB 

Mo'od in tho stools is very significant if tho patient is on 
“of free diet Wasting and anaemia aro usually very 
Gastro-colic fistula when present is clearly indi- 
ct hv diarrhoea, foul eructations, and faecal vomiting, 
The cvV > Pov undigested food and the 

”'■!/ shadows after a barium enema are generally 

conclusive. ^ duodenal ulcer, or especially 

rale nicer or a carcinoma supervening thereon, may be 
01 a gastro-jejunal ulcer. In one case I mistook 
mistak (.urvature, which developed 

^ vcivvs aftei' n' gastro-jojunosloniy kafi been per- 

some ,jicer with stenosis and had afforded 

formed foi duoue a u 

complete relief o na^ to the leFt of tho nave , 

ri-Rh gastra-jejmial ulcer. The ulcer was successfully 

"'chronic cholecystitis, Tom - 

be mistaken for gastio-jejnnal ''’vei, b>it 

ditioiis there is no occult blood in the faccos on a me 

diet. 



435 


M^BOH 17, 1928] 


GASXRO-^JEj’O^iAE ULCER. 


[ 


Thz Bsirwa • 
UZOICXZ. JOUBKAZ. 


'• ■ Memcal Tbcatment. 

■ The medical treatment of gastro-jojunal idceration is far 
more difficult and less successful than that of any other 
form of pentio ulceration, .but it is alirays worth trying 
a thorough course of dieting and alk-alis, with completo 
rest in bid. Every jiossible source of sepsis must bo care- 
fully sou<rbt and removed. Sometimes medical treatment 
meets with success, but, even if it docs not, it makes an 
excellent preparation for tho surgical treatment that often 
affords the only hope of success. Sometimes blood trans- 
fusion on one or moro occasions is necessary before an 
operation can bo hopefully undertaken, 

SuacicAL Theatitent. 

. 1 . For rcTforaiive Peritonitis. 

■ As a rule the patient is so ill when ho comes for treats 
ment that all that can bo done is to close the perforation 

; and drain above tho piibis. Medical treatment is then well 
'tried, and if that, fails a radical operation can bo carried 
'out' later. ' 'Grant Massie^ studied thirty-six recorded cases 
ill addition to his own. Tho largo majority (75 per cent.) 
of the perforating ulcers were -jejunal, those being less pro- 
tected than those at tho anastomosis. Tw'entj’-two of the 
thirty-seven patients died, so that tho mortality is very 
high', nearly 60 per cent. 

2 . Padical Opcralion.‘ 

. This may tax the skill, -ingenuity, and resource of tho 
best surgeon, owing to extensive adhesions, the obscure 
relations of the affected parts, and tho poor condition of the 
patient. It is wise, to insist on complete rest in bed and 
careful medical treatment for at least a week before the 
oper.itioa, which m.ay be a difficult and prolonged one. 
The ideals aro to excise the ulcer, provide free drainage of 
the stomach, and to restore ns far ns possible tho normal 
anatomical and plp'siological conditions. The preliminary 
ladiographio examination may have shown that nearly all 
tile food leaves the stomach through tho pylorus, and at the 
operation tho pylorus and duodenum may be found to be 
patent, any previously existing ulceration having healed 
HI out causmg obstruction. In these circumstances the 
should bo abolished, the ulcer excised, 

■ I ** jejunum dosed without narrowing 

s c lannel. This should also be done when the primary 

ojieia ion « at improperly performed for gastric symptoms 
At, ^ ■'uutural alteration of the stomach or duodenum. 
Inrif *112^ udds further anatomical or physio- 

in motions is to be avoided. Tho addition, for 

freer' 2“°*'!'®'' gu^ro-jejunostomy in tho hope that 

heal ia t 1 stomach may induce the ulcer to 

ulcer 1, It is far better to excise tho 

dannprnnc '1 ^ ' “PP®ur moro difficult and 

the^nosteri •^*J® gustro-jojunostomy is of 

cision ia h? a' TpUical left paramedian in- 
umbilic'ns Tht ®P’Sastrium extending below the 

cxnloratinn "f ®Im“ld commence ns a rapid 

■ apneiidiT nr rrnii a diseased 

the duodenum n" ®*^ould be removed. The stomach, 

for siens of ill ^^® ®lpma should bo carefully examined 
maVSo tv obstniction. Dense adhesions 

;too'verrotka^Mc“n"“'^ 

' of the stoma “®®ii especially on the posterior surface 
The stoma i,i 

- Occasionallv it i,i T.!!. “"<1 sometimes very small, 

or twisted h-r n u. size, but the jejunum is kinked 

shown by tlfe ®®ions, so that the food, which has been 
manner dnko *'° the stomach in a normal 

tho ulcer has l,n° freely along the jejunum. IVhen 

or divided ' find adhesions should be separated 

.brought forward JnP carefully freed, defined, and 

often tedious and important step is 

posterior and invadfn^ m*"’ .ulcer Js 

peritoneal- sac and df° PO"creas. Opening the lesser 
toneum greatly fiMiu *'’’® Posterior parietal pefi- 

fba invaded pancreas ““^‘’'^“t'ou. but some of 

ulcer. A rubber ’^® removed with the 

forward the lumb-ir behind the back helps to bring 
lumbar spine and makes the disserfion easier. 


Having separated, brought forward, and clamped the parts 
concerned in tho anastomosis tho most suitable treatment 
is more easily determined. 

(a) 'Simple. Excision of the Ulcer. 

If tho ulcer is small and not encircling the stoma it 
is often possible to excise it and to sew up the resulting 
wound in such a way as to enlarge the stoma or jejunal 
channel. But in some cases the ulceration may recur, as 
in Case I, unless all the causes of recurrence can bo 
eliminated. 

(b) Excision of the Ulcer and Aholition of the Stoma. 

If the ulcer is largo or . encircles the stoma, which is 
often contracted, it is necessary to excise the ulcerated 
area, thus detaching the jejunum from the stomach, and 
occasionally to make a now and better stoma, but if the 
pylorus and duodenum are healthy and patent, as often 
happens, it is not necessary to remake the gastro- 
jejunostomy; it is far better to close the openings in the 
stomach and jejunum, thus re-establishing the normal 
anatomy and physiology of the parts. 

(c) Aiolition of the Stoma plus Gastro-duadcnosiomij. 

If the original gastro-jej unostomy was anterior, it is 

sometimes possible to perform gastro-duodenostomy, making 
use of the opening left in the anterior wall of the stdmach 
after tho excision of the ulcer. The opening in the 
jejunum is then closed without narrowing the lumen. The 
result in one of my cases has remained very satisfactory 
for ten years. After this operation recurrence of ulcera- 
tion at tho stoma is very unlikely, owing to the free 
admixture of the alkaline duodenal secretions with the 
gastric juice. SimUarly, when the duodenum is stenosed, 
after disengaging a posterior gastro-jejunostomy and 
closing the openings in the stomach and jejunum, a low 
lateral gastro-duodenostomy is made well away from the 
scarred. or possibly ulcerated part of the duodenum. I have 
found this method extremely satisfactory. It is easier and 
better than “ Finney’s operation ” for these cases, and it 
saves the patient from the more formidable operation of 
partial gastrectomy. 

(d) Partial Gastrectomy. 

In bad cases, especially when the gastro-jejunal ulcer is 
recurrent and complicated, and when the duodenum is 
ulcerated, stenosed, or embedded in dense adhesions, it is 
usually wise to perform partial gastrectomy, which may be 
no more formidable than a less ambitious operation. It 
has the considerable merit of reducing the amount of the 
free and corroding hydrochloric acid. In order to avoid 
adhesions and other difficulties the stomach is divided to 
the left of tho pylorus and its distal end is closed, a large 
cylindrical part of the stomach and the gastro-jejunostomy 
are isolated, clamped, and excised without sacrificing more 
of the jejunum than is absolutely necessary, so that the 
opening can be closed transversely without narrowing tho 
lumen. Tho jejunum is then joined to the end of the 
cardiac remainder of ' the stomach after the Polya- 
Balfour-Moynihan method. 

(c) Closure of Gastro-colic Fistula. 

'When there is a gastro-colic fisttda the colon is clamped, 
detached, and closed in two layers without narrowing its 
lumen; it is then covered with omentum and the removal 
of the gastro-jejunal ulcer is proceeded with. In one of 
my cases there was an additional fistula between the 
stomach and the ileum; this can be treated in a similar 
way. 

Results of Opebative Teeatiiext. 

The formidable nature of the radical operations that are 
necessary for gastro-jojunal ulcer, and the thin, anaemic, 
and exhausted condition of many of ^ these patients 
requiring it, would point to the probability of a high 
mortality, but as a matter of fact in good hands ^ the 
mortality is not unduly high. At the Mayo Clinic^ 
the mortality was only 3.57 per cent, in eighty-nine partial 
gastrectomies for this condition. The ultimate results aro 
good and more than justify the risk of this radical opera- 
tion for “ complete relief of symptoms follows the opera- 
tion’ in more than 85 per cent, of the cases,”- From my. 



436 Mmich 17 , 1928 ] 


PROGNOSIS IN EUIiMONAR-Z TUBERCULOSIS. 


t TimIJRm!* 

MzDICiZ, JOCRSIL 


own ospcvienco 1 can tear ont these liopefnl conchisions, 
and 1 firmly holiovo.that either restoration of tho norma] 
physiology or partial gastrectomy is necessary in most 
cases; the former approaches the ideal, hut tho latter is 
sometimes the only practical i-adical method available. 

HUEnESCES. 

^Annals nf Surgerij, 1925, Ixxxiv, 271-283. - Loc. cit. ^ Otty's Hospilnl 
lieporU, 1921, Ixxj, 319. * Loc. cit. « Guy's Iteports, 1924, Ixxiv, 

70. Ibid., 1922, Ixxi, 331; seo also OiicratfOMS of Surgery, vol, j, p. 173. 
'Loc, cit. 


PEOGJfOSIS M PTJLMOMEY TUBEEOULOSIS.- 

ar 

JOHN R. GILLESPIE, H.A., M.D., D.P.H., 

CHIEF TUBEKCULOSrS MEDICAL OFFICEn, CO. DOWN. 

Even in the same community there are cnormons differences 
in tho resisting power of individuals attacked hy tho 
tubercle bacillus. At tho one extreme are those who over- 
come the bacillus so easily that its presence in them is 
never suspected during life; at the other aro tho victims 
of “ galloping consumption,” who are very ill when first 
seen by the doctor, and grow progressively worse until 
death supervenes. Between these extremes are tho majority 
of consumptives, whoso resisting power can bo fostered hy 
appropriate treatment. 

P.VTIENTS WITH Sjt-ALI. RESISTING PoWEH. 

Tho proportion of cases in county Down in which resist- 
ance was very small (1913 to 1924) is shown roughly by tho 
percentage of cases in which death occurred within six 
months of the dato on which each patient was first seen 
by one of tho tuberculosis medical officers. 


Table J.— Percentage Dead u-ithin Six Months. 



T.B. + 1 

T.B. - 


Percentage. 

Tears of ! 
Extremes. 

Percentage. i 

1 

Tfars of 
Extremes; 

Average 

35.0 

— 

25.7 

— 

Jlasimitm 

43.2 

1923 

40.5 

1918 



27.0 

1913 

12.5 

1317 


If we separate these cases into febrile and afebrile, includ- 
ing among the latter all cases in which tho teinpor.nturo 
ceased to exceed 99° F. after a week’s rest in bed, wo 
get Tables 11 and III in place of Tablo I. 


Table II . — Febrile Gases. Died within .Six Months. 



T.B. + 

T.B. - 


Percentage. 

Years of 
Extremes. 

Percentage, 

Years of 
Extremes. 

Average 

43.3 

- 

43.3 

— 

Maximum... 

61.5 

1922 1 

59.1 1 

1922 

Minimum 

41.2 

1914 

25.0 

1917 

Table III.- 

—Afebrile Cases, Died within Six 2Ionths. 


T.B. + 

T.B. - 

1 

1 Percentage. 

Years of 
Extremes. 

j Percentage. 

1 

t Years of 

1 Extremes. 

■ 1 

Average 

12.8 

- 

1 8.1 

- 

1 

Maximum ; 

22.0 

1915 

37.0 

f 

1918 - 
1915 

Minimum 

0 

1917 

; ” 1 

1917 

1922 


Since the percentage of rapidly fatal cases found in 
different years varies so much, w e should be chary about 

* An abridgment of a paper read before the Belfast Division of tho 
British 3Xedicol Association. 


coming to a conclusion as to the efficacy of any remedy 
intended to reduce this percentage, until it has been tried 
111 a large number of cases spread over a considerable 
number of years. 

Almost without exception tho patients who died within 
SIX months were considered too ill either to bo sent to a 
sanatorium or to bo treated at a tuberculosis dispeusaiy, 

1 ftBgeniGiits A\ciG tliGrcfore m^do for domiciliary treat- 
ment, the patient being instructed to stay in bed 'as long 
as tho tomperaturo exceeded 99° F. at any time in tlio day; 
to have a room to himself; to admit as much fresh air 
and sunlight as possible into his loom; and to take as much 
plain nourishing food of various kinds as his stomach 
would allow. 

■Where satisfactory homo conditions were not available 
the patient was advised to go into the union infinnaiy. 
No special treatment, such as artificial pneumothorax, was 
tried in any of them. As there is no county sanatorium 
in county Down, and tho sanatoriums to which wo sent 
patients were unwilling to take had cases, this was tlia 
best we could do. 

Uccent and Non-rccent Cases. 

In 52 per cent, of our cases (1913 to 1924) the patients 
had been ill for more than six months before the tuber- 
culosis medical officer was called in, and in 48 per cent, for 
less. Counting tho latter as recent cases, and tho former 
as non-recent, we get the following four tables. 


Table IV .— Febrile Cases. Died within Six Months, 



T.B. + 

T.B. - 

Percentage. 

Years of • , 
E.xtremes. 

j Percentage. 

[ Years of 

I Extremes. 

.Average 

49.8 

- 

43.4 

- 

Maximum 

63.2 

1919 

67.2 

1922 

1 

Minimum 

32.2 

1916 

22.2 

1 1917 


Table Y.— jVon-rccent Febrile Gates. Died within .Six Months. 


— 

T.B. + 1 

T.B." 


Percentage. 

Years of 
Extremes. 

! Percentage. 

1 

Tears of 
E.xtremes. 

Average 

48.6 

- 

43.0 

- 

lIa.vJmnm 

64.3 

1922 

68.8 

1923 

Minimum ... 

31.2 , 

1913 ; 

12.4 

1913 











































MAKOH 17. 1938] 


PIIOGNOSIS IN PUIiMONABX TUBEBOUIiOSIS. 


The Bumf* • 4.Q7 

. JlEDlCil. JOXTEEli *01 


Talcing the nvcrngo figures f loin Tallies 1\ , V, VI, and 
VH as a basis, ivo can iioiv cInssiO; the oases iii llio order 
of good prognosis as regards immediate danger ns follorvs: 

Table YlH.-I’rrraim-jr oj Palieiits irlio Pied irilhiii Six .Months. 


I. Recent afebrile rntients ... 

II. Kon-receiit nfcbri/c 

HI. Non-recent febrile 

IV. Recent febrile 


From tin's table may be seen the nisdnin of I’rofessor 
MocIIgnard and Dr. Fnbor in asking that .sanoerysin be 
used only in afebrile exudative oas<'s. liy exudative oase.s 
they mean cases in rvbicb tliore bas been proliferation of 
cells rather than formation of fibrous tis-.u(' in the affected 
parts of the lungs. Thi.s is the condition to be expected 
in recent cases. ' Hence afebrile exudative cases are very 
much the same as recent afebrile cases. These are the 
cases in which the best results arc to be expected, whatever 
form of treatment be used. 

Exfenf of Disease as De.realed hi/ Vhi/sieal Sii/ns. 

Tip to this iioint no account has been taken of the extent 
of the disease in the lungs, as revealed hy |)hy.sical signs. 
This is an important consideration. At the first cxainina- 
tinn of each of the jiatients the case was classified accord- 
ing^ to the Turban-Cierliardt rules, the .symbols T.G. 1, 
T.G. 2, and T.G. 3 being enniloyed to indicate tlie extent 
and severity of physical signs. The effect of a further 
suonivision of the cases according to this consideration is 
shown in Table IX. 

Table IX.-Pmenlanc 0 / Patients ,eho Died leithiii Six Months; 

Average of Tirelve Vears, 


T.G. 1 and 2. 



T.B.- 

T.B. + 

T.ll. - 

1 t.b. + 

3.2 

5.4 

8.2 

14.5 

5.3 

5.3 

13.4 

20.0 

23.2 

26.7 

54.0 

55.1 

33.9 

38.0 

47.7 

i 54.7 


inothod ” ; (2) sanatorium, where tuberculin was used in 
very few cases, and then only by a rule-of-thunib method; 
and (3) domiciliary. 

FTo ca.se was classed as treated at di.spensary or sana- 
torium unless at least three months’ treatment had been 
received at one or the other. Patients who received tuber- 
culin treatment from their own doctors under the direction 
of the tuberculosis medical officer are classed with those 
treated at the di.spensary. To avoid confusion, cases in 
which three or more months of dispensary treatment was 
received as well as three or more months of sanatorium 
treatment are not included in Table X, which illustrates 
what has just been said. 

Tabli; X . — After Ten Years, 



Borcentajie at Work after 
Ten Years. 

Perceuta;^e Dead after 
Ten Years. 


T.B. + 

T.B. - 

T.B. + 

T.B. - 

Dispensary 

19.2 

70.0 

72.0 

21.0 

Snnntoriimi 

11.8 

67.0 

88.2 

33.0 

Domiciliary 

2.4 

44.4 

94.1 

55.3 


Afcbi-ile: Becent ... 

.. Xon-recent 
Febrile : Kon-recent 
.. Eecent ... 


anv'iinrHlln ina.y calculate the piobability that in 

iviil lint ** case of pulmoiiaiy tuberculosis death will or 
mil not occur within six months. 

Tim 1 - Dnisc Date. 

into accoimt *' ' item not yet taken 

bv rest in' imU ?,t /cbule eases can be rendered afebrile 
above normal' If tliV"''^'' 1 ““ ‘t "ormal, or not mueh 

120 or more ti o febrile, and the pulse rate 

bowever 1; G''-'''-'-- The pulse rate, 

doctor than'in''h7n7’‘^'’* ** 1 ^ presence of tho 

tlio first visit. The appj'es particularly to 

in .some cases' . Pi^raturc, too, is similarly affected 


in .some cases too, is siiniiariy aiiecxeu 

Let Mobehate Besisting Powra. 

"ho snn-ired inm’rt'b* ''ft'^‘'-i'i®t'>0' of the patients 
seen bv one of tlie t" i^'^ ™o';ti>s after they were first 
number of tlm tuberculosis medical officers. The 

baei ii in the r*; "f ^43 had tubercle 

Ten- Uat fil ®23 l.ad not. There was a 

revavds rest 01-1 between these two groups, both as 

a-af ato f 7sw'r7“'e P-"' There 

each of tliese T B + amrT Tt'" in 

method of treatment. 8‘'o"PS. according to the 

’ pciisarv, 7mrrHibCTc7n (1) dis- 

to what I have called ® “^cording 

u in a previous paper “ a rational 


No attempt was made to select better cases for dispensaiy 
treatment than for sanatorium, nor vice versa. Those who 
were fit for tho one were goiiorally fit for tho other, and 
the choice wa.s left with the patients. 

The o.xelusion of tJio ca.ses in which death occurred 
within six months of tho time when each imtieiit was first 
examined by a tnbcrcnlosis medical officer left the third 
group not very diireionl, to begin with, from the other two. 

It is noleworthy tliat even among jiatients who had 
tubercle bacilli in their sputum, and who did not receive 
cither dispensary or sanatorium trcatiiieiit, 2.4 per cent, of 
those who survh ed the first six months wore at work after 
ten years. If, thoreforo, wo are shown one or more 
patients who liave done well nndor some form of treatment, 
and arc asked to believe in consequence that this form 
of treatment is efficacious, wo should hesitate to come to 
a conclusion until wc know what proportion of the patients 
so treated have done well, and how long they have con- 
tinued well, separating T.B.+ from T.B.- cases. Among 
the latter 44.4 jicr cent, of those who survived the first 
six months werc> at work after ten yeai-s without any 
special treatment. 

Table XI illustrates the effect on recovery and main- 
tenance of working power of (1) the presence or absence 
of tuborclo bacilli in tlio .sputum; (2) the extent of the 
disease in tbo lungs ns revealed by physical signs; and 
(3) the mode of treatment. In this are included all the 
cases diagnosed as pulmonary tuberculosis in the thirteen 
years 1013-25, cxcejit (1) a few thafi could not be traced, 
(2) cases where- death occurred within six months from 
the time when the patient was first examined hy a tuber- 
culosis medical officer, and (3) cases in wliieb both dis- 
pensary and sauatorinra treatment were received for three 
or more months each. 

The figures in the table represent the percentage in each 
section who were at work in jMarch, 1927. Tho average 
time that had elapsed since the patients wore firet seen 
was thus eight years. 

Table XI.— Patient'! first seen in years 1D13-2-J. Percentage at 
ll'erl- in March. 2937. 


Mode of Treatmcut.j 

T.B. - 


T.B. + 

T.G. 1 and 2. 

T.G. 3. 

T.G. 1 and 2. 

T.G. 3. 

Dispensary ' 

82.G 

68.9 

37.1 

9.6 

Sanatorium 

£0.0 

41.7 

15.5 

6.6 

Domiciliarj' 

55.0 

40.1 

11.5 

4.4 


Tliese futures, as well as tliose in laoie coiuuin me in 
the opinffin that tuberculin, when rightly used, is of 
distinct service in the treatment of pulmonarj- tuberculosis. 










• J ilc' 

.438 MAltCH 17 , igzSJ CHKONIO HEADACHE BEDIEVED BY OPERATION. 


M«I 


r Tnc Bnms« 

L Medical Jocrnai, 


CHROKIC HEADACHE AOT) T?ATN IN THE EYES 
RELIEVED BY A NASAL OPERATION. 

BY 

ROSA FORD, D.O., 

OPimtALiriC SURGEON TO THE SOUTH LOKBON HOSPITAL FOB WOMEN. 


Although tliero is nothing now in tho relief of pain by a 
nasal operation, tlio tliroo following cases aro reported 
becanso the indications for the operation were so indefinite, 
and tho diagnosis so obscure, that tho throo ji^itients had 
sought medical relief, many times, in vain. 

Case r. 

An unmarried woman, a teacher, need 32, had suffered from 
frontal headache for ten years, and from pain behind tho left 
eyo and along tho nose to the tip for one year. In addition, sho 
had often been off v.’ork for general debility. On several occasions 
a tired heart” had been diagnosed, and sho was particularly 
troubled by the alteration in her mental condition. She sometimes, 
for example, felt 'unable to reply to a tradesman calling at tho 
door, could not concentrate, or had a ” sense of fear.” She left 
town for tho countrj*, and finally for New Zealand, on account 
of tho ” troublesome pressure ” in licr head, and had returned 
on Iioliday wJion I saw her. There was notliing iii the eyes to 
account for the pain. Glasses had failed on three occasions to 
relieve her, and there was no muscular imbalance. Tlicro were, 
however, two clues — the patient’s past historj' and the fields 
of vision. 

1. The Past History. — She had had post-nasal catarrh, certainly 
Einco tho age of 14, and probably four j'oars earlier, when she 
had measles. As a child she always had colds in tlic head, had 
suffered from frontal headaches and “ muddled head,” and was 
seldom clear-headed. At 19 sho was using fifty handkerchiefs 
a week. At 22 part of the left middle turbinate was removed, 
and this reduced tho catarrh, so that she afterwards only soaked 
two handkerchiefs before breakfast, tlio discharge coming mostly 
from tho left side of the nose. But tho operation was followed 
by tho frontal headache, from which sho continued to suffer for 
ten years. 

• 2. The Both blind spots wore slightly enlarged, and 

tho left had a large relative o.xtension outwards, Tlie fields were 
contracted, especially iho left. 

These two clues led to a diagnosis of sinusitis as Uio cause 
of the pain in tho head and eyes, tlic post-nasal catarrh, and the 
field changes. To confirm this diagnosis the sinuses were a:-rayed,- 
but with a negative result. An aural examination .showed left 
ethmoiditis, but operation was not advised. Local treatment was 
ordered and followed for some weeks, but,- as tho pain continued, 
the patient pressed for further advice, and a second aural surgeon 
found septic tonsils and a high septal deviation to the right. 
There was no pus. A- second ar-ray examination was also negative, 
though tho aural surgeon thought there was a sliglit dullness of 
the left ethmoid. 

The tonsils were enucleated and a partial submucous resection 
was perfonned. Before leaving the nursing home tho patient 
wrote : ” That miserable pressure has been entirely removed, and 
my head is as clear as day and my eyes arc splendid.” A month 
later slio was still free from pain; she said that her menial con- 
dition liad been entirely normal since the operation, and that the 
catarrh had practically ceased. Her blind spots wore normal, the 
relative scotoma about the left bliud spot had disappeared, and' 
the fields were almost full. Eleven months later she wrote fi'om 
New Zealand that she was ” much better in every way and^ 
improving all the time.” 

Case ii. 

An unmarried woman, a nurse, aged 52, had suffered for eleven 
years from left frontal headache, with vomiting, and from pain 
at the back of the left eye for four years. During tho last two 
years the left eye had ached almost incessantly. In addition^ she 
was constantly tired, and felt her mental powers so dimiiiislicd 
that she finally decided to give up her post. 

There vvas nothing in the eyes to explain the pain. Glasses 
had failed several times to relievo her, and there was no muscular 
imbalance. The clues were extremely few and vague. No sym- 
ptoms at all of nasal disease could bo elicited. 

1. The Past History. — At tho ago of 13 there had boon a seven 
months’ illness, commencing witli measles and pneumonia and 
ending with ” typhoid,” in which the eyes and nose had been 

verv bad.” Since then her life had been a long succession of 
geptic infections— continual dental^ abscesses from the ago of 14 
to 26 carbuncles at 27, colitis ‘ , n. . . amour aemoved 

fromUhe left breast at 39, • 'cmovcd at 45, 

cjentral choroido-rctinitis firs , , 

^rbuncles again at 50. This history suggested tho possibility of 
Sniitis, commencing at 13 and continuing as a septic focus, 
Sving no evidence of its . existence except 111 tho sccoiidary- 

S^oth^ contracted bitomporally. The 

• fi ennf ivas cttlargcd, with considerable relative extension. 

Th. r lul bb-nd spot "la/normal, with slight relative extension 

On Vh^e grounds a tentative diagnosis of sinusitis was made. 

A first aGraf and x-ray cxan.iiiation proved negative. Later on, 
a second x-ray examination was also negative, but Mr. Gill-Caroy, 
who kindly examined tier for me, found Iiigli 
the left and tenderness of the floor of the left frontal sinus. 
Xliero was no evidence of pus, and an operation was not advised. J 


cvidciicG all iho teeth were then extracted, and two 
afterwards in the country. At the end of this 
aural surgeon agreed that 
advisable. A portion of the anterior end of tho 
middle turbinate was removed, Nino days later the pain liad 

practically tree from 

headache. Two montlis later there had been two headaches but 
pain,^ and the head had been ” man'cHously better.” 
Vision was niiSi-y at times, and this, ■witli the incomplete freedom 
from headaches, led Mr. Gill-Carey to suggest the removal of a 
further piece of turbinate.^ This was done, and at tho same time, 
m view of the long septic history, the tonsils were enucleated. 
Iwo JBonlhs later there had been only one headache, after a cold, 
-l-ljo fiphls had widened to some extent, especially tho right. 

Obviously tho cause of the headache had been reached, though 
tlio result seemed Jess complete tlian in tlic otlicr two cases, in 
w'hich a resection of the septum was performed. 

Tho sinuses in this case were punctured, washed out, and the 
washings cultured. The right sphenoid was sterile, but from botli 
ethmoids were recovered Htrcjftococc.us longus and Staphylococcus 
o/Wand the left splienoid gave a growth of Staphylococcus albus. 
Culture from tho tonsils produced a bacillus of the Friedlander 
type and Streptococcus longus. 

Case nr. 

An unmarried woman, a nurse, aged 44, had suffered from 
vortical headache and aching of the eyes for. three years. Tho 
headache had begun quite suddenly, without apparent cause. 
Sho had consulted two^ other oculists, each on two occasions, 
without relief. In addftion, she was ** frightfuUy iired,” '‘hope- 
lessly depressed,” and could not roly on her mental powers — 
for example, when playing bridge there would be intervals when 
her mind was a blank, so that she could not continue the game. 

There was no cause in tho eyes for the pain. Glasses had failed 
raanj times to relieve her, and there was no muscular imbalance. 
Again there were two clues — one in the past histoiy and the 
otlicr in the fields of vision. 

- 1. The Past History. — (a) Sho had suffered from post-nasal 
catarrh all Jier life. In infancy there had been two severe 
illnesses, of- which no details xvere available. Possibly the catarrh 
originated in one of tlicse. (b) Eleven years previously she had 
ha3 a septic throat, for whicli she haS been off duty for six 
weeks. Before this sho had considered herself a healthy woman, 
after this sho was never really well, and at the age of 41, eight 
years after the throat infection, her health was so impaired that 
sho was obliged to give up work. • . 

2 The fields. — Both were markedly contracted for small objects, 
-and the right blind spot was decidealy enlarged. - 

These clues led to tlic following interj^rclation 01 the case. In 
infancy some illness liad started a sinusitis, of which at first tho 
onlV evidence was post-nasal .catarrh, although the rheumatism 
and bad Icelb, from which she liad suffered from her earnest 
ramllections were probably secondary infections from the focus 
fn - tho ciuus. Tho^ general health was not further affected, 
because drainage was^ free. At tho age of 33 the septic throat 
^nsed an exacerbation of the sinusitis and increased tho block 
to drainage, so that septic absorption increased, with con^sequciifc 
in hciltli ■ At 41 a further infiammatory increase of the block to 
draS dosed the sinuses still more, Icaaing to tension witlnn 
them - and thus to headadie and pam round tlie eyes. . - 

n?diolo-ical examination proved negailvo, but a high septal 
devf8t on“to the riglit was found, with compensatory left middle 
? pidarecmcnt, and chronic inflammatory changes m tho- 

f“f?„nmi>hrr?n^^ no evidence of pus. Mr. Gill-Carey 

the septum on December 1st, 1927.' Some nasal discharge 
fpllnwcd 'but by December 26th this had ceased. There has been; 
follow , months. .The fields 

r*! p on Tamiary 24th, 1923, show a practically full field, even 
.moll obiccls ^1/2000 white). The right blind spot <20/2000) is 
Ibout the sK, but the increase for a 1/2000 white object is only 

*''lho natient’s mental condition is normal. She can play bridge 
with zest is only occasionally depressed, and is able to take a 
keen interest in life generally. 

Comment. 

Tho folloiving comments mainly refer to rliinological 
matters but in the study of these cases on the horder-liiio 
between two specialties it has been necessary often to step 
over tho border. However, Mr. Gill-Carey has discussed 
and acrees with tho conclusions reached. . 

J)iannosis.—ln cases sudi as these, which aro hy no means 
unconOTon, tho indications of the actual lesion aro often 
extremely indefinite. Tho best duo is generally to bo foniid 
in tho past history. Tlio fields may bo of increasing help, 
whm further experience has been gamed in -this type of. 
case Culture of sinus washings may also give considcrahlo 
assistance with further experience of this method, lladio- 
lonica'l examination is sometimes of value, but a negative, 
ai-rav report does not e.xdudo .sinusites. Ihe absence of 
PUS In the noso (as in all three cases), and oven the ciitiio 
absence of nasal _ symptoms (as in ono case), must not 
expliirlo & diuffnosis of sinusitis. ^ ^ . . 

Etiolony— In tho three cases the sinusitis piobaiy 
started fn 'early childhood with ^omo ilhicss--for c.a^ 
measles — and had continued more or less a , ‘ 

profound debility and various septic conditions. 


AN TJNUSUAri CASE OF FOOD POISONINO. 


r TjrEBnTTi<rTt 
L Medicat. Joctwax. 


439 


MAKcn 17, 192*1 


incoasoa as life wont on, .Inring 22. 59, nnrt 42 years, 

'"tu clovinlion wl.ld. was 

probably tbo reason why the s.nns.t.s or.g.nally failed to 

''Sc.-Tho ronioval of a piooo of bono from tlio nose, 
followed in a few clays by eon.pbto relief of symptoms, is 
a dramatic ending to tlioso loi.g-drawn-o.it histones of pain 
mid disease, accompanied by so nnicli clisabilily and acute 
mental anxietv. The i.ossibility of so simple, a euro makes 
it verv desirable to (loviso incans whereby an earlier 
diagnosis iiiav inovcnt rather than euro such misery. 

JVcrnifioH.— Childhood’s diseases— for example, measles, 
scarlet fever, diphtheria, and wliooping-eoiipli— 111 which 
there is commonly aeiito nasal inflnnimatioii, are apt to 
le.ave behind thoiii a ehronic infection of the sinuses, of 
wliich there mav bo local ovidonco in “^constant colds ” and 
])ost-iiasal catarrh, or tlio child may show only a general 
debility, with few or no symptoms of nasal infection. There 
may, however, bo evidence of. soptio absorption or reteii- 
t’.ou — for example, constant sties, spots on the skin, head- 
aches, rhenmatism, and bad teeth ; this latent .sinusitis 
may continue to bo p.athological tlirongliout the rest of life. 
IHio main method of prevention, thereforo, will ho tlio 
adequate treatment of these childish diseases and their 
after-eliccts. 

Since it is probablo that, had tliero been no septal devia- 
tion, the sinusitis would have healed in the ordinarv ooiir.so, 
the persistence of sj-mptom-S of sinusitis in a child, in spito 
. of tho ronioval of soft tissues — for example, tonsils and 
adenoids — suggests a boiiy .obstruction to drain.agc, the 
removal of which, unless contraindicated, would save much 
liresont and future suffering. 

Post-nasal catarrh,'ovcn when it has continued so long 
that the patient has become resigned to it and considers 
it of no .significance, remains iiovcrtholoss a con,stant 
potential danger. 

Tliese cases aro not primarily oplithalinic, yet patients 
and their doctors naturally sock first the help of ophthalmic 
mrgeons, as all of these did, and must roly on them to 
distingnish those cases from those duo to refractive or 
mnsclo error. 

With such indefinite radiological and clinical signs 
tho rliinologist hesitates to operate, and looks to the 
ophtbahno ogist to strengthen his hands. It m.ay bo that, 


with further 


!• experience, the fields will enable us, in 


certain caso.s, to give a decided 


opinion. 


AjN' ua^ustjal case of food dolsoniag. 

dy’ 

C.B.E., F. W. JIARSHALL, M.B., 

M.D.Caxtab., B.S.DuanAM, 

ICIIFIELD, SlArFS, LlCnpIELD, .STAFFS, 

AKD . 

J. SIENTON, L.R.C.P. axti S.I., 

BAcrznioLOGisT, Covxty or Staftord. 

attacks of food poisoning lias for many 
Wd nvo," ^ of my,stcry to tlio average practitioner, 
enidemi'M' there are many points in the 

still far frmn condition which arc 

infective organism in the case here 
lowical fl was entirely due to tho patlio- 

eSJ ‘"^Pect was distinctly 

caso xvo and the sporadic nature of the 

illness is as folbws^.'^'^ recording it. The history of the 

1927, seen on September 19th, 

(99® to 101° p\ fi hanng had a rise of temperature 

p^ibnormal tomDPrflf,,^?“^ .previous three nights, with s 

dav but mmnf morning. She liad been going out 
vomitins’ ’ TliPr^ epigastric pain and occasiona; 

head four davs nrPvnV,^ i ^ ^hc back of th( 

■immediato subcpr!ito«*°^® ^ Yritbout loss of consciousness oi 

headache and^of^ *‘^rD complaint was of severe occipila 

especially in various parts of tin 

■^as creakinw '^in iim i r? ^he left side. Then 

“ leit temporo-mandibular joint and sht 


complfiincd of fleeting pains in the hips on movcment» Tlierc was 
no diarrhoea and iSn bowels were acting normally; the appear- 
ance of the motions was normal. There was marked hyper- 
iicslhcsin over (ho epigastrium, and also, to a less extent, over 
each renal region. Kvon tho slightest pressure over (lie epigastrium 
caused a feeling of nausea; llic tongue was clean. 

She was given salicylates and aspirin without marked improve- 
ment, tlio lompcr.atnro still rising at night (101° to 102° F.) and 
being subnormal in tho morning. The possibility of pyelitis was 
considered, but Ibc urine wa? acid, contained no albumin, and 
microscopical examination shoAved nothing abnormal. 

On September 22nd she complained of nausea and occasional 
vomiting, Avhich^ latter rapidly became more pei*sistont and un- 
controllable, with increasing" epigastric pain, especially after 
swallowing. There ivas marked tenderness on palpation over the 
spleen, but at this stage the spleen itself could not be felt. 

On September 28tb slic I’as seen in consultation with Dr. T. L. 
Hardy of Birmingham, and the ca.se was regarded as clinically 
f^'^gg^'-stiiig paratyphoid fever. The long axis of splenic dullness 
was slightl)* increased and tho spleen was just palpable. The white 
blood corpuscles were 5,8(X) in number, and a differential coimt 
showed pol.vmorplis 29.5 per cent., l5'mphocytes 59.5 per cent., 
monomiclcai-s 10 per cent., eosinophils 1 per cent. A. serological 
investigation at (lie county laboratory on this date revealed the 
prescnco of 1 in 25 agglutinability to B. acrtryckc Mutton, and 
complete absence of agglutinins to B. fj/pho$us, to B. para^ 
typhosus A, B, and C, to B. cntcritidis Gaertner, B. acrtrycki 
Newport, and to tho dysentery group. 

On September 29lh, as a result of tho blood examination, tbo 
patient was closely questioned as to any article of food she had 
li.ad which might have caused food poisoning, although previously 
no suspicion of this had been entertained. The fact was elicited 
that four daj-s before (he onset of the illness she had partaken 
of some pork pie, and that tlirce other members of the household 
who had. also parl.aken had suffered from slight malaise, nausea, 
and vomiting from one to three days after this meal. 

Tho patient’s vomiting gradually became less distressing and 
was eventually controlled Xv minim doses of tincture of iodine 
and l)v glucose by llie mouth. Tavo days later she developed a 
follicular tonsillitis, but this quickly cleared up with ordinary 
remedies. 

A further sample of blood was taken on October 5rd and gave 
a .similar result to the previous one; a blood culture proA’ed 
negatiA'c. By this time an organism had been isolated from the 
faeces Avliich gaA’c tho cultural reactions of a member of the 
Salmonella group. It displayed marked flocculation in a dilution 
of 1 in 25 with acrtryckc scrum (Mutton type) in less than tAvo 
hours’ incubation in the water bath at 56° C., but showed no 
agglutination with paratyphoid scrum after four hours** incuba- 
tion and standing all night at room temperature. The specific 
scrums for Gaertnor’s bacillus and for B. acrtryckc (Newport 
type) failed to catiso any agglutination. When tested against* the 
patient’s scrum marked flocc\dation was produced in a dilution 
of 1 in' 25, and granulation was CArident in 1 in 50. Highly specific 
standardized cultures and scrums were used throughout, and the 
diagnosis Avas fortunalelv simplified by tho absenco of confusing 
coagglutinins, both in tho investigations on the patient’s serum 
and in Ihose necessary to establish the identity of tho micro- 
organism. 

Tho inlere.sting and unusual points of this case appear 
to bo: (1) A food poisoning which spent itself upon the 
upper intestinal tract without giving rise to any diarrhoea 
or signs of enteritis. (2) Tho slightly enlarged spleen, 
which, together with tho pyrexia and tho blood picture, 
gnA'O rise to a suspicion of paratyphoid infection. (3) The 
nocturnal rise of temperature— on one occasion it Avas as 
high as 105° F. — which is a very unusual feature of food 
poisoning cases. 

So far as could ho ascertained there are few cases on 
record Avhich hear much resemblance to the case described. 
In the majority of recorded cases the onset has been acut-e, 
Avith diarrhoea and vomiting, and has therefore at once 
led to. the suspicion of food poisoning. A search of the 
literature, liowever, brings several interesting points to 
light. 

Dr.s. Perry and Tidy^ report on an epidemic caused by 
the NcAA*port strain of B. acrtryckc occurring in a depot 
in Franco. These authors describe fcAA*o clinical types : 
Typo A, cliaracterized by high temperature, general 
malai.se, A*arious pains, but no diarrhoea ; Type B, charac- 
terized by diarrhoea and vomiting and a normal or slightly 
subnormal temperature. 

It is interesting to note that in Typo A the stools from 
nearly a hundred cases Avero examined, hut in one case 
only was a bacillus foxind resembling B. acrtryckc. Tho 
authors thereforo concluded that this group AA'as not con- 
nected with an infection due to B. acrtryckc^ and was, in 
fact, an entirely separate epidemic. Nevertheless, it is 
tempting to suggest that the case aboA’e described might 
quite easily have been classed in Type A, but in no 
circumstances could it liaA'e been classed in Type B. 

In Type B the onset was sudden, with .abdominal pain 


440 MAHCH I 7 .~i 928 ] THE WASSERITANN, KAHN, ANH SIGITA TESTS COMPARED. 


Tr r TmrnRm^ 

L MF.DICAI. JoCRVAli 


and diarrhoea. Vomiting was common, and cliills, sweats, 
and hcadaciics frequent. In most cases tliQ initial sym- 
ntoms were the severest, and tho patient rapidly improved. 
The duration of tlio diarrhoea varied from a few hours in 
tho milder cases to four to seven days in tho severest 
ones. Headache was rare after the first day. In . tho 
majority of this group vomiting occurred at tho outset, 
and continuation of tho vomiting was tho mo.st serious 
symptom encountered. Pyrexia was unusual, even in tho 
severest cases, and tho temperatnro was often subnormal. 
There was no splenic enlargement or rash. 

These authors conclude, therefore, that tho disease varies 
from an acute gastro-enteritis to a mild diarrhoea. Tho 
onset is sudden and pyrexia is exceptional. Tho course 
lias no resemblance to enteric fever, and tho character of 
tho stools is unlike dysentery. They also consider that 
tho infection in this epidemic was by carriers, either acute 
or chronic. 

Dr. Pleasance^ describes a sporadic case of B. acrtrychc 
infection occurring in a boy aged 3. Tho onset was very 
acute, with severe diarrhoea and vomiting; death occurred 
on tho seventh day. Post mortem a largo splenic abscess 
was found. Subsequently a Gram-negative, actively motile 
bacillus was isolated in pure culture from tho gall-bladder 
and splenic pidp, but when first isolated tho organism was 
not agglutinated by tho specific scrums for B. para- 
typhosvs B or B. acrtryche. Repeated subcultures were 
made, and twelve months after isolation the organisms 
agglutinated with B. paratyjihosus B and B. acrtrychc 
antiserums. Absorption tests wore then performed and 
the organism identified as B. acrtryche. This illustrates 
tho fact that B. aertryehc can at times assume invasive 
powers, and it is possible that in tho case hero recorded 
this occurred to some extent, sineo from tho signs and 
symptoms it is evident that tho organism was not confined 
to the alimentary tract. 

An epidemic is described by Dr. Burgess’ comprising 
703 known cases. The incubation period was two and a half 
to twenty-four hours, and the onset was very sudden, with 
pain, vomiting, and diarrhoea. There were also pyrexia, 
headaches, chills, and sweats. The diarrhoea was very 
severe. The acute stage is stated to have lasted two to 
ten days, but the average was four to five daj-s, and con- 
valescence was rapid. The outbreak was traced to cream 
used in the manufacture of cream cakes, and tho organism 
isolated was B. acrtryche. 

It ,win therefore be seen that, with tho exception . of 
Perry and Tidy’s Type A, all the cases described by these 
authors had an acute onset with diarrhoea and vomiting, 
and as a rule pyrexia was not a marked feature of the 


condition. 

Dr. Savage and Mr. Bruce White* consider that 
Salmonella food poisoning is duo, in tho majority of 
instances, to B. acrtryche, and they assert that, in this 
country at least, this organism is responsible for three-; 
quarters of the outbreaks. These authorities point out 
that they have failed to find any evidence of the ability 
of B. paratyphosus B to produce an ordinary attack' of 
food poisoning, though they admit that paratyphoid fever 
may at times have a sudden onset which may temporarily 
simulate it. The converse is, however, illustrated by this 
case, in ■ which at the onset the irritation symptoms so 
characteristic of B. acrtryche infection were so slight as 
to lead for a short time to a tentative diagnosis of para- 
typhoid fever. 

Not infrequently the serums of patients suffering from 
B. acrtryche infection show coagglutinins for B. para- 
tuphosiis B. If such serums are sent for diagnosis for 
typhoid or paratyphoid fever, and if the investigations are 
restricted to the diagnosis of these infections, it may 
happen that such coagglutination may lead to a wrong 
diagnosis of. par.atyphoid fever; or if, as in the present 
caso, coagglutinins' are absent, a negative ^sult for the 
typhoid-paratyphoid group is worthless. We therefore 
strongly urge that when sending h ood sarnies to a labor.a- 
toi^ for examination when, typhoid or para^phoid fever is 
m^ected, and more especially when the clinical signs and 
svm^ptoms are not typical, a full 

tiio Salmonella group and. tho assoemted organisms slimild 
be required; when multiple agglutinins occur their relative ■ 


' iniportance must bo established ■ by absorption tests We 
have reason to suggest that, should such comprehensive 
agglutination teats be_ more generally adopted, sporadic 
cases of B. acrtryche infection will bo found to be more 
frequent. 

.IVo should like also to emphasize tho importance of tho 
bacteriological exarninntion of tho faeces in every case, as 
tho isolation of the organism definitely clinches tho dia- 
gnosis. This, however, takes somo time and, provided that 
proper cultures and 'technique are utilized, cxaininaiiou 
of the patient’s seriim in the first instance is a vahiablo 
aid to rapid diagnosis; it may help in tracing the sourco 
of tho infection, which may not be available by the time 
the organism has been recovered and proved. 

To a few workers these statements may appear comnion- 
plaoe, but we know from our own experience and that of 
othcra that in routine work, . both clinical and bacterio- 
logical, the Salmonella food-poisoning organisms are seldom 
considered, except when a typical and serious outbreak 
forces them on our attention. 

Reitrexces. 

* Perry and Tilly: Jlcdicnl Research Council, SpccinI Report Series Xo. 24. 

- R. •. r*<incct, 1922, ii, p. £09. 

^ Biirgoss, W, L. : Proo. Ploy. Soc. Med., Section of Epiflemiolofry nnd 
Stnte MetUcinei p. 61. 

* Savage and White : Medical Research Council, Special Report Series No.Sl. 


A C03IPARIS0H OF THE WASSERMANN, KAHN, 
AND SIGMA TESTS. ' 

BT 

T. E. OSMOND, M.B.Caxt.ib., 

PATUOLOOIST, VENEKEAI. DISBASES DEPART-VEKT, ST. THOStAS’S HOSPITAL, 
LONDOX. 


For this' purpose 2,019 serums were taken and submitted 
to all three tests. The greater number were from oases 
of treated syphilis. The remainder included cases in which 
the diagnosis was clinically doubtful and cases in which 
the first test carried out gave a doubtful result or one 
contrary to the clinical findings. 


Technique. 

Tho Wassermann test’ was No. 1 method, as described 
n the Medical Research Council, Special Report Series 
lo ■ 14 Results were recorded as + + ; -f ± ; +} ±; 
nd necative. For ’ diagnostic purposes was considered 
iositivo^and -t- doubtful (in .treated cases ± = positive). 

Tho Kahn test was carried out as laid down by the 
ilthnr 4 but after the first few tests the first tuho of each 
i-Ki nmvtted and only two tubes used — that is, those con- 
aining 6 and 12 parts of serum respectively to 1 of antigen. 

onsTdered positive in eases under treatment. D D = 

°Tho ^Sigma °wa^ carried^out as described in the 

Tedical Research- Council, Special Report Series No. 78; 
Tilv five tubes were used, and tho reading was taken at 
rom twenty to twenty-two hours. A reading of 1.5 units 
nd nnwards was taken as positive, 1 to 1.5 as doubtful 
nntlDve in treated cases), and below 1 as negative. ■ 
the 2 019 serums examined 1,401 showed absolute, 
nd 403 relative, agreement with all three tests wb.cl. is 
A on nor cent Of the 215 serums which showed dis- 
!^eement 205 were from cases of syphilis, either treated or 
^treated. Of those 205: 


The Kahn test appeared to be most correct m 

y^iassermann 

Sigma - »» 

Kahn and Sigma „ 

Kahn and wassermann 
Swma and -n'assermann 


. 72 
. 32' 
. 5 
. 57 
. 31 
. 8 


Kipma ana ” . 

IS it wc“uld appear that the Kal™ Bio 

times the IVassermann reaction 71 times, 

there were 6 

s. In 2 . there, was agreement with tlio _\4assc. 


MARCH 17 


■ 1928] 


METHODS OF OXYGEN ADMINISTEATION. 


L Jlr.DiCAt. JocasAi, 


■reaction, in 1 agreement with tl.c Sigma in 1 partial 
a<ne'cmcnfwitU the Sigma, and in 2 partial agrcoinent 
vntli tlic ■Wass.crmaiin reaction. I'lil.se positives may tlipre- 
fme he reduced to 3 (in 2 of wliicli tlio readings were N 1‘, 
1> and D P P respectively). There were 6 apparently false 
iiositivc 3Yassermann reactions. In 2 the Kalin agreed; in 
2 the Kahn parti.ally agreed; in 1 the Sigma partially 
agreed, and one case was prohaldy syphilis. There were 
thus 3’ “ false po.sitives,” which gave the following read- 
iiigs: ++ (test repeated with the .same result), + (test 
repeated with the same re.snit), and +. 'J’liere was 
1 apparently false positive Sigma test with which the 
Kalin .agreed. 

Coiichisioiis. 

From the aliovc it would appear that whilst there avas 
a high percentage of agreement between the three test.s 
the results were slightly, hut definitely, in favour of the 
Kahn. It is not suggested that this test could or should 
replace the Wasserman'n, hut it is a very Useful additional 
test, especially in cases wlicro the diagnosi.s is in doubt 


or where the 'Wa.ssermnnn reaction gives a + result. The 
Kahn test appears to give a definitely greater proportion 
of po.sitivcs in eases of treated syphilis; in. other words, 
it reniain.s positive longer than the IVasscrmann during 
tre.atiueiit. It is prohahle that had the Sigma tests been 
carried to the full iheuhation period of forty to forty-four 
hours a greater miinhcr of positives would have been 
obtained, hut this was not done on account of the extra 
time involved and consequent del.ay. 

The chief advantage of the Kahn test is it, simplicity. 
It does not require ns many ingredients as the IVassermann 
nor the complicated titrations; it is much more rapidlj- 
carried out than the Sigma with its somewhat elaborate 
apparatus. A reliable result of a Kahn test can ho given 
within an hour of receiving the serum. 

I liavc to thank Colonel L. tV. Harrison. D.S.O., F.R.C.P.Ed., 
Director of the .VencriSal Department, St. ’ Thomas's Hospilal, for 
perniissiou ‘ to’ publish' these figures. 

• ■ RsFEnrscr, 

1 Aincr. Joiim, rubU'c Healthy June, 192t. 


1 COMPABISON OF THE EFFICIENCY OF SOME 
' METHODS OF OXYGEN ADMINISTRATION. 


; , R. HIbTON, M.A., Jf.n., 

-CniKT iSSlSUST, MEDICAL-VSIT, ST. BARThOLOMEW' S nOSPlTAL.* 


Axoxaejiii has hcen classified hy, Darcroft' ns follows: 
'(1) Aiioxie,' whbii thi: hlood has failed to pick up its 
proper loiid of oxygen in the lungs, .so that its oxygen 
])re.ssnro.is tod low; (2) nn.admic, when the Idobd lias pieked 
up .all it c.an cnrrj’, -.so that its oxygon' pressure is iiorinal, 
but owing to deficienty of liaomoglohin its load is not 
snfficientlv groat; ',(3) .stiignaut, when the oXvgen in the 
arterial blood is nornuil, 
blit tho How through the 
capillaries is too slow. 

It is in tho anoxic typo 
that oxygen administra- 
tion is o.specially indi- 
cated, as occurs, for 
example, in lobar 
pneumonia. 


K 

o) 

t: 

.?I?C 

$ 

b 

v> 

3 

Oxec 

CN fN 

Atvee 

'a:— 

>4 





CATHcreK. 
\ OC/ICS 
AtJNNSt CePSf. 

Class 

^ ruNNU 
/0cm . /Ao/f 

Afeivr//. 




1 


r 




; : 

x '4 

< ; 


Am-e / 2 .3 9lirnesOi 

fVAAI/Nure 


Chart 1. 

Chart 1.— Shows that oxyjrcn ej'cn liv 


dope not enrich the alvebfar air. Subject brcathini: 550 c.cm. per breath: 
respirations 15 a minute. (240 mm. is about equal to 35^per-cent. oxypon-iit 
alwiilat ’uir ;* 

Chart 2— fo) anil (b) fhow pressures obtained with the ncAv raouUi-mask. 
(fl) NAitir th'u hostrils closed bv cotion-wool. (b) Breathing air by the nose, 
'O.Nypeit by -the moutli. (SW mm. is about equal to 70 per cent, o.vygcn in 
- aU’colar air.) . * . ’ ' 


^IctJiods. 

Accounts of the 
dilferent methods which 
aro in iiso have been 
given by numerous 
authors.®" The methods 
studied in this "paper 
are (a ) . the tube ■ and 
funnel held cldsclr ' over 
lie mouth and 'note, 'and 

( ) at a measured, distance'; (c) a liasal c.atlioter inserted 
mistril, with' its' ehd in the nasopharynx; (d) the 
T1 pew.mask over the mouth only- 

in (1*** “SIS of compari,son chosen is the inessure of oxygen 
.... “ veolar air of a normal subject breathing at known 

tinn ““pin- Only respiratory methods of administra- 
mentioned here, because intravascular ways are 
in viou-'^ dangerous and subcutaneous injections useless 
enmn, • ” •’? amount that can be absorbed in 

comparison with- the bodily needs.-" 


\^J0D\ 


I 


OAYC£f* if^/^L.Y£OLAn /J/A. 


A^ur/f P/ecc 


3- 


,0 

s fOLi 


.©■ 




/ Z 3 ■9 S 6 7 S 9 Kfi 
/9/irr ornoiy in u rues 

ffc/? rhNNTF. 


fumipl'^^ "P ^ litres a minute, given by a 

I mnel held 10 cm. from +i.„ ai. i. „„ .i.„ 

alveola 
closclv 


Findings. 


alveolar oxvf«>" mouth, lias no effect on the 


Closclv pcessuro. If, however, tho funnel is pressed 

is ahniit under the chin the effect obtained 

of flow of p as with a nasal catheter 'at the same rate 

“ mrnte ^lil'^raise tT' 

BiucU alveolar oxygon pressure half as 

double it' * '' oi'catliiiig air. whereas 3 litres will 

, which is on a smaller scale, shows in addition 


' Receiving n grant Irom 


tlnr Medical -EcFcarcIr Council. 


the alveolar oxygen when the Haldane mask is used. The 
figures here shown for the catheter and mask do not differ 
materially, from those already published.® Mention will 
be made later of the results oht-ained with the moiitlilinask. 

, ... . Comment. 

■ It is incontestable that the face-mask method is a very 
efficient . moans of fnis'ihg the alveolar . oxygen ; hut every 
physician knows tin? clinical objections to tho prolonged n.se 
of a mask which covers the mouth and nose. The reasons 
for a patient’s intolerance may he physiological, such as 
slight obstruction to breathing, or an increase of the dead 
.space with consequent rehreatliing of a fraction of the 
expired air; it yould seem that tho reasons are also psycho- 
logical, for even a normal 
])orson without dy.spnoea 
feels hot and nncoinfort- 
ahle after wearing a 
mask for a few minutes. 
The nasal catheter is 
therefore used as a coin- 
proiniso. Against its 
manifest inferiority in 
raising the alveolar 
oxygen pressure must be 
set the fact of its siln- 
plieity and convenience 
both to patient and 
doctor. "It can even he ' 
used in' t-hildfen.’ ‘ Bv 
its use . o.xygen adminis- 
tration fiin be continued 
for days on' end, uiiinter- 
• . riiptcd .by the. nccessitv 

of feeding, _ by coughing, or by sleeping. IVe have 
shown its effect on the - alv'eohar Q-xygeh. That this 
effect m,ay.he_great. eno.ngh to impiovo the oxygenation of 
the blood in lobar pncnnionia is seen from the following 
c.ases I - - - - - . - 

Gasc l. — Male, aged 44; respirations 42, pulse 125. TIic oxygen 
saturation of the arterial blood before giving oxygen was 85 per 
cent. Rate of flow of "oxygfen 'was 0.75 litre a minute by nasal 
catheter for fifteen minutes. - ’The oxygen saturation was raised 
to 89 per cent. 

Case — -Male,- aged ,50; respirations 55, pulse 112. The oxygen 
satufatidu of the artc'rial blood after having 0.5 litre of oxygen 
a minute by catheter for ta-o hours was 80 per cent. Tlie rate 
of flow was then increased to 1 litre a minute. Fifteen minutes 
later the oxygen saturation had risen to 88 per ceni. 

The rates of flow used in these two casc.s wore, for 
experimental reasons, much below what should he oniployod. 
In pneumonia the flow should ho slowly increased to at 
least 3 litres a minute. The catheter generally ii.sed in 
adults is a No. 9 oesophageal. The lateral hole should bo 
near the tip; the terminal four inches are smeared with- 
cocaine ointment, and the catheter is inserted into one 
nostril until a resistance is felt, when it is witirdrnwn’ 
slio-litlv. If there is no obstruction 'in 'the' liosc tho end 
slioiild'ndw bo' in 'the naso'pliarj-nx. The, patient is more 


Cnir.r 2. - 
funncl held 10 cm. from the mouth 



442 March 17 , 1928 ] 


A= n. T ^ ^eio Modification. 

».sk"S\^::x£^^“"i^> •' •"• '“"■ 

•has also been observed clinicallv^that tl I f "''^66", it 

s ws, “sirH “i ““ 

; £?HS^f .‘'”,5 xxu‘ "‘"p”*- 

■ breathe oxygen by the mouth nddln°l ^ * ?i. to 

tp. breathe air. It aLX, +„ V «aso-fiee 

-more-willinglT bonioZ^tbl comfortablo and 

:% .a Iarg,''CT.‘/k,‘ ™E£;'X,I'“ ?■"« !• ~''0« 


INTUSSUSOBPTIOlI lN.iAN ADULT. 


:hy a Iarge°Lp of thin vnEblr;! - V'” 

•resistance to expiration Tho f ’1 gives a minimal 

■bag comes in Tdenm;th T1 1 connecting the oxygon 
with an inflated ruble. cnsbiorVe 'P’cce ' is’ provided 
it is held in place by a nTeee If ? comfo.-t.ably; 

the head. Oxygen I 3 breathed passes behind 

gas collects during expiratiol n^d tho 

Gilchrist and DavL« havfdol^r.l '^y Haldane, 

principle, which irsimlll / ^®'’ a mod.fication of this 

use.* Chart 2 sloiirthe ‘=®=-«“t in 

the highest fieures -irfi nlitoin a Jilveolar oxygon'; 

plugged with cotton-wool.' By’^Hs® Telfl*? •“''® 
subject the average alveolar oxygen ^ 0^650 mm 
IS not considered advisable te 1 . but it 

indefinitely, since therris e4SnIa".'“°*‘, 
oxygen for three days causes P"'’° 

animals.” ” further work is • “ oedema 111 cei-tain 
use of this app.Iratus and tbn Iff *'‘® «Ji“ical 

in the arterial Wood. 

“Ilaldane‘ t.an?fif,‘'?920,''’uf‘a87 

, ^ ^t-S" “ 

°PiocVp.°25?'*^^° -^ca™. 50, 2 «I., 1921 ’ 

11 T» ^^‘■ysiol., voL Ix!v. ‘ Soc., December, 1927 

“ Bourne : Lancet, 1922, ii 2i 


rn/sssii 

Four days later nffA»s k; i ^ ~ 

Ecvero abdominal pain, accomnSf]'”?^* -’'Y^s attacked by 

then bile, and latteriv v, "^^tter had been first fnn^ 

these te„’d.ays thotoVels '’fn'' 3 ^^'“?'='’ “ faeca! odour';‘"Durie!; 
absolutely constipated. On admKkP,„ cnemata, were 

twelve hours, but the pab co^j^ued t had ceased fo? 

abdomen w.as distended but no? fpAc*^^ and the 

clearly visible, running transversow ln' 11 "-cro 

The hernial sites and the rprfnm ^ ^ . i^dder pattern ” 

“ai? *''C abdomen ° negative and no tumour 

inesialfy befow 7he®nal-eh'' u^d mOTphil? ' was opened 

and mtemittent ether ariaestbe^I intravenous somnifene, 

bowel bulged into the 'wouSd, while ''i'‘>tcd smali 

with a little difliculty. To its inner' T®® brought out 

intestmo could only bo partly uLIrefled ^ “.Is of small 

?”‘*/*i''thcr examination revealed a bard 
mass in the interior of the caecum ft 
now became obvious that an ileo-caecal 
intussusception had occurred, so the" 
i?tracaecal mass was gently pushed out 
through tlio. iIco-.caccal yalve and the 
intupusceptiOn". r/ipidly; reduced.' . Oh’ 
continuing to push .tho“ tumour-further 
towards more healthy bowel it 
■was suddenly arrested about two'fcet 
,from the .caecum,, its pedicle of attach- 
ment arising firom. tlie .inhcrl aspect' o'f 

a broadisli -Meekers- diverticulum about' 
tho Sizo’of the- last- joint ‘of -the- thumb. ' 

Tho diverticulum was of a hlackish- 
purplo hue; the prQxjmal ileum was 
intensely congested and -much distended^ I 
while. tho di.stal portion was narrowed. 

Rcjscction of the parts 'was decided bn 
so tho bowel w.as divided full}’ sjx irfehes 

proximal, and about three inches distal, 

to tho pedicle of tho tumour, Aftei; careful- haemostasis of tho 
soddon^roesenlery tho intestinal ends w'cre rapidly closed by a pui'se- • 
string suture over a I^rker-Moyiiihan clamp, 'and lateral anasto- 
mosis was performed. - Finnllv an enterostomy w'as performed about 
eight inches' proximal ■ to the anastomosis . on tho dilated' loop, 
a small tube being rapidly fixed in the bowel by a couple of purse- 
string sutures. The intestine was then fixed by a single catgut 
stitch to the peritoneum, of the wound; the abdomen was closed 
and the patient put back- to bed in good condition. Ho slept 
tranquillj^ all night; the pulse never exceeded 100 , and there was 
no vomiting. . The ileostomy tube drained very freely for forty- 
eight hours; and the- bowels moved naturally on tho third day; 
the tube became loose on the fifth day, and tho patient left the 
clinio a month after his operation, with the wound soundly healed. 

In this case, since the intussusception was reducible, the 
question arises whether excision of tho diverticulum, 
extraction of tlio pel}!?* transverse suture of tho bowel 
might not have sufBced. A table of statistics, however, in 
Guoiilette^s thesis- shows that in 104 cases resection was 
performed 60 times with 41 recoveries'. In intestinal 
obstruction after tho obstacle is removed experience leads 



INTUSSUSCEPTION IN AN ADULT DUE TO A 
POLYP OP MECKEL’S DIVERTICULUM 


periormeu ou ^imes wii/u h 

obstruction • after tho obstacle la icuiuvcu UA.pc;i AciAut? iCivuo 
to tho belief that enterostomy on tho distended proximal 
loop is an important factor in tho successful issue. 

Tho specimen, placed. by. Professor D. P. D. Wilkie in tho 
museum of the surgical department, Edinburgh University, 
is a thick polyp about threo inches long, springing from 
the inner surface of a ' flattish Meckel’s diverticulum. 
Histoloi'ical examination showed that the intestinal polyp 
consiste'd of fibrous tissue into which hnemorrhago had 
taken place. There was no evidence of malignancy. 

Referexces. 

I Brocq and Gueulette : Joiirn. de Chir.. T. ixviii. No. 4, October, 1926. 

» Guculette : Ihise de Paris, 1925. 


IAN MACDONALD, M.u. 

ntJELVA, SPAIN'. ^ 


A CRITICAL study' of intussusception in tho adult shows that 
in 36 per cent, pf tho cases an intestinal tumour is the 
predisposing cause. The tumours in order of frequency are • 
simple polyps, lipomata, fibromyomata, and adenomata- 
malignaut growths rarely occur in this typo of intestinal 
obstruction. In tho following caso the intussusception w.as 
caused by a pediculated polyp which arose from a Meckel’s 
diverticulum. 

A man, aged 40, who bad previously enjoyed excellent health 
complained of sliglit discomfort round the navel and in tho right 
Iliac fossa. He, However, continued to eat, work, and liv’o bis 
ordinary daily life, and hi s bowels at this time acted normally, i 

We.?minF!?;“B?rdEo‘ Skba Gorman, 


BLASTOMYCOSIS OF EYE AND FACE SECONDARY 
TO LUNG INFECTION. 

BY 

ARNOLD S. FERGUSON. F.R.C.S.Ed., 

AURAL AND OPHTHALMIC SURGEON, JERSEY GENERAL HOSPITAL. 


Fungus involvement of tho lungs, according to tho 
statistics of Colonel Blarett, medical officer of health and 
States bacteriologist, is of frequent occurrence in Jersey. 
Tho following c.aso is of great interest, as tho eye and face 
conditions are definitely secondary to the lung infection. 

A man, aged 58, was sent to me by Dr. Sydney Whitaker. TIio 
patient was very evidently ill and emaciated. There was slight 
sclcro-kcratitis with accompanying ciliary injection of the left eye. 
Within a week the limbal conjunctiva and episcleral tissue snowed 



MA.ncn 17, 1928] 


memoranda; 


[ 


The EBmsni 
^Iedicaz, Jocexai. 


443 


a raised violaceous ll.ickenit.g, and a imK of larf;o R.-anulomaln 
formed a coroua around ll.e cornea At (Im same I, me a large 
bcefy-looking groatli appeared on the rigH cliook This was 
evcised by a consnlling surgeon, bnl by the time the slitclms were 
ready foi- removal there was a recurrence snrca.Iing up to the 
right lower lid, and another growth appeared on the nose, over 

tha Icf( nli'i and lip. . - . , ^ • u fit *i-j 

I made a teiilnlivc diagnosis of tubercle, in spite of the rapidity 
of invasion and the report of a well-known iiatliologist to whom 
a' section of’ the growth had been sent seemed to confirm this. 



Fig. 1. — Case of hlastomycosij. 
Nose infection. 



The eye condition began to look . desperate, and T saw the 
patient witli Colonel Mareft, who suggested c.vnmination of the 
sputum: he reported bla-stomvcosis, and reconnnended .a method 
of .treatment which was earned out by Dr. Wliilakcr with the 
most happy msult. The granulomata and ugly violaceous thick- 
ening liavG disappe.arcd from the eye, the growths on chock and 
nose have also vanished, and the patient has increased 9 Ib. in 
weignt.iu five weeks. 

In view of the intcrc.st of this case, socing that, apart 
ftom his grave general appoaraiico, tieatment of Iiis eye 
for tnbcrclo, would liavc heon hopeless, aiul tliat the other 
cyo was being menaced bv the rapidly advancing growth on 
his right cheek, I have appended Colonel Marett’s notes. 


Morns nv Coloxei, M.vnnrr. 

•The pntient was brought to see mo by jMr. Fergu.son. 
Tlio condition as seen then (April 19 th) showed infection of 
left eye, nose, and right clieok. On iiupiiry he was found 
to 1)0 snfforiiig from cough, with sputum, and loss of weight. 
A section of the growth from tlie cheek had been examined 
by a pathologist. There was rapid recurrence after removal. 
Examination of tlio sputum showed the infection to be 
nionilia, and the method of infection of the skin was 
Miidoubtedly due to the use of handkerchiefs infected from 
sputum. 

TIic treatment recommended was increasing doses of 
potassium iodide nj) to 30 grains thrice daily, and weekly 
increasing doses of monilia vaccine, the parts to ho painted 
with a solution of 0.5 per cent, each of brilliant green and 
crystal violet to combat sepsis, and the patient advised to use 
paper handkerchiefs. It is interesting to note that the report 
of a section stated that the condition was due to tubercle. 
Skin infection witli monilia is known, and is less frequent 
than moniliasis of lungs, no case of donblo infection of lung 
and skin having been recorded according to the literature 
available, but owing to the fact that nionilia skin infections 
are usually on the face, it is quite possible that these infec- 
tions may he secondary to a lung infection. In Jersey tiie 
frequency of monilia of the lung is as common as tuber- 
culosis of the lungs, and most of these latter suffer from the 
double infection. In vHro it has been found that there is 
a symbiotic action between tubercle and monilia. .Tubercle 
grows readily in an alkaline medium, whilst monilin require 
. an acid medium. All cases of true double infection do best 
by having monilia treated first, and then proceeding with, 
tiiborcio vaccine. It must be understood tlmt it was 
solely a inonilia infection in this case, and at the time of 
I making the diagnosis a good prognosis was given. 


iil£m0rjin&a : 

. medical, surgical, obstetrical. 

TAVO CASES OF MULTIPLE URETHRAL CALCULI. 


The folloiring case, in ivhich ret-ention of urine was caused 
.1 10 presence of a very large number of uietliral calculi, 

seems to be worthy of record. 


Hosnital admitted to the Ipoii District 

urine TTe Malay States, sullering from retention of 

there was im' t?! .1" had no trouble in passing urine, and 

a laree hir,l venereal disease. On physical examination 

urethre easily palpable in the penile 

found w'hii-li Turiber back a large sac was 

bandied it ntif f' enormously dilated urethra; when 

be felt “ '""y great number of stones could 

and'the'urctlira''v-n"’'''^° anterior and largest stone, 

weie then cxlrirfni Fo fewer than 120 pbospbatic calculi 

passed into t A tound was 

urethral incision farther stones were found. The 

recoverv Cvst,..™* closed and the patient made an uneventful 
demonstrated ^ ^“‘'aiination at the end of convalescence 


I’crak. Federated Malay States. 


bladder free from stones. 

C. B. Paslev, F.R.C.S.I. 


*>eJoiv, in which close on a luindre 
of the patieni 

Shantun”^ brought to tlie hospital of tl 

difficult micturitinn”fo^*li''^^^^^^* ^ liistory of painful an 

penile ifretlfra^ felt in the posterior part of tl 

to be anothpr Lnwi a rectal examination what appearc 

of the bladder If • ^’ORuded mass could be felt in the positic 
entering the iirnfLvn possible to pass a catheter, since c 

mentioned and U . almost immediately impinged on the ma 
impacted in Ih^ quite evident that this was a stoi 

bladder with urethra. A diagnosis of stone in tl 

distended un to flif> ^^^thra was made. The bladder wi 

poor, as shown bv tUo, „ und the kidney function was vei 

In order to iranmve 

be was given syruo ^ operatic 

bicarbonate in wafAv mouth and 20 grains of sodiu 

eiery two hour's for one day. In tl 


evening he was given 33 oz. (1,000 c.cm.) of a 5 per cent, glucose 

solution per rectum and a similar dose the following morning. 

The operation was performed at 2 p.ra. 

As it was tbouglit that a suprapubic as well ns a perineal 
incision would have to be made, and as the condition of the 
patient did not admit of a prolonged operation or anaesthesia, 
arrangements were made for one of us to opciato on the perineum 
while the other did what was necessary in the suprapubic region. 
Open ether was administered, and an incision was made in- the 
perineum over the mass, with the result that a number of faceted 
stones at once came into view and wei'e taken ’out. In front of 
these was a larger stone, about tlie size of a bantam’s egg 

(li by in.), which was firmly impacted in the urethra, its 

narrow end being directed forwai'ds. When this was removed it 
was found that there were many more of the smaller faceted 
variety packed closely together and forming the mass wliich had 
been felt per rectum. It soon became clear that a suprapubic 
incision would not be needed. When all the stones were removed 
by means of forceps and a scoop it was found there were 93 in 
all, including the large one; the 92 small ones ranged in size from 
1/2 by 7/16 in. to 1/4 by 3/16 in. in size, and were all faceted. 

After they were removed the carity in which they were embedded 
was explored with the finger and found to be the posterior urethra 
much dilated. In its roof the intcnial opening of the urethra 
could be quite easily detected; through this opening a catheter 
was passed, and some ten or twelve ounces of urine were drawn 
off. Though this opening was quite patent and easily admitted 
the tip of the index finger there was not a single stone in the 
bladder, the whole of the 93 being jammed closely together into 
one mass in tlic prostatic urethra. The bladder was drained for 
a few days througli the perineal wound and the patient made a 
good I'ecoverv, leaving the hospital two weeks after the operation. 

E. R. AVnEELEit, M.B., B.S., F.E.C.S., 

iledical Superintendent, University 
Hospital, Shantung, China. 


APPEMDICECTOan' DURING HERNIOTOMY 
UNDER LOCAL ANAESTHESIA. 

The following case presented some interesting feature!!, 
and seems worthy of record. 

A male child, aged 4 years, was transferred to the surgical side 
on October 4tb, 1927, with the following history. He liad a riglit- 
sided inguinal hernia which on succes^ve occasions had been 
presenting more difficulty in reduction. He had a status jymplia- 
ticus with a chronic obstinate cough associated with dyspnoea, 
and ’ a definite record of dangerous idiosyncrasy to general 
anaesthesia. He had been circumcised two years or so prenouslj 
under a local anaesthetic. He was of t peevish, apathetic 

temperamen^^.^^i^^ (October 4th) he exhibited tenderness over the 
hernia. The hernia also presented a peculi^irly solid consistence. 





MABCH 17, 192*1 


!>.57:. THE CABRIBR PBOBEEM. ' > 


r Tht Brittsb 
L AIedioai. Jourkaa 


445 , 


CO) niu) l.randY or champagne, except in the prosoneo of 
flatnlence. Stimulants should ho given ivhothor food was 
heing laUen or not. Ainiiioniiiiii eaihniiato should he 
re.servec) lor patients who had both iineiiiiioiim and 
hroiicliitis. Camphor in oil was nsefii , and snpraroiial 
extract wa= a oood vasomotor stiiinilaiit, hut i(s administra- 
tion required ‘careful watching in cases of elderly people 
■with nrterio-sclcrosis. Pituitriii was hciioficinl in Ilia 
q-iresence of abdominal distension. Vciie.soction should only 
ho performed in special cases when there was cvidciico of 
right-sided cardiac failure. 

With reference to specific medication, Sir Tlioiiins Hordor 
discus.scd tho various methods which had been strongly advo- 
cated from timo to time, including tho niixtnro of iodidc-S 
and creosote, nucleic acid,- and sodium iiiicleiiiatc; ho did 
not favour these methods, hut a]iprqvod the administration 
of large doses of sodium bicarbonato to combat the acidosis 
due to protein destruction. Though there was as yot no 
liotcnt antiserum an aiitipiieiimococcal serum might ho 
recommended, since at any rate it did no harm; it should 
ho given early, and in largo doses. It was .suggested that 
the ortliuary pnoiiinococcal vaccine might ho cniployctl in 
small doses, or a sensitised vaccine with an antiserum given 
in larger doses. Sir Tlionias Border iiicntioiicd iiniiuinogen, 
wliich was made from the washings of tho cultivated 
organisms; ho said that this substance was almost entirely 
free from protein, and its administration had produced 
remarkable re.suUs. Half a cubic cciitiinctrc should he 
given twice in the first twenty-four hours, and 1 c.cm, 
twice in the second. 

A good discussion followed the lecture, questions being 
asked by several members. In reply to one with reference 
to sleep, Sir Thomas Hordor said ho had found uiodinal in 
7I-graiii doses useful ns a hypnotic. At'hcn acuto restless- 
ness and delirium wore present ho ciiiplovcd a mixture of 
1/2 clrnchni of ammonium bromide, with 1 to drachms 
of syrup of chloral, wliich was given two-hourly so long 
as required. , . 

On the proposal of Dr. M.iX'KX'Et.L, seconded by Air. 
OOLix ■ ALih^x^ie, a very hearty i-oto of tlianliS was 
aceorclcd to Sir Thomas Border for a most interesting and 
instructive lecture. , 


%m:ts of jiomfe. 

THE CARRIER PROBLEAI. 

mV^iTq^"® Society of Loudon, held 

‘ ? AH'. H. AV. C.^uson 

T)r look place on the carrier prohic 

''“^CAnTXEv, in opening, said that the car 
enirlAm'’ i" increasing importanco to 
ifs AA bacteriologist, and to tlio physic 

■ni,: also could not bo ignored, fo 

''“"icr in a Aletropolitan Asyl 
thorn lAAVA PPr week to maintain, 

ono hncni't ? many as forty to fifty carriers in 

siderabie ”'ri I^oudou alone was 

tint IiA , subject of the carrier was so vast, he s 
of the , "dth it from tho point of 1 

infectinn ' '***’'* with tlio liiiiiian carrie 

to bo many diseases which were thoi 

as an iiuHt-n and ho would define a cai 

genic miAi-n '' '° ^'arbourod and transmitted a pa 
of infertinn°'^®i^"**™ without showing the usual evide 
was two main types. T 

imn’ortoiiA •*'* 'y.ad'^aown convalescent carrier, of espi 

typhoid fever. All paH 
they RlmivAfl .ose diseases were in a sense carriers, 
fcannem'lf ^ this evid 

carriers and -iVl"® convalescence they became tempo 
the eai of a; 1 n‘‘ “•'hitraiy perfod-twelvo week 
harbonred mt?,' such convalescent patients 

chronic co,wawfnt‘caS.'''“4e''''-' 
toiTtinctiS^r”’ f iraportancrin certain'^esi 

ci^anlsm fiom t“»taet carrier acquired the n 

Sf tCdisT' the disease, but sli. 

gw ot the disease himself. Sometimes bis distance 


ovciitiially broken down, and ho succumbed; such cases were 
known as “ incubation carriers.” Tho contact carrier 
usually harboured tho organism only for a short time, but 
occasionally tlio chronic contact carrier developed as a 
result of tlio organism settling clown in the nose and throat. 
Dealing next in more detail with certain specific diseases, 
tlio speaker iiicntioiicd diphtheria, in which the chronic 
convalescent carrier was of great importanco, being the 
commonest typo of carrier in the general community. The 
important point about such carriers was that tho organisms 
they liarhourcd wero virulent. For testing such virulence 
iiilracutancous tests on guinea-pigs wero used, and the 
sqioakcr emphasized that a person carrying a non-virulent 
typo of diphtheria hacilhis could not give rise to a fresh 
case of diphtheria. All attempts to alter such organisms 
into virulent forms failed, and no return cases ever 
occurred from non-viriileiit carriers. Alore than half tho 
cases investigated with morphological diphtheria bacilli were 
proved to ho non-virnlciit, and this was especiallj- marked 
ill ear cases. Such important results led to tho release of 
many people from an 'irksome quarantine, but it was 
essential that tho virulciioe tests should ho carried out with 
great care, and difficulty was sometimes experienced because 
tho same carrier might liarhoiir both virulent and noii- 
vinilent organisms at the same time. 

- Following the intensive study of a largo number of 
diphtlioria carriers, Dr. AlcCartiioy said he had established 
that the growth of organisms from siicli cases was often 
slow at fir.st, and after this “ lag period ” the diphtheria 
bacillus grow more rapidly, although such cultures should 
bo loft for forty-eight hours instead of the usual twelve 
lioiu's adopted in isolating tho bacilli from active casesi 
This led to anotlier important consideration, for despite tho 
carriers of virulent bacilli comparatively few people were 
infected in this way, and it was suggested that because 
of this lag period tlioro was time for obese attacked by 
the bacillus from a carrier to eliminate the organism from 
tlio system before it did any harm. The intermittent 
nature of tho carrier was also important, and at the Nortli- 
Eastorn Hospital it was now the rule that a patient must 
hare six consecutive negative cultures during a period of 
six weeks before being discharged as cui'cd. On the whole, 
it was tile milder cases which were more likely to become 
carriers, and it u'as commonest in small children. The 
Schick test was negative in all carriers. The organism in 
the case of carriers had an “ extra-corporeal ” existence 
in the products of inflammation caused by other organisms, 
and if such inflammation was dealt with the carrier state 
disappeared. In 95 per cent, of diphtheria carriers some 
pathological defect was found, such as diseased tonsils, 
chronic rhinitis, deflected septum, etc. AATien infection was 
present in tho tonsils, usually of the buried septic variety 
with deep crypts, tonsillectomy would effect a cure in nearly 
all cases. Nasal carriers were more difficult to deal with 
owing to the anatomical peculiarities of the very young 
siibj'ects. In treatment each case had to be considered 011 
its merits; when it was established that the organism 
present was virulent, then the nose and throat must bo 
dealt with. In the nasal carriers vaccines made from the 
predominating organism causing the rhinitis might help 
in about 30 per cent, of cases, and it might be necessary 
to persist until a particular organism was found wliich ivas 
causing the actual condition favourable to the presence of 
diphtlioria bacilli. In other cases the use of a -warm 
alkaline nasal douche was most effective as long as it aas 
continued. In some cases exploration of the antrum had 
shown tlio deep-seated nature of the infection. Dealing 
next with the enteric group of infections. Dr. AIcCartncy 
said that the chronic convalescent carrier was of most 
importance, and probably about 5 per cent, of sufferers 
from typhoid became carriers, tlio rate being higher in 
rural than in urban districts. The faecal carrier accounted 
for 93 por cent, of cases, and there was usually a chronic 
cholecystitis present. It was important in examining such 
cases to secure tho contents of the small intestine by means . 
of a calomel purge, since in formed stools the typhoid 
bacillus might have been , destroj-ed by piitrefactivo 
organisms in the large intestine. Urinary carriers were 
rarer, but inoro dangerous to the community, especially the 
male urinary earlier who micturated several times a day in 


446 Mahoh 17, 1928] 


NARC0t.EPS7, 


J 


r Tits Dnrnra 
■ L UitoicAii JncHvji 


odd places, particularly in rural areas. The purulent typo 
of typhoid carrier was rare. Females accounted for 80 per 
cent, of all typhoid carriers, and the state was rare in 
children! Dealing with the detection of typhoid carriers, 
the speaker mentioned an outbreak of the disease at a 
mental hospital witli 2,000 patients and 800 staff. Despite 
the immense difficulties involved, a complete investigation 
was carried out and ten carriers were • isolated. The 
remaining patients were treated with T.A.B. vaccine, with 
the result that the hospital had been kept free for two 
years, except for ono sporadic case. Tho Widal reaction 
was of little use in detecting carriers, and Dr. McCartney 
stated that his experience with other special tests was dis- 
appointing. Treatment of such carriers was unsatisfactory, 
since removal of tho gall-bladder was not always successful 
and perhaps not justifiable. It seemed to bo better to 
enlist the co-operation of the patient by laying down rules 
of personal hygiene. Public health regulations were un- 
satisfactory, since tho State had no power to insist on tho 
treatment of carriers. 

Dr. McCartney then mentioned carriers of amoebic 
dyseutei'y who might harbour tho cysts for years with 
vague symptoms, but who responded to correct treatment. 
In cerebro-spinal fever it was tho contact carrier wJm 
caused spread directly from person to person, and the 
organism might go through several individuals without 
causing the disease. In tho epidemic season, and especially 
in camps and barracks, tho carrier rate became very high. 
Tho site of infection was usually tho upper respirato^ 
tract, and isolation of tho organism consisted lax-gely in 
distinguishing it from other Gram-negative cocci. Dealing 
lastly with scarlet fever, Dr. McCartney mentioned that it 
was becoming a serious problem as to whether this disease 
was spread by carriers. Of a group of 300 patients, more 
than half still had tho haemolytic streptococci in tho throat 
at the end of seven weeks, although the rate was much 
lower when tho wards were loss busy. Tho question of 
whether scarlet fever patients should all bo examined and 
detained until free from such infection seemed to open 
up too big a proposition. 

Dr. J. Freeman pleaded for an extension of tho original 
idea of tho carrier. Tho old conception of the convalescent 
carrier, as in tho case of typhoid, had already been 
extended to cover tho incubation and the contact carrier. 
He believed that many cases of para-enteric infections were 
spread by carriers; patients often suffered from these 
diseases for years without coming for treatment, and ho 
believed that such cases were tho cause of just as much 
misery in the community as typhoid and dysenteiy. Just 
as in tuberculosis tho person witli tubercle bacilli in tho 
sputum, but no clinical signs of phthisis, was regarded 
as a carrier, so tho woman with chronic gonorrhoea, 
without any obvious sign of disease, was a carrier, and tho 
main function of venereal disease clinics was to protect tho 
community from such carriers. A man with septic gums 
was also capable of transferring such infection to his 
neighbours, and by spraying out streptococci such a 
person might causo a whole variety of diseases in other 
individuals. It was also possible for a person to carry an 
infection which caused trouble elsewhere in his own body; 
such a person could be called an “ auto-carrier,” and in 
attempting prophylactic anticatarrhal vaccination a 
lighting up of some septio focus, where tho offending 
' or'^anisms were being carried, was not uncommon. In 
conclusion Dr. Freeman stated that he held that every 
individual was a carrier and that the bulk of infection 


was duo to carriers. 

Sir John Bhoadbent mentioned some of tho difficulties 
in relation to carriers of the acuto, infectious fevers. Ho 
asrreed that tonsillectomy would euro the throat carrier 
of diphtheria, and he thought that carriers were more 
freouent in the time of epidemics. In regard to scarlet 
fever there were many difficulties. About 80 per cent, of 
all cases of scarlet fever failed to give any evidence of 
contact with another case. In one case of a small girl 
he had evidenco that she had carried scarlet fever infection 
for ton weeks after discharge from hospital as cured. 

Mr. ZAcnART Cope thought it was justifiable to remove 
tho gall-bladder in chronic typhoid carriers since gall- 
stones might form. He also mentioned the -uso of the 


duodenal tube to drain tho gall-bladder, quoting a case of 
Dyqns’s which had been rendered free from infection by 
this method after having been a earrier for twenty years. 
Ho asked whether whooping-cough was transmitted by 
carriers. 

, Dr. A. Feiiinq described a case of enteric infection in 
a. young man, aged 23, who developed an attack of acute 
cholecystitis six weeks after paratyphoid fever. An attempt 
to deal with this ease by removal of the gall-bladder had 
failed, and it had not been possible to get a tube to pass 
into tho duodenum. He asked for advice as to what could 
bo done. Mr. Zacharv Cope suggested that the mucous 
membrano of tho gall-bladder should be destroyed a't a 
new operation. Dr. McCartney, in reply, stressed tho 
importance of remembering both tho parasite and the host 
in all carrier conditions. 


HARCOLEPST. 

At a meeting of the Section of Neurology of tho Royal 
Society of Medicine, held on March 8th, with the president, 
Dr. Edwin Bramwelp, in the chair, a discussion took 

place on narcolepsy. _ ' , . 

Dr S. A. Kinnier Wilson, in opening, referred to the 
fact that, although this condition had been well described 
manv vears ago, there was no reference to it in tbo 
indcMS of Brain since 1899 until Dr. W. J. Adic’s thesis 
of ciEliteen months previously. Dr. Wilson said that his 
interest in tbo subject began when he was house-physician 
to Sir William Gowers in 1907, and he had been on tho 
look out for the disorder for twenty years, althoiigli rt was 
only within recent times that he had raet j*. Ho bad seen , 
several cases in the last year, and it had been suggested 
that this apparent increase in the occurrence of the con- 
1 ad sLething to do with tho times through which 
nassinE.- Ho did not consider, however, that the 
increase in narcolepsy had anything to do with the outbreak 
f In^^ubalitis lethargica, since some of his own cases dated 
attach long before 1918. Ho argued that 
cannot be regarded as a disease, but it was 
vaiiiPi- a ivmptom— a disordered function of sleep— and he 
" ( rred-To sneak of the narcolepsios. He thought narco- 

preferred to spe suggested ‘ hypno- 

epsy was no sleep— or Sir William Gowers’s siig- 

lepsy ■ - ^ -vears ano, “ somnosis.” Dealing ne.xt 

gcstion of ^ ^vilson first mentioned a youth 

with his recenF . irresistible attacks 

t Wn iTd alo tlifpec^iliar but well-known phenomenon 
of sleep, and als powerless under the influence of 

tndS oF cataplexy. A second patient 

npd cataplectic attacks, and, later, began to have 
developed catap examined 

irresistible impukcs to sleep t„,,^j,rks were found' 

* 1 !" te“n td 4o ’ pTantar responsi extensor Two 
to- be ‘ . jiojj tile man had recovered, the 

minntes . after th , had 

reflexes h<i,g time. A third patient presented 

features of attacks of sleep and of catap exy, 
both , -.jtion also sometimes suffered from cataffipsy 
■but, he was unable to move a muscle. Deal- 

?r tranw, > of the narcolepsies Dr. Mdson 

jng wit ^ith attacks of sleep and M 

divided 1 those with prolonged sleep only. Of the fiist 

cataplexy — Uected forty-five cases from the literature 

i fortrvears, and it certainly appeared to be more 
of tho last forty y J , jigst of the cases of pro- 

common at tlio P , , ho resion of the symptomatie 

longed sleep apP ^ that lesions 

narcolopsies, and ^ ventricle were oRcn 

of tho bi-ain in ,°„i i g]gep. Dr. Wilson believed that 

associated with p , ° ti^ gases had a similar nieclianism 
al, tho pr mary n«e^ ho was unwilling 

to that of the ^ ^Clinically, he said, it was important 
to separate «»om, condition of sleep which occurred, 

to consider the patients were aware of what 

It was not true si p, transitional states 


JlixBcn \n, 19^*1 


HEALTH LESSONS-FBbjr BERMUDA. 


f Tiir. BamsH- 
Mkiiicvi. JorBKlI. 


447 


that bv bvoadcaiuf! the conception of sloop n its roll tiou 
to narcolepsy more light was thrown on the condition. 
Dr. Wilson then dealt with the >oh>t>onsl,i,, hetwoen i.areo- 
lopsv and epilepsy; Ho remarked that the rosoinblnnees 

wL much greats-- V'"' ro -U 

the patient in tho fully ostablisliod epileptic fit, with 
loss of consciousness niid limbs in motion, wa.s almost 
the “ corresponding opposite ” of tho eatnjilectic, with 
consciousness retained and complete ntoiiia in all iiiiiscles. 
There acre a fair number of cases witli narcolepsy and 
epilepsv in association, and while the symptoms wcie 
in striking ‘ contrast it might ho that there was a 
similar physiological mccliaiiism behind the two condi- 
tions. -Dealing lastly with the possible iiatliogencsis of 
nafcolepsv Dr. AVilson pointed out that the plienoniona 
were largely inhibitory, and ns in ejiilepsy many of tlio 
processes acre inhibitory, so in narcolepsy these inhibitory 
effects wore pushed a stage further. Pavlov’s views on 
sleep showed that it comsisted in cortical inhibition 
descending to tho mid-brain, and it was possible to 
suppose that if the inhibition did not de.sceiid to the mid- 
brain the state of catalepsy might develop. Ho thought 
that light would be thrown on the problems of narcole]isy 
by consideration of the phenomena of catalepsy and .atonia. 

Dr. C. 'WonsTEii-DiiouoiiT described the ]ironiinont 
features of four cases of narcolepsy which he bad had 
under his care. He said that it was iiinisual for the 
cataplectic attacks to precede the attacks of sloop, and 
he emphasized the extrcnio atonicity which occurred during 
tho attacks of cataplexy. Ho thought that narcolepsy was 
a symptom-complex comparahlo to, say, Parkinsonism, and 
we had yet to discover tho iiaturo of the lesion in the 
nervous system in cases of idiopathic narcolepsy. 

Sir James Ppiives-Stewaiit said that in cataplexy, in 
narcolepsy, and in normal sleep there was this striking 
atonia. He referred to the state of liypersomnia which 
developed in patients with lesions round about the third 
ventricle, and ho mentioned the fact that if the third 
ventricle was inflated with' air then a ]ioriod of peaceful 
sleep often developed. Ho said that tho paroxysmal nature 
attacks had not yet been explained. 

Dr. H. Cohen described some cases of narcolepsy he had 
seen during the last three years. One patient suffered from 
cataplexy- on hearing a sudden noi.se; another boy with 
tf***'j fall to the ground on hearing a iioi.se and 

len del eloped myoclonic nioveinciits, but was conscious the 
A third case, of a wfiman with cerebro-spiiial 
gp nils, used to have epileptic attacks on hearing a noise. 

e had seen a similar gradation of sviiiptoins in cases with 
attacks following uproarious laughter. 

r. Gordon Hoemes mentioned two cases of narcolepsy, 
no s toned an interesting feature in that nose lileoding, 
patient was subject, .stopped during the iiarco- 
P 1 C a aek. Another case of cataplexy developed attacks 
symptomatic narcolepsy, possibly 
k c? 1 °?'^ lesion in the region of the optic tract, had 
bcMhted from the administration of thyroid gland. He 
which cataplexy was brought on by 
imrl-ri which had subsequently developed vei-y 

®lhep had never been a prominent 
Hu disputed One of Dr. Wilson’s 
osrw” ^ "’‘i ‘ stating that during the 

ji i ' '’Sus lie was convinced from personal experience 
f^’lly unconscious. Dr. H. D. 
tinn c lulated a case in which slight emotions, rather 
bought on cataplectic attacks. Tiiis 
hyoscine*''' appeared to benefit froni the administration of 

- . HEALTH LESSONS FROM BERMUDA. 

Section of Tropical Diseases and 
Sneiotr ” ^ Hoy.al Society of Medicine, held at the 

?n March 1st. Dr. J. Gordon Thomson, 
director 'If 't chair. Dr. Andrew Baefodii, 

Medicine School of Hygiene and Tropical 

Dr ■R ’it u paper on health lessons from Bermuda, 
of islums Hormiida was a small group 

trontfol 1 i- . '» Pst Indies. Its climate ,^ras sub- 

* ’ .to a large coloured population many 


features and charactofistics of tropical' hygiene and sanita- 
tion, were, reproduced. Its isolated position had also per- 
)ietua'tcd certain traits apparent among other comimmities. 
forced by similar cii'cumstanecs to work out their own 
salvation. ; Tho islands consisted of acolian liinostono, 
superimposed on a submarino mountain, and covered with 
a scanty reil soil, free from clay. The limestone varied 
in' consistency, hut every-where water readily percolated 
through it. Tlicro was no surface running water. Tlio 
main island had an. area of 9,000 acres, and its liiglicst 
)ioint was only 250 feet above sea level. The scenery was 
diverse — low hills and valleys with marine swamps and 
flesh-water marshes. Tlio islands were well wooded with 
cedar or jimipor, which influenced rainfall and protected 
against salt-spray from gales. The climate was mild and 
nionotonons, but heavy rains and gales wore common in 
early spring, and summer was hot and oppressive, the mild 
weather rctnriiing in September. Only a few of the 150 
islands were inhabited. The population was over 20,000, 
of wlioiii 9,000 were whites, the remainder coloured. The 
cnen-ating climate had left traces on the white population, 
which was easy-going, with a tendency to procrastinate. 
Tlio whites showed a mild “ tropical anaemia,” which was 
really a ciitaneons ischaemia. Hookworm was ab.soiit, 
probably on account of the unfavourable soil; the inhabi- 
tants, however, were usually shod, which liclped to account 
for tho absence. Fifty years ago the cliigger flea was 
common, but it bad now disappeared; this had not been 
satisfactorily explained. Malaria also was absent, and 
aiiopbclincs liad never gained a footing on the islands, 
although opportunities must have been frequent in the 
past for its introduction. The alkalinity of the waters 
might account for this, but tho jiH of Bermuda marshes 
had not yet been studied. Small fish (iinillet), Fundulus 
hcrmvclac, were common, arid these kept down the species 
of mosquitos which were present (Gidex faiigans and Acdcs 
spp.). A balance had been struck between the fish and 
these mosquitos, but tile fish and carnivorous arthropod 
larvae might have been more' successful in externiinatiiig 
niiophcline.s. Tho recent introduction of inalaria into 
Barbados indic.ated that Bermuda’s “ imnuiiiity ” must not 
be viewed with complacency. Among the mosquitos present 
was the yellow fever vector A. aegypti. Numerous out- 
breaks of yellow fever (some of which, however, wern' 
probably really typbns) liad been recorded in the past, 
alllioiigli the disease was now absent. This might be duo 
ill part to the substitution of iron steamers for wooden 
sailing shi|)s; but the fact that the disease never gained 
a permanent liold on the colony was yirobably iiioro 
important. This might possibly be attributable to the 
unfavourable winter; moreover, tho disease had also been 
stamped out in many old-time foci in Aiiicrica. It was 
likely that the long immunity from the disease depended 
chiefly on “ chance.” In Bermuda water was mostly .stored 
in stone tanks, in which Acdcs bred, and the introduction 
of fish was practised. Tho fish might introdneo B. coU into 
the water, liowever, and, although liarmlcss, this 'might 
falsify water examination results. Recent work indicated 
that the spirochaete of yellow fever might bo identical 
with that of Weil’s disease, and investigations in rats in 
Bermuda were suggested. The Bermudian ivas more or 
less immune to the bites of tlie salt marsh mosquitos, and 
this suggested another line of investigation. Dysentery 
was rare in Bermuda, probably because tbero was no 
runriiiig surface water, altbougli flies were i-ery common 
owing to the large number of horses kept on account of the 
tourist traffic. The flies, however, could transmit enteric 
fever, tho second commonest disease there. It was un- 
common among the troops, who had a piped water supply, 
a water-carried sewage system, and anti-flj- measures, in 
addition to. the usual triple vaccination. To rely on the 
vaccine -alone for the protection of civilians was an nnsonnd 
system which should not be the first lino of defence; 
a' satisfactory water supply was mncli more important. 
Tuberculosis was the commonest disease present. Bermuda 
was vei-A- lliickly populated, but. overcrowding was not 
common and slums were rare. TIio disease was rife among 
tlie coloured people because of closed windows, indis- 
criminate expectoration, and a bad milk supply. In.spce- 
tion of school children was. recomniended as a preventive 


448 Karoh 17 , 1928 } 


Jj^^EtoOSES^'THE'-TROPlca, '^■ 


“ '’I''®*' The infant mortality 

S£V:”- ’if ““f *• »ool. “«" 

Sf b’oi" f l.ulC f 

Jrwf.s^Sh!cl/°ifTa?nid^ 

it ono of the most health™ placefiiHlm wS’ 

~es 

similar in many respects. Anopheles Was absent fr<fm +Ro 

H£ £‘ 

ts ‘■'‘.fi'""* ■ivS 

EE%”iff ■?? “ cr=: 

E tfuEr •” V"“ 

fr«i\trrE;K“ 

rfradn^/th”: S :f: 


ff^ 




AJiiinsHrf ■ 
edicai. JoraxAL 


which he v; 


vaa 


foikOTd J plpSf EfnlEVainf" ’7®'“.* '■”'1 

“SrEsS”’'"’""'' ”• ~w”a‘S°s 

pss.srSfprs.“s’s.i^£e 

.w.ofgij-C’vX ™"3 pit"* "°" “"" ‘" ‘’~’ 

disease, citing the absence of vIloTf^ throiring hglit on 
many of the Pacific islands. ^ typhus from 

had'‘to®br°tackled Se ^ 0 .^^"'" ■ *’;?* difficulties 
could be overcome. Com^niei^^^ ignorance 


Compulsion from this country was 
M wo, » slronsl, d„.„„„ri 1„ nJi'll.;?. “'.. ,5'!'’' 


both at home and abroad. similar education 


NEUROSES m THE TROPICS 
The Sections of Tropical Medicine, Fsrchlni-Z' \r„ i 
and Balneolo^ of the Royal Society of Medich.o comb^j 
on March ISfch for a discussion on neurose^i in + 7 ,^ “iinuea 
■ Dr. R. L.<iNGDON-DoiyN presided. 

Dr. H. B. Day, opening, said tliat the subfect was sn 
wide that it might ha considered under tiro headinns- 
neuroses or psychoneuroses as seen (1) in natire inhabitants" 
and (2) in European residents in tropica] countries The 
study of primitive races was a vast psychological siibiect 
lu the unsophisticated native hysteria was veiy prevalent' 
and emotionalism a-as exploited in tribal songs and war 
dances. That hysterical, manifestations were amenable to 
suggestion was recognized by the peasantri- in Ewynt- 
™?dical treatment was employed in ordinary 

hysterica?''n-,'t;£®i'®'m'® ’’’ere prescribed for the 

patient. Turning to the European in a tropical 


electrically clfarced .-itmosiihere tension of an 

downpour. In “tj,'o case of ’ ^ “onotony of a tropica! 
abroad tho risk of breakdown “PPointments 

of psycboncuroses was due to t?e failur'o „ A®, 

mental conflict existed which might lead to a psyched 
neurosis. Of tropical diseases' he mentioned two— mSarm 
and pellagra— whidi produced not only psychoneuroses but 
though more restricted in its 
g Ooiaphica! distribution, was the more important cause of 
nei-vous disorder, and it was estimated that 40 per cent, of 
the adults affected showed mental deterioration, with 
symptems ranging from simple depression to ,confusional 
insanity terminating in dementia. 

Lieut.-Coloncl 0. A. R. BEiiKEi,r.y-Hnj,, I.M.S , sent a 
paper, which was read in his absence. Ho referred to the 
correspondenco wiiich appeared in the Sri(is/i Medical 
Journal in X926 following a letter from , the Bisliop of 
Singapore on mental irritability and breakdown in the 
tropics. Eight replies were published, but no two corre- 
spondents agreed on the cause, and the diversity of exjilana- 
tions suggested indicated the hopeless ignorance which 
existed about a subject the importanco of which could not 
bo denied. Recognition by the laity that Europeans were 
liable to mental disorder in the tropics was shown by such * 
terras as ‘‘ Punjab bead,” “ West Coast head,” and the 
Gorman " TropenkoHer.” The Duke of Wellington 
deplored the irritability of many of his ofBcera in India. 
Novels dealing with life in the tropics abounded in 
references to mental disorder among Europeans — those 
by Kipling, Conrad, Seton Merriman, for example. 
Europeans living in the tropics appeared to bo prone to 
a neurotic sj-ndrome, the central symptom of which was 
n state of hypertension manifested in general irritability 
or morbid anxiety. Ho thought there was some justifica- 
tion for the assumption that the mental disorder of 
Europeans in the tropics was an anxiety neurosis. Among 
causes he mentioned sexual abstinence, frequently inevit- 
able, even among married men, and followed sometimes by 
resort to alcohol as an indirect result; another cause was 
coitus iiiteiTiiptiis, lamentably common among Europeans 
living in tropical countries, and leading to many nervous 
and other -ill results in both men and women. ' Little was 
known about temperature, perhaps the most formidable of 
tropical conditions; but many facts went to suggest that 
an average temperature between 60° and 70° F. was, better 
than one which averaged over 70° P. It was evident, 
therefore, that Enropeaus in tropical countries, unless they 
lived at high altitudes, were under a perpetual disability. 
Climate played an important, though unassigned, pai-t in 
mental well-being. 

Dr. Huon Siannhs said that the correspondenco in tho 
British Medical Journal had laid the blame for disturb- 
ance of mental health in the tropics upon every conceivablo 
component of tho tropical environment. He himself believed 
that the condition commonly seen in the tropics was a 
neurasthenia — a neurosis consisting in faulty response by 
over-action to the diflicuities which life offered, the sym- 
ptoms being abnormal liability to fatigue and irritability. 

This faulty response was due essentially to the intro- 
duction of fear into the mind — ^whether fear of physical 
hurt, or fear as a component of worry, anxiety, appre- 
hension, and disappointment. In the neurasthenic in tho 
tropics harmful emotional and physical stimuli might bo 
seen severally at work. Cases of neurasthenia might ho 
observed which did not differ in their causation from cases 
in this country. There was also, however, the man exiled 
from home, separated from his family, perhaps in financial 
straits, lonely or lacking congenial society, disappointed 
in promotion, unable to escape from monotony, living 
amidst a native population who caused him annoyance 



March 17, 192S] 


VALUE. OF MAHINE 'HEALTH EESORTS. 


f TniBRm« 44 Q 

UeMCAL /OCTorji ’^•xv 


becnuso l.o had never tronWed to wulorstand thevv language 
or their psvcholog.v, beset all day by sodden heat and ihe 
incessant attention of insects, and driven to hcd. oulj^ to 
be kept aivake bv. the reiterated cry of the brain-fcycr 
bird or a chorus of frogs. Such a man mas always r.nlTcring 
from a sninmation of imdliplc, minor,' defence-inducing 
no.xions atinmli. Here, in this ■ emotional and physical- 
unrest, lay the cause of tropical nenrastlienia. ■ 

Jfr. A. F. MacCapl-VK said that ho was one of tlio first 
to Avrite to the British 'htntlral Journal after tho Bishop 
of Singapore’s letter to point out tho extraordinary strain 
on persons in- the ■ tropics as a consequence of sulfcring 
from slight errors of refraction which elsewlicro Avould bo 
almost negligible. With regard to neurasthenia, there was 
often a physical basis for this in some septic focus in 
the oral cavity ■ or alimentary canal, and its existence 
could nearly always he detected by an ophthalmic surgeon 
on an examination of the eyes. 

Dr. J. F. C. Haslam suggested that not only the diver- 
sity in- the British Medical Journal corres|)ondonco but 
also the present discussion went to endorse the contention 
of Dr. Stamms — that underlying the whole of this condi- 
tion of tropical neurasthenia were very man}- noxious 
stimuli. -The speaker, however, was inclined to place 
rather more iveight on pure climatic conditions than Dr. 
Stannus liad done. In industries involving exposure to 
high temperafuro and humidity some recent observations 
by the Industrial Fatigue Desearch Board went to show 
that as soon as a temperature of oi-or 75° F. was reached 
there ivas a falling off both in efficiency and output. 

I euiperature and humidity were undoubtccl factors, Avhen 
they passed beyond tho jioints customarily experienced 
in temperate climates, in exorcising a harmful effect. In 
Australia they a-ero accustomed to speak of a “ kitchen 
neurosis,” a (xindition alfceting women who spent a 
gieat deal of time in the kitchen, which ivas, of course, 
-the hottest part of tho liouse. 

. S'JtnERL.ixD said that it was ivell for 
piacti loners in this country to study this subject in vicAV 
0 le large number of men who during tho war went into 
.® '■op'cs and acquired tropical diseases for which they 
still needed occasional treatment. Ho mentioned the case 
e.xtraordinarv delusions who, 
tviilinPi Fersia, had had malaria, pai-atvphoid, 

Ii'ol) lie ’ sandfly fevers. His mental trouble 

'*R°- F)r. Sutherland iiad con- 
inicnn! Was the victim of chronic malarial 

, _ treatment was begun and tho man was 

Dr M delusions. 

or siibfrnm'*f spoke of the conditions in tropical 

and Conti- Queensland; of which he had experience 
He to their great advantage with 

“ nen-v ” m Shanghai, whicli tvas notoriously a 
tronieal diilni^’ ^’°‘winess ” might bo due to the 

whieli Anoi "di'c^i were rife in Shanghai, and from 

hS ft fr°°,-hut he thought it much more 

whole nlnrf hy tho air of nnsettlemeiit about the 

makinl it1::,^'’^“‘’^ Shanghai witl. the idea of 

conunon tl Permanent home. Pfouroscs were extremeiv 
Sh Rnnrr’A''"'’ to Europeans, 

experience of said that he had liad some 

Sm itnl « Tunis and at St. Peter’s 

leceivofi GS, ^vhere confirmed psvcliiatric cases were 

erouod from equatorial Africa. His own view was that 


Asylum Marseilte:;;brrr 

leceived from equai 

zation *'psophistioated and incomplete civili- 

He Avas neurasthenic was not found, 

mental c.ases^lf^]'^^ ^*'''**' many African 

of disorder- of seen the highly evoiutioni^ied forms 

failurlt'^kA-e^mTuL 

A marine HEALTH RESORTS, 

special referene” + marine health resorts, AA-ith 

Section of Bnl 1 ° was held at a meeting of the 

of Sictne Climatology of tho Royal Society 

the cW Dr. L. C. E. Calthrop in 

ITeber . ’'®°Mied a remark by Sir Hermann 

. could compete, with Great Britain 


in tho variety and value of its marine health resorts. 
IVcbor had niso expressed surpri.se timt although England 
Avas tho first country to establish seaside hospitals and 
sanatoriiims, it had dono comparatively little to develop 
facilities for treatment on tho coast; Tho foundation, of 
tho .Royal Sca-hathing , Infirmary at- Alargate in 1791, 
marked the opening of a iieAV epoch in. physical medicine, 
but it was not until the latter half of tho nineteenth 
century that .’the . roiuarkablo popular, movement seaAvards 
began. A philosophical explanation of the benefit of the 
sea, to .which the speaker was attracted, Avas given b}- 
tho Frenchman Quinton, AA'ho said that tho sea Avas the 
original medium of life, and that from the sea came the 
fu-st living soul. The marino climates of these islands pre- 
sented an interesting study. It Avas commonly said of 
Franco that there Averc throe seas, and this Avas true for 
the coast of the British Islands. Tiie Avestern sea, Avith its 
soft Atlantic airs, was to be recommended for the Avinter 
and spring; the strong eastern seas Avere for summer and 
autumn, and tlic .south coast AA'as for all seasons. A useful 
generalization, subject to many exceptions, Avas that the 
east Avas for the young and the Avest for the old, hut the 
AA-cstern climate Avas not . ahvays relaxing and sedative. 
Along the indeAAted coast thevc Avere health resovts covering 
CA-ery conceivable variety of aspect, shelter, and soil, and 
a luimher of purely local climates apart from the three- 
fold division indicated; those secondary characteristics of 
climates determined vei-y often their A-aluo for invalids. 
Only at the seaside conl’d so many forms of energy play 
upon tho skin and respiratory momhrnno. Passing to the 
dangers of sea bathing, Dr. Fox said that tho duration 
of tho bathe, even as measured in seconds, might easily 
turn a benefit into a peril. A liatho at 65° AVas the coolest 
that should ho recommended for medical purposes, and tho 
temperatnro of om- seas in summer Avas, on the eastern 
coast, 61° to 68°, and on tlic Avostein from 5° to 10° higher. 
Apart from tho danger that arose from chill, there was a 
danger of exciting or aggravating acute or febrile disease; 
probably the explanation Avas. that where the bathe was 
iuidly home there Avas some congestive process already, at 
Avoi-k Avhich aaos aggraA'ated thus. Another draAvhack was 
AA-hat used to lie called “ marine fever ” — a transient dis- 
turhauco marked by slec])lcssness and slight pyrexia after 
bathing. In conclusion Dr. Fox indicated certain tasks 
Avhich might properly he undertaken by tho Section in 
obtaining information and comparing records in connexion 
Avith inarino tiierapcutics. 

Dr. Pr.ncY Lravis (Folkestone) dealt qitli some special 
considerations of marine climates,' such as moisture-laden 
Avinds, pointing out that although tho circulation of fresh 
ail- AA-as an advantage, the force of Aviiid was coincident 
AvitU a high death rate from phthisis AA-lierever a comniuniH 
more or less tainted AA-ith tiiherciilosis of the lungs Avas 
exposed to it. The most important factor was sunlight. 
As for tho effect of seaside resorts on children, the con- 
sensus of opinion from heads of schools AVas that the 
resistance to infectious disease AA-as increased. Epidemics 
of zymotic disease had few tei-rors for those who liA'cd 
at the seaside. The most bracing district in Britain Avas 
the Isle of Tlianet, . AA-hero the sea AA-jnds AA'ere drier than 
clseAA-here. Sea bathing Avas an excellent pastime for the 
healthy, hut AA-as not to he recommended for the ill; as a 
factor in marine resort tveatmcAit it AA-as of minor 
iiuportanco. 

Dr. IV. G. ’WiLLOUCHBi" (Easthounie) said tliat ho Avas 
sometimes asked by inland medical iiractitioners for the 
mean annual temxjeiatuie of Eastbomne ; such a figure 
AA-Quld he practically AAorthless. IVliat Avas rcquii-od Avas 
the mean of the daily niaxinnim and of the daily minimum. 
Another question freqAiently asked Avas the amoAint of tho 
total rainfall; this Avas impovtaAAt aaa some degree, hut 
not uearlv so important as tlie numbor of rainy days. 
He had found one place mentioned in the Meteorological 
Office reports aa-Iici'c the annual rainfall in any one year 
was 80 per cent, above the average rainfall of the countiy, 
hut the numher of rainy days was only 15 per cent, higher. 
He had seen much damage dono by sea bathing; its value 
depended very much on the individual. To those who 
indulged in it regularly there came a day, prohahly in tho 
late autumn, u-lien slight malaise followed the usual bathe; 


4B0 BOBGICAI TREATMENT OF CHBOSIC GiSTBIO nLCBE. 


that was the time to stop. A medical officer in charge of 
tho examination of schooi children' at Eastbourne; who had 

itated'That" ''-'I^an districts, had 

stated that children in rural districts were the least 

1 ved ‘in u and Easthourno who 

lived m comparable homes were about equally so. This 

^"Ctors of good food, clothing, and 

I lousing were more important than climate, but tho feaside 
had a special value in respect of change of air. 

nrnhnhlv°n“" (Torquay) said that there was 

piobahly more iodine in sea air, and ho had been struck 
bj the number of children suffering from defective thyroid 

I I "ell at Torquay. With regard 
deily invalids, this town was recognised as being good 

foi cases of high blood pressure. After surgical opera- 
tions, also convalescents benefited from its equable eliiliato 
IV aim sunshine, and freedom from extremes. Dr. Hallowos 
also spoke of the value of Devonshire resorts in the 
ilieumatic group of diseases, 

(Hastings) said that there were two 
vvbem alimates at Hastings; one on- the seashore, 

vvbeio there was protection from tho east by cliffs, was 

was a hinterland of rising ground to 300 or 400 feet, wis 
definitely tonic, and much cooler than nearer the sea. His 
children suffering from catarrhal con- 
ditions, and debilitated children generally, did well at 
Hostings. He thought there was a field for tho develop- 
ment of marine resorts by the provision of regulated sun 
tieatment in solanums for people, especially sedentary 
business people, who were “ run down ” and out of sorts 
Heatment indulged in haphazard sunshine 

+ 1 ,?^' OVostgate-on-Sea) could not ascribe 

the immunity of seaside resorts from zymotic diseases to 
y particular factor, but its e.xistenoe was undoubted. 
Referring to a remark by Dr. Fox that some children were 
opt to be upset by residence at tho sea, ho said that this 
was only iii cases which had been badly mismanaged. 
After forty years at a seaside resort he had yet to find any 
rheumatic affection result from a visit. ^ 

Dr. W S. Campdell (Sidmouth) said that he had prac- 
tised on the coast of Northumberland and at Sidmouth; in 
spite of the climates winds, temperatures, and country 
being so diverse, tho effect upon children in the two places 

bpn%'t®5 ®l“ldreii were not 

heWb Northumbrian coast. Ho thought that 

seisid^reTorts!'"' 

(Margate) mentioned the dry and 

healing which was observed in these cases. Dr Sutcliffe’s 
Dr. OcTAViA AVilbeuforoe (Bri<shton^ stI/I „i -n 

vvith ordinary childish complaints°recovlre‘d vvo ndeifuCa? 

Brighton, but with heart trouble they did not r,rnVr. ^ * 
vVell She found that convalescen^t chiM'vSr t„° 
Brighton shovved a week y gam of 8 oz., whereas resident 
children who had been ill gamed anything from 9 to 16 oz 
a week. She emphasized a point which applied to aB 
other resorts also— namely, that those -who lived ner 
maneiitly at Brighton needed a change as much as thoEp 
who lived inland. ‘-uose 


r,, ^®®**Tw* 

L Medical JocBiris > 


heralded by profuse as to be frequently ’ 


SURHICAD TREATMENT OE CHRONTC GIASTRTD 
ULCER. 

At a meeting of the Devon and Exeter Medico-Chirurgical 
Society on February 23rd, tho president, Mr. A. D 
Canplee, in the chair. Dr. S. C. Shaw (Barnstaple) opened 
a discussion on the surgical treatment of chronic gastric 
ulcer associated with severe haemorrhage. 

Dr. Shaw suggested tho following classification as con- 
venient in view of tho discussion he wished to promote: 

shon^inte^sS^ with small and repeated haemorrhages at 


“ 

haemrrrh’aae Ih’l. i '^®®".t'®s reduced by chronic 
diffiG. n- Although gastro-jejunostomy offered no 

d fficulties at the time, convalescence was delayed bv the 

suturTnr' hre’;"" nec-sRatS 

suturing, nhicli again gave way partially, so that perfect 
healing was not established until nine weeks from tho 
mnveM°r'^“*'°?" -T^'® effect of the anastomosis 

wb<I-t^+?“ i®'"' ® V''"' ®®®**®"ed two similar cases 

vvheie the abdominal vyound made very slow repair without 

any trace of sepsis.. As a further in'stance of Typo 1 and 
tho danger of delay he described the case of a middlelaged 
man in whom a diagnosis. of gastric ulcer had been estab- 
lished for some considerable time, arid who had been admitted 
to hospital with a view tri operation' on three occasions and 
refused at the last minute. On the third admission his 
condition was so grave that a preliminriiy transfusion was 
considered necessary. The If pints of blood transfused 
had an immediate improving effect, but unfortunately he 
regained a false sense of security, and, as a result, died 
four weeks later from heart failure consequent upon his 
exhausted and anaemic condition. Dr. Shaw reported the 
case of a woman, aged 53, where there was delay in opera- 
I ting, and whore tho ulcer was eventually found to shovy 
characteristics suggestive of carcinoma. Partial gastree^ 
tomy was performed, and ten months later the woman was 
apparently well and had gained considerably in weight.. 
Dr. Shaw said that four- cbriclusions could bo drawn from” 
tho treatment of Tj’ps 1 cases : (1) that gastro-enterostomy 
gave cessation of haemorrhage; (2) that delay was 
dangerous in that tho patient became too weak to with- 
stand the actual operation; (3) that delay endangered tho 
recuperative power necessary for the healing of the wound ; 

(4) that tho danger of overlooking a carcinoma until 
such tinio as it became inoperable must also be borne in 
mind. To illustrate Typo 2 — “ the small infrequent 
haemorrhages ” — Dr. Shaw instanced the case of a man, 
aged 35, first seen five years ago with slight haematemesis. 
There was a vague history of epigastric pain and discomfort 
after food. The subsequent histoiy’ showed recurrence of tho 
pain, but there was no evidence of vomited blood or 
melaena until six weelcs ago. The barium meal showed 
a hypertonic stomach, very active peristalsis, rapid 
emptying, but no definite sign of ulcer. Tho symptoms 
responded to medical treatment, 'and tho man had returned 
to work. ' Dr. Shaw considered that this type of case 
occurred more frequently in younger subjects aged 25 to 
35 and, even gi'anted that the diagnosis of ulcer was estab- 
lished, lie did not advocate the ready adoption of surgical 
measures in these patients in the absence of evidence sug- 
gesting pyloric obstruction. Untoward sequels, such . as 
jejuna] ulceration, were likely to occur among these cases. 

Dr. Shaw then spoke of tho sudden large haemorrhage of 
Type 3, of the urgent problem, and of the heavy mortality 
presented by this class of case, often duodenal in origin. 
Ulceration might occur into some large vessel such as 
the splenic artery, the coronaiy arteries, or tho gastro- 
duodenal. Dr. Shaw advocated operation without delay in 
these cases, having regard to tho danger of .recurrence of 
haemorrhage. Tho ideal operation was that which removed 
the ulcer or controlled tlio source of haemorrhage by liga- 
ture and was followed by gastro-enterostomy. Tho extent 
of this procedure could only be determined in the indi- 
vidual case at the time of operation, and gastro-entero- 
stomy might alone be possible. 

Dr. C. H. MinLEH said that divergence of opinion between 
the physician and surgeon was more apparent than real 
on the treatment of gastric haemorrhage; many physi- 
cians welcomed an operation in that it shortened tho 
period of treatment. A difficult problem often arose in 



Makch 17, ^ 9 JS] 


EADIuii IN CANCER OF THE BREAST 'And TONCUE. 


r The Bnmsni 
L SIedicai, JOCRSlt. 


451 


0,10 of thcso sovoro cases of I.acmorrhago, ow.ng to tlio 
oatient bcin-r too ill for routine cxainiimtion, niul then it 
ivas ncccssa^ to resort to tl.o history for a decision Dr. 
Miller a'^roed in counselling operation in cases of chronic 
nicer ; tho gravest hacniorrlmgcs ivoro to bo feared in tlie 
region of tho lessor curvaturo. Ho slioived a drawing 
illustrating a chronic ulcer ivhich had eroded tho splonio 
vessels and established a dissecting aneurysm. In Dr. 
Miller’s experienco tho acute cases of ulcer wero more 
liable to bleed than ivero tho chronic, but at tho same time 
bo advocated medicinal treatment for aciito cases ivhero 
the indications ivoro moderately safe, nnd advised as a 
broad rule that tho chronic cases should bo treated surgi- 
cally. Fainting nnd sudden collapso woro important signs, 
pointing to erosion of sbrao largo vessel. Dr. Miller 
■finally drovr attention to cases of hacmatemesis in young 
girls ivhero' fainting occurred before tho haematomesis. 
-He said that these patients recovered under tho care of tho 
physician, but died if surgically treated. 

Mr. Noiijlin Lock mentioned eight cases of severo 
liacmorriiago observed in recent years; all but one had 
ended fatally. Four had been treated medically, and an 
equal numbor had conio to operation. Ho agreed with 
Dr. Miller as to tho infrequency of liaemorrliago in tho 
chronic ulcer. Ho had formed a favourable opinion of 
gastro-jcjimostomy alono fiom his own experienco in 
opeiating on theso cases. Ho welcomed transfusion ns a 
.pi^ent help in these sudden severo haemorrhages. 

Dr. Coho reported a favourable oxporietico of tho 
intensive alkali treatment in gastric ulcer, tho results of 
T iicli now made him very uinvilliiig to advise a gastro- 
* Solly discussed tho question of 

r nsfusion and the advisability of introducing a small 
^ Dnie; large amounts might actually increase 
0 la uity to Iiaemorrliage. Dr. Sollv also suggested the 
not aThand'" calcium clilofid'o wheu a doctor was 

tonin' ^0’'ng sHuation which had 

from Riul/ln 'utely faced in tho case of a patient suffering 
tho boom of blood from tho stomach: where was 

tho treatmlnrf^’ * “ surgeon bo called in, or should 

oneintifn 1 The surgeon might say that an 

In tiiis Msn leaving tho patient alone, 

tion was' m "^’i ®^'T1 that tho immediato indica- 

cbloridB nr 1 followed by hacmoplastin, calcium 

bo agreed tbaVh°i adrenalino chloride. In acute cases 
ic tbo flirnn.- * "ns -best, as a rule, not to operate, but 
older folk— -m'' especially chronic ulcer occurring in 

Tlie inteiislrtv^Ti-'^fT'^'^'® ‘duodenal, ho advised operation, 
•than a now fo " treatment was- a modification rather 

;tq be doing weTjn present under his care appeared 

' niodifiprt" favourably impressed with tho 

■Bovem As .regards the cases of 

-Was that ’ 'tlio ^ ^^Porience in the medical wards 

-account of those considered inoperable on 
•treatment Tj'^-.^^^^'^^^'^'rdition recovered under medical 
transfusion topsr also gave his personal experienco of 
a bio- robust m three recent ' cases. On one, 

•rinK°in tbii-ts- effect, death occur- 
'hate eSect waVHriWhg. 

haemorrbf^n^^’ T^EntA Guay recalled five cases of severe 
twenty.fivo° ve^rs'^'^n '*is practice during the past 
Operation no tjiG patients had refused to have 

good'^ iSover? HbI’ ^ 

■valuabis n-Ln'r,* ■ ® found cocaine and adrenaline 
haemorrhage a?d™ir,s^ during the stage of 

■subsequently' magnesium sulphate in small doses 

advance in considered that the most important 

fusion. ®-es^ was blood trans- 
case of the the 

man had refused o'nn^c t* 'T haemoglobin count. This 

ordinary food n ben ho ^“•‘' ^ 

■that excision should L n * hospital. Mr. Candler agreed 
up to the present tim v I]®''^°rmed wherever possible, but 
of tile acute bleeding ®^umion 


RADIUM IN CANCER OF THE BREAST 
AND TONGUE. 

At n meeting of the Brighton nnd Sussex Medico- 
Chirurgical Society on March 1st, the president, Dr, 
Donald Hall, in the chair. Air. Duncan C. L. Fitz- 
iviLLiAMS gave a lecture entitled “ The role of radium in 
treatment of cancer of tho breast and tongue.” 

Mr. Fitzwilliams began by recalling the birth of modern 
surgery, its extensive growth at first and its slower progress 
subsequently as fewer fields wero left for exploration. He 
thought that the time would come when the whole of the 
body would have been , explored by surgical means ; tech- 
nique would have reached its highest, and surgery, as 
known now, would be on the wane. Its nature would alter, 
and, perhaps a hundred years hence there would be con- 
tempt of tho doings of to-day. . One of the present changes 
was tho replacement of surgery by radium in areas where 
it could bo applied. In the tongue radium had largely 
replaced the knife among surgeons who understood its use. 

Mr. Fitzwilliams mentioned the several methods of 
applying radium, and particularly the insertion of seeds 
of glass containing radium emanations. These -seeds were 
planted in the tissues and left there; the radium ‘emana- 
tions diminished gradually and the glass capsules remained. 
Ono dmwback of this method was that if used in a septic 
cavity such as tho mouth sepsis might supervene, and the 
capsule could not he found in the oedemateus tissue. He 
had seen an instance of this in the case of a tonsillar 
growth. A better method was the insertion of metal 
capsules containing emanations with a fine piece . of silk 
attached, so that they could be withdrawn after a certain 
timo. Ho described an instrument after the manner of a 
trocar and cannula for the introduction of these seeds. 
This method of applying radium a-as rather new, nnd it 
n'as too soon to say whethei it would hold its own, but, ho 
added, superficial growths disappeared as if by magic when 
treated in this way. He described the use of needles con- 
taining radium; these needles, of varying lengths, were 
composed of pl.atinum 0.5 mm. thick, so as to screen 
off injurious rays from the tissues. They should contain 
0.2 to 0.5 mg. of radium, and the most useful length, he 
thought, was about one to two inches. He described their 
employment fully, and said that they should be left in place 
for a week or ten days. He then discussed tubes contain- 
ing about 50 mg. of the metal heavily screened ; these were 
good in such cases os carcinoma of tho cervix. An effi- 
cient method of treating cancer was to place large doses 
in the centre of the growth where the cells were degener- 
ating and harmless. It was much better to surround the 
growth with radium needles so as to deal with the actively 
growing edge. The last method described , of using radiuni 
was by tubes or plaques, either of the metal itself or radia- 
tions, which were placed upon the skin. He said he had 
never obtained good results • from this method in large 
growths, but it was a very good -way of dealing with small 
superficial growths, such as rodent ulcers and epitheliomas 
of tho lips. In dealing with . the breast it was pointed 
out that extrathorabid carcinoma alone could be dealt 
with; if the cancer cells had already gained the interior of 
the chest,'the patient would probably die owing to internal 
metastases, however widely the original growth might be 
removed. ' In the early stages of primary carcinoma of 
the breast the knife was far superior to radium; only 
ill atrophic cases, cases unsuitable for operation, or in 
enoephaloid cases was radium recommended. The great 
function of radium lay in dealing with the external meta- 
stases; and these could be treated with the certainty of 
cure.' Illustrative cases were given. In the tongue the 
disease superficially was local, but penetrated very deeply. 

• It was' the failure to realize this depth of penetration which 
was the cause of local recurrence after operation. ^Seeds or 
needles would cause the growth in the tongue to disappear, 
but left a very suspicious hardness behind. Different 
methods of treatment were illustrated. In the glands in 
the neck block dissection combined with the use of radium 
was recommended as the best treatment. Mr. Fitzwilliams 
strongly recommended the use of lead in combination with 
radium. 



MABcn 17, 19=8] 


EEVIEWa. 


r Tm;Bnms« 

SICDlOXZi JOUBKi£ 


453 


HcbicluB. 

SURGICAL TRBATJIENT OF JIALIGNANT 
DISEASE. 

Thebe is somctliiiig .ntniost ovcrwliolming in tlio idea tliat 
a man should be found in these days bravo enough to tnko 
the whole Held of cancer surgeiy for bis task. It is only 
one who, like Sir HomiUbt Wabiko, can coininand immenso 
clinical ’resources such as those of St. nartbolomow’a 
Hospital who could properly set out to teach tbo profes- 
sional world what his e.\-i)cricnco has taught him. "What ' 
these resources arc can bo clearly indicated by the mention 
of 748 cases of gastric, 500 cases of lingual, 1,523 of 
mammaiy, and 51 of uterino cancer in the twenty-year 
period quoted. 

At first sight it is not quite obvious exactly to what 
audience this work. The Surgical Treatment of Malignant 
Disease,^ is addressed. The specialists will [)erlinps think it 
best suited to the general surgeon. The general surgeon, 
on the other hand, may conclude that the specialist will 
find in it just the amount of information about the wider 
field that may suffice him; for tho pages containing the 
letterpress number no more than 667, and a very eonsider- 
ablo portion of these is devoted to illustrations, some of 
them inserted twice and one threo times. No trouble, in 
fact, has been spared to make tho book easy to read, though 
tho regional arrangement of the chapters has tho disadvan- 
tage, which extends to tho index, of not bringing before the 
reader at once all tho information available about such a 
subject, say, as " sarcoma of bone.” 

To review a book like this helpfully or constructively 
would require knowledge and courago like tho author’s. 
It must suffico to speak of tho contents in general terms, 
and to record a few comments that aro suggested by 
reading tho sretions. In tho first place, almost cverr 
BMtion ends with a statement of tho author’s experience 
of radium and irradiation in treatment, supplomoiited by 
a summary of that published by others. It seems that on 
the whole his impression of results is but little more favour- 
able than that of the generality of surgeons a few years 
ap. this IS rather unexpected in view of the results 
0 tamed at the Radium Institutes of Paris and elsewhere, 
not le^t at Sir Holburt Waring’s oivn hospital. It is but 
g o say that tho quotations from other writers offer 
^ useful and yaluablo summary of irradiation re.sults. 
+., 1 . ^ dealing with cancer of tho tongue may be 

Ann'' A’^^P’o^entative of the remaining forty-seven, 
tl i V ^ intention to deal with pathology is disavowed, 
don course, bo excluded. Clinical aspects, inci- 

u'usnosis aro taken in turn ; there is then a 
fnlUn- pf the principles of operative treatment, 

f ■■ f,. I “ discussion of the considerations proper to 
ann<.rfl' ^ '"'*^1 urtent of operation. After a page about 
tl. tn ^ actual operations aro described much 

Onprni' made familiar by^the author’s Manual of 
“’"'Ppr.Vi but expanded and with some additional 
^ ucidate the probable lymphatic involvement. 
In ^ illustrate “ block dissection,” unless studied 

liardlTT i'°° ^ short paragraph ten pages back, 

This ^ttll what is now meant by that term, 

referenno "I"’ concludes with a list of 

a mnst c 1 literature, a feature that will prove 

a riitmrt book, especially as in many cases 

reaard matter is incorporated in tho text. In 

the nrnr. .®.“"cer of the oesophagus no way of escape from 
is intpT f indicated. Under “ Stomach ” it 

savBiii that the author has operated on 

Dublishod"^''^ perforation of a malignant ulcer; tho 
paeo 7f! mentions, are few. The figure on 

ndeomtn sued one of gastrectomv for ulcer, but not 
a: np®' ^°r cancer. The sections on malignant 


diseaco tl, . '-‘‘peer, me sections on mall 

becaiisn nf tu" i intestine aro interesting, of Cuumc, 
cite- and +1 n ^ occurrence of cancer in this 

to the averave^suvlf estimating prognosis, 

• Iji q^ccage surgeon meeting his solitary case . 

Waring, ■Vcjfjnant Discatt. Dy Sir 
Lon don : Milford Oxford Jleclical 1 

U-«rsity Pres,. 1928. - 


Holburt J. 
Publications. 
(Or. A to, pp. XX + 657; 


The discussion of cancer of the rectum reflects current 
opinions. The difficulties, such as avoidance of tear or 
Wound of tho bowel during the perineal operation, aro 
hardly given enough prominenco. Here it may bo men- 
tioned that the book does not embody the anther’s expe- 
rience and advice as to the management of difficulties in 
after-treatment,- which is a pity, since it is in tho cases 
that, unaccountably or explicably, do not “ go right ” 
that guidance is sought by tho less experienced. It is to 
bo noted that in treating malignant disease of the testicle, 
operation extending no further than the internal ring is 
recommended; the theoretically complete operation is 
described, but “ sufficient cases, however, are not yet on 
record to justify tlio general recommendation of this 
method.” The suprapubic route is advised for removal of 
carcinoma of tbo prostate, but an abdominal incision “ two 
to three inches ” in length would not suffice for surgeons 
less skilled.. In speaking of cancer of the cervix uteri the 
author says that a biopsy ought not to be necessaiy, and 
is to bo dejirocatcd as likely “ to expedite tho occurrence 
of metastasos.” It is to bo noted that ho apparently con- 
siders Brodcr’s classification of malignancy of value, and 
in this context relies upon it for an estimate of the likeli- 
hood of glandular infection: must not the value bo mainly 
associated with a biopsy? Chclecysto-gastrostomy (p. 451) 
is recommended, or as an alternative chnlccysto-jejunostomy, 
tbougli on pago 460 we are left uncertain whether cholecysto- 
duodenostomy is not, in tho author’s opinion, tho opera- 
tion of choice. It is encouraging to learn that he has not 
had an operative death from removal of the spleen for 
malignant disease. For those cases of tumour of the hypo- 
physis in which the main mass is above the fossa he has 
found the antero-lateral cranial route the best, but he 
mentions Sargent as preferring the frontal. On page S21 
it is stated that a malignant growth commencing in the 
ganglion cells of the medulla of the suprarenal has the 
usual characteristics of a melano-carcicoma, and the reader 
is referred to Ciiapter 16 (hypernephromhta),' but tlie 
subject does not seem to be further elucidated. In dealing 
with sarcomata of the bones of the upper extremity Sir 
Holburt Waring does not gjve any decided personal advice 
as to tho propriety of amputation, local removal, or 
reliance on non-operative methods. In the discussion of 
operations on tumours of the lungs the value of pre- 
liminary artificial pneumothorax is "not made quite 
apparent, as the a:)aesthetist is told to increase the intra- 
tlioracic pneumatic pressure before the surgeon incises the 
pleura. 

In reading this, or any, book on malignant disease, as in 
reflecting on cases, it is hard to relinquish the hope that 
some practical means may be found of reaching cancer cells 
wherever they may exist throughout the body — either to kill 
them by extraneous means or to awaken protective forces 
surely capable of evolution by the tissues. It is with regret, 
therefore, that we learn that the experience of St. Bartho- 
lomen-’s Hospital with Blair Bell’s method has not 
confirmed the results he himself has demonstrated. 

Sir Holburt Waring is to be congratulated on the energy 
and industry wliich, amid so much exacting public work, 
has enabled him to add this remarkable hook to his 
achievements. 


PEDIATRICS. 

The basic idea of prevention, as has often been said, is 
gradually creeping its way into many branches of medicine, 
and while its presence had been obvious for some time in 
many small monographs on various aspects of diseases of 
children, no author had so far attempted a large textbook 
based fundamentally on this idea until The Modern 
Practice of Pediatrics^ by Dr. William Palmer Lucas 
made its recent appearance. This volume is not by any 
means a “ popular ” exposition of elementary child welfare 
principles, but covers the orthodox field of pediatrics in 
a thorough manner ; and the author has succeeded in 
demonstrating how ev'en the most technical and intiicate 
problems of the research laboratory and the most com- 
plicated clinical aspects of the subject are related to the 


3 The Modern Praclice of Pejtfutries. 
,Ii.D. London : J. and A, Churchill. 
26 fijfurea. 303. net.) 


By ^Y^liDIn Palmer Lucas, M.D., 
1927. (Roy. 8vo, pp. x + S63 ; 


454 March 17, ■1928') 


. BEVIEWS., 


('; ,r TirsUBrnsv 

I L ItEPICXZi 


prevention of disease. Tlie book is divided into two parts, 
the one dealing with infancy and the otiior witli childhood. 
In the fonnor the preventive idea is well ' developed in tho 
care bestowed on tlio pre-natal period and tho physiolo^ 
and patliology of tho infant. Tho latest work on nutrition 
is then taken np and disenssed at some length, so that 
after chapters dealing with niotabolisni, vitamins, intes- 
‘ ’ ' 'y requirements, tho problems 

' o approached on thoroughly 
disorders are considered in 
tho modern spirit, and even if tho terminology (as always 
in this dopai-tment of diseases of infancy) is unsatisfactory, 
tho author makes it quite clear what ho means by tho 
terms ho emjdoys. AVith cha])tcrs on certain .S])ccia) dis- 
orders such as congenital pyloric stenosis, rickets, tetany, 
and scurvy, for example, tho fir.sl part of the hook ends. 
The disorders of childhood are again dealt with from tho 
incventivc standpoint. From a discussion of normal growth 
and nutrition, the .subjects of malnutrition and digestive 
disturbances follow naturally, and the various systems are 
then taken up in tuiii. A chapter on mental problems is 
esjjecially good, and a short .section on accidents is an 
unusual but welcome addition in worlts of this character. 
A final chapter on therapeutic and diagnostic procedures 
contains a very large amount of jiractical advice. At the 
end of each chaj)ter a very full bibliography is given under 
the modest heading of “ reference rcading.s,” and the list 
of authors shows JJr. Palmer to be well acquainted with 
the latest develoimionts of his subject. Well indexed aud 
illu.strated. this volume represents with much success an 
increasingly important new outlook on disease, and at the 
same time it forms a serviceable textbook on tho subject. 

Pediatrics is dealt with in tho wcll-knorvn English 
“ Aids " series by a volume of over 300 pages of small 
print with tho awkward title of Aids to the Uiopnosis 
and Treatment 0/ Diseases oj Children.^ Dr. F. Jtl. B. 
Alle.v has revised tho late Dr. John McCaw’s work for 
a sixth edition, and an amazing amount of information is 
contained in a very small sj)ace. The section on artificial 
feeding has been modified, and is certainly .simple, but much 
too brief, flefei/ences to recent work on lickets have been 
incorporated, and a different classification of nephritis is 
now adopted, while other parts of tho book have been 
brought up to date, so that the popularity of this intro- 
duction to pediatrics is likely to be maintained. 


DIATHERMY. 

Tni: second edition of Dr. E. P. CujtnEiinATCH’s book on 
Diathermy, its Diodnetion and Uses in Medicine and 
Surgery,* has been overdue for some time, tho first edition 
having been published as long ago as 1921. Knoudedgo of 
this method of treatment has grown, and its scope has 
widened accordingly' in tho interval, and this means that 
tho greater part of the second edition has undergone 
extensive review, and a considerable amount of new matter 
has been added. Tho result is that tho volmno has in- 
creased in size by more than a hundred l)ages, and tho 
number of illustrations has been doubled. 

The chief additiojjs are those I'eferiiiig to tho uses of 
diathermy in many of the diseases peculiar to women, 
and in diseases due to tho gonococcus. The surgical part 
has been entirely rewritten and now includes a. fresh 
section on tho new “ cutting currents.” The author lays 
stress upon tho important point timt treatment by this 
method of the cause of an arthritis, such as by applications 
to the diseased cervix uteri, yields results which are far 
better than those brought mbout by treatment of the 
joints alone. 

In our review of this book lu 1921 wc called attention 
to its value, e.spocially as it was almost wholly based upon 
tho author’s own experiences. AVc would again emiibasize 
this iioint. Dr. Cumberbatch’s book is the standard 
woi'k on the subject in the English language. 


.i;,;, ,o tiTe Biaguosis and Treatment J”';? 

MoCaw AID Revised by Freaerick 31. B. M.Dj, ii.RX.P. Sixth 

i'dUwk 'students’ Aids. Series. London : Ba.ll.ere, Tindall and Cox. 

in ■Vrr'M'ie ""'I ®-': 

DlV.in r. Ciimbcrbatch, B.Af.Oxon., D.AI.R.E.Camb., .Ar^C.P. Second 
• ditioa. London: \V. ncincmann (Medical Books), Ltd. 2927» iBeniy 8vo, 
pp. Alii -f- 352; 87 iT^ircs. Zls. net.) 


' FERMENTS. 

Tub book on ferments and 'their'uctioii by C. 0 ppe.vhei 3 ier 
l)a,s long been known as one of the standard works 6u 
ferments. Tho first two volumes of the fifth edition of 
tliis work have recently been completed, and the third 
'Volume, which deals with methods of ferment investiga- 
tion (Die Methodik dcr Fcrmentc; Oppenhbimeu and 
Pincussen'’), is now apjiearing in parts. The editora 
explain that in pievioiis editions the descriptions of 
methods were mingled with the general text, but this 
method was unsatisfactory, and in tlio present edition all 
clcscription.s of methods have been collected into one 
volume, wbicli completes tho general work and also forms 
a practical textbook which can bo used independently of 
tbo previous volumes. Tlic aim of tho editors has been to 
provide in a single book all tbo information needed in the 
laboratoi-y by those investigating ferment action. 

■ AVo have received tho first two parts of this volume, 
v/iiich will bo completed in five parts. Each contains about 
300 pages. It is indeed a striking tribute to the rapidity 
of growth of the science of . biochemistry that a work of 

• this size should be devoted to the description of tho 

• technique of one branch of the science. Tlie first part 

.is devoted chiefly to general matters, and contains articles 
on important physical methods such as polarimetry, 
rcfractoiuetry, neplielometry’, spectral photometry, and 
colorimetry. These are followed by articles on physico- 
chemical methods — namely, the determination of viscosity, 
of surface tension, of hydrogen ions, of electrical conduc- 
tivity, and of osmotic pressure. Another article describes 
Pregr's teclmiquo for micro-analysis. Next the prepara- 
tion of biochemical products is disenssed, and two articles 
bv Lcvcnc on the nncleo-proteins and pbosphatides are 
snocially noteworthy. The larger, portion of the second 
uart is devoted to the description of methods for isolating 
ferments from, vegetable and animal tissues. An article 
hv K Hertcr on tho isolation of important organs m 
animals is of particular interest; it contains thirty-four 
illustrations ami consists practically of a treatise on the 
comiiarative physiology of the digestive organs In another 
article Bickel gives a full description of the operative 
nrocedure for making fistulae of various kinds. . 

^ TudainE from the parts which we have received it would 
appear that the completed volume will fulfil its purpose 
^dndrihlv It will provide an exhaustive hahoratory 
man ml of the greatest value to all workers who are 
s^ccmllv interested in ferments, and it will cover also a large 

tJnn of Eeiieral biochemical technique. The pub- 
Sers are offeAg each volume for M.28 to those who 
s, Ascribe before completion of the work, which is expected 
^j,ri! ; after that the price will be increased. 

PHYSIOLOGICAL STANDARDIZATION OF DREGS. 

^w^h:;h:^ 

;:r„saMe to.all wlio^aro -teresW m 

tlmf SSs of timework in the closing words df an 
mluctioii that he has written : , 

hook comes at a time when Ihc-need for it is 
** Di'. Burn s vear the application of certain bio- 

certain to be fe . this country for the first » 

logical stanuarcl. needing 

c<So^io of ‘ho 

Itos an exceptionally full first-hand knowledge 

S-Thegives^^ 


C^£c|| : 

irmlucrion bv H. V' Rrn. nn. XAii-r 

(I, Oxford University Press. 
ires. Bs. bd. net.) 


'■ lifes (beiiy 8ro. fp.' x'ii ' 


SlABon 17, igjs] 


NOTESiON BOOKS. 


■ 465 


manner in nhich il.o chief biologic.al tests sl.m.kl ho por- 
formod. and also mentions tl>o chief orrors that besot theso 
tests. TIio difficulties attending biological Btandardization 
are verv nuraorons; variations of tocliniquo that ai'o 
apparently insignificant can produce errors of an indeter- 
minate magnitudo. Ono of tlio fundamental diflioultics is 
tho imfortnnato fact that all living animals vary even 
.when animals of tho sanio ago, weight, and sox arc com- 
pared. Tho moans hy which errors duo to this cause can 
be avoided are dealt with very fully. 

This voliinio will bo of particular value because it sbould 
encoiirago an o.vaot uniformity of tcchniqiio in biological 
standardization, and thus promote greater accuracy in 
this work. The fact that such a booh is required to-day 
is in itself an interesting indication of tho trend of modern 
therapeutics. ■ It is not many years since the vnliio of and 
necessity for . biological standardization of drugs was a 
matter of discussion, hut tho iiso of potent remedies in 
doses sufficient to prodiico a dofiiiito physiological reaction 
has made such standardization a necessary foundation for 
modern therapeutics. 


NOTES ON BOOKS. 

In his booklet Slciktnc: and the htan’ Dr. Millais Culpin 
touches in a very interesting manner on the old problem of 
" functional nervous disorder.** Writcr*s cr.amn, stammering, 
spasmodic w^meck have all been described ns functional, and 
much ingenuity has been c.xpcndod upon tlio determination of 
lueir exact anatomical and physiological reactions. Railway 
spine had a long run as traumatic ncuraslhcnia until tho work 
01 Page and Jordan showed that tho symptoms were tho 
factions of the man as a whole and had no relation to any 
lesion of the nervous system. In tho great war " shell sliock ** 
twt the place of rai way spine. Tlicro was liardly a symptom 
m shell shock that had not been known and dcscribo'd vc.ars 
hefore high e.-tplosjves were invented. Forgetful of tho ‘past 
mis condition was caUed a functional nervous disorder, which 
“‘''°™led to: "If you can im.agino an org.imo 
think of anything else.*' So Iiospitals were 
° '"‘b cases in wliich manifestations of 

Culnin theJf " WM ‘?‘'‘-®4ceradcd as physical disease. Dr. 
behfnd t „ “ neurosis? ** and tlicn, " What is 

a fine .and .“^'scussion of tlicso questions is 

problems is "^‘bng. Tho understanding of such 

up fovelher '"IPcctancc. " A great problem is growing 

the sick. IfT"*!. m "’^ceased public coheem for tho care of 
resoonsihiUfv ®cans to be looked after and relieved of 

ciiltv in adinsi;*'™i*^'i,''^r'°“ patient, who already finds diffi- 
recoverv It is demands of life, loses the stimulus to 

in Ih^e' cases especially by lawyers, that 

enforced comnoJ^r^'^ traumatic neurastheni.a when tho law 
often followed paymrat of a final lump sum is 

maintains the Ui "'bilst the continued .allowance 

.birs ""i- 1. s™.!, .-..d- 

soliv^ eniolei ^ “ .null boob which has oppar- 

as it has rLched Popularityin tho United States, 

Dt. Geobge BnoDBrji? h "‘bich is now under review. 

I16 considered together information which 

aad thrown it t to an expectant mother, 

A/i;« ^ of question and answer. It is 

“P. any partic ’ 

enoDch for the ^ud concisely given, ana tnere is qun-e 

^9 a veiy useful ^ assimilate. This book would 

' to tho loDdv nt.S?„!!a° ‘I'eir 


? simple proceedintr question and answer. It is 

mformation is dearlv “P- particular question. The 

cnoDgh for the iina concisely given, and there is quite 

be a veiy useful assimilate. This bo"'-' 

husbands' to thr> t°,"’9“'en who bravely nccompi 
■ stations and outposts of Empi 

animals,' by CAm morphology of the blood of laboratory 

engaged in eiooT-i'inti bo found useful by those 

“ease, work. The animals e.xamined are the 

fov^ dog, hedgehog, monkey, . 

®^gaiis of thesQ nnim^i^ 'blood and blood-forming 

example, in the Vat ^ ^®scrihed in great detail j for 

Morphology and rT7t.nl S^ueral description is first given of the 
fcs from the points in which 

“T"" — — _ - OQd ; then follows a similar description 

SIinin|«‘'e3l^'’jlfekl'*s»5!‘”“‘’,'^e'P‘>'' tl.D.Lond.. P.H.C.S-Ens. . 

KD(3 Cql- T.fri ScTlca. LrOnnnn • IvofT.TTi PnvtV nVrnrVa. 


^fdteii 


subnet ana ScTlca. • 

1.50 riMuhfr Paul B nnA Genrgo L. Brodhpad, 'Xlura 

’ Ws cTilm ^ ^ ■** 

Von Prof. Dr. Carl 

IkiUJO 'iaage. Leipzig j j. uarth. 1927. (OJ x 9h pp. vi 


of smear prepamtions nnd sections of the liver, spleen, .md 
.bone marrow. T.ables are provided of the condition of the 
blMd during hunger and after feeding, in old and in voung 
animals, in venous and in arterial blood, in blood taken’ from 
aiucrcnt sites, of tho blood sugar content, the residual nitrogen, 
tlio percentage of albumin, the index of catalasis, the degree of 
rcsistiinco to haemolysis, the ' coagulation time, and the per- 
cent.ago of haemoglobin. Tho viscosity of the blood and the 
rate of siifasidcnce of the corpuscles are given for those animals 
in wiiicli tho observations were possible ; and in the case of the 
dog Ecpar.Tto observations were made on several difierent 
varieties. The cytology of the blood and marrow is illustrated 
in n number of good coloured plates. The book is in its 
second edition, nnd it may therefore be concluded that it meets 
a want in the laboratory. 

During n visit to Mauritius nnd Rodriguez in 1922-23 on 
nntimalarial work Mr. Malcolji Macgbegoe was impressed by 
klio need for a small handbook dealing with the mosquitos of 
those countries which would provide information to the officers 
and. members of the raedic.il nnd health department, and the 
present volume, Mosquito Surveys,'° is the outcome. It is 
divided into tlireo _ parts. The first is concerned with the 
morphology of the Insect, egg, larva, and pupa, and to some 
nccouiit of its life history. Part II (nearly one hundred pages) 
deals with the mosquitos of Mauritius and Rodriguez and their 
classification with keys; while Part III is devoted to laboratory 
and field technique. The book will have, perhaps, only a limited 
appeal, as Part II is not directly serviceable to workers 
elsewhere, nnd Parts I and III, though on general 


on ground covered by many other authors. 


ground, are 


We have received volume vi of the Selected Contribution! 
from, the Pching Union Medical CollegcM It includes thirty 
papers on medical, pathological, and physiological subjects, 
representing the research activities of the college. A biblio- 
graphy has also been prepared of the publications from the 
laboratories and clinics of the college and hospital for the 
period from July 1st, 1925, to Juno 30th, 1926. 

1! tHosguUo Surrci/8. By Malcolm E. Mnegregor. London : Publlsbed tor 
Iho Wcllcomo Uurcau of Scientific Bcscarch by Baillibre, Tindall and Cox. 
1S27. (Demy Bvo, pp, 282; 69 figures, 3 mops, 15s. net.) 

11 Schetea Contributions from the Peking Cfnion itedical College, 
Volumo VI. Peking. China. (Sup. roy. 8vo; illustrated.) 


PKEPAEATIONS AND APPLIANCES. 

An Electsic Slit-lamp Ophthalmoscope. 

Dr. D. Stenhoose Stewart (Hull), jointly with Mr. A. E. 
Turtille, has designed an ophlhalmoscope in which the source 
of light 13 a 15 candle-power electric bulb placed at the base of 
a tubular handle with a condensing air jacket. The light passes 
through a condensing lens system, in relation to Avhich tho bulb 
can bo focused so as to converge its beam upon a platform 
where certain slides can be interposed singly or in pairs. The 
slide or slides become virtually a source of homogeneous light 
from ivhich a beam is projected and made divergent, convergent, . 
or parallel at will by movement of a lens in a narrower, tube 
carding a battery of inspection lensK and mirrors which enables 
examination to be made either along tho beam . in the ' usual - 
manner of oplithalmosoopy, or across the beanr as a hand slit- 
lamp by. sliding the lens battery upwards, ' when the mirror 
angle is automatically adjusted ' Though it. is not essential, a lens 
U pivoted to the top of the tube, and may be brought into use 
for this purpose. . ■ 

An inherent quality in the design is the very sligiit comeal 
reflex, and the fovea in every case is easily and satisfactorily 
seen without the use of a' mydriatic hy directing the patient to 
look at the light. The nine slides supplied as standard equipment 
permit the instrument to be used as an ophthalmoscope for 
dilated or contracted pupils, by primaiy or secondary illumination, 
or with a red-free filter, or the special screen suggested by Dr. 
Margaret Dobson. It serves as a retinoscope with a virtual point 
or a slit source, with the beam convergent, parallel, or diverged; 
find as a hand sliUlam'p with a fine or coarse beam, viewed by 
separate magnifier or its own lens system. The high lummosity 
nnd tho optical system enable these tasks to he performed 
without any compromise. . , , . - . , 

Tho instrument, with slides, ic obtainable from most mstrument 
houses at the price of eight guineas, and is operated cither 
from the electric light mams through a suitable resistance or 
transformer, or from a storage battery. 

A Captive Cork Clip. ... , . 

Tho “Cute Captive” cork clip,. which has been m roduced by 
a company of that name, is designed to remove the need f^ 
linnUilJ;., onrt-v while they are being withdrawn from bottles 
and'^toLmiLonv^enm^hrough cq?ks being l<«t. The device 
is made entirely of metal, and consists of a li„ht collar which 
clip” on to the neck of the bottle, having attached to it by a 
Sble strip another but smaller collar which carries, the cork. 

Five sizes'^ are manufactured, to fit bottles of from two to. 
Bixteen ounces capacity* 




March 17, ' 


*• THE REAEITY OP DELUSIONS.” 


r TuE Bnrnsn 
Medicjh. Jousnae 


457 


The teaching of Sir James Mackenzie on llio impor- 
tance of recognizing the beginnings of liiscnso, and of 
tlic roio of the general practitioner in llicir detection, 
is Generally accepted. In the case of acute osteo- 
myelitis R-c must look to tlio general practitioner to 
be on the alert to notice the occurrence of fixed pain 
and tenderness at the end of a long bone, especially 
when accompanied by intermittent limping and 
culminating in swelling at the silo of _ pain and 
tenderness. It is common knowledge that in the past 
the early stage of' acute oslcomyclilis was too often 
mistaken for acute rliciimalism ; but acute monarticular 
rheumatism in a child is not very common, and, 
remembering the paramount imiiortanco of early 
diagnosis and treatment in Ibis disease, it would be 
well if osteomyelitis were given the benefit of the 
doubt, and if evci-y practitioner confronted with the 
above-mentioned signs and symidoms liad osteo- 
myelitis in his mind instead of acute rlieumatism. 
The postponement of surgical infervontion in a ease 
of arthritis is of little moment, whereas it may be of 
the gravest import if the ease prove to be one of osteo- 
myelitis. In this coiino.xion it would be advantageous 
to ascertain the relative frequency of monarticular 
acute rheumatic arthritis in cliildrcn between tlio ages 
of 7 and 15 years. 


"THE REALITY OF DELUSIONS.” 

The realm of mental pathology affords few problems 
a- once so obscure and so fascinating as tliose winch 
eoncom the origin and manifestation of ballucinations 
and delusions. The relationship of these two phono- 
mena js close, as every moclical practitioner who lias 
lunacy certifieafe is only too well 
aware. An hallucination is a pcrceiit without sensory 
foundation in the environment. It is not a true 
percept, because somefliiug is perceived where nothing 
” 1 .*^ partakes of the qualities of a percept 
:mrr,™r i ■eictim of an hallucination has an 

immediate behef in its outward reality . A delusion is 

TLf if. indeed, it bo at all definable. 

Bn,l described as a false conception 

hn; impregnable to reason, of what 

inndo^. in fact; but such a definition is 

flip ° point of vierv of psychiatry, for 

of a insane are based upon realities 

of tbp nature it should bo the duty 

j)..' TT^ jobiatrist to discover. It is to this task that 
Fnv De^ne addressed himself in the Long 

Univpi‘«;?*°'^? delivered recently before the 

delusinii<i^>°^ V i'ifi®' *' reality of 

D, n the paradox, 

nsveiiinu™^ chosen a topic upon which his w'ide 
authoritv^^ u^penenee entitles him io speak with 
ha<i fipjL’ more because that experience 

insiffbt pni ®®piy tinctured with rare philosophical 
In a Binmi) Hvith wide scientific Imowledge. 

ha iucid exposition of an intricate subject 

of thptjp formulation for the interpretation 

Psvcbn>ypnff-^'^°'^*[° manifestations than any purely 
clinicaf ^mgenetic hypothesis. Many years’ 

Ld him types of mental disorder has 

PSvchol« nltimate analysis, the 

disease more than obscure forms of organic 

to a ucjvplip? not. necessarily antagonistic 

it Ss R- causation. The^ twn- 

rather tlnn p° — m.-e complementary 

aspects nf til °^^’’®dictory. They envisage different 
15r Devine “The total reality,” says 

I is not revealed bj' exclusive reference 


to either the unconscious biological or the conscious 
psychological proco.ss. The total reality is a biopsychic 
process. We are dealing with the organism as a unity, 
one and indivisible.” He quotes in support of tins 
view the case of a patient wdio believed that be bad 
tlio gift of flight. The delusion bore no relation 
to pre-existing beliefs, to personal interests, or to 
problems upon which the patient might have pondered. 
” Ho will not so much as lift his head to obsen^e an 
aeroplane. It is evident that no connexion exists in 
his mind between that flying and his flying. The 
delusion is inspired from within, and not suggested 
from without; and it clearly belongs to an altogether 
different category of belief than one derived from the 
social milieu. ... it is the outw'ard and visible sign 
of an inward reality — the symbolic expression of endo- 
genous or organic disturbances. It is invested with 
the same ‘ reality-feeling ’ as perceptions stimulated 
from without, because it is itself an intuitive percep- 
tion of organic stimulations from within.” 

In illustration of his thesis Dr. Devine draws a 
contrast between the attitude of a patient' towards 
physical and mental illness respectively. ” Both 
types of malady are the expression of disturbances 
of the organism; but in the one case the patient 
realizes he is Ul, and can more or less localize and 
describe liis suffeiings; while in the other, in most 
instances, the patient has no sense of illness, and ho 
is unable to furnish any information as to the nature 
or locnhty of the stimuli responsible for the morbid 
psychic products which surge into his conscious life. 
Thus the morbid state of the organism iS' not repre- 
sented in the mind of the patient as physical suffering, 
but as depression, unappeasable anxiety, a feeling of 
guilt, delusions of omnipotence or persecution, or in 
the form of visual, auditory, or conaesthetic halludina- - 
tions.” Wo cannot be reminded too often that 
psychiatry is part and parcel of general medicine, 
although it has a terminology (and, indeed, in some 
hands, a jargon) of its own. Dr. Devine is well aware 
that the hving organism ‘ ‘ is not quite the same thing 
to the psychiatrist as it is to the general physician," 
and that psychological medicine, groping too often at 
present in the dark, has to find its way by means that 
are not always too intelligible to the busy family 
doctor. But his philosophical outlook, and the fresh- 
ness and clarity of his writing, lead one to hope that 
the gap between this special branch of practice and 
medicine at large is narrowing rather than widening. 
Evei-y step towards integration, whether taken by 
way of contrast or of comparison, is a move in the 
right direction. 

Dr. Devine compares the evolution of a delusion 
to the unfolding of an instinct. At first a sense of 
anxiety, discomfort, and tension — ^the consciousness 
of changes in the organic life for which the patient 
is unable to account; then the crystallizing-out 
of the delusion, and a new sense of power and 
purpose. “ Just as hunger ” — ^to quote once- more 
from tliis stimulating essay — “ is the echo of nonnal 
physiological distress, so a delusion is the echo of 
morbid physiological distress — the symbol of diffuse 
and unlocalizable changes occurring in the depths 
of organic life. Hunger does not originate in the 
brain, but in the 'depleted cells of the niiole 
organism. It is thus also with a delusion, it 
is the conscious symbol of a morbid state of func- 
tioning of the whole organism. The delusion is real, 
for it is the symbol of organic actuality. Once again, 
then mental disorder is not a thing apart; its investi- 
gation and alleviation are intimately bound up with 
the science and practice of medicine as a whole. 



468 MjLHOH 17,1928] ■ ' - ' '-A&THMA- KB^BA'Kbtr. 


■^'A2a 


fsr:, Tjfy BniTiin , C 
*- L MtDIcAL JoVKXAt 


ASTHMA RESEARCH. . 

Stsiejiatio invMtigation of a morbid process, ivhon well 
planned, wisely directed, and adequately financed, ofFei-s 
the best hope of advance in treatment; Wo are glad, 
therefore, to publish the appeal by the Asthma Rc'soareh 
Council at page 468 for the sum of £50,000 to enable this 
distressing condition to be the subject of co-ordinated 
research. Breadth of vision has not always boon manifest 
In the study of problems of disease and its treatment, the 
main clinical objectives being sometimes forgotten iii the 
»tudy of interesting scientific details; from such a danger 
the present ’proposal is obviously safeguarded. It may bo 
recalled that towards the end of last year a group of persons 
suffering from asthma was formed to organize such a 
research, and we pointed out at tho .time* that such 
an undertaking required the collection and collation of 
information already available, team work, and the estab- 
lishment of oul^paticnt departments where specialists of 
different kinds could co-operate. One illustration of the 
importance of such specialist study was immediately forth- 
coming, for Sir James Dundas-G.rant, in our next issue, 
emphasized the significance of the rhinological clement in 
astlima, and Mr. W. S. Syme later insisted that antral 
disease could not be overlooked in this connexion. The 
formation of an advisory medical committee to tho council 
was welcomed in our columns on November 26th, 1927 
(p. 097) ; it was at once apparent that the extent of tho 
field to be cultivated had been fully realized in a 
practical way by the early appointment of a physician, 
a laryngologist, a phj’siologist, a i-adiologist, a donnato- 
logist, a psychologist, and a biochemist, with tho 
subsequent co-operation of a bacteriologist. Surgeon 
Rear-Admiral Joans, who undertook to act as honorary 
secretary of this medical committee, has since been engaged 
in laying tho foundation of the whole scheme, and the 
time has now come when it is possible to appeal widely 
for financial support of a well conceived and skilfully 
devised plan of research. It is obvious that very much will 
depend on the I'esponse of tho lay public, and wo therefore 
commend to medical practitioners tho suggestion at the 
end of the committee’s letter that the work of the Asthma 
Research Council should be brought to the notice of their 
patients, particularly those afllicted with asthma. 


THE PHARMACEUTICAL SOCIETY'S LABORATORIES. 
The second report of the pharmacological laboratories 
opened by the Pharmaceutical Society about two years ago 
deals with the events of 1927. In the course of the year 
the new vitamin department came into operation, and it 
has been experiencing an increased demand for its 
Boiwices, while since tho beginning of August, when the 
Therapeutic Substances Act came into force and the 
laboratory began to take its predestined place in the 
administration of that measure, much larger numbers of 
samples of pituitary extract have been received for exam- 
ination. The main body of the. work has consisted, as 
before, in the prosecution of phai-macological research, with 
special regard to the investigation of methods of assay, and 
tho examination of manufacturers’ products by biological 
tests. Tho number of samples received for testing during 
the year, excluding those received by the vitamin depart- 
ment was 126, the most numerous being pituitary 
extract, digitalis, tincture of squill, and liquid extract 
of ergot, others including strophanthus, cannabis indica, 
and tho oestrus-producing hormone. In testing digitalis 
the recommendation of the Geneva Conference— that only 
those samples should be considered satisfactoiy which did 
not differ in potency from the international standard by 
more than 25 per cent. — is no longer followed ; owing to 
thofnet that a considerable number of samples submitted 


exceeded the upper limit of strength recommended, a form 
of certificate specifying tho degree of strength has been 
adopted tb cover tinctures of this character. Tho vitamin 
department has completed examinations on behalf of 
manufacturers of throe samples of eod-liver oil for 
vitamins A and D, and of a number of other preparations 
for vitamins A, B, 0, and D. The results of a series of 
research operations carried out at tho laboratories have 
already been made generally available through one medium 
. 02 ' another, among them being one dealing with the 
standard adopted for the biological assay of squill, men- 
tioned in a review of the first annual report of the labora- 
tories on Maj' 14th, 1927 (j 2 . 889). A .mixture in equal 
parts of nine tinctures of squill has -been taken as 
.standard, and tinctures tested -are considered satisfactory 
yvhich do not differ in potency from this standard by more 
than 25 per cent. In connexion with clinical investiga- 
tions into tho action of drugs on the uterus — ^work done in , 
conjunction with Mr, Aleck ' Bourne of Queen Charlotte’s 
Hospital— an interesting point is raised. Exainination of 
the active principles in. ergot has shown that, while the 
specific alkaloid (orgotaniine or ergotbxine) and hista- 
mine exert a considerable effect, tyramine is inert. The 
action of histamine, though powerful, is i-elatively' evanes- 
cent, and tho evidence, the report states, makes it clear 
that the traditional value of ergot for pi-bmoting prolonged 
uterine contractions post ])artum is due to the specific 
alkaloid alone. It is stated that the amount of histamine 
in tho liquid extract of ergot of the British Pharmacopoeia 
is much too small to have even a temporary effect in the 
dose employed, and contains none of the specific alkaloid; 
so that the extract of ergot prepared according to that 
formula since then can have had no medicinal value. 
Tho report argues that since this position arose through 
tho Pharmacopoeial Committee rejecting scientific evidence 
and basing its action on the general approval of many 
medical bodies, tho demonstration given of the uselessness 
of -the watery extract should be taken to show that in many 
cases the clinician cannot form any opinion of the value 
of his remedies, and that the only trustwoi-thy evidence 
he can offer is represented by a slow formation of opinion 
which takes many :decades to complete. 


. HEATING OF LARGE HOUSES. 

A REPORT has been issued dealing with an investigation into 
tho mbrits of that system of warning large buildings kqown 
as the “ panel system.”* This name refers to the fact that 
stcoi pipes, through which hot water is made to fiow,.are 
concealed in the walls or ceilings of rooms behind panels. 
These panels are surfaces of plaster three-quarters of an 
inch tUck painted over in cream colour. The internal 

iviiich are in groups of parallel tubes, the hot uatei 
155° to 140° F. is pumped, the temperature of the retun 
vater being about 120° F. This system of heating 1 
’ssentially one in which radiant heat is supplied at a lor 
:emperature-low as compared with, for instance a gas fii e 
teniDeraturo may be as higb as 2,000 i . 

.ctual temperature of a panel may be 99° F- u^hen tb 
.emperature' of the air nine inches from jJ 

64° F. Putting on one side coal fires and ga 
iras'^as sources of heat quite unsuitahlo for heating larg 
mildincs Dr. Vernon and his co-workers have studied al 
f the follmving methods: (1) The panel system of hot 
rater tubes concealed in the walls and (or) in the ceding 
2) under-floor heating by hot-water f 

f G H Widdows of the Derbyshire County Counci 
a system of beating by means of electric currentjen 


fn Varfow 


A Physiological °^J5‘xr'^D''vo‘naa'°M”A.. nMlited'bJ 


net. 


192a 


British Mxhjcu. Johrxu, October 22iid, 1327, p. 746. 



MAROn 17 , ,1948] 


THE LEAGUE OE NATIONS AND THE .OPIUM TRAEFIC. 


,r TitEBniTisn 
. LMcurcAi. JopRSAi. 


459 


{l,ro«'’ii Itiiios (W iiichps iiitoninl diiUDt'foi'), sonio of wJiicJi 
wore at'ovo Uie floov of ft I'omu and iionr fo boiudics wliicli 
I'lm across tlio room, wliilo tho otlicrs woio pljicod under 
ft skvligUt that occupied two-tliirds of Uie roof area; 
(4) warm air from stoves, wliicli was cironlated under llio 
floor, ns in t''« nc"' Cftthcdral at Invorpool, Tin's last 
method of heating the floor hy hot. air is i)raetically tho 
old Roman method of heating hy the liypniaust, remains 
of which maj- ho seen in n mnnher of riiinml villas- helongiiig 
to tho time- of tho Roman occupation of llritain. As 
installed at lavevpool Uathedral, Dr. Vernon fonnd that 
with air delivered into tho ducts at 150° and with a 
floor femperalnre of about 70° E., tlu' air toiuperature 
could ho maintained at from 60° to 74° E., according to the 
spot where the otiservatiou was taken. Apparently, for 
very largo stone floors, this sy.stem has much to recommend 
if. In IViddows’.s system, with a floor tempernturo of 
between 71° and 80° F., tho air conld bo maintained at 
ahaut 57° F. Turning now to tho panel system, it I'.s 
evident that Dr. Vernon finds mncli that is good in that 
method of heating. He studied panels plnei’d in tho walls 
of largo offiee.s, and also in the ceilings of oflice.s, work- 
shops, hospitals, and .schools, lly ci'iling lieafing alone the 
temperature of the air of a fichoolioom coidd he kept at 
60° F. in cold wcatiicr, when tlie lein/joialiiro of tho water 
Has 135° F. and tliat of tlio coiling ])ancl 100° E. In the 
summai-y wo arc told that “ in ofTiccs and other Iniildings 
he.ilcd by conco.iled panels in the ceilings or wails there 
is a remarkahlo uniformity in tlie distrihutlon of tlio he.it, 
and the air teniperatufc may ho .steady to within 1° E. all 
over the room and at all levels, o.xccpt that a few inches 
helow the ceiling (in a eoiliiig-panel room) tlioro may he 
a rise of about 2°.” “Tho radiation from ga.s fires and 
coal fires differs from that from iiancls, since it may he a 
thousand times more intense. . . . Wit li such high tompera- 
tuie radiation rooms felt comfortahly warm when 7° cooler 
lan eonvection-hcated rooms. In paiiol-hi’atcil rooms, 
lovrevoi, tlio permissible roductioii of air tcmiicraturo was 
ess mil JO _ . Dmier-floor hcatiiig, though it produces 
a very even distrihiitioii of heat, is apt to ho nnplcasant 
’ ’*"'1 finally, “ Hot-water radiators of tho 
01 man t^ie cause an uneven distrihiitioii of heat and a 
ibu era 0 teniperaturc gradient; but they are vahiablc 
down drauglit.s from largo u imlow.s, which 
P‘'”'‘^hlioatod rooms.!’ The report is illiis- 
cr'anhs ’''^ 1 ''“'/ figurc.s, ten tables, and four plioto- 
sfm.i 1 include 0110 of tho tlieniiopilo and tlie 

nines r . calibration, the uncovered 

ctiiirsn* f * panel, and tlio.so of a ceiling jiaiicl in tlio 
ttmrse of constriietion. 


nations and the opium traffic. 

Rations °f the Council of tho Leagiio of 

intorm+''' “ttentiou was directed to the mimcrous 

simipd °°"''°utions which, though numerously 

not- been ratified or put into 

Oninc) n °|''eial ease was that of tho International 
■hat still i'’"' ! Genova in Eebr.iary, 1925, 

seven ratific'*t-^'^''*'i'''^ because tlirce out of the nccessai-y 
“i-e still lackinn”^ '^' members of tlio Council of tlio Leagno 
iaonerative ° '' lieu the unsatisfactory position of this 

uiiiatificU '““''^'''•ion, signed two years ago but still 
February Ifitb^ 'uported to the Hoii.se of Commons on 
asked whether' tl surprising that the cpiestion was 

tion to * ^calcitrant signatories bad any inten- 

of 1010 ^‘^“'iwliile ■ 


of 1912 


the Hague Opium Convention 


Geneva Coiiv'rV'" °l’®''^hion. It will be recalled that the 
macliineiy for” "hilo formulating elaborate 

luanufactured jiarootl!^i”.^ the international commerco in 
principles of tiiti not include tlio American 

tho sunnro<r' ^ of opium and coca 

Sion of opium smoking. These principles. 


which tho American delegates • urged as being implicit in 
tho Uagtio Convention, wero iiot adopted by tho prolonged 
conferences held at Genova in tho autumn of 1924, and 
their omission led to the withdrawal of tho American delega- 
tion, followed hy that of the Chinese. At recent meetings 
of tho Council and of the Advisoiy Coramittco on tho 
Irafiic ill ojiinm, tho Italian delegate has taken an inde- 
pendent lino in regard to tho rel.atioiiship which should 
exist between the proposed Board of Contiol for tho traffic 
ill drugs and the secretariat of the League of Nations; he 
appeared to hold that with tho Hague Convention, and tho 
machinery, now available, of the Council, Assembly, and 
Advisory Committee of tho League, all that was desired 
and all that was coiitcmjilatcd by the Geneva Convention 
might ho accomplished. As regards India, it is to be noted 
that the aereago under Jioppy cultivation is in conr.se 
of reduction, hut the export trade of Indian opium is still 
very largo; in 1926 this amounted to 1,224,140 lb. Much of 
this is consigned to the Far East, and is used for smoking, 
but 88,000 lb. was sent to this country as “ medical 
opium.” The net revenno of the Government of India 
from opium amounted in 1925-26, according to a recent 
statcraoiit hy Lord Wiuterton in the Common.s, to 
Rs.2,03,52,437. 


A STUDY OF RHEUMATISM IN CHILDREN. 

In tho Fchruary issue of the Archives of Disease in 
Childhood' Dr. A. P. Thomson describes a study of the 
distrihutlon of rheumatic infection in some 800 Birmingham 
ehildrci). A rheumatic hnrean lias been established at tho 
children’s liospital of that city, and cases notified by tho 
school medical servieo and from the children’s hospital aro 
included in his statistics. Fj-oin a consideration of the 
influeiico of density of population on rheumatism Dr. 
TJiomson’s conclusion is that, broadlj- speaking, tho more 
dense tho population tho greater tho incidence of the disease. 
Nevertheless, there is a high incidence in many districts 
which arc sparsely populated. There seems no clear associa- 
tion hetween poverty, scarlet fever, measles, or diphtheria 
and tho incidence of rlicnmatisin. A map of Birmingham and 
its suhmbs in relation to water supply is.given, and on the 
whole this niipears to be the most significant factor elicited 
by Dr. Tliomson’s study. Dr. Robert Marshall of Belfast 
in the same issue, reviews 180 children suffering from 
rheninatism, chorea, and carditis. He arranges them into 
five groups, according to the symptoms and the severity of 
the lesions. Tho condition of tho heart wa.s studied hy 
means of the electro-cardiogram, and in 33 of tho 72 cases 
examined there was a normal record. Of tho 119 children 
observed only two had sinus arrhythmia, and the author 
thhiks this hears out Sir Janies Mackenzie’s dictum that 
sinus arrhythmia is a sign of a healthy heart muscle. As 
treatment ho gives salicylates for many months. He pleads 
for further work 011 the prevention of rheumatic heart 
disease, and for tho supervision and care of the rheumatic 
child. 


SEGMENTAL RESECTION OF THE COLON. 

At a meeting of the Surgical Section of the Royal Society 
of Aledicine, held on March 7th under the chairmanship of 
Mr. AVarreii Low, Dr. de Martel of Paris read an interest- 
ing paper in which he described the general prineij^s 
governing tho treatment of cancer of the large bowel. Ho 
emphasized the difficulties occasioned by the infected con- 
dition of tho intestinal wall above tho obstructive lesion, 
and put forward a strong plea for the performance of a 
preliminary caecostomy prior to the carrying out of any 
operation of a radical cliaracter. In the course of Ins 
reniarlis which were illustrated by admirable coloured 


1 Issued by tbe 
Tavistock Square, 
uiimbcr, 4s. od. 


British Medical Association. 
ir.C.l. Yeaily subscription 


London : House, 

(6 nuDibci-s), 2Ss. ; single 


460 Maeoh x7, 1928] 


TyPOGBAPHIOAD USAGE. 


[ Tnr BnmsH 

MedICAI, 


diagrams, Dr. de Martel paid a high tribute to the opera- 
tive methods he had had the opportunity of witnessing 
in London,, and in particular referred to the value of 
Mummery’s suggestion for the oblique division of the 
bowel when effecting an end-to-end anastomosis. During the 
subsequent discussion it became clear that French practice 
and British practice in relation to segmental resection for 
cancer and other conditions of the colon are almost 
identical. Mr. Mummery made the encouraging state- 
ment that cases of cancer of the colon appear to bo coming 
to the surgeon for treatment at an earlier stage of the 
disease than heretofore, and in the course of his remarks 
ho referred to the value of a transverse incision in dealing 
with growths at the splenic angle. Mr. Rowntree also 
referred to the help he had derived from this typo of 
incision, and in connexion with the question of diagnosis 
he entered a plea for the more routine use of the barium 
enema, which he had found to be of infinitely greater use 
than the more tedious process of tracing a bismuth meal 
in its course through the large bowel. Sir Charles Gordon- 
iV'afson referred to the interest and value of these inter- 
national discussions,- and expressed his complete agreement 
with the general principles outlined by Dr. de Martel. 


TYPOGRAPHICAL USAGE. 

It is not yet three years since the twenty-seventh edition 
of Buies for Compositors and Bcaders at the Oxford 
University Press was reviewed in our columns, and already 
another edition has been called for.* It is quite obvious, 
therefore, that this little work appeals to a much larger 
circle than that implied in the title, which, by the way, 
might be altered in future editions, for it is only necessary 
to glance at its contents page to realize how useful it must 
be to all who are engaged in work of a literary character. 
In our notice of the last edition we gave an account of how 
the boob came to be offered to the general public; those 
curious to know are referred to the JoubN/IL of June 6th, 
1025 (p. 1041). The present edition contains a few — very 
few — additions, otherwise it seems to bo identical with its 
immediate predecessor. It is not necessary to repeat all 
that has been said in praise of the work or otherwise, but 
we would like to return to the subject of hyphened and non- 
hyphened words. Mr. H. W. Fowler, in his Dictionary of 
Modern English Usage, says: “ The chaos prevailing among 
writers or printers or both regarding the use of hyphens is 
discreditable to English education.” This, alasl is but 
too true, and it is a moot point whether the lists of 
hyphened and non-hj-phened words published in the Buies 
are likely to assist in bringing order out of the chaos to 
which Mr. Fowler refers. In our last notice we gave 
a few instances in which the use or non-use of the hyphen 
seemed anomalous; it would be easy to make considerable 
additions to those instances. In the list of medical terms 
(p. 30 )“ foodstuffs ” is printed as one word ; in the general 
list of hyphened w'ords it appears with a hyphen. Quito 
a number of terms which are generally printed as one word 
are given a hyphen ; on the other hand, some of the 
hyphened words how commonly appear as two words. Two 
very accomplished journalists, who might well have claimed 
to be termed stylists, had a dislike for the too frequent use 
of the hyphen, and on more than one occasion requested 
that where possible it should be omitted. After all, its 
"Use or non-use is perhaps largely a matter of taste er 
temperament, and if the lists in the Buies were compiled 
for the first edition, which was published in 1893, it is 
easy to imagine that present-day taste may differ from that 
of the compiler. The pity (in this respect only) is that the 
Buies, which were intended especially for compositors and 

^ Rulet for Cojnpotitora and Readers at the Vnirersity Press, Oxfor^ 
By Horace Hart, SI.A. Tte Cncrisli spellin'ts rerised bv Sir Jbmra A. H. 
Murray, LL.O,. D.Litt.. uad Henrr Urndley, M.A., Tw^ty. 

eirhtb edition (ti,„ fourteenth for publication). London I Humpbroy 
lllliord. issa. fSi x 3i, pp. 1S5. 2a. mIO 


proof readers at the Clarendon Press, should have been 
adopted by the editors of the Oxford English Dictionary, 
which is likely to be the standard woi’k of reference for 
generations— and deservedly so. Wo still think the word 
printed as ‘‘ sensorimeter ” (p. 32) should be “ sensori- 
motor,” and we aro quite sure that " manio-depressive ” 
(p. 27) should be “ manic-depressive.” The list of medical 
terms may be of use to general printers, who perhaps come 
across one only now and again; it is, however, not nearly 
comprehensive enough for those engaged entirely in the 
production of medical work. Some sections of the book 
should prove most useful. We have space to refer to one 
only, and that a short one entitled “ Abbreviations used 
in the metric system of weights and measures ” at page 
83. This section is chosen because, in dealing with the 
" copy ” sent in by various contributors, it is a compara- 
tively rare event to meet with the abbreviations given here. 
The following may be quoted as instances: c.c. or co. is 
frequently written for cubic centimetre instead of c.cm. ; 
cgm. for centigram, instead of eg. ; mgm. or mgr. for 
milffgram, instead of mg. ; we sometimes get c.m., and it is 
only by the context that it is possible to say whether 
centimetre or cubic millimetre is intended. Then, too, the 
loiter s is added for the plural form, and sometimes insisted 
on by the author. Various abbreviations for gram aro 
given by different writers; we have seen ” gr.” (generally 
used for grain), " g,” which is rather common, and “ gm,” 
which is adopted- by the Buies, It is perhaps best that 
both' “ gram ” and ■“ grain ” should bo spelled out; it is 
so easy to mistake one for the other, particularly if the 
dot over the i in “ grain ” is omitted. IVe remember an , 
instance where '” gram ” had been set up by the compositor 
for “ grain,” and the'error was only detected in the final 
proof. The word was used in connexion with the dosage of 
a highly poisonous drug, and the consequences might have 
been disastrous had the mistake gone through. Enough has 
been said to show the importance of this section ; in it we 
notice that “ dekametre, “ dekagram,” and “ dekalitre ” 
are printed as here, with a k instead of the more usual cj 
this seems rather pedantic, and Fowler, in his Modern. 
English Usage, favours the c. In conclusion wo should like 
to say that we have found the book of great service; it 
has been our companion for years, and comparatively, few 


days pass in 


which it is not consulted in this office 


generally with success. Our experience must be that of 
others, or the editions would not continue to be issued at 
such frequent inteiwals— this is the twenty-eighth, and the 
fourteenth for publication. 

OXFORD OPHTHALMOLOGICAL CONGRESS. 

The eighteenth annual meeting of the Oxford Opbthalmo- 
loo-ical 'congress will be held on July 5th, 6th, and 7th, 
under the presidency of Mr. Philip H. Adams. The 
members will assemble at Keble College (where accommo- 
dation has again been offered) on the evening of Wednes- 
dav July 4th, and on the following morning a symposium 
will take place on “ The ultra-violet ray,” introduced by 
Professor Leonard Hill and Mr. W. S. Duke-Elder. The 
Dovne Memorial Lecture will be delivered on -the morning 
nf Tulv 6th by Professor Arthur Thomson, his subject being 
° Obsenmtions on the eyes of birds.” One afternoon will 
bo devoted to demonstrations in the Scientific and Com- 
mercial Museums. The annual dinner of the Congress will 
be -held on July 5th in the Hall of Keble College. The 
full programme will be issued in Juno. Mr. Bernard 
Cridland (Salisbui-y House, Wolverhampton) is again acting 
as honoraiy secretary. 

The Kino has appointed Sir Hugh M. Rigby, K.C.V.O.) 
to be Serjeant-Surgeon to His Majesty *" 

Sir R. Havelock Charles, Bt., G.C.V.O., K.C.S.L, who 
has been appointed Honorary Serjeant-Surgeon. 



-MARCH 17, 1928] 


[ The BRtTisn 
Uedicll Jocsxxl 


461 


Daujsoii Williams iRcmoria! Fund. 

FIRST USX OF SUBSCRIBERS. 


S IE DAAVSON IMLLIAAIS rolircd from tlie Erlitorsliip of the British Mcdica] Journal on January 19lh 
last after thirty years in that position and nearly fifty years’ close connexion' with the Editorial 
Department. In a valedictory leading article on January 21st we anticipated that his resignation would 
bo followed by sonic public recognition of the long and splendid services he had rendered to the British 
Medical Association and the profession, (o. medical science, and medical literature. A provisional Executive 
Committee was formed idmost immediately, and on February 25tli ive announced the steps that were being 
taken to promote a testimonial which should give the profession as a whole an opportunit}^ of acknowledging 
our late Editor’s devoted worlr for the science and practice of medicine. Two days inter Sir Dawson William’s 
died suddenly, and the plans for a testimonial during his lifetime had, alasl to become plans for a memorial. 

Sir StClair Thomson, who is acting as Ti’casurer, told our readers last week of the many messages that 
had already reached him froin far and wide in support of the project. We feel confident that the Fund 
will now go forward and produce a worthy monument to a great benefactor of British .medicine. , Its precise 
form will be for the Executive Committee to decide .upon .in consultation with the subscribers, but they will 
no doubt be guided by the knowledge that Sir Dawson Williams, shortly before his death, expressed a wish 
that the money raised should be used ns an endowment for the furtherance of medical research by way of 
scholarship or prize; in this way his name would be linked with work that was always verj’ near his heard. 

’7 e print below the fii'st list of supporters — those whose names were received up to March 10th. Further 
contributions will be welcomed, and will be acJoiowledged in these columns in due course. Though the 
E-xecutivc Committee does not wish to limit the amount of individual donations, it hopes that the sura 
eventually received will include a large number of contributions of two guineas or less, and so represent 
the profession generally. Cheques should be made payable to Sir StClair Thomson, and sent to 64, Wimirole 
Street, London, W.l, and the envelopes marked “ Dawson Williams Memorial.'' The amount so far 
received is £733. ■ • 


Aflaiid, Dr. T. Dvkc 

^^8ison, -Bf. Hon. CJiristopIier, M.D. 

Bishop’s TeiVnlon) 

Adrian, Dr. E. D. (Cambridge) 

Allan, Dr. G. A. (Gla.sgow) 

Andei-son, Dr. J. Ford 

Anderson, Sir Hugh, U.D. (Cambridge) 

Andrews Dr. H. Russell (Lowes) 

Arkwright, Dr. J. A. ' ■ 

f- J- (Southport) 

Balfour, Dr. Andrew 

Ballaiico, Sir C. A 

Ballance, Sir H. A. (Norwich) 

mir^anp' (Bir- 

Barlow, Sir Thomas, Bt, M.D 
&'ir F.K.C.S.'(BatI,) 

B^qvtl Lady, U.D. 

Br..E. Clifford (Botlicrficld) 

M ^I-D. (Glasgow) 

Bennett, Sir Wm., F.B.C.S. 

Berkeley, Dr. Comyns - - ■ • 

James, F.E.C.S. 

B lactll (Montreal) 

Beorge, U.D. ' 

Buclianjijj Dr "p /r*i \ 

Boist. Dr.' E. 'c®-(^uJ° f 

BuUc’r H n 
Buttar, D'r.^Cha^i^-*^-®' 
uzzard, Sip E. F.'irquhar, M.D. 

Gaiger, Dr p. Foord 

Carlfng”’E. Eoa“ p!r.c.’°- (B'»^ffow) 

Chalmc^' Dr'^((^h‘’'> 

ChampneVs, • 

(Uckncidj Francis, Bt., M.D. 


Chaplin, Dr. Arnold . 

Chcatic, Sir I/enthal, F.R.C.S. 

Clioyce, Professor C. C* 

Clark, Professor A. J. (Edinburgh) 

Clarke, Ernesfc, F.R.C.S. 

Coates, W., F.R.C.S. (jilanclicsler) 

Cock. Dr. F. W. (Ashford) 

Coffey, Dr. Denis J., President of Univci^sity 
College, Dublin 
Collcdgc, Lionel, F.R.C.S. 

Collier, Dr. W. T. (Oxford) 

Comtie, Dr. John D. (Edinburgh) 

Coombe, Russell, F.R.C.S. (Exeter) 

Core, Dr. Donald (Manchester) 

Cox, Dr. Alfred 

Craig, Sir James, M.D. (Dublin) 

Craig, Sir Maurice, M.D. 

Cullis, Professor Winifred 

Cushing, Professor Harvey (Massachusetts) 

Dain, Dr. H. Guy (Birmingham) 

Dale, Dr, H. H. 

Dawson, Rt* Hon. Lord, M.D. 

D’Ewart, Dr, J. (Manclicstor) 

Dixon, Dr. W. B. (Cambridge) 

Donald, Dr. A. (Manchester) 

Donaldson, Malcolm, F.R.C.S. 

Donovan, Professor D. D. (Cork) 

Drover, Dr. J. R. (Edinburgh) 
Dundas-Grant, Sir James, F.R.C.S. 

Dunhill, Dr. T. P. 


Eccles,’ \V. McAdam. F.R.C.S. 
Elliott, Professor T. R. 
Eyre, Dr. John 


. Graham-Smith, Dr. G. S. (Cambridge)’ 
Gray, Sir Henry (Montreal) 

Greenwood, Professor Major 
Griflin, Dr. F. W. W. 

Haldane, Dr. J. S. (Oxford) 

Hale-White, Sir William, M.D. 

Hall, Professor Arthur (Sheffield) 

Hall, Dr. F. de HavilKind (Twickenham) 
Hall, Dr. Donald (Brighton) 

Handley, ^Y. Sampson, F.R.C.S. 

Harman, N. Bishop, F.R.C.S. 

Harrison, Colonel L. W. 

Haslam, W. F., F.R.C.S. (Birmingham) 
Hawthorne, Dr. C. O. 

Hay, Dr. Kenneth 

Henry, Dr. R. Wallace (Leicester) ” 

Hill, Professor A. V. 

Hillman, Dr. G. B. (Wakefield) 

Hogarth, R. G., F.R.C.S. (Nottingham) 
Holland, C. Thurstan, Ch.M. (Liverpool) 
Holland, Eardlcy, F.R.C.S. 

Holmes, Dr. Gordon 
Hordcr, Sir Thomas, Bt., M.D. 

Horner, Dr. N. G. 

Houston, Sir Alexander, M.B. 

Hudson, Dr. J. (Newcastle-ou-Tyne) 

• Hiimphris, Dr. F. H. 

Hurry, Dr. J. R. CBournemoutli) 

Hurst, Dr. A. F. (Windsor) 

Hutchison, Dr. Robert' 

James, .R. R., F.E.C.S. 

Jeans, F. A., F.R.C.S, (Liverpool) 
Jefferson, Geoffrey, F.R.C.S. (Manchester) 
Jones, Sir Robert, Bt. (Liverpool) 


'airbairn, Dr. J, S. ^ 

’airbank, H. A. T., F.R.C.S, 

''awceit, Dr. John 
'ciling, Dr. Anthony 
^eli, Lieut--General Sir Matthew 
Fergus, Dr. Freeland (Glasgow) 

E. F., F.R.C.S. (Sheffield) 
'indlay. Professor Leonard (Glasgow) 
'Ictcher, Dr. H. Morley 
^leteher, Dr. William 
'othergill, Dr. B. Rowland (Hove) 
Yascr,” Professor John (Edinburgh) 
’raser, Dr. T- (Aberdeen) 


Cask, Professor G. E., F.R.C.S. 
Gaskell, Dr. J. F. (Great Shelford) 
Gauvain, Sir Henry, M.Ch. 

Gillies, H. D., F.R.C.S, 

Glaister, Professor John (Glasgow) 
C odall, Dr. 'E. W. .(St. Ives) 
Goodhart, Dr. Gordon W. 

Gordon, Dr. Mervyn 
Goi’don, Dr. W. (Exeter) 


Keen, Professor W. W. (Philadelphia) 
Keith, Sir Arthur, M.D. 

Keith, Dr. J. R. (Driffield) 

Kelly, Dr. Brown (Glasgow) 

Kelly, Dr. Richard 
Keogh, Sir Alfred, F.R.C.S. 


Lane, Sir W. Arbuthnot, F.R.C.S. 
Langdon-Brown, Dr. W. 
Langdon-Dowii, Dr. R. (Teddington) 
Lc Fleming, Dr. E. Kaye (AYimborne) 
Lett, Hugh, F.R.C.S. 

Lewis, Sir Thomas. M.IL 
Little, E. Muirhead, F.R.C.S. 

Low, Dr. G. Carmichael 
Low, Y, Warren, F.R.C.S. 

Luce, Sir Richard, M.P. 

T.vnr^on, Dr- Arnold (Hindheadl 


MacAlister of Tarbctt, Sir Donald, B6. 
(Glasgow) 

Macdone.ld, Dr. Ju A. (Taunton) 

McGowan, Dr. R. G. ^Manchester) 




March 17. 1928] 


BCOTIjAND. 


[ Th* Bnrnm 
STfOlCjU, J00BMA& 


463 


lfl0.4°.F. was too rigid. Ho added tliat tlio life of n practising 
.midwife, was, not a- happy one. 'Sonic means- of obtaining a 
•better livelihood for the midwife in a _ working-class district 
slionld be sought. Hero was a direction in which tho approved 
Eoeieties might help by a subsidy. Maternity benefit, it w.is 
Uae, was already available, but this was priniarily for tho 
provision of necessities and comforts for tho mother. Ho 
tliought it undesirable that when tho midwife had called in 
the doctor tho doctor's fco should bo recovered from poor 
persons by the local authority which had paid it in tho first 
instance, because this action made tho position of tho midwife 
an unpleasant one, and the reflection that it would bo taken 
might deter her from calling tho doctor in. The economic 
position of the midwife deserved much consideration. It was 
told of the Hebrew niidwives Shiprah and Piinli, who did not 
obey tlie edict of Pliaraoh, that " God made them houses.” 
The reminder was a suggestive one for public authorities or 
approved societies. 


Progress in Public Health in Scotland. 

StR W. Leslie Mackenzie of the Scottish Board of Health', 
replying to a toa.st at tho annual luncheon of the 
Glasgow-Abcrdeon University’ Association in Glasgow on 
March 3rd, described tlie changes that had taken place in 
public health in Scotland during the last foi-ty years, 
saying that in this period two or tliree great developments 
stood out. The first had been the study of the Poor Law, 
a social service wliieh was still a trouble to. every' Govern- 
ment that came into power. Much of the change in society 
which was going on before their eyes owed a great deal 
to tho quiet, clear, and philanthropic working of the 


Sir Francis CmAjirNEVs s.sid that a temperature of 100.4° F. 
was by no me.uis' tlie only thing for whicli, according to tho 
rules of die Central Jlidwives Board, the doctor might bo 
summoned. The words of tho rule were of the widest possible 
description — “ in case of any iihnormalily’.” 

Mrs.- Bruce Riciisiond spoke of tho inspection of midrvives. 
No inspector now, she thought, was a person who had received 
no midwifery Iraining, hut comparatiA’cJy few inspectors had 
themselves been district midwives, and sometimes the emphasis 
was. lam on the penal rather than, on the educational aspects 
of inspection. Finally, dealing with the economic position of 
the inidwife, Miss said th.at 110 to 130 cases a year 

represented the inaxinium tlmt a midwife could be expected 
competently to handle, and she tliought the wlioHy inadequate 
sum of *150 a year would bo found to bo about her average 
remuneration. ® 


LIVER EXTRACT FOR THE TREATMEItT OF 
PERXICIOUS AIS-AEJIIA. 

Tub folJon ing further stafoniont has boon received from t 
Medical Research Council for publication : 

appearance last week (Bniii.sir Medk 
bv P. 398) of tho preliminary re[)< 

extnni ■ I^a^aarch Council upon the uso of lit 

reniio«tc”i' o® J^foatmcat of poriiicious anaemia, numerc 
of\be tho Council for particul; 

thniiirbi a P^'^P^'fing tho extract. It is accordini 

which tl ° publish tho details of the process 

by the CounS.*^”'’ prepared for tho trial oigaiiir 

based 'nrln +L ”|’*®‘^.tbat tho method descrihed below 
been nublisbo f process, of which an account h 

in thrpn n co-workers. As was stat 

not necessarilv Particular modification ii 

tlie orifriml ^ peculiar value as compared either wi 

“periment alteVnatives, hut t 

oar^Mef s V. shown that it 

and which ^ ready' application on a large sea 

satisfactory proXet!^ indications, yields 

The method is as follows: 

uirt akohof ano"!™ ^32 litres of SO J 

hequentr and “"t- t™'-) H,SO,. S 

tissue again in 2Sn ^weWe to eighteen hours. Suspend t 

wa filter affor tip P‘=" ®t!r frequent 

blued filtrates in nn eighteen hours. Evaporate the co 

u litres ot absoliife Ti° * ™lumo of about 10 litres. A 
wlikb settles Tho o. ^ floccnleat precipitate is formi 

h eentriiuped anO P^™^tant fluid is removed and tho resid 
alcoholic liquifl a„j b® PC “Pti. alcoliol. T 

t“ as small a volumo ^ nngs aro combined, evaporated in me 
!thrins. tnteMu «'en poured, with consta 

it slowly debvdraloa I fi absolute alcohol. Tho syrupy liqt 
sistency. This matprlif alcohol and assumns a toffee-liko ct 
surfaces to ibo dp)„.j .P“*lad into long' shreds to expose fre 
^hydrating action of u T °f ‘be alcohol. When t 

fresh alcohol, and tlio matp ^ exhausted it is replaced 

brittle. Ii j), ,,, broken np and eventually becon 

b.v other suHabll mol f ('» ^-St 

ayam dried as before Thermal'' P°'^‘*°red rapidly a 

aunng tivcse oncratynnx^ « must he exposed to tho ; 

tropic. The dry pon-dei.' possible, as it is very hyg; 
!b°nld contain anlmount*. ‘’'.“"tferred to tubes, each of whi 
fresh liver. equivalent to 250 grams of the origii 


Scottish Poor Law'. Another important matter had been' 
that of tuberculosis. In 1906 tlierewas no special institution 
for tho cavo of the tuberculous, although this disease was 
at that time responsible for nearly 10,000 deaths each year 
iu Scotland. To-day there were 5,000 beds in hospitals and 
sanatoriums available for tuberculosis cases, and they there- 
fore how stood well in regard to provision for treating this 
disease. In 1903 investigations werd undertaken oh behalf 
of tho Royal Commission on Physical Training. At that' 
date no school board in Scotland had any medical officer, 
while to-day there wero no fewer than 130, and, what was 
more impoi-tant, in the 3,000 schools receiving State aid 
and teaching about 840,000 children, some 240,000 of the 
latter were being examined, prescribed for, and treated. 
Tho subject of infant mortality’ was one the study of which 
had developed vapidly during the war. In 1915 a .statute 
was passed allowing any local authority in Scotland to 
provide fov the care of the health of expectant mothere, 
nursing mothers, and children up to tho age of 5 years. As 
a result over 90 per cent, of the population was now in vary- 
ing degrees provided with full maternity and child welfare 
services. National Health Insurance ' ivas ‘ anothor ' im- 
portant matter ivhicli had come in during the period under 
review, and with some twenty statutes bearing upon tho 
subject there were at present apjnoximately 1,730,000 insured 
persons in Scotland. ^Yllatover criticism was directed at 
this matter it must he admitted that medical services of an 
admirable sort had been 2 ’rovided for the Scottish people 
by tho 1,600 doctors who were involved. The greatest 
onterpriso, however, in the opinion of the speaker, was that 
of tho Royal Commission on Housing in Scotland. Some- 
thing like 400 expert witnesses were examined and all 
parts of Scotland were visited during the four years in 
which tho Royal Commission sat. The housing dejiartment 
was now ono of the largest departments of tho Scottish 
Board of Health. Last year 20,000 new houses were com- 
pleted in Scotland, making a total since 1919, when tho 
movement began, of approximately 100,000 houses built to 
accommodate the overcrowded population of Scctland. 
Tliey conld therefore say that Scotland was beginning to 
overtake the centuries of arrears of housing. The newest 
problem was that of tho proper use of hospitals. In 
September last Sir John Gilmour had anaonneed a policy 
intended to secure that all forms of hospital sen’ico should 
he established in a unified, co-operative system. He ihought 
that tho Scottish Board of Health, which was in future 
to be the Scottish Health Department, had played its part 
in preparing tho hospitals to deal with the new preventive 
medicine which would add increasingly to the jiersonal 
fitness of the individual. 

Aberdeen Joint Hospital Scheme. 

A conference was held on March 6th between repre- 
sentatives of the boards of Aberdeen Royal Infirmary, tho 
Royal Hospital for Sick Children, the Maternity Hospital, 
and tho University Court for the purpose of appointing an 
adi'isory committee from each of the bodies interested in 
the Aberdeen joint hospital scheme. Lord Provost Lewis, 
who presided, said that the fund had now reached a sum 
of £300,000, so that he thought they might, with every 
confidence, proceed with the plans for tho erection of the 
new buildings required. He paid a tribute to the directors 
of tho Royal Hospital for Sick Children for abandoning 
the site in Ashley Road and agreeing to build on tho joint 




€66 


March 17, igjS] 


CORRESP’ol^ijiENCE. 


f: 


the water supply. Summer diarrhoea, again, had been 
practically stamped out, thanks largely to the greater 
cloanUnc.ss with which milk was produced and distributed. 
All recent public health legislation was in the same direc- 
tion The medical inspection of school children had done 
much to promote this object. During the year the council 
had distributed no less than throe million copies of various 
publications, including posters, leaflets, and showcards. 
At the annual meeting which followed the luncheon 
methods of extending the council’s work by moans of 
cinematograph displays and loctui'es were discussed. 

Maternity and Child Welfare : Revision Course In 
Yorkshire. 

^ewsion course for health visitors, school nurses, and 
others interested in public health and social serv'ice will 
he held at Bingley Training College, Yorkshire, from 
April 19th to 26th. The course has been organized b\' 
the Public Health Committee of the AVest Riding County 
Council, and has boon approved by the Ministry of Health 
and the Board of Education. Sir' AY. Arbuthnot Lane will 
giie the opening address, and the following subjects will 
be included in the course. A lecture demonstration on 
ultra-violet rays in the treatment of rickets, anaemia, and 
nmrasinus will be given by Dr. Ethel Cassic, chief medical 
officer of child welfare, Birmingham, and Dr. Naughton 
Dunn will lecture on the jirevention and treatment of 
common deformities. The physiology of sex will be dis- 
cussed by Professor B. A. McSwiiiey, natal care and modern 
midn ifery by Professor Carlton Oldfield, and cardiac 
problems in connexion with rheumatic infection by Dr. A. 
Dingwall Fordyce. Dr. R. A'^eitch Clark, medical officer 
of health, Manchester, M'ill deal with isolation, imnuiniza- 
tion, and infection, and Dr. AY. A. Potts with the psycho- 
lo^ and mental development of children. Dr. Eric 
Pritchard will lecture on the diet of children under 5 years 
of ago. Other topics will bo the problem of poverty, post- 
natal treatment by exorcises, and mothercraft. Further 
information, including a complete syllabus, may bo obtained 
from Dr. J . R. Kaye, county medical officer. County Hall, 

A\ akefield, Aorkshiro, to whom applications for admission 
to the course should ho sent before March 24th. 

Artificial Light Treatment In London. 

The London County Council a year ago approved a grant 
of £300 towards the cost of providing artificial light treat- 
ment in connexion with the tuberculosis dispensary schemes 
of the Metropolitan borough councils. The scheme was to 
be experimental for one year. It is now realized that the 
period was too short on which to base a final decision on 
the value of light treatment, and the experiment is to be 
continued for another year, the London County Council 
providing a further £200, which is estimated to be 25 per 
cent, of the expenditure to be incurred by the borough 
councils. The Public Health Committee reported that the 
general conclusion arrived at from the results so far 
obtained, and from information as to outside o.xporiencc 
was that no evidence had been given to show that any form 
of light was a- specific treatment for tuberculous disease 
but that much evidence was available to indicate that’ 
under certain eonditions and in certain cases, light treat^ 
inent accelerated the cure of iion-pulraonai-y tuberculosis- 
the best results were obtained when it was given as an 
addition to residential treatment. 

Central Alidwives Board. 

The Central Midwives Board for England and AYales 
met on March 1st, when a letter was read from the Tyne- 
mouth Joint Hospital Board, stating that the conference 
of training schools affected by tlio Board’s policy had 
been "fixed "for Februaiy 27tli. The Board agreed to extend 
tho approval of Dr. AYilliamson as lecturer to September 
50th next, in order tliat ample time might be given for 
the conference to put its views before tho' Board. AA’^ith 
reference to a letter from Dr. Lyster inviting a discussion 
of a midwife’s liability under Rule E. 20, the Board 
decided : 

(o) That if a midwife had summoned medical aid in respect of 
somo emergency, and another emergency ocenrred in the sub- 
sequent progress of the case, it was her duty to draw the prac- 


L MCDICAt JoUB'tAl 


ll-anS lo^inm'°n h ""as also desirable for -her to 

filled up ‘.and signed ‘ b'^ ber“Tl!e®^l^^''l '•'''P’ 
should, of course be notined' ” i supervising aulliorily 

™uefitras®™equiJed''brR„lo 

(l>) That a note to tbo foregoing effect be added to the rules. 

Furthor suggested alterations in the rules were con- 
sidered, and it was agreed (1) that the alterations sub- 
mitted should bo approved and bo forwarded to the 
Minister of Health for his approval ; (2) that, subject to 
such alterations, tlip Minister of Health should be asked 
to approve tho existing rules as from July 1st next for 
a period of five years. Obsoi-vatioiis to be made 011 the 
resolutions passed at the recent conforeiico between 
monibcrs of the Board and representatives of local super- 
vising authorities wore considered, and with certain amoiid- 
monts were approved; it was resolved to send these to 
tho local siipcn-ising authorities and the delegates appointed 
to attend tho conference. 




MIDAYIA’-ES AND ANTE-NATAL AYOKK. 

Silt, — The issue of the new ante-natal regulations and 
record by the Central Midwives Board raises questions of 
serious importance. 

Ante-natal work to he effective involves a knowledge 
of mediejne which can be acquired only by a training 
such as that laid down for medical practitioners. Tho card 
or case record now being snjiplied to midwives embraces 
a very comprehensive and full report on the general health 
and obstetric condition of the expectant iiiothor. ■ • 
AA’hilo in no way wishing to limit the functions of the 
nursing profession, I would emphasize the danger of entrust- 
ing medical -examinations of a complex nature to iiersons . 
not trained in medicine. The cause of maternal mortality 
and morbidity is to" be found, not only in obstetric com- 
plications, but ill diseases such as toxaemia, or in those 
which affect the cardiac and respiratory organs. 

. One. fails to see how a coursg of midwifery- training, 
however good in its way, can fit a nurse to examine the 
heart with a stethoscojie or to estimate with accuracy, the 
relationship . between the pelvis and the foetal head. 
Measiirenionts at the pelvic brim do not always indicate 
the size of the outlet, or the difficulties that may bo 
encountered at labour. 

Doubtless regulations are issued as to calling in the aid 
of a medical practitioner in doubtful cases, but an obsei-vcr 
whose knowledge and mode of examination are inadequate 
will still he faced with tho difficulty- of deciding upon tho 
presence of abnormal conditions. 

I have the utmost admiration for the splendid work 
being done by the niidwives, and for their infinite patience 
during attendance at labour. I realize also that the aim 
of the Central Midwives Board is to obtain the greatest 
possible efficiency in the service. My only object is to 
point out that ante-natal work, one of the most difficult 
branches of medicine, involves considerations both in regard 
to diagnosis and treatment altogether different from those 
which apply to childbirth. At least two examinations of 
every maternity patient should be made by a qualified 
medical practitioner — one ante-natal and one post-natal. 
The midwife’s case record would then be proiicrly checked. 

It behoves the teaching schools and other similar institu- 
tions to give facilities for intensive post-graduate courses 
in ante-natal diagnosis and treatment so that practitioners 
may have an opportunity of keeping themselves up to data 
in this new. branch of medicine. 

One aspect of the agitation regarding maternal mortality 
intimately touches the medical profession. There is a 
strong disposition on the part of some members of tlio 
public to criticize the medical practitioners obsteti c 
methods. For instance, your issue of hlarcli 3 rd coiitai n 
the report of. a conference on maternal mortality iiincn 
illustrates the prevalence of this spirit of advci-sc eritieisnq 
the main idea being crystallized in the expression tin- 
is danger in the doctor.” This is a strange tiibii c t 



CORRESPONDENCE. 


r TOTBftmsH 4fi7 
ITedich, JocuNAt. * u « 


MAKc n 17, igiSt 

profession wliich’ Iins taken the lending part in making 
British midwifei^ the admiration of tho world. When all 
is said and done tho question remains to bo answered, 
Who trains tho midwives? And was not ante-natal work 
originated by a medical practitioner — Dr. Ballantyno? 
—1 am, etc., 

London, March 51h. LOUISE McIlHOT. 


. DYSPHAGIA ASSOCIATED WITH ANAEMIA. 

Sm, — In a letter in your issue of Jlarcli 3rd (p. 375) 
Dr. Arthur F. Hurst refers to a paper on tho above subject 
by A. Mason Jones and Robert W. Owen which appeared 
in tho Jotmx.iL a fortnight earlier, and which emphasized 
tho association of anaemia with dysphagia due to spasm .at 
tho entrance to tho gullet. With regard to this affection 
Dr. Hurst informs us that ho is “ now inclined to think 
that any spasm adiicli is present is secondary’, tho primary 
causo being achalasia of tho pliai-yngo - oesophageal 
sphincter.” 

For tho benefit of those readers who may bo unacquainted 
with tho term “ achalasia,” I should state that Dr. Hurst 
had it specially coined for himself to dcscribo a state of 
non-relaxation. Ho first aiiplicd it, I believe, to tho 
"cardiac sphincter” in cases of cardiospasm, and has 
since employed it in connexion with other sphincters in 
the alimentary tract. I am not qualified to express an 
opinion as to achalasia of tho polvi-rcctal and anal 
sphincters (vide Price’s Practice of Medicine, p. 580), but 
1 venture to state that all my oxperienco in oesophageal 
• work leads mo to regard with oxtremo scepticism tho 
reported occurrence of achalasia at cither tho upper or tho 
lower end of tho gullet in man ; in such cases tho affection 
is essentially spasmodic, as has boon taught for long, and is 
rtdl maintained by almost all writers on oesophageal 
diseases. . 


To return to Dr. Hurst’s letter. In support of tho 
suggested chaiigo in' terminology and pathology ho states 
that the condition is “ exactly analogous with achalasia of 
the cardiac sphincter, which was formerly erroneously 
u Ti • Ho further states that 

achalasia of tho cardia has now been proved, by the 
pathokgical investigations of Stokes and Rake, to bo due 
to inflammatory and degenerative changes in Auerbach’s 
plexus [I should mention that changes of a similar nature 
were found independently by Munro Cameron in Glasgow], 
V' ich prevent tho normal relaxation of tho sphincter when 
I IS reached by’ pcris’taltic waves carrying food doivn tho 
oesophagus. If similar changes were present in Auerbach’s 
p exus at tho upper sphincter, relaxation at tho beginning 
"'Ti'-' deglutination [sic] would bo prevented.” 

", esiplanation is unfortunate, for Auerbach’s plexus 
not found in tho highest few contimetres of tho oeso- 
P wgus, and consequently cannot influenco tho action of 
Rill entrance. Further, while the onset of 

end of tho gullet in some cases is 
ti it is sudden, and the obstruction appears 

hilit^'^'^f its maximum at once, thus excluding tho po.ssi- 
V, aniearly period of achalasia. Lastly, anyone who 
„ HU oesophagoscopo to enter tho gullet of 

will I,!,'!? HiiHHring from tho affection under consideration 
I rIioU °° ^'”1^1' that he has been dealing with spasm, 
addiinoa wot lengthen this letter by discussing tho reasons 
term " ^-wrst for tho desire he cherishes that the 

Cardin lo^pasm " be abandoned for “ achalasia of the 
Severn! r, " - merely repeat what I have said on 

of tbo ,'^'^®®*°**®~iiHmely, that in cardiospasm the closure 

normal, umMlv”!? always firmer than 

great •+ ^ /v pronounced, and sometimes it is so 
that tho ona to prolonged steady pressure; and 

distinctlv th appearances of tho affected region are 

■actly those of spasm._I am, etc., 

-go-Bj. iiarcli 7tli. BnowN Kelly. 


referred to during the last twenty years I have ha< 

®ither to nhnrr ^arga number of cases of dysphagia dm 

aaly one case oesophageal disease, or both, yet ii 

confronted witl^^^ ^ convince myself that I wai 

■Tho case reforr*'? ’J^^fiwivocal instance of primary spasm 
a to was demonstrated at the Medica 


Society of Loudon, and showed obvious spasmodic con- 
tractions in tho neck muscles as well as of the fauces and 
pharynx on attempted swallowing. ' I have, of course, seen 
a fow instances of dysphagia high up in edentulous 
anaemic women in which a gross anatomic stricture was 
proved to bo absent by endoscopic inspection, though in 
somo other cases sent as' probably functional a definite 
benign anatomical narrowing of the lumen of tho deep 
pharynx and of the cervical gullet was evident eudoscopi- 
cally. 'Whether any of these latter cases are included 
in those recorded by Broivn Kelly, Paterson, Plummer, 
Hurst, and others is a matter of conjecture. 

Mason Jones and. Owen (Journal, February 18th, p. 256) 
accept tho usual' teaching that the dysphagia in the class 
of case under discussion is definitely due to an ab- 
normal spasmodic contraction of a ‘‘ pharyngo-oesophageal 
sphincter.” Killian, usually so accurate a writer, wrongly 
descrihed tho lower of tho two portions of tho inferior 
constrictor of tho pharynx as the sphincter of the mouth 
of. the oesophagus, whereas it is obviously the sphincter of 
tho lower end of tho pharynx, and not an oesophageal 
muscle at all. The circular fibres of the upper end of the 
gullet are not aggregated so as to form a definite sphincter, 
and aro distinct from the constrictor fibres above. This 
obvious nomenclatural mistake of Killian has led to a 
largo amount of inaccurate thinking and writing, so that 
the lesions and the errors of co-ordination of the lower 
end of the pharynx have not been accurately differentiated 
from those of the gullet. 

Dr. Hurst (March 3rd, p. 375) now has doubts as to 
these presumed functional strictures at the laryngeal 
level being really of the purely primary spasmodic nature, 
thinking it more likely that there is neuro-muscular irico- 
ofdiiiation of the nature of want of relaxation (achalasia) 
of. tho lower portion of tho inferior constrictor — that is, 
crico-pharyngeus muscle — which he assumes (and possibly 
rightly) is normally in a state of sphinoteric contraction 
when at rest — that is, when there is no attempt at degluti^ 
tion. A normal sphincterio contraction which does not 
give way to relaxation on attempted deglutition is,' it 
seems to me, for all practical purposes, rather of tho 
nature of a spasm, even though falling short of a cramp, 
and probably that is not far removed from the idea that 
Paterson and Brown Kelly and others have in mind. 
AWi.at I find in these cases is not active contraction, 
obstructive or otherwise, but a passive or feebly active 
condition of tho musculature concerned in the pharyngeal 
part of the act of deglutition. In other words, the inter- 
fcrcnco with the normal act of swallowing is of the nature 
of muscular paresis together with reduced sensibility of 
tho mucosa rather than hyperaesthesia and increased reflex 
contraction. The opening up of the lumen of the 
pharyngo-oesophageal junction preparatory to the bolus 
entering tho gullet is effected in normal conditions by 
certain lingual and hyoid muscles actively pulling tho 
larynx upwards and forwards away from the spine. The 
atrophic changes in tho tongue, fauces, and pharynx are 
slight organic changes and associated, I suggest, with a 
feeble reflex and a feeble muscular response during tho 
co-ordinated pharyngeal act of deglutition. If these views 
are correct the dysphagia is pharyngeal, not oesophageal 
in location, and not entirely functional, and certainly not 
spasmodic, but organic. The lesions are, in my view, 
comparable to those, found in the paretic p.alato of chronic 
nasal catarrh, where the palate is thinned, shrunken, and 
almost immobile, and shows atrophy of the mucosa, 
including the glands, and wasting of the musculature; 
moreover, tho reflex is diminished and sluggish, and tho 
contractile power feeble. A similar condition, I believe, 
obtains in many of these pharyngeal dysphagias, where 
swallowing is impeded owing to feeble effort and the fact 
that tho pharyngo-oesophageal junction is not well opened 
up on account of impaired reflex stimulus. 

I had not noted the enlarged spleen in any of the few 
cases I have seen of this form of dysphagia in feeble 
edentulous anaemic women, for the reason that it was not 

looked for, unfortunately. „ , a ^ v 

Although I recognize the syndrome alluded to by Mason 
Jones and Owen in their paper, I must add that I have 
met with a few cases of dysphagia in women with none 


468 Maech 17, 1928] 


COBRESPONDENCB. 


r TiirERtnaw , 

I lirviCKL JovF.ykL^le 1 1 


of the signs of the syndrome present, which I have had to 
regard as purely functional cases of inco-ordination of tho 
deglutitory act at tho lower pharyngeal level, but with 
no obvious hypertonic spasm, and merely suggesting an 
inhibition of the active opening up of the lumen of the 
pharyngo-oesophageal junction. Such cases correspond to 
some described by the older writers, who failed to dis- 
tinguish between these and those which exhibit tbo 
syndrome. The latter usually show atrophic lesions in tho 
deep pharynx, whereas tho former do not. — I am, etc., 
London, W.l, Slarch 5th. "W'lLLI.'lM SlLL. 


ASTHMA RESEARCH COUNCIL. 

An Appeal for Financial Support. 

Sin, — The Asthma Research Council is preparing a jniblic 
appeal for funds to carry out its object of increasing our 
knowledge of asthma and allied condition*!. 

On the initiative of tho Council a Medical Advisory 
Committee has been formed whose functions are to suggest 
what research work at present being pursued or projected 
should be supported by tho Council, to indicate future lines 
of investigations, and to supervise such work. The follow- 
ing preliminary suggestions have been made: 

1. The formation of an asthma clinic at one or more 
hospitals for the investigation of the “ asthma — liay-fcvcr — 
urticaria syndrome.” 

2. An investigation into the phenomena of sensitization 
in relation to asthma. 

3. An investigation into the nature of the asthmatic 
attack from the physiological standpoint. 

4. An investigation into the relationship of asthma to 
general respiratory diseases. 

5. An investigation into the family histories of asthmatic 
and allied conditions. 

6. An investigation into the nature of alleged “ cures.” 
This would include the continuation of the work of the 
British and American Medical Associations in investigating 
secret remedies. 

. 7. The provision of whole- or part-time research scholar- 
ships and grants-in-aid for such investigations and for 
"others being carried out or projected by general practi- 
tioners, medical centres, or research institutions throughout 
the empire, which are approved by the Medical Advisory 
Committee. 

8. The appointment, from time to time, of travelling 
investigators to visit foreign clinics where investigations 
into asthma or allied conditions are being undertaken. 

9. The publication of any useful results obtained. 

In order to carry out these schemes tho Asthma Research 
Council hopes to raise a fund of £50,000, and the Medical 
Advisory Committee trusts that ineinbers of the medical 
profession will assist bj’ bringing to the notice of their 
patients — especially of their asthmatic patients — the aims 
of the Council and its need of support. Subscriptions 
should be forwarded to the Westminster Bank, Ltd., 
Covent Garden, W.C.2. — We are, etc., 

Artsuu F. Hubst, Guy’s Hospital, 
Chairman. 

R. J. S. McDoAV.\Lii, King’s College, 
Vice-Chairman. 

H. W. Baubeb, Guy’s Hospital. 

L. S. T. BuniiELL, Brompton Hospital. 

E. C. Dodds, Middlesex Hospital. 

J. Fbeesian, St. Mary’s Hospital. 

R. D. Gillespie, Guy’s Hospital. 

V. E. Negus, King’s College Hospital. 

S. Gilbebt Scott, London Hospital. 

T. T. Jeans, Surgeon Rear-Admiral (ret.), 

March 12th. Honorary Secretary. 


PEPTONE TREATMENT OF ASTHMA. 

I have given liundreds of injections of peptone, and 

ordered- hundreds more, and, with one single exception, 
I have never had any alarming results. - - 

Two varieties of shock may possibly follow an injection: 
the ananlivlactic and the ordinary protein shock. In its 
slighter fo^ms one often finds that at the end of a course of 
injections of peptone a certain large dose is reached, after 
which the -patient becomes at once flushed, astlimatical, 
nauseated, and frequently sick. It is then inadvisable to 
give any further injections, because the same thing will 


occur next, time, although tho wliole distress is over in a 
few moments. This is a mild form of anaphylactic shock. 

The severe caso which occurred is interesting. The 
patient had already had a previous course of peptone given 
into tho muscle, which had probably sensitized her. She 
was a sufferer from very severe asthma. I gave her tlio- 
usual initial dose of three minims very slowly into the vein. 
In a few minutes she began to feel ill, and the respiration 
tightened up with increasing asthma. There was an instant 
demand for micturition. The asthmatical spasm developed 
so soA'crcly that the respiration practically stopped and tho 
girl became insensible; the heart continued to beat slowly 
and strongly. By this time I had given her an injection 
of adrenaline into tho muscle. She gradually began to 
come round, and at the end of perhaps three or four 
minutes after receiving tho injection she was breathing 
sufficiently. She spent the night in a nursing homo, and 
went homo by hei-self next day. To her surprise she was 
free from asthma for some five w;ceks afterwards, pre- 
sumably in an anti-anaphylactic phase, but naturally no 
further attempt was made to give her peptone. 

Much more rarely after a small treatment dose the ■ 
patient will complain .a few hours later of. protein shock— 
that is, shivoring, headaches, sickness, and a high tom- 

^^Peptono is a recognized method of inducing protein shook 
when it is given in much larger doses. Perhaps a skin 
test is advisable before commencing a course of treatment, 
c,SDCcially if a previous course has been given, but the 
possibility of an anaphylactic seizure is, I think, usually 

"Tl.e"e?to,mf f us" are.made up in accordance with Dr. ' 

Auld s fi-om horse serum are well known, 

and”many have been quoted, especially in American htora- , 
turc.-I'am. etc., E.R.O.S. 

Lonilon, W.b 

^ -nTirNOSIS OF- CHRONIC APPENDICITIS. ■ 
Recent' corrcspoiulenco-, seems to have left the 
the value of bismuth meal examination m tho - 
question ej the a amotion of the appendix in an . 

diagnosis ef- position, and I offer the following 

nnsettled pp ,o^f stimulating further investiga- . 

observations m tl 0 I ^p],joct. These opinions have 

tion and.discussim^f 

been barium meals, and from operating on ; 

man” Tf tho cfses afterwards, when I have been .able to 

check the x-roy diagnosis.^ consider what are the patho- 

In the first . ,-j o^nendix bv one or moro 

logical P™' "nflammatioii in that structure. The 

attacks 0 bpoadlv speaking, are a round-cell 

microscopic ’.f ’g,. jpsia of connective tissue m all of 
infiltratiou an ^Pj tjjp muscular coat. The resu t 

tho coats, but espoc . j diminish the contracti 0 

of this mflammatoo , -mal v 

*’onSctteg^pnrt^°f the intestine into a more or less rigid 

tube. v^onsed auDoiidix might almost he likened to 

Tho ^'ufmtning ofl the base of the caput caecum 

an of contraction and depending on its 

coh, P°f contents by tlie siphon effects of the 

being emptied caecum. I have not found that- it is 
movements 1 a chronic inflammation “f the append 

possible to uitvg with barium or bismuth. Ihe 

from its Imve seen an appendix after 

number of constriction that barium would 

operation with sue o ^ j „„ rclmncO 

not pass tt’roug 1 1 J ^ diagnosis. Emptying f.aults, 
on filling df^ts I" ““0 my mind the diagnostic features 

must show that the appei and the meal is in 

the ileum and caecum have • emptied and ti e 

the region of the' hepatic flexure, if not m tlie 


MARCH I7i i9=Sl 


COERESPONDENCB. 


t TiiE Bntrus 
jlRsicu. Jo^r»aAXi 


469 


or descending colon. Further, tondorncss on palpation of 
such a filled appendix is necessary to convict it. The 
rough digging in of inquisitive fingers, ns referred to at the 
British Medical Association Meeting in Fdinhurgh, is of 
no value, but with the .appendix visible under the screen 
very careful and gentle palpation over the inflamed organ 
should satisfy one that some inflammatory process has left 
its toll-t.alo tenderness behind, and that tenderness must he 
definitely located in tho visible appendix itself. 

Holding up of tho opaquo meal at tho ileo-caccal valve 
is suggestive of, amongst other pathological conditions, 
some inflammatory trouble in tho right iliac fossa, hut it 
is not diagnostic of appendicitis. In tho same way holding 
up of the meal in tho cnocura mn;/ ho tho result of in- 
flammatory trouble in the appendix, hut it may ho duo to 
other conditions, ranging from functional derangement to 
malign.iut grou-fhs in tho bon’d itself. 

X-ra;i examination as regards tho diagnosis of chronic 
.appendicitis has its limitations, hut if an appendix has 
been seen filled with barium, if it is tender on palpation 
and does not empty ivhen the caecum h.as emptied, then to 
my mind it is proved guilty of being tho seat of somo 
pathological condition rvhich is probably of an inflamma- 
tory nature.— I am, etc., 

, Toil. March 5lh. J. G. CnAIQ, M.B., F.R.C.S.Ed. 


G.4STRIC SECRETION OF NEUTRrVIr CHLORIDE. 
Sir, — .4s Dr. Goodhart has raised this interesting question 
it might be worth while pointing out to your readers that 
there are at present two independent pieces of published 
eridcnco which show that regurgitation from tho duodenum 
IS not sufficient to account for tho total chlorido curve of 
the fmctional test meal. 

(1) Baird, Campbell, and Hern (Guy’s SospHal Heports, 
lu ' j ’ 1 *^' 1S24) found that tho removal of 

the duodenal contents by continuous suction did not cause 
any alteration in tho free HCl or total chlorido cui’vo 
from the stomach. 

■ (2) Hausman, Day, and Clifton (Med. Journ. Austral, 
el. i, p. 6, July, 1927) have calculated that, supposing 
uio stomach contents consisted of pure gastric juice of 
naximum concentration mixed with secretions from beyond 
1 91°^ which also contain somo chloride, tho stomach 
ou still contain less chloride than was actually found 
at tho end of one of their test meals. 

haa gastric secretion of neutral chlorido 

has evidently como to stay.-I am, etc., 

W.I, Marsh 13th. E. P. PoULlON. 


importance of sputum EXAMINATION IN 
S , pulmonary DIAGNOSIS. . 

Jnmv.. pulmonary actinomycosis in the 

sente lOtJi (p. 404) there occurs this surprising 

for patient had boon regarded as tuberculous 

years, and during that time this diagnosis was 

which tuberdpT^-m ^ sputum examinations, in 

would L ’ woro never found.” One 

fact o 1 • ^ clerical eri’or were it not for the 

the bactod”i widespread distrust or contempt of 

eulosis appea'ra' to diagnosis of pulmonai-y tuber- 

lot csa'min!,i*°r*''^° grave errors. Firstly, the sputum is 
as a results' ''v bacilli sufficiently often, and 

nized in ttn number of eases of phthisis pass unrecog- 
that, in tho m ^ ^Ri’uble stage. There can he little doubt 
be diatTincori pulmonary tuberculosis can 

b'oa of thfT. “osb certainly by the examina- 

survey of the 

Weight record fp ° afternoon temperatui’e record, and the 
•ILgnosia. Yet -I most important clue to the 

Upheld, I of this doctrine, which would be 

flioso— and somo’ experts, there are to bo, found 

ussert that it is /®u?SHized teachers of medicine — who 
Soonest detected- n signs that the disease may he 

iusists’ dia'moaio’r.Vi r ® Puthetio constancy of tho radio- 

wst is that , uror m ignoring tho bacteriological 
® observer faiE to recoanizo those chronic 


disoascs that are not tuberculosis. Absence of tubercle 
bacilli after many repeated examinations, where there is 
sputum to he examined, practically excludes tuberculosis. 
This is not always believed, and thus we find bronchiectasis, 
fibrosis, syphilis, actinomycosis, spirillosis, tumour, all 
masquerading as tuberculosis, flloreover, when the eyes are 
opened - and conditions other than tuberculosis are looked 
for, behold they aro found, and wo are told that they 
are becoming much more common than they used to be. — 
I am, etc., 

F. G. CiLVNDLEB, M.D., F.R.C.P. 

London, N.XV.l, Jtarcli 12th. 


COLLECTIVE INVESTIGATION AND 
TUBERCULIN. 

Sm, — ^I was much interested in Dr. Robert Carswell’s 
letter in your issue of March 3rd (p. 375). I gather from 
his remarks that he does^ not consider general practitioners 
have tho time to spend on investigating cases which might 
receive benefit from injections of T.R. or B.E. I presume, 
tliereforo, tliat his idea is ' to have these investigations 
carried out at a sanatorium or tuberculosis dispensary. If 
my deductions aro right I should like to make a few 
rem'arlvs ivitli regard to the subject. 

First, has Dr. Carswell ever seen a case of pulmonary 
tuberculosis flaro up whilst under treatment with injections 
of T.R.? Unfortunately it has been my lot to see two 
such cases, which makes one exceedingly diffident in using 
T.R. in cases of pulmonary tuberculosis, even if under 
sanatorium conditions. 

Secondly, Dr. Carswell suggests ti-ying the effect of 
rapidly increasing doses of T.R. or B.E. in. “ simple, early, 
uncomplicated cases of tuberculosis. ...” I am pre- 
suming ho still refers to pulmonary tuberculosis; if so, 
I may bo unfortunate, but I see very few cases of this 
nature, and personally should certainly advise them to try 
sanatorium treatment in tlie first place. 

Thirdly, I am quite aware that a large number of 
medical men consider that injections of T.R. can be given 
to out-patients, but as I am still dealing only with cases 
of pulmonary tuberculosis, I fear I must disagree with their 
opinions. In a sanatorium, where a strict watch can be 
kept on the patient’s temperature, pulse, etc., and tho 
amount of exercise taken is carefully graduated, is quite 
a different proposition to giving T.R. to a patient who is 
Bring at liome. 

In the latter case one has to trust so much to the patient 
liiraself as regards reaction — that is, rise of temperature, 
slight increase of symptoms, etc. — and if one also realizes 
that T.R. can be dangerous, I do not think that the con- 
terapiated gain is worth the undoubted risk. 

Fourthly, Dr. Carswell unfortunately did not actually 
mention surgical tuberculosis, which in my humble opinion 
derives a very considerable amount of benefit from injec- 
tions of T.R. In this sanatorium all cases of surgical 
tuberculosis have as a complication a greater or lesser 
degree of pulmonary tuberculosis, and very few are, there- 
fore, suitable for injectional treatment. 

Lastly, all patients suffering from pulmonary tuber- 
culosis vary as regards their individual resistance to the 
disease and, therefore, a dosage a-hich might be suitable 
to one case would not necessaril 3 ’ mean that all cases could 
be treated by the same increase of dose or reach the same 
maximmn. Aloreovor, by means of auscultation alone a 
patient’s resistance ’to disease cannot be determined, and 
if signs in the chest increase, then it is fairly safe to 
sav that a good deal of damage has been done.— I am, etc., 

H. Sharpe, 

Medical Superintendent, Hertford Counlj 
Morch 8th. Sanatorium, Ware. 


Sir,— Dr. Carswell suggests the need for collective 
research into the treatment of tuberculosis by tuberculins 
so as to gain some real opinion as to their praper 
values I strongly endorse this suggestion, but I should 
like to go further. Opinions about treatment are 
hopelessly at variance; some practitioners favour fresh 
air and sunshine, somo think that artificial sunlight will 
cure early cases, and some believe that artificial sunlight 


470 March 17, 1928J 


CORBESHONDBNCE. 


BRTTi«ra, . 
Mkdicai. 


only acts by tending to destroy tissue, and so is not good. 
As regards tuberculin, most men seem afraid to use it, and 
from inquiries at sanatoriums I find it is rarely employed in 
any of tbom non’. I am hoping his letter ivill help to 
create a fresh medical interest in the whole subject, 
espcciall3’ the need for the following: 

1. Research for a vaccine or serunr or other practical means 
of really stamping out tuberculosis in cattle, so as to prevent 
bovine infection of our milk and food. 

2. Overhaul of our present public bealtb regulations so as to 
make it impossible for any infected food to be on sale. 

3. Research into some means of earlier diagnosis in the 
human body than afforded by x rays or tlie finding of tubercle 
bacilli in the sputum, so as’ to get cases for treatment at the 
earliest stage. 

4. Investigation of tuberculin and all the other lines of 
tieatment whicli are reputed to do good in certain cases. 

5. Fiirflier research .so as to prepare, if possible, some hind 
of antitoxin for tubercle bacilli, and some official cxaminalion 
of the preparation of the various tuberculins, of which there 
are so manj’ on the market. 

6. Finally, the leading article in this week’s Biutisii Medical 
J ouuNAL emphasizes the need for .studj’ of the question of 
immunity, both natural and acquired. 

— am, etc., 

London, S.E., March 3 rd. GouBON TirPETT, M.B.Lond. 


Sir, — Dr. Robert Carswell, writing in your issue of 
March 3rd (p. 375) to urge the need for such an investi- 
gation, quotes the question nsked b^’ the BiiiTisn Medjc.il 
Journal so recently ns July, 1927, “ To what ostent is 
tuberculin of value in the diagnosis and treatment of 
tuberculosis? ” Ho quotes also the remark: “ Practitioners 
feel that thej' are without guidance as to the cases in 
which, and the conditions under whicli, tuberculin is of 
value; guidance to whicli tlioj' are entitled the more, since 
systematic treatment by tuberculin is advocated by medical 
men with experience of its value." It appears to Dr, 
Carswell that the guidance asked for demands a thorough 
re-cxamiuation into the course and results of cases treated 
in accordance with Koch’s own final conclusions and 
directions, and ho goes on to say that, extraordinary as it 
may appear, adequate clinical examination of Koch’s im- 
portant work on this subject has not yet boon accoin- 
pli.shed to such a purpose as to carry conviction to medical 
opinion in general ; though he notes your opinion, stated 
in 1911, that “ already results were accumulating which 
should convince cverj’one hut the incurable sceptic." 

Personally I hail witli delight Dr. Carsirell’s suggestion 
that the British Medical Association sliould uiidertakc the 
direction of collective research bj’ tlio various Divisions 
into the usefulness of Koch’s tuberculin, for the reason 
that t should welcome any means whatever of bringing the 
inestimable value of tuhcvcuiins into prominence. But 
I would point out that we have here in liondon :ill the 
data and results of 3-ears and years of continuous use of 
Koch’s tuberculins only awaiting examination and report. 
I refer to the classical methods as practised by Dr. 
IP. Canine Wilkinson for the last thirti’-five years. In his 
hands Koch’s tuberculins give unparalleled results in 
pnlmonarv tuberculosis as well as in tuberculous affections 
of bones, 'glands, genito-urinary tract, skin, and even eyes. 
Every Tuesda3’ and Prida3’ afternoon (2 to 4 o’clock) he 
treats cases by injection ot Koch’s tuberculins at the 
Tuberculin Dispensai-y, 32, Fitzroy Street, W.l, where 
seekers after knowledge of tuberculin are welcome to see 
cases in all stages of diagnosis and tieatment, and to 
examine records of cases without end, as also to see 

cured bases. ,, , , 

Duriim tho jmst two years, from results ohsen-ed on my 
own cases (exceeding' twenty) treated on these lines, I am 
left ill no doubt as to the value of tuhercidin irfien 
admimstcrecl orrording to the rules laid doirn hy Dr. 

- C'umuc Wilkinson, himself a pupd of the great Koch. 'The 
words in italics are important, for I am nell anaie that 
tnberenlin used otherwise has “Hed m absolute fadure. 
We come thus to the crux of all the differences of opinion 
on the v.nlue of tuberculin. The time must soon come when 
a commi.sbion will he appointed to examine and report on 
tlie usefulness of Dr. Camac IPilkinson’s work; it is an 


interpretation of, and tho practical supplement to, Koch’s 
own work, wliich has been sadl3’ neglected for so long. 

I have avoided reference to details of tre.atment in this 
letter as Dr. Camac Wilkinson himself, on Jiili’ lOtli, will 
be adih’c.ssing the St. Pancras Division in the British 
Medical Association Houso on the treatment of tuberculosis 
in tho liomo, when I trust that all interested in this matter 
will bo present to hear what can be done by his method of 
using tuberculin. — I am, etc., ... 

London, (V.l, Jlareh 7th, CoRDOX HuME.* 


WET WINDS AND EARLY PHTHISIS. , ’ 

Sir, — The interesting papei h3' Drs. Gordon and Ash in 
Aoiir issue of March 3rd (p. 337) merits the attention 
of all tuberculosis workor.s, though to mo the figures are 
unconvincing. 

(1) Tho number of eases i.s far too small. Expressed as per- 
centages — worked out to two places of decimals — they appear 
impressive, hut the individual numbers used for the calculation 
are mostly under ten, whereas to carry conviction they shouia 
he ill the tens of thousands. Especiall3’ ^ is this true wim 
reference ■ to such uncertain topics as the influence of snhsou 
on disease. No doubt the authors would not claim any finaht)', 
only that' the ' figures are suggestive; but they call them 
“.striking.” It is, of course, impossible to procure a large 
number of patients from such a small are.i, hut in that case 
some Ollier method of testing the influence of climate on 
liih'erculosis should he attempted. . , , . 

12) It is nof. clear what is meant by shelter or exposure, in 
Devonshire, I remember. Dr. Gordon’s results, working from 
the map, differed in 58 per cent, of cases from the decision 
of other observers who actually visited the houses. And one 
wonders -if the world generally^ accepts- Dr. Gordon s con- 
duXn that an elevation of 100 feet shelters I'YTfee iZh 
a mile behind it 

Txi°'nevmi is cited by the authors as supporting their 
(3) 05'°’' '.f,,,.''"™. .s.%vork in South Devon has led .me 
claims, but man) ye i ,, peaking. South Devon is 

‘l“dm s“u'u, w stK'^^ 

exposed to j an ner cent, of inv notifications are 

"■'i’ti'onffron other places! wlio for the most part consider 
importations ° ^ q tuberculosis hospital in lorjiiay 

is opcifon?; 1^0 tire sou?h-we‘st, yet 90 per cent, of the patients 

admitted •Ihere improve. ■ 

■was once described as 
The i yet much move exact.; hut 

“opinioiiolog), a to, ^aiul often do, give voiy 

medical men me -P neecssarv in the treat- 

decided opinions «’° amdu that as a 

heginumg the J jppst eximsed to west winds and 

localities in j p Independent ohserver.s could then 

the ten Incidence of and mortality from tuber- 

...1 •'»»« "" 

ground. — I “Ui, etc., ^ W.tRD. 

Paisnlon, De^nn. 31aich 5th. 


the ACUTE abdomen. 
xiv whole intention in starting 
’ • ’f the attention of tlio profession on tlic appallm,, 
, rivet Die attcniiuii ui i intestinal 

ihat only throe Vj^fran fio content with 

tion early enough. ,.-ces of all types of the 

dancer of delay lu suspected cases ot D1 - j 

Siien cannot he “'irrtd mv Wrimt, hut 

<■ look-and-see surgei) expo- 

A" ” 

leii is aciitCr ^ , ri’»fprcnce to the 

at I say has increasing value P,„(pr 

intiv occurring cases of nhdomrn. i J . 



Karch 17, 192S] 


■OKIVEESITIES 'And CODDEGE3. 


471 


lesion way possihh/ bo present, bownro of delay in doing 
an exploratory laparotomy. 

I saw a caso four days ago in which tho only objective symptom 
was a small tender bruise over tho left iliac fossa. Tho story waa 
that tho wheel of a motor had passed over tho boy’s abdomen. 
His colour was good. His abdomen was perfectly ilaccid. Ho had 
no sickness. His bladder was distended and ho could not pass his 
urine. A half-hourly observation over a' few hours of an increasing 
pulso rate, a flicker of uneasy movement of a coil of bowel seen 
beneath tho flaccid parictes, gavo mo all tho indications I required 
that tho case was ono for e.vploration. I found tho mesentery of 
tho small intestine entirely abrupted from two inches of tho ileum, 
and this portion of intestine, congested and paralysed, but as vet 
unruptured, was adherent to tho back of tho bladder. My 
suspicions were amply justified, I think, though none of tho 
symptoms of the acute abdomen were present on avhich I could 
base a diagnosis. 

Most 0 ! my friends in general praetico candidly admit 
that they c.annot niako regular hourly observations in cases 
under suspicion of being “ acute abdomens,” and they are 
only too thankful, to bo able to send tbcm to hospital “ for 
•further observation and . ojienition if ' thought necessary.” 
On ray'paft I welco'mo cases .it that stage from every point ■ 
bf; view^xcept accommodation. Tin's winter I could at 
,ono tinio have' shown Mr. Billing six eases of “ acute 
■abdoincus ” lying side by side — ail.atyiiical pneumonias — so 
pat I .appreciate the value of • his liint, and hope he, 
knows. that in'sucb cases thcro may occasionally bo a 
concurrent .aeutb abdominal lesion. 

■ ,f .believq that ’75 per cent, of tho patients with acuto 
al'dnmens. ivho die .ought to bo. saved, and such eases will 
■in the futuro.be saved by early operation when tho factors 
controlling tho situation Imvo been properly adjusted. 
.IMial a nced.tlioro is for proper education and organization 
of the profession in regard to this typo of caso. 

. Only tho-last paragraph of , Mr. Billing’s letter has any 
interest, in cases of menstrual trouble, hysteria, com- 
mencing specifio fevers, and jioisoning I have seen 
assoqintod vomiting and abdominal pain which (the 
physician in me, considering all tho facts of the caso, was 
able to persuade tho operating surgeon in mo) did not 
require oporativo treatment, but I confess I am un- 
acquainted with that largo variety of eases ho writes of, 
wncre persistent vomiting associated with abdominal pain 
need cause, no concern lest tliey should suddenly bccomo 

■ acute abdomens.” I feel certain tho profession will bo 
uniicr a debt of gratitude to Mr. Billing if ho will give 

ctailen notes of, say, six typical cases of tho sort ho has 
m mind.— I am, etc., 

GbiSow, March 4lb. ■ WlLLIAil It.VXKIX. 


ergot poisoning among bye bread 
CONSUMERS. . 

.1 ^ good deal of interest has been aroused amongs 

le cwisli community by the article published under th 
owe heading in the British Medicai, Jourxal of Eebruar 
“til (p. 302). 

associated with a number of Jewish institu 
in a in “*'^**t®i'^ble period, and practising as I an 
strantTo"ti. I PO.PR'nted Jewish neighbourhood, it seem 
cott«uUml “®*t'her my colleagues (with whom I hav< 

cases siir.1 ”” ^““j^Gt;) nor myself havo ever como acres: 

coKs such as those described. 

brown or rye, bread is an importan 
•'•"C in some .Tcit.VI. , c 


factor in c U ""f' “‘“"“i m lye, ureaa is an iraportai 
“mount diets ; still the figures given as to tl 

and do ““Rtn’Rs appear very much exaggerate! 

Ilf the 22.85 grains stated to bo consume 

J^ine individual in one day. 


X> 

“ tares *'? I'eliablo baker (who bake 

maximum'^ 15 bread), only contains at th 

He bread ntloa* meal. There is a coarse 

W per cent mn sour,” which contains abou 

ftiis is the ’*“'ter 25 per cent, of rye flour 

possibly be nut meal or flour that couh 

? targer percpnt-„° brown bread, as bread containini 
'sweet and sonv^' ^ititile nor presentable. Th 
Pfincipallv the iq „ not much used, and it i 

■^suming 33 iJ'ti' bread that is consumed. 

“ pound of I've brp-!f referred to above, that hal 

“ent's 5 oz. of floor ncinsumed daily, this only repre 

Ot 'WnipVi TC j. ?_ _ _j.— ■» 


[ TnrBftrnsn 
STrorcu. JouBSii 


flour. Of this 15 per cent. 1 per cent, is ergotizod, and it 
therefore follows that the amount of ergot consumed is only 
3.45, and not 22.85, grains per day as calculated. 

I append the foUowing report of rye bread submitted for 
analysis : 

** I beg to report I have examined the loaf of * rye * bread 
received from you yesterday for the possible presence of ergot. 
I have submitted tho bread to a careful chemical and micro- 
scopical analysis, and I find it is perfectly freo from this poison. 
I have also examined the rye and wkeaten flours from which this 
bread is made, and I find they contain no trace of ergot or any 
other poisonous ingredient. — Dr. E: A. Wagstaffe, M.Sc., F.T.C., 
Analytical and Consulting Chemist, Victoria University, Man- 
chester." 

This applies to tho hulk of rye bread, and the examples 
given by your correspondent.o must have been taken from 
a very unusual batch of bread. — ^I am, etc., 

Bebnard HTibson, L.R.C.P. and S.I.,- 

Hon. Physician, Home for Aged and Needy Jews, 

( ■- Jewish Home for Incurables. . . 

ifanchesfer, March 4£h. ... 


. SHOCK AND ABORTION. ■ . - 
Sm, — While “anticipation,’? “fright,” and .shame . 
are probably contributor}- causes of the sudden- and often 
fatal shock in c.nses of criminal abortion, one can hardly 
feel satisfied that this forms a complete explanation of 
the. condition. Especially docs this seem to^be likely 
when it is remembered that only in , a .very trifling rper- 
centago of instances of criminal abortion does a fatal result 
follow. In the case which gave rise - to this discussion, 
and in the one mentioned by Dr. E. E. -Nicholl (Bbitibh 
Medical Jour-Xal, February 25th, p. 328), a fluid injection 
was used, and it seems probable that in both of these tho 
fluid — soap and water in the one case and a disinfectant 
in the other— on reaching the uterine cavity, was forced 
through the Fallopian tubes' into the peritoneal cavity, 
thereby causing the profound and fatal shock. 

This seems to be borno out by a case which came under 
my notice in hospital some years ago. A woman, a gynae- 
cological case, in the course of treatment was given an 
intrauterine injection; immediately after this she became 
profoundly shocked and collapsed. The only feasible ex- 
planation seemed to be that the fluid had reached the 
peritoneal cavity through the tubes, thereby, causing the 
shock. ■ This explanation was confirmed by her abdominal 
condition wlien the shock passed off. — I am, etc., 

T. J. Hollins, M.D., M.A.O. 

Sandwlcb, Kent, March 6tb. 


?Xnili£r5iti£5 anb ©Hlltgcs. . 


. : . . UNIVERSITY OF LONDON. 

A MEETING of the Senate was held ou February 22Dd. 

A resolution was adopted nuthoriziiifj a variation of the trust 
deed establishing the Geoffrey E. Dnveeii lectureship in otology 
to allow of the estahlisl;ment of a travelling post-grailnate studeut- 
ehip in oto rhiuo-larj.ngology, and of a fund for the promotion of 
research in tho«e subjects. 

The regulations for the first examination for medical degrees 
(Red Book, 1927-28, p. 245, second paragrapli. and Blue Book, 
September, 1927, p. 212, fifth paragraph) were amended to read as 
follows: 

Candidates who have been permitted to offer themselves for 
re-examination in any subject at the first examination for medical 
degrees may offer themselves . . . 


Dr. J. B, Christophersou has been appointed to succeed the ItUe 
Sir Percy Bassett-Smith as examiner in tropical medicine for the 

^ It wns reported that the Registrar of the Royal College of 
Physicians bad notified that Sir Wilinot Herringbam has resigned, 
B3 from March 31st, his membership of the Semite as one of the 
representatives of the College, ami that, in view of the reconstitu- 
tiou of the University, the College did not propose to nil the 

'“S*^?eremony of Presentation Day will be held in the Albert 
Hall ou Wednesday, May 9tli, at 3 p.m., and the gradnatiou dinner 
■will take place the same evening at 8 p.m. in the Groceia Hall, 

^The^leotiou or tliree Beit Feliowsliips for Scientific Research, 
of the value of £250, will be awanlefi on or about July I6tli. Forma 
of application and all information can be obtained by letter only 



472 Mat?ch 17, 1928] 


A!^ onliJarv OP ENGLAND. 

the Presu1e„t. Sir Berlceley .-n^lficbair ' 

^ipJomns and Licences. 


J^WCAr. NOTES IN TARLUIUBNT. 


S. ,.a3 

Mnutccl to 20 ciiiKlidiitPH/^ i\:..i« ^uvgofy were 


Mnutccl to 20 c:iii(Ti(latns. I)ii>]omHs iM O’.? “^r m 

With Mift BTodiciuo j 

to ^4 caudiOates. ^ ^ Uolloge ol PhysicL... 

Sir. IT S rw •>/ .La'aininers. 

Examiuers at the^Sx^il^^Uou of7iif perio™ 


iip£ISSis5s» 


• « ou.geoii was too kjnd-hpa^fpVr j con- 

It M-aVnot' fa , ^vorid “hich wL'noJ ,'"'* P''' 

JJ,EfaIce„ „„<i "iiSr 

b^t Thai ^ 0. 0^0 “f ■•^PP™l for 

out Uiat ^\as too Jonjoto 1 ”'• . t”® Board of Admiraltr 

find been taken tJirough and^barl cases n-hetc appeah 

Rlmnld bko to SCO a foard Vtb « ‘ 7 '=''* 5 .'',^'^"‘>rousIy.’^ 

P ''Ttli at. least one Z.i'i qxccntk 


.IMr v»/»f » T> ■^Ld)oi}ies '!jBon?‘d 

cn tbo 


mical Maits in iMimncnt 

[From OVR PARLIA MENTAltY CORnESPoiuENT.] 


appeals 
’ He 


"“““.7 SCO a Board mfl, a „ i - ,5? ^onerously. He 

prosulcnt, wH, atdeast one rmll exceptive a^ 

of common sense a„,! <»\ > 1 , and aiS 


. — common sense nnr? • oincer on jt, and also 

appoint a. eviba, ^doctor of eminence .?s Trefere^’'" 


A 1 of ominom 

«u .w ,. 


nrmy in 1926 , ihc nearest year f„r“‘'l'- ■‘'*1'’ ' ° 

Uio case rate was 0.91 nn, i^o’ '.*’hicli ho could 


U,c.case rate ^^d tigum^ 


• .....r',*'’'- «as. sj.tfi pe2* 

I ®26 Ibe case rate wiasPl’an Among 

pto.O.n., Tsvo-thirds of the nTcn /nvalS^i "i!'* 
.tuberculosis bad over five year? spr,"w ^ a '’^’’y for 

Ibem were over 25 yeare of n'pn* xr“’ .“ol.niorc than half of 


Sd NT;€i?ZTs"X!^%T'' Air Estimates 

•an“i.li"‘!r'‘'“..(E">orgeney Slrnsra"*!, 


^Htthoriae the toJali?! Erovi.sions) Dill and a biU to 

the People (Equal Francliiser Dn?'’'’.' ^®P’'“o'*ta(ion 

Home Secrelnw t# . ' Jhti’odaccd by f.fie 


Hem., o V h I'ancli 

.■md it will cnfrMchi.se 5 2 S 0 nno i 


V -A. tliese iioanv’ 2 uOf) non 

■c5€t^???8‘th^%m:: The ..o^ 


coine into fot^roft alTd 

he exjiected soon afterwards.’ ’ ^ « t» 


wxAy.* aiLii waras. • .v 

.CommitteeTlected Dr. Kmond .4b? 


for tlie session. Tim C^mmiUep secretary 

small, discussed the Edinlmpfr > * tjje 'attendance Wi* 


committee, o 

small, discussed the Edinbnri?h ""i^,,«^^''"««nce was 


polsoo' treatment for pm'so s'suSo"'f ^°">' 

and liable to infect olhe^ ani w fo disease 

vo untaiy treatment. As to the wisdom of P"" 

jnittmg such proposals to the House s®**’ 


jnittmg such proposals to the House 

the I^^rliamentary Medical rommhL^”"'"’'’”® tnembers of 
divergent opinions^^bi.t tt.e„ oxpressed widciv 


divergent opinions, but they ‘ag^od ™n“?L '"dcly 

the essential gravity of tl?c disease "nd ilm^ a ®P’P'’»si='a 
for Its eradication. The mpctino- ei 2 , a:. .•*° strive 


- it 


■D. i 7- iiie meeting ; 

Hioloction Bill and the Dogs Bill The 'rj"'""” t'". 
Society was renorted lo be ,e.. ■ i ''• I'*® Hoaearcli Defence 

tWeb’y! 


Invaliding from the Navy, 

In the House If rl^J Ac-eraminafic, „f 
proposed a motion decl'aring ?t* 7th, Sir BEaraAM Euxe 

■•®-o|.a4h"e"th'c ■rX‘‘l!r';.,.?^:f .‘’■® B®-p-d ^ 


by service in the Royal Navv anri ,7ttnbulabio to or .aggravated 

pnintcd^’ou t ml whelf tbSae m' 

iiom GreenwjcJi Solmnl ee _ , ®t whether a recruit. e 7 .ie. 


rules 

nf as a bov at iVi'";. “ ^^^’’'''t entered 
lie iiad to satisfy medical deeiei J oi as a man at Tfi 

"Srsl'clX mef‘‘%'inTlit oT'lS’ i" ‘ boy"”? 


tioii were not accepted.”' OneVin G?" “P f®'’ eramiim 

fed and well clothed, but his sleepbie”!'^ J°nth was 
the most part, a metal tank wb ,, ®®P'“g accommodation was 
light. Vcryjften the only ™p’il!;f’,r‘-‘:!,’°’«. ••>'><? only aSfidS 


W yeare of aep Wee .“"a “O'"® taan half of 

.cutosis at a liigl.er rate than dTrj'ibe a- *h® navy got lubcf- 

m a man.of.w.M were very of ’ifo 

cerned. Men often slept bra 1 in , tuberculosis was con- 
touching, in ill-vcnlilS spaks Smlil "b^ ‘’^■"'"“oks 

down at sea in bad weather anil ' e -»• ®hips were battened 
txon was poor. He doubted ’whelbel lb "'oathcr vcalila- 

•wastngo of fet-class ii/ffrom rfitclL such' j 

.State understood ii.x-responsibiJifcv fn ree. '1 Until the 

people it employed and^“m^ome if ^ 

contributory bn.sii!; 'or. some- foriri 'f .."opasaary on a 

tinuo to inSiot ^m-dsbipTmo™ nd oSir”’ '“I- 

' i«r; Ammon-, ‘ m associating himcDif «.;/!, *i x* ., * ■■ 

fee whether (hat couldlie done in tiio imm? 

Dr. \ ERNon Davies said members consfanfly had ca«cs broueht 
.t® their notice which appeared to deserve consideraffon from fh| 
fst '^hicli ■W'ere hcld to bo non-attribulabla to ecrvico 
conditions. Ho had received, a letter from the First lord in iSe 
m which Mr. Bridgeman said ; “ Where there is evidence tlS 
a man invalided for a particular disease has boon exposed to 
e.xceplional conditions of the service involving the risk of con” 
trading that dbscasc^th^. evidence would be .accepted as proof 
pf.nttribiilahihly.’ Dr. Davies remarked that to prove a man 
had been exposed to .exceptional conditions was aif o.x?ccdingIv 
hard. condition lo fulfil. It could bo decided for accidents and 
ccrbsin tropical diseases. On tho other hand, the Admiralty had 
a good case m refusing to accept os atlrihutablo to service eoma 
instances of bronchitis , or rheumatism followed by lioarf disease 
Tuberculosis was m a different category. In only two insthiieei 
would tho Admiralty acknowledge without hesitation that tuber- 
culosis of the lungs was attributable to service. One was when 
a. man bad been nursing tuberculous patients; the other when ha 
had served in a submarine in which a consumptive man liad been 
among the crow. In every other case tho Admiralty Board had 
proved extremely difficult to convince. To say that tho case iiad 
arisen os tho result of excbptional circumstances during a man’s 
service was a matter of opinion. In 1923, 1924, and 1925 not qiiilo ' 

3 per 7 cent, of cases invalided out of the navy were held 
atiiibu'loblc; that was' an exceedingly small pcrcent.agb. Ho 
believed that as tho result of questions in tliat House a com- 
mittee had been .set up to. inquire into tuberculosis. It bad bfen 
silting for some time, and he Ihought^that as a result the Hoard 
of Admiralty was bcginning'to take not quite so stri 


silting lor some time, ana ne t-liought^tliat as a result the Hoard 
of Admiralty was bcgiiming'to take not quite so strict a view as it 
did before. Two yeare ago -he -bad -suggested a scheme of- com- 
pulsory insurance against tuberculosis. The First Lord of the 
Admiralty iiad' considered it sympathetically, but the Board of 
Admiralty iiad turned it do'wn. When tliese men wore invalided 

c..* emi’Hiro nil flinfr wm *•••••« 


well 

for 


Md jt was possible for the Jai? to be blJchcd 


Hammocks weiV’sTu’ng not moi-e than fii feci ®o™rcd: 

/*, ®’''P ','>?? caeryiug a draft to^a formVo'''’ ®'®so«- 

’■* nf n - -V J02C2gll slnflon 'Tl 


Adrtliralty 

Adhiiralty iiaa uuuuu id uuwu, >vnen vnese men were mvaiKica 
out of tlie service all that remained for them was the national 


liehlfh insurance) amounting to about 15s. a week for a short 
time. Then they were sent lo a sanatorium, and when they camo 
out they were left to starve and die. If, xinder a compulsory 
insurance scheme, one penny- a week were deducted from pay, 
every man, if Dr.^ Davies’s scheme was actuarially sound, would 
Jjrtvo a pension of ’£2 a^vcck as long as he lived. 


were (he conditions o*f a world-wide These 

chaticcs of a healthy man avoiding tubei-ulo^y'^^t the 


mail 


because he knew that if he had Umf disease** ho 
charged, and. if Ins servipft «-ov« — h i“ ° bo . 


,,^nsion Ol a ^Ycel£ as long as ne nvcci. . ; 

Mr. Hoke Belisha said that each monlli 5,000 men tried to get 
into the navy and only 500 succeeded. The principal diseases for 
' ‘ * a ivere invalided out of tho navy iverc IJiose one would 


'onid he digl 
‘ n 


charged, and, if his service were not long witho ^ 
if a man had entered since 1921 he must hav!; ^ r pension, 
service, in the event of invaliding, before he in? n ^ 


Survey Boav.l to bo attribiitabie to or .ag"raimteif'h‘v‘)’^ 
when he got a small pension. Tn 1920, wlien thorn 
men m the navy, 265 were discharged for liibercnio-!!*! V?!,? .^24,000 
3 per cent w.re if allowed tl.at fl.eir cases wSe a iilbiaabir I" 

r a^g^Jl•avatcd bv sorviro. Rn<xx-Pn« Tr.^„r. ,, ‘“.“^cinawo to 


which men were invalided out of tho navy iven - 

expect from the conditions of bad ventilation, bad light, noise, 
and confinement. They were deafness, weakened eyesight, and 
.•*i-nn>dp- A civilian who claimed to have contracted luberen- 



m/ .V 7 '.'''“'xiAxuik.-v weio iicm rosponsiDJo in less tlinn Ji ««,. 

certified fo b™ a Sublc t"" ®f 'vbiclfls wera 

1914 11,0 Prcvlrlo.;! P ,r ®'‘' aggravated bv service. Before 
captai,,'.' Tt:S"'“’vo”tbe rel ''•* Hi® man’fot™ 

Be wa.s brouglu befmn o f c" adyaaiagp li® Iiad not got now 
Sir Bertram added that'^fie'^dfil l‘®”'over learned. 


cliest-troublc. A ClVai*«.Aa .>*aw s.a«*.ih>V 4 lU ».AJl.a.«v.A.7.v. V...-.-.-.- 

Josis out of his duty could go to a county court. A doctor -who 
was an Admiralty servant, honest though he was, was not the 
proper tribunal. The place of the doctor was in the witncys.boi. 

■»»* * A ./Yx> flifl if nrtceiVilo in Tiipycnt a lUgll 


la*. AJic uuuLUt ill iiiD 

Viscountess Astor did not believe it possible to pi event a nigii 
rate of tuberculosis on a modern man-of-war. In the American 
navy the rale was also high. 

Mr. Groves cited cases, one of whicli had been rccon«idfrea 


iui. vjBuvta vii wnicjj naci oecn rccoii'-iuwtu 

after the man’s death, on the weight of medical opinion a.f (liQ 
London Hospital. He remarked that if British ex-soldiers bad a 
medical grievance they could go before an independent docior. 
•Sir Gerald Hohler said doctors often followed one another 
KtfP ftliann wVi/.n Vlipv r>JTVP nn fim'nii’in An indnnpndcnt board 


like filieep when they gave an opinion. An independent naara 

\ra<! W«-I\ipji Prtufrl rlpoirlfv nncnc in »« JltmOSphCtO OUffii'*® 


Oticcp *J 2 lll‘HJlt, -fl** 

was required which could decide cases in an 
the service and on the best skilled opinion 


...id on the best skilled opinion. 

Mr. Kellt remarked that the Admiralty must^ not assume tj‘® 
House w'as satisfied wdtli the tribunals provided in respect of ‘no 



, WAPcn 17. 

U ihis point nfiontion wns drawn to ilio fact that forty 
larnibcrs wU not vrcscnt, and that mimhor not a«?cml»hn- tho 
Speaker adjourned tlio Jlonso without any incniber ot tho 
Government replying on th o debate. 

The Army Estimates. 

Medical Services of the dnnt/. 

On March 8lh Sir Lamixo WouTinscTON-KvAN’S gave the House 
rvf rnnimons his nnnimt snrvrv of tho Army Kstimatcs. llo said 
he nS for a vote of £41,(550.000 and for 153.500 men, 13,000 
fewer than last year. Economics had been made in the R.A.M.C. 
Mr Luvsok. following for the Labour party, pointed out that last 
rear of £4 000 rccruus who oftered themselves, about 28,000 were 
cc«pted as meeting Iho army standard of physical fitmss. This 
^•as 53 in every IW, against 35 per cent, in the previous year. 
Sir WiLvntD Sugden raised tho question of tho recognition and 
emplovmcnl of pharmacists in tho army. He said that the Army 
Coundl and tho Secretary for ^Va^ had never accepted tho 
principles which had been accepted by a conference wJjich dis- 
cussed this matter in 1920. Tho War Ofheo was buying its drugs 
and ingredients roadv compounded. If these could be prepared 
under the control of skilled pharmacists in military ho'^pitals there 
TTOuJd, on market prices, bo a saving of 50 to 70 per cent, in the 
cost. Sir RiaiARD Luce said Iho establishment of the U.A.M.C. 
was being reduced by 22 ofliccrs and 284 men out of an ostaldish- 
ment of 4,163^a rcd'uclion of 6.8 per cent. The reduction in the 
rest of the army was only 0.7 per cent. He Iind no ohjcclion to 
the reduction or co-ordination ot bospilnts, to which this reduction 
pf strength was ofiicinlly nllributcd, but tho liospitals must not 
be the criterion of the strength of tlio ILA.M.O. Wliy should 
they have men of the R.A.M.C. doing duty in military hospitals 
bI all? To train the male personnel for dutj* in war the estab- 
lishtnent of the R.A.M.C. must not. be allowed to be based on tho 
actual beds required in hospitaJs in peace time. Tho proportion 
of men in the R.,\.M.C. as compared with other branches of tho 
service was based on tho experience of many years. In the Into 
war there had been praclicnllv no breakdown of tho R.A.M.C., 
although thcro was a partial breakdown in Mesopotamia, wlicro 
the work fell on tho Indian Medical Service, which had been 
ftamd in peace time. Since the war there had hocn a constant 
whittling down of the R.A.M.C., a considerably greater propor- 
tionate reduction than in the rest of tlic army. It was not a 
lacMlial medical service could bo improvised in war time out of 
cinhan medical men. For instance, it was impo''«iblo to improvise 
r* sanitation sendee in war. Sir Richard noted that 

Vote 10 of the Army Estimates contained £69,000 for ncw» build- 
ings at military hospitals throughout the Empire, but said it was 
impossible to tell from tho Estimates how much of the £1,514.0^ 
allocated for upkeep of military buildings was to be devoted to 
cospitals. Last year' ho bad visited Nctlcy, and found an 
atmosphere of gloom, a lack ol paint and care, and the grounds 
allowed to go to^ rack and ruin. Ho appealed to tho Secretary 
matter of the upkeep of hospitals. Let 
them and compare them with n great voluntary hospital. 


MEDICAr. NOTES IN PARIiTAMENT. 


[ 


TWif HnrrrfW 


SIedjcii. Jocrmyi^ 


473 


Sir Richard Luce 


monf e j' r po«sed to tho failure to keep up the establish- 
qfheers in the service. It was difficult to say 
yj ^ ®®^pce did not attract fully qualified men at present. 

pay of tho R.A.M.C. was insufricicnt, bub 
.coming forward, lie thouglit a 
^ 0 - feeling that the ecrvicc was one wliicti was 
medical .officers apd their hcad.s in the army 
redHoUftfl Army Council, This constant 

and mar^A^ 4 i unrest among those already serving, 

war ramn A '5’^, '^^^'bing ' to get other men to join. If another 
ilinistcr fnr scapegoat would not bo the 

tho hidcL'Xf time or any other Minister, but 

W tbf MoL ^ p ^,^^^cal . departments who woull bavo to 
^ono now piecemeal reduction which was being 

tbft mrri.'A’i supported Sir Kichard Lucc*s remarks 

that ihcv^ xcaL Medical members of Parliament felt 

Vicos in^ cnrJ« to' urge an extension of these ser- 

tutilitv of ^^^^^tions, as they had pointed out the 
the narr-^'^® general hospitals for both tho array 
^‘^Qihers of place in peace. Tho medical 

could tho Government to sco whether 

terrices consisted in_that direction. Tho medical 


physicians and parts. Tho tactical part, consisting . f 

^^^nexlon witJi <^9'Jld to some extent, especially in 

but the ndrS* Army, bo improvised in time of 

not bo part, tho nucleus of every unit, 

Territorial A.nnv unless jfc had been trained. Yet in the 

5^®hers of PniiioL'^ ^^pito representations from medical 

Territorial divkir.^ ^ i ^ number of field ambulances in a 
{h® Auelian -t cut down from tbreo to one. In 
jad .Bulioqucntlv Division that field ambulance unit 

U Would be down from three sections to two, 

®f mobilization three field ambulances in case 

difficulty in expansion^^n brigades. Thcro would bo great 
^cessivo. The uiamtained that the reduction was 

down by one-th^^l?^V^n ^^°,Territorial Army medical services 
Us? the diffieSuv^ strength. In the Regular Army 

t/A get fifteen rccnuting. They had managed at 

Thev coulfl™^M^ officers compared with tho sixty 
w?L adequatf» support an army in tho field unless 

rk. Tho Secretarv medical ofticers trained for the 

the difficuftv i« matter fully in hand, and 

uot sirrml J* these men recruited. The real 
of cAl»? thn question of pay, but the fact that 

leave, wevA overworked abroad, and, instead 

-emor men boin» abroad beyond their' time, 

were Tift 4 ,r • i? comparatively junior work; 
^ officers in- tho serdee. • They were 


bccai 


there 


practically deprived of a great deal of their family life when they 
wero getting tow*ards tho end of their service. These men did not 
give a good namo to tho service at home, and that made it all the 
more difficult to get tho junior men. Ho hoped the Secretary for 
War would get the advantages of the service home to the 
junior men ho wished to attract. Mr. Mitchell Basks spoke of 
the value of good dentistry in maintaining the health of the 
soldier. In cantonments in India, even in peace time, if teeth 
•went wTong there was nothin" to do but to have them out, and 
in no skilful manner. Dr. Vernon Davies associated himself 
with Sir Wilfred Sugden's^ remarks concerning pharmacists in tho 
array. Tho navy thought it ncces'-ary to have trained pharmacists 
who had gone through a professional training and examination. 
So did Iho Ministry of Health under the national health insurance 
scheme, and tho Homo Office for tho prisons. If the War Office 
was right they should scrap the pharmacists in the nav’y, prison 
servico, and national health insurance organization, and get tho 
work done by cheap dispensers. Ho commented on the failure of 
Uio Secretary for War to speak about tho medical servnee when 
introducing tho Estimates. Yet an army without doctors was 
of no use. Thcro was something wrong with tho service. Instead 
of liaWng competitive examinations they now had to go to tho 
medical schools to persuade men to go into the army. Had tho 
Secretary of State inquired what tho trouble was? Had he done 
anything to see if tho service could bo made more attractive to 
medical men? Tho present salary xvas extremely good. There 
was too much moving about from place to place, and when 
officers retired after seven .years or so the gratuity was not high 
enough. Tho War Office must remember that it was competing 
with panel practice and with all the public medical appointments 
in this country. When a young medical man, soon after he had 
qualified, could go into public medical sendco and work five days 
a week for £700 or £750 a year as a doctor, he had no definite 
inducement to go into tho army. A short service in the army 
with either an increased gratuity at the end of the seven years, 
or, preferably, with retired pay, giving tho War Office a call 
upon tho doctor at any time, would increase tho popularity of 
tho serWee. If it could be arranged that any medical man who 
had serv'ed in tho army should have preferential treatment in 
any Stato or municipal appointments of medical men, that would 
further make the service popular. 

Rcplyin® to tho debate, Sir Lamino Worthington-Evans said 
Iho War Office had been able to accept some of the recommenda- 
tions mado by a committee of pharmacists. To accept others 
would have involved a good deal of extra expense. Tho 
R.A.M.C, dispensers received adequate training for their duties, 
enabling them to dispense tho prescriptions of the medical officers. 
The adoption of the policy that the hospitals of the three services 
should bo at tho disposal of patients of any one of them entirely 
accounted for the reduction m R.A.M.C. personnel. Some of tho 
personnel which appeared to have been reduced had gone to China, 
and ^wero carried on a Supplementary Estimate. Nevertheless, 
the reduction was inoritablc. Sir Richard Luce had complained 
of tho atmosphere of military hospitals. Sir Laming said ho had 
visited most of them. Absence of paint was not the test of a 
hospital. The test was tho medical servico and tho social servico 
which patients in these hospitals received. His experience^ was that 
real human attention was given to the men in the hospitals, who 
seemed to bo happy and content with the treatment they 'received. 
Sir Richard Luce had suggested that the medical service was 
treated as a Cinderella service, that cuts were made upon it out' 
of proportion to tho cuts made on tho rest of tho army. That was 
not so. In theso Estimates, out of a total of £41,000,000, £2,400,000 
was devoted to the medical service. They had not the number of 
doctors required for establishment. They had done their best to 
make tho service attractive. He had conferred with his medical 
advisers and with tho medical societies, and thought now*, at any 
rato, tho terms and conditions of servico wero agreeable to tho 
medical profession. He had the endorsement of the medical pro- 
fession. Men could now join for seven years, and if they then 
wished to retiro they had a gratuity of £1,000 — a very useful 
addition to the capital of a young medical man about to set up 
in practico. A pension of £1 a day had been given to majors 
retiring from tho R.A.M.C. Sir Richard Luce had complained that 
R.A.M.C. officers wero not directly represented on the Army 
Council. Every branch of tho army could not bo represented on 
tho Council, but tho Director-General of Medical Services had 
direct access to tho Secretary of State. 

A motion to reduce the strength of the army by 50,000 men 
was defeated, and the Estimates passed through Committee. 


Pensions. 

Answering Mr, Scrymgeour, on March 8th, Major^ Ty.-voN said 
that at Dundee for more than a year past tho medical facilities 
at tho disposal of pensioners had not involved attendance by a 
medical officer otherwise than on a part-time basis. Tho medial 
servico was working well and no complaints bad reached mm. 
In case of emergency tho service of an examining medical 
officer residing in Dundee were available. TUfto^ 

In a reply to Mr. Robinson, on March 7th, Sir KmesLEj Wood 
said a man disabled in tho great war trdinarr 

tho National Health Insurance Act rras 

courso of his insurance to medical benefit, mcladm^ treatment 
for his ^ra^ disability, so far as it, did not involve special skill 
and esperience which general practitioncra as ^ to'similar 

bo eicected to possess. An uniDSiired man was entitled to similar 
treatment if in'^rLeipt of a disability pension and not m receipt 
of a total income over £160 a year. „ 

• On March 13th Sir L. WoRTHm-GTOs-Eviirs told Mr Baraes that 
tho fact that an cx-scrvicc man was in receipt of a disability 
award was not in itself a disqualification for appointment to a 


DEATHS IN THE SERVICES. 


[ Thf rRm'TB 
Mepicjll JotrasAt 


474 March 17, 1928] 


temporary commission in tlic Royal Army Medical Corps. Such 
cases, however, had nniuraljj’ to he considered very carefully in 
view both of the possibility of aggravating the disability and of 
the danger of the officer’s breakdown in the performance of liis 
duties. , • . . 

In reply to Br. Shicls, on March 13th, In‘eul. -Colonel G. F. 
Stanley stated ihat tlio total number of disabled officers, nui'scs, 
and men in receipt of pension or other grant from tho Ministry 
of Pensions in Scotlanct was approximately 43,000. In 1925 the 
average number of paticnls attending at Ministry clinics in 
Scotland, and in receipt of in-patient treatment, was 960 in the 
clini^ and 600 in the Ministry hospitals: in 1926 the average was 
610 in the clinics and 495 in the hospitals; and in 1927 425 in the 
clinics and 365 in the hospitals. The number of disabled men 
wlio, in 1927, received treatment at homo together with allowances 
was 1,484. The Ministry had in view hospital accommodation in 
Scotland for current needs of about 400 bods, which would provide 
a substantial reserve. In view of tho decline in the requirements 
of hospital treatment he was unable to estimate what accom- 
modation might ultimately bo found lo bo necessary. There were 
105 Scottish disabled men under Ircatmcnt in Ministry hospitals 
in England. Of these 99 were in four hospitals — namelj', 
Harrowby, Orpington, Coshara, and Maghull — wliich had been 
established for the treatment of special forms and degrees of 
nervous disease, including epileps}’. Six were medical and surgical 
cases, receiving special treatment in Mosslcy Hill (1), Sitlcup (2), 
and Ilochampton (3) hospitals. 


Dr. Toronofp}^ Experiments on the Improvement of Livcstoch. 

On March 13th Mr, Guinness told Mr. Bromley that Dr. Sergo 
.Voronoff had not been invited to visit this country in connexion 
with the improvement of livestock^ but a scientific mission was- 
recently sent to Algiers by the Ministry of Agriculture and the 
Scottish Board of Agriculture to inquire into the results of Dr.* 
Voronoff’s experiments. The report of the mission liad-just been 
published. Arrangements were being made for carefully controlled 
experiments to lest the claims made on behalf of Dr. Voronoff’s 
work. These experiments would not be carried out by the 
Ministry, but by university workers, whose -work was aided by 
Government grants. All experiments on living nnimaJs calculated 
to give pain were subject to licence and inspection by tho Homo 
Office, under the Cruelty to Animals Act, 1876.' ' ' 


SmalUpoT. — Mr. Chamberlain told Lord Henry CavcndUli- 
Bontinck, on March 8tli, that ho had evidence of small-pox having 
been spread during the recent epidemic by pci'sons admitted to 
the casual wards of Poor Law institutions. He had given instruc- 
tions that, for detection of small-poXj all persons admitted lo 
casual wards should bo medically examined. 

Preservatives for Cream . — Sir J. Gilmour, on March ISili, in 
reply to Mr. N. Macloan, stated that he had been unable lo a^ist 
milk-scud's in Scotland to find an alternative preservative for 
cream in place of those prohibited by tho Order,, which was now 
coming into force. Sir Kingsley Wood also informed Mr. Lara'b 
that tho Minister of Health’s attention had been -drawn to the 
increasing use of emulsifiers for the reconstitution of qream, but 
it did not seem likely that the Preservatives Regulations were 
responsible for tho increase. Tlic prohibition of, preservatives 
applied cquallj- to natural and to reconstituted creams 'A more 
probable explanation could be found in the, fact that the .latter 
article was said lo bo prepared at a cost much .lower than that- 
of the former. He was Unable to state how- many prosecutions 
had been instituted by the local authorities in respect of .the sale 
of the synthetic article as cream. The constituents of cream could 
be emulsified so as to produce an article very -similar to nattu-al 
ci'eam. Investigations were, however, being maclo as-to the possi- 
bility of distinguishing between the two articicg by scientific 
methods. Pending the completion of these investigations/ he. was 
nob in a position to indicate what further steps could be taken 
by the Ministry of Health. 


E.A.P. Hospitals . — In a statement furnished to Dr. Vernon 
Davies on March 9fch, Sir Samuel Hoare shows that the Royal Air 
Force maintains .six hospitals — Haltou, with 309 beds and 9 hospital 
officers; Crauwell, with 100 beds and 6 officers; and Uxbridge, with 
10 officers, and Basra, with 35 beds and 5 officere, in Iraq; and 
51 beds and 4 officers— all afc home; Hinaidi, with 200 beds and 
Sarafand, with 77 beds and 5 officei's, in Palestine. These estab- 
lishments were under review. He added that the hospitals in 
Iraq and Palestine provide for British army oRicei*s and certain 
British civil officials in addition to the R.A.F. The pei-sonncl 
attached to most of tho hospitals performed duties apart from 
those directly connected with the hospitals. For instance, the 
officers at Cranwell Hospital were also medical officers for the 
Cranwell Command. 


Inspection of I’actoncs.— rTho Home Secretary announced, on 
■NT'iveh 8th that he proposed to proceed -in the autumn with the 
on a committee to report on the strength of the 
fMtory iuspcclorale. This will, probably he .a dcp.-ii-tmciiial com- 
iniUee In announcing tins decision (iie Home Pccrctai-y remarked 
Uiat he had admitted the iimnber of factory inspeclors -n-as 

inadequate. 

/-irprnmriHs on ^nimoA-.-Sir H'. JovKSOX-HiCKS, replying, on 
March Wti. to Mr. N. Maclean, ivlio asked if iia had causci any 
Riquiiy to bo made as to the iarge increase in the number of 
exporimcnls performed on living animals, and, if ..0, 
any rca'^on had been given for such an increase, said that the 
increase was mainly in ‘ inoculations, feeding experiments, and 


/ 


similar procedures. Ho understood that it was due principaii, 
to tho development of medical science in regard to the standarif- 
izing of drugs and tho investigation of vitamins, and to the steps 
taken lo safeguard tho purity of tho milk supply. He saw no 
ground for.spccml inquiry. 

Anthrax . — In a reply to Dr. Vernon Davies, on March 8th, tho 
Home Secretary said that in the years 1925 to ‘1927 the cases of 
anilirax reported as occurring in factories and other premises 
under the Factory and Workshop Acts numbered 125, of which 
17 were^ fatal. Wool and hair other than horsehair caused 60 
eases with 8 deaths (18 and 1 in 1927), horsehair or bristles 
caused 14 eases with 4 deaths (3 and I in 1927), hides and skins 
caused 46 eases with 5 deaths (13 and 1 in 1927) ; feathers, bones, 
felt, tanned leather, and refuse wore responsible for 5 cases 
(1 ill 1927) with no deaths. 


Eotes in Brief. 

An interdepartmental committee has been cxammiug tho law 
relating to poisons, and the Home Secretary will bring to its 
notice the remarks of the coroner at a Kensington inquest in 
favour of action to restrict the import of the .French hypnotio 
drug known as dial. 

Tn the West of Scotland 157 factories employing young girls 
were not visited by factory inspectors last year, but 86 had been 
visited willun fifteen months, and all but 6 within two years. 

In only Ihrce unions in England and Wales arc no beds, bunks, 
or' hammocks provided -for casuals. In these unions improvements 
arc under consideration, / • , 

Spcci.al arrangements .have been made by tho Metropolitan 
Hospitals' Board, 'with 'the approval of tho Ministry of Health, for 
provision of Ifcatmeut for young persons suffering from the after- 
effects of - encephalitis lethargica with a view to research into, 
appropriate methods of treatment. ... . .t 

The Mini'itry of -Health has been in communication with tho 
French Ministry of Agriculturo concerning an alleged discovery 
of a reniedr for foot-and-mouth disease. 

Colonel 'Hradlam, on March 7th, stated that no naval hospitals 
at home or abroad liad.bcen closed during the past three years 
on account 6f co-operation with other service hospitals. 

$}je M£rbms. 


■ : ■ DEATHS IN THE SERVICES. 

• ' Sir Robert Neil Cajipbeel. 

Colonel Sir Robert Neil Campbell, K.C.M.G., C.B., C.I.E., 
meal Medical 'Service'-(retired), died -at Lahore, when on a 
sil' to India', on' February 18tb, at the age of 73. He vas 
rn on Lplember 28th, 1854, the son of ^ 

^B^ttish- Liflen- Company’s Bank, Trinity, Edmburgli, nnd 
r' (--i 'nf 'tile Edinburgh Institution and at Edinburgh 
Stv- where K^graduated as M.B. and C.M. in 1876. 
'ferin!’- the I M.S. as surgeon on October 1st, 1877, he 
J-S the -fank 6f colonel on Aprd 2nd, 1909, and retired on 
—I o 1 1Qi4 ' After’ a few years’ military service, during 
tn The Nagt Hills campaign of 187^ 
•'ll o ' Kofth-East Frontier, was mentioned in di^atclics 
' r rO''No.' 123 ■ of '"1880, and received the Frontier 
1 1 '/ith' a ■ clasp! "he 'entered civil employ in Assam, 
Ii'e was • for several years civil Burgeon of Shillong, 
'bf the provihed. In 1900 he was transferred 
° ' and 'tilH his promotion to the adminstrative 

-itTued Tho post ofTivil surgeon of Dakka, one 
-lit important medical appointments in Bengal. 
Tnmotion he Lcame indpcctor-general of civil hospitals m 
’ '’roTTited province of Eastern Bengal ond Assam, orea d 

a Pnrzon^ in 1905. After the Royal Durbar of 1911 the 
mentsT^ade bv Lord Curzon were -cancelled. Eastern 

,ngal was > Bengal to fbrro a new separate province, 

r Tssam SaTn beianie a -ail province by dself 

Uen these changes were made 

After his retirement in April, 1914, tie iiaa,,ua j 
it™ at Lochinaben, in Dumfriesshire, when thevpcat 

‘ f r and he rejoined for service. He was then -aPPO'^d 
ir began, and ne j , y pjace Hospitals at 

the command of the 

■ighton for Indn ^ previously 

received of he Kaisar-i-Hind Order, first class, 

"«rd Tot, wli n that decoration was first gia^en-. 

d two dmtghters Hm eUer son, ^"„,r,"rers at (he 

commission m the Jv g wnnnded in Flanders early 

♦ • .. rsf fbp war, was severely Vronncieu m offr-r* 

■Ilipoli in the summer of 191&. 



MARCH J 7 , 192S] 


OBITUARY. 


L LfCDICAL JOCR-XAi 


(Dltiluarir. 

JAiMES WHEATWOY, Af.D.Loxn., 

President oF tlio Society ot Medical OlTiccrs of Healtli. 

IVe annoimccd, nitli nnicli logi-ot, in om- Insfc issiio, tlio 
death of Dr. Jamc.s IVlioatlcy, president of the Society of 
Medical Officers of Hcaltii, and for tn-onty-.soren years 
nedical officer of health for the county of Shropshire. 

James AVlieatley was a .student of King’s College, London, 
and ohtained tho diplomas of JI.R.C.S.Eng. and L.S.A. in 
1886, graduating AI.B., B.S.Lond. in tho year following, 
and proceeding to tho degree of Af.D. in 1890. He obtained 
tho D.P.H.Ed. in 1891. After holding tho jiost of honso- 
plwdcian at King’s College Hospital ho irn.s for some years 
medical officer of licalth for Blackburn, and in 1901 ho 
succeeded Dr. Cliarics Porter, who was appointed medical 
officer of health at Johannesburg, in tho county appoint- 
ment in Shropshire. In this 
position hodistiiignishcd him- 
E^f by his honest onthnsiasni 
for progress in public licalth 
maffei-s. His schemes for the 
improvement of tho pcbplo’a • 
health were alw.ays notablo 
for their careful thoughtful- 
ness and soundness of judge- 
ment. His report on tuber- 
culosis culminated in , the . 
opening of tho King Edward 
llemorinl Sanatorium at 
Shirlett in 1912, while .the , 
co-ordinating of tho work for 
cripjiled ehildron resulted in 
an organisation probably 
more complcto than in any 
county iii tho eoTinrry. , Ha, 

Tras a practical . bolioror in 
tho benefit to bo derived from 
propaganda work, aiid in 
tills he did not spare cither - 
his time or diis energ)-. 

Wheatley, was slow in ; 
coming to conclusions, care- . 
fully balancing tho pros and 
cons of every question, and ' 
olten reserving judgement. 

But having formed his 
opinion on tho coiirso of 
action to ho advised, ho was 
a wnsistent advocate, and 
had no reluctance to be in a , 
nimority. Ho held confirmed 
vicffs on tho relation of 
'et to tlio incidence of . 

“cntal caries, and these ho 
arnestly advanced when • 
occasion arose. 








Pholoi 


m 


H. W. LiUGLEV 


IHieatley was a member of the British Medical 
iulS Public Health Committee 

of ttitv ~ei • "1 elected a member of the Council 

of 11,0 ^"' 0 P®hire and Mid-Wales Branch, was president 

and o'irII^''°i''*i I'T’^os; Wheatley’s c.vtremely thoughtful 
tlwn in *+i mind was’ never better exemplified 

Octobei- lo 1 presidential addre.ss which he delivered in 
of 'MprRo'J ’r?£ installation to tho chair of tlic Society 
only tho 1 “f- Health. That society mourns not 

■fs’iiinst 0 °^^ ”■ President, hut also tho loss of one of 
iate as , reliable, ' and lovable members. As 

'"■‘sdoni in oUo !''’^i‘oatley was questioning his own 

''as not, in +1 "J"S inniself to he elected president. He 
*0 forgo tbn n^- .- 1 ^^ health, and in November he had 
diiiuei-, Incto'o presiding at the society’s annual 

parsing iiomo 'i “dvice, he took a long rest in a 
'llness should onlv n “'''"'?®i®‘'>stically ho urged that his 
i'on. Me had n • ^ ®Pm'®n of as a temporary indisposi- 
®nd appaveiitiv bad occasional heart attacks, 

u 'entlj these became mere severe. About a month 


ago IVlieatley bad an influenzal illness from which he was 
recovering, when, on the evening of Marcli 3rd, having 
been left reading in bed, lie was found to have died. It 
is not conccivablo that AVlicatley liad any enemies. The 
universal respect with which he was regarded was well 
illustrated by tho large and representativo attendance 
when ho was laid to rest in the little parish cliiirchyard 
of Bictan, near Slirewsbiiiy, on Bfarcli 7th. Dr. WJie.-itioy 
was in liis sixty-fifth year; lio leaves a widow and one- 
daughter. 

HENRY AVILLIAM LANGLEY BROWNE, O.B.E., 

_ LL.D., M.D., F-R.C.S.Ed., 

Ch.riim.nn of Council, British Medical Association, 1905-07, 

We have to aiiiioiiiice, with deep regret, the deatli of Dr. 
H. AV. Langley Browne, which took place at his residence 
at Edgbaston, Biriiiingham, on Alarcli 7th. Dr. Langley 
Browne, who was in his eightieth year, died of acute 

bi'ouchitis after an illness 
lasting only tlireo days, but 
for the past seven years be 
had been an invalid as the 
result of an accident which 
caused tho loss of his sight. 

Henry AVilliam Langley 
Browne was the eldest son of 
a medical practitioner, the 
lato Dr. Benjamin S. 
Browne, and was horn at 
Bishop Auckland in the 
county of Durham in 1848, 
and was educated at Syden- 
ham College and Biniiing- 
Lnm General Hospital. He 
obtained the diplomas of 
M.H.C.S.Eng. in 1870, 
L.R.C.P.Ed. a year later, • 
and F.R.C.S.Ed. in 1882. 
Ho graduated M.B., B.Cli. 
Birni. in 1901, and pro- 
ceeded to the degree of AI.D. 
in tho following year. 

Dr. Langley Browne spent 
- the greater part of his life 
in tlio town of AVest .Brom- 
wich, where ho practised for 
fiftj' 3 -ears- — from 1870 to 
1920. Ho was lionoraiy 
surgeon to tho AA’est Brom- 
wicli Hospital from 1871 to 
1904, and later became con- 
sulting surgeon. In the 
affairs of his profession ho 
played a considerable part 
llirougUout his life, being 
rfir: •• r-.. prominent also in civic 

Browse, M D. affairs. He held many offices 

in the British Medical A.sso- 
ciation. In 1889 lie served as chairiiian of the Section of 
Pathology organized by tho Birniiiigliam Brancli; in 1891 
ho was elected to tho Branch Council, and in 1894 becanio 
president of tho Brandi. Ton 3 'ears later he was elected 
clmirman of tho West Bromwich Division, and in 1907 was 
appointed by that constituency to membership of the Repre- 
seiitatiro Bod}'. Ho was Cliaiiman of tlie Council of th«> 
Association in tho period 1905-07, after servinir as a 
member of the central Council from 1899. At tho Leicester 
Meeting in 1905 he Avas president of the Section of Indus- 
trial Hygieno and Diseases of Cccupation. In the following 
year, Avhen tho xluniial Meeting of tho Association took 
place in Toronto, the University of that city confei red upon 
Dr. Langley Browne tho honorary degree of LL.D. 

Some indication of tho place which ho hold in the 
estimation of his fellow practitioners throughout the 
country may bo gained from tho fact that wlion, in 1906, 
ho became a candidate for tho Geiieral Medical Council as 
a direct representativo for England and Wales, iie was 
rotunied at tho head of the poll, and in 1911, nhon^ ho 
sought re-election, this expcrienco was repeated. Ho retired 
from the General Medical Council at the end of 1919. Avhen 


„ „ , 
Ejf; V.:----’ - "J 

^ ' ' ' ' ' r- ' ' ' ' ' 





476 March 17, 1928] 


OBITUAIir, 


[ 


The Bcms* 
Meoical Jooaxiir 


ilic officersliip of tlio Order of .the Britisli Kmpire was con- 
ierrcd upon liini in recognition of liis services within and 
without that hodj’. 

Dr. Langley Browne was a life inemher of the coni't of 
governors of tho University of Birmingham. Tlic inomher.s 
of the Midland Medical Society electccl him as their presi- 
dent in 1902, and he was chosen to fill a similar office hy 
the Association of Factory Surgeons in 1905. During the 
late war ho was a momher of tho Central Medical IVar 
Committee, and also served on the staff of - the AVest 
Broniwich Bed Cross Hospital. His contributions to 
medical journals boro witness to a wide range of interest 
in his profession. 

Municipal affairs attracted his attention, and as a 
member of AVest Bi-omwich Town Council for manv vear.s 
ho was chairman, successively, of the sanitary and linblic 
libraries committee. Ho was also a justice of the peaee 
for the county of Stafford, and a member of the County 
Territorial Association at one time. Among his recreations 
golf took a foremost place, and ho was one of the founders 
and the first secretary of Saiidwell Park Golf Club. 

It is of especial interest to those at headquarters to recall 
that in 1906, when Dr. Langley Browne was Chairman 
of Council of the British Medical Association, he took a 
leading part in tho estahlishmcnt of the staff superannua- 
tion fund, and entertained the nicinbcrs of the jiermanent 
staff, administrative and executive, to dinner in the Hotel 
Cecil. 

CHAIILES HAEOLD BLOXSOME, L.E.C.P. .vxn S.Eii., 
Fairford, Glos. 

The death occurred at Fairford, Gloiicc.stershire, on 
February 17th, of Dr. Charles Harold Bloxsome. aged 70. 
He received his medical education at Manchester, and after 
taking the diplomas of L.E.C.P., L.E.C.S., and L.M.Ed. 
in 1880, held the post of house-surgeon at the Manchester 
Eoyal Infirmary. A year or two later he settled in practice 
at Fairford and became one of tho surgeons at the cottage 
hospital. An enthusiastic bacteriologist, and devoted 
disciple of Lister, he carried out the Listerian technique 
with scrupulous care, and in the course of a few years 
built up a considerable surgical practice. His case-books 
.show that many of his operations would come under the 
category of major operations. 

One operation, though not of this character; is worth 
recording. On June 25th, 1887, he admitted into tho 
cottage hospital a journeyman butcher, aged 67, with an 
cnorraouslj' swollen left arm ; on tho anterior surface 
of the forearm were four hard, purplish-black eschars. 
Having examined some of the fluid from these and iden- 
tified what he believed to be anthrax bacilli, and further 
hearing that tho man had recently skinned and cut 
up a bull that had died in suspicious circumstances, 
Dr. Bloxsome excised and cauterized the lc.sions. The 
man stood the ojreration well, but died the following 
day. Dr. Blox.some reported this to the authorities as a 
death from anthrax, and the case became at once notorious 
in the district. The editor of the local pa]5er published 
an article with a view to proving that a young and 
inexperienced doctor had made the foolish mistake of 
labelling an ordinary case of blood poisoning as one 
of anthrax. The owner of the dead bull wrote in the 
same strain, and attacked the doctor for not publicly 
writing to tho paper to explain how he had come to 
make so extraordinary an error. Dr. John Hitchman, a 
distinguished pathologist, took up the cudgels in Dr. 
Bloxsome’s favour, having had an opportunity of examining 
the fluid which Dr. Bloxsome had removed and having 
seen the bacillus in +’.0 fluid. A fierce controver.sy ensued, 
but in the meantime Dr. Bloxsome had sent all his prepara- 
tions and preserved tissue, with a full history of the case, 
to IMr. Watson Chej-ne, who reported that there could bo 
no doubt that the patient died of anthrax. This .appears 
to have terminated what was certainly an awkward episode 
in the life of a young medical man who had but leceiitly 
settled in the district. In a very short tune his north n.as 
recognized, and he soon had as much "'ork as he wanted. 

• surneon with a limited field- at Ins disposal, he coii- 


iintil within a few weeks of his ..-death. His love for 
bacteriology never waned; he used, apparentlv with great 
SUCCCS.S, auto-vaccines prepared by himself in appropriate 
cases. Apart from his work ho had many other interests. 
As a young man ho was a great lover of horses and 
hunting, he was an expert on throwing a fly, he derived 
intense iileasuro from music, but perhaps ho ’enjoyed most 
of all. a heated discussion on some debatable point with 
two or three chosen friends. His only son is carrying on 
the Jiraclice at Fairford. His second wife, with “her 
daughter, survives him. The very large number of friends, 
both rich and poor, who attended a memorial service on 
Fcliruary 21st at Fairford Church amply testified to tho 
esteem in which ho was held. 


THE LATE SIE EOBEET POETEE, K.C.B. 

A\'>; are indebted to Sir Anthony A. Bowlby, Bt., K.C.B,, 
K.C.M.G., K.C.AkO.j-for the following appreciation of tho 
Jato Major-General Sir Eobert Porter, K.C.B., A.M.S. 
(rotiied). 

I .should like to add a few words to the obitimry notice of 
.Sir Eobert Porter in your last issue, for he was always very 
keen to co-oper.ite with the civilian surgeons in his command, 
and to avail himself in everj' w.ay of their services. It was in 
the early days of the first battle of Ypres, on October 15th, 
1914, that 1 first met Porter at a casualty clearing station 
established in Bethune in a large girls’ school. He had just 
been promoted a surgeon general for services in the field, and 
was D.M.S. of the second corps, and he now was very anxious 
about his wounded, who came in increasing numbers, and were 
far too numerous in proportion to surgical equipment or 
personnel; whilst to add to our difficulties an enemy shell had 
just .set alight a house opposite to the small civil hospital in 
which were some of our most severely wounded men. From 
that day until he left Fr.ance at the end of 1917 I was 
constantly associated with Porter, for until May, 1915, I was 
the only’ consulting surgeon at the front, and it was with 
Porter’.s active co-operation and support that the first steps were 
taken to e.xpand and convert the casualty clearing stations 
so as to make them efficient front-line hospitals. From that 
time onward he took the deepest interest in the surgery of 
the front, and did everything in his power to promote tho 
improvement in the surgical staffs. It is indeed impossible to 
over-estimate the value of bis constant support in our efforts 
to help the civilian surgeons in their work, and it is intere.siing 
to recall that No. 10 Casualty Clearing Station at Eemy 
siding so well known to many of us, was the first casualty clear- 
ing station to be established in tents in the open country, 
instead of in various buildings, as was the custom in the earlier 
days of the war. Early in 1915 the British Expeditionary 
Force became divided into two “ armies,” and from that tinia 
Porter was continuously associated with General Plumer’s 
Second Armv, an army which was always a 'favourite with 
British office'rs and men alike. To the efficiency of this army 
Porter contributed very largely, for he was tireless in vmting 
cverv unit' ai the front, and was always accessible to his officers 
d’rcadv to discuss any proposals for improvement in the 
conditions of the troops. The fact is that Porter took the 
oTcatest possible interest in the British soldier, and was out 
To help hint in his difficulties and to ease his heavy burden in 
the horrible conditions of the Ypres salient. Few people 
1-new how deeplv tlmy were indebted to him, for he was a 
.dlent and verv modest man, whose motto might well have been 
“Deeds’ not ’words.” He was a true friend to the British 
soldier and a staunch supporter of every surgical improvement 
which might help his wounded men. 


TYe ree-ret to announce the death of Dr. J- W. 
Keighley of Blackburn, aged 61 years. He w.ns a 
M Blackburn and studied medmino at 
Edinbnreb and the London Hospital. He 
M B c'lM Ed. in 1894, and proceeded M.D. in 1918- .H 
to;k’Hreat interest in the work of tho British Medical 
A^octotioii. was a member of the Executive 
the Blaekbiini Division for viee-clmHnian f ^ 

Divismn^in 1919^ .an^chairman - '^^He lep^^^^ 



March 17. 3928] 


OBITUARY. 


[ The UniTisH 
SIedioai. Jocbnai. 


477 


1925-27, niul was n luombor of tho Lnneasliiro .and Chcsliiro 
Branch’ Council for 1926-27. Ho was prcsitlont of tho 
■ Blackburn ami District Jfotlical Society in 1919, nml was 
honorary secretary of t!:o Local Sfcdical and Danol Coin- 
niittco from its iiicoiition Mintil three years ago. IIo had 
_hcen a inombcr of the Blackburn Town Council sinco 1907, 
was appointed vice-chairman of tho town hall and public 
baths committee in 1920, and two years later hccanio 
rhairman of tho conunitfeo. In February, 1925, ho was 
elected an alderinan. Ho was placed on tho Commission 
of tho Peace for the borough in 1920. IIo served on 
most of the corporation committees, and was tho roi)re- 
sentativo of the town council on the Lnneashiro Asylums 
Board for nine years. During tho war Dr. Keighley did 
a largo amount of voluntary work for his fellow practi- 
tioners on war service, and was an active lucinbor of tho 
Belgian refugees subcommittee. Dr. Keighley had pre- 
sided over a meeting of tho town hall coinniittco on tho 
afternoon of February 13tli, and owing to indisposition ho 
was prevented from attending a mcoling of the Central 
Conservative Club in tho evening; ho died on Pohvunry 
15th. Ho is survived hy liis widow, three sons, and a 
daughter; one of the sons is n member of tho medical 
profession in Blaekburu, where his son-in-law is also in 
practice. A colleaguo write.s: Dr. Keighley was ever a 
loyal colle.-igue and friend, and, in his quiet and unassuming 
way, was alw.ays ready to do .a good turn for any deserving 
person or cause. His suddeti death caused deep sorrow’ 
to bis medical brctbrcii and Iris colleagues on tho town 
conucU. Ho was a man of tho highest jn'inciple, modest, 
unassuming, and qnictly gonial in all his relations with his 
colleagues and his fellow workcis on the public bodies on 
which lie served. His life was a full one, and ho could 
always bo relied on for punctual atfeiidniico. .Vt a solemn 
requiem mass, prior to the iiitoriiiont on February 20tli, 
tile Hcv. Father Siiigletou, rector, concluded ,a moving 
address by saying that Dr. Keighley never hccamo a cynic: 
lie wised m public life, yet be was not soiled. An im- 
Mantable word never came from liis lips. Ho made no 
istinction between rich and poor, giving to both tho samo 
J'onderfui and undivided attention. His name was held in 
'‘‘ifinisl anioiig tlio [loor, ami, after all, 

. s one of the true tests of greatness and goodness. 

^I'oi’fonn U.vDEuniLL died peacefully in Iris 
sovini^' 20tli, at his residence in Banics, in his 

well belonged to a medical family, 

Brirlirn honoured for over a century at Great 

Tmtnn IVest Bromwich. He was a native of 

Cnllpirp Ills medical education at Trinity' 

1870 “at 5 ’ he graduated B.A., iM.B., JI.CIi. in 

If I? re T?* Hiiderliill obtained the diploma 

of I - . After holding tho appointments 

pital Biiini ^ end medical tutor at Queen’s Hos- 

hain '''S’ resident medical officer at Birmiiig- 
tiitWs Bneeeeded quite early to hi.s 

medical gwieral and consulting practice, and was 

mediMl Cl * . only t^vo years ago. He served 

niaiv aj!,i 1 P®“ii^'>dent, West Bromwich Union Infir- 
Biniinelnni 'ar, 1 “ ^wn as piycsideiit of tho 

ef Jlediral nm ' Counties Branch of tho Society 

oftlie BritWB He was a lifelong menibei- 

^nJerldTs dif •"'f » J. A. S.” writes: Dr. 

^^rgical aiul 1 undoubtedly in consultative 

presence and al 'il!'' Gifted with a coinmandiiig 

'vas a ^ he was bound to succeed 


"as a man of +1 , . "C was ooi 

Kencroaity. Pn,. '® , ^hest integrity and of unbounde 
then consultino- '''*‘y J’®®®® he was first surgeon aiii 

A’’ illustration”' G’mst Hospital, Dudley, 
t'oacd that he ?' ®®''®tRl nature it may be men- 

nnsriM- . 0 a practice of reading up, wlieuevei 


Possible, all tbc st “s' c 

plated doino on "''y ^’^jor operation he coniem- 

patients resnecti'm^ Worrow. He reasoned carefully wit! 
t® force surairat « "" ®P®®“tmn without any attempt 
hno^ him to them. I have so oftei 

®2uitabIo tbing to n ®’® t-bo only fair anc 

and he emphasized the necessity foi 


putting hini.sclf in tho i)ationt’,s place. His opinion was 
largely songlit by his eolleagiies. On Sund.ay ho iiraetically 
kept open house, and at any meal after breakfast it was 
quite prohlcinatical wliethor we sat doivn ten, or even 
twenty. Dr, Underhill was twice married, first to Mary 
Symons, daughter of Major-General 0. B. Symons, by 
whom ho had four daughters and tliree sons, and secondly, 
to Lnej' Cory, sister of tho vicar of Tipton. He was buried 
at Tijiton on February 24th, in the presence of a large 
number of friends. 


Mr. GfiRAtn SiCHBL, who died at Sevononks on February 
29th, received his medical education at Guy’s Hospital. 
Ho obtained tho diplomas M.Il.C.S., L.B.C.P. in 1892, 
and tho F.R.C.S.Bitg. two years later. He held various 
resident posts, and after serving for some years as surgeon 
in tho Koyal Navy was for a time in charge of the light 
department at Guy’s Hospital. He entered tlie navy as 
surgeon in November, 1894. He served in H.M.S. Gibraltar 
at tho Capo from 1896 to 1899, when he was appointed an 
instructor at tho Naval Medical School at Haslar. Ho 
resigned from tho navy in 1905. He was tho author of a 
small work, Amhxdance Notes, which was adopted by tlio 
Admiralty. During tho great war he held a commission 
ns major in the R.A.M.C., when he acted as chief surgeon 
to'tho Lord Derby M’ar Hospital, 'Warrington; he was also 
surgical specialist both at home and with the British 
Expeditionary Force, being mentioned in dispatches. In 
civil life he held tho post of surgeon to the Sevenoaks and 
Holmesdalo Hospital, and the Sevenoaks Hospital for 
Children witli Hip Disease ; he was also consulting surgeon 
to Sovenoaks Grammar School. Mr. Sichel was an active 
member of tho Sovenoaks Division of the British Medical 
Association, and had acted as representative of tho 
Guildford Division at tho Annual Representative Meeting 
in London in 1906. “ C. A. H. F.” writes: It was only on 
August 24th that I went down to Sevenoaks to give an 
anaesthetic for him, and within half an hour of my leaving 
his hoxise ho was called out to help at the scene of tha 
terrible accident on the railway at Riverhead. Here he 
directed operations and toiled ceaselessly for many hours; 
ho shouldei’ed great cares and anxieties for several days, 
looking after a number of patients in the Sevenoaks and 
Holmesdalo Cottage Hospital. I saw him several times 
after that occasion in August, as he always kept open 
house at his clianning residence. Ho had not been so well 
tho last 3 ear or so, but there appeared to ho no reason 
why ho should not carry on. He had personal anxieties 
for some j'cars which had aged him prematurely, hut it 
was not until just lately that ho was considered in any 
danger. His death creates a gap that it will be impossible 
to fill. As a colleague he was delightful to work with ; as a 
surgeon ho was most careful and painstaking, able and 
efincient, shrewd and careful .in judgement. Ho never 
operated for the sake of operating; ho alwaj’s chose tho 
safest and wisest course for the patient, and avoided 
experimenting. Much sjnnpathy is felt for his younger 
daughter, who liad been his constant companion and right- 
hand *' man ” in recent years, and for his other relatives. 


Di’. Winw.vji Herbert Lister Mauriner, who died at 
Bournemouth on February 27th, at the age of 69, received 
his medical education at St.- Thomas’s Hospital, London. 
Ho graduated M.B.Lond, in 1884, obtaining the diplomas 
M.B.C.S.Eng. and L.S.A. in the same year. After a period 
as clinical assistant in St. Thomas's Hospital he commenced 
practice in Bournemoutli, subsequently becojning ^tacJied 
to tho’statf of tho Roj'al Victoria and IVest Hants Hospital 
there. In this institution he held, at the time of his 
death, the appointment of consulting surgeon for diseases 
of the nose, throat, and ear. Dr. Marrmer took an active 
part in local professional affairs. He was one of the earliest 
members of the Bournemouth Medical Society and served 
for a term as president. He was a member of the Executive 
rinmiirittee of tho Bournemouth Division of the British 
Searlssociation in 1906-07 and 1909-1^ vice-chair- 
man in 1912-13, and chairman in 1914. Ho was vi^ 
pre.sideiit of the Dorset and Vest Hants Branch in 1903. 


medical' ^eWs. 


'478 March 17, 1928] 


Tke Bjiinaa 
. Medical Joockai 



STAnCH 17, 1938] 


MEDICAD NEWS. 


r T«ElJRm«n ■ 470 
L SlKUICAt Joitl.VAL “ I W 


Rud Diseases ot Iho Chest bofjliis 011 Mai-oU 19tli. At tlio 

Koval National Orthopaedic Hospital thcro will ho an all-day 

couC'Olroiii jrarch l:(th to 31st, and from March 19th until 
thoSOth tho Hampstead Gouorai Hospital will provide a lato 
afternoon oonrso, inolndln" domonsi rations or short lectures 
In luedioino, suryory, and the spoclaltios. Tlioro will bo no 
Bpecial r.our.so3 hotwccu Match 31st and April IGth, but the 
Fellowship provides a general course ot instruction at its 
nflllinted hospitalsthroiighout the year, coniprchousivo tickets 
being issued for any period from one week to one year, ami 
special arrangoiiients being made lor those limited to part- 
time work. Full particulars of this course, syllabuses, and 
specimen copies of the I’ost-Grailiiatc Ulcdicnl Journal may 
be ob.ained'from the secretary of the Fellowship, 1, Wimpolo 
Street, IV.l. 

The Loudon School of Hyglono and Tropical Medicine is 
arranging cour.'.e-i in tropical hygiene for laymen as well as 
lor medical practitioners. Iiuinirics should bo addressed to 
the secretary ot the School, Malot Street, W.C.l. 


The congress of the Royal Sanitary Institute at Plymouth, 
from July i6th to the 21st no-xt, will com[)riso seven sections 
—namely, sanitary science and preventive modioino, engineer- 
ing and architecture, uiatoruity and oidid weltaio, including 
school hygiene, per.sonal and domestic lij'gienc, Iiygieno ot 
food, hygiene in indii.stry, and vutcrinary liygloue. In cou- 
ne.xion with the cougicss thcro will ho oonloreuccs of repre- 
sentatives ot sanitary authorities, port sanitary anihoritics, 
natinua! health iusuranoo services, medical ofllcers ot 
hesUh, engineers and surveyors, sanitary inspectors, and 
heallh visitors. Further information may bo obtained from 
tlic secretary, (he Royal Sa.uitary Institute, 90, Buckingham 
Palace Road, S.W.l. 

The ISSih anniversary dinner of the Medical Society of 
London was held at iho Trocadero on March 8th, with the 
president, Mr. Herbert \V. Carson, in the chair. The toast ot 
the society was pioposed in a genial speech liy Lord Carson, 
who declared that no one owed inccc than ho did to the 
medical profession, but, greatly as lio admired doctors, bo • 
had seldom seen them at their best as wiiuessos in courts ot 
law. A difflonlt prohlein hoforo boUi professions was to find 
a satisfactory dellm'tion of (nuacy which went further than 
merely saying that it Umatio was a person of unsound mind. 
The president, in Ida reply, .spoko ot some ot his great 
predecessors in ofllee, and congratulated Dr. Foynton on this 
year’s Lettsoinia'u Leo. tiros. The society, he said, was in 
® 3uost nourishing condition, 101 new Follow.s having joined 
It in the past year, and the average attendance at the meet- 
ings held this session was nearly seventy'. The health ot the 
proposed by Sir John Rose Bradford, who said 
tnat the well-merited success ot the society' depended on its 
activity in promoting clinical medicine and surgery, and In 
proridlDg opportunities for medical men to meet one another, 
Bometiriies as hosts and sometimes as guests. Surgeon Vice- 
Aamita! Gaskell, in his reply, spoko of tho enormous help 
given by the heads of the civil profession to tlio Royal Naval 
*1.^ Croolfshaulc also responded to 

tne toa.st in a very entertaining speech. 

Mayor of London presided over the annual 
of St. Mark’s Hospital, Cliy Boad, at the 
Mansion House ou March 8th. It was stated that since fcbe 


middle ot the last 


nm. 1, 1 century every Lord Mayor in turn — except 

sin m pre.sident of the hospital. Sir Charles Batho 

canL.;^! eventful in tlie hospital’s history in 

IViiWtii i-be complotulu and opening ot the new wing. 

tosRrons ^“'''vgement the number ot hed.s had lieen increased 
hak a, eed an up-to-date cancer research laboratory 

adiiiitiBa° P‘'?'’'‘led. Last year 583 in-patients had been 
been attendances ot ont-patients (6,940) bad 

St ytaru- ro tbe hospital’s history. He added that 

the worn ““’y entirely tree liospital of its type in 

etndv ill '’"'^fieons came from every part ot the world to 
forinniiBill'f,^““‘^® treating diseases of the rectum., TJu- 
with an Ji ®bero was a balance on the wrong side this year, 
Mil a e-'^l’enditure over income ot nearly £700, 

Bpoke voi-i/ 1 • the new wing. The Lord Mayor 

pronosefl •,.‘*'*’“‘8 °t the woric of the hospital, and said .he 
“tBce ami to it in tbe course of his year of 

ot ttieCitv^,,! ?t">g tile sheriffs with him. The Corporation 
charitv an,i been glad to assist this deserving 

The \ “ ttgain. 

ttevoied f*! the Edinhnrqh Ucdical Journal is 

otioical ami ‘“perouiosis, aaji contains several interesting 
ooiitribmesa r articles. Professor Murray Lyon 

snmiKiu,, un ai‘, ,1 ‘;f‘t'oal account ot the use ot sauocrysin, 
br. Doualil tyboio in favour of this form of treatment, 

eerehto-sniun’t deals with Iho examination of the 

pargaves. Art.,, t-"* tnbercuJous meningitis locdiagaostic 

Rierapy anangift of^^tho discussion on ultra-violet 


cernh,... . "''cwai 

■ pC ' dnid 

therapy a- *^'^*’o''t _ 

EdinburguVast De\ember'^° Medico-’chirurgical Society • of 


Bn. Brian B. Metcaepe has been retnriied unopposed to 
tho Cornwall County Council as the member for the Li.skeard 
Bivision. Br. Moicalfe is also a member of the CornwaH 
County Panel Committee and chairman of the' South-East 
Cornwall Bivisiou ot the British Me.dcal Association.’ ' 

. AT tho Invitation ot the Board of Management of the 
London Lock Hospital the Minister ot Heallh has appointed 
a committee to inquire into the admiuistralioii'ot the hospital, 
consisting of tho Rt. Hon. Sir John Eldon Bankes (chaiiman), 
Br. John Fawcett, and Mrs. H. J. Tennant. The terms ot 
reference are : To inquire into the management, administra- 
tion, and staffing of the London Look Hospital, with special 
roterciico to tlio arrangements tor the medical treatment of 
tho patients and to the jirovision made for the moral, social, 
and material welfare of the inmates. The proceedings of the 
comiiiittce will be held in private. 

"We are asked to state that hospitals sitnated within eleven 
miles of St. Paul’s desiring to participate in the grants made 
by King Edward’s Hospital Fund for London for tbe year 
1928 must make application before March 31.st to the honorary 
secretaries of tho Fund at 7, IValhrouk, E.C.4. Applications 
will al.so bo considered from convalescent homes which are 
situated within tho above area, or which, being situated 
outside, take a largo proportion of patients from London. 

The National Union ot Students ot tbe Universities and 
■University Colleges of England and Wales is seeking to 
secure hospiiality in Great Britain for foreign stndeuts who 
arc anxious to improve their knowledge of English and who 
are pveiiared, in exchange, to give their services as teachers 
of their own langnages. Applications for hospitality for 
varying periods from Easter onwards have been received 
from a uuiiibcr of French and German students, ail possessing 
satisfactory credenliais, and those interested are asked to 
eominuuicate with tho secretary for Exchange and Tuition 
Visits, National Union of Students, 3, Eudsleigh Street, 
London, W.C.l. . , 

Ladv Hudson has given a donation of £3,000 to the West- 
minster Hospital for the perpetual endowment of a ward in 
memory of the late Sir Robert Hudson, who was treasurer of 
the iustitntion from 1921 till 1927. 

On behalf of The Jlritish Journal of ' 

Cambridge University Press will shortly .■ ■ ■ ■ 

oa The Development of the Human Bt/e 

with a preface by Sir John Herbert Parsons and reproductions 
of 250 original drawings by the author. 

We have received tho first issue, dated January, 1928, ot 
Levante iledico, a monthly journal published at Marcia in 
Spain under tho editorship of Br. Juan Antonio Marlinez 
LadrOn de Guevara, assisted by Brs. Fidel Fernandez 
Martinez and Ramon Sanchez Parra, The issue contains 
original articles on idiopathic entaneous atrophy by Brs. 
Barrio de Medina and Nicolas Calvin, a study of rabies by 
Br. LadrOn de Guevara, the prophylaxis of trachoma in 
Murcia by Br. Eduardo Poveda Pagan, society intelligence, 
and medical news. 

ACCORDING to the returns received from thirty-seven States 
scarlet fever in the United States of America was more pre- 
valent in 1927 '158,978 cases) than in 1926 (143,159 cases) or in 
1925 (155,937 cases). 

Professor Jolly, who holds the chair of histophysiology 
at the College de France, and is tho author of a well-known 
textbook on haeinatological techuiqae, has been elected 
a member of the Acadgmie de M§deoiue. 


Br, Alfons Jacob, lecturer in psychiatry at Hamburg, has 
been invited by the Brazilian Government to undertake the 
establishment ot an institute for the study of tbe anatomy ot 
the brain at Bio de Janeiro, and to deliver a course of lectures 
on nervous and mental diseases from May to July. 

The second congress of the French societies ot oto-nenro- 
ophthalinology will be held at Marseilles from May 25th to 
Zlth, Papers will be read on vascular spasm by Brs. Bremer 
of Brussels, Aubaret and Sedan of Marseille.s, and Portmann 
ot Bordeaux. Further information can be obtained from tbe 
general secretary, Bi'. Velter, 38 Avenue dn President Wilson, 
Paris XVl”. 


The eighth congress ot the Italian society of medical 
idiology will ha held at Florence from May 14th to 16th. 
'urther informaiion can be obtained from Br. Manlio 
,io..n,iir.lo!iia. della E. Umversita, ViadegU 


Affani 33, Florence. 

The following appointments have recently been made in 
forei-n medical facnities: Dr. Georges Fontes, professor of 
biolonicai chemistry at Strasbourg; Dr. H.ms Reinnard 
Scbtniai ot Bonn, professor ot obstetrics and gynaecology at 
Unsseldort; Dr. Rudolf Klapp of Berlin, prolos-or of surgery 
at Marburg; Dr. Amt Kohlrausch of Grerf.swaia, professor ot 
at. Tuhiui?ei2. 


480 Mabch 17 , 1928 ] 


IiETTEEB, NOTES, AND ANSWERS. 


The BRmaa 


L ifeoiCAI. JotTANi^ 


atitt ^itslucrs, 

All communications in regard to editorial business should bo 
addressed to The EDITOR, British Medical dournal, British 
Medical Association House, Tavistock Setuare, W,C,1, 

OElGINAb ARTICLES and LETTERS forwarded for publication 
are understood to bo offered to tho British Medical Journal 
alone unless the contrary bo stated. Correspondents who wish 
notice to bo taken of their communications siiouid authenticate 
them with their names, not necessarily for publication. 

Authors desiring REPRINTS of their articles published in the 
Bbitish' Medical Journal must communicate with the Financial 
Becietary and Business Manager, British Medical Association 
House, Tavistock Square, W.C.l, on receipt of proofs. 

All communications with reference to ADVERTISEMENTS, as well 
as orders for copies of the Journal, should bo addressed to the 
Financial Secretary and Business Manager. 

!Ehe TELEPHONE NUMBERS of the British Medical Association 
and the British Medical Journal are UVSEVM VSCI, DS62, 9SCS, 
and SSBl (internal exchange, four lines). 

The TELEGRAPHIC ADDRESSES are : 

EDITOR of the British Medical Journal, Aitiology ITeslecnt, 
London, . , • ■ ■ 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.). Articulate Wcitccnt, London. 
MEDICAL SECRETARY, Slcdizccra TVegteent. London. 

The address of the Irish OfBca of tho British Medical Association is 
16, South Frederick Street, Dublin (telegrams; Bacillug, Dublin-, 
telephone : 4737 Dublin), and of tho Scottish Office, 6, Drumslieugh 
Gardens, Edinburgh (telegrams ; Azgociatc, Edinburffh; telephone ; 
E4361 Edinburgh). 

QUERIES AND ANSWERS. 


Cramp after Soiatioa. 

II -p.” writes in reply to “ K.” (JonRNAL, March 10th, p. 430): For 
two years alter sciatica I have suffered from cramps of the 
perouel and flexor muscles of calf and thigh at night, and I Dud 
the best way to escape them is to avoid lying oti my back; a hot- 
water bottle to the muscle is a preventive also, but the most 
certain way is to avoid any pressdre ou tlie bnttooks. When tlie 
cramp comes on get out of bed and extend the cramped muscle 
to its lurtbest, and knead it well and hard with the Ungers till it 
softens ; exercise seems to do it good. 

Caesarean Section in Pregnancy complicated by 

POLHONARY TOBERCOLOSIS. 

Db. S. L. B. Wilks (Colwyu Bay) asks whether Caesarean section 
has ever been employed in preference to allowing natural hibonr 
to ensue iu a case of pregnancy oouiplioatod by pulmonary 
tnbercnlosis. He suggests that for a (irimagravirta with fairly 
extensive physical signs, low blood pressure, and much spatnm, 
bnt otherwise an apparently favourable case, iiafuraf labour, 
even assisted by morphine and liyosoine, is likely to involvo 
considerably more exertion and general disturbance than would 
an open operation, which would take only a few minutes. 

A Method op Makino a Blood Film. 

Bdkoeon Comiiandeb F. Cock, replying to an inquiry about tha 
question of tlie importance of the thickness of ttie sli'des used iu 
his method ot mnUiug a blood film (British Medical Journal, 
February 25tli, 1928, p. 306) writes: As this thickness varies so 
does the distance of the glass surfaces between which the film is 
made. Ttie difference of tiiickness met with in the ordinary 
1 In.jand 3 in. slides, will make very little alteration in the results 
obtained by the method 1 have, so lar, described. As regards 
the ivorkiug distance between the glass surfaces, this is oue 
modilioatioii which has been tried: I find as the distance 
decreases so tlie ciiaractersof the film alter, and a stage is reached 
when precantious must be talien to prevent the blood spreading 
bvcapillary attraction, and tlie two glass slides coming iu contact 
with one another. Tlie cliaiige iu the film referred to previously 
is left for others to observe; there are many modifications which 
may be worthy ol a trial. 

Physiology op Depaecation. 

Dr. Reginald J. Ha.sbory (Woldiugliam, Surrey) writes: For 
many years Messrs. Sliaiiivs and Co., Ltd., 81, New Bond Street, 
W 1 have supplied a good type of water-closet answering pliysio- 
Inrtira! veuuiremeiits, in tliat the seat is low an.l slopes back- 
vv^^rds 'ITiis is known as tlie “ reniirol " pattern, tho heights at 
front aud back of the pau being 133 in. and 12S m. respectively. 
Few who have tried closets of iliis ty|ie would ever wish to revert 
to ibe ordinary patterns, as the comfort and efficiency of the 
riiioo nro markedly sunerior. Wiieii renewals are required or 
&osetrpSt iuTnow bniidings I always install this type. 

Winter JIotoeing. 

TiR "E F BebbingtoN (Bury, Lancsl, in ” Cflualian s ” 

/joubnae; December i927, p. 1250) fora jfooa radiator 
hea?iug lamp, writes: I have a small parafflu lamp, made ou the 
priiJcipJe of the miner’s safety /amp, wbJoli cost 93. only and is 
very effective. The f«J) mime is the “ Viking » safety radiator 
lamp, aud it is obtainable from Dewis's Ltd., Markefe Stteeti, 
Dlauchester, and Bauelagb Street, LiiverpooL' 


Income Tax. 

■f HT m „ , J^olor Car Itcjdaccment and Deiinoah. 

M,T.” bought a oar for £250 ill 1924; il he sella now for £20 and 

Lou l’“>■o>'hses a new car for, say. £250, can lie 

expeiiditiire of £250 into tiie cominitatioii to 
ensure full relief? Biiould depreciation be claimed ? 

* (1) The out-ol-pocket expenditure is tlie maximum 

amount of tlie ctoiin-tliat is, £100-£20=£80. (2) lu our opinion 
• !! experieiioe some difflciilty in estab- 

iisbiug his jioiut. We suggest that he should approach the 
inspector of taxes at ouee /or a depreciation allowance for 
1927-28— to be effected against the Jitfy fustalihent of tax— ou the 
writteu.down value of the original car— for example, at 15 per 
cent, on £18D=£27; tlioii for 1928-29 he should chum obsolescence 
nlldwance—tliat is, £89 — and for 1929-30 depreciation on the 
nuexhaiisted car value— that is, £189-£.;7==£153. Iu our opiuiou 
it is advisable to claim depreciation ; in most circumetauces it is 
cv case of a bird iu'the hand aiid another oue in the bush. 

Lociimtenent's JSxpeiises, ' 

“ W, A. H.” asks what expenses cau a locuniteneut' deduct in 
making Ids. income tax return — for example, can he claim an 
allowance for railway and taxi fares ? 

The point is open to some doubt, and is. in fact, a not 
infrequent cause of dispute. In our opinion, if a medical man 
is carrying ou his profession by taking a series of short engage- 
ments as a locnmtcneut, then he is chargetible'nnder Schedule D 
in respect of professional profits, and cau deduot 'tbe traveUing 
expenses, agents' fees, etc., he actually incurs in order to keep 
in practice in tliat particular wsifo If, on the other hand, he is 
taking d long-term appointment which ainonofcs in effect to ati. 
assistautship. then we fear it must be admitted that he is 
chargeable uuder- Schedule E io.res))ect pf tlie enrnings.of that 
particular appointment as a separate unit for assessment. In 
such a case he'ean deduct only the expenses incurred wholly, 
exclusively, and necessarily in performing- the duties of limb 
apiJoiutmeut, aud not travelling or other expenses iuciirred 
dntMior ’to the performance of that work. ^ ' ' 


XiEXTERS, NOTES, ETC. . , 

Painless Fiiibt Labour. 

• ’• A lady who had been married 

DR, F. J. 

ight with a desire to defaedate, 
about IU ^ c Pm, on g^nunmg, she found that she was 

ufnff \he chilli. . Witii some dimcully her hnsh;uul got her 
wk to berl auil then tetolied me. On Rvrival 1 foiina the chijil 
. back to be n molliei- amiisefi at the ciitastroplie. b.lie siiiJ 
l?™i Im'i Vo pciu. obfl 'vool'l “ot miivl going, through the 
®H*oio business ’ again straight away. She niaile a iioraial 
"^'’n'orv but the' child, a male ot normal size and apiiearance, 
f®°i°'onm0 respiratory defect, aiuliii spite of streuiions efforts ou 
had cb“b huUioe it to ooiitiuue breathing, it would not vespoiid, 
M iTphya witl.iii ail l.oiir or two. 1 had a suspioiou 
Hi'V' nwiug to the abuoniml oiroiimstauces ol its birth, it had 
■ drawuThe liquor amuii into the lungs. 

Severe Anaphylaxis. 

, r T. n T> H ’’ writes : A few days ago I saw a boy, aged lO, who 
^'Fio^l a sore throat for a day. A membranous e.xudate was 
liad jiy “ tonsils, so I decided to admmieter antuhpli tliorml 

present „ igiji^alton was unnecessary, as there was no liistory 
disease, and serum had never been given 
of allergic ^ units of sernm siihoutaneoasly, and scaioely 
I lujeote , * uggfi withdrawn when the hoy liad an attack of 

intense dy I eerum was administered 

three ■.;„arial erdptiou had covered the entire imd 

?• Fortunately I bad a bottle of adrenaline (1-1, CBOnn my 

nave 5 minims ot this soUition hypodermically. The 
bag, n".’' symptoms disappeared almost as rapidl.r as they 
anapbjl^MO natieiit’s condition was normal within 

Vinn esiityit-aA rfirtt ihat t-l) 


lirieg elictted the fact that tlie boy 
the night and commenced to 


bad 
ten I 
occa&iw 

« -T ttfwi.et'C and Son. Ltd., Charlotte Street, 
Messrs. C. o* « n charlotte ” hot-water bottle cover, for 

‘'J^ffcfafmelTtbaT, as the etop,.er is completely enclosed 
wjiioli it ‘® j [n5ieued. there is no danger of scalding, 
bottre can be easily filled without the cover being remoied. 


will be fonnd at pagee 4S, 47, 50, 
columns appears iii the Supplement at pa„ 



MAncH aijl 192S] 


aspects' 'OP GArlt-'i’EADDER 'DISEASE. 


r TirBCr.mfH 4R7 

SlEDICAl. JouaXAfc «UX 


... OS - - - 

SOME ASPECTS OE CtALL-BLADDER 
DISEASE. 

DEuymiED TO the Avnsniur. D.ivibiox or the Dkitish, 
JIedicae A.s.socuiiox, Kovejiuei!, 1927,*' 


D. 1’. D. WILKIE, Sr.Gn;, E.R.C.S., 

rnoFESSOR br 'schgehv, CKivcnsirv or EniKBURGir. 
(iriRi Special Plate.) 


Dvring tlie p.Tst few years tlie importance of gnl\-bladi\cr 
diBo.ase lias lioeome more and more .fully recognized. There 
is still, however, a widespread belief that gall-stones con- 
stitiito the important, if not the essential, element in such 
, disease, and a clinical diagnosis of cholecystitis is confined 
hy many to those acute attacks of ohstrnctivc cholecystitis, 
ivliicli are apt to supervene when a gall-stone becomes 
imii.-icted in the' cystic duct or the neck of the gall-bladder. 
Many yeai-s ago Aloynihan drew attention to a group of 
.symptoms which lie termed the inaugural symptoms of gall- 
stones. The.so symptoms — flatulence, nausea, epigastric dis- 
comfort, etc. — ho .showed were frequently present for a 
long period' before attacks of colic proclaimed in classical 
terms the presence ' of one or more calculi. Wo now 
know that these inaugural .symptoms are those of chronic 
cholecystitis, which may or may not go on to stono 
formation. . ’ ' 

Gall-stones are so common, so many people harbour them 
for years and die with them, without appai'cntly suffering 
any very serious tronblo, that many medical men aro 
inclined to regard lightly such evidence of hiliaiy disease, 
and to encourage an c.vpectant attitude nnlc.ss intolerable 
attacks of Colic render a jiatient’s life a burden. 

The more I .see of biliary di.=easo, the more convinced 
I become that it is practically never hnrmle.ss, and that, 
after years of bearable discomfort, many patients eventually 
succumb from disease which is either directly or indirectly 
due to long-standing biliaty infection. This is particularly 
true of patients in comfortable financial circumstances, for 
they tend to spend years in tvying “ cures ” which those 
of the hospital class, fortunately for themselves, cannot 
afford. It is only right to state that the responsibility for 
the failure to deal in a timely or an adequate manner with 
this common disease rests mainly with those whose duty it' 
IS to teach the medical undergraduate. Such conflicting 
views have been expre.ssed, not only in regard to tho 
■frequency and impoi-tancc of the condition, but also in 
regard to the nature of the infection, that no cle.ar picture 
0 the disease is held, and uncertainty here, as elsewhere, 
leads to empiricism, and thus to indefinite delay. 


Kature of Gale-bladdep. Ixfectioxs. 

Certain organisms can grow in bile, notably the Parillu; 
eo I and the typhoid bacillus. Those two organisms have, 
on many occasions, been • recovered from inflamed gall 
I’'''*'f'iii'lnrly during acute attacks, and there ii 
!>)' 'I " , PEcyalent belief that one or other of then 
I ays tlie lading part in the etiology of cholecystitis. Tlii: 

cw, winch I hope to show is entirely erroneous, ha; 
nf T-'i" belief that agents which stimulate a flow 

hU * ” gall-bladder, or are excreted in the 

tAr”" may possibly disinfect it, are of value in tin 
tieatinent of cholecystitis. 

ililo c”'?® years since Eosenow reported his remark- 

Ti-nn of observations and experiments on cholecystitis 
bn ^ of diseased gall-bladderi 

1-1 ‘ ^ cultivate a streptococcus which, on' injectior 
he All'wo I’l to J'ove a selective affinity fo, 

s results were received ' witl 
or hi ’'’’iT'''"’ to find in the bih 

bhiddor? tUr. i-,. walls of obviously diseased gal! 

bis work and^’b-ir be described, disregardei 

° based tlieir opin ions and their teachinj 

• The address was iHustraled with lantern slides 


on the types of organism which they have, in their own 
experience, been able to cultivate in cholecystitis cases. It 
is a significant fact, however, that so many observers have 
failed, to grow, on;/ bacteria from either 'the bile or the 
gall-bladder wall in a large, proportion of their cases of 
cholecystitis. 

In. my own experience I was impressed by the fact that, 
whilst the hile and gall-bladder wall proved so often to be 
sterile on. culture, yet -st.ainod sections of the wall revealed 
tho. presence of .streptococci, in the submucous coat. There 
evidently. was jircscnt an intrafunral infection by a strepto- 
coccus, which did .not.' grow, readily oir most media. 
.'.Illingworth; working iii my'clinic,,was able to sliow that, 
using Bosenow’s sjiecial medium, streptococci could be 
grown from the wall of the gall-bladder in quite a large 
percentage of cases in which the bile was sterile. Ho 
further showed that organisms of the coli group are rela- 
tively infrequent except in acute suppurative cases. 

This' work has hocu carried a stop further by Dr. A. L. 
Wilkie, who has shown that cholecystitis is almost invari- 
ably < an. intramural streptococcal infection, and that 
Rosenow’s contention of a selective affinity- of this organism 
for the gall-bladder in experimental animals is strikingly 
true. IVilkie has shown that in over 85 per cent, of cases 
of chronic cholecystitis, usually associated with gall-stones, 
tho streptococcus can ho recovered in pure cnltnre from 
the cystic lymph gland through which the lymph from tho 
gall-bladder drains. In a smaller percentage of cases he 
has grown the same organisin from the snbinneous coats* 
of the gall-bladder if no bile has been allowed to come in 
contact .with the tissue taken for culture. He has brought 
to light the illuminating and remarkable fact that bile 
inliibits tho giowth of this streptococcus. Hence, when 
a clipping of the whole thickness of the gall-bladder wall 
■ is taken for culture, the bile adhering to the mucous coat 
prevents tho growth of tho streptococcus present in the 
submucosa. Tin's fact accounts for the widespread failiiro 
to confirm Rosenow’s findings. 

Even Judd, working under the most favourable condi- 
tions, got a positive I'Osnlt in cnitnres of the gall-bladder 
wall in only 29 out of 100 cases, and in only 5 out of 22 
sjioeimen.s of strawberry gall-bladder. In only 7 per cent, 
of his cases of cholecystitis was a positive culture obtained 
from the bile (3 streptococci, 3 spore-bearing bacilli). In 
no case were typhoid bacilli found, although in 21 cases 
there was an antecedent history of typhoid fever. B. coli 
was conspicuous by its absence in the whole series. In only 
2 cases out of 52 did Wilkie find the B. coli, and in both 
an acute ob.strnctivo cliolecystitis was present. It was, 
therefore, probably a secondary infection. 

Hollowing tho injection of a suspension of streptococci, 
obtained from a human gall-bladder, into the ear rein of 
a rabbit, Wilkie found that tho animal developed a chronic 
progressive cholccjstiti.s, whether the cystic duct was 
patent or was ligated. The organism evidently reaches the 
gall-bladder by the blood .stream, causes an intramural 
infection, the bile remaining sterile, and from the gall- 
bladder wall 'the organisms are absorbed by the lymjihatics. 
Hence tho importance of the gall-bladder as a nidus of 
focal infection. 

Medical treatment of cholecystitis, to be rational, theic- 
fore, must be aimed at this intramura! streptococcus, attack- 
ing it through the blood stream — for cxanqde, by vaccine 
or by some agent which is absorbed by the gall-bladder 
and passes tbrnngh its wall; but so far wo know of no 
•such agent. Drugs which merely disinfect the bile cannot 
bo expected to have any real value, as the bile, in the 
Aa.st majority of chronic cases, is stei ilo. 

The necessity for surgical treatment in chronic cases 
becomes obvious, and this treatment should consist in 
removing the diseased wall where the infection is located, 
not merely in draining the lumen of the gall-bladder. 


Relationship or Cholecy.stiti.s to Gall-stones, 
Whilst infection of tho gali-blaclder and gall-stones aro 
iisuallv found together, and whilst most evidence points 
to the infection ns the primary factor, yet we have alway.s 


As Hslpcrt lias shotin, the gall-bladder lias no true .submucous coat 
sncli as 'is fouml >n tl»'. stomach and intestine. The term is leMl for 


convenience 


to indicate the co.Us outside the lining 


mucous membrane. 

[3S07J 



482 iTARcn 14, 1928] 


ASPECTS OF GADD-B LADDER DISEASE. 


r, TFjtHofnm 
L MrDICiL JoCBKAi 


believed that there are two types of gall-stone which are 
metabolic in origin — namely, the single pure cholcsterin 
stone and the multiple pure pigment. calculi. Tho former, 
found often in an' apparently normal gall-bladder, is apt 
to bo associated clinically with intermittent afebrile attacks 
of biliary colic in ' an otherwise healthy individual; the 
latter, also found in a gall-bladder showing, no patent signs 
of inflammatory disease, and duo to excess of pigment in 
tho bile, are also liable to cause colic, but no ill health. 

In the light, however, of the work on the bacteriology 
of tho gall-bladder quoted above we may have to revise 
our ideas as to tho aseptic origin of both these tyires of 
stone. This much is certain, that in several cases with 
a single cholestorin stone and a very slightly thickened 
gall-bladder a strejitococcus has been grown from tho wall 
of the latter. Also, in one case of single cholcsterin stone, 
Illingworth isolated a streptococcus from tho centre of tho 
calculus. 

The origin of tho multiple faceted calculi, of mixed 
cholesteriii and bilirubin composition, probablj’ dates from 
an acute attack of obstructive cholecystitis, when tho cystic 
duct, was occluded, either by a single cholcsterin stone 
or merciy by inJianjroatojy oedema. The inhamoiatoiy 
exudate within the gall-bladder in such cases provides 
abtindant material for the nuclei of stones, which, in their 
subsequent growth, reproduce in their strata the history 
of tho successive steps in the gall-bladder pathology. 


Chouestehosis akd the MuLTirnE MuMiEimy Stoke. 

Many surgeons, among whom Moynihan and AV. J. Mayo 
were the first, have drawn attention to a curious condition 
of the mucous membrane of tho gall-bladder in cases in 
which no gross disease was evident from without, whei'o 
small white spooks project from the villi, giving an appear- 
ance somewhat resembling tho surface of a strawberry. 
This condition, which is not uncommon, has been found 
where no stones were present, but also in association with 
several, usually mulberry-shaped, calculi. Boyd has de- 
scribed, and has illustrated veiy beautifully, tho nature of 
this lipoid deposit in tho colls of the mucosa of the gall- 
bladder and in the subepithelial layer, and has .shown how 
small lijjoid-laden papillomata may form and possibly 
become shed off into the lumen of the organ. Mentzer 
has reported similar observations. Boyd believes tliat 
cholesterol is absorbed from the bile by the mucous mem- 
brane of tlie gall-bladder, and, when there is disease in 
the wall, the paths of absorption are partially obstructed 
and cholesterol esters accumulate in tho cells of tho mucous 
membrane and in those of tho underlying stroma. 

Our ob.sorvations, in the many cases of cholesteiosis of 
tho gall-bladder which we have encountered, entirely con- 
firm those of Boyd, and in several tlio various stages 
between punctiform lipoid deposits, lipoid-ladeu papillo- 
mata, and mulberry cholesterin calculi have been present 
in the same specimen. Illingworth has repeated Boyd's 
histological investigations (Figs. 1 to 6). Fin-ther, ATilkio 
has shown that in tho suhmucosa and in the cystic gland 
in every case examined a streptococcus was present. 

The multiple mulberry cholesterin stone is thus of septic 
origin, and the phases of its development are as follows : 

1. Intramural streptococcal infection of the gall-bladder. 

2. Lipoid accumulation in the mucosa and subepithelial 
layer. 

3. Formation of lipoid papillomata. 

4. Shedding off of these to form the nuclei round which 
cholesterol is deposited. 


The C.\i.ciuit Stone of the Ciosed GALL-nL-ADDEi!, 
Occasionally wo meet with cases where gall-stones com- 
posed mainlv of calcium, in tho form of carbonate, are 
shown lip readily bv s rays as dense shadows. In such 
cases it IS found that tlie gall-bladder wall shows signs of 
chronic inflammation and that tho cystic duct is obstructed 
fFi"s 7 and 8). In this connexion the experimental work 
of A L AVilkie is of interest. He found that in the 
cholecystitis produced in rabbits by intravenous injections 
of streptococci calculi were common. In cases where the 


cptio duct was patent cholesterin was the main, if , not 
the only, constituent; in those in which the cystic duct had 
been ligated calcium was the m.iin constituent. 

Symptomatology w Choleoystjtis. 

Tho oiiset of symptoms is so gradual that it is often 
very difficult for the patient to give a precise date to tho 
beginning of tho trouble. A tendency to flatulence coming 
on immediately after eating, often indeed during a meal, 
a feeling of constriction and oppression, causing a desire 
to loosen tho clothing, a sense that the patient has eaten 
ton much, even after a small meal — these symptoms, so 
common among the middle-aged female poiiuhvtion, are, 
in tho majority of instances, duo to cholecystitis. A 
sense of nausea and desire to be sick, coming on at 
irregular times, sometimes accompanied by an aching 
under the right costal margin and in tlie riglit scapular 
region, an aggravation of these symptoms by any exposure 
to cold or chill, with, in many cases, the apjiearancc of 
a faint tinge of yellow in the skin or a notico.ablo miiddi- 
ness of tlie' complexion, are ^•inptoms often attributed to 
“ liver,” but due usually to a slight exacerbation of a 
chronic inflanimafoiy process in the gall-Wadder. Actual 
vomiting is not infrequent at such times, and articles of 
diet, such as potatoes and all fatty foods, are avoided 
as they are found to aggravate tlie discomforts from wliicii 
the patient suffers. Sometimes the patient complains of 
flatulence, the onset of which is delayed for an hour after 
food, is accompanied by “ acidity ” witli hoarthiirn and ' 
waterbrasli, and a gnawing epigastric pain, almost sugges- 
tive of duodenal ulcer, hut differing in two respects — 
namely, in tho comparative failure to get relief by eating 
more, and the absence of the periodicity so characteristic 
of ulcer. 

It is however, by no means easy in some cases in stout 
females to diagnose, from a clinical bistoiy and physical 
examination alone, duodenal ulcer from elioleoystitis. 
tinder the term ” cholecysto-diiodenal syndrome ” I have 
described a clinical picture, almost iiulistinguisliablo from 
that of cholecystitis, wliich is presented by quite a large 
group of female patients suffering from duodenal nicer. 
By special investigation, however, the two conditions can 
bo readilv and surely distinguished, even when both are 
present, which is by no ineans rare. i .f , 

AVlion definite attacks of colic have occurred, if they hare 
been of the real agonizing typo, one may he sure tljat one or 
more gall-stones are present. Attacks of colic simulating 
somewhat closely the true variety due to stone are, how- 
ever sometimes apparently caused by interference witli 
the emptying of the gall-bladder, duo to kinking at the 
nod- Tim removal of such a gall-bladder, wliich is always 
thickened but contains no stone, ba.s, in numerous in- 
stances led to a cessation of the colic-liko attacks. 

I need only mention the attacks of acute ohstrucUre 
diolecvstitis vlicn, with acute pain accompanied by vomits 
ing a coated tongue, often some shivering- and rise ot 


temperature, 


witli marked tenderness in tho right liypo- 


ohondrium and a catch in tiio breath, the picture of a 
steZ impacted in the neck of the gall-bladder, whiel. is 
Ltlimed and tensely distended, is clear and unmistakable. 
Tt Ik ill these attacks that we get tho secondaiy pulmonary 
signs of dullness with crepitations and even 
tlm base of the right lung, due to tho rigid right half of 
the diaphragm. These signs must bo regarded as an 
inte<n-al part of tho cliiucal picture of acute cholecystit-s, 
’a '’must not be allowed to divert attention from the true 
scat of infection. Examination of patients with the x-iay 
™ during such an acute attack has -shown qu.to clearly 
ir, immobile right cupola of the diaphragm, with conseqiieiifc 
impaired expansion at the lower lobe of tho right lung- 
Tho association of cholecystitis with appendicitis nms 
or ho kept in mind. The two conditions in a chroii.o 

use are frequently encountered together. I have on two 
aseaieiicq j ^ ^ siippurativo 


ever 
phase 

occasions ^ix and gall-bladder, occurring simiu- 

fnr the view that inflamniatai-y disoaso of the ePPea 
and gall-bladder represent not consecutive but simultanc 
bl(wd-bomo infections, usually of streptococcal typo. 


simiil- 



MABCn 24, 1928] 


ASPECTS OF GAEE-BEADDEE DISEASE. 


, TirrEiirrT?a - 

L I'coicir, JociwAt 


483 


Special AlKTiinDs or Diagxosis. 

Use of the Duodenal Tube. 

JIiicli was hopoii from what is commonly known as the 
JfcUzor-Lyon test,' whereby bilo is withdrawn from the 
duodenum by means of the' duodenal tube after the intro- 
duction of magnesium sulphate. There can bo no question 
that in ‘eases of cholangitis and in advanced cholecystitis, 
particularly if the large septic typo of stone bo present, ' 
very definite and valuable information may thus bo ob-. 
tained. In quite a large proportion of cases of chole^, 
cystitis, however, we find at operation that the bilo in; 
tiio gall-bladder is normal in appearance and is sterile on 
culture, and, withdrawn by the duodenal tube, could not 
possibly have indicated the intramural infection present 
'in tho submucous layer of the gall-bladder. The results, 
reported by certain observers, of bile infected by B. coli 
being recovered by the duodenal tube in a large proportion 
of cases of cholecystitis, are quite out of keeping with our 
operative experience. 

Cholct^pfograpJiy. 

Since the introduction of pyelography in the diagnosis 
of renal disease there has been no advance so striking or 
so helpful in visceral diagnosis as tho method devised 
and elaborated by ‘Graham and Colo of obtaining shadow- 
graphs of tho, gall-bladder by the use of an opaque dye. 
•Whether the dye be -given intravenously or by the mouth' 
tho results, if interpreted intelligently, are of the greatest 
help in diagnosis. , If a dose of not more than 3 grams 
intravenously, or 4.5 grams by the mouth, bo used, no 
untoward effects are produced, and tho functional capacity 
of tho gall-bladder can bo gauged with a fair degree of 
accuracy. 

, From an c.vporicneo of more than 200 cases I can state 
without hesitation that it transcends all other methods of 
diagnosis, and gives reliable data in over 90 per cent, of 
cases. It is of especial value if used in conjunction with 
a barium meal, as recommended by Dr. Woodburn Alorison, 
for then it may, as it has done in five of my cases, reveal 
a normal gall-bladder and a deformed duodenal cap in 
a patient presenting tho cholecj'sto-duodenal syndrome. 

Tile dye test is seen to greatest advantage in cases 
nhere cholesterin calculi are present in a gall-bladder 
'ritli patent cystic duct. Then the negative shadows cast 
by the calculi enable not only a positive diagnosis of gall- 
stones to bo made, but give accurate information as to the 
t.'pe and number of calculi present. Defective concen- 
lation of tho dye and poor definition of the outline of 
the gall-bladder indicate cholecystitis. B’o have found, 
10.1 eier, in a few cases in which tho clinical history has 
pointed to cholecystitis, that the gall-bladder shadow 
appeared to bo practically normal, yet at operation a gall- 
1 adder with opacity of its wall and with an enlarged 
cistic gland was found, and from both gall-bladder wall 
and from the gland we were able to cultivate a strepto- 
coccus. This simply means that, in the early stages of 
a c ironic cholecystitis, tho gall-bladder function is main- 
ained at a sufficiently high level to allow of an almost 
normal concentration of tho dye. 'Whilst the test is, 
icrefore, of the utmost value, it is not infallible and 
us be used, as must all such tests, as one of many 
“cans of clinical investigation. 


- . ffinEATtrEXT OF G.ill-bladdeh Inteciioxs. 

■ hi all other diseases, we must, before con- 

u-ciing the quc.stion of surgical intervention, assess as 

• ccuratmy as may be the chances of a natural cure and 
ose onered by- more conscixative forms of treatment. 

. . ’ngaid to spontaneous recoveiy from cholecystitis it 
a impossible to obtain accurate data. We are here dealing 

,^.1 . vhronio loiv-gradc infection, the tendenev of 
'^J'houbtedly to persist and occasionallv to flare up. 

* ong Instorios given bv so m.anv patients coming 
o operation indicate rliat, once established 

nds to be sloivly progrcssiv 


the disease 
and that in the diseased 


than ’likolv^ AV 1 g‘''h-stono formation is more 

formed tbk’ u ' '^“ow, further, that once stones have 
the snnllnsf spontaneous cure has gone. Onlv 

colic fovmerW Po-'-s doivn the ducts. Biliary 

uc, toimeily thought to be due to the passage of 1 


stone, wo now know to be due, in the vast majority of 
cases, to the temporary impaction of a stone in the neck 
of the gall-bladder. The almost total lack of a miiscuiar 
coat in the bile ducts is sufficient evidence that colic is 
not due to spasm of the ducts. 

. . Can we, then, by treatment influence the gall-bladder 
infection or prevent the formation of stones? A primary 
. source of infection in the teeth or tonsils should he 
searched for, and, if fennd, dealt with. There is now a 
certain amount of reliable evidence that where there is 
infection of the bilo passages by D. eoli the administration 
of very largo doses of hexamino will influence the course 
of the infection in a favourable manner. In several cases 
of chronic cholangitis I have seen undoubted, if temporary, 
benefit follow the administration of this drug. In the 
majority of cases of cholecystitis, however, we are not 
■concerned with a catarrhal B. coli infection of tho passages, 
but with an intramural streptococcal infection of the gall- 
bladder, and I know of no drug which will influence this. 
Tho use of suitable stock streptococcal vaccines may prove 
to be of value, and this would certainly appear to be the 
most rational line of medical treatment. 

To prevent the formation of gall-stones any measure 
which favours emptying of the gall-bladder and. diminishes 
stasis should he of help. Regular muscular exercise, which 
has been neglected by so many of the patients suffering 
from this disease, must be insisted on. Fat must not he 
excluded from the diet, as we now know that it is the one 
substance which without doubt causes tho gall-bladder to 
contract; hence the discomfort following its ingestion in 
patients who already have gall-stones. Large quantities 
of bland fluid should be taken, finishing at night with a 
.tumbler of hot water with some baking soda. Every 
morning a small dose of magnesium sulphate or sodium 
phosphate is taken to promote a floyv of bile. 

It is doubtful, ns McNec has shown, whether we can 
influence the cholesterol content of the blood or bile by 
avoidance of articles of diet rich in this substance — such 
as egg-yolk, sweetbread, etc. AVe err, however, on the 
right side in excluding them. Ox-bile, sodium oleato, and 
sodium salicylate, given separately or together, as in the 
popular preparation felamine, may, by promoting a flow of 
bile, help to diminish stasis. 

Wo are, however, faced with the problem that, .when 
onco firmly established, infection of the gall-bladder is 
highly resistant to cure by other than surgical mean.s. If, 
therefore, symptoms persist or recur in spite of tho 
measures recommended above, operation should he under- 
taken before secondary changes in other organs or acute 
complications supervene. 

Operative Treatment. 

I do not propose to discuss any technical points in regard 
to operation, but merely to review the principles which 
should guide such treatment and the results which may be 
expected. In the first place, it is obvious that, as the 
disease is almost invariably intramural, removal " of the 
gall-bladder rather than drainage is the rational treatment. 
Only where the general condition of the patient or local 
technical difficulties make the operation of cholecystectomv 
one fraught with a sensibly greater risk should c'holecysto- 
stomy be performed. In my experience the removal of a 
diseased gall-bladder is not followed by any untoward 
symptoms. On the other hand, simple drainage of tlio 
gall-bladder, whilst giving temporary relief, is very 
frequently followed by recurrence of symptoms, and some- 
times by recurrence of gall-stones ; hence the impression in 
some minds that gall-bladder operations are not followed 
by permanent relief. Free exposure that will allow of 
adequate investigation of the ducts is a sine qua non, as 
the failnro to recognize a floating stone in the common 
bile duct is one of the most fertile causes of recurrence 
of symptoms after operation. The stomach and duodenum 
must be examined to exclude coincident ulcer, as, if 
present, this can usually be dealt with at the same time. 

Some Lessoxs feom; 452 Bili.abt Operatiox-s. 

During the past seven years I have operated on 452 
cases of disease of the biliary passages. On reviewing 
these cases certain significant and interesting points are 
brought out. First in importance, perhaps, is tho fact 



484 March 24, 1928] 


KADIOGEAPHY- IN GAtiri-BLADDER DISEASE. 


f - TimBniTi'ni 
Medical Jotj*RxiL ' 


that in 15 cases malignant disease of the gall-hladder was • 
found. The average ago of the 'patients in this group was 
64, and in all a long-standing history of gall-hladder disease 
was given. In every ease gall-stones were present and 
there was evidence of old-standing cholceystitis. In only- 
one of these cases was the disease rohiovahle, and in that 
ono fatal recurrence took place two 3-‘oars later. Tho risk- 
of malignant disease is tlierefore no small one, and is a' 
strong point in favour of timelj' operation. 

In 6 cases the operation was carried out for acuto haenior-' 
rhagic or gangrenous pancreatitis. In 5 of the.se cases, 
which wore all fatal, a long-standing historj- of cholecj’st- ' 
itis and gall-stones was given. Tho average ago of the 
patients in this group was 60 v-ears. In 3 cases (jaundiced 
])atients) an irrcmoi able, carcinoma of the common hilc 
duct was found, and in 7 a carcinoma of the head of the 
pancreas. In all of these 10 cases a palliative cholecj-st- 
enterostomj- was performed. Excluding these 31 cases (25 
malignant and 6 acute pancreatitis) there remain 421 
cases,, of which 357 - were cases of cliolccj-stitis, with or 
without cholelithiasis. The sex ratio was 9l niales and' 
306 females, and the average age at operation was 50 j’cars. 
The disease was found with equal frequenOj' in hospital and 
private practice (213 hospital, 184 private 'cases). 

Several striking difFeronccs were noted in the two social 
classes, however. In the first place, there was a much 
larger percentage of male cases in private practice — 30 per 
cent, to 17.3 in hospital practice — duo, no douht,- to the 
•sedentary occupation in the foi’iner. Sccondh-, tho average 
age at operation in private cases was 54, in hospital cases 
46.5, and the length of hi.story corresponded to this age 
difference — that is, expectant and medical treatment was 
persisted with much longer in those in hotter financial ■ 
circumstances. The most notable difference, however, was 
in the operative mortalit.v, which in iirivate cases was 
6 per cent, and in hospital cases 1.4 per cent. This pro- 
nounced -difference -was attributable to the secondary 
changes and complications which had developed in many 
of the former ; thus in the fatal group there were examples 
of subacute pancreatitis, 2 ca.ses; choleej’stitis with 
cirrhosis of liver, 2 cases; bleeding duodenal or gastric 
ulcer, 2 cases. Furtbeimore, the incidence of carcinoma 
of tho gall-bladder in private was exactly double that in 
hospital practice, and as in manj' of these, cases the patient 
survived the operation for onh' a few weeks or months the 
penalty of delaj' becomes the more evident. 

li/ must be clearh- understood that it is the age and 
soreritj- of the disease, and not the ago of tho patient, 
which is the important factor in prognosis as regards opera- 
tion. In mj' experience clderlj- patients stand ‘operation on' 
tho biliarj- passages verj' well, provided none of the more 
dangerous comjilieations have arisen. - Thus among tho 
74 patients in this series who were over 60 years of ago at 
operation onh- 5 died (6.7 per cent.), and among the 
15 ])aticnts over 70 j-ears of. age there was hut one death. 

In dealing with elderly or bronchitic patients tho advan- 
tages of local anaesthesia, aided bj- twilight sleep, cannot 
bo too.strongh- emphasized. On numerous occasions I have 
removed t.bo gall-bladdor and stones from the comnion duct 
under such anaesthesia without tho patient .being conscious 
of the operation. 

A large .proportion of patients suffering from gall- 
bladder disease are grossly obese, and their muscles, 
including heart - muscle, aro flabby and in poor condition. 
It is a wise plan, and ono which we practise regularly, to 
put those patients on a preliminary course of exorcises for 
three, months, that they may get into training for tho 
operative; ordeal. The remarkable improvement in general 
tone' with loss of weight which results makes the operation 
both easier and safer. 

Cholecystectomv was performed in 253 cases, chole- 
evstostomv in 144. In the earlier years of the period 
under review cholecvstostomv was the commoner operation, 
but in the past thVee years it has been almost entirely 
renlaccd bv cholecvstectomy, with no increase, in operative 
mortality and a vast improyenient as regards the diminu- 
tion of post-operative iiiorbidit}-. ,1 , , -n 

In 257 cases calculi wore present in tho gall-bladder, 
in 140 cnse.s cbolecvstitis without .stone. The improvement 
in health following cholccystectoniy in the 76 cases of tho i 


latter group in which this .operation was performed was, 
almost without exception, -gratifying; in. the 64 cases in 
whicU .drainago of tho gall-bladder was practised the 
impiov'ement following the operation was, in many cases, - 
onlj-.tQipporarj-. 

Common Duct Stones. 

In 47 cases — that -is,- 18 per cent, of the eases of chole- 
lithiasis — ono or more stones were found and wero removed 
from tho common duct. In tho majority of jiatients in 
this gro'ti]) tho histon- of recurring jaundice with colic, 
rigors, and loss of weight left no doubt as to the presence 
of a stone in the duct. In a third of the patients in this 
- gi-oup, however, the history did not present anything 
approaching tho typical Charcot sj-ndrome, tho stones being 
of the silent, floating type. 'Without adequate exposure ' 
and careful exploration tliej- might readilj- have been 
missed, and indeed in 9 cases a previous operation for gall- 
stones had been perfoimed. 

'When the iiaticnt, at the time of operation, was not 
deepiv jaundiced the gall-bladder was removed. 'When the 
patient was jaundiced,' or othefirise very ill, it was drained. 
There were three deaths in this group — a mortality of just 
over 6 per cent. Ilie improvement in health, and rapid 
gain in weight, following a successful operation for stone 
in the common duct are remarkable. 


COXCLU.SXONS. 

Infection of the gall-bladder is probably tho commonest 
of all abdominal maladies, particularly among persons of 
sedentary habits. 

It is usually an intramural blood-borne streptococcal 
infection, and is frequently associated with tho formation' 

of gall-stones. ' - . 

If 'neglected serious, and often fatal, complications may 

*''whcn ’firmly established the disease can only he cured by 
radical surgciy. ' 

In the absence of secondarj- changes and complications, 
such as malignant disease, pancreatitis, hepatic cirrhosis, 
and insufficiency or toxic myocarditis, operation has a low 
mortality and the results, as regards subsequent health, 

“'Eldc'rly^patients may be safely.operatcd on under twilight 
sleep and local anaesthesia. 

T -. 1 . In exorc^s my thanks to Mr. J. J. M. .Shaw for tho 
^ in Fw 5; to Mr. C. F. tV. Illingworth for his 

specimen depided n r. „n eholesteros.s, and to 

TV A L Wilkie nliose icmarkablo work forms the basis of our 
present attitude towards cholecystitis. 

■ ' • t 

THE X-RAT DIAGNOSIS' OF PATHOLOGICAL 
CONDITIONS OF THE GALL-BLADDER. 

BY 

TAMES F. BRAILSFORD, M.B.Bibm., M.R.C.S.Eno., 
hadiolosist, st. dcm’s hospital, birmihguam. 

(in'ffi Special Plate.) 

r, ’ n -c -irrn the ccncrallv accepted opinion of physicians 
FiTpycais ago tlie ge examination 

Tli'"‘?alU, ladder was of 1.0 value. This was due to the 
of tho g. j}eek'(18g9) had demonstrated the shadons 

fact radiographs, most radiologists wero of the 

Holaiul and Robert Knox in this country 
rasfcole, George, and Leonard in America, and 
Pfahici, A > criiefuUy studied the problem, 

Haenisch m Geimnn. , fnll-stoiics could be demon- 

7“,' Irt'rSvTC ».i ttai o» 

strated m “ 5““.:' diagnoses of gall-stones grows 

percentage of coirect / interest, the more 

“Si'” f :s 

rd’expl;i-ience. (An account of the ^^a" 

bladder radiography nms given in a .jf is 

The number of radiologists who 1 3O per 

steadily growing. My own cxpcnenco is tbat.about 3U le 


. 'WILKIE : SOME ASPECTS OF GALL-BLADDER DISEASE. 







JAMES F. BRAILSFORD ; THE X RAY DIAGNOSIS OF PATHOLOGICAL CONDITIONS OF THE GALL-BLADDER. 


March 24, 192S] 


TnEUamsH 
Medical Jocbnil. 




IIaech s4, 1928] 


KABIOGEAPHT IN GAIiTi-BLADDER DISEASE. 


MXOICJX Joci«At. - 


cent of gall-stones contain sufficient calcium to c.ast a 
Bhaamv wliich can bo recognized on a good average radio- 
Erapb A small proportion of tlieso aro very opaque, and 
OTst sfiadon-s as dense and as typical as tlio densest renal 
stone. Tbeso are usually ring-shaped or typical faceted 
gall-stones, tbo aggregation of which gives the outline of 
the gall-bladder (see Fig. 1 ). Tim majority, however, are 
ill-dofinod flaky shadows which can only be seen on good 
quality radiographs taken so rapidly that peristaltic and 
body movements are eliminated, as the slightest movement 
completely obliterates the shadows. . 

With the added devclopinoiit and improvement of 
Graham’s cbolccystography tho x-ray diagnosis of patho- 
logical conditions of tho gaii-bladder ranks as high for a 
diagnostic procedure os tlio barium meal docs for the 
examinatioii of tho stomacli and duodcmim. I have carried 
out nearly 500 x-ray investigations on the gall-bladder, and 
the high porcentago of acciirato results, as proved by 
operation, in my opinion fully justifies the procedure. Most 
of the patients were sent hceanse of obscure symptoms in, 
the upper abdomen, which were not sufficiently character- 
istic or acute to warrant the surgeon doing a laparotomy. 
Some weio sent to confirm tho clinical diagnosis of gall- 
stones. Tho value of the test for such conditions will be 
seen from tho short histories which are given at the end 
of this paper, , 

I have continued to use tho intravenous method of 
administration of the dye — except in a few instances 
where I have not thought it advisable, or where difficulty 
has been met with in injecting tlie vein — because I regard 
it as. tho most accurate. This method has been used to 
cotffirm the diagnosis of cholecystitis — indicated by non- 
filling of tho gall-bladder when the dye has been given by 
the mouth — iu five cases, and in each case a normal shadow 
of the gall-bladder was obtained. 

Ik is essential that the techiiiquo of tho intravenous 
injection ho carefully carried out, and for this purpose it 
may ho necessai'y to ask a surgeon to give the injection. 
This was my early practice, but for tho last year or so 
I have been asked to carry out tho injection myself, and 
fro.m the occasional difficulties met with, and the fact 
that the test is in a sense quantitative, I am confident 
that the knowledge of tlie.so conditions enables the radio- 
logist to give a rbore accurate report. 

in a previous paper- I have given the details of tho 
tecbnique, the errors which may he made owing to faults 
in tho technique, the causes of failure, the nature of the 
reac 10ns to the dye, the other methods of administration, 
and an estiiiiate of the value of tho test. In this paper 
I also pointed out the impoiTaiice of (a) a preliminarv 
uxaiiimation, and (h) a subsequent barium meal 
**1 8® I'J^'^dder is still, visible. The preliminary 
onrl much light on tho diagnosis, 

unueecssan-'^ indications which render the dye injection 

tho lesions previously unsuspected which have 

been revealed by the preliminary investigation are: 

W n tie thorax; (1) Early phthisis with gastric 
sjmptoms. (2) Pulmonary tumour; primary or 
' i^'j I- secondaries from abdominal organs : 

/MT ( 3 ) Aneurysm. 

' ’ ,0!® 1 (1) stone in the kidney or ureter, 

tol l^alcifM tumour in the kidney. ( 3 ) Gall- 
E ones, (a) Lesions of tho spine causing abdo- 
Phip (tubercle, gumma, neoplasm, Paget’s 

disease). . ( 5 ) Abdominal aneui-ysm. 

was recon%'® 4 Vwdth!’“° ° 


unnm- ni„i„;-„ A, patient who had pain in the 

and the ml) n "ij^ ^holeojstograplied by the oral method 
latt e to filL Several months 

The nrcIiminar^“wi!Kf°L“v examination. 


1* . y.' ^ WllUllUIH 

tion of tlm'hn^ todmgraph showed carcinomatous destruc- 
Thf the second lumbar vertebra, 

full of onanuo th® gall-bladder 

anormfi K ^ - unlike 

preliminary radioli^h'°r““ “-ticate that where the 

particulariv in thn°=o gall-stones it is advisable, 

3 those cases where the symptoms are atj-pical 


of gall-bladder pathology, to carry out a barium meal 
investigation of the alimentary tract. 

A married woman, aged 60, complained of indefinite pain in 
tipper abdomen. Slie gave a history of having had indigestion 
and a similar pain for .several years, but during the last few 
months tho symptoms had been more marhed. The surgeon who 
was called in expicssed the opinion that the symptoms were duo 
to gall-stones, and. arrangements were made for the removal of 
the gall-bladder. It had previously been decided to have an «-ray 
investigation, and this was proceeded with the day beforo 
operation. 

Tho preliminary radiograph showed a collection of large gall- 
stones in tho gall-bladder. A barium meal was given, and at 
tho eighth hour an irregularity of the first part of the descending 
colon was «eeu (see Fig. 3). This irregularity was still present 
at tho twelfth hour. Its appearance was eo suggestive of a small 
carcinoma that I ashed the surgeon if he would examine the area 
after he had removed the gall-bladder. This he did, and he found 
a carcinoma, wiiich be resected. The patient made a goed 
recovery. 

Similarly it is advisable to follow up the cholecystography 
with a barium meal even in those cases where the sym- 
ptoms strongly suggest a pathological condition of the gall- 
bladder- and tlie radiographs show a normal gall-bladder 
filling (see Fig. 5 ), for in one case in my series in which 
tho gall-bladder filled normally it was decided that operative 
measures were not indicated. No barium meal investigation 
was made. The patient went lionie and returned a fort- 
night later with a perforated duodenal ulcer from which 
she died. The posi-mortem examination revealed the ulcer 
with massive adhesions and a normal gall-bladder. 

On the otlier hand, two women patients, aged respectively 
32 and 38 , had complained of symptoms in the upper 
abdomen for several years, during which time they had 
been seen by several consultants, who had advised barium 
meal examinations ; these failed -to demonstrate any lesion. 
Their symptoms were attributed to neurasthenia- until a 
cholecystographic examination showed that neither gall- 
bladder filled. In both cases at operation gall-stones wei*Q 
found in the gall-bladder and cystic duct. 

AH gall-stones sbomx on preliminary radiographs contain 
calcium, and it is considered that these are usually asso- 
ciated with inflammation ; their demonstration • is there- 
iforo of great diagnostic value. In no case where gall- 
stones were shown has the- patient been entirely free from 
abdominal pain or discomfort. 

One patient sent to me for an x-ray examination of the urinary- 
tract. the left kidney being large and lender, gave no definite 
history of gall-stone colic, though the radiographs showed tlie 
gall-bladder to be full of stones containing calcium. Sbo was not 
operated upon because a large calculus occupied the pelvis and 
calyces of the riglit kidney, in addition to a stone in the pelvis 
of the enlarged and inflamed left kidney (Fig. 1). A few weeks 
afterwards slie had an acute attack of gall-stone colic, and those 
attacks were repeated so frequently during the next nine months 
that the patient was kept m bed. When they had ceased lier 
condition improved. By the end of the year slie -was able to do 
her housework. A further x-ray examination (Fig. 2) at this timo 
showed that though the kidney stones appeared identical with the 
previous radiographs only one small stone remained in the gall- 
bladder. A radiograph twelve months after tliis showed no gall- 
stones. She had put on 3 or 4 st. in weight, had no pain, and 
felt well. 

In another case in nhich calcium gall-stones were sbomi 
on preliminary I'adiography, a radiograph taken some 
months afterwards showed no gall-stones; the gall-bladder 
failed to fill with the dye, and at operation only a littlo 
grit was found in the chronically inflamed gall-bladder, 
the gall-stones having been passed, 

Tho details of the following case also demonstrate that 
the signs and symptoms may be atypical. 

The patient, who had had her right breast removed for 
earcinoma s few years previously, had an attack of agonizing 
pain in the left hypochondrium. The pain radiated through the 
left side of the thorax and doNSTi the left arm, and lasted with 
great severity for twenty-four hours. The surgeon who had 
removed the breast was called in, but he could find no evidence 
of secondary growth, and suggested that the pain was due to 
haemorrhage into a deep-seated secondaiy growth pressing upon 
nerves supplying the area. A radiograph was taken to demonstrate 
if possible the position and extent of the secondary deposits. The 
Jung fields were seen to be clear, and the heart and aorta -wero 
normal in size, shape, and position. The diaphragm moved 
normally on both sides. I suggested that tho pain might be duo 
to gall-stones, as I had recently seen several such cases of gall- 
stone colic in which all the symptoms had been on tho left side. 
A radiograph showed the gall-bladder to bo fuU of ^aU-sto«ea 
containing calcium, and isolated stones wero sho^yn in a linoi 
suggesting that they were in the cystic duct (seo Fig. 4). 


486 


March 24, 1928] 


fJrSl ! t ^ '''*”**^ solution of some nreoara- 

ons ga\e no donsor shadow than wn-tor wi *4^ 

adow, and tlio chemists have manufactured mtrer nm 

Tiiev*hov ' effects have Lcn seen 

Ti j have not been entirely eradicated. Using this dve 

lilTnr,T!h >’eactions— two in pr^ato pra^c- 

tiCG and three ,n hospital. For nearly two years I 8ar„o 

recently a patient within fiftem minutes of 
the injection showed all the signs of severe shoel“ 

of™|hft"m'er orrntiol a history 

had occurred in her lo^s *She t '''hich thrombosis 

gall-bladder area- 4o had hr%, TZ of paiu in the 

had di^nosed gaU-stones^ a“d fdv sod^ tS"' «.o""£Tlfi 
should bo removed. Owino to I , ■ ga|i-faladder 

passed off 


f:^;:l^ESU^ OF operation for RENAn njtr.nrrrxro . 


,, UnmsH 

ifEPICAl:, JOCRNAL 


oorma, i,,'^ 

feeling after an anaesthetic. ot to bo compared with tlio 

tion in manv cases proved that t^Jo a;-ray mvestiga- 

becn iKsokss. Fiirtlier tho r-riJZ- would have 

give a fairly accufato'opinion of enables ns to 

bladder, and a laparotomrray fa^fto d h " 6""- 

profaablo that the patient iho iC^ts to th„ 
very unfavourable subject for a ge L^l i° liTbo'tT ^ 
Inparo omy and so far it has beeif ieXnco t) at^/J ^ 

So^T, 

It will be seen, therefore, that while thm-o n,-o 
patients with symptoms so severe and urgent tInrT 
laparotomy is cssent al, there arc nafiedts witt * 
so indefinite and atypical th^'^’nV^S^r” 
do a laparotomy. In this latter’ type of case an 4 r-fv 
investigation of the gall-bladder will'Uten prove of mu6h 

References. 

- tliolccyslogrnpliy, Proc. Roy. Soc. 3Jctl., 1927, vol. .v.v. pp. 45-68. ' 


THE LATE RESULTS OF OPERATION 
FOR RENAL CALCULUS. 

HY 

J. F , DOBSON, M.S.Lond., F.R.C.S., 
professor of surgery ik tse umiversitv, and senior surgeon to 
TITE general infirmary AT LEEDS. “‘-"'OEON TO 

(TT^ifh Special Plate.) ' 

tbo last two years to 
ti ace the late history of all the cases of renal and m-eteral 
calculus upon which I have operated since the war Tho 
case-s investigated number about a hundred, and a very 
replied to inquiries. It would 


largo proportion have 


1 
24 
1 
1 
1 

operation 


2 

13 

3 


perhaps be useful first to give the results and then to 
discuss certain points of interest which arise. 

Pyclo-lithotomy (28 Cases). 

Unfcraced 

Perfectly satisfactory 

Corrip/aint of baclcacho {x ray negative) 

Toi r . 1 ” ba«“Rturia (investigation refused)!!! 
nate ffstula and nephrectomy (perfectly well since) 

One of the satisfactory cases died three years after 
from cancer of the larynx. •' ' 

Ifephro-Utliotomy (18 Cases). 

!Nofc traced 

Perfectly satisfactory 

Unsatisfactory 

Vrciero-Yithotomij (14 Cases), 

Perfectly satisfactory 

Well, but deposit in urine (not investiffatedi 
Packacho and shortness of breath (not investigated) 

Late fistula and nephrectomy (since perfectly Tvell) 

Ncjj/ircctomy (29 Cases). 

Perfectly satisfactory 

Well, but has developed disseminated sclerosis 

Well, but suffers from asthma 

Physically well, but melancholic 

Not able to work (not investigated) \\\ 

Well, but slight backache (not investigated) 

Nephrosiomy (7 Cases). 

Well and healed (6 years and 5 years) 

Well and healed (lived 9 years) 

Well, but slight watan' discharge (1 year) 

Fairly well, but still discharging and. has back- 
aclio (4 years) 

Fairly well, but some discharge 

Perinephric abscess and death two years later 

For Bilateral Bcnal Calculus (5 Cases). 

Perfectly well 

cloudy urine 

■to oiieration on second kidney refused 

cun*enco and fatal anuria four years later ... 


11 

1 

1 

1 


23 

1 

1 

1 

1 

2 


2 

1 

1 

1 

1 

1 


In one of the cases of pyelo-lithotoiny there was a 
consiclcrablo degree of liydronephiosis, yet four vears after- 
wards tho patient is perfectly w'ell. 

Tlio three imsatisfactory cases after uephro-Iithotomy are 
the following. 

Cajc 7.-Jn June, 1920 right ncphro-lithotomy was performed on 
a man for a single calculus in tho kidney. There was a small stone 
in tho correspon^ng ureter, which, however, was passed just before 
tho operation. He recovered satisfactorily and remained free from 
symptoms for a time. Some two years later a recurrence of 
calculus was found in both kidneys, and the patient died from 
acute haemorrhagic pancreatitis five yeai's aher the original 
operatiou. ® 

Case In 1920 uephro-lithot-omy was performed on a woman 
aged 48; one stone was removed from the right kidney. Six years 
later sho reported that she had had one or two attacks of haema- 
turia since her operation, and a;-ray examination revealed a single 
calculus in Wie pelvis of the left kidney and two or three calculi in 
tho right kidney. Owing to the unsatisfactory condition of tho 
patient further operative treatment was not thought advisable. 

6 'o 5 c 5.— a woman, aged 28, was operated upon in 1925. Three 
stones wore removed from the right kidney, one by an incision into 
tho pelvis and two through an incision through the lower calyx, 
which contained purulent urine. She was readmitted a year later 
with a discliarging sinus. A'-ray examination was negative. The 
kidney was explored and found to be so densely adherent to tli'e 
surrounding structures ^ that nephrostomy only was done. The 
patient's- general condition improved very much, and a subscapular 
nephrectomy has now been successfully performed. In this case 
primary nephrectomy would have been preferable to a conservative 
operation. 

Tho following three cases are remarkable. ’ 

Case In a woman who was operated upon in 1921 the left 
kidney contained multiple calculi; its function was very deficient. 
The kidney was explored and found to bo hydronephrotic.' Tliere 
was a large quantity of putty-like material in llie pelvis in addition 
to several calculi. It was thought desirable to perform nephrectomy, 
but tbo patient’s husband, a doctor, demurred. The patient made 
a good * recovery ; she had some pain and frequency for a time, 
but this disappeared after a course of vaccine treatment. Five 
years later she was perfectly well. There is, however, no informa- 
tion as to the functional capacity of the kidney that was operated on. 

Case a. man, admitted in 1919, had suffered for some months 

from attacks of typical renal colic on the left side. The pain com- 
menced in the loin and radiated downwards into the testicle and 
the this'll. Slight hacraaturia always accompanied the attacks of 
colic. A’-ray examination showed the renal areas to be free from 
calculus and demonstrated a shadow in the pelvis on the left side, 
but not in the normal course of the ureter. An opaque ureteral 
catheter was passed up the left ureter and was arrested; an x-ray 
photo'^rapii showed the catheter in contact with the shadow, which 
was therefore thought to bo a calculus impacted in an abnormally 
placed ureter. Unfortunately a pyelogram was not taken. Extra- 
peritoneal exploration of the ureter was performed, and the Ictt 
kidney was found just below the pelvic brim with a calculus m 
the pelvis, Nephro-lithotomy was performed. Seven years later 
tho patient was perfectly well. 

Case 6 . — A roan, aged 33, was admitted in 1924 with tho usual 
symptoms of a calculus in the left kidney. A skiagram showed Ino . 
shadow of a calculus, and no suspicion was entertained that "J*® 
in any way unusual. Cystoscopy showed adequate function of poin 
kidneys. Exposure was difficult, and the organ was found to be a 



TJAHCH 24, 1928] 


BESUDTS“ (.r' dPE^ATlbr/lFOR' EEKAL' CAIjCUEUS. 


f TsrDBmsB ■ 4R7 

L SlEDICAl, JOCSHlt * 


horseshoe kidney with the ureter in front and running downwards 
over the isthmus. The stone was in the pelvis and was extracted 
by an incision on the anterier surface. Two years later the patient 
was perfectly well and had gained 28 Ih. 

Case 7 In one instance a stout woman developed a fistula after 

uretero-lithotomy; a small stone was impacted in the ureter 3ust 
above - its entrance into the bladder wall. The kidney was not 
functioning, and a catheter was arrested by this stone. The ureter 
was exposed and found to bo very little dilated. An incision was 
made at the level of the pelvic brim and efiorts were made to 
extract the calculus, without avail. The bladder was displaced, 
the uterine artery tied, and the stone extracted through a direct 
incision; it was tightly gripped by the ureter. The wound healed. 
but three weeks later a fistula formed. A dilated and infected 
kidney was removed. The patient is now well. 

Occurrence. 

■ The after-history of seven cases was investigated where 
-the clinical symptoms were vei-y suggestive of calculus, but 
in which x-ray examination w'as negative. Six of these 
cases have had no further trouble, one has had one attack 
of colic since. 

In the' series of cases investigated a certain number are 
known definitely to have had recurrence of calculus. 


After pyelo-lilhotomy ' ... 
,, nephro-lithotomy. ... 
,, uretero-lithotomy ... 
,, ' nephreclo'my'' 

For bilateral calculus- 
After nephrostomy- 


Recurrences. 
0 
2 
0 
0 
1 
0 


Other cases presented symptoms which might possibly be 
due to recurrence of calculus. 

Possible 

Recurrences. 

After pyelo-lithotoray 2 

„ nephro-lithotomy 0 

„ uretero-lithotomy 2 

„ nephrectomy 3 

For bilateral calculus 1 

After nephrostomy 3 

n 

Two of these cases have been x-rayed with negative results. 

Tie have here definite and certain evidence that recur- 
rence occurred .in 3 cases, and w-e have in other 11 cases 
symptoms developing later on which might possibly be duo 
to recurrence. Unfortunately it has not been possible to 
investigate all these cases, but I have recently seen a 
womtin of 56, upon whom I operated fourteen years ago 
for bilateral renal'calculus ; she has been well until recently, 
hut now has recurrence in both kidneys. Further, in some 
of the cases operations had been performed previously for 
calculus. In two of the nephrectomy cases stones had been 
removed from the kidney by other surgeons many years 
previously. In one of the cases of nepbro-litbotomy a 
stone had been removed ten years previously by another 
surgeon. One case of renal calculus occurred in a patient 
for whom suprapubic lithotomy was done ten years 
previously. ' ' 

According to Braasch and Foulds evidence of recurrence 
of calculus is found in-10 per cent, of cases after operation, 
the incidence of recurrence being higher after nephro- 
lithotomy than after pyelo-lithotomy. Undoubtedly some 

recurrences nro due to small stones remaining un- 
detected at tlie first operation. 

According to Ro\*sing recurrence is due to infection witli 
urea-decomposing organisms. Urinary fistula following 
operation even of sliort duration is the common cause of 
this infection. He states that pyelo-lithotomy, since it 
frequently causes a fistula, is contraindicated, and nephro- 
lithotomy without drainage should be performed instead. 
It IS evident that recurrence of calculus is a veiy serious 
danger, and stones left behind at operation are no doubt 
in part responsible. This risk' will he largely eliminated 
by radiography of the kidney during operation. 

Bovsing s views on the risk of a staphylococcal infection 
from a temporary urinary fistula are no doubt correct, 
though I imagine few surgeons would agree that even a 
^mporary leak is at all common after pyelo-lithotomv. 
Ilather IS it thought that recurrence is more likely after 
nephro-lithotomy than after pyelo-lithotomy. The latter 
operation IS usually done for single, comparativelv small 
atones, with a kidney little damased and not seriously 


infected. The former operation is performed in cases of 
multiple or largo calculi, with some or even a cousiderahla 
hydi-onephrosis, or willi an infection of more , or less 
severity. The risk of recurrence being less after pyelo- 
lithotomy than after nephi-o-lithotomy indicates clearly the 
advantage of removing a calculus before it has had time 
to iiroduce those changes in the kidney which favour 
recurrence. 

In .addition to the risk of recurrence of calculus in the 
kidnej’. there are other changes which sometimes occur at a 
late stage after conservative operations for calculus. In 
this series of cases nephrectomy for pyonephrosis (with no 
recurrence of calculus) .was performed in ;two cases — in 
one four years after removal of a stone from the ureter, 
and in the other eighteen years after a nephro-lithotomy; 
in -another- case- nephrostomy was performed for a pyo- 
nephrosis one j-ear after nephro-lithotomy. 

The figures above quoted show clearly that although the 
results of operations for .renal calculi are. on the whole 
exceedingly good, the risk of recurrence' is such that every 
effort ought to he made when the opportunity is .present 
to adopt. such measures as may be possible to avoid this 
unsatisfactory sequel. In this connexion we must consider 
first the diagnosis of calculi, and secondly, the methods 
practised for their removal. 

DiAGXOSIS of EenaI. C.ALCTrLUS. 

The diagnosis of renal calculus rests very largely on the 
results of the x-ray examination. 

Cases with Typical Bistory, Colic, Hacmaturia, etc. 

In the majority of cases the results of x-ray examina- 
tion are conclusive as to the presence or absence of calculus, 
though sometimes a negative finding is inaccurate. It has 
happened to me on one or two occasions to see a ealouius 
in the bladder which had not been recognized by tho 
radiologist; it is reasonable to assume that a similar stone 
in the kidney might escape detection. It has also happened 
that when an x-ray examination has been negative patients 
have subsequently passed a calculus. On a few occasions 
when the symptoms were very suggestive and tho x-ray 
examination negative I have taken a pyelograih and have 
repeated the x-ra'y examination on the following day, 
hoping that some of the sodium bromide would have been 
absorbed by a calculus, which would then throw a shadow. 
I have not as yet had such a case. In such cases resort 
should be had to pyelography; a lighter area may indicate 
• the presence of a stone, and in any case it will probably 
demonstrate the cause of the patient’s pain— such as a 
small hydroiiephiosis or a kinked ureter, etc. 

I Cases with Atypical Symptoms. 

There are a number of patients with renal calculus who 
suffer very little- pain, merely a vague aching in the hack, 
without such obvious changes in the urine • as to driva 
them to seek advice. An x-ray examination of the urinary 
tract should not be omitted as part of the routine investi- 
gation of cases of indefinite backache, particularly if there 
are any changes in the urine. Tn some cases the calculi 
are absolutely latent, and may only be detected accidentally. 
There are cases of haematuria where pain is negligible. 
A complete x-ray investigation of the whole urinary tract 
is an essential step in the examination of a case of 
haematuria. Birailarly I have seen cases of calculous 
pyonephrosis with large quantities of pus in the urine 
where the history of pain is of the vaguest. 

The Interpretation of the X-ray Photograph. 

In this matter the practice of different surgeons varies; 
some prefer their own interpretation, some attach more 
importance to the opinion of tho radiologist. My own 
practice is to accept the view of the radiologist, though 
I see all films myself and form my own opinion, usually 
before seeing his report. Consultation between the two 
persons concerned is necessaiy in any case of doubt. As 
to pyelograms I prefer my own interpretation. It is neces- 
sary to remember that the x-ray examination is only a part, 
though a most important Jiart, of the complete investigation 
of a case of suspected reuai calculus. 


438 Maech 24, 1928] LATE BBSXJLTS OP OPERATION POR RENAL OAtiOtJEXJS. 


[ XnK Onmac 
UpDICAl, JoORKlt 


■ Occasionallj mistakes may bo made as to tho , number 
of stones in the kidney. Sometimes two overlapping stones 
aro regarded ns one, or two partially overlapping stones 
as one largo stone. On one occasion tho a:-ray film indicated 
tho preseuco of two calculi in tho pelvis of tho kidney, 
and at tho operation only one calculus was found ; only 
after considerable search was it discovered that the second 
shadow was duo to a deposit in the twelfth rib, which had 
been removed to facilitate tho exposiiro of the kidney. The 
shadow was dciiioustrated by K-raying tho portion of rib 
removed. 

There can he no doubt of tho value of profile radio- 
graphy in tho diagnosis of renal calculus, and it should 
bo done as a routine. 

X-ray riiotographij during Operations on the Kidney. 

This method of ensuring tho removal of all fragments 
.of calculi in tho kidney I have used only in two cases, but 
they were both very instructive, and with a bettor apparatus 
(tho one used was a makeshift) and more experience of tho 
method it will undoubtedly bo of groat value. We did not 
attempt to screen tho exposed kidnej', but took two or three 
films as soon as the kidney was exposed. In an ordinai-y 
light operating theatre it must be a matter of extremo 
difficulty to accommodate tho eyesight sufficiently to obtain 
a satisfactory view with tho screen. The main difficulty 
was in withdrawing tho kidney sufficiently to obtain a 
film which did not show tho edges of tho wound. However, 
as this merely interferes with tho shadow of tho kidney 
pelvis, it is not so very important. Tho calculi which aro 
most likely to bo overlooked aro small bodies in tho calyces 
and the substance of tho kidney. A valuable feature of this 
method is that it U’ill onahlo us to say that indofinito 
shadows in the kidney area, associated with a definite 
calculus and themselves simulating calculi, are extra-renal. 

In the first case x-ra}' examination previous to operation 
showed a calculus in tho pelvis of the right kidney and a 
small shadow in the kidney area. The right kidney was 
exposed and- an x-ray photograph was taken; this showed 
tho stone present in the pelvis, with some other small 
shadows also in tho pelvis, but nono in tho substance of 
the kidne}’. Tho pelvis was incised, and a largo stono and 
two or three small gritty fragments wore removed. 

In tho second case x-ray examination showed a calculus 
in tho right kidney with some small additional shadows in 
the kidney area. Tho kidney was exposed and a stono 
felt in tho pelvis, the skiagram of tho exposed kidney ' 
showing no calculus in the kidney substance. Pyelolitho- 
tomy was performed. 

There may on occasions be considerable difficulty in dis- 
tinguishing between tho shadow of an enlarged gland and 
that' of a renal or ureteral stone. Tho following case is 
an example. 


clinical features of tho case, to determine whether nephreo- 
tomy, a nephrostomy, or nephrostomy with secondary 
nephrectomy is indicated. 

Advanced renal changes may, howex'er, he present in the 
absence ^of a palpable kidney. In many cases whom a 
calculus in tho pelvis or ureter has been in position for some 
time some degree of hydronephrosis is present. It is impor- 
tant not only to .ascertain tho extent to which the' kidney 
tissue has atrophied, but also to form some estimation of 
tho degree of infection present. 

Confining ourselves for the present to the comsideratiou 
of cases of unilateral calculus, and to cases where radio- 
graphy shows a shadow in tho kidney area and no sugges- 
tion of a calculu's in tho ureter, wo wish to determine by 
cystoscopic methods the jn'esenco or absence of a hydro- 
nephrosis, and to ascertain ns fur as possible the extent of 
tho infection which has occurred. 

Hydronephrosis can ho recognized by pyelography. Is it 
desirable to take a pyclogram in every ease of venal 
calculus? In practice it is not possible, but in a tolerant 
patient it should bo done. Tho advantage of a preliininai-y 
pyelography is that it may enable the surgeon to determine 
before operating whether a nopbrt ctomy is likely . to bo 
necessary. Tho alternative is to decide this point when 
tho Icidnoy is exposed, it having been previously ascertained 
that the second kidney is efficient. 


Determination of the Functional Capacity of the 
Affected Kidney. 

This may bo done by relying on tho cvid.'uco obtained 
after an injection of indigo-carmine. In some cases this 
may bo sufficient. A more scientifically sati.sfactoi-y metiiod 
is to catheterize tho ureter, take tho phenolsuljdioiie- 
nhthaloin pvoofj and collect a spooimon of mine from tho 
affected side for chemical and bacteriological examination. 

The presence and capacity of the second kidney can bo 
ascertained by cystoscopy after an injection of indigo- 
carmine With an adequate excretion of the dye, and in 
normal time, the presence of tho second kidney niay bo 
accented. Tho more completely satisfactory proceeding is 
to cathetcrizo tho ureter, take tho pliciidlsulphonophthaloiii 
proof have a chemical and bacteriological exaiiiiiiatioii of 

the urine, and perhaps take a pyclogram. , la 1 

T^would not Ill-go that these investigations should be 
a routine proceeding. There is no doubt that some patients 
beconio very Testivo under repeated and uiicomfortablo 
investigations, and sometimes a necessai^ operation is 
declined Tho surgeon should not allow his urological 
curiosity to outweigh tho dictates of common sense. On 
tho Sr hand, tho man who would explore a kidney for 
calculus without previously ascertaining, not niovely tho 
nreseLc but something of tho functional capacity of the 
Folnd kidney, is exposing his patient to very uiineccssaiy 


Case S . — A woman was admitted to hospital in 1925 complaining 
of renal pain. Tho urine contained a little albumin and a few 
pus cells. The j;-ray photograph showed a shadow which was 
thought to bo a calculus impacted in the upper part of tho ureter 
IFig. 1). A pyelogram (Fig. 2} was taken; this showed a littlo 
liydronephrosis with some dilatation of tlio ureter down to the 
level of the shadow, which was clear of tho ureter. Exploration 
revealed a calcareous gland with adhesions and fibrous thickening 
obstructing tlie ureter. The patient was completely relieved of her 
symptoms by freeing tho ureter. 

In cases such as this profile radiography with tho opaque 
catheter in position, and perhaps a pyelogram, will be a 
great help in diagnosis. 


DnCXOSI.S OF ChAXGES in HidNEV and tTllETEn CAUSED 
BY THE Presence or Calcueus. 

It is not sufficient merely to recognize the presence and 
the number of calculi ; the extent to wdiicb tlio function of 
tlio kidney has been disturbed and the presence of seeon- 
daiT destriictivo changes must also be ascertained. 

It may be obvious that a pyoncphiosis has developed; 
tho presence of a tumour, a largo quantity of pus in tho 
urine, tho absence of indigo-carinino from tlio affected 
kidney on cystoscopy, together with general symptoms, 
niako tho diagnosis sufficiently obvious. It 
remains to ascertain the presence of tho second kidiicj, to 
prove its functional capacity, and, considering all tlio | 


‘?^t ns assume that we have determined the presence of 
ratnffis the pelvis of the kidney, with some degree of 
.rlVnuenhrosis and some impairment of kidney function. 

ht to ascertain, if possible, the presence and degree 
MnTe^l^oirof that H It is’voi^ desirahle to do this 

- with .1 considerablo degree of hydronephrosis and a 
infection recurrence of calculus formation is lathor 
hull and a priniaiy nephrectomy may ho preferablo 
tt^ser^ativo'operaLn.'lt is not easy to doterm.no 
•o. tho amount of pus, the profusion of growth of 
'xmiq and the extent of impairment of renal function 
bo' taken into account. In some cases the dcsii- 
fili^ or othenviso of ncplirectomy can only bo <lntcrimnod 

tim oner-ating table. It must be remembered that a 

dnL which is functioning badly may recover considerably, 
ter tlio stone is removed. 

TJukteral Calculus?. 

vs 

in nrnta- lmvl"l! 

tn ..nortnin i. P— 

tho cliangcs in tlio kidney. The nroter maj 


Mabch s 4 , 1928 ] 


LATE EESULTS OP OPEEATION 'POK KENAL CALCULUS. 


the ureteral catheter is arrested hj' the stone. In such 
case one can carry investigation no further than to ascer- 
tain the facts about the second kidney . It is very desirable, 
however, to ascertain the pi’csence or absence of dilata- 
tion of the ureter above the calculus, and in all cases an' 
attempt should be made to take a uretevo-pyelogram. 

It is possible that with a calculus in the ureter there 
mav also be an obvious pyonephrosis. This ])resents no 
difficulties in diagnosis. The problem is to ascertain in the 
less advauced pase to what extent the kidnej’ tissue has 
been distended'or destroyed, and what are the prospects of 
vecoverv of the kidney after the ureteral obstruction is 
removed, or what are the chances of recurrence of calculus. 
The surgeon will not hero have the advantage of exposing 
the kidney at the operation, at any rate in cases where the 
stone is in the pelvic ureter. In the absence of proof it is 
generally wise to extract the stone and await events. If | 
recurrence takes place or pyuria is peisistcnt a secondai'y 
hepluectomy maj’ be done. 

Choice op Opeh.wion. 

lYhether surgeons are too ready to practise conservative 
operations and too unwilling to remove a doubtful kidney 
is arguable. The risk of recurrence being bilateral must 
always be borne in mind, and if there is a recurrence of 
calculi the patient is better off with two damaged kidneys 
containing stones than with a single such kidney. On the 
other hand, is an infected and somewhat dilated kidney, 
one likely to bo the seat of a recurrence, a factor in 
inducing calculus formation in the second kidney.'’ 

Exposure of the Kidney. 

The retroperitoneal route is the usual, and the choice 
of incision is immaterial. The surgeon need not fear to 
divide 'muscles, as hernia is extremely rare, and he should 
never hesitate to remove the last rib. The kidney should 
bo drawn out and handled as gently as possible. 

Fyclo-Uthotomy. 

A sufficiently large incision should be made in the pelvis, 
not encroaching on the ureter. The stone should be 
extracted with the utmost gentleness; large forceps should 
never bo passed into the pelvis and the stone forcibly 
removed. By the use of small forcops and little levers even 
a considerable stone can be extracted without bruising tbe 
edges of the lyound. The wound in the pelvis is sutured 
whenever iiossiblo, and that is iiractically always, and in 
addition the thickened fatty tissue is sutured in place as 
a reinforcement. 

I have little experience of extended pyelo-lithotomy, 
where the incision in the pelvis is carried on into tho 
substance of the kidney. It may involve ligature of a 
retrojielvic artery, which might devitalize a considerable 
area of kidney tissue. 


Kepliro-Utliotomy. 

inds is necessai’y usually in cases of largo calculus or o 
•multiple calculi. The incision in tho kidnev should bo a 
■small as possible, having due regard to tho' fact that th 
calculus or calculi must be removed intact and not ii 
lagments, and tho kidney tissue must not be lacerated 
At one stage m his career my late chief, Mr. Harr 
Littlcwood, was m the habit of splitting the kidney froii 
end to end for the proper exposure and extraction o 
surprisingly few after-haemorrhages 
but the functional capacitj’ of a kidney so treated mus 
have been very seriously diminished. 

The discovery and removal of small calculi in one of th 
calyces may be extremely difficult. In one case, wher 
there was a calculus 111 the pelvis and another small shadoi 
m the kidney area, after the first stone was removed b 
pyclotomy the second supposed calculus could not b 
detected even by incision of the kidnev. A stream c 
fund from the nozzle of a syringe passed through th 
kidney incision washed a small calculus into the pelvi> 
whence it was easily removed. Possiblv it would bo we' 
in all cases to wash out the pelvis and ealvees with 
stream of sterile water under pressure to remoVe any tin 
.calculi a Inch might bo left behind. ova 


[ 


Tirr-IiBrnba - - 
Medical JomxAL 


489 


During tho course of a nephro-lithotomy one is occa- 
sionally called upon to decide whether it is really wise to 
attempt to preserve the kidney. 

Kephrectomy. 

Simple as it is in many cases, nephrectomy may be ■ 
imjiossiblo with an adherent pyoiiephrosi.s. A sufficient 
cxiiosure of the kidney, deliberation, and the greatest caro 
in recognizing and separating the various important 
structures which are adherent — the inferior vena cava, the 
duodenum, the colon — are essential. I prefer to separate 
the pelvis and ureter from tho vessels, fo tie veins and 
arteries separately, and to divide tho ureter at a low level 
as tho last step. It is important not to tear the pelvis, 
and I never use a largo clamp on the pedicle if it can 
possibly be avoided. One cause of a persistent sinus after 
nephrectomy is the inclusion of a portion of tho pelvis in 
the pedicle, and this is favoured hy the uso of a clamp. 
An cxtracapsular nephrectomy is far preferable to a sub- 
capsular, as in the latter ease it is not easy to separate 
the vessels from the jiclvis. In some cases, however, tho 
Eubcapsiilar operation is the only possible method. 

Nephrectomy is possible in the majority of cases of 
calculous jiyoiiejihrosis. There are, however, definite 
contraindications. AVhere iiynria has been present for 
years, and the patient is anaemic, feeble, and emaciated, a 
prolonged and difficult operation is attended with con- 
siderable risk. 

-In one case a large adherent pyonephrosis was removed 
intact with great difficulty; the patient made a veiw slow 
recovery, remainiiig feeble and anaemic for some months, 
ultimately, however, regaining her health. The tumour 
was not examined for some time after the operation, and 
it was then found that the suprarenal capsule, firmly 
adherent to and indistinguishable on the surface of the 
kidney, had also been removed. 

I have not wounded tho inferior vena cava in performing 
nephrectomy for a calculous pyonephrosis, but have done 
so twice in doing . nephrectomy for other conditions. In 
both cases the vessel was controlled by forceps left in place, 
and recovery occurred without incident and without any 
subsequent ill effects. 

Kephrosfomy Secondary A'cphrceiomy. 

This is sometimes satisfactory, though in the majority 
of cases probably a primary nephrectomy would bo prefer- 
able. Nephrostomy alone has its dangers, and a secondary 
nephrectomy, nsiinlly a subcapsular ojieration, may be 
extremely difficult. • . ’ 


Kephrostomy Alone. 

■ On occasions this is tho only proceeding which is per- 
missible, usimlly because of the general condition of tho 
patient. The kidney js explored and incised with as little 
disturbance of the perirenal fatty tissue as possible; tho 
calculus or calculi, are extracted, any septa which prevent 
drainage are broken down (it is not advisable to do this 
with the knife owing to. the risk of haemorrhage), and 
provision is made for drainage and antiseptic instillation. 
'3 think the late results of these cases are better than is 
commonly thought. 

The following arc illustrations. 

Case D.~-A lady, aged 67, bad suffered for years from backache 
and pyuria; a large pyonephrosis had developed, with rapid 
deterioration of health. She was too ill to be removed even for 
an x-ray examination. The kidnev was exposed, a large calculus 
measuring 3 in. by 4 in. was extracted, and the kidnej* drained. 
The wound healed completely in a very short time, and the 
patient lived for nine veal's in reasonable health and comfort. 

Case JO . — ''Anotber case in which even less was done. A lad\' of 
76, who suffered from rheumatism and had just undergone two 
operations for glaucoma, dc\ eloped a large pyonephrosis. Under 
a local anaesthetic the kidney was incised and drained, no attempt 
being made to find a stone. She is now, a year later, in reason- 
ably good health, with a slight pyo-urinarj* discharge wluch gives 
little trouble. 

Case 11 . — A woman, aged 53, was admitted with a pyonephrosis, 
which was drained. No calculus was detected at the time, but 
subsequent x-ray examination showed a small calculus in the 
lower part of the pelvis of the kidney. Nephrectomy was declined. 
Tho wound closed, but re-discharged two months later. She had 
no further trouble for eighteen monlhs, wlicn it discharged 
again for a period* of sixteen months. Since then it has not 



490 


IITaUCH 1928]' 


bate^es^ts of' ofera kon fob kenak CADOCLUS. 


gall-stones. ajtenvanis). She is. iiowever, troubled with 

nephrosis wHli 'mStiple "SiTcuh^’ Kenfirosl m°*" " pyo- 

the calculi removed. and 

remaining. Tlio 
three years 

Case 13.~A ^voman ngod 34, had many calculi in a largo pyo- 
ej. She •vvas too ill for ncnhrrrfnmT» rr\.J* 


to do some honseivork. but the ;.ound ivas"‘dis'clmgh.g.“"‘* 

r;,l’rSs .^^h7™v“c«. ^ 

iftor'o some patients may recover perfoctlv 

aftei a simple nephro.stomy or may bo loft iviUi a sinus 
M causes little trouble; but in all reasonably pronZZ 
cases p. secondary nephrectomy should bo done. ^ 

Extraction of Calculi in the Ureter hj Cystoscopic 
Procedures. 

AnToWen '^‘=0“ practised extensivaly in 

Amoiica of lato years, and varying reports are given 
Accoiding to Peacock, ureteral dilatation was sucemfiii 
It inducing the passage of the calculus in 50 per cent of 
cases so treated. Various procedures bavo been recom- 
mended— for example, passage of a ureteral entbeter alone- 
dilatation of ureter by passing catheters of, varying size or 
by dilating forceps; dilatation and injection of olive -oil 

and other substances; enlargement of ureteral orifice 

(1) by diathermy, (2) by operating cyslosconic scissors 
subsequent passage of catheter, and injection of oil ’ 

My pei;sonal experience of these methods is eompara- 

at the oiifice of the ureter was persuaded into tlio bladde? 
by passing a Luys s cystoscopo and by incising the lower 
uid of the iiretcv on to the stone. In another the ureteral 

urit calculus. In another case the 

uieteral orifice was enlarged with the diathermy terminal 
and oil inj^ected; this was followed by the passage of the 
of oH Sufficed another case mere dilatation and injection 

There can he no doubt that these cystoscopic methods are 
of great value. Probably some of the stones which pass 
after such instrumentation would have passed in any cLe • 
but some would remain impacted, would increase in size’ 
and induce destructive changes in tiie corresponding kidney' 

I have no experience of division of the lower end of tlio 
ureter with the cystoscopic scissors. The objection to this 
would appear to he that haemorrhage would occur and 
obscure the field. Enlargement of tlie orifice by the dia- 
thermy terminal has not this disadvantage, but is not 
Without Its dangers. AIarion> reports a case in which 
stenosis m the orifice occurred, the calculus was not passed 
and the kidney, hecoming pyonephrotic, had to he reinoved’ 
Recently I have had a case in which a small triangular 
calculus was impacted at tlio lower end of the left ureter 
the pointed tip being visible through the cystoscopo’ 
Enlargement of the orifice by tho diathermy terminal’ 
dilatation, and injection of oil were unsucee.ssfiil, and trans^ 
vesical uretero-iitliotomy had to be performed. ’ 

On tho whole, probably dilatation of the orifice with injec- 
tion of oil will he as cfficacions a.s any other procedure 
In tho case of small calculi this ought to be done before 
uietero-Iithoiomy is considered. 


L ilKDrCAt JOL’BXH 


Urcfcro-lithofomy. 

Various methods of approaching the pelvic portion of the 
ureter are practised. I prefer tlio oxtrapei itoiieal, outer 
border of the rectus incision (Battle). I liave not usually 
found it necessary to tie the dccji epigastric vessels. When 
tbo meter is dilated it maj- bo incised at any convenient 
^ forceps passed down; the stone is 

tur, without difBculfy. But in cases where 

ui'e.er is not appreciably dilated removal is not so easy. 


passed down Tho'^urete’from^an''^*'^^'^’^ “ 
pelvic brim has failed ft e ur“f" f ‘'f tl>e 

a lower level, porhans’ afte, t oxpbsed at 

the stono extracted^ hy a direJlf ^ artery, and 

impaction. In niost iust-.^ .incision at the scat of 
factory, hut in one case a fisTuh'fo s»tis- 

nophrcctomy became necessary «■ secondary 

. P»-M. t. •M.-l 

Stem is impacted close to’the^wiJl‘of‘''th 
are exceedingly difficult md in s ^ bladder, which 
tomy and cj-stoUly bt’been clon:?'"^'' 
the hl.addor was opened a No 1 urethml after 

down through thi '""1 

tlio stono into the blaclclor. The tin \vnc +1 
pulled downwards, tho conical upper end of” and 

drawing down tho stono to'the oS, mLVts S 
extracted by an incision in tho bladder wall 

Operation for Bilateral Benal Calculus. 

A number of cases of bilateral renal calculus have been 
seen and some have been operated upon. The most satis- 
factory cases are those in which there is a single calculus 
in the pelvis of each kidney, with little dilatation of tho 
kidney and only a rnild degree of infection. When tho 
calculi arc multiple it is always a question whether an 
operation is worth while I have at tho present moment 
four such eases under observation; two' (both recurrences 
after previous operation, one of my own, oiio of another 
surgeon) eoiilcl not possibly survive any further inter- 
ference, and m the other two the symptoms are very slight 
and I am disinclined to interfere. Tho operations shohld 
bo done at two sittings, and it is a question which kidney 
should bo attacked first. I prefer to do the better-kidney 
first. 

Tho two following cases are of interest, the first 
possessing a wandering calculus and the second being an 
example of recurrence. 

Case IC: Wandering Calculus.— X woman, aged 33, was admitted 
with a history of right renal colic; no pain in left side. The first 
x-ray photograph taken (Fig. 3) showed a calculus in the pelvis 
of tho left kidney and a shadow on the right side in the course 
of tho ureter, the significance of which, however, was not realized 
at tbo time. The second radiograph (Fig. 4). however, showed a 
caJculus in tho pelvis of the right kidney in addition to tho one 
on tho left side. Further x-ray e.x8mination showed that tlio 
calculus was sometimes in .the ureter and sometimes in.the kidney. 

A pyelogram (Fig. 5) taken of the right side showed a considerablo 
degree of dilatation both of the, ureter and of the pelvis. Left ' 
pyelo-Iithotoroy was performed, and three weeks later the right 
kidney was exposed : (he kidney was enlarged, the pelvis and 
ureter dilated. The calculus, found in the ureter, was pushed up 
info the pelvis and removed. A year later the patient w-as very 
well, but had slight pain and occasionally tho urine was rather 
cloudy, with a sediment. 

Case iy : 'Uecurrvnce.—X woman of 50 with several calculi in 
both kidneys. Lett nephro-lithotomy was performed, four stones 
beim' removed from the lower pole of the left kidney. 


heim' removed Irom cue lower pole or tne left kidney. Three 
months later right nephrectomy was done for a pyonephrosis con- 
taining five calculi. A year later the patient was readmitted with 
calculous anuria,' and a small stone was removed from the ureter. 
The patient recovered, but died a year later at home from anuria. 

In this case perhaps palliative treatment would have been 
preferable. 

The Treatment of Benal or Ureteral Caleuhis Complicated 
hy Other Lesions of the Urinary Tract Demanding 
Operation. 

' Alarion- is of tho opinion that in snch cases the renal 
calculus slinukl bo reniovecl first, in view of tbe risk of an 
infection developing in tho damaged kidney during con- 
valcscenco from tho operation on the other lesion. In cases 
of lenal calculus complicated by the presence of a stono 
in tbo bladder I liavo removed tbo vesical calculus first 
and tbo renal stone at a later date. 

There have been it fen' o.vamples of tho association of 
renal calculus and ureteral calculus on the same side. It 
is sometimes difficult to decide exactly what to do. In 
cases irhero the kidney is badly infected and dil.itcd a 
nephrectomy is indicated. According to Alarion it is not 
nocossaiy in snch cases to remove tlio ureteral stone, as 
this will remain latent. I have had one such case in which 
the ureteral stono was passed some time after tlio 
nephrectomy. In another case the patient passed tho 


PERNICIOUS anaemia: and the eiter diet. 


r TiiE EninsB 40*1 

L Medical Journal 


March 24, 19:8] 


ureteral talc-ulus a feev hours before the time fixed for his 
operation. In another case the renal stone mas removed 
from the pelvis and olive oil injected domn the ureter by 
a class syringe, the nozzle of mhich mas passed through the 
pyclotoniv incision and fitted snugly into the upper part of 
the ureter. The ureter became distended and this sub- 
sided suddenly. The cystoscope mas passed at the end of 
the operation and a small calculus mas seen, in the bladder 
lying in a pool of oil. This mas passed a fern days later. 

' I have endeavoured to give, as accurately as possible, 
the late results of these operations for renal calculus. It 
is very difficult indeed to obtain absolute accuracy of state- 
ment on .such a subject unless one has the advantage of a 
large staff to carry out the necessary. inquiries and to make 
the necessary investigations. There is, homever, sufficient 
evidenee to shorn that the frequency of recurrence after 
operations for renal calculus is such that it demands very 
serious investigation. 

REFEnrXCES. 

r Lew : JouruaJ d'VroJogic. xviii, Ko. 1, p. 1. - Itarion : Ibid., xxi. 

Xo. 1, 'p. bl. 


PERNICIOUS ANAEMIA AND THE 
LINER DIET. 

BT 

C. F. T. EAST, M.A,,.M.D.Oxox., F.R.C.P.Loxd., 

^jr:Tiop. PHYSICIAN, king’s college hospital; physician, woolwich 

* "WAR MEMORIAL HOSPITAL. 

Tue follou'ing i.? an account of tlie liistoi’v of three patients 
treated bv the liver diet introduced by Minot and Murphy* 
in 1926. Recent accounts from all sides are shoiving the 
good i*esults obtained in promoting remissions in cases 
suffering from severe relapses. These three patients have 
been under treatment for a year or more. The cases are 
recorded in order to show what may happen afterwards. 


. Case r. 

• A man,^ aged 45, had an attack of gastro-cntcritis in November, 
192o, which lasted several weeks. Six montlis later his tongue 
became sore, and during the summer bis throat and tongue were 
ren* sore from time to time. Early in the autumn the nausea 
?ooe returned, and when admitted to hospital in October, 

1926, lie presented the topical picture of pernicious anaemia. His 
mother had 'had anaemia for a long time, and eventually died 
from it ; her sister was definitely known to have died of pernicious 
.anaemia. 

I .showed a characteristic blood count. The blood 

'iminiDin vras nigh. There was complete achlorhydria, A haemo- 
-I^ic streptococcus was^ isolated from the duodenal contents, bui 
It could not be found in the faeces. From the first he was giver 
^**'1 hydrochloric acid iu large doses, as recommended bj 

After a month in hospital he was given liver : owing to hh 
• gastric symptoms he had great difficulty in taking it, and the 
ingenuity of the nursing staff was fully exercised in making il 
palatable. In one form or another he managed to take nboul 
o ounces a day. An autogenous vaccine from the Imemolvtu 
streptococcus was also administered. 

The improvement in the blood picture began at once, before 
given: this continued afterwards, especiallv 
^ haemoglobin. Shortly after this improvement begar 
.the haemolytic process abated and the blood bilirubin content fell 
fniVif reach normal limits. After leaAdug hospital he kepi 

work “ble to return U 

tho toiiinio a relapse began, and the soreness ol 
iMs live? returned. As soon as the nausea wa; 

was; Konn ^^^cthcr with acid and arsenic. There 

trlobin Th? "ortbl.v in the haemo 

test fell to estimated by the van den BergI 

S’orih X tiZ iVfN’i. improved less satA 

•trhich he had had irSptt®?' of liver similar to thal 


. A woman, aged 51, had had^l^'i.S' of diarrhoea for three vea 

las? frr“mSn?£’slm“?.ad°V‘^f ® odmiiion Po^t 

a-af complete aekorhydria. "fe%cTth Tr^^sltk IZelb 

5,n?,s Er=sr,„5 A. 


three limes a week. The red cells have never returned to a higher 
level than 3^ million, but the haemoglobin has kept^ up to about 
80 per cent. There has been a normal level of bilirubin in the 
blood for nearly a year. Before sbe went out the heart returned 
to normal size, and the spleen could no longer be felt. She has 
now felt very well for fifteen months, and has been able to do 
her housework. 

Case m. 

A w'oman, aged 33, became ill three years prior to admission, 
the symptoms being mainly dyspeptic. ^ After a year she began 
to haVc attacks of diarrhoea, and vomiting became frequent; at 
times her tongue was sore. A year later her appendix was 
removed, but without benefit. The anaemia gradually^ started 
about this time; for four months she had noticed jaundice. 
Lately her ankles had become swollen, and she had suffered much 
from shortness of breath. Her mother had died of pernicious 
anaemia^ - . ^ ^ 

On admission to hospital she was seriously ill; the tongue was 
sore, and she was markedly yellow. The heart was very feeble 
and much enlarged, a gallop rhythm being audible over the mitral 
area. The electro-cardiogram showed heart-block, with ’ a P— R 
interval. of 0.32 second. There was a good deal of numbness and 
tingling of the hands and feet. Complete achlorhydria was present, 
and from the duodenum a haemolytic streptococcus was grown; 
this was not present in the faeces. A vaccine prepared from this 
organism was given. 

At first a blood transfusion was given and she was put on 
arsenic and hydrochloric acid. Improvement in the anaemia began 
at once, and' was most noticeable in the haemoglobin. At the 
samo lime there was a fall in the blood bilirxibm,^ so that, on 
leaving hospital, it was well below the normal. Liver was not 
given at first as she could not take it; later, when her stomach 
was less troublesome, she started the diet, and has kept rigidly 
to it ever since — a period of ten months. She . takes at least 
4 ounces of liver three times a week, but lately has been using 
an equivalent amount of a proprietary preparation. As soon as 
the anaemia improved her heart returned to normal, and the 
heart-block, disappeared. She left hospital last' MarcK and has 
since kept very well. The red cells keep about 5^ million 
per c.mm., but the haemoglobin is maintained ^ at a High level. 

! Haemolysis has not risen above the normal limit. 

During the last ten months she has bad hydrochloric acid with 
her meals, and courses of arsenic from time to time. There has 
I been no increase in the sensory symptoms. 

CoiAniENTS. 

The At^minisfration of Liver, 

Various methods must be tried if the patient cannot take 
the liver easily. A paste in a sandwich of dry bread is 
often satisfactoi*y. Sometimes the taste can be covered 
by the use of one of the strongly flavoured sauces; it goes 
fairly well with marmite. Small lightly boiled lumps are 
taken fairly easily, or it may bo eaten with lemon juice or 
lettuce. 

The Aftcr-Treatme'ni. 

These three cases are not of much value in illustrating 
the effects of the liver diet in the acute stages. It is un- 
fortunate that there is such difficulty in getting patients 
to take liver ithon the gastric sjTnptoms are severe. 

As to the value of liver in the after-treatment, when 
once a remission has been secured, Cases ii and in bear out 
the claims of Minot and Alurphy,- who have had patients 
on liver for much longer periods than eighteen months 
without relapse. Tlie first patient seems to have relapsed 
because for .some months lie neglected to take any pre- 
cautions, The rather poor success subsequently seems to 
show that in the later relapses the treatment may be less 
effective. The after-treatment is unquestionably e^remely 
important; onco pernicious anaemia, always pernicious 
anaemia,” potentially at any rate. If, as Hurst lias .so 
often suggested, the achlorhydria is the weak point in the 
patienVs defences, it is most important for the patient to 
continue taking acid. It is true that difficulties with this 
arise in the acute stages, when the gastric symptoms are 
severe and the mouth and pharynx sore; but apart from 
these it is usually well borne. Dilute phosphoric acid may 
be less effective, but is often much easier to take. It is, 
perhaps, too much to suppose that the artificial acid 
barrier can entirely replace the natural in warding off 
further intestinal infection. Hence it is further of tho 
greatest importance to keep watch against sepsis arising 
again in the mouth and nasopharynx. The continuance of 
the liver diet, whatever its mode of action may be, sliould 
help in preventing any tendency to relapse. 

Prcrrnfion, 

’ The history of the prodromal stages in these cases has 
been given at some length. It is worth while to empha- 
size this pro-anaemic phase, during which the patient may 


402 March 24 , 1928 ] 


A FORM OP SENILE SEIZERB, 


r The Bbitish 

L SlEDICAt JoCBNAl 


suffer from the symptoms of a gastro-mtestinal infection 
from time to time, over a period of several years. If it 
Tvero possible to foresee the ultimate development of the 
anaemic phase much might he done to prevent the later 
stages of the disease from occurring. The family history 
may give a clue. In two of these cases other members of 
the family had had pernicious anaemia. In the case of a 
fourth patient (put on liver diet too lato in the last stages), 
who died, her mother had also died of the disease, after a 
'^emission lasting nine years. 

Attaclm of gastro-intestinal symptoms, with perhaps 
glossitis, in anyone whoso family history shows pernicious 
anaemia, are a portent of the gravest significance. Without 
the family history the triad “ glossitis,” “ g.astritis,” 
” enteritis ” should warrant the examination of the gastric 
juice for achlorhydria. If this ho found tho case should 
^bo looked upon as one of potential pernicious anaemi.a. 
Liver treatment seems to bo proving of real value in the 
acuta phases, and may he of assistance in preventing 
relapse. But many cases might he recognized in the pro- 
anaemic phase, and a long and dangerous illness bo perhaps 
prevented. 

KErrnrxcES. 

I srinot, G. R., and Murphy, W. P. ; Jnvrn. Amer. Vffl. Assoc., 1926, 
Ix.'i.svii. 470. » Idem : Sritisli Medical Journal, 1927, ii, 674. 


A FORM OF SEAMLE SEIZURE. 

BV 

HUGH BARBER, M.D.Loxm., M.R.C.P., • 

noNOBAnr phtsictan, DEKBvsmnE botal iNFinitAr.r. 


after the seizure, without any knowledge of what bad been 
taking place. Tho attacks have not recurred nor havo 
vertigo or other symptoms developed. The expectation of 
life has been what ^ono would deduce from the age and 
cardio-vascular condition, but does not appear to have been 
changed by the accidental occurrence of the seizure; nor 
havo the activities been restricted. 

It would seem that the attack is duo to slight haemor-i 
rhago on tho surface of the brain, perhaps below the pia 
mater, producing coma and cerebral irritation, analogous 
to what may be seen occasionally after concussion. The 
bleeding must bo quite distinct from a free subarachnoid’ 
haemorrhage: tho one lumbar puncture observation 
revealed normal fluid. That it is a vascular lesion seems 
probable, because of tho sudden onset, and there is the 
analogy of epistaxis and retinal haemorrhage occurring in 
this typo of patient. Uraemia does not seem probable; tho 
recovery is too complete, and tho urea in the blood was 
not unduly high in tho one case tested. Tho type of 
patient is not suggestive of epilepsy, although the analocy 
of a convulsion from loss of cerebral , function pfobabiy 
holds good. A temporaiy oedema may be the cause, 
although a local aura might be expected, A localized 
haenlorrh.ago,' either venous or arterial, .seems tho most 
probable explanation. . Embolism or thrombosis is possible, 
but tho situation of the lesion is probably in a region 
whero anastomosis is very free. 


A SIAIPLIFIED METHOD OF ARM-TO-ARM 
BLOOD transfusion. 


Without any warning, an apparently healthy elderly ' 
person falls down unconscious. There may bo some degree 
of clonio spasm of the face or limbs, perhaps more pro- 
nounced on one side. Jn a few minutes there follow loud 
shouting and violent behaviour, necessitating restraint, but, 
possibly aggravated by it. After a variable time tho 
patient regains consciousness and reason, although perhaps 
a little dazed and inconsequent. On full recovery of his 
faculties he will say that the whole incident is a blank. 
Tho whole duration of the attack is perhaps about three- 
quarters of an hour, but may be considerably longer. This 
type of emergency is seen after the event" usually in 
hospital practice, or only in tho casualty department. It 
does not appear to bo described in medical textbooks. Of 
six attacks that I havo witnessed the notes of tho following 
caso describe a typical example. 

A railway storekeeper, aged 66, was , found unconscious at 
8.30 a.m. on January 24th, 1928. He was put into an ambulance, 
in which he became very violent, with struggling and shouting, 
sweating profusely. At 9 o’clock in the casualty department of 
the Derbyshiro Royal Infirmary ho was very violent, "and con- 
tinued so until 9.45, when ho vomited twico and becamo conscious, 
but was somewhat dazed. He was taken to the ward, where ho 
went to bed quietly, saying everything was a blank since his 
last duty performed that morning. Examination showed him to 
be a very stout plethoric man ; his tonguo was furred, his teeth 
wero decayed, and pyorrhoea was present. Tho lungs were 
emphysematous; the heart was normal, but sounds distant. Tem- 
perature normal, pulse 92; artery thick; blood pressure 150 mm. 
sysiolic and 90 mm. diastolic (two days later it was 170 and 110). 
There wero no abnormal signs in the nervous system. Tho urine 
contained a trace of albumin occasionally; but tho blood ure.a 
was only 48 mg. per cent., and tho urea test gave a reading of 
2 4 per cent. His mind was quite clear, but the head felt heavy. 
The day after admission lumbar puncture revealed normal cerebro- 
spinal fluid. Five days later he could walk about quite well. 

Of six cases (five men and one woman) all wero between 
60 and 75 years of ago. There was some evidence of 
cardio-vascular degeneration; but they wero robust, stout, 
somewhat full-blooded people, engaged in their duties. 
There had been some degree 'of hyperpiesis, but no serious 
renal disease. In ono caso tbo disposing cause of anger 
nrecinitated the attack, but otherwise there bad been no 
bistorv of effort, nor wero their duties arduous. In five 
instances the patient had come to himself in about an 
hour; tho sixth patient, after the violence bad passed off, 

I saw walking up aud dow'n his room with tbo doctor and 
butler in attendance. He came round about three hours 


• . • 'k P. SKINNER', M.D., M.B., F.B.C.P., 

- • ASSISTASI PIIYSinAX, SHEITIEtD EOVAL HOSPITAL. 

There aro so niany methods of carrying out the trans- 
fusion of blood, each worker having developed bis own 
techniflne, that it is almost futile to suggest a new method. 
Hoover, as brie who has done a largo number of trans- 
fusions of all kinds and by all methods, I feel justified m 

maKinc' a short practical .ndte on the. subject. . 

■ There can bo no question nowadays of the_ efficacy of 
transfusion as’. ri tb'efapeutic measure for a variety of con- 
ditions arid each clinical condition h.as its supporters for 
one or other method of carrying out the operation ; but 
X'thero cah be equdlly ho question that, granted facili- 
the transfusion of whole blood direct from donor to 
■ ••• i Hia best procedure. This was the origin.al 

’■'‘'fTd but owing to various technical difficulties it 
ri llg.bTen°disoarded in favour of the “citrate” or 

Tlm^transfusion of whole blood is hindered by the roadi- 
+n riot exhibited by blood immediately it leaves the 
""Tnfbelhf surroundings of blood vessels, and, of conrso, if 
Wood ifto remain wliol^that is, to retain all its pbys.o- 
I ’ and physical qualities— this tendency to co.agulation 
logical nnd phys^^^ It forms one of the most important 

of blood, and in cases of Inoemorrhage is the 
most desirable in tho blood to be introduced. 
Trre^er the blood uncoagulablo by citrate appears to mo 
j* +^Tir-t disadvantage when dealing with cases of seieio 
W Pflin" and it is in such cases, particularly in obstetnc.al 
emeieScics, that transfusion offers its greatest and most 

“Vmnkraplc.a. therefore, for the dovelopmeiit of wbole- 
Wnnd tr-ansfusion, and venture to assert that with the 
iv simple apparatus described below anyone who is 

s;sS.i“ * 

‘"Sf'irSS ‘SS j” SKeof 5 

,ivn the wrist the groove in tbo piston c.an be put into 
LT-riTifrC- and cither draw in or expel its contents. 



March 24, 1928] ■ 


A SIMPLIFIED METHOD OP= BLOOD TRANSFUSION 


r TimBnmsa 4Q3 

LMEniCAr.3oirE3riii — 



The only other apparatus necessary is two pieces of 
rubber tubing of stout make about 8 inches long, and two 
iieedles such as arc used for venipuncture, and which can 
be put directJy into the tubing. The drawing will mako 
. . 1 the above deseriiition 

n clearer. , ‘ 

•In carrying ,out 
the operation the 
donor and recipient 
are placed parallel 
and side by side, or 
head to bead with 
feet in opposite 
directions, whichever 
is found most con- 
venient. I usually 
find; the two right 
arms best, in which 
case the second 
position is adopted. 

A small table of 
suitable height -is 
placed between the 
tivo couches, and 
on this the arms . 
are brought close 
together, and the 
usual preparations 
carried out for steri- 
lizing the skin and 
.'■making the veins prominent. Before inserting the needles 
I find it an advantage to fill the syringe with medicinal 
liaraffin fii'st, then empty it and refill it with a solution 
' of sodium citrate, subsequently half emptying it and then 
'leaving the piston with the groove midway between the 
•side openings.- • 

A needle already attached to the syringe- is then inserted 
into the recipient’s vein (this is usually done first, as it is 
•the more difficult) and the piston turned round till the 
■groove is opposite the recipient's opening, and if the needle 
is in.the vein a little blood appears in the syringe imme- 
diately the piston is slightly pulled up. The piston is 
then turned to “ midn’ay ” again and the donor’s needle 
inserted into his vein, the same manosuvro being carried 
out to ascertain whether the needle is satisfactorily in the 
vein. 

If tho venipunctures have been carried out satisfac- 
torily, a little vaseline is smeared over the skin round the 
entry of tho needle and the tourniquet removed from the 
recipient’s arm. Blood is now draivn from the donor, the 
piston turned and pushed down, delivering the'fuH amount 
to the recipient; another iturn, and . the blood is drawn 
ifrom the donor' as. tho piston' 'slides up the syringe barrel; 

■ turm again and .depress' th'e ipiston, and the charge is 
' delivered ito..the. recipient, nnd-so on; 

. Tho operation is so simple that if. venipuncture , has been 
, successf 111 ■ 500 c.cm. ;qf -blood, can be transfused in a very 
short time , (ten minutes), and there is certainly much less 
', ' eaction af te'r, tlfis procedure -' than after any other. 

.- here, conditions allow, there can be no doubt that arm- 
.to-arm transfusions should be, done, and this simple tvpe of 
.apparatus is.capable of-doirig the operation efficiently. It 
15 made by .Du|faud et Cie, 'Paris, and is the invention of 
,a Frenchnian (Df Jdub'et). I't is certainly one of the most 
. beautiful pieces of; apparatus I' have ever used, but as sent 
i accompanied bv two or tliree pieces 

%™ds of needles aiid cannulae-;— one for 
the donor and one for the- recipient; to mv mind these 
-aie totaljy unnecessary, and only tend to complicate what 
can bo a very simple' technique. 

Tlie syringes are made in two’sizcs-iS c.cm. and 10 c.cm.; 
pcrsoiially I consider the 5 b.cin. the better; there is no 
point m using the 10 c.cm. syringe when 500 c.cm. of blood 
can be comfortably delivered in a few minutes with tho 
.smallci* apparatus, - 

. The syringe is not' on the English market, hut can bo 
obtained froni the makers direct or from Messrs. Bell and 
Crpydcn, who have promised to hold a stock of them, since 
when bought dirwt it. requires .about, two moiitbs before 
tbey are delivered tlirough tho custom-house. . ' ' 


MINIMAL EISES OF TEMPERATURE IN 
RHEUMATOID ARTHRITIS. 

BT 

: . L. SCHMIDT, M.D., 

• - -MEMBER or 'THE ISTEEITATIOSAt COMMI’CTEE ON P-HEUMATISM. 

'PISTAKY, CzixaiOSLOVAKlA. , 

Thebe is one type wliich stands out from the large group 
of rheumatoid arthritis .cases; it is distinguished by con- 
stant though often minimal i;ises of temperature, iind is 
associated with a very slow course, which is unrelenting in 
its progress and often defies all forms of treatment. Out- 
wardly these cases are hardly distinguishable from those 
of other types. ' . ! . 

In a discussion some j'ears ago of. pyrexia in rheumatoid 
arthritis' I stated that, “ the febrile types of rheumatoid 
. arthritis ■ are ■ certainly commoner than we generally 
assume.-” I presumed then that the rise of temperature 
in such chronic articular cases might be due to the action 
;of toxins, and further observations have served to confirm 
this view to a large extent, so that I have found Ibis a 
. useifnl basis for rational therapy; Though at that time .1 
only considered temperatures well , above 98.6° F. of ini- 
. portanco; I have gradually become convinced that minimal 
: rises of temperature, even of only a few tenths of a degree, 

, if continuous and not -due to any other cause, are of 
-decided importance from -a prognostic as well as from .a 
■ therapeutic point of view. Moraing temperatures of 
97.9° -to 98.2° F.; which are often regarded as normal by 
medical practitioners and the general public, should receive 
.serious a.ttention in, these cases, since they indicate tho 
. need for a systematic xecording of the afternoon tempera- 
. ture. It will almost invariably he found that the afternoon 
temperature is above 98.6° F., and that almost without 
exception the accom)>anying signs- are of serious prognostic 
significance.. 

- A survey of these cases is not very cheering. The 
patients mostly state that they have been ill for years or 
.at least for many months.. In spite of various therapeutic 
measures, the pain, swelling, deformity, and atrophy of 
muscles .and skin slowly increase. Psychical disturbances 
become superimposed on the organic troubles and find 
expression in tho facies. Tlie emaciation and obvious 
anaemia, which are almost constantly associated n'itli this 
disability, emphasize the tragedj' of the aspect. 

I regard' these cases of articular rheumatism with a 
continuous though minimal pyrexia, when there ' is no 
demonstrable focus of infection in other organs and no 
eride.nce of tuhcrculoiis rlieiimatisni (Poncet’s disease), as' 
being flue to cryptogenic bacterial lesions of polymorphic 
etiology. The question of the primary seat of tlie lesion, 
-and 'whotlier in certain cases .it is the bacteria or onlv'the 

• bacterial toxins which invade tlie joints' and there produce 
the imrious changes, must- ho .'left'. open'T-’flie important 

-point is the entry of substances foreign to ■ the body , of at 
least to the joints, into, the joints, and. the surrounding 
tissues in such amounts that the- irritation set up leads to 
.■I'.arious degrees of .inflammation . and .their sequels. Tlie 
joint tissues and the surroun'diiig fluids are thus toxic 
, n bethel they take the. form of nmcroscopic or merely 
^of .micioscopic exudates .and chemotactic combinations. 

: Absorption of such substa'nces has, according to this view, 
the same significance' a's aii auto-inoeulation. 

- It seemed that the first step towards^ .a cure of these 
arthritic patients mustdake tlie foi'm'of general treatment 
as in the case of tuberculosis, and here a so-called 
“mastlcur" (fattening, regime), cajried out with great 

.care and precision, plays an important part. Objectively 
improvement becomes manifest in two' directions : the body 
weight increases, and the small rises of temperature tend 
'to disappear, though in .some case's only after a considcr- 
.able time. Both these reactions are very delicate and of 
great prognostic significance; they usually run parallel. 

Pursuing the reasoning outlined above the folloiring con- 
clusion was reached: MTien such an arthritic patient is in 
a negative phase and the organism is incapable of reacting 
ib is not only useless but foolish to begin by increasing tho 
supply of toxic molecules from the joints which the 

'TTten. W/n, FToc/u, ‘1S0$- 





494 March 24, 1928] 


; :ii memobanda’/' ■ Sf- r 

. LMjsbicai;, JocBxil 


orgiiTiism is incapablo of antagonizing j this'is a ivell-known • 
principle of all inoculation therapy. In articular rheum- 
atism, hoivcvor, just those organs are infected which, with 
tho muscular -action accompanying each movement of tho 
body, act as a kind of peripheral pumping station, mixing 
tho various body fluids in all directions. In these cases, 
more than ^in any others with localized lesions, movement 
of the joints means an increase in tho inoculation of tho 
body with toxins' from the foci where they have been 
■deposited; If, therefore, wo wish to keep tho body of the 
patient as free as possible from toxins from the joints 
and afebrile the further passage of toxins into tho circu- 

- lation must, as far as possible, be prevented by securing 
absolute rest for the joints — that is, by confining tlie 
patient to bed. The second essential in treatment is 
therefore recumbency, which, according to the individual 
case, is leniently or very strictly enforced. 

When all that is possible has been done to facilitate the 
cure by a fattening regime and recumbency, the patient 
must be guarded from the various harmful forms of 
treatment which are sometimes warmly recommended. I 
refer particularly to tho routine ordering of massage for 
such cases. I regard daily massage in 'these subfebrilo. 
cases as a gra%-o error, analogous to repeated injections of 
tuberculin in febrile cases of tuberculosis. The same 
applies to the often indiscriminate use of diathermy and 
radiant heat. In balneological treatment mistakes are also 
too often made in these cases, when, regardless of the 
thormo-sensitir'e nature of the case, and irrespective of 
general or local reactions, the patient is allowed to'c'ohtinno 
his baths without rest or intermission, and is not granted 
time or opportunity to pass from the negative phase' to' 

- the positive phase of improvement. Tho result is fatigue 
• and exhaustion of the organism instead of beneficial stimii-, 

lation ; the condition remains stationary or becomes worse, 
whereas a rational plan of treatment adequately pursued 
might achieve improvement or even complete cure. 

The line of thought which I have indicated in this paper 
has proved a sound working hypothesis in practice. 


^inioraittra : 

MEDICAL, SURGICAL. OBSTETRICAL. 

A CASE OF VOLVULUS NEONATORUM, 

The. following case seems of sufficient interest to be placed 
on record. . 

A male child, aged ^4 days, was admitted to the South Eastern 
.Hospital for Children, Lower SydenHam, with -a history of vbmit-‘ 
ing green fluid since birth and of passing dark' motions which,’ 
the evening before admission,' had turned to fluid blood; this, 
being passed continuously and in some quantity. Ho was .a 
‘full-time child, large and well developedy and weighed 8Jb.'8 oz.' 
. He was not greatly distressed, the fontanelles were not depressed,! 
but, pallor was marked. Pulse 148, respirations 46, temperature' 
‘ 98.2° E. . ' • . ' 

On examination the abdomen was soft and the stomach 
slightly distended; nothing was found on palpation. Blood leaked [ 
r almost continuously from the rectum, but on rectal examination ‘ 
nothing abnormal was discovered. 

The following day the condition remained much the same, but 
the* temperature rose to 100.6° P. in the afternoon; the flow of' 
blood from the rectum was much less. No food was retained ' 
owing to persistent vomiting, and there was no obvious distension 
of the abdomen. The child died the following morning. 

Pos(-morfc»i Examination. — The abdomen showed a slight 

1 *. • On opening, a small quantity of dark blood-. 

' . ; . ; ■ and presenting in the incision was a mass 

..el. On further examination it was found' 
fha.t'lho stomach and duodenum were noraal, that just beyond’ 
the duodeno-jejunal junction there had been an anti-clockwise 
rotation of 4c small bowel, so that this upper portion -wm , 
tlolitlv wrapped round the last portion of the ilpum just above 
the L-aaec& valve. The mesenle^ was, practically speaking. 


absent, being 


renresented by a fibrous cord containing tho 


arterv. over the front of which passed the 
-superior (that is, the 'artery) constricted 'by tho 

duodenum, and therefore -a ' complete strangulation of tho 

volvulus and ileum, leaving the stomach, duodenum, 

whole of the jejunu a a looking, quite normal. Tho 

of^h'o^taus did nol-‘’show any abnormality. 

Mr. Norman M. Dott has written at len^h the 
subject of anomalies of intestinal rotation in the UnUsh 
•'“urnat o/ Surgenj (1923, vol. xi), and in' the Bnttsh 


■Medical Journal of -February fithj 1927 (p.' 230); ho liaa 
described a case of volvulus neonatorum wliicli was success-, 
fully diagnosed and treated by operation, a result of the 
application of theory and study to practice which must 
have ^afforded him considerable satisfaction. The case -lie 
describes, however, differs from tho, above in several details; 
the absence 'of mesentery and the anti-clockwise rota- 
tion of the bowel are similar, but he describes the stomach 
and duodenum as being greatly distended, ’ and the small 
■bowel collapsed and cyanosed. This case, then, must be 
regarded as unique in the acuteness of the symptoms and 
tho degree of v'ascular obstruction. 

Our thanks are due to Mr. Dott for bis interest and help 
in this case. 

Gilbert IV. Ch.irsley, M.B., Cli.B., 

' Honorary PJiysician, 

George Richardson, M.D., F.B.C.S.Ed., 
Honorary Pathologist, 

South Eastern Hospital for Children. 


EMBOLISM OF APEX OF LUNG. 

Embolism of the I’uiig is fairly common, but if the apex 
of tli'e upper lobe' of the' lung is involved, difficulty in 
diagnosis may 'arise, -These notes .on a case recently 
attended by me miiy therefore be of interest. 

An unmarried woman, aged 40, had suffered from exophthalmic! 
'eoitrei for many years, but had managed to do 'her work as a 
•bbokinv clerk at- a libtel, and had received no medical attention 
•for years.’ ' On December 25th, 1927, she-was suddenly sewed 
'with shortness . of. breath and severe incessant , coughing; she 
vomited her last meal and coughed up smne bright red blood. 
’She was first seeii by me half an hour after the onset of those 
svmDtbnis "Her pulse was about 140, she looked .very ill, and tho 
coSh was incessant; She was given a small ’toe -of morplimo 
hypodcrintolly,-aiid a sedative for the cqugh. , Eestlessncss was 

“-mJlWxt'^y'rany coarse rAlcs were nudiblo-oyer the apex of 
ti,. lung, with bronchial breath .sounds and markedly im- 

the vi'as’slill couginng.up a little bright red 

-pa^d resonapep.^ She v^sjim^coug^^., beat 'was 

blood; the jjne kter chief complaint ivas of the 

two inches ““J? ’Siut mi ivas examined for tubercle badlh 

■ troublesome coUg 1. ^2,1 blood pressure was 160 mm. Hg, 

r?te 120 a m?nute but wifli a few drops of Lugo! a 
and the pulse ram isu gg ^ blood pressure to 

solution of the heart coming to Ho in the nipplo 

145 mm., iT minims of Cugol's solution tfirea 

line. -Sbe. uoulA only take bi„g Attacks. IVith rwt 

times a day; obe lost her cough completely and tho 

in bed for a of the lung cleared up entirely. 

fhFstUI h'ad f sysLio® mui^ur at the apex of the ^.eart con- 
. ducted into the axilla. ^ M.D.Lond., F.R.C^S. 

' SwanagOe ' " ' , * . • r ' ' 

■ 'dYSEHAGIA ASSOCIATED AVITH. ANAEMIA. . ; 

■ ' 4 1 PQ iQ < 3 TTnilar ixi'inaDy points to tho clinifcal 

. The “u Jo by DrI. ^Jone.s and . Given in 

■type desenbed 18tl/(p. 256), Lut, tlie anaemia 

•hS'bierialocytic m-er since tho patient came uudot- my 

•“A^arned'wonm^l^ 

said she bad jj ^ from melancholia and was in uu “• 5 • 

oienopauso she suiiereu i sometimes than at otliere. 

Tlid difficulty m floias-solid food seemed to stick, 

art&''“oth^ tor many yea« Thc^^spleen w as^ P P 

«Tcells“ ^ KloW'd'l 

OTWinrv Elisabeth Croskert, B.Bc., 



r Tsr. Cp.rnsH 
Mbdicai. JorirvAt 


495 


MARCH' 24, 1928] 


SCIENTIFIC FEOCEEDINGS OF BKANCHE3. 


IJrilislj iHibrcal ^ss0nali0n. 

CLINICAL AND SCIENTIFIC PROCEEDINGS. 

MONMOUTHSHIRE DIVISION. 

' Scccnt Changes in ObstcC-ical Pracfice. 

At £i meeting of tlie Monniontlisliire Division lield ai> tlie 
Royal Gwent Hospital, Newport, on March 9th, with the 
cha'irraan, Dr. W. D. Steel, presiding, a lecture on some 
recent changes in ohstetrical treatment was given hy Dr. 
Leslie AVilli.4Ms,' Queen Charlotte’s Hospital, London. 

Dr. Leslie Williams dealt first with the 2-unit dose 
of pituitary extract, which he regarded as one of the 
greatest recent advances in obstetrics, and as calcul.ated 
to reduce the incidence of puerperal sepsis, and to limit 
the use and abuse of forceps. The introduction of this 
new treatment was due to one of his colleagues at Queen 
Charlotte’s Hospital, and according' to his observations, 
both e.xpcrimental and clinical, the drag in 2-unit — for 
example, 0.2 c.cm. — doses, might safely be given at any 
period in labour. The speaker believed the ideal use was in 
a normal labour when the first stage had been allowed to 
progress undci- some sedative drugs such as morphine ind 
scopolamine, and when the pain of the second stage liad 
been controlled by chloroform. In these circumstances the 
ex'pulsion of the child'was.apt to be tedious, and an intra- 
muscular injection of 0.2 c.cm. pituitrin would re.sult in a 
great increase in the power of the uterine contractions and 
the spontaneous delivery of the child. If necessary, the 
injection could be' repeated. The patient should be well 
under chloroform .before the injection was given, as other- 
wise intense and sometimes, almost continuous pain was 
caused by’ the powerful uterine ' contractions. In his 
experience the child, was not harmed in. any way, though 
the foetal heart rate was unquestionably affecied. The 
small dose of pituitrin was oven more valuable for cases 
bf secondai-y , inertia with the head well down. The 
presence of even minor degrees of disproportion between 
■ the foetus and ■ the pelvis contraindicated the administra- 
tion of pituitrin. Its ' use, hbwever, during the second 
stage in suitable cases did not appear to predispose to 
hour-glass contraction, with retention of the placenta. 

■ With the Use of this drug during the first stage, as a 
lulo, the ^uteriile.' con traction's, were 'increased in power 
and duration, ’ and furtbermore were 'regularized. In cases 
of a slowly dilating cervix with painful colickj' uterine 
contractions, his personal preference was to give morphine 
and scopolamine and allow the dilatation to proceed spon- 
taneously, giving further doses of 1/400 gr. of scopolamine 
at inteiwals of a half to One hour if required. Should the 
dilatation stilly be proceeding poorly he would have no 
hesitation in giving a 2-unit, dose of pituitrin as well, and 
repeating if necessai-y. • • • - 


Treatment of Puerperal Sepsis. 

Proceeding, to discuss puerperal sepsis, Dr. Williams sa 
that in the light of present, knowledge the treatment 
puerperal sepsis must be preventive— bv careful prepar 
tion of the perineum and vagina, by effm-ts bn the part 
the accoucheur to. be surgicallv as clean as if he we 
performing an abdominal section, bv the avoidance 
meddlesome midmfery,” arid particularly the avoidan 
of manual removal of the placenta. He felt confident th 
a great improvement in obstetric technique in the count 
generally would result from the present tendency to rai 
the status of obstetrics in the student’s cnrriclilum. . 
things were they all had certain cases of puerperal infi 
tioii. In his experience no- improvement could be expect 
^m the prophvlactic. use of vaccines," or serums, or t 
teo combined. In dealing with a' case of puerperal inf< 
tion the fii-st duty was to decide whether the c.ase was o 
of uterine (or cervical or pcrincall infection whicJi h 
not been kept withiii bounds by the local defciisi 
mechanism, but' had invaded the blood stream 
septicaemia ; or was one in which the infection h 
been localized and there was merely the absorption of to- 
products of the local suppuration — “ toxaemia ” ' T 
former was treated by methods designed to raise t 
patients bactericidal power, while the treatment of t 


latter was local. To distinguish between the two _ con^ 
ditions was not easy in all cases. On clinical grounds a 
blood infection was to be suspected if the disease was early 
in onset, marked by repeated rigors, a high degree of fever, 
and a rapid pulse; they should not be deceived by the 
patient’s subjective sensation of being in good health. The 
final proof of a blood infection was obtainable' only by a 
positive blood culture, and they wore fortunate in the 
improved bacteriological technique of to-day, in that a posi- 
tive result was obtainable in most cases. The treatment of 
such a proved case was briefly this : Absolute rest in bed in 
the open air; plenty of good food, as solid and substantial 
as the patient felt she could, deal with; the avoidance of 
drastic purgatives, but gentle daily enemata if required; 
plenty of fluids; and, lastly, those special steps designed to - 
increase tho bactericidal power of the blood. Here weekly 
intravenous injection of some of tho “606 ” preparations, 
in doses of 0.4 to 0.6 gram, were valuable. Of equal 
importance was tho transfusion of whole blood — small 
amounts, say 10 to 12 oz., repeated onoe or twice a week. 
The value of, these injections might further be increased 
by artificially producing a leiieocytosis in the donor bj- a 
morning injection of 2 c.cm. of sodium nuclcinate, and 
making the transfusion from him in tho afternoon during 
the period of the increased leiicocj-te content of his blood. 
The variety of treatment suggested for puerperal septic- 
aemia clearlj- indicated the inefficiency of these measures. 
His pei-soiial ex]ierience, however, led him to believe that 
there was some value in these treatments by blood trans- 
fusion and tho salvarsan preparations. . _ ' . 

In localized infection it was, of course, obvious that the 
site might be uterine, cervical, vaginal, perineal, etc. The 
principles of treatment were, first, hygienic — fresh air, sun- 
light, and good nourishing food— and secondly, cleansing 
and drainage of the infected area. In the second matter 
they owed much to Dr. Remington Hobbs. The speaker 
was a very firm believer in the efficacy of the intrauterine 
glycerin treatment which Dr. Hobbs employed to promote 
“ tissue drainage.” For uterine and cei-vical lesions the 
hygroscopic action of the glycerin, together with the free 
drainage secured by the diminution of the oedema of the 
mucosa of the uterine and cervical canals, had proved of 
the greatest value. For the more superficial lesions, such 
as an infected perineal tear with septic absorption, the 
removal of stitobes and local cleansing would suffice. He 
wished to lay it down as an axiom that the infected puer- 
peral uterus must in no circumstances be touched with the 
curette, and might be cleared out by a gloved finger onlv if 
haemorrhage, as well as the probability of retained pro- 
ducts, rendered this a necessity. In the absence of haenior-, 
rhage he had no hesitation in advising Fowler’s position, 
pituitrin, , and ergot, in preference to any operative 
procedure. 

Coneealed Accide.nfal Hdcmorrhdge. 

In cases of concealed, accidental haemorrhage it appeared 
that obstetricians might, in the past, have been the direct 
cause of death by tho violence of their treatment. They 
had tried to flog tho practically paralysed uterus into 
contractions by means of -vaginal plugging, tight binders, 
pituitrin, etc. It was now ' realized that the essential 
factor in the case was not the amount of theTiaeinorrhao'e, 
but the' degree of the shock. Post-mortem examination of 
a fatal case of this disease disclosed a bruised “ coppery ” 
uterus with tho muscular 'fibres separated by interstitial 
haemorrhages, 'a retroplacental haematoma, haemorrhages 
in tho broad ligament and iii the retroperitoneal tissues. 
But the total. amount of blood lost was only between, say, 
1/2 and 1 pint. Incidentally, she was also suffering from 
one of the pregnancy toxaemias, but the condition demand- 
ing treatment' was the shock. She .should be kept still in 
bed, kept warm, and given enough morphine to produce 
obvious effects. If she improved it was because tho shock 
passed' off. Simultaneously the uterus would begin to 
recover its tone and she would start bleeding e.xternally, 
the concealed blood being expelled by the uterus regaining 
activity. This was the time further to urge tho uterus to 
effort, and when the shock had passed off and was not 
likely to be renewed by obstetric efforts, to plug tho cervix 
and vagina, to put on a tight binder, and to give small 
repeated doses of pituitrin. As soon as thc' contractions 



496 STakch 24, tgiS] 


•PEESBNT POSITldN- OF JiKUlVhr: TREnAP7V‘- 


fet 


f The Dnnzn 

L SlEDIt'A!, JoL'nj.'ui 


became at al] good and regular the first plug was removed, 
the membranes ruptured; and a fresh plug introduced if 
this was still necessary. If, however, the patient’s con- 
dition showed no sign of improvoqient, but became worse, 
then Caesarean section should bo perfoimed without furtlier 
loss of time. After the child had been extracted — stillborn, 
of course — the uterus might contract or it might remain 
absolutely inert. In the former case tho placenta and 
membranes were removed and conservative Caesarean 
section was completed in the usual manner; but if tho 
uterus remained limp and flaccid evoiy effort must bo made 
to make it contract. It should bo wrapped and massaged 
in hot towels, and injections of pituitary extract should bo 
made into its musculature. If these efforts were successful 
then again conservative Caesarean section was completed. 
But if tho uterus persisted in remaining a bleeding mass 
of bruised and completely I'elaxed muscle, then hyster- 
ectomy must bo performed immediately. If was, of course, 
a rather desperate business to have to perform a formidable 
operation on a woman who was already in a very dangerous 
condition. But his own limited experience led Dr. Leslie 
Williams to take a more hopeful view of such a case than 
was indicated by the percentage mortality rato usually 
quoted. 


PEESENT POSITION OE EADIUM THEEAPT. 

At a meeting of tho Section of Electrotherapeutics of tho 
Eoyal Society of Medicine on March 16th, Sir Heniht 
G. vuvArN presiding, a discussion took place on tho present 
irosition of radium therapy. 

Mr. Haitwakd Pinch, director of tho Badium Institute, 
in an opening address, reminded tho Section that it was 
now thirty-two years since Henri Bccquerol read his paper 
on an invisible radiation emitted by salts of uranium, 
and thirty years since tho investigations by the Curies 
began. Badium at first bad purely non-medical applica- 
tions, but after a time it began to be used by French 
medical men in the treatment of superficial lesions, a sur- 
face reaction being obtained which varied in degi-ee from 
a mild erythema to a definite ulceration. The next stage 
was the use of radium salts enclosed in tubes and inserted 
into easily accessible tumours ; the results were encouraging, 
and presently the help of the surgeon was solicited and an 
elaborate system of surgery of access was practised. Tho 
latest development of all, and an extremely important one, 
was the use of “ seeds ” of screened radium emanation or 
“ radon.” Several years ago the use of unsci'eened emana- 
tion seeds was tried, but they were found to have an 
intense necrotic action and to cause pain, and thei’efore 
were given up. Screening did away with th'eso disadvan- 
tages, and tho results were really surprising. Tho pro- 
portions of alpha, beta, and gamma rays in a specimen 
of radium might bo set out as 10,000, 1,000, and 100 respec- 
tively, and tho alpha raj'S could bo disregarded thera- 
peutically. Of the beta radiation, 94 per cent, was 
absorbed by 1 cm. of body tissue, so that these rays were 
most effective when applied in superficial therapy. Com- 
plete absorption of the gamma rays by the body never 
occurred. Of the patients with superficial lesions who 
came to the Institute, fully 98 per cent, were treated either 
with unscreened rays or with one of four screens — namely, 
0.01 mm. of aluminium — an extremely thin filter — 0.01 mm. 
of lead, which let through 28 poV cent, of the beta radia- 
tion and 0.5 and 1 mm. of silver, when it was desired 
to act on the deeper layers of coritim and subcutaneous 
tissue Mr. Pinch then showed a number of photographs of 
cases illustrating the improvement which had resulted in 
conditions'such as psoriasis, lupus, and keloid after radium 
applications. One case was of mycosis fungoides of the 
abdominal wall which showed what might he called a 
specific reaction to radium. He did not ciaim that the 
method of application- emploj’ed at the Institute iras the 
only one which could bo used with good effect, but it had 
certainly passed the test of a long clinical experience, ^ 


Deep radium therapy ho defined as tho treatment of 
disoaso by .prolonged exposures with radium or “ radon ” 
apparatus so screened as to emit a preponderant hard beta' 
and gamma or gamma radiation only. Tho best standard 
screen for getting the gamma radiation only was 1 mm. 
of platinum, which cut out al] beta radiation, and 
transmitted SO per cent, of gamma. But platiniiin was an 
expensive metal, especially when used for largo surface 
applicators, and an equivalent filtration was provided by 
2 mm. of lead, lead being of approximately half the 
density of platinum. Deep radium therapy might be carried 
but by threo methods: (1) externally, by tubes or other 
applicators, either in contact or at a distance; • (2) by 
omploying surgery of access so as to apply the radium -to 
tho growth from a. more advantageous position; ( 3 ) by 
embedding screened emanation seeds, using a techniquo 
which ho described and illustrated. At tho Badium 
Institute contact radiation was chiefly used — in the treat- 
ment of breast cases, for example, 3 mg. of radium 
element, with a filter of 2 mm. of lead, in actual contact 
was a medium dose. Tho disadvantage of the inverse square 
law, whereby the radiation diminished with depth, was 
countered ns far as possible by tho crossfire method. Very 
little distance radiation was carried out at tho Badium 
Institute, though it was , largely used on the Continent. 
Tho speaker illustrated tho enormous difference which a 
separation of 10 cm. between tho skin and the applicator 
made in the radiation reaching tho tumour. There was, 
however, one form of distance radiation which had been 
very useful— that was the placiug of radium tubes con- 
taining 50 to 75 nig. in a mould of wax compound for the 
treatment of glands of tho neck. 

' There were extreme schools among radiologists, somp ojE 
whom believed in the use of largo doses for a short time, 
and others the use of small doses for a long time. Tho 
pendulum bad swung over from the former' to the latter,- 
and there were many who advocated small doses given for 
0 ercat loneth of time, as though that were the only method 
of any' value.- Mr. Pinch denied this, believing that 
thoro were many cases in which excellent results could be 
obtained with a large quantity of. radiuin used for 'a short 
time Lymphosarcoma and other conditions responded best 
t6 tiiis method, while, on the other hand, slow-grouung 
souamous-celled epitheliomas responded best to small quan- 
titles applied for a long time. Between tlicso extremes , 
there must bo many conditions whore the optimum would 
bo some more equal distribution of the two factors, quantity 

“"^rP-Hment by bufying screened emanation seeds had 
• 1 HJstinct advantages. It involved very little traum- 

•aS and hsnallY necessitated only local anaesthesia; as the 
SeedTwere charged only with emanation it was no great 
^ rLr if thev were lost; and the container, being made of 
"i J 'nnm dM not corrode. Mr. Pinch showed photographs 
^ number of cases of improvement resulting from . 
in deep-seated conditions. One case was m an 
^“fnppmriaii wL bad an epithelioma of the ear, the sizo 

®-]pmon Thirteen seeds were buried, and withm four 
Xs tho whole growth had disappeared. Another case 
" flmrof a woman who came in tho most miserable 
'"nndition with an epithelioma affecting the faucial pillars 
the epiglottis, and running a- little way out of 
“1^^ ^nneaf -wall. Here tubes were buried, and tlio effect 
pbaryiige 1 could only be described as miraculous. In 
“^*®nidlv growing epithelioma of the anal canal, so painful 
a vap'O'I ° ^vithout an anaesthetic was impossib e, 

i‘-*r,^f^ecdrwero inserted, and six weeks later the 
rectum could be examined with perfect ease, and there was 

"tlr“TnchrnlM”^a word of potest and of 
pv Se said that tliere was a certain secti^on of 
A^men who were rather inclined to deprcciato tlio 
Vo^rnHshed by British radiologists. Tliey talked 
work accomplish^ manner of what some professor or other, 

rm^npT/paris or Vienna. Ho took exception to that. 



^,;,^AECH 14, 1928] 


B4PC05IATOtISl IMETAPr/ASIAl pT5 :UTEBIN.B 


[ 


Tnz Tiv-mss 
9J tu>rcA£ Jowf^' 


497 


dosevve<l cvoclit. His prophecy, whicl. Jio made deliber- 
ntelv after the fidlcst consideration, was tliat in tlie veiy 
neal- ’future radium would fom as necessary a part of the 
tui-to-date surgeon's armamentarium as the scalpel, and jt 
would he possible by this moans to handle with confidence 
and success many cases of malignant disease which at 
present. were regarded as inoperable and hopeless. 

The di.scussion which followed was .somewhat curtailed 
owing to the length of the opening address ; Mr. Hayward 
Pinch had intended oulv to speak for half an hour, but 
his remarks wore of sucirintorcst to the very large audience 
that they rejieatedly* bade him “ Go on,” so that his 
address was extended to an hour and a quarter. A few 
speakers, however, contributed their experiences. 

Dr. Knc.ii! HArno.v (Newton Abbot) spoke of favourable 
results which he had seen in oesophageal carcinoma from 
placing tubes containing 4 mg. of radium around the 
growth, and biiiying seeds within it. 

Dr. AVh,i,i.\m Him, was strongly against burying radium 
Eceds in oesophageal growths, ivhich ho thought a dan- 
gerous practice on account of the possibility of perforation. 
He had, however, exposed over a hundred such eases to 
radium. One case had lived for seven years, and at least 
one-third had been distinctly relieved and their lives jiro- 
longed. 

Dr. Dormi.va 'WEBSTEn endorsed Air. Pinch’s disapproval 
of those who wi,shed to lay it down as a law that .small 
doses must be given over a long period. Very successful 
resnlts had followed from the application of large dose.s 
for a short time. Kelly of Baltimore liad even applied 
a gram of radium ou superficial groivths for a matter of 
a minute or two. French workers, on the other hand, 
insisted that cases must be treated with very small do.scs 
for d.ays or for a week or more. The .speaker believed 
timt treatment from a distance was useful in certain cases. 
•Middlesex Hospital was fortunate enoiigli just after the 
war to have a loan of 5 grams of radium, though it wa.s 
very quickly broken up and sent to other centres, and 
•he, for a time, 'was able to hare the use of 0.5 gram of 
radium clement. Using thi.s at a distance of 6 cm., the 
dose being twenty-five liours^ divided up on diffcrcut day.s, 
he found the results very good in breast cancer and supra- 
clavicular recurrences. 

Di'. F. HEiiNA3t.VN-Joiix.sON' hcliovod tliG burring of 
radium seeds to lx: an important method of tlie firtnro, 
hut he hoped that enthusiasm for radiitm would not blind 
radiologists to other factors. In the eouiitry as a whole 
there wa.s not nearly enough radium for the treatment of 
case.s, and, however striking the rc.snits with radinm, many 
of those shown by Air. Pinch could ho paralleled by those 
obtained with a:-rav' treatment, both superficial and deep. 
A judicious combination of a'-ray treatment, diathermy, 
and other measures would enable a groat many conditions 
to be dealt wit.j for which radium supplies were inadee(nate, 
altbongli radium, could it be obtained, might give a more 
_BliGecly and cosnietic result. Moreover, in all this local 
ticatment by radium tlie general condition of the patient 
ehoidd not be lost sight of. He had found many patients 
come tfi the a:~ray department for trcatiiient for reenr- 
Tonces, and, after doing well for a time, appear to come to 
of their response. Formerly these people were 
dismissed with an intimation to their doctor that nothing 
moio could be done, but uow he adopted different tactics, 
and sent some of tliom for ligJit treatment, whereby they 
regained their response in a remarkable manner. Jt 
. appeal od to him that light treatment, properly .applied, 
,proMdeu a means of picking up tlic iiatieiit^s response and 
giving him a now lease of life. 

Hr. G. \ contested some of the statements of 

speaker, and said, that in the treatment of 
epithelioma Jio had found radium much more valuable 
than a* rays. In his hands the latter had been a failure in 
that condition. 

Sir Ciu7ix.ES Gounox-IVATsox had hoped to hear more 
nhout the surgery of access. For the last three years he had 
been dealing with carcinoma of the rectum bv the so^alled 
surgciw of aceoss-^that was to say, he had been takiiirr 
groirtbs nlucli wore too advanced for excision, and tuviu? 
to get tbem tliorovigbly c.xposed ns far as possible' bv 
snrgovy; then he measured up the growth iii cubic milli- 


metres, nnd for cveiy cubic millimetre of giowtli applied 
2 mg. of radium. The whole problem was that of the 
optimum close in the particular ca.5e. One woman with 
a very advanced growth, and who was extremely cachectic 
and ill, had 50 mg. inserted for seven clays; she under- 
went a very severe reaction, but wlien sbe improved 
site did so with groat rapidity. What was wanted was a 
mode of radinm application giving parallel rays to every 
part of the growth. 

Air. AI. H. OnDEnsHAW suggested that the difference in 
hchavionr to radium as between r.npidly growing and .slow- 
growing tumours — the former doing better with' a large 
dose applied for a short time, and the latter with a smaller 
dose for a longer time — ^might he due to the special snscep- 
tibility of the cancer cell to the action of radicun during 
tho process of division. The aim should bo to obtain as 
uniform a radiation as possible through the tumour at 
a time which would catch every cell when dividing. 

Dr. J. E. A. LvNHAJt urged that in hospital radium 
equipment, in addition to needles and tubes, there should 
be fiat applicatore, which were extremely useful. He 
also reported good results from a combination of x rays and 
radinm. Sir Henkv Gauvain raised the question as to the 
possible dangers of radivira treatment. In the early clavs 
of x-ray treatment the rays were used very largely for such 
conditions as Inpiis vulgaris, uuth results udiich were now 
known to be deplorable. AVero such resnlts to he antici- 
pated with radinm, or were there any clangers with radium 
of which n.scrs shqidd be aware? 

Air. Havwaed Ptnch, in a brief reply, said that he had 
not attempted to insert seeds in the oesophagus. AVitli 
regard to the different response of different tumours, the 
supposition was correct that all cells were more vulnerable 
to radiation during the process of division. 


SARC03IAT0US 3IETAPLASIA OF A UTERINE 
FIBR03U. 

At a meeting of the North of England Obstetrical and 
Gynaecological Society at Sheffield on February 24th, the 
president, Dr. Leith AIuiceay, described a case of sarco- 
matous metaplasia of a fibroid tumour. 

Dr. Alurrny said that the subject of malignant metn- 
pUcsin in fibroid tumours bad interested him for many 
ycai-s. In the literature its incidence was given as between 
1 and 2 per cent., while Eden and Loclcycr thought 
that it should he slightly under 1 per cent. Dr. Alnrray 
believed that be had cut representative sections from eveiy 
fibroid that he had ever removed, but the present case was 
the lii-sl definite malignant metaplasia ocenrring within a 
fibroid that bad ever come bis way. Tliis struck bim as a 
remarkable contrast, and suggested that there must often 
have been au clement of doubt in the diagnosis. In all 
likelibood the chance of eiTor in diagnosis had been in- 
creased by inchuling fibroid polvpi. On four occasions in 
bis experience an oedematous fibroid polypus had shown 
n microscopical appearance rather suggestive of malig- 
nancy; cytologicul examination, however, coupled 110 °)! 
complete absence of lecurrcnce in any one of these cases, 
made it quite certain that the oedema was the cause of 
the doubtful apiiearance. The society bad taken its part 
ill reporting specimens; it had to he 'noted, however, that 
two of the tlirce irci'e queried when they were .shown. 
AIosl of the cases recorded bj’ members and others bad 
been a.ssqeiatocl , with rapid growth, and blood-stained 
discharge from the uterus. This latter sign suggested that 
the tnmour, if it really began in a fibroma, had partially 
e-scaped therefrom • there was a loophole for error, inas- 
much as a iitcrine sarcoma, arising, for example, in the 
endometrium, might penetrate fik-.-i’cl growth. 

Tlio case be recorded showed di ‘ : > arising 

in the centre of a fibroid tumour wbieli bad been removed 
by myomectomy. The malignancy was not snspcctecl 
until the specimen was incised after operation. A further 
point of interest lay in the youth of the patient. 

A ■woman, aged 29, who had been mamed for seven Tears, had 
one child .six years old. She had had aching pain in 'the n"ht 
side oH and on for tweii'e months; menstruation (S/23) had Iiocn 
regular and moderate until one month before she came under 
notice, when, four days after an ordinary period, a further and 



498 March 24 , 1928 ) BARCOMATOTTS METABtASlA OP PIBBOIP GROWTH. 


■'*H ‘.'o^ j- BnmsH ! 


1 Medicl jocRSjlti 


similar period occurred. Examination showed a rounded and 
enlarged uterus, tho fundus being palpable two inches above the 
synipuysis pubis. A diagnosis of fibroid uterus was made and 
a solitary fibroid, weighing 12 oz., was enucleated from tho 
right wall of tho uterus at the fundus through an anterior in- 
cision. There was at first slight difficulty in defining the capsule 
anteriorly, but not more so than occasionally happened with 
myomectomy operations. Tho uterine cavity was accidentally 
opened during tho enucleation and was sutured. Tho specimen 
had the external appearance of an ordinary fibromyoma. A 
preliminary incision of tho specimen showed in the centre a soft 
rod and pulpy area, completely surrounded by fibromyomatous 
tissue; a hemisection was postponed until tho speeimen had been 
hardened. There was a complete layer of pale fibroid tissue 
beyond tho central growth, which at no point had reached nearer 
tho capsule than a quarter of an inch. Microscopical examination 
showed a core of haemorrhage and necrosed tissue, with malignant 
areas at the periphery. These areas were definitely cellular and 
appeared to have vascular relations. 

Dr. Tvlurray tliouglit tho growth might well ho called an 
ehdo- or peri-thelioma. It feseiiibicd very much a speef- 
men. described and figured by Leith;' the growth, in that 
case, occurred in a woman aged 44, and tiro years after 
tho menopause. Presuming that there would ho agreement 
that this was in fact a case of sarcomatous metaplasia, ha 
asked whether ho should now remove tho uterus. Tho 
patient, so far, remained fit and well. 

Dr. A. A. GnsHtEi-L (Liverpool) recorded a case of 
sarcomatous metaplasia of a fibroid growth which illus- 
trated some of tho difficulties in forming an opinion on 
the origin of the sarcoma. 

Tho patient was 54 ye.irs of age and bad not reached the meno- 
pause.^ Sho had had four children. Menstruation had been 
excessivo for tho last twelvo years, and slio liad boon losing 
continuously for four months when she camo for consultation. 

The specimen consisted of tho uterus and both appendages, 
removed by total hysterectomy. It weighed 21 lb. and measured 
on removal by 4 by 4 inches. It was regular in outline, with 
adhesions of omentum to its anterior surface. Tho uterus had 
been opened anteriorly and showed a growth projecting from 
tho posterior surface into tho cavity and filling it; tho lower pole 
was necrotic and had burst. On section the tumour was mainly 
whitish and soft in appearance, with areas of yellow coloration 
and some haemorrhages. Sections showed tho growth to bo 
almost entirely a sarcoma of mixed cell typo, composed of fairly 
large spindlo cells with numerous larger “ giant cells ” of varying 
size, many ovoid or polygonal, and containing one, two, or tlirco 
nuclei. Remnants of the fibroid structure were visible in places 
-both at the periphery and among the sarcomatous cells. Sections 
of the uterine muscle at tho base of tho tumour failed to show 
any sarcoma, as did sections of the endometrium close up to tho 
point where the tumour had ruptured. 

Dr. Gemmell said that Whitridge Williams’s article of 1894 
still remained amongst tho best of those on the histogenesis 
of sarcoma of the uterus. Judged by his standards, the 
present case was not likely to have originated in the endo- 
metrium, since that membrane was normal right up to tho 
place where tho necrotic portion of the tumour had rup- 
tured, and also because the muscular uterine wall main- 
tained its normal thickness. It might have arisen from the 
uterine wall, but the presence of myoma-like tissue amidst 
the sarcoma cells and at the perijihery of the tumour opposed 
this view. That the tumour was apparently circumscribed 
did not exclude the uterine wall as a possible origin. On 
the other hand, this myoma-like tissue might be merely 
remnants of the connective tissue of the uterine wall. Tho 
history of excessive menstrual loss for twelvo j'ears was, 
however, suggestive of a pre-existing non-malignant con- 
dition. 

TJtcrine Carcinoma Following Operation. 

Mr. W. Gough (Leeds) described a case of carcinoma of 
the body of tho uterus after interposition operation for 
genital prolapse. 

• The patient, aged 70, complained chiefly of urinary symptoms, 
dvsuria and pain, and there had been haemorrhage in tho urine 
•for the previous month. There was also complaint of bearing- 
down nain in the lower abdomen and back. Amputation of tho 
cerfix.-colporrhaphy, and vesico-vagmal interposition Iiad been per- 
fSmei fifteen years .previously. Since that time she had been 
uSr'tho care i another surgeon suffering from obscure urinary 

•unuei tiiu atrophy of the vaffjna, and no 

posterior to 


‘crTmSnms There was marked atrophy of the vagina, and no 
-Bymptoms. There was a hard mass lying posterior to 

cervix could be lelt.^^^tne bladder. It was 

the .‘“Jr , 1 . tn^ that the surgeon who had operated 

the cL tal Sapse was in tie habit of performing 
on her for ti e genital pro 

the interposition op - investigating tlio condition under 

bo the bpdv of the uterus m es b invaded by growth 

anaesthesia he found tne i-.i. -n-vn the 

■a-hich Iiad ulcerated through ■ about half “ I™!' , 
urethral meaUi s. The bladder was enlarged and, eztenaed well 

'’7 OlfStctricB and Gytiaecoloffy of the Sritith Empire, 1911, 


abovo tho pubos: tho urethra was not affected. Microscopical 
examination, of tlio growth showed it to bo a papillary adeno- 
carcinoma of tho corporeal typo on tho wholo. 

Full-term Ectopic Gestation. 

Professor W. PhEicnEn Shaw described a fuiUerm 
ectopio pregnancy in a primipara; labour pains were said 
to have begun fivo weeks after the expected date of tli9 
confinement. After twenty-four hours tho pains ceased,- 
and did not recur, and from tliat time sho felt no foetal 
movements. Ho saw her four months later and made a 
diagnosis of ectopio pregnancy. At the laparotomy he 
opened a largo sac containing a full-term foetus, macerated 
and foiil-smclliiig. He removed most of the placenta, but 
left beliind those parts which wore firmly adlieieiit. The 
abdomen was closed with a largo packing of gauzo in tho 
cavity. Tho patient Iiad a raised temperature for tlireo 
weeks, but was fit to go home at the end of six weeks; 
Slio was now qiiito well, but a small, sinus remained. 

Mr. St. Geokoe Wilson (Liverpool) recorded a case of 
full-term ectopic gestation treated by Caesarean section', 
with delivery of a living child. He bad seen tlio patient 
first when slio was seven months pregnant, and a diagnosis 
of ovarian cyst complicating pregnancy was made. An 
x-rny examination at term showed tho foetus lying above 
tho pelvic brim, and in an unusual attitude. Ten calendar 
months after tho last menstrual period she reported at 
hospital, complaining of - labour pains and a “ show.’f 
Abdominal section showed that the condition was an extra- 
uterine pregnancy, apparently situated in the right broad 
ligament. The placenta was left in situ, the coid was cut 
short and the incision in tlio sac wall was closed. Tho 
abdominal wall was sutured witliout drainage. Tlio tumour 
in tho abdomen was then about the size of a uterus of 
Iwcnty-two weeks’ gestation. Tho temperature remained 
reised for three weeks, but tho patient '''h® d.scbaraotl at 
throLrof tho fourth week. By this time there had been 
rt?lf diminution in the size of the abdominal tumoui . 
httle d ... gj numerous deformities; 

Vvf l*fm- five months. Recent examination of the mother 
3 hS 1 sweUing about the size of a hen’s egg to the right 

of a normally situated utei us. 

Combined Concealed Accidental ond Unavoidable 
Haemorrhage. • 

v. w IT Lacev (Manchester) descrihed a case of com- 
b-?ed croofalcd accidratal and unavoidable haemorrhage, 
bincd thirty-seven weeks pregnant, 

A A-para, age , haemorrhage. Although this h.ad 

with a V- - general condition suggested that it had been 

been slight, Jj^i/and faint, and the pulse was 120 and weak, 
severe.' She T and complained of no definite pam> but 

she was s?'nBWhrt r'’|„ her abdomen, and of dizziness which bad 
of a continual acbo in Iwr ^ h i 

been abdomen was very large, tense, and tender, 

ttlburaimiria. The fundus; foetal parts wero fc.t 

parlicularly ^ foetal heart sounds could not oe heard, 
indefinitely, but ' admitted ono finger and the 

vaginal examination tii Lacey was confident from 

wal felt to ‘’^v'rSe ^had concealed accidental baemorrliage, 

LTd Tcfdtd^o Performjaesare i;,. 

lend-ed^^^-e was - -idenoo of baemorrh^ into J • 
Incision of the be o^upied by twins; ono placer .a 

and the segment, while the other one was on tho 

occupied tb° uterus, under which, and close to tho edge^ 

posterior wall o' , , qq,e uterus was removed, ihe tw.us 

was about a former was attached to tl'O placerta 

weighed 6 'b. a i forty minutes, whereas the other child . 
pralvia. oud 1'™^/ made T unel-entful recovery, 
stillborn. hacmOTrliago tho blood was examined and t o 

of the concealed haemorr strongly positive. The 

thr'dlscoverer of EdS 

this After demoiistratifig a specimen of enr- 

Socety in 1863. " Professor Simpson had 

St rtt till slUraf first'td 

— of intense paroxysms of pa , p P ;„tensity, 

intermittent, ’”'1 ‘nnd^tliL gradually sub- 


'x. 


ilABCH 24, 19^3] 


.ni 


Oioaa. L 'EEVJETKSCiV;- •• 


[ 


Tht- Bjimsa 
ilEDlCAL JOTTRXAI. 


499 


BidiiK- He also said that this symptom had been reiy 
marked in most of the cases of cancer of the uterine body 
which had come under his observation. He specified one 
instance in which severe hypogastric pain began at 12, 
.1, or 2 o’clock in the day, culminated between 3 and 5 
in the afternoon, and ceased at 6 or 7. On some days it 
returned again from 10 p.m. to midnight. In this case, 
after dilating the ceiwix with sponge tents, Ih-ofessor 
Simpson had scraped away a friable growth, but the 
periodic pain still continued in the afternoons, and his 
■ final note stated that the patient was “ dismissed to-day 
as her cries were injurious to tlie other patients and as 
there was no prospect of giving her relief.” He had seen 
similar - intermittent periodic pains in a case of calcified 
submucous fibroid, and somewhat similar paroxysms of pain 
in a few instances of retention of fluid in the cavity of 
the uterus from occlusion of the os. Finally, he stated 
that, except in those rare cases, the symptom he had tried 
to describe was only to be met with, so far as his observa- 
tion went, in patients who wore suffering from carcinoma 
of the body and fnndns of the uterus. Professor Miles 
Phillips said that this symptom was not often mentioned 
by Englisli writers, for the reason, be believed, that it 
was not often obseiwed. Eden and Eock3’er (Cfynaecology, 
1928), in describing the sjmiptoms of corporeal cancer, did 
not refer to pain of any description. This appeared to 
Professor Phillips to be rerj- remarkijble, as in his own 
series of eiglity-ta-o cases, which he had recently analysed, 
pain was definitely present in sixty (73 per cent.). However, 
Tliomas Wilson in the fl’cie System- of Gynaecology said 
“ Simpson described as an carh- sj-mptom in these cases 
regularly recurring attacks of severe colicky pain in the 
lower abdomen. Tliis would appear to be rare, and I have 
only seen one snob case. The pain is described as a severe 
bearing down, and appears to be due to efforts of tbe 
uterus to expel tbe cancerous tumour from the cavity.” 
.Winter and Iluge in Gynaecological Diagnosis stated that 
another very suspicious and almost pathognomonic sjmptom 
-was found in Simpson’s pains — namely, regularly labour- 
Jike pains, lasting several hours and recurring at a definite 
time of the day. Pozzi, in his treatise on gynaecology, also 
recalled that Simpson first drew attention to the remark- 
able paroxysmal pains which recurred at regular intervals. 
But Pozzi disagreed with some writers, including Schroder, 
.who had .stated that these pains were due to spasmodic 
expulsive efforts, because he had noticed that thej’ still 
continued after lie had scraped awav the friable growth. 
He believed that tlio' pain was a true neuritis resulting 
from involvement' of the nerves supph iiig the uterus. 
A recent case in which this symptom was well marked had 
led Professor Miles Phillips to hunt through his records of 
cases^ of corporeal cancer. He had a clear recollection of 
two instances of Simpson's pain, hut his notes revealed 
two otheis, so lie could record five in all out of a series of 
eightj'-two of this form of cancer. He gave an account of 
these five cases, a study of which led liim to agree with 
Pozzi that the sjunptora was rare, and probablv neuralgic in 
character. 

The PiiEsinEXT said that ho was surprised to note 
Piofessor Miles Phillips’s high percentage of pain. He 
Iiad referred to his private cases, totalling thirty-four, 
and found that in twenty-four there was no complaint of 
pain at all. Two of these patients had dilation of the 
cei-vix with growth palpable at the external os, but without 
invasion of the cervix by raalignancv. It would appear 
unlikel_v, therefore, that pain was associated with attempts 
a extiusion. Five of his patients had complained of 
gnaning or cramp-like pains without periodicity ; four 
of these cases were operable. Five patients complained of 
pain arising apparenth- outside the uterus and referable 
o intestmal colic from adherent intestine, suppurative 
appendage disease, and prolapse. 


tfle Harveiaii Society was held ; 
the Royal ^aterloo Hospit.al on Februarv Ifith at 5 p.m. T1 
president, Dr HmsimT Fuanch, took the cliair. Seven cas 
were shown by members of the shaft of the Rmwl AValerh 
Hospif.al and two cases bv Dr. Twitle and Dr. ‘C o-I'e-Smih 
T he rases were fully discnssed by (he members and visitor 
and at the conclusion of the meeting a cordial vote of than! 
.was passed to tlio, staff of the Bo.val Waterloo Hospital. 




SOLLMANN’S PHARMACOLOGT. 

SoM-xiANx’s Manual of Pharmacology,^ the third edition 
of which we have received, is well known as the largest 
textbook of pharmacologj- in the English language. The 
A'olume contains nearly 1,200 pages, and it is of particular 
value to advanced students because a full account is given 
of tbe chief recent rese.arch work in the subjects dealt 
with, and moreover an excellent selected bibliography of 
a hundred pages is included. This textbook is therefore 
one that has established a high reputation as a convenient 
and well-balanced work of reference. -'We are glad to saj- 
that the author has shown great industry in bringing the 
work up to date, and has included all the numerous new 
drugs of importance that have been introduced into 
medicine in the five years that have passed since the last 
edition appeared. He mentions in his preface that tlie 
recent advances made in pharmacologj' liave necessitated 
the rewriting of many sections of the book, and that the 
bibliograpln- lias been extended bj- 1,200 new references. 

The scope of the hook may he indicated by a few 
examples. The pharmacology of lead occupies seventeen 
pages and contains references to the treatment of cancer 
by injection of colloidal lead, and also a page and a half 
on the toxic properties of tetra-etli}'l lead. His conclusion 
on this last subject is, that although tetra-etlijd lead is a 
highly toxic substance, j'ct the danger to the iiublic from 
its use in petrol appears to be slight, although decisive 
data are still scaiitj'. Among the new substances men- 
tioned for the first time are insulin, parathyroid- extract, 
and the new cliemo-therapeiitic agents such ns Bayer 205, 
and the various organic arsenicals. The .author, takes a 
wide view of liis subject, and has included an account of 
vitamins and radiations and some discussion of other 
problems which lie on the borderline of pure pharmacology. 

Dr. Sollmann’s general outlook indicates a rational 
scepticism. This is illustrated in his summary of the 
results of glandular therapy. He points out the knowledge 
that it is essential to possess before any glandular prepar- 
ation can be used with any certain success in tlierapentics, 
and then concludes: 

“ Gland therapy can be established on a sound basis only in 
the direction Oiat has been indicated, however difficult and 
laborious and tedious this may appear. Its development is 
rather hindered by premature enthusiasm which is inclined to 
dispense willi definite criteria of action, with adequate controls, 
with effective preparations or efficient channels of administration, 
and often with critical diagnosis; which interprets psycliic mani- 
festations as scientific observations, and which depends on 
‘ autistic judgement,’ that is, judgement or rather credulity based 
on desires instead of facts.” 

This volume, ns we have indicated, is, without doubt, the 
most extensive work of reference in pharmacologv in our 
language. In former editions there was a tendency for 
the accounts of the details of conflicting evidence to 
obscure the main conclusions, but tbe new edition sbons 
much improvement in this respect. The author states 
I that the dominant object of the manual was to serve a.s a 
textbook for medical students, but it is scarcely suited 
j for tbe routine uso of undergraduate .students in tlii.c 
couiitiw, because the time they devote to pliarniacology is 
I insufficient to allow them to master a work of this size. 


MIED GFIDAECE. 

Tns title of Dr. A'i'Etixo’s book, Directing Mental Energy, - 
is sufficiently arresting to cause the student to stop and 
inquire whether here at last will be found a real attempt 
to explain tbe secrets of self-direction and of those 
phenomena which underlie tbe ccnver.sion of psycliical 
“ potential ” into kinetic “ drive ” and aceomplisliment. 
The problem is a fascinating one, and should tins work 
lead to tbe discovery of some tangible clue to tbe secrets 

' A Manual of Pharmacologij. By Torald Sollmann, AfiD. Tliird 
edition, entirely reset. Philadelphia and London: tV. B. Saunders 
Companv. 1927. (Boy. 8vo, pp. 1181 35s. net.) 

"Directing Mental Kneegy. By Francis Aveling, .V.(7., PIi.D., B.Se. 
London : University of London Press, Ltd. 1927. (Demy Sro, pp, x + 
illustrated. Ss. 5d. net.) 



600 March 24, 1928] 


..-EEVJEWS. 


caveat that the title ef l,;o j, 1 spite of hi 3 

bonded. We feel that Dr A °'i-^ misappro- 

s.:f 

r£ari;rl';*"3 

life? ’ ” Thus far snticf^t 'mJ 

aSpornt'",uS“^ri?^^ f ' nniii^t: Z 

lines farther on lloTars • '"we c 1, P'^"' ^ 

with making the most of life AVe cf °n hero 

with making economies instead litti concern ourselves 

tL'tntr.,rrSo-S”tt “f ”'■ 
s:!rg-x”.i‘"Z3f?“r 

it eemec + 1 "ascago and emotiona wastace. AVhen 

“iSr;4;, jt 

:»h“‘ jr.% "ii;3 st?-™ «-r.n3 

energy in remeSing XS slmufd 

e^ESSS 

?Jg7ofV“ ■" ™r‘Fs '*=^‘^^''TSseo'Jnd“h^ 

tage of learning by “ spaced repetitions ” rather tlfo i 
continuous repetitions. The third cXL,XXa > 

* ^Thr’^'r“®t°^ ^ passage as a whole rather than in pXts*°^ 

The chapter on emotional wastage is of interest Dr 

Tl.. ,u»iia. „, will “,",„i?= 




fp- r Hf rt r 

L MfiMCAL Joon.v’ii'T 


other side are o’^itlinoXawfims'X thT*”^ tl'cm on tha 

dra!;it;\Xir[eX^^^^ X --'Ss 

authors state that thL h The 

grams for a coiisidSle Xmt 
working with tho collaboration of 
surgical colleagues, it mav he ncc, ^ a* I?"" “®‘^'cal and 
aro authentic, tho diao-nLis net 
the x-ray examination onX ““ 

rec4T';:a;-r'consifXrof « 

collection of x-ray pictures witlTa si ° f 1 “^ heterogeneous 
attached. These form ev;„u' 1 < " • description of each 
no other respects do thnv f ifif Picture books,” but in 

siderablo letteipiess which precedes each division of tho 
in^thfnXm^" very fully and in detail the various points 
nlm 1^ *■ 1 *''° deviation from the 

features ‘'"a ' *’.'® chiiical and the radiological 

featuies. A further point is that each disease is repre- 
sented not by just one radiogram, but by a series of repro- 
ductions showing the different appearances which can be- 
caused by the same disease, varying very considerably in 
different cases according to the manner and position of 
attack, and tJie future development of any disease 
M'hile saying so much in praiso of these works' we are 
bound to add that in one important respect they aro open ' 
to severe criticism. Nearly all the radiographs are of poor 
tecliiiieal quality, practically none comes up to that stan- 
dard of excellence which modern apparatus and modern ' 
technique make possible, and not a few would be quite 
unintelligible except for tho line drawings accompanying 
them. That it is the radiograms themselves that are at 
fault and not the method of reproduction is evidenced by 
tho fact that the paper on which they are reproduced is 
of excellent quality and one side of it only is used. There 
is no doubt that tliis is a serious drawback to both 
volumes, and one which detracts considerably from their 
. value. The best diagnostic work must always' be backed up 
by tho best technique, without which it of necessity fails 
to carry full conviction. 


difBculty. There is un +o<=t .J, presents more of what are known as detective stories is not the only sign 

gence; but Dr Avehni. Im, «■<> It seem’s 

-^-veiing lias also suggestive t bintre xi „ , ,. 


and several economies to propose Tlioi-e 1 
mental tests and o„ vnensPI?,"!!:. •./X° ^l^pters 


PKISON-BEEAKEES. 

The increased and apparently still increasing popularity 
of what are known as detective stories is not the only sign 


**V Kiiv/ w. .w.v J.V cct;;juo 

that fiction alone cannot satisfy the appetite of the public, 
for the number of publications dealing with actual crimes 
and criminal trials has alse increased. Of necessity these 

t I. _H X : X_l-1 x.t. 1 . . 1 


mental tests and on vocational V,',; i “*'? ‘^"“P^'^rs on and criminal trials has also increased. Of necessity 

space is allocated to the discussion of ““^, 7 °"siderable latter are all at least twice told tales, and some of them 

ing suecessful “ sublimation.” problems regard- have formed tho subjects of popular hovels such as 


ing successful “ sublimation. 

This is a book ivhich cannot be read without profit 

GASTRO-DDODENAL RADIOLOGY 

These large and taportant volumes,^ one on the radiology 
of tho stomach, the other on the duodenum, the work nf 
Pierre Duvae J.-C. Roux and Hexri Beclere, are two 
of a senes of books which, when completed will term 
■' The Archives of Clinical Radiology.” After describing 
and illustrating tho normal, each pathological condition is 
taken up separately, and a short note suffices to intro- 
duce a series of radiograms showing the x-rav appearances 
which accompany the disease under discussion. These 
illustrations are in reality the great feature of both 
volumes, and aro very numerous, some 400 alton-other 
The size of tho pages is such that four radioo-rams— ^ 
43 inches by 3J inches — can be put on one page. Tho 
arrangement is that when tho book is opened these wall 

rnr'^rw'°^T, ,P, Tuie Digestif: I. Kitomac et Duodenum 

rcutinic Ch?-"'' ’ JcoarCUailes Roui, Henri Becil-re. Clinique Tli^rai 
Masaon ct cie“'Tqm ° r?f ti JiMecine de Paris. Paris: 

“euroa. S 65 tT\ Iho^iwi voWe^j'’' «2 


w* ixuveis iDucii aa 

AinswortJi^s JaeJi Sheppard and ^ookwoodf which with 
other works of fiction called forth Thackeray^s indignant 
counterblast of Catherine. In that hook he strove to 
sweep away the false glamour with which his predecessors 
had invested vulgar ruffians, and in it he announced hia 
intention “ to tako a few more pages from tho * Old 
Bailey Calendar/ to bless tho public with ono morb 
draught from tho Stone Jug: — ^yet awhile to listen, hurdlo- 
moimtcd and riding down the Oxford Road, to tho bland 
conversation of Jack Ketch, and to hang with him round 
the neck of his patient at the end of our and liis history/’ ‘ 
Mr. PhiiaLIP, 'in his book The Prison Breahers,* makes no 
pretence to do more than amuse his readers by relating 
with gusto the stories of the escapes and attempts to 
escape of John Nevinson, Jack Sheppard, David Haggart, 
Louis Cartouche, Louis Napoleon, George Kelly, and 
Frederick Trenck. 

The Dictionary of National Biography may tell us that 
the real Turpin was a mean and repulsive ruffian, who 
never rode to York on Black Bess or any other mount, 
but that disclosure only affords an opportunity of dcscrib- 


*• The Prieon-BreaVers. By Alban M. Phillip. London : P. Allan and 
Ca, Ltd. 19^. (lied. 8vo, pp. x 4- 282 ; 8 plates. 10s. 6d. net.) 




502 ^'MAKCn 24 , io? 8 ] 


KOYA ET VETERA. 


.ns to cessation of practice or change of address, and 3 were 
struck off under tJio disciplinary powers conferred on the 
General Medical Council by the Medical Act. 

Tn form the Dentists Itcgistcr^^ for 1928 follows the *tyle and 
method of arrangement of the Medical liegisterf but on a 
smaller scale. It cont.nins 14,576 names, of which 6,788, or 
46.57 per cent., are registered with medical, surgical, or dental 
qualifications, as compared with 6,649, or 45 per cent., so 
registered in the previous year out of a total of 14,595 on the 
]{e(jister. The remainder in each case were registered under 
the provisions of the Dentists Acts of 1878 and 1921. Of 401 
names added to the Register in 1927, 362 were registered with 
qualifications, and 38 were registered under the Dentists Act, 
1921. Tlio numher restored to the llegistcr under the Acts of 
1878 and 1921 was 355, and the number similarly removed was 
438. In addition, 135 names were removed on evidence of death. 
For reference purposes a useful feature of this volume is tho 
local list, which shows under each postal district in London, 
each town or village in tho United Kingdom, each country and 
town abroad, and in each of the Services, the names of dentists 
practising therein. 

The Medical and Dcyital Students Dcgistcry^^ also issued by 
the General Medical Council, has a title which is self-explana- 
tory. The numher of medical students registered last year w.as 
1,214, a decrease of 46 on tho previous 3 ’ca»*'s total. Scottish 
registrations numbered 539, an increase of 45; thero were 503 
English registrations, a decrease of 74, and Irish registrations 
totalled 172, a decrease of 17. Dental students registered in 1927 
wore 244 in number, as compared with 229 in the previous year. 


The, Ventifts Tte^iHer^ 1028. London : Published for the Dental Board 
of tlio Uniteil Uinpdom by Constable anil Co,, Ltd. 1928. 

“ Medicat and uental Students Itegisicr, 102S. London : Pnblisliod for 
tho Gencial Medical Council by Constable and Co., Ltd. 1928. (7s. 6d.) 


PREPARATIONS AND APPLIANCES. 

AA^ellcome Livek Extract. 

The discovery m.ide by Minot .nnd Slurpliy in 1926 of tho 
reniBi'kablo ciirntivo action produced by liver feeding in per- 
nicious anaemia has been confirmed all over tlio world, and 
already a considerable advance has been made towards the 
identifirntion of tho curative principle. It is now known that 
this active principle is not a protein nor a lipoid, and that it 
represents less than 1 per cent, of the weight of tho liver. 
It i.s pi'ohably a polypeptide or a nitrogenous base. 

This knowledge lias permitted tho production of liver con- 
centrates. The AVellcomo liver e.xtract (Burroughs AA'^clIcomo 
and Co.) is a light brown colourless powder almost completely 
soluble in water. It has been prepared by a method tested 
and found efficient by the Medical Besearch Council, of which 
a description appeared in our l.ist issue. It is put up in tubes 
each containing a few grams of powder. Each tube is the 
equivalent of half a pound of fresh liver. Tho contents of one 
tube are a minimum daily dose in the initial st.Tges of treat- 
ment for a case of pernicious anaemia, and tho dose can bo f.Tkcn 
in the form of a soup. 

The treatment of pernicious anaemia by liver feeding is such 
a recent discovery that it is still too early for us to know 
whether tho curative effects produced arc permanent. Already, 
however, this treatment is universally recognized to produce 
curative results in pernicious anaemia far superior to those 
produced by any other form of treatment. The production 
of concentrated preparations such as the “ AVellcome liver 
e.xtract will facilit.ite very greatly the treatment of pernicious 
anaemia, and particularly tlio treatment of the severe cases 
where the digestion is markedly deriinged and the administration 
of large quantities of crude liver is difficult. Even in milder 
c.ises the concentration of tiie active principle will permit of 
more intensive treatment than has been possible hitherto. 

CONCENTTIATED A’'iTAJIINS A AND D. 

“ Eadiostolcnm ” (British Drug Houses, Ltd.) is a concen- 
trated solution of vitamin A and vitamin D in a pure vegetable 
oil and is standardized physiologically to contain a defiiiito 
nuantitv of each vitamin. The vitamin content is about twenty 
tirnes that of the best cod-liver oil. Hence three drops of 
radiostoleum is equivalent to a fluid di'aclim of active cod- 

^''Tl\e°''makcrs explain that their vitamin D preparation 
(radiostol) has given very favourable results in tho treatment 
of rickets and that they have prepared this now preparation 
because there is considerable evidence in favour of the view 
th.at vitamin A is .an important factor in the mainlenanco of : 
resistance to infections. They h.avo been able to prepare a 
vitamin A concentrate from a newly discovered source of this 
vitnmin, ami are putting forward the combination of the two 
vitamins for clinical trial. 


r The IlBrnsH 
L Mr-DrcAL JounviL 




THE CAUSE OF THE DEATH OF HULLIAAf, DUKE 
OF GLOUCESTER, SON OF QUEEN ANNE, 

"r-kx ■* 


IN 1700. 

liiEUE must ho few persons interested in liistoiy who hare 
not tried to pietiiie tho jirohahlc state of Great Britain 
niid Europe to-day Imd the little Duke of Gloucester lived 
to succeed liis mother, Queen Anne, and thus have prevented 
tho Hanoverian succession to the English throne. Owing 
to l.hc far-reaching coiiscqruenecs of tlio prince’s death, tlio 
nature of his fatal illness was tho .subject of violent contro- 
versy at the time, and of iiioro reasoned discussion on many 
occasions siiieo. 

In an annotation on an address on Samuel Pepys .appear- 
ing in the Hiitish Medical Journal of February 25th 
(p. 319) I am quoted, correctly, ns attributing tho death 
of tho prince to sinall-po.x. Tho reviewer jiointcd out that 
tho Vicltonanj of J^ational Uiofiraphy says otlicnviso 
[“ orroiicoiisly thought of the small-po.x ”J. I was awaio 
of this, hut the writer of Queen Anne’s biographical iiotico 
produces no evidence, and names no authority, for his 
statement; a jioint in dl.:piito for over two centuries can 
hardly he dismissed in so suinmarj’ a fashion. 

From a consideration of data pieced together from a 
variety of contemporaneous sources, I'had concluded that, 
on the whole, the original diagnosis of smnif-pox was 
probably correct, hut since the matter was debatable I had 
drafted a footnote thereon to bo added to tho address when 
published. Recently, however, in the course of a systciiintio 
scareli in tho British Museum, I eiicoimtered a source of 
information, new to mo, which makes mo fear that T may 
have iiocii giiiJtv of propagating ciror throiigli tho medium 
of tho British Medical Journal. Leaving this evidonco asido 
for the moment, tho particulars whieli I Jmve sucoeeded in 
collecting regarding the circumstances of tho fatal illness 
are, briefly, as follows : 

On AA’cdncsdny, July 24th, the young prince took a boisterous 
share in the festivities arranged to eelcbrato his eleventh 
hirtlidav, and seemed “ fatcagii’d and indispos d m the 
cve ing. “Ho complained a little next day,’ sijys Bishop 
Bmmot, then his tutor, “ hut we imputed that to the fatigue-s 
of a b irllulay.” This d.ay, according to Hannes, wlio did not 
Le the prince until Frid.ay evening, "he was extremelv Sick, 
and complained of his Throat ” (also " of Ins Wd and hack 
T oHrclll “ All Frid.ay ho was hot and Feavourish —to 
TnttreU adds that ho was troubled with “ looseiiesse. 
n ' Siturdav movuing ho appeared better, hut towards cycinng 

Bic lev r t^caTe mo?e vioI^St. " His Higlmess went this D.ay 

the 10'® ' 1 tijis day a Bash came out on his Skin, 

very often to btooi.^uit^, . . On Saturday in tho Afternoon 

^l’'“Feav"ur growing stronger He went into a Delirium, winch 
'"i A his Ulc 1 He%a.ssed this Night as he had done 

f rvlth short broken Sleeps, and incoherent Talk, 
n ** ?rnndav ■ the Pulse mending it was thought probable 

Sn«s’ might recover. About Eleven at Night we were 
alarm’d with a sudden change, and about two Hours aftei . . - 
His Highness Expir’d.” 

c' 1 . nrn tho material parts of Hannos’s account. 
A^irdinir to Luttrell, tho princo did not come under 
A^°[^obfervation until Friday evening, for, writing on 
fnv ho says, “ Pliysitians were last night sent for 
bcl ivenm may have the small pox-” T >o 
*«Hon woro rsir Edward] Hannes and Bidloo, King 
nr-u” ^s Dutch physician. They believed the condition to 
n Ilham s possibly regarding tho eruption ns an initial 
'%'“wwhiH wo migTit assume tli.at its elmvacters were 
•ash, ? suggested a diagnosis of scarlet fever. 

nmded to "“"i/ K JcUirrwif 

Inrhis” himihe^ 



■RIAECH 24, 1928] 


f. - -.J A ,•/- - 

NOYA ET YETERA. 


r THE BnmsB 
aiEDiCAi. JornvAi, 


■ 603 


EadcUffc this seems likely enough, hut the story that he 
refused to prescribe for the patient, .and declared he would 
die the following day, is clearly unfounded. 

. Gibbons 'records that when he first saw the prince on 
Sunday 

‘‘ betwixt Three and Four in the Morning,” “ He swallowed 
with ease, and when 'I looked.'intohis Throat I found nothing 
amiss there. About -Eight, the same Morning . . . Eruptions 
began to appear in his sUin, which towards the Afternoon 
increas’d, and at Night appo.ar’d like a Rash.” He confirms 
the diarrhoea! symptoms, and mentions vomiting of “Vesci’d 
Phlegm.”, .“ He continued in a breathing Sweat and the Rash 
out, till about Eleven of the Clock last Night [that is, Monday] 
when on a sudden He was seiz’d with a difficult Breathing, 
and could swallow nothing down, and dy’d before Midnight.” 

Radcliffe made his examination of the prince at six on 
Sunday evening, -when 

VI found -his Highness-in-bed-witli-a very-high Fever upon 
him, his Flesh e.xtream hot, and a high colour in his Cheeks, 
with several Eruptions upon his Skin and Face, attended with 
a Rash ; which gave some- Suspicions that it might prove the 
Small-Pox; His Pulse ■ was very quick and Feverish j His 
Tongue White, and' his swallowing without pain or difficnlty ; 
his Breathing by fits short and attended with great sighing.” 

_ Ho too mentions the' diarrhoea, and gives details of his 
treatnient, thus .disposing of the.' story that he refused to. 
prescribe. . .. ; ^ 1 . ■. 

On Monday morning,- He was less 'Light-headed, and tlie 
Rash came out more, so that towards Noon his Head was con- 
siderably belter, and his breathing freer, which gave us some 
Encouragement at that time to hope his Recovery.” But, 
“ He was on a sndden, after a little doseing, taken with a 
oOrt of Convulsive Breathing with a defect in Swallowing, and 
a total Deprivation of all Sense, which lasted about an hour, 
and so between Twelve and One at Night he departed this 
Life.” 


Seemingly there wore two elements in the exanthem — 
one more diffuse, the “ rash ” which appeared on Satur- 
day (third day), and a more discrete “ eruption ” which 
showed itself on the morning of Sunday (fourth day). If 
the latter was a true small-pox rash it would not have 
assumed a definitely diagnostic appearance at the time of 
death. Clearly Radcliffe thought that the eruption had 
not sufficiently matured to warrant a definite opinion, and 
except for his suggestion of small-pox, contents himself 
with calling the malady ‘‘ A Malignant Fever with a Rash 
attending it.” Bishop Burnet borrows Radcliffe’s term 
“malignant fever”; while Evelyn makes the unqualified 
assertion that the prince “ died of the small-pox.” 

The foregoing clinical reports of Hannes, Gibbons, and 
Radcliffe I have extracted from their letters, dated July 
30th, given in a most interesting but little-known tract 
in the British Museum, and I am convinced of their 
authenticity. There is no reference to this tract or its 
contents in any account of the prince’s illness which I have 
seen. It is clear that Hannes’s letter is the unacknowledged 
source of Bishop Kennett’s description in his History, 
where it appears, in great part word for word. Sandford 
reproduces it with equal faithfulness in his narrative of the 
prince’s death and burial. James Johnstone, "writing in 
1779, quotes a condensed version of Bishop Renuett. Miss 
Strickland s account is too fanciful and inaccurate to 
repay inquiry into its origins. 

The further evidence, which I have mentioned, appears 
to have escaped the notice of medical commentators; 
certainly, like the tract just cited, it was unknown to 
that tireless scholar the late Dr. Creighton, and this alone 
■ivonld bo sufficient justification for calling attention to 
it lieie. I refer to the report on the post-mortem examina- 
tion, which IS entitled: 


An Aceonnl of the DhsccHon of hh Hintmess William DuJee 
Otorcstcr. D.-awn np by Doetor H. 'ond Sir/n'd by Sim m 


• preamble states^ that the examination was made 
in the presence of witnesses, by order of the Earl of 

to His lato Highness. TTnfortunatclv nothing is said of 
the rashes, presumably because their presence and characters 
bad not been in dispute during life. Except for the s^L 


ficant extract which follows in. full, the,. report merely 
records changes indicative of some acute toxic state. 

“ 4. The Neck was Swoll’n : And upon Dissection the inclosed 
Parts appear’d such, as they are observed in Bodies strangled. 

“ At tile place where the Jugulars arise above the Claviculae, 
the Inflammation approached very near to a Mortification. 

■ - “ The- Glandiilae .Thyfeoideae were - almost black with tho 
contain’d Blood : and being put into Scales were fonnd above 
Five Drachms in weight. ... 

.' “ The Giilet was much Inflamed ; the Windpipe also was 
affected in the same kind, especially the upper part of it call’d 
tho Larynx. In the Larynx, the Membranes that join the 
Cartilages CricoideS and Thyreoides were ..very dark with Gie 
Inflammation. . ’ . . ’ 

“ The Membrane that lines the Epiglottis (at' the root of the 
Tongne) was also Inflamed : insomuch that the Glandiilae 
Miliares of it, which are scarce visible at ether times, were 
here much distended and very conspicuous. 

“5. In the hlouth, we found the Palate inflamed; as also 
the Hvula, tlie'Membrane of which was.swell’d. , . 

“ The Almonds of the Ear (in the Throat) [Tonsils] were 
.swcll’d; and had in them Purulent matter : there being press’d 
out of one of ’em as much Corruption, as fill’d a Tea-spoon.” 

- The report, dated July 31st, is signed hy Hannes and- 
, three surgeons. 

*Tlie immediate cause of death -was an acute phlegmon of 
I the throat, hut whether. primary, which the, rather, gradual 
. onset- suggests, or secondary to one of. the acute fevers,- 
is difficult to decide if wo keep strictly to the facts as 
we have them. The absence of difficulty in swallowing is 
striking. The report gives no hint of any membrane, and 
this, if present, could scarcely' have escaped notice; nor 
does the condition described suggest a complication of 
small-pox at the fifth day. In some ways the attack 
resembles scarlet fever, but the late appearance of the 
rash is out of keeping.. Measles, too, is a possibility, hut 
there is no mention of any catarrhal symptoms, the impor- 
tance of ■adiich ivas recognized in that age. If the sym- 
ptoms had suggested either of these eruptive fevers', pre- 
. snmably it would have been diagnosed,'but the only diseases 
considered in the reports are small-pox and the vague 
“ malignant fever,” a term which even then had no specific 
meaning. In my opinion the malady may well have been 
small-pox complicated by acute laryngitis, the tonsillar 
condition possibly being pro-existent. 

Later, the three surgeons who had performed the autopsy 
issued the following signed “ Certificate ” : 

“ Wliereas ’tis reported that we the Surgeons, who Dissected 
the Body of his Highness the Duke of Gloucester have given 
it as our Opinions, that He dj-’d of a Quinsy, or sore Throat : 
We do now (as we did upon Dissection declare our Opinions) 
that the sole Occasion of His Higlinesse’s Death was a very 
high Malignant Fever.” 

Tho physicians wore much abused for their supposed 
mismanagement of tho case, hut it does not appear that any 
treatment then possible could have averted the fata! issue. 
Queen Anne gave no evidence of subsequent mistrust in 
Hannes, for he was appointed her own physician two years 
later, and knighted hy her in 1705. A satirical .poem 
entitled “ Doctor Hannes Dissected ” ridicules him for liis 
failure to arrive at a final diagnosis eitht^ during the 
prince’s life or after his death : 

•• But how so great a man of Art, 

Should let a Royal Heir Depart, 

And never tell the reason wliy, 

, He sliou’d not Live, or he shou’d Dye ” ! 

W. P. Mac-Iuthce. 

lilTEUATUne. 

Anon ; 'DoeioT Hannes DUttcled in a Familiar Fpistle hy vay of Tiotco 
Teiltsum. 

Barnet : History of Sis Oim Times. 

Kvetyn : Viary. 

Johnstone: Treatise on the Malignant Angina 

Kcnnett: Lives and Reigns of King irUliont and Queen Mary. 

Luttrell : Relation of State Affairs. 

" P.B." ; A Letter to a Friend concerning the Sichness and Death Of 
His Highness the Duke of Gloucester, ll'ith the True Copies of 
Three Letters wrote bg Dr. Hannes, Dr. aibhons. and Dr. Radcliffe 
to the King. . . . --- Many Mistaken 

Jtunionrs .Spread o ' ■ ■■ 

Pillis : Life and Lettc ■ 

Sandtord in Introilucti i's Memoirs of Prince 

William, Duke of ■ ' 

Strickland: Lives of the Queens of Lngland, 



504 ' MA.-RCH 2^; igzSJ TOXICOriOCT' nj KEEiATIM TO'' MEDICAL PBACTICE. ' 


TOXICOLOGY- m ' delation' to MEOiOAL 
PIIACITCE. 

Hakveian Lectube by Sir Williaji Wiebcox. 

At a meeting of tlio Harveian Sociclj- of London, lield at 
Paddington Town Hall on March 15th, under the presi- 
dency of Dr. Herueut Frf.nci?, the fifty-fourth Harveian 
Lecture ivas delivered hy Sir IVilli.aai IVintcox, whose 
subject was toxicology in it.s application to medical 
practice. 

Sir William Willcox remarked that in modern - times 
toxicology had risen to a position of the utmost importance 
in the profession; indeed, it now formed an integral and 
inseparable part of medicine. In recent years the theory of 
.focal infection as an important factor in the causation of 
many pathological conditions — such as chronic rheumatism, 
ga.stiic and duodenal ulccr.s, and diabetes, and as exemplified 
in the contribution of tooth sepsi.s to bodilj- disease — gave an 
extended field to this depai-tniont. Little was known as 
yet of the natiiro of the poisons which caused such con- 
ditions as uraemia and eclampsia. The blood-urea test 
was of great value, hut it was not the urea in the bloifil 
wliich caused the toxaemia; it was something the com- 
position of whicli had not yet been dotcnniiiod. Toxico- 
logical researches on these lines would do much to advance 
knowledge regarding the causation, and thoroforo the pre- 
vention and cure, of disease. 

Pharmacology was closely related to toxicology; the 
therapeutic action of a drug easily merged into a toxic 
action, idiosyuemsy and variations in the degree of toler- 
ance to a drug were constantly bejng encountered, these 
being probably often due to defective function of the liver 
or other organs. 'With regard to the rashes following on 
tlio administration of bromides and iodides, he spoko of a 
ease in which a large lump developed on the faco, and the 
diagnoses advanced included sarcoma. Then it became 
known that the patient had been taking iodide, and this 
knowledge saved an operation, for on stojiping the iodide 
the lesion subsided. An ei iiption might follow quite small 
doses of thi.s drug in some people, ■even as little as 3 grains 
three times a day for bronchitis. Accompanying the iodide 
there was often a salty taste in the month, and an irritating 
catarrh of the nasopharynx. 


Toi'ic Effects of Therapeutic Doses. 

Even ill therapeutic doses belladonna preparations might 
cau.se dryness of the mouth, impairment of rdsion due to 
paralysis of the 2iupil, as well as difficulty in passing urine, 
perhaps because of the action of the drug on the nervous 
system. A dose of 1/100 grain of atrojiine would cause 
retention of urine. Salicylates and salicylic acid jirejiara- 
tioiis might cause, deaf ness or vertigo, and, in those suscei>- 
tible to salicylates, cardiac disturbance such as faintness 
and tachycardia. Large dose.s of the drug might give i-ise 
to the symptoms of acidosis, and then acetone and diacetic 
acid would be found in the urine. The doctor should 
ho on tho watch for this when employing salicylates; 
it was .well to give in addition bicarbonate or citrate 
of sodium. 

Mercurial preparations when used extensively, as in the 
treatment of syphilis, might cause offensive breath, furj-ed 
to!i"UO salivation, stomatitis, looseness of teeth, diarrhoea, 
even ulcerative colitis. These symptoms were rarely seen 
nowadays, however, owing to the use of alternative pre- 
parations for this disease. "When epidemic jaundice was 
so common during the war there were many cases of 
mercurial stomatitis. The administration of opium pre- 
parations required much care, especially in the young, and 
III adults with renal and hepatic disease. He had seen a 
small dose of heroin, given to procure sleep, cause suppres- 
sion of mine. Quinine might cause headache, deafness, 
mjiscs in the ear, and vertigo, but these could be controlled 
b^- giving bromides. In persons having a special idiosa-n- 


crasy iowards quinine the drug seemed to have a selective 
action on the retina, and partial blindness might follow a 
quite small dose.; even optic atropliy had been kiioini to 
follow.-.! .With the use . of quinine for malaria in the 
; Salonica campaign there were inuiiy cases of optic atrophy.' 
- MTtli regard, to modern jdiarraacolpgy,, largo doses of 
liowerful drugs wore at the •pre.sont day advocated fop 
treating a number of diseases. Atoxyl had been used some 
time before its affinity for the diitic noiTe was generally 
recognized; this danger had not been pbinfed out fay the 
A'endoi's of the drug. After salvarsan nausea, slight 
albuminuria, and a small rise of. temperature lasting 
twenty-four hours generally occurred. Therefore, there 
must be no liappy-go-lucky way of administering these 
remedies. Arsenobenzol might have a bad effect on tlie 
liver, and jaundice might result from the hepatitis follow- 
ing its use, this manifestation sometimes being deferred 
for a few weeks. Ehrlich took extraordiiiaiy precautions 
regarding salvarsan before lie issued it for general eraplo}'- 
meiit, and, wliat was veiy important, each jiacket set out 
the dangeix and the contraindications. Prejiarations of 
bi.snuith for intrannisciilar use in .syphilis were not free 
from toxic effects- either; he had seen cases in which con- 
vulsions and coiiia followed their use, Tiyiianosomiasis and 
kala-^azar called for powerful remedies, and care was 
required in their administration to avoid toxic effects. 

The trcatnieiit of cancer bj- lead, recentlj- introduced by. 
Dr. Blair Bell, was an example of the careful use. of a 
poisonous metal to produce the best effect without causing' 

. 'Ti.o treatment consisted of intravenous 

lead 5 per cent, until, over a jieriqd 
■nt had received a total of O.S of a 
gram This had thrown a good deal of light on the 
toxicoloi^- of this metal; lead introduced intravenously 
did not^prochice the symptoms from which the plumber 
suffered In the case of most poisons the great burden was 
borne by tlie liver, though other organs shared too, and 
jaundice was not always present. 


Dangers of Eew Itcmcdics. 

Tlie niiinolin groiiii had been found to act as liver porous, 
and in some cases caused fatal toxic jaundice. 
such drugs as these there might occur mental irritability, 
vLiting, twitehings, stupor, coma, convulsions, and death, 
the temperature becoming very high 311st befoie Ae end. 
The cumulative effect of such drugs must always be remem- 
liei-ed ’ Ho bad known acute yellow atrophy, with a fatal 
termination, occur ten years after employment m a 
munitions- factory in association with tetramtrotoluene. 

• An interesting and important point was that of adopting 
measures to prevent or minimize liver poisoning. It was 
that if the liVer cells were stored with glycogen they 

u-ere able to stand more damage than otherwise; it was iiell 
nere.aoie j j ^ effect when taken on a 

^rrtomach tean when fasting. Therefore, thi^e hours 
injection of any drug, 40 grams of glucose m 

manj“ new drugs, a large proportion of them of 

frtr^virfucs were higiilv extolled by the manufacturers 
ami the vendors. Attention was rarely called, however, to 
, - „Tirl other harmful effects which were ■ liable 

their i^c He thought it most niifortunato 
? /"tT'iSs of drugs did not more fully take .0 
that Vf into their confidence. Certainly the 

uCtTtioner would feel more confidence in a new 
medical 1,;. notice if all the possible sources of 

Srug ’’'^."5^’^^fnlly indicated. No fewer than 257 cases 
'f’fftal poisoMng wk the barbituric, group had occurred 

in the last ““bilging ; the bottle of medicine was 

Pharmacoloa c a g „ vmy 

pvmg place to i„ jt^ use; pitii.ta^ 

voxic <lrug» tinu Q l c -fisa if incori*€ctly 

“•■r* Tetri' ™”' aYISrfS n to 

i™ d;.g., .. ..dpiytab tort 

io kept in mind. . 



THE IMPROVEMENT OF LIVESTOCK. 


[ THsUr.TTisa fiOH 

lIZDIdl. JorRKlX. wuc/. 


March 24, 19:8] 


The Law and Tononinc]- 

There was' no legal definition of poison, hub Bections 
reiatinn- to criminal poisoning referred to a poison or other 
destructive or noxious thinir. In abortion cases noxious 
thing” was used to moan something which might reasonably 
cause abortion. For example, 2 grains of aloes three times 
a day, or 10-grain doses of quinine, were regarded as 
noxious things. If a medical practitioner Buspected that 
poison was being unlawfully administered to his patient 
he must make sure of his ground by having an analysis 
made by an experienced man, and meanwhile move the 
patient to a nursing home and place biiii in charge of a 
responsible iiiirse. He should, also call in, at the eailiest 
opportunity, another doctor in whom he had confidence. 
The poison laws were a wonderful’ protection to the public, 
and valuable information was' obtained from the poison 
registers. A committee was now sitting to frame laws to 
include all the recently discovered poisons. Drug addiction 
had became a matter of international impoitance. 

Sir IVilliam' 'Willcox then made brief reference to com- 
mercial poisoning. The present great use of petrol had led 
to a number of cases of carbon monoxide poisoning; police- 
men on traffic duty had collapsed through inhaling petrol 
fumes. Tetra-ethyl lead was a very toxic substance, and 
' showed a strong affinity for the nervous system. The full 
symptoms did not appear for months, and when in full 
measure they were probably incurahlci A special committee 
had been appointed to investigate this question too, biit it 
would probably have been better if this step had been 
taken before allowing the substance to ho used. With 
regard to the treatment of poisoning in general, the first 
step was to reniove the poison without delay — the stomach 
must bo washed out. Then stimulant treatment should he 
adopted. Eecovery might be a' slow process. 

On the motion of Dr. Wiluiam Hill, supported by the 
President, Sir William Willcox was cordially thanked for 
his lecture. 


VORONOFFS EXPERIMENTS ON IRE IMPROVE- 
MENT OP LIVESTOCK. 

Last November a delega,tion representing the Ministry of 
Agriculture; and consisting of a physiologist, a geneticist, a 
dietician, and a veterinary surgeon, visited Algiers, where, 
in company with similar delegations from other countries. 
Dr. Serge Voronoff demonstrated testis grafting in relation 
to agriculture. The delegation had three main aims: to 
study the technique, to examine animals subjected to tbis 
technique, and to investigate the economic results. 

The technique, which is described in full detail in an 
appendix to the report of the British delegation,* consists 
essentially in the implantation of pieces of testicular tissue 
from one male on the surface of the testes of another. 
For the human subl et monkeys and apes act as the donors, 
but in animals it -is possible to use a male of the same 
species. The scrotum is opened, the surface of the testes 
is scarified to provoke a mild aseptic inflammation, and on 
this scarified area pieces of freshly excised testis are 
implanted and stitched in position. If the operation is 
performed properly untoward sequels are rare. 

It is claimed that the new testicular material replaces or 
reinforces the physiological action of the animal’s own testis, 
and so restores or increases the degree of manifestation 
of those characters which depend for their expression and 
full maintenance on the proper functioning of the gland. 
It is claimed by Dr. Voronoff that these glands also play 
M important part in the maintenance of general vigour. 
He has employed this operation on animals for two dis- 

inct purposes, to rejuvenate and restore the reproductive 
powers of decrepit and infeennd males, and to stimulate 
the growth and general vigour of sexuallv immature males 
ubose testes have not yet profoundly affected the 
developing characterisatio n of the individual. 


Scotland. 


Agriculture 
London : H. jj. 


and FisheriM, Bo.ard of AgWcuIture’ 
Slationcty Olllee. 1928 . 9d. net. 


for 


The delegation examined a bull (Jacky) discarded aS 
useless in 1922, when 17 years of age, and operated on in 
1924 by Dr. Voronoff. During the next two years Jacky 
sired nine calves, after which his reproductive powers 
seemed to wane, and the operation was repeated, apparently 
with some success. . ■ - 

The delegation points out, however, that it is difficult to 
accept this case as a complete and unqu-alified substantia- 
tion of Dr. Voronoff’s claims concerning rejuvenation. 
Stud bulls are usimlly discarded in Algeria when .about 
12 years old, and the fact that Jacky was retained in use so 
long suggests that he was an exceptional animal and that 
be may have reacted more strongly in consequence. He 
cannot be compared with bulls in Britain, wliicli are gener- 
ally discarded when 4 to 5 years old, and exact data as to 
the age to which a bull may prolong his sexual vigour are 
liot available. Jacky, moreover, may have been in ill 
be.altb prior to the operation. In any case bis subsequent 
fertility ratio was oxcejitionally low, and there is a vague 
suggestion of doubt as to the paternity of some of Iiis 
calves. The delegation believes that, although this example 
may support Dr. Voronoff’s first .claim, it cannot he 
accepted as conclusive proof. In any case the use of this 
procedure in British stock breeding would be slight and 
confined only to very special sires; alternative methods, 
such as improved management, are available for extending- 
ev. increasing the usefulness of such, animals. -It is recom- 
mended, however, in the report that further experiments, 
ill this direction should be encouraged owing to the possible 
value of the metliod in sire-importing countries. 

In connexion .with the second purpose. of the delegation 
a number of flocks were inspected in which the operation 
was claimed to increase the production of both mutton and 
wool. Hero, however, the evidence was less satisfactory, 
the exhibit being rather in the nature of n sample of an 
established fact. Definite and detailed information con-- 
cerning the numbers involved, or of the pedigree and 
relationship of tlie individuals exhibited, was not forth-, 
coming. Moreover, the sheep were not confined under 
proper experimental conditions, nutritional factors were 
disregarded, and control w.as unsatisfactory. In the matter 
of weight of progeny, among the samples submitted 
grafted rams were superior to the non-grafted. IVhetlier 
tbis was duo to the direct action of the sexual hormone or 
to an increased rate of growth which might have been 
conducive to an iiiiprovoment of type could not be deter- 
mined. The fleeces varied very much in weight, and 
although it was claimed that there was an increase in 
weight of wool, samples showed no improvement in qiialitv. 

The delegation considers that tlie increment of both 
weight and fleece attained by the grafted sires can have no 
v.aliio in comparison with the cost of the operation, ram 
flesh being inferior in quality; it is only in the trans- 
mission of .desirable characteristics to the progeny that its 
value might lie. 

The economic adv.antages of this procedure in Britain 
are thought to he doubtful ; it is desirable here to increase 
the quality rather than the quantity of wool. There is no 
demand for larger carcasses, but the more rapid attain- 
ment of weight for age might he an economic- advantage, 
provided tliis is considered in relation to cost of upkeep. 

The British deleg.ation concludes that the claim to effect 
rejuvenation of the aged and decrepit male may bo justi- 
fied, altliougli the evidence is not based on critical experi- 
mentation. In any case its value in a sire-raising country 
like this is doubtful, its usefulness being limited to sire- 
importing countries. The second claim of increase in body 
weight and wool clip is supported by the figures submitted 
and the sheep exhibited, but the conditions under which 
the experiments wore conducted, the inadequacy of the 
data, and the methods of presenting them prevent the 
fomation of a critic.al opinion. Its direct economic advan- 
tages appear to bo negligible. Dr. Voronofl’s further claim 
that those “ improved ” characteristics are inherited in- 
volves the acceptance of the hv-pothesis of the inheritance 
of acquired characteristics, which has never been sub- 
stantiated. It is suggested, however, th»t both claims 
might he tested furtlicr and more critically in this country, 
where conditions are more favourable to scientiCo control 
than in Algeria. 



606 March 24, 1928] k . 


THE SIR OHABEES 'HASTINGS tECTGBE. 


f TniUBrnsa 

JocaxAt 


•V. 


THE HASTINGS POPULAE LECTURE. 


THE FOUNDATIONS OP HEALTH. 


Lectuhe by Sir George Newjsah. 

The second popular locturo instituted by the British 
Medical Association, and associated with tho nanio of its 
founder, was delivered in the Great Hall of tho Associa- 
tion’s House in London on Wednesday evening, March 
21st. Tho lecturer was Sir George NinvM.\N, IC.C.B., Chief 
Medical Officer to tho Ministry of Health and tho Board 
of Education, and tho chair was taken by Lord Cozens- 
Hakdy. Among those on the platform were Sir Ewen 
Maclean (President-Elect of the As.sociation), Dr. C. O. 
Hawthorne (Chairman of tho Bcjiresentativo Body), Mr. 
Bishop Harman (Treasurer) and Mrs. Harman, Dr. Arnold 
Lj-ndon, and Hr. E. Lewys-Lloyd, Dr. Chvistino Murrell, 
and Mr. E. B. Turner (momhors of Council), Dr. E. 
Graham Little, M.P., and Mr. C. G. Ammon, M.P. A wet 
evening militated against as largo an attendance as that 
at tlio first lecture hy Sir Berkeley Moynilian a year ago, 
hut tho body of tho hall was well filled. 

Lord Cozens-HaRdy, in opening tho jirocccdings, said : 
I can imagine no subject of greater importaiico to the 
nation than that wiiich- has keen cha.seu for tho lecture 
of to-night, and no man more fitted to deal uitli it than 
Sir George Newman. Ho is in a unique position for 
studying tho problems of national health as a whole, and 
wo have learned to expect from him definite guidance along 
a path mapped out by his knowledge and his vision. 
Progress along that path is slow, and yet how much ground 
has been covered since Sir diaries Hastings fomuied tho 
British Medical Association! .And tho further wo proceed 
along that path tho quicker tho pace tends to become. 
The comparatively recent formation of the Ministry of 
Health was a very great step in advance, and with a 
consistent policy at headquarters many ob.staclos to pro- 
gress have disappeared. In local adniiir'sfration, however, 
we are still left with much overlapping and w.asto of effort. 
That is a state of affairs which will not he tackled hy 
any Govoninient until tho nation at large has come to 
realize liow uneconomic and unsatisfactory it is, and has 
become bi'tter educitc l as to health requirements and the 
best way of securing them. Sir George Newman has told 
us elsewliere tliat it is still too long before a fully sub- 
stantiated medical truth percolates through tlio whole coiii- 
niunity, and I do not think lie lays upon tho public tho 
whole of the responsibility for that delay. In these days, 
when increased interest in health matters causes every 
claim for advance in medical knowledge to he regarded hy 
the press as good “ copy,” and by the advertising expert 
as a peg on which to hang a slogan, it is heeomiiig 
increasingly difficult for the layman to detenniue when the 
point has arrived at wliicli a reputed discovery has really 
become a substantiated medical truth, and antboritative 
guidance on tlieso matters was never more needed than 
now. No one has done nioro to educate the public in this 
respect than Sir George Newman. In those able memo- 
fandiims which issue from tlie Ministry of Health ho has 
shown a great gift for putting his views on subjects which 
lAiglit bo regarded as dry and iinintercsting into a form 
calculated not only to interest but to inspire the layman 
and the medical man alike. 

Sir Geouoe Newjiax, before proceeding rvith his lecture, 
said: I appreciate voiy mucli tho honour wliicli tho 
British Medical Association has done mo in inviting mo 
to deliver this lecture, but it is an honoiii- wliicli carries 
with it some embarrassment to myself, for I am called upon 
to follow in the footsteps of the first lecturer, my dis- 
tinguished friend. Sir Berkeley Moynihan. Though my 
scope of subject is much wider than that taken last year 
bv Sir Berkeley Moynihan, I have to confess to yon that 
I'aro much less the master of my craft than he of Ins. 
Moreoi-er, Sir Berkeley Moynihan is perhaps ttie greatest ! 
medical orator that we have now in England, and to 
attempt to follow him brings its own enibarrassmeiit. 
X.oi*cl Cozens-Hardv has hinted at another difficulty 
winch I have. I am invited to address you for half an 
our or so upon a subject on which you aro addressed 


every day of tho ivcek. N'o one of us ever takes up a 
noivspaper without being advised as to the coiuUict in 
fiealtfi matters of our porson.-il lives. On Monday ivc me 
told that wo must eat only brown bread; on Tuosdav we 
.are assured tliat white bread is equally good; on IVcdnes- 
a*iy that uoithei* brown nor white bread is essential to life 
or liealth; on Thursday wo aro encouraged to believe that 
wo must give up our ham and egg for breakfast and take 
only four tablespoonfuls of orange juice; on Friday we 
aro told that no must wear iiarm clothing; and on the 
sixth day that tho less wo wear the better. There is rest 
oil tho screnth, day, during which wo are able to observe 
that the young iroincn of the new generation aro dis- 
posed to disregard all tlieso recommendations except tho 
last ! In a predicament of this kind, what is a civil servant 
to do? Ho is accustomed to complete obscurity. , His 
business is to pursue a hidden path and Jive a concealed ' 
life. But ho is hrought out of his obscurity into this 
rather jwoomfortahle prominence to offer his opinion iqion 
this much discussed aud thorny subject. I propose not' 
only to he brief hut to ho plain. 

Sir George Newman then proceeded with the ketmv,' 
which is printed in this week’s Supplement. For lack of 
time he omitted certain portions, saying that those iiitcv- 
esfed would he able to read tho published version. 'Pid 
lecture was delivered with great vigour, and was loudly 
applauded at the close. 

Sir EweK JIacleax moved a vote of thanks to the lecturer. 
Sir Goorgo Newman, he said, had claimed to ho something 
ill tho nature of a concealed iicrsonality. That ivas not tho 
wav he impressed his fellow-students in the old days whan 
the speaker was a student with him in Ediiibiirgli, and ho 
did not think it was true of bis after-career. If the great 
progenitor of the Association could hare cast his vision 
forward nearly a century to tho setting of that occasion, 
and have iienrd the lecture by tlie man of the occasion, 
iic would havo seen of the travail of his .soul and have been 
satisfied Tlio setting reminded them of the exfraoi'tliiinry 
developiiients of tlie Britisli Medical Association. Soiuo 
ueoiiia who did not know what the Association was and 
did were apt .to bo surprised that it took an interest ■ m 
the prevention of disease, because that course, pursued to 
the full might he e.xpected to have, a detrimental , effect 
upon the doctor’s living, though, to he sure, lyhatever was 
.mae in tho way of prevention, there would still ho enough 
diseases to live upon, and to die from. But the Association 
was'deeidv interested, not- only in the conditions' of .servifo 
and emoluments of the medical profession but in research 
fi all branches of medical art and craft with a wew to the 
discoveiT of Jmuv truth and tho elimination of old disease. 
Tim Ministry of HeaHi itself represented a great acliieye- 
l?,r 5., MCventive. medicine, and the medical profession 
” ^fmtunatc that at tho head of the medical staff of the 
MiuilfiT there should be a man who inierpreted his duties 
Muiistij nierelv official sirint, but inaiiitaiiied the 

S "dS cont"aetrwith members' of the profession and all 
coneeriied seconding, said that ho 

Tthe nLS revolution. Ho believed that at tins 
ilm countiy was passing through another indnstrial 
mome t ^ steam, but on electricity 

revoluUoi , and that if the social chaos which followed 
rc™hitf«“ was not to be repeated tho giudance 
tho eaihei George Newman would be 

and George had spoken of himself as a con- 

very necessa j- ^ ^ ,T,Ue.ty 

cealed politician green with envy, and ho had 

" 

personal conduct to personal health. 

‘ Sir Geokge ^ 

with lieai-ty morrow lie would return to 

fe':fXm.ity,’ where, however, ho would still remain 
[boir most obedient and p-atefi.I 
The proceedings closed witb a 


of tbanks to tho 


The proceeding.^ closed w.tn '“‘•^,j,.^otor. Industrial 
liairman, which the Bev. B. R' Lv.svYs-Li.oYD 

^elfaro Society) proposed, and Di- D. 


couded. 



THE P;LEABS OF -HEAETn. -' 


r TfTT DRmsa 

L XlrPtCAL Jorawit 


6G7 


March 74,, 1928] 


Britisi) iHetiical journal. 


SATURDAX, MARCH S-lTH, 1928. 


. THE, PILLAES OF HEALTH. ' | 

Health has in all ages been inore or less a matter 
ot public concern.' We know that with the ancient 
Greeks physical efficiency was a cult. In modem | 
times, as the functions of government grew in scope 
and diversity, and protection from external or internal 
foes became subsidiary to the pursuit of the happiness 
and well-being of the governed, health as a means of 
happiness has come to be recognized as of paramount 
importance. The mediaeval ascetic ideal, which found 
extreme and grotesque expression in solitary posturing 
6n a pillar in a state of semi-starvation, has now been 
replaced by a hygienic ideal- embracing both the indi- 
vidual and the community. It is appropriate, there- 
fore, that. -Sir George Newman, as Chief Medic.al 
Officer to the -Ministry of Health and to the Board 
of Education, should choose “ The foundations of 
national health ” as the title of the second Hastings 
Popular Lecture, which he delivered in the Great Hall 
of the British Medical Association’s House on March 
21st. The full text of his address will be found in 
the Supplement this week. 

There appears to be something rather significant 
about the number six in this connexion. Not only 
does Sir George Newman find that since the eighteenth 
century there have been six epoch-making advances in 
medical science; ’he finds also that the principles or 
elements of nutritional health for the bod}’ are six 
in number ; food, fresh air and sunlight, exercise, 
t\’annth, cleanliness, and rest. The fundamental 
problem of health, he insists, is the wise and scien- 
tific nurture of the body, and therefore the construc- 
tion of these six pillars of health must be based on 
knowledge. Organization of this Icnowledge, so as to 
provide opportunity for all men to ensure for them- 
selves and their families the essential conditions of 
nurture, is for him a function of the State. “ In 
a civilized State,” he affirms, "it is the nature 
and nurlm’e of the individual and the communal 
organization of opportunity which are the foundations 
of national health.” Developing this idea to its 
logical conclusion. Sir George Newman summarizes 
the elements of the modern programme of hygiene 
under the headings of sanitary environment, system- 
atic nurture beginning before birth, preventive organ- 
ization, and public medical services. So closely are 
they interlocked that no local authority can afford to 
neglect any one of them. ’ 

A perusal of the Government activities included 
under each of these articles or elements of Preventive 
Medicine cannot but impress the reader with the 
fenoimous extent of the field of State health services 

o-day;^ and when it is remembered that the medical 
piofession has been largely responsible for the origin 
and organization of all these services, it must surely 
be realized how near the doctor has come to supplant- 
mg the priest as the power behind the throne. But 
Newman wisely reminded his audience 
that,- while sanitary and medical experts have their 
place, health is every man’s duty, and that “ progress 


depends more upon social and moral evolution than 
the advance of sanitary science, more' upon wisdom 
than knowledge.” Therefore, while attributing in 
large measure the vastly improved health of the people 
of our generation to the fuller application of medicine 
'.and sanitation to everyday life, he generously acknow- 
ledges the oven greater influence of the forces of 
education, sociology, and biology. 

, The pillar of health into the construction of which 
the Hastings Lecturer goes most fully is food. Here 
he treads, as he is well aware, on difficult and debat- 
able ground, since the medical profession is by no 
means in a position to lay don’n dietetic rules that are 
applicable to all persons. The question constantly, 
recurs to the mind : What is it that makes one man 
able. to thrive, say, on a diet of nuts; and why should 
another object to drawing his vitamins from oranges 
and tomatoes, and yet continue healthy? It is even 
a matter for speculation how far any of Sir George 
Newman’s well-thought-out food rules are universally 
valid, and to what extent their terms are definable, 

*‘ Strict and persistent moderation ” is a very ■\’ariable 
quantity. Large numbers of people appear healthy, 
feel well, and do good work on what to others would 
be imperfectly masticated food, or food greatly in- 
excess of physiological needs. Individual idiosynr 
crasy must have some bearing on the number of 
meals taken, on ho^y much is consumed at each, and 
also on what is eaten and drunk. If we are perhaps 
less alarmed than we ought to be by the Lecturer’s 
caustic commentary on the British workman’s daily 
fare — “a tale of ham and beef, of beer and bread, of 
tea and pickles, of tinned meat and proprietary foods, 
or a weary round of bacon, herring, and cheese ” — we 
can at least agi’ee with him that the customary diet 
of the great mass of our people is far from perfect, 
and that, whatever else is left undone, something 
could and should be done to make their food more 
appetizing, and therefore more nutritious. Perhaps 
Sir George Newman, in his capacity of Chief Medical 
Officer to the Board of Education, may be able some 
day to induce local authorities -to pay more attention ' 
to cookery in the curriculum of primary education; 
In dietetics balance is all-iniportant. Every factor 
has to be taken into consideration — calories, a due 
proportion between carbohydrates find fat, enough 
protein and essential amino-acids, inorganic salts, 
vitamins, roughage, and, last but by no means least, 
variety and palatability. These things appeidain to 
the food; there is also the human factor to be reckoned 
with: "Healthy and complete nutrition is infinitely 
more comprehensive than mere' feeding, mere filling 
of the stomach. It connotes a healthy body in all 
respects.” 


Of the value of the modern propaganda for the pro- 
motion of health there can be no doubt; and in that 
propaganda the delivery of the Hastings Popular 
Lectures must play an important part. The British 
Medical Association has been fortunate in persuading 
such distinguished and eloquent members of our 
profession as Sir Berkeley Moynihan and Sir George 
Newman to give the first two of the series. Probably, 
however, even more could be done by the general 
practitioners of the country, whose sympathy and 
co-operation Sir George Newman is ever ready to 
enlist. Erom the point of A'iew of hygiene the popula- 
tion may be divided roughly into two parts: those 
who, believing themselves healthy, do not bother their 
heads with any propaganda; and those who, having 
in their consciousness some srnall symptom of dis- 
abiiity, are prone to let then’ imagination run riot on 



£08 JUech 24, 192S] 


GAHiL-BIiADDJSK DISEASE. 


r TnEBmTisn 
L3l£iiicjLZ> Jorsxiii 


aiiy suggestions that seem applicable to (heir con- 
dition. Short of some system of compulsory and 
periodic medical examination for the n hole community 
-—a pitch of Slate control to which we have not yet 
risen — the general practilioner of medicine is really 
the only person who can guide the individual of either 
class in the preservation or restoration of health. His 
arc the opportunities for impressing on the carelessly 
the need for caution; and he alone is in a 
position to counteract the neurasthenia-producing 
effects of injudicious propaganda in (hose who aro 
needlessly alarmed. With the helj) of the general 
practitioner it may be possible also to obtain an answer 
to some at least of the ijcrtiucnt questions asked by 
this year’s Hastings Lecturer in his discussion of (ho 
six pillars of healthy human nurture. 


GALL-BLADDER DISEASE. 

It has been said that disease of the gall-bladder now 
bids fair to succeed appendieili.s as the most popular 
subject in the literature of abdominal medicine and 
surgery. This view certainly gains support from (lie 
recent address by Professor" D. P. D. Wilkie to (he 
Ayrshire Division of the British Jledical Association, 
which is published in our present is.sue at page 481, 
for the first of Ids general conelusion.s is that gidl- 
bladder infection is probably the commonest of all 
abdominal maladies, particularly among persons of 
sodeutai'y habits. It is interesting to note also that 
in his experience the results of gall-bladdcT infection 
are particularly serious in well-to-do patients, who 
are prone to spend years in trying " cures ” winch 
hospital patients arc — as he remarks, fortunately for 
themselves — unable to afford. 'Thus in his large 
series of 452 operations performed on the biliary tract 
the average age and opei-ative mortality among (lie 
184 private patients were 54 years and 6 per cent., as 
compared with 46.5 j^ears and 1.4 per cent, among 
‘ 213 hospital patients. Here, then, as elsewhere, 
affluence is not always an unmixed blessing. 

Like Sir Berkeley Alojmihan, whose recent Mitchell 
Banks Memorial Lectui’e was published in the British 
Medical Journal of January 7th, 1928, Professor 
Widde brings forward new evidence that infection of 
the gall-bladder does not take place from the bile, 
and that treatment by antiseptics to disinfect the bile, 
and by washing out the gall-bladder contents, as by 
Lyon’s method, is largely founded on eiToneous 
premisses. But whereas the President of the Eo}"al 
College of Surgeons of England laid stress on the 
lymphatics as the route by which infection reaches the 
gall-bladder. Professor Wilkie's contention, based on 
the work of Dr. A. L. Wilkie, is that there is an 
intramural infection of the gall-bladder derived from 
lire blood stream, and that the lymphatics then pick 
up the infecting organism. Eurther, the responsible 
bacterium is, as Eosenow insisted some joars ago, 
usuall}' a streptococcus, and not, as has commonly 
been stated. Bacillus coU or the B. iijijhosus. The 
presence of the former is probably a secondap’ infec- 
tion. The growth of the slreptocoeous is inhibited 
bv the bile, and hence the failure to eonfh-m Eosenow’s 
results may be explained, for not only may the bile 
bo sterile, but cultures of portions of the gall-bladder 
wall may remain negative from the action of bile 
adherent to the mucosa. Professor WiOde, with due 
caution, indicates his suspicions about the aseptic 
production of a single pure cholesterol calculus, as 
described by Aschoff and Baenieister, and, without 


discussing the relation, in point of time, states that 
in isolated examples of this condition a Streptococcus 
has been found in the wall of the gall-bladder and in 
the centre of the calculus. 

' The diagnosis between gall-bladder disease and 
duodenal ulcer, especially in women, may clinically 
bo SO diflicult that the terra “ cholecysto-duodenal 
sjndrome is iippropriate. . It is here that radio-' 
graphy giros most useful aid in coming to a right 
decision. Screen examination during an acute attack 
may show, immobility of the right- half of the 
diaphragm, and Professor Wilkie’s experience in 
more than 200 cases examined by Evarts Graham 
and Cole's method of cholecy'stography has con- 
vinced him that this is by far the most efficient means 
of diagnosis, since it gives the correct answer in over 
90 per cent, of the cases. In the early stages, how- 
ever, of chronic cholecystitis the functions of the gall- 
bladder may be so well carried out that cholecysto- 
grapJij- does not show any abnormality. We publish 
also in this issue a paper by Dr. J. F. Braiisford on 
the x-ray diagnosis of pathological conditions of the 
gall-bladder. Dr. Braiisford, who UTites from an 
experience of nearlj' 500 cases, agrees with Professor 
Wilkie in advising a combination of oboleoystogvapby 
with a bariujn meal, and prefers the intravenous to 
the oral administration of fetraiodophenolphthalein, as 
more accurate in diagnosis, and safer, for he has had 
no more than five severe reactions. The supei'iority 
of cholecystography over an ordinary ratliogi'am is 
shown by Jus estimate that only about 30 per cent, 
of gall-stones contain sufiScient calcium to cast a 
shadow bv the older method. 

While admitting that B. coli mfections of the gall- 
bladder may be favourably influenced by very largo 
(loses of he.\nmine, Professor Wilkie makes the point 
that in the majority of cases there is an intramural 
streptococcic infection for which no drug is effective, 
though a sta-optocoecic vaccine would appear to be the 
most’rntional form of medical treatment. Well-estab- 
lished infection of the gall-bladder is, however, higlily 
resistant to any but surgical measures, and ho there- 
fore advocates cholecystectomy, which, m hi.s e.xpe- 
rieiice and that of many others, is not followed by any 
untoward results. He regards this operation as much 
more satisfactoiy than' drainage on account of the 
liability to recurrences, after temporary benefit, 
evoei-icMcd by patients who have undergone chole- 
fvstotomy- Here he is in evident agreement with Su 
Berkeley ^Moynihan, who said m the Mitchell Banks 
T -ntiire- “I have no doubt that, until wc are able 
Jr^m-irto understand and to control the eayher 
sJmPtons of cholecystitis and its foregoing conditions, 
removal of the gall-bladder should be performed moie 
£ fli/in is now the custom.* 

tS time being, then, cholecystectomy nppeam 

tn hold the field m the treatment of established bihaiy 
ntoctfo'n In le United States it has become almost 
procedure. Stanley Mentzer. in a recent 
^ o of tt-fil-bladder surgery based on a study of 
?4 000 snectoiens,' says that, whereas eholecystostomy 
toiSj^aomprised more than half the 

ffoll-bladder. to-day it comprises less than 0 p 

LtoC^ac^otttoVfo^ 

pMSogTcafcS" ?nd"crrecystectomy is the 
operation of choico- 




HARVEy TERCENTENARY. 


March sa, 1928 ] 


HARVEY TERCENTENARY, ^ 628-1 928. 

The tcrcentenarj- of the publication of 'William Harrey’s 
epoch-making Dc Motu Cordis will bo celebrated Iiero from 
Monday, May 14th, to Friday, May 18th. Tho arrango- 
ments aro in tho hands of tho Royal College of Pliysicians 
of London, and a programme giving an outline of the 
several functions and entertainments has non- been issued 
in advance for tho convenience of official delegates and 
others. Tho proceedings will open on tho morning of 
May 14th with a reception of delegates by tho King at 
Buckingham Palace. At 3 p.m. there will bo a rcceiJtion 
by tho Pxesident of tho Royal College of Physicians at tho 
College (academic dress), when- addresses will bo presented 
by delegates, Honorary Fellows will bo admitted, and 
eulogies of Hai-vey. will be delivered. In the evening tho 
Grocers Company wiU give a dinner to delegates and guests 
at their Hall in the City, On tho mornings of Slay 15th 
and 16th demonstrations bj- tho Royal College of Phj-sicians 
n-ill be given at University College, London, as follows: 
(1) a reproduction of Harvey’s original experiments dis- 
played einematogi-aphically ; (2) illustrations of some 

I'ecent additions to our knowledge of tho circulation. 
Tho principal functions on May 15th will bo a 
luncheon party at^St. Bartholomew’s Hospital (of which 
Harvey was physician), given by tho governors of the 
hospital ; tea at the College of Physicians, with an 
exliibitiou of boolcs, manuscripts, pictures, silver, and othei 
objects of interest; and a conversazione in tho Hall of the 
Merchant Taylors Company, at which H.R.H. tho Prince 
of Wales has consented to bo present. On tho evening of 
May 16th there will- bo a dinner to delegates and guests 
given by tho President and Fellows of tho College of 
Physicians in tho Guildhall of the City of London. May 
17th and 18th will bo devoted respectively to visits to 
O.xford, by invitation of the Warden and Fellows of Merton 
College, of which Harvey was Warden ; and to Cambridge, 
by invitation of the Master and Follows of Gouvillo and 
Cnius College, whence Harvey graduated. Other enter- 
tainments for ladies aocompany-ing delegates andsguests arc 
being arranged. Throughout tho week preceding the cele- 
bration, including Sunday, 3Iay 13th, tho secretary’s office 
at the Royal College of Physicians, Pall Mall East, S.W.l, 
nill bo open daily from 2 to 5 p.m. for the issue of pro- 
grammes, tickets, and other information. A fidl and 
detailed programme will be published in Mav, and may be 
obtained then on application to the CoUego. Tho ter- 
centenary is being celebrated this week in America by the 
0 ego of Physicians of Philadelphia. Included in tire 
progr-amme are two commemorative addresses On Thursday, 
March 22nd-^tho Mary Scott Newbold Lecture by Sir 
ump ly RoUeston, Bt., on “ Harvey’s predecessor's and 
con empoiaiies, and the Nathan Lewis Hatfield Lecture 
^ J^clcod of the University of Toronto 

on -Hai-vcy s experiments on the circulation.” 


MeDICU. JOCKXIX. 0\^\J 


Medical Mtiseiim of illustrations from ancient surgical 
manuscripts, a sei-ies of engravings of famous physieians’ 
lent by tho Royal College of Physicians of London, niaity 
portraits of local lecturers and professors, as well as a 
collection of Lister relics organized in Edinburgh. Tho 
Cardiff exhibition in July will deal esjrecially with Welsh' 
folk-medicine, which should prove of great interest. 
Tradition says that Welsh medicine was practised hy tho 
a'licieiit Cymiy before they became possessed of cities and 
sovereignties in the time of Prydain ah Aedd Mawr. 
During his reign tho learned men were divided into tho 
three orders of Druids, Bards, and Ovates, of whom tho 
Druids practised medicine and magic. In those early times 
wells, exercise, herbs, and magical incantations were tho 
principal means of healing. -At a later date Taliesin speaks 
of the limn-, Iridney, and the heart as being three intract- 
able organs, and mentions disease of the knec-joints; disease 
of a rib, and phthisis as tedious complaints. Howcl Dha, 
who lived about the ‘time of King Alfred, drew up a cede of 
laws, in which se'\-oral references are made to the medical 
practitioners of tho period, and in which the fees are 
fixed for such procedures as appjlying a tent, administering 
licrbs to a swelling, and letting blood. Rhiwallon, one of 
the earliest authentic physicians of Wales, who lived in 
the thirteenth century, made a collection of medical recipes 
applicable to various diseases, and a manuscript of these 
has come domi to us. Members of his family appe-jr ta 
have practised medicine in 'W'ales down to the middle of 
the eighteenth century, and several of their medical manu- 
scripts have been prcscn-cd, ■so that Welsh medicine has 
a character of its otni. -A manuscript of tho fifteenth 
century mentions some eight hundred medicinal substances, 
including plants, flowers, and roots, of which many are 
still in use, although it includes also much animal 
phai-macy-. This manuscript gives a list of tho essentials 
for a physician, which are a lancet for bleeding and- a 
larger knife; a steel or silver spatula ; a bladder -nith pipe 
attached for injections; a collection of plastera, ointments, 
and jiills; and a sheltered garden of tr-ces and herbs where 
medicines may be grown. Much loro of a medical nature 
centres round the wild goat, and from the ancient beliefs 
about its remedial virtues has probably originated tha 
practice, common in various parts of England till recent 
times, of keeping a goat among other farm stock bccauso 
its presence was supposed to bo healthy for cattle and to 
keep aw.ay disease. Mistletoe and selago wero remedies 
which came doini from Druidic times, mudi used in ancient 
Welsh medicine, and treated with great veneration. It it 
hoped that the influence of these and many other native 
Welsh remedies on medicine may bo traced at tho forth- 
coming musenm, where doubtless many of tho interesting 
Welsh manuscripts preserved in the National Library of 
Wales will also bo exhibited. 


TTp , AT CARDIFF. 

^ IS I 0 sow here m this issue a letter relating to tli 
) opose us oucal exhibition at the Cardiff meeting o 
tho British Medical Association in Julv next, which it i 
niako specially illustrativo of Welsh folk 
aatisfaction that the Hislor 
this -Association is being continue 

t P>-^iaentship of Mr. W. G. Spencer 

Fdiiibur'ib'* "T Pu'sk time last year i: 

m , ro " ; T Edinbul'gh, w 

0 ‘tablbw’l -Umversity in this eounto- t 

year’s prcsidmtTf^H mcdicino, and las 

tho Icctui-ei mf tl a T ^To' """ 

oi-i i , '■uoject. iho museum organized a 

TO a id h 'T l of severafthousan, 

peuons, and included an exhibit by tho Wellcome Histoiicr 


HOURS OF WORK IN FACTORIES. 

The most recent publication’ of the Industrial Research 
Board is concerned w ith two separate problems in connexion 
with the hours of work in factories as they affect women. 
Tlic first considers the advisability of breaking up tlio 
five-hour spell, whero such is in vogue, by instituting 3 
conipnlsorj' rest pause, and the second has reference to the 
effects on output, lost time, and lab'iur turnover of tho 
eight-hour doiihie-shift system. Under the present factory 
law work may not ho carried on for more than five horn's 
without a meal intci-val, and, with tho reduced hours now 
commonly worked, many firms have found it convenient to 
run tho full time in tho morning period. It is significant 

^ Ttco Studies on Hours of IT'ori;; (1) Fire-hour Spells for W’nmm 
\nih Refcicnec to Rett Favicf. By n. >1. Vernon, and *>f. D. 

Vernon, M,Am asYisUKl by I. Lorrain-Smitli, M.A. (11) The Ttro-thift 
Sustcin in Ceiloin Tactorirs. By ^fay Smith, M.A., and 31. P. Vernon, 
3LA, Medical Be-earch Council. Industrial Fatifrue Jtcrearch Board 
Reuort So. 47. London : II.AI. Stationery Otiicc. Is. 3d. net. 



610 Makoh 34 ~, 1928] 


GliAND GRAFTING. 


t TuKTinrnsa ■ , 
JIrnicxL JoenvAL 


^hat tho Factory Dills di-aftcd by the present Government 
and its predecessor both proposed a liinitatiou of four and 
a half hours for any spell, but with the proviso that if a 
stoppage of not less than fifteen minutes uere introduced 
the period coidd bo lengthened, under one bill, by the 
extension of tho timo of tho stoppage by an equivalent 
period, and, under the other, to five hours. The need for 
Buthoritative information on the subject is therefore 
»vidcnt. The first investigation was made by Dr. 
H. M. Vernon and Miss M. D. Vernon, and cormred a 
considerable number of factories and variety of trade pro- 
cesses. Tho advantages of a break during a five-hour 
spell are discussed from various aspects. Phj-siologically, 
nutrition is consideied the most important factor, and 
evidence is produced to show that a five-hour morning spell 
means five and a half to six hours, or even more, without 
food; while, apart from allowing for the relief of hunger, 
it is held that the rest pause affords relief from physical 
fatigue. It is assumed that tho psychological advantages 
may be oven greater than the physiological advantages in 
the case of monotonous repetition work, and in support of 
this it is mentioned that three largo cstabli.shinents showed 
respectively an average of 25 per cent, "labour turnover” 
pel' annum where there was a fifteen minutes’ break, 
42 per cent, where there was a three minutes’ break, and 
94 per cent, where there was no break. Output is shown 
to bo increased where tho operations are wholly or mainly 
manual, but owing to tho variability of sickness-producing 
factors it is admitted tliat tlie effect on health cannot bo 
satisfactorily demonstrated. That there are valid objections 
to the break in certain processes is acknowledged, but it 
is thought difficulties could be overcome. It is finally 
suggested that ten minutes for a break woidd bo proferablo 
to fifteen minutes. The employment of women, and of 
young persons over 16 years, in two eight-hour shifts 
between 6 a.m. and 10 p.m. (6 a.m. to 2 p.m. on Saturdays) 
is permitted by the Employment of Women, etc.. Act (1920), 
provided a joint application be made by employer and 
employed. Special conditions, chiefly relating to wolfai-e, 
arc attached to the permit by the Factory Office. Tho 
system originated during tho war, when it was found to 
be preferable from the point of view of health to the 
working of overtime by women and young persons, and a 
departmental committee recommended its continuance. 
There is not much demand for these permits, and very few 
of those granted apply to a whole factory. Most are 
required for departments which cannot keep pace with 
others in production and as a substitute for overtime 
during periods of pressure, but a number are in force 
permanently at certain manufactories of bosieiy' and arti- 
ficial silk. This part of the report was compiled by bliss 
May Smith and Miss M. D. Vernon; the investigations 
appear to have been carefully carried out, and tlic result 
shows that the system per se has very little adverse 
influence, if any, on workers or trade processes. .Objections 
to it are mainly of a social nature. 


GLAND GRAFTING. 

The subject of gland grafting has excited a considerable 
amount of interest within tlie last few years— not only in 
its application to man, but also to animals— and tbo claims 
made by Dr Serge Voronoff have had a wide, and often 
uncritical, publicity in the popular and agricultural press. 
In the case of human beings critical experimentation is 
difficult, if not impossible, and variables wli.el. may enter 
into this investigation (other than those incident upon the 
actual operative intervention) cannot be measured or 
assessed— as, for example, the psycliologic.al effects on the 
subject. In animals, howevmr, careful and exact scientifio 
control 13 more easily possible, and tile visit of a delegation 
of British scientists to Algiers to investigate Dr, Voronoff’s 


work on testis grafting on bulls and rams is of considerable 
interest; a report of this visit appears at liagc 505. In 
animals two sets of results arc said to follow this opera- 
tion. Old animals are' rejuvenated and tlieir reproductive 
■powers restored; sexually immature animals Imve tlioir 
growth and general vigour stimulated. Moreover,- it is- 
claiiiicd, that these characters are, in part at least, trans- 
mitted to the offspring. This last .statement involves the, 
aceoptanco of tho hypothesis of inheritance of acquired 
I characteristics; generations of scientists have as yet found 
no' defiiiitd evidence in support of this hypothesis. From 
the medical point of view -the rejuvenation of the senile 
I male is of more importance than the acceleration of the 
I growth arid general rigour of the sexually immature. The 
delegation examined the available evidence,- with every 
, assistance from Dr. Voronoff himself, and, while it con- 
I ■ Eidcred that tbo claim was possibly justifiable, it found 
that the evidence was not based- on critical experimenta- 
, tion. It is V 017 doubtful if oitber of the sets of .experi- 
[, nionts would -be of any economic value to British, stock- 
breeders, but it is recommended that controlled e-vperi- 
ments should be undertaken in' this countiy in consequence 
of tbo scientific interest and the wide publicity which has 
been given to tlie subject. In view, therefore, of the 
‘ unsatisfactory state of the evidence- in animals, it would 
■’ probably be unwise to conclude that grafting of testicular 
material in man— the delegation lias not- investigated the 
■grafting of thyroid gland— is definitely advantageous; 
rather should it still be regarded as sub judice. 


CONFERENCE ON RHEUMATIC DISEASES. 
riE coiifeienco on rheumatic diseases, to be held at Bath 
n May 10th and 11th, of wliich we have already pubUsliec 
Siary announcements, bids fair to be an occasion of 
I -mnm-tance both by reason of tho thoroughness of its 
and ihe authority of those taking part in the 
rogxa^ something of an international 

for among the expected speakers are medical 
'■“■■“tom FrtuZ Bellinm, Holland, Sweden, and the 
’""ted sTai Si; Geofge Newman, Chief Medical Officer 
"‘tloMStry of Health, is to preside over the con-, 

^ B and -the vice-presidents include the Pi esidents 

rS To?,! I-"!'*”'” “T 1 

f trie ^re;; . T,-piond. ' and • the Presidents of 

BriSsh Medical Association and the Royal Society 
,0 Bntish " j i 3 to meet in three sessions 

^ T TT,' consecut^cly. the first dealing with social 
’ ? lag second with causation, and the third m 

These sessions will be presided over resper 
•eatment p „ gf penn, Sir Humphry Bollesteii, 

ZsZFBvquhar Bukzard.' The announced speakers are 
^ B dimerous— at one of tho sessions a dozen— as 
Z rZve little room for the open discussion with 
?^“r"it^is' hoped, each session will conclude, bu^. many 
ho heaifi in a three-hour sitting. Among the, 

’’Z dealing with social aspects are Dr. H. . ■ 
icakeis S g gi^gtion of medical treatment of,, 

Standpoint of the approved 
1 the pathology of ^‘^™?,/^Z'r’prof'essor ' Stockman; 



MAKCH 24, 1928] 


A. CENTENARY IN MEDICAE JOURNALISM. 


[ 


Tht BMTisn 
ItEmCAX. JOCKXIS 


511 


part of the subject, including Ur. Homer Swift, and Dr. 
AVeif of Paris. The pliysical treatment of rheumatic 
diseases is to be dealt with by Dr. Gunzhnrg of Antwerp 
and Dr. Campbell JIcClure, surgieal treatment in degenera- 
tive arthritis by Mr. Max Page, and aeuto rlienmatic 
infection in childhood by Dr. F. J. Poyntou. Sir AVilliam 
AVillcox will speak on tho treatment of underlying infection, 
and Dr. A. P. Thomson and Dr. R. L. J. Llewellyn will also 
take part. It is expected that many of those attending 
the conference will be delegates from local authorities, and 
with that in vieiv the Ministry of Health, tho Scottish Board 
of Health, and tho corresponding departments in Northern 
Ireland and the Irish Free State have intimated that they 
will consider favourably applications for payment of 
expenses from local authorities who desiro to be represented 
by their medical officers. The ■ railway companies aro 
issuing return tickets at a cost of a single faro and a third. 
No more appropriate centre could have been chosen than, 
Bath, and the authorities of tho spa, with their traditional 
hospitality, always very evident in the case of medical 
visitors, are giving a civic welcome at the opening of tho 
conference and an evening reception. It need scarcely bo 
said that the bathing establishment will ho open for inspec- 
tion, with demonstrations of tho treatments. The honorary 
organizing secretary is Mr. John Hatton, director of tho 
baths, and the honorary medical secretary is Dr. Vincent 
Coates, at 10, The Circus. Eveiything points to a notable 
assembly, one which should mark the pre-eminenco of 
British medicine in grappling with this group of diseases, 
and wo may look for contributions to the literature of 
lasting value. ’ 


SUPERANNUATION OF LOCAL GOVERNMENT 
EMPLOYEES. 


The Departmental Committee appointed in 1925 “ to 
inquire and report whether any amendments are required 
in tho Local Government and other Officers’ Superannuation 
Act, 1922,” has reported in favour of tho compulsory 
establishment of schemes of superannuation by all local 
authorities, whether separately or in combination, on the 
lines laid down in the permissire Act of 1922.* It is 
recommended that participation in the schemes should be 
compulsoi-y for all officers and non-manual employees, and 
optional for servants and manual employees at a lower rate 
of contribution than officers, the option in the latter ease 
to be exercised through a ballot of the established servants 
of each authority. Tho committee recommends that the 
Boor Law Officers’ Superannuation Act, 1896, should be* 
repealed, and Poof Law authorities in general brauglit 
under the Act of 1922, as amended by the proposed legisla- 
tion, existing Poor Law- employees being allowed benefit 
of special rates of contribution related to the length of 
their Poor Law service. ' It is not, however, thought 
practicable to bring asylum officers within the terms of 
the Act of 1922, and in their case it is suggested that tho 
Asylum Officers’ Superannuation Act of 1909 should be so 
amended as to bring it into line with the Act of 1922 n-ithout 
abiogating tho special benefits it confers on a special class 
of public seiTant. The committee rejects the proposal put 
fornard by several witnesses, and pressed in particular 
by the British Medical Association in the interests of 
medical officers, that provision should be made for the 
addition of a period not exceeding ten years to the actual 
time served for the purpose of computing the amount of 
pension-due to professional officers, who are placed at a 
re ativo disadvantage under the Act by their necessarilv 
late cntiy jiito the local government service. Such a con- 
cession IS permissible under several of the local Acts now 
in opciation. The committee contends that compensation 
for the disadvantages of late entry should ho rather by way 
of immediate higher remuneration than through conces- 




sions in regard to superamiuatioii, but realizes that tho 
proposal for conceding additional years in the calculation 
of the minimum period of service entitling to pension is on 
a different footing. This is fortunate, since it will ho 
sufficiently clear that the medical officer who enters 
tho public health sen'ico with a D.P.H. and ' tho three 
years’ experience in medical practice considered desirable 
•by the British Medical Association will not find it easy 
to complete the full period of forty years’ service before 
the retiring age of 65. A modification in this age is sug- 
gested for nurses and health visitors, for whom compulsory 
retirement at 60 and optional retirement between 55 and 
60 after q period of thirty years’ service is recommended. 
Optional retirement between 60 and 65 after a similar 
period is proposed in the case of nialo nursc.s. The com- 
mittee recommends that in the event of early legislation 
maldiig the establislunent of schemes obligatory, it should 
bo opoii to any local authority by resolution to defer tho 
day appointed for tlie coming into force of the Act for 
a period of five years. There is clearly no likelihood of 
securing the necessary legislation during the present session, 
and it is to be hoped that the period of grace accorded to 
local authorities will bo modified in proportion to tho delay 
in bringing in the measure. 


A CENTENARY IN MEDICAL JOURNALISM. 

The completion of a century’s continuous publication week 
by week is stUl an achieveraont rare enough in joiii'iialisin 
to call for comment, and it is with pardonable pride that 
tho editorial .staff of the New England Journal of 3[cdicine, 
formerly known as the Eoston SIcdiral and Surgical 
Journal, celebrates, in the issue of February 23rd, the 
attaiiiuient of its one hundredth annivei’sary. Actually 
this well-known American periodical c.an claim an older 
ancestry, for of the two publications which were merged 
into the Boston ^Icdical and Surgical Journal when it first 
appeared in 1828, one — tho New England Journal, of 
Medicine and Surgery and the Collateral Branches of 
Science — was foiindc<l in 1812. Its title alone suggests an 
ago when time and space — in the joumalist sense — were 
things of less consequence than to-day. The other parent 
was tho Bnston Medical Intelligencer, which came into 
being in 1823, the 3 ear in whicli our British contemporary 
the Laitert was founded. Since those far-off daj-s tho New 
England Journal of Medicine has passed through tho hands 
of many editoro and proprietors, and it is now owned and 
publislied by the Massachusetts Medical Societj-, with Dr. 
Walter P. Bowers as managing editor. In the centenary 
number there are nuniorous articles dealing with the 
history of the jouinal and of medical science in America. 
Several reproductions of pages of the very earh- numbers 
servo to illustrate the advances which have been made in 
a hmidred j-cars in tr-pographical method. There is a 
certain rich floweriness of expression in some of the articles 
reprinted which is seldom found anywhere to-da\-. AVo 
have road with particular interest the article on the history 
of medical journalism by Dr. Morris Fishb uii, editor of 
tho Journal of the American Medical Association, who 
recalls how his distinguished predecessor. Dr. G. H. 
Simmons, established a coiqis of manuscript cditore, and 
laid down a typographical stj-le for the publications of the 
American Medical -Association, and in inane- other ways 
proved a stimulus to medical periodical literature in the 
United States. Dr. Fislibein ends with some maxims for 
tho guidance of medical editors and their contributors. 
Ho exhorts the latter to bo brief and interesting, and to 
•publish only when they have something new to say or 
sometliiiig old to say in a new way ; to be as careful in 
literary publication as in surgical operation ; to cliniinato 
tmnecessary charts, tables, and illustrations; to iirovido 
ail adequate summary and conclusions; and to quote only 
from literature that they themselves have consulted. 



612 March 24, 1928] EHEPMATIO HEART INFECTION: COLMCTIVE RESEARCH. 


iRr isRrnRB 


COLLECTIVE EESEAECH IN THE WEST 
COUETEY. . 

Conditions PnBDisrosiNO to Rheumatic Infection 
OF THE Heart. 

In a recent revieiv of some of the collective research 
taiT'ied out by the British Medical Association during tho 
last sixtj'-five j'oars vre pointed out that there were other 
forms of collective investigation besides those described. 
We aro now able, through the courtesy of those responsible 
for its inoe|)tioh, to give some account of an inquiiy into 
rheumatic infection' of tho heart, which is being carried out 
In the M^est Country under the most favourable auspices 

Scope of the Inquiry. 

. The scheme was outlined on page 701 of tho British 
medical Journal for October ISth last, and has now been 
working for four months with the enthusiastic co-operation 
of all concerned. The district covered, which includes the 
counties of Gloucestershire, Somerset, and Wiltshire, has 
for some time been regarded as a rheumatic area, and a 
good deal of work on rheumatism had been done in Bristol, 
Bath, and elsewhere before the inception of tho present 
scheme. For several years also the area has been happy 
in the existence of a largo measure of tho co-operation 
between public and voluntary medical services essential 
to the development of any such scheme. Hospital physi- 
cians and school medical officers have been in cordial 
co-opei'ation for several years in both Bristol and Bath, 
where physicians have been working with school medical 
officers in tho selection of children with cardiac diseases for 
special treatment; in Gloucestershire the well-known plan 
of Dr. Middleton Martin has been in operation, while 
both in Somerset and Wiltshire orthopaedic and other 
organizations furnished a useful precedent. The area is, 
moreover, peculiarly suitable for the investigation because 
it offers a ' wide range of conditions, economic ns well as 
geographical. It includes sea-board, fenland, high moor, 

• chalk downs, limestone ranges, and coal measures, with 
largo industrial cities and rural communities of every size. 

The actual scheme had been under consideration for 
several years when, after some unsuccessful attempts at 
enlisting the support of powerful organizations, an appeal 
was made in 1926 to tlie Cardiac Subcommittee of the 
Science Committee of the British Medical Association, 
which approved the project and recommended it to the 
Medical Research Council, by whom the clerical expenses 
of the work are now covered. The plan also interested 
Sir George Newman, who, as Chief Medical Officer to 
tho Board of Education, was glad of the support offered 
in dealing with the cardio-rheuraatic children attending 
the elementary schools. The county and borough' medical 
officers for the area having been consulted, on his advice 
the support of the local authorities was secured and tho 
work definitely set on foot on October 1st la.st. 

Basis for Notif cation and Begistration. 

At the outset those responsible for the inauguration of 
the scheme had to decide upon the basis for notification 
and registration for the purposes of the investigation. In 
the various inquiries already made into the geographical 
and seasonal incidence of rheumatic fever, valuable results 
have been furnished so far as the seasonal incidence is con- 
cerned. Inquiry into the geographical distribution, how- 
ever, has shown the difficulty of securing general agree- 
ment, over an area wide enough to be useful, upon a 
definition of the disease that is to be studied. The position 
is illustrated by the parallel case of pneumonia, in which 
notification has proved useless as a basis for scientific 
observation of a group of diseases simply because what 
one man includes under the term “ pneumonia ” another 
would exclude. And vet it is impossible to make headway 
with the prevention of infectious disease without know- 
ledc-e of the conditions under which it comes into being. 
Nor can this bo secured without the general co-operation 
of medical practitioners over a large area. After consider- 
able discussion of the problem it .was decided that if really 
Valid da ta were to be secured under the present scheme it 

zA?!***'*- •U.-rfira/ Journal Supplement, December 31st. 1527. p. 246; 
January 7th, lg2S, p. 2. -r . 


I SIed/CAL Joi7R*Ilt ' 


must he through voluntary as opposed to compulsory regis- 
tration On this basis all tho -practitioners in the a?-et 
nsked to. co-operate in the registration of- 
c.ises falling within tho following definitions : 

(1) Heart disease arising in connexion with rheumatism chorea 
or scarlet ferer in children between the ages- of 5 and 14 inclusive! 

(2) Heart disease which, though not arising: in connexion with' 

nevertheless rheumatic in type — that is 
tcnlncular, enlargement with mitral incompetence, with or without 
aortic incompetence, or acute' pericarditis arising in children' 
between the ages of- 5 and 14 inclusive. . 

Various bodies of medical men were consulted as to the 
development of tho sehemo, and on the advico of tho 
Medical Advisory Committee to one of tho county councils 
it was decided not to offer practitioners any fee or 
honorarium for their reports. The local Branches and 
Divisions of the British Medical Association approved the 
proposals, as did a meeting of tho South-Western Division 
of the Soeiety of Medical Officers of Health. Through the 
medium of the medical officers of health of the counties 
.md boroughs arrangements were made whereby the regis- 
tration of cases by private practitioners would be supple- 
mented by selection of cases from among the children 
attending tho public elementary schools. 

In order to standardize as far as possible the tj’pe of 
caso accepted it was fortunately possible to offer to the 
school medical service tho assistance of hospital physicians 
with , special expericnco of the disease, to decide whether 
to accept or reject doubtful cases. The various local 
authorities agreed to recommend the necessary expenditure 
on condition that the physicians concerned also offered their 
opinions ns to. the treatment of the children examined. 
Thus it has, been .possible -to arrange for a suiwey . by, 
physicians of experience of elementary school, children under, 
suspicion of heart disease. The local authority is advised, 
by these physicians wliother a child is or is not fit for 
school, whether- games or-dfill sliould be allowed, whether 
institutidrial treatment " is desirable, and so on. As a' 
general principle it is understood that the closest possible 
touch is maintained) with private practitioners in charge 
of such children, and they are offered the .consultative ' 
services of the physicians at their respective clinics in cases 
of suitable social status. Arrangements are being made 
for groups of children to be -assembled not only at the 
physicians’ own hospitals, but also at suitable centres in 
outlying districts. In Gloucestershire.Dr. J. B. Collins and 
Dr D. E. Finlay are undertaking this work, in Somerset 
Dr" O. B. K. Herapath, and in AViltsliiro Dr. Vincent - 
Coates! Similar work is being carried on in tho city areas 
concofiied, by Dr. Vincent Coates in Bath, by Dr. D. E. 
Finlay in Gloucester, by Dr. R. C. Monnington in Salis- 
bury and by Dr. Carey F. Coombs (wiio was a member of 
tho Association’s Cardiac Subcommittee referred to above) 
in Bristol. • ' 

At first the intention was to limit the inquiry to cases 
in which the infection of the heart might be presumed to 
Iiave arisen on or after October 1st, 1927. Experience of 
the work has, however, shown that it will be more profitable 
to collect all available cases of rheumatic heart disease 
arising between the prescribed ages, and make inquiry into 
the home conditions whenever this is possible in order to 
be sure whore the disease began. This must in some 
instances be impossible, but many of the children have 
lived in one house only, and in many the beginning of ill 
health can beidated with accuracy, so that in one "-ay or. 
the other a majority of those registered should bo avaihable 
for environmental inquiries. The next step after registra- 
tion of the case, whether it comes from the private practi- 
tioner or through- tho school medical service, is to make 
these inquiries. Till now the medical man in charge of the 
Thas been asked to do this; but experience suggests 
that this is a good deal to ask of a man who has already 
taken the trouble to fill up and post the form on which the 
case is reported. It is probable, therefore, that in future 
b^ will not he troubled with the questionaiy as to 
environmental conditions unless he expresses a wish to fill 
R uT The details asked for on this qucst.ona^ are 
entrusted to the staffs of tho county health department? 
and assembled at their several offices. 

Tlie co-ordinating point between every 
is at the Bristol General Hospital, where the Unive 3 



march 34i' * 928 ] 


SOME PROBLEMS- OF ^lEPHEITIS.' 


t Troc British R I Q 

MeDICAI- J oUB?fAI. 


ha -5 been instvttinental in forming a . centre for cariliac 
roscarcii with tho aid of grants from fho R. L St. J.- 
Haiinsnorth Memorial Fund and t!io Colston Research 
Society and otlior bodies. ' 

.111 Encoura'giitg licspoiisc. 

The scheme has now been in action for four months, and- 
the response secured has been most encouraging. Tlie 
practitioners of tlie area have sent in a good many reports, 
and it is not likely that many cases arising during thd 
period of the inquiry have missed registration. Tlie medical 
officers of liealth and tho school medical officers, together 
with their auxiliary staffs, have taken the matter up with 
groat keenness. Finally, the iihysicians concerned are 
much to be congratulated on tho public spirit witli ivliicU 
they have undertaken a task which brings them in little 
except hard work and a certain artistic satisfaction. It 
is believed that work undertaken voluntarily after this 
fashion will furnish more reliahle results than any amount 
of records obtained under a compulsory system, and will, 
moreover, afford an excellent opportunity of testing tho 
potentialities, alike for treatment rind for prevention, of 
that co-operation between the three sections of tho pro- 
fession — general practitioner, administrative officer, and 
consultant — which seems to flourish best in an atmosphere 
of complete freedom. 


SOJIE PROBLEMS OF NEPHRITIS. 

Goulsioniak LEcTunns by Dn. T. Izon Benhett. 

The Goulstoniah laictHyes for 1928, on “ Some problems 
of nephritis,” were delivered at the Royal College of 
Physicians of London by Dr. T. Izon BEN'>’Eir on March 
13th, 15th, and 20th. 


The Problem of Uraemia. 

Dr. Izod Bennett mentioned first tho groat variety of 
symptoms iiicluded by different writers under tho heading 
■of uraemia. He distinguislied betu-een cases in which the 
• two ureters became simultaneously blocked, irith resulting 
gradually deepening coma, and the train of symptoms 
which marked the termination of cases of nephritis with 
gastro-intestiiia! manifestations, muscular twitclungs, con- 
’vulsions, and hyperpuoea. Dr. Bennett described in detail 
a ease of the latter type wJiich resulted from bilateral 
cystic disease of the kidneys. This patient first came 
under liis care in 1923, and u'as the uilHag subject oJ 
man}’ observations until she died after the acute onset ol 
uraemia in 1S27. This case was an exarapJo of txraemia 
uithout nephritis, and was therefore of especial interest. 
iUe patient's main symptoms until the. final phase uere 
progressne U'ealtness, anorexia, and a foul, sour taste in 
ler mouth, possibly due to the increased- ammonia and 
urea content of her saliva. She never exhibited hyper- 
DUsion w oedema, and had no nervous s>’niptoras until 

he last five ^ys of her life, when coma and conoilsioni 

supenened. D^^cussing the pausation-of uraemia as ex- 
^ ^ first, reviewed the theoi*} 

.'''hiph had attracted so .manj 
the days of Bright^ and summarized tiu 
of against such retention being tlie caus< 

urea and ^indT^? ^ administration oj 
uneniin • +lin noT to animals did not procluc< 

of' the* Hrtnox’ such as cystic discast 

for m'lnv obstruction, often persisting 

evidence of nraeSa) 7nd the "cc'T" 
of I -i occasional cliscoveiw of cases 

■ questi'ou of non nitrogenoTlutetafc-"^ 
attention to tho retentir the lecturer dren 

sodium chloride in uraemie ^ven oi 

in the case of his- own patieu^’^ft ’ ocenrre. 

evidence he did not tlihik t h P'^'^ 
rohUion had heoii estahlislu-n n i present any dired 

miy of these eheniical UstaimesTn'd o' 

mean of uraemia. osianres and tho nervous piienn 

acidosis, in the sense which indicated tliw 

the blood, could be alkali rcseiTo o: 

- end especially in tbot irit^ *“ ■'‘’1 

.1 tiioso With marked nervous and respite 


tory symptoms. In his own patient tliis decrease in the 
alkali reserve , of the. blood was a marked feature in tho 
final phase.s, although the administration of large closes of 
sodium bicarbonate caused temporary increase without, 
Umvevei-j complete disappearance of -the inusciilar twitch- 
ingSj.and without preventiiig the onset of coma and cou- 
I'.nlsions. This suggested that acidosis was not by itself 
a cause of uraemia, and in considering other aspects' of 
blood chemistry ilie question of tho blood calcium content 
became of importance, although there were inany diffi- 
culties, particuJarJy with regard to the actual physical state 
of calcium in the blood. Tho increase in ' the phosphate 
content of tho blood. in uraemia was found to be associated 
with a diminution in the amount of calcium, and the low 
figure of 6 mg. per 100 c.cm. had been obtained during the 
final stages of the illness in the case described. 

Dr. Bennett then went on to deal with other clinical 
states in which the blood calcium was diminished and in 
which tho sym]itoms of tetany appeared; he cited non- 
malignant pyloric stenosis, parathyroid deficiency, chronic 
diarrlioeal states, rickets, and poisoning by overdoses of 
alkalis. In this group -of cases alkalosis first developed, 
and the other conditions' of tetany and diminished blood 
calcium were also present. It ‘appeared also from tliora-. 
peutic considerations that calcium shortage was the 
common factor in all cases of tetany, and it was suggested 
that there was a true relation between the twitchuigs and 
convulsions of uraemia ivliich was associated with a low 
blood calcium and the nervous phenomena known as tetany. 
There appeared to be a disordered metabolism of calcium 
iti both conditions, and it was interesting to observe that 
in some cases of non-malignant pyloric stenosis degenera- 
tive changes occurred in the renal tubules, showing that 
cbomical changes in the blood might themselves exert a 
destructive effect upon the kidney substance. Turning next 
to certain experimental work Dr. Bennett described the 
effects of forced rapid ingestion of large quantities of 
water in animals, which resulted in twitchings and con- 
vulsions leading to coma and death.. In such cases water 
was absorbed too rapidly to be dealt with by the kidneys, 
and the final symptoms were vciy similar to those of tho 
late stages of renal disease. Other experiments had shown 
that a syndrome indistinguishable from uraemia was pro- 
duced ill animals by the injection of sodium chloride solu- 
tion in the presence of acidosis, without any renal lesion 
being present before or after. It was suggested that in 
tliese. .experiments the convulsions were due to a disturb- 
anc_e of calicum metabolism. In conclusion Dr. Bennett 
referred to the difficulties of exact work without repeated 
lumbar punctures, .iltbough analysis of the cerebro-spinal 
fluid in the case of his patient had given figures similar 
to those of the blood, but usually less marked in degree. 
He quoted Bright's observations on the importance of the 
cliemical aspects of the subject, and expressed his' own. 
indebtedness to his laboratory colleagues. 

The Problem of Oedema. 

In his second lecture Dr. Bennett considered the problem 
of oedema; he admitted at the outset that the complexity 
I fli^ subject made it impossible to form a judgement from 
^ personal observation alone, but careful study led to the 
conclusion that when oedema occurred iii a ease of nephritis 
j it. .was, .evidence of the existence- of an extrarenal factor 
^ which niight’ explain the- nephritis, but was never the con- 
sequence of nephritis. The balance of the evidence to-day 
was against oedema ever being the direct consequence of 
disease.of the kidney, though it was possible that the cau.se 
of the oedema might also provoke disease of the kidney. 
Bright had called attention to the association of albumin- 
uria, oedema, and disease of the kidney, but be bad lieen 
more cautious than many of bis followers in dogniatiziiig 
■ about the exact relation between these conditions. 

Dr. Bennett then contrasted the two main varietic--' of 
nephritis under the names of hydropigenous and nzotaemic 
types, and commented on the tliffitulty of explaining how 
disease of the kidney produced such divergent resulls. The 
type referred to in this country as “ chronic jiarenchy- 
niatous nephritis ” was supposed to be an example of a 
derangement of tho capacity of tho kidney to excrete 
sodium chloride; in support of this it was said that 



5.14 TiIARCH 24 , igzSl 


BOME PEOBIiEMS OF NEPErniTIB. 


! '■':r'r 


[ The I<Bm*a 

MkiUCAI. JOtBVlL 


administration of salt to patients witli .so-callcd renal 
oedema increased the oedema, iriiilo a salt-frco diet often 
reduced it. It mas certain, liomcver, that iho blood 
chlorides were not increased in renal oedema, and the 
diminished excretion was even more marked in cases of 
cardiac failure or pneumonia, where the renal function was 
not interfered with. It appeared more likely. -that -there 
was in renal oedema a “ prcronal deviation of both 
water and chloride, that thei'e was an extrarena] cause, 
and that the salt-retaining kidney mu.st bo dismissed as' 
a myth. In the final stages of renal disease an increase 
in the chlorides often became apparent, and marked 
examples of such retention wore also found in mechanical 
obstruction of the ureters, but oedema was usually absent 
in these cases, despite the high blood chloride. 

An illustrative case was then demonstrated — a man, 
aged 22, who first came, under observation for generalized 
oedema in August, 1926. The urine of this patient con- 
tained large quantities of albumin, but the figures on bloo'd 
analysis showed a normal content of nitrogenous bodies 
and of the chlorides. A high protein diet and the adminis- 
tration of urea had resulted in a marked improvement, 
and the man was back at work with only slight oedema 
now, but his urine still contained large quantities of 
albumin. This case. Dr. Bennett said, was an example 
of. the. class of Ikidney disease now. called “nephrosis”; 
it exhibited the characteristic features, of a urine contain- 
ing certain lipoid substances which were doubl 3 ' refractive, 
and also the excessive amount of cholesterol in the blood. 
This constant relation between oedema in renal disease 
and a high plasma cholestei'ol had been well established, 
but probably these wore not related as cause and effect, 
some toxic disease acting on tho roticulo-endothclial system 
being a possible underlj'ing cause of both conditions. Tho 
kidneys in such cases of nepluosis contained very largo 
quantities of cholesterol in the tubules, and, histologically, 
there were degenerative changes in the tubules, with little, 
if any, in the glomeruli. It was difficult to believe that 
such cases were examples of anj’ primaiy disease of the 
kidney, although secondary changes in a kidney clogged 
with cliolesterol esters might be expected, and did occur. 
The evidence was also against the hyporcholesterolaemia 
being an effect of renal damage. Returning to tho subject 
of oedema Dr. Bennett then dealt ivith the rplation between 
the albuminuria and tho oedema of kidney' disorders. 
Epstein’s view was that the loss of albumin from the blood 
plasma lowered the osmotic pressure in the blood, and water 
passed to the tissues. The high protein diets in such cases 
certainly often succeeded in reducing- the oedema, but the 
theory did not explain tho oedema occurring in other con- 
ditions, and there were cases of nephritis in pregnanoy 
and acute cases of gloraerulo-ncphritis where the oedema 
was out of all yiroportion to the daily amount of albumin 
lost. Further, in the case demonstrated, loss of albumin 
continued although the oedema had largely disappeared. 
Albuminuria did not, therefore, explain the oedema of 
such cases. 

Dr. Bennett then considered certain diuretics for the 
indirect light they might throw on the subject of oedema. 
He said that there was a school of thought which held that 
acidosis was an important feature of oedema; the treatment 
of such cases by alkaline diuretics liad received mucli 
attention for many years. Very large doses might have to 
bo given, but tho results wore often remarkable. In con- 
trast with this line of treatment diuresis had also been 
achieved in desperate cases by the use of calcium cliloride, 
although tho acidity of the urine was actually increased. 
Thus both acids and alkalis could produce the same effects, 
and this paradoxical result might he explained by work 
which showed that any measure which tended to alter the 
titre of the renal blood acted as a stimulus to the renal 
cells. Tlie work of the kidney in cases of oedema was 
possiblv, therefore, directed to compeirsating an existing 
derangement of the normal blood chemistry, and though 
tho strain of such compensation might damage the kidney 
tho primaiy pathological process was an extrarenal one. 

Dealing with experimental oedema. Dr. Bennett stressed 
tlio artificial nature of many such experiments and the 
di-ssimiJai-ity between such oedema and that seen in pure 
lipoid nepluosis. Ho tliought that the work as a whole 


tended to support rather than challenge the belief that 
renal oedema was of extrarenal origin. V'itli rc".tid 
to oedema in general tlierc ajipeared to be no theory beffire 
tlic medical world to-day wliich explained .all .the known 
facts, but the theories which depended on the liypotlie.^is 
that the oedema was a direct consequence of renal injiirv 
broke down almost 'from the outset.' Elwy'ii had suggested 
that “ renal ” oedema was the result of an attempt to 
keep the bipod volume constant, and this again would 
liecessifate an extrarenal cause for the primary conditions. 
In all such eases it was necessary to searcii for" some patho- 
logical change of a wide nature in tissues other than tliB 
kidney. ' Such a change was not the result of nejihritis, 
aitliougli it was probable that the renal and the extra- 
renal damage had a common cause. 


The Trohlem of Hypcrpie.da .in .Nephritis. ■ . 

In his tliird lecture Dr. Bennett pointed out that in the 
case of high blood pressure in its" relation to nephritis there' 
was an absence of essential data, and he emphasized that 
the patient discussed in his first lecture and tlie one shown 
in his second lecture had exhibited no hyperpiesia in the 
course of their i-enal disease. He classified the cases in 
which hyperpiesia was most marked into three groups, and 
dealt-first with " chronic interstitial nephritis.” Two cases 


described by Bright in his Goulstoniari lectures' were first 
quoted to s’liow that Bright had -been puzzled by the fre--. 
quont association of sclerotic kidneys and cardiac hyqrer- 
trophy, and by the irregularity of albuminuria in such 
cases. Snell subjects were examples of the-classical arterio- 
capillary fibrosis described by Gull and Sutton, and it had 
been shown convincingly that in an enormous 'number of 
cases of contracted kidney there was evidence of high blood 
pressure for many years before any .renal lesion became 
manifest. The etiology of this condition of “ iiyperpiesia 
or “ essential hypertension ” was still obscure, but the 
n'resent evidence and the anatomical changes' in the kidney 
were against the theory that hypertension was primarily 
duo to a disorder of kidney function. There appeared 
to bo three stages in the development of the disease. Tlicro 
was at first a stage with the systolic blond pressure in tlio 
neiebbotirliood of 200 mm. of mercury and left-sided ventri- 
cular hypertrophy, but with no other signs or symptom.s for 
many years. Next, the progressive disease of the arterioles 
b, the renal tissues led to .a “ compensated renal failure, 
with polvuria and a urine of low specific gravity and .a low 
concentration of urea, but without changes in the blood 
Semistry. In the final stage the retention of waste pro- 
ducts of protein metabolism began to bo in eyidenec until 
the patient died of uraemia, red sclerotic kidneys being 
found at the necropsy. In summing up this group of ca a 
Dr Bennett emphasized that the disease of the arteiics 
had produced secondary changes in the kidneys hecanse 
vpcipiesia invariably preceded all signs of renal disease, 

’ Md bLause many patients died from other consequences of 
h i Hood pressure without having exhibited albuminuria 
” . evidence of renal involvement. , 

°Vh’i second group of cases domprised the renal comphea- 
The seco b i Bennett described cclamiisia as 

n SomJin a group of eases with certain m,:in.- 
p’stlionsXe to renal disorder, and with severe generalized 
fcstatio jnade their appearance at some timo 

Tl't'Z momtt of parturition"" It had been established 
tm!t 1 elevation of Hood pressure was almost invariably 
fclmt an j . j ; pressure ''’ns 

“ce’rive and iii the majorily of cases it fc 1 to 

after parturition, although occasionally 
r lit peraist or increase. Another group of patients 

■csult of the renal ° j^ot be .■=ett!e(i 

t was incsent Bennett thought that 

nvin" to lack of inroiraation. smec 

L term " toxaemia of ^ 

t tended to keep to tlie front p,irt of tlio 

irdor in which tho renal maniftstatirnis^ m 

rliole. and he mentioned work nhich sugges.ca 


March 24, 1928] 


CONTEOIj or CONCEPTION. 


[ THEBlUTl'iTX RT.5 

Medicai. JocnsAi. 


fii’torio-spastic condition tlio possible ciiuso of tliG liigli 
blood prossiiro' in theso pregnancy cases. 

In tho third group of cases Dr. Bennett dealt with aento 
glomonilo-nephritis, in wliieli elevation of blood pressure 
was presentj tliongli not in tlic focal tjpe. Tlie incidence 
of Iij-pcrpicsia in tin’s condition was, however, not certain 
owing to a lamcntablo lack of evidence. It appeared that 
oedema was an accompaniment of all such cases iii which it 
occurred, and in tho majority tho blood pressure returned 
to normal after tho acute attack. While of a moderate 
degree in most cases of diffuse nephritis, the elevation of 
blood pressure was marked in some, and in theso it wa.s 
probable that the blood piessnro was already high prior 
to tho acute attack, and would usually persist. In cases 
with chronic diffuse nciihritis, resulting from repeated acute 
attacks in many instances, a progressive elevation of blood 
piessuro usually occurred, but it was seldom as marked as 
in eases of “ essential hypertension,” .and occasionally it 
was completely absent. Dr. Bennett then went on to deal 
with tho important question of whether a renal lesion could 
by itself produce an elevation of blood pressure. On physio- 
logical grounds tho answer might be expected to be “ Yes,” 
but it had to be remembered that tho kidney possessed 
considerable powers of reserve. The balance of evidence, 
however, based upon extensions of Rose Bradford’s classical 
• experiments, was that destruction of sufficient renal tissue 
was followed by a rise in blood pressure ; oven so, the 
mechanism by which such a rise was produced had not been 
established. None of the nitrogenous constituents of the 
. urino had been .shown to increase tho blood piessure when 
present in excess in tho blood. It was possible to have such 
an excess of cholesterol in tho blood with a normal blood 
prossnre, and tho search for a pressor substance in tho 
kidney itself had been unsuccessful.' Tho evidence showed 
that hypertension duo to renal disease was slight in degree, 
and when patients e.xhibited extreme degrees of high 
systolic blood pressure — 200' m'm. ot higher — there was 
strong evidence for an extrarenal factor. 

In conclusion. Dr. Izod Bennett pleaded for a wider out- 
look in the consideration of kidney disease. The renal 
function could be readily influenced by slight changes 
in the blood, and even by heat and cold directed to tho 
surface of tho body. Ho pointed out that at the time when 
Bright made his observations alcoholism uas prevalent to 
an extreme degree in this countrj'; this might explain 'to 
some extent the differences between tho piotuio of nephritis 
drawn .at that time and tho fonn it exhibited to-day. Ho 
emphasized that the whole body and its metabolism should 
bo studied in renal disease. 


ROYAL MEDICAL BENEVOLENT FUND. 

At the last meeting of the committee fifty- four cases were cor 
sidered .and £957 voted to forty-nine applicants. The followin 
IS a summary of some of the cases relieved. 

mone'®'‘nm’l ^ '“"'or lost h 

nrofession 'lie ‘lebcate. trainoil as a nurse, ivhic 

work Slie’inq ti-leU^o' "“'l' .fte had a serious bi-eakdown Ihrouali wi 
ftorn’tuliireiiloliJ ‘i™” to romme work, but i.s now sfffferin 

Wi, me as Voted £2 

dauehter’ Iii^ed Applicant and In 

memni liosnital Toil 'be daug-bter, aped 37, was removed to 
tor her maintenance iii 111 ^^ 0 ™°!?/ ^Thiriea“''”'I!" b"® new to use 

“bewanco frW’sis?e"iS,^! ren 

wit’i^'on'iT’cUUd^Ua^etaTifu'.,^^' 'u*'® 7 ^' ""e son, who is marrit 

Rive up his praefiee preparatory school. Applicant had 

e.rhaiisted his'^savines 'rini' ed account of deafness, and hi 
I PUP end n O'by, ‘be eW “Re pension. Vi^ted «0. 

had to ’raitait p’fact^ce i“i® “ losing- all his moni 

£173. llo teeci^S Rifts' °° '’b' ‘e work, and last year mai 

in^hmentrand'^s^pcJLf^Ja’n^oTTs' -Juarter 

sister 'iiavo’supporled tii'ern<S’i?'s'''bv"^tea fi''^'' Both she and h 

Sir^''c1i^i^i-fers"^Svm'riri i t™-i'' Honorary Treasure 

Square/ W l! “t 11, Chandos Streep Cavendit 

many'' applications'* for' cWr Guild still receiv 

for ladFes and nirh ' hnli* cdhts and skit 

working boys. The Gni d'"® secretarial posts, and suits f 
bousebold .articles” The ® f®*" ^ebond-band clothes ai 

of the Guild, 4 Great lFf^m 

) 00, Great Marlborough Street, W.l. 


CONTROL OF CONCEPTION, 

IXTEUKATIONAL >IeDICAL GrOUp’s FiRST BepORT. 

Those who attended the World Population Conference at 
Geneva in September last included representatives of 
medical science from a large number of countries in 
Europe and elsswiicre, and among tho offspring of tho 
conference was the International IMedical Group for tho 
Investigation of Birth Control. This organization was tho 
result of an informal meeting of medical representatives 
of different countries ; it consists exclusively of medical 
practitioners, and aims at co-ordinating biochemical, 
physiological, and statistical research bearing upon contra- 
ception, and disseminating this knowledge so as to make it 
available to all countries. 

The qualifications required of person.? collaborating in the 
work, apart from adequate professional status in their respec-’ 
live countries, are defined as including “ a detached and 
critical .attitude to. the methods now practised.” They should 
be people free equally from prejudices against birth control 
springing from religious or political beliefs and from prejudices 
in favour of it arising from excess of propagandist zeal.” The 
he.idquarters of the committee are in England, and its efforts 
are to be restricted to collecting and circulating the communica- 
tions received. The organization undertakes to act, not as a 
prop.agandist body, but essentially as a medical information 
committee, and in this capacity it will, no doubt, be welcomed 
by all who are interested in this debatable subject. That there 
is need for co-ordinated scientific study is demonstrated 
in the first result of its labours — a circular obtainable from 
the Hon. Mrs. Marjorie Farrer, secretary’ of the committee, 
41b, Clanricarde Gardens, London, W.2. 

This document contains the replies received from Dr. Alma 
Sundqvist (Stockholm), Dr. J. H. Leunbach (Copenhagen), and 
Dr. H. Riese (Frankfort), representing Sweden, Denmark, 
and Germany respectively, to a questionary issued by the 
committee. Dr. C. P. Blacker (Dorking) deals with the 
position in Great Britain, and contributes an editorial note 
st.ating that it has been considered e.xpedient to publish this, 
the first, report without waiting for a reply from the United 
Slates. It is intended to widen the circle of correspondents 
by degrees, and to publish the collected communications 
quarterly. Each communication is expected to include reports 
on (o) statistical investigations regarding the reliability, harm-’ 
lessness, simplicity, or otherwise of different contraceptives ; 
(/j) research work of an immunological, biochemical, or physio- 
logical nature bearing upon the problems of contraception and 
sterility; and (c) information touching the general attitude 
of a country towards birth control, changes in this attitude, 
and in that of the medical profession. 

The scope of the inquiry proposed is therefore comprehensive, 
but the first results are somewhat disappointing. No doubt <as 
the movement gains headway and the various correspondents, 
as the result of experience, are able to devise a uniform 
.method there will be a marked* improvement, but in these 
first communications there is a divergence in style and 
treatment which makes comparison difficult. To some extent, 
of course, this is due to the inadequacy. of .the material avail- 
able. The Swedish communication, for example, consists of 
rather less than twq hundred words. Dr. Sundqvist cannot 
give any statistical information or any news of recent research. 
He states that the public attitude is enlightened and tolerant, 
that, the la^v against giving public information about contra- 
ceptives is a dead letter, and that the members of the medical 
profession are, as a rule, rather indifferent. ” Birth control,” 
it would appear, is not a live subject in Sweden. 

The writers of. the Danish and German reports devote them- 
selves largely to contraceptive methods. Dr. Leunbach states 
that more than three years ago he opened a contraception 
clinic in Copenhagen. His experience in dealing with about 
2,000 cases has led him to conclude that cervical pessaries are 
suitable only for from 5 to 10 per cent, of all women, and he 
has therefore abandonee! the “pro-race” and “Ramses” 
tj^es of pessary in favour of the Dutch type. He states that 
in 800 cases fitted in the year ended October, 1927, he has .so far 
had only three failures, but points out that as the period is 
•short it is difficult to draw any certain conclusion from tho 
figures. 

The German report is less detailed, for the author, Dr. 
Riese, does not restrict the scope of his birth control clinic 


CANADAl 


Vf-'-Tirs linmw 
L SIsdiCal JouBMiii 


61 6 - Mauch 24, 1928] 


to contraceptive methods. Tlie teclmique which lie recommcnels, 
after having Med and abandoned many methods on aceonnt of 
their unreliability and possible harmfnlne.ss, is the employment 
of Tr "suppository in a gelatin base and the fitting of a pessary, 
generally a “Ramses.” His practice, therefore, differs from 
that of Dr. Lcunbach in two important points, for the Danish 
authority has coma to the conclusion, after an e.vamination of 
the effect of various spermaticidcs and suppositories on lixdng 
spermatozoa, that all contraceptive suppositorie.s are practically 
worthle.ss, and he has ako rejected the ” Ram.ses ” type." 
pe.ssai-y as generally unsuitable. Dr. Blacker’s . snmmai-y of > 
the available British evidence on this point does not appear" 
to clarify the position. He stales that at the nine centres of 
the Society for the Provkion of Birth Control Clinics, and at 
that of Dr. Xorman Haire, the Dutch type of pessary is used, 
while at the Marie Stapes clinic the “ pro-race " cervical tjTte 
is employed with, it is claimed, a minimum of 1 per cent, of 
failures. Dr. Haire, however, is quoted as stating that the 
“ pro-iace ” pessary failed in 83 per cent, of the cases he 
had seen. 

Statistics regarding the relative efficiency of various types" 
of pessary and of various spermaticidcs liave not. Dr. Blacker 1 
points out, been yet impartially assembled and compared in 
Great Britain. The same may be said with even greater truth 


of those oBered'in other countries. He adds that the Birth 
Contiol Investigation Committee, which" is associated with tlie 
'International ■ Committee,' is* beginning- to conduct researches 
which will y'ield more-complete and detailed data than any that 
■haye yet appeared- in England.- The report for Great Brit.-iin 
seems to cover the ground more-thoroughlythan any of the others. 

-Tlie publication of this first report of the International 
, Committee should do something -to stimulate a wider, application 
of scientific study to this sub ject and the collection of trustworthy 
-dat.-ibn-a broader basis. The" lack of definition "in statement is 
ia-wcakiiess which c.-in only- be overcome -as the material available 
• is ihefeased. - In conclusion," ft- may be remarked that the 
I - members of the committee seem" by implication to have restricted 
, their studies fo the use of contraceptive appliances and sub- 
stances. Dr. H. Ricse. their German correspondent, has, how- 
' ever, opened up a wider field which may be of even greater 
interest to the medical profession in Great Britain. In intro- 
rlut-ing his memorandum he states that, in his e.xpericnce, 
contraception in c.vtremely poor families, with many children 
and little sense ofsocial responsibility, is generally performed 
by lube re.section'; and later, after describing the method of 
“ birth " control ’’ attiibut'ed to him above, he suggests that 
temporary sterilizatioh by injection of a contraceptive hormone 
‘ would he preferable. 


Cattatra. 

[Fiioji orn Speci.m, ComiF.si'ONDF.NT.] 


Professor A. B. Macallum. 

Thk retirement of Professor A. B. Macallum this, year 
from the chair of biochemistry at McGill University marks 
the close of a brilliant teaching career extending over half 
a centnj"y. On the occasion of his last lecture to his 
students this month, with wliich ho concluded his academic 
career, he received many marks of respect and esteem from 
the faculty and students. He had always devoted himself 
to physiology, hut came to take more and more interest 
in the chemical aspect. Ho was the first to occupy the 
chair of hiochemisti"y at the University of Toronto, holding 
this appointment from 1906 to 1917. Ho tlien served as 
chairman of tlie Advisory Council of Scientific and Indus- 
trial Research until his appointment in 1920 to the chair 
of biochemistry at McGill University. His many degrees 
and publications are evidence of his varied activities and 
achievements, and among them all he retained a love for 
the classics which contributed in no small degree to his 
influence in teaching. It w"as characteristic that in liis 
final lecture (on vitamins) lie should conclude by urging his 
students to acquire the habit of hard w'ork and the spirit 
of inquir 3 ', reading to them the passage from Tennyson’s 
Vhjsscs : 

“ I am a part of all that I have met; 

Tot all experience is an arch wherethro’ 

Gleams that untravelled world, whose margin fades 
For ever and for ever wlien I move.” 

He would have them 

“ Follow knowledge like a sinking star 
Beyond the utmost bound of human thought.” 

Government Travelling Clinics in Alberta. 

A great deal of work was done in 1927 by tlie travelling 
clinics organized by the Provincial Government of Alberta, 
and tlio country members are agitating to liave the plan 
extended to cover the w"liole province instead of the 
northern part only. Whether or not this is the beginning 
of what mav develop into a form of State medicine there 
is no doubt that the demand for such clinics has been 
created, and their activities will probably be widened. 
Each clinic includes three nurses, two doctors, and a 
dentist One of tbo nnrses travels ahead, examining the 
school children. Then the clinic , comes in, but only on 
invitation from local committees interested in the schools 
of the district. The work undertaken is the removing of 
tonsils and adenoids, and tlie filling and extracting of 
teetli, and one of the doctors stays behind for a day for 
tbo after-treatment. - The prices charged are 15 dollars 
for the removal of the tonsils and adenoids, 50 cents for 


extraction of a tooth, and 1 dollar for an ordinary filling. 
The Jliiiistei" of Health for the province sees no great 
difficulty in reconciling tiie w"oi"k of the clinic W'ith that 
of tho local practitioners, as he showed that the clinic 
would probably only visit one place in a year. Tlicre is, 
however, still some' dissatisfaction in tho minds of local 
medical practitioners, both as to the actual w"oi"king of the 
clinic and the possibilities implied in its growth. 

Chiropractors In Quebec. 

Tlioro has been an attempt to introduce legislation by 
which chiropractois ironld be incorporated as a body 
nosscssiiig a definite status in the province of Quebec. 
-The Provincial College of Physicians and Surgeons w-as 
fuHv advised of the matter, and steps were taken foi 
concerted action on the part of tho College and the medical 
schools of the province to place their views before the 
legSature. Accordingly, representatives of these txiciical 
h^ies were sent to Quebec, and it was made clear to the 
Lwslative Council that they w;ero strongly opposed to any 
sudi incorporation being poi-mitted. As a icsult of these 
representations the Council defimtely refused the request 
of the chiropractors. In this respect the province of 
Ouebec has taken a different stand from that taken by tlie 
^ nf Ontario which hns passed a bill by which dll 

are placed L.a footing defined and 
controlled by tlie Provincial Legislature. 


Wivxon d 

[Fr.OM OXJB CollHESFO.VDEXr IX C.iTETOWX.'} 

Medical, Dental, and Pharmacy Bill, 
the hist session of Parliament the Medical, Dental, 
I P»f Bill passed its second reading and reacbod 

comnntlee sUigc-^^Jn^co^^^^^^ Parliament 

-Minister^ tron%?r^:SnLg 

tft sCild ha P^uaeded with in the present session at 
where it was interrupted »i committoc, "^^tead 
introduced dc noro. When recently consideration 
fill was resumed, Clause 76, promising to be somo- 
Jntlntffiiis was passed over for tlie time being, and 
It adopted with little or no dis- 

ioT*' Duifiig tlie debate on the first day chief interest 
ired' in a new^ clause introduced by the Munster to 0 9 
ise 79, as follows : . . , . „ 

(!) No person agroc- 

^‘r"as3oc-,a“e himself in any way VitU any other person for 


MARCH 24,~i9^*] 


BCOTIjAND. 


[ TtrsBamss 
STeDICU. JOCBSII, 


617 


(he purpose of making or fixing, excessive or extortionate charges 
for any service rendered or to bo rendered or for any articla 
supplied bv him by virtue of being so registered. 

“ (2) Unless the circumstances are such as to render it impos- 
sible so to do, every person registered under this Act shall, before 
rendering any service by virtue of being so registered, inform tho 
person to whom tho service is to be rendered, or tho person in 
charge of such a person, of tho fco which he intends to charge 
therefor: (o) when so requested by any person concerned; or 
(4) when such fee exceeds that usually charged for Abe service. 

“ (3) Any registered person who contravenes or fails to comply 
with any provision of this section shall be guilty of improper or 
disgraceful conduct ■within tho meaning of Chapter IV of this Act, 
and it shall be the duty of tho Council or the Board to take 
cognizance of and deal with such conduct under that chapter.*' 

The clause was regarded by certain members tvitli sus- 
picion, but the general feeling seemed to be that it had 
been drawn up by the Minister to placate certain of the 
keenest opponents of the bill, who had endeavoured to estab- 
lish a fixed scale of fees for medical practitioners. Reply- 
ing to a somewhat long-drawn-out debate the Minister 
stated that far from tho new clause being a slur on the 
medical profession it had proved acceptable to the Medical 
Association of South Africa, to which body it had been 
submitted. Legislation, he maintained, was necessary, not 
for tho ordinary medical men, who stood very high in 
South Africa, but for the few exceptions. On a division 
the clause was adopted by 58 votes to 31. 

Another new clause, introduced by Mr. J. D. Heyns, 
member for Middelburg, was to tho effect that if a patient 
died during the administration by a medical practitioner 
of chloroform, or anything of a similar nature, an inquiry 
should be held by a magistrate. Although it was made 
clear that under the proposed clause there would have to 
be a post-mortem examination in every case of death under 
an anaesthetic, even though it was self-evident that no 
necessity for such existed, the mover of the amendment 
insisted that he wished to see an investigation made by a 
person not belonging to the medical profession in order to 
protect the public. The clause, after being redrafted by 
the Minister, was adopted. 

Clause 76, dealing with the conditions under which 
corporate bodies could carry on the business of chemists 
and druggists, , which had been loft over to the last, occu- 
pied the final afternoon of the committee stage. An 
amendment was tabled proposing that the managing 
dmector of such companies should be a qualified chemist. 
Ibis amendment, it was stated, had the support of the 
associated pharmaceutical societies in the Union. Tho 
1 iinist^^ refused to accept this amendment, but on a non- 
party division it was carried by 60 votes to 44. The 
ill was reported with amendments and the report 
s ago set down for an early date. Except for on amend- 
men making it clear that tho bill does not render un- 
iawtul any calling hitherto carried on lawfully in the 
iiion, which may bring into tho arena once again the 
-M chiropractors, faith healers, and others 

ot that ilk, which amendment will be dealt with at the 
lepoit stage, it seems practically certain that the bill 
will at last find a place in the Statute Book this session. 


the public would accord sympathy and support. Ur. 
O’Mally in his address described the nature of the two 
main types of- venereal disease and the results they brought 
in their train. He emphasized the fact that the diseases 
were curable, and urged the necessity of immediate treat- 
ment. He Slimmed up the weapons of attack under three 
heads: first, education, tending to a higher standard of 
knowledge, which would foster higher ideals in a com- 
munity; secondly, better living, conditions whereby the 
environment of the poorer classes might be improved; and 
thirdly, the establishment of free treatment centres. -At 
the conclusion of Dr. O’Mally’s lecture a film showing the 
effects of syphilis as an agent of family disruption was 
shown. Figures exhibited on the screen showed . that 
during the period 1926-27, 1,942 patients had commenced 
treatment at the various clinics in tho peninsula, and that 
21,032 consultations had been given. 




Vital Statistics, 1927. 

The Reoistrah-General for Scotu-ind has issued a pre- 
liminary note on the vital statistics for 1927, which will be 
followed in due course by a full account in his seventy- 
third annual report. The most outstanding fact is a 
further fall in the birth rate, which has now reached 19.8 
per 1,000, the lowest Scottish birth rate yet recorded. 
Tho birth rate was highest in 1876, when it was 35.6 per 
1,000; that for 1927 is less by 44 per cent. The death 
rate of tho year was 13.5 per 1,000, arid the marriage rate 
6.7, both below recent averages. The infantile mortality 
rate was 89 per 1,000 registered births, which was less 
than the mean of the preceding ten years. The death rate 
from all tuberculous diseases was 99 per 100,000, equal to 
the lowest yet recorded, and that from respiratoiy tuber- 
culosis was 71 per 100,000, the lowest on record with one 
exception. Deaths from cancer (6,918) show a further 
increase. The Scottish birth rate for the fourth quarter 
of 1927 was 18.9 per 1,000; in the larger burghs tho 
highest rates were in Coatbridge with 25.4i Glasgow wifh 
21.5, and Hariiilton with 21.3. Of the 23,282 children 
bom 21,601, or 92.8 per cent., were legitimate. The deaths 
numbered 16,939, giving a quarterlj- death rate of 13.7 per 
1,000; in the larger burglis the highest rates were 16.8 in 
Glasgow, 16.4 in Coatbridge, and 16.3 in Dundee. The 
Edinburgh rate was 15.5, and that of Aberdeen 13.0. In 
England and Wales the corresponding quarterly death rate 
was 11.7 per 1,000. which was 2.0 less than the Scottish 
figure. In Northern Ireland it .was 13.7, as in Scotland. 
The infantile mortality rate was ICO per 1,000 registered 
births; the highest figures for the larger burghs were 
167 per 1,000 in Coatbridge, 150 in Falkirk, and 147 in 
Paisley. The corresponding rates in England and Wales 
and Northern Ireland were 68 per 1,000 registered births, 
lower by 32 than the Scottish figure. 


Caaipaign ."against Venereal Disease. 

uf the Women’s Municipal Asso- 
prevention and ' treatment of 
Ton "'IS given to a large audience of women 

oLfded Councillor Mrs. Jliriam Walsh, who 

v^ernntn-Tf ? Iccturer, Dr. Gavin O’Mally, 

association^ vh" i'° Capetown, explained that tho 

lecture ennci'cfo'i ' responsible for organizing the 

CanetoJvn n I p+ uomen who had combined to make 
warto .uud cleaner place. One of their objects 

and to tills health problems in the city, 

to rouse tbe '’ut' decided to organize this meeting 

faciei:: fm%i^fctt:ii'rtr^^^^^ 

and spreading. There Ls ni l Srow-mg 

now tint the 1 more clinics, especially 

a suburb of Capetown^ harb''*^ umnicipality of -Wynberg, 

muiiicipalitv. Wvnbere r“ “ 

some of the verv as a largo area and contained 

necessary to provide fartliur*" J* '^as 

tho other ,vnr!ir 0 muhtie.s in those poorer areas as in 
.the other wards, and their object could be gained only « 


Anderson College of Atedicine, Glasgow. 

The closing meeting of the Anderson College of Medicine 
at Glasgow for tho session 1927-28 was held on March 
15th. Emeritus Professor John Macintyre presided, and 
the prizes and . medals were presented to the successful 
candidates by Dr. John D. Comrie, physician to tlio Royal 
Infirmary of Edinburgh, who subsequently gave a closing 
address upon tho debt of modern medicine to the seven- 
teenth and eighteenth centuries. The lecturer referred 
to the publication, three centuries ago, in 1628, of William 
Harvey’s Exercitatio Anatomica, in which the circulation 
of the blood was demonstrated ; it had como to bo regarded 
as the most important single contribution which had ever 
been made to medical science. The Civil War in England 
had produced not only Harvey-, but other great doctors, 
including Sydenham, who had the merit of introducing 
simple and rational methods of treating patients, and whoso 
pre-eminence had been at the bedside, as Harvey’s was in 
-the laboratory. It had also produced Richard Wiseman, 
the '‘father 'of English surgery,” who hod spent some 
time in Scotland and contributed to tho adranco of 



618 march 24, 1928] 


ENGLAND AUD- WALES. 


{'n^.T. TnEBunTm 
> '■ 1 SfKDICXL JotTBKUi^!' 


Burgory there. Tlie lecturer referred at .Bome length to 
Peter Lowe, who had been trained in the wars in Prance, 
and who had settled in practice at Glasgow, at the end of 
the sixteenth century; his Discourse on the Whole Art of 
Chyriirrjcric was the first surgical hook to ho written by a 
Scotsman, and ho had been responsible for the founding of 
the Faculty of Physicians and Surgeons of Glasgow. Ono 
of the latest surgical workers connected with the old 
College and the old Boyal Infirmary in Glasgow two cen- 
turies after Wiseman’s time had heeu Joseph Lister, who 
had there commenced in 1865 the experiments with carbolic 
acid which had contributed greatly to his fame. The 
lecturer beliered that future generations xroidd accord a 
still higher place for benefits conferred on surgery to Sir 
William Macewen, who had also worked in . the Koyal 
Jn&rmary and had been one of the earliest pioneers in 
aseptic surgery, which was now the routine of modern 
hospitals. Beference was also made to John Hunter, who 
had come from Long Caldenvood, some eight miles .south 
of the Clyde, and to William Cullen, who was born at 
Hamilton and who had been one of the mo.st important 
early figures in the medical schools both of Glasgow and 
Edinburgh. The contributions of Glasgow to chemistry — 
notably that of Dr. Joseph Black, who had been the fix'St 
to discover a gas, carbon dioxide — were also mentioned. 

Larbert Colony Scheme for Mental Defectives. 

Sir Alexander Gi'acie presided over tlie sixty-seventh' 
annual general meeting of the Boyal Scottish National 
Institution at Larbert for Mental Defectives, in Edinburgh, 
on March 12th. The report shoxved that there were in the 
institution more than 500 montall 3 - defective cliildren, who 
were being trained for some useful work, so far as their 
capacities admitted. The directors were at present eng<aged 
in attempting to establish an industrial colony for 300 
mental defectives, but had so far been able only to raise 
half of the £70,000 which was required. In the meantime, 
it was proposed to provide for 50 adult defectives the 
erection of two villas, while Larbert House, the mansion 
on the e.state which had been purchased for the establish- 
ment of the colony, had been converted into a home for 
the all-life care of 36 mental defectives, for whom fees could 
be charged. The latter homo had been opened last Julj’, 
and the proof that there was need for such accommodation 
was forthcoming in the fact tliat more than half of the 
places had been immediately applied for. In the medical 
sujxerintendent’s report it was stated that of the children 
admitted 9 were classed as feeble-minded, 34 as imbecile, 
and 9 as idiotic. It is pointed out in the report that no 
sharp line of demarcation between the definitelj- feeble- 
minded and the dull normal elements of the population can 
be drawn, nor between those who are regarded as merely 
feeble-minded and those who are definitelj’ imbecile. It had 
been thought that the intelligence tests would enable 
definite distinctions to be made, but in practice this had 
proved impo.ssible. Dr. E. D. Clarkson, medical superin- 
tendent, in submitting the report, said that it had formerly 
been imagined that feeble-minded children merely required 
, a longer and slightly different education from others, but 
this idea had proved to be false; mental defiefenej’ was an 
incurable condition, Irence the decision of the directors 
to purchase an estate for the formation of an industrial 
colony. Manj- mental defectives could only be safe in such 
a colony. The chairman pointed out that satisfactorj’ 
progress' had been made with the colony scheme; a good 
lead had been given by the Council of the Women Citizens’ 
Association, which had contributed more than £12,000. 
The directors felt that it was not only the duty of everyone 
to help in the matter, but that as individuals they should 
protect themselves from the menace which was constituted 
by the want of proper control of mental defectives. Lord 
Sands, in speaking of the increasing public interest in the 
whole-life care for the feeble-minded, said that in the old 
days when the greater part of the population was scattered 
over rural districts, the feeble-minded people contrived to 
live fairlv happy lives, but these conditions had now almost 
entirely disappeared, and it was hardly possible for weak- 
minded and imbecile cliildren to grow up in densely popu- 
lated centr’es. Three great benefits were conferred by such 


an institution: the removal of feeble-minded children from 
their homes and the streets, their training, and the ensuring 
of their happiness. 


Debate on Animal Experiments. 

A debate on the question whether vivisection was neces- 
sary or justifiable in the interests of mankind was hold in 
the y.M.C.A. Hall, Edinburgh, on March 16th. Mr. F. J. 
(Rohertson presided, and Dr. F. A. E. Crew of the animal 
research department 'in the University of Edinburgh 
supported vivisection, while the negative was maintained 
by Mr. Herbert Brown of Glasgow. Dr. Crew pointed out 
that experiments on animals weie conducted for the 
definite purpose of seeking information which sliould give 
to mankind the power to control bis physical environment 
as well as the life processes of animals and plants. Be 
believed that the general public should know what scien- 
tists, who were paid by' the State, were doing and how 
they did it. Stories of eats, agonized and suffering from 
artificially produced disease, had been spread abroad and 
embellished beyond all reason. He considered tliat anti- 
rii’is'oction was largely taken up by elderly women through 
fanaticism, as it was rarelj- supported by men. He did 
not consider that these wore the people who were best 
constituted to judge what was necessary or justifiable in 
the interests of mankind. No country could prevent the 
importation of the fruits of scientific investigation, 
although it might banish tlie investigator. He believed 
that animal experimentation was the only means available 
for securing certain knowledge, although it was only one of 
the manj’ tools used by the scientist. After considerable 
disens-sion the motion that animal experimentation was 
necessarv and justifiable in the interests of mankind was 
supported by a large majority. 


(Bttfflnnit mb 


■ Opening of the New Leeds Dental School and Hospital. 

V event which has for long been eagerly awaited by 
il interested in the study of dentistry took place 111 Leeds 
•boa the new dental school and hospital was opened by 
lie Speaker of the House of Commons, the Eight Hon. 
h" Whitley. The Chancellor of the University, the 
of Devonshire, who presided, was accompanied by 
l,e' Vice-Chancellor and other I'^’/esentatives of the 
[r.:,-orsitv including Professor T. Wardrop Griffith, and 
y members of the staff of the Dental Hospital and of the 
eiicral Infirmary. In his opening remarks the Chancellor 
I oc’zpd the ereat importance of the connexion of the 
7 f of Dentirtry with the University and with the 
‘ IiSart at Leeds. Mr. Alexander Campbell, 
Xn ng how ibe cost had boon met, said the Infirmary 
j a site which represented a contribution of 

B%00- the Dental’ Board gave £ 5,000 towards the 
’1 500 toiiards equipment and the members of the 

?nt„f staff harshown the sincerity of their desire to have 
tnner'lv equipped school and liospital by contributing 
7 £2 000 Thi cost of the building and its eqrnpment, 
t fmm’the value of the site, was just over £ 42 , 000 . 
Francis iyke Acland also referred to the value of the 
union which existed between the University, the 
ra Infirmary, and the School of Dentistry, and pointed 

? tbit ?t f 

Iipo ns it was for the patients of any teaching hospital, 
? fhprp should ho present a number of young men and 
desiron of learning all that they could from the 
and example of their teachers. He added that 
n'^Tirk of Mr. Wliitley and that of a dentist had many 
f„rin ™mmon. In the hands of each there 1=^7 
\roi- tn nrevent the other man from talking; each ha 

ntiTplv unmoved to protests against the use of > 
7’“e7h ha'd to view with nni-nffled calm the cxpiilsmn of 



Ma'ROH 54i 




[ Tnr. Bnmsa . R 1 Q 


Leeds, marking as it did tlio beginning of n great scheme 
for tho provision of adequate accommodation for all its 
departments. Ho was confident that the disruption of the 
federal university, of which Manchester, Liverpool, and 
Leeds were the three constituent colleges, and the fact that 
Leeds had to stand by itself, would act as a spur to the 
people of Yorkshire. A description of the new build- 
ings was given on January 14th (p. 72). Locally it is 
felt with prido that Leeds has now ono of tho best, if not 
actually the best, constructed and equipped dental hospitals 
in tho country. Immediately after tho opening ceremony 
a congregation of tho University was held in tho library of 
the ^Medical School. Honorary degrees were conferred by 
tho Chancellor on tho Speaker of tho House of Commons, 
Jlr. Charles Rippon, president-elect of the British Dental 
Association, Mr. W. Sinton Thorburn, warden of tho school, 
and Jlr. Walter Marston, chairman of tho Clinical Dental 
Comniitteo. 




Ministry of Health for Northern Ireland. 

Some important correspondence has appeared recently in 
tho local press on the subject of establishing a Ministry of 
Health for Northern Ireland. In the issue of March IGth 
of tho Belfast News-Letter Dr. Kidd of Enniskillen detailed 
tho arguments in its favour, and emphasized the point 
that the duty of the Minister was to prevent disease ; such 
a function was too often overlooked, although it was of 
much greater value than that of attending to the treatment 
of illness when it developed. Though tho question is com- 
plex- it may be asserted with confidence that the general 
tenets of Dr. Kidd’s letter will receive the cordial approval 
of tho medical profession in Northern Ireland. 


Research at Buxton. 

The first research report of tho Devonshire Hospital, 
Buxton, has lately been issued' under tho joint editorship 
of Dr. C. W. Buckley, chairman of the Research Committee, 
and Mr. Joseph Race, biochemist to tho hospital. The 
research laboratories of the hospital were established in 
1912 to investigate tho bacteriology of arthritis. In 1923 
B research chemist was added to tho staff and a laboratory 
equipped. At first the object was to study the chcmisti’y 
of the Buxton mineral water and its action in the diseases 
for which it has had a reputation based upon empiricism 
siiiM Roman times. Tho scopo of the work has steadily 
widened to include the biochemistry of gout, acute rheum- 
atism, fibrositis,' and arthritis. The present report deals 
mainly with some of these problems. A paper by Dr. D. 
Macmillan, based on .an Edinburgh M.D. thesis, presents 
the results of work on the calcium" and carbonic acid 
content of the serum in chronic rheumatoid arthritis and 
other conditions. Ho shows that the calcium content of 
1 16 serum presents no marked deviation from tho normal 
in 10 rheumatoid group of diseases, and that, apart from 
in ective arthritis, the carbon dioxide content of the 
serum also lies between normal limits. In the infective 
cases there is a slight but definite decrease. This worker 
has also shown that variations in the level of the calcium 
content of the serum may occur in an individual at 
tlie influence of the menstrual 
nciilnr.UM calcium figure is negligible. A paper on 
infective arthritis by Dr. E. Biddle 

Tr.li .fn small group of patients such milk is 

® “Sept in the treatment of chronic constipation 
and the conditions arising therefrom, but is of little value 
peci c agent in the treatment of infective arthritis. 

Tn ICQV Antivenereai fllsasures in London, 
j 1 - in ^li® London County Council’s scheme for 

treatnwnT* f yc“e‘'cal diseases, the number of days of 
101 735 in was 112,413, as compared with 

lios'oitnio 1 patients who came to tho aided 

whom" la .in. 1927 numbered 28,965, of 

venereal ’ found to bo venereal and 10,164 non- 

1923, when it wiri9°006“®DT /®i highest since 
cases tWo c > ^ total number of new 

12,496, aiid of "uiniiered 6,095 ; of gonorrhoea 

numbered 767 278 attendances 

number of bacL?oWi7r ^li® 

request of, and free of c It examined at the 

and 446 practitibnei-s I * ,Pcactitioners was 27,046, 
free supp[; of V "'f 

incuts aJo to be continued for aunt/*"**'"’ •'“'’■“"g®- 

amounting to £93 060 fnr 7. ' t ®"°i’i®i' y®®r, and grants 
and £5,350 for hostels art pathological .work 

further £8 025 in tUn made, together with a 

being provided. Pert^^P*^ additional facilities 

participate with Lonrln!i*'- "^'S'lliouring local authorities 

of user, 17 per cent of tP and, on the basis 

The Government dtfrtls^ 75 ®''^®“'’“'"''° H 
e-xpoiiditure in carrvin/n.t P®'" council’s 

■ _ carrying out approved arrangements. 


Brisiol . John Wrl-ht and Sons, Ltd, 1S2S, pp. 96. 


Public Health Organization in the Free State. 

Dr. E. F. Stevenson, chief medical officer of the Depart 
ment of Local Government and Public Health, in tho 
coiii'so of a recent statement said that whilo efforts had 
been mado to provide a water supply in urban districts in 
the Free State, the drainage was defective in many towns, 
and in some there was no sewerage system. Dr. Stevenson 
stated that the importance of good drainage in towns 
could not be overrated, and mentioned that in Dublin 
in 1904, when the main drainage scheme came into opera- 
tion, the typhoid rate at once fell sha^ly. Defective 
drainage was the cause of diphtheria in parts of tho 
counties of Cork and Limerick. The absence of a pure 
water supply and a proper sewerage system imposed hea-vy 
expense on tho community through preventable illness, and 
it was a sliort-sigbted policy to tiy to save money on such 
essential requirements; this was especially true of tourist 
and holiday resorts, where the normal winter population 
was considerably increased during- the holiday season, and 
sanitary arrangements should be based on - the needs of 
the larger population. Progress in public health reforms 
was hampered by the neglect of local authorities to fix a 
suitable area of charge; to restrict the area to a few 
townlands -was unwise. His department favoured the 
entire rural board of health area being made the area of 
charge for water supplies and sewerage. Dr. Stevenson 
said the main essentials in public health administration 
were sanitary areas of adequate extent and trained whole- 
time health officers to - control sanitary inspection and 
administration. It was difficult to understand the hesi- 
tancy of local authorities to appoint whole-timo officers of 
health when tho cost in most country areas was hut a 
fraction of Id. in tho S. Speaking of the progress made 
in this direction in tho counties. Dr. Stevenson said it whs 
slow but steady. The Rockefeller Foundation had promised 
generous financial assistance over a term of years towards 
tho development of public health seiwices in counties where 
county medical officers of health were appointed. Such 
public health services would come' into operation during 
the present year in a least two counties, and schemes were 
being formulated for other counties" which it was hoped to 
initiate at the beginning of next year. 

Ulster Hospital for Women and Children, Belfast. 

Professor Sinclair presided over the annual meeting of 
the Ulster Hospital for "Women- and Children on March 
15th. The annual report showed that the average daily 
number of beds occupied was fifty-five, and the averago 
annual cost per head was £78 19s. ; 1,808 operations had 
-been performed. The chairman, moving the adoption of 
the report, said that having been an active surgeon in 
the hospital at an early period of his career he had 
watched the development of the institution with particular 
interest and sympathy. Tho work of tho hospital was 
extending and its efficiency was in no way impaired. Ho 
drew attention to the ante-natal clinic, and he hoped tho 
subscribers would pay special attention to that depart- 
ment. On the motion of tho Rt. Hon. Lord Justice 
Andrews a hearty vote of thanks was accorded to the 
medical and surgical staff and to the nursing staff for their 
services during tho year. 


620 Mauch 24, 1928] 


iCOERESBONDENCE. 






HISTOEICAL EXHIBn'ION 2\T avEDIFF. 

Sib, — Tlio History of Medicine Section of tlie British 
Medical Association, ivith the assistance of the authorities 
of the Kational Museum of 'iValcs, projiose at the Annual 
Meeting of the Association this year at Cardiff to stage a 
series of exhibits illustrating the theory and practice of 
folk-medicine, human or animal, in the National Museum 
of tValcs at Cardiff. To this exhibition the Bibrarian of 
the National Library of "Wales has very kindly promised to 
send a series of books and manuscripts. 

The council of the museum has placed the library i-oom 
at the museum at tbe disposal of the Association for the 
purpose, and it is proposed that tbe exhibition should be 
open daily from July 20th to July 28th inclusive. 

The object of this communication is to invite members 
of the Association, particular!)- those resident in Wales, 
ivho may either possess themselves, or be able to procure 
for the jnirpose of the exhibition, any objects relating to 
the theoi-y and jiractice of folk-medicine, in connexion 
both with man and animals, to send them to Cardiff. It 
is thought that many practitioners in the countn- districts 
of Wales will, in the course of their professional ivork, 
have become acquainted with practices of this sort and be 
able to suppl)- objects illustrative of such. 

It is hardly necessaiy to stress the fact that practices 
of the character i-oferred to have a very irapoi-tant ethno- 
logical and cultural bearing in addition to their purely 
medical aspects. Identical practices are iridesproad over 
Europe, and it is hoped, if an adequate rcspon.se to our 
appeal bo i-occived, to institute during the week July 21st 
to 28th a series of lectures and demonstrations bearing on 
the exhibits which will greatly add to their interest. 

Any communication should, in the fii-st instance, be 
addressed to Dr. Straeban, 20, Windsor Pl.ace, Cardiff. 
Objects for exhibition may be sent in June or early in 
July, marked “ B.Jf.A. Exhibits,”, to the Director, the 
National Museum, Cardiff. The name of tbe owner will 
be attached to each exhibit. All exhibits will bo returned 
to the lenders in August. 

Many objects of the character in question will be, of 

■ course, not in the possession of practitioners, but known 
by them to bo in the houses of patients or ot)tci's, and any 

■ assistance which can be given either by Sir Ewen Maclean 
or by Dr. tyril Fax, the Director of the A'aiional Museum 
of "Wales, in order to induce ownei's to lend such objects 
will gladly be given on request . — We are, etc., 

Ewex J. Maclean, 

President-Elect. 

Gilbebi I. Stbachan, 

Ilonorarj General Secretary, 

H. E. FitEDEnicK, 

„ ,, , Honorary Secretary, Section of 

Cardin, March 15th. History of Medicine. 


BEEVENTIVE VACCINATION OF THE NEW-BOBN 
AGAINST TUBEECUEOSIS. 

Sift, — In your issue of March 3rd (p. 364) the results 
claimed by Professor Calmette for tbe B.C.G. vaccine are 
severely criticized on the ground of statistics. Perhajjs 
Wallgren may have changed bis mind noiv that the latest 
figures are available for investigation.' 

Tlio argument tliat cbiklren supposed to liare died of 
.various maladies may in fact have died of tuberculosis does 
,not stand before the following fact ; The genera] deaOi 
rate of children vaccinated witli B.C.G., though exposed 
to ' contagion, is- far lower tlmn tbe de.-ith rale of non- 
vaccinated children, exposed or not to contamination. 

This is not a question of academic.al interest, nor is it 
a tribute of admiration for Calmette’s splendid work. The 
lives of many, children are at stake. Can they bo saved.? 
These lines are meant to urge your readers to approadi 
; tbe question at its very source.— I am, etc., 

' Gustave Moxod, M.E.C.P.lond., 

Vichy. March lOlh. tfJ).Pari3. 

> Premunition or Preventive Vnccinalion against 

Tuberculosis, with the B.C.G. Stalislics and Bceults from the 1st of Jiilv. 

unto llio fat of neccinhor, 1927. By A. Calmette. Amialcs Je 
I /vatitift J^aiiieurf Jnnuory, 1928, vol. xlil, p* -1. 


MIDWIVES AND ANTE-NATAL WORK. 

— The majority of ohstctricians will agree with 
Professor AfeTIroy in her ietter (March 17th, p. 466) with 
rofereiico to niite-natal care. It is true that at a meeting 
recently I hoard one man say that at the institution with 
which ho was connected tlio ante-natal work was done, 
and well done, hy midwives. It must be remembered, Imiv- 
cver, that the midwives attached to such an institution are. 
the absolute pick of tho fiurscs, and in no way represent 
tbe standard of efficiency among midivives as a wjiolo. 

It is very essential that 'the ante-natal care should be in 
tho bands of qualified medical men, and tbe advice that 
I have given for some years past to students who are on tho 
verge of qualifying and going into general practice is that 
the)- should put aside a certain hour creiy week for ante- 
natal oxaniinations; further, that they should get in touch 
with the best midwives" of the district, and persuade tliem 
to bring tlicir own cases for c.xamination on this particular 
da)-, and that they them.selves should employ these mid- 
wives to conduct the actual labour in all tbe normal cases; 
moreover, that tbej- should tberaselvos see tbe patient again 
at the end of the puerperinm. In this way they would 
knoiv all about tbe patient in the event of any unforeseen 
emergency occurring during the labour, and they would 
know the final .state of that I’ntient. — am, etc., 

Lon.lon, W,. March 19(1,. M.ILCOLM DoXALDSOX. 


MINERS’ NYSTAGMUS. 

gin,— In no one of the many letters and papers that have 
been written on tliis subject have I seen, a satisfactory 
answer to the question : How docs minojs’ nystagmus render 
n man incapable of hewing coal.? IVo all knoiv men with 
uncontrollahlo nystagimis (subjectively with a pei^ctnal 
dancing of the objects viewed) who are kewmg and have 
bewod wal for rears as efficiently as their more fortmiato 
companions who’ have not acquired the disease. seen 

mmx patients at the Eye Hospital who, although they had 
an lincontrollnble. nystagmus when standing erect in day- 
light were still hewing witlioiit complaint; those were 
cve^ giddv on stooping. Other patients become very giddy 
on stooping: they may reel after tying bP tbcir bootlaces, 
n ItbS 1^0 nystngnius can be seen m day bgbt and wlien 
. but it may bo revealed at once if the room bo 
dariiencd except for one point of light wliicii they observe 

'^%'m'’Sn^o’at tbe incapacity for work in the pit 
varieh directly as the giddiness on .stooping. Of conr.se, 
'll u tifidlncss may he due to other causes, snch as arteno- 
* 1 nvt but if the patient shows nystagmus ui a dark room 
sclerosis, bi i e^l^ characteristic tremors, 

"" rtv of mdse “etc., giddiness, sufficient to render Inni 
;Zj:Sle o/ pit'wori; may be reasonably attributed to 

"’n woS'Tpcar that this giddiness is a far more 
“ svmptom than it was thirty years ago, I attri- 
F’ frujs to the prolonged in-breeding of those predisposed 
biite this to t"? 1 „„s As I have previously main- 

^•*rd nit viliawes are hotbeds for the propagation of tlio 
tamed, pit A predisposition to the disorder, 

‘ nie coal bewLg is the most exciting c’mse, as among 
' %a 000 underground workers I found tliat the per- 
over rbc acquired the disease m one year was 

fmu-Tm^ S-tcr amon| the coal hewers than that among 

■"‘‘a "Em^ieS^he is the main concern of our 

As tiiG ^ ^ -hrt iii'fTf* Gvcrv innn \rlio Iiss 

n™' 3“' 

dr-nce of the disease \anea alikh tho signs were 

opinion based on one cimninmt.o. , m wlucl. 
not manifest, is unreliable.— I am, etc., p^icn-.M. 


Newcastlc-upon-Tvnv, Jfarcli 171I>. 


March 24, ^1928] 


. •COEEESPONDENCH. 


r THEBRnrsa A 01 

L Mrdxc^ jocR>'^ Uoi 


DYSPHAGIA ASSOCIATED WITH A,NAEMIA. 

Sin,— I iini glad to soo from'liis lettei- in your issue of 
March 17tli that sucli an experienced observer as Dr. 
William Hill agrees with mo that the form of dysphagia 
described in the recent paper by Mr. A. JIason Jones and 
Mr. Eobert W. Owen is not duo to spasm. Dr. Brown 
Kelly’s evidence in favour of spasm is vei^ unconvincing; 
the sudden onset, for example, is just as easily explained 
by achalasia as by spasni. 

■ r cannot agree with Dr. Brown Kelly that the closure 
of the lower end of the gullet is alwa}’s firmer than normal 
in so-called cardiospasm, and that “ sometimes it is so 
great that it yields only to prolonged steady pressure ” ; 
for anybody who has passed a mercury tubo in such a case 
must have been ' struck by the remarkable absence of 
resistance offered by the sphincter,' and by the absence of 
any grip upon it when it is withdrawn from the stomach. 
In exceptional cases temporary spasm may be present at 
first, ■ but this is a result of the oesophagitis caused by 
irritation by retained food, and quickly^ disappears under 

treatment. ' ' ' ' 

Though the old theory of cardiospasm is doubtless adopted 
, in most books on oesophageal diseases, as' Dr. Brown Kelly 
states, this is simply because - they were written before 
Sir 'fiunyihry Rolleston’s theory of inefficient relaxation 
was revived iii 1915 by our clinical and radiological investi- 
gations, and subsequently confirmed by the pathological 
work of . Stokes and Eake. Every physician and surgeon 
interested in disorders of the oesophagus with whom I have 
discussed the subject now accepts the theory of achalasia. 
Apart from the, evidence afforded by the mercury tube and 
by the X 'rays, the complete absence of hypei'trophy of the 
cardiac sphincter-^in striking contrast with the hypertrophy 
of the . muscular coat of the rest of the oesophagus — is 
conclusive evidence 'that 'no long-continued spasm can have 
been present, as this would certainly give rise to hyper- 
trophy. — I am, etc., 


Kew Lodga Clinic, 


' , Arthur F. Hurst. 

■Windsor Forest, JLirch lSlh. 


secondary anaemia; in none was there splenomegaly; in aU 
thero was a definite reduction in haemoglobin, a figure 
round 60 per cent, being commonly found. With the one 
exception tho red cells were between 4 and 5 million, of 
normal size, shape, and staining (allowing for the deficiency 
in Hb), the leucocytes from 6,000 to 7,000 per c.mm. The 
organisms isolated from the phaiynx were pneumococci or 
streptococci. The hydrogen-ion concentration of the saliva 
was examined and tho limits of pH were from 6.4 to 6.6 
—that is, slightly on the acid side of normal. 

Tho only constant blood change was therefore reduction 
in haemoglobin, and that is due, I think, to the restricted 
diet on which these patients live, anything which causes 
the slightest difficulty in swallowing — meat, for instance — 
being rigorously excluded. 

The cause is probably, to be found in the inflammatory 
changes of the mucosa and submucosa. The nerve termina- 
tions in the epithelium are affected; they may even be 
destroyed ; and the swallowing reflex is not initiated — at 
least, it is not normally and instantly initiated. There is 
no intermuscular plexus ■ within two centimetres of this 
region, and unless the pathological lesion is in the medulla,- 
it is difficult to imagine how else the condition can arise; 
although in passing it may bo noted that the sympathetio 
supply of the oesophagus is much more definite here than 
in tho rest of its course.. 

As regards thd analogous condition at the lower end of 
the oesophagus, it seems clear, from the results published 
from Guy’s Hospital and here, that inflammatory changes 
in Auerbach’s plexus are frequently' associated with it. 
A lesion, however, on the mucosal side of the ganglia might 
produce exactly the same effects without the nerve cells 
showing any change at all. Indeed, as I have stated else- 
where,* this may be the common sequence of events-r-that 
the lesion in and around the plexus is tho result of the 
outward spread of a primary oesophagitis. In some cases 
there may bo a specific selection of the ganglia by bacterial 
toxins, but these must bo very uncommon. — I am, etc., 

... J. A. M. Caieeros. ■ 


. Sir, In .’ref erencoi to tho-correspondence in the Joum 
under the above heading, it appears to me that ti 
obviously: easy, passage of -Dr: Hurst’s large mercury-fill, 
rubber tube not -only, knocks .the bottom' out of the cardi 
spasm theory of Mikulicz, adopted by Dr. Brown Kel 
and others,, but also ;exelude3 Dr. Hurst’s own theoiy 
.achalasia -in- that .portion of-tho-gullet which lies betwe. 

le eve of tuo diaphragm and the cardiac orifice, as the 
.1^ no eiudent. abnormdl .resistance to tho passage of tl 
, I ®S®u6rative changes in Auerbach’s plexus consi 
lesion, and this is more compatible with tl 
rnr?itJ. 1^. ! • IS feeblo muscular activity and possibly 
f ® . I eflex-— that is, paresis — than with the theory 
active contraction. * ' ' ' • 

■> that the dysphagias unassociated wi 

the lumen at the lower end of the pharyu 
amlnn- discussion, though not, of course, real 
mmof” 1 o, those near the cardia, an area with unstrip. 

uliarvnx^in^ atrophic lesion in the low 

nasal ntari-l, ^ paretic palate of chron 

aotatvaHancewitlitKni,^!^/* least plausible, ai 
JMflinnrrK c J .1 ^ nndmes as far as I can se 

•nW siw 

bougies, I have recently “ad a ft.-iV 

practice, and am „„„ A **^‘>15 e-xception m my ov 

ment on the assumption tin ° 

paretic as suggested— I am etc 
i.<.adon.w..Ji;rchi6th. ’ ^ . Kenneth A. Lras. 

summarize Si7 findinls^i^Tto 

all. were 

“.I® .ase. In one only was the 


■ Victoria InCrinary, Glas'gow, March 18th. 


- GASTRIC SECRETION OF NEDTRAB CHLORIDE.-. 

Sir, — The letter from my friend Dr. Poulton which 
appears in the Journal of 'March 17th (p. 469) may prove 
a little misleading if left without comment. It is essential 
to bear in mind that regurgitation of the duodenal con- 
tents and the secretion of. a salt of- chlorine by the stomach 
are two quite distinct issues; either may occur alone or 
both might occur together. To prove the occurrence of 
one does not disprove tlie occurrence of tho other, and to 
prove that one gives only a partial explanation of tho 
facts does not necessarily prove , that its missing complex 
ment is' to be supjilicd by tho other. So. that the fact that 
duodenal regurgitation does not by itself adequately explain 
all the facts is no proof whatever that the stomach nor- 
mally secretes salt, as Dr. Poulton’s letter seems to suggest. 
I have often said that if we might assume that both these 
things do occur this would probably provide the most con- 
venient explanation of our problems; but unfortunately 
the convenience of an explanation is no guarantee of its 
correctness. 

One other point is worth noting as it illustrates well the 
difficulties with which w-e are beset. Both the papers cited 
by Dr. Poulton are extremely interesting, and taken by 
themselves, apart from other work, they each make out 
quite a convincing tale ; yet Dr. Poulton is ver3- un- 
fortunate in his choice of authorities, for while neither of 
them really supports the doctrine of gastric secretion of 
neutral chloride they are each mutually contradictory of 
the other in their conclusions. Baird, Campbell, and Hem 
(whose work has, I think, received too little attention) 
state definitely that “it is unlikely that chloride is 
secreted in the gastric juico in any large amounts,” and 
one of their main conclusions is that at least in a pro-por- 
tion of cases the fall in the acid curve is due to neutmlir.a- 
tion by the alkaline pyloric secretion. Hansman, D.ay, 
and Clifton, on the other hand, do maintain th.at a’salt of 

'.Areliirr* of Ditease in Childhood, il, 12, p. 355: Journal of Larmaoloav 
and Otolosy, iliil, 3, p. 213. • « • 


COREESPONDBNOB. . 


622 March 24, 1928] 


r- r. TireURmsH ' 

■ L BIEDICXL JatrRVig. 


chlorine passes throiigh the stomach wall, but they aro 
careful to avoid all mention of “secretion”; and tho 
whole point of their paper is to show that the fall in the 
acid is brought about by dilution, and that neutralization 
only plays a minor role. Further, if Dr. Poulton accepts 
Dr. Campbell’s curves from the duodenum he must dismiss 
as fallacious tho assumptions on which tho whole of Dr. 
Hansman’s calculations are based. To avoid misconcep- 
tion I would add that I should be verj’ glad indeed if 
Dr. Potdton, Professor MacLean, or anyone else can con- 
vince me .that tho stomach can normally secrete a salt of 
chlorine; but so far ns I can sco tho evidence is still 
all the other way, and I know of no reason why 
Dr. Poulton should summon Pavlov to haul down his flag. 
I am, etc., 

. London, W.14, March 17th. GORDON W. GOODILVIIT. 


■ INJECTION TREATMEN1’ OF VARICOSE VEINS. 

' Sin, — Dr. Borcherds’s communication on this subject in 
your issue of March 10th (p. 412) leads one to suppose that 
he regaids sj-pliilis its the common undorl3'iiig cause of 
venous varicosity. In my expericnco there is not tho 
slightest justification for .such an assumption. On the 
other hand, the general use of salvarsan and its derivatives 
is fraught with danger, is very expensive, and, in tho many 
non-S3-philitio cases, quite useless. 

Dr. Barber’s letter on tho same subject draws attention 
to the well-known experiment of injecting strontium 
bromide into a varicose vein and obsen'ing' the centrifug.al 
flow of the fluid. It .should be pointed out, however, that 
tho direction of flow depends upon tho position of tho limb. 
If it is horizontal the flow is contripetally directed. This 
raises the question as to whether it is not unsound practice 
to put patients with spontaneous phlebitis to bed. No 
doubt the specific gravity of the experimental fluids injected 
plays a pait in the'determination of the direction in' which 
thci' shall flow. As I have pointed out in my monograph 
on tho treatment of varicose veins, some of tho injected 
fluid must pass centrally at once, as evidenced hr* the taste 
of quinine or- the immediate tinnitus from salici'late. — 
I am, etc., 

Jlarch 13th. -A- H. DoUTHWAlTE, M.D. 


Sin, — ^It is evident from Dr. Borcherds’s letter that 
he considers the causation of all varicoso veins to be 
S3'philitio, and “ from a pathological point the same 
as ancui'3-sm.” Therefore, ho says, thei' should all be 
treated b3' injections of arsenical compounds, which, as 
he admits, do not cause thrombosis, but presumabl3' act in 
a specific capacity. 

It is possible to concede a certain percentage where 
S3qjhilis is a factor, hut I think, when one considers such 
other factors as pregnancy, increased intravenous pressure 
from uterine causes or constriction of the limb, long 
standing, and man3- other similar conditions, he is bound 
to assume the S3-philitic iiercentage to be quite small. 
Accordingly, I cannot agree when Dr. Borcherds sar's: 
“ 'The great objection, in 013- ojiinion, to the use of other 
' drugs which do hot attack the cause of the disease, but 
produce thrombosis, is the risk of embolism . . .’’ ; first, 
because I do not feel that he is attacking the cause of the 
disease bv' injecting arsenical coratiounds into quite tho 
ma’orit5' of varicoso veins, and secondly, because I main- 
tain that the risk of embolism after injection of solutions 
producing thrombosis has been proved to be negligible. 

I shall be pleased to give Dr. Borcherds references to over 
30 000 injections in the literature to date, in which not one 
single case of embolism has been observed. In m3' oivu 
eximrience during the last three years of over 1,000 injec- 
tions I have had such uniformly splendid results that I do 
not hesitate to ex]iress the opinion that, given great care 
in the technique of injecting sclerosing solutions, we have 
here a treatment which will supersede all other methods 
for tlie cure of varicose veins. — I am, etc., 

Ronald Thornhill; M.B., Ch.B. 

LonJon. WJ, March 13th. 


With reference to Dr. Boreherds’s recommendation 
of ‘ 606 ” as an injection for varicose veins, it ma5’ be 
of interest to recount my solitar3' experience of this sub- 
stance — or rather, neokharsivan — on a varix. 

I was not using, it to cure tho varix, but for , tho treat- 
ment of .syphilis in a woman in whom I found it difficult to 
obtain a suitable vein in the usual site, but who had a 
largo and prominent varicoso vein crossing the tibia on tho 
loft log, apparently intended by. Providence for m3' use. 
1 gave her at least seven or eight of her twelve injections by 
this route, -and can only state that the vein appeared just 
as largo and V'aricose at tho end of the treatment as it did 
before. 

As to Dr. Barber’s letter in the same issue, ho 
apparontl3' maintains .that there is no risk of, .a, clot 
from a thrombosed varix getting into tbe general 
circulation, and I confess I am puzzled. I have seen 
tho statement made several times lately. If it refers 
only to the clot artificially induced in the injection 
treatment it is pi'obabl3- true, but I gather that it 
is intended to appl3' to all thrombosed varices. Is 
tho teaching of the jiast on tho subject, then, all 
wrong? And if so, what is the exjilanation of tho sudden 
deaths whieh seem to have occurred with some frequency in 
this condition? — I am, etc., 

Porlsmoulli, Jlarch 13th. E. W. DeWET. 


COLLECTIVE INVESTIGATION AND TUBERCULIN.' 

gj^ observe that Dr. Sharpe, writing from Hertford 

County Sanatorium, states in his letter in 3'our issue of. 
March 17th that he sees very few “ simple, early, uncom- 
plicated eases of [pulmonary] tuberculosis.” This is a 
very important point. Where are these early cases which 
lie at the root of the whole matter? They are in the 
homes' of the people— in the peculiar domain of the family 
doctor VUiilo welcoming, therefore, investiption any- 
Xre and everywhere, this particular research should be 
conducted locally, under the auspices of tho Divisions of 
riTo^sociation. The tuberculosis dispensary, would foi-m 
a convenient centre if, as is to be expected, the authorities 
wersrtnpathetically inclined, but it is essential that the 
Ltiy^o-operation of those who are most- favourably 
DlacS for diagnosing and treating the disease la its 
* c-fnfTpQ sliould bo retiiinod. 

'"’'l have plfposelv avoided the term “ surgical tubercu- 
losis ” as unscientific. For. purposes of demonstration 
Tisrble lesions are obviously best; otherwise I do not dis- 
visiDie Its . j pulmonary tuberculosis and early 

rricilsis tSicre; only let it be early. One of the 
nrhM wrors of tuberculin work hitherto has been to begin 
wrong end, with the advanced and unsatisfactory 
; wl.ich have resisted other forms of treatment, ' and ’ 
i -pi, tuberculin is tried as a last resort. This is a 
hopriL mothbd. How would surgery stand such a; test .m 
liopeiess . . experience is that in, early pul- 

tuberculosis tuberculin is safe, easy, and effective 
Administered in accordance with Koch’s methods, 

" 'l"with the limitations advised by him. . It is to try out 
large scale Koch’s momentous discovery that my 
Ills been put forward. 

^"fAnve .seen pulmonary tuberculosis flare up both with 
1 «dtLut tuberculin, and although it is impossible to 
" Svidiial cases without full details of tlie morbid 
^'Al^o^^and of the dosage of tuberculin, one may say, 
L'’."-.dIir sneaking,, that the earlier the case the less the risk. 
T'°+b<A>arli'est cases there is none at all; it is mostly 

Imfnne which is responsible for the flaring up of suitable 
tuberculin treatment which would not othennso 

* fnnt one and deserves close attention. Many years 

anrR was suggested by Sir William Watson Cheyne that 
infprtion plav niiscliic\ ous part. 

"And resfslance vaiy,' Lt there, are clear loading 
ind^Stions to guide safely those who have knowledge an 

■"br.” S 

temperature, weight, general, nnd'havo' found 

1 have taught mmiy patients to do so, and have tounu 


March 24, 1928^ 


c6KKBSP6i?DENCB. 


[ Trx Bsmrt fi 9 S 

MeOICAI. JotTBSUi 


that -tile' ordinary patient 'is a wonderfully .acute observer: 
in a matter wbicli so vitally conceriis liimsclf. , . 

I regard tuberculin as tbo key to the tuberculosis 
problem; at tbe same time I look forward, as Dr. Tippett 
does, to tbe possibilities of serum therapy. Tbo question 
of tbe causal relationship of bovine to human tuberculosis 
’is an important but separate question.' 

'When tbo time comes for a central committee to b'o 
formed, one of its duties will bo to consider tbe work 
which has already- been done on tuberculin. In any sueli 
review the' work of Dr. AV. Caniac AVilkihson, referred to 
by Dr. J. Gordon Hume, will fall to be carefully con- 
sidered. There is a feeling that tbo investigation of 
Dr. AA'ilkinson’s work by tbo committee of tbo Medical 
.Research Council was not conducted with that sympathetic 
interest which it deserves. — I am, etc., 

Wandsworth, S-WMS. Match ISlli. RobeUT CaRSTVELI,. 


Sir,-^As a consistent advoeato of the uses of tuberculin 
in general practice, and a convinced exjjoncnt of the value 
of tuberculin in the treatment of pulmonary tuberculosis 
, from the very day of its discovery’ by Professor Koch, I 
■ challenge Dr. Sharpe to produce the luotocols of the two 
' cases upon which ho' ventures to suggest that tuberculin 
is a dangerous remedy for. pulmonary tuberculosis. I wish 
to examine tho evidence which has frigiitcned him. 

In a disease like pulmonary tuberculosis, liable to so many 
vicissitudes, yagaries, and uncanny comiilications, is it 
. remarkable that out. of many cases two might show fresh 
activity?. AA’ill Dr. Sharpe explain the meaning of the term 
"flare up"? The truth may bo that these and other 
ilhdefined disturbances, arising from the natural tendencies 
of .pulmonary tuberculosis, are. laid illogically to tbe charge 
of tuberculin. AATtb my experience of tliirty-stven years, 
in wbicb I.liavo consistently used tuberculin in doses that 
■would terrify Dr. Sharpe, I have seen no evidence to 
m^cate that the tuberculins mentioned by him (T.B. or 
B.B.), provided they are the preparations of Meister 
Lucius and Briining, used in the proper cases, given in 
. the proper- doses, .prepared by tho physician himself on tbe 
spot, and with a due regard to clinical manifestations, and 
injected at the proper intervals,; will increase, for they will 
undoubtedly diminish, the inhei'oiit tendency to progress in 
this capricious di.sease. If Dr. Sharpe would visit tbe tuber- 
culin dispensary I would show him scores and scores of charts 
proving that tempor.;iry increase of temperature, even with 
f .general .clisturbanco, is almost invari- 

. ably followed very soon by a 'distinct phase of improvement, 

' 1 in. the course of mouths, to 

' y '. :i' ' ■ ' ' ■ ■ * ‘ ' -As -a^set-off to bis tivo cases! 

• /. V '* ‘ ‘ 'vbich bo cau control for himself 

- ir he wishes. - > 


developed pulmonary tuberculosis; ho wa 
' foil? Sah S for. four-months, and then at Fvimley fo 

and ycor<!o ^tt 'Ond- tUc' disease became wors 

' was told tba 

for six done._ He went home, and was bedridde: 

cakd in^f wasted to a shadow. I wfl 

with 'T)ro»rp<:<!iv#> Will Consented to treat bin 

taken back to consent, he applied to b 

successful. It is now six a 

-condition after • treatment if ^ 4 T despera 

Dr.-Sharpo can verit™ these 
I can give him in confidence 
2 . I was callpd in ■*/, the patient’s consent. 

■ tuborcnlosia in the third sta“e‘’^,t'-ti“' pulmonai 

larynx, causing lioarsenLs aSu’ „ ' P™nouncod disease of tl 

disease of Uio® vocal cords ,vitr’h,i»" There w 

oedema of both arytenoids The , ulceration ai 

placed under .the care of aunt), ‘ "’ 5 ' , <^°“scnt. w 

■or so after I began treatment limn “ “on' 

Iiad made tbo condition .worse ' l'* * *''•'**' Dm tubercul 

■ said it caused tlie discaS to “ fln H''" ''vonld.ba 

•from. this case, but the natic.f withdra 

treatment with tuberculin 'will D.mt I should contini 

treated bv mo for soreral ve!'. ■ “’’y interference. Ho tv 

sequentiv did splendid wori durinX’^ and after, and su 
■apparently fmo “from any™s^ptm 3 ®of’'disS. 


• I. liiivo scores of -cases in- w-bicli I bavu -observed exactly 
tho saino satisfactory results from the- skilful, bold, and 
adequate use of properly prepared tuberculins. 

Dr.- Sbarpo disagrees with the view that tuberculin can 
bo given to ambulatory eases of .open pulmonai-y tuber- 
culosis with safety, success, and lasting results. AA'bat is bis 
cvtdeuce? Lot him produce it before any judicial tribunal 
and I will prcduco 1113' evidence. M}' knowledge and exiic- 
richcb of tlii.s. disease lend me to believe that 3113- casual 
“ collective investigation ” would bo useless. The oiilv 
investigation that is worth making must be -on. tbe lines 
I hav'e alrcad3' definitel3- laid down in the Dritish Medical 
Journal . — ^I am, etc., 

London, 3V.1, March 17th. ■ ' ’ W- CaM-VC AA'ilKINSON. 


Sir, — ^AT our correspondents who have suggested collective 
investigation into the value of tuberculin ajipear to have 
forgotten tho diversit3' of issues involved in such an 
investigation. Not onl3' is there a great diversit3’ in 
clinical conditions, but tho aims of those employing tuber- 
culin remediallj', their choice of patient for tbe pni-pose, 
their views conce.niing . dosage, . spacing, and increase or 
otherwise. of doses given, are equalh'. diverse. Unless. these 
vaiying. circumstances aro taken into account no . useful 
conclusions can -be drawn. 

Some physicians aim at suppressing the tuberculin sensi- 
tiveness of their jiatient 113- cumulative dosage, . whereas 
others regard this as undesirable and sometimes dangerous. 
Tliis alono results in eiioriiious 'difference.? in . dosage find 
. niode of administration. Sonie control their treatment 
by. -temperature, pulse rate, and other clinical, changes, 
including . the state of ' the blood . histologically and 
chemically, while o.tbers . pay no attention to sncli indica- 
j.tions. Even tempera tnre records are differently . compiled 
by different people, and are _not.alwa3-s comparable.'. And 
clinically tbo same patient will react very differently to 
tho same dose of tuberculin at different periods of bis 
illness, and under different conditions of lifo and 
occupation. 

. It is eminently desirable that accurate investigations 
should be made into tbe action of tuberculin, but this 
can only be done in an institution where evei"}’ factor can 
bo noted and controlled, — I am, etc., 

Farnham, Surrey, Marcii 19 th. U* B* AA^ALTERS. 


PULMONABY TUBERCULOSIS DIAGNOSIS AND 
, TBEAT 5 IENT. '-' 

Sir, — ^I- should like to support Df . F-. G. Chandler’s con- 
. tention in your issue of March 17 tb (p. 469 ) that pulmonarj’ 
tuberculosis is riot soonest detected b3f pb3-sical sigiis. 

As an instance, about nine months ago I saw a. youth in whom 
pulmonary tuherculosis'. was" diagnosed from .the . rbeords of tem- 
. pefuturb arid weight,, general .debility,, and other - symptoms, but 
- in '.wlioni repeated -examinations hy auscultation, etc., gave no 
abnormal . signs'. The diagnosis was confirmed by ' sputum and 
. a^ray' examinations. • - . ' . • . ’ . - - . 

.On the question of tuberculins raised by oilier correspondents 
■fa the saino issue, I mav- say that tliis ' patient was treated with 
■fajections of diaplyte' tuberculosis vaccine (Burnet’s formula); bo 
was kept -at liome for tlie first fortnight to observe the effect 
of tho .first few doses, but afterwards resumed bis ordinary 
‘occupation — clerical work. He has made uninterrupted progress; 
there was' a very slight general reaction after the first injection, 
but tlireo days after his temperature' became normal, and lias 
-remained .so ever since; there have been no further reactions. 
Ho has gained weight steadily, is full of energy, and says ho never 
felt so well before. A recent i-ray examination showed an almost 
entire absence of tbe former shadows, and there is no cough or 
sputum. Beyond ordinary hygienic measures no other_ treatment 
has been given. . He has continued to live at homo fa comfort 
and carry ou as a wage-earner instead of spending mouths in 
a sanatorium at some expense and discomfort. 

The same vaccine has given results surpassing all expecta- 
tions in otlier cases; in one, wliore tbo temjieiaturc liad 
ranged from 100 to 102 ° F. for some weeks, it was brouglit 
to -normal within fourteen days by the vaccine. 

There is a very general distrust of tuberculins generally, 
and one hesitates to give rise to false hopes; but as this 
preparation appears to be a really specific antigen, wbicb is 
free from unpleasant consequences, if given in small and 
gradually increasing doses, allows suitable cases to carry 



624 March 24, 1928]' 


DEATHS IN THE SERVICES. 


[ 


Tire Biimstt 
MeoicAD JoxmxAL ' 


•on ivitJl thoir oi'dinarj’’ occupations, ami docs not require 
! more 'supervision than can be given by the ordinary general’ 
practitioner, it seems worth further investigation.— 
.1 am, etc., 

London, N.AV.8, Slnrch 38th. Ev CcitNOW TluaIAIEII, 


- . ■ SHOCK AND ABORTION. . - 

i Sin, — Dr. Hollins .(March 17th, p. 471) seems to believe ■ 
that shock associated with criminal abortion is duo .for- 
the most part to the entry of irritating liquid into the 
.peritoneum by way of the Fallopian tubes. To maintain' 
his position he has to show that such shock is never pro-' 
diioed in any other way — for example, by the simple dilata-’ 
tion of the internal os in the absence of anaesthesia; and,' 
moreover, ho has to explain the absence of early or imrae-' 
' diato shock in cases of perforation of the intestinal canal. ' 
'Gastric ulcer can perforate without causing shock; and 
a gangrenous appendix may give way with an apparent 
' improvement of the patient, to the extent, indeed, that 

- operation may bo fatally postponed. Dr, Hollins has also 
"to find a cause for “ delayed ” or ingravescent shock, so 
' often unassociated with any peritonitis. 

Truly it is difficult to understand how aberrant mental' 
'•(emotional) states can cause- profound bodily change; but 
that difficulty, I think, is largely due to the fact that' 
though we a'dmit or say that the “ mind ” (that is, the' 

■ brain) affects the body,' there seenis no tangible demonstra- 
tion of how it Can do so or how it does so. In contem- 
plating the causation of jaundice I was greatly impressed by 
. the statement,' admitted by -Faggo and Pj-e-Sraith thirty- 
'seron years ago, that emotion can oanso jaundice.* It is, 

- of course, 'easy to jmsh .such a .statement aside, and, 
because we cannot see, 'or perhaps may never see, how 
emotion can have this effect, to deny the etiological 
relationship. Advance in medicine is not possible with' 

• such attitxide; advance can only occur with the struggle 
to elucidate the vwchis operamli of such imputed -cause. 
Repudiation can enly be maintained when all possible 
explanations have been shown to be invalid. 

As regards shock induced by criminal procedures, I indi- 
cated (in your issue of February 2Sth';-ij. ■327) a/ni^clmnism' 

. causing shock which I think is sound. That all such pro- 
cedures do not cause shock may possibl}' bo explained by 
differeneos in the mentality of the patients: thus, some 
patients are more susceptiblo to pain than, others. In any 
case, that aberrant mental (emotional) states predispose 
to shock, I think, is certain. Dr. Crool;shank plainly is 
of this opinion (March 3rd, p. 375), and I have no doubt 
that others share the view. — I am, etc., 

. - Rugby, .Marcli IBlh. R- H. PAnAJrOnE; F.R. C.S.Eng. ’ ( 


; HEARTH AND CHOICE OF A CAREER. 

■ 'Sin, — During £he last .few years I have been impVess^di 
' with the unsuitability , of various trades nnd professions tO|' 

the physique and general health .of the individuals em- 
•■ ployed in them"! ' TIris- I attribute to the lack of considera- 
;tion of the child’s health in choosing a trade in which lie' 
should enter. Thus -a youth employed in heavy manual | 

• labour and exposed to all types of weather may be found 
•to possess a definite rheumatic tendency, possibly with a- 
'valvular lesion. In these cases some years may already. 
' have been spent in- sendng an apprenticeship to, say, the! 

■ bricklaying or other outdoor trade, which may have to lie ’ 
- discontinued, with the resultant loss of money to both boy 

and parents. 

Again, a sedentary occupation, such as that of clerk, 
•-mav have-been chosen for a boy with a tendency towards 
tuberculosis, and whose family history in this respect is , 

• bad. Here again a judicious consideration of the boy’s 
'health before embarking him on a career would probabfy 
Jiave led to tlio selection of some open-air occupation. I am 
convinced that much of the financial loss to the State 
.caused through illness could be pre-vented by the inedical 

- .man having some say -in the mapping out of the child’s 
.future career. ‘ " 

. My suggestion is that all children on attaining the ago 
' ^'PrincipIet~a7td'Pra'ctice' of J891, ii. 541. *1 


•of 13 or 14 years, and before leaving - school, should be 
modically examined, and the school niedical officer should 
-advise as to the typo of work most suited to tho cliild^s 
health and ph 3 'siqHo.- For -this purpose the various indus- 
tries and professions might ho classified into 'a number of 
groups according to the qnvirqnment and manual or mental 
nature of tho work, -etc. IVliiio this .would entail 'a- little 
extra labour on tho part of the medical officers inspecting 
tho. schools, it would bo- well -justified by the great saving 
of suffering and taxation to the nation, ' 

, As medical ijractitioners we have all met the class of 
youth omployod in some heavy manual trade who, after the 
-first year or two of 3york,' finds himself plij'sically unable 
to carrj' on, and thus becomes a pprmarient burden upon 
tniomploj'nicnt or national health sick funds. Many of 
these cases of more, or less .total .disablement might, have 
been avoided if medical advice had been, given at the 
commencement of the boy’s career. This applies not merely 
to tbo heavy inantml trades, but also to professions such 
as that of teaching, .whore examination on taking up a 
‘hursarsln'p often discloses lesions which make teaching 
unsnitablo for the individual. Hero an examination at the 
ago of 13 would probablv- have revealed the condition, or - 
tendency to it, and led to the suggestion by the medical 
' mini of a more siiit.able' career for the iiaticnt.— I am, etc., 


-Penistone, Feb. '27111. 


Alfhed A; Masseb, M.B., Gb.B. ■ 


SHOCK 'IN BLACK RACES. 

Sra, The letter by Dr. Georgo Sowdon- on ' shock after 

protrusion of intestines in . 3 'our issue of -December "Slst, 
1927 (p.‘1250) contains the statement that ‘‘■the resistance 
of the black races to .surgical shock is conydered % bo 
very; weak.” I feci sure that, a'n exactly oppo-site opinion 
has been formed by medical nien vyho have had to do with 
the Bantu races (Kaffirs) in South Africa. 

.'In ah- experieneo of over twenty years dealing -with 
serious injuries i-esultant upon mining accidents •.'I'.hiiyo 
invariably found that the ' Kaffir is peculiarly- resi-stant 

to: what vve term surgical, shock, • , 

;Tbot tho black ihan makes a good ‘-sttrgical . but , a bad 
inbdical patieht" is- almost a 'tn)i.sm. ' The explanation' vyouW 
appear to be that tlie black man endures the pain of trauma 
and post-traumatic shock in a manner comparable with that 
of the lower animals, but an illness is looked on by Iniii as 
a visitation by a malevolent spirit, 'and ' as such ddmits 
of no explanation. Always a fatalist, the black man ffiak.es 
UP his mind he is going to die, and die he does.— I am, etc., 


Jl^dcpoort, Transvaal, Jan. 2, 


27th. 


S. M. Dickson, MaD. 


, .1 ' ' • PEATHS IN THE SERVICES. - ■ , ; 

August' 9th; 186i; th'e' eldest sob' of ' tkeyhile 

lieutenant-colonel after twenty years’ service, and 
ho -became neute -Qn 'March 1st, 1896, he .was 

nded°"for cWl' employ-merit in' Eg3'pl, and in. that.sery.ee 
rCia the pois sucressiVely of president of the International 

When war broke out in ^ 

and served 'P ’ -H^whs Wntioned'in'dispatebes in the 

-f T rv 1Q16 and received the C.M.G. 

Mn GazclU a ^f Gmco of 

fn" n d John of Jerusalem, ..a.n. Officer of the -LeE.on 

■rf Holrir," and a COmmancler oL the jOrde^of George^ 
Greece. During Ins service m (.)ass;'and 

of the Medjidieh, serond ’jgOO ho -married 

after the war the Order of Nile- in M.R.C.S., 

Annetta Jane,- younger djiughterqfjbe late J.. Na.d!n,._m-,,w. , ... 

of Tipperary;- and leaves, one soDj, *. . . 


MaHCH 2/, 192S] 


SrR D'AVID PERBTEB. 


t UfioiciX Jocr:?;^ 


F 





(Dbitunr^n 

SIR DAVID FERRIER, M.A., M.D., F.R.S., 
liL.D.', D.So., F.R.C.1 ’.Loot., Hos. F.R.C.P.I., 

Emeritii'i Professor of NcnropaUiofosy, King’s College, l,onflon, 
and Consnlling Vha-sleiatv to King’s Collego Hospital and 
I tho National Hospital for the Paralysed and Epileptic. 

We ha-ro to record irith much regret' the death of Sir 
David Fcrrier, tho great Eourologist, on March ISth at his 
rosideuco in Kensington. 

David Fender was horn on January 13th, 1843, at 
Aberdeen. Ho was educated at tho University in that 
city, studying logic and philosophy under B.ai'n, and 
graduated. Jl.A. in 1863, scenring a Donhlo First. He 
then studied psychology in Heidelberg in 1864, His early 
medical education was obtained in • Edinburgh, whore ho 
obtained first-class honours in tho M.D. examination in 
1368, and won tho gold medal 
in tho JI.D. examination ip 
1S70 with an elaborate thesis 
on the corpora qiiadrigemina. 

Ho was elected a Fellow of tho 
Royal College of Physicians of 
london in 1877. 

Equipped wdth such .a wido 
mental training, Forricr was 
essentially tho man to intorcst 
himself in tho problems of tlie 
physiology and pathology of 
tho nervous system, anil lia 
became one of the pioneers of • 
experimental research in Hi is 
subject, bringing to his worlc 
the advantages of the praefieai 
knowledge of tho physician. 

His earliest important publica- 
tion was in the reports of the 
\Vesfc Riding Asylum, where a 
pioneer school of neurology 
had been founded by Sir James 
Crichton-Browno in 1871. In 
tho reports for 1873, Fcrrier 
published bis Experimental: 

Ecscnrchcs in Cerebral Ehysio- 
logy and Pathology. This was 
followed by tho Croonlan ' 

Lectures in 1874 and 1875 on 
LocaliMtion of Fnnetion in the 
Prain, an event of funda- 
mental importance in tho 
history, of neurological science, 
lo appreciate tho signifieanco 
of Fender’s researches it is 
necessary to recall the state of 
knowledge at that tinio in 
respect of cerebral localization 
It was known by Galen that 
lesions on one sido of tha 
br.om might causo paralvsis 
on tho opposite side of the oort 

existed' already 

Sts srifT,” »¥“7S2 

in 1864 Hiighiines ’■’§''^'’‘'"''^63 persons, and 

observations ^on tho classical 

movements fJocl-sonm,, of localized convulsive 

of tho central conml ’a association with lesions 

direct experhucurarevh ^r^ 

work of tho German Dhvs-*\ *a'=ahzation was tho 

1670. These 

stimuli, and that directly excitable by electrical 

followed by movemenfo' '^®''*ain definite areas was 

side of tho hodr— movemont’'”1'^'!''''’ °PP°®ilo 

a knowledpo of the iv,;,.?”** "^.'ich could be predicted from 
first in this counti4 te ° ^limulation. Ferrier was tho 
ments; ho used tho and extend these experi- 

galranic, which was emnlnve/T'^'^r.*- V’^efcrcnce to the 
uas employed by Fritsch and Hitzia and 


•i- ' V 



extended his observations to tho monkey. Ho was followed 
later by Horsley, Schafer, Beevor, Sherrington, and others, 
who repeated the experiments in the higher apes and in. 
man. Prior to theso investigations, it was believed that* 
tho surface of tho brain was inexcitable by any form of- 
external stimulus, and could only he activated by stimuli 
applied to tho peripheral nerves and reaching tho brain 
by central pathways. It was conceded that the cortex was 
concerned in some , way with voluntaiy control of more- 
ments, but no knowledge existed of any Iccalizatiou of theso 
pKonomena, or that a special part of the cortex controlled 
tho movement of particular groups of muscles. Such 
experimental study aroused bitter opposition from the 
opponents of vivisection. In later years tho Research 
Dcfcnco Society was indebted to Ferrier, not only for 
practical substantiation of tho claims of experimental 
medicine, but also for his help as treasurer. 

Fcrrier always acknowledged his indebtedness to the. 

I'csearches of Fritsch and 
Hitzig, and to the profound 
clin-cal and pathological 
observations of Hushlings 
Jackson. In his Gonlstonian 
Lectures of 1878 on tho local- 
ization of cerebral drseaso he 
brought his experimental work 
into line with tho pathological 
findings in cases of cerebral 
disoaso in man. Tho second 
edition of The Functions of the 
Erain appeared in 1886. In 
addition to the localization of 
motor phenomena, tiic more 
dilBcult questions of tho asso- 
ciation of special parts of the 
brain with sensation and tha 
special senses Tfero tho subject 
of prolonged investigation by • 
Fcri”er. A large part of his 
Cronrian Lectures on cerebral 
localization in 1880 Is con- 
cerned u-ith tho visual, audi- 
tory, and other sensory 
Centres, and with tho funej- 
tions of tho cerehellum. 
Though many of his conl 
clusioEs in reference to these 
areas hare been superseded, ho 
laid tho foundation of iniich' 
of out present knowledge of 
the cortical representation of 
sensations; bis pioneer work 
upon the cerebral control of 
movement has long passed tho 
experimental stage, and forms 
tho very basis of all modem 
neurological practice. That so 
much which is now evoi-yday 
knowledge of fundamental im- 
portance was tho fruit of the 
laborious researches of British physiologists and phjsicians 
is a source of legitimate pride to this country. 

Other important contributions were tho Harveian 
Oration in 19C2 on The Heart and Eervous System, and 
tho Lumleian Lectures in 19C6 on Tabes Dorsalis. 

•Many honours fell to Ferrier. He was elected a Fellow 
of tho Royal Society in 1876, and was made a Laureate of 
the French Institute in 1878. He received tho Marshall 
Hall Prize in 1883, the Baly Medal in 1887, tlio Royal 
Medal of the Royal Society in 1890, the Cameron Prize of 
tho University of Edinburgh in 1891, and the Moxon Medal 
in 1912. His knighthood was conferred in 1911; he was 
mado Hon. Sc.D. of Cambridge in 1914 and Hon. LL.D. of 
Birmingham in 1927. Ho was a member of the Council 
of the Neurological Society, on several occasions he held 
tho post of vice-president, and he was president in 1894. 
Ho was one of tho founders of Drain, whicli was started 
in April, 1878, the first editorial committee consisting, in 
addition to Ferrier, of Sir James Crichton-Browno, Sir 
John Buolrnill, and Dr. Hughiings Jackson. For tlie first 


/Jwi-4L^AA<-tn 


626 March 24, 1928] 


OBITUABT. ' 


r Tni BninSH 
L MECtCXL Jocutu. 


five years of its publication tho journal vas ctlited in 
alternate years , 63 ' Cricbton-Broane and Forricl*. In 1013 
Ferrier nas president of the Medical Society of London, 
and of tlio Section of Neuro-patbology at the International 
Medical Congress held in London in that year. He was 
appointed lecturer on pli}’siology at the Middlesex Hospital 
in 1870, and demonstrator of physiology to King’s College 
Hospital in the following 3 ’car ; in 1872 he followed Dr. 603 - 
. in the chair of forensic medicine, and held this position 
until 1889, when he was elected tho first professor of 
neuropathology. 

Ferrier found time in his active life for practical interest 
in the British Medical Association, and was a member of 
the Metropolitan Counties Branch Council from 1888 to 
1899. Ho was also a member of the old Scientific • Grants 
Committee, now the Science Committee, and was President 
of the Section of Ph 3 ’siolog 3 ' at the Annual Meeting in 
London in 1895. 

The funeral service was held on Thursday morning at 
St. George’s Church, Hanover Square. It was attended, 
on behalf of the British Medical .^sociation, bj’ Dr. Alfi'od 
Cox, the Medical Secrctaiy. 

' We are indebted to Dr. S. A. Kixnieu IVilsox for tho 
following appreciation : 

Sir David Perrier was tho last of tho small and choice 
companj- of pioneers through whoso labours tho scientific 
neiu’ology of to-day has come into being. Nearl 3 ' sixt 3 ' 
years have passed since he commenced researches on the 
functions of tho central nervous E 3 'stcra that brought liim 
world-wide distinction and made his name familiar wherever 
neurolog 3 - was taught. AVith those of Hughlings Jackson, 
Horsley, and Gowers, it will ever take that honoured 
position in the memorials of neurological science rcscn’cd 
by common consent for the path-makers and the masters. 
He whs witness of the transition of knowledge of tho 
nervous system and its diseases from tlie stage of empiricism 
and lucky guesses to its fruition in the fertile soil of 
accurate neuro-anatomy and osperimentally proven neuro- 
physiology, and was himself one of the protagonists in this 
amazing revolution. 'Iho commonplaces of neural doctrine 
to-day were the discoveries of his early manhood, and we 
of a succeeding generation can appreciate but faintly tho 
new world then revealed by the objective methods of precise 
'cerebral experimentation. More than forty years separate 
us from the International Congress of 1881, when Ferrier 
gave a brilliant demonstration of the novelties of cerebral 
function and localization before the assembled savants of 
Europe; and fifteen years, too, have elapsed since their 
successors hailed him at the Congress of 1913 as the doyen 
of English neurology. If in these later times his work was 
less often referred to, if the echoes of old controversies had 
long since died away, if clinicians and surgeons cultivated 
the neurological field without a thought of the wilderness 
which it had replaced, a moment of quiet consideration 
would always bring to tlie mind of those who knew him 
and worked with or for him an impressive sense of the debt 
iieurolog 3 ' owed to his imagination and to his persistence in 
following the path of minute and exact experimental 
research. Only a few of his friends are aware of the 
personal abuse which this line of investigation brought him, 
or of the extremes- to which his opponents went in their 
endeavour to discredit his achievement. 

It is on his many services to the experimental ply-sio- 
logv of the nervous S3'stem that his reputation rests' 
securelv nor can it be diminished by any contention that 
the technique was comparatively simple, and that the 
material lay ready to his hand and was only waiting to 
bo utilized Subsequent studies bare not altered his con- 
clusions fundamentally, even if the growing point of neuro- 
locrv has moved away somewhat from the rather schematic 
Tm°r'allel he drew between excitation and response, between 
structure and function. To' many of the younger genera- 
tiorhe was known only as a cUmcian and clinical teacher, 
and this was possibly not tho most original side of the 
man A shrewd observer and a keen student of human 
nature bis contributions to clinical neurology are none 
?he "css bv comparison not so memorable or 
He had 'not Jackson’s breadth of vision, or Gowers s 
faculty of patient and painstaking cliniCcal scrntiny; ^hat 
struck* ail those whoso contact with him was of later 



U 111/ I ICU UllUllAllAXCI.* l-W LiliV 

into bis hands sixty years before. 

Dr. IlATiroxD CnAwruBD writes: 

The Editor has asked me to write a few words of bit 
David Ferrier such as those who think of him only as a 
neurologist may perhaps leave unsaid. From an acquaint- 
ance of nearly forty years with him, first- as my teaenw 
and afterwards as my friend, I should pick out as most 
characteristic of the man two features— first, tireless 
activity of mind and body, and second, as a consequence of 
tho firk tho faculty of keen interest in everything that 
camo under his notice. These qualities were appropriately 
tenants of a frail, brisk, dapper person, with a quick, 
sLinev step, and a face and eyes of penetrating keenness 

situation y P ^igenoies of medical education, com- 

’’i* reAlIcct .veil liis keenness to see tke 
jnterwt. introduced into clinical medicine, put to the 

reactmn, neirly mtrod^ j those days 

tost on the many 3P for ^ clinical 

thronged the 

lectnie be wo n-nrk such as myxoedema, for his 

‘"'‘^rhlday, as k woV to retained the same 
theme, "^Everything about him; ho. was never 

boyish keenness in thT^easide cottage at Porthgwarro 

T’kKent many summer holidays, going ^ “f 

■where he spenv —j livini^ the primitive life ot 

folf ?n Lordon one would often meet him at 
the fisheEW • 1 ^ acquaintance in the world 

rtistrim combined an appreciative knowledge of 

S^'nn+irement from practice his interest in medical 
After his re ^ There was no moro regular 

science ."""k the lectures in tho College of 

attendant than ho at the j-^ep touch 

^^frirCoUege tTat had bestowed on him 0 ’'^ higher 
With "thB Ooiieg^ T_ ^ PrpQifteiicv. for iio 

■“irSCsS -■'•"■I 

ottwmfY BfAYNABD SMITH, C.B., F.R-C-S-> 



Ua’rch 2^, 1928] 


OBITUABT. 


r Tnr Bnrnsn 
L Medicai. JoCEXli 


527 


After a distiiigiuslied career as a student Iio oMained 
tlio diplomas M.B.C.S.Eug., B.B'.C.P.Ijond. in 1898, and 
Bhortty aftenvards was appointed Iionsc-surgeon to tho lato 
Mr. Edraiuid Owen. Ho sorred in tlio South African wai- 
ns civil surgeon to tho 3rd Battalion Welsh Regiment, and 
obtained tho Queen’s Medal and two clasps. On his return 
to Loudon ho was appointed honso-sufgoon to tho Victoria 
Hospital for Children, .and in 1902 became a Fellow of tho 
Royal College of Surgeons of England. Ho graduated 
M.B.Lond. in 1904, and B.S. with honours in 1905; ho 
then held tho post of demonstrator of anatomy in 
St'. Mary’s Hospital Medical School. In 1904 ho becamo 
surgical registrar to tho hospital. He won a great reputa- 
tion as a teacher, and in 1906 was appointed surgeon with 
charge of out-patients to St, Mary’s Hospital and assistant 
surgeon to tho Victoria Hospital for Children. He became 
surgeon to St. Mary's on tho resignation of tho lato 
Mr. Ernest Lane in 1922. 

Mr. Maynard Smith had a brilliant record of service 
during tho great war. In 1914 ho was appointed surgeon- 
in-ebief to the St. John Ambulanco Brigade Hospital, 
and, after devoting himself with tho greatest energy to its 
organization and equipment, proceeded to France with this 
hospital early in 1S15, holding the rank of honorary- major 
in tho R.A.M.C. At Etaples tho St. John Hospital soon 
became famous for tho outstanding perfection of its 
organization, and very many surgical cases wero received; 
never was Mr. Maynard Smith’s brilliant genius as an 
organizer shown to better effect that in tho minutely 
detailed arrangements he made for dealing with tho work 
of the St. John Hospital. His skill gained him a great 
rejnitation in France, and led to his appointment of con- 
sulting surgeon to tho Fifth Army in 1916, with tho rank 
of colonel, A.M.S. In his new position his work was 
equally suceessful, and ho was largely responsible for tho 
surgical arrangements for dealing with tlie heavy casualties 
ot the prolonged battio of Passchondaolo. He also dis- 
tinpished himself greatly during the battio of St. Quentin 
and the retreat of the Fifth Army. He was subsequently 
appointed consulting suigeon to the Second Army, and held 
^iis post until the end of the war. For his services to the 
1 hghting round Kemniel ho was 

. varded tho Croix de Guerre; for his war services he was 
tnree times mentioned in dispatches, and was created C.B. 
and a Knight of Grace of the Order of St. John of 
Jerusalem. 

On his return from his long war service Mr. Maynard 

■ 1,0 * .* busy practice in London and very 

^orlvj in addition to his appointments at 
fat. lAlary s he \vas surgeon to tho London Fever Hospital, 

Edward VII Memorial 

’t) consulting surgeon to Epsom College 

Eoyal Masonic Benevolent Institution for Girls, 
fni- a nays intensely loyal to his old school, and served 

■ f i ' 1 uith much enthusiasm as honoi arv secretary 

litni-'ih • Society. His contributiong to surgical 

ex? pi “ • fractures of the lower 

a foi nior "i medical history of tho war. He was 

Countip« T 1 ■'*^™i .E^nncil of the Metropolitan 

of the ' Medical Association, one 

whei tir\tn ’^ Section Cf Diseases of Children 

in 1908 mid "I -^“n«a! Meeting at Sheffield 

clhfcnl soneral secretaries of the 

Association in April, 1919 ? ^^“ meeting arranged by tho 

shrewd judlimont'in^thf'tl'^'^ distinguished by his 

, operations we. d perfi“\?tar* 

eoUcagnes, patients among 
distinguished courtesy A , kinduess and the 

fill co!u, miiou , I ^ manners. He was a delight- 
in hKothm seta- rip after-dinner speaker.^ As 

mason, being a Past Gran Ad distinction as a Frce- 

Englaud. May nard smita irr of 

robust health bin bp vi ^ heeu a man of 
.activities; hi ’ “I'?"' this to limit' his 

harder ei’cu than th?f a! s impelled him to work 

aierage London surgeon. Surgery 


in general, and St. Mary’s Hospital especially, have lost a 
very genial and kind-hearted man, and a surgeon of great 
distinction. As his war yvork showed, he had a genius for 
organization, and last year ho was largely responsible for 
planning the details of the new theatre block at St. Mary’s 
Hospital; it is sad that ho should have passed away beforo 
its completion, hut the hospital yvill for long reap the 
benefit of tho time and thought he gave to the rebuilding. 
Mr. 'Maynard .Smith married, in 1917, Isabel, daughter of 
Mr, F. I. Pitman, and the sympathy of his colleagues and 
numerous friends goes out to his widow and his son and 
daughter. 

Majoi'-Hencral Sir S. G. Guise-Mookes, K.C.B., yvrites;' 

I should like to hear testimony to the loss both tho 
medical profession and the army hay-e sustained by the 
death of Sidney Maynard Smith. Late in February, 1918, 
Sir Anthony Boyvlby-, then senior consulting surgeon to tho 
British Forces in France, informed me, as D.M.S., Second 
Army, that yve yvere to have the services of Maynard Smith 
as consulting surgeon. His skill as a surgeon had preceded 
him, and was known by his yvork at the Duchess of 
Westminster’s hospital at the base. The Second Army, 
like many- another, had been fortunate in its consultants, 
both snigical and medical, and it did not take long to .make 
certain that in “ Maynard ” it possessed, besides surgical 
prowess, a man of sterling qualities of heart and mind. At 
his own request be was early permitted to pay occasional 
visits to the front line, to regimental aid posts, and to 
advance and main dressing stations. He soon acquired a 
sound judgement as to what was essential to efficiency in tho 
care, treatiiient, and evacuation of wounded. Anj-tbing short 
of tins gave his gallant and kindly soul tho deepest grief 
and concern. With any shortcoming be was never content 
, until a remedy yvas found, and found it iny-ariably yvas. 
At the casualty clearing stations, where bis chief work 
necessarily lay, his cheery presence was always welcomed, 
bis advice eagerly sought, and his capacity for un- 
obtrusive and arduous labour recognized and appre- 
ciated. In the short intervals between the “ crises ” of 
incoming wounded, when alone it was possible to ponder 
and talk over things past and to come, we found in him 
a fund of quiet humour, a sense of timely loyalty, a gift 
of sage counsel, and a contentment that goes with successful 
accomplishment. 

Dr. Alex-INDeb Hodgeixsox, who died in retirement at 
Farnliam, Surrey-, on January 6 th, in his 82nd year, was 
a native of Salford, and received his early education at 
Queenwood College and Owens College, Manchester. Ho 
began his medical career as an apprentice and proceeded 
to tho University of Edinburgh, yvhero he graduated 
M.B., C.M. yvith honours, and B.Sc., being senior 
graduate, in 1873. He was a Baxter scholar in natural 
science, and afterwards pursued his studies at Vienna and 
Freiburg. Dr. Hodgkinson spent the greater part of his 
professional career in practice in Manchester, where he took 
an active jiart in medical affairs. , He served as lecturer 
on diseases of the throat and nose at Owens College, yvas 
a corresponding member of the Societe rran 9 aise d’Oto- 
logie, Laryngologie and Rliiiiologie, and a member of 
various medical societies in Manclicster. He was senior 
honorary consulting physician to the Manchester Hospital 
for Consumption and Diseases of tho Tliroat, in tho 
foundation of yvlilch he played a considerable part. In 
1901 ho attended the International Tuberculosis Congrcs.s 
in London, and in tho folloyving year yvas president of tho 
Laryngological Section of the British Medical Association. 
Dr. Hodgkinsou’s interests extended far beyond the field 
of his profession. He travelled extensively in Australia 
and North and South America ; among his hobbies yvero 
orchid groyving, botany, physical optics, and photograpliy, 
while his recreations included golf, fishing, and moun- 
taineering. His yvife died about a year ago, and ho is 
survived by one son and tevo daughters. 


Dr. JoH>- Ali.ex Lycett, who died at Leamington 
on January- 15th, in his 91st year, camo of a medical 
family-, being the third sou of Dr. John Lycett, who spent 
tho greater part of his career as a ijractitioner ai 



528 - March 24, 1928] 


MEDIGO-IiEGAti. 


• - r Tire Br.msff . 
L MrdICAZ. JoiIBKiA 


Slincliinlinmpton, ivlioi'o he achiorcd more tlian local fame 
by his geological studies of the Cotsuold Hills. John Allen 
Lj-cett received his medical education at the Middlesex 
Hospital ; in 1871 ho obtained the diploma of 
M.R.C.S.Eng., L.R.C.P.Lond., and L.S.A. In 1881 he 
graduated M.D.St. Andrews, and a year later obtained 
the diploma of M.Il.C.P.Ed. After holding various j'osi- 
dent i)osts in the Middlesex Hospital Dr. Lyeett commenced 
practice in ‘Warwickshire in 1872, moving to Wolver- 
hampton in 1874, whore he built up an extensive ]>ractiec 
in that town and the surrounding district, and remaining 
there until his retirement ten years ago, when he made 
his home in Leamington. He was, throughout his career, 
keenly interested in gynaecology, and ]dayed a considerable 
part in the establishment of the Wolvorhani]iton and 
District Hospital for Women, serving subsequently on the 
.staff of this institution as senior surgeon and consulting 
gynaecologist. He co-operated in tlio formation of the 
British Gjiiaecological Society, which was afterwards 
merged in the Royal Society of Medicine. He was a 
member of the Staffordshire Branch Council of the British 
Medical Association in the years 1888-91. 


Dr. WiLLiASt Tiddles, who was born at Leicester in 
1859, died suddenly at Nottingham in February. He 
received his medical education at Charing Cross Hospital, 
whei'e he aftenraixls held an apjiointnient as jiatliological 
assistant, arid- obtained the diplomas of L.S.A. and 
L.R.C.P.Ed. in 1881, and of M.R.C.S.Eng. in 1889. He 
had an extensive practice in Nottingham, and was medic.al 
officer of health for the Melton Mowbray rural district 
and a medical officer of the Nottingham District Union. 
From 1915 to 1919 Dr. Tibbies was assistant physician to 
the Nottingham General Hospital. Ho was a menibor of the 
American Association of Physicians and Surgeons, and of 
the Nottingham Medieo-Chirurgical Society. He had long 
taken an interest in the work of the Biitish Medical 
Association, serving on the Midland Branch Council iu 
1908-9 and again in 1921-22. He was the author of a 
number of books dealing with various aspects of dietetics, 
and his works on food attracted a considerable amount of 
notice during the war, both in Europe and in America. 
He had, at a much earlier period, been the recipient of 
academic honours in the United States in recognition of 
his studies in dietetics, including the honorary degrees of 
LL.D. (1895) and M.D. (1907) from the University of 
Chicago, and D.C.L. (1904) from the University of 
AYashingtou. Dr. Tibbies was a pioniincnt Freemason. 
His son has followed the family tradition and is also a 
member of the medical profession. 


Dr. John R.tonAN Thoaias, who died at Exeter on 
FebruarA- 28tb in his 73rd year, was educated at Ei>som 
College, where he uas Gilchrist .scholar, and at St. Bartholo- 
mew’s Hospital. He obtained the diplomas M.R.C.S.Eng. 
in 1876 and the L.S.A. in the following year. In 1884 he 
graduated MJB.Lond. with honours iu midwiferv and 
diseases of women, in-occeding JI.D. throe years later; in 
1886 he obtained the diijloina D.P.H.Ciimb. After holding 
a resident post in St. Bartholomew’s Hospital he suc- 
ceeded, on the death of his father iu 1877, to a large 
practice in Llanelly, but after about ten years in South 
AA’ales ill health compelled him to letire temporarily, and 
he spent some months recuperating in India. He then 
commenced practice in Exeter iu ])ai-tnershij) nith the lato 
Mr. A. J. Gumming; he also held the posts of Admiralty 
.surgeon .-.nd certifying factory surgeon, and tras a referee 
under the AVorkmen’s Compensation Act. Dr. Tliomas 
identified himself with the voluntcci- movement and the 
I’oi-ritorial Force, from which he retired in 1912 ivith the 
rank of colonel, A.M.S. He was a vice-iuesident of the 
Naval and Militaiw Section of the British Medical Associa- 
tion in 1907. His' seiwices in connexion with the medical 
organization of the AA'essex Territorial Division were 
iTcognizecl bv his ajijiointmcnt as houorari physician to 
Uie King. He Avas a keen marksman and participated 
in nnmerou.s meetings .at AVimbJedon and Bisley. being a 
-nicmber of the team ivbich won the China cup for Dei'on 


in 1895. Golf ivas also among his recreations. Ho was 
greatly interested in literature and art, and himself pro- 
duced many ivater-colour studies, notably of the coast 
near Exeter. 


iitshica-Ktgah 

A JURY’.S A^ERDIGT CRITICIZED. 

T;/n(lall V. Alcoch. 

Membep.s of the medical profession will certainly endorse the 
ohitCT dictum of Lord Justice Scrutton that a Jury is rarely 
a suitable tribunal to trj' a case Avhich involves a right differ- 
entiation between Avliat is an eiTOr of Judgement — Avhicli is not 
actionable— and what is, in fact,' a departure from the degree 
of skill Arhich 'a jirofessional man holds himself out to exercise 

AvhioU constitutes negligence in the eyes of the law. Even 

so, it must be poor consolation to Dr. Arnold Alcock of 
Gloucester to know that, although the Court of Appeal, con- 
sisting of Lords Justice Scrutton and Sankey and Mr. Justice 
Romer, might hai-e come to a different conclusion from that of 
a speclil Jurv at Bristol Autumn Assizes, yet the sacrosanct 
nature of a jury's findings of fact preA-ented the Court of 
Appeal from interfering Avitli their verdict. 

A report of the case as it Avas presented at the assizes 
appeared in our issue of December 10th, 1927, at page 1121. . 
Brieflv a child named Phyllis Tyndall, aged 10, Avho was 
descri'bcd .as “a prodigy at the piano,” fractur^ 
humerus as the result of a fall from a pony. Dr. Alcock 
claimed to have skilfnllv adopted the most approved scientific 
method in reducing the fracture, since during the operation lie 
Sused an .r-rav photograph to be IhroAvii upon the screen, and 
Avlien he had finished his task the radiologist reported that the 
A.r.nr.= Appeaved to be in perfect alignment. Unfortunately, 
hoAACVc'r^^the child's arm became fixed at the elbow and 
vXiiann’s contracture developed, resultrng in impairment of 
' Ap^nt The trial iufv found that Dr. Alcock had been 
neXentmil pt^eeeded to apportion T.2,000 damages to the 

^’Tbe^tmSs of'lLThreT’members of the Court. of Appeal 
ppin tlTverdict are interesting. AYhile Lord Justice Sankey 
upon 'h‘S , jnstice Scrutton that questions of profes- 

‘■’•^'■'aH.ev LLe Avm” difficult, he thought an ordinary jury 
sional ,0 correct conclusion than a 'jury of 

Avasmore hkel .tti^^ Romer ironically observed, however, that 
^f^'^Ak^k must get such consolation as he coukVout of tlie 
H rti 1 b • furv Avas tlie foundation of his liberties 1 
faclthattii.al b 1 . ouliar province of a yury, and 

,t 15 an ;t can be said that there Avas 

venlict cannot h , j their verdict. ' 

r f'’rjuZ^'i^on tei-seTobserA.^ the Jury .Avere the 
As I-'’"' ^,„.e'by the Coiislitution to try actions involA-ing 
persons .-^/^ce and, since there was evidence bcfoie 

questions of ' = entitled to decide either Avay, it-Aias 

them ‘ of Appeal to interfere with the result, 

impossible for .A Comtot^App^^^^^ come to a different con- 

.Although MW constitutional tribunal Avas, tlierc- 

flrrailo'ved to stand, and Dr. Alcock’s appeal was dismissed. 

r.f-«TRATION OF DANGEROUS DRUG 
Tho West bonjl™ .“Fthree gMuces costs on 

'ISp cerUin mirchases of dangerous drugs. public 

tntcivtopvd 

drugs, a™ ‘ ? J,o particulai-s of purchases purchases 

Ecnphons. January 1st he ^ jiamoiphiiio 

.although m Oc ^ of morptiino of otfenee as 

{$«rA;.^,The a„ dangerous 

poised f?;„i«%'Sidr"angei»\.g^^ in thh ™;mtr^ Uicre 
;^arr’;«g|it'i;;‘’^.thaf he had /""gidUy” 





630 March 24, 1928] MEDICAD NOTES IN PARrjIAME’NT. 


r The liBiTisB 
LMnjicAi.JocnKii, 


remain at work in nrlvanccd pregnancy. Any ' suck rnlo of an 
employer did not entitle an insured woman ' to Ricknoss benefit 
under the National Healtli Insurance Acti but if s)ie could produce 
medical evidence to the Ratisfaction of her approved eocioty that 
she was incapable of work, she would be entitled to benefit. I)r. 
Davies asked if Mr. Chamberlain knew this question caused great 
difficulty to medical officers, doctors, and approved societies, and 
whether he could include this class of case in the National Health 
Insurance Bill. Mr. CiiAMUEnLAiN said there was a later question 
on the paper regarding that. 

On March 19th Sir Kingslev Wood informed Mr. R. Morrison 
that the Minister of Health had not recently issued any regulations 
which authorized panel doctors to charge insured persons over 65 
the sum of Is. for medical certificates. Tliore was no power under 
the Acts to fix a foe for certificates which wore not jequired for 
National Health Insurance purposes. Mr. MoaaisoN asked wliether 
insured persons over 65 wno were not eiiliUed to cnsli pensions 
were still entitled to medical advice, and whetlier that medical 
idvice included medical service if required. Sir Ktngsi.ey Wood 
i^eph'ed that, as his answer implied, a charge other than that 
luthcrized under the National IiiBUrance Act was not a ’proper 
charge. 


ujiiic, ou, vaccinated in intancv; 

1 nn' >" infancy ; male, 44, vacciiiatecl in infancy 

l ili sanitary case); maio, 47, and feraak, 

4B, nolli vaccinated in infancj-; male, 57, vaccinaied in infahrv; 
toimlo, 57 vaccinated, in infancy, (fatal cjise, died in' Long Eeacli 
’ l?^ylford_) j male, f>6, vaccinated in infancy. 

"here wore 8 cases in 1D28, as follows; malo^, 14, unvaccinated; 
male, 23, vaccinated in infancy (port sanitary case); female, 32, 
yaccinalcd. m infancy; .male, 34, vacciiialod in infancy and at 
10 years of ago (port sanitary case) ; male, 36, vaccinated in 
Vi 1 (port sanitary case) ; female, 42, vaccinated in infancy 
(fatal case, died in ^ Long Reach . Hospital, Hartford) ; females, 
52 and 64, both vaccinated in infancy. 

In 1927 there were 7 ca’ses, as follows: male, 4 yeai-s, unvaccin- 
alcd (fatal case, died- in Long Reach Hospital, 'Dartford) ; male, 
20,- tmvaccinated (port sanitary case) ; male; 25, vaccinal condition 
doubtful (port sanitary case); males, 29 and 33, both unvaccinaled; 
fomalo, 41, unvaccinated (fatal case, died in .Joyce Gi-een Hospital, 
Hartford); male, 54, vaccinated in infancy; 


Jl/atcrnal and fnfantUe Mortality, 

Mr. Chamberlain has received the resolution regarding maternal 
mortality passed on February 28th at n meeting of 600 repre- 
sentatives of local authorities and friendly societies. Ho is taking 
action to give effect to the recommendations made By tlio report 
recently issued by the Ministry of Health on protection of 
motherhood in regard to medical inquiry into all deaths due 
to childbirth, further training and experience in midwifery as 
a preliminary to general practice in medicine, the appointment 
of an official committee to advise on the whole question of the 
training and employment of midwives, and action to induce local 
authorities to make their maternal services adequate. 

Sir Kiugsley Wood told Sir Robert Thomas, on March 14th, 
that Anoroved Societies Consultative Council has referred to 
a special subcommittee the proposal to modify maternity benefit 
80 as to provide medical and nursing services in addition to a 
cash payment, linking up such services with the maternity and 
child welfare work of local authorities. Mr. Chamberlain will give 
the report most careful consideration as soon as he receives it. 

Answering Major Ropner, on March 14th, Sir Kingsley Wood 
said the infant mortality figures for Houghton-le-Spring and 
Chestcr-Ie-Street during 1927 showed a small increase in each 
district compared with 1926, although the rates were lower than 
for 1924 and 1925, Only the report of the medical officer of health 
for Houghton-Ie-Spring, which was written on February 22Dd, 
1928, suggested under-nourishment as one cause of the increase. 
Other medical officers in the county of Durham attributed to the 
exceptional prevalence of bronchitis and pneumonia the temporary 
increase of Infant mortality in that county during the la«t few 
months, Mr. Lawson asked whether the Ministry of Health 
accepted only death from starvation as proof of destitution. Sir 
Kingsley Wood denied this. Mr. Montague asked whether a 
medical officer's report stated that the deatlis from bronchitis 
showed that there was lack of clothing as well as of food. Sir 
Kingsley Wood said he was not aware of that. 

In a reply to Mr. Robert Richardson, on March 15th, Mr. 
Chamberlain sard that for the quarter ended December, 1927, 
the infant mortality rate for the urban district of Houghton-Ie- 
Spring was 152j and not, as stated by Mr. Richardson, 210 per 
1,000. No official figures were available in this district for 
separate montlis. Mr. Richardson alleged that the rate in 
October was 300 and in January, 1928, 210, but Mr. Chamberlain 
remarked that in a district with so small a population very slight 
variations in the numbers of births or of infantile deaths resulted 
in such substantial differences in the monthly infantile mortality 
rate as to render it of little value for purposes of comparison. 
The addition of one death me.ant an addition of 50 per 1,(W in 
the mortality rate. Mr. Richardson, in a supplementary question, 
asked whether Mr. Chamberlain did not know that the medical 
officer of health , had given the figures from October until 
February, showing little or no diminution, that he said it was 
the highest death rate ever recorded in Houghton-le-Spring, and 
that he was certain it was because of the underfeeding of mothers 
and children. Mr, Chamberlain said that was merely a repetition 
of the question. 


Small-pox. 

On March 20th Mr. Chamberlain gave Mr. Groves a detailed 
statement showing the number of_ smalLpox cases and deaths 
from that disease which occurred in London in the five years 
1923 to 1927, with the age, sex, place of death, and vaccinal 
condition of ^acb case. The statement showed that in 1925 
there were 13 cases of the disease, as follows ; male, 12 years 
of a<'e, un vaccinated ; male, 15, vaccinated , in infancy (a port 
sanitary ca^^e) ; female, 25, vaccinated in infancy ; female, 23, 
unvacemated; two females, 28 and 30, both vaccinated in infancy; 
male 51 vaccinated in infancy (it was stated that this patient 
had beea rovaccinaled in 19X4. but the av-aiiable crideiice did not 
appear lo support this statement); male, 47, and female 44, both 
viicinated in infancy: maie, 50 anrscemated; male, 53, racem- 
ated in infancy (this case was fatal, the patient dying m Joyce 
Green Hospital Hartford); female 79, vaccinal condition doubt/nl; 
male, 52, probably twice vaccinated, poor scars- (port sanitary case). 

In 1924 tliere were 4 cases, as . follows : male, 24, vaccinal con- 
dition doubtful; female, 54, and male. 54 both vacemated in 
infancy; female, 73, vaccinal condition doubtful. ' - 

In 1925 tbere were 14 cases, ns follows : females, 2 years and 
4 years, both unvaccinated ; female, 17, unvacciiiatcd ; male, 24, 
vacemated in infancy (port sanitary case) ; male, 25, unvaci^ated 


■ , Foot-and-Mouth Dhenxe^ 

' In the ‘House of- Lords’, on -March ’ 20tli, Lord Lkhli;_ ashed 
whotlier the ei-istenca of -two distinct types of foot-and'-mou'th 
disease was 'confirmed by the Eesearch' Committee. He further 
ashed if the typo 'of disease most prevalent in Denmark, Holland, 
and Belgium was the same as ‘that which mainly prevailed in 
tin's country,’ and' if the virus had been ' recovered from any 
imported ' supplies of chilled or frozen' meat, ''discount Hald.ihb 
said the Govemraent ought lo search the biological laboratories 
and the iiiiivefsities to find a comparatively young man to devote 
himself eselusively fo research into the bacillus of the disease. 
The Earl of StnAPBiioKE, replying for r.-v'-i — “rt. --.ifl that 

if- the Government' could find anyone i ' ■ '■ i ’ ' : ' i 

work his services would bo employ i, 'i ■ i'' ■ ’ i 

Research Committee had coii.firmed the opinion arrived at by the 
Veterinary College in Paris, that there were two etvains of foot- 
hnd-moulh disease, and that, it animals became immune after 
bein<» attacked by one strain they were not thereby jmevented 
froin attack by the other. Those ■ facts made it difficult to 
eradicate the disease, and the only way they saw at present was 
bv slaughtering infected animals. There was no uiformation on 
life tvoe^of tlie®disease in the Argentine, but it was very prevalent, 
mfe Government hoped that the steps the Argentine Government 
S nmmS to take to check the sending to this country of 
carM&es Ukely to be infected would prove effective. No attempt 
W feen made by the Research Committee to rerover the virus 
from iroPoHed supplies of chilled or frozen mean, because it was 
fou“th?t the task -was impracticable. So . many carcasses were 
• that although they might take carcass after carcass and 

iioS nothing yet ^ time drsease might be brought in. Lord 
Rr rnisaS s^uogested that something migRt .be done to co-operate 
b, H I’ matteY of research with the eminent experts who were 
working in the Argentine a nd Brazil. 

Fdmhvnh Corporation Bill (Tcnercnl Diseases). . 
rv 15 tL Sir Joto Gilmour and Mr. Chamberlain received 

’“f.i'nn reoresenthig the Corporation of Edinburgh, and 
“ ‘^°?b!o^of the ?own clerk, the medical officer of health, and The 
"’"oreal diseases officer of that city, -who set before tlmse Ministera 
which 1 ad induced the Corporation of Edinburgli to 
‘’* 1 ® till Edinburgh Corporation- Bill,- for-_greater powers of 
rnritrollinv - ond curing venereal disease. The speech 
detecting, narticolarly impressive in its citation of 

of the.town clerk was particoia^^^^ Sefiretary 

?i“SSd and till ‘Sinister of Health initiated plainly tot 
for Scotland ana ^al public policy they would be com- 

the House of Comrnons uot to give the bill a second 
P®'dL ®ThTdeputXn was introduced by Mr. Wilii.am Graham, 
reading.- -We nep accompanied by Dr. 

??'’'®'’™^d Sh?els^ Despite the Ministerial declaration of 

Drummond the subject liS^ to 

s Dumber ot ™ .• should not withdraw the bill forthwith, 

Edinburgh Corporation s Commons, 

but claim .a second reading ■ j gj by other corporations to 

It was pointed out inas oins^i venereal diseases had 

secure j reading and been sent lo committees. Other 

received o, sugeested to press on the Edinburgh bill 

members, . ’oo]d prejudice the chances of the bill which the 

(O certain defeat vciild^ldi^wmt^^ introducing on the same subject. 
Glasgow Corporation ^ second reading of the 

On ffao ? S Bill was torially moved in the 

io"? W"®rbeing Ukcn, the bill was put down for that 

day week, ■ ■ 

■ • Tuberculosis in the Aury TTrinLASf 

^®J®‘M*arcTllth,°wPt Ihe Navy Eotoates werojntrcduccd^and 

liscussed, Admiral ’'“yoh ^tho House had discussed m 

hf /opuSn. h" called for immediate inveotigalion and action. 



MABcn 24, 1928] 


MEDICAL NOTES IN PARLIAMENT. 


[ ITh* Bamsa 
Medicai. JanwAt - 


631 


HrATiijiM icnivin" to tlic debate for the Adinirally, 
saM «.e prS’deb^aiV Sn tbo subject bad show« that all 
afdiiu iL House felt sometbiug was wren- He agrc^I hat 
the men themselves might be more satisfied it tlicj 
to some outside hoard, but he pointed out that the iiidcpcndcut 
tribunals of the Ministry of Pensions Averc set up to meet the 
special circumstances arising out of the war, when the inedicai 
hi^toiT of thousands of eases could not bo asccrlaiiicd 11 } tlio 
‘ordinarj’ way. In the navy in ordinary times the medical liislorf 
.. known from Uie moment lie first came ou board. 

-f miirt rln/af/M*® f/tVtTlinfT flirt 


of a man was 


B monieni. no jirsii cuimi uuaiu. 

EveV detairof idrcaae was kiionu. Tlio doctors forming tho 
survey board before which ho came were familiar with the kind 
of service he had, and were therefore better fitted than almost 
anybody else to judge whether the illness from which ho was 
suffering was due to sciwicc. The man who came before such a 
survey board had the doctors or his side as far ns v*’as possible, 
and was given every chanco of staling his case and of calling 
witnesses. Mr. Gnon:s, intervening, said Jio disputed that. 
Colonel Hjhadlau, proceeding, said medical boards of survey were 
held twice in each month under tno authority of tho Connnander- 
in-Chief or senior officer present. Tlio board consisted of tho 
medical officer in charge of the hospital, who acted as president, 
and three medical officers, two being senior medical officers of the 
hospitals and one a senior medical officer of tho fleet or depot. 
The. Admiralty had considered the suggestion that there should 
bo an executive officer on the survey hoard, and tlio opinion was 
nothing ^vould be gained by reverting to a practice which was 
abandoned in 1914. An executive officer Avould either interfere with 
the medical officers in tlie performance of their duties or would 
be a mere figurehead. The medical officer who brought the ease 
Inward appeared before the survey board so that the sun'cying 
omeers stmuld receive full information on tho ease. A complete 
history of each case was made out, showing the details of tho 
onset, course, and the final state of the disnbilitj'. Before 
Buryej’ the officer or rating was required to fill in a form on 
iM-t 'S® a^-ed to state what, in his opinion, caused his 
required to investigate and record 
disability was attributable to or caused by sendee 
if what specific condition 

!«■ reports, with a statement by the officer 

decWfiTi'-Jw? the Commanderdn-Chicf, who made his 

n? be invalided, 

from’ the * asked if the board decided tho ease simply 

decided Ibp man. After tho Comniander-in-Chief had 

Av^s caVulIv Admiralty, where every ease 

being made with medical authorities, compai-ison 

A'hefe the man ship.s or establishments 

decided by the ^ question of attribuUbility was 

the papej^ befo^f Admiralty. These hU all 

except the patiSit : Everything 

bias at the^Admiraltv U there was any 

for reconsideration ot' man. Appeals 

selves or by organiMifrtnrl" be made by the men them- 
wiiicb attributa^ilitv behalf. The regulations on 

in 3 secret and assessed were set out 

They were based on to tho surveying officers. 

Committee and wer^ni^?! P<»t-War Disability 

Army, and Air Forre i„ the Navy-, 

the great difficnltv the remark that 

that there were oJicr HEiDUii replied 

rules by which these cas^n?^, bo fair to say that the 

tho doctors were not nivnn''/m JuHged were too severe and that 
be the case, but to bfame That might easily 

Sir Berlrain Fallc had in Admiralty authorities was unfair, 
year 1920, in which ‘ie^nte cited cases of the 

rejected by an indenendont™™^ i *? . ®^^*'ii^ntability had been 
of Pensions. The truth wa. ?PPp| irihunal undei’ the Ministry 
and hot the tribunal Th^.d • importance, 

fit simply meant that an •'^'5" “ ™a" to the navy as 

ciently, wrong to make it found nothing suffi- 

show* he was a good life ^ “oi to enter, but did not 

tlO''over, that the whole The Admiralty agreed, 

they were looking into it required careful attention, and 

a-as ciamining tfe question'!^?’ all aspects. A joint committee 
of hygienic conditions in the nl “Hoibutability, and the question 
medical consultative hoavd referred to a special 

would guide the Admirallv °/n °“f®‘de specialists, whose report 
Admiralty would certainlv on extent in its policy. The 

oaecs were properly and 'fairK^™^T^^!i"“ Possible to see that these 
'o/>s-. It was easy^trexaeio^M^ aPPUed to tubereu- 

Tho incidence of tliat diselle*«oonf^°'!^ tuberculosis in the navy, 
n cinl hfc, but the conditirm^'^^^ ^ *1'® nn'T 11'“” 

found out earlv mspection were such that the 

° Ho-o passed to other naval topics. 

On JIatch Wtlf"^™^ '^‘0 A'acp. 

Ind“lf H ‘In' ^sabilitiS ''oP'y to Mr. Hore-Belisha,- 

Marines were Koyal Navy 

qaf ffpont in 1926 and 1927 twelve mouths of their 

1927 ? 'ufection, 4 recruit?*''^^'™]^' diseases 

y^rs r’' P^o-nococ^al infection nf ® discharged in 1926 and 1 in 
j ^or rheumatic fever- 6 and 8 in tho respective 

ieal® f'”' Pon-pulSl' 7 for pulmonary tuberculosis; 

fiy infMtin? '^^O'^ulosis. and 3 and 3 for ollief 
iQon’j^ ''0'^: Dirc.ases of tho norvous and mental diseases the 
9 S 5- ntiS*’:?' 1 and 1; paralysis, 1 in 

ainfpri’oHi^Pd 15; insanity ^T^?”d 4; other nervous 

of Hii' 66 and of tlie eye, 34 

- circulator^' system • nose, 2 in 1927. Diseases 

J system . diseases of the heart-r-orgaiiic 29 and 


32, functional 2 and 6; diseases of tho arteries, 1 and 1; diseases 
of Uio blood and spleen, 1 in 1926. Diseases of tlie lymphatic 
^stem : 1 in 1927^ glands and internal secretion, 4 and 2. 
Diseases of the respiratorw system: broiicliilis, 2 in 1927; asthma, 
2 and 2; fibrosis of lung. 3 and 4; pleurisy, 3 and 2; other diseases, 

1 in 1926. Diseases of tbo digestive system : teeth and enms, 

2 and 3; mouth, palate, fauces, and pharynx, 1 in 1926: tonsillitis. 
1 in 1926; stomach, 1 in 1927; intestines, 1 in 1926; hernia, 3 and 1; 
rectum and anus, 1 in 1927. Diseases of generative system: 
varicocele, 3 in 1927. Diseases of organs of locomotion : peri- 
osteum and bone, 1 in 1926: cartilage and joints, 2 and 1; spine, 
1 in 1926; muscles, fasciae, tendons, bursae, 1 in 1927; deformities 
of limbs, 11 and 11. Diseases of areolar tissue and skin : eczema, 
1 and 1; other skin diseases, 2 in 1927. Diseases of urinai-y organs: 
kidneys, 5 and 5; ureter and bladder, 2 in 1927; urinary disorders, 
^ and 12. New growUis, non-malignant, 1 in 1926; local injuries, 
injuries and wounds, 9 and 5. Totals : 1926, 261; 1^7, 250. 


DamjerouB Petrol: Protective Clause in Xcig Bill. 

The bill for the amendment of the Petiolcum Acts was con- 
sidered by tho Standing Committee of the House of Commons on 
March 20th, when Lieiit.-Colonel Sir Viviax He^jdersojt, who 
was in charge of the bill, moved a new clause empowering the 
Home Secretary to make regulations as to classes of petroleum 
likely to be dangerous or injurious to health. He said the 
Government intended to introduce a Consolidation Act in regard 
to the Jaw governing petiolenm and petroleum spirit, but it was 
desirable that certain amendments should be passed first. With 
regard to the recent controversy tancerning dangerous spirit, the 
Home Secretary Jiad set up a committee of inquiry which was 
asked to act expeditiously and report. The new clause would 
enable the Home Seci’ctary to take such action in the framing 
of suitable regulations as might be deemed necessary on receipc 
of the loport. Tlie clause was added without opposition. 


Petrol Fumes in Armoured Oars . — On the i^eport of supply in 
tlic Army Estimates, on Marcli 20th, Mr. Hardie asked what 
was being done to protect men in the armoiu'cd cars and tanks 
from petrol fumes. Sii* La3Id;g WoRXHi:rGTo>'-EvANs itiplied that 
tho army did not use ethyl-petrol at all. They had an experi- 
mental depot at Woolwich, which was constantly experimentingr 
with a view to discovering means of saving human life, and of 
improving defence at the same time. 

Bmohe .l/Ki/cnicnt.— Sir Kingsley AVoon, replying to Mr. Naylor, 
on March 20th, said that by-laws respecting the emission of smoko 
Iiad been made by foui'tecn local autlionties, and confii-med. Two 
regional advisory* committees and one executive committee had 
been set up since tlie issue of the Ministry of Health's circular 
calling the attention of local authorities to the Smoke Abatement 
Act of 1926, in addition to two advisory committees previously 
appointed. A committee had also been appointed by a conference 
of representatives of local authorities to report on smoke ubatement 
in the Greater Eondon area. 

Bcalth Coiulitions in Artiftcial Silk Factories . — Sir Williau 
Joynson-Hicks told Mi% Kelly, on Maxell IStli, that reports on 
artificial silk factories by medical and other inspectors of factories 
who had visited them showed that the conditions of health were 
genci-ally satisfactory, but cases of conjunctivitis had occurred • 
at one or two works, and there had also been cases of dermatitis.' 
Suitable precautions were being taken, and tbc conditions would- 
continue to receive the special attention of his medical stuff. He 
could not answer without notice regarding individual firms or 
factories. 

Dispensing of Bcdtcincs in the iVary. — Dr. Vernon Davies asked, 
on March 14tli, if tlie First Lord of the Admu*altv was aware 
that the dispensing of medicines for men in the army liy dispeutefa 
who underwent a short period of training was, in the opinion' 
of the army authorities, performed adequately’ and economically; 
and W’hethcr he would, in tho interests of economy, introduce the 
same system into the navy, and not engage any more fully trained 
pharmacists. Colonel Headlam, Financial Secretary to the Ad- 
miralty, said he could not accept the suggestion that the replace- 
ment of fully trained pharmacists in the naval service by dispensers 
trained in the manner proposed would make for economy, nor 
did he think the conditions in the two seiwices so analogous' as to 
make such a change practicable. Fully trained pharmacists wero 
employed ouly in naval hospitals and in the naval medical storo 
depot. Pharmacists carried out other duties besides those of dis- 
pensing. They were responsible, in addition, for the supply of 
medical stores to the fleet and for medical store duties in hospitals. 
Side-berth ratings were instructed in dispensing duties only so far 
as they related to the stores in the sendee afloat scales, and per- 
formed such duties imder tlic supervision of the medical oflicer 
of the sliip, who was personally responsible for the correct issue 
and use of all drugs. Dr. Davies asked -whether Colonel Headlam 
held that there was a diffei-ence between dispensing for the navy 
and dispensing for the army. Colonel Headlam said that he could 
not answer for the army. 

Fitness for Labour of Vagrants in Casual IVards. — ^Replying, on 
March 15th, to Mr. Grundy, Mi*. Chasibeblain said medical advico 
w’ould not be obtained on the diet to be supplied to vagrants in 
casual wards where stone-breaking had been introduced. Tho 
dietaries were reconsidered in 1925 in the knowledge that -'asuals 
might have to break stones. He would not order medical examina- 
tion to make sure of the physical fitness of the vagrants who 
broke stones. No task was required from a casual suffering from 
temporary or permanent infirmity. Mr. Lansbury asked if it -was 
not a fact that there were no medical officers at casual wards, 
and that no casual was medically examined before ireing £ct to 



632 Map.ch 24, 1928] 


MEDICAIi NEWS. 


uxoicii. Jovnta 


break stones. Mr. CirAMBEKLAiN said that under an. Order, if any. 
^Bual appeared to require medical attention, thp master was 
directed to obtain the attendance of the medical ofTiccr. Ifc w^as 
always open for any casual to ask to see the doctor. 

liirth and Death Dates in Trojyical Africa . — On March 19tli Mr. 
Amery, in reply to Sir J. Power, said that it was exceedingly 
difficult as yet to obtain reliable returns of births and deaths 
among the populations of tropical Africa. But in areas from 
Vrhicli the returns might bo regarded as fairly accurate, as in 
the Buganda Kingdom of the Uganda Protectorate, and in con tain 
West African towns, there was evidence of slow Improvement 
in the infant mortality rate. In most areas, however, the rate 
remained regrettably high. The Governments of tropical colonics 
were fully alive to the importance of this matter. Infant welfare 
clinics were being established, and women doctors, nurses, and 
health visitors appointed for "special duty; the work of thoso 
officers, notably in Malaya, the Gold Coast, and Sierra Leono, 
had been of a high order. In this connexion ho smccinlly men- 
tioned tho work ot voluntary agencies, such as the Child Welfare 
League of Kenya and the Child Welfare Society of Singapore, and 
the efforts which iiad been made in tlio West Indian colonics 
to deal with this problem. 


Hofipital Dermatological 
Society at 48, Leicester Square, W.C.2, on March 28th, at 
4.15 p.iu.. Dr. It. Craik ivlll read a paper on luonilia, and 
clinical cases rvill be shown. 

A MEETING ol the Medical Women’s International Assoola- 
lion will be Jiold in Bologna on April 11th, and be rollowed on 
Ajiril 12th, 13th, and 14th by an open meeting, to which all 
M'omou doctors tiro invited. The subjects for discussion will 
be: (i) medical measure.^ for the protection of children and' 
young porsons in the various couutries; (2j diseases oftbe, 
cyo in relation to general medicine. The 'Italian railway 
authorities }iavo granted a leductiou of fares in their country, 
ami the programme includes a. reception by the Bologna' 
uniiiicipaiity, a dinner at tho local Pascist beadquarteid 
(Casa del Pascio), and an evening reception given by the 
Intcrnatiouai Executive Coiiiinittee, 'The Italian Association 


Notes in Dricf. 

In a reply to Dr. Salter, on March 15th, Mr. Guinness said the 
eslmialod daily consumption of liquid milk per head in Kugland 
and Wales was approximately Iialf a pint. 

Since the war eleven factory inspectors’ assistants have been 
promoted to the rank of inspector. 

The calves used at the Government lymph establishment for 
the production of vaccine lymph are hired from a contractor. 

On March 3rd, excluding lunatics, casuals, and thoso receiving 
domiciliary medical relief, 1,203,000 persons in England and Wales 
were in receipt of Poor Law relief, compared with 1,286,000 on tho 
comparable date in 1927. 

Forty-five dental companies appear on the statutory list kept 
by the Dental Board. 

Mr. Chamberlain proposes to ask local authorities to furnish a 
return of the financial and other circumstances of the 31,667 
so-called unemployable blind persons in England and Wales. 

In answer to a question on March ISth, Mr. Chauberlatn 
said ho could not, without an alteration of the law, advise 
medical practitioners to notify suspicious cases of diphtheria with- 
out waiting for the results of bacteriological examination. 

In t!ie House of Lords, on March 20th, Lord Strathspey’s motion 
for the second reading of the Public Health (Destruction of- 
Vermin) Bill was postponed until March 27th. 




Sir Thomas Hosder, Bt., K.C.V.O., phs’sioian to St. Bartho- 
lomew’s Hospital, will open the Uuiversity Centre o[ Cardiac 
Kesearoh at Bristol General Hospital ou Eriday next, March’ 
30th, at 3.30 p.in. 

The annual meeting ot the Mental After-Care Association 
■will be held at the Clothworkers’ Hall, Mincing Lane, E.C.3, 
on Thursday, March 29th, at 3 p.tn., under the chairmanship 
of Alderman Sir Charles C. Wakeflold, Bt., president of the 
assosiatiou. 

'The President and Conuoil of tho Medical Women’s 
Federation have issued invitations to a dinner to be held 
in the Edward VII Booms, Hotel Victoria, London, on 
Thursday, May 10th, at 7.45 o’clock. 

The next social eveuius ot the Boyal Society ot Medicine 
•will be held on Monday, May 7th, at 5.30 p.m. At 9.15 p.m. 
Mr, P. B. Tnstiu will give an illustrated address entitled; 
“Milk — from COW' to consumer.’’ 

■ THE-snininer school ot tho British Social Hygiene Council 
will be held at Westminster College, Cambridge, irom^Jnly 
26tU to August 22nd. This year’s programme includes a 
course of six lectures by Mr. D. Ward Cutler on the applica- 
tions ot biology to human life, accompanied by practical work 
in tlie University zoological laboratory every afternoon. 
There will also be a course of four lectures by Professor A. E. 
Heath ou the foundations of psychology, and two lectures on 
the physiology of adole.scents by Professor Winifred Cullis' 
and Dr, I. Feldman. ’There will be five evening meetings, 
followed by discussions. Dr. H. Crichton Miller and 
Dr Letitia Fairfield will discuss the psychology of social 
abnormalities and the vocational training of juvenile deliu- 
(inents. Mr. B. B. 'Turner, Professor Winifred CnlHs, and 
Dr I ' Feldman will be tlie cliiet speakers ou the social 
uroble’ms ot adolescence and the need for recreation. Colonel 
I, w Harrison and Dr. Margaret Borke will open a dis- 
ciissio’n on the development ot tho social aspect ot the 
venereal disease treatment centre. Pro.'essor Julian Huxley 
will address a joint meeting on tlie ?volbtion of mind, 
and a fifth subject for consideration will he tho develop, 
nieut of tho social and educational activities of a branch. 
'Tiio school Is open to all interested in social jirobiems, 
and fall information can bo obtained from tho' socrelary 
of the British Social Hygiene Council, Carteret House, 
Westminster, S.W. 


and tlie programme includes a. reception by tlie Bologna' 
uiiiiiicipality, a dinner at tho local Fascist lie.adquarters 
(Casa del F.asoio), and an evening reception given by tlie 
intcrnatiouai Executive Committee. 'The Italian Association 
of Women Doctors, ivhich is holding its annual meeting during 
the same ivcek, wishes to convoy to the medical women of 
all countries a message of .welcome to Bologna. All parti- 
culars may bo obtained from the honorary secretary of the 
Medical Women’s International Association, Miss JIaitindalu, 
M.D., 28, Weymouth Siieet, London, W.l. . ■ - 

'The annual general meeting of the Cremation Society ot 
England will be lield at the Institute ot Hygiene, 28, Portland 
Place, W.l, on March 28 l1i, at 3.30 p.m. It is stated in the 
annual report of the council that daring the past year 3,266 
cromatioiis were performed at the sixteen ereniatoriuuis in 
Great-Brltain, as compared with 2,877 in the previous year. 
’The -society is iucreasiug in uiiinbers, and numerous public 
iiieeliiigs have heon iield in diilereut parts of the coiiulry.- 
Further information oboiit tlie society may be obtained from 
the secretary, 52, New Caveuilisb Street, W.l. 

. It is nnuoniiced that over fifty institutions have now taken 
advantage ot the educational lectni es for schools and colleges 
arranged by King Edward’s Hospital Fond for London. 'Ih'o 
London County Council has given peniiission for chiidioa 
from the central schools to attend Icctmes on the work of the 
hosnitals, and special slides, used in the course of toe lectures, 
wm he issued to the schools. Amoiig, the Jeoturers are 
Mr W MoAdam Ecclcs and Mr. Zachary Cojie. ■ 

■ 'The Section of Psychiatry ot the Boyal Society of Medibina; 

. liasarroDged for Thursday,' March 29th, at 8.15 p.m., a t.L- 
’busslou on the pathology of alcoholism, lu which members of 
thrMSiioal Section of thb Brioish Psyohologioal Sooio y have 
bcL invked to take part. ’The openers will be Dr. Bernard ■ 

been invite .p tbe’Seotiou ot Psychiatry), 

; , Orichcou Miller (for the 

British Psychological Society). • - ■ . 

Thp Fellowship of Medicine announces that the final week . 
of the Ses St -the- Hampstead 'General Uospita (4.30 to, 

R n m ) aud the Boyal National Orthopaedic Hospiia! (all day) 
6p.m.) au _ jrai-ch 26vh ; post-graduates may. .attend on 
commences - ,ee. On April 16(h a three weeks" 

payment o . I , , ^ ( Waterloo Hospital in luediciue, ■ 

“‘"■'"rv Sud nyt uecoogy occupying th.e atteri.eous and. 

surgeiy, and gynaeoo P.1 jj,ac)c(riar3 

Tn Cp. afin the afLOrnolns. On April 17th. the London, 
c i nofor Hygiene and Tropioal’Mediciue will start a mouth a 
School ot tiygiuuo lum p ,ii„e,,sc 3 on ’Tuesdays , and . 

mi‘'‘’''”lav8 '^'’ 011 ° April ISth Dr..C. B. Hcald will give the first-. 

• llai nractice and in hospital admimstiatiou lot 
of cUuical p j.uijQ health 'will he given at the North*, 
the ■“ Tot N.15, by Dr. 

f ‘TlfomS “edioal snporlntendent on Mondays and 
Wednesdays at ^LlTeto the oCi^e wldch 

commencing on ApiH li b Tbe fee f^ ,egulatioas 

chair. Atter lue joyu . „ MacArthur, D.S-U., 


March 24 ,' 1028 ] 


LETTERS, NOTES; AND: ANS'SVEBS. 


r , tueUritiss • ' ' fi09 " 

LITEDICAI. JoxrRNAfc uuv 


after referrin!> to tlio BritibU Emiiire as beiua llio brif^htest 
iewel in tlio Irish Qrotvn, couimontcd ou tliG-t aluable work of 
Irishmen ami hy the association in promoting co-operation 
hetweeuditTercntpartsot the Empire. Mrs. Claude llettington, 
who also replied, to this toast, delighted, tho audieuce with . 
a stream o( anecdotes suited, as site re'.narkcd, to a meeting 
■which might have been presumed to consist largely of medical 
students. The toast ot “ The President and tl>e Association ” | 
•was proposed by Dr. Bertram Watson, and in his leply Mr. 
G. AV. Dawson referred to the progress made during the titty i 
years ot its existence. Kougs were rendered by Miss Mary 
Sheridan, Mr. PairicU Hughes, audAVing Commander Tyrrell, 
and these contributed much to the pleasure ot an audience 
numbering move than one hundred. 

A PARTI' of torty^fivo medical students from Scotland 
arrived in "boudon on March 17th to devoto five days to 
a programme of domonstralioos, including operations, at 
various Loudon medical centres, among them being the 
Eoyal College of Surgeons, the leading hospitals, tlie lladinm 
Institute, and tho AVeilcome Historical Medical Museum. 
Tlve arrangements -were made hy tho National Hulou ot 
Students. 


Tub Loudon. School of Hygieh'e aud Tropical Medicine lias 
ordered from Messrs. K. aud'J. Beck, Ltd., more than two 
hundred microscopes for uso in the new laboratories now in 
course of coustrnctiou in Gower Street. The microscope is 
of British niaiiafacfure and embodie.s,ccrtain special features. 
The base is ot rigid construction , and . the foot combines the 
advantages of the horse.shce or Continental model witli the 
so-called English foou The stage is ot the completely built-in 
mecbauical type with travel ot IJ fu. -f liu., tiiccutire fop piate 
ot the singe forming the moving part. On tho stage a slide- 
lioJderof new design is ijrovhlcd., iu.wliich tho slide is firmly 
held .withpnt S()riug,s. ,Th'o line adjustment is of (lio double, 
lover pattern, operated by iniilod beads pu eitliorside. The 
body is 8 in. m diamotoraud is provided witli an adjustable 
graduated drawlube. The substage is actuated by rack and 
pitiioii, and ail substage appliances are carried 011 Akeliurst 
slinos; tbns the iuterohaugo of illuminating systems Is both 
easy and aoenrato. Tlio optical equipment is ample lor all 
bacteriologica! rrquiicmeiits, aud the objectives are to be 
'.coloured exfccrnallyso 'as th 'ciiablo fcliein to be recoguized at 
sigbt. Messrs. Beck liavo agreed tUiit cerlalu rigid tests 
sliall bo aiip.ied lo the whole equipment before delivery is 
Accepted* 


fepprt of file Joint Tuborculosis Council tor 1926 and 
iy<ii coiuaius a bnof aceoimt of the activities of (hat body 
siuce tljo issue of the last report luoro tbau feivo years ago. 
Ketereuco )s made to Ibo report of tbo committee on the 
employmentof liiberculou.spefsousis.sued in 1926; tho work 
coutmned, and a further report is promised in due 
, Proumliou ot post-graduate courses for tuber- 
cu osis workers remains ouo of the council’s main activities, 
Ims p.resented a report on dis- 
iH'!, Vn ifi’ercnlosis winch it is intended to embody later 
nnbi r special investigation is being carried 

hnnlonni/ic: ° “> 0 /fte of young oliildreii in tuberculous 

tn Mm prt couDcii lias decided that evidence be offered 

Govemui'enfr. 'A committee 
that- tn>. conned to consider this question concluded 

f esp nmno m ''^“‘“istialioii largo areas were best ; 
tbnettipr wfii “‘’equate salaries tor e.xperts, 

LiiV trai.m.p' ‘’'“SJnosis. tteatmentof patfents, 

iiu . ■ ' ■ Council 

d,( ■ ' . . Govern- 

and Dr.ArnoiflLyitloL’'®^”®' 
AvS-aXn?r“p“ Kensington AVomeu’i 

from the sem?tarv 12 Tehnr“i th“y obtained 

it gives details of the contoceot L request, 

at this centre. '-“'Juacepcivc methods recommendec 


AVM7coimmifor‘'th7mos^'eff7lt National Bi 

in 1927. has been .aw-ai-dpo ^ 


in 1927, lias been Awarded for ca™.P“’ 

tho Northampton Maternitv 

Association, afia therefore it 

ot that body. A special trnnh,^ ^ permanent keepi 

Health and Balfy Week CaSmutoe\v^^^^ 

and certificates of merit to Kelteri^p 
tary CoimiiittoG for Tnfnnf U-B.C. Ladies A"oIi 

Infant WolfarG Opnfvrt Kinj<ston*ou-Than 

A Sunderland County Boroui 

shield, reserved For snSlor areas ^ 

was lield under tlie chairinansldp 

roportod that thoro had b^Fn 7 con?Fipr.i“,p^°'‘''"®- ’ 

ciu uccu a considerable increase lu 


number of in-patients throughout 1927, and emergency accom- 
modation had to.bo provided. .The year ended with-a defleit- 
ot £1,076 and a building debt ,ot £281, Bunds are required 
for new buildings, incimliug a children’s ward and a nurses’ 
home,, whipli', will ireloasc . additional accommodation lor 
patients; In all £30,000 is needed for thoserand other develop- 
ments. In responso to an appetil made a year ago for 
£15,000 to enablo building to' ho started according to plans 
approved by King Ed ward’s Bund, £6,107 has been given or 
promised. The hospllai was opened in 1913, and altliongh 
contributions are asked fioin patients who can afford to pay, 
no patient, it is stated, lias ever been refu.sed, whatever his 
nationality or creed, solely on the ground that he could not 
pay a fee. ' ■ ' 

The Cambridge University' Press announce for early pub- 
lication a volume ol es.says and addresses by' the late AVilliam 
Bateson, P.R.S., edited, with a memoir, by' Mrs. Bateson ; 
and Common Principles in Psychology and Physiology, by 
Dr. J. T. MacCurdy. 

An internntional.pojt-gradnate course on modern therapy', 
with practical clinical work, will he held in Vienna from 
June 18th to 30Ih. Further information may' he obtained 
from the secretary ot . these conrscs, Dr. A. Kronleld, 
Pqrzellaugasse 22, A’lehna IX. 

At a recent meeting at Scheveuingen, which was attended 
by delegates from twenty-five countries, it was decided that 
the international congresses ot ophthalmology which had 
been interrupted by' tlio war should be resumed. Professor 
van der Hoeve was elected president aud Professor Lunds- 
gaard vice-presideut. Au e-vocutive committee was appointed, 

. consisting of Drs. Axeufelil (Germany), Mellor (Aristria), 
Coppez (Belginm), Byers (Canadaj, Marquez (Spain), Morax 
(France), and Ovio (Italy). 

e TuEluternatiouni Labour Office has published f lie December 
issue of Its bibliography Of Industrial Hygiene, whlcU.conlains 
recent papers on Jiygione in general, industrial medicine, 
physiology^ and pathology thronghout the world. Copies 
may be obtained from the International Labour Office, 12, 
Victoria Street, S.AV.l. 

Professor E. Kraus of A’ienna has recently been invited 
by tbe Kepublic.of La Plata to become the director of an 
experimental therapeutic institute. 


%ttUx5, anti ^itslucrs. 


All communications in regard to editorial business should bo 
addressed lo The EDtTOR', British Afecficaf' i/ourncti, British 
‘Medical Asseclatlon Housot Tavistock Square, W„C,1, 
ORIGINAL ARTICLES anil LETTERS forvfarded for publication 
are ’ understood, to be offered to tlis British Medical Jodrhal 
alone unless the contrary be slated.’ Correspondents who wish 
notice to be taken of their communications should authenticaio 
them with their names, not necessarily for* publication. 

Authors desiring REPRINTS of their articles published in the 
British Krdjwl Journal mast communicate with the Financial 
Secreta^ and Business' Srahager, ' British Medical Association 
House, Tavistock Square, ^Y,C.,1, on receipt of proofs. ' ‘ " 

All communications with reference to ADVERTISEMENTS, as well 
as orders for copies of the Journal, should bo aadressed to tho 
Fmancial Secrelarj- and Business Manager. . • ' - • 

The TBLEPHONE NUMBERS of tlio British -Medical Association 
and the British Medical Journal are dlUSEUil OSCi, 0SG2, SS6S. 
and OSGi (internal exchange, four lines)* 

TELEGRAPHIC ADDRESSES are • 

EDITOR of tbe British Medical Journal, AxtioUny yTcstccnt, 
Londoiu 

piWANr/>TAT BUSINESS MANAGER 

_ ^ ' Wesfeent, London. 

M ■ ‘ ^ra',' JTcstccnf, London. 

the Irislj Office of the British Medical Association is 
16, South Frederick Street, Dublin (lelegianis: Bacillus, Dublin', 
telephone : 4737 Dublin), and of tlic Scottish Office, 6 , Drumsheugli 
Gardens, Edinburgh (telegrams : Associate, Edinburnh', telephone : 
24361 Edinburgh). 


QUERIES AND ANSWERS. 


** Q.” asks for suggestions for the treatment of a case of 
. '** ninstiirbatlou ” in n male child, aged about 20 months, circnni* 
cised in infancy, and. with no local irritation present. 

Finish for Motor Car Bobir'S, 

An expert, to whom we have referred n query from a correspondent 
_j**. », * gtates that cellulose finish is with' 

to paint and varnish for motor car 
. fast' colour, rind ease of cleaning, 

but it is wof, ns ti i*u)c, suitable ’^ — ‘ which 

have raised mouldings, screwed tVith 

fiteelhoilies or ainmiuinm panels, . ' , , dlnlose 

I finish is usually move durable. 



634 March 14, 1928] 


tETTEES, NOTES, AND ANSWERS. 


Treatsiknt of Eysiphatio Ohstuuotion 

Col wy>.)- asks for advice as reganls tl.o 
'‘,'voman aged 70, with cotisiderable lymplmtic 
swelling (resemhiing elopliantiasis) in tlie snin-ainibic region 
anil also, to a less extent, of the left tbigb anrlTe^ Tbo'’con: 
ilition lias been progressive, in spite of treatment, for the Inst 

(lenuil°"for''wl?1'^ C>oro is proci- 

dentia, for wbicli a pessary was worn for many years bnt.lms 

now been aliandoned. The treatment lias been lotion^ oin^ 
™®™'>i’inls; iodex; radiant lieat; ir.ays 
o\eiy ton days; general, as for gout; collosol manganese; niid 


rest in bed. 


Cramp after SciATrcA. 


F. W. S.” writes in I'ejily to “K.” (March lOtb, p. 4301* This 
IS dne to rritation in the motor fibres of tlio groat Tciatic nerve 
leoplevho suffer from it generally have a subnormal tempera^ 
tme, and the effective remedy is heat. A warm bath on retirine 
t ie temperature of wliicb is gradually raised until it is as I 
the patient can bear, wit.'i plenty of covering on the bed n°tor! 
n aids, will generally ensure a comfortable night's rest. Radiant 
■ 11 ^"' n '■®'nrnl,and vapour liatlis are perhaps 

1 :^.®??. P.' “1 euconrage elimination. Finally, the patient’s , 


Britiss 

L filEDICAL JoCBMlS 


LETTERS, NOTES. ETC. 


Frecociocs Menstruation?. ^ 

' born fn Mav™ 192 oM®nS’''Srk^-"'-’ ‘''®. “ cl.il. 

montlily inte’ryals.’tberb.bas'beenT s’dgbt blood-stained Sfa 

■ .OMoKs F 5:iie first :p«'S 

.ucioucr JBth, 1317, sncccssive ones occnrnn*' abonf; thp cim, 

lime In November, December, and Jammry, The diBcImr^e wa' 

Tlfo cbn'd\R*beslM‘'™°'"'‘7 ‘o’.R’We t'laii a stain on tliecfoilies 

' aStTS. .t .„a i,.< 



months, and this did not cause any inconvouience or 
discomfort. It cured both sciatica and cramp, - - • 

Preserving the Sterility of nYPODERMio Syringes. 

Medical Superintendent, Friends’ Mission 
llospital, Itarsi, Centr.il Provinces, India, writes in answer to 

■iq27- l,"7i''i7Pni ‘ November 12th, 

"'•'’9b we have adopted and found 
sa.isfacloiw in tins hospital for the past two j-ears or so is ns 
follows. After luitia sterilization by boiling, the hypodermic 
syringes are placed in rectified or metlivlated spirit in n jar 
(previously sterilized), to winch is fitted a screw cap. Such jars 
are obtainable for a few pence. Tlio needles are placed in n 
suitable receptacle in petrol, wbicli wo find is a far better pre- 
servative than spirit, lysol, or cliloroform, which wo have also 
tried. A pmr of forceps are kept in lysol for lifting ont the 
syringes and fitting on tlio needles. Onr injection solutions are 
lilnoed in bottles, closed by small pieces of rubber, such ns old 
cycle tubing, wbicb is securely tied round the iieoks. In one 
bottle 18 kept sterile saline or distilled water, wbicli, before 
giving nil iiijectlon, is dr.iwn into tlio syringe in order to remove 
traces of spirit and |ietrol. After tlie injection the syringe is 
replaced in the spirit jar ivitboiit dissembling and the needles in 
the petrol, wlieyo they remain till next required. Wo Iiave found 
this method quite reliable, and on the few occasions when there 
has been slight sepsis follon’ing injection we liavo traced it to a 
contaminated injection solution. We have employed Bi’ringes 
and needles straight ont of these preservative solutions for intra- 
venous injection without disaster. After use for intravenous 
injection it is onr rule to resterilize the syringe by boiling, in 
order to avoid all risk of transmission of svpliiiis or other 
infection. We rely on spirit for cleaning the rubber caps of the 
injection bottles. We usually add small quantities of some anti- 
septic, snob as one-half per cent, phenol or saliovlic acid, to onr 
injection solutions or tlie distilled water, with the object of 
dealing with any infection which might be carried into the 
bottles on the insertion of tlie needles throiigli the rubber caps. 
These methods have proved quite satisfactory, and we must have 
given some tlionsauds of injections since we established the 
system 


Income Tax. 

Allowunce after Marriage. 

“ J. K.,” who was married on March 14th, asks what personal 
allowance he can claim for the year ending April 5th. 

, *,* Under Schedule 18 of the Finance Act, 1920, the married 

allowance of £225— in lien of the single allowance of £135—13 due 
it the claimant “ has his wife living with him for the year of 
assessment.” The Act does not stipulate that it shall be for 
the whole of the year of assessment, and we understand that in 
snoh ciroumstances ns those of “ J. K.” the full allowance would 
be granted tor 1927-28. He should therefore communicate with 
:the local inspector of taxes asking for the statutory form of 
declaration for relief as a married man, and suggesting that the 
full relief should be credited to the payment due from him on 
July Ist ne.xt. 

Beplaeement of Car. 

" Satus ” bought n two-seater car in 1901 for £500, and has now 
replaced it by a four-seater car costing £295, less £35 nllowauce 
for the old car— that is, £250 net. Depreciation has not been 
claimed. 

lie should claim the amount actually expeiided-that is, 
£260. In view of the cost of the former car and the fact that no 
allowance can be claimed on this transaction for the balance of 
the loss incurred, it is thought that the authorities would not 
press the fact that the new car provides more accommodation. 
It is, however, arguable from the Iteveiiiio side that the £2G0 
Riiould be reduced by the difference, as regards the new make of 
car, between the two-seater and four-seater models. 


7, 7 — , , , iwtci uiiiuu commeiiceii to pass 

from the vagina Olid continued until December 12tli.- Tlie-vnlva 
was congested and the vagina was filled with achocolate-coloured 
nisciini^’c I tne brensts were purple and swollen, and a liard area 
Burroiindcfl tlie nipples. A drop of fluid resemblin'' colostrum 
was casilj expressed. With the cessation of the flow the breasts, 
beciimo nornial. The discharge wiis examined mrcroscopfcal/y 
on the sixtli day, when the red cells were found to be diminished 
'find the swab showed cliiefly polymorphonuclear cells, with 
‘mucus and epithelial debris. Dr. Noble was assured that tliere 
'bad been no interference witlr the nipples. During, the snbse-* 
:Qiient seven weelcs Llicre was no fiirtbpr sign of ovarian- activity . 
or disease. 

Gas Gangrene following a Hoad Accident. 

Dr. W. B. Burke (honorary surgeon, Victoria Hospital, Worlfsop). 
writes: Tlie reports of two similar cases of gas gangrene in the 
British Medical Journal of December 24th, 1927 (pp, IISJ and 
1184j, suggest that the following notes may be of interest: 

A married women, aged 30 and apparoutlj' in perfect health, was 
admitted to the Victoria Hospital on May 30th. 1927, and placed under, 
jny care. In a motor cycle accident the pillion foot rest was driven 
into the right foot, causing a wound 3 or 4 inches long on the inner 
border of the sole of the foot; three sutures to stop haerdorrhage bad 
been inserted bcfoio admission. On examination under anaesthesia 
the bead of the first metacarpal was found to be fractured. The 
wound was thoroughly cleaned; it was not particularly dirty. Bipp 
was rubbed in and sutures were inserted. On the next day much thin, 
ovil-smellinS discharge came from the wound, and bullae, containing 
dark fluid, wore present near it. The leg was swollen and ©edematous 
to within a few inches below the knee, and presented patches of 
brownish-red discoloration to the same level. The smell suggested 
gas gangrene, and amputation above the knee was contemplated. 
Tbero were no constitutional symptoms. Under an anaesthetic it was 
found that all muscles of the calf, except the soleus, had undergone 
softening, having degenerated into brown pulpy masses containing gas. 
Amputation through the middle third of the thigh was iierfonned; 
the muscles and other tissues at the level of the amputation seemed 
perfectly healthy. On June 2Dd the stump seemed healthy in all 
respects, but t'jwards evening constitutional symptoms developed and 
the temperature rose. The brownish-rod discolor ition reappeared in 
the fltump on the next day, toxaemia was well established and became . 
progressively more severe. The gangrene spread up towards the iliao 
region, and the patient died on June 6th. 

Tndffiu" by the two cases in the Journal, and from investigation 
nf the literature on the subject, I can only conclude tliat tins 
case would have yielded to serum therapy, but as such cases are 
few and far between iu general practice, it is a matter of live 
'and learn. 

A Coincidence. 

niPTAiN H. WibLiAMSON, I.M.S. (Quetta, Iiidial, writes ; Iu view 
^ nt its uossible medico-legal interest the following case seems 
worlliyot publicntioii. Asliort while agoachil<l,aje<l IS moiitlis, 
was hronfiht to me with a iiaevus at the inner cantliiis of the left 
nvn I tohl the mother to hriiiy the child to hospital on the 
fnllowhiK Wednesday, when I would remove the naeviis. 
not brill” the dhild on the Wednesday, so the naevns 'vas not 
tonched,''hnt on the following Saturday the child was adinitted 
onfferin” from a sadden and fulminating attack of nieniiioitis, 
Jmiif which it died twelve hours later. The diagnosis vM 
Joufirmed post mortem. Had I removed the iiaevns I coiildi^ 
have avoided the conolosion that meningitis, ocoiirrnife thi 
days later, was the result of infection from the operation. 


Vacancies. 


and looumtenenoies at pages 44 and 4o. _ ,;.„wis6meat 

A short summary of vacant posts notified in the a 
columns appears in the Supplement at page lUJ. 



TREATMENT OF CANCER OF THE CERVIX. 


[ Tnr. BPiTTfE A OK 

MzOICjU. wOU 


MARCH 3I> ^9=^1 


iltinavha 

0^ 

ADVANCES IE THE TREATMENT OF OANCEE 
OF THE CERTIX HTERE- 


HERBEKT R. BPl^XCER, M.D,, 
coysE'LT/.VG ossTrrszc puvszciak to ustivkusitv college hospitai,.- 


It wns 11 -ith .some dilBilejicp tiiat I accepted the inritation 
to oijcn a discussion on advances in ' the troatnient of 
eaucor of the cen-ix/ for the reason that, since I retired 
from practice, just a year ago, my per-sonal advance has 
been in the temporal rather tlian the gynaecological direc- 
tion. Bnt 'tis a pleasant thing, says I.ncrctiiis,t to natch 
onr colloagncs toiling, especially vhen they arc at sea, and 
os loohers-on provcrhially see most of the game, having 
played the game for forty years, perhaps 1 may bo able 
to point ont some adv.anccs ivhieh have been made, some 
advances ivhieh need making, and some methods of inquiry 
nhidi give a false impression of the fact, the degree, and 
the direction of advance. 

In this last connexion I nonld emphasize the futility 
of -placing any reliance upon' statistical inquiries based 
n]ion insufHciont d.ata, nith nliielj the litcJ’nture of the 
snhject abounds.' These statistics purport to give the 
“ absolute cure ” rate of ra'rious methods of treatment in 
figures carried to two places of decimals, and if, like a 
telcbiated Chancellor of the Exchequer, vou inquire the 
meauing of those " dn-mned dots," you will usually find 
that neither they nor the integers have any value, and 
that the " absolute cuvo " rate thus expressed is absolute 
cant. To ascertain the absolute cure ” rate — that is, 
the proportion of patients cured (after, say, five years) to 
patients seen — is a difficult matter on account of the large 
numbers concerned, the nnnt of, conipulsorv notification of 
cancer, and the absence of particulars of the treatment 
"fr IS certificates' of patibnts who hare been 

a oe od nitli cancer; bnt it may be done for .snmll numbers 
without much difficiiltyr-and- I' ap|)cal to the voiinger 
griiaeco ogists to foljow up, for , ,a . period of five or ten 
j hi^st ten .or twenty cases been, and give full 

n 1 Ti* ^ '® wi^TOSc'opic' nppe'ai nnces of the cases 

and the final results; thus -figures will be aiailahle for 
HKsle.ading st.atistics of the present dav. I 
romnli^nl'f ^ Cases of caiicer of tlie cervix 

rieiicp pregnancy, of which' the whole of mv expe- 

iieiice has been given.' ' 

case shoidd^ is' very important that no 

oXamitT ^Hcer' unless it has been 

pathoioo-y The°nw'^f •' gynaecological 

a omirter nf ^ "t Sheiety of Iioiidoii, more than 

mittep +n ■ "i ®®l‘''^lished a jiathologv com- 

t" function T''’ “"d t"'-" cohtin.ies 

of the Roval ttp '"c Obstetrics and Gynaecology 

pccii tWs"' '■ f ••>"<3 «, so far as I know, 

hhmlish “an; 

study of tile pdtMo^ orcanct'orth 
mens accepted hv tb?t «.! oaneer of the cernx, and .speci- 
oxamples U relied upon as true 

case is cancer witiindt * niere statement that a 
such coiiyicw ®-'^.a-a-n.-,tion,..cnrries with it no 

adyaJ:^^ in e-mmcolfet .’’r'T Paportance of tliis 
resemblo caimer of tlm coidi'v vyrtain conditions closely 
hy those who hayo an ' bx',,! / ^^‘^^nosed 

I may mention a few of tbi^f Jc'mu'ledgo of ^naecoJogj-. 
loiim. adenoma, miic-oiis T"-’ Papil- 

sypliilitic and tiibei'ciiloi.s „lcl!f’ “'■■■■ading ulcer, 

oiio-cai-cinoma adenomntnr W epitholioma ; and 

which even microscopic 'cx4rin f'aJ'ffaarai-in 


March a, i," 


^ mayno (nrh.inlil,nt 

^recla, 


Society of London oi 


o'yiijorft ventls, 


^on nuU vtaari’ faborrm^ 

Setl, qn,b„s 'TDluptaR 

QUJti cern*art> snnv< 


cateas. ouia cernere suave est.*' 


of the paucity of cases which have been published, I cannot 
help feeling that among the long lists of cases of “ cancer ” 
operated on some may have owed their non-recurrence to 
their iion-malignant nature. 

Another direction in which advance is needed is in the 
early recognition of the cases, in advocacy of which I 
read a paper' at the meeting of the British Aledical Asso- 
ciation in 1007. I am hopeful that some benefit lias 
resulted from that paper, and the diseiission to which it 
gave rise, at .all events in getting the doctors to examine 
their cases, though I am doubtful whether further -measures 
are not needed for bringing the import.ance of early treat- 
ment before the public. I have found the visits of patients 
to the clinic on the anniversaries of their operation to bo 
a valuable means of bringing the subject before hospital 
patients. 

Pjrevextive Tbeataiext or CAXcnn. 

In the absence of knowledge of the e.ssential nature ol 
the disease the preventive treatment of cancer of the cervix 
is difficult. It is known that cancer of the cervix is almost 
limited to patients who have practised sexual intercotii.sc, 
and mostly occurs in those who have had one or many 
pregnancies. Analogy with experimental cancer leads us 
to suspect the irritation of lacerated and inflamed tissues 
a.s li.kely to lead to cancer, and they have been known to 
be followed by tlie disease. Treatment of those source^ 
of irritation is indicated, and, in relieliioiis cases^ rcinoval 
of the cervix is called for. 

One great advance in the prevention of cancer has been 
obtained by the substitution — for exmmiilo, in cases of 
inyoma— of total hystereotoinr for the .subtotal operation, 
thus ar-oiding cancer of the cervical stump, which lias caused 
the death of several lnmdieds of women. It is a discredit 
to gynaecologists that these deaths should occur. 1 am 
glad to xay that I abandoned the subtotal operation twenty- 
eight years ago; it would gratify wo more than the hast 
line of the quotation from Jm'cretiiis if mv collon<vue.s 
would do the same. * ” 


r will now consider Gie advances which have been made 
in the treatment of cancer of the cervix. 

Omitting a few iiessimists, to whom I have alluded in 
the paper mentioned,- it- will be generally adiiiittcd that 
remarkable progress has been m.ade during the htitidrecl 
years that linre passed since Bliiiideil removed a c.aiiccroiis 
utei*us in X828;* -tliis avas flic fir.st timn that the cancerous 
uterus was .successfully i*enioved in this countrv.-j- 
James Blundell, obstetric physician to Giiy’s Hospital 
m 1823 avrote a valuable paper on “ Ilesearche.s' plia-siol 
logical.aiid pathological,” -which was not considered irortba- 
of piibhcation by the Medical and Cliiriirgical Society. 
The aiillior published the paper pria ntelv in 1825 ■ the 
wpy of that paper in the libraiv of the Boval Collego of 
Surgeons contains some manuscript notes by' Bhmdell con- 
cerning the case of c.aneef of the cervix, and the specimen 
--presen-ed in the musenm of the Boval College of Pbvsi- 
cians— I am .able, through the conrtesv of the curators 
to sliow you. * 

The eiperiments on animals performed hv Blundell bad 
an nnpD.-ta.it influence in the development of abdominal 
sw ion, and Ins case of vaginal hysterectomy for raiicci- 
of the cervix enlarged the- field bt operative trcatiiie.it, 
winch until rcMiit times; wa.s tl.'e -sole meins ol.ciiro at 
oiii dispos.al. Hopele.s.s inde'cd had' iVedn the outlook for 
p.atienfs froni the earlibst times of width we have record^.. 
the Anglo-Saxon lecbli (aboiit' A.h. 000) treated cancer 
- ’IS of a hound’s head to the wound; 

If -it -ivill not yield to that take a 'niin.’s dung, drv it, 
thoroughly mb to dust, apply it. If with this tlioii art not 
to c-ure him tlioti maA'cst jjerei* do 'Jt by /iijv 

late as 1791 Lmvdcr wrote of caiic-or'of the uterus, 
11ns ts a disease so incurable that physicians give it up.”-* 
riuit gi-naecologists of the twentieth century are more 
hopeful is sliown by the many rosea rc-lios in wld’eli they are 
engaged, of which I need only mention that of Tliies'oii 
rimnuni zation hy canccr-albnmiii .and iiniflantatioii of 

*Tjje poUent .sunivctl Ihe opt;rntion ncarlr a vrar r,.. f„i 

-oefouVaTc5i.^^;i,^a™U,ri;''Xv 

t Sautor of Constance, in 1822. w-is fim /ird r a. 

Bucccasfulb'. " ^ ^ rerfomi <lic opcralion 


f35oSJ 



636 March 31, .1933] 


•TREATMENT OF CANCER OP THE CERVIX. 


L Mr piciL Jousstf 


cancer ; -nxid of -Blair- Boll on tlio. treatment of tlie disea-se liy 
leadj Av'liich Jio brought before this Society' in 1026:' it is 
too' soon to iiroiibiincb an opinion oh the 'valiio of this 
treatment, but its dangers have been jSointed o'ut by. its 
originator. For the present, at any rate, the treatment of 
cancer of the cervix resolves itself into removal of tho 
growth by operation or by radiation. 

OrOTATivR Tbe.\taif.xt. 

Passing over tho destruction of tho growth by caustics or 
cautery and the simple removal of tho ccrvi.x (first carried 
out by Osinndci'’ in ISOl), tho opei'atii'o treatment may be 
divided into high amputation of tho cervix and vaginal 
and abdominal hj'stercctomy. 

1. Jlit/h Amputation 0 ] the Cervix. 

High amputation of tho cervix, preferably by tho electric 
caulory introduced by Byrne, is an excellent treatment 
ior early cases, especiallj' in elderly patients; it is free 
from risk and jrermits the continuance' and tho subsequent 
occui’ienco of jnognancj-,' in which respects it is superior 
to atry form of hysterectomy. Iir jratients operated on 
before the menopause it is sometimes follorred by stenosis 
and dysnienorrhoea uirtil the menopauso occurs ; yet even 
these patients have better general health than thoso 
who have been deprived of uterus and ovaries. I have 
rvatched such a patient for twontj’-five years after tho 
aminitation, during which she has been able to fulfil her 
conjugal duties without trouble; in this respect njso high 
amputation is superior to any kind of extended b 3 -ster- 
cctoiny. It is the fashion to neglect tliis o|)or,ation ; but, 

in tho case of an oarh- cancer in an olderh" subject, it is, , 

in mj' opinion, the best means of operative treatment at 1 gjnnds can free themselves from cancer, especiall3' with the 
our disposal. 1 ...•a «« Ar.-mv imtipntB. Jiowever. have remained 

2. Vaginal Hysterectomy . 

. (a) Simple vaginal h 3 -stcrcctom 3 ’ was first successfully 
performed in this counti'y b 3 ' James Blundell on Fcbruar 3 ’' 

12th, 1828. Various aro the methods of carrying it out. 

Tho use of tho canteiy, which I have constantl 3 ’ employed, 
has, I think, some advantages in lessening the haemorrhage 
at the operation and tho fi’equency of recurrence of tho 
growth. Tho whole operation is carried out with tho 
cautery; but it is generally necessaiy to tie tho uterine 
arteries and tho broad ligaments. The vaginal operation 
has a very low rate of immediate mortality, and it has the 
advantages over the extended operation that it docs not 
interfere with marital intercourse, nor, like the abdominal 
operation, give rise to scar-hernias. The minimal risk of 
tho oi^eration renders it of great value in enfeebled or aged 
jmtionts. TJie supei’iority of tbe recovery oi'cr that after 
abdominal hysterectomy’ is so marked that it is surprising that 
there exist g.vnaecologists who never perform the operation. 

(6) Extended vaginal hysterectomy consists in a more 
extensive removal of tho tissues with tho help of pai’a- 
vagina! incisions, unilateral or bilateral, which facilitate 
the isolation of tho ureters and very free removal of tho 
cellular tissue. The oiieration, carried out with var 3 ’ing 
technique by Schauta, Thaler, Peham, StSckel, and others, 
has a higher niortalit 3 ' rate than the simple operation, but it 
has been reduced to 2.7 per cent, by Peham, who claims an 
“ absolute cure” rate of 31.13 per cent., against 27.9 per 
cent, for the extended abdominal operation.’ This is a voi’ 3 ’ 
jcmarkabie result, and is pi'obably duo to the lower mor- 
tality of the vaginal operation; for all vaginal operations 
have the disadvantage that the removal of many glands is 
impossible. The removal of all the pelvic glands is, of 
course, impossible by any operation, and it may bo that the 
extensive removal of glands and cellular tissue has other 
disadvantages than that of increasing the risk of the 
operation. 

The remarkable results obtained by the extended vaginal 
operation have somewhat withdrawn the attention of gynae- 
cologists from the abdominal operation, in which the chief 
ndvantaee lies in permitting the removal of infected glands. 

The extended vaginal h 3 ’sterectoniy, like the extended 
abdominal operation, interferes with marital intercourse. 

In all kinds of vaginal hysterectomy it is important that 
tho peritoneum sliould be carefully closed; gauze introduced 
into tho peritoneum for drainage sometimes gives rise later 
on to intestinal oisti-uction produced by intestinal adhesions 
set up by the gauze. 


3. Abdominal Hysterectomy. 

(a) Simple, .abdominal', bystefectbmy is -useful in cas( 
whore there .aj’e complications . (uterine fibroids tunioui 
of tho appendages) and whore the weakness or advance 
Rgo_ of tho patient renders tho extended operation in 
advisable. It jicrmits more careful closing of the peri 
tonoum than tho vaginal operation, is less likely to b 
followed by obstruction, and has a lower rate of mortalit 
than tho extended operation. 

(h) Extended abdominal jiysteroctomy, which will alway 
ho- iissociafccl iritli tho iiaiiw of Wertheiin. of Vienna, wa; 
proposed by him as a more surgical operation than Hic 
vagina] procodnre, in that it iierniits the wide removal of 
tho tissues and of the peivic glanclk Tiio chief drawbacks 
to tho operation aro its liigh mortality, its late sequelae 
(fistulao and urinaiy infection), and the interference with 
marital ' intercourse ivhicli it entails. ' Although the 
mortality rate has been lowered by the emplo 3 'inent of 
gauze drainage,* I have not seen any statistics showing tho 
frequency with which drainage is followed by hernia of the 
scar and intestinal obstrncticn. The cmplo 3 ’ment of drain- 
age docs aw.a 3 ’ with tbe complete closuie of the iieri- 
toneum, nbicb is one of tbe advantages of operating by the 
abdomen, and favours tbe occurreiice of Jiernia of tbe scar, 
tbo prevention of wliicb is one of tbe advantages of 
operating by tbe vagina. 

With regard to the removal of glands it is to be homo 
in mind that in about two-thirds of the patients operated 
on tho glands are not cancerous, that the removal of 
glands (necessarily incomplete) increases tbe danger of the 
operation, arid that it appeal’s probable that cancerous 
glands can free themselves from cancer, especially with the 
aid of radiation. Many patients, however, have remained 
fi’ce from lecurrcnce for as long as ten years after the 
removal of e.ancorous glands, which is a triumphant result 
of the extended abdominal operation. 

4 Combined Abdominal and Vaginal Hysterectomy. 
Combined methods of operating (abdomino-vaginal or 
rawino-abdominnll-havo some advantages in lessening the 
exposure of tho peritoneum and the danger of infection. 

5. Jladialion Treatment. 

Great indeed has been tho advance in the treatment of 
cancer of the cervix since the employment of radium, 
mesothorium, and Roentgen rays. As my experience of 
this treatment only dates back about a dozen years, and my 
coliea'vue is dealing with tbe subject, I will merely state 
that in my opinion it is the most important advance ot 
all Its curative effects aro incontestable, and it is espe- 
cially valuable in the treatment of cancer complicating 

piCoUai c) Co.xcnusioN. 

In conclusion, I wish to state my 'opinion that the 
ii-fl-itment of cancer of tbe cervix should be eclectic and 
that no one treatment is suitable for all cases. During 
tbo past century a great advance has been made, so that 
to-dav about two-fifths of the “ operable ’ cases can be 
This proportion might be doubled if the cases came 
for treatment at an early stage of the disease. The 
trroat desideratum is to get the cases early; th^’_ may then 
iL treated by one of the methods mentioned. Of these the 
most hooeful for the future is the treatment by r.-idiation, ■ 
tTe teolmique and dosage of which merit, the intens.ve- 
studv of British gynaecologists, which I am sure will be 
advanced by tbe contribution of our Belgian colleague, • 

Max Cheval. Kcrmcs’cm. 

lit -R <?TiAncer* Lettsomian Lectures, and Tiwinurj Com-pUcaling Vrtg- 

nanci^ -irp^snres to be Kecomroended to Secure the Earlier Rcco,«' 

2 Idem : Cancer, 'Britith ’Medical Journal^ 1907, li, pp. 'iSl, 

A Payne's FitzPatrick Lectures. 1903, p. 

* H”R**'spen«r - UistoTy of BritUU Midwifery from 1C50 to ISOO, 1927,?. 125. 

moo. p. ® 

Vitania . A c . y „„„„ Comvticalino Vteonondj, Latour, and t! 

’ di Paris%Z?i y. 702; -ml Berkeley. 


from ■' about 20 per cent." to 2.6 per cent.. 


637 


MkucK 31, 1928] eadxation treatment 6 e cancer of the cervix. [ SIepicu. JocByA£ 


. TEEiTMENT OE CANGEE OE THE CEEYIX 
GTERI BY IERABIATION;'- 

BY 

AfAX cheval, M.D., 

BRUSSELS. ■ 

'Action of Irradiation on the General Condition, 

Is their - recent works Professor Slosse nncl Dr. Reding of 
Brussels have demonstrated tlio action of the x and gamma 
rays on the organism. 

For that purpose the patient drinks a solution of dextrose 
(SO grains of pure anhydrous doxtroso in 200 c.cm. of 
distilled water). The authors detect the quantity of 
sugar in the blood hy Hagedorn and Jensen’s method. 
-They found that the glycohaemia is more intense and 
has a longer duration in patients with malignant 
■tumours than in the others. 

; These authors have shown also that cancer patients have 
a pH above the normal. AVlien these patients are cured 
■by a: surgical operation this state may persist for years. 
On the other hand, if they are treated and “ cured ” hy 
irradiation these symptoms disappear. 

Having no personal ■ experience of the utilization 
of X rays I shall not ■. speak of them, but will only 
Indicate the improvements which seem to result from our 
practice in the treatment of patients by radium. To 
explain these improvements it seems useful to indicate 
precisely the technique which we have utilized since 1919. 


Technique of Citric Therapy. 

In 1919 wo utilized the utero-vaginal method of Professor 
Epgaud, which consists in placing a certain number of 
tubes, suitably filtered, in all the length of the uterine 
cavity, and more tubes, also suitably filtered, in the 
vaginal culs-de-sao. Very early (1920) we gave up using 
needles with a weak filtration (1/2 mm. of platinum), as 
■their action was too caustic, and consequently too local 
p cm.-in distance). Wo have, given the prcforenco to 
tubes filtered by 1^ mm. of platinum, plus aluminium 
1/10 mm., plus rubber, plus gauze or cork. The distant 
action IS greater and extends to a zone of 3 cm. around 
each tube. 

Hnfortunately the cervical canal is not always reparable, 
and we ha-re had cases in which recurrence has taken place, 
™ cavity being the point of origin, 

n the cases in which tubes could not be placed within the 
uterus we have, a month or two afterwards, made a vaginal 
ap'p ication of radium. AVo have since 1922 performed sub- 
0 al uysterMtoniies by the abdominal route — the ceiwix is 
t,enora y difficult to remove — followed by implantation of 
nee es in the cervical stump, our motive being to destroy 
the malignant cells, which are too distant from the vaginal 
tubes : here the local action only is aimed at. 
von ^ found that some of our patients presented recur- 
wn ’^‘^‘§l'''''brhood of the parametrium, in 1922 

■n.,. radium drainage method of Professor Daels. 

radium may be placed outside the 
the .V.,- uoighbourhood of the external portion of 
oneM+rvn ^ f Practised this without any 

c^ses Iiad a certain number of suc- 

- Since methods combined up to 1926, 

Good fesnltc Rogaiid having drami attention to the 

foimdk^ance of radium placed at a 

inc °4 o-rmic Af ° oonstructed an apparatus contain- 

We onl-A lice element or 7* grams of the bromide, 

allows fs tc icl O"'’ apparatui 

as is done 1 V +f P^f'eiits at a time in large fields, 

hTadiMcd ••rf ® "-ho'® of *<= small pelvis i 

4o~ d ’ iofonsity, and, in spite of tin 

nor shnctpd°^^Tj. Patient is neither rendered anaemic 
this metbnd n'u bre to speak of the results whicl 

combSc if , and to say whether it is useful tc 

wo have n t h the local applications or with surgery 

^Lultf Thl-if '“S fo be able to dfscSi 

\To liavG only giren n. r 


o - persons 

^ blit vr e shall appeal to a larg 

London ^ f^iscussion tit the Medical Society 


, -***'-* triui o 1 

statistic ending in 1924; 


number of avithors ' of different countries to demonstrate 
that radium effects a cure in more than one-half 'of the 
operable cases ; that in the cases on the limit of operability 
at least one-third are cured ; and in inoperable cases 10 to 
20 per cent, of the cases are cured. 

Conclusions. 

1. Irradiation seems to effect cures of a better quality 
than surgeiy. 

2. Of all cases treated by radiation 30 per cent, are 
definitely cured; 

3. An improvement of this percentage should bo obtained 
by the new methods, using largo amounts of radium placed 
at a distance. 


^it ^ttbrfss 

ON 

THE CLXNICAE STUDY OF PAIN; 

"With Special Reference to the Pains of Visceral 
Disease.* 

BV 

JOHN A. BYI/E, M.D., F.R.C.P., 

■ ASSISTANT PHYSICIAN TO GUY^S HOSPITAL, 

** Every pain has its distinct and pregnant signification,- if 

XTQ Trill but carefully search for it.** — John Hilton. 

Of all tho symptoms for which wg are consulted pain, • in 
one form or another, is the most frequent and frequently 
the most urgent. Properly assessed it stands pre-eminent 
among the sensory phenomena of disoaso as a guido to 
diagnosis. And yet it must bo confessed that our under- 
standing of its nature and mcohanisms, and consequently 
of its full significance in practice, remains - peculiarly 
limited. We are naturally dissatisfied with invisible and 
imponderable evidence, and it is therefore no matter for 
surprise that recent years have witnessed the introduction 
into medicine of a host of objective methods of studying 
disease, and that the study of subjective symptoms has 
suffered some contemporary neglect. Tlio opaque meal and 
enema; pyelography; cholecystography; the electro-cardio- 
graph; methods of blood analysis; tho various chemical 
tests for gastric, hepatic, pancreatic, and renal efficiency; 
bronchoscopy; lumbar puncture and its developments; and 
the exploratoi-y operation — all these, following in tho trail 
of the stethoscope and the ophthalmoscope and older routine 
methods of physical examination, bear witness to our zest 
for objective information. It is, however, chastening to 
remind ourselves that, notwithstanding all tho help derived 
from a judicial employment of them, these- methods too 
have their limitations, and none of them is infallible. They 
are chielly useful in proving or disproving tho existence 
of established organic disease; in increasing tho accuracy 
of a clinical opinion; and in serving to differentiate one 
form of organic disease from another. They have greatly 
helped in decisions for or against operative intervention. 
They have undoubtedly exerted an instructive and a correc- 
tive influence. In some degree — although, to my mind, by 
no means so much as they might have done — they have 
even enhanced our appreciation -of siibjectivo svniptoms. 
But their contributions to tho early diagnosis of organio 
disease and to tho study of functional disorders are neces- 
sarily restricted, and it is clear that without tho initial 
indication of certain symptoms they could never bo ration- 
ally employed. Moreover, their aid can rarely ho invoked 
in urgent problems dr in the homes of the people. Tliero 
is a very real danger that hy over-reliance on them, hy 
too great an hnxicty to give our patients tho benefit of 
modem investigations, and hy a waning confidence in our 
own clinical ability, wo may conic to lose the astuteness 
and wisdom of our forebears. 

In medical education tho introduction of these methods 
has not been an unqualified blessing, and the training of 
car and eye and hand and tho development of the power 
of inductive reasoning have suffered much. Every ye.ar 
I see a number of mistakes made tlirongh inappropriate, 

* Delivered before tho NcTrca5l!c*unoii*Tyno and Korthem Counlie# 
Medical Society on February 2nd, 1923. 



638 March 31, -1928] 


CI/INICAti STUDY Op' pAIN. 


t TiiB British ' 
ilEDICAr. JOCRXAI, 




uniiccessaiy, or excessive investigation. Not infrequently 
-I liave myself fallen into error for similar reasonsj anti not 
■infrcqnentlj- 1 have extricated mjself from error by a 
,TOtm-n to fiist ]nincij)les, by taking tlio liistory of the case 
again, or by making a moi o careful analysis of the patient’s 
sensations — Nature’s earliest signals of morbidity. It will 
be readily agreed that many of' tho best diagnoses and 
judgements are achieved with the unaided senses backed 
by experience. It will also bo agreed that no course of 
action can train these senses unless it includes expcrienco 
jjatiently garnered at the bedside and' in tho consulting 
room. ■ ■ • ■ ■ 

If I were asked how tho next considerablo advance is to 
bo so'ught and won in tbo field of medicine I should say 
(with grateful acknowledgements to tho influence of Sir 
James Blackenr.ie) by the intimate study of tho physiology 
of- symptoms, and (olico luoro acknowledging our debt to 
other great pioneers in this field — notably John Hilton and 
Sir Heniy Head) I would submit that, our first concern 
xhould be a more extended and intimate study of pain. 

This brings me to a . consideration of method. Now 
icscareh into subjective phenomena does not commend itself 
to the laboratory worker, and caiiiiot easily be pursued in 
the experimental animal. It is presumably for this reason 
that even .the more .recent textbooks of physiology are 
extraordinai'ily reticent on tho subject of all c.xcepting tho 
superficial pains, and that-tlic scanty references wliich they 
■hiako to viscetal pain arc often misleading: ‘ (Thus' they 
nearly all declare that visceral pain is very inaccurately 
'located, and devote mole discussion to the occasional 
sympathetic or somatic than to the far more frequent 
visceral sensations.) Exporiments on the healthy human 
.subject, .such as those conducted by Hurst and his col- 
-laborators in tho coureo of their work on the sensibility 
nf the alimentary canal, are of necessity limited, and no 
anronnt of ingenuity can quite reproduce the experiments 
in disturbed sensation with which Nature herself provides 
■us in our own bodies or those of our patients. Tho study 
of pain must therefore continue to devolve mainly rqion 
the clinicians. 

I wish that time would pei-mit mo to refer to the 
nierthod and the cl-assical contributions of tho pioneers whoso 
names 1 have mentioned, and to the valnablo eommunica- 
tioiis of others, including Boss, Hnrst, and Cope in this 
country, and of Lcnnander, Rudolf Schmidt, and others 
abroad. For my present purpose lot it suffice to recall 
that, whatever the individual trend of tlieso investigators 
may hare been — whether anatomical, physiological, surgical, 
or neurological — ^tho ba.sis of all their researches was clinical 
observation. 

Partly because the immensity of the srdjject compels 
selective treatment, p.artly because visceral paiii.9 have 
especially interested me in my work as a general physician, 
and partly becanse tliey seem to me to have suffered neglect 
in compai'isoiT, for instance, with the pains of -nervous 
disease, I have chosen to confine my attention in this 
paper to the subject of pain expressing visceral disease. 
My remarks will fall into three sections. In the first I shall 
endeavour to summarize the present state of onr knowledge 
of the physiology of jmins affecting the hollow organs. In 
the second I shall outline a simple system for the clinical 
analysis of sucii pains — a system which really embodies 
nothing new, and which is in largo measure applicable to 
the study of otlier pain.s. In the third I shall consider, 
with examples, the practical applications of pain analyses, 
for, after all, tlie chief interest to the practising part of 
onr profession of ail siicJi studies is their bearing upon the 
advancement of diagnosis, prognosis, and treatment. 

VlSCEU.lL P.iTX. 

■ Tbo insensitivenc.ss to ordinary tactile, tbeniial, and 
chemical -stimuli of the .serous and raucous coats of tho 
hollow viscera has been established in various ways. Partly 
on this account Sir James Mackenzie became protagonist 
for the view tliat there is no true visceral pain, but only 
pain projected to the somatic tissues supplied by the same 
segment of tho cord as that wbicli-. supplies the injured 
vi.sciis. This view still finds a few supporters, Tjut common 
experience and experiment b.ave rendered it untenable for 
the majoi ity of students. There is reason to believe that 


Mackenzie latterly modified liis earlier view to that more 
geneially upheld, for in 1922, in response to cei’tain observa- 
tions of my own, bo wrote to me as follows: “It is to 
answer this qne.stion that I have -.spent a long inqniiy and 
have come to tlio conclusion' tliat tbo only known stiiiuiliis 
that produces pain in tlie tissues wbicli are supplied only by 
the autonomic nerves is the contraction of muscle.” I 
would prefer, for reasons which will become apparent, that 
we should state the matter a little differently by 'saying 
that “ visceral pain is due to an abnormal increase in 
tension in the muscular element of the wall of tbo visciis,” 
for a [lositive contraction is not the only caimo of -inereased 
tension or of pain. 

. This -conception of tbo cause of visceral pain can be 
equally well adduced in explanation of pains as divei-se in 
.eliaracter and circumstance, as those of labour, of gastric 
.'ulcer, of -rCna! colic,’ and -angma- pectoris. 'But- there -are 
other observations accessory to the' main coiiclnsion wbicli 
may bo made in regard to tho pains of visceral disease. 
TbeSo I shall summarize as concisely as possible, referring 
to them as “ laws ” of -visceral pain for brevity and con- 
venience, and implying thereby “ present beliefs ” rather 
than “ mialtorable truths.” 


• ■ • “Lavs” of Visceral Pain: 

(1) Viscei'.il pain has its origin in and is due to an abnormal 
increase in tension of tlie m-nscnlar element of the wall of the 
■viscus, this increase in tension resulting either (a)' from con- 
.traction of the muscle, -or (1>) from its failure to relax in the 
face of inci-easing intravisceraL pressure. (Examples : (n) tonic 
spasm of the colon, (I/) bladder pain in the early stages of 
i-rteiition before the musele. fibres have become overstretelicd.) 

(2) Relieving factors in visceral pain, other than those which 
merely deaden consciousness, are invariably factors which 
reduce intraviscei-nl' pres.sure or encourage muscular rela-xation. 
fE-xampIcs : the relief of pain from tho sudden perforation of 
a diseased appendix; the passage of a calculus; the t^mg of 
food in duodenal ulcer; the administration of amyl mtnle m 

*”^l"*As*^vould^ he anticipated if the truth of (1) and (2) is 
eoncetled the severity of mechanically induced pam is m 
invCTse m-oportion to the normal distei^ibility of the visoiis. 
tThus the most severe pains are- found in disease myolving 
tabes of small calibre and small distensibility, such as -dio 
nreter the bile ducts, and the arteries ; the more bearable pains 
ill ilisMse involving organs of wide calibre and a wide range 
of physiological distensibility and postural adaptability, such as 

the stomach and urinary bladder.) '.ii 

till Visceral pain when occurrmg alone or dissociable fiom 
attendant pains in the somatic tissues or other viscera can be 
located by the patient, the localization corresponding, 
W wi I any ^gmental nerve distribution, but with the surface 
making of the%iscus. (E.vamples : the loin gesture of renal 
■i, - flip sternal gesture of cardio-aortic pain: the accurate 
fudiiition of the pfint of obstruction in oesophageal and some 

"'(Srvfsceral pain, having its origin in muscle, is related to 
■*1.1 functional activity of the affected viscus. (Thus it i.s 
increased or relieved by food or fasting in _ ulcer, ’y 

cZl or rest in cardio-vascular dise^e, just as pain in skeletal 
Insrle is aegravaf ed by use and relieved oy rest ) 

tfil Referred somatic pain or soreness in visceral disease may 
^^mn-inv To) severe visceral crises of mechanical ongin, 
?;T^Spmmatotv or ulcerative disease of the visceral wal , 

* I mfre Dartmula''iy if this involves the mnscul.-ir coat. 

arm pain in angina and testicular pain i 
iretarif co’lic; (&) cutaneous soreness in appendicitis and 

"'■,^?,“‘ySl;;ecl"srm'atre pain or soreness in viscer.al disease 
anar from recent crises of visceral p-ain f 

P®’' rl f-nSm.;tory disease of the viscus in 

(&e : interscapular pam and 

'°l8rCoi!vertw!'ab?ence"of somatic pains and soreness^ 

I In rases of -visceral pain dependent on functional d 

rule an cases otjioi^^^riitive lesions in the more d.ste"^ e 

risfera (Examples ; chronic colon spasm; pyloric or 
growths.) 

It nred hardly bo remarked that in actaal practire 
iften cncomitor confusing effects which result t 
extension of ■ disease or multiple 

'• spread” of pain duo to temperamental factors ^ 

lontinueil p^-ehological or physical ill ^0..- 

jualification need not, , .[,g acciinin- 

ilusioiis. It would be impossible to detail hero the 



March 31, 1918] 


CrimiCAIi STUDY OF FAIIT. 


[ 


The British 
Medicad Jocbkax. 


539 


latod cvidcnco on llio basis of vliicli it lias seemed 
austifiabla to formulate tlio foregoing “ laws. ’ 

I The' referred sensory phenomena, requiring for their 
production special circumstances, such as intensity or pro- 
lomration through an inflammatory process of the appro- 
priate stimulus, are infrequent in comparison with the 
local phenomena, and so are of less constant diagnostic 
value. It would therefore seem fitting to devote our atten- 
tion more particularly to the primary visceral pains. It 
is chiefly with these that I shall concern myself in outlining 
the scheme for the analysis of a pain which follows. 

Tee An.altsis of a Pain. 

WTien a patient comes to us with a complaint of pain it 
|is customary and natural to ask him where the pain is 
felt and what its character may he. Each of us, no doubt, 
has his individual method of approach. Often a few direct 
questions and a little patience will elicit replies so informa- 
tive as to put us immediatelj' ou/the track of a reasonably 
accurate opinion, but there remain a host of “ difiicult 
.pains ” in which our sim2)le routine brings no reward, 
and we are left “ wondering,” or are compelled to proceed 
to the iiliysical examination, which may, in its turn, prove 
cxasperatingly negative. Even the “further investiga- 
tions,” when we can indulge in such luxuries or send the 
case to hospital, do not necessarily supply the answer 
to. our jiroblem. It is just in these cases that we feel the 
need for some fuller method of inquiry. A little reflection 
will show that there arc no less than ten rcasonahlc 
questions nhieh may he propounded in any given case of 
visceral pain, and, indeed, of most other kinds of 
pain. Each of these questions has some direct bearing 
• on the qualities or circumstances of the symiitom, and 
so renders our investigation less haphazard. It is true 
that the answer's, to these questions nrust be accorded very 
variable rriai'ks for. merit. IVe cannot expect to obtain 
consecutive or intelligent co-oireration from all our patients, 
but this is no reason for abandoniirg the attemirt. For our 
. failures to “ establish contact !’ or to assess the reliability 
or reinics lye must hold ourselves at least in jiart to blame, 
n'f tb®m, nrust aim at an improved technique. 
Ur tho.se tea questions two have a bearing oir quality and 
quantity, and may be- answered under tlie. headings of 
(1) diarnefer and ( 2 ) sci'crity. Three have a bearing on 
siraomi relationships, and are answerable under the headings 

0 (o) situation (including depth from the surface), (4) 

‘ of diffusion), and ( 5 ) paths of 

1 / r acc. Three have a bearing on temporal rclationsliijrs, 

ans'iverahle under the headings of (6) duration, 

■ /teguciic;;, and (8) special times of occut'rcnce. Two 

* ^ oanng oil detonuining causes, and are answerable 

of ( 9 ) aggravating and (10) reUevhig 
tr, +ii * above these questions directly relating 

T\\ niust also include associated 

- cnnt^i * ^ these .questions are concerned with the 

XI by fbe patient. At a later 

\{o° “ teudernri" ° for. elicited visceral pain 

soreness ”)-. 


) and elicited somatic pain (or 


lt1s coLon tn “f fbe character of a paini 

.'crop Rp'again and agfte descriptive adjective: 

. lualHy, it i, rai,inS‘S ft'!'' f “ M ■ ".•"'''“'t'’ ! 

■ not markodlv fluctuating ^ ^ lasts— that is to say, it i; 
acute irrrtativo gastritis^ '"termittent. In ai 

inteimittont. The “oy be peristaltic am 

dyspepsia is commbnly f 

pain of angina pectoris *■ bursting character. Th 
descriptiouT is-often referred as to def; 

, vico-Iike. The pains of wr “ * bursting, crushing, o 
in their ultimate tliroos'^ar“'^^ fo^»statin: 

• crescendo, and in no tro’n “oarly always continuous an. 
a dull aeho wifieh become ”5 bbey start wit 

The pain of enteritis oi X fnfoforabh 

^ .colicky ’’—that intestinal obstruction is trul 

J ruat IS to say, rhythmically iutermitteni 


sharp, and griping wliile in action, but quickly giving placo 
to ease between the spasm’s. “ Burning ” pains are rarely 
indicative yif gross organic disease. The most familiar 
example is the homely heartburn, with its unpleasant, but 
never agonizing, sense of a' retrosternal and almost 
“ chemical ” heat, although such evidence as we have 
suggests that it is, in common with strangury and 
tenesmus, an accompaniment of spasm. Diffuse abdominal 
burning sensations' are chiefly encountered in depressed or 
emotional patients.- 

The severity of a pain is notoriously hard to measure. 
It is always' well to discover from our patient at an early 
stage whether “ pain ” or “ discomfort ” is the more 
appropriate description. True pain is more likely to mean 
organic disease. Pains which are comparable with or worse 
than those of labour, or rvliich in past episodes have 
required a hypodermic injection, we accept as genuinely 
severe. The effect of the pain on the performance of daily 
duties or mental work or equanimity or sleep allows some 
estimate of its gravity. Recourse to hot bottles, or bed, or 
analgesio drugs may help in our assessment, but in this 
part of our inquiry more than any other our own observa- 
tional powers in regard to temperament or other factors 
likely te raise or lower the “ threshold ” of the individual 
-to pain must be called into play. 

The situation and localization of a pain are best deter- 
mined hy observing tlie imtient’s gesture, and, best of all, 
when the opportunity can be found, or made, .to see him in 
its grip. Tho more defined and accurately localized the 
lesion responsible for a visceral pain the more accurate 
and defined, as a rule, is the gesture of tho patient. There 
are many -significant gestures. A famous iiroprietary pill 
has caught in its advertisements the typical gesture em- 
ployed by the victims of a kidney stone. The pain of 
ulcer is commonly indicated with the tips of the fingers 
applied to mid-epigastrium; the pain of a functional 
I dyspepsia with the flat of a roving hand. Tiie point of 
arrest of a uroterio calculus may sometimes be shoivn with 
a ’single finger. In cases of chronic colon spasm I have 
seen the course of the colon accurately traced by patients 
wholly ignorant of anatomy. Among the best recognized 
paths of reference are those involving the left arm in 
angina pectoris, sometimes extending te the right arm, and 
in either' COSO usually confined te the inner aspect and 
reaching the elbow, the wrist, or even the ring and little 
fingers, and sometimes also rising to the heck or jaw; the 
scapular or interscapiil.vr pain (not slioulder pain) of gall- 
bladder disease; and tlie testicular pain of ureteric colic. 
Superficial and more often deep skin soreness _may bo of 
very real assistance in the diagnosis of gastric and duodenal 
ulcer, of some forms of appendicitis, of cholecystitis, and 
diverticulitis. Referred jiain down the front of the. thighs 
may accompany salpingitis and .’ tubal ’ pregnancy. The 
details of the search for zones of soreness have received 
full discussion in the literature and need not be considered 
here. Care is sometimes necessary to avoid confusion of a 
fibrositic tenderness 11-1111 a true sj-mpathetio hyperalgesia. 

Tho duration of a pain has a very special significance, 
and may frequently throw light on the particular per- 
turbation of function which the pain itself less surely 
expresses. Thus the intermittent pains of intestinal colic, 
so clearly due to peristaltic over-activity, last a few. seconds 
only.- The pains of an anginal seizure (excluding tlie 
sustained agony of coronary occlusion) rarely last more 
than a few, minutes, and depend, we believe (whether, their 
focus be in the heart or its vessels), on an inadequate 
relaxation — or adaptation of iiosture — on tho part of tlio 
coronary plain muscle in response to increased cardiac work 
and a rising blood pressure. The pains of gastric and 
duodenal ulcer last an hour or more, until the stomach is 
empty or replenished. Biliary and renal crises may con- 
tinue for an hour or hours, and often enough until tho 
blessed relief of morphine has been won. In each instance 
wo can nicely correlate tbe time character with tho 
mechanical event. 

The frequency and special times of occurrence of a pain 
are also instructive. Epigastric pain which recurs daily 
and with some constant time relationship to meals is almost 
certainly of gastric origin. Epigastric pain arriving at 
rare intervals, “ out of the blue,” and independently . of 



540 March sti .iQzS] GANGRENE FODEOWING G8E OP -NBGOTIZED'>KRBAEi 


_ r TnEBwTi?ii J/f 
L UcQICAX, Jol’KXAt 


eating or other physiological exorcise, should raise a sus- 
picion of gall-stones or tahetic crises. Epigastric pain, 
absent at times of rest but immediately induced by ceitain 
efforts, is almost undoubtedly due to cardio-vascular disease. 
Of special iimes of occurrence it is also noteworthy that 
angina, in concert with other “ spasmodic complaints,”, as 
obsei-ved by Heberden, has a predilection for. tho early 
hours of tho nioniing after tho first sleep. Tho hunger 
pains of duodenal ulcer often wake their victims between 
tho hours of midnight and 2 a.m., and gall-stone pains at 
a somow’hat later hour. 

Among aggravatitiff factors (taking again tho better 
known types of. pain) exertion, cold, annoyance, and 
particularly exertion after food, may all he provocative of 
anginal .seizures. Jolting is apt to evoke pain in biliary, 
renal, and vesical calculus, and also in sufferers from 
cliJ'onic colon spasm, a disoider which is highly responsive 
also to tho influence of cold, fatigue, worry, tobacco, and 
purgatives. Gentle thumping of the loin will more readily 
evoke tho pain of calculous renal disease than simple deep 
palpation. Of relieving factors rest of body and mind and 
warmth are common to the jnajority of painful visceral 
disorders. Amyl nitrite has an almost specific effect in 
anginal 2 min, but not so in the status anginosus of coronary 
occlusion. Alkalis and belladonna (both jirob.ahly by facili- 
tating jjylorie relaxation) have a well-knomi efficacy in 
gastric pain. Abdominal pressure, ill tolerated in inflam- 
matory abdominal disease, may alleviate the pain of 
intestinal colic. 

Now I would not for a moment have it supposed that an 
interrogatory such as I have outlined can bo employed by 
every husj’ iihysician in every case of visceral pain with 
which he is confronted; hut I would suggest that some 
such method is not only approirriato hut essential if wo are 
to prosecute a careful inquiry into any single type of 
pain ; and further, that it may bo of decided valpo in 
practice in elucidating what I have described as “ difficult 
pains,” and more particularly in those unhapjjily plentiful 
cases of chronic abdominal disease in which physical signs 
are scanty or altogether lacking. I can think of nothing 
better calculated to stay tho epidemic of injudicious abdo- 
minal operations than an extension of interest in pain as a 
diagnostic sj’mptom. 

If 1 were asked to enunciate a few important principles 
for the eveiyday clinical study of pain my choice would 
fall upon the following: 

First, in obscure cases and important decisions to try, 
wheniwer possible, to see the patient when his pain is 
present, for then and then only will his own observations 
be accurate and reliable, and not dependent upon memory, 
and physical signs, absent at other times, may be in 
evidence. Wo all know bow few and far between (espe- 
cially in consulting and hospital practice) are these oppor- 
tunities of seeing our patients in pain. This circumstance 
alone is evidence of the rarity of continuous pain (except- 
ing in advanced inflaniraatory and malignant disease), and 
supports the contention that visceral jiains come and go in 
a physiological sequence and iii obedience to physical laws. 

Secondl}-, to pay particular attention to the patient’s 
gesture, and, if he makes none spontaneously, to ask for 
a manual demonstration w'ith tho clothes removed. •* A 
pain in the stomach ” may mean a pain anywhere between 
the manubrium sterni and the symphysis pubis, and onr 
endeavour must ever be in the direction of greater pre- 
cision. I have several times seen the mistake made of 
supposing a pain to he gastric because it was related to 
food. Colonic pains may also be influenced for better or 
worse by food, but they are situated in the lower abdo- 
men, whereas gastric pains are always epigastric. 

Thirdly, to remember the close association which exists 
between visceral pain and the functional activity of tho 
viscus in question. I once had a case referred to me by a 
cardiologist on a suspicion of stomach trouble with a 
request for a gastric analysis. The patient was an elderly 
man complaining of high epigastric pain after food. 
Before examining him I ascertained that the same pain 
was also evoked by walking, and that tho ca.sG was un- 
doubtedly one of angina pectoris. 

It remains for me to cite from my personal store a few 
case histories which serve to show the value of a full 


analysis of pain, and how such an analysis may lead to a 
more correct opinion or may modify judgement or treat- 
ment in important ways. I have been careful to inehida 
mistakes of my own as well as those of others. How often 
these- mistakes give us insight into matters prcviouslv 
dehatahlo or obscure. 

[Case histories illustrating tho following conditions were 
hero recounted, the detailed descriptions being omitted 
owing to lack of space. . ■ 

(1) A case in which ex^inatioh of the patient dnriiig an 
attack of pain altered a diagnosis, based on careful investiga- 
tions, from duodenal ulcer to gall-stones. 

(2) A case in which the sei’crity of tlie pain Jed to a 
diagnosis of gall-stones and a fruitless operation; in.wliioli a 
radiologist later fouiid a lesser curvature ulcer; but. in wliidi 
tho clinical analysis led to a diagnosis (proved at a second 
operation) of ** chronic posterior duodenal ulcer adherent to the 
pancreas.'* 

(3) A caso of chronic colon spasm previou.sly diagnosed as 
(a) gastric ulcer, (^) renal colic, and leading to laparotomy. 

(4) A case of chronic right-sided colon spasm for which 
appcndiceclomy was performed. 

(5) A case of aortic disease with abdominal angina subjected 
to investigations of the alimentary tract. 

(6) A case in wdiich opinions as diverse as coronary arterial 
thrombosis and gall-stones were entertained by different 
observers.} 

Conclusion. 

It is a criticism sometimes levelled at the clinician that 
his work is regrettably unscientific. In general the 
criticism may seem justified, and we know well enough that 
wo cannot make of medicine an exact sort of science. 33ut 
in particular it is indisputable that a careful clinical 
examination or intjniry is just as much a scientific pi*o- 
ceduro as any other measure of reseai cli. According to 
Huxley’s definition, “ Science is nothing but trained and 
orcanized common sense a definition which we shou d 
be very ready to accept, and which applies particularly 

well to clinical work. , • 

•We hear much talk at the present day of research in 
ceueral practice. I marvel at the temerity of anyone who 
suggest that the busy practitioner should add another 
^rden to his arduous life; but if there is one way of 
researcb not involving too great a consumption of time, 
and open alike to tho general practitioner or to any other 
branch of the profession, it is that of keeping veiy full 
cliuiral notes on selected cases with a view to the solution 
of a selected problem in symptomatology^ No sj-mptoms 
bettor lend themselves to such a process of inquiry than 
,on e of the common pains of daily practice. A senes of 
cases of headache, backache, or abdominal pam, as fu j 
investigated as circumstances will permit, and carefullj 
followed through the yoai-s, will certainly provide individual 
rewards for their investigator, and may ultimately furnish 
material for a reasoned contribution to morbid plij'sio- 
loev ‘system and patience are necessao’, together with 
.an^iiiquiring mind. The only essential apparatus for the 
research is a good card index. 

gangrene following the use of 

ERG OTIZED RYE BREAD. 

BY 

WALTER J. HILLING, M.B., Ch.B.,' 

associate PEOFESSOa or PHAEMAC^GY. UHlVEnSlTY OF I.lVErtOOE, 

H E. KELLY. C.B., M.H.. B.Sc., E.E.C.S., 

PKOFESSOK OF SORCERY, UNIVERSITY OF LIVERPOOL. 

Eakly in 1923 we report^at the Liverpool Medical 

T U rase of gangrene m symmetrical toes, a 

Kihin|\;;;toms. ”a%^.fopS “rth^ 

Slal features of epidemic ^rgotismjnd of this ease 
most commonly in lye, it occasion^ infimts whe^ 


March 31, ,1928] 


GANPEENE FOLLOWING XTSE OF ERGOTIZED BREAD. 


t Tnn BBrmx K 15 

Bres T riT. Jara-vxz. V -t-fc 


'Elymus, and others. The conditions farouraWo to propaga- 
tion are a poorly cultivated or damp, clayey soil, and a vret 
season, together with the presence, at the borders of the 
field, of grasses which can harbour the fungus. The chief 
active principles of ergot have been proved by Barger, 
Bale, and others to he the alkaloids ergotoxino ^and 
ergotamine, and the amine bases tyramine and histamine.^ 
Ergotoxine, which stimulates the ■ peripheral motor sym- 
pathetic mechanism, causes the arterial constriction which, 
when prolonged, ' results in gangrene; excessive, doses of 
ergotoxine paralyse the myoneural junctions of the motor 
sympathetic endings; tyram.ine, liko adrenaline, stimulates 
.both motor and inhibitop" sympathetic receptors; and 
•histamine, which is a direct stimulant to involuntary 
muscle, causes, as is well known, a large fall in blood 
pressure. 

'Ergotism may be of two types — the convulsive and the ] 
gangrenous. The former predominated in epidemics in | 
;Germany,.Eussia, and Eastern Europe; the latter in Prance 
and Switzerland. 

The onset of the convulsive type is characterized by- 
malaise, dizziness and headache, nausea or vomiting, colic 
with chronic diarrhoea, and cold extremities — symptoms of 
small diagnostic value. The more characteristic symptom 
of formication begins in the fingers and toes, and may 
spread to the body. -Severe cases exhibit gastro-enteritis 
with muscular twitchings or painful clonic and, later, tonic 
' contractions of different muscles, while, finally, contrae- 
. tures, chiefly of the flexor muscles of the limbs, may result. 

The gangrenous type may exhibit similar initial sym- 
ptoms; then follows, after intervals varying from a few 
days to several weeks, great pain with an erysipelas-like 
reddening of the skin and swelling in some peripheral part. 
This gives place to pallor and anaesthesia, cyanosis, darken- 
ing .of the part, and the appearance of gangrenous blisters 
with separation of the epidermis ; a sharp demarcation line 
generally results.* 

Prom a study of the epidemics it appears, that some 
individuals are more sensitive to ergot than others; thus 
instances are noted where some members of families eating 
the same ergotized bread remained unaffected or mildly 
affected while. others were severely, poisoned.* The time of 
appearance of gangrene is also uncertain ; it is stated to 
have occurred four days after the consumption of the 
ergot,® or may be. delayed for .a month, or perhaps occur 
after .consumption .has ceased.® Some of these last cases 
appear doubtful, although Kobert recorded delayed poison- 
ing in animals.® Both Kobert and Griinfeld noted in 
Russia that epidemics occurred shortly after harvest time, 
-and generally in years following a preceding bad harvest, 
which^cansed the people to oat the new sea.son®s rye shortly 
had been reaped. . Griinfeld .also showed that ergot 
, kept in a dry room lost activity by one-half each two 
months succeeding the. haiwest'.’ The proportions in rye 
which have caused. epidemics vaiy from 1 per cent, in the 
Poltova, Kursk, ^and Tomsk epidemics*® to 7. per cent, in 
the Novgorod epidemic (1879) and more.** Ergot in doses 
of 0.2 gram daily for one month has been stated to cause 
?**^Si°**® two months later,*® and 1 gram daily induced 
intestinal symptoms in a few days,** while Lehmann 
.regards 0.2 per cent, and upwards as likelv to be injurious 
proportions in meal.** 


Tho foUowing is the clinical record of a man, aged 4£ 
a Polish Jew, hy trade a travelling salesman, who had Uve 
in England for thirty-five years. 


SI? t**fi'''****rT, Liverpool, on Novemb 

o^h.-rPf “"'J dhroioration of the second t 

that he noted first some numbness 
Aw nnfl nleS ® ®''**"? black. The proccss w 

AA toe A lA e A® His history revealld that t 

Aoriouslv been amputated twelve mont 

iti- r- f exactly similar condition two or three mont 
after the first appearance of a discoloration 

A *l^’,'*'«''’'*-r-Tbe terminal phalanx was ohviom 
fionAhA n W ^ showed no definite line of deman 

tionj tho too .was very pamtul, cspeciallv at nieht. There w-Ts 

fmn°oAw Ac ‘T renal disease, and, although it w 

Hi **> either the anterior or posterior tib; 

artery, tho radial artoriK were not undulv palpable*^ or thickenc 
Thera was no apparent of tho t* vi 


hoilways ate black or rye bread, known as "Kosher" bread. At 
Hie amputation of the second toe on Kovember 17th .there was an 
extraordinary lack of bleeding, but the wound healed well without 
further gangrene. Tho patient -was see'n on January 20th, 1925, 
and-was.well except that the circulation was Etill somewhat sluggish, 
although he had then given up rye bread for two months. 

Pathological Jieport. — -Lr. 5Y. Howel Evans, lecturer in pathology, 
Liverpool University, reported as follows : The arteries of largrat 
calibre, at the level of the first phalanx, show well-marked medial 
hypertrophy without calcification, and considerablo regular, diffuse, 
infimal thickening and ante-mortem thrombosis; in one of them. the 
clot is well organized and partly canalizedi There is a very slight 
degree of fibrosis of the adventitia. In eections cut at the level 
of the second phalanx the more distal vessels show less marked 
changes, consisting, chiefly of a moderate degree of intimal 
thickening, sometimes irregular^and without thrombosis. In this 
region the muscle is largely necrotic, no definite changes are 
observed in the arterioles or the nerves, and there does not appear 
to bo any gross alteration in the veins. 

A specimen of the rye bread usually eaten by this patient 
was examined microscopically imd revealed mycelial tissue, 
which,- in chloral hydrate solution, exhibited the oil globules 
characteristic . of ergot. An extract was prepared with 
60 per cent, alcohol acidified with citric acid; it was puri- 
fied with absolute alcohol, and -the residue, after evapora- 
tion, was dissolved in water. This extract, in doses repre- 
senting 88 and 46 grams of bread, injected intramusoularly 
into a white Jjeghom cock, produced after an hour distinct 
cyanosis and blackening of the hack part of the comb and 
marked pallor of the anterior borders of the wattles. 

With the assistance of Dr. W. Hanna, deputy medical 
oflScer of health, Liverpool, we found that samples of the 
flour also contained ergot tissue, and that, in the rye at 
the mill, orgot was obviously present. One sample picked 
over showed 0.1 per cent, hy weight adulteration with 
pure ergot, and, in addition, many of the rye grains were 
blackened and microscopically revealed mycelium. In our 
I opinion 0.1 per cent, represents the minimum of adultera- 
tion, and, from tho relative frequency of mycelium in the 
first loaf, we surmise that the adulteration before our 
inquiries were broadcast was probably greater. We were 
informed that the rye flour was partly diluted with wheat 
flour by the baker, but he was vague about the exact 
proportion of the admixture; microscopical examination 
indicated that it was approximately one-half. - As a pre- 
cautionary and prophylactic measure the medical officer of 
health gave instructions for the dilution with wheat flour 
to be increased.*® 

It was ascertained that the rye had been grown in a 
comparatively restricted area of Lancashire; the farmer 
was quite well aware that his rye was infected, and, since 
1922 was a wet year, it was presumably more heavily in- 
fected than usual. . This patient, however, had suffered from 
gangrene a year previously, and it may bo that in this area 
the relative infection shows merely seasonal variations. 

Samples of the pure ergot taken from the rye. -were 
extracted, and when the extract was added to the isolated 
virgin guinea-pig uterus suspended in Tyrode’s fluid it 
produced powerful contractions of the uterus in doses 
representing 0.02 gram of ergot. 

An important warning . must here be emphasized^ 
namely, that this pharmacological test is fallacious 
and misleading if it is performed with the rye bread 
or on extract prepared from it, because certain cereals 
and starcbes contain a principle which induces powerful 
uterine contractions, but instead of causing, like ergo- 
toxine, a rise in blood pressure, it induces a very 
marked fall — actions resembling those of histamine. 
This was noted hy Macdonald and Grier*® in testing 
the rye in Manchester. Our investigations showed that 
this uterus-contracting principle was present in wheat, 
oatmeal, maize, rice, and potato in variable amounts, and 
in their starches, hut it was not present in specimens of 
chemically pure Lintner’s starch. By various methods, 
such as that of Kutscher,*® attempts were made to isolate 
the pure principle. It was found that concentrated 
extract's produced a decided red colour with Pauly’s diazo- 
benzene reaction, which is given by both tyrosine and 
histidine, and also with Totani’s reagent,** which is 
believed to be characteristic of histidine, but it has not 
been possible to prepare cither a crj'stalline picrolonatc or 
picrate, and, by determining the melting point of tbo salt, 
to identify filially the p.-inciple with histamine. Tbo 
X>harmacological actions and colour tests make it nrobabl* 



642 


inaction treatment of yabicort. veins. 


Buomo.‘;i“?f t° distinguish this case from 

riio loaci iiinb of a male between tJic ages of 30 and 40 
and may recur in the other limb later. M Buer4» ami 

Je,2“bJ “it';; rr - common among 

nicotine- “lolo^. °rganismal- and also 

Wo delayed full publication of our Imowlcdgo becaiiKo 
ue were not satisfied that ‘our isolated c.Z conlT bo 

JSs ‘k' ■iT? ..S S 

oblito.-ans contributed I, bf a d/ef^ ^ . tI>rombo-ang.,tis 

twl 'mo;\;m“'?ftr''t'im^rLh NovombeV;, “abo°«t 

(3) the absence of ge„erartt:;&jranrdiS 


r„TuKi5rtm^H 

1 . Sl£l)ICJE JotniNlL 


gangre.m^thfs nLi“touW°Lavrt;ke,“ 4®-®“'’'^®'^ 

tjuarters to ono nound 4 m three- 

thrombo-angiitis obliterans usimfi ‘=“^^3 of 

vessels of tho limbs wbemno involve tho larger 

circumscribed. ' peripheral and 




287; Zancct, 


mo. 3^... CM,n. 


' Btfvu., iool, XI, 116 ' / 

T ^ohrh. f. yatsau, J856. 

grt/rtiaf "‘T/'- «=■ 

^t,nl 2> f- «5. Griasnofl: 

>■ Swmtiowaky : Land. Med. Record, 1880, viii 02 

1* Debove : Op. cit. * ' 

“ UbertI : Quoted by Lehmann, p. no 

I* Lehmann r dreft. /. Jlyg.. 1893 , xi.v, 113. 

ij O' Health, Liverpool, 1923, p 18’ 

11 i.*“P‘*9"o'‘' ,“0‘' Pwo : BntUh Medical Jourual, 1928, i, ho 
I’Kntscher; Zcntralbl. f. 1‘hysiot.. .vxiv, 163; Zeii. .Va/ir gZuss 1905 
X, 628; Barger and Dale: Trans. Chem. Soc., 1910, xcvii,'' 2 ^-’ 

*• Totaoi : Biochem. Joum., 1915, ix, 387 

-Weber, P. Parkea: QuarL Journ. Med., 1916, ix, 289; Lancet, 19: 
n. ij’ y* Sourasky, British Jledical Journal, 1927, i, 444 
^iR!'M!cr"Vid°*’l927 ^ Journal, 1924, li, 1031 

— Rablnowitz: Surgery, Uynecology and Obstetrics, 1923, .v.\.vvii, 353. 


I^OTES ON THE INJECTION TEEATHEKT OP 
TAIIICOSE VEINS. 

BY 

H. M. HANSCHELL, D.S.C., M.E.C.S., LRCP 

D.T.M. AOT) II 

V =4 =” 

ALDERT DOCKS. 


peri-,.hlebitis of a varix somc- 
mmh ns or very soon after a toxic fever 

V ri4 

Recently. I met with a traveller who, durimr a mild 

Si", S'/wStI •!'" ™ir„M.T'S 

thielr f 'r 1 1 ^ remain in bed, and with a 

took^rf^ur “pp ''®'" sajihonous openimr 

to reproduce homt^and the'n permitted mS 

•eondIC.""S tL'VasfZ^lf^ " similar clinical 

other le-r vaiicose long saphenous vein of tho 

In my experience this has been transient with thr^t 1.™ 
drugs; tile od derivatives more easily cansn fib. ■ * ? 

•oeclusion of the healthy vein. ^ “"d 

In 19^ in West Africa, unable to find an arm vein in 
n fat alcoholic patient suffering from snhtertian Malaria 
b/n S3mptoms, I nad recourse to a visible varix in 

ns log; W grams of qnmme hydrochloride in 10 c cS ^f 
boded ram water were injected into the varix nnri ■+L^'i“ 
«iei. lifted high. This produced tbrombo- and peri-jd.lebiti? 
He suiw.vcd to express satisfaction for the cure of the var^^' 
Somo time later I injected salvarsan into a varLx in thn 
leg of another patient, being foiled of an arm vein • enro 
of the vanx resulted after thrombo-phlebitis and fibrosi 
Such an experience led, with trepidation, to some “ cures ” 
of varicose veins with quinine iiij'ections until after the 
war .Sicard’s work brought ciicoiiragoment to j^roceed Jess 
fearfully and siioradically. “ 

During the last feiv j-eai-s I have treated over 200 cases 
o .varicose veins of tho leg hv- inj'octing into the virinos 
quinine hydrochloride, so°dium 'salicylate; or sod7.^S 


chloride. In over 100 the quinine salt has been used. Ir 
my hands, of the three, it has been the least uncertain ii 
effect. 

Recently, with Dr. J. C. Gilroy, some observations wen 
made on a perhaps callous, but consenting and rewarded 
male patient in the Seamen’s Hospital, Royal Albert Dock 
who had many varicose veins in both legs. About tw( 
inches of uninjected varix were dissected out for centre 
comparison; and also, at intervals of time, tho same leiigtl 
of other varices, ten to fifteen minutes, twenty-four hours, 
and seven days after their intravenous injection with one 
or other of quinine liydroehlorido 13 per cent., sodium 
salicylate 20 per cent., and sodium chloride 20 per cent. 

Naked-ejo and microscopic examination of tho several 
injected varices revealed, ten to fifteen minutes after 
injection, no clot and no recognizablo change in vein wall; 
twentj’-foiir hours after injection, however, the lumen was 
filled vdth firmly adherent clot, the intima was sivollcn, 
with damaged cell nuclei, and there was round-cell infiltra- 
tion of the tissue outside tho vein. Seven days after 
injection the finnly adherent clot was undergoing 
organization. 

, The treatment has had its difficulties, tediums, and 
anxieties for patient and operator. I have found, as com- 
pared with many thousand injections into normal arm 
veins, that only the larger varices are easy to inject. In 
most cases the patient must stand to be injected. For the 
operator’s convenience this standing must be on a level 
considerably higher than that of the floor — a severe trial 
for the nervous patient; all are nervous at first, and somo 
aln’ays. Often the patient may sit high enough to suit tho 
operator; very rarely can injection of a varix bo per- 
formed with tlie patient Ijdng down. A tourniquet above 
the varix helps not at all, one below it sometimes helps 
a very little. 

I’he more advanced the varicose condition tho less un- 
certain is, the effect of the injected drug; but intensity 
of effect may vary in the same leg, with apparently tho 
same size and condition of varix, and same dose of same 
drug. Sodii salicylate 20 to 30 per cent., sodii chloride 
20 per cent., and quinine hj-drochlorido 13 per cent. — 
each sometimes has failed after more than ono injection 
into a i-arix to produce the requisite obvious phlebitis. 
With each tho thrombo-phlebitis and peri-phlehitis has 
sometimes extended quickly far beyond the usual ono or 
two inches of vein above and below tho point injected. 



- TKEA-TMENT OE HEDBONEPHROSI3. 


t THlERITtsa -R4.?? 
JIedicu. JocnKH. 


March 31, 1928] 


This incommodes the pntient, and may even cause a 
preference for a fern days in hed. Tlie operator’s anxieties 

do not count. ... , , 

In tropical medicine quinine injections, subcutaneous or 
intramuscular, have had an occasional lioiiid reputation 
for iiroducing sloughing cellulitis, deep aliscess, and, in the 
tropics, have been folloived more than once by a fatal 
tetanus. It has also been reported that sodium salicylate 
20-30 per cent, and sodium chloride 20 per cent., injected 
under the skin, have caused sloughing. Another kind of 
sloimh, one-eighth to one-half of an inch in diameter, has, 
under ’my hands, been produced bj- each of these three 
drims, aithougli the lumen of the varix had been fairly 
entered. Tills’ slough has occurred ivhcre loops of smaller 
tortuous varicose vein lay closely together ; it appeared one- 
half to three-quarters of an inch above the point injected; 
injections were directed upwards. It is true that to 
transfix a loop in sudi a varix hunch is easy. In these 
cases, however, injection was accurately intravenous, and 
there was no haematoma or subsequent discoloration of skin 
from extravasated blood. 

The clinical events have been : A purplish mark in skin ; 
next daj' this was a grey blister, which later dried to a hard 
adherent black scab surrounded by inflamed and tender 
'skin. Some weeks later the sc.ab could be separated, dis- 
j closing then an excavated pouch filled with black sticky 
!clot, under which lay small grey-yellow sloughs. Micro- 
iscopic examination of clot and sloughs revealed no organ- 
, isms, and none has grorni from clot or slough in aerobic 
jcrdtuve. It is evident that a whole small length of 
ithrorabosed varix, with some of the skin over it, died 
quickly in situ. Healing readily followed on treatment 
.with hypotonic salines. But the patient’s view of the 
matter may be as black as the scab, and in one it was 
almost a jet-black ingratitude; such patients do exist. 

This sort of sloughing, and the far extension of thrombo- 
and peri-phlebitis, appear in retrospect to have been duo 
to too large a dose of the drug for that particular varix. 
Both were infrequent, and have not occurred with more 
;ca\ttvons dosage. In none of the cases, even in those with 
■a rapid -extension of the phlebitis from lower leg to 
-saiilienous opening, lias tliere been noted any rigor or 
• fever — ^both usual features of a septic tlirombo-pldehitis. 

I In hospital out-patients varicose ulcers of leg liave healed 
j ivoll after the iiijoctioii of the accompanying varicose veins. 

I In three women in the third to fourth month of pregnancy 

■ cure of varicose leg veins by injection into them of quiniue 
; hydrochloride produced complete relief from aching legs and 
I oedema of ankles, and 110 hint of relief from the pregnancy, 
j Even doctors have submitted to injection of their leg 
.varices. One or two have lessened the tedium of treatment 

by probing discussions of the symptoms and signs of 
cnibolisin. ■ Tliero lias been no demonstration of embolism; 

■ view of the large number of cases now safely 
injected here and in France, by mauy practitioners, the 
risk of embolism appeai-s to be remote. 

Throrabo-])hlchitis of a vein, whether caused hv bacterial 
toxin, trauma, or “ chemical ” injection, is, tlieii, safe— 
If tliQ tUromho-phlcbitis is aseptic and the vein varicose. 
1 le dose of quinine liydi ochloride 13 per cent, (with methane 



. . . ... — .... . repeat 

an injection next time than to treat a .slough ulcer. The 
most frequent dose has been 1/4 c.cm — and four injections 
at a sitting. 

It has been almost the rule for patients to return later 
(sonic with shorter skirts and some with now one stocking 
only_a thmner one-on each leg) to dem.aiid injection of 
some small veins not thought worthv of trcatnic.it when 
the holder v.aricc.s had challenged operator and patient; 
some, too, to deplore once more the scars of a past excision 
of veins that had not prevented varices reappearing, 
rorhaps a few of t heso v.ain sealj.cl scars can be ‘cancelled 
out bj tbe depressed pigmented sc.n- of an injection sloimh 
or 1.1 sonic cases by tl.o pale snuff-coloured siin.ous line, 
tbe binwiiisb patch, that .narks the track of a past too 
acute iiijcclioi. pen-pblobitis. Still l.atcr, tbo varices, now 
comjilctely forgotten, and represented o.ilv bv a tiiiu hard 
snhcnl.aneous cord; tins more or less beige '.staining nrnv 


bo counted to the operator for unrighteousness. It is 
not unlikely that the stain will prove as permanent as the 
scalpel and" the -slough scars. Ihvo of the earlier patients 
in this series have now all three, yet arc content and even 
grateful to all concerned; such patients do exist. 


THE TEEATilENT OF HYDEONEPHHOSIS. 

BY 

C. C. HOLMAN, M.B., B.Ch., E.R.C.S., 

- HONORARY SURGEON, NORTHAMFTON GENERAL HOSPITAL. 

In general surgical practice* bydroneplirosis is met with 
somcivliat infrequently. It so happened that during the 
year 1927 six cases came under my care, of which five 
appear to me to present features of sufficient interest to 
justify publication. The sixth was a simple c;isg of 
impacted renal calculus. 

Case i. 

On January 16tb, 1927, I was callccl lo sec in consultation a 
farmer, aged 79, wiry and acti%*e, with a tendency to occasional 
over-indulgence in alcohol. ^ About fourteen days earlier he first 
complained of abdominal pain and nausea, but no vomiting. Under 
medical treatment the pain subsidy for a few days and then 
recurred, with abdominal distension and constipation. The 
abdomen was found to be distended, but there was ^ no 
visible peristalsis. Rectal examination revealed prolapsed piles, 
from which he had suffered for many years, and enlargement of 
the prostate. No growtJi could be made out. He was removed to 
a nm-sing home. Under treatment by enemala his condition 
improved and an ar-ray examination after an opaque enema was 
carried out. The enema was badly retained and did not go 
beyond the lower end of the sigmoid. Everything seemed to point 
lo obstruction duo to growth, and an operation was decided on. 

Operation. 

On January 20th an incision was made, splitting the left rectus 
below the umbilicus. The sigmoid was found to be nonnal except 
for some small diverticula. On passing the hand upwards a large 
hydronephrosis of the left kidney was at once found. The right 
kidney icH normal. Tlie abdominal incision was closed and tbo 
patient turned on his right side. A free lumbar incision was made. 
The pelvis of the kidney was found distended to a capacity of somo 
thirty ounces ; it was' very adherent to surrounding structure^. 
The fluid was evacuated by puncture, and the kidney, together 
with as much of the pelvis as possible, was removed rapidly. A 
small tear of the peritoneum was sutured and tlie wound closed, 
except for a drain. 

Tbe patient bore the operation well. He bad to be cathetorized 
the next day, but subsequently passed urine without trouble. Ho 
was well enough to leave the home three weeks after the opera- 
tion, although there was still some discharge at the site of the 
drainage tube. 

The case is interesting from tlio point of view of diagnosis. 
Dilatation of tbe renal pelvis not infrequently gives rise 
to symptoms of intestinal obstruction. In thi.s .case tbo 
tumour was masked in the first instance by abdominal 
distension. The probable explanation .of the misleading 
ar-ray findings is that the prolapsed piles prevented proper 
letcntiou of the opaque enema. The urine was normal. 
The operation had to be carried out rapidly, and no cause 
for the liydroncphrosis was found. There wa.s not sufficient 
prostatic obstruction to affect the right kidnev. 

Case n. 

A medical student, aged 20, had been subject from early child- 
hood to attacks of pain in the left loin, accompanied by vomitin'^, 
and lasting between one and eight days. The pain ixjsc gradually 
pa<ised off. No diuresis after an 
attack had been noticed. On one occasion bacteriological examina- 
urine had been made and streptococci found. Tho 
attacks had become more frequent lately and had interfered with 
ms studies. He had been treated for gastritis, an a:-ray examina- 
tion of the stomach had been made, and he had also undergone 
a course of psychotherapy. Three months prior to my seeing Iiim 
an x-ray examination of llie kidneys had been made clscwlserc, and 
he had been subjected to cystoscopy, after an attack was over, 
with negative results. 

The patient was admitted to the Northampton General Ho-pital, 
and I was fortunate to see him during an attack. He was in 
considerable pain, and veiy tender on palpation in the left 
costo-vortebral angle. He had vomited copiously. TIjc abdominal 
wall was rigid and mu'^cirlar, and no tumour could be felt. A 
little pus was present in the urine. Immediate c 3 '«toccopic examina- 
tion w^ carried out under general anaoslhc’sfa, after an injection 
of indigo-carmine. There was free excretion of the d^'c by the 
right kidney, but none by the left. A catheter passed up the 
lett ureter stopped at 25 cm. A diagnosis of intermittent In-dro- 
uepUrosis was made. 

Operation. 

On Fcbruari* Ith. 1927. a lumbar incision was made, and tho left 
kidney was found much enlarged and reduced to a fhcll. Tho 
pelvis was dilated to a capacity of seven or eight ounecs. Any 


544 March 31, 192S] 


TEEATMBNT OP GONOBUnOEA IN 'WOMEN.' 


[ Tite Bnmsa . • 
MePICAL JoureAC 


Borfc of plastic operation seemed out of the question, so ncplirectomy 
was performed. Tlio lumen at llio urolero-pclvio junclion was 
found to bo very small. Kecovery was rapid. 

Tlic history in this caso was typical of that of intcr- 
mittout hydronephrosis. 'Daero was prosuniablj’ a con- 
genital stricture at tho nretoro-pelv'io junction. When 
secretion of nrino was free tho pelvis would becoino dis- 
tended, with consequent valve formation at tho orifice and 
increased obstruction to tho passage of urine. Had tho 
condition occurred on tho right side a diagnosis of appendic- 
itis would pi'obably have boon made sooner or later. Tho 
previous negative cystoscopic findings wore presumably duo 
to tbo fact that the examination was made when tho attack 
was over. A jryelograin might have settled tho diagnosis. 

Case hi. 

A married woman, aged 53, was soon in consultation on account 
of liaematuria. She stated that slio had passed blood on ono 
occasion seven years previously. When recovering from influenza 
in' Pebniary, 1927, she bad profuse haematuria lasting several 
days, accompanied by pain in tho right loin. Slio was .a very lliin 
woman, and tho right kidney was palpable and tender. She was 
admitted to hospital. Cystoscopy on February 4th, 1927, after 
injection of indigo^carmine, showed active excretion of dye by 
tho left; kidney. The right ureter excreted a little turbid urine, 
-but. no 'dye. The patient- was -then anaestheiized, and .the right 
'kidney- exposed by a lumbar incision. Tho kidney was found but 
little enlarged, the cortex w.as thin and its surface. lobulatcd, -tho- 
renal pelvis was dilated. Tho kidney was removed and found to 
be full of blood clot. No cause for tho bleeding or for tho 
dilatation of the pelvis could bo found. Tho patient made a rapid 
recovery. 

Haematuria as a symptom of liydroneplirosis is recog- 
nized, but is rare. Prior to operation a diagnosis of new 
growth was made, although tho history of liaematuria 
stven years previously was difficult to account for on this 
diagnosis. 

Case iv. _ 

An agricultural labourer, aged 52, had noticed a swelling in tho 
lower abdomen for about three months; for a fortnight' prior to 
admission it had been somewhat painful. Ho was a spm'e, 
muscular man. In the lower abdomen was a largo cystic swofling, 
the centre of which was somewhat to tho left of tho mid-line. 
Cystoscopy showed tho right ureter to bo functioning normally, 
while from the left came a little blood-stained -fluid. A diagnosis 
of hydronephrosis of an abnormally situated left kidney was made. 

Operation. 

Tho abdomen was opened through a left paramedian incision 
below the umbilicus. Tho right kidney felt normal. The posterior 
parietal peritoneum covering the tumour was incised, the swelling 
tapped, and six pints of chocolate-coloured fluid evacuated. Tho 
very large hydronophrotic kidney was removed without trouble 
and tho posterior parietal peritoneum closed, leaving room for a 
drainage tube. Tho patient made a rapid recovery. 

Tho diagnosis of what would otherwise have been an 
obscure condition was made easy by cystoscopy. Tho 
abnormal situation of tho kidney made a transperitoneal 
removal tho operation of choice, and it gave opportunity 
to examine tho right kidney. With a normally situated 
kidney a loin incision should, in my opinion, always be 
employed. 

Case v. 

A young married woman, four months pregnant with her 
second child, was sent into hospital as an urgent case about 
8 p.m. on December 2nd. At 3 p.m. on December 1st, after a 
good ineal, she complained of pain in the lower abdomen and 
vomited During the night she vomited slightly, and was unablo 
to sleep owing to tho pain. She stated that for some years she 
had been subject to occasional attacks of pain in the right loin. 

On admission she looked ill, the temperature was 100° F., and 
nulse 130 The tongue was clean and she was very tender in tho 
rieht loin and in the right iliac fossa. The pregnant uterus inter- 
fered with palpation. The urine was normal., Sho w.as not 
thirsty and micturition was not frequent , Vaginal examination 
did not help It was thought that pyelitis could, be excluded. 
The diagnosis seemed to lie between acute appendicitis and some 
renal condition. The patient was very ill and operative inter- 
nhvioiislv Urgent. The most practical method appeared to 
be to oper uie aMomen and, if nothing abnormal was found 
therein, to expose the right kidney. 

Operation. 

The abdomen was opened through a, right paramedian incision 
iiie 1 m:.,.,,. ^ liftlp free fluid escaped. There was no 

below the ““’i'*’,'; ' * The gall-bladder and left kidney 

inflammation ««=. fPPjfXS’ could not be felt, but there was a 
felt ri^ht^ loin behind the peritoneum. Tho 

diffuse swelling in I =. . (,„j.ncd on her left side, and an 

wound ; P' lUuch blood-stained fluid was evacuated, 

- 'anTTsacc^yt^d^'kidry c^ulf .b'otit lying high uP mder tho 
ribs. On delivering it a hole in the cortex was seen, 
which fluid was sliTl escaping. The kidney was removed to 

wound closed with drainage, A large stone was found blocKing tno 


: pelvis of the kidney. Spontaneous rupture of the thinncd-oiit 
; cortex appeared to have taken place. The patient made a good 
' recovery and did not abort. 

Spoiitunooii.s rupture of a hydronephrotic kidney must ha 
a rare event. Tlie onset of pain in the lower abdomen 
w.-is an interesting fe.qturo. It is a debatable point whether 
' I should hare opened the abdomen, but tho patient w.-is 
' very ill, tlie hour was late, and cases of intraperitoneal 
rupture of a Jiydronephrosis arc on record, so the pro- 
cedure seems to have been quite justifiable. 


TEEATMENT OF GONORRHOEA IN -^VOMEN BY 
SAVABBING WITH MERCUEOCHROME 
AND FLAVINE. 

BV 

R. S. S. STATHAM, O.B.E., M.D., Ch.M., 

. -nOKORARV OYNAECOLOGIST, BRISTOL ROVAL IXFIRMARY ; ASSISTAKT 
MEDICAL OrrlCER, BRISTOL VENEREAL DISEASE CENTRE. 

i EvF.nY gynaecologist who has to treat many cases of gono- 
; coccal infection of the female genital tract will agree that 
• there is no more difficult condition to deal witli adequately, 
'and' that any method whereby tho time of treatment can 
bo shortened is welcomed by patient and medical attendant 
alike Tho method of treatment here described has been 
tried for the last nine months at the Bristol venereal 
disease centre, and tho results are compared with those 
SLd from other methods. Although the total numbers 
are not large the results have been so encouraging that it 
seems worth while recording them in the hope that tho 
Sod may he further tried out at other centres and in 

T^SS^points in the treatment of women suffering 
The jaiiy anj regular attendance, and 

from SPP° skilled and conscientious nurse or medical 
SStil cure is- obtained; and the following factors nro 
^Sssa?in PPy treatment if good attendance is to ho 

'“i S' - 

'”’(0) The patient, must see some steady and increasiug improve- 
ment ill her atmosphere of sympathy and cheer- 

;.JfLfrd"otleto absence '’of any suggestion of moral 

‘"['’iTbt treatment must be efficiently carried out. 

• I -mpil that this method of treatment completely 
It 13 /„■! (i)) and (c). AVith regard to (d) 

“®fLrthepractiLl’treatment in this clinic is carried out 
and (c) tlic pi niir^GS and any success achieved must 

by the enthusiastic co-operation and careful 

bo attributed t t reduced the dis- 

V nf the patient to a minimum, hut they have estah- 
corafort of th confidence, which is tho first essential m. 
hshed a ^j^ats to attend regularly, 

getting the I r of the ordinary methods 

of^compieto Vh’m and bacteriological examination caiiicd 
out on each patient. 

Criicria of Cxirc. , 

..Epciitive nerrative smears from the cervical canal 
Tliree consecu interval, eacli after a 

and f and a culture from both situations, 

menstrual pe"° > treatment at all is given. 

During these __ a similar manner three months 

^ wiU he seen that the patient has been five months 

later. It ^^to^nt when the “ final test ” is taken 
without any t positive a month’s treatment 

If any of these to overy case of 

13 given and t blood tests were perfonned, 

frscLnd following a provocative dose of 0.3 gram of 
stabilarsan. 

■ Mcfhoih of Treatment rrevioiishj Used. 

Of the nia , ■ metliods devised tho following has up t. I 
El bren found by far the most satisfactory and is 

recently ocmi fou y modification of a 

SS Eriirf Tit. C"'"”' O'"'—' 


MAKCH 31 , 1928J 


TEEATMENT OF GONOKKHOEA IN AVOIIEN. ■ 


r Tms 

1. llssiCAj. JorkxAS 


645 


tlio ■nrlihh Journal of Venereal I),scase (January, 1926). 
Briefly, it consists in irrigation of tlie urethra and cciTical 
canal 'n ith a solntion of sodium chloride and chloramiiie-I, 
and then packing the yagina iritli gaur.e soaked m glycerin 
of borax, or glycerin of iclitbyol, or glycerin of eucalyptus 
daily for succcssire mecks. 

While this method of irrigation undoubtedly clears up 
the surface of the cerrix and yagina lyith great rapidity 
it fails in that it does not enable the fluid to reach all the 
folds and pockets of the yagina. The fornices retain small 
pools of infected material, and the vagina being H-shaped 
in section is not fully distended by the floiv from the 
Harrison’s tno-iray. nozzle. It seeuis to be very necessary 
that a daily complete cleansing of tlie mhole area accessible 
should be ‘ ])erformed. The packs, ivhile distending the 
vagina and keeping the glycerin in contact n ith the mails, 
unfortunately act as corks to the cervical secretions, and 
it is surprising how much muco-pus is found pent up behind 
them nhen they are mithdran-n. Undoubtedly the affio- 
ciated chroiiio cen-icitis is not improved by tbe prevention 
of exit of the quantity of fluid exuded in the presence of 
the glycerin. 

The Method under Considci-aiion. 

Tho patient is placed in a gynaecological examination 
chair and tbe vagina is ivashed out with a weak solution 
of boric acid (mercurochromc acts best in a mild acid 
medium). A fenestrated Cusco’s speculum, as large as can 
bo tolerated, is then introduced and the vagina and fornices 
are fully stretched. All muco-pus is now cleared away with 
the boric lotion, and then a swab, sopped in 1 per cent, 
mercurochrome, is rubbed all over, the ceivix and vagina, 
so that the solution reaches every part, including the orifice 
of the cervical canah As most cases display sonic urethritis 
at tbe beginning of treatment a small quantity is run into 
the bladder, retained there for a few minutes, and then 
passed again. The speculum is removed and the treatment 
is now ended. 

In cases in which tho gonococcus seems .resistant to 
mercuroehrome a change is made by using 1 in 1,000 flavine 
for seven days in exactly the same way, and then reverting 
to the morcurochrome. 


.Complications . — The above fifty-two cases include one 
case of acute gonorrhoeal rheumatism of the wrist-joint, 
which, cleared up very rapidly, and two Bartholin’s 
abscesses, which were incised as complete removal was 
impossible. 

Failures . — Two cases have failed entirely to respond to 
treatment and have also made no progress with rontino 
treatment. In both cases there is a possibility of frequent 
reinfection, one case being a prostitute, while tho other 
has a' husband who will not undergo treatment, althongh 
be is infected. 

It will be seen that by tbis “ swabbing ” melbod tbeVc 
is a reasonable chance of getting the first negative smear 
in about a month, while the patients’ symptoms have 
usually vanished some two weeks earlier, and they feel 
correspondingly encouraged. As soon as a negative smear 
is obtained active treatment is stopped. till after the next 
menstrual period, and the patient need not attend, again 
till that date, when she comes up for smears and oultui-es 
only. 


Comparison with Cases Treated hy jtoutinc A. 

Fourteen cases, treated by Iloutine A during tho same 
■ period, were taken as control cases. They were not 
selected cases, being the first cards wliich came . to band 
of those patients who had attended regularly. 

[ . Da.vs. 

Average number of days to fast negative smear ... 

Longest number of days to first negative smear ... 270 
Shortest number of days fo first negative smear ... 60 

There were twenty-one cases in which • treatment liad 
; been going on for over six months, but the attendance was 
, not absolutel}' regular, and so they are not included in the 
above figures, as the comparison was not considered fair. 

Cases Treated first hy Foutinc A and then hy 

jltcreurochromc Su-ahhing. • " 

These cases are perhaps tho most interesting. Fifteen 
cases which had been under Routine A for some time were 
examined and smears taken with positive results. They 
were then put on to the morcnrochromo treatment, with 
tlie following results: 


Comments. 

This method of treatment is rapidly and easily carried 
out,- hut entails care and some practice on the part of those 
performing it. It is absolutely necessaiy that all pai'ts of 
the yagina bo fully distended and swabbed over, and that 
Jio pockets are left untreated. It allows free drainage for 
nil cen'ical secretions and causes no irritation to the 
inflamed surfaces. Mercurochrome, in an acid medium, 
penetrates to a remarkable extent, and the imiuedi.ate 
result is a clearing up of the offensive discliarge, with a 
consequent encouragement of the patient. Since using 
bills method of treatment there have been practically no 
instances of patients failing to attend regularly and com- 
plete the treatment, thongli many of them Iiai'e to come 
considerable distances -for- their d'aily swabbing. 


Fcsults and Comparisons. 

Forty consecutive cases were treated daily except during 
tho menstrual flow. (A few patients missed one or two 
troatments.) In all cases the gonococcus was present at 
tho beginning of treatment. 

Arerage number of days from tbe beginning of 
ticntmcnt till the. first negative smear* was 

. oblamcd 53 j 

. imdoi triatmont (one case) lOO.'o 

Shortest period under -treatment (one case) ... 4.0 

8*®* smear of the final 

Efar“d over .ngaim occurred afterwards the wliote series was 

Bearing out the extremes at both ends, it w.os found that 
twcnty-cigut days sufficed to render the smears necrativo 
in most erases. 

'Tivclvo cases were treated for one or two weeks with 
fi.avino 1 in 1,000 in place of incrcurocliromc. 


Average number of days under treatment 
^ngest penpd under treatment 
biiortc^l period under treatment !.*. 


Pav5. 

45 

91 

17 


Averag-e member of days under Kotifine A and 

still infected ... 1 111.2 

Average number of days under mercurochrome 
to the date of first negative sxrab ... 28.2 

In addition to tliese cases treated at tho venereal diseases 
centre, I Imve foinid this a most useful form of treatment 
in private, practice. Among others, there Jiavo been izve 
cases of pregnancy treated. Tliey all made an uncom- 
plicated rccovei'y and there vras no ophthalmia amongst the 
infants. Tlie only essential is the sen'ice of a good nurse, 
or personal application of tho mercui-ochrome hv tho 
medical attendant. 


Conefnsjons. 

1. This method of treatment is efficient in that it appears 
to cure the disease. 

2. It greatly shortens the time under treatment, and so 
is a sound economic factor,, both for tlie patient and the 
venereal disease centre. 

o. It is not in any n*ny painful or unpleasant. 

4. Tho I'apid improvement in the symptoms is onconr- 
^6*^5 patient, and so regulariW in attendance is 

promoted. 

It is very probable that there may he other substances 
which will jirovo even more efficient than mercurochrome, 
and it is intended that a trial shall he hegun at once of 
the solution of hrillinnt green and crystal violet, used hy 
iVIessi^. Berkeley and Bonner as a vaginal disinfectant, 
this to ho used in an exactly similar manner to tho 
merniroch ron j e. 

I have to thank Hr. S, Ilarfly Kingston, director of the Bristol 
centre, for his cncoura^rmonl in the trial of this method and the 
transfer of numbers of his cases on Routine A for comparison; 
also tho other medical ofQccis of this clinic for their Iicarlr 
co-operation, and the sister and nurses for their cntim«iasm in 
carrying out tho treatment and their interest in reporting the 
progress of the ca«es under treatment- 



/646 LTabch 31 , 192 S] 


UESrCEANDA. 


r Tnr DBrnffl 
L Arj-’DirAL .fODH'fAt 


fltunmratt&a : 

MEDICAL, SUEGICAL. OBSTETEICAD. 

VESICAL BILHARZIA: DOUBLE INFECTION. 

Dr. H. FAinnAniN states, in a memorandum that appeared 
in the Dritish Medical Journal of January’ i4th (p. 52), 
that he knows of only two previous rcforenccs to the exist- 
ence of double vesical infection of S. hacmofobitim and 
S. mansoni. Ho suggests that such cases are commoner 
than is at present supposed. 

In a' paper. published in 1926* I have recorded the exist- 
ence of S. mansoni ova in the urino of no fewer than' 
56 patients. Of these, 48 had double infection with both 
parasites, and 8 had pure S. mansoni infection of tbo 
urinary tract. These cases wero found among a total of 
7,090 individuals examined. Urinary hilharzial infection 
was found in 2,755 — ^that is, 38.9 per cent. Of those 
infected, 1.7 per cent, liad double infection with S. haema- 
tobium and S. mansoni. Among the same series of cases 
S. mansoni infection of the intestinal tract was found in 
3,747 out of 7,136 individuals who submitted samples of 
stools for e.xamination. S. haematobium infection of the 
intestinal tract was found in 65 cases (0.9 per cent.). 

It is quite evident from the. above that double infection 
of the urinary and intestinal tract with theso two species 
of billiarzia is by no means rare. 

3M. Ehai-il, M.D., Ph.D., M.R.C.P.Lond.,- 

Professor of Parasitology, Paoulty of Jfediclne, 

Cairo, Egypt. 


HEAT CRAMP, 

The recent discussion in the British Medical Journal on 
this subject prompts me to write a note on some cases 
once under my care in which the effects of high atmos- 
pheric temperature were manifest in two ways: first, as a 
mild degree of the heat-stroke common in high tempera- 
tures with excessive moisture, well written up in text- 
books; and secondly, cases analogous to firemen’s cramp, 
only occurring amongst the engine-room staff of a modern 
motor vessel, who, though submitted to hard work, do not 
have the excessive toil of the ordinary ship's fireman. Tho 
high engine-room temperature (130° F.) sometimes reached 
in tho tropica is an obvious factor, but associated with it 
is the rather stagnant air, which is vitiated by exhaust 
fumes with a high percentage of carbon dioxide. 

Without exception the cases occurred in men of tho 
finest physique, the onset occurring after several days’ 
exposure to the conditions with malaise, headache, and 
crampy pains in the limbs and abdomen. The body tem- 
perature was raised to well over 100° F. with rapid pulse. 
About twenty-four hours off duty, with drugs to relieve 
pain, and body fluids replaced (tea, lemonade, etc.), served 
to restore them to normal. I did not try the use of 
oatmeal water, which is often recommended, but should 
think this is only an additional way of replacing fluids. 
A.S a prophylactic the addition of salt in small amounts 
to tho mess drinking water, as has been suggested by 
various writers, seemed to prove efllcacious, and as no one 
knew that this was being done there were no complaints 
about bad water. 

Heat cramp in firemen is usually ascribed to excessive 
tissue fluid and salt loss, which is quite a possible explana- 
tion; but in the cases outlined their t.ssks were nothing 
approaching the toil of a stokehold, and suggest some 
failure of the thermic centre, due to or resulting from 
iusulScient cooling of the body, as by reason of their build 
the surface weight ratio of the men was diminished, with 
consequent heat retention, which did not occur in the 
lighter men doing the same work. 

Ravneb Thboweb. 


METASTATIC OPHTHALMIA. 

The following case is, I think, worthy of note on account 
of its rarity and tho dilBculty in early diagnosis. 

A well-doyelopcd child, aged 3^ years, had just been discliarged 
from an isolation hospital after treatment for an ordinary attack 
of measles, from which it had completely recovered; opart from 
tills thoro was nothing abnormal in the' past history. It. was 
brought to tho casualty department because the right eye was 
inflamed; this was considered to be a mild attack of conjunctivitis 
following measics.' When I saw tho eye two days later there 
was considerable injection and chomosis of the bulbar con- 
junctiva, but tho outstanding featuro was a very, considerable 
proptosis, with a puffy oedema of. both iids. • The cornea, anterior, 
chamber, and iris wero normal. The case was considered to bo 
ono of orbital cellulitis, probably secondary to an ethmoidal 
infection, but. tho- temperature, and- puiso'. . wero. normal, i .On. . 
admission to hospital aw orbital exploration .was made,, but' no- 
pus was found. Three days later a second anaesthetic was given, 
when tho typical yellow reflex of pus in the vitreous was seen 
through tho pupil. The eye was eviscerated and found to be filled 
with pus, from which a pure culture of pneumococci was obtained. 
Tho orbit contained .no pus, but showed considerable, swelling of 
all tho rctro-ocular tissues. 

This was a true case of metastatic panophthalmitis; 
the origin of tho pneumococcal infection was probably 
bronchitis, which so commonly accompanies measles. The 
septic embolus apparently lodgefl at tho posterior pole of 
tho cyo in a retinal or choroidal vessel. This focus of 
infection must first have made its presence felt in tho 
retro-ocnlar tissues, hence the very coiisiderablo proptosis. 
Tho infection took some time to reach tho anterior part of 
tho vitreous and so become visible. The correct diagnosis • 
could have been arrived at much earlier had an ophthalmo- 
scopic examination been made, but every indication pointed 
to an involvement of the orbit; metastatic ophthalmia was 

not E. R. CmMPEns, F.R.C.S.Ed. ■ 

Bristol Boyol Infirmary. . 

TUnOD GROUP PERCENTAGES FOR ARABS, 
jiLUUV AND JEWS; 

Analysis of 1,758 Ghootinqs. 

Tv the course of routine blood grouping of patients at ths' 
hospital labowtory during the last five years a certain. 

of data has become available which may be of 
grnernl LeZ. In the aeoompanymg table the 


Armenians and Jews represent well-defined unmaxed racial 
ifroups- under the heading of Arabs a ^rtain number of’ 
Turks ’ Turkomans, and Kurds have been qnavoidably. 
• 1 >rIo/l Their number is relatively small, and the 

^nSs of a small series of "pure” Bedouin Arabs has 
"Jirurnctically identical figures for the distinguishing 
give p ^ J . jjj tiie course of the next - 

fwTelrs tolmpile a series'^for the Kurds, about whom, 

r n _ Tr-finWTJ 


Bace. 



Group I. 

1 

Group n. 

Group m. 

Group 17. 

61-6% 

345=37% 

I?4=21% 

333 =35% 

62-6% 

346=53% 

89=14% 

176=27% 

M=8% 

58=34% 

34=20% 

6? =78% 


-n ho nbsorved from tbu above figures that whereas in the 
Tfofr.— It will bo ^ the relative proportion ol Group It and Group IV . 
case of Arabs ^ figures tbe proportion Is as 2 to 1. 

,s as 1 to 1. in Ann ^ Aliountan, M.D.Cantab. 

Altounyon Hospital* Aleppo. 


Weymouth. 


* A comparative study of the methods utilized in the treatment of 
bilharzia^ij*, with a report, on a. new remedy, “ Eayer..Sp.212,"'ArcA, r. ' 
Sehifff. Troviri'Hjffftcnet U 925, B. 30, pp.‘ 4S1-467. 


wmiEIGN BODY IN THE MAXILLARY ANTRUM, 
w n-irv bodies in the antrum of Highmore are execed- 

i-red 7 was admitted to tho Victoria Hospital, Bang;> . 
. t the history of having had a swelling of the right cheek 

for*’ rer a rear At first the swelling appeared below the inner 
^t^hus of th^right eye; an abscess, presumably lacrymal, formed 
canlhus of the ngm hospital. There was purulent dis- 

rharp^^throuTfh the incision for about two weeks; it then healed, 
S^a^mittl sinus, but the swelling mcrua^ iu,^-e. and 

1 I^Saa'bc^.me\7ocLd^ L.six xnonUis the patient 


-MABCH 31, 1928] 


TREATMENT OF CANCER OF THE CERVIX. 


[ Thb liRrn«tB /i 4.7 

MrDICAf. JoCB>fAL 


'had not- hecn. able to broathc - through it. Occasionallj- there was 
-bleeding’ from the nose. 

On admission to the Victoria Hospital the whole infra-orbital 
region on the right side was found to be sjvollen and slightly 
ocdematous; the furrow between the nose and the check was 
obliterated. There was a small lacrymal fistula, wdiich discharged 
a drop of pus on pressure. Tlio right eyeball was pushed slightly 
upwards and the right 'nostril was almost completely obliterated, 
speculum examination being impossible. The right side of the 
palate was pushed do%vnwards. There was no pain or tenderness 
over the check or palate. Transillumination showed marked 
opacity on the r^ht side. • • • 

A Caldwell-Luc operation was performed. On making the usual 
incision through the gingivo-labial fold and retracting the labial 
flap upwards the anterior wall of the maxillary antrum was 
found to be absent, and a finger was easily introduced into tlie 
antrum. A large mass of cholesteatoma, of the consistency of 
putty, was evacuated, and in the middle of it a hard oval rhino- 
Jith was discovered. A large opening in the lateral wall of the 
nostril was pi-escnt, establishing a communication with the 
antrum. Adhesions in the nostril were carefullj’ broken down. 
After thoroughly clearing the antrum it was treated with bipp, 
lightly packed with gauze, and drained thi*oiigli the nose, tho 
gingivo-labial incision being finally sutured. On breaking the 
rbinolith it was found ’ to' consist of a whole tamarind seed, with 
a thin crust of calcareous deposit on it. 

The gauze plug Avas removed after fortA'-eight hours, and the 
antrum Avas irrigated daily through the nose. Tho patient made 
an uncA-entful recovery and Avas discharged cui*ed tAvo weeks after 
the operation. 

In the I?cv«c de TMrynnologh, d’Ofohgic ct de Ithino- 
wgte^ 1924 (vol, xlr, p. 4Q6), Gamaleia reported a similar 
caso in which maxillary simisitis was kept up for two years 
hv a shell splinter which iiad outored the antrum throuKh 
the cheek. I am indebted to Mr. H. E. Powell, librarian 
Or the IxOTal Society of IMedicinc', for this reference. 

recorded tho following features are 

worthy of note: 

1 . The foreign body evidently entered the antrum from 
the narcs after ulcerating through its lateral wall. 

o ’ , spread into the laci-ymal sac through the 

""I'en the primary focus of suppuration was 
removrf tho lacrymal fistula healed. 

iinwsvilL remained in the antrum for an 

unusually long time; I think it must have been there for 

rL r P='tient had no 

r '"Produced the tamarind seed into 

was niiK- must have been put in ndien she 

calcsrenn. subsequent deposition of 

calcareous matter had converted it into a rliiiioiith. 

Tlo.on.„ospu,,, 


%in:ts 0f 

TREAI3IENT OP CANCER OP THE CERVIX. 

2 Mh** wifh*^AV^^ PT judical Society of London on Slavch 
tirewnn^ • the pre-sident. in the chair, 

XLcs In r'r by H. r‘. SruNcim on 

other hv Or ”i^''®utment of rancer of the cervix, and tho 
cancer of tho r^Ar-r? Bmssels on treatment of 

at pages 535 and ‘‘U'lmtion. The papers are printed 

drerared”his ^^ cCann 

a scepticism whicli'lis^' "'1^'’ regard to cancer statistics, 

tioiicd the common idia thaf 0 ^ 0 ^ 
own impression w.ss that Rires 

origin, with local raanifetetio^ general disease of ohreuro 
the nstiont hcfnnn *1 ‘utions. If one happened to know 

woulS lie ’found Ont in 

a period of snhlicalth hefnr 

appeared. Ho refcrrcl T . '"anifestation 

results of rr:.«"y%*ttrid h° 
similar, and ho ti-icno ti “ ^ superficially were 

some fieW 07 x 0 ^ ‘i ‘*'0 dilfcrenco to 

AVas cancer 7cr cured 2 ’"ww'’'’’ 7 bcrsclf. 

frequent rectn^nres init 

■patients went for as’lonc ® ’’“I’P''" ^^''at 

operation without roe urefnre U 7 

■.mxence. . At the same time one felt 


■that if-siieli patients lived long enough the cancer would 
at some time or other recur. As to favourable signs in 
prognosis, he thought the most important was that the 
patient gained in weight after the operation. Tho tvpe of 
patient was also an important matter. He himself viewed 
with much more misgiving the stout woman who c.amo up 

• for operation than the elderly dried-up woman, iijioii whom 
probably the results of operation, whether limited or^ exten- 
sive, would ho much more siieccssfiil. He was not yofc con- 
vinced that hotter results • could he obtained with radium 
than with tho knife, though if such were proved he would 
give lip the knife at' once.' 

Dr. M.ii.coi.ii Doxmldsox discussed the advantages and 
disadvantages of operation in cases of carcinoma. One of 
the disadvantages was that the operating technique took 
years to learn, and that the initial movtality among 
patients undergoing operation was considerable; further, 
the fear of operation deterred many patients from j;oeking ■ 
advice sufficiently early. On tlie otlior hand, there were 
certain points in favour of radiotherapeiitic methods : tho 
initial mortality was negligible, and the technique was so 
simple that any g}-naecologist could employ it after expe- 
rience of a few cases. The disadvant.nge of radium therapy 
was that at present there was no scientific evidence that 
one could deal in that way with infected glands. It might 
be said tliat there wore two schools, each practising a 
different technique; one of them believed in putting radium 
on the cerrix, .and another in putting it into and around 
the growth by means of needles. It was in Brussels that he 
•first saw the needle technique, and bo bad been impressed 
by it ever since. But it was necessary in all these cases 
to wait for a number of years before speaking with any 
assurance of the real character of- tho results. A certain 

• amount of investigation on what was happening in tlio 
individual cell tinder the action of tlie radium had been 
carried out at Cambridge in the Straiigeways laboratory. 
The evidence so far obtained, working with tissue culture's, 
was that more damage might bo done by small closes 
employed over a long time tliaii by largo doses employed 
for a short time. It was well known that the gamma rays 
of radium had a selective action on all quickly growing 
tissues. He proceeded to show on the screen tables of casc^ 
operable and inoperable, treated at St. Bartholomew’s, 
with tho mode of treatment and the duration of tho 
I'csult. A combination of AVertlieini’s operation with 
radium had given good results in some cases. 

Dr. Doucus Wbbsteii thought it desirable that massive . 
radium therapy, the radium boiiig used at a distance 
should be considered, and it appeared rather extraordiimr-v 
to him that the head of tho Radium Institute, in a recent 
address before another society (ISrifhh Medical Journal 
Mavcli Zath, p. A96), should have stated that he did not 
believe spocmlly in distance radium therapy. Tlie speaker 
thought that results obtained elsewhere suggested that this 
was a very valu.ihle iiietlind. Il’ith regard to a-rav work 
^iiemtercsting point in connexion with gyiiaecologicai 
treatment was tlie use of deep a: rays, botli pro-uperative 
and post-operative, in combination with surgical work He 
thought there was considerable value in a combination of 
metuoas. 

Dr. SiuxTvT Foiisdxke said that nowadays one rarely 
opened a medical ioiirnal without finding 'a report of 'a 
number of cases of carcinoma relieved bv radium, hut what 
It was iiecessaiy to reach was a greater' degree of cortitiido 
^ regard to cure. He hinisolf treated six operable cases 
m this way m 1921-2Z, and out of the six, four were still 
alive and well. M hen dealing with early carcinoma of the 
cervix by radium, it was his experience that in one-third 
of tho cases the glands were affected, and he was perfectly 
sure that the application of radium in the vagina and 
uterus would not influence tho infected glands in the 
ileum region. He was a little doubtful about Dr. 
Donaldson’s remark that anyone could learn radium 
technique verj- quickly; in a certain clinic ho found an 
eminent gynaecologist using radium evidently with 
insufficient knowledge of the agent he w,n< employing. 
The important thing about radium was tho dose, and the 
dose was determined not only by the numher of hours tho 
radium was loft in position, ni'ulti|)Iicd hv the weight of 
the substance, hut also by the nature .a'nd thickness of 



B 4 a MARCH 31, 1928] 


THE PUriPIiESS TOOTH. 


; r The Crrnjs . , 

• t yittilClL JtlCEifit 


the screen employed and the distance of the radium from 
tlio growth. 

In fui'ther discussion Hr. . G. ViLVANDnu spoho of tlio 
limitations of x rays in treatment, especially in deep 
therapy. If only an a’-ra}’ tuho, actuated from a sourco 
of superlatively high voltage, could ho made, results moro 
strilcing and consistent might ho forthcoming. Dr. 
BAnN.aiD referi’ed to the frequency with which in carcinoma 
of tho cervix extraordinarily rapid and widespread dis- 
semination was seen. Dr. A. Goodwin mentioned tho 
lalue of radium following upon operation, hut recounted 
particulars of one or two accidents with radium, such as 
lost needles. Dr. Spjjnceb confined his reply to praiso of 
Dr. Choval’s contrihution to tho subject, and Dr. Chevai. 
added a few ivords, in which ho argued against tho too 
abundant use of needles, and also urged great caro ns 
to tho dose actually given, especially in relation to tho 
distance from tho source of radiation to tho tumour. 


THE PULPLESS TOOTH. 

The Sections of Odontolog}’, Electro-Therapeutics, and 
Pathology held a combined meeting at tho Royal Society 
of Medicine on March 26th for a discussion on tho pulpless 
tooth. Mr. W. Rushtox was in tho chair. 

Mr. Prank Coleman, in a general introduction to tho 
subject, said that more than half tho population had 
pulpless teeth in some form or other, and in 10 per 
cent, tho number of pulpless teeth might ho from fivo 
upwards. He assumed tho term “ pulpless tooth ” to 
denote a tooth from which tho pulp had been removed, and 
tho tooth subsequently treated by filling, crowning, or 
some other moans. A pulpless tooth should not he 
designated a “ dead ” tooth, for tho periphery of tho 
tooth, tlio cementum, retained some vitality through its 
jieriodontal membrane. Tlio main principles concerned in 
tho treatment of teotli with exposed live pulps or tooth 
containing dead pulps ivcro tho following: (1) To remove' 
as far as possible every trace of pulp tissue. In teeth 
with live pulps tho dcsoiisitization of tlio pulp must first 
he assured. This could he brought about by tho employ- 
niont of a local anaesthetic or a caustic (usually arsenic), 
iu which latter case a few days must elapse to bring 
about complete devitalization. Tho method by local anaes- 
thesia was more scientific and would leave tho tooth in a 
less unhealthy condition. (2) To cleaiiso tho root canhl or 
canals of tho tooth, and to treat tho periapical tissues via 
those channels. ( 0 ) To fill the cavity of tho tooth when the 
jieriapical tissues had ceased to discharge through tho 
canal and had formed a scar at the tooth apex. Most 
dental surgeons recommended filling tho roots of tho tooth 
as ivell as the cavity iu the crown (that is, the pulp 
chamber), as by this moans the pei'iapical tissues could 
be further treated if and when necessary. The method of 
treating pulpless teeth which he himself had followed for 
nearly a quarter of a century depended upon the supposi- 
tion that a scar formed around tho apex of tho tooth soon 
after the removal of the pulp. The operation of excising 
the end of a tooth involved in periapical destruction did 
not appeal to him as a rational method of treatment. Tho 
extent of disease of the root was incapable of diagnosis, as 
no lino of domarcation was formed between the living and 
dead portions of the teeth. It therefore became merely 
the empirical removal of a certain amount of necrotic root. 
TJio opening and scraping of sinuses connected with dead 
teeth, tho injection of drugs through those sinuses, and 
other such-like methods were only iialliative whilst tho j 
cause remained. 

Mr. Owen C. Morphv said that all dental surgeons wore 
conscious of the gaps in their knowledge of this problem. 
Ho himself was inclined to the removal of pulpless teeth 
as far as possible, hut there were many occasions when an 
attempt to save even a definite septic tooth was desirable 
•and justifiable. The fundamental principles Underlying 
such an attempt were that the patient mimt ho in good 
health and, except in raro instances, not beyond middle 
arre. TJie justification for the saving of such a tooth was 
that it obviated partial denture, _ which might sometimes 
lead to a greater degree of infection than arose from one 
or two pulpless teeth. He mentioned that that weU-known 


ohsorrer R^eston Price, who, with a team of dental bm- 
goons, bacteriologists, and laboratory, workers, had carried 
out a very extensive investigation in dental sepsis, had 
produced a mass of evidence condemning the puipless 
tooHi, hut his experiments were conducted on rabbits, 
which wore veiy susceptible to streptococcal infection, and, 
morcov'or, received a sudden massive dose, giving tbeni 
littio chance of developing immunity, which was not the 
w.ay in which infection ordinarily developed. Tlio speaker 
bolieyed in tho value of zinc and iodine ionization for 
stcrilizmg those portions of the root not accessible to 
mechanical measures, tlio galvanic current conveying the 
ion into and through tho finest channels. 

Dr. H. M. Worth spoke from tho radiogi'apliic point of 
view. Ho said that thoro were no intrinsic radiographic 
changes to ho seen in a tooth without a pulp, hut there 
wore often certain appearances in or around such a tooth 
which wero of great value in aiding its recognition. After 
discussing, with tho aid of radiographs, the ovitleiice which 
might bo regarded as certain that a tooth was pulpless, and 
tho evidence that was only suggestive, Dr. Worth said that 
tlio radiograph was of use at the commencement of treat- 
ment to climinato tho presence of apical infection, and 
later to follow the effect of treatment on apiciil osteitis. 
It was important, to know whether the apex of a tooth 
under treatment, was completed. A tooth .with a completed 
apex showed tho pulp canal converging towards tlio apex, 
whereas when tho apex had yet to form the canal was seen 
to divorgo towards the apex and the apical foramen to ha 
“ funnel-shaped.” To ascertiiin tho number, direction, and 
lonrtli of tho root canals it was advisable to insert small 
metallic broaches before taking a radiograph. During tho 
process of treatment' of root canals it was sometimes neces- 
sary to ascertain tho presence of piilp nodules in the canal, 
or of a pieco of broken instrument. Perforation of tho 
floex or side of a tooth, was usually seen only iu a radio- 
graph when a metallic broach or pieco of wire, had heeji 
inserted into it before radiography; It was often considered 
necessavv in the treatment of a- root canal that tho apex 
Sd be reached by tho fiUing material, and consequently 
a radiogram was indicated to ascertain this point. Occa- 
Lnally tho filling would be seen to have passed beyond tho 
Ho indicated the limitations of ffi-ray examination, 
anrpointed out that radiography was only a “ positive 

jIuBRiy^BVicK spoko on the value of light in the 
I .„™t of septic iiifoctioi). Tho use of artificial light ivas 
the sSiieot of a good deal of misconception Tlie destruc- 
+*nn nf micro-organisms a side issue. The cloaung up 
M sentic infectiL in various parts of the body following 
f wXdirccted application of general light treatment was 
“ - Airppt effect due to the conversion of the rays into 

“l ' V-il enei-EV in tho tissues, so that the substances were 
*Xstcd aS Sstributed tiiroughont the body. It was 
synthesiz , destruction of bacteria 111 infected 

au^ teXby ultra-violet rays, whoso lethal effect was 
gums Ho strongly deprecated the application 

^f’^ulTra violet radiation to mucous membrane; it was 
atnus and unjustifiable, and some very .unforUiiiato 
dangero J following such .applicatious to. tho 

resulte had, been^ treatment by the red 

throat, action various mfcctivo conditions 

A im In tUo.direct treatment of pyorrlioca red np'S 
sleared P- , value. Gums which were spongy aud bled 
a-nS irave some purulent discharge .were found to clear 
aasily and gave P radiation, which, how- 

.pu-a.. 

“^'i think that any great amount of light was going 
'”°h®Amd on a particuhrly dark problem as a result of 
,0 ^ Ho wished to say a word about pidpless 

Jeciduous for pulpless deciduous teeth was 

;he , -.r^ate With regard to the permanent teeth, 

lot really between teeth devitalized 

^P^al surgeon and teeth already dead. • Ho believed 
t't!^^L^nemissibfo to treat dead teeth, hut a much greater 
"vntv was now laid upon the dentist in this lespc 
rarwfs th"o case twenty ye^rs ago. His treatment must 



Mkncn 31, 192S] 


[ Titr Bnrrira - • 

MeDICU. JoCKilAS «J^J/ 


TREATMENT OF EEETHSiAE BTRICtoBE BX EXCISION. 


bo in the main antiseptic rntlicr tlian aseptic, for aseptic 
dentisti-r, Jic thought, was not yet iiracticaiile. In the 
details of treatment he himself preferred to fill canals 
rather than leave them open as Mr. Coleman had suggested. 

Dr. F. J. BRAiLsroM) discnssed, -with the help' of many 
radiograms, the K-ray appearances of pnlpless teeth, and 
gave an analysis of radiographic pitfalls, whieh, he said, 
might arise from faulty technique of from misinterpreta- 
tion. Misinterpretation of the radiograph was due largely 
to lack of o:sperienco in studying shadows and to lack of 
knowledge of general and dental pathology. Every radio- 
logist who had correlated the jadiographic and clinical, 
operative, and posf-iaortcm findings knew that the radio- 
graph might show only slight changes, even when a massive 
lesion was present. Thus, with acuto inflammatory lesions 
of the skeletal tissues the radiograph might give no sign. 
One could almost say, especially iii acuto conditions^, that 
the more attractive the ■ physical signs the loss the radio- 
graphic signs. In the case of dental radiograjihy, as the 
lesions were often small, it was all the more important to 
pay attention to the finer details. There was no question 
that for the hest intoiqnetation of radiogi aph.s the ohsciwer 
must have a good knowledge of the noi'mal and pathological 
anatomy of the part. 

Dr. Meviijck Jokes recalled that pathological changes 
seen in radiograms were not produced immctliatelv, hut 
were the I’csult of a long morbid process. Recent in- 
fections, even though severe, often showed no .signs raclio- 
logically. There should he complete co-ordiiiatiou between 
the work of the dental surgeon and' the pliy.sician. He 
quoted some authorities to the effect that wlienover a 
tooth showed pathological change it should be extracted. 
The speaker himself believed that a pul])lcss tooth in a 
patient who was the subject of general sepsis should be 
extracted, cren if it showed no pathological eliange; in 
such a case the tooth might at any time heeoine a secon- 
dary focus. In the health}', vigorous young adult, if a 
pnlpless tooth were left fa siftf, it should he periodically 
reported on after radiological examination. 

Dr. A. ErviNGSTOK joined issue with Dr. Worth, whose 
contention that the r-itality or the [lulplessness of a tootli 
rouid be diagnosed by radiological examination appeared 
to hun unconvincing. Any contention based on the pres- 
ence or absence of the lamina dni-a fell to the ground, 
becnise Uie lamina was not continuous. A cyst half an 
inim in diameter might show involvement of adjacent teeth, 
and a though those teeth were stripped of tlieir peri- 
odontM jnembrane yet they were alive. He did not agree 
with Dr. Coleman with regard to unfilled canals. The 
^eakor did not think tliis method entirely satisfactoiy, 
orent of accident to a. tooth so treated, it 
coma not he expected to -resist infection — certainlv not 

method of filling hv ‘silver 
nitrate. With regard to apicectomy, this w.a.s a successful 
operation, hut rt must be jiremised that cases subjected 
o It weie carefully chosen and the hest possible technique 
aptied. It was never certain what was behind the apex 
ot a tooth, and it was always possible that there might 
be organisms present. ^ 

Mr. St. J. SrE.Amr.AK did not agree with JH. Coleman 
tE-it apicectomy was an empirical method of removing a 
ww^'to ' " spb^al obj^rct 

which \vc" ■"’itli the last quarter of an inch, 

f J ‘ ^ ’rtPortant part. Iii •■ipieeefomv he era- 

hnd^ «n “ S»1 aged 19 on whom he 

had successfully employed the operation. 

rot Vn timt a pnlpless tooth should 

not ho retainecl. Inflammation might exist at tho anex 

was“vorv i-h 1 « a''!*';?"* I’«<’'>e1ng symptoms, and it 

at all ‘ -ic' dent "*1* ‘■''‘*‘°g*‘ap'>y would give no evidence 
come ti ‘Vl ‘ surgeon aud as a radiologist he had 

r C A 1*1 palploss teeth hecanie 

nX?css A *“* Ai'"**® ‘"fetioii, and the majoritv of 
reiin ^1 taetl' "-e'-e thaso from wluci, a live pulp had hcen 
removed ,n the process of filling. x„ deali m witli ihlZ 

di^i t5;o^“x t 


thought the effort foredoomed to failure. He believed 
that radiologists should confine their attention to obtain- 
ing a good radiograph and rc'pnrting what it ajipcarod to 
show; they should not attempt to prescribe. He hoped 
that dental surgeons would impi-ess upon patients the 
importance of a proper diet. 

Dr. G, B. B.attek agreed that the majority of pnlpless 
teeth sooner or later caused trouble, but he cited himself 
as an exception, since he had a pnlpless tooth which had 
gii-en him no difficulty for twenty years. 

The Cu.Aliixt.AN (Mr. Hushton), summing up tho dis- 
cussion, mentioned that thirty years previously he had 
lilugged a tootli of one of his pupils with cotton-wool 
soaked in iodoform, and it had only recontlv been ex- 
tracted. Ho did not suggest that that w.as the sj'stem ho 
practised to-day,- hut the case illustrated the length of 
time for which a pnlpless tooth might last! He himself 
had a pnlpless tooth which hb did not think canie into tho 
category of a pathological entity as insisted on by some 
of tho speakers. He helicved. that if a pereoii a'as healthy, 
with a vigorous resistance, little harm would come from a 
filled tooth. 


TREATMENT OF URETHRAl STRICTURE 
BY EXCISION. 

At a meeting of the Section of Urology of the Royal 
Society of Mcdiciiio on JIarcli 22nd, with tho president, 
Mr. Pb.ank Kidd, in the chair, a discussion took place 
on the treatment of urethral stricture by excision. 

Mr. Frank Kidd opened with a brief survey of tho 
liiston' of the ojieration, followed by a short description 
and compaiisoii of the methods of Hamilton Bussell and 
MacGowan. It was claimed by these surgeons tlmt com- 
plete exebion of a portion of the iirethi-a did not interfere 
with tho blood supply or .the jiowt’r of erection, and that 
there was no rccurience of tho stricture requiring further 
passage of bougies. Mr. Kidd favoured MacGowan’s pro- 
cedure with iireliminary suprapubic cystotomy and the 
passage of retrograde bougies from the bladdei- to the 
stricture, since isolation of the iiosterior ureUira and the 
division of tho compressor urethrae produced incontiucnco. 
He^said that the use of the operation of excision of urethral 
I stricture was very limited, since most strictures could ho 
[ treated and cured by internal urethrotomy with subsequent 
USD of Kollmann’s dilator or by simple dilatation. He 
Imd employed e.xcisiou chiefly in periurethral infection 
with fistula formation, and in gases of hard, palpable tunnel 
stricture. He stated that for a successful result the free 
excision of septic, wounds, tracks, and fibrous tissue was 
essential. He Jiad found that excision of fistulae ivas a 
much more satisfactory procedure, than wide drainage. 
Since almost all strictures were situated in front of Die 
triangular ligament there- was no need to damage the 
posterior urethral muscles, and if he found a Bltiilons 
track pa.ssing through the compressor urethi'nc muscle he 
did not damage this structure by following the track 
through it, hut merely ligatured the track on the surface of 
the mnscie, since the deeper portion of the B^tula usiia Hi- 
disappeared. If possible lie. tried to leave the roof of th'e 
iirethra but if this was not advisable he excised the 
alfectcd portion completely, mobilizing the anterior portion 
in Older to join tlie cut ends, but never mobilizing tlic 
pcstenor portion, owing to the risk of incontinence. Ho 
repaired the urethra over a metal bougie^ whicli ivas 
lemoved at the end of tlie operation, and snprapnhic 
drainage was continued for about fourteen days until the 
perineal u'ound had healed.'. He did not know ivhcther 
excision obviated the necessity for le.ss frequent post- 
opei-ative dilatation than other methods, because most of 
the patients on whom he practised excision had been sailors 
with neglected strictures, who did not attend for further 
observation after operation. Mr. Kidd concluded by saying 
that excision should be employed more often in preforenee 
to external urethrotomy, always in cases complicated with 
fistulae, and in some inflamniatorv- and tinuniatic tunnel 
strictwes aud strictures of the penile urethra. Ho men- 
tioned tho value of thyroid extract as a means of venilenncr. 
strictures more easily dilatable. - “ 



6 B 0 March 31 . 1928] 


TREATMENO? OE irBETHBAE STBICTUEE. 


|f,, r TnEBsmj*;. 
L ^Ikoicaz. Joni!fi£ 


' Mr. E. T. C. 3I1LLIOAN said ho used the same teclmiquo 
as Mr. Kidd. Ho remarked that Hamilton Russell had 
now given up tho deep dissection of' tho posterior urethra, 
and did not open tho membranous urethra. Mr. Milligan 
described the urethroscopio appearances in tho development 
of a stricture, and also tho effect of various methods of 
treatment, as seen through the urethroscopo at various 
periods after treatment. Ho showed some excellent pictures 
to domoiistrate his obseiwations. Ho pointed out that in 
inflammatory strictures tho condition commenced in parallel 
rows of follicles in tho roof of tho anterior urethra, 
spreading gradually to tho sides, and rarely to tho floor. 
Ho divided strictures into two main types: ( 1 ) where tho 
centre of the stricture was avascular, translucent, and 
confined to tho mucous membrane, and ( 2 ) strictures com- 
posed of vascular, opaque, fibrous tissue, with spread of 
fibrosis into the corpus spongiosum. Ho added that gonor- 
rhoeal strictures should never be allowed to pass beyond 
type 1 . For the treatment of type 1 dilatation was usually 
sufficient, but, as he had noticed on urethroscopio examina- 
tion, within one week tho stricturo and fibrous tissue had 
loformed. He mentioned that tho urethra was normally a 
closed tube, only dilated to a small degree by tho passage 
of urine, the urethra being, therefore, in a position of 
rest for most of the day and usually ail night. To over- 
come this ho always tied in a catheter for one week after 
dilatation or operation to keep tho urethra dilated. Most 
strictures were of this tyjje. 

Tho second type presented tho problem in treatment. 
Mr. Milligan first tried simple dilatation, and observed tho 
effect with tho urethroscope. If this method was not 
satisfactory ho performed internal urethrotomy and tied 
in a catheter to prevent collapse of the urethra. This was 
a very satisfactoi'y operation, siuco tho cut was in tho roof 
of tho urethra. He did not think that excision was likely 
to overshadow internal urethrotomy. Tho speaker said ho 
had performed excision in cases of stricture uncontrolled by 
dilatation and internal urethrotomy, as demonstrated by 
frequent urethroscopio examinations, and in all cases of 
stricturo complicated by fistula. After excision of a stric- 
ture ho had found that tho urethra was kept permanently 
open by periurethral adhesions. Ho had observed recur- 
rences of strictures about four years after operation, 
coincident with the disappearance of tho adhesions and 
mobilization of the urethra. It was very important to 
excise freely and widely all fibrous tissue to ensure success. 
Excision was far superior to external urethrotomy, since in 
this latter operation tho roof of the urethra was untouched. 

Mr. Ogieb Ward stated that he freely dislodged tho 
corpus spongiosum from its bed in front of the stricture, 
and then, if possible, behind tho stricturo. If ho could not 
do tho latter ho never opened tho bladder behind the 
stricture, but stripped the urethra from before backwards, 
looking for the dilated urethra behind the stricturo. There 
was little danger in doing this, as tho dilated urethra was 
usually immediately opened up before the dissection had 
passed very far posteriorly. He did not perform supra- 
pubic cystotomy except in cases of urethral fistulae. Ho 
pointed out tho difficulty and importance of preventing the 
perineal catheter passed into the bladder from touching 
the suture lino. Extension of the stricturo into the mem- 
branous urethra was found at operation in one case, and 
ho had to dilate this with metal dilators before repairing 
the channel. In his opinion, excision of an impassable 
stricture was far superior to external urethrotom3’. Ho 
had found that in some of his cases after excision dilata- 
tion was not alwaj’s easy. He was doubtful, therefore, 
whether there was less need for post-operative dilatation 
with this operation than with other operations, and also 
whether excision was a euro for stricture as had been 
claimed. 

Mr. Fowler Ward said that he never cut the bulbo- 
cavernosus muscle, but reflected it. He considered internal 
urethrotomy a blind operation, and emphasized the risk of 
severe haemorrhage. For an impassable stricture he por-- 
formed suprapubic cystotomy, passed a retrograde bougie, 
divided the stricture in the perineum, and introduced a 
metal catheter through the urethra into tho bladder, 
leaving it iu for seven days. If this could not be done, • 
on mg to a groat deal of fibrous tissue, he then excised 


tho stricturo. He reported several cases of stricture of 
tho penilo urethra in which he had used plastic skin flaps, 
restoring the urethra with complete success. He emplia- 
sized tho importance of always employing drainage of the 
bladder, either suprapubic or perineal, in all cases of 
plastic operations on tho urethra. 

Mr. Kf..\neth WALKp reported that he had found 
excision of great help in traumatic strictures. He com- 
mented on the difficulties at operation when the stricture 
was far back in the anterior urethra, and remarked that 
though he was often dissatisfied with the immediate 
appearance of his repair of the urethra, he found that the 
end-result was very satisfactory. 

Mr. CniproRD Mqrson mentioned the marked improve- 
ment in recent years in the treatment of gonorrhoea, and 
the early and preventive treatment of urethral stricture. 
Ho believed that in the future operations would only be 
necessary in traumatic strictures. Internal urethrotomy 
was at the present time a comparatively rare operation. 

Mr. WiNsnnnv White said that some of tho worst 
strictures ho had to treat were those following external 
urethrotomy.- In almost -all-cases of stricture a filiform 
bougie conld be passed after patient manipulation, and 
then internal urethrotomy could be performed. 

Mr. Kidd, in reply, said that internal urethrotomy was 
good and most useful in the majority of strictures, but 
excision was necessary in some advanced cases and cases 
with urinary fistulae. The use of a small knife in the 
urethrotome obviated the risk of severe haemorrhage after 
internal urethrotomy. 


PATHOLOGY OF THE MAMMARY COKKECTITE 
TISSUES. 

At a meeting of the Manchester Pathological Society on 
vf 1 lath the nresidont, Mr. F. H. Westmacoit, m the 
^/^[^^a^ntddress^was given by Sir G. Lenthal Cheatle on 
£mal and abnormal states of the connective tissues ,in the 
1 ! w illustrated by specimens and lantern slides. 

^ stf 'Lcnthi>l CheJtle said that the general supporting 
Sir Jjcniu elsewhere, was liablo 

tissue of the breart,^liKe ^ 

A sarcoma could only bo diagnosed from a fibre 
1’^°° A hv studying a whole section of the breast. It was 
adenoma by hyperplasias of the true breast con- 

‘“P+fve tissue from the^accompanying epithelial hyper-, 
nectivo^ pathological importance of the combination was 
the^papillomata. Physiological influences had a 
seen in t*}® P generalized (and as a corollary on the 

peat bear n l^.J section shown of the breast. 

^ ‘foman^^agld 42 , which very closely resembled a state 
°f “Thronic mastitis,” two points were striking : -first tho 
^ of fibro-adenomata, formed and forming; and 

preseiic hyperplasia of the pericanalicular and peri- 

secondly, tli tissue A consideration of the noi-mal 

acinous wn t and at birth would show physiological 
‘’7?- ns betweel the formation of fibro-adenomata at 
on Iho one hand and the so-called chronic 
on the other. Both of these conditions were 
in the specimen described. In the normal breas 
m^anifes enormous increaso of acini and a 

nHsfa of the pericanalicular and periacinous tissue, , 
-Sonc wWoh lymphocytes were common. The fibro-adeno- 
in^which were so common at puberty consisted 
r nHsia of tlio pericanalicular and periacinous fjssues, 
;r7n some of tLm, new acini developed, so that lit t^ 
+i’olnirical part' of the breast there was only an 
patho g y f^pijysiological activity which was “ 

""+L rest of the fame breast. Lobulation of .fib^ 

7 nti was not due to outgrowths from the 

but W primaiy similar^and later changes m 
iroast tissue adjacent to it. The presence of 
miono- tho hvpei-plcstic pericanalicular and pouac 
r„e1 In thf normal breast at puberty a ^ 

and was thus evidence that this tern was an 
ncorrect nomenclature. At birth it was imp 
listinguish a male from a female breast; in bop “ Ajf 
native epithelial hyperplasia, filling the ducts, t g 


^AECH 31, 1928] 


COIiliOIDAI. LEAD. 


[ Tin: URntsH 
Mroicu. JocHXit 


651 


with a hyperplasia of the pericanalicular and peiiacinous 
coiiiiective tissue, containing lymphocytes, gave an appear- 
ance u-hich, in the adult, ivould certainly be diagnosed as 
“ chronic mastitis.” This condition in the adult mas not 
an inflammation, but a physiological change become patho- 
logical by reason of its irregularity and of its exceeding 
the noi'mal. In passing, it was pointed out that most 
breasts of the age to which this condition belonged only 
appeared nodular on the surface owing to hypertrophy of 
the ligamenta suspensoria of Cooper, which isolated fat 
nodules. If the skin was undercut, the nodularity dis- 
appeared. Such breasts were never adherent to the pec- 
toral fascia, as might be the case in the rare nodular 
breasts which were the seat of carcinoma. The elastica 
n'as next considered. Hj'perplasia might ho (1) general 
and associated with carcinoma or with d 3 'sgenetic epithelial 
hyperplasia, or (2) local, in conjunction with carcinoma, 
epithelial h^-perplasia, Paget’s disease of the nipple, or 
hyperplasia of the intra-elastica. It did not represent a 
local resistance to the malignant invasion. Finally, hyper- 
plasia of the intra-elastica was described; in this state it 
often underwent early degeneration.- Hyperplasia of this 
tissue did not affect, the whole breast, and it might not 
produce a loc.alized tumour. On the other hand, it might 
form one. kind of intracanalieidar fibro-adenoma (which 
the lecturer believed to be common), and also certain un- 
common, nnbranching papillomata. 


COLLOIDAL LEAD. 

-^T a joint meeting of the Manchester Medical Society 
and the Liverpool Medical Institution at Jlanchester on 
March 7th, Professor W.. J. DiiiiNo of Liverpool read a 
paper on colloidal lead. 

Professor Dilling said that the standards on which the 
suitability of various colloidal lead preparations for use in 
the lead treatment in carcinoma had been approved had 
been (1) that intravenous injcctious representing 0.025 to 
0.05 gram of load per kilo body weight should be tolerated 
by rabbits without local irritation, immediate or late 
symptoms, and (2) that similar injections in cats should 
cause neither respiratory nor circulatory disturbance. The 
latter was the greater safeguard, since a decided, although 
brief, fall in blood pressure, synchronous with, and due to, 
impairment ofy'the contractility of the auricular muscle, 
resulted from injections of ionized lead solutions and many 
cofloidal lead preparations. Tracings from cats showed 
tins effect on the auricle, with consequent diminution of 
the pulse wave and of blood pressure ; large doses of 
^ approved ” lead colloids frequently repeated could pro- 
CiUce similar effects. Microscopical examination of the 
tissues of mamm.als injected with lead colloids revealed 
fine granules, which microcliemical tests indicated were 
colloidal lead ; a series of microphotographs showed these 
nee in the blood vessels and in the interior of leucocytes, 
i bo spleen contained large numbers in the splenic pulp, 
flee in the blood sinuses, forming extraiiuclear rings in 
the S|>lenic cells, and concentrated in the phagocytic 
sp enoc.vtcs ; the Malphigian corpuscles contained rclativelv 
few particles or none, and where they occurred thev were 
merely minute. The liver contained particles, but their 
ois ri u ion i aried ; thej- occurred in the blood sinuses, in 
the hepatic cells, and in the endothelial cells of Kupffer. 
in the kidney, particles had been found within the 
P “^UMU 1 and punctuating the outlines of the convoluted 
u u es. us organ almost invariably showed evidence of 
1 °^ secreting cells of the cortical tubules, 
0 line cai staining, and occasionallv necrosis; 
g omcru ar congestion and haemorrhage had also been 
enwf; "'so present in the lung, but 

irHii.t- of carbon granules their exact dis- 

uncertain. Granules had not been found in 
Iri Certainty. Microphotographs of the 

in a -Vu "cot"te poisoiTing 

Chemical' an'? granides in comparable positions. 

Chemical analysis of mammalian tissues from these experi- 
ments with tho chromate method confirmed that the kad 
TnU ’’ "“."oooLot'on in the spleen, liver, Imm 

and kidney, and in the blood. Tho percentage in othe? 
tissues examined, incJiiding bone. was. relatively low, but 


indicated the commencement of excretion by the bile and 
urine. The lead grannies were apparently concentrated 
chiefly in the reticulo-endothelial system, but it had not 
yet been possible to trace them to the endothelial cells of 
the lymph glands, of bone marrow, or of connective tissue. 
Tlie only organ in which histological damage was apparent 
after large coUoidal lead injections in animals was tho 
kidney. The clinical importance of this fact was 
emphasized. 


Gastric and Duodenal Ulcers. 

Mr. F. Stuo.vg HrLcxmc (Liverpool) reported a scries of 
183 consecutive gastric and duodenal ulcers operated on 
by him during the past four years. He had, with the 
assistance of Dr. Aidiii, followed up and obtained the end- 
results after a year in about 90 per cent. ; the cases 
included 33 perforations, 65 chronic duodenal ulcers, 
and 85 gastric ulcers. -A.mong the 33 perforations, the early 
mortality was 8.7 per cent., and the follow-up showed good 
cud-results in 90 per cent, of the remainder. In 31 cases, 
ill addition to repair and pelvic drainage,- gastro- 
enterostomy was performed. There were two unsatisfactory 
end-results: one caso where gastro-enterostomy had not 
been perfonued, and one where the gastro-enterostomy 
opening contracted; both required a further operation. 
In chronic duodenal ulcer the operation consisted of a 
vertical gastro-enterostomy running into the lowest point 
of the great cui-vatiire, in some cases with infolding of the 
ulcer, and in some with appendectomy. Tho mortalitj- in 
hospital was 3 per cent., almost entirely from post-operative 
pulmonary comjilications. The “ follow-up ” showed good 
ejid-results in 90 per cent, of those leaving hospital alive. 
There were two gastro-jejunal ulcers (3.1 per cent.), one 
arising four months and one four years after gastro- 
enterostomy; both were cured by partial gastrectomy. The 
other unsatisfactory end-results happened in patients who 
for one reason or another did not have appendectomy per- 
formed at the- same time as ■ gastro-enterostomy. Present 
sjuuptoms in almost all were suggestive of recurring 
appendix trouble. ' This, however, may have been a 
coincidence, as the end-results after gastro-enterostomy for 
perforation showed no such symptoms, although in all the 
latter the appendix had been loft undisturbed. Chronic 
gastric ulcers varied so much in clinical picture and opera- 
tion findings that for the purpose of useful comparison 
they were subdivided into complicated and uncomplicated. 
Tho uncomplicated included small or moderate-sized ulcers 
situated at the pylorus or near the lower part of the lesser 
curvature without serious adhesions. The complicated 
included the larger ulcers of the posterior wall, those 
with perforation of neighbouring structures, those situated 
high in tho stomach, and those accompanied bv chole- 
cystitis, ptosis, and hour-glass contraction. Of' the 55 
uncomplicated cases gastro-enterostomy was performed 
in 54 with 2 deaths, both from pulmonarv complications. 
Ill tho remainder the end-results- were imiforuilv satis- 
factoiy. Mr. Heaney briefly referred to the present views 
on the etiology of gastric and duodenal ulcer in the light 
of tho experimental work of Morton, and to the relation of 
chronic gastric nicer to ga.stric cancer. In his series there 
was no instance of cancer being found in the “ follow-up ” 
in any c.aso of simple gastro-enterostomy for gastric ulcer, 
nor nas there ain- instance of cancer arising after excision 
01 gastrectomy where the specimen removed at operation 
was reported histologically non-malignant. 


CHOCOLATE CYST OF THE OTAET. 

At a meeting . of the Midland Obstetrical and Gynaeco- 
logical Society, held in Birmingham on February 14th, 
with Professor D. C. E.itxeh, the president, in tho chair| 
Mr. Aubed D.\xbt exhibited a specimen of a largo choco- 
late cyst of the ovary, which he had removed from an 
unmarried woman, aged 26. 

Mr. Danby said that the history w.as interostino’. since 
apart from rather severe pain on the first day%f- her 
period, the patient had always been healthy. The evst had 
been discovered during a routine medical examination 
There was a sjunmetrical mid-line hvpogastric .swelling 
reaching to the umbilicus, the size being that of a twenty 


652 MAncH 31 , 1928 ] 


midland obstetkical eociETr, 


v-eoks pregnancy. It could not bo distinguished from tho 
uteius, and an a:-ray examination was made to. exclude 
pregnancy. On opening the abdomen a hroivnish-purplo 
tumour was found arising from tho pelvis, and reaching 
as high as the umfailiciis. It was densely adherent to tho 
suirouiiding structures, moro especially to the posterior 
wall of uterus and rectum, tho right adnexa, the appendix, 
and the great omentum. An ovarian trocar was inserted 
and nearly two pints of thick choeolate-coloiircd fluid 
renioved, containing many blood cells, hut no oxy-haemo- 
.globin. An analjsis showed 30 mg. of urea, 14.15 me. of 
calcium, aud 354 mg. of cholesterol in 100 c.cm. No suaav 
was found. The tumour was removed with difBeiilty oivinc 
to dense adhesions, and several parts of tho wall had to 
^ sacnliced. Large bare areas in tho pelvis were exposed- 
those were peritonized as much as possible, and owing 
to a considerable amount of oozing a rubber drain and 
^iize packing were inserted. Convalcsce^nco was uneventful. 
Histological examination of the wall of tho tumour failed 
to disclose any endometrial remnants. Some of the sections 

wn?iw ? structure 

was that of dense fibrous tissue with red blood cells scattered 
about in it Air. Danby said that the specimen ho was 
showing had u^ortunately shrunk considerably since it 
was removed. He had no doubt that it conirmed to 

Hne nf f if of the endometrial 

tipo of tumour of the ovary, but it appeared to be larger 
han any that writer had described in his paper. A con- 

thlnn'* "’as composed of 

t Imt tlf compressed ovarian stroma, suggesting 

0 fen excavated and sketched 

out on Its surface. The failure to demonstrate the presence 
of endometrial tissue from tho cavity of the larger of these 
tumours was not unusual. To meet with any measure of 
success It was necessary to cut serial sections, but this was 
not done in this instance. 

HT I>\!stocia due io Hydatid Cyst. 

Maslen Jones (Wolvoi'liampton) communicated the 
notes on a case of Caesarean section for hydatid evst 
obstiucting labour. A primipara, aged 25, had bien 
four yeaiE previously for “ cysts on tho liver.” 
Twelve hours after tho commencement of labour tho mid- 
wife had called in a doctor, who found a cystic swelling in 
the pouch of Douglas. When the patient was seen by Mr. 
Jones an hour later dilatation was complete, but the 
advance of a normal vertex presentation was prevented by 
this cystic swelling, which could not be displaced. Obstrii^ 
tion due to hydatid cysts was diagnosed, and Caesarean 
the tho operation 

isolated TntTan «ntain some 

“‘^“Pf'^oneal cysts, an extraperitoneal cyst in 

ConiL. “"‘I “ i" fhe left ovarv 

DnHier uneventful, and the patient refused ai5y 

and a nX'^n'ihe °f general malai"^ 
and a pain m the chest she came up to the out-patient 

department in February, 1928, when a flaccid cystto mTss 

finnw reaching nearly to tho umbilicus was 

found. An s-ray examination of the chest was negative 
An operation was performed, and tho specimens prfdS 
at the meeting included four cysts, which were lying on the 
raised floor of the pouch and loosely attached to the 
peritoneum and omentum. One of these had invaded the 
mesenteiy of the, appendix, which had been removed with 
the cyst. A large specimen consisted of the uterus and 
both appendages; there was a cyst tho size of a golf ball 
growing from. the right ovary, and a very large cyst, which 
was partially intraligamentary, crossed the mid-line in the 
■floor of the pouch, and had completely replaced tho left 
ovary. Slacroscopically . tho isolated cysts were typical 

hydatids, whilst the others appeared to be ovarian in 
origin. Mr. ' Jones said that full pathological findin-^s 
would be reported later. “ 

Sarcoma Botryoides. 

Mr. AIaslen Jones also read notes on a case of sarcoma 
hotryoidcs occurring in a girl, aged T8, who had complained 
of continuous baeniorrhage for eight weeks. A fleshy 
protruding through the vulva was found to 
o an annular baso of attachment round the cervical 


f Tp* nRiTjBt 
aiEOfCAt JotntxiK 


“orS prolongation of the 

amputation of the etvfx Hisro? ® 

polypus showing no evidence of ^ mucous 

waf dZVeA drending Z vagir'"' TtV^as'Snt £ 
tho condition was sarcoma botryoides Histnlarr.’.. u +i 
grape-Jiko bodies were found to consist of r 
tissue containing stellate and round cells! wfth a'l^S 
of squamous epitbeiium. The stellate cells were tlTe morf 
numerous, and wore identical with tboso found in a myxoma 
or myosarcoma. Alore on clinical than histological grounds 
panlp-storeetomy of the Wertlieim type, including the 
greater part of the vagina, was performed. At first the 
patient progressed well after tho operation, hut six months 
aftoru-aras thero was evidence of a recurrence in tho 
abdomen whicli wm considered inoperable. She died a 
montli later with signs of pulmonaiy metastases during tho 
last weeks of life. Leave for a necropsy was. ref used. 

Pulmonary Bmholism following Delivery. 

Mr.^ FmixEAUX Jokd.an sliowed a specimen of pulmonary 
embolism from a primipara, aged 45, who had had a natural 
delivery followed by a normal and apyrexial puerperium. 
SliO was allowed to get up on tho eighth day, when, on 
. walking to a chair, she suddenly became giddy. She was 
at once put back to bed, but later became cyanosed, 
dyspnoeio, and retched frequently. Later there was very 
severe epigastric pain and restlessness; she rapidly became 
unconscious and died two and a quarter hours after tho 
first symptoms." At the necropsy a finn embolus 2^ inches 
long .was found at .tho, bifurcation of the pulmonary artery. 
Tilo' uterus was well involuted and the placental site was 
normal. There was, a small degenerating fibroid in the 
anterior wall of tho uterus. 

Sydatidiform Mole. ' 

Sir. ronxEAUS Jordan showed also a specimen and micro- 
scopic slides of a caso of chorion-epithelioma occurring in 
a primipara, aged 28, who nine months previously had had 
a hydatidiform mole removed. 

Sir. Bbaine-Hartnele (Cheltenham) read notes on a case 
of a hydatidiform mole which ho removed irom an 
unmarried girl by hysterectomy. When ho saw her she 
had been bleeding for somo time, and was profoundly 
anaemic. There was a mid-line elastic swelling reaching 
half way to tho umbilicus, but there were no other signs 
of pregnancy. After a stormy convalescence she made a 
good recovery from the operation, and had since married 
and had one child. 

ripening of the graafian follicle. 

A stEEriNO of tho Edinburgh Obstetrical Society was held 
on March 13th, tlie president, Dr. Haio Ferguson, being 
in the chair, when Dr. Wilfred Shaw described the 
histological changes in the Graafian follicle during the 
process of ripening. , . , 

Dr. Shaw said that through the action of special 
mechanisms the enlargement of tho follicle proceeded 
towards the surface of the ovary, and the discus proligerus 
rotated so that immediately prior to ovulation it lay 
beneath the spot which was subsequently to become the 
stigma. An account was given of the histological appear- 
ances at the stigma immediately before ovulation, and also 
after rupture of the follicle had taken place, and the 
methods of permanent closure of the stigma were described. 

Some distortion occurred in the outline of the follicle after 
ovulation but there was no effusion of blood into the 
cavity of tho follicle, because at this stage the granulosa 
layer was not vascularized, and the engorged theca interna 
shut off from tho grannlosa layer by the mem- 


layer was - - - 

brana limitans externa. In the development of the corpus 
luteum from tho follicle the granulosa ceils hypertrophied 
and gave rise to the large lutein cells. Tho theca interns 


and gave rise x-o tuo luxge xulciii A.UU Lxicua 

cells persisted at the periphery as the paralutein cells. The 
convolutions of the corpus luteum were produced througn 
the enormous growth of the granulosa cells, aided by 


ilARCH 31, 1928] 


FKACTUEE OF CEKVICAIi VEETEBEAB. 


[ The BnrnsH 
Medicaz. JockxaXi 


553 


capillary tufts, which grew up from the theca interna 
layer. The method of determining the time relations 
between ovulation and menstruation was then described. 
It consisted in the' accurate histological examination of 
both ovaries of women with normal menstrual cycles; in 
these cases the dates of the last menstrual period and the 
day of the cycle when the specimens were obtained were 
known. It was' found .that recently ruptured follicles and 
proliferating corpora lutea were demonstrated only after 
the sixteenth day of the cycle— the first day of the menstrual 
period being taken as the first day of the cycle — while until 
the thirteenth day of the cycle only retrogressing corpora 
lutea were found, although, in cases corresponding to the 
post-menstrual phase, ripening follicles were also present. 
It was concluded that ovulation took place between the 
thirteenth and sixteenth days of the menstrual cycle, in 
healthy women constantly without gross variations in time, 
and that it occurred rhythmically once a month. Further 
indirect evidence in support of this view could be obtained 
by observing the earliest time in the cycle when pre- 
menstrual changes appeared in the endometrium, for there 
was good evidence that the corpus luteum produced these 
premenstrual changes. 

The corpus luteum produced from the first follicle to 
rupture inhibited further ovulation ; the remaining ripen- 
ing follicles in the ovaries underwent atresia, and ulti- 
mately gave rise to the interstitial cells. Occasionally, in 
about 5 per cent, of cases, two follicles ruptured simul- 
taneously, and two corpora lutea were found in the oimries. 
If both ova were fertilized binovular twins resulted. 
Ovulation did not occur before puberty or after the meno- 
pause, for at these times no corpora lutea could be demon- 
strated in the ovaries. During pregnancy ovulation was 
inhibited although follicle ripening proceeded normally, 
and again, during lactation, amenorrlioea was determined 
through no corpora lutea being produced. It was pointed 
out that if menstruation was considered as the result of 


the disintegration of a premenstrual endometrium, men- 
struation could be distinguished from abnormal uterine 
haemorrhage; with this definition it followed that men- 
struation was invariably preceded by ovulation. Menstrua- 
tion did not always follow ovulation : examples of this 
were seen in the case of pregnancy and in the condition 
described as corpus luteum persistens. The problem of the 
relation to conception was then raised, and it was pointed 
out that fertilization probablj’ occurred only after the 
fourteenth day, but, since spermatozoa might suiwive in 
c generative tract for some time after coitus, 

lullowed that coitus might bo fertile before this time. 
uTiether coitus could be fertile after the fourteenth d.ay 
depended upon the survival period of the ovum after 
ovulation; in human beings there was very little evidence 
to show wliat this period might be. It seemed, however, 
that tho least fertile part of the cycle was the late 
premenstrual phase. Evidence was brought forward to 
snow that the amenorrlioea met with in advanced stages 
ot conditions such as Graves’s disease, diabetes, and 
uementia praecox was due to an inhibition of ovulation. 

n account was then given of the changes in the ovaries 
as a resu t of x rays and radium used therapeuticalh- to 
crea c an artificial menopause; it was shown that with 
ripening was inhibited, with smaller 
tiin 'Ji^ inhibited, and it was concluded that 

° radiations in producing an artificial meno- 

dmncp. "®‘' ‘'‘® The 

Th'itrfpp iT-n 'a ovaries in Schroder’s metropathia haemor- 

inhiliiHnn evidence was adduced that the 


FRACTDRE OP CERTICAL VERTEBRAE. 

Acodem of Pathology of the Royi 
Smft T T Fobrnaiw 17th, tl, 

present, J- T. O F.\nnimi,, ,n tho chair. Sir WinuA: 

ron-: p 1 " shoned a specimen consisting of tli 

Xfl ' T' a removed from a mat 

'’st 'vv? “ 'rniglit on to his heat 

Sir ’S\ Ilham M heeler said that when the patient ws 


admitted to hospital there was a lacerated wound over the 
right temple, and partial paralysis of both legs. The knee- 
jerks were exaggerated; tliero was no Babiiiski sign and 
no ankle clonus. The pupils were small, but reacted to 
light; the temperature was 98.6° F., and tho pulse rate 
80. After the lapse of twelve hours both the motor and 
the sensory paralysis in the legs were complete. Tho right 
arm had become weaker tliau tlie left, but the muscles were 
capable of co-ordinated movements. The left arm seemed 
unaffected. Four hours later the right arm was lielpless 
and the left arm weaker ; the abdomen and thorax had now 
become paralysed.- The temperature was 103° F., and 
respiration was carried on by movement of the diapliragm. 
The man was fully conscious, and it was therefore obvious 
that the total paralysis was not produced by an intracranial 
lesion. Fracture of the cervical vertebrae below the third 
(emergence of the phrenic nerve) was suspected. The man had 
several times moved his head freely backwards and forwards 
and from side to side; in fact, there was no limitation of 
movement. Spinal puncture revealed that the fluid was 
not under pressure and contained no blood. The condition 
of the p.ationt remained unchanged for another ten hours, 
when he suddenly complained of headache, vomited, became 
unconscious, and died; the temperature then was 109° F. 
An x-raj' photogiaph taken before death showed an injury 
in the nature of a “ sprain fracture ” of the fourth, fifth, 
and sixth cervical vertebrae, hut there wag no displacement. 
At the necropsy it was ascertained that tho chief lesion 
was produced by hyperextension of the neck, the inter- 
vertebral discs between the fourth and fifth, fifth and 
sixth, and sixth and seventh cervical vertebrae being torn 
open. Some insignificant fragments of bono were detached ; 
there was no exti-adiiral haemorrhage, nor was any blood 
extravasated beneath the meninges. The cord itself 
appeared intact. Sir William Wiieelcr thought that tlio 
trauma to the cord was analogous to the trauma produced 
by overstretching of the brachial plexus or of the musculo- 
spiral nerve; it was difficult to explain why the paralysis 
was not complete until about sixteen hours after the injui-y. 
The points of interest in the case wore : (1) Tlio suspicion 
that the man was suffering from a head injury — a suspicion 
which was at once dispelled by the presence of wide para- 
lysis in the absence of unconsciousness. The free movements 
of the head in the presence of such an injui’y were note- 
worthy. (2) From the time of the injury to the man’s 
death tho iiupils were contracted ; this was cliaracteristio 
of severe injuries in the lower cervical region. Sir William 
Wheeler traced the course of the sympathetic fibres from 
the cilio-spinalis centre to the Gasserian ganglion, and from 
thence to the eye. (3) Tho uppermost lesion in tlie spinal 
column was just below the phrenic nerve.' (4) Wide varia- 
tions of temperature occurred in lesions in this situation, 
Brodie h.aving mentioned a patient who died with a 
temperature below 83° F. (5) Further examinations of 
sections of the cord might throw some more light on the 
exact pathological condition, and thus explain tho gradual 
nature of tho jiaralysis. 

Sarcoma of the Lung and Liver. 

Dr. R. H. Micks road notes on two cases of sarcoma of 
the liver ; in one patient the condition was associated with 
a pulmonary groirth, and in the other it was melanotic. 
Dr. Bait exliihitcd specimens in both cases. 

A man, aged 41, was admitted to hospital complaining of pain 
in the left side, and difficulty in breathing. Pus was found in tho 
left plural cavity. Tlie liver was greatly enlarged. Tho necropsy 
revealed a tumour involving the left pulmonary root, and spreading 
diffusely throughout the lung, in the apex of which there was a 
large cavity, and at the base numerous small abscesses, though 
Ihero was no evidence of tuberculosis. The liver was greatly 
enlarged, and when fixed weighed 7 lb. It was everywhere 
infiltrated by the tumour in a diffuse manner. Microscopically tho 
tumour was a small round^iell sarcoma, 

Tho second patient, a man aged 61, when admitted to hospital, 
complained cliiefly of epigastric pain, and was jaundiced ; the liver 
was distinctly enlarged. At the necropsy a greatly enlarged liver 
was found which, when fixed, weighed 91 lb. Scattered throughout 
it wore nodules of melanotic sarcoma, mostly pigmented, tbougli 
some were free from pigment. None of tlio other organs 
involved, and no primary focus was found after a careful examina- 
tion. The microscope corroborated the nakedKije diagnosis. 


654 March 31, 1928] 


EEVIEWS. 


f r»i BnrnCT 
MeDICAI. JOUBKlA 




ABDOMINAL SURGERY OF CHILDHOOD. 
Pediathics is a comparatively recent specialty, and if the 
process of suhdivison goes much further it is possible 
that children u'ill before long have their own surgeons, as 
they now have their own physicians. Ours may indeed bo 
an ago of over-specialization, but the children’s surgeon is 
in the unusual position of being able to call himself 
“ general ” or “ special,” as his fancy dictates or his 
company demands. At any rate, Mr. L. E. Barrikgtok- 
W.uid’s book on The Abdominal Surgery of Children' will 
soon convince tho ignorant or the sceptic that a wide 
variety of diseases may lurk within the narrow limits of 
a child’s abdomen. Tho book is founded on tho author’s 
work at tho Hospital for Sick Children, Great Ormond 
Street, and ho has dedicated it to Mr. George E. Waugh, 
'• whose' generous and original mind has stimulated 
so many in the past twenty years.” Great Ormond 
Street is the thread that runs right through it. Tho 
patients and the hospital museum havo provided tho 
subjects of the illustrations, and a late house-surgeon (Mr. 
C. A. Keogh) has contributed some excellent drawdngs. 

Tho opening chapter is devoted to general principles, 
and might be read with profit by evciy doctor. Tho treat- 
ment of children, both before and after operation, is fully 
considered, and tho author drives a final nail into tho 
cofhn of purgation and starvation as a preliminary to 
operation. Glucose receives its duo weight as a thera- 
peutic agent, and details are given of the sti'engtbs and 
ways of administering it. Tho general reader will probably 
begin with intussusception or congenital pyloric stenosis, 
and he will find much to interest him. Wo confess to dis- 
appointment at finding no mention of that form of intus- 
susception — neither acute nor chronic — which seems best 
labelled “ intermittent.” Mr. Barrington-Ward believes 
that colopexy should be performed when an acute intus- 
susception has recurred. Ho does not refer to the con- 
ception of the mobile ascending colon as a safety valve 
against strangulation in such patients, though any further 
attacks must surely be more dangerous if tho habit of 
intussusception is not cured by colope.xy. The chapter on 
congenital pyloric stenosis is full of good things. There 
are some excellent tables to show the effect on prognosis 
of age, weight, feeding, and length of symptoms, and the 
illustrations here are particularly good. Tho hospital 
series includes 310 patients, and thus provides material 
for an authoritative consideration of the whole subject. 
Results have improved from an 80 per cent, mortality in 
pre-Rammstedt days to about 18 per cent. ; there was only 
one death in twenty-five patients operated upon in the 
first half of 1927. 

The section on maldescent of the testis and its treat- 
ment is less satisfying than the rest of the boob; some 
pronoimcement on the late results of operations would 
havo greatly strengthened it. Mr. Barrington-Ward is 
optimistic on tho subject, though he does not seem to 
practise Sevan’s method, which often converts an im- 
possibility into a fairly simple proceeding. There is no 
mention of typhoid fever in a list of eauses of enlarge- 
ment of the spleen, though kala-azar and malaria appear. 

“ Nbn-surgical drainage of the bile ’’ is a riddle without 
an answer, and “ obstipation,” on page 245, is a word 
whose proper place, many will think, is the dictionary'. , 
However, we must not carp at such trifles when a book is 
so free from misprints, errors, and omissions. Tho exclu- 
sion of tho gonito-urinary By’steni certainly leaves a big 
gap, but no doubt it was unavoidable in a work of this size. 

° Tho book is veiy well produced. There are eighty-two 
illustrations, each chapter has its list of references, and 
there is an index of names as well as of diseases. Mr. 
Barrington-Ward writes .fluently and clearly in an agree- 
able manner, and wo think that his book should make 
a wide appeal alike to surgeon, genera] practitioner, and 
student. 

* T/to Abdofitinal Surgery of Children. Bv L. E. Barrington-Ward, 
•E.R.C.S.Etl., P.n.C.S.Enc. Oxford Medical Publications. . London ; 

' «V‘r Oxford UnJversitv Press. 1926. (Demy 8vo, Pp. xjii + 283; 

8- figures, 3 plntcs. XSs. net.) • 


NERVE TRACTS. 

Professor Keieier, of tho University of Texas, has 
attempted a protean task in_ Nerve Tracts of the Brain 
and Cord: Anatomy: Physiology: Applied Neurology.' 
Ho takes for granted that tho student is acquainted with 
tho gross dissection of tho brain, and proceeds directly to 
tho anatomy of tlie tracts. Tho description of Wallerian 
dogoncration and tho cle.ir exposition of tho value of the 
Marclii and Weigeit-Pal technique is exceiiont. Tho 
second part deals with the anatomy and physiology of the 
nervo tracts from tho point of view of tho eJinical neuro- 
logist, and the third part deals with the diseases of the 
nervous system in . terms of the various syrndronies. The 
hook is an attempt at filling a gap of ' which all. clinicians 
arc keenly aware, and represents tho result of many years 
of teaching. Supplemented by an adequate supply of 
sections of tho brain and cord of the normal, foetal, and 
diseased brain, tho book provides an excellent scheme for 
teaching purposes. The publisher cannot, however, be 
complimented on the illustrations, as they are badly repro- 
duced and calculated to exhaust the patience of the 
beginner who is trying to unravel the numerous complexi- 
ties' of structure. A bad diagram is like a bad map — ^it 
leads us hopelessly wrong. 

Terminology is a bugbear, and the use of the term 
“ tclodciidria ” for the branching of the axones is not 
justifiable, as it confuses the clear distinction between 
axono and dendrites, which Golgi insisted upon. From 
the morphological point of view several of the definitions 
are questionable.. With reference to the lower motor 
neurone it is said that “ the axones end in special motor 
nerve endings in striped muscles or by synapsing with 
svmpatbetic neurones for tho supply of unstriped muscle 
or of elands.” This contradicts Gaskell’s conception of the 
-m!o 2 v' of tbo lower motor neurone with the cell of tho 
svmo.?tbctio ganglion. Tho distinction between the symp^ , 
tl.etio anil tho bulbo-sacral outflow of tho parasympathetic 
is also omitted. ' Tbo view that protopatbic -nDpulses are 
c-irried by unmyelinated fibres and epicratio by myelinated 
'fibres is Still a rash assumption. Hair-sense should not be 
regarded as identical with tickling, for the latter is vrell 
developed on tho palms and soles. The statement that 
Head fails to find representation of the sixth to' the . 
twelfth thoracic nerves in the nucleus gracilis or.cuneatus. 
does not justify tho author m saying that tactile dis- 
rr^.-nation and postural sense find no representation in 
thoTunk a^d a?o limited to. the limbs Similar y, the 
statement that visual impressions are stored in the left 
■ Inbe only in right-handed persons is not based on 

r ^ Ao statemebt that certain efferent fibres from the 
vermis and flocculus pass alongside the vestibular nucleus 
IrH mut interruption and join the vestibulo-spmal tract is 
fteect eviction to Horsley’s teaching that no fibres 
r«n directly from tbo cerebellum to the spinal cord. 

^There m one feature of Professor Keiller s book for 
wbicb bo dcsorres the greatest praise-namely, that be has 
• himself to the human brain. Many of the recent 

+””thnnks have dealt almost exclusively with tho brain of 
sheep 0 “ forms, to tie exclusion of tbo 

h' in of man. The value of comparative neurology is ; 
pram , • student is not a morphologist. 

A^wnsiderable improvement in the standard of the 'H^tra- 
W sboidd convert this first effort into a standard 
maMal and assure for it as great a popularity as 
Oberstejner’s manual of forty years ag o. 

. ' ' ■ protein metabolism. - 

The regularity with which the successive instalments of 
ProfessS^iio FiiMH’s comprehensive textbook of pl>y«o- 
lovical and pathological chemistry” come to us is a tribute 
to'^the industry with which the author executes his formid- 
able task Tho sustained level of interest and critical, 
r 1 ' v Aionlavcd in each new subject are tokens of his 

S’S’SSS)! "vol u... 1 i. ~ . .jjs 


■uroloa„. By t 


ft-ioli Pnrf \ 



MiBCH 31, igisj 


BEYIEWa 


J TuE Rfifi 

Mu)1CAT.J0CICCAI. 


sections (Parts IV and V) of Volume U are now before ns. 
This volume is to be devoted to the chemistry or meta' 
holism, and the present parts have for their subject the 
metabolism of protein, purine, and carbohydrate. _ In 
Part IV we are given a full discussion of the chemistry 
of tbo digestion of protein and of the proteolytic 
euKvmes, of protein svntbe.sis in the animal body.aud of the 
biQ^iemistrv of ure-a, hippuric acid, creatine, creatinine, 
oxvprotoic acid,, and the cyclic structures involved in the 
me'tabolisin of the amino-acids. The concluding chapter 
deals with the biological breakdown of haemoglobin and its 
relation to tbo origin of tbo bile pigments. Part V opens 
with a discussion of the physiolo©' and pathology of purine 
metabolism.' There follow detailed rcriews of onr know- 
ledge of the digestion, storage, and mobilization of carbo- 
hydrate, of pancri^tic diabetes, and the role of insulin 
and of pliloridzin uiabetes. Concluding chapters treat of 
the biochemistry of glyeuronic acid, lactic acid, and the 
chief fermentative processes. Professor Fiirtli continues to 
display a wide acquaintance with the vast literaturo of his 
subject and an unusual ability to marshal it with a critical, 
j'ct not dogmatic, hand. 


. THE LABYRINTH. 

Db. B.iLnEXWECK has incorporated nine lectures on the 
physiology, central connexions, examination, and pathology 
of the labj-rinth into one volume.' This is of a hand}- size, 
hut the capacity is less than appears, because the text is 
printed only on the left-hand page, whilst on the right are 
numerous sketches and illustrations relating to points in 
the text opposite, ju.st as a lecture might be illustrated by 
a running series of diagrams on the blackboard. It thus 
happens tiiat some pages are occupied by several diagrams, 
others by one only, with here and there a blank page. Dr. 
Baldenweek apologizes for Ids inability to demonstrate tho 
tests on tho living subject, but the combination of clear 
Writing, consecutive thought, and wise choice of illustra- 
tions is such as to make this of the least consequence. To 
ensure the necessary emphasis, to lender some points per- 
fectly clear, there are some deliberate rejictitions and 
illustrative digressions, hut these arc merely the arts of an 
experienced lecturer. It may be said that, short of actual 
demonstrations on living subjects and objective specimens, 
these lectures are as satisfactory an exposition of a most 
intricate subject as it is possible to attain. The examina- 
tion of tho ear as an aid to tho neurologist is becoming 
almost as much a matter of routine os the examination of 
the eye, anil these lectures should prove of the highest 
assistance to instructors in otology and to those whose 
work brings them into frequent contact with a department 
There is no clearer account, and it is 
difficult to imagine that tUevo could he one, in ■which 
all tho^ difficulties and obscure points are met by such 
simplicity of language and such profusion of illustrations; 
in short, by so complete a grasp of the subject. 


„ . SYMPOSIUM ON THE MIND. 

Ihe scientific study of the human mind has probably heei 
handicapped by the speculations and hypotheses o; 
pliilqsophci's-_social metaphysical, and educational. Th, 
opinions of these philosophers, from Plato downwards, ar, 
sea Clod vougU a vast mimber of volumes, aud it is bi 
no means easy to ascertain how far their views have am 
physiological basis. Couseqiientlv there is great value fa 
the geneiM reader 111 the series of lectures delivered las 
year at Kings College, London, and gathered togethe 
into one volume, with the title The aiind- under th, 
editorship of Dr. R. J s. McDowacn, professor of pl,>-sio 
log}- at the College. The object of the lectures was to'giv, 
the piihhc a concise gcncr.al idea of the mind from severa 
academic staudpo.iits, and to show the complexitv of th 
subject and the difficulty, at present, in reaching definit 


The medical man and the scientist will probably regard 
Pi-ofessor McDowall’s statement of the ph}-siologioal view 
of ■■mind, ■ taken - ii-ith tlie biological asjicct described by 
Professor Julian Huxley, as tho more rational argument, 
even if it be admitted- that there is still much that is 
difficult for physiolog}- to exjilain. Anyhow, tho argument 
is more intelligible to the finite mind than the exposition 
of nioderii philosophy, as reiireseiited by Lloyd Morgan, 

• MTiiteliead, and Genrile, set forth -in tho loctiire by the 
Dean of King’s College, the Rev. IV. R. Matthews. Com- 
fessing our inability, to grasp the absolute, reality, and 
the transcendental ego, as expounded by Gentile, we are 
i gratified to find that Dr. Matthews himself is unable to 
, accept Gentile’s wholesale scrapping of objectivity. There 
may bo satisfaction to he derived from asserting that the 
table at which wo sit has no objective existence, hut that 
somewhere in reality there is a real table; yet for prac- 
tical purpose.? it seems probable that greater progress in 
knowledge of the mind will he made by beginning at the 
bottom, and investigating. menta} phenomena as they are 
presented to our senses. Similarly, it seems hardly likoly 
that much advance will be made by labelling oneself an 
interactionist, a parallelist, an epiphenomenalist, or any 
of the other brands of philosopher described by Dr. 'Aveling 
in his lecture on psychology. 

■When the intellectual Philistine has made an effort to 
grasp the meaning of the lectures given by the psyehologirt 
and the philosopher, it becomes hardly necessai'}- to pui-siio 
investigations into the views of the educationist, tho 
sociologist, and the aesthete. It is sufficient, perhaps, to 
quote a remark of Professor McDowall, “ Man’s conception 
of Mind is tho greatest evidence of his conceit. The 
human mind has suffered from the fact that its study fell 
into the hands of the philosopher long before the experi- 
mental observer came into existence. It is for this reason, 
pi-obably, that Mr. Collingwood thinks that when lie wants 
a country cottago liis mind creates an aesthetic something 
which existed previously only in his imagination. 


NOTES ON BOOKS. 

The first quarterly number of the seventy-eighth volume of 
Uie Gut/'s Hospital lieports^ has as the frontispiece the portrait 
of the late Professor Adrian Stokes, of whom an extremely 
sympathetic appreciation is given, containing e.xtracts from his 
letters when with the Rockefeller Commission on yellow fever 
ia West Africa. These show that the results obtained there 
threw doubt on the now generally accepted view that the 
disease is caused by the Leptospira icteroides. During his four 
years at Guy’s as Sir William Dunn Professor of Pathology 
Stokes made a unique position for him.self as an inspiring 
teacher and unfailing source of help, to whom all turned'! 
Sir William Hale-White contributes a note on the birthplace 
of Richard Bright and on Briglit’s two earliest papers — his 
thesis for the Edinburgh doctorate on er}-sipelas in 1813, and a 
dissertation on gangrene read before tlie 'Royal Medical Societv 
of Edinburgh in the same year, wJiich is reproduced in full. 
Dr. G. IV. Nicholson discusses the problems of heredity in the 
light of pathology, and concludes that potencies are trans- 
mitted, but that .cliaracters are always acquired. In his essay 
ou hyperpiesia Dr. A. H. Douthwivite speaks highly of the 
therapeutic effect of venesection. In recording a' case of 
pancreatic cyst associated with diabetes Mr. O. A. Beadle 
reviews the literature, and finds only three similar cases. 
A case of meningitis accompanying pneumonia and followed bv 
recovery is recorded by Mr. R. L. IVaterfield, and one of cii't 
thioat in, a 5-months infaut hv Mr. N. Eckhoff. In his article 
on cataract Mr. Marcelli .Shaw provides some interesting 
historical details, and analyses the re.sults of the medic.sl treat- 
ment of this disease. Mr. W. Sf. Moilison’s historical account 
of the work of Samuel Sharp and his predecessors on the 
functions and surgery of the tonsils was apparently stimulated 
by the “ Critical inquiry into the present state of .surgerv ” 
by this surgeon to Guy’s Hospital from 1753 to 1757. 

It is not sui^rising that a second edition of Dr. C. L. Daxa’s 
Peaks of Medical History,’ the first edition of which was noticed 
in our columns less than two years ago, has so soon become 


(Cr. 8vo, rp. xvi+316. 85.6d ^ 


*Guy't Uo9vHal Iiciyort», Vol. 78 (Vol. 8, Fotjrtli SAripa). Ko 1 JncHorv 
1928, Edited bv Arthur F. Hursl, M.l>. London t The Lancet Ltd fMed* 
8«>. PP. 186; 2 plates, 1 figure. Annual suli'^cription, £2 2s • sinel^ 
numbers, 12s. 6d. net.) r > 

Penl:$ of Bfedic'it Biftory: An OntUnc cf tht rmUttinn r>f 
ilfdicint- for the V*p of MtfUtol ^tmUnU'ornl VracUtinnfrf riv ChQrIf»^ T 
Dana. lt.D.. I-I-D. S^ml edition.- X™- Vort: pl.B ifoel/r! I?c“ 193 
(Demy 8vo, pp. 105; 62 illustrations. 3 dollars.) . 







tiTUliiErAII fcE'GTtlRES ON EPIEEPSE. 


March 31', i9=S] 


r. TitsBumss * 

( llr.DiCAJ, JOCRSit. ' 


EPILEPSY. 

LL’MLEL\.>v LECTURES BY DR. JAMES COLLIER, 
The Lumleian Lectures Tor 1928 TVero delivered at the 
Roval College of Physicians of London hy Dr. James 
Collier, physician and lecturer on medicine, St. George s 
Hospital, on March 22nd, 27th, and 29th. 


The Nathbe of Epieepst. 

In his first lecture Dr. Collier said that he had chosen 
“ epilepsy ” as his subject because it seemed to him oppor- 
tune to 'reconsider this symptom-complex in general in 
view of tho new clinical facts which had been brought to 
light and the new conceptions of the nature of epilepsy 
which had arisen. He mentioned a few recent hj-potheses 
to indicate the necessity* for an analysis of tho opinions 
held by authorities, sometimes widely . divergent, with the 
object of producing a useful working theory. 

His own argument was that the clinical phenomena met 
with in idiopathic eijilepsy, in epilepsy from local lesions 
of the brain, and in the symptomatic epilepsy occurring in 
disordered metabolic states, general diseases, and intoxica-' 
tions, were identical and truly indistiuguishahle. Further, 
that those occurring in narcolepsy, migraine, vaso-vagal 
seizures, idiopathic syricbpal attacks, and perhaps also in 
tetany, were, phenomena of the same order, and were closely 
allied to those of epilepsy, with which they occasionally 
mixed. He believed that there was one pathological factor 
common to all these conditions — a metabolic dyscrasia, tho 
nature of wliich was not always quite tho same, so that 
different clinical syndromes occurred in which the prognosis 
varied. 

So far ns the • so-called “idiopathic” epilepsy which 
affected man and the animals was concerned, no patho- 
logical changes liad been found upon which any hypothesis 
as to the nature of epilepsy could ho built. The findings 
had heen for tho most part frankly negative. Attention 
liad therefore heen turned to the possible discovery of an 
explanation of epilepsy' in somo-p'erversion of the chemistry 
of life — some metabolic dyscrasia* leading to tho presence 
of suhstances within the system- wliioh acted upon the 
nervous system as did convulsant poisons, and might cause 
in some cases the progressive impairment of its higher 
functions. • 


The lecturer, mentioned a number of experimental 
a investigations along tlies'o lines, and- referred particularly 
lo the enticing- theory, put 'forward“hy Bossard that the 
immediato qauso of the* epileptic attack was “ anaphylactic 
shock" from some product of disordered metabolism, the 
local effect of uEich was upon part of the cei’ebrum, while 
the general ' effect'- was shown -by' the fall in the blood 
pressure and thy leucoijmiia which, Bossard claimed, invari- 
ably and immediatclj* preceded every epileptic attack of 
any magnitudy.' Bossard’s hypothesis was not contradicted 
by any experimont.aI ovidejice, and upon it all the clinical 
manifestations of epilepsy could he intelligibly explained. 
It was a useful working hypothesis for the present. By 
far the most important statement "was that one of the 
essential features of -the epileptic attack w.as a f.al! of 
blood iircssure. If this was true it was of far-reacliing 
importance, for it did away with the hard-and-fast line of 
separation between epileptic manifestations and syncopal 
.att.acks.which had been laid down by many authorities. 
Such initial fall of blood pressure, if proved to be constant 
in tho epileptic attack, would serve, the lecturer hoped, 
to rid tliQ mind of that explanation in pathology of so 
many ill-nndcrstood diseases— arterial spasm. 


3Icfnlqlw risfurhance the EssenHal Cnusc. 

. The lecturer submitted that there wore manv clinics 
rcaUires of epilepsy which strongly supported .a 'metaholi 
disturb^anco as tho essential cnuso'of tho condition. 

fl) Ilio very comnion incidence in earlv infancy, whe 
tho personal metabolism might not bo str'onelv orginizet 
nor tho developing brain higlily stable, and the importan 
mlliienco which so definito a niotabolie disorder as rickef 
might have in determining tho incidence of cpilepsv; als 
the inc.dcneo .at thy time of pnbertv, when importan 
iiictaholic changes might ho presumed to occur, and agai 
.a small incidence in the degenerative period of life, whe 


metabolic regulation might he failing. The periodicity of 
epilepsy also might be most reasonably explained on tho 
grounds of a metabolic dyscrasia. 

(2) The usual immunity of the epileptic woman from 
attacks during pregnancy, a fact only to he explained on 
the basis of the correction of a faulty metabolism in the 
mother by that of her foetus. On the other hand, epilepsy 
might occur only during pregnancy; this form probably 
belonged to tlie class of eclampsias due to anaphylaxis from 
foetal products. 

(3) Status epilopticus, for which, in the lecturer’s view, 
the only explanation was on the grounds of an acute 
autotoxic process. The condition closely resembled experi- 
mental convulsions from tho exliihition of convulsant 
poisons. 

■ (4) The immunity of the habitual epileptic from many 
common diseases — an immunity which he showed in common 
with the subjects of infantilism, idiocy, or 'cerebral 
diplegia,' and wiiich favoured the ai'gimient that in the 
epileptic subject metabolic perversion was a fundamentally 
important factor. 

. ... Organic Epilepsy. 

Tho occurrence of epilepsy in connexion with every con- 
ceivable variety of local disease of the cerebral hemispheres 
■was a difficulty in the conception of a fundamental factor, 
for epilepsy in a disordered metabolic state. . Tho idea of 
organic epilepsj* as something quite apart from idiopathic 
epilepsy, with a different clinical aspect and etiologj*, had 
impeded progress in the knowledge of epilepsy, for there 
was really no difference whatsoever between tho clinical 
manifestations of epilepsy resulting from organic disease 
of tho nervous system and those of idiopathic epilepsy. 
The lecturer had himself obsen-ed every known feature 
characteristic of idiopathic epilepsy in cases of organic 
disease of the brain. He had seen every conceivable 
variety of local attack, both sensory and motor, occur in 
idiopathic epilepsy, and he was in tho habit of teaching, 
perhaps too dogmatically, that the commonest cause of 
I Jacksonian epilepsy was idiopathic epilepsy, but that 
actually was his individual experience. 

There was no iesion of the brain that would certainly 
{iroduce epilepsy, whatever its nature or position; on tho 
other hand, there was hardly a lesion of the brain of any 
nature which had not produced epilepsy. Obviously, there- 
fore, it was not tho lesion of the brain alone which was 
responsible for the condition. Thors must he some other 
factor which, together with the brain lesion, could pro- 
duce epilepsy. This second factor had been widely sought 
in many directions, but the lecturer submitted that it was 
in reality the same disorder of metabolism which he had 
already put forward as the fundamental cause of idio- 
pathic epilepsy, hut existing in minor degree, so that there 
were no spontaneous outbursts until tho local lesion of the 
brain was added. 

• He went on to describe the experimental work of Dandy 
and Elman at the Johns Hopkins Institute at Baltimore, 
which ga%*e_5omo support to his idea of the tmitv in cause 
of idiopathic epilepsy, organic epilepsy, and .svnipfoniatic 
epilepsy. These experiment.alists had shown t'hat a local 
lesion of the brain, not in itself epileptogenous, could in 
junction with a disturbing agent in the general hodv 
circulation,- again not in sufficient dose to ho epilepti- 
genons, produce^ both local and general epilepsy. That 
was the pfoposifion, said the lecturer, which ho had 
already advanced as a possible explanation of epilepsv ns 
occurring from local disease of the bi-.-iin. 

■In conclusion, he spoke of those happenings iisualiv c.'illed 
convulsions, with which were found on occasion — lie would 
not say commonly — most, if not all, of the clinical phono- ■ 
mena which characterized epilepsj*, the clinical jiictiirc qua 
epileptic manifestations being sometimes indistinguishable 
from epilepsy proper. He submitted that since the train 
of phenomena resembling those of epilepsj* was well known 
to occur from disordered mitritionai sfate.s, from interfer- 
ence with important organs of niotaholi.sm, and from 
infections and intoxications, all of which were jirodiictivo 
of metabolic dj-scrasia, it was a fair argument that all 
epilepsy might he similnrlj* c.aused, and that svmptomatic 
convulsions and other opilepsy-liko manifc.staf'ions should 
bo included in the epilep^ description. 



568 Ha'rch 3i| 1928] 


_I-I 7 Mr,ErAN;iiEdTURES'ciN-^PinEPSr, 


Tt, Maladies. 

innnifestations, or ansinc 'tindnr+"r*'°"’ parallel 

"" ‘ circumstances.' 


Tliose 


uarcolopsv, and tetanv n-orc\v'l*l ^ctany- Migraine 

epilepsy, 'from locanem’oiiq nt tf occur, as did 

to be very good eiUmr f there seemed 

in the samo^cliL®aI and imthn’r'' 1"® '"‘‘'"‘ties 

of n*mh some of them might be^only farletieT^' ' 

.nd’ P””™', I'M Ml,,; 

i"., *™ ‘p r'“''p ■"M'S- 

nud .mental states;. (2) that of P^^alyscs, 

Ho maintained tha/ i sSe 


tlio epileptic fit ivas fright 

examples of this. Moreofer; h^did^nof 
.tndinoiis records - ’ "c."''* not 


Y- Tut hnmsa 
- JIBWCaI. JoCBjflt 


and ^ that ho had seen many 

of rofioy "''‘y tto nniJti- 
.^.'!. ,.T.(®P®y _tcom almost 


always pimson^ ^^^ih gllr'S! ^ 

first group almost exactly sombled t msn '"f ^T‘® 
in epilepsy, excent tlnr Hm.r ^ those nlncli occurred 

y’..r'L £,;• z zvTii “■> 

; om o?v''“' f “"“'■S' . "S“T™ 

rtici. ofta, foiii,.,,, 
migranio and epilepsy they ' 


f possible, f6rra bf stimuJus-alite' ocvcl — 

■and sensoiy, and occurring indiscrSlf^a‘'teI®^““'“^■®®"“'■■'■' 
epilepsy, organic epilepsy, and •/" '‘^'oP'itiiio 
• be oxclnded from- tbo ckss of 

as "reactiyo.” It would seem ^ "*”cb were hnown 
was usually a malady per se but narcolepsy 

with epilepsy in its maniICkatU tba Tt wr 
pathology in a metabolic dyscrasia’and T r’ ? 1“ 

' tbo netvous system but tlist ■ iosions of 

th, d ,S. “1, ;.T' “• "Mm* M 


W’itii t?io headaolie, 

-1 • ^ --- UlbO 

epileptic attack. In both 

rapid increase ofTntnmranHr 
of the brain. It seemed qm't^ cleTTlTt'thTTw 
of ^-mptoras in migraine esnited fron twn i ^ ^P'‘’"P® 

.. cesses— the first from snml ,,, ^ ° distinct pro- 

i^r Ti"®. " oo 4 '”i»“' bS; 

Kr,r'®“ “ 

di.it 

iT“'sSrl,TTdgF,rirosi^of£T 

posterior regions of tlio hmr,’ o 1 '1'’* always, ut the 
association ■ of swelling of the hv^”^ baying tlio special 

pSo-fEi"?. rs I'f ™ ■ "“i 

duced always ToT a sTfden em J™®'* P™' 

pleasurablo kind There nms r*°”i most often of the 
between these two iSfetT T aTtacr^Th""*"', 
of sleep, usually withnnt ■ , . ® attacks 

emotion; the catanlectie ett nse, might occur upon any 
and blends were met with^'fiT 

occurred together ft w„’l oataplexy and sle^p 

attacks had° their basis iT a 
iiarcoplexy there was no qnalitTTe T 
of the human being to bis surroim reaction 

exaggeration or misplacement of events oftho T "" 

Dr. Adio considered tlmt t.lm ^ “ormal state. 


to 


disorder of the nervous .system m-imotn “ ™“etionaI 
disturbance of tho niiciens endocrine 

centres of the mid-brain. 


oonsidored that the malady was a fnuctuTnai 

hvn""]''" ^ endocrine 

and adjacent 
Tlio pnriillclisni botweeii iJianv nf -fTin «i r. 
and those of epilepsy was striking aFd ft\°J narcolepsy 
worthy that thero bad been authoritatively "i”*®" 

the pathological explanation of narcolep.sy a^metshP?^^,®® 
order peculiar to the individual and, alternatiff), 
lesion of the nervous system. Collectively both it’ ^ 
ditions might , be given as tho pethologicnl 
and that-was .the same jmtliology as . ho was soLm-^- 
tho explanation of epilepsy. ® submitting as 

Tho arguments urged against tho relation of narcolen,.. 
wpth epilepsy were not very strong. When T>r 
stated his-determinatiou that the two conditions were uT 

itsr J4“'“ sr .l‘t tr- r™ 

«« « s 


( <^nd Vaso-vagal Attacks. 

forms of- epilepsy by Pnodmaim in- 1006 as worthy of 

an inlnbitmn of tho higher psj'chical processes lasting from 
five to ten seconds,- the power of speech -and of voluntary 
moyement was .1, abeyance, but the automatic movements 
were refamed. The lecturer argued that the contention 
that pykiiolcpsy was a disease sut generis fell to the ground 
utterly; it was, m fact, simply a- variety of epilepsy. The 
■ variation, m the natiiro of the metabolic disturbance which 
underlay epilepsy was responsible for the typo and- the 
constancy of tbe'jihenomena which resulted. 

• Vaso-vagal attacks— called vasal ■ because of the con- 
spicuous . pallor of tho - surface and. coldness of the 
e-xtremities, and vagal because of the common occurrence 
of, epigastric and ■ cardiac discomfort and respiratory 
restriction— made up a definite syndrome which had an 
important bearing upon epilepsy and related conditions. 

• Ho was convinced, -as th© result of many observations, that 
tho pallor at the commencement of the epileptic attack 
and that seen in the vaso-vagal attack, the attack of 
migraine, and in the syncopal attack,- were all duo to 
tlio same cause — namely! a general fall in blood pressure. 

In tho vaso-vagal attack there was plenty of time to deter- 
I mine this fall accurately. Ho had seen many patients 
!. with vaso-vagal attacks, and -he gave 'details of, a case in 
which ho had observed the attack from start to finish on 
at least twenty occasions. But vaso-vagal attacks were 
not epileptic, though, like those of migraine and narco- 
lepsy, they might mix clinically with epilep^' and were 
amenable to tho same medicinal treatment. It would bo « 
well to follow Gowers and class them as distinct, hut 
belongiug to the same clinical and pathological group, 

St/ncopal Attacks. 

Tho lecturer had often wondered why fainting attacks- 
had been so stringenth- sojiaiated as having no association 
with epilepsy; he supposed it was because the lowering 
of blood pressure was slow and prolonged enough to bo so 
obvious, and because the syncopal attack appeared so often 
as an affective reaction to some very definite though often 
trivial cause. He ..held ve^- strongly that the syncopal 
attack was not an epileptic attack, but that it was a 
phenomenon of the same order and dependent upon a 
similar pathology, and should be classified in the same 
group with epilepsy, migraine, narcolepsy, and vaso-vagal 
attacks. It seemed to him that the otherwise liealtliy 
people who were subject to syncopal attacks had a personal 
metabolic peculiarity not far removed from that -vv-liich he 
had suggested as the underlying factor in epilepsy and the 
other conditions just mentioned. The fall of blood pressure 
so conspic-iious in the syncopal attack -was an essential 
element in all the others.. , 

After dealing with the occurrence of convulsion in 
syncopal attacks, the lecturer closed with a few words on 
the association of epileptic -manifestations with those of 
tetany. -Tetany was certainly the result of metabolic dis- 
turbance, for it could bo produced by calcium deprivation 
and by parathyroid extirpation, and removed thereafter 
by calcium administration and parathyroid feeding. In 
rare instances it might appear as the result of a local lesion 
of the brain, and a few cases were recorded in ivhich both 
epilepsy and tetany so resulted. ' The sudden onset of 
general tetany was n.sually associated with sudden loss of 
consciousness, as was the general epileptic attack. 



MARcn 31, 19-8] 


tiUMLEIAN IiECTDBES , ON EPILEPST, 


[ 


Tjis Crttiss 

StcDICAt JOCRNAt 


559 


CLI^^CAL FkAWRES of ErlLFTSY. 

In Ills third and concinding lecture Df- Collier called 
attention to some of - the clinical features of epilepsy rrliich 
had a hearing upon the argument he had advanced as to 
the cause of the disease. Mental deterioration^ though 
commonly met nith in epilepsy, was no necessary associate 
of the disease. The highest nioiital attainments had long 
been kncivn to. accompany a ' recurring epilepsy of life- 
long duration. Nor did mental failure seem to have .any 
relation either to the severity or the frequency of the 
epileptic attacks, and progressive mental degeneration was ^ 
met with in patients in whom the attacks were neither 
SQVoro nor frequent, and was absent iir p.atients who suffered 
such attacks. Mental deterioration- might precede the 
epileptic manifestations hy months or years. It was cer- 
tainly not roused hy the occurrence of fits. In those cases 
which presented mental deterioration there was another 
factor at work besides that which produced epilepsy, and 
in arguing th.at this was a metabolic disorder it was easy 
to add a further such disorder, similar to the hjqoothetic.il 
cause of, dementia praeeox, in order to account for the 
association of mental deterioration with epilepsy in some 
cases. 

. The lecturer supported Muskens in his recent opinion 
that myoclonus -epilepsy was not a blond of two diseases, 
hut that myoclonus was a characteristic manifestation 
of epilepsy and simply an exaggeration of jactitation, 
which was a common phenomenon of cpilejisy. Simple 
paralysis was ono of the essential epileptic manifestations, 
not dependent upon, nor in train of, any other epileptic 
incident; it might be the solo manifestation of an epileptic 
attack, just as the paralysis of migraine usually was the 
sole manifestation of the migi-ainous attack in which it 
bcourred. • He went on to describe in close detail a case 
which illustrated the nature of epileptic paralysis, and 
drew attention to the amazing effect which a strong 
psychic disturbance had upon even an organic epilepsy, 
changing the type of the .attack from an infrequent and 
general attack to a very frequent and local one. ITitli 
regard to the lowering of blood pressure, he had argued 
that this was a characteristic manifestation of the attacks 
of epilepsy and of the allied maladies referred to in his 
second lecture. He would not place lowering of blood 
pressure as the immediate cause of the ejjileptic attack, 
nor of any of the epileptic manifestations, except the 
blanching of the brain and the skin — though this might in 
truth be the real relation — but ho thought it a common 
manifestation of the commencement of the epileptic attacks, 
and he wished to bring epilepsy into line with the other 
epileptiform maladies in which such lowering of blood 
pressure did occur. 


' _ . E}^lcptic Processes. 

^ The Site of origin of epilepsy seemed definitely confined 
to the cortex^ of the cerebral hemispheres ; every local 
lesion productive of epilepsy which he had seen had been 
in or near the convolutions, or had been in such a position 
as to allow of some secondary process affecting the con- 
volutions. &me authorities, however, held that epileptic 
attacks might originate from subcortical centres. Tliej 
• • maintained their arguments rather from the standpoinl 
hat the symptoms of tonic fits were such as they would 
expert to result from disturbance of function in tlie basal 
ganglia, because these showed in some degree the same kind 
of rigidity ns did basal ganglia lesions. This was verj 
debatable ground. No one would deny that in letliargii 
encephalitis tbo strangest varieties of paroxysmal pheno- 
mena often appeared, and this disease affected the 
basal ganglia in particular. Tlie lecturer drew attentior 
at this point to the newly described svroptora of epilepsi 
, -Siven by Knnpp-wbicb was held to' have its origin ii 
we putamen and optic thalamus. The case described hi 
usual type of genor.al epilepsv in a child 
ipth fits increasingly frequent, speech slow .and difficult 
hmbs and trunk rigid, with perrersity and slow spon- 
■ movements, facial grimacing, and emotional o-rcr 

activity. Tko picture came to rosomblo exactlv that oi 
tho ni.^.ady winch Gowers called “ tetanoid cho'roa,-” am 
which M ilson had now named " hepato-lenticular degcncra 
tion, in which there were conspicuous lesions in tin 


lenticular nucleus. Tlic lecturer described a characteristic 
case of Knapp’s syndrome which was recently under Itis 
earn; it convincingly indicated the truth of Knapp’s 
picture, and left it open whether tho cortex or the basal 
ganglia was primarily at fault. There was nothing in tho 
nature of the fits in this case to suggest anything but a 
cortical origin. Tliey were local tonic-clonic fits without 
loss of consciousness, they could be arrested, by strong 
voluntary effort, and they could be produced reflexly. 

loss of Function and Feteose Phenomena. 

, toss of function was the most commonly occurring 
feature in all epileptic symptoms.' So far as the highest 
functions of the neivons system, commonly referred to tho 
cerebral cortex, were concerned, the phenomena of epilepsy 
were, with one exception, unvaryingly those of loss of 
function. The whole train of positive phenomonh did not 
seem to belong to the highest levels of tho nervous system, 
except in the occurrence of the “ dreamy state ” and of 
highly organized hallucinations of hearing and vision. 
The opinion was widely held nowadays that tho essential 
element in the epileptic attack was a sudden loss of func- 
tion, local or general, in the higher levels of the nervous 
system, and that all. positive phenomena which occurred, 

. such as hallucinations aud convulsions, -were of tho nature 
of “ release ” phenomena in lower centres.' This, which 
was known as Hartenberg’s theory, seemed to he the best 
.working hypothesis for the explanation of epilepsy, though 
its terms “ inhibition ” and “ releaso phenomena ” seemed 
inadequate physiological words appended to very obvious 
things, of the real nature of which almost nothing was 
known at present. Tho lecturer suggested here that if 
, tho theory of “ release " was correct, so'me of the release 
I phenomena, which he instanced, must he of the negative 
i order. 

■ The Treatment of Epilepsy. 

Tlie lecturer concluded with a few remarks on treatment. 
Tho less the life of the epileptic patient departed from 
that of the normal person the better would bo the result 
of medicinal treatment, and the more hopeful tho outlook. 
In every case of epilepsy where it was possible education, 
occupation, and vecre.ation should continue without any 
restriction. Since the introduction of the malonyl-iirea 
compounds for tho treatment of cpiloiisy their very groat 
value had gained universal acceptance, and luminal, which 
might bo taken as a typo of them, had largely supplanted 
the bromides. It had much tho same effect as they had, 
and did not cause acne or dyspeptic symptoms, hut there 
seemed still to ho some cases which did better on bromides. 
IVhichever drug was used, there appeared to he no advan- 
tage in ndniini.stofing it more than twice a day, or in 
employing any hnt moderate doses. The whole purpose of 
these remedies seemed to ho to anticipate and prevent the 
fit; it thcreforo appeared useless to give these drugs for 
tho treatment of nocturnal epilepsy except in single doses 
at liight, or for diurnal epilepsy except in a single dose 
in the morning, or for epilepsy that occurred both hy clay 
and by night in doses both night and morning. Inasmuch 
as the attacks appeared at regular times, and could bo 
aborted one fiour previously by a dose of tbo remedy, tbo 
epilepsy could bo tbe more successfully treated. The only 
other remedies which really influenced epilepsy were zinc 
salts and belladonna. 

- Status epilepticus, however, was completely resistant to 
the remedies just mentioned. In that condition there was 
. the utmost necessitj^ to preserve the bodily' nutrition and 
Btfongth by careful use of food, fluids, and stimulants 
administered from the first by tho nasal tube. Any remedy 
which had a depressant effect, such as luminal or bromides, 
-did more harm than good. Paraldehyde, first used hy Dr, 
Arnold Camiichael at the National Hospital, was of signal 
valne in tlie treatment of status epilepticus. It could bo 
given in largo doses, up to 8 drachms, without ill effect, 
and was readily absorbable from tbo rectum when mixed 
with an equal quantity of olive oil. The lecturer said 
that with this remedy ho had s.aved many patients in 
status epilepticus when their condition was so desperate 
as to make him believe that without it they mu.st havo 
died. He rerommended the use of par.ildehydo in any 
epilepsy in which conv llsivo attacks wore frequent. 



860 March 31, 1928] 


THE SPREAD OF MEASLES. 


t TnE Beiush 
Mceical Jocnirip 


3Sritt6i) JHetitcal fotitnal. 


SATURDAY, MARCH 31st. 1928. 


THE SPREAD OF MEASLES. 

In the presonfc-clay immunologica] epoch in the history 
of medicine, when so many diseases have yielded tlio 
secret of tlieir origin, and at the same time disclosed 
their antidote, it is matter for regret that one of the 
commonest infections, and one which contributes in 
a substantial degree to the mortality of the country, 
should to such an extent have baffled inquiry as to be 
accepted meanwhile by public health administrators as 
an inevitable evil. Despite the progress of sanitation 
and the general improvement in ways of living, 
measles continues in populous communities to prevail 
in repeated outbreaks nhich ultimately outstrip every 
effort at control, though their case mortality in recent 
years has happily been reduced by the gi'owing practice 
of removing selected children to hospital with the 
object of preventing fatal complications. The solution 
of the problem of measles is still in early stages, and 
every eSective contribution to an understanding of the 
circumstances under which the virus passes from 
person to person is of interest and value. 

A study by Dr. James L. Halliday of the 'Puhlic 
Health Department of Glasgow,* which deals with the 
occurrence of measles among young working-class 
children in the city during poi'tions of 1925-26, throws 
light on the part which may be played by the stylo of 
housing on the spread of this disease. In the worldug- 
class quarters of Glasgow the people are housed on the 
tenement system, each house, usually of three or four 
stories, being divided up into tenements of several 
apartments, arranged in flats and joined by a stair- 
way which is the common playground of the children. 
In Scotland the house is called a tenement and the 
tenement a house. The words are here used in their 
English senses. In one house of four stories wth 
fifteen tenements, as the author recounts, among ten 
children under the age of 10 who had never had 
measles nine developed the disease. The infection 
was intz’oduced by one school child, who uifected all 
the others. In another house of four stories with 
twenty-nine tenements, twenty-six of which opened on 
two common stairs, while three had front doors opening 
on the street, among twenty-two children under 10 
who had not had measles fourteen took the disease. 
Four of ' the fourteen were school children, and ten 
were under school age. All the three houses with front 
doors of their own escaped invasion. In a short cul- 
de-sac of seven four-story houses, including 108 
tenements in all, among eighty-eight children under 
10 who had not had measles forty developed the 
disease Of the fortv cases nine were primary; the 
rest were mainly infected on the stairs. In some 
instances the disease was introduced from schools m 
others the source was not discovemd; but in all three 
places once measles was brought m its chief propaga- 
tiorwas not in the line of the family, but among tlie 
children leading the community life on the close or 
eoiZon stair. “These struct ures are insepa rable _fr^ 

..vn inquiry S" 

cLncif''^SPeciil Report Seri« No, 120. 

V, London : il.M. Stationery Ofiice. J928. Is. net. 


the tenement style of dwelling in the older quarters 
of Glasgow, which thu.s lies open to the charge of 
favouring the spread of measles. 

•As regards' the cul-de-sac referred to, Dr. Halliday 
pertinently comments upon the fact that, though 
eighty-eight children were exposed to risk, only forty 
were seized, and suggests as an explanation that the 
forty-eight who escaped had been immunized by 
receiving from time to time subinfective doses of the 
floating vims diffused about their neighbourhood. TFe 
think tlii.s view correct. It accords with Dudley's 
theory of the velocity of infection, under which infec- 
tive charges which fail to infect, 'though they wither 
away, yet leave their host enriched with protective 
antibodies. It fils in, too, with the experience of 
G]as"ow in the measles outbreak of the winter of 
1907^8 — one of the largest recorded in the city— when 
it was shown by J. Brownlee that at tlie close of the 
epidemic all liable to attack had not been infected; 
since children of susceptible ages who had not ■had 
measles repeatedly .came under his notice during the ^ 
cusuin" summer on their admission to the Glasgow 
fci'cr hospitals with other infectious diseases. .Ihey 
wore regarded then as susceptibles who had escaped; 
we should think of them now rather as inimunes 
who liad resisted, having been .immunized by exposure 
io subinfective doses of infection during the course 

°^The by the house which is composed of 

tenements, as contrasted with the house which has its . 

measles at “Kg. 7ui,initted; The moidenco 

brough op y Glasgow cliildren under the age of • 
of measles great in houses, composed 

It arinTerXdi^ed houses erected in 

40 ma in 

nob jiau meiisies ^ incidence of 

“ evlTa-e up to 5 was higher , in industrial 

measles ctsisting entirely of houses com- 

and than in residential districts where 

posed of These relations have a sinister 

such houses disproportionate risk of 

significoncD ^ec mortality of 

death afc tb® the first year of life, according 

measles m • gtudy, was sixty times as 

to figures -g . poi- Aberdeen, Ilenfrewshire; 

■®"'®f*'T 5 vminlbam id order the corresponding figures 
and l^Hnun^liam though not so high, 

are 25, 21. 01 *^^ . ^^t attributes to the houses 

'■f Kaemente -^*-h he has dealt with and 
composed ^ j type, a definite responsibility 

to houses of d 3 of measles at early ages, when 

for favouring the sprea self-contained 

the risk young children from 

house, ter tLn the house composed of teae- 

measles, ^ houses, however-, arc essen- 

rmot-and-braneh policy is not called fOT, 
tiaUy had. °Xlin"s in Scotland, of modest height, 
and teneme oasSi^es and spacious aii-y staircases, 

with wide well-htpass‘j J 

may yet measles mean- 

scheme of things. JtepH bv its own laws and 

while of ffs recurrent outbursts by 

determining tho per Jt has itself created. 

the number of mrmu produced by subinfective 

The immunity belie ,vbich follows a survived 

doses is short-lived^t successive epidemic 

attack IS usually , . the total number of 

adds an appreciable quota „cts\)ur country 

immunes in the population, and protects our 


MABCH,3Ii .192^3 


BIAGNOSTIC VAIiGB OF PAIN. 


[ ■ itoBat m as - -RR7 

Mrrstcju.Joc*2CJA OUJ. 


from such widespread visitations os fell upon Faroe 
in 1846, when measles was introduced from Copen- 
hagen, or on the Fiji Islands in 1874, when the chief 
brought the disease ■with him from Sydney. 


DIAGNOSTIC VALUE OF PAIN. 
Thkoughout the ages pain has been looked upon 
almost wholly as an evil thing. Poets, indeed, have 
sometimes sung of it with picturesque imagery', and 
fanatics have inflicted it upon themselves in the hope 
of acquiring merit or of purging themselves of sin; 
but by the great mass of mankind 'pain has ever been 
regarded as an evil to be got rid of if this be possible, 
and, if not, to be home with fortitude. In an age of 
self-medication this attitude towards pain has become 
intensified, and if we could put the clock back some 
thu'ty years a great many people would probably be 
much less inconvenienced by the fact that they -would 
find no taxicabs on the streets than by their inability j 
to buy a bottle of aspirin from the chemist. Yet it 
seems clear that, if the matter is looked at philo- 
sophically and in its widest aspect, pain is in truth 
a blessing, and that, as Eichet said, it is a fundamental 
factor in human progress. We need not here discuss 
it in its biological aspect, or go deeply into its nature, 
in Sir Charles Sherrington’s definition, as a psychical 
adjunct to a protection reflex; but, looking at it within 
■the narrow limits of clinical medicine, with which we 
are more particularly concerned, pain is presented to 
us as a sign and a warning, to be accepted with 
gratitude rather than endured with curses. JIauy a 
•weary hour of anguish might be saved if the medical 
attendant could but assess correctly the meaning of 
a pain; and how different would be the outlook for 
many a patient with cancer if only the very onset of 
the disease were marked bj' the agonizing pain of 
angina instead of the phantom t^^-inge that passes as 
a stitch! 

The importance of the careful investigation of pain 
ns a guide in diagnosis was brought prommently 
forward more than sixty years ago by John Hilton in 
his classical lectures at Guj'’s Hospital on Rest and 
Enin; and although the seed that he then sowed has 
borne abundant fruit — ^tended and nurtured as it has 
been by the patient and penetrating observations of 
later investigators, notably' by Eoss, James Mackenzie, 
and Head in this country— we are still impelled far 
t'OO often, either by ignorance or by lack of slrilful 
observation, to fall back on some such explanation 
as rheumatism ” — now, as in Hilton’s day, " our 
favourite phantom.’’ If progi'ess has been slow, this 
IS in no way due to fcsrgetfvilness in the famous school 
whein Hilton taught, as the clinical teaching of 
Jacobson, the researches of Hurst, and the biological 
musings of Professor Pembrey have borne eloquent 
witness. Following in the same tradition, Hr. J. A. 
Eyle draws further attention, in an address which we 
publish to-day, to the diagnostic value of pain and 
the need for a more extended and intimate clinical 
study thereof. In this paper Hr. Eyle confines him- 
self, for the most part, to visceral pain, but much of 
what he says is equally applicable to the subject as 
a^nhole, and in relating the results of his own expe- 
rience and the methods with which lie sets about his 
observations, ho has much to sav that should prove 
a help and an encouragement to others. Hilton himscE 
laid chief stress on what lie called sympathetic pain, 
winch was practically the same thing as the 

rcfciTcd or somatic ” pain of later writers, and 
he related many cases in which the patient refused 


to accept a diagnosis that placed the . origin of the 
pain somewhere else than "at the site where it was 
felt; but he was far from neglecting the information 
to be gained by careful obsen-ation of the patient’s 
own sensations. The important help that may be 
given by the snfferer’s own spontaneous gesture in 
describing the pain is sometimes brushed rather 
brusquely aside by the over-zealous possessor of the 
latest gadget for testing skin sensation, but it is given 
a prominent place by Hr. Eyle, whose vh'id descrip- 
tion of the various gestures brings to mind the old. 
Latin proverb; Ubi dolor, ibi digitus. 

The reasons for our mability to grasp the commonest 
of all symptoms, and to make It the centre point in 
diagnosis, are only too clear. Pain is elusive, here 
at one moment ' and gone the next, and (fortunately 
•for us) so completely forgotten, except for the fact of 
its occurrence, that we often have no words with 
•which to describe it. Then, again, there are no means 
of measuring its intensity or of comparing pain in 
different subjects. M’hat is an agony to one may be 
borne h-ith comparative indifference by another — or 
so we say, and who shall judge the tnith? Nor is pain 
easy to " place,” and even if it can be located w'e 
know that it may be due to some far distant lesion. 
Authority, too, will sometimes fail us, for disease 
changes its ground and pain shifts with it, so that new 
sources of pain are constantly being added, to be con- 
founded with those we were beginning'to understand. 
But above all others looms the difficulty of distin- 
guislffng the pa'm of organic disease from functional 
pain. Bichat’s advice to feel the pulse may be of 
service on those rare occasions when the patient is 
seen during an attack, but for the most part the 
observer must rely on his ouii unaided judgement, 
which may too often be at fault. Dr. Eyle suggests 
that the astuteness of -our forebears in judging of these 
things — their ch'nical acumen — may be in danger of 
being lost through too great a reliance on laboratory 
methoflsj and many a good judge ■will agree with 'hirn ; 
but it is open to the other side to suggest that the 
absence of any laboratory method in .the cEnical 
I investigation of pain is, at least in part, the explana- 
tion of our lack of working knowledge. All ■will, at 
j any rate, agree that It is undesirable and unnecessary 
[ to await such developments before undertaking the 
more intimate clinical .study for which Hr. Ttyle pleads. 


MEDICAL CO-EDUCATIdN tN LONDON. 

The question of medical co-education in Xondon has been 
raised with some prominence lately in the public prc.ss, 
following an announcement that three of the metropolitan 
medical schools, irhich during and since the war have 
admitted women students to their courses under temporary 
arrangements, have now resolved to take men only in tho 
future. The schools in question are those attached to 
Cliaring Cross, King’s College, and the ■Westminster 
Hospitals, and in this decision they arc following the course 
already pnrsned at the London Hospital and at St. Mary’s 
and St. George’s. At University College Hospital the 
number of women students is limited to a small figure, 
while the medical schools of St. Bartholomew’s, Guy’s, 
St. Thomas’.s, and tho Middlesex Hospitals have hitherto 
opened their doors to men only. The effect of tlie recent 
decision would therefore bo to confine the medical educa- 
tion of -women in the metropolis to the London (Eoval Free 
Hospital) School of Medicine for Women and, with strict 
limitation in respect of numbers, to Uuiversitv CoTIece 
Hospital Medical School. Thus to all intents London would 
revert in a few years’ time to tho position it held before 



563 


“ISiUticH 31 ; 1928 ] 


Aap'f! ■ . -v IV. . ■ • 

FAMILIAIi HYPERTKOPHIC PYLORIC STENOSIS. 


[ Th* Barnrt 
SlmeiL Joc&XAX 


lodger has been exploited, enconraged, or forced to engage 
in prostitution. The medical siiperrision of persons sus-' 
pected of being: capable of spreading the disease is, ha\r- 
ever, '.maintained. The medical authorities may require 
those suspected of spreading infection to present a medical 
certificate or to submit .to .a medical examination. In the 
p.ast women alone were obliged to submit to medical exam- 
ination and supervision; henceforth men also are subject 
to the same measures under certain conditions. The super- 
rision of women is not confined to the comparatively few 
persons .registered bY the police, but ’is' also extended to 
the . clandestine prostitute. It is . hojjed that by tliese 
means it will be possible to stamp out centres of infection- 
more effeetivel}' than hitherto. The problem of profes- 
sional secrocj" js dealt with.in-xfich ii way that doctoi's' are- 
Ijetd. to he free to' report - infected persons to the health. 
authorities. Blit, ' as .- already pointed out, it is only a; 
patient , who refuses treatment who is subject to coercive 
measures. Generally speaking,' responsibility has shifted- 
from tho police to the medical profession, although tho 
police have not been wholly excluded from the field ; they 
will continuo to deal with persons soliciting in the streets 
or. committing other-offences against public deccucy. 


- familial- HYPERTROPHIC PYLORIC STENOSIS. 

The exact etiology of the so-called catigenltal hypertrophic 
stenosis of the pylorus is still a matter in dispute, but the 
occurrence of familial cases strongly suggests that it is not 
an acquired, almort accidental, characteristic. Evidence 
as to its familial incidence has been collected by E. J. 
Caulfield in America, -who rcpoi*ted one family desertbed 
bj Finkolstein in which four children wero affected. At a 
meeting of the Section for the Studj' of Disease in Children 
^.the Royal Society of Medicine, held on March 23rd, 
Drs. B. A. Cockaj-no, .A. Moncrieff, and W. P. H. Sheldon 
demonstrated some striking examples of the familial inci- 
denco of this malady. They described uniovular twins, 
Un cr t le care of Dr. R.. Hxitchison, in whom hy|>ertropliic 
s eiiosis of the pylorus had been diagnosed and confirmed at 
operation in each case. These twins had been both bom 
^ ^ presentation, with one placenta, one chorion, 

and two amniotic sacs. Tho only other child in the family 
months old and healthy. Ono twin began to 
\orai at 3 weeks old,, and the other at a month old; 
Imth were brought to hospital within a week of tho 
beginning of the vomiting, and Hammstedt’s operation was 
pel orme in each case. The other familv slioim at this 
meeting consisted of five children; the oldest, a girl, was 
healthy, and the youngest, a boy aged .4 years, had shown 
o biMi esta-tions of the disease. Of the remaining three 
>s TO lad been successfully operated upon in early 
' congenital pyloric stenosis, and in each the 

^million was defmitely confirmed at operation. Tho other 

twelfth vomiting beginning on the 

Stenosis definite evidence of pyloric 

sloraftiT "°“iting had stopped 

famil-t- of fiv ' I'ospitaL Here, tliercfore, in a 

certain e ° V* existed one possible and two 

re^X C. strachauert has 

ECVcn-mnn+l f nt . 5 as been found in a 

xerj- Eti-onnlv °that stillborn, and this indicates 

It., s. a, developmental error. Dr. 

nroh^hlv * 1' ophiion ;■ that pyloric stenosis 'is' 

bo provod'imW recessive, but this cannot' 

condition ' f ' ’ to the familial incidence tho' 

account for It f ' ■'’'^"'^0 intermarrmgo would 

fullv imoi-stnl ^ Pbssihlc, too, that as children success-' 
oiie'ratfnn' introduction of Ramnistedt’s 

Xdi aTv'^T of obsem-ing the 

fiuqdrioryj ^e.of.tho disea.se-nmy.be afforded,%i-X 

* Annalt otSiirgcry, lirn, 167 . ^ 


a characteristic operation scar dating from earlv infancy 
will bo better evidence than at present offered -by even the 
. most definite Eistoi-j- of characteristic vomiting cured by 
' medical-means: in- either' of the parents of a- pyloric baby. 
In tho meantime, the recording of familial cases gives 
strong support to- the theory of congenital abnormality as 
tho cause of the condition. 


SEASONAL VARIATIONS IN DISEASE. 

Ip “ Nature hates calculators,” as Emeraon said, what 
.must her feelings he towards a medical paper which includes 
nearly two hundred statistical cun-es? Tho paper read 
by Dr. C. O. Stallj-brass of Liverpool to the Section of 
Epidemiology of the Royal Society of Medicine on March 
, 23rd. .was: thus aceonipfiniedj 'and bis. subject-.:-the seasonal 
I -Variations of diseases-^otild scarcely-^ have -been explored 
' with ' greater pains. He had even worked out cuiwes for 
diseases, not commonly thought of as seasonal — -for example, 
curves based on -returns for - cities' as far apart -as those 
of Scotland and of Sweden, showing gonorrhoea to be an 
. autumn disease, and primary syphilis a winter disease with 
its peak in Jannai-j-. His main argument was that seasonal 
I variations in -disease, -like the spread of infective , diseases 
generaliy, depend upon three primar 3 ' factors — the presence 
of micro-orgaiii.sms, tbb mode of transmission, and the 
• susceptibility of the tissues. ' All other factors, in this 
relation largely climatic, could act, said Dr. Stalh’brass, 
only through these primary factors, and therefore were 
-secondary. They iuclnded temperature, relative and abso- 
lute humidity, rainfall, wind, sunshine, barometric pressure, 
and perhaps atmospheric electricity and, in addition,- there 
were certain influences arising out of the effect of the season 
upon human activities, such as school holidays, indoor 
crowding in winter, annual festivals, and so forth. The 
paper was largely an attempt to express tho effect of 
variations in the secondary factors in terms of the changes 
which these -produced in . the primai-y factors. To express 
the total effect, of the three primaiy factors on the 
spread of infection the author chose — or coined — the term 
“ dispersabilily.” The effect of climatic changes, ho said, 
was often cumulative, and this was most pronounced in the 
autumnal group of infections, whose seasonal occurrence 
could not be directly explained by temperature changes. 
He cited enteric fever as an example of a cumulative effect 
of atmospheric warmth prolonged even for months after 
the maximum temperature had been reached. 'Vl^hy should 
enteric fever differ from cholera, dj-sentoiy, and diarrhoea 
in this respect.? Tho explanation might be that these three 
diseases had short incubation periods, while enteric fever 
I was long in developing, so that, other things .being equal, 
in enteric the number of foci of infection would bo rela- 
tively slow in multiplying. An examination of the curves 
of dispersability showed that while cholera, dysenterj-, and 
_ diarrhoea exliibited single curves with maximums in May- 
Juno or June-July, enteric fever, on the otheV hand, had 
a double ci^e of dispersability, with maximums in April- 
May and in August— September. The difference hetiveen 
enteric and the "triad of intestinal diseases just named 
might perhaps bo something more fundamental than mere 
length of incubation period. Tlie definite rise in enteric in 
May had been noted bj- other observers, bnt its significaiico 
had- perhaps been ororlooked. He had himself noticed that 
'Tronic typhoid carriers mo.st often gave rise to other cases 
in -their families in the spring. In throat and strepto- 
coccal infections generally it nas obviously impossible to 
account for autumn prevalence in relation to the length 
of incubation period. An investigation of the curves of 
■dispersability showed that all these presented a double or 
.dromedary curve, with maximums in April-May or 3Iay- 
■Juiie, and in August-Septomber or Scptcniber-Octobcr. 
Carriera of scarlet fever or diphtheria appeared- to show 
'increased activity in the spring, more especIaflj'- in'AIay. 


564 March 31, 1928] 


. EOTAL MBDICAD' BENEVOLENT FUND. 


r Tnu v * 

Uepical Jol'b.vu. 


TIio curve of carriers of virulent cliplitlicria amongst 
London school cliildrcn in some recent years showed a 
douhlo formation, with maxinnims in May and in Octohor. 
It avas customary to attribute the increased activity of tho 
carriers to tho prevalence of catarrhal complaints or colds, 
but there migl^t bo other factors at work. In Now York, 
and ho beliovod in Paris also, both scarlet fever and dipht 
thoria had recently heen spring and not autumn diseases. In 
New York tho maximal prevalence of both diseases was in 
May, although tho maximal dispersability was in tho Into 
autumn. Dr. Stallybrass wont on to say that tho effects of 
temporaturo upon human susceptibility would appear to bo 
evanescent The rapid rise of rcspiratoiy mortality conse- 
quent upon a cold spell soon passed away with the return of 
milder weather. But might there not bo a certain cumu- 
lative effect of climate upon susceptibility? The discovery of 
vitamins which were dependent upon tho action of sunlight 
on plants or animals suggested that a certain climatic 
influence — namely, deficiency of sunlight or of ultra-violot 
radiation — might be c.apnblo of producing such cumulative 
effects. But if deficiency of vitamin could reduce tlio 
resistance of tjio host to infection, might there not bo an 
action of vitamin in increasing tho activity of tho A’irus? 
The discussion on tho piapor called forth two interesting 
contributions — ono by Sir Leonard Bogers, who showed 
curves of certain diseases in India correlated with tempera-; 
turo and humidity changes, and tho other hy Professor- 
Major Greenwood, Avho mentioned that for certain diseases' 
tho seasonal variation had become relatively greater. The 
difference between tho seasonal maximum and so.asbnal 
minimum in scarlet fever was very much greater . during 
a recent period than it was a quarter of a ccntiiry ago. 
If the incidenco of infective diseases was duo to two factors, 
one entirely uncontrollable and the other rcmoA'ablo, then 
the smaller this second factor became, said Professor 
Greenwood, . tho more obvious and striking would bo tho 
seasonal variation. At any rate, tho seasonal variation of 
scarlet fever was tending to bo sharper, and tho same 
phenomenon had been noted in America. | 


A CASE OF MISTAKEN SEX. 

Physical hermaphroditism in minor degrees is not very; 
uncommon, and is mainly interesting becauso of tbb' 
developmental problems concerned. It is geuorally detected 
early in life, and the practical difficulties associated with it 
are, as a rule, mot before puberty. Unusual interest 
attaches, however, to a case reported lately by Dr. A.' J. 
M'ilson,' since tho ago of 30 was reached by a person with 
marked genital abnormalities without the occuri'cnce of any 
untoward circumstances duo to a male being mistaken for 
a female; in fact, the true sex was only discovered when 
advice was sought for pain in the lumbar muscles. Inquiry 
elicited the fact that this supposed woman had had no 
menstrual period of any kind,_ and physical examination 
revealed very definite male characteristics. The body was 
lean and muscular, and dark wiry hair covered the limbs 
and chest; tho upper lip and chin resembled those of a 
dark-haired man who had shaved for several years, which 
proved to'have boon the case. The voice was guttural and 
broken, tho pubic hair and breasts were of the masculine 
type, atid tho movements wore athletic. The scrotum was 
small, cleft, and not pendulous; it contained two obvious 
testicles and a web of skin bound down to the scrotal cleft 
a short but thick penis, which had no prepuce, but showed 
liypospadias, the urethra opening on tho lower surface near 
tho corona. A smaller and blind opening was present on 
the lower surface behind the urethral orifice, presumably 
the prostatic vesicle or homologuo of the uteius. Micturi- 
tion was performed in the squatting position. Election of 
tho penis had been experienced, and, during sleep, ejacula- 
tion of a whitish fluid. Tlie patient’s sexual attraction was 
1 Clinical Journal, Februa:^- 29tt3, 193. 


towards women, and the interests were those of a male, 
There seems to have been somo doubt at birth about the 
sox, but tho child was brought up as a girl, and until tJie 
ago of 30 had shared a sister’s bed. There' were' seven 
brothers and sisters, all physically normal. As regards 
treatment we aro informed by Dr. AVilson that the sex and 
name were duly corrected; tho patient received operative 
treatment for tho genital malformation, and afterwards 
wont to livo in another place. 


THE ROYAL MEDICAL BENEVOLENT FUND. 

The annual meeting of the Eoyal Medical Benevolent Fund 
was held, under the presidency of Sir Thomas Barlow, on 
March 22nd.' The report for tho year — ^the ninety-second — 
which was presented by Dr. Newton Pitt, stated that 
during 1927 tho applications for relief had mimbered 450, 
and that grants had been made in all but five cases.- 
Among the grantees wore 46 doctors (four of them medical 
women), and 177 widows and 124 daughters of medical men. 
Tho persons rcociring annuities included 16 medical mm, 
70 widows, and 86 daughters. Altogether tho number of 
individuals relieved was 623, at a total cost of £13,346, in 
which sum tho working expenses rejjrosented ■ loss than 
10 per cent. Tho income derived- from subscriptions and 
donations amounted to £7,590, as compared with £7,250 m 
1026, and from invested property to £4,857, as compared 
with''£4 7'i8. Among tho special donations included in the 
voar’s'. ificomo was £1,000 from Dr. AV. Tinker (second 
doifafibriV £800 from tho British Medical Association, 
Cimritieg Committee, and £625 from the Mcdical-Insuranco 
Aec'ncv-' Grateful acknowledgement. was m.ade of tho assis - 
anbo of tho British Medical Association in collecting sub- 
Lri6tbn's.fiom- its membors-during the past year the sum 
rPc'eK-cd'thfoiwh this channel was £1,271, an increase of 
S^nd in cooperating with tho Fund in several cases 
- i..infr'ii\TCStikation and assistance. It was stated that 
dAitdne tlio .year, on a vacancy occurring in the secretary- 
fl in Ir Cli.a'rters Symonds, for many years treasurer of tho 
^’i^vrilimtarilv undertook tho work of tho secretaryship 
• mb h parlly in order to ascertain whether its 
"e r as to require a whole-time or part-time 

'^“nrn'tarv ' As a result a part-time secretary had lately been 
secret. . - ^i^omas Barlow was re-elected as president, 
Syr^nl as treasurer,, and Dr. Newton Pitt 
" w -M Handficld-Jones as honorary secretaries, 
tlio’ existing vice-presidents, who were re-elected. 
Besides tbo y. -w. Hey Groves, Dr. J. J. Perkins, 

T)r^ 1^ B Soltau of Pl'ymonth were called to that 
® V’in addition to tho members of the committee 
office; and were re-elected. Sir Charles 

ZK S''- George Makiiri, Sir D’Arey 

Ballance, • gpencer were invited to join the 

Power, "'"J of thanks to tho president 

maiia^mont. I ^ ^ |^,rthornG said how fortunate the 
and officers, JJ • j^s adminis- 

Fund was revered hy the whole profession 

tration. 1^' 1 . another instance of his devotion to 

the teeasme . laonths of secretarial toil, and Dr. 

the jlr. Handfield-Jones were admirable 

Newton Pi gjj. cbartora Symonds, m rcplj, 

t dnrin* bis ’experience as secretary he had lenrnt 
uaid that ° of tho Fund than ho had ever 

“before The usual votes of thanks to all the various 
known and a special vote of thanks to the 

Tdi al ALiati^^ Ls moved by Sir- Tbomns 
British Med Association gnen 

Barlow, who saiu cnirit which made it 

material help, but had given it in a spirit wl.icl. 

all tho more welcome. 

M'f roerct to announce the deatli,_ on March 25^ 
Dr Hiwb Plav.fair, consulting obstetric and gjnaec o 
sureenn°to Khm’s Collego Hospital, London. 


March 31, igiSl 


THE TUTELARY DEITY OP MEDICINE. 


t TsxBirnra 
ysziicAX Tonxii. ,y. 


ict Sctcra. - 

THE TUTELAP.T DEITi' OF AIEDICDsE. 

Tjie Claims of Imhotep. 

BY' 

JAMIESON B. HURRY, JI.A., JI.D. 


I . 


For many centuries Asklejrios lias Ijeen accepted by the 
i ivitized world as tlie cinbleiuatic god of medicine, without 
any inquiry as to the propriety of conferring this dignity 
on him. Recent research into the history of medicine, 
however, has hrouglit rival claimants into the held, and 
the time has come when their relative merits should be 
examined with a view to a general consensus being arrived 
at. Such' a broad survey of the gods of medicine of the 
ancient .world as has recently been published by Jayne* 
shows that the various nations of the anciotit world have 
recognized innumerable gods of healing, some with a local, 
others with a national dr even an 
international' reputation. Among the 
best known may he luentioiicd Ea of 
tho Babylonians and Assyrians (said 
to be tho earliest deity associated 
with healing), Dhanvantari of the 
Hindus, Verethraghna of the 
Iranians, Eshmun of tho Phoenicians, 

Imhotep of tho Egi^ptians, and 
Asklepios of tho Greeks and Romans. 

■ AVhen, however, the history of these 
deities is examined, tho evidence of 
their earthly career usually proves to 
ho of tho flimsiest description; there 
IS little more than a shadowy tradi- 
tion, nothing amounting to proof 
that the reputed god of medicine was 
actually a man of flesh and blood, 
stilly less that lie ever practised the 
healing art. The one exception is 
that of Tmhotep, the famous vizier 
and magician-physician of the time of 
Pharaoh Zoser of the Third Dyuastv. 

Imhotep was born in Anklitowe," a 
suburb of Memphis, on the sixteenth 
day of Epiphi, the third month of tho 
harvest season. Tho year of his birth 
is uncertain, hut may bo assigned to 
about 3000 B.o., .since he was a con- 
temporary of Zoser, whoso reign is 
holicved to Iiave begun about 2980 n.c. 

His father, Kanofer, was a dis- 
iinguishod architect; his mother was 
named Khreduoiikh. Imliotep formed 
jiart of a long lino of architects, there 
being no fewer than twenty-three 
named ancestors and descendants in his pedigree who were 
aychitccts, inchidiiig his son Rahotep. 

This lorsatile man Imhotep, whose name signifies “ he 
who comes in peace,” was renoiyiied as an arcliitect, as 
a sage, as an astronomer, and as chief lector priest 
01 ritualist. But he was spcciallj’ distinguished as a 
nmgician-physician, and so impressed his contemporaries 
that- after his death ho was raised first of all to tho rank 
c 2850 b.o.), and finally to that 

ot lull deity of niediciiie (circa 525 b.c.). Temples w^ero 
erected in his, honour at Memphis, Pliilao, and elsewhere, 
to winch flocked patients from far and near, manv of whom 
returned to their mud hovels on tlio banks of the Nile full 
o gi atitudo for the gift of healing that had been bestowed 
on tliom. His worship lasted till about a.d. 550 — that is, a 
few years before the conquest of Egypt by the Moslems. 

ilius in Imhotep wq have, not a mere mythical creation 
o 1 10 imagination, but a definite and specific personality, 
of whom many historical details h.avo survived — a beloved 
plysician who ministered to bis sick and suffering fellow 
coun rymen, and who has left behind him the memory of a 
we -spent life dovoted to the public weal. The famous 
Mop-Pyramid, familiar to every tourist who ascends the 
iMlc, vcmnins as a striking memorial of his architectural 



skill. There also survive many statuettes representing him 
as a inedi'cal demigod, os well as bas-reliefs on temple walls' 
representing him after full apotheosis. The accompanying 
engraving, -which is taken from a wall painting in a 
temple at Philae,=. shows him in the stage of full deity of 
medicine, carrying the .usual emblems of divinity — namely, 
the ankh, dr sign of “ life,” which is carried in the right, 
hand, and the sceptre of power in tho left hand. On the 
grounds of prioi'ity, of nobility of character, of brilliant 
services to his country, and of an enduring reputation as a 
healer of disease, Imhotep has strong claims to be recognized 
as the patron spirit of medicine, as the emblematic god of 
our ancient profession. 

In view of such overwhelming qualifications it seems on 
first thoughts strange that -Asklepios has for centuries been 
accepted by the civilized world as the deity of medicine, and 
it is interesting to inquire how he attained to this dignity. 
His cult appears not to have extended much further 
back than tho time of Homer, who is believed to have 
lived about tho year 850 n.c. Although Homer spe.iks of 
Asklepios as a “ blameless lihj-sieian,” 
itiTpot apvfio3i\ and the father of 
two heroes, Makhaon and Podaleirios, 
who were physicians in tho Greek 
camp at the siego of Troy, most 
historians assign him a mythical 
origin, and describe him as the son 
of Apollo and tho nymph Coronis, 
who w-as educated by the centaur 
Clieiion, and instructed by him in 
tho art of healing disease. Yet other 
authorities assert that Asklepios iiovef 
existed as a man of flesh and blood; 
but was merely tho poreonification of 
certain ideas. However this may be, 
we know that in the course of time 
remarkable recoveries from disease 
became ciystallizcd round a real 
or fictitious poixonality, who wa.s 
afterwards apotheosized by grateful 
humanity. Numerous tomjiles were 
erected in his honour in Greece and 
elsewhere, tho oldest one being at 
Trikka in Thessaly, while otliem were 
at Epidauros, Cos,’ and Pergamos. 
Tho cult of- Asklepios gradually 
spread all over Greece, and became 
so popular that by the time of 
Alexander the Great between' three 
and four hundred temiiles were dedi- 
c.oted to this deitj’ of medicine. It 
was introduced into Romo at tho time 
of the great plague early in the third 
century b.c., and from that period 
onward gradually extended througTi- 
oiit the civilized world, Asklepios 
being accepted ns the emblematic god of medicine, the 
i-eputed healer and consoler of men. His figure appears 
on countless statues, chaitei-s, diplomas, coins, and seals 
associated with hospitals, medical schools, and societies 
throughout tho world. 

Tlio neglect of Imhotep is doubtless attribiitablo to tho 
fact that 'Western civilization has been nurtured on the 
literature of Greece and Rome. Not till Young and 
Champollion deciphered the hieroglyphs about a century 
ago was tho liistoiy of ancient Egypt revealed to tho 
learned world. Now that Imhotep has emerged from tho 
mists of antiquity as the first physician whose biography 
has descended to us, the time has surely come when justice 
should ho done to this Egyjitian deity. To him iinqiicstioii- 
ahly belongs tho highest place in our hagiology; to him 
should physicians all the world over look up as tho patron 
spirit of tho ars medendi, as the emblematic god of 
medicine. His portrait should become the badge of our 
profession. 

Apart from the strong historical claims of Imhotep to 
occupy tho throne so long the seat of Asklepios appeai-s the 
desirability of having as our figurehead a specific human 
personality, a man of flesh and blood, instead of one of 
uncertain and probably mythical origin. Of the life and work 


Imbotep as Deity of Medicine. 



666 March 31, 1928] 


THE STUDY OF MENTAU ABNORMAtilTT. 


f Tftx Damni 

1.MXDICAZ.JODSSA& 


of Asklepios scarcely niiylhing is known, wlicreas of Imhotep 
there remains at least one striking architectural memorial 
as well as mnnerons opigrapliical and papj-ric inscriptions, 
statuettes, and mural rej^ieaontations,’ all pointing to a 
distinguished and well-spent life, doroted in part to puhlio 
service and in part to tho healing of the sick. In selecting 
Imhotep as its tutelary deity the medical profession would 
erect on its pedestal of honour a most distinguished 
Egyptian who for many centuries before our era had been 
worshipped as tho deity of medicine. 

Rtpr.iiKSCrs. 

* W, A. Jayne: Tte Uealivg Ootl» of Ancient Cirtltzaifong, 1925.. 

- CL J. P. C'liampollion : Monuntentjt tic VKijupte ct tic In Xubic, 1835-45, 
1, Plate tv.vtUi. 

por further details see tnihoteib the Vizier anti PhitKician of King 
Zoter, anti afterirartls the Ugi/t>tian (ioil of MetUcinc, by J. It. II. 


THE STUDY OF HENT2\L ABNOIlilALiTY. 

PjlOLl!GOMliXA TO THE EsTAIILISIIMENT OF A NaTIOXAI. 
LAnonATOItY Foil THIS I’uitrosE. 
nv 

W. 11. D. FAIRBAIRN, M.A., M.B., Cii.D., 

Dirt.. Psven. Jin., 

LECTUEER IN PSYCIIOLOGV, UNIVERSITY Or I'.DtNBUEOn. 


In tho British Medical Journal of January 14th, 1928, 
there nppeai'ed a plea by Profefisor R. J. A. Berry of 
Melbourne in favour of a national laboratory for tho study 
of mental abnormality. This project deserves encourage- 
ment from all interested in tho welfare of tho Empire, and 
it is to be hoped that heforo many years elajise tho 
proposal may have aroused sufficient interest to make its 
realization a roasonablo e.'cpccfation. For some reason tlio 
study of mental abnormality has conspicuously failed to 
fire the imagination or enlist tho support of tho British 
puhlic. This fact is all tlio more remarkable in view of 
the appeal which this study appears to make to the citizens 
of the United States. Tliere the subject is not only held 
to be important, but receives practical support; liero 
neither general interest nor support is forthcoming. In 
ronsotpienee there is no institution in this country really 
comparable to the Psychopathic Hospital in Boston. It is 
true that in London, through tho generosity of tho 
Commonwealth Fund, the problems of mental reactions in 
eliildren are about to be attacked on a Jai'go scale, hiit 
even here the impetus appears to originate in tho United 
States. 

In view of this unsatisfactorj' state of affairs Professor 
Berry’.s plea comes none too soon, and ought to be a 
tiumpet call to others who share his desire to see .a 
national di.sgrace removed, 'While, however, tho estab- 
lishment of a national laboratory for tlio study of mental 
abnormality is an urgent need, the proposal would bo in- 
complete without further cli.scussion of tlie lines upon 
which it ought to be established. Alaiiy wiio liave rend 
Professor Berry’s plea will agree with me that the basis 
upon which he would have it established is too narrow to 
ensure its being of optimum value to the community. It 
is true that, when he deplores the lack of co-operativo 
effort between nou-correlated .specialties in the past and 
.--.dvocates unity of study in the future, he lends an 
apparent atmosphere of breadth to Ins proposals. To dis- 
cover how essentially narrow they are, honever, we have 
only to ask how this unity of study is to be achieved. 
Though it is never explicitly stated, the general trend of 
Professor Berry’s paper leaves the reader no doubt as to 
the answer which he would give. Towards the end of his 
paper he makes the following definite statement; 

“ The first place to seek for menial abuomiality of all kinds, 
and certainly those which art comnioifly classified as antisocial, 
are the cells of the human cerebral cortex, and this slndy 
demands co-operative national effort. That there has not hitherto 
been any co-operative effort t* study the mental abnormalities 
appears 'to be due to a lack of appreciation of the simplicity of 
the great principles underlying the construction of the vertebrate 
neuraxis." 

Ho represents the study of the nervous system 'at the 
present day as being illogic.nlly divided between neurologj* 
and tbe psychological sciences on an anatomical basis; 
ncnrulogy is represented as ton; erning itself with the 


receptor and effector neurons, psychology and psychi.Ttry 
as concerning themselve.s witii the internuncial neurons in 
their normal and abnormal functioning respectively. He 
■ then goes on to-makc this st.itemcnt; ■ -- 

“ To divide a functional entity, like the neuraxis of man, into 
a scries^ of watertight, non-correlatcd specialties appears to be 
tmseieniific and calculated to breed error. It is rather unity ol 
study which is so essential.” - - - 

As tho earlier and greater part of Professor Berij'a, 
paper is ilcvoted to the interpretation of human conduct 
ill terms of neurons and their development, it would seem 
tliat ho believes unity to be best attained by substituting 
for all the partial, non-correlatcd specialties the study of 
the physiologj' of the nervous system. It is presumably to 
this study alone that, in Professor Beny’s vieiv, the pro- 
po.sed national lahoratoiy is to bo devoted. It is with tho 
object of drawing attention to tbe dangers of a spurious 
attempt at comprelieiisiveness in tbe study of mental 
abmii-ninlity, and in the hope that discussion will favour 
the adojition of a genuine comprehensiveness, that I 
submit the following observations, 

I. The functional entity to be studied in problems of mental 
abnormality is not tho neuraxis of man, bnt man himself as 
a psvcho-p'hysical organism. If if is unscientific to study the 
receptor and effector neurons in isolation from the internuncial 
neurons and vice versa, it is at least eqaaily unscientific to 
isolate the neuraxis from the rest of. the organism. The 
neuraxis has definite functions to fulfil, but it is no more a 
real fnncfional entity than the’liver. The neur,-ixis may, indeed, 
be considered for purposes of science in relative isolation as, 
indeed, neurology does consider it; but, if we desire to estab- 
lisli a comprehensive science, the functional entity with ivhmh 
we shall concern ourselves will not be the neuraxis, but the 
orcanism. That the neuraxis is meaningless apart from tbe 
rest of the hod}' evident when we ask ourselves what signifi- . 
^tnre the neuraxis has for mental abnormality in isolation from 
tb entcrine organs. Professor Beriy has made the mteresl. 

• ttoZni that- ■■ 75 per cent- of those antisocial reactions 

"'^•t Mdoli society ae^ks to protect itself, and known as 
r®*-™ 'v ’ are directed against the person or the property—sex 
ciimc , ' . „ meaning can we ascribe to crimes 

and , „e„raxis conceived apirt from the gonads’ 

sfin fi™a.ee have'cu.imes against property or the steps 
? 1 bf socTetv to prevent them, if we regard the neuraxis 

v associated, as it is, with the disposition of-self- 
,ntim.ateb Cannon has shown, with the dis- 

assertion, . ,, 5 g,,,,jt,jon, attack and defence. I'urther, if 

positions of self p meaningless in isolation from the 

''*rofTb dH it lass meaning when divorced from 

rest of tli_e no Antisocial reactions arc complete y 

psychological p ean only 

unintelligible 1 * ^ introduce the psychological 

be adrquatelj motive, and purpose. The crime of 

conceptions , failure of a few pyramidal ceils to 

•Tnrthe functi^B ot the infragranute ^rtex; it is also 
b viour of an oi-ganisra whose sexual impulses h.ave not 
the ,^3 to the social sentiments in the process of 

been subordinated^ to ^ conceiving it the latter .is 

developraenh Of and the more fruitful. If, then, we are 
the more s>gn entity on which to base a compre- 

seekmg a je behaviour, whether normal oi 

hensive seienc found-the entity 

.abnormal, t her ^3.^ uoibrns short of the human psyclio- 

■\vhicU uena'e:*, 

ph.vsical entity in all behaviour is the psyche- 

II. S'uce follows that neither physiology nor psycho- 

physical organis^^^^^ science that considers hut one aspect j 
logy, f claim' to offer a comprehensive study o 

the organism, ^^y^normal ' reactions. In actuality no sud 
either pvisls- if it did, it -is-puld partake of the 

unifying scie "yjoubtless such a science will , 

Tr% d but m'flie meantime there are insufficient dale 

elaborated, but accumuRted 

^ctnt slash knowledge hy allowing the varied 
?- 1 soicLes to work unrestrictedly in their own fidd ; 

IXtZ" their various findings -ith^ one _another.^ Ja 


- “XTsion --of the field hetween the various sp^ 
nng so, division ^ ,!,r 

lienees is not a inai.it; • 4 •„ prized In' 3 

Ivanee of modern taowledge the 

nlliplication sciences. On y > 


MAHCH 31, 1928! 


field can advance in knowledge take place. The history of 
science is the history of the birth of new sciences. The finitude 
human mind necessitates increasint? 


THE STUDY QF MENTAIi ABNORhlALIIY. 


science is me nistory of the birth of new sciences. The finitude 
of , the human mind necessitates increasing specialization as 
knowledge accumulates. Even two thousand years ago it was 
only possible for Aristotle to cover the whole ground tf human 
knowledge because he was the greatest genius in history 
To day It would be impossible even for him to compass the 

div ided between various partial sciences. Comprehensive s^tudv 
of hnman reactions is not to be obtained by suhstitnUr.™ r n 

relate the various reLlt<; attempting to 

another. To attelt to with one 

of mental abnSity t TlSr ^ 

nervous system to usurn fl.! T a® Physiology of the 
sciences would be a procedure J “a"'®’' 

af results. To devote m labm-if . retrograde and barren 
be of little value to the commun°t?/ ° ‘ 

light ■uponim Jt'LmVofTefrT 

allowed to proceed unrestricld n fh ‘o bt 

and the boundaries between tl ^ ^ properly delimited 

clarity of thought is ioSble and^"^ 
outcome. An allocation of the fieM^' the inevitable 

Berry believes to exist at the nres^^f* 1 ^ * '•'**^ which Professor 
avoided. If the boundaries he 

believes them to be drawn them w m ^ "here he 

his advocacy of the physiologv of°th*^ J'aatification for 

in questions of abnLmal human "aura.xis as final arbiter 
fields are not delimTterin thTmann''^''”"?'- ‘he 

According to Professor Berry n^row' ‘ represents, 
the receptor and effector neurons of thfT, 
logy and .psychiatry concern- ihL * 1 "®.“rasis, and psycho- 
neurons .in, their: normal and ahn ''“, tefe^uncial 

The unifying science wliose' cause ha°n?''!l respectively, 

hand, concern itself with the wbM P would, on the other 
entity. The science which concern “ functional 

as a whole is, of course," the nhvsinl^ neuraxis 

regards the other science^. 7^ nervous sj’stem. 

ni reality drawn as follows ■j7°“®®rned, the boundaries are 
for clinical reasons, in two ’respects ''®f®‘®‘®.h3 outlook, 
neuraxis in isolation from thf re t ’nf in *° ‘'’® 

further restricts itself to the nnn^-j ^ the organism, and it 
m its anatomical aspects so fir a., fi!" rr^fion of the neuraxis 
Psychology takes as its sublet maH ‘*’®®®®®- 

neurons, but the psycho nSnl • ‘’'® i^fcrnuncial 

restricts itself, holever to “ "hole. It 

organism-namely, the normal bet, °f ‘he 

fer as that can' be intS d in 1 ’”“'' “'® 

Bsycluatry resembles psvcholotrv in mental process, 

behaviour of the orgmdsm' Wnr •‘;°“,®®™'"g hself with the 
process but, being a clinical sdence U h“ 
and, for practical reasons " restrini ’ u , " narrower field, 

abnormal behaviour as indicates further to such 

reality. Physiology (which, 'so far^1°^v'“'^ adaptation to 
fessor Berry would set up as ^ neurological, Pro- 
resemb es psychology in that it ndn"/°'"P.''®'’®"®‘''® "®'ence) 
the behaviour of the whole ®"hject matter 

psychology in excluding those fsn T’ f™ni 

vhich can be interpreted in ter 7 n''^‘^^% human behaviour 
restricting itself to those aspects w^ f . Pvoness, and 

physical and chemical terms onlv '’® interpreted in 

cated each of the sciences cone’ern^''^'" ‘ ‘® houndaries indi- 
a.utonomj-, and is justified in attemn^‘' '1 ‘o complete" 

as far as they can be carried 1° P®®’^ conclurions 

attempt, however, on the part of "’‘"“uf inconsistency. Any 
the field belonging to anoflier is to"‘i sciences to usurp 

of co^islency and clarity of tbnn%?" “‘®^®®‘® 

physiolojp- of the nervous‘svsl»,., .1 ^ ®^®'“ fov the 
to establish a protectorate for the cl.*^ “""®^ ®'’'" 

IS to make a claim which will wT *'’® Sonuine science 
laboratory for the comprehenri 'e st , '"7 ®'i®“''"ntion. Any 
which may be established in the fm abnormality 


' 667 - 


r/um“ubfe°cf““‘ contribution to the solution of the problems 

Lastly,- attention must be drawn to the futilitv of anv 
E^eme for the study of mental abnormality which' fails to 
ecognize the claim^s of the psychological sciences. There is ' 
an unfortunate tendency m some medical circles to depreciate 
the psychological in the interests of the physiological sciences 
Since modern medicine is based upon physiology it is easw to 
see how_ this tendency arises, but the result is^n nnnecejarv 
impoverishment of medicine. The belief that the first pLTe^ 
seek for mental abnormality is the cells of the cerebrJ 

prorinc«'’^ril,*° conceptions of the 

p ovinces of the -various sciences such as have already been 

to^sert ^“‘® ^®Sitimate for the phj-sfologist 

tormt of fg '°‘n° problems of mental abnormalit/ in 

terms of the cells of the cerebral cortex, if such a solution “ 
consistent with other physiological facts; but it is eqnaHv 

thet'Trlhl •I'’® P®y'*°J°E'“l sciences to seek a solutiorof . 
these proble^ in terms of mental processes. Both attempts are 
that Th ' bit a survey of the last twenty-five years s^gesfs 

nnde a"™®’"'? '’'® ®^"“°®® "b'cli takbn place to^the 
understanding of mental abnormality during that period ^ 
crived its impetus mainly from the' side of the psychological 
sciences. Certain contributions have undoubtedly'^ been ^de 
by neurological physiologists. The work of Pavlov and ht 

=s“s ■ 

case, it really offers no explanationrthat hive" not ’ aLZ 
w^rk of'piem^ j“ ‘/"“d w P=y®^®>5gital conceptions. " Thb" 

worK 01 Jrierre Janet and Henry Head mirrlif aicr. i 
mately cited as ha^ng received its inspiration from the dSec 
tion of neurological physiology The tJie direo- 

conception of lissocLrTd’ o^ Hfad> trrupo^rt' 

physiological id^s In the 

psychological conceptions is also notewo^y and *^e°Tkh 
mterestmg fact appedis that not only the vidu^ bnt'jb'’" 
limitations, of the dissociation theory depend nnnn h‘ 
logical ideas. The limits of Tno^i’ “pon his.psycho- 

sensatiohist psychology It is the al^*nd^ the limits of his 

pj-iholos, .»d Ih. . diJ°t”S?aioI.r!°S“|”?*‘" 

sj, i-rL'tr r 

J.=y .. a. i.cb -r, 

to the psj'.cho-analytio school. ^ “ mainly due 


hult'il^vLur ™y’ i^Sm“" 

may be -illustrated by a “a Wnt ' 

paper. Discussing the effect of envivoo” Berry’s 

brain growth, ho says- . onmental stimuli upon 


plctc& caV off1™t?l\Mld bSSmes ‘’® 

acoustic cortex and a' corresSg?y -‘nVa. ^ 

.rient":/\t“ToUy% Sr®'' a failure of develop-, 

sponding diminution of gpoo ^ implies a corfe- 

the sort of a™X?ron L^^b- p' ‘“t®“‘,g®"®®- This is just 

a; not 

^r^-odurLSLte ako Vst irpeSe^’d 

s' »»: 

present being conducted at the George Combo l'^- “1 
Laboratoiy of Edinburgh University bv° Dr ^-^®'’°'®g‘®“i 
his workers. Though the results of'tl,;^ • ‘ J?''®ver and 

still incomplete, and thus not avaikl f aro 

those so faV obtained . would scer l jn .P“Wication, . 

prisiugly slight degree to which tlm ‘bo sur- 

fa 10 wnicu tho general intelligence 




0COTDAND. 


f TBBDnmsrf 
Sletxcu. ”*■''' 


Makch 31, 1928! 


negligible. Colonel rorster adds, that, fortunately for tho 
Province, the rule does not furnish an equally sound basis 
on which to forecast the occurrenco of cholera in epidemic 
form, but ho thinks it worthy of note that the greatest 
cholera epidemic in tho Province since 1901 occurred in 
1921, when tho plague mortality reached the lowest recorded 
in these twenty-six years. Colonel Porster tells an inter- 
esting stmy of an outbreak of a disease resembling cholera, 
and of indigenous origin, in a village jnst outside Simla. 
Tho disease ' was clinically indistinguishable from true 
cholera, but the post-mortem and bacteriological findings 
definitely negatived this diagnosis, and so the matter was 
referred to tho police. The bodies were exhumed, but 
chemical examination failed to reveal the presence of any 
poison in them. One survivor of an afilicted family fled 
to a village in the Ambala district, developed symptoms of 
cholera, and died, his death being followed by an outbreak 
of so-called cholera in tho village. The district medical 
officer of health of Ambala investigated this outbreak, hut 
again tho bacteriological findings were inevitably negative 
for cholera. Colonel Forster concludes, therefore, that in 
the Punjab there is an indigenous disease which clinically, 
and also as regards infectivity, is indistinguishablo from 
cholera, though the post-mortem and bacteriological 
findings contradict this etiology. There is at present no 
evideneo as to tho real cause of this disease or the extent 
to which it contributes to the total cholera mortality. 


Sanitation Aleasures in Connexion with Fairs and 
Festivals. 

, During 1926 no fair or festival in the Presidency of 
Bombay was responsible for any outbreak of epidemio 
disease, and some indication of flio nature and extent of 
the preventive work which lay behind this gratifying 
achievement is given in the annual report of the acting 
director of puhlio health. Dr. Jamshyd Jfunsiff. Tho 
itineraries of the various bands of pilgrims are ascer- 
tained in advance, and arrangements are made to inspect 
the various halting places and to provide medical super- 
vision along the routes. Large staffs of medical officers 
. and studmt assistants, with sanitary officials, are collected 
and distributed according to pre-arranged plans, in order 
to assist the local authorities. Wells are treated with 
permanganate solution, reservoirs are filled with sterilized 
water, trenches are provided for pilgrims, and cholera 
hospitals are opened. In suitable centres the incoming 
and outgoing pilgrims are inspected, ambulances are kept 
in readiness, and cases of infectious disease with any 
contacts are isolated. Hefuso is carefully collected and 
burned, foodstuffs for sale aro regularly examined, and 
any found unsuitable are destroyed. Specially qualified 
inspectors are placed in charge of tho vegetable and fruit 
markets. Adequate provision of water is ensured — a matter 
of considerable difficulty in some places — and special pre- 
cautions have to be taken to prevent pilgrims from bathing 
in the drinking water. Chlorinated water is made available 
for pilgrims night and day in some towns, and all storage 
J^servoim and cisterns are carefully and regularly sterilized. 
Temporary dispensaries have also been found very useful in 
certain towns to deal with minor emergencies and prevent 
more serious discaso from developing. Some impression of 
0 number of pilgrims dealt with may be gleaned from tho 

1 AK ■Ti'o”" “nitres: Pandharpur (two fairs), 

165,312 and 91,529; Nasik (two fairs), 58,907 and 77,974; 
Saundatti-lellamma, 125,000. The numerous smaller fairs 
and festivals receive similar attention. Cases of various 
infections diseases occurred in 1926 in all parts, though 
epidemics wero absent, and it can easily bo realized whtt 
.on immenso amount of sickness and suffering is prevented 
by this systematic scheme of prophylaxis, and how many 
lives aro saved each year^ ^ ^ $ j 


T-,, Wales Atedlcal College, Patna. 

^liilo Sir Norman Walker was making his tour i 
India last year as representative of tho General Medic: 
Council ho visited the Prince of Wales Medical College i 
I atna, which has not yet been recognized officially by th 
Council. Ho spent some days there, making 1 carof, 
examination of its equipment, curriculum, and gener: 
competency. In tho annual report of tho’ work of thl 


institution during 1926-27 the acting Principal, Major 
R. B. M. Porter, I.M.S., announces that during the second 
year of its existence all the departments have been brought/ 
into effective action. ' Tho accommodation for hiohgical 
students has been increased by one-third, and minor 
improvements have been made elsewhere in the buildings. 
A good pathological museum is being developed, and a 
provincial pathological laboratory is to be established, 
together with a department for antirahic treatment. 
Cultivation is proceeding of a small botanical garden for 
the use of students, and the museums of anatomy, 
pharmacology, and biology are being extended. Although 
the department of physiology is at present rather hampered 
by restrictions of staff and space, good work is in progress; 
a biochemist is to be appointed, and experimental work in 
this subject is being carried on. For instruction in practical 
midwifery tho students go to Bangalore. In addition to 
the ordinary curriculum a three months’ post-graduate 
course was conducted during tho year. 


^tathnh* 


Edinburgh LL.D. Degree. 

The list of thoso to whom the honorary degree of Doctor 
of Laws has been offered by Edinburgh University contains 
tho names of several distinguished members of the medical 
profession .and of person.? connected with it. These includo 
Sir John Bose Bradford, K.C.M.G., M.D., F.B.S., Presi- 
dent of the Boyal College of Physicians of London; Dr. 
James Cossar Ewart, F.R.S., formerly Professor of Natural 
History, Edinburgh Universityj Dr. George. Lovell Gulland, 
formerly Professor of Medicine, Edinburgh University; 
Dr. James Haig Ferguson, M.D., formerly Senior Lecturer 
in Midwifery and Gynaecology, Edinburgh University; Dr. 
Robert Alexander Fleming, P.B.C.P.Ed., formerly Senior 
Lecturer in Clinical Medicine, Edinburgh University; Dame 
Mary Scharlieb, D.B.E., M.D., M.S. ; Dr. F. G. Donnan, 
F.R.S., Professor of Chemistry in the University College, 
London; and Mr. Henry S. Wellcome, founder of the 
Wellcome Research Laboratories at Gordon College, 
Khartum, and of the Wellcome Bureau of Scientifio 
Research and the Historical Medical Museum, London. 

Glasgow Cancer Hospital. 

Tho annual meeting of the Glasgow Royal Cancer 
Hospital was held in the Merchants’ House, Glasgow, on 
March 25rd. Sir John JIacLeod, Bt., presided, and among 
thoso present wero Sir John Gilmonr, Secretary of State 
for Scotland, and Sir George Beatson, senior surgeon to 
the hospital. The chairman stated that the ordinary 
income in the past year had increased by over £800, and 
tho hospital was doing valuable work in the direction 
of investigation into the nature of the disease for which 
it provided. Sir George Beatson, speaking on the work 
of the year, stated that enough was known in regard 
to cancer to say with confidence that it began as a local 
malady, Tho hospital admitted both operable and in- 
operable cases in order to furnish them with the best 
medical skill and trained nursing that was possible. It 
also existed to investigate the disease, and, if possible, 
elicit a cure. They had come to tho conclusion that for 
inoperahlo cases the best sj’stem of treatment was by 
irradiation with radium, a: rays, or ultra-violet rays. It 
had been found that tho ultra-violet ray treatment, rather 
over-praised at the present time, was being used tinwisely, 
and that many people were ei’en installing apparatus 
into their oivn homes. A careful study of this subject was 
being made in their research department. Tliey would like 
to make this hospital the centre for tho distribution of 
radium emanation in Scotland. Sir John Gilmonr remarked 
in regard to hospitals generally that whatever changes or 
advances might take place the fund.amenfal thing which 
they must try to preserve was tho voluntary principle. 
The death rate from cancer in Scotland had reached a 
very' high point, tho figure being 141 deaths per 100,000 
people during 1927, tho highest death rate yet recorded 
and second only to heart disease among causes of death* 


670 March 31, 1928] 


CORRESPONDENOB. 


f 3 ' r Bnmsm ' f 
J ■ L SlKwcit JopExii 


This meeting should show tho citizens of Glasgow that Iho 
malady was being dealt with as ono of the problems facing 
tho country which could at least bo mitigated. He believed 
that research was essential if tlicy were to make progress, 
both in regard to hospitals and disease, as well as in many 
commercial enterprises. He was glad to know that pro- 
gress was being mado in cancer research, and lie thought 
this ought to bo encouraged by everyone. 

Discussion on Pharmacopoeia Rc,vlsion. 

A meeting of the North British bi'anch of tho Pliarma- 
coutical Society of Great Britain, held in tho Society’s 
Ball at Edinburgh on March 2lEt, discussed tho question 
of revision of the British Pharmacopoeia. Mr. Peter 
Boa, Ph.C., pointed out that tho 1914 edition, which had 
been produced prior to the war, was now fourteen years 
old, and did not cover many new things introduced in the 
interval. There had been in tho last Pharmacopoeia a 
drift towards a reduction in the number of preparations, 
and this had led to tho provision of ready-made prepara- 
tions for the practitioner by wholesale manufacturers. He 
thought that if the Pharmacopoeia ivas to regain its jirc.s- 
tige with prescribers it would bo necessary either to in- 
crease the number of iireparations or, alternatively, while 
making the Pharmacopoeia a standard for drugs, there 
should be some official complementary book containing suit- 
able preparations for medical use. A strong plea for the 
reintroduction of imperial weights and measures in the 
Pharmacopoeia was made by Mr. Henry Stout, Ph.C. 
Although the last edition, he said, had given only metric 
weights and measures, tho custom was still almost univcrs.al 
in manufactui'ing, retailing, and dispensing medicines to 
employ the imperial weights and measures, and for these 
practical reasons they ought to be included in tho official 
publication. 

Deaconess Hospital, Edinburgh. 

The annual meeting of the Cliurcli of Scotland Deaconess 
Hospital was held in Edinburgh on hfarch 19tli, with the 
Eev. D. J. Montgomery Campbell, hloderator-Designate of 
tlio Church of Scotland, in the chair. Tho Rev. Dr. A. 
Eiddes, vice-chairman of the board of management, in 
submitting tho report, said that the hospital was in n 
fortunate position, because twelve mouths ago it bad been 
faced with a debit balance of £1,000, while now this bad 
been convorteil into a credit balance of over £550. The 
number of patients treated in the wards during the year 
bad been 782, an increase of 99 over the number of the 
previous year. Tho number of surgical operations per- 
formed bad been 598, while the number of out-patients 
bad been 6,914, with attendances numbering 23,457. It 
was now necessary to raise £7,000 every year for its man- 
agement on efficient lines. The institution was unique in 
Great Britain in being the only hospital carried on by a ; 
Church, and it disehaigod a double pui’pose, treating the 
suffering and injured and providing a training place for 
nurses who bad the intention of taking up mission work I 
in this country and beyond the seas. The chairman, in 
moving the adoption of the report, said that bo knew no 
form of practical Christianity which was so interesting as 
the work done by this hospital. He was strongly in favour 
of tho voluntary sj-stem in the management of hospitals 
for many reasons. He was quite sure that a compulsory 
hospital could not command to the same extent the best 
of medical, surgical, and business talent for its work. 
Further, it was good for the community that it should 
have to do this work. The relation between Church and 
medicine was a very old one. Hospitals, like education, 
had begun with the Cluircb, and it was vaUiablo that the 
connexion should, in some way, be maintained. 

An Ancient Scottish Surgeon. 

At a meeting of the Greater Edinburgh Club, bold in the 
STOod Hall, Edinburgh, on Marcli 14th, Mr. John Smith, 
F.S.A. gave an account of the career of John Naesmyth, 
surgeon to King James VT of Scotland and I of England. 
He was the son of Michael Naesmyth, Chamberlain to the 
Archbishop of St. Andrews, where be received bis early 
education. Choosing the profession of a barber-surgeon, 
bo joined tlie Incorjroration in Edinburgh in 1588. In 
1575 lie Iind been a member of the retinue of Xord Seton, 


proceeding ostensibly on an embassy to Queen Elizabeth, 
but actually entrusted with the perilous task of delivering 
to Mary Queen of Scots certain letters from the Hegeiit in 
Scotland. He succeeded in his mission, although tho letters 
were discovered aftenvards, necessitating bis hasty return 
to Scotland. Naesmy'th afterwards rose to high favour with 
King James, but becoming involved in a plot with Francis, 
Earl of Bothwcll, ho had to retire to France, nlicre he 
stayed for about six j-ears, and was appointed chief surgeon 
to the Scots Guards of tho King of France. In 1600 he 
'married Helen MacGrath, daughter of one of the most 
opulent citizens of Edinburgh, and prospered greatly. 
Being reinstated in favour with King James, he removed 
with the court to London in 1603 as court physician, and 
in 1604 was appointed roj-al herbalist for life. Dying in 
London on September 16th, 1613, in the fifty-seventh year 
of his life, Ids body was, by his own request, removed to 
Edinburgh and interred in Greyfriar’s Kiiln,-ard, whero 
a handsome monument still marks his resting place. 




GLAND GRAFTING AND INHERITANCE, 
gm, — In the articles headed “ Gland grafting ” (p. 510) 
and “ Voronoff’s experiments on tho improvement of live- 
kock” (p. 505) in the British jiledical Journal for March 
24tU it is suggested that Dr. '\’’Dronoff's claim that tho 
improved characteristics wldcli, according to him, appear 
in tho offspring of “decrepit and infecund males” who 
bavo been rejuvenated by implantation on their testicular 
tissue of portions of the' corresponding tissue from young 
and healthy adult males, and which in turn are tra/isniitt<?d 
tn their offspring, “ involves the acceptance of tho liypo- 
Ibeds of the niheritance of acqiured charactenstics. Even 
inesis m Voronoff's claim that tbeio 

-.to .nd .toi. to 

tr. tho nroeeny of rejuvenated rams, this surely 
doer'not prove that^an acquired charactenstio 'men 

• berited ^Aii acquired characteristic, in the strict bio- 
inlmritcd. alteration in the somatic colls caused 

S V hv the cnviroiimont. The appearance in offspring 
direct j uy 11 e from the action of the environ- 

, 17 ,:;”“* ;s.r .f to », e.,...™ .. 

incut I , transmitted acquirement. 

^1 wodd appeU to consist in the replacement or 
M the senile bv virile' testicular tissue, 
rciii/oicc cat , ^ j . material reinforces the pliysi^ 

AVhero the S . ja„duiar tissue there is mcvoly 

logical wanilg reproductive power. AVhere, 

a revinfim tissue the position is more 

however, uot, I think, necessarily iiivobo 

complex, b liypotbcsis of the inboritaiico of aeejiiircd 

acceptaiico of .r j^t ffiay be elucidated with tho case 

charactormtics Mj point mj 

«-V.ffofb eccl i ’puiToses. This bull, whom we wil 
gvaftfd^ith a pioco of the roprodiictno 
, c „ virile bull “ V.” After the operation J 
fs'“s^d1o^lave'sirod^^ cahms.' Now, if thm was 
follows that, since the gametes of A 
surely It foU ore the off- 

'tt of “J.” but of “V.” 


' T ” but of “ V.” Biologically speaking, 
T^%:7mmelyJoteil as protector And_food^Jw^W- 


J” has 7nd ha ^ more participation ui 

? ctm-o If tL nine calves than li gardener ha 
'%! nrodurtioii of cucumbers that have grown in las 
* a result of his transference of pollen fimn 

ames . stigma of the female fi®' ‘ 

'^’"'^Hnoroved characteristic appearing in the P™? ? 
[ly nnpi , ,i j>g u mating activities arc rccei' 

gu “V,” are gernfinal (blastogcnic) in nature and not 

Thrclso is paraUeled by an experiment of Borerk » 
mo^ed the nucleus from vu-pn cgg-rel of ^a^- 

■chin (Echinus microiuberculatus) 

tb the spermatozoon of anotlior , o lar« 

anularh) Tho egg-cell so treated tho 

til the characters of the paternal echinus oiuy. 


MMICH 31) *928] 


COKRKSPONDENCE. 


[ TsE Bninsa 


571 


main substance of tho egg-cell provided nutriment for ilio 
dauohter-cells,, but did not transmit to them any of its 
parental characters. It should bo stated, however, that 
Boren's experiment has been severely criticized. Perhaps 
a better illustrative parallel is to bo obtained by a con- 
sideration of tile reproductive capacities of tlie scion tuig 
used in plant grafting. The bud, which contains the germ 
cells, when inserted in the bark of a different variety of 
plant, reproduces tbo kind of flower or fruit tkat charac- 
terized not the tree or bush on which it now grows and 
of which it forms a part and from whoso sap it draws its 
food,, but tbo tree' from which it was originally taken. — 

I am, etc., ■ ' 

ChAHLES M. BE.lDXELr,, 

Aberj-Sfusth, ITarch 25th. .... Surgeon Eear-.ldmiral. 


. , THE NEW POUTBAIT OF JOHN HXJNTEE. 

S'la, — ^With reference to tho “ new ” portrait of John 
Hunter, Mr. Buckston Browne (Joiirnof, February _ 25tli, 
p 326) corrects an error made , by Sir Arthur Keith as 
regards Christie’s catalogue, hut in doing so suggests that 
the namo “ Seton,” to whom the portrait is there attri- 
buted, was either fictitious of that 'of a quite unknown 
man. 

Before this letter appeared the error had already been 
pointed out to me. Seton, or Seaton as I understand it 
is more usually spelt, was a known portrait painter of 
Hunter’s time, as will be seen, from the following extracts 
from recognized authorities. 

Graves's Dictionary of Artists. — Seaton, John Thomas. ? Seton. 
Exhibited 13 Portraits at the'Society of Artists and 3 at the Royal 
Academy between the years 1761-1777. 

Jtedgrave's Dictionary of Artists. — Seaton, John Thomas. Portrait 
painter. Pupil of Frank Hayman, studied in tho St. Martiu’s Lane 
-Academy, also a .member of the Inooi-porated Society of Artists. 
Ho exhibited half-length portraits at tlie Eoval Academy in 1774. 
He 'was practising iii Edinburgh about 17^0, and was in high 
repute, which his works merited. He was living in 1806. 

Bryan's Dictionary of Painters and Engravers (edit. 1889, vol. ii) 
gives a similar account of Seaton. 

As to the remaining question — ^by whom and on what 
authority the 'portrait was attributed to Seaton — I have 
the following information. 

Mr. Alartin of Christie’s, usually .responsible for drawing 
up tlie catalogues, and a recognized authority on pictures 
of that period, states that the pictures of Mr. SIcCormick 
caniG to them all labelled according to the owner’s own 
attribution and description. Although Mr. McCormick 
may have told his friends ho thought the portrait of 
Hunter was by , Gainsborough, ho evidently did not con- 
sider^ it worthy .of- being labelled as by that artist. The 
McCormick pictures consisted of 157 lots, several of which 
consisted of two or throe pictures, and formed a full dav’s 
sale, but they only realized between £4,000 and £5.000. 
. Ir. Alartiii added that the picture was very unlikely 
to have been by Gainsborough, or it would not hare been 
passed over by tho export dealers.— I am, etc., 

Egliam, March 23rd. CecXI* F. Be.\DLES. 


BEIKSH DOCTOKS IN MADEIRA. 

Snt,.— Opposition to tho presence of British doctors in 
us island lias now been ended by a generous concession 
authorities at Lisbon by which tho modus vivendi 
established with me sixty -years ago is respected and ampli- 
e . 1 enclose a copy of a telegram from our Ambassador 
fully the privileges conferred on ns. 

. 0 ale bj no means unmindful of roiir assistance in 

the Journal contributing' to this happy issue from our 
difficulties.— I am, etc., .. 


iladeira, March 20th. 


, Michael GE.sBH.Sii, AI.D., 


P.R.C.P. 


', A* to which Dr. Grahham refers i 

addressed from Sir Lancelot Carnegie, British Amhassado 
at Lisbon, to tho British Consul at Funchal, and repeate 
o 10 'oieign Office. Tho position has been the subiect o 
discussion between tho Ambassador and the Portiigues 
authorities following a report that a threat had been mad 
o spe lom *Iadeira foreign doctors who wero practicin 
theio rvithont benig legally qualified to do so (Supplemcm 
August 20th. 1927, p 118). Dr. Grahham explateed 4 
position in a letter published in tho Journal on Septembe 


24th,- 1027 (p. 566). The telegram defining the Portu- 
guese Government’s attitude reads : “ Permission granted 
for British physicians and surgeons to attend forei^ers 
living in and visiting Madeira. They must exhibit their 
diplomas to inspector of health at Funchal.” 


AIIDWIVES AND ANTE-NATAL WORK. 

Sib, — The letters by Professor Louise Mcllroy and Dr. 
Malcolm Donaldson (March 17th, p. 466, and March 24th, 
p. 520) show an imperfect acquaintance with the rules of 
tho Central Midwives Board w’hich they criticize. 

Dr. Mcllroy criticizes the Board for telling a “ nurse ” 
to “ examine the heart with a stethoscope.” Will die 
kindly quote the rule referred to, as 1 cannot find it? If 
tho foetal heart is meant it should he stated. The 
examination of the foetal heart is surely essential. 

She also speaks of “ calling in tho aid of a medical 
practitioner in , doubtful cases.” Will she kindly read the 
rule referred to? It runs as follows: ‘‘In all cases of 
illness of the patient or child, or of any abnprmality 
occurring during pregnancy, labour, or l 3 nng-in, a midwife 
must forthwith calUn. to her. assistance*a registei'ed jnedical 
practitioner ” (E. 20). 

She also refers to “ diagnosis.” “ Diagnosis ” is not 
either expected or desired; the presence of any abnor- 
mality ” at onco obliges the midwife to call in medical 
aid, and she is the only person who has it in her power 
to discover abnormalities in pregnancy where a doctor is 
not in charge of the case. 

Dr. Malcolm Donaldson endorses Professor McHroy's 
views. I would point out that, whatever may happen in 
the future, a veiy large proportion of labours are at 
present attended by mid wives. If midwives were now to 
bo abolished, many women would fall back into the hands 
I of the untrained handy-woman. The object of the rules of 
' the Central Midivives Board is to make pregnancy, par- 
turition, and lying-in in charge of midwives os safe as 
possible. — I am, etc., 

H. Q. Westlet, 

IfOndoa, S.'UM, Uorch 26tli. Secretary, Central Midwires Board. 


THE EXPECTANT MOTHER. 

Sib, — Tlio care of the expectant mother has hocomo 
a national question, and tho Queen, in her recent message 
to the Alaternity Mortality (Conference on March 1st at 
the Central Hall, Westminster, expressed the opinion that 
the time had come for, concerted action. Local authorities' 
must. by non- have realized their responsibilities as regards 
tho ante-natal, natal, and post-natal cafe of tlie expectant 
mother, especially amongst' the poorer classes of. the co’m- 
niunitj'. No one can deny that the care and treatment- 
deemed necessary' for the well-to-do in the ti-ying time of 
childbirth must ho equally necessary for the poor. 

It is aU very well for local authorities, whoso duty it is to 
deal with these matters, to appoint and direct educated 
and trained women to go round or instruct in tho clinics 
the people who live in the humble homes, and give advice 
as to what they should do and what they should not do. 
This, ^no doubt, is most excellent, but those of us who havo 
been in medibal practice for many years know to our sorroa- 
Giat these poor women are not able to do as they are 
advised, inasmuch as they are compelled by force of circum- 
stances to continue their' homo duties up to tho very hour 
of .their ebnfinoment, and to he up and about again in a 
ncek or so, or even less, doing the washing, cleaning the 
house, getting the children off to school, preparing tho 
husband’s dinner, and all the other responsibilities of a 
home. Tho well-to-'do expectant mother can, however, rest 
for weeks before and after the birth of the child. It is not 
surprising, therefore, that our hospitals are so full of' 
working-men’s wives requiring surgical attention owing to 
relaxation of the tissues. 

Local authorities havo been empowered by Circular 
M. and C.W.A. of tho Local Government Board, dated 
-August 9tli, 1918, to provide home helps; nearly ten yeai-s 
havo elapsed, and how few havo exercised this power! 
Tho time has como when they must wake up to the heavy 
responsibility which rests upon their slioulders. Homo helps 
must be working u-omen; they can no doubt ho obtained 


675 Maech 31, 1528] 


CORKESPONDENCE. 


and paid bj' the local authority, to \yhich Iho State <-mi 
mako a grant. They should tako ovci' the rvholo or tho 
greater part of thoi housework of the. expectant mother for 
a short time .before and after childbirth, and so relievo tho 
mother of this burden. Then, and onlj' then, can it he 
expected that maternal mortality will bo reduced and 
more healthy children bo horn. — am, etc., 

Aethue d\l. Baefoed, M.D., 

Chicliestor, Sussex, March 17th. B.P.II., F.R.F.P.S. 

I'HE PROTECTION OF BIATERNITY. 

SlE, — Although wo are all anxious to sco a diminution 
in maternal morbidity, I do not think that Dr. J. .S. 
Fairbairn’s jomaJ’ks at the lMidwive,s’ Institute .(as reported 
in the British Medical Journal of March 17th, p. 462) 
ought to be allowed to pass unnoticed. 

He said that “ some doctors had stated that forceps wero 
Used in half tho cases the}’ attended.” IVhat doctors wero 
these? Certainly not avci-agc general practitioners. I can 
understand that an occasional individual, cxccptioually 
slrilful, with very well trained assistants and a faultless 
aseptic teclmigue, might use forceps where the majority of 
us would prefer to wait longer — and possibly sightly; but 
I am afraid that actually Dr. Fairbairn has boon tho 
victim of a fishea'inau’s yarn. 

However, because of this statciucjit I have taken tho 
trouble to look up the notes of my last 200 cases. J find that 
I used the forceps in fifteen cases only, and one of these 
was that of a multipara to whom I was calletl by a midwife. 
This, it is true, is ratlici’ more than twice the percontago 
which Dr. Fairbairn guesses to be that of institiitions, but 
I do not think we can expect to get ouis down to that level : 
bocauso of our much larger proportion of in-iniiparae — ! 
40 per cent, in this series. I suspected five of tho 200 to 
have subsequent .genital infectious. Fir-o other initients 
had pyrexia due to causes such as hacilluria, juaumiary 
infection, and infiuenza. 

I believe that these figures are in no .way oxccptional in 
general practice — in fact, I do not doubt that many doctors 
can show bettea’ ones — -hut .they do suggest that the general 
practitioner is not tho danger to his patients that our . 
critics represent, and I like to think that tho morphine and 
scopolamine that wo can give in the first stage, and tho 
chloroform which cases .'SO much tho last part of the second, 
holp .to justify our attendance evon in cases of normal 
labour. , 

I hope Dr. Eaiiibairn will forgive mo if 1 add that tho 
necessity for accuracy is so great, and tho avay of .exag- 
geration so easy, that it is (difficult to be too cai-efid when 
addressing an unscientific and lunoritical audience; cqre- 
ciaDy is this the case when .the .speaker is uno wlio is 
supposed to he more au fait with actual practice than tho 
mere official. — I am, letc., 

London, S.E.26, JIarch 20th. IV. BI. PeXNV. 

IMPORTANCE OF SPUT.UM EXAMNATION IN 

P-ULBIONARY DIAGNOSIS. ■ 

SiE, — Dr. Chandler’s letter emphasizing the value of 
sputum examination is .welcome because there is no (doubt 
that .this aid .to .diagnosis .is sometimes neglected altogether, 
or tliat an insufficient number .of examinations aie made. ' 
Practically all public health authorities jgive facilities for 
free examination, so that there. should ibe aio (difficulty about 
getting a .patient’s sputum investigated .early and often. 

The following points may be usefully summarized : 

1. In -cases .with early manifestations vepeated -spatnm 
examination may be necessary before .the bacilli are found, 
alfhough positives sometimes occur at first .trial where there 
are few signs and symptoms. 

2. The kind of case described as running its course without . 

sputum or positive sputum includes the acute and some .sub- ' 
acute itj'pes. The signs and -symptoms, however, itsually -become ' 
distinctive before the illness has proceeded far. : 

3. In -chronic and .long-standing cases of pulmonary disease, 

with frequent cough .and much spit, even two or .three negative 1 
findings go n long way towards ruling out tiibercniosis. 
Bronchiectasis is commoner than many people suppose, and ,‘ ' 
some of its symptoms .(streaked sputum, dry pleuris}-, aind ' . 
exacerbations dne to localiztxl broncho-pneumonia) resemhle , < 
tuberculosis. Asthma and chronic 'bronchitis m.-^’ mask lulicrcle, 
.wliicn xemains undetected u-ntil tlie sputum is .examined. ' 


4. There is no typo of sputum absolutely typic.-,] of uul- 
moniu-y tuberculosis ; iiummuL-ir .spiituin occurs in .otliei- diseases, 

mucoid drop -may swarm with tubercle 
t • ^ experience goes, tubercle bacilli .are not 

often found in foul-smelling sputum, and in tarhj cases it is not 
usual ^ to find Iheni associated witli large numbers of -other 
organisms. 

5. It is worth while talcing trouhlc to obtain a good 
specimen for examination, and avoiding or.il, nasal, and traclieal 
secretion, also Epccimeits contaminalecT vith food and tobacco. 
A few simple .directions to tlie patient, and particularly instruc- 
tions as to rinsing the month with water before expectorating 
into tile tube, are all that is required, Two or three spits ara 
quite enough : one does not want a tiibefiil. 

— I tim, etc., 

County of Roxburgh, March 20th. G- R. PAGE, M.D., D.P.H. 

SlE, — I heartily agree with Dr. Chandler that the 
“ absence of tubcrcio bacilli after many repeated examina- 
tions . . - practically excludes tubcrcujosis.” .He wisely 
alludes to tho ■“ pathetic constancy of the radiolo^st’s 
diagnosis of tuberculosis,” and we all ioiow lipw 
’’pathetically constant” that usually is — simply because they 
apparently dub every abnormal shadow they see in a chest 
radiogram as of tuberculous origin, without reference to 
its being evidence of an active or passive condition, or to 
its haring originated perhaps some years previously, or 
to its havin" some other causation. This pathetic con- 
stancy is unite equalled, if not s.urpasscd, by some zealous 
tuberculosis workers of to-day, who diagnose any abnoinml 
condition they find in a chest as -of tuberculous ongm, 
basinw tbeir diagnosis upon physical signs and ignorjng 

■ tho .fact that -the physical signs of puhuonaiy tuberciUosis 
aro in soino respects tho -same, and in -othere closely 
resemble those produced by a large numhiw .of other diest 
diseases Thev thus .become blind to that -largo nnd 
h cS-r ons^mblo which includes hrqnchieoiasis .sdioosis 

■ fnterstitial pneumonia, spinllosis, ayphihs, and 

, chronic nlj producing the “ damaged lung (of 

RWoro) with physical signs and a-ray ^pearanoes closely 
t«b^culesis, and,- as Dr. -Chandler puts it, 

s.. a-vH., . 

!rubcrculosisOfficer*.Dcrl»j*sliireBoTtnt3 CounciL 
ChestcrficWAl^rch 20 th. 

TREATMENT DF PNEUMGNLA 

■ .Cl T xunnese the majority of doctors would agree that 

■ pnemnonia are self-curative, and nothing can - 

most cases -ot pner nursing; this may be true, 

be ‘done TOW to dogmatize or to he .too certain 

- but It m rar^ medicine. IVe all have onr experiences 

' of anything again, failures. I see another 

with success .ggld— sodium nudeinate— and some give 

new remedy w “ ^ ^ ^ good and proper 

^ very good ac^nnt^ot^ p,ty 

- ."’’iuore general habit. I might-say -that I liavo 

. it IS -not a m pneumonia very successfully with 

treated a „tococcus serum. I remember one case, 

polyvalent to ,a very .bad septic hand, where the 

which serum brought doavn the temperature, 

first „ .temperature was .mounting up, and a 

S.'5 “■ 

recovered. ^ aouble broncho-pneumonia in o 

Another aus a case I in une injeerton a 

•child .about t; treptococcus serum , (Parke, Davis and 

whole ..phial (Of nntistrj^^^^^ Hot packs and aftenrar* 

'Co.), and _li‘ , , . producing copious perspiration, 

wrapped J"' ^.^as somewlfat heroic, .and pcrtiaps ^ 
admit -child; but anyway it proved snece^ ^ 

too pleasant for ^ .hopeless-looking -case, nndn-«« 

•and no donbt it -davs 'Drior to tins. , 

treatment had been as -compared 

Howeve.-, 4e « 1913. bv 

iTaf - do not hive .a -correct hacterioloS.ccl 
(diagnosis. — ^I -am, etc., ^ TTvvn-e.sst, 

Medical Officer, Bandon, CO. Corfc 

March 16th. 





SIE DAVID DEBBIER. 


674 Maiich 31, 1928] 


[ 


TntBBmnr 
SfeDicxt Jocxxik 


CObitiiarij. 


THE LATE SIB DAVID EEHBIEB. 

“Wb liavo received from Sir Cii.uiles Bai.bance tlio following 
tribute, supplementing the memoir wo published last week : 

Sir David Eerrior belongs to that small group of groat 
men who rediscovered and recreated the scicnco of experi- 
mental neurolo^’, lost to mankind since the times of 
Galon. Feirior was experimenting before Charles Beevor, 
Victor Horsley, or myself were students of medicine. His 
first paper was published in 1873. In this pajror numerous 
experiments were related bearing on the subject of the 
localization of the functions of the brain. Some later 
papers dealt with the discovery of tho I'isnal and 
auditory centres, and tho understanding of tho symptom- 
hemianopia, and in 1879 two papers were published, (1) on 
pain in the head, and (2) on vomiting, in connexion with 
cerebral disease. Tho supremo value of the experimental 
method was exemplified in Fcrricr’s life and work. Ho was 
fond of quoting from G. H. Lowes, “ Every discovery is a 
verified hypothesis; and there is no discovery until \-erifica- 
tion has been gained ; up to this point il was a guo.ss, 
which might have been erroneous.” Cruveilbier, in 1830, 
knew, as Hipocrates did, that a lesion of one side of tho 
brain was not seldom associated with paralysis of tho 
opposite sido of tho body. Broca showed at the Anthropo- 
logical Society of Paris in 1861 tho brain of a man who 
for twenty-one years had lost tho faculty of speech. There 
was softening of tho third left frontal convolution. Fritsch 
and Hitzig, in 1870, marked out certain centres on the 
brain by means of electrical stimulation; but Ferrior soon 
loft this work far behind by precisely charting on tho 
corebi-al cortex certain centres for movement and for the 
special senses. How littlo those facts and tho inferences 
from Forrier’s paper in 1873 had reached tho mind of the 
profession is illustrated by tho statement made in a lecture 
I attended six. years later, in 1879, as a student, that “ the 
brain functioned as a whole.” 

Ferrier’s work wms brought prominently into notice in 
the Physiological Section of tho International Medical 
Congress in 1881. A dog was shown by Goltz and two 
monkeys by’ Perrier. Experimental injuries had been 
inflicted on the cerebral coi'tox of each of these animals. 
The condition of tho dog was supposed to prove that 
localization of function in the cerebral cortex did not exist. 
One of tho monkeys had characteristic cerebral hemiplegia; 
as it came into the room Charcot remarked, ” It is a 
patient.” The other monkey showed no signs of hearing 
when a percussion cap was snapped in its immediate 
vicinity. Thus all doubt as to tho truth of the great 
doctrine of cerebral localization was laid to rest, and the 
ground was prcpai’ed for the marvellous progress of tho 
•coming years. Ferrier, in the Marehall Hall Oration in 
1883, said that “ Dp to that time cerebral localization had 
been absorbed like latent heat by medical science itself as 
distinct from medical and surgical practice, but that tho 
unfailing safety of experiments on animals made it clear 
thiif similar results would soon be achieved on man 
himself.” This foreca.st was soon to be verified by tho 
wonderful operations of neurological surgery. 

While it is comparatively easy to trace in history Sir 
David Ferrier’s share in the progress of neurology, it is 
more difficult to write of his attractive and vivid per- 
sonality. To me the world .seems barren without the 
presence of my great friend. Sir David was of slight 
build, his mind was extraordinarily alert and full of many 
kinds’ of knowledge, and his hands wore small and capable 
of the most delicate manipulations. I often said to him 
that it was a good thing for some of us that he was not 
a surgeon. From the time that I was elected on the staff 
of the National Hospital, Queen Square, now nearly forty 
rears ago, Sir David was in all circumstances and at all 
times a most inspiring and kind colleague. No wonder, 
tlion, that iiiy memory of him is OJio of deop afrection and 
admii-ation. No time or trouble was of any’ importance 
to him if he could, by' his presence or counsel, aid mo in 


my work. Up to tho time of his last fatal illness liii 
mind was as keen and eager concerning problems in neuro- 
logy’ ns it was when I first knew him. Blany, I am sure, 
could testify as I am trying to do. 

Sir David was never so happy as wjien ho was able to 
place bis rare genius and wisdom at tlio disposal of, and 
, for tbo encouragement of, a junior. His deliglitful keon- 
ncs,5 and inteiiso interest when attending an operation 
or an c.xjierimcnt often masked to otlier visitors tlie real 
reason of bis presence, wliich was to give support and 
confidence to a friend or junior. He has huiJt in the 
minds of those privileged' to he associated with him a 
temple of gratitude, and has left behind him a rich legacy 
— ^tho examjile of a long life of unselfish scientific labour 
and a record of splendid and fimitful achievement. 

In the gradual evolution of truth it would seem that 
at tho end of each stage of tlio history of knowledge a 
groat mail appears who is the herald of the dawn of a 
wider insight iiito light and truth. -Carlyle, in his lecture 
on the hero as pact, takes as examples Dante and Shake- 
speare; he calls them “ the Saints of Poetry.” Two 
great and fit men appeared in the sixties of tho last 
confnrv Hngliiings Jackson and David Ferrier. Tiiey 
inav ho named “ tho Saints of Neurology’.!’ Hughlmgs 
Jacirsoii represented, as Hippocrates ■ did, . tho highest 
devclonnicnt of iiitelleetual and clinical re.searcli-tho 
• verv Eoiil of neurology; while David Fcn-ier, the soul 
of practice,” awoke in tho minds of his contemporaries and 
•later fellow workers a desire to explore the old ground by 
the oxiierimcntal method, and to unearth- truths long con- 
cealed Even- part of neurology has felt tho vivifying 
inllueiire of tbo principles and practice emanating from 
tbo bold imagination and .inventive gemns of these great 
men The iiifinence of their labours on the progress of 
tho nlivsiologa- and pathology of the nen-ous sy-stem has 
been nmve.a=al and immense, and thus to them science owes 

''VlTworJfl mores on in a succession of dreams and their 

^^''’’'Tl’^'eaiiPos’oMhe ™xt!“‘we ought nfver '’te "forget 
ndmt'is‘^(h'e to those who have gone before.* It is difficult 
for anyone to bring himself to believe that what is noi 
foi anyo property and Idiowledge of all uas 

•miLthe perilous and toikome discovery of David Ferrier. 
r Hn-’h ings Jackson is the Socrates of neurology , so 

mav^be described as the John Hunter of nourology. 
c Hip'boast of Augustus that he found Romo Iniilt of 
•J*."," aid left it built of marble. Jackson and Fernor 
f " the kiiowlcHlge of cerebral physiology practically nmi- 
foiiiid t ^ beautiful science. ^Vo speak 

existen , . iqbonrs of Pasteur and of Lister: it is 

'1 domain of neurology of the 

? itaTlabours of Jaclcson and Ferner'. They are among 
iminort. ■ the liiiman rare. They hare 

,madc^‘lDaig’>t the way for us. their linmhle surgical 
■followers. 

' -n, AimiEX Tuuner sends 'us the following appreciation : 

^ 1 1-1 nf Sir David Ferrier,- after an illness of soino 

Hon “recalls to many a vmd personality in the iiro- 
duration, work of a pioneer eiiaracter a«-oia- 

fcssion of '"®cl i seventies of tho 

plished nioio 'manv vei^s afterwards, the name of 

,ast century, Certain areas of the eorte-X 

brain ‘to which he had attached specific functiois 

of the b am careful experimentation. H s 

as » residt “ this country to ehicidate tha 

was tlie \ on scientific and experimental Imcs, 

functions of ti e aJiich up to that time had be >> 

■^ition was published, the estahlvsbed 

si‘ KSiSoS' -s i-r .. «. 



IlfLU-H 31, IQ! 8] 


OBITUABT. 


r Tnr Crm-TH 

L llEOiaVt. JoCBTfAI, 


575 


brain, as revealed by liis oxai work in' conjunction ivitb 
that of bis contemporaries. Much of his original work 
u-as published in tho Transactions of tlio Boyal Society, in 
Brain, and in numerous lectures, "papers, addresses, and 
communications to learned societies during a number of 
years. As an examplo of his graphic method of dcmon^ 
strating his 'work, referenco may bo'made to the exhibition 
of a monkey at the International Aledical Congress in 
London in 1881. Before exhibition he had destroyed the 
first temporo-sphenoidal convolution on .both sides. "While 
the animal was disporting itself in tlio presence of the 
assembled physiologists a percussion cap was exploded. 
The monkey, remained perfectly unconcerned and gave not 
tho slightest indication of having heard anj-thing, while 
. another; monkoy was observed to siart; Suddenly and show- 
si^s of fear.. ^ 

At ah early, ago, in conjunction with his colleagues 
Jackson,' Gowers, Bastian, and others, he became one of 
tho • founders of the British school of neurology, which 
"has .contributed so extensively .and fruitfully during the 
last half-century to our knowledge of tho structure and 
functions of tho nervous system, and has done so much 
to promote tho stndy of nervous diseases throughout the 
world. To his medical colleagues, and to a large public, 
ho soon became known as one of the foremost of scientific 
physicians of his day, and he rapidly acquired an extensive 
consulting practice. He served upon the medical staffs of 
King’s College Hospital and the Kational Hospital in 
Queen Square, holding success! vel}’ tho posts of assistant 
physician and physician, and eventually becoming con- 
sulting physician. In hospital and in private practice he 
possessed a manner and a style in ■ tho e.xamination and 
treatrnent of n case which carried conviction. Ho was an 
investigator rather than a teacher, a physiologist perhaps 
more than a clinician. The bout of his mind in youth 
was towards philosophy and tho classics, hut he developed 
into a man of science, and later became a physician whose 
opinion in difficnlt cases was largely sought. 

ITerriev’s industry was ciionuous. Over a 
period of about thirty years his working day began at 
'm ■ ana ■ rarely terminated before 

midnight. Mhen I became associated with Him in e.xperi- 
mental work in the neuro-patliological laboratorv of King’s 
l^llege in 1890, although his days wero fully occupied with 
espial du les and tho hoary burdens of an increasing 
p ac e ound time to risit the lahoratary most after- 
noons and to assist in experiments from. time to time. One 
fViv remarkablo features of his career was that 

f ° - J3 professional life ho combined the pursuit 
<”^1 ^ practice of his profession. His earliest 
expeiimental work dates from 1873, while his last con- 

teals w' in 1888_a period of twciity-fivo 

nfnJ essentially an enthusiast both in work and 

ktw h th him, while into the 

atooJt\nv^ t the energy, interest, and spirit of an 
in uuro r "'n" nction, forceful 

inan'^°.iffpiM'" ^®nacious of his opinions; yet withal a 
mucli hnmaTi hindly nature, and imbued with 

showed the charLto/'of make-up. 

bquiinfdiSn^;“ya""^l‘’i “'"<1 “'3 “nuuer, and an 
seeker ffter^ infomatio"n “"d successful 

clcarlv nnd cT. I 1 thought clearly, wrote 

nc^nt.’denetinUisScottlhorl'gii?''''^ 

At one rieriod^^n^f recreation upon tho sea. 

to deep-sea fishine^ autumn holidays were devoted 

interest in medical and'’L"^°VF“^'^^'”® dominant 

ronular attendant nt +i ^amntifio matters. He was a 
ho had filled most of tlm ^ of riiysicians, of which 
Koyal Institution 

Hurinc tho last in-r. -r- ^ Koyal Society of" Medicine, 

his disability as strcnuouX”L'h fought 

over cefebbariocalfeatiou in^his earUorUfl? battles 


Air. WALTrK G. Spenceu writes: 

I would like to mention the first occasion and the last 
one on which I had the opportunity of listening to Sir 
David Ferrier. On the first, at the Brown Institution, 
Horsley and Beovor were engaged in electrically exciting 
areas on tho surface of the brain of an anaesthetized 
anthropoid ape. Ferrier was looking on, and discussing 
confirmations and minor elaborations of results obtained 
by him upon lower-grado monkeys, as well as the patho- 
logical correlations which, had followed. Shortly before 
last Christmas I was able to show' to Sir David Ecohomo’s 
Atlas, just purchased' by the Eoyal Society of Aledicine for, 
its library. As we viewed each of the mucli-enlarged 
photographs- of microscopical sections taken from the T^r-^ 
face- of tlio brain,— each demonstrating. some variation in. 
oho from the other, he took special delight in noting that, 
a difference in structure was now demonstrable, confirming 
differences already proved to exist as the result of experi-, 
mental and pathological inquiry. It was very evident that 
Sir. David Ferrier not only, retained his memory, hut had, 
kept up acquaintance with the progress of neurology. 


GEORGE STEVENSON AIIDDLETON, M.D., 

M.A., Lt.D., 

Consulting Physician, Royal Infirmary, and Eoyal Hospital 
for Sick Children, Glasgow. 

We have to announce with much regret the death of 
Dr. George Aliddleton, one of the leading figures in tho 
medical profession of the West of Scotland, which took 
place at his residence in Glasgow on March 21st, after a 
painful and prolonged illness. 

George Stevenson Aliddleton was bom in Aberdeen in 
1853, and received his early education at the Grammar 
School there, proceeding later to the University and 
graduating in arts with honours in 1873. Among his 
classmates there were Sir Watson Cheyne and Dr. Andrew 
Laws, the medical missionary. It was, however, in 
Glasgou’ that he commenced his professional studies, , 
graduating BI.B., C.AI. in 1876, and proceeding to tho. 
degree of AI.D. in 1884, on each occasion with honours. 
In 1853 he obtained tho diploma F.B.F.P.S.Glas. 

After graduating Dr. JXiddleton held resident posts 
sneoessiveiy at tlie Eoyal and Western Infirmaries in 
Glasgow, being associated there with tho work of Sir 
Hector Cameron and Sir William T. Gairdner. Later ho 
accepted an appointment as superintendent of Knightswood 
Fever Hospital, but work of this kind did not possess much 
attraction for him, and before long he resumed his con- 
nexion with the University on becoming assistant to his . 
former teacher. Professor Gairdner, a position which he 
■ held' for thirteen years. In 1894 he was appointed full . 
physician at tho Glasgow Royal Infirmary, with which ,he ,• 
w.as actively associated, for nearly twenty years. His , 
success as a teacher during this period may bo judged 
from tho fact that his , former students deemed it 
worth while to induce him to conduct for their benefit 
a special class, which may be regarded as constituting the 
foundation of post>graduation work, in Glasgow, From 
1906 for several years he gave his services also as senior 
physician to tho Royal Hospital for Sick Children, Glasgow, 
holding office as honorary consulting physician to that insti- 
tution and to tho Royal Infirmary after his retirement. 
During tho war li^held a commission as lieutcnant-colonol, 
R.A.AI.C., and was chief physician to tho 4th Scottish 
General Hospital, Stobhill, Glasgow. 

'. Dr, Aliddleton took a full share in public affairs, devot- 
ing himself largely, as was natural, to higher education. 
For eighteen years he was a member of tho board of tho 
Royal Technical . College, Glasgow, and in 1018 ho was 
elected to tho council of the University of Glasgow, which, 
in 1915, had conferred on him the honorary degree of 
LL.D. He represented the Royal Faculty of Physicians 
and Surgeons on tho board of governors of tho Royal 
Samaritan Hospital for over a quarter of a century. In 
both tho Association of Physicians of Great Britain and 
■Ireland and in tho Glasgow Mcdico-Chirurgical Society ho 
had -held office as president.. His decision to retire from 
cctivo practice was announced just over two yciirs ago^ 


OBITUAEY. 


676 March 31, 1928^ 


^ [ 


The Br.ms* 

Meuical Joimsit 


R-hciij at a gatlioring described as unique in the medical 
Iiistorj’ of Glasgow, he was entertained to dinner on the 
occasion of Ids Boventy-tUird birtliday by an assembly of 
bis old college friends, colleagues, aud assistants. 


AVo arc indebted to Dr. C. O. Hawthobke for >tbc 
following personal appreciation : 

Altbougb Middleton hold for many years a prominent 
position as a physician and clinical teacher in the medical 
school of Glasgow it was neither his professional status 
nor his recorded work that explained the influence ho 
exerted on his colleagues and the regard ho received from 
them. For long, neither himself nor his work gained 
mi'ch in the way of recognition. Ho had no gift of self- 
assertion, and his temperament led him to quiot studies 
rather than to controversial activities or to brilliant 
achievements. Ready motliods to popular success were not 
for him, and his limited ability to see a virtue in com- 
pi’omise did not alwaj’s coinraond him to his colleagues. 
Ho was not conciliatoiy when he felt a principle to be at 
stake, and he was inclined strongly, and even obstinately, 
to hold to liis own views ; while, if he had prejudices, ho 
did not disguise them. Altogether, jiartly' from circum- 
stances, partly from his personal qualities, the c.arlier jjart 
of his profe.ssional life was Jiardlj' an easy one or an 
encouraging one. 

TJie later part of the story is of happier quality, for it 
includes confidonoo freely given and fully justified, work 
worthily accomplished, merit recognized, aud “ honour, 
lore, ohedionco, troops of friends.” And the contrast 
helweon the earlier and the later years finds its explana- 
tion in the cliaracter and personal qualities of tlie man as 
these gradually became manifest in professional work and 
lesponsibilities, aud in tho opportunities of social life and 
comradeship. Efficiency and thoroughness and sincerity 
were the conspicuous notes of his practice as a clinical 
teacher and physician, and many of his pupils and houso- 
jihysioians became not only his disciples, but also his 
devoted admirers and affectionate friends. Gradually bis 
capacity for sound and impartial judgement and his 
unbending rectitude won the confidence of bis colleagues, 
and thus high duties were entrusted to him without hesi- 
tation. Ever 3 'onc recognized, whether in agreement or in 
disagreement, that he was over loj'al to what he conceived 
to he the worthy motive and tho larger interest. His 
decisions and opinions might be questioned, but never his 
integi'itj'. In personal friendships, as in public affairs, he 
knew the meaning of loyalty and sinceritj- and frankness. 
No master of smooth phrases, he never shirked a candid 
judgement, and his counsel, often sought, was valued oven 
wlien it was unpalatable. To the new generation Middleton 
was necessarily the representativ'o of the oldei’ school and 
tho established tradition, but those of us who knew him 
well through manj’ chequered 3 'ears will recall him as one 
who, “ in praise and in dispraise the same,” held ever a 
stead 3 ' course and gave of his best to the cause and serrtce 
of profession.pl dut 3 ’ and of loyal comradeship. , 


RICHARD JOHN KINKEAD, M.D., 

' Professor of Obstetrics and Gynaecology, TJniversily College, 
Galway. 


We regret to announce the death of Dr. ®ichai-d John 
Kinkead,’ for fift 3 '-threo 3 -ears professor of obstetrics and 
gynaecology at XTniversity College, Galway, which took 
Saco at his residence there on Mai-ch 18th, at tho age of 84. 

The son of a" clei’gyman, he was bom at Ballina, county 
Mavb in 1847. Ho received his medical education at the 
Echhols of the Royal College of Surgeons of Ireland and 
Trinitv College, Dublin, obtaining the diplomas L.R.C.S.I. 
and L M. in 1865 at the age of 19, and graduating 
M D Dnhl in 1873. For a brief period, between 1865 and 
1867 ho practised in Tnam. In 1875 he was appointed 
m-ofessor of obstetrics and gynaecology at Queen’s (now 
Hniversitv) College, Galway, and held that appointment 
to tho time of his death, being also lecturer in medical 
jnrisprudenco and hygiene. He artod . as cx.ammer m 
these four subjccte to the National VnirersiW of Irel.aml. 
For no.-irly fifty yeai-s ho was gynaecologist at the Connty 
IiifinnaTy, now merged in tho Central Coniit 3 - Hospital, 
.Galway, and for au almost equally long period, covering 


the troubled, times of tho earlier Home Rule agitatioa, 
the biiiu lem chstiirbaiiccs of the pre-treat}’ years, and 
the inter cinl conflict, ho was medical officer at Gahvay 
a Fellow of tlio Roval Academy 
of Medicine of Ireland, and had held the office of presi- 
doiit of the Irish Medical Association. He was the author 
of a number of publications, of which tho titles are a 
sufficient index to his rersatility; they included Our Homes, 
flic Irish Medical pTactitiouers^ Guide, Insanity, inebriefu 
and Crime, and Our Senses and How They Serve Vs. 

Tho affairs of the College to which he was attached 
attracted a largo share of his attention, apart from his 
teaching work. He was a member of the council of the 
old Queen’s College and of the ' governing body of its 
successor, one of the constituent units of the National 
thiivcrsity of Ireland, until recently, and as auditor of 
Queen’s College gained fame as a public s\ieaker. He had 
for some time past been unable to fulfil his professorial 
duties, hut the governing body of the College decided, in 
recognition of his work, to retain his services. - 

In the Church of Ireland he ranked among the. leading 
personalities in the diocese of Tuam throughout his life, 
and a feiv years ago his services wore recognized by a 
presentation from the bishop, clergy, and laity. Ho was 
a member of the General Synod of the Church, and lay 
honorary secretary of the Tuam Diocesan S 3 -nod; and in 
his own parish of St. Nicholas had occupied almost every 
office open to a layman. As a Freemason he held the 
position of Prortneial Grand Master for South Connaught. 


A colleague, “J. M.,” writes: A man of remarkable, 
force of character arid originality has passed away in 
the person of R. J. Kinkead, who has been for several 
Ecnorations of medical students one of tho outstanding 
figures of University College, Galway, which, although one 
of the smallest and poorest of the university centres of 
Great Britain or Ireland, has a far-dnng chain of alumni 
wherorcr English is spoken. In the training and educa- 
tion of these men to adapt themselves so well to .all 
circumstances Kinkead took a large part. He , was a. 
fearless operator and never failed to command the into«.st, 
of his class in the lecture room and the wards. His 
interest in professional affairs was unflagging, and many 
rears avo he was elected by his prof^sional brethren, 
nresident of the Irish Medical Association. A phase of 
Ids work which brought him into the limelight which 
illumines the ephemeral political celebrities and thoije in 
contact with them in a country given to political activity,, 
was his position as surgeon to tho county gaol, which w.-is 
freeuently in former troubled days selected for the con- 
centration of a number of political prisoners. In a very 
difficult position Kinkead ran his course so fairly and 
evenly that no party had any opportunity to attack him. 
AinoiiK tliose who came under his care were the late Mr. 
tXi Dillon and tho late Mr. William O’Bneii. In 
..ddifcion to his professional activities he took a h-irge part 
in the life of the community. With his outspoken honesty, 
robust common sense, wide sympathy with his fellows, and 
Hreo outlook on'life ho filled a place in the regard and 
oc+npm of his contemporaries not often attained, and d 
cViGil- this short and inadequate tribute will find an echo 
rtevef the past students of Galw.ay College are td bo 

found. 


TOHN PBROy INGHAM HARTY, F.R.C.S.Exa., 
B.A., M.B.. B.Ch. R.U.I.. 

c.irppon Ear, Nose, and Tliroat Department, Bristol Eoyal 
° * Infirmary, 

Tp i-eci-cfc to nimouncG tlio death, at tho cai‘]y age of 4 i 
F Mr^ Jorin lugliam Harty, honorary /"''gf'’" 

le bar nose, and throat department of Bristol Gen 
[osiri^l, who died on March 10th after an operation for 

‘jf™'Hnrtr received his early 

iiecn’s Colffige, Cork, and in 1902 graduated M.B., 

A O R U-l- After spending several years m pr 
iacrice at Halifax, he decided to specialize m nose 
iroat work, and'Btudiod m Leeds and London, 
ort ncriod of eighteen months }ic passed both tho pr « 

,d final ^amiimtions, and in 1912 obtained tho diplom* 



MaBCH 31. 


OBITUARY. 


t TKK Eninsn ^77’ 

SfEDICAt JOCRXAIi * * 


F R C.S Eng. Aftci- lioUing resident appointments in 
Loudon and Carditf, lie n'ent to Bristol as lionse-sni-geon 
to tUo ear, nose, and throat department of the Royal 
Infirmary, suhseqnentiy becoming registrar of tlio depart- 
ment, and beginning private consultative mork with 
\n\mctUi\to success.- 

Mr. Hart)- was a keen Territorial officer, and on 'the 
outbreak of the lato war was mobilized with tlio 3rd South 
Midland Field Ambulance. He accompanied that unit to 
Franco early in 1915, hut soon afterwards was attached 
to the 6th General Hospital at Rouen as a specialist, and 
organized tho nose and throat department . for the Rouen 
base. IVIiilo holding this appointment tho illness first 
developed which ultimately caused his death. Towards tho 
end of the war ho was transferred to tho Royal Air Force, 
and served with it as a spceialist until his demobilization 
in 1919. On returning to Bristol he resumed his work, 
and in 1921 was appointed honorary surgeon in charge of 
tho ear, nose, and throat department of tho Royal 
Infirmary. Ho held a number of other public appoint- 
ments in Bristol, being clinical lecturer on laryngology to 
tho Hniversity, consulting surgeon for diseases of the ear, 
nose, and throat ..to ,.SoutbmGad--Hospital, and aurhl 
surgeon to the Education Committee. Ho was a member 
of the British Medical ' AsSoe'iaflori' aiid of' the Bristol 


Medico-Cliirurgieal Society. 

A colleague writes: The death of J. P. I. Harty has 
deprived Bristol of ono of its best known consultants, and 
has caused a gap in tho circle of his colleagues and friends 
which it will be well-nigh impossible to fill. Those who 
mat him for the first time after tho war little realized 
how* much it bad changed him. A noted Rugby player 
(lio played twice for the South of Ireland, and was 
** capped for. his medical school all the time be was a 
student), he played most games w-ell, and was endowed 
with a magnificent physique. A typical cheery Irishman, 
w’ltli a never-ending fund of good stov'ies and jokes, he was 
tho^hest of companionSj beloved alike by his colleagues and 
patients. Prom tho date of his first illness in Franca he. 
never enjoyed good health, and in later years, in spite 
of numerous operations, ho was greatly aged and never 
free from pain— at times very severe— hut always so bravely 
borne that those who did not know him well seldom had any 
Idea of the distress ho was enduring. He “ did great good 
y stealth. Tho shoals of letters received from liis poorer 
patients are an eloquent testimony to the affection ho 
inspired m them.. Ho married, in' 1916, Helen Dorothy, 
aug 1 ei of tile lato Dr. Clarke of Kensington, and leaves 
two young sons. & ■ 


JAMES DAVISON, M.D., M.S., M.R.C.P., 

Consulting Fiiysician, Royal iqctoria Hospital, Bournemouth. 

" 't'' regret that we have to announce the deatl 

Sr ;■ Bournemouth, who died there ei 

Match 18th, in his eighty-second year, as tho result of ai 
attack of pneumonia supervening on an illness which ha< 
ke^ him confined to his bedroom for several months. 

native of county Down, and commenced hi 
later to'^Tl'Tl-'”'' nt Queen’s College, Belfast, proccedini 
DnLi^Uv in Q«een’: 

Ho sftei’wnrilo'^'V,''''^ M.S. ten years later 

London and in studies in Edinburgh am 

For a’ aim. t ^ ol^tained tho diploma Jf.R.C.P.Lond 
lor a shoit time after heginnine his iirofessiona 

h" visited Sheffield Medical School, and afterward 

to Fnela d Zealand. On retnrnini 

in 18 R? +1 led clown m Boiirneinoutli, commencinj 
in iottd t\\^ nssocintion irifli fi,/,*' ? t • t. 

tinned until his death. The o Dr Dat' ^ "•Inch con 
an t raa.-i ^ ^ B avisoii $0011 €st ablisliei 

organtzatiou ostiihlishmeiit am 

Bournemouth 

staff as senine ,, 1 ,... • ■ ^ period ho served on th 

nose a, id throat I’i‘.vsician in chargo of tho oar 

Physiri."! ^"ho h Sr”i;ST “'iini 

mj-pitai. in 1&88 ,,.as elected physicia: 


to tho Royal A'atioiial Sanatorium for Consumption and 
Chest Diseases, Bournemouth, being consulting physician 
at the tiino of his death. He was also honorary examining 
physician to tho Alexandra Sanatorium, Davos, Switzerland. 

br. Davison, tliroiiglioiit liis active life, took a con- 
siderablo part in professional affairs, and over a long 
period filled various offices in the British Medical Associa- 
tion, being a member of Council in 1910. The period of 
bis service as honorary secretary of tho Dorset and R est 
Hants Branch included the year 1891, when tho Annual 
Meeting of tho Association was held at Bourn enioiith ; as 
local secretai-y his ungrudging expenditure of time and 
money did nincli to make the meeting a success. In tho 
Dorset Branch ho was a member of tlio council for several 
periods, acted as secretary for a second term, and held 
office as president in 18S6. At the Annual Meeting of the 
Association in 1892 ho was vice-president of the Section 
of Diseases of Children. Only last year, in making a 
routino communication to tho Central Office, Dr. Davison 
took occasion to- express his- -continued- interest' in tho 
advancement of the Association’s work and to voice his 
regret .at being unable to see tho new premises. Ho was 
also a Fellow of the Royal Society of Medicine and of the 
Medical Society of London, and had been president of 
the Bournemouth- Aledical Society and vioe-president of 
tho British Laryngological, Rliiuological, and Otological 
Society. 

His favonrito recreation most of his life was horse- 
riding, and in his earlier years ho was a keen follower of 
hounds, riding regularly with Lord Portinan’s and the 
A^ew Fore.st packs, and it was with regret that he was 
forced, with the passage of time, to abandon this pastime. 
Whilo he did not take any vciy prominent part in public 
affairs, other than those associated with liis profession, he 
was a well-known and popular figure in Bournemouth. 

• At tlie funeral at-St. James’s Church, Pokesdoivn, repre- 
sentatives were present from the Dorset and "West Hants 
Branch of the British Medical Association, the Bournemouth 
Aledical Society, and the staffs of the Royal National 
■Sanatorium and of the Royal Victoria and West' Hants 
Hospital. Dr. Davison is survived by his widow and two 
daughters. 


HENRY GOFF KILNER, M.B., B.S., 

Honorary Surgeon to tho IVest Suffolk General Hospital. 

By the sudden death, on March 17th, of Dr. H. G. Kiliier, 
at the age of 42, East Anglia lias lost ono of its most 
greatly loved and talented sons. Tho second son of Dr. 
Charles . Scott Kilncr, Henry Goff Kilner was the fourth 
generation of that family to practise medicine in Bury 
St. Edmunds. Educated at King Edward Vi’s School in 
Bury, he entered the Middlesex Hospital, whore, after .a 
brilliant career in the medical school, he gained the senior 
Broderip Scholarship. After qualifying as M.R.C.S., 

L. R.C.P. in 1909, he held the appointments of honse- 
pliysicinii, house-surgeon, and obstetric honse-physiciaii, 
,and became demonstrator' in anatomy. Ho graduated 

M. B., B.S.Lond. in 1912, and was appointed house-surgeon 
at St, Peter’s Hospital for Stone. On the outbreak of 
war Kilner was gazetted second licutenaht to the 5tli 
Suffolks, and served as a combatant till the Ai-niy Order of 
tho summer of 1915 requisitioned medically qualified men to 
associate themselves -ivitli- tho R.A.M.C. Ho was present 
at Gallipoli, where ho sen-ed in a hospital ship. Subse- 
quently ho was on the headquarter staff at Mudros, and 
then in Egypt with the 29tli Division. At a later date ho 
served with the 7tli Field Ambulanco in Franco, and 
became D.-\.D.M.S. to tho 2nd Cav.ali'y Division. IVhilo 
there he was awarded tho Croix do Guerre and was twice 
mentioned in dispatches. 

Returning to Bury St. Edmunds after the war, 
Kilner acted as surgeon to tho hospital for disabled 
men under the Biitisli Rod Cro^s Society and tho 
Ministi-y of Pensions, and was elected honorary surgeon 
and honorary radiologist to the West Suffolk General 
Hospital. He ivas a loyal worker in the British Medical 
Association. Ho served on the Suffolk Branch Council in 
1920-22, Was tho representative of the West Suffolk Divi- 
sion in the Representative Body in 1620-21, and was a 
member of tho Executive Committeo of the’ Division in 




March 31, igjs] 


MEDICAL NOTES IN PAKLIAMENT. 


[ TtreBnmss R7Q 
Hxaiicii. JoTBSift 


of tlio cramped acconimodalioii of the men in tbo battleshyis. 
A letter had appeared in tho newspapers on the prev.mis day 
asserting that in tha Portsmouth district there were 1,600 men 
who had been turned out of tho navy, but whpsp disease had been 
held to bo non-atcribuUble. Cornparin^ statistics of tuberculosis 
in the navy and in cidl life for found thcro were 

diSerent rates of incidence. In cml lifo between 20 and 25 years 
of a<'o tuberculosis was decreasing, but in tho nai.’y it was 
increasing. That led to the susnicipn that there was some con- 
dition in tho navy tho effect of which was eswntially different 
from what happened in civU life. Ho had lately been informed 
that a committee was sittin® to consider the matter, bnt had last 
met somo montlis prenously. Ho was anxious tlmt something 
should be done now. There were slowly but surely dying of con- 
sumption in this country some hundreds of men who had served 
in the naw and were convinced they had contracted tho disease 
in tho navy. Nothing had yet been done for them, except for 
tho 15s. a week which they might get from the national health 
insurauco scheme. It was impossible for any tuberculosis case to 
live on that money. It was a scandal to tlie House, to tbo 
Admiralty, and to tho country. Mr. HAnniE said the records of 
tho conditions in the old wooden sliips^ of tho navy could bo 
consulted, and did not show that tho disease affected tho lungs 
of tho men as it did to-day. Ho asked whether the Admiralty 
had troubled to find out what really occurred when men slept 
surrounded by . non-breatbing materials. The same point had 
arisen- in discussing steel houses. Lath and plaster were materials 
capablo of absorbing what men gave off in their breathing during 
sleep, but when men slept surrounded by non-absorbent materials 
tlicro must bo serious. consccj^ucnces. IVas it not possible that in 
tho sleeping places in ships •there should bo a material capablo of 
ateorbiiig what was given off during sleep? ‘ ’ ' ’* 

any analyses in warships^ during tho middle 
Captain Garro-Jones said the medical ser 

required investigation by Mr. Bridgcman. In the Admiralty 
Sailing Directions for Pilots ho had come across directions for tho 
maintenance of health of officers and men of the n&vy in 'West 
African waters. No medical officer with any knowledge of the 
‘subiecl could have revised them for a ccuturj-. Such diix?ctions 
ought to be revised and "kepi up * to date to meet the rajjid 
changes of medical science, particularly in tropical medicine. 
Mr. ilRiDGraAK said the* Admiralty was trying to find out the 
facts about tuberculosis- and to provide as far as possible for 
avoiding its dangers. If any member had facts whicli were 
unknown to tho Admiralty he would bo glad to receive them 
and to refer then to the medical and other authorities. Mr. 
Mardy- Joxbs asked if Mr. Bridgeman knew of the conditions 
under which British workere were housed at tiie Singapoi'e naval 
base. The base was ou low-lying laud full of wild jungle and 
brooks, which were centres of malaria. Special precautions should 
be taken for the comfort and health of those who went there. 
He asked whether out of the £500,000 to bo spent on tho naval 
base tms year any portion had been allocated for studying 
health problems. 

The Mouse then agreed to the Na^ Estimates. 


— Pciirions, 

SmELs asked the Minister of Pensions, on March 
V J consider returning to Scotland the 105 Scottish 

uisabled ex-seryico men under treatment in hospitals in England. 
Maiov iavou, rn reply, said that when treatment near a man’s 
norac could be arranged it was given, but in the interests of tho 
- and in view of the varied types of disease and the 

niglily specialized treatment required by them and given in 
uct adopt in all cases tho coui-se 
su^estod by Dr. Sluels. Dr. Shiels asked whether tbo Minister 
.lini that Scotland had highly skilled medical men able 

c«cs. Major Tryo^j said tho question 
wi « inc medical skill alone, but also of available hospitals. 

mentioned by Dr. Shiels could not be received in 
\ hospitals, nor could all be placed in one institution. 

would be required for each type -of case, and 
Dr ^vindliug number of patients, 

lion of whether Majoi Tryon asserted that no propor- 

Maior Tnvn'j suitably treated in Scotland. 

S to start be Reasonable or practic- 

to deal -with Hm hospitals in Scotland 

dealt with in ,?”^.jj^^mdhng number of cases being 

included a af a ex-semce cases which 

MaW ^Yov treated iu Scotland, 

couid not be accepted Vc^VhSnTt^,”°P ^ )“iEe Proportion 

EOVCII border-linn ..Til ““P'i®ls. For example, the twenty- 

of tbo men bad^oT^ve^^lonn timn^r''*^^ at. Cr’iigleitli. ManV 

of treatment. He had sl?n Se S 

and had found them to be satfeLf. bospitab 


SO impoverished that they were no longer able to look after 
themselves. He had to ask liimself whether these agencies in 
South Wales were breaking down, and whether the condilious 
tlicro were so dangerous to health or so different from tliosc in 
other large industrial areas as to justify the employment of 
fresh agencies to supplement those ah'eady in ciistcnce. They 
could not have such distress, unemployment, and impoverishment 
without some effect on the health of tho people, but, while they 
must keep a very careful eye on what was happening to the 
public health, and especially the health of the children and 
expectant .mothers', , there was no reason, up to the pi*cseiit,- to 
believe that it had reached any very disquieting or serious ^inl. 
Until he was satisfied that the efforts of the people of SouUi 
Wales to help were exhausted, he would be unwilling to relieve 
the serious shoriage of boots and clothing among tbe children by 
tho iiM of public funds. 

Lord Hustace Percy, replying to the debate, said that at the 
beginning of this year he sent inspectors into South W’alos, and 
the result of their sample medical inspections showed that the 
percentage of malnutrition varied enormously from area to area. 
That could be duplicated in many industrial areas in other parts 
of the country, and probably even in London. There was also 
great variation between different schools in the same area. At (he 
present moment neither the average rate of malnutrition among 
children in South Wales nor the .range of malnutrition .was 
different from what was found in industrial areas generally. It 
was not at present an exceptional condition, blit would need very 
careful watching. There was danger tliat where the depression 
in trade had existed for eight years or more thero would 
ultimately a sudden break in health. If feeding were needed in 
those areas, it was needed on a strictly selective basis on medical 
inspection. 

Sirevgih of Colonial SIcdical Stti^s. 

Ou March 26th, replying to Mr. W, Baker, who asked what was 
tho authorized strengtli of tho official medical staff in each of 
the Crown Colonies, Mr. - A^ery said that in colonial medical 
appointments, whicli were usually filled by recruilment in this 
country, it was only in tho West African medical staff that tlio 
number of vacancies was considcrablo. For most other colonial 
medical services Ibero was a surplus of candidates. When vacancies 
occurred they were advertised in the medical and other press, and, 
in filling appointments, tho Colonial Office received assistance from 
the universities, tbe medical schools, and tho British Medical 
Association. Latterly a number of applications had been received 
from dominions candidates. Tlio onicinl medical staffs of the 
various colonies were : Basutoland, authoi ired strength 11. vacancies 
0; Bechuanaland, authorized strength 6, vacancies Oj Swaziland, 
2 and 0; Kenya, 9^ and 6; Noribeim Rhodesia, 16 and 1; Nyasa- 
land, 22 and 0; Somaliland, 11 and 0; Tanganyika, 114 and 4; 
Uganda, 77 and 2; Zanzibar, 19 and 0; Gambia, 6 and 0; Gold 
^ast, 100 and 20; Nigeria, 161 and 27; Sion*a Leone, 26 and 0; 
Cyprus, 38 and 1; Gibraltar, 7 and 0; Palestine, 55 and 1; Ceylon, 
363 and 0; Mauritius, 18 and 1; Seychelles, 5 and 0; Fiji, w and 0; 
Gilbert and ElUco Islands, 5 and 0; British Solomon Islands, 3 
and 0; St. Helena, 2 and 0; Hong-Kong, 18 and 4; Wei-hai-wei, 
2 and 0; Straits Settlements and Malay States, 310 and 10; 
Baliamas, 9 and 0; Barbados, 11 and 1; Jamaica, 57 and 0; Cayman 
Islands, 1 and 0; Turks and Caicos Islands, 2 and 0; Leeward 
Islands, 22 and 2; Trinidad, 39 aud 0^ Winda^ard Islands. 19 
and 1; Bermuda, 4 and 0; British Guiana, 45 and 0; British 
Honduras, 8 and 0; Fallilaud Islands, 3 and 0. Tho figures of 
authorized strength given above related to tho whole establishment 
of medical officers, both those recruited from this country and 
those who were recruited locally. The figures of vacancies related 
only to appointments usually filled from this country. 

Sir W. Davison, on March 26th, asked if tho attention of Lord 
Eustaco Percy had been called to an address whicli had been given 
in London by the_ Chief Medical Officer of the Board of Education 
in which he rcfcircd to the ignorance of the mass of the popula- 
tion in regard to diet r*- ’ - hereby tho 

general health of tbo * ■ 'd Eusta<x 

Percy ^iil tho Board < ■ ro^'ision of 

instruction of this uatur a syllabus 

of lessons on tho hygiene of food and drink and a handbook of 
suggestions on healtJi education. Mr. Kelly urged Lord Eustace 
Percy to make tho samo recommendation to public schools. 


26Ui" Mr. pS'Biil, on Marcl. 

SoM%a?e! Yn'’ 

sufferinp from IncI; of ™ PJ' found scliool children 

el. subnoi^norf^^^^^^ ''23 out of 3.tM5 

11, e niotlicm wes Siv of 


Go-ordination of ihc Fighting Services, 

On March 27th the House of Commons debated tbo third reading 
.of tho^ Consolidated Fnnd Bill. Bir It. Hdtchison suggested an 
alteration in the administration of the fighting services in order 
to eecuro greater coordination and control. There would be con- 
siderable advantage in greater co-ordination of hospitals and other 
medical matters. The country might get a wider medical^ service 
by bringing the medical sendees of tho Army, Navy, and Air Force 
under ono control. 

Mr. Baldwik said that the present was a period of transition, 
and a continuation of the present methods met our peculiar con- 
ditions best. Ho would like to show, by way of illustration, what 
was being dono by co-operation between tho hospitals at tho 
present time. In that respect tlierc had been a move forward in 

tlie last year or two. Tho Ro^'al Air F *■' ‘ * ’■ ■ arato 

hospital at home, except tho two big . 

and Cranwell. They had no hospital . ■ ■ , ^ 

thcro was a small officers* hospital of twenty-five beds at Uxbridge 
for dealing with flying accidents which might occur at that centre 
But abroad, where the Royal Air Force was in control, they main- 
tained tlieir own hospitals, and during 1926 there were up to 3 000 
admissions of personnel of the navy, the British and Indian 
armies, and local forces of Iraq and Palestine treated in the Eoj'al 


680 March 31, 1928] 


tTNIVERSITlES AND COLLEGES. 


TuiBnmsa 

L MePICAL Joes'*!* 


Air Forco hospitals. Tho military hospitals at Cosham and 
Povonport were closed in that year, and arrangements were made 
for the sick of tho Portsmouth military area and of tho military 
EtatioDS in the Devonport area to bo treated in tho Royal Victoria 
Hosmtal at Notloy or tho Royal Naval Hospital at Haslar.’ and 
tho Royal Naval Hospital at Plymouth. No fewer than 3,000 of 
the R.A.F. personnel received treatment in tho naval, army, and 
civilian hospitals during tho last eighteen months. In tho eamo 
way there had been considerable trealmont of Air Forco and army 
patients in the naval hospitals, both at homo and abroad. 

Tho possible pooling of other hospital arrangements had been 
examined, and in some cases had been found impracticable, but 
there wero some places which were still under investigation. Tho 
Air Forco itself made no general contracts in regard to medical 
supplies; it took tho existing army contracts. Slandardixation 
and pooling had been agreed to in principle in regard to the 
ambulance trains, and the details were being worked out. The 
India Office was being invited to co*operato, and number of 
other matters were now being studied by the general medical 
eerviccs, etc. In research co-ordination was effected tlirougb three 
co-ordinating boards for chemistry, physics, and engineering. 


Ititiliirsitiis nitiJ ©ollc^is. 


UNIVERSIir OF LONDON. • 

Dr. W. W. Jameson, medical officer of health for Uorusey nod 
loctiu'or ou public health and preveufcivo medicine at Guy's 
Hospital Medical School, has been appointed, as from January Ist, 
19‘<i9, to tho Uulvorsity Chair of PuUlic Health at the Loudou 
School of llygiono and Tropical Medicine, 

Tho clogcoo of D.So. in Auatom}’ has been conferred upon 
Professor W. E. Do Gros Clark, F.IDO.S, 

Tho Committee of tho Medical Members of the Senate has 
RppoUitod Or. John Fawcett as its chairniau /or the remainder of 
^hc academic year. 


UNIVERSITY OF rilYERPOOD. 

The following candidates have been approved at the examination 
Jiidlcaled: 


Destruction of Vermin, 

In the House of Lords, on March 27th, Lord SinATiisrinr moved 
the second reading of the Public Health (Dcstructiou of Vermin) 
Bill. He explained that tho bill provided that if it appeared to 
the local authority, on tho certiucate of tho medical officer or 
sanitary inspector, that any articles in any premises used for 
human habitation were infested with vermin, or were likely to 
bo 60 infwted, the local authority, at its expense, should cause, 
those articles to bo ciennsed, disinfected, or destroyed. If it 
ap^peared to the local authority, on tho certificate of tho medical 
omcer or tho sanitary inspector, that any premises used for human 
habitation wore infested with vermin tho local authority should 
give written notice to the occupier or tho owner if the premises 
were vacant, requiring him to clcanso tho premises. Tho notice 
might require the removal of wallpaper or other covering from 
tho walls. Aa a penalty for default a fine not exceeding £5 was 
provided, and a daily penalty of 10s,, and tho local auUiority was 
authorized to do tho work and to recover the costs. Clause 3 
provided that on the application of any person tho local authority 
might tako auch measures as were deemed necessary to free that 
person and his clothing from vermin. Where it appeared to the 
local authority, on a report from tho medical officer, that any 
person pr his clothing was infested with vermin, and that person 
consontod to be removed to a cleansing station, the local aulliority 
might cause him to bo so removed. It ho did not consent a petty 
sessional court, if satisfied on the application of tho local authority 
that it was necessary, could make an order for his removal to tho 
cleansing station. It was provided that tho cleansing of females 
should be effected only by a registered medical practitioner- or by 
a woman duly authorized by the medical cfficor. As soon as tho 
occupier of a house became aware that it was infested ho was 
required to send notice to the medical officer of health, and if a 
person became infested he must notify tho medical officer. 

Lord Banbuiiy moved tho rejection of tho bill, and said it was 
absolutely unnecessary. It enacted clauses already in existence, 
and some of the new clauses converted the private individual into 
a police officer. They would compel him to do the business of the 
local authorities, who already liad powers through their medical 
officers and sanitary inspectors to find out if people had got 
vermin on them or not. Viscount Gage said that tho Miniver 
of Health was not convinced that any real defect existed in tho 
present, law on these matters. After further discussion Lord 
Banbury’s motion was carried without a division, and the bill was 
rejected. 


Diphtheria among Elementary School Children. — ^Mr. Orno 
Nicholson asked, on March 22nd, whether parents of. children 
attending elementary schools in the county of London were 
notified of cases of diphtheria in such schools, and given an oppor- 
tunity of isolating any child who had been attending; and 
whether there was disinfection of classrooms in which cases had 
occurred. Lord Eustace Perct said tho arrangements made by 
tho London County Council for dealing with cases of diphtheria 
in ordinary schools were based on experience over twenty years, 
and he W’as advised that all reasonable precautions were taken. 
He did not propose to interfere. 

Health of Workers in Artificial Silk Factories. — ^Mr. Kelly asked 
Sir W. Joynson-Hicks. on March 22nd, whether any of the reports 
received from Lancashire or Derbyshire on artificial silk factories 
showed that work in them was harmful to health. Sir W. 
Joynson-Hicks said the reports did not show this. Complaints 
about the Derbyshire works had been received in 1925 and 1926, 
but extensive alterations had since been made in plant and 
buildings, and no further complaints had been received. Mr. Kelly 
asked whether any recent reports had mentioned blindness duo 
to workinw in the artificial silk industry. The Home Secretary 
replied that no complaints had been received for a considerable 
time and urged that if Mr. Kelly had informaUon showing that 
blindness had arisen from working in the industry bo should 
furnish the information to the Home Office. Sir William added 
that he was unaware that any recent report from a Home Office 
inspector had mentioned any cases of eyesight being _ affected or 
of workers being operated upon for blindness. Artificial silk was 
a new industry. Home Office inspectors were watching it care- 
fully, but at present had no evidence to establish it as being 
dangerous in any particular. 


Final M.B., Cn.B.— Part It J. D. Bright-Richards, J. P. Planagan. 
Tart II: A. L. Beresford, A. E, Carrol, A. Gardner, W. W. Gerrard, 
O. A. Talwrn-»Tones,- . -r t, t ' 

DiTLOiiA IN Mepioai/ Badioloqy and ELEcraoLoax.— N. j. Baiton, 
u. V. BerTing6'>0, E. 0 Pox. Norah M. Walker. 

EirLOMA IS TaoPiOAU HtoiENE.— R, B. Evans. W. J. Laird, H.Y.R, 
Miller, Q. H, Pearson, J. U. Pottinger, S. A. Wilkinson. 


VICTORIA DNIVEKSITr OF MANCHESTER. ■ 
rilE following candidatea have been approved at the esamluatlon 
udicated: 

r, p n -W C. V. Brothwood, Miriam Florentin, T. Peirson..T. B. -Wiley. 

nmioiii IV PVvcuoLooiCAI, MEPICINK, Paot I.-l^ Hiudlev. J. B. 

“ HokVvT. H. Sbeplw. H. Slafford. 

m.n fnllon-ii)'' nivarils have been made; Sidney Renshav? Prize 
n^Avslolo"y, i. Davis i Daiiutesey Senior Medical botiolawliip, 
? V. iVfiglit; Daiiutesey Junior Medical Sobolaiships, C. H. Giaj, 
^itnmeruiau. 


DNIVERSITi’ OF DUBLIN. 

. TniKiTY College, Dublik. j; 

.. ih.,so whose names were published last -weelt (p. 529) 

aflJ l!?« "ifor jLarH.Cl.., B.A.O., the lollowmg have 
‘■“';‘;;nroida?^hoeyami7;atim^ • , 

maiP l_,ir(,(ertci Mediea u*'d Therapeutics t 

INAL M-Ri-FART I. rr p^tholonu and Bactenolonv i 

T ^ Wilson.'FsO.'SV. A.Mahoa- , »Uinsou, 

Pt'Dundon. U. R- F- Tweedi. 

It F. \V. Kv Allen, A.. J- Bur tf iinou. Miuiui/en/J 

5- B; H Blau Aobb* preegim, J. A. Dowds. A, J. Bmden. 

• ' ♦ Passed on high marks. 

anPTFTX OF APOTHECARIES OF LONDON. _ 

E loilowin^an'lidates have passed in the suhiects indicated. 

Graham. H. J. Hwcourt.M. Hurwits. 

, J. Bockitt. E. B. Bowen. M. Harwite. 

Sanders. W.Ziv. 

imwivnKii.-- g,auted to Messrs. E.E. 
°.‘^‘ji'THarcourtrBnd N. S. J. Roberts. 


OTBHRE Eodleston, °“.*^^^°®“Teroe°iSryfel^^ 

Doctor of Laiva 

■bincb^oe Wales, as Diiesiaent of Ki^g Edwwd^ 
Toad for Lonclon has of J** 

1 lie held uuder the tinsploos o' with tbe 

tan Branch of the Pharmaoeut^^^ g,,thb 
bion of the. neighbouring Div sions uoroogb 

UcerolheaUhforGreeinuch,^^^^^^ 




682 March 31, 192S] 


LETTERS, NOTES. AND ANSWERS. 


PE[.VI0 ClItCUMFUnisNCI! or Inpant at Biutii. 
••iNQUliiiiu ” Bales : Would somoone leiiidly Rive me llio BVOi-a','e 
xnensnremcnts of a full term child — round the pelvis — afc tlic level 
of the iliac crests or at the level of the trochanters. T oaniiot 
find the average circuinforciice of the )>clvis of.a child at birth 
in any book of reference. Is tlnfre any difference noted botwouti 
the male and female civoumferential zneasiirement at birtli? 

The bitrochanterlcciromnfcroncoaiid Iliac cirGUinfereuco 
cannot be easily dissociated becanso of the. difficulty of taking 
the former measurement when the thighs are partly flexed 
* on the trunk, as Is usually the case in the newborn, ffiiio fnlb 
term cliild lias a circnmfcrcnco at the level of tbo iliac crests 
of 9 in. to 13 in. The bitrochantcrlc diameter Is ±4 in. Tlio 
following data are given by Le Damany (“ Q'lolqnes proportions 
dn corps cliez les nonvean-nds,’* Journ.de I'Aiiat. cl dela Ph'jn,t 
1910, Paris, Tome 46, pp. 654-693): “The transverse diamslcr of 
the trunk at tlis level of the iliac crests is 7.4 cm. and 7.2 cm. in 
the male and female respectively (0.203 and 0.197 of the stature}. 
The difference is therefore insignincant. The antcro-poslcrlor 


out, the authorities are w.lling to accept ns a painieut on 
flccoiMita sum representing the taxon theamouiitof the probable 
liliiinaie liability. It should be roineinbered that iu such a case 
ns tlii's the authorities will not accept cash accounts ” iiuleai 
the jtredecessor a receipts arc brought into the computation. 


LETTERS, NOTES. ETC. 

A Listerian in Alabama. . 

Dr. L. Tj, TTiLL, F, a. C. 8., of Montgomery, Alabima, was a pnpll 
of Lister at King’s College Hospital, Loudon, and his enthiisia'iiii 
for Ills great m.ister Jins not wane!. He Jias written a iiiosl 
cloqiiflit hiograpliical and personal notice of Lord Lister nnder 
Ihc title of “Lister’s Centenarj’/' which appeared originally iu 
the American Journal of Surgery laafc August, and has now beec 
rojirinied in pamphlet form. Dr. Hili is the master of a polished 
style, ninl his choice of Jauguage is as sound as was his choice ot 
a surgical teacher. 


diameter of tlie trunk at the level of tlie anterior superior iliac 
Bpiu?c is 4.4 cm. and 4.5 cm. in the mile and female (0.0375 and 
0.0892 of the stature). Tiio difference is due to the more salient 
anterior-superior iliac spines iu tlio female.” 

Chance’s Filter for Ultra-violet Hats. 

Dr. S. T. B:*.ggs CMiddleton) inquires a\)3Ut the uao of Chance's 
filter (Wood’s glissi in conjnnctton with the ultra-violet ray 
lamj). lie asks if it Is suitable fur diagnosis an.l treatment other 
than In ringworm cases. 

^ Wood’s glass, of which Chance's flltor Is.made, is a glass 
of dark violat line, which trinsm ts only the rays at the oxtrenio 
violet mil ultra-violet end of tha spectrum. When light from 
a source ricli in ultra-violet riys — for example, the niorcnry 
vapour lamp— passes through it, flnoresconoa is caused in various 
Biibstancis, The filter is useful in the diagnosis of ringworm of 
the so lip. becanso infejted sta nps fluoresce sd strongly that they 
fitand out like sliver bayonets, an.l ara quite numislakablc. 
It must, howiver, bo remembered that epidermal scales and 
vaseline also fluoresco, altliougli not so strongly ns to cinic any 
diCTuulty iu rooognizhig ringworm of tho scalp, but for that 
reason this test is inelesi for the diagnosis of ringworm of the 
glabrom skin. There seenn to be no other cuUuoons condition 
in which AVood's glass nislsts in the di.iginsis, uor is it used in 
any way in treatme.it. Its scope is liin’tel to ringworm of the 
scalp alone, iu which It is useful both for miking the original 
diagnosis an.l for testing the resnlti of treatment ; with its aid It 
is quite evsy to pick out a s njie re n lining infected stump. 
The ex.aniination mint, ot course, be male in a darkeueJ rooih. 

Income Tax. 

Commencement of Liahilitg. 

G.” was employe 1 as an assist ml from Mavcb, 3927, to 
November, 1927, and again in January, 1923, for two weeks j ho 
then st’.ii'ted iudepenlent practice. What is the basis of liis 
liability for tho years to April 5tli, 1928, and 1929, and should he 
approach tho authorities? 

♦** For each year t’le basis' of assessment in those circum- 
Btances will be the curceut year. We s.iggesfc that “ B. G.” 
BhouUl prep ire an acoo lilt of his earuiugs and expenses, eithor 
as at' December 3lst, 1935, or the expiritiou of twelve months 
from the date as from w’.rdi he coniie.ioel iu.lepoudeut prac- 
- tice, aul use it to oomp ite the liability (Ij for the poriol from' 
the latter dite to April 5th, 1923, an 1 (2; by agreem ent with tho ' 
authorities, for the year te April 5tb, 1929. It would seem that* 
“B. G.” cinnot usefully deal with the matter until the end of 
. this year, and he -will then probably find it most coni'enient to 
write to the local inspseto.* of taxes, enclosing a copy of his 
Gtatemeiit of account, and asking for .the forms of declaration* 
We gather that our correspoudeut did not purchase aud take 
over an existing practice. 

Succesdon in a Practice. 

“ M.B., B.C H.” has recently purchased a practice which lias since 
“decreased considerably.” He asks if lie must pay tax on the 
basis of his predecessor’s earnings? 

♦ * Tha Income Tax Acts provide that iu such a case the 
amoaub of tha gross asse.snient sho.iU be uuaffectad by tbo 
change in proprietorship, bat entitles tha successor to claim — 
■under Hale 11, Oases i aud ii, Schedule D— for an adjustment at 
the end of tha year if the profits have fallen short from some 
specific cause. Apparently our correspouleat will be able to 
inVoke the assistance of that proviso, aud- ha may find it con- 
veuient to make up his first account to April 5tli, 1928, for that 
parpose. The local iuspcctcr miy ba technically correct iu 
Baying that tax should be paid bn the existing assessment and 
nny relief obtained by rexiayment, b.it we have usually found 
that where a prlma facie case for application of Hule 11 is made 


' The Use of Abbreviations. 

DiL Charles Jl. Box (fjondon, W.) writes: The annotation oii 
“ T 3 'po"r.apliicaI Usage ” in 3 ’oiir issue of March .17th leads me 
(o iisk.^why are the letters T.B, {=Tiibercle Bacillns?) so oUen 
printed ns an abbreviation for the word Tuberculosis? If au 
abbreviation mu-H he used surely Tb. is more correct. . - j 

* ♦ This matter has already been dealt with iu the Journal, 
thoiigh we cannot at the moment recall where. The usage lias 
prob U)Iy come about through contributors sending to the press 
their rough ca>e notes, instead of writing them out in printable 
form ftiiif also through the tendency of physiologists and others 
to'“*lapso into presenting tlieir readers with ‘protocols’ o 
MDCriinprits rblatefl ii) Inlioraton- slanf,'.” I'l our opinion it ii 
iiot correct, it is not evaa safe, to ii3e oitlisr of tlie obbreviiitions 
referioillo for we liave known these letters to Bland not oiilj 

■ for >' Inbe'role baolllns ” an.l " tuberculosis,” but nlso foi 

• 1. lob.rcniin ” We remember an instance of a oontribnt jr bolus 

;i caUea to a conanem3ut(t.b.).” No, it was not the birth of a 
tiibsrcio baelllns to wliloli iie was oalle.l, nor was the niolbei 
. 1 lin,,.- llie m-anlng ot tlie letters lu tins lostance was 

lb ’»* There are no doubt o'tlibr terras for wliicli t.lns 
t>vln birth. employed (torpefio-boat, for esivmplel, 

■ ^?T"jrmrabt vei ilginriw^ vrere Dncle Esmas telling 

Sll Lb fnlllles in H.ose flays ot rush and burry, lie would rete. 
ffiTar.babyas''T.B.",ov-”T^ . ■ • - . 

Severe An.aphyl.axis. 

. •irfT\T» /Wni '\rorth) writes t In the note on seAer6 

pn. H. OArnWOb Kim fCm^avoi J ^ ,„s 

• nnapbylaiis on ^ follow tlie injection ot almost any me.llui' 

describe.! t'jf’j®. . ygj,, or lympliatio vessel? I persoimlb 

ineiit tiieie symptoms otter one ot a series ol 

„.„Ar cllcefl exactly llie.e .h . nna i 11 l' of . tlio 


r«ii.- over llie lace, neon, no, . 

■ai3appe«®a wUhiii fitteeu of twenty m.untos,. 

GAi.i.-Bi.ADDEn Disease. ‘ ' 

9a; AoAtf Kirby) i:e^«toPro^sor_^ 


cave Butferins P"'‘'''h-.si‘rV of fi^nnent pravimis nttacKs. 

jwuflice., TI.ere wa® “ Kstoiy ^ j 

She bad. been s®®«'>y.";°l°ibeRa11-blaafler .yith besam aej 




t™te M X was excised during an 

Stk stile wttol^ . • . , 

• jIedicae Golf, vnoc^' 

». ""'■•SS 4”i. 'r&S. I- 

• • ■ ■ Vacancies. , •, ..neg#!, 

ssfisssssiiss 




684 APBir, 7 , 1928 ] 


THE^HWoRBHAQfo^DUT^EerSr 


Tim m >!/‘c iViuu&ci- 0 / PZoiricij ■ 

commonl/ho]d\™i7brs\atcTrLlor“'^^ 


aro 


?^.£E=£?S“”*“™:;-3s; 

il» noS S'phw/i.'r”'"? <’"!■’"* I“™t,hagto 

„, piSi..‘»4^ri‘v”si;r„ '■ 


dency to bleed, below 10 nnn n’. 1 , ' i'^ abnormal Icn- 

and below 1,000 fulminnnf°° ® baetnorrbages arc severe. 


V- -'•v.-.M, MUILUV lU.UI 

and below 1,000 fulminant. 

These points will now bo considered. 

e.dhero to cajiilfary^^dcVect’s ”e'*t ^bat plalcict.s 

rbages could not exist Kr7nv ,mm^? 
tial reduction in platelets Cws 

rbagica often have lonir nree'edi^r ”^i baoraor- 

'vbieh are of the saiM typo^ ^''of lef 
ebservations now show tint i ^ ^ ® seventy, and 

stages to intennedi-ite and I ‘ 'educed in these 

dividing hne 7ti or nl 'I’bcro is no 

separates the ’state of inirn'7o°\ whicli 

iniidor preceding stages. ^ " ’’”“'’‘°*'‘'bagica from the 

and grades of pnrnnrr lmln , f°>-ms 

numerous. Tliis^ also annlie's ? ^'^araturo aro 

jnirpura. Patients in ihL symptomatic 

f''om some serious disease and”b ahrnys suffering 
tl-nugh the amount of lnaemorri,Li'T/:m"’‘^'’r 7 
circumstances a veiw sick nn+.^ slight; in such 

exhibit little change^-n tl P-rpiIra may- 

shown to apply to^LanhvhctnW "I®® bo 

can he summed up by saying that evidenco 

tion in numbors «‘heh capiJla®rv l 7mn ® t""' '** 

to any considerable e.vtent, ir7ospectiv‘e t?®tbe 

Jd after 

rednetidn of pbateJets fnd thf S7easro7b 
it IS impossible to say whicli comes S '’7^'?®'“'’'’^^'''’®? ’ 
occurrence of baemorrbao-<.» i. , 1 ,® . 1 " .V bowever, tlio , 

the converse should be true n m®! platelets, 

haemorrhages is preceded that the cessation of 

?f Poerste^s sho7s th7 tlnj n^s®' ^ 

m a state of severe purpura w.Th T*'® P‘'‘*‘0«t was 
platelets. The haemorriiane/77. ! ^‘”^P>ote absence of 
'-•as not until three days W that 
a rise in numbers. CJearlv tlm 7c 7 pJatelets showed 
ihages preceded the risrof^.^eieS ‘®" 

4. This contention was nri'n-moii 1 . 
that platelets are reduced in piS-, ‘p on the belief 
not in other forms of purpura TIu'c ^ “^“ntriagick and 
be -incorrect, but it dois not noZtl ib! P-'cved to. 
purpura of any grade is due to ?eduction 
With regard to the relationship of nhtlZ i® Platelets, 
haemorrhages, the following pointe inn7be7otcd:®“^’“'®'^ 

the icem-renee ™f*haemo7lm7s™’Th *f h®'‘'?*“tion ■""'thont 
I" . -^-...bave bad 


■ • ' 'H/ 

(.Azsiax, JotSSlS 


factors. Wl7„ anlcmia andT. 

is no reason for the splee7to7 T® ®^''®”cc(l ticro 

such circumstances it ir„r. r n®"'“‘'®®'’' »> ia 

marrow i,s 7rod.7fn7 ®‘'’^7 ”u'®^ 


« , jP-irnocE.VBsis. 

J'oiir structures or tissues must he considered in flm 
pa hogoncsis of capillary haemorrhages ; (1) the plafelels- 
(2) tho spleen, which destroys effete platelets- 15) ilm 

thrcanilhHe ‘ Pjatelets; ‘(4) the endothelii of 

nceni i l ’ ** ''“"S.'' "'.b'ch tlio haemorrhages acimlly 
tl7 7i:7l ’ "? if r“'" circumstances, other porlions of 
t he reticulo-endothelnim. The marrow and spleen app.r- 

meiliunTofThi ^troLts:®. ®®“®"''®«''® ^'®*® 

/i77® *'*cc'-ies are the folioiring. 

fbat purpura haemorrliagica is an entitv 
^ c-istmct from all other purpuras, and is duo to .in essential 
^ "****^^'“^^^/**^ cau&ed by lack of forniatiDij by fiie manw. 
(2) Kaznelson attributes the primary- disturbance to over- 
activity of the spleen, which destroy-s" excessive numbers of 
platelets. ■ 

Both these theories arc based on tho belief that a 
reduction in the number of platelets is the essential cause 
of pnri'ma haemorrhagica. • This has been shown to ho 
impossible, and liencc some other factor must exist. As 
the S))!ccn and innrrow can only- act through the platelets, 
tliey- cannot constitute the essential "cause. An increased 
I pormcahitity from some defect of the capillaries romauis 
as tho only possible primary factor. 

• It is suggested here that so long ns the capillary oiido- 
thelinm is normal or intact blood will not escape even in 
tho absence of platelets, hut in the event of any defect. of 
abnormal permeability, then the. number of available plate- 
lets and the maintenance of the supply will become decid- 
ing factors in tlio occurrence and extent of the liacmot- 
rbages, tiie function of the platelets being to adhere ii 
masses to abnormal intima, Bedson's researches gin 
c.vperimcntal snjiport to this view. Ho was able ti 
separate two factors necessary to produce purpura ir 
normal animals: (a) an injury to the endothelium wliicl 
he caused by injections of an appropriate serum, and (t) 
a reduction of platelets which he produced by injections of 
agar-serum. Neither of these alone produced haemor- 
rhages. ffhe known phenomena of 'the primary purpuras, 
both clinical and haematological, are explicable on this 
view. 

Con.sidcr what will occur to an individual in whom the 
capillary endothelium develops local . sites of increased 
permeability. At first the platelets circulating in norma! 
number defend the weak spots and check the haemorrhages 
and the associated tendency to an increase in the bleeding 
time. Adhesion in masses to the threatened spots leads 
to a fail in numbers, until the platelets aro no longer able 
efficiently to protect all the weak areas. Haemorrhages 
will then commence and the bleeding time increases. Is 
the platelets fall a" vicious circle is est.-iblished, and t]ie 
haemorrhages and bleeding time will progressively inercaso 
more and more rapidly. The marrow, by responding io 
the increased demands, may establish an equilibrium at 

7>A4>1t.n rxf 4-l,« A ,1-, 


grades of purpura, both with Tnd 
(n) An attack of purpura haemorrhagica 
taneously while platelets are still absentT ^ ®P™- 

(iii) Both Bedson and Roskam bavo • 

daced the platelets to very low figures ^vitlwuTTh‘‘^^^ 
rence of haemorrJiages. ° ' i«ont the oc 

Therefore tho absence of platelets cannot 1,0 ti 
factor leading to capillary^ haemorrhages and 7m®f 
primary cause must be present ® ® ®“ 

isfncori^i®*"'^®"®® S'''"®" i^at this statement 


re- 
occur- 


medium stages. Return of the capillaries towards nornisl 
I at any period will abate the haemorrhagic state aad 
diminish the demands on the platelets; the bleeding time 
will diminish with this change in the capillaries even 
before tho platelets have appreciably- increased. II"’ 
recovery of the capillaries may be rapid (as occurs m 
urticaria) or slow, and may he partial. Platelets in rar}- 
ing numbers will still be required and consumed in ih 
protection. 

• UllTlCAIlIAP PunrUKA. 

Urticarial or anaphylactoid purpura includes the forms 
known as Henoch’s and Schonlein’s purpura. There 's 
extensive clinical evidence of tho close relationship betrreen 



A-PRIt* 7. 1928] 


THE HAEMORBHA.Gia DIATHESIS. 


Ittctau. SonstiM 


rticarial pmpvwa, Iwcmovrliagic purpura and urticaria, 
(star puWisbed a .carefuf study. In urticarial purpura 
wellings occur in which there is no haemorrhagic factor, 
,nd there are also two varieties of superficial haemor- 
hages: (a) purpuric spots, scanty in tho early stages; 
h) areas of ecehymoses into the swellings. Appearances 
imilar to the latter can be produced in haemorrhagic 
lurpura hy the subcutaneous injection of saline. The 
laemorrhagcs in this test are produced by distension 
;ausing infury to capillaries of reduced efficiency, and thus 
iiffer from true purpuric spots. 

A patient with Henoch’s syndrome is sick at the onset, 
lot from the purpura, but from the urticaria, He is more 
lick than purpuric, and there may be little fall in the 
ilatelets. A slight increase in tho capillary defect leads 
:o the same position as in haemorrhagic purpura, and the 
lase is often said to have changed from Henoch’s purpura 
;o thrombopeiiia and purpura haemorrhagica. 

Splenectomy should he considered in this group as in 
ithcr forms of primaiy purpura, and it is unjustifiable to 
iay that operation is contraindicated. 


SpnENECTOllT. , 

The results of this operation are extraordinarily good, 
except in the acute cases, which would probably die in tho 
absence of operation. In many of the clironic cases there is 
an immediate cessation of the haemorrhages and a rapid 
rise in'the number of platelets. A similar rise in pl.atelets 
occurs after splenectomy for other causes and when jier- 
formed experimentally in animals. There is also a rise, 
though of a greater extent, in the number of leucocytes, 
and within twenty-four hours the numher of polynuclear 
cells alone may exceed 30,000 per c.mni. Such a rise cannot 
bo ascribed to the absence of the destructive action of the 
spleen, and tbo immediate rise both of leucocytes and of 
platelets must be due to flooding of the blood with reserves 
from the marrow. Tlie immediate cessation of the haemor- 
rhages is due to this large numher of platelets being suffi- 
cient to protect the sites of capillary defect. This obvious 
S-xplanation is supported hy Bedsou’s experiments. 

ibis is the. most favourable, hut not invariable, course 
splenectomy. The results may he summarized in 
the foUorving five groups; ' 

, I- Platelets rise high and then fall to about a normal 
level. H.aemorrhages cease, and do not return. 

8. Platelets rise, but subsequently fall to a very low' 
level. .Haemorrhages cease, and do not return. 

3. Platelets rise and fall as above, but haemorrhages 
return in. varying degrees. 

4. Platelets fail to rise to any great extent, but haemor- 
rhages cease. ’ 

5. Platelets fail to rise, and haemorrhages continue. 

These different courses depend on variations in the 
lotlowing factors: 

(i) The degree of capillary defect, and its transient or 
permanent nature. 

(ii) Condition of the marrow. 

liii) Alteration in the platelet circulation due to the 
absence of the spleen. 


Il ith regard to tho last,. it mav he accepted that iu the 
absence of the spleen the tissues which undertake its 
lunctions work at a lower standard. This is undoubtedly 
what occurs m acholuric jaundico. Eewer platelets will 
thus bo destroyed by the marrow and a larger number avail- 
able for the protection of the capillaries. This is a 
permanent gain. 

Tho capillary defect may pass during the period of high 
protection after splenectomy, oi- it may only pass partially 
and still require protection bj- platelets, resulting in the 
Eubsequent fall. The platelets may or may not be sufficient 
0 picvcut the haemorrhages, thus accounting for the 
second and third courses. 


The marrow may bo already denuded of reseiwes, and 
icnce the initial rise will not occur, or only partially, 
ourscs 4 .and 5 will follow in these circumstances, depend- 
ing on the recovery of tho capillary defect and the platelets 


Tlio various courses which follow splenectomy can thus 
he followed on the theory that the primary defect lies in 
the capillaries. 

TltEATJIENl. 

splenectomy. 

In view of the successful results following splenectomy 
the essential question in treatment is when the operation 
should or should not be advised. 

1. Acute Oases. — ^The mortality here is very high, but a 
study of the cases in conjunction with our knowledge of 
their, normal course suggests that the fatal cases would 
lirobably have died without the operation. 

2. Chronic Cases. — It is here that the results have been so 
good, and the only questions arising are as follows: 

(i) Is the condition such that in the absence of operation 
lifo can continue without serious impediment or risk.!’ 
A certain numher of cases obviously fall into this category. 
The decision is often easy, but in doubtful cases many 
IJoints have to he taken into consideration— that is, the 
c.xtcnt of the haemorrhagos, their duration, and any 
evidence of increasing severity, the degree of anaemia, and 
ovidouce of strain on the marrow', as shown by leucopenia. 

(ii) AVith regard to the remainder, for what reasons 
should operation not he advised? 

(a) As regards direct operative risks, this depends on the 
usual risk of any major operation, ' hut especialh' on tho 
degree of anaemia and the risks of heart failure or 
thrombosis. These risks possibly may he diminished with 
greater e.xperience with the operation. The rapid rise in 
platelets may dispose to thrombosis. 

(b) AViiat cases will do badly if they survive? This will 
dex>end on (1) excessive permeability of the endothelium, 
and (2) aplasia of the marrow. ATitli regard to the perme- 
ability, the extent of the haemorrhages is little guide, as 
many extreme grades do well. The duration of the bleed- 
ing time may prove to be a better guide, hut at present 
observations have not been very accurate; possibly up to 
thirty minutes is consistent with a good outlook. AA’ith 
regard to aplasia, the number neither of platelets nor of 
I'ed cells is a guide. Observations suggest that if the tot.al 
number of polymorphs is definitely below normal a good 
result cannot be anticipated, but even in these cii'cum- 
stancos there is no evidence that splenectomy makes tho 
patient worse. 

3. Urticarial Purpura. — The patient here is sick 
primarily because he is urticarial, and not because ho 
is haemorrhagic; yet it may he suggested that the exist- 
ence of purpura or bleeding of more than a trivial degree 
is an indication for splenectomy, whatever ho the number 
of platelets. 

Transfusion. 

Transfusion, may completely abort an attack, but usually 
the improvement is only temporary. Unfortunately suit- 
able donors must be chosen with special care for purpuric 
subjects. 

Plochade of thc Rctieulo-Endothclial System. 

It is generally accepted that the immediate effects, of 
splenectomy are due to the flooding of the circulation W'ith 
platelets, whatever may he the origin of this occurrence. 
The question arises whether this effect can he produced by 
any less dangerous methods than an operation. . Bedson 
found that a certain definite rise in platelets followed 
splenectomy. He found also that an equal rise followed 
injections of Indian ink, designed to block the reticulo- 
endothelial .cells. Tho evidence points to tho rise in plate- 
lets being identical with that which follows splenectomy, 
for if this operation is performed immediately after the 
blockade has raised the platelets no further increase occurs. 
It is reasonable to suppose that these injections will pro- 
duce a similar rise in human beings and a similar effect, 
at least temporarily, to that of splenectomy. 

Conclusions. 

1. Increased permeability or defect of the capillniy- endo- 
thelium is the essential cause of the haemorrhages' in tho 
haemorrhagic diathesis. 

2. Alterations in the number of platelets are sccondarv 
to the capillai'y haemorrhages. 

3. The haemorrhagic purpuras form a single group, and 


686 ApriIi 7, 1928] 


THROMBO-PHriEBITIS MIGRANS. 


arc only separated from urticarial (nnajjliylactoid) jiuiiiura 
and urticaria by tlio degree of the capillary defect. ' 

4. Splenectomj' sliould liavo a permanent beneficial effect, 
tbougb protection from capillary baemorrbages may not bo 
complete. 

The term “ angio-staxis ” is suggested for the condition. 


THEOMBO-PHLEBITIS MIGEANS. 

BY 

T. GILLMAN MOOUHEAD, M.D., F.R.C.P.I., 

REGIOS PnOYKSSOR OF PJIYSIC, DUBBIN UHIVEP.SITY; 

AND 

LEONARD ABRAHAMSON, M.D., F.R.C.P.I., 

HONOnABY VISITING PHYSICIAN, MEKCEBs’ HOSPITAL; PROFESSOR 
OP PIIARSIACOLOGY, ROYAL COLLEGE OF SURGEONS IN IRELAND. 


Phlebitis of widespread distribution, recurrent and migra- 
tory, has been described from time to time. In most of 
the descriptions we find an association iritb various 
suggested etiological factors. As far back as the time of 
Paget, Lancereanx, and Hewitt wo find rciiorts of a 
numbor of cases in wbicb gout ivas invoked ns tlio exciting 
cause, though often with but scant justification. 
Daguillon' described a series of cases of migratory phlebitis 
in 1894, and regarded the condition as an indication of 
" an arthritic constitution, witli or without actual gout.” 
In a case publislied by Ncisser- in 1903 tlioro was a cloaf- 
ent history of syphilis, whilst in two cases recorded 
by Schwartz’ in 1905 there was advanced pulmonary tuber- 
culosis. In other cases of more or loss widespread phlebitis 
we find an association with various conditions, such as 
rheumatic fever, trauma, and a number of toxic and 
cacliectic illnesses. 

The first description of a type of recurrent phlebitis in 
which no causal factor could bo adduced, and which 
])ossessed individual and constant symptomatic features, 
was made in 1905 by Bi-iggs,‘ who thought that the causo 
was possibly to bo found in a sclerosis of veins analogons 
anatomically with arterio-eapillary fibrosis. 

Tho tj^ie of plilebitis wliich ive are about to describe, 
and of which ive have seen four cases, differs from th.Tt 
of Briggs and other writer.s in tliat in eacli patient there 
was definite evidence of involvement of visceral veins as 
well as of peripheral veins. Tlieso cases had so many 
unusual features in common that we ivere led to tho con- 
clusion tliat we were dealing with a rare type of jihicbitis 
siii generis, to wliicli ive could find hut little reference in 
the English literature. 


Case Ilistories. 

Case i. 

A lady, aged 55, suffered from an illness diagnosed as pleurisy 
in September, 1926. Early in October she was bitten by a 
mosquito on tlie left band, but no local septic symptoms 
developed. A week later she got extensive thrombosis of the left 
cephalic vein. In another week the veins of the riglit arm 
became involved, and ten days later there was extensive dry 
pleurisy, involving mainly the right lung, but also the base of 
the left. Throughout there was mild pyrexia. This cleared up 
slowly, and the patient was progressing favourably when, three 
weeks later, there was an attack of violent abdominal pain, with 
collapse and accompanied by severe malaena. The patient at this 
timo was extremely ill, and mesenteric thrombosis was diagnosed. 
Recovery took place, and everything seemed well, when, after an 
interval of a month, the left saphenous vein became thrombosed. 
Subsequently the right saphenous vein was also involved. Finally, 
a branch of the facial vein became affected, and was followed by 
some ulceration of the mouth, this event occurring about six 
months after tho beginning of the illness. Each attack of 
phlebitis was accompanied by fever, but in the intervals the 
patient was fairly well. .Apart from the facts above stated nothing 
abnormal was found. A blood culture was sterile; tho heart) 
kidneys, and other organs were normal. Various treatments were 
employed, including peptone injections and a vaccine made from 
streptococci isolated from the teeth. It was not apparent that 
any treatment had any special effect on the course of the disease, 
apart from relieving symptoms. Since the involvement of the 
facial^ vein the patient had made slow but satisfactory' progress, 
and is now, twelve months later, except for some persistent 
oedema of the legs, practically well. 


r Tax RnrasM 
' WrDiCAj. Jontxix. 


of T«W ^ last twenty ycarSy suffered towards the 

192/, from a mild pyrexia! attack. This was accom- 
of P'’’”- ™e possibility 

cleared on i i" ‘'■®='‘,ssed, but in a couple of days the attack 
tim later the patient went on a holiday. On 

cveni^^ “j- 11”® I'al'day lie walked about tlirco miles, and that 
wnTsvtnf Ins right leg. Two days latir tho leg 

^ obvious phlebitis of a superficial vein 

abov^^^norLl f^o'rS';”’'" 

After three weeks’ rest the patient returned home, and after 
resumed work. Soon after, tho right 
jCo, v.hicli had returned to normal, again became swollen and 
tender, appaiently due to thrombosis of the deeper veins. A week 

i?f 1 *' small vem in tho left calf became thrombosed. This 
settled down in a fortnight, and tho p.aticnt was apparently 
going on well when pain in the left side of the thora.x developed, 
and a pleural rub^ at the base of the left lung was detected. 
Inis was accompanied by a smart fever and haemoptysis, and as 
tlio spiituni was found to contain pneumococci in pure culture 
a* diagnosis of mild pneumonia was made. After five days tho 
attack cleared up, -but haemorrhagic sputum continued for about 
a fortnight. 

The next event was an attack of abdominal pain with flatulence, 
fojlowod by thrombosis of the right saplienous vein, and again 
mild pyrexia. This attack subsided, and the patient was sent 
to a nui-sing home for 'full examination. A complete ar-ray 
cxaniination revealed nothing abnoimal, a blood culture was 
sterile, and tho Wassermann reaction negative, ilild anaemia, 
but nothing else, was found on full examination of the blood.' The 
urine was sterile, and contained nothing-abnormal, and a complete 
examination of the faeces showed nothing wrong. 

Just as tins examination was complete, pain was again expe- 
rienced over the . left lung, and another attack of apparent 
pneumonia developed, again accompanied by some haemoptysis. 
Fivo days after tho subsidence of this attack there was a severe 
bout of anginal "pain, believed at the time to bo duo to 
thrombosis .of a cardiac vein. This was accompanied by a veiy 
rapid fibrillating pulse. When this attack had subsided the 
patient again returned home, and tho day afterwards liad j 
further pneumonic attack, in which tho base of the right lune 
was involved. 

Tlio last event in this long illness w'as an. attack of violcnj 
abdominal pain, so violent as to produce complete collapse. Tlih 
came on in tho evening and lasted several hours, and altliougl: 
no malaena followed, it was diagnosed as an attack of inescntcrK 
thrombosis, owing to its resemblance io a similar attack seen ia 
Case I, in which* malaena W’as a prominent symptom. 

During tho whole of the illness, which lasted about six^niontlis, 
and - which included eleven thrombotic episodes, _ the patient was 
depi'csscd and felt ill, and suffered froin lassitude. He looked 
anaemic, and there was marked loss of weight. A week after the 
abdominal attack his spirits began to improve, and his tongue, 
which Jmd been furred all through, became’ normal. From this 
timo on ho made slow but satisfactory recovery. 

Case hi. 

Tliis palicnl, a woman, aged 50, had enjoyed robust health until 
the month of June, 1924, w'hen she developed phlebitis in the 
re-’^ion of tlic left foot, with i*esuUant pcain, tenderness, a«d 
swelling. - This attack -was the precursor of many similar attacks, 
Wiiich came on at varying intervals and affected the veins of the 
left leg, left thigh, and later those of the right ankle and leg. 
With each attack there was mild pyrexia. _ In addition to involve- 
ment of superficial veins tliere was implication of deeper veins 
with marked oedema. Tho patient spent five weeks in bed, and 
for nine mouths rested for most of the day^ on a couch. - 

In April, 1925, phlebitis attacked the .veins of the right liacu, 
whicli became painful and tender. Shoi*tly aftervrards the jett 
hand became affected. On September 30th, 1925, the patient 
was* admitted to hospital for investigation. The ankles were 
oedematous, and the ^in of the legs was thick and discolouvca, 
diowini? the appearance seen frequently after a severe attack or 
nhlcbitis. Over the inner aspect of the thigh a number of 
nodules could be felt, with a distribution corresponding to tno 
coui*so of the large saphenous vein. Blood culture w’as negatne. 
Thpre was severe pyon'hoea, and culture from the gums yicidca 
a pure growth of Streptococcus viridans. Teeth extraction wa 
ndvised *and a vaccine prepared from the gums. 

Iroprovcmont continued until December, 1925, when the 
/ipveloned symptoms and signs similar to those of . a nu 
pneumonic attack. This was accompanied by haemoptysis ai 
Ev moderate pyrexia, and necessitated a month s stay m b • 
siiortly afterwards phlebitis developed in a vein of the 
This was followed by a further remission, which lasted 
month of June, when some pain, fcnderiiess, and sivc , 
developed in tho flexure of the right knee. No further at 

^*Duriii" hei* i'llnoss the patient experienced considerable 
loss of appetite, and general deterioration of 
As residua of tlic recurrent attacks there is a 
developmeul, after exertion of swelling 
on tiio left side, and to stiffness of and paiu in botli lOgS, 
even moderate exercise. 

Case rv. . 

a' nurse, aged about 22, got a superficial burn on 
ankle in February, 1922. Tliree months later there ""yrejin, 
thrombosis of the superficial veins of the left le , ^ 

mr.ic? tin hiif. wfis folloTOed two months latei b\ 


-APEIIi 7, 1928] 


r Tire BRmsH 

5ISDIC.lL JOU&XAL 


687 


HISTORY OF A TYPHOID OUTBREAK; IN PRETORIA. 


of practically every superficial vein of (lie riglil leg. A soclioii of 
a vein was removed for exaiiiiiiation and showed a firmly 
adhei-ent clot, with slight thickening of the vein wall. Cultures 
mado from ttio vein wei-e sterile. An absolutely complete 
cxamiiiatioii at this time failed to reveal any cause for the 
trouble. Further events in this ease were thromhosis of a super- 
ficial i-cin ill the ahdoniinal wall, and of one or two other super- 
ficial vciu-s of the trunk at intervals of two or three months, each 
attack being accompanied by a general febrile reaction. Finally, 
a vear after the beginning of the illnes.s, the right popliteal vein 
became aftcclcd. In this case no involvement of visceral veins 
took place; but recovery was very tcdioirs, and the patient was 
onlv able to resume work about two ycais after the beginning 
of iier illness. Various trcatmcni.s, including collosol manganese 
and peptone, were employed, but do not require detailed comment. 


THE IIISTOEY OE AN OUTBEEAK ,UE TYPHOID 
FEYEE IN PEETOEIA: 

AVnii SpKCiAii Reference to the Detection of . 
Typhoid Carriers. 

BT 

ADRIANUS PURER, M.D., 

PATHOLOGIST TO THE PULTOHIA HOSPITAL (AT THE TIME ACTING M.O.H. OF 
THE MUKICTPALITV OF PEETORIA), 

AND 

B. DAVIDIiVE PULLINGER, M.B., B.S. 


It will bo soon Unit the main foalurc of tlioso cases is the 
tendency to motastatic extension, often at Ion" intoiwals. 
The tvonblo c-ommonccs in a segment of a perifilieral vein, 
which bcionics painful and tondcr. Redness and swelling 
ensue, and there is slight or mndernte jiyrexia. Soon the 
symptoms begin to subside, only to ivappear in some 
portion of the same vein or of a distant vein. All four 
limbs may be involved, and with each lecurreuce of 
phlebitis there is a recurrence of pyrexia. 

In association with the tendcnc}’ to extension we note 
imidication of visceral veins. Thus the pulmonary involve- 
ment with haemoptysis, noted in three of our eases, was 
referred hy us to a ]irocoss in pulmonary veins similar to 
that met with in the peripheral veins. Ihnholism was 
negatived by the definite absence of characteristic symptoms 
associated with this condition. In this connexion wo would 
like to stress the conspicuous absence of embolic symptoms 
in our cases, though the patients were not confined to bed 
throughout their illness, and must therefore nt one time 
or another have been in a condition most favourable to the 
production of embolus. In two of our cases synii>toni,s of 
mesenteric thrombosis were encountered, and in one patient 
symjitoins occurred which suggested involvement ot a 
coronary vein. This implication of a coronary vein 
is unique so far as the literature is ooneoniod. tliough it 
seems likely that the paroxysm of tachycardia ni a case 
described by'Legrand® was duo to tin’s cause. 

The etiology' of the condition is ohsenro, though the local 
signs of inflammation and the method of. spread suggest 
forcibly the presence of a blood infection, Tliis view is 
strongly advocated by Vaquez and Leconte,® and later hv 
Legrand,' in connexion ,witli a scries of analogous cases 
described by them under the title subacute venous 
septicaemia.” Legrand quotes two cases ill which the 
stioptocoeeus was isolated from the blood stream. In our 
cases blond culture was uniformly negative, but was not 
lepeated with sufficient frequency to permit definite coii- 
clusions. In one case severe pyorrhoea was iireseat. Apart 
^ V? focus was found in any of our patients. 

Tile disease follows a prolonged course with alternations 
or remissions, more or less complete, and of subacute reciir- 
lences. TJie nltimato prognosis seems to be favourable, 
though functional disahilit}' may persist. It is interesting, 
rlimigh perhaps inapi>osite, to draw, .attention to cases 
quoted by Bnorg^r* in which recurrent phlebitis of super- 
hciar veins was the precursor of tlirombo-angiitis obliterans, 
in! i\ encountered by us, and it is 

'.Tt' , .*Y Buerger s cases did not belong to the grouj) 
n itli which we are dealing, “ 


Tun history of this - outbreak is of interest in that it 
illustrates the nccossitj- of empowering medical oflSters 
of health to exercise a closer supervision of dairies than 
has been the case hitherto, especially so far as the native 
element in such places is concerned. It also shows the 
superiority of the complement-fixation test over the agglu- 
tination test of Widal for tracing the conr.se of an outbreak 
and discovering carriers. 

The total number of cases in this outbreak was twenty- 
eight, incliuling seven among natives. Only one patient 
died, a European female child, one of the first to be 
infected. This low mortality is probably duo partly to 
the proinjit recognition of the disease in the later cases, 
when medical practitioners and the public were aware of 
the probability that slight illness in a famih- supplied 
by the incriminated daily would probably turn out to he 
typhoid fever. The typhoid case mortality in Pretoria is 
ordinarily about 7.5 per cent. 

The first patient was a European hoy. The usual 
inquiries were made as to the supply of milk and food 
to the household, hut since nothing suspicious was found, 
and it was said that the chihl drank very little unboiled 
milk, no further stops wore taken. Quite a dilTereiit light 
was thrown on the matter, however, when, two days after 
this child had been notified (complement-fixation test 
positive, Widal test po.sitive, typhoid bacilli recovered from 
blood), the daughter of the proprietress of the dairy which 
supplied this household, who had been ailing for some time, 
was .subjected to a typhoid comjilement-fixation test, and 
her reaction was found to he positive. This patient was 
removed to hospital as soon as the diagnosis was estab- 
lished, and on the same day "blood specimens were taken 
from the eleven natives employed at the dairy, who 
were all. “healthy” and at work. The result was sur- 
prising, for seven of them reacted iiositively to the 
ty[>hoid complement-fixation test. Of these seven, five were 
strongly positive, one just positive, and one weakly positive. 
Widal tests were performed at the same time, but onlv two 
positive reactions were obtained: the serum of one hov, 
which was definitely imsitive with the complemcnt^fixation 
lest, agglutinated only in serum dilutions up to 1 in 20, 
while the serum of the boy whose complement-fixation 
reaction was just positive only reached 1 in 40. 

This largo number of positive findings mado the position 
very difficult. From past experience we know that carriers 
as a rule give a positive complement-fixation reaction, hut 
we also know that this test remains jiositive for a varving 
period after convalescence. It scorned absurd to assume 


. Summarij. 

+: phlebitis of extensive distribu- 

ebaraeter, showing involvement of 
lionimiitv prolonged course, and relative 

iirotn..! ‘ . ■i'^ throw no light on the etiologj', but 

lc-o-.v.l the hope that it will stiimilato 

‘^'“culate the cause of this imiisiial but 
kientific'gas^“ " ' ’ tbcraiieutic efforts on a 

1 r» ReTEREXCES. 

^ cUn. lie la Phlebitc Prim., T/itVr tie Paris, 

. lYm ■■ 51'Srans. Arc!,, f. Path. cI.-!.-raii, 1905, 

I'lJ'gragd A,e;°c!tY 

•Itucrccr: The Circutatonj UMmlauccs of the Eztrc::,itic;. 1924, p. 279. 


that seven out of eleven natives einplovecl at one dairy 
were eavricFs. A nuicli more probable explanation of the 
.situation was that there had been a local epidemic at the 
dairy among the native servants, and that wo wore con- 
cerned with the tail-end of this epidemic. Interrogation of 
the proprietress and the natives at fir.st seemed to elicit 
facts which supported this view^ There was a vague history 
of several of the natives haring heen down with ” malaria ” 
off and on during the previous weeks, and Iiaving been 
dosed with quinine for that reason ; and there was also a 
tale of a young native. who had been engaged two or three 
months before this trouble started, but who had never done 
any work and had been either malingering or ill most of the 
time. This rather imaginary young native had how dis- 
appeared, and all our attempts to trace him proved in vain. 
31oreovcr, the more we pressed for further details about the 
illuesse;> of the natives in the past weeks the more vague, 
coiifusod, and unreliable the information became. There 



688 April 7, 1928] 


HISXOKY OF A TYPHOID OHTBBEAK IN PEBTORIA. 


t inB /iBmra 
MEDICII. JOQRBIL 


evidently existed a marked roluctaiico to assist us in clearing 
up tho position. 

Wo therefore put our own construction on tho matter and 
dealt with it in tho following way. All tho native.s except 
Olio were rciiiovctl to tho isolation ho.spital on the same 
day on which their blood tests had been poi'formcd, on tho 
strongtii of a ningistrato’s order procured for tho pur2ioso. 
Tho ono native left behind gave a negative test, and had 
. been employed at tho dairy for sixteen years. It was 
assumed that when a native has worked at a dairy in town 
for that period, and is exposed to tj-jihoid infection without 
harm, ho is either natui'ally immune or has bcconio so by 
having had tho disoaso. That ho was tho carrier I'espon- 
sible for tho whole outbreak was highly impi'obablo for the 
samo reason, and also because he gave a negative comple- 
ment-fixation reaction. Moreover, as this boy had been 
in tho dairy’s omjiloy for so many years, he would be very 
valuable to his emi)loyer, who was considerably disconcerted 
by tho removal of all the other natives, and u’ho naturally’ 
experienced great difficulty in carrying on her business. 
Still, this was better than closing the dairy altogether. 

The rather drastic measure of removing all tho natives 
was, iir our opinion, warranted on tho grounds that there 
evidently had been, or was at inesent, an outbreak of 
tyiihoid fever amongst tho native employees, and that at 
any r-ato those who I'eacted positively had something to 
do with the outbreak; that there might very well be a 
carrier amongst them; and that, further, those four boys 
who gave a negative reaction might have bMomo infected 
quite recently, so that removal of only tho obvious cases 
would not have the desired effect of stamping out tho 
infection. Taking away obviously infected natives and 
leaving behind a few possibly or even prob.ably infected 
ones would have been a half-measure that might easily 
have undone whatever u-ould have been achieved by the 
steps taken. It was also found that the native quarters 
at tho dairy wore not in good condition, and that when 
onoe infection had started there probably every native would 
fall a victim to it. 1 

That the measure of removing all tho natives was not 
too drastic became evident three da3-s later, when two of 
the natives developed manifest typhoid fever at tho i.sola- 
tioh hospital. These were tho two boys who had given 
a weakly positive and a just positive complement-fixation 
reaction. 

Tho other measures taken to prevent the further spread 
were : disinfection of tho dairy premises and the sending 
of a written warning to all tho customers of tho dairy to boil 
their milk. Naturally this last jneasuro was not, strictly 
speaking, necessary. If tho source of infection had been 
remov'ed, as we believed it had, there was no need to boil 
tho milk; it was thought, however, that with such a lai'ge 
number of infected natives at the daily some infectious 
material might still persist, notwithstanding thorough dis- 
infection of the premises, and that therefore tho boiling 
of tbo milk might help to destroy any source of infection 
that remained; 

It may be stated at onoe that the measures taken were 
quite successful, though the mischief had been dono before 
they were put into force. During tho ensuing fortnight 
an unusuallj' large number of tj-jihoid notifications reached 
the health office at Pretoria. These cases were investi- 
gated with particular care. With very few exceptions 
(and these were chiefly persons from outside the town) 
all tho cases could be traced to tho consumption of milk 
from the incriminated dairy. In all cases except one the 
patients were customers of the dairy; in that ono case tho 
patient was in the habit of drinking milk at a teashop 
which was supplied by tho dairy. The large majority of 
patients informed us that they usually drank their milk 
unboiled; in two instances tho only person in a household 
to contract the disease was the one who insisted on taking 
his milk unboiled, whilst the other members preferred it 
in the boiled condition.. Still, considering tbo risks of 
.infection run by the public in those daj-s — as, for instance, 
the man who contracted typhoid through drinking milk 
at a teashop — one is impressed bj’ tho relatively small 
number of persons who contracted the disease. Even if 
allowancG is made for a fairly largo number of ambu- 
latory ” and otherwise undiagnosed cases, the conclusion 


is inevitablo that thoro must exist a pretty iridely spread 
immunity against the disease. 

The removal of tho natives had tho desired effect of 
oxtiiiguishiiig tlio source of infection. A fortnight after 
the natives were removed the notifications came to an 
end. Several weeks later a child in a family supplied by 
tho dairy was found to be ill with typhoid, hut closer 
investigation siiou’’ed that in this faznUy another child hud 
been ailing for many weeks, without tho true cause being 
suspected, and tliat this other child had become ill at tho 
Mine tune as tbo largo crop of victims of the outbreak. 
Tho ^hiiry couhl therefore only bo held indirectly respon- 
sible for tins late case. 

Notwithstanding the fact that only one case terminated 
fatally, tho disease was not of a mild type. Relapses were 
fairly frequent, the disease lasted tho usual timo in most 
cases; and altlioiigb, as always liappens, some cases, were 
very mild, there were also several in which tbo life of the 
patients ivas seriously endangered. A complement-fixation 
test was performed in all cases but one, and was uniformly 
positive. Blood cultures were attempted four times with 
a pure growth in each case. In addition, Widal tests ivero 
lierformed on four patients and were positive in oiilj* two. 

To return to tbo natives who had- caused the outbreak. 
It has already been stated that two of them showed manifest 
sj’injitonis of tjqiboid infection throe days after they wero 
removed from the dairy ; their disease ran a normal course. 
Of tho other eight, the throe who gav'O negativ^o complement- 
fixation reactions at tho start remained negative. Com- 
|)ieniei!t-fixatioii tests were performed once every week on 
all these natives; in addition to this, regular weekly 
examinations of tho stools and urine wero instituted. 

The unpleasantness and difficulties of repeated stool 
examinations are considerably relieved by adopting tho 
following technique. Strong glass rods are made, about 
1 cm. thick and about 15 cm. long, with rounded ends. At 
about 1 cm. from one of the ends a hole, about 2 mm. wide, 
is drilled across the rod, care being taken that the edges 
of tho hole are left smooth. The rods aro inserted into 
test tubes, with a plug of cotton-wool in the mouth of the 
test tube, just lilce diphtheria swabs, and sterilized in this 
position by hot air. A sample of stool can how bo obtained 
from any patient at a moment’s notice by taking the glass 
rod from tlie test tube, inserting it into tho patient’s 
rectum (vaselining is not necessary), turning it round a 
few times, and, after withdrawal, replacing it into tbo test 
tube. Sufficient material will alwaj’s find its way into the 


Jrilled hole. _ . 

It would have been of considerable interest if these 
stool and urine examinations could have been performed 
immediately after removal of the natives. Pressure of 
ether work prevented this, and it was thought more 
idvisable, both with a view towards preventing further 
spread among these natives and in order to make a possible 
larrier amongst their number harmless in tho shortest 
possible time, not to lose time over examinations, but to 
nstitnte preventive treatment without delay. In Pretoria 
ive have so far obtained very good results from the use of 
she Besredka method of immunizing against typhoid. K 
seems to liavo definite prophylactic value, and also an 
iiidoubted effect on “stool carriers.’’ On three consecii' 
sivc mornings each person takes one bile pill, followed by 
i pill containing 40,000 million typhoid bacilli, killed by 
leat. (Paratyphoid bacilli are not included because this 
ntection is practically non-existent in tliis region.) Tins 
a-eotment was given to the isolated natives a couple 01 
lays after arrival at the isolation hospital. It probably 
issisted in keeping the natives with negative blood tests 
ree from infection, although here also tho improvement m 
anitary conditions,, as compared with those obtaining at 
he dairy, must have had an influence. . 

When the first stool and urine examination was made 1 
ras found that not one stool of tho eight yielded .tyP““' 
lacilH. In ono urine typhoid bacilli wero detected in la’'S 
lumbers. This native had been engaged by ^ 

lonths previously, and had acted as stable 
,oy As tho infection had only spread from 5 

ulto recently, it must bo concluded that this nativ d 

rrived at. tho daii-y in a perfectly sound conditio , . 

hat be had contracted the infection at tho dairy. -U 


Apeid 7, 1928] 


IHFECTIONB DUB TO DEAD AND SEPTIC TEETH. 


[ Tnr Enrass 
Medical Jociixal 


589 


E strongly positive ' comploiiient-fixation reaction for 
typlioid, but his Widal reaction was negative from the 
start, and remained so for some weeks after. The three 
natives who persistently showed negative blood reactions 
and negative findings in both urine and stools were dis- 
charged from the isolation hospital after four weeks and 
returned to the daii-y. It was thought that one might 
rely, if not on their natural immunity, then on the im- 
munity acquired from the Besredka prophylactic treat- 
ment.’ This loft five beys, one of them the urinary carrier, 
and the four others giving positive complemcnt-fi.xation 
but neg.ativo Widal reactions, and negative findings in 
stools and urine. After tho urine and stools had been 
examined five times, and it had been noticed that during 
these weeks their complement-fixation reactions had become 
weaker and weaker, it was considered that it was safe for 
them to return to work, and tbej’ were allowed to resume 
work at tho dairy. The only one then left over was the 
urinary carrier ; his blood gave a persistently positive 
complement-fixation reaction, and his urine every week 
showed typhoid bacilli. It was not to bo expected that 
Besredka treatment could have had any effect on this 
condition. Tre.atment was therefore instituted with 
ordinary typhoid vaccine given under the skin, and large 
doses, of .urotropine, but. after many weeks, although the 
typhoid bacilli in. the urine showed signs of diminishing in 
number, they were, still to .be found. It took four months 
before tliey disappeared entirely and the bo)- could be 
discharged. 

This constitutes the history of tho outbreak. Tho moral 
of the story is. that if the first case of typhoid at tho dairy 
had been recognized as such— whether it was tho imaginary 
stray young native or a member of the regidar staff — 
much suffering and unhappiness would have been pre- 
vented. Our dairy by-laws place the obligation on dairy 
owners to notify the health department of any case of 
infectious or ' contagious disease occurring on their 
premises; it is evident that this is an unsatisfactory 
arrangement.-- Tlie onus thus rests, on the health depart- 
ment to prove that the dairy owner was aware of the fact 
that a^ disease amongst tho personnel was infectious or 
contagious, and th.at will always be difficult. The whole 
responsibility should be transferred to tho health depart- 
ment, provided that at the saine time it receives the 
powers and facilities to examine all employees upon their 
being engaged by the dairy, and at regular short intervals 
thereafter. This examination should include a blood test 
or t^hoid fever, and the foregoing record amply shows 
that for such work the complement-fixation test is superior 
o the \I idal. If the "Widal test had had to be relied on 
tie urinary- carrier. would not have been detected with tho 
same rapidity, and where two other natives at the time 
gave a positive Widal reaction the investigation would 
probably have stopped at that, and tho chief culprit would 
have carried on his work. 

It remains to give a brief description of tbe principles 
iniqiio of the complement-fixation test for typhoid, 
c lave for many years insisted on the necessitv of aban- 
oning agglutination tests for typhoid in South Africa, as 
™ajority of cases cannot be 
. g ose y this method. We have also obtained some 
^ animal experiments that this failure to 

which we have demonstrated in South 
^'I'l partly due to the prevailing excessive 

on nn-r n + 't aomplement-fixation test is positive in over 
^1 n n . o cases, is as a rule not positive in persons 
•from “Sainst typhoid but are suffering 

parK ct f'+i 'j^aatious disease,, becomes positive at a 
dise.ase, and is much more helpful in the 
only drawback is that it requires 
tests Oiir '"*‘1''® and much more care than agglutination 
.tests. Our present procedure is as follows. 

no®Tffcrenfo™be’Lecn‘’tyX^d stS 

pensTon if l pstPd t “‘"F 0 . 0 m. per slope. The sus- 

i^erSLirctflt md'X’ouIr'a 


of mercury.. It is only by strictly observing these rules that a 
potent and constant antigen can be prepared. Each filtrate must 
DO titrated afresh with each new haemolytic system to be used. 
This is dono by employing diminishing quantities of. filtrate, from 
0.5 c.cm. to 0.05 c.cm,, with 0.5 c.cm. of guinea-pig complement 
diluted ten times, making up to 1.5 c.cm. with saline solution, 
incubating for one hour, and then adding 1 c.cm. of haemolytic 
system. A control tube is required which contains only saline and 
complement; to this tube also 1 c.cm. of Iiaemolytic system is 
added. Tho time is noted when this control tube has cleared, 
and ten minutes after this the tubes are again inspected. The 
tube which then shows complete haemolysis and contains the 
largest quantity of antigen indicates the quantity of antigen to 
be used in the test proper. The antigen is then* diluted so that 
0.5 c.cm. contains the suitable dose. As a rule we find that 
0.3 c.cm. represents the quantity of antigen to be used. 

If the filtrate is to be kept for more than a few days it is 
advisable to add 0.25 per cent, carbolic acid to the filtrate previous 
to titration. A good nitrate has considerable keeping qualities, and 
although we do not use it after it is fourteen days old we have 
found that it >vill keep its antigenic properties for at least thirty 
days. 

We prepare, haemolytic system by determining tbe minimum 
quantity of a sheep’s cells-rabbit serum which, in the presence 
of 0.5 c.cm. of ten times diluted guinea-pig serum, will completely 
dissolve in two hours 0.5 c.cm. of a 5 per cent, suspension of 
sheep’s cells, the total volume in each tube being made up to 
2.5 c.cm. Four times tliis minimum quantity of serum is then 
used in the test proper. The serum is suitably diluted for thh 
purpose with saline, and equal quantities 6f diluted serum and 
5 per cent, sheep’s cells suspension are mixed. 

The patient’s serum is inactivated, and 0.1 c.cm. is put up with 
0.5 c.cm. antigen, 0.5 c.cm. complement 1 in 10, and 0.4 c.cm. 
saline. This is incubated for one hour, and then 1 c.cm. of 
haemolytic system is added. At the back of every patient’s tube 
is a serum control, containing 0.2 c.cm.- of the patient’s scrum, 
no antigen, 0.5. c.cm. - complement,- and - 0.8- c.cm. saline. In 
addition an antigen control, containing 0.5 c.cm. antigen, 0.5 c.cm. 
complement, and 0.5 c.cm. saline, is put up. - • . ' - 

Readings are taken when the antigen control has cleared, and 
then for every individual patient when his serum . control tube 
has similarly cleared. Serums from the later stages of the disease 
show complete and lasting fixation; those from earlier stages show 
partial fixation, which is often not permanent. It is useful to 
include a known positive, serum in the series, either from a 
previously tested typhoid patient or from an injected rabbit. 

Human tenim. which produces complete fixation under these 
conditions will retain that quality when kept at room temperature 
for a considerable time. 

By following this, technique we have heen able to make 
a positive serological diagnosis of typhoid fever in case.s 
where the presence of the disease was established beyond 
doubt by positive bipod cultures, but where WidaFs agglu- 
tination test was persistently negative. 

We have found the metliod particularly valuable in the 
detection of carriers. " Here we* also’ often found a negative 
Widal and. a .positive, complement-fixation reaction, as 
illustrated by the case recorded in this paper. 

' : ■ * . . RErEHENCES. 

* Pijper : Sopt/i -Afncan Jlef/fcal- Eetofff, February,’ 1923. 

2 A. Pijper and .B. :D.- Pullmger ; /ournal of the iltilical Atsociation of 
South .-l/r/ca,, January 22nd, 1927. 


THE HOLE OF DEAD 'INFECTED TEETH 
IN. AUTOGENOUS INFECTIONS. 

■ ,BV- 

A. P. BERTWISTLE, M.B., Ch.B., F.H.C.S.Ed. - 

■\Vhile the literature teems with worlrs on the evil effects 
of pj-orrhoea alveolaris — ^and there can he no doubt as 
to its baneful effect on health — there is another dental con- 
dition which is hut now receiving the attention it deserves 
— namel,-, the tooth which has died before or after filling, 
and which has subsequently become infected. Tliat death 
may occur without pain makes' the condition all the more 

unsuspected. 

Tho bacteria in pyorrhoea pass into tlio mouth, where 
the majority are ingested by the salivaiy coi-puscles; tlie 
rest pass on to the stomach and are destroyed, if the gastric 
juice is normal. In the case of the filled tooth the bacteria 
cannot regain the mouth by way of the original deca,-, 
but must enter the bone, from which tliey or their toxins 
may be disseminated by the blood stream to all parts of the 
body, when those tissues which are “ below par ” fall a 
prey to them. By the irony of fate it is those people who 
take care of their teeth, having no untreated caries, who 






April 7 > 1928 ] 


rEAOTUEE OF THE NAVICUIiAB. 


[ The Bsixjvu 
Medicaa JoCltXAX. 


601 


bone, from rvliioh tlie.v may tlioii pass into tho mouth 
botmeen tlio tooth and tlio bono, but in the greater number 
of cases tho pus lies pent u]) in the apex, forming an 
abseess. Hero in tho sinusoids of the marrom it is free 
to exert a toxic influence on tho whole body, as is shown 
by the anaemia which is so common in these cases. 
Apparently the relatively avascular tissues, such ns fibrous 
tissue and synovian membrane, are the usual sites of election 
for local manifestations. Tho pulp chamber contains a bead 
of pus; any increase in tho number or virulence of tho 
bacteria causes increased pressure, which results in toxins 
and pus being squirted down into tho bone. Natural 
resolution, which can occur in bone, cannot take place here, 
owing to the fact that the walls cannot collapse and no new 
tissue is available to fill tho pulp cavity. Harely, however, 
calcification occurs. 

As with other streptococcal infections, once a patient has 
been' attacked recurrences are very liable to occur, either 
from residual infection or from the subsequent infection 
of other teeth (Cases 1, 2, 6, and 8). 

It is not yet possible to give a complete list of the diseases 
caused by infected teeth. Among those given are fibro- 
myositis, arthritis, .and lymphangitis. To these may be 
added: others of a' “rheumatic” nature, and possibly' 
Dupu^rcu’s contracture. It must not be thought that 
every icase will clear up on removal of the infective focus; 
the condition may only be diagnosed when the disease is 
advanced, and then even its arrest may be problematical. 

Sir William Willcox^ states that the disabilities i*espon- 
sible for one-sixtli of the days lost iti the industrial world 
come under the categoiy “ rheumatic.” In 100 consecutive 
cases of this nature he found the tooth to be resnonsible 
in 72. He writes; 


The eradication of the primary focus in early cases of arthritis 
has, in my experience, been followed by cessation of active inflam- 
matory changes of the infected joints. Where bony changes have 
occurred, or other destruction of the joint, it cannot be expected 
mat removal of the focus of infection will rectify these. When 
aclivo inflammation of the joint has ceased' treatment for restora- 
tion of movement wUl be followed by real improvement." 

Much has heen written on the areas of rarefaction seen in 
skiagrams of the teeth, and Weston Price has brought 
forward evidence that there are granulomata shutting off 
the toxins and bacteria from the general circulation. This 
may be so ; I have heard of a man with six such areas who 
is m perfect health. Surely, however, there must be a 
gia^e iiotential danger of tho resistance of this granulation 
issue becoming lowered from time to time and allowing 
toxins and bacteria to escape. 

Impoitant advances might be made if all suspicious 
^ 1 ound at necropsies of patients suffering from the 
iseasGs mentioned in this article, and others of obscure 
origin, ueie extracted and cultures made of their contents. 


Summary, 

. J* f: tooth may die painlessly before or after filli 
infection readily occurs, and such a tooth may be the fc 
ot autogenous infection. 

pyorrhoLXSs.™''^'' ^ 

a radiogram indicates apical infection, 

the qnilp does not signify absence of disease 

edeiiSon^^of'^^ sjmiptoms after extraction, or 

fropment-! ni' <lue to tooth remnants such 

tragments of roots, abscesses, and cysts 

tion if* ncccssaf-y at the time of ext 

6 The comn, attempted, 

terth^aio tlTn diseases caused by dead and infec 

xeeLii aie those termed rhpniT^o+;« ^ i xn 
synovitis, and arthritis. fibromyos 

alymysium^T'thk J'f 'P p 

and ot Dr. Canti ^on the bacteriS^g^rin^esUgaP^ 

> it'. LaxvfonTWnage?-';'?ffaS(o^''"'^^ .September ISth. 1928, p. 
*T1 ig Filled DG.id Tooth a-s a Dierasrf of Bone, p. 2 

November 6th, 1926, p. 953. Streptococcal Infection, La 

Jo, •Vfrficai.Sfrricf, August. 1927, p. 
! Sir William Willcox : 'practitioner, August. 1927. 


FBACTUEE OF THE KAYICULAR. 

BY 

K. PATEESON BROWN, M.B., F.R.C.S.Ed., 

ASSISTAKT SURGEON, ROYAL INFIRMARY, EDINBUHGn. 

So many patients are seen suffering from a persistent 
painful disability of the wrist following an unrecognized 
fracture of the navicular (Fig. 1) that it is important 
that the symptoms of this lesion be more widely known. 
These symptoms are characteristic, the treatment is simple, 
and the results extremel}' satisfactory if the patient is 
dealt with soon after the fracture occurs. 



Fig. 3. — Radiogram of the carpus taken two years after the injury, 
showing. A, the two ununiteil fragments of the navicular. There 
are dennitc Oi..o*arthrit1c changes present. 

No attempt is made in this pajier to consider every 
a.specf of the subject — this has been done already by Todd.* 
My purpose is rather to accentuate the clinical features of 
the condition which are of diagnostic importance. 

Fracture of the scaphoid bone (os naviculare) is by no 
means an uncommon lesion. In the past two years I have 
seen forty-six examples of tho condition, but unfortu- 
nately the majority wore late cases. These patients come 
to hospital complaining of persistent pain and stiffness in 
the wrist and inability to carry out their work oflSciently, 
The history usually is that months or years previously the 
patient had fallen and injured the wrist. Either it was 
treated as a simple sprain or he paid no attention to it at 
the time, hut the wrist never fully recovered, and was a 
continual source of trouble. If patients are to be spared 
a disability such as this it is essential that the fracture 
from which they suffer be diagnosed at once, and as the 
symptoms are so definite and characteristic, provided that 
this lesion he kept in mind, there should be little reason for 
its escaping notice. 

The mechanism of injnr 3 ' is usually a fall on the out- 
stretched band, very similar to that which produces a 



Fig. 2 . — Case of recent fracture of the navicular, showing the 
dorso-radial swelling. Note that the swelling docs not extend to 
the ulnar side of the wrist. 


CoHes’s fracture. Less commonlj- the fracture results from 
the back-fire of a motor car. On examination of the 
wrist no gross deformity is noticed, hut a verj- definite 
oedematous swelling is seen, situated on its dorso-radial 
aspect and extending into the anatomical snuff-box, with 
the result that the tendons bounding it no longer stand 
out prominentlj' on extension of the thumb (Figs. 2 and 3). 
The swelling does not extend to the ulnar side of the wrist. 
Palpation reveals normal bony points, but there are tn'o 
points of marked tenderness — one over the dorsum of the 
navicular, imracdiatel}- below the line of the wrist-joint, 
and the other in the anatomical snuff-box, iinmediatclv 
below the styloid process ot the radius." Pain at the site 


692 APRiii 7 , 1928 } 


FiiACTUflE OF THE' NAVICULIR. 


of fractui-o may also bo elicited by Yaiigbaii's kniitkle 
percussion test, which is described by Todd. 

" Tlie metacarpal joints are all fle.\ed to a right angle, or 
if possible the patient is made to clench the fist; he is then 
told to keep his eyes shut, whilst the surgeon taps the knuckles 
smartly, one after another. If the fracture of the -scaphoid 
IS present sharp pain will be elicited when the head of the" 
second metacarpal is struck, but not when any of the others 
is struck.” 

I have not found this sign of groat value in diagnosis. In 
.some cases it is 
not present, and 
ill others it would 
aiipcar to be 
])resont although 
110 fracturo is 
seen on x-ray 
examination. 

Tile movements 
of the wrist, both 
in flexion and 
extension, are 

markedljr limited, 
and the latter 
movement causes 
phin referred to 
the dorsal aspect 
of the navicular. 

Pain on flexion is 
rarel}’ localized to 
a definite point. 

The clinical features may be summarized as follows: 

1. Swelling on the dorso-radial aspect of the wrist. 

2. Obliteration of the tendons bounding the anatomical 
snuff-bo.x. 

3. Tenderness over the dorsum of the navicular. 

4. Tenderness at the base of the snuff-box. 

5. Limitation of flexion and extension of the wrist, the 
latter causing pain over the site of fracture. 

AVhilo these symptoms are always proinincut in recent 
cases they persist in untreated eases for long periods. I 
have recently seen a patient who had had an untreated 
fracturo of the navicular for two years, and at the end 
of that period, when ho canio to hospital, ho still showed 
all the characteristic signs which have been described. 

I would stress the fact that diagnosis can be established 
without an x-ray examination, but, when available, plates 
should be taken to confirm the diagnosis. It is of the 
utmost importance that the skiagram bo taken with the 
hand in marked ulnar deviation, for only in this position 
will all fractures of the navicular be detected. 


■ f .TnERAms* 

„ SliiuiCAj, JornsiL 



riG. 4 . 


Fig, 0. 

Fio. 3.— Note the svte’hiiK in tJie onatomical snuO-box with maEkinr of the e.itensor and abductor 
tendons. 

Fig. 4.— PIiotofrr.apli taken Hve weeks after a fracture of the navicular, which had been treated in 
a plaster case. Tlie patient was cntiiel\ free from pain, and full dorsiflexion was possible. 


TitEATMENT. 

IminobiJiziltioii js the keynote to success in the treatment 
o lac me of the navicular. The value of active move- 
nuii in uppei Jiiub fractures is widely recognized, hut 
the nuniber of patients who suffer from a chronic dis- 
a following what has been erroneously diagnosed 
treated by active movement, is 
sufficient proof that m this type of fracture, at .least, it 
IS 110 o bo iccommended. When the patient is seen 

early the follow^ 
ing treatment lias 
gii'cii excellent re- 
sults. A plaster 
case is applied to 
the forearmj 
wrist, and hand, 
the wrist being 
dorsiflexed_ and 
tliG fingers and 
thumb maintained 
in the position of 
normal grip. In 
most cases it is 
necessaiy to.glvo 
an anaesthetic to 
enable sufficient 
dorsiflexion to be 
obtained. The 
parts are im- 
mobilized in this 
plaster for a period of three weeks, but at the end of a 
fortnight the upper half of the plaster is removed to allow 
of massage. At the end of the third week the plaster is 
discarded and free movement encouraged. All the patients 
who have been treated in this way liave obtained perfect 
results, both as regards movement and freedom from pain 
(Fig. 4). 

AVhon the jiaticnff is not seen until a month or two have 
oIap.sed immobilization has not proved of value. In some 
of the.so cases the proximal fragment has been removed 
by operation, but the results are not very satisfactorj-, 
and equally good results have been obtained by a prolonged 
course of massage, together with exercises for the wrist and 
hot and cold douching of the part. In my experience, 
liowovor, the vast majority of these patients are left with 
a chronic disability, pain and stiffness in the wrist, and 
with a marked tendency for osteo-arthritic changes to 
occur (Fig. 1). 

REFEnEKCB. 

^British Journal of Surgery, toI. 9 . 


TWO CASES OP ACUTE YELLOW ATROPHY OE THE 
LIYER FOLLOWING ADMINISTRATION 
OP ATOPHAN. 

BV 

L. J. A. LOEWENTHAL, M.B., Ch.B., 

ChimCAL ASSISTiXT, SKIK nEPABTMEBT, HVEKPOOL EOVAI, IXFIRMARX ; 

AV. A. MACKAY, M.D., 

nOHOEAEY SUEGEON, SOUTHPORT IKFIRMARY; 

AKD 

E. CRONIN LOY^E, M.B.E., M.B., B.S., 

HOHOEAEV PATHOLOGIST, SOOTHFOHT IHFJRMARY. 

In 1922 Schroeder' first drew attention to the toxic pro- 
perties of the drug variously known as phen3lcincliouinic 
acid, cincophen, quinophan, atophan, agotan, and pheno- 
qiiin. His seventeen ca^s— chiefly of mild poisoning— con- 
sisted of headache, gastro-intestinal disturbances, and 
transient jaundice; while Y'^orster-Drought= a j-ear later 
reported a similar case. Following a communication from 
Langdon-Brown= in 1926, a dozen fatalities were reported 
by Evans,-* Glover,^ AVillcox,® and Y'ells.' 

In his presidential address to the Section of Therapeutics 
of the Eoyal Society of Medicine Grabam' emphasized the 
fact that every fatal case recorded was the result of 
uninterrupted use of this compound for a more or less 
lengthy period. Individual susceptibilitv- plays a certain 


part in determining the production of poisoning, as may 
also previous hepatic derangement, but it is noteworthy 
that there is no record, except in our second case, of any 
untoward result of this form of therapy where the drug 
is given in the correct niaiincr. By this is meant its 
administration for periods of not longer than four da 3 S 
with iiitei'vals of not less than four days, as advised by 
Graham. This method brings about the maximum excre-j 
tion of uric acid; the extension of the drug beyond tliesCj 
bounds, tberetove, is not only therapeutically useless, but. 
nia 3 - be positivel 3 ' harmful. 

The following arc notes of the authors’ two cases: 

. Case i. 

Jicai hu L. J. A, L, before the Liverpool Medical lastitiilion 
on February 23rd^ 1028. 

E. H. aged 55. bad suffered from rheumatoid arthritis for many, 
years. In Jnlj', 1327, on the advice of a neighbour, she began 
taking atophan at the rate of three 7i-grain tablets <laily mid 
without intermission. During the second week of January, 1928, 
she developed mild jaundice, apparently without any other sym- 
ptoms. Tlie final catastrophe occurred suddenly. The jaundico 
became more pronounced, on January 20th coma followed delirium, 
and she died on the following day. , , 

The faeces had retained tlieir normal colour througiiout, ana 
on this account a diagnosis of “ acute yellow atrophy of the 
liver” .was made. In view of the self-administration of stopuan 
a coroner’s inquest was' held and a post-mortem examination 
performed. 


April 7 , 1928 ] 


MEMORAUDA. 


r iiiF.rr.in«ai 
L'JIcdicat. Joo:^. 


593 


Patholog'^cnt llrport. 

(By the courlc?y of Dr. W. Howel Evans of Ihe University 
of Liverpool.) 

J/orro.sropfra^/y.— The liver was the typical ycliow-ochre colour, 
ivilh small reddish cell areas. It weighed about 19 ounces, ami 
I'csemblcd in consistency a fluid jelly contained in a thin capsule. 
The gall-bhuldcV was normal, and contained a small quantity of 
bile. There were no gall-stones present. 

Micro^copicaVij . — Sections showed a motlorale degree of multi- 
lobular cirrhosis, which probably antedated the acute yellow 
atrophy. The great majority of the liver cells were completely 
necrotic; some areas- showed fatty degeneration. There seemed 
to be practically no attempt at compensatory regeneration. The 
picture is that of almost complete necrosis, with the addition of 
the areas of fibrous tissue and.. the round-celled ■infiltration duo 
to the multilohular cirrhosis. 

. Case ii. - . 


long before any criclence of elinital jaundice could be 
observed. 

6 . Kven if administered in tlio eorroct intermittent 
manner plionylcinchoninie acid or any of its congener- 
may be a dangerous drug. TJie authors feel tliat its 
indiscriminate nsa is veiy undesirable. 

IlEFEr.llXCES. 

* Schroedcr, K. : Vpefilrift for Laeprr, September 7M), 1922, p. ll'Jl. 
nefereiices 2 to 7 are to the Pritiah Medical Journal of the d.ites given. 
~ Worslor-Drought, C. : January 27th, 1923, p. 148, » I,angdon-Brown, IV. ; 
July 3r(l, 19^, p. 37. * Evans, G. : July lOtli, 19^, p. 93. * Glover, L. G. : 
July 17th, 19^, p. 136. * Willcox, Sir 3V. H. : August 7th, 1^, p. 273. 
"Well:*, C. J._L. ; October 23rd, 1926, p. 759. * Graham, G. : Presidential- 
ndtlrcN'!, Section, of Tlierapeutics and Pharmacology, Royal Socictv of 
Medicine. October, 1926. Sec also JJrttish Medical Journaf, October 
1926, p. 688. 


^rnmraitba : 


Ilc 2 )ortcd bp IT’. A. ff. 

^rs. K., aged 55. Previous* liistdrj* — nothing pertinent. On 
April 28th, 1927, the urine had Been tested, aiid "gave specific 
gra^^ly 1010, reaction acid, no sugar or albumin. In May. 1923, 
she bad sustained a fracture of tbc skull, with wound (compound 
fissured fracture). In the second week of December, 1927, -she 
was ordered, for neuritic pains, atophan (7^ grains) three times 
a day for three days a, week, 'and to'.takc'cach morning a lea- 
spoonful of sodium bicarbonate.* According to her daughter’s 
evidence at the inquest she never exceeded the dose, and ceased 
lakingdliG drug about the cud of January, 1928 — five weeks before 
death. Thi*< was about a fortnight before the onset of jaundice. 

On Fcbruai'j' 15th I found her jaundiced to n slight degree. She 
^vas put to bed, but became deeply jaundiced, and evidently was 
going downhill. Tlicrc was some tenderness over the gall-bladder, 
and, owing to- the uncertainty of the diagnosis, oxploralion was 
deterniincd upon. A small cirrhotic-looking liver was. found, but 
no dilatation of the ducts. She died within twcnlv-four hours 
on lyiarch 5lJj. 1928. 


- The urine had contained bile pigmenU The facce^ tould not 
be got free from urine, and the examination of them gave 
eqmvocal^ i'esult& as regards the evidence of bile, Po^t mortrin, 
a hiphasic van den Bcrgh reaction was obtained on the blood. 
^0 Tjb^otis cause of the atrophy was found, and it was thought 
‘TT^^ suspicion ^to the coroner, who licld an inquest, 

ine e^Tcme quantity she could have taken is 540 grain.s spread 
1 days’ interval followed each 67^ grains. 

1 i she told bor family that the drug was doing her good; 
later she liad expressed a doubt. 


Pott-mortem -Jlcport (E. C. L.). 

• * The liver was considerably smaller than noimal, 
lyeig ling about 26 ounces; it was soft in consistency, 'its capsule 
s lowing typical shrinkage. The cut surface was of (he tvpical 
ye ow-ochre colour and studded with small i oddish areas. The 
fr‘ - a or and bile ducts were normal and patent. No gall- 
_^ones or cho]ec>'Stitis were present The pancreas was normal in 
.jec and consistency. The spleen was not enlarged, but rather 
cous*sleiicy than normal. The kidiicvs were normal in 
.-ize, but somewhat soft in consistency. 
i rcroscofuniff}/. Liver sections .flowed marked necrosis of the 
interspersed with round-celled infiltration, without 
finJor- opniont of any multilobular cirrhotic changes, the picture 
S jpityi of acute yellow atrophy. Sections of the spleen and 
no abnormal findings,. Sections of the kidneys 
Pnifliov parenchymatous degeneration of the tubular 

I'cphrili™’ si'ESest a considerable amount of subacute 


. Conclusions. 

■ P^tetiylciucboniuic acid and its congent 

bear in”ndnd'' 'illicit the medical practitioner should alwa 

; ?-* premoniton- symptoms, althou, 

X ^uminiiria, gastro-int<^tinai di.sturhaiices, a: 

n.W - Acute yellow atrop 

usheis m the fatal termination. - 

the piesent wo -would suggest that the presen 
oi any evidence of nephritLs should he co 
this drut^^^ ^ <-'oati'aindication tor the administi*ation 

sign of intolerance, .such as nausea or li 
7 indication for the immedia 

stoppap of adnuiiistration of the dm- 

K-t*:, :. ^ ^ ^'^^'^ction a 

onvihi ^ patient’s senim will prohahly giro t 

cplJq patliological effect upon the li\ 

, • i (uescii. the opportunity for omitting treatmei 


MEDICAL, SURGIGAL.-DBSTETEICAL. 


GAS 'gangrene OF SIGMOID. 

I VENTViiE to tliinfc that the following case, resulting in 
death froni toxaemra in twelve- hours, must be fortunately 
of rare occurrence. 

On February 27th, at 3.15 a.m., I was called to sec a man, 
aged 51, with- violeniiabdominal pain which had lasted about an 
liour. He had vomited twice, and had passed a little blood and 
mucus. The pain had begun in the right iliac fossa, and had 
become generalized. He was a healthy man, and looked less than 
his age. There was no history of any abdominal symptoms what- 
soever, and of no illness except “ rheumatism.” 

Condition on Examiimtion. — He appeared to be very ill and was 
in obvious agony, though not collapsed. The temperature was 
98® F., and the pulse 88 . The tongue was furred, brown, and 
very drj’. The abdomen moved on respiration; it was somewhat 
distended and extremely resistant, though there was no board- 
liko rigidity. Tlic tenderness was marked and universal. No 
assistance was given by a rectal examination, 

Diugnoids. — This was difBciilt to fit in ■with any of the ordinan.- 
causes of an ” acute abdomen ” in a man of his age. It was 
decided to operate on the assumption that volvulus was present, 
and a quarter of a grain of moiphinc was given. 

At 4.30 a.m. the pulse was 100 and the temperature was 100® F. 
There had been no more vomiting, but the pain was quite 
unrelieved. 

OjHration. — After a second injection of a quarter of a grain 
of morphine and 1/100 grain of atropine, the right rccliis was 
displaced outwards below the umbilicus; free peritoneal fluid 
welled up on opening the cavity. The appendix was found to 
be normal, the gall-bladder was Slue and apparently normal ; the 
intestines were not unduly distended, and there was nothing to 
suggest an obstruction; Uicrc was no sign of duodenal or stomach 
contents, nor was any ulcer felt. There was no question of acute 
pancreatitis or of diverticulitis. The only abnormality I could 
find was in the lowest 'part of the sigmoid, where it passed into 
the rectum; this was rather s'wollen, oedpmatous, and stained by 
a few purple petcchiae near the mesenteric border. I was fraritly 
puzzled, since I hardly thought a lesion so low down, and so 
unfamiliar as a cause of an abdominal catastrophe, could account 
for the acute onset and extreme illness of the patient. Hi« 
genera! condition was good and the pulse had hardly risen ( 120 ). 
Mr, Arthur Cooke -also carefully examined the abdominal cavitv 
and found everything normal except the sigmoid. Ho had never 
seen such a case, but hazarded an opinion of a B. irclchii infec- 
tion of the affected loop, and 10 c.cm. 'of gas gangrene serum was 
injected immediately. At the end of the operation the pulse rale 
was 100, nnd a rectal saline was given. At 9 a.m. the pulse was 
still only IPO. The tongue was more moist, and his colour wa«i 
better, but tlie agony was unrelieved. Morphine (1/4 grain) was 
given. At 12 noon the pulse had risen to 140; he -ivas flushed 
and there was cyanosis. The breathing was rapid. Tlic patient 
was evidently still in terrible pain; he had not vomited sinct» 
the operation. The abdomen was somewhat distended. Anollicr 
quarter of a grain of morphine was given. At 2^15 p.ni. the 
patient had become cyanosed and grey; he was completely coma- 
tose and pulseless, and died a quarter of an hour later. 

Post-mortem Permission for -a limited necropsy was 

obtained, and at 9 p.m., with Dr. H. E. Nourse, I explored tlie 
abdomen through' the original incision extended upwards. The 
post-mortem changes generally were very marked for the- short 
lime since death, and the odour on reopening the distendeil 
suture line •^as appalling. There was muc* 
toncal exudate, and the changes in the 
to complete gangrene for about sir inclu 
reficclion of tiie peritoneum. There was n ■' 

bubbles of gas were - observed below the peritoneal coat. Else- 
where the abdomen was quite normal. 

I sent-some of the fluid and five inches of the gut to the Bonnelt 
Laboratorj*; the following is a summary of Dr. C. H. 'Whittle’s' 
pathological report. 

1, Erudaic. — Large numbers of Gram-positive capsulated bacilli 
were found in films. Culture; (n) aerobic— streptococci and 
atujihylococcus ulbvs‘, {b) anaerobic — a bacillus of the B. tcclchit 
group. 

2- Hrrtions of G7tt. — ^There was intense congestion and gangrene 
of the* whole wall and bleeding into the lumen. The wall was 


594 APRiri 7, 192S] 


paclccd \vilh /?. v'dchu. Tlio blood vessels of ilio mesocolon of tbo 
nITcctcd pari wero Uirombosod; llio vessels sliowccl no sign of niiy 
j)i‘ovioiis disease. 

3. Aiihiial hweutntion. — giiinon-pig inoculated inlramitsculafly 
and sulieiitanoonsly with broth enUnros died within forty-ciglit 
hours from gas gangrene. Tlio organism was highly pathogenic. 

It is difficult to assign a caiiso for a primary tlirombosis, 
ficcanso 'Mr. Cooko and I aro both satisfied that there 
could havo been no volvidns in tho relatively inimobilo 
loop. 

If, alternatively, it is assumed that the thrombosis was. 
secondary to tho intensity of tho ■ inflammatory process 
(which must have started in tho mucous membrane), the 
reason for the selection of tho sigmoid for attack in a 
perfectly healthy subject has still to be explained. 

Tho case was as tragic as its origin was obscure. 


Gambridgo. 


B. Salisbuuv Woods, IM.D., F.R.C.S. 


TEEATMENT OF VAlilCOSB VEINS BY 
INJECTIONS. 

In tho course of a series of treatments for varicose veins 
of tho lower extremities my attention was drawn to tho 
fact that tho size of tho veins varied considerably with tho 
act of respiration, and it occurred to mo to mako.uso of 
tliis when injecting tiiem. If a patient, citlier standing 
or lying down, is asked to take a deep breath, the veins 
will he seen to dilate on inspiration and to contract on 
expiration. This phenomenon is best .seen in markedly 
dilated veins on the inner side of tlio thigh, especially’ 
over the great saphenous vein; it occurs in a lesser or 
almost imporceptiblo degree in the veins of tho log. 
It exists, however, in all cases. 

Two requirements must bo fulfilled to obtain .satisfactory 
results in treating varicose veins by scleiosing injections: 
(1) the injected fluid must not bo too diluted by. tho 
amount of blood in the vein, and (2) tho fluid must come 
in as direct contact with tho endothelium of the vein as 
possible. For these reasons tho- injections must bo given 
with the patient lying in certain positions wliicli tend to 
empty the veins as much as possible of their blood; taking 
advantage of tlio changes duo to respiration will, I holieve, 
also help in this. 

The site for injection having been purified, the patient 
slionld bo asked to take a very deep breatb; while ho is 
doing so tho needle is inserted. He is then asked to 
breathe out very slowly, and tho solution is injected while 
he is doing this. In this way tho needle will he inserted 
when the vein is distended, and the injection wili bo given 
W’lien it is almost empty. In making use of respiration 
and posture I have found that a smaller quantity of tbo 
sclerosing solution w'ill bring about the same cml-rcsults, 
since tliero is less blood to dilute the fluid, and also tbo 
walls of tho vein aro in closer contact with the injection. 
After all injections tho patient sliould lie down for ten 
minutes, and during tliat time bi’eathe slowly and lightly. 
It will be noticed that when a vein has been successfully 
treated its size is no longer affected by fesiriration. 

I havo ventured to record these details since I have been 
unable to find any reference regarding tlie effects of 
respiration in connexion with varicose veins, and think it 
may he of interest and worthy of further study. 

London, s.W. T. Henky Theves Bahber, M.D. 


LARYNGEAL MYXOEDEMA. 

The fact that tho diagnosis, and therefore the correct 
treatment, was missed by general practitioner, physician, 
and laryngologist alike in three successive cases of 
laryngeal my’xoedema, suggests that a note may he useful. 

Tho first case was that of a surgeon, aged 65. He had always 
had good health, although there was, on rare occasions, slight 
albuminuria. He complained that when he tried to sing all he 


coiild set instead of a cleat note was a grunt. There was some 
swelling about the eyes; liis voice was hoarse; there was pro- 
nounced oedema, red. glazy, of the mucosa of the back and sides 
of tbc larynx and ot the ventricular bands. On a gram of 
thyroid extract twice daily ho quickly got rid of the oedema of 
hia face and larj'nx, regained his voice . and vigour, and has 
continued an active professional life for the last four years. On 
inquiry it was found that his sister died of myxoedema. 


MEiVTORANDA;- f TnR Enmsn ' 

— . LiTEprCAL JOLRYAI 

The next case was that of a Salvation Army officer, aged 60, 
nijo found open-air speaking a difficulty. Tho symptoms in this 
case wore not pronounced as in the previous one; the vocal cords 
were sound, hut there was some beefiness of tbo rest of tho 
iarynx, thinning of the ^ebrows, and clear waxy skin with 
scattered telangiectases. ^ Tij© whole aspect suggested hypothy- 
roidism, and the diagnosis was made instantly on inspection by 
my assistant. Thyroid extract cleared- up the case. 

The third case is the most interesting. A lady of 70 came to 
me m July complaining of laryngitis, for which she had been 
sent homo from the coast, although she had been tliere only two 
days and the laryngitis had lasted six months; the voice, 
indeed, was hoarse, the mucosa above the glottis, and especially 
on tho back oF tho larynx, was boefy red. Moreover, she Iiad 
marked exophUialmos, and gave a history of severe Graves’s 
disease when she was 50, which liad disappeared by tlio time she 
was 40. Viewed across the room, however, her face looked thick; 
and, when asked about it,* she used the suggestive expression, 
“ When I wash my face it fills my hauds.'^ Under a fortnight's 
licalment with thyroid extract her symptoms disap*prared — 
except the exophthalmos. This was a case of hyperthyroidism 
p.-issing during forty years through fibrosis into the “ hypo ” 
stage, but leaving the exoplitbalmos for witness of the hyper . one. 

Tlio eaiiso of error was simple and the same in all — dis- 
traction from the general appearance and symptoms by the 
patient's complaint of tho laryngeal condition; There 
was some excuse in each case : in the first because the 
patient was a man, and so familiar to his colleagues that 
lliey were thrown off thoir guard; in the second because 
the symptoms wore slight ; in the third because bf tho 
exophthalmos. If myxoedema is not suggested to the 
observer’s mind by the patient’s appearance and 'voice the 
moment tho latter enters tbo consulting room the diagnosi.s 
is apt to be missed. The laryngeal picture, however, is 
unmistakable. ‘ Tlie back of tho larynx looks like a beefy 
led shield and throws itself at one’s eye. Certainly the 
pale aiiaemic appearance of some textbooks was not ex- 
emplified in these cases. A “ laryngitis ” that has lasted 
for months and loaves tbo true cords practically un- 
changed in appearance is presumably myxoedema. . 

James Adam, M.I)., F.R.F.P.S.Glas., . 

Surgeon for Dieeoses of Ear, Nose, and Throat, 
Glasgow Parish Council. 


Ilc|j0xts of 

■the ETIOLOGY OF ALCOHOLISM. . ’ 
The Section of Psychiatry of. the Royal Society of Medicine 
Coined with the British. Psychological Society. on March 
29th for n discussion on the etiology of alcoholism. 
t Vncdon-Do^vn, president of tho Section, was m the cliaii. 

Hr Be.™ Hart, opening, said that to tho question 
“AVliv do certain people take alcohol- to excess? many 
wer- had been returned. Leaving aside such facile 
Inualions as that alcoholism was a vice or a disease— 
'^’''*’laiiations which added nothing to knowledge-— theories 
a ^ e,^^ put forward emphasizing the part played by 

‘" editv hv the mechanism of habit, and by the response 
trslreLs ana strains in tho mental organism. Psycho- 
1 theories of recent origin tended to .dominate tho 

anti t\ie otlier factors were now in some tlanpi o 
f 'nw unduly minimized. In the modern psychological 
to the subject it was held that the forces which 
men to take alcohol to excess were, in some measure, 
uvTidentieal with those which impelled men to take 
“^?raH and it would seem that the causation of alcoholism 
IX at all. ana - i„to tho effects of alcohol. 

Clert had divided mich effLts into P^ychomotor sLmn- 

tao 

consequent release of impulses. . , . gaitl that 

“ dullin" ** -process, in general it might +ni-frn in 

psycho-analyst accepted the view that “ partly 

order to achieve a psychological aim, . , -j^ainment 

ill tho assuaging of conflict and par y ' gupborio 

of freedom of expression for repressed forces. The 1 



59 G April 7, ig 8] 


ETIOIiOGX OF ALCOHOLISir. 


r Tiif Rbiti^h 

i. IIlMCAL JuCHKiJi 


and a regicssivc cliango whereby the activity of the cortical 
centres was snbprdinated to thalamic control. Acquired 
inhibition succumbed to instinctive pressure, and con- 
ceptual thinking was submerged by perceptual activity. 
It might bo presumed that these changes depended on two 
pliysical mechanisms, one largely and the other entirely 
liypothotical — namely, change in intracranial blood pressure, 
and alteration in functioning directly occasioned by altera- 
tion in the chemical constitution of the cerebro-spinal fluid. 
The modification of feeling tone or euphoria thus iirodueed 
might be sought under many circumstances. In the first 
place, any effortless attainment of oblivion mnst necessarily 
constitute an alluring retreat from most forms of conflict. 
People were enabled to forgot their past follies and future 
difficulties; in other words, a retreat from conceptual 
to perceptual ideation was frequently pleasant, if not 
desirable. The introverted found in alcohol a chemical 
solvent of those inhibitions that dammed up his self- 
expression, and the man with an inferiority senso felt 
himself 100 per cent, better when alcohol had blurred his 
discriminating capacity. The ps3’chasthcnic, with his con- 
stitutional intolerance of strain, phj-sical or emotional, 
derived from alcohol a temporar}’ rise in the threshold of 
consciousness. Similarly there wore two groups whoso 
demand for alcoholic euphoria was based upon phj'sical 
state.s — one the hj popietic. and the other the snbthyroidie. 
Probably- the factor of low blood pressure entered into a 
v'crj’ liigh proportion of all cases of alcoholism, especiallj- 
among women, the ill-nourished, and the toxic. That 
alcohol afforded satisfaction to many snbthj-roidics was 
notorious; prcsumabl}’ the mechanism was a gcnei'al vaso- 
motor stimulation. On the other hand, hyperthyroidics did 
not tend to bo steady drinkers. Another group was the 
sensorial tyjre, who sought the modifications in sensoi’y 
experience produced by alcohol. To this group belonged 
those who alternated alcoholism with excessive auto-erotism. 
The “ rebels ” sliould also be mentioned — those who drank 
because their fathers were rabid temperance reformers, just 
as the son of a fanatical Calvinist became a Roman Catholic 
and the son of a Toiy Minister became a Fabian. In this 
group gold cures or injections of alkaloids reached the limit 
of absurditj’. He also mentioned the group which showed 
an association between alcoholism and epilepsy, tho “ dual 
personality ” group, and the manic-depressive group, this 
last resistant alike to analytical treatment, to forced 
abstention, to medicinal cures, and to affective .nfluences.' 
In this group the alcoholic craving might be a feature 
cither of tho depressed or of the exalted phase, but not,, 
in his experience, of both phases. j 

Professor George M. Roueutson agreed that no single' 
formula could be adopted to explain tho etiologj- of- 
alcoholism ; nor could there bo one therapeutic method. In 
most cases a lowering of mental functioning by some pro-' 
cess or other was involved, in consequence of which the 
mental powers were less able to encompass difficulties; it 
might be duo either to a ps3chic or a somatic cause. In, 
most cases there was conflict of some kind, and in addition 
temptation and tho presence of facilities. Ho doubted 
whether theie was craving for alcohol in the same senso 
as for morphine in the morphine addict. In the latter 
case there was probably a toxic chemical change in the. 
blood, and ho did not believe that the same thing occurred 
in alcoholism. Again, tho sudden cessation of alcohol in 
■the case of the alcoholic, while it might possibl3' produce 
delirium tremens, did not result in anything like tho same 
damage as the sudden cessation of morphine in tho case 
of the morphine addict. 

Dr. IV. H. B. Stoddart quarrelled with the definition of 
alcoholism given by Dr. Hart — that it was tho state of a 
person who took large quantities of alcohol — for he (Dr. 
Stoddart) maintained that a person might bo an alcoholic 
before he had taken any large quantities. During tho war 
ho saw at least four cases of delirium tremens occurring 
in people who, prcviousl3’.to tho restrictions on alcohol, had 
been quite nnderato drinkers. During the restriction 
period, however, these people had attacks of anxiet3' as 
tbo time for the closing of public-houses drew near, and 
drank as much alcohol as the3' could obtain; all of them 
developed delirium tremens. The speaker therefore 


regarded alcoholism as including tho state of a person 
who believed that ho could not do without alcohol; it 
was not ncccs.sary to take large quantities before becoming 
an alcoholic. He added that in tho treatment of delirium 
tremens to cut off all alcohol sharjily might be serious. 
J\onada3'S it was usual in this condition to give a little 
alcohol. ° 

■ J^r. .-Ii/rREr) Carver (Birniingham) answered Dr. 
.Mapothers question as to whether euphoria could be 
obtained without the patient knowing that he had imbibed 
alcohol. In certain manic-depressive cases some alcohol 
had to bo given unknown to the patient; it was given 
with paraldehyde, which was so .pungent as quite to dis- 
guise tho alcoholic taste. The patient was told that it 
was medicine, but the euphoria was forthcoming as usual. 
Dr. Hart had stated that in ordinai'y recurrent attacks 
of alcoliolism ho did not think tho craving arose boforo 
tho taking of tho first dose. Tho speaker’s experience of 
cases w.as different. Tho craving most certainly arose 
before they had touched a drop. 

Dr. T. A. Ro.ss said that craving for alcohol frequently 
arose in a person who was encountering difficulties, or 
some obstacle which was too much for him, or experiencing 
some strong emotion, thus differing from the craving for 
morphine, wliich had a physico-chemical basis. In his 
cxpericnco delirium tremens or other accident did not 
often' result from tho sudden cutting off of alcohol, but 
ill tlio case of morphine addiction the drug ' could ’ not 
bo cut off suddenl3'. 

Dr. Artuer Hadfield thought that the majorlt3' of 
people w'ho suffered from alcoholism — not of the social type, 
but of the drug type — were people of highly strung tem- 
perament. This introduced an heredity factor, because 
tcinporaniont ' was in most cases inherited, and there was 
also a physiological factor in which low blood pressure 
played a part. But tho fundamental factor ho believed to 
bo regression — these were people with a fatal predisposition 
which prevented them from facing tbo difficulties of' life, 
simply bccaiiso they had never grown up. 

Dr. M. P. liE-inY spoko of the- good effect of suggestion 
in combating the fixed idea of the alcoholic that he must 
ii»vo alcohol; it depended, of eourse, on the non-rcsistanco 
by tho patient to the injection of the opposite idea. 

Dr. J. D. Roleesion drew attention to tho ancient and 
modern association of alcoholism and prostitution ; ' the 
modern association was disclosed in tho recent reijort of 
the committee of experts appointed by the League of 
Nations. There was also an alcoholism which might -be 
described as of tlierapeutic origin. Some persons who were 
originally abstainers became chronic inebriates because 
they had been ordered by their doctors to take soma 

alcohol. 1 

Dr. J. Branuer said that ho had been a little alarmed to 
hear that evening of tho multitude of abnormal psycho- 
logical states which must be held to account for tlie 
habitual addiction to alcohol even in moderation. IVas it 
really necessary to call in a psycho-anal3-tical explanation 
of the “ Frotliblowers ” ? And would it not bo necessary 
also to apiily the same researches to the much-advertised 
effects of certain tonics and “ sovereign remedies ”? 


FEMALE SEX HORMONES. 

At a' meeting of the Section of Comparative Medicine of 
the Royal Society of Medicine, held on March 28 th, with 
the president. Sir D’Arcv Power, in the chair, severa 
short papers 'Vvere read, of which two had a general medical 

interest. . . 

Dr J. IP- Trevax spoke on recent advances m om 
knowledge' of the female sex hormones.' Ifo said fta 
now tlmt tliorc was a method of standardizing and isplatnio 
ono of tlio fcmalo sex hormones great extension o 
knowledge was possible. Dealing with the “ 

problems of the differentiation of the sexes Dr. 1 c 
illustrated the essential features of the chromosoino di 
mice and went on to describe tho freemartin, wliick 
a calf with the external genetic pattern of the -jj, 

internally like the male. 'Iliis calf was always' a t'’'.'"’ 
anastomosis of the placental circulation with a twin 


. . 7i >9=8] 


FEMALE SEX HOBMONE3. 


r TireBninsn 

L UeoicAL Jozivix, 


597 


The testis dcveloiied in the mnlc bcfoio tlio ovary m tho 
female, and it' was snpi'osotl that a liormono from the 
testis ’'incveiitcd tho aoveldpment of the c6rrcs]ioiiding 
female hormone in. tho freemartin. This was tho first 
of the sex hormones. The next changes occtirrcd at 
luibortj-, and it was especially tho cyclic anatomical changes 
which liad recently been stndied, mostly in tho rat. At 
oestrus in this animal there was not only a swelling of- 
the external genitalia,' bnt there waw an actual change in 
the character of tho vaginal secretion, .wiiereby cornified 
epithelial cells almost completely replaced the leucoc 3 -tes 
which were present in the dioestral jicriod. There were 
correspontling, if not so easily dctcotahlc, changes in other 
animals. The first stop towards finding out something 
about tho cause of this phenomenon was tho discovery that 
the hormone concerned could bo obtained by a process 
of alcoholic extraction of tho ovary in a certain way, and 
the biggest experimental step was made by Allen and Doisy 
in 1924, when they produced tho characteristic changes in 
the vaginal secretion of the rat by tho hormone they' had 
obtained from the ovaiy. This it was proposed to call 
destvin, arid it could be obtained from the ovarian residue 
in an amount of about 200 to 300 rat units per kilo. It 
could also ho obtained from tho follicular fluid and from 
the placenta, and, what was very surprising, also from the 
corpus luteum. The effect of injection of oestrin was to 
produce oestrus in rats, oven if they had their ovaries 
previously removed. If a young rat was splayed its vagina 
remained as a solid cord of cells, hut within twenty-four to 
forty-eight hours after the injection of one to two rat units 
of oestrin the vagina became a tube. Oestrin had been 
obtained from tlie ovaries of tho sheep in the ancestral 
period, and this raised the question of why oestrus was a 
cj'olical phenomenon. It had been suggested that it was 
due to the ripening of the follicles, but Parkes had 
destroyed follicular tissue in mice by means of x rays, and 
fhese animals went on haring tho cyclic phenomenon as 
before. The nest problem was whether the corpus Inteum 
u as responsible, and recent work bj’ the speaker suggested 
that the corpus, luteum contained another sox hormone, 
which might be called anti-oestrin. Tliis might explain 
the absence of the cyclic phenomenon during pregnancy, 
101 the blood at this time contained veiy large amounts of 
oestrin. rinally, Dr. Trevan suggested the possibility of 
jet another hormone concerned with reproduction, and he 
also discussed tho role of the anterior lobe of the iiituitary 
in preventing the onset of puberty. 


Vaccine, 

n j +7’ described his work with B.C.G. (Bacil 

a me e-Guerin) vaccine and guixiea-pigs. This work ha 
been undertaken by himself and Dr. C. C. Okell to confir: 
tno uork of Calmette on the prophylactic effect of B.C.f 
.T’ni'r®! *“’^e‘'c«Ious infection of guinea-pigs, fi 

Pnin ^ propagation of the B.C.G. vaccine I 

• ‘ i oier a period of thirteen years, and then describe 
series of experiments which ha 
'' Sroup of guiiiea-]jigs 20 mj 
eirfit intravenously, and after five 1 

strain ^ virulent bovine tubercle bacilli 

of surviv'il^w'T ^+ 1 *^ c° oyo^all. The average perio 
eLtrol ’reeks, as compared with 

B.C.G v^cine ° which had not received tl 

of twentv ireA siii-vived for an average peric 

snccumh^nTi?- vaccinated group si/ did m 

ciilosis ’ These showed no signs of tube 

the tiino i'ave escaped being infected i 

neriod of nxclnding these tl 

sidonhlv Innn-e '+ 1 tweiitj--iifne weeks, and still coi 
there w7p ^ ^ ooutrol group. The fact th: 

IZt Znl/r , vaodnated group was , 

infection 7 '^ aveimge increase in weight afti 

Dared with the ^oo times as gi-eat in the vaccinated as cor 
B O C i-ie ■ oiiimals. Dr. Parish concluded tin 

;.SSp«S'” tteSisj " »«»"•• ?- tl 

“ fs. ‘r 

Vo.ir .after had . been kept alive .for 

of'tubcrcu!osi3.™“ necropsy there was no sig 


ABERDEEN MEDICO-CHIRUEGIOAL SOCIETY. 

At a clinical meeting of the Aberdeen jMedico-Chirurgical 
Society on March 1st, the president, Dr. Thovi.^s Fbaseb, 
in the chair, Mr. G. H. Colt showed a hoy, aged 12 years, 
who' hud fallen down three steps and struck -the left side 
of Ills abdomen. The boy -felt sick, but did not vomit, and 
had been kept m bed. After a week an epigastric swelling 
appeared; it extended into the left loin, and there was an 
evening rise of temperature to 101° -F. Tho swelling was 
apparently fluid, and its dullness merged into that of the 
spleen; the colon lay below it. Tho blood count and 
diastatic index were both normal. From the fourteenth 
to the twenty-first day there had been profuse bright 
haematuria,- which had begun and ceased suddenly; no 
clots wefo passed. The size of the swelling had somewhat 
diminished since ■ his admission on the twelfth d.ay. No 
other symptoms had been noticed, and the temperature had 
not been raised. The quantities of urine passed and the 
urea percentages in the urine and blood were normal. 
Tho diagnosis lay between a pseudo-pancreatic cyst 
(Jordan Lloyd) and a renal cyst or haematoma. Dr. J. A. 
Stephen described the liistory of a case of difficult feeding 
in an infant where lactic acid milk and insulin and intra- 
peritoneal salines were employed. The child weighed 
5 lb. 6‘ oz. at birth, and during the first period of throe 
and a half weeks on breast feeding the gain was only 
li -oz. For the next seven weeks it was given a supple- 
mentary feed of lactic acid milk four-hourly for three 
days ; it was then weaned and fed on lactic acid milk. 
In four months the child gained only 1 lb., and yet it had 
made quite satisfactory progress at the end of one year. 
Dr. Edwakd "iVALKEa exhibited' a male child, aged 11 
months, showing several of the stigmata of Mongolism. 
Tiie skull was brachyccphalic, but without marked occi- 
pital flattening. Tho features were small and high 
coloured. There was a slanting palpebral fissure down- 
wards and outwards, a reversal of the common peculiarity 
which has been reported in otherwise typical -Mongols. 
The nose was small .and snubbed, and the tongue, which 
■was large and broad, protruded from the mouth. The 
abdomen was large and tumid; the skin showed exag- 
gerated mottling and was rather dry on the face, but not 
elsewhere. The thyroid gland was palpable. Mentally 
the child was bright and friendly, but it appeared to. he 
stupid and was given to grimacing. A diagnosis of 
Mongolism associated with hypothyroidism was suggested, 
and thyroid extract was being administered as a thera- 
peutic test. Mr. AiEX-iNDER Mitchell showed a case of 
ectopia vesicae in a boy aged 5, There was no actual 
prolapse of the posterior wall of the bladder, hut only a 
defect in the anterior wall, with a short penis and tho 
lower half of the circumference of the urethra alone 
present. A plastic operation on the bladder was not con- 
sidered advisable; it was hoped that the sphincter control 
of the rectum would improve when transplantation of the 
nreters into it could he effected. Mr. George S. Datidson 
showed an x-ray film of a patient with a Naegele pelvis, 
who first came 'under his care in 1927. The point empha- 
sized was that there ought to bo much closer co-operation 
between tbe obstetrician and radiologist. Mr. Williasi 
Anderson sbowed a case of chronic pulmonary suppuration 
treated by cautei-y pneumectomy (Graham’s method). 
Repeated aspirations had failed to locate pus. Four inches 
of tbe seventh, eighth, and ninth ribs posteriorly were 
resected. An indurated area was being excised when 
thick, foul pus escaped. The cavity was cauterized ■a-idely 
in all directions and packed, the skin wound being only 
partially closed. Tlie convalescence was fairly smooth, bnt 
a sinus persisted at the patient's back. The woifnd was 
opened np and extended in an upward direction, the sixth 
rib being resected, the thickened area of the lung again 
thoroughly cauterized, and the wound packed. There was 
a free discharge of pus, and irrigation with flavine caused 
the sputum to be stained yellow. Five weeks later, how- 
ever, the sums ivas practically dry, and soon after this it 
healed up. The patient- returned to work as a street 
porter, which involved the dragging of a hcai-y trollev 
cart. His only complaint was slight hre.athlessness on 
extreme exertion, and the clubbing of tho finger tips 
entirely disappeared. 


DUB APHiri 7, 1928] 


BE VIEWS, 


[ 


hltURlriSH 

Medical Jotuviit 




THE SOCIAL STKUCTUIIB OF ENGLAND AND 
WALES. 

AVhk.n'evee tlio tiiiiG comes for organizing a national census 
jhoso responsibio for tbo work receive many suggestions 
for increasing the field of inquiry, and every year Govern- 
ment departments ai-o invited or e.vhorted to obtain this 
or tliat now piece of statistical information. It not infre- 
quently happens that those who make proposals are ill- 
acquainted both with the difficulties of the task they set 
and with the published results of similar inquiries. Thci-o 
is some excuse for this, because the mere mass of official 
publications is great, and it often happens that the precise 
meaning of some tabulation can only bo grasped if the 
descriptive text — perhaps separated from the tables by a 
wide space — is carefully studied. In recent yeam a good 
deal has been done to smooth the path of the private 
inquirer by the Government itself — for example, in the 
admirable Guide fo Official Statistics — and by organizations 
such as the League of Nations, in its handbooks of the 
official vital statistics of many important countries; but 
there was room for a treatise such as that of Professor A. M. 
CAnn-SATJXDEns and Dr. D. Cahadog Jones,* which should 
illustrate the lessons to be learned from a study of the 
official, and some unofficial, data. 

The authors first set out the salient facts as to the 
number, age, sox, marital condition, housing, geographical 
distribution, iirdustrial, and occupational classification of 
the people. Next they consider the statistical measure- 
ment of social status, the numbers and nature of occiqia- 
tional associations, and other aggregates. The means of 
estimating national wealth and income are next con- 
sidered; and then in turn education, irays of entering 
occupations, State provision against misfortune, taxation, 
charity, tbo measurement of povertj-, tho prevalence of 
crime. Einally, the distribution of "intelligence” and 
the differential birth rate are discussed and illustrated. 
Tho authors have treated their material in a lucid and 
objective way; tho medical reader will find, in their dis- 
cussion of tho subject, matter of particular interest to 
him, little fo criticize, aud much which he should know, 
but perhaps does not know. Professor Carr-Saundors and 
Dr. Cai'adog Jones, having set out the facts as to the 
differential not fej-tilities of various social strata, abstain 
from rejoicing or bemoaning. 

“ Tlio net results of dilferential rates of contribution," they 
remarlc, " may bo favourable or unfavourable. It is at least 
possible that, even if they are unfavourable in respect of inborn 
intelligence, they may bo favourable in respect of temperament 
and physique, and that, therefore, the general trend may not be 
in the direction of biological degeneration." 

Similar caution is displayed in the introduction to the 
chapter on inborn qualities, although the authors seem 
to accept tho view that the intelligence quotient is a. 
measure of innate qualities; it might perliaps be remarked 
that tho conclusion that “ most of those tested are 
moderately gifted with intelligence ” is a truism, having 
regard to the definition of an intelligence quotient, 
although, of course, the result that very high and very 
low quotients are about equally numerous is not a truism. 
It might perhaps have been an improvement had rather 
more space been devoted to the discussion of the measure- 
ment of “ intelligence,” whicli is a somewhat controversial 
issue, but a very interesting and relevant one. On the 
other hand, perhaps a little too much prominence is given 
to Professor Bowley’s estimates of future populations, 
since these are based upon demonstrably false assumptions 

namely, that the death rates will continue to bo the 

same as'in 1910-12, that the annual number of births will 
remain as in 1921-23, and that there will be no migration. 
Professor Greenwood’s conjectures (published in Matron, 
r, 1925), which assumed an improvement of the death 
rates continuing to 1927 , and that the birtlis would 
decrease logarithmically', have a somewhat more plausible 

Surcc}/ of Social Structure of F.ngland and Wales as Ulus- 
trafrft Jji/ istati«tic9. By A. 51. Carr-Saunders and D. Caradog^ Jones- 
* Milford, Oxford University Press. 1927. (Demy 8vo, pp. 

.4- 81 tables. 10a. net.) v j 


blit, so far as hivths are coiicetnoci, this foundatioii 
the fLtr'° of population than 

Theso, however, are not points of much practical im- 
portance, and wo can unreservedly commend the booh, 
winch should bo very useful to all interested in the present 
position and prospects of our country'. 


THEEE BOOKS ON PATHOLOGY. 
pATHOLocy, instead of occupying, as heretofore, a merely 
subordinate position as tho liandmaid of practical medicine, 
has now established its claim to bo considered an inde- 
pendent^ science. Tho new point of view lias necessarily 
had its influence) on methods of teaching and tho character 
of textbooks, as is clcai'ly shown in Professor Oertel's 
book Outlines of Pathology.'^ Tbo book is based on the 
method of teaching adopted at present in tho McGill 
tliiivcrsity, where pathology is dealt with primarily not 
as a preliminary medical subject, hiit as a scientific and 
cultural branch of knowledge. Completeness in detail, 
such as was aimed at in the older textbooks, is not its main 
purpose, nor are pracfical applications to the art of healing 
discussed to any considerable extent. Tho student is 
brought to the threshold of the subject, and an effort is 
made to unfold critically the origin of, and trace the 
different methods of attack upon, the great prbblehis in 
pathology, and to emphasize its constant interactions with 
other sciences. The author considers that the increasing 
wealth of positive information which is at present 
scholastically h.anded to the student as a necessary equip- 
ment is bewildering rather than illuminating, and his' 
endeavour has been to stimulate the student’s interest arid 
critical faculty rather than burden him with innumerable - 
details, which he will discard, in the main, after his 
c.\amination. The subject is developed in two main 
sections— on etiology, and on pathogenesis or the develop- 
ment of disease. Under etiology are considered, first; 
subjective or internal factors— namely, hereditary or 
ancestral qualities and individual or developmental 
qualities; and secondly, objective or environmeirtal factors 
--namclv, physical and chemical agents' and organized 
parasites. Under pathogenesis are considered in the first 
place infection and immunity, or the interrelations between 
mihjcctivo and objective causes of disease; and sceondiy, 
pathological ' anatomy and histology, including the manner 
of development of morbid lesions. It may bo said that 
these lieadings exhibit nothing new; the book does, how- 
cver exhibit a novel and striking difference from the older 
tvpe of textbook in its more philosophical spirit, and in 
its recognition that pathology is something more than the 
mere dScription of anatomical lesions with passing refer- 
ences to their causes; that the foundations of the subject 
are to bo looked for in such matters as the laws of heredity 
mid somatic development, the reaction of cells to environ- 
nieiital changes, the nature of immunity, and the physical 
and biochemical relations of the cells. The author brings 
these and kindred subjects into prominence, ■ and links 
tliem up with the facts of pathological anatomy. It is only 
by such a method that the student can bo taught what 
pathology is. 

Textbooks on pathology generally reflect to some exte.^ 
tho temperaments of their autliors— anatomical, 

1 rrirni unctical, or philosophical — but there appears to be 
Sirtendcncy to piesU the subject in Hs entirety 
n J to all its aspects. Dr.' Powem, IYhite’s hook on 
The Principles of Pathologtf is an example of this ten- 
deiie-f or rather it is an attempt to lay the foiindations of 
an aH-emhracing exposition of the subject which, in . 
ontiretT would seem to he beyond the powers of a singl 
nithor^’ It is, therefore, not a textbook on pathology, 
r caiefuily d ■an'u ground plan, starting from ^;b>eh the 
indent n av feel confident that he can build up the entire 
^jKufout any fear of omitting important 

3 Outlines 
ing Co. 1327 
nei). 


8?^ 

'kc Pr!,,cip!r> of 

o., Ltd. 1927. (Demy 8vo, pp. x4-Z79, 8 ngucc-. 


F.R.C.S. Publications 
Ko. XVIT. " 

Green and Co. 


April 7, 1928] 


REVIEWS, 


[ TriR Br.msH 
UeOICXX. Jo(7F.KAX> 


599 


Siicli seems to havo boon tlio intention of tlio nntlior, and 
lio has carried out liis scheme with cousitlerahle success. 
Tlie basis of an attempt of tliis kind must necessarily 
consist in a satisfactory scheme of classification— one that 
will enable every detail' to he included and to he put in its 
proper place in relation to other details— and tlio author 
lias placed classification in the forefront of his work. He 
lays down four main divisions of tho subject — namely, 
morphological, chemical, physical, and physiological patho- 
logy, and deals with each of these along two lines — 
hiostatics or morbid states, and hiodynamics or morbid 
processes. Tho biologic and scientific aspect of tho subject, 
which is too often neglected in ordinary textbooks, is there- 
fore placed in proper relief. Considerable ingenuity is 
e.xhibited in the subordinate classifications adopted, among 
which m.ay be mentioned the classification of pathological 
processes into (1) consecutive, or those which are the 
direct .effect of injury in the widest sense of tho term; 
(2) adaptive, or those whieh arise as a reaction against 
changes in tho environment and tend to neutralize or 
compensate for injurious action; and (3) autonomous, or 
progressive processes which are harmful and neither adap- 
tive nor reactive against changes in tho environment. 
The value of a sound classification and nomenclaturo can- 
not be pvorcstimated, and Dr. White’s book is a contribu- 
tion to this subject; but the work contains, besides, verv 
good and concise descriptions of the morbid states and 
processes themselves, and such chapters ns those on surface 
lihenomena, surface tension, electric charge, adsorption, 
and diffusion aro particularly clear and valuable. The 
book should assist the student in obtaining an insight 
into the scope of pathology, regarded as an independent 
science. 


v.ins.s^ s textbook of Iluman Pathology* presents the 
subject 111 the traditional form adopted in works on patho- 
ogical anatomy — that is to say, it treats in the first 
instaiioo of general pathological processes such as degenera- 
1011, inflammation, and tumour formation, and in the 
sccon part deals with the special pathology of the different 
organs. This arrangement is considered bv the author to 
position of pathology in the 
Kiihi'peV ournculum and tho best way of presenting the 
brS»= T' ‘"*'?4“otion to, and a basis for, the clinical 
iintlmlncrv- ™o<licine. The more intricate problems of 
definifo^ discussed in sufficient detail to permit of a 

auemnf '"I- “t issim, and an 

tlieor\^ TI distinguish clearly between fact and 

the honlr subject matter appears to be complete, and 
suitable f osonts the broad facts of pathology in a manner 
a for biological stddent as avell 

aLcast nf medicine desiring to keep 

abreast of this ever-enlarging subject. 


Da T? av nr w ^EB'^ATOLOGY. 
h^as Lv ^^^t'look on Diseases of the Sk, 

altboueb in distinction of a second editic 

increase in in uudergone the usi 

orieinal vnl ' general characteristics of t 

ti-if bLk ^ -ts’Tst I" 

Di* Mnnirpiin k ^*^st appearance we remarked tli 

colmired Ste Tu'L ^ 

than thirfv-oii- n 1 ^“ct there are no feu 

wo should thinlT illustrations in this edition, most 
expressly sta+erl’ Mr? plmtographs, although this is i 
upon c^lnilfi, '?"eli too much store® is often , 
always satisfnnt cations, which aro not by any mej 

they' are ven- uo doubt that in this "instai 

mei'it on the formereditiom 

rcflected”1rtl?r, <f'°l?gical research since 1923 : 
on diseases diin^T^*^ additions to the chapi 

oiving cl ieflv to Die 

g ^iiclly to the stud ies of Pernau, herpes is n 


an introduct?TO°by^Simon'p{p^n*^'r T. Karsner, II.D. 

1927. (Med? 6° l-omion = J- H- L-PPincol 

‘m, cases I- ^ 20 plates. dSs. net.) 

Second edition revised and^Lw'J* »IacKenna, JI.D.. B.C 
Co.v. 1937. (Roy. 8vo PD in i Baillibre, Tindal; 

1 voy. ovo, pp. xii + nsii; 145 figures, 36 plates. 253. ni 


included, whereas in tho first edition it was included among 
tho neurodermatoses. Dr. MacKenna also touches in 
passing on the interesting question of the relationship 
between tho dermotropic strain of the virus and the 
neurotropic strain, which, according to tho researches of 
Lovaditi, is the cause of encephalitis lethargica. He men- 
tions also tho recent attempts to treat lupus erythematosus 
with intravenous injections of certain gold preparations, 
such as kiysolgan. He -is not, however, enthusiastic about 
tins line of treatment, and -he is equally cautious on the 
subject of thallium acetate as a remedy' for ringworm of 
.the scalp. Hero wo note that he makes no reference to the 
convenient method provided of making a naked eye 
diagnosis of ringworm of tho scalp with the help of the 
fluoreseenco of the infected hairs produced by ultra-violet 
light shining through the deep purple of Wood’s glass. 

Speaking generally, our examination of the second edition 
of Dr. Macivenna’s book only serves to confirm the verdict 
given upon .the first: that he has produced a textbook well 
above tbo average, tborough, practical, sound, and easy to 
read, which may safely be commended both to students and 
practitioners. The only fault wo have to find is with the 
binding, which is not sufficiently strong; those who study 
the book as thoroughly and as often as it deseires will be 
fortunate if, in course of time, it does not come to pieces 
in their hands. 


SURGERY AT THE SAHRfiTRIERE. 

The second series of Travaitx dc la Clinique chirurgicalc et 
dll Centre anticancereux de la Salpctriere* brought out' by 
Professor A. Gosset, fully maintains the high standard of 
matter and presentation set up by the first series, which 
was reviewed in these columns a year ago (1927, i, 144). 
Of the ten articles. Professor Gosset is personally respon- 
sible for four, solely in the case of two, and conjointly in 
the other two. The volume, which is generously illustrated, 
begins with a full account of the organization and activities 
of the department under his direction by Professor Gosset, 
who, in giving a brief historical sketch, pays a special 
tribute to his teacher and predecessor F. Terrier (1837- 
1908), who did so much to introduce surgical asepsis. 
-4.mong the laboratories attached is a biological one under 
the care of Dr. J. Magrou, who has devoted much time 
to the investigation of vegetable cancer, and contributes 
an article on the tumours due to the Bacterium 
tumcfaciens. Professor Gosset and M. J. Charrier describe 
tho removal in two stages of tumours of the ascending 
colon — a method which they think likely to diminish the 
mortalitv from this operation. Dr. Robert Monod’s report 
on tho combined radium and surgical treatment of 75 cases 
of cancer of the cervix uteri is very encouraging, as many 
of the cases were sent in as inoperable, and 55 per cent, 
of the cases were well three years later. In a beautifully' 
illustrated and detailed account of 38. cases of the straw- 
berry gall-bladder Professor Gosset, with his collaborators 
AIM. Ivan Bertrand and Georges Loewy, points out that 
in 20 of their cases tho gall-bladdet contained free mulberry 
calculi, and reiterates their opinion, expressed in 1920, 
that detachment of the lipoid-laden villi is one, if not the 
sole, mode of .the formation of cholesterol calculi. The 
strawberry gall-bladder, in their view, though not the 
result of inflammation, is pathological, and good results 
are obtained by cholecystectomy. Clinically the symptoms 
of a strawberry gall-bladder without calculi are the same 
as those of cholelithiasis. In an article on the surgical 
treatment of mammary cancer, based on Halsted’s methods 
and dealing with 102 cases operated on between Januaiy, 
1919, and January, 1927, Professor Gosset states that of 
the 84 traced, 47 aro alive and well, 25 of them three years 
after operation. The indications, technique, and results 
of degastro-enterostomization are described by AI. Alarcel 
Thalheimer. The clinical and sigmoidoscopic aspects of 
clironic haemorrhagic and purulent proctitis are set out 
by M. Roger Savignac, who promises a further account of 
the etiology and treatment of this peculiarly obstinate 
affection. AI. Raymond Bernard describes the technique 
of removal of malignant glands from the neck, and 

• Traraux ile Ja Clinique chirurgicalc et Hu Centre anticanefreux tie 
la Salpetrierr. Publies par A. Qosset. 2e. seric. Paris : Mos.son ct Cie. 
1927. (Imp. 8vo, pp. 273; 134 fi;pircs* fr. sans majoration.) 


BEVIEWa 


600 Apbil 7, 1928] 


■[ 


Tnr. rnmTH 
Medical Jomsu, 


M. Manrico Boiireaii provieles the results of t«-enty-sovcn 
years’ experieiice as an anaestlictist; ho has produced 
general anaesthesia 24,000 times, and has had only throe 
Joaths. He. finds that pulmonary complications aro much 
commoner in hospitals than in nursing homes, and ascribes 
this to tho difforonco in tho preparation of the patient, 
especially tho hygiono of mouth and teeth, and to exposure 
in transit through cold passages. Professor Gosset, how- 
ever, lias tho teeth specially examined and a solution of 
methyleno blue aiiplied to them. 


GYNAECOLOGY. 

The second edition of Dr. J.smes Yottno’s Text-hook of 
Crtjnecology’ has recently been published, and tho author 
is to bo congratulated anew on a very satisfactory pro- 
duction. Tho plan of the book has not been altered, but 
fresh matter has been introduced in several chapters. 
Eecont work on the phj-siology and anatomy of tho corpus 
lutoura has been included, and the discussion on the rela- 
tion between tho ovary and menstruation is well treated. 
In the treatment of carcinoma of tho cervix tho claims of 
radium aro advanced. Heyman’s figures of 40.5 per cent, 
of five-year cures are quoted in support of the author’s 
leaning towards radium treatment as opjiosed to ■ the 
Wertheim operation. Dr. Young describes Bubin’s test 
for tho patency of the' Fallopian tubes, and a diagram of 
a simple apparatus for practical use is included. Tho 
chapter on ovarian tumours now contains an account of 
endometrioma of tho ovary in accordance with tho view 
set forth by Sampson of America. Apart from these 
changes, the book varies little from the previous edition. 
It is perhaps rather strange to see a British textbook of 
gynaecology with its title spelt in tho American fashion, 
but this is a trifling matter in a work admirably suited to 
the needs of the final-year student and the recent graduate. 
The book has been greatly improved by being printed on 
more pleasing paper, and its continued success may be 
looked for. 


NOTES ON BOOKS. 

The author of The Essentials of Otology’ states that “there 
are very few books on otology that the student can read 
intelligently.” Tho meaning of this sentence, which appeiirs 
to lay the onus of intellectual quality on student rather than 
book, is not perfectly clear, but if it is intended to imply 
that there are very few books on otology intelligible to the 
average student a singular want of appreciation of con- 
temporary otological literature is displayed. Such works are 
quite numerous, and the claim inferred by this remark is the 
more unfortunate because, after careful perusal, the book by 
Dr. McAulikfe cannot be given a place among them. The 
more it is studied the greater appears the chaos which the 
author has contrived to compress into a comparatively small 
space. The chapter on tests, for example, which is placed just 
in the middle of the book, contains some si.xteen pages, of 
■which no fewer than thirteen are devoted to an analysis of 
nystagmus Anatomical studies, which are now'here more 
important than in dealing with diseases of the ear, are relegated 
to the end, the place usually assigned to deaf-mutes, who are 
certainly not of much importance to students. “ When to tie 
off the jugular ” provokes a paragraph of five lines, which do 
not tell the reader, looking for guid.ance on difficult points, 
“ when.” The radical mastoid operation is dismissed in a few 
lines, and its results are condemned as altogether unsatisfactory. 
AA^e should perhaps add that the book is well bound and printed 
on good paper, and that it contains a few good illustrations of 
the simple mastoid operation, after Dr. Whiting’s well-known 
work on the modern mastoid operation, without the usual 
acknowledgement- 


Mr. Charles Wicksteed Aeaisteo.vg is a eugenist, who is 
convinced that the English, and probably other races, are 
degenerating as the result of. democracy and humanitarian 
legislation. In The Survival of the Unfittest’ he states his con- 
clusions that “ a differential birth rate, obliging .all ranks 


’ .4 Textbook 0 / Gt/necatoffi;. By James Voung, D.S.O., JI.D., F.K.CLS.E<I. 
■Second edition. Edinburgh Jtedical Series. London : A. and C. Black, 
Lid. 1928. (Cr. 8vo, pp. xvili-l-338: 183 ngures. 15s. net.) 

• Tbe Essentials of Otology. By George Birmingham -AIcAnlifle, A.B., 
yu, P.AC.S 'Oxford Jlcilical Publications. London and>New Vork: 
Oi-ford Universitv Press. 1928. (Demy 8vo, pp. .xv -H77 ; J!6 - figures 

It-, net.) ■ " 

’ The Surriral of the Vnfitlcst. Bv Charles Wicksteed Armstrong. 
London : The C. W. Daniel Company. "1927. (Cr. 8vo, pp. 160. Os. net.) 


to recruit from the classes below, must cause the rot to spread 
slowly upwards ” ; and that since tho war the process has been 
hastened ‘ by legislation more and more dysgenic, better and 
better calculated ^lo hasten the catastrophe which we refuse to 
sec approaching.” By improving environment appearances caa 
be improved for a certain time; but if the hereditary factor- 
IS neglected the time comes when improvement in environment 
can.no longer prevent the downfall. Tho statesman, it appears, 
has not merely allowed breeding in man to go on haphazard : 
he has deliberately interfered with a view to helping the unfit 
to survive and reproduce, and “ the e.xtrao'rdinary excuse for 
such interference with the divine plan of evolution has been 
that in man natural selection is no longer operative.” lae 
worst instance of man’s interference is, in Mr. Armstrong's 
opinion, the National Insurance Acts. Tho only national -insur- 
ance which he finds not prejudicial is that against old age, 
and to some e.xtent that against widowhood. As Jtr. Arm.strong 
thinks that “ every sane man knoivs instinctively that the 
proper cure' for unemployment is useful relief work ” he would 
seem to he afraid of the conclusions which really follow from 
his arguments. Mr. Armstrong’s solution for our troubles is 
to establish a settlement of eugenists. He suggests the Soulli- 
Easlcrn Pyrenees as the home for the settlement, where tho 
cult of beauty and good government could be developed. It 
■is perhaps disappointing that a tirade against the 'doubtful 
blessings of democracy and humanitarian legislation should end 
in Utopia, but, as Mr. .Armstrong says hopefully, the w^rld 
owes its progress to the unconventional, and the crank “ of 
to-day may be the revered teacher of to-morrow'. ' • 


Mr. A. L. Rowse, Fellow of All Sonls, has contributed to 
the General Series of the Psyche Miniatures, which must be 
distinguished from the Medical Series, a charming essay 
On History: A Stufty of Present Tendencies,’’ dedicated to the 
members of the Essay Club at Christ Church, where pre- 
.sumahly it was read. It is arranged in chapters, with the 
headings "An analogy,” “The present situation and the 
problem,” “ A sketch of a theory of history and applications 
and a Conclusion.” From the time of Hallam and Macaulay, 
and throughout the Victorian age, the attitude of historians 
can bo summed up as the glorification of the English Constitu- 
tion; but this tradition has faded away, and historians have 
now fallen back more and more upon the solid work of arranging 
and editing sources, and upon a more, exacting standard of 
critical methods. But with its advantages tffis method has 
its drawbacks, and .the present generation might be criticized 
for burdening their books with notes and addenda which, from 
lack of constructive power, such as Macaulay so pre-eminently , 
Tinsspssed ■ have not been incorporated into the body of tlie 
text His remark that " a whole essay might be written alone 
nn liifi tvrannv of references ” may apply even to some medic-at 
vwi ers Cconcludes on the cheerful note of Lord Acton's 
dictum; the study of history “ fulfils its purpose even if it 
only makes us wiser, without producing books, and gi-ves us 
the^gift of historical thinking, which is better than historical 
learninC. * 


In commemoration of the seventieth birthday of Professor 
ternhard Nocht, director of the Institute of Tropical Diseases 
. Hamburg, a collection of articles on tropical diseases" has 
,een 'published by his friends and pupils. Over ninety special 
ontribulions have been sent in from investigators in 
iaht different countries, and the hook is a handsome tribute to- 
•world-renowned scientist. Numerous illustrations and tables 
re incorporated ' in it, and there is a good photograph of 
r ■VT/artVlf, 


The fifth volume of scientific reports'” from the Institute 
Infectious Diseases at Tokyo, edited by Dr. You 
iliviCAWA contains thirty-six papers (of which twenty-eight 
-Fnelish and eight in German) devoted to bacteriology 
A oernlolv pathology, biology, chemistry, parasitology, and 
L" AleA enfomo^ogv. The subjects discussed include (he patho- 
llnesis'of experimental pneumonia in rabbits, antirabic vaccina- 
,enes , of cow-pox lymph, the oxidase reaction 

’'’"I’aeteria' chicken sarcoma, the function of the supraren.-il 
orto poUssium deficiency in animals and birds, and e.xperi- 
nentai studies in hook-worm mfection. 


p. 103. Z 3 . 6 d.net.) Bernlierd 

Arbeiten 

oclit zu scinei ; " ■ ■ Ausland?* 

ainb«rj:isch© i ‘ ' (Imp. S'o, 

Skitakn. 

sio. Tin- 651: Illustrated.) 


?. 1928] 


EPILEP3T. 


IhxBmttsS 
. Steoicjix. JocBXAC 


601 


Brittst) iHetitcal journal. 


SA-TUEDAT, APEIL 7Tn, 1928. 


EPILEPSY. 

The subject of epilepsy — or “ tlio epilepsies,” lo use 
a convenient and more clastic terminology — lias of 
recent years been attracting the attention of neuro- 
logists, psychologists, and biochemists, who have 
severally approached its manj’ problems from some- 
what different angles of study. The older conceptions 
of epilepsy tended to regard it as a disease of the brain 
itself — some peculiar inborn abnormality of the nerve 
cells by reason of which rccuiTent explosions, so to 
say, of neural energj' occurred, with the production of 
convulsions or other manifestations of the disease. 
The failure of many careful and prolonged histological 
studies to find any adequate structural changes to 
account for the symptoms led gradually to the 
abandonment of the conception that epilepsy is in any 
sense essentially or primarily a disease of the brain 
itself. And more modern trends in the study of dis- 
order of function in the nervous system, as opposed 
to that of actual structural changes, have gone far 
to widen our conceptions of the epilepsies, both 
in regard to their forms and their etiology. That 
rigid barrier — so' artificial but yet so attractive on paper 
—between epilepsy and hysteria has been seriousl}' 
breached by many clinical obseiwations, and this in 
itself is an advance of no small value; recent investi- 
gations of the epilepsies, moreover, may fairly be held 
to illustrate the advantages of broaldng down the hard- 
and-fast line of demarcation between “ organic ” and 
functional ” disease. 

Dr. Kinnier YTlson has lately published a valuable 
paper on Epileptic variants”* which brings into 
prominence that wider conception of the epilepsies 
vhich now prevails,^ both as regards their forms and 
their causes. In this article _in the Journal of Nenro- 
logy and Psycho'pathologij attention is drawn to the 
Men that the clinical phenomena of the epilepsies 
considered as escapes from physiological 
inhibitions, and that such escapes of function may be 
exteriorized in the form of motor, sensorv, or visceral 
sjmptoms. Thus on the motor side Dr. Wilson 
recognizes five variants ; (1) myoclonic or regional 
epilepsy, (2) epilepsy partialis continua, (3) tonic 
epi epsy, (4 co-ordinated epilepsy', (5) inhibitory or 
akinetic epilepsy. The sensory variants he classifies 
as tollows ; (1) reflex epilepsy, (2) sensory epilepsy, 
(3) affective, epilepsv. Among the visceral variants 
he places that peculiar symptom-complex termed by 
attacks, which that distinguished 
author fully described twenty years ago in his book 
le Borderland of Epilepsy. . It is interesting to 
term " inhibitorv or akinetic 
epi eps\ Dr. Wilson places that peculi.ar disorder of 
une ion cataplexy, a condition which has lately been 

- a racting much attention, especially since the publica- 
tion of the viiluable paper bv Dr. W. J. Adie on 

arco ep5\ yitli which the cataplectic attacks seem 
to be so closely associated. 

- Pt. .Tallies Collier’s Lumlo ian Lectures (of which 

= Brn 19a, x'lii™a7*' ^'tVrhoimlholoo'J, 'Ui, Xo. 31, 223. 


W'e published abstracts in our last issue at page 557) 
cover wider ground, embracing as they do the whole 
subject of epilepsy. On the etiologieaAside Dr. Collier 
brings forward convincing arguments in favour of the 
view that epilepsy is essentially due to a metabolic 
disturbance, although the exact nature of these dis- 
turbances is not particularized; indeed, we gather that 
in his view the disturbance need by no means always 
be of exactly the same order. While many may be 
found to accept freely such a hypothesis as an 
acceptable explanation of that condition which is 
termed idiopathic epilepsy', we feel that the lecturer 
is on less sure ground in maintaining the same thesis 
for cases of organic epilepsy — that is, those cases 
associated with some gross organic lesion of the brain, 
such as a tumour. Even in this latter variety, how- 
ever, a good deal of evidence is available in support 
of his view, especially the experience of the enormous 
numbers of wounds of the skull and brain in the war 
w'ith the relatii'eh' very small incidence of consecutive 
epilepsy, as well as recent experimental work of great 
interest which is quoted in the lectures. Interesting 
parallels are drawn by Dr. Collier between the clinical 
phenomena of migraine, py'knolepsy, narcolepsy, vaso- 
vagal ' attacks, and even tetany', the opinion being 
submitted that migraine, for example, may' be regarded 
as a particular form of local epilepsy, associated with 
a local swelling of the brain, analogous to angio- 
neurotic oedema and dependent again on some 
metabolic dyscrasia. 

Dr. Collier and Dr. Wilson agree in their inability 
to separate narcolepsy' from epilepsy', differing in this 
respect from Dr. Adie, who has attempted to dis- 
tinguish clearly between them. A loss of function is 
regarded by Dr. Collier as the essential feature of 
epilepsy, agioeing with the physiological inhibition 
defined by Dr. Wilson. If this view be correct the 
positive symptoms of any epileptic attack must be 
regarded as release phenomena, occurring at Icn'cr 
levels of the neiwous system. Such a physiological 
conception is certainly attractive, and appears to fall 
into line with the recent monumental researches on 
conditioned reflexes of Pavlov and his colleagues, who 
have shown that sleep itself is but a matter of internal 
inhibition — a discovery which seems to dispose of the 
idea that release symptoms must of necessity be 

positive,” using that term in the sense defined by 
Hughlings Jackson. The Lumleian Lecturer is un- 
doubtedly in advance of cuiTent opinion in his con- 
tention that the ordinary fainting or syncopal attack 
is not to be clearly separated from the epilepsies either 
on etiological or on physiological giounds. It may he 
admitted at once that cases are to.be found in which 
the two seem to merge almost imperceptibly into one 
another, yet general experience is still, we think, far 
from admitting their identity. 

Muck has been written of recent years on the 
psychological aspects of epilepsy; some, indeed, have 
gone so far as to claim for it an inevitable menial 
causation as well as a particular mental make-up. 

It is probably true to sa)' that the balance of 
opinion is not in favour of accepting such a view, 
but this is 'far from denving the powerful part 
played by the emotions in the production of 
attacks. Such a concession, however, to the psycho- 
logists does not imply a surrender of the metabolic 
theorv. The correlation between body and mind is 
constantlv being displayed in all the function.al dis- 
turbances, whether these be exteriorized in symptoms 
referable to the nervous system or to others, such as 
the respiratorv or the digestive. The elucidation of 
problems such as those is a task which modern medical 


602 Araiii 7, 1918] 


BREAST-PBEDINGf, 


r The Ilftms* 

4. Medicii, Jotmsii, 


rescni-ch is liappily -n-cll disposed to undertake, and in 
such a field the further studj’ of the epilepsies may 
furnish fruitful results. Biochemical studies of 
epilepsy have been numerous, but they cannot as yet 
be said to have aehieved results which carry much 
conviction in regard to the essential etiology of its many 
rai'iniits. Nor, we fear, can a claim be made out for 
any gi-eat advance in treatment. On the metabolic 
side the multitude of “cures,” such as vegetarian 
diets, fat-free diets, ketogenic diets, and others, is in 
itself a confession of failure. A close study of the 
metabolism in the condition known as status 
epilepticus — where, as Dr. Collier rightly points out, 
a definite toxaemia must ceriainly be present — might 
succeed in throwing more light on this difficult 
problem, though the opportunities for such research 
are few and uncertain. 

A healthy discontent with the mere label of 
epilepsy is the proper attitude of mind; the epilepsies 
should be regarded as S3'mptoms, whose essential 
causes have as yet to be unravelled, po.ssibly 
indeed varying with each individual case, whose 
peculiarities, therefore, are all the more deseri'ing 
of careful study. 


BREAST-FEEDING. 

A SURVEY of medical literature during the last 
decade or so clearly indicates the increasing impor- 
tance attached to breast-feeding. -A.s Dr. Frank 
Howard Richardson pointed out not long ago when 
discussing the progress of breast-feeding in New 
York State, ‘ “ Even though much of this enlarging 
volume of medical attention has been concemed 
with public health measures rather than with 
private practice, still there has been a steadily’ 
increasing tendency on the pai-t of students of infant 
health and nutrition to concern themselves with 
some of the multifarious problems connected with 
the natui-al feeding of children, as compared with an 
earlier (and still altogether too prevalent) tendency 
to experiment with artificial methods of nourishing 
babies.” Nevertheless, it is still a difficult matter to 
obtain exact information, even from the most recent 
literature, on the prevalence and duration of breast- 
feeding in the community as a whole. It may, how- 
ever, be taken for granted that breast-feeding is more 
usual in hospital than in private practice. 

The findings of an investigation on ‘ ‘ The prevalence 
and duration of breast-feeding in hospital practice ” 
in- the Obstetrical Unit of the Royal Free Hospital 
have been I’ecorded and discussed by Professor Louise 
Mcllrby.' She remarlts that in obstetrical depart- 
ments it is the endeavour of the medical and nursing 
staffs to induce the mother to nuree her infant unless 
the mother is suffering from pulmonary tuberculosis or 
advanced cardiac disease, when lactation is contra- 
indicated. Owing to distance and other causes all 
the infants born in a hospital cannot attend its welfare 
clinic, many of them being taken to the local practi- 
tioner or to nearby welfare centres. This practice 
makes it difficult to* obtain 'information as to the dura- 
tion of breast-feeding. In the Obstetrical Unit of the 
Royal Free Hospital every -mother is made to nurse 
her baby vvhen possible, and every means available is 
taken to enable her to supply a sufficient quantity of 
millc for the needs of her irrfant. 

Complications with the breast or nipples' ■which 

* 7o«rn. AMcr. Med, A& 90 C,, vol. 89, Xo. 18. 

Ohgtet. and Gi/naecol. of the British Emiiire, "Winter Number, 


prevent sucklirrg, as well as a deficient supply of milk 
call for appropriate treatment. Professor IMcIlroy 
. stresses the importance of carious teeth and pyorrhoea 
as causes of failure iir lactation, much improvement 
in the rnfant s v/eight chart often following suitable 
treatment of the mother’s teeth. Further,- during the 
last few months treatment of the nursing mother by 
artificial sunlight has been carried out, and the results, 
which will be published later, are said to be most 
encouraging. When the supply of milk is inadequate, 
and cannot be improved, supplementary feeds are 
given, in some cases twice daily and in others by 
alternate feeds. Fresh cow’s milk is preferred to dried 
or condensed milk. Only where it is learned that 
home circumstances would not render cow’s milk 
available is a dried milk given, so that the mother may 
be taught in hospital how to prepare it, and also that 
the infant may continue at home with the same 
method of feeding as it has liad in hospital. Professor 
Mdlroy is positive that it is a mistake to cany out in 
hospital a method of feeding infants which is only 
possible for a trained staff, and which is beyond the 
capacity of the mother and her' home surroundings. 
She points out that tlie infant suffers enough' from its 
dislocation at the end of ten days without adding to its 
discomfort by complete change of food. It is, also, 
bettor to begin artificial feeding in hospital and to 
treat the breasts for the prevention , of lactation in 
those cases in which, owing to occupation or the 
necessity of separation from the infant, the mother 
cannot nurse it. On an average 5.1 per cent, of the 
infants in the Obstetrical Unit ' of the Royal Free 
Hospital leave the hospital entirely artificially fed. 
A much larger proportion of, artificially fed babies 
attend the welfare clinics, from which it may be 
gathered that all the mothers do .not continue the 
methods they used in hospital. 

In reply to a questionary in the form of a personal 
letter, the condition of 730 infants with reference to 
the method of feeding was investigated .'about nine to 
tvvelve months after birth. Of. these, 333, or 45.8 per 
cent., were entirely breast-fed — among these there 
were 16 deaths; 33, or 4.5 per cent., had supple- 
mental feeds after leaving hospital — among these there 
were no deaths; 7, or 0.96 per cent., had supplemental 
feeds while in hospital — among these there was one 
death; 320, or 43.7 per cent., had artificial feeding 
substituted after leaving hospital, and" ainong these 
there were no deaths; while 37, or 5,1 per cent., were 
never breast-fed, and among these there were 3 deaths. 
Professor JlcIIroy believes it desirable that all mater- 
nity hospitals should have a follow-up system in 
co-operation with the infant welfare clinics, so that 
supervision of the health of the nursing mother- may 
be systematically carried out. It is open to question 
whether a delicate mother should enthely feed her 
infant- supplementary feeds may be necessary to keep 
it in health, and were found to be more satisfactoi'y 
tlian entire artificial feeding., 

Tn this investigation the infants in satisfactory home 
tand to b. in better health to 
those living under poorer conditions, eiea alien 
entirelv breast-fed. Altliougb among the PO°i; 
feeding is more economical than any method 0 
artificial feeding, yet its benefits are ^ “ 

counteracted by the straggle for a 
and unsuitable home conditions. It may 
concluded that, although nine months bro«sffc«b e 
is the ideal to strive for, yet care smd 
be given to the nursing mother if this is to yield 
results thflii artificial feeuin^j- 




Xraiii 7, igjS] 


BA.'iLiISS AND 8TAEDING MEMORIAD. 


r The British 
L MedICAI. JOCRKIX. 


605 


public with prbfcssionni duties scorns to bo fatal to any such 
claim to exemption from iucoino tax. To quote the Master 
of the Rolls once more: “ XJnless the Council eorao ex- 
clusively and fully u-itliiu the spirit and intention of the 
statute of Elizabeth I do not think they can claim exemp- 
tion.” It seems to us to bo a serious blemish in the income- 
tax code that income which is in part expended in the 
discharge of very grave and rcspousiblo duties to the public 
should bo liable to tax on the ground that the other part 
is not so expended. The exclusivoncss of the charitable 
function docs not seem logically to have any real bearing 
on tho equitable claim to exemption for such income as is 
expended “ charitably ” in carrying out tho duties of a 
statutory body such ns tho General bledical Council. 
Whether an appeal to tho Houso of Lords will bo made we 
do not know, but the Council’s legal advisors will not bo 
encouraged by tho judicial views expressed. 


BAYLISS AND 5TARUNG MEMORIAL. 

The opinion has been widel)’ expressed that there should ho 
some memorial to record the great services rendered, both to 
the science of physiology and to its applications in the 
practical problems of medicine, bj* the labours of Sir William 
M. Bayliss and Professor Ernest H. Starling, who were 
intimately connected for so many fruitful years. Tlio 
patient zeal of the one, tho fire and enthusiasm of the other, 
and the eagerness of both to place their knowledge and 
experience at the disposal of other workers, have led to a 
rmiversal appreciation of their services. Tho number of 
those in all countries who have profited directly from their 
help or indirectly by their influence is very great, and their 
writings stand as monuments to their industry and learning. 
A widely representative committee has been formed to issue 
an appeal for funds wherewith to commemorato tho con- 
nexion w'ith physiology of these great partners in a manner 
of which they themselves would have approved. The com- 
mittee is of opinion that the most fitting memorial would bo 
the creation at University College, London, of. a Bayliss 
and Starling Studentship, open to any graduate in science 
of any university, or any graduate or undergraduate in 
medicine of suitable standing, to enable him to spend a year 
or more in such training in physiology and biochemistry as 
would fit him for research. Subscriptions may be sent to 
Professor C. Lovatt Evans, F.R.S., at the Institute of 
Physiology, University College, Gower Street, AV.C.l. 
(Cheques and postal orders should bo crossed, and endorsed 
• Bavliss-Starling Memorial Fund.”) The Governing Body 
of University College has agreed to assist tlio appeal by 
remitting all fees payable by the selected candidate. 


T.+n cn n health IN INDUSTRY. 

tne held of preventive medicine tho increasing attention 
now . given to health in industry, to accident pi’ovention, 
an to welfare work constitutes an interesting development 
in social organization, involving as it does the co-operation 
o 10 State, the employei-s' associations, the workers’ trade 
unions, and numerous private individuals. The second 
^"‘^“strial Health Education Society, 
or illustrates ono sido of the movement in which 

medical practitioners play an important part, in company 
''f ii ^'“1 labour organizations. In the course 

0 10 year the work of the society has extended con- 

si eia y, and tlio increasing demand for its services shows 
a ui espiead interest among workers in occupational 
iseases and their prevention. The main purpose of the 
ec 111 cs given has been to convey information to those liable 
o 0 irectly affected, but the discussions which have 
o ouet 1 10 addresses given by medical practitioners have 
ft"- . ^ useful purpose -bj' -bringing to light eom- 

p tun s which bad previously been known only to those en- 
ga„e< in tho particular occupation concerned. Kbeiimatism 
appeals to bo the most common trouble in indust ry , and 


a leaflet on tlio subject lias been prepared for circula- 
tion by the society by Professor E. L. Coliis. Another, on 
‘‘Mule-spinner’s cancer,” by Dr. Prosser White, is in course 
of preparation for distribution among cotton operatives. 
The advancement of education in industrial health sliould 
bo assisted also by the establishment of the Home Office 
Industrial Museum, which is a permanent exhibition of 
methods, arrangements, and appliances for promoting 
safet}-, health, and welfare among workers in manufac- 
turing industries. It is tho first of its kind in this 
coiuitrj'. Tho descriptive catalogue which lias been pre- 
pared (obtainable from H.M. Stationery Office, KIngsway, 
IV.C.2, price 3s. 6d. net) is designed to servo not onh- as 
a guide to the museum, but also in some measure as a hand- 
book on the subject. Sections in the museum are given 
to accident prevention and safety devices, illustrated by 
examples and photographs, to labour-saving devices, and to 
welfare; but medical interest will centre mainly in the 
section devoted to industrial diseases, dealing especially 
with anthrax, lead poisoning, silicosis, and. dermatitis. 
Photograplis aro employed to show preventive methods 
adopted in various industries; charts indicate the incidence 
of the diseases, models illustrate the lesions they pro- 
duce, and micro-pbotogvaphs of pulmonary conditions are 
exhibited. Doctors who practise among industrial workers 
liable to occupational disease should find the health section 
of the museum a useful source of information. 


THE NEW IRISH FREE STATE MEDICAL REGISTER. 
The now Register under the Saorstat Eireami (Irisli Free 
State (Medical Practitioners) Act, 1927, will, ns announced 
in om- advertising columns, be established on May 26tli, 
after which date no person will he entitled to any of the 
rights and privileges of a registered medical practitioner 
unless his name appears therein. Such a person will not, 
for example, he entitled to recover fees for advice or 
attendance, or to hold any public medical appointments in 
the Irish Free State, even though his name appears in tho 
general MciUcal Jieghier. Any person whose address in 
the general Medical liegiater is outside the Free State 
must, to he entered in tho new Irish Register, make 
application to tho Medical Registration Council, Room 
123, Custom House, Dublin, giving full name, address, 
and qualifications, between April 25th and May 26tli. 
Persons whose addresses in the general Medical Segister 
are in the Free State are entitled to he entered in the 
new Register without application, but it is suggested that 
aR who desire to be registered should make application, 
particularly if the 3 ' have changed their address since the 
beginning of the year. Those who are not entered on the 
neAv Free State Register at its establishment can only 
be registered subsequently on payment of the prescribed fee. 


At the meeting of the Royal College of PIn-sicians of 
London, held on April 2nd, Sir John Rose Bradford, 
K.C.M.G., M.D., F.R.S., was re-elected President. 


The King has made the following appointments to His 
Majesty’s medical household in Scotland : Honoraiy 
Physician, Ashley W. Mackintosh, M.D. ; Honorar\' 
Surgeons, John Marnoch, C.V.O., and John Fraser, .ill. C. ; 
Honorai'y Surgeon Oculist, Arthur Havens Sinclair, M.D. 


, At the last meeting of the Council of the Royal Society 
of Aledicine the Nichols Prize was awarded to Dr. Peter 
L. McKinlay and Dr. Remington Hobbs, tbe prize being 
equally divided between them. This prize, of £250, under 
tbe will of tbe late Dr. R. T. Nichols, is offered everj- three 
years for the most valuable contribution b\- a British 
subject towards “ Tlie. discoveiy of tho causes and the 
prevention of death in childbirth from septicaemia.”. 



606 April 7, 1928] 


THE ECONOMICS OF MENSTRUATION. r 

■ — Llfisnicit. JoPBNUi 


THE ECONOjriCS OF MENSTRUATION. 

It is notowoi'tliy tliat during rccoiit years tlic pliysio- 
logical nature of the nionstrual oyole lias received more 
general recognition, and tliero has been some tendency to 
doprecato tlio view of this period ns a time of disability 
and ill health. AVhilo this attitude of cultivating liealthy- 
juinded indifference to nionstruation should go' far ton-ards, 
preventing many, if not most, cases of d 3 ’smenoiTiiooa, it- 
is still urged that the industrial emploj'inent of women is. 
always bound to bo unsatisfactoiy on account ■ of tho 
economic loss entailed by an imreliablo worlcer, and it is 
often alleged that women are greatly handicapped in 
professional and business life bj- j)h 3 ’siologieal instabilit}’, 
said to be the natural consequence of a conspicuous montlilj' 
rln’thm to which all their functions are subject. For some 
j-ears past tho Industrial Fatigue Research Board has been 
conducting investigations into the effect of the menstrual 
cycle on working capaeity, and in a recent re 2 )ort* two 
lines of studj' are considei-ed. 

Psychological Considerations. 

Miss S. C. M. Sowton and Dr. C. S. Myers deal in tho 
first part of the report with the influence of the menstrual 
c^cle on mental and muscular efficiency. The subjects of 
tho investigation were arranged in two groups, of which tho 
first, “ A,” consisted of thirteen universitj’ students, and 
the tests consisted of the " siiearing ” tests and a simjdo 
form of “ number-checking,” which were emploj’ed everj’ 
week-daj' at tho same time each morning during two 
successive terms. Tho subjects were unaware of the exact 
nature of the investigation ; details of tho occurrence of 
the menstrual period were obtained by a simple procedure, 
a short dailj’ bulletin of tho subject’s general condition at 
the time of the test being recorded, and tho occurrence of 
the jjeriod being noted among several other general obsciTa- 
tions, including such occurrences as headaches, excitement, 
and woriy. The influence of practice soon made itself 
evident in these univorsitj' students, and the vacation 
considerablj- interrupted the work, so group “ B,” con- 
sisting of sixteen industrial girls, was chosen. The test 
chosen ivas a modified form of “ number-checking,” witli 
tho introduction later of the “ dotting ” test, while the 
experiment was continued for six consecutive months. The 
results of both series of experiments were analysed bj- 
means of composite cui’ves and other statistical methods, 
and before considering the conclusions to bo drawn from 
tho investigations the report enters veiy fullj’ into the 
efficacj' of the tests and the validitj- of the deductions. Tho 
results in each individual case are carefullj' scrutinized. 
Of the twentj'-nine subjects seven had to be rejected owing 
to insufficient data being obtained or to gross irregularitj' 
of performance, and in one case because of illness. Of the 
remaining twenty-two, five showed no alteration in per- 
formance of tho tests at the menstrual period ; in four there 
was a better performance; in nine the performance was 
worse at these times or just before them; while four showed 
a better or worse performance according to their stage of 
familiarit}'' with the tests After discussing various points 
in regard to social status, the feeling of pleasure or dis- 
pleasure at the tests, general jjhysical fitness, and other 
matters, the report concludes this jiart of tlie work bj- 
saying: “Any lowering of efficiency at the tests which 
occurred at or near the menstrua] [Deriod was not in general 
greater than that which occun-ed at other times — ^that is 
to saj-, no experimental evidence was obtainable that the 
mensti'ual period in noi-mal women is associated with 
serious incapacity for mental or muscular work.” 

Physiological Considerations. 

In the second section E. M. Bedale considers tho rela- 
tion' of the menstrual cycle to general functional activity. 
A three mouths’ study of a single subject under conditions 
controlled as closely as possible was made in a healthy 
woman, aged 30. Observations were made twice in twentr*- 
four hours of tho bod}' temperature, the basal metabolism, 
pxilso rate, blood pressure, and resj^iration rate in the 
post-absoi-ptivo resting condition, the vital cajia’city, and 
gg ytain orgometer experime nt, s. The diet was fixed, and 
Eta‘”m"ry ® 


the hours of bed, exercise, and occiqjation were all 
scheduled. Ihe subject kneiv the j)ur[)ose of the experi- 
ment, but had no prejudices as to the result. The work 
«as to a certain extent disturbed by the delaj’cd onset of 
the jicriod in the sccoinl month, and by a general deteriora- 
tion of vigour which set in about the middle of the 
experiment. A simple statistical device, slightly modified 
iioin one used by jMooi'o nnd Barker, ivas employed to' 
; aiialyseithc. results, at tho end of tho e.xperiment, and the 
conclusions I’cachcd ma}' be summarized in the following 
quotations : . _ - . . . 

The evidence of the present e.xperiments seems to be that 
a periodic heightening of functional activity above the average 
occurs late in the intermcnsfrual phase of the monthly cycle, 
and that a corresponding reduction below the average is found 
shortly before or at the onset of menstruation.” 

“ There seems no reason to think that the fundamental 
phj’siological rlij'tlim in women is such as to affect, either 
considerably or constant]}', the quantity or -quality of their 
industrial work,' provided always that no pathological con-' 
dilions are present.” 

Tho general deductions from this report are of great 
economic importance, since the work tends to confirm the 
result of other recently published investigations on tlio 
menstrual cycle. It may now he asserted more definitely 
that this physiological phenomenon has, as a rule, 
no lioticoable effect on working capacity ‘among normal 
healthy women, and such a statement will he of special 
interest to those concerned in industrial matters. 


JOSEPHINE BUTLER, 

Centexaht Tributes. 

Ic seems a long time since the activities nnd adventures of 
tho early suffi'agettcs. How much more remote are the 
davs of Joscpliino Butler, a great part of whoso Ufe was 
devoted to working for the repeal of the Contagioiis Diseases 
Acts 1864-69. In an endeavour to illuminate this shadowy 
neriod for tho benefit of the present generation, and also to 
keen green the memory of a groat and noble woman who 
was born one Imndrcd years ago, Dame Millicexi Fawcett 
has compiled a hook entitled Josephine Butler: Her. Tier/; 
and Principles, nnd their Meaning for the Txcenticth 
renturu ' To many people to-day her name is unknown, 
and after reading this bonk it must come to many ns a 
surnrise that in the years 1869 to 1886 it was a .household 
word either for warm praise or bitter denunciation, 
according to tho views held on the work to which she 
Imd devoted herself. Sixty years ago it was unknown for 
wonien to speak in public; two years later in 18TO, Mis. 
Butler was addressing mixed audiences all over England 
on the subject of prostitution. During those years, alien 
ni-olonged and furious controversy raged round the question 
of +ho^ “ State regulation of vice,” Mrs Butler was the 
oLJ^l figure not only in this country, but also on the 
S^itfficnf It is difficult for ns to realize the courage, 
and intense conviction needed in those days for a aomaii 
to chaUcimb public^ opinion on such a subject. Josephine. 
Butlef ffiwli irresistibly to the work, insp red by her, 
valour’a band of men and women who gathered round liei. 
“ Mrs Butler was the head and front of the movement 
throughout, her beauty, her grace, her eloquence, and 

Lomltable coi.rago won adherents on every sffie an 

secured tho victory for us at last —so mote Di. -Hen 

''''About 1868 great, alarm was felt at the 
vcner'’eal disease: not only in the fighting MA al o 

in the civil population, and so the first of the Conta^ioi 
Diseases Acts was introduced and readily passed. 1 
svstem of regulation of prostitution then existing m 
France was regarded, almost without exception, by tl 
medical profession and police administrators "S “" y. 

method of dealing effectively with this problem. ‘ 

French system women registered ,, "t,.e 

set apart' in certain houses tolerated or licensed b} 

'Josephine Boiler: Her tfork and Principles, on't II. 

the Tirentielh Century. By J Uliccnt G. G.B.E unu 

"irner. London: The Assooialion for Moral and Soeia 




APRIIi 7 i 1928] 


BCOTIiAND, 


t TExfismu 
JJzricxi. Joc»xit • 


police. The inmates of these houses could ho medically 
examined at stated intervals, and were subject to the 
control of specially appointecl police and medical officers. 
In Prance sncli control operated as a police measure, but 
in England it was inaugurated by Act of Parliament. The 
Contagions Diseases Prevoiitioii Act CWomon) had been 
passed in 1864, and further Acts wore thought necessary in 
1866 and 1869. They applied at first to fourteen naval 
and military stations, but it was intended by degrees to 
extend their operation throughout the cduntiy. Mrs. 
Butler was firmly convinced that such State regulation of 
inostitution and the traffic in women and children were 
interdependent; that the licensed house ■ constituted the 
chief market for the traffickers; and that the only effective 
any to abolish tho traffic was to raise continuous and 
uncompromising opposition to official regulation of vice in 
eveiy shape or form. She felt strongly that .such regulation 
infringed tho rights of women as citizens. In her speeches 
and writings she appealed again and again to tho main 
principles of tho British Constitution, above all to tho 
famous words of tho Great Charter — “ To no man will wo 
sell and to no man will wo deny or delay right or justice.” 

Tho first association formed to oppose tho Acts was 
inaugurated in 1869 at Bristol, following tlio meeting of 
the' Social Science Congress, at which tho Acts had been 
discussed. Almost simultaneously tho Ladies’ National 
Association for tho samo purpose was formed, and tho two 
societies worked together in tho closest harmony until 
success was at last achieved. Tho fight nas long and 
arduous, and not (incrediblo as it may seem) without 
physical danger for Mrs. Butler, but victory was finally 


hers in 1886,, when tho Contagious Diseases Acts "were totally 
repealed. Tho direct but later consequences of this accom- 
plishment aro manifold. Dame Millicent Fawcett appends 
a list of these results, with the dates of their achievement. 
Tho year 1927 saw tho publication of Parts I and II of tho 
League of Nations Experts’ Report on the Traffic in Women 
and Children,^ which referred appreciatively to the great 
campaign of Josephine Butler. This report endorses for 
tho world all the principles for which she fought in this 
country. Wliat the report proclaims now, with the autho- 
rity' and prestige of the League of Nations behind it, one 
woman dared to say fifty-eight years ago rmder very 
different conditions. To her belongs the honour of being 
tho first to organize a challenge to the State regulation of 
vice and the double standard of morals. 

This year has been published Human Merchandise : .4. 
Study of the International Traffic in XVomcn,^ by H. 
Wilson H.irkis, a book commemorating Josephine Butler. 
It summarizes the report of the League of Nations referred 
to previously, and should have a wide appeal, particularly 
for those who take an interest in the work of the League. 
Ono of its. objects is to prove that certain national social 
problems can only' bo solved by international action. It is 
a happy incident in the celebration of Josephine Butler’s 
centenary' that further testimony should be forthcoming 
of tho good which has sprung from the seed sown by her. 


2 League of Nations Report, Obtainable from the League of Nations 
publication agents, Messrs. Constable and Co., 12, Orange Street, London, 
(In two parts, 2s. and 7s. 6d. respectively.! 

* /fwwan UcTcliandne : A Studi/ of the liiternattonal Traffic in Ji'omrTU 
By H. Wilson Harris. London : E. Benn, Ltd. 1928. (Cr. 8vo, pp. lii 
+ 272. Os. net.) 


Tuberculosis in Scotland. 

The annual report of tho Royal Victoria Hospital Tuber- 
culosis Trust, Edinburgh, which has just been issued, 
describes the work of tlio Trust in regard to tlie care and 
prevention of tuberculosis throughout Scotland and at the 
Southfield Sanatorium, Libertoii, during tho past year. 
Uno point noted is the great increase in the number of 
applications for the admission of young children to the 
CO ony , this is regarded as a good sign, iudicating au appre- 
cia Ion of tho fact that tuberculosis is generally implanted 
m early life. While it is admitted tii.-it the claims of 
persons y, ith adianccd tuberculosis must be met, in the 
mterest both of the individual and of tlio community, it 
is pointed out that tho eradication of tuberculosis would 
no e achieved by this alone; in tho scientific care of the 
u erculous child, it is hold, lies tho sure Hue of .advance, 
auQ It this was more thoroughly realized by [larents and 
coctors throughout the country tho depressing procession 
o tuberculous -cripples would disappear in tiio course of 
c When a child is received at 

bouthhckl Sanatoriiim Colony the presence of tuberculosis 
and Its extent are defined. Thereafter, by eveiy avail- 
mh child’s physiological resistance is raised, 

taken to meet particular issues. The 
in +1 w"' milk is considered an important link 

nninif m against tuberculosis, and tlie Tuber- 

Hnrlnn ’.'“c developed a herd of tubercle-free c.attIo 

, ® years with two objectives — namely, the 

bK? 1 -'^'^ tubercle-free milk and tho acquiring of a 

+ 1 1 *^ ' ^iich could he sold as cattle free from 

tuberculosis. The herd now numbers approximately 100; 
of utilized for maintaining the supply 

nn ^ ^ large clientele which readily takes 

fi L IS available. Of the remainder, about a score 
on 6 ready in a year as milk producers for sale to 
laimers, and the number of cows that would be available 
u increase year by year. With regard to research, it 
as 16 desire of the committee to co-operato as far as 
possi e with tuberculosis care committees. Tho committee 
opes o appoint two special workers for the prosecution 
systematic investigation, for wliicli it would be in a 
posi ion to afford opportunities if an annual sum of £600 
cou d bo obtained. During the past year 211 patients hat 


been admitted to the sanatorium colony from all parts 
of Scotland. Six additional beds have been rendered avail- 
able for patients, and the extension of the nurses’ quarters 
has proved of great assistance in administration. The 
Trust is co-operating closely with tuberculosis committees,' 
and financial grants are made in special cases to assist the 
families of tuberculous patients. The report is attractively 
illustrated and contains a reference to the visit paid to' 
the sanatorium colony by members of the British Medical 
Association during the Annual Meeting at Edinburgh last 
year. Sir Robert Philip, President of the -Association, is 
vice-president of the Trust, which owes its inception in 
large measure to his genius. 

Edinburgh Ataternity Hospital. 

Tbo eigbty-tliird annual meeting of subscribers to the 
Royal Maternity and Simpson Memorial Hospital, Edin- 
burgh, was hold on March 27th. Dr. T. G. Nasmyth, 
who presided, called attention to some of tlie chief features 
in the annual report. Tho number of patients delivered 
in the hospital during 1927 had been 2,094, wliich was the 
largest number for one year in its histoi^-. The institu- 
tion in its indoor and outdoor work dealt with 38i6 per 
cent., or more than orie-third, of all the births in greater 
Edinburgh. The ante-natal clinics were growing in popu- 
larity and usefulness, and in the past year 10,002 visits 
were paid to these clinics. During 1927 83 nurses and 
287 medical students’ had been trained. Dr. Nasmyth 
announced that it had been agreed for financial, adminis- 
trative,' and educational reasons to amalgamate the 
Maternity Hospital with tho Royal Infirmai-y. The site of 
George Watson’s College, upon which it was proposed to 
rebuild the hospital, wotdd not bo available for some years, 
and tho arrangements for amalgamation were accordingly 
still in au unsettled state. Tho hosiiital must remain 
under its present management for about six years to 
come, and tlio need for support was greater than ever. 
The income from the fees of pupil nurses had now almost 
disappeared, because, in common witli tho otlior Scottish 
m.aternity hospitals, they had to offer freo hoard and 
training in order to secure the requisite complement of 
nurses provided with previous hospital training. Tlio 
deficit on the ordinaiy working account for the past year 
had been £3,026, and the hospital had no rcsei-ye funds 
which could stand a repetition of such shortages. If the 
work was to be continued at its present high standard 


608 APItlli 7 , igaS] 


inELAND. 


C " TnEBnmsH 
Memcu. J0XT.JIH. 


of efficiencT a stabilized subscription income of £4,000 per 
juiuuui must bo forthcoming. 'I'lic adoption of tlio report 
^yas seconded by Mrs. Burnett Smith (Annio S. Swan). 
Dr. James Haig Derguson, moving the re-election of tlio 
directors, said that the object of tlie hospital was to 
provide a maternity service for the eastern counties of 
Scotland, and this they had to do at present from an under- _ 
sized, olisolete, and * out-of-date building, incapable of 
adequately overtaking 'its important function. 'Jhe fact 
that the hospital was practically the same in structure as, 
it had been fifty years ago, notwitlistanding the greater, 
work done, was not the fault of the directors, but .was duo 
to the apathy of the public, which had failed to realize 
what it ought to do with regard to this institution. 

Proposed Extension of Qalashlels Hospital. 

. In the annual roport of the Galashiels Cottage Hospital 
recently issued, the necessity for extension of the hospital 
is urged. Surgical work appears to have increased much in 
i-ecent years, rendering the present accommodation in- 
adequate both for the number of patients and for adminis- 
trative requirements. Maternity cases which are likely 
to be complicated have also been admitted in recent 
years. Although the hospital was primarily intended for 
the town of Galashiels and its immediate neighbourhood, a 
view is now gaining ground that the hospital might serve 
a larger area, and donations amounting to £3,000 hare 
already been received for the purpose of extension. 

Glasgow Sick Children’s Hospital. 

The forty-fifth annual report of the Glasgow- Boyal 
Hospital for Sick Children has been recently issued. The 
number of patients treated in the wards of the hospital 
was 7,143, while those considtiug at the out-patient 
department numbered 83,591. The average daOy number 
in residence was 244. Ordinary expenditure amounted to 
£33,294 as compared with £32,108 in the previous year. 
The country branch of the hospital at Drumchapol, which 
was inaugurated by a gift of £17,500 from the trustees of 
the late Mr. Peter Coats, is reported as being still £4,000 
.short, and the directors make a special appeal for this 
sum. It is also intimated that a sum of £10,000 is 
required to provide facilities for research work in the 
hospital’s pathological department. 




Royal Victoria Hospital, Belfast. 

The annual meeting of the Hoyal Victoria Hospital, 
Belfast, was held in the King Edward VII Memorial 
Building on March 20th ; the Marquess of Dufferin and 
Ava, chairman of the board of management, presided. The 
annual report dealt w-ith the amalgamation of the Belfast 
Maternity Hospital and the Boyal Victoria Hospital, and 
also witli the alarming increase of motor accidents ; investi- 
gation of these cases sliowed that a large number of the 
drivel's were not insured. The total number of medical 
and surgical cases admitted into the wards during 1927 
was 5,450, of which 202 were cases of motor and bicycle 
accidents; this did not include a large number of minor 
accidents treated in tbo out-jmtient department. About 
50 per cent, of the injured were pedestrians, tho majority 
of whom had been knocked down by motor cars or bicycles; 
uearlv 25 per cent, of the total were motor cyclists. Death 
had followed in 16 cases. About 50 per cent, of the 
patients had head injui’ies, and aboiit 30 per cent, had 
fractures of tho lower extremities, which necessitated pro- 
longed stay in hospital. The number of beds constantly 
occupied by patients suffering frain motor accidents during 
the year 'was 17. The estimated cost to the hospital 
amounted to £1,906, of which only £236 had been 
recovered to date. The honorary treasurer said the total 
receipts wei-o £58,646, of which the workpeople’s contri- 
bution amounted to £20,665. The reduction in the cost of 
maintonance per bed occupied from £129 to £124 18s. 7d. 
indicated the economy in management. The adoption of the 


report was proposed by tho chairman, seconded by the 
Vice-CIinncollor of tbo Queen’s University (Dr. Living- 
stone), and passed unanimously. Lient.-ColoncI Mitchell, 
O.B.E., cliairnian of tbo medical staff, proposing the 
adoption of its report, drew attention to the increasing 
work- of the laboratories of the hospital and of the radio- 
logic.a! department. Tlio report was seconded by Dr. Eankin 
and passed. Professor Lindsaj- proposed the re-election of 
tho honorary treasurer. Dr.’ Henry Berrington, and of the 
honorary secretary, Mr. E. A. Heron, and bore testimony 
to the hard work of both on behalf of the hospital. - 


Dentists Bill in the Free State Senate. 

Tho Irish Pi-ee State Dentists Bill was taken in the 
committee stage in the Senate last week. Its provisions 
and tho discussion which marked its passage in the Dail 
were outlined on March 17tli (p. '465). • Sir Edward Coey 
Bigger, 31. D., moved an amendment that in Section 41 the 
words “ Dental Board ” be substituted for “ Medical 
Council.” Sir Edward said that the section as it .stood gave 
powers to the Jlodical Council to exercise very important 
functions in relation to dentistry. He held that the 
Dental Board should be in a position to make suggestions 
and also to regulate the curricnlum for the qualification of 
dentists. Jfr. O’Farrell said that the proposal in the bill 
to leave the matters of examinations for dentists and 
their professional standard in tho hands of the hledical 
Council was illogical and e.xpensi ve ; ' it placed the Dental 
Board in a very linmiliating- position, and he could see no 
reason for the idea, except that it was a eopj of something 
else. Jlr. JIcGilbgan, Jlinister for- Industiy and Com-, 
mcrce, said that be bad been in touch with the medical 
in-ofcssion and the Dental Association, and their vionj 
were entirely contrary to those expressed by Sir Eda-ard 
Bimrer. The view of the Dental Association was that it 
would suit its profession better to' leave the matter of 
education to the Medical Council. Sir Edward Coey Bigger 
contended that tlie Jlinister had not met tho pomts raised. 
Ho himself bad made it his business to get into touch 
wHh tTo prominent men in the dental profession; who 
thouEht that the arrangement proposed Fy him would he 
ideal Bv twenty-one votes to fourteen the House rejected 
the amendment. With reference to persons who might feel 
that they had a claim to be included in one or of 

tbo schedules, the cliairman said that these schedules had 
boL reCod to a subcommitteo to look into the cases 
S and also into certain further applmations. The 
rlmm’ittce had decided to adjourn the matter to allow 
rddittonal iJications to be sent in. Sir Edward Bigger 
said tLt the committee had that morning extended the 
neriod during which applications could be sent in until 
^ Ifith Further consideration of tho committee stage 
wL adjourned, pending the report of the subcommittee. 

Vaccination in the Free State. 

On the motion of Mr. S. Everett (Labour) the Vaccina- 
l-Ameiidrnent) Bill, 1928, was introduced m the Fieo 
Qf ia 7 ertslatiire. This measwre, which is a private 
bill proposes to alter the law governing vaccina- 
merabei ® ^ ^ ^ statutory declaration of conscientious 

h-ootior-^nd amfnding the Public Health (Ireland) Act 
1 B 79 or Section 7 of the Vaccination Amendment 

’lR79 It gives parents the right, to declare vntlnn 
’ mlnihs from the date of birth of a child that vaccina- 

rights enjoyed by persons m England and V ales. 

Bangor Sewerage. 

Ind df the neighbouring parts of the province, "'‘’j 

“nsidorabV -.fety that statements ^ 
sewage contamination, of the % 7";" reeom- 

holme, which adjoins it. The qOO Uut, what- 

mencls a sebemo winch will cos ® ’ g„],itation 

ever the outlay, it m generally felt ^l-at t he sani 
of this beautiful and convenient resort must 
irreproachable. 


ApraL 7 , 19 = 8 ] 


ENGLAND AND WALES. 


r Titt British 
L MkSICAI. JOUENAI. 


609 


(Ipn^Iantf antr Mali's. 

Roynl Snnitnry Institute Congress. 

The tUivly-niiitU cougicss of tUo Royal Saititary Institute, 
which is to he hold at Rlyinonth from July 16th to 21st, 
will bo attouded by delegates from somo three hundred 
societies and sanitary authorities, and by representatives of 
the universities, Government departments, the dominions, 
and several foreign countries, yiscount Astor will preside, 
and the popular lect\irc will bo given by Professor W. E. 
Dixon of Cambridge. The arrangements follow tho usual 
lines; the congress consists of seven sections, eight 
. conferences will bo held, and there will ho a health 
exhibition. In tho ■ section of preventive mcdicino the 
president is Dr. L. Rajchinan, medical director .and sccrc- 
.tiiry of tho Health Committee of tho Lcaguo of Nations; 
Professor Hobday will preside over tho section of veterinary 
hygiene. The remaining sections are devoted respectively 
to engineering and architecture, maternity and child wel- 
. fare, personal and domestic hygiene, tho hygiene of food, 
and hygiene in industry, the last-named section having for 
its president Mr. Ramsay MacDonald. The first coiiferenco 
■ will comprise representatives of sanitary authorities, the 
second reprcsont.atives of port sanitaiy authorities, and tho 
remaining conferences will bo composed of representatives 
of , national health insurance services, medical officers cf 
health, .enginecis and surveyors, sanitary inspectors, and 

r. ealth visitors. Among sidijects on which discussions are 
being aiTanged aro the tuberculosis problem, immunity 
methods in scarlet fever and measles, the rheumatic child, 
and various aspects of national health insurance, including 

. tho sickness experienced among insured persons. 

•Training and Rscruitment of Health Visitors. 

Tho Ministry of Health has issued to local authorities 
cari-Ting out maternity and child welfare schemes a 
circular (879) dcaliug with the position of health visitors, 
and recalling the decision embodied in Circular 557, to 
which reference was made on February 21 st, 1925 (p. 384). 

^“'loHuced in tho previous circular that on aud 
after April 1st, 1928, the Minister would not approve the 
appoiiitniciit of a woman for tho first time as a whole- 
time oincer of a local authority with health visiting duties 
iinloss she had obtained tho new health visitor’s certificate. 

ms certificate could only bo obtained by women wlio had 
at ended ono of the prescribed courses of training, and 
j existing health visitors who had completod at least five 
service. To facilitate tho obtaining 
o e new certificate by ■ existing health visitors it has 
non been decided to reduce tho qualifying period to three 
years, tiie new- circular further states that the Minister 
*1 position of existing lioaltii visitors 

suou (1 be fully safeguarded, and that each local authority 

s. iou u pay^ full regard to the claims of those candidates 
in making appointments, although they have not obtained 

0 new certificato. Authorities arc reminded that the 
mistiy maintains a list of all health visitors whose 
..ppomtmonts have been approved by it, aud that local 
si? m this connexion, desire information 

r,f°+i with the department. The remainder 

"^'*.** ‘conditions of service, recruit- 
snm..’ ' of training, ivhich appear to bo causing 

anxiety, ^'ide variations exist and difficulty is 
mg expel iciiced in securing candidates to undergo train- 
ng owing to the inadequate remuneration offered in many' 
aieas it is therefore feared there may be a shortage. 

‘ asks local authorities, when the remuneration 
0 maltfi visitors is under consideration, to give full weight 
e fact that new oxtrants have now to devote three 
..u( a lialf or four years to their training. Reference 
IS made to the conditions, of training set out in Merao- 
an um lOl/Jf.C.W. of February, 1925, and alternative 
I '? + 1 ^ f ‘f^^'C'i^ed for overcoming the difficulty created 
A the expense of undertaking a six months’ 

10 e- line course of instruction while earning no salaiw 
acted as a deterrent to some candidates. In 
r-n., which the ordinary full-time six months’ 

ISO las been -provided candidates agree to serve in the 


areas for at 'least six. months after obtaining tho health 
visitor’s certificate, and receive from the local authority 
during training an advance of salary-, to be repaid during 
their first six months of service. Further, the Minister 
is prepared to approve a course of training covering not 
less than three academic terms, including all necessary 
subjects and providing for lectures, visits of observation, 
and practical work. Such a course, it is suggested, could 
be organised, for example, jointly by a university and a 
local authority, and the latter body could facilitate attend- 
ance by appointing the students, who must be trained 
nurses with the certificate of tho Central Midwives Board, 
as probationer health visitors, their work, under super- 
vision, being regarded as part of their practical training. 
They might bo paid a salary not exceeding three-quarters 
that of the ordinary commencing salary of a health visitor. 
The salaries paid for health visiting would be eligible for 
grant under the Maternity and Child Welfare Regulations, 
but, if this was obtained, no grant would be payable 
in respect of training under Part II of Memorandum 
lOl/M.C.’W. Proposals of this kind are invited by the 
Minister with a view to securing suitable candidates who 
could not otherwise enter. 

Small-pox among Casuals. 

Tho Minister of Health has been advised that it will bo 
necessary to maintain the arrangements described in his 
circular (859)i to which we referred on January 28th 
(p. 154), for tho detection of small-pox among casuals. 
A further circular (880) has therefore been addressed to 
boards of guardians in England and Wales directing that 
medical officers shall continue to examine all casuals 
admitted from April 1st to Juno 30th with a view 
to detecting cases of small-pox. The circular states that 
if the procedure already outlined is observed it should not 
be necessary to keep casual wards closed after adequate 
disinfection has been carried out. Their prolonged closure, 
it is suggested, in.-vy lead to the dispersal of casuals in other 
places and to the spread of small-pox. Guardians aro also 
reminded that the powers conferred on them to detain 
liersons suffering from infectious disease do not extend 
to persons who, though they may have been exposed to 
infection, are not actually suffering from disease. There 
is, therefore, no power to detain such persons beyond tlio 
prescribed period of two nights, even though they have 
declined to be vaccinated. 


HEAT CRAAIP. 

Sin, — I was much interested in the description by Dr. 
Rayiier Thrower in tho British Medical Journal of March 
51st, p. 546, of cases of acute cramp occurring, not among 
stokers or miners working in hot atmospheres, but among 
men working in the engine-room of a motor ship. From 
Dr. ’Thrower’s description, however, I can entertain little 
doubt that the cause of the cramp is the same — namely, 
acute poisoning by water. 

AVhen we say that the “ osmotic pressure ” of the blood 
must be kept constant what we really mean, as I have 
several times pointed out, is that the diffusion pressure of 
water, just like' the diffusion pressures of many other sub- 
stances, must be kept constant. This pressure depends on 
the relative concontrations of, water molecules and other 
molecules, and, in the case of the blood, more particularly 
on the concentrations of sodium chloride. The kidneys are 
constantly engaged in regulating this “ osmotic pressure,” 
but in the case of men engaged in pretty heavy muscular 
exertion they are almost completely thrown out of action, 
as was very clearly shown a feiv years ago by Dr. Pembrey 
and his associates. 

Now a man who is both sweating hard and working hard, 
and is at tho same time drinking water to relieve his thirst, 
is losing chloride rapidly in bis sweat and at the same time 
replacing the sweat, which contains about a quarter per 
cent, of sodium chloride, by practically pure water. ’The 
kidneys at the same time are out of action, so cannot deal 
with the excess diffusion pressure of water. The re.sult is 
acute rise in the diffusion pressure of water or fall in tho 



610 April 7 , 1928 ] 


COBRESPONDENCB, 


[ 


The PurriSK 
Hxdicai. JotrsxU 


“osmotic pressure”; and violent attacks of cramp nro 
symptomatic of this. 

The whole subject has for some years past been occupying 
part of tlio attention of the Birmingham University Mining 
^Research Laboratory', of irbicb I am director. Professor 
Moss discovoj'cd iho existence of lioat cramp among miners. 
tVhen a miner, who had already had an attack, was 
examined uudei'groimd by my son, Mr. J. B. S. Haldane, 
he found, first, that only a few cubic eentiraetres of urine 
had been secreted during the whole shift, and secondly, 
that this urine contained not the smallest demonstrable 
trace of chloride. There was thus acute shortage of 
chloride. ' . ' ' 

Perhaps few persons realizo how much sweat, and there- 
fore how mucii chloride, a man who is thoroughly acclima- 
.tized to heat may lose in a short time. Professor Moss 
•found that a 'thoroughly acelimatizod miner from hot work- 
ings lost, in the eximriincntal hot chamber, as much as 
65 lb. an hour, though the sweating of an uiiacclimatized 
mail is feeble in comparison. — I am, etc., 

Oxford, Jfatoh 3Ist. J- S. HALDA^•E, hl.D,, F.R.S. 


GLAND GRAFTING AND INHERITANCE. 

Sir, — T he letter of Surgeon Rear-Admir.al Charles M. 
Beadnell in your issue of March 31st (p. 570) is clearly 
written under a complete misapprehension of the nature 
of the various testicle-grafting operations. 

He is under the impression that any offspring sired by 
Hie grafted animal after the grafting arc descended from 
spermatozoa derived from the foreign testicle which has 
been implanted. Tliis is definitely not so. Neither in 
Voronoff's operation nor in the operations of Stoiiiach, 
Lichtenstern, Muhsam, or any of the other workers in this 
field has it been found possible to bring the graft in such 
a relation to the testicle itself, or to the vas deferens, that 
spermatozoa from tho graft could be emitted in the 
auiraaVs semen. Net has it yet been found possible to 
maintain the graft in such a condition that it will continue 
to produce spermatozoa in its new position. Microscopic 
examination of grafted testicular tissue, at intervals after 
its transplantation, show clearly that tho spcrraatogcnctic 
tissue degenerates, and sperm cells are no longer produced. 

Thus, since (1) the graft ceases to produce sperm cells, 
and (2) even if sperm cells were produced by the graft 
they could not find their iray into the semen, there can 
he no question of the future offspring of the grafted 
animal being descended from the gametes contained in the 
graft. 

It is curious that the medical profession in this country 
seems to know so little about the technique and results of 
the various so-called “ rejuvenation ” operations which 
are more widely practised elsewhere. It is very desirable 
that some exact observations should be made under strict 
test conditions, first in laboratories and tlien in hospitals. 
In the meantime, those of us who have carried out the 
operations in a considerable number of cases are convinced 
that if one chooses one's cases wisely one often does got 
remarkable results. And it is important to emphasize 
tho fact that the improvement which often follows the 
operation is not exclusively, or even predominantly, sexual. 
— I am, pte., 

London. W.l, March 50 th. NoRMan HaiRB, Ch.M., M.B. 


mNIMAL RISES OF TEhIPERATURE IN 
RHEUMATOID ARTHRITIS. 

gjjj Dr. U. Schmidt is to be congratulated on his 

timely article in your issue of March 24th (p. 493) advo- 
cating rest and feeding in those cases of rheumatoid 
arthritis in which the temperature is unstable. Any form 
of movement involving the affected joints he regards as 
provocative of auto-inocnlation. It is difficult to improve 
on the clarity of his words: 

“ Tho important point is the entry ot substances foreign to the 
body or Soeast to the joints, into the joints and the surrounding 
Sk in such amounts that the irritation set up. leads to various 
d^rJi of inflammation and their sequels The joint ti®u« 8^ 
tla6 surrounding tissues are thus toxic, trhetlier they the fo^ 
of macroscopic or merely of microscopic- exudates and chemotactic 
combinations, Absorptio.n of such suhstaiices has, according to 
this view, the same significance as an auto-inoculation." 


Long-standing fallacies notoriously die hard. One of the 
wor-st is embodied in tho idea that to prevent pcrnianent 
stiffness patients must be kept moving. iEvery medical 
student knows that inflammation has to he treated by 
rest, and yet continually this universal rule is broken or 
is disregarded in the ea.se of arthritis. Personally I would 
go much further than Dr. Schmidt, and would urge that 
tho treatment of rest advocated by him should not bo con- 
fined to cases in which a general intoxication is present, 
but that in all arthritics treatment should be begun by 
reducing tho voluntary movements of those joints showing 
active disease. The amount of movement to be permitted 
is largely a matter of e.xpcrienco, but it is always better 
to bo on tho safe side, and even a period of complete 
immobilization of one or more joints is preferable to 
permanent disablement. 

Til-' rorei f,i<;or in all ca.ses should not bo the 
<>•' , but the control of auto-inoculafion. 

Fortunately' in tho majority of cases auto-inoculations are 
not sufficiently marked to prevent gentle movements of 
some kind. Thus, for example, even febrile cases at rest 
ill bed may often be permitted to move their lower limbs 
once or twice a day — a very different proposition from con- 
tinually walking about on them. The difficulty is that in 
so many mild degrees of arthritis, particularly osteo- 
arthritis attacking one joint, patients can seldom bo per- 
suaded to give np their activities. Yet, when • through 
some intercurrent illness these activities are forcibl.r cur- 
tailed, it is invariably found that tho pain in the affected 
joint has lessened or even disappeared. , . 

In every case of arthritis, from the mildest to the most 
severe treatment should be directed toward reducing the 
active’ movements in affected joints, more especially in 
those of tho lower limbs. In some cases no measures short 
of complete immobility will prevent niito-inociiJation. In 
tlie-se after a period, experiments can be made first with 
v'orv slight passive movements, and then with more enor- 
cctio voluntaiy movements, in order to find that degree 
of activity which the patient can undertake wathoiit pr^ 
roUins auto-inoculations or increasing the local inflamma- 
forv tfiauKes. The former would be shown by malaise, pain 
^ toinls or even in a rise of temperature; the 

bv uain ’in and around the joint itself. If tliese 


Kpte wre more" genm-aiiy ^cognized and univereally 
Sd there is little doubt that the crippling results ot 
ai-Litb would be less in evidencc.-I^anR^otc.,^ ' 

London, W.l, Mnrcb 


nvciRTf AGIA ASSOCIATED AVITH ANAEMIA. 

vour issue ot March 24tli Dr. A. F. Hurst takes 
Mention to my statement that the closure of the lOwer end 
The gullet in cardiospasm is always firmer than aomal, 

‘""a 

•f »c fxoTft tUft stomach, 

n!- Hurst naturally contests my statement, for, if true, 
^ i'fl^l?ablished Hew that the disease in question is 
:.aiff^fm reSes further confirmation, while that as to 

mMcM that a more exact estimate of the degree 

Itisself-eruient^ a 

*He tra'^dua* introduction of an oesophagoscopc umler 
®n+rnl while the patient is recumbent and ana-S 
iual conti p,.actice^ than by passing bliiidl.r, or with 
etizcd, as is n y e mercui-y tube, as recommended 

AU S iny“aseB. Wing “ f?"' '’f ^ 

Dt. earcfidly examined with reference Ao 

?\mmv of the cardiac canal to undergo 
e tendency or r ap^ree of resistance offered by 

iitractiou, and than the normal has 

.diiv. .p». 

ntaihibg 1 lb. 5 fF “thrSwer onS of the ocsopha^s 
itruments and where the muscular 


kpmh 7, igiS] 


COEEESPONDENGE. 


r TraBnmsa * Rl T 

MSSICIX. JOUESAL wii 


fibres aro imstiipod — lie accepts this as proof of the absence 
of spasm. He considers that if spasm did exist there Tronld 
bo rcsistauco such as tlio anal sphincter in a state of spasm 
offers to the introduction of the finger. Surely an inappo- 
site comparison. 

Turning for a moment to the upper end of the oesophagus. 
When this is inspected in tho nianucr above described in 
cases of the same nature as those ivhich formed the subject 
of tho paper by Mr. Mason Jones and Mr. B. D. Owen 
I have invariably found such firm closuro that any other 
diagnosis than spasm was inadmissible. I do not deny that 
in some of these patients tho muscles concerned in pro- 
jecting the food into tho oesophagus may’ have been weak 
and possibly paretic ; or that spasm of tho crico-pharyngeus 
extending over a period of years occasionally gave rise to 
an .appearance resembling a circular membranous stenosis, 
but which w.as shown to bo duo to tho spasm.* Paresis or 
achalasia of tho crico-pharyngeus itself certainly did not 
exist. 


Tho only other important reason advanced by Dr. Hurst 
in support of his recommendation to substitute tho term 
“ achalasia of the cardia ” for tho term ■' cardiospasm ” 
IS that in the disease in question “ hvportropliy of the 
cardiac sphincter is never observed after'deatli, even if tho 
obstruction has lasted twenty or more years, although long- 
continued spasm would necessarily lead to hyticrtrophy.” 
In reply to this objection I need moi’cly iioint to the pub- 
lished drawings and descriptions of specimens in which 
moie^oi less of tho terminal poi-tiou of tho oesophagus 
01 - -- cardiac sphincter” has uiidorgoiio hvportropliy." 
My patient was aged 21 years' and Dr.‘ Camoroii’s 
nas years. In both of these young subjects there was 
pronounced hypertrophy in the wall of tho cardiac canal. 
I'rom remarks made by the late Professor Shattock in this 
onnoxion one is lod to inquire whotlior this hvpcrtropliy 
oes not exist in many of tho cases at a stage earlier than 
examined post mortem, and wliotlier the 
cluanges iii tlio muscular coats so frequently 
cause muscle which at one time was hyper- 
tiophied to appear of normal or diminished tliickness. 

cmirl!t!nnr°^^' is based upon three negative 

cardia absence of- sense of obstruction at the 

siiliinetni. file mercury’ tube, absence of grip bv tlio 

auratl'“ ^ tube is easily wit idi-awn, 

sWn tw i'yportrepliy. In this letter I liav^ 

acoiiaintaTir. methods of observation and an 

to nrove ^ literature of tlie subject go 

leaur' id T “ "liicli Dr. Hurst denies in 

reality exist. — ^I am, etc., 

Glasgow, March 29th. ■ ' BnOWN KelLT. 


f PtlLMONABy TUBEBCDLOSIS 

Ecenti’cai 11 ^°"‘'.,‘!°’'*'espondents seem to be vei 

c.ases of linln” possibility of tho “ cure ” of advaiici 
tlio restnvaf tuberculosis. If by “euro” is meai 

possible biit°”c °i ^®®broyed tissues it is, of course, ir 
tc health in Pmaiis the restoration of tho patiei 

nd“dLn"Sarlrrf” 'T daniaged'^lu.ig 

course, been ^dotio “pd sputum, this has, - 

used is tbo i" ."’*merous instances. The methi 

tuberculin (H T S ) “ ’^““"'zation of the patient wii 
tho eatarrb naaa ’ • potogenoiis antigens made fro 
' Before the tho sputur 

special iuvestiriata ®'“°”®tratod a. series of these cases to 
Tho' natien+a Medical Eesearch Cotinci 

iredfofd Me K f ‘••"d w^ll now; At tl 

grams of such arrested east.“ 

miss'imieiy^examfded^a’ medical insurance coi 

cases all nf '+I series of these advanced arresti 

disease Dr 'M^ " * “^questionable evidence of arresti 

“bo fonvardo^i mode a report to his commissio 

corned iltoo ^ Government department co 

_j;pl_ ^ssrs. Hewlett, who are '.a n-ents for my tube 

I-aci/iiffoh, ■* PoKt-cricoUl spasmodic slrlctiirc,” Jout 

1919. ,1 285""''“'-. <*"<' Otol., 1918, p. 270, and author's pap^r, ibi. 

pnd'’7>roc™j[J,?’r“''‘*’®,W«''S in Journ. Inn/ngol. a/ul Olo!., 1927, p. 5 
ibid., vol. -rilt Sect ilv Sect. Larv-iigol., p. 67: nuthor-rca 

drc7i. of Di,. t'n CMWI.ood’.°voi.'i'i, p.'3sg"‘* ''' “ 


C'liliii, have demonstrated a’-ray photographs before and 
after treatmoiit at several medical exhibitions. These 
patients are alive, well, and aro not infections, but parts 
of thoir lungs aro destroyed and replaced by fibrous tissue, 
and in niaiiy their hearts aro displaced by the contraction 
of this fibrous tissue — one who is perfectly well and active 
to such an extent that the “ apex beat ” is in the right 
axillary line. 

Early cases can bo restored to such an extent that no 
evidence of disease can bo discovered by physical examina- 
tion, and aro tliercfore useless for demonstration purposes 
to the sceptic who invariably suggests an error in diagnosis. 
Except ill 0110 exceptional case of acute lobar piicumoiiio 
phthisis with massive consolidation and no sputum, the 
diagnosis in which was made by the response to tuberculin 
(H.T.S.), all, cases in which- 1 claim arrest and cure have 
had acid-fast tiibcrclo bacilli in their sputum. I have 
enabled many general practitioners to cure patients, and I 
hope to SCO every practitioner treating his own patients ; he 
will give them a far better chance of recovery — indeed, in 
advanced cases, their only chance of recovery. 

Tuberculin by itself will produce an increased per- 
centagd of cures, but nothing like the percentage of 
cures produced if complete antigens aro used. Tuber- 
culin cannot bo expected to induce antibodies against 
virulent streptococci. May I say again, however, that 
tuberculosis will not be stamped out or reduced to reason- 
able proportions by the treatment, however effective, of 
advanced cases? Normal natural immunity -n-ill protect 
against the tubercle bacillus, as is evident by the survival 
of the majority of us. This normal immunity can bo 
assured by a few inoculations with a potent tuberculin. 
1 assure members of families- in which tuberculosis has 
occurred that they will not develop the disease if they 
receive those inoculations; I have been practising this for 
over twenty years and I have yet to meet with a failure. ■ 

Finally, I would say to the opponents of tuberculin that, 
like strychnine, it is a potent drug, and must be used in 
proper dosage. It is easy to kill any patient with 
strychnine, it is easy to kill a tuberculous patient with 
overdoses of tuberculin ; but no physician kills patients 
with strychnine, and no patient is killed by tuberculin 
given in proper doses. — I am, etc.. 

University College, Dublin, March 261h. "W.-M. CroftOM. 


EFFICACY OF TUBERCULIN. 

Sir, — With regard to the efficaej- of tuberculin I have 
been long convinced that one of the chief obstacles 
to a conclusion on a sound scientific basis has been 
the absence of proper “ controls.” Enthusiasts commonly 
adduce a series of cases treated successfully bj- tuber- 
culin, but do not contrast tlicso results with the results 
of ti’oatment of a similar series of cases -ivithout tuberculin. 
Tuberculosis, in the early stage, is a disease from which 
complete recovery will spontaneously occur in a fair pro- 
portion of cases if reasonable precautions aro taken. Tho 
necessity, therefore, of proper “ controls ” is obvious if wo 
are to avoid the old fallacy of arguing post hoc, ergo 
propter hoe, 

'\Vliere an effort has been made to conduct an investiga- 
tion with such “ controls ” — as, for instance, in that of Dr. 
Noel Bardswell at King Edward VII Sanatorium, Midhurst 
(Prcliminarij Hcport on the Treatment of Palmonarij Tuber- 
culosis with Tuberculin, H: K. Lewis, 1914) — the result has 
I>eeu to discredit tuberculin. In a prefatory note to this 
report Brofessor Karl Pearson states: “ If it were possible 
the scientific method would be to select patients suitable 
for tuberculin treatment, treat only tliose whose siirnanics 
began with A -to K, and then compare the results with 
simple sanatorium treatment of tho remainder, L to Z, of 
these selected patients. Thus in two or three years wo 
should know exactly the value of tho treatment. When all 
selected cases are treated as at present we shall have no 
suitable control to determine whether the treatment has 
any veal value, unless, indeed, wo again leave it off.” 

My own experience of tuberculin goes back to 1912, 
when tuberculosis officers in many areas were almost under 
compulsion to give tuberciiliii. Patients received injections 
twice a week, provided they could bo taught ho-w to keep 



612 ApriIj 7, 1928] 


COREESPONDBNCB. 


r TirKPmnsH 
I 2lEaiCAi.Jaunrtt, 


a tcmperatiirc clmrt officiontly. 3 also had iiatieiits under 
tri'atmont. at sanatorhiins, a-hcro tiie dfeels of ti-ealinent 
could bo more closely observed. My e.\i)erience was that 
the cases adiicli ajipeared to do well aitii t\ibDj-CHlin were 
precisely those cases adiich would be expected to do well 
tinder any ircatmetit (sanatorium or otherwise) — iiamciy, 
the cases where the disease appeared to bo in the incijiient 
stage, for tho roost part “ ambulant afebidle cases,” or 
those in which there was a possibility that no active tuber- 
culosis was really pj'csent, tubercle bacilli jjcver having been 
demonstrated. This draws attention to the necessity in any 
scientific investigation of dealing separately tvith eases in 
which tubercle bacilli have been demonstrated and tho.se 
iu which they liavo never been found. On the otlier hand, 
I have rceord,s of cases in wliicli tuberculin apjiearcd to 
aggravate tho disease, and in which the condition improved 
(as shown by tenipei’ature chart, weight, and the feelings 
of tlie iiatient with i-egard to lassitude, apjictite, etc.) on 
the discontinuance of tuberculin. As regards the Jess 
favourable type of case, I unhesitatingly echo the words 
of Dr. Bard&weli.- “ Tuberculin cannot bo looked upon as 
a means wlieraby an unfavourable case can be converted 
into a favour-able one, or as likely to turn tlie .scale in a 
patient’s favour when his progi-ess is doubtful.” The 
method of administration was that of slight reactions, 
and I have confined my remarks to pulmonary tuberculosis. 

Is it not taking a very sanguine view to expect that one 
of tho fii-st outstanding successe,s of vaccine treatment 
should he with such a widespread and iutraetahle disease 
as tuherorilosis.*' M’hat real scientific basis is there for the 
belief in tho efficacy of vacernas in therapeutics? All the 
unequivocal successes with vaccines have been not ivith the 
cure of existent disease, but with the protection of the 
healthy iudividunl against disease; its great vietorie.s have 
been won not in therapy, but in prophylaxis. Professor 
J. C. G. Lcdingham (British Medical ,3onn«i!, May flth 
and 15th, 1926) gives reasons for doubting tho sjrccific 
action of vaccines in vaccine therapy, ruruiicnlosis, for 
example, may respond as well to a vaccine pi-cpared from 
B. coH cotiuiiuni.<i or S. typhosus as to a stapbylocoocic 
vaccine. The temperature in typiioid fever has been 
promptly reduced by an intravenous in.jectiou of typhoid 
vaccine; but it was found that an injection of B. coli 
communis vaedne, or even less sjiecifie .substances such as 
casein or- albuniosc, could produce the same effect. On tJie 
other hand, in vaccine propliylaxis, he points out, the 
vaccine roust bo of true specificity. The one stands on -a 
sura scientific basis, tlic other on a shifting foundation of 
conflicting clinical testimony. If, then, we look to tuber- 
culin as a weapon against the tuhercle baeilliis. we should 
expect to find it successful — ^if at all — as a prophylactic 
rather than as a therapeutic remedy. The hitherto unequi- 
vocal success of bacteriology iu therapeutics has been not 
with vaccines, but with serums, and unfortunately so far 
there seems to ho small hope of finding an antituberculcsis 
Borum, nor is the disea.se one that lends itself to such 
hope. — I am, etc., 

Clifion, Bristol, .March 23rd. D. EATHEaHE.\l). 


MIDWIFES AND ANTE-NATAL WORK. 

- gin, — I have read with intorc.st tlie letter.-, of Prafessor 
A. Louise Mcllroy and Dr. Malcolm Donald'-on (hlarcli 
17th, p. 466, nod March 24th, p. S20, respectively). That 
ante-natal work is still in its very infancA- is only too .si\d 
a fact. Meetings to “ discuss ” mirtcrual moi-bidity and 
maternal mortality seem to be held almost daily, but “ dis- 
cussions and resolutions ” seem to he as far as they jiroceed. 
HaFing, wntil almost a year ago, been for lietween trvo 
and three years in charge of the ob.steti-icJi] and gviiaeco- 
loo-ical words of^a large and modern Poor Law institution, 
I °liave been appalled — sometimes I have been almost 
terrified— by tbe so-called midwivos one meets in general 
jn-actiee. To suggest that more tban a vei-y sirniH per- 
centage of tbem ran give pi-ojier ante-natal s-n]>ervision is 
absut-d. Many of tire old mj-tlis and superstitions of the 
dark ages of miclwifesy still persist iu -their miilst. Their 
d^lef arm seems to be trininpliaiitly to infonn the practi- 
tioner on bis arrival as to tbe state of the os uteri — 
■wliotber the patient be iu labour or not — and for tins 
inforinatiou they api>car to cxpoc-t a certain amonnt of 


praise and admiration. Tbe nholc system appears archaic. 
That admirablo body tbe Central Midwivos Board to my 
mind must continue to strive to jiroVide tbe inotbei-.s — and 
future mot!ici-.s — of Britain with a body of inoro efficient 
and less iiieddlesomo midwive.s. Many of those at present 
III practice could elicit as much information from the 
jialpation, etc., of a straw-stu/Fed sack as from tlie palpa- 
tion of a pregnant abdomen nearing full term. 

But is the midwife entirely to blame? Two abnormal 
conditions that run he avoided have come to niv notice 
nnh-e often than one would e.xpec-t; and thev are: (1) 
eclampsia— a practitioner, not yet middle-aged, informed 
1110 that he had about six or c'igbt “ unavoidable ” cases 
of this almost Iiistorical condition in his practice each 
year ; and (2) lirccch presentations in primiparae. A still 
very large percentage of these ca.ses occni- irith, in many 
cases, fatal rosnlts to an other-wise healthy infant. The 
jn-actitionei- is not to blame; he must undertake midn ifery, 
or else his practice will suffer financially. 

Queen Mary- has locently expi-exsod the hope that in the 
ne.ai- future the figures foi- maternal morhidity and maternal 
mortality would show a marked decrease. This hope can 
only he fulfilled when matemitv work comes much more 
iinder the jurisdiction of obsteti-ical and g 3 'naecological 
specialists iu inateruity hospitals, inatei-nitv hoinc.s, or, 
where circumstances permit, in the patients’ homes. It 
seems a pity that obstetrics has not shown the same progress 
a.s siirgeiy since the days of that iiioneer. Sir James Y. 
Simpson. — 1 am, etc., 

irailon. NA Miiieh 25th. I.^X S. Robebtso.V-B.UX. 


■ SUPERANNUATION OF MEDICAL OFIMCEBS 
OF HEALTH. 

glE The article on page 511 of your issue of lilaroh 

24th about tbe report of tiie Departmental Committee -on 
the Superannuation of Local Government Officers offers 
cold comfort to medical officci-.s of health serving those 
authorities which have not yet ndojiteil tbe Local Govern- 
ment and other Officers’ Superannuation Act, 1922. As 
shown .on page 539 of the Noramber, 1927, issue of TM 
Loral Borerament 6'cri-icc, the official organ of the National 
Association of Local Government Officers, only 16,962- (that 
is 2.89 per cent.) of the total number of public- officers 
in’ tlie country remain unprovided for by superannuation 

artmental report has been over tivo years uncler 
the consideration of the committee, and it is now quite 
time all medical officers of health wore placed on an equal 
footiim in respect of superannuation, espcemliy seeing tliat 
the rwort recommends compulsion being applied to any 
i-eoalcitrant local authorities. Junior medical officers can 
leave tiieir posts to obtain these benefits clsewbeie, but 
he .seniom must stay where they are. Cannot the Parham 
mentan- Medical Committee see its way to take early 
m«on 'on their behalf? Otherwise elderly medical officers 
aiurt continue in office, even though they mav become 
olnScailv incapacitated, whilst tbe more capable juniors 
to avoid entering the service of Uie less pro^ 
irre-ssive local authorities, the public welfare in these aieas 
being thereby doubly I'-'dioapped.-I^am, ^ ^ 

March ^th. 

SALAEIES OF MEDICAL AVOMEN. 

—I have noticed with much concern the extremely 

"itiSS S'oi pliS hS. T>» 

i:5s?l\rS •sii.rS'r Bi.k 

llcdical Association.-I am, ^tc. Orrici®. 

O'?*!, ■WWW- . 



Atoii. 7. 't928] 


OBITUARY. 


- r The Bnmsn . 
L Medicai JorKsu. 


613 


©biiitnrir. 

HENRY LAWRENCE AIcKISACK, 51. D., F.R.C.P., 

Consulting riiysician to tho Royal Victoria Hospital, 

Belfast. 

We have to nnnounco with much regret tho death ot 
Dr. H. L. JIcKisack, on JIardt 26tli, after a short illness, 
supervening on some months of impairod health. His loss 
will bo deeply* felt throughout tho medical profession in 
■Northern Ireland. 

Henry Lawrence JIcKisack was a nativo of Antrim, and 
was born .at Carrickfergus in 1859. His school days were 
■spent at Holy wood and Broadslairs, and ho was for somo 
years a student at tho Royal Academical Institution. After 
engaging in business for a short time ho entered the 
medicardepartinent of Queen’s College, Belfast, and gradu- 
ated in the old Roy.al University^of Ireland ns M.B.,M.Ch., 
5I.A.O. with honours in _ 1887. Ho proceeded 51. D. in 
1890, obtained tho diploma JI.R.C.P.Lond. in 1904, and 
was elected F.R.C.P. in 1916. Among tho important 
posts in Belfast which ho hold were those of visiting 
])bysiciaii to the Royal Victoria Hospital and the Ulster 
Hospit.al for IVomen and Children. Ho later became 
consulting physician to these hospitals and also to His 
Jlajesty’s Forces in Northern Ireland and to tho civil 
service. Dr. JIcKisack held tho appointment of clinical 
lecturer . at Queen’s University, Belfast, and had been 
an examiner in medicine at Trinity College, Dublin. 
He was a past president of the Ulster Jlcdical Society, and 
served ns president of tho Ulster Branch of the British 
Jledical Association in 1914-15, and he was one of the 
original members of the Association of Physicians of Great 
Britain and Ireland. 

Dr. JIcKisack contributed numerous clinical articles to 
medical periodicals, including one on atypical exophthalmic 
goitro which appeared in tho Tlritis'h Medical Journal 
'.P. H's principal- work, a Dictionarti of Medical 

Diagnosis, was published in the- autumn of 1907. Although 
arranged on the alphabetical system, this useful and clearly 
mitten book was informed throughout by a definite purpose 
—to help the student to acquire the habit of approaching 
eiei-j' case with an open mind and refusing to form an 
opinion, rintil ho has observed and reflected upon all tho 
signs and symptoms. Among its best articles were those 
on physical signs in tho lungs and heart. He also pub- 
is le , in 1912, a smaller'book entitled Siistcmaiic Casc- 
a^ing. Both works passed into a second edition. 

™hoague writes: No more popular medical man than 
j lived ill Ulster. He had the capacity of 

pressing his impartiality on others, and of enabling them 
1 “ question. Everyone knew that he was 

+ 1 - uud upright, and so could be absolutely 

*• "V 1 ° inspired confidence and affection in his 
patients and colleagues. He is survived by a son and 
wn= 1 i,"’ much sympathy is felt. His elder son 

jicKkn "r Corps during the war, and JIrs. 

McKisack died about a year ago. 


r JI.D., F.R.C.P., F.B.C.S., 

oiisuUmg Obstetric Surgeon, King’s College Hospital. London. 

D.^" Zorpf ‘^=='^11, on JIarch 25tli, o 

anti tn-Ti^r. 1 many vears obstetrit 

a wpl?t ° to King’s College Hospital, am 

Hni'b t " medicaAvorld of London. 

Fdinimi.pi Playfair was born in 1864 a 

and bn ^ father was General Archibald Plavfair 
• I be « as a cousin of tho late William Smoult Playfair 

Coiletro TT ’+1 ®?^t.903), obstetric surgeon to King’: 
Plav?a!v^l‘’^’J‘*n ’ footsteps he followed. W. S 

countrv ono of the first obstetricians in thii 

instG^f1 nf 1 doing his own abdominal operation: 

Fettet; P them over to a general surgeon. Fron 

London . "P went to King’s College 

in Lord Lirtci-’" ” ° studying medicine served as dressei 
Hosnit-il TT ^ building of King’s Collegi 

mid'tlm de^^pVf L.R.C.P. diplonm: 

Etiulv in P^ ^•B.Loud. in 1890, and after a period o 
i Geiinany proceeded JI.D. in 1892. He then heh 


in succession at King’s tho posts of resident accoucheur, 
obstetric tutor, assistant obstetric surgeon, and lecturer 
on practical obstetrics. He obtained the diploma of 
JI.R.C.P.Loiid. in 1896, the F.R.C.S.Eng. in 1899, and was 
elected F.R.C.P. in 1918. For somo years Playfair held tho 
appointments of assistant physician to the Royal Waterloo 
Hospital for Women and Children and gynaecological 
surgeon to the Jletrojiolitan Hospital, relinquishing them 
when he was elected to the full staff at his own hospital. 
Ho was an able and lucid teacher, and extremely popular 
with all his students. On his retirement from active work 
at King’s College Hospital three years ago, owing to 
impaired .health, he was elected consulting obstetric 
surgeon. Ho had served as examiner in midwifery and 
diseases of women for tho English Conjoint Board, was 
consultant to a number of cottage hospitals in towns 
near London, and enjoyed for many years a considerable 
private practice. 

Wo are indebted to Sir G. Lentievl Che.itle, K.C.B., 
F.R.C.S., for the following personal appreciation : 

It is a sad, respectful custom wliich ordains that those 
of us who are left behind should publicly state our, impres- 
sions of our friends and colleagues who have recently 
passed away. I recognize the inadequacy of mj- attempt 
to treat thus the memoi-y of Dr. Hugh Playfair. With 
deep regret his colleagues, students, and friends learned 
that ill health necessitated retirement from our midst. 
It was with iirofound grief we heard that our hopes and 
desires for his recovery in the quiet, happy, and pic- 
turesque home that had been planned by JIrs. Playfair and 
him, had all been in vain. Our friendship began when 
1 was house-physician at King’s College Hospital and ho 
was one of my clerks. I recognized his ability, and entrusted 
him with many duties that were additional to his official 
work. In those early dnys Playfair had already deter- 
mined to specialize in gynaecology and obstetrics; with 
that object in view he began to study for the F.R.C.S.Eng. 
as well as for the JI.D.Lond. .Although he was a clerk to 
Lord Lister he never became house-surgeon; he limited his 
house appointments to those intimately bearing upon the 
work of his life. In the early times of our professional 
careers Hugh Playfair and I occasionally visited the clinics 
and towns of interest in Europe. He was an ideal com- 
panion, and he kept the eye of a skilled financier on our 
expenditure without stinting our enjoyment. In -many 
cities we scoured the shops of dealers in “ antiques.” In 
ono of these establishments we were pestered by a dealer 
whose goods we did not consider were as genuine as ha 
tried to make us believe. AVhi’a he had disappeared to tho 
back of his premises in search of more convincing “ pieces ” 
we took the opportunity of making a rapid exit and 
decamped. Feeling that we had skilfully solved an embar- 
rassing situation we hastened into a similar shop two or 
three doors away, to continue our hunt and partly to hido 
ourselves. JYhile .thus engaged we failed to notice tho 
attendant of our inspection. At last we turned our atten- 
tion to him, and were horrified to see tho same person 
whom we had just ei'aded; he owned both premises. 
While antique hunting in Jlilan Playfair unearthed a type 
of picture he was then collecting. The picture is in his 
collection! Playfair’s instinct for attaining his object was 
so iiiten.se that he failed to notice the incidence of a 
small earthquake, which sent the owner of the shop and 
me into the street in great alarm. On our return wo 
discovered Playfair still expostulating with the .'.ssistant 
upon tho enormity of the sum demanded for the picture. 
Neither of them ha'd been aware of the earthquake. 

Our busy lives necessitated a loss of touch with each 
other, yet in the nature of things my family and I reaped 
the benefit of his friendship arid skill, tho value of which 
I can never' repaj*. Playfair loved his home, his pro- 
fession, art, and all his fellow creatures. His guests must 
have been struck by tlieir host’s taste in art as well as in 
hospitality.' His knowledge, appreciation, and judgement 
in selection were always increasing his art collection and 
beautifying his home. The love he bore his fellow creatures 
was i-ecipi-ocated by all those with whom he came in pro- 
fessional or friendly contact. JVo are all sure that ha 
passed a happy life as well as a successful ono. Pl.ayfair’a 
death leaves a gap in our lives that can never bo filled. 


614 AphiIi 7, 1928] 


OBITUABr. 


r - Tnr Britict • 
llKDicAL'Joesyii. 


JAMES BUCHANAN YOUNG, M.B., D.So., P.B.S.En., 

Formerly Lecturer on Public Hcallb, University of 
Edinburgh. 

The death took pl.aco suddenly, on March 17th, of Dr. 
James B. Young at Iris rcsidenoo, Dalveen, Liberton, 
Edinbui'gh. Dr. Young had for many year's been lecturer 
in prrblic health at the University of Edinbirrgh, and was 
well known to many gonerations of medical students. 

James Buchanan Young was born in 1866, atrd took the 
medical course at the University of Edinbur-gh, where he 
graduated M.B., ■ C.M. in 1890. Detorrrrining from the 
first to devote himself to public health, he took the B.Sc. 
degree irr that department in 1892, and irr the following 
year became a Doctor of Science in Prrblic Health. lit 
1892 ho became assistant to the late Sir Dougins Maelagait 
in the department of forensic medicine, which at that 
time included the teaching of public health, and be con- 
tinued In this capacity as assistant to Sir Henr}' Littlejohn 
when the latter succeeded to the combined chair in 1897. 
In the following year tiro srrbjects of forensic medicine and 
public health were separated, and irlren, in 1898, Professor- 
Hunter Stewart was appointed to tiro ■ chair of public 
health Dr. Young became his assistant. In 1902 the 
Usher Institirte in Public Health was established irr 
Warrender Park Road, and upon Dr. Young, as assistant 
to the professor, fell a very large share irr the organization 
of this institute. The important work of I'cpor'tiiig upon 
clinical material examined at the iirstitutc in connexion 
with the prrblic health work of the city devolved irpon 
Dr. Y’oung, and in this matter he rendered for many years 
invaluable help to the city and to the practitioners of 
Edinburgh. In the laboratories a gi'eat part of tire teaching 
of the largo number of medical students passing through 
the department of public health, as well ns of graduates 
taking a practical cotrrse for the B.Sc. degree, was done 
by Dr. Young. Many students who graduated through a 
pei'iod of thirty years will remember with gratitude his 
helpfulness, kindliness, and devotion to duty. In 1921 his 
long period of service as an assistant was recognized by his 
appointment as the first lecturer in public health in the 
University of Edinburgh, and he continued work in this 
capacity to the time of his death. 

As a Fellow of the Royal Society of Edinburgh he took 
much interest in the irork of this society, and made 
numerous contributions to it, such as an account of 
“ A new apparatus for counting bacteriological colonies in 
roll cultures,” communicated in 1893, and on “ Chemical 
and bacteriological examination of soil,” with special refer- 
ence to the soil of graveyards. 

The interment took place at the Grange Cemetery, 
Edinburgh, on March 20th, and was attended by a large 
number of representatives of the medical jirofession. 


yriLLIAM MUIR SMITH, M.B., C.M., 

Eastbourne. 

We regret to record the sudden death from heart failure, 
on March 26th, of Dr. William Muir Smith. Ho was born 
at Irvine, in Ayrshire, in 1861, and graduated at Glasgow 
University as M.B., C.M. in 1884. After qualifying he 
went as assistant to Dr. Wilson at Crewe, and from there 
to a practice in the country, at Bourton-on-the-Water in 
Gloucestershire. There he led the hard life of a country 
general practitioner, and in those days, before tho arrival 
of the motor car, did much of his work in the saddle. His 
spare time was occupied in hunting, for he was a lover 
if horses. Ho had by this time married, and, as bis 
familv was increasing, he sold his practice at Bourton and 
proceeded to Eastbourne in 1893, and lived there until 
the time of his death. He soon acquired a largo practice 
in Eastbourne, but being a man of tireless energy and 
restless spirit entered into many other activities. He was 
a keen politician, an enthusiastic Liberal, and a forceful 
platform speaker. For many years he actively supported 
the Liberal candidates, and was engaged in the lyork as 
ohainiian or vice-president of the local Liberal Association. 
He was appointed a justice of the peace in 1906, and as 
magistrate appeared on the bench whenever time would 
permit. A true Scotsman, he was a prominent ' member 


of tbo local Scottish Association, and had the honour 
of proposing tlio “ Immoi-tal Memory ” at the Burns Night 
auiJier, an oration which subseqnentiy was printed in 
pampiilet fo™. Ho was a Presbyterian and an elder of 
wie Ciiiircli. Ho was a life vice-president of tbo Amateur 
^^ootball Association, and for very many 3 ’'cars an actire 
member of the .Eastbourne Crick.et and Football Club, and 
diairman of. tbo Eastbourne Football Club for twenty-five 
years. JSo always took a keen and active interest in 
medical politics. In the early nineties there was much 
friction between tho friendly societies and the medical pro- 
fession; and so in 1895 there was st.arted the Eastbourne 
Provident Medical Association. This was a “ club ” by 
whicli tho members obtained medical treatment on pay- 
ment of a small weekly sum, but which was controlled and 
administered by- the doctors themselves. Muir Smith was 
largely instrumental in founding this provident association. 
It was one of the first started in tlie counti-y, and is' 
still flourishing to-day. He was actively connected with 
national health insurance work from its inception, and was 
secretary of the Local Medical and Panel Committee'until 
the time of his death. His most active public interest was 
the work of tho British Medical Association. It was only 
last year that his twenty-first year as secretary, of the 
Eastbourne Division was completed, and the occasion was 
honoured by the presence of Dr. Alfred Cox at the annual 
meeting and dinner of the Division. Muir Smith never 
missed a meeting, and was the representative of the 
Division at tl Association for 

many years. '■ ■ these activities he con- 

ducted a large general practice, and was clinical tuber- 
culosis officer to . the borough of Eastbourne, with charge 
of the tuberculosis hospital. A man of decided and fear- 
less ojiinions, final in his judgement, a somewhat curt and 
outspoken manner concealed a generous and warm heart. 
He never spared himself, and did his utmost in other 
people’s interests; none came to him in vain for help or 
advice. For the past twa.years his health had been failing, 
but bo continued with his work. He leaves a widow, five 
sons, and ono daughter. 


Tbo Medical Secbetaet writes: The above notice gives 
a vei'y good idea of Muir Smith’s activities, and it says 
truly that his main interest outside his practice was the 
British Medical Association. It has been- my good fortune- 
to come into contact with many men for whom the Associa- 
tion was a real hobby to which they gave much time and 
interest and a few men for whom it uas the object of 
something approaching devotion. Muir Smith belonged to 
the latter select few, and during the course of my long 
friendship with him I received much advice, frequent 
remonstrances, more in sorrow than in anger, when he 
thought we were not strong enough at headquarters, hut 
always devoted co-operation. He was absolutely fearless, 
and conscientious to an extent which his colleagues at 
Eastbourne must sometimes have found rather trying, but 
they never questioned his honesty, his knowledge of his 
Bubiect or his intense desire to serve his profession. In 
1926 writing to ask mo if I would attend the annual 
meeting which would celebrate his twenty-first year of office 
as secretai'j', he said: 

••Ut that time I will have completed my twenty-one con- 
vears as honorary secretary. I know tho members will 
^.ni- entertain the idea of my resigning without some belter 
fUnn advancing years but I feel that I have served my 

lirand generatfon credit, I hope). long enough and I an. 

menhie someone of the rising generation from taking aedve 
JneSLlion in the work of the Division and getting initiated 
laiticp , ,j (.[,e position before I am called hence; and 

rah I might depart of a sudden it is my duty to resign. Again, 
wiombers do not vrovry aljoufc medical politics so lon|r ns 
aT Se head of affairs^ I feel that the present, one-man 
i» inimical to the enterprise of the Division «' 
idmimsl future salvation in this direction. Not that my 

X-raF in the work of my office, in tlic betterment of the 
Or politics in general, is abated in its keennes» on 
tittle from thirty vears ago. During all *'“5 long period 
have-not been absent from a singlo meeting 
1- oTPciitive- I have been representative at the Bcprcsciilaliv 
md? twelve' annual meetings ;'^on Branch Council ever since 
iranch^as formed; past-president Sussex Branch; '>Pf“M„i’ond 
lan of the Division; honorary secretary of Local Ncdical a 
■nnel Committee ever since formed; aUCTded ever 

f representatives of Local Medical and Comm.tH_^^^ 

ince instituted; served on Insurance Committee ^ ^ ,7 
n etc.— .all of which, I think, constitutes a bit of a rccora. 



AFUIIj 7, 192S] 


TMEDICAL NOTES IN PARLIAMENT, 


t TREBBmsn 
Medical Jocrval 


615 


It is sad to think' tlmt his prcsontimont that lio might 
die suddenly uhilo still holding ofnco lias ])ioved true, 
hut I cannot help feeling glad that he retained to the 
last an office of which ho was so very ])roud. 'J’hc Asso- 
ciation can have had few moro loyal or inoro devoted 
servants than Muir Smith. 

' Dr. A. Deaxe writes; By the death of Dr. Muir Smith 
his colleagues in Eastbourne have lost a most sincero and 
indefatigable worker on their behalf. As sccretar}' of the 
Eastbourne Division for twenty-one years, and of tho 
Panel Coimuitteo since its commencement, ho has done 
extraordinarily keen and strenuous work, much of which 
has been carried out in the small hours of tho morning. His 
loyalty to his profession and strong integrity of character 
won the deepest respect and regard from his colleagues, 
to whoih ho was ready to give his help without stint 
of time or trouble. Ho was a staunch fighter on contro- 
versial subjects, and ever with a sense of fairness and 
justice. His self-sacrificing work on behalf of his pro- 
fession, added to that of a very busy practice, must have 
been a great strain oh his health. His keen and vivacious 
presence will be sadly missed by his follow iiractitioners, 
who as members of tho Association gratefully recognize 
tho inunonso work he has done for this Branch. 


illibical in |JarUamcttt. 

[From our Paruamentaux Courespondeiit.] 

The Paiiiaraentary Medical Committee heard an address, o 
Alarch 28th, from Sir George Buchan’an on the health wor 
organized by the League of Nations. He said tliis xvas mixc' 
^ith questions of international hoaltli, wliich wore dealt wit 
oy other machinery and might be divided into intergovem 
mental health work pd “ fraternity ” and mutual educatioE 
lo the International Health Office at Paris were allocate' 
|rormai^ agreements, and conventions, general enidemiologica 
discussions, and monthly bulletins, and tlie Consultative Counci 
of Nations Health Organization. To the Healti 

ion at GeneA'a ivere allocated combined e.xpert studies 
■ i’ mtelligenco services, special missions 

0‘'S«n'2ation bv the League Assembl; 
WnlS ‘■‘^*•,1 ^®®Sue-s health budget was for abou 

Brit’iT ^ “• I5o<^>'efeller grant of £20,000. Th 

I sent nominated by the l^reigu Office to repre 

'Ho\?ns o'"’ British Ministrv of Health 

ofmmfttee V niembcr of the League's Healti 

meelinns nf n"** i" attended with the British delegation a 
techn cal ad vs" “"<5 Council, when desired, as Britisl 

by the Paris ami gave examples of the ivork don 

national 9a. ■( Ceneia organizations in liaison on the Intel 
peutir and 1926, and in regard to thera 

had '-'r" standards. International slandai'd 

arseholipnvnls " 1°^’ msulin, pitiiiUry extract, digitalis 

tetanu'i anH vaccine standards for diphtheria 

the wUctA.-ni jsentery and serum diagnosis test standards fo 
organizS Imd’ and other tests. Combine, 

and Ucanda s ^ arranged against epidemics in Polani 

Special dfst’as '^i" O' against yellow fever in Africa 

Ka fnto smsu" been made both at Paris an. 

maniasis and nth 9° o' '"accinia, malaria, cancer, Leish 

■The fi-alernitv ■■ bad been of great value 

each year, was ^essenuluv T 't'" ' become more importan 
universities, raediral Lcie«e^s"^""o"' departments 
little' official character The 'i’‘^!'’‘d«al experts and lia. 
George Buchanan’s rem’arlT ^fedical Committee heard Si 
interest. Subsequentlv tbe small-pox ivitli specia 

IIie -Hitchin Board oL OnmO co^a'^ered a letter fron 

posal that 

of small-nnv laa. i m order to check the sprea< 

three weeks nr^ iccif should 'close all casual wards fo 

casuals for \hat period ‘'’® " 

action. Dr. DrfmArnvn q* ® Committee decided to take R( 
Committee 'snni-o- nn tr the honorary secretary of tlr 

-members if ^Iforliament-^fo^‘’^'r,''''®’S‘‘’ ¥ medica 

institution's af Aldo-of". "'Bitary hospitals and medica 
lion’s' bill uskiic furtfo' Begarding the Edinburgh Corpora 
cases theComm!H»; ^ venereal diseas, 

nttitude' iow.ivds tbn tSveed that while it could take ho officia 
to ventilate the subie^t"?"^"^'' ™®™bers ought to cndeaA'on 
men ■ wheii the bill wal “P^^bjog for or against as medica 
at a dntn . 1 ,-. n .“5 '^’^cussed in the -House of Common 


• , auujec 

1 ''hen the bill was 'discussed 
atadalemotthenfixed. . _ 

of Lap, "fogs"' 'ThV^T'] "r to the Protec 

P'-ngs Act, the Industrial ■ and Provident- Soci. 


(Amendment) Act, the British Guiana Act, and the •Rating 
(Scotland) Amendment Act. 

Mr. Hayes, on March 28th, introduced a bill to amend the 
^rearms Act, 1920, in respect to the definition of firearms. 
Ho explained that he proposed to include within the definition 
of firearms “ toy ** pistols which had the barrel and chamber 
plugged, but which were capable, by boring, of conversion into 
lethal weapons. The bill was read a first time. 


Tetra-elhyt Lead in Motor Spirit. 

Committee of Inquiry Appointed. 

In the House of Lords, on March 29th, Lord Betckmasteb 
asked the Government the constitution of the committee set up 
to inquire into the danger arising from the use of tetra-ethjd 
lead in motor spirit ; why the committee was not sitting in 
public, and when their report was expected. He moved that 
serious warning should be at 'once issued by the Ministry of 
Hcaltli on the possible danger from the use of tetra-ethyl. 
Lord Buckmaster said that the committee had been set ud in 
pursuance of a resolution which was before the Lords about 
a month earlier. Ethyl spirit, he said, had been advertised in 
this country for more than nine months, but no warning had 
been issued to any person who was compelled by his occui>a- 
tion to use it. Employees at petrol stations had heard nothing 
of tlie danger from the use of this spirit, and one had told him 
that it w’as splashing over his hands daily. Since last speaking 
in the House on the subject Lord Buckmaster had received a 
letter from a medical man who said he had examined parts of 
a car which had run for some 3,000 miles on ethyl petrol. The 
deposits proved to contain over 60 per cent, of soluble lead. 
jSIr. J. L. Jeffery of the Board of Trade had examined the 
parts and confirmed the chemical findings. On December 22nd 
this doctor had handed all the facts in writing to the Board of 
Trade, but nothing further had been done. The same doctor, 
writing in the medical press, had asserted that in the United 
States, between the autumn of 1923 and the spring of 1925, 
the fatal cases numbered from M to 16, and aibout 100 non* 
fatal cases were known to have occurred. Death from this 
poison was preceded by one of the most hideous forms of 
insanity, much resembling delirium tremens. The poison was 
almost incapable of remedy, was cumulative, and was slow in 
action. Lord Buckmaster said he had a letter asserting that 
Dr. Harris, the Commissioner for the Board of Health for New 
Yoi'k City, had forbidden the sale of this spirit there, though 
it was sUll allowed in New York State. Switzerland had 
forbidden its sale throughout tho whole country. Lord Gagh, 
x'cplying for tlie Government, at once read the names of the 
committee which liad been set up. They were as follows : 

Chairman: Sir Frederick Willis. K.B.E., C3., who was until 
recently Cliaimian of the Board ot Control. 

• Dcimrtmcntnl Representatives. — Ministry of Health : Sir Gcorgo 
Buchanan, C.B., M.D. Home Office : Dr. J. C. Bridge, F.R.C.S. 
(Senior Medical Inspector of Factories). Air Ministrj’ : Mr. D. R. 
Pye, M.A. (Deputy Director of Scientific Research). Medical 
Research Council : Sir Charles J. Martin, C.M.G., D.Sc., F.R.S., 
F.R.C.P. (Director of the Lister -Institute). Government Chemist : 
Sir Robert Robertson, K.B.B., D.Sc., F;R.S. War Ofiice : Major 
W. R. Gahvey, O.B.E., J/.C., M.B. (Director of Experiments in 
tho Chemical Warfare Department). Department of Scientific and 
Industrial Research: Dr. C. H. Lander, D.Sc. (Director of Fuel 
Research). 

Xvn~of}tcial Members. — ^Mr. A. Cliaston Chapman, F.R.S., F.I.C., 
Sir William Willcox, K.C.I.E., C.B., M.D., F.R.C.P., Professor 
W. E. Dixon, M.D., F.R.S. 

Secretary : Mr. S. F, S. Hearder, Ministry of Health, Whitehall, 
S.W.l. . 

Lord Gage said . the committee would have to examine 
conditions throughout the country to see what precautions 
were taken by manufacturers arid ' distributors, how far the 
action of the trade in informing the public sufficed, and how 
far it should be -reinforced by statutory regulations. Labora- 
tory research might be needed, ■with repetition of some of tho 
American experiments. - The investigations of the committee 
must be prolonged. Meamvhile the Government could not, by 
-an official. warning, , prejudice the products of a particular firm 
without the strongest ‘reason for doing so. There had been 
three inquiries into tetra-ethyl in the United States. Tlie last, 
a verv elaborate one, by the Surgeon-General’s Department iii 
AVashington, involved .experiments not only on animals, but 
on human beings. These committees had not found actual 
evidence that harm had resulted from the ordinary commercial 
use of tetra-ethyl petrol. Though no legislation was intro- 
duced the committees did recommend precautions both in manu- 
facture and in distribution in garages. Writing on March 3rd 
to the Ministry of Health the Surgeon-General saM : 

' “ As a' result of this report, the precautions recommended by 
this' Commission [that is, the American. Commission] for the manu- 
facture of. the substance Iiave-becn carried out, and. the effect of 
tho use of ethj'l spirit on the distributors throughout a large area, 
of this country has been under tho immediate observation of the 
Public Health^ Service in co-operation with the authorities of tho 



616 ApriHj 7 , 192 S] 


MEDICAti NOTES IN PAKEUMBNT. 


r Tin: JjRrriM 
SfKoiciZ, Joravit 


University of Cincinnali and otliors. f rany add lliat, notwith- 
standing tile Into publicity given to tlio investigations and Iho 
general use of the substance all over the United Slnlca and 
Canada, no instance of lead poisoning has been . reported in Iho 
lay or medical .press or to any of our Federal or State 
authorities.’' - ■ . _ ' ' - 

Lord Gage asserted that during the five years tlie spirit liad 
been in Use in' Ainerica no one liad discovered a single case ol 
lead poisoning from its use, thougii its consumption ran into 
millions of gallons a year. Telra-clliyl was blended in tliis 
country under precisely similar conditions to lliose prevailing 
in America, and tlie Home Office had satisfied itself that llio 
precautions were adequate to meet the risk of poisoning. 'If 
the new Britisli committee found evidence controverting the 
findings of the American committees it could issue an interim 
report and the Minister could immediately apply to Parliament 
for powers. A Petroleum Bill awaited third reading in the 
House of Commons, and contained a clause enabling the 
Minister to make regulations for the distribution or manu- 
facture of any class of petroleum spirit wliich appeared to him 
dangerous or injurious to health. Other substances containing 
lead compounds equally poisonous were manufactured and 
retailed, subject only to the same restrictions and regulations 
as prevailed in the manufacture and dislribiilion of tliis ethyl 
petrol. The Minister of Health saw no use in prejudicing the 
inquiry by condemning this substance before the committee liad 
reported, and lie was not persuaded that tiio public would suffer 
serious risk before tlie committee issued an interim report. ■ ; 

Lord suggested tliat the Government sliould instruct 

the committee to is.sue an interim report on the question 
whether prima facie this substance was of a dangerous character 
and whether there ought to bo some restriction in its use. 

Lord Montagu of Beaulieu said that so far as bis c.\pc- 
rience of tetra-etliyl was concerned there bad been no definite 
bad results.- There was danger if fotra-cttiyl was allowed to 
rest on the hand and danger from the exhaust. Tlie ordinary 
cxliaiist from a motor car consisted of carbon mono.vidc. If 
they added tetra-ethyl lead it made carlion monoxide more 
liable to cause insensibility. He bad definite cases of the effects 
from the exhaust of a car running on the road, in one case 
upon both the driver and the occupants of the saloon that was 
being driven. The inquiries iii the United States were not 
very conclusive, when read carefully, and, in addition, the sale 
of tetra-ethyl was not allowed in New York City. It was 
absolutel}’ barred in the tunnel whicli ran under the Hudson 
river, because of its effects. Tliero was sufficient evidence to 
make people wlio used this petrol very careful in doing so. 
The Government, lie considered, bad been somewliat dilatory in 
setting up an inquiry. 

Lord SALisBUnv said the committee which had been appointed 
was going to sit at once, and liad been asked to expedite its 
findings. He did not see what more could be done. Un- 
doubtedly the American inquiry was very careful. By raising 
a debate twice Lord Buckmastcr liad let those interested 
throughout the land know that questions had been raised in 
Parliament about the' poisonous qualities of tetra-ethyl. He 
Would see that the suggestion of a request for an interim 
report was considered. 

Lord BucKsrASTEB renewed liis suggestion tliat tlie Govern- 
ment should issue a warning to the public. Lord SAUSBunr 
cited a warning issued by'the firm selling ethyl petrol. Lord 
Buckjiastek said that that warning, so far as lie knew, was not 
read by the people who handled the spirit. Nobody denied the 
spirit was dangerous. Lord Buckmaster’s motion calling upon 
the Government to issue a warning was tlien ‘ defeated by 
36 to 21. , ■ . 

The terms of reference to the committee which was announced 
in the House of Lords on Thursday, March 29Ui, are .- “ To 
inquire into the possible dangers to health resulting from the use 
of motor spirit containing load tetra-ethyl or similar ' lead- 
containing compounds, and to report what precautions, if any, 
are desirable for the protection of the public or of .individuals 
in connexion with the use or handling of such motor spirit.” 


Small-pox. 

■ Mr. Chamberlaii? told Mr. J. Baker, on March 28th, that he 
had renewed the instruction that, with a view to detecting cases 
of small-pox, all persons admitted to the casual wards of Poor 
Law institutions should be medically examined. Small-pox was 
known to the Ministry of Health to have occurred in some sixty 
casual wards during the present year. 

Answering Dr. Fremantle on March 29th, Mr. Lhamberlaoi said 
the Metropolitan Asylums Board, the Sarrey Small-pox H^pital 
Committee, the Uxbridge .Tomt Hospital Board, and the Willesden 
Urban District Council had respectively available tor small-pox 
2123 beds, 19 beds, 26 beds, and 25 beds; of these, only 6 w-ere 
then occupied. Dr. Fremantle asked whether Mr. Chamberlain 
know that two cases of small-pox in the tnfirm ward at the 
Brentford Union institution had to be isolated there from March 
16th to 22nd, and another case from March 25th. Mr. Chamber- 
i-Ais said he knew of this. Dr. Fremantle asked whether the 
ilinistor would secure that vacant beds in smalhpox hospitals were 
arailabla for coses of small-por from neighbouring areas subject , 


ho'’ha'?r.m‘‘n®e?ej''^^ cxpouscs. Mr. CuAmrnum replied that 
h^nltal ncre 1 authorities possessing sroall-noi 

"jaommodation to admit patients from other districts, the 

for Ihn mwnhie ‘ b”'’ "J’ "madequatc provision 

for lliD ptirposo. Dr. Fremantle asked whether: Mr,- Chamberlain 
wa.s asing lm_ powera of persuasion to get this sdlfish policy of 
local authoritiM nltei-ed. Mr. CnAMBXRLAiN said '.hb could not 
accept timt definition. In mo.st infirmaries provision was made 
for isolation treatment of infectious cases. 

On March 29th Mr. Groves asked ' whether butchers buying 
calves at Iho Government’s Hendon lymph establishment wcrl 
jnformed uiat incy had been used for inoculation, whether 
butchers oJTerjng such calves for sale were compelled to exhibit 
a notice that tlie calves had been used for inoculation; for what 
piirposo rabbits were inoculated at the Hendon establishment, and 
whether rabhds so used wero destroyed. -Mr. CnAmERlAtK said 
Mr. Groves had already had facilities for visiting th'o. Hendon 
establishment, and suggested that he should go there ’again to 
secure inforniaflon. Two Government clerks had been occupied for 
ft whole day answering Mr. Groves’s last question, n‘nd>ior him 
to ask for further detailed information was scarcely reasonable. 
Jifr. Mo.vtacue pressed for a rcply^ to the question aoqut’butchere 
and calves. Mr, Chamberlain said butchers were not' informed 
that calves had been used for inoculation, nor was there any 
compulsion ‘.to exhibit a notice of the fact. Answering a. further 
question .by Mr. Groves, Mr. Chamberlain said that after pro- 
duction of iho lymph a calf vas hot used again,' but was 
slatightcrcd. The carcass was at the disposal 'of the contractors 
who supplied it, and was sold' for food. i : a ' 


^hops Sill, 'i ' . ‘ 

When a Standin" Committee .of the..House oj Commons, con- 
sidered the' Shops jBiiron“Marcir27nrM1ss''WiLKiHsqN moved to 


SldCrCd lUG OnOpS 

omit the subsection permitting a shopkeeper to supply goods after 
hours if reasonable grounds existed for ‘believing' that the article 
was required in- the •case of -illness.* -She said'that article sold 
in chemists’ shops and other .things required as matters of life and 
death were ‘already ‘covered *by other clauses of the bill, bpints 
wore dealt with by entirely- diiferenfc.Jegislatipp, and. the subr 
section she' was discussing would -apply very largely to the con- 
ients of the overage grocer's shop, none 'of which was bkcb to 
he needed jn cases of: sndden 'illn'c-ss.' : Sbo.'.insfanced . licef-fca, 
muslard. and oil. Hr. Vernon Davies denied that Uie other sub- 
section to which Miss Wilkinson referred provided 

which were needed in sudd-sn illness. Sir William 
Ffickl u bill made clear that. t^.BkoP was 

inen foT the needs of sidkness it was not to be "sed for Hie sale 
oF Ollier gOTds. The amendment was withdrawn and the clause 
added to the bill. 

r, .1 fh/cTuilon foT AdCTioids . — Oil March ^^nd Mr. 

Mf^Bisrra^askcd^Lord Eustace Percy whether he 

'T? l.% been done in spile of protests by the boy’s molher, 

under -^hal autborSy the action had been taken. Lord 
and asked i.fx v>od received a report on this case from thr 

^TSd'^cdTcIl offiror. Ho^ understood that 

school -mcd ^i^wn obtained before tho operation was porfomod. 

Fvis nM^due te dofret or failure i^ the autUority’s ari-angcmcnts 

for treatment. March 26th Mr. CiiAMBERLAra, in reply 

Housing StnUsM numbers of houses com- 

lo Gciiem district councils rn England and 33 alra up 

plctcd by rvriu 92 532 under the Housing itet, 1923, ana 

March Isl, 1*8, „ - . j jg 24 . The number of bouses not 

24,525 under the Housing Act^ , 

exceeding £?6 rateable I aiue^^^ ^ 1 st, ' 1923 , to Septcuiher 

|0Ui!‘’F92l"'”® latest date for wbicF figures were available, -ass 

76,387. n>^hfi,nhnir nme^t — Mr. Chamberlain, 

■ -NaiioJtal Lmut -Colonel Mason, said that there iv-is 

Implying on Aprffi2nd t^ . jv„s Ihere any 

[^paTFr eatoent 

Notes in Brief.- - niiamberlnin 

training and supply o • “ j e.i>ftrtlv the VoIuutV^ 

■ ‘ all shops where synthetic cream is . 


APRIL 7, 1928] 


MEUlUAti NEWS. 


I Tnn BsiTKn 
AIedical Jotokal 


617 


3 




The King visitoil tho Woolwich Wav iiremorial Hospital on 
■Match 27th, when ho was vccoivoa hy Mv. B. Komp, E.G.C,, 
tlio clmivmnn ot tho hospital ; Lord Dawson, consulting 
physician; Siv Bovlteloy Moynllmn, consulting sui-gcou; and 
Mv. Cecil Kowntroo, chaivinau ot tho Metlical Coininitteo. 
His Majesty matlo a tonv ot tho wavds and special dopavt- 
ments, and inspected tho now stainless stool and chroiuium- 
plated fnrnituro in tho opovating tlieatvcs, made by Messrs. 
Arnolds to Mr. Eowutroo’s designs. Ills Majesty exiiressed 
his satisinetiou at hearing that all tlio cquipniont was ot 
British inannfaotnro, and congratulated tho chairman on the 
heanty and etUcieucy ot tho hospital. Botoro leaving the 
King planted a codar tree in tho grounds. 

To celobrato tho centenary ot tho Royal Free Hospital, and 
in aid ot tho centenary appeal tor tho now extensions, tho 
medical staff and students, with some other friends ot tho 
hospital, ate organizing a ball to talto place on May 1st, trom 
9.30 p.m. to 2 a.m., at tho British Medical Association llonse, 
Tavistock Square. There will bo dancing in tlio Great Hall 
to Newman’s Band, with short cabaret turns by well-known 
artistes at intervals,' whilb ample space for bridge players 
will be provided in the Hastings Hall. Tickets, to iucludo 
supper, are one guinea each, and. may bo had from any 
member ot tho committee, from tho Royal Freo Hospital, and 
from tho Honorary Secretary, May' Day Ball, 24, Mecklon- 
burgh Square, W.0.1. 

A MEETING ot the West Kent Medlco-Chirurgical Society 
■will be hold on Friday, April 13tb, at 8.45 p.m., at tho Miller 
General Hospital, Greenwich, S.E.IO, when Mr. R. Ogier 
n ard will give an addresson some difficulties in tho diagnosis 
and treatment of urinary diseases. 

Under the auspices ot the Fellowship of Medicine a special 
coupe m infants’ diseases for medical officers of welfare 
^ntres and others wilt be held at tho Infants Hospital, 
Westminster, from May 7th to 19th. In addition to lectures 
and demonstrations visits will bo paid to tho Model Pasteur- 
izing Plant, Willesden; tho Nursery 'Training School, Hamp- 
stead; the V.D. Centre, Thavies Inn; tho Homo for Blind 
Babies, Chorley Wood ; and tho Infants Hospital Convalescent 
Home, Burnham Beeches. Details may bo obtained from 
the secretary ot tho Fellowship, 1, Wimpolo Street, W.l. 
and December^ Infants Hospital will be held in August 


....In course on diseases ot the nervous syst 

National Hospital, Queen Square, tr 
consisting ot clinical lectures a 
week-day afternoon, except Wedues^ 
/j.,,, work in the out-patient department each wo 

Saturday, and a series ot seven pathologi 
tuo „ flemonstrations. A coarse ot eight lectures 

physiology ot the nervous system will 
1,0 o there are sufflcient applicants. There will a 

twelve clinical demonstrations on 'Tuesday a 
««.... ^ coons, chiefly on methods ot examination of' 
oussystem. Alimltednumberof st.nUmit.B ran bo enre 

and tl 


'■ methods of examine 

w Alimlted numberof students CflU UKi CUlU 

Clerks. Full details regarding the course and fcl 
I'f* Obtained from tho secretary, Med 

TTrtctnif'il cy f-rr 1 


q.uZT Obtained from the secret! 

School, National Hospital, Queen Square, W.C.l. 

io International Congre.ss ot Photography, wl 

m London from July 9th to 14th, under 
takrnl-,cni„*'!i°!»®°^‘'^.^*^°‘°sraphic Society, is tlie firs 
its ^tranches ot photography 

aud'iiipH,nV°°^’ radiography, photomicrograi 

drsiussei m chendsti'y and biology, wili 

ot exhibitinno'',?n7-''''^'°?,® and illustrated in a se 

prints nbotnmiPi.^I!® congress. Offers ot radiogra] 
FnteiTk Shonm hp photographs ot biolot 

secretarvto i-hf> a-s possible to the honoi 

South Kensington, Committee, the Soieuco Muse 

tho^ex^°T'w^vU°ir tl’® Society ot Arts announces 1 

will be tor Dm which on this occa 

will be maflp^in^Tp^ Poblisbed work on medical jurisprude 
prize turn! 17“ 1329. -Dr. Swiney, the donor of 

provide on left £5,000 to the sooiet; 

consisti’iip anniversary ot his death, a p 

amount Dm money to the s; 

general being made alternately for medical 

orFo cCm?,m^!“®®- ,^“y desiring to submit a v 

writini' to d?o ler consideration should do s 
■W 0 2° not ® secretary ot tho sooietj', John Street, Adel 
jointly C t m®7 November 30th; the award is n 
Physk;ians Tp®°?'®7y ^‘'ts and the Hoyal Colleg, 

jnrisprnfloilop^^® ino7 awards for works on meii 
JurisprndoucG, m 1909 and 1919, wore made to Dr. Cha 


Mercior for his books, Criminal licsponsibiliti/ and Crime and 
Criminals respectlvelj'. Ono of the earliest prize-winners, 
in 1859, was Dr. Alfred Swayue Taylor, whoso Medical 
Jurisprudence has lately appeared in its eighth edition, more 
recent awards going to Dr. C. M. 'Tidy in 1889 and Dr. J. Di.xon 
Mann in 1899. 

As announced in our advertisement pages applications for 
tho Dickinson 'Travelling Eesearoli Scholarship in Medicine 
and tho Dickinson Surgery Scholarship must be made by 
May 1st to Mr. Frank G. Hazel], secrotaty to the Trustees, 
Manchester Royal Infirmary, from whom farther information 
can be obtained. Tbe former is ot the value ot £300, tenable 
for one year, and candidates must have graduated at the 
University of Manchester, with distinction in medicine and 
surgery, in any ot their academic years immediately preceding 
tho award ot such scholarship. The surgery scholarship is 
open to students who shall have received at the University 
of Manchester and the Royal Infirmary instruction in 
pathology, medicine, and surgery necessary for obtaining 
the degrees ot M.B., Ch.B.Manch. 

The Royal AVestininster Ophthalmic Hospital will move 
to tho new building in Broad Street, High Holboru, W.C.2, 
on April 10th. 

The British Guiana Medical Annual for 1925 has been 
recently issued at the cost ot 7s. It contains the transactions 
ot tho British Guiana Branch ot tho British Medical Asso- 
ciation for the years 1922-24, four original articles, and two 
clinical notes. A supplement deals with leprosj' in British 
Guiana, incluiling the related statistics and legislation, and 
also a note on treatment. The public health and medical 
statistics of the colony, usually published in this Annual, 
have been postponed to the 1926 issue, which is in course ot 
. preparation. 

The February issue of tlio Kenya and East African Medical 
Journal contains an account of the annual meeting of the 
Kenya Branch of tho British Medical Assooiatiou, and a 
review ot the medical history of the colony during 1927. 
Attention is drawn to the improvement of railway com- 
munications, and to tbe closer co-operation ot the public 
medical and health services iu tho various territories in East 
Africa under British rule. Other articles in this issue deal 
with tho serological diagnosis of B. pestis, tbe treatment of 
ulcers with Stockholm tar, and inoculation ot the monkey 
as a means ot diagnosis of small-pox. Tho scries ot simple 
notes on tropical diseases is continued, with a practical 
account of tho treatment of plague. 

The third congress ot tho International Society for Logo- 
paedics and Fhouiatiics will be held at Vienna from July 12th 
to 14th. Further information can be obtained from Professoi: 
E. Froschels, Perstelgasse 6, IVien IS. 

The eighth International Congress ot Dermatology and 
Syphllology will bo held at Copenhagen from August 5th 
to 8th, 1930. Further information may be obtained from 
the general secretary, Dr. S. Lomholt, Kaadhnsplads 45, 
Copenhagen. 

A COURSE in oto-rhino-laryngology will be held at Strasbourg, 
under the direction of Professor Georges Cannyt, from July 
2nd to 14 th. 

The Joaroal 0/ ihc Egyptian J/e'iieat/tssociafion has daring 
tho last ten years been printed solely in the Arabic language. 
Commencing with tbe issue ot January, 1928, translations, 
or summaries, of the articles appear in English, French, 
German, or Italian. The first number published under tho 
now conditions inoiudes articles in English on the biochemical 
race-index ot the Egyptians ; biiharziasis of the conjunctiva, 
illustrated bj' coloured plates ; and the determination of tho 
solubility of digitoxin. 

THE Bruxelles-Medical has recently published a special 
issue devoted to the annual congress known as the Joiirnfies 
M6dicales do Bruxelles, held last June. The issue contains 
abstracts of tlie principal communion tioas, with portraits 
ot their authors, and an illustrated account of tlio social 
functions. 

A NATIONAL fund is being created in Sweden for presenta- 
tion to King Gustaf V as a gift on bis seventieth birthday 
in June this year. Tho King intends to expend the fund in 
promoting cancer research. A special institute may be estab- 
lished in Stockholm. 

The following appointments have recently oeen made in 
foreign faculties of medicine : Dr. Hermann Straub ot 
Greitswald, professor of internal medicine at Greifswald ; 
Dr. A. Kohlrausch ot Greitswald, professor ot physiology at 
Tubingen in succession to the lato Professor Trendelenburg; 
and Dr. Belak, professor ot public health at Debroeziu. 

Chairs ot therapeutic hydrology and climatology have 
been founded at tho facnlties ot medicino ot Paris, Lyons, 
and Montpellier, with Drs. Villaret, Plfiry, and Giraud 
respectively as their first ooonpants- 


618 April 7, 1928] 


liETTEES, NOTES, AND ANSWERS, 


t TnE Dftmw 

MkDICAT. JopREAt 


mtti 

All communications in regard to editorial business aliould bo 
addressed to The EDITOR, British Medical Journal, British 
Medical Association House, Tavistock Square, W.C.1. 

ORIGINAL ARTICLES and LETTERS forwarded for publication 
arc understood to bo offered to tlic Ruitish EIedical douuHAt. 
alono unless the contrary bo staled. Correspondents \ybo wish 
notice to bo taken of tbeir communications slioiild autbcnticato 
tbcm with Uicir names, not necessarily tor publication. 

Authors desiring REPRINTS of their articles published in the 
Bbitish Medical Joubkal must communicate with the Einnncial 
Secretary and Business Jlanagcr, British Medical Association 
House, Tavistock Square, W.C.l, on receipt of proofs.^ 

All communications with reference to ADVERTISEMENTS, ns well 
as orders for copies of tlio Joubnal, should bo addressed to tho 
Einancial Secretary and Business Manager. 

Tho TELEPHONE NUMBERS of tho British Medical Association 
and the British Medical Joubsal arc MVSICVH 3S6t, 9SG2, OSGS, 
and OSGi (internal exchange, four lines). 

Tho telegraphic ADDRESSES are ■. 

EDITOR of tho British Medical Journal, AHioloay JTcsIecnt, 
Loudon. 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.). AHiculatc ITcatceiil, London. 

MEDICAL SECRETARY, Mcdisccia ircficrnt, London. 

The address of the Irish Office of tho Brilish Medical A.ssociation is 
16 South Frederick Street, Dublin (tclogrnuis : llacilluti, Dublin-, 
telophono : 4737 Dublin), and of the Scott isli Office, 6, Drumslictigli 
Gardens, Edinburgh (telegrams : Assoeinic, L'dinburub ; Iclepbono : 
£4361 Edinburgh). 

OUERIES A.ND ANSWERS. 


CURO.VIO BnONOHITIS AFTER Ga3 POISOVINO. 

D. M. M." asks tor nuy suggestions in treating an obstinate case 
of bronchitis caused originally by gas vioisoniug in Franco. Tho 
secretion is both abuudant and free. All the remedies indicated 
iu ohrouio bronchitis, inoinding tar, miuoral aoids, and bella- 
donna, have been of no avail. The patient is aged 54 and other- 
wise healthy. 

Nephrostomy. 

A cop.m!SPONDEN'r inquires ns to tho iiso of the word •'nephro- 
stomy” in Mr, J. F. Dobson’s article on “Tho late results 
of operation for renal calculus,” puhlishod iu our issue of 
March 24th (p. 486). 

* ’ We have referred the point to Mr. Dobson, wlio writes : 
“Nephrostomy” implies iiicisiou and drainage of Hie kidney, 
and is the term whioli ought to he used in preference to 
“nephrotomy,” wbicb merely means an incision into the kidney 
nud does not imply drainage. The term “ nepbro-litbotomy ” is 
used to describe the operation of incision of tlio kidney, extraction 
of the calculus, aud suture of the kidney. If a surgeon incised 
the kidney with the iutenlioii ol removing a calculus, could 
not fiud the calculus, and closed the iuoisiou by suture, that 
operation would be correctly described as a “ uepbrotoniy.” 
With our more precise methods of diagnosis tlie operation of 
exploratory uoplirotomy is now rarely performed; but many 
Burgeons will remember the period when such operations were 
rather common. Wliou nothing was found the case was labellod 
“nephralgia,” and oonrideut assertions were made by the more 
optimistic operators that the patients were cured of their 
symptoms by the iuterfereuce. 

Income Tax.. 
d/otor Cur Allowance. 

“ W G S." bought a car iu January, 1923, for £475 and sold it in 
1927 tot £60, when be houglit a oar of aaottier make for £265. 
He has been allowed a total sum ol £132 iu respect oI depreciation 
^the old car for the three years to 1921-28 inclusive. 

• * * The allowaiieas to be claimed are: (1) Obsolescence 
allowance— as an expense of the year 1927— tho actual sum 
expended namely, £235-£B0.=£205. (Note— Tins does nbt exceed 
tie oo't ot the car replaced after deducting the total wear aud 
tear allowauces given tbereou aud the sum obtame.I for the old 
car.) (2) Depreciation allow'anoe foi 19-S -9, £265 at 15 per 

cent.— 

Appointineiits and Post-Graduate Study. 

..w r R 0’'i3 in praotioa in the provinces as an ophthalraio 
“ F. O. B. Ar. 13 n i ftnpoiutmeiit as clinical assistant at a 
surgeon, aud bolds u "Jmguot as a professional expense (1) the 
London hoM>'h’-'-,,.C“.“°.Y,p‘LQgmtal • (2) the cost ot attending 
expense ot '"'8 3) lie expense of attending 

incideutal hotel c.xpouses? _ , -i - i. , 

(1) We understand that the authorities do not object to 
the incinsiou of the fees iu the general return and the deduction 


ot the travelling expenses, hut this presumably proceeds on the 
assumption that the appointment is one of appreciable value— 
for example, wo imagine they would objoot to the deiliiotion ot 
expenses to on luiioiiiit in excess of the gross value of the 
appointment. From tho point ot view of strict law, ond apart 
from any departmental coiicossion, the dediiotiou is not due. 
(2) nud (3) There is neither law nor concession to support tlie 
claim. 


LETTERS, NOTES, ETC, 


IlLtTr.nKAl. MORTAlilTY AND PELVIC DEFOiaiirY. 

Dr. liATiii.F.EX 0. Vaughan (London’, W.2) writes to suggest that 
a factor wliioh has been overlooked in discussing the causes of 
iiintcrnal mortality is nialdevelopnieut of the female pelvis. 
No ante-natal care during pregiiaiici’ can remove a defect /iro- 
diiced during growth of the pelvis, and tlierelore, she says, 
considerahly more ntteution should be devoted to this part of 
the body iu early life, 'i’lie complex nature of the proeesse,! 
involved is inilicated by the fact that sexual differences are 
present iu the pelvis by the fourth raoiiHi of iiitrauteriue life, 
that twenty-one centres of ossification are oonoerned in tlia 
doveloiiim' sacrum, twelve more iu each iimomiiiate bone, aud 
fortv-hvo centres coiitimio to grow actively until the age ot 25, 
when tlio process is complete. TlAis any failure in the factors 
DceesBiivv to proper dovolopment and ossilioatiou may have very 
serious conseqiioiices in later life. The head only doubles in sw.o 
from birth to maturity, whereas the size of the pelvis at pubert.i 
is tbrico that at birtii, but the three boues composing the in- 
nominate are still only united by cartilage at the aeetabiilnm 
Dr sui’ycBts that the greater elasticity of the pelvis at 

rmhe'rty^may explain the partiality for eaiW marriage in tlie 
ftast hi view of the assistance given to childbirth .b.v 
KlaslicilV- She emphasizes tlie necessity for further imostig.i- 
tion of Hie growth of Hie pelvis, particiilarl.v during Hie rapid 
fitaue from 8 to 15, and calls attention to tho possibility o 
fln{&voli''ht ami ventilation in houses and worlishops giMiig 
rise to imporfoct pelvic-development in girls. 

AprENDICECTOSIY pniH.NG HER-NIOTOMY Ilf AN 
rf r CnAVEN Veitoh (Huntingdon) telers to Dr. D..,MaO' 
Mr. H; p- Aiavch 17 Hi, p. 443) and writes: On March 22iu1, 
kouzio’s “se (Mavch , t ,,, nffniittod to Hiintingdoii 
1927,amal6 '•'it'' a Blrangnlatei right 

County Uosp.tal a„„estlietic was g ven, and when 

mgmnaU eoiia. a ge caecum nipped iii its neclr am 

I opeuecl the sac I mi_i ^ removed it, completed 

tho appendix ly ^ oircumoised the baby. 



„ Btraui'iilateft lierniii or uosieon i.u= .eported. 
Th“s?B'ti r yomigest ago at which I have removed an appendix 

oi euoouuterod a Btraugulated hernia. 

Lime-deficient Food and Carditis. . , 

, „.,rTe q-iEPHENS (Swansea) writes IVhile.ou, a recent 
t)P.. G. NRkhH , j. jmjies i was agreeably surprised to find that 
holiday to the M ilisease or any deaf nud dumh 

there wcie no “se o jgeq maiuly on vegetables, 

cbildreu on vigi^g-all grown ou soil well impregnated 

fruit, and coTOi—toeethor with milk from goats or cows 

with lime irom the coTOl \Yrn inclined to ask to what extent 

or the my theory that acute rheiuiiatism aud eardtfs 

this substantiates niy whose food 1ms been maikedly 

occur only l.ii|,v,ued with a perverted appetite tor . acids, 
defleiout _m li ■ jwyatteatioii has been drawn to tho interesting 
such ^ OtrWmarv 28th, p. 140), togetlier with yonr 

report by and X wish to point out that whilst rats of 

comments thoieou, direotioii of that growth is also very 

growth oe S grow quickly, bnt in the wrong . iree- 

iraportaiit. ^‘"'^1,.® t ig all important tlmt growth in ohihlrcii 
tio;.,ana development ol that type of cl.ihl which 

sliould be toW" 's disease— namely, the milk-fe;l one 

riAY’-pr falls ft niKo onrfiP.ivp val 


-- to heave oisease — t A-*.... r • ,«. 

never falls “jj vinegar. The curative value of calcuim 
with no such as ohilblaius, ot oaioium 'oilitle 

salts in "'Pgftloiuni permanganate in gastric ulcers, ai d 

obi'ouic fitrin m carillac ulcers, serves to 


mta 11* rtf 1’n.lcium ueruianijiuitue lu 

__U'Ouic ^<5015 0 cardiac ulcers, serves to 

of cftjfa safiisfv ft uUysioIojiical need. 


COllOKtai lOnii iu A.AAAw,.--, 

BiUestumt these salts satisfy a physiological need. 

EHH.VIUM. , 

^ ,T TTiNsrHELl. has called attention to an f''*’ 

DR. H. M. S*'' jpe iiijeotion treatment ot ''"■‘■‘5?/'’ , 
ill his- V'l'P'",?" Jonrn-il ot March 51st. In page 543, imo 41 
pablished m the .. methane should, of 

Irom the V|,„„p .. 
course, be “ urethaue. 

YACANOIES. ■ n„oaS 

ISOTIFIOATIONB Ot otnees vacant m nniversiH^ 

Of .v-ant^reBident^aud^other^a;^^^ 


aud of vftcauc ^ 

wm be fouRfl raHnerships, assistantsbips. 

co\uinus»aua aavern = ant? 51 . 

nud looumteneucies at p ^ adverfcisemei*^ 

A short summary of vacant posts noti^d m 


ALKAIilNE TBEATMENT OP GASTRIC UECER. 


r The Br.msH 
L llEDrc-ir. JocBvjLi. 


619 


ApkU. I9:S] 


^ ICrchiri 

o:c 


THE 


INTENSIYE ALEALINI'; TKliATMl^NT OF 
GASL'IUG AND DUODENAL Ul.OER. 


DKUVKIir.D TO THK ICkNT or THi; UlSrrisH 

MroicAL A.ssoa.\TTOx 
ny 


HUGH JtAcLEAX, M.D., V.Sc.. V'.Ii.C.P., 
rnorEssoR or medicike, ukiversitv of loxoax; iiir.Ecron or the 

n.!.VICAI, MEDICAL IIKIT, bT. THOM^S’S HOSPITAL. 


To tlie general jiractitioncr the troiitmeut of gii'-tiic' and 
duodonai nleoration has ahvays hristled ivith difheiilties. 
Patients biidering from the.se lesions are Ircquently cneonn- 
tered in general medical ]naetiec, and very often the results 
of medical treatment are nnsatisfaetory. If relief does not 
come within a short time the patient is generally handed 
over to the Surgeon, since it is considered that, on the 
whole, medical treatment in the.se cases i.s not l erv effica- 
cious. Surgical interveution i.s not infri'quently productive 
of excellent results;. on the other hand, the last state of 
the patient may be worse than the liist, and though 
surgery has many successes to its credit in this field it has 
also many failures. Different view.s are held as to the exact 
indications for surgical treatment, hut the appearance of 
a well-marked niche or so-eallcd “ penetrating ” nicer in 
the radiogram is often accepted a.s evideiiee that tire 
condition i.s not likely to he benefited by medical treatment, 
and .so operation follows. In many ease.s operation i- (jnite 
unnecessary, for excellent rc.snlt.s may usually be obtained 
by simple medical nieaus wbicb can be ciiiite easily tarried 
out by any medical practitioner with little or no ineon- 
yenienee to tiie patient. This can he done hv the use of 
intensive alkaline treatment. Before descrihing this treat- 
ment in cletail it is necessary to make a few preliminarv 
observations. 


Thu Use or Alkalis in Stojiacti Lksion.s. 

For a very long time indeed alkalis have been used In 
almost every medical practitioner in the treatment o' 
gastiie conditions. That these snhstaiiees have a veri 
marked action in relieving distressing gastric svmptoin 
i^s' known to all. How they produce this effect is a matte 
or discu.ssiou, and opinion on this point is not unanimous 
According to some obseiwers this action is an indirect one 
while oUiens take the view that it is due to the antaeii 
properties of these bodies. Pcisoiiallv, I have little douh 
that t be latter rieiv.is the correct one. If the action wer. 
an indirect one after absorption it is impossible to ii.iagi.i. 

would folloiv so qiiiekli- aftei 
ingestion as is usuallv the case ^ 

tffis f somewhat strange tba 

alkJ ttJr intensive “use o 

from su' undoubted benefit was derive! 

benefirwas us'ifnn .ccognir.ed that thii 

* s usually but a temporary oiio and +hat ven 

tbaTaSrd time. Assiimini 

wonder that more plivsicia?,* Vr 1 ^"'?’ 
to its ultimate eoneltion and give sufficient * 
to nentralize the acid temporlrih m t t ’ f T ' 
periods.. Logical! V, this would httl.l ? ra 

statement is correct. It is ouite r 

men did give large doses of\feli but t ■*'' 

the credit of first pointing out tb t n t "if 

he cured bv giving sufficient i "t®*' T 

alkaline for several davs or wtks tl 7’ ^ t -"- 
very iiifercsting paper' m.bfi J! i ^iirat,- in ; 

method, it does not apiia? to l ’ ' i"" S'PP.v ' 

enthiLsiasm in this co\mtn7 P^'f "P "‘‘th an; 

tact that Sippv’s diSw; this was due to tin 

suite of nic, • ^ Somewhat elaborate. Ii 

the trcatineiit it is 'Tn danger o 

safe. For five years mv inp ' imrfeetl; 

y colleagues and I have used s 


simple niodifieation of the method with most excolieiit 
results. Altogether over 350 patients have been treatad 
without any untoward symptom.s. Indeed, I have not been 
able to find a single case of any toxic cfrccts when onr 
modificiition was carried out. The method is now in us,, 
by iniMiy of the staff of St. Thomas’s Hospital and by manv 
of onr leieiit gradimte.s, yet I have found mi one who Im's 
had the slightest diffienlty with the trealmeiit. In our 
experience there is no method that gives sut-ji extelleiii, 
fe.snlts'in a short time. It is simple, requires no .speiia’ 
knowledge or supervision, and can be carried out at the 
patient’s home, however bumble his circnmstaiices. 

Exi-EIUCN-CES WITH INTENSIVE AlKALINE 'IllEATAIENT. 

Personally, I luivo always been interested in tiie pbvsio- 
logy and pathology of gastric secretion, and veiw many 
years ago had frequently given large doses of sodium 
bicarbonate and other “ alkalis ’’ in cases of severe dv.s- 
)icpsia. In 1920, when I was put in charge of beds at 
.•st. Thomas’s Hospital, we btwan to test various meth.ods of 
treatment for gastro-duodcnal nlcerntion, and among these 
methods leas the n.se of large doses of alkali. This eon- 
tinnod until 1923, when it apjieared to ns that the results 
with alkali Avere very much bettor than those afforded by 
other means.' In 1923 the majority of onr gastric eases 
were treated hy the intensive alkali method, ivitli such 
excellent results that since 1924 the method has been used 
as a routine one. The results have been gratifying in the 
extreme, and far better than we had hoped for. Uiieom- 
plicatod Hirers clear uj) in a short time, as indicated by 
X rays, and in the groat majority of eases all the symptoms 
c'lisappear quickly. Often large “ penetrating ” nicers 
clear up in a feiv weeks. .So far we liai'e not had a single 
instance of an nicer recurring at the site at ivhich it was 
formerly present as indicated bv i-ndiograms. Our opera- 
tion list has gradually diminished, and for the last year 
not a single case out of over 70 treated has required opera- 
tion. Even in jiatients suffering from ])ylorie stenosis an 
opei-ation can often be avoided by the use of alkali treat- 
ment. For tlie last year we have had only one patient 
readmitted to the wards after ho had undergone treat- 
ment. Tiicso results are altogether better than any we 
Iiave had by other means, and seem to ns to indicate that 
in the judicious use of alkali wo have a method that will 
cure the average case of uncomplicated duodenal or gastric 
nicer. 

In my monograph’ on gastric diseases published in 1925 
1 pointed out tlie great value of this method of treatment, 
and further experience has more and more impressed me 
with its value. At the beginning of this year my colleagues 
and I published a paper showing a number of radiograms 
illustrating the excellent effects obtained by this treat- 
ment.' This article elicited a certain amount of criticism 
uhich had to a large extent hut little bearing on the facts, 
blit nothing licipfnl transpired. Apparently, however, if 
we may judge from the mass of correspondence received 
from meciical practitioners, this article lias served to stimu- 
late interest in the method. For some years I have 
described the alkaline treatment at various meetings of 
meciical men, and invariably, so far as I know, those who 
have tried it have had good resnlt.s. AVe hope to jiiiblish 
a detailed account of our medical unit results at an early 
ciate, hut, so far, the conclusion we have arrived at is to 
the effect that the method nil] cure the ordinary case of 
gastro-chiodeiial ulceration. Patients with adhesions and 
other complications are probably not suitable cases, but we 
Iiai-e some evidence which may suggest that even cases 
with adhesions to sundry organs may do quite well. On 
this point, however, we are not certain at present, ft e 
hace so few failures that on general averages .some of our 
.siicx'csses probably had complications. 

The Eaijonale or Intensive Alkaline Tueataient. 

In jiearly every case of severe clyspep.sia and ulceration 
hvclrochloric acid is present in the stomach secretion. Xow 
it is well known that hydrochloric acid is very injnrioiis 
in the case of an nicer: it causes irritation and prevents 
healing. This has been amply proved by Bolton’ and 
niaiiA- others. To what extent the gastric jiepsin is also 
responsible for this deleterious action is unknown, but- 

[35io;i 


620 Apniii 14, 1928] 


ALKALINE TKEATMENT OP GASTRIC ULCER. 


tliis i.s of 110 groat importance, since pepsin is inactive in 
tlio al)scncc of acid. Tlie imirocliloric acid is therefore the 
important factor in preventing the Iiealing of an nicer. 
Wliilo this is gencr.ally admitted, there .seems to he a good 
deal of confusion regarding the matter. It is sometimes 
said that there is not necessarily anj- excess of acid con- 
centration in gastro-duodcnal idceration. This is often 
true, but why worry about excess of acid? Tlio ordinaiy 
normal acid secretion is sufficient to cause the damage. I 
Very often tliero is a “ hyperacidity ” in the sense tliat 
the stomacli continues to secrete acid after digestion is 
completed and the food lias passed on to tho intestine. 
This acid must do a very great deal of liarm. 

A theoretical objection to the use of largo amounts of 
alkali is to tho cifcct that it prevents gastric digestion. 
This is, however, exactly what we wish to prevent. If 
tho food is passed into tho stomach in a finely divided 
pultaceous mass there is no need for gastric digestion. 
Tho food is i)asscd into tho duodenum and digested bj’ 
tho pancreatic juices lower down. Stomach digestion is 
not essential to health, and its temporary suspension will 
do no harm. Now it is a strange fact that ulceration 
practically never occurs in the alkaline small intestine. I 
In the first part of tho duodenum ulceration is common, 
and hero acid frequently comes into contact with the 
mucous membrane; in the remaining parts of tho duo- 
denum, where an alkaline medium is tho rule, ulceration 
is almost unknown. All this seems to indicate, on theoretical 
grounds, that ulceration is in some way associated with 
tlio presence of hydrochloric acid. This conclusion is 
enormously strengthened by tho observation that ulcers 
will heal when they are no longer subjected to tho action 
of acid, but ai'o bathed in an alkaline medium. 

Detaiis of Intensive Alkaeinf. TnEATjtENT, 

Sufficient “ alkali ” must ■ bo given to prevent tho 
Iiresonce of free hydrochloric acid in tho stomach for some 
time. The substances gonei ally used to neutralizo the • 
acid are sodium bicarbonate, magnesium carbonate or 
oxide, and calcium carbonate. In America magnesium- 
ammonia phosphate has boon frequently used, and a mix- 
ture of calcium phospbato and magnesium phosphate 
has been recommended by Shattuck, Bohdonburg, and 
Booker.' Sodium bicarbonato being very soluble is an 
excellent antacid, but has tho disadvantage that it tends 
to produce a secondary increased flow of acid. It is not 
satisfactory to use this substance alone, but when asso- 
ciated with less soluble bodies such as magnesium and 
calcium carbonate a very satisfactory mixture is obtained. 
It does not matter very much what combination of 

alkalis ” is used, but the following jrowder will bo found 
to give excellent results. 

Sodium bicarbonate 5ss 

Heavy magnesium carbonate yi 

Calcium carbonate yj 

Bismuth oxycarbonate 513 

It is important to have the bowels fairly free, and 
usually the above mixture, when given as directed, will 
produce a fairly free bowel movement. Should this be too 
free, some extra bismuth carbonate may be given, tvliile, 
on the other hand, if constipation shoidd prove trouble- 
some extra “ magnesia cream ” may be given in doses 
sufficient to overcome tho difficulty. Bismuth carbonate 
does not neutralize acid to any appreciable extent Under 
ordinary conditions unless the acid is in gre.ater concen- 
tration than is usually found in the stomach. It does, 
however, seem to possess some beneficial effect in gastric 
lesions, and is very useful in rcgnlating any diarrhoea 
that may be present. Calcium carbonate is an excellent 
antacid with little effect on the bowels ; magnesium car- 
bonate, on the other hand, tends to act as a mild purg.a- 
tive, but is a good neutralizer of acid. 

In order that the powder should have its maximum 
effect the patient should bo put on liquid diet for a week 
01- longer according to the severity of the condition and 
the intensity of the symptoms. Pain usually disappears 
within forty-eight hours, and the patient feels comfortable. 

If definite symptoms ])ersist after two or three days’ treat- 
ment it is probable that the condition is not an ulcer, or 
■ that adhesions to adjacent organs are present. The im- 


[ 


TirzBrmsa 
HzDiciL Joesvu 


portant point in treatment is to make certain that suffi- 
cient nllcnli IS given to control gastric acidity. Tins is 
pnerally quite easily done during tho daytime, hut mav 
bo more difficult to accomplish during the night. It 
usually liappciis that the patient sleeps well if tho acid 
IS satisfactorily controlled, but if this is not the case lio 
oiten wakes up complaining of pain and discomfort. 
It IS tliereforo necessary to warn the patient that lie 
must take a dose of tlie poirder when he wakes np with 
feelings of discomfort. By this means the difficulty of 
lircventiiig accumulation of acid during the night may bo 
overcome. 

Tbongli it is host to have the patient in bed during the 
early stages of treatment, this is not always necessarj-, 
and wo have treated many patients with success in tlie 
out-patient department. After some weeks of treatment 
the amount of powder given is gradually reduced. Patients 
with duodenal ulcer should, however, take the powder 
three times a day for two to three months. Ono most 
important point is to warn the patient that be aiiist 
resume taking the powder and go on to liquid diet for a 
few days if any symptoms return. By this means an 
attack which might otherwise prove troublesome can be 
cut short. Patients who have had ulcers are sonietfmes 
liable to .attacks of dyspepsia when they get run down, or 
after sonio infection such as influenza, but these attacks 
do not mean that there is a recurrence of the ulcer. This 
we have shown by x-ray investigation in such cases. 

Tiioiigli the exact details of treatment may be varied 
to suit different patients, the following general scheme 
will bo found useful in the majority of cases. 


First Wcel\ 

Tho patient is kept on a fluid diet consisting of milk, or 
milk with Benger’s food.' About three pints of milk per 
dav are given in feeds of approximately 8 oz. every two 
lioiirs. It is important, especially during the earlier part 
of the treatment, to prevent the clotting of milk in the 
stomach, and in order to ensure this 10 grains of sodium 
citrate are added to each feed of milk. This, of course, 
acts as a neutralizer of acid as well as an anti-coagulant. 
A small tcaspooiiful of the “ alkali ” mixture described 
is civen every two hours shortly after the milk. The powder 
is best swallowed in a little water; care must bo taken 
to stir the mixture thoroughly immediately before clrmk- 
inc The powder is practically tasteless. About six to 
seven doses of powder are given per day. In addition, a 
double dose is given immediately before going to rest at 
niebt. The patient is warned that if lie wakes np at 
iiinht with any pain or discomfort he must take an extra 
doso of iiowder, or more than one dose if necessary. 

Generally, it is quite easy to control the acidity hj the 
above procedure, but in a few severe cases it is difficult. 
This failuro to control the acidity usually becomes obmous 
to the patient by a return of the pain or discomfort. 
When this happens the patient must always take an extr.i 
powder • if the pain is due to insufficient neutralization it 
is immediately relieved by this extra dose. 

In severe cases it is a good plan to give rather , 

dose of the mixture every hour, for a two-hourly inten. 
mav allow of the passage of the whole of the ponder fr 
tlio^stoniach, with the result that free acid may be pwsen ■ 

I have frequently used this plan with excellent tmu ■ ■ 
Tn ordinary cases one or other of the above methods 
generally give the desired effect. 

from remal disease or pyloric stenosis slight modifica 
may be advisable, but this will be discussed later. 

Second ITcck. 1 

If the patient has bad no pain or discomfort 
clays a little solid food is now added. If any .. ; 

,“'pahi still persists tho prooednre of he first eck^i 
continued for a few days longer. If ‘ 

ivnintoms the powder may now be reduced to fi 
times a day, the quantity of milk “men 1 . 1 

ilso. Two or three eggs are now added to t e 
lieaton np, or lightly boiled egp aie g ■ ercaw. 
’ollow'ed by small amounts of toast and butte , 

Pile diet is then gradn.ally increased milk, 

lie week the patient is taking, m addition t 



■ ApRIIi I 4i 19-®] 


■ Alkaline tbeatment op gasibio ueoeb. 


r Tn?I?ism«fr 

t JlrOICAL JoCRSiX 


621 


a ccrtaiu amount of toast, plain biscuits, butter, eggs, 
custards, a littlo porridge, and mealc tea. A dose of 
powder immediately before retiring is laben ns before, and 
tbo same care to take a powder during tbo night if pain 
occurs is still nccessaiT; also an extra powder must bo 
taken if pain or discomfort occurs during the day. Indeed, 
it is very important during all stages of the treatment 
tliat any discomfort arising by day or night slioiild bo 
immediately cbeckcd by a dose of powder. 

Third Weel-. 

Powder reduced to four or five times a day, and at bed- 
time. Food is gradually increased and sbonid now consist 
largely of eggs, cream, to.ast, butter, plain biscuits, rice 
and other cereal puddings, porridge, cu.stards, a littlo 
.steamed white fish, and a .small amount of potatoes. 

Sodium citrate need no longer be added to any milk 
taken. 

Fourth, Fifth, and Sixth ll'ech.?. 

Milk is taken only in tbo usual nveiage t(nantities. 

Powder is reduced to tlirec or four times a day and at 
bedtime if no pain or discomfort is present. Food is still 
further increased with the addition of chicken, pn-fioahly 
creamed to begin with. In the fifth week a little meat 
(mutton or veal) may ho taken, hnt only a ■•niall amount. 

By the end of this time the patient i.s takno' a simple, 
nourishing diet, and the nicer shottld he heated or well 
on its way towards 
healing. All the sym- 
ptoms should liavo 
entirely disappeared in 
the averago case. 

After-Treatment. 

The powder should 
be taken two or three 
times a day for 
another sis to ton 
weolis. If there is an 
entire absence of sym- 
ptoms the powder may 
then be given up 

driving the day, but 1.— Caso i. V-ray finJmgs. (a) January 3rd; ((i) January 19th; (r) January 97eh. 

a dose should be taken 

at bedtime for several months. If any symptoms per- 
sist the powder should be taken two or three times 
a day for several months. A powder containing a 
suitable amount of magnesia may be taken at bed- 
time as a laxative for years without doing the .slightest 
hann. It is impossible to give e.xact directions with 
regard to the length of time the powder should 
he taken, for this differs in different patients. It is, 
lion ever, better to err on tho safb side and to continue 
the powder for a long time if there is anv evidence of 
clj'spepsia. 

It goes without saying that any sotirco of infection, such 
as septic teeth or tonsils, should 'bo attended to. IVlictber 
or not the wholesale extraction of teeth, so largely prac- 
tised to-day, is an advantage or otherwise is a point for 



discussion. 


Diet, 


Much of what is written regarding diet is purely 
empirical and has no scientific basis in fact. Indeed, for 
many ot the statements made in the literature there can 
be no foundation whatever. Rules regarding diet can bo 
made quite simple, and may be .summariacd as follows, 

* patient should avoid any article of food which would 

end to cause physical irritation in the stomacli. Now since 

flL' 1 u J^'Sested to any appreciable extent in 

■nrnbnvtTi'^** 'Ti’*^*'' ® "ct be taken. ' .Salads are therefore 

p ibited. The same applies to such articles .as currants, 

that would tend to leave an 
r< m ml ^"^1 stomacli. If this principle is 

remembered the patient cannot go far wrong. 

ini.',. *0 cause, a marked secretion of gastric 

aii.r™ in small amounts. Beef-tea 

and meat extract.s of .al kinds should be avoided. 

at Olio should he taken never to take too large a meal 

4 'ri, f ’ often tends to bring on symptoms, 

it Jnte« he tlioroughly well masticated, so that 

stomach in ji homogeneous pultaceous mass. 


SmoI:ir]g and Alcohol. 

Excessive smoking is a very frequent cause of gastric 
symptoms, and the less tobacco is indulged in tjie better. 
It should bo given up entirely for a time. Alcohol should 
also bo avoided, for it tends to excite the flow of gastric 
acid, wliicli is so injurious to patients suffering from 
ulceration. 

Other Considernfions. 

IVlicii tlio above treatment is carefully carried out as 
indicated, no other therapy is necessary in the averago 
case. Tho tendency to excessive secretion of acid can 
sometimes be controlled to some extent by giving fats or 
oils. For this iniiqiose they are of little value unless given 
on an empty stomach between meals, but if the patient 
can take olive oil, a dessertspoonful, two or three times 
a day, shortly heforo meals, may prove useful. Cream 
acts in a somewhat similar manner. 

Various other measures may he used, hut it is unneces- 
sary to discuss them liere. Probably belladonna is tho 
most useful drug, but it is seldom nceessai-y. The value 
ot tonics and good general conditions as part of after- 
treatment is obvious. 

Results of Theatsient. 

Tbo rapidity and ease with which the majority of 
gastric ulcers lieal when this treatment is used is very 
striking. It was hoped tliat actual photographs illustrating 

this point might be 
given in tho present 
article, but this was 
impossible owing to 
printing difficulties. 
Drawings from four 
cases are therefore 
given. Those have 
been carefully copied 
from the originals by 
an expert, and have, 
been drawn to scale; 
they present exactly 
the same appearances 
as the original photo- 
gi-aphs, and show well 
how quickly those 
ulcers disappear without leaving any trace whatever of 
their presence. 

Case i. 

A police sergeant, aged 38, who had had symptoms for over 
nine years, was admitted to hospital on Janiiary 2nd, 1923, on 
account of recurring attacks of haematemesis associated with 
severe epigastric pain. Melaena had been marked of late. Three 
rears ago he commenced to have *’ hunger pains,’* which caused 
him great inconvenience, so that often he was unable to remain 
on duty. He was alwaj-s conscious of some more or less intense 
upper abdominal discomfort. At times food gave relief, but 
sometimes it only intensified the discomfort. He had had many 
forms of treatment, but STrTnptoms gradually became worse. 
He stated that he had vomited blood on four occasions during 
the three months before admission, but never in very large 
quantity. Vomiting bad been troublesome, and recenth- the vomit 
had contained niucli mucus. There had been considerable loss of 
weight during the last year. Palpation showed marked epigastric 
rigidity, especially on the right side; there was also a very tender 
area above and to the loft of the umbilicus. 

■rhe patient - was put on intensive alkaline treatment on 
January 5rd. He quickly lost all his symptoms, was quite com- 
fortable, and in about three weeks from tlie beginning of the 
treatment all signs of the ulcer had disappeared. 

The jr-ray findings are shown in Fig. 1 (o! (i) (r). In the fiist 
photograph (January 5rd) the j:-ray report was “ Iargc_ pene. 
traliug lesser curvature ulcer low down.’’ The next radiogram 
(January 19th) showed ” a smaller crater low on lesser curvature.” 
The third radiogram, taken on January 27th, sliowcd a normal 
stomach with no appearances of ulccr- 

Tho patient is quite well and has had no further symptoms. 

Case ji. 

A hoilcrmaker, aged 55, had sutrered from stomach irouMc for 
thirty Tears. He was admitted to hospital on .January ICUi, 
1928, with a provisional diagnosis of carcinoma of the rectum. 

WS 5 verj* nud wasted* flud slioiico rnsrlccd cnc/icxin. 



(e) 


rears He had vomited fivquently, especially during the last fev.- 
vears’ Food nearlv always made him worse. During the last six 
months his condition became so bad that he could scarcely gee 
to his work. He thought his stools had been tarry. Marked 
tenderness and rigidity were present in the epigastrium, and Ida 


622 Apriii 14, 1928] 


ALKALINE TEEATMENT. OF GASTRIC ULCER, 


; r TmsBRiTm , , 
L'M^dicil Jousxifc . 


general condition "was very bad. Nothing was found in tho rectum. 
A diagnosis of gastric ulcer was made, and a radiogram taken. 
The patient was put on intensive alkaline treatment, and soon 
obtained marked relief. He is now quite fit, and says that ho 
has not felt like this for over twenty, years. 

Tho changes in the ulcer are shown in Fig. 2 (n) (h) (r). In 
spile of tho length of his illness tho ulcer healed completely in less 
than two months. Tho first radiogram showed a largo pene- 
trating lessor curvature ulcer with much delay in emptying of 
stomach from atony.’* Tlie next one, taken about a month later, 
showed “ crater still 
present but very much 
reduced in size ; local 
tenderness not present.” 

Tho third radiogram, 
taken a fortnight later, 
showed the entire dis- 
appearance of tho ulcer. 

These results, in a case 
of thirty ycai-s’ stand- 
ing, aro certainly very 
striking. The patient 
has put on weight 
steadily and is now 
quite fit and well. 

Case hi. 

A police constable, 
aged 44, says lie has had 
stomach trouble ” ever 
since he was a young 
man,” but that it Fic. 2. — Cason, 
generally improved when 

he went on to a milk diet. He has had several teeth removed at 
intervals during tho last seven years as they were “had.” He stales 
that he has suffered “ indescribable agony ” during the last five 
years whilst on duty, with a feeling of “ hunger and emptiness.” 
For this period he has never been able to get relief for more than 
a day or two, no matter what ho took. Recently he has lost weight 
and his ordinary clothes arc now much too big for liim. The 
epigastric area was very tender and rigid. His general condition 
was bad, and he looked as if he had euftcred a good deal. 

He was admitted to hospital on January 9111, 1928. A radio- 
gram taken tho following day showed a large penetrating lesser 
curvature ulcer (Fig. 3, «). Ho was put on intensive alkaline 
treatment and almost immediately got relief from his symptoms. 
A radiogram taken on February l4th still showed a crater, but this 
was considerably smaller than before (Fig. 3, 6). Another radio- 
gram taken on February 23rd showed that tlic ulcer had entirely 
disappeared, tho report being ” no ulcer now seen ” (Fig. 3, c). 

This patient is no\v quite free from symptoms and is rapidly 
gaining weight. 

Case iv. 

A married woman, aged 35, was admitted to hospital on January 
2nd, 1928, on account of a long-standing dyspeptic condition 


Axk.mjne Theatment in Pyloric Stenosis. 

It might bo thoiiglit that stenosis of tho pylorus from old 
ulceration would not bo much influenced by medical treat- 
ment, and that tho aid of surgery should always be sought 
in such eases. Strange as it may seem, intonsiyo alkaline 
treatment is often of tlio greatest value in pyloric obstruc- 
tion, and, if tho symptoms are not too severe, a trial should 

bo given to this treat- 
ment before deciding 
on operation. In mild 
cases alkaline treat- 
ment often gives ex- 
cellent results, and 
even in patients 
suffering from inter- 
mittent vomiting re- 
lief from symptoms 
may bo obtained. In 
this connexion Sippy' 
remarks that 

“Pyloric obstruction, 
even of the highest 
grade, and of long 

. . . duration as evidenced by 

Showing changes in ulcer : (a) January 19lh; (t) February 23rd ; (c) March 6th.' the presence of vigorous 

peristaltic waves sliowing 
lliroiiffh the abdominal wall, history of vomiting food eaten the 
(lav before for many months, the aspiration of food eaten 
twelve or more Iioiirs before, and the presence of abundant 
saicinac, often rapidly disappears, so tliat at fbo end of ten 
(lavs’ or two weeks’ management, seven hours after tho largest 
and coarsest kind of a motor meal is given tlie stomach is found 
empty.” 

Tlio reason for tliis wonderful effect of alkali depends 
on tlie fact that the obstruction is often due not to fibrotjo 
clinnccs alone, but to inllanimatoiy oedema and spasm. 
Under the infinence of alkali tho spasm rehaxes and the 
oedema subsides, so that a way is formetl sufficiently largo 
for the passage of food. I use this method in "" but tho 
most sevoro nises of pyloric stenosis, and generally with 
Zd ?esuUs. Sometimes, indeed, tho effect is really 
Striking. About two years ago an elderly lady, aged 72, was 
admitted to St. Thomas’s Hospital with all tlie usual signs 
She vomited two or three times a week, and 



of stenosis. 






.lo-’l- 


(a) (t) (c) 

Fig. 3. — Case iii. Showing changes in ulcer; (a) January 10th; (It) February Iflth; 
(c) February 23rd. 




Fig. 4.— Case IV. Showing condition of duoflcnum 
(a) on January 1st, (6) on February 3rcl. 


becoming so severe that she could not carry on her lioiischold 
duties. *^he gave a history of more or less troublesome indigestion 
for some ten to twelve years. She had had mucli nausea, (ogetlier 
with pain, for which she could never get definite relief until 
recently when slic bought large quantities of patent alkaline 
preparations. When she went on to a very low diet she obtained 
some relief, but she always had a definite sense of discomfort. 
Her weight had got progressively less, and on admission she was 
thin and careworn, with much epigastric pain and tenderness. 
A radio^^ram was taken before the patient entered hospital, and 
the reno'rt was as follows : ” Stomach a little low and showing no 
rltindpmil can Emptying is definitely delayed. Appearance of partial 
pXio obXcrion%\ogubly due to an old ulcer ” (Fig. 4. n). 
‘‘Treatment was commenced on January 3rd, and another radio- 
gram taken on February 3rd. The patient’s symptoms cleared up 

fromediately and she is now quite well. 71 .1 

The report on the second radiogram (Fig. 4, nas general 
appearance much improved— emptying m normal time— a small cap 
now seen.” 

Many other similar results could he given, hut the i^ove 
w'ill serve to show the extraordinary marked and rapid effects 
produced by this treatment, even in very long-standing cases 
with severe symptoms and marked cc-ray changes. 


i often 
gh tlio 


food eaten twenty-four or thirty-six hours hefore was . 
fnj.nrl in the vomit. Peristalsis was observed througl 
abXmhml 111, and it was obvious that the condition was 
passiim- on to a serious stage. An operation v as ^"88^ 
arthe onlv means likely to help, but this the pat.ci^ 
obstinatelv" refused, and no amount ot persuasion coi 
induce her to vicld on this point. Though it was tlmn,, 
tint the ease was much too severe for medical treatnui , 
o trinl was civen to alkalis. In a short tune all the 
symptoms passed away, and the patient could take a cei a"^ 
amount 0 / food without discomfort. It is over I ‘ 
since she had the treatment, an<l she has „ 

during that time. Special inquiries made 
elicited the fact that she is doing quite noil and has 

'■r'iS'S's 

as indicated above may bo used, hut lu '5'?. , i bylow, 

with vomiting a slight modification, as indicate 
may be advisable. 



APftii- 14 . 1928 ] 


SURGEKT OF (ji'STRO-DtTODENAXii TOGERATION. 


[ Trrz URiTi’m ROQ 
Medical JocRXAi. 


Ailkced Daxoeks or Intensive Aekaeine Teeathent. 

IV'o medical man need lie afraid to iiso this treatment. 
In some natients it may give' rise to .slight symptoms, 
especiallv during the earlier stages, hut generally these 
symptoms rapidly .subside, and the system accommo- 
dates itself to the comparatively large amounts of alkali 
ingested. According to American writers, the chief 
symptoms encountered are, fust of all, dryness of the 
mouth and thro.at, followed by hc.adache, nnorexia, nausea, 
and vomiting. There may also lie mental deincssion and 
loss of energy. Analysis of the blood in some of these 
patients shmv's that the nitrogenous waste inoducts may 
be somewhat increased, while there may be some inter- 
ference with the “ acid-b.acc equilibrium ” of the body. 
This so-callcd “ alkalosis ” following the use of very large 
doses of sodium bicarbonate has hcen described, among 
others, by Hardt and Rivers' in 1923, by Brown, Eusterman, 
Hartmann, and Rowntrcc" in 1923, by Ellis” in 1924, by 
McVicar'” in 1924, by Houghton, Venables, and Lloyd" 
in 1925, and by Jordan" in 1926. 

From a careful perusal of the literature on alk.alosis it 
seems fairly clear that the medical ])raetitioner need not 
fear in the slightest degree to use the intensive alkaline 
treatment as indicated hero. That certain symptoms may 
occasionally appear is admitted, but they are exceedingly 
rare. Indeed, it is obvious that, in many cases n hore the 
symptoms were described, quite excessive doses of sodium 
bicarbonate were used. The exact dose is not always given, 
but where it is recorded it often amoimtod to about 
30 grams a day over long jieriods. When the treatment is 
used as indicated here there is practically no risk of 
alkalosis in otherwise healthy people, and even if symptoms 
should intervene there is no harm done. If the p.atient 
complains of headache, nausea, vomiting, anorexia, and 
excessive dryness of the mouth it is quite ea.sy to stop the 
treatment for a few days. So -far, as alreadv indicated, 
I have never seen anyone who had any symptoms. If 
followed on the lines indicated here the amount of sodium 
bicarbonate taken daily is too small to cause any damage 
in ordinary cases. That there may bo some danger when 
the patient is suffering from chronic nephritis is admitted 
(see Stieglitz" and others), and the same ni.ay be true 
when veiw marked pyloric stenosis with excessive vomiting 
IS present. 


Gamble, Ross, and Tisdall" show'ed that about 40 per 
cent, of the chlorine of CaCl. acted inside the body as 
HCl. Indeed, instead of causing an alkalosis the bivalent 
cations (calcium and ' magnesium) produce an acidosis in 
the body (McDonald and Godfrey””). 

Therefore, in a case of very severe pyloric stenosis it 
would obviously bo best to use as an antacid, not sodium 
bicarbonate, but calcium carbonate, or this along with 
magnesium carbonate. The carbonate would be changed 
into chloride by the gastric acid, and some of this would 
act as hydrochloric acid in the body, and so tend to 
prevent the drain of acid. That calcium carbonate acts 
quite efficiently as an antacid has been demonstrated by 
Loevenhart and Crandall.'” The safest treatment for 
severe pyloric stenosis would therefore appear to be by 
means of a powder consisting largely of calcium carbonate 
with some magnesium carbonate to help the bowels. Tea- 
spoonful doses of such a powder should be given oii the 
lines indicated above for the ordinary powder. In addi- 
tion to this, small doses of calcium chloride would help 
the alkalosis. 

Generally speaking, the intensive alkaline treatment is 
not associated with any real danger under ordinary condi- 
tions, but the treatment must bo carried out on the general 
lines indicated here, and the vastly excessive doses of 
sodium bicarbonate sometimes used should be avoided. 
References. 

* Sippy : Jotirn. Anier. Med. .isfioc., May 15Ih, 1915. 

- Hurst : lirithli .Medical Jouniat, April 4tli, 1920. 

” AlacLean ; Modern Vieice on Diffestion and Gaetric Disease^ 1925, 
Constable and Co., London. 

” AtacLcan, Jones, ami Fildes : Lancet^ .Tannary 7tli, 1928. 

” Bolton : Uleer of the Stomachy 1913, Arnold, London. 

” Sbattuck, Rohdenbnrg, and Booker; Jottrn. Anier. Med. Axroc.. 
January 19th, 1924. 

' Hardt and Rivers : .ireii. Intern. Med., 31, 171, 1923. 

* Brown, Eusterman, Hartmann, and Rowntrec ; Ibid., 32, 425, 1923. 

” Etiis : Quart. Jourii. Med., 17, 405, 1924. 

"AfcVicar: Tran*. Anier. Gaetro-Ellterol. Aesoe., 27, 230, 1924. 

" Houcliton, Venables, and Lloyd : Guy's Hasp. licports, 75, 149, 1925, 
"Jordan: jolirii. Anier. Melt. Assoc., December 4tli, 1926. 

" Sticplitn : .-treti. Intern. Med., 47, 11, 1928. 

" Haldane, Hill, and Luck : Joiim. Physiol., 57, 301, 1923. 

" Gamble, Ross, and Tisdall : Anier. Jotirv. Vis. Child., 25, 455, 1923. 

" McDonald and Godfrey : Med. Jonrii. and Record, Jtay 5th, 1926. 
"Loevenhart and Crandall; Joiirn. Anier. Med. Assoc., 3Iny 14th, 1927. 


DEBATABLE ASPECTS OF THE SURGERY OF 
GASTRO-DUODENAL ULCERATION.^ 

BY 


Special The.vtme.vt in Pvloric Steno.sis. 

In ordinary ^ses of mild jiyldric stenosis with little or 
no vomuing but showing marked r-rav elianges, the 
ordinary alkaline treatment may bo used. In severe cases, 
However, with excessive -vomiting, there is practicallv no 
communication between the stomach and the intestine, and 
in such c.ases hydrochloric acid is constaiitlv being lost to 
le bo y by vomiting. This results in a decrease of acid 
and .a consequent relative increase of alkali, so that the 
)0 y 111 s may tend to pass to a more alkaline condition 
than normal Tins “ alkalosis ” may ho accompanied by 
tli? sLf'T'’ pronounced being tetany. If 

nf uil V dependent on relative or absolute excess 

Lemons “bvious that it might be 

siiclf as s T alkali especially a soluble alkali 

the condTtf"“ for this would tend to make 

an acid to niak" u^" JL‘' acid "iLs':' 

eivine oT sarV^^ P’^®®f'ralh- absolute obstruction the 

could^iot -get tiiro^ 1-,™. 

tlip Vilrtpri T+ 6*1 into tliG intestine and so reach 

rtomach and 1 "®>>t™Ii 2 c the acid in the 

chloride * Finn +1^^ f'nown out, either .as bicarbonate or 

f "‘'“s i'T 

tlm nv lorn' " of the oedema aucl spasm of 

into the intestine! At“!h|''"s!a ”"®'‘f ’’"T 

' * , 1-iiis Stage an excess or sodiiiin 



bv the mnntlk o,+e, caicinm chloride when take 

to ui^inc hLn! I “• "" cquiv.alent in effei 

ivumh IS ^in -thn t the cnleiu. 

cmaiiis m the intestine while the chloride is absorbet 


CHARLES A. PANNETT, M.D., B.Sc., F.R.C.S., 

PRorESSOK or stjegery, university of LONmos; surgeon to 
ST. mart’s hospital. 

So long as the innate nature of gastro-dnodenal ulceration 
is still ranked .among the unknown phenomena of patho- 
logy there is hound to he disputation about the manner 
of its control. Controversy arises over many problems of 
the disease and its complications, hut the greatest of these 
is the problem of the uncomplicated nicer. 

The Need or Impbopbiety of Suegery' for the 
Uncoaipli’cated Dlceh . 

It is most perplexing to read the writings of physicians 
and surgeons, for they are often directly contradictory in 
their a'iews and recommendations; hut their very dis- 
cordancy engenders the suspicion that the conclusions of 
the extreme enthusiasts of medical or surgical measures 
must largely cancel each other out, and that the trntli lies 
somewhere between tliem. Tlie relevant facts upon which 
alone a sound judgement can be based are simply stated. 

(a) XJlcers of the stomach and duodenum can and do heal 
without the aid of surgery when conditions arc favourable. 
This has been proved by actual visual inspection throiigli a 
gastroscope,” by the x-raj’ disappearance of tlio nicer 
niche under medical treatment,” ” and by the finding of 
the scars of ulcers after death at nccrojisy. 

(b) Certain ulcers fail to heal with the most caictnl 
medical treatment, or they heal and break down again 
so that the symptoms recur. The niimher of ulccr.s whicli 
will heal witliout surgical help is large. It has hcen stated 
that jtost mortem as many scars as open ulcers are to be 
found.” But one pathologist discovered nine times as 
many scars as ulcers in the stomach.” This is the highest 

• .V leclurc ilcliviTcrt to Hie Kensington Division of the British Medical 
Association on March 23rd. 



624 April 14, 1928] 


SUKGERX OP GASTED-DUOBBNAti' ULCERATIOIT, 


Tnr Bsrmn - -r c 
LileoicAL Jocftsit ‘ 


proportion of scars to open nicors I have been ablo to 
fiiul roportcct. Quito possibly scars in tbo stomach got 
overlooked at necropsy, and this higher figure nioro ncarl}' 
appi-oaches tho truth. At any rate, it is certain that the 
tendency to healing is great. So a most important rule, 
to which there are a few oxcejitions, may bo laid down : 
A’o nicer jiatient should he subjected to' operation until 
niedieal treatment has proved a failure. 

It is pertinent to ask what proportion of idccrs respond 
to medical treatment. One observei', in 944 cases, found tho 
porcoiitago for gastric ulcer to be 62.5, and for duodenal 
ulcer to be 79.5.” These facts should bo graven upon the 
mind of every operating surgeon. Howevei’, certain of 
these immediatel}' cured cases will relapse. There aro not 
many records of the late results of medical treatment. 
Forman,' in 32 cases followed up and subsef[uently a:-raycd, 
found 57 irer cent, failures. The number of permanent 
cui'es is certainly much smaller than tho number of imnic- 
diato successes. Is it possible to select tboso eases which 
will pi'ove resistant to treatment? Several observers have 
said that there is no relation between tho rate of healing 
and tendency to relapse and tho length of history or size 
of tbo niche, but this last statement is open to doubt. 
When the niche is large, with a rounded extremity, healing 
is not so likely to occur or remain permanent, particularly 
as tho gastric or duodenal wall in its neighbourhood is 
often fixed 63- the ulcer having invaded tho pancreas and 
caused much surrounding fibrosis. Tboreforo it seems 
right to conclude that, while tho tendency to repair is 
great, a significant percentage of ulcers cannot bo induced 
to heal by medical moans alone, and that of those that 
do heal a certain number break down again. It is thus 
justifiable to resort to surgical measures when medical 
treatment has failed, provided alwa3-s that tbo moi'tality 
of operation is not too high — a consideration which will 
be dealt with in tho next section. 

Choice of the Tite of OpEn.vTiox. 

Having decided that there is occasion for surgery, it will 
be necessary to select flie typo of operation. A simple 
operation, gastro-onterostoniy, can alter local conditions 
in tho stomach so that healing may bo assisted; or 
more can bo effected by tho removal of tho diseased 
part of tho stomach, whereby tho tendency to ulcer forma- 
tion in the future is veiy greatl3' diminished. Both of 
these aro indirect methods, though tho latter is often 
spoken of as a radical procedure. To chooso betn'con these 
we must know how effective each is, and what is its 
accompanying mortality. 

Gastro-jejunostomy. 

In the case of gastric idccration there have been a 
number of reports of what success gastro-entorostomy 
can bring. Emanating from all parts of Europe, from 
America, and from this country, they show a surprising 
agreement in all essentials. It is found that about 75 per 
cent, of open ulcers at tho pylorus aro made to heal, but 
only about SO per cent, or less of ulcers awa}' from this 
region. There can be no doubt at all that gastro-jejuno- 
stomy does not meet with really striking success in gastric 
ulcer, yet it would not be right to leave the matter here 
without asserting the fact that sometimes unexpectedly 
large ulcers have healed when this oi^eratiou has been 
performed. It obviously has its place, and should be 
considered when other methods are either impossible or 
fraught with grave risk. 

When wo consider the use of gastro-jejunostomy in the 
treatment of duodenal ulcer there is no such general 
agreement. Thus Aloynilian,® Walton,” Balfour,'” " and 
Sherren'” obtained complete cures in 85 to 92 per cent, of 
their patients. But other clinicians have not achieved 
anything like the same success. Wydler,'” Forsyth," 
lewisohn,'” Smithies,'” and myself'' can only count upon 
50 to 70 per cent, of cures at most. The mortality 
of gastro-jejunostomy ranges from none in 500 cases 
(IMoynihan*®) to 8 per cent, by such a skilled operator as 
von Haberer.'” It is bound to be higher in the statistics 
of those surgeons who reserve it for the worse risks, but 
1 believe it fair to assess it at 4 to 5 per cent. 

Tho liability to haemorrhage from a gastric, but par- 
ticularly a duodenal, ulcer is about as great after an , 


.operation as before. Perforation of a .gastric ulcer may 
occur subsequently, but- very rarely that of a duodenal 
iilwr though this IS not unknown. There is also a very 
dchnito incidence of gastro-duodonal ulceration, the fre- 
•quoiicy of which is estimated from 2'" to 18 per cent." 
Sometimes a gastro-jejunostomy performed for duodenal 
ulceration will cause this lesion to heal, but subsequently 
an ulcer will form on tho lessor curvature of tho stomach. 
1 have known this happen in 4 cases. Curiously enough, 
Kowlands mentions a similar case in a recent paper upon 
gastro-jcjunal ulcer.”' If we accept the hypothesis I put 
forward"* as to tlio conditions favourable to the formation 
' of peptic iilcer.s— namely, admixture of the duodenal with 
tho pyloric secretions — it is easy to see how euro of the 
duodenal ulcer will lead to relaxation of pyloric spasm and 
so to duodenal regurgitation along the gastric sulcus once 
more during the later stages of digestion, a phenomenon 
which is absent when a duodenal ulcer exists. Conditions 
thus become favourable to ulcer formation on tho lesser 
tiirvaturc. 

Hcsection Operations. 

Wo may now turn to the facts about resection opera- 
tions. Tho properly conceived operation of this type not 
only' removes the ulcerated area, but also takes away so 
much of the pyloric part of the stomach that tho second, 
stage of gastric secretion is very much interfered with,- 
thereby lessening the disposition to further ulceration. 

I have knowledge more particularly of three types of such 

operations the Pean resection, the sleeve resection, and 

tho Jloynihan variety of Polya’s procedure. They all meet 
tho requirements stated above, and are indicated in different 
circumstances. There aro many reports of late results of 
resections for stomach ulcers (see references 13, 20, 23, 24,. 
25 and 26). TJie successes range fi-om 70 per cent, to well 
over 00 per cent., most observers giving tho higher figures. 
AIv own late results give 80 per cent, perfectly well. At 
aiiv rite’ it mav bo said that, with the same standard- of. 
cure 'those reso’etion operations give half as -many' good 
results acaiti as gastro-enterostomy. It is widely held that 
a hich mortality is associated with gastric resection, a 
very much higher death rate than with gastro-enterostomy. 
But this is not so. Amongst 59 gastric resections for 
uIcL I had 3 deaths. One of these, due to a technical 
fault at the operation, was preventable; the others were 
from lung complications, which are very imperfectly under 
ii+vol This makes a mortality of 5 per cent. It is 
•♦l a’ serious mortality, but not so very high when it is 
,Lred that 83 per cent, of all cases submitted to 
mrhad tho resection operation performed on them, though 
niLv were in a poor condition from malnutrition or a 
Epvpre haemorrhage. 

^’'iVt us now turn to tho much debated subject the. resec- 
♦ ■, of duodenal ulcers. At one time the removal of the 
*'ffooted segment of the duodenum was regarded im impos- 
but it was shown by the work of von Haberer, 
lorpi- and Clairmont that this is not so. Some 
■‘‘“aonE irho claim good' results from gastro-enterostomy 
came time recommend excision of tho anterior ulcer 
at the same time and easy. The operation of part.a 

V pptnmv is not performed by many men because of 
m"” behef that it is an extremely dangerous one. I have 
nai-tial duodenectomy for duodenal ulcer 61 times 
[rith 2 deaths, both from lung complications. Mo'tovcl 
1 ^ or.Vs includes the very first cases, in which tho tech- 
tliis seiios perfected. The mortality rate is, 

nique was . 3 ^ ^ operation in 

horefoie 3| P ^ the callous 

TaE ’extended too far down the duodenum; sometimes 
ms undesirable because the ulcer is small and soft. 

^ Thave performed a resection in only 72 per cent, of 
"es mm leaults of the procedure harm been much mor 
+P.-V than those of gastro-enterostomy. Of 21 case 

latisfacto y than H 

iperated upon m by j m 

''T ^ irathm One other patient had such very slight 

5“ i,. b. 

L. Co,., .ling In”. .11“ yr 

I’o ensure success, it is necessary to than a 

jortion of the pyloric region of the stomach, 
jjnpJ© pyJorcctoniy must be done. 



U 


APRIIj 14, 1928] 


SUBGERY OF GASTKO-DUODENAIi UOGERATIOJT. 


[ The British 
J lEDlCiL JOCRKAI. • 


625 


Having brouglit out tlio facts, it is now ])ossil)lD to 
acljudicato ui>ou the question of operation in the uncom- 
plicated ulcer. With few exceptions, every gaslric ulcer 
patient should bo submitted to a cotir.se of medical treat- 
ment. ■'tYhcn, by proper rest, diet, and medication, the 
pain cannot be controlled, vomiting continues, and weight 
is lost, then surgery is indicated. If there has been a 
single haemorrhage of any volume in the ptist, and an ulcer 
can be demonstrated by the x rays, an operation should be 
carried out without a trial of medical measures. AVhen a 
Haudek’s diverticulum is large, with a rounded, blunt 
end, it is often wise to advise an operation, as rclap.se 
in many cases oceure. Finally, economic conditions may 
i-equire that the patient should bo got well with a.s little loss 
of time as possible. Pcrhaiis he must work to live, or ho 
is performiug such valuable work for the community that 
his services can ill bo spared. Such circumstances must be 
vcjy carefully weighed before a decision to ojjci'atc is made, 
remembering always that there is about 5 per cent, 
mortality associated with the procedure. 


The Bleeuing Ueceu. 

The controversy on this problem cannot be so easily dis- 
missed as some surgeons would wish by accepting the 
statement of man}' of our medical colleagues that a patient 
seldom dies from such loss of blood. The truth is quite 
otherwise. Haemorrhage from a chronic idcer of the 
stomach or duodenum is a serious menace to life. Bulmer 
recently, in 500 cases, reported a mortality of 8.3 per 
cent." ^ From our point of view the clinical course of the 
event is important. Sometimes the victim ivill die in a 
few hours from a single massive haemorrhage. He is at 
once beyond human help. More often he rallies fioiu this 
first haemorrhage, but his immediate future is fidl of peril. 
Bleeding from an ulcer is of the secondary typo and 
follows the characteristic course of this uffe'etion. The 
uncertainty of the arrest of haemorrhage is great : very 
frequently after a few da}'s a further loss of blood occurs, 
anti this inay he repeated until the patient’s strength is 
sapped .to his extinction. Cannot ordinary surgical prin- 
cip es be applied to this gross complication? The answer is 
not quite simple to give. 

Arrest of haemorrhage means a rather big operation 
which the patient may not bo in a condition to stand, 
and this, combined with the undoubted fact that numbers 
t! under expectant treatment, has led 

The,,? of. surgeons deciding against operating. 

B e vl '"■el' tl'Ot it is held 11.1^ 

onm-sGon compensate for those lost when 

cvCT rl f '"’“f 0 ® “ routine. Of late vears, bow- 
oneraHn oo^ouf^nt changed. Not only have 

fusion nf 1,1 n stomach become safer, but tho trans- 
forniM-lv «■ 1 ? ojjei-ate in circumstances which 

rhanp I’nc ° Imvo proved fatal. Immediately a h aemor- 
shocl- the patient falls into such a state of 

This sbnM- r'll surgical procedure is precluded, 

method hr’ 1 ^1* lo'vered blood pressure, is tho natural 
the erodofl ‘ , 'oo™orrhage is arrested and clotting in 

actually happenTd tho pItLt'’car“‘'‘ti i*'“" ’'"f 

should be taken ARTf including a transfusion, 

estimate of br;»n"^. ^ 'I ‘■»“fos from Ifis shock an 

the fall in piilso ratn **^^1*'* be made by observing 

haemoglobin in his blood'^ estimating the percentage of 
over 100 means that tUo, i'^ *1“ '"'Inch remains 

Wood. OpSon U riskrb ?■ 

with only 50 per eent^'of^f possible. A patient 

poor state to ^ifiomoglobin is m a ren' 

circumstances it can in favoui*abIe 

abvay. he nle^ss:" irs^^ra^ " 

tbesia is ratnrrlo,) “ giave case. Local anaes- 

employed oidy general “naesH .^‘"^f^'cr, but I have 
of the loweriJ of blooT * somewhat afraid 

block produces^ Or,p„ ■ which the splanchnic 

operatiC immt Im 1 “Women tho ttqie of 

or dnodoimrtomv lt'e 1 '.'"’“•i ^ 

wliciicver it ic topUn,- n ^**<1 should ahvavs be done 

W- I-roimr metl odl -■ Fortunately a resection 

c. n non bo performed with very little 


further loss of blood. Sometimes it will bo decided that 
resection is too dangerous: then the arteries supplviiig 
the ulcer must be tied, a procedure whieli mav necessitate 
the opening of the viscus and ligation from within. 
A gastro-jejunostomy is useless for stopping haemorrhage 
from a gastric ulcer. 

To -sum up: Every case of bleeding from a gastric or 
duodena] ulcer should be looked at from a surgical point 
of view from tlio first. There should be a disposition to 
operate as soon as ever the condition of tho patient will 
allow. Tliougli the step is a serious oiiej the adoption of 
this policy, taking the precautions which I liave men- 
tioned, will save more lives than the pursuit of a solely 
expectant attitude. It is fatal to wait for successive 
liacmorrbagcs before considering operative treatment. The 
patient -will only he reduced to such a state of weakness 
that ho is unlikely to stand it and suirive. 

The PiuiFon.wED Ulceb. 

The problem of the perforated idcer is not whether an 
operation shoiiid he performed, but whether any other 
procedure should he added to tlie essential closure of tlie 
perforation. On the Ckmtinent operators have actually, of 
late, been performing typical resections of the stomach 
in cases of perforation — a dcvelojiment in gastric surgery 
so amazing that it must be passed in review. In this 
country there are many surgeons who hold that a gastro- 
enterostomy .should be done at the time the ulcer is 
sutured. These surgeons claim that the anastomosis is 
frcqiiontlv necessary because the suture of the ulcer leads 
to pyloric stenosis ; thev say that convalescence is smootlier 
and the risk of the new suture line failing to hold 
diminished, as the stomacli cannot become distended. 
They also make a great point of the fact that by doing 
a gastro-jejunostomy they are performing a curative opera- 
tion upon the nicer. "What, once more, are the facts? 

It is recognized that many ulceus which perforate are 
acute lesions, they have a different pathology from the 
chronic ulcer, ami once the crisis is over conditions lead- 
ing to the formation of such ulcers may never recur. 
Unless the technique is very clumsy tho pylorus will not 
ho obstructed bv the in-turning of the stomach wall neces- 
sary to close the perforation. It is also proved by late 
investigations'’ that many patients after simple 

suture are permanently cured and never again suffer from 
their ulcer. I believe that tliis vecover.v rate is perhaps 
overestimated and' that the true pereentage of cures is 
probably about 50 . Gastro-jejunostomy is, tlierefore, iiii- 
iieccssaiy from this ])oint of vieir in one-balf of the 
patients; as a fine stomacli tube will relieve, distension 
of tlic stomach should blocking of the pylorus by the suture 
have occurred, it is not to be recommended on this account. 
Should the ulcer give trouble later another operation will 
be necessary, but it will not preferably be a gastro- 
enterostomy. The patient with a perforation is so ill 
that the less done to him the better. For this same reason 
I think resection in the presence of a perforation is not 
to he recommended. It would obviously be wrong treat- 
ment for an acute ulcer, and certainly too severe as a 
routine method for a perforated chronic lesion. 

The L.cte Cic.ctkized Stcts^-Cch. 

When an nlcei' has cicatrized it may leave the stomach 
with a narrow pyloric canal, or if it lias been on tho lesser 
curvature an hour-glass constriction deformity may result. 
Sometimes the two deformities occur together. When there 
is pyloric constriction alone a .simi>!e gastro-jejuuostomy 
wili often give an excellent result. The opeiation has its 
place, and should he done when there has lioen so much 
vomiting tliat the patient is dehydrated and is suffering 
from chloride starvation, wliich cannot be remedied by the 
injection of salt solution. In every other case I believe 
a Pean tvpe of resection is preferable in pyloric stenosis. 
For hour-glass constriction, though a simple gastro-gastro- 
stomv will frequently meet the case, I prefer a sleeve 
re.section or the Pean operation. Chloride starvation must 
always bo investigated in ever}- patient in whom theie i.s 
some' defect in the passage of tlie contents of the stomach 
into the duodenum. It should be corrected before any 
serious operation is undertaken. 

Surge!-}' is not likely to say tho final word in the treatment 


626 


TTOKHCCLOns BO»ES «B 




IP e«i • 11 ,, RKFrilKNCKS. 

37, 217™''"’ " '’i»'=<'l>'. “ml !>.’ W AbViS ; 

r. p ■ IhifJ., 1926, 39. ‘ 


/!rf7(. /h 7. ,Vr//., 1926, 



3 p' j : Lancet, 1924'/ 780.' 

;;f: ^0. ™- 

1» 1925, i. 538. 


m o* V. i Jjancpt, ibilJ), j. 5J8 

21 i- laucrl, 192S, ij, ibo7 ’ ’ *• 

1 = r ■ t : £'■,(,>71 .1/f,7/eo( 'jminwl 1928 I 41B 


1923, i, 221. 


1925, p. 22. 
n? ®* 'I"'!'! "nd ,T, 

J R. Wnnkc : Dcut. Zri't."/ 

2. M KuUscha-Lis.i.bcrf: : Ilii<i;, 1925, 19l 
2, ?,'• Fr “dmann : Ibid 1925, 192, 191 
... P'llniei’ : Lancet, i927, ii, 168. 




VIceralion, I,ondon, 


r Tur. nemsH > 

L iUEDlCAI. Jocfixii 








the type of tubercle bacillus commonly 
PRESENT IN TUBERCULOUS LESIONS 
IN BONES AND JOINTS. 

Two Cases with Unusual ^ymhcrs of Tubercle Uacilli in 
the Vischargeti. 

DY 

LOUIS COBBETT, . M.D., F.R.C S 

(From tbo Dopartmont of P atbology, CambridRo Wedic'al Scbool.) 

The question wlictlicr tuborculosis of bones and ioints is 

boinE is f‘bni somo biimnii 

Imnorti i”, J” ?' "ol ivitliobl |>|-.olk,l 

opS.“’.7„s\“ £ ,V.“,cMv lit 7'T'‘ 
tbo ™io o7 ;i,X7ro ,,s‘’T;"f 

tuberculosis, all agreed in^find: •mnian 

present in the g^eat maioritv n/ 'ri* * tubercle bacillus 
joint disease which thev^inveaf ^ 'f 
type. Cases from which the bov^ 
obtained occurred, but they were uncommon 

70 cates oUtTereXis^of btrs^^J";!!:^ 

Laboratories of the Royal College of Phvsi"- Research 

burgh, came to the surprising ^conclurir thT 

than 41, or 57 per cent.' of tl^m, tt^^^rd^ bS 

of bovine 13716 alone; that 3 gave a n,;^-+.,.. a , . 

mammalian types; and that only 26 or 37 '’“i* * 

yielded tbo human type alone. P*"' 

These -findings were so different from those of all 
observers, who agreed in putting the proportion of such 
cases infected with the human bacillus as high as 80 • 

cent, or more, that they were not received without criticism 
by bacteriologists who had worked in this field. Nevertlie 
less, it seems that it is just^ these exceptional results 
obtained in Scotland that hav'e attracted the attention of 
English physicians, rather than the far more extensive 
investigations made in this countr}’. ' 

It therefore seems worth- while calling attention to the 
mhom “n ;V Eastwood, than 

in the sehoororthrE"®^";?’''''^'’- '• 

lool of the Royal Commission, 1901-11) could be 


n ~ Hoard nuH 

lieiisivo study of tlio tvnes'^' f t^i '' a most compnv 

'•arions kinds of hm.mn tnhe ■ . a> 

l.as extended over Xnty^ Sr'td' 

joint tiihercniosis is concLnell’ i 
investigations, now inch des X , «'•« different 

cases of this kmi? in S tt ° Tr 
lias licen fully determined. tubercle bacillus 

. ibis is tlio total dealt with bv A 9 Pi-.'ffi+i * i • t 
scrtalion for tbo degree of Pb D.&mb ^ 192^ It 
includes 14 cases investigated by the Eovnl Poe • ■ '' 
as well as a'.um.bcr in uf.ioh tbo' ouh'nit': re X""rt 
from materia taken directly from the bone or joint but 
from somo other lesion. For tin's rea.son I prefer to gnolo 
fiom a jiaiicr by tbo same author entitled " TnberciilosL 
‘’■'.'S"', ^5,'° I'uman subject,” read' at the 

clovcntlr iV-itional Conference on Maternity and Infant 
Welfare held m London on July 5tli to 7tli, i927. It deals 
with 541 cases of boiio and joint tuborculosis, with -tbo 
result tliat 81.3 per cent, of them were found to bo caused 
by tiibcrclo. bacilli of the iiiiman type. This percentage 
refers to patients of all ages; if one takes only children 
iiiidci 5 jcais of ago (102 cases), tlic percentage so infected 
iiatiirally falls; but even here it is over 70 per cent. 
Under 10 years (327 cases) it is 75 per cent. Tiiis total 
includes a few eases from Scotland. These, in d so'niewliat 
earlier paper by the same author,* aro separated from 
the English cases, with tbo result that a lower proportion 
of infections witli the human type of bacillus is found in 
them than in those from England and 'Wales. The differ- 
ence, iioivevcr, is not groat; for Scotland the iicrcentage 
of infections with tho human t37io of bacillus is 71.4 
(28 cases), wliilo for England and 'Wales it is 81.7 (389 
casc.s). For children under 10 the corresponding per- 
centages work out at 63.6 and 75.4 rospectivelj'. 

Frequency of Tubercle Bacilli of Human Type in Tuberculosis 
of Bones and Joints. 

No. of PercentORowi 
Coses. Human Typ, 

All ages 541 81.3 

Under 10 years ... ... ... 327 74.6 

Under 5 j'cars. ; 102 70.6 


71.0 

81.7 

63.6 

75.4 


Enrjlish and Scottish Cases Compared. 

Scottish cases, all ages 28 

English cases, all ages 389 

Scotlisli cases, under 10 22 

English cases, under 10 288 

Thus from this exbaustivo and competent investigatioi 
we niaj' conclude, indeed, tliat infection from tho tuber 
cuioiis coiv is a good deal commoner in Scotland tlian .it i 
south of the border. But it must bo pointed out tlia 
tlio proportion of liuman infections in Scottisli cases foiini 
by tlio English authors — namely-, 71.4 per cent. — is very 
different from tlio 37 per cent, (or if we include the mixed 
cases, 41 ])er cent.) found by Fraser. 

The fact is that bone and joint tuberculosis, commonly 
results from tubercle bacilli being transported to the part 
fr'oin -some tuberculous focus (often a small and iiiisus- 
peefed one in some lymphatic gland) by the blood steam. 
Ill this respoet it falls into line with other liaeinatogenoiis 
kinds of tubercle — namely, with general tuberculosis, tuber- 
culous meningitis, and geiiito-urinary tuberculosis, in each 
of which tlie proportion of infections caused by* the human 
tymo 'of tubercle baciilus has been found to ho in tiio neigh- 
bou'rlidod of 82 iier cent. In tuberculous meningitis it is 
even a- little higher still. ^ ^ i 

It-cah therefore be stated positively that in England anti 
Whales ■■•tli'e great majority of cases of bone and joint tuber- 
— „j.0 caused by bacilli of human type, derived from 
case of human tuberculosis, and that they Iiave 
1 with the cow. Cases of bovine origin do 
indeed^occur, and in very young infants constitute nearly’ 


culdsis' ar 

another c..ou - , - 

iiotliiii'g- to do with the cow. Cases of bovine origin 
’ ideed- occur, and in very young infants constitute iiei...j 
a. third of tlie total, but taking all ages tdgetlier they do 
not amount to one-fifth. . 

It is interesting to note that in tuberculosis of the 
vertebral coliiinn bovine infections are rather commoner 
than ill tuberculosis of the hip, and tliat in this latter 
condition they are somewhat more frequent thali in tuber- 
culosis of the knee. Tho higher incidence in the spine i? 


APBIIj 141-1928] 


EARLY DET:ECTI0N 0F TUBERCtiE^BACIDril IN SPUTUM:. ■ 


627 


oxplainod by Grifiitb on tbe ground tlinl somo of tlioso 
lesions .nro cniiscd by direct, infection from tbe abdominal 
cavity, vherc, of course, as it is well known, the ratio of 
infection with the bovine to that witli the human typo 
of bacillus is high. 

Siijnificancc of Notiihcrs of Tuherch. Thirilli in ihc 
Discharges from a Tuhcrcuious Joint. 

Two samples of pus from tuberculous joints which eamo 
to this laboratory, attracted my attention on account of tho 
Umusual numbers of tubercle bacilli they contained. The 
jseverity of the disease turned out to bo unusual also, and 
lit seems that tho numbers of bacilli in joint eases may 
have some prognostic significance. These cases, therefore, 
seem to be worth reporting. 

A married woman, aged 38, was admitted to Addeidirookc's 
Ho.spital, Cambridge, on June 23rd, 1927, on account of severe 
pain in the left ankle. She came under tlie care of Mr. W. H. 
Bowen, to whom 1 am indebted for notes of the case. On 
admission there was a swelling on the outer side of the joint. 
This was aspirated five days after admission. The fluid 
then taken was sent to me on account of the numbers of tubercle 
bacilli, wliich were visible in stained films made from it. 
■ii known, the bacilli in such specimens are, as a rule, 

either few m number or not to be seen; but in this specimen 
they were so numerous that it was difficult to believe that one 
ivas not looking .at a ricli sample of tuberculous sputum; 
another unusual point was that there were well-formed pus 
cells present. Here was a case, then, worth investigating, and 
1 proceeded to determine tho typo of the tubercle bacilli. 

Ihe clinical course of the case showed a disease of great 
activity ihe history on admission was seven weeks onlv, and 
consisted chiefly of severe pain in. the left ankle, especiallv at 
3 . :.. appeared to be e.vquisitely painful on' the 

■ ^ ^ patient. Soon after admission it 

kS,. h P“™P'astio splint; but seventeen days 

filter It was necessary to aspirate again, and 20 c.cm. of caseous 
heesmo f ' rsnioved. The disease progressed rapidly, and it 

limb. This was done forty- 
condition of th a^rnission. But though the wound healed the 
she nnidlv 'f improve. On the contrary, 

nth "seven and died of meningitis on November 

ioint Tnliei-el°"\'^ nw symptoms had first appeared in the 
in ce;ehm.sn nil found a few dayi‘ before death 

writes • “ TIio removed by lumbnr puncture. Mr. Bowen 

of the" nrneoss standing feature of the case was tbe rapidity 

Inberde • evees.* ^°u"d marked signs of cerebral 

in the b'lseinent m ’ ^ 1 ”"^’ f!uff®u'ug of convolutions, tubercles 
lungrime of ventricles.’ In both 

elsewhere recent font ®oars at the ape.v, and here and 

cavities with en oommencing to break down into little 

dX‘rmi;^iyTurrcler"l= ew^”^ 1 °', 

on the sm-fnnn nf (u *^ 1 - ■ . f®" ruinute tubercles were seen 

mesenteric "elands and kidneys or spleen. The 

glands wpiE nmnf'"^ peritoneum ware normal. The bronchial 
caseating foci. enlarged ■ and beginning to show small 

arrived'iii^ini^ahs'”*^'^ ‘^'ob in tubercle bacilli, had 

sVeiks laJer i oh a?n“’, ^ "'f -‘o deal with it. Three 

present, but riot iii any“hinK™Hke"tl'^''"''' ■"'’ll"' 

and pus cells were now^atent From originally seen, 

inoculated and a cultufrrSd f/n tl”s sample animals were 
The culture grew luxuriaS t ^ “ f"f>®rculous guinea-pig. 

latches of ' gl.vcerin-agar, and, on suitable 

Four rabb ts v^vf - “’/*•, P‘“duced a vellow growth. . 
bacilli from a-onnri 'ntraperiton’eally with 10 mg. of 

months later fat and'^il^'l/”'’^^' 

lesions did not excried thoi ®™"T- “*1 

tubercle bacilli nf h fu®®® usual after such an injection of 
enS coCions 0 ^ 0 " ‘yP^uuuiely, a few little lightly 
cav'itv but in r.nn°' oo^ep-purulent matter ill the peritoneal 
occurred, and at the*^‘^f* Paralysis of the hind legs had 
lesion was found in ^ Vo^l-mortem examination a tuberculous 
cord. Such a lp.:in vertebrae, pressing on the spinal 

bacilli of human 1 " 'a.uot unknown after injections of tubercle 
have met , type into the rabbit; both Griffith and myself 

the conrlnsinn - t’l 'ts presence in this case in no wav weakens 
belonged in Brn f^ "ith which we we^e dealing 

been used for manv™fn *^‘'P®‘ strain of bacilli has since 

and it has all ai"^ uther experiments having a different object, 
inabilitv to "nr 1 shown- that low degree of virulence and 
is oharact prist ■° fU’usrcssive disease in the -rabbit which 

*0 8^ 00 ^“" “a .‘yp®- the guiiiea-pig it proved 

iiruieut, and caused fatal tuberculosis. fb f 


The second case avas that of a tuberculous wrist-joint in 
a man aged 69 years. As in the other case, it avas the tubercle 
bacilli in the pus from the joint that first excited my interest 
in it; hut they avere not so numerous as in the first sample 
from that case. Some avere seen in most of the fields: the 
largest number seen in any one field avas fia-e. 

For the clinical history I am indebted to Dr. Christopher 
Tylor of Long hlelford, Suffolk. The disease in the joint came 
on after a slight injury caused by jarring it severely avhen 
using an a.xe. About the same time the patient dea-eloped a 
cough, and had physical signs indicating tuberculous mischief 
in the lungs. The disease in the aa-rist-joint then became more 
acute, and there avas ea'idence of fluid. Six months after the 
commencement he avas sent to Addenbrooke’s Hospital, Cam- 
bridge, avhere an operation aa-as performed by Mr. Cooke, aa-ho 
let out a . large quantity of pus, curetted the avails of the 
.abscess cavity and the bones, and closed the avound avithout 
drainage. A feav d.ays later the patient returned to his home. 
After this the pulmonary disease ada-anced rapidly, and he 
died a feav aveeks after his discharge from the hospital. No 
liost-morfetn. examination avas made. 

A culture raised from a guinea-pig inoculated from the pus 
shoaved all the characters of the human tj-pe, and produced 
a’oluminous nodular groaa-ths on glycerin-potato, avrinkled 
films on glycerin-agar, and pigmented groavth on certain 
batches of serum. 

Tavo rabbits inoculated intraperitoneally aa-ith 10 mg. of serum 
culture on September 22nd remained well, and avhen killed tavo 
months later avere avell-groavn, fat animals, avith no sign of 
tubercle beyond the usual little collections of caseo-purulent 
matter lightly encysted in a thin membrane (aa-hich _one so 
frequently sees in the peritoneal cavities of rabbits injected 
aa-ith the'human type of bacillus), and in one of the animals a 
little avedge-shaped streak of chronic, tuberculous disease in one 
kidney. 

There ean therefore be no doubt that in this ease, as in 
the other, the tubercle bacilli concerned were of tbe human 
type, and we may conclude that the fact that numerous 
tubercle bacilli are visible in stained specimens of pus 
from tuberculous joints is not inconsistent avith an infection 
caused by bacilli derived from another case of human 
tuberculosis. 

The unusually rapid course and the fatal termination 
in these tavo ca’ses, selected only because there avere large 
numbers of tubercle bacilli visible in the discharges, raise 
tho question avhether the presence of these bacilli in 
numbers such as these cases shoaved -would justify a grave 
prognosis. One hesitates to draaa- this conclusion from two 
instances, but they at least call for further observations 
of cases of a similar kind. 

Reterekce. 

» Dorine TnhercuJo^iM in Relation to Man. Published by the National 
Cleaa Milk Society, 1925. . 


EABLY DETEOTIOY OF TUBERCLE BACILLI 
IN SPUTUM : 

Pk.\ctic.\i. Methods of 0bt.41ntn-g S.\TisF.\CTonY 
Speoiiiexs. 

BY 

■ SIR J.AMES DUNDAS-GEANT, K.B.E., M.A., M.D., 
F.R.C.S., 

LARYNGOLOGIST TO BROMPTON HOSPITAL FOR CONSUMPTION. 

The importance of the early detection of tubercle bacilli 
ill the sputum has been most strongly insisted on by 
Dr. Chandler and bv various correspondents in rot-eiit issues 
of the liritish dicdicat Joarnat. I can heartily endoi-se 
their vieaas, and I propose, therefore, to describe some a-erv 
practical means for applying tbein in cases of difficulty such 
as not infrequentlv present themselves. i 

In many of th'ese cases in which the general clinical 
evidence is in favour of tbe diagnosis of tuberculosis the 
report on tbe sputum supplied by the patient is th.at no 
tubercle bacilli have been found. As often as not tlii.s is 
because a good specimen of the sputum has not been 
obtained Many patients seem to be unable to eject the 
liquid frbni the bronchi, but involuntarily swallow and 
spit little more than frothy saliva from the mouth. By 
means of coaxing, and urging them to “ shoot it out into 
the bowl” while the head, is kept down over it, a bettor 
specimen may often bo obtained. If this fails, an active 
eoimh reflex may be excited by getting the patient to, sniff 


628 Araiiu 14, 1928] 


THE EBSISTANOE PACTOB IN DISEASE. ■ ' 


[ ■•TiJErnmos ‘ 

Ml.D2C.lI, JorBXl£ 


t!io vapour - of oleum sinapis volatile from tlio neck of 
. 1 , bottle (s.iy o six-ounoo medicine bottle) nt the bottom 
of «'bich there is about half an ounce of the oil. This gives 
off the va 2 )our all the more readily if the bottle is warmed 
over a lani]). Two or three sniffs generally result in a 
good cough and the exirulsion (with a little encouragement) 
of the ejecta from the larjmx and trachea into the basin. 
The sister in charge of the throat room at Brom{)ton 
Hos[)itaI is of the oinnion that if this does not excite a 
cough there is j)robably no Iar 3 ngoal tuberculosis. I cannot 
go quite so far as this, but 1 am sure that the jrroecduro 
described has often given us a ” positive ” result wlicn all 
irrevious examinations had i)rovcd “ negative.” In a recent 
case a historj- of syphilis led to a diagnosis of that disease 
as the cause of the hoarseness which was com{)lnined of, 
no bacilli having been found, but a sniff of the oil led to .a 
cough and the expulsion of a small quantity of S[)utum, in 
which the bacillus was found in fair abundance. This 
procedure should, of course, not be i)rcccded by anaes- 
thetization of the nose or larynx. 

Another method of value when by anj’ cbanco the former 
fails is the infralarijngcal injection, bj’ moans of a sy'ringc, 
of a few drops of the lotion wo use for cleaning tij) the 
larynx — namelj-, a weak solution of sodium bicarbonate to 
which is added a little hydrogen peroxide. This is done 
under the guidance of the laryngeal mirror, and it often 
works well, but in some cases wo are baulked by the 
obstinate closure of an irritable laiynx. 

In a case of this kind I recently tried another process. 
The patient either could not or would not cough, and 


failed to respond to tho methods above described. I there- 
fore apj)lied to his case tho infncijjlo of transnasal instilla- 
tion used for tho introduction of oily solutions into tho 
larynx. The patient was seated with his head thrown 
back and his mouth wide open. Ho was instructed to jjant' 
in and out through his mouth and not to swallow. While 
ho was doing this I gently' syringed about half a drachm 
of tho soda and peroxide solution drop by drop through 
tho nose. A small quantity entered the larynx and started 
a coiigii rvhich resulted in the expulsion of a little sputum- 
into tho basin. Tubercle bacilli were found, and the- 
diagnosis established. Tho .patient was not upset in the 
least, and reported himself later as feeling much better. 

I har'o occasionally caught on the laryngeal /nirror 3 
little patch of sputum sufficient for staining purposes, if 
tho patient coughed spontaneously or did so hr- instruction 
during tho examination. Tho examiner does well to wear 
a muslin veil when practising this last method. 

Tho administration for a few days of potassium iodide, 
if not otherwise contraindicated, is known to facilitate tho 
expulsion of sputum, and my colleague Mr. Ormerod and. 
I have made uso of it for this purpose. 

These processes have helped in many cases of doubt or 
difficulty, and I describe them in the expectation that 
others will find them useful. It need hardly be said, 
however, that they should not be practised without dis- 
crimination. Tho most appropriate cases are obviously, 
those in which thero is doubt as to the diagnosis, and in 
which, therefore, the disease has not reached an advanced 
stage. 


THE KESISTANCE EACTOE IN DISEASE: 

With Specui, Eetebence to SBPTic.rEjiw and Allied 
Conditions. 

BY 

JEFFREY RAMSAY, O.B.E., M.D., M.R.C.P., 

PHYSICIAN TO BLACKBDBN AND EAST LAXCASUIRE ROYAL INFIRMARY. 


In January, 1927, 1 was called into consultation in a case of 
facial eiysipelas. The patient, who was in extremis and who 
died some six hours later, appeared to have been an other- 
wise healthy and abstemious man, and his death drew atten- 
tion to the unsolved problem : What is the true or chief 
factor in causing the death of a patient wlio is suffering 
from a septicaemic condition? Tlie question was put to 
several medical colleagues, and the answers were interest- 
ing, if not very illuminating. One man replied that the 
cause of death was a profound toxaemia ; another, that the 
centres in the brain were jmt out of action by bacterial 
toxins; a third gave it as his view that death was duo to 
cloud)' swelling of all the colls of the body ; a fourth 
answered that he did not know, and a fifth suggested that 
death was due to a lack, of resistance on the jiart of the 
jiatient. 

Such diversity of opinion indicates the difficulty of the 
question at issue, and although we may theorize as to the 
cause of death, the majority of us must admit frankly that 
we can offer no certain exjrlanation of it. But wo are on 
safe ground when we say that death has resulted from 
the jiatient’s lack of resistance to the effects of bacterial 
invasion. This is, of course, a self-evident fact. If his 
resistance had been all-sufficient, it is unlikely that he would 
have died. 

“ The patient seemed to have no resisting power ” is a 
phrase that wo have used, often woiideringly, when a pre- 
viously -healthy man has succumbed to some infection — when 
be has been poleaxed, so to speak, by a disease from which 
he might reasonably have been expected to recover. Six. 
men may have lobar pneumonia, and one — often seemingly 
the healthiest prior to the illness— may die, while tho 
remaining five recover. Or death may occur unexpectedly 
following an apparently successful operation for appen- 
dicitis, or from septicaemia following a normal childbirth 
in which no manual or instrumental- interference was 
required. 

AVliat is this lack of resistance, this subtle x factor, 
which determines a dangerous downhill course or even a 
fatal issue? 


I desiro to put forward the hypothesis that our successful 
resistance to bacterial infection depends largely on the 
orderly response of certain of our endocrine glands 
nainclv, the sympathicotropic group comprising the thyroid, 
snScnal, and'pituitary, and tl.o vagotropic group com-, 
prising the parathyroids and the pancreas. 

Expebisiental Considerations. 

■Extiination of tho thyro-parathyroids produces a reduc- 
tion inutile phagocytic properties of the ffiucocytes in a 
/.viTTiI man- extirpation in monkeys produces increased. 

iabi to animals, there, IS. 

f - «ntlv a fatal result.’ Extirpation of the suprarenals 
frequently BfataMesu^^ fatal! With regard to the 

nituitary Cushing’ states f “ My own impression 
ll to7aI extirpation often provokes a peculiar tiain of 
^ tnmo uassiiiK from cachexia to coma and ultimate 
Smith’ fays that if the pituitary gland of ijts is . 
out by the^ buccal route an invariable syndrome 
In young animals there is cessation of growth, and 
" . Inlt anCls there is. inter alia, physical impa.ment 

witSrophy of the thyroid, parathyroids, and suprarenal 

“a Pxtirnation of one or other of these glands may 
Since e. P . results, surely it is only sound common 
produce ^ severe infection in the blood stream, 

sense to assume t^ simultaneously, may pro- 

attacUing each an^ei^^ easily be fatal. To swamp an 
“■•/o Mand with a potent toxin must surely cripple 
uftactU sometimes to an extent which may be equna- 

leut to or infections in childhood haemor- 

I„ producing 

rhage may ‘ t associated with convulsions, vomiting, 
pr-ofonnd ‘“Pf "^J®Lnlt generally- occurring within 
and purpura a al lesu g ^ 

quelled successfully. But in eeitain 

Appears to bo c. “XAhr Llffiwkig «nians the 
fatal, and I suggest that the louownib 

i»-vT-»7r>nn+jnr»«5 in nianv sucli CaSGS. 



ApKTI* t 4 i 1928] 


THE RESISTANCE FACTOR IN DISEASE. 


[ Tire Britt 5S 

IiTCDlCXX. JOUBNI& 


620 


■ {a) Thn patient may 
slructed glands 


have started -life avilli faultily con- 

(6) He“m'ay\iavo a natiiral tendency to faulty balance in the 
endocrine glands. Camraidge,"’ working with Howard, has 
c.arried out experiments with mice, and has found that in 
some apparently hcallliy animals a low hlood sugar is a 
recessive character, transmitted in accordance with Mendel’s 
theory of heredity, and he suggests that it seems prohahle from 
the experiments that the hypoglycaemia is due to hyper- 
fnnetion of the pancreas relative to the glands of the opposite 
gronp — that is, thyroid, suprarenals, and pituitary. 

This hcroditaiy dysfunction or Inck of hnlanco is interest- 
ing, since the percentage of sugar in the hlood of the peri- 
pheral circulation appears to ho similar under like con- 
ditions in all mammals. It seems not iinreasonahle, there- 
fore, to suppose that human beings may exhibit similar 
hereditary tendencies to imperfect balance of endocrine 
secretions. Such endocrine imbalance would explain certain 
cases of diabetes mellitns in young children; it would 
.explain also the tendency to diaiictes as a racial or heredi- 
tary condition, and would, in my opinion, explain a low 
grade of resistance to infection in some young children. 

■ (c) Some gross or, more usually, subtle toxin from the apices 
of the teeth, from the nasal sinuses, from the tonsils, from the 
•digestive tr.act (as in alcoholism) or from elsewhere may have 
-been at work, undermining the healthy activities of his endocrine 
glands.^ Such a condition may -he cumulative in old persons and 
.inay account^ for senility, sometimes of premature tj’po, also for 
the glycosuria which occ.asionally develops in later life, and for 

' which elderly people succumb to acute infections. 
-- 1 J may be_ the victim of unsuspected vitamin deficienev. 
•Mcl^arrisoii has shown that vit.amin defects lead to endocrine 
ciianges; the adrenals and pituitary enlarge, while other 
endocrine glands show more or less atrophv.” Hence there must 
".'u Pighini'i has found that if tadpoles 

T.oL'; thyroid gland from pigeons in which beri beri had 
n ®-’cclusive diet of polished rice, the tadpoles 

n j . acceleration of growth wliich is produced 

the thjToid gland from normal pigeons. This 
^^Pf'tnent points to the assumption that a deficiency 
.•fLctSn.,®f inhibitory effect on the healthy 
•before ttio^ thyroid gland. For more than a century 

6U wL used cod-liver oil was discovered the 

the natient’e knou-n beneficial effect in raising 

fef P^ttficularly to pulmonary affections, 

the endocrine a disturbance of balance in 

of exonlithalmfc ''ntness the well-knot™ fact that cases 

air- raiSs on To showed a great increase during enemy 

“oLed anxM^or -n"-. reasonable to think tLt pro- 
be associated ^r!n trauma of any kind may cause or 

patWcoHonIe Ini ^bnlance. The gonads are sjrni- 

conditioIi^°^sucl/n '^l**'*i damp and other adverse climatic 

■“dn; of reslstamelnd""';?’'' “2'^ 

diseases. In tlill case it f of the advent of certain 

■from the nerve ondir, possible that impulses may pass 

■ produce imbalance by wav^If M ®"rface of the skin and 

•It is well-knotti! thaUn hvde^ti ®J™P“‘';atio nervous system, 
to heat and in Iwothyro^dfsm tTIIld!™ '' intolerance 

Br6wn^r^*I‘”Tlf ''f f summed up in the words of Langdon 
Susborderftofr'’ “ woll-planned her- 

tho due ordering of tluT*'’" appropriate flowers. For 

endocrine svstom” I beli-etm 

a stago further— if n ^ ^ simile may be carried 

. herbaceous border there Hnf T 

on the endocrine glands ll sf sudden strain thrown 

" Hafing outlined certain " f ? emergen^, 

nexion witii the theorrif ^j’P^^^antal points in con- 
raontion some clinical^d + resistance, I wish to 

desirable -te touch on f 

associated with tJiP +tt-^ Physiological and other features 
. 1. Tlio 'jvmnnfiw + Sjoups of endocrine glands, 
comprises t ho fiyroicl function, 
group resnnndo ■ ’ ^^’Prarenal, and pituitary, and this 

fighfol fliff of '^^‘t'^rnal foo bv Activating 

pyrcll°?’/f, internal foe (bacterial invasion) 

that these* frHnrlc: F^hctions. It is clearly recognized 

?ystem,Trenw!V .^1-= sympathetic nervous 

body for defence^* eoncerned witli the activation of the 

secretory impulses of. the thyroid are under 


the control of the sympathetic nervous system, but it is 
innervated also from the superior and inferior laryngeal 
branches of the vagus. It alone of all the secretions of 
tho body contains iodine.’ Thyroid secretion accelerates 
lliG heart without augmenting the strength of tho beat ; 
increased secretion diminishes sugar tolerance and mav 
I also the basal metabolic r.ate. It is well known that 
hypcTthyroidism may follow sepsis in tonsils or tcetli in 
adult life. Adrenaline stimulates the force and frequency 
of the hoart-heats, raises the blood pressure, and may 
excite glycosuria, because it tends to empty the glycogen 
reservoirs of the liver. 

The anterior portion of the pituitary gland is concerned 
chiefly with the mechanisms of growth, and it is believed 
to influence the basal metabolic rate. As regards groivtU, 
it is interesting to note that when a child has recovered 
from some acute infection its bodily growth is often 
thought to have been accelerated, a point which suggests a 
stimulation of the anterior portion of the pituitary gland. 

Dott” considers that the liv-pothalamic region of the brain, 
wliicli has been called the liead ganglion of the sympathetic 
nervous system, acts in conjunction with the anterior 
portion of the pituitary gland in its metabolism-regulating 
function. Tlie internal secretion of the posterior portion 
of the pituitar}- gland has the property of slowing the pulse 
and raising the blood pressure. It appears to have a 
balancing effect on carbohydrate metabolism, inhibiting, 
for example, tho effect of drugs which tend to change the 
hlood sugar concentration away from normal in eitlirr 
direction. Its overaction leads to glycosuria, and stimu- 
lation may play a part also in raising the basal metabolic 
rate.” It appears to be an antidiuretic, and its action 
on uterine and other muscle is well known. 

It will be noticed that little mention has been made of 
another set of endocrine glands — namely, the gonads, which 
are linked up with the sympathicotropic group. Extirpa- 
tion of the gon.ids, or their dysfunction as a result of 
disease or involution, may and does cause certain disturb- 
ances in the body processes, but I am unable to produce 
evidence that they play any important part in resistance 
to acute infection. For a similar reason no mention is 
made of the pineal body. 

2. The vagotropic glands, anabolic in function, com- 
prise the parathyroids and the pancreas. 

Vines’s” work has emphasized the importance of the 
parathyroids. He has demonstrated that parathyroid 
substance is a pliysiological adjuvant to -the normal 
mechanisms of defence, and lie states that there is some 
evidence tliat the production of antibodies may depend on 
the functional integrity of the parathyroid glands. He 
has shown that the calcium content of the hlood is lowered 
in infective conditions. Tlie parathyroid glands probably 
act as regulators of calcium metabolism, and, further, the 
giving of parathyroid gland may raise the polymoipho- 
nuclear leucocyte count in infections.' The extract has a 
sedative effect on the nervous tissues; its diminution may 
lead to irritability, restlessness, and even to tetany. 

The pancreas is probably activated, to some extent at 
least, by the parathyroids, and in the present connexion it 
is only of moment in relation to its function in helping 
to raise sugar tolerance. 

Clinical Aspects. 

I wish now to consider the clinical aspects of a patient 
wlio is in the early stages of an acute infection such as 
puerperal' or other septicaemia, and to correlate the signs 
and symptoms with special reference to the sympathico- 
tropic and vagotropic glands. 

I desire to stress the point that the first effect of a 
severe bacterial invasion is a stimulation, obviously pro- 
tective in character, of the sympathetic nervous system, 
in relation to which are the sympathicotropic glands. At 
the same time tliere is an inhibition of tlie vagotropic 
group, which may be actually paralytic in character — that 
is, it mav result from imperfect response in these glands — 
or.it may he a relative effect, by which I mean that tho 
vigorous response of the sympathicotropic group may swamp 
the activities of the vagotropic group, thus causing im- 
balance in the whole endocrine mechanism. 



630 ApRii/ 14', 1928] 


THE'HESISt ANCE l^XoTOli %'ilSEASE’ 


Skic by side with the dinicnl fmdinjrs at jui oaHv sliitro 
of the .ufeetion I tnlndate the fiadiag^ i„ a case ,4i -K 
rapicl/y approaching a fatal tenninatiou. 


Tit Ti'EKnmMr'A 
liIrnjcALTouESAi _ 


Clinical Findiiais: 


Facial nspccb 
SIdn ... 
Miisculatui'd 

AfentalsCato 

Tcmpcrnttire 

r«lso ... • 

Respiration 

Blood pressure ... 

Urinary socretiou 

Basal n:etal)olic 
rate 

Sut’ar toloynnco ... 
Blood calcium 


Early, 


Usimlli' iUishoa 

Hot and dry. but gome- 
limoH prrppirjnj’ 
Movements may bo strong 
and iiiay even rcqulro 
restraint 

Varniblo, Hometimes clcax*. 

often delirious 
High and fiwinging in typo 

Bapid. generally regular 

Rapid and regular 

Often slightly above corjiinl 
for patient’s ngc 
Merging from normal to 
scanty 
Raised 

Tends to bo lowered 


lioworcd 


Bate. 


l*alo or cynuoscil. 

Cold and eJammy. 

liimp. Feeble, iiregiilnr 
movements niny occur. 

Usually lotbargic. 

May fall soddcnly before 
death. 

Rapid, frequently irregu- 
lar. 

Rapid and uballow, wjtb 
irrcgularsigbing before 
dcatli. 

Bow. 

Scantj*. 

Not dctonuincd.owjng to 
KcnotiRnoss of patient’a 
condition. 

Blood sugar immediately 
ticforc death averages 
0.15 per cent, (see 
below). 


!a'p!vse!i't'!.g 0.15 i)er'cwi'rinVit-'^‘''i' 

miiditions IK Johar pucnumni-i 1 ^ such 

is-datod f,g„..o, a. it is iZ’s^ « 

carry out a c-oa.picdo .sugnr-t'oierabca S t f 


stimulating effect on flio 

i'ai..L‘d '''° /'}!’'<!, tliu basal metabolic rate is 

abut, and the sugar tolerance is lowered. 

Fp^SSSifiigl 

fiJin'l “iU, ( 1,0 .,i,r,K-njie 

are intact glycosuria is not c.^ited Alfllor- "'.‘'f 
nmreased adrenaline inhibits Joss of heat and f » 
timt such siinrar^nnl ^ foilop*s 

initial stages oTa’i aenfo o'! use in the 

temjjeiatui'e to a imint wifavmn- Pi ^Iie internal 

micro-orgnni.sms in the blood to t!ie growth of 

Wood caleinm and low simar tniflr-,”* t>ssue.s. Tito low 
fnnctioiiing of the vagotropic XLds"''^ 

1 inning now to the signs and svinntoins ivltini 
the approach of a fatal termination imm- 
to indicate a failure of glandular oUlw * ^ f^tuies seem 
blood pressure points to cessation of suprarenal’s ‘^'T 
perliaps with that of thyroid and post-pifnitarv ^ secretion, 

It is a significaut fact that limp mnscuJature is an out 

stanclmg event, prior to death, in experimental ren, or al 

of the pituitary gland, 'iliere is also, of course rl,„ ; 
taut fact tliat, in an acute infection, the linlscleVH'’”'^” 
selves have been inundated with the toxins produced bv h"' 
invading orgamsim But may net this muscular eoiiditi",! 
ho due in part to failure of the siiprarenais to siippiy a si b 
stance acting on the myo-neural junction and maintainin' 
mnscle tone in iionnai circumstances? The irritahilitv a d 
resticssnoss may bo due in part to parathyroid failure as 
well as to the direct effect of the toxin on the brain cells * 
wi^’i'i > ^'>0 ' resident staff of the 

oi.Tl Infinnary, is carrying out observations 

the blood sugar immediately prior to death. His work is 


lying froiu such 
an 

iHiieh may have been hAliL^nns^in’^r^t^^teria 

ioiieni g of blood pressure and a fatal result? ® • 

J cinhrej-' points out that the heart is very suscentibla 
to a rise of teniporaturo and malnutrition, PerJianf this 
innlmitntion may consist in a lack of normally balanced 
constituents of the blood, so that the lie,iit, like other 
musoles, is there^}* enfeebled. In this, connexion it is 
interesting to note that adrenaline aotimliy dilates thi 
coioiinry vessels in spite of its general vaso-coiistrictivc 
action. If the Wood supply to the . myocardium ■ is thus 
increased by dilatation of the coronary aiteries this may 
explain to some extent the prompt action of intr.acardiao 
injection of adrenaline when the heart has apparently 
ecuscil to heat. If adrenaline is lessening in tlie Wood 
dining the later stages of aii acute infection the coronaiy 
avtorics will fail to allow of tlie passage of an adequate 
blood siijiply. Fm-ther, it is possible that the Wood which 
does reach the myocardium is wanting in other eon- 
stitiieiits ivliicli should normally be supplied by the endocrine 
glands. . ■ 

3Inny physicians consider that digitalis is of little use 
ns a licnit stimulant during an acute infection such as 
pneuinoiiin. As 3Iackenzie=® said; “The factors exciting 
the licart, such as high temperature, toxins, or the in- 
vasion of tho licart by specific organisms, exert an influence 
over tlio lienrl wliieh digitalis cannot overcome.” 

Tlio modern tendency is to combat heart failure In these 
and other conditions by such substances as post-pituitary 
or siipraronnl oxlraefc, and in this way we niaj- be feeling 
oiir way towards the right path. Indeed, it is possible that 
when such a remedy succeeds it may do so, in part at 
least, by supplying a si>ecific deficiency in the Wood. Oiio 
medical friend of mine to whom I' had mentioned this 
matter treated a moribund case of lobar pneumonia with 
massive doses of thyroid extract, and to his astonishment 
the patient recoyefed. 

To 'hmke use of an everyday expression, it is no good 
blaniing the carburettor for the faulty running of an 
eii"iuo if the real cause of the trouble is petrol which is 
inadequate in character. • • ' 

Jt is possible that the liver may play a not iiicoiisider- 
ablo part in resistance to acute infection, but the means 
for assessing hepatic function in such a condition are soiiie- 
uliiit inadequate. In like manner I know of no explana- 
tion, which has been proved hitherto, as to why tho 
phagocytes flag in power ' under certain conditions, and 
I su'T'rest that this may he due to deficiency of endocrino 
gland - secretions in the blood stream. Beferenco to this 
point has already been made in ■ connexion with the para- 
thyroids. As regards agglutinins, opsonins, precipitiiis, 
and bacteriolysins, Dudgeon 'states : “ Unfortunately tho 

presenoe of all these substances, even in large amounts in 
tho Wood, is not necessarily an indication of the patients 
resistance to a bacterial invasion.” 

If then, it can be accepted that exhaustion and failure 
of many of the endocrine glands may bo an important 
factor in • allowing the patient to be overcome by the 
invading organism, I submit that it is a rational procedure 
to supply him, from the beginning of the infection, with 
gland products to aid the tissues in their fight. 

I suggest that the initial stimulation of the thyroiOf 
parathyroids, and suprarenals throws a sudden strain on 
these glands, and it has been pointed out that thejgmnus 

£. C fi-n 


XU HIT.- — “ 

may be faulty from congenital causes, from the cttccc o 
toxins, or as a result of avitaminosis and oBier factors. 
AVe liave little means of estimating the efficiency ef 
glandular response until the time of testing comes. Iney 


April 14 ,- 1928 ] 


SniPLE ILEO-CAEOAI, E-yMPHADENITIS. 


631 


mav fail or tlicy mav witlistaiul tbo strain, Init it is liarclly 
safe to wait. An a’cnto n))pon(Iieitis may subside without 
the surgeon’s aid, vet it is usually moro prudent to call 
for that aid. Bv supplying gland products wc attempt to 
reinforce tlio natural defensive mechanism and thus to 
prevent its exhaustion. Just ns in.sulin may he said to 
rest an overstrained j)ancrens, so other glandular ex-tracts 
mav co-operate with the natural secretions and allow them 
to continue their work without depletion of their strength. 
In tlio words of Vines : 

“ Tho aim of treatment should bo fundariicntally to encourage 
tho re-establishment of normal^ conditions (that is, a metabolic 
balance), and since tho endocrine- glands are the regulators of 
normal metabolism it is to them that -\vc should look for a means 
of obtaining the end in view.” 

- Geikie Cobb has called the.so tho glands of destiny, and 
it is probable that tho personality or “ make-up ” of each 
member of the human race is influenced profoundly by tho 
predominance of oho or more .of the,, endocrine glands. 
This imiilics that there is an ondocrino balance which is 
normal for each .individual, • though differing widely in 
different individuals; and I believe, that health depends 
upon the maintenance of that normal balance, with slight 
hut constantly occurring deviations according to tho needs 
of tho moment. 

Departure - from health, bn tho other hand, probably 
depends on, or is associated with, an unusual deviation 
from the normal balance. Tho compass is deflected more 
Dr less violently. If, for some of the reasons which have 
been given — for example, faulty diet or long-continued 
emotional strain— the endocrine glands become temporarily 
inefficient, acute disease may result from tho advent of 
a virulent organism in tho system, which then resi)onds 
well or badly, according to the underlving condition of the 
endocrine glands. If the latter aro'only slightly under- 


mined as regards their efficiency, they will respond 
adequately to the sudden stimulus of an" acute infective 
condition, in which case recovery is likely after a struggle. 
An example of this is lobar pneumonia. If the endocrine 
response is poor, death is probable. Even if- the invading 
organism is one of comparatively mild virulence, death 
may result if the -endocrine glands are inefficient^ An 
example of this would bo the occurrence of boils, or a 
scratch on the skin, followed by septicaemia in a sufferer 
from diabetes; or the occurrence of puerperal septicaemia 
in a patient with apical infection of the teeth, pre- 
supposing that no interference with tho normal course of 
labour has been necessary. 

According to this vnew subacute and chronic diseases 
represent varying degrees of virulence in attack, balanced 
by varying degrees of endocrine response in defence. 
Having set forth the theory, I am cari-j-ing out work 
at present' in connexion with its application to treatment 
in aciite infective conditions. 

.... Referen'ces. 

* Vincent, Swale: Internal Seeretioug and the Dnctlegg' Glands, p. 320. 

* Cushing,' Harvey : British Medical Journal, July 2nd, 19^, p. 5. 

* Smith, -P. E. :-Djsabilit5c8 caused by H.\ pophysectoray'and thefr -Repair, 

Journ. Atner. Med. Assoc., 1927, Ixxxviii. 158. . 

* Brown, W. • Langdon : The Endo'eriues /n -General Medicine, p. 22 ; 

■* p. 74; • p. 2; • p. 26; * p. 99;-« p. 27; p.-65; ” p: 93.- - 

** SfcChirc, J. C.x Proe. Boy.. Soc. Med., March 3rd, 1927, p. 1027. 

** Cammidge, T. J. : Practitioner, August, 1927, p. 105. 

** Pighini, G. ; Biocheviica c Therania Sperimentale, 1927, JuU'Jlst, p. 249. 

Dott, N. M. : Medical Annual, 19^, p. 374. 

** Cushing, llarvcy : British Medical Journal, July 9th, 1927, "p* 52.’ 

” Vines, H. W. C* : Parathyroid Glands in Belation to Disease. 

“ Ibid., p. 83. 

** Fraser, K. : On Iodine, Appendix to Annual Report of the School 
Medical Officer, Cumberland, 1925. .. 

Miller, E. : Types of Mind and Body, Psj'che Sliniatures, Medical Scries, 
p. 60. 

2* Pembrey, M. S. : Price's TexthooV of the. Practice of Medicine, p. 8 . 

-- Mackenzie, J. : Diseases of the Heart, third edition, p. 379. 

Dmlgron, L. S. : Bacterial Vaccines and their Position in Therapeutics, 

p. 4. 


SIMPLE ILEO-CAECAL LYMPHADENITIS. 

BY 

C. JENNINGS MARSHALL, M.D., M.S., 

■ , • F.R.C.S., 

ASSISTANT. SDEOEOH, CHARING CROSS HOSPITAL, AND VICTORIA 
. HOSPITAL FOR CHILDREN. 


The subject of mesenteric Ij-mpliadenitis has from time to 
time attracted attention, probably, Iiowevci', not to the 
extent it merits. Considerable ..confusion still exists 
apparently, to judge from tlie writings tliat appear now 
and again, as to the forms in which tlic condition 
occurs. The disease may .be purely tuberculous, purely 
non-tuberculous, or a mixture. -Tuberculosis of the glands 
may be diffused, but much more frequently is localized to 
the ileo-caecal angle; its late effects here, particularly as 
a cause of obscure chronic right-sided pain, are familiar 
-to all. It is not uncommon to find a septic exacerbation 
of the process, just as is so often seen in connexion with 
•fcervical adenitis. 

. I* is desired hero to call attention to the existence of a 
simple adenitis, which may he either an acute iiiflamm.a- 
tion or a chronic hjqierplasia. Occasionallv a chronic 
hyperplasia is found tlirougliout -the mesentery of the 
jn younger, children affected by some 
c ironic enteritis; much commoner, however, is the 
condition here described, which is localized to the ileo- 
caecal lymphatics. 

J. . Clinical Features. 

The disease is seen chiefly between the ages of 5 and 15, 
and IS moro frequent in girls. Acute attacks may or may 
not have been preceded by other acute attacks or bv 
■chronic abdominal symptoms-for example, dyspepsia. A 
•large proportion of patients conform to type: 'the child is 
a me -y feeder, is listless, easily tired sallow, is liable 
.to acidosis; the miiseulaturo is hypotonic. There is sbme- 
■ times antecedent bowel irregularity, and acute attacks 
until I** R definite catarrhal condition. It is 

irlmn ^ ^ ^ considerable proportion show cervical 

tonsUlar Troubr av “-f j.*;™ there h.as been 


/niinnijt c .1-’ . , ‘® Stopping power ot the 

wpro°in defences of tho mucosae 

were m general deficient. 


Acufe Aitachs. 

The pain is rapid in onset and nearly always riglit- 
sided, but sometimes is epigastric or diffuse at the 
beginning. Vomiting and nausea are relatively infre- 
quent; the appetite may bo retained tliroiighput, and the 
tongue remains moist and only slightly furred. Fever, is 
early and often mncli liigher than in apjiendicitis, not 
uncomnionly reaching even 102° to 103° F. The bowels 
may be loose or- constipated ; the breath often smells -of 
acetone. True abdominal rigidity is not found, though 
the right side may not move freely; deep tenderness is 
jircsent over a band about an inch wide under the outer and 
middle part of the rectus muscle, above McBurney’.s point. 
Swollen glands are commonly palpable with a conscious 
patient, practically always under anaesthesia. Pain i.s o.fteh 
elicited by either active or passive movement of the hip! '' 

The disease is os rapid in recovery as in onset: -two or 
three days usually sees it end- while the pain itself may 
last only a few hours. It will he obvious that while, there 
is a superficial resemblance to appendicitis, the two. con- 
ditions are sharply cut clinicallyi- - 

Chronic Cases. 

The patient comes under attention for repeated attacks, 
usually very short, of -abdominal pain; -there m.ay be 
dyspepsia, and the case - usually agrees with the type 
already described. The pain -may be right-sided, umbilical, 
or epigastric; there may sometimes bo persistent aching, 
worse on movement, on the right side. In a great number 
of cases the himpj- glands- can be felt — the p.atient has a 
thin lax parietes ; only slight tenderness is present. 

. P athologt. 

The glandular condition is localized to the ileo-colic 
chain, and affects the ileo-caecal group in particular. In 
some cases glands were enlarged up to and in contact with 
the duodenum, and the lowest were commonly adherent in 
the ileo-caecal angle ; .-nodes are frequent on the anterior 
and posterior aspect of the ileo-caecal junction, and in the 
meso-appendix. In the acute cases the swelling is con- 
siderable, the retroperitoneal tLssuo is oedematous and 
abnormally vascular, and tlicio may bo a small amount of 
clear- colourless fluid in the peritoneal cavity. In the 
chronic oases the glands are firm, nearly ahvays discrete, 


632 Apriij 14, 1928] 


MEMORANDA. 


r TsxSmm ^ 
L If KDicu. Jordan, 


and i-iirely liii-ger tlmn a fdbovt. Tlioro is ncvor any 
evidence of poritoileal thickening or adlioKion over these 
glands, as is so common in tidjerele, nor are there visible 
the nliitisli or jellondsh patches of tliat disease. The 
glands are scinitraiislncent, fawnish or grey, never white; 
there is never caseation or suppuration. The total inimber 
of nodes is not greatly increased, as is so characteristic of 
tuberculosis, nor is there dense periadenitis. .On section 
the glands are homogeneous and linn : in acute cases they 
are oedomatons and exude fluid, and show microscopically 
all the signs of acute inflammation; in chronic cases there 
is simple hyperplasia. Ciiltui'o in two acuto cases gave a 
growth of 7J. coti ■ in manj’, however, it was negati\-c. All 
cases easily projiounccd non-tubcrculous on tho above 
npi)earances were confirmed microscopically. 

The bowel was carefully inspected in all cases, but in 
none was there any external evidence of ulceration, 
inflammation, or hyperplasia of .submucous hanpb nodes. 
In one case with intense glandular swelling the torininal 
two inches of tlie ileum and tho caecum were intensely 
and uniformly glistening and rubbery, with the np2)earanee 
seen after reduction of an intussusception — the condition 
was clearly one of lymphatic obstruction, and a result, not 
a cause, of tho glandular disease. In goiicral there is no 
gross apjicndieular di.seaso (and it may be .stated that 
manifest apijcndicnlar infection — for example, suppnrafion 
— is not associated with such glandular swelling ns here 
described). Vejy constmitly, howei'or, there is a diffused, 
sivollen, snecnlent condition of tho mneosa, slight jioly- 
morphonnelear infiltration, and lymphoid hypeildasia, at 
times considevahle. Other abnormalities — oxyuridcs, soft 
faeces, submneons fibrosis — were fairly common, hut did not 
appear relevant. 

P.STIIOOEXE.SIS. 

Once again it must ho insisted that this disease is not 
tuhereulous, and occurs chiefly in a very distinct type of 
patient, whoso nnicosao offer but poor resistance to tbe 
pa.ssago of bacteria and in whom exacerbations of infection 
are apt to precipitate attacks of acidosis. Tliat tho 
ineidenco is chiefly on tho ilco-eolic glands would suggest; 
the altered nature of tho bowel content in this region as 
a determining factor. No confirmation of a catarrhal 
di,soaso of the caecum was obtained by microscopy of a 
small portion of this excised ■with the aiijicndi.v. There 
is, however, another po.ssihility : it is commonly .said that 
lymphoid tissue, wherever found, is defensive, a barrier to 
infection ; aiiiiliod to submucous nodes, such a view is 
certainly oiicn to the gravest objections, the structure of 
some such masses in iJarticxdar giving the imjiression of 
being de.signed to favour the entrance of bacteria info tho 
system. The appendix, by its stnictnrc, invites infection, 
and by its nature causes stasis and eiiliaiiceniciit of 
bacterial virulence. In a largo ixvoiiortion of cases, but 
admittedly not all, treated by appendicoctoiny there has 
been not only cure of the symptoms but also a considei- 
able improvement in general bealtb. Treatment by intes- 
tinal antiseptics lias been quite valueless, but, in view of 
their general iiiefficacy, perhaps the argument fails to 
carry weight as to whether or no the bowel is the source 
of the infection. Tlie ixroduction of the acute attacks of 
pain max' perhaps excite curiosity; it seems probable they 
may be vascular or neurogenous in origin, owing to the 
intimate relationship of the diseased stnicturcs to tbe 
nenro-vascnlar snijply of tbe gut. In a recent case of 
acute adenitis it wa.s seen at operation that in-egiilar 
peristalsis had been excited, for, in addition to pronounced 
glandular disease, there was the beginning of an intus- 
.snsception in the terminal ileum. 

A protest should be registered against the widespread, 
rather liappy-go-lncky “ child will grow out of it” atti- 
tude; chronic infections in childhood may be the cause of 
orave’ damage, which may not become apparent until the 
.^tresses of middle age find the viscera exhausted; and it 
should bo remembered in this particular instance that the 
infected lymphatics, as lias long been known, are cap.able 
of inducing disease in such organs as the pancreas, gall- 
bladder, and pylorus. 

Tiic.xtiiext. 

In tbe acuto cases, tbough recovery is invariable without 
intervention, and the diagnosis from appendicitis is nsualjy 


casil}' made, it will nevertheless often bo felt that opera- 
tion is safest, if only to juit tho diagnosis beyond doubt. 
In such instances the appendix will ho removed. 

In the conservative treatment 'of hath acute and cliroiiio 
cases tho mouth and throat arc put in order, tho boucls 
ai'o regulated, and tho diet modified — green vegetables 
with jilenty of roughage seem to exercise more influence 
than any other dietetic factor. If there be acidosis both 
.sugar and alkali are nccessaiy'. A fair trial may bo given 
to tlie.so and other general 113’gionic procedures (in my 
experience seaside air, sunlight, etc., have proved dis- 
.ipfiointing in these cases). A very considerable propor- 
tion of patients resisting such treatment will he cured by 
appcndicectomy, and the opjioi-tunity can be \ taken to 
verify the iion-tiiborciilous character of the case by micro- 
.scojiy of a gland. This again needs emphasis, as there 
seems to bo an ineradicable general impression that all 
enlarged abdominal glands are tuberculous. 


SWTI,STIC.\I, SuitMAWY. 

Total cases 48; average age 10 years. Females 74 per 

^’‘icitic Cases (8).— Dnratioii of symptoms three and a half 
days (average). Culture of S. coli from glands in 2 eases. 

Chronic Casts . — Average duration of symptoms fen 
months. Tho iiaticnt conforms to type in about 75 per 
cent. Pain purely local in 72 per cent., on walking m 
20 per cent Glands felt without anaesthesia in 74 per 
cent.' Constipation in 52 per cent.; occasioiml diarrhoea m 
15 per cent. Tonsils removed in 17 cases. Urinary cultnrc 
necativc— 9 female eases. Case.s operated on 28; oxynndcs 
in appendix in 6 cases; culture of glands always sterile. 

• VcLus -Cases difficult to trace. In those followed, cures 
with great imiu-ovement in general health noted from six 
the n!i to five rears. Pour recurrences after operation 
ril one ^^e dmi'c were several attacks during the firs 
month after operation, none since; one case had seAcinl 
iiioiit I an 1 Dental caries: one cate 

attacks u] “Pathology”) in which- a larp 

(referred removed; this was actually said to be 

U.;^”yea.-s later! this s^nied to be partial obstruction, 
possibly due to adhesions from the operation. 


^tmaraitbs: 

JIEMOAL. SroGIOAU. OBSTETEICAi. 

CAT? COMA OF THE STOMACH. 

« Hinn’s report on March 10th (p. 393) of 
fa. J.iMES S. ■ ■ i .(rliieli clinically simulated 

auodonal niwi aa obseiwation. 

ndoubled case ,i;+i'nn is said to be extremely rare, 
Although the cond Tannary 22nd, 1927 (p. 139), 

I, other ease Brauder. In^otli these instances 

y Mr. H. S e ^gjjnitcly to stomach or duodeinnn 
'■".’f ZmS fGlt,ire,s, whereas in the case I saw the 
^'*^tnmatolo"V was entirely different. 

lontiis was in no way - related to .the 

bdomen. Tin sickness, and his man’s 

lod; he had , tumour mass about jho size o 

as found 1 °. g g jeft hypochondnum and eHendi g 
enched o„r was slightly abdomioal 

jigasfrium. | ^nth a d'osn®®'®,.® patient 

otched. ■ He , , • appearance he looked mor ■ ajjjpg 

iberculosis, but m and tbe position of the » 

ith a t this. A blood examination efJP ^ lOOOO 

;cmcd to sPPPf^.f .^0 with 4 , 500,000 erythro^lcs a^ ^ 

ohin percentage of Vcount Mr. 

small portion and an eniar a n 


Arititi I'll lOss] 


POUTAi CIRRHOSIS. 


t Tnr. Rnirrsn 
ilrojciR JoxnisAt 


633 


wnitlpd narl oMlie specimen to Dr. R. M. Ruclmnan, city patlio- 
locht, who imlepeiidcntl,v dinf-nosed H a sarcoma. 

^riie patient remained in liospilal for two weeks after operation, 
and during tliat time Ins appetite romnined good; lie had no 
namea or vomiting, and little discomfort save for spasmodic 
attacks of abdominal pain. His annomia rapidlv became woi-sc 
liil Uic Uaomo<»lobiu percculugc Iirvtl fullon to 30, willi about 
2 000 000 veil colls; the nnaomiu ronmined of n snnplo secondary 
type. He died three weeks after going home. 

Apart from tho rarity of tlic timiorir tlio cusp is interest- 
ing becanse of the entire nbsenec of digestive disturbances, 
wliieb may be explained by tbc fact tlmt the ncojiiasni, 
origiliatiiig, as siicli tumours are .said to do, in the sub- 
nnieosa, spread outwards in the middle coat and did not 
.apparently cause ulecratioii of tlie mueosa. The olber tivo 
patients mentioned liiid delinite digestive symptoms, but 
ulceration was jircsent. 

Ai.EXAMir.n Smith, JI.B., Ch.B. 

Jtobrovslon llospitol, Glas■go^\. 


TUEATMhIXT OF HKCTAL FHOLAPSE BY 
IXJKCTIOX. 

AVhile tile trentraent of baemorrhoids by tlic injection of 
carbolic acid and liamnmoHs, or of other ])re|iaratioii, is 
well established as a surgical procodiirc, little or no atten- 
tion appears to have been directed to this form of treat- 
ment for the cure of prolapse of tlie rectum. A considerable 
number of cases have now been treated liv me, or under my 
supervision, in this maimer, with satisfactory results. Tho 
following ease, treated and reported Ijv Dr. A. Briggs, my 
resident bouse-surgeon at the Biistcr'n District Hospit.-il, 
may be given as an e.xamplo. 

A man, aged 66, _ was admitted in November, 1926, complaining 
or pain, and a feeling of something coming down the back passage 
on defacoation, of ten years’ duration. Examiiialion revealed a 
recta! prolapse which protruded on straining for fullv two inches 
beyond the anal margin. Patient was also Biiftering 'from chronic 
% .1“ ®" n ‘"Sb'nol bubonocele. Once a week for six 

^ j Y*' ’ ll. prolapsed rectum was Injected with carbolic 

inmameUs. starting with a dose of 1 c.cm., and 
The patient was discharged, at the end of 
Hiat Thf E7'i''£“a ttfolxpsc- He reported in March. 1928, 
down." “ * further trouble, and did not come 

In this case, then, six injection.s wore .siifficiont to remove 
n rondition of ten ye.nrs’ standing, and it iins not recurred 

01 o\ei a year, notwithstanding the patient’s poor general 

carried out with even greater ease 
1^ 'hjt^t'tion of liaomorrlioids, since 110 spoeuluin is 

ilmi iTb “i’ w "‘f* 'css pain. Care 

it is to,,'" n f'’® prolapse after injection, and 

tho loos*" ^ i" " injections after 

noecssarv down, using a .speculum, if 

John A. C. M.vcF.wr.x, 

„ JI.B.. C.M., F.n.F.P.S.. 
oHrceon, Glasgow Royal Infirmary 
• and Glasgow Distiict Hospitals. 


Ix hepatic abscess. 

IV y -IJ ” reported by Drs. AV. A. Barnes and 

niiiy deservo°reeortog 

lnfumarv**on"l)iircmber* 28?h’ 'lol?®'”!* Lanensler 

Dockrny.^sufferb^Tom appendid?i'' ®- 

usual P^ramSan ®fn“fafon”'’Th'e'‘‘'nvr™','®'’ “PP®”,''’’' throiigli the 
a few davs and comnlnino/? ran a temperature for 

made an nneventful recov^n- *^^^cn5ion, but otliemise 

•A few d-ays after liw ?otnro T " ‘''"^■“rgea on Jam.ary 21st. 
called in and found bnr home Dr, Dockrav was again 

mdcfinite abdominal pain whidi'’finvn ® "m 'Torrent attacks of 
T^hcro was freoueni settled in the epigastrium. 

Her temperature ran»pd sometimes for liours. 

between M and ll “''3 “1° I'-. =>■''1 f’® P“'*® 

Februarv 4th, and it w.i.s 

After ‘admission she compWd ‘'’a''"' ■*" 

ness over the rir,ht Inbe nf localized pain and tender- 

appear to be enfareert Ti, bver, which, however, did not 
the .spleen w.a, normal; rholccvsHlfs abdominal distension and 
On February 8th I a^ain f suspected. _ _ _ 

on opening the npriionr,.™ operatea using Kocher’s incision, and 
abscess in tl e Ii?e^ sXsJk^rf i^traigl.t on to a single localized 
dense adhesions between Hie i.‘’e golf-ball. There were 

and transverse colon of the lircr and the stomach 

gall-bladder. ’ of any trouble in the 


Tlio pus Iiaving been evacuated, a rubber drainage tube and 
gauzo packing were inserted, and tho wound was closed. The 
palionl made an uninterrupted recovery and left hospital, feeling 
quito well, on Marcli 7tb. 

'\ViLLi.\3i George, M.B., Cli.B., 

IFonorary Surgeon, Royal Lancaster Infirmary. . 


Htports of Annettes. 

PORTAL CIRRHOSIS. 

At a meeting of the Section of Pathology of tho Royal 
Academy of Atedicine in Ireland on Alarcli 16tli, the 
prosident, Dr. T. T. 0’F.\nnEi.L, in the chair, Dr. A'. AI. 
Syxcf. read iiote.s on a case of portal cirrliosis, and Dr. J. 
L.mt- demonstrated the specimens. 

A woman, aged 56, was admitted to hospital in August, 1927, 
complaining of weakness and jaundice. She bad been operated- 
on two years previously for abdominal pain, and a small piece 
of liver had been removed for examination, the diagnosis being 
portal cirrhosis. The jaundice bad commenced in the previous 
February. On admission the patient was rather deeply jaundiced 
and wasted; the hepatic facies was absent, and there was no 
history of vomiting. Tbc liver extended two finger-breadths below 
llic costal arch, and was slightly irregular on the surface ; tlioro 
was sliglit ascites. The urine contained bile, and the van den Bergb 
test gave a strong direct positive reaction, which v«s slightly 
delayed ; the Wassermann reaction was negative. The spleen 
becaAne slightly enlarged, and superficial distended veins appeared 
reaching from the groins to the umbilicus; the ascites remained 
slight, and the jaundice deepened, but the tenmer^urc remained 
normal except for occasional rises to 99° or 100° F. Death occurred 
in December. Clinically tho case presented the appearance of tlie 
unclassified type of hepatic cirrhosis associated with enlarged 

*^TIic liver was slighllv atrophic, and when fixed weighed 40 oz. 
It had a well-dovclopetl “hobnail" appearance, and on section 
showed the typical appearance of a portal cirrhosis. Little fatty 
change was seen macroscopically, but the bver was deeplj bilo 
stained. Microscopical examination revealed the appearances 
commonlv fomid in an advanced portal ciitIioeis. Ill sections 
stained with Malloi-v’s aniline blue the reticulo-endothebal cells 
were clearlv seen, many of whicli contained bile. The spleen was 
slightly enlarged, and when fixed weighed 6 or. 

The PiiESiDEXT said that newly formed bile ducts were 
move conuuonly found in the otliei' tj'pes of cirrhosis than 
in portal cirrhosis, and he wondered why in this case there 
had been bile retention : lie had only met with it in one 
rase, and that of genuine alcoholism. He suggested that 
ill the iiresent instance the pigment had been picked up by 
the ICupffcr cells, and thought that it might he a dis- 
advantage to remove the spleen in these cases. 

Dr. A. R. Farsons said that this case seemed to combino 
the two tvpe.s of cirrhosi.s — namely, the biliary and portal 
.and he regarded it as more like a case of the fomier. 
It made the dilterontial diagnosis between these two types 
of cirrliosis still more difficult. 

Bacterial Agghdination. 

Dr. J. AA’. Bigger read a paper on recent work on 
bacterial agglutination. He first dealt with the discovery 
of the phenomenon of agglutination and some of the early 
oh.servations made on it. He explained Ehrlich’s views on 
the relation of agglutinin to agglutinogen, and pointed out 
the differences between major and minor agglutinogens 
as demonstrated by Castellaiii’s absorption technique. He 
then reviewed Smith and Reagh’s work on flagellar and 
somatic agglutinogens and agglutinins, and the discovery 
by Beyer mid Keagli that flagellar agglutinogen was therroo- 
liibiie.' Dr. Bigger’s paper was chiefly concerned with the 
discoverv by AA'eil and Felix of H and O types of ciiltnre, 
and the' investigation hv these workers, Sachs, Arkwright, 
Goyle, Bruce AA'hitc, a'nd others of the relation between 
the three types of culture (normal, smooth variant, and 
roimli variant) and the three agglutinogens (H, 0, and R). 
He'showed that the normal type had two agglutinogens: 
H (heat labile and flocculating) and 0 (heat stable and 
Kraiiulating) ; the smooth variant only had O agglutinogen. 
Slid the rough variant had a new heat-stable granulating 
aeMutinoeeii, K. Dr. Bigger next pointed out the impor- 
tance of Andrews’s discovery of tho alternation of cultures 
of certain bacteria, paiticii'larly tho Salmonella bacilli, as 
regards their H agglutinogens between the specific and 
group types. He concluded his paper with a consideration 
of Bruce AVUite’.s work on the antigenic constituents of the 
members of the Salmonella group. 


634 APMti 14 , 1928 ] 


REVIEWS. 


[ Tn* DRm« 
McdICIL J0UB5iA 


llcbkltjs. 


HOWA-RD KELLY’S " GYNECOLOaV.” 

The jirefaco to tho now woilc on G\jiiccoloij}i' l)y Professor 
HowAitD Kelly and a group of colleagues indicates that it 
is tlio swan song' of tho master whoso name it hears. It 
hegins, “ The day’s work is done, in the chiaroscuro of tho 
evening I pen my last lines,” and its closing words arc, 
“ My pleasant task is done; tho shadows fall well aslant my 
page; it is almost timo to draw tho curtains and turn 
on tho Groat Light. To boon companions and trax'ellors 
all — Vale!” A book that opens thus and boars tho 
imprimatur of a revered name cannot ho discussed as if 
it were ono of tho many medical treatises that oomc tip 
for notice aud soon pass out of mind. This contribution of 
Howard Kelly’s is of tho naturo of a review of his expe- 
rience in gynaecology by ono who has served in tho front 
lino while it advanced from where ho found it in tho 
eighties to tho much further forward position in which he 
loaves it fort}’ years on. In his own words, “ Kot often 
does a man have a chance to write two books on the same 
subject at an interval of a generation, especially after such 
notable changes as the gj’naecological field has witnes.sed.” 

If we were to try to give a goucral impression of this 
book we should describe it as an attempt to set out 
what has been done in tho author’s lifetimo in gynaecology, 
particularly America’s contribution aud the position 
reached by tho subject in the United States, with sugges- 
tions as to tho direction which its further progress in 
that country is likely to take. Though it is not all from 
his own pen, this book is of him and his school, and out 
of its forty-nine chapters the master is rosponsiblo for 
eighteen, and no other single collaborator for more than 
three of tho remainder; and throughout the work Ids 
influence is paramount. It covers tho realm of gynaecology 
and even transgresses its frontiers, at any late as marked 
out in this country, aud is made up of a series of essays 
or tracts on the modern aspects of the subject, ranging 
from its anatomy, physiology, and pathology through its 
various therapeutic methods to its relations with endo- 
crinology, psychiatry, and electrotherapy. Mention of some 
of tho chapter headings will best illustrato their essay-like 
character. There is one on “Peruterino tubal insufflation” 
(I. E. Rubin) and another on “ Sacral anaesthesia ” ; ono 
on “ Adenomyoma,” and another on “ Endometriomata.”' 
“ Protein therapy ” and “ Pneuraoperitoneal roentgeno- 
graphy ” have each a chapter, and two chapters of etpial 
length and both profusely illusti'ated aro given to hyster- 
ectomy — one by the abdominal and the other by tho vaginal 
I'oute. These examples will serve to show that .sjiaco is not 
allotted to the subjects solely because of their importance 
in g 3 naecology, but rather because of recent work or recent 
tendencies that have called for special attention. 

The series of four chapters devoted to prolapse and 
injuries of tho pelvic floor may be singled out for tho 
interesting review and beautiful illustrations they give of 
what surgery can do for these conditions. There is an 
anatomical chapter on the fascia and ligaments of tho 
pelvis, another on laceration of the perineum, and two 
covering “ cystocele and prolapsus ” and “ rectocole and 
enterocele.” The Mayo operation for prolapsus is 
advocated, together with excision of the pouch of Douglas, 
ill order to throw forwards ^ tho weight of the intestines 
ill the erect position and relievo the rectum and posterior 
vaginal wall. There is an interesting chapter on menstrua- 
tion, amenorrhoea, and dysmenorrhoea (Novak), in which 
tho tendency to pay too much attention to anatomical 
defects is deplored, and a plea put forward that more con- 
sideration should bo given to the study of physiologj- and 
tho causes of disorders of function. 

■The whole book is of very great interest to us on this 
side of the Atlantic for the picture it gives of differences 
in nractice and thought. Noteworthy fe.;itures are tho 
description of how a curetting may be done in the office ’> 
and without anaesthesia, the greater emphasis that is laid 
on auxiliary examinations— blood investi gations, basa l 


1 G 
K^w 


; uTTTTa V Tvollv MD Lli.D., and collaborators. 

'•vork a'ml' London? n. Appleton and Co.’ 1923. (Roy. 8vo, pp. -xx-xvl 


-1- 1043 : 767 figures, 12 plates. 50s. net.) 


metabolism estimations, and suchlike — and even tho 
much greater frequency in the United States of lumho- 
sacral strain, wljicli almost suggests that in that coiintiy 
Ihcro nnist ho some inherent weakness of that pelvic jonifc 
in its womenkind. Even tho variation in tcclmical 
language is striking, when wo read tliat dilatation and 
ciirettago is so common a procedure that “ it is commonlv 
docketed in our protocols simply under tho initials ‘ D.' 
and ' C.* ” In short, this work is certain of a welcome 
from Professor Howard Kelly’s British colleagues, not only 
hccausc it is his own review of tho work of himself and his 
co!liihorator.s, but for tho picture it gives of modern 
gynaecology as seen tlirougli the eyes of tho best minds 
in tho United States. 


PSYCHIATRY. 

Menial Disorders," by Dr. HuBEar J. Norjian, is an 
omiiicntly loadablo book. Tho author has departed from 
traditional (iroccduro by relegating to a later portion of 
tho book the ])sj'chological chapters which generally servo 
in most textbooks as an introduction to the study of mental 
disorders; but tho arrangement is probably a sound one, 
for by according priority of position to the descriptions of 
tlio actual mental disorders the author ensures that tho 
reader will approach tho more theoretical parts with added 

interest. , . t ui n j. 

'This book is divided into two sections. In tho hrst 
clinical aspects of psychiatiy are dealt with, followed by 
an account of disorders associated with constitutional 
instability. Nothing of importance seems to have been 
omitted, even where the descriptions err on the side ot 
iiiuluo brevitv. Tho chapters on disorders. a^ociated with 
tho psvchoncui'oscs call for moro comment. The classifica- 
■tion^f thopsvchonenroscs is a highly controversia subj^t, 
bM by excluding Freud’s elassifieat on altogether Dr 
N^-nian would seem to have carried li.s wish foi the 
nvoi^ico of controversy a little too far., Ho seems out of 
svinnathv with tho Freudian interpretation of hjsteiical 
sympatli) nuotes Rosanoff as saying that tho par- 

phenomena. q j j matter of comparatively 

in tho 0^ of hysterical mamfestations, 

This may bo so, but tho removal of tlm ^ho 

^ t tho^nmo thing ns radical cure of tho disease. The 

* t nf since devoted to a description of epilepsy and 
amoiiiit of s^t ^ ^ these chapters 

insmiit) ^^tical wisdom.^ Under tlio hoadmg o 

'‘tomX or associated disorders are grouped alcoho 
symptomn .. . mental disorders associated wti 

dtns s onT iMections, and those associated wiB. 
bodily system and with tho epochs of life, 

disease of ^ is satisfactory. In tho cliaptei 

TJio ac^mit gn on of we might perliaps have 

examples in fo,. establifhing a defence under 

fiillv stated. tiiG g ^ , , main formula is 

the M'Naghtcn ^’'^^"“/Xi'native Lfei.ee is, not quite 
accurately stated, This, however. 


curately stated, This,’ however. 

Dr. Norman before^!! 

a small “^^^ig^t’and practitioner, and the aiithoi s 
mended to the merit. Considerable expam 

[hftS Vould be advisable in any future editions. 

applied biochemistry 

-s -j 

— : .7 Norman, M.U-, Cli-U-E •. ,, ,, 


3 erow Steaaiiy, > : FTv^ - 

= in',’ordc«. .Bv ’(C’r. 8vo, I"’- 

.iml Glas. Edinburgh . E and s. = ^ 

+ 453 : 57 figures Withrow Horse, Fh.D. 51 .D 

» Appticil , co-operation of ; 270 55“"’' 

revised and reset w ib 8 vo, rl>- 


London 


April 14 , 19 - 8 ] 


NOTES ON BOOKS. 


635 


stuclent is n nioio or loss fixed quimtity, it is necessary to 
make a careful .selection so as to present to him or her only 
such portions of a special subject ns are definitely related 
to mcdicino as a whole. This general aim is to ho com- 
mended whole-heartedly, for biochemistry shows a tendency 
to develop as a specialized form of organic and physical 
chemistn- and thus to become less and less intelligible to 
the medical student. Professor Morse, who in tbo prepara- 
tion of this second edition has had the assistaneo of 
Ur. JosKi’ii IjOOXF.v, concentrated his attention on those 
problems of biochemistry which arc of importance in the 
practice of medicine, and all who teach biochemistry to 
medical students will find the volume of great value and 
interest. Its iierusal however, suggests certain doubts 
as to its suitability as a textbook of biochemistry for 
, medical students themselves, at ain- rate for those who 
study in this country. The first obvious objection is to its 
size, for it contains nearly one thousand pages. This is 
due in part to the fact that directions for practical work 
are included in the body of the book, where details of 
some hundreds of exercises arc given. In the second place, 
biochemistry has been interpreted in' a wide sense, for the 
first hundred pages deal chiefly with physical chemistry. 
Hence the volume is considerably larger than is required 
by tbo ordinary medical student in this coiintrj- who is 
studying biochemistry. 

The book is profusely illustrated; the illustrations vary 
in value, for some are of quite simple chemical apparatus. 
A series of portraits of tbo leaders of biochemistry in 
-\merica form an interesting feature of the book, but a 
somewhat curious effect is produced in places by the alter- 
nation of these, portraits with illustrations of individuals 
suffering from various forms of deficiency disease. The 
genoi'al impression obtained from reading the book is that 
it is distinctly difficult to follow tbo main lines of descrip- 
tion, partly because the text is broken up by descriptions 
of exercises and partly because the range of subjects dealt 
with has forced the authors to deal briefly with certain 
difficult points. This last feature is especially marked in 
the portion devoted to physical chemistry. 


MALIGNANT FEVERS IN CHILDREN. 

It is well known that side by side with mild or seve 
forms of various acute specific fevers there are malignai 
types which are terrible in their fatality, and yet gi' 
little or no iiost-mortc7n evidence as to how they differ fro 
tile ordinary forms of such diseases. Professor V. Hvtin: 
las collected a vast amount of clinical and pathologic 
imestigation in a volnino devoted to the malignant sy 
(lomo 111 diseases of childhood,'* in which ho endeavou 
0 deal with some of the problems of these curio 
maladies. It is especially in young children in hospitf 
a t lose malignant forms develop in the course of sin 
generalized diseases as typhoid fever, scarlet fevc 
ip 1 leiia, or in localized infections such as bronebit: 
enterq-cohtis, or eczema. The clinical manifestations 
ma ignanej appear to be various erythematous eru 
ons, i omiting, profound iieirous depression with sig 
do H disturbance, subnormal temperature, ai 
nml necropsy tbo blood is found to be da 

blnorl ' organs are in a state of congestion wi 

t enfiv “"‘1 f'^tty infiltration, but pre 

cliiiio^l "vf- ^ found to correspond with the curio 
w 1 ^™fn^ror Hutinel deals in some deti 

nifl ” n® if appears in tyijho 

he siiirio ■ fken in a particularly good secti' 

thiiil-Q +I 1 + + 1 '^ pathological and clinical experiences. I 
ill TOOT, ^ Pkeiiomenon of anaphylaxis plays a pa 
“ soii«:ti‘i. fi’at streptococcal infection in 

foniio patient niay ex]ilain some of the maligna 

in n M 'M * ,n* section the hygienic measures necessa 

“ provent the onset of t 

the niiK-'il- . 1 ” nro well discussed, since this 

Professni 't'? "inch such a fatal malady can be attache 
irofos soi Hut inel is well known as an exception^ 


I’.'iris : 'Masion'^e^^cin MalatUra ilc VEnfancc. Par V. Hi 

majoration.) C- 13^8. (JleO, pp + job. 32 fr. 


[ The BnmsH 
Medical Joubnax. 


observer, and tbose 300 pages of careful observations and 
cautious generalizations might well serve as a model for 
monographs of this typo. 


BLOOD GROUP DETERjMINATION. 

A sstiti. monograph by Dr. Schiff= on the technique of 
blood group determination gives in a most concise and 
businessliko manner all tbo facts that are known about 
blood groups, with clear instructions for their investigation. 
Blood grouping is now fully recognized to possess great 
importanco in relation not only to the therapeutics of 
blood transfusion, but also to anthropology and medico- 
legal work. There was need for a book such as this, in 
which tbo knowicdgo scattered in numerous periodicals is 
gathered together and made accessible. Wo are glad to 
noto that Dr. Sebiff does not regard as of much clinical 
importanco the bogies that have been raised from time 
to time in the shaiie of groups additional to tbo usual four. 
For clinical purposes be recommends a relatively simple and 
rapid method of group determination. More elaborate 
methods aro described for researchers and for medico-legal 
purposes; even tho investigation of dried blood is included. 
The text includes a number of diagrams, some in colours. 
We can sti'oiigly recommend the Avork to those avIjo are 
interested. 


KOTES ONBOOKS. 

Professor Ch. Achard has again collected his clinical lectures 
at the Hopital Beaujon for a third A’olume,® and the tAventy 
articles Avhich this book contains cover a Avide range of sub- 
jects. Two lectures are devoted to pernicious anaemia^ and 
some of the leases described have been carefully -chosen- to shoAv- 
how difficult- the diagnosis may be in tliis disease, and 
how cautiously results must be estimated. A very instructive 
lecture is on the development of tuberculosis -in the lungs of 
men aa*Iio had been gassed in the war. Whereas in the early 
days after the Avar phthisis Avas rare as a sequel to gassing, 
it is now becoming increasingly common. Hodgkin’s disease 
is AA’ell discussed, especially from the pathological point of 
vicAv, under the name of malignant granulomatosis. The last 
lecture in the present series, lioweA^er, is undoubtedly the best ; 
it is entitled “ Pharmaceutical specialties.” Professor Achard 
carefully weighs up the advantages and disadvantages of Avhat 
are called in this country ” proprietary preparations,” and he 
states deliberately that the harm they do outweighs the good. 
Tlie volume contains some very good radiograms and other illus- 
trations; it is Avell produced in the Avell-knoAvn *‘ paper cover ” 
style at a very moderate price. 

La Bases Plnjsiijues dc la BadiothCrapic^ (the physics of 
radiotherapy), by Jean Dtjbost, is one of a series of short 
treatises on electrotherapeutics and allied subjects Avhich are in 
course of publication under the direction of Dr. Duhern. It 
deals A'.'ith x rays only, and stress is laid upon the point that, 
Avhilst superficial x-ray therapy is comparatively simple, deep 
x-ray therapy is dangerous, and especially so unless the qualified 
radiologist Avho directs it is Avell up in the scientific side of 
radiotherapy. The matter it contains is divided up into six 
chapters. After introducing his subject in a first chapter of 
generalities, the author continues Avith chapters on the pro- 
duction and the absorption of x rays. Filters and filtration 
are next considered, and, following a chapter on transformei's, 
coils, and radiometry, and other methods of measuring the 
quantity of rays, the author concludes by contrasting super- 
ficial, deep, and semi-deep radiotherapy. It should be noted 
that the subject is approached entirely from the physicist’s 
point of view. 

The work on I{i/potcnsio7i^ by Dr. Alfred Friedlander, 
professor of medicine at the University of Cincinnati College of 
Medicine, forms A’olume xiii of Medicine Monographs, and is 
a reproduction in book form of the paper Avhich appeared in the 
May issue of MedichiCy and was abstracted in our Ejdtomc of 
October 1st, 1927 (para. 281). 

^ Die Tcchuik dcr liluttjriippcnuntersuchvug. A’on Dr. Fritz Scliifl. 
Berlin: J. Springer. (Extra Post 8vo, pp. vi 4-66; 28 figures. R.M.6.) 

* Clinique .Medtcalc de VHOpital hcaujon. Par Ch. Achard. Tr<iJ«it*me 
Serie. Paris: Jlasson et Cie. 1928. (lied. 8vo, pp. 324; 24 itgurc'^. 
32 fr, sans majoration.) 

^ Leg Bases Phqsiqurs dc la Badiotnvrapie. Par Jean Dubost. Les 
Actualites Plusiotherapiques, II. Paris: Gautier-A'illars ct Cie. 19C8. 
(Post 8vo, pp.'93; 50 figures. 10 fr.) 

^ Hupotension, By Alfred Friedlander. Medicine llonographs, A* ot. XTM. 
London Baillitre,' Tindall and Cox. 1927. (Roy. 8vo, pp. xvi -f 193. 
133. 6d. net.) 



636 ' April 14, 1928]' 


THE FKACTURE PEOBIiBM. 


• Tifc Bfimsa . . 
lUhtiiAL JoCIlHit 


Brttisl) iHctitcal JotirnaL 


SATURDAY, APRIL I'll!!, 1928. 


THE FRACTURE PROBLEJI. 

The discussion on the troatment of reconf fracUires 
by operation, -which was held in the Section of Ortho-' 
pnedics of the Royal Society of ]\Iedicin'c on April 3rd, 
once more ventilated a much ve.xed question. It was- 
ojiened by Dr. Charles Scudder of Boston, Massa- 
chusetts, who is one of the leading authorities, if not 
the very first authority, on the subject of fractures in- 
general. The treatment of fraelures Inis always been 
an important pai-t of surgery, although of late years 
it may have lost its attraction for some surgeons, 
whose interests have become locked np in the treat- 
ment of disease in the cavities of the body, and 
especially in the abdomen. It is to-day of gi-catcr 
importance than ever, and of growing importance, for, 
as we said when reviewing, the last edition of Dr. 
Seudder’s book on fractures,* the number of accidents 
involving injury to the skeleton has increased to an 
appalling total with the rapid increase of motor traflic, 
while such accidents occur, not, as in former times, 
mainly in the neiglibourhood of cities and well-equipped 
hospitals, but in all parts of the country, wherever 
there are roads and motor ears to run upon them. 

Dr. Scudder took a wide view of his subject, ns, 
indeed, his experience and his scientific training 
impelled him to do. On the whole, he was inclined 
to favour a more frequent resort to open operation and 
adjustment of simple fractures than has lately found 
favour in this country, although he frankly stated that 
there were certain types of recent fracture, such as 
those of the neck of the thigh bone, which he and his 
colleagues in the fracture service of the Massachusetts 
General Hospital did not at present consider suitable 
for operation. He was inclined to place exact 
anatomical correction of fractures first, and to esteem 
it as the best means of ensuring good functional 
results. Sir Robert Jones, who followed him in the 
discussion, was in favour of less radical measures, and 
set a good functional result as the ideal to be aimed 
at, no matter what the anatomical end-result might 
be. As one of the advantages of open operation and 
metallic fixation Dr. Scudder claims quicker healing 
and a shorter period of fixation. Sir. Hey Groves, Mr. 
Fairbank, and some other speakers took a contrary 
view, maintaining that m their experience repair was 
delayed -ivhen plates or bands or screws were used. 
Dr. Scudder ’s eloquent plea in favour of living bone 
tissue and its right to be treated as a sensitive growing 
01 "an of physiological importance, and not as the mere 
material of a mechanical framework, is, we think, 
better respected by the non-operative than by the 
platmg method of treatment. 

The differences of opinion among some of the most 
skilful and most e.xperienced surgeons as to the best 
method of treating any particular type of fracture are 
due not so much to personal idiosyncrasy as to lack of 
exact knowledge of results. If it could be shown autlio- 
ritatfvelv that a certain method was unquestionably 
the best, all surgeons would follow that method to the 
exclusion of others. In the United States and Canada 
the Fracture Committee of the American Medical 

— - ^ Britlth Medical Joxtnial, March 10th, 1928, p. 396. 


Association and the American College of Surgeons hna- 
laudably attempted to arrive at some such conclusion, 
but, as Dr. Scudder told his audience on April 3rd, 
their efforts were to a groat extent frustrated by (lie 
imperfection of the records, even those of hospitals 
classed as belonging to grade A. Until a similar 
inquiry has been made in this country it is not possible 
to state \rhethcr our records are more satisfactory or 
not. Dr. Sendder’s standard for a fracture specialist 
is a high one, and no doubt it is reached not only by 
hiinsJclf, l)ut by his colleague-s of the fracture service 
jof the iMassacIiusctts General Hospital. He rightly 
: postulated for such a surgeon wide and deep scientific 
knowledge and a delicacy of technique not less than 
that of an abdominal surgeon. He recognizes, ns we 
all do, that the first treatment must as a rule be given 
by a general practitioner, and that ns the quality of 
that treatment has a most important bearing on the 
' later progress of the case, it must be .appropriate and 
skilful. The definitive treatment should be under- 
taken by skilled specialists, who would use the be.st 
means available, whether these included open opera- 
tion, plating, or more conservative methods. Assum- 
ing .an adequate supply of -skilled general practitioners 
able to give proper early treatment, is the supply of 
specialises and surgical teams adequate? We agree 
with Mr. Cochrane that it is of no use issuing instruc- 
tions if the .skilled staff and organization which is 
necessary to cairy them out does not exist. In a 
recent annotation on some aspects of the matter- we 
once more directed attention to some of the crym^ 
heeds of fracture treatment m our hospitals. 

It is to be hoped that the important discussion that 
took place last week before the influeifrial pthenug 
1 * the ]3ni*nes Hall of tlie l^oyal foociet\ 

M Jdn 1 it migM 

of J- t, a ),int from our American 

and try to ascertain the results of 
Sre°it methods of treatment as practised through- 
mft ti e bS Empire. We' all know that good 
c 1 r.irfachieved by extension methods, by .massage 
"v ninubdion, bV followers of the teaching of 
and m. • • ^j,g' by open reposition, and by 

jii, W Dowden of Edinburgh has recorded 
^ rf^nw onnl results from a non-restrictive me hod 
good ,,es movement, eyen in compound frae- 

wbich li of deformity. Wc want to be 

turns and ^ f of the merits of this and eyeiy 

^;:^ne Sotog tbefr defects. To enable this 
e we need a set of criteria by which the 
to be ^.hat method to employ m anj 

surgeon imo iu substitute one means for 

given , ,g there is need of surgeons who 

anothei. skilled in the surgery of fraetmes, 

bid k^nly interested in this important work. 

■nvc;PHAGIA ASSOCIATED WITH ANAEMIA. 
DASPH domain of practical medicine ara 

Problems m tb complete solution, 

seldom capable to sections of so vast 

Wo.to, “elh ngr„Vk,„ rs* »'« 

and est**n"T, “ enlarging their horizon. From this 

only be possible 1^5 , 

point of yis" ,, -..Kiopf nf flvsnha"ia associated 

Medica] Journal on the ° ‘ renewed 

with anaemia iV'-^Llngs Since Brown Kelly and 

interest in its widei bearings. a,..-,-,,- nttcntion 

Person in -parafr. commuruca 1 ^ 

to it in 1919 tliis chnicaUypej)f^lspl^n_^ - 



Arniii i-i, 192*] 


DTSPHAGIA ASSOCIATED WITH ANAEMIA. 


E THsCnmsa 

USCICAZ. JOCSXAS 


637 


rccoivcd the notice it dcpon-es, nnd its discussion is 
still niainly confined to laryngologists. It may tliore- 
fore be opportune to give a short survey of some 
aspects of the problem. 

Its essential feature — a gradually increasing inability 
to swallow, occurring only in women — generally brings 
tbc patient under obseiwation about middle age, when 
she is no longer able to swallow more than liquid food. 
Little is known of its early phase, as the patient is 
rarely seen on the threshold of her difficulty, which 
is usually of long standing, and upon tliis point 
further obseiwations might well be forthcoming. Once 
established, though it may vary and be improved by 
passage of a bougie, it is rarely absent. The patient’s 
general state long remains good, nnd, learning to 
model her life by tbe limitation of “ a small swallow,” 
she is able to carry on domestic duties until a late 
stage. She is frequently edentulous. In most cases 
glossitis is present, and the atrophic change in the 
mucosa, extending to the buccal cavity, phni 7 nx, 
hypopharynx, and even to the upper part of the oeso- 
phagus, is limited to the food tract. Anaemia is a 
prominent symptom. Endoscopic examination reveals 
a characteristic departure from the normal. The 
rounded mucous folds of the deepest pari of the hypo- 
phatynx, which permit an oesophagoscopc to be passed 
with ease, are now thin tense bands that change 
direction or come into prominence as the tube seeks 
the opening. This is small and difficult to find, 
because it is often minute, even pinhole or a narrow 
slit. Once entered, however, it can be dilated to take 
a large-sized tube. The rigidity of the parts, retained 
even in deep anaesthesia, and the thinness of a mueosa 
verj' liable to crack, demand care to avoid making 
a false passage. 

Interpretation of these changes has called forth 
considerable discussion. Brown Kelly and Paterson 
regard them as primarily due to pharyngo-oesophageal 
spasm, .though it cannot be gainsaid that tbe altered 
Txrm**'' some extent emphasize the difficulty. 

■ 1 ' done much to clarify our 

• i*^J^T** relations of the lower pharynx 

unable to view it as an active con- 
nf j tlysphagia he looks upon as pharyngeal, 

a”*’’ “ ’"'oscular paresis coexisting with 

—.a...® of the mucosa and an impaired 

his may well be the explanation in cases 


reflex. 


■ V wc mu tiA Jiauaiiuii 111 uabcb 

pffnvf ^1'® endoscope to enter without much 

Tlio V perhaps belong to a different category. 
rplavatf^,f suggestion of Hurst, who sees in it non- 
rnnsfy'iM . the lowest part of the inferior 

viewq nii°fl’ ® harmony with his well-Imown 

be hard uatum of ” cardiospasm.” But it would 
coexistent ° Ti”*^inn^ spasm was at least not 
a bourne ’and’the’*f“n^ patients of passing 

v-hen ft is successfnl*^" 

Dr TTiivcf a significance of their own. 

achalasia of dhrcTrdh'?^ 

■ the against cardiospasm, and 

to have mn ®®i't'Cspondonce columns appears 

between hi « ^l^bate on this ^int 

Hiffiev ” if Brov-n Kelly, 
in thp TTi'ii'n anaemia has been regarded as 

Perhans fn ho of the haemoglobin content, 

food. Pomo by the enforced restriction of 

Kel'v’c! *5P°''*'iug lately on a group of Brown 

point of view’oHhe'^f * f 

tion to 1 noo P]^ysician, Hurst has dra^\'n atten- 
69 caspQ Dlunnner and Vinson, reporting 

sLudarv nnn flysphagia, of which 37 had 

recovered on "thf splenomegaly. The patients 

le, administration of iron and the passage 


of a bougie. There is no mention of glossitis. Careful 
examinations in this country had failed to note 
enlarged spleen, but Hurst himself has recently 
observed four cases. Further investigation of this 
aspect of the problem is clearly desirable. 

Finally, it is worth bearing in mind that malignant 
disease shows a strildng tendency in women to invoKe 
the. oral pharynx and hypopharynx, the area of the 
atrophic change in the mucosa, and this termination 
is no unusual event in the cases under consideration. 
In men, on the other hand, in whom this dvsphagia is 
never seen, cancer is more common in the tongue and 
lower oesophagus. This striking contrast in sex inci- 
dence suggests the taking of a wider view of the whole 
problem. We are far from having heard the last 
word, and there is clearly' a need here which begs for 
close co-operation between the larynsoloHist and the 
physician. 


THE PULPLESS TOOTH, 

In the -Toiirnal of Jilaicli 31st (p. 548) we gave an account 
of a discussion on the puljiless tooth at a joint meeting 
of the Sections of Odontology', Electro-Therapeutics, and 
Pathology of the Royal Society of Medicine; in an earlier 
issue (.Tannary 28th, p. 135) we repoi'tcd a paper hy 3Ir. 
Arthur Bnlleid on apical infection, read before tlio Odouto- 
logical Section of tlie same Society: and last week (p. 589) 
we published a paper by Mr. A. P. Bertwistle dealing with 
the same subject. Perusal of these communications shows 
that the pnlplcss tooth has no real friends. The doctor 
asks, “ What damage is it doing? ” while the dentist seeks 
on the one hand a means of sterilization, and on the othei: 
hand a reliable clinical answer to the question, “ Is it 
infecting the jratient? ” No one disputes its power for 
evil. Mr. Bertwistle gives an answer to the doctor’s quoi-y 
in a series of interesting cases which axe well worthy of 
study, and quotes Sir' William Willcox to show how pre- 
valent are “ rheumatic ” diseases due to pulpless tectli. 
There is a general agreement that the infecting agent 
is a streptococcus, but while the present confusion of 
nomenclature persists it is impossible to know wbetber 
Sircpfococcits salivarhts of one author is to be regarded 
as identical with Strepfococcus longits (non-baemolytic), 
or with Streptococcus longns rar. viridans of another, 
or wbetber there is a definite differentiation. This 
is a point we hope tbe Streptococcus Committee will 
soon clear up. Mr, Bertwistle gives “ tenderness on 
eating ” as tbe most trustworthy clinical sign that 
a pnlpless tooth is infecting tbe patient; but tbe 
experience of the dentist is that tenderness to pressure 
on tbe gum over tlie apex of tbe root is an even 
more delicate test than discomfort on biting or percussion, 
while there are cases in which not even this tenderness can 
be elicited. Radiography has not provided a fcdl answer; 
no lesion may be demonstrable by' a; rays, and yet the tooth 
may be infecting the patient. There is, indeed, consider- 
able controversy as to tbe meaning of tbe x-ray' appearances 
observed round the apices of dead teeth. A radiolucont 
periapical area fading away through a less radiolucent 
area to noimal hone has hitherto been regarded as a sign 
of open infection, and as showing a failure of local resist- 
ance. An area of sclerosed bone surrounding a radio- 
lucent area or .immediately' around the pnlplcss tooth has 
been regarded as at least a better bar to infection and as 
showing some power of local resistance. These vicus .are 
consomant with the generally accepted pathology of hone. 
They have, however, been vigorously challenged by Weston 
Price, This author concludes, as the result of both clinical 
and laboratory investigation into a large number of cases, 
that exactly' tbe reverse is tbe case: the sclerotic area 
betokens danger, the fading radiolucent area betokens 



638 Aprid T4, 1928] ' A SWEDISH SOCIAD EXPERIMENT IN TUBEROHEOSIS ■ f rur.rinm.m 

I 5 ( LMedicai. JoLnvii 


active rosislanco. However this way lie, Bulleid found 
goinis in every graniilonia lie examined (the radiolucent 
jieriapirni area is occupied cither, hj* a granuloma or by 
pus), and the not result is that any divergence from tho 
normal shown, by x rays must bo considered as a danger 
signal; and even normal ai-ray apjioaranccs arc not a 
guarantee of safety. On the question of tho sterilization 
of the pulpless tooth, tho combined discu.ssiou at the Royal 
Society of Medicine is very illuminating. Pulpicss tooth 
are divided into those alrcadj- dead and infected, and those 
whoso jndps tho dentist kills, and which, cx In/pothesi, are 
sterile qua the root canal. Tho first class may be sterilized, 
•more or less, mechanienlly and by tho ii.se of germicides; 
tho second class maj' bo brought to a successful issue by 
aseptic treatment througliout; but so insistent are the 
'dangers of infection in the work of dental surgery that no 
speaker, was found to claim permanent success for cither 
class. Pulpless teeth must always remain suspect. In the 
course of this discussion Dr. Murray Lovick, for the Section 
of Electro-Therapeutics, vividh’ described tho danger of 
applying ultra-violet raj-s to the mucoiis mombinnc, but 
reported good results from treatment of tho gums by red 
rays. Ionic medication was referred to by one speaker 
only — Mr. Morph}- (Section of Odontology). 'Whether, or 
under what conditions, an electric current can be passed 
through a devitalized tooth-i'oot is a cpiestion which might 
well occupy the Section of EIcctro-Tlierapcutics, and many 
dentists, wo undcr-stand, had Imped that an' answer would 
be forthcoming in this joint discussion. 


A SWEDISH SOCIAL EXPERIMENT IN TUBERCULOSIS. 
"While most tuberculosis workers Imow something about 
the Pramiiigham demonstration in tho United States of 
America, it is probable that few are familiar with a some- 
what similar experiment which was started in Sweden in 
1904, In that year tho then secrctai-j- of tho Swedish 
National Association against Tuberculosis, Dr. D. Bulirc, 
drew up a programme, according to part of which some 
poor parish, situated in a remote area with had communi- 
cations, inhabited by a comparatively stationary po|)ti1ntion, 
and afflicted with tuberculosis, was to bo chosen for demon- 
strating the effects of a carefully organized campaign 
against this disease. A cottage hospital was to be pro- 
vided, with accommodation not only for tuberculous 
patients, but also, in a separate part of the building, for 
children who were still quite healthy and who had been, 
removed from tuberculous surroundings in their own 
homes. A tubereulosis officer, assisted by a special staff 
of nurses, was to live in this parish, devoting his time to 
examining as many as possible of the inhabitants, and to 
helping them to lead healthier lives and to roar a new 
generation which sboidd be less afflicted by this disease. 
An account of this experiment has lately been publislicd in 
Acfa Tuhercvlosea Scandinnvica' by Dr. G. Neander, the 

■ present secretary-general of the Swedish National Associa- 
tion against Tuberculosis, and for many years resident 
tuberculosis officer in the parish in question. This parish 
is in the district of Neder-Luleii, in tho county of 
Norrbotten, in the extreme north of Sweden. A mani- 
festo was issued which stated the objects of tho experiment, 

• and the inhabitants of the parish were invited to sign it. 

■ The first tuberculosis officer was appointed in Januai-j-, 
1906 and his wholesale examination of .the inhabitants 
showed that TO.75 per cent, of the 1,498 persons examined 
were suffering from undoubted pulmonary tuberculosis, 
and ' 5.9 per cent, from suspicious signs of this disease. 
When, in March, 1908, Dr. Nea nder was appointed as 

* The Halsari " Institute in Korrhotten. An E.\periment. on the Lines 
of Social Hjcfii-ne in tlie Far Nortli of Sweden organized by the bwedisli 
National As&ociation against Tuberculosis, together with a Siuny on the 
nisseminaiion of Tuberculosis in Sweden. By Gustaf Keander, M.D. 
erum the Acta Tnberculusea Scandinavfca. Translated by Greville Grove. 
r-openhaBen : Levin and Jlunkssaard. 1928. (dj x 10, pp. 127 ; 20 figures.) 


tiihorcnlosis officer, ho proceeded to examine 1,652 of tha 
1,860 , inhahitants of tho parish, finding undoubted pul- 
monary Inberculosis in 10.23 per cent., and suspicious sign.? 
of this disease in 4 per cent. Several of these suspects 
being found to bo definitely tuborcnlous, the proportion of 
ca.scs of undoubted 2 iuImoiiaiy tuberculosis amounted to 
12 jier cent, of tho total poiiulation oxaniinod. In an 
additional 2 per cent, there were signs of surgical tuber- 
culosis. AVIiilo S[)aco docs not jjormit of oven a brief 
rcfcrenco to all the activities of this tuberculosis experi- 
ment or donipnstration, it should l>o noted that an inguiiy 
was simultaneously conducted into tho incidence of bovine, 
tuberculosis in the same jiarisb, and, though there were 
many o])])prtimitics for infection of the cattle by tuber- 
culous attendants, none of the 263 animals, belonging to 
. forty-two herds, gave a positive reaction to tuberculin. 
It would llicrcforc'scem that the tuberculosis from whieli 
the inlmbitnnts suffered was of human origin. In 
November, 1926, Dr. Neander again carried out a goneral 
inspection of the entire iropulation, 1,834 persons being 
o.vamined. The number of cases of pulmonary tuberculosis 
found in 1826 eorresponded to 8 per cent, of the total 
population, ns compared with 12 per cent, in 1908. • "With 
the addition of cases of surgical tuberculosis the total inci- 
dence of tuberculosis was 9.5 per cent, in .1926, as compared 
with 14 per cent, in 1908. A comparison of the tuber- 
culosis death rate for tlio two five-year periods 1911-15 
and 1921-25 showed that in tho whole county of 
Norrbotten there was a decrease of 11 per cent., in the 
whole of the district of Neder-Lulea it was only 0.5 jjer 
cent wliorens in tlio experimental area it was 28 per 
cent.’ Dr. Neander disclaims any intention to assert 
cateeoricallv tliat this decrease was the result of the demon- 
straUon, but he suggests that there are good reasons for 
nrosHining that it was the principal cause of this decrease; 
and it was achieved at comparatively little cost. 


the PRODUCTION. OF ALKALOIDS. 

T V Hr.Nity,' in a recent address to the Society of 
“oiiomio'Biologists, .pointed -to some curious unsolved 
■ohlcnis regarding alkaloids. The importniice of these 
:bst.Tiices to mankind is obvious, for as a people we <mn- 
nio them bv tho ton in ten, coffee, and tobacTO, thej 
nstilute our most valuable medicines, and their abuse 
the form' of roorphino and cocaine is a serious social 
oblbin-' ,'-Tlm first alkaloid to bo ' discovered-naraely 
binc-was isolated more than a hundred years ago and 
0^^1011 organic chemists have worked contmi.onsly at 
1 isolation and analysis of these substances Conse- 
aiitlv a large amount of exact knowledge has been 
rnitecd regarding alkaloids. Hundreds have been d.s- 
vcred niidUie' chemical constitution of the great niajoiit 

il>n determined, and finally tho synthesis of a coii- 
leraWe .miniber lias been achieved. Nevertheless no 
r 1 alkaloid lias so far been replaced comnierciallj y 

' ?nrvet claim to rival the plants in the efficiency of Ins 
"'iifacture of these chemicals. Moreover, the syn icsi 
tl ! ml important medicinal alkaloids, such as mo - 
• „l'nine and cocaine, has not yet been achieved, 
'T ^Tiiv simthetic product been discovered winch is » 
;; equivalent of any of those drugs. aiffimd 

~ f 

,V the' plant makes those valuable tl.e 

have heon advanced to account for the occurrence 
'ffllSctnS: (X) that they 

■tive agents; (2) th at they arc plastic pio duct^ 

° 1 . . e-fO IQ*??. 


639 


APRII. 

fov fuitlu'i- uso 1)y tlio (3) Uiat tlioy avo waslo 

pvdtlucts. Uo showed that iho fif-st view was imlonaWo, 
nnd that the balance of evidence was in favour of alkaloids 
hoiii" waste [nodnets. Ho nienlioned in sn()i)oit of this 
view the fact that alkaloids are not as a rule found in 
quantity in seats of active motahnlisin, such as the leaves, 
except in short-lived ])lants, where other means of storage 
are not availahle; hut that in i)orenninI plants the usual 
source of alkaloids is the liark or the seed coats. If this 
view is indeed correct, nnd alkaloids are only accidental 
waste products stored hy plants in any place where they are 
conveniently out of the way, then their intense and specific 
pharmacological actions hecome more mysterious than ever. 
The attcni[)fs to produce synthetic substitutes for natural 
alkaloids have been surprisingly Unsuccessful. For example, 
organic chemists and pharmacologists all over the world 
iiaVe tried to obtain substitutes for cocaine. Many 
vahiablo drugs have been discovered, hut none of those pro- 
duced is a’ full substitute for cocaine ns a local anaesthetic. 
The suggestion that these alkaloids, so hard to imitate, are 
riierely accidental waste inoducts tinges our disapi>oint- 
nients with humiliation. 


[■ Tnx Bnm'fH 
L MeDIC-II. JoraKJlI. 

stitiicutSj niay produce imdesirablo effects when taken i)i 
laigo doses over a long period. If the doses used for 
animals in tlio experiments are transferred directly on a 
basis of body weight to the human subject, very largo 
amoimts of cod-liver oil would have to he given to piudnco 
ill effects in babies. But, as Agcluhr rightly points out, 
ill the dog, for example, the actual maximum doses of 
drugs are often higher than in the human subject, and he 
quotes ono recent case of a prematnro infant which died 
when 4 months old, in which the characteristic changes were 
present in the heart following a daily administration of two 
teaspoonfiils of cod-liver oil. This is a largo dose at this 
agtj, but it is ono wliicli is not infrequently given by 
dUtliiisiasts, and, in view' of modera concentrated pirepara- 
tibns of tho vitamins of this oil, it seems neccssaiy to call 
attention to tho possibilities of harm from overdosago. The 
nn/dical practitioner is very likely to receive his information 
OiiHlicse vitamins from manufacturers’ pamphlets, where the 
Work of such iuvestigatoi-s as Agdiihr is not likely to receive 
mention. Tlie subject is of sufficient importance to warrant 
further investigation. 


■ POSSIBLE ■ DANGERS 'OF -COb-LIVEB OIL,' 


POSSIBLE DANGERS OF COD-LIVER OIL. 

Thk administration of emulsions of cod-livcr oil to even 
quite young babies is a very widrmircad practice at the 
present day almost throughout the Wc.stoni world. .Vt 
some iustitutions nud in some welfare centres almost every 
patient receives certain viLamins in this form, and it is 
generally, assumed that even if defuiito dcfic iciuy disease 
is absent the employment of cod-livcr oil is certainly 
piopbyinctic and can do no harm. During the past few 
years certain investigators have called attention to the 
po^ihlc dangers of cod-liver oil administration, and in tho 
Scandinavian medical journal Arid Pacdtnfrira a contro- 
versj- has hron in progress since 1926 hctwcon E. Agduhr 
and A. Hojor on tliis subject. In a I'ccent issue* the 
p' ^1.*. bis latest work and replies to tho criticisms 

of Hojer. Agduhr has shown tliat in animals on a basal 
t let cod-liver oil may produce a poisonous by-eft'cct hy 
pio ucing changes in tlio musculature of tho licart. Hojer 
maintained that those changes were due to overdosago 
.with vitamin A only when B and C wore deficient in the 
r*"'. -kgduhr, in reply, brings forward evidence to 

Slow lat iitamins B and C were well supplied in his 
experimental basal diet, and cites also some iK*w work on 
a is in which, with a basal diet of Iiay, oats, and 
in nips, eniiebed by *marniite and lemon juice, morplio- 
ogica an c ectro-cardiographic changes in the heart have 
of 1 to 5 c.cin. of cod-liver oil per 
0 ocj wciglit. He considers Hbjer’s fui’thcr criticisms 
some c G all, and concludes that the changes produced 
“’'•-b'-er oil have nothing to do with 
Si f “"b C vitamins, althongir the work is 

suscent^Tr - animals differ greatly in their 

also h ' ' ^ ^ 'e poisonous effects of cod-liver oil, and 

these cfr“"r ®bow a greater resistance to 

niontlis baling the summer than during the winter 
vit-niiiii a" problem of wiictJicr 

oia-iiiisii> ir iiause of these poisonous effects on the 
were L-ill a i ^ "fab by Takahaslii iu which animals 

nathele 1 ^ P°‘®‘a'o«s doses of hiosterin. Although the 
reS 1 completely identical w’ith 

timi ill tl changes in the heart and fatty degenera- 

vet it ; "'Cl produced by overdosage with cod-livcr oil, 
obsciTp 1^' ^be differeiico in the injuries 
sidor ihl • fjcmiter than can he explained hy the con- 
Taknlnoi concentrated doses of 'poison given in 

the vitani'if ‘^‘'^I’^a'inients. Agduhr believes, therefore, that 
o the oi l, together, possibly with other con- 

’■Ma Pa.dMrica, 1928, val. vii. fasc. 3-4. p. 289. 


WORLD POPULATION PROBLEMS. 

AIost of tho pressing social and economic questions of 
to-day are outgrowths from tho central problem of jiopnla- 
tion. In the sphere of domestic affairs housing and public 
liealth are notable examples, arising as they do from tho 
urbanisation which has more and more characterized our 
history for the past 150 years. In international affairs 
tho old concoption of foreign policy as being primarily 
concerned with prestige and territorial sovereignty no 
longer ohsciires the fact that commercial treaties, tariff 
barrioi'S, nnd migration policies are tho things that matter. 
Standards ' of living, adequacy of employment, social 
sei-vices, and public health are tlie criteria hy which a 
nation is now judged, rather than tho extent of its 
icalms or tlie mugnifieeiice of its ruler. TTar is threatened 
or waged not for the dignity of a king, hut to secure 
outlets for the cnergj' of a pcojilc. Tho Disraelian division 
of England into “ two worlds ” inaj- be applied to the 
whole globe. Tliere are rich countries which have 'an 
adequate poinilation and a superfluity of material wcaUh. 
There are poor countries in which, with over-population, 
hunger is a normal circumstance and famine an ever- 
present danger; in them housing is poor, tho public health 
organization insufficient or absent, and disease widespread. 
There is no need to emphasize the dangerous instability 
that must arise irhen such sharply contrasting circum- 
stances exist in a world in which improved communications, 
the free exchange of knowledge and news, and closer trade 
relations are m.aking isolationist national policies impossible. 
There is at least tho appearance of inequitj', and this becomes 
a peril when, as in these present times, tho “ have nots ” 
are conscious of the sharp differences between their position 
and that of the “ haves.” International problems of this 
nature are unfortunately often left to the frothy senti- 
mentalists or to the hard-headed ‘‘ jiractioal ” people who 
over-simplify the problem, confine themselves to the more 
obvious Tacts, and shirk the study of causes. Something 
lias, however, been done to provide a rational scientific 
basis for discussion, and a valuable collection of material 
for study is now availahle in the Proceedintjs of the 11 orUl 
Population Conference,' which contains reports of papeix 
read at Geneva last summer. Sir Bernard Alallct, formerly 
Registrar-General for England and kVales, presided, and 
the conference included representatives (in tho iinotficial 
sense) of every important country and almost every branch 
of science. Ono of the aims of the conference was to bring 
the sociologists more into toucli with the biologists, thus 

' Proceedings of the. World poimlotion Con/rrmce. Edited hy TUrr. 
Margaret Sanger. I^ndon : E. Arnold and Co. 1S27. (Jlcd. 8vo, p’p. 3^; 
i plate.' 203. net.) 





ArniL 3^, 1928] 


ENGLAND AND WALES. 


[ Tirz Eritish 
ITedicai. JocB.VAi 


641 


in tlio citv. In 1904 ho 3vas olccloil lo the ' Edinburgh 
Town Coiinci!, and in 1909 ho was appointed to tlio board 
of inanagcinciit of tho CoUogo of Art. After 1910 bo 
heoaine treasurer of tho Citv of Edinlriii-gli, and held this 
post for several years. Since tho introdnotion of tho 
jiational heaUh insuraiieo sehcnio ho has tahun a very active 
part in its administration in Scotland. 

Presentation to Dr. James Crocket. 

Dr. James Crocket, who has retired from tho post of 
medical superintendent of- tho Consnniptioir Sanalorinin of 
Scothind, Bridge of IVciv, was on March 31st presented 
with a testimonial. In acknowledging tho gift ho said that 
tnhercnlosis, so far as Scotland was concerned, scenred to 
bo a disappearing disease; ho heiioved that in little more 
than a generation it would ho a factor of relatively minor 
iniportanco in tho lifo of the nation, and would prohably 
bo as rare as t\-phus, leprosy, sni_all-p»x, or plague. Between 
1912 and 1S26 there had been a fall of 43 per cent, in tho 
death rate from this disease. Tlio climate of Scotland was 
often wrongly blamed for tuberculosis, hv\t while in 1926 
its death rato in Scotland had been 99 per 100,000, in 
Paris it was 301, in Madrid 293, in ^Innila 541, in Sofia 
577, and in thirty Swiss cities 137. It was indeed some- 
what difficult nou’ to find a country ivlicro the death rato 
Iiom this disease was lower, than in Scotland. Other 
climates might bo pleasanter, hut few countries were 
healthier. With logard to tlio efficiency of treatment, in 
1912 the Bridge of Weir Sauntorinin had discharged 3 per 
cent, with tho disease ajiparcntly arrested, 63 per cent, 
improved, while 34 per cent, wore not improved or died. 
Compared with this, in 1926 40 per cent, of those dis- 
chaigod had tho disease arrested, 34 per cent, wore 
mipror^, and 26 per cent, wore not improved or died. 
Xhis might ho duo either to tho fact that tlicy were now 
dealing with a more hopeful ty^io of tho discascj or bccanso 
e diMasc was changing its cliaracter and hceoming more 
ameiiahle to treatment. Tuberculosis was an index of social 
wi. ibo death rate was 

legislation had done more to bring about 
uVeHirii anything contributed by 

wniilJ T... * I'figislatiyo measures in this direction 

p ore im estmeiits with great capital appreciation. 


atti Halts. 


At 


1 „ Research by Medical Women. 

Women’s London , Association of Mec 

the Brit, 27tb, at the Hous. 
Bolton fin Association, with Miss Ehza 

nave on in the chair. Miss M. ChadI 

Hesearch work undertaken by the Ca 

special formation in 1925, ' 

at the Bnv-)) 'w Ii'eatment of uterine cai 

for Women %l .South London Hos] 

the Ner ^‘‘?abetli Garrett Anderson Hospital, 

Dr. Hurdon^* ^''^omen, in co-operation 

most nart in concentrating the work for 

apparLt Tt *)"a was becoming more and i 

auffieeat’firS es^™aied th.nt £10,000 w. 

A-ears rarlim 1 Di. Huidon said that during the last 
tl.c tVattntofi “''S<'- the place of, surgew 

dosavn wi= „ ‘ Cancel occurring in accessible situati 

part°atlenuato standardized, and for the i 

iaJf of t?iP Unfortmijitely move i 

was alresdv'^inrf'^^^ presented themselves when the gre 
aimptom's had firsT 1° wine months £ 

treated bv n noticed.' In the series of < 

tion onlv cw’wnttee of the "Women’s Medical Pec 

operable when first s 
holm Ind' iJl ° technique used by Heyinan of Si 
over W cw t’® ''"hole his re: 

Manv Chnfinont better than those of oil 

Praiico and clinics used this tcciinique thong] 

favoured Itegaud seemed to be , 

final outcome of ^‘“'b'J'ct to make any claims for 

obseiwation Of t*® cases under Dr. Hurc 

October ' lo'pi; „ , Patients who started treatment beti 
L x-25, and March, 1S28, there were 169 ease 


cancer of the cervix, 15 of cancer of the body, and 4 of 
cancer of the vagina or vulva. In March, 1928, 70 per 
cent, of these patients were still alive. Of those who were 
opcrablo over 95 per cent, were living niul were free from 
symptoms. Certain complications might occur after radium 
treatment, such as fistulac, rectal ulcer, or pain, tenesmus, 
and the passage of blood or mucus. These complications 
were happily rare; for example, fistulae attributable to 
radium had occurred in only two cases in the series under 
discussion. The following up of patients was most impor- 
tant; though it was very difficult to trace them, especially 
in- London, only two bad been lost sight of. Dr. Helen 
Cliambor,s pointed out that the most suitable technique 
could only be determined after many years of trial, but the 
work of Professor S. Russ on experimental animals had 
'be.en most helpful. He had inserted tubes of radium and 
then excised a piece of the tumour after varying intervals, 
testing the viability of the piortion excised by transplanting 
it into another animal; in this way the range of effect, 
wlitoh was tho most important factor, could be esfimafed. 
Dr. Chambers showed diagrams of the various metliods used 
in different clinics, explaining that the method of inserting 
a tube into the cervix without placing other tubes in tho 
vault of tho vagina was ineffective. She emphasized tho 
importance of distributing the tubes in view of the fact 
that tho range of effect did not exceed half an inch. Soft 
rays bad low penetrating power and caused local sloughing; 
hence the need for screening. The ideal aimed at was the 
disappearance of the growth ivith the minimum damage to 
healthy tissues ; gamma rays appeared to be the most useful • 
agent for this purpose. Professor Louise Mcllroy con- 
gratulated the association on the first piece of organized 
research undertaken by medical women as a group. She 
commented on the fact that patients in early stages often 
omitted to report their symptoms, which might be very 
slight — perhaps a little haemorrhage and no pain, even 
when tho growth had reached the inoperable stage. For 
the last two years she had ceased to operate on cases of 
cancer of tho cervix, and was using radium instead, with 
what appeared so far to be excellent results. It was 
important to disseminate the knowledge that non-operative ’ 
treatment’ w-as available, since this might lead patients 
I to seek advice earlier. Miss G. Dearnley said that the 
impi-ovement in general liealth after radiotherapy was 
1 impressive. She had removed one uterus after treatment, 

I and no trace of growth could be found even microscopically. 
Miss L. Martindale remarked that more beds were urgently 
lequired. It was often difficult to find i-oom for patients 
to return to hospital for the requisite three doses. 

Hallam Hospital, West Brom-wich. 

I Some interesting references to recent developments in tho ' 
j hospital system were made at West . Bromwich on the 
1 occasion of the formal opening, on March 30th, of tho new 
administrativo block, x-ray department, and nurses’ home 
at the Hallam Hospitahby Sir "William Willcox. The .re- 
organization and reconstruction of the hospital, which is 
controlled by the AYest Bromwich Board of Guardians, has 
been in progress since 1925, when the old workiiouse infir- 
mary was renamed and became, by consent of the Ministiy 
of Health, a self-contained institution. The Rev, J. 
Scarlett, clinirman of the guardians, who presided at the 
opening ceremony, described tho changes which had been 
brought about in modernizing the buildings and equipment, 
and in securing the services of a visiting medical staff, of 
whom the members of the hoard were proud. Hallam , 
Hospital, he "said, was hot intended in any way to enter 
into competition with the voluntary hospitals, which he 
hoped would never die, hut tho guardians were compelled ' 
to make provision for cases for which 110 accommodation 
could be found in the voluntary hospitals. Sir "William 
"Willcox congratulated the guardians on their broad-minded 
policy, saying they had done something which would occupy 
the attention of the country, the Government, and the 
nation as a whole. They had set a fine example to the 
governing bodies of similar institutions, and he anticipated 
that Avhat" had - been done in "West Bromwich would he 
lollon-c'd hy a similar advance in hospital reorganization 
thronehont the country. Tho hospital was run on lines 
exactly parallel with the most advanced of modern voluntary 
hospitals. Sir William JYihco^: further expressed the view 


642 April 14 , 1928 ] 


CORRESPONDENCE. 


f . . f' TfiEUnm^a 
' ■ iMrwcAi. JocBsu. 


tliat thoro was great need and ninplo room for both 
municipal and voluntai'y hospitals; ho did not holiovo muni- 
cipal hospitals should ho in anyway siihseiTiont to, or in any 
way loss efficiont than, voluntary hospitals. JIo concluded 
hy pointing out tho value of the Hallam llo.spilal as a 
centre of medical education and research. Dr. Douglas 
Stanley, visiting physician, referred to the extraordinary 
wholehearted co-oporation tho medical staff had received 
from the committco and hoard rcsi)onsihlo for the ho.spitnl. 
Tho committoo had given tho staff almost evorythiug they 
required. A vote of thanks 'to Sir William AVillcox was 
moved hy the Jlayor of AVest Bromwich and secoiuh'd hj- 
tho Mayor of AA'edneshury. Figures quoted in tho .souvenir 
booklet issued at the opening ceremony dcinoii.strate the 
increasing use which has been made of the facilitie.s 
offered hj- tho hospital. The number of palieiit.s admitted 
rose from 2,304 in 1926 to 2,963 in 1927, and the nuinher 
of operations performed from 120 in 1925 to 690 in 1926 'and 
924 in 1927. 

Coroners’ Inquests in London In 1927. 

The luimher of deaths lejioi'ted to London coroners in 
1927 was 7,478, as against 6,934 in the prcviou.s year, hut 
only 4,442 inquests wore licld, .as against 5,143 in 1926. 
Of the inquests 82 jicr cent, necessitated posl-mortcm 
examinations. A verdict of murder was returned in 21 
cases, of manslaughter in 6, of suicide in 611 — an incrca.se 
of 11 on the figure for tho iirevious year. Four inque.sts 
were held in connexion with e.xccutions. Deaths from want 
of attention at birth decreased from 57 to 27. Tlio number 
.of people who met their death h}- accident was 1,916, as 
again.st 1,760 in 1926. Injuries accounted for 22 dcath.s, 
and tlieie were 60 deaths hy drowning, as compared with 
50 in the previous year. A verdict of “ death from 
natural causes ” was returned in 1,610 cases, and there 
were 27 verdicts of “ cause of death unknown.” TJie 
inquests on newly horn children decreased from 146 to 108 
(61 males, 47 females) ; thei o were 7 verdicts of murder 
of the newly horn, and in 35 cases it was decided that the 
child was stillborn. Excessive drinking accounted for 30 
deaths, an increase of 2 over tho previous year. Tho total 
cost to the London County Council of inquiries made hy 
coroners and of inquests held in 1927 was £31,44^. 


Carmpoti&cttcc, 


STREPTOCOCCI AND. PDERPERAL SEPSIS. 

Sill, — The recent letter to tho Times, supporting the 
view that real research work into tho origin, etc;, of 
puerperal septicaemia is required, calls for the support of 
all workers on the subject. 

In some recent work on antiseptics which we have been 
conducting in this laboratory one aspect of this question 
has been emphasized. The usual standard for antiseptics is 
the Ridcal-AValker tost, or a modification of it, using the 
B. fi/pliostis as the standard organism. In our work we 
have shown that the action on different organisms, and 
different strains of the same organism, varies in a marked 
degree, and that an antiseptic which may be efficieiil for 
B. typhosus may he quite inefficiont for other organisms. 

Garrod’ showed that this selective action was marked in 
experiments with B. c'oli and streptococci in faeces. Our 
experiments have borne out these eonclusions. To take 
ono example only: lysol, which is largely used in obstetric 
work, is almost ineffective in its action on some strains of 
streptococci, taking fifteen minutes to kill in a dilution of 
1 in 100 in ordinary saliile or distilled water, whereas in 
albuminous fluids the lethal power is considerably reduced. 


— I am, etc., 


J. 


Bacteriological 

University 


Department, Citv Laboratories and 
School of Hygiene, Liverpool, 
April 7th. 


M. Beattie, 


R\DIATED EHGOSTEROL AS A DRESSING 
FOR AVOUNDS. 

Sir, — -In continuation of my note. ’ On irri^iated 
orgosterol as a dressing for wounds,” published in the British 
Medical Journal of March 3rd (p. 559), I h.ave endeavoured, 

— •*X«. P. Garrod, Britteh Sledtcal Journal, February 27tb, 1926, p. 367. 


with jMr. F. .A'oung’s help, to ascertain whether any g.iin in 
weight oecm'.s wlien orgosterol is irradiated. 

The Kjjrct of Itudmtion.—X film of orgosterol, 15 to 16 mg., 
tbinl,' spre.-u] on a glass plate, 65 sq. cm. in area, was weighed 
before and after c.iposurc to tlie ultra-violet rays from a mercurv 
vapour lamp at a distance of 14 in. for forty minutes. The gain 
in weight of such a film after radiation was .about 7 per cent. A 
eorresponding cholesterol film, radiated in the same way, showed 
very little gain. 

The Kjjcct of Ozonhttiion , — ^An orgosterol film wa.s also exposed 
to ozonized air nt room temperature for four liours. Tiie gain in 
weight after ozonizalion was about 7 to 10 per cent. — that is, 
laitlicr more than the gain which follov.-s radiation. A correspond- 
ing cholesterol film, after ozonization, under similar conditions, 
showed* only a slight gain, which svas slightly increased by a 
second ozonization. 

Thus .a marked difference in tho capacity rapidly to absorb 
ozone is cliaracteristic of tho two different sterols. In tho 
<-ase of orgosterol a saturation point seems to he reached after 
radiation for from thirty to forty-five minutes, depending 
on the thickness of tho film and the activity of the lamp. 
Further radiation under the conditions mentioned above 
gives very little additional increase in weight. Tins satura- 
tion point is reached le-ss quickly on ozonization than on 
radiation, and a slight gain may be recorded on a second 

ozonization. . , , r v „„ 

A’erv little loss in the weight gained has so far been 
noticed in the treated films after exposnre'to the air at 
room temperature in cither case. This means that the 
adsorbed or added oxj-gen is not released at any appreciable 
Rlicod under such conditions. A chemical examination with 
t he starch potassium iodide colour test, previously described, 
\ ihat the capacity for oxidizing potassium iodide is 

.S ffi eiin woWlf wi,i.u Wl.., I..U. 

Inve rtabli hed tho fact that the formation of vitamin D 
hnio t, of amj the absence of, oxygon. It 

occurs • tbaf ns ' Dr. Rosenheim has . 

seems oxidation of the potassium iodide Ah 

suggested to \’ * *: %„(, to a peroxide (or ozonulo) 
Ihe starch colour test is due J^o^ ^ 

:o"d’ iiffo 

^ i^d 

•■'."'I, trtrented suggests that some relatioiislup docs o^^st 
similnrl> tientcu, & cb oxide formation and the 

between tho ‘/XnX D. This difference 

capacity for on a difference in the structural 

in bchavionr.mnst 1 AVhether the formation of 

constitution of ^ preliminary or, as seems more 

the peroxide 1^ merolv a side reaction in the 

the optimum 

process of vitamm - ■ - - ' 

onditions may be 


U formation, auu 1 . , 

for obtaining the maximum yield of 


conditions u - 

-^a-d ’^i:;s;;r;r'on wounds 
that the action a„sp,.ihpd. may be due 


tions, that the " f ’^Xnsiy described, may be due 
aiul granulating sui fare ,1 eigosterol rather than to 

•t? *■'? poin“ ^ opens up important pos- 

Lciccsler. 24t>'- ^ 

■ . , ■ gall-bladder INFECTION^ 

Sin,— If ■“t^r's'igns .^d* "symptoms of chronic, recur- 

ilinically show tlie " 11-bladder, then I feel t 

rent Lur issme of March. 24th (p. 481), has 

Professor AA ilkie. in J » ^ bacteriological side 

nite aeon^ , ,,rios. of oases -n 

jf-tlio mattci wliei j ^ prmiaiw mtra 

the great organisms of the coh-. 

mural infection as secondary invaders, 

typhoid group streptococcal infection is not 

That low-grade doubt. Having recently 

uncommon ram-'an’rbartSogicaHy some sixty 

ixaminod iiiatologiea ly and bamei jpe 

, ,”1^“;. .von V ,»< 

Sb-i ‘IK b,. In ol.bi 



ApRIIj Ml *9^^] 


COKRESPONDENCE. 


E Th£ BbitiOT 

llEDICAl, JOCRKAI 


643 


niiiieaml to bo streptococci could bo scon in the walls: 
ill four of tbeso positive streptococcal cultures wero 
obtained, and tbc histological appearances of the remainder 
were similar, altbough no organisms could bo grown. 

On tho oflier band, my series contains also nineteen 
cases in wbicli the gall-bladdor wall, particularly tlie 
mucosa and tlio tissue subjacent to it, showed chronic 


inllammatory changes, possibly a little moro active than 
those associated with a very chronic intramural infection, 
hut entirely without histological evidence of old pre- 
liminary bacterial invasion deep in tho wall. From these 
nineteen gall-bladders organisms of tho coli-typhoid group 
were readily grown, two of them giving typical pure 
cultures of 11. iijiihosns. It seems to he quite clear that 
intramural streptococcal cholecystitis is more common than 
was formerly realised, hut 1 do not think that this fact 
provides a reason for describing as uncommon the typo of 
case long recognized ns duo to direct primary infection of 
the gall-bladder and its contents by organisms of the coli- 
typhoid group, which may rcacli tho bilini'y tracts via the 
blood stream and liver. Ascending infection of the bile 
ducts may on occ.ision occur, though tho finding of eoliform 
organisms, especially in the gall-bladder bile obtained by 
duodenal intubation, does not, of course, give anv indica- 
tion as to the origin of the infection, but simply shows 
its presence. Nevertheless, tho material obtainable by 
duodenal intubation in tho two types of cholecystitis is 
s nkingly different, and may tlicroforo help the decision as 
to whether biliary antiseptics and biliai-j- drainage will be 
ene cial or whether surgery should bo resorted to at once. 

^ 'ntranniral streptococcal typo of cholocvstitis 
no ling abnormal is found in the bile unless the process 
oi.J foimation has begun, in which case fragmentary 
cholesterol crystals aro quite common. In the coli-typhoid 
1 . ^ o'dy contains tho infecting organism, 

from tho biharv tracts, 
P'gH'ont, and sometimes a few leuco- 
t!nno n-o-o jncidenco of tho purely intramural infcc- 

of clirnnln ^ patieiits sliowing clinical evidence 

suircpsti! pn ®at'on of tho gall-bladder as Professor AVilkie 
improvement 77/ 'I 77’ ^ ^o frequently see obvious 

hexainino n-i .^7 * '® Rilministration of large doses of 

bladder and tlrn mucosfH am^tc® 
l-»doa,.s.W.,.,pduni.- .■ ' F.A.Ksorr. 


Sir James Barr, in this month’s Practitioner, rejects the 
use of oxygen in the treatment of pneumonia. He is right; 
it is a most expensive expedient, and I have never seen it 
of the least use. The need for it arises frequently from 
a distended right heart, and the right treatment is blood- 
letting. I have known tho most remarkable results follow 
tho latter expedient, whereas I have never seen oxygen 
give moro than a very temporary relief. Dr. Maidlow advo- 
cates in tho treatment of pneumonia many small remedies 
ivhich certainly would add greatly to tho comfort of the 
patient. In this connexion, except in the most debilitated 
patients, I recommend the use of a commode and not a 
bedpan; the latter always induces straining and unnecessary 
exertion, whereas tho former causes a freer movement of the 
bowels, saves much discomfort, and is more cleanly. It is 
extraordinary how many complaints will yield to simple 
and common-sense remedies and healthy surroundings 
without resorting to the innumerable vaccines and serums 
and tho hundred-and-ono nauseous drugs, which generally 
do more harm than good. Our profession, through the 
recommendations of chemists, is rapidly losing touch with 
the writings and textbooks of our best authorities, and 
is getting under the spell of the treatment of every variety 
of diseased conditions by nen" vaccines and serums. 

Dr. McCormick (March 3rd, p. 376) thinks that Dr. 
'Ataidlow’s letter breathes the spirit of a bygone age. It 
does nothing of tho kind; it mentions facts, not theories, 
and gives good reasons for tlie opinion lie expresses. Tho 
physicians in tho past gained their knowledge mainly from 
clinical research and experience. The young physicians of 
to-daj' base most of their opinions not at all upon clinical 
facts, but on x-ray ohseiTations and the reports of various 
bacteriological authorities and chemists. Di the same issue 
Dr. Robert Hutchison writes (p. 335) : 

" It may be doubted whether ordinary bedside observation of 
I tho signs of disease is as good now as it-was a generation or two 
ago. . . . There is, I believe, a real danger lest the increased use 
of laboratory tests, x-ray examinations, and other short cuts to 
diagnosis should lead to a neglect of tho information to be obtained 
by the skilful use of the unaided senses, and to a comparativS 
atrophy of these from disuse.” 

This is exactly what is taking place in tho training and 
education of our young surgeons and physicians; they aro 
being taught to rely too completely on the extraneous aids 
to diagnosis without closely examining the clinical features 
of disease; upon which all accurate information should he 
based in tho first instance. — -I am, etc., 

Omagh, March, 1928 . EnWABD TnOMTSOX, F.R.C.S.I. 


qrn acute PNEUMONIA. 

Moidl’ > 1 *4^ '^7 ’'’^h much interest and pleasure Dr, 
tfcal nth, p. 238). It 7as so prac 

rnmmi.n; +' scnsG, und so different from raauj 

all ^Rggfisting, often without sufficient trial, 

too oftnr,” 1-7" for various diseases, which onlj 

fession wl, ' 't G‘'®Rt bulk of the medical pro- 

exnei ipn(.r>°h "iu have had a very long and variet 

outcoiTTo t u “’®P'tRl and private practice, and tin 
as Dr Afol u .7'^ practical investigation is much the same 
results ’ '^i^RPPoiutment, especially at the 

treatment by the new methods of drug 

a cure witl " ^ ™8jorit}- of such cases Nature will effect 
0ba7c7 am assistance if only given a fail 

rienceci ‘physic/a^''" ”wr7 “ 

Natnrf>»c nffri a 've find in practice is tlial 

by the ton f interfered with and destroyed 

zealous ’ apeated examinations, and over 

to foilrpt medical attendant. Doctors seen 

maiorln- ,'7 Paaamonia is a specific fever in the greal 
ciiio itself I with a local manifestation, and wil 

not iimlnl,'. • 7 ''’'’7'marked crisis in eight or nine days ii 
pueumonm "ith. .Nature’s method of treatinj 

which n-ill O® “PP'md to numberless other ailments 

and i favourably if only left alon, 

read of no! ' ^n nearly every- medical journal wi 

vienceil nl,'- f^ffi^^^miis and new remedies, which the expo 
the hieliost” notes, but disregards, unless hacked hi 


THE NEW PORTRAIT OF JOHN HUNTER. 

,SiK, — The incomparable Oliver Goldsmith represents 
George Primrose, the eldest son of tho Vicar of 
Wakefield, as asking his art-dealing cousin how to become 
a “ cognoscento.” Nothing more easy, says, the cousin; 
first of all, you must always find fault. 

This wonderful new portrait of Hunter is the most 
interesting we possess, for it shows him exactly as he lived 
and lectured, wart and all (pace the shade of Oliver 
Cromiyell). But it has had’ to fight a hard battle ever 
since it appeared upon the wall of Christie’s saleroom. 
At fii-st the cognoscenti said it did not represent John 
Hunter; this denial has, however, been blown to the winds; 
and now Mr. C. F. Beadles comes forward and asserts that 
the painting is not by Gainsborough, and tliat its late 
owner, Mr. AlcCormick, “ did not consider if worthy to he 
tahetled as hij that artist." I am sorry, for Mr. Beadle’s 
sake, to have to state very plainly that this is an absolute 
misstatement of fact. On my table, as I write, is a M-inch 
label which was screwed on to the frame when the picture 
was put up to auction : 

“ John Hunter, F.E.S., 1728-1793. Physiologist and Surgeon. By 
Thomas Gainsborough, R.A., b. A727, d. 1788. (British School.) ’ 

Mr. Martin alone knows why no notice was taken in 
Christie’s catalogue of this tablet, and why tho picture is 
there attributed to “ Seton,” a name which, of course, 
conveyed nothing to me. It now appears that this 
cabalistic word meant “ John Thomas Seaton.” It is, 
however, "a pure siiiTnise to attribute tho portrait to this 
artist. To siqiport his nil admirari attitude Mr. Beadles 
instances the neglect of the picture at the sale by the 



644 April 14, 192S] 


V 


COBEESPOND33NOE. 


Tnr BnmsH 
Medical JocBKAi. 


expert dealers. Did tlioy ncgloot it? And if tlicy did, lia.s 
Mr. Beadles forgotten the great Huntington picture trial 
of 1917? Hero export donlers had to refund over £20,000, 
the price they had obtained for “ the nio.st beautiful and 
attractive Romney ” a great so-called exjiert .snore lie had 
ever soon. Next day the picture was dramatically and 
incontestably proved to be by Ozias Hnmidiry ! My friend 
the late Mr. Milner thought this ])ortrnit of Htinter might 
be by Hone. Jfr. Martin and Mr. Beadles think it may 
bo by “ Seton ” — 1 bog jmrdon, John Thomas Seaton; 
so that it is evident the greatest experts may differ. The 
late owner of the picture and I think it is by Gains- 
I'orongh, and theic for the jnesont the matter may be 
left. — I am, etc., , 

London, W., April 2nd. G. BrCIvSTOX BllOWNF. 


INJECTION TREATMENT OF VARICOSE VEINS. 

Siu, — In a portion of Dr. Dewoy’s lettei' to tho llrilisli 
Medical Journal (March 24th, p. 522) he asks me if 
I meant in my letter, published in your issue of March 
10th, that in all cases of thrombosed vnrix there is no 
fear of clots getting into tho general ciretdation. 

There is great danger, and rlcath occurs from clots 
breaking olf and getting into tbo general circulation from 
thrombosed veins. This is, however, only to bo looked for”^ 
in disease coupled with infection of the vein. Tho pro- 
duction of a chemical thrombosis is brought about in (piite 
a different way. Sclerosing injections — many of them arc 
anticoagulants — destroy only tlio inner wall of tho vein 
primarily; later a clot forms in the same way as it docs 
in a ligatured vessel — that is, the destruction of the endo- 
thelium at the site of tho ligature; at this point a 
thrombosis forms. If a ligatured vessel becomes tho site 
of infection the thrombus may disorganize, soften, break 
down, and get into tho general circulation as an embolus 
or emboli. In aseptic conditions no such thing takes place 
— emboli never form. Infection, therefore, must bo con- 
sidered as tho sine cpia non to tho formation of emboli, j 
With strict asepsis and in properly selected cases there 
is no fear whatever of producing emb(»li by the present 
methods used for the injection of varicose veins. 

Dr. Douthwaite in the latter part of his letter (March 
24th) speaks about tho practice of putting patients 
suffering from spontaneous phlebitis to bed. 

If the spontaneous cases are due to injections I find that 
patients do very well getting about, but in the case of 
severe reaction rest on a couch with the limb in tho most 
comfortable position possible for a day or so is all that 
is necessaiy. — I am, etc., 

T. Henhy Theves B.\nni:R M.D., B.Sc. 

London, S.W.7, March 25th, 


SMALL-POX AND “ CASUALS.” 

Sir,— D r. Duncan Forbes, medical officer of health for 
Brighton, in a letter to the Times of March 23rd, called 
attention to the spread of small-pox in the south-eastern 
counties, and said that ” this spread is in groat part due 
to the uncontrolled movements of tramps known to have 
been in contact with the disease.” It is, of course, gener- 
ally admitted that the tramp in the common lodging house 
is a far greater danger than one in the casual ward, where 
at least some sort of supervision is given. To state tho 
problem is to suggest tho remedies which can be aiiplied 
by the Minister of Health under the great powers given 
him by the Poor Law Act, 1927, without waiting for any 
further Act of Parliament. It is possible that an Order 
or Regulation of the Minister will be needed to back up his 
circular. 

In the provinces some 137 casual wards have been closed 

mostly recentl 3 - — by the Ministry and the local boards of 

guardians. In other words, 137 places where the tramp 
could go with comparative safety- to the public have been 
taken awa\-, and manj' tramps have been driven to sleep in 
common lodging houses, or in jilaces where there is and 
can be no proper supervision. A laige number of these 
wards should be reopened at once. The Minister has the 
power to do so under Section 69 of the above-mentioned 

ct. the ^linister should issue to all boards of guardians 


a circldar of a far more effective nature than the circular 
of January 23rd, 1928 (Journal, January 28th, p. 154). 
'J’he tramp should be examined by the doctor, not only 
before he goes out, but when lie comes in. Otbenvise 
during his two days’ detention ho will have plenty of 
time to infect other casuals, who will proceed on their 
journeys before the doctor makes tho tardy inspection 
Miggc.stcd by the Ministry of Health. ‘‘ Contacts ” should 
not only be “ offered vaccination,” but should he given 
.some trilling inducement to submit to that operation, and 
tohl that if they remain during the necessary period thej' 
would be given docent food and accommodation, and not 
-treated as casuals. 

May I conclude with a special uord as to the safety of 
London? Practically all the closed wards on the routes 
to London, at least within tliirty or fortj’ miles of the 
metropolis, should be opened. It should be so arranged 
as to distances that the destitute wayfarer will have no 
temptation to go to the common lodging house or “ sleep 
rough.” If at each casual ivard two medical inspections 
are made, and the other precautions taken, the risk to 
London will bo enormously reduced. By a wonderful over- 
sight .stone-hienking has been made one of the tasks for 
the metropolitan casual wards. A slight discussion on the 
subject took place in the House of Commons on March 
ISth. The object is, of course, to deter men from coming 
into these ward.s; but the effect is to keep men who may 
be infected with small-iiox from coming into decent' clean 
niiarters, where infection would be promptly dealt with. 
AVhat I have said ns to the routes to London is applicable 
to other towns, and tho folly of tho London stone-breaking 
is nlso visible in some places’ in the provinces.— I am, etc., 

J. Theodore Dodd, 


St. LconurUs-on-Seti. March 27tl,. Barrister-at-Law. 

P S —Since this was written a memorandum has been 
issued’ but I have not yet had an opportunity of seeing it. 

•• • As stated last week (p. 609) the Minister of Health 
1ms' oxtouded the period during which casimls must bo 
evnmined for a further three months. The ciiculai 
announcing this decision recognized the danger of dis- 
nci" iiig persons who had been e.xposed to infection when 
wards are closed owing to occurrences of small- 
Mr Dodd’s suggestion applies, of course, to casual 
closed for other reasons. The circular reminds 
wimidions that their powers do not extend to detention 
e.sons who, although they may have been exposed to 
• r^ tfoTs disease, are not actually suffering from it. even 
11'^ tbev feline to be vaccinated. On February 25th 
324) we gave details of the outbreak of _fraad-l>^ 

T mainlv in a Poor Law institution.-Ed. B.M.J. 


OF THE BIRTH RATE ON THE AA^ERAGE 
^FFLClur age AT DEATH. 

o Afiv I call attention to what appears to be an 
I f in the popular appreciation of the increase m 
ersiglifc of lifeV ^ This is commonly taken to be u 

O average ^ .age at death, Mit really the T 

nonymous distinft consideration. The average 

■o ‘j year is easily estimated from ^atistics 

1 Horn death Ltification.’ Other ^“'’tors affect the 

tirate of. the length of life justly to he expected for each 
•wborii child. » , ace at death is n 

Generaffy, the mcreaso M^the^aveiag^^^^ whereas 

trihuted a^on t decrease in the birth rate, 

c^^tran eleVatio’n in tho averlige age of tho population 

:d the fifn^erav^ age of the whole population. 

The elevation of tl o & older portion, or its 

- ^ 

latTve^prorainc'nci ofThose wWch^pertam^^ te 

the )Sod of Hstpei-Mi:^:'of stui fuither les.sening 

e birth rate.-I am, etc., M.D., D.P-H- 

lAfrirfll 28 tll. .* 


April 14, 1928]' 


MEDICAIi NOTES IN PARLIAMENT. 


[ Ths Bnmsa 

MZDtCJU. JouBXAjb 


646 . 


Htttiirrtl llotcs in ^^nrlituncnt. 

[FbOJI OTO PARLIAMENTAnV ConUESPONnENT.] 

Lvsi AN-eek the House of Commons, before rising for Easier, 
read the National Health Insurance Bill a second time, sent it 
to a Standing Committee, and passed ii money resolution 
attached to the hill. The House also debated rural lousing 
and Poor Law relief. It will reassemble 011 April 17th. 

National Health Insuranco Bill. 

Debate on Second Heading. 

On April 3rd Mr. Ciiaubeblaik moved the second reading of 
the National Health Insurance Bill. Ho said that this national 
health insurance scheme was a tremendous undertaking. Under 
it to-day, some 16,000,000 people were insured in tins coiintrv, 
each of them paying a weekly contrilnition. wliicli mdividiially 
amounted to only a few pence, but which, vdicii n^ed together, 
formed a tremendous aggregate of about £25,000,000 a year. In 
such a huge scheme it could not bo wondered at if, from time 
to time, it was found capable of improvcinent. and if, all Inc 
time, there were constant demands for the simplification of its 
machinery. Tho bill was a further attempt .at simplification of 
machinery, although it contained some improvements of siibsUncc. 
It was founded principally on a recommendation of tho Roj-al 
Commission appointed in 1924, under the chairmanship of the late 
Lord Lawrence of Kingsgate. There was on tlio order paper 
a Labour amendment for the rejection of the bill, but Mr. Rhys 
Davies, who would move it, seemed to have found notlnng to 
condemn or even criticize in tho bill. The lion, member liad, 
however, sought to found his motion for rejection on what the 
bill omitted. No’ doubt Mr. Davies was aware that the bill had 
been approved by tho Consultative Council, and tliat the approved 
societies generally would bo grievously disappointed if the bill 
did not become' law. 

Mr. Chamberlain then explained the bill in detail. The Pro- 
longation of Insuranco Act would be abolished and a new scheme 
would be substituted, under which all the penalties for arrears 
of contribution incurred because a man was genuinely unable to 
find employment would be abolished. Clause 1 contained the 
largest concession to insured workers and Iho biggest simplification 
of machinery that had been introduced into tho national health 
insuranco scheme since its inception. Under the new arrangement 
lor prolongation of insurance any genuinely unemployed person 
would be retained in insurance after having -coased to pay any 
contributions whatever for between two and a half and three 
years. That was a provision which would meet all the ordinary 
cases of unemployment likely to arise. Again, in tho ease of a 
man hitherto continuously insured for a period of ten yeai*s 

vc.|m cFtAM M.. ... ._1. 1 f.11 . I .. .A , , . f .1 1. . 


for, but unable to obtain work. This would prevent any man who 
had been m regular employment for a substantial period losing 
ins old age pension because of any difficulty lie miglit have in 
indm| employment after lie became 60 years of age. Referring 
to additional benefits, particularly dental and ophthalmic benefits, 
Mr. _ Lnamberlam said that tin's was a very important matter. 
Its importance lay particularly in the fact that these treatments 
vero largely preventive as well as curative in character, and that 
tne large sums, amounting to about £4,000,000 a year, which were 
I ”” approved societies on dental and 

ophthalmic benefits might bo expected in due couiso to bring 
new reward to tho approved societies by tho improvement in 
general, health which they were calculated to produce. It was 
ivno ■while the administration of medical benefit 

, y safeguarded in the original Act, and conditions 
were laid dqw-n in the body of that Act for that administration, 
and the Ministry was given.power to make regulations still fuillier 
o elaborate tliose provisions, nothing of the kind was to be found 
m, original Act in regard to additional treatment benefits, 
iiiat could not bo wondered at, because tlioso benefits liad not 
„ - t tUeir present importance; but now that they had 
1 pitcli of development it was very neces- 

Sl,„i^- similar care should be taken in regard to dental, 

th. “t'mr additional treatment benefits to sec that 

llm jpraperly expended and to the best advantage of 

to ? people. In Clause 14 (3) the Minister was given power 

tion-tl 4,.^. go.yerning the administration of any addi- 

iinH.i benefit, and the' general arrangement of services 

reconnir.A .{‘■aatnient was to be provided. It was widely 

of a- hational lieallh insurance circles that something 
tho .ESS required. Taking dental benefit, for instance, 

the .^“““Bil, recognizing how necessary it was that 

dentiF^n^^*^ siKieties should be able to command an adequate 
ment of “ reasonable price, recommended the establisli- 
a commifi committee to deal with this matter. Accordingly, 

a conraitteo composed equally of the d( ' ' ' '' ^ ‘''- 

societies, known as the Dratal 
and \ho”n;of''P-*° ""S’."®*® “°ditic 

servipp Pr®i®ssion, and to ensure the proper working of the 
1 l-be joint committee was to be con- 

success worked with a considerable amount of 

Btatutorv Kr.,4 . ® M difficulty-lhat it was not a 

not worl- K. ’ that it- hjid to work bv persuasion, and could 
of nrpinfijA Tliere had been a considerable amount 

service nnsteJM.^ failure in some places to get the best 
of the authority on the part 

*♦1 iienefii, Joint Committee. One of the things which 


he desired to do W'as to make regulations, under the clause to 
which ho was referring, which would enable him to give that 
authority to the joint committee, to ensure that any decision 
that it came to should bo made binding upon all the approved 
societies coming into tho scheme. 

Dr. Veunoij Davies ; And upon tho dentists? 

Mr. ClIAMBERLAI^' I Ycs. Tliev hoped to get a similar committeo 
set up to deal witli ophthalmic additional treatment benefit. 
Another matter on which it was necessary that he should have 
power to rnako regulations was in regard to dental clinics. Some- 
thing appeared to have aroused a certain amount of confusion 
ill connexion with this subject. Judging from his own corre- 
spondence, ho Avas convinced that many members of the dental 
profession had altogether exaggerated what was in contemplation. 
Ho said at once that there was no intention of doing anything 
moro at present than embarking on an experiment or two in 
order that they miglit thorou^ily explore the advantages or 
disadvantages of the S5'stem of dental clinics. The argument 
in favour of. tho clinic was that where they got a dense 
population and could rely on a steady flow of patients,^ 
could get, in a clinic, a standard of equipment and specializa- 
tion among the staff which it would be unreasonable to expect 
from a- single practising private dentist. ^ He supp(«ed that the 
argument against the clinic was that it was going to drive 
out the private practitioner and set up a monopoly. The matter 
had been discussed by the Dental Benefit Joint^ Conimittee, 
and they did not come to any conclusion except this — that they 
thought it very desirable that an experiment should be m«ade, so 
that they might see whether tho advantages outweighed the dis- 
advantages, or vice versa. If the bill passed through Parliament,, 
it was his ’intention to make regulations for the setting up of 
such experimental clinics, one or two, perhaps, in Loudon, tie 
repeated that in no circumstances could he contemplate abolishing 
the free choice of dentists. No one must be compelled to go to 
a clinic if ho would rather go to a private practitioner. It would 
certainly be a condition of tlie acceptance, even of an experi- 
mental clinic, that there should bo adequate representation of 
the profession on its management. , a r at « 

Dr. Davies : Arc wo to understand that the ^ consent of the 
local dental profession will first of all be obtained before the 
clinic is established? * , . 

Mr. CHAMBEKLAIN : No; I do not think I can give any apurance • 
to that extent, certainly not at this stage. But I do not antici- 
pate that wc shall have any difficulty in selecting the most suit- 
able place for an experiment of tins kind, where we shall not 
arouse any violent feeling of hostility on the part of private 
practitioners in the neighbourhood, mth regard to dep^osit con- 
liibuloi-s, under Clause 10 those people who, on account of bad 
health, could not get into an approved society, would 
into a new section of deposit contributors, to be called the 
Insurance Section. They would be entitled, not only to tho 
equivalent of their own contributions plus the State 
but they rvould be entitled to all normal statutory benefits given 
under Se original Act. If in the committee stage, Mr. Chamber- 
lain added, amendments were put forward with the object of 
improving the bill, they would receive most careful and sjm-, 
nathctic consideration from tbc Government'. 

Mr Kiivs Davies moved : “ That this Ho^e, whilst prepared 
.r.pirome ■ ■ --'mnal health msurance, cannot 

ateiit to the I 'Jfhich fails to recognize, 

fi^the liulit the necessity for making tho 

scheme more national in character by establislung the right of 
entry to' many persons now excluded, neglects to make better 
benefits possible by restoring the State contributions of vvbicli the 
National Health Insurance Fund has been deprived, and fails iii 
many respects to carry out the recommendations of the Royal 
Commission.” He said that it was a travesty to state that this 
hilt was brou-'ht forward as a result of tho recommendations of 
the Roval Commission. Out of 122 separate rccommendatieiis 
of the ‘Commission the bill contained only 32. In fact, the bill 
was Durely an administrative measure, and the big questions 
affectum the health of tho 16,000,000 insured people of this 
countrv°wore left entirely untouched. He said he would like the 
Minister to explain what was meant by Clause 3, dealing with 

medical charities,” particularly in South Wales. He understood 
that some of those medical charities were doing excellent "orlv 
and he hoped he might be pardoned for a little suspicion that 
the medical profession were influencing the Minister of Health 
unduly in that respect. 

Dr. FbeuAnile : Never. , , „ i i 

Mr Davies said that before they could consent to the abolition 
of these medical charities ho thought they must secure evidMce 
as to whether there was any abuse of the privileges granted them 
under the original Acts. The two most important recommenda- 
tions of the Roval Commission related to the pooling 
and to the abolition of insurance committees, and Thl 

neither. The Minister seemed to have “voided Clause 11. The 
Royal Commission was very emphatic that something moio shouM 
he^done in connexion with maternity benefit and the ca.e of 
married women in general under the national health insuranco 
Sheme Clause 11 did make the position of marned women very 
muX dearer but it did not touch those issues raised by the 
Royal Commissioii-the terrible tragedy of tnaterual 
hi this country, about 5,000 women dying annually in childbirth 
This M did not touch that problem in the .least. He wanted 
tho Minister to safeguard the interests of the insured persons by 
makS“ it compulso?y on the approved society to include words 
S t ie%ffi!ct that if the insured person failed to go to a clinic 
he could still choose his own dentist or optician. He had no 
Xticism to offer on tho clause relating to penalties except one. 
iTe hdped that the Minister, in dealing with penalties by regula- 
tion would see that whatever penalties ho inflicted on tho 
administrators of approved societies and insured persons ho would 


646 ’■ April 14 , igiS-] 


MEDIOAIi 'KOTES IN -PAEEIA'SiENT.' 


r^fr'.TffiDiimrt ’h. 

L MEDiaa Jocwu 


inflict similar penalties on the mcflicaJ practitioners, dciilisU, and 
opticians who might transgress the law. Some mt‘!nbcr.s of Uio 
medical profession were issuing medical certificates definitely with 
a-view to increasing their panel pnacticc, and as far as he. knew 
there was no provision to deal with eases of that kind in this 
bill. If it was proposed to give the Insurance Cornmillces tilli- 
nmtely the administration of some benefits which wore to-day 
administered by approved societies the Minister of Hcallh would 
fmd himself in a difliculty with the Consullativo Council. If 
there had been any abuse at all in connexion with tlio ndminis- 
trntion of national health insurance he was convinced that it 
occurred under Section 26. AVhat had been done had been done 
probably strictly within the wording of the section, hut it had 
not been done vcr>' lionourabiy. bJe supporied the full ixipcal 
of that section. If any approved society Avanted to do anything 
by way of clinical work or granting money tOAvnrds charities or 
hospitals it ought lo do it cJcanlv and above boaid. The Royal * 
Commission recommended tlmt the scope of inateinity benefits 
should be extended to cover medical and midwifery sornecs in 
addition to cash benefits. It would he interesting to !cam why 
that provision had not been included in (he hill. The Commission 
further recommended the extension of the scope of medical benefit 
in respect of dependants of insured persons in receipt of nckiiess 
or disablement benefit, lo improve provisions at the time of 
prognancy and childbirth, the provision of denial bcnefib as a 
normal benefit, and, above all, that the insured population should 
be entitled lo specialist services as well as ordinary medical 
practitioner services. Were it not for the fact that the Stale 
grant had been reduced the majority of societies would have been 
able to pay for specialist services. 

Sir KrxGSLirA' Woon said the fact that there had been no 
proAision made in the bill for specialist services had nothing to 
do with the Economy Act. 

Mr. DxWIKS .«:aid that the bill w.as a very small contribution to 
the problem of national health insurant. It did not assist 
in the solution of the Jicalth prolilcrns of the counlrv. 
Wliat about cancer and rheumatism? Nothing Avas done in 
the bill to deal with (hose diseases. Wlicn they compared (he 
bill Avilh the recommendations of the majority of the Royal 
Commission ho thought that the Opposition AA’cro justified np to 
the hilt in moving this ♦amendment and carrying it to a division. 

Mr. WiiiTELEY seconded the amendment, 

Dr. Fkemaktle said that there Averc certain points Avliich natur- 
ally concerned A’crj’ closely the medical and dental professions, and 
ho wished to A-oico one or (avo of the feelings on those points. 
The medical profession generally avouIJ bless the bill, in certain 
parts strongly, and in other parts they would find it good in 
Jess degi'oc. Ho Arishod lo call attention to the fact that the 

dental profession Avero naturally A-cry much concemed, but they 

Avould be partly reassured by the statement Avhich the Minister 
had made that afternoon. He hoped that possibly tho Parlia- 
mentary Secretary to the Ministrj* of Health miglit be able, in 
replying later, to gxA’e the further assurances that were required. 
He (Dr. Fremantle) could speak perhaps with greater conviction 
for the dentists, inasmuch as it avos a Jfriendly piofcssion for 

AvliicU he had no direct responsibility, but he Jiad this from the 

body representing the dental profession. There Avcrc three points 
Avhich they hoped to see definitely established in the slatement 
that afternoon. The first Avas Umt the insured person sltould have 
the same freedom of choice of his dentist ns he enjoyed with 
regard to his medical adAuscr. He tliought that the House had 
had a A'ery definite categoiical statement that would be satis- 
factory to the dental profession. The second point Avns that the 
acceptance of any agreement as to fees and conditions of service 
arrived at after free negotiation by repi'esontatives of approved 
societies on the one hand, and of the dentists on (lie other, should 
be subject to the approval of the Minister. Tlic difficulty was 
that they met Avith collective bargaining eA’erywherc. Unless 
the results of collective bargaining ^^’crc made to hold with all 
parties concerned, especially Avitli those who Avcrc less inclined or 
Jess able to carry out a bargain, the main object of collective 
bargainmg fell to the ground. The third point was that there 
should be no lay interference with the proressional discretion of 
the dentist in the treatment of his patient. Alwaj's the criticism 
by the professional men^ of the approved societies Avas that 
instead of simply confining themselves to administration the 
approved societies interfered Avilh the actual professional treat- 
ment, which only a professional man was really able to control 
and to criticize. 

Sir Kikcslev Wood here asked Dr. Fremantle to explain 
a. little more Avhafc. he meant. 

Dr. FREMAXTI.E said that he meant that the difficulty of 'any 
lay control of professional persons was that in these matfem 
they did, interfere with the actual professional side. It was for 
that reason that tlicy had their supervising officers. The doctors 
were naturally very sensitive. He thought that was really the 
onlv reason why sometimes thei’o Avas friction between the pro- 
fessional men and the approved societies. It was for that reason 
that one could not accept ' ‘ ^ the nioA-er of 

the amendment that the ■ ■ should be done 

away with and their duties ^ ,, , * - , societies. That 

raised the old original criticism that wus levelled against the 
Insurance Bill. It was obvious that approved ^cietics could 
not properly administer these medical m.atlers. The Jnsurance 
Committees were formed in order that they might get a better 
idea of the benefits to be administered. It 'ras quite true, also, 
that the Rovat Commission suggested that tlio duties of the 
Insurance Committees should be distributed to the ^propriate 
local authority. That proposal was not, as M;r. Rhys Davies had ' 
said, to refer these duties to the apprOA'cd societies. It was^ to 
break np these duties and distribute them to the appropriate 
local authorities. He supposed that the reason was quit-e clear. | 


The wliolc qiicslion of local government was noiv the suWeet ol 
™ Commission, and they must wait for tho 
result of that before tlitiy could see how the local authorities 
Avero going to ho so arranged that they could properly have those 
duties placed upon thorn. Wlien they got the Avhole subject of 
' d up and put on an ordinary and 

•pod to have this question of the future 
. decided. He u'as quite sure that the 

fimdions of the Insurance Committees ought to bo blended with 
tiiosc of the licalth authorities general/v. One of the muia 
critichins of the insurance system Avas that, whereas it was 
largely introduced by Mr. Lloyd George as a measure for the 
prevention of sickness, it had failed in the prcA'cntion of sickness 
to a Acry largo extent. The amount of sickness among insured 
persons remained very much the same, although he belieA'cd that 
the kind of treatment applied had curtailed each case of sickness 
lo n considcrabJp extent. TJie sj'stem certainly gave relief, but 
for prevention it was of A'cry little advantage. One of the objects 
nut fonv.ird in connexion with tho original bill aa'hs definitely lo' 
link up the question of prevention and the question of sickness by, 
making a special provision by Avhich, AA-hen any particular area 
was found to bo sufioring from a very excessive amount of 
sickness in any one respect, steps could be taken at once to turn 
liio AvhoJe services of the Insurance Act on to that particular area,, 
Tlinl iiad been found to be impracticable. ^Yhy? Because the, 
measure was introduced originally independent of the existing 
heaUh organizations. This was a danger that they constantly 
had in that House. They seized upon a new idea; they intro- 
duced a new bill; they introduced a new scheme of organization, 
with a new «ct of committees or even of actual authorities, and a 
new set of officials all the Avay through, and they added to their 
burdens wliilo diminishing certain others. They had to use the 
ncliial machinery they had, and to improve it. He thought that 
local authorities might be used as the central authority for 
ndminkterin" mcdical benefit under this Act. 

'n.cro X special form .of benefit which ho was sorry 
was not provided for as an additional benefit. 

Lro hA cases of maternity. The nnswer of the Parliamentary 
Lmtary Avould be that maternity benefit was pronded by a money 
nnvmcnt lo the mother, who vras responsible for pronding Hie 
SidSe or having materiiilj- services. The objections to it were 
Kirt^obrious. In too many cases tho money was required so 
Itrrrntlv for Other purposes that it was not sufficientlj 

services tiiat were so necessary. He was glad that a 
the m.idwifery serui^ (o inquire Into the training and 

committee When that committee reported he had not 

Bupp y of 3 ''*'®?- 1 it" „ouId show that for a long time the 
the in the more scattered parts of the country 

imnibcr iiint there Avas an immense difficulty 

some ue. oKIa fn a better service in Uui 



. • f nrlnratcd Eirl who wouia Avanc iq luuu 

type of cducaica g down to a pecuman' benefit, and be 

properly. provision introduced 'into the hill which 

would Cset aside for tho 

would enabje a _uj,e,.„tion of midwives. He hoped that the 
improving i insurance miglit he always kept upperm^, 

af tlicy worked this system during tho 
and that, as rncy couid use tins sum of £25, 

"^^ai not mmnly for the relmf of trouble, bat 
to of nreventable sickness and disease, 

for the proven -..nnjrtin" the amendment, urged that tl'C hill 
Mr. ’r^^-iSon^for family medical benefits. This question 

Bliotild P™,. ' imoortant one for many reasons. He did net 

had heremo a > surpluses accruing lo the . 

know ® they would provide a sura suffiment to give 

societies were pooled of insured persons. He wished to 

medical benefit to of administration. Approved societic 

call attention t fi _ people on sickness benefit to 

sent a '“'•B'vo.rofRUs for eraCnW That was done in 

regional medica , fupd of the approved society, hut the n J , i 

interests of Spcurred came ^ the administrative fimd ofj 

montofflioe|pensesi™unea^^^^^j^j ^ oomo^ iK 

the aoinctj . S“cti jj were to flow 

benefit fpd.d account tho administration was likely W ^ 

tho administrative udcount^^^ efficient supervision uliK^I 


it tho administration was -“ . vj 


-uM-stant piecenie^ 
Icgislatioii. speaking as .fu '«ccptiOT'”^ 

minor points, umen f . „ 

the I ' 

Ml 
made 


• le which ne iioptu — 

thi hTS-thatrefc^ice had been 

Sf«rof the dtn^dment of See on 

,*■".1? and one hon. Diembpr said that Jh . to 


made j „,,rT one lion, membor said that _w{es to 

original Act, anfljne ^ 

i^a'kl ^nTio special 


charitab e m special 

...uno 6-—~ where their members miglrt requ.r ottam 

emcrgency'^a os n ^^]„eh they could ' J jtai, 

treatment . vj* . • „ made to the funds of vne i i 

ThaTvmTt Hght and /!™;-\te"’addltiS'V'^ 

^gtt'onirto 


Aprid I-t, IQSS] 


medioai, notes in parliament. 


r The Bninsa 
I Medicxl Joubnh, 


647 


the inlicrcut right of every insurca poi*son. Tn ii\c North of 
Ireiand medical benefit was not (Ttvcii, mul tlio result was very 
unsalisfaclory. It Nvas suggested by sprue soeiotres that Uiov 
ought to have the right to exclude incinhcrs in Norlhorn Ireland 
from participation in ^oireral valualion until Novtheru Ireland 
brouglil in a system of niedienl benefit. The vrou’ they put 
forward was tliat the clause was unfair to their members ii\ the 
I’lnglish and Scottish societies which had incnthei-s in Northern 
Ireland. He iioped that the Minister^ of llcaUh would consider 
that question. The overwhelming opinion cx])re‘5si‘d by llio people 
concerned was against the aboUUou of Insiii'aiicc Coinnultccs* 

Hr. Morgan Ionss said thero were in South Wales institutions 
-known as minors’ medical aid societies. There was a considerable 
measure of apprehension among them ns io what precisely the 
Minister of Health .sought to do through the medium of Clause 
3 of the bill. These societies had existed for a very long time, 
and after some difficulty were rccoguitcd seventeen yeai-s ago at 
the passing of the original Act. lie believed they find something 
around 40,000 members, and if they included dependants the 
number would exceed 100,000 for whom medical .services of various 
kinds wero being provided. But they had had to face opposition 
from the British Medical Association, and also, Ihey claimed, from 
the Insurance Committees. These bodies operated verv largely on 
co-operativo lines. The objection came, he believed^ generally 
from the British Medical Association — and there had been pretty 
severe and sustained fights on the i.ssue — that those societies had 
a larger measure of lay control even than w.as found under the 
system of Insurance Committees, He did not want to develop an 
attack on the doctors generally in this matter, luit ho was 
entitled, in defence of^ nis constituents, to submit a ease in 
support of . these societies. They drew a contrast between fho 
tieatment nicten out to these medical aid societies and that meted 
out to private panel practitioners, and llie contrast wa« one which 
induced them to believe that the scales wove heavily weighted 
against these medical aid societies largclv because they were 
subject to the ban of the British Medical Association. 

TTi!*^*A SmcLS said that ineinhoi's on his side of tho 

it went, was 

Jt did not go to anytiiing Ukc the extent they 
TnSnL f ^tncndinont of tho National 

• As a responso to tho recommendations of the 
ftf ^ seriously inadequate. The Minister 

thnt f department were not primarily to blame for 

maftV^T iL i I connexion wUh so many other 

done so prevented from being 

in these House felt ouglit to lie done. Economy 

restraint oecessary, and the Treasury must exerciso 

one direct?o»f^1n^ licnltii of the people was 

and wliero so-called economy was misplaced, 

health and provide adequately for 

giant had iiot*^ if lowering of tho State 
wa.s it that wo P.^o'-'ision of specialist benefit, why 

piWect of itP tlmtMhcro was no early 

bene^t for L insured P9sitiau in ic!?ai-tl to specialist 

Pcysoii requiring a consultation or o 

person. 


treatment was*exaWhr^?/.'^"“ requiring a consultation or operative 
Unless it was arurLZ/ f uninsured person, 

voluntary hosnifnl winch would ho admitted to tho 

list, an? had^o take i'‘o liospital’s waiting 

ment w.ts deiaved hJ-'^ }^ip’ ^ '^ot'sequenco tiiat treat- 

greatest advantage bpnd the time when it would be of the 
person dependent ’ on °f ahaits which left tho insured 

ohiiousiy lUaiisfaeloL ^P>^«ulist benefit was 

by the ^general or r?" ailments could bo dealt with 

might retiuire onor.?*"*^ . *’”1®^*^*°'’'^'"' Ti'® more serious cases 
applianccsr^-rav^r I^ni latest laboratory 

at present tho^ineJ^j ^ treatment, and other aids from which, 
a scheme which mmnH '''“t out. Yet hero we had 

vision of •“ '“‘(‘onal scheme for tho pro- 
to it, and surely U? insured persons who contributed 

out that so ionir^-is i ‘^“‘"""ssioii . was right in pointing 

was unsalisfactOTv treatment was withficld the system 

of its meiXrs ‘''<= on^ ‘'*e rights 

hospital question i"?.® “hriously linked up with the 

vohintarj- hosSs h^ 'ri ® ‘ “ol' tackle at all. The 

from the insurance ‘®P®“'odly made requests for allocations 
Ihey treated, but all thpy*^f'’ii''i,^‘®"“^® rim number of patients 
would enable soeirlieo^i ^ o permissive clause which 

Hie Kconeniv Tet contributions to hospitals. Before 

societies did^ make 'e^ ni w" riie House certain approved 

bad come in it' liad'h^*” hospitals, but since that Act 

Now they we„ d'ffi.cult or impossibic for them to do so. 

^Bedicai benefit- n 6^'*® donations to count ns 

allocation of mmiev Either an 

ment hetwpPTi ‘leati or some other financial arrange- 

youia he nece^arr fund and tlie voluntary hospitals 

fu’st place, in desirable for two reasons: in the 

J^pecialht persons should not, as now, 

H'atthc voJunt’n SiT “ Clarity, and, secondly, in order 
ili'2 ease soon even, as they expected might be 

^ic chiTicult Hsl' nf should bc'assisted to carry on 

?!”• Ereinantle\' ^ It necessary funds. He commended 

insurance through the national health 

^applying moro should be found for training and 

®?>sting than wero at present available. The 

sif’kness benefit adequate in tho matter of 

fiat rate svstfni* if ,!!* t something to be said for the 

had a hiohni. rnff. he found that almost all other countnes 

<hat thc'’Mink?i! benefit than we had. He was glad 

^’(•mbei's to a , bad relieved the minds of many 

''"as desirihlf.^+i,'^ t by his statement about denial benefit, 

made a statutorv Hental Joint Committee should be 

paint of view ' r important, from the public 

. as Men as from the point of view of the dentists. 


tlint fhej’o should be a free choice for patients, and lie was glad 
Ihftt that privilege had been preserved. There was no doubt that 
•r r ®iV j 1 ! u ^ ordinary foi-m of treatment, and 

U tim dental benefit vveeo given to all insured pei-sons, the health 
01 lUese persons ivould be very considerably improved. There 
wove many diseases caused by bad teeth. A great deal of the 
rheumatic diseases, about which so much was heard in industrial 
life, and which produced a very heavy sickness rate with important 
economic complications, were really a form of chronic infeciion 
duo to bad teeth. Therefore the c.vpenditurc on dental benefit 
was, in the long run, a very economical expenditure. The same 
applied to a lesser extent to the efficient treatment of the cj’os. 
The supplying of proper glasses to people who sufTered from eye- 
strain was very important. The fact should bo emphasized that 
nllhoiigh ihe itoyal Commission had recommended these addi- 
tional benefits, and public opinion approved them, it was im- 
possible to supply them witlioufc a restoration of the State grant 
which was given before the Economy Bill was passed into law. 
He very earnestly urged the Minister of Health to put up a 
stronger fight with the Treasury to ensure that economy was 
not practised on tlic health of the people. If this bill could not 
bo siiflicicnliy amended, he hoped another measure would soon 
be introduced, bringing in some of the more important pro- 
visions which the Iloyal Commission thought necessary. Many of 
Uicm looked forward to the time when the normal task of an 
insurance medical practitioner would not be so much that of 
curing people as of examining them periodically, so that the 
earliest signs of disease could bo detected. That comprehensive 
scheme could not be carried out until the extended benefits, now 
so much needed, were given. That, again, could not be brought 
about unless more money was brought into tho scheme, which 
could only be done by a lestoration of the proportion of t!3c 
StaCo grant wliich we had before the Economy Act was passed. 

Sir H. Cautlsy said that ho viewed with great apprehension 
the steady increase in the amount paid out in sickness benefit 
nil over the country. Unless some steps were taken to clieck 
this expenditure the whole scheme, sooner or later, would be 
jeopardized. Tho extensive unemployment of the last fciv years 
might account for some of this increase, but "not altogether, 
because it happened that in the rural societies, where there had 
been no unemployment, tho same symptoms existed. Probably 
it might bo true that the increase of sickness benefit was greater 
ir. llic large industrial centres which bad been severely liit by 
unemployment. The scheme for the administration of sickness 
benefit rested entirely with tho doctors, and the only control 
was the appointment of a medical referee. He did not think tlio 
system could be improved in that respect. Tlje sole judge of 
wlicn an insured person required medical service and should 
receive his ccrlificato to get medical benefit must be the doctor, 
subject to the procedure relating- to the medical referee. His 
suggestion ' to tlic Minister was that, if the doctor was entrusted 
with this responsible work, his position ought to bo made, as 
far as possible, such that it did not conflict with his duty. Ho 
had, as his private patients, perhaps the man’s wife and family, 
and if he lost that particular patient he lost the whole family. 
The same thing happened when a doctor had to certify the patient 
as being oft benefit. His (Sir H, Cautley’s) suggestion was that 
no one should be entitled to change his doctor without giving, say, 
three or four weeks* notice. In such cases as those to which ho 
had referred, no doubt tho fit of irritation would have woni off 
in a day or two. the person would have gone back to work feeling 
better, the vvhole thing would have blown over, and he would 
no longer liave any desire lo change his doctor. It had also been 
suggested to him that, in addition to notice, reasons should be 
required, but he did not approve of that. It would encroach on 
the free right of choice of doctor, in which he was a great 
believer. In the few societies with which he was directly con- 
cerned it had been found that in many cases where they had 
had to appoint a medical referee the patients had never gone to 
that medical referee at all, but had at once gone back to work. 
He asked the Parliamentary Secretary if the facts and information 
in his own office did not bear out tho case he was making for 
this small alteration, and he hoped the Minister could see his 
WJW make this reform, which was oulj' common sense. 

Dr. Vernon Davies said that the only way the Opposition could 
attack this bill was by making some obscure reference to a past 
raid on the insurance 'fund and by pointing out that the Minister 
of Health was very subservient to the Chancellor of the Exchequer. 
If that wore true it increased his (Dr. Davies’s) admiration for the 
Chancellor of the Excliequer if ho had sufficient power to overawe 
or lo guide the Minister of Health, because among the medical 
profession in this country the Minister of Health was not by any 
moans regarded as a soft man. In fact, they found him rather 
.difficult to deal ivith, and perhaps sometimes a little autocratic. 
With regard to the question of the medical aid societies or clubs, 
though he held no brief for the British Medical Association, he 
imagined that the objection it had maintained for a long time was 
that the system adopted by these societies put medical men under 
lay control. For some years now he believed the Association had 
taken certain steps to advise medical men not to apply for these 
appointments. What happened in these cases was that the medical 
man became the servant of a lay committee, who had power to 
dismiss him. 

Mr. Morgan Jones : Just as in the case of the medical officer 
of health. 

Dr. Davies said that when they applied the Insurance Act to 
these medical aid societies they were in a difierent position at 
once, because tlie essential thing under the Insurance Act was 
that the patient must have freedom of choice of doctor, and he 
had not that choice in the case of the clubs. That was one of the 
great objections to the present system, but from all that he had 
heard he believed tlie standard of medical treatment which these 
medical aid societies had been able to give had been very high. 


648 Aprii. 14 , 1928 ] 


MEDIOAt; NOTES IN PARDIAMENT. 


[ 


TnzBBm!! 
UfpiciL Jortsii 


Poisonnllj', if lio interpreted the clause ri/jliLlv, ho believed tijnt 
the existing medical aid societies would not ho interfered with, 
but lie liopcd that no new societies would .bo allowed to bo formed. 
He did not agree with all that had been said on the question of 
matcniit}* mortality. Tho greatest di/Tjoult}’ of all was wot tho lack 
of medical aUcndanco or sufiicienl nursing attendance; it was Uic 
conditions under which the conriuomcnt took place which w'ns the 
danger at the present time. A great move towards improving tlio 
condition of affairs would bo to move such patients into a homo, 
where they could he attended to hy their own doctor and their 
own nurse. Tlio essential thing in ophthalmic benefit was flint 
the insured person should receive cfiiciont and sat isfnctor^' advice, 
and the scheme which the British ^lodicnl Association )ind siig* 
gested to supply a sufiicicnt number of trained doctoi's who would 
work at fees suiinhlo for improved socielics was the best way 
to deal with the subject. Ophthalmic clinics would be run bj' 
qualified men, who would give the host attendance and nltcnlion 
at the lowest price. He hoped that the Minister would not allow 
freedom of choice in tliat matter. An omission from the bill was 
ill regard to the question of secrecy concerning venereal disoaso- 
The Minister knew that a guarantee or promise was made to 
panel practitioners that any information received in connexion 
•with the treatment of venereal disease was to ho lield secret and 
inviolable. That guarantee or promise was made also to insured 
people, but now a judge in the High Court bad decided that a 
panel practitioner couht be compelled to disclose such information. 
TJio Minister ought to iccognize this difficulty, and something 
should be put into this bill to meet it. He would ask the Minister 
to remember that there was a preventive as well as a ciiratu'o 
side to national health insurance, and peiTonally he had doubts 
as to wlietlicr the most economic way of getting rid of their 
surpluses was by establishing dental and ophthalmic boncfits. At 
the ages wlion tlioso benefits applied people as a rule were capable 
of full work, and could afford to pay the dentist .and eye surgeon. 
More good would be done if instead of pushing their surpluses 
forward they pushed them backward, and did something to 
oslablish clinics for rheumatism, where they could get at iho 
children and tlic young people after scliool age, when rheumatism 
was so dangerous* give sunshine treatment, and hy other means 
help to establish a firm foundation of health at an early age, so 
that when they did enter industrial life llicy would be fitted for 
it in every way. 

Mr. John said that Clause 3 would abolish medical institutions. 
Speaking as one who had been connected with medical institutions 
for the last sixteen or seventeen ycai’S, ho could not understand 
the reason for this. No complaints had been brought against 
these institutions, and they were subject to approval every year 
by the Insurance Committees. The medical institutions w'cro 
really getting down to the fundamentals and objectives of (bo 
National Health Insurance Act itself, on tlio lines of attempting to 
co-ordinate the whole of the medical services. The benefits not 
only included what was contained in the regulations with regard 
to medical service, but the other benefits or tlio medical ifi.stitu- 
tions. He was a member of a medical institution called the 
Mid-Rhondda Medical Aid Society, and in addition to the medical 
benefits contained in the regulations, such as proper aid and dia- 
gnosis of the complaint or aiscase, they had the use of (he patho- 
logists and second opinions with respect to expert specialist advico. 
Dr. Davies had been arguing for the right to increased benefits 
in the direction of pooling a certain proportion of funds for (ho 
payment of experts or specialists. That w’as not necessary with 
the medical institutions, which at present provided expert and 
specialist advice and special treatment. They also provided all the 
laboratory facilities, and dental and ophthalmic treatment and 
benefits. Everything necessary for the patient from (he curative 
point of view was provided by the institution. Every member liad 
^ choice of doctors. Every six months ho could contract out 
of the scheme and go to the individual practitioner. Again, it 
tnie that the lajTnan controlled (lie medical provision. 
He (Mr. i^lins) had brought the qualifications of the medical 
institution before the House in order to appeal to (lie Minister not 
to dissolve these institutions. 

Greenwood, supporting the rejection of the bill, said 
that the measure did not meet what was undoubtedly the national 
need. The existing sysfem, within the limits laid clown would 
certainly be improved, but that system was not broad or largo 

■ enough. The Minister ought to have turned his mind to tlio 
tremendous question of how to develop the health service to the 
maximum on its preventive side. The annual reports of the chief 
medical officers of the Ministry of Health and the Ministry of 
Education referred every year to the enormous amount of pre- 
ventable disease which ultimately was found battening on the 
health insurance fund. There was no more serious problem to-day 
than the standing disgrace of 3,000 deaths of mothers in child- 

■ birth, and the right hon. gentleman, if ho had not been pre- 
pared to accept all the recommendations of the Royal Commission, 
should at least have ensured that the funds were available to 
deal with this great problem. The bill, however, left out one of 
the most important steps that ought to be taken in the extension 
of the national health insurance service. 

' Sir Kingsley Wood, replying to iNe debate, said that all the 
’leaders of the approved societies desired that the bin should have 
' fi soeedv nas'^a'^e. But for the opposition of the approved 
-societies it would be perfectly possible to put into operation the 
scheme of specialist services without bringing ^y additional 
funds into the national insurance system at all. No one Imd a 
right to say in tliat House that the specialist sernces were not 
being adopted on account of the Economj' Act or of anj' question 
of finance. The Royal Commission went very carciuily into the 
qticstion of specialist services, and stated that if the approved 
societies would come to an agreement and pool their funds that^ 
Fchcme could be put into immediate operation without any further * 
addition whatever, either by way of extra contributions or of 


mont nTn that medical treat, 

rnont sliould be provided for tlic dependants of insured ncreoia 
would mean brinpng m altosotlior, including the peopFe arto 
nero nlrcady in the sclietno a total of not fewer than 31,000,000 
people, and the cost would ho an additional £10,000,000 a year. 
Ho could assure he House that the Minisfer o{ Health would 
pivo very syrnnathcfic consideration to any amendments moy^ 
m committee wiiicli were designed to improve the bill 

Tlio amendment was rejected by 206 votes to 95, and the 
second reading was agreed to, the bill being committed to a 
standing committee. 

On April 3rd Sir J. Gilmouk infonned Mr. Stephen that he did 
not intend to abolish tlie Panel Committees appointed in con* 
nciioa with the national liealtli insurance scheme. T)ie term of 
o/Tico of all Panel Committees in Scotland was extended by 
regulations till May 31sl, 1929, and the Glasgow Panel Committea 
would, therefore, fall to be re-elected at that time. 


JJcorffOTtiznfion o/ Offices {Scotland) Silt: 

In Standing Committee on the Reorganization of Offices (Scot 
land) Bill, on March 20tli, an amendment to retain in existenci 
Hio Scottisli Board of Health was negatived by 27 votes to 18. 
Tiio amendment was moved by Mr. JonssTON, who said tlicre 
was no demand in Scotland for the abolition of the board system, 
and no resolution from any public authority had been produced 
in support of tlio cliange. Sir Joint Giljiour said there had been 
a number of complaints about delays in settling certain questions. 
In Eneland llic hoard system had been replaced by the depart- 
mental system. He liimself had found the board system mgt 
inconvenient for carrying on tlie business of the country. He 
could not get from the chairman of the board m Edinburgh the 
direct and immediate advice which every other ^mster could 
S from the head of Ids department m England. The ah<>''tion 
of tho board would not prevent the interests m Scotland which 
were concerned with problems of liealth from direct consultation 
with the Department of Health. That department and the other 
nrtttr flAnartmcnls would continue to bo in Edmbtirgb, as in the 
nast ^fo^r ns long ns Parliament determined. ' Dr. Snras said the 
Board of Health was tlie most progressive government depart- 
,nenf in Scotland or England, and its annual report was a 
ItrLuvit^ n licallli matters, in supervising the 
of lo a" authorities, and in t^o inspec ion of .J “ 

have, been done so elTectively by a single ■nd'’'''’"?!- the 

the head of the was'rbe rde merely 

“‘inUdffiatrtorhntel oto^ Ms work would suffer. Dr. Emoi 
** orinciplc of adminislralivo conccnti-ation had PS 

‘^o' sSvv'uo -aKo^tprsrth^^^ 

Scottish services would remain as groat as in the pi^t. 

Sfeease .'vaf. '?Ie‘added'^ that tTm. Acts in question did 

To^'roquire not£ation ^to he^del^^^ 

■ma'drs'’ol”^y “ t'‘“ lamination. 

"Idtaiion of S’S 

.^fslricU Vd the fa^ 

Government undu'- Ho^ hope of 

wo» 

Wales. invadoKrihe^^disease. and 16 uases had occujr^j 

tions t'ud been ” jjp ^ under the Lunacy - "jirF'clly under 

in institutions “ut {huso institutions were only mdirccliy 

Deficiency Acts, ^u , , 

the Minister of ilcaiu _On April 3rd 

■ - Coses from Artificial SUh ii ,i,ere had b"," 

Emission i./formcd Mr. B, Young that Iheie ^^ 11 , 

Sir Knroso^ '' unpleasant gases frqrn the health of 



SdciVs'having fnithor investigation made. ^ 

y,„cr,nition«/ of ’ J eS/S 

o^"?.m‘Lp||nceofcfficiency^^ 

eyesight, of tbs tii .„iination Commission Mg dcparlmcnt 

tfie fntornational lUnnunaU^^^ us dcp^„„„„l 

in September. ^ * ^cd at the conference, i 

would not be >:cprc=ented at in j, tuient of Seen 



Arniii 14, 1928] 


MEDICAr. NEWS. 


[ Tttt Critiss 
3il£DICAX. JoCltNiS 


649 


Industrial Research. Certain of the technical and industrial 
organizations concerned in the subject would also send repre- 
sentatives. . _ . , 

!\oic.t in Jinef. 

On April 3rd Sir P. CuNUrrE-LisTEU told Lieutenant Commander 
Kcinvorlliv that the inspection of crew spaces on British merchant 
vessels wa's one of the duties of the Board of Trade survey staff, 
which numbered 198 in all. Any defects discovered were notified 
to the owner or agent, with an intimation that if the defects 
were not remedied tiie space would have to be added to the 
tonnage of the ship, and that this pioccdurc had the desired 
cfTcct. It had been his experience that wherever defects had 
been broudil to the notice of shipowners practically in every case 
they had been attended to. 

The total amount of the invested funds of approved societies 
in connexion with the National Health Insurance Act at December 
31st, 1927, was approximately £111,000,000. 


^£rbicc5. 


TERIUTORIAL MEDICAL DINNER. 

A REuyiOM dinneh, open to all past and present Territorial 
medical officers, including « la suite officers, xviU take place, 
under the auspices of the Territorial Army Medical Association, 
on May 11th, at 7,30 p.m., at the Connaught Rooms, Great 
Queen Street, W.C.2, with Alajor-Gcneral Sir Richard H. 
Luce, K.C.M.G., C.B., AI.P., in the chair. Price of dinner, 
.12s., e.vclusive of wine. For tickets application should be made 
to the Secretary, Territorial Army Medical Officers Association, 
36, Russell Square, W.C.l. 


Slntbtrsiitcs anti Colleges. 


UNIVERSITY OF OXFORD. 

The Electors have awarded the George Herbert TTunfc Travelling 
.'“cholarship, 1928, to Thomas Holmes yellors, B.M., Oriel College, 
casualty surgical officer at the Aliddlesex Hospital, 

At a congregation held ou March 31st the following medical 
degrees were conferred ; 

B.M.— D. H. Brinton, Olivo H. Lister. 


UNIVERSITY OF DURHAM, 

•The following caudidates have been approved at the examination 
ludicated: 

Tninn M.B., B.S.— PatTiolooi/ end BacfeiHol^aVi Ztat^ria Me<1ic<i, 
Pliarmncoloou. aiulPharnutcv : Puhlic Health; Medical JuriS’ 
priaunce; H. XJ, G. Harrison. Patholoou and Dacrertoloov, Materia 
Meaica, Phanuacploau, General Principles of Therapeutics, ami 
J/mrmflci/,* Public Health ; Medical Jurisprvdence: ’A. R. D. 
Pattison.fJ.C. Arthur. M.Sc.. tA, Franklin, S. Adler W F. Cross. 
K. Panics, A. Dayjs, S. M. Gnrstcin, 0. M. Gillis. Katherine M. 
Girhnp. C. E. Goldberg. H. \V, T. Hall, J. O. Lawson, .T. A. Lonnox. 
Tw Maddlsoii. W. Mail'. J. H. »*ool, J, K. H. Scott. 

J. w. M. Stevenson, J. B. Tilley, H, AVillcox. J. Wolfe. 

* First-class honours. t Second-class honours. 

ROYAL COLLEGE OF PHYSICIANS OF LONDON, 

Av ordinary comltia of the Royal College of Physicians was held 
utSp.m. on April 2iid. ° 

The President, Sir John Rose Bradford, gave the annual 
presidential address and reviewed the work of the College. The 
iimnber of Fellows was 385 and of members 916, Gifts of the 
« -fuN 1 Fellows (Sir James Hope aud Sir Percy Bassett- 

smitn) had been received. The President gave an account of 
lie iiie and work of the following Fellows who had died during 
he year: Ernest Heiiry Starling, Henry Cook, Sir Horatio Bryan 
Uonkin, Charle.s Wilberforcc Daniels, Alexander Blackball 
Morison,. Amaud Jules McConuel Routh, Sir Percy WiUiera 
Bassett-Smith, Sir Dyce Duckworth, Sir Dawson Williams. 

I'errier, Hugh James Moore Playfair, Heury Lawrence 

McKisack, and AYilliam Joseph Tyson. 

Sir John Rose Bradford was re-elected President for the ensuing 
year. 

Wilmofc Heriiigham as representative of 
° of the University of London was accepted 

I repefc. It was decided not to fill the vacancy, as the 
^,3® University would shortly he appointed and 
e Uollege would not be represented ou it. The President was 
1 Pomted as delegate to the commemoration of Harvey’s discovery 
oj the Academy of Medicine in Paris. 

T Boissiei'e w’as declared to be no longer a 

• • College, having been convicted in the High Court 
(Guovee Division) of adultery with a patient. 

Tropical Medicine aud Hygiene was granted to 
the following forty-four candidates : 

C. R. Amies. MaiT N. Andrews, R - ' . . . ~ 

>1 Fairbairn. • 

M. M. I* ikn. O. M. Francis, W. 

in S' Har 

I^veVt Jolinston. E. B. .Tones, Marmret e! 

M a. a. E. jr. Slaci-aby, B. C. Slahajan, 

V‘r p -f- Oonvala. T. Paruktttti Ammal. 

G I Slmw J- D. Reynolds. Enid A. Robertson, 

Miman r;„e; 4' T Hilda M. . Smith. A. E. M. 
C. H. Wil&it H- Whitman. N. J. vrillans. 


iilctitcal Jitbs. 


The King hns appointed Mr. Laurence George Brock, C.B., 
to be n Commissioner under the Mental Deficiency Act, 1913, 
to fill the vacancy caused by the retirement ot Sir Frederick 
Willis. 

The next meeting of the Harveian Society of London avill 
bo held on Thursday, April 19th, at the Paddington Town 
Hall, at 8.30 p.m., when there will be a discussion on the 
treatment ot ulcerative colitis from medical aud surgical 
points of view. It will be opened by Dr. H. Letheby Tidy, 
followed by Mr. D. E. C. Norbury, Dr. E. Bellingham Smith, 
and Mr. C. P. G. Wakeloy. 

, A meeting ot the Society of Medical Officers ot Health will 
bo held at the Guildhall, Bath, on April 20th, at 2.30 p.m., 
when there will be a disenssion on causes ot the decline in 
tuberculosis mortality. The opening speakers will be Sir 
Robert Philip, Dr. W. M. Willoughby, Professor E. L. Collis, 
and Professor M. Greenwood. Before the meeting the Mayor 
of Bath will entertain members of the society' at luncheon. 
Those who intend to be present are asked to notify Dr. J. F. 
Blackett, M.O.H., Health Offices, Sawclose,- Bath, not later 
than April 16th. 

The following additional appointments have been made to 
tho staff of the Woolwich War Memorial Hospital : Obstetric 
surgeon, Mr. Harold Taylor, F.R.O.S. ; senior anaesthetist. 
Dr. de Canx; anaestliecists. Dr. Moore Smith and Dr. Dyson. 
Dr. Cowie and Dr. Moore Smith have been elected to tho 
medical committeo ot the hospital to represent the interests 
ot the practitioners in the Woolwich district. 

The Health Org.auization of the League ot Nation.s, follow- 
ing the policy adopted since 1926, has arranged a series ot 
special study courses for medical practitioners wlio have 
specialized orwho desire to specialize in malariology. Courses 
will be held this year in London from April 25th to June 13tl), 
in Hamburg from May 7th to June 13tb, in Paris from 
Jnne 1st to July 13th, and in Rome from July 2nd to July 
30th, tho instruction being given in each case in tlio Janguago 
ot the country concerned. Details may be obtained from tho 
Information Section of the League of-Nations, 16, Northumber- 
land Avenue, W.C.2. 

Following the establishment ot an ortbopacdlo branch by 
the Melbourne Children’s Hospital the committee is inviting 
apnlications lor tlio position of medical superintendent; 
details will bo found in our advertisement columns. A small 
experimental ward for orthopaedic work has been in existence 
lor about two years, aud its success has led the committee to 
undertake a larger scheme. The new buildings now in course 
of erection on a spacions site at Frankston, on the sea coast 
twenty-six niiies from Melbourne, will have accommodation 
for 100 patients, provision being made for physiotherapy, 
hydrotherapy, and occupational therapy departments, a 
gymnasium, and school rooms. All the wards will be entirely 
open on one side to facilitate heliotherapy. It is expected 
tliat the new hospital will be ready for occupation about 
May, 1929. 

A SOCIETY with the name of the London Jewish Ho.spital 
Medical Society has been constituted, with its headquarters 
at the London Jewish Hospital, Stepney Green, E.l. 

The King has confirmed the appointment ot Dr. Kenrick 
Stanton Wise (Surgeon General) to bo an official member of 
the Legislative Council of Trinidad and Tobago, and of Dr. 
Arthur Hutton MeShine to he an unofficial member. 

Health and Empire, the ionrnal ot the British Social 
Hygiene Council, has embarked on its third year with the 
Marcli nnmber, published by Messrs. Constable and Co., at 
2s. 6d. An editorial note explains that the conncil is anxious 
to extend the circulation ot the journal, and the current issue 
includes material in easily understandable form intended for 
parents and others concerned with the education of yonth. 

The League of Nations announces the publication of tho 
International Health Year-book, 1927, tho third annual volnmo, 
which contains reports on public health in twenty-seven 
conntries in 1926. These countries Include the leading 
member-states ot the League, the United States of America, 
and the Soviet Republics. Tho first three sections ot tho 
work deal with demography, budgets, and he.alth legislation 
respectively ; the fourth is devoted to the preventive aspect 
ot medicine, the fifth to its therapeutic side, and the sixth to 
general questions, such as the control ot foodstnffs, water 
supply, and health insurance. Copies may be obtained from 
the Leagne ot Nations Publications Department, Geneva, tho 
price being 16s. in paper wrappers, or 20s. in cloth. 

A chair ot tnhercnlosis, founded by the Conseil General do 
la Seine, has just been established at the Facnlte de Medeciue 
ot Paris, and Professeur Leon Bernard has been appointed as 
. its first occupant. 


650 Apriij 14, 1928] 


LETTERS, NOTES, AND ANSWERS. 


( Tur Brrrtw 
MtxiiCiz Joccyit 


Tub Congress ot Fronch-spoaUlug Alienists and Nonro- 
legists will 1)0 licid at Antwerp, under the presidency et 
Pretossers Henri Claude ot I’aris and Auguste Ley of 
Brussels, eu July 23rd, when tbo fellowing questlou.s will bo 
discussed: catatenia, introduced by Prol'ossor Paul Dlvry ot 
Liege ; neuralgias ot tbo upper limb, introduced by Professor 
H. Roger ot Utar.scilios ; and treatment ot gouoral paralysis, 
introduced by Drs. B. Dujardin otBrussclsand RcncT.argiowa 
ot Paris. Eurthor inforiuatiou can bo obtained from Ibc 
general secretary. Dr. F. Mceus, 21 Norviorslraat, Antwerp. 

The first congress ot tbo Gorman society for rcscarclies 
on the circulation was liold at Cologne, under tlio presidency 
ot Dr. H. E. Horing, on Marcb 5tli and Gtb ; it was attended 
by 150 meinber.s from all parts ot Germany and ropresonta- 
lives ot eight foreign countries. Tlio chief subjects for 
discussion were tbo problem ot circulatory wcalcuoss, intro- 
duced by n. Eppiugcr ot Freiburg, and tlio formation ot 
normal aud abnormal cardiac stimuli, introduced by J. Ribl 
of Prague. 

The third Polisli Congress ot Stomatology will bo held at 
Cracow in May on tlie occasion of tbo twonty-flftli anniveraalj' 
ot the foundation ot tbo Chair and Institute of Stomatology. 
“Dr. Aiabed Denker, professor ot medicine at Halle 
Hniversity, lias been elected a corresponding member of Ibc 
Otological Section of the Royal Society ot Medicine. 

Dft. Cecil Mitchel Rolston, ciilet medical ofllcer, has 
been appointed au olllcial member of tbo Legislative Council 
of the Presidency of Dominica. 


%dUvs, aittr ^itslucrs. 


n 


' ! 7 brcatlunj', as if oC ctinlinc ovij'in 

uilJjoiit ilionclij, but tliei'D ik ho valvular trouble. The catarrh 
bccftiiie worse iiftor stiiyiijt. at an Iiotel fifteen mouths a^o, 
^\lieic a parlicuiarly virulent type. of inflnenzii pcemed to be 
prevalent. -I-bo patient, a woman a^'od about 45, dovelopeil au 
Hcnlc attach of innnenza after reaciiin^; home, with the astlmm- 
liUc symptoms. 

Incomk Ta.x. 


J^. * inquiron whether a boolclet is piiblislied with special 
reference to income tax roturna by medical men. 

We arc not acquainted with one, and can onl^' sujjgest 
Unit our correspondent should pretmre a statement seftfn^^ out 
nil the expenses which he coiisider.s may reasonably be re^jarded 
ns havinj* been incurred for professional purposes, and enclose 
n copy with his income tax return. Wo shall bo pleased to deal 
with any specific question whicli maj’ arise in the jireparntion of 
the f*tatemeiit or after its receipt by the inspector of taxes. 


Expenses of Illness. 

]^n3iox ” liad an illness in 1927, and inquires as to what expenses 
he can deduct in computing his profits for that year. 

*** The cost of the locnmtencnt, including expenditure oh 
hoard, service, etc., wlien supplied, can be dedneted as being 
incttcred in the earning of the profits of the practice, and sitni- 
larlv with regard to any payments that may have been made 
for services rondored to hi? clients. 13nt payments made— for 
example, to tlio nurse, radiologist, etc.— for personal services 
rendered to onr correspondent are not proper subjects for 
dcdtiction. Admittedly they were necessary to maintain him in 
ix. position to continue to earn an income, but it is clearly estab- 
lished tliat their personal nature takes them out of the allowable 
class of expenditure. ' 


All communications in regard to editorial btisincss shotitd be 
addressed to Tho EDITOR, British Modical Journal, British 
Medical Association House, Tavistock Square, W,C.1» 
OUIGINAL ARTICLES and LETTERS forwarded for publication 
are understood to be offered to tho Britisk Medical Journal 
alone unless the contrary be staled. Correspondents who wish 
notice to be taken of their communications should authcnticato 
them with tlieir names, not necessarily for publication.* 

Authors desiring REPRINTS of their articles published in tho 
BnmSH Medical Journal must cominunicalc with the Financial 
Secreta^ and Business Manager, British Medical Association 
House, Tavistock Square, W.C.l, on receipt of proofs. 

All communications willi reference to ADVERTISEMENTS, as well 
as orders for copies of tho Journal, should bo nddressed to tho 
Financial Secretary and Business Manager, 

The TELEPHONE NUMBERS of the Brili.sli Medical Association 
and the British Medical Journal arc ilUSKVit OSGt, USOi, VSGS, 
and VSG^ (intoinal exchange,, four lines). 

The TELEGRAPHIC ADDRESSES : 

EDITOR of the British Medical Journal, Aidologij IVQstccnt, 
London. 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.). Articulate Westernt, London. 

MEDICAL SECRETARY, Westrent, London, 

The address of tho Irish Office of tlic British PJcdical Association 
is 16, South Frederick Sheet, Dublin (telegrams: liacUhts^ 
Dublin-, telephone: 62550 Dublin), and 'of the SeoKisli O/Ilee, 
6, Drumsheiigii Gardens, Edinburgh (telegi'ams : 

Edinhiirr/h Iclephouo 24361 Edinburgh). ' 


QUERIES AND ANSWERS. 


A Faf.cal Fistula Pad, 

> Tube ” asks for suggestions for au appliance or pad to protect 
a faecal fistula. Although the discharge is very slight, itneccssi- 
tales at present a chuugo of the adhesive plaster and gauv.e pad 
about twice a week. 

Radical Cure of Herpes Genitalis. 

Du. D. S. POTTANNA (Vienna) asks for suggestions as regards the 
radical cure of herpes glans penis and preputialis. Local treat- 
ment relieves the condition temporarily, but fresh crops of 
herpes come and go for many mouths. 

Cure of Chronic Blepharitis. 

V A. R.” asks: Cun a permanent cure be effected in a case of 
chronic blepharitis of fourteen years’ standing in a girl aged 18? 
There is no error of refraction and' the general nutrition is now 
satisfactory. TJie usual silver applications (nitrate and protargol) 
and mercury ointment give temporary improvement only. Are 
staphylococcal vaccines useful? 

Paroxtsm^l Coryza. 

“F. D. J.” asks for advice in the treatment of a chronic and 
occasionally very acute mucous nasal discharge, which comes 
on at any time, but is often worse at night, preventing 
sleen for hours. The turbinate bones have been cauterized, the 
teeth dealt with, and au autogenous senim has been tried. 
Various sprays and douches have been employed withontbeneflt. 
The antra are normal. Acute basal congestion often follows an 


letters, notes. ETC. 


Nephrostomy. 

Mi> T r Graham, F.R-C.S.Ed. (Bishopstokc, Hants), writes with 
reference to Mr. J. F. DobsoiVs explanation of the use of the 
evm •• nci'hvosloniy ” (Jouvml, April 7tl., p. BIS) : 

With nil due deterenoe to Mr. Dobson, I consider the term 
n,i'',,,,,rcd in the case in point. Tlie term "nephrotomy” 
rucltidcs nil iiecessnry droinnse nHer operation, with n view, 
llJf, to eventual closure. "Nephrostorny, onthe.otliet 
I'n I,,? means melting ii stomn or month— immely, a permanent 
That Jlr. Dobson does not iiiteiid the latter is ohvions, 
t o^flvst case mentioned in his article (March 24tli, P- 48^ 
iienhrostomv alone ” distinctly proves, lor he Bn.)s with 
’'.'.ifimitsatisfaclioii ” tlie wound healed completely m a very short 
cuden s " ncplirostomy ” in such a cose is obviously 

^''•"?’nrihiL' If this uoinoiiclatnre is adopted we will soon be 
rpeoUhig of o-tteriial nretlirostomy aud traclieostoniy. 

SHOCK IK Black Eacb^. 

V w HoAKB (Salford) agrees with Dr. Dickson (March 24th 
that the colonvcd races moke good surgical bid bad 
P' I .mtieiiK He writes: My first exporieiioe on t East 
mediciil patic ^ fell down au empty sliip’s hold and lauded 
was Whciin nropeller shaft casing. Taken out ns 

on k'® ' pioced mideu a gangway out of the sun. In a few 

dead, ko ' ^.ered, had a drink ot water and Iialf an onion, 
"'T'vVif- two hours’ Bleep was back ot work again. Ljvter on 
E'wptiniis Operated on for stone in the bladder 
I BOW '"iiLtir After the dressings were applied they 

witlioiit a'i d' . operator’s hand. In the war, 

rolled oft the t ohiiieso, the converse was illustrnled : a very 
with Indians and Dm e . itined them at once 

'‘“r.nnate nS^al^rounds. Yet an Arab cliild with 
on no '‘dem me ’ indifferent. to its iiijiuies, and 

TOCES IK CAKADA. 

A kcmeke of ^ ^vs desi^d t^meet the ne^ 

Cnnaraaiid])k’t^taj^linesn. twenty-three 

National “^ouniey ot 6,60D miles, but permits a ef“I p' 

days. VaMorii Canada, while another, a tonr ot s * 

n mil week ‘‘ Canada, permitting ^ke crossin and 

weeks, gives fm "ptinent by different routes, with Hnee doj 
i-ecrossmg of tlie con „ , ■’j Kooky Moiiutaius, two dB}3 

in the Nat.o.ml^Eark Vanconver 

on the Other tours vary in fiuratiou b^tuee 

on the Faciflo c , ^ official escorts attached 

I’^'^-ll'rSponsTbilitj^ ^ke organizers have aimed at keeping 

costs as low as possible. 

Vacancies. /.rtiiprffls 

will be found at .f ’ ^to partnersbips, 

andTocurnmn^nl^^ io tbe advertUemont 


ArKlIj 21, 19=8] 


TnE MENSTEUAr, FUNCTION. 


[ Tnc Bnin^n 
MfDJCAI, JOCRA-Ai 


651 


HSritiiilr ^ssoriatioir ?Cfrhtr£ 

051 

PRACTICAL APPLICATIONS OP RECENT YIEWS 
ON THE MENSTRUAL PUNCTTON. 

Given- to tue SuErriniJi Vivisios , Decejibeji Drn, 1927 , 


BECiaHTH WHITEHOUSE, HI.S., F.E.C.S., 

TEOFESSOR or GYNAEcbtOOY' ANIl OBSTETRICS, ' UNIVERSITY OF 
CIRMISGHAM ; CYNAECOLOGICAL SURGEON, GENERAL IIOSFITAL, 
BIRMINGHAM; surgeon, BIRMINGHAM MATERNITY HOSPITAL. 


Sir.inge beliefs .olioiit iiiciistni.Ttion nro very ividcspvc.icl, 
and tins clonient of mystery seems, ns Novak says, “ to 
have inhibited intelligent efforts to study.” It was taken 
for granted that the funetiou was essentially a cleansing 
]noccss, its purpose being to cleanse the blood of various 
impurities, a view still held to-daj’ liy not a few lay 
members of the community. One of the important practical 
applications of recent views on the menstrual function is 
the sweeping aw.Ty of this atmosphere of superstition and 
speculation. During the last few years what may bo 
described jis a new “ sexual physiology ” has been written, 
and facts have come to light ivliich iirove that the liiiman 
species in essential details shows but a variation of sox 
plienomciia common to other members of the mammalian 
family — a vari.atioii dcsignctl to secure tlio maximum 
reproductive activity. This knowledge in duo com so must 
piodiico in the lay mind a more natural atiiiosiihero nitli 
regard to everyday ideas about tlio mciistiual function, 
p lieu menstruation ceases during the years of active sexual 
life a woman, if not pregnant, still coniinoiily believes her- 
self to be retaining some noxious principle to the dotriracnt 
of her licaltli. Also many members of our own profession 
still regard the menstrual function as being nothing more 
than a preparation for pregnancy. 

I need not describe at length the observations and 
experiments which lim-c led to the modern coiichisiou that, 
in the human species, menstruation is a composito function 
luiolving two distinct factors. It is necessary, however, 
0 state briefly the nature of the essential factois, as other- 
wise much of what follows liiay I,c difficult to comtiicliciid. 

,p, 2’^';- Ocsiroits Cijclc. 

10 tune when physiological activity of the reproductive 
jys cm occurs in mammals is called the sexual season, and 

11 *.'^ Ins period a scries of cyclical plicnomcna take place 
eyries.” Each cycle is physiologically 

dnitlcd into four separate phases: 

I' t (amenorrliocn). 

P nod of growlli and functional activity of the sexual 


organs (pro-oestrum) 

(oestrum)”^ " ■when fertilization is effected 

^ ocTt'rum)?^ pregnancy or “ pscudo-prcgnancy ” (met- 

variation occurs in different species with 
° presence, absence, and duration of each of 
subsections of the ocstrous CA cIe, and also with 
sp?,Ai ° number of complete oestroiis cycles in cacli 
Bleeding, aitificial selection, and luxurious 
stxinl n'-*i introduce great i-ariaiion into the 
cpvh':, N j ”'* i''mls — a fact comnionly utilized in 
eeitain breeds of domestic animals. 

differen'w* from flio genital tract in the case of 

In snmn occurs at two points of the ocstrous cycle, 

so-'-i nt ’ ^ A'*'*; b slight bleeding from tlio ntei-iis is 

livncipprr,- I'vo-oestruni due to extreme local 

ci.w organs. Iii other types, as the 

liiceimiir-- f' ™ly_ oeenrs at the end of the psciido- 
lii vet mV ”"d expulsion of a false decidua, 

var DiK i'V oxamplo,- sheep, mare, sow, and 

®r;uvs at a'l? eitl, uterine cavity 
tioii or'iluVi,’, • '"I' Bis stage of pro-oestrual conges- 

g iiiAohitioii at tile end of pseiido-2Jrcgnaiicy. 

In the 2 Iumnii Female. . 

toeiitii fn +l,p j*”. ovulation occurs from the tbir- 

this noint'^aTt menstrual cycle, and 

1 • tate of pseudo-pregnancy exists until its 


termination about the twciity-oiglith day. Necrosis of the 
menstrual endometrium, or “ decidua ” as it should be 
called, then takes jilaco and external haemorrhage begins. 
Fari passu with the completion of the pseudo-iiregnancy a 
state of jiro-oestrum develops, which also reaches its acme 
about the tivonty-eighth day of the cycle, and persists 
during the expulsion or .abortion of the jiscudo-jircgnancv. 
Tills is followed at the concinsiou of the menstrual haemor- 
rhage by a short oostrual period — Nature’s provision to 
promote fertilization of the next ovum to be liberated from 
a maturing Graafian follicle. 

The menstrual discharge in the human species, therefore, 
normally contains blood as a lesult of two distinct factors-^ 
namely, that resulting from necrosis and abortion of the 
pseudo-pregnant decidua, and that duo to jiro-oestrual 
hyperaemia. Tiie blood is mi.xed with the secretion of tlie 
uterine glands liberated as the result of necrosis of the 
superficial or compact layer of the menstrual decidua. In 
all mammals activity of the uterine glands is a jirominent 
fe.Ttiire of pro-oestrum, and the human species is no ex- 
ception to the rule. The glands of the body and the cervix 
jirobably have, however, a very different function. The 
secretion of the corporeal glands is jioured out onl}- after 
necrosis of the endometrium has occurred. It contains 
excess of calcium, a ferment or “ thromboljsin ” which 
dissolves blood-clot, and apparently also a hormone which 
stimulates oestrus. The cervical glands, on the other hand, 
onl}' produce, mucus, and probabl}- their function is to 
facilitate the passage of jiroducts from the coi'iius uteri to 
the vagina. 

The glandular activity of the endometrium during tlie 
jiro-oestrual state is a very interesting phenomenon. It is 
moi'e than possible that the liigli calcium content of the 
secretion is a iirovision of Nature for the needs of the 
developing ovum should fertilization occur, ns is the case 
with the so-called '' mare’s milk ” of ungulates. The other 
great function of the’ secretion is to dissolve and clear aivay 
the product.? of the unfertilized abortion or unwanted 
decidua if fertilization is nob effected. This fact has a 
practical application to which I shall refer presently in 
connexion with the cause of nienstnml pain. In the light 
of recent work upon ovulation and tlio corpus luteum, 
menstruation must be regarded as representing iirimarily 
the end of a pseudo-pregnant state resulting from tlio 
preceding ovulation. Tlio unfertile abortion is in addi- 
tion comjilicated, and in a sense masked, by the verj- 
evident glandular activity, oedema, and h3-2)eraemia of 
pro-ocstrum, superimiiosed upon the primary phenomena in 
readiness for the next ovulation. 

It is a proA-ision of Nature to waste no time. Not only 
is anoestrum or the “ rest ” period in the human species 
completely abolished, but Avhilo the remains of tlic previous 
debacle are being cleared awar- the stage is being set for 
the next scene, ivliieh Nature trusts maj- ho more success- 
ful. Appreciation of the fact that menstruation involves 
two functions in the sexual c\ele, each sen-iiig a definite 
physiological process, hut overlapping tlio other, throws 
light upon W'liat otlionvise is a difficult problem. 

“ Oesfrin ” and “ Ovarin.” 

The menstrual function iias been studied during recent 
years from both these iioints of view. During the last 
tweh'e months references to the ovarian hormones, jiar- 
ticularlj' the so-called “ oestrin,” liai-c frequently ajiiiearcd 
in the medical press. Now the lecognition, isolation, and 
investigation of the phj-siological properties of oestrin is 
rescarcli associated ivitli the iiro-oestrual and oestriial 
factors of the sexual ci-cle. On the other hand, the clinical 
and experimental observations resulting from destruction 
or remoA-al of the Graafian follicle or corpus luteum are 
concerned ivitli the pseudo-pregnant aspect of meii.struation. 

The c.auso of pro-ocstriiin and oestrum is niidoiihtedK- an 
accumulation in the tissues of the hormone oestrin demon- 
strated bA- Allen and Doisy in America and by Dickens, 
Dodds, and "Wright in this country. This oestrus-pro- 
ducing hormone, although present in the liquor folliculi, 
is not confined to the follicle. It has also hcon demon- 
strated in ovarian tissue Avitlioiit follicles, in the human 
jilaccnta, and in the secretion and tissues of the uterus. 
It has not, lioAAever, been found in the corpus luteum, and, 

L35”] 





'662 A'pbil 21, 1928] 


THE MENSTRUAti EONCTION. 


- r - THtDamai 
LMKDrat Jorwii 




nccording to tlic recent experiments of A. S. Parkes, its 
|)ro(hiction is also iiulcpendcnt of ovarian follieiilar 
.activity.' ' ' 

At the present time tlicrc appear.s to bo rAtlicr a wide 

■ .spread opinion tliat the oostnis-prodneing liornioiie is all- 
important in the production of menstruation in the linman 

. species. Personally I am not prepared to admit that it 

■ is more than one factor.' Ocstrin will cause liyperaetnia, 
develojjment, and glandular activity of the uterus, but 
there is no evidence to shoa- that it produces growth of 
the ondometri.al stroma ahieh, when com])leted, eonstitute.s 
the decidua. Decidual development requires the constant 
stimulus of another hormone of the ovary — “ ovarin,’’ 
present in both Graafian follicle and corpus hiteiim 
Ocstrin cannot be demonstrated in the corpus luteum, and 
yet, when this body is excised, necrosis of the endo- 

'inctrinm with haemorrhage always occurs. It terminates 
the .pseudo-pregnant state. 

An interesting scries of observations carried out in -my 
department shoa'cd not only that destruction of the corpus 
luteum results in necrosis of the endometrium in from 
. forty-eight to hoveuty-two hours, but that similar trauma 
to ripening Graafian follicles also produces a like elfect. 
In other words, the integrity and development of the endo- 
imetrium require the constant supply in the circulating 
blood of a hormone other than ocstrin, and elaborated in 
both follicles and corpus hitoum. If this sujiply is cut off 
for any reason, then the endomolrinm nccrosc.s at whatever 
cslago of. development it may be. The fact (bat menstrua- 
tion occurs with necrosis of the endometrium within a feu- 
hours of exci.sion of the corpus luteum appi-ars to provide 
indisputable evidence of the inde(iend('nce of ovarin and 
Do.strin. Doth bormonos are important for the econpniy of 
the individual and Iho mainlonance of the .sjtecies, • biit 
each serves a separate function. 

The c.ssentinl points, therefore, in (ho theory of menstru.-i- 
tion which 1 am .setting out are these: The menstrual 
function, in the human female ropresent.s two things—' 

(1) The nbortion of a useless dccidim of (lie pscitdo-pregiiaiicy 

corresponding to the preceding ovuintion. 

(2) The acme of pro-ooslrum to promote fertilization at the 

succeeding ovulation. 

The abortion is the re.sult of cutting oft' the supply of 
ovarin through death of the ovum and its corpus luteum. 
Pro-oestrum is caused by accumulation in the tissues and 
uterine glands of ocstrin. 

These views receive a practical application when the 
various pathological conditions associated 'vith the 
menstrual function are considered, lu view of the conf- 
])lcxity of the function it is not surprising that anomalies 
of it are common ; indeed, it woidd be strange were it not 
so. The establishment and regularity of the. normal 
menstrual rhythm in health from puberty to the menopause 
is a very remarkable phenomenon, and ivhen we take into 
consideration the changes in the sexual cycle which can 
artificially be produced in other members of the mammalian 
family by such factors as changed environment and fcod- 
-ing, it is only to be expected that the conqdieations and 
complexities introduced by ev-olution and civilisation will 
be reflected in variation from type. 

“ White Menstruation." 

Such variation usually proceeds along progressive lines, 
but occasionally phenomena that are atavistic or rev-er- 
sionary are scon in the human s 2 )oeies. It is important to 
lemerabcr that atavism can occur with regard to plij-sio- 
logical function just as it does with anatomical structure. 
'Two or three examples will make the point clear. Tlie 
first is the phenomenon known as “ white menstruation.” 
Tudividuals are occasionally .seen iii wliom the- menstrual 
function' is - never exhibited on, noimal lines," in .that no 
haemorihage occurs, ■ .although the conformation and struc- 
ture of the sexual organs .pre.sent no abnormality. Such 

P 5 ;pgi*iencc the usual. nienstiual molimina attribut- 
able to the onset of the “negative ph.aso” .and the develoii- 
luont of pro-oestrum-; but thp subsequent desebarge consists 
of the secretion of the uterine .glands only-. There is no 
endometrial necrosis and no external haemorrhage. Por 
ii iiarallel wo- mn.st study the sex cj'cle of- a iiolyoestrous 
• nianimal such ns the. merino, slieep, where the end of 
psendo-jiregnaney is not .accompanied hy tissue necrosis. 


Alinor degrees of the same atavistic type are not so ut 
eoiiinion. In these subjects tJio menstrual haemorrhage i 
very slight and may only ho -present for a few horns. 0 
L tiio other iiand, the jieriods may be separated by what at 
' apparently long intervals of amonorrhoea. Patients of th; 
typo commonly also suffer from severe menstrual pai 
caused hy defective jihysiologieal function of the iiteiiii 
secretion. 

The important jiractical jioint is that ovulation 
normal and therefore fertility is not impaired. Hence 
is -im wise ever , to express an ojiiniou ■ upon the poss 
hillty of pregnancy in cases of apparent amenorilioe 
without first making a very careful plysical examination. 

“ Vicarious Menstruation.” 

Another interesting anomaly of somewhat similar typ 
is the so-callcd “ vicarious menstruation.” 'The explnm 
tion of tlicse interesting cases probably lies in an abnbfmt 

■ and e.xocs.sive pro-oestrual hjqieraemia,- associated with at;: 

■ vistic nhscnce' of endometrial necrosis. A parallel can I) 
found in tlic corneal haemorrhage which occurs during th 
iiro-op.sfnim of some rodents. On two occasions I hav 
kiiown Imeiiiatcinesis occur during the pro-ocstrnah state 0 

the domestic cat. ' . . 

Another c.xplanation of vicarious mcnstrn.ation is uii 
h.alaiiccd iiition between the psendo-pregnant abortion am 
Ihe -nio-ocstrual state. -The local- congestion -and -gcner.i 
vnso-dilatatioii pfodneed by the activities of bestrm an 
Gormallv relieved by the' liaeihorrlmge wliicb ensues wliei 
t'be- pseinlo-iwcgnmicy ends.-- If for -various reasons, a a 
vistic 01- otherwise, tliis pliysiological necrosis docs no 
take place, the congestion is likely to be relieved . 
•l-iiemorrli-.i"c-from otlier mucous surfaces.- Tbero -is, . 
- S 'Ac-? little doubt tbat.altboiigh both, factors of.t n 
'm stru-d-’phhnonicnon usnally 'coincide, either maj h 

^motiht "Rivin- to an exaggerated pro-oestrual state 

i cl me ®cnscs° of hypertlijToidism there is evidence ol 
-In some ernes 0 ^ i3 „o means alway; 

with hicreased fertility -or even increased men 
Ls * ln exoiihtlialmic- goitre; during -the earl; 
i-nnw that menorrlmgia is the rule, and can bi 
stages, V ' excessive pro-oestrual conge.stiou snperim 

explained bj ex^essj^^^P 

‘’"'Tntior s suppressed, and although pro-oe, strum a 
^^'S^are Ten marked.- amonorrhoea is. commonh 

y"''.", tv’ and commonly dysmonorrhoea also, 
frigiditj, • example of atavism to which I sli. 

enii ‘utt^;?" ,4= Ztlf mSfLtili^Mh^^ mU 

case of -v gu - a solid rounded clot, which s\ipei 

eUscliai-ge. t ' nren-nant. It was interesting t 

married !‘merriage the menstrual discharge assumet 

“ ”” ” ■ ' 

intense pain. ^ accustomed to gibup our 

casis orilnli. Jlogicnl uterine !>aemovrlmge “gia.” 

phenoinena only, but it sufficed for the time. 



666 Aphid si, 192S] RINGWORM AND ITS TREATMENT. 


f TrfErnms* 

L MroiCAn Jockki^ 


OIT 

EINGWOEM AND ITS TEEATITENT. 


DelIVEHED BEFOIiH THE HeNBON DiVISIOK OF THE UltlTIfin 
Medicae Association 

BY 

J. M. H. AIacLEOD, M.D., F.R.C.P., 

PHYSICIAN FOPv DISEASES OF THE SKIN, C1IAHING CROSS HOSPITAL; 
CONSDLTANT PHYSICIAN FOB DISEASES OF THE SKIN, 
SIETROPOUTAN ASYLUMS DOAP.D. 


Inthoductohy. 

In selecting riiiguoim as the subject for tills locfiire, 
which your Div'ision has so greatly Iionoureil 1110 by asking 
mo to deliver, I have been guiilcd in my choice bj- CN()C- 
rionco that tho recognition of ringivorm is liable to prove 
a stumbling block to tho practitioner, and that the difii- 
cnlties of its successful treatment lire apt to be so great 
as to render it almost a subject of reproacb by the laity. 

Riiig'vorm is a common affection of the skin, due to a 
group of mould fungi, ivliicli may attack tlie glubrons skin, 
hairs, nails, and in rare instances, by oeitcnsion, the 
mneons membranes, tbo clinical appearances of wbicb 
differ according to the variety of fungus responsible, tho 
site of tbo lesions, and the individual pcciilinrities of the 
skin affected. 


RiNGAVOnJI Fcnci. 

Tile fungi-, or hypbomycctos, of riiiPivorm constitute an 
interesting group, which lias boon placed provisionally in 
the order of tbo Asconiycctos, and in tbo family of tbo 
Gymnosaceao. In tbo skin they grow ainicrobicaliy in the 
tonii of a network of mycelial tbroails or “ liyplme,” 
uhich constitute tbo i-ogetativc part of the fungus. Tlic 
liyphae break up into small sections, to wliicli tho name 
“ spores ” has been apiiliod, which in turn bec-onie 
elongated into new hyphae, and so perpetuate tho fungus. 
Other methods of reproduction occur if tlio fungus he 
grown anaerobically away from the skin. In cnllure, for 
example, reproduction takes place by clilainydosporos-, 
Avhilo in hanging drop preparations it takes ' place by 
endoconidia. Its true motbod of reproduction, liowcver, 
is aerobic, ivlieu it proliferates by moaiis of aerial bypbae 
with terminal and lateral buds. 

For many years it has been known that liiigwonn is 
due to a number of different fungi, wbieli are so closely 
allied and so similar in their microseopieal ajipearanccs 
as to bo almost indistinguishable, but are capable of 
differentiation 113’ cultivation on certain artificial media. 
Certain of them are found onl3' on the Iiuniaii skin, while 
a considerable number occur in lower .animals, mid in birds 
from which they are transmissible to man. The fungi are 
tiansmitted directly by contact, or indirectly by infected 
combs, brtisbcs, caps, clothes, bath mats, etc. It is even 
possible that the infection may take place hy spores blown 
about m tbo atmosphere, as dried spores have been sliown 
to be viable for move than a year, and might easily remain 
about rooms where infected persons had been. 


Pathogenic Action. 

The fungi of ringivorm have a double action on the 
skin; ( 1 ) a corrosive action on the epidermis, hairs and 
nails, owing to the elimination hy tho fungus of a kerato 
lytic ferment; and ( 2 ) an irritant action from their raniil 
growth and tho toxic influence of the ferment which 
results in inflainmatory reactions, varying in degree from 
mild eiythema to vesico-inistiilar or even grannioinatoiis 
lesions. The degree of inflammation is depondeiit oii the 
variet3’ of tho fungus — those of animal origin koine 
specially viriilonl — and the susceptibility of tho indiviflnal 
skin, Avhich maA’ he a natural peculiarity, or acquired as 
tho result of some constitutional distnihance. As an 
example of the latter happening, I iecentl3' had a case of 
riugAVorni of tho scalp in a cliild, in AA-liich tho lesions 
were of the diy, scaly, slightiv' inflamed type; an attack 
of measles supeiA-encd, and the. patches of vingAVorm became 
acutely inflamed, raised, and dotted OA'er Avitli vesico- 
piistules. 


Varieties oj Fungi. 

Tliero avo two main groups of ringworm fungi, known 
respectively ns tbo Sliciospora and the Tricliopliyta. 

1 . Microspora, — In Great Britain there arc four A-arictics 

of inicro-sporn Avhich are of practical importance — namely, 
tho ill. nmloni/ii (Grnhy, ■niim (Bodin), 

jl/. caninum vcl Uiitosum ■ ■ j/. fclineum 

(Colcott Fox and BInxall). Of these tho 31. nndouini is 
hy far tho most common, and is rospomsiblo for at least 
00 per cent, of all cases of ringu’orm of tho .scalp, and 
for a largo number of those of tbo glabrous skin. It is a 
human ringAvorni, uhilo tho other tlireo, as their names 
indicate, are of animal origin. It attacks tlio scalp in 
children, hut rarel3' tho adult scalp, a^ at pubort3’, for 
some reason so far unexplained, the scalp hccomos an 
iinsuitnhlo soil for it.s growth, and, conscqiientlA-, scalp 
ringworm in ehildrou, duo to this fungus, tends to 
di.sappcar spontaneously about tho ago of 14 years. 

2. Trirhophijla. — There are tAvo main varieties of tricho- 
l(li3'fa Avliicli attack tho human skin — namely (ii) tho 
T. cntlotrichcve, uhich arc of human origin, and (6) tho 
T. ecto-ciulolriihciic, Avhieh arc transmitted ftom animals., 

(a) In this conntiy there are three principal A-arietics of 
T. emiothrix, Avhich are distinguished hy presenting dis- 
tiiictiA‘C eolonr.s when groAvn on proof agar in tho dark — 
immely; (1) T. cratcriformc, a cream-coloured culture.; 
(2) T. fill pita re II III, a 3 'elloAv cratcriform culture; and (3) 
T. iiciiiniiifitiiiii, a greyish-3-elloAv acuminate culture. 

(b) The T. ccto-eiitMiichcoc form tho largest group of 
the riiigAA'orm fungi, and most of them are of animal 
origin. Tliey are responsihlo for the majorit 3 - of cases of 
ringworm in adnlt.s, Of these tho most common are: tho 
T. iiircitin of cats and dog.s; T. cqiiiniim of horse.s, some- 
times found in the beard in man; T. rosacciim of foAA’ls, 
in wbieb it gives rise to tbo discsiso knoAATi ns “ AA-bito 
cro^t ” ; and T. viohicciiiii, wbicb bas boon recoA’cred from 
siiiipurutive ringworm of tlic beard, face, and scalp. 

In addition tliero arc .scA-eral varieties of tricliopliyta of 
liumim origin, to v.-bieb the namo Epidcvmopb3-ta has been 
given svieb ns tbo E. ingiiiiiolc (Sabourand) and E. rubrum 
(Castelloni). Tlic.so are mainly ro.sponsiblo for ringAA-orm 
of tbo criitcb and axillae, and the ecBomatoid ringAA-onn 
of tbo feet and bands. 


ClLNICAL jVrrEAIlANCES. 

Glabrous Shin. 

Any part of .tho glabrous skin may bo attacked by ring- 
lorin tbo. lesions varying according to, tbo fungus rospon- 
ible and tbo typo of skin nffectod. They may bo scaly 
imeules, irregular, ringed, or gyrato in shape, A-esico- 
mstnlar patclies, or occasionally .granulomatous nodules, 
be more virulent lesions being usually of animal origin. 

Tbo iiitcrtriginons regions — namely, tbo crutch, axillae, 
leiicatli the breasts in stout women, and the iuterdigital 
nnccs between • tho fingers and toes — may be the .sites of 
i sDCcial variety of ringAvorm, Avliicb bas been knoAA-n 
-ariously as tinea cruris, dbobie’s itch, or eczematoid 
I'ncAVorni. This variety, which came originally from the 
Sort 1 ms increased enormously since the great Avar, as 
aVirc numbers of the truops campaigning in the East were 
nfocted Avith it, brought it home, and spread it among 
he civil nbpidation. Its exact manner of transmission 
s uncertain, but it is probably most often coiiA-cyed in- 
i:.-ectlv bv Avalking barefoot on infected floors, by bath 
oats water-closet scats, etc. It is possible that in sonio 
•oscs’ tbo strong belief in India that the dhobie, or Avaslier- 
lian is-i-csponsiblo for its .spread, by Ayaslimg clotbos m 
look of stagnant, infected Avater, may not bo ill founded, 
riie obicctionablo liabH of Avearing ‘trousers next lb o .skill 
s a likely Avay of keeping np the infection, and in public 
schools it lias been traced to boys AA-cariiig promiscnously 
1110 another’s football shorts, or other garments. 

In the crutch and axillae it gives rise to irregular patches 
vitli a Avell-defined, soiiiotimcs festooned, border, which may 
le scalv or raised and dotted oA-cr with oozing p.apules or 
.-e.sico-pustnlcs — hence its old namo “ eczema niarginatiim 

^ On the feet and hands it occurs in three main t3'pe.s. 
fl) An acute vesico-hiillous type, generally known as 


niNGWORM and its tbeatment. 


I* Tnt TSmnTrt 
I Mr.D!CALJoU7lNAl< 


667 


Apbiij 21, igjS] 


“ cczciiintoitl lingwonn of llio oxlremitics,” wliicli nltaclts 
D)o hitoraisiliif cfrfls, !\«i\ mfty <•''« oovsum 

of fho foot- or tlio back of Uio liand in orYtlicmnlons 
iiatclics, wliich may bo scaly, or dotted ovci" witii vcsico- 
imsfnlcs, or may jircsoiit a sbari) edge, ivitli dclaL-iicd, 
undermined skin. This typo is often mistaken for acute 
ccaonia, and many cases forincrlv labelled dysidrosis btdong 
to this category." (2) A cUronii; type, whicli may succeed 
tlio nciite "tvpo, by iuUofuiito, scaly patcucs. 

(3) A thick scaly type, affecting the palms and soles, in 
ivlucli the horny layer is not only thickened hut fissuicd. 
These patches aVc irregular in .shape, with detached edges, 
beyond which may bo an erythematous areola, and small 
vcsico-pustulcs. Between the toes, especially between the 
fourth and fiflli toes, the skin is ajit to become white and 
sodden, Uke suede leather, and fissured in the folds. The 
nails may also bo iniplieatod, bocomiug discoloured, thick- 
ened, brittle, and raised up at the free border, owing to ! 
a thickening of the nail-bed. Snbjectiyo symptoms aro 
not infrequent in connexion with it — such ns itching, dis- 
comfort, and even pain from fissures, wliich may bo so 
great as to interfere with walking. 

The diagnosis of cczcmatoid ringworm may present great 
difficulty. In the extremities it has to ho distinguished 
from “ dysidrotie eczema,” or even in sonic eases from a Into 
syphilidc, and eases aro not infrequent which have been 
treated as eczema for years before tlicir true nature was 
recognized. In doubtful eases a microscopical examination 
should always bo made. With this object a scale should be 
dctaclicd at the growing edge of tlio lesion, or a covering 
of a vesicle removed, and placed with tlio dci'p side upper- 
most on a microscopic slide. A drop of liquor potnssac 
should bo added, a cover-slip aiiplicd, and the siiecimcn 
examined with a high power. It may he necessary to 
make several preiinratioiis hefore a positive result is ob- 
tained, when the fungus can ho detected ns a network 
of mycelial threads among the epidermal colls. 

Scalp. 

The clinical appearances of ringworm of the scalp may 
ho conveniently considered under three lieadmgs; (1) sup- 
purative ringworm; (2) microsporou ringworm; and (3) 
eiidothrix ringworm. 

1. Stippiirafivc Bingicorm. — Suppurative ringworms of 
the scalp arc known as kcrious, and arc geiicvally due 
to trichophyta of animal origin, tliougU occasionally in 
children they may he caused by micros]iora. They may 
occur at anj- age, and constitute the majority of ringworms 
of the ■ adult scalp. The lesions arc boggy, jihlegmoiious 
raised patches, with a shiny, angry-looking surface, and a 
well-defined border, and are' usually dotted over with small 
pori-foiliciilar abscesses, from which ooze heads of soro-pus, 
and in the centre of which a loose stump may often be 
defected. On palpation they have a peculiar soft, fluctua- 
ting feeling, which loads the inexperienced to incise them 
in the expectation of finding pus, instead of which only a 
few drops of blood or serum exude. The suppuration is 
duo to the infiammatoi-j- reaction of the scalp to the fungus 
itself, and not to a ^condary infection with jms-cocci. 

2. illicro.sporon liingxrorm , — The microsporon is respon- 
sible for the familiar, mildly inflamed, scalv patches in 
children, in which tlio hairs are broken off short and form 
the characteristic ringworm stumps. In tiie infant, rvlicre 
the hairs are delicate, the patches may bo definitely ringed, 
hot in older cliildreu they arc usually irregular in shape. 
The stumps are easily recognized, being thicker than the 
healthy hairs, and presenting a dirty white, opaque, or 
posted appearance, due to a sheath of fungus around them. 
Eecently a useful aid to the diagnosis has been fiiriiished 
by the ultra-violet rays through ,n Woods’s glass screen, as 
ringworm stumps become fluorescent under this light, and 
hv this means not only patches of ringworm, but isolated 
infected liaivs can be detected. As a rule the inflammation 
in this type of riiigworni is mild, hut occasionally, owing 
to .some pecnliarity of the scalp, on account of which it 
reacts more powerfully to the fungus, it ni.iy be so severe 
as to go on to siip]iuration. Should this happen, it is to 
the advantage of the patient, as the ringworm becomes 
self-cnrative. 


3, Kndofhrix Ifiiipirorm. — Undotlirix fungi aro respon- 
sible for about 5 per cent, of tlio cases of .scalp ringworm. 
The clmrncleristic lesions ]irodnced by them are small, scaly, 
rouiidisli patches, irregularly distributed over the scalp. In 
certain cases short stunqis arc present, but more often tho' 
affected hairs aro broken off at the orifices of tho follicle.s, 
forming plugs like comedones; hciico tlio name “ black-dot 
ringworm.” These plugs aro difficult to remove, except 
by a comedo expressor, or by dotaeliing a scale covering 
an affected follicle, when the plug appears as a small spiko 
Oil tho under surface. Eiidothrix ringu'orm is generally 
of human origin. It is difficult to diagnose on account of 
the smallness of tho patches and the shortness of tho 

stumps, and is ' ' t, as the fungus has 

no tendoiicj' to , at puberty. 

• Theatjiext. 

Ringworm, being a local affection, is not amenable to any 
form of internal treatment. A number of experiments' 
have been perfonnod ■ in connexion with tho production of 
immunity, to it in man and animals by the injection of 
vaccinos, hut these have only been partially successful in ' 
the case of snppurativo ringworm of animal origin, and 
have not helped materially in tho treatment of the disease, 

Glahroas Shin. 

The treatment of ringworm of the glabrous skin is as a 
rule a simple matter compared with that of the scalp. 
When the lesions are dry, scahj patches, or ringed lesions, 
tho scales should ho removed by scraping or by washing 
with soap and water, and tho patches painted daily w;ith 
liniment of iodine, or with tincture of iodine, to which 
10 per cent, acetic acid has been added. After about a 
week. the iodine has usually destroyed the fungus. Tho 
cure may then he completed by rubbing tho patches for a 
few days with a 2 jicr cent, salicylic acid and sulphur 
ointment. In delicate skins iodine may prove too irritat- 
ing, and in such cases 3 to 6 per cent, benzoic and salicylic 
acid ointment may be substituted. 

In siippuntlirc ringtrorin p^ainting with iodine, followed 
by the application, after a week, of a 4 per coni, animo- 
niated morenry ointment, will generally effect ‘a cure in 
about ten days. 

In ringworm of tho cnifch and axillae more active 
vomedies arc necessary, Tlic .affected parts sliould be 
scrubbed daily, or oftciier, with Iiot water and soft soap 
to remove tho crusts, scales, and discharge.s, and an oint- 
ment rubbed in containing either 5 per cent, oxidized pvro- 
gallic acid, which, though effective, has the disadvantage 
of being dirty, or a 3 to 5 per cent, benzoic and salicylic 
acid ointment, a valuable combination' which was suggested 
by 'Wliitfield.’ "Wheii painful fissures are present lihout 
tho inguinal regions they may ho healed by jiaintiiig with .a 
3 per cent, .solution of silver nitrate in spirit, or with 
friar’s balsam. By this trcatmoiit a cure is generally 
effected in two or three weeks, hut, to prevent reciiiTcnces 
it is advisable that the parts should bo painted daily for 
about ,a fortnight with a 10 per cent, solution of tincture 
of iodiws in 60 per cent, spirit. It is important also that 
the underclothing which has been worn previous to tho 
cure of the disease should be destroyed or thoronrrhly 
disinfected. ■ ' 

■ The treatment of cczcmatoid ringivorm of the oxtremi- 
ties, c.specially of the feet, requires even greater energy to 
effect a cure. Before applying tho above remedies any 
vesicles should he opened' and scales and loose epidermis 
removed, and when the lesions are aentoly inflamed and 
purulent the inflammation sliould first he reduced by boric 
compresses, or by soaking the feet in boric baths or in a 
solution of potassium permanganate. The most intractable 
typo of all is tho intcrdigital earictxj, with white, thick- 
ened skin between the toes. In such cases the feet should 
be soaked daily in salt water — wading in the sea in summer 
! being a valuable substitute— to macerate the thickened 
skin and allow the remedies to penetrate. Of tbeso the 
most useful aro the salicylic and benzoic ointment a 
saturated solution of salicylic acid in spirit, tho ran- 
tinuons' application between the' toes of 4 per cent salicvlic 
plaster, or daily painting with a 3 per cent, silver nitrate 
solution. Tho socks should be of wliite or natural coloured 



668 April 21, 1928] 


EINGWOEM AND ITS TEEATMENT.. 


[ T«e Bnmni 
Medical Jot;B!ri& 


iTOol, and changed at least once daily, and an antiseptic 
powdex’ dusted into the feet hcfoi'e they ai'o pxxt on. After 
tlie socks liave been norn thej' should be soaked in a solu- 
tion of lysol, or stox-cd. The hoots also should he disin- 
fected by occasionally sxx'abbing ont tho inside xx’ith a 1 in 
20 solntion of lysol, as it is possible for the fnngns to 
i-pmain gioxxdng on the sodden leather inside the boot, and 
to \xoik its xvay through the sock and reinfect the foot. 

Scctlp. 

The ease xvlth xvhicli ringworm of the seal]) is spread 
xiecossitates the isolation ol cases as soon as they aro 
iccognized. As a proliminai'y to treatment the hair should 
he cut short with clippers, such as are used bx' barbers. 
1'his is preferable to shaving the scalp, as, when it is 
shax'ed, it is more difficult to distinguish the healthy from 
the diseased hairs. The scalp shoukl then bo covered with 
a closely fitting cap made of cotton or other light material, 
which should be continuoush’ worn. 

The treatment of ringxvorm of the scalp may be con- 
sidered under the txvo headings of sup2)uratix-c and jion- 
suixpuratix'c ringxvonn. 

(u) Suppuratii'c Ilinr/worm. — Pustular ringworm of the 
scalp is much more easil3- cured than the diy t\-pos, as the 
condition is self-curativc, the suppuration loading to a 
destruction of the fungus. The treatment consists of 
keeping tho scalp clean bj- the ap])lication of boric com- 
jnesses or of mild antisejitic ointments containing boric 
acid, salicj'lio acid, or ammoniated mcrcxiiy. When the 
swelling and inflammation subside a red bald patch is left. 
As a rule the hair grow'S ox'cr it in about six months, and 
onl.v in rare instances, xvhero superficial ulceration lias 
supervened, does permanent baldness result. 

(h) X'nn-snppurativc Bingicorm. — Tho diy, scalj- forms 
of ringworm of the scalp are the most intractable. The 
difficulty of curing them is a mechanical one and due to 
the impossibility of reaching the fungus in the depths of 
the follicle by medicaments applied to the surface. As an 
illustration of this I maj- cite a case of microsporon ring- 
worm in w’hich I had tho head kept shax'cd and the patches 
])ainted daily xvith liniment of iodide until blistering 
occurred. When this was healed, hairs were epilated, 
jilanted on proof agar plates, and cultures obtained. This 
procedure xvas repeated throe times in six months, and 
ahvays with the same result. To euro these cases it is 
nccessai’y that the diseased hairs should bo corajiletely 
shed. Unfortunatel3’, epilation b3- forceps is useless, since, 
however carefull3' it ma3- be done, certain of the stumps 
are bound to be bi'oken off and part of the infected root 
loft behind. By far the most effective and rapid method 
of getting rid of the diseased bail’s is b3’ the a: rays, ami 
it is tho method generall3’ adopted. Occasionall3’ scalps 
are met xvith that react so strongly to almost an3' irritant 
aixplication that the x ra3’S may be unnecessai'3', fhe 
scalji ma3' bo so sensitix^e that the fungus itself causes so 
much di.sturbance that tho ringxx’oi’m becomes cured spon- 
taneously by tho hairs falling out, leaving temporary b.ild 
jxatches, suggesting alopecia areata, but differing from the 
latter in that the patches are generally inflamfed and 
present no typical “ point-of-exclamation ” hairs. In 
infants under a year old the use of the x ravs is 
inadvisable, and a cure can generally be effected by” suit- 
able pax-asiticide applications, such as ointmeixts of sali- 
cylic and benzoic acid, iodide of sulphur, etc., as the scalp 
and bail’s in tho ixxfant are more delicate. About puberty 
also, in the case of microsporon infections, the emplo3-- 
ment of the x rays is unnecessary, and parasiticides xvill 
suffice to hasten the spontaneous cure xvhich occurs at 
that time. 

Parasiticide Treatment. 

When tho x ra3’s are not available, or their use is 
undesirable, it is necessary to resort to some paxasiticide 
application, of xvhich there is a large choice. It may be 
said that tho value of a parasiticide is dix-ectly dependent 
not so mxich on its caustic action, or its poxver of killing 
the fungus directly, as on the amount of inflammatory 
reaction, shoit of ulceration, it is capable of setting up. 
Of the numerous iiiitants and parasiticides which, hax'c 


been employed tho txvo xx-hich I have found to bo most 
usofxxl are croton oil and sodium chloride, both of xx’hich 
act indircctl3’ b3’ the acuto reaction to xx’hich they gix’o I’ise. 

X-ray Treatment. 

Iho a?-ra3' treatment is more lajiid than an3' other 
method, and has tho adx’antago of being painless. In 
competent hands it can bo done, as a rule, xvith absolute 
safct3-, not 01113' far as the skin is concerned, but xvithout 
any deleterious effect on the health and groxvth of tho child; 
and tho fear xx’hich xx'as at one time cngendorcd in the 
public mind xvith regard to harmful effects of tho treatment 
on the brain is xvithout foundation. It is an operation, 
hoxx-ex'cr, xvhich is b3' no means cas3-, and necessitates not 
onh’ a suitable a'-ra3' .S3'stcm for tho jiurposc, and a xvorking 
knoxx'ledgo of the mensuration and application of the arrays, 
but an intimate acquaintance xvith the disease and its 
management. Without this it is a highl3' dangerous pro- 
cedure, and ma3' lend not oixl3' to sovoro dermatitis, but to 
permanent baldness. Tho casual fashion in xx’hich it has 
so often been undertaken in the jiast 113' those either lack- 
ing in technical skill or in knoxx’ledgo of the disease has led 
to tho most disastrous results, and has too often brought a 
x'aliiabie treatment into disrepute. 

The X ra3’s act simi)l3' ns a depilatoi’3-. Tlicy do not 
dcstro3' the fungus, and a culture of ringworm 0103' bo made 
from hairs xvhich have fallen out as a I’csiilt of exposure 
to them. 

I shall not attempt here to describe in detail the x-ray 
tccliniquo nor tho apparatus most suitable for tho piiiiiose; 
these can best bo demonstrated in the operating room. 
The procedure is, briefl3', to expose tho xx’holc of the scalp 
once to what is knoxx’n ns a pastille dose of x rays, xxliich is 
tho maximum dose the skin can stand xvithout harmful 
effect, and xvhich is sufficient to c.ausc the hair to fall 
out xvitiiout so injuring the papillae and follicles as to 
prcx'cnt rcgroxvth. To expose tho xvholo scalp imifoi’inly it 
is necessary to divide it up into five areas, xx-hich are irra- 
diated seriatim by xvhnt is knoxx-n as the Kionbook-Adamsoix 
method. The time occupied in exposing tho entire scalp 
varies according to tho appai’atus and tho methods of the 
oixerator. At Charing Cross Hospital our ax’orago time is. 
about threc-quaiters of an hour, and this ineludes not only 
the time taken in exposing the various areas, but also that 
occupied in placing the child in the different positions, and 
carefull3' fixing tho head at the required distance from the 
anti-cathode of the tube. During the exposure it is essen- 
tial that the bead be kept still. As it is dangei’ous for the 
nxii’se or operator to attemixt 01x3' foira of ro.straint it ma3' 
bo neccssar3', xvhen vor3' 3'oung or restless children hax'e to 
bo ra3ed, to cmplo3' a speeial couch on xvhich the child can 
be .strapped, and the head fixed in the required iJosition. 

The X rays hax-e no apiiarent effect on tho scalp at the 
time of the exposure, nor are any marked sensory sym- 
ptoms produced by them. Young children arc sometimes 
D’i"htcncd by the noise; on tho other hand, they may as 
rca'dily go to sleep during tho exposure. A foxv hours after 
the expo.sui’e, especially since the introduction of poxx-erful 
Coolidge tubes, the child may be a little out of sorts and 
sick but the indisposition is transient, and there arc no 
after-effects. About fourteen da3’s after the exposure a 
slight ei’ythema may appear, associated xx'ith itching, and- 
iii'^the iiext fexv days the hair begins to fall ont, the 
defluviura generally being complete by tho txient3'-first d.ay. 
Eight xi-eeks later the hair begins to groxx' again as a fine 
down and regrowth is complete in about six months. As 
a rule it is advisable to irradiate the entire scalp, even 
when the disease appears to be confined to one or txx'o areas, 
as it sax’es time in the end, for tho infection is almost 
certain to spread to other parts in the interval betxveen tho 
exposxxrc and the fall of tho hair, necessitating a further 
exposure, xx-hich may be difficult to do xx-ithout overlapping. 

The chief risk of the treatment is tho danger of over- 
exposure folloxved by dermatitis and incomplete regroxx’th 
of the hair. With proper care and modern technique, 
hoxvever, this shoxdd be a rare occurrence. 

At one time it xx-as believed to bo inadx-isablo to x-ray 
children under 3 years of age, before tho fontanelles had 
closed. Further experience has shoxx-n that, provided the 
child can bo kept still by tho use of a specially, designed 


USES AND ABUSES OF m’DROTHERAPy. [ jtX'.cal ' G59 - 


ATOIIj 21, 10=8] 


corn'll, on which the child is sUnpiiod, yonnper children, 
and even infants of twelve months, may ho treated safely 
hv the rays. 

'Before exposure to iiio jc rnvs ilie hnir siionul bo cut 
short with clippers and the .scalp washed. Should any 
aenlo inniunmatory distnrhance he present, sueh^ as 
inrpeligo from Feratchinj:; or irritation from previous 
tvoatment with para.siticides, especially iodine, it should 
he dealt with previous to exposure to the rays. If this 
jirocantion ho neglected and the expoamo ho made on an 
inilamed scalp, the irritation and itching presovrt may lead 
to scratching, secoiulaiy inoculation of pus-cocci, and more 
or Ic.ss sovoro impetigo. After the cxiiosure a cotton cap 
should ho fitted to the scalp and worn ccmtiiuionsly, and 
every day a 1 per cent, ammoniated mevenry ointment 
should ho gently nibbed over the scalp. On the fourteenth 
day the scalp should bo washed with a non-irritating soap, 
snc-h as Castile soap, and the washing repented daily until 
the liair has fallen out. \Vlien the deftnvinm is complete, 
about the lwonty-fir.st day, the child censes to ho infec- 
tious, and may return to school, a small brown sUnll-cap 
being worn until the hnir grows. The after-treatment of 
the scalp, until the hair returns, consists in washing and 
niassaglng it daily with almond oil or weak boric ointment, 
to stimulate the circulation and so encourage the hnir 
grorrth. 

Depilnfion by Tfioliiutn .'Icctatc. 

The most recent method of depilating the scalp is by 
pure thallium acetate. Thirty years ago Sahourand 


{THE USES AXD SOME ABUSES OF 
HYDROTHERAPY. 

BV 

B. G. GORDON, H.D., D.Sc., F.R.C.P.En., 

PIIYSlCliS TO THE r.OVAl, MISEBAL WATEB KOSCITAL, BATH. 


Tiram is apt to ho some mystification amongst practitioners 
ns to the method which nmy underlie the madness which 
Ic.ads spa physicians to [lorsuado their patients to he boiled, 
hnkort, or beaten, and induces these unfortuiuit<‘s to submit 
to these afflictions. Probably everyone is agreed that when 
a patient comes to a spa he benefits from the fact that 
ho enjoys a change to a dilTcrent climate, to a different 
environment, to different fond, while he leaves lus business 
and home worries behind him. Also ho c-ouics with the 
idea of Imving treatment, and thcrcfoic will do wli.at he 
is told ns to diet, exercise, and rest. 

I/ydrof/irrapy an Adjnvanf in ihc Cure of Disease. 

R'ith all these factors I do not .jiropose to deal, hly 
subject is, What do the waters do? Now at onco wo must 
admit that they do not do what they onco were said to do. 
For example, it is recorded that at one time ladies came 
in large crowds for the cure .at tho bath in order to be 
relieved of the distressing malady of sterility. Nowadays, 
alas! this is no longer tho case, ’indeed, it was whispered 
not long ago that a sweet yonng thing had approached a 
most austere physician, and asked demurely whether the 
ladies’ douche was a suitable cure for the opposite con- 
dition. In thoso days spas were famous for the cure of 
the seiin'y, tho scrofula, aud the gout — diseases which no 
doubt are still with us, hut neither so common nor so 
picturesque in these degenerate days, when A'itamins and 
soapsuds have displaced tho harou of beef and the strong 
wntoi-s. 

Nevertheless, even to-day, if the ciodulous practitioner 
consults the guide to any spa and ohsei'vos tho table of 
contents, ho finds two headings — indications for treatment, 
and contr.sindic.Ttions for the same. Tlie first occupies 
several pages, tho second probably two linos — those with 
acute fevers who might infect the inhabitants, aud those in 
the last stages of heart disease who might die, thorebv 
adversely affecting tlic n'tal statistics of tlio f.smous health 
resort. Tiie practitioner wonders how he still retains Ms 
livelihood, since a ticket costing a few .shillings will brimr 
liractic.'ill.y ail his patients within reach of cure, and ret 
wc sometimes hear tiie spa physician complaining that" he 


allompled to produeo a depilation of the scalp by injeeting 
a solution of thallium acetafe, but tho treatment was .so 
unsuccessful that it was ahandoiicd. Recently, as the 
rcsAill of the experiments of RtiseUkc aud others, its use 
has been revived. It is given by tho moutli, in a dose 
of 8 to 8.5 mg. per kilogram of body weight, tho drug 
being dissolved in .sugar water, and given on an empty 
stomach. About ten days after its ingestion tho hair 
begins to fall out, nnd tho depilation is more or less com- 
plete by tho nineteenth day. Tho infected stumps do not 
fall so readily as the healthy hairs, so that the cpil.atiou 
may have to bo completed by extracting tlicra with forceps, 
or by applying strijis of ndliosivo plaster. During the time 
in which the doflnvium is taking place the scalp should 
he painted daily with 5 per cent, tincture of iodine, and 
a 6 per cent, sulphur ointment rubbed in. 

As tlie thallium acetate acts through tho sympathetic 
nervous system, nnd may cause severe general disturbance 
in the child, associated with drowsiness, irritability, pains 
in tho joints, and weakness in the legs — symptoms which 
ilcvelop about tho eighth day — it is adA'isahlc tliat tho child 
should ho kept in bed. 

This treatment is only suitable in tho case of young 
children up to 4 or S yeai-s of ago, as in older children 
the dose necessary to cause the depilation is too great 
for safety. . The treatment is loss satisfactory than the 
a: rays, and, owing to ' tho dangci'ous general symptoms 
associated with it, should be employed with the greatest 
caution. 


cannot pay for the upkeep of his third Rolls-Royce. 
Naturally the practitioner knows that all these dise.ases 
are not cured by hydrothcr.Tpy, aud is apt to cln.ss spas 
and all connected with them ns quacks and know-alls, 
whose ]>rofessions are closely in correlation with thoii' 
ignorance. Yet ibis is not by any means fair to .sp.as, and 
I le.ads to a neglect of wlmt can be done by physical means 
of treatment. 

The confusion all arises from the pernicious habit, intro- 
duced by no less a person than Galen, of thinking in terms 
of diseases. Any really hoircst physician — 1 cannot here 
speak for stu-gcous — kuow.s he never cured a disease in his 
life by this or that special means of tre-atment. On the 
olhor hand, ho docs know that by his general management 
of tho patient, both from tho physical and mental stand- 
point, he so improved tho latter’s power of adaptation to 
lus environment tiiat ho •recovered from the varions sub- 
jective symptoms and objective disabilities which for tlio 
sake of convenience the medical profession have agreed to 
call this or that disease. Let us tliorefore got rid of tlio 
first great abuse of hydrotherapy, the idea that it cures 
any disease. Wo must realize that in its proper sphere it 
may be a useful adjuvant to promoting tho rccovorj- of 
certain patients in virtue of what it docs. If wo wisli to 
summarize this action wo may include the effects of hydro- 
therapy under four heads: washing the patient within or 
without as the case may bo; waste elimination— and if 
anyone should desiro to change tho spelling of waste I for 
one do not complain ; alteration in the capillary circula- 
tion ; and, fourthly, reflex effects from stimulation of the 
superficial nerve endings. 

External Hydrotherapy. 

Hydrotherapy may be administered externally or intern- 
ally. Let ns first consider the external application. In 
all seriousness I wish to lay stress on the word “ wash.” 
As we shall sec in a moment, it is by elimination tliroiigli 
the skin that bydrotlierapists seek to bring about a large 
part of their re.sulfs, and unless and until the skin is 
really clean adequate sweating cannot take place. It is 
doubtfvil if too much stress can he laid on the importanco 
of the .skin as an organ of elimination, and a verv short 
experience of the maladies of middle life will convince 
anyone of the frequency with which the function of the 
skin is upset in one way or another. It is not so verv 
long ago that every patient who came to a spa expected 
to he told that he was gouty, and what people expect thev 
■frequently get. Hence the old-time spa phvsician set up 



660 Aphiii 21, 1928] 


USES AND ABUSES OF HtDEOTHERAPT. 


[ The nnmsB 
MtOJCiL JoUQ'til ' 


for himself a little golden idol — ^the idol of nrio acid. Tho 
patients a’ere told that by moans of the treatment which 
they underwent uric- aoid was expelled ' from every orifice 
of the body. It may he supposed that some sceptical 
patient demanded proof, and some phj'sician fell to tho 
temptation of a deception which, alas 1 is still alive among 
tho less well informed outside and even inside tho i)ro- 
fession. It was found that at tho beginning of treatment 
litmus paper laid on tho skin turned red, while later it 
turned blue. What more simple? Elimination of uric 
acid — cure of gout? Nothing of the kind; simply washing 
tho skin clean. If tho sweat was really acid it would 
he a post-mortem phenomenon; tho sweat is always alkaline, 
hut tho sebaceous detritus in a skin which does not habitu- 
ally sweat freely is acid, and till that is removed tho litmus 
paper will turn red. Having washed our patient wo 
further proceed to make him sweat, and it is hero that 
we may lay claim to real therapeutic results. 

So far as Bath is concerned, shortly after tho war Dr. 
Vincent Coates and the present writer managed to per- 
suade some long-suffering ex-soldiers who were out of a 
job to come into hospital and submit to a fixed routino 
of diet and exercise. Drs. Pincent and Rayment, the bio- 
chemical experts in the XJniversitj- of Oxford, then carried 
out some investigations on tho urine and sweat of these 
men, who wore divided into two groups — one ingesting and 
bathing in mineral water only, and tho other group using 
tap-water and producing sweat by other means. Quito 
definite differences were found in tho excretion of calcium, 
sodium, and potassium ions, ns well as in tho distribution 
of the acid radicles. 

So, as a result of well-authenticated and controlled 
experiment, wo may say that tho mineral water has a 
specific effect on excretion. Whether this is duo to radio- 
activity, to the peculiar colloid content of tho water, or 
to saline concentration in tho water, wo do not know, and 
tho determination of these questions awaits further experi- 
ment. However, from tho present standpoint this is of no 
great importance, since tho experiments do advance tho 
argument that it is by skin action that results are obtained. 

The next effect of the external administration of water 
is on the capillary circulation. There -is littlo enough 
exact knowledge about capillary circulation, but wo recog- 
nize that at present we are only on the threshold of a veiy 
important field of investigation. It is known that only 
a comparatively small proportion of the ca])illary circula- 
tion is patent at any given time, and that changes in tho 
relative patency profoundly modify not only tho blood 
pressure as a whole, but also the local distribution of tho 
circulation. Tho effects of capillary dilatation, therefore, 
which may be expected to ensue are relief to a labouring 
heart from reducing the resistance to bo overcome, altera- 
tion in congested organs ov/ing to the redistribution of. the 
circulation, elimination of toxins by means of the sweat 
glands activated by the greater flow of blood through the 
skin capillaries, removal of locall 3 ' deposited toxins, and 
softening of fibrous and scar tissue. 

That reflex effects occur .as a result of tho stimulation 
of the end-organs in the skin and mucous membranes by 
means of tho pressure and thermal effects of water is 
perfectly obvious to any observer, but the analysis of these 
from the neurological standpoint is extremely difficult and 
complex, and quite out of place in a paper such as this. 
Suffice to say that the rate and rhythm of tho functions 
under th-o control of tho medullary centres are profoundly 
modified, at least temporarily, while tho general metabolic 
exchange is definitely altered. 

We must next'- consider shortly by what moans these 
results may be brought about. The effect will depend on 
tho teinperaturo and duration of the bath and on the 
pressure ■ of the water. Baths may bo cold, tepid, sub- 
thermal, thermal, and hypothernial. 

The cold bath at less than 60° F. constricts tho superficial 
capillaries, stimulates the nerve-endings, and causes reflex 
increase in the respiratory quotient and pulse rate. Diuresis 
is subsequently evoked, with consequent elimination of toxins, 
and the general metabolic exchange is increased. , 

The action of the tepid bath from 60° to 85° F. resembles 
that of the cold bath, but is of less iutensity. 

The subthermal bath from 85° to 98° F. is of significance 


in so far as it appro.aches the temperature of thermal indiffer- 
ence (93° h .). At this point general metabolism is unaffected, 
and as peripheral stimuli on the circulation and nervous .system 
are reduced to a minimum these baths are definitely sedative. 

Tlicrinal baths from 98° to 104° F. dilate tho superficial 
capillaries and lower blood pressure temporarily. The general 
temperature of tho body and of tho circulating blood is raised. 
The effect on the ncuro-muscular system is sedative, spasm 
is relaxed, and pain relieved. . Elimination of toxins is greatly 
promoted by diaphoresis, both immediately and subsequently. 
The increase of body heat augments general metabolism. 

Hypcrlhcrmal baths from 104° to 112° F. cause immediate, 
constriction of the peripheral circulation, followed by dilata- 
tion. There is tonic effect on the ncuro-muscular system if 
the duration is very short, but a marked sedative and even 
debilitating effect may ensue if immersion is prolonged. 
Elimination of toxins is promoted by diaphoresis, general . 
metabolism is incr*.sed, and tho body temper.aturo is raised. 
Caro must be taken in tho administration of thermal and , 
hypcrthermal baths, since if too prolonged they may give rise ‘ 
to the condition known as thermal debility — an increasing 
weakncs.s which may be of serious significance in patients witli 
heart disease. 

Tho pressure effects of baths aro as follows: 

1. General — in immersion baths. Tho effect of the gencr.al 

superficial pressure of a large volume of water on tho body 
is to increase tho rate of peripheral circulation in two 
wavs; first, by mechanically’ emptying tho superficial veins; 
anil secondly, by reftexly increasing tho rate of c.a'pillary 
flow. ■ ■ 

2. Local — by douches. Douches may bo stimulating or 
sedative according to their teinperaturo and pressure. 
Alfusion by a largo volume of warm water at low jircssuro 
has a sedative effect, relaxing spasm and relieving pain 
and dilating superficial capillaries. High-pressure douches, 
especially if applied to a small area through a narrow jet, 
constrict tho local capillaries and exert a powerful rofle.x 
stimulating effect on the neuro-muscular system and on tho 
respiratory and vasomotor centres. It is unnecessary to 
point out that while such treatments .aro being given other 
methods, such ns massage and electrotherapy, may be 
administered. 

Internal Syd rot h crapy. 

Taken internally the water acts in tho same way by 
washing and waste elimination. 

Leaving aside those waters which claim a definite medi- 
cinal quality from their chemical content, such as sulphur, 
iron or iodine, whose action belongs to pharmacology in 
its more restricted sense, tho action on tho stomach is 
mainly physical, flushing the organ with a warm non- 
irritating fluid, hastening tho passage of its eont-ents 
through tho pylorus, diminishing secondary fermentation 
of carbohydrates, and cleansing the wall of tho viscus, pre- 
paratory to tho next nieal. It probably causes temporary 
incrc.aso in tho flow of hydrochloric acid and ferments, and 
has no aperient effect in tho amounts usually prescribed. 

In addition to their physical action in irrigating tho 
tissues and promoting the removal of toxic material, these 
waters would seem to have peculiar properties in pre- 
venting tho deposition of urates in tho system. The in- 
KCstion of the water is rapidly followed by free diuresis, 
to which is largely duo its value in gout and other con- 
ditions characterized by faulty elimination. 

Administered by tho rectum in tho form of tho Plombioros 
douche the water acts as a cleansing agent, removing tho 
faecal material by means of tho first injection, and dis- 
solving the mucus which may cling to the lining of tho 
bowel by the' second. This second injection may be made 
a useful vehicle for the administration of disinfectants, 
etc., in cases of bowel disease. 

I think it is only right to say tha.t in tho wrongful 
administration of tlio Plombieres doucho lies one of tho 
chief abuses of hydrotherapy. Only too frequently ono 
meets patients who say, “ I was at' a spa two months ago 
and got such benefit from the Plombieres treatment; but 
now I am as bad as ever, and I think I had better go 
back.” ' This may be voi-y gratifying to the spa, but not 
to the patient, and generally means that too much fluid 
has been injected at too great a pressure, thereby dis- 
tending an already atonic colon. All that is ever needed 
for an efficient douche is li to 2 pints from a height of 



ArRir. sr, 1928] 


OVARIAN SARCOMA IN A CHILD. 


[ Tire Bnrnsn 
MzDtCAZ. JorsNXb 


661 


n lo 2 feet. As ti nnsal/iiliiuyitgcnl, or vngiiinl rtouclio 
a. bliiiul miuoniR. water, may net ..ns n vnhinhio .solvent ' of 
iimcus, a ’ elohiising agent, or as a veUielo for other 
medicaments. 

So mhrli for the use of hydvothernjientic nicfhods. Tho 
indications must bo not for tins or that disease. Let ns 
get nwav from Oalen ami bis elassilicatiou of diseases and 
bark to'lHiipoerates and the estimate of the total person- 
ality; bodily and mental, of onr patients. Wlien the doctor 
lias arrived at a diagnosis, not that the patient is s\ifrcring 
from thi; or Hint disease, but tbat he requires a elmiigo 
of scene and ocenpation, elimination of jioisons, or a 
redistribution of eirenlation, let him remember the possi- 
bilitie.s of a spa and b.vdrotIiera])y. On the other hand, lot 
him not exiicet results from hydrotherajiy whore tho.se 
etfeets arc not likely to help, for in this lies abuse of Imlro- 
therajiy. Obviously nento di.soa.se of any sort is not suited 
to sucii treatment, at least until tho active stage of tho 
disease has abated, and, above all, the submission of a 
ease of nento rheumatism to' hydrotherapy within three 
and probably six month.s of the attack is to be avoided. 
Where there is any cardiac affection which ha.s not com- 
liletcly subsided I am prepared to say that these cases always 
do badlv, and oven cases which do not .shou an\ evidence 
of cardiac disease on tlieir arrival at a .spa may do so in 
the course of their treatmeut if sufTieieut time has not 
been .allowed to claji.sc sineo the acute attack. 

; Pinally, let ns face the facts of hydrotherapy and lealizo 
what ive can do with its aid, and confine Qurs<.lves within 
these limits. Tho worst abuse of hydrotherapy is the 
teiulency to make a mystery of it, and to regard it in any 
way .as a miraculous cure for any and every tlisoasc. 


•OTAHIAN SARCOJIA IX A CHILD ASSOf'IATKD 
■NA'lTn SEXU.AL PRECOCITY, 
av 

A. H. SOUTHAM, Jil.D., M.Cn.Oxox., F.R 

ASSISTAST SVr.OEOX, SOVAL MAXCIlESTEa ClIII.nilCX'S UOSelTlI. : nO.SOR.lKT 
• ASSISTAKT SUROEOK, SALrORO ROYAl. IIOSPITAX. ; UCTCRCR •» 

JX OPERATIVE SUROERY, tJANCUEStER CXIVERSITI 

Ceiitaix tumours. of childhood are associated with stiikmg 
general nlmorinalities. Tliis is .specially true of tiiinoiir.s 
oj the gonads, adrenals, and pineal body, which may he 
associated with precocious sexual matnrit.v. Tlie ntimher 
of recorded cases where tiic abnormality has liccii toiiiid lu 
association with a tumour of the ovaiw is coiii]iarativelv 
.small. In these ease.s niciistniation is estahlislied at such 
ah early age as to be 'truly precoeioiis, and there is also 
louiid oulaigomenl of the mammae and the growth of 
pubic hair.. 

. The explanation of the rel.ation of the tunionr to tho 
general condition ]irodncod has led to considerable .S2>eeiila- 
■fion.. It is well established that tlie gonads iiave a direct 
niflncuee on sexual development, and it is possible that the 
■ttiiiiotir^ may lead to an increased formation of tiie Tissue 
n.hieh influences development — the changes ]irodueed arc 
snnply the expression of a true precocious jinherty. 
Klemperer, who accepts the view that tho interstitial 
colls of the gonads are essential for the normal devolojnnent 
of the sexual characteristics, believes tliat those tumours 
^^sociated with sexual precocity avo sarcomas dovived from 
■pie. interstitial coils. If this opinion can be acccjited, tiien 
^ 11^* activity of the tumour tissue might be adduced as the 

yanso of the developmental anomalies noted. 

, The origin of ovarian tnnionr.s i.s somewhat obscure. They 
are. generally met with during the period of sexual niaturitv, 
jitit are also occasionally seen ia cliildreu. The incidenco 
of malignant tumours of tho ovaiw in childi'cn increases 
markedly during the second decad^that is, at and after 
puberty. Cases occurring in children under 10 years of 
pgo are remarkably rare. 

j' The case recorded in. this paper occurred in a child in 
lier third year of life, and a malignant • tumour of the 
light ovary' was associated with sexual preeocitv. The 
tumour was subsequently removed and the patient remaiiEs 
■''PP-'>''ei't sign of recnrronce two and a half 
vehi'.s afler opeiation'. - ' . ' • .... 

0 ' - - • .... . - ; 


.The following is the history of 'the case, 
il'ho ji.ilieiil wn.s .stilted, to Imye been a perfectly be.Rlthy child 
siiico birlli, ■pi'c'sontuig ■ no nblioiniiil 'symptoms 'whatever. Wlien 
2 years mid 10 nioiitli.s old slie had .some vaginal haemorrhage 
lasliiig throe days, and shortly after this a swelling was noticed 
in tho abdomen. • 

When brought to hospital there was a well-marked abdominal 
tumour about the siEO of a cricicot ball, firm, rounded, and freely 
mobile, rather to the right of tho niid-liiio and below tiie 
iimbilicu.s. The child was normal in weight and height, biil.il 
was noticed tlial lliere was distinct ciitargcmont of both breasts, 
conforming to the adult female type, and in addition there was 
a marked development of the jiiibic hair. 

Whilst under observation in Ibc Ciiildren’s Hospital she had 
a second vaginal hncmorrlmge, which occurred twciily-ciglit days 
after llic previous period. In view of these symptoms a pro- 
visional diagnosis of an ovarian tunionr was made; a r.sdiogram 
proved negative, and cystoscopic examination showed- that both 
kidneys were acting normally. 

On August 26th, 1925, tlie abdomen was opened by a right 
paramedian vcctns incision and a freely mobile tumour war. found 
arising from the right ovary. It was free from adbc.sidns, and 
there were no peritoneal or glandular nictnstases. The ulcros 
appeared large for the child’s age; the left tube and oyar.v were 
iioriiial. The tumour and right Fallopian tube wore removed 
intact and tlie wountj closed. The child made a straightfor'ward 
recovery from the operation. 

The specimen was examined by Dr. A. E. Somerford. : 

' ratholofficn! Riporl. . 

The tiimonr, wbicli weiglicd 225 grams, was about (he size, of 
a cricket ball; and was. ronndcil in form, • Tlierc was no' distinct 
capsule. *11 w.as pr.actically a .solid tunionr, but on. .section Ihcic 
were some cystic areas o'f small sizo filled w'itli altered blood. 
Microscopically the growth had the structiirc. ot -a 'small round- 
celled sarcoma in which there were immerous areas of haemor- 
rhage. There were no remnants ot ovarian tissue present. • 

Suhscqncni Jlistory. 

Since (lie operation the child has developed normally. The 
breasts have decreased in size, tlicrc has been no . further 
menstruation, and the pubic liair lias been lost. A recent examina- 
tion two and a half year.s after operation has revealed no cndenco 
of recurrence of the liiiiioiir, and no melastases could be di.s.covefed.' 

Itcmnrla. 

Tbo |)oiiits of .siiccinl intcrc.st in tbc case arc tlie rarity 
of llio foiiilitioii and tlie early age at wliitli tbc tumour 
was disiovcrod, most other e.ases recorded occurring ' in 
older oliildrcn. 

Tlic iintui'c of the tumour was established patliologically 
as being a .snvcomn, and it is interesting to note that tbo 
ovary itself could not be recognized either by the , naked 
eye or by the iiiicroseopc, being coniiilotely incorporated in 
the tnniour. 

j\fter removal of the growth tbo condition of tlio cliild 
lias retui'iicd to normal, and although the tumour was 
histologically innlignaiit the subsequent history of tlie ciiso 
has been .satisfactoi'y. 


THE CAUSE AND TEEAT3IENT OF THE CRISiS -IN 
LOBAR FNEUalONTA.* . 
by 

ALEXANDER CANNON, M.B., Ch.B.Leeds, 

GOVERXMEXI MEDICAL OEFICEE, HOXC-KOXG. 

In South China and Hong-Kong quite 90 per cent, .of the 
-cases of lohar pneumonia are caused by the p.neuinoeoccus 
of Fraenkcl. Tlie crisis is not duo to immunization, for 
if this were tho cause the f.all in temperature would he 
gradual as the immunity increased, and hence the curve 
j would drop very slowly over a number of days. The droji 
in temperature is, however, sudden, often occurring withiii 
a few hours, and hence the cause cannot be exiilained in 
this- .way. 

The pneumococcus grows very readily on blood agar,' 
producing a characteristic green coloration; no otlierl 
known organism can produce this particular green colora- 
tion, on blood agar. Moreover, it is known that after a 
time the pneumococcus censes to grow in the samp iaedinml 
and it has been shown experimentally that this is due to 
the formation of hydrogen peroxide or some 'other. per2 
oxide, and that no other agent can produce'- the same' 
identical colour. ... ■ : 

Numerous experiments show that the pneumococciis 



t Tn* Cnmnf 

McDICU. J00KN4fc 


662 APiiir. 21, 1928] . THE CBISIS IN EOBAR PNEUMONIA. 


pioducos tlio gas oxygen, wliich acts favoiivaWy on its 
growth for a time; bnt when sufficient oxj’geu has been 
set free' to benefit and make tbo “ soil ” inoro snitablo 
for rapid growth tbo organism sets free oxygon in excess, 
which has been shown to ho very detrimental to growth,^ 
so much so that the cocci die. Thero is a limit to tho 
utility of oxj'gen, for beyond a certain strength it defeats 
tho object for which tho organism apparently produced it. 
AVhen this point is reached in pneumonia tho crisis is 
reached, and the temperaturo rapidly drops to normal or 
subnormal ; in this way Nature provides its own cure. In 
experimental investigations tho usual laboratory methods 
were used for tho collection of tho gas produced by theso 
organisms, and without exception tho gas was proved to 
bo oxygen. 

Method of Administering Oxygen in Pneumonia. 

There is a very small point which is of great importanco 
in the use of oxygen in pneumonia, and is tho seoret of 
the success which has followed my treatment of all pneu- 
monia cases: tho oxj'gen should ho used warmed. In tho 
past the uso of oxygen has been tho causo of moro deaths 
in pneumonia than ono cares to contemplate, simply 
because it was administered cold and not warmed to tho 
required temperaturo; hence the lungs were chilled and 
the patient could not stand the shock. Tho oxygen should' 
be heated by passing the gas through coiled Littre’s tubes, 
immersed in a water-bath kept at a temperaturo of about 
120° P., the gas being passed through tho tube at a slow, 
rate, which is gauged by tho comfort of tho patient, wlio 
breathes quietly and does not complain of tho “ choking ”, 
feeling which occurs when tho gas is administered too 
quickly. By keeping a thermometer in tho tube it was 
found that tho gas passing through at this very slow rato 
was about 99° P. when the wator-bath registered 120° ,F. 
Ono thing to watch is tho risk of sudden collapse when tho 
crisis occurs; this can fortunately bo avoided by tho daily 
administration of pituitrin, 1/2 c.cm. being administered 
hypodermically morning and night, tho heart action being 
safeguarded by the old-time proven remedy of digitalis 
administered from tho onset of tho disease ; tho omission 
of this has been responsible for the loss of many a case- 
of pneumonia. Every clinician can verify tho fact for 
himself that oxygen rapidly cures theso cases, and every 
bacteriologist can satisfy himself that - tho pneumococcus 
alone among micro-organisms can produce tho" particular 
green coloration to which reference has been made. 

That the foregoing method of administering ox 3 -gen is 
effective in the treatment of pneumonia is evident from 
tho clinical observatipns recorded below. Among the 
Chinese the disease is moro common in males than in 
females. As medical officer in charge of H.JI. prisons in 
Hong-Kong and Li Chi Kok I have still to report my first 
female pneumonia patient, although it is quite a common 
disease among the male prisoners. My statistics show 
noticeable epidemics, when house after houso was infected 
in Canton, and then would come a spell when for months 
not a single case of pneumonia would occur. Tho epi- 
demics were most prevalent in May, Juno, and September. 
Persons such as police and coolies, who are exposed to 
weather changes, showed a marked preponderance of cases. 
Most patients had a previous history of similar attacks 
having occurred one, two, or three years before, which is 
a point of great interest. Most attacks occurred after tho 
moist heat (humidity of over 95) so characteristic of South 
China ; the majority of the patients were whisky drinkers. 

Clinical Observations,. 

A rigor was tlie initial symptom in 65 per cent, of tho cases 
anti 25 per cent, had a noticeable malar flush, often simulating 
typhoid fever; this latter disease was eliminated by laboratory 
methods and clinical findings. 

Headache was a prominent feature in 29 per cent, of cases. 

Pain in the right side was complained of by 27 per cent., and 
pain on tho left side by one patient. 

In 84 per cent, of tho cases tho respirations at the first visit 
ranged between 40 and 47; in 16 per cent, of 'cases 27 to 34. 
Witnin six hours of commencing treatment in over 50 per cent, 
of cases tho respirations had como down to somewhere in tho 
region of 27. Within two days of treatment tho respirations 
ranged between 16 and 20, and the patient was apparently well 
on tho third day. 

With three exceptions tho temperature recorded when tho 
patient was first seen was between 103° and 104° P. In one of 


tho threo exceptions Iho temperaturo did not rise above 99° F., 
although ilio physical signs and symptoms were definitely thoso 
of lobai* pneumonia; this patient had also a marked pleural 
effusion on llio left side. In all cases in whicli oxygon was 
administered tho sanio day for a quarter of an hour, every hour, 
passing tho gas through a Littre’s tube, tho patient's temperature 
reached tho normal within three days. 

Tho following caso, selcctc,cl at random from over ono 
luiiulrccl cases, is typical of all patients so treated : 

A man, aged 48, when first seen had a temperature of 103.8° F. ; 
tho respirations were 40, tho pulso 109, and the malar flush was 
marked. There was frontal headache, and pain on tho right side 
of tho^ chest which was said to bo mucli increased by deep 
breathings Ho wanted to cough, but was prevented by the pain. 
The urtno was very dark, with a trace of albumin; the faeces 
wero well formed, but had an olTcnsivc odour. He complained of 
slight thirst, but when water was given ho refused it. 

Oxygen was administered as previously described. Six hours 
later tho temperaturo was 102° l\, the respirations were 25, tho 
pulso and tho headache ' had almost gone. Tho pain in tho 
chest was much relieved; ho was able to cough,- but there was 
no sputum. Tho urino was not so. dark, - but contained alburni/r.; 
Tho patient Imd not had any further rigoi'S, though thero had 
been somo previously. Although breathing was still not as free 
and easy as normal, ncvertlicless tho' patient had a good sleep. 

• Tho next day at 10 a.m. tho temperaturo was 102° F.J tho 
respirations 24, and tho pulso 68. There was no pain in tho chest, 
and no headache. Tho sputum was free and thick, but only- 
suggestive of tljo “ rusty ” colour. The urine contained no 
albumin. Ho had passed faeces which were well formed and 
normal in colour,- Tho typical physical signs of lobar pneumonia' 
wero disappearing, and fine crepitations were' heard at-tlic base. 

On tho third day at 4 p.m..thc temperature >*as 98° F.,.tho 
i‘Cspiral!ons 15, and the pulse 70.* The sputum was diminishing, 
tho urine was dark, but contained no aloumin, and tlio patient 
bad passed a normal motion.’ 

Recovery was rapid and complete, tKe disease being apparently 
cured ^vitmn' threo days, ‘the ' patient getting up on tlio fourth, 
day, and out on tho sixth day. When last seen ho was enjoying 
a swim.* ■ * . ' - ' 

Tho crisis appeared in roost, cases to _ occur during tho 
nicht, when tho patient was asleep. None of these patients 
felt weak or complained pf any disability whatsoever, and 

they breathed rather freely all tho time. 

Oxygon does moro than merely increase metabolism: it 
destroys disease. 


-DiiTGER OF INTRAVENOUS CALCIUM THERAPY. 

BY 

w. u. M. LLOYD,' M.D^, M.Sc., L.M.C.C.. . 

rDenattni'cnt of Pharmacology, University of Western Ontario 
• > ‘ Medical Schoo], London, Canada.) 

Iktkoduction. 

Calcium has been given intravenously in the treatment of 
lead poisoning, infantile tetany, tuberculosis, Blight s 
Iincmorrhngo, heart disease, and in tho pre-opera- 
tNr,^’epa'ation of j.aondiced patients. Cpshny (1924) 
ifated that calcium 'injected directly into tlie Wood stream 
acted rancli liko digitalis in that it , accolorated and 
stronctliened tlio heart beat in small doses, but in largo 
doses It seemed to bo poisonous, tending to bring Die hej/rt 
to 1 standstill. Brown, MacLaclilan, and Simpson (1920) 
observed tliat doses of 1.25 grams of calcium lactate given 
intravenously to infants suffering from tetany, resulted in 
.trmvsincss dv'spnoea, cyanosis, and sometimes collapse. 
Neumann ’(1920) reported favourable results iii cases of 
Ineniorrhago and of acuto and chronic diarrhoea from the 
•X-venous injection of 5 to 10 c.cm. of a 10 per cent, 
solution of calcium chloride. Grovo and ynies (1921) 
Tininted out the value of the intramuscular injection of 
100 minims of a 1 per cent, solution of' calciuni chloride in 
cT^^os of haemorrhage. Walters (1921) reported the use of 
calcium chloride in 10 per cent, solution intrayenoiisly ni 
tho pre'-operative preparation of jaundiced patients. T.ie 
trnatnient was efficacious in producing a shortening of the 
Wood-clotting time This author stated that calcium lu 
small doses, lis lO c.cm. of a 10 per cent, solution, might- 

bo given intravenously without harm. . 

Tn a further study of the .action of calcium chlorido giion 
intravenously Walfors and Bowler (1924) found that 
anuroximately twico the amount of the salt was lequiied 
to raise the Wood calcium of jaundiced dogs to the same 
level as that of normal dogs, and this in spito of tho 
fact that tho Wood calcium content was practically the 
same in the jaundiced arid' ndrniar dogs before and after 



Arniii ii, 19:8] 


DAKGER OF INTRAVENOUS CALCIUM TUERAPy. 


f Tnsl^Rrns* fjfilJ 
L JOTHlJf AS vuu 





injection of it lellinl dose, wliich sugK'-'>^t<‘d >' cnlcium dofi- 
cicnev in -Itio jiuindiced niiiimils Itiiifc nas not ai)i>nront. 
Tlioy' noted that wlicii tlic drag was ndminislercd iiilrn- 
vciimisiy to patients tlieio i-es\dted a iinieiconing of tlio 
pulse rate and a sensation of lieivt over the entire body. 
'Hiey observed that lids was the effect to which llerschsolin 
and' jffaendi gave the name of “ dynaniie effeet ” of intra- 
venous adiniidslralion. T!ie same piienomcnon was seen by 
these latter authors to follow the injection of quinine, 
dextrose, hexamethyloneletrandne, and tirea ; it proved 
transitory. At the same time, Walters and Rowler made 
comprehensive studies of the effects of intravenous injec- 
tions of calcium cliloride on the electro-cardiograms of dogs. 
A 10 jier cent, aqueous solution of the salt was used and 
injected at the rate of 1 c.em. per minute. The iujoclion 
of toxic doses into tfie blood streams of dogs hvouglit about 
various alteratioiis in rate, distiirhanees' of (imduelion, 
eetopie origins of impnhse, and, when earned to a still 
further iioiut of toxicity, disturlianecs of the fumlamental 
co-ordination of the heart, and vcntrirular tihvdlation, 
uldeft was foftowed f)y deatli, Jtoderate doses raused only 
an alteration of the pulse rate; this occurri'd ennsislently 
at an early point in tlic injection, hut was produced by 
smaller amounts of 
tlio solution in tbo 
normal than in tho 
jaundiced dogs. 

After the maximal 
accclerntioii was 
reached there was a 
mnrlvcd variation in 
rate, following which 
tile initial inaximnm 
was rarely exceeded. 

Condiietion disturli- 
anees appeared, 
marked by short re- 
curring periods of 
heart - block, and 
notched Q.R.S. com- 
plexes, which made 
their appearance 
more frequently ns 
the enntiiiued injec- 
tion assumed a more 
toxic effect. There 
next ocem-rod an in- 
crease in. tho ampli- 
tude of the T wave 
with a gradual cn- 
uoaclmicut on the Q.R.S. complex, vcntrienlav fihrilla- 
tio" and death. The ectopic origin of iinpuisos was demoii- 
stiated by ttie appearance ot inverted T waves and periods 
of nodal rbytbni. The rate at which the injection was 
giien Was of some importance because tlie concent ration of 
calcium in tho blood .stream seemed to be a factor in the 
toxicity of any dose. In two instances following a rapid 
injection the calcium content of the Wood taken from the 
heart immediately after death was twice that of the blood 
a 'eii fioin the external jugular vein. The investigators 
ascubcd the death following largo dosc.s of calcium to the 
oc cun once of ventricular fibrillation rather than to a 
calcium rigor. 

Singei (1921j rejiorted the use of calcium iiitr.avenonsly 
' ^ ^ lO ppr cent, .solution) associated with the 

..t minis 1 ,. ion of digitalis bj- the jiioutii in the treatmeut 

0 cau lac diseases with dedoma. Tho cahinm increased 
the tone of the ventricles, effecting a .slight rise of blood 
pi .ssnro, sowing the pulse, and causing an occasional 
diuresis. Calcium he believed to be “ the whip and the 
rem for digitalis. 

Popcscu-Inotcsti (1925) was able to induce jdieiiomena of 
.symp.atbetic excitation-namely, tachveardia. hypertension 
mydriasis, I.yperglycaemia, and somc'time.s tachypiioea-bv 
the intravenous injection of .small doses of calcium (0.1 to 

1 gram) ; tlm use of larger doses (1.5 to grams) caused 
excitation of the pavaspnpatliotic with hradveardia, miosis, 
and br.idypnoea The hypertension in the first instance he 
heheved to ho due to direct stimulation of the muscular 
filires ot the vascular wall. 





Scelig (1925), calling nttoiition to tho pos.sibio ill effects 
upon the heart and sniieutancons tissues of tho intra- 
venous injection of tho 10 per cent, solution of calcium 
chloride, rocoiiiinpudcd in its stead a dose of 50 o.em. of 
a 1 |>er cent, solution, which would not cause subcutaneous 
sloughing, and wliieli, particularly when injected slowly, 
had little if any deleterious effect ujion tlic heart. 

lliu-iiig the course of sonio experiments in oiir laboratory 
olcctro-cnrdiograiiliic records were taken of the heart of 
innn during and following calcium administration iiitra- 
vciionsly. The technique and results of these experiments 
are described below. 

Kxvv.uiMv.xT.'ii. Tecuxiqw.. 

The solutions used for iiitraveiioii.s administration were 
1 per cent, and 10 per cent, solutions of caicinm chloride. 
These solutions wero accurately jircparod witli chemically 
pure anliydvons ealeiinn chloride and distilled water; they 
were slovilizod by autoclaving. Tlic skin of tlio .‘■iihjoet’.s 
right arm in the region of the antecubital space wa.s .steii- 
lized in each case with alcohol, and the injections were made 
into the median cubital vein. Needles and syringes wore 
sterilized by boiling on each occasion, a 60 c.cm. .syringe 

being employed in 
tbo tii-st experiment, 
when 50 c.cin. of a 
1 per cent, solution 
of caicinm ehlovido 
was injected, and a 
10 c.cm. syringe in 
the second experi- 
ment, when 4 c.em. ot 
a 10 per cent, solution 
of calcium chloride 
was administered. 
Tho injections wero 
given slowly. Tlio 
autiior, a 135 Ih. 
man, acted as tho 
Bub.jcct of the ex- 
periment in each in- 
stance. 

During both experi- 
ments eiectro-cavdio- 
graphic tracings were 
taken of the. normal 
period, tho period of 
injection, and, in the 
first experiment, the 
period after the in- 






rt:V==¥5^ 





ruRihili riBioo or injictjcm . 


l-iwiiw-curujogram (Lend 2) ol the author’s case, showing siTio*auticulaT bloolc occurring 
dunug jnUa\cnou^ calcium admimslration. 


jeetion, the loads of the electro-cardiograiih being in each 
case tho right arm and left leg. 

Obskrvatzoxs. 

In the first experiment, when 50 c.cni. of a 1 per cent, 
solution of calcium chloride was injected intravenonslv, 
an electro-cardiogram lieforo, during, and for eight minutes 
aftei injection was taken, No subjective or objective 
symptoms beyond the normal were observed in the subject 
of expel iiiiciit. The electro-cardiogram showed no changes 
fioni the normal during and following the injection other 
than a slight increase in the heart rate during the period 
in which the needle penetrated tho skin. 

The second experiment, in which 4 c.cm. of a 10 per cent, 
calcium chloride solution wore injected intravenously, w.as 
more productive of results. MTicn 2 c.cm. of the .solution 
bad been iiijeetcd tlic subject experienced a sensation of 
warmtb over the entire body, acconijianied by slight head- 
aclic and a feeling of fnllnes.s in the head. It was decided 
to coiithnie the injection. Dizziness occurred diirine tlie 
period of injoctiou of the second 2 c.cm., and thi^ Was 
closelj- followed in tho coiir.se of the next three seconds bv 
syncope, respiratoi-j- faihiie, upward deviation of the eves 
diiatatiou of tho jininls, rigor of the mn.ssctcrs iuid 
asphyxial extensor spasm and riiriditv. 'J'hc strino- of tho 

io ho standi, m 

stdl. The subject was taken aw.oy from the elootrodc° 
placed in a siqnne jmsition upon tlio floor, and a-lifirloi 
vespivatiou instituted. An attempt was made to massa-^c 
the heart through the abdominal w.all and diaphragm at the 



664: Apisrii 21, ig2S] 


MIXED TUMOUR OF NASOPBAXiruX. 


r Tnz DnjTtm 
SrenrcAL Jouusii, 


left costal margin. In the coiirso of four or fivo minutes 
voluntary respiration was again establislicd, tho pupils con- 
tracted, and consciousness was regained. No residual effects 
wore noted. 

Tho examination of the elcctro-cardiogram during this, 
period showed the normal cardiogram to bo replaced by 
cue in which the rate of tho heart was reduced to one-half. 
No changes were to bo seen in tho P.Q.B. comple.x at tho 
time of this change in the frequency. Each wave possessed 
its normal order, time r-elationship, and character. After 
this bradycardia had lasted for ten seconds it was replaced 
by a series of small waves, which were suggestive of vibra- 
tion of tho string. There is no evidence in the cardiogram 
that the ventricle was beating during this period. At tho 
end of the curve, when the subject was removed from tho 
electrodes, these small fibrillaiy waves were less frequent 
but of greater amplitude. There wa.s as yet no evideiico 
of the R wave of ventricular contraction. The’ tracing was 
that of a prolonged sine-auricular block. 

Comment. 

From these few observations it is not possible to reach 
any conclusions as to the effect of calcium upon the normal 
electro-cardiogram. 

Whether tho effects noted in tho second experiment aro 
evidences of vagal stimulation or a direct action upon tho 
genetic nervous system of the heart independently of any 
extrinsic nervous supply it is impossiblo to state. Tho 
nature of the results obtained rendered it inadvisable 
to repeat the experiment following atropinization. 

The disturbances of conduction noted aro somewhat in 
accordance with those obtained by Walters and Bowler in 
the dog. I simply desire to call attention to tho occurrence 
of cardiac disturbances of conduction as a result of intra- 
venous calcium administration in a dosago that has been 
commonly used. 

SoMStAny. 

Tho intravenous uso of 4 o.cm. of a 10 per cent, solution 
of calcium chloride is dangerous. Tho electro-cardiogram 
shows what we believe to be a sino-auricular heart-block. 

To my clnof,^Professor J. W. Crane, and to Drs. Waud, Gordon, 
Kitchen, and Vine, I wish to acknowledge my gratitude for their 
help in the performance of this study. 


varieties of new growths in this region aro nasopharyngeal 
fibromata, angiomata, endotholiomata, carcinomata, and 
chondrosarconiata. 

Tho report of tho following case is therefore considered 
of interest because of tho Jack of references to similar cases 
in tho English textbooks. 


A boy, aged 7 years, -was scut to St. Helens Ho.spital for the 
removal of adenoids; ho suffered from frequent colds and nasal 
obstruction. On examination by anterior rhinoscopy nothing 
abnormal w.as found ; posterior rliinoscopy was difficult, but tho 
lower polo of a smooth greyish-pink tumour was seen partially 
filling tho left nasopharyn.x ; this mass did not bulge tho soft 
palate of that side. By digital examination a firm sessilo 
tumour, about tho size of a small nut, was palpable, occupying 
the left side of (he post-nasal space. The tumour did not bleed 
during e.xamination, and appeared to spring from the lateral 
Avail of the nasopharynx, between the left choana and the 
Eii.stachian orifice. TJiere was no history of epistaxis or pain, 
and no evidence of involvement of the middle ear or of the 
neighbouring lymph glands. . • • - 

•A diagnosis of na.sopliaryiigeal fibroma was made, and subse- 
quently tho tumour was removed with post-nasal forceps 
without undue liaemorrliage. Tho child Avas examined three 

moullis later, Avhen the nasopharynx appeared clear. , . - 

' Professor Beattie kindly examined tho specimen and mado 
tho folloAving report : • ' > 

This tissue consists of an area of irregular cartilage, an 
area of adenomatous tissue, tho acini being lined by a high 
columnar epithelium (similar to tho lining in the gland 
spaces of tho ovary), and a cellular area mainly Avith round 
mononuclear cells. Tho section suggests a tumour of con- 
genital origin from some abnormal structure. 

BroAA’ii Kelly has classified a group of tumours occurring 
in tho plmiynx as follows: (1) teratomata, (2) teratoids, 
and (3) mixed tnmours — “ arising from cells at the junction 
of Ha-o types of opitbelinm. Some may assume mildly 
malignant characters.” Tho tumour reported above belongs 
ti tho last class, and is more correctly called a blasto- 
terntomn; it is similar to tumours arising in tho parotid, 
subniaxillary region, lip, palate, orbit, and, as recently 
described, in tho molar glands. 


IIEITHRaCKS. 

SIF Sinnlr Tlioroson : DUeatei of the 'Note and Throat, third cdillon, 19^ 
l'ro6 %Tsoe.mi., Laryngoloeicnl and Otological Sections, 192J-24, svl. 

cfioVynool,, xxxiii, 1916. J. 

Lionel Eilield : Lancet, September 29tli, 1927. 


RETEnEXCE.'^. 

Brown^ A., jracLachlan, I. F,, and Simnson, R . : Effect of Intrarenons 
Injections of Calcium in Tetany ana the Influence of Cod-liver Oil 
and Phosphorus in the Retention of Calcium la the Blood. Amer. 
Journ. Dis. Child., 19, 415, 1920. u « i . 

Cushny, A. R. : A Textbook of Pharmacolog}! and Thcrancutic$ Fbiln.. 
eighth edition, 1924, pp. 554, 555, 557. • . xm 

Grove, W. R., and Vines, IT. W. C. : Control of Hacmorrliape by Infra* 
muscular Injection of Calcium Chloride. Brituh Mcdthal journal, 
1921, 11, 40 

Neumann, w. : Calcium Chloride for Haemorrliagcs. Mtinch. med, Woclt., 
67, 1290, 1920. 

Popesci^Inotesti. C. : Action of Calcium Ion on Vegetative S\8tera in 3Iaii. 
C. R. isoc. de Bxologxe, 93, 752, 1925. 

Scelig, M. G. : Localized Gangrene following ITvpodermic Administration 
of Calcium Chloride. Journ. Amer. ilctl. Assoc., W, 1413, 19<5 

Sinfrer, G. ; Calcium in Heart Therapy. Whti. kiln. IVoch., 34. 24*7, 1921, 

Walters, W.: Pre-opwativo Preparation of Patient*! with ObstrucUvo 
Jaundice. Surg., Gynecol, and Ohstet., 33, 651, 1921 

W'allers, W., and Bowler, J. P. : ibid., 39, 200, 1924 


A iriXEO TOMOUE OF THE HASOPHARYHX 

BY 

JOHN E. G. McGIBBON, M.B., B.S.Lond., D.L.O.,. 

HOSOBARY ASSISTANT AURAL SURGEON, EYE AND EAR INFIRMARY, ' ’ 

tlVEBrOOL. 

fVHh a Pathological Report hy 
J. M. BEATTIE, M.A., M.D., 

FEOEESSOR OF BACIERIOEOGY, UNIVEF.SITY OF LIVERFOOE. 

It is recorded by Sir StClair Thomson that “ neither 
simple nor malignant neoplasms are found, except rarely-, 
in tho post-nasal space. The innocent growths aro so 
uncommon that every new formation in this region should 
bo looked on with suspicion.” On the other hand. Sir 
William Milligan, opening a discussion on nasophai-yngeal 
groAAths at the Laryngological and Otological Sections of 
tho Royal Society of Medicine, stated that growths in tho 
post-nasal space are not uncommon, but that their presence 
'a frequently overlooked; and further^ .that the principal 


A METHOD OF TREATING FRACTURES OF THE 
CLAVICLE WITH DISPLACEMENT. 

BY 

G. W. MILROY, M.B., Cn.B., 

WIGAN. 


’UODAIU.Y the most commonly used method of treating 
imnlo fractures of the clavicle with displacement is either 
'hat originally described by Sayre, or tho bandage devised 
iv Doiigis. One great disadvantage of the former method 
f Son is the fact that the strapping used to support 
ho eiboAV so often slips over tho point of the oleciauou 
iroocss, allowing the arm to drop, Avith recurrence of the 

*^I?"an endeavour to avoid this difficulty the piaster is 
ometimes applied with the adhesive side next to the skin, 
nils certainly prevents any slipping, but it does not alloAV 
,f accurate adjustment, and, also gives rise to mucli dis- 
•omfort often amounting to actual pain, particularly 
irund tho point of tho elbow. This pain seems to be 
■qually severe Avhetlier a slit for tho olecranon process is 
nacle in the plaster or not. If, on the other hand 
louglas’s method of bandaging is employed, tho 
llsadvantage is again evident. The bandage as a uholo 
oTdTto beime loose, and tho final turns round the elhoAV 
ind over tho opposite shoulder slip off the elbow and alloiv 
ho arm to drop. The bandage may remain m good posi-. 
.ion during the day, hut when the patient is in bed, and 
nrliciilarlv if he is someAvhat restless, as these patients 
isually "ai'C the bandage will soon work loose. It is- a 
;ommoii experience to find a patient Avith a 
lavicle, which has been reduced and firmly bandaged on 
mo day, returning next morning with tho bandage 
Doso and tho deformity renew’ed. 


ATOIIj SIi 


MEMOBANDA. 


r TurCcrnsn Rfiti 

LUedicii locnxAi. 


To ovoreomo these clifficulties ] have been using a modi- 
fiealiou of Savie’s inethoil which has given great satisfac- 
tion. Tlio hieUiod devised is ns follows. 

.Two five-foot lengths of calico handage arc required. 
•The first, as in Sayre’s original method, is looped loosely 
round the affected "arm ns high up as possible, the loop 
being fastened with a safety-pin. 'file usual jiad is iihiccd 
ill the axilla, the .shoulder is pulled hack a.s far as possible, 

and the bandage is carried 
across the back of the trunk, 
round across tbe che.st, ami 
piiiiied to itself just beyond 
the looji round the arm. 

The .second bandage, which 
should be at least, six inches 
wide, is slit from one end for 
a little lo.ss than half its 
length, and is then njiplied 
to the injured arm in the 

form of a .sliiig, with tbe two 
tails to the front, in the 
following inanner. The un- 
cut end of the bandage runs 
from tbe unaffected shoulder 
across the back to the elbow 
of the affected arm, which 

it supports, a ])ad of wool 
being plated betivecii it and 
the olecranon. The bandage is ad justed in such a way that 
the two tails originate an inch or so in front of the point 
of the elbow. Those tails arc then carried round 

opimsite sides of the forearm, and are twisted together 

once or taice as near to the bend of the elbow as is 
possible. They arc then carriisl forward a.s spirals in 
opposite diroftion.s round the forearm, thus crossing on the’ 
dorsal aspect of the middle of tbe forearm, and al.so at 
tbe front of the wrist, where they are again twisted 
together and carried on as one to the .sbouldei'. Tbe ellio'.v 
is then drawn upwards, forwards, and inwards to the 
icqnired position, and ses'iinal bv tving tbe ends of tlie 
'■ sling ” over the unaffeefed sbouIdeV. The sling effect of 
the second bandage has been found to be verv stable; the 
iirs't looii of the tail.s rouiul the forearm just bevond the 
elbow effectively prevents any slipjiing off tile elbow. 

The spiral round the fois’ann rvill he found to support 
tiR* forciinn coinfortnblv ii» tlio usunl position jn-ross 
tin* «uk 1 tho combination nf the two baiulngi.*s :ui(i the 

axilliii V piul will supply llic fom'S" iK*cc\s>arv to canw the 
jiitoral fragment of tlio elaviclr upwards, backward*’, and 
latciallx, wliicli is so essential for a perfect result in these 
rasc’s. 


Ittrmai'fntiia : 

MEDIC-\L. SURGICAIi, OBSTETBICAXi. 

VARICOSE YEIAS IN THE BROAH LIGAMENTS. 

T 11 wr been ici>eatedly striuJi by the frequency with which 
mioinuHis varicobi* veins of tbc> pampiniform plexus occur, 
but I bavo been unable to find much written about tliem, 
and ten little eoncerning their treatment. Tho questions 
natuially arise whether these varices are themselves the 
cause oi abdominal and pelvic svmjitonis, and how theV 
should be treated. . j ; 

Most of the jiaticnts T have seen have complained of per- 
sistent pains of a dull acliing character, and a weight m the 
lielvis; most of them also had ragiiial disclmrge, which in 
case.s vas gbnocoecal and jn others gave ])ure cultures 
of jj cttl'/. A few i>:itieut& had been curetted, with no 
henent. On examination they complain of sharp pain on 
pio^-sure in tho foniices, similar to that of inflarnmatoiw 
adne.xal disease; eventually the pain and discharge have 
deiEandcd an exploratory operation. 

Many of the jiatients* liavc been under 55 rears of ao'c. 
The menstrual history is iiovma!. An operation discloses 
IK) tnbal disease, uo ndbesion.s, and no uteiiiio displace- 
ments; tbe iitoi-n.s J.S in some cases sligbtlv enlarged, but 
tlicre IS present a huge black mass of varicose veins. In 



all cases one condition has been very constant — namely, 
cystic enlargement of both ovaries. It seems unlikely that 
this cystic state of tlic ovaries is the cause of the 
pains, bccaiiso the condition is often seen wlien operation is 
porformod for other abnormalities. 

AVo arc faced with the following juoblems; a patient, 
aged, say, 35, comes with constant uti'i-ino disebarge and 
pain, enlarged cystic ovaric.s, and this condition of varicose 
veins in tbe broad ligaiiient.s. AVliat i.s tbe eoriect troat- 
iiicnt';' Jt seems niilikoly that the di.scbargo will cease 
unless the uterus is removed, wliicli is .scarcely justifiable at 
that age. 

. Again, sbmtid , the cystic ovaries be removed? How 
sliouUl the varices be treated? AVbat i.s to be done with 
a patient who lias no iiterjne disdiaige, and whose only 
abiioriiinlities are varices and ey.’-tic ovnrics? 1 put these 
questions with tbe hope that experienced gynaecologists 
and .snrgeuiis will givi- ns tlie benefit of their advice and 
pi active; at jueseiit the subject ap])cais to mo very full of 
iliffieiilties. 

C. L. (!n.iN'vn,i.i;-Ciu)’jr.\x, E.R.C.S.I., 

• Surjrt’fm, (Jriin^by unci Dhtrict Ilo'pital. 


FOREIGN BODY IN THE BLADDER CAUSING 
CALCULUS FORMATION. 

Foi.i.owinc tbe ease reported by 5Ir. Guy Chambers in the 
Jouriml of November 5tli, 1927 (p. 827), in which a hairpin 
forinod the luielcus of a vesical calculus, and Mr. A. Ralph 
Thonipson’s rejmrt of five cases of foreign bodies in tlie 
urinary Iiladder (.lanuary Wtli, p. 51), details of another 
ease should also luove of interest. 

The patient, a wom.m aged 67, is suffering from sccoiulaiy 
deuienlia following nianir-depi’cssive insanity, and shows marked 
amnesi.a. For some time she saffered from mcontincnco of urine, 
which appeared to bo more of an iucoiivenicncc to others than 
to jicrsclf. At no lime did she complain of any pain, nor, in fact, 
wa.s any clinical hisloi-y procuraldc from Iier, On vaginal cxainina- 
lioii she was found lo'liavc a large liaid tumour bulging into the 
t anterior wall of the vagina just behind the cxlcnial orifice of 
the uicthra: ibis suggested a stone, .and the diagnosis w.as con- 
firmed by the passage of a bladder sound. In view of the 
proliablo presence of .a foreign body, I decided to remove the 
eloiic by tbe suprapubic route! When tbe bladder av.as •opened 
the stone was found to bo impacted over tlie internal urclliral 

orifice, and to be fixed in tins posiliou by a bairpin, the tVec 

extremities of •wliicli were embedded in tlic bladder wall. The 
remora! was difficnU, Uic more so because tbe bladder wall avas 
BO friable that it would scarcely hold a stitch. Tlic stone was 

about the size of a large egg; it wciglicd 125 grams, and avas 

composed mainly of urates and pliosphales. 

As .shown in the illustration, tho offciidiiig Imirpiu 
traa-ersos tho stone in tho longitiuliiial axis, and has 
evidently formed the nucleus around aajiicli the stone avas 



formed. 5 ho lengtli of time taken hy tho stone to form 
may bo guessed at from the patient’s liLstora-. It may be 
assumed that the introduction of tho hairpin occurred 
during a jiliaso of mania, and that it therefore had been 
ill the bladder for ujiavards of two years. It is estra- 
ordiuary that the patient did not complain of pain and 
that the hairpin did not perforate tho bladder, in view 
of tile fact that both extremities were embedded in tho 
wall. 

There was some degree of cystitis present before the 
operation, but despite this tlie patient’s condition three 
weelcs after the operation is favourable, and she continues 
to improve. 


I am obliged to the subcommittee of the hospital for permii^ion 
to publish tins case. ‘ 


Colney iratch Mental Hospital, K.ll; 


J. McFadze.cx, 

il.D., Cli.B.GUw., F.K.C.S.Eug. 




666 April 21 , 1928 ] > 


TTJBEBCULOSIS OF THE URINABT TRACT. ■' 


f Tne UniTii* 
MtDiciL JocawAft 


-DYSTOCIA ASSOCIATED AVITH A VAGINAL BAND. 
The following case appears to bo worthy of record iiias- 
mnch as an occipito-posterior presentation in a primipara 
was complicated by a vaginal band. , . 

In a primipara, aged 23, who had never previously had a 
vaginal examination, labour began in the morning; progi'ess was 
slow, the pains being slight, and she was first examined in the 
afternoon. When' making iho first vaginal examination Ihoro 
appeared to be some fold of mucous membrane in the neighbour- 
hood of the os, which admitted two fingers, the whole of ilio 
parts being soft. Seen again at 6 p.m. very little progress 
appeared to have been made, but the presentation was diagnosed 
as being occipito-posterior. At 8.30 the os bad reached the size 
of a five'sbilling piece, and the existence of a peculiar strand of 
mucous membrane had become more evident. Labour was pro- 
gressing slowly, but the pains were not very strong, and the 
membranes had not broken. The patient was examined again 
at 10.30, when it was found that a finger could be hooked round 
what appeared to be a fleshy band lying up against the expanding 
os. The patient was put into tho lithotomy position and anaes- 
thetized, and a vaginal speculum was inserted. It was then found 
that a fiesliy band extended from tho caruncula to the posterior 
vaginal wall far back; it was about half an inch in thickness in 
its thinnest part. It was ligatured in two places and divided. 
Labour then progressed in the usual way, delivery being accom- 
plished by turning the head and applying forceps. 

Tho case derives special interest from tlio 2 Ji‘cscjico of tho 
thick vaginal band; which would appear to bo of tlio nature 
of a 2 >artly bifid vagina. I can find no reference to this 
condition in tho textbooks. 

Docking, Norfolk. AV. JeUDWINE, M.D. 


DELAYED INTBACRANIAL HAEMORRHAGE. 

The following clinical details of a case of cerebral haemor- 
rhage occurring several days after an accident seem to bo 
worthy of record. 

A girl, aged 2, while playing, fell and struck her head against 
tho corner of a sideboard. She was stunned for a few moments, 
but quickly recovered, and her foster-mother, a careful woman, 
did not think medical advice necessary. There was a small 
bruise and abrasion on tho forclicad, but nothing olso was 
detected. The child remained in appai-ently normal hcatUi until 
eighteen days later, when sho stopped eating while having a 
hearty breakfast, clenched her teeth, and died within a zniniito. 
No other history of further symptoms, such as vomiting, headache, 
or drowsiness, could be elicited after careful questioning of 
those who had been in contact with tho child. 

A fost’inortcm examination revealed a bruiso about one inch 
in diameter on the left temple; thero was no fracturo of tho 
skull. Under the dura was found a considerable quantity of 
blood clot, probably about three ounces. Tho left frontal lobo 
of the brain showed a contusion corresponding with tho position 
of tho external bruise, and there was a similar contusion caused 
by contrecoup on the right occipital lobo. Tho subdural 
haemorrhage appeared to have come from tho ruptured meningeal 
vessels over the frontal lobe contusion. Thero was no haemorrhage 
into the ventricles. The other organs of tho body wero normal, 
and no food was lodged in tlic air passages or gullet. 

The points of interest in this case are : (1) tho compara- 
tively slight nature of the original injury and of tho 
immediate symptoms; (2) the long latent -period of appai*- 
ently perfect health; (3) the sudden and unexpected death, 

Worcester. N. DuGGAN, M.B,, E.R.C.S. 


SCORBUTIC SA\^ELLING SIMULATING AN ACUTE 
BURSITIS. 

The following case may he of interest to readers of tho 
Journal. A woman, aged 25, sought relief for a swollen 
knee. She had a large pre-patellar swelling, the skin over 
which was thinned and glazed, suggesting an abscess on tho 
point of rupture. Free fluctuation was present. The 
swelling- was -about the size of a large orange, and tho 
patient stated -that it had been causing her considerable 
pain since it started, two months before her visit to me. 

' I anaesthetized the part by means of a 2 per cent, 
solution of novocain, injected -into the medial aspect of the 
thigh just above the knee. Using a 20 c.cm. syringe, I 
pushed a long needle into tho swelling, penetrating the 
skin some three inches away from tho swelling itself. On 
withdrawing the piston some blood began to flow into the 
barrel, and I realized that, instead of a pre-i)atellai* abscess 
or bursitis, I was dealing with a sanguineous scorbutic 
swelling, scurvy being reiy ijrevalent amongst tlio natives 
in these parts. I removed nearly ten ounces of dark 
sanguineous fluid, and the patient derived' great relief. 

Sulenkama. South Africa. R- L- PATERSON, M.B., Ch.B. 


Rrjiarts af 


TUBERCULOSIS OF THE URINARY TRACT. 

At a meeting of the Section of Surgery of tho Bov.il 
Academj- of Medieino in Ireland on Marcli 30tli, the 
president,^ Jlr. Andrew Edlleuton, in tlio chair, Jlr. 
Henry adi: road a pnjicr on the surgical pathology of 
tuberculous diseaso of’ tho urinary tract, and showed 
lantern slides. 

Mr. Wade said that during a period of five yeans to 
1926 ho had had 57 cases of renal tubercnlnsis under his 
care; of these patients, 21 wore males and 36 females, tho 
average age of tho males being 29 and that of tho females 
34 years. Tho average duration of their illness was two 
years and five months. Tho outstanding complaint in 
49 cases was frequency of micturition. Tiiborclo bacilli 
wore found in tlio urino in 26 cases. Tho importance of 
a pre!iminar 3 ' T-ray examination of tho entire nrinarj- tract 
was emphasized, since this not infrcquentlj’ revealed tho 
presence of tnhercnlous diseaso in one kidiicj’. C^stoscopic 
examinations were performed in overj’ case; tho nverngo 
number of cystoscopie examinations was 1.6. In virtually 
every case the bladder capacity was found !.o bo reduced, 
varying from 10 c.cm. to 300 c.cm., tho average being 
166 c.ein. Tho degree of tho diminution of tho bladder 
capacity was an approximate indication of tho severitj- of 
tho case, and the incrcaso in tho bladder capacitj- sub- 
sequent to operation was a verj- valimblo indication of tho 
improvement that had occurred. The presence of a “ golf-' 
hole ” ureter was diagnostic of tnbcrcnlons diseaso in tho 
kidney above. Tho earliest indication was a swelling of 
tho mucous membrano with congestion and oedema. In 
overj’ case bilateral ureteral catheterization was attempted 
and was achieved in tho majority. Pyolograms were taken 
on both sides; the author had found no harmful results 
follow this practico. Wlicro tho catheter could only ho 
passed for a few centimetres a ureterogram was taken. 
Tho pj-clographic findings varied with tho stage and typo 
of the’ disease present. In the earlier ti-po of case which 
had proceeded to cavity formation tlie outline of a normal 
pelvis and normal calyces was seen at ono part with a 
filling defect from cavity formation communicating with 
tho pelvis at another part; this appearance was diagnostic. 
Tho appearances seen in a ureterogram wore also diagnostic 
whero tho ureter was involved; tlioso wore the irregular 
dilatation of tho channbl and its irregular outline. In an 
early case the amount of secretion from tlio diseased 
kidney might bo greater than from tho healtliy side. In 
cases wlioro the examination was difficult chromocystoscopy 
was of value, especially to indicate the situation ' of tho 
orifices. In a very occasional case, wlioro doubt still 
existedj certain methods ■ of operative surgery had been 
rccommonded as an aid to diagnosis. ’ Catheterization of 
tlio ureters through the open bladder was 'not advocated. 
Examihatibn of the ureter through a gridiron incision in 
the* loin- "b®- value in certain cases. Tho treat- 
ment of tuberculous disease of the kidney advocated was 
nephrectomy whero the disease was unilateral, since a 
spontaneous natural cure of renal tuberculosis did not 
occur. Of tho 57 patients, 53 were operated on, 2 were 
found to bo inoperable, and 2 declined operative treat- 
ment- 1 patient died in hospital from a cardiac 
thrombus. In' 34 patients the wounds healed by primary 
union- tlioir average stay in hospital was twent)--on 0 days. 
Twelve patients' left Iiospital with a small sinus still 
nnhealcd; 6 left with a larger sinus, the result of partial 
breaking ’ down of tho wound. In ono case tho wound 
enth-oly broke down, but completely healed five montlis 
Kiibseouentlv. Every patient was re-examined on several 
o3ons. A complete euro was obtained in 34 ca.ses; 
11 patients wero improved, and 6 died after leaving 
hospital. Repeated c)-stoscopio examinations showed that, 
whero* tuberculous ulcers had boon present on tho surface 
of the bladder, these usually disaiipeared rapidly, first 
from the base and lateral walls, and later from its roof. 
Frequency of micturition might persist, being due to a 
chronic ulcer or to a localized interstitial cj-stitis; in 
tlireo cases it was found to be duo to persistent, non- 



iLrRii> II, 




SITHGICAIi CONDITIONS OP THE STOMACH. 


r TntliMTtVR 

[ McdicalJocrsu. 


supi^urativo streptococcal cvstitls. lu llie 6 put touts avIio 
died after leavinp Iiiispilal, deiitli was due (» disscmina- 
tiou of tlio fiibercidoiis iiifoctioii in 2 oases; 2 died frora 
Hio continiKHl activity of tlie nniemovod infection, and 
1 died throD and a hnif years after the operation from 
annrin. Ho liad completely recovered from tlie tuliemdous 
infection, and the anuria was due to liydroneplirosi.s 
originallv produced ivlicii the bladder was in porsistont 
systole prior to the operation. The sixth patient died 
from a ])riinnrv ndenoeareinoma of the liver four and n 
half years after the ri^ht kidney was removed for tuber- 
ciiious disease. Tiiero were no signs or .symptoms of dise.ase 
of llie nrinary tract. Complete microscopical sections of 
the entire organ were made in thi' 53 kidneys removed. 

, The PiiKsii)K.NT said that ill health preceding tnborcnlons 
di.scase of the kidney wn.s in a large number of cases 
entirely absent, and patients .suffering from this disea.se 
usually only consulted n surgeon on account of frequency 
of micturition, which became so .severe ns to interfere with 
their work. The shadows irhich were found in the region 
of the kidney .and ureter were pitfulls, iind it ivas only 
hy the ureteral catheter and pyelograms that it was 
possible to difforentiato them, and to show that they 
had .any relation to the kidney. Diminution of bl.addor ' 
capacity, irhich was a feature of en.ses of tuherculosis of the 
kidney in the o-arly stage.s, was also very imiiortaut in the 
later stages. The. presence of tuherclca on the mucous 
membrane of thn bladder iv.a.s mentioned in te.vtliook.s, but 
his esperieneo ivas that these were not often i-een. Uni- 
l.atcr.al diuresis was one of the earliest and most important 
signs of tuberculosis of the kidney. 

Air. A. A. AIcConnesi. referred to the iiccc.ssity of very 
eshanstivo preliminaiy cxnmiiintinn in ca.scs of tuber- 
culosis of the kidney, and said that in renal disease, if it 
was not possible to make a dingno.sis before operation, it 
was very unlikely that one would be made .siil»c«iuently. 
Ho himself did not use pyologrnm.s, since he felt that the 
less manipulation of the kidney practised in tuberculous 
eases the better it would be for the patient. Ho had 
seen cases in which the htaildor iind been .severely involved 
U’ith tubcrculo.sis at the time of operation, and in which 
the ureters could only bo found by the injection of 
indigo-carmine, though, there had ' been no bladder 
symptoms whatsoever. 

• Mr. SmoN Pkinolf. said that in his experieiue ne.ar!y 
50 ]icr cent, of late cases were obviously bilateral and 
inoperable, and ho referred to the use of tuboriuliu in 
those cases. When it was difficult to make a diagnosis, 
convalescent treatment, after, a course of tuberculin, 
rendered it possible to come to a more definite conclusion 
regarding operation. 

. Mr. L. G. Gckx thought that cases of bilateral tubercu- 
losis irerc not rare. In the last few months he had .seen 
five cases, all of which, in lii-s opinion, were inoperable. 
He considered it unwLse to perform nciibroctomy in cases 
in winch there was any diseaso in the other kidney, or in 
any other part of the sj'slcin, joint, bone, or lung.. Tuber- 
culin in a great many cases prolonged life, but nepbm tomy 
was the ideal treatment for cases in wlticU tuberculous 
disease iras confined to one kidney, one ureter and the 
bladder. 

Mr. M replying, said that he had jievcr seen tuber- 
etdous nodules on the surface of the bladder, and agreed 
that more was learned in these cases before an operation 
than at one. 


wero given of wasting associated with marked filling 
defeet.s which was due to fibrosis, papillomata, or the 
(ircssuro of tumouns outside the stomach. In yet another 
case fibrosis in the lino of traction of the omentum 
adherent to a hernial ring had involved the outer coats 
of the stomach, giving rise to an hour-glass condition with- 
out ail ulcer. I’lilegmonous gastritis v.as described, and 
lesser degrees of gastritis and duodenitis were mentioned 
as possible pro-idcorativo conditions. It was suggested 
that more prolonged treatment should ho given to ordinary 
atfaeks of indigo.stion, and .special attention should bo 
paid to the teeth. If the condition re.sisted medical treat- 
ment or .showed signs of reenrronec fnithcr investigation 
was necessary, and in persons over the age of 45 sneh 
treatment should not he prolonged. A tenclonc}' in some 
familic.s to ulcer was illustrated In’ tliree ca.so.s in one 
generation. Aa regards the relation of ulceration to 
cancer it was stated that in only three cases had such an 
etiologj’ been detected. The various methods of surgical 
treatment of simple and Iiour-glass ulcer were considered 
and eases were described. A jio.stcrior gn.stro-enterostomy 
with infolding or excision of the ulcer was thought most 
suitable for ulcers near the pylorus. Kamnicrer’s method 
of gastroplasty had been employed for hour-glass contrac- 
tion with no active ulcers. It was thought that when 
skilled assistance and nursing were available, partial 
gastrectomy for ulcers on the lesser curvature or situated 
posteriorly was the best operation, since unpleasant 
sequels wero rare and the operation was often less difficult 
than that of freeing a penetrating nicer by means of 
excision, suture, and gastro-entcrostomy. Reference was 
miide to a case of lioiir-glass stomacli with a meso-colic 
Iterniii. Two other cases were recorded as being related 
to moso-colic hernia ; in one the apex of the duodenal- 
jejunal flexure wo.s pressing through the meso-colon, and 
had. formed a kind of divcrticuhiin in the lessor sac, and 
in the other a one and a half inch posterior gastro- 
enterostomy was found to exist without there being any 
abdominal sear. In the latter case it was uncertain 
whetber •tbero had been an — . -.r . i- • • jpg 
jejunum, or a condition of •’ the 

stom.ach. In carcinoma the advanced nature of the cases 
when seen hy the surgeon was cited as an argument 
against the prolonged medical treatment of indigestion in 
later life. In advanced cases, exploration, or even a 
palliative operation, was a .serious matter, hut was to be 
j commended in view of tbe fact that tbe diagnosis was 
; .sometimes ’wrong and a growth amenable to surgery might 
I be found. Tlie survivals justified taking the risk in cases 
which ni>peai’cd to bo hopeless. Quo patient survived for 
twenty-two months after a gastro-enterostomy ; nnotlior 
was alive and well seven years after gastro-gastrostomv 
ami gastro-enterostomy for carcinoma, confirmed bv 
.secitions of the gland. In anothec patient, who was rapidiv 
going downhill, a four-inch malignant papilloma was 
found to bo iuvaginating the stomach w.all, and six other 
papillomata were present: a year later, however, the 
patient w.as .still alive and grateful for the relief. It w.ns 
stated that in early cases ' parti.al gastrectomy by Toly.a’s 
method was used, the' posterior abdominal glands being 
removed as completely as possible ; several cases wero 
recorded in wliicli aiiparent curd had resulted. Only one 
case of sarcoma had hceu ciicouhtered ; this occurred three 
months aftcr'partial gastrectomy and proved rapidly fatal. 


' SURGICAL COHDITIOKS OF THE STOMACH. 

At a meeting of thd Liverpool Medical Institution on- 
Alarcli 22ik1, a joint paper by Mr. G. C. E. Simpson and 
Air. D. R. Owp.N entitled “Some surgical conditions of 
the stomach ” was read. 

• After a brief reference to congenital conditions, tbe 
antbors stated that cei'taiir .simple conditions of tlie 
stomach gave rise to symptoms and s’-rny appearances 
closely resembling those of ulcer or cancer'. In one case 
in wliich the sj’mptoms had lasted for eighteen montlis 
and the -.r-ray indications suggested g.-istric nicer, a fi.sh- 
hone was found in the lesser omontnni; iu another case 
a fibroma of the lesser cun’aturc was lU’csent. Illustrations 


CYSTOSCOPY IN CARCINOMA OF THE CERTIX. 

At a meeting of the North of England Obstetrical and 
Gynaecological -.Society at Liverpool on Alareh 16th, Dr. 

. A. A. Gemmei.u (Liverpool) read a paper on eystoseopv in 
carcinoma of the cervix based on a study of 111 cases of 
this’ disease. 

Dr. Gemmell described tbe mothod employed to determine 
clinically the opcrobility of these cases, and showed how 
cj-stoscopy added “ sight ” to “ touch ” in estimating- 
anterior extension. The appc.arances seen were described 
in their order of gravity as being: (1) bulging of the 





ArRiD 21, tgiSj 


BEVIEWS. 


r T>rr.llprnsB fiOO 

L JlEDICil. JoCIUfil, ^ '^y 


I’kiriifuri. 

FEKNCn TEAClllNX; IN PUIU.IC Hl'.ALTH. 

An iin))nrfnnt rvont Iins rowiidy occtu-icc! in ftio l’'icnc]i 
jmWic lionlUi world — tlic issue of two larjjn voluim's soltiiiK 
out the lorlurt's ou pwtdie given ul the lu-.lilulo of 

Uygiciio of tiio Paris Favuliy of jlodiciiic Iiy soino tiiirt_v- 
oigUl teachers, under tlic direction of I’nifesMU' I.nox 
PruNMin. professor at the faeuUy and a leelinical ailviser 
to tile llealtli Jlinistry, and 3t. Poinatr Dchkk, assistant 
professor at five faeadty and a jdiysieian of tlie I'aiis lios- 
jiitals. The 'names of some of llio writers arc- a!rc-ad) well 
laioan in this eountry. Thus Profi-ssor Ilernard, oho writes 
most of the text on tnhercnlosis, represents l-'rani,- on the 
Health Section of the League of Nations ; other familiar 
names are those of Professor K. Ilrnmpt, wlio writes on 
relapsing and yellow fevers; At". If. Vallee. Iionorary 
director of the National Veterinary fsehoed at .Vliort, 
whose eollahoration is, nnforlunalely, limited to anthrax; 
Dr. Jules .Renault, teelinicai adviser to the Jtiuistry of 
Health, who deals with the sanitai-y dc-fenc e of laud 
frontiers; Dr. Henry Pottevin, director ot the Oflioe 
Tnteniatioual d’Hygiene Puhliqne, who was tin- idnious 
jrersou to write on international sanitarv toiuenticms; 
JI. R. Sacqucpco, Aledcciu luspccteur de r.trmee and 
professor at Val do Grace Hos]iita!, who writes ou food 
poisoning; 31. R. Sabouraud, who deals with rrufiuiirtn : 
and 31. L. Rollanfs, wlioso work on activated sludge is so 
well knoivn, writes ou sewage and trade wastes. 

■A consideraWo part of tho voliimc.s i.s from the |>eii of 
M. Ch. Dopter, who deals with general epidemudogr- ami the 
prophylaxis^ of several of the individual di.sea.-a'v — haeiliary 
and amoebic dy.scnfcety, pneumonin, intiuenwi, diphtheria, 
and^ tetanus. His writing is marked throughout hy 
clarity of stylo, simplicity of diction, and excellent arrange- 
ment of matter. An interesting ]ioinl lie hi mgs out is 
the wholesome intlueneo of the various eou--tituents of 
I"’*?.,}' especially the acids) in dostioMiig typhoid 
bacilli; evidently any contamination of wine by tvplioid 
sufleiw or “carriers" is rclativolv haiiiiles-,. White 
wine is oven safer than red in this respect. A.s might be 
expected, the text ou food is Iwlh full and adequate ; the 
eon^mption of a largo number of species of edible fungi 
m i'rance is reflected in the section bv M. H. Martel. 
duectoT of the veterinary sen-iees of the Department of 
the ^inc. The extent to which the collaboration of the 
veforinary profession has been sought is miieli to be eoin- 
mcn oc . le 1‘reiich people, who at one time had a 
raotctl objection to the use of anv otlicr timn fn-^h meat, 
have been forced by economic changes to hare rerource to 
frozen and chilled meat; they will obtain a good deal of 
comfort from rending the praise of chilled meat br 
AiV of the National Veterii.arv School at 

Alfort. There is much useful information to Knglish 
hygienists lu ins section and in that on the preservation 

o L<»'tat-Jacol,, a viii-presidei.t 

of the F i-eneli Cold Storage Association 

lie Fioaee ib-mnin .' 
fo™» f 'f hphorism well in the 

lZ %Zlh-Z 'Adequate' space is givmi to the baby and 
Tronssean writes'^ ii physician to I’Hopital 

fed 0 ^ 0 f ' 1 detail on the 

Vroteeti'nn ef ! children, and on the 

Jioteetion of healthy and nnhealthv children, 'flie safe- 

adequate attention from 
^ ion of r’r, A- Couvolaire, hut the eonsidera- 

heinV ^ ti infant, a paltry eighteen pages or so 

bemg de.oted to this important siihiect. 

wrTrtmi* 'bv^'^tr h-gione of otenpalion (283 pages), 

Mbfe -e /rr 1 Pro's, Inspector-General to ti e 

Ministii of Labour Sf 51. Duvofr, an assi.stant professor 

‘ilf if Pons hoS])itals, and 31. K. Kolin- 
i- of Paris laboratorv of toxieolon-v it 

^i fenlt to find anytliin-g jn't praise; tho«gl,°romc 

e, Robrn 


slight ropetitiDU might pi-riiaps have been avoided. Tile 
eliiipleiK on water (31. R. Dienert, tho chief of the I’aris 
Water dejiartment), on .sewage and trade wastes, and on 
housing (3f. Rdonard Arnand, the chief Government 
nvehitect) are quite equal in standard to tho rest of the 
hook, ami the illiistratioii.s here are decidedly Iicipfiii. Two 
figures depict activated sludge installations at Dniyhitlmo 
and Withiugton, when the air is blown into tho sewage. 
31. Rolunt.s is able to ineiudo a diagrammatic representa- 
tion of. u French installation (at Mosly) where the air 
is shqiped into the sewage by jiaddlos, as at Sheffield. 
Vital statistics are treated in a somewhat novel manner 
hy 31. 3'vcs Biviuid, chief statistician to I’lustitut 
d’lrvgieite, who hy the use of diagrams makes hi.s text 
much clearer to "iion-medical readers. Professor Bornaiil 
toiieludos with a very interesting chapter on tho relation 
of the medical jp-ofe-ssion to public health. 

Tho editors have certainly succeeded on tho whole in 
presonting a course of uniform teaching with but very 
littlo repetition. Certain of the lectures, notably- the one 
on tho feeding of tho infant, arc sot out in an admirable 
way, the .separate divisions of the subject being adequately 
di.stingiii.slied by cro.ss-hendiiigs in the right-sized capitals, 
a fcntiirc of eon.sidcrahle value in a hook which must 
largely serve as a work of refeience. But tho collaborators 
are apt to give scanty references; there arc a few foot- 
notes to some of the sections, hut no real attempt at a 
bibliography. These volumes bring out the woll-lcnown fact 
that the organizjition of jnihlic health in France is far 
heUind that of this country, hut they also show- that as 
scientists and writers onv French colleagues can rival the 
best of other nations. 


UB0L0G3' AND SYPHILOLOGY. 

Du. C. H. Chetwood’s ProHhr. of T'roloi/y and SyphiU 
otoijij- lias roached its fourth edition, a fact' which by itself 
testifies to its popularity. In the new edition many altera- 
tioiis will he found, among others a change of publishers. 
As the author says in his preface, since the appoavatic'o 
of the preceding edition nnmistakahlo progress has hceh 
made in urology. Ho is indeed of the opinion that tho- 
last five years have boon more fruitful in innovations and 
discoveries than any corresponding period since his hook 
first appeared. Ho cites, as examples, the introduction of 
new internal and local antiseptics, notablv hexvl-resorcinol 
ac-nflayine, and iitercnioc-hrome. Diagnostic nietliods siicl’i 
as jiyeiographv, have also been develojied, and the use of 
diatliermv as a means of troatmeiit has extended. -All 
these improvements receive adequate attention in the 
new edition. 


in in-osiatic- surgery tbe importance of pre-operative 
and post-operative treatment has received wider' rceoen'i- 
tioiij and the iiortioiis of tho hook dealing with these 
matters have been amplified. Dr. Chetwood, himself a 
pioneer in the method of treating contracture of tho 
Wackier neck, im.v.s clue attention to this important .suhicet. 
However, he does not appear to he convinced that the 
varioqs perurcthral means of treating this disease arc of 
necexsity the treatment of choice. In his opinion open 
opciation and duision of the contracture bv means of 
scisrovs gives Ijcttoi- results in some cases. He therefore 
sounefs a note of caution on the subject, giving it as 
Ins opinion that “ the end-rosnlts following the different 
operations have been of variable success in the past, and 
must be observed over long periods to estimate correctly 
the ccimjiarativc advantages of both ojicn and closed opera- 
rtons. It IS perhaps a jiity that he has not given a 
description of the pcrnretlu-al methods that have been 
intiodneecl for the li-eatment of thi-s condition, since mauv 
of his readers are unfamiliar with .such in.stnimeiits a’s 
the eautery punch, the diathermy punch, and Collim's’s 
diathermy knife. ‘ “ 

The sec-ond part of the work is devoted, as before, to 
Kyphilology. Custom has ordained in the past that .sWiliil- 
ology- should ho considered a branch of urology- jii the 
fciture; peiliaps, the association of urology and%-philolouv 

^/'larfirr of VruTufft; outf Sifphilohtuu. Uv Clifirlos Tt tZ 




ArniL ai, igaS] 


NOTES ON BOOKS. 


r TntBnmta ^71 

LMjtDICAI.0OCUNlIi VI X . 


BSYCHIATBY KOB NUUSKS. 

Bn. AuTiuni V. Novks’s Tcxihoul: of rs;ic}n<ih;i^ rcpicipiits 
tin- losuUs of nn expcripiico of .sovi-rnl yoais locfuriiig on 
psychiatry to stmlonts of Saint Kliralictiis Ifospita! Train- 
ing School for Nnrsos at AVa.shingtoiv and to nicmhors of 
ether training schools of nursing. There is a real’ demand 
for such a hoolc .as this, .specially designed for the use of 
the nursing profe.ssion, for the ordinary texthooks on 
mental disea.sos arc too technical and olahorate for nurses' 
n.sc. Br. Koyc.s gives a .skilful presentation of his subject. 
He de.al-s n-itii the strnelure of tho mind, mental meehan- 
isins, and the nature and causes of mental disease in 
r\neqnivocat phraseology,- availing Hvunself largely of the 
results of p.syeho-analytic teaching. The elassifieation of 
mental diseases is discussed, and the psychoses arc dealt 
v.ith seriatim. Tlie chapter ou mnuic-deprc.ssivc psychoses 
not only gives n clear ]>ietnro of the variniis forms of 
this .syndrome, hnl contains much wise jnactical advice. 
Bemenlia praecox is treated fully, a\id hero again the 
nui-siug hints given are partievdarly vnlnahle. An a<loqunte 
account of the hlood and corchro-spinal fluid in oases of 
general paralysis snp]ilcmcut.s the descri])tion of the neuro- 
logical aud mental condition in that disease, ^'here is a 
short chapter on mental deficiency, 'fho care and manage- 
ment of tho nioiit.al patient are discussed, and the rel.ation- 
ship of nurse to patient is nnderstandingly handled. Biblio- 
graphical references supplement each chapter, aud lu addi- 
tion many hooks and pamphlets are quoted for tho henefit 
of those n-ho desire .a more extended knoalcilge of 
psychiatric literature. 

In Xur.iinff Mental anil A'rrroii.s Bi.'iro.Tr.'!''' Br. A. C. 
UccKi.r.v has prosentod his subject along much the same 
lines ns in his well-known book T/ic JIu.hm 0 / l^xi/rhiafry. 
The method, .so siicccssfulh employed in that hook, of 
presenting tho subject of mental disorders from the stand- 
point of general biology, serves hero to provide the nurse 
with a clear nnder.standing of the groundwork of her 
subject. Br. Buckley remarks that among mental dis- 
orders there is a relatively largo number which, medically 
considered, arc in tho same clas.s as bodily iflnosses, and 
that if tills fact were more widely recognized the j>resent- 
day artificial distinction between mental disease and bodily 
disease would disappear. Ho docs not ignore, however, tho 
distinctions that arise in the nursing of these two classes 
of illness, Imt stresses tho very special nttciition that must 
be given to mental patients on account of the alteration of 
behaviour. Bctailed instructions are given with regard to 
the special feeding procedures required in certain cases. 
The methods of promoting sleep arc described, and mucii is 
said about the necessity for the elimination of waste jiro- 
dnets in these cases. There is a serviceable account of the 
various psychoses, and one section of the book is devoted 
to a description of tho diseases of tho nervous .svstein. 
Special therapeutic methods are described at length ; these 
iucludp various hydrotherapentic measures, all ofVbicb arc 
fully illustrated. ^ This hook is a welcome addition to 
Lippincott’s Nursing Manual Series. > 


THE FAITH OF A SCIENTIST. 

Tjie first of the series of lectures provided for by tlie 
Halley Stewart Trust were given by Sir OwvEn Boboe in 
tbc year 1926, and bavo now been published in a book 
entitled Science and Unman Progress.^' It will be remem- 
bered that tho object of the founder of the Trust was the 
encouragement of clear thinking in the realm of religion 
and education, as well as to encourago charitable enter- 
prises beneficial to the community. Sir Oliver Lodge, in 
his opening lecture, began by assuming that the founder 
of tho Trust designed that it slioidd ho “ free and open 
and nnhampered by restrictions such as may at anv time 
become out of date— a living Trust, ready to be adapted 


» .t Teithool nf Peychtatrij. By Arthur P. Noyos New York • Tl 
Jtacmillon Companv ; London : Macmillan and Co., Ltd. 1927. (Demy 8v 
pp. XU + 335; 12 figures lls. net.) « ■’ 

■” Niireiiiff .Venial aiidJVcrrmi! Dijensps. n,- Allwri Coulson Buckle 
il.n. London : J. B. tippincott Company. '1927. (51x81, pp 31 i 

57 figures, m fid. net.) ' a> ii - 

Seienee and niiiuan Propret:!. B.v Sir Oliver Lodge. London: Geori 
Allen and Unw)n, Ltd. 1927. (Post 8vo, pp. 187. ds. fid. -net.) ' 


and utilized in accordance with tho necessities of tho 
lime.” This .■i.ssumption, one obviously in keeping v.ith 
tho .spirit of the foundation, has encouraged Sir Oliver 
Lodgo in these six lecliiro.s to survey tlio whole universe 
mid comment in philosopliic vein on tlie aims and develop- 
inonl of mankind, . the relation between theology and 
.science, tlie jiroblom. of survival .after death, and other 
mysteries of • onr existeiire. In those territories, however, 
ho only pauses for a moment, and ho is soon off again to 
tho recurring motive of every lecture — tho invisible spirit 
population of tho universe. On this subject ho is often 
eloquent^ ns in tlio following p'assago (p. 61): 

-* Evidence is nccuraiilating that hiimanit}' as -n whole is- not 
isolated in the universe, as it used lo think it was, but Ibal we 
arc in close and afTcclionatc toucb witli a bigber order of beings, 
wliD realizo our difiicuUics, help our struggles, and who, rocog- 
niiing the vital importance of lids earthly period of existence, 
arc straining their tacuUics to tbc uttermost to step in wherever 
they arc given the opportiinfty— not by force, not with any com- 
pulsion, bill by permission, by good will, or in response to entreaty 
— so that, by co-operating with us, they can contribute to tlie 
advancement of the whole.” 


NOTES ON BOOKS. 

Although the medical profession has produced many poets, 
.some of them numbered ■.imoiig the immortals, it is difficult 
lo say oflhami why Ihi.s should be so, for tbere is no apparent 
connexion between" poetry aud medicine. Some, like Keats and 
Boberl Bridges, may imvc entered our profession without any 
strong leaning towards its practice, and soon afterwards devoted 
tliemsclvcs with .single mind to the Muses. Others at the Cud 
of a busy week’s work find recreation in the writing of verse 
ns nn escape from the liard realities of the medical life. 
Others, seeking an outlet for the gift of expression, weave 
medical thoughts nnd experiences into a metrical pattern. 
Among the third group a place could certainly he claimed by 
Mr. Bishop Haiut.tN, even though tho professional items in 
To-day, and Other Verfee'- are relatively few in number, and 
it would, we think, bo more correct to say that at heart 
he belongs lo the second. • If tho themes touched on in this 
daintily produced volume arc hero and there a little pedestrian, 
and better suited to prose than verse, tho author’s range of 
subject and metre is wide, his pen moves with enviable freedom 
in very diverse moods, wliile the sincerity of his feeling and 
his broad luimaiiity can be felt on every page. 

The growth of population in most European countries may 
be expected to lead to tbc exploitation of countries hitherto 
little known, and Mr. Henry M. Grey, in an interesting 
account of a l,500-mi\cs trek on mule-back through the swamps 
and forests of Eastern Bolivia, describes that country as Tiie 
Jjund of To-morrow.'^ Its natural resources are numerous. 
Gold, copper, tin, and petroleum occur in easily worked forms, 
■ivlnle the rich earth readily grows cocoa, coffee, cereals, cotton, 
and tobacco. ’Tropical and subtropical fruits are plentiful, 
rubber grows wild, .and, in parts, there is rich and abundant 
paslur.->ge for cattle. 'The disadvantages of the country are, 
however, numerous ; the temperature in tlie localities visited 
ranged from 50° to 100° F. in the shade, but the author was 
there only in the' cold season. He describes the climate in 
some places as ideal.” Dangerous wild .anim.ils are scarce, 
but tile ” minor liorrors ” appear to lie abundant. -Owing to 
tlie numerous swamps mosquitos abound, and malaria is 
common. Ticks, tarantulas, v.Tmpire bats, jiggers, “ mosquito- 
worms," large black ants, and snakes— including the anaconda 
and boa-constrictor — ^were met with during the trek, and some 
rivers are infested with fishes ivhicli render bathing dangerous. 
In addition lo the sting-ray, two fishes of particularly' objec- 
tionable habits W’ere noted : the peraila delights in biting off 
the fingers, toes, or other projecting parts of the batlier; wliile 
the handeroo, about one inch in lengtii and no thicker than a 
match, may dart into any natural orifice of the body, W'lience 
it is difficult to dislodge. Tlie rivers also abound in jncarcs, 
or small alligators. Bands of savages, armed with bows and 
arrows, spears and clubs, raid the dense forests, and are 
responsible for many murders a-nd the brutal mutilation of 
travellers. The arrows and spears are poisoned witli curare, 
which is prepared in secret by the cliicfs and “ medicine men.” 
Tlie author states frankly that he is not a naturalist, tlie object 
of his journey being to report on a rubber estate, and his com- 
ments on the prev.ilent diseases are naturally not of great 
scientific value. ' Although malaria is found in the vicinity of 

To-ttay, and Otiter Verecs. ^N. Bisitop Harman, 3LB„ F.E.C.S. 
London : The Lindsey Press. 1928. (Cr. 8vo. pp. xii + 196. Ss.) 

rtie Land of Tu-nwrrow. By Henry 51, Orey. London; It. F. nnd G. 
IVitherby. 1927. (Demy 8vo, pp. 224; 6 plates,'! map. 123. 6d, net.) 



672 Atril 21, 1928] 


PEEPARATIONS AND APPLIANCES. 


r Tut Bumf* 

L II cMCi(> JonxiA 


the numerous swamps, enterjc, cholera, and yellow fever are 
apparently unknown. Beri-beri is common,' and tlio de.ath rale 
from tins disease varies from 2 to 50 per cent, according to tlio 
locality. The author himself contracted the disease,' and alli'i- 
buted the cause to eating rice, as bread was rarely obtainable. 
A^enereal diseases are said to be rife among the natives in the 
interior, having probably been introduced by European lrader.s. 
A great drawback to the exploitation of this fertile country is 
lack of transport. The railway is gradually creeping north 
from the Argentine, but had made little progress at the time of 
the author’s visit, the year of wdiich is not stated, but it \vas 
shortly before the outbreak of the great war. AIulcs proviiled 
the chief means of transport, as the rivers, though numerous, 
are not navigable in the upper reaches, which alone (low througli 
Eastern Bolivia. When the railwa.y has extended beyond Santa 
Cruz, when roads suitable for wheeled traffic have been con- 
stiucted, when the swamps have been drained, tho rivers 
bridged, and the savage bands civilized, there awaits the 
planter and the miner a rich country- But before .all its 
benefits can be realized there is work for the advisory e.xpert 
in tropical hygiene. 

Blacli’s Vetcrinnr;/ Dictionarji" is tho inevit.ablo companion 
to the same publishers’ medical dictionary. It is modelled on 
the same plan, and is printed and published in a similar form. 
It provides a ready work of reference for all who own animals, 
and it should be a useful volume for those who practi.se human 
medicine. In straightforward, almost non-tcchnic.al, language 
it explains all that the animal owner requires to know about 
the diseases which affect his stock, and it explains these on a 
rational basis— that is, anatomy and physiology precede the 
merbid discussions. It also provides a .satisfactory manual of 
first aid for animal diseases, but it in no way attempts to make 
“ every man his own veterinary surgeon ” j rather it encourages 
the employment of skilled aid where necessary, and e.xplains 
why and when this is required. Besides the purely practical 
part of tho dictionary there are numerous fairly lengthy articles 
on genetics, diet and dietetics, parasites and parasitology (an 
article very fully illustrated with to.xt-figurcs), and breeds of 
live stock (with numerous plates of typical animals). Tho book 
is edited by Mr. W. C. Milleh of the Royal (Dick) Veterinary 
College, Edinburgh, and the articles referred to above (among 
others) have been contributed by specialists in these branches. 
A volume such as this does much to explain the pre.sent stand- 
point of veterinary medicine, and to dispel the old idea — which 
still lingers here and there — that it is a purely empirical art. 
'Those who use this work will realize that there is only one 
science of medicine, and that its application to animals is 
based on the same general principles as its application to man; 
the technique only differs. The price of tho dictionary is 
remarkably low when one considers its size — over 1,000 pages 
and 400 illustrations — and the excellence of its production. It 
should accordingly prove of groat value and importance, not 
onlv to the animal owner, but to the student and practitioner 
of human and veterinary medicine. 


Lee's UicTotomhi’s Vade-Mecum''^ requires no introduction 
as the standard work on microscopical technique, and the ninth 
edition, edited by Professor BnoNTii Gatenby and E. 
CowDRAY, will doubtless receive a very warm welcome. The 
embryological, psychological, protozoological, and entomological 
sections have been revised and enlarged, and new sections have 
been introduced.^ Special^ attention has been paid to the index, 
and, as in previous editions, the information is set out with 
exemplary clearness. It would be difficult to praise the book 
too highly. ‘ 

Immortality,"' the till? of a sm.all book in which this .subject 
IS philosophically treated by Dr. I. Harris, is of interest 
to flit rriGn. Tliis is not tli6 first tinio tliflt pliysiciJin Iiss 
expressed his views thereon; twenty- four years ago Sir William 
Osier gave at Harvard “ The Ingersoll Lecture on the Immor- 
tality of Man,” entitling this charming but short address 
” Science and imaiorluliiy.” Dr. Harris believes that science 
can provide the material for a creed which will act as a living 
pulsating force for all sections of the community. ® 


The first issue of IF/zo’s Who in the Nursing WorUl^"^ is 
intended to supply to the nursing profession ai]d general public 
particulars of administrative and examining bodies, the nursing 
services, nursing associations, institutions and societies, nurse 


Black's Veterinary Dictionary. Edited by William C. Uliller 
jr.R.C.V.S. London : A. and C. Black, Ltd. 3928. (Demy 8vo, pp. yiii 
4-1081; illustrated. 21s. net.) 

Bollcs Lee's Microtomist's Vaile-Mecnm. Ninth edition, edited by 
.T. Bronte Gatenby, Ph.D.Dubl., P.Sc., etc., and E. V. Cowdray, Ph.D. 
London: J. and A. Churchill. 1928. -(Demy 8vo, pp, x-h710; 9 fi;^rea. 
20j.) 

Itn mortality. Bv L Harris, JLD. London ; Williams and Xorgate. 
1927. (Cr. ,8vo, pp. vii 4- 68. 2s. 6cl.) 

U'/to’s ir/fo in the Nxirsiny Wahl. London: The IT. Edgar Smitliers 
Publishing Company. 1928. (Fcap. 8vo,‘ pp. xii 4- 229. 5s. net.) 


training schoohs, clubs and journals, and a list of prominent 
persons in the nursing world, whicli will probably receive 
considerablo additions in subsequent years. It should prove 
a useful work of reference. TJ>e only important omi.ssion we 
)iavo detected is the absence of any mention of the Jiospitals 
of the Metropolitan Asylums Board among the London fever 
lio.spitals. 

Those who have lo.irnt to rely on the Union Castle Mail 
Steamship Company's South and iJasf. African Year Bouk''^ 
as a guiuo to any and every aspect of life, work, and transport 
in South and Hast Africa will welcome llie appearance of the 
thirty-fourth issue at lialf tho price of former years. The 
section on licallh and climate nfTords, as usual, information as 
to tho facilitic.s available for invalids. It is a pity that the 
recent suspension of tho i.ssuc of permits for the entry of 
tuberculous patients into the Union — a matter of considerable 
importance — is Tiot noted under this licad at page 85 as well 
as under ” Immigration ” at page 191. 

*• The South and East African IVffr Book and (Ivide. Edited by 
A. S.'unlcr ilrown, F.U.M.S., and G. Gordon Brown, E.H.G.S. Thirty- 
foiirtii edition. l,ondon : Samp‘'On Low, .Mnrston ond Co., Ltd. 19..3. 
(Cr. 8vo, pp. Iv + 919 ; 32 mops. 23. 6d.) 


PREPARATIONS AND APPLIANCES. 

A Loop rou JIeasurixg the Blood Coagulation- Time. 
Proeessor 0. S. Ginns, M.B. (Dnllioiisio University, Nova 
Scotia), writes: In 1924 I described an instrument for the 
acciirat’c and convenient measurement of the eoaguiation time 
of liiiman blood.* This inslrnment consisted essentially of a 
5 mm. platinum wire loop, on which is formed a bead of blood, 
wliicli', on being warmed to body temperature by placing the 
instrument in a basin of warm water, rims freely on the wire, 
stopping, however, very sharply when clotting lakes place. .In 
order' to form the bead of blood tlio loop was cut tliroiigli 
in one place, wliicb weakens it considerably, and thus renders 
it liable to be distorted on being used. Eeoonlly I have found 
that if in place of the actual gap a virtual gap is made liy 
a small imloiitalioii in the wire at right .mgles to the piano 
of the loop, this functions equally well, and the loop is far 

**?"nve received several complaints that my results could not 
be confirmed. In every case the c.aiise of the trouble has been 
tlic use of an improper loop, this being cither too small cr, 
more frequently, made of loo thick wire, lyliich sliqiild be 
No 31 or No. 32 B.S.W.G. (usually the size supplied for 
clicmic.al flame tests). Eurllicv experience with tins method 
liarcoiifimied my original results. For anima work reference 
mav also he made to a second paper on tins siihject.- 

q’his instruniont is now obtainable from Me.ssrs. C. F, Palmer, 
Jlyograpliic tVorks, Brixtnn, Louden, S.AV.2. 

iRRAniATED ErSOSTEROL. 

„ Yiganlol ” is a preparatiaii of irradiated crgostorol accurately 
standardized and prepared by I. G. Farbcnii.dustiio A G. 
tPInrmac. Dcpl., Baycr-Mcislcr Lucius) and E. Merck of 
D.armsI.adt. R is sold in Ibis country by H. U. Napp, Ltd. 
(3 Zl 4 Clements Inn, Kingsway, W.C.2) Irradiated crgostorol 
is beloved to bo identical ivilh vitamin D, and t ie preparation 
s ffilcmlcd for tlio provcnlion and treatment of disturbances ot 
bn.ie fornialioii. " Vigatilol " is sold in liquid form (1 per cent. 
"^1 bi oil- do,=o 5 to 10 drops daily), and in sugar .and 

cbbcolatc-coatod’ tablets containing 2 and 4, mg. of irradiated 
cSerol rcspoelivciy. Tho vendors claim that t ic preparation 
bS Sven excellent clinical results. It possesses a pleasant flavour 
!..^d lbr makers estimate that the 2 mg. tablet is equivalent 
in vitamin D content to more than a tablespoonfiil ot cod- 
liver oil. - 

Dimol Snuff. 

The Dimol Laboratories, Ltd., have produced au insufflation - 
fnr the prevention and relief of nasal catanh. This 
powder for in glass tubes, and medical practitioners 

antiseptic snuh containers in the shape of a miniatmo wiiio 

R^Vil^ with a slip-on neck and movable cone controlled by means 
bolUo, Jiith a s p removed, tho bottle inverted and 

in^'tlie back of the hand. The price of this little dis-' 

at Is. each. 

Ah EMEnoENCY Brandy Flask. 

nravioH’s brandy flask should prove a bandy addition to the 

wflh"uie“neef for a’^forksm-cilT'and efn 'be 'rapla^ras o’fTeral 
■with tho **“'* ‘^ , j. If is shaped to fit the pocket, and an 
neecssayy. ““‘ reach ii- lialf-ivav up the eoiilainer,- 

aluminium drinking, cup, *.c"y'**"= sold.- 

cives some protection against breakage, ilie .tlask.s, as soiu, 

contain Martell’s three star brandy. 


> O. S. Gibb.- : .1 Clinical Blood Coagiilomcter, Quart. Jouni. of Meil., 
nViCw ' .7in;7u. of rhusioh, 1925, lix, 4^ 


Arniii ai, J 92 S] 


NzmONAI. HEATiTH INStlRANCE IN SOE^n AEBIOA. ■ [M,m?».jTcS>L 673 


NATIONAL HEALTH INSURANCE IN 
SOUTH AEEIOA. 


SOME PROBIjEJIS FOR SOLUTIOX. 

Yiii'i Oovcvuiiiout of tUo Union of South Afvico ht\s oppointocl 
0 Pnrlianicntovv Coninus''ion to incjuiro into nml icpoifc 
upon Iho questions of old ago pensions, insuvnuco against 
siekness and uneniidoviucnt, and foe widows and orphans. 
Tho Commission has' concluded its investigations with 
regard to old age pensions, and is now engaged on those 
relating to the other matters which have been referred 
to it. It is understood that flicso other matters aro not 
to ho dealt with picoemoal, but are to be combined in ono 
scheme of national insurance. It is improbable, therefore, 
that any schemo evolved can becoino actually oi>erativo for 
at least four or five ycn«, but even now suggestions are 
taking form, and a provisional bill embodying sumo of these 
suggestions is in process of drafting. 

The medical profession in South Africa, and indeed tho 
whole of tho British Medical Association, is vitally con- 
cerned with such of these proposals ns rclalo to national 
hc.alth in.surancc, and though it may bo jircmntnrc as yet 
to come to a decision on certain important details — for 
example, the amount of tho remuneration to be asked for 
such services ns tho profession may render, or the nature of 
any machinery for tho investigation of complaint-— it is 
now becoming a matter of some urgency for the profession 
in Soutli Africa to make up its mind on certain broad 
questions relating to tho general nature of the scheme. 
Indeed, tho Alcdical Association of South Africa (British 
Afedieal Association) has been asked, sonicwluit iii-i-tontly, 
by tho Parliamentary Commission to keep it iiilormcd as 
to professional opinion on many important points. .Viiswers 
to theso questions must be forllicoming within tlio next 
few months if they aro cITcelunlly to inllnenco the ojiinions 
of the members of the Commission and tlio natiiro of their 
ttpovt. 

GEOoiiArnicAi, axd Racul DiFncft-Tirs. 

It is clear tlmt conditions in South Africa UilFcr radic.ally 
from those in Great Britain, or indeed in any otlicr coiintiy 
which has adopted a sehemo of national hc'altli jiisiiranec, ■ 
and that thcreforo no existing sclicmc for such ni-uianco i 
_ could he applied to South Africa without tlie most fiiiida- 
mental alterations. 

South A,frica is a countiy of vast extent witii a relatively 
small population, only a small proportion of nliiih is of 
pure European descent. Considerable tracts may -till he 
described as unsettled or of a strictly colonial ihai actor. 
In the romahulor indiistrialiaation has not proceeded veiy 
far. A few industries are concentrated in a small miniber 
of areas, and -the great mass of labour is poorly paid, being 
mainly native or coloured. Certain of the e.xisting in- 
dustries, such as tho railways and tho mines, have already 
established schemes for medical attcndanco and sickness 
insurance of a far-reaching and practieallv compulsorv 
character. Tiicre seems to bo nothing in 'South Afric'a 
coricsponding to tho Poor Law medical arrangements in 
England, hut there are a number of “ district surgeons ” 
whose duty it is to respond to medical calls from those 
unable to pay any fee, provided that certain foi'inalitics 
are complied with. 

It is thus evident that perhaps the most fundamental 
question to be determined is the extent of tho working 
population which tiio insurance scheme should cover. Shall 
it be for the urban population only, rural areas being 
exckidcd? And, if so, what is to 'be the definition of 
a rural area? Shall it bo for whites onlv, or for whites 
and colomed— natives, Indians, and Alalays' being e.xcluded? 
Shall it incindo or e.xclude those employments which have 
already established adequate schemes for medical benefit? 
fVliat should be the limit of income under whicli employees 
aro insured persons, and should such limit apply to manual 
workers as well as to others?. 

Unfortunately there are no easily available statistics- 
whic-b would assist judgement on these matters, and it 
is certain that an all-embracing in.suranco sebenie would 
involve administrative difficulties of a formidable, but not 
i.-CCiSarily insuperable, character. Nevertheless, on genei-aj 


principles it is clear that any scheme of medical benefit 
which did not apply to rural areas, or to the coloured or 
nativo population, would ho open to the objection tliat it 
would meet tho needs of those who required it least to 
tho exclusion of tlioso who required it most. Tlio political 
complications, too, which might arise from any such pro- 
posals arc by no means negligible. 

Tho pvobloni of- tho sparsely populated areas is in any 
case difficult, hut thcro arc certainly two methods by whicli 
it might bo dealt with. It would ho possible to schcdulo 
certain regions ns in the unsettled or pioneer stage, and 
thcreforo outside practicable medical provision. Other 
regions which havo advanced hoyond this stage, hut in 
which tho scattered population, and tho great distances 
which a doctor iniist travel to render service, make insnr- 
nneo acliiarinlly impracticahlo, might bo provided for apart 
from tho insurance schemo, lint simultaneously thcrowith, 
by somo form of subsidy to medical practitioners (tlicro 
aro several such forms possible), somewhat on tho lines of 
tho Highlands and Islands nrrangoments in Scotland. In 
districts not schodulod under ono or other of Ihoso headings 
tho ordiuarj- insurance scheme would apply, with, of course, 
a mileage fund in addition to tho common remuneration 
in certain areas. Alternatively, it might ho possible to 
define, in this respect, tho pci-sons to whom the insurance 
medical benefit would apply as those living within x miles 
of a doctor — again, of course, with a mileage payment to 
those pvactitionci's travelling beyond a certain distance 
(loss than x) to visit their insured patients. Tlie main 
difficulty of tho latter suggestion would ho found in tho 
migrations of insured persons and of practitioners ; hut, in 
case it ho adopted, it is an urgent matter for tho profession 
to detormino tho appropriate value of «. 

ExxnxT OP IxstmED PorTOATioN. 

Tho coloured people, as distinct from tho natives, aro 
concentrated in tho Capo Province, n-hcre they have tho 
parliamontai-y franehiso and exercise much political 
influence. It would seem almost impossible to exclude them 
from medical benefit. Administratively it would not bo 
so difficult to exclude Ibe natives; but if this were done 
much of tho social and public health valuo of the whole 
schemo would ho lost. It seems probable that the question 
of colour will ho avoided h}- not mentioning it at all, hut 
by giving special consideration to tbo position of low wage 
earners. Sucb a class would include not merely most of 
the natives and coloured people, but also many of tbo 
class known as “ poor whites,” prepondcrantlj* low-class 
Dutch. It will be remembered that in the national health 
insurance srheme of Great Britain special provision ns to 
premimn is made for low wage earners. Whereas, howevci', 
in Great Britain this class comprises an almost inconsider- 
able number of persons, in South Africa it would include 
a very largo number of insured persons if there is to bo 
no distinction of colour. This must profoundly affect tbo 
nature of any insurance scheme, and a suggestion for 
dealing with tho situation so envisaged may be worth 
considering. 

Tho suggestion is this : that tho main general insurance 
schemo should be cstahlishod nationally on such a ininiinum 
basis, both as regards contributions (whether from 
employer or employed) and as regards benefits, as would 
meet the needs of tho groat mass of low wage earners; 
and that upon this minimum should be superimposed a 
compulsory industrial iusiiraiico for each of tliosc indus- 
tries wliicli are sufficiently largo and sufficiently organized 
to permit of it. The minimum schemo would, of course, 
include medical benefit, and this would hare to bo as good 
and as fvdl for one class of insured persons as for another. 
Provided that none fell below the minimum, both contri- 
butions and otlicr benefits might well vary from industry 
to industry (or, by agreement, even between different 
classes of workers within an industry), according to tlie 
needs of the ease. Those industries which fulfilled tho 
necessary conditions might he scheduled in tho parlia- 
mentary hill embodying the scheme, and the Alinister of 
Public Health might he empowered to add to tho schcdulo 
other industries as, in the course of time and natural 
development, they arrived at a suitable stage. Administra- 
tion in such oases would he b 3 - industri- — in tlie ordiiiarv 
case hi- locality — ^hiit there would proh'ahh- havo to bo a 


674 Apeil 21 igaS] 


KATIONAIi HEALTH IITSHBANGB IN SOUTH- AERICA.- 


. . f Titr. Bnm*rt . 
LMewcal Journal 


certain amount of interlocking of administration, inasnnicli 
as certain functions might well bo ijerformed hj- the local 
administration on behalf of the industrial organization, 
especially with respect to outlying members. 

■ Such a. scheme would- allow of the continuance of somo 
existing provisions for medical and other benefits already, 
working fairly satisfactorily in connexion with tho railways 
and some mines, though modifications in detail might bo" 
necessary to bring them into confoi-mity with tho gcner.al. 
scheme. It would also permit of provision being made 
for medical advice and treatment to tho dependants of 
employees wlioro this is ono of the benefits already pro- 
vided, or in other suitable cases. In a highly indu.strialized 
country such a scheme would present great dilliculties, but 
it would not be inappropriate for Smith Africa. There are 
probably only four industries in that country which could 
bo immediately scheduled as carrying contrihntions and 
benefits above the national minimum — the raiiw.a 3 -s, tho 
mines, tho building trade, and tho distrihuting trades 
(mainlj- shop assistants and warehousemen). Between them 
these include the majority of those who would become 
insured persons. 

Under any national health insurance scheme, or anj- such 
combination of national and industrial insurance as that 
suggested, tho question of an income limit for employees 
to be included at once arisc.s. In Groat Britain the iiieomo 
limit is £250 a j-ear, and this ajiplies to non-manual workers 
only, there being no limit in tho c-aso of manual workers.- 
In South Africa a tentative suggestion has boon made that 
the income limit should be £400 a year, but representatives 
of tho medical profession have declared that this is much 
too high, and havo expressed the opinion that any income 
limit agreed upoii should apply to the whole of tho insuved- 
populution. Tliis appears to be both logically and .socialh" 
right, and has boen proposed by tho British Medical Associa- 
tion for Great Britain. Here, however, it is declared 
to be administratively and industrially impossible to-apply 
an income limit to weekly wage earners. • Tho oonditions 
in South Africa seem to offer a more favourable ground 
for tho experiment, which would bo of groat value if suc- 
cessful. The lower income limit of £6, or at most £7, a week 
has been mentioned as an alternative to £400 a year. This 
is ono of the points on which the profession should come to 
a speedy decision, and it is obvious that reliable .statistics 
of employment at various rates would be most helpful. 

Scope of tuk Medical Service. 

In the circumstances of South Africa tho determination 
of the scope of medical advice and treatment to bo pro- 
vided should prove a less difficult problem than that of 
the extent of the insured clientele. Thera are three con- 
siderations which together should go far towards influencing 
a decision on this point. 

(1) Experience in Great Britain has shown that the 
restriction of medical services to those w-hich in the best 
interests of the patient can projierly bo rendered by- general 
pi actitionei s as a class not only materially- lessons the public 
health advantages of the whole scheme, but also requires 
the formulation of a large number of regulations or j-ules 
which complicate tho scheme and annoy- many- of f ho.so who 
participate therein. 

(2) the line of demai cation in South Africa between 
what are commonly regarded, as general practitioner services 
and real specialist services is peculiarly difficult to draw 
partly owing to lack of specialist facilities over large areas 
throwing more responsibility on the general practitioner 
and partly owing to the stage in the development of 
.specialism within the profession which has at present -been 
i-eached even in the larger towns. 

- ,(3) 111 - the main . sclmmcs for medical treatinont on a 
contributory basis which' arc now in operation in South 
Africa it is u.siia! to include all kinds, of medical services 
even full hospital provision. . . , ... ... , 

It .thus .appears -desii-ablo and feasible that any 
health insurance system established in South Africa 
should from the begiuning make the medical pro- 
vision much more complete than -in Great Britain; and 
the medical profession might well advise the Parliamentary 
Commission in this sense, cveii though it be recognized that, 
financial considerations must also bo a. factor in the ultimate- 
decision. 


Furtiieu Practical Questio.xs. 

If, then, a health insuranco Bchemo bo. postulated which 
includes a largo proportion of tho working population and 
lias regard to the requirements of tho ‘low wage earner, 
and in w-hich various classes of medical practitioners may 

- participate, there still remain several important 'quc.stion.s 
relating to the form of contract and tho methods of pro- 
viding medical attendance; and those tho medical pro- 
fc.ssion may reasonably bo asked to ansivcr at an early date. 
Broadly, they may bo stated as follows. Should tho Govern- 
nient make a contract for medical services ivitli tho 
organized i)rofc.s.sion as a whole, or with tho individual 
practilioiicr? Should all registored medical practitioners 
bo free to take jiart in the work (tho “ panel system ”), 
or should tho service bo staffed by selected practitioners 
only? Should advice and treatment bo sought and given 
ns far ns possible on tho lines of ])rivato practice, or .should 
this be by means of .specially- established “ clinics ’'F 

..111 Groat Britain tlio contract for service is . made .with 
each individual practitioner, though this, -of - course, does 
not ill any way ]>rcvcnt the negotiations ns to terms and 
conditions of .service being .conducted, on behalf of all 
practitioners. concerned, by a central .professional organiza- 
tion. In Japan, on the other hand, the agrcciuent as to 

- medical benefit under the insurance schenio is bctiveen the 
Government and tho Japan Medical Practitioners’ Associa- 
tion. It consists, of tliirty^fiye .articles, and. is signed by. 

' the president of tho association -and by tho director of tho 
' Biirean of-Social Alfair.s. Under tliis agreenieht tho medical 
atfendaneb on all insured persons' is in . tho hands of tho 
association (except w-horo patients arc placed in public 
hospitals), w-hich has made itself responsible for providing, 
regulating,- and supoi-vising such atteiidanoo for tho w-holo 
of the in.siired pojiiilation,- -Such a contract as this necessi- 
tates tlio. adoption of some -methods of inspection and 
detailed control, w-hich would not be, very congenial to 
iliosc - iniluciiced by eitlior British or Dutch professional 
traditions, and enta.ils.,a,. responsibility, for .administrative 
detail which jirobably neither the Bri-tish Medical A.ssocia- 
tiou nor the Medical Association of South Africa (British 
Medical Association) would readily undertake. Nevcrthc- 
le.ss this arrangement is .«nid to have worked well in Japan 
' during the short jicriod of two years during w-hich -it baa 
been in operation, and to havo proved so far satisfactory 
to the profession in that country. It is for tho practi- 
tioners of South Africa to say- whether it is attractive, 
or othonviso, to them. ■ 


SoJiB Fundamental Considerations. 

- Two of the fundamental- principlcs-which-tho. profession 
in Great Britain 1ms found it essential to adopt and main- 
tain in connexion with national health insuranco are: (1) 
tho right of every registered medical practitioner to take 
part in tho service if he chooses to accept and abide by the 
proscribed conditions; (2) as complete a freedom of choice 
by insured person of doctor, and by doctor of patient, as 

circumstances allow. . . . i . i 

It is held to bo inequitable and unyu.st that wlicii a 
Government makes communal provision for medical attend- 
anco on any considerable proportion of the population it 
should cut off so largo a field of w-ork from those w-lio are 
lc"-ailv qualified to practise therein and reseiTo it for the 
cl-mscii few; and it is regarded as important to niaintam 
tho methods and traditions of established medical practice 
as far as possible, and to preserve that personal rclation- 
ship* between doctor and patient which is so valuable an aid 
to miccess in the treatment of disease and the maintcnauco 
of health. Thoro is no reason why these principles should 
not apply to consultant and specialist jiractico as well as to 
that of the general practitioner, and -they should hold good 
ilist as much in South . Africa . as in Great Bri^in. In- 
South Africa,-indeed, .the-.setting-up of-an- insurance scheme 
would afford, an o|iportunity of so apiilyiiig these- principles 
as to do -awav with certain uhdesirablo features associated 
with the pro'sent -system of selected "district surgeons’’ 
and medicarofficers of the railway service. There are, on 
tlie other hand,' some possible' administrativo and financial 
advantages about a system of sclectcd staffs; but it is not 
easy to- suppose that the profession in South Africa will 
consider that these outweigh the considerations held to bo 
so vital bv tho nrofession in Gi’eat Britain and elacwhcic. 



kVUlh 21, I92S] 


K^LTtOnAIi nE\LTH INSTIRA.SOE lN_,B OPTg AFRICA. [meDIOi^'I. JOCBVXti 676 


It is Inrgeh' to presorvo tlio <1osirnl)lo fcnUircs of pvivnlo 
tvml family pvaclicc, with its iuvnliinhlo opportunities for 
Iho teaching of personal and donieslic hygiene, that Iho 
medical profession in Great Britain has preferred the 
Bvstom of domiciliary and coiisuiting-room work to that of 
tlio so}^rvrrvtc)y oslab)is\icd cUuic ivs tUc oidittivry 

method of giving medical attendance. Tlio British Medical 
Association advocates theso methods ns being generally 
prefcrahlo oven in consultant and Epcoialisl inaelico, though 
it is rccogniaed that in certain mens and for iiarticular 
purposes tho eslalilishment of such ** centres ** may bo 
useful under suitablo conditions. 

The cii'cumstancos in Sonfli Africa differ from those in 
Grc.at Britain, 'and make the determination of this ques- 
tion of tlio method of giving medical attendaiuo under 
a health insurance scliomo a matter of peculiar difficulty 
and importance. It might bo easier in several respects 
(social as well ns financial) to provide medical advico and 
treatment for Indians, Malays, natives, and coloured, 
perhaps for low-paid workers in general, at cenlvnl clinics 
than in any other way. Tiicrc aro dnelors in many towirs 
who would desire to take part in a health iiisiuain e service, 
but wbo do not wish to cultivate iivnitico amcmg these 
classes of the population. Somo of tlo'se dm (<n s would, 
however, not object to giving se.ssional atteiulanco at a 
clinic for such persons. Th.’s apjilies aliko to general 
practitioners and to specialists. 

It is highly nndesirablo that the profession should ho 
divided into distinct classes, and that any excuse should 
bo given for tho stalemont that nn inferior kiml of medical 
attendance w.as provided for the native as comi)nred with 
other insured persons. For this reason, among others, 
it may be found that somo combination of clinic and 
doniiciliaty medical attoudaneo may ho judged suitablo. 
In coining to a decision it is to bo hoped that the Associa- 
tion in South Africa will in no case abandon without due 
cause tho more customary and private methods of practice 
in connexion with insurnneo work, and that, if any limited 
sj-stem of clinics is cstahlishcd at all, the ariaugoments 
insisted upon will bo such as to prevent tho selection of 
a permanent staff of mcdic.al officers to do tho clinic work 
to tho csclnsion of their fellows who may ho suuilnriy 
qualified. It is quite possible, oven in chaics, to dovi^o 
a system of sessional attendances which will spread tho work 
as'widely as possible over periods of time, 

Thcro is one further question as to method whith tho 
Medical Association of South Africa (British Medical 
Association) is asked to reply to: this i.s the meihod, as 
distinct from tho amount, of remuneration. Shall it he by 
rapil.ation, by case value, by items of attemlnnce, by 
sessional fee, or oven ,by salary? In this matter the 
experience and the full consideration of the jieint by the 
profession in Gycat Britain may bo reg.arded as almost 
tho _ detei'mining factor. The opinion in t r at Britain is 
practically unanimous. It is that oi-diiiary medu-al attend- 
ance under an insurance scheino should he remunerated 
by capitation fees, and specialist attcndauco by fees per 
item of attendance. If, however, there is any attendanoe 
at central clinics this should bo paid for by appropriate 
sessional fees. If after some time cxpcricnoe shows that 
particular kinds of attendance at individual clinics can be 
stabilized at a salaiy corresponding roughly to tho sessional 
fees in tho special instance, there would he no objection 
to the n.aming of a yearly salaiy for such attendance, 
provided this is open to revision. 

Tan Task nvionE the South Afeic.vx PaoiEssiox. 

The Federal Council of the Medical Associ.ation of South 
Africa (British Medical Association) and the Branches of 
the Association throughont the Union aro faced with a 
tesk of much difiicuily, requiring both knowledge and 
judgement. It is unfortun.ato that the great majority of 
tho members of the Association in that country have no 
knowlcdgo whatever of tho actual working of insuranco 
practice. In so far as this weakness can lie remedied by 
tho experience of the members of tho British Medical 
Assoeiatipn in Great Britain, thi.s is freely at the disposal 
■of those who have the main responsibility in. South Afi-iea. 
Already something has been done to make this available 

There is every reason to believe that with a united and 


effective nnd alert Association in South Africa, and with 
nn apparently syirpathctio nnd rcasohablo Farliamcntavy 
Commission, there maybe established in tho Union of South 
Africa a scliomc for affording medical advice and treatment 
of all kinds to employed persons unable 'to provide it 
adequately for tbomsolvcs which shall ho consistent with 
the interests of tlio medical profession and greatly to tho 
advantage of .individual and public health. 


SCnOLABSniPS AInT) grants in aid of 
SCIENTIFIC RESEARCH. 


Scholarshifs. 

Tim Council of tho British Mcdic.al Association is pre- 
pared to receive applications for Research Scholarships as 
follows: An Ernest Hart Memorial Scholarship, of tho 
valuo of £200 per annum, and three Research Scholarships, 
each of the value of £150 pci annum. Theso Scholarships 
are given to candidates whom tho Scionco Committee of 
tho Association recommends as qualified to undertake 
research in any subject (including State Alcdicino) relat- 
ing to the causation, prevention, or treatment of disease. 
Each Scholarship is tenable for one year, commencing on 
October 1st, 1928. A Scholar may ho reappointed for not 
more than two additional terms. A Scholar is- not ncces- 
Earily required to devote tho whole of his or her time to 
tho work of research, hut may hold a junior appointment 
at a university, medical school, or hospital, provided tho 
duties of such appointment do not interfere with his work 
ns a Scholar. 

Grants. 

The Council of tho British Medical Association is also 
prepared to receive applications for Grants for the assist- 
ance of rosc.irch into the causation, treatment, or preven- 
tion of disoa.so. Preference will ho given, other things 
being equal, to members of the medical profession nnd 
to applicants who propose as subjects of investigation 
problems directly related to practical medicine. 

Conrfiiions of Aicard: Applications. 

Applications for Scholarships and Grants must bo made 
; not later than Saturday, Juno 2nd, 1S28, on the prescribed 
form, a copy of which will ho supplied on application to 
I tho Medic.il Secretary of the Association, B.5I.A. House, 

I Tavistock Square, London, AV.C.l. 

Applicants aro required to furnish the names of three 
referees who are competent to speak as to tlicir capacity 
for the research contemplated, to whom reference' may ho 
made. 


ROYAL MEDICAL BENEVOLENT FUND. . 

Ar a recent meeting of the committee sixfv-onc c.ases were con- 
sidered and £1,057 voted to fiflv-one applie.ants. Since the 
beginning of this year a total of £2,203 has been nmde in gr.nnis 
to urgent cases of distress. The following are short notes on 
a few of the cases iielped. 

Widow, osvd 39, of M.B.Abcnl. The hnslmnd 'died of cancer in 
December, Isp. He was just emcrgini: from financial difficulties, bavin" 
recently started a new practice, wT.en he became ill. and -died cl esnee? 

y.i' expenses of the illness. Tire widow lias 

been left with a boy> aged Ifl, and a capital of onU’ £‘^5 Vo»cd £2A The 
case was telcrred to the Gmid for worb to bo obtained for tlic ividow. 

Widow, aged 51, of .U.D.Camb. The husband w 

Fund, At nis death the pension from Epsom an 
ceased, and Ids widow has been left absolutely 

- I®®, '^'Ork in return fot board and lodtjine, which wiU irive her 
limo to look for a salaried post. Fund voted £2b. 

Daughter, nged 58, of 3f,K.C.iS.Eng. has since the death of tier father 
*upporte<l herself and her delicate sister hy literary work. In 1925 
wio became ill from^ overivork. She has gradually sold' all she had, and 
now she and her sister ore living in lodgings, for which they pay £1 
^ week, including food for bot)j. voted 

Daughter, aged 65, of L.B.O.P.Ed. was working os a governess in Russia 
at the time of the revolution She was forced to leave, nnd lost ail her 
savings. Sho lias returned to this country at an ace when it is impos- 
sible VO eowtinvie wotVu Hot total Incotne is only i.60 a year. The Fund 
voted ft further £ 26 . 

The demands for help increase and subscriptions are very 
urgently needed, and should be sent to the Honorary Treasurer, 
Sir Charters Symonds, 11, Chandos Street, Cavendish Square. 
.W.l. 


Tho Roj^al Medical Benevolent Fund Guild still receives 
many applications for clothing, especially for coats and skirts 
for ladies and girls holding secretarial posts, and- suits for 
working boys. The Guild appeals for second-hand clothes and 
household articles. The 'gifts should be sent to the Secretary 
of the Guild, 58, Great Marlborough Street, W.l, 


676 


Apbil 21,' 1928] XOKDON SEWAGE AT^ID a?nE KIVER THAMES. 


IvitiMj jMlrttcal fottrual. 

SATURDAY, APRIR 21st, 1928.' 


LONDON SEWAGE AND THE RIVER 
THAMES. 

I riE speuclmg of a quarter of a million pounds on Avhat 
is essentially a henltli measure is a matter of sonic 
moment even in London, nliere big figures cease to 
aiTCst attention by reason of tbeir familiarity ; and 

onlv“in‘'a '’n™ ‘' ’‘1 instalment 

only in a proposal ivlncli may involve in its coin- 

tivertv “ I’ro*j’cni s„me 

'<l^chorl Of that now 

iuter^’ ^ becomes of more Iban passing 

deeddeJ?™''''!’ County Council 

• I tanabln^ 7 °" r ” ““^-‘ 1 ^' -^SSO.OOO'to install 
ffl n ' I r of dealing with quantities of sewa-e 
affluent of from five to ten miiiion gallons a day At 
bo p7-csent tmie tbe volume of sewage eflh.eni 
ally entering the Thames at Rarldng and Cross o"s 

- f"’ 260 "million Indio' s"’ 

. -These streams form, in effect, tributaries of ' no 
meonsiderable size to the River I’hanies DisJi,.,rae 

Sb effluents mix 

m-oo'c ^ nnci take part in its movement. A iiro- 
oies.sire passage of all the water in the river' lakes 
pace m the direction of (he sea. but, owil. to he 
de, such passage is not continuous in its (Hrection 
Owing to the oseillation of the tide, the pnw.vss ^ 
effluent seawards from (he outfall is snbleel to 
mersal. A particle of effluent .starling froiiAnc of 

' o' .'"h w mil ^ ohlMidc can ouh* 

,1 ti w allies down the river before it is met bv the 

7< cmnii.g flood tide. It is thereby car 0 d 'bnSi 
idtliough not back to the original point of dlpartS’ 

S an seta further down tEriWcr 

"t ‘o?' s'fi ">■ ‘I'' 

until ultiinatelv it -ca I Pi'ogi’cssioii eontimies 

1.S subjected at the outfalls to sedimelhfuon “qC 
precipitation operations at the outfalls I n • 'il 
deposition of the cruder snslon cP ■" 

-sewage. The organic matters I hIIcJ l 
solution flow out with the effluent and .arc the mil 
actors of pollution. The effluent a/rc^rSio 
hghter suspended matters which the disinlogn L If 
the grosser solids in the sewers has produced ” Tl?! 
report from which we have quoted does not inform ! s 
of (tie extent to which these princip.a] factors of not 
ution have affected the River 'ihames in hL plUt 
through London; but we are left to infer that a denree 
ot pollution has been reached which it would be unsafe 
to permit to continue. “ Experience has proved that 
the calls which are being made on the -London mnin 
flrainage system, and 011 the capaeif.v of the river .as 
the hiia place of disposal, hare reached a point when 
s^s should be tnken. ” 


Tui: IJnmfffc 
JlrjJlCAT. JOCTIXIH 


loifdon Po members of the 

Loi don County Council that they have not wailed 

until the evidence of the senses has forced a Publie 
jceognition of conditions which could not be tolerated 
And winJc, on the other liand. the Council I'as-Sfc 
moiod prccipii.atoly, it ajipe.ar.s not to have wasted the 
peiiod of grace allowed it for deliberation. In addition 

Xir?' present 
iXld Vn "’ffl’cction to provincial .authorities 
engaged in grapphng with kindrwl but oven more 
I Kssmg problems, and the authorization of proioimcd 
and pmct.eal scientific investigations, Iho Comidl ha.s 

it I. ‘;““®"Ued tbe mo.st eminent exports 

t could find tp advise it in tlic stnpeiidou.s imdeA 
lakmgs which 111 the long run would obviously have 
to be faced. It -is dear, from the different solutions 
of thc.^ pitiblems that liave been propounded, that 
lIio giuli in Knowledge has enonnonslycontracled the 
scope of the CoimdTs commitments, ns it lias simpli- 
ncu dillicnltios and economized resources. Tn 1890 
it was foreseen that wliat is now recognized as tlic 
mmiodiate duty of improving the methods of London 
.sewage disposal would ultimately Imvc to bo di.s- 
ebarged, but at that time it was regarded mainly as an 


' IltilliJI 

eiiginccnng problem involving works far inon 


, .» c JUT iijulu costly 

tlian any wincii are contemplated to-day. Two eminent 
erigineers. Sir Renjamin ] 5 aker und“ Sir Ale.xander 
Binnie, who bad been consulted, reported hi Fobrnnrv, 
. 1891 .' The einir.se of action ndvoc.'ited by them, ‘if 
.and when liic <inimlily and quality of effluent -passing 
.into llie river liecame more than could bo assimilated 
by (lie- river without causing nuisance, was to move 
an outfiili fnrllier down tlic river. Shell Haven was 
•sugge-sted as. a possible site, and the engineer also 
oxprcs.sed the oiiinion that if it wore considered im- 
lierativc to disidiargo the metropolitan sewage into the 
sea in its crude condition without any risk of injury 
to the estuaries of the Tliamc-i, tlio Blackwater, and 
the Crouch, then a project for an outfall sewer fifty- 
six miles long, from Crossness to tbe deep water of the 
• ^ “ ■ lid ho found worthy of serious 

■ ■ to the advance in knowledge 

of sewage purification, it is now seen that' such colossal 
expenditure ns would be involved in engineering under- 
takings of this magnitude is not only nimecessaiy, but 
would provide no real remedy. IVhether discharged 
info tbe sea or info . the estuary, sewage in such 
volume as that ot Loudon would necessarily lia.ve to 
be treated. Fortunately, after prolonged study of the 
ways of natural purification, methods of treatment 
h.avc been evolved which entail no sacrifice of the 
costly plant already provided, and are applicable at 
the silos of the present outfalls. 

q'hc County Council has satisfied itself that' what is 
known as the activated sludge method is apjilicable 
to the treatment of the effluent from' the area it 
administers. Exiiaustivc investigation has shown 
that this effluent pollutes the Thames in course of its 
passage through London, to a degree at which further 
steps for its improvement are imperative. The method 
which, after the fullest investigation, the Council has 
decided to apply provisionally, on a scale which can - 
be regarded only- as an instalment, involves no sor.ap- 
ping of the jiresont inadequate methods of sewage 
treatment. It begins where tlio present treatment 
leaves off, and carries purification to an innocuous 
stage at which, without' menace to the great health 
interests of the metropolis, the effluent may safely’ bo 
-discharged into tbe wafers of tbe Thames. It is lioped 
that, as a roiult. of the experience gained in proceeding 
by degi'ces instead of by a single comprobeusivo 
scheme, economies will be effected and, in respect of 


Couuty'’eo,",^,cSf‘'on'peta“Sy''£m.^S’"‘''‘' “K *“ UunUon 



Arniij 2:, 1928] 


THE NATIONAL HEALTH INSUBANCE -BILL. 


[ TncDnm^ff fi77 

Medicai. JocnsAi. * * 


opi‘i'ii(ions on so viisl n scalt', Ihc errors ot inexperience 
nvoidod. Liirj'C i\s iiro the sums of money involved, 
the cost ot treiiting London sewage is relulively low. 

To T,ondon, clustered on the banhs ot the Thames, 
the i)roservation of the salubrity ot the river is ot the 
first iiuporlanee. .Since only the tidal waters arc 
afiected by the large volumes of ellhieut they receive, 
the problem’ of purification is a comparatively simple 
one — much simpler than that of the riparian autho- 
rities of the upper reaches, wheie cflluevUs mingle 
with the ])olable waters whieli supply London. But 
altliongh simple it is of first-rate importance. Nothing 
can bo permitted which threatens the healthiness ot 
till! metropolis ajid if.s environs. 'I’hc gi-e.it waterway 
and spacious and unobstructed airway of I lie Thames 
estuary is doubtless one of the main environmental 
-factors which have given London the enviable position 
in regard to health of which it is so justly proud; and 
the, London County Council is to be congratulated on 
its watchfulness and pn'.sciencc. its courage and 
faithful discharge of primary ohligatioiw, in the great 
enterprise on which it has so unostentatiously 
embarked. 


.THE NATIOELVL HEA.LTH INSURANCE BILL. 
The National Health Insurance Bill was givi-n a second 
residing by the House of Commons just lieforc the 
-Easter recess. This bill- proposes to make changes in" 
.administration and in connexion with additional treat- 
•ment benefits, the proposals being inainlx ba--od upon 
the less important recommendations of the Majority 
Heport of the Royal Commission on Health Insurance. 
A summary of the provisions of the liill was given in 
our Sapplcmcjif ot March 17th last (p. 89), and a full 
report of the debate on the second reading will be 
found in the Parliamentary Notes in last week’s 
•Journal (p. 645). It is by no means easy to under- 
stand from the text of Ih'c hill itself the effect of its 
provisions; but a careful consideration of that text, 
of the official explanatory memorandum, of the debate 
on the second reading, supplemented b\ the notes ot 
an interview between representatives of the Insurance 
Acts Committee and of the Ministry of Health, 
suggests that there is a real danger of our profession 
treating the matter too compluisantly. I'uring the 
preparation of the bill, and, indeed, since its introduc- 
tion, the Ministry of Health has stated tliat there is 
hut little in the bill that affects the medical profession. 
It is true that with most of its clauses the profession 
is not directly or seriously ’ concerned, but it may be 
found that certain sections of the bill raise once more 
.qne.stions of fundamental importance to the medical 
profession, and that there will be grave danger if some 
of these sections pass unamended. 

W ith many of the provisions of the bill there will 
be hearty agreement. The considerable simplification 
xvith regard to contributions, arrears, and benefits 
effected by Clause 1- (and some others) should help 
towards a smoother working of a system, all parts of 
whieli hax'e suffered from over-elaboration and lack of 
uniformity. The stoppage of the subterfuge by which 
new institutions, not otherwise qualified for lecog- 
nition, have been brought into existence in South 
Wales through a misuse of the power of maldug 
_ collective own arrangements,” will be welcomed. 
I he establishment of real insurance conditions for 
deposit contributors who are unable tbrovigh ill health 
■ to join any approved society will remedy an obvious 
hardship. An inci'eased control by the Ministry over 
the rules and maladministration- of approved societies 
should tend to lessen gross abuse and injustice. ■ The 


cslablishnient of two new classes of insured persons 
will not be objected to, since, they are of the same typo 
ns those leelnn'eally employed under a contract of 
service, though the extension of the insni'ancc" scheme 
to some 25,000 additional persons is not without its 
interest to medical pracliitioncrs. 

It is those parts of the bill directly or indirectly 
affecting tlie provision and administration of additional 
treatment benefils which require the closest scrutiny, 
and whieli may be found to necessitate either impor- 
tant amendment or strong opposition. These are 
Clauses 4- and T4, the first schedule, and parts of 
the second" and third schedules." It will he remem- 
bered that the mo.st . important ami ■ urgent of the 
recommendations of the Koval Commission was that 
the scope of- medical benefit should be extended so as 
to . include for all insured persons consultant and 
specialist services. The cost of such extension was 
estimated at about £1,250,000 a year, and was to be 
provided by a very limited pooling of future surpluses 
of approved societies. In the course of the debate 
on the second reading of the bill it was reiterated by 
several members of the Opposition that the absence 
ot provision for a general specialist service was due 
to the effect of the Ecouonij" Act of 1926. There can 
bo no sympathy with this statement in the minds 
of those who remember, or refresh their memory 
with regard to, the provisions of that measure and the 
debates thereon (see articles in the British Medical 
Journal of April lOth’ and 24th, 1926, pp. 663 and 
750). Sir Kingsley Wood was correct when he said 
that ‘‘ the fact that there had been no provision made 
in the bill for specialist sen’ices bad nothing to do 
with the Economy Act. But for the opposition of 
the approved societies it would be perfectly possible 
to put into operation the scheme for specialist services 
without bringing any additional funds into the national 
insurance system at all.”- It is o"wing entnely to the 
shorlsightcclncss and selfishness of the larger and more 
prosperous apjirovod societies that such a scheme is 
not now in operation, or at least under discussion. In 
its absence the Ministry of Health nat-urally desires 
to make the most of whatever additional treatment 
benefits arc possible for a certain number of insured 
persons. Sucli a patchwork system, ho-wever,- can 
never be satisfactory either to the patient or to the 
medical profession or to. the Ministi-y, and the con- 
ditions governing it require the closest scrutiny lest 
they should be contrary to the interests of the pro- 
fession aud prejudicial to the future development of 
national health services. 

The projiosals of the bill in this connexion may be 
described as follows : (1) to abolish, as an additional 
benefit “ medical treatment and attendance for anj' 
person dependent upon the labour of a member ”; 

(2) to add as a new additional benefit “ payments to 
aiiproved charitable institutions in respect of any 
treatment of members required for the prevention or 
cure of disease, not being treatment within the scope 
ot any other additional benefit or of medical benefit ”; 

(3) to restate somewhat more accurately the remaining 
I additional benefits; (4) to give power to the Minister 

of Health to nialie regulations ” with respect to the 
administration of any additional benefit and with 
respect to the arrangements for the provision of any 
service towards the cost of which payment may be 
made by "way of additional benefit ”; (5) to define more 
clearly the natnre of a ‘‘ charitable institution ” to 
which an approved society may make contributions; 
(6) to repeal the present requirement that additional 
benefils “ xvhicli are in the nature of medical benefit ” 
shall be administered by and through Insurance 


THE WEIiFARE OF HOP-PICKERS. 


[ Thf Ttrittw 

lletitCAL JOUtXKlL 


678 Apriii 21, 1928] 

Committees, and not by approved societies. Tbo full 
effect of these amendments can be appreciated only 
If they are read together. 

Eequh'ements which it is essential for the profession 
to safeguard or secure are : (1) that there shall bo no 
possibihty of any approved society seeking to provide, 
administer, or control any medical service either 
directly or “by resorting to devices which are not 
conducive to good administration ” (to quote the 
Ministry); (2) that there shall be no compulsory 
negotiating with any approved sociotj' or representa- 
tives of approved societies as to the terms and 
conditions on which medical advice and treatment 
will be given; (3) that there shall be free choice 
of si)eciaiist or consultant, and (to quote a phrase 
used by the Minister of Health, Mr. Chamberlain, 
during the second reading debate) that " no one 
must be compelled to go to a clinic if he woiild 
rather go to a private practitioner (4) that 
there shall be a suitable guarantee that a general 
specialist service shall be established as soon as pos- 
sible, and that meanwhile any additional treatment 
benefit that becomes widespread shall bo made 
statutory for all insured persons, and that in either 
case the service shall be administered by Insurance 
Committees or public bodies corresponding thereto, 
and not by approved societies. 

It is clear that some of these requirements are not 
met by the bill as it stands. One or two phrases used 
by the Minister of Health in his speech on the second 
reading seem to make it doubtful whether he realizes 
exactly what the medical profession wishes or the 
importance it attaches thereto. The profession can 
never give awav in the case of the consultant or 
specialist what it has secured for the general practi- 
tioner; and it is bound to have in mind the situation 
in which it would be placed if a Minister of Health 
entirely sympathetic to the wishes and ambitions of 
approved societies were to make regulations and to 
interpret Acts of Parliament. Both Mr. Chamberlain 
and Sir Kingsley Wood gave the undertaking that 
amendments put forward with the object of improving 
the bill would receive most careful and sympathetic 
consideration from the Government. With this in 
mind, no doubt the Insurance Acts Committee and 
other committees of the British Medical Association 
concerned will be able to obtain such explanations, 
■assurances, and amendments as shall Secure the aims 
of the profession. 


THE WELFARE OF HOP-PICKERS. 

ExjiunQ recent years tlie public has become increasingly 
interested in the welfare of those thous.ands of town dwellers 
who annually migrate, mainly from London and from the 
' Black. Country towns, to the hop fields of Kent, Worcester- 
shire, and Herefordshire. These folk, who are mostly in 
humble circumstances, combine business with pleasure, and 
have for many years — even generations — regarded the 
picking of hops as a means of affording themselves, their 
children, and other people’s children a three weeks’ holid.ay 
in the counti-y. Of the 25,597 acres of hop gardens in this 
country, 15,696 acres are situated in Kent, and into these 
spacious gardens of the Weald there debouch annually from 
the congested quarters of East London some 70,000 pickers, 
'mainly women and children. No one will deny that the 
conditions under which these .thousands of casual workers 
'undertake their journeys to and from the hop fields have 
improved enormously during the past five years; those with 
a long experience of pickers’ camps will further agree that, 
generally speaking, the conditions of camp life have reached 
a higher standard than existed before the war; and there is 


agreement amongst local observers that the conduct of the 
hop-irickors and the genoi-al health of their children have 
altered considerably for the hotter during the last twenty 
years. Thero aro visible signs, moreover, that the medical 
necessities of the hop-irickers are receiving more and more 
attention ns each season comes round. But from a paper 
on the health of hop-pickers and the sanitation of hop- 
pickers’ encampments, ' read by Hr. Alfred Greenwood, 
county medical officer for Kent, at a sessional meeting of 
the Ro}-al Sanitary Institute held in Maidstone on April 
13th, and from the discussion which followed the paper, 
wo learn that, in the opinion of the count}- health autho- 
rities, thero is need for still further improvement, both ns 
regards the sanitation of camps and in the organization 
of medical services. Dr. Greenwood acknowledges that 
somo camps aro satisfactory in every way, and indeed wo 
know of somo Kentish hop-growers who have gone con- 
.sidorably further than the letter of tho by-laws, and whoso 
arrangements for their temporary employees aro beyond all 
praise. In tho majority of ‘camps tho present-day con- 
ditions aro not essentially unsatisfactory, and they aro 
improving; but the word “ disgraceful ” is not too strong 
to describe tho insanitary conditions which have often been 
ohsen-cd in certain other camps. Gross overcrowding, 
unsatisfactory and dangerous water supplies, and tho 
neglect to make and maintain proper consci'vancy arrange- 
ments in hop-picking camps are grave defects which it is 
tho duty of local authorities to prevent, not only in tho 
interests of tho hop-pickers, but in tho public health 
interests also of tho local inhabitants. Wo gather, however, 
that Dr. Greenwood is not satisfied that all the local autho- 
rities concerned make sufficient uso of tho machinery at' 
hand for dealing with these matters, and he considers that 
somo councils have in certain instances shown unmerited 
leniency when administei'ing tho existing by-laws. Ho 
suggests that tho registration of encampments and tho 
granting or withholding of annual licences would improvo 
matters. From tho point of view of public health adminis» 
tration this step probably would bo helpful,. provided regis- 
tration wore made applic.able to all existing camps, and 
not merely to .those that might bo started in tho future; 
and provided also that tho local authorities — who would 
administor tho licences — were not unduly lenient. What 
the economic and political results of compulsoiy registration 
upon tho hop-growing •industry would be is another ques- 
tion. In tho meantime, wo think it quite possible that 
more might bo done to gain the support of tho local 
branches of the National Farmers’ Union, • which can 
probably bring useful irrcssuro to bear upon recalcitrant 
.and backward farmers. Tho question of how best .to 
co-ordinate the various voluntary medical organizations 
already in tho hop gardens, and -tho encouragement of 
others where wanted, is certainly one ripe for consideration, 
and we have no doubt that the Ministry of Health would 
consider sympathetically any wish which local authorities 
might express regarding the formation of a joint committee 
to discuss the matter. 


THE THERMO-CAUTERY FOR SEPTIC LESIONS. 

The tbormo-cautory has been used in tho treatment of 
a variety of lesions for many centuries. Hippocrates refers 
to a case of abdominal suppuration in which the discharge 
of i)us ceased after cauterization, and Abulcasis, who died 
in 1013, and who wrote a summary of Islamic surgery which 
was regarded as a classic in tiro mediaeval schools of 
Europor mentions more than forty uses of the c.autcry. 
Early in the nineteenth cerrtirry “ moxae,” consisting of 
rods of specially prepared charcoal, which were ignited and 
then applied to tho skin, were used in Paris and elsewhere 
as counter-irritants in the treatment of chronic abscesses, 
and oven in chronic inflammations of the respiratory or-gans. 
Recently Professor Bier of Berlin has reintrodrreed tho 




Armi/ 2ir i9=s] 


TnEimC-CAIlTEKY FOR- BEFTIC -IiESlONS. 


, r TnBUnmsnt . fi7ft 

LMkpzcij:. JocKirAX* viu 


iiso of tho ciuiU'i-y into tlio tfoiitinonl of wipintrivtiiiK 
lesions, ami veporls" tho. i-psiiUs olitaiiicd in AOZ cases, a 
lavgo pro]>oi't.iou of n-hicli n'cco A-cty satislactoi-y. In all 
tUo eases, tveateil since 1S25 he Ims tisetl a tliovino-caniery 
tlosigucd liy Hudenfoldt, wliieli is heated hy a inistnro of 
air and henv.olino nndev pi-cs-snvc inside a eantcey point of 
nlnmiiiiuin hrouKO, ns ho has found this much more effective 
than other types. The technique employed in the tve-atment 
of largo abscesses, including ahscessos following trauma or 
abdominal operations, is ns follows; minor lesions are not 
imluiled in this series. The nhseess is freely opened, ns 
much neci'otie ti.s.siu' n.s pn.ssihio is removed, and the wlmle 
is scraped with sharj) si>oons. The cavity m then cleansed 
of blood, pus, and detached granulation tissue, and is 
cauteriaed. It is desirnhlo to have the cavity as free froth 
blood as possible, either by working in a bloodless field or 
hv carefully tying bleeding ves-'cls. The wound is then 
ciosed without drainage, catgut suttires being iiscil where 
necessary for deep structures, while for the .skin edges 
a “ eor.se!et dressing is emjiloyed; this is described by 
F. BangO' as cons-isting' of a strip of gair/.e att.a>hed to tho 
skin oh either .side of tho wound by .some foim of glue, 
preferably laa-stisol. Tho .two edges of the noimd are then 
hrougiit into apposition and kept there by huing a silk 
tbread across and nero.s.s over sinall dress book', previously 
.sewn to tho two strips of gauze. The immi-diate loi-al 
rc.sult of eautorization ks a.s a rule an mute r<-.i( lioiiaiy 
inflammation with abutulanco of pns, often lout smelling; 
in spite of this, however, the pain is relux.il, and much 
hotter scars, sometimes oven linear in typv . aie olitaiued 
hy this method thaii when draiuirgc is emplowd A brisk 
general reaction, with rise of temperature and sweating, is 
common. Tho method has also lieeii adopted with good 
ic.sults in tho treatment of suppurating joiuts, lu several 
knee eases dcscrihctl tho iuuor surface of tlie < .ipsule was 
scraped and cautcrir.otl, earo being taken to avoid the 
cartilage, and tho tvound then closed. In the iieatment of 
necrosis of bone following tranma or oaleomyelitis tho 
results of cauterization have been no better than those 
obtained by other operative measures; for ihronie bono 
abscesses, on the other hand, Bier considers tins method 
Btiperior. In suppurating' tenosynovitis the miioi surface 
of the tendon sheath has been cauterized, hut how the 
results in these casc.s compare with tliosc of other iiicthotls 
is still uncertain. Bier ascribes his results to the inflain- j 
matoi’y reaction produced hy the cautoiw, and considers 
that tho effects attributed to the specific virtues of various 
fluids used to irrigate suppurating wounds are really due 
to an analogous inflammatory i-oaction induced hy tlieir 
irritant properties. Superficial scarification of tho skin 
with the cautery as a comitor-irritaut he docs not consider 
of ranch value. He gives, however, a preliminary acconnt 
of a number of cases of goncralized septic infection and 
pyaemia in which tho focus of sepsis was more or less 
iiiaceessihle, aud which were therefore ti'eated bv cauteriza- 
tion at tho “sito of election.'' For this pui po.se he lefleeted 
a.i area of skin aud subcutaneous tissue the size of the 
palm of the hand or larger, gcnonilly near the costal 
margin, carefully applied the cautery to its deep surface 
and to the exposed surface of the .siihjaccnt museidatiiro, 
aud then sutured tho wound again. As a result certain 
tissue constituents are disintegrated, and the benefieiaT 
effects -recorded in a small -proportion of these cases nre 
thoiigiit to be duo to -the absorption of -these disintcgi-ation, 
products and the consequent general veactioii, evidenced 
hj tho associated pyrexia riiid acc-elot-atcd pulse rate. How' 
this differs from the reaction produced by tho various 
specific and non-specific agents recommended in recent 
years for a similar purpose is not stated. Since in noarly' 
all tlie cases included in the -last g roiqr the prognosis was 

'' nfu/^"p I'Olli, 1S28, p. 201; rebruary 17tli,p. Z46, 


practically hoiicicss boforo tho treatment was - applied, it 
is not surpri-sing that the mortality rato is high. Sum- 
marizing -his t-onelnsion.s, . Professor Bier states that many 
(Totail.s of technique .still requiie elaboration before this 
method -can ho used with safety and to 'the best advantage 
ill tho treatment of tho severer goncralized forms of 
sepsis. 


THE NATIONAL PHYSICAL LABORATORY. 

Tjir. riqiort for 1S27 of tho National Phy.sical L.aboratoiy,’ 
although it runs to 250 quarto pages, is the haic minutes 
of the many-sided work carried on at Toddington. Tho 
special invc.stigations undei'taken at the laboratory arc 
generally of a kind which extend over a period of years, 
“ creepiug ou from point to point,” and even when they 
ar<> completed, or a stage in them is completed, it is not 
into the annual report that the work goes, but iii papers 
communicated to appriqwiato bodies. During 1626 and 
1S27 tbo number of official communications made by the 
staff of the laboratory to scientific societies, or tcrhnical 
journals was 165, ami besides these a largo mimhcr of 
papci-s wore enntrilmtod uuoffieially. The annual reports 
merely give a hird's-cyo view of an almo.st ,hewihlei-ing 
activity carried on in six principal departmonts — namely, 
those of physics, electricity, metrology, engineering, aoro- 
dynnmics, and mctallni'gy and nictatln'rgit-al ch'criiistry. 
T'he physics department- alone has a staff of just upon 
a hundred. Jlueh of the work done at the Uihoratory 
is routine testing. For example, half a million -clinical 
thermometers w-ero- -tesleil thcle last year,- also 10,000 
lenses and other optical instrnments. .Weights, b-alance.5, 
mca-suve.s, ehronmneters, all kinds of instruments of pre- 
ei.sion, are verifies!. Again, the laboratory fumishos a 
standard for radiological apparatus; 41 radium prepara- 
tions were examined during the year, including a few 
radium watei-s and the like, tested by tho alpha-ray 
method. The samples of protective materials to-stccl 

numbered only 19,- as compared with more than 200 a couple 
of yeans ago, and 17 n-ray instaUations, inelnding these of 
sorcrai of the principal London hospitals, were examined 
hy tho staff of the laboratory. A great deal of radio- 
logical work i.s proceeding, but it is directed at present 
mostly to the use of x r.ays in tho industrial sphere. Work 
is being done, however, on the measnreraent of x-rav 
intensity and dosage, for which a special ionization 
chanihor, where tho ionization is produced in a gas at high 
pressure, has heon set up. High-voltage researcb is actively 
proceeding. Million-volt transformers are being or bare 
been installed in a special bigh-voltage building, and we 
kiioa- that in various electrical institutions, including 
those concei-ned with vadiologs-, very mncli is hoped from 
these experiments in high voltage. Illumination research 
is another matter to which tho laboratory is paying atten- 
tion. A comprehensive investigation is taking place into 
tho effect of glare on visual acuity, the value of different 
.S 3 -.stcm.s of illumination for tho carrying out of fine work, 
ami a proper diffusing glass for street lighting. The 
acoustics of buildings is another field of operation. l''ci-y 
few public halls can be said to be perfect acoustically, but 
in this respect audiences suffer long and arc kind.' It is 
possible to remedy a good deal of tho trouble in a defective 

- building hy ceiling canopies or liniugs and by the uso on 
’ appropriate- occasions of electrical aniplifiei-s with- loiul- 

- speaking projectors (as is done in the- Great Hall of tho 
• British McdicaF Association House), but the elimination of 

the defect in many buildings can only be accomplished by 

- structural alteration, which goes to prove the nccil for 
■ consulting an acoustical expert before a building is erected. 

Another piece of work carried out at the laboratory is the 

- inyestigation of dental amalgams,- both in regard to the 

* Published by Siationery Ofllce; 7s. 6d. net. 





^Lrmij 23 1 3918] 


EVOLUTION OP A HEALTH DEPABTIIENT. 


• r Tnr.nnmw • fiRl 

LilrmciL JoonHASi viu*> 


Ims jiwl fov\vnrt\ n sdicme fov tU« evcaliou of a great 
iiicaicnl rentvo for ^ilollram-no to co-ordinalo and extend 
existing ngeneics. Addressing a recent ineeling in Dmt 
city, Professor Perry said tlio trend of affairs in hospitals, 
as in other dcpnrlincnts of life, was tonards tlie establish- 
ment of more complete and effective units. lifodern pro- 
gress mado it a requirement that there .should bo a group 
of schools, hospitals, and institutc.s, all dovetailed into 
a general plan of education. In such centre.s all tho 
hnowlcdgo now available to medical science could he brought 
to boar tipon the treatment of disease and for tho ptirposo 
of odneating ])rartitioners. Tlicy were not designed 
mcrelv to serve a local need; the benefit of a medical 
discovery in Melbourne at once accrued even to people in 
Siberia, as well as to people in Ijondon and New York. 
For tho creation of a Victorian health centro in Melbourno 
thev required: (1) a university school of medical, dental, 
ami allied sciences; (2) a nniversilv clinical hospital of 
200 or SOO beds, which should ha retained for post-gradnato 
work and paying patients; (3) a general hospital of 500, 
600, or 700 beds; (4) medical co-operation and the closest 
university association between thc.se and all other metro- 
politan and leading provincial hospitals; and (5t one central 
guiding administration and administrator. Professor Perry 
said that everywhere, especially in Canada and tho I'nitcd 
States, ho found medical schools and h.ispitals being 
removed from one silo to another to give effect to 
eentralir.ation schemes. Tho advent of scientific medicino 
had given longer life to tho prc.scnt generation, and the 
medical centre movement, which was rapiiliy developing 
all over tho civilir.ed world, protni.sed to give still longer 
lifo to tho generations to come. It promoted tho supply 
of more efficient doctors, nurses, and liealtli workers, with 
.a greater certaiuly of providing relief in disease. Tho 
extent to wliieh ctmdilions in Australia resemble those of 
this country are revealed in somo of Professor Perry’s 
remarks regarding tlio present position in Molhoorno. Ho 
is anxious, like so many in tliis country, to s.cc unmediato 
provision mado for tho expansion of liospital a<coinmoda- 
tion; hut, wliilc a keen advocate of contrali/.ition, lio 
thinks that tho identity and autonomy of tlw existing 
hospitals should he preserved. 


THE EVOLUTION OF A HEALTH DEPARTMENT. 

Tiir. Public Health Pepartment of tho State of Illinois, 
on the occasion of its jubilee last vear, pnlilishcd a record’ 
of tho health of tho State from tho time of tho first 
settlers to tho present day. Little is linown of tho health 
conditions of the early Indian inhabitants. The first white 
settlers, Frcnch-Canadians, arrived in 1670. Their writings 
contain few references to health; they roav ho prcsrimod to 
have been a Iicalthy race. Tho Pritish, wlio occupied tho 
territory from 1763 to 1780, suffered severely from malaria 
and small-pox. In 1780, when tho Pritish fort was 
captured, American colonists began to settle in tlic State. 
As their numbers increased disease hocamc prevalent and 
assumed menacing pi’oportidns. JIalaria rvas the principal 
illness; it affected every member of the community, young 
and old alike. Typhoid fever, though present, was obscured 
by tho dominating malaria. The cholera pandemics of tho 
ninetoentlr century readied Illinois on more than ono 
occasion, and small-pox was common. Since the establish- 
ment of tlio State Department of Public Health' in 1877 
malaria has almost disappeared, mainly as a result of tho 
drainage of swamps. Typhoid, wliich rose as malaria fell, 
has yielded in its turn to improved sanitation, and small- 
pox, despite resistance to vaccination, has been brought 
under control. Hos]iitals and laboratory facilities have 


KiSi, wiUi William A. Evani JI.D., D.P.II,, Goltiri 
' v>’ 3v. Bicharcison, A.B. In two parts. Illinoi 

httltc Department ol llcaltii. 1927. (Sup. roy. 8vo. pp. «2; ilUiitrat^ 


been provided, and an efficient child wolfavo service has 
reduced tho heavy mortality among infants and young 
children, 'rho unavoidably inconiplcto vital statistics of 
tho early years of tho department’s work render acourato 
comparisons difficult, hut it m.ay ho noted that tho averago 
ago at dcatli has risen from 33 in tlio days of tho settlers 
to 58 nt tho present time. Admitting that diminished 
activity on tho part of tho Indians may have conduced in 
somo mcasnro to thi.s result, tlio fact remains that gonuino 
health progress has been made, and tho dojiartincnt, in tlio 
closing words of its report, may fnco tho fntnro with 
confidence, 


DAYLIGHT IN BUILDINGS. 

One of tho most important problems of city lifo is tho 
arrangement for lighting of tho interior of buildings. 
Tiicro has been great improvement in artificial lighting of 
recent years, lint tho problem of daytime ilininination is 
ns yet unsolved. Tho value of spaco tends to crowding of 
building, and this causes obstruction to lighting, however 
largo and- well planned the windows may be. Worse still 
arc tho effects of increasing height of buildings: houses 
that wero formerly' well lighted are now overshadowed and 
their interiors aro gloomy. Tho Department of Scientific 
and Industrial Research has turned its attention to tliis 
problem. In a paper on Penetration of Daylight and 
Sxinlight info Dnildings (London: H.M. Stationery Office, 
price Is.) tlio present state of our knowledge is set 
out, and tlicrc is a promise of speedy inquiry info 
tho liitiiorto nninvestigated questions that arise fhcrcmi, 
Tho lighting of a room is good or had in proportion to the 
unobstructed sky area visible at tho working or floor 
area, Wlicro little or no sky is visible, as in a room on tho 
ground floor of a well area, then tho ligiiting is bad. 
IVliero a full sky is seen, as from a top floor room of ari 
unobstructed bouse, the lighting is good. These conditirns 
can bo measured. The outside daylight on an averago 
dull day is taken at 250 foot-candics, and it is found tiiat 
tho minimum interior lighting — the "grumhlo point” (that 
is, tho point nt wliicli rcasonahio people will complain of 
poor light) — is 1 foot-candlo. That means tliat all positions 
in tho room which have a “ sill-ratio ” of loss than 0.4 per 
cent, will ho unsatisfactory. Tho chart of the area of 
a rooni whicli has visible sky can be plotted out and the 
ratio ascertained. Among other matters consideration is 
given to tlio effect of wliitcning tho obstructing walls. 
This device is found to bo of advantage so long as ibo 
whiteness is fresh, Imt in a city of smoko and grime tho 
benefit is short-lived. 


The spring meeting of tho British Orthopaedic Assoc ia- 
tion will be held in Paris on Friday and Saturday, April 
27th and 28tli. 


We regret to announce that ]Mr. John Stephen McAi-dle, 
jirofcssor of snrgciy at University College, Dublin, and 
senior surgeon to St. Vincent’s Hospital, died at the ago 
of 69 on April 14th, after a long illness. 


Pkofessor G. Elliot Saiith, M.D., F.R.S., will deliver 
-tho Huxloj' Memorial .Lecture at the Royal College of 
Science, South Kensington, on Friday, May 4th. The title 
of his Iceturo is “ Conversion in Science.” 


'The formation exf a jMasonio Lodge in connexion with tho 
British Medical Association is now being considered by 
a small committee. All Masons who mar' bo interested are 
iiivitcid to apply for information to Dr. Hubert C. Brisfowo, 
Tho Cottage, Wringtoii, near Bristol. _ 





rcarrangemonf iinporativo. Tlio fiiio medical laboratory 
provided by tbo ItocUcfcllor Foundation trustees is tuo 
latest aofiuisition. Tho main hospital now contains 
380 bods, and considerable relief is alfordcd by a con- 
valescent homo of fifty-four bods, four miles outside the city. 

Its nursing school has established a wcll-caruod reputa- 
tion. Instruction is highly organized, and its preliminary 
training school in Anthony Houso has long been a notable 
feature. 

Itoy.iL HAiLsnaYAD Se.imen’s HosriTAt. 

Tho riso of Cardiff ns a port soon made necessary tho 
provision of hospital accommodation for tho seamen of 
many nationalities frequenting it. ■ Accordingly tho old 
21-ton frigate 11.31. S. Hamadryad was lent by tho 
Admiralty at tho time wooden hulls were being discarded. 
It was fitted up as a hospital with sixty beds, and opened 
ill 1856, its main financial support -being derived from j 
a voluntary levy of 2s. per TOO tons register on all ships 
using tho port, floored in a ' creek or pill, and afloat 
during high spring tides, it soirod'its purpose for forty 
years, and, in spito of being unsuitable in many ways, did 
excellent and successful work.i Low' ceilings made the 
wards difficult to ventilate, and in tho' operation theatre, 
lit by gas, tho proceedings averoTiablo "to bo interrupted 
by phosgene gas formed by decomposition of tlio chloroform 
vapour in tho flame. This phendmonoii was first described 
in this country in a paper based Sn' observations rhado on 
board the old ship. ... I , ■ 

When the year of tho Diamond Jubilee came it was’ 
decided to celebrate it by raising a fund to erect a per- 
manent hospital. . Besides giving a site tho late Marquess 
of Bute, who took a personal interest in the proposal, made 
provision for its completion and equipment, and it was 
■' opened in 1907. 'The site, though suitable as regards 
position — it was washed by tho tide, reminding the patient 
of his native element — ^u-as otherwise a difficult one to 
deal with. To provide foundations piers of concrete had 
to *be carried down through nineteen feet of soft clay to 
tho hard gravel— a very costly proceeding, which entailed 
placing the wards one over the other on three floors. It 
has three main wards of sixteen beds, each with a two-bed 
ward adjoining. TIio medical superintendent’s house is 
separate from . the. hospital, but connected with.it by a 
covered corridor. Tho building and equipment coat £30,000. 


City JIextai. Hospital. . ^ ■ 

This institution, of which the city is justly proud, ’has 
been a pioncei* of modern ideas in the treatment of mental 
disease. Recognizing that psychiatry in^ this countrv will 
mako littlo progress until voluntary clinics aro' established 
such as exist abroad, an endeavour has been made. to 
advance by effecting a compromiso between tlio roal 
psychiatric clinic and the ordinary mental • hospital. 
Situated three and a half miles from Cardiff, the hospital 
was opened in 1908 with immediate provision of 750 beds 
and administrative provision for 1,250. A chemical research 
-laboratory has been organized, with a specialist staff ; the 
original pathology laboratory has been greatly extended, 
and equipment for diagnosis and treatment such as is 
found in a modern general hospital has been. installed. An 
out-patient department for the early psychoses and psycho- 
neuroses, at the' Royal Infirmary, has been conducted 
weekly for eight , years , from’ .the Mental Hospital, and 
this is. continue in the belief that the establishment of tho 
nocessai^. indoor’ clinic-' in “psychiatry as part of, though 
not, in contiguity' with, the infirmary buildings is bound 
to be realized. in time.' The 'chemical research laboratory, 
started . in 1910,. was one of - the earliest of tho ■ kind in 
a mental hospital ln_this country, and has published much 
valuable' work'.. The. successful effort to get Government 
recognition of ...research . in_mmtal hospitals by way of 
State .aid owes .much to tho. initiation of the Cardiff City 
Mental Hospital..; A pioneer step as far as England and 
"Wales is concerned— and probably the most drastic of the 
kind in this country as a whole — ^was the replacement of the 
system of male nursing by that of female nursing. With 
exception of three male wards the entire hospital is staffed 
by female 'nurses with, in some wards, a male for sub- 
ordinate duties. The whole work of nursing is controlled 
by the matron, male supervising authority being abblished.- 

PfiixcE or W.ALEs’ Hospital for Liiibless anu Cripples. 

This was opened in 1917,- in the first place to deal with 
the limbless casualties of the war. It is now a general, 
orthopaedic hospital supported by contributions, subscrip-' 
tions and endowment. It provides fifty beds and an out- 
patient department, arid is vei'y well equipped. Its work, 
which' is over extending,' is thoroughly rcprcsentaliye of 
1 modern orthopaedic surgery. 





684 ' April 21, 1928] 


SOUTH 'AFEIOAN 'MEDICAri CONGRESS. 


t Tiir l5niTi*H 
MeIUCAI^ JofKHAt 


. Union Hospitai.. 

The first hospit.nl under the Toor Law in C.-irdiff was 
built in 1872.' It has heeii enlarged repeatedly sineo, and 
now contains 300 beds for “ acute sick ” — not including 
the sick bods provided in the poor-house. It i.s being 
developed on modern lines, with a consultant staff. Many 
patients unable to enter the voluntary hospital on account 
of a large waiting list now seek admission hero. Its work 
continues to expand so much that it has been decided 
to remove to a now building of 400 beds, with ample 
pirovision for expan- 
sion, about to be 
erected on a site on 
the confines of the 
city. 

Welsu National 
School of Medicine. 

The School of Medi- 
cine was established 
in 1893 as jiart of the 
Universitj- College of 
South Wales and 
Monmouthshire, one 
of the constituent 
colleges of the Uni- 
versity of Wales. It 
owed its inception 
largely to the advo- 
cacy of Dr. W. T. 

Edwards, President 
of the British Medical 
Association at the 
Cardiff Meeting in 
1885, who took an 
active part in the early movement for higher education in 
the Principality. It w^is formally opened by Sir Richard 
Quain, the President of the General Medical Council. In 
addition to the early subjects of the medical curriculum 
it made provision for the teaching of anatomy, physiology, 
materia medica, and pharmacology, the clinical subjects 
of the fourth and fifth 3 'cars being taken clscwlnu'c. The 
School met with well-deserved success, and at the present 
time many of its students occupy distinguished positions 
on the staff of hospitals in London and elsewhere. Efforts 
wore made from time to time to extend its .scope, and in 
1909 an increased grant from the Treasury led to a chair 
of pathologj- being founded. Wlien the Haldane Royal Coin- 


mis.sion on Universit}’ Education in AV.alcs was appointed it 
reviewed the whole position, and in its rcj)orl in 1918 
recommended that the School be completed, and that the 
departments of mcdicino and .surgerj’ bo organized on 
the hospital unit system. The authorities of the Royal 
Infirmarj' having undertaken to make provision for those 
units within the hospital, tlie Treasni'j’ and other bodic.s 
agreed to fnrni.sh the ncce.ssarj- funds, and in 1921 the 
AVelsh National School of Medicine, as it now became, 
was established with a full curriculum. 

In the matter of 
buildings the School 
owes much to the 

munificence of Sir 

AV i 1 1 i a m James 
Thomas, Bt. His 
splendid gifts com- 
prise the fine pIi 3 '.sio. 
logy block erected on 
tho Nojvport Road, 
and tho now building 
for the department 
of public health and 
school of proventivo 
mcdicino completed a 
year ago — a group for 
which it woidd be 
difficult to find an 
equal in this country. 

In 1924 tho trustees 
of the Rockefeller 
Foundation made a 
grant of £14,000 to 
aid tho medical unit. 
It covers the cost of a 
laboratory in the Royal Infirmai'y for tho department of 
medicine,’ tlio building of which . was finished in ,1027. ’ 

Tlio controversy which has been waged between the 

University College and tho University over the administra- 
tion of tile School since its completion has l.ately reached ' 
a settlement by way of compromise. It provides for 

the preliminary subjects remaining with tho College, tho 
clinical departments being made a separate school cont 
ts'olled by the University, and a special arrangement for 
anatomy and physiology. AAlicther such a solution is well 
adapted to deal with tho growing complexity of medical 
education is a question upon which opinions may reasonably 
differ. 



The Old “ Hamadiivad ” Hospiial Ship. 


THE SOUTH AFRICAN MEDICAL CONGRESS. 

[Fnoii OUR Correspondent in Pretoria.] 

The first Annual Scientific Meeting, of tho Medical Associa- 
tion of South Africa (B.M.A.) was held in Bloenifontciii 
during the week commencing March 12th. This was the 
twenty-second South African Medical Congre.ss, but the 
first since the profession in South Africa had been 
organized into a single united association affiliated with 
tho British Medical Association. Owing to the central 
situation of' Bloemfontein, the attendance of members ivas 
very good. This central situation in the Union makes it 
most convenient for congresses and conferences of all 
kinds: So often are these held in Bloemfontein that it 
has come to be known as the City of Conferences. It is 
the capital of a province the size of- England, but with a 
population of only one million — 200,000 Europeans and 
800,000 natives. Bloemfontein was the capital of the old 
Free State Republic, and at the time of union of the 
provinces in 1910 the city, along with Capetown and 
Pretoria, made a bid for becoming the ciipital of -the 
Union. Eventually the honours were divided ; Capetown 
in the south, with its Jiandsome houses of parliament, 
became the legislative capital, Pretoria in the north 
became the administrative capital, while Bloemfontein 
became the judicial capital. ' 

The congress' was officially opened by Mr. Justice Jacob 
de Villiers, judge of appeal iii the Raadzaal. In an 
admirably framed address .be gave first expression to a 


feeling wliicli pervaded all the iiroceedings : the duty of 
the profession to educate and guide the imblic so tliat a 
bealtliy nation might be produced. 

The Papers. 

That the profession is alive to this duty was demon- 
strated bv the presidential address of Dr. C. Hugh Bidwell, 
who spoke on the subject of practical eugenics. In tho 
previous congress at Pretoria Dr. Sanders, in the presi- 
dential address, had taken as his tlieme the text, “ Everv 
child has the right to be well born.” Dr. Bidwell followed 
up this theme, and in an iutercstiug and controversial 
paper showed how tho general public could assist in this 
worthy object. In his opinion sterilization of feehle- 
rainde’d and mentally deficient jiersons should be legalized 
as soon as public opinion could he educated up to it. 
AMluutary limitation of families he justified where there 
were recognized medical reasons, to secure adequate 
intervals between births, whore- patcriial wages did not 
allow of further increase in tho family, or where hereditary 
defects might possibly ho transmitted. Tile State must 
decide that persons receiving public assistance shovdd not 
have unlimited families. Should persons deharred bj- tho 
State vet produce’ children the}’ must he submitted -to 
enforced segregation or sterilization. 

Dr. E. G. Dru Drurj’ opened the section of medicine 
and mental hygiene with a jiapor on tlie theory and prac- 
tice of inhibition. This contained much valuable matter 
seiwed up in an attractive and racy manner. Other useful 



ATOIIj 51 , 1918] 


SOUTH AFRICAN MEDIOAIi CONGRESS. 


t niE BurnffS fiflR 

llrOlCiL JCORKlC v> o u 


pixpovs iu this section xvcvo on rcpvcssioUj onkylnstounosis, 
hay fever, and action of extract of solninim psondo- 
capsicnm; bat tbo outstanding contribution was n Iccturo 
on dental .sepsis in its relation to general pathology by 
Sir Frank Colyer of tho Royal Dental Hospital, London. 
His lecture, wliicli was listened to ivilh close attention, was 
illustrated by adinirablo lantern slido.s, tlio moro remark- 
ablo in that many of them were from photographs taken 
yeans ago udien i-ray photography mas still in its infancy. 

Tho opening paper iu tbo surgical section was read by 
Professor Saint of Capetou-n University, on abdominal 
emergencies. Tiiis paper mas of particular interest to tbo 
general practitioner in Soutii Africa, on nhoni it is often 
incumbent to carry tbrougb an emergency abdominal caso 
owing to tho impossibility in many areas of obtaining 
assistance or transport. Fortunately difficult surgery I 3 
not usually involved, particularly if limited to life-saving 
me.isnrcs. For an opening paper this ivas considerably 
shorter than tho average, but it raised so many interesting 
points that a long and valuablo discn.ssion iras cvokerl. 
Conditions in South Africa make it necessary for a largo 
proportion of tho profession to bo ahlo to do its own 
surgery. Interest in surgical mailers is, tlicrefove, always 
great, and shows itself in well-attended meetings and 
largo numbers of papers on surgical matters at congresses. 
This was again tho enso at tho present congress. 

Tho public health section was opened with a paper which 
dealt with tho medical practitioner’s place in tho local 
government and health administration of South .\frica, 
road by Dr. Cluvor. Tin's contiiuiod tbo theme of Mr. 
Justico do Villiors. After a description of tho organiza- 
tion of local government in : South Africa some local 
problems were discussed, and some of tlio fields indicated 
in which tho counsels of tho profession wore necessary for 
tho successful dovolopracnt of the growing nation. Thoro 
was coiisidorablo discussion on tho various points raised in 
this paper. Dr. Brackonbury warned tho members of tho 
profession of tho necessity for equipping thcniM Ives with 
preventive kiiowledgo so as to ■ bo able to supply needed 
advice. Clinics and similar institutions for combating 
disease woro growing up all round, and iinle.ss doctors 
co-operated -with such bodies they were liable to bo deprived 
of iogitimate svork. Other contributions in this section 
wore a bio-sociological surs-cy of tbo colour problem in South 
Africa by- Dr. Hay Micbol, who speaks with considerablo 
authority on tho subject; an Instructive account and 
demonstration of tho Schick and Dick tests and pro- 
inoculation against diphtheria and scarlet fever 
by Dr. Pratt Johnson; a paper on bacterial filtrates in tlio 
treatment of bactorial infectious by Dr, G. Buciiaiiaii; and 
an address on bactcriopbago in tho prevention and treat- 
ment of experimental pkiguo by Dr. J. H. Haiwoy Pirio. 

Dr. Brucc-Bays opened tlio section of obstetrics and 
gymaccology with a paper entitled " The doctor, tlio mid- 
wife, and the patient,” and Dr. F. B. JIudd tlio special 
subjects section with an account of anaesthesia in general 
and tho general practitioner in particular. 

. . Distinguished Visitors . 

Only four visitors from outsido South Africa attended 
were Dr. H. B. Brackenbury, Chairman of 
too Council of tho British Medical Association; Sir Frank 
Colyer of tho Boyal Dental Hospital, London; Dr. H. B. 
Oenslmm of Stockton-qn-Tees ; and Dr. C. D. Hatrick of 
New Barnet. These distinguished memhers of the parent 
.^sociation were officially . welcomed by Mr. Justice 
da V liners when ha opened too congress. At too same 
time 10 voiced tho e.xtremo regret and disappointment felt 
American colleagues who had contemplated 
attending this congress, under tho auspices of the American 
College of Surgeons, had been unavoidably prevented from 
doing so. \ ery valuable services were rendered to too 
^sociation by Dr. Brackenbury, who came to attend toe 
c c r general meeting of tbo Medical Association 

of South Africa as tbo. official representative of too parent 
.<ysociation in Great Britain. His visit was made at con- 
siderablo sacrifioo to himself, and was very hurried. On 
tho occ^ions when ho addressed congress he spoke with 
the authority of useful experience, which is invaluahio to 
an infant association-such as tho South African body. Sir 


Frank Colyev’s contribution to tho medical section, which 
lins already been referred to, was 0110 of tho outstanding 
features in congress, and is likely to influence profoundly 
tlio iiltiliide of niodicnl 111011 in South Africa towards tho 
matter of dental sepsis. 

Kntertainmenfs. 

'riio joint honorary sccrotancs of the local committco 
wero threo Bloemfontein ladies — Drs. Alice Cox, Marion 
Thomson, and Loiiiso 'i'omory. 'I'liis probably accounted 
for tho undoubted success of tho social side of congress. 
Dancing was provided on threo nights. After tho presi- 
doiitinl address on tho first nftornoon. Dr. and Mrs. 
Bidweli wero at homo in too Rnadzaal grounds, and that 
night tho nin 3 ’oral reception was held in tlio town hall. 
On tho Wednesday afternoon tlio Administrator’s garden 
liarty was held in the Prince’s Rose Garden — a garden 
which was laid down in 1925 to coniiiicraorato the visit of 
the Priiico of Wales, and which has become one of tbo 
sliowplaccs of Bloomfontcin. On tho remaining afternoons 
tennis, bowls, and other forms of amusement woro provided 
at tbo Ramblers’ Club. Tlio entertainment was sufficiently 
varied to suit all tastes, and on tbo danco nights tho few 
not so inclined pla 3 -cd sedate bridge or attended theatrical 
porfonnaiicos. 

Trades Exhihition, 

Tho oxtensivo exhibition of drugs and clinical appliances 
was housed in tho Reitz Saal of tho Grey University 
College. It was opened on tho first morning by Dr. S. M. 
do. Kock, vice-iiresidciit of congress. All too well-known 
firms wero represented. There wero exhibits by Allen and 
Hanburys, Hind Brothers, Taeuber and Corssen, Petersen 
Ltd., H. K. Mulford, tho Surgical Manufacturing Com- 
pany of Joliaimcshurg, Oppenlicimer and Son, and Asso-^ 
ciated Proprictai’ 3 ’ Agencies. 




Regius Professor of Physiology at Aberdeen. 

The Kino has appointed John James Rickard Madeod, 
D.Sc., LL.D., M.B., F.R.S., to bo regius professor of 
ph 3 -siology iu tho University of Aberdeen in place of Pro- 
fessor J. A. MacWilliam (resigned). Since 1918 Professor 
Madeod has held tho chair of physiology in the Faculty 
of Medicine of the University of Toronto. After graduating 
in modicino at Aberdeen in 1898, lie became demonstrator 
of jibysiology and lecturer in biochemistry at the London 
Hospital, and was Mackinnon Research Scholar of the Royal 
Society. From 1903 to 1918 he was professor of physiology 
in too Western Rcservo University, Cleveland, Ohio. Ho 
was president of tlio American Plysiological Society in 
1922, and in tho following year was elected FJt.S. and 
received jointly with Dr. F. G. Banting too Nobel Prize 
in medicine. In 1825 ho was president of the Royal 
Canadian Institute, and he is an honorary Fellow or 
corresponding member of many medical and scientific bodies 
in Europe and America. He is the author of important 
works on ph 3 'sioIogy and biochemistry, more particularly- 
in relation to carbohydrate metabolism and too introduction 
of insulin into therapeutics. The earliest accounts of toe 
pioneer work on insulin by klaclood. Banting, and Best 
that appeared in this country were published in toe British. 
Medical Journal of July 22nd and September 9to, 1922; 
and on November 4tli of the same year Professor Madeod 
contributed to our columns a general statement of tbo 
physiological and therapeutic efiects of insulin. He will 
take up his new duties next autumn. 

Edinburgh Corporation and Venereal Disease. 

A public meeting was held in the Usher Hall, Edinburgh, 
on April lltli, under the auspices of too National Council 
of Women, in support of the Edinburgh Corporation’s bill 
for ■ compiilsoiy powers in connexion with the treatment 
of venereal diseases. Tho Countess of Cassillis presided 
over a largo attendance. Three of the members of Parlia- 
ment for toe city, Sir Patrick Ford, Sir Samuel Chapman, 
and Dr. Drummond Shids, wero present on the platform 
and spoke in support of tho bill, while apologies for absence 
wero intimated from Mr. William Graham, M.P., and Mr. 




ENGLAND AND WALES. 


[ Tnr nnrnsn fi<J7 

Mrriicii. JounMii * 


Arniii St, 1928] 


pvovitlcil tlu\t llio piiwcrs iil' Itio Cciionil Moilirnl Cottiicil 
will cimlinuo ns liofoiv, sitliji'ol (o (lio Inw of loenl roois- 
trntioii for praclitioiioi's iiviiis in t)u' Kioi' Btiilo. Tlio 
GoiR'inl Moiliciil Cotmoil, Miid Ilr. Coffi'y, vomnins, nnil 
poopU' will'll tlioy 1110 tiimlilicd nin vof-isloi- with Iho 
Ci'iii'i-al Mi'ilicnl Coiiiiri!, Iml if ilioy wish to practiso in 
tlio Kioo State tlicy nnist havo tlioir nann-s I'litoml on 
tlio Fi'co State llegister, oven tliongli they aie enteroil on 
tlip general .Ifrii/rnf llri/hlrr. J)r. Coffey esiireKKoil tlio 
opinion that it wonlil lie wise for all young ineilieal prac- 
titinners qualifying in Southern Ireland after the estahlisU- 
uient of tho Free Stale Kegister to have their names 
entered on hnth registers — the general Mi'ilirnt Jieyi.^trr 
and the Free Slate Register, lie added that the Free 
State Jfedieal Council had now coniiileled most -of its 
preparatoiw work, and it is linderhlood that tho first 
Free State Medical Register is likely to he puhlished soon 
after damiary 1st, 1829,' and reissued thereafter every 
year. Applications for registration should he sent to the 
Medical Registration Council, Rnoin 125, Customs House, 
Buhlin, 

Food Preservatives In the Free State. 

The draft regulations regarding the use of preservatives 
in food issued hy tho Irish Frce State Minister for Local 
Governnieiit and I’lihiic Health tinder hts statutory 
powers make tho sanitary authority and ofiieers of local 
authorities rcsponsihlo for tho enforcement ol tlie regula- 
tions. A pcr.sou who exposes or offers for sale hy retail 
any article which contains any preservatiw must hihel the 
article or exhibit a notice in a conspiemms ptaie, so as 
to ho easily rcadahio hy the customer. No pet-on may 
sell cream which contains any thickening snhst.ince, and 
no person may sell any article for use as a jiri si rvativo of, 
or colouring matter for, any article of food if such use 
would ho contrary to tho regulations. .\nv officer autho- 
rised hy the Minister and any officer of ihe sanitary 
aiithoritj' acting in tho execution of the-e regnlutions is 
empowered to enter prcmi.scs where artiih-s to uhiih these 
regulations apply arc prepared, packed, labelled, or .stored. 
Ho may tako samples, and, if so required. in.'d>e rc.i.soiiahle 
payment. If an article hs sold within tho di.stri<t of tho 
authority contr.ary to tho regulations, the authority or 
officer c.an, in addition to taking proceedings ag.unst tho 
seller, tako proceedings against any prcvioii', .seller of tho 
article, and tho sale by tho previous seller will he deemed 
to have t.akon place within tho district of the authority. 
Subject to any directions given hy the Rcieiiuc Com- 
missioners, after consnlt.ation with tho Minister, the 
customs and excise officers will have power to take samples 
of consignments of imported articles to which thc.so regu- 
lations applj’, and to send them to the State chemist for 
analysis. Tho certificate of tho State chemist or the public 
analyst of tho result of the chemical examination of a 
sample will be sufficient evidence, unless the defendant 
requires that the person who made the examination bo 
called as a witness. These regulations will not apply to 
any articlo intended to bo exported or re-exported, or for 
use as ship’s stores. 


ftttJr Maks. 


■ The National League for Health and Maternity. 

The . I'oport of- tho National 'iicaguo, for Health, Mater- 
^ ^ 'Welfare for 1927 gives ample evidenco 

or tho wiclo range of useful activities carried on by the 
seven national societies federated under this title for 
co-ordination and mutual assistance, eacli retaining its 
autonomy. The leaguo arranged in 1927 a series of lectures 
to V'anous organizations of women and girls, circulated a 
him on physical education, sold no fewer than 360,000 
copies of Its publications, administered the Tired Mothers’ 
ioliday Fund, and controlled and financed three con- 
valescent homes for infants and young children. On tho 
educational sido the National Association for. the Preren- 
lon ot Infant Mortality continued tho important task of 
pioviding, hy means of lecture courses, advanced and 


olcmcnlnry instruction for health visitors, nurses, mid- 
wives, and other.s, anti arranged two series of Iccture.s 
on tho hygiene of married life intended for educated 
parents. In luhiitioii, ciforts were made hy research, dis- 
cussion, and ]iro])ngaiuhi to advance tho objects of the 
association, 'fhe report of tho Association of Infant 
Welfare and Jtulernily Centres cx]iresscs regret at the 
slow growth in 1927, this being due largely to tho failure 
of centres under imiiiitipal control to secure affiliation. 
Nevertheless, satisfactory progress is being made in tho 
work of the 1,200 centres already linked with tho associa- 
tion. The report states that centres arc now frccincntcd 
alike hy the working classes, though not by tho poorest, 
hy the artisan class, and hy various grades of middle-class 
iiiothcrs, hilt that there is a growing desire among tho 
comparatively well-to-do inothcrs for centres of their own, 
supported entirely hy payment. One such centre has been 
cstahlished in Chelsea, and another is being organized in 
a rural district. The work of the league has been ham- 
pered by financial difficulties, and nlthoiigli .some henefit 
is gained from the considerahlo profit on the sale of puhli- 
cationn, fiirlhcr assistance is needed to ensure more adequate 
provision for the programme whicli Is contemplated. 

Central MUvvIves Board. 

At a mooting of tho Central Jlidwivcs Board for England 
and IVales on April 4th Sir Francis Chainpncys was re- 
elected chairman, and it was announced that jfr. Victor 
Bonney ami Dr. Vincent Dickinson had been ro-clccted to 
tho Bo.ard hy the Royal College of Surgeons and the 
Society of Apothecaries respectively. In reply to a letter 
from tho Ministry of Health it was decided to inform tlio 
Mini.stor that the Board is in agreement with him as to 
tho desirability of an inquiry into tho training of midivivos 
and the conditions under which they are jiractising, and 
that two members of the Board will ho willing to seivo 
upon any committeo which ho may appoint in this con- 
nexion. Tho Board licpes timt the Minister vVill, at 
the same time, hoar in mind tho importance of mobilizing 
all tho best nvailahio forces in inrc.stigating tho problem 
of maternal mortality. A letter was read from the Ministi-y 
enclosing a copy of 0110 from the General Medical Council, 
and requesting the Board’s observations on tho resolution 
adopted by tho Excciitivo Committee of ,tho Council 
regarding the memorandum on administration of drugs by 
midwives. Reference to this resolution was made in the 
Supplement of JIarch 31st (p. 109). It was agreed that 
a reply, as drafted by the chaiiman and approved by tho 
Board, bo sent to tho iMinister. In response to letters from 
tho medical officers of health for Gloucestershire and 
Liverpool tho following resolutions were adopted t 

That in tho Board’s opinion a midwife has, like a doctor, the 
right to refuse to book a case which she does not desire to attend, 
and that this right would be properly exercised when the midwife 
has reason to believe tliat the patient will refuse to permit the 
necessary examinations to be made or to carry out tbe-midwife’s 
proper instructions. Tho Board’s opinion, of ■ course, does not 
extend to cases where attendance may be demanded on humani- 
tarian grounds, or in respect of which tho midwife, as regards 
attendance, owes a duly to some other body, person, or authority 
responsible for tho provision of an adequate midwifery service. 
Tho midwife is quite at liberty to consult the local supervising 
authority in any doubt. Under these circumstances tho Board sees 
no necessity to' consult with the Ministry of Health with regard 
to tho opinion in question. 

Willi regard to tlio definition of " abortion,” if the Board finds 
that tho present definition is misunderstood, it will reconsider it 
at tho next revision of tlie rules. 

- The following resolutions were adopted in reply to ’ a 
communication from tho honorary secvotai'y of tho Council 
of British Ophthalmologists : 

1. That in tho existing rules ot the Board it is stated that it 
is desirable that, whenever possible, arrangements should be made 
tor pupil midwives to visit ophthalmic liospitals or the ophthahnic 
departments of general hospitals for the purpose of gaining direct 
experience of ophthalmia neonatorum. 

2. That as soon as sufficient centres for the tre.”.tment of 
ophthalmia neonatorum aro establislicd, fhe Board will take into 
consideration the question ot making tho attendance ot pupil 
midwives at such centres compulsory. 

3. That as regards tho “ recognition ” of ophthalmia neona- 
torum tho Board does not expect midwives to diagnose disease 
of anv kind, but to obserro and report “ any abnormality ” 
(Rule E 20). In the case of affections of the eyes, it requires the 


688 Apriii 21, 1928] 


COKBESPONDENCE. 


[ TffiDnm** 

llKOIClL JOTBSII 


midwife to siunmon medical help in all cases of inflnnnnalion 
of or discliargc from the eyes, liowcver slight ” (Hole E 21 (5) ). 

It was agreed that the following note he added to 
Itulo E 21, and that the Minister of Health he asked to 
nj)])rovo the addition : 

the foregoing lists arc not cxhauslivc and do no! include all 
cases m winch medical help should be summoned.” 

According to Rule E 20, “ any ahnonnalitv ” rcqtiires 
I'ledietil hel]>, Ihc in.stancos in Rule E 21 refer fo .some of 
the most striking and important abnormalities. 

Lunacy Returns for London. ' 

Hie tot.al number of insane persons for whose aeeom- 
reodation tlic Loudon County C'onneil was rcs])onsihle on 
January 1st last, according to a return prc.sented to the 
Connell, was 20,147, an increase of 340 during the year. 
,Of tins nnmher, 19,715 were accommodated in the London 
county mental hospitals, and all but 1,400 of the total 
inimhcr provided for were rate-aided eases. In addition 
to these patients, for whom the London County Council is 
dircetly responsible, there were 132 insane persons resident 
in 1 oor .Law guardians’ institutions in London, 104 boarded 
a A/m r gnai'diaiis among relatives and friends, and 
4,540 harmless ehronie patients aeeommodatcd in the Metro- 
politan Asylums Board’s institutions. The mimhcr in this 

" ith under the 

1 ental Deficiency A<ts, is the lowest recorded sineo 1890. 
liic tot.al niinihcr of insane persons chargeable to parishes 
and nnions in the county of London and lo the coiuitv 
Itself at the hcginning of the vear was 23,620 as 
compared with 23,474 in 1926. , , as 




TREATJIEX’r OF CASTRIC AND DirODEN-\L 
ULCERATION. 

lih'X' the eonunnnieations by Professor 

MacLeaii in the last nnniher of llie Jinti.l, if c, Heal Joarnal 
(p. 619) and in the Laiirct of January 7tli with verv great 
interest, for, like many surgeons, I have long liold that the 
treatment of iilcer.s of tiic stomach and dnodeniim bv 

onlhT't" r f toniiiorary method, wliieii 

ouglil to be replaced bv medical measure.s 

The adniiiiistration of large closes of alicali would seem 
to he the most rational method of treatiiient, for mv 
experience has been that with gastric nicer tlie acid is iii 
the upiier limits of normal, and is considorahly rai.sed with 
pyloric and dnodeiial ulcers. 1 have also frccinently shown 
th.it the occnrrence of gastro-iejniial ulceration is almost 
c tirely dependent upon the presence of a high aeiditv, 
.yd hence IS pracHcally only found with pyloric and 
duodenal iilcers and in tlie male sex. The cpmslioii, hoii- 
eici, is iihc-thei; under iiioderii conditions of civilized life 
.the aclmiimtration of large doses of alkali can produce so 
permanent a cure tliat a patient is able to ret irn to Iiis 
work and to live on a nornial diet. Up to the present time 
jibysicians and siirgeoy have both produced a karge amon, t 
of evidence to show that certain ulcers can be So treatecl 
yth satisfaction yere.as others will require operative 
intervention, and the differences of opinion which Inve 
arisen have centred rather round the question of what .X 
the definition of a gastric ulcer. 

- The choice of treatment has been most ably discussed 
in a recent paper of Dr. Izod Bennett in the 'journal of 
Eebiaiary 4tli (p. 168), a paper which should be read bv 
everybody interested in the subject of gastro-duodeiial 
ulceration ; but in this paiicW the variation in definition 
is made evident, for Dr. Bennett mentions two groups 
which ought to be treated surgically, and four others 
which probably ivill require surgical treatment. He goes 
on to say, however, that the remainder probably form 
80 ]ier cent, of the total, whereas to most surgeons there 
is little or no remainder, and therefore wo are inclined 
to say that all cases of chronic gastric ulcer should be 
treated surgically. The 80 per cent.- of Dr. Bennett either 
y not come to us because they are relieved by inedic.a] 
-iiattnent, or, if seen by us, are diagnosed. rather as acute 


iilci'r.s or erosions. Rrofc.ssor MacLean, on the other hand, 
claim.s that those ulcers whicli wc slionhl all groii]) ns 
chronic are cured by alkaline frcntniciit, and it is im- 
portant to consider value of theso claims. As Rrofe.s.sor 
MacLean admits in the coiresjiondenco following his 
first article, the alkaline method is not new: in fact, his 
Ircatmont is almost identical with that taught 1110 hv the 
Into Dr. E. J. Smith when I was his student in 1903. 
Hence there has been plenty of time for it to liavo been 
ndcquntoly tried, and up to the prc.scnt no large scries 
of figures lias avor hcoii jiuhlishcd showing a high per- 
centage of .satisfnctoiy results. 

Professor MacLean states that his rc.sults' arc based on 
five yeai-s’ cxjierienee of this method, and it is po&sible that 
he has obtained lasting cures thereby, but he jiroduees no 
eoiivineing evidence iliat sncli is the' ease. In liis present 
paper he quotes at length four cases, every one of wliieli 
lias oiily been .treated for four months or less, and in bis 
previous paper in January only one bad come under treat- 
ment for a 7 )ciiod of longer than a year. Now if there is 
one point in the symptoms of ehronie nicer wliicli has been 
aiipreeiiiled by .surgeons, it is that there is a definite 
periodicity, and that many patients m.ay remain absolutely 
free from symjitoms wiiboiit any treatment whatever for 
periods lip to six iiioiitlis or a year. Heme it is wholly 
iiicorreet to state that bceauso these iialients have remained 
well siiiec the alkaline tre'ntment was instituted they 
were permanently cnii^L Moreover, the continnation of 
.such medical trc.atnicnt is associated with very considerable 
clanger. Since Pi'ofcssor MncLoan’.s paper was publi.slied 
there liave come under my care four cases in wliicli the 
so-called “ MacLean treatment ” has been carried out in 
the larger London hospitals without any ixdief, and when 
I operated upon them they were found to have iiiopcrahio 
earciiioma. It is only hogging the (pirstion to -say that 
ehronie ulcers do not become caicinoinntons, an opinion 
with which ninny — iiieliiding my.sc'If — do not agree. Tiie 
fact remains that many conditions iliagiwAcil ns nicer 
heeomc or arc careiiionmtoiis. 

Tliat the clangor of perforation and haemoiTliagn is not 
ovcrconic by alkaline treatment has long been realized, .and 
mv experience has been in exact accord wifli that of Sir 
Berkeley Moynihan — namoly, that the m.ajoriiy of cases 
upon wliicli 1 operate have iiiidergone many courses of .sneh’ 
medical troatniciit, only to have a recurrence, often willi 
clan"erons syiniitoms. As against tliis, one has to consider 
what arc the rcsiilt.s which are to he obtained by surgical 
treatment. In an article now in the press, which 1 have 
written for the Nelson Surgery, 1 have investigated all my 
eases of nicer that have been operated upon iqi to date; 
these lUiinher some 1,200, and the lesnlts show that hetween 
80 and 90 per cent, of them are cured, hnt the invc.stigation 
of a series of cases varying from one to fifteen years is very 
difficult to c.stimate with accuracy. From this jioint of 
view the statistical iiiquiiy concerning cases operated upon 
fioin 1920 to 1924 wliicli is being carried out by the Briti.sli 
Medical Association will be of vers 'great value, and it is 
to be liopcd that it will institute a similar invostigatioii 
of tlic viilne of medical treatment. The analysis of my own 
cases for tins report has been iniicli more laborious tlian 
I had anticipated, and lienee 1 have only coiiiplotcd iqi to 
date the groiqi of pyloric ulcers, hut these show that 86.5 
)ior cent, of the total arc ciiied, or, oliniiiiating three cases 
that have been lost sight of, 90.6 ])or cent, are cured. 

Unfortiinately some disrepute has fallen upon the surgical 
methods hv leasoii of some enrions figures which have been 
published," as in Mr. Paiiiiett’.s ])a]icr in your last issue 
(p. 623). 'There is no doubt that the immediate mortality 
and the incidence of complications are inversely ])ro])or- 
tioiial to the technical skill of the operator, and therefore 
it is not fair lo accept Mr. Paiinett’s statement that the ■ 
mortality for gastro-cnterostoniy is from 4 to 5 per cent. 

In my earlier eases the mortality was between 2 and 3 per 
cent, for simple gastro-enterostoiiiy, hnt in my last sera s 
of 150 cases there has been 110 death. In the same way 
errors of technique, such as the -use of Murphy’s button or 
of silk sutures, gicatly increase the incidence of gastro- 
jejunal ulcer. I have frequently shown that, taking all 
ulcers, the incidence of this complication is 1.8 per cent., 
while for duodenal ilk-el's it is about 3 per cent. 


AphiIj ai, igaS] 


CORRESPONDENCE. 


[ Tur.r.nm'in 
MCDtCAI. JOCJSNXI. 


689 


It is nlso curious to iioto Uiut. Mr. I’oniiott Rtalos that 
‘‘tlio liability to liaoiuorrhngo from a gastric, but particu- 
larly a iluodcnal, ukcr is about as great after an operation 
ns before.” This slatemeut is ilillicult to accept. I havo 
shoa-n that in my own series baemorrhago occurs with 
duodenal ulcer in about 25 per cent, of the cases. I havo 
never known a duodenal ulcer por.sisl after a well-performed 
gastro-enterostomy, and every caso of haoniorrhago that has 
occurred alter an operation has been duo to a gastro- 
jejnnal ulcer— Hint is, it occurs in 2 per cent., or less, 
of tho total. "With the growing demand for operativo 
treatment and the increase in tho number "of smaller 
hospitals theso operations havo unavoidably to bo carried 
out by those whose oi>;)ortunitles for performing them 
occur but seldom, and since with us all oxporicnco does 
much to decrease both tho mortality and tho frequency 
of after-complications, tho results so obtained must of 
necessity be relatively poor; hut it is unjust to blamo the 
oporativo measures for such complications. Tho results of 
carefully performed operations are based upon largo .series 
of figures, and at present no evidence has been produced 
that they can be equalled by medical treatment. — I am, etc., 

London, tV,l, April 16th. J * IVaLTOJ*. 


THE HEALING OP PERFORATED ET,CERS. 

Sm, — Air. Paunett, in his interesting addicrs, states 
that probably about SO per cent, of perforated gastro- 
duodenal ulcers are cured by simple suture. I am inclined 
to think that tho percentage is considerably more. For 
many years I did not do primary gastro-enterostomy in 
these eases, hut told tho patients to return in about six 
weeks for tho aimstomosis to bo made. In nearly all there 
were still signs of uloeration or thickening. 

At last a man was not readmitted until threo months 
after the perforation. I opened tho abdomen intending 
to do a posterior gaslro-jcjnuostomy, but could find nothing 
to warrant it. Tlioro was no traco of ulcer, thickening, 
or pyloric stenosis. Tho only sign of tho previous condition 
was tho patch of gastro-hepatic omentum which had been 
fixed over the lino of suture. Tho abdomen was closed and 
tlio patient was discharged in throe weeks, looking and 
feeling qiiito well. Ho was told to como back if ho had 
■iiO' f'l’oublo, but has not done so. 

binco then I havo done very few second operations in 
theso eases. — I am, etc., 

Lancaster, April 16lb. A. S. BahLINO. 


THE EXPECTANT MOTHER. 

Sir,-— In view of Dr. Barford’s plea in tho Journal ol 
^ (P- for further efforts on the part of local 

authontics, I think the experience of tho Bristol Royal 
Infirmary may prove of interest. 

ante-natal clinic was established in connexion 
with tho maternity department of this institution and 
became an immediate success. I need not ciilargo Upon 
tlio great benefits it 1ms conferred on tho patients, or the 
importanco of tho teaching facilities to tho medical student: 
(nttendanco is compulsory) and pupil midwive.s. There is 
in addition, an infant welfare centro and post-natal 
chine conducted by specialists. During last year 1,40C 
new patients wore seen and practicMly all of them 
attended regularly; 1,200 were treated during their con- 
finemeiit by the Royal Infirmary_700 in the wards and 
500 in the district, Tho remaining 200 were accounted foi 
I'on labours, removal from Bristol, and aboul 

120 » consult-ation cases ” from private doctors anc 
municipal clinics. 

As tbo total birth rate registered by tlio city authoritie: 
is below 7,000 It will bo seen that the Royal Infirmarj 
dc.-il3 witli about one-fifth of tho expectant mothers ol 
Bristol at this clime. Dr. Lily Baker has been appointed 
spocia assistant physician in charge of tho ante-natal work. 

approached tho local authorities in hopes of gettine 
some help in tins important work, but was met with e 
-./■ years. I then applied direct to the 

1 mis ry M HcaRli, who were most courteous and helpful, 
a d sent Damo Janet Campbell to look into the situation; 
blio expressed the opinion that wo ought to get “ a good 


annual grant and a capital sum to start off with.” Letters 
to that effect nro in tlio possession of tho secrotai'y to the 
Royol Infirmary. 

After much delay I again approached tho local authorities 
and was 'asked to explain tlio situation to a meeting of 
tho hcaltti committco. At tho end of a long discussion 
it was proposed that tlio health authorities should, pay 
£200 per annum and close ono of their own clinics, which 
cost that amount annually, sending theso cases to tho 
Royal Infirmary. This very fochlo offer was accepted as 
being belter than nothing. The infirmary clinic is held 
threo days a week, and if tho municipal rate of salary of 
£1 Is. per clinic was paid to Dr. Baker it would loavo 
about £40 a year towards the Royal Infirmary in its ante- 
natal work. Dr. Baker generously offered to hand over 
tho salary to tho treasurer of tho Royal Infirmary. 

To iny surprise, when tho agreement came to bo signed 
it was made a condition that tho town council should 
havo a member placed on tho Royal Infirmary committee, 
and that tho municipal patients should not bo seen by 
students. Tho infirmary committco did not seo their way 
to accept these conditions, and tho offer lapsed. I under- 
stand from Professor Raynor that exactly tho same thing 
happened at the Bristol General Hospital, where some 
800 cases are dealt with annually. 

AVhilo I know that tho municipal clinics aro most 
efficiently and carefully run, and are doing excellent work, 
I feel sure that everyone will agree that ante-natal clinics 
at teaching hospitals, where it is possible to send tho 
patients to cardiac, dental, and other clinics, are at any 
rate equally efficient, and equally deserving of help and 
support. I then applied once more to tho- Ministry of 
Health, pointing out that tho Royal Infii-mary and General 
Hospital together saw one-third of tho expectant mothers 
of Bristol, many of tho cases being “ consultations.”- 
I received a most sympathetic letter, which showed that 
tho local health authorities were the causo of our receiving 
no help in spito of tho strong recommendations of tho 
Ministry in London. 

In view of my experience I feel that Dr. Barford is 
unlikely to soo his excellent suggestion carried out when 
local authorities can disregard the advice of tho Ministry 
of Health, unless ho is so fortunate as to have an 
enlightened health committee to deal with, as in the caso 
of Cardiff, where, 1 am told by Professor Maclean, about 
£2,000 a year is received by the Cardiff Royal Infirmary 
to enable them to do their best for the maternity work 
among tho poor of tho city, — I am, etc., 

R. S. S. ST.vrHASt, 3I.D., Ch.M., 

April 4lli. Honorary Gynaecologist, Bristol Royal Infirmary. 


TREATMENT OF ACHTE PNEUMONIA. 

Sm, — As ono who has also read with pleasure the letters 
of Dr. Maidlow and Dr. Thompson, I wish to record my 
belief that tho sentiments which tho writers express aro 
shared by tlio majority of medical practitioners, and in this 
district at any rate the practice is on tbo lines which Dr. 
Thompson advocates. 

It is in pneumonia more than in any other disease that 
tho physician is called into consultation, and so gets many 
opportunities of seeing what form of treatment is being 
carried out. 

I find very little use being made of oxygen, or powerful or 
nauseous drugs or vaccines or serums. In nine cases out of 
ten tho doctor avoids disturbing tho patient for purposes 
of examination, having once made his diagnosis. As for the 
discomfort of the bed-pan, it is now quite cordmon to find 
that no special anxiety is felt about the bowels acting at aU 
during tho height of tho fever. 

, Yet satisfactoiy as it is to stand by whilst Nature per- 
forms her cure, I think wo aro all alive to the possibility 
that ono of theso days some remedy will bo forthcoming 
which will reduce the present mortality of pneumonia, and 
I fail -to seo how any remedy or preventive can be proved 
unless someone is prepared to try it, A spirit of enterprise 
tempered with caution and an honest endeavour to do hq 
harm should not bo discouraged. — am, etc., 

Birmingbam, April 14Ux, LboXARD G. J. MaCKBTii 



690 APEiii 21, 1928] 


CORBESPONDENCK 


r TnElJnmsa 
L MEDtClt JOUBTTAL 


GLAND GRAIi’TTNG AND INHERITANCE. 

Sill, — If Dr. Norman Hairo will carofully rciicnise my 
letter ill tlio Journal of March 31st (p. 570), lie will, I 
think, realize the non-jiistification of his stateiiient in the 
following issue (p. 610) that I had “ written tinder a 
eomplete misapprohonsioii of the nature of the various 
lesticle-graftiiig oiieration.s.” T’he main purport of nij' 
letter was to suggest that, oven if either of the two supposi- 
tions of Dr. Voroiioff and his followers — that the “ new 
testicular material replaces or reinforces the physiological 
action of the animal’s own testis ” — he true, the fact docs 
not constitute evidence of the transmission of acquired 
eharacll'is. Incidcntall}’, I pointed out that if the moJiis 
operantli ho the first of the two h 3 -]iotheses advanced, the 
fertilizing agents wherewith the rejuvenated hull jneky 
sired nine calves must have had their origin in the im|iorted 
gland tissue. If, as Dr. Hairo sajs, this is not the case, 
then clearlv the alternative hy’pothesis of Dr. Voronoff and 
his school — that the foreign gland replaces the jilij-siological 
action of the animal’s own gland — must he ruled out of 
court, and there remains as exiilanation of the alleged 
inheritance iihenomena a mere tonic effect upon the latter 
of the introduced glandular tissue. — 1 am, etc., 

ClI, MILES M. BE.\nNCLL, 

.Vberystwytli, April Bth. Surgeon Rcnr-Adniiral, U.TC. 


ACHALASIA OF THE CARDIA (SO-CALLED 
CARDIOSPASM). 

Sin, — I have no hope of persuading Dr. Brown Kcllj' of 
the error of his views, but his last letter (April 7lh, 
p. 610) so seriously misstates the evidence in favour of 
achalasia and against cardiospasm that it calls for a rcjil.v. 

It is not clear what ho can mean by cardiospasm, as ho 
denies the existence of a cardiac sphincter. But whereas 
the greater part of the oesophagus always has a potential 
lumen, the lowest inch, whicii coustitutos its intra- 
ahdominal portion, is closed and forms a physiological 
sphincter, as can he easily seen with the x raj's, and as 
Dr. Brown Kelly apparently realizes when he speaks of a 
“ cardiac canal.” That this represents an anatomical 
.sphincter has been demonstrated by Poulton, myself, and 
others. 

The inflammation and subsequent degeneration of 
-luerbach’s plexus found by Stokes and Rake, and more 
recently by Cameron, must result in failure of the sphincter 
to react to stimuli. The sphincter cannot, therefore, iicr- 
form its normal function of relaxation nor its rarely exer- 
cised power of contraction ; it conscquentlj' remains closed — 
that is, in its noi’mal position of rest. This, with secondary 
dilatation of the oesophagus, is what occurs in animals 
when the vagi are divided. The changes found bv Cameron 
in Dr. Brown Kellj-’s fatal cases are obviouslj' incomjiatiblc 
with his theory of spasm. 

In the vast majority" of cases reported both in England 
and abroad no hypertrophy of the sphincter was present. 
In a seveic case of mine in which the patient was cured 
by longitudinal incision of the sphincter, Mr. R. P. 
Rowlands, who operated, was astonished at the extra- 
ordinary tenuity of the muscle, and he demonstrated to all 
who were present the absence of any spasm in the closed 
sphincter,' which was over an inch in length and extended 
from the opening in the diaphragm to the stomach. I 
expect that the exceptional cases in which hypertrophv is 
found represent those mentioned in my last letter (March 
24th, p. 521), in which secondary teniporaiy spasm occurs 
as a result of the accompanying oesophagitis in the earlier 
stages,' before the degeneration of Auerbach’s plexus is 
complete. 

lYheii spasm is present considerable resistance is felt to 
the passage of the mercury tube, which is tightly gripped 
when it evontuall.v enters the stomach, exactly corrcsiiond- 
ing with what occurs in anal spasm — a most appropriate 
comparison. This is in striking contrast with the complete 
absence of resi.staiice and gripping noted by all cibservers 
in uncomplicated cases, and in the rare cases with tem- 
poraiy spasm when the latter is overcome as a result of 
treating the oesojihagitis. 

Dr, Brown Kellj- apparentlj' legards the forced passage 
of a rigid ocsopliagoscope in the recumbent position under 


an anae.slhetic as a more natural method of examination 
than allowing a flexible mercuiy tube to be dropped by the 
patient himself through his sphincter. As a matter of fact, 
tlio mercuiy tube closelj' ajqn-oxiniatos to what happens 
under natural cenditions, because the closed sphincter givc.s 
waj" when the column of food in the oesophagus exceeds 
a height of about eight inches, closing again as soon a.s 
the eight-inch level i.s reached. It is in this way that 
nutrition is maintained. The weight of the mercury tube 
i.s about the same as that of the column of food in the 
dilated oesophagus. On the other hand, it is difficult to 
pass a rigid instrument past the angle formed by the 
p])liinctor with the rest of the oesophagus, particularly 
when the latter is so dilated that its lower extremitj- is 
actiialh" below the entrance to the sphincter. It was for 
this reason I introduced the mercuiy tube to replace rigid 
hoiigic-s, which could onlj- bo passed with groat difficulty. 
I have no doubt that Dr. Brown Kelly has mistaken the 
spasm of the diaphragm caused by the pressure of his 
in.strumcnt for spasm of the cardiac sphincter, which is 
actually within the abdomen and not within the thorax. 
Mau\- of the earlier ocsophagoscopists recognized that the 
spasm was diaphragmatie, and actualh’ regarded this as the 
cause of the condition. — I am, etc., 

Anrunit F. Hrnsi. 

Xciv I.o<l"e Clinic, Wimlfcor Forest, 

April 9tli. 


THROMBO-PHLEBITIS MIGRANS. 

Sill, — I read with gicat interest in your issue of April 
7th (p. 586) the account given by Professor Moorhead and 
Dr. Abrahainson of a condition which thoj’ call “ throinbo- 
))hicbitis migrans.” The authors say they can throw no 
li"ht on the etiology, though they state that the method 
of spread suggests forcibly the presence of a blood infection. 

I might mention that in an essay on “ influenza in 
"encral practice,’* written in 1925, I drew attention to 
the comirionh’ observed occurrence of venous thrombosis in 
practice ever since “ influenza ” returned in 1918. In 
the same place ,I described the jnilmonary and mesenteric 
lilienomonn now mentioned • by Drs. Aloorhond and 
Abrahainson, and showed that the former were often 
wrongly diagnosed as pneumonia ” and “ pleurisj-,” and 
the latter were often confused with appendicitis and 
intestinal obstruction. I attributed the pulmonary 
symptoms to infarction and the abdominal to mesenteric 
embolism. . Further, I noted that cerebral, coronary, and 
renal (nephritis and haemnturia) embolism were often 
associated with influenzal attaeks, or occurred during in- 
Huenzal seasons. It is true that thrombosis in pori])heral 
veins was not seen in all my eases, but I assumed that 
there must have been thrombosis .somcielierc in those cases. 
The process niust be the same, and it is only a matter of 
accident where the thrombosis occurs. In so.me of mj’ 
cases of pulmonary infarction (or thrombosis) jaundice and 
intense anaemia were observed; both these phenomena 
strongly suggested the presence of a haemolytic strepto- 
coccus. . . • c 

As jaundice and anaemia were often seen m cases ot 
influenza with no sign of thrombosis, it was natural to 
suiiposo that the thrombotic cases were related to influenza. 
In fact an initial diagnosis of influenza was made in most 
of the thrombotic cases. A chronological study over ten 
vears of these thrombotic and embolic cases settled the 
matter beyond doubt. The fact that they almost in- 
variably occurred when the influenza curves rose, and were 
rarely seen when influenza became scarce, seemed conclusive 
evidence of the importance of influenza in the production 
of venous thrombosis and embolism. In the ten j'ears 
1918-27 there have only been three (1920, 1921, and 1925) 
without an eiiidemic ; it is not to be wondered, therefore, 
that venous thrombosis is fairlj’ common. Yet I believe 
the Evm]itoins produced by it are often not aiiprcciated 
by those unacquainted with o])ideiniological happenings. 

" It is of interest to note that Dr. IVliittingdale of 
Sherborne, Dorset, reported seeing in general practice in 
the twelve months prior to March, 1926, a large numbei 
of cases of jihlebitis of the lower limbs with a “ large 
I>roportion of indmonarj- infarcts,” and, in one case, 



Arniij =1, iQiSj 


CORRESPONDENCE. 


“iiuiltiplo ccioUnil emboli.”' Dr. Whiltingdnlc, liko myself, 
looked upon tho pulmonnry and cerobeal complications as 
being duo to embolism. Drs. Moorhead and Abraliamson 
aro at paitis to slion- th.it embolism nm.s not present in 
their cases. Most, of the pulmonary cases I liavo seen liavo 
co«o on rapiiUi/ with aculo chest pain, pleural rub, and 
tlio spitting of clmractoristic blood-sputa, and woro cer- 
tainly iuslanccs of pulmoiiary embolism. Many of them, 
further, bavo occurred in closo chronological proximity to 
cases of pulmonn\-y embolism after operation, confinement, 
etc. 

I have seen a very largo number of tbo.so pulmonary 
mesenteric, cerebral, and renal thromboses (or embolisms) 
in tbo last ten years, so many, indeed, that I wroto in 
1926 an o.ssay with tho litlo " Tlio infective factor in 
embolism”; this has not been published, but most of tho 
points now I'aiscd by Drs. Moorhead and .tbiahamson 
appear in it. I would suggest that thr.imlio-phlebitis 
inigrans ns described by tho latter is not uneonneeted with 
tho influenza which every panel doctor knows only too 
well to bo constantly with us. — I am, etc., 

Aunnosn \V. Owen, M.D,, R.S.Eond. 

Abcrdarc, April Ttb. 


THE C.VHSES OP ALCOHOLIC INEDltl KTY. 

Sin, — ^Tbp intorc.sting discussion on this suli|ovt which 
was reported in your issue of April 7th (p. 694) loads us 
to give «uno details of tho experience obtained here. 
Obviously tho essential causo of inebriety is the actual 
drinking of alcoholic beverages. Never to have taken 
alcohol in any shape means never to, have come tiiider tho 
primary cause. No total abstainer ever bocinm's alcoholic. 
Then follow a largo number of causes: hei.sUty, habit, 
stress and strain, a psychomotor stimulus to obtain a 
ouphovic affcctivo tone, tho as-suaging of conflut, and tho 
attainment of freedom of expression for ropresMil forces. 

From a survey of tho many hundreds of iiatimits who 
liavo passed through tho two institutions of tb«’ Norwood 
Sanatorium — Beckenham and Rondlcsham — it i- i lear that 
heredity is a decided cause, not a mcro coujoi tnre. It is 
this heredity influence, “ tho inborn soil ready for the 
seed,” which has given riso to tho rather ex.iggcrated 
belief that ” tho alcoholic is, beforo he even touches a 
drop, an abnormal person.” Persons with an alcoholic 
parcnt.ago should remain total abstainers, if they would 
remain freo from danger. But it is another heredity 
factor that also appears again and again — namely, that 
which is popularly called the “ nervous ” or ” unstable ” 
typo of individual. Hero again total abstinenco is the 
dictate of “ safety first.” 

Habit undoubtedly, together with easo of access, plays 
a large part in many a downfall. But thcro have been 
quite an appreciable number in whom heredity and habit 
seemed to be absent as causal factors. The.so havo been 
those who have had recourse to alcohol “ as a drug to 
ovorcomo stress and strain, or to drown distress and 
pain ” — in short, for its narcotic action. It i.s hero also 
that tho psychomotor stimulus to obtain a euphoric affec- 
tive tone is so powerful, and, once started, the desire for 
more may bccorao overpowering. A man — a weak man, 
and often a lazy one — takes alcohol because it docs seem 
really to assuago conflict, and to allow him to perform 
those lepicssed actions with ” a clear conscience.” 

In tiio methods of treatment adopted the fiist aim should 
ho to rid the inebriato of all klcohol ; tho second to bring 
him back, as far as possible, into a boaltby state of mind 
and body, and then to re-educato bis will to a liiglior 
piano of living. It is here that treatment away from 
friends and business lias in so many cases proved per- 
manently successful. 

Investigation is still being .carried out as to any histo- 
Icgical -and cliemical clianges in tho blood of the inebriato, 
and it IS possible that results may indicate further causal 
factors and improved lines of treatment.— We are, etc., 

A. W. Gfobge. 

Bcckfnliam Ptirl<, .Vpr il ISth. GeoRGE F. VixceNT. 

^ Lancet, 1926, vol. p. 575. 


f TiiP.nnmsn 

MrDICAI. JOCUNII. 


691 


THE ELECTION TO THE COUNCIL OP THE ROYAL 
COLLEGE OF SUBGEONS. 

Sin, — Every year, almost contcniporaiiconsly with tho 
advent of tho cuckoo, 1 am assailed by letters solicit- 
ing my veto for ono or other of tho candidates for election 
to tho Council. 

These may bo divided into four categories: (1) From a 
Fellow timt I know well about a Fellow that I know well; 
(2)' from a Fellow that I know slightly about a Follow that 
I know well; (3) from a Fellow that I know well about a 
Fellow that I know slightly; (4) from a Fellow that I know 
slightly or not at all about a Fellow that I know slightly 
or not at all. 

Most of them aro typewritten, but many have appended 
to them, by way of sigiiatnro, a hieroglyphic which can 
only bo decoded 113' reference to the printed address and 
tlio Medical Dirccionj. This is perhaps not surprising if, 
as would sometimes appear to ho the case, tho writer is 
circularizing all tho Fellows of tho College. 

Apart' from occasional references to tho advantages which 
would, in the writer’s opinion, accrue from tho piesonco 
of a provincial surgeon or of a specialist on tho Council, 
tho tenor of those letters is peculiarly consistent. It is 
to tho effect that tho Follow in question is an excellent 
surgeon, is an admirablo teacher, is consumed by a jiassion 
to spend his days in sitting on committees, and would be 
an ornament to any society of wliicb be might be elected a 
member. I am prepared to believe that in every case these 
statements aro wholly true, but I doubt if they have ever 
affected tho result of an election in an3' appreciable degree. 
It is obvious, for instance, that letters in the first two 
categories are supererogatory, and it is unlikely that a 
letter in tho last would indiieo a conscientious voter to 
reconsider a course of action upon which ho had already 
decided. I believe, therefore, that this output of propa- 
ganda is to all intents and purposes valueless, and I am 
convinced that it would bo more dignified to conduct tho 
olection without it. 

I would liko to add that it is not many years since the 
electorate of Chicago was approached by similar methods. 
But when it was discovered that canvassing by post had 
little or no effect its place was taken by the 'browing 
of bombs into tlie houses of tho opposing candidate or 
candidates. Ainoricaii methods havo before now been known 
to pernioatc this effete Continent, and if this ono succeed.s 
in doing so I shudder to think what life may bo like 
in Harley Street in a few years from now. — ^I am, etc., 

London, April 13tli, IvOR B.ICK. 


TREATMENT OP PROSTATIC ENLARGEMENT. 

Sm, — In reply to a letter of Dr. J. Curtis IVebb in the 
British Medical Journal of December 3rd, 1927 (p. 1053), 
referring to the treatment of enlarged prostate by a: rays, 
I would like to say that I have had a similar satisfactoiy 
oxporionco. If ho will , refer to the Australian Medical 
Journal of Slay, 1911 (pp. 214-18), and of December, 1912 
(pp. 817-18), ho will find reports by mo on a series of 
cases so treated. 

For two years or more, up to the time L left Ballarat, 
no prostatectomies wore performed at the Ballarat General 
Hospital, all cases of enlarged prostate being referred to 
tho i-ray department for treatment, so successful wei'o tho 
results of a:-ray ti-catment. 

Sirico starting in Melbourne after the war I have had 
several cases, and all havo been relieved. Tho last case 
astonished me. Tho patient was over 70 years of ago, with 
large calculi in tho lower end of both ureters. He declined 
operation, but was so much relieved b3’- the treatment that 
ho was able to discard bis catheter, that bad bccomo abso- 
lutely necessaiy to him, and left for tbo country', where lie 
lived. His health was greatly improved. Since then I have 
not heard of him. 

Why this method of treatment is not more universally 
employed I cannot understand, as relatively small doses 
only arc necessary to achieve tho desired result. (I give 
about one-fifth or a quarter of a unit skin dose or less, 
twico a week, at 100 kilovolts through a 4 mm. 


692 ' April 21, 1928] 


CORRESPONDENCE. 


[ Tnr BntTi»n 
M RDTCAL J OCRTlt 


aluminium filter, tlio patient sitting on a .special cliair 
rvith a tube under it.) As a rule relief begins on tlio 
tenth day after the first raying. If no imi>rovement is 
manifest in a fortnight operation can be performed avitliout 
the treatment in any way com])licating it. I found that 
jiatients over 60 years of age give the quickest results, Imt 
with more ponetratiug radiations I should think tho treat- 
ment would be equally effective in younger jiaticiits. 

It is interesting to note that my early succe.sses were . 
achieved with a 12-in. coil, one milliampero of current, 
and a 6-in. spark gap through a filter of one only millimetre 
thickness of aluminium or glass. — I am, etc., 

Melbourne, Feb. 14tb. ClIAS. E. DenXIS, O.B.E., j\I.D. 


DEL.A.YED NOTIFICATION OF TUBERCULOSIS. 

SiK, — Much has recently been spoken and written I'ogard- 
ing the late notification of cases of tiibcrcido.sis, and 
statistics have been published indicating that in the county 
of London an average of 47 per cent, of cases of tuber- 
culo.sis die either unnotified or within three months of 
notification. 

I have attempted to throw light on tho subject by 
looking into the figures for tbc borough of Lewishani,, 
aud have to report as follows : 

During 1927 there were 175 deaths from pnbnon-.wy tuber' 
culousis and 20 from other forms of tuberculosis in the borough- 
— a total of 195. Of this number 37 cases of pnlmonary tuber-, 
cnlosis and 20 cases of non-pulraonary tuberculosis \tcrc either 
uiinotificd or notified within three months of death — a total 
of 29 per cent. ; that is to say, nearly a third of tho deaths 
wore notified late or not at all. Going into detail, I find that 
of the 20 non-pulmonary cases 14 died from tuberculous 
meningitis, 2 from acute peritonitis, and 4 from tuberculosis 
of other regions, none of the 20 having boon ill for throe months 
prior to death. Of the 37 pulmonary cases 31 were notified 
within three months of death, while 6 died unnutified. Of the 
31 dying within three months of notification 12 died from 
acute phthisis (3 of them suddenly), 7 bad never previously 
attended a doctor, 3 were 'strangers, having only recently 
removed to the borough, and 4 wore wrongly diagnosed — 1 as 
bronchitis and emphysema, 1 .as bronchitis and .asthma, 1 as 
pleural effusion (sudden death), and 1 as a wasting child (died 
from miliary liiherculosis). Five had been ill and had attended 
a doctor — 2 for si.x months. 1 for a year. 1 for two years, and 
1 for forty-five years. Of the 6 uiinotificd cases 1 Ii.ad been 
notified three years previously, bad left the borough, and then 
returned without the knowledge of the authority, 1 died from 
a sudden haemorrhage, 1 was diagnosed at the necropsy, 1 w.as 
not previously diagnosed, and 2 had been under doctors for 
three months and many years respectively. 

Thus of tho 57 cases, only 7 could reasonably have been 
notified at an earlier dale, bringing down the figures 
from 29 per cent, to 3.5 per cent. It woiihl be interc.stiiig 
to know whether these figures tally with those of other 
districts. — I am, etc.. 

Rose Jonn.vx, M.D., D.P.H., 

Catford, S.E., April 3rd. Tuborcalosib Ofllcer for LcwiUinlli, 


THE “ CURE ” OF PULMONAR.Y TUBERCULOSIS. 

Sin,— There appear to be three distinct lines of action 
ill Dr. W. M. Crofton’s method of treating pulmonary 
tubereiilosis : (1) tuberculin therapy, (2) vaccine treatmont 
of so-called secondary infection, and (3) the use of iodino. 

. It is only in respect of Dr. Crofton’s use of tuberculin 
that the following remarks are offered. H.T.S. (human 
type tubercle bacillus solution) is stated to contain 1 mg. 
of dissolved tubercle bacilli in each cubic centimetre. The 
bacilli are dissolved iii.benzoyl chloride. “ The largest dose 
of this solution required is .01 mg.” (I quote from Dr. 
Crofton’s book). If this figure refers .to. the weight, of 
dissolved tubercle bacilli it indicates that Dr. Croftoii 
works with quantities of bacillai-y substance under a 
maximum of 0.01 mg.; if tlje figure refers to the solution 
itself it indic.ates a very much smaller quantity. In either 
case there is here a crucial departure from Koch’s method, 
in which the greatest iin]iortance is . attached to high 
do.sage, and in which ' the maximum both with T.R. and 
.R.E. is 20 nig. solid . bacillary substance — a dose two 
thousand times greater ;than the maximum dose of fl.Ol mg. 
mentioned aboWe; Koch -himself states that ’f at the 


beginning of immunization such small doses are given 
(0.002 mg. T.R.: 0.0025 mg. B.E.) that no immunity worth 
-speaking of is to bo expected, and th.at first when one 
arrives at larger doses of 1/2 to 1 mg. iininistakahlo 
evidences of immiinization present themselves.” Again, 
"in the immunization of tho .soiiiul and tho treatiiient of 
the sick it all conics to the use of as largo doses as ]) 0 .ssihli'.” 
And ill Ills last pJtiiiouncciiient, made in 1909 in the jirefaeo 
to tho third edition of Bandolier and Roopko’s textbook, 
he expressly declared “ that it is liosido the piirpo.se to 
stand still with tho. mininiuiii doses which .are often 
employed, 0110 must not forget that it is a matter of 
active iinimiiiization, and that it can only ho advantageous 
for the sick if not too small a degree of imiiiiiiiity is 
reached.” 

Another important point is Dr. Croftoii’s de])artiiro from 
Koch’s classical method of eoiiiiniiiiitioii of tlio bacilli in 
favour of the n))plieation of heiizoyl eliloride as a solvent. 
'This intcrc.sting method, which was first devcloiied some 
tw'enty yours ago by Dcycko in his search for a solvent or 
activator of nastiii, the leprosy tiiborciilin. may or may not 
he an iniprovcineiit on Koeh ; it would ho intore.stiiig to 
have tho results of comparative exporimoiits. But the only 
evidence on this point which Dr. Crofton olFers is tlmt 
" the .clinical results with tuhcrcle bacilli, dissolved in 
: lieiizoyl chloride have been so satisfactory.” 

- Considering the closage employed, the complexity of the 
treatiiient; and' the eoinplcxity of the problem, • one feels’ 
that some further body of evideneo will -require to he pro- 
duced in favour of these two important departures from 
Koch’s elassieiil mctlimls to entitle them to preferontinl 
consideration. — 1 am, etc., 

•'WumiMMiitii, .S.W., Arm 7 tii. RonEiiT C.inswELr,. 


• Sin,— ^Tlie letters of D'rs. Croftoir a'lid' AYeatlierlioad are' 
interesting as showing that ilio subject of tiiherciilin is 
still alive and that work is being done. Neither writer 
distinguishes between tho two great classes of pulmonary 
tnhcrciilosis victims; it is on tliis vital point that many 
investigators stiimblc. Tho first class includes eases in 
which the disease is acquired in infancy or early childhood, 
and the .second those in whicli it is acquired after piiljerty. 
Patients who have survived after an early infection wliieli 
inav have . shown itself as a hroneliitis, pnoimionia, 
marasmus, or retarded growth are benefited by iiijoetioiis 
of bovine tiiherciilin (P.T.O.), and after piihorty by Koch’s 
“ old tnhereiilin.” 

Patients infected after puberty recover, if the disease is 
not too far advanced, when roiiioved from tho source of 
iiifeclion. If cireiimstaiices do not ])ermit removal an 
increased resistance may ho obtained by weekly injections 
of Koeb’s “ old tuberculin.” Observations on this subject 
are of doubtful value when the date and source of the 
infection are not ascertained. I tliink tlic following 
instances are worthy of record. Two families of children 
under ny care remained more or less .stationary while 
roceiviii" weekly injections of tnbcrciiliii, the yiniiigcr 
ones taking P.T.O. and the older ones O.T. At my 
suegestion the mothers submitted themselves for injee- 
tiohs- both wero substantial heavy women in the early 
forties. One two-liiindredtli of a cubic centimetre of Koch’s 
“old tiiherciilin” gave in each mother a profound reaction, 
and sloughing at the site of the injection, which ended in 
improycmeiit in both families. Though I have seen definite 
cures in advanced cases, I have also encoiintorcd disasters ; 
1113 ' best results occur when the source of the infection has 
been more or less definitely ascertained andj if necessary, 
trcated.-^I am, etc., 

: Buxton. Al-m Bill. CrAWBHAW HoI,T. 


THE HAEJIORRHAGIC DIATHESIS. . , 

giu H. L. Tidy, in his interesting and enlightening 

article on the haemorrhagic diathesis (April 7th, p. 583), 
considers it impossiblo to say whether the reduction in 
platelets precedes the increase of hacinorrhagcs or i-ico 
versa, and mentions Poerster’s case in’ which; althongh the 
Iia"enio’'rrhages ceased spontaneousi}-, there was no rise in 
l>latelet's until three days later. May it not ho that all 


Arnir. ii, 1928] HrEDIOO-tEGACi^ ^ 693 


tlio platelets pvoiliicoil l)y tlio iiinn-o\v liocaino ndlicront to 
itofocts in tlio capillary endollielium, niul tliat until these 
defects required no wore platelets, no incrcaso would 
appear in the Wood? So long as tho platelets were being 
massed as fast as they were made, the microscopo would 
not show any apiireciahlo increase, and bceauso haemor- 
rhages had ceased it docs not follow that no further 
massing of platelets was necessary. Then again, in 
Foerstcr’s patient tho marrow might have been taxed to 
tho point of exhaustion just at tho time of cessation of 
haonvorrhage, and three days were necessary for recovery. 
Had Foerstor given his patient an injection of somo solu- 
tion to destroy tho platelets just after tho spontaneous 
cessation of tho bleeding ho might havo found that tho 
haemorrhages recurred. If, however, they did not 
reappear, then ho might concludo that tho platelets did 
not bring about tho cessation of haemorrhages. — I am, etc., 
Yelverton, South Devon, Arril 8tti. H. D.WIS, jM.I3. 


CLINICAL OPrOHTUNITY FOIt JIIDWIFF.IIY. 

Sru, — ^In recent discussions on maternity problems tho 
point of view of two quito important people lias not 
emerged. I refer to tho maternity patient and her 
husband. In this village working men consider it a point 
of honour to provide their wives with .a doctor’s services 
at confinement, hoping thereby to secure for them greater 
alleviation, and perhaps a more spcotly and secure delivery. 
Tho accoucheur whoso bag contains tho chloroform bottle 
will always retain a considerable part of ordinary mid- 
wifery practice. But tho medical student’s clinical expo- 
rienco is lessened becanso midwifery opjiortunities are 
given to C.M.B. candidates who dc.siro the qualification, 
but do not intend to practise. 

If more opportunity for tho medical student is desirable, 
a stricter rationing of clinical material is surely necessary. 
— ^I am, etc., 

Pcrrar'l Common, Oson, .Saril 2n(l. E. L. C.vntlNO. 


^ctiico-ICtgnl. 


ST.<VND.;VBDS OF SOBRIETr : MORE ItlAGISTERIAL 
DICTA. 

A rnnaiiEii case illustrative of the difficulty of obtaining any 
clear legal definition of what constitutes drunkenness was 
heard in tho Marylebone police court on April 16th, when a man 
was diarged with being drunk in charge of a motor car. The 
divisional police surgeon gave details of his examination, and. 
stated that he formed the opinion that the man was drunk ; he 
admitted, however, on cross-ex.aminalion, that if this had been 
an ordinarj- case of a person charged with drunkenness ho would 
have said that he was sober. Tho magistrate, Mr. Bingley, 
thereupon remarked, “ YYcll, that is the end of this case.” 
Tho police surgeon said the man’s incapacity depended on what 
ho was charged with doing, and Mr. Bingley replied, ” You 
are totally wrong. That is not the law.” When tho witness 
stated, * A doctor has no means of determining whether a man 
is drunk unless he is considering the particular thing tho man 
was doing, or failed to do,” tho magistr.ato said, ” If that is 
so you need not bother about all these tests.” Giving his 
decision, ^ Mr. Bingley said that the law used the expression 
drunk, and in a case before the superior court the Lord 
Chief Justice stated that “ drunk meant drunk." All he (tho 
magistrate) had to do was to satisfied that the man charged 
before him was or was not drunk. It might be advisable that 
the law should be altered. All sorts of phras cs could be 
imagined to describe that culpable condition, but the law as it 
stood said " drunk." The doctor had said at the end that ho 
thought the man was too drunk to drive a car; but that was not 
the law. It had nothing to do with tho doctor whether tho 
man was in charge of a car or was lying in the street; the solo 
question was whether ho was drunk. In view of the doctor’s 
evidence he was not satisfied beyond all reasonable doubt that 
the charge had been proved, and the accused would bo dis- 
ciarged. A similar view was recently expressed, also at 
Marylebone (reported in the Journal of March 31st, p. 573), 
by another magistrate, Mr. Hay Halkett, in- a case of the 
same kind. 


HUSBAND’S RESPONSIBILITY FOR WIFE’S 
TREATMENT. 

At Common Low’ a wife cun pledge her busband’s credit for 
necessaries suitable to tbo position ho allows her to assume, 
and his Honour Judge J. W. McCarthy, in the Harrogate 
County Court, has recently held that treatment received by 
a wife in tbo private w.ard of a hospital comes within tbo 
category of a necessary whore tho husband is a man well able 
to afford to p.ay for it. Tho defendant was Jlr. Norman 
Hudson of The Gables, Pannal, a landowner and a member of 
tbo Br.ambam Moor Hunt, and ho refused to pay for his wife’s 
treatment for scarlet fever in a private ward at the Harrogate, 
Knarcsborougb, and Wetberby Joint Isolation Hospital. Mrs. 
Hudson was placed in a private ward at her own request, and 
when the matron showed her a letter in which her husband 
rcpudi.atcd liability shortly after her admission, she observed : 
“ It is just like him. I am his wife, and ho will havo to 
pay. Ho is a well-to-do man.” The defendant was a most 
unsatisfactory witness on tho relevant evidence as to his means, 
but ultimately bo had to admit that he hunted twice a week, 
kept a largo stable, owned a large car, and was co-owner with 
bis brother of a large amount of land in tho neighbourhood 
of Harrogate. From these facts it appeared evident to tho 
judge that treatment during illness in a private ward of a 
public hospital rather than in one of the public wards at the 
expense of tho rates w.as a necessary suitable to tho wife’s 
position in life. His Honour found it difiicult to express in 
measured terms his opinion of tho conduct of a sporting land- 
owner trying to force his ailing wife into a public' ward of a 
hospital rather than pay six guineas a week for accommodation 
and treatment suitable to her station and habits in life. 


(Dbiiitaiu. 

RICHARD LANE JOYNT, O.B.E., M.D., F.R.C.S.L, 
Surgeon to tho Meath Hospital, Dublin. 

"We much regret to announce tho death, on April 4th, from 
pneumonia of Mr. Richard 'Lano Joynt, tho distinguished 
Dublin surgeon. A native of Limerick, he received his 
early medical education at Trinity College, Dublin, 
obtaining tho diploma L.M. in 1889, and graduating M.B., 
B.Ch., B.A.O. in the following year; ho proceeded !M.D. 
in 1892, and obtained tho Fellowship of tho Royal College 
of Surgeons of Ireland in 1894. Election to tho surgical- 
stair of tho Meath Hospital and County Dublin Infirmary 
followed, and at tho time of his death Mr. Lano Joynt 
was senior surgeon to that institution. Ho was a member- 
of tho Council of tho Royal College of Surgeons, and had 
beoii for some years one of its examiners in surgery. 
During the war ho sen-ed in the Royal Army Medical 
Corps with tho rank of lieutenant-colonel, and for his war 
seiwiccs, more especially in connexion with orthopaedics, 
ho received the O.B.E. 

Wo are indebted to Sir Tiiom.vs Myxes, F.R.C.S.I., his 
lifelong friend, for the following appreciation of the man 
and his work. 

By the death of Mr. Richard Lane Joynt tho surgical 
profession has lost one of its most remarkable pci-sonalities. 
To tho general public ho was merely a surgeon of repute, 
discharging quietly and efiiciently his daily work in a largo 
clinical hospital, tho Meath, and amongst his private . 
patients. Within tho surgical profession itself lie was 
much better known, and the respect and admiration felt 
for his remarkable talents were both intense and profound. 
Ho was indeed a remarkable personality. To a thorough 
knowledge of his profession ho added a most intimate 
acquaintance with the technicalities of almost every kind 
of handicraft. Ho was a metallurgist and mechanician of 
a very high order, and possessed extraordinary skill in the 
manipulation of the tools of craftsmen who work in wood 
and metals. This skill and knowledge were ever at the 
disposal of his friends and colleagues, and many of the 
most successful results in tho treatment of grave injuries 
in tho Dublin hospitals were duo to apparatus, often quite • 
original in design, not merely suggested by him, hut . 
actually made with his own hands in his own workshop. 
During tho great war his capacity and aptitude in this 


694 Apkil 21, 1928] 


OBITUAKY. r Titn nitTnii 

j LMriTCALJotnvAt. 


braucli of surgery was brought uuiler the notice of the 
Imperial Govoriiment, and ho was gazetted a lieutenant- 
colonel in tbo Il.A.M.C. and appointed general inspector 
of orthopaedic factories in Great Britain and Ireland. 
Sir Itohert Jones, tho great orthopaedic specialist, who 
was jnincipal medical officer in charge of the maimed 
victims of tho war, soon learned to appreciate the rare 
gifts of his subordinate, and sot him tho taslc of designing 
apparatus, often of the most complicated character, to 
meet the very diverse demands which the tragedies of tbo 
war liad produced. Many maimed victims of tho war 
who have lost more than one limb have had their lives 
made tolerable and their capacity for useful work 
increased a hundredfold by tho apparatus designed, and 
in manj- cases actually made with his own hands, bj’ this 
modest Irish surgeon who has just passed from us. At 
an earlier stage in his life he was one of tho pioneers in 
cc-ray work, and, like too many of these pioneers, paid 
a terrible price for his enthusiasm. Before its dangers 
wore known, and tho means for guarding again.st them had 
been developed, bo was attacked in tho bands, and for 
rnanj- years suffered agonies which ho bore with his charac- 
teristic uncomplaining fortitude. 

Apart from his professional and mechanical skill, bo was 
a scholar of wide range and taste. Ho possessed an acute 
intelligence and a retentive memory, and this, with tho 
extraordinary catholicity of his taste and studios, made 
him a most interesting and delightful companion. English 
literature had in him a most fervent worshipper. The 
works of Shakespeare, Goldsmith, and Sheridan wore to 
him a constant inspiration. Intensely interested in Irish 
archaeologj', he was a mine of information on placo-naincs 
and other points of interest in his native land, which ho 
know from end to end as few indeed Icnow it. Outside 
his professional work ho was a daring and experioncod 
yachtsman, and nothing gave him more jjloasure than to 
leave his work behind for a month or so in tho summer 
and sail away in one of tho many boats he owned to 
explore the Scottish lochs, or the bays of tho south and 
west coast of Ireland, or tho sunny shores of France. 

Ho was a member of tho Council of tho Royal College of 
Surgeons of Ireland, and for many years one of its 
examiners in surgery. Had ho wished it, his many friends 
woidd have gladly elected him vice-president, but bis 
modesty forbade his acceptance of the responsibilities of 
such an office. As a clinical teacher he was immensely 
popular with his students, and by his colleagues in the 
Lleath Hospital and by his brother surgeons everywhere 
his memory will be held very dear. 


F. B. WILLMER PHILLIPS, JI.A., M.D., D.P.H., 
Medical Officer of Health, Bedford ; Consulting Phy.sician, 
Bedford County Hospital. 

fit E regret to announce tho death, which took place 
suddenly on March 23rd, of Dr. "Willmer Phillips, medical 
officer of health for Bedford since 1905, and honorary con- 
sulting physician to the Bedford County Hospital. 

Francis Barclay Willmer Phillips was born at Brighton 
in 1853, and entered as an undergraduate at Balliol College 
while Jowett was Master. He received his medical educa- 
tion at Guy’s Hospital, and obtained tho diploma 
M.R.C.S.Eng. in 1883, graduating M.A., M.B.Oxon. and 
B.Sc.Lond. two years later, and proceeding to the degree 
of M.D.Oxon. in 1889. In 1902 ho obtained the 
D.P.H.Camb. Soon after qualifying he successively held 
appointments as resident obstetric surgeon at Guv’s 
Hospital, assistant medical officer at the Eastern Small- 
pox and Fever Hospital, London, and as resident clinical 
assistant at the East London Hospital for Children j and 
about forty years ago commenced practice in Bedford, 
taking a prominent part in the evolution of the County 
Hospital there. 

In 1905 he succeeded the late Dr. C. E. Prior os medical 
officer of health, and in 1914 received a full-time aiipoint- 
mont in that office, with the additional duties of medical 
officer of schools and police surgeon. Later he became 
also medical officer of the infant welfare centre and 
medical superintendent of the isolation hospital. ’ During 
the war, -when, tlicre was a very -large concciitratioii' of 


troops at Bedford, ho acted in close co-operation with the 
militaiy authorities, .served ns an officer in the local 
volunteer training corps, and acted as medical officer to 
Bedford Prison during tho nhsenco of tho lioldor of that 
post. 

In tho affairs of his profession Dr. Phillips played a 
considcrnblo part. He was a member of tho Royal 
Sanitary Institute and a Fellow of tho Royal Institute’ of 
Public Health, and in tlio British Medical Association 
served as a member of tbo South Midlands Branch Council 
in tlio period 1896-97. His main intci’csts otherwise wore 
scientific and cultural; he was a keen classical scholar, and 
at tho same time was devoted throughout his life to mntho- 
inatical and biological studies, j-et found opportunities in 
his lator j’cars to extend his knowledge in the fields of 
palaeontology and Russian litcratnro. For many yeans 
he was associated with the Mathematical Association, tho 
London Mathematical Society, and tho Bedford Arts Club, 
'riie interment was at Hove. At a funeral service held 
earlier in St. Paul’s Church, Bedford, there were present 
the Mayor and Corporation in state, representatives of 
almost every civic department and of many other organiza- 
tions, and a large number of mcmbcr.s of the medical 
profession, tho British Medical Association being repre- 
sented by Dr. E. R. Fasnacht. 


CHISHOLM WILLIAMS, F.R.C.S.En., 

Formerlj- Elcctrotherapcutist, West London Hospilnl. 

We rogret to announce tho death, which took place suddenly 
at Finchley on April 10th, of hlr. Chisholm Williams, one 
of tho earliest in this conntiy to foresee and develop tho 
medical uses of x rays, and one who, like many of those 
pioneers, suffered gravely from tho effects of. handling 
this then dangerous medium. George Chisholm Waldomar 
Williams began his iirofcssional career as a student .at 
St. ’I’liomas’s Hospital, and obtained the diplomas L.S.A.. 
in 1891 and IM.R.C.S., L.R.C.P. in 1892. In 1898 lie 
obtained the F.R.C.S.Ed. From his earliest days ns a 
practitioner be was keenly interested in tbo application 
of-olectricity to medical practice, and devoted his .spare 
time to experimental irork. In 1895, seven weeks after 
Professor Roentgen bad announced tlio discovery of the 
ravs which wore named after him at the time, Chisholm 
Williams snccooded in repeating the original experiments, 
and in making an x-ray photograph of his own fingers. 
Tliorcaftcr liis devotion to the development of this dis- 
coverv was unbroken, and lie gave particular attention 
to llio. employment of the rays in tho treatment of tnher- 
tmlosis and cancer with a considerable degree of siicecss. 
He was appointed surgeon to the City Orthopaedic Hosjiital, 
London, in 1894, and. gavo ids services to that institution 
for some fourteen years. From 1903 to 1908 he was in 
charge of the x-ray department of the West London 
Hospital, and lecturer in radiology to the West London 
Post-Graduate College. In 1906 he joined the staff of 
St. John’s Hospital for Skin Diseases. 

From 1916 to, 1919 ho served with the R.A.M.C. in 
tho rank of captain as elcctrothorapeutist to tho Eastern 
Command Depot. It was at this period that the evil effects 
of the years of exposure to x rays, at a time Avhen neither 
the need for nor tho means of protection were known, 
became fully apparent. Tho condition of his Imnds had 
been severely aggravated by contact with septic cases during 
liis war service, and a prolonged series of operations became 
noccssarv; after years of suffering tbo whole of one hand 
and two" fingers of the other were amputated. As a result 
be was forced gradually to relinquish all active work. It 
was only last ye.ar that his services to science and his 
sufferings in its cause obtained recognition. In June, 1927, 
ho received from the hands of tho Dnko of Connaught, 
at the prize-giving ceremony in conucxiou with the St. 
Thomas’s Hospital Medical School, tho bronze medallion 
of the Carnegie Hero Fund, the highest award of that 
body, given “ for heroic endeavour to save human life,” 
together with a cheque for the first instalment of a 
liensioii awarded him by the Fund. A few weeks later 
he was granted a Civil List pension in recognition of bis 
self-sacrificing and devoted sendees in the application of 
X rays to the diagnosis and treatment of disease. 


APRlti St, 1958] 


OBITUARY, 


r Tnr. Unrn’in ROfi 

t IfciUClT* JOtmHU, VVK/ 


THE LATE HR. A. B. NORBURN. 

A coi.twctjr. solids us .sonio fiirtlicr jiorsmml dolails about 
tlio hto Hv. AlbciT Edward Norburu of Bath, of whom 
a short obituary iiotico niiprarod on ]9econil)cr 17lb, 1927. 
After CTaduatiiip, Dr. Xorbuni acted ns surgeon in 
the Union Steamsbip Company, and tlio large 11 umber of 
.voyages bo made between this country and South Africa 
proved of great benefit to bis benltb ; bo sociirod many life- 
long friends, and bis clear judgement and strong penson- 
ality won for bim tlie confidence of all. IYIumi be settled 
later in Bath bo quickly oslablisbed a large iiracliee. 
His numerous activities tbcu and during Ibe war told 
adversely upon bis bcaltli, and be wa'. sereral times 
obliged to take long jieriods'of rest. Mention 1ms 
previously boon made of bis services to tbc Bath and 
Bristol Division ; it will also be recalled ibat in I'ounexion 
with tbo Annual Meeting at Bath in 1925 be a.-n- closely 
concerned in tbo work of preparing and ai ranging the 
admirable Bool; of Jliif/i, written specially (nr tb.it meeting. 
Besides taking a prominent part in this edit, n ml uork he 
contributed the cbaptcr.s on " I’rcsont-da\ tlatli " and 
“Later ecclc.sinstical liistoiw.” The book uas l■nImi<U•rod 
one of tbe best and most complete of it-, kind ever issued. 
Last autumn Dr. Korbnrn went on a visit to Italy, and 
appeared to bnve benefited much in lieallli. but .1 inrtuiglit 
after bis return boiiie be became ill with a|i|ieii,li, itis and 
died early in December. The large attendame at the 
funer.al service testified to tbc esteem in wbn b Im was bebl 
by his colleagues, patients, and friends. Dr. .V.n Inn 11 ivas 
unmarried. 


Dr. Rini.vnD IVii.sov Muli-OCK, wbn died in a uiirsiiig 
Jionio at A'orwieb on Jfarcb 23rd, in bis fift\-tliird year, 
spent tbo greater part of Iiis professional life at S.mthwold, 
Suffolk, where be was one of tlie best known nuiong 
local practitioners. He iccctvod bis medical edneation at 
'IVinity College, Dublin, graduating 3f.B.. B.C'Ii., B..\.0. 
in ISOO, and proceeding M.D. in 1902. .\fter nbt.niiiiig bis 
first degree be took part in tbe war in ,'^<mtlt Atiiea, 
sen-ing as civil surgeon with tbe Royal IVcst Kent Uegi- 
iiient. Subsequently be comineneed praetie,'' ni Soiitinvoid, 
where be was an active worker in connexion nitb the local 
hospitals. Ho was honorary medical oflici'r to Snutbwold 
Cottage Hospital, modicnr officer to fit. Felix S.liool, 
honorary medical referee to .the British Hospital for 
Incurables, Streatbam, and held also a number of otbei 
appointments. The work of tlie British Rod C ross attracted 
bim, and be devoted inueb time and energy, as eom- 
inandant of tbe Soiitbtvold V,.V.D., to its activities. During 
the wav, in^ addition to maintaining bis instnictioiril work 
with the 1 .A.p., be acted as chief medical offieei at a 
temporary hospital established at Henbani Hall, and to tbc 
heavy strain imposed upon bim by tbe.se labours, added to 
the work of Ins practice and iit the civil hospital, i.- 
^tributcd tbo illness wliieb ultimatclv caused bis death. 
Dr, Ifullock was a member of tbc Medical Offit-ers „f Sebool- 
Association and of the British Ifodical .\,s.soeiatioii. lii the 
mtter body be served as ebainuan of tbe North Suffolk 
Division in 1922, and was president-elect of tbe Suffolk 
iqnch alien be died. His tvidespvead iirofossional aitivitio 
did not leave luncli time for other pnbli,, .affaus. He wm 
for three years a member of Soutbwold Town Couneik 
leiug elected in 1905, but on completing bis term of office 
did not seek re-clccHon. In Froeinasonvv be took a con- 
siderable interest During recent ve.ars 'sbootiug was hii 
chief rocreation, but in I, is stuelcnt davs be was a keer 
oarsman and rowed for bis college. Dr. F, W. Bukton- 
Kt-NMXC writes.- Suffolk has again sustamed an irrepnralile 
loss m tbe death of Dr. Ridiard Slullock of Soutbwold 
h our years ago bo liad a severe .attack of piieuiuouia, am 
altbougb be returned to full work-, it is probable tlial 
ns health was never wholly restored. Two months age 
be uas found to bo suffering from „ liopolcss inaladv 
but be coutiiiued to work until he was forced to gi{-< 
in. He had won a remarkable position for liini&elf n 
‘ind Ills large practice allowed him littb 
*1 V,' best work was done at tin 

Routbwold Cottage Hospital. To serve ibis institntioi 
e md trained himself in operative surgoiy and ii 


rndiologj', and for many years liis beds wero kept full with 
patients sent for operation from tlio surrounding districts. 
Ho devoted himself bc.art and soul to tbc hospital, and its 
welfare was bis chief bobby. Dr. Mullock was not passed fit 
for service abroad during tbo late war, but no one could 
have done more useful work than bo did as chief medical 
officer to 'Hcnlinm Hall Hosiiital and as commandant 
of the Red Cross braneb, Tbo town of Sonthwold gave 
evidence at bis fitncnil of tbo estimation in which he was 
hold both ns a friend and as a dortor. His grave in tbc 
cemetery is overlooked by the hospital, where be has left 
.sticli a blank. Equally loved by Ids patients and by his 
colleagues, be was to have been president of tlie Suffolk 
Braneb of tbe British Slediea! Association this summer, 
and bo bad busieil himself with proiiaratious for the meet- 
ing at Soutbwold. He leaves a widow and two sons and 
a daughter, for whom tbo greatest sympathy is felt. 


Dr. C.wr.snisii Fi.r.Tcnmi, who died 011 Marcii 3rd, .-it 
tbo ago of 45, obtained bis medical education at the 
AVe.stminstcr Hospital, graduating JI.B., B.S.Lond. in 
1906, and obtaining the diplomas M.R.C.S., L.R.C.P. in 
tbc .saino year. After qualifying be served for a time as 
boiise-]>bysician .at tbe IVestminster Hospital, and later as 
assistant medical officer at tbe County A.syliim at i.eek. 
Subsequently be was appointed resident pathologist at tbe 
Royal Southern Hospital, Liverpool, so beginning tliat 
work in connexion uritli clinical patbologx- with wliieb bis 
name is most closely associated. In 1908 bo joined tbo 
.staff of tbo Laboratories of Pathology and Public Health 
in Harloy Street, and for tbo past eight years was 
director of that institution. Ho wn.s also honorary patho- 
logist to tbc King lidward Memorial Hosjutal, Ealing. 
A colleague writes : By tbe death of Cavendish Fletcher 
clinical pathology has lost one of its ablest osjioncnts. 
Engrossed in its pursuit, bis solo jircoccupation was with 
its advancement and with tbc perfecting of its technique. 
While .a tboi-ough master of all tbe present manifold rami- 
fications of patliology be excelled especially as a' morbid • 
histologist, and bis verdict on the interpretation of histo- 
logical features was seldom falsified by tbe subsequent 
liistory of tbe patient. Much of tbe intense labour which 
he devoted to technical problems will never bo known to 
the world, but those whose privilege it was to have him 
as a colleague and eo-worker gained immense belli from 
him. He leaves a widow and one son and one daughter, 
with whom much sympathy is felt. 


Dr. John .AncHin.ti.i) C.tMpnEu., who died in Glasgow on 
.April 6tb, was a native of Inverness-shire, but spent tbe 
greater jiart of bis life in Glasgow, where bo received bis 
medical education at tbe Anderson College of Medicine, 
obtaining in 1900 the diplomas L.R.C.P., L.R.C.S.Ed., and 
L.R.F.P.S.Glas. Throngbont his professional career be 
devoted himself to teaching and to Pp-*— ■ 
and for nearly thirty years was connect 
Royal Infirmary. Until 1914 be was assistant bacterio^ 
logist and in that year be was appointed bacteriologist, 
a position he bold at the time of bis death. He was also 
lecturer on bacteriology in St. Mungo’s College. At an 
earlier period ho served on tbe .staff of tbe .Aiidei-son 
College of Medicine, where bo was for ten years, as senior 
demonstrator in anatomy, associated with" the late Pro- 
fessor A. 5t. Buchanan, and for a time be was pathologist 
to tbo Ministry of Pensions Hospital at Bellabouston. He 
acted in a consultative capacity for a number of local 
antborities in the IVest of Scotland. Dr. Campbell, who 
was regarded as one of tbe jiioneers in tbo use of vaccines, 
was a member of tbe Glasgow Medico-Cliirurgica! Society. 
A former collcagno. Dr. Ei,I7-.\bf,th F. Butlkh, writes : As 
one who for many years worked with Dr. Campbell in the 
bacteriological laboratory of tbc Glasgow Royal Infirmary, 
I should like to testify to one aspect of his character and 
activities which J had exceptional opportunities for observ- 
ing, I refer to bis e.ager willingness to give liis time, his 
labour, and his kindly consideration to all in need who 
came to claim them. It might be a student going lip for 





Armti *1, jQiS] 


TVIEDIOAIi NOTES IN PAKEIAlilENT. 


[ TssliBinn fiQ7 

UbWCII. JOCBITAl. wOl 


New Zciv!ft«i1),\'ci)orlliiK Hint tlio Gouiioll ot tlio Collofio of Surucona 
of Aoatnxlnaliv moat eli'onijly niiprovo nuil nioal enniostly liopo to 
Imvo pul into pi'iiollconUlio enrlioat poiBiblo moment Uio proposal 
to pvoviilo tor tlio Prlmai-y Examination tor tlio Followslilp ot tho 
Itoyal Colloijo ot auvticous ot Kntjlaml boiiid liolil in Stntoa of tho 
ComraouweaUh of Australia ami in the Dominion of New Zcaiaml, 
mill stating' that any nsnistanco It may ho in tho nower of thole 
Colleilo to ylvo In fnrtheronco ot that proposal will bo most fully 
and willingly ('Ivcn. Tho matter was referred to a oommitloo for 
consideration. 

ILilktl I’nzf. 

The Council bciiu; desirous ot abowiny appreciation of tho 
services of Sir I’rcderlo O. llallott, 0.15.E., in connexion with tho 
e.xmninntions for tlio I’ellowship and tho Elconco in Uoiilal Snryery 
from 1S77 to lOT, and Sir F. llallott liaviny expressed a wish that 
the personal yift which it was proposed to malio to him ehonld 
talco tho form of the endowment of a prixo to bear liis name, it was 
ayreed tliat stock bo purchased by tho Treasurers of tho Colicgo 
on boliaif of Sir F. llallett, and that they bo antborized to reinvest 
tho fund at any time it lliouybt desirable; and that the interest 
from the finul so established bo oxiionded on a prize called tho 
llallott I’rizo, to be awarded under such rcynlatlous as the Council 
inav from time to time determine. 


Jlrculufienj. 

The Halletl Prize shall bo ojica to candidates admitted for the fli-et timo 
to the primarj’ examination in anatomy and pliysiolocy fur the I'cllotvsliip 
conducted by the lloanl of Hxnmlncra in Ibis country. 

The priro at o-icli examination shali consist of a sum of five culncaa 
with a certificate of the award of the priro. 

Tlio prize sball be awarded to tlio oliciblo cnndidalo. if any, obtaining 
the lilsliest marts, who sliall liave readied a standard considered by tbo 
Cxsiiilnors anlllcleutly liidl to justify tlio award of tile prize. 

If two or more caiididate.s ore found to liave voaclied the reauired 
standard and to have been allotted tho same number of marts, being tbo 
biRlicsl obtained by any eligible candidate, it shall bo oi»on to tbo 
cxiunlners to take siicli steps as they may tblnU desirable to cnablo them 
to ndjndicato in tlio matter. 


ROYAIi COIiliEGE OF rnVSlGIANS OF IRELAND. 

.\T tbo tnoiitlily biisiiicss meeting ot the President and Fellows, 
held on .April 131b, the following members nominated on 
daminvy Bill — Robert Wallace Nesbitt, 31. LI., and O’Dotiel Tborulcy 
Dodwell lirowiic, 3f.l3.— were duly elected Fellows ot tlio College. 

Frederick John Ryan, L.U.G.P. and sj.T., was stated to have 
completed tbo examination foe the Diploma in Pnblio Uealtli ot 
the Koynl Colleges. 

Xlio following candidates, having passed the Final Conjoint 
Examination in .Medicine, Surgery, and 3lidwifory, were formally 
admitted by tlio President to ’the Licences in Mcdtcnic anti 
.Ridwifeiy of the CoUego; G. F. A. Comion, P. Daiv, E. P. dfabootl, 
F. L. G. Malone, R. J. M'Closkoy, J. F. Power, P. B. Walsh. 


^Ir&ical flotcs in |)itvliiimcnt. 

[Pr.ojt OTO PAnu.i3ii:.VT.utv ConnEsro.vDENT.] 


The House of Commons reassembled on April 17tb. when tlio 
Army and Air Force Animal Bill was passed tlirough com- 
mittee and read a third time after a debate on the retention of 
the death penalty for cowardice. On April 18tli tho House 
went iiito committee on the Equal Franchise Bill. The Edin- 
btirglz Corporation Bill, which asks Parliament to grant that 
corporation further powers for dealing with venereal disease, was 
set down for second reading on April igth. Tho Government 
had agreed not to put its AVlxips on in opposition to the hill, 
a course xvhicli had previously^ been threatened, but .a group 
of members, as xvell as outside organizations, is.sncd ajipeals 
to rnerabers of Parli, ament to oppose the measure- On the 
previous day the Conservative Health' arid Housing Committee 
wa.s summoned to hear the bill expounded by Sir Patrick Ford, 
an Edinburgh member. ■ . ■ ■' 


On Am-n niV'"c''"T ■K'''™*® Clinics in Scatland. 

replying to Mr. Buchanan said 
m of towns m Scotland xvitU a census population of 

; a public clinic for dealing xvilh 
was twenty-sjx, of xvhich seven had a population 
T-'m’ *?“.r8bs, in order of population, were: 

Ohdebank, Falkirk, Airdrie. Rutherglen, Dumbarton, Port 
PetSn’d Musselburgh, Haxvick, Renfrew, Saltcoats, 

Jo'mstone, Alloa, Kirkintilloch, Barrhead, 
®“akliavcn, 3Ie(liiI, and Innerloven, Rothesay, Dunoon, 
’* f ■^orligelly, Fraserburgh, Bo’ness, and Gourock. In 
tm-eo of these burghs— Falkirk, Inverness, and Eutlierglen— 
venereal disease clinic was in course of being 
act’ve con'jideration. Four of these burghs— 
-x Glasgow, Musselburgh, and Gourock — were so con- 
Gie clinics of adjacent larger towns as not 
independent provision. The remaining nineteen burghs 
a greater or a less extent by the nearest avail^lc 
eleven of these burghs the Scottish 
1 Health h^ not thouglit the question of providing a 

♦!*« ? be Eulficiendy urgent to call for pressure by tiieni 
aulbontics, having regard to the facilities available 
tomi<?. In the case of tho remaining eight 
•h^?i Dumbarton, Hawick and Galashiels, Pctoi-. 

head and Fraserburgh, Saltcoats, and Kirkintilloch— the question 


of ostablisliiiig a burgh clinic or a joint clinic had been considered 
by tho responsible local authority, and remained open. Tlio 
development of the schemes in all areas was being carefully 
watclicd und reviewed by the Board. 


T( ini‘(thjjl haul in Motor Spirit. 

On April 17th fho IIo««c of Commons considered the Petroleum 
(Amendment) Bill on tho report stage. Clause 4 of this bill 
authorizes tho making of regulations concerning classes of ‘petro- 
leum likely to be dangerous or injuiious to health. To this clause 
Mr. Hardie moved an nmendment pving the Horae Secretary 
power to prohibit the sales or uso of petroleum spirit which ho 
might, by order, declare to be so dangerous or injurious to 
licaltli .tliat precautions for tho protection of persons employed 
or engaged m handling or using such petroleum spirit wero 
impracticable. He said that tlic amendment referred to tetra- 
ethyl lead ill petrol. 

Sir \V. • Joystson-Hicks said ho would accept the amendment. 
Tolra-clbvl lead in petrol was now the subject of an inquiry, and 
if fho Homo Sccrcfary should, ns a lesult, declare that this 
particular spirit was injurious to hcaUh, the amendment would 
usefully come in. , ^ ^ 

The nmciulincnt was agreed lo. Tho report stage of the bill was 
completed, and ilic bill was read a third time. 

A copy of the report of tho American Commission on the uso 
of Ictra-cthyl lead in motor spirit will be placed in the library 
of tho Hou«c of Commons. 


, • Prji.fionx. 

Answering Dr. Drummond Sliicic, on April 3rd, Major Tryos 
said bo was not awaro of deep resentment among panel prac- 
lilionoi’*? at the scant courtesy with which their certificafos "and 
opinions ^ycro regarded by Iho Ministry of Pensions. U was 
certainly incorrect to say" that tho supposed reduction in tho 
necessity for hospital accommodation .in Scotland was due to tho 
fact that many cx-scrvice men w'ero being refused treatment 
which they required. 

Major Tryo??' told Mr, Bowerman^ on April 5th, that tho 
closing of tho Ministrv* of Pensions clinic at Camberv.’ell was nob 
contemplated, Tim crmic at Bnlinga Street, Westminster, had, 
however, special facilities for sui*gical treatment not availablo 
elsewhere, and in their own interests certain cases living in other 
parts of London were on occasion summoned to it. 


yationnl /»At/m/?cc.* .Vi7r«.7c and Drup Co$i ». — Answering ques- 
tions put on April 4ili by Sir Robert Thomas, Sir Kingsley Wood 
said Ihcro was no spcoal conliibution per head among insured 
persons towards the cost of mileage and drugs. The amount 
availablo for mooting this cost was 3s. 3d, per insured pereon in 
each country, but as Iho tola! expenditure on mileage and drugs 
in Wales' exceeded that amount, the Act authorized payment out 
of the National HcaUh Insurance Fund (England) to the Welsh 
National Health Insurance Fund lo meet the excess expenditure. 
It had never been considered necessary that the Association of 
Wclsli Insurance Committees should be represented as such on 
the Medical and Pliarmacculical Committees, which were charged 
with apportioning among Insurance Committees the sums avail- 
able to defray the cost of medical treatment and drugs in 
Euglaml and Wales. There were Welsh representatives on tho 
committees. 

Kf/r JJhaUix in thr .Vf/ry. — Asked by Sir Robert Thomas to 
explain the fact that in 1926, of 1,726 invalided out of the navy, 
386 were on account of. diseases of the eye. Colonel Headlam said 
that 345 of these cases were due to congenital deformities — long 
sight, short sight, and astigmatism. Five men were invalided for 
defective' colour vision, three for injuries, three for cataract, and 
llio rest for chronic inflammatoiy or degenerative conditions. No 
special inquiry seemed necessary. It was in consequence' of th© 
more frequent and rigorous examinations after a man had joined 
tho service that latent errors of vision were detected. 

Third rnrty /ndriunify /iisureucc.— On April 17th Mr. Atkinson 
inlrodpccd a bill. to provide for tliird party indemnity insurance. 
Ho said, the bill provided that it should be the duty of an 
insurance company, in so far as they were liable for third party 
claims, to pay those claims direct lo the injured person. The bill 
was read a first time. 

.VotcA in Brief. 

At the ynd of February, 1927, 102,864 houses were under con- 
slniction in England and Wales, and 126,611 had been authorized 
but not started under the Acts of 1923 and 1924. 

Mr, Amery, replying to a question on April 17th, said that 
seventy-one cases of dysenteiy had occurred among the prisoners 
ill tho Sinarango Prison Camp, Malaita, and there had been 
ciglit deaths. Seven cases were still under treatment on April 2nd. 

Sir Kingsley Wood states that measures arc being taken to 
prevent floods from tho Thames in the county of London in 
accordance with the report of the recent committee. 

Sir Kingsley Wood informed Mr. Kelly, on April 17th, that 
inquiries v/ero proceeding into the effects of artificial silk manu- 
facture on tho health of the people resident .in tho neighbour- 
hood of such factories. 

The reports of the Government Inspector of Mines for Cornwall 
show that tho health conditions of Comisb tin mine^ are generally 
salisfactoi’y and* have improved of recent years. The health con- 
ditions at Cornish china clay works are good, and no cases of 
di^eoso duo to the conditions of employment have come to the 
iiotico of tho inspector. 






700 Ap^ 21 , 1928 ] 


LETTERS, NOTES, AND ANSWERS. 


r Tnz Driti.s 

LMRUICAL JuUDNiL 


crypts. Sir James Daudas-Graiit also reforroil to tlij’mol water 
as a useful prophylaotlo garglo, aud reoorameuilod tlio clearing 
away of caseous masses filling tiie tonsillar crj’pts by means of a 
fine dental Byriuge, with tbo. point bent at a right angle, charged 
with hydrogen peroxide (equal parts of the teu volume BOluliou 
and warm water). 

Paroxysmal Ooryza. 

!' W. M. M.," in reply to “ F. D. J.’s " question about the Ireatnient 
of paroxysmal niucous nasal disobarge, suggeata the adiniuistrur- 
tiou of calcium aud parathyroid extract, or thyroid extract. 

Dr. Lindley Sktvell (Manchester) offers tlie following recom- 
mendations: (1) A fruit and vegetable diet, including milk, 
eggs, meat, and fowl. (2) Talcing some calcium iirejiaratlou 
/or a considerable time and with regularity. (3i Painting tbo 
middle turbinal oud middle mental region of the nose with 
3 per cent, silver nitrate solution once a week for five or six 
times. (4)Aoliango of residence to some- seaside place, snob ns 

. Weston-super-.Mare or Grange, where miultlats are left at low 
tide. (51 A careful searcli for any possible source of irritation, 
Buch ns fowls, leather beds or pillows, dogs, cats, new paint. 

Income Tax. 

Seplacanent of Car and Instrtimmls, etc. 

“ W. T. C.” bought a Morris Cowley car in 1923 for £250 and in 
1927 sold it lor £40, buying a Morns O.xford car lor £215. What 
claims should he make, and what is the position with regard to 
expenditure on books aud iustruments? 

*,* As regards the car he should claim obsolescence allow- 
ance, as a professioual expense of the year 1927, as follows; 
£180 (or rather, the exact cost in 1927 of n Morris Cowloy car of 
Eimilar type to the one replncedl leas £40, say £140; also depreoia- 
tiou allowance for 1927-28, £215 at 15 per ceut.=£32. Tbo 
position with regard to books aud instruments is that expendi- 
ture ou their replacement is admissible, but the cost of improve- 
ment, as compared with the original value of tbo old article, 
must be excluded. There is the further difficulty that uutii tbo 
old instrument or book is definitely “BcrappaJ" the new one 
represents au addition aud not a renewal ; If tbs former is useless 
it is obviously advisable from the income tax stauilpoint to got 
rid of it altogether, and thereby avoid a possible objection to the 
claim. 

Motor Car Transaction. 

** G. W. M." bought an 11-h.p. car in 1922 for £330 and sold it in 
January, 1927, for £65, when he bought a shop-soiled 14-li.p. car 
for £449. lu the last two years be has had 15 per cent, ou £40 
depreciation allowance lor the old car — say £12 iu all. 

Obsolescence aliowauce, £330— £65 — £12 e= £253, as an 
expense of the year 1927. Depreciation allowance lor 1927-28, 
15 per cent, ou £4I0=£66. 


letters, notes,, etc. 


Lectorers on Social Hygiene. 

Dr. a. H. Hark.nuss (honorary medical secretary, Hrltish Social 
Hygieue Council) writes: Owing to the numerous calls the 
British Social Hvgiene Council is in need of the services of 
additional medical men: (1) Those who would be. willing to 
leave London and to undertake froip. three to teu days’ lecturing 
with publio health films in the provinces; (2) those with oxperi- 
euce in iiopular speaking willing to address general industrial 
audiences on problems of social Iiygiene iU London and the 
Home Counties area. Full particulars are given lu an advertise- 
ment iu this week’s issue. 

.1 Treatment of Pneumonia. .. , 

DR. J- W. Dgncan (Birmingham) refers to Dr. D. Hennessy’s 
letter on, the treatment of pneumonia by polyvalent autistrepto- 
cocc.il serum (March 31st, p. 572), aud reports six cases, three of 
wliioh were treated with antistreptococcal serum aud vaccine 
and recovered, while the three other patients died. He adds that 
■ there is notliiug sensational in the use of the serum • the 
temperature, as a rule, does not fall,' but there Is no crash at the 
’crisis. ■His-point is that injections of serum, followed by small 
doses of vaccines, seem to be very beneficial iu these cases.' 

The Pdlpless Tooth, 

Mr. a. P. Bertwistle writes : I thank you for your references 
(at p. 637 of the Journal) to my paper on “The role of dead 
and infected teeth in autogenous infections.’.' There are, how- 
ever t'n ■ ■ ■■’■■■ ■'Vilham 'Willcox does not specify 

pnhiless ■ oI VO per 

cent, of ■ J stated that the most impor- 

■ taut Big ■ . “ Oh clinching the jaws and on 

^ percussion, not “ on eating.’’ . 

Starting Points for a Tuberculosis Campaign. 

Dr. Goruon Tippett (Loudon, S.E.) suggests tliat-ps_a preliminary 
to a general campaign to stamp out tuberculosis^ it is necessary 
to determine the following jioiuts: Is food infection by tubercle 
hacilli harmful, and, it so, why is it not prevented? Does not 
. 'exi.osnre of food lend to oontnmiuation .by human .tubercle 
haciUi? Is any case ever too early for treatment? Some further 


tost (ho says) is required to prove defiiiltoly tlie presence of 
living tubercle haoilli in the body. Some haoteriological pro- 
cod iiro is necessary so ns to make it clear whether tlio treatment 
has boBu suocqssful or otherwise, since physical examination 
• limy bo misleading. Dr. Tippett considers that sucli a criterion 
of cure is essential, because otliorwlso it is Impossible to he 
sure that any form of treatment la effective. Ho adds tliat tlie 
examination of sputum for tubercle bacilli should only ho uiiilor- 
taken by a baoteriologist, who should be a fully qualified niedinil 
praotitlonor, and should report ou conditions other limn the 
mere presence or absoiico of tlieso Imcilli. 

Survival op Quadruplets. 

Dr. Kenneth J. Franklin (I'liannacologlcnl Laboratory, Oxford) 
writes: The following extract from Henley Begistor (Diocesan 
Transcripts) Ims been s)iown to me by Mr. C. It. Ohilinm of Oriel 
College, and. In view of llie rarity of survival of quadru|dets, 

I am sending it 011 to you. It may also siiggeat to the ourioiia 
a possible source of further iiitprinatiou ou such subjects. 'The 
entry In tlio register is: 

“ Calli. Fiilloclis, aged 36. died iu childbed, with four children 
born alive, bur. 16 Feb. 1799.” 

Five Generations attended by One Doctor. 

Dr. L. j. Hood (Meiboiirne, Australia) asks wbetlior any oilier 
medical practitioner has bad wliat lio considers the unique 
exporiciico of attending five generations iu tlio 0110 family. 

! Dr. Hood writes: The great-great-gruudmotber.is now aged 90, 
and has been a patient of mine for nine years. Her married 
dangiitor and grahddaiigliter liave both been uiider.iny care for 
Eoino years. 'Tlio groat-granddnngliter was married last year, 
and is now tbo mother of a bonny boy, both of whom I attended. 

The Gorilla at Home. 

Lieut.-Colonel Clayton Lane, I.M.S. (ret.), referring 'to “Noles 
on tbo gorilla,’’ a recent article iu tlie I'rocccdings of the Zoo- 
logical Society by Dr. Neville A. Dyce Blinrp, "West African 
Medical Service, writes: “Tlie varied opportunities ■for adding 
to knowledge iu nuexiiected ways wliicb fall to ofilcers m ciir 
medical services abroad is illustrated from IVcst Alrica. In tlie 
Mamto division of the Cameroon the gorilla is hunted and eaten 
by man, and attacks roan at siglit. Hot a few hunters owe their 
lives merely to tlio remote position of tlie gorilla’s tliumbs, so 
that from his imcertaiii grip a man nmy wriggle. Sueli iiiifoV- 
tuiiato manners make it no liglit task to observe the creature’s 
habits, but Dyce Sharp’s information ami observations warrant 
the following statemoiits regarding gorillas aud cbiinpauzees. 
Ill tliat locality the chimpanzee is a timid, monogamous, widely 
distributed herd animal, both sexes making femall untidy bo.ls, 
like storks’ nests, 30 It, to 50 ft. up in tlie trees. Tlie gorilla is 
a fierce, polygamous, family animal, living on steep terrains 
1 200 ft. to 5,000 ft. above sea-level, and together with his four 
to six wives and their children, and perliaps au elder sou not jet 
tbrnst out to fend for liimsolf, |iatroIliug au area of twenty to 
forty square miles. The bead of the family is not arboreal,‘but 
makes. for himself, of stout bent saplings, branclics, twigs, and 
' 'leaves, a luxurious bed on the ground, porliapt 9 ft. across and 

■ 1210 . to lSIb.'deep, ns nearly resembling a spring mattress as 

■ the materials permit. It is said by the natives that tbe"oM 
man ’’ allots to each wife her own tree fork, where she builds, 
as be does' from 'material withiu arm’s reaeli, a bed 3 ft. or 4 It. ' 
in diameter. Dyce Sharp has repeatedly verified the fact that 
tlie liead of tlie family, reclining. at ease against tlie tree trunk 
adjacent to which bis bed is built, can walcli tlie arboreal iie.sl 
•of every wife". No bed is used for more timn one night. 'Tlie 
gorilla, tbongb fond of grubs aud caterpillars, is easoiitinllv 

a Vegetarian, eating mainly the growing jioiuts and stems of a 
'BU''arcnue-like soitamiii, and Hint in prodigious quantity, as w.II 
pe'cleaf from tbe'estimate that the amount of undigested faecal 
• • residue'besido.'but not on, the bed of a single male vins estimated 
. nt 251b'. to 30lbi It is interesting to speculate on the feelings of 
! a 11*111000 being who daily lost the equivalent of 2 stone between 
-bod and brenkrast. 'Tlie day’s life, particularly for the liend o( 
the family, must be litt'e else than n strenuous senrcli for food, 
the making ol a bed and of a toilet, and the periietiiatiou of the 
Biiecies. But this routine may be abruptly terminated by tlie 
violent irrnptioii of a stranger— some new-grown male wln> 
iirposes, tlirougb a grim and bloody fight, to appropriate tlie 
arem and feeding grounds of the gorilla iu possession." 

Hew Lighting Laws for Motorists. 
iFor the convouieuoe of motor owners aud drivers the Automobile 
Association is issuiug a booklet epitomizing tlie various ebauges 
iu the law relating to lights ou vehicles, lu addition to the 
Road Transport Lighting Act, wliicli comes into operaliou.on 
April 22ud, there lire certain ebauges wliiob are to be tlie subject 
of regulations made under that Act, and immediately these 
ie"ulatiouB are issued llie A. A. booklet will be available, free of 
charge to any motorist ou aiiplioaliou by postcard to tlie 
Secretary, Automobile Assooiation, Fauum House, New Coventry 
Street, W.3. 

' ‘ , Vacancies. . 

Notifications of olBoes raoaut in universities, medical colleges, 

' and of vacant resident and other, appointments at ho3pital.s, 
will be found at pages 53, 56, 57, 58, and 59 of our advertisement 
colnmns, and advertisements as to partnerships, assistautships, 
End iodumtenencies 'at pages 54 and 55. 

-A short summary of vacant posts notified iii the advortiseraout 
columns appears in the Sujiglement at page 13S. 


CAUSES OF OECEINE IN TUBERCULOSIS 5IORTALTTT. 


[ Inr 

M^UCCAL JOOBVAt 


701 


Arr.Uj 2S, tgjS] 


^biirfriS 

Tins GACSES or THE DEOLIKE IN 



nv 

Sin ROBERT PHILl]*, AEU., LL.B.. 

pKOi'Esson or lUBEncuLOSis ix the vxiveiimtv or Eoixavncn; 
rr.EsiDEKT or the British jtEnicAE assoiiatiox. 


liKT inp nave imliilgcnco for the iutroduetiou ot n Brief 
personal vefercnco rvhich has bearing on the signifieanee 
of oiir (liseiissioii ib-ilny. tViiilo tiihi'rciiiosi> lias hoeii 
known from all times it has, during the past fifty ycai-s, 
assumed a uc\r aspect. Throughout the latter period wfc 
have come to realize, as never before, nhat wo arc up 
against. It so happens that niy inediral history rovers 
that period of fifty ycai-s almost to a day. During the 
first four years, as an undei-graduate in inedieine, one 
became familiar with the general helplessness and hopeless- 
ness of medicine in resiicet of tnhereulons disease. Patho- 
logy Imd revealed innch regarding the morhul anatomy of 
tnhcrele, hnt little regarding the natural history of the 
disease. Diagnosis was limited to prononiued <ases; pro- 
gnosis w.as, for tlio most part, pcssimislie ; ami treatment 
eiupivical. Tuberculosis remained, as i ventured to eall 
it in my graduation thesis, the ojiiirohrium of medioiuc. 

Although tlic old-time conccjition of its iiifeetiee ehaiaeter 
had already recen-cd scientific confirmation in the seventies 
hy the jirolonged investigations of Villemiii, it nas in 
1882-83 that bacteriology dcmoiislralcd, once for ail. the 
eaiisnl organism, I remember vividly the /I'peivnssioii of 
Koch's prononnccracnt. To tlioso of ns who nine working 
in laboratory at the time it called fm pause. Miero- 
.s’eopieal work on other lines was arrested iu tavoui of a 
consideration of the new claim. 


Frc.di Iloiizon-. 

It was the coming of that event at tliat pailieular 
moment which detennined the interest of a Hletiim — an 
interest as fresh to-day ns when it was kiiidleil, fomliiiied 
lalioratory and clinical observation (oinpclled one gradiiatlv 
to the eonelusion that the attitude of mcdii iiie to tuher- 
cnlosis was wrong. Atteutlou had Ijcen comeutrated on 
end-resnlts, and these especially in the lung. 'J'lje phvsieian 
disease presented itself in aggravated form. 

1 lie lusal fact of infection having been aeeepti’d, it seemed 
clear that the principles which goA-orned the detection and 
eontrol of other infections might he ajiplied to tnber- 
eulosi.s, .and, especially, that in phiee of waiting until the 
eiFecAs of the tubercle bacillus were eiamaiit— often evident 
to the man in the street— our aim .should he to aco.Wi /or 
the earliest manifestations of iiifeetiou and probe into 
conditions which conduced to grosser disease. It was 
stmty of thc^natnve of the infeetion aud of the essential 
cause of death in tuberculosis uiiich led to t!ic proposal 
• observation aud the estnhlislmient, 

in IW, of the tuberculosis dispou.snrv 

The circumstances were thought-impelling. Hhv was 
the prognosis cominonH- .so uufavourab]o.» IVhv did’ most 
oi the ,,at.ents d.e.» Why wore the eases under treatment 
so largely those of advanced disease? W.at was the natnr.il 
history of the disease? Why, infection 

eoiitriuted of which those ca.ses trere the final fruit? Why 
was the di,se,ise undetected at the earlier stages? Answers 
to these tjnestions were gradually evolved. It emerged that 
the , advanced stage constituted hut the hist .scene in the 

enlfifr ."’Action. It heeame evident that the 

emhi'r sfnt/es of infection must be .loiitjht for. Tlio infec- 

sHcuiit”^ f r ^‘“oed to its source and tlie commencing 
le Pin "'“r® determined. Observations on tliose linl 

le 1 to the concept, on of tuberculosis as a bouseliold dise.ise 

bold Pmm lud lamination of tbc liouse- 

Sit nni niKl. oilier environmental 


OmverV ot 'neAm‘”,ew'’LT April rflirfSTl 


Gradually tbo jiroblom extended. Tuberculous infeetion 
was seen to be widesiue.id tbroiighoiit civilized fomnuiiiities. 
For the most part it was eoiitracted in childhood. Varying 
degree of resistance to the infeetion was offered hy different . 
individnals. The resultant of the infection depended on 
the amount of the infecting dose and its rcjietition, ami 
on the resistance offered hy the individual. The tlegreo of 
rc.sistaucc was influenced greatly by environment — intcr- 
jiroting that term in a wide .sense — and to some extent by 
racial ipiality. In conscijiiciiee of this the outward mani- 
festations of the infection differed much in character and 
degrc.c. 

All this meant a revision of the medical outlook, Atfen-' 
tion bad to bo directed; (1) towards the detection of the 
infection at tho earliest possible moment; (2) towards 
dctuberculizatioii of the tubereulized individual as speedily 
and tborougbly as might be; (3) towards tbo elimination, or 
at least progrc.sbivo Ic-ssening, of environmental condition', 
wliicli fostered the advance of infeetion by lowering indi- 
vidual resistance; (4) towards securing sufficient duration 
of efficient treatment in presence of pvononneed disease; 
(5) towards tbc limitation of the spread of infection from 
advanced eases. 

Frohtiion of the Tiibrrciifosis Scheme. 

In order to meet the different issues there evolved jiro- 
grcssivcly the several elements in what is now deserihed 
as the tubevcnlosis scheme, generally applied tbvongbont 
the land. In so far as it iias really met the issues and 
been cffieicntly handled the wacliinery lias proved senice- 
ahle. If experience has shoivn that the quality and temjlcr 
of the machine, as erected in different areas, have not 
alwyys been equal, nor the standard of the irersonncl in 
charge, tliat is only wlmt was to be expected. 


Sj)rriuiiz.C(l 'I ruining. 

Time is improving both the machinery and tho pei-sonnel. 
Tho purposes and liang of its different parts are becoming 
betli-r tmdersfood ; the training of tbo officers iu charge 
is being progress iycly adapted to the needs. Tims, at tho 
I iiivorsity of Edinhnvgh tho undergraduate in medicine 
has a com-se of thirty meetings on tuberculosis. The course 
is practical and compulsory, and tuberculosis is inohidcd 
among the subjects for the final examination iu medicine. 
Candidates for tho Diploma in Public Health attend a 
further course of twenty meetings, and the subject foniis 
part of the examination for the diploma. 

The Departmental Committee on Tuberculosis recognized 
and enforced the need for special training and experience 
in dealing ivitli the disease. It seems .singularly inoppor- 
tune that, just when the machinery is getting into motion 
throughout tho connti-y, the proposal has been made to 
replace the specialized staff by officers in the public health 
.service nho happen to have time, but may have little 
experience of or interest in tbo complex problems. Tlie 
issues involved arc critical. It is not good poliev to swaii 
horses in crossing the ford. 

Fectinc of Morfaliti/: .Irceicratlng Drop. 

lurning to tho subject more definitely before us to-dav, 
the title of the discussion assumes that there has Iieen 
a decline in mortality. One wonders nhother the extent 
of the decline is quite realized. Judging by loose state- 
ments in the press, it is clear that there is need to 
empliasizo its remarkable extent. 

The graphs showing the decline in mortality from tuber- 
culosis iu Scotland from 1871 up to the ])re.sent date tell 
their oa'n stoii'. The remarkable dceliae has been con- 
.tinuoiis thronglioiit the period. This is, Iionever, not all. 
Closer examination reveals that the rate of decline has 
been an accelerating one. This is evidenced by the .slmip 
downward trend of the line of mortality. Had there 
been no increasing rate of drop tbrongbout the period the 
don-nwavd trend of the cniwe would liar-e been less steep. 
As the Registrar-General for England (.Annual Report for 
1^0) says; 

"Not only is the absolute fall (of morlalilA-) greater, but, as 
compareiJ with the lower level of mortality prevalent at the present 
day, the relative fall is' very much greater than would has'O 

[ 3512 ] 



702 April 28 , igiSj 


CAUSES OP DECLINE IN TUBERCULOSIS MORTALITY. 


f . Tiir Bmtm* 
Mkdical JocnNit • 


resulted from an equal absolute fall at an earlier period, had it 
ever occurred. 

The uniformity of the_ average annual decrement of mortality 
lopresents an ever-increasing acceleration of the rate of fall, when- 
measured in-proportion to the total extent of mortality remaining.” 

The acceleration of the drop of the death rate of all 
tuberculosis for England and Scotland respectively is illus- 
trated in Tables I 

Fig. 1.— SCOTLAND. ‘ 

Tubckculosis — Dcath f?Arcs — /( S /7 " /925. 


and II. Tlio numbers 
on tbo tables aro 
five - 3-early means, 
centring on tbo j-ear 
selected. If, in tbe 
case of England, rve 
compare successivelj’ 
tbo death rate of 
each of tbe j-ears 
1881, 1891, 1901, 

1911, and 1921 with 
that of ten j-ears 
before, the 1881 
death rate in Eng- 
land shows a drop of 

14 jjer cent., the 1891 
death rate a drop of 

15 per cent., the 1901 
death rate a drop of 
19 per cent., the 1911 
death rate a drop of 
21 per cent., and tho 
1921 death rate . a 

■ drop of 20 per cent. 

The corresponding 
figures for Scotland 
aro : the 1881 death 
late shows a drop of 
17 per cent,, that of 
1891 a drop of 21 per 
cent., that of 1901 a 
drop of 9 per cent., 
that of 1911 a drop of 
21 per cent., and that 
of 1921 a drop of 
31 per cent. 

Tho figures from 
Ireland (as shown in 
Tahlo 111) are simi- 
larly instructive. 

Ill Excess of Decline 
from Other Causes. 

All very well, says 
the cz'itic; but the 
decline in tubercu- 
losis mortality is in 
line with the drop in 
the general death 
rate, of which it is 
hut part expression. 

This is not so. The 
.accelerating drop in 
the tuberculosis death 
lato exceeds greatly 
tho drop in mortality 
from all diseases 
throughout the same 
period. The extent 
to which the decline 
in the death rate 
from tuberculosis (all tuberculosis, pulmonarj- tuberculosis) 
has exceeded that from all diseases is illustrated likewise in 
Tables I, II,, and 111. 

If wo take the last complete decennium, 1911-1921, the 
drop in the all tuberculosis death rate in Scotland (Table 
II) amounted to 31 per cent., and the drop in the 
pulmonarj’ tuberculosis death rate to 27 per cent., as 
against a drop of 7 per cent, in the death rate from all 
diseases. Taking the entire period of fifty jears, the 
death rate from tuberculosis was reduced bj’ two-thirds, 
while that from all diseases was reduced by rather less 



than one-half; or, viewed in another way (Tahlo JV), 
while in 1871 tho deaths from all tuberculosis constituted 

16.8 ])er cent, of deaths from all diseases, in 1921 tho 
deaths from all tuherculosis constituted only 9 per cent, of 
the deaths from all (li.sc!ises. And, .similarlv, irliilo in 
1871 tho deaths from jnilmonary tuberculosis" constituted 

11.8 per cent, of deaths from all diseases, in 1921 they con- 
stituted only 6.2 per ' 
cent, of the deaths 
from all diseases. 

Tho next point that 
occurs to one is. How 
does tho decline in 
mortalitj- from tnher- 
enlosis stand in rela- 
tion to mortalitj” 
from other groups of 
killing diseases? Tho 
facts arc so well 
known to joii that' 
detailed statistics are 
nnnccessarv. Broadly 
speaking, if wp com- 
paro (Table V, Scot- 
land) tho mortalitj’ 
of 1891 (mean of 
three j’cars round 
1891) with the mor- 
talitj’ of 1921 (mean 
of three j-cars round 
1921), we find, that,- 
of a 'total annual 
saving' of life in 
respect of all causes 
of death of 557 per 
109,000 of tho popu- 
lation, the decline in 
tuberculosis mortality 
is responsiblo for a 
saving of 126. Com- 
pared with this, the 
group of heart 
diseases shows a 
nogligihlo saving 
onlj-, while kidney 
aiul vascular diseases 
show an actual iu- 
cieaso of mortality, 
and cancer a markecl 
increase. 

Not Uniform 
Throughout the 
, Worhl. 

A coiniiarison of 
tho mortality from 
tuberculosis in Great . 
Britain with that of 
other countries is in- 
structive. Tlio mor-. 
talitj’ records in 
different lauds vary 
much, and tho de- 
clino in the death 
rate is correspond- 
ingly various. If we 
take Paris, as repre- 
senting France, and 
Vienna, as repre- 
senting Austria, attention is at onco arrested bj’ tho 
high death rate from tuberculosis prevailing in theso old 
centres of civilization. Tncidentallj’, these high figures are 
illniniiiating in v’iew of tho suggestion frequently made that 
diminution in mortalitj’ from tuberculosis throughout the 
world is the rc.sult of an advancing immunization of 
civilized populations against the disease. In Paris prior 
to the war the death rate ran about 400 per 100,000, and 
in Vienna apparently about the same number. After the 
war Franco began to look into tho matter, and during the 
past few jears there has been gradually instituted an anti- 


ApRITj sS, 1058] 


CAUSES OP DECUINE IN TOBERCUEOSIS MORTAMT?. 


r Tfrr; 7^nm«t» 7n^ 

' X Memoal.Toubvai. • fvo 


tii)ioicuIti‘.is morciiiciit. .In 1921 tlin ilonili vnin for Piiric 
was 286 i>er 100,000. In 1920 tUo ilciilli rale for Viriiiia, 
wVu'io inrilical oiKloavour nas imsoli ■(IiM>i oaiii-/.oil, nns ro- 
porlcd at; AOS per 100,000. 


Of coimlrie*. aliicli hold a cons])iciioiis jiKaro in rc.sjit'ct of 
oom-orlrd idforl a^niji.st tnliorrnlosi.s wo may taUo as an 
osamplo from Enropo (apart froin Groat Britain) Denmarlc, 

and from outside Enroim 


Fig. 2.— SCOTLANO. 

TuBEacuiosn —Abe Death Rates. 




TaUinj: tlie serernl arron- 
disspnients (districts) of 
Paris. M. Itenri Sellier, 
of the Office Pnhlio 
d’ Hygiene Soeiale dii De- 
partement dela Seine (Rap- 
port presente an Conseil 
General do la Seine, lleeeni- 
lier, 1927), indieate.s that 
eonsiilerahio differences are 
heginiiiag to show thein- 
solvcs in tlie , mortality 
rates, and that those differ- 
onecs are rt'ferahle to tlie 
differences in respect of 
aiititnhercnlosis activity. 

;The variation in death 
rate, and the amount of 
its recent decrease (or in- 
crease) in the Severn! arron- 
dissements is illustrated in 
the chart of I'ari.s (p. 705) 
prepared by JI. IMarccl 
Aloine, statistician to the 
Ooniite National. 

A similar ohservation has hcon pidili.shcd hy Professor 
C'onrniont in relation to the city of T.yons, where antiinhcr- 
culosis measures have heen applied for some twentx years. 

Tabw I.— ENOi.AKn ASi> IVat.es. 

Veatlis from All G<ttisef,froiii I'lilirroidoflt, ati(l/ioiii Fidinoiiary 
I'uhercidoH/. 

(Xnaibci’s ovo fivc-ycftrly means cealrius on the j enr mnaett.i 


p 


kpiipppi#. 

ss:sn:Ks 

iiili 

SpRSpSSS 

i| 

■1 

•#•*•*•*■* 

Ip*p»ppp«« 

BIppSpSpp 


RK::{:a 

sasasss: 



(••ppfpppj 


•pp«*SlS« 


pSSmp 

URmpSpi 

pppppppppp 

ilSxppffl 

Baaasj 

SSSSSS9!Sf 

M 

rM {•••MP 

■ppppppppI 

•paaippppp 



it. 

g;;«t 

iKiHsH: 

Rstsns 

USKSppS* 



Rsasau 


Ksst::: 

mitux 

Spppppppp* 

••ppppppp^ 

pin 

ySiH:! 

1 

iE 

HHui 

in 

Sf*5f5«5| 

isr^R 

tpppppppip 

jwUnnj 

pSSSSSSpSS 

Haaaa 

BW. 

yyilyy 



•ppppppSU 




is: 



ISi«35 







mSSmSS* 

kSHHi 

gx 

m 


SSJ 


pTpppSSSg 

PPPMPPPPP 




1§!»| 

mijns 

iHpXRK 

Jig|i[U 


II 

M 

PI 

KK^y 

iir-rsHj 

^^MMPPPP 

pmpSupSp 

as:aR» 

pppppppipp 

pppppppppp 

pppppppppi 

pppppppppp 




SUsH::: 


ss 

a 

5: 



•ppasppM 

aiaaiS: 

s 


i3 

igiSHa 

SSpSSpSppS 

??«««««!« 

••••pappB 

[: 

11 

H 

tiHHnH 


paxippppp 

PpaPPPpSSS 


s 

anisKji 

ssa 

'PP'PPMPPP 

ppppppptpp 



y 

H 


kW^PPPPP 

ppppppp*/ 

p»«pppp»p 

itilMUi 


1 

aSsin 

m 


m 

lli 

1 

1 

1 


■ 

ii 



Ywr. 

AU 

CrtUfos. 

i 

, Pulmcn.' 

H \ Tu»«<’ 

rtMtiiicf- 

Vo.’^r. 

All 

Cjuisos. 

TubCJ'Culosls, 

Pulmonnrj Tuhcj'cnlosls, 

j Both 
j So.NC#. ; 

Both 1 
Sc.xfs j 

Mnlo-. 

FtMtUllff.. 

Ilntlt ; 
SCNO'. 1 

MaU- 

1 Both 
! 8o\o>. 

Both 

So\cs. 

1 

MMcs. 1 

1 

Fcunlos. ; 

Both 

So.xos. 

Males. 





2<iiinl>tro/ Death 





Number cf Deaths. 




IS71 

531,93t 

69.593 j 

35,739 

33.851 , 

52.761 f 

26.125 

' 25.541 

1871 

75.495 

12,533 

6.ni 

6,422 

8,755 

4,029 

4,726 

1831 

517,293 

63,617 

35.760 

32,837 1 

■ 19.156 ; 

25.C99 

24.038 

185t 

74,271 

11,612 

5.587 

6.C25 

8,112 

5,713 

4,399 

1S91 

559.631 

65.216 

35,022 

30,221 ; 

15.315 

24.535 

20.980 

2891 

73,206 ! 

9.835 

4.858 

4.997 ' 

7,261 

3,426 

3,735 

1931 

551.276 

59,102 

35.062 

26,210 

11.1S1 

23.019 

17.865 

1 t931 , 

79.18S 

lO.COl ! 

5.075 

4,928 : 

6,910 

3,439 

3.471 

1911 


51,665 

23,666 

23,031 

37,551 

21,158 

, 16.206 

19U 

72,?03 ! 

8.466 : 

; 4,315 1 

4.151 

5.451 

1 

2,761 j 

; 2.693 

1921 . 

i 472,105 

«,023 

23,151 

19.866 

33,659 . 

18.291 

> 15.366 

1921 

69.145 ' 

5;912 ' 

' .3,025 ' 

- 2.917 

■ 4,091 

1 2.06S 1 

‘ 2,025 


1871 

1881 

1891 

1931 

1911 

1921 

1871 

1831 

1891 

1901 

1911 

1921 

1871-1881 

1831-1891 

1891-1931 

1531-1911 


Ueath Jlnfes jiry lOO.riCO oS Poinilatiou. 


the United States. 

In Denmark an intensire 
campaign has been main- 
tained f()r .some twcnty-rivo 
years, with large eontrihn- 
tions on tho i>art of the 
Government, fa 1001 the 
tuhercidosis mortality of 
Denmark was 210 per 
100,000, and in 1922 it was 
95 ]ier 100,000. Profe.ssor 
Knud Faher of Cojicn- 
hagen, whose judgement is 
worthy of high considera- 
tion, states that at the 
present time Denmark has 
the lowest death rate from 
tnhcrcnlosis in Europe, and 
traces this decline to the 
highly' concerted effort 
directed against the infec- 
tion. 

■ Taking New York as. 
tj^iical of. Araorican anti- 
tuhcrculosis work, for the 
initiation of which the late Dr. Hermann Biggs rvas 
especially responsihle; tho figures aro striking. Tim’s, 
in 1907,’ at the commencement of a special effort to- 

Table II.— Scotlasd. 

TXoth? from All Causes, /row Tiiierculosh, and from Piilmonari/ 
Tul/crcidoflt. 

(Numbers are fivc-j'carly means centring on tUe year nnmcil.) 


Jtales per jCO.OOO. 


2,210 

306 1 

323 

£99 

232 

239 

226 

1871 

2,217 

' 373 

381 

366 

26i 

252 

269 

1,992 

261 1 

283 

■ 247' 

169 

199 

180 - 


1,9SB 

311 

-310 

311 

217 

206 

227 

1.930 

225 1 

219 

202 

156 

173 

. 140 

1891 

■1.913 

215 

250 

210 

■' 178 

176 

179 

1.701 

182 

. 210 

156 

128 

150 

106 

1901 

1,771 ' 

' 221 

235 

214 

155 

158 

151 

1,393 

143 

161 

123 

2C4 

121 

87 

39J1 

1,529 

178 

287 

163 

115 

120 

110 

1,246 

114 

128 

' loo 

89 


78 

1921 -I 

— 1.416' 

122 

129 

115 

81 

88 

80 

109 

Comparison u 

Hit i<:i (= 

mi 




. . 

Comparison vith is: 

1. 



100 

100 

100 

ICO 


100 . 

1871 

'■ -100 

100 

100 

100 

100 

100 

100 

90 

SS 

. -SS 

85 

81 

83 

80 

1881 

• ,»8 

83 

81 

85 

83 

62 

84 

87 

74 

77 

.70 

67 

72 

62 

• 1891 

. 86 

65 

'66 

66 

68 

70 

$7 

77 

59 

63 

54 

55 

63 

47 ■ 

’ 1991 : 

' ■ 79 

' ■^63 

61 

58 

59 

63 

56 

63 

47 

51 

42 

45 

51 

33 

1911 

65 

48 

49 

46 

44 

48 

41 

56 

37 

40 

34 

38 

42 

35 

.1921 

63 

33 

34 

31 

32 

35 


Percentaoe Sect-ease ofSealh ItateSemmial. 



*. Fercentaoe Decrease 

of Itaie^Decenniat. 


10 

14 

12 

15 

19 

17 

20 

1871-1851 

12 

17 

19 

15 

17 

18 

16 

3 

15 

12 

18 

17 

13 

22 

1881-1891 

2 

21 

19 

23 

18 

15 

21 

12 

19 

16 

23 

18 

13 

21 

1891-1901 

9 

9 

7 

11 

15 

10 

16 

IS 

21 

22 

21 

19 

i 

IS 

1991-1911 

14 

21 

20 

21 

26 

24 

27 

I 11 

20 

22 

19 

14 

' 17 

IQ 

1911-1921 

7 

31 

31 

32 

27 

■ 

27 





















704 Araili 'zS, 19 ^ 8 ] CAUSES OF DECLINE IN TUBERCULOSIS MORTALITY. [ Titr nniTJfl* 


TABLE III.— IBELAKD. 

Deaths from All Causes, from Tuberculosis, ami from I’ulmonary 
Tuberculosis. 

(NumLers are five-yearly means centrinjl on tlio year nnnicO.) 


Year. 

All 

Causes. 


Pulmonary Tubercnlods. 

noth 

SCKCS. 

Until : 
Sexes, i 

Males. 

Fomalc'*. | 

1 

noth 

Sc.xes. 

Male-. 

Pcmalcs, 


Number of Denibs . 


1871 

92.647 

13,673 

6,775 

6,193 

10,234 

4.910 

5.291 

1881 

95,552 

13.8C4 

6.5S0 

7,224 

10,561 

4,831 

5,6S0 

18J1 

85.521 

12,787 

6.C99 

6,633 

10,016 

4.688 

5,328 

1901 

80,292 

12,407 

1 6,109 

G.238 

9.613 

4.633 

4,930 

1911 

73,845 

9,811 

' 4,879 

4,932 

7.593 

3,754 

3,812 

.1921 

66,867 

7,318 

1 3. 89 

3,829 

i 5,689 

1 2,671 

3,C18 




Rates per lOO.OJO. 




1871 , 

1,712 

253 

257 

249 

189 ' 

187 

191 

1881 ; 

1,856 

2-7 

260 

27J 

204 

193 

215 

1831 

1,818 

272 

253 

280 

213 

:02 

223 

19:1 

1,801 

278 

278 

1 279 

216 

213 

218 

1911 

1,632 ' 

223 

£23 

224 

173 

171 

175 

1921 

1,526 

163 

H8 

178 

131 

.121 

141 



Comparison U'Uh 2STL 



1871 

100 

100 

i 100 

10] 1 

100 

100 

ICO 

1881 

109 

1C6 

101 

110 ! 

103 

103 

113 

1891 

106 

108 

102 

112 

113 

1C 8 

117 

1901 

105 

110 

108 

112 

114 

114 

114 

1911 

93 

£8 

87 

90 

92 

91 

92 

1921 

90 

66 

61 

71 

69 

65 

74 


Percentage Increase or Decrease of Rate-^DereuuiaU 


1871-1881 

+ 9 

+ 6 

+ 1 

+ 10 

+ 8 

+ 3 

+13 

1831-.891 

-3 

+ 2 

+ 1 

+ 3 

+ 4 

+ 5 

+ 4 

1891-lSOl 

-1 

+ 2 

+ 6 

0 

+ 1 

+■ 5 

- 2 

1931-1911 

-7 

-20 

-20 

-20 

-20 

-20 

-20 

1911-1921 

-9 

—25 

-29 

-21 

-21 

-29 

-19 


Table IV.— Enqi.and and Scotland. 

Death Dates from All Causes, from Tuberculosis, ami from 
Pulmonanj Tuberculosis. 


0 

f-» i 

Death Hate 
per 1.0)0 from 
All Causes. 

Death Itate per ICO, COO. 

Deaths per cent, of Dentils 
from All Causes. 

Tuberc 

miosis. 

Pulmona ry 
Tuberculosis. 

Tuberculosis. 

Pulmonary 

Tuberculosis. 

Eng- 

L.nvl. 

■ 

Scot- 

land. 

Entr- 

laud. 

Scot - 
laud. 

Eng- 

land. 

Scot- 

la.id. 

Eng- 

laud. 

Sc-A*- 

land. 

Enjc- 

miHl. 

Scot- 

land. 

18?1 


22.47 

305 

373 

232 

261 

13.9 

16.8 

10.5 

11.8 

1831 

; 19 22 

19.88 

164 

311 

189 

217 

13.3 

161 

9.5 

11.2 

1301 

19.30 

19.43 

225 

215 

156 

178 

11.7 

11.8 

8.1 

8.6 


17.01 

17.71 

1 

; 182 

224 

128 

155 

10.7 

12.5 

7.5 

8.7 

1911 

13.98 

15.29 

143 

178 

104 

115 

10.2 

11.8 

7.4 

7.6 

1921 

12.46 

14.16 

114 

122 

89 

84 

9.1 

-9.0 

7.1 

6.2 


co-ordinate antituberculosis activities, more particularly 
by a combination of the institutions concerned with the 
dispensary control of tuberculosis, the tuberculosis death 
rate was 238 per 100,000. In 1921, notwithstanding an 
increase in population of a million and a half, the death 
rate from tuberculosis stood at 106 per 100,000. 

From the cities and counties in Gi'eat Britain various 
illustrations Tnight bo cited. For the present purpose one 
Avill suffice. The administrative county of Lancaster, n-ith 


Taiili;- V.— E.vgland and Scotland. 

Sarimi of Life jur 100,000 of Population, lSOl-1021 {O-ycarhi means). 



e 

-1 

1- 

5- 

10- 

iS- 

25- 

35- 

45- 

5 :- 

(5- 

75- 

England and 

IlVdfS- 

Ali cntificn ... ,.. 

72j 

8,935 

1,483 

192 

89 

155 

318 

587 

857 

1.338 

2.122 

3,330 

Pulmoimrj’ tuber* 

70 

(5 

21 

15 

22 

52 

12G 

166 

141 

1C5 

££| 19 

ctilosln 

Otlier tuber- 

^5 

818 

155 

27 

11 

2 

2 

2 

1 

42 

+ 3 ; +7 

Ifoaplratory tllfi* 

203 

1,756 

349 

21 

6 

17 

46 

120 

265 

737 

6C 

1,147 

ordem 

All other CAURCR 

405 

6,:2£ 

95£ 

129 

50 

87 

144 

299 

439 

491 

1,09. 

2,171 

.All cnuficR 

557 

3.931 

1,218 

293 

178 

252 

357 

493 

(62 

STC 

1.K4 

1,552 

Piilinonarj'tul'cr* 

97 

65 

33 

35 

58' 

155 


151 

96 

■ 

48 

18' 

cu'nsls 

0 1 h « r tuber- 

'29 

35J 

114 

40 

16 

+ 2 

44 

44 

+ 8 

4£. 

+7 

, 

entosia 

Kcsplratory ells- 

148 

933 

193 

29 

15 

22 

37 

no 

252 

1 

442j 

tSi 

551 

ortliTW 

All other caiiKC.s . 

!B3 

2.621 

878 

191 

69 

117 

148 

236 

322 

36; 

49S 

783 


a population of nearly two million, has, hy common agree- 
ment, one of the most com))reheiisivo .schemes, with whole- 
time consultant tuberculosis officers. The following table 
compares ten years jn-e-war, when there was no coinjileto 
tuberculosis scheme, with nine years post-war, when tho 
tuberculosis rt'Iiemc was more developed. 


Year. 

Piilinnnnry Tul-cr 
culi>*ls Death lilt 
I>er no.*'' 0 of 
Pojmlatlon. 

. . 

AvemKo 

Drath.^ 

hate.' 

Year. 

Pnlnionary Tiilx'r 
culo'is Ihit 

j>er JUu.iO'j of 
Population, 

( 

*! Areraijo 
Death 
hate. 

Prc-tvnr. 



Post-Wrf. 



'l«5 

ss 


1919 

80 \ 


1006 ■ 

85 


1520 

76 


1S07 

91 


■1921'- 

73 


1903 

£5 


1922 

77 


1909 

69 

86 

2923 

70 

>■ 70 

1910 

80 


1924 

68 


1911 

88 


1925 

67 


1912 

85 


1926 

64 


1913 

82 


1927 

61 


1514 

87 / 






These examples might bo multiplied. Enough has been 
ited to support the view that, whore special anti- 
iiberculosis work is undertaken, results follow, and that, 
onvorselv, iu proportion as a ?ais,scr-/airc policy 's Piir- 
iied little happens. Taking the map of the world, it 
N-ms fair to sav that' the more striking declino in 
mrtalitv fi'om t'nberculosis is to be found in those 
mutries where co-ordinated measures against tuberculosis 
aA'o been continuously applied throughout a sufficiently 
roloiiged period. AVhere tbero is no marked declino one 
lay iirotty surely predicate the absence or slackness of 

jiicortccl cftoi't'* 111 

A fiirthor interesting comparison is to oo found bOLWcen 
rbaii- and rural districts. It is frequently stated that 
iborculosis is a' disease of cities and that country areas 
re relatively exempt. This is doubtless true for the most 
art. Referring to tho point however, a recent "•‘‘tor m 
lo .imerienn Beriew of Tuberculosis (Octobm-, 

535) says that, while it was true at tho begiiinmg .of 
lo century, “ there is now evidence that in rural Aew 
ork (State) the mortality from tuberculosis has since 
soil in excess of the urban mortality, and that this excess 
as increased year by year”; and with reference to tho 
imo point, tho editor of that review says, “ AVo are 
istified in tho assmiqition that tho antituberculosis cam- 
aigii, immeasurably better carried on in tho cities, is 
igiiining to toil, is therefore fundamentally sound and 
Feot.ivA on/1 vaanc'+ lio r\i*irnni ved to more nurnoso in the 



















CA-XJSES OF DECMNE IN a'lI^KCIILOSIS^MOR^^^T. 


Ai'UlIi sS, 1938 ] 

” , In UocDil)'' tUis arc tl.c i.rcscnl IurU 

'rrl'litv laL rcc!.rttc<! fro». tl.o i.slamls nf Srnllautl m 
ccmi-ariswi witli tlinsc of tl.o country as a xrliolc. 

infer, .rr/n(ioa 0 / Th-rlinr: rou/iil,„ton, 7;’nrf««. 

Scv "t:'r 

^::[ts‘causca tue tl!? ^.u" 

lu'^bo u factors. SVc stuUl all 

a ", -00 that evc,rv influence which has uuve e lor f >'■ physio- 
U^^ital welfare of the commumty ’I 

the rciluction of the luherculosis (leatli ial« as of tlie 

i"- "[ “".fr' 

interest in .sanitavv matters, whirl, roin.ne.ue.l n. IJcta... 
some ciffhtv vea.-s as<> and resulted m the aiipointmenl of 
the RovarConunissiou of 1869 was a l.r.ma.> «f 

first imVovtance. the reim.-t of that Co.unu^su,.. n. 1871, 
and the estahlish- 
luent of the Eocai ■■■ + d* 0 * ® -t 
Oovernmeut Board, 
meant a ,)ractieal 
awaUenin,; thronpli- 
out the land. The 
powerful wash of the 
wave is well illus- 
trated hy the re- 
markahle words of 
Lord Beac-onsfiold at 
Itlnuchcster in 1872: 

“ After all, the first 
consideration of a 
Jlinister should he 
the health of thu 
people.” It is note- 
worthy that the sreat 
statesman looked he- 
yond disease to the 
goal of health. 

Another significant 
influence has hcen 
the general edneation 
of the people during 
the past fifty years. 

This has meant a 
wide diffusion of 
knowledge hitherto 
restricted to a limited 
portion of the com- 
munity. Alongside of 


r TntnnmsB 705 

tMrpJCALJokTisil. ' 


Tjc. 3.— Decline oC annual mean death r 
various dislricls of Pari^ bc t\NCCn 


dcivirtment of the State, which in turn functions and 
dii'ccts in ohedieme to the demand of enlightened pnhlio 

”‘’Sso wide inllncneo.s, which have hoen reflected in tho - 
reduction of the gencial mortality lull of the ° 

no less cc. tniidy played their part ... the decline of tuhoi- 
eiilosis mortality. The more tho natural history of tuher- . 
eulotis is comprehended, the more free y w. I the- va no 
ho admitted. No serious worker 1.1 ttiheicnlosis mil fail 
to give them their proper place. 

Spcciatizcd Vnerfion of Effort. 

None the Ies.s, tlic student of tnhere.ilosis cannot hut 
believe that tho.se general influences would not have 
hromdit ns to the fortunate iiositioii in which wc stand 
to-dav, apart fioin the moie definite direction and eon- 
centratiou of effort, towards the special prohlcm of tul.oi- 
cnlo.si.s. Indeed, this eoneentratmii of study mth legal d 
to an infection whose hlighting properties may he traced 
' from Itio cradle to old 

agi' has actually hn- 
jii’Ueil many of the 
advances in hygiene 
which our generation 
has witnessed. Tho 
tracing of tuher- 
eulous infection to 
the home, and the 
detenninarion of its 
early manifestations 
in the child and of 
its presence in other 
contacts, the reeog- 
nitimi of prejudicial 
iiiflucncos in certain 
occupations, the 
revelation by the 
sanatorium of the 
marvellous influence 
of open air and sun- 
light, have widened 
the horizon of pre- 
ventive medicine. 
Tlie recognition and 
application of those 
principles has led to 
progress in other 
fields Imyond tuber- 
culosis. 

In an address 
urging the establish- 



■ale from pulmonary Uibcrculosis iu tUe 
the periods 1909-13 and 1919-23. 


munity. iviougsmi- * f 

this we note the various nioveineiils for the hctteiincnt 01 
housing and working conditions, tlio associated ri.se of the 
standard of living, hclter wages and hettor snpidies, am 
the regulation of working hours, witli greater facilities lor 
regulated rest and open-air activity. 

Among measures directed particularly towards the maiii- 
teiiancc of health .should he included the Natioual Health 
Insurance Act and tho medical examination of school 
children. Tho health interests of tho iiisuicd portion of 
the community were placed more definitely in tho hands of 
the general body of tho medical profession, and the child 
was submitted at an important stage of his development 
to the trained medical eye of the school officer. With this 
should he linked the inoic recent direction of attention to 
jnohlcius of maternity and child welfare. By these several 
avenues it has been possible to approach and anticipate 
the beginnings of disease in a way previously impossible. 

Those influences — and the brief catalogue might be 
extended — liave tended to increase communal vitality and 
to limit the tendency to, and the ravages of, disease. 
They have been the cause of the gratifying drop in the 
general death rate of the country, urban and rural, ami 
in tho mortality rate registrable in special groups and 
aieas. It is impossible to emphasize overmuch the snni- 
tarv advantages which have accrued fiom the cstabii.sh- 
ment throughout the country of a uniform co-ovdinajted 
he.altli service composed of highly trained graduates in 
medicine, under the inspiration of, and responsible to, a 


‘**0 "0 VOfctlUllOil 

] incut of sanutorinms at tho first British Congress of Tuber- 
( enlosis in 1901 I veuturcc! to say ; 

j It seems Id me that wo arc on llie Uu'cshold of a still wider 
I dcvolopnicnl iu the application of the open-air principle. In our 
I Ireatmcnl of disease we want to realize more fully that the action 
I of pine flesh air is directly curative. In the adaptation of the 
system to other medical conditions there seems to exist the 
potential of successes comparable to, if not so «^lnking in character 
as, those obtained in surgery through the adoption of aseptic 
measures.’' 

Only ilie other day Professor G. Bnbertson of tho 
lloyal Kdinhnrgh Hospital for Mental and Nervous 
Diseases, in pleading in his annual report for a larger 
outlook on mental disease, says : 

** How comparable Uiis new psychiatric crusade to the suc- 
cossfxil campaign against ttibcrculo'ib. . • • Forty years ago 
patients were sent to hospitals with cavities in their lungs and 
in tlie last stages of tlie disease. Ari’angcmcnts were therefore 
made to discover the disease at an earlier and more hopeful stage; 
out-patient clinics and dispensaries were instituted; finally, the 
family and the home came under review foi early and preventive 
ii'eatmciit. Let psychiatiists go and do likewise, and may they 
be as successful." 

The forward march of preventive medicine during tiio 
past fiftv years, iu which members of this society have had 
an honourable i>laco, has led to numerous triumphs. Theso 
have been achieved hy many means — sometimes by the 
application of general physiological principles which, in 
XU’oportion to success in application, negative disease, 


706 April i8 , 1928] 


TEBATMENT OB ACTJTB APPENDICITIS. r Tniunmi. 

L MXDICAI. JOCBKUt 


Bometimes by speciijlizod determination of effort towards 
particular issues. In relation to tuberculosis both lines 
of approach havo tended towards tho decline of niortalitj'. 

A TuTjcrclc-frcc Herd. 

My view regarding tho control of tuberculosis in the 
human species is in keeping with the lines on which tho 
farmer can establish and maintain a tubcrclo-freo herd. 
When tho Tuberculosis Trust of Scotland resolved to form 
such a herd procedure took two directions ; (1) towards tho 
elimination of infection within and tho exclusion of risk 
of fresh infection from without; (2) towards tho main- 
tenance of tho herd under completely physiological con- 
ditions of environment. The first requirement was met 
by the institution of careful antituberculosis measures 
and application of tuberculin tests, and the second by 
scrupulous regard to air, sunlight, space, nutrition, cleanli- 
ness, and tho education of farm and dairy hands. Inci- 
dentally, it may interest members of tho society to know 
that the young immature stock (prior to milking age) passed 
the whole of last summer — web though it was — and tho 
whole of this winter — cold and stormy as it has been — on 
a hill pasture at an elevation of 800 to 1,000 feet, in tho 
open air, day and night, without one case of sickness. 
AVo began operations five years ago, and for tho last threo 
years tho entire stock, numbering 109, has stood tho rigid 
tests imposed by tho chief veterinary inspector of tho city. 

In handling the more complex problem of tuberculosis in 
man, medicine has in view both sides of tho shield: first, 
the limitation (exclusion?) of infection; second, increase 
of resistance. Tho tuberculosis scheme, as built up in this 
country, rests largely on those foundations. On tlic ono 
hand, every fact in tho natural history of tho infection 
comes to havo value, along with facts from comparative 
study of other endemic and epidemic diseases. On tho 
other hand, tho groat physiological principles which pre- 
ventive medicine has known how to harness and hitch to 
her wagon on other j’oads have been adapted to tho problem 
of tuberculosis,- and havo been expanded by tho convincing- 
lesson of tho sanatorium and open-air school. 

Scientific Patience. 

For tho appraisement of results patience is 1100055017 — 
scientific patience. It is essenti.al to rjomoniber that tuber- 
culosis differs from other infective diseases in respect of 
duration and of clinical expression. It is a disease of a 
lifetime — it may be from infancy to old age — and its 
protean manifestations change with tho seven ages of man. 
Assuming that our antituberculosis measures aro sound, wo 
cannot expect tho entire effects to bo registered quickly. 
The gains can bo gradual only,, with acceleration of tho pace 
as time goes on. More marked reduction is likely to bo 
evident at certain ages in relation to certain aspects of 
intensive activity. That is pretty much what wo aro 
finding a postponement of death, a saving of life in 
childhood and in early adult life. 

Tho Eegistrar-General for Scotland, Dr. J. C. Dunlop, 
to whom I am indebted for invaluable co-operation on tho 
statistical side, has drawn my attention to the remarkable 
fact (Table V) that, out of a total saving of life in Scotland 
between tho ages of 15 and 35, during the year 1921 as 
compared with 1891 (three-year mean), moro than Imlf 
was duo to reduction in mortality from pulmonary tuber- 
culosis. 

To me, as a fairly seasoned hand, tho outcome appears 
satisfactory. . In so complex a situation it is hazai-dous to 
attach rigidly , cause to effect. - Bather than try to credit 
the result to this or that particular factor it is, in my 
opinion, more just and. sound to admit that there have 
been numerous contributory factors. The continuous 
decline in mortality, the recent acceleration of that rate of 
decline, and the displacement of tuberculosis from chief 
lilace in the list of killing diseases, havo been duo to a 
combination of influences and activities which have found 
practical expression in the tuberculosis schemes of tho 
couutiy. To tliis it should be added that, when all is said 
and done from the side of medicine, another factor of 
governing importance must not be lost sight of — namely, 
the determination of the nation to face the issue, cost what 
at may. ' - - . 


THE TEEATMENT OE ACUTE APPltNDIClTIS/' 

BY 

H. H. EAYNBll, M.B., F.R.C.S., 

CONSOLTINO SURGEON, MANCTIESTER CIIILDBEH’S UOSPITAI.; SENIOR 
ASSISTANT SURGEON, MANCHESTER ROYAL INEIRMARY. 

Ijt .a consideration of tho treatment of acute appendicitis 
it is relevant to point out that tho number of deaths -from 
this disease in England and AValcs has not diminished 
during tho past fifteen years, yet it is certain that tho 
proportion of favourable cases — that is, the early case.s — 
that arc submitted to operation is much higher now than 
it was fifteen years ago, and also if is fair to a.ssunic that 
tho improvement in operative technique during tho same 
period must havo helped to reduce the case mortality. 

It may bo suggested, tlicroforc, that the maintained 
national mortality rate is duo to an increase in the number 
of cases — an actual increase or an increased recognition 
of tho disease. An examination of the annual statistical 
reports of the Manchester Royal Infirmary shows a steady 
and substantial increase in tho number of these cases during 
tho last fifteen years, but during the same period at this 
hospital the case mortality- of the disease has fallen to such 
an extent that tho gross number of deaths tier annum at 
tho end of the period is iniicli less than it was at the 
beginning. Thus in tho practice of one of tho largest 
general hospitals in the country a steady increase in tho 
number of cases during tho past fifteen, years synchronizes 
with a substantial fall in the actual number of deaths from 
this disease, and, that being the case, tho maintained 
national mortality rate of acute appendicitis ought to 
bo a matter of concern to tho surgeon, particularly if 
ho is also a toaclier of surgery. 

Tho foregoing remarks aro based on tho following 
statistics. 

Aeii/c Appindiciti) and Prrlfi/p/ililis in Kngland and Wales. 

(From the Registrov-Gcncral’s Eotiirns.) 

Average onnual number of deaths per million persons during 
tho four years ending 1914 =7U. 

Kvnrana auuuaf iiumbcv of deaths per million persons during 
the four years ending 1926 = 72. 

.Vancticstcr Uopal tnfirinar!/. 

In) In the threo years ending 1915 tho average annual number 
' ^ of admissions of acuto appendicitis = 550, or 5.4 per cent, 
of the total admissions to hospital. 

Avcra'»o annual number of deaths from acuto appendicitis 
in same years = 69. 

lb) In tho three years ending 1926 tho average annual number 
' of admissions of acuto appcndicitis = 850, or 7.6 per cent, 
of the total admissions to hospital. 

Average annual number of deaths from acuto appendicitis 
in same years = 48. 

Policy of Immediate Operation. 

An account of tho treatment of acute appendicitis cannot 
ignore tho divergence of opinion among surgeons on tho 
imlicy of immediate operation in all cases irrespective of 
tho duration and pathological development of the disease. 
Surgeons in this and in all other countries in which 
appendicitis is prevalent agree in advocating removal of 
the appendix in all cases in which the disease is still 
limited to tho appendix, before perforation or before tbo 
onset of a local or spreading peritonitis, and no one with 
any experience of ' abdominal surgery, I think, would 
venture to criticize this policy. It may bo assorted with 
confidence that there is no more beneficent operation in 
surgery than the removal of a gangrenous or tightly dis- 
tended appendix whilst this is still intact. So, too, at 
tho other end of tho scale, when a case is seen for tho 
first time late in the course of the disease, and on the ono 
hand there is clearly an abscess, or on the other hand tho 
disease is manifestly subsiding without suppuration, no 
one would dispute the' projiriety of operation for evacua- 
tion of the abscess in the one or of a policy of masterly 
inactivity in tho other. But it is in between these two 
stages that tho surgeon first encounters tho groat majority 
of his cases; in this largo group peritoneal infection has 
taken place which may be localized or diffuse, an d even if 

* A paper read before tho Manchester Surgical Soollty ca December 6th, 
1927. 


APnili aS, 1938]- 


TBEAXMENT OF ACUTE APFENOICmS. 


r TitiDnmsa 707 

L M«DtCAt. ^ 


localized the iilteiisitv of the infection varies considerably 
menrding to the type of aj)iiendicnliu- lesion. It is in llie 
tveatiueut of cases in this gronji that there is .some diifer- 
•enco of opinion : tiumgli it is i.roliablv correct to .say tlmt 
the great maiovitv of surgeons advocate immediate oiicra- 
tioii, and tliat those mIui advise postponcnleiit of tlic 
operation nio dceidedly in tlie minority. 

The advocates of po.st)ionciiient, aniongst whom are 
Ehcrren,' Me'KoiU T.ovo,= and some of Itie .surgenns of 
St. Thomas’s Hospital, advise tlial in those ca-es of acute 
appendicitis ivhieh come nnder the notii'e of the surgeon 
only after perforation and tlie onset of peritonitis, local 
or sjireadiiig, no opcralion should he performed until the 
patient's response to careful iian' 0 |icralive treatment 111 
liospital or nursing home lias hoeu ohservod ; that approxi- 
matelv in two out of three .such eases the di,-e,i-e either 
will s'uliside entirely or will terminate in a uell-Ioialized 
abscess which may ho safely and simply evacuated after 
the acute pliaso has passed; and that those case-, in ahich, 
after a period of one to three days, tlic disease appears to 
be extending, the operation ran bo carried out aitbout 
more risk to life tlnni obtnin.s wlien the operation is 
carried out at once. In nil tliose cnse.s in ivhieb llie 
disease siihsidcs a-it!iont operation, append uedoniy is 
carried out as soon as' it appears wise to do so. In siinnort 
of tins policy of delay is it urged; (1) that the niortnlity ; 
rate in tins large group as a whole is reduced ; (2; that the 1 
incidenco of post-operative complications is Mil)-.taiitially 
Toduced-, (S) that the period of illness and ilisabitity is 
shorter and less trying to the patient. 

My own opinion in this matter is l.argely influenced by 
the experience of a recent series of 245 cousocutive cases of 
acute appendicitis, all of which have been under my caro 
and have been closely observed by me. Ko e.ascs wbieh 
, ivere manifestly settling down at the lime 1 first saiv them 
have been included in this series, fn 52 ol these the 
operation was postponed, and it .should he said that in 
scloctitig these at the time of tlie first examination 1 chose 
them from the large group of local poritoniti- cases, and 
in no case was operation deferred for spreading or diffuse 
'peritonitis. AH of them were treated in liosjiitnl or niii-s- 
.ing homo. Tho results in those 52 can ho grouped in three 
classes : 

A. — Twcnly-cigbt sctlleil down coniplctetv within one to two 
weeks. AU but 3 bad appciidiecctomy pe'rforniod a few weeks 
after scttliag down. There were no deallis and no coinpiiealioiis. 
There is no doubt in my mind llial nmiiv of these case- .-oored 
Iieavily by this policy. 

B. ^ — ^Tivelvc cases terminated in liic formation of a local abscess 
wliieh required operation for drainage; in 8 of them it was 
impossible to remove tlie appendix, but of these all sa\e one sub- 
mitted to appeiidicectomy a. few weeks later. There wore no (h albs 
and no serious compticalions in this group, Uioiigli the beahng 
of tlie drainage track occupied four to six weeks in llircc of them. 

C. ' — Twelve cases required oporaliou during live acute stage after 
eriods of delay varying from one lo four days. Tlicre wore 

deaths; of these, 2 were due to inle-Slinal obslriiclioii. which 
in one case was prcseitt at llie time of operation and was the 
reason for tiic operation, and in tlio olbt'r u developed three 
weeks after the operation when the patient was toady for 
discharge from hospital ; one death was ascribed to acute toxaemia 
a few hours after operation; in. this case the operation was not 
performed by me. but as I advised delav in this case, and two 
days later advised opcralion, it is rigid' to include it. Of the 
h, ^ recovered the appendix was vemoved in 8. In one 
of them the condition of the patient unquestionafaiv became much 
worse during Uie period of delay, owing, to toxaemia from a pro- 
gressive abscess and to associated ileus. He was oiilv retrieved by 
opcration for evacuation of the abscc'ss and mobilization of llie 
tm'minal ileum, followed by assiduotis'aftor-trcatment. 

Ill 193 cases (approximately four-fifths of the whole scries) 
the opoiatioii, was performed without delay after the fiust 
.examination irrespective of the duvatiou ov stage of tlic 
disease. These may be grouped into' the followiug types. 

Group A.— Jppnidix iiof rcrfornttil [ 6 j fV/srs). 

Many of these cases were iiislan'ccs of gangrenous appendicitis, 
and several yielacd a Instory that covered more than two tlavs — ^the 
cojiventjonni duration of the pre-perforalive singe. 

There was one death from . putrnonarv ctnhorisin eleven davs 
after operation, in a stout woman of alcoholic habits, 
Comp/frai/Dt}x. One patient developed panopUtbaUnitis twentv- 
eight dap ’after operation; two weeks after operation, when 
appaicntly well, he was allowed to get up; the temperature rose 
the same night and assumed a sepljcaemjc type for tho next four 
weeks. The eve was evenluallv removed. In the notes on the 
operation made by mo the same day it is stated that the 
appendix, n high rclrocolic one, was eiiliiely gangrenous* and 


during extraction some leakage of its contents was unavoidable j 
ibc wound sunpuvated a little. There was one case of minor 
putinonnry emoolistn. In C cases there was a mild degree ol 
wound sapput'fliioii. There were no cases of post-operative 
piieuinoiua. 

Group B. — Lora! rfritonitia 

Tho cases in this group bad pus in the peritoneal cavity around 
the appendix, usually associated with perforation of the appendix, 
but in Rcveral llmro was jio visible perforation. 

TUevo were two dcattis, one fronv intestinal obstruction, that 
began six days after operation for pelvic porilonilis— a case with 
a History of only twenty-six hoin*s' illness before operation. The 
other death was‘ from sepliciiomia (? portal pyaemia) eiglit weeks 
aher operation and Uvo weeks after discharge from hospital. This 
man was in good condition when discharged homc,^ but there was 
a clean sinus in tlie wound; his homo surroundings were very 
bad, un<i the dressing was done by his aged wife. 

C'owi?)h'f« There w'crc 7 cases of posL-oponstive pneumonia 

(4 of these were in children under 12 and all except one wore on 
the right side). One patient had intestinal obstniction, subacute, 
and recovered without operation. There was one case of pelvic 
abscess requiring drainage by tho rectum fourteen days after 
operation, and tlierc was one case of subphrenic abscess. 

Group C.-^Sjfrraflhti/ or Vif/uxr Perifoniih (.11 Cnsrs). 

The condition was always associated with a visible perforation in 
tho appendix or with a leaking appendicular abscess. In the former 
type the liistory in 17 cases did not exceed forty-eiglit hours; in 
tho latter type the history clearly fell into two phascs—lhe fust 
phase of moderate pain 'and vomiting, often not causing total 
{ncapacily, and the aecond phase, beginning two lo four days 
later, marked by sudden onset of very severe pain and more or 
less collapse^ Only 2 cases could be classed as having general 
perUonitis, and Ihc^e account for 2 of the deaths. 

There were 4 dealhs in this group, as follows : One case of ileus 
and secondary haemorrhage of undetermined origin despite 
inor/cHi examination'— case of general peritonitis. One case of 
general peritonitis four days after operation — case of general 
peritonitis at operation; vnsf^tnorfntt examination. One patient 
died under tho anneslhetic — cthor convulsions. The fourth 
death was that of n patient with ileus plug pulmonary' oedema 
eupervenin^ on chronic bronchitis and emphysema. After admission 
ot this patient lo the home the operation was delayed for twelve 
hours because of Ins bad general condition; in addition to chronic 
bronchitis he was very fat and heavily addicted to alcohol. His 
condition appeared to 'be worse, locally and generally, after twelve 
hoiir.s, and 1 regarded his chance of recovery as very small with 
or without operation, but as slightly Inghcr with operation. 

Comp/irationg, — One case of acute intestinal obstruction seven 
days after operation; the patient recovered after enterostomy. Ono 
case ot pelvic abscess requiring drainage bv the rectum. One ca.se 
I of subphrenic abscess drained two and a haU months after operation, 

' Four cases of pneumonia of the lower lung— on the right side in 
three and bitaloral in one. Two cases of breakdown of •vround 
with extrusion of bowel on to the abdominal wall on the seventh 
and eleventh days respectively. Botli were associated with severe 
wound infection and pci-sistent cough. Both recovered after 
rc-siUme and support of the abdominal wall by adhesive strapping. 

Group D. — /(6«ccfi:s (IJ Cases). 

This group consisted of patients with a history of seven to 
fourtecii days' illness. There were no deaths. Thc"^ appendix was 
removed in 4 cases only. The one complication was in a patient 
with n minor type of pulmonary embolism. 

The summarii^cd rrsnlts in the whole scries is as follows; 

24S consecutive cases with 10- deaths, or mortalitv rate of 
4 per cent, 

193 cases ^ 01-0 opeiatcd upon at once with 7 clc.-iihs, or iijoi- 
laiity rate of 3.6 per cent. All these, except those admitted 
m the terminal abscess stage, had the appendix removed. 

52 cases liad their operation postponed witli 3 dcatlis, or mor- 
tality rate of 5.7 per cent. 

In 24 of iiioso oporation Jiad to be performed diii'ing the 
acute stage or because ot abscess, and in 9 the appendix 
was not removed. 

It iiiay bo that it is misleading to compare tlicse two 
mortality rates, for the cases operated upon at oiieo iiichule 
62 in wUicli the appomlix bad not perforated and in vrliicli 
thoro was no marked degree of local peritonitis, whilst all 
the _ deferred ones presented clinical evidence of local 
perito!uti.s ; on the other hand, the deferred cases do not 
include the more severe types, for in no case was the opera- 
tioi} postponed in diffuse or lyidespread peritonitis. Heinoye 
tho iioh-pcrforated cases altogether and the mortality rates 
arc 4.6 and 5.7 per cent, for immediate and deferred cases 
respectively. 

In attempting to measure tho value of the policy of delay 
I attach move importance to consideration of the features 
of the more severe cases in each group. Of the 7 . patients 
who died in the immediate class, in 3 tho duration of the 
illness before operation did not exceed thirty liours- 2 of 
these had perforated and had pelvic peritonitis,’ and 
I think it very donbtfni if tho advocates of delav after 
perforation would have elected to practise tho method in 


708 April 28, 1928] ^ TREATMENT OE ACETE'’APPENi>IOITI 3 . ' 


such early and severe cases ; one (death from pidmonai’y 
embolism) had not i^erforated, and is theroforo irrelevant 
in this argninent. Of the 4 remaining deaths, one, a yonth 
in relativol}- good condition, died of ether convulsions 
during the operation, and the 3 others presented at the 
operation such w idespread peritonitis, coupled in 2 with a 
very unfavourable general condition, that there is not the 
slightest ground for thinking that delay would have altered 
the issue in any case. As alrcadj' stated, in one of them 
a delay of twelve hours was made on account of tho 
patient’s unsuitability for anything but imperative surgery. 
Now of tho 3 deaths in the unsuccessfully delaj-ed eases, 
one died of acute intestinal obstruction during convales- 
cence, and his death cannot, in my opinion, bo attributed 
to tbo delaj' in operating; but in tlic matter of the 2 other 
deaths I felt at the time that their prospects of recovci-j' 
had been reduced by waiting. Tben of the 9 who recovered 
after a delayed operation done in the acute stage, one at 
least ran a much greater risk than he woidd have done if 
he had been operated upon when first seen. Deterioration 
of the patient undergoing non-operative treatment for 
appendicular peritonitis is not merely due to extension of 
tho peritonitis or an* increase in size of the abscess, but 
often is the outcome of ileus caused by implication of tho 
lower ileum in tho walls of tho abscess cavity, and to the 
resulting inflamiuatoiy infiltration of tho bowel wall. 

Of tho 115 cases with local or diffuse peritonitis which 
were operated upon at once tho majority of these made 
rapid recoveries (70 of them wore soundly healed within 
two and three weeks), and all without exception had the 
appendix removed. It seems highly improbable that the 
delayed method would, if it had been employed in all of 
these, have given results nearly so good. 1 am therefore 
opposed to tho policy of delaying operation in all those 
cases of acute appendicitis in which ])crforation and 
peritonitis, local or diffused, has occurred. I think any 
policy based on a sharp distinction between the periods 
before and after perforation is unsound. Some of tho worst 
cases in which operation is urgently required are those 
that begin with perforation ; I have operated upon several 
such cases within four to six hours of tho first symptom 
and found a largo perforation, whilst in tho loss acute types 
it is frequently not possible to dotormino with precision 
whether perforation has or has not occurred — particularly 
so in pelvic cases. So, too, any policy based on the 
duration of the disease — that is, a policy which lays down 
that cases seen within tho first forty-eiglit hours .shoidd bo 
operated upon at once, but that in those seen after the 
second day and up to the fifth or sixth day tito operation 
should be delayed — is ill founded ; observations at opera- 
tions, if correlated with the history of tho case, will show 
that time and pathological progiess do not keep pace. In 
my belief some of the third-day cases are those in which 
the immediate operation is most essential, in view of tho 
pathological conditions revealed at operation, and, in the 
hands of an experienced operator, tho great majority of 
such cases do very well. To hold these opinions is not to 
believe that every case of acute a])i)endicitis should bo 
operated upon at onco simply because the disease is regarded 
as active. It is certain that a considerable proportion of 
cases, even after the occurrence of peritoneal infection, will 
subside under proper treatment without operation,’ and 
that if we were able to pick out these cases we might in 
many of them defer the operation, with, great advantage 
to the patient, to a quiescent period. But to make this 
distinction in all it is necessary to keep the patient under 
- observation for one to three days, and most surgeons feel 
• that the advantages to the patient who does settle after 
' this period are outweighed by tho increased risk to the 
patient who does not. However, I believe it is possible to 
exercise discrimination in some withoyit adding to the risk 
of the others. 

After all, the tendency in the past twenty years has been 
to init the operation for acute appendicitis almost on tho 
same footing in the matter of urgency as tho operations 
for acute intestinal obstruction and perforated gastric 
ulcer, and in 10 per cent., or possibly 20 per cent., of the 
appendicitis cases this is correct. But is it right on that 
account to abandon all effort at discrimination in regard 
to the 80 per cent., especially in view of the commonness 


of tho disease and tho conscquenco that tho operative wor 
must therefore at times bo performed by those whos 
training and experience do not fit them to undertake sue 
an important and serious operation? In seeking a basi 
for this discrimination, though I have argued that it i 
unwiso to attempt a h.ard-and-fast division into classc 
according to lapse of time or occurrcnco of perforatior 
I think wo may from our clinical experience and obsoiwr 
tions at operations recognize certain types in which it i 
safer, and in other ways bettor for tho patient, tha 
immediato operation shovild not bo undertaken. SucI 
for example, as the following. 

1 . Tho patient who presents a firm hard mass in tb 
right iliac fossa, in tho right loin, or over tho fore par 
of tho iliac crest; tho mass is ill defined at its edges, i 
often extensive, and is free from marked tcndcrne.ss. Th 
history shows a duration of four to eight days, and duri:ij 
much of this timo the patient has had insufficient or iii 
treatment; ho has been out of bed and possibly at work 
Such a case will commonly subside entirely under propc 
treatment; much less frequently the mass will slow!; 
resolve itself into a well shut off abscess, which can b 
easily and safely opened. An immediato operation in sud 
a case is likely to prove difficult and unsatisfactory to th 
surgeon, and the convalescence following it will bo pro 
traded and troublesome. Furthermore, an operation jicr 
formed ns an emergency in this typo of case will nov 
and again disclose a mistake in tho diagnosis — a mistake 
which may involve the surgeon in an operation for whicl 
neither he nor the patient is suitably prepared. 

2 . Tho patient in an earlier stage of the disease, witl 
a liistory of two to four days’ illness not marked by ! 
severe onset, who presents an area of wcll-localizcd musculai 
rigidity, witliout extreme tenderness, over the’ appendicula: 
site, llis temperature is raised, his ))ulso modcrateh 
accelerated; tho increase of both is often accentuated whci 
first .scon by recent transit to hospital or home. Sucl 
a patient is by no means always best dealt with by imme 
diato operation, and tho following circumstances shoulc 
bo regarded as indicating a temporizing policy in this type ; 

(o) Retrocolic position of appendix as shown by positioi 
of rigid area and of maximum tenderness.- 

{h) Condition of patient unfavourable for an .abdomina 
operation without a period of observation and preparation 
by reason of stoutness, chronic bronchitis, especially i: 
there is much emphysema, alcoholic habits, and senility. 

(c) History of many attacks of approximately equa 
severity in the few years preceding this attack. 

(d) An environment unfavourable for .a serious abdomina 
operation and for the necessary after-care of the patient. 

On the other hand, a patient of healthy type who present! 
localized but well-marked rigidity accompanied by cxtreim 
tenderness, and whoso history indicates a severe onset oi 
a severe exacerbation since onset, should generally bi 
operated upon without delay. So, too, evidence of .i 
pelvic position of the appendix or of spreading peritonitii 
is strong ground for the performance of an immediat( 
operation. 

Finally, I would suggest that in those cases in which thi 
disease is allowed to subside without operatipn it is wis( 
to allow an interval of three to eight weeks before under 
taking appendicectomy ; a long duration of tho process cl 
settling down demands a long interval before appeu* 
dicectoinj'. 

Technique of the Opehation. 

- Incision .-i— There is no incision that can be called the best 
of the three — the gridiron (McBurney’s), tho Battle, am 
tho paramedian — which are in common use I prefer tin 
paramedian in most cases. *I partioularly employ it ii 
cases of diffuse peritonitis and of pelvic peritonitis, ant 
if in such cases drainage of the peritoneal cavity h 
required it can be satisfactorilj* employed through thii 
incision without making an additional stab wound. Tin 
tube should bo made to pass through a slit in tho rcetm 
muscle so as to allow this structure to fall back into it! 
natural position. In the case of suppurative peritonitii 
localized in the right iliae fossa this incision may b( 
objected to on the ground that the ope' 7 crosses clear 



SOME 


iU'W^ ”S allows 

l''^"*‘T,rXl. to an iafoctoa nvea J' ;j;,,,ai„c(; and nuuu- 
nn . ^r n.is i\\'ci\ lO ' +i,.»n mi iiopvoncu 

m^mim 

loeiViau or Baitic’s .Ml n<; i<; cowiialiblo with good 

abscess sboald be ' ^s to alToril tlio most direct 

,K"''"''tbroi,Bb tl.e ;;;a;:a\'-;aa; Mter t\ie iirotoc- 

possible of tbo ‘^‘’6^ "f„^’!!'l'7nrclVnt, the buata.a of the 
away of any pas ™"j,, .Jt,..,,.tion of an nnperf.irated 

appendix is ,.^V‘ ,,t ...aondix w.tbont rapturing 

bat friable or even e‘'.'’R i(..,Uaoe of it-- contents is by 
it 6r allowing the f elf'll., ‘ ^ ope. at. on for aei.te 

far tl.e n.ost importanl sUp J tl^^^ 1 _ appendix 

appendicitis *" V'^'’ ..etrocolic or pelvic po^itlon it is 

infirmly embedded " 'f v f..-s dividing h. base, 
generally better to .^al tl.e.i dividing tl.e 

iuvaginating tlie eaecal ='‘' tip. For this pro- 

appcndiciilar attaclnncnts „iaet removal of 

cedi.re a free exposure 'V,Xd ainiemlix is followed by a 

tFo pns is confined to tl.e r.glit l’'’^ « wliicl. 

P -d 

. to^t'rS f^P^J^nnons a» 

that bind it to tlic post-pe VIC " f ^ presence of 

ileum must also bo carefully ’ ‘"„y'ap .endix the 

a foiil-smolling abscess aioiind a g. „ U upa 

ileum may be intensely 10 -P«>-aom c and ts « a 
and rigid and lierc and there co^eled b\ P>n‘«^ flattened. 

bfi 

the bowel to transmit its contents, f • . .^.^.treatment, 

. tl.an ins St on a rational plan ot atur y"-' 


T ^ — 'crv 

, t:i"l.n .1 

t iW»o.r « 


,„i (I.). i" »'vrs"".«o c,.ie"u.'"<i”s x™ ";' 

os Fi”- 

•■^iil'Sksa^£2Fr.o'Si: 

‘.WU prevent a catastroplie. 

SOME XOTES OX BIAOXOSIS." 

- BV 

CLAUDE^ mVismsfi^TC pV.r.sinrxr 

— ■ 1 
Tt this meeting I recognised 

in ouc ^ Itv no 


^VlIK^• invitcu to t. inc som 

in/1- of diaonostic accniacj i -^.-iv that an accurate 

°L? a™i. -»« U“ 1 “=" 


llv tnat. an 

Vu'a way which wouin I” 'in hospital diagnosis 

?iT°t^irsiir''^Tho‘Us^nre^^^ 

^^'rZ LZ for the next forty-eight liours or moie tl m Unless a o»se i ^ pathologist 


hours gradually iucreasmg '1"""^^^,''=® ' ,v.irawn.' I" 

”'ln ^'g^d'^ttaduage of the peritoneum,, t'- tondenev 
of the majority of surgwus to ‘““1’'°^ ^"\"%pendieitis 
less has been a feature of the ^eoT that tl.e 

a recent Himtcrian Lecture. 

FT' 

S'S'vSi. ™f s%s ri"£Z; 

SeFThv Iho'latter more particularly when tl.e ileum is 
known to- he hadly damaged. 


»eratiuy, . r.^i,inTn the most 

lent ‘diagnostician IS limitations as well as our 

It is well to recogi - .^.-ivial or transient or obvious, 
advances. Bnless a <=“"« ;" The clinical pathologist, 

"T are at once expert specialist often help us 

the radiograplmr, TF; “ p^imps as often left m doubt 

to a conclusion, but "5 " P creneral consultant, whose 

The same may be said ° ^Tffitv, tbough of signal 

im"does“knou- be U.e fepiitatlorrS 

meats ot the pundit "Im co^s^ tbe^rep^ nnreliable ; tlm 

able to diagnose every ca e • n diagnosis tbat 

fact being tbat, up to tim pres nl.en 

is more than a qu“le impossible, 

ir. would be most helpful, ottei i 

-r- 7 r.4 riinicdl. ZIefhods. 

The Udafn-e It the patient are sometimes 

The aspect and demeanour, a 

so characteristic ^'^Tistake tlfe tabetic, tlie Pa'k'nsonmn 

glance. Ko one can mistak Graves’s disease. The 

ov the fully ‘^«''T°Tt’s Complaints and sensations can 
history of the olicited, for the key to the tionhlo 

•An m^'nriti'l.MediMl Afsocintion. 

Wells division of tlie lirui.n 



710 Apeii> 28, 1928] 


SOME NOTES .ON DIAGNOSIS. 


r Tn* JixtTit* 

I llrnicjL JooRtib 


is often foiiml here, whilo tho family history and collateral 
evidence may he, of equal value. Still, it is upon evidence 
obtained through tho trained .senses that one mn.st depend 
in all but obvious eases.' I propose to olfer a few words | 
oil tho kind of help which each of tho senses provides, ' 
and in so doing it will servo my purpose best to begin 
with those which help us least and keep tho most im- 
portant to the end. 

Taste hardly counts, though it is hi.storically associated 
ivith the diagnosis of diabetes; and, whilo tho olfactory 
sense maj’ bo conclusive, as in alcoholism, oziicna, 
acetonaomia, and B. coli abscess, its scope i.s .strictly 
limited. Touch and hearing I'un a eloso race, though 
hearing wins easily if wo include what is learned from 
tho iireliminary inquiiy, and from tho character of tho 
patient’s voice and utterance. In physical examination 
these two often help each other out, ns in tho timing of 
a thrill and a murmur, and in the feeling of resistanco 
which accompanies the percussion note of apical consolida- 
tion and pleural effusion. But percussion generally depends 
on the sense of hearing alone, and tho ability to detect 
slight differences of sound varies voiy much in different 
individuals. I never helioved that it was possible to map 
out the stomach by percussion, and tho advent of the r-ray 
meal has put it largely out of coui't. Most misleading is 
the percussion of adjacent gas-filled viscera. A few weeks 
ago I tapped with two coins over the epigastric and 
adjacent areas, while a colleaguo moved his stethoscope 
about, and pronounced the stomach to bo greatly dilated. 
But a stomach tube failed to bring off any gas, and .an 
hour or two later tho coils of an enormously distended 
small intestine were found to fill this area, indeed tho 
whole of tho anterior segment of tho abdomen. Tho only 
thing certain about percussion of adjacent hollow viscera 
is that tho results are uncertain. To a Ic.sscr extent, for 
the possibilities are less egregious, I have always hold ns 
suspect the percussion line of tho loft border of tho heart. 
Very different outlines are made by equally capable 
observers of tho same case, and I have frequently found 
that the radiogram is smaller than tho area mapped out 
by percussion. 

Ausoultatioii, of eoui'so, yields iiiraluablo information ns 
to both lungs and heart, but it is well to hear in mind 
what erroneous doctrines have been taught through many 
decades, not because tho auscultation was at fault, but 
because tho deductions were founded on theories which 
have proved to be erroneous. It need not have. taken 
about a hundred years to find out that a systolic mitral 
murmur was often quite harmless. Possibly tho most 
unequivocally useful information rendered by tho stetho- 
scope is connected with tho recognition of tho foetal 
heart beat. 

Coming to tho tactile sense alone, and using tlio term 
in its widest significance, so as to include recognition of 
tenderness, heat, cold, resistance, and fluctuation, wo find 
an immeiiso amount of information available. Texture, 
irregularity of surface, foreign bodies, crepitus; tho 
examination of the pulse and tho heart; aneurysm; 
fremitus and friction; and tho exploration of tho throat 
and pelvic organs, carry us far. And the reflo.xes aro 
probably destined to carry us much further than is as yet 
generally recognized,_ 

. If I have run rapidly through some points connected with 
tho diagnostic value of what we may almost call the minor 
senses, it has been mainly for the purpose of bringing 
into contrast tho overwhelming importance of tho sense of 
sight. It has been veiy largely in proportion to tho degree 
in which different divisions of clinical knowledge have been 
brought within .the range of vision that our powers of 
diagnosis have increased, and, fortunately, the rango is 
being continually extended. The gencr.al glance, which, as 
already mentioned, may he diagnostic, is much more often 
sucgestlve. Pallor and cyanosis, obesity and cachexia, 
facial expression, lameness, and similar features, give us 
leads which are generally true. The distortions of sui’face 
produced by fractures, dislocations, tumours, and hernia 
are, of course, obvious. Beyond this the skin and the 
tongue and the throat can be seen unaided ; sputa and 
excreta can bo inspected, and nrino tested. For the rest 
"e must rely upon instruments, and while the use of almost 


all iiistriiinoiits requires iiracticc, tbo intorpretatioii of the 
re.siilts requires more, and invariably lags behind. Prob- 
nlily ill all ease.s interpretation will , over bo liablo to 
revision and exteli.sioii. IVliat should wo know of (lyrexia 
without tbo clinical tliormometor? Yet while a glance at 
a tciiiperatiiro eliart,, along . with its record of pulse, and 
respiration, may bo in. itself diagnostic, who will say that 
wo lire at tlio.end of tho knowledge which this siniplo, 
little iiistriiincnt may bring? It is only quite recently that 
tho cliuraetoristic charts of lymplindenoiua and rat-bite 
fever have lieen recognized. 

What would bo our knowledge o£-tlio diseases of the ej'O 
and of tlio nervous system witliout tbo opbtlialmoseopo? 
And wlint .should wo know of the larynx if it could not bo 
soon? AVlint would our general knowlcdgo of disease bo 
witliout tbo revelations of the inicro.scopo, with its histo- 
logical ])atliology, its blood counts, and tho intricacies of 
liactcrioingj-? Without transilliiinination a filled antrum 
is a .sealed book, and the new knowledge of heart di.scaso 
doponds c.ssciitially on visible tracings. 1, 

Tho cavities of the body in the immediate vicinity of 
the orifices liavo for long been c.xplorcd by means of 
speeiila, but the ingenious applications of electric light 
wliich provide Us with cystoscopcs and sigmoidoscopes, and 
with appliances by moans of which the mucosa of tlip 
stomnch and other remote iiitoriinl surfaces are being 
hroiiglil into view, aro matters of yesterday. Tlio advent 
of X rn3's soon broiiglit the acciirato diagnosis of fractures 
and dislocations, and the localization of foreign bodies;- 
the sockets of tlio teeth, tho pitnitarj- fos-sa, and tho con- 
tents of tho thorax wero brought into the available field 
later; and while tho exploration of the gastro-intcstinal 
tract hj’ means of barium meal and enema seem to have 
been long enough with us, tlio discovciy of lipiodol and 
similar substaucos has recently added tho bronchi, 
pulmoiiaiy cavities, tho gall-bladder, tlio pelvis of the 
kidney, and tbo ramifications of sinxis and fistula . to. tho 
internal regions cxplorahlo by sight. Tlio objection is 
sometimes raised that skiagrams may give misleading 
infornintion. But this applies to all diagnostic methods, 
and skiagrams, like clcctro-cardiograms, may need export 
elucidation. In ohscuro cases tho exports themselves nmy 
ho imzzlcd. None of tlio new methods has reached its 
zenith, and interpretation, ns already stated, necessarily 
lags behind observation. 

It is not without purpose that I linvo emphasized tho 
naramouiit value of vision in diagnosis; it is not without 
purpose that I pass on to a few obseiwations about tho 

Dftense Manjfcstations in the Shin. 

Those parts of tho bodj- which aro most , open to easy 
and coiupleto examination hj' sight and by touch ought to 
ho those about which we know most, and in which changes 
duo to treatment, general and local, should ho most obvious. 
If such an area is also that most acccssiblo to microscopic 
investigation, general and bacteriological, surel.v every 
facility exists for obtaining full knowledge of its jiliysio- 
log)', its patholog3', the diagnosis of its diseases, and their 
successful treatment. Y’ot if there is one part of tho body 
which seems more puzzling than tho rest, both as to 
diagnosis and as to treatment, I feel sure that a good 
many of us would think of tho skin. 

Tho experts who gather at tho meetings of tho dermato- 
logical societies often exhibit rarities and curiosities, and 
oiuj may often 'notice the words “ Case for diagnosis ” on 
tho agenda. Truly tho skin is a humiliating structure. 
The limitations of our knowledge as to tho essential iiaturo 
of a lesion, and of its etiologj-, progress, and treatment, aro 
hero .so obvious that, it is, not easj- to dccoivo either ourselves 
or our patients ; and mauj- have ■ said or thought tliat we 
know less about tho . skin than about almost auj" other 
sj-stem. Yet it may well be that, as should surely ho tho 
case, wo do know more about tho skin than about any 
other part; and that our ignorance of the invisible organs 
1 and sj'stems maj' still he as profound as was our ignorance 
of the diseases of tho fundus oculi beforo tho daj-s of tho 
oplitlialmoscopo. 'Phere are., hut few’ skin diseases con- 
cerning which onr, knowledge maj’ he said to ho comploto. 
Ono such is scabies ; the cause is clear, the lesions are 
chai-acteristic, and the treatment is known and is curative. 



iLPRin 28, igasj 


r Tur. Bnnn«t ^ 
L'Mcoicu. Joo&xix. . 


SOME NOTES ON DIAGNOSIS; 


711 : . 


With tiro syplivUdcs the ease is different ; the nUimntc cause 
is known, lint wliv slioiild the lesions bo so strangely varied ? 
^Vhv, ugrtin, should the ubiquitous stnphylocooeus have so 
uronouncoil an attraction for tho skin of the adolescent? 
And if endocrine instability is evoked, why should it select 
its unfortunate victims so capriciously? Of many well- 
known skin diseases wo really know nothing as to tho 
essential nature or cause. Of individual lesions wo know 
that vesicles and pustules arise from very different causes— 
local irritation and infection, certain drugs, smail-pos, and 
60 on; but, except in the ease of burns, trauma, and local 
infection, we know nothing of- the reason. 

Transient nnoninlies seem, if possible, to he even more 
bewildering. How strange are the characteristic rashes of 
the exantlieinata, each with its distribution and its period 
of incidence and decline; and perhaps still more curious 
are the palloi-s, flushings, and sweatings from emotional 
causc.s, each being part of an iiumcdiate i-esiion-.c to )nirety 
psychic influences involving widc.sprcnd nervous endocrine 
and circulatory adaptations in many parts of the body, but 
of -nhich tho skin reactions are alone in evidence. What 
effect does emotion have over other secretions'' Wo know' 
samothiug of occasional venal response, and a go<id deal 
about tears. Emotion may cause profuse weeping or may 
diy up tcara. What effect may it have on the gastric and 
biliary secretions? Doubtless jirofound cffei t.s, of whicli 
emotional vomiting, appetite juice, and the suggestive 
comments accompanying a earminative lueMriplion arc 
mere hints. What is the meaning of the inialdy pallor with 
brownish wandering patelies seen on the hue uv jea- 
siekness and in other conditions in wliieh hile regui gitatos? 
We sw tliese tilings on tlio skin, but what is lie- liver — j 
that immenso organ which works in sileiux' and in darkness 
— tloing.*' All wo can say is that wc don't know . At a 
recoiit operation in which the liver was exposed J noticed 
littlo blisters which came and went and wandered, raising 
the capsule as they moved. What was going on uitliin the 
recesses of. the organ? Wc talk glihly about the liver heing 
“ out of order,” but we do not know what is liappciiiiig, 
and -extremo cii-rhosis, wliich had never I'veu beou 
suspected, may bo discovered in tho imt-muitt in room- 
One .might dilate similarly u]ion other organs which, like ; 
tlic Uyor, work in silence and out of sight. 

It is on tho skin that we do see what is actnail.v going 
on, and it is hero that wc may best gauge the extent of 
our knowledge and of our ignoranee; and, surely, the 
balance is heavily weighted on the side of ignorance. And 
do not the grey, brown, black, anil strawlierrv furs, and the 
curious wandering raslics of tbo tongue, ’and the little 
ulcers and linomorrhagcs on tho giims’’and on the eoiiu-a, 
point in the same direction? Doubtless auaiugous pallors, 
flushings, swellings, furs, ephemeral ulcers, and desquama- 
tions occur with equal frequency' in nnscon areas, and 
accompany and perhaps aeeount for svmptoms for which we 
have daily to invent mytliical reasons. 


If /lof Oonsfifvics a Diagnosis 
In discussing any question it is well to know what we 
are talking about. Which of us, asked to define the word 
‘‘ diagnosis,” could supply a definition aeccjitable to all? 
lu tliQ {ii*st volume of tUe James McicVf'uzie ' Imiiivic 
lieports (1922) there is a paper on tlie results of a 
collcctiye^ investigation which had “ the primarv object of 
detci mining in wbat proportion of the cases met with in 
general practice it is possible to arrive at a diagnosis," 
and tlic first difncnlty encountered was tbat no .satisfaetoi-y 
definition of the word could be fonnd. After much debate 
the following was framed: “The recognition in the patient 
of a known disease from the symptoms wliich are charac- 
Wiistic of it. If we .agree to include signs under the 
term symptoms, as Mackenzie alwavs did, the definition 
will satisfy most of us. But the difficultv which was nest 
experience m separating what may he faillv called “known 
disease.s ” from among “ the maze of .sv’mptoras and so- 
called diseases in which medicine is becoming lost ” was 
a real one, and one which we shall all do well to bear in 
Space forbids moro tban tbe briefe.st epitome of 
tho paper. A classification wide enough to embrace all 
cases was evolved; the “known” (diagnosable) ■ diseases 
wore divided into five classes according to whether tbe 


cause was known, surmisable, or frankly unknown, while 
cud-results, such as the v.alvular lesions, and secondary ■ 
diseases, such as cystitis, each received n soparato coin- 
parlinont. Of the’VSiV eonsccutivo cases investigated a 
“ diagnosis ” was .inndo in only' 28 per cent,, while in 
22 per cent, a partial or provisional diagnosis was allowed. 
But just half of tho cases examined did not present tho 
symptoms cliavactevistic of a “ known disease,” and were 
eoiisoqucutly scheduled ns ” undingnosable.” Some of theso 
cases were simple ephemeral complaints ; some were isolated 
symptoms, such ns unexplained headache, insomnia, tin- 
nitus, and so on. Many were examples of groups of dis- 
jointed symptoms siicli as wo often meet with and which 
bring discredit on the ' profession, because one doctor 
attaches one label and another another. 

“ Wc cndeavourcil," -says the paper, ‘‘ to divide the midja- 
gnosable class into groups — for example, intestinal toxaemia, 
iicurasllicnia, dyspepsia, etc. It miglit be better not to employ' 
such terms at all, os they are’ apt to give an. unconscious bias 
in favour of one theory over nnotiicr. The iindiagnosable cases,’’ 
it concludes, “are apt to cause despair to the general prarti- 
tioucr, but if they are viewed rightlv they present him with 
an invahiablo field of study which is really open to him alone.”. 

The reason why tlie field is open to the general prneti- 
tioncr and to him alone ” is that lie is the only man who 
has the opportunity of following tip his cases from month 
to month and from year to year. By patient obsei-vation, 
record, and study Mackenzie differentiated the cardiac 
arrhythmias, wliieli had at first caused him “.despair,” 
and real knowletlgo of heart disease dates from theso 
resoarehes. It was only while engaged in general praetieo 
that he wa.s able to follow u)i liis case.s as bo did. But 
lie was alone in his feelings of despair; his eontcwipoYavics 
were satisfied with theories now known to be erroneous. 

Turning to the mass of ailments which still arc “ uudiar 
gno.sable,” bow many of us are there that recognize tliem 
as such? Are they really apt to afflict ns iritli desp.air? 
jVre.we not prouo to think that we Jiold the key to the 
bulk of these anomalies? Did wo not, thirty years ago, 
a'-erilie countless ills to “uric acid”? IVas there not a 
time — not long gone by — ^when tbo “ np-to-date ” practi- 
tioner bad a vaccine for almost everything? That “ blood 
pressure ” should ever have been a jiopiilar “ diag!io.sis ” 
seems almost as strange as the queer idea tbat everything 
could be “ Coued.” These things may have had their day, 
but many of us become obsessed by tbe new or revived 
ideas as they come along, and perhaps it is the word 
“ toxaemia ” that is now on top of the wave. Toxaemia 
may be obvious, or probable, or problematical, but the 
relegation of its origin to the colon is often no more tlinii 
a guess, even wbcu faecal analysis seems to point that wav. 

The colon has liad a long innings, hut tbo c.irly 
canonical axiom, “ Cut it out and cast it from tbec,” 
has disapi>cared, -while tho more recent advice, based 
on high, transpontine anthprity, “Grease it and -leave 
it alone,” is disregarded. 'Sour milk had a look 
in some twenty years ago, and fizzled out. Possibly 
acidopliihis may .share a similar fate. To “ chaime tli’o 
flora ” mav prove as difficnlt as to " disinfect.”'’ But 
lie arc on firmer ground when the escape of organisms c-au 
b-i proved. Bowk'iiidsJ has sbowii that the intestinal wall of 
vats fed on a full vitamin B diet was more than twice 
as thick and firmly knit as in the case of the controls; 
and in the few eases where he tried the treatment ho 
found that uriuo which was teeming with B. coli “ soon 
became stevite when the iiatient was placed upon a con- 
centrated - vitamin B diet.” May not the well-nouvished 
intestinal wall also prevent the absorption of toxins? 

The vitamins liave reniovcd several obscure diseases from 
the region of bewildered speculation into the very front 
rank of diagnosable diseases — that is, into the small but 
ever-enlarging class in whicli tlie cause is definitely kiiosvn. 
But the work hy which these rcsidts have been secured lias 
not ■ come from the general practitioner. In endocrine 
disease also the best work has come from tho laboratoi-ie.s 
and the schools; and, though the practitioner, has bv 
therapeutic experiment discovered various forms of suh- 
tliyroidism, and done hopeful work with paratbvroid anil 

perhaps with other liormoncs. Ins hhmdorbuss n-ork 

generally the result of eommcrcial suggestion — has hceu 
terrible; I sometimes' wonder liow many' hlundcvhwss 


712 April 28, 1928] 


VOLVULUS OF THE SIGHOID. 


f Tiir rjtiTi«n 
iiu vr. Jr.ii'vjt 


preparations Avonld pvoclnco any result at all if the thyroid 
element ■was cut out. 

If therapeutic experiment along toxncmic, endocrine, ami 
similar lines can ho called “ investigation,” ivo general 
practitioners aro doing our duly nohly. Hut I seo little 
of the patient lahorions roseareh to wliich Maekonzie 
devoted his life — these tn-o kinds of inquiry lie poles 
armnder. Mackenzie’s standard is too high for most of us; 
wo lack the insiglit, even if wo possessed the energy. 

Is there not, however, somo midway lino along which 
we may all hope to do a little real, and jiossihly useful, 
work? There may ho many; hut anyone who forms the 
hahit of taking short notes — if only of eases which av\‘ 
obscure or which possess some points of special interest — 
finds in the course of a few years that a fund of material 
has accumulated some of which will certainly throw light 
on his subsequent reading and experience. Much \isef\il 
work which, among other results, helps to clncidati' 
diagnostic problems, depends essentially on the existence 
of some such store. Further, if wo keep our eyes open 
wo all occasionally come across eases — or possibly cases i)\ 
series— of obvious illness which, after careful investigation, 
are not found to conform to any k\iown disonso or even 
label. Such cases ought to be recorded. The work is seldom 
wasted, nor is it without reward. 

A curious comment on the lino of thought I have been 
pursuing is that, while a store of notc.s, such as ] have 
referred to, has served mo in good stead when impclhal 
to deal with such matters as cardiac murmurs,- or the 
effects of opium on Cheyne-Stokes breathing and csirdiac 
asthma,” it has been the cases I have recorded a.s un- 
diagnosablo which hnvo been noticed in quarters never 
anticipated, and have brought mo unexpected recognition. 
A case of sudden death in a, subject who had never shown 
cardiac symptoms, but which proved to have been duo to 
tho rupture of an aneurysm of tho ventricle,* has, I learn, 
been used by certain teachers in both hemispheres as an 
example of this (happily) undiagnosablc condition; while 
a series of large spleens, recorded in tho early nineties, 
presenting anomalous symptoms and occurring in three 
generations,” is quoted as the initial link in tho chain 
which led to the differentiation of acholuric jaundice,' now 
a “ known disease ” with very characteristic features. 
These are examples of the fact that records which seem 
useless or lost may prove to be what somo other observer 
is looking for, and that crumbs scattered on the waters may 
icturn to us after many days. 


Refwjexcks. 

‘ Rowlands : Prac. Roy. Hoc. .Veil., 1927, p. 1721. = Wil.soii ; Jlrllith 

Mcniciil Journal, June 22nd, 1913. ^ Idem : haucet, December 22nd. 1323. 

* Idem : ibid., Aueust 2nd, 1919. = Idem ; Clin. Hoc. Tram., vol. 23, 1890, 

p. 102; vol. 26, 1893, p. 163. ‘ Campbell ; Quart. Journ. .Vci/., 1926, p. 331. 


YOLYULUS OF THE SIGMOID.* 

BY 

GAKKETT AVKIGHT, F.U.C.S., 

SENIOR HONORARY SURGEON, SALTORD ROYAL HOSPITAL. 


Volvulus is a coiupavatively x’are pvimavj* cause of jutos- 
tinal obstruction in this country, though in some jiarts- of 
Russia and Eastern Europe it forms approximately one- 
third of all tho cases of intestinal obstruction, while many 
of the cases recorded in English literature coneex-n Indian 
subjects. 

Rokitansky described three forms of volvulus: (1) i-ota- 
tiou of tho bowel on its mesenteric axis; (2) lotation of 
the bowel on its longitudinal axis; and (3) tho inter- 
twining of two coils of intestine. By far the commonest 
of these, so far as tho sigmoid colon is concerned, is 'the 
hist, and it is to this variety that 1 shall confine my 
attention. 

As far back as 1878 Lcichtenstei'n cleaily descidbeil the 
anatomical condition's necessary for the production of this 
form of volvulus. These are a long mesentery with a 
-narrow attachment to the abdominal wall. Cleai'ly the 
length of the mesentery is a developmental question, and the 
same is probably true of the narr owness of its attachment. 

IXcdical^AsLjciaUom Laacasbito aad Cheabire llranch of the British 


Many writers have stressed the inllnenco of ehionie con- 
slipalion in ]n'oducing liyiiertrophy and dilalivtion of the 
sigmoid and in setting uji chronic inflaminatory changes 
in the meso-sigmoid h'adiug to (.ontraction of this striictme. 
These changes are e,s])eeia!ly seen near tho attnehmeiit of 
the meso-sigmoid to tlie iilidominal wall, and lead to 
narrowing in this region. It is innch more prohahio that, 
the constipation so frequently iiiesent is the result of tho 
aualomieal peculiarities— uaiuely, the omega ’loo]) arraiige- 
iiieiit of the sigmoid colon, which is looked u))on by some 
authors as a mild form of idiopathic dilatation of tho 
colon. The changes in the me.so-sigmoid consist of fibrous 
hands on the peritoneal surface and not of fibrous changes 
in tho structure itself, and prohahly result from jilastie 
jioritoiiitis set up by repi'atcd attacks of partial strangula- 
tion. We .shall see later on that these attacks often occur 
before the final nexite attack takes place. 

To sum up, the anatomical factors necessary are a long 
me.so-sigmoid with a narrow attachment to the abdominal 
wall. Both of these may ho congenital — that is, a con- 
dition of mego-sigmoid with, in some casc.s, an exaggera- 
tion of tho normal V-shaped attachment of the mesentery. 
Tlio narrowing of the base of the mrsontery' nmy he 
iiiercased by repeated attacks of i>artial strangulation 
leading to the formation of filiroiis hands on tho base of 
the meso-sigmoid. 

When these factor.s arc present an attack of volvulus may 
ho precipitated in various ways. I’lidoiihtedly, constipa- 
tion, by loading tho bowel, nmy so increaso its weight that 
the loop falls into the pelvis and tho root of the mesentery 
hecoim'S twisted. The resulting obstruetion produces a' 
distension of the bowel and tho twist hoconie.s increased. 
Finallv, the circulation is obstructed and still further di.s- 
lension follows, and the jiicturo boeomes complete. In many 
eases tho exciting cause is a powerful aperient taken to 
relieve tho constipation. Sometimes an iteute attack is 
produced by violent jiliysical exertion, tho movements .of 
tho abdominal wall pressing on a loaded and enlarged 
sigmoid ami twisting it on its mesenteric axis. 

It is a significant fact that x'olvulus is commoner in men' 
than women owing to tho stronger abdominal wall in this 
sex to"cthcr with tho smaller capacity of tho pelvis. In 
oiio^of'iny patients tho final acute attack which brought 
him to operation resulted from tho exertion of mowing 
his lawn, followed by an aperient which was necessitated by 
several days’ constiimtion. 

Diet mav have some effect, and it is said that a vcgct 
tariau diet, with its largo residue, is liable to produce 
volvulus. Possi.hly this factor accounts to some extent for 
tho geographical distrihuliou of the condition. 

Ci.ixic.M, .SvMriosis. 

Tho usual mental picture one forms of volvulus is tha 
of an exti'cmoly acute intestinal ohstruclion with rapid aui 
excessive distension of tho abdomen 'and early onset o 
peritonitis. This is tho description which is presented i 
Keen’s Si/stem of Surgenj, and also by Troves aiv 
Barnard though both the latter writers comment on th 
fact that vomiting is an inconspicuous feature at tho ousel 
and may bo entirely absent. Both those ivritei-s state tha 
vi.siblo peristalsis is very rarely seen. 

While there can be no doubt that tho final attack ivhic 
leads to operation or death is of this. type, it is becomiii 
inci'casiugly recognized that long hoforo this takes plac 
there may" ho symptoms of a more chi'onic and rccurrcn 
tvpe. Pernstrom* discusses this aspect of 'the conditio 
very thoroughly, and diiferentiates clearly' hetween-’ acid 
and chronic forms. In many of the acute -cases an Tnvesti 
'mtion of tho previous history xvill' reveal the factHhat tli 
patient has sxiffercd from vaguo colicky abdominal pain 
from time to time, often associated with diarrhofia an 
offensive stools. The attacks aro often tei-minated' by th 
passage of a largo quantity of flatus or a very largo stool 
In oim of mj’ patients, a man of 52 years, there was 
history, dating back six months, of attacks of abdomiiu’ 
colic with constipation. These were usually brought to a 
end hv a dose of salts, ivhich produced a coiiious 03 ;aeuatio 
of motion and flatus. ' 

The chvonic symptoms,' which are probably- duo-to sligb 
I twists rectified sjioutaneously, therefore resolve thomselvc 


A-PRIti iS, lOaS] 


PB-ESERViLTIOK OP ;jEI.IiO'W PEYEU VIEES. '?13 


into attorks of abdmninnl colic coinciding witii constipa- 
tion, follonod I)V relief n'itU a copion.s stool and tlic passage 
of a laico qnaiititv of flatus. . Any oin' of tlic.^c attneUs 
may torminato in an aonlo' volvidiis and it sccins ])iol>aWo 
tlint the determining fnclov is the civcnlalion in the 
atfocted loop. Sh long as tlio twist is not Kumemnt to 
interforo with this theip is a chance of sponlancons nn- 
Iwistiiig. The iiupovtaucu of this factor is ilhistcated l>y 
t.Uo vavying way in which an aente attack supemencs. In 
most c.ascs the onset is qnick, but in some it is much nio*e 
gradual. 

■ Main- vears ago I Imil nadcr my rave in the PootU Hall 
Infirniarv a mentaUv dcfiricnl. man, need hS yeai-s. My altcutiou 
was called to him Gy the allcada'nl becaaso he was roinplniniag 
of abdominal pain.' 1 found him not mgcnlly ill, willi a 
modrratrlv dislcndcd abdomen and very evident visible noristapis 
of tbc large bowel type all over tlic abdomen. His condition was 
not serious, and I walcbcd him for some days before I operated. 
At opeialion there was an enormous volvulus of the .sigmoid 
without auy slraiigulnlioii. niid 1 succcssfullv excised the sigmoid 
loop ill two stages bv ilfikultca's method. I'isildc peristalsis was 
also a well-marked feature in the' case 1 ineutioiied previously. 

That the progress of the final attatik may ho slow when 
strangnhitiou is absent is also, .supported hy the ease of 
a iiicntally deficient iimlc, aged 22 years, reported l-y 
Edward Milton .Footo.= The. first symptom was abdominal 
distension, noticed hy an orderly, and operation was nndor- 
taken thveo days later heeanso of increasing distension 
and visible pen.st.alsis. 

A nmeli move striking cxaTnido wa.s recorded by Manriie 
Riclinrdsou.’ 

The patient, a man aged 47, congenitally deaf and dumb, bad 
Mificred from soveco atincks of abdomiiinl pain wn.li constipation 
tor five years. The nllack which led to operation was piecipi- 
tated by a dose of castor oil, and for a mouth after the oieel 
tlieco was no passage of motion. The abdominal distension 
gradually increased, until at the time of operation it was very 
great, and was accompanied by visible peristalsis. Tlierc was iio 
vomiting. AUbongb tbc attack bad lasted so long tlieic was no 
gaiigi'cuc, but the allcetcd loop was dark in colour. The bowel 
was aspirated, untwisted, ancf fixed in position. Tlie volvulus 
recuiTCd five nioiillis later, and was itieii resected suecvs'fuUv. 

-V-vtiy examinntiou in patients snfTering from symptoms 
of chronic volvulus may ho of groat value. A harinm 
enema will show the greatly enlarged sigmoid loop. On 
two occasions I have operated in eases of this type and 
Imvo .siieecssfnlly removed the .sigmoid loop. In <>iio this 
resulted in a complete euro of the symptoms, hut the other 
liaticnt still suffers from constipation and ahdominat pain. 


TltE.rTJlENT, 

The treatment of acute ■volvulus is entirolv snrgital. 
Eitflc is to be gained by wasting time with cncniat.n, anil 
purgatives only make conditions worse. tYhou the loop is 
viable it is often possible to cvae-iinte it liv a tube pushed 
up from the anus ^guided by a baud in the abdomen. The 
twist' is then easily undone, and, .so far as that attack 
is cbnccrncd', the patient is cured. Manv attempts have 
been made to prevent future twists hv fixing tho -sigmoid 
to .the, abdominal wall or hy plcating'tiio mesentery. All 
of these arc liable to he followed 'hv recurrence. Indeed, 
one might almost say that vecurrenee is the rule. 

There can he no doubt that the ideal treatment is 
resection of the ^ sigmoid loop. This is always essential 
when tlie houel is too damaged to recover, and I heiicve 
it is the riglrt treatment in all .cases. I have empioved 
it in aU -four acute eases I have had to deal with. One 
patient, 'vitU a gangrenous sigmoid, died from prolajise 
of the small gut alongside the double-ended colostoniy 
I had made, tins happened on the fifth dav, and np to 
that time the patient . had been very well. The accident 
was certainly due to an error in technique. The other 
three patients, in all of whom gangreno was absent, 
leeosoiod. The method I adojitcd in all four ca.ses wa-s 
immediate i‘csection of the affected loop with a double- 
ended colostcniy, Eater an ond-to-end anastomosis' ivas 
made in two of these patients. The third saved me the 
tvouhle hy re-establishnig her intestinal canal spoiitaiieouslv 
1 Ins two-stage oper.ation has seemed to me to ho safer than 
an immediate end-to-end imion. There is no donht that 
imniediato anastomosis gives a much cleaner and plea.santer 
lesiilt, .and it may he, as Air. Alorlcy iioints out, that there 
IS not the same accumulation and distension in the colon 


ahovo tho Tolvnlti.s ns there is in eases of carciiioinatous 
ohslniction, and iheveforo not the sniiie risk vvitk immediate 
iiimstoTOosis as there is in these latter eases. 

Eiiinlly, it is soiiiolimcs possible to recognize the pi-cscnee 
of intermittent syinptoiiis from chronic volvulus. tViieii 
this is so, and tho diagnosis is confirmed by the a--iay 
appcavaiieoB, it seems justifiable to excise tlic sigmoid loop, 
as I have done on tivo occasions. 

nnr.srscr.s. 

irerhslriim: Acta Chinirfficn Hmnlinnrirn, vol. Is!, fosc. II-III. 
s route: llo^lnn Med. and Siirg. Jmini., 1B33, vol. i. ’ Rlcharilbon ; Tram. 
.liner, Surj. Amoc., \ol. xv, p. 585. 


TlTEPBESEliTATIOK 01 ' TELIOW PETER TIPI'S 

SV 

A, AV. SICLLAMS, 

IfEPARTMEKT OF TROPICAL MEDICITTE, HARVARD MEDICAL SCTIOOL, 

ASD 

EDtVARD KINDLE, 

BtiT- MESiORisi. in;sr.>.RCn tellow is •ERoncj.t. medicise. 

(From tbc Wellcome Kurooii of Scientific Rcseorcb.) 

Tuf. study of yellow fever has recently been greatly facili- 
tated hy the iinpnvtant discovery (Stokes, Bauer, and 
Hudson, 1928) that tho eoiiimoii rhesus monkey {.lincacu.s 
rlie.siis) is very susceptible to this infection. Hitherto the 
iiccc-ssity of using human voliintceis for any exjieriments 
has jirevontcd a very , sy.stomntic study of the disease, and 
therefore the value of this discovery cannot he over- 
estimated. 

Uiifortuuatoly the cost of ' s from 

India to the \Vest Coast of ' trans- 

shipment in Europe, is very considerable, as the double 
jonrnoy involves a vciy high mortality. One of us 
(A. AV. S.) found tho mortality of monkeys sent to E'est 
Africa was such that their average cost came to iiearly 
foiir times that in London. Apart from financial con- 
siderations, the study of the yellow fever virus can he 
conduetod far more readily in countries where the natural 
carrier of the infection is absent. Experiments in !ocalitie.s 
where .Icdes (icp;;))(i may be present involve keeping all 
infected animals under mosquito netting to ])revoiit the 
chance of their being bitten by any mosquito and possibly- 
starting an epidemic. Consequently infected inonkers iii 
such localities arc always a potential source of danger to 
the community and involve continual attention. In toni- 
perato countries these difficulties do not arise, as even in 
the presence of Acrfcs the temperature conditions arc such 
that the mosquitos could never hecome infective. The 
development of the virus in tho iritermediate ho.st is 
extremely slow and uncertain at a temperature of 22°. C.. 
and the optimum tom]icr.iture seems to be in the.neigh- 
howvhood of 25° C. Consequently the disease is re^ricted 
definitely to countries wlici'e -such conditions prevail, and 
lias never become endemic in temperate zones. 

Hitherto the study of the disease, has been confined to 
the regions in which it occurs, unlike the majoritv of 
human infections, ^whicli can, now be investigated in tlie 
main labor.atpries.of Europe and America, for although the 
French AdIIow Fever Comniissiou (Marchoux, Salinibeni, 
and Simond), 1G03, carried infected mosquitos back to 
Paris from Brazil, no method of nvaintaining the virus was 
then known. 

Considering the evidence in support of the view that 
yellow fever is caused hy a filterable virus, it seemed of 
interest- to see .whetiici- the virus could maintain its 
vitality when frozen, in the same way as many other 
filterable viruses, and accordingly an attempt was made 
to transport infected material in this manner. 

The strain of virus employed was isolated from a case of 
yellow fever in a young Syrian at Dakar (Matin’s. Sellards, 
and 'Laigi-ot, 1928). This patient suffered from a mild attack, 
cliaraetci-ized by two febrile periods separated hy a short intev- 
missloii. The conjunctivae were slightly jaundiced and congested, 
and the urine coiit.ained a trace of albumin. On the seventh 
day of the disease, just before convalescence, the patient showed 
signs of collapse, with marked cardiac' symptoms. Twentv hours 
after the commencement of the fever sixteen mosciu’Aos' {Acder 



POISONING BY A NON-ARSENICAD WEED-KILBER. 


714 April 28,' 1928] 


■ Tjrr nnm** 
XlrcicxLJotf'tit 


cgupfi) 'vere fed on tlio patient, and at tlio same time 4 c.cm. 
Ilf blood were collected and inoculated into a rhesus inonhey. 
Two days later this animal had a slight fever and was found 
dead on the eighth day after the inoculation. At the necroi>sy 
a slight jaundice was observed, and also lesions resembling thus.; 
of yellow fever. The blood and a suspension of liver were 
inoculated into two young guinea-pigsi which remained healthy, 
thus excluding the presence of Lr.ploiplta ktcroiths. 

Twenty-four days after feeding on the patient the mos- 
quitos were allowed to feed on a rhesus monhey, whieh showed 
a sharp rise in temperatnro after an incubation period of three 
days, and succumbed to a typical attack of yellow fever two 
and a half days later. Another monkey was also infected by 
this same batch of mosquitos. 

This strain was maintained in nionkcys, either by the bites 
of infected mosquitos or by direct passage, for a period of 
nearly three months, all the animals showing the charactcri.slic 
symptoms of the disease. Shortly before leaving Afrie.a one 
of these monkeys was killed at the height of the infection, and 
some of its blood, and also pieces of liver, were collected in 
sterile tubes, which were then carefully sealed to exclude air, 
and at once frozen in a mixture of ice and salt. The scaled 
tubes, in metal containers, were kept frozen during the journey 
t> London — a period of twelve days — and on arrival were 
inoculated into two rhesus monkeys. 

Tile first monkey, inoculated with an emulsion of the liver, 
showed a rise of temperature after an incubation period of four 
d.ays, and was found dead on the morning of the seventh day. 
Its temperature chart (Fig. 1) is reproduced herewith, and 



Fio. 1. — ^TeniperaturQ chart ot rlic^us nionkri inoculated 
with a suspension of fror.en liver from a case of yellow 
fever. Tho animal was found dead on the nuiraing of the 
eighth day. 

it will be noticed that on the day preceding death the tcui- 
peiature was subnormal, a common feature of tho disease in 
monkeys. On the last day of the disease the animal showed 
symptoms of jaundice, which were particularly well marked in 
the ears and face. At necropsy tho subcutaneous fat, and 
especially that around the pericardium, was intensely yellow. 
The liver was mottled and pale, and showed marked signs of 
fatty degeneration. The stomach contained a quantity of the 
characteristic coffee ground material. 

The second monkey was inoculated intraperitoneally with the 
frozen blood, and as it showed no rise of temperature on the 
fourth day it w'as reinoculated with infected liver material 
from another monkey. Tho following day it showed a rise in 
temperature, but in view’ of tie subaequeut course of the 
disease, as sliow’u in the accompanying chart (Fig. 2), it is 



Fig. 2. — ^Temperature cliait ot rhesus monkey inoculated 
with frozen blood from a c.ase of yellow- fever, and rcinocu- 
lated on the fifth day with infected liver material. TIic 
animal was killed on the tenth day. 


somewhat doubtful whether this first rise was the result o 
the blood inoculation or not. Four days after being inoculatei 
with the infected liver emulsion the temperature showed 
distinct rise, which continued the following day, when th 
animal was killed. At necropsy the oqly obvious features o 
the disease were slight jaundice in the subcutaneous fat, fait; 
degeneration of the liver, and slight inflammation of the liniii] 
of the stomach. Subinoculation into another monkev, how'ever 

yebo"- fo'-e^^. Culture 
•md Fletcher’s mediiSg;^ aU glt^ncgmivrr^^^^ "'"P" 


]i is evident, therefore, tlial tho yellow fever yirtis can 
inaintniii its vii itlcnco when frozen for at least twelve days, 
and possibly much longer, a property wliicli will ho of 
consitlorablc assistance in preserving tho virns and fnrtlicr 
.stiidie.s on tho natnio of (In* infection. 

A\V j-hould like to expross; oar thanks to Dr. C, Wenyem, 
F.R.fJ., for providing us with accommodation, anti also for much 
valuable as^-islnnce. 

inuUOGIUPJfV. 

Marrhmi.r, Salimlii'ni, and Simond (1903); La fievre jaunc. Jnn. /n#f. 
/Vyf/'ur, ToJ. 17, jip. f^-73h 

^farellotlx ainl Simond (1906) ; rtndFs Eur la jniuif’, Ibifk, vol. 20, 

pp. 16, 104, and 161. 

Jfnditx, Hellard*', and Laigret (1928) : ScnibiJlib* <lu Vftcftcuff au 

vinm do la iW'vro jaiinc. ii. Atnd. .SVA, vot. 10>, pp. 604-606. 

H.'niri*, and llutb/ni (1928): Tho Tran>‘inIw<ion of Vcllow >*«'ver tc 
yfncacxts rhtett'*. Joum. Amtr. J/rd. Anoc.^ %v»l. 90, pp. 253-25'1. 


A FATAL CASE OF POISOFTIXG IIY A XOX- 
AKSESICAL 'SVEED-iaLLER. 

SY 

A. II. B. SMITH, M.C., M.B., Cir.B.Eii., 

noxoKAr.v si'r.orox .and n-tniOLOGisr, li.asi 3 .ly ckkeiial iiosi-ital. 


Ix tho following e.-iRc of poisoning hj’ a wcod-killer tho 
elTncts were so profound and so rapidly fatal that an 
neoonnt of the clinical course would scorn to bo of general 
interest. The weed-killer talrcii consisted of 75' jier cent, 
tar .acids cmnlsilirsl with soap; it was dark in colour, had 
a strong smell of tar, and fonnecl a milky omn/^ion in 
water. Tho makers reported that both lysol and this 
wcod-killer consisted of carbolic acid, soap, and water, 
Ivsol containing 50 per cent, and the wocd-killci- 75 per 
cent, carbolic acid, wbilo the proportion of soap in lysol 
was larger. They also stated that tbo .symptoms of poison- 
ing produced by tbo weed-killer would bo similar to tboso 
of carbolic acid or lysol poisoning. 

Commercial crcsylic acid, so-called liquid carbolic acid, 
consists of 35 per cent, ortliocresol, 40 per cent, mctacrosol, 
and 25 per cent, paracrcsol. Tbo effects proilueed by the 
crcsols aro identical with tboso of phenol ; inotacresol is tbo 
least poisonous, and paracrcsol tbo most poisonous (sea 
Brifid* r/mrmnrculirol Codeji, p. 369). In cases of poi-ou- 
iiig by crcsol tlio treatment for carbolic acid slionhl bo 
cniplovcd (ibid., p. 370). Taylor, in MetVicttl Jitik- 
nriideiicc, de.scribes as comparatively innocuous a snb- 
stanco consisting of 20 per cent, crosylic acid with neutral 
livdrocarbon oil and resin soap ; it is a dark-colonrod 
liquid, mildly antiseptic. One instance of poisoning by it 
is reported jn detail by Dr. Pinner, who states that tbo 
effects aro not fatal. 

Tho clinical details of tho case aro as follows. 

The maximum amount which could liavo been swallowed was 
iust over 2 fluid ounces (56.763 grams). To test the accuracy ot 
this statement the average contents of a series of unopened tins 
w-ero compared with the contents ot the tin from which tho 
poison had been taken. Tlio patient, a well-built man, aged 32, 
liad alwnvs enjoyed fairly good health, but had recently been 
crcatly w'orried 'by tho death of his wife. Somewhere about 
10 am. on .Viigust 21st, 1927, be look tbo poison, and about 
10 40 n'nciglibeur found him lying in bed; he was groaning, but 
nuife conscious, and refused a cup of tea. Ife did not complain 
of pain and had not vomited, lYhen I saw him, at 11 a.m., ho was 
comatose; tlici'c was no corneal reflex and his breathing was 
stertorouL He was markedly cyanosed, and Ids pulse was fast 
and almost imperceptible. His skin was cold and clammy, and lio 
was sweating profusely. In his breath a strong smell ot tar was 
delected, similar to that of a liquid contained in a glass by his 
side and in a tin ot weed-killer also in the room. Careful exani- 
inaliou revealed no sign of corrosion of the lips, tongue, mouth, 

°'H^''*was removed to hospital, and about 11.20 was receiving 
treatment. The stomach was waslied out, and the returning 
fluid, milky hi appoaraiire, had .a strong smell of tar; it con- 
tained no foodstiilTs. After repeated wash-outs white of egg was 
put into tho sloiiiacb, and in view of his cyanotic condition 
oxvgeii was given; atropine sulphate was also injected hypodcr- 
micallv. He rapidly went, downhill and died about 11.40 without 
regaining consciousness. There were no signs of corrosion of tbo 
lips, moutb, longue, or pharynx. 

Tlio necropsy revealed no signs of any abnormality save an old 
pleurisy ill the left side. The stomach and oesophagus were 
removed and tbo coiileiits sent for analytical examination. Garc- 
fnl examination of both stomach and oesophagus showed not tho 
slightest sign of corrosion or excoriation. The stomacli contained 
no food, only some turbid fluid w-itli a strong smell of tar. 

The report of the analyst staled: 

** The contents of the stomach smelt - of phenols or tar acids 
and tho distillate gave a strong reaction for them. No cyanides 




A-rmii iS, 1028 ] 


MEMORANDA. 


77 

Mnpioit, JocviuA * ^ ^ 


or livdrorvniiic nciil were present. No mercury, lend, copper, 
arsenic, or tin were present. No nlknloidal poison could bo 
delected.” 

In view of Iho .os.scrtion by Pinner .i.s to tlio rolntivo 
liarmlossncss of crc.sylic acid, nnd of tlic .statement of tlio 
makers of tbn tTCpd-killor that the toxic action of tliis 
substance rrould bo similar to tbnt of carbolic acid nnd 
lysol, it serins tbnt in this case, at all events, tho toxic 
c’ltccfs were not those usually seen in a rase -of rarbolic or 
lysol poisoning. The symptoms rvero tbnso of a poison 
acting on the nervous .sy.stcm— tho so-called narcotic action 
of carbolic acid and its bomologncs — and this action was 
probably due to the porncrcsol. It is evident that cmnlsi- 
licd preparations of the tar acids (carbolic bomologncs) aro 
not necessarily corrosive; if a 76 per rent, emulsion is 
tested on the Up or tongue tlio effect is simply a temporary 
smarting, whereas carbolic or lysol produces burns on even 
bard skin. 

Con riti.stoii.':. 

My object in reporting this case is tbrcefold ; 

1. To show that cresol or cikisylic acid is not tlio 
innocuous substance described by Pinner, at all events 
when taken in a concentrated form as an emulsion on an 
empty stomach. Under tbeso conditions, when the toxic 
crcsols are jiresent, tbo rapid absorption of the poison by 
tho stomach lias a profound and fatal effect on tbo 
nervous system. 

2. To suggest that a sub.stanro wbieli can have so rapid 
and fatal a result sbould be included in either Part 1 or 
Part 2 of the Scbcdiilo of Poisons. At present it can bo 
sold' over tbo counter bj- any person, provided it is con- 
tained in a closed vessel distinctly labelled poisonous, with 
tbo name and address of tlio seller and a notice of tbo 
special purpose for which it is intended. 

5. To urge that more attention sbould be paid in text- 
books to tbo toxic action of tho crcsols on tho nervous 
system. Attention .seems to bo focused maiiilv on 'the 
corrosive action. This is true of carbolic acid, and of lysol 
to a lesser degree, but when we deal with the crcsols 
(cresylic acid), tlio corrosive action is nogligiblo, while tbo 
toxic effects on the nervous system aro profound. 


ERYTHE3IANODOSTJJI A^'D ACUTE ENDOCARDITIS 
rOLLOMTNG TONSILLmS : 

Rr.covEnT afteii TntLVTsrcxx with AxTisninrTocorcrs 
Seuum, 

BY 

A. MARKSOK, M.B., Cn.B., 
rn'EnpooL. 


The following case seems of snfucionfc clinical interest to 
record. 

On January SOtli T was called to see a girl, aged 22 , suffering 
from acute follicular tonsiiiilis. A swab taken for diphtheria 
proved ne^alive, and the patient was given a sodium salicvlate 
nnxturc. Dcfcrvescenca with amcUotation of symptoms occurred, 
and by tlio fifui day tho temperature was norrnal and the throat 
mucti better. Tho next morning, however, the patient was worse, 
and the temperature had risen abruptly to 102° F. The face was 
flushed, she was sweating profusely, and she complained of painful 
6po(s on the le^, pains in her joints, dyspnoea, and palpitation on 
moving. Evammation of the legs revealed a crop of large, 
roundish, raised, tense swellings, of the whole thickness of the 
skin, along tho anterior borders of - both tibiae. Bright red, 
glossy, and cstverneiy tender to the touch, they presented the 
typical eruption of erythema nodosum. The right knee, right 
ankle, and left wrist were painful, but not swollen. Tbe pre- 
cordial impulse was increased, tho first sound at tho apex was 
roughened, and tho second pulmonic sound accentuated. I recalled 
the association of erythema nodosum with true rheumatism, and 
accordingly increased the salicylate doso to 20 grains every three 
hours, combined "’ith eoamm bicarbonate. A sedative lotion was 
also prescribed for the legs. Tho urine was febrile, and contained 
a littlo albumin. During the next few davs the tempera- 
ture ranged between 101° and 103.6° F., and fresh crops of 
erythematous swellings kept appearing on the legs and thighs. 
There was now at the apex a soft, blowing, systolic murmur, 
conducted into tho axilla, the second pulmonic sound remained 
deunitcly accentuated, '^nd an- apprcciahlo increase in the Irans- 
verso area of cardiac dullness could bo detected. There were no 
rigois, the spleen was not enlarged, and the lungs were clear 
bevero pain continued in the joints, and now affected also those 
of the -lingers of both hands, hut no arthritis developed. The 


mlicylatcs, Iiowcvcr,' did not influenco the temperature nor relievo 
Iho joint pains. 

On tho fifth day following the onset of the erythema nodosum' 
and the cndocardilis tho patient was still very ill, with no 
Fign of improvement. The temperature was 103° F., and tho 

I mlso 120; she was still d^'spnoeic, and a fresh crop of swellings 
lad appeared that morning on the right log. That afternoon 
I injected 25 c.cm. of polyvalent antistrcptococcus serum well 
under the skin of the flank. The result was almost 'dramatic. 
By tho next morning tlie temperature had dropped to 99.6° F., 
nnd tho pulse to 90; tlic joint pains had gone, tho tension in 
tho erythematous swellings was relieved, and the dyspnoea was 
much better. From that day no fresh crops of erythema nodosum 
appeared, and those already present, even the new ones of tho 
previous day, disappeared in five daj's. On tho third day after 
the injection some peritonsillar inflammation developed' (until 
then tho throat had been much better), and the temperature rose 
from 98.8° to 100° F. 1 injected a further 10 c.cm. of the serum, 
and twelve hours later tho throat liad improved and the tempera- 
turo was normal. Tho temperature and pulse have now remained 
normal for a fortnight, no acute sj’mploms have recurred, and 
tlio girl feels much bolter. At the time of wriling she is .being 
kept in bed a little longer for her mitral condition. 

I am aware that the connexion of crj'thcina nodesum 
with rlicnmatism, although long debated, is not proved, 
but there were justifinble grounds in this ease for asso- 
ciating tho two conditions — -namely, tlic initial tonsillitis, 
the joint pains, and tho endocarditis. In spite of -this, 
however, largo doses of tho salicj'Iate liad no effect. It is 
well known that tonsillitis can bo an ' etiological factor ni 
acuto endocarditis, and, judging from the remarkable effect* 
of tho antistrcptococcus serum in this case, it is pos.s»Me 
that tho tonsillitis ushered in a train of streptococcal 
developments, producing not only t)io endocarditis, bnt 
also tho erythema nodosnm. The etiology of tlio latter is 
still not decided, although Rosonow claims to have isolated 
a bacillus with coccal forms. I am convinced that the 
serum had a decided beneficial effect on tlie erythema 
nodosum in my case, and, this being so, there may be 
boro a point of etiological significance in connexion with 
bis tlicory. ' 


^tnmratrta : 

MEDICAL, SUEGIOAL, OBSTETEICAL. 

DIAGNOSIS OF “ FLFURAL SHOCK ” FROM 
COCAINE POISONING. 

Thk differential diagnosis of acute cocaine poisoning and 
pleural shock ” may ho a very difficult matter, as the. 
following report of a case shows. 

A denial mechanic- wns readmitted to Win^^lcy Sanatorium on 
March 16th, 1928, and, owing to constant bloediug, it was decided 
to perform artificial pneumothorax, though this was not otherwi-^n 
required. I ordered a 1/4 grain of morphine to be injected lialf 
an hour before the operation, and the patient Keemecl unduly 
anxious to know what drug liad been emploved. 171100 I came 
for the oper.ation lie asked me wliat local anaesthetic we used 
.and I told him cpicainc, each cubic centimetre of which contains 
cplnino 0.0003 gram, and cocaine hydrochloride 0.02 gram. 
I thoudit the question a professional one and treated it as such. 
Ho made no comment. The injection of 1 c.cm. was 'nven with 
tho «sual -smaU syringe .with . its .corresponding needle, and 
I felt the pleura; since tho patient was nervou? I paid par- 
ticular notice to tho effect of this, but he did not feel the prick. 
^7ishin^ to W’ait for five minutes and to lake hi^ mind oii inc 
artificial pneumothorax, I talked about the war, in which be bad 
been gassed and had suffered from neurasthenia. He suddenly 
becamo faint, and cried out V I am going *’ ; he was at first quite 
limp and looked like a corpse, then there followed a spasm, tho 
face was- drawn to one side with marked stiffening of the left 
stcrno-cleido-mastoid muscle, reminding me of the classical 
picture^ of^ torticollis in the textbooks. The teeth were clenched 
and grinding, tha respirations rapid, tho pulse could not be felt 
at tho wrists, and there were only very feeble indistinct heart 
sounds. I thought the condition was delayed pleural sliock. 

.-I administered strychnine grain 1/60 on empirical grounds, and 
after half an hour tlio ivholc attack was over. In tlic aftevnocn 
be was much better and told me he had an idiosyncrasy to 
cocaine; this I verified subsequently. 

In bis introduction to Forensic Medicine Dr. Burrklge 
gives the symptoms of cocaine poisoning as — 

“ If a poisonous dose has been absorbed the person becomes pale, 
feels faint, and may fall to the ground. Convulsions followed by 
unconsciousness may occur. The pupils are dilated and insensible 
to light. The pulse may bo uncountable at first. On recovery the 
patient complains of diminished censibility of the hands, etc. In 
several cases cpilepUrorm convulsions have occurred, followed by 
death in a few minutes . 




kvniis zS, 1928 ] 


BASAIi METABOmSSr. 


f Tnr Dnmyjt 
IfcDiCAi. JocaxAii 


717 


IUjJ0rts nf ^orktiis. 

BASAL JILTABOLTSSr. 



' nirtMljolisrii in ciinicni moelicinc. 

Br. liynU inAvcnicA tliat ostiinntion of linsnl inctafiolisni 
had been of great value to the jdiysiologist in the investi- 
gation of initritional prohlcnis long hcfoie any nso had lieeii 
made of the method elinically. • Ho outlined tho methods 
in use for tho estimation of basal mctaboliam, referring 
shortly to the method of direct calorimetry, which, 1(0 said, 
was too comiilicated for clinical work, and proceeded to a 
description of the method in general use where the basal 
metabolic rate could ho calculated from tho collection of 
'expired air under standard conditions. Tho patient had 
to ho porfecllj- at rest mentally and physically, and post- 
absorptive— that is, having taken no food for fifteen hours 
previously. The data necessary were tho lioight .and 
weight of tho patient, the total volume of expired air over 
h known experimental period, the respiratory quotient, and 
.oxygen cotisumptiou during'the timc' of c.stimation. Under 
Buitahle conditions uniformity of results was achieved by 
this method. In one mild caso of oxophthnlmie goitre, 
.where the estimation had been carried out four times 

■ at three-monthly, periods, the oxygen consumption on 

these occasions had been 254 c.cm., 251 c.cm., 25S c.cm., 
and 258 c.cm. per minute, wiih the respiratory quotient 
about 0.S2 on each occasion. Br. Lyall pointed out that 
the experimental error in the method w.os about or 

minus 8 per cent., but he hcliovcd tho error toiulcd always 
to be towards tho upper side. Thus a basal metabolic rate 
of plu^ 10 per cent, was within normal limit.s, but a b.asal 
metabolic rate of niiniis 5 per cent, showed a degree of 
reducfion upon which one was entitled to pUue diagnostic 
importance. A series of 45 easo.s of cxopbtlmlmic goilro 
bad been investigated once or repeatedly by this 
method. The basal metabolic rate was ini leased from 
15 to 30 per cent, in 14 eases, from 30 to 60 per lent, in 
22 cases, and to above 60 per cent, over normal in 9 cases. 
The liiglicst rates were plus 87 per cent., plii.s 97 per cent,, 
plus 100 per cent., and plus 105 ))cr cent. Three of these 
four severe cases had auricular fibrillation. The patient 
with the liighe.st rate was a tj-pical caso of the fulminant 
type of the disease. .Generally speaking, tho group of cases 

. cl.issed as mild by estimation of basal metabolism nerc 

■ those likely to become- good civil lives within a reasonably 
short period of medical treatment alone. The cases in the 

’. group of moderate Ecverjty wore likely to stand operation 
'.well if.'tliere .ifas, no other coutrainciicatioii. Tlic group 
, with basal rates above ' plus 60 per cent, made poor 
; Surgical risks; , The speaker enumerated the additional 
, factors which should be taken into account in considering 
the operative risk : (1) There should be no organic lieart 
.-disease; (2) the blood urea should bo below 50 mg. per 

- 100 c.cm. ; (3) the patient slieuld have already regained 
.h.alf the previous loss, in weight; (4) the blood pressure 

- should not vary further from normal than 140 mm. Hg 
systolic and 70 mm. Hg diastolic; (5) the patient should 

. have already regained self-control in fair measure. In 
nine of the cases in which glucose tolerance tests had 
been carried out the blood sugar curves showed inability 
to deal properly with glucose. The condition should not 
be confused with true diabetes, although iu this series 
. three cases of diabetes mellitus occurred. Eleven rases of 
myxoedema were investigated, the basal metabolic rate', 
varying from minus 3 per cent, to minus 42 per cent., the! 
average r^uction being 14 'per cent. In four of these* 
cases previous exophthalmic goitre bad been present, and* 
. the time factor in tho change from hyperthyroidic; 
symptoms to hypothyroidic was discussed. A series of- 
■cases of toxic adenoma of the thyroid and simple aaonora,-i' 
• shown that tho basal metabolic rate was raised in tbe^ 
former group of cases, but not in the latter. In nuhertV 
goitre the basal metabolic rate was not increased. The 

■ «st™atio.n had not been found of value iu the diagnosis 
of malignancy of the thyroid gland. In summing up' 


shortly Bv. Lyle, said that the estimation of basal meta- 
bolism was of valuo in the diagnosis of the less pronounced 
degrees of thyroid dysfunetibu. In his opinion it would 
give help in progno.sis'aiul indicate' tho line of treatment 
in cstabli.shod cases, .and would be of value in the control 
of treatment, cs 2 iecially by r rays. 

■ nyspiTuiTABisar. 

At a meeting of tlio Section of Neurology of the Koyal 
Society of Medicine, bold on April 19th at the West End 
Hospital for Disc.asos of the Nervous System, Brs. C, 
■WonsTEn-BiionoiiT and B. W. CnowHunsT Aucher showed 
jointly a caso of dyspituitarism occurring in a boy, aged 15. 

The patient, who was normal at birth, was said to have begun 
to sit up and cut his teeth at tho usual ages, but did not walk 
unlit nearly 3 years old. After this he increased rapidly in 
■stature, and became much fatter than the average child of nis 
age. He went to school at the age of 5, but made no progress ; 
lie never learned to read or write, but showed some interest in 
lucchanical things. His general boliaviour was always good. 
During the last year he had been unable to get about very well, 
owing to weakness of the legs. Tlie appetite was always very 
large, and the boy was unusually fond of sweets. Thirst was 
within normal limits. Though there were frequent attacks of 
vomiting at night, sleep was fairly good; there was no trouble 
with headaches, and the sight and hearing were normal. Sexual 
development was late. iHs present height was over six feet, .and 
his weight IBsl. Bib. There was pronounced general obesity with 
fairly uniform distribution of the fat. There was ^ight dilTereii- 
lialion of the shoulder and pelvic girdles, but no padding in the 
supraclavicular rcgio'ns or on the dorsum of the hands. The -hair 
in the pubic region was scanty and conformed to the male, dis- 
tribution. The skin was normal in texture, and covered with a 
slight groB-tli of fine ha'r. Muscular power was relalivcb' weak. 
The forclicad was full and prominent, the jaws large, the palate 
arched, and the upper teeth projected beyond the lower. The 
temnerature was invariably subnormal and the pulse rate aver- 
aged 90; the functions of all ihc'cranial nerves were normal, and 
there were no disturbances of sensation or co-ordination. The 
motor power in tiio upper limbs was fair, but below normal. The 
two hands were constantly held together in n position of flexion 
at the wrist, full extension at tho mctacarpo-plialangcal joints, 
hyperextension at tlio inlerpbalangeal joints, and approximation 
of the lips of the fingers to each other. The lower limhs appeared 
to be normal, except that in standing the knees were held closo 
together and tho feet were separated. The abdoiDiual reflexes 
wore brisk and equal, and tho other refle.xcs normal. The gait 
was slow and awksyard, witli the knees close together, and the 
feet separated. At an x-ray examination the sella turcica was 
found to bo rather small, but scarcely outside the normal limits. 
The frontal sinuses wore, unusually large and the .lower jaws big 
and prominent. The epiphyses of the wrist were normal, but 
those of the fingers had united. It was added that the mental 
age of the boy, according to tho Stanford modification of tho 
Bmct-Simon scale, was between 6 and 8, though for questions 
involving simple matters of conduct it might be placed at the 
higher of the two levels. His intelligence quotient was about 
fifty. 

CliOrcol’s Arfhropnfhy of Jloth .TTn'sfs. 

Br. lyorster-Drought- also showed n case of Clwrcot's 
artliropathv of both wrists occurring in a painter, agcci'50, 
who had complainoil of swelling of the right wrist since 
1918. The onset was gradual without .pain, and about a 
,year later tlio left wrist hecatno -slightly affected. Tho 
clinical details were as follows'. ■ ' • 

The right wrist was irregularly' enlarged and much deformed. 
On the dorsum, towards the ulnar side, there was a large swel!in-r 
conlainmg some fluid with bony thickening beneath; a similar 
hut smaller, swelling was situated on the radial side 'of the joint 
The enlargements w;cre not painful or tender. Flexion and lateral 
movement at the joint was .moderate, and extension was very 
hnuted A-ray examination showed ^tolal disorganization of Ih'e 
the carpus having almost entirely, disappeared, the lower 
it® and ulna being- dislocated dorsally on the 

Tnctacarpal bones. The left wrist was considcrablv 
especially towards the ulnar side, and was deformed. An 
^ V showed an early stage of Charcot’s arthro- 
Pp httle bone damage. Tho mctacarpo-phalangeal joints 

ox the ieft index and middle finger were also swollen and 
enlarged, bvw tteeVy ToovaWe. .The right pupil was larger than 
the left, and neither reacted to h'glit, though each responded to 
•accommouauon-convergence tests. The other cranial nerves were 
normal. There was some ulnar and tendo-Achillis analgesia: the 
knee-jerks were present, the right being slightlj' brisker than tho 
Jett; arm-jerks, abdominal reflexes, and anklc-jorks were normal; 
the plantar response was flexoi, and no definite inco-ordination 
was detected. There was no history of syphilis, but the 
Wassermann reaction was positive, and the colloidal gold lest 
snowed a curve of the luetic type, 

Br. AVorster-Brought said that during tho past three 
years tho patient had been treated with courses of nor- 
arsenoVillon intravenously and bismuth intramuscularlv. 
The neurological signs at the right- irrist and met.acarpo- 
plialaiigeal joints had remained unaltered, but flic 'left 
wrist had slowly become worse. 



BEVIEWS. 


718 Apriii 28, 1928] 


[ Tnr.T^niTi'N 
SfKDiCAL Jocnrii. 




HT5REDITY. 

To tlio^c who were young in the ilnys of the Ifoiiicric 
battles of the Monclolians ami hioinctricians, the inwiisal 
of such a straightforwaril ami impartial aeeonnt of tho 
present state of opinion as Dr. Ciir.w’s Ovfianic liihcnliiiin'c 
ill Man' is particularly interesting. The smoke of tho 
battle has long ago been dissi])nted, ami, alas! the two 
protagonists, Bateson and AVeldon, aro gone. Like most 
issues hotl}' contested between scientific men of genius, tho 
decision has hot been wholly in favour of either. If, like 
a boxing match, a decision wore to bo given “ on ))oint.“,” 
no doubt tho Mondelians would have it. Not only in intel- 
lectual suggestivencss, but even in the utilitarian field the 
investigations which sprang from tho rediscovery of 
Mendel’s work have been more fruitful than those which 
were promoted by tho school which was at fir.st directly 
hostile to tho Meiidelians. But it is not less true that in 
the field of human inheritance tho splendid work of Karl 
Pearson and his pupils and associate.s — among whom the 
late Edward Nottlesliip was not tho least — has demon- 
strated that tho contempt of the earlier Jlendolians for tho 
methods of Galton and his followers was unwarranted. 
Dr. Crow is of opinion that tho namo of Thomas Iliint 
Morgan “ will surely bo added to those of tho immortals 
of science. He does not merely stand on tho shoulders of 
Mendel; seeing further, ho 'has .sintiiig therefrom to 
conquer a province of his own; ” and a largo part of this 
volume is devoted to au exposition of the work of Professor 
Morgan, based upon an iiitoiisive study of tho fruit llv. 
Drosophila mclnnogastcr. 

Dr. Crew (whoso book has grown out of a course of 
lectures intended for medical men) has taken considerable 
pains to make tho subject clear, and has, wo think, 
succeeded. Tho difficulties aro of two kinds. In the first place, 
although geneticists often used to S]icnk lightly of “mathe- 
maticians,” to understand tho po.ssiblo numerical .sorting.s- 
out of factors when tho number of units is more than 0110 or 
two really requires a gras]i of the ideas of that ))articular 
branch of mathematics which rejoices in tho formidable 
namo of “ combinatory analysis.” In tho .second place, 
any visualization of the chromosome theory compels the 
reader to brush up his acquaintance with a part of 
cellular physiology that is not very easy to follow. Chapters 
II to IV of Dr. Crow’s book will tliorcforc make some 
demands upon the reader’s attention. It might, iicrhnps, 
have been worth pointing out that tho number of possible 
coinlnnations of chromosomes in tho zvgoto is tho sum of 
the binomial coefficients (56 in tho thi'rd lino of tho table 
IS a misprint for 64) of (A + B)n_that is. 2n-_and to illus- 
• tiate by symbolic multiplication, as well as by mere dia- 
grams, how tho frequencies of tho various combinations 
aio reached. The remaining chapters, dealing with con- 
sanguinity, inheritanco in man, and disease re.sistancc and 
immunity, are easier reading— the cynic will iicrlians s.av 
because our detailed knowledge of these matteri is so much 
-less than what wo know about the genetics of Drosophila 
mdanogastcr. But these, chapters are very clearly a id 
interestingly written, and contain very few instances of 
the dogmatisni which is so common in writings upon liuman 
iidioritance. We have only noted a few instanee.s which 
struck us as 111 need of modification. Wo think that tho 
remarks on tho inheritance -of left-handedness aro too 
summaiy, and that the psychological complexitv of this 
particular problem should be noticed. The remark that “tho 
pandson of long-lived grandparents is by far tho bettor 

risk for an iiisuranco company than is one of short-lived 
ancestry ” is more dogmatic than any published evidenco 
known to us warrants. Similarly, tho statement that 
tlicrq IS no doubt that tho principal determinant of 
longevity is heredity, and the average duration of life of 
a population cannot bo modified at all profoundly by mv 
sort of improvement in State medicine,” is only true if 
n o define the word “ profoundly ” in some special way. 

EainbS?"/,'’ f "'‘'•“■''"WO in .Van. B ^ ~ 


Crew, jr.D., D.Sc„ Ph I 
Id Boyd. 1927. (5^ x 9, pp. i.x 4 . 21 i| 


These, however, and a few other similar dicta, do not 
detract from the general merit of tho liook, which wo 
strongly recommend to tho medical reader ns a careful 
introduction to tho subject. 

The book is agreeably prefaced by a biogrnjihy of tho 
distinguished Birmingham jiliysician William Withering, 
in whose honour the lectureship Dr. Crew licld was founded. 


CllEMlC.VD I’ROPERTIES AND I’lIARMACOLOGlCAL 
ACTION. 

Dits. Tj. Hucou.vkxq and . G. l'’i.oiir.xcK in their hook 
I’rincipus ili: Vhiirniiicoilymimir,- have courageously attacked 
tho difficult ])robIein of the relation between chemical con- 
.stitution and pharmacological action of drugs. Tho general 
purpose of tho hook is set out thus in tho preface: 


"The Iccbniqtie of physiological iavestigalion is daily becoming 
mote ))crfeet; our knowledge of molecular arcin'tocture is con- 
tinuously increasing and becoming more accurate ; and fnially, 
pby.sical cbeinislry will doubtless bring fonvard all FOi-ls of new 
conceptions wbicli will illnminatc the way. When all tlics(* synerpe 
factors have produced - tbeir full cITect pbarmacoilvnainie will lie 
n biological science, still developing, but based on solid foundations. 
The book is a miniature and imiierfect represontation of one of 
the first stages of tins cvolnlion, a period that is of the biglicst 
interest, as is the connnencenient of any subject which is destined 
to increase and pci Imps, fated to play an important role. For, 
after all, surely the cssonti.al object of medical science is to 
relieve pain and, when possible, to heal the sick. It lequircs 
conr.agc to prononitco tins trnlb wbicb is so often veiled from 
lliose workci-s, otherwise admirable, who aro better equipped to 
dc'cribo than to liglit discaso.” 

Tlio intentions of the nntliors deseiTC, therefore, the 
highest pr.aiso, but the task they have attempted is one 
of uncommon diffienity. Anyone who attempts to coiTcIato 
chemie.al constitution and pliarmucologicnl action is faced 
with a vast mass of material of very varying acenrnty. 
Here and tlicro definite eorrclatioiis occur hetwoen some 
structural or jiliysico-clicniical property of coiiiponiids and 
tho intensity of tho action that they produce on living 
tissues, hut such correlntions are exceptional ca.scs scattered 
niiiom' innnmornble nneo-ordinated details. 

Fri!Tikcl’.s .Irene ” ’ ' ’ was noticed in 

onr issue of May . s most oxhanstivo 

work on the subject. 'I'lint encyclopaedic volume is an 
oxannilo of 'rcntonic industry, but it is essentially a work 
of reference, and gives no general view of the problems 
dealt with. Tlio anthors of the present work have kept 
their material within mnnagenblo limits and have produced 
a vondahlo volume. They describe clearly important 
exanqilcs of drugs in which some recognizable connexion 
is apparent between chemical .structure and phariiiaco- 
logicnl action. A few of tho prohloins the authors deal 
with arc ns follow.s: Drugs acting on the various tyjies of 
iiciwo endings — namely, sensory nerve endings, endings of 
incdullntcd nerves and autonomic neiwo endings, narcotics, 
nntipyvctics, and such specific remedies as the organic 
conipomids of merenry, ar.sonic, antimony, and bisiiinth, 
and tho antiseptic dyes. 

Tho hook is particularly interesting hecanso it gives a 
fairly fall nccoimt of the important, rc.searclics in chemo- 
therapy that have been carried out by Frencli 'workers, 
of wboni Fonrneaii is one of the best known. 'I’lie .signi- 
fienneo of this work is apt to ho overlooked, hecanso the 
great majority of referenco hooks aro in German, and 
thc.se tend to emphasize the work published in their own 
language. The volume concludes with two short but inter- 
esting chapters on war gases and anti-gas measures. Tlio 
authors remark, however, that this information is out of 
date, hecanso all the gases descrihed have already heen 
superseded by others whoso composition is secret. 

Tho authors deserve praise for their endeavour to . give 
a coherent presentation of the difficult subject that they 
have chosen, hut it cannot ho said that they have succeeded 
in throwing niiicb new light on the jirobloms they discuss. 
Tho reason for this is that onr present ’ knowledge is 
unfortunately inadequate to permit of any imjiortant 
generalizations regarding tho relation between cheniicnl 
properties arid pharmacological action. 


Princiiica do Pharmacodiinamio. rnr L. lIiiKOUiicno ct 0. Florence. 
Pans: Masson H Cle. 1928. (Med. 8 vo, pp. viii -F 391 ; illnstralcd. 
I w fr. sans nmjorntion.) 


Atoiii 28, 19:8] 


BEVIEWS. 


r TnrnnmBit 71 P 

I Mr.PJCAi. Jocrnal * 


TJIORACOSCOPY. 

No tlbubl exists ns to tiio viiliio of cndoscoiiy ns applied 
to tlio l)\ni-lder, stomach, and hromdiinl tnhes, and it 
remains to ho shown whetiicr the method can bo nsofnlly 
applied to the plonva and peritoneal cavities. That it is 
feasible in tho ease of the plevira has been proved by 
Jacohaous, who has sncccssfully msed it in his operation 
of division of jdeurnl ndliesions, and surgeons will welcome 
two excellent woiks on tho subject — the AUns Thornro- 
sropifoiP of Dr. Fr.ux Covx and the textbook and atlas 
of lapnvo- and thornco-scoiiy* by Dr. Ilofiini Konnscji— in 
which tho technirpio of the method is described and the 
appearances seen in various diseases depicted. 

Dr. Cora’s work is purely an atlas, with brief explana- 
tory notes on tho illustrations. Of tho latter it is im- 
poiihlo to speak too highly ; tho drawing and colouring nro 
very fine, and tho plates nro sufficiently numerous — fifty in 
numher — to give a good idea of the value of the method 
as an accessory means of diagnosis and in controlling 
ojicrativo procedures. Several plates exhibit tho operation 
of Jacobaous, and ovciy detail of tho proceduro can bo 
followed os' if the operation were being conducted on tho 
Eurfaco of the body. The descriptions of the plates (as well 
as. tho preface) arc in Italinu, German, and Englisli. 

Dr. Korbsch’s work has a different scope; it deals with 
tho peritoneum ns well as tho pleura, and gives full 
details of tho technique of tho operations, their indications 
and complications, with fifteen coloured plates in illustra- 
tion of tho lesions; further, it enters into considcrablo 
detail relating to the pathological anatomy of tho lesions 
brought into view, in their several stages. How far it 
will bo considered justifiablo to resort to laparoscopy as a 
substitute for cxploratoiy laparotomy is at present doubt- 
ful; tho former is tho less serious operation, but tho latter 
enables the organs to bo handled as well as seen — a great 
advantage. 

The two books referred to will assist the surgeon in 
forming an opinion on tho possibilities of these now 
pi-ocodurcs. , 


SANITARY LAW AND PRACTICE. 


■BonEKTSox and PoarF-U’s Sanifanj Lnir rnid I'radice^ has 
iu its sixth edition been added to, amended, and, wlicro 
necessary, rewritten to keep jiace with the changes of the 
last- seven years. It now takes iu the Sanitaiy Officers 
Order of 1926, the hlemorandum on the duties of Medical 
Officers of Health of 1925, and tho Puhlic Health Smoke 
Abatement Act of 1926, which omit.s the word ‘‘ black ” 
as qualifying smoke in respect of which nuisance mav he 
held to occur. It deals with tho Puhlic Health Act of 
1925, and the various regulations as to meat and foods, 
including the Preservatives Regulations of 1925, which have 
come into operation since the fifth edition was published. 
-The Tuberculosis Order of 1925 is likewise quoted. The 
Alilk .and Dairies Amendment Act of 1922, with the Act 
which it brought into operation, and relevant Orders, and 
•tlio corresponding Acts and Orders for Scotland, are all 
duly set forth. The Housing Act of 1925 is presented and 
explained. The work in its present form contains sections 
on central and local health administration, on offensive 
trades and slaughter-houses, on the dairy hj*-laws, on in- 
fectious disease and its notification, and on tuberculosis. 
If treats competently of water supplies, sewage disposal, 
and housing. The subject of welfare is effectively pre- 
sented, tho mother, the infant, and the school child being 
dealt with in order. Tbo concluding item is tho Public 
Health Infectious Diseases Regulations of 1927. The work 
is therefore well up to date, and can once more be recom- 
mended to tho student of public health as an ample and 
trustworthy guide. 


Covn. Milano : Sperling < 
Kupfer. 192a. (Ilo.v. Ato; 50 plates, £1 17s. 6d.) 

*I,eUrlHch iimf Atlas iler Laparo- imtl TJior'at-osinpif. Von Hr. Ro 
Korliseh. Lehmanns meduinischc Lehtbacber, BiJnd is. MOncIii 
J, F. Lehmann. 1927. (Roy. 8ro, pp. 73; 15 plates. SLID.) 

v r.".’"', r™'''’'''- Bv tv. Rohorlson, ■M.H.Glas., D.F 

r.R.C.P.Ed., and Charles Porter, 5I.D., B.Sc., Jf.R.C.P.Ed. Sixth editi 
enlarged. London ; The Sanitary Publishing Componv. 1 
1928. (Demy Bro, pp. xix-h815; 51 figures. 'Zls. 9d. post free.) 


MEDICINE AS SHOIVN IN ART. 

Dr. C.in.ixBs has eoUcctcd and. published much material of 
ati interesting and curious nature in connexion with the 
history of medicine and medical men; and out of his 
extensive store of knowledge has now brought to our notice 
the rejircscntations of disease iu painting and sculpture 
in a copiously illustrated work entitled Esculapc chez Ics 
Artisics^ Contesting- the notion that science and art aro 
incompatible, lie recalls that great artists, such as Leonardo 
d.a Vinci and Alichaclangclo, made very careful studies of 
anatomy in order to render their mastoi-picces moro 
accurate, whereas Raphael’s representation, in tho famous 
picture of the 'Iransfiguration, of a child in a fit with tho 
innsclcs of a developed athlete, is an example of an error 
which might have been avoided. Dr. Cabanes then refers 
to Rastenr and Charcot as artistic spirits, quoting Paul 
Richer’s dictum that n work of art is tho translation of 
an idea into niatorinl language. 

The morbid conditions rcpvodvtccd in pictures and sculp- 
ture arc considered in successive chapters, ■ the first dealing 
with facial affections, such as rhinophyma, asymmetry, 
paralysis, spasm, and ono of leishmaniasis on an ancient 
Peruvian vase of tho period of the Incas. Various dwarfs, 
pygmies, and court jesters nro copiously reproduced, . and 
tho chapter on tho great historical epidemics is rich in 
illustrations of huhonic plague and its groat patron saint, 
St. Roch, drawn from the author’s private collection. 
Leprosy also is well represented, and the picture of 
St. Antony tormented by tho Devil, after Afatthias 
Grnnewald (1515), is reproduced, with ,a. noto .about- the 
nature of tho lesions shown — syphilis, leprosy, plague, or, 
as tho autlior follows J. K. Huysnians in believing, gan- 
grenous ergotism. In tho chapter on hysteria and hystevo- 
opilcpsy, whicli Cliarcot and Paul Riclicr and Aleige so 
thoroughly explored, the anther points out that domonio 
possession was hysteria, and- gives an account,, with illus- 
trations, of tho well-known dancing mania of St. Guy. 
Tho phenomena' of insanity and epilepsy are graphically 
depicted ; then representations of surgery from the. time 
of tho siege of Troy are dealt with; and in the section on 
pathologj- in art urologists and dentists find a place. In 
an appendix on tho thyroid gland Professor van Loersum’s 
recent article in Jatnis on this subject is laid under 
acknowledged contribution. 

I This pleasantly written monograph provides a most useful 
I store of information, which those interested in the history 
I of disease will do well to consult. 


NOTES ON BOOKS, 

As a change from the encyclopaedic catalogues of symptoms 
which tho American medical author seems to delight in inflicting 
upon the reviewer, it is refreshing to meet with Dr. Fraxcis 
W. Palfrev’s book on TAc Specialties in General Practice,'' 
Dr. Palfrey has' compiled his' hook in collaboration with pro- 
fessors and instructors at the medical ' school of Harvard 
University, Its protluction is justified in the preface by the 
obvious truism that “ the total of medical knowledge has 
become so large that it is beyond the capacity of any one man 
to have, a complete command of the \vhole in all its branches/' 
A less trite argument is that “books on special subjects are, 
most part, written from the point of view of the 
specialist," often laying emphasis on rare conditions and 
operative 'procedures which are of subsidiary interest to the 
general practitioner. Dr. Palfrey has kept bis contributors 
well in hand they have summarized sanelv the knowledge 
which the general practitioner should possess in the specialties, 
and have ,.rightlj\ avoided controversial disenssiom Thus -few 
people could object to the preface on the delicate subject of 
sexual hygiene with which Dr. Dellinger Barney opens his 
section on genitp-jirinary surgery. Dr- H. C- Solomon will 
liave on his side many experienced general practitioners when 
ho says that the prevailing idea that small doses of alcohol 
are helpful in the cure of alcoholism is probably incorrect. 
Dr. X R. Toubert's proposition that extension of the mother's 
.thighs diminishes the risk of rupture of the perineum mav be 


* JFacuJone chez Us AttiHcs. Par Dr. Cabanas. Paris: Lg Francois. 
1923, (sj X 7i, pp. ; 198 figures. 15 ft.) 

^ The fjiecialUes in General Vraetice. Compiled by Francis W 
Palfrey, M.D.. in coliaboration with various authors. Phnadclphio ana 
London: IV. B. Saunders Company. 1927. (6 x pp. 748. 20s. net.) 



YILIiEMIN— PIONEER, 


t tvr. Hftmin* 
KfErlC,!!,, Jocn'fU' 


720 APBiii 28 , 1928 ] 


cun’cot, but socnis iucoiisistcnt with the presumably natural 
scpiatling position in paYturitioii. The book is a veatlable 
sumiuaiy of useful knowledge. 

Fighters 0 / Story of Men ami iru/urw uho Mnvv 

A-chitved thenily Despite the Handienp of the (Meat Mhtit 
Plufjur^ IS the title of a book by Dr. J. A. Myeus, Associate 
Professor of Preventive 'Medicine in the Dnivovsity of 
Minnesota, who sketches the life stories of twenty-four persons 
prominent in very diiferent walks of life in order to oncouvago 
thi victims of tuberculosis by showing how much can he done 
hy others similarly stricken. The female representative is 
Elizabeth Barrett Browning, and among the twenty-three men 
Schiller, Bichat, Laenuec, Keats, E. D. Trudeau, Lawrason 
Brown, and ^IcDugald McLean represent the medical pro- 
fession. Nicolo Paganini and Predcric Chopin stand for inu.sic, 
Aubrey Beardsley for pictorial art, Cecil Rbodos for statesman- 
.ship, St. Francis of Assisi for tbe Church, and Dostoievsky, 
Leigh Hunt, Artemus Ward, aiid others for literature. Rather 
curioYisly R. L. Stevenson is only mentioned incidontallv as a 
patient of Dr. E. L, Trudeau, but Dr, Myers lias wiscl}’ dis- 
unned any criticism by frankly admitting his difficulty in 
rhoosinc those to include. Some of the people ho de.scrihes are 
fortunately alive, such as Dr. Lawrason Brown. Air. Albert 
Edward Wiggam, who, it is delightful to hear, ** plays nine 
holes of golf every day ’’ and “ lectures cveu before Mich 
medical groups as the clinical stall of the Mayo Clinic,*' and 
Will Irwin, an American author, a list of whose works h; 
thoughtfully appended. Tuhevcnlq.sis has been credited willi 
causing mental exaltation — for example, Chopin is said to have 
been thus enabled to compose some of lii.s mastorpicers — but 
Dr, Hyers considers a more trustwortby exphimiLion is that the 
enforced physical inactivity provides more opportunity for 
moiital work and output. 

* f ij 7 /itcr« of Tate: A of Men nmf vho Ilnre AcUierfI 

(•icatlif Despite the UauOicap of the (irent White Playiic. T\\ ,T. Arthur 
M>ers. With an intioduction by Chavlc.^ H. Mayo*. Bahlmore: The 
Williams and Wilkim Company ; Loiuiou ; Baiilierc, Timlull ami Cox. 
3927. (Cr. 8vo, pp. xix + 318. iSs. 6<l. act.) . 


Itoka tt Uctcra. 


VILLBSIlX— PIONEER. 

A Chapteh in the Histoey of Tudeeculosis. 

The liiiiidrecUh Eiiiiiversavy of tlio birth of ^''iIIcmin ivns 
I'olobrated recently in Paris. He it was wlio convinced 
a" large proportion, if not the majority, of tlio leaders of 
I'rench medical tliongbt that tuberculosis was a .specific 
communicable disease, and tbvougb them many of tbe phy- 
sicians , and pathologists of other countries, though it 
iipoded tile domoustration by Kocli of the tubercle bacillus 
to clinch tbe matter and convince everybody. It may seem 
strange to-day that the fact should over have been in 
doubt, and it is not easy fully to realize tbe state of 
confusion that existed about pulmonary con.snmption in 
the middle of the last century, Tbe prevailing belief 
among the public was that it was inherited, and tli.r current 
opinion in the medical profession was that it was due 
to a diathesis. In the Mediterranean countries there were 
traces of a popular belief, shared by some members of tbe 
medical profession, that it was contagious. Tliis was siiffi- 
ciciitlj’ well known in France to cause expcrimeut.s to 
be made, but these yielded negative or ambiguous re.sults. 
Ill 1843 Kleucko claimed to have produced generalized 
tuberculosis by injections into tbe jugular of certain colls 
ho identified as tuberculous, but he failed to impre.ss 
Germau medical opinion. 

Villemin’s early work wa.s received in a critical spirit, 
by his own countrymen. It was deemed revolutioiiai-v, 
as, indeed, events proved that it was. Ho was helped to 
form his views about tubercle by the study of disease in 
animals. Ho foimcl analogies between tuberculosis and 
glanders, which Gobier in 1813 had proved to be con- 
tagions and inoculablc from horse to horse, and Ror'er 
in 1842 to be transmissible from horse to man. Villcjuin 
bad observed how glanders spread in Ibo regimental 
stables, and he made use of the analogy when he uTote 
■' We cannot escape from tbe idea that in the production 
Ilf phthisis tbe barrack is for the soldier wliat the regi- 
mental stable is for the horse in the production of glanders.” 
-tg.ain, .he obsen-cd that tbe poor man’s cow feeding by 
the roadside escaped tuberculosis, whereas in some big dairy 


farms nearly every cow snccninbcd. Ho studied bis snb- 
jeet with great energy for years, and found iimny more 
facts of human anil animal pathology all converging to the 
.same conclusion, but be encountered also many difficulties, 
iiieliiding tbe circnm.stanco, enijdia, sized hy Laenncc, tliat 
phtlii.sis did not hahitimlly spread in poor families living 
under the worst conditions, and the opinion of Virchow, 
wliose inHucncc was then dominant, that “ caseous 
piicuinonia ” was not tuberculous. 

Villoinin was in no buriy to publish, but bis fii-st essay, 
which appeared in 1861, showed the direction in which 
his mind was working. It ivn.s not until December 5tb, 
1865, that bo brought before the Academib do Medccine in 
Paris bis conclusion tiiat tubercnlosis was a virulent 
specific disease. The tbe.sis rather took the academicians’ 
breatli away, but after considering the matter for nearly 
a year it was .seen that its con3cqncnco.s wore too big to 
warrant any decision, except after experiment and ample 
discussion. Accordingly in October, 1866, a committee of 
.sumo of the most distingnislied French pathologists of tho 
day was appointed. Its report, presented by Colin a year 
later, showed that its members were .sitting on tlio fence; 
tlipv eonfirmed the ncoiiracy of Villemin's work, but were 
not prepared to reject tUa theory that tuberculosis might 
occur spontaneously. There ensued a debate wliicli, as is 
tbe way of the Aendemy when it is interested, dragged on 
until the long vacation of tho ensuing year. Coiin’s report 
was then accepted and tho e.sseiitial imrt of Yillemin’s con- 
tentions thus approved. Moamvbilo ho bad assembled his 
observations and arguments in a book wbieh was widely 
read, and bo bad won some jiowcrfnl snpiiorters ; among' the 
pathologists perhaps tlio mo.st influential was Coniil. 

Laennee bad maintained what was eallod the “ unity of 
phthisis,’’ a view, as has been said, aftonvards attacked 
hy Virchow. But Dacnnec and tho majority of tho 
clinicians who followed him were impressed- by the fact 
that tbero was little evidence of tho transmission of 
phthisis from one adult to another. Professor Bezancon, 
w'ho delivered the prinripal speech at tlio cclehration, called 
attention to tho fact that when Villemin fii-st promulgated 
ins theory infantile tuberculosis was little • understood. 
It was now realized, Boznneon said, that it was nece.ssary 
to considci- separately the problem in tlio child and in the 
adult. Tlio fact tliat the infant’s organism was very 
sensitive to tnbcrcnlons infection dominated the whole 
pathological story. In tho adult, with his more resistant 
organism, though infoetiou might occur aud was always to 
bo feared, “ the danger is rattier in the ro-awnkoning of a 
tuberculosis of infancy wliicli Iiad become Intent ” ; conse- 
quently the problem was the study of the reasons- why the 
latent tuberculosis was re-awakoned rather than to discover 
tlio causes of contagion. Had Viilemiu been aware of this 
he would have had less difficulty in convincing the 
clinicians of his day-. 

There was a considcrablo body of opinion against liim in 
France Gennuny, and England, among pathologists as 
well ns’ cliniciaiis. It is indeed strange that so many 
should bavo blundered in tboir experiments aud in tlio 
iiitorprotation of them. It was, perhaps, because bactcrio- 
lo'»v was in its infancy; the fact tliat microbes bred true 
was not fullv assimilated, nor tbe need for precautioms to 
pi-ercnt contamination tborougiiiy gra.sped. As tlii.s now 
denartment of scienco developed not a few of its votaries 
began to make tentative experiments witli tuberculous 
products, until Kocli, the most famous of Villemin’.s 
followers’, by the happy thought of the .solid oulturo 
medium and by working out a new technique, discovered 
tho tubercle bacillus in 1881 and convinced all. 

Yillemin was the sou of a small farmer in the Vosges, 
and hoped to become the village sclioolmastor, but he was 
conscripted. His colonel scut him to study raedieiue at 
Strasbourg, and bo ontered tho military service of the 
French army: quite early in life ho bocaine professor in 
the array medical school at Val do Grace. Ho was elected 
a member' of the Aeadcmio de Aledcoiuc in 1874; eighteen 
years later be became its vice-president. Professor .Acliard, 
tlio present general secrotaiy of tho Academie, said, during 
tho celebration, that be would certainly have become its 
president but for ids earlv death, which occurred in 1892. 

D. W. 




THE DECLINE OF TOBEBCULOSIS. 


r TurUnm'^Tr 7OI 

JOCRKAT. ' 


Arniij :S, iQiS] 


Bvttisl) ilctjical fotivnal. 


SA.TUBDAT, APBIL 28tii, 1928. 


THE DECLINE OF TUBERCULOSIS. 

Sir. lIor.KiiT PniLir, in liis vecout wldrcKs al Bath to 
the Society of Medical Officers of llcaUh, printed in 
enr opening pages this week, has turned liis attention 
to the causes of the decrease in tuberculosis mortality. 
'J’hat a great decline in the mortality from the disease 
lias oceurred and is occurring in this country is matter 
of common knowledge. It may bo readily confirmed 
by a comparison of the tuberculosis death rate in the 
middle period of last century with the happier con- 
ditions of the present daj'. The rate of decline has 
followed, on the whole, a fairly uniform course, except 
in so far as it may be hold to have been accelerated 
during recent years. Tuberculosis is a disease whioh 
is prevalent in animals, from which it may be passed 
to man; it is capable also of being transmitted 
directly from man to man under certain conditions. 
In the human subject it usually runs a somewhat 
protracted cours' ' im its early non- 

infective stages, • ■ ' ■ lo diagnose, to the 

infective lesions of its terminal phases, which arc too 
gross to escape observation. Under such conditions 
it is scarcely to he expected that the variation of any 
single factor could have produced the progressive fall. 
The question of the causes which have been at work is 
one of ■ considerable complexily. Tuberculosis, how- 
ever, has been to Sir Robert Philip the interest of a 
lifetime, and he is therefore well fitted to speak with 
authority oh the causes of its decline. 

Tlie antituberculosis campaign which developed in 
this country soon after 1911, aided by the funds made 
available by sanatorium benefit under the national 
insurance .scheme, and by the moneys then voted by 
Parliament for the construction of institutions for 
the treatment of tuberculosis, was inspired in groat 
measure by the linked dispensary and sanatorium 
system which Sir Robert Philip had established in the 
city of Edinburgh. He properly ascribes to this class 
of nork a share in the credit for the reduction in the 
incidence of the disease, though he does not lay such 
exclusive stress upon it as some who have elsewhere 
carried on schemes modelled upon his example. 
Eeeognizing that the downward course of the tuber- 
culosis death rate had begun long before anv formal 
antituberculosis regime had been instituted, he seeks 
his solution in those causes which began to operate 
as a result of the movement which followed the Royal 
Commission of 1869. ' An awakened interest in 
sanitary matters, an improvement in the educational 
standards of the people, a diffusion of general and 
special knowledge among classes previously' excluded, 
a betterment of housing and working conditions, higher 
wages, shorter hours, better feeding, the open-air 
life — all these contributory' factors have, in bis view, 
increased communal vitality and tended to curb the 
ravages of the disease. 

It is probable, too, that many of these contributory 
factors have acted also in a direct manner by' cutting 
across the path of infection and reducing the frequency 
of the opportunities for the transmission of the virus 
to children at young ages. The path of infection 
between bovine animals and man is being closed, as a 
result of recent milk legislation, bv the sale of milk 
from tuberculin-tested herds, and by the Tuberculosis 
Order of 1925. But these specific factors, yaluable 


as they are, were preceded, and are still being 
reinforced, by (hat group of causes which, taken 
togeUier, make up what is known as the social uplift ; 
an influence which has, with some few exceptions, 
been ranged on the side of health — unconsciously 
hygienic during tlic ages when medicine itself was 
ignorant, consciously' hygienic at the present clay, 
when medicine, owing to its notable advances, is able 
to contribute in such an effective manner to the 
welfare of the community. 

It is true that medicine in the case of tuberculosis 
has not yet evolved a generally accepted specific 
prophylactic. It is possibly true that some part of the 
treatment of tuberculosis as now carried out is un- 
economic, when cases come under notice too late to 
be cured, so that expense is incurred in the protracted 
treatment of those who can never regain their working 
capacity. . Even if it were so, the linked .antituber- 
culosis system is well justified of its works, for the 
treatment of the obviously sick is not the sole or the 
principal object which it serves. The tuberculous 
infection is followed back into the homes of the people ; 
early associated cases are discovered and put on treat- 
ment; the pre-tuberculous are shepherded along the 
paths which lead to health; defective environmental 
conditions arc rectified ; and an unobtrusive, bub potent, 
antitubcrculosis propaganda is set on foot, precisely in 
the places and among the people by whom it is most 
required. 

Su- Robert Philip, in a personal reference with which 
his address begins, touches on the work of Yjllemin. 
A note on this pioneer in the study of tuberculosis 
which appears elsewhere in this issue (p. 720) will be 
read with mingled interest and regret by many who 
had frequent occasion, during his lifetime and tenure 
of office, to delight in the cogent and graceful pen of 
Sir Dawson Williams. In this note, written a few 
weeks before his death, our late Editor refers to the 
critical spirit in which Yillemin’s early' work was 
received, and tells how the French Academy of 
Medicine sat firmly on the fence when presented by 
Yillemin with an essay in which he showed tuber- 
culosis to be a virulent specific disease. The lives of 
medical pioneers have too often fallen in unpleasant 
places. Harvey, when he discovered the circulation 
of the blood, lost much of his practice. Jenner's 
Enquiry was rejected by the Royal Society. Lister 
encountered hostility- and opposition for many, years. 
Sir Robert Philip, living in a more enlightened age, 
has had better fortune. His election to the Presidenev 
of the British Aledical Association, the position which 
be now adorns, is not only a mark of the personal 
esteem in which he is held by' the profession, but also 
a recognition of the distinguished part he has played, in 
the movement for the control of tuberculosis, of which, 
as he says with characteristic moderation in the closing 
paragraph of his address, the outcome appears 
satisfactory. 

THE ANAEMIA. OF MALIGNANT DISEASE. 
That anaemia is often associated with malignant 
disease, especially with cancer in its later stages, is 
a common observation. This anaemia may be of any 
degree of severity, and in the severer degrees may 
form a picture almost indistinguishable from that 
of pernicious anaemia, and in some cases may form 
so prominent a symptom as to dominate the clinical 
picture. This condition has been discussed and care- 
fully analysed by Dr. David Eisen.’^ He finds that in 

^ Anaemia as a Predominating Symptom in Malignant Disease. David 
Eisen. M.B.Tor. The Canadian SIcdicat Aaociation JovmaJ. vol. :cviii 
Ko. 12, p. 1506. 



722 Apeiii 28, 1928] 


THE ANAEMIA OE MALIGNANT DISEASB.' 


eases in whicli the anaemia consUtutcs a prcdoininat- 
ing symptoin in malignant disease the patients’ com- 
plaints may largely be referable to the anaemia, and 
that measures tending to its I’elief may sometimes 
result in considerable temporary improvement. He 
divides this class of patients into three groups, accord- 
ing to the relative predominance of the anaemia over 
the other associated symptoms. In the first gioup 
are comprised patients who present a marked anaemia 
of the primary type, accompanied occasionally by 
other symptoms of primary pernicious anaemia, but 
M'ith no definite evidence of malignant disease. In 
this group the malignant disease present is usually 
cancer of the stomach, and manj' writers have com- 
inented on the occasional resemblance of the blood 
picture in this condition to that of pernicious anaemia. 
In the second group are included patients who present 
a clinical syndrome sufiSciently characlerislic of 
malignant disease to cause its presence to be sus- 
pected, but not definitely established, and in whom 
the associated anaemia overshadows the remaining 
symptoms. The third gioup is composed of patients 

who present definite evidence of malignant disease 

usually of the gastro-intestinal tract— and in whom 
the symptoms are largely duo to the accompanying 
anaemia. i j o 

As a typical example of the first group Dr. Eisen 
records the history of a man, aged 59, udio was 
considered to be a case of pernicious anaemia 
eren during treatment in hospital. It was only 
on Ins second admission to hospital that evidence 
or gastric retention was obtained, and ar-rav 
examination then showed advanced carcinoma of 
the mid portion of the stomach, the patient dvin" 
tivo weeks later after a palliative operation. Necropsy 
stomach to be infiltrated bv a firm 
colloid-hke tumour undergoing ulceration, which micro- 
seopic examination showed to be an adenocarcinoma 
inhltratmg the entire stomach wall and extending 
into the serosa. Dr. Eisen contends that the diagnosis' 
ot permeious anaemia made on the first admission 
voiild seem justifiable in the presence of achylia 
dorsal sclerosis, and marked anaemia of a primnrv 
type in a well-nourished man with a virtually ne-a- 

of evidences “of 

strei T- ^^oreover, this diagnosis was 

hospitiSion ^ improvement after 

_ That malignant disease, especially of the stomach 
simulates pernicious anaemia has long been recocr- 
nised. Almot and other writers, though aLTtlul 
the association of a pronounced haemolytic anaemia 
of the primary type with malignant disease “dfi not 
admit -that it constitutes the causative factor of this 
anaemia, especially in cases in which the severity of 
the anaemia appears to be out of proportion to the 
extent of the lesion. Almot, however, suggests that 
the pernicious anaemia may in some way predispo^ 
to the development of the malignant disease!^ Sevwal 
writers— Soanenfeld, Naegeli, Hirschfeld, and Zadek— 
record cases in which cancer of the stomach has 
developed during the course of pernicious an.iemia 
Although it cannot be denied that the simultaneous 
presence of malignant disease and pernicious anaemia 
may be a mere coincidence. Dr. Eisen will not accent 
this as an explanation of all cases of malignant disease 
with a pernicious anaemia syndrome. It ivould be 
dimcult on this basis, he contends, to explain whv 

- -bieu the 


r Tnr. nriTTnw 
L WkI’Ical Jnrii'fif. 


evidence is needed to 
siippoit Die now that pornieious anaemia offers a 
specific predilection for iJio occurrence of ninlimant 

cml'lfnf T sfomneh. Eiirther, it cannot with 
ccilainty bo proved in any ease that cancer of the 
s omneh became superimposed upon pernicious 
anaemia, as gaslnc cnrcinoma may notorionslv be 
prcsenfc for a long time witbout presenting any dinr- 
actcristic sympioms. A typical case of the ‘second 
group IS nkso recorded in which the anaemia was the 
oiilslanding feature and appears to have been the 
actual cause of denlh. The comparatively high colour 
index, the extreme anaemia with leucoponia and 
relative lymphocytosis, in the absence of evidence of 
external haemorrhage suggested tlie diagnosis of 
pernicious anaemia early in the disease, and the 
vosl-mortcm findings of increased pigment deposits 
in the viscera support this view. Haemolytic anaemia 
nssoeinled with malignant disease appears to bo 
uncommon. The close resemblance to pernicious 
anaemia of the two cases cited .suggests an etiological 
rclationsbip for the anaemia. Whether, however, 
the aclilorhydria played an etiological or an adjuvant 
role in the production of the anaemia, or whether all 
the phenomena were caused by a 'circulating toxin, is 
difficult to state. An illustration of the third type of 
patient is provided by the case of a housewifej aged 
62, in whom the palliative c-ft’ects of transfusion were 
doinonstrntecl. This probahlj’ results from stimulation 
of the haematopoietic S3'stcm, nnd .ma^’ bo expected 
to occur in cases of malignant disease, with sj’mptoms 
mainly referable to the anaemia. The possibility 
of haemolysis after transfusion cannot be ignored, 
ns mentioned by Ewing, who considers that it is 
duo to a toxic action on the transfused blood 
by hnomolysins engendered by the absorption of 
necrosing tumour tissue, to wliicli the patient’s 
own blood appears resistant. It is not at all 
clear why such pronounced anaemia should occur in 
certain patients with malignant disease; probably 
several factors ore at w.ork, . including persistent- 
liacmorrhago, impaired nutrition, absorption . of 
necrosing tissue, and occasionally haemolysis. Aplasia 
of the bone marrow, except as secondary to chronic 
haemorrhage, does not appear to present any definite 
relationship to the malignant process. 

To whichever of these three clinical groups the 
patient belongs ho may expect to obtain considerable 
alleviation of his symptoms from the adoption of 
measures directed to the relief of the anaemia, chief 
amongst which stands blood transfusion. The danger 
of haemolysis of the donor’s blood, however, should 
be kept in mind, and tests for this possibility should 
alwavs he made beforehand. 


GENERAL PRACTITIONERS AND THE DAWSON WILLIAMS 
MEMORIAL FUND. 

I.v our issue of Alarch 17th (p. 461) we published the first 
list of supporters of- a memorial to Sir Dawson Williams. 
Tho project began in Januarj- as a Testimonial Fund in 
recognition of the great services rendered to medical science 
and t!io medical profession by Sir Dawson AVilliams during 
tho thirty years he served as Editor of the lirifish Medical 
Jctiriial. His sudden death on Fobruai-y 27th, less than 
six wcolcs after retirement from tho editorship, prevented 
his many friends and admirers throughont the profession 
from making this public acknowledgement of their esteem 
and regard during his lifetime, hut tho Executive Cora- 
mittoo decided, very rightly, that what had been done 
should ho continued with the object of establishing a worthy 
memorial to a great benefactor of British medicine. Its 


l^EW LIGIIT ON YELLOW FEVEB. 


. r 3'«p. Dnmsa 75!3 

L Mepicil Jocn^AX. * ^ ^ 


ArRir. 28, 192S] 


f(,rm will 1)0 ik-oiilod upon, in (kic course, wlicn the Mil)- 
Miiliors have been coiisultoil. ]u tlio uicniiwliilo we me 
asUeil to lunbe it known tbnt tlio Fund is still open, and 
that f\ivtliov contributions, small or largo, will be welcomed, 
in order that tbo memorial may be widely rcpiescutative 
of every braneli of ])rofessional work and study, and not 
least of the great body of general inaclitiomn-s, whose 
interests Sir Dawson '\YilVmins bad ever at heart from 
beginning to end of his editorship. 'J'he fullest i>articipa- 
tion in this project by those whom he so often spoke of 
as “ the working doctors of the country ” would be more 
than fitting; indeed, without it this memorial, whatever 
the sum raised, would be inadequate. jMany general 
juactitioners have already .subscribed generoush, but the 
le.sponse will, we hope, soon he even more widespread. 
The names of all contributors will be acknowh-dged in these 
cclumns. Cheques should be made payable to Sir StClair 
Tb.omson, who is acting as Treasurer of the Fund, and 
sent to 64, AVimiiolc Street, London, AV.l, and the envelopes 
marked “ Dawson 'Williams Memorial.” 


NEW LIGHT ON YELLOW FEVER. 

The study of yellow fever has been greatly advanced by 
two recent diseoverie.s, which throw a new light on the 
'nature of the virus and . incidentally fnrni.sh additional 
evidence that Lepfosi'ira ic.icroidcs Nognclu i-. not the 
causative organism of this disease. Since 1925 the West 
African Yellow Fever Commission of the Uockefeller 
Foundation, with lieadquarter.s at Lugos, has been studying 
mnnerous sporadic cases of yellow fever in Nigeiia and 
the (foki Coast, and a recent report' by the late Professor 
Adrian Stokes (who died from the disease), in conjunction 
with Drs. Bauer and Hudson, contains the first definite 
record of the transmission of this infection to laboratory 
animals. The common rhesus monkey, UdiKociin rhesus, 
and also, to a lesser degree, the Indian cro'ined monkey, 
M. sinicus, are found to be very .sn.sceptible to the disease, 
which may be transmitted cither by the bite.s of infected 
mosquitos or by the inoculation of blood from a yellow 
fever patient. Curiously enough, the local monkeys, and 
even elumpanr.ecs, were found to be immune, as uell ns all 
the ordinary laboratorj- anini.als. The disease has been 
carried tliii-ty times from monkey to monkey by the inocula- 
tion of infected blood or serum, with fatal jcsults in every 
case e.vcept one, when the animal recovered and was subse- 
quently immune. In addition, twenty-two monkeys were 
infected by transmitting the disease from one animal to 
another by the bites of infected mosquitos (,S7rf;«<iii/io 
fasrUtfa). Mosqiiitos invariably became infective when 
fed on infected monkeys during the first or second day 
of fever, and after an incubation jjcriod of not more than 
sixteen days remained infective as long as thev lived. 
One mosquito produced fatal infections in two monkeys 
when it was fed to them eighty-five and ninety-one days 
icspcctiyely after feeding on an infected animal. Fortu- 
nately, the infection does not seem to be transmitted to the 
offsjiring, as largo numbers of mosquitos reared from eggs 
laid b}' infected females were fed on a monkey with 
negative results. The course of the disease in monkevs 
is similar to that in human beings, and the jiathological 
changes, including the Jiost-inortcm ajipearances and morbid 
histology, closely agree with those described as typical of 
yellow fever. In an attempt to isolate the causative 
oz'ganism cultures ivero made of infected biood in various 
media, including those used for leptospirae, and also the 
tissues of infected animals were carefully examined, but 
in no case was any organism found that could be regarded 
as the etiological factor. Moreover, guinea-pigs, which are 
extremely susceptible to infection with Lepfospint icteroides, 


“ait Hudsoa: Experimrnlai Tr.ih!‘inU>ion ol Vdli 
MnVdi, 19 ^^°'^“'°’’^' }oum. of rrop. Med., vol. 8, Ko. 


were quite unaffected by the inoculation of material from 
yellow fever cases. Independent investigators have shown 
that L. icfrvvidc.s is serologically identical with L. ictero- 
Iwciiionhiiiikic., and it is now almost certain that the 
organism described by Noguchi as the cause of yellow fever 
must have been obtained from cases of "Weil’s disease, or 
possibly fi’om patients with a double infection. In our 
))j-escnt issue (p. 713) we pubiisli an article by A. IV. 
Selhtrds and K. Hindle advancing knowledge of the disease 
a stage further. IVorkiiig with a strain of yellow fever 
isolated in Senegal, they wore able to confirm the fact that 
rhesus monkeys are vciy susceptible to the disease. They 
then made exjzeriments on the nature of the vims, and 
found that, like vaccinia, rabies, distemper, and many 
other diseases caused by filterable viruses, the infective 
agent is nnalTcetcd by cold, and if frozen will maintain its 
vindence for at least twelve days. It appears probable, 
therefore, that yellow fever belongs to the group of diseases 
caused by filtci'able viruses, and experiments have shown 
that the virus in the blood can pass through Berkefeld 
liltei's V and N, but not through a. Berkefeld IV. The 
preservation of the frozen virus affords a simple method 
of transporting the infection, and as a susceptible animal 
is now available the disease can in future be studied, in 
regions where tl\e natural transmitting agent, Stepomyin 
fnscuifii, is absent, and there is no danger of the infection 
being spread by stray mosquitos. Although it is a little 
early to assume that the Now AVorld is now free from 
yellow fevei', no cases have been recorded since the eradica- 
tion of th(‘ endemic centres in Brazil by means of anti- 
mosqnito campaigns. In AVest Africa,, on the other hand, 
epidemics of increasing severity have occurred in recent 
years, and this region still icmains a potential source of 
dang<'r to all tropical countries in which the transmitting 
mo.sqnito is present. 


FRACTURED CLAVICLE. 

A nnoKKN collarbone is such a common injury on the road, 
in the Ininting field, or the recreation ground, and its 
routine treatment has led to such satisfactory functional 
lesults, that there may seem little scope for im))rovemcnt. 
Nevertheless it cannot be denied that, except by operation 
and the introduction' of foreign bodies, exact anatomical 
restoration is very rarely attained. It is gOJiejallv 
admitted that such operations should be reserved for very 
exceptional cases, and wo are often left to coiitent ourselves 
with a result which involves some disj)laccmcnt of fi'iig- 
ments and consequent deformity, however slight it mav be. 
Last week (p. 664) we published an article by Mr. Alilroy 
in which he describes iv modification of the method of treat- 
ment by bandaging which he has found more satisfactoiy 
than the ordinary routine proceeding. Tlie use of 
adhesive strapping instead of bajidaging has been 
advocated by sonie surgeons of late years, but we do not 
remember to have seen a report of the effects of its use in 
a large series of cases, until the appearance of a x’ajier in 
the •toiniial of the .*li7icrir07i ilcdicaJ Associaf'ioti by Dr. 
Fade Conwell of Alabama.* His ninety-two cases, which 
were all .treated during four and a half years in thu 
Kmployees’ Hospital in Fairfield, Alabama, seem to have 
included more severe injuries than usual, for nineteen of 
tliciu were complicated by injury to the shoulder-joint and 
four by injuiy to the sterno-clavicular joint, which, with 
nine eases of marked overlapping or displacement, seem 
all to have' been treated by traction and abduction and 
external rotation while recumbent. Dr. Conwell does not 
say how many cases were treated with adhesive strapping 
from the beginning, nor does ho give any records of com- 
parative measurements, of the injured and sound clavicles 

■ Fraclutcs of the Clavicle : A simple fixation drcs.oDff, with n summary 
61 the treatment anil results attained in ninety.two cases. Ilv H Earle 
Conwell, 3I.D. Juiuii. .inter. Med. .iesoc., JInrch 17th, 1928 p*. 8’8 



724 April s8 , 1928] 


■THE "PRODHCERS’ BHOaET.’’ 


f Tfir Ifarnm 
iferucAt JounHit 


by wliicli some estimate of tlie s\iccess of the ti-catnient 
might ho formed. With sucli a wealth of material as the 
Tennessee • Coal, Iron, and Railroad Company niipcars to 
provide, it may ho hoped that at a future time Dr. Conwoll 
will provide ns with exact and valuahlo data ns to these 
injuries and their anatomical results. The method I'ccom- 
mended requires the provision of four strips of adhesive 
material each four feet long and four inches wide, one 
largo axillary pad, and one small pad of felt to jirotcct the 
site of fracture. One of those strips is designed to pidl 
hack the shoulder, one to judl down the ends of the frag- 
ments, another to lift up the clhow and shoulder, and the 
last to pidl tlio elhon" into the side, and thus lever the 
outer fragment oxitwaids. It will thus bo seen that the 
principles on which the dressing is applied arc familiar. 
Dr. Conwoll no doubt righti}’ concludes that no hearable 
ambulatory ticatrcont can ho trusted to correct cases of 
sovore overlapping of fragments. The method which lie 
has described is worth a trial. 


EUROPEAN VITAL STATISTICS. 

The importance of vital statistics as the basis for any 
intelligent system of public health administration is now 
veil recognized, and it is therefore somewhat surprising 
to learn, from a paper on vital registration in Kiirope 
which Major P. Granville Edge read hofore the Royal 
Statistical Society on April 17th, that not only arc there 
countries in which the collection and cla.ssification of 
information of this nature is still oii a restricted scale, but 
also that in some countries, while there are admirable 
“ paper ” systems, these systems are not efToetivcly 
administered. Moreover, in his investigations Major Edge 
has found wide divergences in jiractice between one country 
and another in such matters,, for cxamjdc, as the registra- 
tion of stillbirth.s, the methods of dcatli certification, and, 
most important of all, in the classification of causes of 
death. It is obviously most unsatisfactory for purposes 
of comparison that in Belgium, France, Czech.ostovakia, 
Hungary, Germany, and in the rural areas of Scandinavian 
countries, the declaration of the cause of death mav he 
made by non-medical persons. Variations in nomenclature 
are very considerable; the detailed international list, which 
has been in existence for nearly thirty years, is used only 
in England and Wales, Scotland, Ireland, Czechoslovakia, 
Holland, Germany, and the United States. In two of those 
countries, however, as already mentioned, definition by non- 
medical persons of causes of death vitiates the value of the 
final figures. Four European countries use the abiidged 
list only, and a number use special nomenclatures. No 
uniformity exists in methods of collecting data. The 
practice in certain countries of having statistical summaries 
completed by local authorities as the basis for the national 
returns means, in Major Edge’s words, that “ technical 
operations requiring specialized knowledge may be carried 
out by people lacking either medical qualifications or the 
statistical training necessary to the task.” Many further 
examples could bo quoted from this source to show that 
extreme caution must bo exercised in any attempt to 
compare the vital statistics of any two or more European 
countries; the completely conscientious statistician who 
desires to employ such comparisons will be forced, indeed 
to begin by comparing the relative national systems, and 
that is no light task. Apart from' the difiiculty arisintr 
from differences, however, the known deficiencies in some 
cases rob the national figures of much of their potential 
value. In Great Britain the position appears to be more 
satisfactoiw than elsewhere, and Major Edge believes there 
is more danger of .the central statistical authorities 
attempting to do too much than of their task suffering from 
neglect or bad organization. He suggested that some of 
vvtnrnc'^ri' statisticians seek to get -more • from statistical 
lan eso retm-ns can fairly be expected to yield. 


and stated that some of tho proposals for improved classifi- 
cation which he had' scon seemed to postulate in central 
offices a greater ability to determine accurately what caused 
a death than was possessed by a certifying practitioner. 
Many doctors will no doubt sym])athizc with the sentiment 
which Major Edge exprc.ssed in his closing remark, that 
“there is even a danger that, if tho central authorities tako 
too much upon themselves, medical practitioners ma 3 ’ pay 
even Ic.ss attention than the}' do at jirescnt to the official 
publications.’-’ 


THE “PRODUCERS’ BUDGET.” 

AVhbn Sir. Churchill took control of tho nation’s finances 
his reputation for vision, administrative capacit}', and 
political courage created a general expectation that his 
Chancellorship would prove meinorablo for its permanent 
elfect on our financial policies. In his progress towards 
ncl-.icvcmcnt on the ■ grand scale Mr. Churchill has lieen 
impeded by tho clogging weight of debt redemptions and 
readjustments, by tlic reduction in receipts which inevit- 
ablj' folloivs a reduction in tho general price level, and 
lastlv, bj' the upheaval and trade dislocation which followed 
the general strike, the piolongcd effects of which raised an 
exasperating obstacle in the path to those large financial 
reforms which iUr. Churchill has now outlined. It is 
obvious that the Government’s proposals will be subjected 
to critici.sm from many quarters, but they are evidently 
the result of long and careful study, and in the main 
appear to be wisely directed to the urgent necessity for 
removiu"- the heavy pressure of local rates on the basic 
industries. In his Budget speech Mr, Churchill devoted 
more time to an explanation of the proposals for debt 
r'mlcmption than is usually given to that topic. Tho minor 
features of tho fiscal changes will excite little opposition or 
enthusiasm. The additional faxc.s— 6d. each on mechanical 
li'ditcrs 33.1 1»^>’ valorem on imported buttons 

“°not already attached,’’ and an additional 6d.-por gallon 
on British wine— are not likely to amuse much indignation, 
nor is tho hoped-for drop of one farthing in tho retail prico 
of simav as a result of a slight reduction in tho sugar tnx 
likel\°to be very warmly acclaimed by British housewives. 
The increase in the children’s allowance for income tax is 
welcome; to those taxpayeis whose ineomo is assessed to 
anv considerable extent at tho standard rate tho additional 
relief afforded will be £9 8s. in respect of two or £18 12s. 
in the" case of four children. Incidentally, one result of 
tho change will be to raise appreciably tho eifertive limit of 
nssessiuciTt to tax in the case of parents as distinct from 
other taxpayers— a development which Mr. Churchill 
bumorouVlv referred to as “another application of our 
conoral policy of helping the producer.” The chief interest, 
horvever, in tho proposals centres round what is obviously 
tho preliminary announcement of a bold policy for tho 
*.„i nno of the serious handicaps under which tho 
older British industries are labouring to-day— the pressuro 
of local rates on unremunerative businesses, hfr. Churchill 
stated the facts concisely and graphically, and imido il 
clear that a vicious circle has been created in many Indus- 
Uial localities, unemployment causing higher rates, which 
. turn lead to the shutting down of additional works, 

more unemployment, and still higher local expenditure, 
The details, so' far ns they were disclosed, it is not possible 
to discuss at this stage. It is evident that hlr. Churchill 
anticipated, and was prepared to deal with, criticism that 
performance was to follow ne.xt year, and not at an earlier 
date. IVe confess that his defence for such a postpone, 
nieiit appears sound. The problem can be stated -briefly, but 
any satisfactory solution must tako into account so many 
factors of a verv complex situation that the fullest possible 
preparation and discussion of the detailed proposals are 
essential if success is to be achieved, Tho principle of 
forming a fund to start the new scheme before it can bo put 


APRIIV l8, TO-.S] 


INCOME-TAX KETERNS EOR 1928-29. 


[ Tftf: Tlnrnsff 

MKPlCAJy JolTJNAt. 


726 - 


into opcrntion is uimsunl, to say tlic least, in dealing with | 
tliis typo of problem, tbmigh its npplieation to inanmnee 
sebem'es will bo familiar. On this point the Chancellor 1ms 
shown his courage;’ for the s.ake of the soniidness of the 
scheme ho is willing to give a tompoiary advantage to his' 
critics. As with so many otherwise beneficial schemes, this 
proposal has its disadvantage in the necessity for providing 
largo sums which can only ho raised by taxation, and Air. 
Churchill has fallen hack on tho consnmers of i>otrol to 
supply him with ammnnition for his fight on behalf of oiir 
basic industries. Presniimbly ho has been led into this 
step by tho low level of recent prices as compared with 
those of a year or two ago, and, in the case of heavy lorry 
consumption, by tho apprehension that the growing conijic- 
tition with the raila-ays is leading to an inieconomic 
competition for heavy trallic. IVo are ilisposi'd to think 
that a prima facie case has been made out for the proposals 
in principle, hut a considered vieiv of the argniiieiits against 
it lias not yet been developed, and undoubtedly on points' 
of detail fnitlicr information and discussion are essential. 
For instance, the proposed exemptions from the duty are 
rc.stricted to oil used afloat in tho fishing fleets, hunker 
oil, and light .oil used in agriciillnra! tractors. Doubtless 
there will be many other claims for similar piivileges, and 
we trust that among them the case of the luediral practi- 
tioner will not ho overlooked. He is a " prodmor ” of 
essential services to the comniiinity — vital services literally 
as well ns figuratively — and ns such can faiily <!aim that 
he .should not ho seriously penalized by a producers’ Budget. 
IVo are inclined to doubt whether the Clianeelloi has suffi- 
ciently taken into account tho very great extent to wbioh 
light cars are used for profc.ssional and bu.sim 's purposes 
in circumstances in which an increnso in running costs by- 
taxation would impose an unfair burden on tin' tnx|iayer. 


INCOME-TAX RETURNS FOR 1928-29. 

JIosT of our readers wilt already have received from the 
local inspector of taxes tho form for the doehiration of 
income on tlio basis of which income tax will be jiaid for 
1S28-29. Tho is.siio appears in general to have been made 
at an earlier date than usual, and in most ca.ses tlie 
declaration required will probahly appear more formidable 
than over. Wo understand that tho finidamontai reason 
for these changes is tlic desire to avoid tho trouhicsomo 
multiplication of requests for declarations wliich in the past 
have been a source of very natural aiinoyanee to tboso 
taxpayers who, as in the case of some medical men, hold an 
appointment or an office the inconie from wliich falls within 
tho jurisdiction of different authorities. lYhcther this 
desire is alone responsible for the promptitude with which 
tile forms were sent out at the opening of the nciv financial 
year wo do not know, hut presumably, if it sliouUl load to 
speeding up of the official labmiis, earlier application for 
the amount due, and earlier payment of the tax, tho 
Treasury would derive additional satisfaction from tho new 
departure. It is, of course, clear that if a single state- 
ment is to be accepted it must bo made in sufficient detail 
to enable the separate items of taxable income to bo 
correctly assessed. We have not apparently yet reached 
the stage at which the authorities are prepared to assess 
the whole liability of a taxpayer from one office ; that would 
clearly be tho most convenient arrangement from the tax- 
payer’s point of view, and perhaps tho unification of his. 
declaration is a stop in tliat direction. Where there is 
income liable to direct assessment it may be regarded as- 
falling either- under Schedule D or under Schedule E — 
the latter dealing with the earnings of employment. 
Hitherto tho authorities have supiilied one form of 
declaration for each schedule; this year two alternative 
forms aro in use in each ease. It would seem that where 
tho income of tho particular taxpayer is thought to ho 


fairly simple to declare, then the dcclar.ation required — 
No", ll.v or 12.V— is restricted to a .single statement of total 
income, together, of course, with the completion of any 
claims to relief in rcspcct-of- children, life assiiraiiro, etc. 
AVIiorc, however, the income is ccnqilicated, and particu- 
larly where liability to snpor-tax may exist, tho form of 
dochiration-^No. 11 or Xo. 12 — has been c.'qiandecl to pro-- 
vido, infer (iHa, for tho separation of tho assessable portion’ 
of’ the income from tliat which is taxed by deduction or- 
dealt with under Schedules A and B. If this fundamental 
distiiietioii he home in mind tho form will be loss puzzling 
than it may appear to ho at first sight. Tho .severance of' 
the assessable income from the remainder has no doubt' 
been effected p.artly hceaiise of the position with regard to 
super-tax. For 192&-29 separate sni)cr-t.ax returns will 
apparently ho required, hut from 1929-30 onwards tiie 
intention is that tho income-tax declarations shall serve 
the purpose of the super-tax, or rather of the “ surtax,” 
to give it tho name it will then bear, as well as of the 
ordinary income tax. Unfortunately for the achievement 
of coniplcto simplicity, assessable income is measured for 
income-tax purposes by tho amount of the income of tho 
previous year, wh.ereas income taxed by deduction is 
regarded as iiicomo of the year of receipt. Bearing this 
in mind, and also tho fact that super-tax is eliargonblc on 
the amount of income liable to income t.ax for the previous 
financial year, it will ho realized that the maintenance 
of a lino of division between the two classes of income for 
each year v.ill assist the taxpayer in seeing how tho amount 
liable for snpor-tax has been calculated from liis declara- 
tions — for cxnmpio, that amount for tho year 1929-30 will 
be the aggregate of the assessed incomo for 1927-28 plus 
tbo other misccllancons incomo for 1928-29. In this con- 
nexion wo may perhaps point out the advisability of 
I'ctaining a copy of the declaration made; duplicate. forms 
for the puvpnso cun bo obtained by application to tho 
inspector of taxes. The authorities have stated very 
definitely their desire for ono complete return only, and 
any medical man receiving a second form — for example,’ 
in respect of somo ajipointment or owing to a change 
of address — should return it uncompleted excejit for -the 
insertion of particulars as to the address, etc., from which 
his full declaration has been made. 


DEATH OF OR. J. A. MACDONALD. 

AVn have to aiiiiouiico witli sorrow tho death, at Taunton, 
after somo montlis of progressivo ill health, of Dr. J. A. 
Macdonald, HuL.D., ono of tho most popular and most 
respected Icadov.s of tho British Medical Association during 
the past quarter of a century. Dr. Alacdonald became 
Chairman of Representative Alcetings in 1906, retiring in 
1909, and then held office as Chairman of Council for°the 
nnprocedented period of ten years. Since 1920 ho had been 
Chairman of the Journal Committee, and a stauncher 
friend of this Jouriial it would ho impossible to imagine. 
Ho visited on behalf of the Association the Australian 
and New Zealand and somo of the Far Eastern Branches 
in 1914, and went on a similar errand to South Africa 
six years later. He had been a direct reiuesentativo of 
tho profession on tho General Aledical Council since 
19H, and for a considerable period was a member 
of its Executive Committee. Notwithstanding tho lioai'y 
claims upon a general practitioner in single-handed 
country practice, ho thus found time through many eventful 
years to give unsparingly of his best to his profession. 
Whenever tho British Aledical Association needed excep- 
tional services, demanding sound judgement, devotion to, 
tho interests of tho Association, and a commanding person-' 
ality, it called on Dr. Alacdonald, and never in vain; AVe* 
hope to, publish^ a mmnoir, with personal appreciations and 
a portrait, in our next issue. _ , . . - ; 




Arniti sS, 1928] 


SCOTLAND. 


Tnr Jlnm^n 
MnDICAt. JODRSAl, 


727 




728 April 28, 1928] 


IHEIiAND. 


r Tiin Hrin?n 
MrmcAi. JocuMiL 


the Continent the nicdito-lognl expert willi a \vcll-cqiii]r))cd 
laboratory formed an es.-.ontial ])art of the machine for 
investigation, and it was of great value to the police that 
they shoidd he able to obtain scientific co-ojieration when 
they required it. In England it had been considered to ho 
more efficient and less ex)iensive to employ specialists in 
different scientific subjects from outside as fho\’ were 
required. This had much to commend it, but those expe- 
rienced in these subjects knew well that a largo amount of 
information was lost in certain cases. Ho helieved that tho 
time had arrived when an effort should he made to sujiply 
medical men trained in forensic medicine to fill the positions 
of police surgeons, coroners, etc., and that, to facilitate 
such training, the whole of the mcdico-lcgal work of a 
district should bo concentrated in one central place. These 
conditions were found in Germany and Franco, and, in 
fact, in nearly every country except our own. In Egypt, 
the country with which the lecturer was most familiar, 
attached to the office of proctneur-ricnrral there were 
laboratories and scientific equipment, with a personnel of 
medical officers — jiathologists, chemists, a'-ray and photo- 
graphic experts— all of whom wore whole-time Government 
officials. In this laboratory about 800 examinations of 
viscera for poisons and about 5,000 samples of narcotic 
drugs had been investigated last year. If those examina- 
tions had been made on an individual basis tho cost would 
have been about £45,000, rvhereas tho total cost of tho 
whole section was less than £10,000 per year for more than 
10,000 individual examinations and reports. The saving 
was thus seen to bo relatively enormous. Such institutes 
might well be inaugurated in this country, with a .status 
similar to that which had been accorded to tho practice of 
hygiene. 


East Fortune Sanatorium. 

In the fifth annual report Dr. Charles Cameron, medical 
superintendent of the joint sanatorium for tho south- 
eastern counties of Scotland at East Fortune, states that 
the sanatorium for a ]iei'iod in the past year was, for the 
first time, fully occupied. The demand for accommoda- 
tion was, however, met except as regards tho needs 
of children, where a certain amount of difficulty was 
present. The numbers of patients admitted from tho con- 
tributing counties during the year were; from Midlothian 
54, llest Lothian 61, I’oeblos 9, East Lothian 37, Berwick 
2/, Iloxburgh 15, and Selkirk 15. During the year in all 
284 patients had been admitted and 252 discharged. Of 
thosc^ admitted, 126 suffered from tuberculosis of the lungs, 
and in all these cases tho disease had been present for a 
long time before they came to the sanatorium. A largo 
niimber of cases suffered from di.seaso of tho spine or of the 
joints; many of -these had already been treated at hospitals, 
and afterwards jiassed to the local authority for sana- 
toiium treatment. A large number lequired prolonged 
tieatment, and it is suggested that admission for this type 
of case should be sought at an earlier stage. Of tho male 
patients treated up to tho present time for disease of tho 
lungs and chest glands, 204 were much improved 251 
improved, 41 stationary, 373 worse, and 282 died- while 
among women patients 227 were much imiirovod 226 
improved, 118 stationary, 489 worse, and 92 died Tbero 
had been no deaths in children, and 393 were much 
improved. 


Prolongation of Age in Scotland. 

All address on the question, “ Is the health of the iiatioi 
improving? ” was delivered by Dr. AVilliam Bobertson 
medical officer of health for Edinburgh, to the Edinbiii-"! 
Eotary Club on April 12th. The lecturer said that ti 
1861 Edinburgh had 170,000 inhabitants, with an annua 
death rate of 23.1 per 1,000 of tho ]iopulation, while las 
year the population was over 424,000, with an annua 
death rate of 14.5. More people were now living to a rip, 
old ago than formerly. Last year, between the ages of 5( 
and 65 there were 931 deaths, and among those over 7; 
years of age there were 1,186 deaths, while between the age 
9 ! 15 and 45 only 883 persons died. It was becominj 
I'do' cf u V important that attention should .be paid t 
®vrioi,'sn. P°PV'^*i°u of the cities, because the birth rate hai 

PoimlatTod ^ was 33.4 per l,00i 

lulat.on, vi.do at present it stood abmit 18.7 


While, however, infantile mortalities of 130 per 1,000 hirths 
were coniiiionly encountered ovi-r fifty vears ago, the death 
rale among infants had now been reduced to 83 ]icr 1,000 
births. Too many C3 people had been bred in tho countiy 
ill the past, but it was expeeted that a new generation of 
persoii.s resistant to disease might in future be seen, so that 
.several years would be added to the life span of every indi- 
vidual. If reliance were placed upon vital statistics, it 
seemed likely that the expectation of life, when the year 
2000 ,i.p. arrived, might, on an average, amount to 
82 years. At the present time it was between 58 and 60 
years. 




Report of the Free State Commission on Cican Miik. 

The rcjiort of thi5 Free State Interdepartmental Com- 
mittee on Clean IMilk, which has now been ])ul)lished, 
recommends the adojition of tho “ accredited herd ” .sy.stcm 
in ojreration in the United States of America, and among 
other recommendations it is suggested that all milk vendors 
in countv borouglis and urban districts should be liceii.sed 
nnnually'bv the sanitary authority personally and in rcsjiect 
of the jircniiscs used by them for trade purposes. In tho 
event of refusal of a licence a right of appeal to the 
district court might bo given. The definition of milk should 
include buttermilk, skimmed milk, and separated milk; 
bottling should bo undertaken only on rcgi.stercd promises, 
and tho bottles used for milk should bo of standard size and 
be stamped with the measure of their capacity. Tho sale of 
objectionable articles in tho same shop as milk should bo 
forbidden. The committee considers that a dairy employee 
should be made liable (in place of his cnqiloyer) for an 
offence under the dairy regulations, if it is proved that he 
has deliberately neglected to use conveniences provided for 
tho protection of tho purity of milk. Provision for small 
loans to individual borrowers for the purpose of improving 
their cowsheds is recommended. Administrative action to 
have the Bovine Tuberculosis Order, 1926, extended to 
include “ any. cow showing clinical signs of tuberculosis and 
excreting tubercle bacilli ” is urged. The use for human 
food of inllk from cows suffering from specified conditions 
should, it is suggested, be restricted. Diphtheria in dairy 
omplovecs should be included in tho Public Health 
(Pneumonia, Malaria, Dysentery, etc.) Begiilations, 1919. 
It is advised that a revision of tho Dairies, Cowsheds, and 
Milkshops Order, 1908, bo undertaken, with special regard 
to inspection of cattle, tho grooming of cows, the lighting, 
floor construction, and drainago of cowsheds, the washing 
and sterilization of utensils, tho wearing of clean overalls, 
and tho observance of personal cleanliness. Urban autho- 
rities should be empowered to follow the cattle from their 
districts whon sent to summer grazing outside, and tho milk 
supply of urban districts should be controlled by systematic 
bacteriological oxamin.ation. Tho committee feels that in 
view of the competition of other countries it is essential 
that the cattle and daily products exported from tho Free 
State should be of the highest standard and free from all 
suspicion of disease, but regards the problem, however, ns 
ojjg^of perplexing difficulty. Complete eradication from tho 
herds would be the ideal polutiou, but in view of tho 
enormous expense that would be involved the question must 
be approached with due regard to the resources likely to 
be available. From evidence submitted it was thought 
in-obable that Irish stocks generally had a comparatively 
low percentage of infected animals, and . that many of 
the small herds may be entirely free. The introduction 
of a svstein of graded milk is recommended, and it is 
tboucht that two grades should suffice at first: “ Grade A 
(tuberculin tested) ” and “ Grade A.” The sale of 

liasteurized milk should bo permitted only in accordance 
with defined conditions, and persons employed in tho 

production of graded and pasteurized milk should bo 
medicallv certified. The proposals in legard to graded 
milk, which must be produced by a -tubercle-free herd, 
if adopted, would have an important effect in the 

eradication of tuberculosis in cows, and it is recom- 
mended that milk producers should be encouraged to 

work towards this end by the iirovision of free tuberculin 





730 Aprii. 28 , 1928 ] 


CORRESPONDENCE. 


[ Tft Dnms* 

SlfcDiCAL JOCRNAX. 


correct there must ho an addition of chloride to the stomach 
other than that supplied hy the gastric juice, saliva, or 
by means of regurgitation from the duodenum. 

In the second place Campbell, Baird, and Horn’s expori- 
ment on case M. B. in the Giiy’s Hospital J{c 2 >orts, vol. 74, 
p. 34, Fig. 5 (1924), shows' that apparent neutralization 
of the gastric contents took place even though all the 
fluid in the duodenum was being removed by suction. 'J'lio 
fact that this latter fluid was bile-stained, while the gastric 
contents contained no bile, shows that actually no regurgi- 
tation did take place. 

There are two ways of accounting for this finding : 
(1) that the stomach was supplied with chloride apart 
from the gastric HCl, as was suggested by Hansman’s 
calculation, or (2) that the pyloric mucous membrane itself 
produced alkali which neutralized the acid. It is true that 
the authors favour the latter view; hut it is worth seeing 
where it leads us to h 3 ’ calculating tho state of aflairs 
in the gastric contents at the end of this experiment — that 
is, at one hour thirtj’-seven minutes. 1’aking the true or 
active HCl as the average of tho total and free acids (as 
recommended bj- them in Appendix 2) we find that 100 c.cm. 
of gastric contents were equivalent to 17 c.cm. N/lONaOH, 
and contained 0.06 gram Cl. Similarly, there was 0.29 
gram Cl as total chloride, and tho mineral chloride was 
tho difference — namely, 0.23 gram Cl ; 0.343 gram 
Na,CO, would have been required to iiroduco this mineral 
chloride from the gastric HCl. AVo will assume, with 
Hansman, that pure gastric juice (containing 0.5 ]ier cent. 
HCl or 0.486 gram per cent. Cl) was being secreted by tho 
stomach at this point, and that this and tho alkali required 
to neutralize it were the onlj- fluids present, while tho 
fluid of the meal had been passed into tho duodenum. 
Then the alkali must have diluted tho gastric j;iieo in tho 
ratio of 29 to 48.6 — that is, 59.6 c.cm. were diluted up to 
100 c.cm., which means that the neutralizing alkali con- 
taining 0.343 gram NajCO, was contained in 40.4 c.cm. of 
fluid, so that the stomach secreted- a juice containing. 
0.85 per cent. Na.CO,. This is well above tho highest 
estimate given for tho alkali of the pancreatic juice, which 
surely is a rcductio ad ahsardum. Further, it is vciw 
unlikelj^ at this time either that tho gastric juice was 
leally up to full strength, or that if it wore there was not 
some dilution of it with tho fluid of tho meal, sinoc March 
had only been absent for seven and a half minutes. Either' 
of these factors would tend to still further concentration 
of this hjqjothetical neutralizing fluid. 

now to the state of affairs in the duodenum, tho 
authors found that tho concentration of Cl was actually 
greater than in the stomach. It is difficult to see anv 
other reason for this than that some absorption of fluid 
was taking place. Apart from this, the duodenal contents 
.only varied from .t ie stomach contents by the addition of: 
wni “cld’tion of further alkali, so that the free 

■ disapiieared. Calculation shows that 0.09' 

gram Na,CO, would be required to neutralize the remain-' 
mg HCl (containing 0.06 gram Cl) in 100 c.cm. of gastric 
contents. Assuming that this was provided' entirely by' tbe' 
pancreatic juice of 0.7 per cent. ■ concentration, it would 
mefin that 100 c.cm of gastric juice would only require 
13 c.cm. for its neutralization. Sdmething extra might be' 
allowed owing to the fact that the duodenal contents were 
probably actually, alkaline; but it is impossible to imagine' 
in this case that the stomach provided 40 c.cm. of a vei-v 
strong alkaline fluid .and the pancreatic juice about one-' 
third of this amount. One would wonder that the alkaline 
function of the jiancreas had been developed at all if this 
state of affairs was at all common. 

We are thus left with Hansman, Daj-, and Clifton’ 
explanation, that the stomach was receiving a store of 
mineral chloride, as' the more reasonable explanation of 
Campbell, Baird, and Hern’s experiment. 

Pinallv, this explanation, which sureh- must imply a 
secretion of sodium chloride bj' tho gastric mucous mem- 
brane, is compatible with the high chloride in tho duodenum' 
found In- Campbell, Baird, and Hern. I do not see how 
otherwise this is to be explained, apart from the impossible 
uou rahzation hypothesis detailed above. — I am, etc., 

April laih. E. P. POULTOX*. 


STREPTOCOCCI AND PUERPERAL .SEPSIS. 

Siu, — Profe.ssor Beattie’s letter in t'our issue of Ajiril 
14th (]). 642) raises, questions of comsiderablo theoictical 
and ju-actical interest. Ho stales that recent work con- 
ducted in his laboratory has shown that tho action of 
antiseptics on different organisms varies in a marked 
degree, and that an antiseptic which may bo efficient 
for R. typhosus may bo quite inefficient for other organi.sms. 

This statement affords important and valuable confii-ma- 
tiou of a generalization iniblishod from this dojiartment by 
Professor Dreyor, Mr. S. G. Kriegler,- and myself many 
years ago, and communicated to tho Pathological .Society 
of Great Britain and Ireland at-its meeting in July, 1910.* 
Further detail of tho work was elaborated and carried out 
by Kriegler under our direction, and was published bj- him 
in 1911.- In his paper comment was made as to tho value 
of the Rideal-AValker test, to which Professor Beattie 
refers ns tho “ usual standard.” 

Iii our work tho conclusion emerged quite clearly that a 
test of a single organism, or group of organisms, with any 
given antiseptic against carbolic acid affords no criterion 
whatever ns to tho value of that antiseptic against other 
organisms or groujis of organisms. I quote the following 
fiom Krcigler’s “ conclusions 

“ ... it is not possible to conclude that because a particular 
antiseptic is very active against a particular viirielj- of micro- 
org.anism, it will necessarily bo active against another micro- 
organism of a different variety.” 

It is satisfactory to learn that this important problem 'is 
again receiving attention in tbo work wliich is being dono 
in tbo University of Liverpool. — I am, etc., 


E. W.’ Aikvey AValkeb. 


Sir William Dunn School of rnthology,' 
Oxford, April 19th. 


THE FRACTURE PROBLEM. 

Sin,— In your issue of April 14th (p. 636), in referenca 
to tho' Frncturo Committee of tbo American Medical Asso- 
ciation and American College of Surgeons, it is .stated that 
“ until a similar inquiry has been made in this country 
it is not possible to state whether our methods are more 
satisfactory or not.” The writer seems to have overlooked 
tiie fact that a committee was appointed by tho British 
Medical Association in 1910, and tho report of that com- 
mittee was in due course published in tho British Medical 
Journal (1912, vol. ii, p. 1505). Although the repprt is 
now sixteen years old, I venture to think that it contains 
much information of value, and that its conclusions are 
in the main still valid. . . , 1 

One important truth in particular was demonstrated by 
tho investigations of tho committee, and that is, tho im- 
portance of securing a good anatomiciil result. AA’hile it is 
true* that in some instances a good functional result may 
ho obtained in spite of .a bad anatomical result, such a 
happy issue is the' exception, hot ■ the rule. This w.as 
summed up in conclusion No. vii of the report, which 
states: “ Although tho functional result may be good with 
an indifferent anatomical result, the inost certain way to 
obtain a good functional result is to secure a good 

anatomical result.” , , li • xi -i i 

The teaching that a good functional result is the ideal 
to be aimed at, no matter what the anatomical end-result 
fna-y be is fallacious and misleading. The ideal to be 
aimed at is a good anatomical result, and a good functional 

result will follow. , , , . , , . j 

In many cases it is impossible to obtain a good ana- 
tomical result except by operative measures, and it is of 
interest to note that in paragraph vi of the Fractures 
Committee report it is stated that “ In nearly all ago 
groups oiierative cases show a higher percentage of good 
results than non-operative cases. 

As regards treatment by massage. I was one of tho 
members of the committee who visited Paris to investigato 
the results of that treatment by- tho methods of Lucas- 
Cliampionniere. It is not an exaggeration to say that we 
were profoundly disappointed at the results shown to us. 
I am quite aware that the expression ‘ ‘ H-eatment by 

1 Jaiirn. Path, and Pact., 1911, vol. xv, p. 133. 

® Centratbl. f. Baht., Parasit., -and Infect., 1911, Band 59, s.' 481. 



Ai'niii 28, 1928] 


CORKESPONDENOE. 


t Tjn;D&mss 
irEoiCiX. Joc»ati» I OX 


” now moans soinotliing very difTorcut from the 
met hods used ten years ago; nevertheleis, enrront views 
as to wliat exactly massage means arc very conflicting. So 
far ns tlio long Itoiics aro concerned, mnssngo without 
immohilization is nob a satisfactory method of treatment; 

Tlio conclusion of the Fractures Coiniiuttcc on this matter 
was as follows: 

“ No inntliod, wlictlicr non-oporalivc or operative, which does 
not definitely promise a good anatomical result slionld he 
accepted as the method of choice. For this reason mobiliza- 
tion and massage by themselves have not been found to secure 
a high percentage of good results.” 

— I am, etc., 

London, w.i, .tprii iTtii. Hr.nnr.uT J. P.wrnBON-. 

%* Wo had not overlooked the Association’s Report on 
Fractnres of sixteen years ago, bnt on consitlerntion wo 
did not refer to it, hccan.so it did not seem to he relevant 
to tlio prohlom under discussion. If Air. Paterson will 
read again tlio passage ho criticizes ho will find that 
it runs: “ Until. a similar inquiry has heen made in this 
country it is not. possible to state whether oiir rcrorih nro 
nioro .satisfactory or not ” — meaning the way in which they 
aro kept, as tho context shows. 


DEAD AND INFECTIHI TEETH. 

Sin, — I ani'a littlo surprised that Afr. A. P. Bcrtwistlo’s ■ 
admirahlo and exceedingly imporlant article on dead aind 
infected teeth has, so far as can he judged from your 
eovrespondenco column, not attracted much attention. Tho 
role of dental infection in tlio production of iniutmcrahic 
metastatic bacterial diseases has long hocn reeoguized, 
Ihaiiks to the pioneer work of Dr. William Hunter. And 
yet there can ho no doubt as to the general attitude of 
scepticism held by medical men as to the efficacy of oradi- 
catiug dental disease in the treatment of these conditions: 
.it is amply .supported by the clinical experience of hordes of 
patients who have heen edeiitulatcd witlioiit obvious benefit. 
Afr. Beilwistlo rightly points out that it is tlio wrong typo 
.of dental infection tfiat is looked for in sucli eases. It is 
iiot tho case with profuse pj'ovrlioca; nor — and liero I am 
in strong agreciiiciit with Air. Bcrtwistic — is it always tho 
case in whicji radiograms show rarefaction about tho roots. 

Tile stopping of tcotli in which tlic pulp cavity lias heen 
■nifectcd is a .surgical Iicre.sy, and I would like to put 
forward tho suggestion tliat it is tlio duty of tho medical 
profession to discounteiiancb tlio procedure. — I am, etc., 

London, w., .spin 23 iii. C. Jennings AI.snsn.sLL. 


THE TYPE OP TUBERCULOUS LESIONS IN 
BONES AND JOINTS. 

Sin, — Tho articlo hy Dr. Cohbett on tlio type of tubercle 
oaciilus in tiihcrciilous lesions in bones and joints in your 
, issue of April 14th (p. 626) is of interest in many direc-, 
tioiis, not tho least being tho focusing of attention upon 
tho practical importance of the parts played hy two tyiies 
of tuhcrcio bacilli in tho production of extra-pulmonary 
lesions in tho luiliiau hodj'.' 

\\orker.s^ in saiiatoriums and tnherculosis officers avo 
pl'ivilegod in their knowledge of fainilics, and many children 
of their tuhcrculbus adidt patients pass, in course of time, 
through their hands. As a purely clinical observation one 
knows that tlio human typo hacillus is the probable infecting 
oigauism in a majority of the cases of noii-pulmouaiy tuber- 
culosis seen in these cliildvoii, and it is surprising in how 
- many caso.s (apart from olio’s actual knowledge of phthisical 

■ parents) oiio can get a history of contact with infected 
adults. It is not altogether a case, ns soiuo seem to think, 
of a different bacillus producing a different form of disease; 
both can produce exactly the .same clinical type of disease. 
It is rather a. case of tho different susceptibilities of tissues 
to a generic infection at different ages, and our knowledge 
on this jioint is vague.’ 

Tho cow liiiist he viewed in a reasoned perspective. So 

■ must the tuberculous adult (including tho sufferer from 
lupus, whoso capacity for damage is often entirely over- 
looked hy those who treat him), and the public, unfortu- 
nately, is being educated to mistrust the former more than 
the latter. 


The question of tho rolation of tho numbers of tubercle 
bacilli in tho discliargo from tuberculous joints to the 
lirogiiosis is of interest. ^ 

Late in November, 1925, a man 56 years of age was admillcd 
to East Fortune Banatorium, sullcring from tuberculous disease of 
his right sacro-iliac joint. The history was of fairly short duration, 
and lio died early in Februai'y of tho following year. 1 have never 
known a tuberculous patient to suffer such pain as he experienced, 
and his course was one of progressive emaciation and asthenia. 
In January I obtained from a swelling on the posterior aspect of 
llio joint some hlood-slnincd fluid, which contained multitudes of 
small particles of tuberculous granulation tissue, in which tubercle 
bacilli were present in enormous numbers. 

This patient’s death was from disease of his joint. Tliere 
were Bt> complications, and, in fact, no other clinically 
dotectablo areas of disease. — I am, etc.. 

East Fortune, East Lothian, April lath, U. C.VMEHON. 

Sin, — Dr. Loin's Cobbett’s article should do much to 
correct tho erroneous view held by so many people as to tlie 
relative importance of tho human and bovine type of 
tubercle bacillus in hone and joint lesions. 

In this connexion I should like to draw' attention to an 
investigation’ which Drs. Edington and Guest of Sheffield 
University kindly mado at my request. 'They determined 
tho typo of organism in 38 of my hone and joint cases. Of 
tlic.se 7 were in the ago group 0-5 yeai-s ; 12 in the age group 
5-10 years; 14 in the age group 10-16 years; 5 were adults. 
Only 2 cases, both in tho ago groiip 10-16 yeai-s, wore 
infected with tho bovine typo of organism ; thus tho figures 
show that only 6 per cent, of cases in the age group 0-16 
years were so infected. 

AVhen comparing this low porcentago of bovine infection 
as found in Sheffield with tho much higher figures given by 
other observers, es])ccially in Scotland, Edington points out 
that this seems to have somo relation, first, to the small 
amount of milk consumed in Sheffield, and secondly, to tho 
lower incidence of tuberculosis in cows as evidenced by tho 
small number of infected milk samples found in Sheffield 
compared with tlioso in other areas— ^for example,' Edinburgh. 
Those points avo brought out in -the following table : 

Edlobtirgli. SUefndd. * 

Peveeniage of bovine infection in hono 

liihcrcle in children .' ... 26.3* 6.0 

Pints of milk consumed per head" per 

day 0.42 0.27 

Percentage of mixed milk samples 

found to contain tubercle bacilli ... 20.0t 7.5 

•Grimtii, 1916'. tl916. 

— I am; etc., C. Lee Pattison, AI.B., 

Medical Superintendent, King Edward VII 
llospUal, and Surgical Tuberculosis 
.April 20tii. ' Officer, Sheffield. 


EARLY DETECTION OF TUBERCLE BACILLI. 

Sih, — ^To the excellent suggestions made by Sir James 
Dund.as-Grant in your issue of April 14t)i (p. 627) T would 
add ah examination of tho faeces. Frequently where there 
'is no sputum expectorated much is swallowed. If it coii- 
tains tubercle, bacilli these will bo found in the faeces. 
Tubercle bacilli in the faeces, provided food containing 
tubercle bacilli is not being eaten, is almost pathognomonic 
of pulmonai'y tiiherchlosis. There is for practical purposes 
no difficulty in this examination, and I have found it of 
great clinical value. 'The tubercle hacillus is the only 
acid-fast and alcohol-fast hacilliis likely to occur in the 
faeces. Tlio bacillus may occur in great mimbei’s when 
there is little or no sputum, and this probably explains the 
tuberculous rectal fistula which may precede the obvious 
manifestations of pulmonary tuberculosis by two or three 
yiiars. — I arh, etc.', ' 

F. G. CB.AN'DLEn, AI.D., F.R.C.P. 

London, N.WT.l, April 17tb. 


EFFICACY OF TUBERCULIN THERAPY. 

Sitt, — Dr.- WeatUerhead (April 7th, p. 611) vei-y rightly 
emphasizes the necessity of a control series in adjudging 
the efficacy of treatment in tuberculosis, hut his implica- 
tion that such investigations have gone to prove that 
tuberculin is useless calls for challeugo. 

Kvemscr choso 110 patients expectorating tubercle bacilli, 
treating 55 with tuberculin; they were not selected, 

* study of tnborclc bacilli isolalctl from care? of surgical tnbercnlosls 
(chiefly bone and joint) in the Sheffield area, by J. AV. Edington and 
D. Guest : JouTH. 01 Uyijicnc, vol. X.VV, Xo. 1, February 27lh, 1926. 




OBITUARY. 


U SlcpicAi. Jouitxii 


Armij 28, 1028] 


Tho s/iio qua non of successful trontniont is tlmt tlio static 
juncliino must lie sulTicicntly iinworful. Tho small machines 
in uso by the unqualifieil electricians are absolutely useless. 
— 1 am, etc., 

London, U',, .\pril 21st. llOLF CuL.VSY. 

THE EXPECTANT ItOTHER-. 

Sin, — I have read with interest Hr, Statham’s comments 
on this matter in yonr last issue (p. 689) in reply to my 
letter of JIarch 3ist (p. 571). Hr. Stjitbam appears to bo 
unfortunate in having in Bristol such an un|irogressivo 
council to deal with; and as one who has .served for some 
years on municipal and county council bodies, ho will, I am 
sure, permit mo to give him a gentle lead. 

At the next city council election in Bristol Dr. Stathnm 
should bo fi^camlidalo, and if ho runs bis election on natal 
treatment, now tbat women have so many votes, ho will no 
doubt be elected and then will bo on tho highway to obtain 
tbat which appeal's to have been so sadly neglected by the 
Bristol council. Tho method to adopt is to speak freely 
on tho matter in open council if ho is refused what is 
wanted in committee, and if ho is a man persistent and 
determined in character, ho will find tho other monibcrs 
will givo way, and tho battle will bo wini ; and tho more 
shanio brought upon the authority, the more ivill Dr. 
Statbam bo respected and admired. — 1 am, etc., 

Chlciu-sior, April 22nil. AnTiitiu M. B.inronn. 


THE ELECTION TO THE COHXCII. OF THE 
BOYAL COLLEGE OF SURGEONS. 

. Sin, — 3Iy old friend jMr. Ivor Back is pleubod to bo 
facetious. I cannot but think that it a letter is written 
to a Fellow 0110 knows, advocating a candidate, in many 
cases this candidate will get a vote which be might not 
otherwise have received. If 1 write to iiiy friend Ivor 
Back and ask him to vote for Jones, he may havo a .spare 
vote and is not quite certain ivhether ho will give it to 
Jones or Smith, but as I havo suggested Jones, especially 
it ho values my opinion, he will give his vote to Jones; 
and if 3Ir. Back was going to vote for Jones I have dono 
no harm in writing to him. On the other hand, I con- 
sider it an impertinence to write to a Fellow one does not 
know, so that I should strike out from 3Ir. Ivor Back’s 
list Nos. 2 and 4.— I aiii, etc!, 

London, W., April 23td. ErnEST CL.vnKE. 


©IiUuar^. 

L. R. OSWALD, M.B., C.JI., F.R.F.P.S., 

Honorary Consulting Physician, laic Pliv6ician.SuperinlcutIcnt, 
Glasgow Royal Mental Bfospilal. 

We regi-ct to record the death, on March 24tb, of Dr. L. R. 
Oswald, who was for many years physician superintendent 
of tlio Glasgow Koval Mental Hospital, Gartnavel, and 
lecturer on psychological medicine in tlio University of 
Glasgow. 

Landel Bose Oswald was born on October 4tli, 1861, at 
Blinkbonny, !Markincli, Fife, and spent Ids early youth and 
Gcliooldays there. He bad not tho opportunities enjoyed by 
many other boys of his time, and it was not until after lie 
had come to Glasgow that ho decided to .tako up tlio study of 
medicine. "Before entering the ruedical school of Glasgow 
University ho had worked in an apothecary’s shop, both in 
Markiucli and in Glasgow, and during a, great part of his 
luidergraduato career ho continued to assist the apothecary. 
His life iras.no easy one; ho worked hard, both day and 
night; ho had few holidays, yet nevertheless ho completed 
hi^s medical career with honours,, and gained the Brunton 
Memorial Scholarship as the most distinguished graduate of 
his year (1888). Previously ho had obtained a bursary for 
distinction in tho first two professional examinations, and 
a prize for excellence in clinical medicine. 

,,,^11. appointed house-physician to Sir 

William T. Gairdner in tho lYestern . Infirmary, Glasgow 
this position for a year. Dr. Yellowlees asked Si^ 
.n illiain Gairdner to recommend a man of promise, and 


without hesitation Dr. Oswald’s iiamo was suggested, so in 
1889 ho was appointed a junior physician at the Glasgoa' 
Koyal Asylum. X'’ollowing this appointment lie obtained tho 
diploma of tho Medico-Psychological Association. Later ho 
was awarded tho Fonlis Travelling Scholarship, and visited 
and studied at tho laboratories of Wernicke at Breslau, 
Flcchsig at Leipzig, and Pick at Prague, submitting the 
results of his research to tho trustees of the scholarship. 
In 1895 ho spent four months in the United States of 
America studying tho system of asylum administration 
there, and paying particular attention to mental disorder 
as it affected the negro. In the same year ho was appointed 
superintendent of the Gla.sgow District Asylum at Gartlocli. 
He was re.sponsible for the organization of tbat institution, 
and its up-to-dateness to-day is the result of his great fore- 
sight. While there ho was responsible for recommending 
the employment of women nurses in the male wards, and 
exercised a gi'oht influence in raising the status of the 
asylum nurse. Gartlocli Asylum was the first mental hos- 
pital to build a separate nurses’ home for its nurses, and 
that was iirovidcd on bis recommendation. 

Dr. Oswald succeeded Dr. Yellowlees as pliysician 
supcrintcnilcnt of the Glasgow Koyal Mental Hospital, 
Gartnavel, in 1901, and in 1904 was appointed lecturer in 
psychological medicine at the University of Glasgow. Four 
years later bo was successful in establishing, in connexion 
with the Western Infirmary of Glasgow, a department for 
mental and nervous diseases, and was appointed coii- 
snltiug pby.siciaii. About the same time he was among 
those who were particularly interested in organizing the 
AVestern Asylum’s Roscarcli Institute, which has done excel- 
lent work, and attends to the needs of over 6,000 patients. 
Ho held many other appointments. -At tho Annual Meet- 
ing in Liverpool of the British Medical Association in 
1912 he was president of the Section of Neurology .and 
Psychological jledicino; ho was president of the AYest of 
Scotland Medical Association; ho served on a Royal Com- 
mission to report on tho mental condition of the school 
children of Glasgow; and ho interested himself in all move- 
ments having to do with the care and betterment of the 
mentally alHictod. 

These aro the baro facts of bis career. The man himself 
was an out.stamling personality. Ho was brought up in a 
[ hard.scliool, he worked indefatigahly- throughout his career. 

I and ho demanded a high standard, from those who worked 
with him. There were times when he may have bceji 
thought unduly hard and impatient, hut this was soon 
forgotten when it was realized that everything was done 
and said for the best interests of his colleague's and Iiis 
patients. Ho had acute clinical insight, and his ability 
to sum up a situation quickly and clearly was tinrivalleti. 
His method of eliciting tho facts was almost judicial in 
its thorougliness, and altliough this cross-examining style 
did cause an element of uneasiness, yet it was tactfuUy 
done, and never left any resentment. It is not too much 
to say that his whole life was bound up in the institution 
which lie served so faithfully for a period of twenty years, 
until his retirement, from ill health, in June, 1921. His 
hearty was in his work. At all hours of the day and night 
he might bo seen going round lii.s wards, .talking with bi.s 
patients, diso^issing what was best to do for them, .and 
keeping .in tbo closest possible touch with them. Tbcy 
depended on him, and maiiv will ever bo grateful to him. 
He was not easily approachable, but bo made many friends, 
and all admitted to his friendsbip were channed by bis 
broad understanding, Ills souse of duty, and bis sterling 
worth. AVben off duty bo was a most entertaining con- 
versationalist, .always had a fund of reminiscences and 
stories at his command, and enlivened any comjiany. 

As a .lecturer he was able to put bis knowledge forth 
in a clear, coherent manner. He gripped bis audience, and 
bis clinical demonstrations particularly were characterized 
by great force and lucidity. It was unfortunate tbat bo 
did not contribnte more to medical literature, as'bc bad a 
happy mode of expression, and his mind was so keen, 
clear, and well ordeied that ho was able to sum up bis 
experience in a most instructive manner. His time, how- 
ever, •was fully occupied. , Tbero was no department of the 
institution tbat lie did not know about, ho took an interest 
in everything tbat went on, and, in consequence, ho handed 





APniii 28 ,- igiS] 


MEDICAIi NOTES IN PARLIAMENT. 


[ Tirr Uumsa . 

itroiCAL Joranit 


it was at onCo anangcil tliat Hio volume slioulil bo includoR 
ill tlio series known, under tlio cdilorsliip of Mr. Ogden,, 
ns the llistory of Civilhutiou. Tlio book a]ipeared in- 1026, 
and has already aehieved marked popularity and general 
Biieeess. Ry it Cumston’s name will uiidouhtedly ho 
reineiiihcrcd' and it is chnractorislic of the man. There have 
been, and are, ninny historians of medicine with greater 
teehnical equipment; tliero are others who aro greater 
seholar.'r, or who have made greater contributions to special 
departments of historical knoivlodge ; but Cniiisfon's book 
is a wide and generous survey of the suhjei't, made by a 
man who had practised long and successfully as physician 
and as surgeon, and fi-om whom nothing liiimnn was 
leiiH'to or alien, fn fact, just ns if. may be said that one 
of his most successful “ occasional papers ” was a little 
essay, written in Freneh, eoncerning “ notre sympathiqne 
confrere Fraiujois Rabelais,’’ so there was much of 
Rabelais in Ciiiuston. Not that lie was llabchiisian in tho 
sense in which the Kiiglishinan in tho street uiider.staiids 
the term, hut that, like R.abchiis, an Hippocratic physician 
by nature and by training, and, like him too, not without 
experience in a speciality that reveals a great deal of what 
is weakest — and sometimes much of what is strongest — in 
human nature, and, with a wiilc . knowledge of men and 
things, he became a great and kind-hearted ohserior and 
critic of life — iiiipulsivo and prejudiced, tolerant and 
wise, philosophical and genial, caustic and Uiiid-liearto<l, 
and above all syinpathetie to eveiything lint ahat is mean 
and despicable. And it is perhaps not allogethi-r fanciful 
to trace some rc.scniblaiico hctwceii two portraits 'now 
beforo tho writer— one, a' copy of the faiiitius Oeneva 
likeness of Rabelais; tho other, a recent crayon drawing 
by a Geneveso artist of “ notre syinpathiqne lonfrere,” 
Charles Greene Ciimstoii. 


tVo regret to record tho death, on April 12tli, of Mr. 
Euu.xu tVrLLi.tii Wii.LETT, for many years amiestlictist to 
St. Bartholomew’s Hospital. Ho was horn in 1856 at 
Brighton, where his father, Henry Willett, was well known 
as a collector, and antiquarian. Ho was educated at 
Wellington and New College, Oxford, graduating B.A. 
with first-class honours in natural scieiico in 1879, M..A. 
and M.B. in 1885, and M.H, in 1904. His medical studies 
were pursued at St. Bartholomew’s Hospital, where his 
cousin, Alfred Willett, had lately boon promoted full 
surgeon. After qualification Edgar Willett was appointed 
house-surgeon to Sir William Savory, and in 1888 he 
obtained the F.R.C.S.Eng. diploma with tho intention 
of practising as a surgeon. He served for a few years 
on tho surgical staff of tho Mctro]iolitnn Ho.spital and 
of tho Belgravo Hospital for Children, but becoming 
interested in anaesthetics he took up that branch of 
tho profession, and was appointed anaostlietist to 
St. Bartholomeir’s Hospital. As an anaesthetist Edgar 
M illott was careful ratlier than brilliant, but no patient 
ever suffered any mishap in his haiuls from any lack 
of attention. In 1905 he was elected president of tho 
Society of Anaesthetists, , He re-signed his appointment at 
St. Bartholomew’s about twenty years ago and went to 
live in the country, hut on tlio outbreak of the war he 
voUiiiteerod for service and was appointed to the Croydon 
General Ho.spital, of which ho became registrar, with the 
tompoi'ary rank of major, R.A.M.C. On the termination 
of his sen-ice he retired to his house in Sussex, near 
Forest Row. He had a very quiet, retiring, not to say shy 
disposition, and consequently never had a very laa'ge circle 
of acquaintances, hut his friends knew h>m as one of the 
kindest hearted of men, very ho.spitahle, and ever ready 
to do a good turn. Ho enjoyed country life and was a. 
fair golfer and shot, and ranked above the avei-nge as a 
croquet player, but failing health prevented him from 
enjoying his pui-suits to the full. 


We regret to announce tho death of Liciit.-Coloiicl AV. I. 
Thomc.sox^ D.S.O., which took place at Omagh, co. Tyrone, 
on --Vpi'il 12th, after a prolonged and severe illness. AVilliam 
Irwin Thompson received his medical education at Trinity 
College, Dublin, where he began his studies after sei-ving 
tlironghout tho South African war as a trooper. Ho 


graduated M.B., B.Ch., B.A.O.Duh. in 1905, and in the 
snino j'car obtained the diploma D.M. Suhsoquoiitly he 
joined the Royal -Irmy Aledical Corps, serving at homo and 
ill India, and in 1914 was attached as medical officer to the 
5tli Dragoon Guards. Ho proceeded with that regiment 
to France at tho outbreak of tho European war, and had 
tho ill fortxmo to lio taken -prisoner xvithin a few- w-coks 
of landing. . For cloven months he was detained as a 
prisoner of war, and in that jicnod suffered coiisiderablo 
privation, from the I'ffects of w-liich he never fully recovered. 
On his return to Eiiglnnd ho w.as employed for a time 
in training veevnits, hnt hofore the end of 1915 he embarked 
for France for a .second timo to take command of the 
65th Field Amhiilaiice. His services were rcc-ognizcd by the 
award of tho D.S.O., and ho was several times mentioned 
in dispatches. -Ifter-tho war ho was again employed in 
India for several years, hut in 1925 he was appointed to 
tho Connaught Hospital, Aldershot, w-here ho served until 
ill health caused his retirement. Colonel Thompson had 
a close family association w-ith tho medical profession. His 
hrotlior w-as Arajor-Geiicral Sir Harry Thompson, K.C.M.G., 
A.M.S., who died in June, 1925,. and w-hosc health also 
was undermined by experience as a prisoner in Gei'inany in 
tho early yeai-s of the w-av. Colonel Thompson w-as the 
nephexv and son-in-law- of Dr. E. C. Thompson of Omagh, 
a former president of tho Tyrone Division of the Ulster 
Branch of the British Medical Association. He is survived 
by his w-idow- and a young son and daxighter. He was 
interred at - Portru-li w ith militar 3 - honoui-s, detachments 
of his oxvn corps and of tho Ro^-al Inniskilliiig Fusiliers 
hoing present. 


illriiirnl ^^olrs :n 

[Feom our Parli.miext.srx Correspondent.] 


The Budget 

Ox April 24th Mr. CHURCHUi introduced the Budget in the 
House of Commons. Ho proposed a duly of 4d. a gallon 
on petrol and light oils, including kerosene and turpentine, but 
regretted that he could not accompanj- it .by aiij- reduction in 
the iiorse-pow-er tax on motors. Tlie rate of income tax is 
unchanged, but the abatement for a fii-st child is raised to £60 
and for subsequent children to £50, to be allowed from the j-ear 
of birth. The diitj- on inipoi-led unrefined sugar is reduced by 
Id.-per lb. Duties are imposed on lighters used in lieu of 
matdies and on imported buttons-. Mr. Churchill sketched out 
a great scheme of rating .relief, to come into force in October, 
1929. Bj- this agi-icultm-al land will be relieved of all rates,, 
and productive cnlci-pi-ises employing manual labour, together 
with railwavs, canals, and docks, ■ will be relieved of tliree- 
fourtlis of file rates. The Government is establishing a fund 
w-licrcw-ith to pay contributions to local authorities to make up 
for these rate rcducti'ons, contingent on the passage of a 
Valuation Assessment Bill after the Budget and a Local Govern- 
ment Bill next winter. Mr. Churchill said the latter would 
carry out overdue reforms in local government, and would 
substitute a sj-stem of block grants, quiiiqiiennially- revised, for 
the present system of Goveiiimeiit aid to health services and 
other local services. Education and police w-ouhl not be in- 
cluded^ in this. For certain purposes of local government, 
including Poor Law- and liighwa^-s, w-ider administrative areas 
w-ere needed and w-ould be proposed. Jlr. Cburcbill announced 
that 111 the past three j-ears the number of officials in the civil 
departments had been reduced by 7,000, and that a further 
scheme had been prepared to suppres.s 11,000 more posts in five 
j-ears. 'The defence departments were also to be examined 
w-ith a view to retrenchment of staffs. 

On the subsequent days this w-eek the House of Commons 
continued a general di.sciission on the Budget. On April 23i-d 
the House of Commons completed the committee stage of the 
Equal Franchise Bill, and read the Local -Authorities (Emer- 
genej- Powers) Bill a third time. 


Edinburgh Corporation Bill, 1928 (Venereal Diseases). 

Second Jicndinff /iefased. 

Oil April 19tli tho' House of Commons refused, by 156 to 95, 
to give a second leading to the Edinbui-gU Corporation Bill. 

3Ir. Peihick-L.iwresce moved tbo rejection of the bill, and said 
that, though a private bill, it raised issues of fundamental national 
impovtaiice. He said tlio bill would not operate more speedily 
to get rid of venereal disease in tho country. Expci-ienco and 
a common-sense vica- of human nature convinced him that tbo 
reverse would be the case. ^Tlic promoters of the bill bad circu- 
lated a memorandum -in -winch they offered to make considerable 



MEDICAt/ NOTES IN PARDIAMENT. 


r Tnt r.MTto* 7Q7 
L lIr.DJCJX JoOBira* ■ * W • 


ArniL, iS, jgiS] 


pnivo ncciilonl foUowinp ' tlic trontinont, aiul it ^II^^ 

known ns nnitr yellow nliopliy of llie liver, followed not ii 
quentlv. Mmiv dOctois of liipli stnndinf; In-lioved (lio old mol 
of li-c.-ilmrnl. was ns oITcelivn in liie loiif; rnn. Apparenlly, l>y me 
operalion of this liill one pnriienlar nictliod of Irealmcnl,' and 
that alone, was to he enforced,, and if a patient declined that 
inelhod, and demanded trcntnient hy the older nirlhod, ho was 
not only to be refused it, hut punished for demundiug it. 
was nn'entirely new principle in Ilritisli law. 

, Ur. I'remast'u: iuteivened and asked where that provisioi 
11.., i.:n 


a IcrriUlo disease, 
rollowcd i)ot infre- 
method 
llic 


That 


iu tiie hiU. 

Ur. S.iLTKn said n nationt had to submit lo liraliucnt pre 
srriicd i»y tho inodical oflircr. Tliat was tlic iiupluMtiou of (he 
clauso denliuij with Iho sul)jcct, Ife a'ikod lln' Socrctaiy fot 

o-.ii 1 ...1.... I..,.. :e ^ ......x ....(Tvxt./x.l .s.. .I.V.X4I. .V.. II.. 


vision camo 


(he 

UA'imiij; ivivii iiiu Mii»jvk:i, a*v a-ixt-ti ui'- s-'v-tiuim ^ for 
Scotland whollicr, if a man sufTcicd itjjiiry or <lcalh as the 
result of (ix'atmcnt comjnd.sorily applied a^jainsl his will, (hat 
man would not have n claim for damages rUher ajjamsl (he 
doctor who Rave the (rcatincnt or u|!ams( tlio institution of 
wliich (lie doctor was an ollicial, Ofliciats of (ho Kdinhnrgh Cor* 
poralion had met the Varliamenlary Medical ComimUec and had 
supplied liguros showing that iu 1S22 the percentage of defaulters 
to all persons presenting themselves was 18; in 1925. IS; in 1924, 
12; iu 1925, 13; in 1926, 12, and ho had been (old that in 1927 
it- was 11, That showed (hat (lie present voltmlaiv method \va<5 
etTeclivc in spile of the fact that, as he was told, the Edinlmrgh 
Corporation had only one official who followed uj) these defaulting 
cases. Before introducing such drastic pronos.'tlv, as the bill 
further otTorts should he undertaken on voluutaiv tines, with 
more cfTcctivo iiic<fical persuasion and an incroavi-d miinhcr of 
followc.i-s lip. The experiment of compulsion had been made in 
many countries, but not hitherto in Great Brilam. Dr. l?aUcr 
declared that a man suffering from voneixal dis<*ase who attended 
one of these clinics regularly' might he infect loux and might 
remain infections for many months, and go on ‘‘preading inlcc* 
(ion amongst the pojjnlalion. The bill did not jnopo^c to deal 
with that man, hnt_ it propo’sed lo deal with another man who 
iiiighi not be infectious at all, but had siinjily not followed up 
his treatment for as long ns the modicnl ofTiccr thought he ought 
to have done. He added (hat lie woul,! not. suppoit a bill for 
segregating persons sufToring from venereal disease tdl Ihev were 
^Glared cured.. It would bc^ ineffectual. The bill before the 
Houso would drive venereal disease underground, and there was 
a risk that it w'ould increase it. 

Dr; DRUMifovD SincLS, supporting (he hiH, said that u was 
designed to fill a gap iu (lie Iiuectious Disca^c^ Acts, tinder 
wfucli tUo country had possessed compulsoiy poweis smee 18S9. 
V enereal diseases liad not hecn brought under thes<’ because 
(ill recent veal's theu* responsibility for disastrous aftci-offocts 
was not rcalired, them specific cause's were unknown, and there 
certainty of a cure. Kowover, higli medical and legal 
authority beheyed that venereal diseases could come i.iulcr the 
opcr^ion of the Infectious Diseases Acts, and certain parts of 
U’Ni K' ^'cre identical with provisions of those Acts. 

I disease, except in ver^' few eases, no insiKutional 

required; the treatment might be pioionged for 
tthlo during treat ment lo carry on 
iis ordinary employment. Therefore the bill had b.«cn mtrodiced 

(lie procedure of the Infectious 
Comniissiou could not recommend com- 
Sn i ''1**^** treatment centres 

tml (1 r^"' "■<=*■<= faiiiilinv will! (he modern 

““v* ""'isaecd n lime when compulsion 

hkrfhe >»■' Comniiuee oullincd something 

nent ™ TIlO Ol.lv SCI .OUS (irgu- 

nem nnd i-'”® ’‘••''■'I’er vohuit.vrv trcal- 

“"dorground. People mIio were most 
uSmcMf nf 'Vi I‘“<I no personal anocialion with the 

of h^liiJ Venereal disease omcers, medical 
nnrfhf't- viVu' ^ public health committees took 

ngjiv'f nv -inv’ awarc that anv vcucroal disease 

fi apj. medical oflicer of liealth in Scotland had sii^gestcd 

voTn„tt‘;-’’;T4f Si”" ,'”■'1 opmation^irihe 

and be ^ ° 'oliiiitary system could go on perfectly 

wmi.M nnul’^hl ‘ J “'"P'llsoly parts of the bill, which 

Dr V™/* i of people. Ur. Salter and 

feter^T to the '‘"‘'"''’o »‘sks to the patient. They 

reterred to the stale of things ten vcai-s aeo and liicir stati 

followinR^inieclion^'^^P/r * 1 *^' ' *(ocn one death 

few Mwein. 

st^Xd fha?^m-er"(h:HfX'*”^’i (oodical press liad recently 

Ur ■^.Xr.Tr ’'“d occurred. 

wS'cemnarable experience in Scotland. The risk 
drawr”^ W heL;H?‘-i.-?"“P‘^dymg when they had teeth 
• ■+ 1 L spitals while undergovntr an operation Tho' 

" nsTXf tCVeth;;; pofnc Llhorit/ walTusUfed 

treatment there was absolute’ cerlaintv* n?°^°*'*'** 7*^*°^^* 
these people if they were nXt^ 

•TbX-ldh.L.-;i?’'’'?h‘° 7 -“ ^ohmfar? XyXtcm a eu««s'' 

Sidd nXt b?^Ssily°obseU™^ pledge of eecreej? 

weV^'arcrafy-Mlmvet’np by“letfer‘' and 'T ^ “f" 

danger fi.o™. i ’ out had many people who, careless of the 

tW^nXnt over ’"‘0 “ l-ost year 

..i. 


ill Scotland rhowed that £62,000 would he required next year. 
The local aulhoritic*^ Imd to make a contribuliou wbich raised 
(he total to over £87,000. In the w’holc of Britain they were 
.•spending over' £300,000 to provide free Ircatmcnfc and skilled 
specialists with a view lo stamping out the disease as a part of 
preventive medicine. The doctor’s ideal was preventive medicine, 

' and ho looked forward to a lime wdicn he would not be curing 
disease, hut, instead, would be keeping people well. Our general 
.hospitals, our Poor Law hospitals, our asylums, our prisons, 

, were largely filled with the end-products of this disease recorded 
tinder llic names , of ditTeront conditions. The expert of tho‘ 
Ministry of Heallli on this subject, at the recent Imperial Con- 
ference at Womlilcy, estimated tliat the treatment of venereal 
disease at tlic present time saved £50,000 a year in asylum 
expenses, and, if treatment could do that on only one aspect of 
the end-results of Uiis disease, what would entire prevention 
achiever Compulsion and early treatment would prevent many 
of these. late developments and release many bods in our ordinary’ 
hospitals. Medical oflicci*s of health and venereal disease officers 
denied that compulsion would drive the disease underground and 
send people to quacks. His experience, which was confirmed by 
all clinical officers, was that the great bulk of the patients were 
eager to get well and gave no trouble at all. Under the new 
provisions (licsc people would not be aftccled by the knowledge 
that compulsion would be used on others of a different mentality. . 
The people who defaulted did not come to the clinic because 
tlie^* were weak-minded or frivolous or utterly careless and 
irresponsible. If compulsion brought any change in tho volun- 
tary attendance it \vouId have a good effect. At present the 
public * did not sufficiently realize the seriousness of venereal 
discascy and the fact that there were no compulsory powers in 
connexion with it impressed on the public mind the idea that 
venereal diseases wore not so .serious. With regard to treatment 
bj* quacks, it had been illegal and a serious offence since 1917 
for an 3 * unqualified person to treat venereal disease. Dr. Shiels 
said ho was surprised at the action of some women’s associations 
against the bill, and at the unscrupulous use made of the name 
of Josephine Butler. To say that the bill was analogous to the 
Contagious Diseases Acts of the middle of the last century was 
an insult lo the . citizens of Edinburgh. In modern days 
prostitutes did not form a large percentage of the patients. If 
tlicy became infected they were eager, for obvious jcasons, to 
get cured. Women’s societies who objected to the bill might 
seriously consider the ease of the innocent children, cf whom 
between 200 and 300 attended the Edinburgh clinics — children who 
should have been born hcaUhy, but who had been condemned to 
suffer tho stigma of this disease. The bill did not abolish class 
distinctions, but all types of people attended tho clinics, people 
of all social grades^ xhc compulsory methods in- Europe had 
only been used against prostitnlion, and had no reference to 
the syst9m suggested in the bill. In Germanj*, however, a system 
had been introduced a few weeks ago on the linos of the bill. 
In Toronto a similar sj’stcm was working, and loss than 2 per 
cent.^of prosecutions Nvas needed (o make it effective. He himself 
. had investigated tlie system in all the Slates of Australia, and 
had a special interview with the director of medical services in 
Melbourne on the subject. They were perfectly satisfied wdlh 
the system, and there had never, been any demand for doing 
away with it. Dr. Shiels understood that the Government 
opposed the bill because it was local and not general. The 
Scottish Board of Health had more than once spoke of the need 
for compulsory measures. The English Ministry of Hcaltli, how- 
ever, had alwa\'S seemed to have a curious ” prejudice against 
any legislation on the subject. There was nothing in the private 
bill argument, because much of tho general public health lec^is- 
lation had been built up by local experiment. Even the Infectious 
Diseases Act of 1889 was in operation in Edinburgh for ten 
3 ’cars before it became a general Act. Compulsory notification 
of tuberculosis was m force in many towns before it became 
general. 

Sir John Gilmour said. that as the Minister I’csponsible for public 
hcaUh m Scotland he approached the bill without technical know- 
ledge, but'fceling that it deserved the closest consideration by tho 
country and the House. Ho regretted that ho would Bave to 
advise the House to reject it. Ho 'did so after careful considera- 
tion with his advisers. Letters and communications bad been cited 
from the Board of Health which referred to the possibility arising 
of using compulsion, but these communications had been made 
before the issue -of the most itjcent reports on the problem. 
Venereal .disease^ was a scourge, and thej* must make as great 
progress as possible towards eliminating* it, but tho measure of 
progress must alwaj's be in proportion’ to, ' and not in advance 
of, the A'oluinc.of public opinion in support of it. The Board of 
Hcaltb recognized tho skill with wdiicli the Edinburgh Corporation, 
as others throughout Scotland, had endeavoured to deal with this 
problem. Cases such as those cited of the deliberate infection 
of. children rightly’ aroused the indignation of those who jiad 
to deal with 'the problem, but lie asked the House whethei', if 
compulsion were authorized, these cases could bo more casilj’ dealt 
with, than now. The Trevethin Committee had said : “ It has 
been suggested by some that in order to secure unbroken attend- 
ance of patients at clinics a modified form of notification sup- 
ported by appropriate compulsoi-y measures should be applied to 
those vrlio have once attended the clinics . . . but in our view such 
a system would be more likely at the present time to deter than 
encourage attendance, and it seems difficult to justify the imposi- • 
lion of a penalty on those who have come for treatment while 
leaving untouched those who have made no cflort to seek treat- 
ment.*^ Sir -John submitted that was a condition which this bill 
would propose to carry out. On those grounds he was compelled 
to say to the House that he did not think they would be wise 
to proceed with it. 


T38 April i 8, igjB] 


lUBDICAL NOTES IN PARLIAMENT. 


[ Tnk DniTifK 
Mcwcal Jovmu. 


Sir Basil Prro asked why Sir Jolm Gilinour implied that tho 
bill dealt only with those ullendmg clinics and left out all %viio 
did not attend. 

Sir John said it seemed obvious llmt unless Ihoy also had 
compulsory notification' that would be the result. He pointed out 
that tho Corporation of Glasgow Avas bringing forward proposals on 
difTcrenl lines. 

Mr. Kirkwood asked ivlietljcr Sir John Avould .support Iho 
Glasgow bill.' (The draft of this bill proposes compulsory nolifica- 
lion of venereal diseases.) 

Sir JoKK Gilmouu: Sufiicient for Ibo day is Ihc evil thereof. 
Concluding, he declared that under the volunlary sysicm great 
progress had been made. The experiment proposed was hound to 
have effect* on areas far outside lliat in whioli it was made, and 
if it failed, or partially failed, would have reactions ivhicJi many 
could not foresee. He Avas compelled with regret to ask the House 
to reject the measure. 

Hr. Fremantle said the House had that day seen the rnedical 
profession divided because of its boncsty and determination to 
tackle difficult questions. The medical members had certain 
grounds in common. One was a realization of tho intense Acrious- 
uess of the 'evil they were trying to treat. The piihlic W'as 
insufficiently aAvare of. the seriousness of tho position. The Royal 
Commission of 1916 had ooncludod tlial one person in ten of the 
whole population of our large cities Avas infected with syphilis, one 
of the great killing diseases. Gonorrhoea, one of the great 
crippling diseases, Avas equally or more prcAuU-ui. It was true 
that by the volunlary system the nunilicr of defaulters had hcen 
reduced, and he hoped it Avould eontiinio to he reduced; hut did 
any impartial man or Avoman imagino that any voluntary 
system was going to secure the ti-calmcnl of those avIio w'crc 
recalcitrant? The GoA’crnmcnt and those Avho opposod the hill 
were content that notliing should be done for (l»o«.e jicople. TJie 
medical profession Avas unanimous that the main ba'^n of the treat- 
ment of the disease, and still more tlic measures of prevention, 
must be volunlary. All statistics, from other countries were incom- 
parable because under this bill tlicy meant to keep the Aoliintary 
system. He had scon tlial system Avorlcing in Kditilnirgh. Ten 
years ago it was almost taboo to mention these subjects and 
difficult to get anyone to appear for ticatmcnl. How thev saAv the 
cases pouring in, sitting side by side in tlic general clinic, and 
Anxious to continue their treatment. Tlicy knew its effects, they 
knew that confidence Avould be icspcctcd, that tbc secrecy was ns 
absolute as it could bo made. They gaA*o Iheir names and 
addresses that tliexr treatment miglit be continued and u record 
produced if they lapsed for a time and came back. That record 
was confidential. One medical officer Avas responsible for Icccping 
it under lock and key. The officer knew that certain people con- 
tinued treatment while others rcfu^-cd it. At present liic ones 
who refused, after a short space of time infected people right 
and left. It Avas often found that the Avives and chilarcii who 
came in Avere all infected. Tlie doctor know tliat the man was 
continuing to spread the infection, and at iho present time could 
do nothing to compel that man to continue Ircatmcrii. The maii’.s 


the bill. The medical officer now luul information through ihc 
cases of friends or relatives avIio came for (i*catmcnl, and avi-oIo 
privately to the man concerned. In many cases he could gel the 
man to come for treatment, but a certain iiiiniber aa-ouW not 
come. This bill would enable him to say, “ You must forward me 
a certificate that you are being treated.” It was not compulsory 
for the man to come to the clinic even if he was poor. There 
•were poor men’s doctors to Avliom he could go and fi'Oni Avliom 
he AA'ould get a certificate. 

. Dr. Salter asked Avhai Avould happen if the applicants for treat- 
ment refused to give either thcii* names or nddresAcs. 

Dr. Fremantle said they Avould Jiol he treated, but that Avould 
not happen. The success of this bill depended on administration 
and personal contact, and because the medical ofliccis Avho dealt 
with this subject kneAv Iioaa' to get at the people by Ai'isc means 
it avouM be a success. The measure of compulsion Avas kept in 
the baBiground in dealing with infectious diseases at the present 
time. Practically no one refused to be taken to an isolation 
hospital, but there Avas the power of compulsion behind He 
supported the bill as an experiment. Applications from other 
tiuthorities Avould have to be considered on their merits. 

Mr. Ernest Brown, as an Edinburgh member, denied that there 
was a unanimous public opinion in Edinburgh in favour of the 
bill. He had refused to back it, but could not say whether liis 
elcctoi*s were for or against it. The issues raised in Clause 3 
had never been discussed m public in Edinburgh. It Avas not a. 
•bill that should go before the Pita ale Bill Committee. 

Sir Samuel Chapman, another Edinburgh member, said he Avas 
a sponsor of the bill, but not at prebcnt a supportei-. He desiied 
to sec it sent to a select committee. 

Mr. Stewart, as a member of the Lunacy Board, argued for the 
voluntary system. If the country decided in favour of compulsion 
•it should be a general system. , 

Lady Astor said they had found that compulsion would not 
do away with this disease. The Contagious Diseases Acts, instead 
of doing aAvay with disease, only increased it. Only under the 
voluntary SA'stem had they a chance of getting at the men and 
women victims. There Avas only one Avay Avhereby they could 
• protect tho children — by a single moral standard. In Australia 
the dcfaullei*s, under compulsion, had never been below 75. per 
cent. She gave figures shoAving that in Bradford, Avbich had the 
powers now asked for by Edinburgh, the number of babies affected 
Bonorrh<^al blindness had increased since compulsorA* trcal- 

impracticable, and if any 
•land it. No bm'wonld^ ^ because they did not imdcr- 

^ JNo bill ^^ouU create more disturbance in the Country 


than this was likely i o' arouse. If tim bill pas.sc(l it ivould fall 
tnofo Ij^’pvily on the Avomcn than on the men. 

Mr. >\iLLTAM Graham said that in preparing the bill Ibe Edin- 
burgli^ Corporation recognized that it, involved a more limn 
local issue. At Iho end of (cn years* c.xpcncncc they Averc satis- 
fied t he case for second reading could bo cstnblishcfl. Tbc Slate 
provided 75 per cent, of tho expenditure on venereal disease clinics, 
nml the interest of (ho (nxpayers Avas io see (hat (here Avas -not 
sonic inherent U'cakness in the system which undermined a good 
deal of Die Avork done. Scottish local authorities in (heir repre- 
sciilativo assemblies, rucIi as the Convention of Burghs, liad in 
recent yeai-s passed resolutions urging that some sort of com- 
pulsion was needed, and the Scottish Board of Health had in 
reports from 1922 alluded to the possible consideration of con- 
nulsion. Tho subject had been fuily considered by Did Edin- 
burgh Corporation. Only Iavo mcmbci-s of the corporation - bad 
dissented. In Edinburgh' the voluntary system had liccn pur- 
sued to the utmost limit, but a list of defaulters remained, Avliich 
oA'cr tlio last five years ran from 850 io 1,000 people, over irhom 
ibe corporation bad no real power to compel them to continue 
(rentment. The lady almoner Imd A'isilcd a large number of 
cases, and ivas salishcd that Edinburgli had now reached a point 
at Avliich this dofniilting class avrs steady or fixed. He submitted 
iimt a case had been made out for investigation by a select 
commit tec, and that a great corporation should be alloAved a 
chance To experiment, even by exceptional methods, 

Mr. Rcr.YMGEorn read a statement from Dr. Burgess, medical 
officer for Dundee, who said : ” Our experience is such as io 
suggest that further powere are necessary, 1 find that during 
llie last four years an average of only 36 per cent, of tho 
patients who ceased to attend our centres did so because (hoy 
wore certified cured, and of Die remaining 64 per cent, a very 
small proportion were transferred to other centres.” The doctor 
favoured some compulsory incasui*cs, making it a legal duly 
on ihc medien) praelitioner to notify the disease. Dr. Burgess 
also held that before coolly measures Avere introduced facilities 
for free treatment of .all infected pei'sons must bo available to 
cA'erv person. I ncilities must not only be of the nature of clinics 
for out-patients, but nl^o of Avards for*iii-palient<. 

As stated above. Ihc second reading of the bill Avas refused by 
156 to 93. Dr. Jlrummond Shiels told for the bill and Dr. 
Graham Little ngai»«l il. Members voting against the second 
reading included Dr. Vernon Davies, Dr. ’Waller Elliot, Sir 
Hichartl Luce, and Dr. Alfred Salter. 

yatioiKi? fff fifth ‘ Insuntticc HiU. 

A standing committee of t!>c House of Commons commenced, 
dll April 2-ltlt, to consider the National Health Insurance Bill. 
On the first clause, making amendments regarding continuous 
iristir/mce coni ribiil ions by volunlary contributors, and arrears, 
Mr JohnWon proposed that after the extended period an insured 
jici^on should continue to be ' treated as such for a further 

c/iAMCERUiN said that when he first saw this amendmeut 
he was disposed to regard it as a joke, An insured person was 
noAv entitled to one year nine months’ of free insurance when 
unemployed, and, if genuinely unable to got work, to another 
vear which might be further prolonged if ho had boon ill. 

^ Labour members of the committee argued that special exten- 
sion Avas required for men in tlic coal-mining areas, and pointed 
out that some trade unions retained unemployed members on 
the books for ns long ns seven ycaiN. , 

Mr Harvev pointed out Dial after one year .nine monlhs the 
imcrnnloved nmn av.ts only entitled under Die original Act to cash 
honofits "subject to a reduction, but under Ibc Prolongation of 
Benefits Act, a temporary mcasnre, he Avas nOAv kept in insur- 
'incc and entitled to medical benefit so long as be Avas nnemploYod. 
There was nothing ludicrous in proposing to make that proAusion 

Daa'IES commented that a subsequent section pro- 
vwipd* that an insured person, of CO, if unemployed after ten 
Years in continuous insurance, was to bo Ucatod as an insuixd 
hekon for five years so as to pieservo his pension rights, bir 
ivTvrsLEV Wood J^aid that provision Avas inserted at the special 
of the trade union representatives on the Consultative 
rrtimcil Mr. Ruvs Daa’ics said that Avhen it suited the Govern- 
ment p'oUcv the Government actuary could always put his hand 

^*^Dr Drummond Shiels said there Avas no doubt’ that after a 
of miemploviueut in this country men avcic not physically 
?ii and -were specially liable to illness and death. 

* Tvlr Chamberlain said Dial the subsection keeping persons over 
KO in tho scheme did not entitle them to sicknes<; or disablement 
^Anofit Members who supported the amondmcnl adA-anced 
aro-umcnls Avhicb, carried to their logical conclusion, meant that 
alf insured pei-sous’ rights should be secured in perpe)uit\\ The 
foorocontatives of the trade unions on Die Consultative Council 
h'ul romc to the conclusion that in this clause they had got all 

thev could reasonably expect. Under the bill, if at any time 

durino'- the period of Iavo and three-quarter years the uncm- 
man could Ke.t ouc Avcck s Avork, lie Avould start all over 
If must not be thought that even medical benefit meant 
Sf eipenso to the societies. People left out of tl.c bill as it 
stood were only those permanently unemployable and theroiore 
not suitable subjects for insurance. 

Mr Ehys Daa’IES remarked that the number of pei'Sons Avho 
’had come into the old age pensions conlribulory scheme liad 
Lecu less than aars anticipated, and there Avould be a surplus 
which he desired to retain for the benefit of insured pei*sons^ 

The amendment aa'Qs defeated by 18 to 15. . e- , ■, j 

Mr. Ehys Daa^ies proposed that at the expiration ol exlcndcrt 


APRIIi 28, 1928] 


MEDICAL NOTES IN PARLIAMENT. 


t' 


' r Tnrrntnsrt 
' ■ LsIedicai. JovKiril. 


licncfit (he unemployctl contrihiitor should he entitled to become, 
^vi(hiu (he next year, a voluntav-y contributor. 

Sir Kingsley Wood pointed out that rcpulations under the 
Act pcrmitlcd the Minister to make regulations regarding 
(he Icnctli of tiino allowed for such an option. It wouia bo 
better to leave this power of regulation to llio Minister, who 
would give careful consideration to the point raised by Mr. 
llhvs Davies. The amendment was withdrawn.' 

On (lie proposal (hat Clause 1 be added to the bill, Mr. Knvs 
Davies said tbo clause was an improvement on the provisions of 
(be Prolongation of Rcncfits Act. NcYCrlliclc,<is, tbo approved 
societies bad been called upon to bear a burden, the result ot 
\mcmp\ovmcnt, wbicb really should have hccu carried by others. 
On top 'of that (he Kcohoniy Hill had prevented the Minister 
from propounding the improvements in national health insurance 
which should have been made. 

Clause 1 was added to the bill by 18 (o IG. , . 

On Clause 2 Mr, Broad moved an amendment to tbo provisions 
for Ibc payment of benefit to insured persons in bospilals, sana- 
(oriiims, and other institutions. The bill propo'jctl that tbo 
luoncv should be paid by weekly instalments. Mr. Broad argued 
that it would be more valuable ns a lump sum on convalescence. 

Mr. CiiASinERLAiK said the bill followed the recommendation of 
the Royal' Commission, which liad been approved by the Con- 
sultative CounciU 

Mr. Rhvs Davies said the Consull alive Council could only 
express its opinion on issues' submitted (o it by the Minister. 

Mr. CiiAMnEatAis said the Council was free to ask for anything 
to bo referred Vo it, and the request was never refused. He 
promised to consider at a later stage the matter raised by 
Mr. Broad. • ' , 

The committee then ndiourned till April* 26tU. 


In a reply to Sir Robert Tliomas, on April 18tb. Sir Kingsley 
Wood said the uverage cost of drees and appliances per insured 
person in 1927 in the areas of Welsh Insurance Committees was 
approximately 29.5d., and in the areas of English Insurance 
Committees fe.ld. The lower cost per head in Wales might be 
due to the large, number of persons in the Principality who 
received treatment for minor complaints. 

•Sir Cooper Rawsqk asked the Minister of ITcaltli whether his 
attention had .been called to the report of (bo Easi Sussex Insur- 
ance Committee with regard to a ease in Hove, in winch it was 
alleged that a panel doctor was visited by a regional medical 
officer of the Ministry, \vho criticired bis methods of prescribing, 
and that subsequently the doctor was threatened wuh action on 
the part of the Ministn* unless be prescribed' medicines of a 
cheaper character. Sir Coe per asked wbal was the reason for 
such an interference with the jurisdiction and authority of the 
Panel Committee. - ' 

, Mr. CiiAMaERLAiN said Ins attention bad been called to the 
ease, and he was »considering the report of the East Sussex 
Insurance Committee, The visit • of the* regional othcer was 
directed to ascertain, in accordance with the Medical Benefit 
Regulations, whether the case etiould be referred to the Panel 
Committee. The warhin,? to the doctor indicated that in certain 
circumstances such a reference might have to be made. 

Answering Captain Fraser, on April 19th, Mr. Chamberlain 
said that in the National Health Insurance Bill now’ before the 
House provision was made for the inclusion in the list of addi- 
tional benefits of a new benefit under which approved societies 
would be able to make payments towards the cost of massage 
and cicctrothcrapcutic treatment of their members in approved 
institutions. Captain Fraser asked whcllicr massage would be a 
direct additional benefit or given indirectly through institutions. 
Mr. Chamberlain said it took the form of a new benefit, and 
power was given to make contributions towards its cost. 

: In an answer to Mr. Hardie, on April 19tli, Mr. Chamberlain 
said he would watch with' interest the experiments being made 
in tlie provision of treatment in clinics for persons suttering from 
rheumatism, but the Government did not intend -Itself to set up 
such clinics. 


Foot-aud-^fouth Disease. 

Mr. Hurd, on April 19th, suggested that Mr. Guinness should 
issue a regulation that in all luiure importations of meat from 
the Argentine or elsewhere the head, including the tongue, and 
the , feet must be attached to the carcass, as the lesions which 
indicated foot-and-mouth disease were most apparent in those 
parts. Mr. Guinness said the suggested regulation would not be 
effective in preventing the importation of possibly infective car- 
casses. Animals might be killed when in the incuoative stages of 
the disease before tlioy developed lesions, and their carcasses did 
not sliow recognizable signs of the disease. To prevent^ carcasses 
of animals wliich had been killed when in the incubative stages 
of the disease Irom being imported into Britain, the Ministry 
of Agriculture had requested tlie South American Governments 
not only to prohibit the - export to Britain of all carcasses of 
infected animals, but also of any animals which had been in 
.immediate contact with them; and laws had been passed by. those 
Governments to give effect to the Ministry’s suggestions. He was 
confident that those laws .would be effectively enforced and that 
they would afford a greater protection than would the regulation 
suggested by Mr. Hurd. 

•Mr. Guinness, replying to Mr. Hurd, on April 23rd, said that 
out of 91 outbreaks of foot-and-mouth disease confirmed this year 
in 29 eases the disease originated in pigs, but 25 of these were 
traced to infection from other outbreaks. Of the remaining 4 cases, 
in only 2 was there any evidence that infection might have been 
contracted by the pigs coming' into contact with butchers’ waste 
containing meat scraps of foreign or English origin, 'but there was 


110 proof that tin's ■was the source of infection.* Tlie Fool-and- 
Moutli Disease (Boiling of Animal Foodstuffs) Order, as amended 
in February last, not only made it an offence to bring any meat, 
bones, offal, etc., into contact wtlb animals, or to feed them to 
animals, until tbo materials bad been boiled, but also made it an 
offence to permit animals to come into contact with the materials 
until the latter bad been boiled. Mr.* Guinness further slated that 
the possibility of infection ' of foot-and-mouth disease in chilled 
carcasses had been demonstrated by the Foot-and-Mouth Disease 
Research Committee. The Boiling of Animal Foodstuffs Order- of 
1927 was designed to prevent any infection wliich might be intro- 
duced in this way from reaching animals in this country. He was 
not prepared to givo instructions for the- systematic testing of 
carcasses to prove the c.xislcnce of a contingency which Iiad been 
admitted and had been provided against’. The Orders requiring 
the destruction of liay and straw used as packing for imported 
goods and tlie sterilization of meat wrappings before being brouglit 
into contact with animals were calculated to be ' an ^ effcctivo 
safeguard against the introduction of foot-and-mouth disease by 
any such materials which might be contaminated by the virus. 
The enforcement of these Orders was a duty of the local autho- 
rities. Nineteen prosecutions under. these Orders by, the local 
authorities had been notified to his department, r^ulling in 
. thirteen convictions. 


Satiihtr}/ Conditions in Bop-pickin/; Camps. 

On April 19th Dr. Vernon Davies asked the Minister of Health 
if his attention had been drawn to a recent address by the 
county medical officer of health for Kent referring to the sanitary 
conditions of some hop-picking camps, and the administration 
of certain rural distrfet councils in connexion therewith; and what 
proceedings, if any, he proposed to take to remedy these condi- 
tions. 

Mr. Chamberlain said this address and a report made by the 
medical officer of health were receiving consideration. He had 
no power to compel a local authority either to adopt or to 
enforce by-laws on this subject, but had represented to the local 
authorities . tlie importance of their administrative functions in 
this matter. • If necessary, he would continue to do so. 

. Dr. Davies asked wlicthcr, if Mr. Chamberlain’s powers were 
insufficient to deal with the local authorities concerned, he would 
seek further powers in order to deal with them. Mr. Chamberlain 
said that depended on other considerations. - 

Sir Kingsley Wood, on April 23rd, told Mr. Briant that though 
there liad been an improvement in recent years he could not say 
that the; Minister’ of Health was satisfied with the conditions 
cxisting-in the hop fields. The reports of officers of his depart- 

men* ^ ‘ ' euts, and there appeared no sufficient 

rcas* • The ‘whole question ’ was receiving 

furt’ npulsory registration of camps wbula 

not ^ ulties. 


Bcf;tstr(ition (Rirf/is, BarriageSi and Deaths) BtU. 

On April 20th Captain Gunston moved the second reading of 
the Registration (Births, Marriages, and Deaths) Bill, wliich 
provided that on an office of superintendent registrar, registrar 
of marriages, or registrar of births and deaths becoming vacant 
the Registrar-General might declare the office a salaried one and 
see that' the successor to the office received a proper salar3% on 
a scale approved by the Treasury. The bill allowed* the officers 
to act over a larger area, and authorized the Minister of Health 
to increase the fees up to 50 per cent. It also proposed to extend 
to all births and stillbirths the provision whereby, under the Act 
of 1874, if the informant removed after the time of the birth 
and before registration, he could go to the registrar in' the area 
to which he removed. Captain Gunston remarked tliat modem 
conditions did not lead to increased fees for registrars of births 
and deall^. The aggregate of births and deaths had fallen from- 
39 per 1,000 m 1913 to 29 per 1,000 in 1927. - - 

Mr. Geoffrey Peto seconded, the motion for second readino- 
Mr. ScuRR moved the rejection of the bill, objecting that it 
sliouiu )ia>e been brought in as a Government measure. 

bir Kingsley Wood said every Minister of Health in recent 
years had been made acutely aware of the dissatisfaction among 
registration officers. *Thc average total of fees per registration 
dislnct was novr £137 per annum, and the system held out ho 
promise of promotion. 

Dr. FREMAipix defended the introduction of the measure as a 
private number’s bill. By the same method two years ago they 
secured the Midwives and Maternity Homes Act; last year the 
Nux'Sing Homes Registration Act and the Mental Deficiency Act. 
j^o years^ ago also they had passed a measure for improvement 
registration of births and deaths. This bill was connected 
With the last proposal. In theory the bill proposed to transfer 
rcgjslratjqn from a local to a national service, but' the period 
of transition might be very long^ The power of the Registrar- 
General to make regulations under the bill would be subject to 
the approval of the Minister of Health, in whose hands the 
appointments would be. Social services, especially in public 
health, depended largely on the facts got together by the 
registration system of the country. The whole of vital statistics 
depended on.it, .and statistical research was based on it. .The 
Eugenics Education Society had issued a letter in support of 
the bill. 

Dr. Vernon Davies said it would be impossible to make this 
a whole-time service. The work of a registrar of births and 
deaths was almost entirely notification of facts. The records of 
these went in^ course of time to the Registrar-General, in whoce 
office all the important work was done. Work on vital statistics 
had to be centralized. To increase the registration districts to 


740 April 28 , 1928 ] 


UNIVEnSIIIES AND OODDEGES. 


[ Titr imiruB 
JfrfGCAE JoCUXAt 


100.000 inlmbitaiils ■r'ouUI bo irnpracticablo, and fo llic service 
coul(l_ not be a full-time one Ihrouplioul. the country. Tlic 
building of hospitals and inalernily homos hud con‘>i(lei'ablc cITocl 
on fees, of ■which Dr. Davies gave examples. 

After further discussion the l)ill was road a second time and 
Bent to a standing coinmitlec. 


rrofcctio)! of Dof/it Ji'iU. 

Sir Robert Gower moved, oii April 20l!i, ilinl. the Prolerlioii of 
uogs Kill be read a second time. He said he had M-enied ii 
second reading for a similar bill a year ago. Mcmhci.s fiom nlino«>t 
every consUluency had assured oorrespondcnls that Ihev would 
vote tor the second reading this year. 

Lieuleiiant-Commandcr Kenwoethv, in seconding, said he had 
iiitioduced bdls to prevent all living creatures Tieiiig used for 
vivisection. He asked llic House to give a second r....(1iug To Iho 

nipiiK Ts -T I'ITI'-e 5,a>(l the dog was necessary for cei tain experi- 
n eiits as it uas mojst like the human being in its intciiml orL'an*^ 
and ina,.j. other parts of its body, moi-e so than 11,^,'!.’ ^ 

nut the bmle if'' without any cnieslioii being 

d^nsTi'oT, uron,ple.«r'‘"'"’"“ 


Bin\vl^\'^ril^Tcmuu''imcf' i-mship) 


®ljr ^frbirfs. 


DEATHS IN THE SEnviCES. 

did in Eo.uhui on 

gTilT’fd'''"'fJ h’ ''''■ ">K^"cu:™;Td^f AiTrdT^ vihorr i;'.: 

•enini T’’?' 30tli, '’igoS. He wal 

diif^^ic^from^rqOT\ and Alutlcy 

of 1885-fifi in (I T?* iorvod in the Sudan caiiijuiigii 

h. the e ; ‘ tg.vptiaii Frontier Field Force, was iiLimt 

a'd h ‘'>6 Egypt ian’ Iiiodal 

e Ivliedives bronze star. Ho also served *in tlie Soiitti 
.\fricaii uur from 1899 to 1902, in charge of the Princess 
Ch isiian Hospital and of the llUi Brigade Field Hospital Ho 
took part 111 operations in Natal and^in the Trnnsva.al when 
he .shared in the relief of Ladysmith, and was nre'enl ii ho 

ByeatwwrrgaT"|-:in?/rd?i° 

• Soidh LoHdon “ '-o‘» ds for 

MX“'tdedTTVansdown^'’Bil'th/'m^^ 

ThonmTVamTs Bnrk^ o7sheptoTaral^ I*®'’- 

at Trinity College, DuU 7 w here he ducaled 

1881, .and I.Ch. in TsS^'.’Tnd 'tlf if D 'p Tf 

After studying also at A^ienna he entered the T AI 

0,1 September 30th, 1882. became Heutenant-colonei a'ftcw hSv 

years service, and retired on January 1st IQin TT„ twenty 
the Burma war in 188AB7, was inentioned b^ dfsnafer'’ 
G.G 0. No. 561 of 1887, and received the ■medal wf.Trf cHs;," 
Most of his service was spent m civil employ in the BoS^ 
Presidency, where, for some years before his retirement be Tvh. 
civil surgeon of Poona, surgeon to the Sassoon Hospital there 
and superintendent of the Poona Medical School After liis 
retirement he rejoined for service in the great war. and served 
in the Indian hospitals at Brockeiihurst and Brigliton. 

Lieut. -Colonel Edwin IVilliaiii Eeilly. JIadras Medical Service 
(let.), died at Llandudno on December 21st. aged 68. He was 
born on September 29th, 1859, the son of Edwin Keilly, medical 
assist.aut, of Calcutta, and educated in Calcutta and in Edin 
burgh, where he took the L.E.C.P. and S. in 1881. Entering 
tile I.M.S. as surgeon on April 1st, 1882, he became lieutenant- 
cmoiiel after twenty years' service, and retired on July 18tli, 
and ' „ retirement he rejoined for service in the great war, 

office,, at yfev officer of the lioipital 
.. ct., at ^^orsley Hall, near Alanehestor. He served in the 


Burma campaign, of 1880-88, wlion he took pari in tlie oper.v 
lions of the 2nd Brigade, was j, resent in the act ions at 
Kjp.iiing and S.aheiiailiii; and reeeived' tlie medal with two 
clasps. AIosl of Ins .service was iiassed in civil ennilov in tlie 
.small province of Berar, now ninalgiiniiited with the’ Central 
1 roviiiccs. 


Slnilitrsifics nitb (KoIIcgcs. 

DNIVEBSITi’ OF LONDON. 

Univkiisity Colli:gi;. 

Amoko tlic public lectures arranged at Universitr College, London 
to lake place during tbo cuiTont term is a course of tliree on 
*‘Tlicplmrmacolotilciil evidence for current metbodsof trentment," 
to be given bv Dr. J. IT. Durn ; the first icctnro will bo on Tuesdav, 
May let, ami tlic others on the two following davs, all at 5 p,ni. 
A Horics of tliroo lectures on “ ^Vnatomy and tlic problem of 
beliavloiir'* will bo given by Dr. G. E.'Cogbill of the Wistar 
liistitiilc, riillndelplifn, at 5 p.m. on May 7tli, 8th, and 10th. 
Profotsor L. J. IIciulerBon of llarvard la to give six lectures, bis 
ftiibjccl being “Jllood: u stud}' In gonernl physiology”; these 
lecttircB will ho given on Tite.sday, Thursday, and Friday in two 
successive weeks at 5 p.m., the first being on May 15th. On 
Friday, dune Ist, at 5.50 p.m., ITofessor Spearman will speak on 
'.riie* psychologist in the school.” All these lectures arc open to 
ttie public without fee or ticket. 


UNIVEllSITY OF GLASGOW. 

Tin: following degrees were conferred on April 2l8t : 

M.t\— *Mnnol d. Prown. ‘W. C. ITarvos*, MV. A. Iloruo, 1\V. Urown. 
•T. \V. Oralmm. IW. Kapler, D. O. Taylor. 

Cii.M.— I). U. 1'. HoborU. 

M.II.. Oil.lb— M. B. M. fioberlson. ir>. Fraser, III. H. Moyes, iD. R. 
MiUinan. IConstanro D. Roberts. J. Aitebison. T. R. Raird, 
T. Rarrowiuftn. C. Rlack, R. Rrown, D. II. W. Cameron, .T. ar. 
Caniovskl, W. CrniR, Mobel 1C. Cniiekpbnnk. A. F. R. Dewar. 
\V. M. Dickson, Katberino M. Donttlas, S. K. Drainer. W, Dnncan, 
B Dunn. J. 0. Dyer, T. Dnnock. 0. II. Gibson, L. P. Gray, A. lien- 
dor?OB. «7. Hinds. EHzabctb C. ai. .Tack, J. C. Kano. J. O. Kirk, 
L Lamont. H. Leslie, P. L. B. Lorcut, iRftbella K. A. Macdonald, 
danci ■ *' * *- ” •’•^arlanc, Mnrgiiretl. McGill, 

A I. • • ' • “‘acH. Mnepberson, A. n. W. 

Marsl: • MonlKomcrj*. T. Y. Muir, 

• J • • • ■ L. Pirrie, J. A. Roddrop, 

* • . . • Hobcrlpon, d. L D. Roy, 

M Srs . * C. Taylor, W.S. Thomson, 

♦ With blfib commendation. 1 With commendation. 

* With bonours. 

were also presented to the successriil 
. » • II. S. Krtiikcu, Y.C., Memorial Prize of £5, 

ftwarueu lu l»iu w’ho obtained the highest marks in the 

subject of pathology in the professional examinations held in the 
venr 1927, and the Macleod Gold Modal for surgery to J. F. Ueggie; 
Ihc Mneewen Medal in surgery to Margaret >V. Tiiomas ; the 
Asber Asher Gold Medal for laryngology and rhinology to 
S. d. Scott. 

CONJOINT BOARD IN SCOTLAND. 

Tin-: following candidates have been approved at the examination 
indicated: 

ittvat rxAMiNATioN.— T. ailchrist, H. T. Chapman, Agocs Donaldson, 

^ • A F* J C Cbitty.'d. T. Erakine; J. E. Mnlholland, R. D. Jones, 

H K* Kapur, N. A. F. do Soyza, H. A. Sbakerlcy. J. Leibman, 
\v \Vnllace. M. R. Ramjohn, S. N. Chopra, d. P. Lo'-'an, J. Lees, 
T, *AI Davies, Eileen M‘Cabe, N. Macleod, W. Allan, A. J. dc Villiers, 
a’ u p Amies, R. D. Buckner, A. El-Sayed All Anmiav, C. B. Good- 
win T Kelarkar, H. L. Cohen, C. E. Vaz, H. Singh. iVfrdicttic; N. S. 
FmRor A. dacorovitch. N. tV. Laing. H. "W. A. Marshall, H. M. C. 
do Silva F. E« L. Stewart. Siiroeru: ^V. D. Alvis, J. Campbell, 
H Gunavataiia, H. Lazarus. M. RifTaat, C. K. Row. B. Schulman, 
O Steru. UMiviferv: O. Ajilmde, A. d. F. Almeida, AV. D. Alvis, 
A n F. Arnott. J. Campbell, A. M. Fraser, H. Gunavatana, 
a’ Tacorbvitcb, K. Kanagasabapathy, N. W. Laing, JI. Lazarus, 
afftrv E J Magee, A. B. O’Brien. B. Schulman, F. E. L. Stewart, 

TT t •’ ,7 T>..7 T-- xr.Kr,f47. . 

' ■ B 


I. W, Spence, E. U. Thomas. 


SOCIETY OF APOTHECARIES OF LONDON. 

The following candidates have passed in the subjects indicated: 

SunGERT— G E. Bent. A. E. D'Abreu. D. Jacobson, D. K. Reynolds, 
I.'O. B. Shirloy. A. E. Vawser, • 

Medicine.— H. B. Blaker, H. T. Ince, H. T. Rylance, "W. Z IV. 

Fouensio Medicine. — B. Elliott, J. H, Johnston, N. H. Kettlewell, 
E. A, Lipkin. _ 

Midwitert. — A.-E. Gibbs, C.C. F. "NMiite. 

'The diploma of the Society has been granted to Messrs. B. 
Elliott, H. T. luce, D. Jacobson, D. K. Reynolds, H. T. Rylance, 
and I. O. B. Shirley. 



APurti sS, tgjS] 


MEDICAIi NEWS. 


t Tnr Bnmra • 741 

3IeDicjii.}omNir 


. lEcMcal JEtcbs. 

, Sm Berkeley MoyniiiiVN, Bt., B.B.C.S., will prcsldo a6 
the first niiiuial aiunor nml iiiootliii; of mombora ot tbo 
University ot London Ulcdlcal Grnduntoa Society at tlio 
LnuHham Hotel, Portland Place, at 7.15 for 7.30 p.m., on 
Tuesday, May 8tli. Any medical yradnato ot the University 
ot London can join the society by sondiuf,' a life snbsorlptloa 
of £L to tbo honorarj^ treasurer, Mr. W, McAdaui Ecclos, 
M.S., 124, Harley Slroot, W.l. 

. Four Grcsliam Lectures on tbo need ot chaufjo and tbo 
medical aspects of Die health resorts ot Eiiftland and Wales 
will bo delivered by Sir Kobort Armslrouu-.Touca, M.D., at 
Gresham College, Basiugball Street, E.G. (tlirco minutes’ 
walk from tlio Bank Statlo"', on Jfay Ist, 2ud, 3rd, and 4tb, 
at 6 p.m. Admission is free lo tbo public. 

SORGEOK Commander B. F. Dudley, R.N., will open a 
discussion on tho problem ot diphtheria control In crowded 
iuslttntions at a meeting ot tho Naval, Military, and Air 
Force Hygiene Group ot tbo Society ot Medical Oillcors of 
llcallh on Thursday, May 3rd, at tho house ot tho society, 
1, Upper Moutague Street, Kussotl Square, W.C., at 5 p.m.; 
medical practitloucra'lutcrostod lu tbo subiect are Invited to 
attend. 

The Eoj’iil Society ot Arts, John Street, AdelphI, W.C.. 
has arrauged two lectures for Wednesdays, Stay 2nd and 
May 9tb, at 8 p.m. Tho llrst will bo by Jfr. William Taylor 
on standardization in apparatus for science teaching, and 
tho second by Captain R. W. Lano ou tho sterilization ot 
milk. 

A CONFERENCE, organized by tbo Society ot Chemical 
Industry in co-operation with its London section and 
chemical engineering grenp and tlic Institution ot Chemical 
Engineers, will bo lield in London from May 11th to May 15th. 
It has been arranged ns a practical reply to a friendly 
challenge by tbo Earl ot Balfour, who recently e.'cprc.sscd bi.s 
appreUousIon regarding tbo ability of British chemists to 
apply soleutlfio knowledge toiuduslry. ' An iutcrestiiigsorios 
of discussions lias been arranged dealing witli sucii important 
subjects as the economic utllizaiion of coal, water, and air. 

■ 'Fuel probloms'arc, ot course, rocoiviiig au iucrcasiug amount 
ot attention; questions relating to water supply aro of great 
consequence to Industry; tiio llxation ot nitrogen from tho 
air and the pro.lnotlou ot tortillzers tiierctroiu is perhaps tho 
greate.st coutrihiitiou yet uiado by soleiico to agdeuiture. 
Members of tho couleronco will liavo au opportunity ot visit- 
ing tho Rolbarastcd Experimental Statlou. Tlio feature of 
gpatest general interest will probably bo tbo address to bo 
given by Sir Alfred Mond, president of the British Soienco 
Guild, ou scicuiinc reseatcU as applied to industry. 

The Council ot tho Derby Medical Society has arranged a 
course ot post-graduato lectures on applied physiology to bo 
given at tho Derbyshire Royal Infirmary by Dr, W. L ingdon 
Browu, at 3.15 p.m., on Wednesday atteruoons from May 2nd 
to June 6tb, both inclusive. The lectures aro designed to 
show tho bearing ot recent advances in physiology on the 
clinical work ot general practice. Particulars may bo 
obtained from Dr. G. E. Kidman, 134, Oamaston Road, Derby. 

The Fellowship ot Jlediciiio and Foit-Graduate Medical 
Association announces that tUero will be two demonstrations 
next week, both taking place on Tuesday, May 1st, one at 
1 p.m., by Mr. Goulden, at the Royal London Opbtbalmic 
Hospital, and another at 3 p.m., by Dr. H. C. H. Bull, at the 
Royal Waterloo Hospital; both- are open to all members ot 
the medical profession without fee. Tlie special course in 
psychological medicine at tlio Maudsley Hospital, as already 
announced, begins ou Monday, April 30tb, and ou the samo 
day there begins a month's course in dermatology at the 
St. John’s Hospital, Leicester Square. Practical pathological 
demonstrations will be arranged if desired. Fear special 
courses are due to begin on May 7th, occupying periods ot 
varying duration ; they are In diseases ot infants, for a fort- 
night, occupying each afternoon ; diseases of the throat, nose, 
and ear, occupying all day tor three weeks; a course at the 
Central London Ophthalmic Hospital for tour weeks, occupy- 
ing each afternoon ; and ono iu neurology at the National 
Hospital, Queen Square, lasting for two months. Full par- 
ticulars and copies ot all special course syllabuses may be 
■ obtained from tbo secretary, Fellowsliip of Medicine, 1, Wim- 
polb Street, W.I., who will also supply iutormation concerning 
the general course ot work, which continues throughout the 
year. 

In connexion with tlie University ot Liverpool Clinical 
School ante-natal clinics, will be held at the Royal Infirmary 
on Monday and 'Thursday mornings at 10.30, and at the 
Maternity Hospital on each morning, except Saturdays and 
i nndays, at 11.30. Tlio fee Is £2 2s. for three months’ 
ai sndance. 


Tub 300th anniversary ot tho birth of Marcello Malpighi, 
tho founder ot histology, was celebrated at Bologna on 
March 10th. 

The Lord Lieutenant of Berkshire, Mr. J. H. Beiiyoii, will 
open tbo now operation theatres ot the Royal Berkshire 
Hospital, Beading, on Tuesday nc.xt. May 1st, at 12.15 p.m. 

The Right Hon. W. Ormsby-Goro, M.P., Under Secretary 
ot State for tho Colonics, has been appointed a trustee ot the' 
Belt Memorial Fellowships for Medical Research in place of 
the loto Sir Artlinr Sbiploy. 

A PRELIMINARY mooting ot the Committee ot Inquiry 
appointed by the Government to examine tbo questions 
raised by tlio use ot totra-etliyl lead in motor spirit was held 
ou April 20tli, when tlio existing iutormation regarding lead 
ethyl petrol was considered and the question ot pioceduro dis- 
cussed. Tbo next incotiug ot tbo conimitteo will be held in 
Boom Gl, second floor, II.M. Olllce ot Works, St. James’s Park, 
S.W.l, at 11 a.in. on Monday, April 30tli, aiid evidence will 
then bo taken from tbo Air Ministry and tbo Anglo-Aiiiericau 
Oil Company. 'Tbo proceedings will be open to tho public. 
The duty ot tbo coiiiinittcc is to ascertain wliotlier the use ot 
ethyl petrol is in any way dangerous to health, and any 
persons wishing to give cvidoiico ou tliis question should 
comiiinnicato with tbo secretary ot tho committee. Ministry 
of Healtli, AVliiteball, S.W.l. Tbo naiuos of the members ot 
the coiumltteo were given in the Journal ot April 7tli (p. 615) 
in a report of the discussion which took place in the House of 
Lords on March 29th, when Lord Gage announced its com- 
position and described tbo scope ot its investigations. 

A TABLET has been erected in St. Mary’s Cbnrch, Whit- 
cburcli, O.xoti, in memory ot the lato Sir Rickman Godlee. 

The Treasury has made an Order under the Finance Act, 
1926, exempting from key industry duty anhydrous hydro- 
cyanic acid ; lactic acid, wliicb satislles the requirements of 
the ISritisU i'harmacopoeia-, metaldehydo ; methyl chloride; 
B. potassium chlorate ; and syntbaliu. 

With tbo April issue ot the JSrilisU Journal of Inebriety 
a quarter ot a century ot publication is completed. The 
Societj' for the Study ot Inebriety was founded in 1884, and 
tbo lirst number ot its Proceedings appeared in July ot that 
year. It was continued quarterly until the session 1901-2, 
when tlio proceedings were published in a single volume and 
tlie British Journal of Inebriety appeared for the first time. 
Tlie present issue contains appreeiatory notes by Sir Arthur 
Nowsbolme, Sir William Willco.x, Mr. C. J. Bond, Sir William 
Collins, Dame Mary Sebarlieb, Mr. McAdam Ecoles, and 
many others. 

To mark tbo completion ot its fortieth year the Nursing 
Mirror and Midivives Journal, which first appeared in 1888 
as a supplement to the Hospital, publishes its current issue 
as a special “ birthday number.” 

The following appointments have recently been made in 
foreign faculties of raodiciuc : Dr. A. Schmiiioko of Tubingen, 
professor of pathology at Heidelberg; Dr. Wilhelm von Gazen 
ot Gottingen, professor of surgery at Rostock; Dr. Eduard 
Rolin ot DiisseUlort, professor ot surgery at Freiburg; Dr. 
Novoa Santos ot Santiago, prolessor of medical patbolo«y at 
Madrid. 

The International Labour Offleo has issued a further set ot 
pamphlets forming part ot a. secies wbioli, when complete, 
will constitute tbo Encyclopaedia of Industrial Health. 
Eighty-seven parts have already appeared, aud the seven 
new issues deal with the bakery trade ; bleaching ; breathing 
apparatus, respirators, and gas masics; cadmium, carbon 
bisulphide; carbon tetrachloride; cobalt. Each subject Is 
dealt with in its relation to hygiene, pathology, and social 
welfare. 'The entire series will ultimately be published in 
volume form. 

An interesting acconnt ot the existing medical organization 
in Pekin is embodied iu a Medical Guide issued by the 
National Medical Association ot China ou the occasion of its 
seventh bienuial conference there early this year. It is 
intended ultimately to expand the Guide into a complete ■ 
Tuedical directory lor China. The present issue coutains 
lists ot medical institutions and of Cliiuese physicians; 
with descriptions ot the public health organization and 
teaching institutions in Pekin. In spite of tlio political and. 
linancial dililculties progress is being made in the provision 
ot treatment and ot educational facilities. There exists at 
least the framework ot a public health service, and the 
Government maintains at Pekin a National Epidemic Pre- 
vention Bureau, erected, perhaps with a subtle sense ot 
humour, on a site adjacent to the Temple ot Heaven. It 
appears that the hospitals and teaching institutions in tho 
main are still largely dependent upon nou-Cliinese support ; 
the Pekin Central Hospital, which o|)ened in 1918, is said 
to be tho first general hospital establislied and conducted by 
Chinese practitioners on modern lines. 


742 April 28, 1928] ; LETTERS, KOTES, AND ANSWERS. 


[ 


Tiir Bumn! 
Srt-mcAL Jot'll jfii 


Jintcs, anil ^nsliicrs. 


All communications in rcg:ard to editorial business Elioiitd bo 
addressed to The EDITOR, British Medical Journal, British 
Medical Association House, Tavistocit Square, W.C.I. 

ORIGINAL ARTICLES and LETTERS fonvarded for publicalion 
are understood to bo olTered to tlio Buitisii ManicAi. Jouukal 
alone unless tlio contrary bo stated. Correspondents ivbo wish 
notice to bo taken of llicir comniiinications should nulbcnticnto 
them with their names, not necessarily for publication. 

Authors desiring REPRINTS of their arliclcs publislied_ in llio 
BaiTisn Medicai, Jouukal must coniniuiiicatc with the I'iiiaiicial 
Secretary and Business Manager, British hledieal Association 
House. ‘Tavistock Square, W.C.I, on receipt of proofs. 

All communications with reference to ADVERTISEMENTS, ns well 
as orders for copies of the Joorkai,, ahould be addressed to ibo 
Financial Secretary and Business Manager. 

Tlio TELEPHONE NUMBERS of tlio British Jfcdieal Association 
and the Baixisn Medical Joursal arc MVSHVM OSGl, OSCi, HSCS, 
and SSG^ (internal exchange, four lines). 

The TELEGRAPHIC ADDRESSES are: 

EDITOR of tho British Medical Journal, Aitiology irM/cciif, 
London. > 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.). Articulate TTrstrent, London. 
MEDICAL SECRETARY', Jlcdi.sccrn ITr.stffiit, London. 

IDo address of the Irish Ofiicc of tho British Medical Association 
is 16, South Frederick Street, Dublin (telegrams : flneiltiix, 
Dublin; telephone: 62550 Dublin), and of the Scottish OfTice, 
6, Drumsheiigh Gardens, Edinburgh (telegrams : Axxociatc, 
Edinburgh; telephone 24361 Edinburgh). 


QUERIES AND ANSYtrERS. 

Obesity after CniLDBiRTn. 

“ C. F.” aslta !or auggealioiis for the troalmoiit of n young married 
lady, aged 21, with a baby 10 mouths old, who has got very fat 
Binoe the birth of her child, having iiicroasod about 21 Ib. Ilor 
height ia about 5 ft. 2 in. Dieting has boon tried. Tlioro Is no 
sign of hypothyroidism. 

Creaking in the Joints. 

*' H. S." asks: What is the signinoanoo of tGndono.v to creaking in 
the joints, without other signs or symptoms, developing at the 
nge of 30? Wiiat is the siguiOoanoo wlieii this is assoolatcd witli 
slight thickening of synovial edge of joints, witti some acliiug 
and tiredness in all joints (chiefly largo) after movement? 

Dermatitis after Ultr.a-vioi.et Radiation. 

“ YV. A. K." asks for suggestions for the treatment of a mild 
dermatitis of the face— espeoially nose— in a lady, aged 25. The 
condition lollowcd a course of ultra-vioict radiation nine months 
ago. Being in an overheated room causes conspicuous and 
nnsigtitly red areas to appear. Sedative lotions, ointments, and 
hazeliue preparations have failed to effect any iraprovomeiit. 

Incojie Tax. 

“A. S. B.”ha3 been building up a practice de uoro and asks for 
■' information on various points, tlio nature of which will bo seen 
from the replies. 

* , ' (1) The return for 1928-29 should bo made on the amount 
of the gross income of 1927-28, less the expenses incurred in that 
year. (2) The amount to be claimed for tiie accommodation, 
surgery, and use of waiting room provided by bis parents is the 
amount reasonably paid ; if no payment was made no deduction 
is due. (3) The same applies to the services given in keeping 
■ the rooms in order, etc. (4) Books are like instruments, in that 
only replacements are allowed. (5) The subscriptions stated 
' seem to us to be aliowable. ' 

. Salary with House, etc. 

“ C.'L. P.” holds a resident hospital appointment with salarv 
plus house, rates, fuel, and light. 

» , * He is taxable 6u the salary only, but should bear in mind 
that the position ns regards income tax would bo otherwise if his 
. appointment, were for a fixed amount, subject to deductions for 
, house, etc., .though the,- total, advantages of his appointment 
. . might be the same. , , 

Motor Car Transaction. 

“ C. E. D.” bought a 15.1-h.p.-oai' in February, 1923, for £863 and 
■" ■ hold it iu' March, 1928, for £125, when be bought an 11.8-h.p. car 
lev £650; Wbnt can he claim ? 

(1) As a claim to obsolescence allowance the amount Is 
£650-£125=£525. We assume that the occasional private use is 
negligible; if it is not, some Seductiou should be made on that 
acconiit. (2) Depreciation allowance due is 15 per cent, on 
£650 for the year 1928-29. “ C. E. D.” does not state the date to 
, whioli he makes lip Iiis'yeav’s aoborints; the bbsolescenoe nllow- 
, mice has to be treated as oiie. of the year's' expenses, and it bis 
neconnta are made up to December 31st it will not affect his 
UabiUly until 1929-30, but if he has been taking Mai’cb 31st or ■ 
' bri 92 ^M diite, theu.the financial year affected will ' 


LETTERS, NOTES, ETC. 


viw. l.l.Mlli.llloxH AITENIII.I) BY ONE DOCTOR. 

In our last issue'fp. 700) Dr. L. ,T. Hood nslicd wlieflior iinv other 
medical practitioner bad liad tlio o.xjiericnce of uttemlhig five 
geiicrntioiis in one family. Mr. H, B. Turni;r (lioiidon) writes: 
1 have attiMided live gouerations in two families, and in one of 
them the mill Individiial (a girl) is now about 141 vears old, 
BO that (witli luck) I might even run to a sixth 1 


Colonel A. N. Fleming, A.M.S.frct.) (Edinbmgb), writes: I can 
(jiiotolbo case of . the late Dr. Gibioii of Caiii|)beltown, Argvll- 
sliire. About forty years ago my grcat-gniiulniotlier died liiid 
before Iter dcatli my sister liad two oliililren. Dr. Gibson liad 
been tlic (lunily doctor for many years, and at some time or 
iiiiotlicrnlteMded all the liidividiialB concerned. Dr. Gibson liad 
another claim to fame: not only did ho live to bo nearly 100 years 
of ago, Imt actually coiitlniied in active inuotico till lie was well 
over 90. 

The Forgotten Swab. 

Du. K. I. Letters fSydney) writes: The second of the cases 
recorded in Dr. .Segar’s iiitcicstiiig memoramliini on swabs left 
witiiln the nhilomeii (January 2l6t, 1928, p. 95) is not absolutely 
iiiiinnc. In Williinl Bartlett’s A/ter Treatment of Surgical J’utients 
(C. V. Jlosby Company, St. Louis, 1920), vot. i, p. l79, 1 Dud the 
loilowiiig; “A colleague reiinested mo to explore 'one of bis 
patients for a very itl-ilcfliiod symptom-complex, winch liad 
followed nil operation on tlie pelvic viscera. Wo were both 
Biirpriscd, and my colleagno greatly embarrassed, by, finding 
a very largo gauze pad tightly encapsulated between iiilostinnl 
coils.' The lulorcstliig tiling about tins case, and tlio reason for 
quoting it, Is tliat It oxempllfies in ho uncertain way Nature’s 
inctliod ol spoiitancona relief, which must bo rntlicr froqnoiitly 
afforded such palloiits. There was no mistaking the fact that 
one corner of the thick gauze pod was driiwii out and twisted 
into a conical mass, of whicli tlio distal six or eight centimetres 
were smeared witli faeces. Upon further inspection of tlie woniui 
wo found tliat this gauze coiio had lieon withdrawn from an 
opening in tlie Intestine, into tho lumen o' • 
was gnidnallv being drawn by peristal 
ill tho course of time, tlie newly formed . 
lay would have been emptied and its walls collopsod; then, lin'd 
liio foreign body not obstrnctod the intesliuo, it would liave 
ovcntnally been passed out tliroiigb the amts, and quite possibly 
Hover been noted at all by the patient,” 


Back to Sir Thomas Browne, 

‘ N. 3 ” writes : I boo that the old dispute about the inheritance of • 
aennired cbaraotcristics has boon raised once again, tbongli not 
with asperity, in your columns. On this matter some of ns are 
willing with Omar, to leave the Wise to wrangle. But when 
sucli questions crop up I am reminded of tlie sayings of a 
iibvsicinii of long ago. Sir Tliomns Browne was well aware 
of 'the " slnrdv doubts and bo.vsterons objections, wherewith 
tlic nnliapplnes’so of our kiiowlodgo loo ncorely neijiinlntetb us.” 

“ I remember (lio sa.vs) a Doctor in Pliysiok ol Italy, who could 
not portcoUy believe tlio immortality of the sonie, because Gnieu 
Bccniod fo make a doubt tlioreof. . . . 'Tlio wliolo Creation is 
a mystery, and particularly tliat of man. ... In our study of 
Aiialomv tboiois a masse of mysterious Pliilosophv.” We may 
not be able in tlicso times to follow the author of Jteligio A/idici 
lbron"ii all ins curious specnlatloiis, but it Is interesting to 
lecairsomo ol bis mnsings on the problems of life. The world," 
savs Sir 'Tlionms Browne, “ was made to bo inimbitod by boasts, 
blit studied and coiilemplatod by man : 'tis ibe debt wo owe unto 
God and the lionmge wee pay for not being boasts; without this 
the world is still as tliongli it Imd not been.” Nature lie deniios 
“ not witli tlio Soliooles, the principle of motion and rest, but, 
that streigbt and regular line, that settled and constant course 
tlin wisedom of God bath ordained the notions o( liis creatures, 
according to their severall kimls. . . . Now this course of Nature 

God seldom niters or perverts, but like an excellent Artist hath 
” contrived his worke, that with the selfo same instruments 
without a new creation bee may effect his ob-enrest desigiios.” 
And again introdnoing an odd train of thought, he makes this 
..--L.,.,,! v'nniark : “ There is no liberty for causes to operate in 


n. loose and straggling way, nor any effect wliatever but hath its 
warrant from some universall or superioiir cause.” Hlsewlieie, 
in the Garden of Oijrns, lie observes that “ The Aeqtiivocall 
nroduetioD of 'things mider uiidisoerued principles, makes n large 
imrl of generation, though they seem to hold a wide miivocaoy 
in tlieir set and certain Originals. ... AH tilings began in 
order so shall they end, and so shall they begin again.” From 
n literary point of view these last two seutenoes are in striliiug 
. contrast, I prefer the second. 

* South Afiuoak Medical Congress. 
g, — should have beeu included in the 

les section of tho Orst annual scion- 
• “ Association of South AfHca(B.M. A.), 

• ■ .'red iu our issue of April 2l8t (p. 684}. 


Vacancies. 

Notifications of offices vacant in uuiveraities, medical colleges, 
and ot vacant resident and other appointments at hospitals, 
will be found at pages 51, 52, 53, 56, and 57 of our advertisement 
columns, and advertisements as to partnerships, assistantships, 
and locumteneucies at pages 54 and 55. 

A short summary. of vacant posts uotifled.In the advertisement 
•columns appears in the Supplement at page 179, 



Mat 5 , 192 S] 


r,AEYNGO-FISSUEE FOE INTEINSIO CANOEK. 


r TnrITRrnsn 74 

L ^fniic-vr. JotJE'<4r. • 


KTRINSIC CAKOER OE TII15 LARYNX, OEl^R ATEl) 
.ON RY.LARYNGO-FISSURE: . , 

/.V.VF7;/-l '/’F AXD ULTDIATK liriSUl-TS* 

DV 

Srn SxCrjAiR TIIOJfSON, Af.l)., 

F.K.C.P., I’.R.C.S. 


ISTllODUCTIOX. 

To bp your giipst of lionour on ibis important orcasion — 
tho fiftietli annivprsnry of tlio foundntion of the first nnil 
most imjiort'ant society in America devoted to tlie sjiccinlty 
— is a pleasure and a dignity I deeply esteem. In ju'c- 
paring a communication for this Association I have done 
ihy best to maUc it worthy of your acceptance by seeing 
that it was comprehensive and comideto. It includes every 
ease of intrinsic cancer I have treated by laryngo-fissure; 
the after-history has, fortunately-, liPen .available in every 
instance, and nothing has been extenuated or .set down 
in malice prepense. This- record is the result of over 
twenty-eight years’ - experience in carrying on the pioneer 
work of Butlin and Semon.t It embraces my earliest 
efforts as well as the results of more mature knowledge and 
technique. It therefore, I hope, carries the lessons both of 
early anxieties and of increased experience. It is tho 
largest personal record which has, so far as I know, been 
contributed to tlie subject. Although none of us is quite 
freo from bias, I vonturo to claim that tho work is sincere. 

LaTivxno-FissunR; A EKrixirtoy. 
liaryiigo-fissuro is an inadequate expression to describe 
the operation I practise; ri.s.snro of the laryii.v, or splitting 
the thyroid eartilago, or thyrotomy, should only be a term 
employed to indicate the route of approach. I’nlso employ 
this route for a simple exploratory examination of tho 
larynx. Wc may continue with Uio term “ laryiigo-fissnro ” 
in this sense; hut students will start with mistaken ideas 
if they think that it. still means simpiv “splitting the 
thyroid eartilago and takiiig out n vocal cord.’’ The opera- 
tion I practise means excising a. mass which contains in 
its centre the whole cord, and includes tlio anterior eoni- 
missuro in front, part of the arytenoid hcliind, the vciitri- 
cutav hand above, and the siihgloUic -area below. This 
excision goes deeply cnoiigh to include the perichondrium 
lining the thyroid cartilage and, occasionalh-, that on the 
inner Mdo of the cricoid ring. As tlio grehlcr part of one 
thyroid ala IS nlso e.vc,sea (to obtain freer access and seei.ro 
bettei licalmg) it will bo seen that a so-called “ fissiiro ’’ 
'aiyngcctomy. Operations for 

of /bo /"'Y" ? '“'"S bbtairf a full-face view 

sao/fn t ‘ ® • of the disease so as to remove it, with .a 

s/e,iw“f7 ’"Y'Y" i" *''» directions, while 

mutilatfon'” sa e j o ic patient and avoiding nnneee.ssary 

- ClIXICAI, jM.tTMIIAt. 

caL ofli.t^f’';?*''’’ Iniwngo-fissure, on 70 

cases ot intrinsic cancer, of tlic larynx 




r . , Aiuoinuu 

ileJfl. by invitation, before fl... k'Z — f — 

”, '.Is i^ini-cenlcnni.-il mectine in Larynpological A&roeiation 

1 ■' For 11,0 en=„c i'S 'a "nUiineton no Urn.. r<f 


1 For the casc'i tecognizcil catlv '' "^ ’’’'Ston on Jtav Isf, 1328. 
in*' *" Ihe meflirnll' eP'^ratcil upon by llio'e 

rcsnli, rviopi, j,,, ranked - Unl'm I'ave yielded 

-J7,S''ry . (D. Dr.v.>on llclavan ''■''"“P'” "’'"'sra 

2,lli Meeting, 1901 , j,. 2(i?J ’ ■'’"'erwan Laryngotogical Association 


Ages : 

21-30. 

31-40. 

41-50. 

51-60. 

61-70. 

Over 70. 

Over EO. 

MaIo 

0 

2 

14 

28 

13 

5 

1 

Fomalo 7. 

0 

. 

3 

2 

' 2 

0 

0 

0 

Total (both scjcos) 

. 

0 

5 

16 

30 

13 

5 

1 


_ TABbc I. Cases Operated vpon hij Larynno-fissure t inon-tOM 1 . 


Ko. oC 
Cases. 

^ Private . 
Cases. 

Hospital 
. Cases. 

Auo 

Limits. 

Male 

63 ' . : 

— 



Fenialo 

' • -7 ■ •. 

' £6 

= ' 7 

40-80 




4 

3 

J5-5S 

Total 

-70 - J. 

- 60 ^ . 

: 



nro onlj’ le.ss iiiimcrous for tlio simple reason that tlio 
ignorant and uneducated do not present tliomscivcs early 
for wbat they regard as. a trifling Iniskiiicss, or, if they 
do, will not accept advice until the lesion has so far 
advanced that complete laryngectomy is the only possibility. 

. Affc Di.tirihulion. 

In the next table (11) wc note tho incidence of mj’ 
70 cases according to sox and decade. 

Taw.!! II. — Incidence, nccordiitp to Ape and Sex, of TO Cases of 
Jiilrinsic Cttnccf of the Larynx. 


Here it is noticed that • cancer of the laiynx is -not 
unknown between 30 and 40 -years of ago (of course, cases 
at iiiucli earlier ages have - been recorded) ; that, in mon, 
it ma}- occur in -advaiicod - life ; ' lind that it appears to 
be most frequent with them in the sixth decade of life. 
With regard to the females in my list (7) the numbers' are, 
perhaps, too sinalf to justify many conclusions; but it is 
.at least noteworthy that, \vith them, cancer would appear 
to be mot with eavlicr in life and to bo rarer after 60. All 
these women wore non-smokers and abstainers. 

Earhj Experiences. 

All those 70 cases were operated on through a laryngo- 
fissure. The first ease was twoiity-ciglit years ago, in 1900, 
when I followed the tcclmiquo I had learned at first hand 
from Butlin and ' Scmoii. It included the' injection of 
inorpliihc, the insertion of Hahn’s tnbo, the curetting of 
tho wound after jnccomoal removal of visible disease,’ the 
abandonment of the tracheotomy tnbo at the conclusion of 
the operation, and the return of tho patient to bed " with 
the head on a low pillow.’’ As always happens when look- 
ing back on the road of surgical progress, one wonders at 
so many successes. 

■ Ef.sults. 

Afire and Free from Disease. • 

Jty re.sults are displayed in the following tables. The 
first shows that, of 34 iiaticiits alive to-day, 32 have survived 
periods varying from three to iiiiiotcon years from the date 
of operation. 

TAUbF, III. — Thirlp.fonr Coses of Intrinsic Cancer of the Larynx 
Alice and Veil, Vithont JJecnrrcnce, after Lanjnpo-fissure. 


6 

o 

If. 

eS 

O 

d 

o 

® 2 
wc. 

<o 

K 

O 

t/J 

a 

a> 

<y O 

u -x 
&<< 

Period sineb 
Laryngo-fi'^suro. 

d 

o 

O 

S 

■§1 
o o 
w n. 
<50 

y. 

o 

ai 

P 

o 

OO 
y, tt 

c-< 

Period 

sinto 

Larj'ngo- 

fissure. 

6 

59 

M. 

78 

19 years. . 

45 

35 

F. 

42 

7i years. 

11 

4aj 

M. 

64J 

15 „ 

47 

60 

3r. 

67 . 

7 

IS 

65 

M, 

78 

13J „ 

50 

53 

3X. 

5:} 

£i .. 

21 

66t 

M. 

80 

12i . 

52 

40 

M. 

45 

6 „ 

22 

59 

31. 

72 

12i years 11 since 

53 

58 

M. 

64 

6 „ 





Mland operation. 






26 

16 

F. 

571 

Hi years since -first 

54 

58' 

M. 

64 






cord ; 4^ since 

i 









second cord. ., 

55 

47 

M. 

55 

52 », 

27 

57} 

M. 

69 

Hi years. 

i 










56 

80 

H. 

85i 

5} .. 

29 

47} 

31. 

■59 

11} 











58 

79 

NI. 

81 

5 

31 

£0 

ST. 

61 

H 








- 


59 

52 

M. 

57 

5 4. 

32 

53 

31. 

64 

H 











61 

4S2 

F. 

55 

4.5 .. 

33 

67 

sr. 

78 

11 „ 











62 

58 

AT. 

61 

7l 

35 

EO 

M. 

70 

10 „ 











63 

55 

31. 

SH 

3i .. 

38 

40 

F. 

50 

91 











6J 

74 

AT. 

77 


41 

33 

F. 


years since 










I aryuRO-fissnro ; 

65 

54 

31. 

57 

3 .. 





7i voara since 










partial laryngec- 

66 

. 62 

31. 

65 

3 





tomv. 






42 

48 

M. 

55} 

8i years 

69 

56 

31. 

56 

4 months. 

■44 

£8 

M. 

66 

8i „ 

70 

62 

3X. 

62 

2 


L35I3} 


744r May S, 1928I LAEYNGO-FIBSUBE FOR INTRINSIC. CAKCER OF THE LARYNX. [, 

t 5irr>i(At.JvcoKAt 


Two cases aro too rccoiit to siipiiort any claim for 
prolonged onre, bnt tlioir inclusion serves to illnslrale 

other points. 

Frmnlc Cases.'- '■ 

In this table the vitality of the females may lie noted. 
Five out of seven aro alive ■ at periods r-arying from 
four -and a half to eleven and a half j-ears afterwards, 
iilthongh two of them have had to ho treated for a rccur- 
lence. In Table IV it will bo secTi that the two other 
females in ray collection (Nos. 12 and 35) .survived fourteen 
and a half and nearly four years, to die, without any 
l ecurrence, of influenza and cerehral haemorrhage. ' 

Healthy, Vsefal, and Pi-nlnnged After-History. 

Attention might he directed to the advanced age of 
many of the survivors, to their health and vigour, and to 
the social well-being secured by having conserved a useful 
voice. No. 11 is a Canadian, sent to me sixteen years 
ago by Dr. Birlcett, whoso diagnosis was confirmed by you, 
Mr. President, clinically, and by Dr. Jonathan AVright 
from the biopsy. No. 18 is an active shipbuilder iu 
Scotland. No. 21, in his eightieth year, writes that he 
.still cj-clc.s. No. 31 is an admiral; he is devoted to social 
work and can address meetings in the o]ien air. Four are 
physicians in active practice (Nos. 52, 59, 63, and 66).* 
Two are lawyers who conduct largo atrairs (Nos. 47 and 
55). A clergyman is able to preach twice on .Sunday 
(No. 44). A schoolmaster retains his iiost (No. 50). A 
gentleman, aged 67 when operated on, i.s now 78 (No. 33). 
Three years ago he passed safely through the operation 
for enlarged prostate. This year he celebrated his golilen 
wedding .-tnd made a speech which was andihle at a dinner 
he gave to 120 of his emjiloyecs. No. 56 is a retired 
judge who follows the hounds on hor.sehack, five and a half 
years after his operation and in his eighty-sixth year. 

Deaths from Other Causes. 

Of the 73 patients 18 have died from other causes, with- 
out recurrence (Table lA’). Of those, it will ho noticed 
that 13 had lived a minimum period of three years with- 


Table lY.— Eighteen Dentin from Other Cauees, ivUlmu 
Tlecurrcncc. 


Case 

No. 

AKQ at 
Operation. 

Aro at 
Death. 

Period after 
Operation. 

Cause of Death when 
Ascortuinnblo. 

2 

^9 

505 

13 years 

Larj-ugltis. 

3 


58 

10 „ 

Tubcrclo, 

5 

54 

61 

7 

UnknoAvn (hospital iiaticnt, 
spcctod 2 •years before death 
and found sound). 

8 

58 

6]A 

35 

Aneurysm. 

9 

68 

74 

6 

IJrouchitls, 

10 

55 

60-763 

5-? 8., 

Pneumonia fan Indian subject). 

12 

55 (F.) 

67i 

M5 

InQuonza. 

17 

69 

75 

61 ., 

Coi*ehral haemorrhage. 

23. 

68 

763 

85 „ .. 

Urinary toxaemia. 

25 

’ 72 

84 ' 

17 .. 

Heaxb failure. 

28, 

48 

49 ' 

11 niontha 

Developed pleuropncnmonm 
with fetid empyema 1 month 
later. Operation:' Rood re- 
covery.* 

' 30 

63 

bb 

Is years 

Angina pectoris. 


75 

855 

103 „ 

Heart failure. 

35 

58B IF.' 

62 

35 .. 

Cerebral haemorrhage. ' 

36a 

70 

74 

4 

Unknown. 

37 

e9i 

78 

9 

Heart failure; arterio-sclerosis. 

■10 

56 ’ 

55 ■ 

50 hours 

Operative (haemorrlioge, mor- 
phine, pneumonia). 

51 . 

42 

42 

4 days 

Operative (rupture of oeso- 
phagus). 


* No details obtainable, but liOgan Tui*nei* found no si^ns of recurr<»nce 
two months befor.j death. 


out any recurrence, while 3 of them died ten or more 
3'ears after: operation. (The two operative deaths*' will 
be considered, later.) .. ^ ■ • . 

o * u before the Royal Society of Jledicine, November 1927. 
t toe. Hoy. Soc. Med., December, 1927, Laryng. Sec., p. 1. •• 


Deaths from Matiynaul Disease Dl.seirhcre, Without ■ 

’ ’ ' ' Iteeurrenre,.' ■ ■ ■ ' 

If ^ time [lermiticd it would he iiitcre.stiiig to .study ii 
detail tliii seven eases in tlio next table— that of deat! 
from eareiiioiiia clscwliere, without local return of tin 
diseaso (Table A"). In two of them (Nos. 15 and 57; 
the virulence of the caiicer must ha^'o■hccn verv intense 
for glands in the- neck were invaded within four mic 
six months, ■ and . tho patients ,wcro -dead within sever 
and eleven month.s, ’ altliongli the hiryn.x in each ca.se wa: 
free from recurrence. 

In r-onti'ast to those cases arc Nos. -39 and 7, in which the 
glands did not develop until four ami seven years after 
operation. 

Ill Case 1 (the first I over operated on) I watched the 
larynx remaliiiiig free, while a c.ameron.s growth developed 
on the lingual ton.sil on the opjiosite side. 

Ca.se 13 show.s how a jiatient can remain free of disease, 
in excellent voice and vigour, for eleven years and' then 
die of malignant di.seaso .so remote from tho lai-ynx as the 
gnll-hladdcr and liver. 


TAm.i; A'. — .Scrcii Deaths from Later Derelopmeitt nf Valiyuant 
Disease Htseiehere, the Larynx llemaininy Dree. 


Case 

No. 

Ago at 
Ojicm- 
tlon. 

Time of Onset after Operation. 

Ago at 1 
Death. 

Time Klnp«;ed 
since Ojiera- 
tion till Death. 

1 

' 47 

Malignant disease at Iwsc of tongue 

- 50 

3 years. 


opjiositc side, started It years after 


73 ycara. 

7 

43 ; 

Lari nx filled up 3 to 7 months aUor 

51 


operation. liaryngectomy after 
9 months, but no cancer growth 






found in excised Iar>'nx(?.syphilis). 
DiiTuso malignant disease in 
glands of neck 7 years later 


11 years. 

13 

SS 

Death from malignant disease in 

69 

nbclomcn, found at operation too 
extensive for removnl 

523 

7 months. 



15 

52 

Inflltration of glands of nock within 


' 583 

4i years. 

■ 39 

64 

Glaiuls in -neck 

43 

54 

Jteclia^tiiial stands (ar-ray findings) 

; 57 

3 years. 

57 

39 

Glands in neck within 6 months 

395 

11 months. 


Deaths from Local Itccurrcncc. 

■ AA’c now 'conic to the local recurronecs. There were only 
11 all males. It will ho noticed in Table A^I that in 8 of 
these the rcetirronoc took place within the first year.' This 
supports Semoh’s dictum that a rccnrrchce generally fakes 
place witliin the fii'st twelve months. Personally I feel 
little anxiety if the third mouth passes without any 


suspicions ^'mptoms. 

Tadij: vi . — Eleven Deaths from Local Remrrenee. 


Case No. 

Onset after Fissure. 

j * Period till Death aftor Fissure. 

4 

' 8 months 

20 mouths and 12 months aftor total 
laryngectomy. 

lU 

7 4 to 6 months 

? 9 months. 

-14 - 

' 3 >*cars 

3 years (second laryngo-fissure :dealh 

from idiosyncrasy to heroin). 

16 

2 months 

1 5 months. 

■ 39 

3 years 

1 45 years. ■ 

20 

3 months 

I year. • 

24 

1 month suspicion, and 
certain in 4^ months ; 
tracheotomy at end of 

15 months. 

46 

5 months 

2 months (deolmedlaryng- 
ectomy) 

11 months. 

4^ years. 

48 

’i. years 

49 

2 months 

7 montlis. 

-67 

-- - ■ -2 months 

4 months. 



- 



-Tticsp-carlv relapses snoum iim, uu — - -- 

eiice of disease.” AA'e 'arc more likely to advance the 
uhiect -if we frankly fegai’d them rather as incomplete 

emovais,” and -then investigato why tho operation was 

• failure, or why the case was unsintahlo foi tins t\pc 

The other three re-growths developed three ycais after 
he laryngo-fissure. Case 14 was in a very I 

’he lesion occupied the anterior two-thirds of the 1 „ 





May 5, igsS] 


tAK'SNaO-FlSS'DRE FOR INTRINSIO .CANCER OF THE RARYNS. 


[ TmsIJRm** . 
MzDtciz. JomiifU* 


746 


cor(\ invndcd tlio commissure, and descended into tlio sub- 
clottic space. Here I mas n littlo doubtful of having secured 
sutficicut margin, and tlio pathologist was unahlo to report 
a cootl civcumforcnco of Iicnltliy tissue. Ilio patient 
rclmncd to India (and to his alcohol and tobacco), was 
there inspected and passed from time to time, and returned 
oxaettv three years afterwards with a recurrence at the 
anterior extremity of both cords and in the subglottic 
space ticlow the anterior commissure. At the second laryngo- 
fissuro it was seen that the re-growth liad originated in 
this area, Ilis death from heroin (recorded under “ opera- 
tive deaths ”) was particularly disappointing, as the patho- 
logist’s report encouraged tho lioim that the second removal 

had' been complete. . . , 

No. 19 was a case of long-st.anding lioar.soness. in which 
a large growth was almost entirely located in the sub- 
glottic region, and required the exposure of the inner 
surface of the cricoid. Tho pathologist ropoite l on tho 
removed mass that ” the growth has reached to the lino 
of excision at two margins.” Yet three clear and nctivo 
years passed before there was any suspicion of re -rowth. 
This occurred so stealthily in the stibglottie aiea that, 
when it- declared itself, tho disease was too advaiii-ed for 
further operation. 

No. 48 was a similar case, hut more promi..in;r. The 
disease loft each extremity of the cord free, but di Mpnded 
oh tho inner surface to below tho level of tiic i m d. 
Excision) to cyb and touch, appeared. to ho s.itist.K'torT, 
but tho pathologist reported “ there cannot bo much 
margin of safety posteriorly.” ■ Tho patient wa- rc;;iilarly 
inspected, and remained quite free for throe years, when the 
disease rettiniod on tho same side. liaryngectoniy was 
recommended, hut declined; ho had radinm tioamiont 
elsewhere, and died one and a half years after the return 
had been diagnosed. He, liho Case 14, indulged iiooly in 
whiskj’ and tobacco, both before and after larynco-lissnrc. 

In all these threo eases it was tho snhglottic sdnation 
which thwarted success. 


Operafirc DtnOts. 

Of tho 74 laryngo-fissures ])crformcd on 70 patients 
(2 of tho 70 having been operated on for a local reeurreiice 
and 2 rcqnirhig a supplementary laryiigo-fissiiref 2 have 
died within forty-eight hours of the operation. The first 
case, No. 14, has already hecn referred to in T.ihU' VI. 
He was successfully operated on in 1913, .After three 
years' absence in India he returned with a local retur- 
reiieo; a second laryngc-fissuro passed off without untoward 
incident in 1916, hut he died forty-eight hours later with 
droivsincss, contracted pupils, and complete suppression of 
urino. There was no uniisinil bleeding at the operation, 
but a small haemorrhage took place twenty-four hours 
During mj’ absence ho was given half a grain of 
heioui, in three doses of onc-sistli of a grain, within 
taenty-fonr hours. One of these doses had not been 
ordered; yet half a grnin'was not a largo dose. A tracheo- 
tomy tube bad,. fortunatclv, been left in after operation. 
Death appeared to be due to an idiosj'ncrasv for heroin 
in a very alcoholic subject. 

The second case. No. 40, had suffered from syphilis of 
tlio larynx for four years before a subglottic intrinsic 
c.-inecr developed. There was much bleeding at the opera- 
ion and again within two hours. Through a misunder- 
standing more morphine was given than was intended — 
namcl}-, three-quarters of a grain — and ho died with 
symptoms of septic pneumonia within forty-eight hours of 
operation. A tracheotomy tube had been loft in situ, on 
account of the free bleeding at the operation, the sub- 
glottic extension of the disease, and the syphilitic basis. 

third case, No. 51, died on the fourth day from 
rupture of the oesophagus, duo to post-anaesthetic vomiting. 

lac last was a very rare accident, not connected directly 
wi 1 the oper.otion. Tho other two occurred in very un- 
promising subjects, one being certainly syphilitic and* both 
o them alcoholic. Still, 1 think death would liave been 
aioicled if no soporific had been given. I now refuse to 
giie an opiate of any kind before or after operation, and 
_ 01 bid all dopes” before anaesthesia (mixed, local and 
Mineral). Accepting these 3 , cases , as operative deaths, 
us Mould giio a de'ath rate of 4 per cent. — ^a very 


. diffoTont figure from that recorded by the pioneers of this 
.subject, and from tliat still existing in the feu’ statistics 
which are rarely pnhlisliccl.* ' ■ . 

If permitted to delete ensb No. 51 (riipturo of the oeso- 
phagus) I have had no operative death since Vase' No. 40. 
This scqucnco of 30 cases .without a disaster encourages 
mo to give it as my opinion that if a laryngo-fissure is 
carried out with tlio precautions and care I insist oh, in 
, regard to liacmorrhago and tho descent of blood into tho 
bronchi, then it should ho -an operation free -from any 
danger, except those iric'idehtal' to 'all' operations. 

■ Lasting Cure. ■ ■ 

Wo need not revivo barren ' discussions as to how long 
. after operation a' patient may lib 'regarded as pcirmanontly 
cured of cancer. ... - ' . , ■ ' , 

With feiv ■ exceptions, all patients aro in middle or 
advanced life. To ensure a comfortalilb' and a vocal exist- 
enco for ton to twenty years to 12 men who" have' passed their 
forty-seventh to sixty-seventh year (as in the' first 12 cases of 
Table' HI) ; ‘to operate 'bn nicn of 79 arid 80 years of ago. 
(Nos. 58 and 56), aiid to show’ them healthy and vigorous) 
five years afterwards; aiid to restore doctors, lawyers, 
elorgyhich, and schoolmasters' to their calling, are' surely 
sulliciont evidence to' claim this method as’ securing per- 
manent cures. ■ . ‘ ’ 

Y^ou, jVIr. President, when addressing this Association 
on this samb subject twenty-four years ' ago, said that 
“ statistics based- on ■ alleged cures of less than three years' 
duration arb -li-orthlcss'.” ? 

A scrutiny of the tables I have submitted will show that 
63 patients' are eligible .bn this' basis,' and that .48 of them 
were alive and well, and free from' recurrence at tho end. 
of three years. t This lasting)cufo of 76 -per cen-t. has been 
obtained without restricting bhesblf to particularly pro- 
mising cases. As tho indications for iafyngb-fissur'e have 
not yet been quite established— beyond that of being a 
suitable operation for many cases of intrinsic cancer — 

1 thought it right to try it in various iritralaryngeal mani- . 

festations of tho disease. Although this may have im- 
paired ,.tho statistical results, , it has enabled me to form 
sonio clear conclusions as to the indications and limitations 
of tho laryngo-fissuro route for tho eradication of intrinsic 
cancer of tho larynx. These will ho embodied' in a forth- 
coming publication. : ' 

COKCLTJSIONS. 

I trust that tho evidence I have submitted justifies tho 
conclusions I have now formulated for 'some years. This 
latest and largest record satisfies . me that if intrinsic 
. cancer of the -larynx is diagnosed early it is best operated 
on by laryngo-fissurc — an operation which should be free 
from danger to life and followed by an adequate voice and 
a lasting cure. Tlio only necessities for this consummation 
. aro early diagnosis and meticulous care in operative pre- 
caution and procedure.! By educating tho public to p.ny 
prorapt regard to persistent hoarseness, and by teaching 
tho profession to appreciate the niceties and necessities of 
early diagnosis, the number of larvngo-fissures and, the 
proportion of lasting cures will ste'adily increase, while 
the need for laryngectomy will as progressively diminish. 

^ In other regions of tho body there may he better remedies 
than surgery can 'bupply. In intrinsic cancer of the larynx 
other, simpler. and surer, remedies no doubt will one day 
be discovered; but, at present, there is.no better way than 
snrgeiy and tho laryngo-fissuro route. By this VTQ can 
securo results- which have not been surpassed in the 
treatment of cancer in any other internal region of 
the body. 

1 « , Reterezjce. 

>P. Bryson Delavan ; Trans. Amer, Laryng. Astoc,, 26, 1904, p . 155. 

• "The results of indiscriminate operation have been so bad that their 
records are unobtainable because suppressed ’’ (D. Bryson Delavan, 
loc. cit,)* 

t These figures are arrived at by deducting from my 70 cases the 

2 recent cases (69 and 70), the 3 who died of other diseases before the 
threo years ■were completed ’(2, 28, and 30), and the 2 operative deaths 
(flO and 51). This leaves 63 cases on which to formulate results; On the 
other side of tho balance sheet are tho 32 thrce*year survivors in 
Table I; tho 13 ^Ybo died of other diseases after a lapse of three 3 'car 3 
(Table IV), -and the' 3 cases which succumbed to malignant disease in 
other parts of the bodj’, four and a quarter, seven and a ' half, and 
eleven years after laryngo-fissure -(Table V). These, added together, 
show <8 who had passed the three-year limit. 

J" Mistakes haraly short of criminal have occurred in laryngeal opera- 
tions done by inexperienced men working wifii absolutely no trained 
helpers " (D. Bryson Delavan, loc. cit.). 


746 May 5, 19. 8J ANASTOMOSIS OF RECUBUENT IiARYNGEAE AND PHRENIO NERVES. 


. liir 

MrDieii. Joi B’fix, 


AK\STU]\l()SlvS BETWEEN TUI'] EECIJJU5ENT 
L.\EYNGEAL AND PIIEENIC NliRYES. 

'I'hr ('oiiditiuii 0/ ilir. I iif rliisir. -Ilii.sr/c.s (titd A’f/’ccs 0/ {he 
Lai'i/nx nf a lilicsiit ilunkri/ moic f/Kiii 'Three Yeiir.t, 
mid Tiro Yciirs, nfler Oiiinifinn. 

BY 

LIONEL -COLLEDGE, M.B., R.Cii.C.\mii., F.R.C.S., 

SUBGEOK, EAIl *SD THROAT DERARTMIOJT, bT. C.EOROE’b 
HOSTITAL ; 

ANH 

Sir CHARLES BALLANCE, K.C.U.O., E.R.C.S., 

CONSULTING SURGEON, ST. THOMAS'S HOSI'ITAL. 

(ir/</i jS'/jtcm? Plate.) 


'The Ojicratiuiis. 

Phjht iS'ii/c. — Rccurreiit laryiigcal-iiIncHie ciicl-to-sitio 
anastomosis ppiformcd tliree yoar.s aiul four inontliN 
before death, A longitiidiHal incision was iimde in the 
middle of the plirenic uerre; tlie divided distal end of 
the recurrent laryngeal nerve was inveigled into the slit 
in the |)lirenic nerve and fixed ^hy one stitch of the finest 
catgut. On direct examination of the larynx the right 
vocal cord was seen to be paralysed. 



(Small itieclian incision made 
in nncldlc of phrenic trunk.) 



710/ II.-Kht-Mis monkey. 
Hcourrciit larytij»oal*nlireiiic 
cmMo-crul nnastfomo-is. No 
unn»toniOAiM of ilistnl part of 
phrenic to .iny ofhor nerve. 


Left ,Side . — Recurrent laryngcal-phrcnic cml-to-ciul ana- 
stomosis iJerformed two years before death. The out ends 
of the two neiwes were brought together b}’ ono stitcli of 
tlie finest silk (.Van Horn, arterial). On direct exantinn- 
tion of the larynx the left cord was seen to be paralysed, 
while the right cord was moving normally. Tlic distal end 
of the divided phrenic nciwc was not anastomosed to any 
other neiwe. 


Avidl, and that tlieio i.s no eoiitraction of any jnirt of tlie 
left Imlf ol tlip diaphragm, tlio cupola moving u[)wnrds and 
(lowiiwavds with respiration. After (lie left half of the 
ihaphragm was jiaraly.sed it was noticed (hiit the monhey 
never regained the power of moving nml jnm|)ing rapidly 
about the large eage in whicli ho was (.onniied. At no tinio 
did this monkey suffer either from .stridor and difiienlty in 
hreatiniig, or from parado..i(al movement of the vocal 
cords. 

iWciO/ZM/. 

(A) The Diaiihmiim.—'TUc riglit half of the innsele of tho 
diiiiiliragin was tliielc, firm in te.xtnre. red in eolonr, and 
of normal appearance. 'J'ho left Imlf of the mn.scle of tlio 
diaphnigm was thin, light pink in eolonr, and flabby in 
texture. .Toining the left |)lireiiie nerve in tin; thorax 
(hoioiv the site of scetion) wa.s a small nerve whicli arose 
from the hraehial plexus. This root of the left phrenic 
nerve was not seen :it the operation. The left phrenic 
nerve below the site of divi.sioii was smallev than the right 
jilirenie nerve. 


description of photomicrographs on plate. 

Sole . — Tho rlirht recurrent laryufjcal netve wu^ divhletl an«l the 
dUtu! »‘n<I ana*‘t'Hno'<o<I with the phrenic nerve Jhice yrnrs and four 
tiionlhfl Iwfnre the drnth of tho m(nike>. The I'*ft reciirront laryngeal 
nerve wan divided and (ho distal end unuciotno'-ed with (ho phienic 
iier\e two \eaiH heforo the death 'of the monkey, 
ri(5. l.--Lef( (Tieo-arvtenoidons posticus inuM'lc (x 850).' Note tho 
IratiHUTM* t«lrialion of tiip muscle. Cujal ►taui. 

Ktc. 2.— UiRid ericOHirv tonoifleus p()?-llcu>i tnu/'clo (x 850). Note the 
tran^\c^^^• ^tllulinIl of tho mu^rlo. Cajal :*tain. 


Fmj. 3.'— Ix-tt crico-arxtcnoldpus postlcn*- mn*'cle ( x 400). Note the 
end or^jati' him! nirvo fibres. Cajal htiun. 

Pk;, 4. — Rit;ht erjco-arylrnoidou'' po^ticu** mu'*clc (x 350). Note tho 
p/'fh'eilon of the end or^'an on Ihe’Kjd" of ffn* slnafcd mn«oJo fibre, 
.i|*o the neivn fibre.''. Cajul >tu»n. 


5 — I.ef{ «TioO'ar> tenoifhnis po»tjcn*4 I^u^clo (X <00). Note 
if^jeiieruted liiitidifs of jione fibns jn nniMde. Cajal ^(ain. 

j*,r, 6— ni^bt ciico-arvlonoidtMi'* postj’cu« mn‘cle (x <C0).. .Note 
'iej;rm*ra(e<l iHindli" of norve filnrs in muscle. Co.ial ►tiun. 

J'lG. 7.-'Left crlro*ar\tenoi«lcus latcl•nli•^ mu'^clc (x 850). Note the • 
traii's'c^e i-tria(ion. Oajal ttain. 

Fic. B.—KIpht erico-ar.vtonnidcus lateralis muscle (x 850). Note the 
imnsvcr.'C stnution. Cajal stain. , . 

Fic. 9.— Left lh.\rO'arytcnoldeus muscle (x 850). Note the tran‘>M.'r!!e 
stiiafioi). Cajal Ktain. 

Fic. 10.— Bipht th\ ro-nrytenoideus muf«clc (x 850). Soto the trans* 
vtTM* slriation. Cajal stain. 


• FJf5. 11.— .^rvtenoideus muscle (x B59). Note the transverse strintion. 
C.ijal stain. 

Fi«. 12.— heft recurrent larynptal nerve (x 850). Note rppenemtion 
of axis cylinders. Cajal htain. 

Fic 13— ni"ht recurrent lavvnscal nctTc (x 1,000). Hardened in 
Muller’s ’fluid and stained by the Weipert and Stroebe mcthwls. 
hrficulor appearances (nenro-kcratin) in the medullary sheaths. The 
nvis cnlindeis arc coloured as well as the neuro-keratin network. 
"There U reason to believe that the apparent icticulur structure is 
dm- to the way tlie itivrlinc constituents have undergone coapnlntion 
mid 'cpaiation under *the influence of the hardciiinp reapent.’ Tho 


'ItcsuJt of the Experimental Operations, 

(A) The Vocal Cords . — Six months after tlie operation 
on the right side the right vocal cord was moving syn- 
chronously with the left. Six months after the operation 
on the loft side the loft vocal cord showed a wider abduc- 
tion movement than the right. It must be remembered 
that on the left side the recurrent laryngeal nerve liad 
been attached to the whole phrenic nerve. Thus while 
the excursion of the right cord, following end-to-side ana- 
stomosis, was approximately normal, the excursion of tho 
left cord following end-to-end anastomosis was greater tlian 
normal. One week before the death of the monkey Sir 
David Ferrier, Professor Cushing, and Dr. Dale saw tho 
movements of tliese vocal cords through the direct laryngo- 
scope, and the greater movement of the loft vocal cord 
was still evident. The movement of the vocal cords was 
filmed,^ and the wider abduction excursion of the left cord 
was demonstrated in the him. 

(B) The Eiaphragm . — It was obvious on inspection of 
t)i0 abdominal wall that the right half of the diaphragm 
was contracting while the left half was jjaralysed. Pro- 
fessor. Elliot Smith, Dr. Beattie, and Mr. Melville examined 
the movements of the diaphragm by means of the radio- 
graphic screen.- Their repiort states that all parts of the 
right half of the diaphragm were contracting equally and 


(B) The Larynx . — Tho intrinsic muscles on both sides 
were dissected and separately placed in hardening fluid. 
The small nerve going to' each muscle u'.as demonstrated, 

1 each muscle was defined a portion , of the nerve 
mssin".to it was divided. Tims each small nniscle was 
liHccd^^iu the liardening fluid with a portion of its nerve 
attached. Each of the muscles appeared to be plump, 
normal in appearance, and red in colour. 

(C) The rccitrrcnt laryngeal and phrenic nerves were also 

prescr Jtemarhs^ on Striated Muscle. 

On examining the microscopic sections of the iiitrinsio 
muscles of the larynx the pattern of, tho striation is seen 
to vary. It is hardly to be supposed tliat the striation or 
the different muscles is essential!}- different. The autho- 
rities a"rce that the microscopical appearances of muscle 
in contraction arc not the same as when relaxation is 
present- indeed, Starling states that in contraction there 
is an apparent reversal of the situation of the light and 
dark stripes. According to Engelmann tho isotropic (singly 
refractin") part diminishes in volume in, contraction, while 
the anisotropic (doubly refracting) part increases. The 
real meaning of striation is unknown. This is not essential 
to contraction, for unstriated muscle contracts. The main 
difference between the two classes of muscle is tliat the 


r The DnmsH 
L SIedicai. Joorxaz. 


M,vv 


5, 1928] 

LIONEL COLLEDGE AND SIR C. BALLANCE : ANASTOMOSES BETWEEN THE RECURRENT 

LARTNGEAL AND PHRENIC NERVES. 








may s, 1928 ] 

LIONEIi COLLEDGE AND SIR C. BALDANCE : ANASTOMOSES BETWEEN THE EECUEItENT 

LARYNGEAL AND PHRENIC NERVES. 



Fig. 14. D®. 


A. WATT, R. C. J. MEYER, AND A. CAMPBELL: OPERATION I’OR PITUITARY TUMOUR. {See p- "dS.) 



Fig. a. — S bowintr position of the tumour. 


SYDNEY SMITH: IDENXIPICATION FROM A FINGER-TIP REMOVED BY A BITE. {Seep. 757.) 




Fig. 2. — Finger-print of right index finger of accused. 


may S, 1928] 


OIERA-TION rOR I'lTUlTARY TOMOXJR. 


f ThkDbjtis* 747 

L&IC£>rCAl.JoCll!rAZi »*' 


ty])icnl cross stviutcd musclo fi'ivo is dciicndcnt on tUo 
iiiipiilscs from tiio central Jiovvous system to set it into 
activity. 

The. <Sliiini!(i(ii)!i of fhc Cortex Cerrhri. 

Rcforc the mouljey was killed the right ccrehrnl cortex 
vas stiimdatcd with the faradic current, a Sherrington 
single electrode being employed for the ])nrj)oso(sce Fig.16), 


DESCRIPTION OF PHOTOMICROGRAPHS ON PLATE. 

Fio. 14.--riiotomlcroi:raph ot musdo Imntllc^ in riphl ImU of 
(liftlthMjjm (x 700). I'lircF jears otul tour nionllif' recurrent 

iorynpoal-phrenic cn(l*to-s{<lo nerve nnastonio'jjM ; «lio\viutr Hint this 
method ot operation Imtj left no pormonenl cflecl on thij> half of liic 
dinphrapm. 

rio. 15. — riiotomicrojjraph of nutsclo hiindles In left Imlf of 
diaphragm (x 250). Two ye.irs nftcr recurrent laryngoal-piircnic end* 
to-end ner\e oimFlomosIs.* The <H^tnl rtul of the phren«c nerve was 
not anastomosed to any ottier nerve. No trnnavcTM' Rlrmtion is shown 
in l\»c photograpii. On’examining many other Roctions faint t>trialion 
of a mtisclc hnnille wna occoRinnaMy scon, and tliis perhaps was due 
to the fact revealed at the autopsy that helow the point oi roction of 
the phrenic ncr\'c a t>maU nerve from the brachial jilcxus joined the 
phrenic nerve in the thorax. 

Fig. 16. — Drawing of right half of brain of t!ic monkey (natural 
.sire). A, Faradic stimulation ot the cortex at this jioint caused eleva- 
tion of the upper lip on the left side. K, Slinuilation of the cortex at 
B cau&cd abduction ot the vocal eonls. Xlntortanately the point ot the 
cortex at whicli the maximal adduclion movement o( the vocal cords 
occurred was not marKcil. It was in front of the area which on 
stimvilalion paused abduction ot the vocal cords. The odducljou 
movement was much stronger than the abduction movement, wliicli 
was distinct from the abduction movement associated with the 
respiratory rhyihiii. 


lysed for lliroo inontlis with no sign of improvement in tho 
condition, a iccurrcut Utryngoal-phrenic nerve anastomosis 
should he forthwith curried out. 

iVofc.^Figurcs sliowin^ regeneration of the pliicnic and recurrent 
laryngeal nor^'cs after similar auastonioscs had been clTcclod w'crc 
ptiblishcd in tlic ]lnt\$h Miiliad Journal, March 26th, 1927 (seo 
Figs. 5 and 6 in plalo facing p. 555). 

The cxpcriniental nerve anastomoses ivcrc carried cut at tho 
National luslitule for Ilcsoarch, Mount Yernon, Hampstead. The 
microscopic specimens and' photomicrographs were prepared by 
Miss Glascock and 3klr. Stewart at the Koyal College of Surgeons. ' 

JlCTnnr.vcrs. 

* 55cc llrilifU Medical Joui'nnl, March 26th and April 2nd, 1927. - Ibid., 

April 2nd, 1927. ^ liritifU Mtilieal Journal, 1889, and Trans. Tfoy. Sue., 
1890, B. * Jlritidi MeJiral Journal, 1092, nnd Proc. Jlofj. Soc., 1895. 

^ iJrUiih Medical Journal, July 30th, 1927, p. 158. 


OPERATION EOR PITUITARY TUMOUR. 

Eepoiit op a Case. 

BV 

ANDREW IVATT, M.B., R. C. J. AIEYER, M.D., 

r.R.C.S., F.R.C.S., 

ASD 

ANDREW CAMPBELL, M.B., F.R.C.S., 

CESEEAL HOSPITAL," JOUASSESBUP-C. 

• (H’if/i Sj)cci{il I’tatc.) 


I'lic corlicnl nrc.is stinmlalcil conosiiond to thoso oiigii'«lly 
dofiiiod by Semon and Hoi-.sloy. The intciest of the cerebral 
stimulations carried out by ns is that tho nerve iinpnlscs 
passed along the phrenic nerve, then through the phrenic- 
rocurrent laryngeal end-to-end anastomosis to the recurrent 
laiyngesil nerve nnd intrinsic laryngeal inuschs. 

Somon and Horsley’ showed that nnilatcrnl stimulation 
invariably produces bilateral effect. They at ffiit thought 
that there, rras no abduction centre in the brain cortex, 
but they demonstrated that direct excitation of the accessory 
nucleus in the mcdfilla always evoked abduct lou of the 
vocal cords. They found no difEcnlty in evoking comjiloto 
bilateral adduction movement of the vocal cords by stimu- 
lating an appropriate area of tho cerebral cortex. If the 
stimulation is iirolongod the ** besoin de respirer ** over- 
comes tho influence of tho artificial stimulus and evokes 
a powerful abduction movement of the vocal cords. They 
.explained these divor.so effects in this way: Phonation (that 
is, adduction) -is a pnrposivo or volitional act, wliiic abduc- 
tion is essentially I'clatcd to the so-cailcd automatic pro- 
cesses of organic life — that is, abduction serves inspii'ation. 

In the later paper these authors show that there is 
a definite area on the cortex of tho brain, .stimulation of 
which causes .abduction of the vocal cords. They point 
out that Krause (1878) was tho first to localize the 
phonatory area in tho cortex of the dog's brain. Forrier, 
however, had prcvioiLsl}- reported that excitation of a 
certain cortical area in the dog elicited barking. Risien 
UusselP described separate areas of tho cortex ot tho brain 
in wliicli excitation ■ evoked the movements of abduction 
and adduction of the vocal cords. Risien Russell also 
separated the abductor from the adductor nerve bundles i 
in tlic recurrent laryngeal neiwe — the abductor fibres being 
situated on the inner side of tlie nerve, while the adduction 
fibres are on tho outer side. Stimulation of the abductor 
fibres produced unilateral abduction movement only, while 
division of the abductor fibres caused atrophy of the corre- 
sponding abductor muscle. IVe have been unable to 
separate the abductor nerve bxindle in the way described 
by Risien Russell. 

Operation in Man. 

It would appear that the proper operation to perform in 
man in cases of paraljsis of a vocal cord is recurrent 
laryngeal-phrenic nerve end-to-sido anastomosis. This has 
been suceessfitl in the one case in which this operiition has 
been carried out,'* Independent" of the cases in man in' 
which by stab or gunshot wound, or during an operation," 
tho recurrent laryngeal nerve has been divided, and in 
which an immediate anastomosis should be effected, "we .are 
of opinion that if a vocal cord (of' cords) has been para- 


A EnnoPEAN, aged 23 years, complained that during the 
last five or six years his left eye liad been noticeably 
weaker than the right. In November, 1926, he suffered 
from severe headaches when reading for an examination. 
In February, 1927, when marking the register, he found 
that when he thought the pen was touching the hook 
it was actually about an inch away from it; he was 
unable to see- with the left eye alone. There was no 
complaint of headache, no vertigo, and no vomiting. At 
tho beginning of -April Dr. iMeyer was consulted, and the 
patient was scut into hospital for investigation under Dr." 
Andrew "Watt. 


The previous history showed that the patient had fallen 
off a horse in 1918,' but though unconscious for some time 
lie suffered no other ill effects. Fn 1919 he had influenza. 
In 1920 he was . hit over tlie left eye hr a cricket ball. 
There is no family history of neri'ous or eye trouble, and 
tho father, mother, brothers, and. sisters are all well. He 
smokes ten to fifteen cigarettes daily and is a. total 
abstainer. , His condition ' on admission to hospital was 
recorded as follows. , 


The patient is a well-built, healthy looking individual, about 
5 ft. 8 in. tall. There is no abnormality in his gait and tho 

f rips of both hands are normal. There is' no tremor;" the motor 
unctions and the various reflexes -are normal, as is sensation. 
The bowels are’ ycgular and the appetite. is. good ; there is no 
frequency of micturition, and urine analysis reveals nothing 
' abnormal. The heart and lungs are sound, and the "Wassermann 
•feactiori is negative'.' ' ’ ' - 

Examination- of the cranial nerves shows the sense of smell to 
be- normal I'^^vision is impaired, pupils react to light and accom- 
modation, there is no . ocular paresis, no nystagmus, and no 
strabismus. There is no anaesthesia ot the face or scalp. The 
functions of the seventh nerve are normal, and there is no im- 
-pairment of taste. The movements of the tongue and swallowing 
are normal. The basal metabolic rate is normal. 

Blood sugar before glucose meal (200 grams) 0.11 per cent. 
„ ,, 30 minutes after glucose meal ... 0,16 ,, 

.. BO - - „ „• ... 0.14. „ - 

... . ,. 90 .. „ „ . „ ... 0.13 - „ 

.. 120 „■ „ . ... 0.14 . „ . 


Sugar was not found -in the -urine before the glucose meal, but 
.a trace was present two houi-s after. The cerebro-spinal ' fluid was 
under a pressure of 250 mm. water. The globulin was not in 
'exc^s of the normal, and the sugar percentage was" 0.09. The 
sodium chloride figure was 720 mg. per lOO c.cm. No character- 
istic curve was obtained with gold solution. A cell count 3-ieIded 
a total of two h-mphocytes per c.mm. 

A blood count taken on June 18th w.as as follows : ' haemo- 
globin 95 per "cent.; colour index 0.98; red cells 5,810,000; -leuco- 
cytes 8,000; polj-morphonuclears 52 per cent.; large mononuclears 
2 per cent.; lymphocytes 46 per cent. The red cefis showed Elio-ht 
amsocytosis with a very moderate degree' of poly-chromasia. ’ 

The patient was referred to Dr.- Campbell fo'r examination of 
the car, nose, and throat, and for the vestibular tests. Both 
drumheads were retracted, and he could hear a whisper at over 
16, feet on both sides. Tuning-fork , tests were normal There 
was no spontaneous nystagmus, no spontaneous "past-pointino- and 




748 Mat 5, 1928] 


OPEBATION FOR PITUITARY TUMOUR. 


[ Tub iJnmw 

SfBMctr, Jarntna. 


no inco-orclination ; tlio body bnlnnco ic.sls gave normal rcactiDii*^* 
and diadokokincsia v:as present. . 

J’cisfiOuldi' 7'c.sfn: 

Turnin'; to right gave an after nj-stagnuia to left la«liiig 
25 socoiuls. 

Turning to left gave an after nystagmus to right lasting 
55 seconds. 

Turning to right past-points 6 indies to riglit with left arm. 

Turning to right past-points 4 inches to right with right arm. 

Turning to left past-points 10 inches to left with right arm. 

Turning to left past-points 6 inches to left with left arm. 
Cold syringing the left ear at eB” F. elicited a rotary nvstagmii.s 
to the right in 45 seconds and past-pointing to left with hoth 
arms. Cold syringing the riglit car at 68° F. elicited a rotary 
nystagmus- to the left in 25 seconds and past-pointing to right 
with both arms. It was concluded tliat a supratentorial lesion 
was present. 


Opeh.vtion Notes hy Dit. C.tMi’nF.LT.. 

Thu diagnosis of a pitnitnrv tinnour was estahlishuii anti 
foiifinr.ud by beautiful stereoscuiiif films taltoii liy Dr. 
•■Iiidrtw Watt. Tlie eye tests indicatod jm'ssnre on the 
ehiasma, perhaps move on the left tlian on the right side. 
Tills finding was forrohorated hv the vostihnlav tests. (For 
skiagram see Fig. .\ in speeial jilate.) 

On June 13th, 1927, nndor rectal anaesthesia, given hy 
Dr. F. B. jMudd, a suhmucous lescctinn of the nasal septnin 
w.is ))erformcd in the usual way after removal of hoth middle 
tuihiuates and a slice of the right inferior tnrhiiiate which 
Imppi'iied to ho in the way. Tlie nasal imicons niemhrnne 
w.is sprayed with 1 ounce of 10 per cent, cocaine and 
adi I a-iliiie solution twenty minutes heforo o))cration. The 
antevior wall of the sphenoidal sinuses was thin and easily 
removed. The sphenoidal sinuses came into view, and 
a rounded tumour was found to occupy the upper part of 
the lavities. (See Fig. 1.) There was no septum between 






Fig. 1. 


the vinusi's, hut there wore one or two spicules of hone 
which indicated its site. 

A small piece of bone was removed from the most 
dependent [lart of the tumour i)y means of a gouge, and 
the rest of the tumour was uncapped with suitable forceps. 
There was little bleeding. The mucous membrane of the 
sphenoidal .sinus was removed. 

Tlic result at this stage was that the tumour covered by 
dura was occupying the upper lialf, or almost half, of the 
sjihenoidal sinuses. On removal of the very thin hone there 
was no dropping downwards of the tumour. A syringe 
introduced into the growth did not draw liquid, but gave 
■the impression that the tumour was solid. No pacfiing 
was introduced into the sjdicnoidal sinus. Tlie only com- 
munication to the nose was tlivougb the sphenoidal ostia. 
The mneo-poriostenm covering the anterior wall of the 
sjihenoidal sinuses had been reflected intact. A" large piece 
of the nasal cartilage was slipped hack between tho septal 
flajis, and each side of tlie nose was packed with a glove 
finger into which gauze had been introduced, so as to keep 
the septal flaps lightly together. The operation lasted 
one and a half hours. After leaving the theatre there was 
some respiratory difficulty, and the patient did not come 
round for six hours. 

On the following day there was a suspicion of an acute 
ajipcndicitis, but this pain was jirobably due to the z-oetal 
other. The nasal packing was removed in twenty-four 
liours. A mild antiseptic spray was used for another 
twenty-four hours, , after which tlie nose was gently irri- 
gated with saline solution thrice daily. The recovery from 
the first stage of the ojieration was uneventful. In a week 
he was up and walking about the ward. No improvement 
in eye symptoms followed at this stage. 

On Juno 27th, under open ether anaesthesia and cocaine 
spray to the nasal mucous membrane, the operative field 
was reopened through the nasal .septum. It was -noticed 
that a large part of the cartilage which had been rojdaced 
bad been absoi-bod. The sphenoidal sinnses were easilv 


entered. Tho tumour had not descended, and the whole 
shins and dura were covered "with granulations, which hied 
'■onsiderahly. Tliere was no difficulty in making a crucial 
incision of the dura, though the growth uvis iirobably also 
iiieisi'd ill the atlemjit. No descent of tumour was observed 
during the oprration, and there was no suggestion that tho 
growth was anything hut solid. There was no escape of 
any liquid other than blood; hlecding after incision of tho 
dura was easily i oiitrollcd. Tho operative field was closed 
hy hriiigiiig the septal flap.s together without any packing 
in the sphenoidal sinus; fingers were again utilized to keep 
the flaps ill aiijiositian. Towards evening tho patient was 
rational and ajijiearcd to he doing well. On the following 
day, though he had passed a good niglit, ho did not .seem 
quite rational. .He was able to recognize the surgeon and 
uiir.se.s, hut ansivered “ Yes ” to all questions and nothing 
oI.se; hy tho evening he failed to rceSgnizo anyone.. Tlio 
temjieratnrc rose to 102° F., and we. feared that meningeal 
.symptoms were commencing, though there was no other, 
indication of this. 

■ On June 29th he woke up jicrfcctly rational and -rapidly 
imiirovrd, with a gradual drop in the temperature, which 
liccame normal on June 30th. After this he gave us no 
onxielv; he was alloivcd to get-up a little on the eighth 
day after the Eceoiul operation,. -hy which time he was 
conscious of improyement in his .eyesight. He was dis- 
charged from hosjiita! on July 12th. 



Vir 2 — Visual ficliK showing condition at dales before and nfler 
onoration ladt viHion=fingcrs nt 2 metres; 25 mm. white. Sight 
vision=&i5; 6 mro. white. 


It was thought that a decompression by two stages was 
a safer procedure than by one operation. No thought of 
iinv aUcmjit to remove tho tumour w-as entertained. It is, 
iiowevcr, jiossiWe that if the tumour descends and fills up 
the sphenoidal sinuses so that further decompression is 
-r.ot ijossihle, then we may with greater safety remove the 
anterior muco-periosteal wall of the - sphenoidal sinuses, 
leaving the posterior, edge of the nasal septum in xiltr, and 
thus exiiosc the tumour mass through windows which will 
remain permanently open. The tumour itself may then 
be -attacked surgically or made to shrink hy clectro-coagu- 


^”T)ie main danger of the trans-sphenoidal route is sepsis, 
laving bare tbe field of operation to invasion by organisms 
from a possibly septic nose or nasopharynx. 

An attempt to- remove the tumour at the first operation 
would'probably, almost certainly, have resulted in infection 
of tho intracranial structures and death ; whereas by 
gradufd stages, and as the occasion demands, this three- 
staco "removal has much to recommend it from the point of 
view of safety. No’ attempt was made even to remove a 
small piece of tumour for the microscope because of the 
nossibilitv of infection. No purpose would be served hy an 
accurate knowledge of the jiathology of the tumour. If it- 
n-ere found to he malignant nothing could bo done, and if 
it iiroved to bo innocent we could still do nothing more for 
the present. It 's possible that in the descent of the 
tiimonr it may become strangulated by tho narrow bonv 
neck through which it must pass ; this will not occur until 
tho sphenoidal sinus is completely filled. 

The fields taken by- Dr. Meyer on October 4th, compared 


May 5, I’gsS] 


ATTimXIES BETWEEN EnBTjkATIBM AND TUBERCUEOSIS. 


t TrrrUnmra ' 74 fl 

BIctncxL JocnsAt. 


with Die iipRls before operelioii, show a eousWortvblc im- 
provcmeul in the pntiont’s eyesight, espeeielly iu tlio right 
eve. Tliore is a sinnll jierfovntlou in the nasal so])tiim, and 
liici'C me n fen- adhesions between the septum and tlio 
lateral nasal wall. 'I’hb anterior walls of the sphenoidal 
sinuses are easily inspected. There is no cvidelico of 
sepsis in the nose. 

The patient was first- seen, in April, 1S27, oxannned 
thoroughly and treated by surgical operation iu Juno, and 
reported on after exaininatiou on October 4th. 

Notks by Dn. It. C. J. MsYEn. 

Objective -examination showed no abnormality ns regards 
tho outward appearances, motility, and pupils; tho 
AVernicke pupil reaction was demonstrated later. Tho 
fundns was healthy, but tbevo was slight hypermetropic, 
astigmatism ; tlio svibsoqiicnt wearing of glasses stopped nil 
headaches. Bight vision = 6/6, J.l. Loft vision = hand 
rcliox centrally, but fingers -at 3 metres nasally. This 
called for examination of fields, the broad results of which 
arc indicated in the diagrams. Fig. 3, A (right eye), 



A B 

Fio 3. ' . 


shows the right upper outer quadrant lost ; the jiatient 
was quite unconscious of right qundrantic los-i of field until 
o.xnmination demonstrated it to him. In Fig. 3, B (left 
eye), the temporal heminnopia is seen to cro^s tlio vertical 
middle by about IS . degrees. Tim patient was quite con- 
. scious of loss of vision of loft eye, which drove him to 
seek medical aid. 

Tho examination suggested tho presence of a pituitary 
tumour involving the deft side much move than the right, 
hut later on under portion of chiasma. I handed tho case 
over to the physician, radiologist, and surgeon, but the 
patient could only come for observation CMay 28tU). 

Two oporntioiis were performed — ono on June 13t!i and 
tho other on Juno 27th. On July 13tli, at tho request of 
the surgeon, fields wore .again taken (tliero being no 

- chango in any otlier condition of the eyes). The right 
. upper qiiadrantic scotom.a had now diminished to a smaller 
.■sector.' • (See Fig. 4, A.) Tho loft scotoma had also 

- diminished, (Sec Fig. 4,- B.) . . 



On Soptemher 1st a friend stated that the patient was 
“ quite better,” wlucb meant, at any rate, a decided 
improvement. (N.B. — Patient lives in the country and 
over a hundred miles away.) 



On October 4tli tbo patient unexpectedly arrived for 
examination. This showed the right scotoma to be still 
further dimmisbed. The left scotoma was also diminished 
someu'hat. Eight visioii=6/5, J.l. Patient does not feel 
tiie scotoma, and this does not exist for luminous objects 
at all now. Certainly a most striking improvement. (See 

shows great pallor of nasal side 

that IS, atrophy is showing actualiv at the disc. (Seo 
t’ ig. 5, B.) ' , 


THE AFEINITIlilS BETWEEN llHETJMATISIlI 
AND TDBEIICULOSIS. 

BY 

AV. CAMAC AVILKINSON, M.D./ F.B.C.P., 

LOKDOS. 

TonEncoi.o.sis connotes tlio morbid changes caused by living 
tubercle bacilli in the living tissues of man and aniinals. 
As the tissues react they present lesions of endless variety 
in degree, kind, and .time. The outstanding and chavac- 
tcrislic lesion is the tubercle with its epithelioid and giant 
cells, blit there are also lesions as ■ acute as those of 
septicaemia or pyaemia, and, on tho othc'c Iiand, as elironio 
as those of-, chronic-, rheumatism.. Indeed, it seems likely 
that many so-called “ vhcvuuatic” affections, which do not 
Yield to antirheumatio treatment, arc really manifestations 
of chronic tuhcrculosis. Even joint affections accompanied 
by pain and' swelling may be thbercnlons in nature. 

Tho brilliant investigations of Liebermeister, with the 
help of his new acetic acid-antifovmin method, seem -to 
establish the froquoricy of chronic inflammation free from 
any tubercles as a distinct and even independent lesion 
of tuberculosis. These chronic inflammatory lesions are, 
indeed, often the cnd-rcsiiUs both of aciite lesions and 
of true histological tubercle, but Liebermeister holds that 
they may he independent of citlier of these lesioiis and are 
common in many organs, and parts. They have been over- 
looked T>ecansc- death' docs not occur in this- chronic- stage; 
and there is no chance of seeing them. Such lesions may 
ho tho fons ci origo of the inultifafious disturbances of 
function occurring in the early stages of chronic tuber- 
culosis. The lesions are the most chronic that occur in. 
tuberculosis, and cause mainly mild and transient sym- 
ptoms. Thus it may he impossible after a long lapse of time 
to trace them to their true cause or fix the time of their 
occurrence. Living tubercle bacilli may be found in these 
chronic lesions, and evidence supports the view that these 
quiescent lesions m.ay bo reactivated. These lesions aro 
most common in the secondary stage of chronic tuber- 
culosis, when tubercle bacilli, in small numbers, more or 
loss isolated, and certainly not in clumps or masses, aro 
circulating in the blood, before tertiary disease occurs in 
the apex of the lung. Amongst other manifestations, 
tuberculosis may cause lesions suggesting rheumatism of 
joints with painful swellings, in some cases with’ erythema 
nodosum, iu others with erythemata, pains -also in muscles 
and in one or more joints; pains in the chest without signs 
I of pleurisy, pains' in the neck and in this- oy-es or' head, 
disturbance of tlio heart’s rate and 1 -hytlim-i.even pains 
I in nerves (sciatica). Liebermeister . has demonstrated the 
.presenco of those chronic inflammatory lesions notably 
in lymphatic glands, serous iiiembi-aiies, even . in tlie 
meninges, in the lungs, liver, kidney, spleen, veins, skin, 
eyes, and larynx. Jlay- not -these lesions he responsible 
for the various, symptoms that may and do occur and pass 
away in the early stages of chronic tuberculosis, and 
espociaiiy of chronic apical tuberculosis? 

.hor the -most yiart these lesions elude ns, and ive can 
only bring them to light by means of tuberculin. Twenty 
yeare ago I suggested the possible existence of these lesions 
because doses of tuberculin excited pains in various organs 
and parts in a manner that seemed to indicate a focal 
reaction. For many years I have observed pains in special 
muscles and joints, time after time in the same part after 
each dose — in the hip, or knee, or little finger, or thunib, or 
beet; in the back or sbonlder; in bones or muscles, siicJi 
as severe cramps in tbo calves of the logs; pains also in 
the epigastrium, doubling up the patient after each dose,, 
and even boring or lancinating or cutting jiains in tlio 
shoulder radiating down the arm, or deep pain in tlie chest. 
There are strange individual idiosyncrasic.s, bot-anso in the 
same patient, after injections of tuhorcuUn, tho same parts 
arc apt to suffer, though the site of injection varies. 
These pains, in fact, may he related to chronic inflam- 
matory lesions and may he really focal reactions. One has 
great opportunities of studying these pains, their varieties 
and situations, after injections of tubcrciiUii. Naturally 
there is no other way of investigating them. 


ot o’^ 1 notary 'I'hc so-i-a 

i^a^vCcV ej > ^Yic 'a^’J 'mature. Cro^:^^'''^ ' ai-Ythc'"*' 

, anA ! lie o^ M,cv "RaAcV"® v,ctwcca c>J 

:vV'’ ss « "“ 

X Uno'' t\ievc '''\' -.5 %\AiAc 8 - ^ ^ot 6 UXia 

\wit tA^at t ;,eVca'°"'^;.acjxAcnt\y- “ gUaUaft .a scc" 

odosam aad ^,aia '\ ava>- ^ Y bavc >'ot "ava 

a-v^ewa vUoaiaat'^ \aaA aay 

,:;:a:^ C aS^- I 

^s.5BttBsi£-“:::;:;: 

Bat. cve Aa'a' V ^ca aAa'oa'^ * Y^YaAi avo YAiAvty 

«'» ;ui»“'"-£.. »' s Si., •r"* ■ 


ii* “-'Si" ;»r ts" '«“ s TiS Vs'SS 

a''^* °l\MAawAog'3ts evo- ‘ eva^aK'V't'^- 

rs affoct.oas ,vit>s, .^^cs tA>at 

-,.e , Parson'S 

qaestioa (YQ 26 ') f' caascs o^ luavAa’d 

Ici-Atis. testAioo^y'-^Ye tAie ve Aias '’‘:*^\,siH'ctod 

X,i Aas g' ‘ j^ad g°"^ coaaaoaAy taAiovc'® '® ' tAval 

,;f SS.,r i "r . -s'S^s'-'S ,Ss' 


s». , . .......sr s ,sLSs.A“Srs 

a Aas g' j^ad g°"^ coaaaoaAy taAiovc'® '® tAvat 

sr„:rs. “ css 

\„iv X disease doe sus\iected. 

piiiovtana y aarooa Yosis is a ^ Ylic „t cstva- 

i ScvcaAAaAias a has .vap'“ > aso aJj' Y,atcd, and 
cases ta'iai Y veiaeip’ ^a '■a® ^j-vt Aiave aa , ,,ecn 
as tAie ®'^V^;voveiaeat ®'®^ad discoai£o 

'^'S'pata. t®"‘':Sed. aaiatisai j' a^W y®“'! 

A.AA t'le '’ . Yias 'aai ^s ^ ' ypv tvcataie" Yiac«t 

aAiotopAio^'^^^evaA y®*"® Yiad Aieea aadei .^„A,n ti®a ^ 

-'sss " "sr .S"< 

tveataieat ^^ce ^^cat tAie a.is 

cYAvcctAj YaAectia" “^advocated, ' {com £'''®. and 

ts“ 

Is- S"'"”’ ''"“ »“ “• 

caeaiatog j-iAied. . ceoan’®® • taAim’®”'”^ pntinK 

.,v,a civciiai ^ ^iaftiiosis (Xivoaic, ^^^y mevea 


aeniatogi- -Ased. .eciaii'®® taAicvcnAia its \ 

act cii-e""' Y.,- diagao®'® {Ay cAnoa'®’ y y’'®^®^ .. often 1 

A^s^oa ;® ^;r*at taAa-f to 

^;:rAiest d^Va^ratti-’’ 

■S'ssfr^rs -iiSi ' 

reasoaiag J iaVAave sacA ^„{,evcaAia, ^ J ^ {.y ?^’to cAiecAi 

T:aA>cvca\ia ^ ct am 



MAT 5, 1938] 


ENDOORINB HVinAriA-NOE AND CHRONIC AliTHRITIS, 


I TnECnrns« 7^1 

MtDicii. JocnsAt ' * 


down,” acfuratolv niul precisely, these iiiashcd forms of 
lobcreulosis^io the eye, in the nose, in the larynx, and 
even in internal organs and systems, at a time when 
diagnosis is otlierwise extremely difTicnlt and treatment 
relatively easy. Certainly in such cases tiie effects of 
tnherenlin nsed as a remedy hy an expert are often magical 
in suddenness and completeness. 

General hospitals, and some special hospitals, might 
help earnest .students and-suffering humanity hy est.ablish- 
ing -a special ward and. an ont-patient department for tho 
study of- chronic - tnhercodosis in both its common and 
erratic forms. • ' 


ENDOCRINE IMBATANCE AJTD ITS RELATION TO 
GIIRONIC ARTHRITIS.- 

, ■ BV 

G. L. KERR PRINGLE, dif.C., M.D.Ed., 

nosoR.mv rnvsrcux to Tire royal bath hospital, iiaiirooate. 


Thk views and opinions of the ancient anthoritics before 
tho days of cellnlar pathology and bacteriology are of dis- 
tinct interest in- the light of onr present knowledge. 
Hippocrates laid down tho axiom that “ Gout never 
occurred in women until the menses had ceased." 
Tro<issea\i' and Charcot’ believed that chronic articular 
rheumatism was associated with tho beginning and end- 
of menstruation and with pregnancy. Orde,’ in 1879, 
suggested ' that there was evidence to show that there 
(vas .some relationship between uterine disorders and 
rheumatoid arthritis — such as severe arthritis with 
dysmenorrhoea and arthritic paroxysms coincident with 
menstruation — views with which I am in full accord. 

At all these .stages in a woman's life considorahlo strain 
is being thrown on the endocrine glands. These glands 
begin to assert thcmselve.s in early foetal life, and ns 
they have no function in respect of external relation, their 
secretions must bo entirely occupied with internal regula- 
tion, so that from the first any endocrine defect must 
disturb the b.alanco. In childhood tho endocrine system 
retards maturity to give time for further development, 
and htilir.es glands such as tho thyroid, subsequently kata- 
bolio in .action, in tho service of active growtli. As 
•puberty advances, tho retarding gland — the thymus — 
atrophies, and the katabolic glands, like the thyroid, take 
on their oa-n action. During lu-ognaiicy all the endocrine 
glands are working at full capacity, though some are 
antagonistic to each other. This continues iluriiig lacta- 
tion, whilst at Hie climacteric tho ovarian hormone dis- 
appears and more work is thrown on the thvroid, which 
itself is on the down grade. 

There arc two groups of endocrine glands; 

1. Parasympathetic or extended vagus — anabolic in action — 
the cell-islets in the pancreas, and the parathyroids. 

2. The_ sympathetic — katabolic in action — adrenals, thvroid, 
and pituitary. 


Tho rliythm of life largely depends on the fluctnatinj 
balance between these two. 

All the ductless glands, especially those co-operating witl 
the sympathetic nervous system, participate in tin 
development of sexn.al characters, the tlmoid and possihl- 
the })Ost-pitmtai-y tipping the balance toivards feminism 
and tlie anterior pituitai-y towai-d; 
pinlism. Tlius tlie thyroid sIiow.s increased actix'^ity a 
puherty, the catamenia, .marriage, and pregnancy, am 
undergoes partial involution at the climacteric. 

Tlicrq is a close association hetacen the gonads and tin 
pituitary: neither appeara to be able to get on am 
develop without the help of the other. The internal sehre 
tion of the ovaiy stunnlates the secretion of pituitrin; am 
the development of a corpus luteiim in pregnancy check 
this process on hehalf of the foetus until the time for tin 
uterus to contract and for the milk to flow. 

Llcaellyn' first drew attention to the association of tin 
?ndocriiics and chronic rheiiinatism, especially of tin 
Au-oiiic villiis type occnrritig in wommi at the menopause 
" corroborated -b 

Ribiciie, Rosen, H. K. Thompson,’ Cecil and Archer' 


FcliriMi^'ninJ IlBiPosate Medical Sociel 


.and iminv others. At a discussion on climacteric arthriti.s’ 
tho subject ivas considered under tho wider term of “ hypo-, 
glandular nidhritis.” It was pointed out that this con- 
dition of joints was hy no means confined to women at tlio 
climacteric, hut tlint it was seen in young xvomen due to 
thyro-pitiiitary failure. Cumberbatch concluded that there 
is a type of arthritis closely associated with, if not entirely 
due to, disturbance of the endocrine function of the ovai-y, ■ 
and gave the following reasons for these conclusions.. 

1. Some of flic cases occurred in young women in whom tho 
. menstrual function was being established. Tlie'y developed 

arthritis - of tlie rheumatoid type and amehorrhoea occuried. • 
There was no evident primary focus of infection. The applica- 
tion of diatlicrmy to the. interior of the pelvis brought the 
arthritis to an end and menstruation returned.^ 

2. Other cases occurred iii women at the other end of 
menstrual life. In many the climacteric commenced at an 
early 'date and menstruation ceased. In these," again, tliere was 
no evident primary focus of infection. The application of 
diathermy usually arrested tlie arthritis and menstruation 
recommenced, in the cases in wliich the onset of the climacteric 
was premature. 

-Robinson considered that arthritis is directly or 
indirocvtly due to inactivity of tlie -corpora lulea of tho 
ovary. This inactivity may occur at any time after 
puberty, and- may or maj' not be associated xvith absence' 
•of mcnsti-iiation. Heating - the ovary by diathermy 
' increases tho activity of tho ovarian function; 

Returning to the view of Trousseau and Charcot tliat 
‘ chronic artliritis is a disease associated with the' eom- 
inencomont and cessation of menstruation and also • with 
. proghahey, I have seen quite a number of young girls in 
their .teens in xvhom the start of menstruation had been 
delayed, or who hod had one or two periods and then 
stopped. They wore large, fat, well-developed girls, who 
compluinod of pains in joints and muscles. 

One girl, nged 12i, had for six months complained of pain in 
iicr right knee; she was listless, had never menstruated, and had 
all the appearances of thyro-pituitary deficiency. .T rays showed 
a small rarefied area just ocneath the articular face- of tho 
cartilage of tlie tibia. Her tonsils -were found to he septic, 
and removal was advised; this was carried out, and thyroid in 
sniaii doses was also given. This case did not begin to' improve 
until six months after the enucleation, when slie started to 
menstruate, pain ceased, and slie resumed her previous activity. 
Her mother suifered from chronic villus arthritis of the 
menopause. 

In another case the patient’s mother suffered from Raynaud’s 
disease, wliich was not of a severe type. This girl w-as very much 
like tho previous case in appearance; she was over-developed, 
w-as altcclcd by amcnol-i-lioea, and ’ tbe rheumalic condition was 
more in the nature of a fibrosilis of tlie erector muscles of tho 
spine, though there was some doubt as to tbe condition of tlie 
dorsal vertebrae as seen with x rays. 'When I first saw this patient 
she had had her tonsils enucleated about fourteen days previously 
and was in a markedly hyperthyroidic state, with rapid pulse, 
muscular tremor, and thyroid gland slightly enlarged. 

Crammer’" remarks that “ it is well known that acuto' 
infections are soinetimes follou-ed by symptoms which niav 
not unreasonably he .attributed to tlistnrbances of the 
thyroifl-adrciial function. The stimulation produced by 
these toxins may develop into a Graves’s di.sease.’’ Tli'e 
thyroid is one of the defensive agents against infection, "and 
I behove in this case the removal of the septic tonsils 
produced a flooding with thyroxine, the patient having 
most prohahly been liypothyroidic before. 

Langdon Brown” points out how frequently tonsillar 
sepsis may bo a factor in producing hypothyi-oidism in 
childhood. Kc are familiar with the fact that tonsillar 
sepsis is likely to excite hj’pcrthj'roidism after puberty, 
but until the gland has experienced the actix’ating effect 
of puherty — that is, before the gland has taken on its 
katabolic duties — it is apparently more easily exhausted 
than cxc'itcd to over-activity. Once the thyroid has taken 
on its katabolic duties xve find patients with all the sym- 
ptoms of rheumatoid or atrophic arthritis — as, for instance, 
the young woman in tho early twenties. 

Llewellyn had frequently pointed out that the early 
symptoifis of rheuinntoid disease, prior to the development 
of joint swellings, are very similar' 'to the secondary 
features of Graves's disease and also Ravriand’s' disease 
and he believes that all these diseases are due to endocrine 
instability or imbalance. McCari-ison had pointed, out that 
in the^ goitrous regions of the Himalavas rheumatoid 
. arthritis is very common. 



752 Ma.y 5, 1928] 


ENDOCRINE IMBALANCE AND CHRONIO ARTHRIXIS. 


[ Ine nnmtw 

Mebtcit.JaaKii& 


In my experience also I Ijolicvo lliat a lilstory of thyroid 
enlargement and rheumatoid arthritis is extraordinarily 
common. 'When you examine the patient tliere may he no 
evidence, hut on inquiry into the past history it is astonish- 
ing hom often you mill get a histoi'y of goitre. I have 
recently had under treatment a case with the following 
family histoiy. 

Maternal grandmother suffered from goitre; mother had a goitre 
as a girl and died at 76, hedridden with arthritis, high iilood 
pressure, and attacks of angio-nourotic oedema. Tlie patient has 
three sisters — all of whom suffered from Graves’s disease, one 
developing the disease a week after marriage. A lirothcr was laid 
up for a long lime, and it was Uiouglit tie was going to develop 
Graves’s disease, but he is now quite fit. Ttic patient when I’-t 
to 13 years of age had a very large goitre, and did not start 
menstruating until she was 17, wlien siie Iiad considernhlc dy.s- 
mcnorrhoea. At 19 the heart was said to he weak, and for Itie 
last few years slic lias suffered from tachycardia, auricular flutter, 
and fibrosUis. 

Assoc’miion' of Pregnancy irifli Illicinnntold Arthrillx. 

For years I have been struck with the fact that n i»ntiont 
with rheumatoid arthritis will give you the following 
histoiy: that she hceame pregnant, and that during 
pregnancy slie was very imich better, hut that during the 
Iiuerperium all the symptoms returned with increased 
.severity. This clinical fact has given mo mueli tlionght. 
Now the thyroid is an active accelerator of motnholisin,' 
and its close connexion with reproduction is .shown by 
its frequent iihy-siological enlargement in the female — at 
puberty, marriage, and pregnancy, and sometimes at 
menstruation, and by its partial involution .at the climac- 
teric. During pregnancy great strain is thrown on the 
thyroid and the patient often becomes hypotliyroidic for the 
time being. Thou there is tlio association of the .secretion 
of the corpus luteum and the pituitary, the internal 
secretion of tlio ovary stimulating the secretion of pituitrin; 
when the corpus luteum develops in in'egnancy it chocks 
this process in the interest of the foetus. Langdon Brown 
points out that the blood sugar curves of pituitary glycos- 
uria and the glycosuria of proguaucy aro .similar, and 
suggests that the latter , condition is duo to pituitary dis- 
turbance, which is comprelicnsihlo, since pituitrin di'reetlv 
inhibits the action of insulin. This sugge.sts that the normal 
holding up of pituitrin during pregnancy allows sugar to 
bo storod up more readily in tho interest of the offspring 
through file unchecked action of tho insulin. Again, 
Cumherhatch and Robinson' put forth tho. hyqVo'thcsis that 
arthritis is directly or indirectly due to inactivity of the 
corpora lutoa. - 

It is worth considering, therefore, whether tho exhansted 
thyroid tends to reproduce tho symptoms of rheumatoid 
disease, which liave been held up in some way by the corjnis 
luteum’s inhibitory action on the posterior pituitary, and 
has thus restored the endocrine balance during pregnancy 
witli amelioration of all the arthritic symptoms. 

Arthritis of the Menopause. 

The loss of tho internal secretion of 'the ovary along 
with tho partial involution of tlio thyroid proctuccs a 
mild mjxoedematous or hypotliyroidic state. Cliniciillv wo 
know definitely that those cases improve with small closes 
of thyroid extract, some with the addition of ovarian 
extract and others with the addition of pituitarv extract. 
I have particiihirly noticed how frequently these arthritic 
symptoms occur in cases where an artificial mcnopaii.se has 
been induced and how improvement takes jilace under the 
above treatment. 

Llewellyn'^ holds that there is a definite rliouinatic 
diathesis due to endocrine instability, an instability which 
is observed in children and wliicli is the forerunner of acute 
rlieumatism. Ho bases his opinion on the following points 
believing that : 

1. The tendency of rheumatism to cimnge its facies with the 
onset of puberty, the predilection of rheumatoid arthritis for 
the reproductive period and of .ostco-arthritis and gout for the 
menopause or pre-senile epoch, suggest that tlie endocrine 
changes associated therewith account for the superficial diver- 
sity, but fundamental unity, of these affections. 

2. Rheumatic children are all hypothyroidic. 

■ 3 . Thyroid swelling very often ensues at the outset of acute 
rheumatism. 

4. There is a definite geographical overlapping of goitre and 
acute rheumatism. 


5. Acute rlieiunatism is an example of endocrine heredity. 
He quotes McCarrison : that the victims of simple toxic goitre 
arc not only liahio to Graves’s disease, lint, wor.so .still, hand 
on to their children a cnmlition of thyroid instability. 

6. Both hypo- and hyper-thyroidism may follow acute 
rheiiinnlisin. 

7. There i.s a higher incidence of rheumatism in goitrous than 
ill iioii-goitroiis children. 

8. It is n clinical fact that some case.s of acute rheumatism 
do not improve on .salicylates until thyroid extract i.s added. 

9. Siihlliyroidism spells siihoxidatiori, and vasomotor in- 
stnhilily implies irregularity in the supply and distrihutiori of 
o.xygeii to tlie tissues. 


Now, .some may ask, wliero do infection and scjitic foci 
come in, anti how is it that if you remove the septic foci 
the jinliont so frequently improves? The thyroid gland is 
one of Iho great defences against infection, and if tho 
)mlient is already Buffering from instability of the thyroid 
— cither liypo- or lij-pcr-thyroidism — the jircsciicc of an 
infective focus will not improve matters,- and its removal 
may, anti probably docs, in many, cases rc.storc stability, in 
the same way ns the removal of septic tonsils is so often- 
tlie commencement of imiirovement in a case of Graves's' 
disease. 

Olliers may ask why it i.s that vaccines and protein shock 
arc hciicficial in these cases. Crammer answers this quc.s- 
lion when he says that the fact that many liacterial toxins 
stimulato the thyro-ailreiial ajtparatus illustrates tho 
curious and as yet uiie-vplaiiicd iihonomcnoii that in .some 
infections the injection of non-specific vaccine, and even 
proteins, may have a striking therapeutic effect. Tlie effect 
<if the injection of these substances is to produce a typical 
rigor. The rationale of tliis .so-called non-specific vaccine 
therapy, and protein therapy, would ho that it elicits an 
increased functional activity from tho thyroid adrenal 
ainmralus— in fact, “ sympathetic fever,” which is one of 
the normal reactions of tho ' organism against bacterial 

infection. . , , 

There is another point worthy of consideration — patient? 
frequently tell us that ' their synqitoms of rlicuniatoid 
arthritis commenced after a nervous shock, as an air raid, 
the death of a parent, an accident, etc. I have always 
holiovod that there is a ])sychological element in many 
cases of arthritis and endocrine imhalanee, especially of the 
kalahalic glands; their close association with the gonads 
supports this view. I have never been satisfied that sciitie 
• foci were the. solo causes of these diseases, hut that hchiml 
it all -there was a soil or diathesis which I' holiovo' to ho 
cimnected witlPendoeriuu, instability or imbalance. 


Urmu-XTES. - — ... 

1 TroiiB^cmi : New Sjdciiliuni Society Publications, vol. tv. Clinical'^ 

- ri.‘!f^coW^^Ncw- Svilenbnni Society Publications, 1881. 
sonic Clinical Socictv, February, 1879. 

« I l,.,v..il>n • .tilliTilti Dcformaiil, 1E09. 

s niliicrrc : /trilirti .Vfi/icnl Juiiniat, Ejiilomr, para. J23. December 13th, 
1913 

cnovoii'' n/froDiV fler Gegeiifrarty p, 81 , 1917 . 

TH K Tliow'-on • JiOHton Mcfi. oiul Sury. Jnuri}., April 2nil, 3925. 

*rrril Arclicr: Joiini. Auier. Meil. .Imc., 1925 , Ixxxlv, 75 . 

• 0 pHninf'tcric ArlliritiP, Prnc. Jioi/. Soc. Med., Jnnunry, 1925 . 

!• Crainmcr • /iri(. Jmi,,. Exper. Pall,., vol. vii, .No. 3 , p. 95 
n I aiirdon brown: The Kiidocriiiex in General Medicine, 1927 . 

^Ucwcllyn : A^jiceff of lihcmnatigm and Gout, 1327. 


SEA-SICKNESS AND ITS TREATMENT. 

BY 

-R. ALLAN BENNETT, M.D.Loxd., M.R.C.P., 
sonnEox, pacific steam navigation company. 

Se.\-.sicknes.s in its milder forms may ho regarded as an 
occasion for jesting by those whom it docs not trouble, but 
for some sufferers its anticipation may poison the prospect 
of a voY’age, and it may cause prolonged discomfort or even 
death. ^ A woman, aged 40, rather debilitated by fever, 
travelling in a sliip in wliich I was a passenger maiiy. 
vears ago, died, after ton daj-s of coiitiiuial vomiting 
which no treatment conld clieck. Such a catastrophe may 
ho rare, but cases occur too frequently where suffering is 
prolonged for many days and the patient is reduced to 
a state of extreme mental and physical prostration. 

No age, no condition of life, is exempt. Old people going 
oil a vovage for tho first time, sailors who have used tho 




754 Mai 5, 1928'] 


. ■FiLTAI, SUPPRESSION OF URINB. 


< T«j! immnt • - 
IMmcAiiJorsinii, 


Imt to tile niecliiinical cliniigiiig of tlio jiaticnt’s environ- 
ment. The specific gravity of tlic vatcr is 1020, and llio 
liocly is supported very lightly on the hnttoeUs, the shoulders, 
and the back of the head, with the toes just toiiehiiig the 
end of the hath to prevent the legs from floating free. The 
hath itself shares tiio rolling and pitching of the ship, lint 
the water it contains has not time to resiioiid, and keeps 
its level, with the patient immersed in it jiartaking of its 
relative immobility. AVatching a hathfiil of water in a 
rolling ship the surface apjiears to slant this way and that 
with the movement of the vessel, hut a s]nril level floated 
on a cork raft will show that the water is nnaffoeted. If 
the ship is ]ntching the long axis of the hath should ho 
foro and aft ; if rolling, athwart ship. The ])nticnt must 
not he able to see tlio ajipareiit o.seillatioii of the water,- 
and the eyes should ho bandaged — voluntary shutting is 
not enough, since in many cases vertigo is increased by the 
effort of closing the eyelids. If this procedure is carefully 
followed it always, in my experience, lessens the dizziness 
and gives relief, wliich is valuable in scvei-e cases, and often 
permanent. . , ' . 

FATAL SUPPRESSION OP UHINJ5 CAUSED BY ‘ 
LATENT HAEMAGGLUTININS.- 

BY 

GEOFFREY SHERA, M.A., At.D., R.Ch.ckxTAn., 
M.R.C.S., L.R.C.P., 

TATIIOLOGIST TO THE PRINCESS ALICE MEMORIAL HOSPITAL, EASTBOURNE, 
AKD TO THE EAST SUSSEX COUNTY MENTAL ItOSMTAL. 


PoLnowixo blood transfusion with an apparently com- 
patihlo donor, tho ocenrrenee of a condition akin to hla'ek- 
water fever, both in its symptoms and morbid anatomy, 
and sometimes with a fatal issue, is fortnnutely nncommon. 
Bk.ker and Doihhs (1925)' record with illuminating detail 
tvo such fatal cases, and add very valuable experimental 
observations. Roynes" refers to a '■case reported .by 
Bcrnheim’ where, after transfusion, ' haoinoglohiiinria- 
occurred, and progressively increasod until .the fnnetiori 
of the kidney became so much interfered with, by doiio'slls 
of haemoglobin or damaged corpuscles' that the patient 
died- with supjn-cssion of urine and all the' .sigms of^ uraemia; 
Dyke' mentions two cases of hacinoglohinnria ilno' to li 
Group 2 case being mistaken for a Group 4 ■.owing.to.n. 
low title, Group -3 serum being used for the preliminary 
testing. Keynes" also refers to non-fatal transient haemo- 
glohinuiia, and I myself have noted this' phenoiiiciioii" on 
two occasions. - . • . • ' 

interest in this connexion to note that Y'orke 
and Nauss working on tlio pathology of hlnckwotcr fever; 
injected rabbits with haemoglobin and produced intrarcnal 
obstruction. B aker and Dodds, repeating these experi- 
ments, found that m order to produce renal precipitation 

strengroraf loa't''r 

^mparing three fatal cases, one of mine and two of 
Blakei and Dodds all liave certain clinical features in 
common : onset within a few hours ; pyrexia 9go to IO 40 • 
jaundice; methaemoglobinuria; and ■lumbar pain with 
sj-mptoms of uraemia. One case was fatal in four davs 
my case m eight days, and tho third in nineteen diivs’ 
Eitrogen retention was apparent, and the cases took on 
tiic picture of latent uraemia. 

One of the Blaker and Dodds cases showed a blood m-on 
of 102 mg. per cent, on tho fourth day, 178 mron Z 
tenth day, 400 mg. 011 thp sixteenth day, 618 mg. on the 
seventeenth day, and 803 mg. per cent, after death Tho 
second showed a blood urea of 287 mg. per cent., aiid mv 
case on the third day showed 174.6 mg. jier cent. ^ 

Cljnka} Uisfortj of the Vres'eni Case. 

A woman, aged 36, was admitted to the Princess Alice Memorial 
Hospital, under Mr. A. H. Croot, -witli a history of five and a half 
weeks’ amcnorrhoca,- except for a slight •“ loss ” four days before 
admission. She had .a black discliarge, with abdominal pain, con- 
sUpation, and vomiting. She was very blanched and restless' 
and had- the obvious appearance of severe' haemorrhage • of some 


diirnlion. Slin w.as very lender and rigid in the left ilmc fo-sa, 
anil there was linlhicss in tiic flank?, wiUi a fluid thrill. Her’ 
pulse was MO, the respirations 28, and the tcmperalure 97.D°. 

During the operatidn a pint of the husband’s lilood was tr.nir- 
fiiseil after prcluniimry eross-tesling of the patient's serum againsl. 
(iio (ionor's^ cclis for (liirly niinulos nt room (ompcratiirc- aiu(* 
with the nul of the microscope. Both tloiior and patient wci«'. 
idciitinrd ns Group 4 (Moss). At Die operation tlic ahdomcn was 
opened hy n median incision and mncli dark blood and clots oozed 
out, also a small foetus. The ripliL Fallopian tuhe was found, to' 
ho ruptured; it. was lied and removed, The, clots and blood were 
swabbed out and the ahdomon was closed. The wound remained 
clean subsoqucnlly, and the patient showed very sliglil signs of 
reaction, the temperature rising only to 

Aftcr-IIUtorif: 

On the next day (.Tunc 20Lh, 1927) the general condition of tbo’ • 
patient wa.s very good; she talked cheerfully, but slight icterus was. 
noted, and there was complete .suppression of urine,. She com- 
plained of some abdominal pain, which was probably renal. 

A calbelcr wo-s parsed and 6 or., of blood-stained urine were’ 
obtained, full of blood debris. The pulse was IIG, the respirations 
24, ami thc'.maximum temperature 99.5®., 

•Jiino 21st. Suppression >vas complete. A catlictcr yielded only 
2 ox. of blood-stained urine. The maximum tcmperalure was 
99.5®/ the pulse -100, and the respirations 24. . . • 

. .Iiiiic 22nd. . Only . li oz. .of. urine were oblaincd by catheter, 
ilol-iiir bhlb«, rectal salines, pilocarpine, and alkalis were given 
without •ctTcci.* The hlood urea was found to bo 174.6 mg, per 
cent. /The pnlsc' was 100,- the respirations 24, the lenipcmtme 
99.2®, and the van den IJcrgb- reaction was-au indirect positive. 

Juno Only .2^ oz. of. .urine were removed by catlictcr. 

Immiiar pain was* now marked. The pulse was 92, the respira- 
tions 22, ami' tiic ■^temperkrure 93.C®. ' 

June 2Uh. - Ouly, V or.^of uyinc obtained. Abdominal distension, 
was noted, and diurctm was given wilhont cfTcct. Tlie pulse was 
Ibe rcM>irations 20,. and tbe Icmpcmturo 93.4®. 

June Kill. ■Si'’ns of uraemia appeared in addition to Imcmolvtic 
iaundico, and . t lie patient' became drow'sy and irritable. Tho 
Rvstolic blood ‘ prr‘^surc was -119 and the diastolic 78. The tom- 
pVraturc w*as subnormal. ... 

• The patient died suddenly on. Juno 27th. . . 

■ ‘ " • PonUviortr'm Eraminat'tou. 

Thr nwronsy- performed in my nhscnco by the Iioure- 
.iirimori Dr. F. Jiiing:- -Early adhesion? were evident hotween 
I c wound and the .site of. removal, of the rup tured ectopic gcsla- 
limi The kidneys were enlarged and of a pale colTeo colour, with 
dngofgcmcnt showing' as slriations m tho medullary rays. . Tha 
capsurc-. stripped readily.’ The corlcx was diminished m width; 
ReonUined-somo engorged, ytsso s as striated lines, but the most 
klrik iiir fenhire was 1)10 marked engorgement of. the medullary 
faw -Microscopical sections' rovcaled intense engorgement of tlie 
canillnrics find tubules. Bowmnn’s capsules gave evidence of coni- 
wUsifin -and- thC'tnbnlar.. cells showed flattening and pressure 
S^rop^^y’■>ritil■.flisappcaranc'c^of many of the iiviclci. Tho tubules 
vliufn full of red blood, colls or debris, and there was cloudy 
kwelliim wliero the condition' was furthest advanced.- 'The devclop- 
of fine intcrfuhular connecting tissue was visible. Tha 
was- clearly- the seat of advanced parenchymatous changes 
d m ?o’Tack’ of nutrilioii-'df-..lhe colls, which was in turn duo to 
I reRuro Atrophy and toxic changes. Eosin-staimng material in 
masUs and -gramdes wns cvident in parts,; Ihc bladder contained 
cofice-ground material. .--In regard to Ihc liver, the bile ducl.s were 
Vnakkcdlv ■ outlined .macroscopically, and ■ the. picture of chronic 

Vcnoifs c'ongeslion was present (nutmeg type). Microscopically 
• ilmrc wcro similar'chiin'gcs Hue to intense venous congestion with 
conscouent pressure atrophy 'of the cells leading to parenchyma- • 
tons degeneration, ns evidenced by cel! vncuolation and .loss of 
nuclear °sliiining. The spleen was very congested. Ollier organs 
were mncroscopieally normal. 

Tho caiiBo of tleatli was tliercforo prcsiim.ably uraemia duo 
to mecliaiiical hlockago of the kidneys and liver by blood 
cell awo-lutination iiroccodiug slowly and progressively owing 
to tlie^ureseiicc of small but cFcctivo amounts of agglii- 
tinocoii in the iiaticiit’s scrum. Undetected incompatibility 
was obviouslv tlie cause. Tlio patient and donor wero • 
aunarciitiv b’otli Group 4, but a subscquoht repetition of 
the • cross-test (donor’s ■ cells and patient’s seriiiu) revealed 
at the end - of- sixty-five mimitos a definite macroscopic 
"aeclutiuation. .It will bo remembered that thirty -minutes 
had heon allowed, and in the desperate condition of the casa 
no longer delay- was permissible. In the. paper by Blaker 
and Dodds' it- is recorded, in connexion .with their first ■ 
fatal case that there had been some question as to tlio 
group interpretation,- and,- in regard to the second, both 
donor and recipient were- apparently Group 4, hut subsc- 
quentlv a cross-test showed the patient’s serum to agglu- 
tinate'tbo donor’s colls. On more than one occasion I have 
found ■ that - an apparently Group 4 donor’s cells w;ere 
agglutinated by a patient’s sevnm (apparently also Group 
4). A simitar effect ivas recently noted by Dr. Dyson of 
St. Mary’s Hospital.” ‘ ' 



756 May ‘ 5 , 1928 ] 


COMPLETE INVEUSION OF UXBnUS. 


r TiiKr.nmjm . 
i. MrMc-n. JorrAiL 


Jhtciliiis rnli, comincncod. (hiring tlic lliirci nr foiivtli inoiiUi. 
The vaccines were jnepared Iiy Dr. C. JO. Jenkins, patho- 
logist to tiio hospital. 


JicsuJfs of Trcaiment. 

The total nnmhcr of new patients for the years 1922-25 
inclusive was 424 ; this figure incUules only those in whom 
the gonococcus was identified, and consctincntly, although 
the total figures are cousiderahly redneed, other forms of 
urethritis arc confidently excluded. Of these 424 patients 
150 attended for a period of one month or h'ss and then 
disappeared, leaving 274 for eonsidcration— 134 of 1922-23, 
and 140 of 1924-25. In one-third of these jialients it was 
not the first attack of gonorrhoea. Tlie aeeompanying 
tablo illustrates and serves to compare tln> results of 
treatment; the figures are, however, prohahly more useful 
for purposes of comjiari.son than as statisties, .since a pro- 
portion of the patients did not eoin])!ctc their treatment. 
The numbers dealt with in each period rernnin, however, 
approximately equal. IVo Iielieve that if home treatment 
by means of an outfit wore replaced by hospital treatment 
at more frequent intervals much more salisfaetovy results 
would bo obtained. 

1922-23 192t-2S 

(Vaccine). (No vaccine). 

Number of patients 134 ... 140 

Number without poMenor v.rctUritis 263=19% ••• 16=11^% 

Number with complications 24^:18% ... 42^=307^, 

Number cured 60 = 49% ... 45s:32% 

Average period before a negative 

test 5 months .. 71 months 

Average incubation period 7 days. 


The figures in this tabic rc(jiiiic some consideration. 
First, it iis obvious tliat but few jiaticnts escape a posterior 
urethritis; secondly, the luuuhers cured aio to soiuo extent 
misleading, for of those who do not appear as cured tlio 
majority ceased to attend before a negative test was 
obtained, and many of these were about to rcacli this 
stage. The real interest lies in the comparison, and it 
is seen at oiye that the percentage of com])iicaUons 
(avthntis, epididymo-orchitis, and rheumatism) was greater 
in 1924-25, the percentages of cures less, and the period 
of attendance before the first negative te.st was obtained 
longer than in 1922-23. It is again emphasized that save 
for vaccine treatment the routine was in all rc.spocts the 
same during these four years. Some small variations may 
bo expected between different years, but to u.s it appears 
justifiable to attribute these niavhed differences to the 
yaceinc treatment. 


COMPLETE INVERSION OP THE UTERUS : 
RECOVERY. 

BY 

DANIEL M. DONOVAN, L.R.C.P. .\xd S.Ed. 

pnvstcux TO Tire coustv of conx ltihg-im iiospitai,.^ 

The very raio occurrence of the condition present in the 
patient whose case is dosevibed below is .sufficient warr.aiit 
tor placing it on record and particularly so, since the 
treatment adopted was followed by complete recoverv 
According to most authors, in only 50 per cent, of these 
cases is suen an outcome to be expected. 

A marrred woman, aged 37, was admitted to the Ernvillo 
Ljung-m Hospital, Cork, at 8 p.m. on September 17th 1^7 in 
labour; she complained of great pain on micturition.’ and ’the 
urine was found to contain blood. She was apparentlv a 
healthy woman, was the mother of ten living'^Siildrcm and 
had three miscarriages. Her menstrual history was normal and 
she had never suffered Irom any serious illness. She had a had 
time on the occasion of the birth of her first child, the labour 
extending, according to her own account, over three and a half 
manually pLcenta was retained and. had to bo remov’d 

At 1 a.m on September 18th she gave birth to a male child 
weighing 11 lb. Profuse bleeding occurred after the. child had 
been boin, and the patient collapsed. A hypodermic iniection of 
1 c.cm. of pitmtrm was administered, followed bv brandy. After 
!« fv expression of the' placenta by the 

4 attempted, and sudden - and complete 
mversion of the uterus took place; there had been no traction 


on the cord. Shortly before 2 a.m. I was summoned by teleplione 
ami fonml the patient very Inid indeed. The jml<io was im- 
perceptdde, the face was edvered wiDru cord clammy sweat, and 
tttc !;ef<pirations were, faint ami fast. I was informed that a 
ptemiar idacenfa was half dcliv<re<I, and discovered tlic ntenn 
with the placf'nla covered by memlirnnes completely* external to 
the vulva, and extending down nearly to licr knees. It was quite 
evident that no lime must ho lost if tho patient’s life was to ho 
j)vc««C'rve<l, I liastily came to tlio conclusion that i\nae«;thes{a was 
out of the r|nestion; the lime that would elapse before 1 could 
have the nssistanro of my colleagurs would have heeii fatal. The 
scripus^ almo'^t dying, condition of the patient did not wainr.it 
my administering an anaesthetic and performing the lUct^ary 
manipnlation.i myself. IJy doing so I conhl not mainlain sntK- 
factory anucsthesm, and, moreover, it would have been impo'^'^ilde 
to keep my hands from becoming infected. In anv cum* I did 
not think the patient was fit to take an anaesthetic. Having 
rovoied the lower alidomen and (highs with towels wrung out 
of normal salt solution I proceeded ns follows. From where I 
could feel the edge of the placenta I tore llirongli th*’ menihranrs 
with my finger in the middino and eomplctely swept them otT ihc 
uterus all round. I then proceeded to separate tho placent.a and 
found ihat it was .very adherent at the margin, hnt that towards 
the centre it had already separated from the uterine wall (o a 
considerable extent; the cavity thus created had fdlcd with blood, 
which hy now was one large clot. 1 waslicd over the surface of 
the uterijs with hot salt solution, and seizing the organ with my 
two hands I endeavoured to reduce iU size by squeezing the 
blood from it. I kept up this pressure for a few minutes, and 
then, removing my left hand, grasped the now much diminishfd 
uterus with my right hand, and svas able to return it completely 
within the vagina. Gentle upward pressure then at once 
restored it io its normal position. 

Having replaced tho uterus I now turned my attention to the 
general condition of tho patient, wlio was practically unconscious 
and npparenliy dying. Another 1 c.cm. of pituitrin was adminis- 
tered hypodermically. Two pints of normal salt solution .contain- 
ing i dVachm of ndVenulinc solution w'as injected into the axilhio, 
and the patient was ordered 1/30 grain of strychnine with 1/lCO 
grain of djgjt aline every four hours hypodermically. She w.as 
also given salt solution by Uic rectum every four hours. She 
regained conscion.sness at 5 a.m., and hy (liat afternoon had 
apparently got ovci Ihc' giavc shock, but she then complained 
of severe headache. ^ ^ , 

.Her lemperalUYC that afternoon was S7.6° F», the pulse rate was 
120 ami the respirations 52. Tlcctal salines and liypodrrmics of 
strvchninc and digilaline were discontinued. The temperature 
rradunllv ro«o to holween 101® and 102® F.,' and. she had a rigor on 
the third dnv. Slic was then given an nitraulerino douche ■ of 
evIHu solution, which, was repeated' every day for four days, and 
x.iliwri.K'nlly every alternate day for fourtqcu days-. On- the 
intervcniiie 4avs the vagina was douched with cylim solution. 
She was also piven i drachm of the liquid extract of ergot twice 
(Inilv durinp this time. The Icmpcraturo gradually suhsidrd and 
she 'was quite well and out of bod on the twenty-second day. 
No further coniplicatious occurred, lind she left hospital at the 
end of four weeks quite well. 


Coiirplclc inversion of the iitorus is said to ocenr oniy 
once in 250i000 cases, and is iistially pnt down to tlin 
following cnnscs ; ( 1 ) traction on tiio cord ; ( 2 ) too vigorous 
com|>ressioii of the fundus; (3) sudden delivery, especially 
if tho mother is standing; (4) exertion after delivery, as in 
coindiiiig; (5) short cord of whatovor otiiilogy. 

In this case none of these causes existed, except that; 
pressure bn the fundus wns tried, as st.atcd, to express tho 
placenta. This, however, was porfoimcd hy a highly 
.skilled and very ox])ericnecd mirso, and for that reason 
inav he 'eliminated. ■ Agiiin, tho condition is said t() ho 
more common in primiparae, and my patient had given 
birth to ten children. , n 

Opinions are divided as to whether tho placenta slionkl 
be separated from tho uterus hotoro atterai>ting to replace 
the latter.' I have no doubt that it I had attompteil 
'replacement without previously removing the placenta 1 
should have had considerable difficulty in doing- so; if t 
had succeeded I should then have had much more trouhlo 
in removing tho very adherent jilaccnta with tlic nterns 
ill situ and the, extra tinio involved would prohahly have 
been fatal to the patient. ■ . . 

The fact of tho patient not being anaesthetized has been 
alreadv explained. It would no doubt liare made things 
easier for nio if the patient had been under tlip inflnciue of 
an anaiis'tlietic, but I am satisfieci that delay was out of the 
question and -that speedy replacement of the uterus and 
treatment of the jirofquud shook gave the patient the only 
cliaiicc,' aiid tliat .a poor one, of recovery. 

1 am indeblert to my. coUe'agiie Dr. P. J. p’Bnen.,,fpr lyliom I 
was'"acling on this occasion, for permission to, publish this case. 
To him also is duc ti large measure of praise for the ultimate 
recovery of the patient, since he took over thc c.ise from me on 
the day' after ’the birth, 'and continued an attendance on her till 
she left- hospital! ' • * ' 


JIBMOK&.NDA.. 


r TntnnmsH 7fi7 

t MTDtcxi.3oT:*xii. I ^ • 


May s, igiS] 


^cmoraitJia : 

• BfEDICAL, SURGICAL, OBSTETRICAL. 

IDEN'TIFJCATION FROM A FJNGKn-Tir 
REMOVKD Ijy A BITK. 

(With' Special Phitc.) 

A I'intsON' ln'oko into a lioiiS(' in an l'i"\i)tiau village with 
intent to ml) or with some other intent. During his 
jieregrinations he entered the room of a woman, and she, 
ill self-defence, hit his. finger with Miffieient force eom- 
pleteiv to sever the tip. The visitor made his escape 
without being recognized, ns the place was in absolute 
daikiiess. 

Fortnnntely the lady did not swallow the finger-tip, hut 
handed it over to the police when she laid a complaint 
the following morning. Instructions were issued to watch 
for anyone with an injured hand, and ten days afterwards 
a man with his right hand wrapped up in a liandUerchicf 
was arrested on suspicion at a railway station in the 
district. It was aseertained that he had lost a portion of 
his right index finger, and he was .sent to the medico-legal 
dcjmi'tnient, togetlier with the seized finger-tip, in order 
to aseert'ain whether the portion hitteii oR heloiigod to the 
iiijiircd hand, . . 

On examination of the acensod person it was found that 
the injury to the finger had been cnii.scd hy a hite. X-rav 
examination of the hand .shou'etl that tlie Into had passed 
through the base of the terminal phalanx of the index 
finger. A’-Tay oxamination of the spceipien showed that 
the (listul j)ortioii of n plininiix was present. A comparison 
of the finger-nail on tlie specimen with that of the left 
index finger of the acctiscd showed tliem to he exactiv 
similar. 

Thetc was thus an extremely strong presumption that 
the man arrested was the guilty person. The a« iise<l ira.s 
then asked if he had been in trouble before to wliieli lie 
replied that on a previous oecasioii he had been arrested 
on n false charge— that was in 1019. The antecedents 
hnrenii wins inirncdi.atcly asked to siipplv tlic finger-iirints 
taken on tliat occasion, and on comparison of th^ print of 
the right index finger with Hie tip bitten off it wis found 
that the liiitterns and ridge dotiiils wore identical. 

the oiigiiial fi^iigor-prini. Soreii points of identitv Iiavc 

mnnv"' h » g<'Oat 

of ?iie aemSd. “'-“■fixation 


Sydxev .Smith, M.D., D.P.H., 

Professor of ’Kfedicut Jnrispriulpnce, 
University of EclinUiirgh 


. EMBOLUS OP the SUPERIOR MESENTERIC 

' , . , artery. . 

and svLLis r 1? textbooks of the sign: 

o tli^slorT v ohstruetTo. 

rln w f, P nieseiitenc artoiy- prompt me to place o. 
lecoid the crimcai lnstovy of a patient i/nder mv cLc ,vIk 
leceutly developed tins complication. ‘ ' 

(ions 'and account of " palpita 

fibrillatiiif. Until the previou” fol a, -f 

/tfe, interrupted bv no^ sDcci-il ^ an acijr< 

c-nJarged, but no bruit was detected heart was slightlj 

in bed and wa? was instructed to res' 

three times daitv. ?n (wo she u 

thenceforward the heart steadiFy 

puhd had become regular aiid tenth day tin 

troubles were ended. She was hovrpvf^y’^’u 
dosage being reduced to 10 mi'mtii Two 

sudden attack of xcry severe aKriArv,- ® 

to the epigastrium, jfc occurred mainl: 

which had consisted of some milk midday meal, 

few minutes later it was and n 

Her condition was unchanged throimJinn/M”***?*® diarrhoea, 
evening. The vomit at first ^'nnc.; afternoon and early 

subsequently of bile-stained fluid ' Th ^ contents and 

Wiihin hair an ho^ of IL nnerf n stool was faecal, but 
passing blTOd-stained mucus. Tlii vLitfn/''und' A1-v'’l‘'''"^ 
severe. The abdomen remained “St "und no i 
devcoped. The pain was described^ as' cltk^ 


mainly in the upper half of the abdomen. There was no sugges- 
tion of collapse, the patient repeatedly altering ‘her po«^ition in 
bed, and at limc.s getting out in attempts to ease the pain. The 
pulse remained strong and steady. ' Rectal examination was 
negative. No drug alleviated the symptoms till about 6 p.m., 
when two large doses of bismuth were retained, apparently casing 
the pain and stopping the vomiting. 

Towards 9 p.m., however, the pain regained its original severity 
and was accompanied by repeated retching or vomiting snd occa- 
Monal diarrhoea, the stools now being smaller, but still consisting 
of blood-stained mucus. At midnight no fresh signs had developed 
in the abdomen and the pulse rate remain unchanged. An in- 
jeetiou of morphine was given, and for the next four hours 
relief was obtained.- At 4 a.m. the pain recurred, though to a 
less degree. The abdomen was now a little tender over the 
caecum and ascending colon, but still there was no local guarding 
or rigidity, no visible peristalsis, and no apparent distension or 
free fluid. Throughout the morning the pain continued with 
occasional short intermissions and occasional vomiting, the vomit 
being yellow fluid. The - bowels were not again opened. The 
abdominal signs remained unchanged, but the pulse rate increased 
from 70 to 94, though still remaining strong and regular. At 
2 p.m, the tenderness over the caecum und ascending colon had 
increased considerably, the abdomen appeared rather distended, 
and free fluid was present. Tlie patient complained of some pain 
in the sole of the loft foot. Half an hour later faecal vomiting 
commenced and the right side of the abdomen became moderatelv 
rigid. Arrangements were now made for the patient’s admission 
to the Gloucester Royal Infirmary'. Just prior to her departure 
from home the left radial pulse became obliterated, and shortly 
afterwards numbness and coldness of the left hand and forearm 
developed. 

5^dmis5iou to the infirmary the patient was seen by Mr. A. 
Alcock, who diagnosed (he condition as being embolism of the 
superior mesenteric artery. By this time distension Iiad increased 
very considerably, the whole abdomen was rigid and. tenderness 
gcneralixcd. Mr. Alcock opened the. abdomen under local anaes- 
thesia; pngrenons small intestine was found, and the dia^^nosi*; 
was confirmed. The wound was closed, and the patient died the 
Following day. 

This ense not only affonls an iJIustration of the clintcai 
picture liuble to be found in ombolic obstruction of the 
superior mcpcnteric artery^ but it al.so shows tlie im- 
portance of n thorough consideration of everv smiptoiii, 
liowever small, before coming to a conclusion. The first 
clue to the correct diagnosis was presumably the pain in 
the foot, but at the time of its occurrence I attached little 
importance to this symptom, and thought that the cause 
of all the trouble was probably a volvulus or possibly au 
intussusception. 

Harold J. Selbt, M.R.C.S., L.R.C.P. ■ 

Kewnliam-on-Sevcrn. 


TKUM TKrAMJS. ' 

The ense of tetanus described bv Dr. J. D. Chisbolm and 
Dr. Arnold Rensh.aiv (February 4th, ji. 175) Tecalled to 
my mind a case in my own experience. 

A Hausa man was brought to hospital on a lorrv ; wlien I saw 
him first he was resting on his abdomen and chest, with botli head 
"5“ -iV J ® raised and with marked risus sardonicus He wa.s 
admitted to a single ward and further investigation showed that 
tlicro were suppurating cluggers in the toes of botli feet. Left 
to mmsetf the patient lay on his right side, with marked archin» 
1®"?1 retraction of the head. He was bnable tS 
separate his teeth, but could move his arms and hands His 
temperature was not raised,, hut the pulse rate was increased 
On attempting any examination or on the slightest disturbance 
spinal muscles, and risus sardoniW 
Ram seemed to be most intense in the lower cervical and lumbar 

obta’ra^'hlsrJ?? 'of muscles. It was impossible to 

oota.n a history of the sickness, but apparently he had been 
helpless for about five days before ndmissiL. ^ 

„;5i* toes were treated and a soporific given; that 

night the patient slept well. Next day there was very little 

toofc^llauftfTo 'rj's slightly diminished. He 

d^es "'u • ?°tassium bromide was given in moderate 

^ 1 four-hourly and later three times daily. After four 
"'’"O'ls were heahn» and the spasms were less serere. 

favourably till in the third 
pMient was able to walk with only slight stiffness of 
about to bc discharged when he passed a 
ge quantity of tapeworm; after helminthic treatment he left 
the hospital apparently in normal lieabli. 


Altlioiigh on admission this patient had been considered 
moribtnid, complete rest and freedom from disturbance, 
together with scdative.s and dressing.s to the feet, were the 
only lines of treatment open to ns. I despaired of his 
recovery, thinking that even had antitetanic serum been 
available the rase was too far advanced for it to be of use. 
I had been led to this conclusion hy the earlier caw.s 
which I had previoirsly unsticcessftiliv' treated with iar"e 
doses of the serum. I have never before seen recover^- ?n 
such a severe case. ^ 


Reblta, Nigerit ' Q LoWE. 



768 May 5 , igj 8 ] 


SCIENTIFIC PROCEEDINGS OP BRA-NCHES. 


[ TMnBnmw 
Jfl DICAl. JOURSIL 


Brittslj ittttiicnl ^ssodntimi. 


CLINICAL AND BGILNTIPIC PllOCKEDINGS. . 

- CITY DIVISION. 

FibiosHis. 

At n meeting of t\\o City Division, on Ajivll ovti, nt tUo 
Metropolitan Hospital, nith Dr. Pinin' Hamili in tlie 
eUaiv, Dvs. T. H. G. Snonn and G. T. Loughuqiiougu of 
the Metropolitan Hospital read papers on the treatment 
of fibrositis. 

Dr.' Shore recalled that in the report of the Ministry of 
Health, 1824, “ rheumatic ” diseases were stated to account 
for one-sixth of the total invalidity of th.c working popula- 
tion. Half of this was stated to be due to joint disease, 
and the bulk of the remainder comes under the head of 
fibrositisi Chronic rheumatism, muscidar rheumatism, and 
fibrositis had been tlefined by Stockman as “ a condition 
of chronic inflammation of the white fibrous tissue of .the I 
fasciae, aponeuroses, sheaths of muscles and nerves, liga- 
ments, tendons, periosteum, and sidicutnncous tissue occur- 
ring in all parts of the body, and giving rise to pain, 
aching and stiffness, and other symptoms, the result of 
preceding general infections or of local infiammations or 
injuries.” The name fibrositis ” was first given by 
Gowers in 1904. From Stockman’s histological investiga- 
tions it appeared that the local lesion in the fibrous tissue 
consisted of an inflammatory hyperplasia, scattered in a 
patchy manner in the affected parts. At first was seen 
a localized collcctiou of fibroblasts and Icvicocytcs, with a 
serous or sero-fibrinous exudate ; later on, young fibrous 
tissue was formed. When acute exacerbations occurred the 
tissue became swollen, and more inflammation and exuda- 
tion was seen, with, later, move fibrosis. Like all newly 
formed pathological fibrous tissue this contracted, and pain 
was produced by the pressure of the contracting tissue on 
nerve endings and on the nerves tlicmselvcs; jiavtial 
strangulation of vessels accentuated the tvoviblc. Tho 
tissues affected were those wliich carried the blood vessels 
and acted as insulators for tho nerves, but derived them- 
selves very scanty supplies from cither. Vessels supplying 
the actual fibrous tissue wore very small, and were, tlierb- 
fore, especially liable to bo affected if the cause of tho 
trouble was of an embolic nature. In chronic cases, in 
which foci had heon inflamed several times, fibrous thicken- 
ings, somewhat resembling tive nodules of acute rheum- 
atism, might be found; these iiad been called “tophi 
rheumatici.” They appeared to bo capable of interfering 
with the vessels conveying Wood to more distant parts, 
either directly fay pressure or_ indirectly by deranging the 
vasomotor mechanism. As a result muscular weakness and 
muscular wasting might he produced. The initial lesion 
in fibrositis was histologically of the same nature as tho 
rheumatic nodes of Aschoff in the myocardium. The cause 
of the fibrositic lesion might reasonably be expected to 
be similar to that of rheumatic myocarditis. Although 
no definite causal organism was known it was iirobably 
resident in tho apices of infected teeth and the tonsils 
or, less commonly, in tho prostate, the urinaiy tract, the 
cervix uteri, the gall-blatlder, and, perhaps, the intestine. 
Infections such as “ colds,” influenza, gastro-intestinal 
catarrhs, and infections of the accessory air sinuses were 
enough to light up the trouble in the primary foci, and 
indiscretions of diet, constipation, and gout might deter- 
mine an attack. Dr. Shore suggested that the actual 
e.Tu«e of the pain was of a vascular nature, either a vaso- 
constriction hy toxaemia or a structural interference with 
the vasomotor niechanism, or, more likely, both operating 
together. The various local measures were directed to 
iiicroaso the blood supply to the part, and when they 
relieved the condition they did so in that way. Massage 
should always he applied to the most painful parts, for 
it was there that permanent fibrous thickenings existed, 
which massage alone could disperse. Others were faradism, 
ionization, diathermy, radiant heat, and ultra-violet light* 
which probably acted mainly in the same way. In cases 
in which intoxication from constipation had a share saline 
aperients were valuable. Certain drugs wliich had dia- 
phoretic actions hy virtue of being vaso-dilators relieved 


fibrositic pain; such were ammonium acetate, spiritus 
aelheris nitrosi, and Dover’s powder. At one time quinino 
was much used for' this purpose, and on account of its 
cost was often: adulterated with .saliein: 'This led to tho 
uso of saliein, and later the salicylates and aspirin; at 
about tho same time the coal-tar derivatives phomizmie and 
phcnace'tin became popular, a very favourite mixture being 
aspirin, phenacctiii, and caffeine.' IVhen gout could ho 
shown to ho a factor in tho case colehicum and the moro 
veeout cinchophen wore useful for a time, hut could not bo 
expected to act after thoii' function of eliminating excess 
of uric acid has been performed. These drugs should ho 
employed iu short hursts only. Giiaiacol carhonato was 
useful in some eases. Calomel and blue pill were very 
useful internally, and tho mercuric iodide ointment extern- 
ally. Dr. Shore bad found potassium iodide disappointing, 
tliough Graves found his own attack passed off so that 
he noticed relief coming almost hourly, after he had suffered 
for several weeks on other remedies. Iodine had been used 
for intramuscular and intraveiioiis injection, as well a.s 
externally as a counter-irritant. Methyl salicylate, luoulhol, 
and camphor, tliough their smell was ohjeclionahle to some, 
were quite good as c.vfornal applications. Fibrolysin liad 
proved very disappointing in tho hands of most who had 
tried it. Vaccines, whether “ stock ” or autogenous, had 
also not been very beneficial. 

Dr. G. T. LoUGiiiioitouon confined bis remarks to tho 
physical treatment of fibrositis, including the mechanical, 
electrical, and nulio-therapeiitic procedures. Skilled 
massage lielpcd to relieve muscle spasm in tho acute stago 
and to induce hyperacmia of the alTected tissues; iu tho 
more chronic cases it freed tissuc.s matted together by old 
oxndato, loosened stiff muscles, and so enabled them to 
increase the blood supply both to themselves and the parts 
around them, and by actual attrition icmovcd the fibrous 
nodules associated with this disease. Electrically driven 
vibrators were sometimes used, hut their action could not 
bo accurately contvoUed. Of true clcctv.ical methods ioniza- 
tion was still used, but tho actual amount of drug intro- 
duced through tho skin in ionic form had been proved to 
be so small, and also to bo carried at onco by the super- 
ficial blood stream, that it could not' possibly have any 

■ effect. Anv benefit which occurred must ho duo to tho 
steady passage of current through tho affected tissues: 
this ^if steady and prolonged long enough, would uii- 
dou'btcdly reduce effusions and exudates, first hy the forma- 
tion of ions, and secondly, by causing these ions to move 
in a constant direction through tho tissues. This process 
altered the chemical constitution of tho effusion, and 
helped reduction by changing tho osmotic pressure. It 
was being used for fractures at tho Royal Free Hospital 

• with much subsidence of tho swelling and earlier relief of 
naiii. The sudden contractions which occur as tho result 
of tiio stimulus of intermittent currents loosened tho 
1 adhesions if present, and slightly increased blood flow would 

■ occur in the muscle. Radium and x rays wore pene- 
trating, bigh-power rays, and their action was too dcstruc- 

■ tiro to bo of any use iu fibrositis. In spito of its super- 
ficial absorption, uUrn-violet radiation was an extremely 
potent agent iu tho cure of fibrositis; the explanation of 
this was probably : (1) the benefit was partly due to tho 
general tonic action; (2) the I'.cat produced by ahsorjition 
travelled inu’ards hy conduction, tho absorption taking 
place deep to tho superficial blood stream; (3) the hyper- 
aeraia produced also spread inwards hy reflex action; 
(4) tho apparatus used also produced waves of many other 
wave lengths going right down into the infra-red, and it 
might be that it was from these other rays, or the com- 
bination of them all, that the benefit was produced. Tiio 
ravs from the snn or its substitutes, the carbon arc and 
various tberapniitic lamps, acted mainly by their_ general 
tonic action on the blood; the deep effects were secondary 
to this or ■ depended on the presence of rays other than 
those of visible light , Heat in various forms had long 
hecn used as part of the cure of fibrositis. Iu order to get 
energy to the deeper affected parts either diathermy 
currents or the most penetrating infra-red rays must bo 
used. Diuthenny was a enneut of such high frequeiicy 

'that it could not bo felt: considerable power could theie- 
fore be passed through the patient, which hy the resistance 


Mat 3, i9»8] 


NON-EXOEETORT FUNCTIONS OF THE KIDNET. 


t Tne Bnmsit 7#iQ 

■MzvtCAI. JOCSXAL * ^ ^ 


of the tissues uns chnngcd into heat. Heat, generated 
in the deep tissues, ])rought I'apid relief h}' vaso-ailatatiou 
and inereased Wood supply ; seeondlj’, heat acted ns » 
eatalytic agent, starting eheniieai reactions such as tho 
oxidation of products of fatigue and disease; thirdly, 
energy hy molecular and atomic collisions formed new 
ions, u-hich in their tuni altered tho electrical charges of 
atoms r\nd the chemical and physical state of molecules, 
■as, for example, reduction of the viscosity of exudates and 
tho increase in the permcahility of membranes. At j)rescnt, 
the most useful physical aids in tho treatment of iibrositis 
were, in the acute stage, diathermy to produce internal 
heat, and ultra-violet rays, preferably from a cored carbon 
arc which gave almost the .whole range of ether w.avcs, 
the shorter for their tonic effect, and tho longer infra-red 
rays for the heating of the deep tissues in a way similar 
to, or perhaps better than, diathermy. In tho more chronic 
stage contiuxiancc of the. above two methods was required, 
with the addition of skilled massage to remove adhesions 
and for the unmatting of tissues. 


fieports nf 


THE NON'EXCRETOliY FUNCTIONS OF 
THE IQDNEY. 

At a meeting of tho Section of Jfedicine of the Royal 
Society of Medicine, held on April 24th, with tho president. 
Dr. A. F. HunsT, in the cliair, Professor SxArrEn of 
Amsterdam read a paper on the non-cxcretoiy functions 
of the kidney and their clinical importance. 

Professor Snapper said that the kidney was usually 
regarded as an organ of excretion, but if the energy used 
up by the kidney were calculated, although a large amount 
was required for jiroducing tho hyperosmotic urine, this 
did not account for all the energy consumed. It was 
customary to regard tho liver as having an excretory 
fmiction for bile, hut as being mainly a gland liaving great 
metabolic importance. In tho same way the kidney had 
an excretory function, but had also a metabolic function. 
He then iioiiited out the importance of the obsei-vations 
of Nash and Benedict,' who showed that ammonia was 
formed in the kidneys of certain animals, a factor of 
great moment when largo amounts of acid had to be 
excreted, for the process could continue effectively so long 
as the kidney function was unimpaired. In certain circum- 
stances this function of tho kidney was impaired and 
a condition of acidosis resulted which could be obseiwod in 
uraemia. In diabetic acidosis also the imjmircd function 
of the kidney for ammonia formation interfered with the 
excretion of ketone bodies. The important point in diabetic 
conditions was, of course, tho accumulation of ketone 
substances in the body fluids, and there were cases of 
diabetic ketosis in which the amount of ketone substances 
in the urine was only very slight, although a large 
ketonaemia was present. In such cases the ammonia 
content of the urine was hardly increased at all, and even 
after ti’eatment with insulin such cases for a long time 
passed urine witli diminished ammonia excretion. Tlie 
ketonaemia in such cases must he regarded as partlv due 
to the failure of the fmictiou of the 

kidney. Dealing next wi'b . .. of the kidney. 

Professor Snapper mentioned the well-known power the 
kidney possessed for the synthesis of hippnric acid when 
perfused with benzoic acid and glycocoll. Such sy-nthesis 
liad^ recently been confirmed as occurring in the Iiuman 
subject as a result of expci-iments on kidneys removed at 
operation, and it had also been shown that a similar 
synthesis took place for other acids of the benzoic scries. 
Another non-excretory function of the kidney* was its power 
of oxidation, and this, had heen shown experimentally to 
occur with the aromatic fatty acids. It Imd also been easy 
to show by perfusion experiments that beta-oxy-bntyric acid 
and diacetic acid conk) bp destroyed in large aiiionnis bv 
the kidney, and it was therefore important to consider 
whether in diabetic coma the condition was in anv way 
due to an impairment of this oxidative function of the 
kidney. There were still cases 'of diabetic coma in which 


treatment hy insulin rednecd tlic hyperglycaemia, tho 
hypcrketonacinia, and the ketouuria, and yet failed to save 
life. Most cUnieians considered that such cases died of 
a failure of tho eirenlatory system. Tho. .speaker was of tho 
opinion that while these eardio-vasciilar factors were of' 
great importance there were other factors, of which renal 
iiisnfficicncy wa.s next in scrionsno.ss. It had been known 
for a long time that albuminuria was frequently present, 
especially in eases witli ketouuria, and tite older clinicians 
thought that there was some connexion between these two 
conditions. Iii diabetic coma it was often possible to find 
evidence of retention of urea and non-protein nitrogen 
in the blood, and nracraic coma was .sometimes diagnosed 
erroneously. One jjossihle reason for nitrogen retention 
was the oliguria which occurred in s\Kh cases, but this was 
not the only cause, for some had ])olymia and still had 
nitrogen retention. The urine in these circnnistanccs con- 
tained only small amounts of inca, and it was evident 
that the kidney function wa.s impaired. It was possible 
to divide examples of diabetic coma into two groups. ■ In 
one, in young subjects, owing to incorrect diet, there was 
a liyperproduction of ketone substances causing intoxica- 
tion, even though tho destruction of such substances was 
proceeding at a normal rate; these could be cured hy 
insulin, which stopped the hyperproduction of these .sub- 
stances. In tbe other group degenerative ebanges bad set 
in in tbe kidneys, and even a moderate production of 
ketone bodies led to intoxication. Insulin would remove 
the liyperproduction of ketone bodies in shell cases, hut 
the impaired kidney function led to death, for the destruc- 
tion of these ketone bodies did not' go bn properly. There 
were pathological proofs of tbo.so ebanges in the kidneys, 
for at antojisy they could he found to be yellow from 
fatty degeneration, and microscopic examination revealed 
glycogen degeneration in the tnbnlcs and a special form 
of nceiosis in certain of the tubules, especially in the 
desc-ending limb of Hcnle’s loop. Frofessor Snapper lastly 
dealt with the importance of these functions of tho kidney 
in diabetic therapy, calling attention to the’ high fat diets 
used in certain countries, in which ketosis did not occur as 
long as the amount of protein was small. It was suggested 
that by relieving the load on tho kidneys in those low 
protein diets the destruction of ketone bodies in largo 
amounts could bo carried out. 

Dr. R. D. L. 1 WREXCB said he thought those ease.s of 
diabetic coma which did not recover died from circulatory 
depression rather than from renal changc.s. He found casts 
and protein in the urine of every case of coma, and tlie 
prognosis did not appear to depend on this. • Ho agreed' 
that in cases witli oliguria the prognosis was had, hut iio 
thought this was probably due to low blood pressure 
rather than to renal insufficiency. He did not think that 
the addition of ]iroteins to a high fat diet produced ketosis 
because of tho added ’ load on the kidney, but was more 
probably duo to tho production of fatty acids dnrint' tho 
metabolism of the proteins. 

Dr. E. P. PouLTOX said that nitrogen retention was 
almost a regular feature of diabetic coma. He thought 
that circuI.atory changes were of most importance in the 
death of those patients who did not respond to insulin. An 
important point in treatment of such cases was the giving 
of large quantities of fluid. 

Professor F.ahr (Minnesota) thought that the caiise of 
de.ath in those cases of diabetic coma which failed to 
respond to insulin was circulatory faiUire. He nieiitioned 
recent work in America and Germany which wont to shmr 
that a condition resembling shock was present in such cases. 
Sir John Broadbext, Dr. P. J. CAJiitinoE, and Dr. P. 
Parkes IVeber also took j)art in the discussion, and 
Professor Sxai'PER replied to certain questions. 


POST-ENCEPHAEmS PROBLEMS. 

At a meeting of the vSection of Epidemiology of the Royal 
Society of Mediciiie on April 27th Dr. Altax C. P.vrsoxs 
read a paper on post-encei)liaIitis lothargica and its 
problems. 

Dr. Parsons said tliat encephalitis lothargica was first 
recognized in this countiy ten years ago; wliile the- etio- 
logy of the disease remained obscure there was more 


760 MAT 5, 1928] 


POST-ENCEPHALITIS PROBLEMS. 


Trtr nr.mrt 
Mi'ftJCAL JoUR’flt 


knowledge now of its varied clinical ninnifeslaiion.s, and 
certain facts concerning its epidemiology liad been noted. 
The disease seemed to bp relatively prevalent in tbeso 
islands compared with other conntrie.s; diagnosis, treat- 
ment, and prognosis were difficult. Attention was now 
being chiefly focused upon post-encephalitis — the chronic 
phase of the disease which frequently follows the so-eallcd 
acute attack ; it was marked by various signs and symptoms 
which might cither have persisted from tlio original illness, 
or might have supervened after tho acute attack had 
apparently ended or had passed unrecognised. II|)on the 
general population encojrhalitis lethargica, fortunately, 
made but small impact, and its incidence rate of 0.06 per 
thousand might bo compared with that of 0.07 for enteric 
fever, and contrasted with rates of 2.10 and 1.45 for 
scarlet fever and pulmonary tuberculosis respectively. 
But, with tho possible exception of ccrcbro-spinal fever, 
there was no disease which had, at tho same time, so high 
a case-mortality rate and so high a case-di.sabloment rate. 
In most of the fatal cases death occurred during the first 
three weeks of the primary illness, but it had become 
evident that in a not inconsiderable number it supervened 
at much longer inten-als after onset. Thus of 452 death 
certificates received during 1926 in which tho necessary 
particulars were given, 9.7 per cent, had recorded the 
death as occurring two years, 6.9 per cent, three years, 
and 2.6 per cent, six years after onset. It might bo 
estimated that encephalitis lethargica eventually killed, or 
helped to kill, between 35 and 40 per cent, of those whom 
it was known to attack. 

Consideration of various series of after-histories relating 
to patients notified in London, Glasgow, Belfast, Man- 
chester, Bristol, Sheffield, and other largo towns .showed 
that a largo proportion of patients did not completely 
recover from their primary illness, but suffcrerl from 
sequels of varying severity. Thus of 1,173 patients notified 
in London during 1919-25, and whoso eases were reviewed 
in 1926, 29.1 per cent, were found to bo suflering from 
sequels; in 356 unnotified patients of tho same scries tho 
sequel rate was 60.9 per cent. A review, after twelve 
months’ interval, of tho cases notified in tho peak year of 
1924 in Loudon, Lancs county, Sheffield, Glasgow' 3Ian- 
chestcr, Belfast, and Ncwcastlc-on-Tyne, showed that tho 
sequel rates respectively for these local scries of cases were : 
London 35.4, Lancs county 45.8, Sheffield 65.7, Glasgow 

37.3, IManchestor 50.7, Belfast 74.7, Nowcastlc-on-Tyno 

34.3. Tho mean sequel rato in the case of 3,112 patic'nts 
notified from these same cities over varying periods worked 
out at 41.9, and in rather more than half tho number of 
patients the sequels were serious enough to prevent work 
or education. 


The signs and symptoms of post-encephalitis were 
gcneially reminiscent of those which characterized tho 
primary stage of the disease, and, with tho important 
exception of Parkinsonism, as emphasized bv H.all it 
might be said that serious sequels wero usually 'anticipated 
by severe symptoms in tho initial illness; mental deteriora- 
tion and conduct changes wero also characteristic of the 
afterraatli of encepha htis lethargica. By reason of their 
inteiesting varie|.y the sequels of encephalitis invited 
classification as die primary symptoms of tho disease had 
done, but for administrative purposes it was more useful 
to classify the post-encephalitis sufferers, rather than their 
symptoms, into three groups; (1) those who suffered niainlv 
from physical sequels; (2) those who chiefly showed siens 
of mental deterioration; (3) those who exhibited demoraliza 
lions. This grouping was only loose, and a patient might 
partly qualify for two or more groups at the same time Or 
ho might pass from one group to another at different stages 
of his post-encephalitic career. No physical sequel was so 
well known as Parkinsonism; indeed, so common and so 
important was ibis particular syndrome that by some it 
was regarded as almost synonymous with post-encephalitis 
lethargica. Roughly speaking, about half tho patients who 
manifested after-effects developed Parkinsonism sooner or 
later ; tho latent period varied in most cases between three 
and eighteen months, but in a few instances this had 
been prolonged for two, three, and even five years. Unlike 
paralysis agitaiis, post-eucephalitio Parkinsonism affected 


malc.s and fcinnlcs about equally and wins by no moans 
I restricted to elderly subjects; tho majority of sufferers, 
Miidccd, wero under 30, and children wero commonly 
I affected. Isolated instances of recovery had been reported, 
,tiut as a general rule the. condition ended fatally, .and 
'accounted for tnosl of tho Into doatlis from cncopiialitis 
i lotbargica. 

It was probably not too mneb to say that tlio montnl 
processes of every subject of encephalitis lethargica wero 
affected in some degree, either in tho primary attack or 
subsequently, and tho patients themselves fell c.asily into 
two classes — namely, those who were restless and excitable, 
and those who wero didl and depressed. Typical of tho 
irritable or jio.sitivo typo of mental distnrhance (and almost 
pathognomonic of post-onccphalitis) was tho nocturnal rest- 
lessness associated with tho inverted .sleep rhythm uhich 
was so common in children. Positive symptoms of a move 
sovero tvpo were displayed by those older patients who 
were subject to maniacal outbursts or homicidal imputeos. 
A different- piclnro altogether was presonted by 1 10 
depressed or passive typo of post-encophahtic patient. Jim 
Imekward child’s inability to make any progress at schoo 
was duo to a dulled intelligence, an impaired memory, and 
perhaps drowsiness, rather than to the rc.stlcssncss im- 
paticjicc, anil lack of concentration which made tcachois 
despair of tho excitable typo of child. Children in an 
advanced stage of Parkinsonism often provided examples of 
the passive tvpo of case, hut it was mainly adidt patients 
who tvpicnll3' suffered from mental anergm. , The mental 
dislmhanco in both the excitable and the depre^ed types 
might ho sovero enough eventually to justify certificatio , 
tho cxcitnhlo ones mainly for tho sako of oGicr.s, the 
nnssivo onc.s mainly for their own protection. Vp to the 
end of 1927 there liad been admitted to mental hospitals 
Hid mental deficiency institutions 674 patients whoso 
meltrconilitlon was^ caused by encephalitis lotbargica 
The snbiccts of dcmoralizntion.s (Group HI) "0>c foi the 
el unit ridldrcn and adolescents; .tbrongli lack of inhibi- 
tion tbev had become quite unmanageable at homo, w#re 
• 1(1 Iviiie and thieving, committed crimes against 

ami found their way into rcform.atorics or prisons. 
^1 'it-ns little or no intollectnal impairment in the case 
^";r„Jeb dren though they often lacked the “capacity 
for* mental comparison and discwraiiiation ’’ ; 

Zrnlly defective, and exhibited startling changes, foi the 

I " Tho m-ot'len«*of post-encephalitis varied considovnhly 
^ v,rth the ago of the patient. Eoleasod from the 
ilisdn nS mul rontfno of hospital life, with a disposition 
1.^1 eX altered and with nocturnal restlessness as a 
^iir'iifc svmntoiii, the young irritable cliild soon bccnino 
rC— cable ov, as the subject of Parkin- 

sonism ho '’might bo teased by thoughtless biotbcis am 
Ss ’ or scolid by impatient parents for a slowness of 
’ •>! nnd bodv the significance of winch was not nndei- 
In cither case tic patient was out of place at home. 
In LcndcTthe question of edneatiou had to bo co.i- 
Ldeied and generally speaking, it was found that a return 
their usuM school Vas not practicnblo for children 
seriously handicapped by post-onceplinhtis. For “mo, the 
schools ^for backward children might provide the axtia 
indtvidnal attention and patience required; unfoitunatelj, 

1 the nbysiccl and mental consequences of the 

disease wero so frequently accompanied by conduct changes 
that these children imposed an unjustifiable strain upon 
and might cause physical or moral barm to tho 
other children. The resources of tho Board of Education 
might then become exhausted, and it was in these circling 
stances and for children with some prospects of imprm<> 
ment, 4at an enceplialitis unit like that at M inclnnoro Hill 
—with its special arrangements for canning on the cluUl s 
education while under medical tre.atraont and institutional 
disciplinc-seeiiiod to meet a neef 

reformatories had not, in tho opinion of tho Homo Oflice, 
proved siiitahle repositories for the troublcsomo hoy or girl, 
Of tho 108 children admitted to tlieso Homo Office schools 
up to January 31st, 1927,. 57 had been discharged, and 
of these '95 per cent, showed no improvement. Fresh clim- 
culties arose when tho youth, now over school ago and 


BEVIBWS. 


[ thk xsnmsH ' 7fil 
SlemciL JocBifii. 


Mat 5, 1928] 


iinlouluillv more tinugcrous, was aiwhiugoa fvoin th(- Homt: 
Onice sfltool; ho vns iiioro than ovor luisviitoil for Ins lioinci 
lio rnrdv gavo satisfaction it i)infOtt o\>l in omploymont ; 
lie miglil lie toloratod for a time in a Tnor Tauv institution 
if ho consented to remain there; and, until tl\e Mental 
Deficicney Act was amended at the end of 1027, it was 
seldom tlrat such a ease eodld he eerlified. Tims under the 
principal Act of 1913 it was not found possildo to certify 
more than one-fifth of the juveniles under training in 
Home Office schools, iiteanwhile, the ex-reformatory school 
inmate might c-ome into more serious contact with the law, 
and ns a result he placed in a Borstal institution, or he 
might he committed to prison. Borstal training had not 
apparently jirovcd of much avail; hut of the 72 jio.st- 
encephalitie suhjeets who were admitted to prisons during, 
the )>eriod A]>ril 1st, 1925, to ^larch 31st, 1927, the 
SIcdical Commissioner reported that 54 *' showed either 
110 harmful elfcct from imprisonment or were definitely 
improved.” 

The adult post-encephalitic patient, sufferiug typically 
from jdiysical infirmities or from mental anergia, was less 
prominent, though often prc.senting an anxious domestic 
prohlem. It might bo the hreadwinner who covdd not 
retain his old job, nor prove himself .suitable for others, 
who then sat at home by the fire homoauiug his fate and 
liccoming a hurden on his family. Or it might he the wife, 
once the intelligent maimstay of the home, who had now 
hccomo careless and lethargic, uiAnindful of her children 
and without any interest in her household duties. Such 
cases were not eligihlo for hospitals, nor were they nelcomed 
in convalescent homes and such places. Eventually a 
certain nnmhcr of these patients hecamo certifi.ihlc, hut 
a greater proportion found nltiinatc refuge in Poor Law 
institutions. 

FniThcr rc.scareh into administrative methods was heeded 
before it eonld ho decided what were the hest method.s for 
dealing with these various types of post-enecphalitis patient. 
For the present, it woidd seem that young snhjccts, under 
puhorty, with slight psychic disturbance and niioso general 
prospects were not hopeless, merited such institutional 
facilities as the Mctroiiolitan Asylums Board had provided 
at u inchmore Hill; for manv of the difficult adolescents the 
amended Mental Deficiency Act of 1927, it was hoped, 
Mould jirovo scrviocahle iu securing for tlnun ndeejuate 
control and protection. That the, lot of the unccrtifinhle 
adult cunld ho lightened and his domestic anxieties relieved 
had been proved by tlic c.xamides of Bristol, Glasgow, and 
other places, ■where, as The residt of .sv injiathf ‘tic ciKoporfl- 
tion uenveen the various local clojuu'tnionis cotuornccl, 
special arrangements had hocn made for these patients in 
existing Poor. Law institutions. 


A MEETIXO of tile Wolverhampton and District Clinical Club 
mu 'tv "n * Hospital, Wolverliamptoii, on April 

, . -^^STON demonstrated ch'nicailv an instance of 

bilaternl CIrarcot’s joints, affecting the knees, in a patient 
with tabes doesahs. Mr. ,S. JfAsLEK .Tokes deserd.ed a case 
of liydramnios associated with uniovular tuiiis, and criticized 
several theories accounting for the great exce.ss of liquor amnii 
in t Us condition. Dr. W. R. Someaset exhihited the inhoJer 
for closed ether anaesthesia which he has invented, and 
desenbeej various methods of using it. He emphasized the 
benefit of starting anaesthesia with ctlivl cMovide before passim, 
on to full ether. ■ : . ’ > o 


The Bu£ic;nVe ffericir, published for the Eugenics SocieG 
has hitlierto been circulated among members of that hod 
only, but it iias “ow been decided, in order to meet th 
groTving interest which is believed to exist, to make tl 
/ ecifir available to a wider public hv placing it on sale i 
the ordinarj' way. For the April issue-llie first to appes 
under the new reg,m<r-.T more attractive format has b^ee 
Tc«o^r?'i the contents is an extended report of tli 

1928 Gallon Lecture on ‘‘Causes of Racial Decay’’ hv Mi 
C J- Bond, of which a summary was published in our issi 
of lehruarj Mtli (p. -315). A noteworthy feature, particnlarl 
ot tlie editorial notes and hook reviews, is the lively, not ( 
■saj proyocntiyc, manner in which the various rontributoi 
ciciil With their subjects. 




"TAVLOR’S rirKDICAL JITRISPRUDENCJ*:.” 

In ])i*t']>ai'ing an ciglith edition of T<n/ioj'*s I^r/ncipics of 
Medical J urixinudcacc^ the publishers have very wisely 
sidfinitted the work of revision to well-known authorities 
in both the medical and legal professions. A medical man, 
even thongli jiosscs.siiig extensive court oxjicrieiice anr, 
perhaps a law qualification, is hound to regard the siihject 
from the medical aspect, and the advantage of having the 
legal viewpoint incoi'iiorated in this premier work cannot 
be overestimated. Especially is this the case in the present 
edition. 

Professor .Svdney vSjcith is one of the few men wlio 
liavc devoted tlicniselvos entirely to the study of forensic 
medicine; he has enjoyed tinrivallod opportunities for 
forensic firnetice in Egyiit, where until recently lie was 
the principal inodico-lcgnl adviser to the Egyptian Govern- 
ment. Togotlior with Mr. W. G. H. Cook of the jMiddie 
Temple lie has not only hroiiglit Dr, Taylor’s famous work 
up to date, hut has restored to it a groat deal of the 
personal touch which is so apt to be lost when a book 
passes through the hands of a long succession of editors. 
\’erv much of the work is, of courae, uncliaiigcd. We would 
have liked to sec Professor Smith break away from the 
custom of previous editions, and include a clcscriiitioii of 
the powers and functions of the General Medical Council 
and of the relations of the doctor to the State. A textbook 
of medical jurisprudence is perhaps the only' place in 
medical literature which is suitable for a description and 
discussion of the legal obligations, penalties, and control 
to wliieli a medical man submits himself when he places his 
•iinnic on the d/edicul Itrijister, and we hope that an 
adequate account of this important matter ■will be included 
in the no.xt odilion. 

Like other subjects in medicine, medical jurisprudence 
is growing, and its offslioots are tending to outgrow the 
parent. As in previous editions, much space has been 
dovotetl to insiiranco and workmen’s compensation. ‘These 
snhjccts have now grown to such an extent that they possess 
n literature of tlieir own, and the question U'l'ises whether 
they should not be omitted from a book on medical juris- 
pnidonce. The subject cannot be dealt with thoroughly 
-even in a work of these dimensions, and when " Taylor ” 
ceases to be the aiitliority on any question it indicates that^ 
like public health, the subject has become a study on 
its own. 

Professor Sydney Smith has made a special study of 
fiicarms, their identification, and the injuries they pro- 
duce. His large experience of such cases lias made him 
one of the chief authorities on this subject, and, as we 
should expect, the section dealing with gunshot wounds 
contains much fresh material. 'Tlie , otlicr sections, espe- 
cially that on identity, have likewise been stamped with the 
mark of personal experience. In the toxicological part of 
the work the description of gas. poisoning, wliicb has come 
into such jiromiiieiicc lately, lias been tlioroiiglily revised. 
This iinrt of the hook in general is well up to elate. The 
legal aspect has been dealt with in an equally thorough 
mnniier, and in a way which gives the reader confidence in 
the legal views e.xpressed. A reference to tetra-etliyl lend 
in motor fuel appears, though the recorded symptoms of 
industrial poisoning liy this means are no doubt too recent 
t.-) allow of a full description. 

Taylor's HleiVica} Jarisprriihncc needs no introduction or 
commendation : it is an c.sscntial book for any medical man 
■to consult before appearing in a court of law. This neiv 
edition shows many improvements, though there are jiarts, 
notably in the description of the course to he adojited- by 
'medical men in cases of doubtful natural death, Tvhere 
1 a definite line of action would be preferable to a dis- 
ci!.s.sion. The additions and iniproT'emeiits in this eighth 
I edition render it indispensable as a work of reference to 
anyone engaged in the practice of forensic niedieiiic, and 

T aiifl Vractice of Medical Jvriepradeace. Edilrtl 

bv Svtlnov Sinilh, JI.D.Ell., Il.P.H. Eifrhtll ediMon, WHIi a complete 
revofiin of (he IcRal aspect bv W. G. H. Cook, Ll,.D.Eoml. l.omlo!i : • 
J. ond K. Clmrchiil. 1328. (Rov. Bvo, Vol. 1, pp. viii + SOO, 39 heiirce; 

1 Vol. II, pp. V + 361, 1 fi;;uTcs. 63s, nci.) 



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Mat 5, 1928] 


NOTES ON BOOKS. 


I 


Tit* Bums* 

MrOlClX. JotTBUM 


763 ■ 


ttiroiigli .trniisitionnl forms. Tlie article ou cerebral 
“ laeimae ” was ’ the oatconte of an observation of tbc 
relative infreejnenev of haemori'liages and soltenings in tbc 
brains of old boiniplegics, wliich Mario bad si>ecial oppor- , 
tnnities of observing. He fonnd that in the majority of 
cases tbe' lesions bad tbe form of a nnmber of spaces 
or bunnae, varying from tbe size of a millet seed to tlmt 
of a bean, and sitnated in or' near tbe grey centres or in 
tbe pons. He bold tbe laennac to be ,dne to softening and 
degeneration, and tbe constant coexistence of avtcrio- 
.sclerosis .suggested that this nas a snfiieient explanation; 
in some instances, hoyever, tbe^ arteries in the foci were j 
freely permeable, and Marie snggested, as a possible altoir 
native explanation, that tbe softening resnltcd from an 
inflammafion of tbe pcrivascnlnr sbeath, abicb was in all 
cases found to be considerably dilated. l‘osl-movtetn 
empbyscma was definitely excluded. Tbe present volume, 
like its predecessors, is full of interesting matter. 


ANALYSIS OK THE FAECES. 

Da. Bb.vk Gai’i.tiku bn's filled a gap in tbe long series of 
laboratory textbooks by bis description of tl\e clinical 
analysis of tbe faeces,' a third edition of wbicb bas been 
published. He .starts with a careful account t)f tbe nature 
of tbe several faecal constituents in bealtb, and di.scii.s.ses 
the factors concerned in their production. He then gives 
detaijs of the various inve.stigations, both macroscopic and 
microscopic, emphasizing tbe procedures wbicb dctenninc 
tbc presence or absence of abnormalities. Special attention 
is given to the general pliysical cbaracteristics, substances 
derived from tbo food or from the digestive processes, 
bacteriologj-, and ])arasitology. Tbe subject of tlio appear- 
ance of tbe different forms of fat in tbe faeces is treated 
with particular care, tbo conditions regtdating their occur- 
rence being defined in order that tbcii* diagno.stic valuo 
nuiy bo made evident. Numerous illustrations are supplied, 
but to an English mind • tbo absence of an index is 
regrettable. Tbe infonnation is given clearly and well, and 
tbo various methods are fully explained, tbe author bas 
achieved tbe rather difficult task of relating laboratory 
investigations to clinical conditions without peVmitting the 
book to exceed a reasonable size. 


NOTES ON BOOKS. 

The foiirtoentb edition of Grccii*s of Patfcology and 

Morbid Anatomf bas been revised and enlarged by Dr. A. 
PiXEY. \ ery few alterations have been made, except in tbe 
sections on nephritis aiid surgical shock, and the book still 
retains the form with which so many generations of students 
have been familiar. The original edition applied in 1871, 
and was'One of the first systematic introductions to English 
students of (he cellular pathologj' associated with the name of 
\ irclmu. Since the puhlication of the last edition five vears 
ago Ur. rhomas Henry Green has died. He had been unable 
to take part in the preparation of new editions for several 
years, but the tradition he established has been worthily main- 
tained by a succession of subsequent editors. It has alwavs 
been a favourite book with students, and is likely to remain so. 


Ihe transactions* of the second session of tlie Australasia! 
1 ledical Congress (British Medical Association), which wa: 
held at Dunedin, Kew Zealand, in Pehruary, 1927, have no\ 
been collected and published in volume form. A summary' o 
the proceedings appeared in the five issues of the Britisi 
ilfcd.cfd dated March 26lh to April 23rd, 1927 (a 

pp 584, 622, 670, 7^, and 773), so that those who m.r 
have been attracted by any point mentioned at tliat tim* 
will now be able to obtain the fuU text of the papers 
ogeth^' with the discussiops which took place. It may h' 
^ session "of the Congress was held a 

Melbourne in [November, 1923. At the more recent catherini 
m I^inedin tfi^. Association at home was represented ]y 
Dr. Cooper Pattin ot Norwich. It would be superfluous t* 
. attempt to . detail the gro und covered in the meetings of tJi. 

‘rrccit flr Coprotogie Clinujue. Par Dr. KenO Caiillier 
ro Dssair Albert Robin. edition; entierement rptoiidne. Paris 

54 ^927. (Post. Bvo, pp. 567; 105 figure^ 7 plates 

K an(f Morbid Anatowy. Ilevis.ecl am 

Sptim 1 jbR.C.P. Fourteeiitli edition. UniveiYiti 

Jlrrtical 1 iiblishingCo., Ltd. J928. (Demy fllo, pp. Iviii + a77 ; iltu'traled.] 


twelve sections; the range of subjects was almost coextensive 
.with (lie field of modern .medical science. The president, 
Sir D. E. Barnett, in his address, dealt with medical 
iderds'and lay criticism, and in a special meeting a series of 
papers on preventive medicine, the relation of the private 
practitioner to the* Slate and to the hospitals, and national 
•insurance was given. Considerable general interest, attaches 
to the popular lecture on ** The coming of the Maori ’’ by 
Dr. 1\ H. Buck (Te Rangi Hiroa), director of ^laovi hygiene. 
Ill format and typography the volume is excellently produced, 
and useful indexes to .speakers and subjects' have been pro- 
vided. Tlie illustrations deserve .special mention ; there are 
numerous reproductions of diagrams, drawings, pliotographs, 
and skiagrams, many on special plates, wliich add’ considerably 
to the value of Uie various papers, and give an additional 
distinction to ah intere.sling volume. 

In content and format the 1928 edition of T/ic I carbool: of 
the l7»nTTr.'»i(i>x 0/ the Empire® maintains the now familiar 
style of earlier issues, and althougfi a few pages have been 
added the volume remains still, of a convenient size for a work 
of reference. IVithin its covers are compressed the central 
facts relating to some seventy establishments of univei*sity. 
standing, with staff directories, information relating to_ 
curricula, degrees, diplomas, fees, etc., and various other 
matters. A useful appendix contains a guide to professions 
and careers open to persons possessing university gualifications, 
and others embody particulars of research giants and centres 
of research outside universities. The indexes are notably well 
arranged. 

* The Yearboal' of the Vniverfiitiefi of the Kytpire, 102S. Pitblislipd for 
llie Universitit's linrp.Tn of tljo Britibli Empire. Lomlon : G. Bell and 
Sons, Ltd. 1S28. (Cr. Bvo, pp. viii -f 866. 7s. 6d.) 


PREPARATIONS AND APPLIANCES. 

Hyoscixe Hydrobromide. 

IrOR the convenience of medical practitioners who wish to pre 
scribe full doses of liyoscine hydroororaidc for oral administration 
Burroughs iVcllcome and Co. now issue “ tabloid ” hydscine hydro- 
bromide, grain 1/100 (0.00065 gram) in bottles of 100. “Tabloid ** 
Uyoscine hydrohromidc 0.0003 gram .(grain 1/220 approximately) has 
been issued for many veal's, as have also several strengths and 
combinations for hypodermic use. 

A Syrtxoe roR Ixjectikg Varicose Veixr. 

In giving injeclion? for the chemical sclerosis of varicose veins 
• the ordinary “ locord “ .«iynngc of two or three cubic centimetres 
capacity, with very fine hypodermic needles, has been the instru- 
ment of choice amongst practitioners, though it has the following 
disadvantages. 

(1) The needle of a “ record “ syringe is in direct line with the 
barrel, so that the latter, more particularly in the case of 
awkwardly situated veins, is apt to obscure the segment of the 
vessel to be injected. 

(2) As a proof that the lumen of the vein has been entered a 
little blood must be aspirated along the needle into the syringe. 
This blood, by mingling with the sclerosing fluid in the barrel, 
fouls it for subsequent injections. 

(3) The graduations found upon the “ record syringe are not 
particularly adapted to the technique. 

In an eiiort to overcome these disadvantages Drs. Katherine 
Cellan-Joncs and C. J. Cellnn-Jones (North Shields) have recently 
had made a modification of the syringe produced by Katz some 
years ago, and after a te.st period of three -months they are 
satisfied that this syringe is a most useful and reliable instrurhent. 

As shown by the accompanying illustration the syringe has a 



glass .barrel and piston, the former graduated in capacities cf one- 
quarter of cubic centimetre, the latter coloured dark blue for 
convenieiice in gauging the amount of a colourless fluid which 
IS to be injected. The lower end of the barrel passes into a glass 
capillary tube bent upon itself and possessing, towards its 
exti-emity, two small dilated chambers. A white opaque back- 
ground has been introduced in the length of the capillary in 
order to' render the appearance of a minute column of blood more 
easily visible. The metal nozzle of the syringe, wliich snugly fits 
all sizes, and makes of hypodermic needles, has the same coeflicient 
of expansion as gla'-s, Thus readily allowing of sterilization by 
boiling. A me^I safety' calcli situated beyond the graduations 
fits lightly into’ a groove upon the piston, and prevents the latter 
from falling accidentally from the barrel. 

\Vlien a vein is entered blood can be aspirated along the 
capillary tube into the' ampullae, and when subsequently an 
injection is made the blood is forced back into the vein, leaving 
the remaining fluid in the barrel clear and untinged. In this' way' 
BIX or more injections may bo conveniently administered .v ithout 
having to change or wash out the syringe. 

This instrument lias been manufactured for Drs. Collan-Joiics by 
Braun and Co. of Mclsungon, Germanv; the London a^^ents are 
Adair Dult and Co., 47, Victoria Street,* S.IV.l. 



764 ' May 5 , 1928] 


BBITISH IiARTNGOLOGT. 


r Tiir.Unmnt 


iHetiical fotirnaL 

SATURDAY, MAY 5th, 1928. 


BRIIISH LARYNGOLOGY. 

Tub invitation extended to Sir StCkiir Tlionison by 
the president of the American Laryngologieal Associa- 
tion— the most exclusive body of its hind in any 
country — to give the address of honour on tho flfiietli 
anniversary of its foundation, is a pleasant reminder 
of the cordial relations existing between the medical 
profession in the United States and in Great Britain. 

The address itself, which may he found in full 
in the opening pages of our present issue, deals with 
the treatment of intrinsic cancer of tho larynx by 
the operation of laryngo-fissurc, a subject which the 
orator, by teaching, demonstration, and research, has 
made peculiarl}' his own. He is now able to trace 
the fate of seventy patients subjected to this method 
of treatment, a record which is unequalled either in 
point of numbers or in results. There is little likcH- I 
hood that it will ever be equalled in numbers, for 
intrinsic laryngeal cancer is a relatively uncommon 
disease, and there are now so many competent 
followers of Sir StClair Thomson’s teaching and 
technique that cases suitable for this operation will 
doubtless in future be distributed between numerous 
well-trained operators. It is more profitable to inquire 
whether the results are likely to be equalled or 
surpassed. Sir StClair Thomson admits an immediate 
death rate of 4 per cent. — that is, three post-operative 
deaths in seventy cases — yet if the case-histories of 
these three patients are carefully studied it will 
be noticed that in all of them death was only 
indirectly due to the operation. The full and accurate 
record demands a technical mortality of 4 per cent. 
Here, as often, the statistics prove a vicnsoiujc en 
chifjres, for the direct mortohty of tho operation has 
in reality been nil. There -14' therefore no challenge 
to be feared in this respect. ' 

Of all the 70 patients thus treated, 34 are now alive, 
and of these 32 have survived from three to nineteen 
years from the date of operation without recurrence; 
18 patients have died from other causes without 
recurrence, 7 have died from malignant disease else- 
where, and 11 have died from local recurrence. The 
record must be studied in detail to appreciate the 
real significance of these figures, which give 76 per 
cent, of lasting cures. The pioneer work on this truly 
conservative operation was performed by Butlin and 
Semon in this country, but there was no finality about 
it, for in some respects they left it in an unsatisfactory 
state; and so here again, without in any way detract- 
ing from the merits of what has already been accom- 
plished, it may be that, based on the experience 
gained and faithfully recorded in these seventy cases, 
this 76 per cent, of lasting cures 'may be raised still 
higher. Brilliant as it is for any series of cases of 
malignant disease, and making allowance for certain 
favourable peculiarities about cancer in this part of 
the body, it is yet possible that the knowledge gained 
by the study of Sir StClair Thomson’s seventy cases 
will enable laryngologists to make an even ,, better 
selection of cases for this operation, and so yaise the 
percentage of lasting cures. Each of .these cases,. 


|liowe%'CX', has been studied so carefully and exhaust- 
ively, and tho operative results have been so good, 
(that it really seems as though there is but little more 
to bo done in this particular direction. 

! The paper by Sir Charles Ballanco and Hr. Lionel 
JCollcdgc, whieli also appears in, this issue of the. 
■Briiiiih Medical Journal, brings to a definite conclusion 
Ml certain lino of iuvostigation into tho possibility- 
of treating laryngeal paralysis by means of nerve' 
inhastomosis. 'I’ho earlier stages of this experiment 
iwill bo familiar to many of our readers, for they 
have been recorded in these columns. -A bilateral 
anastomosis between tho phrenic and cut rccun-ont, 
larj'ngcal nerves in a monkey resulted in complete 
restoration of synchronous movements to the vocal 
cords, and the animal was kept for three years, tho- 
result being confirmed bv repeated examinations before 
Dr. Harvey Cushing and' the late Sir David Perrier and 
Sir Frederick Afolt, among others'. The animal has 
now been killed, and microscopic examination of the 
larynx shows complete recovery of the muscles and' 
nerves concerned. Proof of the functional success 
of this experiment is thus confirmed by histological 
examination, and, further, it has been possible^ as 
the direct result of experimental work, to apply the 
method to the relief of symptoms caused by bilateral 
abductor paralysis of the larynx in a human being. 

These two papers, the one recording a purely clinical 
roccarch the other almost entirely confined to a 
laboratory investigation, show that British -lar^golop 
is well able to maintain its position. They should be 
an cneduragemont to tho younger laryngologists m this 
country to carry oh tho torch. 


PURE MILK PROGRESS. 

Hucit energy and ingenuity have been spent in recent ■ 
years in the attempt to improxx the purity of the 
mUk supply of this country. It is satisfactory to 
Si from an. article by Dr. R. Stenhousc H ilhams, . 
csUrch professor in dairy bactenology m he Umvei- 
sav S Reading, and Jlr. W. A. Hoy of the same 
unLrsity, printed in tho Journal of State MedwmeJ 
that in their opinion substantial progress has already 
Icon r“adc From a series of tables dealing with he 
milk supply of various large towns and of • arge dis- 
tributiim agencies these research workers show that 
Lc number of farmers producing milk with low 
bacterial content has increased very largely duriii„ the 
vnef five or six years. Thus with one firm in Birming- 
ham the -number of farmers supplying milk contain- 
•nrr nn OH avcra''o fewer than. 10,000 bacteria per cubic 
centimetre was only 2 in 1922 and as many as 69 in 
1926 Between April and August, 1927, one firm m 
the Midlands- supplied milk which consistently ^a.\e 
a count of below 200,000 per cubic centimetre on 
arrival in London, and several other farms m the same 
area had nearly a record A very large ^ 

of samples in various districts stood tho Bacillus coii 
Lst Xigh an examination of the tables published 
Ss that it is more, difficult to eliminate cohform 
orsnoisms than to reduce the count. ' , - 

Professor Stenhouse Williams and his fellow workers 
in the Rational Institute for Research in Dair}!!!^ a 
Reading are impressed by the excellence of the woik • 
of which the milk industry- is now capable. Fie calls 
attention to the encomiums, in a recent -issue ot tbo 
Journal of the American Medical Association, on Oieat 
Britain’s long list of large- cities free from -a single 


1 Journal ol State Medicine, vol. x.\ivi, No. 2 . 


MjiV -S i 1928] 


PURE raEK. PROGRESS,' 


[ • THBDarnsn ' •' 7fi^' 

Midicxi lounwAl. ' 


death from -typhoid -fever; -mid he nttribuios the im- 
pi'ovciiient -in, the purity ‘'of the milk supply in ibis 
eountvv to tWo sUihvili-^wise advice concerning proper I 
methods of handling milk, and a financial stimulus. 
He finds that the object has been furthered by county 
clean millc-compotitions, which were originally started 
in Essex by the Howards Dairies; by the advisory 
liacleriological posts set up under the auspices of the. 
Winistrv of -Agriculture in provincial centres; by the 
Ministry of Health’s ' system of granting licences^ to 
those who wish to produce a better quality of milk; 
and by the educational facilities now provided and 
increasingly made use of at such places as the Chelsea 
Polytechnic. Through these means very remarkable 
work is being accomplished, even by tenant dairy 
farmers who do not possess adequate chilling facilities 
for use during the summer months. 

Owing to the difficulty now experienced by farmers 
in obtaining skilled milkers, two other research workers 
at Reading 'University, hir. A. T. R. Mattiek and Mr. 
F. Proctor, have been investigating the production of 
milk of low bacterial content by moans of milking 
machines. The difficulty with this method of milking 
has been to keep the parts of the apparatus clean; 
so that, as with the old-fashioned domestic water 
filter, more germs were liable to come out at the exit 
than entered at the inlet. The observers used for their 
experiments, which arc described in a recent issue of 
the Journal of Hygiene,' two units of an Alfa-Laval 
milking machine, one of which was washed witli water, 
first cold and then at 185° P., while the other, after 
preliminary washing, was sterilized by steam. It was 
found that extraordinary fluctuations occurred in 
bacterial counts, whether the apparatus was sterilized 
or merely washed. Investigation showed that the 
contamination took place from water in the vacuvun 
pipe line, from which bacteriaTound their way into the 
milk receivers, although a check valve was’ provided 
in the lids. By adopting a simple method of traps 
to the pipe line, and turning all vacuum supply taps 
upwards, the observers were able to obtain remarkably 
low bacterial counts in milk, especially with the 
sterilized unit, even twenty-eight hours "after milking. 
They are convinced that 'milk with small bacterial 
content and of good keeping quality can be produced 
by the use of milking machines; that the milking units 
and their rubber components can be sterilized success- 
fully by steam; and that contamination from pipe lines 
can easily be prevented by their methods. They found 
also that milking machines had no adverse effects on 
the cows or on their milk yield. 

Thus the dairying industry, as Professor Stenhouse 
Williams remarks, has made great strides since the 
days when a few people like ]\Ir. Wilfred Buckley 
were producing clean milk and creating their own 
markets without official support. On the one hand, 
there is an increasing desire to make use of scientific 
knowledge, not only among large firms, but in manv 
much smaller businesses; on the other hand, there is 
the growing recognition that better work is worth more 
money. These two factors, operating side bv side, 
have caused a marked improvement in the cleanliness 
of oiir milk. Continued collaboration between farmers 
and dealers, working in close touch u-itb those who are 
studying their problems in the laboratory, should lead 
to further progi-ess all along the line. ’As knowledge 
increases we may expect the high standard of efficienev 
already reached by the licensed millc producers in 
forward areas like Reading to be attained throughout 
the eoimtrv at large. 

‘Journal of Uyjient, vor xxvii. So. 2.- 


AN INTERNATIONAL COMMITTEE FOR RESEARCH ON 
INFANTILE PARALYSIS.- 

An iittcrnational committep for the study of infantile 
paralysis has recently been formed under the chairmanship 
of Dr.AV.^H. Rdrk," director of the Bureau of Laboratories 
of the New York City Health Department. Arrange- 
ments have- hoen- made for a- concerted three-year attack 
on the difficult jirohlems of jirovcntion and therapy jire- 
sented by thi.s -formidable and crippling disease. To enable 
roscnreli to lie ' conducted at a number of centres - in tlie 
United States and- in Europe, a sum- of -250,000 dollars has 
been t-oiitrihuted by Mr. Jeremiah Jfilbank, a prominent 
New Y'ork financier who takes an active personal interest 
ill liosiiitals and charities. The folloiviiig centres have 
been chosen for the proposed researches : Bureau of 
Laboratories, New York City Health Department; the 
jiathologieal institutes of Cohiinhiii, Hai-vai-d, and Cliicago 
.Universities; the Pasteur Institute, Brussels; and the 
Lister Institute, London. These various institutes are 
represented on the international committee hy their respec- 
tive heads. The personnel of the committee is as follows; 
Chairman, Dr. W. H. Park; vico-chairman, ' Dr. Joseph 
A. Blake (New York); Drs. E. 0. Jordan and Ludvig 
Hektoeii of Chicago University; Drs. F. P. Gay and 
Frederick Tilney of the College of Physicians and Surgeons, 
Coliinihia University; Drs. Milton J, Boseiiau and Hans 
Zinnser of Harvard University; Dv. Lee K-. Frankel of the 
Metropolitan - Life Iiisiiraiicc Company; Sir Charles J. 
Martin of the Lister Institute, London; and Dr. JiilcS 
Bordet of the Pasteur Institute, Brussels, Mr. Samuel 
j\I. Greer and Dr. Josephine N. Neal will act respectively 
as treasurer and secretary, and tlie committee’s licad- 
qiiarters will he Dr. Park’s office at the Bureau of Labora- 
tories, East 16th Street, New York. Directors of research 
at each selected centre will be free to initiate such investi- 
gations as seem to them desirable and within the- compass 
of their respective institutions. The results of such 
resoavehes will, however, be studied and co-ordinated by the 
international committee, and will thus constitute a joint 
piece of work. At the Lister Institute special arrange- 
ments are being made for research on poliomyelitis under 
the direction of Professor J. C. G. Ledingham. It would 
ho difficult to overestimate the importance of this 
ventui-o. In no field is new knowledge more iirgenth' 
desired than in that of the nenrotropic viruses, but the- 
necessity of employing monkeys for the experimental study 
has impeded progress by reason of the hea-vy cost involved. 
It is nearly twenty years since Landsteiner showed that 
the virus of poliomyelitis could be transmitted to monkeys, 
hut the little knowledge since gained of this and other 
nenrotropic viryiscs has not materially clnrified the pre- 
ventive and therapeutic outlook. The present time is very 
favourable for a new attack on the problem. The last 
decade has witnessed very considerable developments in onr 
knowledge of virus diseases, and methods of attack which 
have proved of promise in the investigation of certain other 
viruses may well he exploited in that of poliomyelitis. The 
generosity of Mr. Jeremiah Milbank in making the new 
venture possible will be widely appreciated. 


ARTIFICIAL HUMIDITY IN COTTON CLOTH FACTORIES. 
The effect of artificial humidity on the health of cotton 
weavers has been a controversial question between employers 
and employed for rather over fifty years, so that on the 
iiitrodnction of the Factory Bill of 1925, which contained 
clauses dealing in some degree with this matter, it was 
considered opportune to have a conference of both sides 
under Home Office auspices with a view to final settlenienf 
of the differences.' Although the operatives still insisted upon 
fofat abolition of artificial humidity, and the employers 
claimed not oitly that' such action could hot ho justified. 


766 May 5 , 1928 ] 


• AKTinCIA-L HtiMIDITX IN COTTON CLOTH FACTORIES. 


r Tiie Dftmn 
KtbtCALJovnii, 


but tlmt it woiiiil destroy an iiiiportiint braneli uf the 
industry, botli parties were able to agree that a Dcjiait- 
luental Committee would bo a suitable body to deride 
the questions at issue. The committee was set up 

immediately, and on the .scientific side included Pro- 
fessor Leonard Hill, IMr. F. T. Pcirco of the Briti.sh 
Cotton Industry Research iVssoeiation, and Mr. I). R. 
Wilson of the Industrial Research Board. Tho report' has 
now been issued, and should, on tho whole, give, satis- 
faction. To cover tho points of inquiry agreed upon 
by the conference, investigation was made on ^(1) tho 
extent of mortality ai\d sickness among we.avcrs in 
selected areas, (2) the offoet of total abolition on 
trade, (3) tho extent of foreign conqictition and re.stric- 
tions against humidity in other countiic.s, (4) whether 
improved sizing could lephico humidity, (5) the effei-t 
of humidity on fatigue and productivo eiricienc}-, and 
(6) the effect of air movement in reducing discomfort. The 
obtaining of reliable information respecting the health of 
weavers in both sections of tho industry was necessarily 
regarded ns the keystone of the inquiry. Tho requisite 
mortality figuies for males for tho period 1S21-22-23 were 
obtained from tho Registrar-General, and though fhc.se 
are not given in tho report they are presumably similar 
to those published elsewhere.^ Tlicy are distinctly against 
the humid shed, but, acting on tho views cx]ucsscd by 
such eminent witnesses as Dr. T. H. G. Stevenson, Pro- 
fessor M. Greenwood, Dr. Daley, and Dr. A. B. Hill, tho 
committee is of opinion that tho figures aro too small 
to admit of any definite conclusion being fornicd. The duty 
of obtaining morbidity statistics was delegated to the 
Industrial Fiitigno Research Board, the report, drawn up 
by Dr. A. Bradford Hill, being reviewed in these columns 
on January 14th last (p. 65). Tho committee expresses 
agreement with the findings, wiiicii were to the effect that 
there is no evidence that emplpyinent in humid sheds gives 
rise to more sickness than employment in nnn-linniid sheds. 
Bearing in mind the moitality returns (so far as they aro 
helpful) and the evidence of Sir Thomas Lcgge and others, 
it IS concluded that one class of shed is no more dangerous 
to health than the other. Begarding the cltect of hnmidity 
and of sizing on the tensile strength ainl extension 
projieities of cotton, Mr. Peirce, a member of the com- 
mittee, lu'oduced ovideiue which should convince the most 
eonservative employer that ho need not go beyond reason- 
able limits of tenqievatuve and humidity to weave bis elotli 
ellectively. It apjicars tluit humidity lias nuicli more effect 
on cotton yarn tlian lias temperature; it increases the 
strength and extensibility markedly up. to a limit of 80 per 
cent., but at a less rate over this; short staple cotton seems 
to be the most sensitive to humidity. The sizing of yarn 
is rcgiuded as effective for its jiurposo, but the suggestion 
that it could be sufficiently improved to serve as a 
substitute for humidity is strongly negatived. It is there- 
fore agreed that, uhilst hnmidity is essential for the pro- 
duction of certain classes of cloth, tho abu.so of this agent 
could he further regulated with advantage. That foreign 
countries are competitors, and do not so far regulate the 
use of humidity, is agreed. jMr. S. Wyatt, who gave 
evidence, has previously shown in a report to the Industrial 
Fatigue Research Board that excessive humidity does pro- 
duce fatigue and diminishes efficiency, and as a result of 
later 'experiments, carried out for the committee, he has 
found that the highest output was obtained at a dry 
bulb temperature of 72^° to 75°, and with a relative 
humidity of 75 to 80 per cent. Reference is also made to 
this observer’s investigations on production of effective 
inside air movement by havi ng paddles attached to the 

1 Rf|iort of the flpjiQrlmfulal Committee 011 Artificial llntiiiility in' 
(.•.Itoai ttnth Factories, with Ajutendices. London: JOf, Stationcrv 
CiJTice. lSi8. l.s. 5(3. net. 

^ Iteoistrar-Ocneral’s Occcnm'a! Sujjjilcmcnf, 1921 , Part 11, pp.' tavii' 


.shafting. Tho iiso of these i.s recommended for iinjiioviiig 
working coiidilimis when tho temperature heeomi's exce.s- 
sive, ti.s in Slimmer time, the as.snraiiee being given that 
air movement 1ms no detrimental effeet 011 tho yarn. 
2 \Iteraiioii.s and luldilions to the regulations aie renim- 
meiuied: the words “ luiinid shod” to he replaced by 
“ weaving slied,”' thus almlishing the present di.stiiietion, 
niul power given' to tho Chief Inspector to grant relief t,> 
shed.s where eaiiditions are satisfactory; artificial liumidifi- 
ciition to cease at 72^° wet biilh, instead of 75°; weaver. s 
to cease work and leave tho shed if wet hnlli ti'inpcraturo 
exceeds 80°; tho miniiiuim dry hnlh teinperatnie to ho 
50° for the first hiilf-honr of tho day and 55° for tho 
lesl of the day; plans for conversions or new sheds to 
he Mihmitted by tho local authority ^o the snpcriiilciidiiig 
inspector of factories before sanction; provision to ho nmdo 
for conliiiniiig ventilation diiring tAe meal tinie and after 
work i.s finished ; suitahlo cloakrooms to he provided for all 
.shed.s; air intakes for ventilators to ho better designed and 
pinced. Acting on the cvidenco of I’rofcssor Leonard Hill 
mid Dr. Vernon, it was not considered advisable to adopt 
a " kata ” standard for tho sheds. 


MEDICAL WOMEN'S INTERNATIONAL ASSOCIATION. 

A 3iEF.Ti.sn of tho Council of tho Medical Women's Iiitcr- 
lintionnl Association was held at Bologna on A])ril 11th, 
and was followed on ^Vpiil 12th, 13th, and 14th by an open 
meeting, at whicli papers were road on medical nicnsiircs 
for the protection of children anil young persons ,i'n tho 
various countries, and on diseases of the eye in .relation to 
gdicral medicine. There was an attendance of some 120 
medical women representing fourteen different countries, 
and papers wore also, received from eight oUior countries 
which were nnahlc to send delegates. Spain and Sweden, 
whicli have quite recently formed . affiliated associations, 
sent fnllv accredited delegates for the first time, and 
' Japan, wliorc there are over 1,000 medical women, con- 
' trihiitcd a specially- printed paper in Gorman on tho 
! protection of cliihlrcn. Tho meetings were held in the old 
: anatomical theatre of the " Archiginniisio,” which ha.s 
liccii preserved as' a liistorical inomnneut for the last 
hniidrcd years,, since tho transfer of the Univer-.ity to 
newer buihliiigs. It dates from the slxtooath century, and 
is entirely jianellcd in cednrwood, while the rostrum, froia 
which the paiicrs were read, is supported by two carved 
amitomiciil figni'cs. 2 H the farther end is the grille, hciiiiid 
which the inquisitor watched proceedings in the sevcnteciitli 
coiiturv. Tile local committee, in co-opcratiun. with the 
municipal and central authorities, had made the most 
generous and extensive arrangements for social cntcitaiii- 
ment and for visiting the various hospitals, including tho 
famous orthopaedic institute, tho Istitnto Rizzoli. The 
! Queen of Italy had consented to give her name as patroness 
of the conference, and a ” committee of liononv ” had boon 
formed with Signor Mussolini ns lionorary president and 
■ Signor Turati, .socrctary-gcneral of the Fascio, as vice-' 
president. An impressive inangnral ceremony was held 
in the library of tlio old University, at wliich siiecclies were 
made by the prefect, rc))resonting tlie Italian Govornmoiit, 
the podesta of Bologna, and Professor Viola, president of. 
tho Faculty of Medicine. Lady Barrett, jn-csideut of the 
Medical Women’s International Association, replied. An 
afternoon reception was given by the podesta .and tho 
municipal authorities in the fine old town hall, which was 
decorated with tho flags of all tho nations, and on the 
evening of April 13th a dinner for 200 people, followed by 
a concert, was given at tho Fascist headquarters of 
Bologna by the women's section. It was attended by all 
tho foremost personalities of tho town and University of 
Bologna, speeches being made by tho prefect, tho vicc- 
podesta. Dr. Carenpino Ferrari, president of tho Italian 



Jik-i 5, igiSl 


BEA-8ICKNES8. 


t TniDnmre 

UedICUU JOCBVXl. 


767 


Assni'intiim, mill Dr. Lea Giorgi, oliaii-mmi of Uio local 
coimnittoc. Sliss Slaitindalo rciilieil on hclijilf of the 
^U'llkalW'tmicn’s Intcnuitiohal Association. Iteccptions were 
also given in- tlic local coinmittec of medical women, and by 
the ollicevs of the Intcniational Association (Lady Barrett, 
Dr. Jane Walker, and Aliss Martindale), at the Hotel 
Brim. A notable and most enjoyable week closed with 
c.xpeditions to Kavenna and Bimini, where the municipal 
and medical anthoritics gave a hospitable welcome. 
At Kavenna Inneh was ]novided in tents in the famous 
pinewood of Dante, and speeclios were made, both in 
Latin and Italian, by the prefect and others. At Rimini 
the chief medical ofiicer of health and other local doctors 
met the medical women at' the station, and, after a reception 
at the town hall, they aero coiidnctod over the large 
children’s convalescent home a'lucli lies by the sea. All 
who attended the international meeting came away with 
grateful memories .of the ho.spitality of the Italians and 
admiration for their powers of organization on a largo scale. 


SEA-SICKNESS. 

Sr,A-sicKNn.ss, its causes and treatment, is a subject of 
perennial interest. Its symptoms are only too well known 
to the victims, though they arc difficult to describe accu- 
rately to those . who have never experienced them. Their 
exiilanation is by no means simple. Wo print on page 752 
a short article by Dr. R. Allan Bennett which sums up iu 
a' convenient way a good deal of experience in this matter, 
uhich is one of real , importance; for the condition may 
make a voyage a inisorj', and with the great majority of 
travellers' by sea materially detracts from the pleasures of 
anticipation. The cause of sea-sickness is certainly not 
merely fear or anticipation, though these may greatly 
increase the liability. With a moderate ocean swell the 
milder symptoms may bo experienced iu mid-voyage by one 
who has till then been so happy tliat. lie is not even thinking 
about their possibility. The undue celebration of farewell 
by the medium of meat and drink is clearly inadvisable, 
but Dr. Bennett's 88 per cent, of. patients who had over- 
eaten either before or during the voyage docs not seem to 
differ .significantly from the percentago of tbo ordinary 
iion-su(fcriiig population at sea or ashore who do the same 
thing. As regards prevention, tbo avoidance of constipa- 
tion and the cultivation of confideneo ajipear to be the 
chief things necessary. The latter may bo aided by the 
lireliminary swallowing of a capsule or b^' anv weird device 
in which ilie individual believes. Cross-channel passengers 
have been known to assort that they have avoided all dis- 
enmfort by keeping one oyc closed throughout the passage, 
or by the continuous eating of apples. A prophylactic 
mixture containing bromide and chloral with aromatics 
sometimes appears to be of. real- help to the neiwous 
liassenger on the longer cross-channel trips, and clilorctono 
has helped others, though its after-effects may be disagree-' 
able, as is true also of sonie of the much-vauiited proprictai'y 
lemedies sold at fancy prices. .^Iii longer Voyages the 
consensus of opinion among stewards and stewardesses 
if there be such consensus (for we .understand that now- 
adays tbo ship’s doctor is not usually consulted), may not 
be a bad guide to Deatment. 'This, added to personal 
experience, tends to suggest that the horizontal position 
and fresh air are the two main requirements. The former 
is best secured in one’s cabin, the latter on deck. This 
necessitates a nice adjustment of the balance of advantage. 
Dr. Bennett’s dictum, that “ however cruel it may seem, 
patients should be driven out of their c.abiiis into the fresh 
air,” will not bo universally accepted. In the less severe 
cases, and with moderate weather, it is no doubt true, 
and .should be acted uiion; but in the presence df severe 
symiitoiiis and weather there may bo much to be said- in 
favour of no attempt to get-up.- Aloreover, if one has to 
suffer, it is usually preferable to suffer in seclusion. If 


nausea be very great one or two moderate doses of cham- 
pagne often give most relief, or, as .a second best and if 
the idea bo not too revolting, dry ginger ale. Beyond these 
things, as a rnio, there remains no resource other than an 
appeal to an unfeeling captain for a judicious choice of 
weather. 


THE CONGRESS OF AMERICAN PHYSICIANS AND ' 
SURGEONS. 

The progranime of the fourteenth triennial session of the 
Congress of American Physicians and Surgeons, which was 
held at the beginning of this week at Wa.sliington, D.C., 
has just veached us. This assembly differs in its constitu- 
tion from any gathering of medical men with which wo are 
familiar in this country, for it consists of fifteen, con- 
stituent associations and societies, which hold their annual 
meetings eveiy third year simiiltancously and in one place, 
and devote the time of two meetings of the Congress as a 
whole to the discussion of subjects of general interest to 
all the fifteen component parts. In fact, the Congress 
icseinblcs an Annual Electing of the British Alcdical Asso- 
ciation, blit differs from it in the fact that except for two 
days in three years each of the sections. leads an. indepen- 
dent life. The programme is a very full one, and after 
looking through it wo are not surprised to find that a 
projiosal is to lx: brought forward at tlio request of tbo 
American Pediatric and tho American Gynecological 
Societies to make the meetings of the Congress quinquennial 
in future. Tho amount of correspondence' and discussion 
necessary to arrange such a programme may well require 
a longer interval for vecuperaticin than tliveo years. The 
membership of. the coinjioncnt associations includes many 
Canadiams, u'liose contributions to tlie programrao show 
that they arc. by no means inactive. Certain European 
lihysiciaiis and surgeons also appear among tho readers 
of papers. Dr. J. IV. Kefnolian of Belfast -spoke (by 
invitation) on encephalitis periaxialis diffusa .before tho 
American Neurological Association, and Mr. Harry Platt 
of Manchester read a paper on iieriphcral nen-o complica- 
tions of certain fractures before the American Orthopaedic 
-Association — a subject full of interest just now 'h'lien the 
treatnient of fractures is so much discussed.. Sir StClair 
Thomson contributed the address on laryngo-fi.ssure for 
cancer which 'appears in our present issue and is discussed 
in a leading article, and Dr. S. A. Kiiinier IVilson of 
London spoke on organic nen-ous disease in identical twins,' 
reporting on four sets of such which have come, under his 
obsci-vatioii. The name of only one continental European 
surgeon ap])ears in the programme — namely. Dr. Rene 
Lcriche of Strasbourg, who has reviewed the siirgeiy of 
the sympathetic nervous ' systeni before the American 
Surgical Association. There are many subjects of. interest 
mentioned in this programme', and as sonie of the 'entries 
are accompanied by brief abstracts an idea may in those 
i cases bo gleaned of the probable nature of the contribu- 
' tions, . The remarkable case of Miss. Helen Keller is tho 
subject of pap.crs .in . the otologicab and tho neurological, 
section’s. ' It ;wifl be remembered that' this patient,' ■yho 
had been blind,' deaf, and dumb from infancy, was trained 
to a very high degree of knowledge and culture by tho 
devoted efforts of Miss Sullivan of the Perkins Institution 
at Boston, on the lines followed by Dr. S. G. Howe in the 
teaching of Laura Bridgman, whose brain is to be tho 
subject of discussion by tho .American Neurological Asso- 
ciation. Before the same society a paper is to be read on 
Charles Darwin and- Joseph Leidy of Philadelphia. Tho 
abstract postulates the equal importance of these two 
writers as “ the two greatest biologists of tho nineteenth 
century,” showing how much a change of some seventy-five 
degrees of longitude may have on estimates of the relative 
importaiieo of scientific achievements. 

' See .l/aiiV .IliiacU. The .stnry of Uclcn KcHcr anil Iwr European Sisters, 
troin Uio French of Gerard Harry, rublishcd by IV. llcincmanii. ISIA 


f T}(£narTMu •• 
I Jovnjut ■■ 


768- Mat 5 ,- 1928 } OONFBRENOE ON KHEUMiTIO DISEASES. 


' CONFERENCE ON 'RHEUMATIC DISEASES. 
AiiitANO.EMnNTs- Iinvt' TioAV booil'coliiiilc'ted for llio Coiiforonco 
on Bhonniivtio •Disoaso.s io-bo bold at Until on Ultiy lOlli 
and lltb; of nhidi wc Rnvo iircliinimuy iiarlioidiire on 
Marcb Z4th (p. 510).' Tlio ^noffi nnniK' lias bcOii dnnrii np 
with great tboroiighnoss,. and ovorvthing ])oiiit.s to a very 
.sncce.ssful and jirofitablo sorios of di.scn.ssion.s. Tlio tbroo 
main spssion.s, dovotod fc.spootivoly to sooial aspects, cansos, 
and trcatiucnt,- will be presided over by Lord Dawson of 
Benn, Sir Humphry Uollo.ston, and .Sir Farqnhnr Unaznrd. 
Tlic scope of these discussions will embrace rlienmatic 
fever, both nento and snbaente, chronic mnlliiile arthrili.s, 
fibrositis, and degenerative arthritis. The jiroceedings will 
open on Thni.sday, May 10th, at 2.30 ji.in., with a civic 
welcome by tbe Mayor of Bath, Alderman Cedric Chiver.s, 
and an inangnral addres.s by Sir George Ninvinan, iire.sident 
of the cmifcrenee. The jirogramme of social entertain- 
ments inclnde.s a dinnei' paity given by the iilayor at the 
Gnildhall on Thursday evening, followed by a conver.sazione 
at the Pump Room, when the guests will be received by 
the Mayor and the Alayoress (Madame Sarah Grand); and 
a Inncheon on Friday, given hy the chairman and members 
of the Bath Divi.sion, Briti.sh Afedical Association. On 
Saturday the Balneological Section of the Royal Society of 
Medicine will hold its annual meeting at Bath, when 
demonstrations will be given at tbe Hot Mineral Batlcs 
and Royal Mineral Water Hospital. Tbe.so will be open 
to all those attending the Conference on Rheumntie 
Diseases. 


A CORONER'S JURY AND HOSPITAL ARRANGEMENTS. 
No particular authority attaches to the rider of a eoroner’s 
jury. It is, in fact, as a rule a generalized expre.s.sion of 
opinion based on the circumstances disclosed in the one 
incident a'itli which they have been concenu'd. Dike most 
generalizations from a .single imstanee in any braneli of 
investigation, the presumption is that it is wrong. "When, 
however, such a rider is encouraged and endorsed by the 
coroner it becomes of someivhat more importance, for the 
coroner is a man with cither a medical or a legal training, 
or both, who has probably had ox|)orionco of many inquests. 
Nevertheless, even then the idiosyncra-sies of the coroner have 
in some cases to be borne in mind. Theie is perhaps some 
justification for taking iniblic note of the rider added bv 
a jury to their verdict of “ Death from natural causes ” 
lit a recent inquest upon the death of an elderly man who 
had been brought to Guy’s Hospital and, after a careful 
examination; sent thence to St. Giles Hospital, Camber- 
well. After saying that the house-officer who saw the 
patient “ showed all due' care, and that no blame was 
attached to him,” the jury added tluit “they eoiisidercd 
tliat the systeni which allows patientg to be transferred 
from one hospital to another on the opinion of 0110 doctor 
only (and that a junior house-officer) is gr.avely unsatisfac- 
tory, and that no patient .should be so transferred without 
being seen, by two resident officers, ' both of whom should 
initial the removal papers.” The coroner himself aslcs 
that the hospital authorities will inform him what steps 
they propose to take witli the view of preventing such 
“ regrettable occurrences.” He will no doubt receive a 
courteous, aiid jierhaps a reasoned, replj-, but the Jiiedieal 
committee of the hospital and the profession generally can 
scarcel}’ be expected to do other than dissent from the 
implications of tho rider and the request. These appear 
to be two ; (1) That there is some legal right to question 
the propriety of a practitioner undertaking an ordinary 
medical service by reason of his age or experience; and 
(2) that the decision as to how a patient is to be dealt with 
must ui no case be nmde on the authority of a. single 
piactitioner. tvith regard to the former it is sufficient to 


say that it i.s registration by the General Medical Council 
which determines -the legal status of a medical, iiraclitioner.- 
All such pruelitioners. arc, in law, tqxm. an equality, and 
any legal inquiry as to competence shotdd be.te.sted by that 
criterion. To adopt any otiicr attitude woidd result in tho 
subjection of eveiy medical practitioner to a challenge as to 
eompetenee, which is irregular in law and would I>c variable 
ill iiraetiee. IVith legard to the second implication, it is 
enough to point out that dcci.sions in every way comparablo 
to tliosii referred to have to be made, not merely at 
hospital.s, but by every private practitioner in active prac- 
tice every day; and that to accept a rcconiniendation such 
a.s that of the coroner’s jury would not only entail absurd 
administrative incouvenionccs, but would belittle the 
ordinary responsibility of registered medical practitioners 
ill gcuieral, or would at least east a grave reflection iqion 
the competence of ho.siiital medical officers in comparison 
with other lucmbers of their profession. 


A CAUSE OF NATURAL VARIATION. 

Tin: occurrenee of occasional variants and the iiei jictuation 
of them by nnlural selection is a fundamental conception 
of the Darwinian theory, and various causes have been 
.suggested for this natural variation. There are probably 
a mnltiplicity of factors at work. In a short note in 
A’oftirr .4. It. Olson and G. N. Lewis' of the Chemistry 
Department of the University of California direct atten- 
tion to an agency ivhich the^ lielicvo plays an inqiortant, 
if not a predominant, part in producing variations among 
plants and animals. It has been shown that tho treatment 
of the fruit fly and the tobacco jilnnt by x rays produces new 
and permanent varieties far in excess of those normally 
occurring, both as regards number and dilToreheo from tho 
parent. R'licn a bud of the tobacco plant was irradiated 
80 iier cent, of the resulting seeds which germinated were 
decided variants, the variation from one planting being 
greater than what iiad been nototl in tho normal plant for 
over a quarter of a century. Not all of the variants .wore 
fertile hut others seemed to bo more fertile than tho 
normal plant. The niithois hclievo that such variations as 
actually occur in Nature are largely due to the reactivity 
of the ciivironnient. Their suggestion is an iiilcrcsting 
one, but would bo more captivating if it could be shown 
that there was an nnnsual variability of the fauna and 
flora in places wlicre radio-active materials occurred m 
abundance. . 


The Morison Lectures will be delivered before the Royal. 
CoUofie of Physicians of Ediiibiirgli by Dr. John Carswell 
on Mdudhv, AVednesdny, and Friday, May 7th, 9tli, and 
Xltli, at S o’clock. The subject this year is Psychology 
and medicine.’! , 


The second St. Gyres Lecture will bo given' by Profepor 
K F,- AVeiickchach in tlie Barnes Hall of the Roj-al Society 
>f Medicine’ on AVe'dnesday, May 16tli, at 4.30 p.m. 'The 
-ubjcct will he “ The lieaft and circulation in a tropical 
rvitaminosis (beri-beri).” Tickets of admissmu may bo 
ibtaincd from tlic Secrotao' of tbe National Hospital for 
Diseases of tlio' Heart, Westmoreland Street, AV.l. 


A Scientific Evening will be lield at tho Royal Free 
Hospital on May 9 th, at 8.30 p.m., when various demou- 
strations will bo given and cinematograph films sliowii. 
Further information may be obtained from the secretary 
at tile hospital, Gi*ay’s Inn Road, AV;C,1. 


1 iXature, April 23th, 1928, p*. 673 



.1928I 


EEGTAL OIL-ETHER ANAESTHESIA. 


[ Tire BBiTiiH ' 7fifl 
Medical JocBUAX. 1 w 


ANAESTHESIA BY THE KECTAL INJECTION OF • 
OIL AND ETHER AND OTHER DRUGS. 

A iir.viF.w of tlio piM'Ei'nl position as vcgavils tlio rectal 
adniinistrntion of ctlicr aiul oil as an aiiacstlictic iu 
surgical practice, ami of niorpliinc, magiicsiuin sulpliatc, 
and ether analgesia in surgical and obstetric practice, by 
Dr; Robert A. Hatcher, professor of pharmacology in tho 
Cornell University . Jlcdical College, has been published as 
a series' of special articles, which opened iu tho Journal 
of the .‘line lien II Medical Association for December 17th, | 
1927. 

I, — Rix'tai, Oii.-ETnKU Axaestiiksia. 

Professor Hatcher dephnes' tho fact that Gwathniey, its 
originator,' should have- attempted 'to develop tho method 
without adequate animal bsporimeutation, with iho result 
that theories have" been based on erroneous views, and 
accepted and repeated by later wi iters; he proceeds to 
quoto numerous extracts from the literature of tho sub- 
ject, and, after discussion, to summarizo his conclusions. 
Theso are as follows. 

1. That oil-ether mixture is an adv.ahce over other methods 
of rect.al or colonic administration. 

2. That anaesthesia is readily induced with mixtures of 

varying proportions, but in practice a inixfuro containing equal 
volumes of oil and ctlicr' is probably the ihost suitable, since 
resultant bowel irrit.atidu is less than when higher percentages 
of ether are used. - 

3. Tliat the bowel must be washed out immediately the 
operation is over, . and all . residual mixture removed. Prior 
to introduction of the mixture the neighbouring skin must be 
adequately protected from possible leakage of oil and ether 
by -smearing the parts with v.aselinc. 

. 4. T'liat 'ether is absorbed froin tho colon and not from the 
rectum; eon'sequently the warmed mixture must be introduced 
slowly 'for a period of some ten minutes high up into the colon 
proper. ‘ • 

'5. 'That the ’advantages of the method are: (n) It spares to, 
some extent' the respiratory passages, (i) There is less salivary' 
and bronchial secretion, [c) It lacks certain disagreeable 
features of ordinary inhalation methods, (d) The excitement 
stage is often lacking, and when presejit is usually of short 
duration, (c) There is less nausea and vomiting during anaes- 
thesia and after operation. (/) There is a clear field left for 
the opera tor. in head and neck cases. 

6. That the . disadvantages . of the method are ; (a) The 
depth of anaesthesia is not under perfect control, as is the case 
with inha'lation anaesthesia, and in certain cases this fact may 
outweigh all advantages, (ti) There is always some intestiniil 
irritation after administr.ation, and in a small number of cases 
this may be severe and accompanied by haemorrhage, and niay 
even end fatally, (c) There is greater injury to tho liver with 
this method than with inhalation anaesthesia when similar 
■ quantifes of ether are administered. 

7- shares with inhalation anaesthesia the following 

-drawbacks*, (o), It has the same pharmacological contraiiidica- 
lions. (h) It cannot be used in a room with an open dame, 
(c) The patient has to be kept under obserx-atio'n until conscious- 
ness -returns, and in the- case- of oil-ether anaesthesia this 
period may be prolonged, (dj It often needs preliminary- 
medication such as morphine injections, or subsequent inliala- 
tion anaesthesia where deep narcosis is required. 

8. That detailed statistical studies of accidents due to anaes- 
thesia conducted in various w-ays are urgently required. These 
must contain suitable classifications to permit of the correct 
evaluation of varying factors. *' Until forthcoming, no com- 
parisons as to -the relative safety of any method as compared 
W'ith any other, can be made. The dose of ether should be 
regulated according to the xveight of the patient, and it seems 
probable that 2 grams of etlicr per kilogram of body weight 
is the maximum dose that can be given with safety, following 
a hypodermic injection of from one-sixth to one-fourth of a 
grain of morphine, the latter dose depending also on bodv 
weight. 

9.. That_ the choice of an anaesthetic and its mode of adminis- 
- tration need the same careful consideration whatever be the 
method of anaesthesia employed. -Routine methods are dangerous 
and irrational; 

10. That lack of adequate -statistical studies of the occurrence 
of post-operative pneumonia and its causes. makes it impossible- 
to state w'hether this follows oil-ether anaesthesia with greater 
or less frequency than, other forms of anaesthesia. 


II. — SrNnicisiio rV>Mt,Gr,siA. 

Tho author next proceeds to discuss so-called synergistic 
analgesia. This was introduced hy Gwathmey in IS21 and 
consists, iu tho addition to the usual hypodermic. injection, 
of mor'phino, of a small amount of magnesium sulphate. - 
Ho claims that this addition increases tho value of the. 
injection from 50 to' 100 per cent., and so allows much 
smaller quantities of ether to ho used. Gwathmey divides' 
the stages of anaesthesia into four— tho first being that of 
excitement, tho second that of analgesia, tho third that of 
surgical anaesthesia, and tho fourth that of overdosagb. ; 
Ho propo.scs to make use of the first and second stages 
only, in which excitement is abolished, so as to make, 
expert supervision unnecessary, and it is with synergistic, 
analgesia that ho proposes to effect this result. Hatcher 
discusses tiib literature of tho subject which followed 
Gwatlimey’s original paper, and comes to the conclu.sioii 
that tho evidence) is not convincing that tho use of from 
2 to 6 c.cm. of a 50 per cent, solution of magnesium 
sulphate materially lessens the amount of ether required 
hy rectal administration to induce anaesthesia.’ Per contra' 
there is no doubt that tho amount of morphine used has 
a decided iiinucnco on tho total quantity of ether required ; 
but there is ample evidence .that tho action of morphine 
on the re.spiratory centre 'is synergistic with that of ether 
and magnesium sulphate, and that numerous deaths have 
resulted from their combined use. What has been said, 
concerning tho advantages and disadvantages of rectal 
anaesthesia applies equally to tho so-called synergistic 
analgesia, and the evidence brought forward by Gwathmey 
in support of his claims with regard to the latter form 
of analgesia is hot convincing, hloreover, expert super- 
vision is still as necessaiy as ever with, regard to the 
welfare of tho patient submitting to the induction and 
maiiiteiianco of anaesthesia. - • . ■ 

III. — Axaigesia in GHimBiniHl 

Hatcher next discusses analgesia in childbirth, with 
particular reference to tho claims of synergistic analgesia,' 
and after citing numerous papers on the subject conies' to' 
the conclusion that synergistic analgesia is by no means- 
safe in tho hands of tiio unskilled, and that tho commercial- 
exploitation of proprietary products based on th*o Gwathmey 
formulae is potent for. much .hai*m, since it will inevitably 
tend to promote the thoughtless and ill-advised use of, the 
method. No method of inducing analgesia is suitable for 
universal use! So-called painless cbildbirth is frequently, 
a most difficult problem. Tho general practitioner is often' 
misled into believing that ho can secure better results by' 
the method that ho reads about than by tho methods With' 
wliicli lie is familial*, when in truth it presents no cssen-* 
tial advantage, and may prove inferior in his hands to 
that in which he has acquired a degree of skill. - - - 

The Gwathmey method skilfully used will undoubtedly 
mitigato the paiiiy'qf labour*, but no woman should h'e 
i promised a painless labour, since even Gwathmey admits, 
that only a small proportion of patients havo relatively 
painless labour. 

Obviously tho dosage of morphine and ether should be * 
calculated on tho weight of the patient. ' After an average ' 
dose of morphine the maximum dose of ether foi* a' -a’onian 
of average size amounts to about 2J ounces. Tho quinine 
used in tho Gwathmey method frequently overcomes the 
retarding effect of morpliine, but labour is sometimes pro- . 
longed even with largq doses of quinine. A great difficulty- 
lies in tho.cstiination of, the time that will elapse before' 
labour is completed, with consequent uncertainty as to the 
time wheii the enema should be administered. Talkative- 
ness and motor' unrest are difficulties ivliicli, in the absence 
of suitable attcndaiits, may prove troublesome to deal with; ' 
Rectal irritation may be important. 

Tho question of the x'aluo of magnesium sulphate with 
morphine and ether, cannot ho ausw’ered at present. 
Many state that it has a clinical value, .but there is no-: 
evidence that, it potentiates tho action of morphine,* and 
animal experiments slio.w . that there is a summation -of * 
toxic effects. There is probahl}- also a summation of thera- 
-peiitic effects. . ' ' 

, .On the whole, then, the opinion of the author w’ould ' 


770 May -5, 1938 ]" 


IBEriAND. 


r 7nr. n»m« . . , 

L y KUlCAt. JoCkVit 


seem to be that rectal oil-etbor aiiaoKthcsia ami analgesia, 
whether used \vitli or without other drugs sueli ns 
magnesium sulphate or quiniuo, should he induced onlv in 
selected cases and at tlio hands of tho skilled aniiesllielist. 
Tho methods, even in the hands of the skilled, so for from 
being harihless,' show, ' or appear to show, nnfavonrahle 
results with greater froquency than is met with nsnallv in 
the case of the various inhalation methods. The fnrlher 
inferenco is obvious and needs no elaboration. The 
enthusiastic claims of tho pioneers, ns so often happens, 
have not been borne out by tho cxpeiience f)f .snbserinent 
workeis, and aecidonts have happened which cannot bo 
explained away on tho assumption that a faidty teehiqnc 
was entirely to blame. TJndoubtcdl}* rectal anaesthesia and 
analgesia have a place in tho anaesthetic sun, but it has 
by no moans as yet been pioved that this pl.oee sbnnid be 
granted them at the e.xpense of thoMildor methods. An 
examination of the autlior’s papcr.s in the original will 
convince most British anaesthetists that his conclusions arc 
soiind and that tho anae.sthetic millennium has not yol 
been reached. 


TETRA-ETHYL LEAD IN AIOTOR SPIRIT. 

ComHiiffrp of Inquirtf : Evirlrnr-r from Avi^rica, 

I HE first ordiii.ary session of the commilteo apjioiritod bv Ibe 
Minister of Healtli, Mr, Neville CImmlierlain, to iiiqnire into 
the poisdde danger (0 health resulting from the nst of motor 
spirit containing lead tctra-cthyl, or similar lead-ronlaining 
compounds, was held at the Ollice of Works on April 30tli. 
The naine.s of the committee are .as follow.s : 

Clf/n;nr"oi fti; %^‘SS'ro’, 

Medical Inspector of Factories), Air Ministrv : Mr^b) n rVc M A 

Bjfr'eoto^r^® " 

Sccntaijj : Jir S. F S. ilcardcr, Ministry of ireallli, Wliifclinll, .S.W.I. 
Evidence was t^en from representalive.s of the Amerie.an 
producers and the British distributors of ethyl petrol, and from 

’■ogardiiig experience in its use. 
Pnr Graham Edgab, director of rese.irdi to the Elhvl Gn.coliiie 
Corporation, New York, stated that his company h.ad ^1 

ctr^luee:-“"atre°'h:i‘d^ 

SraslrFjS/SriSFJri 

hazard to public health ‘from the nse”of etlivl "1 

no grounds foy prohibiting it, provided its dU?,. | , 0 “” ""^’1 
were controlled by proper reculatinns ® distiilmtion and use 
gafions- the citie^ '^ivb'idVSner he sp “"if'j' 

objection. The United States Bureau oTMinel f"' 
animals from three to six hours ner dav fr, expo.sed 

an engine burning this spirit; after a ^period^ o'? 
there was no storage of lead and no ^ymplom of® .months 
Tests on human beings were made by e-xpo^n^eronno 
as severely as possible to ethyl gasoline in varioL X” AdtJI 
groups not so exposed as, controls. Searching medicil ‘ 

tion established that no individual in any of the rJ '^“mina- 
evidence of; lead poisoning or any other ii^ury to hLuiPrclut? 
mg in any w.ay from ethyl gasoline. The e.xpericnce of 
corporation liad been that when their product was intind.., j 
into new territory reports of alleged injury were numerous whUo 
from territory m which its use had been extensive such ronnrt 
were negligible. Reports were investigated wherever possible^ 
m no case had there been any substantiation of the rumour that 
any injury could be traced to the use of ethyl gasoline. Referring 
to the result of an investigation recently published in an Enelisfi 
newspaper, Dr. Edgar said no conclusions whatever could be 
readied from consideration of data so fragmentary. Replviinr 
an stated that theirs was a new industry, and that 

‘'so,ne‘'of ^md to be closely 

*■■' 80 ™,,?);. handling ethyl had been 

Gw p^l ten ylars, Vd wouM 
^ne next ten years, m view of 


possible cnmiil.-ilive effecl.s. A.s yet there had been no deteriora- 
itioii in-lhe health of the .staff. - 

The rapid c.xioiision in the ii.se of ethyl gasoline in Canada 
amt tile. United Stales was dc.scrihcd hv iMr. A. M Maxwctf 
vice-president and sales manager of the EtlivI Gasoline Corpora- 
Itpii who lidded that, last year the corporatinn, which .supplied' 
tliirty-six of (he major oil companies, did not receive a .single’ 
roiiiplamt of damage to health from users. Mr. H. S. Tecxer 
of tho ^n^lo'Amorrcfln Oil Company said his company was 
thoroughly convinced of the .s.afctv of the (etra-cthyl m’ixtm-e 
before inarkeliiig it in England. Although its repre.senl.ativcs 
iiau studied ovory availahlo source of cv'idcncc, and iuid hocn 
intimately conccrncci in liandling tlir product in tJicir blending 
plants, whore the staffs were rogtilarly inspected hv competent - 
medical practitioners, tliey liad not cncountorod llie lea.st indica- 
tion that the handling of the spirit did or could produce’ tlie‘ 
.slightest deleterious effects to tlie worker, the motor car u.ser, 
<»r tho juihlic generally. 

Afr. Pye, rcpre.scntjiig the Air Ministry, stated that exhaustive 
experiments liad been carried out in the laboratory and during 
long evolutions of two .squadrons. At no time had tlierc been 
any report of iline.s.s among tho personnel handling ethyl spirit. 
In high-speed aero engines the projiortioii of letra-elhyl lead u.sed 
in (lie petrol was often considerably higher than in the mixtures; 
sold eoinmercially. Dr. BniDGE of the Homo Office said the 
Anglo-American Oil Company fully consulted that department 
lieforo tliey put ethyl spirit on the market. The inquiry was 
adjourned. 


Krrlfntb. 


rnrewcll Dinner to Professor J. A. LIndsny, Belfast. 

Ok the occasion of his leaving. Bolfnst to take up i-csidciice 
ill Immloii, Dr. James A. Ijind.suy, Emeritus Professor 
of Medieino in the Queen’s Univer.sity, Belfast, and senior 
eoiiMilting physician to the Royal Victoria Hospital, was, 
on April 24tli, entertained at a complimentarx- dinner. 
Professor Lindsay’s hosts were his colleagues of the visit- 
ing stalls of the’ Royal Victoria ‘Hospital and the Belfast 
Maternity Hospital.” Ho has for some years past been 
clmirman" of the hoards of both these institutions, and in 
that cajiacity has exercised an important and beneficial 
inlliicnce on” their development. In the after-dinner 
.spee<'hcs his colleagues found mueb to recall in connexion, 
with Ids viiliinble sor.viccs in raising .the .standard of the' 
local hospitals and in the advancement of medical eduea- 
liou in Belfast. Professor R. J. Johnstone, M.P., a fomicr 
pupil of the giic.st of the evening, paid his tribute in some 
ainiisin" verses conqioscd for the occasion. Professor 
Lindsnv is a past-president of the Ulster Branch of the 
British” Mixlical Association, and was jiresideiit of the 
Section of Jfcdiciiic when tho Association' bold its Annual 
Mooting at Belfast in 1909. He u ill bo greatly missed by 
members of tlie medical profession tlirouglioiit Northern 
Ireland, uho unite in wisliiiig him boaltli and liappine.ss in 
Ids retirement. 

The Coming Public Health Conference In Dublin. 

'J'he aims and objects of the public licnltli confcreiico 
xvldcb is to be licld in Dublin from August iStli to 20tli 
wore the subject of au address by Sir IVilliam ’riiompsoii, 
AI D. at a recent meeting of the Dublin Rotary Club. It 
was he said, xvcll known to everyone that medicine and 
surgery had made greiit progress during the latter pai-t of 
the uinctoentli century and up to the present time, hut it 
was recognized that in future it would ho maintained more 
in the direction of prevention of disease than otherwise. 
For some sears past special attention had been devoted to 
proveiitioiv not only, by the medical profession, hut by big 
business firms and .jiublic bodies having the' healtli and 
welfare of their employees and of the community at heart. 
It xvas to forward this object that over forty years ago 
the Royal Institute of Public Health was established. The 
Dubliii lilcdical School, which deservedly held a world-wide 
reputation, was, said Sir 'William Thompson, one of the 
first to institute a diploma or degree in public healtli— -as 
far back as the .sixties in the last century — and, happily; 
they bad still xvitb them Sir ifohn Moore, ulio was one of 
the earlier graduates. Dublin business bouses had not 
been hehiudliand in looking after tho health of their 
employoe.s, notably the firms of Guinness and Jacob. n>e 
holding of the yearly congress in large centres throiighont 



Max. 5, '■ 


ENGLA-KD AljD WAGES. 


{ Tine nnmn 
Mkdica:. JoCkKAt 


771 


Grrat Britain, Ii'oland, and on tlio Coiitinont,. as tlic 
Institvito' did, rvas a means of bringing togcUioi' those 
interested in public Iiealth and allied work to discuss the 
problems wbieli arose from year to year. In addition, 
this served, tbrougb tbo' jiresSj'to edneate the pnbljc and 
kce]i, it informed of tho j)rogress made in fbe pievontion 
of disease, which would add to the healtli and happiiicss 
of tho cominnnity. Last year the- congress was lujld in 
Belgium, in 1926 in Bristol, and seventeen years ago it was 
held in Dublin. Tho eongress was made np of delegates 
appointed by nniversitics, medical colleges, boards of 
health, and other institutions interested in public work, 
through invitations sent by the Institute in London to 
such bodies in Groat Britain, Northern Ireland, tho 
Continent, United States, and Canada, In Saorstat 
Eircann the invitation was sent hy tho cxocutivo comniittco 
of tho congress. Tho Mansion Itonso had been jilaced at 
the disposal of tho congress for offices, by kind permission 
of tho city commissioners. Tho matters to bo discussed 
were of practical importauce from every point of view, and 
should bo intefesting and instructive”' to tho citizens of 
Dublin and tho people throughout the Free State. They 
had some of the most important public health workers in 
Great Britain and tho Continent coming across. Sir 
illiam Milligan of Jianchester; Dr. Yarricr-Jones, super- 
intendent of Papworth Tuberculosis Settlement ; Sir Henrv 
Gauvain ; Dr. Stevenson of the British Ministrv of Health”; 
Dr. Leighton of tho Scottish Board of Health; Dr. 
Trimble, tuberculosis officer, and Dr. Fulton, Children’s 
Hospital, Belfast; Dr. M urtzon of Denmark; .and Professors 
Abercrombie and Beattie of Liverpool. From an expert 
and scientific point of view tho success of the congress was 
ensured. Dublin, lip continued, had always been noted 
for its hospitality, and the executive committee was doing 
its utmost to live up to past- traditions'. It might bo asked 
if any good results followed the .1911 congress, and what 
Imnefit was expected to accrue from tho coming congress. 
One had no hesitation in saying that those who took part 
in the 1911 congress were unanimouslv of tho opinion that 
much boneat resulted therefrom. Public health conditions 
had advanced considerably during tho seventeen rears, 
although Uie great war and their own unsettled cond”itions 
inten-ened. Ho wished publicly to pay a tribute to the 
icco Government and Public Health since 

lb22. There was now in Saorstat Eireann one of the be.st 
means for tho appointment of medical officers of health, 
edic.il officers, and ah appointments on health— through 
the selection board. The adoption of this system was a 
bold and courageous step for the Executive Council to take; 
lit ® pe I ica point of view it alienated some support, 

ensured a body of public 
Thf * in any other countrj'. 

‘’^Gicir people would bo improved and 
prosperity and Iiappmcss ensue. 


T*'® .Rotunda Hospitcl, Dublin. 

At a meeting of the Section of Obstetrics of the Royal 
I" Ii'cland on April 20tli Dr. Bethel 
Solomons read the clinical report of the Rotunda Hospital 
for the year 192^27, mid films' were shown to illustrate 

of wi° ^“bopiaii tubes after the injection 

ofl.piodol and the method of performing x-ray pelvimetry, 

dn;^ that the x-ray plant installetl 

firing the year had proved useful in obstetrical and 

treatment. Tlie pathological 
. aboratory liad been reopened. The scope of tlie aiite- 
greatly increased, and it was 
sn.w f! that antc-iiatal study should bo made dompul- 
®’'®'ties A small ward had been opened fpi 

■itnn 1 British Medical Association 

^andard or morbidity had been used and the “ Rotunda ” 
method also was followed ;' the results proved to he identical 
at the end of the year. The luimher of Caesarean sections 

tmn. The treatment of eclampsia had scarcelv altered 

u as T'T Gio gynaecological wine 

talitv hospital. The gynaecological inor- 

U -I 1 1 ■ The master of the hospital 

thanked h.s assistants, Dr.s. Taylor and O’Doiiel Browiie 
for tbeir share in the preparation of the report, and he 


referred to the. excellent, work , of the matron and nursing 
staff during the year.. Dr. Gihhon FitzGibhon, . presidont 
of tho Section, said that tho treatment of septic cases at 
tlio Rotunda Hospital was apparontl)- much the same as it 
had been' at. tho end of his term as master. Ho did not 
put much faith in collosol iodine, hut thought that it was 
beneficial .in some cases. In tlic last few years treatment 
hy vaccines ' and antitoxins had decreased considerably. 
AVIicn performing Caesarean section the lower segment 
operation was more difficult than tho classical form, but it 
was the bettor procedure; he did not think that it would 
have iniicli more infliicnco on the recovery of an actnalh' 
infoctod case, and heliovod that, such cases should always 
be drained at the time of operation. In no case of 
accidental Imomorrliago was plugging of the cervix indi- 
cated. He had had most disastrous results in cases of 
placenta praovia .which had heen sent into the 'Rotunda 
Hospital plugged. Sir '^VillinIil Smyly emphasized tho 
importnneo of educating modicaT students in midwifery, 
and commented on tho recent improvements at the 
Rotunda Hos)iital. Dr. Louis Cassidy, said that at tlio 
Coombe Hospital it. had been found tliat at least 50 per 
cent, of tho women who developed sepsis had not heen 
interfered with. Ho hclicvcd that there wero three causes 
for sepsis: the possibility of toxins, A septic focus in the 
teeth, and residual urine in the bladder. Foetal' mortality 
seemed to ho tho main difficulty in midwifery at present; 
this was largely duo to lack, of ante-natal treatment, and 
the new ante-natal clinic at the Rotunda Hospital sliould 
be of great value. Dr. J. S. Quin said that of all the 
improvements in the Rotunda Hospital none was of more 
value to students than tho clinic for infants. Dr. R.- J. 
Rowlettc remarked that a great forward step- had heen 
taken in restoring the pathological laboratory at this insti- 
tution. Dr. N. McI. Falkiner suggested that a detailed 
register of the patients who came to the ante-natal depart- 
ment and were delivered in tho Rotunda Hospital should 
be kept and compared with tho records of those patients 
who did not attend; only in this way could the value of 
the department he estimated. ■ 


anti Mabs. 

A Private Patients’ Home Insurance Scheme at Norwich. 
Tur. opening of a new private patients’ homo at ■ the 
Norfolk and Norwich Hospital marks tho beginning of an 
interesting effort to meet the needs of tho middle classes 
in respect of hospital facilities. In the scheme now in 
force there tlie provision of pay beds is associated with an 
insurance schema, the membership of which is' limited to 
persons whoso incomes fall within certain defined limits. 
Admission will ho restricted to persons whose incomes do 
not exceed («) for single persons, £350 per annum ; (6) for 
married couples without childien under 16, and widows 
and widowers with children under 16, £450 per annum ; 
and (c) for married couples with children under 16, £550 
per annum. A yearly premium of £1 10s. will entitle a 
member to free in-patient' and' certain special ou-t-patient 
treatment for himself, his wife, and any children under 
the age of 16. Tho scheme . embraces “hospital” treat- 
ment only, and before a patient may he admitted he must 
bo seen hy a member of the hospital staff in consultation 
with his own doctor; the fee for such consultations is not 
liiovided for by tho premium. Oiilj- members of tho hospital 
staff can treat patients under the scheme. Alaternitj-, 
mental, and infectious cases cannot ho admitted. The 
premium covers all surgical, medical, and maintenance 
costs, including those of special departments, while in 
hospital, hut not tho cost of any special appliances, drugs, 
or instruments which may be ordered for treatment after 
discharge. Power is taken by the management committee 
to control the extent to which members may remain in 
hospital as in-patients or attend as out-patients ; ' no one 
may remain as an in-patient for more, than four consecu- 
tive -iveeks, or attend as an out-patient for moro than 
eigiit -weeks in any six months, except by special- arrange- 
ment. The department is managed on behalf of tho 
hospital board hy a committee, on which subscribers to tlie 









OOimESPONDKNCE, 


t jnr. nnm^a 
JIedicjx JeriPtit 


- 774 May 5, 1928] 


ac‘id-fnst form and its slow growth, has mado tho luuntifac- 
ture of a potent antigen diffienit, and, except in tlie ease (»f 
old tuberculin A T, special grinding apparatus has had lo 
be devised. In A T Koch hoi)ed for the ))rescncc of toxin 
freed from the hacillary body by autolysis. 1 think he 
achieved it to a certain extent, for I have always tliought 
A T the best of all tho ordinary tuberculins. In the manu- 
facture of H.T.S. (human type tubercle bacillus .solution) 
no .special ajiparatus is required. 

I)r. Carswell is exercised by the smalhic.ss of tho dose, 
but 0.000000001 mg. actual 'weight of the original live 
tubercle bacillus, obtained by dilution, is a potent thera- 
peutic dose of H.T.S. , and must not he e.xceexled as a 
primary dose in tho immunization of established pulmonary 
tidierculosis. He will I’oalize, then, that 0.01 mg. is ten 
million times the primary do.se. 1 feel that the p.atient is 
safe if I attain to a dose of 0.001 mg., but it is not alway.s 
possible to do so, as the maximum dose varies with the 
individual. 

H.T.S. is, therefore, a very ])otont antigen. 1 believe it 
to contain free toxin. 1 have made a solution of the bovine 
type (B.T.S.), but have found in practice that H.T.S. gives 
just as good results in “ surgical ” cases. Apparently the 
toxin of the tubercle bacillus is, like that of the di|)htheria 
bacillus, fairly uniform in quality — of course, the ideal 
would bo au autogenous tidjercle bacillus antigen for each 
case. This answeis the first part of Dr. Crawshaw Holt’.s 
letter (p. 692). I most thoroughly agree with the .second 
part, for tuberculosis will not be controlled until contacts, 
infants, and calves arc rendered relatively immune by 
preventive inoculation with tuberculosis. — 1 am, etc., 

Dublin, April 23rd. IV. M. CllOKTOX. 


THK CAUSES OF ALCOHOLIC INEBRlK'n'. 

Sir, — In your issue of Apiil 21st (p. 691) Dr.s. George 
and Vincent lay greatest stress upon heredity ns “ a 
decided cause ” of alcoholism. This is not borne out 
by the experience gained in the institution of which 1 am 
medical superintendent. It is true that not only jiationt.s, 
but their relatives also, are generally anxious to .shift what 
the)’ consider the opprobrium of inebriety from themselves 
to their defenceless forebears. In spite of this perhaps 
natural desire, only a small pioportion can adduce any 
reliable evidence in support of such a scaiiegoat type of 
excuse ; against which most of us knou’ that whci’e there 
has boon marked pai’ental excess the children tend to 
become rabid teetotalei’s. Drs. George and Vincent do 
admit that there are “ quite an appreciable number in 
whom heredity and habit seemed to bo absent as causal 
factors’.” In my experience their ” appreciable number ” 
is the vast majority, and the heredity fiictor when pre.sent 
is so accidentally, not causally. It would appear with at 
least equal frequency in a sample of tho popidation taken 
in respect of any other affliction. The bugbear of heredity, 
which we all trail with us in some sort, stultifies thera- 
peutic endeavour, though it serves as au ever-present help 
in time of trouble. ^ 

Careful psychological investigation in every case reveals 
the presence of those other factors which Drk George and 
Vincent touch upon so lightly and dismiss so easily My 
experience has convinced me that the essential iind'erlying 
factor in alcoholism is the desire for the mental effect of 
alcohol, and not easy access to tho drug, nor habit nor 
heredity, whicli latter serve at most as auxiliary deter- 
minants. Of course, alcohol is an addiction drug, and the 
“ alcoholist ” is not able so to control himself and his 
dosage as to maintain the, to him, exactly desired effect 
In aiming at what is to him ” euphoria,” he oversteps the 
mark and, like all neurotics, finds that his last state is 
worse than his first. Not infrequently addicts hate the 
taste of alcohol and refer to it as “ the bea.stly stuff,” but 
this does not prevent them from again having recourse to 
it when the adequate stimulus recurs. 

Unless the inime importance of the individual irsvcho- 
logical factor be apju’eciated a , rational therapy and 
reorientation can hardly be expected. Concurrent iilid 
incidental determinants must, of course, be attended to 
mid so far as possible be removed, but the essential is to 
'scovor in eacli individual alcoholist ” the psychological 


factons which motivate his flight to alcoholic euphoria ”• 
111 all cosis, and in spite of tho fact that he is aware that 
a price must be jiaid for this flight. — I am, etc., 

t'alibt’elc, .ipril 27th. ALFRED It, C.tRVU.R. 

“ DRUNK IN CHARGE.” 

Sir, — This subject has again been brought forward in 
your i.i-.sue of Ajiril 21st (p. 693). As tho condition 
is so I'asily recognized by an onlooker, it is unfortunate 
that th(> evidence of the jiolico surgeon or the judge- 
ment of the magistrate should bo at fault in what is, in 
cvervono's opinion, a matter of fir.st-class public impor- 
tance. 1 beg to submit herewith a few desiderata for 
your readers. 

The time between the moment of arrest and of tho 
accused being examined by the jiolico surgeon should ho 
ns short as [lossihle. Then, with tho man’s name, age, and 
addre.ss, he should ho inyited to tell his own story. If this 
is rational, and if there is no suggestion of incoherence of 
speech, disorder of behayioiir, jiosturo, and dress, or dis- 
orientation of time and place, then tho fifteen to twenty 
tests commonly applied are unnecessary, for the nian is 
not drunk at the time of examination. 

As a rule magistrates prefer tests, and therefore it is 
wise to put the man through some of these, selecting tho 
most striking results for tho oar of the magistrate. The 
fact, however, that the condition termed “ drunk ” is duo 
to alcoholic loss of guidance and control of .the highest 
centres should be evei’ ]n’esont to the mind of the surgeon 
during his examination, and, further, enable him in the 
wilneS,-box to give Jiis evidence in a manner that is lucid, 
calm, and decisive.— *1 am, etc., 

,.„0on. N.W.:, April 22, rb J- >lAXmn..K. 

THERAPEUTIC USES OF OXYGEN. 

_]t was with considerable a.stonishment that I read 

the article on the cause and '' The 

lobar pneumonia in your i-ssue of Aiiril 21st (p. 661). The . 
•luthor states that “In the ,,ast the use of oxygen has 
been tho cause of more deaths in pneumonia than one 
cares to contemplate, simply because it was administered 
cold and not warmed to the required temperatiire. . . . 
Tbis sweeping statement is entirely unsupported by facts 
and is palpably incorrect. The small amounts of oxygen 
commonly used in many of the’ current non-quantitative 
methods of supposed oxygen administration are not suffl- 
to effect apinociably the temperature of the total 
volume of insi.ired air, and m en with efficient quantitative 
methods the addition of, say, two litres per minute of 
oxygen would not reduce the temperature of the iiispired 
ni; to anv significant exTent. On the other hand, good 
results hnVe been obtained -witliout oxygen treat- 

ment of pneumonia cases out of doors m cold dry air- 
H’lviiig had considerahle experience of tlie administratioii 
of'oxvgen, both warmed and cold, in pneumonia and other 
^nnditioiis of oxygen lack, I can state dogmatically that 
warming per se makes little difference, and that 
tlint the method he efficient and the rate of oxygen fl 
adequate the results are excellent. Much more cou d 
said^ regarding tho facts of tho case— it is sufficient, h 
ever to protest rather against the manner in which 
iiinrcurate a statement is made. _ . 

The final sentence also contains some amazmg inaccu . - 
eies Oxygen dees not increase .metabolism. AYhcre the 
nwiren siippl)' 'S insufficient for metabolic needs the amnia 
rapnllv snecumhs from progressive oxygen lack. 
mmital evidence clearly shows, however that the me, 
belie rate is independent of the supply of oxygen 
tliat the latter he adequate (vide any textbook of P'‘?® 
Ino-vt The rationale of oxygen administration consists m 
in?reksing the oxygen percentage of ^k® ‘'l’''®®’"’' "‘J' 
eientlv to overcome a .pathological deficiency of P®^* 
ability of the pulmonary cpitbeliiini and so to P®®',®'” 
abolish oxygen lack. Oxygen does not destroy di^®^ 
although peroxides, in the absence of excess qf, 
or peroxidase accumulate in cultures of pneumococciis to 
an extent sufficient to inhibit the gVowtli of the organisms. 
Efficient oxvsren administration overcomes the pnlmquar) 




776 Mat 5 , 1928 ] 


MEDICAL NOTES IN PARLIAMENT. 


to receive sickness or disablement benefit in a lump sum if the 
society or commiMeo concerned Ihouglit that .special circiimslanee.s 
warranted (Ins. Dr. VraNON Davies asked wlietlier nayinent would 
H itouiT''^ ° ^0- S'l- KingsLes- Wool said 

•'‘'"e'Mm'f't to provide that where any 
not to (l eTcuf'S'w® 1 ° i‘'‘? polienl it should he paid, 

inaiidaiW ’^1',*' ‘9. Jnsliliilioii, imleM! thal were 

Ha nev ssi 1 "f public funds. Mr. 

he wmdr) lil-l! ''’i ‘7’ ’i®" v”" ’'lO'olo ot all institution said 

alrolX '>?, P®*') to that institution, power- 

was so. to have it so paid. Sir Kingsley Wood said that. 

lh?clause1i7amenckdT "o<l l'>o eoniii.itleo carried 

Ac?“mf “'"^d'ooiit to Ihc provisions of (he principal 

enLl that administr.alion of medical bcnofil, and proposes to 
.1 =‘tter a dale to bo prescribed, no in.sttred nei-snn 
^ nurse or employoo of a?i institution simll h(^ 

medial TreXmnt''7'"H™ own nrnineemenls for 

™Lonfs"h™iigTi ant"?"'™ o? iijslitnifon"'^ 

not called upon to W* ^ m P'-iolilioner was 

exoecled h„) b,' /i "'‘'f ”'o.'o .sltiH than could be reasonalilv 

treatments aiid bcnofi™''wcTe Tro 'ordinal" 7’ (!' >'H‘<licn'l 

instihitioii were oiitif led to ra-ordinated that members of the 
both surgical and medical Th o * from a iiumlier of doclors, 

tp.atnicnT, niasstgc, iS i trea mcnr"s"nd“'r, '’'"r'''®'' f®’- 
skilled doctors and surgeons A* If,",.’! ‘'"‘'‘"iljorntor.v work from 
tiy tbese medical inllilftfons He l,7d •‘^7 "'7® ongaged 

included 4,000 uiiempldVed If Dm i/b mind one sclieme wliieb 
recognition those " Id be ler" 7.'' ’l°t Ret fmiber 

.service. Panel doctors cmdd n7i i.® ®tt without any medical 
Ho cited the progress of the Mid Tii®*t'7i ®7r 7 *''!'® them over. 
In 1913 it was appSved for ^bom '«!« ‘ 7'^'®'*' iiV'' ®®®‘®ty- 

practically 6,000 meuibers receivfnc ^ , ."‘O'njx'rs. Now it had 
appliances, surgical appliance^ artiTlcLMi'mli t®?"*'"®''*- medical 
and oculist trMtment * No !ti’dl7;d, ®i" <lrnlal trealment, 

these treatments. ' ^ mdiudual practitioner could provide 

ot'Srr,mXrfwhi7h‘'w7ri°'in ?°"®''"-® '"®<''®<'' 

the National ™®7®7® "h'uh "orp in ciislcnce at the pas.,nge of 

legislation. 1 .'...'i "" touched by this new 

brought inti ' ■ '.i. .’®® ‘iisliUilions had been 

dispositions so as to escape (f,o „ '® ‘ rlaimcd to make 
medical benefit. This had dine unde '‘®®‘''.''ernicnls of 

gi«ar;?x-;,/vss 

gia-i. ti,, ,ig 

a. s CjTssiXvt'JS s “t'Vs 

a77'®i®^™® as instiFutims Jxistine at Vb“ themselves 

Act. A number of these so-called lo.ri® i- Passing of Ihc 

obligation to render anj retmns to n.e'7^'®": "■®®® ’■"<>rr no 
no effective control to see Hint the 7tandar7’’7 "’®r‘' 

^'‘‘F,‘=>ent, .In some cas« t) is '^•7®''‘®‘'‘ ‘reatmcnl 

rs7®’e®,ie7®l®v« bo. no profi't as ah D?77?' ."J.®"®, « .P®7t 


[ 


fnr. Jlnmjw 
MtojcALJotrs«fH' 


where there should bo no profit all =* P> 

expende^d on behalf of the insured ’nc7=o. w®. "'®"®y '‘'"■"M Im 

ment thought, the payment to i 7.^7 i '' I'ore, as tho deporl- 
ensured the best medica? sfiVei- was iiol of a kind that 

asking -Parliament teSiX'ne" 'll’ saw "’as "feht 7n 

tions not coming under iSection 24 inslilu- 

existpng m 1911— must apply to the S’®*" with societies 


an adcqu,ate standard of treatmmt for''D‘'® ®^^®®‘ ®"®"' 

approved they would iiave to .supplv*n?nne7'®V' "‘“'"’’ars. IVlieo 
menfc anrl cr#snoMaii,r Proper rGl.iir«o it.. ■>. “ 


ensuring 

nieiit and generaiiy Tondu"l®"©r ®®^“rns "to 7h 

institutions had been conducted Each original 

®®,7^ ™orits. case would bo considered 

miftce for approval. The secrelmy oT^h^e^nt '® Com- 

for Glamorgan had said before the Eoval Committee 

no cause ot complaint against these -fehnSo? mf'®" fie fiad 
scheme collecUicl £7,218 last year,- and the wfini^^*® Mid-Rhondda 
tration was £100. It had seven doctors and Dai77i ®^ ■'“Immis- 
lifi"; 1 * f ” '.'®® mstitutipns recoenFz7d^ ®o'aries 

Medical A^ociation. Their efficiency and qiiafiTirnf* ^ British 
pare with those of any other doetorf in SoWh Walc®""n!l^“''’ ®»™- 
had ex Mnded £4,0(30 on a proposed hospital for its ®®fieme 

John added that he understood Sir Kin»glev W„7i 7*’®®®- Mr. 
assurance that, subject to schemes Aeing worked a® ®*®® 
standards of the Ministry of Health, no serioms ohWi’”^ ‘® the 
be raised to their approval. That beine so bo "'“"M 

objection to Clauses. ^ withdrew hfe 

Dav^jes asked ■ whether Sir Kineslev \Vooa» 
meant that future schemes on similar lines ifoul'd 1 ^°®^ ® speech 

me?' a’i'L^teWh-MjeTe 

A?ocwtiS/ W1 ?®ut?now7ire^BSisb'''SL,.^,!^ 


Associali'on^ had\^t^’i<c'^f some years now tiie^^British 

-youo applying for such a joll'Ti c^ns'Ju 'lb7 ISifa! 


iiimpKe'-, ,?<'lie,?i°nfeL rot;v7f7,?'r'", ‘'‘i® 

s#affi5slaS3J3$ 

Jir. Uatts Raid he did not approve of these institutions but with 
ro..(f.?7"^ Jewontent in the coiinfry with the n.ahire of the 
nf ooT" * ' ° ‘mtional hcalfh insurance, a number 

of people were . anxious to hand lhcm.sclves logclhcr to make 
iiiiaiigrnieiits with private doclors midcr a system by which 
he liTOiratico ^mmittecs would hand over to them U,i capita- 
don fee, and the patients would bo willing to pay a supple- 
mentary fee to make sine (hat they- got decent attendance 
as insured prisons. Re held no brief for the iiislitutions or 
clubs under discussion. The medical attendance they gave w,as 

<'quntly as had ns— if it were possible lo be as bad ns the 

medical nUeiiilaiicc under the national health iasurance. He spoke 
from knowledge of the attendance which insured persona got under 
iinlioiinl health insurance. It was not the fault of the doclors 
Under the Nnlioiinl -11001111 Insurance Act a doctor's lime wa-s 
taken up in a large measure by red-tape regulations and by 
keeping silly records which were ol no use lo anybody, and which, 
when they, eventually arrived at the Miiitslrv of Healtli, were, lie 
understood, destroyed, no use being inndc'of them. If certain 
groups of the insured population banded themselves together and 
made a private avraiigcment with medical men to attend them 
on the basis of the c.spitalion fco jihix some cxlra pavniciit which 
they themselves voluntarily made, and that aiTangcmc’nt could not 
go on it this claiiso was allowed to remain, lie agreed with the 
proposal to dclclc the clause. 

Mr. Rhys Davies said Dr. Watts belonged lo the Neolithic Age, 
Ilonllh iiisiiraucc hod conic to .slay, and doclors wore now anxious 
to come into it, as payments wore secure and they were much 
hotter off than in (he days before the Insurance Act. Ho was not 
sure that people in South Wales were getting the best medical 
service. In some of these institutions the medical men wore 
splendid fellows so far 'ns their personality was conccmotl, and 
gained the copfideiicc of the nation, but might not be competent- 
medical practilioncrs- 
Claiisc 3 was then approved. 

Clause 4 pioposed to permit approved .societies and Insurance 
Commilloes, with the consent of the Minister, to make suhscrip- 
lioiis and donations " of an clceinosynar)- character” to hospitals 
and similar cliaritahlc institutions, oven although, in the case 
of the approved society, no disposable surplus was disclosed 
at the last- preceding valimlioii. This was altered slightly at 
the suggestion of Sir Kingsley Wood to make sure that the 
clause did not bar new socielics. 

Mr. Bbiast moved to pcrmjl subscriptions to ” hospitals, dis- 
pensaries, and other iiistiluLioiis.” He thought tho definition 
should bo wiilcncd to cover future institutions with new methods 
of trcatnient,.both preventive and remedial. Sir KraesLEV Wood 
said the clause endeavoured to end a svsteni bv which under the 

l„... ,wls.rsss4 nfT« sffsi. Inlrcvs 4 A .e 1 i 


saiu me s4AiuvAA*-.rA»is.-s.i av t:uu «t u.v wuiuii unaer me 

previous Jaw ailvantage was^ taken to enter hy way of contract 
with some insfitulion, nnil rotnvn to receive certain benefits 
for incmber.s of • tlic society. That -was perfectly permissible at 
tJie time, but in- Iho opinion of many societies was detrimental 
lo lhe?n. Ho must resist the amendment. All the societies should 
do in future was to make genuinely charitable gifts to institutions. 

Mr. UuYS Davies said they should^ have in tlio Act some inter- 
pretation of wimt chnritaolo institution ” meant. He gave a 
case where officers and committees of approved societies had 
formed themselves into a “ charitable institution,” and another 
where an approved society decided lo establish a clinic from 
funds granted under llic same pretext. ■ All money spent from 
national health ^ insurance funds by Insurance Committees and 
approved societies should be audited to its destination. By 
subterfuges societies had been able to detach money from their 
benefit funds to provide additional benefits which they could not, 
in law, provide. • • 

Mr. Meller said some societies had used this section to offer 
additional benefits in anticipation of a surplus which they had 
no reason to assume would come to them, and in order to 
attract people to ‘their societies. If that could be stopped it 

would be desirable. TJic Rc*"' )t, I'ccommcnd that 

gifts should be made to except out of a 

surplus, -but this ‘bill went ^ ^ »uiziiig that there 

were cases where some gift might be made to an institution 
whereby special treatment could be obtained. 

rDr. Drvmmond SiUEls said he was interested in the section as 
connected with 'the' important subject of -specialist benefit. The 
committee bad heard speeches showing the _uusatisfactory 
charaeter of tlie present medical benefit under the insurance Act. 
Societies in the past had tried to make arrangements with 
voluntary hospitals that ni return for a donation a' certain number 
of beds W’ould be reserved. In many cases that arrangement had 
been refused, as managers of voluntary hospitals had not felt 
they were entitled to make such allocations. He asked Ns’hcther 
an arrangemeht with a voluntary hospital for a certain number 
of beds to be set aside for a particular approved societj* would 
oe allowable under the clause. 

Sir Kingsley Woop said-Dr. Shiels would have an opportunity ' 
ot raising that on another part of the bill. 

voluntaiy gift could be accompanied by 
of in^iv^u treatment of an individual or of a number ' 





May. 5 ,' 1928 ], . 


SIR WlttiTAM onURCHrBT. ; 


t Tit* Dnmim 
Mrdical JoonMix> 


779 




jilnsician to tlio Royal General Dispensary in nartliolomon' 
Close, and assistant physician to tlio Victoria Park Hos- 
pital for a time'. In 1866 lie was put in charge of the 
eliolcra ivnrds at St. Dartholomow’s Hosjiital, and then for- 
tlireo months iras actiiig apothecary for Mr. IVood, thus 
doing tho ' work snhscqucnUy discharged by house-' 
physicians; in March- of tho following year (1867) ho ivas 
elected assistant physician; and eontinned to. do much work 
in the post-iiioitcm room, publishing papers on cerebral 
patbology and aiionrysms in tbo llosjiUal licijorts. Between. 
1868 and 1880 he niado thirty coniinnnications to tho old' 
Pathological Society of London, all but two before 1874. 
Early in 1875 lie liccanio full physician to tho hospital, and 
when- ho was- elected consulting physician in 1902 had. 
taught no fewer than forty-six honsc-physieians. As a- 
general physician — a typo now becoming exceptional — 
Church was i extraordinarily sound ; one of his former 
house-physicians, who has siuco . 
followed in his footsteps in 
being physician at their did hos- . 
pital; recently expressed' doubt, 
if bo ever made a serious mis- " 
take in diagnosis. - Ho taught' 
ludro by' example .than by. prel - 
cept, and had a-shrewd eyo to'.; 
tho main issues, 'rathcr avoid- 
ing extreme rodnomeuts of. 
diagnosis.-- Long apprenticeship 
'in tho post-mortem room, or,' 
ns ho usually called it, . tho ' 
dead house, - bad given him a 
sense of duo proportion, and 
this oxporionco ho increased 
by constant visits when full ■ 
physician. His.houso-physiciauB 
learnt moro from him than - 
did those who wore mainly 
concerned to pick up hint's 
thought to ho useful in steer- 
ing them ■ safely through • tho 
jaws of tho examining bodies. 

He certainly nevor " laid him- 
self .out for piuctico,” and his 
voice, was not .heard, in tho 
jimrkot-placo; hut, though ho 
gave .110 sign of disappoiiit- 
mont, he was not so indifferent, 
to private practice as was 
commonly supposed. . ! ■ . 

At the Royal Coliego of. 

Physicians of London he held 
the offices of Examiner in 
1874, 1875, 1884-86, Councillor 
1888-89, Censor 1890-91, Senior' 

Censor in 1896, and was elected 
President 1899-1904. The firat 
election, on March 27tb, 1899 

the lilte Sir Samuel Wlks, was 
tlie ■ close . contest between him and tho 
Sir IVilham Broadbent,- and. was impressed indelibly 
on the memory of those present bv the sudden fadure of the 
u ' '"^cessitated tbo votes (Church 77, 

Broadbent 67) bemg counted, bv tho glimmeiing light of 
a mnglo lamp— a Rembrandt-like effect 

Tiuoiighout his life he shouldered laborious and nccossarv, 
but not invariably interesting, tasks as a matter of dutv 
Without any suggestion, that- this was the reason, and, more- 
■ "]''®*sred the business thoroughlv. At tho 

Hospit.al School , committees he was indefatigable, and was 
s.aid to have carried the staff on his back. On tho General 
Medical Council he represented tho University of Oxford 
roni iS89 to 1898, and ori Sir Henry AcIancKs resiguatioxv 
of tho rcgius professorship of. medicine in 1894 was his 
o vjous. successor, but- for family reasons ho declined to be 
put forward. When he became .President of tho Roval 
ege of Physicians of London official anpointinenta 
crowded upon him. ' In .1900 he wont to Soutli Africa as a 
member of the Royal . Commission, on .tbo Treatment of the 
- bick and Mounded in tiio .South African war. •On,.tbo 
anuouiicomeiit of this Commission tlioro were some questions 




* r<, C./- V- 


i'* .j'"'. 

Jr ••/... ,\C, 7', 

■S' s .S'.-, z/' 


- , -v'-ail.-'-r'’ V'- •' 1'. 

■ • V'-"." ■ - 


r ■ ' 



Pftulu by] 


n.skcd ill n critical tone in the Hoii.se of Commons about some. 
of tbo members. of the Commission, and in answering them. 
Lord (then Mr. A. J.) Balfour showed up their futility hy, 
adding, “ I snjiposc that someone will, ex]iress douht ahon't 
Dr. Chiu-ch’s appointment?”. In 1901 ho served on tho. 
Boyal Commission on Arsenical Poisoning hy Beer in tlio 
Midlands, and in 1906 was on tho Royal (Commission on 
Vivisection. Ho was chairman, of the executive eommittea 
of the Iinjierial Cancer Research Pvuid from its foundation . 
in 1902 until July, 1923. .He took an active part for many, 
years (1903 to 1918) as chairman of tho distribution com- 
mittco of the . King Edward VII Hospital Eund for London, 
and was also ehaivraan of the distribution committee of the. 
Hospital Sunday Fund until 1922. As President of . tlie 
Royal C-ollcgo of Pliysicians ho was naturally called upon, 
to give introductory, addresses; in October, 1901, ho 
dcliveroci the address at. t]io opening .of tho winter, session 
- - 1 mt tile Yorkshiro College, 

i.eods; at. the Oxford Meeting 
of tho British ^ledical Asso- 
ciation in 19Q4 he gave the' 
Addrcss.in Medicine on “ Our 
sanitary needs, with special 
reference to. tile national' 
health”; and, in 1905 he 
addressed the York Medical 
Society on " Medicine in the 
past, present, and future.” 
AVhon Sir Andrew Clark, who 
was president of tile .Roval 
Mbdical and Chiruvgical 
Society-, died in November, 
1893, Church was tho senior 
'incdical vice - president; ' and 
avcorUiiigly acted as president 
for the . romaiiulcr of tho 
session — by no means a light 
task, for it involved the pre- 
paration of , tho president’s 
, address, chiefly composed of 
detailed obituaries of deceased 
Follows, wliicli (and particu- 
larly in tlio case of Sir Andrew 
Clark) necessitated many and 
minuto inquiries. ' In 18*94 ho 
becamo one of tho lionorary 
tveasvivers of tho society, .mid 
in 1905; when senior Iioiiorai*y 
treasurer, directly after ceasing • 
to be President 'of tbo Royal 
College of Physicians, .became 
chairman of the organizing 
committee, which, after two 
years of constant negotiations, 
succcssfnlly accomplislied the 
anialganiation with seventeen 
other medical societies into 
the Ro.-ral Society of ..Medicine . in 1907, of which he 
a|ipropriatoIy. became the first president. The enormous 
Inborn- of conciliating and satisfying the wishes and rights 
of the contracting bodies had been unsuccessfully attemjited 
several tinies hefbre-lfor c.xaniple, in 1870, when the 
number of interests concerned was very miicb smaller. This 
eventual success, for wbicli the honorary secretaries — tlio 
late Dr. Arthur Latham and Mr. H. S. Pondlebui'y — and 
the late Sir John MacAlister played admirably in team 
work, owed mncli to Sir IVilliam Cliurcb, for be was, as 
Sir M illiain Osier said wlion seconding liis election as presi- 
dent, “ that rave bird in the profession, a good business 
niaii. .’ He continued the honorary treasnrersbip during 
bi.s -presidency (1907-09) until 1913 (except for tlie vear- 
1911), thus steering the financial course of the society 
tlirongli the troubled waters of finance during tbo most 
critical years of transformation and early growth, 

. Clmrch was not a voluminous writer, but wliatever lie 
did, and. usually it was in response to some; special call ■ 
was tbo outcome of inncli work and solid thought.- He 
delivered tlio Havveian Oration at 'the . Royal Golloge-of 
Physicians of London- in 1895, the ycar aftev Sir -Lauder 
Brunton, wlio for years' was liis corresponding assistant 


[i’/l/oit and Try. 

Sir ^YII:.LIAM Church, Bt., K.C.B. 



780 mat 5, 1928] 


SIR WILLIAM OniTRCn, RT, 


t Tff* I5nm« 

MrDICAL JOTTRSIL 


physioiaii. His Hnrvcian Oration on “ The rise of physio- 
logy in Engtaiul ” was supplemented hy an ai>pendix in 
sn'vall print oecnpying rather more than half the nninher 
of pages that tlie'Oration itself did, and containing nnieh 
interesting detail, the ontcomc of patient research. Ho 
M-as Editor of Si. iinrtholomrw’s Ifosp'itnl Jiepori!.' for a 
nninher of years (1877 to 1893), bringing out the thirteenth 
to the twenty-ninth volumes inclusive, and a large part 
of what ho Ivrote on purely professional snhjeets is emhediled 
in their pages. He contrihiitod to the first volume a paper 
on ichthyosis with congenital malformation of the aorta, 
and for “the last time, in 1897, acconnts of elinieal eases 
from his wards. The thirteen jiapers hetween these two 
cover a wide range of medicine, as is .shown hy refereneo 
to some of them, sneh as his report on 136 cases of cholera 
with 44 deaths, or 33,08 per cent.,' treated in the lio.spittil 
in 1866; two valuable reports on- ecrehral’- pathology; in ■ 
1868 and 1869; a discussion on the etiology ol_ aneury.sms 
(1870), on pyaemia (1893), dijilitheria (1891), iiydat ids '(ISOd). 

A most, important contrihntion w.as his analysi.s of nearly 
700 cases of rhenmatic fever ' (1887), on which he wrote 
with authority in the first and .seeond cditioiis of Alllnrtt’.s 
Sysfein o] Medicine. A great 'deal of time-consuming and 
exhanstivc investigation was- entailed in his historical 
account of “Onr hospital pharmacopoeia and apothecary’s 
shop,” and in an appendix to thedirsl iii.stalmeiit “A note 
on the six gifts of Thcophilns Philaiithropos or Roliert 
Poole.” (The "gifts” of Robert Poole, . ]iliy.siciaii to 
the Middlesex Infirmary and the .‘small-iiox Hospital, , 
and a follower of George"’ 'Whitfield, were iiiilili.shed 
works, of which the fifth wasHhe, Plyi/.dcol Vei-lr .l/criiai.). 
He also wrote obituary notices of his colleagiie.s James. 
Andrew and Sir Thoma.s Smith. Tn 1899, in an address, 
to the Abevnethian Societ,v o'f the -hospital, he reviewed 
“ The progress of medicine - during .tlie reign of Queen 
Victoria,” a period then almost corresponding to his 
own life. • ' - - 

Many honours, entirely unsought, rightly came to hipi; 
he was created a baronet in '1901 lind K.C'.Il. (Civil) in 
1902, an Honorary Fellow of • University College, Oxford, 
and an Honoj-ary D.Sc. of that' Univcr.sity in 1904; he 
was also the recipient of the Honorary -D.SiaVietoria, 
D.C.L. Durham, and LL.D.Glasjiow.- Ho was a 'keeii .shot, 
fond of horses, and was afoiie time a prominent ineiiiher 
of the London Skating Club.: Hb travelled little' abroad, 
as he had many interests in his county home, where after 
his retirement he was active as a ooiinty councillor- and 
justice of the peace, and in other respects. ‘ 

Tall, handsome, and with a fine presence, lii.s features 
when at rest were serene and of a natural -niieoiiscioiis 
dignity, but they did not invite' any attemjit to dictate; 
bluff, or override his -opinion,' which he always gave-quite - 
plainly. Surprisiiigly modest, .without diffidence or' shyiie.ss, 
he was firm, but never showed anger, and was alisoliitely 
devoid of self-seeking or log-rolling; h'o' was iiideeil a jiist- 
man, whose impartial decisio,ns and wise advice inspired 
general respect and confidence. Kind aiid ho.spitaWe, he 
naturally had numerous friends- in different Walks of life; 
and among the profession- he -served .so well-tliere’iire -many 
who owe him much for generous. '.help, and eveif more for 
a wonderful example. 

In his early professional life he lived fir.st in Granville 
Street, Portman Square, then at 2, Uppei- George Street 
Bryanston Square, and all his ifiai-i-ied life at 130 Hai-lev 
Street. In 1875 he married his relative Sybil Constance 
daughter of C. J. Bigge of Linden, Nortliiiniberland, who 
' was an. uncle of Lord Stamfordliain. Lady Chureli’ died 
suddenly in 1913, leaving one daughter and' two sons, tile 
elder of, whom, John -William, was killed in the war (1918) 
and the yoniiger, Jlajor Geoffrey Selby Church, J/.O.’ 
E.F. A., succeeds to the title. -- 

The funeral took - place on Monday, April 30th, at 
St. Mark’s Church, Woodhill, near Iiis home. A memorial 
service was helc! at the same time at the Church of 
St. Barthplomew the Loss inside the precincts of the 
hospital with which he iiad been connected for sixty-seven 
years. It was attended .by the Pre-sideiit, Censors, and 
Officers of the Royal College of Physicians. 

Hu3Iphiiy Rolueston. , 


PERSONAL Al’PRECIATIONS. 

AVe are indebted to Sir Aitcifiii.M.n G.timoD for the 
following apjirei.-iation : 

The death of Sir AVilliam Ghurf.-h, at the ripe age of 
90 year.s, removes from amongst its the Nestor of the Oxford 
Medical School and the last suivivor of a generation of 
jiliy.sici.'ins and .surgeons to St. Bnrtholomew’.s Ho.sjiital who 
.seem, to those who were taught by them, to have included 
an iiiniMial niimher of men of outstanding personality. For 
Oxford Sir William had .strong affection from the day.s 
of his youth when, having taken a first class in the Honour 
School of Natural .Science, ho was for- a time Lee’s reader 
ill anatomy and a .senior student of Chri.st Church. At 
a later period he re]irescntcd the University on the General 
Aledienl Coiim-il, aiid .served -on- the Board of the Faculty 
of •Medjciiie. He always Iiad -the interests of the Oxford 
Afedical ftcliool near -to his heart. At St. Bartholomew’s 
lio" Is ' l-incfiv ■ rbmemb'ored ns a wise coiinsellor, whose 
.advice always reficcted lii.s own high standards,' and alwn'y.s 
eoiirteoiis a'iid coiisideratb to Hiose with whom he came 
ill i-ontaet. He was nho’ a' very .able admiiii.stratov, and 
his colleagues testified how . much of the .suc-eess of the 
Medical Schoor was diio to its treasurer. ■ Tliese qualities 
found even wider scope during the .six years of his presi- 
<leiic-v of the Royal College of Physicians. By birth and 
taste’s a country squire, and "fond of country pursuits, Sir 
AVilliam devoted hi.s best energies to any work in committee 
i-oom' or wind which he liiidertook. No one was moro 
regular in atteiidaiice, anil. although he was not at his best 
as a i-liincal teacher, ,on’e recalls comsidtations in which 
he alone reaehed a conect diagnosis, and sentences which 
Mi'mmcd inrtersely .airtjiat needed to bo said on a subject.' 
His friends and piijiils rejoiced that he was able to enjoy 
the evening of 'his lifb, .spent in his coiintry home in the 
siirroiiiidings nhieh he loved so well. 

Dr li. SfoittnvJi'i.rT'cnEii, senior physician to St. Bartlio- 
-joiiicw*s 3‘lospi^t^l) 1 ilos • ^ - 

As "one who 'servod'uiiderrSir William Church, first as 
a clinical clerk' aiid hlte'f nS his house-physician, and aftor- 
wnfds had . the privilege; of- enjoying' his friendship for 
iianv vears, I am glad -to; have an opportunity ot con- 
tribiitiiig'a few lines about his' work at St. Bartholomew 3 
Mnsiiital His fine'' presence;, his bushy eyebrows, and Ins 
keen penetrating dark- eyes with their kindly oxpres.s,on 
made him a most impressive figure m the wards. He did 
lint trivc bedside addresses but said comparatn eh little, 
tboHch he always liked to he questioned by Ins clerks, and 
tlicii he would talk freely i.t -reply. As a teacher he was 
■nc-rliaps moro valiinblo to his house-phyincians -than to 
Mudeiits.. During his twenty-eight years of office ns ]ihysiciaii 
ho had forty-six hoiise-iihysicians, and all of those who actecl 
in that cLpaeitv felt 4at they owed him a great debt of 
in-atitiide for his sound' teaching 111 clinical medicine. His 
nbwef of diagnosis was very, striking, and rarely, if eie , 
was it foiiiid to' be mistaken.. It was alwa.vs based on 
I most tiloi-oiigh • phv.sicnl exaniimition, and never did h 
1 ntteiii'pt a diagnosii based on. insufficient grounds. He wa 
I " fiiie -niorbld anatpiiiist, . .and for years pm'forined t o 
’ medical post-mortem examinations at the -hospital. T1 
records so carefully drawn up by him are evidence of 
his devotion to this important department of inedicino. 

'ts a pillai- of strength on the medical staff, as ho was 
- indeed a wise counsellor. His honesty of pur)iose, s iic 
imiiartiality, and sound - judgement were recognw^d a 
valued by all his colleagues. As ch.airmnn of tho 
CommittL for many years he played a great part 111 bui.t- 
hig ^ the school on a firm ‘basis. After his >'etirem^t 
from active service on the staff he served on laj con 
mittees to the' great "advantage of the administration of tl 

^*”what one could always feel with Church was that 
in him one had a wise Triend of great experience and 
judgement, to whom in times of- doubt or trouble 
alwavs go for advice and help, and that this Mould b 
forthcoiuing in full measure. I think . he was the mos 
honest and' truthful man I have ever had the lionoui ot 



Mat 5, 1918] 


-T. A. MACDONAIiD, M.D., liL.D. 


[ TitRlinm’fn 
Medical Joltival 


781 


J. A. MACDONALD, J\I.D., Jl.Cn., LL.D., 

Tasl Cliaii-mnn of Council niiil of tlio llcpTOscntativc Body, 
r>riU>;li Medical AsfOcinUoii; ConsuUing IMiysiciaii, 

Tumiton nml Komoi-sct, Hospilnl. 

In our Inst issue wo Imd to nuuouiico with deep regret 
tlio dentil of Dr. J. A. Mncdounld, whicli took plnce, ow 
April 23rd nt his homo in Tnunfon, after an illness of 
some mouths’ duration. In him tiio British Medical 
Association loses one of its great figures, a man of out- 
standing character, universally liked and respected, who 
devoted a very largo part of his working life to the 
interests of. the medical 
profession and tho 
welfare of his brother 
practitioners. 

James Alexander 
Macdonald was born in 
1853 nt Newtownnrds, 

County Down, and on 
leaving school studied 
for tho teaching pro- 
fession. Prom his 
earliest days he rvas .a 
fine athlete. Ho played 
for Ireland in tho 
Bccond International 
Hngby football match 
against England, and 
was in the Irish team 
foi' several years; ho 
also played in one 
international Associa- 
tion match against 
England, and was an 
international lacrosse 
player along with his 
three brothers. After 
a 'short time as a 
schoolmaster nt tho 
Methodist College, Bel- 
fast, he decided to take 
up tho profcssioir of 
medicine, and entered 
as a medical student at 
Queen’s College in that 
city, graduating AI.D. 
and M.Ch. at tho old 
Royal University of 
Ireland in 1887, and 
- -B.A.O. in 1889. . To a 
man of Macdonald’s 
open - air tastes and. 
sjilendid physique tho 
life of a country 
practitioner naturally 
appealed. On coming 
to England some forty 
years ago as assistant 
to tho late Dr. Gcorgo 
Cornish of Taunton, he 
soon became identified 
with the public life of 
the town and district. 

Ho succeeded to Dr. 

Cornish's practice, became medical officer to the Taunton 
Board of Guardians, and was appointed to the staff of 
tho Taunton and Somerset Hospital, which ho served for 
many years as physician, though surgery was perhaps 
his strongest professional interest. He took a keen 
interest in politics, both general and local, and was 
for a long timo chairman .of the old Taunton Conservative 
Association. Ever ready to encourage sport in his 
adopted town and county, Macdonald’s services were in 
constant demand at athletic meetings of all kinds. He 
was a very familiar figure on the county cricket ground 
at Taunton, and maintained his interest in Rugby football 
up to tho last. 

In the British Medical Association, which ho soi-vcd with 


such ability and distinction, Macdonald hold almost every 
office. Ho had been a member of tho AVest Somerset 
Branch Council from 1894 onwards, and had acted as its 
roprcseiilntivc for the past twenty-five years, holding office 
ns president of tho Branch in 1899 and again in 1626. In 
recognition of his work for the pi-ofcssion in the AVest of 
England ho was elected an associate memher of tho Doi-set 
amt AVest Hants Brancfi. Ho hccamc a meinher of tho 
Central Council in 1906, and soon afterwards was elected 
Chainnnn of tho Ropresentativo Body in succession to 
Sir A'ictor Horsley. Ho held this post for three years, and 
was then chosen to succeed Air. Edmund Owen as Chairman 

of Council, Ho retired 
from that position in. 
Juno, 1920, after 
serving for ten arduous 
and eventful years, 
which included tho 
Insurance Bill crisis 
and tho whole period 
of tho war. Ho was 
elected a A'^ice- Presi- 
dent of tile Association 
at the Belfast Annual 
Alectiijg in 1909, hold 
office as President of 
tho Section of Aledical 
Sociology at tho 
London Meeting in 
1910, and during tho 
Birmingham Alceting 
in 1911 received the 
honorary degree of 
LL.D. from tho Uni- 
versity of Birmingham. 
Tho Association’s Gold 
Modal of Alerit was 
awarded him in -1913. 
In tho following year, 
he made a tour of tho 
New Zealand, Austra- 
lian, and some of tho 
Ear Eastern Branches,- 
and he acted again as 
•ambassador ■ ’ of ., the- 
- parent-hddy to Ovei-sea ' 
Branches 'when ho- 
visited South Afjica 
soon after r'clinquish-- 
ing tho chairmanship 
of Council. These, 
visits ■ wore greatly • 
appreciated by all 
members of the 
Branches, and thes' did 
much' to-bind closer 
togotlicr the British 
Jlcdical Association at 
liomo and overseas. Dr. 
Macdonald’s absence 
in South Africa during 
the latter part of 1920 
was taken as an appro- ' 
priato moment to set 
on foot an appeal for 
a testimonial fund in acknowledgement of his long and self- 
sacrificing work fox- tho Association and the profession ; the 
presentation was made to him during tho Newcastle Annual 
Aleeting by Sir Clifford Allbxttt, the outgoing President. 
Fxom 1920 onwards Alacdonald was chairman of tho Journal 
Committee; this was work ubicli made a strong appeal to 
him, and lie was admirably equipped for it by temperament 
and experience. His loj-alty to the Journal and its staff 
was made plain to all every year when ho presented the 
Committee’s ropoi"t to the Represontativo Body-. 

For the past seventeen years Alacdonald had been one 
of the direct rcprescnt.ativcs of the profession in England 
and AVales on the General Aledical Council, and during 
a considerable part of that period he xvas a member of the 





782 VlIlY 5, 1928] 


f liir jinmw 
Mrf»iC4f, Jooiifu. 


o. A. MACDONAIiD, M.D., hh.V. 


Exeoiitivo Coinmittoo and of Uio I'kfncation Cottnnitloo. He 
was diligent in attendaneo at Connnittoo and Conneil 
meetings, and took a deep intcicat in tlic disciplinary 
business. Another pioof of the trust rc])oscd in JIacdoiiald 
by his fellow practifionors was their choice of him tor 
presicle over the early sessions of the Conference of Kepro- 
sentatives of Local Aledical and Panel Committees, fn 
October, 1919, he was appointed by Dr. Addison (the first . 
Minister of Health) as a niomhcr of the Consvjltative 
Council on Alcdical , and Allied Scrrice.H. Lastly may he. 
mentioned his presidency for several years of the Irish.' 
Medical Schools’ and Gradnates' Association. 

The funeral, on A])ril 26th, was r-ery largely attended — 
indeed, the whole of Taunton seemed to have Itirned mit 
to the chnrcli sorrico, and a large nninber of the town.s- 
people walked to the cemetery. There wiw a big attend- 
ance of rreemasons, Dr. Macdonald having been a very 
prominent local Preeniason, and also a Past Grand Officer. 
The medical profession was well rcinc.sented. The 
Chairman of Council (Dr. Drackonhury) and the Medical 
Secietaiy (Dr. Cox) represented headquarters. Drs. P. J. 
Gomez and H. C. Bristowc represented the Conneil ns well 
as the West Somerset Branch, and Dr. D. E. Finlay the 
Gloucestershire Branch. Two other collcagnes and old 
friends must be mentioned— Drs. A. E. doscelyne anil 
J. T. Cameron, who had attended Dr. Macdonald during 
his last illness. 


PERSONAL TRIBUTES. 

We are indebted to a number of leading old coHcaguc.s 
and friends of Dr. Macdonald in the work of tlic British 
Medical Association for the personal appreciations that 
follow. 

Sir jEKN^n TEi?R.\ti, writes: 

It is told that, when Coleridge died, Charles Lamb would 
iccalt hi.s loss from time to time and suddenly e.xehiim, 
“ Coleridge is dead! ” Even .so will some of us .speak of 
Macdonald. He has been so long a familiar figtirc in the 
Association that only the older members can think of a dav 
wiion his name was not yet a household word. Thongli 
already well known in his own locality, it was tlie po.sitioii 
lie assumed under the new constitution in 1902 which 
brought him quickly into general notice, so that he was 
actually the second on the list of Chairmen of (lie Repre- 
sentative Body. He could be moved to a fiery indignation 
by iniustice, was pitiful for distress or failure; but it was 
the straightforwardness of the man which gained and held 
the hearts of all. There were elements in Jiini through 
which he played some pavts^in life: strong in body and 
mind, ready to see an ojiporlnnitv and steadfast in gi-asp- 
mg It easy to follow because easilv understood. Tlioso 
were the tilings which made him in' earlv life an inter- 
iiatioual football player, and later, for So I'ong, a lender of 
men. )' hen he rose in a meeting there woiild be 110 vague 
generalities He spoke to press some definite iioiiit or 
expose a danger and he would, perhaiis, end with a 
w imisical, almost wistful, smile and “ I reallv do not see 
what else you can do.” Men trusted him, for he tni.sted 
liimself. Who can say if there was still work for him to 
do? Blit we may be glad, as he was glad, that fullness of 
years was given to him that lie might be a pioneer in tlic 
constitution of the Association, a .strong tower for ns 
while the Insurance Act was in the making, and in otlier 
stormy times, and a framer of plaiis for future good in the 
quiet days of peace. 

Sir Ewen j. Maole.4n writes : 

The flr.st vivid impression I have of Macdonald was 
gained at the Exeter Meeting of the Associ.ation in igpV 
when he was elected to succeed Victor Horsley as Chairman 
of the Representative Body. A i-erj- different tvpe of man 
in physique, outlook, and otherwise, but, iione tbe less a 
sound instinct bad determined tlie clioice. Tlie .'V.ssociation* 
under its reconstructed machinery and with the compelling 
personality and ability of Horsley to focus- it, Imtl taken 
. lunch new ground in various directions, and needed a 
loailcr of r.ather the '• strong silent ” type to bring it 

Of the stvoiig r-thlotic type of build, I.is b.and.some 


features, woll-slilipod head, and .silvered hair combined to 
gather from any mcoting orcr which he /iicsidcd a quick 
confidence wliic-Ji wii.s confirmed liy the tones of the p!c.aK- 
iiig, good-c:irryiiig voice. His fairnc.ss of mind and icady 
wit were further attributes wliich went to make hiiii ilio 
admirable cimirman he was. He would not, boireccr, 
tolerate for long any fantastic dement derdoping in a 
ddmto, or the di.scnssion of any proposal inciting to 
precipitate- actToii. Many a time in the Rcprc.sentiitiva- 
Body and -in the Council- would a -few sentenco.s from him, 

. charged ivlth Itindly satire or strong- disapproral, .speedily 
bring the ])rocccdings within the pale' of common sense.”. 
When he was not in the dinir, to “ put up Mae ” towards 
the end of a debate meant to gather and consolidate the 
practical and feasible points which remained or had 
emerged in its course. 

He had -no occasion to seek popularity; it c.ame to him. 
He was trusted of men, and radiated friendliness. He 
w.as a man of intense ]>oliticnl conviction, even perliaps of 
bins, and yet in the days of the insurance negotiations, 
when feeling was running high, I have .seen him, though 
with some obvious effort, control his words and demeanour 
hctlcv to pursue the task in hand. When acute differences 
arise, some men display their worst qualities, others their 
best. To differ from Macdonald- did not -mean to dislike 
him. On the contrary, in a captivating degree, ho hud 
the enpneity of agreeing to differ. As it happens, some 
weeks ago i met, on a public occasion, the distingid-shcd 
statesman who was responsible for -the'- Insurance Act, and 
he said: “How is old Macdonald? He was against ns, 
bill 1 liked him ! ” Macdonald and 1 would sonictinie.s, in 
retrospect, fight over again the feudal battles between our 
respective elans, and as often ns not it would end up by 
Ids making the passes of striking a dirk into the bench 
and jocularly challenging me to rememher that wherorcr a 
Macdonald .sat was the head of the table. 

Amongst the many and varied services of outstanding 
importance wiiicli Macdonald has rendered the Association, 
none, I tliiiik, can be counted of greater value than his 
insistence on Sanity of outlook iind common sense in its 
eoimsels. The many years during which ho devoted so 
much time and oneVgj- to arduous work at headquarters 
and elsewhere must have cost him much in finances and 
ill health, and it is with a full heart 1 recall that when 
in Kdinlmrgh last year I said we would welcome him at the 
Cardiff Meeting, ho replied pathetically, “ I’ll surely come, 
oW man if I’m alive.” We shall miss him profoundly. 

Mr. K. B. Toiixeu writes; 

jMv acquaintance with J. A. Macdonald began more than 
fiftv" rears ago in the flnn-y of a scrimiimge in a twenty- 
n-sidc match jilnycd on the Rnthmincs Ground at Dublin. 
Both of ns being what are now culled “ front-row 
lovwavds,” we saw (and felt) a good deal of each otliei- 
duriue that strenuous lionr and a half. AVe afterwards 
cemented our friendship at the dinner, where we sat next 
to each other. Exactly the same thing Imppenod in the 
tivo siibsoqneiit years, the first in London, the second in 
Dublin again. For many years after 1878 (wiion the last 
of these meetings took place) I only saw Macdonald occ.a- 
sionnlly when 1 met him at an Irish match at Blnckhcath, 
Richmond, and later on at Twickenham. I know nothing 
of his connexion with or work for tho British Aledical 
Association, as 1 was not then a member. I was thci-efore 
astounded, when I attended iny -first Representative 
Meeting at the. Guildhall, and Dawson Willinm.s took me 
off to intvodnee me to the Chairman of -Council, to find my 
old friend and opponent of days gone by in that position. 
Since then, for tho last seventeen years, I have been- very 
closely connected with him in almost every aspect of B.M.A. 
wovk^^-on committees, conferences, and Council meetings. 
During the war his help to me when I was Chairman of 
the Hepresentativo Body was invaluahlo, and on those most 
important committees which followed the peace I more and 
more learned to value and appreciate his qualities. He 
never spared himself. Ho was always ready to give of Ins 
very be.st for the good of the piiWic and of tho medical 
profe-ssion. He was a whole-heaitcd B.M.A. man, and 
clm-ing all the -years' of hiS work with' anil for that body 
was alivays ready to do whatever in Iiini might lie to con- 



■MA,t 5, 1938] 


J. A. SrAOOONAEiD, M.D., Lt/.D. 


[ TnrJlnmfs 709 

MtDjcii. JomjfAi, * 


EoHdi\to its fti-cngth ixiicl ixiestigo; nud its iircsci't liigli 
ptwitiiw is in n V017 gvpvxt incixsvxvo dm- to iiis long, 
din otod, and ,xmsolfisIi work. ^ He was a Iinnny fighter, 
eIiH|iU’nt and generous in deliate, nitli tlio God-given gift 
of hnmonr. An outstanding figure in onv inofession, wo 
Khali not soon look niion his like again. 

Sir RonEiiT Bor.\3r writes; 

During tho last quarter of a century “ Jfacdonald of 
Taunton has been a name of nioiuent in tho British 
Medical Association. For more than fifteen yeare ho has 
heen to ino a' vivid and admiiahle personality. Admission 
to the freedom of his friend.ship these twelve years past 
1ms heen a high privilege. My liret experience on the 
Conntil was in' tho early years (it his long term of office 
as Chairman, hofore tho shadow' of ill health fell on him. 
Hi.s effortless gra.sp of intricate and important bnsiiie.ss, 
even at the end of a long tedious day, and his intuitivo 
kuoadedge of the tendeneies of his Council niemhers were 
always surprising. There wa.s much of per.sonal inagnctisni 
in his rule. He could ho advisedly silent or speechful 
himself, would brighten tho dull delmto with hnmonr, 
cueourage the timid, muar.le the verbose or irrelevant, and 
quell the insubordinate. 

At tho .annual meetings he was at his best. A tower of 
strength in difficult situations in tho Representative 
Alceting, by a few sentences ho would clarify an apparently 
hopelct-s position or prevent some step which would h(> 
foolish or unsafe. Ho was never prone to long sjxeeehcs at 
those times.- His utterances wore pithy and to the point, 
and on occasion he xvould thunder with a fine indignatioif 
wlici;c his feelings were deeply stirred. Then at the various 
social functions- he was equally a prominent figure. 
Though Ireland w.ns his birthplace, one always thinks of 
Macdonald as typically British in his demeanour and out- 
look; Ho had the best traits of all our island nationalities, 
eren if the humour and tho keen political instinct of his 
home country were ttro of the most dominant. In his youth 
no mean athlete, Macdonald was still a golfer when I first 
knew him, and to the end of his days a s])ort.sniaiJ in the 
highest sense. In medico-polities he was never quite recon- 
ciled to the steady inroads made hy State and local .services 
on tho domain of jirivato practice during tho last three 
decades. Yet he -(vas too much of a statesman to allow his 
fceliiig-s to interfere with his recognition of an inevitable 
trend. The advance of tho British Medical Association in 
the early years of its present constitution xv.a.s due m the 
main to the sound sense and devoted labours of a relatix'elv 
small band of workers. Among tbe.se J. A. Macdonald will 
alwacs hold a pre-eminent ])lace ns a statesman and a 
worthy ambassaclor of the profession. In the nienioi-v of 
his friends tho plctnro of that noble bead and sturdv figure 
will ever stand for all that is stvaigiit and true and 
lovable. ' ' - 

Dr. C. 0 . H.xwthorn'e writes: 

The annoniicement of the death df Dr. J. A. Macdonald 
must bring ^ a sense of loss to all members of the 
British Aledical .\ssociation. So prolonged and so con- 
spicuou.s is his record of service tliat mauv who never know 
him personally will feel that a commanding figure has gone 
from amongs-t us. In the In'stor}- of the Association his 
name is written in large and firm oharaetors, and just as 
he gax c gladly, so in turn he received confidence and 
gratitude in full measure. A prominent memory of 
Macdonald for those who have been associated with him 
in counsel, in debate, and in administration will cer- 
tainly be a recognition of the definiteness of his views 
and opinions. To differ from liim was, of com-se, possible, 
bntjiot to misunderstand -him. Jfever hurried in his con- 
clusions, and not unduly impatient of opposing arguments, 
ho liad a large capacity foi- decision and an ability to 
stand fast where he had chosen his ground. These qualities 
made him an ideal chairman and .an efficient adminis- 
trator. In similar fashion he was a veally gallant ally, 
and equally ^a formidable opponent, when a fighting cam- 
paign was in progress; ancl he had a manifest joy in 
battle that engaged the goodm'll even of his friends the 
enemy. His mind, like his physique, was of the robust 
order, and though circumstances sometimes compelled him 
to eompromiso he had no love for this facts -of streteg}-; 


what aiipealed to him was the rigour of the game. Yet, 
withal, he was, a very lovable personality, and in tho inner 
• counsels of- the Association it Is not only -his wi.sdoni and 
commousonso and expcrieuco we shall mis.s, but also his 
generous and large-hearted fellowship. 

Dr. H. B. BiucKE-vntTRY writes: 

If wiw not until after my election to the Council of the 
Association in 1914 that I knew SlacdonaUl, though I think 
I had previously attended at least one conference of which 
he also was a member. Ho was at that time Chairman of 
Council and of the Insnrance Acts Committee, and he acted 
also as chairman of tho Conference of Locail Medical and 
Pane! Committees. My first imjirossions were of a striking 
and attractive personality and an extraordinarily eaimble 
and effective chainnan. - Later one discovered, along with 
one or twd iiigi'aincd prejudices which often influenced 
his pronouncements rather than his actions, a soundness of 
judgement, a grasp of bard facts, anil an appi-cciation of 
practical difficulties which made him a -ivisc counsellor and 
a valuable leader of ojiinion. It was perbajis a little diffi- 
cult-to become intimate with him, but a natural and innate 
rc-serve did- not .sncecod in obsenring a bi’oad and abun- 
dant sympathy. HiS was a pouerful intellect and a strong 
character, aixd he placed these and alt his great abilities 
at the disposal of the -Association and px'ofession to a 
degree and with an unselfishness wldclv have, 1 think, never 
rctxiived sufficient ai)]>reeiat{(m au'd acknowledgement. Over 
a long scries of years he sacrificed time, energy, economic 
prospects, in tho interests .of his fellow practitioners axxd 
of the organized profession. In these iuteresits he worked 
hard and continuously and wisely, especially in connexion 
with the British Medical As-sOciation and tho General 
Medical Coulicil, to tho amazement of those who were in 
, a position to appreciate what he was doing, and in a way 
1 which deserves the great gratitude of all those who have 
benefited thereby. The memory of his fine figure, lovable 
peiSionality, and tnisted Icadei-ship is one to cherish, ■ 

I Mr. iM. Bishop Hahsi-sk writes : 

1 To Macdonald there fell the unique lot of guiding the 
; counsels of oiir Association, anti through them the pro- 
fession at large, during some of the most stirring epochs 
of .the last hundred years of medical life. There never 
was a time when medical opinion and temper were so 
stirred as ’ during the passage of the Insurance Bill 
thiough Parliament. There never xvas a , time when 
national life was so stirred ns dni-ing the great war. 
Through the years of formation of professional opinion 
hofore the, launching of .the original Insurance Bill, and 
during the negotiations of the terms of the bill, Aiacdonald 
was at the holm. -Again, in that other epoch, perhaps 
more cat'aclysmal tlian any other of tho world’s , history, 
ill the time of the war, Macdonald was at the helm of the. 
Association's affairs. He was Chairman of Conucil from 
1911 to. 1920, and tlirough -.ill these years he devoted 
himself to the sen-ice of his professional colleagues and 
their" husines.s in a manner that few have realized. " Tlie 
character of Jiis work that strikes the. mind, when one 
attempts to judge its quality and to sum up the 
impressions of it in some terse expression, was balmier. 
Ho was a man in wliom there was slioivu to the full that 
perfect coherence of cool thought and calm judgement that 
gave a perfect poise in the times of human storm, when 
passions were aroused and temporaiuouts xvere battling in 
the dust of the arena. During these difficult years, when 
sides waxed and waned, he never lost his sense of pro- 
portion or failed to keep a fair bal-ancc between the 
swaying parties he had to guide. Reputations w-ere made 
and marred, hut his steadily appreciated. Surely that w-as 
the mark of a man of worth. It is sometimes suggested 
that physique and chaiactcr are correlated, that the one 
is the reflex of the other; it surely w-as so with Macdonald. 
In physique he was stability pei-sonified, though not of the 
sort show-n by the stone pylon, -wliich is stable by virtue 
of its w-eight, for w-itli all his solid strength he possessed 
a manifestly strong current of vitality, which was part of 
his stability. If tlierc be an " inferiority complex ” that 
forces some to vindicate their existence, to assert that 
they are there, then Alacdouald w-.us born with a most 
enviable “ superiority complex ” that gave him a mind 



May 5, 1928] 


OBITUARY. 


[ TraCRrm* 7ftR 
llKOicii. JotrBjrii I ov 


list. Ill debate his voice was never heard on any subject 
without good occasion arising, and when lie spoke he 
struck homo and carried conviction. His honesty of pur- 
pose in evorvthing ho said and did was universally accepted. 
Sxicb is my'e.xjmriohco of our bid friend, and the affection 
which I bore towards him will remain green, in my meuiorj’. 


The death is announced of Dr. Jane Hendehson 1 
RninvEN, one of tho best known medical women in 
Johannesburg, which' took place in the General Hospital 
there on March 28th, after a brief illness. Dr. Henderson, 
as she then was, recoivod her mcclical education at the 
London School of Medicine for Women, and studied later 
in Paris. Ill' 1890 she obtained the Scottish triple qualifi- 
cation, L.R.C.P., L.R.C.S.Ed., and L.R.P.P.S.Glas., 
graduating M.D.Brux. in the following year. She had the 
(listinction later of being' olio’of the first medical women 
to bo appointed to tho resident staff of a mental hospital, 
and for two years was assistant medical officer at the 
Holloway Sanatorium, Virginia tVater. Subscqiicntlj’ she 
commenced practice in Glasgow, where she remained for 
about .seven years, during which time she devoted herself 
largely to work at the AVynd Mission Dispensary in that 
city. In 1002 her association with South Africa began, 
when in the aftermath of the war she received an appoint- 
ment under tho Colonial Office for work in connexion with 
the concentration camps, and became medieal officer of the 
camp at Krugersdorp. On her marriage soon afterwards 
she took up her residence in tho country, but for many 
ye.ni's'past had been living in Johannesburg, where in 
addition to carrying on private practice she was one of the 
medical Officers at tho school clinic. Dr. Ituthven’s activi- 
ties, however, extended considerably beyond the affairs of 
her profession; she took a leading part in various women’s 
movements, and for a number of years was president of 
tho Women’s Enfranchisement Lcagvjo. She was also a 
vice-president of tho Women’s Civic Society and a member 
of tho National Council of Women ; she was, in 1909, 
elected a Fellow of the Royal Society of Arts, and had 
recently contributed to the proceedings of the South 
African Society for the Advancement of Science a paper 
on international intellectual co-operation. Social and 
political affairs generally possessed a deep interest for her, 

■ and she had travelled extensively in Eurojio and America. 
Among other activities ra.ay be mentioned her work in 
connexion with the District. Nursing As.sociation, her mem- 
bership of the I.«ague of Nations Union, and her interest 
in the affairs of the St. George’s I’rc.sbyterian Cliurch, 
Johannesburg, in which she was recently elected a 
manager. 


Dr. John Lawson Rankin-e, who died suddenly on 
April 14th, was born in 1881, and received his medical 
education at Oxford Universitv and Guy’s Hospital, 
London, obt.aining the diplomas M.R.C.S.Eng. and 
L.R.C.P.Lond. in 1907. -He then served for a period as 
house-surgeon at the Dumfries and Galloway Roval Infir- 
mary, and later was a clinical assistant at the R'oyal Eye 
Hospital, Southwark, before embarking in practice in the 
Border district, first at Mallsburn, Bewcastle, and at 
Fergus Hill, Kirklinton, and finally at Longtown, where 
he spent the greater paid of his professional life. He was 
medical officer of health for the Longtown rural district, 
and took a considerable part in organizing the provision 
in the area for dealing with infectious disease. During 
the war he was for a time in charge of the lo.cal Red Cross 
Hospital, and later received a commis.sion in the -Roval 
Army Medical Corps, serving in the East with the acting 
lank of major. References to" his death were made in the 
eburches of several denominations, and a memorial service, 
held in Arthuret Parish Church, Longtoini, was largely 
attended by all classes of the community, and notably by 
rejnesentatives of the public health service and the medical 
profession. Dr. D. C. Ediiigton and Dr. G. T. Willan 
^piraoiited the British Aledical Association, of which 
I - Rankiue was a member.- He is survived by his widow, 
n son, and a daughter. - 


Dr. FiiAXcis Penny, who died in Doncaster Infirmary 
on Ajiril 15th from injuries received in a motor accident 
five days jireviou-sly, was until recently medical superinten- 
dent at the Barnsley and Wakefield Joint Sanatorium, 
Mount Vernon, Barnsley. He received his medical educa- 
tion at King’s College, London, where he wiis a Warneford 
Scholar, and in 1834 obtained the diplomas M.R.C.S.Eng. 
and L.S.A.Loiul. As a hoiise-Burgeoii at King’s College 
Hospital he was associated iritli Lord Lister. Subsequently 
ho held rc.sideiit' posts at tho North Devon Infirinai-y, 
Barnstaple, and at the Doncaster Infirmaiy, and sei-ved 
as a civil surgeon ' in the South' African war. A keen 
intci-o.st in travel and exploration later' led him to seek 
employment abroad, and he acted at various times as 
medical officer to various mining companies in regions so 
diverse as Spitzbergen and Contra! Africa. During the 
late war "he sci-ved' at sea, and in more recent years 
was, for a period of about six .years, medical superinfen- 
dent at the Mount Vernon Sanatorium. At tho time of 
his death he was ongaoed in preparations for a voyage to 
New Zealand. A former colleague writes : Francis Penny 
was much loved, and was veiy popular with his patients. 
He. held very decided opinions in various medical matters, 
and strongly believed' that most of our modern ailments 
were due to overeating. Ho. believed in periods of fasting, 
and never, of late years, took more than two meals a day. 
He rarely used tuberculin -in bis practice, and avoided tbo 
use of all soninis and vaccines as far as possible. Penny 
was one of the jiioncers in the use of ultra-violet light, and 
his results in the treatment of lupus wcic very sati.sfactoiy. 
He was a good tennis player, and often defeated opponents 
more than twenty years bis junior, and ho was also very 
fond of dancing. The funeral seiwice was held at Lawns- 
wood Crematorium, Leeds, and was attended by several 
members of his family, including his brother, Colonel 
Penny, A.M.S. (retired), tbo mayor of Barnsley; the 
chairman of the Health Committee of Wakefield; and the 
medical officei-s of health for Barnsley and Wakefield. 


The late Dr. Geouge Cn.\ni.ES K.«ioP, who died suddenly 
at his residence at Herne Bay last August, was of Danish 
descent but of English birth, having been born in London 
in 1853. He was educated in part at Heidelberg,, and 
afterwards entered as a -medical student’ at the Middlesex 
Hospital, obtaining the diplomas M.R.C.S.Eng. and L.S.A.’ 
in 1875. For about a year ho held a resident post at this 
hospital, suhseqnently becoming a surgeon in the service of 
the Royal Mail Steam Packet Company. .He next returned 
to the Aliddlescx Hosiiital as tutor in physiology in tho 
medical school, with notable siicce.?s as- a teacher, and later 
was for ten years clinical assistant at the Royal London 
Opbtliahnic Hospital (Moorfields). In London, and later 
at Herne Bay, to which place he removed in 1907, he 
built u)) a cousider.ahle practice as an eye specialist, being 
for many, years, honorai-y 'ophthalmic surgeon to the Herne 
Bay Queeii Victoria Memorial Cottage Hospital. Through- 
out practically the whole of his life Dr. Karop took a keen 
interest in microscopy, being closely identified -with tho 
Quekett Microscopical Club, which lie joined in 1873, and 
of which he was the houoraiy secretai-y from 1883 to 1904. 
He was also a Fellow of the Royal jllicroscopical Society, 
and seiVed for a time on the council of that body. -Micro- 
scopical research was his ■ chief bobbj-, his main interest, 
ajjart from its medical aspects, being in the (Vafomaceae. 
He took no prominent part in public affairs in Herne Baj", 
but be was a well-known and respected figure in that town, 
nhere he was much esteemed for his personal qualities. 
His wife died in 1926; ho is survived by three sous and a 
daughter. 

The following well-known foreign medical men have 
recently died ; Dr. Je.ix Danttsz, of the Institut -Pasteur, 
Paris, Coiumauder of the Polish Order Restituta, aged 67 ; 
Dr. Eugene Heetoghe, vice-president of the Royal 
Academy of Alcdicine of Belgium; Dr. L. KLEiNwXcnTEit, 
formerly professor of obstetrics at Czernowitz, aged 89 ; 
Dr. OsK.\r. Bail, professor of hygiene at the German Uni- 
versity of Prague ; and Dr. Rich.vkd Pribkaai, professor of 
•Yrhysical chemisti-y at Vienna. . , 



M.^V s," 


-MBDIGAIj NEWS.- • 


t Tr<r DniTi*«n 
Mkoica:. J<ien*<At. 


787 


I'lU'. Bollowsliii) ol Jrcilicino ami Post-Grartnato Slcdical 
Association nmiouucos that on Stay 8tli thoro will bo two 
clinical ilcnionslvations, one at 2 \i.ni., at the Cancel' Hospital, 
by Mr. Ernest Miles, ami auothoi' at 2.30, by Ur. Erew, at tho 
Hospital for Sick Chiklrcn. On May 9th Sir. Creovea will 
give a aoinonstration at the Koyal Lomlon Ophthalmic 
Hospital; all three acmousUatlons arc open to mombors ot 
tlio inoilical profession without foe. Sevoral cour.ses arc 
being given throngiiout May. In .mlOition to those- alreafly 
in progress, on Slay 7th four other courses begin.. These ai-e 
an afternoon course for two weoits at tiie Infanta Hospital ; 
a course in ilisoases of tho throat, nose, and ear, occupying 
all day, for tliroo weeks ; an afternoon course in ophthal- 
mology, continuing for four weeks ; ami a course In neurology 
at tho National Hospital, Queen Stiharo, -which continues to 
June 29th. Pull particulars of all special courses and of the 
general conrao ot work may bo olitaincd from tho secretary 
of tho PoHowahip of ilodicino, 1, IVimpolc Street, W.l. 

The third lecture of tho post-graduate course on cancer, at 
tho Leeds Medlcai School; under the Joint auspices ot the 
Leeds and West Biding Modico-Chitnrgical Society and the 
Yorkshire Connell of tho British Empire Cancer Campaign, 
will be given on May 9th, at 3.3Q p.m., by Professor G. Grey 
Turner, his subject being cancer ot tho rectum. The lecture 
is free to medical practitioners, who should, however, inform 
the secretary ot the British Empire Cancer Campaign, 
47, Parle Square, Leeds, of their intended presence at least 
two days previously.' 

The spring meeting ot tho South Wales Medical Golf 
Society will be lield at Sontherndown golf course on 
Thni-sday, Jiay 17th. The divisional stage for tho Treasurer’s 
Cup (tor the Cardiff Division) will also take place on the same 
day at Sontherndown. Other Divisions of tho British Medical 
Association wishing to held tlieir conipotitions on the same 
dale are asked to communicate with Dr. T. Garlleld Evans, 
127, Cathedral Bead, Cardiff. 

A CONFEiiENCE to consider the position ot women iu the 
service ot liospitals will be held at tho JIary Snmucr House, 
24, Tntton Street, Westminster, from 2.30 to 6 p.m. on 
Tuesday, May 8th. Tlic spoalter.s will iiiclmle Dr. Graham 
Little, M.P., Dr. Jlargaret Emslio, Miss Eleanor Batbbonc, 
and Jliss C. Pnltord, and tlio throe questions to be discussed 
are : (1) opportunities tor training of women medical students ; 
(2) tbe appointment of womou to jiaid and honorary medical 
posts in hospitals ; and (3) the appointment of women on boards 
or comuiittces of management ot hospitals (including mental 
hospitals). Visitors’ tickets (price Is.) and further particulars 
may bo obtained from the National Union of Societies for 
Eqiml Citizenship (wliieU has oonvoued the conference), 
15, Dean's Yard, S.W.l. 

medical 
vho 

- jindsey County Council tor tlTo past 
twenty yeax^, was presented with handsome gifts from his 
associates— doctors, dentists, nurses, and clerks — of the 
health department and from tho staff of the county council 
as a whole. 

by-laws ot the Boyai Society ot 
privilege of associate membership to 
1 ^' veterinary practitioners on tiie terms formerly 
“6mber.s of the modical profession. The 
fo open,' subject to election by the 

bxgmbers ot the three professions who apply for 
eleeUon xvithm five years of their , first professional qiiliflca- 
tion, at the end of which period the privilege lapses. A’n 
hjis paid three annual subscriptions may, if 
emrmfce*^lee^ Fellowship, be admitted xvithout payment ot 

Medical Staff List, revised to show the 
appointments, held by oflicers on November 30tli, 1927, gives 
in 'siei-rp "t specialist and research appointments, one 

Gold 1 ®’ file Besearch Institute for the 

Sal fi^ Besearch Institute. The 

CotcLi esttiDiisiiiueiit of tho staff is now 215 

.agreement, about bacteriological 
adnntpd Utilleiin of Hygiene has provisionally 

of recommended by the 1920 

of Ba^tPHokf.<isi^“\“?° appointed by tbe American Society 
in ^'ascription ot this system is published 

m tbe February issue ot the BitlMin. x au u 

• D^lrtmpn7?s‘'^ivJa Italian state Tourist 


o c. .A. 

Os his departure to take up the appointment of medic: 
ofUoer of hoalUi for East Susses Dr. B. Asliloigh Glegg, wh 
has been 31.0. H. to the Lindsey Countv Council tor tho na- 


spa a medical lecture will bo given, followed by visits to 
I bathing cstablisbiuonts, etc. 'Tlio texts of loctures will be 
provided iu English, Freiicli, and Genuaii; and interpreters 
familiar with these languages will accompany the party. 
Tho inclusive charge will bo 1,500 lire (about £16 10s.) for tho 
tour; I'odnced faros will bo available in Italy to and from the 
■points of assembly and dispersal. Full information may bo 
obtained from tho Euto Naziouale • Industrie Tnristiche 
(Italian State Tourist Dopartuient), Via Mnrghera 6, Borne. 

-TxiE ninth international neurological congress xvill be held 
in Paris on July 3rd and 4tli, wlien a discussion will be 
held on tho diagnosis and treatment of cerebral tnmoms, in 
wiiich Drs. Clovis, Vincent, Bfieiere, Bollack, Hartmann, and 
do Startel will talco part. 

- A medical congress on diseases of the rcspii-atoi'j’ tract 

• will bo held at Clermont-Ferrand, under the presidency of 
Professor Castaigno ot Paris, and xvill include excursions to 

• La Bouibonlo and Mont Dore on 3Iay .27lh and 28th. Tho 
subjects for discu-ssiou will be tho treatment of tuberculosis 
in tho spas ot Auvorgno and centre of France, treatment ot 
diseases ot tho pharynx and larynx at these spas, and injec- 
tion ot mineral waters into tho tissues. Farther Information- 
can be obtained from tho Centre Medical, 23, Place Brechim- 
bault, 3tonlins (Alller). 

Tub fifth international congress of thalassotherapy xvill be 
held at Bneurest and Constantza from Maj' 21st to 29th. 
Fnrtlier information can be obtained from tlio general secre- 
tary, Strada 3Iantuleasa 35, Bucarest. 

Dr. August Gartner, professor of hygiene at Jena Uni- 
versity, celebrated his eightieth birthday on April X8th. 

According to the Stockholm correspondent of the 'I'imcs 
this year’s Nobel Prize xvinners will receive about £8,700 
each from the Nobel Fonudation. The prizes to be axvavded 
in 1928 are for physics, chemistry, medicine, and literature. 

A PRIZE ot 3,858 francs will be awarded bj' the Sooiete do 
Neurologie ot Paris for the best work on- the treatment of 
disseminated solerobis published between July Xst, 1927, auxl 
July Ist, 1928. Further information can be obtained from 
Dr. 0. Croozou, 70 bis, Avenue de Jena', Paris. , - . 

A BlDD has been inlroduced in tbe Legislature of Trinidad 
and Tobago to provide for, the medical inspection ot Govern- 
ment and assisted schools and ot the pupils atteuiling such' 
schools.' • • ■ 


KetUxs, ^aUs, antt 


All communicationi in regard to editorial business should bo 
addressed to r/ie EDiTOR, British /Wec//ca/ Uournatf British 
medical Assoclatfch House, Tavtstoefe Square, W.C.f. 

ORIGINAL ARTICLES and LETTERS forwarded for publication 
are understood to be offered to the British Medical Journal 
alone -unless the contrary be stated. Correspondents who wish 
notice to be taken of their communications sliould authenticate 
them with their names, not necessarily for publication. 

Arbors desiring REPRINTS of their articles published in the 
British Medical Journal must communicate with the Financial 
^cretary and Business Manager, British Jledical Association 
House. Tavistock Square, W.C.l, on receipt of proofs. 

All communications with reference to ADVERTISEMENTS as well 
as ordei-s for- copies of the Journal, should be addressed to the 
Financial Secretary and Business Manager, 

The telephone NUMBERS or the British Medical Association 
and the British Medical Journal are MUSEUM VS61, 9SG2 9S6S 
and OSGi (internal exchange, four lines). ’ ’ 

The TELBGnnPHtC -ADDRESSES Site. ■ 

EDlTOli of the Bnmsn Medical Jobukal. Ailiolonv TTcslccni. 

Zottdolu. . » 

' ' ^^NANCIAL SECRET^VRY and BUSINESS MANAGER ' 

FTcstoj/ London, 

^ MEDICAL SECRETARY, Mcdisecra Wcstccnt, London. 

TIio ad^e^ of the Irish Office of the British Medical Association 
Frederick Street, Dublin (telegrams : BacUlus, 
telephone: 62550 Diihlin), and of tho Scottish Office* 
^ Urumsheugh Gardens, Edinburgh (telegrams: Associate, 
Edinhurr;h) telephone Edinburgh). 


QUBRIBS AND ANSWERS. 

Hardening the Feet. 

*‘H. R.” wishes to know the best method of hardening the feet 
preparatoi*y to a long walking tour. 

INC05IE Tax. 

•* * • • . • . Cash Basis. 

“ J; C. G. C.*\started practice iu 1926-27 and paid tax for that year 
on the basis of his gross bookings less expenses. Gnu he now 
.adopt the cash basis? 

-*** Tbe revenue authorities object to the cash basis as 
applied to a new practice until the point is reached at which the 
ceceipts Ii'om oW are likely to balance the' unpaid 


788 MiT si 15283 


LETTEBS, NOTES, AND ANSWERS. 


r Tiwntmw 
L Mkdicaj. JoDaVAt 


Bcoounts foe tlie year for wliipli tlio accooiit is paiii. Probably 
they will insist on tbo “ boolcings " basis lor at least throe years. 
It should ho borne in mind that it is the probable s'alue ot Iho 
outstan ling debts which Bhould' bo bronglit in, and tlicrotoro it 
there are any particular cases in which it is not expected that 
tl)e wlioie anionnt will be received, deduction should bo made tor 
probable speoiflo losses. 

Deduction for Vue of House. 

“S. n." owns ilia house, which is assessed at a not value of £45. 
Ha lias claimed to deduct, ns representing the professional 
' portion, the sum ot £25 “ as one-third ol a rcasomiblo' rental 
value.” The inspector ot taxes declines tonllow more than £15— 
that is, one-third ot the net assessed value. r ; ' 

*,* The assessed value must ho taken ns the l)aRis, and there- 
fore the inspector’s attitude is correct. “ S. II." should, how- 
ever, bear in mind that as £45 is the net value, any cost of inaln- 
teinnce, repairs, etc., applicable to tile professioual portion ol 
the iiouse may be separately charged ns professional expenses. 

Motor Car Expenses. , ' 

“N. B. C.” inquires which ot the expenses incurrod-in running 
a car for professional purposes mav bo dednoted. from gross 
income. 

All expenses maybe deducted c.xcept tliose incurred In 
the pii. chase— as distinct from the cost of replacement- of the 
car or its iniprovoment. This includes, for instance, tlic annual 
cost of insurance, but, of course, tlio sums received mhst be 
bronglit ill against any expenditure rosnltlng from accident, etc. 
To ilio extent, liowever, to wliich the car is nsed for private 
purposes tlie total cost must lie restricted— for 'ex'ampie,' by 

10 per cent., or wliatever percentage may be reaaouable. 

Motor Gar Traitsactions. j ’ ' 

"I. I,.” bought a Singer car for £145 iri February ot thie yerir. 
What allowance can lie claim for 1928-29? 

*.• Depreciation, namely, 15 per cent, of £145— Ih.at ls, 1122. 
■When tlio car is replaced an obsolosconco claim can probably lie 
made, ns 15 per cent, is usually found iiisiinicicnt iii 'such' 
cU'ctiitulaiices. • . . ■ ■ 


h. 1\ .” bought a c.ar in 1926 for £170. 
and bought another car tor £170. 
claimed. 


Ho has now sold It for £60 
No depreciation has been 


,* Too actual out-of-pocket cost of the now car— that is, 
£170-f60=£UO— can be claimed ns a professional expense ol the 
current year.. It will be seen that it is the income-tax return 
for 1929-50 and not for tbo current financial year tliat will bo 
affected; ... ■ 


'• A. P.” inquires what is tlie annual percentage fignro for donrecin 
,tioii on a car for tlie first, second, and third year! 

The normal rate granted niipears to he 15 per cent 
■though no doubt there; are, cases where 20 per cent, is given 
-having regard to the nature of the work tho 'car has ttf perform 
9 he rate is applied fo' the <■ writteu'down " valno^tlmt is Hit 
cost price as reduced by allowances for' the'- previous years ’ Or 
a oar costing £400 the allowances would work out as follows ; 

First vear-£4(M at 15 per cent,=f 50. leaving £310 - 

anna jear— £289at IS.per cont.=£43, leaving AJIsl 
and so on. » u . 


LEXTERS.- NOTES, ETC. 

PROGNOSTIC Significance’ OF Lauqe NrjiBERs or 

’ ' Tubkkcle Bacilli in,Pus. 

DR» B».CIjARKR (Belfast), referriiiif to-T)r t*-« 

the relative frequency of human and bovifie^^tublredins-*^’® ® 
issue of April 14th (p. 626), reports tlie case nf a 
Who, following.plemisy.at the age of 10, was ndmBtod”'to 
with idiyaical .signs of infiltvatiou of tho npper^hnlF of 
long and tlie upper fourth ot the left luim Vh» ° “S''* 

examined four times for luhercle bacilli without re^iiii™ mi"® 
•patieut improved rapidly, the temperature hecomliig normal 
after nine rveelis In hospital. Nearly a year Jater n ra 
caseating tnberonlous gland developaa-'ou the left side m ti 
neck, and the patient began to lose ground steadily. Jreiiii ..ir 
supervened and the patient died. Pns aspirated from ‘’fi 
swelling was found to coutaiii.tnbercle bacilli m large immli«i-o 
,in appearance tliey were long and thiu.-and contained 
granules. Lesions of the human type ayjpeared in an inooiifnio.? 
guinea-pig. u.avon 

. . Bodt and Mind. 

Mr.F.Matthias Al.EXANDEE(Lohdon,B.-W.l writes; Dr. A.Mnrdoch 

of Bexhill-on- Sea has drawn my attention.' to yonr leadiii,. 
article entitled “ The reality of dolnsioiis” in the' Srltiih 
Medical Journal ot March 17th (p. 457). DA Devine's oonclnsioii 
■ quote, tliat a.delusioii is “ the conscious symbol of a 

state of functioning of tlie wliole organism ” and his 


- to mo, n.s my practical tcnohiiig experience 

of oxer thirty years lins hcoii based upon tho imiiossibilitv of 
BOpavating tho so-called mental and physical elnnonts n anv ol 
-our dealings with tl.e human organ sun T 10 “ Srhaiwcs o 
t .0 organism,’ irlgcl. Dr. IJovino slatos express 
•both types of malady,” I have round to ho duo in ererv rase 
to wrong iiRo niid fiiiictioiiiug of tho whole orghnisin 1 have 
ovoivcii n tcchnlqiio tlio object of wlilcli Jr to restore to niy pupils 

'f’ 11 °^^ '"r ‘b treat manlfesls! 
t oils of dlsoaso ill wh ch I am- not inlerested. 1 have fomiil 
Mmt ii hero. Its application is aiicocssfnl. symptoms, whether 
niaiiifoRting thomsolvcs ns ‘'.physical or mental illnesses,” tend 
lallkoilo disappear ill process; and medical men who have sent 
.pupils to me, and u-lioso names 1 enclose, can verily this. 

• Dr. lotcr jirncdoimld brought out this point very clearlj- hi tho 
.ndilre-sa whicli ho gave to tbo Torksbire Jtranoh of tbo Brilisli 
Medical Association, and wblcli you piiblisbod on December 25tli, 

■ t"“/>,a"u ill niy book Constritctire Conscious Control of the 
Individual, to which j-ou gave a /avoiirablo review, I made mr 
position quilo clear at tlio outset Iiy delliiiiig my use of tlio form 
.••psycho-physical” ns covering all inanilestatioiis of liiimau 
activity. -IVlion yon express the liopo tliat tho gap between 
psychological incdicino anil mcdicino at largo may narrow intlier 
t!i.--;i widen, may I suggest timt tlio first stop towards siicli an 
■integration must lie a statemeul ol a technique liv means of 
‘which tile cause ot tho “ morliid stato of functioning ot tho 
'whole organism,'' which Dr. Devine stato.s lies behind mental 
and phj'sical ill nesses alike, may bo found anil crnilioated ? 


' BTriniT'Ococci and PonnrF.r.AT, Sr.psis. 
j Mr. .1. T. AlNsi.ir. Wai.ker (London) writes; If Professor Beattie’s 
I reference to tho llldenl- Walker tost in his letlor in yonr issue 
of Aiwil 14th was Intended to imply tliat tlio only organism 
nscil in this test Is B. tuphosus, ho lias given an ontirclvcrioiieons 
impression. In my original note, piiblishcd in tlio Peactilioner • 
' In 1902, I gave an example from my laboratory note-book, 
showing tli'o result obtained for a certain preparation X wlien 
tv'orking with" Ji. ’edt as the tost organism. 'Tlie mnitipic, or 
'cocflicient, was 10.0. 'Tlio following quotation is taken from tho 

■ saihb nolo : “ Of course,' a different mnltiido will he found when' 

' wbrltlng .with different organisms. In tlio case cited above tlie 

. .inniliplc itQUild for. X when tested against a pure cnltnro of 

■ S.vallida aureus wits,4; but tills only bears out Dr. Houston's 
• cxcollcnT observation on tbo necessity for tlio clioice ot a 
: 'disinfectant being governed by tlie purpose to wliich it is 

' 'proposed to put it.” _ 


Tni: •' Rising Test ” FOR Acute Abdojien. 

Dr • K. llArr (Blbcrach, Wiirtcmberg), referring to Mr..,C, Ii. 
oVaiivillo Chapman's memorandum on a diagnostic test tor 
ncnlo abdominal conditions (October 29th, 1927, p. 785), states 
lliat ho first recognized tho value ot this tost in appe'iidicUis in 
1921 and pnhiislioil a note on it in tho Medizinisefte A'fiin'fc (1925, 
No ’ 4 I), giving it the name ot Bitnitijhnrepunpsschmerz. Ho agrees 
with mVV Cliapmaii as to tlie assistance given by it in the stage 
before abdominal tenderness appears. 


’ Chronic Diarriioea causp.d ry a Feather Qcit.i.. 

Dit n! U. Jones (Glasgow) reports tlie case of a man who Imd 
snffo'red for iiinny years from pain in tho bowels and diarriioea: 
ho was coiisidcrahly relieved, hut not onred,'by treatment, witli 
liiilv. kino CO. lie suhsequ'enUy passed throogli tlie bowel a 
liavd' brittle, smooth, polished liud somewliat flattened tiibiilar 
Ira‘'ment, wliich ivas hrownisli and about tlio size ol an onliiiary 
• inarch. Jt iiad been removed from tlie bowel with considenibic 
difiicniiy, and subsequently tbo patient Imd no diarrhoea, and 
the abdominal pain and discomfort entirely disappeared. 'TIio 
sDcciinon api'cared to bo a quill from tli.o wing or.featlier ol a 
small brown bi.id. 'The patienlstatcd that when in South Africa 
sbvcrnl vpars previously Iid frequently dined on snipe and 
'guinea fowl, aml'miglit quite easily have swallowed a quill, 
'bommenting on this-case Dr. Jones writes: I have boon con- 
sidering very carefully tlio question ot diagnosis and the line of 
trcalmeut Islionld- Iiave adopted Imd I previously known that 
such a foreign body was in tlie bowel. In tlio first place, to 
<lia"uo 30 a foreign, body such as a quill is by no means cosy. 
A onill stuck into a Sausage and i-rayed only tlirows a faint 
sliadow which would be almost imperceptible were tlie sausage 
'nlaced within the abdominal wall. To find a solvent that will 

'dissolve a quill is a diflicult matter. Hydr-— -.- 1 . 1 =— 

Bucli as liydroobtorio and' snlpliutio— and 
soda— and potassium iodide or bromide, ■ 

a feather or quill. Bromine converts a feather into a brown 
mass and nitric acid. causes a feather and quill to disappear 
comn'letelv, hut neither ot these could be used for niedloiiml 
purposes." Since xvilfl animals, sucii as the fox, eat birds, 
includin'' tlieir featliers, their digestive secretions must contain 
'some solvent whiob acts upon feathers and qnills, or else they 
must pass tbrongb tlio alimentary canal uudissolved. I should 
be glad to Imve tbe opiuious ot others ou this poiut. 


I’ACANCfES. , 

Notifications of offices vacant in universities, medical colleges, 
1 andofa-acant. resident and other.appoiutments at hospitals, will 
.be found at pages 54, 55, 56, 57, 60, 61, and 62 of our advertisemen 
columns, and advertisements as to partnerships, assistantships 
and locumtenencies at pages 58 and 59. ^ i 

A short snmmarv of vacant posts notified in the advertisemen; 
columns appears in the Siijifilriiient at page 203. ' 



PAXHOGENESIS OF ACUTE PRIMARV GLAUCOMA. 


[ lUK ItRITtSS 

Uedicil Joes'! A& 


789 


May 12, 1928] 


jVbiiriss 

ON 

THE PATHOGENESIS OF ACUTE 
PRIMARY GLAUCOMA.' 

ItY 

A. MAITLAND RAMSAA', JI.D., LL.D., I'.R.F.P.S., 

UOXORARY OIKECTOR, JAMES MACKENZIE IS5T1TUTE EOE CLISICAl. 

r.EiEARClI, ST. ANDREWS; COSSULTISO OMITllALMIC SAIEGEON, 
GEASUOW nOYAE INITUMAEY AND OEIITUALMIC INSTITUTION. 

Geaucosia is not n diso.TSO in itself, but v.otlier a symptom- 
complex whoso charnctcristic fcaturo is incicaso in tho 
tension of the eyeball. It was, however, tho peculiar 
greenish reflex from tho pupil that first attracted atten- 
tion and suggested tho name glaucoma. Centuries had 
to pass before IVilliam Mackenzie drew attention to tho 
hardness of glaucomatous eyes. That was the first obserra- 
tioii of real value in the study of glaucoma, and may bo 
regarded as the foundation of all present-day knowledgo 
of tho subject. 

IVlicn considered from tho clinical standpoint glaucoma 
may be primai'y or secondary ; primary when it is unasso- 
ciated with any other disease in tho affected eye, and 
secondary when tho glaucomatous seizure arises as a com- 
plication of a pre-existing pathological condition. Tho 
attack is acute or chronic, according to the presence or 
■the absence of congestion of the ocular blood vessels, but 
inflanimation in tho strict sense of the word never occurs 
during the course of acute primary glaucoma. Venous 
congestion is alone responsible for tho severity of the sym- 
ptoms, which vaiy greatly in dogreo in different cases.' 
In the majority they are subacute and recurrent, but in 
a small proportion they may bo described as fulminating. 
In these cireumstancos glaucoma is seen in its most tragic 
form — tho onset, course, and termination being tlio inci- 
dents of a ' few hours. ' A single attach occurring with 
dramatic suddenness results in total and irrcvocablo loss 
of sight. Such a disaster is nil tho more overwhelming, 
because glaneoma usually aliocts both eyes, and although 
olio may be attacked considerably’ in advance of tlio other, 
yet in a few desperate cases both suffer simultaneously. 

, Si'AIrjOSIATOtOGT. 

Acute glaucoma , can he, described as one of tho emer- 
gencies of general practice, . and in manv instances it 
appears, to come a's.a.bolt from' tho blue'. The patient 
goes to bed . apparently iii his usual liealth, but in the 
early hours of the inorning is awakened by agonizing pain 
in. the head, accompanied by- feverishness, nausea, per- 
sistent I'ctching,. and bilions, vomiting. The condition is 
so alarming that the family, doctor is sent for in haste, and 
unless he knows well iviiat he is about ho may easily do 
the patient more harm than .- good. It is cjnito probable 
that no one will speak about the eve, because even 
although tho failure in vision has been noticed, it lias been 
tacitly assiiniGcI to be duo to biliousness. The attention of 
the patient, and of -those surrounding him is occupied 
wholly as a .rule ivith tho severity of the ]iaiu in the 
head, tho iiauseo., aucl tho vomiting. The true nature 
of tho condition, therefore, may ho easily overlooked, 
and if tlio doctor ■ is also deceived the result will be 
deplorable. 

Acute glaucoma is not by -any means a common disease. 
It may liapiien that a medical man has been many vears 
in practice before .ho is called to treat a case. Ho oiiglit, 
however, always to bear the disease in mind, and never to 
forget to examine the eye of 'a patient said to be suffering 
froiii a severe bilious attack, Every country doctor ou-rht 
to bo able to recognize acute glaucoma. Tlie're is not much 
difficulty in tho. di.ignosis. , The eye is tender and the 
patient shrinks from the slightest touch; it is hard, and 
said to feel too big for its socket. The bulbar conjuncti va 


is congested and oedematons; the cornea is steamy, and in 
many instances so insensitive that it can ho touched 
without tho patient’s knowledge; tho pupil is dilated, 
irregularly oval shaped, and irresponsive to light; the 
anterior chamber is shallow. At this stage of the exam- 
ination the general practitioner must bo on his guard 
not to ■ misinterpret the significance of these signs and 
symptoms. 

" Tho chief local condition with which acute glaucoma is 
often confused is acute iritis; hut the stony hardness of 
tho eyeball, tho dilated pupil, tho shallow anterior 
chamber, and the loss of sight form a group of signs 
sufficiently diagnostic to prevent glaucoma from being 
mistaken for any other disease. Unfortunately, however, 
glaucoma and iritis are still confused by the unwary, and 
tho consequences of such an error in diagnosis arc deplor- 
able, because tlio treatment for glaucoma is the opposite 
of that for iritis. It is well known that in iritis tho 
vigorous use of atropine is imperative, hut it is not so 
well Iniown that if a mydriatic ho instilled into an eye 
Euffering from glaucoma the sjmptoras will ho aggravated 
and tho chances of recovery of sight will ho materially 
lessened. There are few errors in diagnosis which are 
followed by such disastrous results; - 

Although the patient may never have consulted a doctor 
regarding his eyes until the onset of the acute symptoms, 
careful ;inqnir3’ into tho history of the- case will nsualh’ 
elicit the fact that for weeks, months, -or j-cars he has 
suffered from transient attacks of dimness of vision. These 
attacks are often so fleeting that little significanee is 
attached to them, and as a rule the patient does not think 
it worth while to mention them until something in . the 
course of a medical examination recalls them to mind. 
Tho fact that such attacks are usually made light of 
and quickly forgotten makes it all tho more necessary 
for tho family doctor to ho quick to- appreciate and 
appraise at their proper value any remarks regarding 
eyesight made in 0 casual manner during tho course of 
conversation.' ' ' 

Suspicion should at once ho ai’ousod if a patient says 
that now and again lie -lias seen objects., tlirough a fog, 
and that lights Lave appeared to be surrounded bj- rainbow- 
coloured rings. Inquiry will usually further elicit that 
while these symptoms are in esent there is a dull pain in the 
eye -and forehead, and if it should happen . that the doctor 
was consulted during one of these attacks ho will romemher 
that tho cyq was .more, or less ro.d, hard to the touch, tho 
cornea steamy, and tho puiiil dilated. If tho examination' 
bo carried furtlier bj’- the use of the ophthalmoscope it 
will be seen that the retinal veins are enlarged and that tho 
arteries pulsate as they pass over the optic disc. M’hen tho 
patient is kept under icgiilar ohsen-ation it will bo dis- 
covered that the attaclis are recurrent and vary in dura- 
tion from a few mhuitcs to several hours, while in the- 
interi-als tho eye to all appearance is healthy. Recur- 
rences become more and moro frequent and protracted,' 
however, until at length a state of increased tension is- 
permanently established. In' the majority of instances that 
sequence of phenomeua is easily followed, " but . there is 
usually considerable difficult^’ in* understanding the under- 
lying cause of the condition.' --. - 

Tho increased tension of the e3’ehall is not a disease in 
itself; it is only a symptom of a general condition, whoso 
etiology is at all times ven,- difficult to determine. ' '\\lien 
an eye is predisposed to glaucoma an3-thing that depresses 
the action of the heart ma3’ determine a seizure, which in 
tho majority of instances can be clearly traced to mental 
distress or moral shock, to the injurious influence of cold or 
of hunger, or to worry, sleeplessness, or fatigue. In many 
instances also there are present such associated conditions 
as anaemia, lithiasis, hroiichitis, persistent constipation, or 
the suppression of some habitual discharge. Acute glaucoma 
occui-s frequently in women at tho menopause. Lagrange 
has defined glaucoma to be “ a sick 030 in a sick hod3’,” 
and Laquer says that Gvci-i-thing " that dilates the pupil or 
debilitates the patient ” mai- precipitate an attack. It is' 
characteristic of the onset of the disease that the increase' 
of' tension is intermittent, hut sooner or later it hccomes’ 
.permanent-.. By, the time that stage -is ..rc.aclled, however,' 
the cause of the disease is usually obscured by its results. 

[3514] 



790 Mat h, 1928] 


PATHOGENESIS OE AOUTE PBIMAHy GEAtJCOMA.' 


[ Tire Eninw 
Uedicie Jot'nNU. 


Etiolooy. 

The oiAilier glaueoina can ho tleleotod, therefore, tlio 
iiioi'o likely is its etioloey to he diseovered. No progress 
aill he made witli this (|iiest, however, until the pliysio- 
logical iiK'ehaiiisiii whereby the iiitraoeiilar leiisioi) is jniiiii- 
taiiied in a state of health is proiao ly nndeislood, hec.anse 
without such knowledge it is not ])ossihle to detect the 
earliest aheri'.ation whieh transforms the physiological into 
the pathological. It must he home in mind that there is 
no essential difference hetwoen physiology and pathology. 
No sharj) line of demarcation separates the normal from the 
ahiiormal. By the recognition of symptoms, howevei', the 
trained clinician is able to detect the beginnings of disease, 
at a time when the morbid process giving risi; to it is still 
on the borderland of the physiological. I''nnetion rather 
than structure is the foundation of the science of niedieine. 
A physiological problem cannot he argued from the stand- 
point of pure anatomy without grave danger of falling into 
error. The special recpiiroments of every oi'gan Jiecessitate 
certain modifications of structure, but the basis of vital 
activity is the same in every part of the body. The unifi- 
cation of both physiological and ])athoIogicaI ]>rocesses nmst 
be recognized. If, for example, the etiology of acute 
glaucoma bo sough.t for along anatomical lines the disease 
will inovitabi}' seem obscure and mysterious; but whenever 
it is recognized that evei-y vital i)rocoss take.s ])lac(! through 
the walls of the capillaries, glaucoma is at once brought 
into line with other pathological conditions which ari> 
clearly defined and well understood. 

The study of the ctiologc- of glaueoma has passed 
tiu'ough many phases. Hypolhese.s deemed ithporlanl in 
their day have had, with the advance of scients' and the 
increase of knowledge, to bo ])ut aside: but they were 
useful at the time in so far as they i)ave<l the way to the 
aecjui-sition of fuller knowledge. The tension of the eye- 
ball dei)ends upon the fluid content of the globe, and the 
theory generally accepted is that the intraocular fluids 
are derived from the capillaries of the eiliaiy processe.s,* 
and that in a .state of health a close relationship e.xists 
between intraocular ju-ess\no and general blood jirossure. 
ft has also been demonstrated that, starting from their 
source, the intraocular fluids jiass forward through the 
circumlental space, the ])nsterior chamber, and the pupil 
to reach the angle of the anterior chamber from which 
they escape from the eye into the canal of Sehleinni, 
through the filtration spaces in the ])cctinato ligament. 
'When that mechanism is in proper working oixlor the 
tension of the eyeball is liable to very slight variation, 
consequently the intraocular pressure resembles the general 
blood pressure in so far as both are maintained at a 
fairly constant level in the normal conditio): ; luit sudden 
and great variations are liable to occui* in s))ch moi'bid 
conditions as glaucoma and hypcii)iesia. It must not he 
concluded, however, that high Ijlood jJi’e.ssurc is in itself 
an essential .factor in the etiology of glaucoma. The two 
conditions fiequently coexist, but the I’elationship is prii'cly 
accidental and is not one of cause and effect. Arterial 
piessnie must exercise a certain aiuou-nt of influence upon 
the tension of the eye, but the iTnportant factor in the 
legnlation of the intraocular ])ressure is the pressnie in the 
capillaries. That being so, the clue to the pathogenesis 
of glaucoma js likely to be found by a study of the 
ca])iiiary circulation in the eyo. 

Many of the old theories of the causation of "■lancoma 
were based upon the hypersecretion of the '’aqueous 
humour; - that hypothesis is open to serious objection 
■When the excictoi-}' channels in the cornco-iridic anolo 
ai-e in good woildng order any increase in the inflow '’of 
fluid is at once compensated by a corresponding increase 
in the outflow. The results of clinical experience inore- 
oVei-, have demonstrated that when the secretion of tlio 
aqueous is excessive, this reciprocal arrangement is quite 
efficient in maintaining the normal tension of the eyeball. 
On tbe other hand, the pathological study of eyes 
enncleated as a result of sccondai-j- glaucoma has demon- 
strated that hardening of the eyeball is due, not to ovor- 
secrotiou of the intiaoeular fluids, but that it i.s the result 

tiou'spac" 

olistruct tbc outflow of AuUk'"')'-'^ 1 and 

now of fluuts. winch, being retained within 


the eyeball, cause a gradual and progi-cssivo increase in 
I elision. 

Knics and IVehor wero among the first to sugge.st a' 
roleiitioii theory for primai-y glaucoma similar to thafi 
generally adopted for the .secondary form of tbo disease, 
and the epoch-making rc.soarcho.s of Prie.stloy Smith support 
their view. In the cnrlic.st stagc.s of primary glaucoma, 
however, occasion for excision of tho affected oyo never 
nrise.s, coii.spqiioiitly before it is possible to obtain material 
for miero.seopic examination the disease has advanced so 
fiir that, although end-results can ho fully de.scrihed;: 
nothing whatever can bo learned of tho mode of origin. 
Tho opportunities for ohsemitioii are not much nioro 
favonrahlo from tho clinical standpoint, hecanso tho family 
doctor rarely .sees a caso until the disca.so is fully 
developed. He has had no opportunity to note tho siihtio 
changes which have led tip to the acute seizure on account 
of which ho has heeii consulted. Nevertheless, it ,is tho 
preiiimiilory .syiiiptom.s- that ought to he carefully studied, 
iiwaiisp until the niechaiii.sni of their production .is 
properly niulcixtood it is impossible to explain how it has 
come ahniit that an eye apparently quite healthy in 
the evening is attacked by a formidahlc disease hoforo 
morning. It is always assumed that the eye affected was 
predisposed to giancoma, and from the anatomical stand- 
point .such a prcsli.spositiou niidoiililedly exi.sts. 

Priestley Smith lia.s demonstrated that eyes liable to 
giancoma are .smaller than normal, and, in view of the fact 
that primarv giancoma is 11 disease of late adult life, ho 
has pointed’ out that, while the lens contiiine.s to grow 
throughout life, tlie size of the eyebafi, after a certain age, 
remains stalioiiary. In some instances, therefore, the dis- 
proporlinii hetwee’n the hulk of tho fens and the size of tlio 
globe hecoiiii's .so pronniiiicod that tho circiimicntal .spaco 
is oliliteratcd. Whenever that occurs increase of prcssitro 
ill tho vitreous ehamher pushes the lens forward, and 
closes tlu> filtration angle by tlie aiiproximatiou of tho 
base of tho iris to the posterior surface of the conica. 
Uoteiitioii of the iiitraociilar fluids leads to the develop- 
ment of symptoms of giancoma, and those will steadily 
persist so long as the drainage system of the eye remains 
blocked. If tbo circiiinlontnl spaco has been encroached 
upon griuliially the eye can so far adapt itself to the 
altered’ conditions, ami acute symptoms do not occur, hut 
if oil tlio other liaiul, obliteration takes place suddenly 
signs and .symptoms of acute congestive glaucoma at ouco 

uviso. ^ 

The most iiieticiilons study of the pathological anatomy 
of an eve that has been excised for glaucoma can, how- 
ever rcWal nothing more than ciid-rcsiilts. .\n exainina- 
tioii'of the cyehall can never by itself reveal the cause of 
the disease. The sick body, as Lagrange said must also 
he considered, hecanso, until glaucoma is hroiight into line 
with diseases whose etiologj’ is well estahlislicd, its patho- 
genesis cannot he jiroperly understood. It is necessary in 
the fii'st place, however, to recall tho physiological prin- 
ciples which icgnlate the intraocular circulation and con- 
trol tho •intraocular ])ro.ssuro. An essential postulate for 
the coiitiuiiatiou of the circulation in tho eyeball is that 
the arterial pressure he higher than the capillary, tho 
capillary higher than the venous, and tho venous higher 
tlinii the intraocular. The capillaries, rather than tho 
arteries, are the chief regulators of intraocular pressure : 
any obstruction to the venous outflow is of much more im- 
portanco to tlio eye than high prossuro in the arteries. 
This prc]ioiidoratiiig influence of venous olistriiction is 
duo ■ in all probability, to its immediate effect upon tlio 
capillaries. Any local interferonco with the venous circu- 
lation ^ligature of tho venae vorticosae, for example — will 

at once precipitate an acute glaucomatous seizure. AVheii, 
however, the problem is put in its right sotting and seen 
in its proper perspective, the hehavionr of tho capillaries 
is the one thing that is fundamental, both in physiolog}' 
and in pathology. It is all-important, hecanso tho 
capillaries are not only tho dynamic part of the cir- 
culatory system, but they also demonstrate tho .sum 
of tho purposes for which circulation of tho Wood 
exists. 

BrysQn,= in the e.arlj- days of the James jVIacljenzie Insti- 
tute for Clinical Eescarch, was tho first to suggest that tho 



May 12, 1928] 


PATHOGENESIS OF ACUTE PEIMARY GLAUCOMA. 


r TarCBmsn 791 

LMcwcai. JoCSSAt 


Ciipillnrics play tlio prcdoiainaut rolo in all vital activities, 
mid tliat tlio otlicr parts of tlio vascular system are con- 
trolled by them and aro Eubscrvioiit to their roquiremonts. 
On several occasions ho has brought forward clinical 
cviilenco in support of his views, and the truth of his hypo- 
thesis has been proved by many laboratory workers, among 
whom Krogh, Lewis, and Hale doservo special mention. I 
Thoso observers have domonslratotl that tho capillaries act ] 
independently of tho other parts of tho circulation; that I 
they aro called into uso only ns they uro required, and 
that thero is an enormous rcsei-vo of shut-down capillaries 
in an organ while it is resting. Tlio capillaries and tho colls 
associated with them may ho said, therefore, to act together 
as a physiological unit. 'When tho feeding time for a cell 
' is duo tho capillaries associated with it open at tho right 
moment, and after sufficient nutriment has been supplied 
they close down. This nutritional process goes on inter- 
mittently so tar as individual cells aro concerned, but 
constantly over tho body ns a whole. Tho result is that 
blood is sent round at tho call of tho dilfereut colls, while 
tho utmost economy is practised in its distribution. This 
regular lluctuation of tho capillaries is tho basis of all vital 
activity.’ It explains why it is that separate parts of an . 
organ work in shifts — some of tho component cells being 
in action while the others aro resting, and vice versa. If 
- all tho capillaries were to open up siinultaueously it is 
common knowledge that they could contain moro than tho 
wholo of tho blood iir tho body, and tho animal would 
bleed to death into its own capillaries, because, stagnation 
having taken place, circulation would cease. 

It is generally agreed that tho tissue Iluids eomo from 
, tho blood plasma by dialysis through tho walls of tho 
capillaries, and Duke-Elder has domon^itrated that tho 
, intraocular fluids obey tho same physico-clicmical laws. 
Ho believes, thoreforo, that tho aqueous humour is a dia- 
lysate, and has brouglit forward cvidcuco to prove that 
it is neither a secretion nor a filtrate. His work has put 
tho physiolo^ of llio intraocular circulation into lino with 
tho circulation in tho body as a wliolo. That does not 
. mean, however, that there aro no local differences in special 
organs, but Duke-Eldor believes tliat the apparent anomalies 
, are to be explained by tho difference in tlio permeability 
of tho capillaries. Each organ, has its own needs, and 
possesses within itself physiological adaptations for the 
purpose of satisfying its requirements. In carrying out 
this process tlio permeability of tho capillaries is oiio of tho 
most important factors, porniitting only tho right quantity 
and tho proper quality of nutrient fluid to ho dialysed 
from the blood plasma. 

In the eyo tho capillaries aro very impermeable, relative 
to those in other parts of tho body. 'Wliile, as a rule, tho 
. tissue fluids aro dialysed at a pressure of from 1 to 
^ tho eyo dialysis takes place under a pressure 

■ * 25 mm. Hg. The aqueous, therefore, is comparable 

to tlio tissue fluids, both as regards its origin and its 
metabolism, but it. differs from them qualitatively in pro- 
portion to tbo relative impermeability of tbo capillaries. 
In the eye tho special arrangements may be described 
ns a “ biological adaptation to keep tbo intraocular fluids 
as far as possible optically liomogcncous.” That is to say, 
that a simple modification of the same physiological process 
which regulates the function of tlie capillaries in all tho 
otlier parts of the body is sufficient to secure tho trans- 
parency of the dioptric apparatus of tlio eye. That physio- 
logical arrangement is an apt illustration of one of the 
main contontmns of this paper — namely, that although 
peculiarities of structure are necessary for the architecture 
of tho different organs of the body, yet it is ono and the 
, samo physiological process which regvdates and controls their 
, vita! activities. 

departure from health in tho eye is indicated 
by dilatation and increased permeability of its capillaries 
but except in tho case of direct injury the cause of this 
must be sought for in the general health of the patient 
rather than in the eyo itself. Tho eye is not only in tho 
body , it is also of tlie body ; tliat is tbo key to the proper 
understanding of the glaucoma problem. 

• Intorferenco with the circulation of tho blood through 
the eyeball and the consequent alterations iu tho composi- 


tion of tlio intr.aocular Iluids aro the outstanding features 
of aouto congestivo glaucoma, and in every instance loss 
of tone in tho wall or tho capill.aries is responsible for tho 
onset of an attack. Of the predisposing causes, in addi- 
tion to tlio small size of the eyeball, tho most important is 
tho wear and tear of life, with its cumulative autointoxica- 
tion and its vascular degenerations, while among the 
causes directly precipitating an attack may ho mentioned 
ovor-cxcitomcnt, crushing misfortune, sorrow and bereave- 
ment, excessive fatigue, prolonged exposure to cold, 
repeated indiscretions in diet, or a bout of drinking. It is 
almost certain that glaucoma cannot occur in anyone who 
is qiiito healthy. Doubtless in many instances the disease 
reveals itself with ’ appalling suddenness in one who is 
apparently healthy, but in every case of that kind a careful 
scrutiny of tho patient’s medical history will disclose 
symptoms, both local and general, which, though regarded 
as trivial at tho time of their occurrenco, wore really 
premonitory of something much moro serious. It is difficult 
to detect tho earliest signs of failure in the delicate 
physiological mechanism for keeping the tension of tlio 
cychail at a normal level. These must, however, be inti- 
mately associated with an alteration in tho behaviour of 
tho capillaries which regulate intraocular pressure, and 
the truth about glaucoma will not bo known fully until 
all tho factors governing tho circulation, both of the blood 
and of tho iluids within the eyeball, have been cleaily 
demonstrated. 

It is known that tbo body contains two groups of sub- 
stances mutually antagonistic — a histamine group, acting 
as dilators of tlio capillaries, and an adrenaline groiqi, 
acting as contractors. During life thero must he a con- 
stant give and take between tlicso two groups in the 
effort to maintain equilibrium, which is readily disturbed 
in one or other direction by the influence of hormones. 
AITienever ono of these groups gains ascendancy over tho 
other disturbance in the capillary circulation occurs suffi- 
cient to place tho patient in the borderland of the patho- 
logical. Dale and his associates have mode a careful study 
of histamine,* and have demonstrated that when this 
substance is injected intravenously into a living animal it 
causes such extreme dilatatiou of tho capillaries that 
the blood stagnates and at the same time the capillary 
walls become so permeable that oedema of. the tissues 
occurs from loss of blood plasma. Thoso changes may 
become so extreme that the circulation is brouglit to a 
• precariously low point by depletion of the central vessels. 
When such circulatory disturbances are general throughout 
tho body secondary shock arises, but when they are iocn- 
I lized in the eyeball acute glaucoma supervenes. Both in 
( acute glaucoma and in secondary shock, therefore, the 
underlying cause is the same, and from the pathoIogi< .oi 
point of view one condition may be regarded as analogous 
to the other. 

To sum up, it is probable (1) that the first stage in tho 
pathogenesis of glaucoma is a disturbance in the capillary 
circulation leading to a general dilatation accompanied by 
increased permeability of their walls ; (2) that tho con- 
dition is brought about by tho action of a toxin which 
upsets the delicately balanced mechanism controlling tho 
function of tho endocrine glands, and thereby interferes 
.with tho normal action of the sympathetic nervous system. 

One of the earliest symptoms of glaucoma — ono that 
occurs before increased tension in tho eyeball has become 
permanently established — is dulling of sensitivity to dim 
light and del.ay in dark adaptation.’ This failure in light 
minimum is duo to interference with tho function of tho 
layer of rods and cones of tho retina, which derives its 
nourishment from the choriocapillaris. Whenever these 
nutrient capillaries lose tone the blood stagnates, the 
rods and cones suffer, and the light sense becomes 
disordered. 

■ Although severe congestivo changes and oedema of tho 
ocular conjunctiva aro such outstanding characteristics of 
aouto glaucoma, they are neither primary' nor essentia! to 
tho attack, but are secondaiy to the changes which have 
occurred already in the capillaries. The glaucoma is 
fully established boforo the surface of tho globe has 
becomo congested; but unless tho patient has '’consulted 


792 MAT 12, 1928] PATHOGENESIS OF ACUTE PBIMAllY GEAUCOJTA. 


Tiij IJstTnir 

ib JiT'Trm 


liis (loL'tor (hiring a iiromoniiory attack, tiu' ili.soaM) Is 
very seldom seen in this early stage.” Tliat, limrcvcr, is 
tho timo when it can ho .studied in its simplest fnrni, 
hecauso a premonitory attack dilTers from geiniiiie 
glaucoma only in so far as it jiasscs olV C|ui<;kly. The 
pathogenesis of both is the same. Tin- eong<!stiv(> changes 
are something superadded to a pre-cNisl ing condition, and 
it is not difficult to iiuderstand how they originate. The 
incrca.sod dilatation of tho eajiillaries and the increased 
permeability of their walls causo great inlerferenco with 
tho intraocular circulation. An increasing ohslriiotion is 
therefore offered to the return of tlu' hlood hy the vi'ins, 
and whenever stagnation occurs acute glaucoma Miper- 
venos. The phenomena seen in tho eye rrsimihle what 
occur.s in tho tlii’omhosis of hlood cessels in other pnits of 
tho body — acute pain, vasonlar congestion, oedema, and 
lo.ss of funetion, Tiio giavity of an attack is in great 
measure determined by the 'severity- of thos<' secoinlarv 
vascular complicatioms. The elin-f .stress is felt at the 
coriieo-iridic angle, where tho eirenlation can ho said to 
bo strangnlalcd, and tho state of tho cyo may he com- 
pared to a hernia which has hccomo strangulated. In holh 
imstances danger is oxtremo until tho strangidation is 
relieved. 

_ Tho initial caiuso of glaucoma m.ay hn traced to (he 
injurious action of a toxin of tho histamino tvpe, Tt is 
probably of biocheinieal rather than of Iiacteriar origin, 
and IS manufactured in tho courso of defoetivo inetnholiMii’ 
duo to pewsistent constipation, hejiatic iiisuffieieiicv or 
renal iuadocjnacy. There is, however, littio difl'erenVc in 
tho action of a biochemioal toxin and oiks of baelerial 
origin. Both cause dilatation of eapillarios witli increased 
permeability of their walls. 


A.v A.\’.(Locr. 

A good cxaiiipio of tlio action of both form.s of toxin 
IS seen in a eompari.son of neute glaucoma with nelitc 
glomcrulo-nepiiritis. Tlio ciliary processes in tho <'yo ami 
tho glomeruli in tho kidney show iiianv features in common 
liio chief fmictiou of both is to dialyso fluid through the 
wa h of e.apilhirios, ami tlio dialysato in both cyo and 
kidney coiitaiiis .wery suhstanco present in hlood iilasnia 
T.iero IS this clifTcrcnco, however, that tho quotient varies 
according to tho osmotic pre.s.suro of tho hlood and the 

wf/rn the walls of tho capillaries. 

W itli those reservations tho aqueous Inimonr may ho taken 

wiih ‘f tho ejo wore supi.licd 

null ,a tulndar arrangement similar in function to that in 
the kidney, the aqueous, after passing through it, would 
)o tm nod into urine. Moreover, while tho reaction of 
tho normal aqueous is almost neutral, in glaucoma it is 
(listiuetly alkaline.’' A change in tho osmotic prossuro and 
a diminished hydrogoii-ion concentration of tiio hloo'l 
permit an excess of sodium to pass through tho walls of 
t ° toiincl that tho sodium content of 

tho blood IS diraiiiishod in glaucoma, and that observation 

in tho blood. Those chants S to incta'r 
in tho capillaries followed by (damage to tl, eh” 
become so permeable that Uiey adow "'“r'’ 

to escfipc. Tho normal aqueous contain^tl,^ in’otcin, 

glaucoma it is present in appreciable amount A i - 
of the aqueous is due, tbm'eforo to V.'™.""!"'! 
process which gives rise to the iiresenco of allnu? * ' 

urine, and if tlio' cyo were by tlm 

gloat iniponneahility of the capillaries of tho cilinw^ » 
cesses the presence of proteii, in tho aqueour 1,^ 
would bo of frequent occurrence. “Tueous humo.ir, 

These widespread changes in the capillaries and in the 
(cins inust cause groat increase in the size of tho organ 
affected, and as both the eye and the kidney are encS 
witlnn a Him capsule, increase of tension readily sunev. 
ones. \\ hen that occurs a state of glaucoma may bo said 
to exist both in the eye and in tho kidnev-the abnoi'^al ' 


III Ihe la.st result, that can ho accomplished hy performing 
irnleetomy in ihe eye, and hy stri])ping the capsule in the 
kidney. 

T’lii.vcirf.irs or TiicAT-urNT. 

Tile rational (ll■afment of ghuicnma is based on a know- 
ledge of the same physiological principles which are so 
lu^lpful in the study ef its etiology. ft is not possible, 
however, to atteiiipf in this paper anytiiing more than a 
brief and general ikscnssinn of tho problem. Tn cbiisidcr- 
ing the pathogenesis of ghuicomn, it has been stated that 
histamine niiil aiireiialine are mntnally antagonistic, and 
that wlien the histamino group of toxiii.s predominates 
incivasisl inlrnocnhir pr(>ssnre arises, ami will persist and 
hecoiiie permanent if (he noxious cause cannot he removed. 
The phvsiolngical antidote to all jioisons of tho histamino 
type is adrenaline,* which consequently is the rational 
trcntmi'ut whenever capillaries arc over-dilated and their 
cireuhitien obstructed. When administered artificially 
ndrenuline restores the circnhitinn and prevents loss of 
Hniil thi’oiigh tlie walls of tlie capillaries by improving 
their tone. A ixdrobnlhar inj'ection of alimit 3 to 6 minims 
of a 1 in 1,000 solution within a few minutes i-ediices tho 
tension of 'a normal eye. In primarj- glaucoma it has a 
similar effect, ami in some instances its use has brought 
about a cure of tho disease. TIio use of adrenaiino must, 
however, he carefully safeguarded locally. It is a very 
powerful mydriatic, and hy dilating tho pujiil to tho maxi- 
mum might readily cause serious complications hy pushing 
the iris into the cortieo-iridie angle, thereby obstnicting 
.still fnrtber Ihe escape of fluids from tho eye. Its use, 
tliercfore, must always be ])rcceded by energetic in.sfilla- 
,tion of escriiie drops to keep the pupil contracted. Treat- 
ment bv adrenaline is, moi-covor, usually ineffective in very 
aontc cases of congestive glaueoina, it being powerless to 
relieve the seeomlnry complication duo to thrombosis at tho 
venous exits.® In these eirciinistances tho first thing to 
he done is to relievo tho stranglehold at tho’ corneo-ividic 
niu'Ie. Sleej) is Xatnrc’s euro for glaucoma, consequently 
the fii-st. indication in cvoij caso is to relieve pain— hy tho 
administration of morphine hypoclcmiically, tho continuous 
application of Iieat to tho eye’, free leeching of tho temple, 
and eseriiie instillations to keep the jnipil contracted. Tho 
general condition of tho patient also demands attention. 
At tho oiito't a calomel purge, followed, ia three houi-s, by 
an alkaline saline draught, is nlwaj-s helpful, and ought 
to ho ve|)catcd if necessary. Tho fact that intraocular 
prossuro can ho lowered hy producing a hyjicrtonic state 
I of the hlood has led Duko-KIdcr, following jivcvious 
i ohscrvcr.s, to recommend tho intravenous iiij'cctiou of 
50 e.cin. of a .supersaturated saline solution. The tension 
falls n.s a result of abstraction of fluid from the eye, hut, 
as tho treatment interferes with the whole fluid traffic 
of tho body, it must ho used with caution lest dangerous 
symptoms siipcrvono from too rapid a fall in the general 
blood pressure. 

In spile of those conservative moans of treatment, hoiv- 
evor ocular hypertension may persist, and in these circum- 
stances operation will ho required. The solo object of 
operation is to rodiico tho tension of the eye and to pre- 
vent the recurrence of hypertension. No operation can , 
1)0 said to be a cure for glaucoma, in spite of the fact 
that thousands of sufferers, who would othcraise havo 
been blind, havo boon enabled to retain their sight hy tho 
aid of one or oilier of the various operative procedures that 
have been introduced since von Graefe discovered tho value 
of iridectomy. 

Tho aim of every operation for glaucoma is to establish 
a filtering cicatrix which will act as a safety v'alvo through 
w’liich excess of fluid can escape from tho cyo during any 
recurrence of high tension. This immediate end may bo 
successfully attained, but nevertlieless . tlio disease may 
progress. Tlio treatment of tlio patient himself, therefore, 
must always ho considered to bo as necessary after, as it 
was before, operation, 

I am creatly indebted to Uio following books of general reference. 
Priestley Smith ; Pathology and Treatment oj (jiaucnr.ui, 1391. 

V, Morax : Olaucomc et Olanromatenx, 1921. Elliot; .-1 TreatUe 
on Ghtueama, 1922. Duke-Elder: Recent Adranccf in Ophthahno- 
3927. Thomas Lewis : The Blood-vessels 0 / the Human Rkin 
and their Rcspoixscs, 1927, 




794 MAY 12, 192S] CALMETTE’S STATISTICAL STUDY OF B.O.G. VACOINATrOH. 


Table IV.— MorLiifd/ from Tiiherculosis of Iiffnnts f:xposctl to an 
Itiftclioti, Iff Itelaiion to the Severity of the Disease in the Carrier 
oj Ifijection. 


r Tns nRmn 

LifsniCAL JOU»XA& 


Infants in Families witlx 
Infections Tuberculosis. 

Carriers of Infection. 

In tho 
Last Stage. 

Advanced. 

Sliuht. 

Kot 

KciH)rtcd. 

Infected 

23 

10 

7 

5 

1 

Kot infected 

13 

3 

1 

8 

1 

Total number of 




1 


infants 

, 36 

13 

8 

13 

2 

Deaths from tuber- 



i 

1 



cnLisis 

. 6 

4 

2 


— 

Percentage deaths of 






exposed to ri-k 

,16.7 

30.8 

25.0 

0 



The leader will recognize in this tahlo Dr. Catinetle’s 
percentages of 30.8 and 25, hnt ivhal, ho will ask, is 
the source of tho 78 infants upon which, according 
to Dr. Calmette, tho tahlo is based? Tho answer is that 
if one adds up all the figures in tho second column except 
the percentage, tho sum is 23 + 13 + 36 + 6 = 78; that is, 
we reach 78 by counting all tho children who survived 
twice and all those who died three times! It is not easv 
to understand how this mistake could have been made, 
because oven a person completely ignorant of Cicrinan 
and without a dictionary would surely wonder why thero 
were four categories of absolute figures, and would have 
noted that 6 is 16.7 per cent, of 36, not of,78. However 
this may bo, tho simple fact is that the percentage mortali- 
ties of 30.8 and 25 aro based rospcctivclj' upon 13 and 8 
observations. 

No further remarks upon Dr. Calmette’s treatment of 
literature seem needed. 1 pass now to tho contention that, 
in the present report, in addition to repeating errors in 
the citation of the literature. Dr. Calmette has introduced 
statistical errors of a novel kind. On page 11 of tho 
report there is a section headed “ Enfants vaceines dep'uis 
nioins d’un an au ler decemhro 1927.” Tho first para- 
graph of this section reads as follows (italics aro as in tho 
original) : 

“ Sur les 5.749 enfants qui figurent dans notro fictiier, 3.808 no 
sent vaccinds quo depuis nioins d'uno amnSo au 1" ddcombro 1927. 
A cetto date, on avait comptd parmi eux 118 dieis donl 34 par 
maladies presumdes luborculeuses. Lour mortalitd gdndralo (par 
toutes eauses do maladies) dtait done do 3.1 pour 100, alors qu’en 
Fiance la mortality gdnerale des non-vaeeinis, avee on sans contact 
tubcrculeux, est do 8.5 pour 100 n{s fivants. La mortalitc 
yeniralc dc clro a un an cst done dc plus dc moitid moindre chce 
les vacancs cn contact tubcrculeux quo choz Ics non vaccinis arte 
ou sans contact." 

Now the ratio of 8.5 per cent, is tho ordinary ineasuro 
of mortality m the first year of life; that is, it purports 
to tell us— and, .unless the fluctuations of natality or 
mortality from month to month and year to year arc very 
arge, it does eflect.vely tell us_what is the proportion of 
hve-horn children who, being exposed to risk of death 
for a uEole ye?r from birth, will actually die within that 
3 808 duldren in Dr. Calmette’s report 
aro definitely stated to have been vaccinated less than a 
year from the date of closing the observations. Therefore 
if the record of mortality extended from birth to tho first 
anniversary of birth it covered some part of tho first 
year before they had been vaccinated at all; if it only 
covered the period during which the infants beloiiRcd 
to tho vaccinated class it is not a record of tho mortality 
of tho whole of the first year of life, but only. of a part 
of that year. On either hypothesis tho ratio of the number 
of deatlis to tho number of children cannot be compared 
with the rate of mortality in tho first year of life. From 
a consideration of the details printed amontrst Dr 
Calmette’s doenments it would appear that tliiT second 
method was that adopted in compiling the data. Omitting 
three cases of death after the ago of 1 year it is found 
that no less than 38.26 per cent, of tho total deaths were 
months, and only 12.17 per cent, in the first 

tion of dea'ths the greatest propor- 

s in the first year occur in the first month of 


life. Thus in ICngland and Wales (1926) 45.38 per-cent, 
of tho total dentils under 1 year occurred in tho first 
month of life, and only 23.28 per cent, at ages over 
6 months, 'jho cxjilanation of Dr. Calmette’s figures is 
prcsumnhly that he is dealing with tho mortality, not from 
birth, hut from (on the average) an older age, hence tho 
largo proportion of deaths at older ages. An elementary 
mistake in the handling of statistics has been made, and 
a mistake lyhich would necessarily show a result favourablo 
to an;/ treatment. 

1 do not think that it is nccc.ssary to examine Dr. 
Cahnette’s statistical methods further; it seems to mo to 
bo proved that tho latest report, whero it differs from its 
predecessor, differs from it for tho worse, and that it 
cannot be regarded ns a serious contribution to scientifio 
literature at all. 

If tho question wore merely one of academic discussion 
it might well be left there — indeed, it might well never 
have been raised. 'J’o paraphra.so Mr. Shaw, Dr. Calmette’s 
excursion into statistics might properly havo been received 
with that silence which falls upon ordinarily good-natured 
people when a man of distinction offers, ns his contribution 
fo tho ili.scussioii of a matter ho has never studied, an 
absurd blunder. But it has been suggested that those who 
aro unable to accept these strange bibliographical and 
statistical methods aro indifferent to tho possible impor- 
tanco of tho subject in its practical applications. As a 
statistician I naturally attach valuo to tho statistical 
method ns an instrument of research. If a scientific man 
claims that ho has proved by somo other method than tho 
•statistical that such-or-snch a means of treatment is good, 

I am naturally not very ready to believe him ; hut I neither 
have nor claim tho right to impose my belief upon others. 
If Dr. Calmette had stated that, on experimental grounds, 
ho was satisfied that his method of vaccination was a valu- 
able nrophylactic, and had confined himself to tho kind of 
reasoning contained, for instance, in the first pages and 
the fifth and sixth sections of his report, 1 should not have 
been convinced because, infer alia, I do not understand 
how a livinn rnrriac-that is, something quiintitatively 

determinate-can bo a satisfactory means of therapeusis; 
but I should have felt that my knowledge of tho litoratuio 
and tcchniquo of modern immunologj' was so amatcunsli 
that it would have been an impertinence to bandy words 
with an investigator who has uevoted his life to such 
Kliidics But Dr. Calmette has not adopted this course; 
le 1, ns 'deliberately appealed to tho statistical method, and, 
'mv SmiTsion', his use of that method has been so 
gravely defective that no confidence c.an bo placed cithei 
+1 bis statistical inferences or in tho reliability of tho data 
which ho has assembled. Tho collection of data is at least 
as delicate a business as their analysis, and a writer who 
shows so littlo respect for logic in analysis is not like y to 
have been more circumspect in assembling data, for analysis. 
I'seo no hope of obtaining statistical data from Franco. 
Tf an niipeal is to bo made to statistical nietliods in other 
eoiiiitrieV wo should bo quito clear what conditions havo 
he fiiifillcd to give tho statistical court jurisdiction. 

‘ if wf confine ourselves to tho case of the incidence of 
fatal tuberculosis in the first years of life, and desire to 
whether a particular treatment applied at the 
l.ecTiniiiiic of life reduces tho risk of death, our first 
dilficulti'^ is tho smallness of tho material. 'The total 
aiiiicui ) istered deaths from all forms of tiiherculosis 

"raee Idef 1 year in England and Wales in 1926 was 
niilv'862 or 1 8 per cent, of tho whole number, 48,757, of 
dShs uglier i. and 1.24 per 1,000 of the total number o 
livo‘births, 694.563. Suppose, tben, wo were to Lake by lot 
pverv tenth reiiistered live birth and to divide tho sample 
T aav 7 OOOo“liv 0 births into two sets of 35,000 each, 
to’ treat ono moiety and leave the other as « 

Wo should expect, on the average, some deaths fioni 
tuberculosis in tho control senes, tho expectation being 
subject to an error of sampling- of approximately b.b. ir, 
then, in tho treated series tlicro wore 23 or fewer deatl s 
from tuberculosis, wo should rcasoniibly conclude that is 
was easier to believe that tho treatment had really beei 
beiiofieial than that a very improbably largo divergence naa 
arisen by tho luck of sainiding. Such a comparison, it tne 
conditions of random sampling had been strictly fulhliec, 



u, 1928] 


VITAL OAPAOITY IN HEART DISEASE. 


r Tnr.BnmsB . 7PK 
L MeDICaI. JoURNAt I Cv/ 


^vl)nkl lie iiei'foetly satisfactovv. Rat in actual ]iracticc llio 
larger tlie “ samjilo ” tlie less )iiol)aliIo is it that the cdu- 
<\\ti(ius will ho fulfilled, aud the ^lossiliility of controlling a 
Kam))le of the order, of 10 jicr cent, of the wliolo annual 
hirtiis is virtually an imiiossibilitv. Take a less ainbitious 
scheme, and suiiposo that in some town of moderate size, 
a town of some sixty or seventy thousand inhabitants, with 
an annual quota of, say, 1,000 births, the children could 
ho treated randomly — for example, every second child 
whoso birth was registered from January 1st in some 
year to be treated. Wo should expect on the average 
less than one registered death from tuberculosis in tho 
control SQO, and no strong presumption of advantage would 
he raised by a nil return from the treated series, taking 
onlv a year’s experience. 

Evidentl.v it was a sound instinct to .seek for a decision 
amongst tho class of material where a higher rate of mor- 
tality was to ho expected. That is tho significance of Kjer- 
I’etci'sen and Ostenfohl’s work. What can we conclude 
from their investigation as to the probable range of mor- 
tality in the first year of life of in-contacts? We can, of 
course, at once dismiss tho preposterous suggestions of rates 
of mortality of tho order of 25 per cent., even from all causes. 
Had such a rat.c really prevailed in tho population sampled 
by Kjer-Petersen and Ostonfeld, their “ expectation ” 
Mould luvvo been 61 deaths n-ith a standard deviation of 
6.77. Actually the.v obsei vcd 19, and the odds against such 
a deviation as 42 arc of the order of a thousand millions 
to one. If, hoM'cvor, one might postulate a into of mor- 
tality from tuberculosis in tho first year of life even of the 
order of S to 10 per cent., .the comjiarisnn of sainjilcs of 
order 500 Mould not bo waste of time. We should expect 


in our control 500 from 25 to 50 deaths, and if the treated 
sample returned, say, only some 15 to 30 or fewer deaths, 
n case would have been made out which would he rather 
strong. Whether it would bo ]n-actically ]mssihle to use 
this method, hero or in America, it is liard to say. The 
number of instances of births in families M-ith one or more 
cases of open tuberculosis which come to tho notice of the 
public healthy authorities within any one area and Mithin 
a limited period of time is small, and the difficulty of strict 
random sampling is great. We arc concerned,' not with 
guinea-pigs, but M-ith human beings, and it is not easy to 
induce those ivho have the medical cliargc of human beings 
to administer to any of them a treatment which they regard 
ns worthless, or to abstain from administering to anv of 
them a treatment which they regard as valuable. None of 
us can dramatize thi.s coii/lirf n-ith tho .art of Mr. Sinclair 
Lcivis in 'Morf ill Armti-smifh , hut all of us have, to a 
greater or less degree, jjarticipated in it. I do not expect 
that tho v.aliie of Ji.C.G. will he determined on these lines, 
liiko most methods of treatment, its use or neglect M'ill he 
determined by psychological considorntions. But to the 
still small, but increasing, number of medical men uho 
attach importance- to statistical accuracy it is of some 
moment that methodological errors having the .sanction of 
the name of a distinguished inve.stigator .should at once 
be pointed out. That is my rea.son for writing this article. 

llErEr.EXCES. 

> Ann. lie Vlnstitut Vatltnt, xlii, 1928, 1. = Ibiil., xli, 1927, 201. 

'llrilirh }!et>ieol Janinol, 1927, i. 8!5. * Ibid.. 1928, i, 261 » Ibid IS’I 

i. 8». Mbid., 1927, i, 1082. i Iliid.. 1928, i, 620, ^ VpM-rifl f„r targrr. 
Marcli 31=1, 1927 (.Vo. 33), iip. 257-261. • Vent. .Vfd. Wnch., list J., 1916, 

1310. ■' lleilr. 7 . Klin. d. Tnlier., x\, 1911, £0. 


YITAI; CAPACITY IN HEART DISEASE.'- 

BY 

H. WALLACE JONES, M.Sc., M.D., M.R.C.P., 

SETtlOR nOKOTURY ASSISTANT PIIYSICIAK^ LIVERPOOL ROYAL INFIRMARY. 
(From Uio UcatV Dtpwlnicnl ol llic Ht>yal Iiinimary.) 

It lias liocn .the aim of iuvesUgatovs for many ycar'> to 
(Icviso sorao bimple tost to estimate tlio functional tapacity 
of the heart, apart from tho subjective sc^sation^ of the 
patient. Slaiiy tests have been introclucccl from time to 
^V'ii I* ^ purpose, based as a rule ou the response 
of the heart to some form of exercise — tiie simplest cousist- 
ing of taking the pulse rate before a fixed amount of 
exercise, immediately after the exorcise lias ended, and 
aftci an interval of a feiv minutes. An exercise tob-riince 
largely been m.-ide U'.e of by the 
ilinistrv cf Pensions for purposes of ass^essmpnt of carrliac 
disabiJitiop. 


A tost Uhc tills one, based on changes in tho pulse rate, 
open to tlic objection tlmt it is more a inea.-^ure 
of tlio excitability of the sino-auncular node than an iiuli- 
cation of the capacity of the Ueavt, aud doneuds ou uiau\ 
other factors quite iudepoiident of the cardiac roserre 
power. After vital capacity had been introcluood us a 
measure of tho extent and pi-ogro.<,s of certain lung eon- 
(Utioiis this test was applied to patients suffering from 
cardiac disabilities by several observers (see reference.s 
1 to 4), M- 1.0 foimd that the .vital eanaeitv u-as ren- 
much helow normal standard when anv serious' cardiac 
condition Mas present; mIuIo Pe.abody ' and WcntM-ortlP 
.-.No drew attention to the fact that there was a definite 
lelationship between diminution in tho vital capacity and 
a tendency to dyspnoea on exei-tion * ’ 

Before considering the changes M-hieh orenr in eardi.ac 
patients It IS advisable to consider wliat i.s meant by vital 
capacity. Hutchinson^ many years ago divided the volume 
of air in the kings into the following divisions : 

O'r— ,vir winch cannot be expelled and is left j,, 

nema!'«ph-a"ior''^ kf ^^0-1 at l,,c end of 

respifafrom""^''^”^ “>‘=P*red or expired during normal 

insp&m ke inspired after normal 


• Based on a p.ipcr read before the' 


Liverpool -Mcdicil Institution. 


S. 1 ltd/ cnpnaf.v—Aic sum of llio reserve air, lid.l! air. and 
complcmcnlaiy an— that is. the greatest amount of air which can 
, uc* oxpoUed tiilcv U\e deepest pos-sibte iusplratiou. 

In this investigation a .simple'wnter s/iii-omcler (Eig. 1) 
has hecn n,scd, gradnated in cnhic centimetrEs and balanecd 
so Unit no effort is required to rai.se the cylinder. A barge 
miniber of glass moiith))ieccs ircie inovidctl, ,so that they 
could he readily disinfected hc- 
tween each patient without loss 
of time. 

It is always advisable to ex- 
plain fully the ivorking of the 
machine before aetnally taking 
the lueasnromont, as’ it is 
neeessan- to get the jiatient’s 
M-hole-hearted to - operation to 
obtain an accurate result.' Each 
patient M-as given three attempts, 
the Iiigiiest being taken as the 
vital eapacity. In taking the 
reading, if there is any tendency 
to expire through the’ nose this 
.should he closed hv pinching 
during expiration. When patients 
Mere not confined to bed the 
-record M'as always taken stand- 
ing, aud generally in their 
Oldinary clothes, - With regard 
to the jintients who Mere con- 
fined to bed they wore all able 
to sit lip in bed M-hen taking 
t le leading, .so that it was not necessary to correct 
tlie reading for the 5 per cent, diminution in the vital , 
capacity M-Jiicli -has been shoM'ii by Christie and Beams* 
and Rabnoiritclf to occur when the reading is taken in tho 
iccuuihent position. Oiviiig to tho variability of the vital 
caitacilv aceordiiig to the height, sex. age, and race of tho 
iiidividiial concerned, the simjile reading of the mimber 
of riihic centimetres expired gives little indication of tho 
deviation from the normal, unless the reading is expressed 
in percentages of the , standard vital capacity for that 
individnal. 

In this investigation tho vital ca])aeitv is expressed as 
percentages of the standard vital capacity for that parti- 
cular patient. It would be out of tho scope of this paper 
to enter into all the different methods for calculating the 



Fig. 1. — ^W’nter spiromeleT. 




796 MAT 12, 1928] 


VITAti CAPACITY IN HEAPT DISEASE, 


t Tnr Hamw 
Mfdicai. Jocn'fAL 


otandaid vital capacity ; probably tbo most accurate is that 
calculated on tlio surface area of the body ns estimated by 
the method of Du Bois,® whore tho vital capacity is two 
and a half times tho surface area in men and twice tho 
surface area in women. This is, however, .a somewhat 
lengthy proceeding, and West” has shown that for all 
practical purposes tho standard vital capacity in cubic 
centimetres can be determined bj’ midtipl}’ing tho standing 
height of tho patient in centimetres by twenty-five in men 
and twenty in women. Ago also modifies tho reading con- 
siderably, but it has been shown by tho work of Bowen 
and Platt” that this alteration with ago onlj’ takes place 
during youth and after SO years of ago. As tho cases in 
this series, with one or two exceptions in tho high tension 
group, fell between tho ages of 20 and 50, it was felt that 
the variation duo to this factor woidd not materially alter 
the results. 

Before investigating cardiac cases it was thought desir- 
able to take a series of normal men and women and sco 
what variations took place between tho actual vital capacity 
as tested by tbo spirometer and tho calculated standard 
vital capacity of tho individual by means of West’s 
formula. Fifty men, mostly medical students, and fifty 
women, chiefly nurses with a few students, were tested in 
this way. 

ntal Capacit;/ 0 / Fi/tp ^'ormal Jfalc.i. 

An csamin.itiou of Fig. 2 chows thnt there nrc considcrablo 
variations among healthy individuals, and readings of 20 to 30 per 

VITAL CAPACITV normal MALES 50 

CCS 

6.000 

5.500. 

5.000 

4.500 

4.000 

5.500. 

3,000, 

2.500 

2.000 


ponmal V C 


sfl.s; 4: s; 61 T a' 9 ' lo' ir eft 1. j. 3. 4 

,2-rrShowlng tho vital capacity ot ntty normal males Tho 
TcrUcal line indica^a^ the vital capacity in cubic centimetres, tho 
ranife°i( Wr, “O'* obliouo line tho Etandoril vital 
ea<>h height 03 calculated by means of tho formula' 
Each individual reading Is shown ns a dot ‘ormuia. 

tent, above or below normal arc quito common without any 
apparent eyidenco in the health of tho individual. In epito of 
these individual variations, however, tho average of tho* group 

riorpttnf 

ntal Capacity of Fifty Normal Female. (Fig. 3 ) 

The variations in this group are if anything gre.-ftcr than in 
the male group, and the number of casL in^whieh tho actua" 


VITAL CAPACITV NORMAL FEMALES .SO. 


CCS. 

6.500. 
5,000. 
■4,500 

4.000 

5.500. 

3.000 

2.500. 
24300 


:rmNorma! VC. 


■sn P 2- 3- 4- 5' 6- 7' S’ 9" 10" ir Gl> 

Fio. 3.— Showing tho vital capacity ot fifty normal females, 

nnmer'Sfs'''"Th^ mneh below the calculated normal arc more 
slightly hew'^norm^S"*^ per cent.— 



I'lo. 4,— Curve to show tho effect ot organic cardiac disease on 

vital cajiacity. 

normal individiiaU and is alnwn by tho broken lino. The curve 
of tho organic cardiac cases is taken from 50 cases and is 
indicated by tho continuous lino. 

Itcadings oMained in ihc Various Groups 0/ Organic 
Cardiac Cases. 

Gaocr I: The Arcraye Vital Capacity of all Oryanic Cardiac 

Cates. Most of Ihc cases in this group were nblo to nttend tho 

heart department, and only in comparatively few cases were tbo 
patients confined to bed. Tho cases examined numbered 54; tho 
nverago vital capacity was 53 per cent. 

Gnocp II : The Vital Capacity of Biyh Blood. Pressure Cascs.-r 
All over 160 mm. systolic pressure, most of them over 200 mm. 
Number of cases 13; average vital capacity 55 per cent. 

Group ID: The Vital Capacity of Mitral Stenosis Cases.— 
Thrift cascs are subdivided into two groups— Ihoso with normal 
riiyihm and those with auricular fibrillation. Tho nverago vital 
c-apneity for tho whole group was 47 per cent. (K CMCs); for -tho 
noS rhythm group 56 per cent. (12 cases); for tfio auricular 
fibrillation group 40 per cent. (13 cascs). 

Group IV 1 The Vital Capacity of Cascs of Aortic Ilcyuryita- 
<ion.— Tho number of cascs in this group was 10; tho avorago 
vital capacity 59 per cent. 

Group V ; The Vital Capacity of Cases of Auricular Fibrillation 

r-indj There were 16 cascs in this group, with an 

Irlgo vUal capacity of 45 per cent. 

Troop VI: The Vital Capacity of Cases showiny Abnormalities 
* It rirctro-cardioyraphic Record. — (1) Left vcntriclo pre- 
pondcrating-averago vital capacity 50 per cent. (13 cases). (2) 
Ttml.l vcntriclo preponderating— .avorago vital capacity 51 per cent, 
re .mscs) (3) Inverted " T " (ex. Lead III only)-avcrago vital 
canacitv M per cent. (7 cascs). (4) Q R S abnormal— average vital 
capacity 53 per cent. (3 cascs). (5) Auricular fibrillation— averago 
yitnl capacity 42 per cent. (14 cascs). 

Tlieso figures show that tbo vit.al capacity is_ markedly 
diminished when any organic cardiac condition is present. 
In certain conditions, especially in tho mitral stenosis 
group with auricular fibrillation, this diminution is very 
marked wliilo in tho high tension cases and in aortlo 
disease it is not relatively so marked. In the cases showing 
changes in tho electro-cardiographic record, apart from tbo 
low reading in tho fibrillation group which has already been 
noted there is no special change in tho averago reading 
of any of tbeso particular groups. A series of cases were 
kept under observation for a considerable time to boo if 
any chango took place in tho vital capacity with varying 
states of compensation in tho same patient. In two of 
tbeso cases auricular fibrillation supervened during tbo 
period of observation, and we had tho good fortune to 
obtain records of tho cases while the heart was heating 
with its normal rhythm and subsequently records of tho 
samo patient when auricular 'fibrillation was present. 




MW 12, 1028] 


TlTAEi CAPACITr IN HEART DISEASE. 


t int Bnmn 

Mr.DiCAD Jox7srJU> 


797 


Tlio fiisl of tlicsc cases was a man, nRcd 44, Burtering from mitral 
stenosis willi a sliglil mitral leak. I'ig. 5 sliows llio licarf rale 
and vital capacity of lliis patient for a period of two monllis. Tho 



chart shows clearly the drop in tho ratal capacity which occurred 
with tho onset of auricular fibrillation and the subsequent improve- 
ment which look place on full doses of digitalis. (I am indebted 
to Dr, Xnce for this chart and that shown in Fig. 6.) 

The -second ease was that of a woman aged 26. also with mitral 
stenosis. Fig. 6 shows tho ctfect of rest and digitalis on the heart 
rate and vital capacity when tho heart was boating with a normal 
rhythm, tho pulse rate falling steadily, and the vital capacity 
rising. The second part of the chart 'show.s tho record obtained 



from the same patient when she was readmitted two months later 
with auricular flutter, which soon became auricular fibrillation. 
She was extremely^ distressed on admission, and the vital capacity 
was not taken until she had improved considerably, but even then 
it was very much below the lowest figure wdicu normal rhythm was 
present, and though improvement took place under digitalis it never 
subsequently reachcdjt^previous figure. ' 

Another intercstiiig 'case' of this ccries was that of a bealtliy 
man. in whom auricular fibrillation had been accidentally induced 
■by means of an electric shock,* His heart was turned back to its 
normal rhythm by quinidine, but relapsed into fibrillation and 
again had to bo turned back by. quinidine. IVo took records of 
his vital capacity during the whole of the period of transition 
from one rhythm to the other, and' at no time did the. change 
in the vital capacity between the period of normal rhythm' aiid 
the periods of fibrillation exceed 100 c.cm.— a relatively terv sligl,t 
change. * ‘ , 

A series of cases of disorderly action of tlie heart, or the 
'' offovt syndrome,” wore also investigated. This group 


is of special interest in view of tho marked dy.spnoc.u on 
exertion which, as a rule, is one of the characteristic 
features of this disease. 

All the casc.s iuvestigated wero very well marked examples 
of- this condition, ■■ and . wp.fe mostly of men .in receipt 
of a pension for this disability as a rc.snit of service in the 
war. The cases investigated numbered 9, tho average vital 
capneity being 85' per cent,; the lowest individual reading 
was 75 per cent. 

Those results in eases with disorderly action of tho heart 
aro in agreement with those published by Levine and 
Wilson” • in* this 'eoniitry and by White'- and Adams and 
Sturgis” in' America. The very slight diminution in the 
vital capacity of this group is very curious in view of the 
marked dy.s]>noca which all these jiaticnts had, and show.s 
that the dyspnoea which is associated with functional 
disease of .the heart is very different in origin from that 
duo to organic cardiac disease. Leaving out this group, 
winch is in a class by itself and depends on so many factors 
dii'tsido the cardi.se condition, it is ajiparcnt tliat the vital 
capacity is an indication of tho amount of dy.spnoca in 
cardiac 'disease, and though many- question that it pictures 
tho cardiac condition more clearly than , records of tho 
blood pressure and pulse- rate, and in support emphasize 
those cases where the reading does not ch'auge i-apidly with 
varying states of compensation, yet there is no doubt that 
it is a valuahle mimerical expi'essibn. of tho amount of 
dyspnoea. 

If one takes all the cases together they can, broadly 
speaking, be divided roughly into the following four classes, 
according to the amount of dyspnoea : 

1. V.C. above 60 per cent. — dyspnoea not very marked. 

2. A'.C. between 60 and 40 per cent.— moderate amount of 

dyspnoea. 

3. V.C. below 40 per cent. — considerable amount of dyspnoea. 

4. 'V.C. below 30 per cent. — ^palicnl usually confined to bed with 

ortliopnoca. 

As in normal persons, however, a * considerable amount 
of individual variation takes place. 

Many views have been expressed as to bow this diminu- 
tion in the vital capacity in cardiac conditions is brought 
about. Sicbeck’'* believes that it is duo to engorgement of 
the capillaries of the lung alveoli, causing distension of 
the alveolar walls with increase in the fibrous tissue. 
Drinker, Peabody, and Bliimgart'^ have 'investigated tho 
effect of pulmonary congestion on the ventilation of the 
lungs in cats, and have shown that pulmonary congestion 
produced by compressing the pulmonary veins .at their 
entrance into the left auricle caused a marked diminution 
in the air passing tiuongli the lungs, and that recovery 
soon occurred when .the pressure was released; but that 
if this compression was maiulained for. sufficient time to 
cause exudate into the lungs a more or less ponnaiient 
diminution in the air passing through occurred. The}- 
believe that vasmdar congestion can act in two ways; (1) 
by encroaching upon the alveolar spaces by the congestion 
limiting their size: (2) by diminishing tho'elasticity of tho 
lungs owing to the congestion^ .like erectile tissue. 

Meakins and Davies,'' in. summing up the evidence, 
expr^s the opinion that the decrease in cases of organic 
cardiac disease is probably due to some structural change 
in the lungs. In favour of such a change taking place is 
tho slow alteration in the reading with changes in the 
degree of compensation, and also the fact that the diminu- 
tion is greatest in cases of mitral stenosis, especially when 
associated with auricular fibrillation, a lesion which is 
extremely likely to produce permanent changes. -in the 
lungs. 

Ill conclusion, I should like to emphasize the follow*ing 
lioints : 

1. The vital capacity is a valuahle numerical expression 
of the amount of dyspnoea in organic* cardiac cases. 

■ 2. If ;is a' useful indication as to the general progress of 
treatment, though the changes in the reading only follow 
slowly the'varying degrees of compensation of the heart. 

3. Thp. vital capacity is* most diminished in casc.s of 
mitral stenosis, especially when associated with auricular 
fibrillation. .. ; ....... .... , 


798 MAT I'z,- 1928] oraij administration- op panc reatic preparations. 


- r Tiir J3RrTi*ii . 
L McDtciz. Jomxit 


4 . The reading is no indication of tlio amount of 
dyspnoea in disorderly action of tlio licui't or functional 
disease. 

5 . It is of littlo valiio in tlio early diagnosis of cardiao 
conditionSj owing to tlio variability of iiornial standards. 


R, 


* Pratt, J. II. : /Imcr. Journ, ^cd. 5c!., 1922, clxiv, 813. = OpK/, 
B. : Journ. /Iwicr. }lcU. Assoc., 1922, Ixxviii, 1685, ^ 
and ’Wentworth, J. A.: Arc7t, /ntrrji. Med., 1917, xv, MO. ■* Zistin, 
T. A.: Ibid., 1925, .xxv, 259. * llutchinfion, John: Mrd.^Chir, Trnnt. 

(Lond.), 1846, xxix, 137. « Christie, C. D., and Bcnm-*, A. J. : Arch. 

Intern. Med., 1922, xxx, 34. ^ Rabnowitch, I. M. : Ihld., 1923, xxxl, 910. 
» Du Bois, D., and E. F. : Ibid., 1916, xvii, 853. » We^t, H. F. : Ibid., 
1920, XXV, 205. Bowen, B. D., and Platt, D. L. : Ibid., 1923, .xxxl. 579. 
^‘Levine, S, A., and Wilson, F. N. : Heart, 1919, vii, 63. *- White, 
P. D. : Amer. Jouru. Med. Set., 1920, cllx, 856. Adam?, F. 1)., and 
Sturgis, 0, 0. : Ibid., 1919, clviii, 816. Sicbcch, R. : DettL Arch, f. 
Klin. Med.-, 1910. C, 204 *3 Drinltcr, 0. K., Pcabo<ly, F. \V., nnd 
Blunigart, II. L. : Arch. Intern. Med., 1922, xxw, 77. JIcnKln®, J. O., 
and Davies, II. W. : Rcspjrator»/ /’unction Di Hisease. 


oral AD3IINISTRATION OF PANCREATIC ANJ> 
OTHER PREPARATIONS IN THE TREAT- 
MENT OF DIABETES. 

ET 

C. B. S. FULLER, M.C., M.A., AI.D.Caktati., M.R.C.P., 

wisaiESTm. 

(From the Medical Unit Laboratories, St. Thomaj-s Hospital, Londnn.) 


The discovery of insulin entirely clmnged tlio fonner more 
or less hopeless outlook in cases of diabetes mellilus. It 
has enabled diabetic patients, ivbo under previous condi- 
tions would have boon dead before now, to load nctivo 
and useful lives in comparativo good boaltb. Such emer- 
gencies as operations and coma arising in the diabetic 
patient aro no longer rogai-dcd with tbo same dread ns 
fcinierly, for, in the majority of cases, both can now bo 
dealt with successfully. 

_ Tbo mode of action of insulin is still a matter of con- 
jGcture, but it apparently helps to store carbobydr.atc in 
tbo liver and other tissues; at tbo same time it plays a 
part in the combustion of sugar. In tbo normal individual 
tbero IS found an almost constant difforcnco between tbo 
arterial and venous blood sugar content, tbo latter being 
less by approximately 0.04 per cent. In oases of diabetes 
this difference is reduced or disappears, showing an in- 
ability on tbo part of tbo tissues to deal adcqu.atcly with 
supplies of glucose. Similarly in diabetes tbo lengthening 
of the normal blood sugar curve aftdr tbo ingestion of 
carbohydrate shows that tbo liver is unable to store 
glj-cogeii from the portal circulation as in the normal 
individual . After adequate treatnmiit with insulin and 
suitable diet both these abnormalities show a rctnrii 
towards the normal. 

1 Ji* J"®®" definitely that insulin is destroyed 

both by tbo gastric and the intestinal juice; wbetb'er given 
111 acid or alkaline media, or in alcohol or glycerin it 
•no appreciable effect on the blood sugai^or carbobW^n 
metabolism. Oral administration on^ a full or Sy 
stomach, appears to make no difference; no absorption S 
active substance takes place. It was hoped at firk that 
some way could be found of giving insulin by tbo moitb 
to obviate- the unpleasantness of frequent liypodcrbiic in 
jcctions, but so far these attempts have not been attenHori 

In this respect insulin seems to bear a close resemblancB 
to the extract of the posterior, lobe of the pituitary gland 
. which on ■ hypodermic injection has a - definite effect' in 
raising blood pressure and causing all unstriped miisclo in 
■the body to contract, whereas after oral administration' it 
has no demonstrablo effect. • . ' . 

: Thyroid extract, when its value ‘was first discovered in 
■the treatment’ of myxoodema,_ was given' by injection' b'u't 
later- it was, found, that- it could equally well be ’given 
orally, as it 'was -absorbed and' exerted its effect in 'the 

uBulm a fresh impetus was given to tbo use of various 


pancreatic and otlier . extracts for oral ndmini.stratian in 
tbo cases of dialiotos mcliitus. 

Tbo continued bypodcrinio injections in tbo case of 
patients on insulin- troatmont soon bocomo irksome and 
may give rise to considcrnblo trouble tbroiigb sepsis if tlio 
patient 1)0 not careful with bis cleansing of skin and 
syringe. In tlio case of tbo hospital class of patient tlio 
oxpciiso of tbo insulin very often gives rise to difficulty, 
tboiigb now, since tbo considcrablo decrease in price, this 
is not of so iiiucb importance as formerly. 

These points liaio made it seem worth while to iiivcsti- 
gato somo of tbo many oral preparations wbicb aro at 
present on tbo market for use in tbo treatment of diabetes 
mcliitus. Tbo claims made for tbeso prcpar.atioiis aro 
many nnd varied. In somo cases tbo pamphlets oven go so 
far ns to cliiiin euros on an ordinary mixed diet. For 
exniiiiilo, tbo synthetic insulin tablets A and B wore said 
to pi’oduco n euro in a fortnight whilst the ])nticiit lyas on 
an ordinary diet. A similar claim was made for tbo diatana 
mixtiiro. , • 

Parke Davis’s pancreatic extract (Alnckcnzio Wallis) is 
claimed to bo of valiio in somo cases of diabetes; in from 
two to tbreo weeks on a suitable diet tbo extract is said 
to- cntiso’ a reduction in blood and nrino sugar and an 
improvement in the patient’s clinical condition. Messrs. 
Parko Davis stato that if no imiirovomont is foiiiul in 
fiom two to tbreo weeks tbo troatmont should bo dis- 
continued. Tbo improvemont alleged in somo eases might 
quite well bo duo to tbo strict dieting, and, not to the 
pancreatic extract at all. They state that they do not aim 
at reducing the blood sugar to tbo region of 0.1 per cent., 
but they endeavour to rcdiico the blood sugar, to the region 
of 0.15 to 0.20 per cent., nnd to docreaso tbo sugar in the 
ui’in’c. No rcforcnco is made to tbo effect on tlio kctoiio 
bodies, ivbicb are in many respects of moio i.mpoitanco.m 
estimating tbo patient’s condition than tbo, amount of 

Carnrick, in tbeir . litoratnro relating . to, .tlio 
nnncreatic extract put on the market by tbcin,, give a 
grnnli showing the blood sugar and nnne sugar in a case 
Kc-!trd on llicir preparation. In. this case the- sugai , dis- 
oirpfl from the urine and the blood sugar fell to normal 
n fmv d’lYs Tlioy stato, bowever, thnt the patient u’os 
;:L«fo»;)'rc.iln'r/?ibdict:.prcs«mably’a^ 

L bo started .taking the 'pancreatic extract, so that the fall 
i.lnnil ami nrino sugar may have been duo to tbo 
"Ifrirtwl diet' Indeed, in tbo light of my observations 

OccoriS Wor) there is little doubt that tbo diet was tbo 

‘”’tSbc.’''point*‘’^''Wcb must bo considered ' is tiio , fact 
that d ibotM is- well known to vary from tim'o to time, 
rnid that temporary improvement may occur apparently 

"TS" claims -as- to tbo ■exact' motbod of action of 
nncroatic preparations for oral administration aro made 
F’ + m voiulors. In most, cases those claims aro .ratlmr 
and o-cnerally stato or infer that tbo actiyo coni- 
vaguo, . . . - >piicsd assertions iinist obviously, bo wrong, 
poiient j(,st,.oycd rapidly in tbo stomach and intestine, 
ir/r l ow ver posliblo t\iat tbero may bo some other snb- 
not insulin, present in .those .preparations wbicb, 
ndniiiiisterod orally, may bo absorbed and Etimnlate 
^om^S"^ wbicb 'controls carbol.ydrato mctabolisn. 

■"*Tt'*bns'^bccii found experimentally in dogs that if tbo 
‘ ■ nc "lio completely removed, injections of insulin ndl 
Fidv T-cc,i Uio 5 “live for a short period. If, bowever, 
a vei-v sinall portion of tbo pancreas bo loft, insiibn ni^jec- 
tions^vill keep tbo dog alive for an indofimto period. Ibi 
nn'ints to tbo fact that tbo pancreas .may secreto 
vnmn nthpr internal bormono besides insulin, and it is con- 
ceivable that this substance, ' whatever it "Sd 

bo present in the oral preparations 
from tbo alinieiiUiT tract wd.on 
If tills' were’ so it might benefit cases .of 

treated with these . preparations even tbougb, of corns , 
they wore iiot absorbing any of tbo insulin 
preparations. All kinds of tlieorics could bo formed as 
the typo and mode of action of this pancreatic sccrotio , 
but as its presence is a pure bj’potbcsis, conjectures as o 


MAY 12, 1928] 


OEAI. ADJiraiSTKATION OP PANCREATIC PREPARATIONS, 


.r Tut Bnmsn . 700 

Ljlrujcja. JoCBSii. t \}sj 


Woik' !\utl silo, of action seem latlior fnr-fotclied. As several 
eases wliich have been under luy care seem to sbon- that 
this substance, if jircsent, is not nt any rate absorbed in 
.sufficient q\iantity to be observable clinically, tbc question 
becomes even less worlby of consideration. 

Insulin .seems to bo rendered inert very rapidly by gastric 
and intestinal juices, but aleoliolic extract of insulin has 
been found to produce a slight effect on the blood sugar 
n-ben given by the mouth, and this is in-esumed to bo due to 
the rapid absorption of part of tbo in.sulin vith tbo alcohol 
before tbo gastric .secretion has bad time to destroy it. 
From the i)ractical point of view this method is of little 
value, as the percentage absorbed is too small to make it 
a satisfactory proposition from the economic standpoint. 

It is claimed for most of the pancreatic extracts that they 
increase the percentage of the food absorbed during <ligos- 
tion. If this be so it seems to be a disadvantage rather 
than an advantage, bec.an.se the f.ault in di.abetes lies not 
in the absorption, but in tbo ntjlization of the food after I 
absorption. If wo increase tbo absorption we increase the 
amount of materials with which the body has to deal, 
thereby tiirowing a greater strain on the rarboh 3 'drato 
metabolism. It is well known that it is exceedingly difficult 
to get di.abotic jiatients to adhere for an\- length of time 
to a very rigid diet, and this would increase tho difficulty'; 
at tbo same time, any action of this kind would tend to 
diminish tho bulk of* tbc faecal matter, which is a .dis- 
advantage. » 

It is possible that these pancreatic extracts given by the 
mouth may stimulate some internal secretion other than 
insulin which aids in tho utilization of carbohydrate within 
the body, and if this is the ease the effect would bo reflected 
in the blood sugar estimations and in tho general condition 
of 'the patient. On these grounds it was determined to 
give these preparations a trial under standard conditions 
to see if they did produce any alteration in the pationt’s 
condition. 

Some difficulty was found in finding suitable patients 
on whom to' test these preparations, ns an endeavour was 
made to got some mild and some moderately .severe eases. 
Imfortnnatoly some of tho latter, whilst tliey weio being 
standardized on a comparatively low diet, showed symptoms 
of the onset of diabetic ‘coma’, and bad to bo placed on 
ipsnlin to prevent their condition getting worse. This 1ms 
somewhat reduced the uumher of eases treated on these 
preparations, but the evidence of those cases in ivbich tbo 
tieatnieut was carried through is cxtrcniclv constant. 

In carrying out tiio investigations eacli patient was 
placed on a moderately low diet— say, 980 or 1,050 calorics 
in most cases. The twcnty'-fonr-bourly collection of urine 
was examined daily, tbc total sugar and acetone being 
estimated; after the excretion of sugar bad been constant 
in amount for several days the oral jircjiarations were 
administered for periods of a week to a fortnight, con- 
trolled by daily^ estimations. In some c.ases preparations 
containing pulvis cretac or pulvis ciniiamomi were made 
similar to the real preparations, and these were adminis- 
tered without tlie patient knowing of the substitution. 
This was done after the real preparations bad been adminis- 
tered over a period of several days in order to ride out any 
psychical factor which might be influencing the results. 
In other cases sugar tolerance curves were don© on tbo 
blood, flr.st of all without and then following a largo dose 
of one of the preparations. The sugar estimations on tho 
urines nere done by Bertrand's method, and the acetone 
estimations by acid distillation method, whilst tbo blood 
sugars were estimated by MacLoan’s method. 

The follon ing case is ty'pical of a number in which the 
various preparations were emploved. Details of these cases 
are unavoidably omitted owing to lack of space. The 
festdts were similar in all tho cases. 


eso a.flmitM to hospital on Octol 

Ktli, 1923. All Ins family had been hcaltliv. Tlie patient h 
had mumps, diplitheria mcasle-s, and wlmopii.g-cough as 
child. He nas rejected for the armv owing to his eyesight a 
varicose veins Five years ago, when wofking in 'Canada, 
noticed that he always felt Incd. was thiirtv, and had a nas 
His doctor told him he liad diabetes, a 
gave him a diet, to which he kept more or less for three yea 
not dwted. In August, 1923, he had 
rcliirn of his original symptoms. In. addiliin he lost 


weight, and had numbness .and pains in Iho legs and marked 
iiungcr. On admission no definite physical signs \vcre found. 
Tho ttrino was acid, specific gravity 1030, sugar and acetone 
present. 

He was first placed on a diet equivalent to 1,050 calories, and 
then star%'ed, and worked up gradually to a diet consisting of 
51 grams of carbohydrate, 61 grams of protein, and 53 grams of 
fat, wi(h a total calorific value of 980. On November 22nd, 1923, 
lio started to lake 5 capsxiles of Carnrick^s internal secretion of 
pancreas C three timed a day before meals. On December 4th 
lie started taking 10 capsules three times a day, and two days 
later 20 capsules three times a day. On December 11th the 
patient commenced to take 5 imitation capsules, containing pulvis 
cretac, three Uircs a day, and on December 14th he was given 
10 units of insulin twice* daily, his diet being altered to carbo- 
hydrates 40 grams, protein 56 grams, fat 164 grams. 

The patient felt weak when on the low diet, but said he felt 
much stronger when he started on the capsules. When taking 
the larger numb?r of capsules daily he did not feci so well, and 
compiamed a lot of flatulence, but he said that he felt very well 
indeed while taking the capsules of pulvis cretae. Hi? weight 
fell during starvation, but just before starting the insulin In's 
weight was 8 st. 5 Ib.^ the same as on admission. 

Tho patient was discharged from hospital on January 5th, 1924. 


Table shotptnp Hreparntion piren, Blond Supnr Concentration^ and 
Amoimt^of Sugar I’^xcretcd, 


Date. 

Preparation Given. 

Blood 
Sugar 
per cent. 

Sugar 
E-vereted 
per Day 
in Grams. 

1923. 



11.2 


21 


0.235 

8,0 


22 

5 Carnrick’s capsules t.d.s. 

0.245 

3S.0 


23 

0.255 

48.8 


24 


0.262 

40.0 


25 


0.262 

47A 


26 


0.262 

55.0 


27 

. « 

0.260 

•55.5 


28 

* ». 

0.260 

56.8 


29 

*. .. 

0.258 

34,5 


.30 

. t. .. 

0.2S5 

32.0 

Dec. 

1 

.. .. .. 

0.253 

41.0 

7. 


0.250 

42.0 


3 

10 Camrick’s capsules t.d.s. 

0.245 

43.0 


4 

0.210 

«.o 


5 

20 Carnrick’s capsnles t.d.s. 

O.i'65 

62.0 


6 

0.287 

Jl.O 


7 

0.295 

63.0 


8 

.. j. ♦ 

0.212 

£0.0 


9 


0.216 

41.8 


10 

5 capsules chalk powder t.d.s. 

0.227 

39.S 


11 

0.236 

44 8 


22 

0 256 

26.0 


13 

«• >. .« 

0228 

62.5 


14 

Insulin given 

0.125 

72.0 


15 

0,157 . 

17.0 

" 

25 

M 

0.162 

7.5 


TIourhj Blood Sugar Bsllmalions. 


Time. 

Nov. 2lst 1923. 
Diet Only. 

Dec. 3ra. 1923. 

15 Carnrick's 
Capsules per Day. 

Dec. 9:h, 1923, 

60 Carnrick’s 
Capsules i>er Day. 

9 a,m 

0.222 

0 241 

0.271 

10 „ 

0.207 

0.302 

0.218 

11 

0.221 

0.266 

0.244 

12 

0.235 

0.216 

0.227 

1 p,m 

0.252 

0229 

0.2-16 

2 „ 

0.234 

0.241 

0.222 


Consideration or Resttets. 

From the clinical, point of view none of the cases showed 
or felt any improvement in tiieir general condition wliilst 
liaving the %*arions pancreatic extracts; in fact, two 
patients complained of feeling weaker while on the 
extracts. One of those patients had to be rather hurriedly 
put back on insulin injections, as he developed a rapid 
pulse, went off his food, complained of abdominal dis- 
comfort, and became drowsy, with breath smelling* of 
acetone. In fact-, lie exhibited the premonitory symptoms 
of coma. 

Tliree patients were treated with Parke, Davis and Co.’s 
pancreatic extract (Mackenzie Wallis). One of these, a 
married woman, aged 35, showed little alteration in lier 
Wood sugar levels whilst taking the tablets; the glycosuria, 
on the other hand, possibly showed a fall at tho start, but 
for the last few days before ceasing to take tho tablet? 
had returned practically to the original level. -The aceton- 
uria, on tbc other band, tended to rise rather than fall 
during the exhibition of the tablets. As far as can bo scen 
this patient was not influenced by. the administration of 













800 MAT 12, 1928] 


OEAL ADMINISTEATION OF PANCREATIC PHEPARATIONS. 


t Tnt Pnmw 


tho tablets, and her blood sugar remained between 0.25 
and 0.30 per cent. After being put on insulin injcctioms 
and an increased diet she improved very rapidly, and has 
sineo done extremely well. This patient’s blood sugar esti- 
mations, done at hourly intervals,' showed a greater varia- 
tion when she was taking tho tablets. As far as ean bo 
j’eu from this case, ono of moderately severe diabetes, tho 
patient was not in tho least benefited by the administra- 
tion of the pancreatic extract. 

Another of these patients, a married woman, aged 53, 
said she felt bettor whilst taking tho tablets, but she also 
said so whilst she was having tho imitation capsules con- 
taining puh'is cinnamomi compositus. Her acetonuria and 
blood sugar curves showed little alteration. Tho urinary 
sugar also was little affected whilst taking tho tablets. 
After being placed on injections of insulin and a much 
increased diet, consisting of carbohydrates 56 grams, 
protein 63 grams, and fat 182 grams, her acetonuria and 
glycosuria disappeared in about a week and her resting 
blood sugar fell to between 0.100 and 0.150 jier cent. Sho 
has since kept verj’ well. While this patient was taking 
tho imitation capsules tho blood sugar finished at a higlier 
level than at other times, but at ono period fell to a 
lower level. From tho other data, too, this patient was 
not materially affected by tho exhibition of tho pancreatic 
extract. 

In the third patient tho curve after tho pancreatic 
extract rose to a higher level than it did when no extract 
was being given, but tho final reading two and a half 
hours after tho glucose was slightly lower than in tho 
cuive when no capsules were taken. Theso variations were 
of no significance. 

With regard to tho patient whoso case is recorded in 
the text, during tho period while ho was taking tho cap- 
sules tho glycosuria reached its maximum when ho was 
taking tho largest number of capsules — that is, sixty a day 
— and tho blood sugar w.as also highest at this point. 
Whilst taking tho capsules tho blood sugar and glycosuria 
levels did not appear to bo appreciably altered, and tho 
blood sugar remained above 0.200 per cent., even on tho 
low diet ho was then having. Immediately after being 
placed on insulin tho blood sugar fell to tho region of 
0.150 per cent., in spite of an increased diet. Tho first 
blood sugar curve, taken while tho patient was on diet 
alone, showed a lower resting blood sugar level, but a higher 
level at 2 p.m. than either of tho oth(5r two curves. Tho 
second curve, taken while tho patient was having five cap- 
sules three times a day, showed a very marked idso after 
breakfast to over 0.300 per cent. There followed a marked 
fall, and at 2 p.m. the sugar concentration was .about 0.240 
per cent. The last curve, taken while tho patient was having 
fifteen capsules three times a day, showed a high resting 
blood sugar, 0.270 per cent., but tho readings then kept 
lower ranging between 0.220 and 0.250 per cent. Possibly 
this last curve shows a lower average level than tho other 
two, but It must be remembered that tho blood sugar 
curves vary in the same person from day to day, and 
there m no real improvement in tho average level in spito 
of t^e fact that the patient was taking tho enormous 

11 1 . u number which it 

would be difficult to get a patient to coiitinuo taking over 
a long period of tirao, ^ 

A ptli case that of a labourer, aged 26, was a severe 
and long-standing one, with considerable emaciation and 
marked asthenia. He was on diurnal injections of insulin 
and a diet of 40 grams of carbohydrate, 56 grams of pro 
tcin, and 186 grams of fat for six weeks before tho exhibi' 
tion of tho capsules, and improved considerably ■ in hig 
general condition. He was receiving 25 units of insulin 
night and morning, but this was stopped for a period and 
tho patient then given five capsules of Carnrick’s internal 
secretion of pancreas three times a day before meals On 
examining the blood sugar, glycosuria, and acetonuria 
estimations it ■ was found that on ceasing the insulin 
injections there was a very marked rise in glycosuria 
acetonuria, and to a less extent in tho blood sugar leyels’ 
At ono period while ho was taking tho tablets tho patient 

Si the i^i^S Wotafl ® 

. Immediately after recommencing the injec- 


tions of insulin tho glycosuria and acetonuria fell rapidly, 
and tho blood sugar dropped to nearly normal limits. 

Another patient, a girl, aged 15, was given some 
synlhulio “ insulin ” tablets. Tho tablets wero divided 
into two kinds, A and B, and theso wero supposed to bo 
taken altorimtely every two hours, six in all being taken 
during tlio day. "While tho patient was taking tho tablets 
thcro was no improvement in cither tho glycosuria, 
acetonuria, or blood sugar levels, but before discharge 011 
5 units of insulin twice daily her urine was free from 
sugar and acetone, and her blood sugar hud fallen to tho 
region of 0.100 per cent. ; sho had put on weight and 
felt very well in herself. 

Tho last patient was a man, aged 49, with a history of 
diabetes for seventeen years and a ten days’ histoiy of a. 
patch of superficial gangrene on tho right big too. Ho was 
placed on a liquid jircparation called “ diatana,” which 
was credited with curing diabetes on any diet in a fort- 
night. Later on ho did well on insulin. 

In considering tho various cases together from tho point 
of view of results, tho value of tho different varieties 
of treatment must bo looked at from several aspects. 

In tho first place, are they a cure? In no .instance has 
thcro been any evidence of cure, but in the case of most 
of tho preparations no claim that jtlio treatment would- 

produce a euro was made. • 

In tho second place, is thcro any evidence that the 
treatment was beneficial to tho patient? In no case is 
there definite evidence of any improvement whatever whilst 
...uler treatment. The patients either remained stationary 
r ended to go downhill, in spito of tho fact that most of 
tlmm i^ro on low diets, which would have been quiU 
i sufficient for thorn to livo and work on outside Tho 
1 i)omcr whoso case is referred to, who was on a sufficient 
diet to get on with outside, after being on capsules for 
r Wc bad to bo hurriedly put back on insulin injections 

S,?t. 1 it <l,.l l/w.. in tl." >t>E« 

‘’’t T mrT923 a married woman with diabetes, who 

^‘'l"fct’ mackonr.ic Wallis), was admitted to hospital in 
extract (Mackcn ^^ of insulin and other appropriate 

UeTtment sho was able to leave hospital later compara- 

the above, many patients have been treated at 
qt^'Hiwins’s Hospital with pancreatic mouth preparations 
duriS the last two years. In no case was the slightest 
benefit produced. 

CoXXLUSIOXS. 

the consideration of tho data given it is clear that 

? n^rrS^S-ffiely po 

rions, sfch as “insulin synthetic’’ and diatana, f have 

^°'\s‘\ecai°ds'"thr’milder cases, in none of tho above 
4 ^- Is^could any definite improvement bo traced, cithct 
ibn clinffial co^ndition of tho patient or in the blood 
levels In those patients on whom blood sugar 
verrtaken over several hours no definito differenco 
curves ' jovcl could bo detected as the 

^Irnf treatment with oral preparations. In fact, all 
result ,.„-,,ifs point to tho conclusion that tho oral 
the of no value in the treatment of 

prepiua probably tlio improvement attributed to 

diabetes i„ reility been duo to the 

sfricrtBet^tlm patient has been put on at tho same time. 
Tn ntbor words, tho patients would have done equally 
well if put on tho diet alono. Tho only value 
seem to possess is that some patients, if placed on a stnet 
diet alone, feel that they are receiving proper t.ea^ 

ment, and the giving of tho oral preparations obi lates 
this difficulty’. 

I am indebted to Professor H. MacLean for his kindness in 
allo-wing nio to carry out theso investigations in his wards, 
to Dr. C. H. Budvo for his help with tho laboratory worK. 







MiV£ 12, '1928]' 


MropiA IN onir«r>HooD. 


[ TnrrnmsTT 
Mehicai. JoertxAt 


803 


in n 1)oy, ngod 11, wlio In*;! Juno was cnvviod into liis 
onl-]niticnt clopnrtmont totnlly lUinblo to stiuid or nallc. 

PivotogvniiUs wcvo siiown ilhislrnting tlio. srissor-lcg 
clrfoiinity of llic liml).s nnd tlic cqninns dcforinity of tlio 
foot. Tlio ontorior division of- tlio obturator norvo was 
divided in tbo gi’oin, and tbo position of tlio limbs was 
covrootod by suitable apjilianccs. The boy was now able 
to walk unaided, tliongli with a spastic gait. 


0 f 

OBSTETKICS AND GYNAECOLOGY. 

'At a meeting of tbo Section of Obstetrics and Gynaecology 
of “the Itoyaf Society of Medicine on April 20th, with tho 
president, Mr. Cojiyxs BKitur.i.KY, in the chair, Professor 
Blaih Belt, read a paper on tho malignant functions of 
the chorionic cpitheliuin. He expressed tho belief that 
chorion epithelium was malignant in nature, though nor- 
mally under control. Since the trophoblast was the earliest 
functioning tissue in the fertilized ovum, the specific 
process of malignant neoplasia eonsistod of a reversion of 
tile differentiated, highly spofciali'zed, somatic coll to, or 
towards, tho earliest type of cell capahle of obtaining 
nut riincnt for itself ; this process was known as dedifferen- 
tiation. Professor Blair Bell then proeceded to siiow that 
dediffeventiation was an essential foatnre of somatic 
malignant neoplasia, and that the placenta, or more 
exactly the chorionic cpitlioiinin, was a malignant tissue in 
respect of its functions. He referred to tiio work of 
llarhurg of Berlin, demonstrating the importanci- of gluco- 
lysis in the motaboli-sm of malignant tumours. The 
speaker then described his own iuvostigatious of human 
placental tissues. 

Mr. B. H. pAii.tsiortE, in a paper entitled “ Eclampsia 
and its treatment: an experience with spinal auac.sthe.sia 
. jii one case,” discussed critically the various forms of 
treatment of this condition. He outlined his own theorv 
as to the causation of eclampsia, and criticized several of 
the current mews. Ho then described a case succe.’-sfnllv 
trc.ited Ij.v spinal nimestlicsia, and expressed the opinion 
that the lateral position was most important in this 
procedure, 

Mr. C. D. Bu-vn showed a specimen of a teratomatous 
ovarian tumour with torsion of the pedicle in a girl 
apil 11 . Microscoiucal investigation showed areas of 

pasmoidal ma.s.scs, largo mnltinucleatod ccIK lining .a, 

7 P°' 3 gonal cells derived from 

hanjians s h^cr. Plio patient a few weeks later developed 
a tumour in the parotid gland and died n ithin a fortnight 
after att.icks of profuse Imemoptysis. Mr. Bead .Bso 
of malignant change in the corpus 
an nnmn!‘’-eV‘''^"'® JHetaphasia. This was obtained from 
ntei-re 1 ••>ged 34, who had complained of 

wnoi more than a month, Micro- 

uone‘"mf CI Conditions. 

The upper mass in the , items o.xhihited glandular Iiyiier- 
plasm with slight invasion of the mutle coat. ' The 
columnar cells had become stratified and omhivonic in 
character in part, and the lower area presented an Vpe«r- 
anee not uuhke that of a .squamous epithelioma This 
spctiinen uas discussed hy Professor Blair Boll, who o-are 
an epidiascope demonstration of metapla.sia in tissues. 

. CHILDHOOD. 

Sis 

«,.t 'iipi si"" , 'S-'- p™” 

SS”S„S Sf 

its incidence, and’siid ^“'''‘feation of 

earlier tlian 'was gonomll^snpl^T’";"';^' 
with as earlv as 6 years old ^whn 1 me* 

cud congenital cases wore somoGnmf 


alike in males and females, myopia was most prevalent in 
children attending State schools, who constituted 90 ]ier 
cent, of all children between tho ages of 7 nnd 14. 
In America 40 ]icr cent, of the children in State .schools 
became myopic during their period of education, nnd ■ tho 
impression gained from observation was that the case was 
similar in England. When tho serious results from break- 
down in after-life were considered, it w.as clear that there 
was a really grave problem which, so far, had attracted 
insufficiont attention generally. Tho four theories most 
widely held as to tho causation of myopia could he divided 
into two classes — “ postural ” .and “ predisposition.” TIio 
“ postural ” theories attributed tho condition to ( 1 ) cxecs- 
sivo convergence, and (2) tho effect of gravity. Tho 
“ predisposition ” theories cited ( 1 ) a small ciliary body, 
and (2) diminished resistance of the sclera; An examina- 
tion of the first tlirco theories showed that in the end they 
were dependent upon tho fourth. All three conditions 
might bo coiitrihiitory, hut without an abnormal distensi- 
bility of tho sclera they could not he deleterious in their 
action. In discussing the fourth theory* Dr. Schnrr said 
that heredity miglit undoubtedly bo a contributory cause, 
but it did not account for those cases, which were hv no 
means infrcciuent, in which there was no histoiy of myopia, 
hnt, on the contr.ary, there was even a history of iivper- 
metropia in the family. An investigation of tho height and 
v.-eight curves of myopic children in the Barclay Home, 
Brighton, sliowcd tlmt there seemed to he some definite 
relation hotweeu myopia and metabolism. A series of 
gmpbs of contrn.sting cn.ses, with which Dr. Scluirr illus- 
trated this point, showed that whore the myopia was found 
to bo incicasiug there wa.s always a falling off in the weight 
and height ratio compared with tho normal. This condition 
was not found where tho myopia was stationary, oven if 
corneal nchniac wore present. The material available so 
far bad not proved sufficient for any firm conclusions, but it 
afforded a bnsi.s for interesting spcciilntioh ; it was insnfn- 
cieiit also for an adequate series of “ poiideraT indices.” 
On the otlier hand, it gave very good grounds for tbo 
suggestion that the cause of myopia might he found in a 
consideration of aberration of gi-ondli in children. If 
lefractivc errors fell into a medical categorj’ this consti- 
tuted the strongest .argument, nnd one which so far had 
not been used, against allowing opticians to proscribe 
glasses. A description of the work in a nivopc class brought 
forward the question of tlie future of the chiTdj-en after 
they left the schools, The estahlislimcnt of workshop, 
where myope, could compete with persons of like dis- 
ability, apjioared to be more reasonable and les., nastefni 
of money tlian sending them out to compete with normal 
persons. Dr. .Scluirr emphasized tlie point that the c.ariv 
detection of myopes was a most important duty of mcdica'l 
officers in charge of schools; the general jnactitioner could 
pve u.seGil advice 011 such matters as snltaWo exercise eood 
food, sufficient sleep, and the choice of ].rofcssion. ’ “ 

^ At a meeting of tlie Forfarshire Medical Association at 
Tliiiversity College. Dundee, with the vice-president Di r 
Mit-WB, in the chair. Professor J. A. KyxScu Irthe 

‘'m complications of u’terine fibroma tf 

s..ul that filnoul tumours were not the benign innocent nrmvths 
they were once supposed to be: tbev might be assochtfd with 

Tffi^:?dVdi.'-^®ri’ ffself in the utenis 

that ma ielv. T for if it could be shown 
ha ; Li complications occurred at all frcquentlv it would 
Ml ^ for cariy removal of fibroids. ’The cases 

tlie tomnor ‘ sai'comatous degeneration of 
the tumour , (2j fibroids associated with adenocarcinoma of the 
noaj ; and (o) fibroids associated with squamous-cellcd epitbe- 
boma of (lie cervix. Analysing his last 200 consecutive cases 
ot abdominal liysterectomy for fibroids, be bad found that 26 
pallets were under the age of 40, and in none of these was 
lue nbroia complicated malignant changes. Araonu tlis 

vemammg 174 there -were 8 cases of malignancy. Of these 
* .'ret;® associated with adenocarcinoma of the body 2 with 
cpitliehoma of the cervix, and 3 were sarcomatous, 'The com- 
bination of squamous cancer of the cervix with fibroids must ba 
regarded .as an accidental occurrence, but there seemed to he 
seme etiological association between adenocarcinoma of the bodv 
of file uterus and fibroids. His view was that when fibroid's 
were found m a woman ovM the age of 40 the uterus should 
be removed on account of the increased tendency to maiicnant 
complications after that age. ^ 




804 MAT 12, 1928] 


REVIEWS. 


[ Ini' URmn* 
MlblClL JocRXiX 


flcbitlus. 

RADIOLOGY. 

Three out of four volumes of tlio vork entitled The 
Theory and Practice of Padiology,^ ky Dr. Bernarh .T. 
Leggett, have heon published. These are, respoetively, on 
“ Electrical theory applied to radiolog}’,” “ Tho physics 
and measurement of a;-radiation,” and “ A’-ray appiiratus 
and technolog)’.” Tho fourth volume, uhieh is in coui-so 
of preparation, will deal with tho “ Diagnostic and thera- 
peutic applications of x-radiation. ” Tho three volumes 
under review aro largo Imoks, profusely illustrated; volumes 
i and ii have each from 240 to 300 pages, and tho third 
is even larger, for it runs to 550 pages. It need .scarcely 
be said that between them they cover very comidetoly tho 
wholo of the subjects indicated by their titles, and we may 
add that they do this in a very systematic and detailed 
manner. Tho student who is preparing himself for ono 
or tho other of tho diplomas in radiology should most 
certainly find in them tho answers to all the que.stions ho is 
likely to bo asked cither in tho papers or in tho oral ])art 
of tho examination, and incidentally it woiild appear that 
they contain a great deal which he cerlaiidy woidd not bo 
asked. Tho author has introduced at the end of most of 
tho subjects a series of questions based largely on those 
set for D.M.R.E. examinations; they aro suggested ns 
“ exorcises ” upon the chapter or chai)tcrs dealing with tho 
particular subject. No doubt tho correct answers could, 
in most cases at any rate, be dug out from the text, but 
we venture to suggest that as tho questions aro set it 
would have added greatly to their value, if not to that of 
tho volume, if tho author had seen fit to add, i)erhn])s in 
an appendix, his conception of how these questions .should 
be answered. 

To take the volumes separately. Nvnnber ono has six 
chapters, which discuss separately the dielectric circuit, tho 
electric circuit, tho magnetic circuit, vaiying current.s, 
electro-magnetic machinery, and tho electron thcoiT. 
humorous illustrntioiis help to chicidalo the text, but si 
good deal of tho mathematics included therein makes it 
somewhat hard readiiig for tho ordinaiy medical man. Wo 
do not, however, moan this remark to bo taken iti any 
sense as advorso criticism: tho author clearly indicates 
tlmt, though primarily written from tho i)oint of view of 
radiology, tho work was not written for tho purposes of any 
particular examination. ’’ 

Tho second volume is concerned with tho physics and 
measurement of x-radiation, and deals, among other things 
with light and heat, tho origin and properties of x-radia- 
tion, the measurement of both qiiallty and intensity, and 
the dangers of radiology. In two appendices tho author 
tlml ^ recommendations upon protection and 

t oso re nting to dosage. He rather adversely criticiv.es 
tho English recommendations on protection, cLcfly from 

SltiL° It is^’T-f ''‘f: --'^facturer^' diX 

culties. It IS of interest to note that up to tho present 

able by law. Some fifty pages aro allotted to a chanter 
on the dangers of radiology, not only the risks f rom tlm 
rays themse yes. but also the various'^ electrical and other 
dangers. This is a valuab e chapter, full of useful informa- 
tion and references to literature. Voluino iii is veiv 
large, and savours overmuch ,of tho instrument maker’s 
catalogue; at the same time this perhaps enhances ts 
value as a reference book in which information on anv 
point of instrumentation can easily bo turned up and thn 
more readily understood by means of the pictures. Nothin^ 
appears to have been omitted. A - — — ' * - . 

chapter is that on the radiological ' ° 

it is with plans of departments, bot '■ 

Useful information on this subject has often in tho p^t 
been difficult to obtain, and in this cli.apter, again pro 
fusel^y illustrated, a distinct want has been practicallv 
dealt with. In another part the differ ent kinds of ai-ray 

of Radiology. By Bernard J. Weett ' 

i'"“» 

VP. on + 650 ; 53) figures fsa. njtb Sevres; 253. net. VoL III, 


tubc.s aro do.scribcd and compared ; whilst tho detailed 
account and description of high-tension transformers is of 
groat vnltio. 

It is not possible in a review of this kind to enter into 
any further miniito detail. Tho three volumes aro excel- 
lently got up, printed in good legible typo, and the ilhis- 
tralioiiH leave nothing to bo desired. Wo can congratiilato 
Iho author upon a fino piece of work, invaluable for 
refcrcnco and a mine of information for tlioso in search of 
expert knowledge. 


BLOOD PRESSURE. 

Tin; fourth edition of Jilood-Prcssurc: Us Clinical Applica- 
tions,’ originally written by Professor G. W. Norris, 
appears with tho collaboration of Dr. H. C. Bazett, pro- 
fessor of physiology in tho University of Pennsylvania, 
and Dr. T. I-I. McJIii.l.vn, cardiologist to tho Philadelphia 
General Hospital. Tho spirit of team-work is further 
shown by tho inclusion of four chapters by authorities on 
blood ])rc.ssure in nervous diseases (Dr. F. G. Grant), 
surgery (Dr. G. P. ^fuller), obstetrics (Dr. N. W. Vaiix), 
and ophthalmology (Dr. 11. AV. Scarlett). Tho chaptcra 
on phvsiology aro now. Professor Bazett, after stating 
Poiseuillc’s law, lays stress on tho importance of recog- 
nizing that a riso in blood pressure docs not necessarily 
imply any increase in the peripberal resistance, and that 
a normal mean blood pressure, which is obtained by adding 
oiie-tbird of tho pulso pressuro to tho diastolic, is not a 
definito indication of a normal circulation, for a normal 
pressuro level can be maintained by abnormal adjustments 
of tho circulation into and tho |)criphcral circulation; thus 
tho systolic and diastolic pressures hro often practically 
normal when dyspnoea, oedema, and cyanosis arc jirc^nt. 
Whereas an abnormally high or low blood pressure shows 
that tho circulatory into or tho periphery rcsistanco is 
disordcrcel, a normal blood pressuro does not prove that 
these factors aro normal. Tho subject of tho capillaiy 
and venous blood pressures is duly summarized, and diurnal 
and postural variations aro described under physiological 
eonsiderations, and again in tho following chapter. 

Tho section on instrumontal estimation of blood pressuro 
is copiously illustr.atcd by useful figures and diagrams, and 
nttmition i^s called to tho occurrence, when tho auscultatory 
method is used, of unexplained periods of silence, so that 
nalnnlion at tho wrist may give a higlicr systolic pressuro 
tlmirb) the auditory method; this ” silent gap ” is more 
frcouciit in repeated estimations than in tho first of a 
series and in some circumstances, but not 111 all, its 
nrcsenco may bo duo to venous engorgement. Silent gaps 
iiavo attracted veiy little attention in this country, except 
from P. C. Gibson. After discussion of the yanations of 
blood pressuro that may bo regarded ns physiological, tho 
fLc^tional efficiency of the circulation as estimated by blood 
iiipssiiro and allied tests is fully considered. 

^ Tho important subject of pathological high blood 
meanine thereby pressures above 160 mm. Hg sptohe and 
100 diastolic, receives full and s.atisfactory treatment, and 
much useful and some curious information is given, such as 
rl ■ view that high blood pressuro is commoner in 

Pff'bnnded than in right-handed persons. Tho directions 
Ilf t" treatme“ are fhoroiighly Lnsible, and this well- 
written treatise well maintains its repU.arton as a useful 
practical guide and source of reference. 

TTnrlov the title L'hypcriehsion artcricllc solitaire’ Dr. 
L Pellissifr discusses tho' much debated subject of high 
blood piessurc without any discoverable morbid lesion such 
aq nephritis. This, in fact, is tho essential hypeitension 
of many authors, especially Americans, but the 
“ essenUal ” is advdrsely criticized by the author > 10101 , 
liko idiopathic,” merely a cloak 

critical essay, 'which contains tho details of sixt) cas 
studied clinically, and a bibliography of 249 items, inclu d^ 

> Bloml.presfure ; m ??; 'Thoma°"jt.’ 

AB 51T D ’ llonrv Cuthbert Bazett, B.M., B.Lli.Uxon., T_n,if,n: 

McMillan, ’’ a.-IJ., Fourth edition, ^Ijorouphly J plate. 

Henry Kimnton. ' 1928. (Med. Bvo, PP- via + -87 , 1 coloureu r 

sowaire Par H. PePisMer Paris : Masson 
et Cic. 1927. (Med. Bvo, pp. 272. 30 fr. sans niajoratlon.) 


5 •. , ’T I, "i 

MW 11 , 1928 ] 


REVIEWS. 


f TirnBnmsn 
L ItlEDXCXL-JOCniilX. 


805 


a fair siiriukliiig of ..I'kiglish liapors, it is latlior Biuprising 
to fiiul-tliat tliorc is lio rofoi'onco to l)y|)Pr))ic'.sia or to Sir 
Cliffovit A\U)\itt. Tlvo coaccptiou tfwU tlievo is a form of 
])mo pviiaitive liigli.ljloocl pressure without any causal renal 
lesion is ascribed to VaCjtuv. in 1903, who considered that 
the excessive activity of the adrenals was the responsible 
factor. After seine discussion in tlio light of more recent 
knowledge, Dr. Pellissicr, who adinils that he has never 
found any inacroscoinc or microscopic evidence of changes 
in the adrenals of his cases, concludes that the rise of 
arterial blood pressure is due to excessive adreualinaemia, 
which, however, is only the means, and not the ]>rimary 
factor. . The underlying cause is a disorder of humoral 
iuetaboiism, which stimulates the adrenals, breaks down the 
physico-chemical balance, and irritates the symp.atbelic 
system. 


A TEXTBOOK OF. BIOCHEMISTRY. 
rnoFEsson A. T. C.miehox’s Ti^rihnoh oj Ilioclicmhtrff' is 
certainly not a ponderous volume, yet it contains a remark- 
ably complete survey of a very wide field. The book is in 
substaiice the written version of cour.ses of lectures delivered 
to- students of science and of medicine. Thus it assumes 
ill the reader no previous knowledge of biochemistry, and, 
as e-ich successive topic is dealt wUli, the fuiidamcnt.'tl.s are 
exidained before the details are described. 

The busy medical student will find in tbis book a concise 
account of the facts with which ho is ex[)octed to become 
familiar, while, for the benefit of those who ivi.-.h to explore 
the subject further, more detailed accounts of topics of 
general intcrc,st are appended. There is, for instance, a 
very interesting section on comiiarative digestion, which 
includes descriptions of the digestive processes of plants, 
protozoa, invertebrates, and vertebrates, and a chapter on 
biochemical processes in industry, dc.scribing some ingenious 
practical applications of the subject. It should also bo 
. noted that- sensible and scientific accounts of diet and 
vitamin reciuiremcnts arc given, which will provide tho 
student .with a sound basis for, studying dietetics. Indeed, 
by dint of the skill -with which he has cxnideiised an viii- 
wicldy mass of material into small comp.ass, at the same 
time omitting nothing essential. Professor Cameron has 
, created a tpiito-exccptionally readahle textbook. 

The author himself puts forward in his preface the plea 
that it is neces-sary, in order to ai'oid confusing tho 
elementary student, to adopt a somewhat dogmatic attitude 
when dealing with controversial points. This is doubtless 
true, yet the one fault we have to find with the book is 
that it contains one or two statements which are definitely 
not in agreement with tho facts as at present known. 
For example, while the author’s unquestioning belief in 
the existence of the enzyme urease in crvst.alliue form may 
sru'prise the cautious, it is quite possibly well founded; but 
his conclusion that the ammonia present in the urine is 
formed by the kidney, from, ure.a lias a large weight of 
evidence against it. Similarly the statement that pepsin 
docs not attack the CO-NH links in proteins is definitely 
contradicted by the results of recent researches on peptic 
digestion. These are, however, matters of detail, and will 
certainly not prevent this Terfbool- of Biochemistry from 
attaining tho popularity witli students and teachers wliich 
it xindoubtodly deserves, , 


PEDIATRICS. 

Nkaiilt . seven years liavo passed feince Professor J. P. 
Crozeu Griffith first published liis textbooh in tivo 
volumes on The Diseases of InjaxiU and C/tildrcn/ ami for 
tlio second edition now publisbcd lie .lias liad tho assistance 
of Dr. A. Graeme jMitciikll. The preface says tliat even* 
part of the book lias been subjected to a thorough review, 
and it is obvious from, tbo references to recent literature 


Z?iocArmi8fry By A. T. Cameron, D.Sc.Ed., F.I.« 
v Swale Vincent. LE.D,. >LB., P.S 

* Churchill. 1928. (SixBkpp. 

■‘Thr Siscaset ol Inlants apd Chnarm. D.v J. P. Crozer Grimtii, M.l 
rii.U., _ anO A. Graemo Mitchell, M.D, Sccontl tKlilion." reset. Vh 
aclctploa and Gonilon; W. E. kaunders Company. 1927. (Boy. 8i 
tol. I, pp, xiii 4- 783 -4-65; 233 figures. Vol. II. pa viii 4 - 9?7 4 . F 
vSumes)^’ rloles in tho.Gvo volumesl'^-SOs. ntl t 


ju’ofuscly appearing througho.ut the work that this edition 
1ms hccii comidctoly revised. The result is an authorita- 
tive textbook, well' illustrated, carefully documented, and, 
above all, pvosenting a very well balanced account of the 
vast subject. An excellent feature is tho inclusion of such 
subjects in surgery and tho special branches with which 
physicians, treating the diseases of children should he 
more or jess familial'. - • - 

It may. he complained that tho two largo voliiiiics which 
result contain too much; for the general practitioner, but 
a's a work of rofcrciico it is remarkably practical in its 
detail on such matters as diagnosis and treatment. In this 
respect there are still some- -small- matters calling for 
criticism. .The anthdr states that ho is embodying in. the 
hook largely tho results of his own experiences, Init it is 
scarcely fair to say (p. 647, vol. i) that tuberculous 
mediastinal glands present “ few if any cHiiiciil manifesta- 
tions,” nor is it in accord with modern teaching to include 
coetiac ilisease vaguely along with other forms of " chronic 
intestinal indigestion in older children ” (p. 142, I'ol. ii). 
The treatment of semvy (p. 718, vbl. i) is rather brief, 
no mention being made of such methods as the use of 
dcacidified lemon juice. The inclusion of such conditions 
as “ athropsia ” and “ malnutrition ” in the first volume — 
a long way from the digestive disorders and feeding diffi- 
enlties — does not help in a proper conception of nutritional 
disorders in infants, and, if these terms are to he used 
at all, they do not justify inclusion of the disorders in a 
section containing such other diseases as rickets and 
rheumatism, for example. 

Such criticisms almost exhaust tho faults to be found 
in more than eighteen hundred pages; for the rest tho 
I work demands high praise. Tho section on the acute 
infectious fevers is especially good, and there is much to 
he learnt from the description of such disorders from the 
point of view of a pediatrician rather than of the specialist 
confining his activities to the fever hospitals, as in this 
conntn'. Rickets is well described, and a well-documented 
brief summary of its ctiologi' i.s very good. The section 
on diseases of the rcspiratoiy system begins with a useful 
chapter on “ cough,” and the treatment of the common 
cold ill oliildren is well set out. Tho specialist will find 
inueh that is stimulating to thought in these two volumes, 
and the general practitioner will not go to them in vain for 
help in the solution of his most trivial problems. 


R0ST:M0RTEM TECHNIQUE. 

The now edition of Dr. SnExxAx’s book on post-mortem 
examinations, ‘ which haS been long overdue, shows 
evidences of cimsiderahle revision. ItTiilo the original 
plan remains the same, additions have beep made in the 
descriptions of the lesions with' the object' pf making the 
work to some extent a textbook of special ' pathologv as 
well as a guide to jiosf-iiiorfcrii ' technique. Among . the 
sections which have been extended in this direction may 
he mentioned those on diseases of tho blood vessels, oil 
pneumonia, on the thynuis' and thp'oid, on jaundice, on 
tho splenomegalies, ■ on' nephritis, and on diseases of tho 
nervous system. Further,' additional measurements have 
been funiished of the embryo' and of children from birth 
onwards, and a chapter has been added on medicmlegal 
post-mortems, dii post-mortcms on stillborn infants, and on 
cases of death under anaesthesia. Aluch of the subject- 
matter of tho old edition has been rewritten and the 
remainder recast, so that, as the author states, the work 
is practically " a ■ new book. It is the outcome of Dr. 
Shchnan’s long personal experience in post-mortem work, 
and therefore eoiitnins fii-st-hand infoi-mation oii the 
subject and technical recommendations that hai'e stood 
the test of time. IVith regard to the arrangement of the 
subject-matter, the jmst-mortem room and its equipment 
is first described, with general rules as to tho conduct of 
the necropsy and the restoration of the body after its 
p'erformance. Then follow the external ..examination, of 
the body and the opening of the body cavities, "n-ith tho 
order of remov.al and methods of examination of the 


“ .uMrtriMP unw Aiu-uiiore oiiejinan, 

F.R.C.S.Ed. Second edition, London : The Scientific Tress (FaWr and 
Givyer, Ltd). 1927. (Demy 8vo, pp- viii 4- 664; 213 figures. 253. ueL) 


806 MAY II, igiS] 


BEVIEWg. 


r Tm Biimi* 

L Uxpzcit Jonzfii 


viscQva. A valuable chapter on certain special cases deals 
with necropsies following death from poisoning, fn^ 
account of which is very full, and other cases of medico- 
legal importance. In an appendix useful information is 
•rivcu on methods of preserving specimens for tho museum 
and on simple methods of preparing microscopical sections 
and staining bacteria. Tho section devoted to tho per- 
formance of a necropsy in private houses furnishes 
hints which, if followed, will render that operation less 
unpleasant to tho operator and tho inmates than is 
sometimes tho case. 


APPENMCrnS. 

Thk latest addition to tho Surgical Monograph Series is 
Appendiciti!:,' by H. A. Rovsteh. This monograpli resolves 
itself into a collection of many and varied facts and 
theories concerning appendicitis, which the author has 
succeeded in correlating and criticizing in such a way as 
to jiroduce a very clear and iiractical doscri]ition of tho 
etiology, pathology, diagnosis, treatment, and complica- 
tions of inflammation of tho a|)[)cndix. 

Many interesting observations aro made on tho etiology 
of the disease, especiallj’ with regard to tho part played 
by diet, intestinal worms, and foreign bodies. Pathology 
is discu-ssed in relation with etiology. Tho chapter on 
diagnosis contains many useful suggestions, and tho 
value of a:-ray diagnosis in chronic appendicitis is fully 
discussed. A chapter is devoted to appendicitis in 
children, and this gives a particularly clear description 
of tho difficulties and dangers of the disease in theso 
circumstances. Tho prognosis of appendicitis is careful 
and fully considered, and special attention is directed to 
tho gradually increasing mortality rate at tho present 
tiino in tho United States. Dr. Hoystcr says that the ono 
way of lowering tlio death rato in appendicitis is to 
operate at tho first onset of symptoms of inflammalioii 
of tho organ. “ Far better results aro obtained by tho 
mediocro surgeon in early cases than by tlio more capable 
operator in late cases mado dangerous by complications.” 
Iho full and lucid review of treatment of tho disca.so in 
every phaso should provo useful to tho surgeon as well as 
to tiio general practitioner. Complications, their preven- 
tion, and treatment aro well described, and also special 
ptiints in tho post-oporativo care. 

At the end of each chapter a long list of references is 
given which will bo useful to those requiring more detailed 
knowledge of any branch of tho subject. 


THE MAKING OF A MAN, 


In The Struggles of hlale Adolescence' Dr. C. Sr.iNronn 
ItE.\D provides a thoughtful account of the influences which 
underlie the confused psychological development of this 
stage in life. Ho approaches their consideration from 
tho Freudian standpoint, but avoids what ho stigmatizes 
as ‘‘ freakish interpretation of ill-digested theories,” and 
retains throughout a clear practical outlook. Opening with 
an exposition of the various conflicting psychological 
trends, he emphasizes the danger of neglecting these at 
the time when they can ho most conveniently dealt with. 
A vivid picture is given of these warring forces as being 
a necessary part of normal growth into manhood ; and tho 
development of various reactions to them, such as repres- 
sion, compensation, displacement, and identification, is 
traced. The second part of the book is concerned with 
tho possible results of this conflict and tho paths which 
lead to health. The reader can hardly fail to ho reminded 
of Kipling’s story of the .ship that found herself, aiid sorao 
will recall the deep insight into human character' revealed 
in ancient Hindu literature, which describes symbolically 
tlio yoking and control of the divciso elements in tho 
personalit}'. On this “ finding of oneself ” depends very 
largely tho happiness and usefulness of human life, and 
Dr. Head has mado a very valuable contribution not 
only to individual, but also to national welfare. Tlici-o 


^ Aviicndicilis. ’ ByHubert Ashley Royster, ’A.B., Jf.D. Surgical Mono- 
"iniiUi, - under tho editorial supervision of Dean Lewif*, A.B., M.D., 
Kugeno H. Pool, A.B., JI.D., and Aithur W. Elting, A.B., M.D. New 
York and London : D. Appleton and Co. (Sup. ro}'. 8vo, pp. xii + 370 : 
50 figures; 2 plates. 21s. net.) 

I „ Adolemncc. By 0. Stanfqril , Hc.ld. M.D.Lond. 

i-ouaoa . Gcoigo Alien and Uawui, Ltd. 1923. (Post 8vo. pp. 218. 73. 6d. net.) 


aro few short cuts to .success in tlio task of cbaractor 
Iraiiiiiig or in tberapentical psychology, but careful 
perusal of this hook by medical practitioners, teachers, 
niul imreiits would iiinko tho way easier for many’ of them. 
Tho author has iold a difficult talo in simple language. 
Any criticism of details would ho out of place in view of 
Iho vnhio of his worl: ns a whole, regarded cilhef as a 
textbook of one branch of prcveiitivo mediciiio or as a 
coiilrihulinii to tho science of education. 


NOTES ON BOOKS, 

Tin; plan adopted by Dr. C. 1). Aaiion in his textbook on 
DUco’d of the Diijcslivc Organs’’ is to follow tile path of tho 
divestivo trecl, beginning with diseases of tho sfoniacli, liver, 
gall-bladder, bile ducts, iiancrc.as, small intestine, vermiform 
apiiciidix, .caccani, colon, rcctiiin, and amis. Altbougli tlia 
dUeascs of these different organs nro considered cbicfly from 
the medical iioint of view, the author inchides descriptions of 
the simple pathology and dingnosi.s of diseases wlncb conio 
xvitbiu tlio province of tlio siirgTOii— a.s, for instance, tumours— 
but does not attempt any complete nceoant of surgic.al beat- 
moiif Oeiieral medical and dietetic treatment nro given special 
ploininence, and there nro cl, .spiers on 

{re.ilinenl and mineral waters. Tlic book is well ilhislrated 
and indexed, and will bo found a iiscfid work for refciencc. 

Gmwlonu for Nurses^' is tho title of the latest publication 
frorf the pen of Dr. CnossE.N of Washington, but wo wou d 
suggest that "An atlas of gynaecology” would more aptly 

iS ™ 3'nS3 .S“ mS ™ “Ij; 

Jtcrjiitcr ^ i frijo useful dassific.'ition o£ 

Kingdom ‘'so tlmi with tho aid of an cxcol- 

jircvioiis to trace institutions which' give relief m 

ictil index it IS ' „niiciion sickness, and permanent oi 
11,0 various forms ^vic’v ^ tliii previous year 

temporary distress. of institutions situated in pr 

deals lucidly Jchxapolis. This edition will maiiftain the 
iS -illation woflby 'previous issues: it is aii indispensable 

I.,-..!,- of reference. 

r,' nnicUtc Oread, with Special l^lcrcuca '"eir 

Trraunent. Dy Cl.aHe3„p.,_Aaron,,^Sc.D..^M.D.. RA.C.^. 


T)iayno*i8 - ^ 

Fourth ethtlon, 35 plntet?. « vvrs 

vf .ss afi's?"™”;' “ 5 ,i£> 

iri: a-i. S’Ms-ssis 



PREPARA'flONS AND APPLIANCES. 

“ VaPOROLE ” EPBEDWEE, irtcoltf 

issued a ^ Any means of an atomizer, ilm 

to the of eiXdrine 1 per cent., menthol. 

r compound cons S I 2 . per cent, m a base of 

boPi and oil ivn,litv liQUid parafiiii). Such a spray 

•oleine” (a / applied locally in bay fever 

les cpbednno f " f the nharvnx and nasal mucosa.. 

congested condil ons^^of^the^pto^ ^ 

5 slated , mid promise to provide, a very effective. 

■'""f^'^the of hay fever and of engorged 

ea"taiThal conditions of the nasopharynx. ' , 

Liver Extbaot B.D.H. t a. 

,lo Of liver extoc . dMeall7en<l found efficient by the 
h has been tested of one tube corre- 

ical Research f i, jjver and this quantity lias been. 

d to half a pound of fresl, liver, ana u anaemia, 

d to be tlio most suitable ^ , • iqemicious anaemia 

remarkable value of liver treatment » P/™^Yract5 possess 
ovy universally recognized, palatability and 




May ij, 1928] 


COMMENTS ON THE CASE OF TFNDAEE T. AEOOCK. 


f TiiEBftmsa . fiA7 

iIr.DlCAL Jor«<*t. tl I 


.S0.AIJ5 COMMENTS ON THE CASE OF 
TYNDALL v. ALCOOK : 

Wixn Eejuuks as to xnn Okicik of Iscir.vrjtio 
CoNinAciuJir.. 
nY 

ERNEST W. HEY GROVES, M.S., F.R.C.S., 

rnoFTssoK or suKnrr.Y is the DKivrnsiTY or beistol; surgeok to 
THE OESERAE HOSPITAL, BRISTOL. 

FRon.Mii.T tlio majority of medical men who heard or read > 
tho account of this case, reported briefly in the Jiritish ;! 
]\[cd!cal Jouriinl of December lOth, 1927 (p. 1121), and ‘ 
.Mnrcli 24tli, 1928 (p. 528), were greatly sliocked at its. 
TC.siiIt. Tiioro can bo no doubt that it throms an added • 
light on tho daiigefs which beset tho practitioner in tho | 
trcntmorit of a fracture. , . 

Let me first briefly relate tho accepted facts of tho case 1 
and tho trial. ; 

• In July, 1926, a girl, Phyllis Tynd.all, aged 8 years, fell' 
from a donkey and bnrt her left elbow. Mrs. Tyndall, the ' 
patient’s mother, did not lake her child to tho nearest doctor 
for first aid or bandaging, but decided to apply to Dr. Alcock, ■ 



Evngeon to the Gloucester Royal Infirmary. Accordingly, with 
the assistance of a neighbour, the child was taken in a motor 
car to Gloucester, a distance of ten miles, Avithout any splint 
or sling, the injured arm being merely held in a more or less 
extended position of the elbow-joint. Dr, Alcock, being 
apprised by telephone, was waiting to receive the patient, and 
actually first sa%v her in the' motor car. He recognized tho 
serious character of the inju^-, and therefore did not have the 
child out of the car, but himself got into it and was driven 
to the consulting rooms of Dr. Goss, the leading radiologist 
in Gloucester. In Dr. Goss’s rooms the cliild was anaesthetized 
and .r-raj'ed. This showed a typical supracondylar fracture of 
tho humerus, with great backward and uprvard displacement 
of the distM fragment, and the shaft of the broken bone so 
near the skin surface that it must have been pushed forwards 
through the muscles and other soft tissues in front of the 
elbow-joint (Fig. 1). Dr. Alcock then made traction upon the 
forearm, and gradually flexed it at the elbow, bringing the hand 
M till the fingers touched the shoulder of the injured limb. 
He felt the displaced lower end of the humerus moA'e forward 
into place, and being satisfied as to the reduction of the dis- 
placement, he fixed the arm up in full flexion by passing 
adhesive plaster round the doubled-up limb. There was no pad 
in tho flexure of the elbow, nor any bandage encircling any part 
of the arm or forearm. A bandage was placed over the 'flexed 
arm, and at this stage a further examination rvas" made by the 
0 : rays, with the screen, and Dr. Goss told Dr, Alcock that the 
reduction had been satisfactory and tho position good. 

In order to obtain a record of this position a jnate ivas taken. 
The cliild was still unconscious, lying on the a:-rav couch the 
tube being below. In order to get a lateral view of the elbow 


the arm was rol.itcd outwards so that the liand lav on the E.amo 
level as tho back, but on the outer side of the sboulder. The 
resulting x-ray film (Fig. 2) was not developed until the next 
day, and it is not quite clear when Dr. Alcock saw this, as his 
opinion that salisfactorj’ reduction of tho displacement had been 
cficctcd depended on liis own palpation of the limb at the time 
of the manipulation and upon Dr. Goss’s opinion of the sci'ccn 
e.xamination. However, as it so iiappencd, tho trial largely 
turned upon tho interpretation of this x-ray film. 

The x-ray picture having been taken, the arm was replaced 
with tho hand in front of tho shoulder and a bandage p.issed 
round the body and left arm; thus there were three sets of 
bands round the • limb — first, adhesive plaster ; second, a 
bandage, these two. going round tlie doubied-up arm ; and a 
third bandage surrounding the arm and body. 

Dr. Alcock then took the cliild in a motor car to a nursing 
homo himself, and gave instructions about her c.are. She 
remained in tho home for fifteen days, and Dr. Alcock saw 
her daily during this period. From the first fetv days and 
onw'ards Mrs. Tyndall, the patient’s mother, was constantly 
asking that the child might be taken home, but Dr. Alcock 
nbsolntcly refused to hear of tliis. Within a day or two of the 
accident it became apparent that the circulation of the hand 
was impaired, and the extreme position of flexion was relieved, 
the arm being brought down first by a few degrees and then 
to nearly a right angle. 



It was not clear at what precise moment Dr. Alcock' recog- 
nized the existence of ischaemic paralysis, and he stat^ 
quite frankly that he had in a largo experience never seen such 
a condition before. It was, however, pretty clear that he did 
recognize the gravity of the condition before the child left the 
home, os he told this to one of the relatives. For about two 
months more the child attended the Gloucester Izifirmarv as 
an mit-patient under^ Dr, Alcock’s care, but as the authorities 
of that institution did not consider she was a suitable patient 
gr a charUable institution she was transferred to the Children’s 
Hospital, Byistol. X-ray photographs at that institution showed 
posterior displacement of the lower end of the humerus, which 
had become attached to the shaft by a new periosteal bridge, 
the original shaft of the humerus projecting forwards above and 
in front of the elboiv. An operation was performed, and the 
projecting portion of the humerus was removed, but this did 
not materially improve the elbow, which was almost fixed at 
a right angle. The final condition of the arm showed a well- 
marked iscnaemic contracture of the forearm flexors and a stiff 
elbow. Dr. Alcock, after a trial lasting four days, was found 
guilty of " negligence," and was ordered to pay £2,000 damages 
to' the plaintiff, Phyllis Tyndall, and £150 to 'Mrs. Tyndall, to 
reimburse the latter for expenses incurred in the treatment. 

Having now given the main facts of the case, I should 
like to make certain comments on its medico-legal hearings. 
The first and most glaring thing is the interpretation 
which was put on tho term “ negligence.” I venture to 
say there never was, and never will he, a fracture case 
which was treated with greater care and solicitude than 
that of Phyllis Tyndall by Dr. Alcock. Ho met her in the 


808 MAY 12, 1028] 


OOM51ENTS ON THE CASE OF TYNDALI/ v. ALCOOIC. 


[ Tirr npirna 
Jfri.jcir. JocRSAL 


C 

inisi 


motor car; ho took licr to an a'-rny specialist; lii> iiiiin'S- 
thetizod her; he used the a’ rays hid'ore and after treat- 
ment; lie treated her by the nniversally approved method, 
lie was assnied by an experienced radiologist that the posi- 
tion was satisfactory; ho took the patient himself to a 
nursing homo, and gave her tinremitting care lirst at the 
homo and then as a hospital out-patient. And yet this is 
consistent with negligence! 

The second striking fact is the w.ay in which a fracture 
;ase and the reading of an .r-ray rdni lend lla inselves to 
nisinterprotation hy a jury. Counsel for the p'aintilf made 
a great point of this being “ a perfectly simple fracture.” 
In the technical sense that it was a closed and not an 
open fracture this wa.s qnito true, hut if by this it was 
meant that the case was a siin|)le one in the ordinary 
sense of the word, and presented no dilhenlty, f most 
strongly disagree. There was not only fraeinre, Imt great 
displacement; the child had bi-en jolt('d over a rough road 
in a motor car nithont the piotection of any splint or 
sling; the shaft of the hnmeims was almost projecting 
throtigh the skin, so that it must have torn through tlie 
overlying muscles; and yet this was a •' perfectly simple 
fractiiio ” 1 And again, take the phra.s(> “ setting a frac- 
ture.” The common idea is that setting a fracture consists 
in peifect locking together of the broken surfaces, whereas 
it is common knowledge that this is very .seldom done apart 
from open operation. That dis[)lacement can bo ri'dnccd 
or even over-reduced, leaving the fractnis'd surfaces in a 
favourable position for union by callus, though not actually 
touching one another, is an idea not ticceptable to the lav 
mind. 

Great controversy took place on the interpretation of the 
a'-rny film taken after manipulation. IVns it an antero- 
posterior or a lateral view? The plaintiff’s experts held 
that it was an antero-postorior view, in spite of Dr. Goss’s 
plain desciiption of how it was taken. 'They said that tlic 
shape of the bones showed that they were" viewed in an 
antero-posterior direction. In giving' this opinion the fai't 
was ignored that the arm was rotated outwards in order to 
got the picture, and also that this pietnre did not reiu-e- 
sent tho bones as they lay when the arm was iilaccd in 
front of tlio chest. 

If the picture is an antero-])osterior vimv, then it shows 
some lateral displacement; if it is a lateral view, then it 
shows that the displacement has boon over-reduced and that 
the lower fragment of tho luimerus has been brought 
forward to lie rather in front of the shaft. Hut in anv 
case, what ha,s this to do kith ischaemic paralvsis or the 
stiff elbow? Appatently it was enough to c.mviiice the 
juiy that the bones had not been “ set ” for them to con- 
clude that the paralysis was caused by this faulty setting. 
The plaintiff s case was tljat there was lateral displacement 
of the lower end of the iiumcrus upon tho shaft, but not 
one Mold of explanation was given as to how this lateral 

The Td‘e'r'of T 1 cause ischaemia. 

The idea of a blood effusion round tho fracturo first 

pres, sing upon the veins and then hrincin- tho circidalVo.. 
to a standstill was dismissed as hypotlmtieal No effiis m 
could bo seen 111 the x-ray pictures, hut tho “ niissbt ” 
bones were there, and that ivas enough 

The next point upon whitii I sUo„id like to coiiiinent 
was the interpretation put upon Dr. Alcock’s conduet after 
the first treatment and upon the indefiiiiteness of his 
ovidencc, • 

Groat stress was laid upon discrepancies of various wit 
nesses about tho releasing of bandages. Mi-s Tviulnll 
declared that for fourteen days tho bandages iv’oro "iiover 
released; but evidence was given that sho had never seen 
the arm niidone, and she only judged hy the fact that .shc’> 
always saw it siirronndod by the body bandiu'-o. 

Then it M-as impossible .to he certain on wliith day tho 
flexion of the arm ivas released; But surely after tlio'laiiso 
of oighieen months this' is quite natural, jn the same M'av 
Dr. Alcock could not be clear when or how he first leco'r^- 
iiized tho existoneo of ischaemic paralysis. Tiiis may seem 
strange to a layman ; hut surely any man of experience 
of coLestt "'‘° failing, circrdatioii and the .sig^s 

- that if a ■liiubTs''-ni®’ oi'fan insidious, and 

D- rr'y overlooked. 

aiiny leahzed before a week bad passed that 



inaii, it ivas represented to tho jury as being tho conduct of 
one who kneiv lie had made a fatal hinnder and wished to 
liide it. 


The initnie of tho damage to tho arm was very difficult 
to exjilnin fairly. It is trno that the imisclos or mnsclo 
fibres affected liy ischaemic jinralysis are iicrmanontlj- lost, 
and this ivas repre.scnfcd ns though tho wfiole forearm ivas 
])ernmiiently and totally phriilysod. In reality it is only 
(Vilain gronjis of mnscic.s ivhich aro affected, and nsnally 
some fibres of even tlieso e.Scnpe, so that, as .Sir Boherfc 
Jones lini; shoivn, ischaemic eimtractnre is capidile of groat 
nmelioratioh hy patient tre.atmcnt, and tho hand fiecomos 
nitimiitely quite useful in n limited degree. Similarly the 
fdiroiis ankylosis of tho clhoiv is a condition susceptihln of 
improvement. But in this case it ivas suggested that tho 
left anil ivas permanently useless, and that tho child, ivho 
iva’s represented ns a potential musical genius, had had her 
career ivrecked. ■ 

But there is niiother question of great importaiico 
suggested hy this case, quite iqiart from tho manifest 
idisiirditv of saying that a ivant of alignment of the hones 
eansed paralysis of tho arm — and that is. What was tho 
real ranso of the ischaemia, and could this have been 
avoided? It is a matter of conimon agreement that the 
prime eanse of ischiieniic contrnctnro is ii damage to tho 
blood ve.ssels and soft parts. This may have been caused 
at the lime of tlio accident, and ivns probably aggravated 
by the iviint of proper “ first aid.” The condition of a 
child ivitli a broken elbow-joint sniTomidcd hy sivelling 
and effusion is one which often has to bo considered and 
the correct lino of treatment dotermined. On this- very 
Doinl tlicre is not enough oniphnsis laid doivn in textbooks 
Iipon' the importance of ivatching tho circulation rather 
than the fracture; and in particnhir it is. not nsnally recog- 
nized that acute flexion oj tho olhow alivays has a con- 
.stricting effect upon the blood vessels. In all individuals 
in whom I have tried tho experiment, including myself, 
forcs'd ncxion of the normal clboiv-joint can readily ho 
brou-ht to a point wlicro tho radial pulse ceases. And to 
this observation anotber may be added. A ease i.s taken 
ill which some operation in the nciglibonrliood of the olbow- 
ioint is to bo performed. It is noted wliat degieo of 
forced flexion is required to canso cessation of tlic radial 
luilse Then after tho arm lias been relaxed, about one 
oiincc of .saline .solution is injected under tlio skin and deep 
fascia in front of tho olboiv. Tho arm is tlion again flexed, 
niid it will bo noted that tlio radial pulse disappears ivitli 
a much less extreme flexion than before. This shoMS that 
the iiicro iircseiico of effusion round tho joint, quite apart 
from actual injury to tho Wood vessels, makes flexion of 
tho elbow liable to obstruct tho circnliition ; therefore it 
should ho clearly understood that it is aliviiys a most 
daiicoroiis thing 'to flex a swollen elbow-joint, and if this 
i.s done a most careful watch should bo kept on the radial 
pulse, both at the time of manipnhition and for some days 

”*^AVhon'a^casc of fracture of tho loivcr oiid of tho humerus 
is iircsontcd for treatment some hours after the accident 
prosoiitino much swelling, it is far hotter to ho content 
to leave tho limb alone, simply supported upon a pillow, 
until tho effusion has subsided. It is quite trno that tins 
delav eeiicnillv means that manipulative reduction of tlio 
fracture will ‘he impossible, and in these circumstances 
open reduction, which is qnito a simple matter is iiidicatcil. 
Through an external or posterior incision tho blood clot 
is evacuated, the separated fragment is replaced, and then a 
moderate degree of flexion will bo qnito cnongli to rctani it 
ill position without any actual suturing of the hone itselt. 

It is Jierhaps unnecessary to add that if _ isclmcnno 
paralvsis has already developed, then no reposition pt tne 
bone,' even if done within a feW days of the accident, Mill 
have any effect in relieving it — another proof, if such ivero 
needed, of the absurdity of suggesting tliat ischaemia could 
he in anv M-nv duo to a M'aiit of alignment of tho hones. 


MAT 13 , 1938] 


PHTSIOTjOGY op the CEUEBRili HEMISPHERES. 


r Tnrifnmn P/)0 
LMEDWAt.Joc»»» 


PHYSIOLOGY OP THE CEREBRAL ITESriSPHERES. 

PnoKr.ssoE Pavi.oy’s Chooniam Lr.cTnnr.. 

Tnn Ciooni.iii Lecture on certnin .problems in tlio physio- 
logy ot tho cerebral hcmisplicrrjs was delivcrctl before the 
Roval Society by Professor I. P. P.wj.ov, For.Mom.K.S., 
on'Tliursdav., Jlav lOtli. Tho following is an abstract. 

The function 'of tbo nevvons system is to maintaitt 
dynamic equilibrium within tbo organism, and between 
tile organisiji and its environment. In tbo latter case tho 
equilibrium is, in tbo higher animals, extremely complex, 
and is achieved mainly by means of the homispborcs. Those 
continnonsly analyse and synthesixo cvorrls occurring in the 
environment, and in correspondence with its changes cstab- 
Jish temporarv connexions between events, whether simple 
or complex, and various activities of tlio organism, in 
particniar those of the sholoto-mnsculnr system, which is 
preponderantly concerned in roneting to environmental 
changes, and is likowiso itself highly differential and 
integrative in its response. 

At present tho physiology of tlio hemispheres exists only 
in outline — as a framework .consisting of only a limited I 
number of known factors, such ns excitation and inhibition, ^ 
their two-directional movement in tbo form of irradiation ' 
and concentration, and, their mnttml induction. The 
working out of the vnnnmcrablo details of their intimate 
mechanism is a colossal |n-oblem of tbo future. At present 
in this respect wo do bnt colioct fi’agmcntary observations, 
a small part of which, comprising the latest investigations 
carried out by the author and- bis co-workers (subsequent 
to ‘ the publication of the author's book Conditioned 
llcflexcs), are given hero in summarized form. 

I. 

• . The development of new tomporai'y connexions between 
external agencies and definite reactions of tho organism 
(development of conditional reflexes) depends on tbo coin- 
cidence in timo of tbo action of tbeso agencies upon the 
■ receptor mechanisms of the organism with the various 
activities of tho organism evoked cither by external stimuli 
effoctivo since birth, or by external stimidi which Imve 
becomo established as such after birth, or finally by changes 
iti the internal condition of the organism (automatic 
stimuli). Under these conditions tho formation of the 
connexion is a physiological law. 

In order to become a firmly established, powerful, con- 
ditioned stimulus tile extcrnat'stimulus must begin to act 
slightly before the particular activity of the organism, and 
may even ccaso a few seconds before tho beginning of the 
activity. If, on. tho other hand, tho given activity con- 
stantly begins before the stimulus, cither no connexion is 
established or, if any is established, it is weak and suiwivcs 
only for a short time, and the specialized excitatoi'y effect 
of the stimulus is invariably replaced by general inhibition. 
Tho biological significance of this fact is not yet clear, 
"Where the stimulus begins to act before tbo given activity 
of the organism, and continues during that activity, the 
reflex tends to increase in strength and stability. 

Tbo mechanism nnclerlying these phenomena cannot be 
expressed in terms of tho general properties of tho coadical 
tissue without further investigation. 

... II- . 

Tho analysing activity of tho nervous system is founded 
in the first instance on the peripheral receptor organs, 
which constitute not only a receptive mechanism, but also 
an analysing apparatus of the organism. To the peripheral 
points of the analyser separate points correspond in the 
cortex (the primary and simplest cortical mosaic). A good 
proof of this is that by applying definite external stimuli 
belonging to the same analyser — ^as, for example, different 
auditory stimuli it is possible to produce various disturb- 
ances or fatigue at different strictly localized cortical 
points. _ In this manner a very delicate method is opened 
up for investigating the construction of the cortical parts 
of the ^analysers, and it is possible to distinguish special 
areas in tho cortex relating to the different analysers 
such as the visual and auditory, from certain other cortical 
elements of those analysers, which are dispersed probably 
over the whole mass of tho cortex of the hemispheres Not 
only are these dispersed elements incapable of performing 


any higher synthesis and analysis, but they have a very 
low degree of vitality, as evidenced by tho rapidity of their 
transition into an inhibitory state under the infiuonco of 
external stimuli. 

ni. 

Tho conditions determining tho cliaractoristics and the 
magnitude of tho excitatory and tho inhibitory effects of 
conditional stimuli arc bcwilderingly complex, and are 
only gradually being registered and classified. 

It is obvious that tho magnitude of the positive effect is 
directly related to the amount of energy applied to tho 
receptor organ. Tho phenomenon of summation of weak 
stimuli conics out clearly. Tho limit of normal excitability 
and the optimum strength of stimulation are also definite. 
In tho case of very strong stimuli and of the summation of 
medium stimuli tho cxcitatoi-y process rapidly changes into 
an inhibitory one. Of course, tlio strength of stimulus is 
a relativo quantity, varying greatly with individual differ- 
otiCGs of nervous system. 

Since most probably the. points between which the now 
connexions aVo established arc in the cortex, it follows that 
tho variations in the effect of conditioned stimuli will ho 
dependent on tho inuthal relation between the different 
cortical points corresponding with the different conditioned 
stimuli, and also between the different points of those areas 
of the licmispberes which aro affected by tbo unconditioned 
stimulus. For instance, the conditioned stimuli based on 
food and acid respectively become ' connected -witli- tbo 
chemical analyser of the hemispheres, and therefore, if in 
the experiments both sets of conditioned stimuli aro used, 
their effect will be determined not only by the interrelation 
of . the points cbffcsponding to the stimuli, but also by tho 
relation existing between the alimentary and “acid’.’ points 
of the chemical analyser. ' 

IV. 

Tho accumulation of observations upon the normal and 
. pathological activities of the hemispborcs gives grounds 
for distinguishing various types of nervous system. There 
is the excitable type, 'which always displays, partial 'or 
completo failure when confronted by difficult relations' 
between the excitatory and inhibitory processes, and which, 
if the experiments are continued, ends by developing an 
abnormal and extremely protracted weakening of tho in- 
Iiibitory activity, attended by an exaggerated general 
excitation. At the other extreme stands tho inhibitable 
typo, which very easily becomes subjected to inhibition by 
stimuli cither unusual or slightly stronger than usual, and 
which, when confronted by comparatively difficult relations 
beta-een the excitatory and inhibitory processes, passes into 
a state of complete inhibition for prolonged periods of 
time. 

In between can be placed the well-balanced type which, 
successfully and without any signs of abnormality, estab- 
lishes in all cases a balance -between the opposed nervous 
processes. This type comprises two varieties qf animal, 
differing greatly from one another in external appearance 
-—the stolid animal, always quiet, and the animal wliicli is 
j lively under ordinary conditions, but becomes drowsy with 
[ surprising rapidity under monotonous conditions. Tho 
tatter variety lias some difficulty in obtaining a balance 
between the two processes. This grouping of tho types 
.of nervous system corresponds closely to the ancient classi- 
fication of temperaments; the excitable type — choleric 
temperament; the inhibitable type — melancholic; the quiet, 
balanced type— phlegmatic ; and tbo lively balanced typo — 
sanguine. 

[Dr. W. Horsley Gantt, in his Medical Review of Soviet 
Russia, which appeared in these columns from time lo titna 
during the last four years, makes frequent mention of Pavlov’s 
wort on conditioned reflexes. His first reference is in oiir 
issue of September 20th, 1929 (p. 533), where he deals with the 
work of Pavlov and his collaborators. In . this article Gantt 
notes that the recent work of this school on “ conditioned ” 
reflexes had already received attention in the liriiish Medical 
■Journal, and refers to our report of the International Physio- 
logical Congress held in Edinburgh in July, 1923, at which 
Pavlov delivered a lecture on this subject (see Journal, Aiiinist 
lUb, 1925, p. 256). The whole of Fart I of Section vf ot 
Gantt’s •• Review ” is given up- to Pavlov’s work, aiid consists 
chiefly of a most absorbing account of his researches concerning 
conditioned reflexes in the dog [Journal, June llth, 192^ " 
n. 1070).] 


810 may 12 , 1928 ] 


THE UAllVEY TERCENXENAuy. 


[ 


Tnr r.nmiB 
JfrntctL JotBXib 


Ifittsl) Jlttiical foiii-nal. 


SATHBEAT, JIAT 12T)!, 1928. 


THE HARVEY TERCENTENARY. 

wcfk (li‘lc";itc'- frimt 
vmivi-i'Jiitii's jiikI iiicilicjil 
sdcici If^ I liroii^lioiil (111- 
\v(ir!(( will iiK'cl in l.iniilon 
1(1 atli-nd ilic (•('l(.■ll^;lli(.lIl‘^ 
))i(i\n(iU(l l)>.tlu! liouti 
College (if i’livsiciiiiis <»f 
].(jn(Uiu in hoiKiiir (if llin 
lltrcc limidrcdlh iinnivcv- 
sai'V ol I lie [inldicalion of 
V.'illi;iiii 1 Iinacy’s "rent 
\vovl;.llu' Dr Mnlii Cniilir, 
in \\l\i(di lie jirovi'd foi- 
all iiiiio Id-' theory of 
(licj maimer in uliieh tin- 
blood cirenlaled. 

No pain^. have been spared lo make. (Ids oeeasion 
fully worthy ol the meinoia of Harvey. IIkj "real 
dii-eoxerer and the most, distineiiislual I'VIlow on 
the roll of tlint. College whieli noxv ()a\s him homage. 
It. it, fitting that this giithering should he coniiHiscd 
of representntix'cs of all nations, for llarxcy’K work 
is the coinuion hc'rituge of the world at large, 
and lor that reason this ctdebralion naaiginV.es no 
humidaries, cdther national or racial. .111, therefore, ' 
will meet together next \x'e(d< on common ground to do 
honour to the man who coufeired upon niuuUind one 
of its most signal benefit. s. The international cdiaracler 
of the celebration is impressed upon evc'Vy item of 
the programme. His Majesty the King has graciously 
consented to receive the delegates, thus setting his 
seal to the imiiortance of the event. At the recep- 
tion of the delegates at the College of Rhysieians by 
the President four creations of Honorary Fellows wiii 
be made which will be represeulat i\-e of t liose t hvough- 
out the world who have contributed so largely in our 
liine to the extension of the boundaries of mtaiieal and 
scientific knowledge. ^Jhe three distinguished men — 
Sir Charles Shorringlon, Professor Chaiiffard, and 
Professor Keibel — who xvill be called upon to (Icdiver 
eulogies of the great xvork of Haiwev will worthily 
represent the sum of medical and seiei'itific endcavouV 
wherever it exists, and at the dinner given by the 
College of Physiedans in the ancient Guildhall (>f the 
City the gathering xvill represent all nations, all shades 
of opinion, and all classes. Not Ica.st of the ceremonies 
will be the scientific demonstrations given at Univer- 
sity College by Sir Thomas Lewis and Hr. H. H. Halo 
on behalf of the College of Physieiiuis. Here I ho 
actual experiments of Harvey will be I'epcated, and 
by means of a clever cinematograph film the .audience 
■will be able to see, almost, ITarvey conducting his 
experiments as they were X'wdormed throe hundred 
years ago. Huring the celebrations also an oppor- 
tunity will be given to the delegates to inspect the 
treasures of the College of Physicians in the shaiac 
of books, manuscripts, portraits, and other objects of 
mtovest. Some of these relate to Harvex', such as 
ms autograph letters, the diploma given him hv the 



University of J’adim, the fir.st edition of the Dr Molit 
DoriDu, and (lie eljony ))oin(er used hv him for 
(he piirp()S(‘s of demonstration when delivering the 
Ltmilciim Leeliircs in wiiieli he first annonnecd the 
es.scnlial parts of Jiis (Iicory. 

From the foregoing the magniinde of the eclcbra- 
(inns will he nnmifesl, hut the imporlance of ITarvey s 
discovery may not la; so evident to all, and soiik' may 
not he iiiforin(;d oxaelly eonceniing the far-re.achiiig 
elTc.'cls of his work. Indeed, there can be little doubt 
that whik; (he central fact of Harvey’s discovery of (he 
eireitlalioii of the. blood is well known lo all, many are 
unaware, that he overthrew a llieory which had held 
(he inefhhal world in bondage for nearly fifteen hundred 
vears. It .luaamie.s onr duty, therefore, to describe 
(■(•rlain features of medical thought existing before 
llarxxw’s time, in order to ai>()reeia(o at its (me xvorth 
till' tremendous effeef of his di.seovery, and to show 
how it o\)ened Hie road down wiiieh siiccessive investi- 
gators have (ravelled to reaeh onr iireseiil-day triumphs 
in tile realms of jihvsiology and medicine. 

Until the heginiiing of tile sixteenth eenlury all the 
Imowledge possessed by Ihe uorld eoneorning medieiim 
and scienet' was obtained from the ancient trreek.s, and 
(hat Imowledge had been finally .systematized and 
reiliieeil to order by Galen, who /loiirished during the 
second eeiitury After him medical and sciontihc 

thomdil shiiiihered for thirleeii hundred years, and 
s„ paramount had his inlhienec Ixicome that if was 
r. oarded as impious to question Ins aiithorifx . 1 ho 

nsidi of lliis attitude was that medical- writers \\eio 
reduced to the sterile task of merely commenting upon 
what Galen had said, for to criticize, to doubt, or to 

0 ire w, as .ml permitted. Indeed, so great wJis 
Oaliai’s aiilliorifv that -Tolm Geyues, a l-ellow of the 
Gollis.e of Pliv.s'ici.ins, was in 1559 threatened with 
.Ti in f()r tliiviiv’ lo iinpugu U. Ibc 'wi'ilingA o£ 
tNleti' da il with alT branches of medicine, including 
t.ali.ti ,.,Kvftlolo-n- and he gave an explanation 

"f The’ wav in wWeh the’ blood performed Us function 
, uTv a on mUvition of the body. In order to 
1 . f. d the importance of Harvey’s discovei-y it 

mu emtaiKl iw 1 

,,,| be the circulation of the 

v;,y;ud the admirahic\lescription of that, theory. 

’• , ’h'v Hr Giuirles Singer will be quoted. It is as 

f'.lk ws - '• 'n>e food taken into the body became con- 
Sal i chyle by the intestines, and was earned 



S U. "--uf:::;tur;:.i ai;d endowed by the liver 

Jhehlo(^^d tl ^ the hepatic vein and the mtenor vena 
T e rig t skfe of the heart. Hem it was 
' , of Is impurities, which found egress by ineans 

\mlmonaiv artcrv and the lungs to the external 
“f ^ rp\ • veuous blood, thus purified, e’ohcd to and 
air. Hus ■ carried (.in the functions of mitri- 

r'^ But a ‘^nuill part of the venous blood Altered 
1 , he sei'uun of the heart, by means of invisible 

Ihioug 1 where it came^ mto 

pores in (a tl . reached that 

contact w i 1 iw e tlw 

ehambei bx UH the air and 

£'"io I«.i of sSS? 

the arterial blood xx'hich floxyed to the 

endowed there with the highest form of , x to 

hnoxvu as ‘Animal Spirit, ” and xx-as dislnbule 



CONSULTANTS AND THE NATIONAL HEALTH INSUBANCB BILL. 811 


■ May la,' 1928] 


Iho body by moans of tbo nei'vcs, which were believed 
to bo hoHow canals, and gave rise to the highest 
functions of motion and sensation." 

• Ifrom this description of the theory of Galen 
regarding the circulation of the blood it will be seen, 
therefore, that the main supports were: (1) the liver 
as the source of the veins and blood : (2) the communi- 
cation between the right and left side of the heart 
through minute and invisible pores in the septum 
between the ventricles; (3) the presence of three 
vitalizing essences; and (4) the absence of any circular 
movement of the blood propelled by the heart. This 
was the theory of circulation, based partly on anatomy, 
partly on hypothesis, and fantastic in the extreme, 
which was accepted for more than a thousand years 
solely on the great authority of Galen. Until it was 
overthrown it postponed and fettered any advance in 
physiology, much in the same way as the theory of 
D phlogiston ” held back any advance in chemistry. 

Bo the position remained until the sixteenth century, 
when, under the influence of the revival of learning, 
the mind began to free itself from its bonds, and when 
men began to summon up courage to doubt and to 
inquire. The first attack made upon the authority 
of Galen came from the anatomical side in tlie year 
1545, when Yesalius published his Dc Humani 
■Corporis Fabrica, a book in which he described what 
he himself had seen when dissecting, and not what 
authority asserted. With regard to the septum of 
the heart Yesalius admits at first that the invisible 
pores must be there, although he could not see them; 
later, however, he says boldly that they do not exist. 
Columbus, Cacsalpinus, and Servetus dealt with the 
lesser circulation, and Fabricius soon after described 
the valves in the veins. But they all lacked the power 
to draw the all-important conclusion. It was left for 
Harvey to make the discorerj’, and to give to the world 
the convincing proofs of his theory. This he did 
in his book, the Do Motu Cordis, published three 
liundred years ago. His first position was to establish 
the primacy of the heart as the great factor in the 
circulation. Prom e^eriments and observation Harvey 
saw clearly that the heart was a muscular organ 
always propelling the blood it had received from the 
veins to the tissues of the body. Then he asked him- 
self, Where did this blood thus propelled go, and 
whence came the blood in the veins to be carried to the 
heart? Prom quantitative estimations it was impos- 
sible to believe that the blood propelled by the heart 
could remain in the tissues, for he estimated that in 
an hour the heart propelled to the tissues more than 
the total amount of blood contained in the body. This 
observation forced on him the inevitable conclusion 
that the blood was always being propelled by the heart 
to the tissues, and that the same blood only could be 
carried back to the heart from the tissues by means 
of the veins; or, as Harvey says, “ I began to think 
whether there might not be a motion, as it were, in a 
ch’cle." With the adoption of this idea the direction 
and use of the valves in the veins became clear, .and 
also the direction and use of the valves in the heart 
and arteries. The thesis was therefore proved, the 
victory won, and Harvey takes his lawful place 
beside his peers, Copernicus, Galileo, Newton, and 
Darwin. The sight of the blood passing through the 
.capillaries was denied to Harvey, for the establish- 
ment of this fact was reserved for Malpighi, who 
was bom in 1628, the year of the publication of De 
‘Motu Cordis. With that fact proved, the theory of 
Harvey concerning the circulation of the blood became 
.unassailable and fixed. 


This great achievement of Harvey had far-reaching 
consequences. Before his advent no progress could 
be made in physiology, for its foundations were faulty. 
But after the acceptance of his theory advance was 
rapid and sure, and it is not too much to assert that 
it is entirely owing to his illuminating discovery that 
such signal triumphs in medical and physiological 
science have been registered ever since. As a mark 
of our appreciation of the immense debt we owe to 
William Harvey, the great founder of modern physio- 
logy, we present to his memory next week the homage 
of the world. 


, CONSULTANTS AND THE NATIONAL 

health insurance bill.- _ 

In a leading article on April 21st last (p. 677) we 
suggested that the National Health Insurance Bill 
now before Parliament ought to receive from the 
medical profession, and especially from those practising 
as consultants or specialists, ’more" attention than it 
seemed to be receiving; that in its present form it did 
not meet some of the most important requirenients 
of the profession; and that an endeavour should be 
made by the British Medical Association, particularly 
by the Insurance Acts Committee, to secure satis- 
factory explanations, assurances, and amendments. 
This endeavour has been promptly made; but we are 
obliged to return to the matter because, though the 
Minister of Health has satisfied one such requirement, 
the position remains quite serious in other respects. 
The bill as introduced would have made it difficult, 
perhaps impossible, for an insured person to receive 
medical advice and treatment by way of additional 
benefit from a specialist or consultant except at some 
clinic or charitable institution. By reason of an 
amendment, suggested by the Insurance Acts Com- 
mittee and accepted by the Minister, a more private 
mode of consultation will not be ruled out or dis- 
couraged. It will still require vigilance, however, in 
watching regulations and the clauses of suggested 
schemes to make sure that the Minister’s own 
principle, that “ no one must be compelled to go 
to a clinic if he would rather go to a private 
practitioner,” is fully maintained. 

Certain other amendments wei;6 suggested to the 
Minister which he has not felt himself able to accept. 
Yet if the object these amendments had in view is not 
by some means attained there may easily arise a 
situation which would not be consistent with the 
honour and interests of the profession, and in which 
the British Medical Association might have to advise 
its members not to take part in any, or in sorne 
particular, additional treatment benefit. The profession 
was of one mind in the earlier stages of national health 
insurance in saying that practitioners would not sub- 
mit to the administration and control of appro%'ed 
societies, even though this were to be governed by 
Regulations which might be made by a Minister of 
Health. It is to he expected that it will be equally of 
one mind in saying that the freedom which it won for 
general practitioners shall not be withheld from con- 
sultants and specialists. The bill as it stands definitely 
endangers this freedom in the case of consultants and 
specialists, if it does not, indeed, make it impossible. 

"Under the present Act no additional benefit which 
is "of the nature of medical benefit ” can be 
administered by an approved society. Of, the existing 
additional benefits there is one only which is un- 
questionably of this nature. This has never been 
operative; and is to be abolished by the new bilk. 


812 


MAY 12, 192 S] O 0 ^?SUt,XANTS AND TIIK NATIONAD HIvA DTII IHSPRANCE BHiD. 


t Xnr rnm« 


(US- 


Therefore, it is argued, _lho ’7urh!r\-e'i>o\U-d. 

al'-ilitv oil approved socioln's uui) ^ * ( 1 ,*^ 

Even so, the eouedusion does not ioHow froiii ih - 
toinisse;; and in any case (he pnnc.plo eunnlM^d 
L- the clause is so valuable that^ it might vc . 
allowed to stand even if it had no iiuiuediate ••'in''< 
tion. But the soundness of the arguim-nt dwa .p- am 
—even the good faith of (he arguinent_ seems h. di- 
appeai— when it is discovered (hat m one o1 i s 

schedules the bill intioduces fresh wor.ls inh. 1 m 

description of some of the other adihtional benehts 
which mako them clearly, not only in (he common 
acceptation of the. language, but according to Uie mosl 
authoritative legal opinion, “ of the nature ol medical 
benefit.” ‘‘ The payment of (he whole or ain part., ol 
the cost of treatment ” may, as mosl law\ers ag'cis 
not bo of that nature; but ” the pauneiit of (he wiiolc 
or any part of the cost of thr /iwii/k/oii e/ treatment 
certainly is. Under Ibis deserij.lion, aecompanied by 
the repeal of the restricting clause, it, seems evident that 
approved societies, without resorting to the indirect 
and doubtful methods now cin]iloycd, could themselves 
establish their own clinics for ophthalmic treat incut 
under Clause 13 of (he schedule, or for any oilier kind 
of specialist Ireatmeiil under Clause 16. lii this i 
way they might be in a position to selcet and eontiN)! ; 
Btafis, medieid and other, and largely to deterniiiie the ; 
character of the treatment to be (siiTied out. 

It is not suggested that the best of the appmved 
societies would wilfullv abuse their powers; and it is 
quite true that under the bill they would not be eom- 
pletely free to do as they liked, bul would he gnverneii 
by Eegulntions to be made b_N the itfiiiister of Health. 

It is not suggested, either, that the llegulaiioiis would 
be unreasonable or improper, or that the ]irofcssion, 
Ibrougli (he British Medical Association, would not bo 
consulted with regard to them or be willioiit its 
influence upon them, as is now the case. In the event 
contemplated such regulating would he not oiih useful, 
but imperative. The protection of Stataite La\y is, 
however, better than the jirotection of Ilegulations; 
and the consultants and specialists cannot coni eiiiplaf-e 
with equanimity a slate of afltaii's wliiidi would eoin]Hd 
them -either to abandon a legitimate sphere ol practice 
or to submit to objectionable conditions which the 
esperieiioe of another branch of their profession has 
proved to bo inlolcmblc. 

Either the words ‘‘ the provision of,” italicized 
above in the description -of additional benefits, sliould 
be deleted, or the restricting subsection of Section 75 
of the Aet of 1924 should be allowed to stand, or 
should be so amended as to maintain tlic principle 
■ that when an additional benefit is -of the nature of 
medical benefit, in whatever other way it may he 
administered at least it shall not be adininist-cred by 
an approved society. The present situation -is a .serious 
one for a considerable section of those engaged in con- 
•sullant and specialist practice. The importance of 
securing, if it be possible, one or other of these amend- 
ments is great, not only to them, but to the whole 
pi-ofession, in order to maintain its ti-aditious and inde- 
pendence intact. Even if there be failure to aeciu'c 
such amendments it will, of course, .still be possible 
for the profession to withhold its services from a society 
or to refuse to give medical advice and (rcatmeuit 
under Eegulations to ■which it objects ; but it may 
j-et be that a realization of the position and of the 
reasonableness of the request may lead the Govern- 
ment or Parliament to avoid such an undesirable 
situation. To secure this, ho'wever, the proles-sion 
luiist itself bo not merely alert, but active. " Jt is 
not enougli to. wHl,' we must also do.” 


GLAUCOMA. 

It is only a few generations since physiology was 
considered an uniniporlinit fragment in the subject of 
niialoiiiv, and hardly iiinrc than one generation sinco 
bioclicii'iisiry was biiVcly recognized as an entity at all. 
To-day the' Whole of the slniclurc of medicine and 
fur''cry is slowJv being consolidated on the basis of 
i.Ii "sio'logical facts, and physiology itself is being 
hit'vrpivted and ‘-1 lulled ipore and more tlirougli the 
iiH-dimn of (be still more fniuhuncntal .science of 
hioehcmislrv. 'I'liei-e are few jiroblcms of patlio og.y 
where this (.•ndeney is seen more evidently than that 
of the eliologv -of glaucoma. For years it has been the 
subject of iii'quiry and invcsti^ition ; but 
work has hc-eii directed along the lines of patholog cal 
amiioinv and gross end-results, the problem has 
remained obscure. In his sng.ccstivc lecture, which 
■mneavs in this is^iie. Dr. (Maitland Eainsay has mdi- 
i-aled how the trend of recent work i.s ilirowmg new 

even 
that 

some deeper insight into it is being gamed,- and some 
a w n v l ive been -made whicl. cannot but bear fi-u.F 

Sk- 


.-d how the trend of recent work ks ilirowmg n 
1 1 unon the maUor, and althongh the problem is 

1 .-. «"l'-i'il in tins .way., il ' 


1 ilint. lUC liUtlUlh , 

tennneo fquestTon 

eond.lions shonld fi^ nuthoritics are 

whieli n t.iiuiu Trom bio 


eye 'vhicli dithis probable 



^neral biological Hrfv its own 


eafisfv its own 

every jyr' Eamsay aptly puts it. 

peculiar nccu . , chaicture are necc.ssary for 

!• ultbough pecuhanUos » ^ Uie body, 

"’t r’”r S t S.»o?Solo!;t».l inr"' 
St'la.'k a»i=»>~l!,"»b"lt'nSi»r.i 11... ...00.1 


IS I UUJi. ^ f XT 

-r- ■ f with the circulation of the 

An the consequent change in the 

through '"•j \,;o^ylar fluids, aro two of ibc out- 
nalm-c uUach of acute glaucoimb and 


standing fcMnres conclusion that the 

all the evidence p pc found in that 

essentia cause of th^ vitaUdiaiiges 

part of the e mu ,g „ ,],s. 

take place t clrcnlation, leading to 

turbanec n this p capillary walls, accompanied 

ni-al ;bl« pcrmcabifitv. WkBwt the cause of 

.mereased pci obscure; presunif 


or duo to some substance “ ^ its 

plaLna-like^ fluid into the tissue spaces of the oy . 
with a consequent rise of pressure. ns to 

Tire matter,' however, is not fol 

be without any other complicating 


MAY io^S] 


“FRIEI^DS OF THE OLt> ASHMOLEAN.' 


• r Tjiv 7>Rrn3tt . 
LJIkMCJI. JOtXSAI. 


logicnllv the iutYnoculnr prc';s\ire is elimiginl hy larfors 
ol'hor iiinn ilio slnlc of the capiUnrios, anri pafho- 
logicaliy gi'cat risos of i nnsion tian bo nioi. wilb in ens^js 
■vvhoreiu the gnliro ovoal tTncl, oonininiiig the gi-ont 
mass of ociilnv capillaries, is compressod almost out 
of existence fay somctlims else, 'i’iic appcai-ancc of 
n glavicomatous eye, xvilK fhc lens pushed fonvards 
and fhc auferior chamber shallow, suggests forcibly 
Ihnt this factor is a swelliug of the vitreous. This 
swhstance is a colloid, and it is' found under expori- 
inental conditions to he cnpufalo of a considerable 
amount of swelling-, but Iho conditions detenniuing 
the volume changes of saicii a mass arc as yet imper- 
fectly knomi. Colloid chemistry is a science even 
younger than hiochomistry. Hei-c. again the cjiusal 
factors are chemical in nature, most probably of 
general nictaboUc origin, and their assessment and 
elucidation is one of the most interesting an<l impor- 
tairt appliftitions of biochcmista-\-, which must in fhc 
meanwhile be left to llic future. The trouble is that 
‘‘glaucoma ” is not a disease, but a symptom common 
to niany diseases, and it is illogical to look for an 
explanation of every rise of intraocular piussurc along 
tile rsnmc lines. It is one of those problems which 
become more eomplieat'od the more they are investi- 
gated, but which for flic same reason hecoiiic more 
faseinating. 


“FRIENDS OF THE OLD ASHMOLEAN.” 

A SoetKTY of Friemls of the Old .Asliraoloau was foriiioil 
at a meeting held at the house of the Roj'al Society of 
Medicine on May ^nd, under the chnirniaudiip of Sir 
Rnnijilwy Rolleston. Tlic purpose of the society u dl i>o 
to assist in the ivstoration of the Old .Ashmolean huihling 
at Oxford as a pnl)!ic AsUmolean Museum of the history 
of science. The gift to Oxford aliont i'lvs' yo.ars .ago of 
the I/ewis Evans <:Dll(X.'tioii of scientific instninienls has 
maslc the scheme possible, and it is hoped to provide, 
hy means of annual snhscri]itinns, for the purchase of 
desirahio ohjccts of historic scientific interest to add to 
the collection, 'flie Uuirersity has shown appnwat hy 
allotting the upper room in tiic. Old .tsJimoh'aii building 
for this purpose, and several of the; colleges and .ertain 
city companies have given financial assistance. But it 
is hoped that the new society may render further assist- 
ance in the acquisition and consei-vatioii of objects of 
scientific and medical interest, iiesidt-s securing tiie Old 
Ashmoleaii wlioily as a sc'ientific institution in tlie Tniver- 
just as Sir Tlioinas Bodlej- restored the libnuy tliat 
now bears his name. Sir Humphi-y Roilcston reniinded 
tlio gathering that tlic Old Af-hmolean was named after 
and provided with a local habitation by Elias -Ashniole, 
the famous antiquary, in 1683. This had tlie distinction 
of lieing the oldest mnsenin for natural histoiy in the 
Ivingdoiu. Its recent rebirth as tlio lewis Evans collection 
of scientific instninienls nvis due to Mr. R. T. Gunther, 
who, among many other acts of devotion to science in 
Oxford, collected the stld scientiric inslrnments for exhibi- 
tion for- the presidential address given before the Classical 
Association in 1319 hy Sir William Osier, “ who being dead 
yet speaketh.” Mr. Gnnther then gave some details of 
the aims and imrposes in achieving irhat the chairman had 
called " this pious act,” and said that the I,ewis- 33vaiis 
collection was in nrgeut need of more space- Tlio present 
time svas favourable for the lestoralion of tlio building. 
The great Oxford KixjUfli Dirtionmy was completed, and 
the book stacks which had hlockcl up the rest of the 
exhibition space in the old mnsenm might readily be 
GVacuat-ed as part of any Bodleian extension scheme; two 
such schemes were now under consideration. Sir Hinnplirv 
Rollcston, in a few further remarks, discussed some special 


reasons in favour of the project. Knowledge of a science, 
ho -said, was inf'omidctc without an acquaintance with the 
history of its dcvclopuu'nt to .supply guidance in avoiding 
pitfalls and fallacies, ami to .suggest fresh avenues for 
investigation. I'kir such a histoiy recourse was usually- 
made to lioolcs, hut a museum was auotlier .source of 
.information, and in .some ways the ■complonient of a library. 
Kot only in the sciences hut in the arts was a museum 
disjilaying instruments and inachinei-y of great value. 
Medicine, struggling to become some day an c.vact science, 
was or should be an applied science, and a collection of 
inslruincnts illustiating the way in which the applications 
of science had led to its advance was Iieyond question most 
■instructive. Sir Humphry gave one example of the way 
in rrliieh iiisti-umouts of pincision had not' only .added 
.to laiowledge, hut stimulated investigation — namely, 
Ijacnncc’s introdnetion in 1819 of auscultation by . means 
of the stethoscope. Auscultation had been practised heforo 
that date, but psydiologically . the possession of a new 
instrinnent served as a spur to Iiacnncc to pay most careful 
•and prolonged attention to tlio sounds that could lie heard 
in the chest. It was much the same with regard to Piorryls 
pleximotei- and mediate percussion,- which in itself, and 
apart from its teuiporaTT influcnc-c in stimulating investiga- 
tion, was inferior as a method of eliciting physical signs 
to Auciibrugger’s long-neglected direct percussion, which it 
was intended to snjiprscde. Tlic debt cardiology owed to 
tiic po!ygTa]>li, the clDctro-cardiograph, the ortliodiascope, 
and the sphygmograph neerl not he laboured, nor, in other- 
fields, tile value of tlie thermometer, the mia-oscope, and 
so forth. Medieinc levied heavy contributions fr-oni the 
more exact sciences, and dcpemlcd ior its advance largely 
on their assistance. In vctuni fov' these gifts it was meet 
and right tliat medical men, not only those interested in 
its history, but all who looked to its, future with a lively 
sense of benefits to come, should contribute of their 
syinpatliy in a practical form. Tho scheme was then sup- 
ported ill .short spcoclms hy Dr. E. B. Knnhol, speaking 
fioni the paint of view of astronomy; Dr.' AV. T. Caiman, 
from that of zoology; Dr. A. G. Gihson, patliology; .Sir 
George Fordham, caitograpliy; and by Professor -A. . F. 
.Boycott and othois. The resolution approving of the 
formation of a Society of Prfciids of the Old .Aslimolcan 
wa-s moved by Sir D’.Arcy • Power and seconded by Dr. 
Dixey, and carried. Among Uiose who sent Icttci-s of 
regret at imilnlity to be present and approved tlie purpaso 
of the. gatlierii-u' . were I/ord Crawford, Sir Fai-quhar 
Buzzard, Sir .A-rchib.ald Gimod, and Professor G. Elliot 
Smith. It is understood that a meeting of the new .society 
will he held aiiiiiially at Oxfoi-d, when accessions to the 
•collections will be • exhibited. Tlic minimum subscriptiou 
Is 5s. a year; it may Jjo sent to tiso Treasurcr of the Friends 
of the Old .-Vsliinoleau, at Barc-lays Old Bank, Oxford. 


WELFARE OF THE BUND. 

The Seventh aiuivial report of tho .Advisory Committee on 
the Wolfaro of the Bliiid to the Alinistcr of Hcaltid shows 
that there is increasing knowledge of and caro of the blind 
ill this country. There has been a growing tale of the blind, 
due without doubt to tho discovery of case.s brought about 
by recent legislation. There arc known to he 17,252 blind 
persons botiveen tho ages of 50 and 70 ycai-s, ;uid of these 
no loss than 84 per cent, are' in i-ooeipt of benefits luidcr 
the' Blind Persons .Act. The annual value of the pensinns 
granted is £364,000. This sum, together iritli tiie 
Exchequer grants payable in respect of sjiecific .services 
for the blind, repicsents a very substantial State contri- 
bution towards the cast of making provision for, the blind. 
The Stato grants and pen.sions have released voluiitan- 
finids for other purposes, such as tho relief of hliiid persons 

* Semitii Jlrimrt of tho Aitrirnry f ouimittfc on the n'otfare of the EtinJ, 
I0fC~CT. Loudon ; Stationers Office. 1523. 6d. net. 




NON-TUBERCUIiOXIS FIBROSIS OF THE LONG. 


t TnzBRTTin 
MxDicii. JoinuiAS 


815 


MA\’ li, 1928] 


of vpocial lu'ils fill- tlio lubiMcuIoits; and Im thiiilts that 
Fi-aiu'o lU'i'ds 40,000 111010 hods, at a cost of 880 millions of 
fi-aiips ! Snroly a pvopositioii liko this l oqnives the careful 
ronsidoratioii of all possible figiives of incidoncc and inor- 
talitv in various coniitrios hofore salvation is sought at 
snob a cost. JCoroovor, it would bo iiitorostiiig to learn 
how far the roinnval of soiircos of infection to special bods 
is VilcoU- to excel the Granclior system and Professor 
Caliiiotte’s vaccination with B.C.G. The boardiiig-oiit of 
the very young is dealt with in an article in La Vie 
Mi'iiicnh by Professor Leon Bernard, and Dr. G. Poix 
writes on tbe results of six years’ preventive vaccination 
against tnbercnlosis. It is evident that many doctors in 
France are looking to preventive vacciiintioii as a means of 
largely rednciiig the mortality fi-om tnbercnlosis. 


NON-TUBERCULOUS FIBROSIS OF THE LUNG 
IN CHILDREN. 

Anv method of differentiating tuberenlons and 11011- 
tuberenions primary fibrosis is always of great interest. 
Ill a paper in tho February issno of the Archicef 0 / Dhense 
la (/7iih//iOad‘ Drs. Agassir. aiid Gill reported tbe results of 
the study of a nnmbcr of cases of non-tnberenlons fibrosis 
in clii’drcn. In tho 37 cases examined there was a family 
history of tnborentosis in 2 only; there was also a previous 
history of measles, wlioopiiig-congh, or pnennionia in a 
largo proportion. The authors are inclined to distinguish 
between pulmonary fibrosis and broiichioetasis, and they 
■suggest that since fibrosis pi-ceedos bronchiectasis it is 
possiblo that the former may • exist without the latter. 
They found that cough was frequent, expectoration .slight, 
dyspnoea not complained of, liacmojitysis rare, and cyanosis 
a constant sign of this disease. Tho temperature charts 
were normal, except for an occasional i i.se wlicn a portion 
. of the lung became inflamed in non-tubcrculons fibrosis, 
while in tnborculosis tho leinperatnre was as a mlo 
constantly aliovo iiortnal. .\'-ray examination revealed a 
defloction of the mediastinal contents in iion-tuberculous 
fibrosis, and the basal lobes were more commonly affected. 
In tuberculosis there is a mottling or woolfiuess throughout 
the lung, more marked in tlie region of tho apex. Examining 
the blood for its oxygen content, these authors conclude that 
in fibrosis tho blood oxygen content is diminished, whereas 
ill tnbercnlosis the blood oxygen content should bo normal 
except in massive infection of the lung. In fibrosis where 
tuberculosis develops later the oxvgcn content should 
increase ivitli the advance of the tuberculosis, whereas in 
a healing and fibrosing tuberculous condition tho blood 
p^ygen content should decrease as healing proceeds. They 
believe that the prognosis of noii-tuberculous fibrosis of the 
lungs is very much better than that of pulmonary tuber- 
culosis.^ Ordinary open-air treatment in convalescent homos 
or .sanatoriums for children is very suitable in this disease. 


INTERNATIONAL CONFERENCE ON CANCER. 

As announced in ^ur issue of April 14th (p. 640), an 
International Conference on Cancer, convcnetl by tbe 
British Empire Cancer Campaign, will be held from J11I3’ 
16th to 20th in London, at tho lioiiM} of tho Ro^'al Society 
of llodiciiio. Physicians, surgeons, pathologists, and radio- 
logists from all parts of the world whoso work has been 
closolv associated with iuqnii-j- into tho causes and cure of 
cancer will attend, and the Koval Society and all tho 
principal universities, medical schools, and scientific bodies 
of this country have appointed delegates. Sir John Bland- 
Sutioii, Bt., vice-chairman of tho Grand Council of the 

3, Xo. 13. I'.-tied by the Britiph JIctHcal Association. London; 
llon-e, T.avi-iock Sf(ttarc, W.C.l. Yearly subscription (6 numbersl 
■25'. Single uunibor, 4s. 6d. - ■ * 


Cnmpaign, will preside, and >Sir Richard Garton, chairinan 
of tho Finance Committee, is acting as honorary secretary 
of the Conference. Ou Wednesday, July 18th, H.R.H. tho 
Duke of York, President of tho Campaign, and the Dnche.s.s 
of York will receive the delegates and their wives at 
Lancaster House (Loiulon Mnseniu), which has Iicimi lent 
by the trustees for thi.s purpose. 


ROCKEFELLER MEDICAL FELLOWSHIPS. 

Tjik Rockefeller Medical Fellowships for tho academic year 
1928-29 will shortly be awarded by the Medical Research' 
Council, and applications should bo lodged with tbe Council 
not later than Juno 1st next. These Fellowships are )iro- 
vided from a fund with which the Medical Research Council 
has been entnistod lij- tbe Rockefeller Foundation. 
Fellowships arc awardctl by tlio Council, in accordance with 
the desire of the Foundation, to graduates who have had 
seme training in research work in the primary sciences of 
medicine or in clinical medicine or suigcrj-, and are likely 
to profit hy a jioriod of work at a university or other chosen 
centre in the United States before taking up positions for 
higher teaching or research in the British Isles. -A FcUow- 
sliip will have the value of not less than £350 a year for 
a single Fellow, with extra allowance for a married Follow, 
payable monthly in advance. Tinvelling expenses and some 
other allowances will be made in addition. Full particulars 
and forms of application are obtainable from the Secretary, 
Jlcdical Research Council, 15, York Buildings, Adclplii, 
London, W.C.2. 


Dk. Geouce H. F. NutWll, F.E-.S'., Quick Professor of 
Biology in the Uuivorsity of Cambridge, ' lias been elected 
a foreign con-esponding •member .of the Academy of 
Medicine, Paris. 


The aunnal general meeting and conversazione of the 
Medical Society of London, an-anged for Jlondayi May 
14th, has been postponed to Monday, May 21st, 'when Sir 
Archibald Garrod will deliver an oration entitled “ LeUons 
on rare maladies ” at 9 p.m. 


The Royal Society of Tropical Medicine and Hygiene 
will celebrate tbe twenty-fii’st annivci-sary of its fonndatiou 
by a dinner at the Cafe Royal on Wednesday, Jime 20th, 
at 8 o’clock, when the Right Hon. L. S. Amei’y, MJ., 
Secretaiy of State for Dominions and for tho Colonies, 
will be tb.e principal guest. 


As yve go to press wo have received a report, prepared for 
the Alinistry of Healtli by Dr. J. Alison Glover, on non- 
specific chronic arthritis, with sjiccial reference to the 
provision of treatment.' This is the third of a series of 
reports from tho same pen concerned with public health 
preventive aspects of tho so-called “ rheumatic ” diseases. 
The fii-st, which dealt with the incidence of these disahling 
conditions in adult insured persons, was noticed in om" 
columns on March 1st, 1924 (p. 395). The second dealt 
with acute rheumatism in childhood in its relation to heart 
disease, and was reviewed on July 3Qtli, 1G27 (p. 187). 
Like those earlier documents, the present one is intended 
both tor the nso of medical practitioners and tor tho 
guidance of the lay public. An appendix by Dr. R. 
Forteseno Fox and Dr. Margarethe Alautner de.scribcs the 
treatment of rheumatic diseases by physical methods in 
Germany. We Iiopo to notice the report in some .detail in 
an early issue. • 

' Reports on Public Health and ifedical Subjects, No. KL London : 
H.M. Stationery Ofiicc- Is. 6d. set. . ’ 


816 May 12, 1928] 


THE IIARVEX OnAPED AT HEMPSTEAD, 


f Tfir Ilnmni 
Sfr htr*!. JtfTSjrtt 


%\)t UarltriT Cljajjcl at Itcmpstratr. 

BV tnr. BATE 

SIR DAWSON WJLLTAl^IS. 


William Hahvey died in his cighlicth vcnr on Juno 
3rd, 1657, at the house of his brother Elinb at 
Eoehampton. This brother had, about the year 1647, 
acquired by purchase from Sir Charles Alordaunt rhc 
Manor of Winslow (or Wincelow) at Ilompstead a 
small Essex village situate about seven miles cast 
of Saffron Walden and some fifty miles from London. 
The church, in which is a chape' known as the Ilnrvcy 
Chapel, was originally 8 Norman structure, dating 
from the reign of William Rufus, who in 1089 settled 
it on Battle Abbey, Sussex. A late Norman font and 
fragments of the 
Norman chancel are 
preserved in the 
existing church. 

The church was 
rebuilt about tbe 
year 1340 in the 
Decorated Gothic 
style, the four 
clustered pillars, 
supporting pointed 
arches, separating 
each of the aisles 
from tbe nave, 
being highly orna- 
mental and beauti- 
ful. The Harvey 
Chapel, on the 
north side of the 
chancel, is a plain 
rectangular brick 
building, with a 
high-pitch tile roof, 
and lighted by a 
large triple - light 
window. This chapel 
contains sixteenth 
century memorial 
brasses of a date 
prior to its asso- 
ciation with the 
Harvey family. 

Beneath the chapel 
Eliab Harvey had 
in the year 1655 
built an outer vault 
as a sepulchre for his family; and it was here, ns 
we shall see, that the mortal remains of the cwcnt 
William Harvey were first laid. The fabric of the 
Early English church still exists, except that about 
one-third of the west end of the nave was destroyed 
when the tower fell in 1881, and was rebuilt in 1884 
at the cost of upwards of £2,000. 

The church contains altogether some nine brasses 
dating from 1472 to 1530, to representatives of families 
resident at the three ancient manors of the parish . 
The memorials to rhembers of the Harvey family 
in the chapel begin with Eliab, who.oivned and occu- 
pied one of these manors, his wife, and children, and 
descend to another William Harvey and his wife 
shown in a pair of very striking 
The^ Roubiliac, the famous sculptor. 

also a fine memorial tablet to Admiral Sir 



Marble Earoophagua containing tile remains of William Harvey. Ererlod by tlio Koyal 
College of Physicians in llcmpslcad Church, Essex, low. 


Elinb Hnn-cy, who was in command of ilic Temvraire, 
chosen by Lord Nelson lo ho his supporting ship, nt 
the bnlllc of 'J'rnfaignr. 'J’hc earliest memorial in the 
church is Iho exceedingly ‘ini cresting ihirleenlh 
century mnriile tablet in the floor of the chancel with 
a Norman-French hiscrijition, dccipliornblo only by 
the indentations in the stone from which the inlaid 
lettering has been displaced and lost. The rending is: 

‘ Dame Margeric do Basingge gist lei Dieu do sa 
nlmo cit morei Amen in'English, “ Lady Arnrgerie 
dc Basing licfli here; May God tipbh Iwr .soiil- have 

■ mercy, Arneu.” 
Again-,- .nnolhcr 
interesting • relic "is 
• an heraldic lipirnot 
set' ' on . an iron 
hrncket above the 
.-pulpit, f;imriohntc(\ 
by t lie Harvey- crest 
— a hand supporting 
h crescent at the 
finger-tips.. ' . ' 

- • . Tlie sarcophagus 
.containing .'.the re- 
mains of . Williard 
Harvey himself is 
wfithin the chapel,' 
but the nphiiihent 
' td'- him is just' out- 
side" on the north 
VnlL of the' nave. 
It .consists of. a 
marble bust, with ‘ 
his arms above, and 
a long find. laudatory 
Latin inscription 
below. The bust is 
sot in a niche,' over 
which is' a' small 
arched ' p 9 cl i m e'n t 
having, ' upbn its 
rising ' sides, ^ , tw;6 
ciipids .in 'pqsturp 
of distress, 'one of 
which is represented 
holding in his band 
a death’s head. The 
monument is a composition of black and white marble, 
veined Sir Benjamin Ward Eicliarclson, who tooK 
a ci-oat interest in all that pertained to the last 
resting-place of Harvey, came lo the conclusion that 
this bust had been copied from a cast of the face 
of Harvev talcen after his death; in this opinion he 
was supported by Mr. Woollier, R.A., who visited 

the church in 1878. . . 

Eliab who was Harvey s executor, resolved that ms 
brother’s bodv should be placed in the family 
had constructed. The funeral started fi'om 
on June 26th, and was followed far beyond the City 
walls by a large number of the Fellows of the Colleoe 

of Physicians. , . , i 

Harvey’s body was simply wrapped in lead Y’ltiiou 

a coffin, which seems to have been a custom 
to the Harvey family. The leaden case used loi 



5 tAY t2, 1928] 


TTIE HARVEY CnAPEE AT nEMPSTEAT). 


r T«e BRnTm 
L JlrOXCAl^ JOCRNAI. 


817 


Witiiani llavvoy \vu« roughly shiiped in Iho form of a 
body, If.iving a head, neck, and shoulders, from wliich 
if gradn.dly tapered towards the feef, wliere it was 
turned up at a right angle. It had a broad hreaslplaie 
with the following inscription in raised letters : 

DOCTOR 

WILLIAM HARVEY 
DECEASED THE 3 
OF JUNE 1657 
AGED 79 YEARS. 

\\lion visited in 1847 by Eicdiardson, and again in 
1659 and 1868 by Dr. A. P. Stewart and Dr. (aflrw- 
wards Sir) Richard Quaiu, the leaden shell lav upon 



the floor just beneath a small window in the eastern 
«all. J he suggestion arose that the remains should 
be wniovtal to M est minster Abhev. and was favoured 
b\ Dc.an Stanley; but he ivas then in failing health, 
' clone until m*'.tters were brought to 

. cusis 111 •Jaiiuaia , 1882, by the fall of the tower of 
the church ho chamage was done to the Haiwey 
U apel, but tlie College of Physicians decided to take 

fn \Yard Richardson reported 

to the College m February, 1882, that the lead of 

® S?'“g fast, and suggested tlint the 

lemaiua should he raised to the Harvev Chapel above 

appointed a committee, 
consisting of Sir Wdlinm Jeniier (President)’, Sir 
lames Risdon Bennett. Sir Henry Pitman, and Drs 
Simekmg, Richardson, Iredcrick Fan-c. Quain,' and 
- . P. Stew ait. It was decided to keep the remains at 


Hempstead, but to remove them to the Chapel above 
the vault and. to place the .leaden case in a sarco- 
phagus. The floor of the Chapel was strengthened 
by pillars built in the vault, and a plain sarcophagus 
of pure white Carrara m.arble provided. The raemoriul 
was designed and carried out by Maile and Sons of 
Elision Road. 

The following inscription was placed at the head of 
the sarcophagus : 


WILLIAH HARVEY 
Born 1578. Died 1657. 

The following was cngi'aved on one side; 

The rciaaias of William Harvey 
Discoverer of the Circolafioii of (he Blood 
were reverentially placed in tliis sarcopliagus by 
Uie Royal College of Physicians of London 
in the year 1883. 

A leaden case was also prepared, in which was 
placed the edition of the works of Harvey published 
in Latin by Ibc Royal Cbiiego of Physicians of London 
111 1766, and edited by Drs. Akensidc and Lawrence. 
On one side of tins -was' engraved : 

-GHUELIII HARVEII 
Opera Omnia 
. Edita 
IIDCCLXVI. 

On the other side was inscribed : 

■■ The complete works of William Harvey 
deposited October 18th, 1883. 

A memorial bottle, liei-metically closed, was also 
prepared andwvas wrapped iii lead. In it was placed a 
inemorial,. engrossed on vellum by Messrs. Harrison 
of St. Martin’s Lane. The leaden case enclosin® the 
bottle bad inscribed upon it ; ° 




Deposited October 18th_, 1883. 

The following is a copy of the memorial itself ; 

“ f';® William Harvey lapt in lead .simply soldered 

w. as laid '''tbmit sbell or enclosure of any kind in the Harvev 
\ aoH of tins Chuicb of Hempstead Essex, in June 1657. 

In the course of time the lead enclosing the remains was 
from exposure and natural decay so seriouslv damaged as to 
endanger Us preservation rendering some rep.air of it the dutv 
of those nUerested in the memory of the illustrious discoverer 
Of the circulation of tlie Blood. ■ i 'tfier 

“The Royal College of Physicians of .which corporate bodv 
Haivey was a mimificent Benefactor and whicli hv^ his f.avouV 
the possessor in perpetuity of his pafrimoni.aI Estate u 
Buimaish, Kent, did m the years 1882-83 by permission of the 
RcTOtatives of the Harvey family undertaL that duty 
el, ^ »®® 0 )d“nce with this determination the leaden mortiiavv 
r as repaired ^ 

the Haiw-eV f Representatives of 

the Haney family and of the President, all the office-bearers 
and many other Fellows of the College of Physici.aus whose 
the’Mae” was reverently m.nslatod from 

its •eee'^'t-^ ' ^ raised bv the College for 

Its reception and preservation.” ^ 

Hie scroll was signed by four members of the 
ttarvey family, and by the President,- Censors 
reasnrer,^ Registrar, Haiweian Librarian, and a 
mimber ot Fellows of tho College,- who attended at 
Hempstead on St. Luke’s Day (October IStli), 1883 
-the leaden coftm was then raised to the churchyard 
and carried up the nave and aisle into the H.orrev 
Sw ’ f Pf«-bearoi-s being eight Fellows of the 
College, of whom the last survivor was Sir Dyce 
Duckworth, who died last January. ,At the concliS 



818 may 12, 192S] 


HARTEY TERCENTENARY CELEBRATIONS. 


[ 


Tnt numtii 
IfrMfiL JorR'Tii 


of a short scr%'ico tho leaden shell was lowered into 
the sarcophagus, and the President of the College 
placed the case containing the scroll in a glass bottle 
and the metal box containing tho copy of Jlnrvcy's 
v.’orks also in a bottle, beside the leaden conin in the 
interior of tho sarcophagus. 


'Note . — Sir D’Arcy Power .saj's, in his blasters of Mcdiciiio 
Sciies, that tho marble momunont containing the bust of 
William Harvey is “ high in tho wall of tho Church at 
Hempstead.” Tho ornamentation of tho tablet is hold 
and effective, and below tho bust is a long Latin in.scrip- 
tion. Ho .quotes from tho report of Mr. Thomas AVoolncr, 
R.A., as follows: ” Tho features ju'cscntcd by tho bust aro 
clearly those of a dead face. Tho sculptor exhibits no 
knowledge of sculjjturc cxccjit nhen ho was copying what 
was directly before him. With tho cast of tho face for his 
copy ho has shown tnio artistic delineation, hut all that 
ho has been obliged to add to mako up tho bust as it stands 
is of the worst possible quality. Tlio oars arc i)lncod 
entirely out of position, tho largo redundant head of hair 
is altogether out of character, imaginary, and badly 
executed, and the drapery of tho should'crs is simply 
despicable.” ' 

Tho Latin inscription upon tho original memorial to 
Harvey reads: 

GULIELMU.S IIARVEIU.S 
Cui tarn coicndo Nomini assurpimt oiniics Ao.uIcmiao 
Qui diurnum Sanguinis molum Post tot Amioniiu 
Millia Primus invciiit 
Orbi Salutcm Sibi immortalitatcm 
. Consequutus. 

Qm ortum ct goncrationcm Annimnliurn Solus omnium 
A Pscudophilosopliia Liberauit 
Cui debet 

Quod sibi inuoluit liumanum genus Seipsam medicina. 

Screnis Jlnjcstat: Jaw bo ct Carolo Brilanniarum Monarchis 
Arciiialrus, ct ebarissimus 

Collcg : Mod : Lend : Anatomos ct Chirurgiao Profe.ssor 
Assiduus, ct foclicissimus 
Quibus Illuslrcm Construxit Ribliolbccam 
.Suoq, Dotauit ct Ditauit Palrimonio. 

Tandem 

Post triumpb.alcs 

Contemplando, Sanando, inveniendo, 

Sudores, ' 

Varias domi forisq. Statuas Quum lotum circuit 
Microcosmum Mcdicinac Doctor ac Medicorum 
Improles Obdormiuit. 

111° Junii Anno Salutis ClOlOCLVll, Actalis LXXX° 
Annorum ct Famao Satur. 

BESURGESIUS. 

Of tins a liberal English tr.anslation (by tho Rov 
^101^"" Hempstead) is Ts 

WILLIAM HARVEY 

to which honoured name all the Univcr.5ilii;s 
SWI r. sraatest veneration : 

Mho after so many thousand years fust discovered 
the constant circulation of the blood 

obtaining thereby health to tho world and immortality to 
himself •' 

Who alono of all men r^eued the birth and generation of animals 
from false philosopli}' 'tinmais 

To whom mankind aro “aebted ter tho knowledge of nicdicino 

Cliief and dearly-loved physician to their Serene Mijeslies 
James and Charles, Kings of Britain- * 

Diligent and successful professor of anatomy and eiirrrev,. • 
College of Physicians at London; ^ 

for whom he erected, and endowed with his’ own estate 
a magnificent library. ’ 

At length 

after labouring with success in his studies, in Iiis practice and ’’ 
his discoveries, ’ 

And after many statues had been erected both at homo aud 
abroad, 

When, he had encompassed tho whole order of Medicine and of 
Medical Science, this learned man 

died -vYithout issue on tho Third of June in the year of our 
Lord 1657, of his age the 80th, 

Full of Years and Honour. 

"WB SH.4LIi RISE AGAIN. 


nAUYJA' TJtROENTKKAHY OELEIiRATIOXS. 

MAY Hth to ISi'ir, J!>28, 

Tniioft.it the courte.sy of tlio I’rc.sideiit .ami liogistrar of lbs 
Iloy.al Collcgo of Pliy.siciniis of London wo Jiiivo icccivcd 
an ndv.aiire copy of tlio full jiroginmmo for the Icicontcnarv 
cclebrnlion iie.xt week of tlie juiblication of Dc ^lotii Corilii 
by Williiim H.arvoy. This ]iioginmino is a bc.autifiil docii- 
incnl., printed in p.miijiiilct form, with three fine plioto- 
gr.nvtiro jibitc.s, ono being a reproduction of Hnn'cy’s 
portrait by .Taiiscii, the .second showing the Arms of Ibo 
College, after Richard AVallis’.s design, and the third sboiv- 
ing tlio Collcgo Insignia disjilaycd on tlicir tassollcd velvet 
eushion. Tlio whole work lias been carried out with 
ifs'crcnl care by Mr. Emory AValker .at Ids Hanimcremith 
press. The text includc.s a .short account of Harvey’s life 
and work, an historical note on the College and its 
possessions, and an imposing list of the delegates from 
twcnly-tine foreign countries, from the Dominions beyond 
(Iio .seas, and from the British Isles, wlio will bo received 
bv the King at Biickingliam Palace on Monday jiiorning 
and will take part in the other ceremonies. Besides these 
otTicinl dclegalo.s, ninety in mimbor, from nniversitics, 
eoHcges, and scientific bodies at homo and abroad, Han-cy’.s 
birfbplare will be represented by the Mayor of Folkestone; 
his school by the late Headmaster of King’s Scliool, 
Cantorbiirj-; lii.s hospital by the Tron.surer of St. Bartholo- 
mew’s; bis College at Cambridge by- the Master of Gonville 
.md Cains; Merton College, Oxford, by bis successor to-day 
in the offico of Warden; and the Harvey family by the 
Rev. Ro.scndale Lloyd. The delegate of the British IMedical 
Association is its President, Sir Robert Pliilip. 

* At the reception to bo hold by tlio Roy.al College of 
PliTsicians on Alondny afternoon four eminent men will 
bo admitted ns Eonoraiy Fellows— the Earl of Balfour, 
KG 0 M-i F.R.S., Sir Ernest Rutherford, O.M., Presi- 
do’nt’of the Rovnl Society, Professor Pavlov of Leningrad, 
and Profe.ssor Wenckebach of Vienna— and short cnlogie.s 
of Harrev will bo delivered by n physiologist. Sir Charles 
Slicrrington, O.M., F.R.S., a .pliysiciaiq Professor A. 
CImnffard of Paris, and an anatomist, Professor Fraiix 
Kcibel'of Berlin. Tlio other functions during the week are 
indicated in tlio .abridged timo-tnblo printed below. After 
tlio iunclicon party at St. Bartholomew’s, Sir AVilniot 

Hcrriimliam will give an account of Harvey’s connexion 
with that hospital. Tlio visit to Cambridge will bo followed 
by a mceliiig of the Physiological Society to bo held there 
on Saturday. Tlio Harvoy tercentenary will be celebrated 
in Paris on the following Tuesday, May £2nd, at a 

comm'emorativo function arranged by tlio Academio do 

Aredcciiie. TIME-TABLE. 

Mondny, M(iy JifJt. 

Il „ TO,_Bcccplion ot Delegates by His Majesty tlic King at 
Buckingliam Palace. 

->• V..1 — — a aiilinguislicd guests by flie 

* P-”'" .llego of Physicians at the 

. Addresses bv Delegates. 

■ Follows. Eulogies or 

Harvey. 

G 30 for 7 P-™- — Dinner given by tlio Grocers Company at 
Grocers’ Hall. 

9 p.m.— Lady Bradford “ At Homo ” at 8, Mancliestcr Square. 

Tuesday, May 15th. . 

in xn T m to 12.30 p.m. — Demonstrations arranged by the Eoia 
10.30 a.n . of. Physicians in tho Pliysiological Deparl- 

mont of University College. A 
Harvey’s ori-1: ’A . ™t 

malo^rapli. J* : ■ ■ . . • ; . 

additions to oa:- <: ■ 

1 15 n m — Lunclioon at St. Bartholomew’s Hospital given uy 
' ■ ^ ' tho Governors of tlio Hospital. . . 

d n m -Tea at the Royal Collcgo of Physicians wit h cxliim- 
^ tion of books, MSS., pictures, silver, and otnci 

objects of interest. , tt „ i . nr.-- 

9 p.m.— Conversazione at Merchant Taylors Hidl b> P - 
• ^ mission of tlio Court ot the Company. H.R.H- 

rtf Wnlrtc lin«t rnnsp.nlcd tO bC pl'CSCnt. 




May li, 192S] 


■ HABYEt TEBCENTENAB'Y CELEBRATIONS. 


r The Bbiti^ QT Q 

L MF.DICaE JotJBBAl. u X 


. - ! n'c(?»^st2rtyi ^tay iGth, 

■ 10,30 a'.iii. to 12.30 p.m.— Demonstrations nvranged tiy tlic Royal 
College of rliysicians in tho Dliysiological Depart- 
ment of Univemily College. 

6.30 p. 171 . for 7 p.ni.— Dinner given by tlio rresitlcnf. and 

Fellows of tlio Royal College of Pliysicians in llio 
Gnildliall of tlio City of London. 

Thursdon, May ITHi. 

Morning and Afternoon.— Visit to Oxford by invilation of tbo 
, Warden and Fellows of Jlerlon College. 

8.30 p.ni. lo 11 p.in. — Reception . at llic Ronnis of tbo Royal 

Society, Burlington House, by tbo Fresidenl of tbo 
Royal' Soeicty. 

FrUlnj/t .1/(71/ ISth, 

Morni77g and Afler770on. — Visit to Ca7nbridgo by inritation of 
tho Master and Follows of Cains College. 

DEMON’STIt.STIOXS .tX UnIVEPSITY COLLEGE. 

■' Tile following' denionstratioit’s, 'arranged by the Rtryal Collcgo 
of Physicians, will bo give7'\ at University College, Gower 
Street, V/,C., on the nrornirrgs of Tuesday, May Ibth, and 
AYednesd.ay, Al.ay 16tlt. ' ■ 

• At 10.30 a.ni. each d.ay there will bo ,an exhibition of a 
cii(crnatograpb ftbri of Harvey's experinrents, prepared l7y Sir 
'Thon7as Lewis ai/d Dr.' H. H. Dale. At 11.30 the following 
dc7n07istr.ations illnstrati7ig recent additioiis to lc((u«ledgo of 
the circulatip77 will be givei7 ; 

.1. Professors Lovatt Ev.ans and AVracy will give a denron- 
.Strat7077 of " the isolated mamn 7 ali.au bearl-lung ])rep.\7alion.” 
The preparation to be shown is one devised by the lato 
Professor E; H. Starling tor tbo purpose of studyi77g tbo 
reactions of tlio maniinalian heart to incasnrablo changes in 
the conditions under wbicli it is working. The heart and 
lui’gs arc completely .isolated from tbo rest of the animal, f ho 
normal peripheral circulation being replaced by a system of 
tubes representing its arterial, capillaiw, and venous components. 
The rate of inflow of blood into the I'igbt auricle, the tenipeia- 
tury and composition of this blood, as well ns the jieriplieiaal 
resistance against which tbo loft ventricle works, can lie varied 
and measured at will. Further, tho effect of variations in 
any of ^tbese factors on the volume of tbo boaiX, on its rate 
of beating, and. oh tlie coronary flo\s', niay' readily' be studied. 
Tbo demonstration is dosfgned primarily"^ to sliow tlie nature 
, .tx^ctiou of tile isolated lieart to changes in the work 
winch- it IS called upon to perform, Tlicso changes in work 
are here brought about by' variations in the venous inflow or 
(ho peripheral resistance or in both. The effect of clianges in 
tlie CO^ tension in tlic gas ventilating the lungs, ami of tlio 
addition of adrenaline to the circulating blood, will also bo 
shown. a > 

2. Dr. H. H, Dale will demonstrate an apparatus for artificial 
circulation, designed by Dr. E. H. J. Schuster and liimself, 
and consisting of two diaphragm pumps, tlie tlirows of wliicli 
are independently adjustable while the machine is in action, 
7 he two pumps are made to replace tho two ventricles of the 
heart, so that tho reactions of the blood vessels of botli major 
and mincir circulations, and the resulting changes in resistance 
and m distribution of the blood in the sy'stom, can be studied, 
free from tiie complications of compensatory' or other clianges 
in the action of the living lieart. One pump carries out the 
circulation through the lungs, the otlier througli tlio whole, 
or any selected part of the systemic circulation. This system, 
with its artificial heart and natural resistances, is in somo 
sense a counterpart of the heart-lung preparation, 

Arthur Keith will demonstrate : (o) models made in 
ITO to illustrate the movements of the human heart and to 
explain the negative wave in the jugular pulse, and (*) Sir 
James Afackenzie’s origmak polygraph preserved in the Museum 
of the Royal College of Surgeons. Sir Arthur Keith will also 
gue- a brief account of the anatomical examination of hearts 
obseived and recorded by James Slackeiizie durinf'^ his practice 
\n Burnley. ... 

4 .. Sir Thomas Lewis will demonstrate, with thn help of 
Dr. Ronald Grant and Dr. K. E. Harris, on Wednesday 

• only at 11.50 a.m., somo reactions' of ' tho himmii skin to 
stimulation, illustrating contraction' of the minute vessels and 
their reactions to injury'. 

5. Dr. . B. "VJ. S. ^lackenzio will show somo of Sir James 
3i.ackcnzie’s original apparatus. 

Some tickets are still available for these demonstrations, and 
medical practitioners who desire to be present should apply 
for them at once to tho Registrar, Royal College of Physicians, 
rail M-all East, S.'lA'.l. 


LYaiPnADENOAIA AIS^D RELAPSING PYREXIA. 

Dn. M.vcN.ilty’s REPonx. 

interesting and instructive facts concerning this 
manifestation of lyinpliadenoina aro to ho found in a 
report entitled “ An investigation of lyniphadenoma witli 
relapsing pyrexia,”' which has hecn prepared for the 
Ministry of Hcaltli by Dr. A. Sahisbury MacNalty, medical 
ofBccr to tho Slinistry'. 

Dr. MacXalty discussc.s tho iiomonclatnro of the disease 
and favours tho term “ lyniphadenoma ” for all types in 
which there are definite and rccognizahle histological 
changes in tho lymphatic glands. Refcning to Osier’s 
classification, Dr. MacNalty regards lymphadcnonia with 
relapsing fever as a clinical entity' possessing distinctivo 
features. Ho points out tliat tlio disease has long escaped 
recognition as a clinical entity owing to tho difficulties 
in diagnosis beforo Reed estahlishod tho histology' of 
lyniphadenoma in 1902 ; it has hecn given various desigml- 
tions, such as “pseudo-leukaemia” (infectious form) (Pel) ; 
“ some morbid appearances of tlie glands and ■ spleen ” 
(Hodgkin); and “lymphosarcoma with relapsing fever”. 
(Rcnvoi'.s). Gowers, Miisscr, and Taylor have sjiecially 
drawn attention to the relapsing fever in lyniphadenoma. 
Dr. MacNalty descrihed thirty-two cases of the disease in 
tho Qiiartcrh) Journal of 'Medicine in' 1911, and since the 
publication of tliat paper lie has obtained abundant evidence 
that this disease has salient and individual features which 
make it a distinct clinical syndrome. 

Tho etiology is similar to that of the chronic form of 
lymphadenoma, and both have the same histological changes 
in the lymph glands. ' Lymphadenoma exists without any 
ovitlenco of tuberculosis, and therefore it cannot ho 
reg.arded as an atypical form of this infection. There is 
no doubt, however, that it predisjioscs to tuberculosis, and 
that it 'is likely to be confounded with it, as is shown by tho 
reports of the cases in tliis investigation. Lymphacloiionia, 
thougli it disseminates and infiltrates non-lymphatic struc- 
tures such as bone, cannot bo regarded as a new growth on 
this account, for tlio granuloniata — syphilis, tiiberouiosis, 
and actinomycosis — behave in a similar fashion. The 
“ Hodgkin’s sarcoma ” is regarded by Professor Turnhull 
ns a “ lymiihosarconiatoid ” typo of inflammatory reaction; 

I ho goes further, and considers tliat lymphosarcoma is an 
; inflammation and not a, new growth, because tho deposits 
only involve tho Malpighian bodies of the .spleen, and do not 
1 affect the spleen pulp. Symincrs regards lyniphadeiionia as 
I a transition stage between the granuloniata and the new 
[ growths. 

Though tile cause of lyiiiphadeiioma is at present un- 
' known the halance of evidence is in favour of it being a 
specific infective graiuilonia of protozoal origin, 'riie fact.s 
tliat appear to .support this hypothesis are tho familial 
tendency; the acute course in certain cases, death occurring 
within six weeks; and tlie remarkable outbursts of fever, 
together with its relapsing character and the sometimes 
(periodic enlargement of the .glands. Its clinical history 
is analogous -to certain protozoal diseases, such as, malaria 
' and relapsing fever, and the beneficial results occasionally 
■obtained by arsenic also simulate tho results obtained by 
■ this drug in protozoal infections. Osier sujiported this view 
of the disease, and suggested that it might ho a spivillosis. 

; Dr.- Mervyu Gordon, however, has failed to isolate a spiro- 
|cliaete by using the anaerobic culture methods which have 
ipioved efficacious in tho culture of Spirochacta pallida. 

I Bunting and Y'ates claim, to have isolated a Gram-positive 
jplcomorpliic diphtheroid bacillus, but this has not been 
: confirmed. Bacteria' have also' been obtained from the 
ihlood during tlie pyrexia! periods, and the pyrexial attaclcs 
.have hecn regarded by some ohseivers as being a terminal 
.infection. This cannot be true, for tlio disease may start 
• acutely; the febrile attaclts may last for as long as four 
"years, and somo cases pass into tbo chronic afebrile form 
’of tlio disease. Dr. AlacNalty lias investigated the blood 
■for parasites, performed splenic puncture, made repeated 
•blood cultui'cs, and cxaiiiiiicd the body secretions on many 
occasions, all with negative results. 


'. 1 Reports on Public Health and Jlodical Subjects, No. 60. 
,H-iL Statvouory Ullicc. IS'/S. Is. 6d. act- 


London I 


'820 ■ May li, 1928] 


tiTMPHADENOMA ' AND EELAPSING PPEEXIA.' 


[ The Bninsa 
IIedICAL JouEK&Xr 


The most common primary site is the cervical glaiifls, | 
but Dr. Turnbull found from .post-mortem figures that the 
primary site in 40 per cent, ‘of cases ‘U'as the abdominal 
glandsj in 30 per cent, the intrathoracicj and the cervical 
glands fn 22 per cent. Experimental pathologj’ has not, 
as 3 'et, helped to elucidate the problem, because the disease 
apparc'ntlj" cannot bo transmitted to animals. Professor 
Woolridge rc])orts that dog.s are liable to a sj’ramotrical 
bilateral , cnla rgoment of tlie.Umph glands, but sections 
of these glands have none of the histological appearances of 
IjTnphadcnmha, but of Ijunphoma. Dr. MacNalty s\iggc.sts 
that anthropoid apes might be suitable animals for experi- 
ment, since the\- have proved so useful in the investigation 
of sj'philis. 

The granidomatous nodules are found in structures other 
than lymi)hoid tissue — nameh', the liver, kidnej-s, ureter, 
and pleura ; the}' direct!}' invade bone, and occur al.so in 
the marrow of long bones. The histology of this disease is 
similar to that of chronic lymphadcnoma. The various 
stages in its histology, as previously described by Longcoi)c, 
have been confirmed by examination of glands in the 
present series, particularly the marked fibrosis in the 
advanced stages and the cellular composition of the glands 
in the earliest .stages. In fact, it was possible to recognize 
some correlation betw'con the histology and the duration of 
the disease. 

Dr. MacNalty finds that the disease is most common in 
youth and early adult life, the commonest ago incidence 
being 20-30. The .symirtomatology is well described, interest- 
ing features being the symptoms produced by intratlioracic 
deposits and the various abdominal manifestations de.scribed 
by Eolleston. In its onset the di-seaso is usually insidious, 
and it has been mistaken for influenza or early pulmonary 
tuberculosis ; it may, however, commence with the dcvelopJ 
ment of sudden respiratory symptoms. The disease may bo 
superimposed on chronic lymphadenoma, as in one case 
reported. 

From a esreful analysis of the salient features of the 
many previously reported cases and the author’s seventeen 
cases Dr. MacNalty has classified the disease into two main 
types ; (1) a form with enlargement of the external glands, 
with or without involvement of the internal glands; (2) a 
form in which the internal glands are alone involved. The 
first type is further subdivided into two groups, one with 
slight or no enlargement of the glands during tlio periods 
of pyrexia, and another group in which the clinical iiicture 
alters suddenly during the attacks of pyrexia, the glands 
becoming much enlarged, tender, hot, and jiainful, with 
adherence and reddening of the skin. The second group 
is uncommon, and very closely resembles acute suppurative 
lymphadenitis. The various t}'pes may occur as inter- 
mediate or mixed forms. 

Dr. MacNalty has drawn an accurate, clear-cut, clinical 
picture of this disease, and among many other interesting 
peculiarities he points out that excessive appetite is often 
!\ prominent feature. The prognosis is very unfavourable, 
particularly in the second type — namely, that with internal 
glandular involvement alone. A’ ravs do not have any 
pormanent curative effect in this disease, but arsenic is 
undoubtedly beneficial in many cases; Fowler’s solution is‘ 
said to be better than intravenous forms of arsenic such as‘ 
salvarsan and neosalvarsan. Difficulties in differential 
diagnosis are greatest in this second type, for in tyiie 1’ 
excision and microscopy of a superficial gland will settle the 
nature of the condition. This histological examination should 
always be performed when a superficial gland is available. 
Chronic pulmonai-}' tuberculosis and chronic tuberculous 
adenitis W'ith relapsing fever are most likely to bo con- 
fused with the disease, and a diagnosis can often only be 
made by consideration of the clinical features and by a 
]irocess of elimination. The author discusses the differential 
diagnosis very fully, and this part of the report should 
jirove very useful to the clinician. The recognition of this 
disease is not of mere academic interest, but it is impor- 
tant from the point of view of prognosis and its separation ’ 
from other diseases.’ 

Dr. MacNalty has i>erformcd a very useful seiwicc to 
clinical medicine. From the admittedly ill-assorted group 
of diseases characterized by enlargement of the . lymphatic 
Slauds he has separated one clinical D'pe, distinct in its 


morbid hisiology, sufficiently unlike other diseases in its 
clinical manifestations, and unhalting in its forward march. 
As already indicated, it is important to recognize this 
dLsoaso because of its particularly unfavourable prognosis. 
It may be added also that' the best hope for the discovery 
of some effeetiv'd remedy lies in the accur.ate definition find 
study of this infection. 


aittr 


Clean Milk Production. 

Anothkh “ social evening ” took place at the Eoyal Society 
of Medicine on May 7th, when Sir James Berry, the 
President, and Lady Berry received a very large number 
of Fellows and guests. During the evening an illustrated 
address was given by Mr. P. B. Tustin, who has been 
associated . for many years with the campaign for clean 
milk, on the processes of niilk production and distribu- 
tion. He gave an expert account of the breeding of coivs 
for milk-producing purposes, and the economics of the 
dairy farm. Discussing the mechanical milker, worked by 
a vacuum pump, ho said that this was a very good and 
efficient arrangement, provided only that an intelligent man 
was in charge ; othcrw'isc, used carelessly, it was liable itself 
to bo a source of contamination. He insisted that the 
production of clean milk w'as a matter of method rather 
than of expensive equipment, and he described an experi- 
ment which showed that even in an extremely insanitary 
barn — hot that sueh places wore to be tolerated — clean milk 
coiild bo produced, given proper methods in the handling 
of the cow and the taking of due precautions. The equip- 
ment necessary for clean milk production included curry- 
comb, brush, and clippers, and a bucket of water. The milk 
should bo received in a small-top pail, the milker should 
thoroughly wash his hands before beginning his job, the 
stool on which he sat, and the position of w'hioh lie had 
often to adjust with his hand, should be clean, and, given 
these conditions, with fastidiousness as, to the cow’s udders, 
all contamination in the milking pyoce.ss should be avoided. 
Mr. Tustin said that the dairy farmer had made enormous 
strides in clean milk production during the last few years. 
Such cleanliness had been very largely stimulated by clean 
milk competitions, of which there w'as only one in this 
country in 1019, while there W'cre fifty-eight, in different 
counties, last year. Mr. Tustin de.scribed the method of 
pasteurization and the clarifying and other equipment -of 
the modern milk factory. In milk consumption per head of 
population, he said, the British people were unaccountably 
backward ns compared with the Scandinavian nations, and 
even w'ith America and Canada. He also dw'elt upon the 
reallv extraordinary organization whereby milk produced one 
day in Somerset or somew here else, on the next day finds its 
w av, pasteurized, bottled, and scaled, on to the London door- 
step — an achievement at least as expeditious, he claimed, 
as anything that the post office can show' in the way of 
delivery, and relatively cheaper. In proposing a vote of 
thanks to the lecturer, Dr. Andrew' Balfour said that he 
noticed that Mr. Tustin had not touched on the sophistica- 
tion of milk. This was no longer an important problem, 
perhaps, in this country, but in tropical countries it w'ds 
v.erv much a matter of concern, and he recalled how a 
hospital in Mauritius once received its milk w'ith small fish 
swimming about therein 1 The fish, which had been used 
for the destruction of mosquito larvae, had been scooped 
uj> in the w'ater so profusely added to the, milk. 

Leicester Eoyal Iniirmary. 

The report of the Leicester Eoyal Infirmary and 
Children’s Hospital for 1927 records a further increase in 
the demands made upon that institution, and it is there- 
fore pleasing to note that the financial position is satis- 
factory and that tho governing body has enough confidence 
in the outlook to’ undertake provision for future needs. 
Admissions during the year numbered 6,788 against 6,485 
in 1926, and the number of out-patient attendances W'as 
151,281 against 146,733 in 1926. A point of .some interest, 
ip view' of tlic keen discu.ssion. now current legarding tho 
future of the hospital services, is that of the in-patients 



JlAY 12, 1Q2S] 


SCOXIiAND, 


r TnEBnmsH 001 
JfKmcAi. JotmsiX. <^^4. 


tvcatod nvproximntely 60 per cunt, wore insured persons 
and members of appvoved societies. The proportion would, 
of course, bo considerablv Iiiglior if patients of 16 years 
and under and 65 yenre and above were excluded, ns such 
patients are not within the scope of the national insurance 
scheme. From the total incomo of £78,009 Iho board was 
ablo to meet the ordinao' expenditure, provide for soverni 
substantial items of extraordinary expenditure, and wipe 
off part of the nccumul.atcd deficit of previous yeans. 
Ordinary expenditure, at £69,679, was £1,557 below the 
1926 figure, in spito of the fact that the work done was on 
a more extensive scale. Kxtensions in progress include 
a temporary ward of thirty beds, two new wards of fifteen 
beds .attached to the orthopaedic department, two new 
operating theatres, and the reconstruction of tho kitchens, 
the estimated cost being £31,000. On July 1st it is in- 
tended to begin tho reconstruction of tho central wing, 
which will provide three wards in place of two, at an 
■ estimated cost of £50.000, making a total of £81,000. 
3Ir. H. T. Jfills of Langton Hall has undertaken to con- 
tribute one-third of tho cost, up to £20,000, of tho central 
wing reconstruction, and other donations amounting to 
£22,863 have been received. 


Women Medical Students and London Hospitals. 

A conference attended by about two hundred representa- 
tivo women was held under tho auspices of tho National 
Union of Societies for Kqual Citizenship on Stay 8th to 
consider tho question, in the light of recent events, of 
women in tho seiwico of hospitals. The speakers included 
Dr. Graham Little, JI.l’., Miss ICleanor Itathbone, presi- 
dent of tho union. Dr. Margaret Kmsiio, and others. 
Several resolutions were carried, tho principal one pi'o- 
testing against tho oxelusiou of wbinon medical students 
from all tho London general hospitals with training schools 
(with^ tho exception of the Royal Free Hospital and, for 
a limited number of vacancies. University College Hospital). 
Dr. Graham Little said that there was no sufficient jiro- 
vision at tho present niontcht for tho. teaching of women 
medical undergraduates in London. There wore large fields 
of medicine, loft untilied by men, which ought to bo taken 
up by women, and he foresaw an enormous possible expan^ 
Sion of medical work in this respect. Even if one wanted 
to do so, ho could not stay tho ontiw of women into 
medicine, and therefore the wise course was to secure tho 
professional education of women in the best possible way. 

tie material- and facilities for women medical students in 
London— tho best eentro in tho world for tho purpose— were 
lua equate the result would simply bo to take women to tho 
no such fantastic position existed. Miss 
Lle.anor Eathbono . laid stress upon tho f.act that tho 

+'l?X"-iin ®“PP®‘ded by women as well as by men, and 
that they depended to an increasing degree upon funds 

n® ’I? "'<='b "cro asked to contribute, 

* collations or deductions from wages. An 
nnfl ^ being nintlc to establish a male monopoly, 

subscribers to hospitals were virtually being 
wlnt' b' ° their sex -from the training which 

Th 1 ™!lod “ men’s ” liospitals-Lthough 

was 'w'"?" as men— afforded. It 

sciitaWvp ° ^utional Union to organize a repre- 

■ Wnitl *'"■« view before the 

local a to call upon 

■admin“ tratinn a/ bodies responsible for tho 

■ u^rn^n of re , tho' .appointment of 

ypraon on the lesponsiblo committ-ees and to cive eaual 

S thal^isiU^™"''"^ facilities. A- further ®esolu?imi 

bo required to col^ptTTet't Urf 

r To s ntd’iT r ^ ^ 

air men+ni T ^ '+1 of women doctors in 

WstaSU ,o ,o 

-f “^ked tho London County 

Menz?pT / medical officer of healthy Dr, F. 'N. K. 

vestieatJ' on the departmental committee to in- 

'estigatc the present situation in rceard to the traininp- 
and employment of midwives,- as he feck that Dr. Menzies’f 


knowledge of tho subject and interest in questions affecting 
malernni welfare would bo of considerablo assistance in tho 
inquiry. Dr. Monzics, however, is at present absent from 
duty owing -to ill health, and has been granted sick leave 
until tho ond of Juno. Tho council has agreed to Dr. 
Menzios serving on tho committeo, subject to liia state of 
health on liis return to duty allowing him to do so. The 
council has agreed that ono of its assistant medical officers. 
Dr. Nancy Holloway, shall exchango duties for a period of 
ono year' with a school medical officer. Dr. Elo.anor Stang, 
attached to tho health department of AVestern Australia. 
Each officer will continue to reccivo her own salary from 
tho authority, at present responsihlo for its payment, and 
any adjustments are left to bo inado privately. 


Hospital Problems in the Highlands. 

A cox'FF.niixcE convened by the Scottish Board of Health 
to assist tho movement for hospital co-operation was hold 
this week in ,tho Town Hall, Inverness, under the chair- 
maiiship of Dr. W. E. Elliot, Under Secretary of State for 
Scotland. In a letter sent to tho voliintai-y liospitals and 
puhlio authorities in tho counties of Inverness, Moray, 
Nairn, Ross and Cromarty, Caithness, Sutherland, and 
Orkney, representatives wore desired to discuss some of 
tlio immediate questions arising in connexion with the 
Novlhcru Infirmary at Inve’rne.ss. It was considered desir- 
able that tho directors of this institution, now under con- 
struction, . should know what will bo its. relation to other 
voluntary .hospitals in tho north, ' and particularly what 
accommodation and services it will hq expected to provide 
in connexion with sorvicos administered by tho public 
authorities for tuberculosis, maternity, children’s diseases, 
and venereal diseases. Following the recommendation of 
tho JIackonzio Committeo on hospital services, tho Northern 
Infirmary is being equipped as a central hospital for the 
northern region. A sum of £60,000 out of the £100,000 
required to give effect to this recommendation has been 
already raised, and building operations liavo commenced. 
It was arranged that Dr. Elliot should lay tho foundation 
stono of tho infirmary on May 8tli, and that on May 10th 
ho should perform tho opening ceremonies' at tho extended 
sanatorium which is managed hy the British Bed Cross 
Society at Stornoway, and at tlio extension of tho Lewis 
General Hospital at tho same, place. The two latter func- 
tions formed an iniportant landmark in the history of 
hospital organization in the Outer Hebrides. The Lewis 
Hospital is an experiment in State medicine .in a remote 
part of Britain which will ho watched with interest for the 
influence it may have upon developments further south. 
Tho largo island of Lewis has a population of over 32,000, 
and until very recent times medical practice’ was possible 
only on a limited scale, mainly on account of ‘difficulties of 
transit, so that the practices_ of earlier generations in tho 
shape of hereditary healers 'and village bone-setters still 
persist. Tho hospital Bohemq inaugurated hy the Scottish 
Board of Health has now gained the confidence of the 
people. The original hospital,' erected' by public subscrip- 
tion in 1896, ‘Was enlarged in 1912 to provide twenty beds. 
Owiiig'tq local prejudice it was not. fully used until 1924, 
when a specialist, snrgcoh ivas appointed in Stornoway by 
the Board'. The new Iwspital will contain twenty-four beds 
and four cots, and has been equipped with x-ray plant, an 
operating theatre, a laboratory, and all the other requisites 
of a modern hospital. It also contains a private wai-d. 
Cases requiring special surgical treatment which are not 
urgent are referred to hospitals on the. mainland. The 
scheme of providing specialist services .has now been, in 
operation since 1926, and already great demands have been 
made upon the hospital, -where still further extenrion will 
probably, it is' thought, soon bo required'. Tho Board of 
Health will not contribute towards maintenance, so .this 
charge will have to be met by local contributions and pay- 
ments. The nursing service, controlled by lo.cal committees 
is subsidized by the Board of Health', and it is expected 
that a much extended district' nursing scheme will shortly 
be instituted. , 


822- Mat 12, 1928] 


IREIiAND, 


[ Tirr. BBrns* 
Medical JocrmaXi 


Summer P st-Gredunte Courses in Glnsgow. 

The Glasgow Post-Graduate Medical Association has 
completed its arrangements for post-graduate teaching in 
that city during the coming summer, from June to 
.October. The instruction is offered in three forms— a 
general medical and surgical course, certain special clinical 
courses, and clinical assistantships. The general course 
will occupy four weeks, from August 20th to September 
15th, and has been designed to include most of the subjects 
likely to interest general practitioners. Throughout this 
period the mornings will be devoted to general medical 
and surgical diagnosis and minor surgery, in the Royal 
and Victoria Infirmaries, while special subjects will be 
taken at various appropriate centres in the afternoons. 
Demonstrations in psychological medicine will be given 
on the four Saturday mornings at Duke Street Hospital 
and at Gartnavel Mental Hospital. The subjects covered 
in the special clinical courses, intended for general practi- 
tioners who have not much time to give to hospital work, 
include surgery, obstetrics, g3-naecolog)', derniatolog3", 
radiolog3', venereal diseases, diseases of children, and 
diseases of the ear, nose, and throat. At most of the insti- 
tutions taking part in the work of the association a limited 
number of clinical assistantships are available during the 
summer months as well as at other times of the 3-ear. 
These appointments afford exceptional opportunities for 
special stud3’, and graduates securing them are expected 
to enrol for three months. Copies of the syllabus ma3- he 
obtained from the secretary (Dr. James Carslaw), Post- 
Graduate Medical Association, The Universitv, Glasgow. 


East Fortune Sanatorium. 

IVith regard to the annual report by the medical super- 
intendent of the East Fortune Sanatorium summarized in 
the Vritiih Medical Journal for April 28th (jn 728), it should 
be explained that the figures published respecting results of 
treatment referred to the number of days spent in the 
sanatorium by patients ultimately discharged in various 
conditions. Thus of the male patients treated for diseases 
of the lungs and chest glands, those irhoso- cases were 
clinically quiescent on discharge had remained under 
treatment for 227 da3's, much improved 204 days, improved 
251, stationary 41, worse 372, while those who 'died had on 
the average been treated for 282 days. The corresponding 
figures for women were: 181 d.ays clinically quiescent, 
227 much improved, 226 improved, 118 stationary, 489 
worse, and 92 days for those who had died. Of the 
children, those who were discliarged clinicallv quiescent 
had remained in the sanatorium on au average 205 days 
much improved 393 days, and there had been no deatbs 
among children. The total number of deaths was 29. 


McKisack Memorial Fund. 

A 3IEET1.XO of the subscribers to Hie McICisack memoria 
fund (announced in our issue of April 21st p 686 
will be held in the Bo3-al Victori.a Hosiiit.-il’ Belfast 
on May 17tli, at W.30 a.m., immediately before tiie clinica 
meeting of the North of Ireland Branch of the Britisl 
Medical -Association. All those who intend to join ar 
asked to forward tkeir subscriptions before that'^date* si 
that the accounts may bo closed. They mar be sent t 
Dr. M. Calwoll, 56, Wellington Park, Belfast, or to an' 
other mcraher of the committee. ‘ ■ 


The Need for Hospital Co-ordination. 

Senator Sir Edward Coey Bigger, M.D., ,sj>eaking as 
chairman at the annual meeting of the Monkstown. 
Hospital, said that before referring to tlie jiosition of tho 
hospital and its need for greater financial assistance ho 
woiUd like to mention two points connected irith "the 
question of hospitals and hospital treatment in the 
country. Tlio first was that, although they had some of 
the most highly skilled plysici.aus, surgeons, and specialists 
in the world, who gave their services most freely and 


wholc-hcartcdh-, in tho large voluntary hospitals, they irere 
not employed to tho extent that tho3' should he or to tbo 
host adyantage. More co-ordination was required between 
the .small and the largo hospitals. Many patients were 
admitted to tho small hospitals who needed the most 
skilful diagnosis and treatment; by sending them to tho 
larger clinical hospitals, with their special tspiipment and 
complete organization for laboratory work, K-ras- and 
radium therapy, and diagnostic investigation, patients 
would receive the advantage of tho host available advice 
and treatment. This could bo carried out under the 
Public Health Acts by co-operation botwcon the local 
health autliorit3- and the largo voluntar3- hospitals. The 
liospitals would, of course, recover tho cost of treatment 
from tho health authority. Such co-ordination would ho of 
the greatc.st benefit to the patients, to tho hospitals, to 
medical .science, and to the training of students and 
nurses. The other point Hint he wished to make was that 
tho State provided a medical son-ice for those ii-lio were 
unable to pay for treatment, hut there was a large class 
above those who could claim free treatment who could 
not, on account of their limited means, pa3- the usual 
medical fees — either for prolonged illnesses or difficult 
operations or even special diagnoses — for wiiom sometliing 
might be done. There liad boon a groat change in the 
■position of hospitals (luring recent years. The develojuneut 
of hospital treatment as against home treatment was 
conrtantly increasing; the (lifficult3- and expense of modern 
methods of treatment, combined with tho dcpondonce of 
tbo.se raothods on skilled nursing, had made it practically 
impossible for them to bo carried out at home. He meu- 
tioued these points in tho iiopc. that tli03- might receive 
serious consideration. Proceeding, Sir Edward said that 
Monkstown Hospital had done most useful work, and it 
was surprising that so many cases should hare been treated 
■in such a small hospital. The remarks that he had just 
made about small outlying hospitals in the country- did 
■not appb’ to tho Monkstown Hospital, which had a very 
larve staff of honorary and consulting physicians and 
surgeons. He liad referred to small hospitals with, 
perhaps, one medical officer and, possibl3-, fort3- or fifty 
beds. Ho was glad to see that in Monkstown Hospital 
wards were pi-ovidod for people with limited means. In 
the' financial part of the report there was one item which 
greatly pleased him — that was tlio provision for nurses’ 
pensions. The money spent in Monkstown Hospital had 
been well spent; such a hospital was a tremendous asset to 
the district. He hoped everyone would realize his resjronsi- 
bility in regard to it. 

Vaccination Bill in the Dail. 

A resolutioir recently adopted by tho executive com- 
mittee of the Irish Medical Committee with regard to the 
Vacciiiatioir Bill now before the Dail states that tbe 
executive committee has learned with arrxiety of the jrro- 
posal to permit exemption from compulsor3- vaccination on 
the irle.a of conscientious objection. In the opinion of the 
committee airy tampering with the compulsor3- action of 
the vaccination laws would be likely to render the laws 
nuvator3-, and to expose the population of the Irish Free 
State to the grave danger of au epidemic of small-pox. 
The danger was all the greater because of small-pox now 
being rife in England, a condition which had been brought 
about by the very step which it was now proposed to take 
ill tbe Irish Free State. 

Education of Alentally Defective ChJdren. 

At tho meeting of the Belfast City Council held on 
May 1st the School Bledical Services Subcommittee of the 
Belfast Education Committee recommended that the jn-in- 
cinal committee should draw the attention of the Ministry 
gf "Education to tho necessity for the establishment in 
Northern Ireland of an institution where mentally defective 
children, ordinarily resident in Northern Ir eland, might be 
educated. 

A Medical Officer s Sestgnutwn. 

At the same meeting of tlio Belfast Corirorntion attention 
was drawn to tbe resignation of Dr. R. McCuiiocIi a.s assis- 
tant medical officer for tuberculosis. Tho chairman of tho 
Tuberculosis Conunittee said that Dr. McCulloch could not' 



HAT 12, 1928] 


CORRESPONDENOB.' 


r Tttf.Unmsa 'ft 93' 

1. MrpicAi, JouBsit. ^ w 


SCO lus woy to coin^^ly with « iirovision that lio should 
record his tiino at tho iiistituto hy moans of tho " clock ” 
instead of hy ouloring his signaturo in a hook. Tho regula- 
tion had heen nirpvovcd hy tho corporation, and other 
iiioinbors of tho iiistituto staff had coiiijiliod with it. Thoro 
had been discussion about it, and opinion was divided. Tho 
resignation was accepted. 


Cnms|imtiJcnr0» 


Cl'CLiaVL VOitXITING AND APPENDICITIS. 

Sin, — Cases of cyclical vomiting in children frequently 
develop symjitoms suggestive of acuto appendicitis. Tliero 
is danger of hurried resort to operation with tho great risk 
attending upon general anaesthesia in tho prcscuco of 
acidosis. 

A simple test can bo used which will often decide for or 
ng-ainst operation. Having observed tho relief of distress 
and tho relaxed condition of tho patient’s limbs and 
abdominal wall following an attack of vomiting in a severe 
caso of cyclical vomiting some years ago, I used emesis, 
produced by giving the same child two tumblors of water 
to drink, in a siibscquciit attack accompanied liy fever, 
with pain and rigidity in tlio riglit iliac region. Tito 
ciiild vomited promptly, and at once tlio resistance over tho 
appendix was felt to have disajipcared. The child died soon 
after operation for appendicitis, performed <a few mouths 
later during my abseneo from town. 

Shortly afterwards another severely ill patient was saved 
from operation through tho use of tho same manceuvro, 
and made a good subsequent recovery on strict diet with 
alkalis. During tho last week 0110 of my students used 
Gie emesis test on .a caso sent into tho Kingston General 
Hospital for immediato operation, willi n similar result. 
A full clinical examination revealed the acidosis and tho 
true condition. 

I have not mot with any mention of this method of 
diagnosing the presence or absence of appendicitis in this 
class of case, and apparently it is unknown to many. It 
seems nurth while recording, so that full trial may bo made 
ot It. It may ho well to remember that in tlicso davs of 
safe and successful surgciy thoro are conditions where tho 
necessary anaesthesia may lead to death.— I am. etc., 

Tuomas Ginsox, 

April 23r,L Profe^^or of Pharmacoiogv and Tlior.apoutics, 

^ ^ Queen’s Uiiivcrsily. Kingflon, Out. 


DErVD AND INFECTED TEETH. 

28th (p. 751) Mr. C. Jennings 
ilarshall very rightly draws attention to tho importance 
article on dead and infected 
eeth (Apiil 7th, p. 589). In his desire to cmpliasize thig 
he closes with tho rather sweeping statement, “Tho 
stopping of teeth m which tho pulp cavity lias been infected 
IS a surgica heresy, and I would like to put forward tho 
anggestion that it is tho duty of tho medical prolcssion to 
(iiscounteuance tho procedure.” 

May I be allowed, for a definite reason, to repeat very 
briefly one or two of tho facts having a bearing on tho 
opposite side of the question p 

“ P“>P cavity has been infected ” 

must include not only those in which tho pulp has died 
from infection, not only those in which tho pulp has been 
killed by tno dentist owing to its involvement in the carious 
process and mevitablo infection, but also, according to 
recent bacteriological lyork in America, a considerable pro- 
portion of filled teeth m which tho pulp still reacts, 
althougb sluggishly, to the ordinary vitality teste, which 
1)10 lice no local signs or symptoms wiiatsoever, but which 
have been proved in a certain number of cases to hare 
caused rbenmatoid conditions that have 'cleared up on 
lemoval of the degenerating pulp and its replacement by a 
properly inserted filling. Mr. Jennings Marshall must 
Uerefoio be prepared to recommend the extraction of all 
dead and a proportion of living filled teeth. 

Ihero is an old observation on this subiect which wiil 


bear ropotition, to tho olfcct that tlio doctor examines 
llio mouths of n small proportion of tho population, mostly 
sick; tho dentist thoso of a largo proportion of tho popula-- 
tion, mostly in good health. Why should tho forntcr, on 
tho strength of what lio sees, condemn tho dentist to a 
policy of wholcsalo extraction, tho clFects of which, in 
mutilated mouths, spacing of tho teotli and consequent 
interstitial caries, traumatic occlusion and consequent 
pyorrhoea, faulty mastication and consequent chronio 
indigestion, ho is unlikely to see or realizo? 

In America, wlicro tho importance of Hunter’s teaching 
was aduiitled and acted on moro quickly and more whole- 
heartedly than in more conservative Britain, a policy of 
100 per cent, extraction of dead teeth was tho almost 
immodiato result. A careful study of tho dental litoraturo 
of recent months clearly points to a gradual hut pro- 
gressive rctiiiii to a micldlo course based on more careful 
selection of eases for root canal work, and in face of 
tho brilliant and devastating bacteriological studies ot 
Rosenow, and tho voluminous, if less convincing, work ot 
Weston Brice. In tho Journal of the American Dental 
Association for Jnnuaiy, 1928, Coolidgc reports a series 
of 147 carefully selected eases for root canal filling, shoiying 
3 per cent, failures, 19 per cent, where there was still a 
slight elomont of doubt as to tho ultimate success, and tho 
remaining 78 per cent, undoubtedly successful. 

In advancing these points I have no wish to belittle tho 
dangers of infected teeth, and until a solution of tho 
problem has been found theso dangers cannot possibly bo 
ovor-omphasir.od ; but a policy of 100 per cent, extraction 
is a policy of despair which, recommended blindly by tho 
medical profession, can only retard and impede progress 
towards that refinement of diagnosis in tbo choice of suit- 
able eases for conservative treatment, and that development 
of technique in root canal therapy, which provide the only 
real way out of tho present position. — 1 am, etc., 

Bru«d5. JtAj- Ist T- DuxCAX GoTOD. • 


INHERITANCE OF .^lENTAD DEFECT. 

Sin, — Any editorial pronouncement in tho BritisK 
Medical Journal of necessity carries such weight that I 
am tempted to invito your attention to the annotation in 
your issue of April 21st (p. 650) on sterilization of the 
fccblc-miiidcd in Alberta, where this sentence occurs:, 
“ Scarcely any fact is moro securely established than that 
it is only a small, almost negligible, minority of mentally 
defective persons who are tho offsiiring of parents them- 
selves ccrtifiably mentally defective.” On the other band,- 
1 read in a paper on heredity of fecble-mindcdness by 
H. H. Goddard, Vineland, N.J. (reprinted from tho 
Eugenics Bcviciu, April, 1911), with regard to one single 
family, “ Since this was written this family has heen 
further investigated, with the result that we now' know 
tho facts concerning 319 niemhors, of whom 119 are feeble- 
minded, with only 42 known to he normal.” Can you 
assist me in reconciling the two statements? — I am, etc., 

Bristol, April lOtb. D. S. DaVIES, M.D. 

%* ’The two statements to which Dr. Davies directs 
attention aro not contradictory. It is true that where both 
parents are mentally defective the offspring are almost 
certainly mentally defective also, and that ei’en where 
one parent only is mentally defective, some of the offspring 
are likely to show the same characteristics. Nevertheless, 
it is true also that in any generation only a small proper-, 
tion of mental defectives are the children of parents who 
themselves aro ccrtifiably mentally defective, the over- 
whelmingly • larger proportion being tbo children of 
apparently normal parents, of “ carriers ” who themselves 
aro normal, or of thoso w’ho suffer from mental or nervous . 
instability or from psyclioneuroses or a mild degree of 
mental abnormality not certifiable. It follows that, for the 
purpose of eradicating or preventing tho spread of mental 
deficiency, tho sterili.\ation of a small number of feeble- 
minded persons would be ineffective,. Attention may be 
again directed to the pamphlet on Sterilization and Mental 
Deficiency published by the Central Association for Mental 
"Welfare, 


824 Mat 12, 1928] 


CORIUilSPONDENOE. 


t T«K rRITia 
Ucmcxx. JornsAX. 


ERYTHEMA NODOSUM AND TUBERCULOSIS. 

Sill, — Dr. "NV. Camac Wilkinson, in liis article cntitleil 
“ The allinities between rhcnmatism ancl tnbercnlosis ” in 
yonv issue of May 5th (p. 749), makes particular reference 
to the association of erytliemii nodosum with tuberculosis. 
He goes so far as to say, “ . . .1 have not once seen 
eiytheina nodosum apart from tiibci’cidosis.” That the 
association of the two conditions is a very close one is 
evident from the fact that, from a clinical standjmint, it 
tan bo demonstrated in fully 20 per cent, of cases of 
erythema nodosum, if a careful physical examination is 
made, and if the after-history is followed up. I leportcd 
a series of such cases in the liritixli Mctticul .lournoJ of 
April 25th, 1914 (p. 909), and in a hook, ivhich is at 
jnesent in the press, I have added reports of many others. 

It does not necessarily follow from this that erj-thema 
nodosum is a tuberculous disease; indeed, in the great 
majority of cases even the use of tuberculin has failed to 
prove this — a failure resulting possibly, as Dr. Wilkinson 
remarks, not from the tuberculin, but from the- adminis- 
trator. He says that histologically the lesions of erj-tln-nia 
nodosum cannot be distinguished from rheumatic icsioiis 
of tlie skin. Personally 1 have no knowledge of the 
histology of rheumatic skin lesions, but 1 have on several 
occasions excised ej-j-theniatous nodes, and the hi.stology 
of mature nodes is identical with that of tuberculosis iii 
epithelioid and giant cells. 

My own view is that erythema nodosum is a specific fever 
which leaves the patient uudnly susceptible to tuberculosis. 
Whatever the explanation may be, liowcvei-. Dr. AVilfcinsoii 
has senod a most useful purpose in drawing attention to 
the association of the two conditions, for many lives are 
wrecked or sacrificed by failure to take precautions after 
en-thema nodosum, a disease which is still generally 
regarded by the profession in this conntrj- as a mild 

cutaneous disorder demanding little or no" attention. 

I am, etc., 

Clifton, Biiblol, Slaj’ 5th. J, 0, SY!MES. 


THROMBO-PHLEBITIS MIGRANS. - 

Sin, Tile subject of thromho-phlobitis migraus, discussed 
ill your issue of April 7th (p. 586) by Professor T. Gillman 
Moorlieact and Dr. Leonard Ahrahamsou, and continued iii 
join issue of April 21'st (p. 690) bv Dr.Owi'n, has interested 
mo very much, as lately I have had five eases of this 
condition. 

Ill Professor Moorhead’s article the authors .stress the 
conspicuous absence of embolic symptoms, in .spite of their 
patients’ habits being most favourable to an embolus. Tlicv 
note subacute occurrences, aud have been at pains to show 
that the blood, cultures wore sterile ; they .state also that 
the various treatments used had no apparent effect on tlie 
TOuree of the disease. Of the four cases cpioted in this 

inhirv’ previous illness, one had an 

injuiy, and two were persons of middle age who were 

aiipai-oiitly in robust health. ■ 

111 Dr. Owen’s comnnmication this condition is reeoe- 
nira-d as oceurrmg in the presence of an infineuza epidemi? 
in pro.x.mity to oiiorat.ons, and in confinements. It would 
therefore appear that there i.s no .specific- relatioushi 
between tins condition and micro-orgaiiisms, but it must 
be pnniarily regarded as ivsuUing from the general .state 
of the patient, who is affected later by some infection 
or chemical changes which femporarilv loner the .roncral 
i-esistancc. 

There is one factor common to all these conditions and 
that IS the state of the soil (that is, the patient) which 
when exposed to a fuithor strain, as by an infcc’tioii or 
ail anaestlictie, evinces one common result manifested bv 
thronibo-plilebitis. 'TIio ebanges wbielt lead up to the result 
— nahicly, a thrombosis — are obviously piimarlly concerned 
with the state of the blood, aud that is the one coiuiuoii 
cause: and I submit that the true cxplauation is arrived 
a't by the work of IMr. J. E. R. McDonagli, and jilaiuly put 
forward in volume 2 of The 'Xntnre of Disease (p. 289) and in 
nil article by biiu in the Lnuect of April 16fh, 1927 (p. 845) 
in wliich.thrombo-pblobitis migraus is fully ilisciissod. 

The state of the blood being the real cause of the iiiani- 
fcstation of a thrombo-phlehiUs exiilains at once bow it is 


that the original thrombus occurs — which may he in a super- 
ficial vein in a limb where it is evident, a dccji vein in a limb 
where it gives rise to physical sign.s as in enteric fever, or 
ill a viscirs where it is seen post viortcm as an infarct — 
and' that thromboses may be multiple and reenn-ing, thus 
giving rise to the condition of so-called tliromho-plUcbitis 
“ migraus.” As long ns the blood remains in the condition 
of dehydration and liable to gelation, so long are throm- 
boses likely to occur, and do so in any part of the bod}-. 
That the condition in the lungs should ho caused by a 
dolachnieiit of a clot from a vein lodging in a branch of the 
juilinonary artery is ruled out by the fact' that the affected 
area iii the lungs docs not always correspond with the area 
.siipjilicd by one vessel, and, iiiort-ovcr, that in some cases 
where the affection is widespread, involving the whole of 
an U)iper lobe, the embolus would have to he of n vciy 
considerable size, and, fiirtherinore, thrombosis here may 
be jirinian'. 

The treatment in all my cases lias been tlic same as that 
carried ont and described by Mr. jMcDonagli" in Ins article 
in the Laneci, and }ia.s been successful in all. In some cases 
I have noticed that after the fir.st injection of .snp 36 there 
has heen some pain locally at the site of the thromhus in 
vessels in the leg. 

It is only natural that in an influenza epidemic, where 
a large number of jiaticnts arc alfeitwl, some of those 
would he in sncli a primai-y condition as to develop a 
tiu-omhosis owing to the siipcraddcd infection. In fjost- 
operation cases it is dne to the anaesthetic, and in preg- 
nanev it is most likely to occur in women who have albumin 
in the urine, and who are in a debilitated condition and 
affected by oral sepsis. 

The ])oints I wish to emphasize aiT that this condition 
is not due to any specific organism, and, ns such, cannot 
be regarded as primarily a bacterial infection; that it is 
encoiiiitevcd ns a sequel to various diseases and injuries ; 
that it depends more on the condition of the jintient than 
on anv otlier factor: and that the idea that subsequent 
tlirombosos arc due to the detachment of emboli cannot he 
anv longer seriously considered. — I am, .etc., 

Poct-ins, t'orlelfc, .\pril M . M . jErDWlXl:, M.D. 


EFFICACY OF TUBERCULIN. . 

gip Tlie views expressed about tuherculin are somewhat 

opposed, hut car. be simimarized as follows: (1) It is 
dangerous. (2) It is useless or no better than ordinary 
treatment. (3) It is nsefnl, but esiiccially so if some par- 
ticular preparation is employed. (4) That those .who 
practise tnberenlin do not employ " controls,” and, there- 
fore thev cannot gauge the value of their treatment as 
comparccl with other methods. 

(1) Tuberculin is certainly dangerous it used in- unsuit- 
able cases and in tbe wrong doses. Dr. Crofton (April 7tli, 
i> 611) rightly says : “ It is easy to kill any patient with 
sti-vchnin^ it is easy to kill a tubDiciilDiis patient with 
oterdoses of tuherciilm ; hut no physician kills patients with 
sii-i-clniine, aud no patient is killed by tuberculin given in 
proper doses.” In my ajiinion no one sliould attempt the 
tiiTiorcuIin treatraeut’ of advanced cases of liibeiculosis 
ivilh'out first- undergoing a course of iiistrucfioii at au 
institution where tuherculin is systematiraUy given. 

(2) X went to Dr. Camac lYilkinsoii’s clinic as an absolute 
sceptic- some six years ago, hut. gradually became convinced 
that in his haucls, at any rate, tuberculin is the remedy 
iKi'i- execUenee for tuberculosis. "What struck me was that, 
without auy medicines, the gciieral. health of the patients 
seemed to be better than that of those treated on ordinary 
lines. I was so impressed tliat I started a tiiboreulin clinic 
in mv own' hospital, which I have cavried on ever since. 
I" have had excelleut results in early tuherciilosis and 
asthma'. In open tuberculosis I can only describe uiy 
i-esults as " fair.” 

Pj '\Yith regard .to tlie special v.alue of particular pre- 
parations I cannot speak much from personal expeiiencc, 
but all tuberculins aiipcar to act in the same way. This 
is coufii-nicd by the jiheuomena of the tubeiciiliu reaction, 
which arc similar whatever tiiliciciiliii is iwed, the only 
diffpi-eiicc being in the degree of the rcactiou, whicli varies 
with -the toxicity of- the jirepafation. It seems to me. 


MA.V 12, igsS] 


OBITTJAliy. 


[ Tiir. I^Rmsn QOR 

MrOICAl. JoCKNAt. Oti\J 


therefore, that a kiiowlodgo of' ir/icii to use it and how 
to nso it is moro important than tho selection of n 
particular antigen. 

■(4) It is moro (lifTicnlt to maho a comparison hclwccn 
cases treated hy tuberculin and by ordinary methods than 
would bo sujiposcd. Attempts have been mado to comparo 
tho mortality amongst those who have Imd tuberculin and 
those who have not. In order to convince tho non-believer 
in tuberculin, statistics have been ehiclly confined to tho 
eases with tubercle bacilli in tho sputum. Now tuberculin, 
to bo of real service, should be used in tho early stages 
before tho bacilli have appeared- in tho sputum. Even in 
tho later stages, however, it would appear from tho com- 
paratively few cases that have been recorded that lifo can 
, bo prolonged by tuberculin in a certain percentago of cases. 
In tho earlier stages tho diagnosis cannot bo made with 
certainty without tho uso of tuberculin and skiagraphy'. 
If the former shows hypcrscusitivencss and tho latter indi- 
cates activity tho condition is certainly tulicrculous. Even 
if there aro no radiographic changes and no abnormal phy- 
sical signs, and yet there are symptoms of early tuberculosis, 
the physician who uses tuberculin will bo on his guard 
if he gets a strong positive reaction with it. Ho will not 
necessarily treat such a patient with tuberculin, but if 
that patient is not progressing favourably under ordinary 
methods ho certainly will do so. To produce statistics 
whidi will . convince tho. unbeliever is, however, dilTicult, 
for he cuts tho ground from under one’s feet by' saying, 
“ Evei-yono.rcacts to tuberculin,” which is, of course, a half 
truth, aiid depends on what is meant by a tuberculin 
icaction. The comparison with ” controls ” is not so easy 
as it sounds. 

' In my hands I find ; 

• o' OT tlirivo on tuberculin. 

“febrilo and tbero aro no 

4 That ‘‘'“'■osis do not benefit greatly. 

5 T at Z “Sfhma it acta almost as a specific. 

a Vtmatori,^?L I^n 'll wisest to send tiio patient to 

?clS?n‘ itTa has become stabilized, bbt. on bis 

.-I am, etc., 

London, E.O.. Agril aKU. F. E. GuNTEK, M.D. 

MEDICAL ADTOGIIAPHS. 

‘'™ endeavouring to compile a list of medical 
antearanbs Possess a collection of medical 

l)cing to oncourago this niotUod of 
liavo for +1 ^ memory of those pioneers of mcdicino who 

nLcs Hvo a tho Veil, but whoso 

nam^ live as the benefactors of mankind. 

ColIep-n°nf that aro possessed by tho Royal 

Rovaf College of Surgeons, tho 

mSiired r tL n moro recently 

t^mo bnt^tbpv Association, aro familiar 

both at home nu^l ™''st ho many other professional societies 
interest of recognized tho historical 

dated with no Ib “^morials, especially when asso- 

sueh sodPt 1= -n r"™ ?f Portraits. I kail bo grateful if 

collections they possess. i“krete. '‘"y 

■ ’ •’ JdATIESOX D. SvRTlX. 


®Ij£ ^£rbir£5. 

n.„. 

T. B. Dixon M S Decoration to Surgeon Commander 

on Anmiii Idih i “O was born in Jersey 

tion in^lRTt Edinburgh double qualifica- 

1875, be became ' r o® surgeon on September 30th, 

service and retirerl ®““p*‘,®“*^®"oof"Colonel after twenty years’ 
ho S emnlnvpd 3rd, 1897. After retirement 

from l898teiS08,andTtGundte\®te"k^^^ 


01iitnartT. 


THOMAS VILLIERS CROSBY, M.D., 

Consulting Pliysioian, Leicester Royal Infirmary. 

IVn regret to record tho death of Dr. Thomas Villiors 
Crosby', honorary consulting physician to tho Leicester 
Royal Infirmary', who died at Leicester on April 26th, after 
a prolonged illness. 

Ho was a son of tho Into Mr. James Crosby of Biirles- 
combo, in East Devon, and was a pupil at Blundell's School, ' 
Tiverton. Ho received his medical education at' University ' 
Collogo Hospital, London, and graduated JI.B.Lond. in 
1894, proceeding M.D. in 1903. After holding for a 
short tiino a resident appointment at University College 
Hospital ho commenced practice in Leicester. His 
connexion with tlio Loiccstor Royal Infirmary beg.an'in 
1902, when ho was appointed honorary assistant physician ; 
ho subsequently bccamo honorary' physician, and was still 
attached to tho iiifiriiiai-y in a consultative capacity at tho 
timo of his death. In 1908, on tho organization of tho 
Territorial Force, ho received a commission as major in 
tho Royal Army Medical Corps, being appointed to tho 
5th Northern General Hospital, with which he served 
througlioiit tho lato war. At one timo he held office as 
president of tho Leicester Medical Society. His main 
interest was always in his profession, but in ■ the years ^ 
before tho war ho served for a period as a member of tho' 
Leicester Board of' Uiiafdians, and ho was also associated 
with tho Alasonic organization as an office bearer. Dr. • 
Crosby is survived by his widow and by two sons, one of 
whom. Dr. G. J. V. Crosby, is in practice at Bushhy, 
Lciccstorshiro. 

A colleague, "A. V. C.,” writes: The long and sad illness 
of T. V. Crosby has been a source of sincere regret to his 
many medical confreres, in Leicester, and his death came 
as something of a relief in that ho had been spared further 
suffering. It was a sad chain of events. Ho was for years 
a very successful practitioner and, thoroughly weary, ho 
retired at Christmas, 1926, hoping to enjoy a well-earned 
rest.- In the course of a few weeks he became aware of 
a serious malady affecting him ; with his medical friends 
lio discussed critically tho probabilities of any relief from 
an operation. Ho underwent it, however, only to learn that 
any radical treatment was impossible, and he obtained very 
littio relief. His bearing in that illness was characteristic of 
tlio man ; ho maintained his imperturbability, so prominent 
during his active professional life, with its many anxieties 
and difficulties, even when be himself was the victim of 
circumstance. For more than twenty years he was an 
honorary physician to the Leicester Royal Lifirmary, a 
loyal colleague, and a conscientious worker. He was always 
ready to givo a helping hand to others, and always perfectly 
u’illing to assist in anything -a-hich might help in tho 
smooth running of the medic.al -wards. His kindly disposi- 
tion endeared him to everyone. He had many friends, 
enjoyed being in company, and a-as fond of sport, hut in 
recent years his work monopolized his wholo time and he 
found little chance of recreation. Country bred, he lived 
his active life in a largo town, but his ta-stes were simple; 
ho cared nothing for shoa’, and his sympathies a'cro broad. 
Such characters are tho most laudable members of our 
profession, and the memory of T.V.Ci’Osby a'ill ho cherished 
alike by patients and colleagues. 


. THE LATE DR. JAMES WHEATLEY. 

Db. Ch.uiles Porter a-rites from Johanneshurg : 

. May I bo permitted a a-ord of sincere appreciation of 
my old friend James MTieatley, tho announcement of a-hoso 
passing, though I knea' recently that he a'as ailing, a-as 
quite unexpected. 1 first met him on my transfer from 
East Kent to Stockport early in 1892 (some thirty-six 
years ago), and frequently thereafter at the excellent and 
pleasant meetings in Manchester of tho North-'Westcrii 
Branch of Medical Officers of Health Society; and a'o also 
foregathered annually at various congresses. Wheatley’s 
charming personality and characteristic modesty were Veiy 
engaging, whilst his fairness of outlook and sound judge- 
theut mado discussion with him a very helpful privilege. 


826 MAY 12, 1928] 


MEDICAL NOTES IN PARLIAMENT; 


The npiTTSH 
JIkbical JoCRKit 


When, in 1902, I resigned ttie jiost of conntj- 
Shropshire, to come out hero as Johannesburg, 

I could think of no one better suited in every way for tlio 
Shropshire appointment than he ; and it was a source of 
particular pleasure when he applied and was selected for it. 
Tor “ those who cross the sea ” the attenuation of old 
interests and valued friendshi])s, even with men sucli as 
Delepine, 'Wheatley, Niven, and many others, is inevitable, 
hut keenly regrettable; regular correspondence soon flickers 
and dies. But in 1926 (just after my retirement ns 
M.O.H., Johannesburg) Wheatlej" wrote me, at consider- 
able length, from his pleasant garden in Shrewsbury, a 
very interesting letter about his work in and i>lans for 
the county, and his contemplated withdrawal before long 
from active official life; hut, characteristically, he said 
little about himself, and I did not then gather that ho 
was failing. My hope of meeting him again in that 
Shrewsbiu-y garden is gone ; hut one is indeed glad that he 
lived to enjoy the well-earned recognition by his con- 
freres of the excellence of his life’s work, and the expression 
of their high personal esteem, when they honoured him by- 
election as president of the Society of Medical Officers of 
Health, an honour he was destined to enjoy for all too 
brief a time. 


decided to specialize in public health work, and in 
September, 1920, he obtained thp D.IMI. and graduated 
B.Sc. of the National University of Ireland in public 
health, both with first-class honours; he was the first in 
Ireland to obtain the latter distinction. He then served 
for some time as school medical officer under the London 
County Council. In August, 1922, ho was asked by Dr. 
M. H. J. Hayes to organize the sanitary work of the Free 
Stato Army, and ho hold the post of chief sanitary officer 
in the Free Stato Army nntil SoiJtcmbcr, 1925, when ho 
was awarded a llockcfellcr Fellowship for the purpose of 
studying public health work in the United States. Ho 
studied at Johns Hopkins University, and obtained the 
Doctorate of Public Health. He was the first medical , 
officer of health a])pointod under the new Free Stato 
scheme, and took up work in Cork a year ago; he coin- 
])letely organized the public health work of the city, 
e.specially as regards tuberculosis and child welfare. _.Ho 
married in July, 1925, Sliiola, daughter of Mr. J. J. 
Flynn of Dublin, and leaves one son and one daughter. 
He twice won the Free Stato Ai-my golf championship, and 
during his university career twice ropresonted University 
College, Dublin, in throwing the discus and putting the 
weight. 


Dr. Sanger Brown, whose death at the ago of 76 is 
reported as having occurred at Chicago' on April 1st, was 
a well-known neurologist. He was from 1892 to 1897 
professor of medical jurisprudence and hygiene in. Rush 
Medical College, Chicago, and was also professor of clinical 
neurology in the College of Physicians and Surgeons, 
Chicago. IVe are indebted to Sir Edward SnARVEY-SciiAFEU 
for the following details. Dr'. Brown canie to London as a 
young man and worked with me in 1886-87 in the Univer- 
sity College laboratory on sensory localizations in the brain 
of the monkey. Our joint work was published in the 
Philosophical Transactions, 1888. The main result was to 
show that the cerebral centre of vision lies in the occipital 
lobe— occupying in the monkey the whole of that lobe, but 
as regards centi-al vision being chiefly concentrated on its' 
inner surface. Previously it had been held (by Ferrier, 
Gower, and others) that the angular gyrus represents the 
cortical centre for vision; but in tho joint work above 
alluded to it was proved that this gyrus could be removed 
■nnthout any effect being produced on vision. It was also 
shown that appreciation of sounds is not confined in tho 
monkey to the first temporal gyrus— the part which, when' 
stimulated, causes pricking of the opiiosite ear and 
movement of the eyes to tho opposite side-— for not only 
could this gyrus be removed, but all the rest of tho tem- 
poral gyri could be destroyed or removed on both sides of 
tho brain without any marked impairment of heariiiK. 
ihis Has also contrary to the generally received doctrine 
fined\r ""PPrecintion of sounds is con- 

situated iM tho lobe and is chiefly 

Ameita Dr R S)-"'®- On his return to 

Amoiica Di. Blown continued for a time to carry on 

02iperiments on the monkey’s brain, but the time occupied 
by these experiments proved incompatible with the claims 
of a growing practice, and he had reluctantly to relinS 
them. Of late years he practised entirely as an aliS 
having been for twenty-three years head of a large mentai 
sanatorium at Kenilworth, a few miles north of Chicago 

■\Vo regret to announce the death of John 
C.MiiiOLL, M.C., M.D., medical officer of health for Corl 
who died recently at tho early age of 38. Dr. Carroll 1 h 
was the fourth son of tho late 'N’^incent S. Carroll, Dnndair 
House, Dundalk, studied medicine at University Colleir 
Dublin, and graduated M.B., B.Ch., B.A.O. in 1913 g 
received a commission in the R.A.M.C. in August 1914 
and served in Gibraltar, Blalta, Egypt, and France and 
won tho Military Cross in April, 1917, for attending the 
wounded at an observation post, although the enemy con- 
tinued to concentrate heavy shell fire on it. During tlie 
attack on Ypres in August, 1917, his dressing station was 
blown up, and though he was not wounded he suffered 
severely from sliell-shock. He later served with the Aitov 
Occupation until 1919. After leaving .the R.A.M.C. he 


iitibicffl iJotts in ^Darliaitunt. 

[From our Parliasientary Correspondent.] 

On May 7th the House of Commons read the Equal Fraochise 
Bill a third time. Scottish Estimates for health, education, 
and agriculture were put down for Blay 8th. hut progress was 
reported before they were discussed. On .May Stli-Mr. Everard 
obtained leave to bring in a bill to control the production, 
distribution, and sale of reconstituted and .synthetic cream. 
He claimed that the bill w.as in the interests of public health ; 
Dr. Vernon Davies was among its backers. 


National Health Insurance Bill., 

On May 3rd tho standing committee of the House of Commons 
which is considdririg the National HdaHli lnsiirahce Bill considered 
rinuso 14 which proposes to amend the provisions of the principal 
Act resne’eting the application of surpluses by approved societies. 
Sh- TiiosTs Davies moved to add “ for the support of district 
nnrs^ ” to the purposes enumerated in the bill ns those for which 
nnriroved societies may make occasional subscriptions or donations 
out of their disposable surpluses. He said this, addition would 
be valued all over, the country. , - - . 

• Mr Rnvs Davies said there would be strong opposition to the 
KiiePMtion. Officials and members of approved societies objected 
In nultine on tho funds of the societies expenses which ought to 
enme oiit^of the local rates or from the Exchequer. Sir Thomas 
f)i?Jics”rproposaI was to take £1,000,000 or £2,000,000 from tho 
r..r.,l« of the approved societies and relieve the voluntary insUtii- 
Iffins of the country of the duty of collecting the money. This 
o-oonrlmcnt if passed, would compel the societies to reduce the 
£rs"ck™ei beiiefit by 2s. 6d. or 5s., and hand over that money 

‘°BIi" CiiAMBEamra said that I' " ’ ' ■’ relevant to 

Ihi amendment, which only, ang various 

iLftebV institutions '■\Si*seI 

of occasional subsciiptions . 

V’^Mm aSment. A society could fairly argue that by an 
SLm dmiatmn U> a district nursing association it would 
occasionaj. do^^ which might become a charge on its funds. He 
I ■ ; .■ ., . ■ ■ nursing associations were covered in 

.- .. .luthorizing gifts to ** other similar 

■ ; ■ .: • .. ■ i doubt had been expressed on that. 

■ ' . i').- ... ■■ 1 ■ aed to point out that the schedule of 

oa'aii'lonnl benehts wnicn was appended to the bill already pro- 
for the payment of the whole or any part of the cost 
of^tbe nrovision^of nui-ses for members. Under Uiat an approved 
of the proMSio nurses. But if Mr. Cliamberlani 

thought tim ameldmenfwas an improvement he would not carry 

‘‘ M?™B“to''said it was absurd for every society to •think it 
could moride its own nurses. In many cases the medical man 
Xo wSuW perhaps only go to see a patient once a day, was of 
less service than -the district nurse. , r - 

Mr Meller said the amendment was not a development of the 
additional benefit schemes. If there was sufficient money for a 
nuisin*' scheme the society would come foi-ward with one and the 
MTids"Sr would agree, the amendment was to meet the case , 
where a society had already allocated the greater part of its 
surplus to other schemes and had a small _ amount over, which 
it mifrht use for charitable purposes from time to time. 

Dr^VEHNON* Davies asked whether the committee understood 
the distinction between district nurses and nurses. present it 
was dealing with district nurses. District nurses visited patients 
once or twice a day. They were often run as charitable institu- 
tions; and he saw no reason -why approved societies should not 



MAY II, 191S] 


MEDIOA-Tj notes in PAREIAMENTi 


[ TnrBnmffi . 007 

MCDicAirJocnsAi. • 


be iiUowed to ccnlribulo a HtUo toward their fund. All insured 
persons had a chiini on tho services of these nm*sc?, whether they 
paid or not; they simply went on tho rcconmicndatiou of Iho 
doctor. 

' Tho amendment was agreed to. 

Dr. Waits moved to uulhorizo tho grant from tho djspo‘;ablo 
surplus of Ruhscriplions or donations for tho ])rovi«;ioa ot x-ray 
oxaminalions in eases of fracturo or suspected fracture. Ho paid 
an x-ray photograph was necessary in tho interest of the patient 
and of tho doctor. In recent tho courts had lield that 

failure by .a doctor to get an x-ray photograph rendered him liablo 
to an action for damages if anything went wrong with the frac- 
ture. A panel doctor had no means of getting an x-ray photo- 
graph unless ho paid for it. Tlio Cheshire Insurance Commitlco 
and tho Flint Insurance . Committee, among other*', had asked 
Dr. Walls lo bring forward this claim. Tho cost would be trifling. 

Sir KiNGSLn* Woon said anything that could bo dono to Bccuro 
proper examination of fractures would bo dono if tho finances of 
tho societies pcrniiltcd, Tho amendment proposed hy Dr. Watts 
could not appropriately bo inserted in tho clauso under considera- 
tion.' If Dr. Watts merely wished to cnconrngo hospitals which 
wero doing x-ray examinations, tho society could givo them an 
occasional subscription. If ho asked that tho commiltco should 
proWdo for x-ray examinations, that should bo considered under 
the first schedule of tho bill, and could bo discussed on an amend- 
jnciit in the name of Dr, Sliicls. [This amendment proposes to 
insert the following new benefits : Tho payment of tho wholo 
or any part of medical or surgical ppecialUt scrvic^'^. Tlio pay- 
ment of the wholo or part of tlic services of a midwife or medical 
practitioner in cases of confinement. Medical treatment or atteiid- 
iiwee for any pci-son dependent upon the labour of a member.**] 
if* V^^***^ understood that insured persons weio entitled 

to the best medical attendance. 

Sir Kingsley Wood said they wero entitled lo tho attcndanco 
mentioned in tho Act. 


Dr,_ Davies said if a doctor did not make an x-ray examination 
ho might miss a fracturo altogether. If a doctor was not certain, 
now, under present conditions, could a patient obtain the best 
skilled attention? 

Sir Kingsley Wood said if tho commitlco desired lo discuss 
whcUicr x-ray examination canio within the duties of tho ordinary 
tlio bfll do so on another part of 


wholher tlicro wna any part of tho bill in 
^ , commiltco coulj insert provisions to secure Uio payment 
01 i-ray exanunations. 

tho’fn^Sule'oTtirlill!*'” 

Ts!!' '•‘OO withdrew, his amendment, 

adminhtyyi^f Provide that additional bcncnis should bo 

entilled-'ty'^it ^ brancli of wliicli tim persons 
wero h/n,o "■•'oro Hm benents 

bo" couhl Lnoo^K?.*' rdireJ from practice, 

Beforo tho^xili^nii profession in an unliiascd way. 

miltcK of H,o of 1911 tlio lav coni- 

'“iomabfe and ‘I'o idea that it was 

men. When ^ii^i ^ if? ?^*otild employ or engage medical 

medical health insurance scheme was framed tho 

•membek^^ffrarned Si on ““i opi-i™. bf-.e 

dignity or conducive to their 

of lay^ people nartieiiNrlv 'S ’ ‘ managed by a committco 

benefit* 'Thb’ annrmv 7 y medical treatment or medical 

nXnal health “ reason why. under tho 

of tho doctors Tho ®‘^!'r'ne, -they should not have control 

wUch medical irien- were not pifuS th"'^ by 

societies. aWiich had imvbr beeh aWe th 1 f 

ment. Them woo’ oooo 'o got over then- disappomt- 

.raedical profession, and tlio idea U at “"‘"e,'’"*''" fb° 

own interests, irresnbctiv'o ' of *■ profec*' ‘ts 

.State, the apWovel'^soeie^ics any tho®^ whatsoever The 
co-onerator’^ • nnn’ft i* ^ medical 'men should bo 
.would have to reco>»nfze that'thi^v °*'b®‘‘®- The’ approved societies 

The medical prrfS a Iso had^„"„-‘'f f 

approved societies but mVw! i ? bo superior to tho 

them. Tho Na mial HeaUlf Tu, "of "'ork under 
section 5 nrovdrd IW ^ Section 75, Sub^ 

medical benefit tbev should 'he° benents were in the nature of 
Insurance CommdtZ by and tliougb the 

State ■ recognized'^that SedTta'l" m'en^ l’‘“^ *•''“? subsection the 

stances bo placed under tlm^it,™ ■ ?bould not in any circum- 
societies on ?ho-question of medirarbenTfit"'' I't™*™' “PP™™^ 

to, delete this su:;section, the’ view of thd’ni-*'-')''® 1’“"’ 
was unnecessary or iinworkabli T1.5 the Minister being that it 
tho subsection was a 'safe>or-,yi -Pbe medical profession said that 
Ihb app“som?tieVs& "hfe fr''' deleted; l«t 

as regards additional henpfif o rcrestabhsli the position, 

■ which tlio profession tbouehl °r consultant character. 

The piTfe”io.i l,ad”ooSnm by tlie Act ot 1311. 

would not always occufav that fr llinister ot Health, but lie 
regulations to ensure that th^nofnl “'ebb 

rei^urationi: flf^nonriofi /aC. •- would bo safeguarded, but 

. m?drS profession said ti c °f b'.e Minister.’ Thd 
it bad 'uifl f],nf Hies enirii? was the only safeguard 

benefits would Lake p'os'lblo 

societies of . oplithalroic clinte. - ‘ . ^^'^blisliment by approved 
culti4' causS™bv'iecffoV7s"(L'of^^^^ endeavour to avoid tho diffi- 

medical benefit";jL^^p"Lsfbt‘'rd' b’’o^"^^^%i"t Si 


ilid not sav who was to administer Ihcso benefiU. If the Minister 
was left to provide by regulation under Clause 14 (3) for tho 
administration of theso benefits, they would bo administered by 
n joint body, on whicli the medical profession and the approved 
societies would be represented. Tlicy could rely on tho good sense 
and fairness of Parliament lo see that these regulations were not 
rovci*scd. 

Mr. IIauney asked wliy the Ministry proposed to change tho 
arrangement whereby approved societies administered additional 
benefitH of a cash character and Insurance Committees those of 
a medical cliaraclcr. 

Sir Kikoslev Wood said that Tnsuranco Committees were nob 
appropriato bodies to administer tho new dental and ophthalmic 
benefits. So long as tlio subsection cited by Dr. Davies was in 
cxistenco it was impossible for administration to be by a joint 
body on which ajiprovcd societies and members of tho medical 
profession would sit. 

Remarking that he had mado his protest. Dr. Davies withdrer/ 
his nnicndinent. 

Mr. Rhys Davies moved to omit n provision regarding additional 
benefit which ran: “.Regulations may be made with respect to 
tho administration of schemes under this section and of any 
additional benefit, and with respect to the arrangements for the 
provision of anv scrvico or appliances towards the cost of \Yhich 
payment may bo made by way of additional benefit; and any 
eclicmo providing for any additional benefit shall, except so far 
as liio Mini**tci' may otberwiso direct, have cflcct as if tho 
regulations relating to the benefit were inco^orated in the scheme, 
and tiic provisions of the scheme made subject thereto,** He said 
liQ did so to secure information about tho projected establishment 
of dental anti ophthalmic clinics. TIic whole country could not 
bo covered with clinics, nor could insured persons bo compelled 
lo attend them. He hoped clinics would be set up by approved 
societies in association. If the societies were only allowed to 
do so singly tho largo societies would alone be able to establish 
clinics. He assumed clinics would be established in Manchester, 
Liverpool, Glasgow, Cardiff, and liondon. The regulation to bo 
issuctl should make perfectly clear that the insured person had 
freedom of choice, and should not be compelled to attend against 
his will. The dental profession had secured their status, and the 
antagonism between them and the British Medical Association 
was not as great as that between the medical profession and the 
people who practised optics. The panel doctor and tho dentist 
had been definitely fixed into the national health insurance scheme, 
but an approved society did not at present compel an insured 
person to go lo on ophthalmic surgeon, though some approved 
societies paid tho expenses of an ophthalmic surgeon, who would 
civo the patient a prescription to take to the optician who provided 
tho glasses. Tho ideal would be to pend cver^- insured person lo 
a qualified medical man who had specialized in eye diseases and 
for his prescription lo bo made up by an optician, but, as a 
member of the Departmental Commiltco which inquired' into -the 
registration of optical practitionci's, Mr. Rhys Davies thought' that 
day was far distant. Did the Minister propose to allow the two 
systems to, continue? Dr. Vernon Davies would say that there 
was a sufijclcnt number of specialists in eye diseases, and that tho 
Minister sliould lay down regulations whereby every insured person 
was first examined by one of them. The number of .pei*sons 
qualified to deal with the eye was about a tliousand, and they 
were no more qualified than the best opticians. Even if there were 
a largo number of specialists in eye* diseases in the medical 
profession they would not live in the districts, such as the South 
Wales coalfield, .where eye disease was most prevalent. 

I)r. Veriton Davies approved generally of what Mr. Rhys' Davies 
said, but not that the best qualified optician ■was the equal of 
a qualified oplitlialmic surgeon. . : ■ . 

Mr. Rhys Davies averred he had said the best qualified optician 
was as capable of providing a, proper pair . of ‘spectacles as the 
ordina^ medical practitioner wlio had not affected to bo & 
specialist in eye diseases. ' . . ... 

Dr, Davies said most general practitioners had no interest in 
tho examination of eyes for spectacles. . The Britisli Medical 
Association said that there were in this country about a thousaiid 
doctors, experts hi ophthalmology^ .who were prepared to •work 
tho scheme. The British Medical Association and the profession 
generally should bo given their chance; the Minister should accept 
their offer to run the 'scheme. 

Mr; Harney said’ that by tho subsection under discussion any 
scheme formed by an api>rovcd society would be deemed to have 
incorporated in it regulations promulgated by the Minister. That 
would, empower, the Minister to say that persons receiving 
additional benefits must go to institutions or clinics set up by him. 

. Mr. Chamberlain said ho had given a definite pledge to the 
Houso of Commons that a free choice must remain a feature of any 
scheme. To bind his successors he was ready to accept an 
amendment tabled by Mr. Whiteley which ran : “ Provided that 
such regulations shall not restrict tho right on the part -of any 
insured person to obtain treatment from any practitioner, clinic, 
or other insUlution with whom arrangements with respect to that 
form* of treatment have been made in accordance with the 
fcgulatidns.’! . ' ‘ ■ 

■Mi\ Meller asked if the Minister, before coming to a final- 
conclusion with any professional body with .whom he was negotiat- 
ing, -would submit the proposed terms to the Consultative. Council. 

Mr. ' Chamberlain said ho was pleased to give that assurance.' 
He added that he did not intend to authorize .the setting up of 
a' dental clinic by an approved society,, managed solely by, that 
society. These clinics wero. to be experimental, and managed by 
a joint. body, representing both the professional classes and the' 
'approved societies.* The question of the opticians and ophthalmo- 
logists was very important. Some defects of sight were not caused 
by mechanical alterations or faults in the construction of the eye, 




May 12 , 1928 ] 


'MEDIO, Vti NOTES IN ]?ATlDI,UtENT. 


r Tiir Bnmrrt 

L Wr.DiCAi. Jotmxit 


829 


bo chnrfrcd to Iho ndministration account. ITo had no reason to 
think Iht'V couUl not bo met ont ot that. They uuionntcd ou tUo 
average to less than n halfpenny per member per jcur. 


Durintr his statcm*'nt on national health insiiranco in Northern 
Ireland (a Ktatcmcnl made to tho standing comrnittco on tho 
National Health Insurance HHl, and hricdy reported in tho issue 
of tho Joi/r/mf for May 5lh, p. 777) Dr. SiNa.Ain said tho sugges- 
tion that Northern Ireland sliould bo excluded from tho common 
valuation under tho national hoallh msuranco schemo would 
practically compel it to establish a health in«5urnnco sclicmo of a 
nature similar to that which existed In Great Britain. That would 
bo an extremely complicated businc??s, becau«;o tho dispensary 
eystem, which had existed in Northern Ireland for sovcrnl genera- 
tions, would require to bo remodelled by tho establishment of 
medical benefits similar to those existing in Kngland and Scotland. 
The Minister for Homo Affairs in Northern Ireland had appointed 
a Commis'jion to look into tho affairs of Poor Law ndnimistra- 
tion in that counlrv, and a report had been furnished to tho 
Government of Northern Ireland at tho end of last year. Tho 
Minister of Labour in Northern Ireland acted for tho Ministry 
of Health, and had adopted a medical rcfcrco evstem, of which 
tho health societies availed themselves freely. Tljo certification 
system in Northern Ireland left something to bo desired, but 
tho medical rcfcrco system now in forco would soon help to 
correct any alleged irregularities of certification. Ho begged tho 
commitlcQ to ucsitato before accepting the amendment, and 
to give tho Government of Northern Ireland time to remodel 
their local government services, and with them tho dispensary 
system, thereby bringing Northern Ireland into lino with Great 
Britain. Northern Ireland was far too small an area to support 
a national health insurance schemo of its own. Tho dispensary 
system that prevailed in Northern Ireland suited admirably tho 
largo agricultural arcar., but It was not so much availed of in tho 
industrial areas. If suflicient time were given, it miglit bo that, 
in tho long run, a new scheme of health benefits would bo adopted 
in Northern Ireland, 


SmaU~pox, 

Answering Dr. Frcmanllo, on May 3rd, Mr. CnAMnniL^ix said 
tho report of tho Departmental Commiltoo on Vaccination was 
being printed, and would bo ready at on early dato. 

On May 3rd Mr. BaOMFitU) asked what moans were adopted 
by tho omcials of tho Ministry of Ilcallh to determine whether 
samples of lymph contained vaccinia virus, Mr. CnAStnEni.An? said 
tho methods od«^tcd in pursuanco of Article 8 in Part I (B) of tho 
second schcdalo to tho regulations wero those of Calmcttc-Gudrin, 
Gins. Sofaernhe^ and Groth, which wero recommended by tho 
femall-pox and Vaccination Commission of tho League of Nations. 
Mr. BROunriJ) asked what wero tho characteristic lesions duo to 
vaccinia nr^ referred to in tho Therapeutic Substances Regula- 
tions. Mr. C^MBERLAix said the characteristic lesions referred to 
wero tbo production of tho specific and characteristic vesicles on 
® inflammation with cloudiness and opacity of tho 
Snjnea-piM and rabbits^ and local areas of infiltration 
appearance in tho caso of tho intradcrmal 
farther asked to what extent rabbits 
Purposo of propagating lymph in tho Government 
f‘«t brouglit into use for that 
‘'''“t durino tho last she 
of rabbits used was trvolvo. Rabbits for this 
sysfcmutically used sineo 1902, and for two 
years previously m preliminary expcriir"***”' ** *’ 

Mr. BnouriELD asked whether, in vie 
recently published third edition of 

yweei^o lTnnr/*^DTOdnpJ^?/"in**f to tho various sources of 

Mr ChuSe^Hin ®°'^ornmcnt lymph establishment, 

for’ aseertaining whetlieJ ‘the ^vi'rSe 3 "oht'"'“ “a 

different sources were identical in 11 ,.;. from so many 

view of tho fact that no caS form sner "■ 

disenvpppd Mr rs,,.-.rr, ^Pocitio to vaccinia had been 

cited as regards 'tho various^sf rccs ‘"i 

to refer to vaccine lymph in gcncfnl 
at tho Government l^iph estalhshment a” 

tho lymph now used at tho Gmframeni 

derived from calf lymph oririnX ohtri?^^ establishment was 
tho strain had since been carrfed on hff n . i''?” Cologne, and 
animal to animal. In these ^ transforenco from 

taiumg whether different 

bem nfiRfd^o^thTli'Scf of Institution has 

casual wards, which, with his ./neS‘Uvf " tedriLflsIi! 


iho Briti*;!! Government w'ith concealing its drug exports. Ho 
called attention to tho fact that iho amount of raw opium returned 
by Great Britain ns exported to tho United States was less than 
tho amount of raiv opium returned by tho Government of tho 
United States ns imported from Great Britain. Tliis discrepancy 
was being examined by tho two Governments. It was probably 
duo In part to tlio fact that tho returns related to different 

f icriods, tho British being for tho calendar year, tho American 
rom July to July, and in part to tlio fact that opium sold from 
Great Britain miglit actually bo exported from Great Britain, but 
ehipped direct from a foreign port to tho United Slates. There 
was no reason to question tho accuracy of tho British official 
flgurca. 

In a previous answer to Mr. Sc^ngcour, on May 2nd, Sir 
Austek CiiAyRERLAiN denied that tho British representatives on tho 
Opium Comrnittco of tho League of Nations had opposed tho 
cffoVla of tho Italian rcpresenlativo to prevent tho Opium Control 
Board being mad© independent of tho League and representativo 
only of tho interested Government. Tho point at issue was tho 
relation of the Kccretariat of the Board to tho secretariat of tho 
League, and iho British representatives, with some other members 
of Iho Opium Committee, acted in tho belief that tho views they 

S ut forward gavo oiTcct to tho intentions and provisions of tho 
pium Convention. 

Licut.-Commaiidor Ke^twortity asked if Mr, Locker-Lampson was 
awaro that tho figures ho bad road out did not include one show- 
ing that tho total world requirement for medicinal purposes was 
only 15 tons, and that at least twice as much was being manu- 
factured. Ho asked why Parliament should not tako drastic steps 
to prevent an excessive amount being manufactured and sent out 
by profit-making firms in this country. Mr. LocKER-LAi.n’soi? 
replied that for that reason tho British Government had ratified 
a convention setting up a Board of Control. 


Treatment of Venereal Disease. — Miss Lawrence asked Mr. 
Chamberlain, on May 3rd, tho amount of grant giveh towards tho 
treatment of venereal discaso in tho years 1921 and 1927, and tho 
amount wliich local authorities had been informed was tho 
maximum they would receive for tho year 1927-28; the number 
of treatment centres for venereal disease in England in 1921 and 
at tho present timo; and tho number of health authorities whero 
no such centres wero provided. Mr. C^A^^BE^LAI 2 l replied that tho 
grants paid to local authorities for this purposo amounted to 
^21,^7 and £272,921 during tbo financial years 1921-22 and 
1927-28 respectively. Tho maximum grant payaolo to these antho- 
rilics in respect of tho financial year 1927-28 was £286,763, There 
were at present 177 treatment centres in England, compared with 
184 in 1921, tho reduction being duo mainly to tbo policy adopted 
in somo largo towns of concentrating tho work of two or moro 
centres in ono centre^ at which tho facilities for treatment had • 
been extended. Facihlies for tbo treatment of venereal disease 
had been provided by all tho local authorities responsible for this 
work, but in a few eases tho treatment centres wero outside tho 
administrative areas of tho authorities. 

Tuberejilosis : Cost of Sanatorium Treatmcnt.^hlr, CHAimERLAnr 
announced, on May 5rd, that tho average cost of residential 
treatment in tuberculosis sanatoriums during 1925-27 was 49s. S^d. 
per patient per week. Tho total sum spent in any year on 
sanatorium treatment proper was not separable from' tho amounts 
spent on other treatments of tuberculosis. Dr. Verjton Davies 
asked whether tho accounts could bo altered in future years to 
give tho cost of sanatorium treatment. Mr. CnAUBERLAnf said it 
was difficult to soparato sanatorium treatment from other treat- 
ment in residential institutions. Answering a further question by 
Captain Boorke. Mr. CnAMDERLAEK said tho tuberculous schemes 
of ell local authorities provided for tho observation of patients- 
discharged from sanatoriums. Ho had no figures to show th© 
porcontago of such patients who wero permanently cured of 
tuborculosis. 


Procedure repardin^ Discharae of Certified Persons. Itfr . 

Richardsoh asked tho Minister of Health, on May 3rd, if, accord- 
ing to a recent ruling of tho Board of Control, tho procedure 
under Section 49 of tho Lunacy Act of 1890 for tho examination 
of a certified person by two doctors with a view to discharge was 
now held to require that tho two doctors, instead of visiting onco 
oach^ with an interval of seven daj’s and giving an independent 
opinion, should visit tho patient together on two separate occasions 
with a like interval of seven days; and whether ho would intro- 
duce legislation at an early date to simplify and facilitate tho 
procedure so ns to placo the opportunity for discharge conferred 
^ this section^ within reasonable reach of tho poor. Mr. 
CnAMDERLAnr replied that tho ruling of tho Board of Control was 
given after full consideration of tho terms of tho section. Tho 
point raised had been noted for consideration in tho event of 
fresh legislation being introduced. 


T_ . OMtput of Morphine. 

tho world outnut of helwcen 1921 and 192£ 

A statistical ‘o”' 

pave the figures as abmifc xn League of Nation? 

figurra wero incomplete.' 'Th” T926‘’°n^r 

morphine which wero nro,i,,o„j ° ‘iguro Included quantities ol 
non-danger^u, products sS transformation into 

•nanufaduired for safn o. Tho quantity of morphine 

tho manutariurrormo^^l,ioo\'^i* waller. In Great BStain 
tho last fi?? had shown a steady decrease during 

‘hat tho ItaVn ”~’tari°ve aware 

u representative on tho Advisory Committee charged 


Jfincra* Phthisis due to Roeh-horing. — On May 3rd Sir W tt.t.ta m 
Joynson-Hicks, who was asked by Mr. GRianrix anout tho extension 
of tho schedule of industrial diseases to includo men wlio contracted 
miners* phthisis whilo rock-boring in coal mines by compressed air 
machines, said tho matter would have to bo dealt with by a scheme 
under tho 'Workmen*a Compensation Act, 1925, and he had asked 
tho Departmental Committee on Workmen’s Compensation for 
Silicosis to adviso as to tho terms of a scheme. Ho had offered for 
this purposo to appoint to tho committee two representatives 
of tho industry on each side, but had not yet received tho reply 
of tho Miners^ Federation. The disease was not notifiable, and 
no etatistics woro available, but its' incidence, to a limited extent, 
in tho coal-mining industry had been establisned. 


830 May 12, 1928] 


TINIVEHSITIES AND COEDEGES. 


[ Tirr.rniTTrt 
MKn?C*L JotHTfAt 


Dtifif.s of Itcgifitrars of lUrths and Draihs. — On May 7t]i Mr. 
CiUMaERLAiir iolti Sii C. Oman that a rcpisirar of biHlis and 
tleolliJ? was required by regulations to I'oport to llio coroner 
e\erY death whicli, on the information before him in Ihc medical 
certificate or otherwise, was due to any one of certain prescribed 
causes or occurred in certain prescribed circumstances, and, 
pending consideration by tlie coroner, to defer registration and 
the issue of an authority for burial. He had thus no discretion 
to decide whether to report such cases or not. He (Mr, Chamber- 
lain) was aware of no reason for apprehension that registrars of 
births and deaths did not discharge taithfully the duties of Uicir 
office in those cases where they also licld Poor Law office. 

MilK- Produciion in Entjhivd and ire/r.s. — On May 7tli Mr. 
Gpiitkess, in reply to Mr. R. Young, stated that llic total 
amount of milk produced in England and Walcs^ dunng the past 
two years, exclusive of milk fed to calves and pigs, but inclusive 
of rnilk manufactured into various products, botli on and off 
farms, as well as milk consumed in liquid form, had been esti- 
mated as follows? June to May, 1925-26, 1,135 million gallons; 
June to May, 1926-27, 1,150 million gallons. “Certified,** ‘Grade 
A (T.T.),” and “ Grade A ’* milk constituted approximately 1 per 
cent, of the milk consumed as liquid milk. No reliable cstimale 
for “pasteurized” milk was available. The terms “clean** and 
“purified” were not recognized as official designations; (lio.y 
were entirely relative tenns, and tiic quflntitics of milk sold under 
them were unknown. 


Slnilicrsittcs nitti ©ollrgcs. 


UNIVERSITY OF OXFORD. 

At r congregation held on May 3rd the following medical degrees 
wero conferred: 

J>.M. — Jj. N. Jack‘»on. 

B.M. — C. \V. Flcimning. 


UNIVERSITY OF LONDON. 

TInivkusity Coluiok. 

Ik addition to those announced on April 28tli tp. 740) the public 
lectures at University College, Gower Street, during tlic current 
term will inchido one by ProfcKSor Ross G. Ilariison of Yale 
XJuiverBitv, on “Modern trends in the study of animal develop- 
ment.” The lecture, wliicit will bo given at 5.30 p.m. on Monday, 
May 2lEt, is addressed to students of anatomy, idiysiology, and 
zoology, and is open witliout fee or ticket. 


UNIVERSITY OF SHEFFIELD. 

The following candidates have been approved at the examinations 
indicated : 


Dt/it(nfcrt/ in 'a Prison Camp.— -On April 30lh Mr. Amery 
informed Mr Ronme Smith that bis latest information on Hie 
outbreak of dysentery in a prison camp at Malaita was given in 
n reply to a question on April 17th. So far as his information 
went, cnl 3 ’ one of the natives was arrested by the cud of October 
last. Arrests w^rc still being made in Fobniarj^*. The trials 
would ordinarily bo conducted by the chief magistrate of the 
protectorate, hut he had to leave the prolecloratc owing to ill 
health, and another judicial officer had to be sent to the pro- 
tectorate from Fiji. He (Mr. Amery) proposed to await the 
report of the High Commissioner before deriding whether any 
inquiry* bv the Special Commissioner in regard to happenings 
between the arrest and trial of the prisoners was *clcsirablc. 
Until he received that report he was not prepared to enlarge 
the present scope of the inquiry. 

Insanitary Areas in Pljpnovih. — On May 1st Sir Kikcsley \Vooi> 
told Mr. Hore-Belisha that the Minister of Health had seen the 
icport of the medical officer of health for Flj'inoulh for 1927, 
in which ho stated, >vith reference to the three insanitary areas 
which lie scheduled in Plymouth more than three ycai*a ago, that 
itfc appeared almost incredible that the short, (hough necessary, 
foimalitios regarding his repi'csontation should still be incom- 
ploled and that matters should have advanced so little towards 
any definite end. A scheme dealing with one of the areas m 
question had been submitted to the Minister, and he had directed 
.a public inquiry into the scheme. Ho was making inquire* as to 
the other two schemes. Tiie report of the medical officer of health 
for 1927 Slated that upwards of £100,000 was spent by owners of 
insanitary property in Plj’mouth on repair work during tlic veai-s 
1924-27. ^ 

of Voluntary Bospitnh. — Sir Kiwcsley V’ood, rcplviug to 
a question, said that no complete statement of (he amount of 
rates paid in respect of voluntary hospitals was available. In the 
opinion of the Minister of Hcaltli any proposal to dc-ratc voluii- 
lavN' hospitals must be considered m relation to similar claims 
made on behalf of other charitable and public institutions. 

HtUif] P( trol. — Sir PniLip Sassoon stated, on May 2nd, that cliiyl 
jKLroI was by high-speed aircraft during practice flights iii 

the Air fecrvice. The Royal Air Force had been cxpcrimcnling 
for four ycai-s with tiiis spirit, and bad no evidence to show that 
It was more dangerous than ordinary spirit. 


1 moc 0-7 J 1 Eotes in Brief. 

. expenditure on the school medical services 

was £1,516,995 and the receipts £66,910. - ' 

During the twelve months ended March 31st, 1928. 14 nnhnals 
weie cremated on account of foot-and-mouth disease and 6^ 
wTre huned. * v ^ 

During 19^ there were 1.Q2S fatal and 172,883 nou-faUl acridenls 
at uuucs uuder the Coal Mmes Act, resulting iu U2a deatlm 'vnd 
dhablemcnt for more than three daj-s lo 173,C43 persons^ ^ ^ 

In 1927 there were, 48 fatal accidents in the Ro^-al Ai.- 
,vill. 55 deaths; in 1928, to AprR 2Rb. there had b«n IS^fatai 
accidents with 24 deaths. tatal 

The Minister of Health cannot reconsider the decision not In 
allow the use of sulphur dioxide in the treatment and mRlin? 
of barley. 

Tlic birth rato for the administrative coimty of London in loov 
was 16.1 per 1,000. The boroughs with Hie liigliest birth raiJ: 
woie Shoreditch (20.7) and Bethnal .Green (20.0;. ^ 

At the beginning of April 2,685 maternity and child welfare 
centres were known to the Ministry of Health in England and 
iValcs as against 2,575 a year prcnously. 

Sir Kingslej* Wood states that he cannot give an assurance Hiat 
the proposed* Local Government Bill ^vill await the report of the 
Royal Commission on Local Government. 

In Glasgow, on March 31st, the number of houses inliabrted but 
certifitKl unfit for human habitation was 3,007. 

The governors of the Royal Veterinary College are endeavourin'^ 
to obtain the necessary funds to rebuild Hie College, and the 
ilmzstrr of Agriculture has promised a grant of £35,000 on a 
pound for pound basis. 


FlKAli 51.14., Cii B. (Part 1).— J. D. Gray, Itessio nntlierloj*. 

TuiiiD M.B., Cu.B. — \V. H. CarliBlc, A. Cohen. *l-*. Kllis, R. B. Gonld. 
Iris 51. Moody, S. K. PanniKor, IT. H. I’uilar, L Slesnick, J. IL 
IViJbonrn. 

♦With distinction in patboloffs'. 

4 IVitb disiinclion in anatomj', pathology, and iiharmacology. 


UNIVERSITY OF DUBLIN. 

TniNiTY College. 

At the first summer commencement of Trinitj' Term, lield ou 
May 5th, the following meilical degrees were conferred; 

M.D.—IV. B. Aykroyd, L. C. Brough. 


ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH.' 

A QUAUTKULY meeting of the Royal College of Physicians of Edin- 
burgh was held on 5Lvy Ist, when the president, Dr. Robert A. 

Fleming, was in the chnir. , ^ , , , . , * 

Ur. James Tbomsou was introdnced nnd took jmb scat as a 
Fellow of Ibo (Jolleiie. Dr, John Bowes McDougall and Dr. Anna 
Justina Angnsta v\ ilson were elected Fellows. 

Alfred Joseph Clark, Margaret Black jilartiii, David Taylor 
ItIncUio, Joseph Ryland Whitaker, and Mohamcil AbU El-Hamid 
Goliar. were elected n embers of tbe CoJlevc. , 

Dr. Robert Thni wan elected a representative of the College on 
the tioujointCommdteeof Mana^emetitof theTripleQualiQcation. 
Dr WIBinm Russell was elected the repreventailvo of the College 
oi/the General Council of Medical Edncatiori aud Uegistration. 

^ The Lister Fellowsliip was awarded to Dr. Charles G-, Lambie, 
V R C.P., for his w’ork on carbohydrate inetabohsm. 

At an extraordinary meetnig held the same day, Dr. Walter 
Tyrrell Benson was electetl a Fellow of tbo College. 




The next session of the General Meilical Council ■n'ill 
'omoience at 2 p.m. on Tnosday, May 22na, when the 
President, bir Donald MacAli.ster, Bt., IC.C.B., M.D., will 
-aUe the chair and yive an address. The Coaocil will contiuue 
to sii Irom day to day until the termiuation of its bnsiness. 

The next quarterly meeting of tlm Royal Medico-Psycho- 
Inoical Association will beheld on Wednesday, May 16th, at 
British Medical Association House, Tavistock Square, 
w.f’l under the presidency ot Dr. Hamilton Maw. Tlie 
ninth ’Mand.sley Hectnro wiU be given, at 3.30 p.m., by Sir 
John aiacphersoD on " The new psychiatry aud the influences 

which are forming it.’' 

■PROFESSOH W. E. Dixon will deliver a Chadwick pnbllc 
lectnre on June '7th, at 5 p.m., in the Chelsea Physio Garden, 
OT narcotic plants. 

A MEETOfG of the Chelsea Clinical Society will be ueld on 
Mnv 15th at 8.30 p.m., at the Hotel Rembrandt, when Dr. 
T H Rufi’el and Dr. O. L. De Wesselow will open a discussion 
sn the clinical value of biochemical molhoils. The meeting 
will be preceded by dinner at, 7.30 p.m., and after the dis- 
cussion the annual general meeting o£ the society will talce 

At the meeting ot the Biochemical Society to beheld to-day 
(Satnrday, May 12 h), at 2.15 p.m., at the University of 
Birmingham, a number of communications will be made, 
including one by Mr. S. H. Edgar on the composition of the 
blood in acute rheumatism of cbUiUiood, and another by 
Me-ssrs. E. M. Hume, H. H. Smith, and I. Smedicy-Macl/Dan 
on ihe biological examination of irradiated zymosterol tor 
vitamin D. . ... 




832 May 12, 1928] 


IiETTERS, NOTES, AND ANSWERS. 


[ Tni: URiTifR 

MeDICU. JODRSiL 


Bucli receipts are Tisnally mev^ea in a i)ractitionor*0 {'cncral 
earnings for assessment uiuler Schedule D, and Uie objection to 
tbe allowance of travelling expenses is then waived. Unfor- 
tunately, “M.D.” has no fund of general earnings with which the 
appointment receipts can be merged, and in such circumstances 
the concession referred to would not apply. Wo can only 
suggest that when “ BI.D.” is called upon for a return he should 
request that that demand bo left over until he has been twelve 
mouths in the new worh, and that he should thou maUo an 
inclusive declaration deducting all travelling expenses and other 
costs incurred in doing the work and ask for the matter to bo 
dealt with on that basis. As tlie car will presumably bo largely 
used for private purposes, it may bo best to keep a record of tlio 
mileage driven for professional purposes and divide tlic total car 
expenses proportionally. 

Dc(hi''lion for Residence, 

S.” explains that since Ins last year’s return was made ho 
has purchased his house. What can he deduct in the form of 
rent? 

*** The same proportion as was previously applied to the 
rent paid should now be applied to the net assessment under 
Schedule A on which “ S.” now pays income tax as the owner 

of the premises. 


•resign my post. My desire to got hack into harness, to justify 
niy years of hard study, amounts at times almost to an obsession; 
moreover, X seriously need tlio hel[> that a reasonably paid post 
would provide for a war-disabled husband and a small family. 
Uut I know that the position is hopeless in the face of this 
appalling state of nufimi>loyment amongst moilical women. X 
would go fiirtlicr than “ Uouiity Medical Officer” in stating that 
“it reacts unfavounihly,” etc. ; I would say tliat It is a disgrace 
' to the profession, and calls for smart action by the Association 
ns n whole, and tlic AV^omen's X’edoration in particuiar. Lot 
them rouse themselves from their ease. The closing of the 
medical colleges to women at any rate will save m vny from 
bitter disilhisionnicnts in the future. At the same time I feel 
sure that the power of such as those who couuteniuice with 
unconcern tliis artificial nttcmpc to subjugate women in the 
sphere of medicine cannot iiltini itely prevail. And so ” County 
-Medical Officer” and his liypothctically’ out-ot-woric colleagues 
will not have to tremble for long. 

“A. M.” writes to express his agreement with the letter of 
** Comity Medical Officer ' with regard to iho remuneration of 
medical women, lie thinks that steps should he taken to reduce 
the entry of womou into the medical profession in view of the 
seriona overcrowding, iw illiistr.ited by the fact that fifty or one 
hundred women apply for small a()pointments. lie adds tliat 
these “student appointments are stippo^ed to be tenable for 
six montlis, but are actually retained for long periods by women 
who iiavo been in practice for four or five years. 


Value of Board and Lodriinfi. 

“ J. C. H." was engaged as a temporary assistant on terms winch 
provided for free board and lodgings ; be is not staying under 
ins principal’s roof, but the coat of bis board, etc., is paid for 
him. Is he liable for taxon tbe value? 

*** He is not liable on any advantage which is not received 
in money or in a form cjipable conversion into money; on 
that principle and on the facts stated he is nob liable for tax 
on the value of the board and lodgings. If “J. C. U.” made 
a return for assessment including that value as part of his 
statutory income he can claim back the tax |>aid in error — or 

, have it set against tbe next iuatalmeub due— but if be loft the 
assessment to be made in the absence of his return and then did 
not give notice of appeal witbin the statutory period of twenty- 
one days, we fear ho has no legal remedy. 

Motor Car Transacthus, 

**N. W. J.” bought an E car in 1924 for 4350 and sold it in 1927 for 
£75— when the price of a similar new car was £280. In 1907 he 
bought a "NV.K. car for £575. What should he claim ? 

*** (1) Obsolescence allowance, £350-£75=£275— but it is 
possible to contend tliat the allowance should be£280-£75^£205. 
(2) Depreciation allowance 19i8-29, £575 at 15 or 20 per cent. 

“H. A. T.” bought a 11.4 h.p. car in January, 1926, for £250 and 
sold it in January, 1928, for £100, buying a 12.24 h.p. car for £250. 
His accounts have been made up to April 5tl» each year. What 
allowances can he claim? 

*** Obsolescence allowance as an expense of tbe year 1927-28, 
the out-of-pocket expense— namely, £230-£l00=:£i30, and de- 
. in-eciptiou allowance for 1928-29, 15 or 20 per cent, ou £230. One 
point should perhaps be mentioned— that is, that as there was 
• a slight increase in horse power it might bo contended by the 
revenue authorities tiiat there was some measure of capital 
expenditure involved in the pnrehase of the second car. The 
difference is. however, so small that it is thought that that con- 
tention would not be pressed seeing that the second car cost less 
than the former one. 


LETTERS, NOTES, ETC. 

. Salariks of Medical Women. 

O.” w’rites: Tour correspondent ” Conn tv MpfUM .1 nm™i» 
. (April 7th, 612) me when, rererri^r’i^the eZ 

Balfvnes oi women asBisUuits in t-eiienil praotitS, lie conclmfes 
that ‘.i Such a couiiitiou of affairs mast react imfiivomablv min.! 
the wliole profession, ami tlie first to suffer will be the main 
members of the |.nblic healtli service." 1 aeb mj-self repeaSd y 
"Howf" but fail to fliKi the answer. I ayroe with him wirole- 
lieiuteaiy that well-qiialihecl women do work tor their board 

■ oiilv, and tliat tlie addition of £3 a week is a reiatively priiicsiv 
cmulmiient to many. I ndmiie sncli women for their coara»o 
ami tenacity in sticking at nil costs and saci ifice to tlieir callim. 

.l.et not “ County Medical Officer” commiserate with them" 
After twelve montlis’ ho-pital experience 1 was offered £150 per 
annum (out of wliicli I liad to pav for my own board and loib.ini; 
in an insanitary two-roonied cottage in the v llage) to act as 
assistant to a distinguished retired colonel. He himself Uve^. 
with his small family m a charming and roomy house. I had 
too high an opinion of myself, and refused this post. About the 
same time X was offered a post under a South wales medical aid 

■ society at £450 per annum ; acting ou the advice of tlie Secretary 
of the British Medical A«5sociation I courageously refused. After 
further clinical experience I encceeded in obtaining a public 
health post at a salary of £600 per annum. Having worked for 
three years ami paid ofl my linancial obligations to my parents 
and my old school, I married, and for this offence was obliged to 


Five Generations Attended by One Doctor. 

Dr. James Adam illamllton, lianarkshirc) writes: Dr. L, J. Hood’s 
experience (April 21st, p. 700j of attending live generations m 
one family has also been mine for some years past. I am hoping 
I may attend the sixth. 


Unusual Pigmentation of Scalp. 

Dr. U. G. Cooper (Bel-Abhes, Algeria) refera to the' report by 
Dr. D. I. Walker (Kobnmry llth, p. 243) of tlie case of a boy who 
had a paicli of jet black hair on the right parietal and frontal 
region of tiio scalp, the hair otherwise being of a sandy, fair 
colour. Dr. Cooper remembers a similar Well-marked case in a 
boy aged 12-14, whom be saw in I5diubnrgh about twenty-five 
Years ago. This boy had pronounced red hair, with an oval 
patch of black as large us a ben’s egg over the upper part of the 
right occii:>ital area. 

Commerce in Radium. 

With reforcnco to an article'umler tins heading which appeared 
on January 7th (p. 19i, a correspondent informs ns that, bcshles 
the knoum deposits mentioned therein. large dejiosits of uranium 
■ ore are now being developed in the Flinders Range in Lbo 
Hortlicrn Section of South Australia. 15x tensive lodes of aiuunite 
and lorbenite, not associated with any other metal or mineral, 
have been found, and radium element has been extracted from 
these ores at the Australian Radium Corporation’s trealincut 
works at Adelaide. 


The “Transparent” Card Hingp... 

The device which now bears this name, and which was formerly 
called the “ M. H- S. Card Clip,” is the invention of an JGugiish 
doctor and is manufactured bj^ Messrs. Cooper. Denison, and 
Walkden, Ltd.', bt. Bride Street, J‘l.C.4. It is designed to furnish 
a means of keeping index cards, notablythoso used in insurance 
nractice, permanently grouped witliout the use of clumsy wire 
clips* by its use a numbor of cards can be quickly attached to 
one another to form a “ book.” liacU binge consists of a small 
double disc of strong liglit fabric, the two parts being united by 
ijjio of stitching and the inner surfaces of the discs being 
gummed, BO that the edges of the cards may be fastened firmly 
' iietween them. 

The Petrol Engine. 

Tm The Petrol Engine tbe staff of the Motor provides motorists, 
^ mpchaiiics, and others with a brief and clear account of tlie 
construction and use of the petrol engine. The descriptions ot 
fhe various parts of the engine are simple, and the book is \yell 
» illustrated, so that it is easy for one with no nicchauical 
- iin«» to understand tbe working of bis machine, whetborit 
*iin a tonriug car, a motor cycle, or a commercial vehicle. Iho 
first chanter gives the history of the early development of the 
internal *^conibustiou engine. At tbe end there is a chapter 

* ri*»ccribing the chief types of engine for petrol-electric lighting 
'sets The hook is a useful addition to the Temple I’ress senes 

of manuals for motorists. Its price is 3s. 6d. 

Motor Tyre Manufacture. 

rvav T)nnlop Rubber Company extenils to any medical practitioner 
who is interested in motor lyre equipment an invitation to visit 
fhft works and see the manufacture of tyres in progress from the 

* t-Aw rubber to the finished article. Any reatier who desires to 

Advantage of this iiivilatiou sliould communicate with tho 


Vacancies. 

HOTIFIOATIONS ot Offices vacant in universities, medical colleges,, 
and of vacant resident and other appointments at hospitals, ' ill 
be found at pages 48. 49. 52, 53, 54, and 55 of our advertisement 
columns, and advertisem*uits as to partnerships, assistantships, 
and locuratenencies at pages 50 and 51. 

A short summary of vacant posts notified m the advertisemeuB 
columns appears in the Supplement at page 211. 



'M\T ^0• >0-8] 


I5TMUNIZATIOH AGAINST DIPHTnEUTA. 


[ 


Trrr nnmrr 

MrMCAI, Ji>CH*<AL 


833 


^ illrMrnl ^ssorintion 3Crrlurc 

ON 

IMMUNIZATION AGAINST DIPHTHERIA, 
SCARLET FEARER, AND TMEASLES/' 

DEiJVEHF.n TO tiif. Hatoogatk Rivision ok MAitcit 17 tii, 1928, 

BV . . 

S. MOXCKTOX COPEMAN, M.R., F.R.C.P., F.R.S. 

RirnTiiriUA. 

'Thf. outcome of PcIiFing’s vcscufcIics on tfiplillieria, resutt- 
iug in the introduction of antitoxin, constituted a great 
advance in tlio treatment of tliis disease, liy alTording tl>q 
possibility of mitigating and even of aborting attack, 
jnovided’ tbat the antitoxin is employed at a sufficiently 
early stage. Jlorcover, if “ contacts ’’ are inoculated before 
any symptoms have developed, incidence of the disease can 
-be prevented. Unfortunately, bowever, tlie passive im- 
munity thus prodiiced is of a very fleeting nature, not 
extending, as a rule, for a period longer than three rveeks 
or so. Consequently, although of undoubted service in face 
of an existing outbreak, the inoculated individual will, in 
all probability, prove just as liable to contract the disease 

• if subsequently exposed to infection. 

It is to the work of Schick, first published in 1910, tb.at 
,u-e owe the introduction of a means of testing for the 
presence or absence of immunity, and of the method of 
orfinc immunization again.st di]ihthoria, which has put 
into our hands a moans of prevention the value of which 
has now received recognition throughout the civilized 
world. In this country work on the lines laid domi by 
Schick was not taken up to any extent for a number of 
yeai-s subsequent to its publication. lJut in America the 
case was very different, more especially in Now York, 
where, owing to the enthusiasm of Dr. IV. M. Park and 

• of his assistants, Dr.s. Anna IVilliauis and Abraham Zinghcr, 
investigations ’were initiated at an carlv date and on an 
extensive scale. 

It was not, however, until 1S21, on the occasion of an 
outbreak of virulent diphtheria in the Southmead Infir- 
mary of the Bristol Union, into the circumstances of 
iich 1 made inquiiy, that official investigation into the 
potential i-ulue of the Schick tost and of toxin-antitoxin 
inotHlation.s in connexion with diphtheria prophylaxis was 
^ nil latcd. Here our first attempt at iiniuuiiization (on a 
nurse in one of the diphtheria wards, who, unfortunately, 
turned out to bo a serum reactor) was followed by con- 
siteiajc rise of temperature and malaise on the part of 
-e pa icn . Happily, however, this case proved to bo quito 
"'e subsequently found that by 
the ^ » minimal preliminary sensitizing dose of 

f"" given 

-i.cntv-four hours later, even i 


is ,, ,;in e 1 i« mhom reaction 

trouble aril‘ing.'"“' ^ mitliout any similar 

Sotlhinrrinfima^ ZT ouf''- 

H orz.JrsL:: 

Ins mit aenin 1 * "ork was carried out diphtheria 

""cas ‘"/'TV,, 

a local van be judged by 

of persons who lua^e rcTvereT f™ '’'ruf 
otherwise immune to the JITL ^Hal'tl'eria or are 
1/30 unit of antitoxin. per enffie ’ 
of toxin used in the .Sd ier testT ’"l n 

positive reaction in persJl » 

antitoxin in the blood 


into, but not under, the^ski^ToVf. i"g 
forearm 0.2 c.cm of a frll i V '® of the 

diphtheria toxin of fidl st ' dilution of standardized 
thl needle fs iLe ted 
?nd in this and otheilninntiae - '--'’A"' 

IS neeossan-. As a control 


i ‘AV /eoln 


a certain amount of practice 
a similar amount of the same 


in n,itural ooloor phoij^s^lj^ri’y. 


re, which was illustrated with 


solution, previously heated so as to destroy the toxin, is 
also injected inlvadormally on the ojiposito arm. The 
results fir.st become apparent after about twenty-four lionr.s, 
lint it is diffieiilt to he certain of an accurate reading 
before at least ninety-six hoiir.s have elapsed. 

The reaction 'njipears on the surface of the skin at the 
site of iiijcetioii as a positii'c, a negative, a pseudo, or 
a comhiiied (positive) reaction. 

(a) The positive (susceptible) vcnction is indicated by a 
roughly circular area of a more or loss deep red colour 
around the site of injection, while no change occurs on the 
control arm. It is dne to the irritant elfoct of the toxin 
acting upon tissue cells which are not protected by anti- 
toxin. A positive reaction indicates tliat little or no 
antitoxin is present in the }iaticnt’s blood, and tbat, in 
conseqiiciico, susceptibility to diplitlioria exists. 

(h) In the negative (imiiuine) reaction tliore is no ebango 
at the site of injection on either arm, and a result of this 
kind indicates immunity from diplitlioria. 

(c) In a “ pseudo ” reaction there is an approximately 
equal area of redness on both arms, which usually reaches 
its height in about twenty-four hours, and may have com- 
pletely faded by the fourth day. The pseudo reaction 
is non-specific, and occurs in persons susceptible to the 
action of “foreign” proteins in general; it is to be 
regarded, equally with the negative reaction, as indicating 
iiiimuiiity to diphtheria.’ 

(d) The combined (positive) reaction presents elements 
of both the positive and the pseudo reartion in the same 
individual. In this ease a reaction occurs in both arms, 
that on tho arm inoculated with potent toxin being larger 
and visually presenting a distinctly defined, central red 
area. The pseudo element on both arms .disappears early, 
leaving persistent evidence of the Inio positive reaction. 

Under tho auspices of tlie Aliiiistry of He.alth Schick- 
testing, followed by immunization of individuals giving 
a positive reaction to the tost, lias now been carried out 
on about 50,000 children and adults in various “ centres,” 
institutions, and sccoiidai-j- scliools in this country, with 
the satisfnctoiy result that, with tho exception of two or 
three specially susceptible cases, none of these children, 
even when exposed to risk of infection, has subsequently 
, contracted the disease. And whereas, in one of these insti- 
I tutioiis, limited outbreaks of di})litberia had, for several 
ycai-s, been tho cause of much trouble and expense at 
intervals of a few months only, since the work was com- 
pleted — witli the added precaution of the immunization, 

I when requisite, of further admissions — ^tbere has been 
i absolutely no recrudescence of the disease. 

In view of the increasing prevalence of diphtheria the 
j suggestion has been made that tho education authorities 
should follow the load of Kew York and undertake the 
testing and iinmnriization by the Schick method of all 
children of school age. But I would suggest tbat it is 
of even more importance to' aim at jininunizatiou of all 
children of pre-school, ago— at the period, that is, of 
greatest danger, and in order to obviate appreciable risk 
of contracting the disease .when they come in close contact 
with otiier children on joining school. This work, until 
recently, had only been attempted on a comparatively 
insignificant scale in this country. 

Doubtless publication of reports (unfortunately justified) 
as to certain fatalities which occurred in Austria about a 
couplq of yoare ago; in some similar instances at a previous 
date in America, in consequence of the use, for immuniza- 
■ tion purposes, of batches of toxin-antitoxin mixture sub- 
sequently found to . contain excess of toxin ; and, most 
recently, in Biinderberg, Queensland, concerning which an 
authoritative report is still awaited, has somewhat naturalh- 
deterred -various authorities from advocating and arranging 
facilities for carrying out the work. However, recurrence 
of such mishaps is improbable in future, owing to the fact 
that anatoxin, or toxoid, which is entirely non-poisonous, 
is now successfully replacing toxin in the immunizing- 
mixture. 

■ rurtTew of the fact that a high percentage of infants 
over the age of 6 months are likely to he snscoptible con- 
siderable saving of time and energj- can he gaivjed bv 
omission of the preliminary Schick test. Research, morA’ 
over, is being directed to the possibility of reducing tho 

13515]° 


834 Mat 19, 1928] 


IMMUNIZATION AGAINST SCARUET FEVER. 


[ TriEnnrnsH 
SlT.xncKV Jocn»i&' 


three immunizing closes noiv required to tuo, or even one, 
and also of combining a first immunizing dose lyith the 
preliminary test. But, evhenever ])ossiblc, it is most 
desirable to perform a further Schick test about tlireo 
months subsequent to the last immunizing inoculation, as 
it is known that in a few instances the ordinary pro- 
cedure may not suffice for conferring adequate protection, 
and so may have to be re'peated. 

Reduction in the number of inoculations requisite for 
the attainment of an adequate degree of protection would 
undoubtedly constitute a valuable advance towards more 
general acceptance of the method. But even so, opposition 
is still likely to be encountered, as there undoubtedly exists 
widespread objection to the adoption of any theiapcutic 
measures involving the use of inoculation methods. Yet 
it is certain that we have at our disposal, in the immuniza- 
tion of infants and those of school age, a most powerful 
weapon in our fight against the ravages of diphtheria, but 
much propaganda work will be essential in this country 
if the desired end is ever to be attained. 

I desire also to advocate most strongly the Schick-testing 
and, if necessaiw, the immunization of all nurses employed 
in fever hospitals before being allowed on duty in diph- 
theria wards. 'This, I am glad to know, has been the rule 
as regards the staff of the Bristol City Hospital, for 
instance, since January, 1922, with the residt that no 
completelj- immunized member of the staff has ever developed 
clinical diphtheria. But, as pointed out by Sir George 
Newman, “ theie aie still many i2ifectious diseases hos- 
pitals where nurses arc allowed to attend diphtheria cases 
without having been offered the advantage of this method 
of protection.” He adds that “ one largo authority calcu- 
lated that the total cost to the hospital of every nurse 
wdio took diphtheria was £28 lOs., while the cost of 
immunizing a nurse was 2s. 9^d. only.” 

SCAULF.T Feveh. 

During an official visit to New York a few years ago 
I was afforded opportunity of studying work then in 
progress on the bacteriology of scarlet fever, on methods 
of immunization, and on the specific treatment of indi- 
viduals who had alread}' contracted the disease. The work 
was, in large measure, concerned with what is known as the 
'■ Dick test,” so named after its introducers, a test which 
exhibits many analogies to the “ Schick test ” for 
diphtheria. 

As the outcome of their study of the bacteriology of 
scarlet fever the Dicks, api)arcntly confirming earlier 
results by Klein, Tunicliff, Bliss, and Meiwyn Gordon, 
claim that a haemolytic streptococcus, long recognized as 
a mici'o-organism constantly present in the nasopharyngeal 
cavities of patients suffering from scarlet fever, consti- 
tutes the probable etiological agent of the disease. But 
considerable difficulty has been experienced by all who have 
worked at the subject, owing to the fact that it seemed 
Jjractically impossible, by the inoculation of the usual 
laboratory animals, to produce a disease bearing any definite 
resemblance to scarlet fever. Various observers have 
shown, however, that by cultivation of the' supposediv 
specific haemolytic streptococcus in blood-broth a toxin caii 
readily be produced inoculation of which in the human 
subject is said to have caused some of the main features 
of the natural disease, including the rash. This toxin 
suitably diluted, is used for the ])urpose of the Dick test for 
determination of the susceidibility or otherwise of indi- 
viduals to scarlet fever, the te.st fluid being inoculated 
intradcrmally in ))recisely the same manner as the solution 
of dijihtheria toxin in performance of the .Schick test. 
The results following on the use of this test are also verv 
similar to those observed in the case of the Schick test 
except that the reactions appear more rapidly, being at 
their maximum intensity after an interval of about twentv- 
four hours, and subsequently fade niore quickly. 

Further evidence in favour of possible specificity of the 
toxin is afforded by the fact that its effects can be com- 
j'lctely neutralized by admixture with blood scrum obtained 
fi'om a convalescent scarlet fever patient, or with the serum 
of a horse which has been immunized with the toxin. 
Furthermore, if serum from either of these sources be 
‘njectccl iiitradermally into the skiii of a patient .suffering 


from ail early scarlet fever rash a hlanching of the rash 
over the area of the injection is produced in the course of 
six to eight hour.s subsequently. This iihcnomenon, of 
considerable service as an aid in di.agnosis, is known as tho 
Schultz-Charlton reaction. 

As regards the extent of the reaction . following on tho 
Dick test among children not suffering from scarlet fever 
very similar results to those well known in connexion with- 
the Schick tc«t have been obtained. Thus in the earliest 
stage of' life a child a])pareiitly obtains fleeting placental 
immunity from the mother, so Giat up to tho ago of 
3 months, at any rato, the Dick test i.s likely to afford 
a negative result. At subsequent ages the relative pro- 
portion of positive and negative results, as in tho case of 
tho Schick test, will develop according to age, to social 
status, and as to whether tho child is town or country bred. 

Many thousands of children in ho.sj)itals 01; infant welfare 
centres in New York, found to give a positive reaction to 
the Dick test, have now lieen inoculated intramuscularly 
with scarlatinal haemolytic streptococcus toxin. As in tho 
case of the Schick work, these inoculations have usually 
been three in number at weekly intervals. These, in tho 
niajoi-ity of instances, have not given rise to 0113- undue 
reaction locallv or constitutionalh'. Again, as in the case 
of the Schick work, it is important that tho results of these 
inoculations qua immunization should be determined b)' 
a further Dick test after an interval of three or four 
months from the last inoculation. 

About a couple of 3'eai-s ago the Committee on Scai-let 
Fever, a])pointed bj- the Ministiy of Health, decided that 
it was desirable that intensive investigation into the 
etiological relationship of certain hacmol3'tic streptococci 
to this disease, and the diagnostic value of the Dick te.st, 
should be undertaken under tho co-ordinated direction of 
a team of expert pathologists and clinicians. With tho 
object of ensuring, as far as possible, that the work 
carried out in the different laboratories should be on 
strictly comparable lines it was arranged that similar 
methods and, so far as possible, identical materials should 
be' employed b3' nil the diffeicnt workers concerned. 

Tho scheme ultimately adopted has comprised, on the 
clinical side, perfoi'manco of the- Dick test as a routine 
measure on all patients notified as suffering from scarlet 
fever admitted to certain infectious diseases hospitals, 
together with a further Dick test, when possible, prior to 
their discharge. On the pathological side, throat dis- 
charges of scarlet fever patients admitted to these hospitals 
have been examined for the presence of haemolytic strepto- 
cocci, while, for purposes of comj)arison and conti-ol, 
strains of these micro-organisms of non-scarlatinal origin 
have also been isolated from various sources, and sub- 
mitted to thorough investigation in the various labora- 
tories concerned. 

It is essential to bear in mind that' the pi-oblems con- 
nected with the diagnosis of scarlet fever, and of immuniza- 
tion. against this disease, are, in certain respects at 0113' 
rate Vnucli more complex than in the case of similar work 
in connexion with diphtheria. Of primar3’ importance is 
the necessity for accurate differentiation of the specific 
micro-organisms responsible for the production of the 
disease in suscej^tible individuals. Tho departmental sub- 
committee has lately arrived at the conclusion that a 
haemolvtic' streptococcus is to be regarded as the respo'lisible 
a"ent but the variet3' of strains that have been isolated 
from the throats of patients suffering from this disease 
renders it difficult, as 3'et, to determine precisel}' whether 
one particular strain, or any of several varying strains, 
are speciall3' concerned. Again, the divergent results not 
iufrequeuth’ met with in connexion with the classification 
of haemolytic streptococci 83- agglutination and absorption 
tests introduce further difficulties. 

■An interesting point, to which sufficieut attention has 
hardly perhaps hitherto been paid, concerns the nature 
of tho population which it is sought to immunize r/im 
degree of susecptibilit3- as estimated bA' means of the 
intradormal test. Experience has clearl3’ indicated, in the 
case of our work on diphtheria, that whore a certain 
general basis of imniunit3' alread3- exists it is compara- 
tively eas3' to increase the extent of this immunity to a 
i sufficienth- high level. On the other hand, in certain 



May 19, J0=?1 


IMMUNIZATION AGAINST MEASLES. ^35 


institutions vliidi for yours ))rcviousIy luul Ijcoii coni- 
iilotctv free from lliis iliscaso, o"'ing to the fact 

that most of llio clilUlrcn luo looniilctl from wmffoclcd 
rural districts, we found Unit im'munitv was praoliwdly 
non-existent. And .so, unfortunntoly, llio building up of a 
sufliciciit degree of immunity proved ii matter of no little 
difficulty, requiring indeed, as eventually bec.amo evident, 
a time interval more lengtliy than previously observed. It 
remains to be seen wlietbor the vcsiiouse to iimnuiiization 
work in scarlet fever will be found to run on .similar lines. 
It is, 1 tbink, as yet liaitlly possible to e.-limate wbat may 
oventnally prove to be its ’prcci.se value as compared with 
immunisation against dipbtboria. As a matter of fad, 
so far as is at present known, aliaiiiment of anytbing 
like comploto immunity by'means of inoculalion inetliods 
ap)icar 5 to be dAidcdly more diffienlt of aeeomplisbnicnt in 
scarlet fever tluui is tbo ease with dipblberia. Moreover, 
there is, unfortunately, reason for believing Ibat immunity 
thus prodiiecd is by no means jicrmaneul. 


. MK.i.si.n,s. 

As in diphtheria and scarlet fever, so also in tbo ca.so 
of measles, infants ap\)car to inherit some temporary im- 
munity from their niolliers, which is said to lad until the 
fifth or sixth mouth of cxlrauteriuo life. From this period 
onwards, however, up to the age of 5 years, mortality from 
measles is high (from 15 to 15 jier ecnl,), mainly owing to 
its complications — a fact which renders de.siral)lc some move 
cKcctivo method than '■ tlie careful nursing of each case ” 
which' c.t present, as wo are told, constitutes “ tbo only 
possible way of reducing its mortaiity.” It is thoveforo of 
iuteiest to realize that a metiiod of imnuinization lias been 
worked out roconlly wliicli has been reported by many 
observers to be of value in this couuexioa. Tlic iiiothod con- 
sists, in its original form, of tlio .snbcnlaneous administra- 
tion of small doses of senim obtained from patients recently 
convalescent from the, disease. If required, advantage may 
bo taken of tlic fact that antibodies are also present, 
altliougli in smaller quantity, in the Ecrutii of adults who 
liavo bad measles, 

iceo v j"tcrcst to nolo that as long ago as the year 
lioS 1‘rancis Homo of Ediuhurgli iutvoduecd n mctlio’d of 
active iniimuiization agaiii.sl measles which liad been 
suggested by Alexander jfoiiro in tbo previous year. About 
iorty years ago Hugh Tliompsou, a vaccinator appointed 
by ttio facility of Piiysicians and Surgeons of Glasgow, 
oiJsed a method of blistering nicasios convalescents and 
laceiiiating contacts with the sonim, for whieli ho claimed 
goo results. In this connexion, ns in ko luauv others, it 
is curious o note how history has a habit of repeating 
itself, ns illustrated by the fact that onlv last year 
ro ^sor vai Leinor of 1 lemia introduced a siniiiai 
■’ ^biploymeiit of which, however, he discontinued 
jiress ® ^ campaign of opposition from the daily 

.of scarlet fever, progress in regard to 
owino (n 11 - t uioaslcs has been greatly liampoved 

of measles, \'lthouS°vSous“L-'‘'®“''‘^' 'l"’"' 

incriminated from® time 

definite kiiowlodgo a the Wi • i f VT 

methn.l bacteriology of measles, the 

bf “convalescent 

which dcnvtiirls nlready referred is obviously one 

ompioverhi consideration. This wa/ flrsl 

of measles in Tunfs ‘'i cP^cbiw 

employed extensively be subsequently been 

llichardsoii and Connor !n ^ Ziiiglmi' and hj 

Munich, and by Bebre in T> .h' Degkwjtz in 

.ilk .j, 

employing'^ tL^’sSnm niotliods ol 

vaflscout serum into healthv'‘“°; 9 of coii- 

immunitvMvbich lasts ahonf eontacts; in this case at 
tion during the firstlir e month is produced. _ (2) Injec 


If the scrum he iiijccted af/cr the sixth and hejore the 
■ninth- day, mcasios will, nevertheless, develop; hiit the 
attack will ho modified in the length of its invasion period, 
and by tlio tihscnco of catarrhal symptoms, Koplik spots, 
and high tem])craturc. The crujilion also, if xircscnt, is 
less coniliiciit, and tbo iiiaciilcs aro smaller. 

Injection at Iho heginiiing of the period of invasion 
(about tho tenth day) will result only in local inhibition of 
llio rash — the' plioiiomonon of Debrc — as regards which it 
should perhaps ho nioiilioncd that it is , not, as has been 
suggested, coiiiparahlo with tho Schultz-Charlton roaetjou 
in scarlet fever. 

Wilh regard to the production of active - immunity; 
besides tho method iiieiitioiied of inducing a modified 
attack, Kicollc has suggested that tho child it is desired 
to protect he given 10 c.cm. of convalescent serum, and, 
twoiity-four hour.s later, 1 c.crar of blood from an eaidy 
case of measles. If tho injection of blood ho repeated, itds 
slated that tho iiiiiiiuuitv produced is likely to he per- 
manent. This method is prohahly reproduced in Nature 
when 'serum is given to a ven- early case. 

Tho results obtained by the majority of workers who liavc 
used tho earlier mothoils referred to have been decidedly 
favourable, as, indeed, is evidenced by the fact that 
municipal collecting and distributing centres for tho serum 
liavo been established in connexion with hospitals in 
Germany, France, and America. 

No original work on tho subject had been published in 
this country prior to a paper by Dr. IV. S. C. Copeman,’ 
recording successful results obtained by him in face of a 
somewhat exceptionally sovoro epidemic of tho disease which 
prevailed during tho period February to July, 1925, at the 
Cliildvcn’s Hospital in Paris; and it will ho of interest ,to 
members of tlio Harrogate Division to recall tho fact that 
Drs. Smith and Miller, working on similar lines, recorded 
somo successful results in a communication to the Patho- 
logical Society of Great Britain and Ireland in January, 
1927. _ . ■ 

In view of the importance of lessoning, if possible, tho 
mortality from measles in this country, we shall doubtless 
all agree that it is cminoiitly desirable that investigation 
, of tho whole suhjcct should he officially undertaken . as 
speedily as possible, perhaps somewhat on tho lines of that 
recently initiated in connc-xion with the work of the 
I departmental conimittco on scarlet fever, 
j Meanwhile, it is encouraging to learn from Sir George 
Nowmaii that the Ministry of Health, in conjunbtipii 
j 'With tho Medical Research Council, is maintaining close 
observation upon tho important investigations of Dr. 
Dcgkwitz, especially conceniing tho nso of -a sheep serum 
introduced by him, and the prophylaxis of measles 
generally. 

Kefcrexce. . . • ' • ' 

[ ^ 7oumal of December, J925. 


PTJNGOTJS INFECTIONS OF THE HANDS 
AND FEET.' , . 

SI 

K'UPERT HALLAM, M.D., 
nosoMnv pavsiciAx is charge or the skis nECARTUEKT, 

. THE EOTAL ISTIRUASX, SUZEFIEED. 

The diseases to which I wish to draw attention are deeply 
situated in the epidermis and aro very refractory to treat- 
ment. Many varieties of fungi may be pathogenic and 
provoke changes in tho skin. Their classification is com- 
plicated, but broadly they ma-y bo divided into (1) tho 
ringivorms (Gj’mnosaceae), (2) the yeasts (Saccharomyces), 
and (3) somo members of the order Hyphomycotes such as 
monilia. The reactions of the skin may be to aU appear- 
ances identical, and the same species of fungus is able to 
produce lesions which differ clinically. Tho subject is still 
further complicated hecauso many moulds and fungi aro 
saprophytic, occurring on normal skin without producing 
any reaction, hnt both the yeasts and the ringworm mycelia 
have been found consistently invading the layers o’f the 
.epidermis in tho same typo of skin lesion; in addition, the 
lesions hare also been produced successfully by rubbing 


836 Mat 19, 1928] 


FUNGOUS INFECTIONS OF HANDS AND FEET. 


r Tnf.Bnms* 

L UZOICAZ. JOURKlXt 


tlie culture growth into scarified skin. Experimental work 
in this branch of dermatology is limited, for animals have 
a high degree of immunity to some of the species. Koch’s 
jjostulate is therefore difficult to verify ; hut there is 
sufficient evidence that certain forms of skin disease are 
the response of the skin to the action of fungi which are 
])athogenie. Clinically they may he divided into (1) infec- 
tion of the interdigital clefts ; ( 2 ) acute vesicular eruption 
of the hands and feet; (3) infection of the nails. 


Injection, of the Interdigital Clefts. 

In many patients the fungus responsible is the opidermo- 
phytou ; this is the same parasite which attacks the upper 
third of the thigh and the groins, and causes the so-called 
dhobi itch or tinea cruris. It was first described clinically 
by Hebra under the name of “ eczema marginatum ” so 
long ago as 1860. Afterwards the parasitic nature of the 
m.-ilady was recognized, but it was not until fifty years 
later that Whitfield’ in this country, and Sabouraud in 
France, called attention to parasitic lesions occurring on 
the feet, which were shown bj' Sabouraud to be due to the 
same fungus as the circular or polycyclic lesions of the 
groin. 

Sabouraud’s classic studies of tbe cultural characteristics 
of the pathogenic fungi knowji at that time established on 
a sound basis the importance of those diseases and led 
to an immense amount of research. It has since been 
proved that it is possible for the fungous elements to be 
carried by the blood stream, and to give rise to a gene- 
ralized rash iJolyraorphic in character (Arzt and Fuchs, - 
.\mbrosoli’). In 1918 V. Grad'enried'’ successfully inocu- 
lated two human subjects with the epidermophytou'. Bloch’ 
had previously shown that these fungi had the property 
of producing an allergic or sensitized state of the skin, 
but not always an immunity in the true sense of the word. 
Ho infected himself with the trichophyton and afterwards 
grafted a piece of bis skin on to a patient sxiffcring from a 
leg ulcer; the grafted skin alone was shown to be sensi- 
tized to the toxin of the fungus, thus demonstrating that 
the sensitiveness is a cellular pheiiomciiou. 

Some individuals are more susceptible than others, and 
it is not uncommon for one partner of a marriage to 
remain free from the infection although the other has 
suffered from it for many years. We must note also that 
different fungi have a predilection for various parts of 
the body. The intordigital infection, whether it be due 
to the epidermophytou or other fungus, may bo present for 
s ears without the patient experiencing anything more than' 
an occasional slight discomfort ; yet it may flare up suddenly 
and rapidly spread to the axilla, the gluteal cleft, the sub- 
mammary folds, and elsewhere, not only causing consider- 
able distress, but incapacitating the patient from following 
his or her occupation. 

• overwhelming proportion of the patients the disease 

IS first noticed in the interspace between tho fourth and 
fifth toes of one or both feet. If the toes are separated 
a white macerated epidermis is observed, which can be 
detached 63 forceps; small vesicles may be present at the 
edge or under the sodden skin, and not infrequcntlv a 
fissure IS to be found at the apex of the cleft If 'the 
macerated skin is removed the exposed surface is seen to 
be of a bright red colour. The same condition may be 
present between all the toes, or may be limited to one 
or more clefts on one foot for years. In many cases if the 
plantar surface of the infected toes is examined it will be 
^eeii that this too is infected and fissured. The disease 
is inclined to spread along the sole, causing eczematous 
lesions together with increased cornificatioii and painful 
fissiiring. In addition, a dermatitis of the anterior surface 
of the legs is often present, and also in the hands one 
or both palms will sometimes be found to be fissured. It 
should be noted that tlie infection may occur on the instep 
without the toes being involved. As already stated, the 
axillae and groins may be affected, gii'ing rise to circular 
or polycyclic patches of rod inflamed skin. The following 
cases seiwe to illustrate tho above descritition. 


-V married wonuin siifTcred from solid oedema of botli cars and 
imsi-aiiri(mlnr fissures, with maceration and inflammation of the 
of the upper gluteal cleft. Maceration and fissures occurred 
ween the toes of hoth feet, and mycclia ucre found in the 


epidermic scales from between the toes. The patient ]ia« been 
aware of the craeks between tho toes for six years; the other, 
lesions had been present for two years, and were thought to bo 
seborrhoeic eczema. 


A man complained of pruritus ani of ten years’ duration. Ho' 
had had vanous treatments, includfng innumerable ointments, 
ultra-violet light, and x rays. Examination revealed extensivo 
dcimatitis of the perineum and buttocks, with the characteristic 
fissures between all the toes. Mycclia were present in the -scales 
from tho toes. The patient stated that the toes had been soro 
for more thaii ten years, and that the complaint was thought to, 
be a manifestation of gout. 


Two patients had dermatitis on (he forehead and the upper lids 
together with mycosis of the toe.s, verified by microscopica 
examination. 


f 


AVith referciico to tho second patient mentioned, it is 
interesting to note that A. Castollani® drew attention to 
tho fact that pruritus ani might be associated with a 
fungous infection. Ho found either tho epidermophytou 
or trichophyton present in 11 out of the 54 eases ho 
examined. Some of tho skin complications are probably 
duo to sensitization phenomena, and are not caused by tho 
local growth of tho fungous elements; for although it is 
possible to recover tho fungus from tho accompanying 
lesions between the toes, repeated examination fails to find 
it in other situations. 

There is no doubt that the disease is more common in 
the middle classes than among the manual workers, and in 
my experience during the war groin ringivorni was more 
frequently met with among tho officer.s than aniongst the 
men. Outbreaks of a serious naturo have occurred in some 
public .schools. The incidence is relatively high_ among 
young men; this is probably explained by tho infection 
taking placo through the medium of bathroom floors, 
towels, etc. JCxiierimonts show that tho epidermophytou 
will live for at least a year in a dry state, and it has been 
rocovored from infected boots four months aftei' they were 
discarded; Tho incubation period is thought to bo about 

twelve days. . . , - , 1 ■ Ti 

Microscopical examination is essential for establishing tlie 
diagnosis, and may have. to bo repeated several times before 
tho true naturo of tho disease is detected. The actual 
technique, is simple, but requires some practice before the 
mycclia can bo recognized. Jipidermic scrapings should bo 
taken preferably from the edge of tho toe lesion, teased 
ill liquor potassae, and then examined with a 1/6 in., 
objective. The mycelia aro long, slender, highly refractilo 
threads. ISxact identification can only be achieved by 
culture on special nieilia, but description of this process 
is outside the scope of this paper. 

Treatment to be successful necessitates meticulous care on 
the part of the patient and his medical attendant. This 
is easily comprehensible when it is realized that the fungus 
occurs deep in the epidermis, is buried in all tho nooks 
and cranies around tho nails, is hidden in socks and boots, 
and in many, cases is found to be growing in the nail 
substance itself. It is very resistant to moist heat, but 
according to Schamberg and Kolmer’ is killed’ when boiled 
for ten minutes. The same authors found that tho 
epidermophytou is also easily destroyed b}’ weak antiseptics. 

Unfortunately it is no easy task to destroy these fungi 
in tho living subject. In order to do so tho exfoliating 
sodden epidermis must bo thoroughly removed daily with 
a curette, and the toenails must bo pared and scraped. 
As it is difficult for the average patient to perform the 
contortions necessary, it is advisable that this part of tlie 
treatment should be allotted to a third person. 

There is a wide choice of remedial apiilications, the most 
noted of which is an ointment recommended by AVhitfield, 
wliich now has a world-wide reputation. It consists of 
benzoic acid 5 per cent., salicylic acid 3 per cent., in a 
base of coco-nut oil and vaseline. -Although the fungicidal 
property of tho ingredients does not appear to bo very 
high, yet in many of the cases an application of tlio oint- 
ment brings about a rapid improvement. Other remedies 
are tincture of iodine diluted with ten, volumes of sjiirit, 
a 2 per cent, aqueous solution of mercurochrome- 220 , and 
5 per cent, chrysorobin ointment. In my experience tho 
first and the last' named are the most serviceable, but 
whichever is chosen will fail unless the jireliminary 
cleansing is carried out with exacting care. Tho feet 
.should bo washed daily. Socks should be of cotton, and 



FUNGOUS INFEOl'IONS OP HANDS AND FEET, 837 


mat i 9 i 19-8] 


\ioilccl for -toil wi\iv>tre ilaiiy; >Joots uiul shoos rofiuiro I 
ilusting iiisido with iin antispiitio powder sueh ns hone 
acid. Tho trcaiineiil shniild bo continued for ul least 
a month after nil sii;ns of tho disenso have di.snppeiirod, 
and infected hoois and chitliing should then lie de.stroyed. 
Surrounding dermatitis of the feet, if present, .should ho 
treated bv tho same remedies, 1ml a fraetiuual doso of 
a; rays will greatly assist in its disa])pearanco. 

In 1908 Ci.aro’cchi* described a dermatitis limited to 
tho webs of tho fingers; this closely resembles in nppenr- 
nacc tho affection in tlio clefts of the toes mentioned above, 
but it is caused by other species of fungus— monilia or a 
member of tho yeast group. It is curiously selective in 
position, for in tho majority of pntient.s its h.abitat is tho 
wob between tho ring and niiddlo fingers, nltliough other 
webs may bo involved. It is much less common than tho 
mycosis of tho toes, and so far lms only been met with in 
women, most of whom have an occupation ncccssit.ating 
tho frequent immersion of tho hands in water. ICnufnmnn- 
•tVolff’ produced similar lesions of her own hand with a 
culturo from a patient with tho disease. This disease is 
refractory and should bo treated on the same lines ns tho 
mycosis of tho toes. 


Such patients are usually of tlio hospit.al class,- .attending 
for tho fust time. They nro oftmi in a pitjahio state; tho 
hands aro ballied in pus, undei' which is a dirty sodden 
skin, buttonholed in numerous jilaces by the rnpturo of 
.some of the pustules. It is astonishing how rapidly theso 
patients iinprovo if all tho dead ov'erlmnging opidormis is 
removed daily, and a wet dressing of 1. jicr cent, solution 
of silver nitrnto is applied thrco or four times a day. Tho 
oedema disappoar.s, fissures lical, and, although the slcin is 
covered with tho black stain of silver oxide, it is soon 
apparent that tho disease is under control. At tins stage 
a fractional x-ray exposure materially hastens rccovci-y. 
If the patient is spared tho pyogenic infection, tho vesicles 
dry and tho skin exfoliates in about fourteen days. In 
such a case a jirotoction by boiled cotton gloves or sterile 
gauzo will siiDico. 

A girl, aged 10, was admitted to ShelTicld Eoyal Infirmary 
siilTcring from ve.sicular eruption on all her toes. A pure yeast 
culturo was obtained from tho vesicles on tlirco successive examina- 
tions. This case is inlercsling as she bad provioiisly been admitted 
to I'irvalo Hospital for tiio same complaint. A few weel:s later 
rIio was discharged cpiito healed; but tho vesicles returned within 
a fciv days — reinfection from her bools probably accounted for 
tho recurrence. 



tesicular eruption on toon A pare yoasi culture was ofilatacd 
irora the vcsiclca. 


ChciropomplioJyx, 

The clioiropompliolyx of Hutchinson or tho dysidrosis of 
Tdbui-y Fox lias recently hecii tho subject of research end 
discussion, and tho consensus of o[)iiiion is that this 
vesicular eruption of tho hands should in no small propor- 
tion of cases bo regarded as a mycosis. Knufniann- Wolff 
demonstrated a fungus in the vesicles in 50 per cent, of her 
cases. Daner'" slated that, oxcliiding trauma and pyo- 
genic infections, most cases (80 per ecnt.l ircre of mycotic 
origin. 1 have made -a practice of examining tho cases 
occurnng in this district, and liavo found mvcolia present 
in comparatively few. It is likclv, however; that a more 
pio onged search would reveal a larger iici'cciitagc of 
posi ive cases. Tho trichophyton apiicars to ho tho most 
ejuen aggiGssoi% but members of tho voast group aro 
a so responsible. The complaint is prone to rcciir, and is 

Altimn T°ft people, particularly women. 

® ^ bauds suffer more frcQueu'tlv than tho feet, 
to find vesicles' in both situa- 
liiirnino- The eruption is preceded by 

+ 1 " f Small deeply situated vesicles then 

being the borders of tho 
and sbnol I almost iiivariahly synimctricnl, 

j,v,, ’ ° IwesGiit on the feet, the vesicles aro less 

sltinieil tbov'*rl°” ^ bands. As the vesicles aro deeply 
secoiidariK- f « ^■'iptnro easily, but they may bo 
and rnntiii " 1 ’ " they increase in size, coalesce, 

IviLliZV L bands accompanied by 

tho mistules “ f'letlior complication. Unless 

opitlermis rem “bd tho whole of the exfoliating 



affection of tho beard or any other part of the bodv. 
Itecentlj', liowovor, cases have been described in England 
and abroad which are duo to a yeast — Oospora {Oidhim) 
ajhicans (Avid Scott,** Sbelmiro,*- Kumcr*’). 

When tho disoaso is confined to tho nail itself it com- 
inonccs at the free border, which becomes irregular, brittle, 
and of a dirty grey colour. This change gradually extends 
towards tho lunula. In certain cases, and particularly 
when tlio " thrush fungus ” is responsible, the changes in 
the nail are accompanied by paronychia. The appearance 
is then as follows : Tho soft tissue bordering tho nail is 
oedematous, red, and raised. AVhen gently massaged a 
sero-piiruleut fluid may bo pressed from under the margins. 
There is often some crusting at the bottom of the nails, and 
if this be removed tho nail fold is found to be detached 
from the nail. The free margin of the nail is raised by 
a brownish-groy debris. It is at first localized to one nail, 
but after vaiying intervals others are involved. The bands 
aro more commonly affected than the feet. Changes in the 
nails which closely rosomblo the above are met with as an 
accompaniment of other diseases, or may be due to infec- 
tion with staphj'lococcus or H. coli (H. MacCormac*-*), but 
careful microscopical and cultural examinations reveal an 
invading fungus in an increasing proportion of cases 
examined. 

Tho treatment of the affliction is difficult, whichever 
variety of fungus is concerned. Perhaps the most success- 
ful procedure is avulsion of tho nails, hut oven this drastip 


838 Mat 19, 1928] TREATMENT OF MALIGNANT 


remcd3- cannot ahvaj-s be relied upon to accomplish the 
desired residt, for a recurrence niaj’ follow when the nail 
grows again. A more simple method is to pare and scrape 
the nails to the utmost limit of the jiatient’s endurance, 
and then apply a 2 per cent, solution of silver nitrate or 
Fehling's solution. It is essential to keep the fingers diw, 
for the disease is most common in those whose occupation 
entails the immersion of the hands in water. It is also 
advisable to continue the treatment with a weaker solution 
after the disease is apparentlj- cured. 

In eonclusion, 1 would emphasize the point that the.se 
diseases are more common than is generally supposed; they 
are of sufficient medical and social im|!ortanec to deserve 
recognition and stndj’ hr' medical practitioners. 

REFLREKrrS. 

1 WhltfieUl : Lnuert, 1908, u, p. 237. 2 Ai7.t untl Fnchs: .lrc?i. /. 7>er«». 

Si/jili,, 1923, No. 52, p. 143. ^ Ambioboh : (iiorn. ItaL mol. Tcn.^ 

1923, No. 3, p. 233. ’ V. Grafifiined . Bcnn. Koch,, 1918, No. 6, j). 361. 

•' BIocli . 'Aeil. f. Wjfj. u. IiifectionKl-raid-h., 1909, No. 63, p. 68. ^ Castollaiii : 
Joinn. Til'll, MciL, November 15tb, 1926. • SchamberK and Kplmer : Arch. 
Bi-riii. iiiiii Stfi'h., December, 1922, p. 745. * Ciarocchi : (Unru. Jtnl. tl. 

vial, ecu., 1908, 43. 239-2-55. ® Kaufmaiin-Wolft : Derm. Zctl., 1914, 21, 385. 

Dnrioi Lancet, September 27th, 1919, p. 578. '• Avi<! Scott. Drit. 

Jiuiiii. iJeim. null Si/nh., 1927, No. 39, p. 119. >- Sbelmirc : Arch. Derm, 

nnd Suph., 1925. No.' 12, p. 789. Kumer : .Ire/i. /. Dcrnt. v. 1921, 

136, 12. i'MacCormae. itrit. Joura. Derm, and Syph., October, 1927, 
p. 398. 


lUpart 

ON 

Tin-: TREATMENT OE MALIGNANT DISEASE BY 
COLLOIDAL LEAD. 

BY 

STANLEY IVYARD, M.D., M.R.C.P., 

iSSISTAKT PHYSICIAN TO THE CANCER HOSPITAL, LONDON. 


In view of the success claimed in the treatment of 
malignant disease hy moans of injections of colloidal load 
I visited Liverpool in April, 1926, and, with Professor Blair 
Bell’s iicrmission, saw some of the patients who had there 
been submitted to the treatment, and observed the technique 
of the process. Although I was unimpressed by the results 
which wore shown it was considered necessary by the 
Cancer Hospital that the method should be fully investi- 
gated. Di'. Lorna King was therefore appointed to assist 
me, and together we have treated a total of 88 patients 
in this way. Of these, however, 32 were given a preparation 
of colloidal lead hydroxide, and 1 omit details of them for 
three reasons — namely : (1) the preparation differs from 
that used by Professor Blair Bell in that all the lead has 
been converted to hydroxide, whereas in the latter only 
a variable and unknown proportion is in that form; (2) it 
is extremely toxic — ill effects so freciuently follow its use, 
and are so marked, that I consider its employment un- 
justified; (3) no evidence of benefit was obtained in any 
case. Moreover, it has often been emphasized that .satis- 
factory results could be obtained only if the lead ho pre- 
pared in a particular manner, and if its pharmacological 
effects he closely watched in each patient. That nuicli 
impoi tance need be attached to such a statement is more 
than doubtful — the method used in Liverpool for preparing 
the metal has been many times changed, and there is no 
evidence wiiatever that one method is more .successful 
theiapoutically than another — but it was obvious that, in 
the first place, the original technique must be .strictly 
followed. 

Fifty-six cases were treated strictly by the Liverpool 
method — namely, 35 at the Cancer HoN|iital, 18 at St 
James’s Hospital, S.IY., and 3 ^irivately. In describing 
the results no differentiation is made between these series.^ 

Mcf/io<l oj PrejKiring ihe Colloidal Zend. 

AVIien this work was coiuraenccd it was inipos.sible to 
obtain colloidal lead except by preparing it for oneself. 
The necessary apjiaratns yvas erected by Mr. C, E. PJiillips^ 
consulting physicist to the Cancer Hosjnt.al, and consisted 
essentially of' a circuit containing a voltmeter and an 
ainmctor together with an adjustable, resistance, such that 
a curront of 70 volts and 10 amperes ]Uis.sed when an are 
was o.stablishcd between two pure lead electrodes immersed 
in distilled water. The water was placed in a porcelain 


DISEASE BY COLLOIDAL LEAD. 


howl with a few .small lead shot. One electrode was then 
fastened .so that its lower end was in contact with tbo 
shot, which were constantly stirred with the other electroile 
while the ciiri-cnt jiassod. In twentj- minutes a colloid 
suspension of load (about 0.5 per cent.) wa.s obtained. Its 
concentration -was estimated hy a modification of Ncstlcr's 
method — a not vciy accurate one for such quantities, but 
the most praeticahio in the circumstances. For use, tbo 
suspension was diluted to exactly 0.5 per cent., and 0.4 per 
cent, gelatin, 2 per i-ent. sodium chloride, 0.05 per cent, 
potassium chloride, and 0.027 jior cent, calcium chloride 
were added. 'The prrqiaration is very unstable, .sedimenta- 
tion quickly occnis, and oxjgon is rapidly ahsoihrd from 
the air with the formation of veiw toxic lead hydroxide. 
It must consequently he used at once, and cannot be jire- 
pared in bulk for use at a later date. 

From time to time certain slight modifications were made. 
First, 4.0 per cent, of gelatin was added instead of 0.4 jier 
cent., so tb.at the preparation was soliil at ordinaiy tem- 
peratures. In this condition it conld.be stored in scaled 
am|>onlos, and remained stable for scveial months. Then 
iso-electric gelatin was substituted for. the ordinary suli- 
[ stance, and bad the same .stabilizing,.effect without becoming 
solid. Sometimes a trace of a reducing agent was_ added 
to hinder the formation of hydroxide. Finally, we reverted 
to the original preparation. 

All these preparations are essentially the same, and 
there is no reason to stqipose that their therapeutic action 
differs. 

Ti/pc of Pntient Treated. 

Most tipcs of malignant disease have been treated — 
epithelioma, carcinoma, and sarcoma. In every case the 
disease was inoperable when first scon, or was vcctirrent 
after operation. Many of them were in an advanced stage 
of the disease. To obtain suitable patients for such work 
is far more difRcnlt than appears on the face of it. A largo 
majority of the. inoperable patients admitted to hospital 
are having, or have had, some other form of treatment 
(for example, radiation), and ore therefore nnsuitahlo for 
this, since any change observed could not be certainly 
attributed to either method. If the patient bo not already 
under some form of treatment he or slio is generally too 
near the end for any form. Another difficulty is that very 
often tlic patient refuses to remain long enough in hos]iital 
to give the method a chance. No patient in this .series had 
received any but snigical treatment. 

Dosage. 

In deciding on the dose to be given an attempt was 
made to give the maximum amount of lead which did not 
endanger life, and to keep the patient as long as possible 
under the influence of this quantity. With six exceptions 
the initial dose was 0.08 to 0.1 gram. ln»one case thi.s was 
repeated after seven days, with the result that the patient 
became very ill ; there were several rigors, repeated 
vomiting, and marked jaundice. From these effects .she 
oventnally recovered, and survived about seven months, 
but it was not considered justifiable in any other case to 
repeat the dose at so short an interval. In seven cases the 
second dose was given a fortnight after the first, but 
again the reaction which followed was generally intense, 
so intense that it was decided to allow ah even longer 
interval. In six case.s an initial dose of 0.05 gram was 
given, and repeated in approxiniatol}- a week. While these 
showed no better tlieiapeutic results than the others, the 
reaction follou ing each injection was reduced to a mini- 
mum, and never amounted to much. For the remainder an 
initial dose of 0.1 gram was followed by the same dose at 
the end of three weeks. Even after this interval some 
reaction was almost invariable, but was in no case serious. 

Subsequent doses must depend, both as to the quantity 
and interA'al, upon the i-eaction of the individual }'atient. 
Our aim has been to administer a total of 0.6 gram to each’ 
patient, and ,.wo commenced by repeating the original dose 
of 0.1 gram at intoi*\als of three weeks to six doses. This 
proved' disastrous, for tile only two patients who were .so 
ti-cated (one u ith five and the other with six doses) both 
died of uraemia within eleven days of the l.a.st dose. We 
thei-ofore changed the procedure and gave throe doses of 
0.1 gram at intervals of three weeks, and then continued 



Mat 19. i9=s] 


TREATMENT OF StALIGNANT DISEASE BT COriBOIDAD DEAD. 


t Tnr, Cfim«m 
MrciCiD JocBSiX 


839 


with (loses of 0.05 grnm nl intervals varying from « j 

night to a nioiiih, according to the condition or liio 
pivticnt, nncl i\o otlior iiistaiico of ron:\i coin]>ncations 
clinically di.scovcrahlo ivns cnconntcrcd miiungst those who 
■ iccoived the latter doses. 

The tivo cases nioiitioiicd ahovo called attcnt-iou to the 
iiiiportanco of dctormiiiiiig, if iiossiblc, lioiv near ono ha.s 
a\i\'ivoacUcd to tho patiout's tolerance* Bnt no method of 
doing so was discovered. In both cases, before tho last 
dose, tho nrinary nrca was adcrinatc, the blond nrca was 
well within normal limits, there was' no marked anaemia 
iior deficiency of haemoglobin, and little or no pniictato 
basophilia in the erythrocytes. Lead is, of course, a cumu- 
lative poison, and it seems as though it nccniinilates tip to 
a ])oint without causing any approcialilo damage to the 
kidneys, but immediately that point is passed there is a 
sudden or rapid destruction of certain of tho venal 
elements, so tliat tlio urinary nrca falls, tho blood urea 
rises, and tho patient becomes uraemic. In ono of these 
cases tho blood urea was steady between 18 and 36 mg. 
per 100 c.cm., but four days after tho last injection it 
had risen to 146; in tho other, it was 28 to 34 until the 
last dose, whereas two days later it was 77, and another 
s five days later 111. 

Observations were made on certain of the cases with 
plionolsulplionephthalein, as well as on tho various nitre-, 
genous constituents of the blood — for exainjilo, uric acid, 
creatinine, etc. — with the object of detcrniiniiig whether 
any change could thereby be discovered which nouhl indi- 
cate damage to the kidneys before evidence was afforded 
by tho urine or blood urea. No significant chaiigo was 
found, nor did any other case of uraemia occur (though 
ono other patient had died of this condition after a com- 
paratively small dose of lead before these observations were 
conmicncod). 

Probably tho best method of deciding whether, and when, 
another dose shall bo given is by clinical cxperioncc. Tlic 
patient’s colour is important — too marked pallor contra- 
indicates immediate treatment. A veiy severe reaction 
suggests a longer intciTal. A reaction, oven though 
inodorato or slight, if long drawn out, calls for delay in 
administration of the nest dose. Examination of tho blood, 
really helps very little. There is a more or less marked 
fall of haemoglobin within a few hours of each injection, 
but as a rule rccoyeiy takes place. If tho haemoglobin 
falls Very much, or if it fails to recover its previous figure, 
treatment must bo discontinued or dclavcd. AVo found 
that the number of red cells showing punctate basophilia 
was no evidence whatever for or against continuation of 
treatment. 

_ Immediate Bcaciion. 

Following the injection there is nsually some general 
reaction, but very rarely does it amoxiut to much. It is 
either of two main typos ; (1) rise of temperature and pulse 
frequency, rigor, generalized pains (head, hack, and limbs); 
(2) nausea, diarrhoea and vomiting, and abdominal pains. 
It may come on in a few minutes or he delayed for two 
or. three hours. A sensation of chilliness without actual 
shivering is tho commonest reaction, though not infre- 
quently there is a slight rigor. Doth of these symptoms 
remain but a short time, and as a ride pass off within ten 
to sixty minutes. Occasionally' there is no rise of tempera- 
ture, more often it rises to about 100° F., in a few cases 
it will rcacli 103° F. or thereabout; but 100° to 101° F. is 
usual. Thero may be a feeling of malaise — the sensation 
is apjiarently indescribable; there may or may not be some 
Iieadacbe. Nausea is commonly experienced. Abdominal 
pain ^ and discomfort were observed once or twice, and 
definite colic once. ' Abdominal symptoms may bo accom- 
panied by' diarrlioea. Only' three times was a severe 
reaction seen— temperature 102° to 103° F., dyspnoea, 
cyanosis, a small frequent pulse, and pain in tbo head 
and back. In only two cases was there any local reaction, 
shown by swelling and .pain in tho growth. 

In some cases tho types have been combined. Docovenr 
was quick and appears complete from the first typo of 
reaction. In the second typo the patient felt ill' for a 
considerable lime— in two cases the abdominal discomfort 
as d for fu e ivceks, and in one of these ivas followed by 
a blue lino on the gums, a metallic taste in the mouth, 


and sluggish kiico-jorks. Both ovontunlly rocovored, and 
ti'catmeni was. continued. In no case has death oceurred 
as nil immediate result of an injection of lead. 

Occasioually a prolonged roactiou was ohscn'cd. Slight 
hoadiiclio commenced an hour or .two after tho injection, 
but disappcaroil after a night’s rest. In tbo morning, 
however, there was .slight nausea, and tho patient might 
even, vomit. This coiulitiou of di.scomfort. — there is an 
indofiiiablo feeling of malaise, a suspicion of nausea, loss 
of, appetite— may persist and only pass off in six or seven 
day's. 

It is quite impossible to foretell the occtirrcnoo of a 
reaction; it is no more likely after a first than after any 
subsequent injection. 


Zafe Bcactiou. 

Rarely was there any apparent effect upon tho growth 
itself — thero was no swelling of tho mass, no increase of 
pain in it, and no breaking down ; but in two cases swelling 
of the growth, and pain in it, wore noted. It is difficult to 
say wliether these effeets wore the direct result of lead, or 
merely that of tho natural progress of the disease. 

Effect on. the Blood . — Somo degree of anaemia generally 
follows tho injections, though the effect on the erythrocytes 
is not extreme. Tho number of the latter falls, often con- 
siderably, but rarely below 3.5 million. Even after con- 
siderable doses of lead they niay' remain well up (5 to 5.5 
million). A more marked cllect is exerted upon tho haemo- 
globin, which falls more rapidly' and to a greater extent. 
In spito of this, only once had we to cease treatment on 
account of tlio condition of tho blood. Stippling of tlie. 
red cells was found to a greater or less extent in all case.s, 
but appeared to have no special significance from a pro- 
gnostic point of view, and after a short time little or no 
importance was attached to this finding. The white cells 
did not appear to bo alFcctod in any way. Except in one 
case, when a carcinoma of tho breast was complicated by' 
diabetes, tbo injection of lead did not influence tbo sugar 
content of tho blood. In the diabetic, however, it seemed 
to increase tho circulating sugar and exert an adverse 
inftuciico on tho course of the disease. Three cases of 
uraemia have already been mentioned ; in no other case was 
clinical evidence of renal damage obtained — ^tho urine 
remained normal and tbo blood urea showed no significant 
change. In a few cases the excretion of phoholsulphono- 
phtbalein was tested, but no abnormality was found. In 
somo otliors tbo nitrogenous constituents of the blood, other 
than nrca, were also estimated, but without demonstrating 
any- pathological change. 

Effect on the Urine . — ^Tho urine in nou-fatal cases' has 
shown variable alterations. In many cases the amount 
excreted in twenty-four hours has been very much 
diminislicd for seven to fourteen days after an injection, 
usually (but not always) with diminished urea excretion. 
Cases w'ith reduced urea excretion (even though this ho 
marked) havo shown no clinical signs of renal incompetence, 
liavo had no rise of blood urea, and have had further injec- 
tions of lead without ill effect. 

Uraemia . — Three cases of uraemia occurred. One of 
these must 'certainly bo attributed to tlie direct effect of 
treatment, and is, indeed, 'a case of acute lead poisoning. 
This patient received in all 0.6 gram, of lead in tho course 
of three months, and eleven days after the last injection 
she .died presenting tho typical picture of uraeniia. 
Towards the ,ond tho excretion of urine diminished, 
albumin (at first a trace, later in considerable quantity) 
and casts appeared in it, and tbo blood urea rose from 
0.034 to 0.111 per cent. At autopsy tbo kidneys showed 
well-marked changes in the tubules, but none in the 
glomeruli. It is more than doubtful wliotlier the other 
two can be attributed in any' way to the lead administered. 
In one the original lesion uas a carcinoma of the cervix, 
which eventually' penetrated the bladder and involved both 
ureters. The blood urea rose from 0.C36 to 0.146 per cent. 
At necropsy tho pelvis of each kidney was dilated, and 
the kidneys showed numerous minute abscesses scattered 
throughout. The other died of uraemia after, a total of 
0.25 gram of lead. A carcinoma of the rectum had heeu 
excised, some time jirevioiisly', but a local recurrence 
appeared and, spreading to the bladder, involved both 


840 JlAT 19 , 1928 ] 


S'XPHILIS OF THE HEART. 


t ins EnmsH 
Msloicax 


ureters. The kidneys sliowed extensive interstitial fibrosis 
■nith tnbniar changes superimposed. In both these cases 
ureteric obstruction and snbserpiont bacterial invasion of 
the organs are sufficient .to account for the microscopic 
lesions. 

No case of t^'pical chronic lead imisoning occurred — 
constipation, colic, peripheral neuritis, cncc 2 ihalo])athy, 
wore never seen — but one jjatient ])resentcd a l)lne lead 
line on the gums after 0.25 gram of lead given during a 
jicriod of eleven weeks. 

Autopsies were made' on 17 of those who died, and tho 
post-mortem findings were remarkably constant. In no ca.se 
nas any sign of regression observed in the growth. In 
some cases it showed advanced degeneration (but no central 


Table showing the Mesults in 50 Cases of Malignant Disease 
treated by Colloidal Lead. 


Patient. ' 

! 

Disease. 

1 

A. C ' 

Ca. thyroidci 

A. F 

Ca. thyroidei 

C. P 

Ca. recti 

C. H 

Ca. mammae 

K. S 

. Ca. mammae 

A. H 

Ca. mammae 

L A. (nl 

Ca. mammae 

B. D. ... 

Sarcoma femoris 

1. D 

Ca. A’ontnculi 

A. B 

Ca. mammae 

AY. A. S. (t) .. 

Ca. veiitriculi 

S. H 

Ca oesopbayi 

B.S. (cl 

Ca. soli oris 

K. T 

Ca. cerA'icis 

S. G 

Ca. ceiA'icis 

E. 0. (c) 

Ca. cervicia 

D.N 

Epith. oris 

S. W. (0) 

Ca. OA’arii 

T. G 

Melanomatosie 

M. H 

Ca. mammae 

tv. K. f.. 

Epith. pharj'ngis 

T.R 

Ca. vesicae 

H. D 

Ca. recti 

E.S 

Ca. mammae 

C.S.B. 

Ca. nodotum cerA’i 

M. A 

Ca. vesicao 

A.B.P. (<I> .. 

Ca. mammae 

A.tV.H. ... 

Epith. oris 

C. J 

Epith labii 

B. A 

Epith. soli oris 

M. B 

Ca cervicis 

K.H 

Epith. soU oris 

A.B. B. (c) ... 

Ca. oesophagi 

E. D 

Ca. OA'arii 

c. c ' 

Epith. soli oris 

K. P 

Ca. OA’arii 

E. N 

Ca. mammae 

H. E 

Ca. mammae 

tv. C 

Epith. labii 

A. G. B. 

Ca. oesophagi 

il. c 

Ca. ovarii 

tv. G.(c) 

Ca soli oris 

F.B. 

Ca. oesophagi 

W. P 

Ca. recti 

M. N 

Ca. vesicae 

E. M 

Ca. A’esicae 

D. N. (0 

Ca. mammae 

G. S. (e) 

Epith. tonsiilae 

F. 0. ... ... 

Co- cervicis 

A. G 

Epith. soli oris 

J. C 

Epith. oris 

A. h. 

Ca. A'esicae 

A.K.B.W ... 

C&. mammae 

n. 31 

Ca. mammae 

F. T. 

Ca. mammae 

G. S. E. (c) 

Ca. prostatne 


Duration of 
Treatment. 

Total 

Dose. 

Jlosultff. 

169 days 

0.55 gram 

Died. 

15 .. 

0.2 

„ 

Died. 

<13 

0 25 


Died. 

225 .. 

0.45 


I. S. Q. 

lOG .. 

0.3 


tVorsc. 

107 .. 

0.35 


tVorso. 

107 

0.05 


Died. 

132 .. 

0.57 


Died. 

45 .. 

0.17 


Died. 

65 „ 

0.3 

•• 

tVorsc. 

46 „ 

0.22 

... 

Died. 

— 

01 


Died. 


0.09 


I. S. Q. 

— 

0.1 

M 

Died. 

— 

0.08 


Died. 

— 

0.08 

.. 

I. S. Q. 

— 

0.03 

M 

Died. 

— 

0.07 

.. 

I. S. Q. 

— 

0.104 


Died. 

49 days 

0.3 


I. S. 0. 

115 .. 

0.508 


Died. 

77 

0.251 


Diet). 

21 .. 

0.2 


Died. 

&8 M 

0.35 

.. 

Worse. 

84 .. 

0.45 


Died. 

42 „ 

0.295 


tVorse. 

105 .. 

0.53 


Worse. 

22 „ 

0.2 

„ 

I. s. Q. 

16G 

0.6 


tt'orse. 

1G6 .. 

0.075 


Worse. 

54 „ 

0.4 


I. S. Q. 

36 

0.3 

„ 

Died. 

3S „ 

0.1 


I. S. Q. 

65 

0.35 


Died. 

176 M 

0.575 


Died. 

17G 

0,1 

„ 

Died. 

2:7 .. 

0.26 


Died. 

28 .. . 

0.3 

.. 

Woi'se. 

55 

0.3 

„ 

Died. 

43 . .. 

0.3 


Died. 

35 .. 

0.25 


Died. 

35 

0.1 


r. S. Q. 

35 

0 1 


Died, 

35 

0.1 


Died. 

41 .. 

0^29 

.. 

Worse. 

41 

0.29 

.. 

Worse. 

98 „ 

0.4 


Worse. 

20 .. 

0.2 


Died. 

74 .. 

0.5 


Died, 

86 „ 

0.6 


Died. 

147 .. 

05 


Died. 

5S .. 

0.4 


Died. 

94 .. 

0.45 


ImproAcd, 

36 .. 

0.2 


Died. 

197 .. 

0.6 


I. S. Q. 

21 .. 

0.32 

... 

I. S. Q. 


(o) This patient also had diabetes, (b) Died of baeinateni»si.s (e) T,cft 
bospiial at own request, (d) Still under treatment, (e) Refnsed furtber 
treatment. 


necrosi.s, and no change which is not commonly seen when 
no lead at all has been given), in others thoie was no 
dcge;ieration whatever, and in evci-y ease the mass of 
growth was larger than when treatment commenced. In 
nearly every instance tho brain, liver, and kidney.s 
showed evidence of damage as follows. In the br.tin there 
was extreme .superficial (.subarachnoid) oedema, with free 
fluid at tho base. The choroid irlexuscs wore markedly 
oodematons. Tho liver showed extreme fatty degeneration. 
Apart from the cases of uraemia, tho kidneys showed no 
maoroseoiiic change. In most tho cells of tho convoluted 
tubules stained badly and showed some degree of desquama- 
tion, but it is possilile that this is largely, if not entirely, 
a post-mortem process. But tho localization of the changes 
is iiotcwoithy : in no case was anj- abnormality discovered 
in the glomeruli or the cells of tho loop of Henle or tho 
collecting and .straight tubules. In view of tho fact that 
these npi)earauccs are not such as arc met with in cases of 
malignant disease treated by other methods it is fair to 
presume that they directly result from tho toxic action of 
the lead preiiaration emjrloycd. 


Fiiud Mcsult.s. 

Of the 56 ])atients treated one only — with a small snjira- 
clavicidar gland which a])peared one year after amputation 
of tho breast for carcinoma — showed definite improvement, 
the gland being now only just ])alpable, whereas before it 
was about the size of an almond, and quite visible. 
Although clinically a definite diagnosis of secondary malig- 
nant disease was made, there is no jn-oof that the gland 
was in fact malignant. 


No a))\n'eciabIo change took jilace in 12, but of these 7 
received admittedly inadequate treatment — 2 because they 
were so ill that it was decided to leave them in jicacc, 
5 because they refnsed further injections. Five received 
from 0.3 to 0.6 gram of lead in all, but tho local eondition 
remained unchanged. Another 11 were actually worse 
after treatment,, of whom 2 received less than 0.3 gram of 
lead in all (one was considei cd too ill to receive more, the 
other refused). Nine received from 0.3 to 0.6 gram, in spite 
of which the malignant growth progressed. Thirty-two 
died of whom 8 had received only one injection each. In 
other words, of 40 i)atients who received sufficient load to 
warrant tlic expectation of some benefit, if any over occurs, 
22 died H were clearly worse, 6 showed no change in 
oithei- direction, and only one in any way inH)roved. (Fidl 
results, witli total dosage, are given in the accompanying 
table.) 

Conrhision. 

Of 40 jiatients who have received 0.2 gram or more of- 
colloidal lead intravenously, only one has shown aiiy 
improvement, while tho majority are dead or obviouslj’ 
mucli worse than before treatment. So far, then, as my 
observations go there is no sU])i)ort for the statement that 
colloidal lead exerts a beneficial influence upon the progress 
of a malignant growth. ^Moreover, it is cei'tainl}- a difficult 
and dangerous therapeutic method. 


SYPPIILIS OF THE HEART. . 

BY 

I. HARRIS, M.D., 

jionohary physician, uverpool heart hospital. 


It is of the utmost importance to recognize syphilis of the 
heart, this being one of the few heart affections ' which 
almost invariably yield to treatment. In many eases, it is 
true, tho iinproA-emeiit dno to antispecific treatment is 
not pronounced, but there are doubtless numerous cases of 
cardiac syphilis in which proper treatment has effected a. 
complete cure. To overlook a case of syphilis may mean 
the whole difference between normal health and permanent 
disability, and sometimes even betAveen life and death. 

Tho incidence of syphilis in heart disease has been 
greatly underestimated in the past, and there are but 
scant references to it in the older textbooks. Mackenzie,* 
for instance, dismisses it Avith a feAV Avords, and authors 
like Romberg= actually express the opinion that syphilis 
of tho Iieart is rare. As a matter of fact S3'iAhilis is a 


Mat 10, i9:S] 


ByrniLlS OF THE HEART. 


[ Tnr. Tinm’fa 
JtrMCAl, JoCRVAt 


841 


vovy common cnvcUnc nffoclum, Imt luiforlmmtnly in llm 
uiiuoritv of rases it- i.s not rreogui'/^ed. i •>* f it 

'riiis imnor is Imsod on n hmulrod i nsos of sypiniis of the 
honi't la!:cu from pnlicuts aUeiuiiug the Jionrt. llospilai; 
they reprosent iibout 9 imr coul. of nil coses at iliis 

institution. ,r , i 

It is obviou.s tlml pnticiit.s intli .stnuglitforiviu-d syphilis 
do not ntlond lio.ort bospitnls. Tim incidence of cardiac 
svpbilis in patients attoiiding venereal disease climes must 
lie considerable, and no doubt a good percentage of nonro- 
si'i)hib’tic.s bare damaged bcarls. Syphilis of the heart 
must therefore bo a common affection. In the great 
majority of the oa.sc.s the true character of the diSTOSo 
Mas recognised in ibe first instance at the Heart Hospital, 
altboindv many of these people acre attending other insti- 
tution” and sonic had been scon by proiiiiiiciit consultant 
physicians. ObvioiKlj- the diagnosis of .syphilis of the 
iioart is very difncidt 

At the outset it is ivoH to reeogniae (hat there is not one 
.single inetlmd, talcen bj- itself, on irliieb ire may rely abso- 
lutely for the diagnosis of cardiac syphilis. In order to 
make a reasonably certain diagnosi.s of cardiac sypiiilis it 
i.s essential to employ .all procedures avnilablo for the 
investigation of the disease; a single method cannot abso- 
lutely be relied on, but employed in coiijiinetion ivith other 
methods, the cvidciiee of e.ardiac .syphilis may be so strong 
o.s to amount to a certainty. 

The metliods used arc the 'Was.sennnnn tost, examination 
of the pby.sieai .sigms, elcctro-cardiograjihic investigation, 
study of the symptoms and history, and the use of anti- 
. specific treatment. 

The. Wnssrrm/inn Test. 

tVe depend a great deal on this lest, hut it is not 
absolutely reliable; tivo specimens from llie .s.ime pnticnl 
•sent to different lahoratoric.s irili snmetiines give contra- 
dictory results, oivfiig in some instnneos to inaccnraiy. and 
in otbor.s to niJTorenco in tbo methods employed. More- 
over, even in this country, ns is ivcll knoiv-ii, a positive 
IVasscrmann reaction doc.s not invariably denote syphilis; 
it is believed that tiibercido.sis and infective endoe.arditis 
may, in the ab.scnec of syphilis, give rise to .a positive 
reaction; it must also bo borne in mind that a positive 
reaction may iiidicato only congenital syphilis. M’e aetnally 
have all instance of n positive 'Wassermnnn rcaition in a 
grandchild and n graiulmotlior, and numerous ense.s of 
members of a family ivitb sneb reaction.s irbicb can onlv 
bo explained by tbo lioroditaiy factor. On the other band, 
a ncgatii'G result does not mean that the patient is free 
froin syphilis. There seems to be o general ronsonstis of 
opinion that in the second stage of syphilis a positive 
reaction is the rule. 

In heart cases, lioirever, ive are dealing mainly with 
latent ehvonic syphilis, .and there arc without doubt a 
jeialn oil large miraber of ca.se.s of cardiac lues wbieli give a 
negative i\ assennanii reaction. For instance, in one almost 
certain case of cardiac sjyiliilis repeated Trassennann 
tests- of tbo blood .serum wero negative, and the spinal 
fiiiid alone gave a positive reaction. Still the fact remains 
tliat a positive reaction in this country connotes svpbilis 
in more than 90 per cent, of all cases.’ 

T have profound faith in a positive tVnssermann reaction 
oi tiio leasons. In a large number of positive cases there 
was found corroborative ovideiico of lues in tho form of 
nemo-sypliilis. More significant still, manv of these cases 
responded to aiitisypliilitic treatment to such .an extent 
as to leave no doubt about the character of tlio disease. 

1 t link ivo are justified in concluding that a positive 
reaction even with a single plvs, goes a long way towards 
t be establislimont of a diagnosis of cardiac svpbilis; still 
sypbiiTtir " P^'-ticnlar heart’ affection is 

nr ■ , Evidenre of Cardinc Smh'dh. 

svm./r ^ inatbognomonic for 

SMiliihs of the heart does not exist.’ IVe diagnose be.art 

mani? fanses, but these 

Tlter^f- way, whctlier structural 

. icuio-icntiiciilar bundle may give rise to block 


whctlier the disea.se is due to .syphilis or to other factors. 
1 maiiituiii, however, that in nuiny instances it is possible 
to diagnose syphilis of tlio heart with a high degree of 
probability from the clinical evidonco alone, and in the 
majority of easc.s ihis evidence is .such as to raise a stiong 
suspicion of syphilis. 

Uraitdly spoal.ing, there arc two features which are 
characteristic for eiirdiac .syphilis. As is well hiionn, this 
iiifecHoii attacks tho aorta' and the coronary arterie.s, and 
disease of the latter gives rise to varion.s affeciioii.s of the 
myocardium. Syphilis affects the heart ninsele with much 
greater frequency limn does any other agent known to 
ciiuso hoart disease; lliero may bo .syphilitic aortitis, or 
aortic rcgtirgilation, or other fonn.s of iiifttlion, but 
usually the myocardium will also bo datnaged. 

IVe’niay contrast tbi.s with the ihoiiwatic v.alvular heart, 
where the myocardium i.s relatively .seldom affected. Out of 
88 electro-cardiograms of caso.s of cardiac syqibili.s, only 
9 were normal ; in the same mimber of cardiograms taken 
from rlienniatic valvular heart cases 42 wore normal.^ Tbo 
eases of rheumatic origin wero very much more advanced 
clinically than the syphilitic cases, so that the incidenee 
of myocarditis in the rheumatic heart in relation to the 
syphilitic is relatively much less than these figures .show. 

* This point i.s of practical irnporfanee in tbo diagnosis of 
syphilis. Take a case of noiTic regurgitation in which, 
although it is not a very advanced case, tlicre is evident^- 
of myocarditis; this circumstance in it.self favours the 
diagnosis of cardiac syphilis. In syphilis, moreover, the 
physical signs of a particnlar cardiac affection are not 
generally clean cut, the clinical picture Is not usually true 
to type. In a case of rheumatic aortic regui-gitation, for 
instance, tho clinical signs are usually definite and cor- 
related. There may be pronounced enlargement of tiie 
left ventricle, and the npo.x beat will bo pointing outwards 
and cloivnwards. There arc usually such indications also 
as a pronouneod water-hammer pulse, the different signs 
being correlated in a certain proportion. Wo nmy find 
such a picture occasionally in syphilitic aortic regurgita- 
tion, hut in the majority of easc.s the ciinicnl picture will 
be atypical. For instance, from an examination of tlip 
aortic area wo may expect a largo left ventricle and the 
typical appenr.ance of the patient, but absence of one 
or the other indication is frequently obsorvod. Again, in 
many instances, on esaininiition of the heart wo have diffi- 
culty in pinoing the iibnorma! signs in a definite category.. 
The heart docs not seem to be noi-mal, and yet there are 
no distinct signs of valvular trouble; there is no enlarge- 
ment in a given direction. We may be tempted to laho! 
it “tired” or “irritable” heart; it docs not j-oally fit 
in properly with either. In such circiinistanccs it is 
advisable to investigate tlio case from tho point of view 
of syphilis. 

Passing from tfie general to the particular, aortitis is 
probably a most common event in syphilis; it must be 
miiembcred that syqihilitie aortitis usually means syphilitic 
myocarditis. AYe may exjiect increased dnllness over the 
aortic area, but tins is not always easy to make out. In 
tho early stage of aortitis wo often. dcpe’nd for the diagnosis 
entireli on accentuation or altei-ation of tho second aortic 
sound. 1 want particularly to emphasize the point that 
awentnation of tlio second aortic sound in the ahsence of 
high blood pressiivo, in cases where there is c.itliei* a liistorv 
of syphilis or a jio.sitive Wassermann reaction, is quite 
sufficient evidence for -tho diagnosis of syphilitic aortitis, 
and, incidentally, syphilitic myoc.arditis. Usually the left 
ventricle is slightly enlarged; often there is a systolic aortic 
murmur, a diastolic munnui' appearing later. Charac- 
teristic of these murmurs is also the fact that they cannot 
be relied on to he always audible — they appear and dis- 
appear. It is easier to distingnisb between aortic regurgi- 
tation due to syphilis and aortic regurgitation due to 
rheumatic fever, than hetween the former and aortic 
trouble .secondary to such conditions as high blood pressure. 

Syphilis does not seem to bo a common factor in mitral 
disea.se. I have, however, bad a number of typical cases 
of mitral stenosis with a positive M'assermann reaction 
and no history of rheumatic fever. Is mitral stenosis 
sometimes duo to -congenital syphilis? SyTibilitic mvo- 
caixlitis, cardiac irregularities, e.vtra-si-st’oje, auricular 



842 May ig, 1928J FUNDAMENTAL FACTORS IN TREATMENT OF PHTHISIS. 


r The nnrnni 
I MkDJCAL JoURVAI, 


fibrillation, Jioart-block, and brancli bundle lesion aro all 
common in sj'philis, while the “ largo silent heart ” is 
sometimes caused by it, and I have known instances of 
syphilitic pericarditis. Infective endocarditis sometimes 
gives a positive Wassermann reaction, and it is assumed in 
this case that such a reaction docs not mean syphilis. It 
is, however, interesting that Byrom Bramwell,’ in a book 
published before the Wassermann test came into vogue, 
gives syphilis as one of the causes of infective endocarditis ; 
so acute an observer must have bad good reason for bis 
belief. 


disease. A positive reaction, particularly in a patient with 
somo cardiac trouble, ought to bo sufficient indication for 
a prolonged course of antisyphilitic treatment. Wo aro 
making this tost part of the routine examination at tho 
Heart Hospital. 

I am indebted to - my house-physicians, Dr. Wilson and Dr. 
Waters, for their valuable help in connexion with tho case-taking. 

IlKFEarXCFS. 

.'Mackenzie: Yrri Snok of Heart Hiecaee. -Romberg: Krankheiten 
dee Ilerzene. ^ Byrom Bramwell : Text Hook of Heart Diecaea 


Symfitoms. 

Broadly speaking, symptoms of lieart failure aro tbo 
same, ivhether the underlying cause is syphilis or something 
else. It has been asserted that nocturnal dyspnoea is 
characteristic of cardiac sj’philis. This has not been my 
experience, but as many of my cases are early cases of 
syphilis it is possible that if we take only advanced cases 
nocturnal dyspnoea ma}- be more frequent. Tho one charac- 
teristic symptom of syphilis in my cases was cardiac pain, 
which was present in 70 per cent., but this pain has not 
usually the characteristic features of a classical angina 
pectoris. In my experience tho great majority of typical 
cases of angina are not due to syphilis. The pain in tho 
syphilitic variety is not so intense, does not appear so 
suddenly, and differs often in distribution from tho pain 
met rvith in true angina; occasionally, however, the pain is 
similar. 

The next important symptom is tho gastric pain; pain 
is frequenth' referred to tho stomach, simulating gastric 
nicer, but the gastric symptoms are easily distinguishable 
from those which may be duo to heart failure. 


Elcctro-careliographic Evidence. 

The electro-cardiogram gives information about tho con- 
dition of the myocardium and also the nature of different 
irregularities. The great majority of electro-cardiographio 
abnormalities, however, are not characteristic of syphilis, 
and only denote a damaged heart muscle. They aro, how- 
ever, of the utmost importance in the diagnosis of cardiac 
syphilis, because in many instances it is by means of tho 
electro-cardiograph that wo are able to demonstrate con- 
clusively that there is something wrong with tbo -heart. 
In my experience, however, there is one typo of electro- 
cardiogram characteristic of syphilis — at least, I have so 
far not seen it in any other disease. It consists of certain 
wavelets all over tho electric lino. 


Blood pressure reading yields nothing characteristic 'of 
syphilis of the heart; the majority of cases do not show 
abnormal blood pressure reading. 

The result of treatment is often a valuable aid in 
diagnosis. ^ A patient was admitted into hospital suffering 
from gastric symptoms, but obviously very ill. The electro- 
cardiograph revealed branch bundle lesion, a condition 
invariably fatal if not duo to syphilis. In this case syphilis 
was subsequently admitted by the patient. Antispecific 
treatment of a few weeks’ duration was sufficient to restore 
the patient to practically normal health, and the electro- 
cardiogram became normal. Another patient developed a 
heart affection which was diagnosed as tired heart ; he got 
able to w.alk only a yard or two, and became 
^most blind He denied syphilis. After admission to the 
Heart Hospital the Wassermann reaction was found to bo 
double plus, and antisyphilitic treatment was so effective 
that this man is now able to follow his employment In 
this case, no doubt, the diagnosis of syphilitic myocarditis 
was correct. All cases of cardiac syphilis do not show such 
good results under treatment, but in my experience tbo 
groat majority improve definitely. 

I have said sufficient to make ib clear that from clinical 
evidence alone it is quite impossible in every case to 
diagnose syphilis of the heart with absolute certainty. 
Tho disease is veiy common. Those who concentrate oii 
the subject will probably make fewer errors in diagnosis 
than others, but all sometimes overlook a case of cardiac 
syphilis. It is obviously a very serious matter to leave 
a case of syphilis without treatment. In my opinion we 
h.avo no alternative but to adopt tho Wassermann test 
as a routine procedure for all cases suffering from heart 


SOME FUNDAMENTAL FACTORS IN THE TREAT- 
MENT OF PULMONARY TUBERCULOSIS. 

BT 

SAMUEL H. STEWART, M.D.Edin., 

SOUTHPORT ; 

- LATE MEDICAL SUPERIXTENDENT, BELFAST MUNICIPAL SANATORIUM. 

In tho search for guiding principles in dealing with cases 
of pulmonary tuberculosis it is moro instructive to 
approach tho subject from tbo point of view of objective 
in treatment than to attempt a classification of methods. 

Tbo discovery of tho tubercle bacillus by Koch led to 
tho rational adoption of all those measures calculated to 
stimulate tho normal resources of the body so that tho 
patient might overcome tho infecting micro-organism — 
indirect thcrap}-. It was also to be expected that direct 
therapy', in tho form of vaccines and serums, would emerge 
from the discovery. The aim of tho direct and indirect 
therapies is, therefore, similar, for tho objective in both 
instances is to overcome the tubercle bacillus on the lines 
of immunization, producing a serological immunity. 

Tho is.sHO is thus simplified, for, whether tho patient is 
aided by such traditional methods as good food and fresh 
air in overcoming the infection, or whether vaccines and 
serums aro administered, it is assumed that the toxin- 
antitoxin balance is involved, and that increase of tho 
antitoxic content will lead to healing. Tho terms “ toxin ” 
and “ antitoxin” aro used hero in tho widest sense. 

Now the existence of a toxin — probably entirely endo- 
toxin is established, but what evideneo is available in 

favour of the existence of a specific antitoxin in tho soro- 
louical sense? That tho human body must have some 
method of dealing with tubercle toxin is beyond question. 
Sanatorium principles and probably tuberculin therapy 
heighten the capacity to withstand tuberculous toxaemia, 
but the vital point remains: Does a highly positive resist- 
ance to toxaemia on tho part of tho patient necessarily 
ovorcomo tho tuberculous infection or lead to healing of 
tho diseased focus? In other words, is tho defence against 
the disease purely a local histological problem independent 
of systemic resistance beyond that required to maintain 
life? 

In dealing with tuberculosis we havo becomo so accus- 
tomed to accepting direct and indirect therapy as resting 
on an established basis that it may seem absurd even to 
open the question. Still, the answer to tho previous 
query involves tho validity of tho present attitude to tho 
treatment of this disease. 

My survey covers some clinical and experimental aspects 
of tuberculin therapy, clinical observations, and patho- 
logical findings. , I wish to emphasize that this survey is 
onlv an expression of my attitude to the question raised. 

Tho presence of an antitoxin in the blood has not been 
proved by direct tests; besides, if such an antitoxin exists, 
its presence should be manifest in clinical experience. 


TtmERCULIN. 

To obtain evidence of this antitoxin as contrasted with 
detoxication tuberculin was studied. The first point to 
become prominent was that relatively enormous doses could 
bo administered at the end of a gradually increasing course 
without any apparent improvement in the pulmonary 
lesion. In such a case the patient has obviously increased 
detoxicating power, the general condition may also be 
good, and yet such a favourable situation is not coincident 
w'ith healing power. 


May 19, iqjS] 


FUNDAMENTAti FACTORS IN TBEATSfENT OF pnTHISIS. 


[ Tjfc Hritiw 
ityotcxt. SocnyiXt 


843 


Of eoxii-sc, it. muj- bo nrguocl Hint tlic nbovo citation is 
only an oxani'plo of toloianoo to injected toxin if focal 
reactions aro ignored. At least ono may accept increased 
tolerance to injected toxin and proceed to tc.st the position 
as follows. It is rccognir.ed Unit a sltin reaction to tuber- 
culin is a miniature tuberculous lesion. Now lesions cstab- 
lislicd cutaneously are capable of observation. As skin 1 
tests are more informative in children than in adults 
1 selected altogether forty tuberculous children suitable ! 
for tuberculin therapy, and ]icrforme<l a quantitative skin j 
test. A note was made of the sensitiveness and the time . 
required by the papule to di.sappcar. The.se children were 
treated with the same brand of tuberculin over a period of , 
three moiitlis, the ultimato dosage varying with the c.apa- 
city of the child. .AVithin the period when I could still ’ 
have injected the last dose of tuberculin — namely, on the' 
eighth day — ;! repeated , the quantitative test and made • 
notes as before. , , : 

Comparison of the results revealed no relation in regard' 
to cither sensitiveness or duration of disappearance of the 
papule and the artificially produced systemic tolerance. 
One rather expected to .find on the whole an increased 
sensitiveness.' ’ . _ 

Cutaneous reactions aro too imperfectly understood to, 
make any rash claims' oii the basis of 'these experiments; 
still, the trend of the results is ^again unfavourable to ' 
the standpoint that healing is necessarily dependent -on 
systemic toleranco beyond that required to maintain life. 

1 have sinijily recorded the results of these tc.sts on a 
comparative basis in the same case without asserting a 
defined relationship between tissue and skin sensitiveness 
ordinarily. 

These observations as to the otfccts of tuberculin aro in 
accord with the attitude of the majority of tuberculosis 
workers to tuberculin therapy. 


_Clixic.\l .\xd P.wnoiooic.ti, Evjdkxce. 

There is an inevitable association in the infonuation 
afforded by these two sources, consequently tho tacts arc 
recorded under ono heading. 

Post-mortem records definitely indicate the power of tho 
human body to cure tuberculous lesions in its own way; 
yet the exercise of this poaer fails to confer immunity 
to further disease. AVhen disease occurs it is usually 
referred to as the result of broken-down iminnnitv. Is 
this justifiable? If the factor determining activity of 
oi^aso is failure of immunity, why should a patient' 
.suffering nom prolonged pulmonary tuberculosis not pro-' 
. ‘ 5 ^ . ^ parts of the body susceptible to the 

inlectioii. Li-tic hyperseusitiveness '' is more a defence 
of a theory than an explanation of this fact. I think 
generalized tuberculosis in ]irogressivo 
phthisis IS against reduced immunitv as being the iTcter- 
mining factor in resistance. 

1 ? comparatively common experience to find 

atent disease becoming active as tho result of a fall, a 
Won on the chest, the occurrence of an acute illness 
^amagiug the lung, or the resumption of a life where lung 
umction IS placed at a di-sadvautage. It is difficult to 
we bow the humoral asiieets of immunitv are involved where 
die exciting cause is a fall or a blow, 'it seems to me that 
aauma IS a more vital factor, and the same factor is at 
work n-hero activity results from illness and bad environ- 
ment. 


Tbe.se observations amount to a claim that trauma, 01 
strain, is an important factor in the causation of tuber- 
pulosiE, a factor, too, operating locallv, and that general 
immunity as such is negligible. Thev do not, Imwever, 
exclude a local cellular defence, a histogenoiis immunitv 
wh.rb in a sense is an enlightened way of referring to 
the « not sufficient to oxphiin away reactiva- 

tion pn-tlie basis of a .short-lived general immunitv, because 
the longer a case has ' remained healed the lesk are the 
ennnees oi rencAYod disease. 

Now tlie same idea may be approached from a different 
clinical angle— namely, the progre.s.s of multijile lesions in 
a patient dying from tuberculosis. I bad under obsciw.a" 
tion for over tiro rears- a patient dviiig slowlv from 
piilmoiiaty tuberculosis, and during tb.at peidod be effected 
apparel, healmg of an osseous l?sioii. In patients ^UU 


multiple lesions it is not uncommon to see some healing 
and others advuiiciiig, while the case as a whole is going 
downhill. 

At this point it is interesting to survey the cjucstion 
of healing, it is recognized that healing in tuberculosis, 
ns met clinically, is not by resolution, neither is it 
dependent on the extinction of the iiifcetioii. The term 
“ Iioaliiig ” in this disoa.so is really more accurately 
regarded as a i'c]ilnccnicnt of the. primary jiliysiologically 
active tissue by a practically inert siibslaiicc which acts 
ns a barrier to further damage by the bacillus. Such is 
the pafbologv of tiibcrcido.si.s that nny agent acting tbroiigli 
tho circulation miist fall short, of coniplete cxtirjiatidn 
of the infection, and consequently tissue replacement will 
remain a vital factor. ^ , 

On the nbovc reasoning the .cla.ssificatioii of objectives 
ill treatment- as direct and indirect therapy does not seem 
to mo- well founded. AVitii our present knowledge of im- 
munity rcac-tioiis, iiicliidiiig the reaction of tuberculous 
and non-tiibcrciiloiis subjects to infection and toxin,- I 
cannot sec that .a ease, is made out for the liiimoral factors 
of imniniiity. The iiitrodiictioii, of , an iiiti-rmodiaie factor, 
siieli as lysin, may explain the difference between ininiiiiiity 
in tuberculosis and suph a disease as diphtheria, but we 
have then only a liypotlietical jiresoiitatioii of the subject, 
wTiicli doc.s not fit in -witlr clinical -cxpenciic-e. 

The specific renctioii to infeetipii and toxin when inocu- 
lated suggests a specific histogenoiis defence; it is a local 
jiliciiomciioii, and ivould not seem dependent on high 
general resistance to toxaemia on the part of the patient. 
In these days of much advertised seniins it would be inform- 
ing to have the basis of their efficiency. 

Again, if the general rcsistanco bo not a vital factor in 
local defence, the basis for treatment by sanatorium and 
allied methods is still to be established as a stimulant to 
bo.aling. That the sanatorium, being the embodiment of all 
those factors which make for health, is a sound treatment 
of the patient is beyond question. It is also obvious that 
the restoratio.i of systemic resistance is desirable in the 
interests of living, but the elaborate building up of systemic 
resistance with the object of prodneiiig healing is vci-y 
questionable. Tlie sanatorium does, however, afford th'e 
patient an opjiortiiiiity to effect healing which might bo 
witlibeld in tlio less satisfactory environment of' many 
lioiiies. ’ ■' 

• For the sake of lucidity I might recajiitulate that, Rrst, 
treatment of the patient is not necessarily treatment of the 
disease, and secondly, the patient must lie treated to allow 
time for the local cellular defence to effect restraint of the 
disease. 


a lie crcatmeiit ot the patient is that of- a bacterial 
.toxaemia; the treatment of the diseased lung is rather 
that of a damaged than an infected organ. I take this 

standpoint on the basis of the — ‘ ' r 1 

prc.sent known; healing is maiiil; ' 

replacement process, not oven ’■ ■ , * pj 

the, infection. The relative iiidilfereiicc to systemic toler- 
ance and the after-history also seem to me to uphold such 
a standpoint.. Even if a safe bactericide were found such 
an attitude would still he indicated ’ 

This presentatioii of the ..subject, in my opinion, demands 
uist, of the chimaged organ as a fii-st stop in treatment. 
Support for this demand is got from observation of cases - 
thus an attack of pleurisy often heralds an improvement 
in the disease; a serous effusion is also beneficial. The 
moclianical .support arising from these conditions is appa- 
rently contributory. Again, a general review, of tiiher- 
ciilosis reveals the great predominance of clinical di-sea-se 
in organs the- function of which involves movement ■ 
mortality rates from tuberculous infection show the .same 
association with mobile organs'. Add to these observations 
the fact that where mechanical immobilization can lib 
effected— as, for iustance, in joints— the results of treatment 
are far .superior to those obtaining in the case of the liinr^s 
Purely, then, a prima facie case is made for rest "in 
treatment. * 


Again, ui the treatment of a pyrexial patient ateoluto 
lest IS the only therapeutic measure available Tim 
toxaemia is lessened because the lung is heiim less it 1 
turbed, and consequently the metabolic. SloSVoIt 


844 May 19, 1928] 


BKONCHO-PNE'UMONIA IN OEIIiDEEN. 


[ TrTR Hrithh 
SfEDlCiL Jocn*!!*, 


functions aro totter controlled. It is agreed that toxaemia 
is much more easily overcome than tlie disease itself, 
llest in bed brings about the recovery of the patient, but 
the disease remains a problem. To effect the local healing 
which I have previously emphasized I wish to suggest that 
local rest of the lung should be the aim at this stage, 
rather than graduated exercise.- In short, the plan is local 
and general rest until toxaemia is controlled, followed, if 
possible, by continuous lung rest until repair has been 
effected. 

Some Points Concerning Tocae Rest. 

' Some hint as to the application of local rest is given 
by the observation of healing or healed cases. In such 
patients, apart from the attempt at muscular restraint, 
there is retraction of the chest wall ; fuller investigation 
usually reveals displacement of the heart and mediastinum 
towards tho diseased side. In other words, the diseased 
lung is permanently protected, in that its field of opera- , 
tion is finally restricted. This is usually referred to as a 
result of tho pull of the fibrosing lung ; I regard it rather i 
as a compensatory process brought about by the healthier ■ 
lung increasing its field of operation, and at tho same time • 
ensuring restraint of function on tho part of tho diseased 
organ. 

It may reasonably be argued that there is no good outlook 
for bilateral cases. As a fact there is not much for the 
moderately advanced bilateral case; improvement, if any, is 
usually temporary. We all have seen rare cases of exten- ' 
sive tubercle clear up in an apparently miraculous manner. 

I have felt that most of such cases are examples of super- 
ficial lesions where the pleura contributes to tho result by 
piomoting fibrotio change, and an enhanced cellular defence- 
may be in operation; but the miraculous case is not our' 
problem. 

To return to the question of retraction, which I have' 
described as compensation, I wish to emphasize its vital- 
importance. A tuberculous lung is au organ as permanently 
damaged as a heart with diseased valves. In tho latter 
case every effort is made to establish compensation, whereas' 
in the former I am not aware of any real recognition of 
such a process, which is probably more protective than 
functional. 

To investigate the possibility of inducing compensation, 
and also tho results accruing from it, I devised an appliance 
controlling tho ribs on ono side and .leaving the oiiposito - 
side comparatively free. In a suitable case it was found'- 
that rib restriction brought about some displacement of tho' 
mediastinum in a few -a-eeks; this must be a compensatory, 
process, as fibrous retraction could not bo operative. It 
may bo that the obvious is being laboured in this connexion, 
but its recognition in treatment is not obvious. As to- 
resulis, I liave no hesitation in asserting that, acting on 
the above basis, healing was effected in cases where other' 
methods, including the sanatorium, had failed, and these 
patients have remained well over four years. These results 
are claimed for the princiiile; no claim of universal cures 
is intended. 

In the production of rest certain factors have to be kept 
in mind. After considerable work on the question of rest 
in treatment I defined certain postulates, which are as 
follows : 

1. Tlie method must be capable of comparatively wide 
application. 

2. The method must not restrict unduly those conditions 
-ivliich promote a healthy state of the body and mind, 

3. It must promote compensation, and not impair to any 
considerable extent tho normal function of the opposite lung. ’ 

4. - In the event of healing being effected the patient’s physique 
'must he unimpaired. 

5. It must recognize tlie mechanism of respiration. 

6. The usual distribution of the disease must be noted and 
efforts made to promote rest at the zone of extension of the 
disease, and thus facilitate the formation of “ barrier ” tissue. - 

The postulates 1 to 4 require tio further elaboration; a j 
note on the last two, however, is indicated. j 

Enlai-gcnieiit of the thoracic cavity is hrotiglit about i 
mainly by movement of the ribs below the second, and bv ' 
diaplu-nginatio moveineiit. Lung movements are siibsei-i-ient 
to these two factors. Tlioracic oiilaigement ill any diiec- ■ 
tioii causes geueral enlargement of the lung; thus Keith 


has shown that movemouts of tho diaphragm are reflected 
oven at tho Imig apex. Again, tuberculous disease in the 
lung inoro frequently starts in tho upper part aud spreads 
downwards. 

With these ])oints in mind, it may ho pormissiblo for tho 
sake of explanation to suggest that W'o have a lung frac- 
tured at tho zone of extension of tho disease, with an 
upper diseased and relatively immohilo fragment, and a 
lower more actively movable fragment. With this concep- 
tion it will he seen that rest can only ho attained if 
restraint ho applied to tho moro freely moving fragment. 

C0NCI.U.S10N. 

This paper is concerned with principles rather than 
methods. Eurthcr olahoration may bo desirable in certain 
parts, hut I think I have indicated sufficient grounds t;> 
justify a trial of moro widespread surgical measures in 
treating pulmonai-y tuberculosis. 

Condensation rather tends to give tho impression of lack 
of halanco iii tho statement of a caso. Still, if I have 
made my objective clear, and given some indication of tho 
lines along which it should bo sought, my purpose in 
writing this article is attained. 


BRONCHO rPNEUMONIA IN CHILDREN TREATED 
by INJECTIONS OP EMETINE . 
HYDROCHLORIDE. 

BY 

C. -ROBERTSON WILSON, M.B., Ch.B., D.P.H.Ed., 

lATE SENIOR ASSISTANT MEDICAL OmCEH, BOOTH HALL INTIRMAHY TOR 
CHILDREN, MANCHESTER. 


The alkaloid emetine, chiefly known for its specific action 
in amoebic dysentery, has in tho past been vaunted as a 
remedy for other conditions, notably tlio arrest of .baemor- 
rhago (especially haemoptysis) and respiratory diseases. 
Witliiri this'latfor group falls broncho-pneumonia, to wliicli 
disease alone tho ensuing observations refer. BurdiclO 
says “ Tbero is now accumulating evidence that the 
remedy lias some beneficent action in this class of diseases 
aside 'from that due to its expectorant properties.” Ho 
goes on to state that Raeburn, Elandin, and others believe 
that this action is of a decongestant nature. Littlo seems 
to have been written concerning this method of treatment 
during tho past ten years, so some further notes on tho 
matter may perhaps prove of general interest. 

The Booth Hall Ohservations. 

Tho cases treated wore not picked ones, but SO consecu- 
tive cases of definite broncho-pneumonia, primal-}' or 
secondary, admitted to the hospital, which takes patients 
from birth to 16 years old. As a control, 50 furtlicr cases 
treated by any other method were observed, these only 
being selected in so far that just the same number of 
secondary cases were taken as had occurred in the emetine 
' series. 

Dosage. 

Bertrand" states that for pulmonary conditions bo used 
a smaller dose than that normally given in dysenteric 
cases. The daily dosage used in this series was roughly in 

accordance with the following table : 

. • Age up to 4 years ... ' 1/9 grain 

4 to 10 years 1/6 „ 

10 to 15 years 1/3 „ 

These wevo used as commencing doses, hut each caso had 
to bo judged by its reaction. In the majority of cases these 
amounts were found quite adequate, to produce effects. 
The salt of emetine used was the hydrocliloride, . this being 
the most readily soluble, and the suitable quantity -was 
administered daily by hypodermic iujcction. 

Tho number of doses administered to any one case in the 
series varied from two to nine. In the main it was found 
that if at the- end of six daily injections of tho drug tho 
case had not shown definite signs of .settling, as regards 
temperature, pulse, respiration, and clinical picture, littlo 
further benefit was to ho expected from its use. In .a 
number of cases tho doses were discontinued short of six. 



memoranda. 


[ Tirr nrmnt CdR 

Bfr.DiCAt* JoimxAt vxv/ 


MAY 19 , 1928 ] 


Coinlifions of Dosoyc. 

To oiisuro tliiil the action of the, emeUno injocUons only 
tva? obscivod, no other ex|)ectoinnt or diaphoretic mixture 
wa-s administered along with the ti'eatinont. Tho onlj 
additions permitted were local applications (such ns anti- 
])hlogistino), hrandy, and injections of strychnine where 
desirable. 

Effects Observed. 

I'lven in those cases which did not hnnlly settle after 
this treatment its effects were evident. These included 
a fall in the temi)cratnre after nn injection and n corre- 
sponding fall in the pulse rate. The respirations seemed 
little afTecfcd directly, but gradually tended to follow the 
temperature and ptilse. A striking loosening of tho 
expectoration was soon evident, in some cases even .after 
the first injection, and the type of the accompaniments 
heard on auscultation changed to the. coarse bubbling typo 
of idle. 

At this point the cases seemed to divide themselves into 
two gi'oups — ono where exiiecloration became profn.so and 
tho che.st cicai-ed, tho other a here the chest appeared to 
clear up without the occurrence of the free expectoration. 
It is, of course, possihle aith children that sputum was 
■swallowed in some of these cases, but tins type of clearing 
seems to have been noted also by Uaeburu’ among his first 
group type of cases (non-tubcrculons). Ilenon'* found that 
the temperature fell, dy.spnoca was reduced, and that tho 
facility of expectoration ans greatly increased. These 
cifects he found more evident in broncho-piunimonias than 
in lobar pneumonias. 

Tlio dopressant action of emetine never ma<le it.self 
really evident, and these cases did not reejuire any more, 
in tile way of stimulants, than the control series. The 
only case which showed a possible toxic sign (diarrhoea) 
wa.s one in wiiich the patient died with this as a terminal 
comjdication. Whetlier or not it was attributable to 
emetine is very doubtful. 

Comparison of the figures obtained in the emetine scries 
aiid those obtained in tlie control scries is not encouraging. 
Both series consisted of 50 cases, and in eacli there were 
42 primary and 8 secondary cases. The figures are as 
Tolloivs : 


Emetine Control 

Series*, S^rie^. 

Curca 27 =s s;% ... 30 = 60% 

Died ; 20 rs 40% 20 = 40% 

Recovered, but not settled 

after cmoliue 2 = 4% Ifil 

Improving; removed by 

pa»*cnts 1 « 2% iXtl 


> average duration of febrile symptoms in cured cases was 
4.5 days lu the emetine series and 6.2 days in tlic contx'ol scries. 

Conclusions. 

Both scries give a death into of 40 per cent., and the 
percentage of definite cures in each case docs not differ 
greatly. Thus emetine hydroclilorido on these results 
cannot he considered as a cure for hroncho-puenmonia. 
The highness of the death rate in both instances may be 
condoned to some extent hy the fact that tho majority 
of the patients were drawn from the Ter\' poorc.st areas of 
’Manchester, were initially possessed of a poor degree of 
natural resistance, and in many instances were brought to 
Iiospital too late to iiope for really effective treatment. 

Tho febrile period seems on an average to be reduced in 
the emetine series, and in both series tlie fall was by the 
iisxud forai of lysis. 

As pi*erioiisl 3 * mentioned, in no case were definito toxic 
Symptoms present, nor was any nndno depressant cfFccfc 
noted, tiov did any objectionable local reaction occur 
following injection of the drug. 

At hilo not acclaiming the use of emetine as a specific 
Tomedy, it certainlv- appears tc> bo of clinical value, and 
this may be summed up briefly as follows: 

1. In children the effect gained hy tlie daily injection 
fcaves in many instances a struggle with the child to get 
ji to take medicines b}* the mouth, thus giving patient 
and attendant alike a more restful time. For this alone 
it should he a vafuabie method for the general practitioner. 


where difiictdty in this direction is only too often present 
owing to amateur nursing. 

2. Tho fohrilo period of the disease appears qnito 
definitely shortened when tlio average of cases is taken. 

3. TIio .stomach is left free from any irritation by 
expectorants and given a better chance with such nourish- 
ment as' may ho taken. 

My (hanks arc dne (o Dr. J. D'Ewart, medical superintendent, 
for pcnmVsion to make use of rny observations. ' 

Rrpr.nKXcrA 

• /Hfcrartfionfll Clinicf, vob ii* 1915, p. 42. ‘Bull, de VAcmJ. dr Mrd., 
1914, p. SS7. * lirltirh ^Irdical Journal, 3rarch 28tli, 1914. Gaz. des 
IldpitauXf March 12th, 1914, 


biedicaij. surgical, obstetrical. 

SABCOMA OF THE STOMACH. 

Two cases of sarcoma of tlio stomacli have been ropoiteil iu 
tlie pages of tbo Bnlisti IMcdirnt Journat during tbe past 
tliroo mmitlis by Mr. James S. Hall aud Dr. Alexauder 
Suiitb. As this condition is so rare tlio following account 
of a recent caso under my care in the Royal Islo of Wight 
County Hospital may bo of interest. 

Tho patient, n gardener, aged 32, bad a fainting aliack ton 
Jamiary 9Ui, 1928. Previously, altbougb be was anaemic and lacka- 
daisical he had bad no severe illness, nor suffered from dyspepsia 
or pain in the abdomen. On January 11th he had mclaena, which 
lasted until January OTlh. From that lime onwards his health 
improved, nllhoiigli ho was very we,ak .and profoundly .anaemic. 
The mclaena was thought to be due to gnstro-duodenal ulceration, 
for wliich lie was treated. On' February 5th, at 2 p.m., he com- 
plained of severe epigastric pain, which lasted continuously until 
ho was seen by mo at 9 p.m. At that time he looked very ill, 
and slated that tho epigastric pain was still very severe. He had 
not vomiled and his bowels had been well opened. The abdomen 
was moderately rigid and moved slightly on respiration, and tho 
epigastrium was tender. Tho liver dullness was not obscured, but 
extended for two inches below tho costal margin. Pulse 72, tem- 
perature normal. Nothing abnormal was found in the lungs. In 
view of this attack of pain supervening on an attack of melaena 
his condition -was lliouglit to be that of a ruptured gastric or 
duodenal ulcer, so he was removed to iiospital for immediate 
operation. 

Opemlivn . — On opening the abdomen through a right para- 
medial incision a maroon-coloured tumour presented. Tin’s was 
delivered and was found to bo pedunculated, having a pedicle 
ono inch long and attached by a two-inch base to the lesser 
curvature of tho stomacli. The tumour .was very' much congested 
with large vessels coursing over its surface. It w.ss firm, about 
tbo sire of a foetal head, and bad the appearance of sarcoma. 
The tumour was removed together with one inch of gastric wall 
beyond the attachment of the growth. The stomacli w.as sutured 
by a double row of stitches, and the abdominal wound closed. 

Except for a slight consolidation of the base of the left lung 
the patient had an uneventful convalescence, and he w.as dis- 
charged from hospital on March 3rd. On April 7th lie reported 
himself to be much improved and able to take a fair amount of 
exercise and to do a little work. Before leaving the hospital 
a radiogram was taken of the patient’s cliest, but there were 
no signs of secondary deposits of sarcoma in the lungs. 

Pathological Ilrporl.—The tumour was sent to Dr. L. Firman- 
Edwards, pathologist to the hospital, who reports : The tumour is 
a large brain-like mass about the size of a foetal head, with 
numerous small haemorrhages in it. It has the macroscopic 
appearance of a sarcoma. Microscopically the tumour is made up 
of spindle-shaped cells with laigc elongated nuclei, arranged in 
a wbovl-likc formation. Between the whorls the cells form a fine 
network like that of areolar tissue. ’There are no true blood 
vessels, hut embryonic blood spaces occur throughout the section, 
and thesc have in many ci^es a lining of endothelial cells. The 
structure is typical of a spindle-ceiled sarcoma, although in some 
ways suggestive of . an endothelioma. 

I Tills case is interosting in that, in spite of tbe size of 
the tumour, tho patient had no symptoms until the fainting 
attack and the appearance of mclaena, and ono was led 
to suspect rupture of a gastric or duodenal ulcer owing to 
the sudden attack of acute epigastric pain on Februarv 
5tli. This sudden onset of pain was undoubtedly due to 
torsion of tho pedicle of the tumour. Its maroon appear- 
ance at the time of the operation, and the patliologica! 
report of numerous small haemorrhages in it, bear out 
this assumption. 

A. H. Hesmp, M.B.; 

Surgeon lo the Royal Isle 
Consultin': Sin-j;con to 
valesccnt Home fo 


,B.S.,F.R.C.S.Eng., 

of IViclit Countv Hospital, 
Rinj? Edward V/I Con- 
r OfliccrSt Osborne. 


846 May 19 , 1928 ] EABLT DIAGNOSIS OF OANCBB OP BECTUM AND COLOK. 


r TtfE TJntnini 


A CASE OP POLYDACTYLISM IN THE FOOT. 
Although cases of polydactylism may not lio extremely 
uncommon, it must bo rare indeed that an instance, suclx 
as that recorded below, is met with in which tlio patient 
has as many as three additional digits on ono foot. There 
is, too, more often than not an hereditary tendeney to 
the deformity. This was absent in tho present case. Aliles 
Atkinson, , in the British Journal of Surgery (vol._ 9, 
1921-22, p. 298), records a case of hereditary polydactylism, 
in which it was possible to trace the occurrence of tlie 
deformity hack through four generations: of 48 persons 
traced, 26, or more than half, exhibited a condition of 
polydactylism. In no' instance, however, was there more 
than one extra digit on any ono limb ; although Atkinson 



mentions that cases have been reported in which there 
were as many as eight digits on ono hand, and a case with 
nine toes occurred in America. 

The present patient was a lady, aged 82, who was found 
to have eight separate and fully formed toes on tho left 
foot. On inquiry I could not trace any other member of 
tho family with a similar deformity; indeed, tho relatives 
did not know that tho patient had anything wrong with 
her foot at all. Unfortunately no radiogram of tho foot 
could ho obtained. 

I am indebted to Dr. Campbell of tho Public Health 
Department for tho excellent photograph with which this 
note is illustrated. 

A. Ebnest Sawd.w, M.B., B.S.Lond., 

F.K.C.S.Ed., 

Honorary Surgeon, Derbysliire Hospital 
for Sick Chihlron, 




EARLY DIAGNOSIS OE, CANCER OF RECTUM 
AND COLON, 

At a meeting of tho Subsection of Proctology of the Royal 
Society of Medicmo on May gth the subject of tho carlv 
diagnosis of cancer of tho rectum and colon was debated 
The chair was taken by Sir Chaules Gouoox-Watson. 

Sir ■\ViLHAJl DB CouROY AVheelbr, dealing with the 
surgical aspect, said that ho was doubtful whether he had 
ever seen an early case of cancer of tho rectum or tho 
colon, and from the literature he discovered that most 
surgeons had bad the same lamentable experience with 
regard to late recognition. In tho Breslau clinic 70 per 
cent, of cases of cancer of the rectum were inoperable on 
arrival, and ho thought tho figure for St. Alark’s, London 
was similar. In connexion with tho lack of early recog- 
nition, ho drew attention to tho relative frequency of 
cancer of tho distal portion of the colon, because it was 
just in this situation tliat early diagnosis ought to be 
made. From tho diagnostic point of view, cancers in tho 
distal region were really external cancers, comparable with 
cancer of tho breast. If early diagnosis ' could bo made 
tlioro would bo a rich reward, for even under present con- 
ditions 50 per cent, of excisions of cancer of the rectum, 
and 60 tier cent, in tho case of tho colou, were followed 


by five years’ euro. Jlorcover, under modern conditions, 
tho operativo mortality was becoming negligible. IVith so 
many iiii-ssod diagnoses it would bo jirofi table to review tho 
diagnostic armoury. All tho authorities he had consulted 
commented on tho lack of thorough examination in sus- 
picious cases. Each patient ought to bo examined 
thoroughly, but ho thought it only fair that thoso who 
specialized in this branch of surgery should make allow- 
anco for tho busy general practitioner, who was often 
misled by high abdominal .sj-mptoms predominating in tlio 
first instance.' Ho himself had seen several cases, and 
there wore many recorded in litcraturo, which had been 
examined for dyspepsia by x rays on many occasions, 
when tho caiiso was within easy reach of tho finger in tho 
rectum. Numbers of cases of cancer of tho rectum wero 
mistaken for haemorrhoids owing to perfunctory examina- 
tions, notwithstanding tho fact that students were taught 
to beware of so inexcusable a mistake. It might help in 
arriving at an early diagnosis if students examined tho 
pelvis bimnnually per rectum in tho same thorough and 
systematic way as tho vaginal examination was performed 
by gynaecologists. Just ns tumours in tho rectum and 
rectal sigmoid wero easily felt, so tumours higher up 
could be easily seen, and tho simplicity of tho sigraoido- 
scopic examination was insufiiciently realized. No examina- 
tion of this kiiul was complete without employing x rays 
after a bismuth meal and bismuth enema, but hero ho 
wanted to sound a note of warning to tho general practi- 
tioner, that radiologists wero not infallible, nor wero their 
dicta 'akin to tho gospel. Often a practitioner sent a 
suspicious case to a radiologist straight away; nothing 
definito was seen, and tho caso was left for perhaps a 
year until an inoperable growth had made its appearance; 
Ho thought it a grave mistako to tako a radiological 
report as proof positive of cither absonco or proscnco of 
a rectal or colonic growth, though ho gladly admitted that 
tho bricks of tbe diagnostic building were cemented together 
bv tho radiological findings. In tho routine examination 
of tho faeces occult blood was not found unless there w as 
some definito alteration of tho gastro-intcstinal tract. 
After speculating on tho cause of the anaemia m cancer 
of tho colon, which might bo duo to tho loss of small 
amounts of blood, ho said that tho .anaemia was never a 
contraindication to operation, though exploration should 
bo tho last resort. If there were occult blood and sus- 
nicious symptoms, and if tho a:-ray findings wero suggos- 
Hvo tho caso was ono for exploration, supposing no 
tumour was palpable. Unfortunately there always remained 
nroun of patients who would not seek medical advice. 
Thov corrected their constipation by purg.ativos their 
diarrhoea by astringents, and tbeir lassitude and weau- 
ness bv chaiigo of air and holidays; they were doctored by 
themselves, their friends, and tho daily press. Some good 
miebt como in this respect from cancer campaigns, and 
tlio public must bo taught to avoid thoso paths of neglect 
which led inevitably to the grave. 

Dr CuTunEM Dukfs described the way in which tlie 
nathologist could bo of most servico in tho diagnosis of 
Lncer at an early stage. He would leave on ono side those 
still unsettled problems of pathology that centred round tho 
ovi<r:n of malignancy, and limit himself to answering tho 
pr.a1;tical question, “ What can a pathologist do to help the 
mimeon make up his mind whether or not 1 ns patient has 
cancer of the bowel? ” and said that the answer was dis- 
.a'ppointinglv brief; it was limited to tho fragment reinoyed 
for diawnos'is. Ho knew no reliable way of recognizing 
thoso changes in tho blood which must accompany cancer 
from its first beginning. Some time ago ho had hopes ot 
agglutination tests with a peculiar strain of B. coli, but 
the procedure proved useless for diagnosis, because only in 
the later stages of cancer was it positive, and even then 
the results were often equivocal. Similarly, tho altera- 
tions in tho urino which eventually accompanied rectal 
cancer arrived too lato to bo of practical v.aluo in diagnosis. 
The chemical and microscopical examination of the faeces 
had been explored almost in vain. The occult blood test 
miglit bo useful in certain cases, but many other possible 
sources of blood in the stool had to be borne in mind. The 
prospect of finding a fragment of cancer epithelium in tho 


MAT 19, 19=3] 


EABIi'? DIAGNOSIS OF CANOBH OP BEOIUM AND CODON. 847 


(Uiilvdcjccto w.is iibout iis liopcloss iis tlio search for n iiccillo 
ill a' liaVKtack. TJicre ira.s, iioivover, one nsjicct of recent 
work at St. Mark’s Hosjiital which iiiiglit ho useful to 
surgeons. The so-called innocent adononia of the how el was 
a fre<iuent juccursor of cancer, and Dr. Dukes had had the 
opiiortunitw of deinonstratiiig to the Snhsection jirepara- 
tions illustrating the onset of malignancy in adenomatous 
tumours, jioiuting out how* often an I'arly howel cancer 
was accompanied hv a cluster ol sessile adenomata and 
patr'hes of epithelial hyperplasia scattered over the mucous 
memhraUG for several inches ahore and below tho grow th. 
The existence of these jiroliferations w.as a warning against 
the misconco])tion of regarding the malignant disease as 
strictly limited to the area of tho howel which here the caiu-er. 
If on sigmoidosco]iic examination no obviously malignant 
tumour vvere discovered, this ohsen*aiion should point to 
tho need for a very close medical .sujiervision in the imme- 
diate future, with re-examinations with the sigmoidoscope. 
IVith i-egavd to the microscopic examination of fragments 
of suspected tumour, already defined as the most useful 
fiiiietioii of the pathologist in early diagnosis, it was worth 
while to consider which particular region of the. tumour 
was most likely to permit a decisive opinion. The patho- 
logist made up his mind chiefly from the general di.s- 
position of tho cells and their relation to neighhouring 
tissues. Too much reliance should not ho placed on the 
morphology of individual cells, for in a rapidly growing 
adenoma hi which the intenelationshiii of the ciiithelium 
was strictly preserved, and in which tliere was no encroach- 
ment, into .subjacent tissues, cells might he found which 
o.xhihited all the generally accepted mark.s of malignancy. 
The individual cancer cell, separated from its fellows and 
neighbours, possessed no histological feature that might 
not he paralleled in a cell separated from a nou-malignant 
tumour. With isolated cells the Jiighcst maguifii ation i-ould 
not distinguish tho malignant from the benign, ^luch more 
could bo learnt from the general arrangement of the epi- 
thelium, hut this also must not ho taken as au invariable 
giudc, because tho disorderly disposition of the cells in 
cancer might he closely mimicked hy the prolifi’ialiou of 
a benign tumour. Tho only unequivocal .sign of lanccr of 
the bowel, was the intrusion of atyjtical epithelium into 
regions where such epithelium was not normally found. The 
mrtieular features which tho pathologist wished to study 
Acre most conspicuous in tlie tissue at the edge of the 
jUmour. A fragment removed from this region would show 
Ihe normal epithelium side hy side with the neoplastic, and 
K ould allow of comparisons being made between the natural 
iistological appe.araiice and Dio di.sorderly disposition of tho 
non giontli. Moreover, the margin of tlic cancer was its 
growing point, and therefore a fragment from the edge was 
the best means of recognizing the nuclear jiccidiarities of 
malignant cells. The inaiimn* of removal of the fragment 
vs as important. It should he handled carefullv, and not 
squeezed or cut with the knife or scissor.s. If the fragment 
could be removed hy dissection that was the method of 
choice, but almost equally satisfacton* samples c-ould ho 
obtained hv means of a punch. Fin.allv, it was well to 
rcmeiiiiei that a negative rejiort; stating that there was JiD 
evidence of malignancy discoverahlo, did not necessarilv 
impl^ that tho whole tumour was henign. The repoH 
referred only to the particular portion sent for examina- 

Dr. Gh.vham Hodgson, who spoke from the radiological 
point of view, said timt it was gcncrallv acljnowledged that 
an efteient a*-ray examination could be of great assistance 
0 the surgeon hy confiiming clinical suspicions and hy 
localiziiig the growth and defining its extent. The mort 
iiiiportaiit radiologic.-il sign of carcinoma of the colon ivas 
XI 1- showed on the screen many examples 

of the radiograpliic.al appearance of this. Earlv growth in 
the part of the colon where the calibre was wide, as in the 
caecum, was I'erA* apt to escape observation if. screened or 
ladiograplicd in the antero-qiosterior plane. In these sitna- 
tioiis ohhqne views were essential. He also described the 
dual exposure teelmique. 

41,?' ; said that the advanced period in 
case at which the ^irgeon or physician saw the patient 
In his last "twenty-four private cases the 


w.os lamont.ahle. 


livenigc duration of symjitoins before the patient came to 
him was ten and a half niontlis. A careful hi.story of 
svmiitoms was the most inqiortnnt thing in diagnosis. TIio 
patient, usually liail some definite ahclomiiial symptoms, 
which ciiiiic on fairly smldeiily aftci* a iieriod of health j, 
generally there w.ns discomfort and some eliaiigc iii tho 
regnlaii'ty of the bowel action, almost as often a tendency 
to loo.scnc.s.s and irregularity as to constipation. On further 
iiivcsfigiitioii it was striking how infrequently was* tliere 
any iihnorniality in the .stools. Out of tho twenty-four 
eases just mentioned the stools in only five showed, on 
naked-eye exaniiiuuion, any abnormality, hut 011 a more 
oluhorate cxiimiiialion occult blood was found witliout a 
single execplioii. He .thought tJiat of all the signs ami 
.svmploms the presenre of occult blood was tho most 
constant. .He had never yet seen 11 ease of growth in 
the stomach or coloir without occult blood being present. 
Occult blood .might, however, also he found in one or two 
other coiulitioiib, incindiiig rare cases of tuberculosis of the 
colon, and, cnriohsli* enough, localized adhesions, 'With 
regaril to 'j-rav exaniiiiatioii, all were agreed as to its 
great value, hut- it was very important to" realize that 
there were cases of fairly iiilviinccd growth of the colon 
ill which a hariinii oiienia showed iio ahnormalitj*. .Both 
the delay and the shape of the filling defect helped to 
distinguish the gfoirth from other eodditioiis which might 
simulate it.. He emphasized the value of the sigmoido- 
seoi>e, and added that until this was rceogiiizod as an 
instrument which the general practitioner ought to use 
cases would he mi.ssed. There were certain cases, however, 
in wliicli the signioidosco])e did not help, and diagnosis 
depended on indirect methods, such as x rays and occult 
blood. In tho earliest eases of all x rays were negative, no 
tumour was palpable, and all one lind was the histor.v and 
the occult blood. 

Mr. J. P. LocKH.AnT-^InMMEiiY said that if growths in 
the colon were detected during the early stage the results 
of operation wore admirable, and the rceurreiice rate low. 
He douhted whether 25 per cent, of cases of eareinoiim of 
the colon ever reached the surgeon in an operable state. 
Methods of diagnosing eareiiioma of the colon had Improved 
enormously during the last twenty years. In his earlj’ 
practice it was oxtromoly rare to come across a case unless 
there was acute ohstniction, hut now in at least half the 
cases of eareiiioma of the colon that he saw there was no 
obstruction, or such obstruction as existed was relieved 
without operation. The improvement in diagnosis was 
partly due to the use of the sigmoidoscope, jiartly to the 
testing of oeeiilt blood, and verv largely to tho x-nw 
picture and its careful interpretation. The 3* rays wore 
most useful as coiifiriiiatory evidence, though thev should 
never he taken as negativing a positive, diagnosis. Tlie 
general ])ractitioner, however, was coming to realize the 
iinportance of early and thorough inve.stigatioii, and the 
education of the public would follow in due Course. 

Ml*, tv. B. G.MiiiiEL said that among the out-patients at 
St. Jlark’s he had discovered during the last few years 
an .appreeiahle niiriiher of , early carcinomas which' the 
patients themselves had not -.suspected, having come for 
some minor eoiiditioii such as piles. 

^Ir. L. Is. C. NoiiBUiiY cniphiisized the need of routine 
examination of the jiatients. Ho had had two cases of 
niisn.si)ocled carcinoma of the loiver sigmoid in youngish 
patients who came up with a history of recent jiiles. It 
was tempting to assume that that minor cause was the 
Avholo tronhle, hut the sigmoidoscope showed 1111 early 
groirtli, Aiiv youngish patient who gave a recent history 
of pilc.s should he very carefullv examined witli a vioiv to 
the detection of carcinoma.. The general practitioner could 
help more, but the trouble was that the national insiiranco 
system pvaetitioners had such huge lists as to make it 
quite impossible for them to perfonn any rontino 
examination. 

Mr. E. T. C. ISIiDMG.tx tlionglit it very important that the 
patient should not undergo any preparation before a 
sigmoidoscopic c.xamination, since, if the bowel was washed 
out before using tho iiistnimeiit, the whole appearance was 
often changed. Frequently the sigmoidoscope eimhled a 
diagnosis to he made, even in the absence of a skia-wam 


848 MA.T ig, 1928] 


BOTHBIOCEPHALUS INFECTION. 


[ Tnr, Bnmnt 
Mrdical JoCltNAK 


In a tnmouv high up palpation should always he performed, 
.since it might indicate whether induration was present. 

’ Sir AVilliasi WnEEUEB; replying hriefly on the di.seussion, 
touched on the difficulty of learning the suhseq^uent course 
of events after patients had been operated upon. Ono' 
practitioner to whom ho wrote specially about a iiatient 
who had survived for at least four years after operation 
replied that the man had suddenly disappeared. Tho 
speaker did not think a patient should be sent to the 
radiologist without particulars, since a negative report was 
more likely, and the patient might drift on in false 
security. There was value in tho suggestion that prepara- 
tion should not precede an examination with tho sigmoido- 
scope. 


BOTHRIOCEPHALUS INFECTION. 

At tho annual general meetiirg of the Section of Tropical 
Diseases and Parasitology of the Royal Society of jMcdicino 
on May 3rd the president. Professor R. T. Lmper, described 
a crjqitic infection with Dibothriocephahis latus. 

Pi’ofessor Leiper said that it had frequently been 
supposed that bothriocephalus infection in man caused a 
serious typo of pernicious anaemia, but experimental proof 
of this was still lacking. In 1922 a number of experimental 
infections in man with this parasite had been undertaken 
in his department at the London School of Tropical 
Medicine. Two of these were maintained for over three 
months, and tho parasites were then expelled with male 
fern. No appreciable anaemia was produced, but there 
was an eosinophilia which increased to about 15 to 16 per 
cent, after three weeks, and thereafter diminished to about 
2 per cent, for the remaining time. In ono of these cases 
treatment was apparently successful as, altliough no heads 
were recovered, no ova were found in the stool after 
several weeks. In Pebruarj', 1928, tho patient con- 
tracted bacillary dysentery in Egypt, and an examination 
of his stool in connexion wjth this infection disclosed the 
fact that tho tapeworm was still present. Professor 
Leiper thought_ that there was little doubt that this 
was a continuation of tho original infection. An examina- 
tion of the blood showed that tlio eosinophilia was still 
under 2 per cent., while the total count was 7,000,000 red 
and 6,150 white cells. The only clinical symptoms wero 
occasional tenderness in tho epigastrium beneath the gall- 
bladder, and at other times in tho region of tlio umbilicus 
and tho appendix. No migrating segments of tho tape- 
worm had been seen in the stool since treatment, although 
careful search had been made for them. The fact that no 
anaemia had developed during the fivo years of infection 
suggested that there was still some unlniown contributoi-y 
^ctor involved in this so-called bothriocephalus anaemia. 
Professor Leiper also demonstrated sections of the intestine 
of an experimentally infected animal to show that tho fluko 
Jleterophyes IicterOphyes was actually pathogenic and caused 
an e™sion of the mucosa. Finally, he drew attention to 
the fact that bilharzia disease, which had been reported 
from Cyprus many years ago by Dr. G. A. AVilliamson, 
bad recently been found by himself still in tho same 
endemic focus. Four out of seventeen boys examined had 
ova in their urine. A prolonged search for snails disclosed 
Rullinus locally, although not elsewhere on the island 
Cjqirns, geologically, was connected with Asia Minor— not 
with Egjqil^and the recovery of SiiUinvs from various 
other islands in the Mediterranean suggested tint if 
once widespread before the siibmergeuco of tho basin. The 
parasite might have come, to Cj-prus either from Egypt or 
from Syria. • 


Climate and Epidemic Disease. 

Sir Leonaud Rogehs then gave a lantern demonstration 
entitled " Climate and tho incidence of small-pox, plague 
and cholera, and tho forecasting of epidemics.” Hs said 
that small-pox epidemics had gradually decreased as vac- 
cination had increased, and epidemics were now irregular in 
India. The ihcidenco was high in certain States, such as 
Dio Punjab and tlio United Provinces, but very low' in 
Pengal ; ho showed that it varied directly with tlio absolute 
umidity, and not with tho temperature. A low absolute 


humidity was always followed by an epidemic. In England, 
owing to lack of vaccination, tho disease had increased over 
sixtj’fold in the last six years, and hero also tho lowest 
ahsoluto humidity (which was in Docemher) was followed 
by an incrcaso in tho munher of cases in January. Tho 
roverso was also true, and tho lowc.st number of cases was 
in tho month following tlio lowest absolute humidity. Here, 
of course, relative liuiiiidity and ahsoluto humidity wero 
almost equal. Plaguo varied very much in India with 
population, temperatnre, and tho species of rat flea present, 
but Sir Leonard Rogers demonstrated that the epidemics 
depended on tho saturation deficiency, computed from tho 
absolute humidity and tho temperature; when this was low 
plaguo was low in tho following year. Cholera was believed 
a hundred years ago to have spread all over India from a 
focus in Bengal, hut it did not do so now. If the ahsoluto 
humidity was low tho disease died out in the cold weather, 
and widespread cholera was impossible. Tho various out- 
breaks followed tlio rise in absolute humidity. Tho endemio 
areas in India wore Assam, Bihar, South-East India, and 
Bombay, where it had not been absent during tho past 
thirty years. A knowledge of these facts would cnahio 
tho local autlioritics to forecast epidemics and take tho 
necessary steps to stop fairs and pilgrimages, or to make 
arrangements for combating tho infection in time. 


THE KAHN TEST FOR SYPHILIS. , 

At a meeting of the Scottish Branch of tho Medical Society 
■for tho , Study of 'Yenereal Diseases on May 2nd, in tho 
Hall of tho Royal Faculty of Physicians and Surgeons of 
Glasgow, with Dr. W. G. Ceaiik in tho chair. Dr. R. L. 
Kahn gave a lecture on tho clinical aspects of tho Ealm 

reaction. , 

Dr. Kalin first reviewed tho history of serum diagnosis 
of syphilis, touching upon tho discovery' of the Spirochaeta 
pallida % Schaudinn and Hofmann, tho extension of 
knoivledgo about complement fixation by Bordet and 
Gongon, and tlio development of tho Wassorm.ann tert by 
AVassormann, Neisser, and Bruck. Ho then discussed tlio 
early attempts to develop a precipitation test for syphilis, 
bcirinniiig ivith that of Michaelis in 1907, and reviewed tlio 
work of Sachs and Gcorgi, Moinieko, and Dreyor and AAffird. 
Dr Kahn said that his own early studies wore in connexion 
with tho phenomenon of precipitation. Ho showed that 
the requirements for optimum precipitation results when 
evphilitic sonim was mixed with an antigen-saline snspen- 
Sion were as follows: (1) optimum concentration of antigenic 
linnids in the antigen, excessive or deficient concentration 
pi^eventing precipitation; (2) proper physical state of 
antigen suspension; (3) correct quantitative relation 
betn^on scrum and antigen snsponsion ; the number of 
antigen units must not exceed the number of serum units ; 

shaking — ns a probable means in hastening collision 
between tho interacting particles; (5) dilution of the 
mixture of serum and antigen suspension should be a 
minimum. These observations formed the basis of tlio 
Kahn test. The outstanding features of tho test were its 
relative simplicity in performance, the rapidity in obtaining 
results— the test requiring no incubation and being com- 
hleted after shaking the reagents for three minntes-^its 
rclativo economy, its availability in all parts of the world, 
and its application to resoarcb in extemling ^ 

tbo serum diagnosis of syphilis. AVitli regard to tlio 
relation between the Kahn and AAffissermann tests, iAi. 
Kahn claimed that tho interaction between serum aiia 
antigen was tho same in both. The result of this inter- 
action was directly visible in the Kahn test by the 
tion of a precipitate, while in tho AVassermann test, tiie 
result being inr'isible, a special indicator (the baeinolytio 
SA-stem) was employed to render the reaction visible. Too 
Kahn test was described as being highly specific tor 
syphilis and not affected by pathological conditions other 
than syphilis, but it should not supplant careful clinical 
study of each case. Dr. Kahn also discussed such exten- 
sions as tho quantitative serum test, the qualitative and 
quantitativo spinal fluid investigations, and tho more 
sensitivo “ nresumptivo " procedure. 


MAT 19, 19 = 8 ] 


EEVIEWS. 


r Titr.nEmsTX 
L MEDtCAL Jounnij. t/* V 


llcluclus. 

I'UACTURKS OP THE NECK OF THE PEJUIK. 
PiioiKsson riFUltE Bixnr.T is well known as an uclvoeato 
of early surgical inten-ention in the Ivonhnent of fractures 
and somo other injuries. Tn'o of his disciples, Drs. Jacques 
• liEVl'.ur and CnAm.r.a GinonK, surgeon.s to the linsjiilals of 
Paris, have put on record their experiences in the study of 
operations for fracture of the femoral neck, with .special 
reference to the remote results of such proceedings.' Their 
statistics include 83 cases treated with metal screws and 
57 floated with autogenous bone grafts or heterogeneous 
hone pegs, including 7 in which the methods of auto- 
genous graft and metal screw were comhiued. The mor- 
tality of the metal scrciv cases amounted to 13.25 per cent., 
while that in the bone graft cases a'as only 3.5 per cent. 
Tile authors explain that this groat contrast is due to the 
severity of the cases subjected to the metal screw method 
being much greater, and that also these cases were all 
recent, while the others wore not so. In a late series of 
metal screw cases (1920-24) there have been no deaths. As 
to the old bugbear of hypostatic pneumonia and the 
dangers of keeping elderly people in heil, it has hccomo 
tho custom in Professor Deibct's a-ards to keep patients in 
bed for sixty days, so as to make sure of good union 
before allowing walking. 

In tho second part of the book an el.aborate ap]iaratus and 
its application aro described, by tho use of which the posi- 
tion of tho fragments is ascertained under tho x rays. 
This appliance is maintained in place during transit from 
tho ff-ray room and upon tho operating table. It carries 
a guide through which drills and pegs or screws arc 
passed, and the authors claim that with its use they can 
be sure of inserting pegs and scrc'ws in tho correct position 
in tho nock and head of tho femur. The operation thus 
performed is not subcutaneous, for tho great trochanter 
has to be exposed bj- incision through skin, fascia, and 
muscles, but tho joint is not opened except in so far as 
is necessitated by tho passage of a peg into the head. 
From JauuaiT, 1924, to May, 1926, 23 cases were operated 
upon in tins manner with 2 dcath.s — one, aged 50, from 
acute shppiirativo arthritis, and one, aged 67,' from cardio- 
jmlmonary affection fortv-cight hours .after operation. 
Fifteen results aro cla.ssod as -‘. good,” and 6 as “ had,” 
excluding tlie 2 fatal c.ascs. 

This report, if wo may so term it, is a valuable one and 
full of information, and it can be recommended to those 
who are interested in the treatment of this troublesome 
fracture. The apparatus described by the, 11111110105 appears 
to US' to be complicated and clumsy, hut the fact remains 
that ‘in their hands its use has . given good results. 
Evidently much practice, accuracy, skill, and team work are 
required for the successful use of this macliinc. That it 
does not exclude tho risk of sepsis, against which it was 
chielly designed, is .shown by the facts recorded by MM. 
Ecvenf and Girode. ^ If e tliink tiiat in those cases for 
wliicli nailing is thought more suitable than Whitman’s 
abduction method most British surgeons will continue to 
jirefer the open method such as was described by Mr. 
Hey Groves in ins Bradshaw -lAJctuve (Jlyifish Journal of 
Surgery, vol.- 14, 2 j..' 48S), bv which the actual state of 
things can be exposed to the’ eye of the operator, and all 
chance of the interposition 'of soft iiart.s - between the 
fragments is done away with. 


. B.-iDlOGRAPHY OF THE tllllNARY TRACT. 

So majiy advances have been made since the publication of 
Hr. .11 . 1. Beaasch’s work on Urogrnpliy- ton years ago 
that bis second edition, prejiarcd in collaboration with I)r. 
B. H. Hagek, is to all intents and purjioses a new book. 
By the eominehonsive title of “ nrogi’aphy ” is meant 


all methods of investigating the urinaiy tract by x rays 
after distending Hk- lumen with opaque llnid. At one 
linio this method of study was confined to the pelvis and 
calyces of the kidney, hut it has now been used tlironghout 
the whole’ of the urinary .system. Dr. Braascli’s jiosition 
.at the Mayo Clinic has afforded him unique opportunitie.s 
for the employment of nrogiaqihy, and it may bo said 
without hesitation that tho collection of jdates jiuhlishcd 
in his new work is the finest that wo have seen. 

In tho chapter tfoaling with the normal renal pelvis as 
many as ninety-nine excellent pyclogvams have been pro- 
duced, .showing every variety of kidney that may ho con- . 
sidcred to lie within the range of normality. This large 
collection allows the reader to appreciate tho various 
forms thopiormnl iicivis may take. Since tho chief danger 
in tlic interpretation of a pyelogram lies in the mistaking 
of a variation of tho normal kidney for an abnormality, 
the reproduction of this excellent collection is invaluable. 
Following the 'section on tho normal kidney are chapters 
dealing with abnormalities of position, dilatation from 
obstruction, dilatation of the pelvis and ureter resulting 
from inllammation, renal and ureteral calculi, renal 
tumours, and congenital abnormalities. All of them aro 
illustrated with excellent idatcs, and in tho text sound 
advice is given on the subject of diagnosis. Chaiitcr xi 
i.s devoted to cystography. The author has found, as have 
many other urologists, that the use of solutions of tho 
halogens is often followed by intense pain, . and he has 
therefore omjiloycd, for the purpose of distending the 
bladder, a 5 ]ier cent, emulsion of silver iodide. This not 
only serves as an oxcollont opaque medium, hut has tho 
advantage of exerting' a soothing ahlise])tic action on an 
inflamed hhuldor. Uo has found cystography of use in 
tho diagnosis of diverticula, new growths, and jirostatic 
enlargement. For tlic making of nrethrograms he employs 
the .same solution of silver iodide, jilacing the patient in 
tho dorso-latoral position and tilting the pelvis to ' an 
angle of 45 degrees with the horizontal. Tho urethra is 
distended by means of a syringe, and tlie opaque solution 
is injected during the entire time of exposure. This is 
necessary, since otherwise the jiosterior urethra will not 
ho shown on the iilato, owing to the rapid escape of fluid 
into tho bladder. 

In conclusion it may he said that this is the most com- 
plete work on the subject that has yet been )niblislied in 
the English hangnage. The illustrations have been cbo.son 
from wiiat must be one of the finest collections of ijyejo- 
granis at the command of any single urologist, and’ dis- 
crimination and a nice sense of proportion have been 
shown in deciding on those which should be reproduced. 
The text, which deals chiefly with the interpretation of 
the iilatcs, is written in clear and simple language, so .th.at 
the author’s reasons for. arriving at his diagnosis are 
easily appreciated. Cci-tain more recent allied methods of 
diagnosis, such as pyeloseopy, have not hcon included 
within tlic scojie of the work, hut otherwise it m,ay be 
regarded as complete. It is unfortunate that the cort of 
reproducing so many plates has 'forced the i>ub!isher.s to 
make the price of the work so high as it is. 


i of Opg Fraclnrcs ihi Col d,, EtOjmr, Pav Aacqoeb Levaiif 

pt Ch. GliOflc. Pans; Mas6on el Cio. (Rov. 8vo, pp. US; 165 nSiires 
30 fr. sani ma]oration.) ' ' ‘ 

XTrngrarhu. By WiUiam F. Braasch. B.S., Jl.D.. F.A.C.S In 
Mllaboration with Benjamin jj. 71 .,^;,^. B.S.. 3I.D. .Second edition 
^viRcl ami cnlaiged. Philadelphia and London ; IV. B. Saunders 
Compoiiy. (Roy. Svo, pp. 530:'753 ngiifft. 60,. net.) • 


AIE'THODS OF CIrINICAL DIAGNOSIS. 

In choosing the volumes which are to form his own inti- 
mate libraiy for immediate and ready reference, it is' of 
Uie utmost importance for the student and the recently 
qualified man to includo at least one of those handy 
little books .which deal with the bedrock elements of jiro- 
fe.ssionul knowledge,_ without which the most comprehensive 
disi>Iay of textbooks is but as the sounding brass and the 
tinkling cymbal. In extending a hearty welcome to the 
latest of these. The HethoJs of Clinical Diagnositt,^ bv 
Drs. A. G. Gibson and 'iV. T. Collier, it is safe to 
predict for it a siicedy jjoinilarity. The antiiors wiselv 
remark that more errors are due to the omission of some 
jiart of the examination of a patient tlian to luisintev- 
jiretation of the signs discovered, and throughout the book 
emphasis is laid on the systematic ohsen-ation of every 

r The JIoOioils of Clinical Diaijnoti». By Alc.vandcr Georuc Gibson 
M.D-, r.R.C.P.. ami William Tregonwell Collier, JLD., SI.R.C P^ London- 
E. Arnold and Co. (Cr. SvO. pp. riii -a 3S3 115 figures. I2s.6d'net) 


850 May 19 , 1928 ] 


REVIEWS. 


[ Tn* nRin>t« 
2Tr.DICAL JutEXit, 


detail so that even tho slightest sign of abnormality may 
not he missed. 

, The book follows the lines usually adopted in works of 
this kind. Commencing with an account of tho general 
methods of examination commonly employed, a chapter is 
devoted to the examination of the regions of tho body 
from scalp to sole. Tho systems are then discussed 
seriatim, special chapters being devoted to tho examina- 
tion of children and to clinical pathology. Tho book is 
packed with useful information presented in a lucid and 
interesting manner. Throughout attention is focused on 
.clinical observation, instrumental and laboratory investiga- 
tions being very properly shown to be supijlcmcntary to 
and never to be substituted for a thorough examination of 
tho patient himself. At .the same time all tho chemical 
methods in general everyday use, such as tho fractional 
test-meal, tests of renal efficiency, urine analysis, and so 
forth, are briefly but clearly described. 

It is surprising what a wealth of information tho 
authors have compressed within 398 pages, and that they 
should have done so in such a readable manner is proof 
that they have accomplished what they' set out to perfonn. 
Tho make-up of this book is a great advance upon that 
of some, at least, of its popidar prototypes. The printing 
is clear and the diagrams are adequate. A work such 
as this will be constantly referred to not only by the 
student, but by the man in busy practice. Drs. Gibson and 
Collier are to bo congratulated upon producing a volume 
worthy of tho school which Sir William Osier did so much 
to invigorate and revitalize. 


THE MEDICAL ANNUAL, 1928. 

The Medical Annual'’ is an old and tried friend and its 
reappearance is always welcome; the forty-sixth issue, 
with its array of ablo contributors and its wealth of prac- 
tical information, fulfils our expectations. Research is no 
longer confined to the laboratory ; all clinical workers have 
become imbued with its spirit. Although 1927 was not 
marked by the discovei'y of any outstanding specific remedy, 
there has been much steady progress. In medicine the 
liver treatment of pernicious anaemia has occupied a great 
deal of attention during tho past year, and two papers 
appear on this subject in the volume \mder review; one of 
them deals with the principles on which tho treatment is 
based and their significance in relation to the prognosis and 
pathogenesis of this disease. An interesting summaiy of 
tho malarial and other microbic methods in pyrexial therapy 
is given. Alcoholism is dealt with by two writers — in rela- 
tion to tests for drunkenness and to the treatment of chronic 
inebriety— and there are articles on the value of antimony 
in kala-azar and of chaulraoogra oil in leprosy. The specific 
serum for employment in acute poliomyelitis, prepared by 
the Pasteur Institute of Paris, and the treatment of epilepsy 
aie discussed; ''^lile a group of papers deals with epidemic 
encephalitis. There is a careful review of present 
knowledge about vitamins. Among newer drugs, cardiazol, 
novasurol, and ouabain are considered in relation to their 
action on circulatory failure. Students of preventive 
medicino will find much of interest in the papere on the 
reduction of infantile mortality, on the etiology of 
rheumatic fever, on isolation with quarantine in pneumonia 
and on epidemics in boarding schools. Two modern methods 
of treating gonorrhoea are deserihed : by intra-urethral and 
subcutaneous injections of toxin-free gonococcal prepara- 
tions, and by irrigations with mercurochrome and glucose. 
The suggestions for the treatment of cases of gonorrhoea 
and syphilis on the lines followed at St. Thomas’s Hospital 
deserve attention. 

Decent progress in surgery is reflected in papers dealing 
with toxic symptoms in appendicitis and their treatment 
with anti-gas-gangreno serum, the importance of the CO, 
content of tho blood in abdominal surgery, prolapse of 
the rectum, cerebral abscess, oesophageal spasm, and intus- 
susceptions in children. A case is recorded in which the 
abdominal aorta was successfully ligatured. A paper 
oil tbo treatment of sprains and synovitis should prove of 


■ < riij JUiJicat Annual. Forty-sixth year. 

V : Simpkin. Jrarshall, Ltd. 19; 

1-0 nsurc... 53 plates, ros. net.) 


Bristol : J. Wrigbt and Sons, 
(Demy 8vo, pp. xeix + 6M; 


value to tho general practitioner; and tho articles on the 
isolation of an organism in cases of trachoma, on tho rela- 
tion of foreign proteins to conjunctival spring catarrh, and 
on tho oifcct of tho cinema on the eyes will bo of interest to 
tho oplithalniologist. Jlaiiy obstetrical and gynaecological 
paper-s appear, among which may ho mentioned tlioso on 
genital prolap.se, sterility, and tho caro of tho pregnant 
woman. Various anaesthetics and anao.sthetic measures are 
described, and tho series of papers on radiotherapy contains 
much helpful information. Scattered throughout tho hook 
will bo found many practical notes on diagnostic methods, 
such ns liver function tests and cholecystography, and a 
section is given to tho pathology of “ late ” rickets. 

Tho usefulness of tho Annual is much increased by well- 
reproduced diagrams and plates, and by tho inclusion of 
items of general information, such as lists of new drugs and 
medical and surgical appliances; books of tho year and 
medical nnd scientific periodicals; a directory of sanatoriums, 
spn.s, and other institutions; and an official nnd medical 
trades directory. Of tho work as a whole wo may say that 
tho editors,' Dr. Carey Coombs and Mr. Rcndlo Short, have 
onco more performed a difficult task with skill and 
judgement. 


FOUR TEXTBOOKS OF BACTERIOLOGY. 

Dn. Wjiitiiv’.'? hook Medical Sacferioloffij" is a conveniently 
sized handbook on medical laboratory methods. A short 
description is given in tho first part of tho hook of all tho 
pathogenic bacteria nnd protozoa and tho commoner 
helminths, and in tho second part, devoted to applied 
bactoriologj’, tho author discusses tho' uso of bacterial 
preparations, tlio collection and examination of specimens, 
laboratorj’ aids in tbo diagnosis and treatment of indi- 
vidual diseases, and the bacteriologj' of water, milk, and 
food. For tbo student this volnmo lias tbo merit of being 
neither too detailed nor too condensed, and for the regular 
laboratory worker its practical outlook should ensure it 
a prominent place of reference on tho bookshelf. 

"Wo have beforo us an old copy of tho fifth edition of 
Zinsser’s Text Booh of bacteriology, which appeared in 
1922, and also tho sixth edition of 1927, nnd wo notice 
many additions in tho present edition,® notably in the now 
section on tbo pathogenic protozoa and in tho sections 
dealing with immunologjL Substantial alterations have 
been made in the chapters on pneumonia and streptococcus 
diseases; -a separate section dealing with scarlet fever has' 
been inserted ; tlie chapters on tho filterable virus have been 
completely rewritten and rearranged. These are only a 
few of the changes. We notice that in every chapter of 
this long and carefully documented book the author has 
persevered in bis original plan of providing a fairly full 
account of tho present state of our knowledge of the 
bacteriology of the infectious diseases, with critical 
reference to many modern developments of theory and 
technique. 

Professor Fonn’s Text-Book of Bacteriology'' is an 
example of an attempt to give a complete and accurate 
description of the microbes commonly encountered in 
routine bacteriological work in medicine, comparative 
pathology, hygiene, and public health. But tho impartial 
cataloguing of this host of microscopic creatures is almost 
a superhuman task, and the author has been forced to 
give prominence to the human pathogenic bacteria and 
. the problems they create, and to give only a brief descrip- 
tion to all other bacteria.' Although' tho book begins by 
aiq)roaching bacteriology as an independent science, the 
reader is conscious of a change of direction as bo proceeds 
through tho sections of general and systematic bacteriology 
to those which deal with infection and immunity. But 

^Medical Baolcriologu : Dcscriptifc and Applied, including Elementary 
Belminthoiogn. By L. E. H. Whitby, M.D.Catnb., M.R.C.P.Lond., D.P.H,. 
London : J. and A. Churchill. 1928. (5 + 8), pp. vH + 320 ; 74 figures. 
lOs, fid.) 

‘ A Text Book of Bacteriology. By Hans Zinsser, M.D. W’ith n section 
on pathogenic protozoa by E. E. Tyzzer, 3I.D. Sixth edition, rewritt^, 
revised, and reset. New York nnd London : D. Appleton and Co. 1927- 
(Med. 8vo, pp. XX + 1053 : 181 figures. 303. net.) 

e Text-Book of Bacteriology. By W’iiliam IV, Ford. Philadclphin nnd 
London : W. B. Saunders Company. 1927. (Roy- 8vo,‘ pp. 1069 ; 186 figures, 
9 plates. 37s. 6d. net.) 





Tne Dumw 
VcbiCALSoOMUA 


852 Mai 19 1928J 


i-’j 


CONFERENCE ON RHEUMATIC DISEASES. 


BATH, May lOth and 11th, 1928. 


The Conference on Rheumatic Diseases, which took place at 
Bath on Thursday and Friday, May 10th and 11th, proved 
the success which its hard-working promoters deserved. It 
was attended by a very large ijroportion of those whoso 
names have been identified with recent investigations into 
tho subject, also by many delegates from local authorities, 
and it attracted some distinguished visitors from Prance, 
Italy, Belgium, Holland, and Denmark. Tho medieal pro- 
fession in Bath supported it in largo numbers, and tho fact 
that the annual meeting of tho Balneological Section of tho 
Royal Society of- Medicine was held in that city on the day 
following the Conference helped to swell the attendance. 
At no period of tho meeting, not even at tho wane of tho 
sessions, were there fewer than 250 present. 

The president was Sir George Newman, Chief Medical 
Officer of tho Ministry of Health, but each of tho three 
sessions — on social aspects, on causation, and on treatment — 
had its separate chairman — namely. Lord Dawson of Penn, 
and the two Regius Professors, Sir Humphry Rollcston, Bt., 
and Sir Farquhar Buzzard respectively. During tho day 
and a half of tho meeting thirty communications woro pre- 
sented. Their authors were in most cases compelled to 
inako a severe condensation — a task evidently neither easy 
nor congenial — but only so could time bo allotted for general 
discussion. Even as it was, tho great mass of written 
material, as well as tho .shortness of time available, rather 
hindered that free interchango of views and experience 
which the word “conference ” implies. The Organization 
Committee had taken the greatest pains for months past in 
planning every detail, with the result that all tho papers 
were printed in advance and were available for distribu- 
tion, and will be published subsequently in a volume. 

Tho city of Bath was hospitality itself. Tho only shadow 
oil the occasion was the Ulness of the Mayor (Alderman 
Cedric Chivers), who had taken a most generous share in 
facilitating the Conference. In his absence the Deputy 
Mayor (Mr. C. H. Hacker) expressed tho local welcome, 
to which Sir George Newman, as president, replied. Ho 
mentioned that the Minister of Health first of all had been 
invited to preside, but found himself unable to do so owing 
to numerous political engagements; when in duo course 
tho invitation was transferred to the Chief Medical Officer 
of tho Ministry Mr. Chamberlain expressed tho earnest wish 
that ho (Sir George) should attend, and state with what 
interest and expectation the Minister viewed the occasion. 


Presidential Introduction: The Frohlem Stated 
In a brief presidential address Sir Geouge Newman sait 
that the Conference had assembled to consider the nature 
of the campaign to bo organized for tho conquest or con- 
trol of rheumatism The urgency of this matter had beor 
niado manifest by tho advance of knowledge of the hetero 
geneous group of, morbid jojnt conditions and by the dats 
- furnished for the first time by the school medical servici 
and tho health insurance system. It was now known thai 
acuto rheumatism of children was sowing seeds of a growinc 
harvest of disease of the heart and nervous system anc 
that tho chronic forms of rheumatism were serioush 
crippling many hundreds of thousands of people. Th< 
disease was a drag on industry, a heavy handicap on tin 
Worker, a source of oppressive financial loss to the State 
and a potent cause of excessive mortality and ill health 
Tho main difficulties were three: (1) neither the "respec 
tiyo relation of tho varied forms of rheumatism to eacl 
other, nor their distribution over the world generally o: 
in this countr 3 -, could as yet be exactly defined; (2) tin 
Cuusa causuiis of this morbid group was not known witl 


certainty; (3) tho varied medical experience was not yet 
in working accord as . to tho best means of treatment.- 
Happily advances were being niado in all three directions, 
but they awaited integration. “In treatment some swear 
bj' heat and light, and others hy water, somo by massage 
and manipulation, and others bj' rest, and some, rightly 
enough, swear not at all, but proceed from case to case 
with tont.ativo empiricism.” Tho hj-potlicsis which at 
present held tho field was that acute rheumatism was tho 
reaction of tho human body to tho presence of tho Strepto- 
coccus .viridans, possibly a constant habitant of tho bod}’,- 
in .which event attention must bo concentrated on tho 
conditions, circumstances, or predispositions, external or 
internal, which induced it to assume an activity resulting 
in rheumatic fever. Speaking broadly, tho attempt must 
bo made steadily to improve tho personal and environ- 
montal hygiene of childhood, a closer and more vigilant 
supervision must bo exercised over susccptiblo children hy 
tho infant welfare and school medical services, and the 
methods of diagnosis and treatment of those found suffering 
from tho beginnings of this disoaso must bo organized. In 
chronic rhoumatism of the adult thero must bo further 
intensive and comprehensive investigation, not only in tho, 
laboratory, but at tho bedside, and oven in tho factorj- and 
workshop. As in aciit-c rheumatism, so here research was 
needed into tho social and causative aspects, and expe- 
rieneo of therapeutic measures must bo pooled. Not only 
must thero bo medical co-operation, but also the co-opera- 
tior of contributory public agencies, such as social, health, 
and hospital services.. Ho closed" by giving somo general 
counsel to those suffering from • any degree or form of 
chronic rheumatism, first, to seek medical advice and submit’ 
to tho removal of possible sources of infection in their 
owti bodies; secondly, personal hygiene and istricl modera- 
tion and selection in food and drink, exercise, and so 
forth; thirdly, vigilance in avoiding predisposing con- 
ditions, such ns dampness and chill, unsuitable clothing,- 
excessive use, misuse, or disuse of tho stricken joints, or a 
clogged alimentary system. 

Social Aspects. 

The Cost to the Nation. 

Sir WALTEii S'. Kinneaii, Controller of Health and Pen-, 
sion Insurance, Ministry of Health, opened tho Social 
Aspects session by an estimate of the cost to the country 
of industrial rheumatism. Ho applied to . tho most recent 
-sickness experience of insured persons— that for 1927=— the 
conclusions ■ of tho Ministry’s, committeo bn the , incidence 
of rheumatic diseases, which reported in 1924. ,, Tho com- 
mittee found that approximately one-sixth of tho .total 
period for which siclcnes's and disablement benefit was paid , 
to men (one-sevehth in the case of women) was due to 
rhouraatio diseases. In 1927 such total benefit in Great 
Britain ■ amounted to £20,000,000, representing 34,000,000 
weeks’ incapacity. Making certain adjustments, he 
thought it probable that tho incapacity duo to rheumatism 
amounted to 5,500,000 weeks, with an approximate dis- 
bursement under tho insurance scheme of £5,000,000. To 
this must bo 'added about £12,000,000 as tho amount, of 
wa<=e 3 lost to insured persons through rheumatism, and 
even this total of £17,000,000 did not include anything for 
the cost of medical treatment of sufferers not totally 
incapable of work, the cost of nursing in bad cases, or the 
necessary institutional treatment, nor did it cover fully 
persons over 70, or make any allowance for dependants of 
insured persons. ; 

Organization of Medical Treatment. 

Dr. H.- B. BnACKENDUiiY, Chairman of Council, British' 
Medical Association, spoke on the organization of medical 
treatment of industrial rheumatism. Ho described such 
treatment as including the elimination of infected foci, the, 



Mat- 19, 


COKPEUENCE ON BIIEUilATIC DISEASES. 


' r TncBRiTisi* " 
Lilr.DICXl, JoUB5AI> 


n.lininistratiou of ilnigs, nml tlio uso of various physical 
agencies or methods. The luolitem of organmation was to 
provide treatment for tlioso unahlo to provide it for them- 
selves, without any waste on unsuitablo cases, or unucccs- 
sarv ti’uYcUiug or sujK'rfluous cqviipincnt, but uith the 
greatest nvailublo knowledge, experience, and skill placed 
at tiie service, of tho patients, and witli every possible 
facility for education and rcscareli. After tracing tho 
attempts nmdo in Germany and Holland to secure this 
organization, lie saiil that this etfort he was speaking 
jiriiicipallv of tho German effort — -did' not afford the guiil- 
aiiec which might have been exiiected. ^lost of it apjicared 
to bo a little haphazard; there did not .seem to be that 
careful selection of suitable casc.s, considered prescription 
of appropriate treatment, or adeejuate supervision of treat- 
ment given which was so desirable. Any organized scheme 
must seciir'o tho goodwill of the medical profession and 
of tho approved societies. ■Unfortuiiately, under prc.scnt 
conditions in this country, not every insured person was 
entitled to specialist and ancillary help of the required 
typo. This was unfortunate, and the medical profe.ssion 
was almost univei-sally in agreement with the report of the 
Boyal Commission that spoeiaiist advice and treatment of 
all kinds should become part of statutory benefit ns soon 
as ])ossible, and he available for all insured pcr.sons and 
administered by some responsible public body. Two practical 
schemes, compatible with the jirovisions of the amending 
Insurance Bill before Parliament hud now been submitted 
to the profession and the public. One was the out- 
patient clinic to he est.nblisbcd in London under the au.s])ices 
of the British lied Cross Society, and the other the 
scheme for spa treatment of insured |icrsons under the 
auspices of tho British Spa Eederation. The latter had 
received, certain conditions being accepted, the approval 
of the Council of tho British Medical Association, it was 
to be hoped ‘that both these seliemes would hcconie operative, 
and, indeed, that they would be united, hut they must 
conform to certain requirements if they were to receive the 
hearty support of the medical profession — namely, that no 
patient should he treated except on the rceommeiidation 
of a registered medical praclitiouer, that any patient who 
could easily obtain Uie requisite treatment for himself 
should be refused, that where conditions made such a course 
feasible the possibility of a patient obtaining medicnl 
advice at the private consulting room of a specialist in.stoad 
of an institution should he provided, and that there should 
be suitable opportunity for practitioners to obseiwe and 
obtain experience of tbc methods cniiiloyed and their 
results. One consideration wbieli Dr. Brackenhury stressed 
was the need for co-operation of the vecomnicnding practi- 
tioner and the specialist. Org.aniKed medical treatment for 
industrial rheumatism, both at spas and at suitably equipped 
clinics in the larger towns, should ])rove a sound national 
aiid^ economic investment, but if di.sappoiiitmeiit was to be 
avoided something more than zeal and optimism were 
leqmied; the problem to be solved was primarilv one of 
medical science, and not of pliilantliropv. Tiie main value 
of an organized scheme or institution would consist in the 
improved facilities and opportiinitics it would afford for 
that clinical and pathological observation and rc.search 
ulueh was so neces.sary for further success in combating 
an obstinate national scourge. 


Continental Experience. 

the last speaker bad made a special mention of tli 
pioneer ont-p.ntient clinic for phvsical treatment oiienei 
in Amsterdam 111 1905, .nml its founder and director 
^“'lowed with some remarks on tli 
pioblem in Holland. After a statistical leview, bis geiicrf 
conclusions were that the number of eases of rheumati 
fever, not only' in children, but in adults, was relative) 
sm.nll in Holland, also that the number of cases of rheuni 
atoid arthritis ivas smaller than in England. He mentione 
that the Dutch Society for Combating Rheumatism, foundo 
year, was collecting statistical d.nta on the incideiie 
of rbeum.ntic dise.nses, and that with regard to nomoncla 
ture. which was the first problem to be tackled, the Soviet 
had adopted the noinenclatnre of the British Jlinistrv 0 
Health as set forth in its report in 1924. As secretaA- 0 
the International Committee on Rheumatism also Dr Va 


Brecnicii had remarked with sati.sfactioii that several other 
eountric.s had adopted this same nomenclature. 

Dr. H.\n.s J.yNSES of Cojioiihagoii gave some account of 
the various groups of cases treated annually in tlio pliysio- 
thern|>eutic department of tho Bispebjerg Hospital. He 
dilTorentiati'd betweou primary chronic progressive poly- 
arthritis and .secondary chronic rheumatic polyarthritis, as 
did His and other Geriiian authors, though lie knew it 
iiiiglil be very di/Tieiilt' to divide tlioih. In his opinion 
progressive polyarthritis — ^real rhciimatoid arthritis — was a 
disease siii peiirri.i, probably of endocrine nature, while 
secondary chronic rhciim.atic iiolyartliritis was simply the 
result of" rheumatic fewer, often of repeated attacks, and 
certainly of infective nature. 

Ell rironmcnf and Incidence. 

Dr. Rncix.iiD Milobii, who was honorary sccrot.oi-y of 
the British Mcdic.al Associ.ition Subcommittee on Bheum- 
.atic Hc.art Disease in Children, spoke on the influence of 
environment 011 rhoiiniatie infection in childhood. Juvenile 
rheumatism, he said, was massed amongst the children of 
the poor and practically absent from the cliildren of tho 
well-to-do. This class incidence was so clear that until tho 
cxpl.aiiation of it was known tho large-scale production 
of the disease could not be understood. It was not due 
to case-to-casc infection. Tlio general trend of medical 
opinion was in favour of regarding it as an enrironniental 
disease. So close was the association betweqn yuvenilo 
rheumatism and tonsillar disease that it seemed as though 
the environmental factors at work must to some extent 
centre round the production of diseased infected tonsils. 
One of the rc.s sons for tho immunity to rheumatism amongst 
well-to-do chiidron was tho presont-dny practice of early 
and complete removal of tho tonsils. It was probably not 
correct to regard juvenile rheumatism as a poverty disease, 
for there was evidence that its frequency did, not neces- 
sarily increase as the lower depths of poverty were reached. 
Poverty w.as a predisposing cause of immense importance, 
i but some otlier factor, a common concomitant of poverty; 
i must .also be .at work. Dr. Miller believed that the environ- 
mental factor of chief importance, combined with poverty, 
was damp dwellings. Tlicsc had a real and particular 
connexion witli the dcvelojiment of juvenile rheumatism. 
Rbsidonco in damp dwellings governed to some extent the 
distribution of the disease witliin the rheumatic stratum 
of society, and dolerniined in many cases why one family 
sulfcrcd and another of the same grade of poverty escaped. 

Tlio closing paper of tho session was read by Dr. J. 
Amson Gi,ovrji of tbc Ministn- of He<olth, who "spoke on 
tho general incidence of rheumatic diseases. He accepted 
an estimate of 5 per cent, as the proportion of patients 
in genera] practice wliose ills might be classified under the 
heading “ rheumatic.” He even ventured on an estimate 
of the number and species of rheumatic patients seen bv 
an insurance practitioner with a list of 2,000 (1,000 male's 
and 1,000 females), all of them persons over 16 yeai-s of 
age. Such a .practitioner during the year would "see, for 
all diseases and accidents, 930 of the "persons on his list, 
and of these some 55 (33 males and 22 females) would be 
suffering from rheumatic disease, of whom 9, if the law of 
averages held good, might be expected to belong to the 
acute Thciimatic group, 30 to tho fihrositis group, and the 
remainder to the chronic arthritis group. Tlie incidence of 
acute ^rheumatism (‘rheumatic fever) was one of the bright' 
spots in the present position of rheumatic diseases. It was 
undoubtedly declining; in the Ro 3 ’al Navy, for example, it 
had fallen roarkedlv. In exhibiting a table illustrating the 
occupational incidence Dr. Glover drew attention to tho 
extraoi’din.aiy incidence of all forms of rheumatic disease, 
but especially osteo-artliritis, among workers in metals. 
I\ ith regard to chronic conditions, whose importance was 
one of tile many startling silhouettes of State medicine 
revealed hr tlio financial .searchliglit of national insurance, 
he quoted some figures from hospitals which showed, what 
was generally agreed, that the large general hospitals 
worked under such severe pressure from more acute cases 
that they could not admit more than the smallest frine'o of 
eases of chronic arthritis. Further institutional provtsion 
was jiecessai-y for dealing with chronic arthritis, in which 
disease there was a stage when the patient’s admission to 


854 May 19, 1928] 


CONFEBENCB ON RHEUMATIC DISEASES. 


f Tl«V. JJBJTHII 
MzDICAL JoCBMlC. 


an institution, u-ith tlie range of diagnostic inctliod and 
treatment there available, would ho veiy advantageous. 

Dr. R. 6, Gordon of Bath said that no disease could 
he attributed to ouo etiological factor, and perhaps this 
platitude was more applicable .to the chronic rheumatic 
diseases than to most others. No one could doubt that 
in all forms of fihrositis, infective arthritis, and inoro 
indirectly osteo-arthritis, - faulty elimination played an 
essential part, and it might he that too little attention 
had been paid to intrinsic poisoning, resrilting from failure 
by the patient to get rid of his waste pi'oducls of meta- 
bolism. In almost every case the skin was at fault in 
some way or other, and ho specially' invited attention to 
certain factors making for inefficiency in the prope.r secre- 
tion of sweat. These were, first, a humid, cold atmo- 
sphere; secondly, fatigue (in which skin action was 
notoriously upset, excessive sweats occurring alternately 
with periods of complete inaction), and thirdiv, emotional 
strain, for it was a commonplace that emotions aflectcd 
the skin — for example, the sweat of terror and the dry 
skin of anxiety, an effect probably brought about almost 
entirely through endocrine, and especially thyroid, activity. 
It would do no harm when dealing with these rheumatic 
conditions to bear in mind the effects of climate, f.atiguc, 
and emotional str-i.in, especially worry and depression-. , 

Lord Dawson of Penn, who presided over this session, 
deprecated the allusion to rheumatism as a “ poverty 
disease,” because this carried with it the implication that 
if the poverty were removed the disease also would 'dis- 
appear. But the incidence of -the disease was not in pro- 
portion to the poverty. It was found, for example, in the 
families, of railwaymen and postmen, . who, though not 
affluent, could not he classified as poor. It was the domestic 
environment which needed altering. Ho vontui'ed to say 
that the improvement in the housing' of the working 
class, better ventilated homes, more sufficient and scnsihlo 
clothing, a better ordered dietary, would all play a larger 
part than the more question of poverty. Recreation, too, 
ho i-egardcd as extremely important — not merely time for 
recreation, but its right employment. It was not so much 
more recreation that was needed as more knowledge of how 
to use it. Ill this connexion he thought that whilo tho 
securing of the eight-hour day had been invaluable to tho 
worker, there was some disadvantage in makiii'' it too 
rigid. He thought it would be well if, while maintaining 
the average, tho worker could on certain days woik for nine 
or perhaps even ten hours, so that at the end of the week 
~!ie--iw>uj^ have an accnmulated leisure which would be 
available for recreation really worth while. This redis-^ 
tvilnitioii of hours of work and recreation might be recom- 
mended to the serious attention of tliose contiolling indus- 
try. Lord Dawson added that some of the trouhles of 
1 heuinatisni which were noted with advancing years were 
to a largo extent an expression of strain— the over-use or 
unbalanced use of certain body structures. When there 
was strain there was increased liability to infection. Damp 
and cold were the precipitating causes, hut in tho back- 
ground the determining factor was fatigue, often lone 
coutiniiecl. ^ 


The C.rusATioN or Rheumatism, 

Tlio second session was presided over by Sir Hojiphui 
Rodleston, who, in some brief opening remarks, said thai 
tho ■ terra “ rheumatic diseases ” was convenient i| 
uiiihrella-like, as it included those acute and chronii 
infections, rheumatic fever and the rheumatoid groups 
and it - might ho well to raise again the question ol 
•the relation of these groups to each other, and to cbnsidei 
v.hether there were any connecting links or common etio- 
logical factors. At ono end of the scale there was acute 
rheumatic fever; which might, mainly or exclusively attaci 
tho heart, and -when it had not done so was remarknbh 
amenable to salicylates; at the other end, there was osteo- 
arthritis, largely if- not entircl3’ a degenerative lesion 
which did not. induce cardiac lesions and did not Tesponc 
to salicylate treatment. Between these two extremes then 
«as a chain of gradual transitions. The characteristh 
IcEion of rheumatic fever was the formation of nodules. 

subentaneous ti.ssues, suhmiliary in the heart 
ous nodules had often been found in rheumatoic 


.-irthritis and ostco-ar'thritis, hut ho' had ' not found any 
ovideiico that the siihniiliary nodules occurred in tlio licai t 
in chronic rheiiiiialisiii. b'ihrositis, tho noii-arthritic form 
of chronic rhenmatism, was also nccoiiijianicd by nodulo 
fornintioii. These thickenings wore riot so cliaractcristic 
liiitologieally as the rheumatic nodule, hut Dr. ■ Hadficld 
would presently c.xhibit to the Confereiico microscopical 
sections of panniculitis demonstrating endaiteritis, and st 
shoiyiiig evidence of a blood-borne agent, and at any rate 
sonic rescuihliiiicc to tlic rhenimitic iiodiilo. Panniculitis,' 
like fibro.sitis iiiid Jihroniyositi.s, might ho duo to various 
causes, and possibly it was stretching a )ioiiit to conclato 
its fihrotic thickenings with siihniiliary nodules. As to 
infective factors. Sir Ilimiplirj' RoIIo.stoii said that tlio 
much-debated streptococcal nature of acute rhciiiiuitisiii, 
in S2)!to of criticism, had steadily gained ground. It might 
ho aigiicd that the various niemhors of the family of 
I'hoiiniatic diso.T.scs were streptococcal in origin, and that' 
their clinical and striictural differences depended on varia- 
tions in the “ seed ” and inborn or acquired dilfeieiiccs in' 
tho “soil” — iiamclj', tho constitutional, metabolic, ’ and 
endocrine factors. On tho whole, the speaker concluded 
tliat it might be roasoiiahle to suggest that varying degrees; 
of diminished constitutional rcsistanco of tho fibrous tissui-s 
or of sensitization to infection on the ono hand, and on the; 
other the action of different kinds of streiitococci, might' 
ex2>lain tho dilferciit clinical manifestations seen' among 
the diseases grouped for convcnienco under the heading 
“ rheumatic.” 

Predisposing Faefors in Childhood. 

Professor WinniED Vini.vo of Leeds University brought 
forward the thesis that tho lai-gc majority of rheumatic' 
children had a liistoi-y of health defect for.moiitlis or years 
before they Idevclopod their first frank -rheumatic attack, 
that their health defect, if carried on into the rheumatic 
))oriod, did much to colour the complete picture of tho 
rheumatic child, and that it bore a very intimate relation- 
ship to the clinical rheumatic aflcction which followed. 
It was a relationship which might bo much more than, 
sav, the relationship between being “run doivn ” and the 
development of an attack of infhieni'.a. In his opinion' 
the iirc-rlieumatic child was at least a potential rhcuiiiatio 
child, jierluips. a child sown already with .the seeds of- 
rlicuiiiatism; To his mind this rolatioiisliip .seemed clear 
from the frequeiic}- with which tho iiroceding health defect 
occurred, the peculiar and significant repetition of tho 
same grou]) of symptoms, and the fact that so iiiaiij' of 
I these symptoms, such as noi-vous instability and limb jiaiiis, 

- had in the past been rooognized as pointing to the 
rlieiimatic child. That a toxaemia was in cxisleuco, and 
that it was bacterial in origin, few would deny. As to 
where this toxaemia arose, tho throat suggested itself, but 
this was not a complete explanation; the relationship of' 
abnorraarstates of tho intestinal tract to tho pre-i'liouiiiatic' 
debility- had to he considered. Professor Viuiiig bolievciL 
that the child’s digestive system was a factor in the etiology 
of rheumatism which had failed to receive adequate i-oi-og- 
nition. Rheumatism in childhood was ]irimarily a disease 
based upon a nutritional distnrhaiice brought .about by a 
prolonged dietetic deficiency, either in vitamin B or in . 
protein in coiijiiiiction with a relative excess of carbo- 
hydrate, or possibly both these factors. 'While the brunt 
of tho defect fell upon the aliineiitary tract, yet the .results 
■ were 'widespread, and produced loss of tone in all the 
'.systems. Secondarily, rheumatism was a streptococcaL 
infection, the organism jiassing through the weakened lines; 
of defence, and so in-odiicing the toxaemic element of tlio ' 
debility'. 

Dr. Dingm'ald Fobdyce, honorary physician, Hoyal 
Liverpool Cliildreii’s Hospital, mentioned three predisposing 
factors in rheumatic infection in childhood — namely, , in- 
stability of the nervous system, digestive disorder, and 
weakness of lymphoid defence. He held that while the first 
two were 'usually closely associated, the third might result 
in rheumatic infection without either of tho other condi- 
tions being marked. AVlicu all three were marked .there 
Was serious danger of heart infection and chorea ; ivhen 
nervous instability and digestive disorder alone were marked 
the threat was chorea, and when lymphoid, weakness aloiio 




■Ma'y'xq. igsS'j 


CONFERENCE ON RHEUMATIC DISEASES. [mSJ ® jo’Zuvat. 855 


v.-is iii.'wUod ilio dnngpr was of lienvt infection, \vhilo 
chovc.i xvns not inneli to l)0 fonved. Tlio predisposing 
factors ns lie saw them were simple and homely, and on 
tlmt very aeconnt ditlienlt to control. The moral soemod 
to he that there was no royal road to the jireventiou of 
rheumatism. If, however, there were more hods at com- 
mand in conntrj’ hospitals, and adequate provision of snit- 
ahlo residential schools, the scmirgo of rhenmatio Jioart 
disease would he very largely swept away. 

The Tiacfcn'nl Facfnr. 

The hacterial origin of rhenmatisin was discussed hy 
Dr, C.MiKY Coojras, physician to the Bristol General Hos- 
pital. Ho hold that the causal factor was infection rather 
than intoxication, and that tho infection was hlood-horne. 
To tho question ns to-tho portal hy n-hich the strcpiococcal 
organisms entered tho hlood channels only an incomplete 
answer could ho returned. That tho tonsils wore respon- 
sihlo in many instances was so prohahlo th.at it might 
perhaps he trc.ated as proved. The clinical evidence in 
support of the view that tho strcjitococci might enter 
through tho intestinal wall appeared to lihn vague, but it 
was on the face of it uidikcly that there should he only 
one spot in the whole alimentary tract through which these 
streptococci cotdd porictratc to ‘the vital fluids, and there- 
fore he could not feel satisfied if tho tonsil only was 
hlamed, I he view might ho accepted that the tonsil was 
certainly, and the intestinal mucosa jiossihlv, responsihlo 
for admitting this virus into tho systemic circulation. 
But there remained some unknown quantity in tho equation 
whereby tho halauco between defence and attack was upset 
in favour of tho hatter. For the moment he did not feel 
.able to claim more than that the streptococci were prohahlv 
derived from tho ajimontary tract in which they were 
ahvays iirescnt, that it was only hy a conjunction of extran- 
eous iiiHueueos that they were enabled to inflict injuiy to 
tho tissues, and that the fact that the injuries inflicted 
conformed closely to a certain jiattern ohscrvahlo even in 
histological details was duo rather to constancy on the part 
of these extraneous influences than to the spocificitv of tho 
organisms themselves. 


; The Cardiac Problem. 

Rheumatic fever visualized as esscntiallv a cardiac 
problem was the subject of a paper hv Professor Fehn'-ike 
BE z.txfox and Dr. MATniEc-Pirnnr, Weil of Paris, which 
nas road hy the latter. The authors considered that the 
general point of view. with regard to rhoumatism should he 
completely changed, that the disease should not he con- 
sidered as consisting of a series of acute lesions, first 
.'irticnlar .and later cardiac, hut rather as a truo chronic 
disease, similar to tuberculosis. Tho articular lesions 
appeared the most- important' only because of their painful 
nature, winch prevented them from passing unnoticed. 
The eiulo-pencarditis was really much more important, and 
this after a period of development readily became obscured 
again unti l a definite cardiopathy was 'established which 
led to cardiac irreguhanty. The reservoir of the rlieumatic 
vinis was the heart, the endocardium, the perio.ardium, and 
partieularly the myocardium. The acute attacks were dis- 
tinguished either 'by a recrudescence of the cardiac lesion 
01 hy fresh articular symptoms. Tlie authors held that 
this method of intei-preting the fundamental part plaved 
In the heart was the only way of explaining the develop- 
ment of the disease, winch frequently, after f stage during 
a Inch articular and cardiac signs were preseiit simuf- 
taneously, progressed with cardiac signs onlv, and became 
more and more severe. 


■ Pannicvlifis. 

■ The causa uon of fibrositis and panniculitis was disem 
y Professor Rilph SrooraiAX of Glasgow. In fibrosi 
ho said, the u-ntant was most commonly a hacterial tc 
p odneed either at the site of the lesions bv small coIo, 
qf microbes winch had established themselves there, oi 
uas cavnml possibly from a more distant site bv thh hi 
s ream. Cold and wet had from time immemorial h 
c ted as causes of chronic rheumatism, and it was poss 
that tney might he capable of setting up .a fihrositir 
he was inclined to regard them more as exacorbif 


factors when tlio lesions wore already present. With regard 
to tho etiology of panniculitis, this was quite a diffci-cnt 
condition • from obesity or myxoedemn. JIany women at 
Iho.mciiopaiiso tended to lay on fat, and if they happened 
to he subjects of suhcutaneoiis fibrositis they then began 
to suffer, or suffer move severely, from its effects. Tho 
explanation was probably an increased growth of tho con- 
iieetivo tissue to support tho mass of fat, and increased 
tension duo to weight. , Professor Stockman showed some 
lantern slides of ancient carvings which indicated .that 
imnniculitis was a frequent and perhaps a fashionable 
condition among females in earlier civilizations, as it was 
with certain primitive tribes at tho present day. 

Pathological Investigations. 

Dr. GEOFEnirr Hadeield, demonstrator of pathologi' at 
Bristol "University, described a recent investigation made 
with the object of discovering whether there was a s2iocific 
tissue reaction in tho chronic rlieumatic disorders or any 
group of them. More work needed to be done, hut enough 
had been brought out to justify certain statements, such as 
that in some types of infective arthritis skin nodules 
occurred, having a constant histological structure, which 
appeared to rosomblo tho primary lesion of acute rheum- 
atism in tho heart wall, skin, and synovia closely enough 
to make it likely that both were duo to a micro-organism 
of the same gioiqi. A similar tissue reaction was occasion- 
ally found in the lesions of tho more chronic types of 
endocarditis, which appeared to ho duo to local infection 
hy.faoc.aKor oral streptococci in patients whose general 
iinmnnity to those organisms was high. Tlie pork suggested 
— hut did no more than suggest — tliat in chronic infective 
arthritis infection was hy a saprophytic streptococcus to 
which the patient had a high degree of general immunity, 
hut a loiv degree of local immunity in the synovia of his 
joints. 

A paper on the comparative pathology of tho 'subject was 
read by Professor Ton Hare of the Royal Veterinary 
(^llcge, London. It described a study of equine arthritis. 
Not only horses, but dogs, and possibly daily cattle, are 
infected with rheumatic disease, and Professor Haro said 
that there was evidence for the belief that it originated 
in thorn in early maturity. Heredity, sox, food, and 
environment did not appear to have any etiological 
significance. “ 


iite e.nciocnne hactor. 


Tho question of the endocrine factor called forth two or 
three contrihntions. Dr. W. L.axgdox Brown thought that 
attention should ho confined to the thyroid and tlie ovaries. 
Any influence that the other endocrine glands might have 
was, to say the least, problematical. It was a striking fact 
that, as the recent report of tho Ministrv of Health showed 
the incidence of mortality from acute and cardiac rheum- 
atism, and also the incidence of rheumatoid arthritis and 
osteo-arthritis, were markedly higher in regions where 
goitre was endemic. "While not going quite so far as 
Ijle\\cll)n, y^no held that the hereditai^- transmission of 
rheumatism consisted in the transmission of a tendency to 
thyroid inadequacy or instability. Dr. Langdon Brown 
.agreed that such inadequacy or instability was ,a factor of 
importance. He behoved tlmt tonsillar sepsis played a 
large part both in rheumatism and goitre, and that lack of 
lOLinc entered into the production of both hyperthyroidism 
, and hj’iiothyroidism, cither of nliicli conditions provided 
a suitable soil in which rheumatism could flourish. He 
was doubtful as to any direct influence of tho ovaiy. If 
ovfwian deficiency were a primarv cause one would expect 
to find rheumatism and rheumatoid arthritis chieflv diirinn- 
the child-hearing epoch, which was not the case. He 
believed the condition of the thyroid to he the principal 
endocrine factor. . ^ ‘ 

Dr. F. G. Thomson (Bath) considered that tho dose 
connexion of certain forms of chronic arthritis with abnor 
malities of thyroid activity was clearly bronght out in the 
case of rhemnatoul arthritis on the one hand and villous 
(or what he would prefer to term climacteric! arthritis 
on the other. It was a matter of common observation that 
rhenmatoid arthritis ' was veiy frequently complicated bv 
symptoms of liyperthyroidism. He showed some dia-raiS 




CONFEBENOB ON' BnEUMATIC DISEASES, 


T«e Bnm»* 
Medical JotR'TAXi 


866 May ig, 1928] 


illustrating the correspondence between the two diseases. 
The close association of chronic arthritis witli want of 
endocrine balance was also clearly shown in the case of 
villous arthritis, occurring in women at the mono])anse. 
This disease was usually associated with definite evidence 
of endocrine deficiency in the form of fibro-fatty thickening 
of the subcutaneous tissues, dryness of skin, and tcndeiicj’ 
to alopecia. The hrawnj', middle-aged woman who 
developed painful, swollen, and dreaky knees at the climac- 
teric formed one of the commonest types of the so-called 
“ rheumatic ” patient. This form of arthritis was so well 
defined, so true to type, and so closely associaled with 
other changes incidental to the menopause, that he thought 
it justifiable on clinical grounds alone to regard it as 
climacteric arthritis. 

Dr. Kerr Pringle (Harrogate) spoke of the “ atrophic ” 
group of rheumatoid arthritis cases, in which focal infec- 
tions pla3 cd no part. This atrophic group was confined, he 
believed, entirelj’ to the female sex, and ohseiwcrs had 
pointed out the similarity of the prodromal and carlv 
symptoms to those occurring in Graves’s disease. A history 
of enlargement of the th^'roid would often he found. The 
patient would often saj’ that her sj'mptoms were relieved 
during pregnancy, to return in the puerperium. The stimu- 
lation of the secretion of pituitrin by the internal secre- 
tion of the ovary was arrested by that of the coi'inis lutcum 
until the time for the uterus to contract and the milk to 
flow. It appeared to the speaker .well worth considering 
whether the inhibitory action of the corpus lutcum on the 
posterior pituitary had any part in the amelioration of the 
arthritic symptoms during pregnancy. 


Popers Taken as Head. 

In the absence oi the authors a number of jiaiiers were 
taken as read, to be embodied in the proc'cedings of the 
Conference. Dr. R. G. Gordon briefly indicated their 
nature. Dr. Kahlraeter of Stockholm discussed the .sedi- 
mentation reaction, which he found to increase enormonslv 
as compared with normal controls, in acute rheumatism niid 
-gettt-.--The chief point of the paper was the iirognostic 
value of this sign; until the cuiwe of the reaction fell to 
normal, exacerbations and recrudescences were apt to occur. 
Professor H. Strauss of Berlin contributed a paiier on the 
endocrine factor, which he did not regard as causal 
entirely; treatment by endocrine preparations did cood 
in conditions, but seldom alone effected a cure Dr 

Ralph Pemberton of Philadelphia recounted some exncril 
ments on the capillary circulation, and considered that a 
good many characteristic symptoms of rheumatic disease 
were due to a fai ure of the flow of blood through the small 
capillary channels. Dr. J. C. Small of the same cRv 
summarized his investigations on a specific niicro-organ1sn\ 
uli.ch he named S. eardioarthritidU, and said that wit 
treatment by vaccnies with cultures of this organisuriie 
had obtained beneficial results. Dr Homer SuHft f i- 
Rockefeller Institute, New York had a rensnn 1 
the subject of rheumatic fever as due to ly persensuTeness 
to streptococcic invasion Dr. Gordon Watson of Bath 
subiiiittcd some work by Dr James Lindsay and hiinself 
suggesting that the cause of chronic rlieumatisin was the 
result of the actions of toxins, endogenous and exogenous 
and that the systemic imbalance might be initiated bv a, iv 
two or more of such factors as focal sepsis, mental st.a ?, 
or shock, systemic infection, cnvironnieut and climate 
endocrine imbalance, faulty metabolism, or disease f 
various organs. Mr. Tinibrell Fisher bf the London ‘scho”ol 
of Clinical Jlodicine luml a long paper on the pathology 
of chronic arthritis, discussing the complex iiatholomcal 
changes, and pointing out that in the same joint might 
be seen tfle phononiena of repair, inflammation and iimv 
growth. ’ 

General Viscussioii on Causation. 

Dr. F. J. PoYNTON (London) thought it necessaiy still 
to keep an open mind as to the difference between 
'licumatism and rheumatoid arthritis arid osteo-artliritis 

tfretivelv^tn f"'""' ’'‘"‘I possible 

rlmroii linits " ‘tic units, and cardiac units, and 

voreur. would nro,- "’I" strepto- 

it 'would!”' *^ primary cause, though 


^ Dr. P. LazarUk-Barlo w (Queen Maiy’s Hospital, 
■ Carshiilton) said that ho had isolated from throat cultures 
of children siillering from acuto and subacute rheumatism 
an unusual type of streptococcus, which ho believed to 
ho identical with the A'. cardwarthTuUlis of Small of 
Philadoliihia. On the whole, exiierimcnt.s had .shown that 
this organism could form an endotoxin from which an anti- 
toxin could bo jiroduecd. 

Dr. L. BnuTitAND (Antwerp) described some ivork on the 
anaerobic bacillus described by Achalmc thirtj- j-cars ago — ■ 
a jiolyniorph microbe which could assume the coccic form. 
Ho believed that this was the cause of acuto articular 
rheunmtism. Ho had .succeeded in isolating it from 
synovial fragments in chronic rheumatism, and ho had 
treated jiatients with a vaccine from cultures of this 
organism with beneficial results. “ I am in possession of 
tho right treatment for true rheumatism, and the most 
effective at tho present moment. These results have been 
correborated ly a large number of Belgian and foreign 
practitioners.” 

Dr. RuiT.iiT Watertiod.sk (Bath) said that although ho 
could give no statistics in confinnation, his experience of 
fibrosilis and chronic arthritis left him with tho imprc-ssioii 
that a previous attack of rheumatic fever or chorea was 
little if at all more frequent in tlfe.so sufferers than in 
patients admitted to tho hospital for other complaints. 
He thought the tendency to ahandon tho distinction, first 
drawn by Sir Archibald Garrod, between rheumatoid 
arthritis and osteo-artliritis was to bo regretted, because 
though many intermediate, perhaps mixed, cases were to 
bo met withj tho differences in tho clinical picture and in 
the anatomical changes in well-marked examples of tho 
two were so great ns to leave no doubt that they had 
little or nothing in common. . , , , , - 

Dr. J. B. Burt (Buxton) exhibited a bone taken from 
a horse suffering from osteo-arthi-itis, and said that one 
out of even- eight of tho horses which came to slaughter in 
London had what was known as- “ cabhorso disease.” 
From this example he contended that trauma alone could 
produce artiiritis, that strain on the ligaments was a 
factor— possibly the first factor— in tho formation of bone 
changes and that the heredity factor was important. 
Rheinna’tism in animals ' offered a valuable field for 

invc.stigation. , . , „ , f 4. 

Sm-gcon Vice-Admiral Gaskei.l spoke of tho extreme 
rarity of the old classical rheumatic fever nowadays in the 
navA- also the remarkable drop in tho incidence of chronic 
rheumatism. A similar reduction in those forms of heart 
disease siqiposcd to be due to rheumatism had not been 
experienced. 

Dr. P. Watson-'Williams (Bristol) said that tho 
undoubted association of-_chronic sepsis in the tonsil with 
the incidence of rheumatic conditions had been well brought 
out bv Dr. Langdon Brawn. Endocrine imbalance was one 
of the consequences frequently encountered by those iilio 
had to deal with chronic septic infection. In these jiro- 
cesscs, going on so slowly, sometimes for j-ears, there ivas 
ample time for clinical development to take place. .-It the 
climacteric and in pregnancy rheumatoid manifestations 
wore apt to bo more marked, and he would suggest that 
this was mcrclj’ in manj' cases tho result of the lessened 
tissue resistance incident to those jihases of life giving to 
tho focal infection, which was alwajs present, greater 
oiiportunities of manifesting itself in characteristic lesions. 

Dr. Henry Ellis (London) spoke on the biochemistri- ot 
rheumatism, which, he said, governed the whole situation. 

In endocrine rheumatism one did not get any distiirbaiiee 
of the acid-base equilibrium in tho urine. If one found 
no variation of the acid, no increase of tho sulphates, no 
diminution of tho phosphate.s, one' could bo almost abso- 
lutely certain that it was the endocrine form of rhouniatism. 

Dr. G. Holmes (Harrogate) described investigations on 
fifty lios]ntal cases suffering from chronic arthritis, not all 
of one tj-pe. To his surprise ho found no evidence of hypo- 
or hvper-tiijroidism as shown by the basal metabolic rate. 

It was known that clinically the administration of thyroid 
was beneficial in rheumatoid arthritis, but it was of some 
interest to bo able to take a series of fiftj' cases and find 
that they had normal metabolic rates. 

The session closed with a few remarks in French by 



MAT TO, to?8] 


Profossor-PisANi of Florence, wlio hronglit to tlio gatlicving 
tl>o felicitations of his Italian colleagues, and slated his 
view tliiit tlioro wus fi positive I'oliition botAVcon chioiAic 
rhouinatism and disorder of Uio endocrine system. 

The Tueatjtent or. IturnMATisM. 

Sir F.vnquiiAn BuzzAiin iiresidcd over {ho final session, 
remarking that ids hvothcr regiu's of Candiridgo had 
accepted responsibility for the .causation of rheuinatisin, 
so that surely Oxford could shoulder the burden of its 
treatment. True, as causation preceded treatment, the 
older univcr.sity' might have claimed the jirevious session 
for its oAvn, hut in this particular instance it was felt that 
the inia.smatic properties of the fen country established a 
right of precedence which could not he, disputed. “ How 
is it that yon doctors have never discovered a euro for 
rheumati.sm? ” was a rebnko not infrequently addressed 
to them; and the only faithful reply must ho that the more 
they knew about many diseases the less they know about 
their cures. The problem of rheumatism was highly com- 
plicated, and not, simplified at all by any attempt to bring 
all conditions blessed with that name into one p.athological 
category. The problem involved in treatment was the 
problem of causation, the proper assessniont of causative 
factors, and tbo requisite knowledge to prevent and destroy 
their influence. In the long run it was a problem of 
provontiA'o medicine. Hfcanwliile, spa treatment was in- 
valuable from several points of view, relieving suffering,' 
preventing erippling, and offering opportunities for 
vcscarcb. 

Prevention of Chronic Pheumotism. 

Dr. R. L. J. Li.t.wei.t.tn, in a jiaper on the prevention 
'of chronic rhcum.atism, said that if the fundamental truth 
that man and his environment were one organic whole 
had never been lo'.st sight of, the salient role of the skin 
in rhouniatisra would never have been minimized. The 
primary signs of physiological inadequacy in rheumatic 
subjects were instability of the blood supply of the skin 
and also sweat, secretion. This pointed to what should be 
a basal principle in prophylaxis — namely, tho maintenance 
of the functional efiicicncy of tbo skin. JIany textbooks 
on acute and chronic rheumatism contained not' a word 
about skin hygieno, although tho skin and mucous mem- 
brane were our first line of defence against weather 
changes. The maintenance of tho skin’s efficiency was best 
achieved by hydrotherapy, with alternating applications 
of hot and cold .water to tho skin surface. Dr. Llewellyn 
went on to discuss tho principles underlying tho prevention 
of muscular rheumatism, including the maintenance of a 
due balance between food intake, muscle output, and skin 
efSoiency, tho avoidance of “ occupation misfits,” the 
recognition of “ motion study ” as cssenti.al to scientific 
management in industry, the avoidance of fatigue and the 
■wrong use of muscles, the arrangement of rest pauses, and 
tho necessary hygienic conditions in tho workroom. He 
also spoke of the proybntion of rheumatoid arthritis, the 
key to which, lie considered, consisted in recognition and 
treatment of the pre-arthritic or premonitory phenomena. 

Bhenmatic Infection in Childhood. 

Dr. P. J. PovxTOx of University College Hospital, 'a’lio 
dealt with the treatment of acute rheumatic infection in 
childhood, declared himself to be no believer in the treat- 
ment of young children with acute rheumatic carditis by 
means of salicylate of soda. He had instead treated tho 
severe forms of rheumatic carditis in children by the ethyl- 
ester of methyl-phenyl-cinchoninic acid, knoivn by ■the 
proprietary name of “ tolysin.” Ho had used this drug 
now for some four years in very grave cases of young 
children in whom tliere had been pancarditis and often 
also nodules, arthritis, and chore.a, with general toxaemia. 
Ho mentioned certain objections to salicylate when it was 
pushed, including possibly death from coma, also depres- 
sion, which he had never seen follow from the cinchonic 
acid preparation just mentioned. He would not pretend 
that salicylate of soda had no beneficial effect in rheum- 
atism, for ho knew that it had, but whatever the action 
mighty be it was not specific a.s quinine was specific to 
malaria. The drug ho had mentioned was milder in action, 


but, ho believed, clearly of value, and ho recited a number 
of cases in which treatment had boon carried out with 
tho ethyl-ester with good results, and without causing 
nny anxiety on account of troublesome symptoms. 

Dr. A. P. Tiiojirox of tho Children’s Hospital, Birming- 
' ham," dealt with tho organization of institutional troat- 
. ment for rheumatic children. Until recently, he said, no 
organized system of treatment of rhouinatic children 
existed; tho disease had certainly attr.acted the attention 
of tho school medical service as a frequent cause of pro- 
I longed .absence, but nothing ivas done by any public health 
authority to remedy tho evil that tho inquiries disclosed. The 
■ ordinary case might require, at one time or another, three 
’ different types of treatment: in hospital during the acute 
phase; in a convalescent home, where nearly all tho time 
might bo spent in bed; and finally, in an institution in 
which the child’s return to activity could he regulated 
under c.areful supervision. In Birmingham children with 
aento mnnifc.stations of rhcum.atism were admitted to the 
Children’s Hospital in tho ordinary way, were later -tr.ans- 
ferred to a convalescent homo, whence they went in batches 
to Baskervillo' School, a special residential school, con- 
trolled by tho local education authority. Dr. Thomson 
gave an illustrated description of this institution, its 
special equipment,' and its daily routine.. In showing a 
group of the children playing cards he mentioned that card- 
playing was quite a valuahlo corrective for chorea, because, 
if tho player had chorea too badly, ho could not help 
showing his hand to his opponent 1 

Vaccines: their Use and .dbiisc. 

Sir 'WiLT.iAjr Wilecox, in speaking on the treatment of 
tho underlying infection, said that in his experience of 
hospital practice one did not meet to anything like tho 
same cxent to-day with the virulent cases of rheumatic 
foA'cr in children which were so common thirty years ago, 
an improvement rrhich ho attributed largely to tho 
doA'clopment of school hygiene. He went on to speak 
particularly of vaccine therapy.' Vaccines, he said, should 
not be given until the case had received the fullest clinical 
investigation, and any existing foci of infection had had 
appropriate treatment. An abuses of A'accine therapy Avas 
the administration of vaccines in cases of chronic rheum- 
atism where obvious foci of infection were present — for 
example, septic teeth or tonsils. Vaccines wore contra- 
indicated where “ sensitization ” to the toxins from .the 
infection existed, also in cxojihthalmio goitre, if this was 
associated with chronic rheumatism. They were of A'alue in 
chronic rheumatism when any gross focus of infection had 
been removed and the toxic process ivas being carried on 
by tho chronic infection of a mucous surface with its 
accompanying glandular tissue. It ivas advisable to begin 

with a vaccine of iveak strength — ^say 5,000,000 per c.cm. 

and after a preliminaiy course to proceed with a stronger' 
, vaccine of, say, 50,000,000 per c.cm. Any evidence of 
symptoms of sensitization was an indication for discon- 
tinuance. Stock streptococcal vaccines made from other 
patients were in his experience far inferior to autogenous 
vaccines. Antistreptococcal . serum was not indicated in 
cases of chronic rheumatism. Protoin-shock therapy had 
: been disappointing. 

Fhxjsical Treatment. 

Dr. J. Caaipbelt. jMcClure of London dii'ided physical 
treatment into t-wo groups; (1) exercises, baths, and radio- 
therapy, which effected alterations in metabolism and raised 
the general resistance to infection, and (2) massage, local 
applications of heat, douches, and manipulation. The value 
of the A’arious forms of physical treatment was much 
debated. A great deal depended on the ■way in which they 
were applied. No form of physical treatment was more 
stupidly applied than massage. The good effects of general 
massage rvere often nullified by hear-y massage of the 
abdomen to counteract tho tendency to constipation, on 
the extraordinary idea that one could produce good effects 
by the rough handling of the colon itself. BatJis, again, 

improperly applied, could be dangerous to the patients for 

example, if given at too high a temperature liavine regard 
to the circulatory and metabolic capacity. He emphasized 
tho importance of electrotherapy in tbo treatment of all 


CONFERENCE ON RHEUMATIC DTSEAS^S^ 857 



868 May 19, 1928] 


CONPEEENCE ON RHEUMATIC DISEASES. 


[ Tnr: EBrn*ii 
Alestcjx Jorsxix 


T\astod and atonic muscles in ilienmatic disease. Massage 
and baths coxild do nnieb, Init nitliout tlie addition of 
electrical treatment a great deal of time was wasted. .In 
this condition, as in others, no one form of ])liybical treat- 
ment was enongli. The Plomhieres treatment was extremely 
nsefid in cases where rheumatic manifestations were asso- 
ciated with a chronically inflamed and infected colon ; it 
should, however, he administered hy careful and skilful 
persons. He had knomi its misuse — in comhiiiation with 
an excessive diet of lactic oals — ])rodnco in a j)cr.son, who 
at the beginning of treatment was as reasonably healtlij' 
as most nervous persons living under considerable str.-iin 
could he, an obstinate mucous colitis. He had always 
found that the best results were obtained by a combination 
of various forms of treatment. 

Professor IsinoiiE Guxziicno gave an account of the 
Brugman Hospital at Brussels, wliich is an antirhenmatic 
centre, with an elaborate ph\siothcrapeutie service. Since 
it staidcd this centre had received about 220 patients, and 
he claimed that in 50 per cpnt. the rheumatic pains had 
disapjieared altogether, and in 60 per cent, the movements 
had been considerably improved. 

The Scope of Siirficrtj. 

A jmper on the scope of surgery in the treatment of 
dcgencrativo arthritis was to have been read by Mr. Jilax 
Page, but he was unable to be present, and th'is phase of 
the subject was dealt with very briefly by Jlr. AViiiTCliuitcil 
Howeli., who described the various 'methods of treatment 
open to the surgeon in those cases. These methods included 
traition, mobilization with or without traction, arthrodesis, 
and in a limited number of cases artbroplastv, or the 
formation of a new or false joint. Bv means of lantern 
slides he indicated the types of cases iu'wliich these various 
procedures were biiitablo, and laid stress upon the fact that 
in no ease should manipulation be performed without 
X rays. Arthritis could be prevented, and very often could 
bo cured in its early stages. 

Gcnercil Discussion on Treafinent. 

Dr. M uiiiEx CnowE asked why vaccine troatinent was not 
uiiiversa l^y used. Ho had found groat beiiefits follor. from 
It. raulty techiiique was possibly a reason why it was put 
<m the shelf. The first principle of treatiiient— the .small 
dose— was too often disregarded. He had ca.scs under 
tieatment at the present time which got a verv defiiiito 

ace ne" of « million of streptococcal 

^mnnn' ® “3%. should any case start with nioro than 
500,000, and 2,000,000 might easily be the iiiaxiiniim 

manufacturing districts snfF ° liatients drawn from 
disorders largriy aUributrWe rheumatic 

cjucntly tliev^liLl spoiirwepP, onvironiiient. Fre- 

tlieir own neighbourhood without bmmfit'^,'ut T 

ment 111 a large and well-eauiunn.l 1 ’ I"? ‘‘ffoi treat- 

a great influence 111 promoting recoverv ItTn i ’ i J 
the treatmeiit of rheumatism could afford 'to bo imioraut of 
the groat spa hospitals and the wealth of clinica'l • 1 

they presented for study, and a conference of that 
character would be incomplete without some consirlL.i- 
.of spa treatment, the most ancient of all methods 

Dr. VixcEXT Coxites (Bath) gave some personal exne 
nonces of the treatment of infective arthritis. The es 
tials of treatment were the raising of immuiiitv and The 
correction of biochemical abnormalities. The condition f 
a iiatient in the acute or subacute stage of the diseaL 
should bo regarded 111 much the same light as that in which 
''"f. virstoiiiary to regard iiuliiioiiary tuberculosis or 
tlodgkin s disease, fn the chronic stage in which infection 
and there was apparently no likelihood of 
i=anir\tht’T: regarded in n.nch the 

miIUmops ’H!ei"’r' customary to regard 

■n'd hone — na-olv g'vmg end-results in joint 

"a.-oli, as an orthopaedic ease. He described 


the thorough cxaminatioiis whereby biophemical and 
bacteriological anomalies .slioidd bo .sought for and adjusted 
in an attemjit ns far ns possible to rai.se the immunity of 
the individual. AVitli regard to the joints themsolvos, in 
the acute .stage rest in splints was indicated to obviate the 
ivell-kiiown deformilie.s. No joint which was hot or tender 
should be mnnijinlutcd. In the subaeuto st.age much could 
be done by bydrotberapy and .splinting; a mud-pack to, 
say, the knee, followed by a dcoji bath, was an excellent 
prelude to the readjustment of an e.xtensiou splint. 
iMnnipnlation under anaesthesia could be safely indulged 
in in a large number of chronic cases. Care must bo taken 
that not too much force was used. Spa treatment was 
useful thronglmut the course of the disease. 

Dr. Hans Jax.sipv (Coiionhageii) gave the following 
general principles of his treatment : 

Lumbago : Il.adiant bent or hot air, followed by massage. 

Sciatica : In first slagc.s, bed ; afterwards wai-m fomentations in 
woollen lilankels; later radiant beat and massage. 

Snbaciile polyartbrilis : Very cautions use of physical lieatnieiil. 

Chronic polyarthritis : Hot air, steam bath, diathermy, active 
and passive exercisc.s. 

O.sleo-arthritis : Vigorous wanu treatment followed by energetic 
fnassage and exercise of the muscles, but never massage of the 
affected joints (hip or knee) tbeniselvcs. 

In some further discussion Dr. Aeex Cawadias (London) 
mentioned that he had found his best results with common 
stock vaccines. In vaccine therajiy be thought the method 
of procedure was more important than the material used. 
Ho believed there was a great future for shock thora])y. 
Dr. Donald B!11Ai.s (London) spoke of the effects of intro- 
ducing oxygen beneath the skin and of treating rheumatic 
ease.s with emanations of radium and tborinni. He had 
seen re.snits from those applications, made at the Pasteur 
Institute in Paris, which wore amazingly good. "With tho 
help of lantern .slides he described the technique. Dr. P. 
M'atson-’WilliaJIS (Bristol) emiihasized the difficulties that 
confronted one in the endeavour to detect focal infections. 
The history of the patient’s symjitoms was most valuable. 
One should persevere in tho search for focal infection, 
because, if this could only be found, a very considorable 
step had been taken towards stopping the progress of the 

lesions. . -j i 

Sir FAEQUiun Buzz-tnn, in closing the sc.ssion, said that 
it would be impos.sible at the moment to estimate the 
results of the discussions, but if no other immediate results 
were forthcoming, tho exchange of views could not fail to 
stimulate new interest in the subject, new ideas for re.seaixli, 
and new hope for the future treatment of rheumatism in 

all its phases. , ^ . 

Sir George Newjun, iiresideiit of tho Conference, pro- 
posed a resolution, which was seconded by Dr. R. .-I. 
Fleiiikc, and heartily carried, thanking the jMayor and 
municipa'l authorities of Bath for their most lavish hos- 
pitality, and acknowledging also the convenient arraiige- 
nieiits made by the local Organizing Committee and by the 
director of the City Baths (Mr. John Hatton). Sir George 
Newman added tluit he proposed to take tho earlio.st oppor- 
tuiiitv of presenting to the Minister of Health and the 
President of the Board' of Education a) copy of the 
lirocecdings of the Conference. 

Civic Entert.vinsient. 

On the evening of tho first day of the Conference a civic 
reception to the visitors was given at the Puni)) Hooni. 
About 400 guests were received by tho Mayoress (Madanio 

- ■’ . of the 

boinson, 
cellent 

programme was provided by' the Pump Boom Orchestra, 
and°supper was served in the Roman Promenade and in tho 
Museum. 

Tho reception was preceded by a dinner at the Guildhall, 
over which the Mayoress presided. The distinguished 
company’ included nearly all those taking a prominent part 
in tho work and arrangements of tho Conference. Among 
the guests were Lord Dawson of Penn, Sir George Ncwniaii, 
Sir Walter Kinnear, Sir Farquhar Buzzard, Dr. R. A. 
Fleming (President, Royal College of Physicians, Edin- 
burgh), Sir Janies Berry’ (President, Royal Society of 




15, lOiBl 


SUNLIGHT IN MODERN MEDICINE. 


[ Tin; Unm'ut ftRO 
Mr.Dic11.J0cRN.1i. 


Morticino), Dr. H. 11. Brnckciibury (Cliairmnn of Council 
of tlio British Modiral Associiitiou), Dr. J. I'nii Brocmon 
(HQiior.avy Socrctmy of tlio Interuiilional Coniiuittoc on 
Rheumatism), Sir. S^iviiro Siiriggo (Editor of tho Lancci), 
nnd Dr. N. G, Ilornor (Editor of the liritish Medical 
Journo!). 

The speeches -wero brief, ns nn early adjournment rvas 
made to the Rump Room for the reception, but tho health 
of tho city of Bath uas proposal in an eloquent oration by 
Lord D.vu'.son or Pkn-n, mho sjmhe of tbo distinctive quali- 
ties of this bcautifvd city of the IVcst, udiich had survived 
time and chnngo in so mondcrfid a may. “ Its Roman 
rohmins boar witness that its beauty of design, its dis- 
tinctive adornment, have ever been its pride; and enshrined 
in this fabric of beauty there is left to this day that spirit 
of independence, tliat civic consciousness, which were tho 
mainstay of tlio Roman Empire — qualities which, wo note 
with ])rido nnd rejoicing, are still active and vivid in tho 
Bath of to-day.” It was, however, tho eighteenth century. 
Lord Dawson continued, which gave us a Bath conscious 
of its gifts nnd resources. Men of genius raised from 
amongst its craftsmen worked together ns if inspired on a 
harmonious town-planning, and thus was sot a perfect, 
stage on which (ho sparkling comedy of manners was soon 
to be played.' After tho passing of Beau Nash and his' 
regime Bath went for a while into tho shade, but its spirit' 
.and tradition survived,- nnd to-day it was to be seen and 
admired of all men — a spa unsurpassed in equipment nnd 
direction, in vision nnd civic purpose, nnd full nnd over- 
flowing hospitality. 

LUNCHEON BY THE BATH DIVISION. 

In the interval between tho morning and afternoon 
sessions on May 11th the medical visitors to Bath were 
hospitably entertained to lunch at tho Grand Pump Room 
Hotel by the Bath Division of tho British bledical Associa- 
tion, rindor tho ch.airmanship of Dr. R. G. Gordon. In' 
proposing tho health of tho guests Dr. Gordon esplaincd 
that, although tho Conferenco was not in any way a 
B.M.A. function, its Organizing Committco was in fact a 
Bubcommittco appointed by the local Division of tho 
Association, and ho and his immediato colleagues (Dr. 
Thomson, Dr. Waterhouse, nnd Dr. Coates) had received 
much help and oiicouragoment fi'oiu tho headquarters 
of the Association. It was therefore with particular 
•pleasure that they, .welcomed tho Cliairnmn of Council 
(Dr. Brackenbuiy) at tho Conferenco and at this luncheon 
party .- Tho toast was responded .to by Sir Farquliar 
, expressed the appreciation of himself and 

Ins fellow guests for tho boundless hospitality with which 
they had been received by the city nnd tho medical pro- 
fession of Bath. Sir Humphry Rollcstou proposed tho 
hoaltli of the Division, and spoke of the affection with 
which Bath was regarded throughout tho profession. He 
coupled tho toast with the name of Dr. F. G. Tiiomson, 
President of the British Medical Association in 1925-26, ‘ 
and now cliairman of tho Organizing Committee for this 
Lonference, whom everyone was delighted to see restored 
to full health- and vigour. ■ Dr. Tiiomson acknowledged the' 
compliment, and three of the distinguished medical visitors 
from abroad addressed a few words of greeting and thanks' 
to their colleagues at Bath. 


n ^^^^’EOLOGICAL MEETING AT BATH. 

Up tlie dav following tho Conference on Rheumatic 
Diseases the Balneological Section of tho Roval Society of 
Medicine held its auiuial meeting in Bath.' Members of 
tile Section and a number of others who had attended the 
pioceedings on Thursday and Friday assembled in the 
Pump Room at 9.S0 a.m. on Saturday for a visit to the 
not mineial baths, and saw demonstrations of treatment 
on aiipropriate cases in the various establishments. At 
11 0 clock clinical demonstrations were given at the Royal' 
Mineral Baler Hospital by the physicians of the hospital, 
Di . Rupert B aterhouse showing cases of osteo-arthritis 
Dr. J. LiiicEay cases of gout, Dr. Vincent Coates cases of 
• infccUve arthritis. Dr. ®. G. Gordon cases of fibrdsitis 
and Dr A. Gordon Watson cases of sciatica. lu the afterl' 
noon tho visitors went on a motor tour of Bath and its’ 
environs, by invitation of tlie Hot Mineral Baths Com-' 


mittco. This was followed by an inspection of tho Roman 
Thermae, and tea on tho Roman Proinenado; in the' 
evening a concert was given by the Pump Room Orchestra. 
Sunday was mainly given up to charabanc excursions to 
tho Mciidips nnd Cheddar, returning by way' of B'clis, and 
in tins manner four very' enjoyable and instructive days 
wore rounded off, _ : , 


SUITLIGHT m MODERN MEDICINE. 

Clinical Experience in England and Scofland. 

A Chadwick public lecture on “ Sunlight — ^natural and 
artificial — and' it's use in modern rhodicine'” was given by 
Dr.' Walter Elliot, M.P., Under Sccrctai-y of State for 
Scotland, on May 15th, at tho British Jlodica! Association 
House, Tavistock Square, London. 

Dr. Elliot referred briefly to the development of the medical 
employment of sunlight, nnd said emphasis -was noiv laid upon 
the constructive or healiiig power of radiation, particularly 
of short-wave (ultra-violet) radiation, hut the effects were still 
a matter of active discussion. Public authorities were making 
extensive use of this method- of treatment, and their experience 
already formed a large body of clinical opinion which would well 
repay attention. 

In England and IVales, by the year 1926, 64 centres liad been 
established by local authorities directly^ and 56 by voluntary 
agencies, to which loc.al authorities sent cases. In addition, 
light treatment was carried out at 11 school clinics,' at 7 
hospitals, and at numerous centres established by' voluntary 
agencies to wliich children were sent. In Scotland there were 
30 centres in sanatoriums and hospitals belonging to local 
niitboritics, and 6 in private sanatoriums. There were also 
21 centres under child welfare schemes, and it might be taken 
that all the larger and several of the smaller voluntary liospitals 
possessed installations. There -were also some installations in 
the larger Poor Law hospitals. This gave a total of over 
170 centres in all. 

Experience in England showed that tho best results were 
obtained in treating (1) lupus, (2)' certain skin conditions, 
(3) rickets, nnd (4) superficial lesions in surgical tuberculosis. 
Tlic general conclusions of the reports received by the Ministry 
of Health were tlint, while ultra-violet light was by' no means 
a general specific for all forms of disease, it formed a useful 
accessory therapeutic weapon, especially in combination ■with 
other metliods tested and approved by time; further, that the 
time was not yet ripe for any co-ordinated classification of 
results. Tho Scottish verdict was somewhat more enthusiastic. 
A special report by (he Board of Health stated : “ Its ‘value 
in the less severe forms of non-pulmonary tuberculosis is 
unquestioned. In pulmonary cases the results have not been 
discouraging, but much more work will require to -be done. In 
child welfare work on the whole the results are most en- 
couraging. They fully justify the expense and labour involved 
in providing this method of treatment.” 

The explanation of these differences of opinion, Dr. Elliot 
continued, might be found in the ultra-violet radiation recorded 
in the respective countries. In Ventnor the average daily 
readings for November and December, 1926, were 2.35. ' In 
Edinburgh the readings were nil for the whole three months 
-between November, 1925, and March, 1926, and even in Marcli 
and April the readings only averaged 1.1. It was obvious, 
therefore, that one would expect a supplementary source of 
ultra-violet light to sliow more marked results in the North 
than in the South. In the Ehort-\Yave radiations a therapeutic 
factor of considerable potency' was available, although its 
working was by no means clearly understood. He wished to 
draw attention to a passage from one of the Scottish reports, 
w’here tiie observers pointed out that ” its therapeutic properties 
are in the main limited to conditions of growth or function 
that are below normal. The increase of body weight, improve- 
ment of mineral content of the blood, increasing of the bacteri- 
cidal power of the blood, took place when individuals were 
below normal, but no corresponding effect took place with 
normal individuals.” This view ivas strikinglv emphasized by 
experiments carried out by Henderson in Aberdeen. 

Dr. Elliot concluded that irradiation was of value in removing 
a condition which, although widespread in modern life, was 
still a symptom only'. The illness of which this condition Was 
a symptom was deficiency' in diet, lack of accessory' food 
factors, vitamins, or mineral salts. Effort should be directed to 
the removal of the root cause, and the work of the ultra-violet- 
ray therapist would come into close relation' to that 'of the 
nutritionist. The fundamental requirements of the normal 
being were yet far from being met;' these Were fresh air 
fresh water, fresh food. Till these were met the administrator 
would have a part to play in the twentieth century not less 
I important than he had in the nineteenth. 


860 Mas 19, 1928] 


RHEUMATIC DISEASES. 


r TnBtinM ' 

L Umcix JocmxA& 


ItitiSf) jHelJical Jotitttal. 


SATURDAY, MAY 19 th, 1928. 


RHEUMATIC DISEASES. 

A CoNFEiiEXCK on Rheumatic Diseases was iield at 
Bath at the close of last weeli, under the presidency 
of Sir George Rewman, Chief Medical Otlicer of the 
l\Iiiiistry of Health. ^Ye think \yc may say that the 
objects of this conference have been attained. As the 
president remarked, the chief affliction of Grejil, Britain 
in the twentieth century would seem to be rheumatic 
disease, as tuberculosis was of the nineteenth century. 
For many } ears a number of individual workers liave 
been engaged on the study of rheumatism, and the 
time has now come when their several results .and 
theories may with adaamtage be correlated and 
discussed, so that the medical profession may sec its 
way to tackle this problem systematically. It will 
occur to those who read the account of the papcr.s .and 
dheussions published elsewhere in our present issue, 
and the full proceedings which \vill appear shortly in 
book form, that nothing startlingl)- new has been given 
to the world, and perhaps this could hardly be 
expected. tVhat seems to us to have been the chief 
note of the Conference is in a sense paradoxical : the 
lack of similarity between acute rheumatism at one 
end of the scale and osteo-arthritis at the other was 
stressed by several speakers, while others insisted that 
there might be more justification for the common 
term “ rheumatic " than has been hitherto supposed. 
Tt niust be the purpose of future research to resolve 
this paradox. The maladies to which the human race 
is heir may be roughly divided into two groxips. Those 
in the first group are due to specific causes, thev 
present a fairly constant clinical picture, and sooner 
or later a specific remedy is found ; as an example may 
be mentioned the malarial plasmodium and quinine. 
Those in the other gi’oup have a complicated etiology, 
their clinical manifestations are manifold, and there is 
no certain remedy which can be used effectively, 
though the number of patent medicines claiming to 
cure is immense. 'J’o this group rheumatism un- 
questionably belongs, for even in the acute disease the 
sj)eeificity of salicylates is being called in question. 

It seems obvious that if rheumatism is to be cla.ssed 
m the second group of maladies the problem presented 
must be envisaged as a biological one, and not as 
symptom.atic. Ram and affection of the joints may 
bo the most striking features from the subjective and 
objective standpoints respectively; but the physician 
in the futm-e must not let his attention be diverted 
by them from the appreciation of what lies behind. 
Nor does he lack reasons for taking the wider view for 
in the insured population alone, comprising not more 
than one-third of the whole, the cost of ilieumatism 
in money is upwards of £17,000,000; and, if the late 
effects of rheumatic carditis in children are taken into 
account, the rheumatic group of diseases must be 
reckoned One of the principal causes of death in the 
community. 

So far as acute rheumatism and rheumatic infection 
in childhood are concerned, the war against these 
conditions must begin in infancy. Although heredity 

ocs not seem to play very much part, the constitu- 


tion of the child undoubtedly doc.s. Rheumatic infec- 
tion is apt to occur in the “ nervous child,” and when' 
infection has taken place the ; “ nervousness ” is 
increased in a vicious circle. Diet is of considerable 
moment, for the pre-rheumatic child tends to be 
intolerant of carbohydrates and is often deficient in 
vitamin B. The lymphoid system of these children is 
poor in quality, and soon becomes converted from a 
defence ag.ainst micro-organisms into an absorbing 
surface for the microbes and their toxins — hence 
llic importance of close altoutiou to the hygiene of 
lomsils and adenoids; while failure of the intestinal 
lymphoid structures is responsible for the toxic 
debilitated stale found in children before and after 
actual infection lias taken place. The endocrine 
system is ill-balanecd, as is shonm by two phenomena 
wliich arc familiar after infection has taken place — 
namely, the irregular and abnormal sweat secretion, 
and the tendency to hyperpyrexia, wliich may often 
be controlled by ‘insulin. The skin is inefficient in its 
response to cold and damp, which may explain the 
marked effect of damp houses on the mcidenee of this 
disease. There is also a sensitization of the tissues 
to certain micro-organisms and their toxins, particu- 
larly to the Slcptacoccus viridans and its allies, and .a 
phasic variation between- this sensitivity and a relatiie 
immunity may occur all through childhood, explaining 
the frequent remissions and exacerbations. This may 
culminate in an absolute immunity in adult life. 

Opinion is still divided as to the causal organism, 
thouffli most observers admit that it is a streptococcus, 
which is probably a saprophyte in ordinary circum- 
stances, onlv becoming pathogenic when sown on a 
suitable soil. Evidence is accumulating that such 
sireptocoeei of low virulence may induce a specific 
tissue reaction in the form of the nodule analogous to 
tlie tubercle and the gumma. Various special strains 
of streptococcus wliich arc believed to be the .specific 
cinisnl organism have been described ; the most recent 
is that termed in America the Slrcpiococcus cardio- 
arthrUidis. Although not an infectious disease, evi- 
dence is not wanting that under certain couditions 
it inav be mildly contagious, especially in the .singe 
■before clinical sipis have become manifest. If serious 
complications are to be avoided, not only must rest 
and appropriate treatment by salicylates or other 
dru"s be given during the active stage, but convales- 
cence must be managed with the greatest care liie 
rheumatic child must not go back to the rough-and- 
tumble of ordinary school life for at least a year 
after the attack, but coinploie rest in a convalescent, 
home is not generally necessary for more than six 
weeks; therefore the provision of .special schools is 
a necessity. Since the main incidence of rheumatic 
infection is on the elementary school child, the charge 
for these schools, if and when they are established, 
will presumably be on the State. 

■ When we turn to chronic rheumatism the nisn 
tiling that strikes the eye is the complexity of the 
pictm-e In this picture, however, certain feature 
are found which resemble those of acute rheiimatism . 
the disordered -skin reaction, the disturbance o 
endocrine function, and the specific tissue reaction 
to low-grade streptococci— namely, the nodule. Jhko 
acute rheumatism, these conditions— whether miec- 
tive arthritis, fibrositis, or osteo-artliritis— must he 
looked upon as biological deviations, as system 
diseases. The first two have their seeds in earU inc. 
while the last may be a part of the general deteriora- 
tion of advancing years affecting joints wliicli have 
been 'weakened by .strain, trauma, or infection, nc mg 
separately or together. In the investigation ot these 


May X9, 1928] IMMUNIZATION AGATHBO? INFEOTIOTJa FEVERS. 861 


<1isei\sos il is necessary to pay nttonlion to the bio- 
choiniail constitution of the patient, and deviations 
from the normal. will often, if not always, he met witli. 
The commonest are disturbances in sugar tolerance, 
alterations in the y)!! values of the body fluids, and 
abnormalities in the metabolism of calcium', phos- 
phorus, and sulphur. The endocrine organs, and 
more particularly the thyroid gland, are as a rule at 
fault, hypothyroidism being associated particularly 
with ilbrositis and chronic synovitis, and dyslhyroidism 
with infective arthritis. Foci of infe(!tion arc of great, 
but 'not ex-clusi\VVimp6rtnnce,'and faulty elimination 
must also be taken into account.' Treatment of these 
conditions may be grouped under six heads : (1) 

removal of septic foci by surgical or medicinal means; 
(2) promotion of elimination by means of physio.- 
therapy and hydrotherapy, more particularly by the 1 
skin; (3) establishment of immunity from the invading I 
organisms by means of vaccines, given with due dis- ! 
crimination in respect of dosage and interval ; (4) 
induction of tissue reactions by various forms of shock 
therapy; (5) correction of endocrine imbalance by 
administration of suitable extracts; (61 massage and 
other physical and hydrological methods which aim 
at the alleviation or removal of local lesions. Tf the 
ease comes under treatment i-easonably early such 
methods warrant a favourable ]irognosis. 'I’liey can be 
carried out at a well-equipped hospital or clinic, Imt 
probably the spa is still the best centre for their 
administration. Physical treatment is expensive, and 
therefore often beyond the reach of the industrial 
population, unless the State, through the national 
health insurance scheme, extends this opportunity for 
treatment to its beneficiaries. Jlention should also be 
made of the place of surgery in the treatment of 
rheumatic diseases. In the. first place, orthopaedic 
principles must be applied in the maintenance of 
posture of joints and muscles; and secondly, when the 
case has been neglected, -or when in spile of treatment 
contractures and deformities have resulted, a helpless 
cripple may be restored to comfort and usefulness by 
means of arthrodeses, arthroplasties, and kindred 
operations. 

Such appears to be the gist- of the contributions 
made in the corirse of three strenuous sessions at Bath. 

^ t\e believe that the promoters of the Conference inay 
feel confident that they have collected a mass of 
material which will stimulate further research into 
these difficult problems of causation and treatment, 
and point the way to the more efficient application of 
what is already knorni. 


niMUXIZATION AGAINST INFECTIOUS 
FEVERS. 

The need for talnng stock of new procedures for the 
pievention and treatment of disease arises from time 
to time, and in the opening pages of our present issue 
toere appears the report of an opportune lecture by 
Dr. Monckton Copeman, in which he survevs recent 
developments in immunization against diphtheria, 
scarlet fever, and measles. In connexion with the . 
treatment of diphthex'ia it may be wise to recall that 
these new methods of prophylaxis in no way invalidate 
the wise rule of prjietice that when a patient shows 
niembnuie in the throat :md a suspicion of diphtheria 
arises, impelling the doctor to take a swab, antitoxin 
®“Ould be given then and tliere. For the prevention of 
the disease Schick testing and aefive immunization 
rave proved their utility, and in the case of mrrses 
m, diphtheria wards and of children, in residential 


institutions in wliich diphtheria is endemic, sufficient' 
experience is now available to justify action. None 
of tlicsc nurses should bo Schick-positive, nor should 
the children, unless the parents refuse the protection 
offered. In regard to the general population it has 
often been said that, though any idea of compulsion 
will be equally distasteful to medical administrators 
and to the public, every parent who desires protection 
for his children should have ready access to an 
immunization centre. Many public health authorities 
already meet this demand. 

The Dick test and active immunization against 
scarlet, fever have clearly conic to stay, though the 
exact field they will occupy and the details of the 
optimum methods in their application have not yet 
been finally settled. Evidence from Benson and 
others indicates already that the personnel in scarlet 
fever wards can be almost entirely protected against 
the disease. In infected residential schools and 
kindred institutions in which scarlet fever is endemic, 
these measures, properly ttpplied, give (he responsible 
authority n confident control of the position. In an 
emergency a dose of 5 c.cni. of antitoxin will protect 
contacts for from seven to ten days, and allow time for 
other appropriate incasnres to be applied. Here again 
(be busy practitioner will feel that bis coui-se in' the 
toeatment of the disease is clear. 'Wlien be -is called 
to an obvious case of scarlet fever be need not feel 
obliged to remember that the Dick test and the Shultz- 
Clinrlton blanching tost will be positive, and that 
haemolytic streptococci are present in almost pure 
culture in the throat — ho may be glad enough to recall 
(hose facts when in doubt about a diagnosis in a diffi- 
cult case or during a iTonblesome atypical epidemic 
in a school — but he trill remember to give intra- 
muscularly an adequate dose of scarlet fever antitoxin 
at once if the patient is severely or even moderately ill. 

The vexed question of the interrelation of the 
haemolytic streptococci must at present be left to 
the immunologists. It is interesting that Pansh and 
OkelP find scarlet fever antitoxin more useful in 
neutralizing, in the rabbit, the haemolytic strepto- 
cocci of puerperal- and streptococcal septicaemia and 
erysipelas than the autogenous scrums. Their sugges- 
tion that scarlet fever antitoxin should be given an 
adequate trial in the treatment of all infections 
caused by the luieinolytic streptococci has a certain 
amount of clinical support, and will appeal to many 
practising physicians. , ■ - 

We are glad that the use of convalescent serum in 
the fight against measles has agahi been brought before 
the medical public.- To the child aged less than 
3 years, and particularly to one already stinggling with 
some other illness, an accidental exposure to infection 
witli measles is a serious matter, for at this age 
mcasle.s is a grave menace. The knowledge that 
5 c.cm. of liuniau convalescent serum given in the -first 
four or five days after' exposure will completely protect 
such an infant, or will give safety to a schoolboy due 
i-o sit for an important school examination, and that 
(be same dose given between the fifth and ninth day 
after exposure 'will almost certainly allow a very mild 
and transient attack of measles to develop with subse- 
quent active immunity, will often be gratefullv recalled 
by the busy practitioner. Tet it is disturbing for him 
to have this Imowlcdgc but to be unable at present 
to get supplies of the serum when required. Lord 
Monkswell, in a letter printed in 'the. Times on 
-May 4th, called attention to a case in which it was 
impossible to procure the serum in London, and a 


> P.iiiUi. H. J., ami Oltpll, C. C. : Lancet, 1928, i, 715 
* See liritUh yiciltcal' Journal^ 192S, i, 189. 


862 MAX 19, 1928] 


SNDOSCOP7, 


[ Tok Rimn 

MtDlCil. JoVftXAft 


telegram had to be sent to Paris. A convalescent 
adult can easily spare 300 c.cm. of blood. Jne voiw- 
teer can be told, without exaggeration, that the thirty 
doses of serum resulting will certainly remove much 
anxiety from many troubled mothers, and muj cjuiio 
probably save the lives of a number of infants. Such 
a presGutation of tbe case should maho a powerful 
appeal to many convalescents. A healthy adolescent, 
12 to 15 years of age, could easily spare 100 to 
150 c.cm. of blood, and Dr. Canti’s' success jn 
obtaining small supplies from volunteer patients 
suggests that the appeal will often ^ succeed. ^ It 
would be a great source of satisfaction it the Medical 
Department of the Ministry of Health, which has 
done so much aheady in other directions, could over- 
come the difficulties in the way of organizing a central 
supply of convalescent serum for urgent cases of 
measles. 


ENDOSCOPY. 

The originators of endoscopy could scarcely have foreseen 
the extent to which it has proved to ho ca]iahlo of dovcloj)- 
incnt, although its introduction into the ])racticc of 
medicine is of relatively recent date. It is natural that its 
foremost and most dramatic triumphs should ho thoso in 
which life has been saved by tho extraction of foreign 
bodies from the air passages or oesophagus, or even from 
tho stomach, hut in the past few years its application to 
the diagnosis and tz'catmcnt of disease lias also made 
striking progress. Of those who have devoted themselves 
to the study of this highly .specialized work it is no over- 
statement to say that Dr. Chevalier Jackson and his asso- 
ciates ill Philadelphia have accomplished more than all 
other contemporaiy workers combined. It would seem, 
indeed, that in so far as the extraction of foreign bodies 
is concerned Dr. Jackson has no further fields to conquer. 
The first edition of his Bronchoscopy and Esophogoscopy 
was an abstract of the large work Peroral Endoscopy. The 
latest edition of tlio smaller work- is on the same linos, 
hut the scope is broadened; there are fresh details, and it 
contains, among other now matter, an interesting account 
of the course directed by Dr. Jackson at the Univorsity of 
Paris. He tells us that “ when Peroral Endoscopy was 
published in 191^ five cases were mentioned as beyond tlio 
limits of bronchoscopy.” ” Every one of thoso cases would 
have been quite simple to-day,” and the only exception that 
he now admits “is in the case of foreign bodies tliat aro 
so small as not to he localiznhio.” " Tlie impossible 
111 bronchoscopy for slender foreign bodies, such ns pins, 
in minute bronchi at tho periphery of the lung ” has been 
practically eliminated. Of the method generally Dr. 
Chovaher Jackson says “ it is all a matter of plumbing.” 
The meta^phor scarcely does justice to an art wliicli has been 
brought to such a stage of refinement, though tho meaning 
m clear enough, but it there are any general principles 
invo red this is about the only one. The summit lias Imcn 
reached by the detailed study of a large number of cases 
by the selfless co-operation of a number of fellow workers’ 
both colleagues in other branches and assistants and hv 
the ceaseless adaptation of instruments to meet the infinito 
variations in the problems which demand solution. Perhaps 
this last consideration is the most important of all for 
• endoscopy is an art which lends itself in no way to make- 
shifts or brilliant improvization. Everything depends on 
proper instruments and assistance, and for the inox- 
pencnccd operator it is better to leave a case alone than 
approach it eithor with an insufficient equipment or it 
may bo added, without reading i>r. Jackson’s book. “ Tl«j 


= BronS.M.m' health, 1927, xx, 218, 

Sc.D., By 'Chevalier Jackson, MD 

10 plates. 36s. net.) ® PP- 'IS?; 179 figures' 


motto of tho endoscopist should ho, ‘ I will do no harm.’ ” 
Primuni non noccrc is a riilo of gonornl application, hut tho 
account of tho state in which many patients reach the 
Uronchoscopic Clinic in Philadelphia .after iinsucco.5sfuI 
endoscopies elsewhere shows that it applies more forcibly 
hero than almost niijwlicro else in nicdiciiio or surgery. 
It would ho impoB-sible, therefore, to exaggerate tho benefit 
resulting from tho training which a largo number of tho 
yoiingor scliool of laryngologists Iiavo received at, the 
Bronchoscopic Clinic. 

THE FOUNDER OF THE RED CROSS MOVEMENT. 
Hr.xnt Dunant, tho ccntcnai-y of whoso birth was colc- 
hrated at Geneva on May 8th, founded tho Rod Cross 
inovcincnt, which ranks voiy- high among the international 
organizations associated with tho name of this Swiss city. 
Genova wa.s, in a sense at lea.st, tho home of Calvinism; 
it was tho domicile of tho now forgotten First Inter- 
national; it is to-day tho seat of the Loagiio of Nations; 
but no idc.al or entorpriso which lias originated in Geneva 
has gained such world-wido approval as has the Rod Cross. 
Duiiniit was a member of a patrician family of the Bepuhlio 
and Canton of Geneva, .and appears to have derived his 
interest in tho care of tlio sick and wounded in w.ar from 
liis ndmiratioii for tho achievomonts of Florciico Niglitingalo 
in tho Crimen. In 18S9, when Franco, Austria, and Sardinia 
hocamo involved in war, ho went to Italy, and at tho h.attlo 
of Solforino assisted in the removal and care of tho 
wounded. Threo years later ho .jniblislied his impressions 
under tho title of Eouvenirs dc Solfcrino, and in his con- 
clusion uttered tho hope that before long the treatment of 
thoso who suffered in war would he governed by a general 
a"rconicnt providing for their relief irrespectivo of their 
nationalitv. Dunant’s siiggo.stion having been favourably 
received a'lul actively supported in Switzerland, ho under- 
took a missionary tour of v.arious European capitals to win 
wider support. In October, 1863, a conforenco of repre- 
sentatives of various Governments was held at Geneva, 
and certain fundamental principles were enunciated, the 
effect being to embody in international law the idea of 
rcsncct for tho wounded and of a incasuro of ininnmity 
for medical personnel and material. Tho Geneva Con- 
veution camo into being in tho following , year, when 
dolcoatcs of sixteen countries, at an assembly convened by 
tho Swiss Federal Government, agreed to its provisions aiu 
adopted tlio emblem of tho red cross on a white ground, the 
symbol being the Swiss Fcdcrnl colours reversed. Tins side . 
of tho movement gave tho wounded a definite title to jno- 
tection, hut tho other side, which resulted i" .crcatio 
of the Red Cross societies, has been of equal ^ 

The establishment of tho first Geneva committee, the 
International Committee of Assistance to the Rounded, s. 
JolSowod 60 on afterwards in Great Britain, for exam, Jo 
by tbo inauguration in 1870 of the National Soc.el) for 
Aa to the Sick and IVoiiiided in Rffir-tlio parent of the 
British Bed Cross Society. It is -uuneccssnij o i 
t. b, 

Cross Committee, notably in _conpexion 
war, and the various national bodies 
Since then Red Cross work has taken a ne o 
.and to-day tho chief concern is with than 

war, hnt of peace. In a \,,fc less 

thoso associated with trenches and 
important to suffering men and women, tho 
tradition which inspired the founder of t 
persists. Henri Dunant has not , j'j jatter 

Luition of his work, for ho died in 19“- fety. 

years were ovorshadoweel by sickness an ' pn^ther un- 
it is pleasant to, recall that ho was , the 

rewarded and unrecognized, for m roral 

rocipiont of tho first Nobel Peaco Prmc, aud oi , 

I occasions foreign orders were beston od upon 


May 19, 1928] 


YELLOW FEVEB IN WEST AFRICA. 


UUUCAX. J0CUI& 


863 


MULTIPLE EXTRACTIONS OF TEETH. I 

It is a cTirimts fact tliat, tlcspito the liovvov uuivorsaUy 
evoked by tlio sight of tho dontist’.s foi-ceps, tooth extrac- 
tion is still widely regarded ns a very minor, almost eon- 
temptible, operation. “ Oil, wliip it out with a whiff of 
gasl” is tho attitude of many )ieoido, both among the laity 
and among members of the medical jirofession. — as if .shock 
and sepsis were nnlviiown after operations in the month. 
In a post-gradnate lecture delivered lately at the Royal 
Dental Hospital of Ixindon' Dr. Harvey Hilliard, .senior 
anaesthetist to that institution, urged the importance of 
a more serious view of tooth eNtractiou, es]ieeially of 
multiple extractions. Dr. Hilliard has thirty years exiie- 
rience both of general practice and of dental ana« .stheties, 
and may claim to speak with authority. He holds that 
multiple extraction of teeth should rank as a major oiiera- 
tiou, to be performed in a nursing home or at the patient’s 
own residence, after due medical examination (ineludiiig 
blood examination) and proper preliminary pn-paratiou : 
and that an adequate period of couvale.scence should be 
arraugeel for, and tho patient immediately fitted with 
tem))orarv dentures, so that ho can juirtakc of the diet he 
has found by experience best suited to him, and thus be 
saved from tbo risk of being half starved, with its inherent 
danger of consecutive disease. As the result of his own 
experience Dr. Hilliard finds that ]iatieuts siilfer 1 nub less, 
as regards both shock and sepsis, if all tho teeth are taken 
out on one occasion. Operating at homo, as opposed to 
extraction in tho dentist’s room, allows of the ttse of a 
preliminary injection of atropine and morphine, nhich in 
tuin may render prolonged nasal “ gas ” available in eases 
otherwise calling for ether. Dr. Hilliard’s lecture is of 
more than passing interc.st, and tho views he luits forward 
diserve careful consideration, though we suspect that some 
medical practitioners and dental surgeons will find diffi- 
culty in agi'Oeiug that whole.sale e.xtractioii at one operation 
is a good routine procedure. 


of this little outbreak is iiitorestiiig. Tlio disease was 
doubtless introduced from one of the several infected 
areas but a few miles from Accra. The first case was 11 
Syrian, as has happened before along tho coast of We.s-fc 
Africa, Dr. Relwyii-Clarko then traces tho circumstances 
leading to the infection of subsequent cases, with a shoi-t 
clinical account of each, and the measures adopted to 
prevent tho sjircad of tho epidemic. There was, as is 
commonly tho ease, considerable difficulty in making a 
diagnosis within the fir.st three or four days — that is, during 
the |ieriod when the patient is infective — and the lack of 
some means of getting over this difficulty was severely felt. 
Clinically the disease varied somewhat from yellow fever as 
.seen in America, as has been before remarked, and in no 
case, coiifirmiiig ])revious exjierioncc in Africa, was tbo 
Lffitoxpira ictefoidcs discovered. ’The American commission 
has, however, using .some of these eases as tho source of tho 
virus, carried out siiecessfiil experimental transmission to 
animals, and all recent Avork goes to prove that yelloAv fever 
is caused by a filterable virus, and that L. icteroides is 
identical with L. ictero-hacinorrlinyica , and plays no paid; 
in that disease. Les.sous may be learned even from so small 
a series of facts as are presented in tho Accra report. Ajnong 
the.se are the necessity for an efficient medical and sanitarj- 
.service, armed with the needful resources and backed with 
tho c.ssential legal powers to act ; the urgent need of some 
biochemieni tc.st a.s a rapid means of diagnosis at an early 
stage of tho disease; and the danger involved in non- 
segregation of native populations in townships Avhich in- 
clude European inhabitants. This last question is one 
Avhich, of course, not only arises when protective measures 
again.st yellow fever are under cmisideration, but in malaria 
and other tropical diseases also. It is one which has often 
not been sufficiently recognized by Europeans, and has led 
to feelings of antagonism on the part of the natives, but it 
.should never bo lost sight of Avhen dealing with toAvns 
cotitaining native elements whose standard of hygiene is 
below the EurojAcan level. 


YELLOW FEVER IN WEST AFRICA. 

R JIILE it no longer inspires the old terror, and has been 
robbed of its strongholds in most [larts of the New World, 
owing to tho ease .with which the insect vector Aides 
(Sfegomijia) argenteus can be attacked, yellow fever still 
inescrves the secret of its identity, cA'on though, as 
recorded in our issue of April 28th, 'some new light has 
lately been throAvn upon the nature of the virus. More- 
ovei , the disease still continues to smoulder ou the AYest 
Coast of .Africa, blazing up from time to time into smaller 
epidemics nhich no one can afford to neglect. These have 
been the subject of communications by various writers, 
such as Lasnet (French West Africa, 1926-27, VvU. Acad. 
Med.), .Aitkin and Smith (Lagos, 1926, Trans. Hoy. Soc. 
Ttop. Aled. and Syg.), and now the outbreak in Accra 
(March^une, 1927) is dealt with bv Dr. Selwcm-Clarke 
U 1 a report published by the Gold' Coast Government.” 
For the whole colony during the year 1926 there had been 
8 European and 57 African cases; during 1927, 14 (10) 
Europeans, 88 (25) Africans, and 5 (5) Svnans (the 
numbers in parentheses being the number of fatal cases 
among them), a bigger outbreak than had over previousTv 
been recorded, leaving out of account the csfhnafed figures 
given by the Rockefeller Commission for .Asamankese 
( 26). TIio large number of African cases is worthy of 
note, and is probably explained by the easier methods of 
communication on the one hand, and, on the other, the 
greater facilities for recognizing tho disease. For the town 
ot Accra the figures were 3 (3) Europeans, 9 (4) Africans, 
rm (4) S 3 iians; these are small figures, but tbe history 


J l.iiiicel, .\pri} ^l^f, 1928. 

lieport on Jelloic Fcrcr in Accra 1<177 fJnlri 

Oovrtnment riinting Office, Accra. 19*. S ‘ 


LIGHTING AND FINE WORK. 


L.rsT year there was issued a joint report of tho Indus- 
trial Fatigue Research Board and Illuminating Research' 
Committee on an inqniiy into tho optimum illumination 
required for typesetting by hand in the printing industi-y. 
The results suggested that with a system of direct lighting 
output did not reach its maximum, nor errors and turned 
letters (letters set upside down) their minima, until an 
artificial illumination of approximately 20 foot-candles was 
attained — an amount believed to bo much liigher than 
that usually found in printing offices to-day. This investi- 
gation has now been extended by an inquiry into the kind 
of artificial lighting^ that_ gives the best results as judged 
by tho same tests in this operation, taken as typical of fine 
work. Illumination was standardized at 10 foot-candles, 
but the type of lighting varied from direct to semi-indirect 
and Complete indirect, with the intermediate provision of 
combined direct and semi-indirect. Tlie direct was tho 
common bulb lamp, but in the tests the lamps were fitted, 
into a trough that reflected tho light upon the type-case 
and protected tho eyes of tho comiJositor. Semi-indirect 
lighting was obtained by reflectors of various types above 
tho lamp and opal shields below it. The tests showed tho 
usual diurnal variation in output and errors; output 
tailed off towards the end of the morning and again in the 
late afternoon, while errors at fir.st declined and then 
tended to increase as fatigue came on. There was some 
evidence that the semi-indirect system gave the best results • 
output was increased and errors diminished. The mixed 
system of direct and semi-indirect lighting, though highly 





864 Mat 19,. 1928] 


OnARLES NICOLIiE. 


Titr 

MUjJCAL'JouRS'AI, 


appi-oved by the printers, did not scorn so favonrablo to 
accurate work. Indirect lighting, whero’ tho lamp u'as 
enclosed within a white enamelled opaquo bowl surmounted 
by a trumpet-shaped pale blue glass intended to give an 
approximate daylight effect, was much liked by tho 
printers, but was not entirely satisfactory. Tho main 
conclusion derived from this report is that good lighting 
. — good by reason both of sufficiency and of wiso distribu- 
tion — is a true economy in furthering tho comfort of 
workers and improving their efficiency. In conclusion, it 
may bo suggested that good lighting in tho home, though 
less susceptible to investigation and less obviously of 
economic consequence, also deserves tho greatest con- 
sideration, notably whore much sewing or study is done. 


CHARLES NICOLLE. 

This year has witnessed tho twenty-fifth nnnivorsai’y of 
tho assumption by Dr. Charles Nicollo of tho charge of 
tho Pasteur Institute at Tunis. At tho end of last month 
the event was celebrated by a distinguished company, which 
met in the municipal theatre of tho torni. Representatives 
were present from tho Pasteur Institute in Paris and from 
medical societies at Rouen, Havre, and elsewhere, together 
with the General Officer commanding tho Prench troops 
in Tunis, several officers of tho navy, tho Swedish, Spanish, 
Italian, and United States Consuls, and His Britannic 
Majesty’s Consul-General in Tunis, Mr. J. M. MacLeod. 
A congratulatory message was received from Madame 
Vallei-y Radot, Pasteur’s daughter. Dr. Consoil presented 
to Dr. NicoIIe a beautiful gold medal to express tho gr.nti- 
tude of tho French people to their admired compatriot. Dr. 
Nicolle, in replying, spoko of tho grey sky of Rouen, and 
alluded to his Norman ancestry. Ho modestly touched but 
lightly on his own fundamental work, but drew attention 
■to the wide and varied usefulness of tho Pasteur Institute 
in Tunis.^ He referred to its antimalarial research, to tho 
transmission of typhus fever to animals, and to tho invc.sti- 
gation of trachoma. He recalled the study of aioditorrnncan 
fever, the serum prophylaxis of measles, investigations into 
rabies, and other matters by which the Institute has 
rendered such signal benefit, not only to North Africa, 
hut to medicine in general. One speaker quoted Flaubert 
w Salammbo : “ Tunis is a land of greenery and birds. 
Under its orange trees tho air is so sweet that it is ininos- 

Th!r P prophetic. 

fIuiIp / Octavo 

wholfi I I author and inspiration of tho 

men in'^ thir*' Dr. Charles Nicolle. Scientists and inodical 
men m this country will join with their collea-uos in 
Franco and all over the world in congratulating D^Nieo ,^ 
on this anspieiona occasion, which marks a rta.^0 i^his 
dis mgnishad service, hnt happily does not put°a perffid 


A CORONER'S DISCRETION 

Thu office of coroner is an ancient and honourahle one 
Dr. RTiitelionse, coroner for South-East London is 
barrister-at-law and the author of Notes for OvuiL^ 
of Coroners’ Olfieers and of The Coroner oid iX Jffic' 
He, in common with all other coroners, is supnosed to 1 
at liberty to do and say whatever lie Rkes i„ l,;g 
court, subject only to the jurisdiction of the Lor 
Lbancellor with respect to his removal. Nevertheless tb 
conduct of an inquest and public pronouncements mad 
by a coroner in his court may still bo tlio subject of puM: 
comment and criticism. At an inquest held recently a 
Greenwich a verdict of “ Death from natur'al causes ” wa 
recorded in the case of a man who died suddenly whil 
ascending an omnibus. In the course of the 
appealed that a doctor, at the instance of tho Londoi 


General Omnibits Company, liad been ■present at tho jicrf- 
morfem examination without Imviiig previously asked the 
permission of tho coroner. Thereupon Dr. AVIiitcliouso is 
reported to bnvo said tiiat “ if tho company does tilings 
hko tliat I will shut them out of court entirely,” and 
“ 1 will SCO that the doctor is never present in my court 
on any future occasion.” It thus appears that tho coroner 
has aunouiiced in advance his intention to e.vcludo from 
his court, cither ahsohitely or in certain coiitingciicics, one 
or more persons wlio may quite prohalily bo the most matorial 
witnesses in some future cases. Surely if a coroner may 
admit or exclude such. witnesses at'Jiis wliim and plcasnro 
confidence in the U'-efiihicss of inquests cannot fail to be 
nudennined. The medical man concerned in this incident 
committed the error of not asking tho coroner’s permission 
to attend the post-mortem examination. No doubt he was 
at f.anlt; but exemption from tho necessity of attending 
heforo the coroner in fiilnrc may, of course, be regarded 
fioin the personal n.spect as a privilege rather than as a 
punishment. In view of the remarks of tho coroner in 
this caso, too, it may ho worth while to point ont at any 
rate one matter which is outside tho coroner’s discretion. 
Section 22 (4) of tlio. Coroners (Amendment) Act, 1926, 
reads ; " ‘Whero a person states upon oath heforo tbo 
coroner that in bis belief tbo death of tbo deccas'ed was 
caused partly or entirely by tbo improper or negligent 
treatment of a mcdic'al practitioner or other jicrson . . . 
stieb medical practitioner or other person shall liave the 
right, if bo so desires, to be leprcsented at any post-mortem. 
examination.” 


THE NATIONAL DAIRY COUNCIL OF CANADA. 

Tnr, report of tho proceedings of tho National Dairy 
Council of Canada contains several features of interest from 
tho medical point of view. Tho first impression, perhaps, 
is tliat of Biirprlso at the efforts mndo by tho dairy interests 
to incrcaso the consumption of milk lind daily products. 
It is natural for traders to wish to dispose of ns much of 
tlioir mcrchnudiso ns possible, but to tbo avorngo person 
milk is BO mncli a staple of food that it soems hardly 
worth while to labour tho point with . advertising. An 
nrlielo will bo written, for example, around sncli a remark 
ns “A bottlo of milk and a, bath,” which was the first 
rcqno.st made by Lindborgli after his famous transatlantic 
flight, and this will bo publisbod in tlio newsiiapers ; or 
olso sets of posters and bulletins sbowiiig tbo oner^- 
liroducing food valuo of milk, butter, and ice cream will 
1)0 sent to tcacbeis and bonio nurses tbroiiglioiit the 
country. Such “ rules of health ” are promulgated as tho 
following: ‘‘ A bottlo of milk is a bottlo of liealtb , 
Open the window and tbroiv out your chest ” ; “ Be true 
to your teeth so that they will not bo false to yon. 
Prominent .atlilctcs arc the keystone of some of tlio. 
advertisements; just before tho priKo-fight between Tmmey 
mid Dempsey some enterprising person discovered la 
Tnnney drank a quart of milk a day. "’liilo Dempsey tonk 
only n glass, and this was widely advertised in the Cl . „ 
papers. It is clear, however, that *1'® , 

National Dairy Council’s activities has 
tbo moro advertising of dairy products. the 

of sanitary precautions is fully recognized, and on 
immediate results of tho convention was 
resolution calling on tbo Government of Canada to hr „ 
legislation providing for “ a single, uniform, an 
pulsory standard of inspection of all farms produci g 
and cream.” Tbo need for somo sucli . pr 

methods througboiit tbo country is becoming all B ‘ 
in view of the widening of tbo markets for dairy A j 

The deplorable incident of tbo typhoid epidemic in 1 
last spring served to show that one province a ‘’j'® , 

an improved system of inspection. Other ma 



M/iS ig, 192S'] 


PARTIAL DEATH. 


•r iiTE rnm^rt - AfiR 

LUkdicaj. TotmwAt. wuw 


ilisfussrd woro tlio pastouiiziUion of milk ami llio oratlica- 
tioii of bovine tuberculosis, ami oiv tlios(> points also resolu- 
tions wore passed calling for legislative action. The gre.atcr 
part of the discussion i?i tliis convention was very naturally 
concerned with the business aspects of dairying, but credit 
is due to those who conduct this husincss for <li.spl.nying 
a wide ami intelligent intcre.st in tlio sanitaiy problems 
arising from the. handling of milk and other dairy p’-odnets. 
Due prominence was given to the fact that the eighth 
World's Dairy Congress is to be Indd in f'Jnghiml this 
July, under the patronage of the King, who has invited all 
the delegates to visit Windsor and see his dairy and herds, 
in which it is known he take.s .so keen an interest. 


PARTIAL DEATH. 

I.S' the course of one of the addicsscs at the staff meetings 
of the Jlayo Clinic' Dr, K. Libinan spoke on the subject 
of invasion of the body during life by the llorillux itcro- 
gniu CO /IS Hint IIS, especially after operations, uhen it may 
imitato lung complications, such as embolism and broiichc*- 
pmuinohia, and may cause unexplained post-operative 
deaths. The- clinical picture in these cases is “ moderato 
fever, signs in the lung rcscnd)ling broncho-pneumonia, 
and then a. sudden sharp ending with j)iduionai*\‘ oedema 
and vei'y high temperature. If a ])atient has a cadaveric 
look or omits a cadaveric odour, or if the peculiar blue 
discolorations of the skin are prc.scnt, there is more reason 
to .suspect the presence of this condition.” Dr. Libman 
answers his own inquiry, “ What is the meaning of this 
general invasion?” by suggesting that the patient may 
bo regarded ns partly dead, wliich would account for 
the cadiiveric appearance and odour, and the multiplication 
of bacteria which does not occur under ordinary conditions. 
This question of partial death, which had interested him 
for years, he found to be no now idea, for ^lichel Peter, in 
his lectures on heart disease (Xcfoiis <lc cliniijiic iiiedicalc, 
1870, ii, 791) dealt with “ mort partiolle,” and a century 
i.ii ioi Bichat, in his monograph Itcchcrchcs iiliysiologiciucs 
sur in vie ci la mort, discussed the problem with particular 
reference to tlie brain, lungs, and heart, and the influence 
of death of one organ on the others— a subject in these 
days f.inuhar enough in connexion with gangrene of the 
extiemities. Di. Libinan quotes in conclusion Peter’s 
expressive dictum, ” One lives until one stops dying.” 


THE ACADEMY OF MEDICINE OF JERUSALEM. 
Phobahly the most completely international and polyglot 
medical association in the world exists to-dav in Jerusalem, 
uhere at least ten mother tongues are spoke'ii by the fortv- 
five members of the Academy of Medicine, and where there 
are almost as many different training schools and modes of 
thought as there are members. It may bo recalled that we 
gave a short account of the progress of the medical depart- 
ment of the Hebrew University on March 7th, 1925 (p. 471). 
It IS not surprising that the foundation of such a society, 
eicn iiitb its i-eiy laudable objects of proiiiotiiig good 
feeling amongst medical practitioners and the encourage- 
ment of scientific rcsearcli, encountered niaiiv obstacles. 
Indeed a first attempt failed on account of the language 
ifficulti, but this has been overcome, and the first issue 

in Oii-Ewing, 

m mates that the association promises to ho a flourishing 

«mceni winch should go far to solve some of the problems 
o i^dical practice 111 Palestine. Some of the health 
questions which have to bo faced in that country can be 
otter approached if there are full facilities for discussion 
tneen medical men, and the m,Ucfin, by ,,riiiting papers 
mJuU PC l,y reporting dis cussions, will greatlv Lip 


those who are unnblo to attend. A jiapcr on hliiidiiess in 
Palestine by Dr. A. Tricho in the present issue illustrates 
this point. It is estimated that tliere are twenty times as 
many blind there as in Great Britain in proportion to tho 
population, despite tlie. fact that ophthalmia iieonatoruiii 
is unknown. Of a large group of binocular blind patients, 
72 per cent, were found to liave external disea.se of tho 
conjunctiva as tlie origin of their disability. Trachoma is 
the cause of many cases, and acute inflammation super- 
vening on this is very frequent. Glaucoma and cataract 
come next, with 7.83 and 6.85 per cent, case incidence 
respectively. Tuberculosis is not uncommon, but syphilitic 
affections of the eye are comparatively rare, despite the 
fact that tho natives are widely infected with the spiro- 
chaetc. The- vast majority of the blind in Palestine are 
Arabs, and Dr. Tricho insists that bettor general hygiene, 
with expert and timely treatment, will prevent hlindncss 
in 75 per cent, of ca.scs. Tho }Ju/Icfin also contains an 
aeeouiit of tho very successful second annual dinner, held 
on June 23rd, 1927, with Dr. V. Kalbian, president of tho 
academy, in the chair. Dr. Emmanuel Kant, president of 
the older Jewish !Modical Society, was a guest on this 
occasion, and it is clear that tjio relations between tho 
academy and the larger Jewish socict)' arc of tho happiest. 


METHODS OF SLAUGHTERING. 

Dk. Geu.m.!) Leighton of the Scottish Board of Health, 
ill his Benjamin "Ward Bicliardson Memorial Lecture (now 
published in pamphlet form), has given an excellent sum- 
mary of the present position of the meat food industry 
from a jiublic hoaltli point of view. On the advantages of 
the modern abattoir under tlio direct control of a public 
health authority over the privately owned slaughterhouse 
no doubt can exist. The high standard of ' proficiency 
dorannded of inspectors is good for both tho public and' 
the trade. Tho former can rest assured of obtaining meat 
in a wholesome and fresh condition, while tho latter can be 
confident that no carcasses arc unjustly condemned. Dr. 
Leighton is not satisfied with the methods of slaughter of 
pigs, calves, and sheep. He thinks that no animal should 
bo killed by bleeding witliout previous stunning. Much 
improvement in droving and sea transport can yet be 
made. Rongli treatment of ahiinals prior to entering tho 
abattoirs causes much nnneccssai-y suffering. Dr. Leigliton’s 
view that animals are indifferent to scenes of bloodshed 
within slaughtcrhoiisos must be listened to with respect, 
though it leaves us only partially convinced. He advocates 
the large central abattoir built on the open hall system 
as opposed to one divided into a number of small booths 
The central open abattoir is best for the disposal of 
offal, and also offers greater facilities for pathological 
examination. “ 


Wf. are informed that the Rockefeller Foundation has 
made an offer to tho Government of India of the sum of 
£100,000 to build and equip an All-India School of Hvgiene, 
opposite tho Calcutta School of Tropical Medicine, on 
TOndition that tho Government of India becomes responsible 
foi the staff, and that tlio Indian Research Fund -Associa- 
tion, wliich controls the medical research work in India, 
liccames the governing hotly. This will allow the present 
hygiene section of the Calcutta School of Tropical Medicine 
to be used for tlie nuicli-needed expansion of that 
institution. 








2nd, 1926, will be 
holding the office of Director-General AMS will 1 
unveiled in the Queen Ale.xandra Militarv Hosnital Chm.l 
Millhank, S.M'., on Saturday, Juno 2nd, “at S a.m. ^ ' 




866 lliY ig, i'gaS], . 


'llite ‘Scmntenaxg. 


Tn* Bnrtm 
MeiJicit Joutvili 


EECEPTION OE DELEGATES BY THE KING. 

Ox Mondaj', May 14tli, delegates from universities and 
medical societies tlirougliout the world mot in London 
to attend the celebrations arranged by the Eoyal 
College of Physicians of London in honour of the three 
hundredth anniversary of the publication of William 
Plarvey’s great work, the Do Motu Cordis. The fii'st 
event on the programme was the reception of delegates 
at 11 a.m. by the King at Buckingham Palace. The 
delegates, numbering nearly 100, were presented to 
His Majesty by Sir John Bose Bradford, K.C.M.G., 
F.B.S., President of the College, who delivered an 
address in the following terms. 


ADDEESS TO HIS MAJESTY. 


May it please your Majesty. 

By Your Majestj-’s gracious invitation we. arc 
gathered here to-day to celebrate the. Three Hiindrcdtli 
Anniversary of tho first publication of IVilliain Harvey’s 
famous book, the so-called He Motu Cordis, in which he 
announced to tho whole world the discovery already inado 
known by him to his own medical colleagues in hi.s Iceturc.s 
before tho Eoyal College of Physicians. Tliis book Harvey 
dedicated to His Majesty King Charles tho First. ' • ' 

Harvey’s demonstr.ation that tho same blood must flow 
unceasingly round and round tho body, visiting its remotest 
parts, swept away the visionary speculations of his pre- 
decessors and paved tho way for a scientific exjilanation of 
the purpose of the Circulation of tho Blood. Thus it is 
tho publication of tho De Motu Cordis has been rightly 
acclaimed as the Birthday of Physiology and of Scientific 
Medicine. 


Science knows no boundaries of race or nation, and 
obedient to this doctrine Bepresontatives of Medical Science 
from many lands have joined with Bciircscntatives of the 
Universities and Scientific Societies of this Kingdom and of 
the Dominions of your Empire Overseas to ii.ay homage to 
the memory of this great English Man of Science. ° 
Your Majesty, in identifying yourself with this Com- 
memoration of Harvey’s work, is but treading in the foot- 
steps of your Eoyal Ancestors. King James tho First and 
King Charles the First both set a true value on Harvev 

Mm wm** ti'"' J’’U'sician, and tho latter supplied 

lam luth the bodies of deer from the roval herds for his 

vonstantlv brought to King 
to hin?mucrof r"''°“‘*‘“ ’''n’crtioii, and exhibited 

sL ed the rail ? work. Together also tl.ev 

ai eel the raie experience of watching the beatinn heart 

iihsArcLSs* 

M" ®"’'" i'?**" 

Charles and James, and aftenvardf at 
Co“ile'e^^“"‘^'‘^'' '“''‘"’"^’ Warden’ of Merton 

brightest ornament, 1 have the honour to oxnvLrf Y 
Majesty the dutiful thanks of every member ^ r 
Delegation for the honour of this RTCention b w'f 
Your Majesty to-day participates in the^ CelobraLn^'f'’ * 
which we are, all assembled in the Capital of Your Empi/e* 


THE KING’S EEPLY. 

I thank j'ou sincerely for your Address. 


, j'-'" at., 4 \uur Auaress. Tf. ie « -w 

pleasure to me to join with' iriv people in welenm- 
many distinguished men from my Overseas Domini ^ 
ind^d from all parts of the civilizers imw as^mn 

immortardiscove.r'’"'' ^'"'■‘•"’Wnajy of Harv’ 

between' my Partin Addr 

1 ir in to-day s ceremony and the action of 


•ey 


prcdcce.ssor.s, who befriended Harvey in his lifetime. I .am 
proud to think that tho Kings of England of that day, 
recognizing Harvey’s great gifts, granted their patronage 
and help in his work, and are thus entitled to the credit 
of having contributed to tho new birth of medical science. 

Tho importanco and value of 'William Harvey’s work 
cannot be exaggoruted. In' an ago when physiological 
knowledge was in a state of darkness and chaos, he laid 
tho essential foundation for a science of physiology by 
donionstrating not only tho fact of tho circulation of tho 
blood, but the manner in which it took place. He dis- 
cerned and taught that tho true method of scientific 
progress is by observation and 'cx])orimcnt, and it is for 
this, and not merely ns the author of a single discovery, 
however brilliant and fundamental, that wo to-day do 
honour to tho name of Harvey. 

Science, ns yini truly say, knows no boundary of race or 
nation;' Harvey’s own career is an instance of this. He 
was -a graduate not only of our own Cambridge, but also 
of Padua, which ancient and illustrious University I am 
happy to sec represented hero to-day. His great book was 
published in Latin, the universal language of learning, and 
won acceplnnee for itself and fame for its author through- 
out . Europe.' But, though scicnco is international, ' each 
country’s contribution m.ay still bear the marks of the 
iialionaF character. And hero wo may proudly note that 
Han-ev, in' his' threefold capacity ns a .successful physician 
ill .private practice, as physician to St. Bartholomew’s 
Hospital,' and ns an eminent student and investigator, fore- 
shadowed what is now,' and has long been, characteristic 
of British physiology— the combination of research with 
medical and surgical jirnctice, allied with a generous 
devotion to the servicb'of tho poor in the public hospitals. ' 


KECEPTION AT THE BOYAL COLLEGE OF 
PHYSICIANS. 

' An^tisstox OK HoNoa.iuy Fellows. 

F. Library of the Bbval College of Physicians, with 
oral portraits of , Harvey looking down from its walls, 
sonted a brilliant spectacle on tho afternoon of May 
I, when the President (Sir Jonx Rose BR.toror.D) 
ci’vod tho delegates and distinguished guests in connexion 
h tho Harvey Tercentenary. Tho occasion was made 
more notewoithv'by thc-admission to Honorary Fellow- 
,, of tho College of the Earl of Balfour, O.M., Sir, 
lost Rutherford, O.hl., President of tho Royal Society, 
ifessor I p. P.avlov of the Academy of Sciences, 
lingrad, ’and Professor K. F. Weiickebaeh of the 
idomy of Sciences, Vienna. Throe eulogies of Haney 
•c pronounced, the first by an English physiologist. Sir 
rrles Sherrington, O.M., tho ” 

.•sicinn. Professor A. Chauftard, and the third j 
nnan anatomist. Professor Keibel. ^ 

Lcadeinic dress was worn, and the gowns ai 
le fifty British and foreign universities made a v 

[mo: ' seventeen European countries vYre re.w--:|-| 
the assemblage; there were six delegates from tl 
tes six from Br tisli Dominions beyond tlic .seas, 
fersn; in Great Britain and Ireland had its delegate. 

Royal College of Surgeons of England “." J 
leges of Physicians and Surgeons of Edinlnii 
blin were all represented by their Picsu ^ , 
lition there were delegates .T' P 

1 scientific societies, the medical fho 

nv, and Air Force, the Indian » v..e- 

tisb Association, the British ”"£,,1 

ted by Sir Robert Philip, its nt 

learch Council, '^"d other 

iKl “ 






868 May 19, 1928] 


THE HAEYEr TEKCENTENAKT. 


t r Tffc nf.m« 

■ i SfEDICAX. Jonc!tiX. 


EULOGIES OF HARVEY. 

The remaining business was tlie pronouncement of three 
eulogies on Harvey by Sir Charles Sherrington, Professor 
A. Chanffarcl of Paris, and Professor Franz Keihcl of 
Berlin, after which the President briefly expressed the 
thanks of the gathering to the three speakers, and the 
proceedings terminated. 

Sir Chahles Siiekhixgtqn. said that in William Harvey 
they bore in remerhhrance one who was Fellow, Censor, 
Treasurer, and, for a daj', President-Elect of the College, 
its benefactor by gift and bequest, and part and parcel of 
its pride and honour. Three .and a half centuries had 
passed since his birth, and three since his unforgettable 
book. In science as in letters, the book is of the man. 
Harvey’s book embodied not only Harvej-’s thought, but 
what his hand had contrived, searched for, and found; At 
the Renaissance the spirit of man turned from an old 
order, “ cabined within a rounded scheme of things,” to 
move and inhabit for itself afresh. The new dav broke 
first on scholarship and letters; in science it adventured 
first among the stars. When it turned to explore the 
inward meaning of organ and organism, the living func- 
tion, the Renaissance teas William Harvev. 

Harvey was the pupil and fervent admiiV-r of the masters 
of antiquity. To him, listening in the steep theatre at 
Padua to Fabricius expounding in Latin the jiarts lis- 
phayed below on the anatomy table, Aristotle and Galen in 
living authority were as present as was Fabricius himself. 
But his famous exhortation to others— to search out Nature 
bv experiment— he addressed early to himself. For his 
great discovery he applied only those means and appliances 
which had been at men’s disposal from classical aiitiquitv 
onwards. His was the triumph of the new spirit aided 
only by its own fieedoin. He was the coming of niodernitv 
not that he was entirely modern, for he let ten years pa‘<-s 
between his discovery and sending to the jiress the slender 
book which engendered modern medicine: I'lic iiicssa"-e had 
m fight its way, and in some quarters did so slowly? But 
Harvey relied on the truth and the future. Ho could 
hardly have guessed the long train of gifted men who were 
to extend his work— Einthoven and Starling so freshly 
lost to us, and, of his own College to-day. Dale and Lewis, 
brilliantly extending by discorery his original discovery 

To supply m fort3'-nine small pages a refutation of nine- 
teen centuries’ tradition of continuous error argued a fine 
restriiint. But once at least Harvey gave his spirit rein, 
and in forecasting the uses which must accrue to the blood 
in virtue of its circulating, burst forth into a luxuriant 
pass.ige. This was a new Harvej', a Harvey fired with 
constructive imagination, a Harvey who could write in red 

loveT” n “ Everything is full of 

i,?. i 1 springs of his enthusiasm was 

his philosophy of nature. 

Sir Clmrles Sherrington concluded: “The work of 
Haiiej , the spirit of it no less than the import of it pro- 
vides his euloa- and makes superfluous all other. H s^> 
discovery, aside from its .intellectual worth, seen ref an 
Item of knowledge than which no other singl^ item hi s" 
.served to grow, as from a seed medicine as if now knmv it 
And It was the reassertion the rebirth, of the method of 
experiment which wedded to observation, had crelrd 
the med.cine-and the surgery-of the civilized -.nfrW 
to-day. To engender medicine aneiv is to engender a wliolo 
world of correlated know edge ; and an attendant world of 
beneficence no less. The circulation of the bloon ri 
meaning of the heart the light of a victorious nilhof 
May we not affirm that modern medicine does in fact t t 
there? Harvey, founder of modern medicine 1 He 
himself have felt no term can carry richer or lovelier nr 
from a grateful world.” ^ 

Professor CK.iurF.iitn said how greatly he appreciated the 
invitation to speak at this commemoration. The honour 
embraced the -Academj* of Medicine of Paris, of which he 
was .a delegate. To speak of Harvey and his book was a 
real joy to a physician. In the first place, he was creatlv 
impressed by the courage exemplified in its publication 


Onl^- a voice here and there, such as that of Vesalius and 
Servetns, in the sixteenth centiirj' had disputed, with 
groat temerity, the authority of Galen. Hanoi' himself 
lost part of liis practice, and had many opponents, less 
in his own countrj’ than in Itali' and Gormaiii', hut mo.st 
of all in Fi'ance. If his discoverj' was a work of courage 
it was also a work of ]).atiencc. The speaker reminded 
Iiis audience that in 1616 , twelve j’ears before the public.a- 
tion of, his book,- Hnrvci', to. an aiidienco of about forty 
persons at the College of Phi'sicians, 'made a public state: 
mont of his ideas regarding the circulation of the blood. 
The ])ublication was pfcecdcd by many years of silence — a 
period of ineubation and verification necessary to all great 
work. There was a similar period of quiet in the history 
of Francis Bacon before he gave to the world his A’on/m 
Organtiiii, and the same was true of Newton, and Pasteur, 
and Darwin, and others. Genius had long patience. The 
wise man avoided the error of premature publication. 

Another most striking characteristic of Harvey’s work 
was his industry. It was through a variety of direct 
obsen-ations on many different creatures that ho gradually 
overcame the difficulty of his subject and arrived at his 
explanation of the functions and structure of the heart. 
But he had also the vision to see far ahead how many 
problems could be solved, how much advance made possible 
as a result of this now conception. Harvey was fully con- 
scious of the immense future scope of his discovery. As 
time had gone on, the truth of it had been preserved; it 
had been supplemented by the modern means of observation 
av.ailablc, but not diminished, only completed and multi- 
plied in value. His work stood intact. In other respects 
also, in the general precepts which he laid down for the 
teaching of anatomy, for example, not one word needed to 
be taken away. In embryology ho showed the same grasp 
of his subject and the same striking modernity of ideas. 
And Harvey himself was in no way inferior to his work. 
He was a man of the highest moral character, true to his 
convictions and friendshi])s, devoted to the interest of the 
College, of which he was a most generous benefactor. It 
was fitting that on this occasion the whole world of medi- 
cine should unite in eulogy and in pious gratitude. 

The final eulogy, by Professor Fn.txz Keibel, was 
delivered in German. We are indebted to Dr. J. D. 
Rollcston for the following translation : 

It is my' privilege to say a few words on the relation of 
William Harvey to anatomy. First of all, let me brieflj* allude 
to the relation of phj'siology to anatomy. Both sciences have 
a common root and are thereby closely associated, but even in 
their terminal ramifications to-day they are not completely 
separated from one another. I need only remind you that the 
wide subject of joint phj'siology has received most attention 
from .anatomists. The same was time, even in a greater degree, 
in the time of William Harvey', and we know that Harvey was 
not only a' great ■ experimental physiologist, but .also an out- 
standing anatomist. Of anatomy he said that it' should not be 
learnt froth books, but from dissections; not from philosophical 
dogmas, but from the structure of the body. 

Harvey, of course, like all great discoverers, bad hi.s pre- 
decessors as well as his followers, who brought his work to 
completion. ' It is a remarkable fact that Andreas Vesalius, the 
great reformer- of human anatomy, can only in a very restricted 
Sense be included among them, in spite of his excellent descrip- 
tion of the heart., Vesalius could not find any pores in the 
ventricular septum, but, nevertheless, supposed that air passed 
through it, on tliis point being in agreement with his great 

opponent Galen. . , .1 r 

Among Harvey’s predecessors must be mentioned tlie untor- 
tunate Servetus, -who gave a correct description of the lesser 
circulation in a theological book entitled Cliristianismi liesiitutio 
(1553). This work was burnt with its author, but it has recently 
been suggested that it was known to Eealdus Columbus, who 
gave a similar description of ' the lesser circulation, although 
he made no actual mention of the work of Servetus. The 
other predecessors were Caesalpinus, Cannani, and Fabricius ab 
Aquapendente, Harvey’s teacher at Padua. Cannani discovered 
the valves of the veins, of which Fabricius published admirable 
drawings. Fallopius also should not be forgotten. 



May 19, 1928! 


THE HARVEY TERCENl’ENARY. 


■[ 


T^iE Ditmta 

ittVlC^Is JOCBXi£ 


869 


anatomiga de 

MOTV cordis ET SAN- 

GVINIS. IN ANIMALI. ; 


. \U these men had in tiieir linnds the hey to the Rrcat 
riddle of which Harvey said at the com.neneeinent of his 
studies with I’racastor that it was so ditncult that God alone 
knew the. answer. -They , were in pos.session of a number cf 
isolated facts, hy proper application of which to inductive 
conclusions thev might have solved the riddle of the function 
of the heart; hut they did not draw therio concluhions, and 
therefore to William Harvey belongs the full glory of h.aviiig 
discovered the circulation of the blood and the function of the 

lic.art. . - , , , , , 

Among those who completed Harvey a work should be men- 
tioned .Marcello Malpighi, who discovned the capillaries, and 
Aselli, Pecquet, and Rudhcck, who discovered the lacteals and 
receptacuhun chyli. It is -true that Harvey used the word 
“capillaries,” hut applied 
it only to. the., finest 
terminations of the 
arteries. He convincingly 
proved the conne.vion of 
the arteries with the 
veins, but did not succeed 
in denionslr.ating it, the 
demonstration of this con- 
ne.xion being left to 
Malpighi in the lungs and 
urinarj' bladder of the 
frog. The discovery of 
the lacteals and recep- 
taculum chyli may bo 
regarded as . important 
additions to the doctrine 
of the circulation of tho 
blood. Malpighi’s dis- 
covery was made in . the 
year 1661, four years 
after Harvey’s death in 
1657. ■ In 1665 Malpighi 
discovered tho blood 
corpuscles. 

Some time elapsed 
before tho doctrine of the 
circulation was ' generally 
accepted, so firmly rooted 
were Galen’s errors and 
so great was the reputa- 
tion of this ancient phy- 
sician, who for centuries 
was worshipped as a 
saint. New problems, of 
course, arose, and addi- 
tions' to knowledge were 
made. I need only allude 
to the auriculo-ventricular 
bundle— whose discovery 
by William His, junr., 
almost alt of us can 
remember — a bundle 
which gave us such im- 
portant information about 
the functions of the 

heart. We also must not forget that Harvey 


SXEB crTJTlO 


,BVS, 


interest 


the 


took 


a keen 

study of organisms, ami is 
therefore to bo regarded as one of the founders of comparative 
anatomy, iloreover, the latest investigations on the heart and 
circulation rest on the foundation which Harvey laid in so 
masterly a manner, and this foundation will last as long as our 
science survives. 


of the delegates Lord Haiiwortli, Master of tho Rolls, 
showed himself fully acquainted wnth tho life and work of 
William Harvey, and recalled that Harvey himself may have 
dined on that site as tho guest of his brother, who was 
a raemher of tho Grocers Company. Eloquent replies in 
fluent English were made hy Professor J. van dcr Hoevo 
(of tho Royal Academy of .Sciences, Amsterdam) and Pro- 
fessor G. H. Monrad-Krohn (of tho University of Oslo). 
Tho toast of “ TIio Company of Grocers ” .was very .appro- 
priately in tho hands of Sir John Rose Bradford, President 
of tho Royal Collcgo of Pli)’sicians of London, who has had 
long associations with tho Company, and whose name, with 
that of Sir James Paget, appears on the roll of its Honorary. 
Erecmen. In tho course of his speech Sir John mado 

ackiioivledgcmcnt of tho 
splendid hospitality of 
tho Grocers Company 
on this memorable occa- 
sion, and. , indicateel 
Eoincthing of the debt 
owed by medicine to 
that ancient City Guild. 
Many of our readers 
aro well aware that in 
mediaeval times tho 
Apothecaries wore 
linked with tlic Grocers, 
and so remained until 
their separate incor- 
poration as a Company 
in tho reign of James I. 
Tho Grocers Company 
lias always given, and 
continues to give, 
generous aid to hos- 
pitals and other chari- 
table agencies, but moro ' 
than any other . Guild 
it lias recognized tliat 
in tho advancement of . 
education and of scien- 
tific discovei-y lies the 
best hope of diminishing 
poverty and suffering, 
and of promoting 
national health and 
prosperity. It has given 
practical effect to these 
views hy the establish- 
ment of schools (notably 
Oundle), tlie provision 
of Ecliolarships at tho 
imiversities, and tho 
endowment of scientific 
..research. With the 
object of encouraging 
original research in 
preventive medicine 
tho . Company awards 
scholarships . to assist 


arrLiELMi barv^j a^cli, 

^ MMRwhf^'^rofcfns'^AttMmwmCoI- 

^ ' .’UrJit eruoi 



r Jl/IKCOFJ'RTT, 

Sumptibus GVILIELMI FIT ZERL.. 

DC.“Xxrni» 


Title-pace ot Atet editioa of llaoey’p Dc Mo(u Corditt published at ’ 
Frankfurt, 1623. 


THE GROCERS C03IPAET. 

Among the principal events of this Harvey Tercentenary 
jveek has been the banquet given by tho Worshipful 
Company of Grocers in its magnificent Hall in the Citv 
M bondon on Monday evening. A very large and distiu- 
guis led company ot official delegates and other guests were 
received by the Master, Lieut.-Colonel Francis W. Hentli, 
- wardens, and u*ere sumptuously enter- 

ai o f' ^ which tlio great City Companies 

aU-i ^ " orld over. The speeches, and the music 

, veie worthy of the occasion. In proposing the health 


the investigation of matters connected with the causation 
of disease or the means of preventing premature death. 
Discoveries of mhch value have resulted from the ■work of 
Grocers’ research scholars, and not a few of those who have 
earned distinction in that branch of science, such as 
Woolridge, Sims Woodhead, MacFadyen, Rose Bradford, 
Starling,' and Bulloch, have been helped on their way hy 
the Company’s endowments. Moreover, when the scheme 
for founding in this counti’j- a School of Preventive Medicine 
was delayed in execution by want of funds the Grocers 
Company, by timely financial help, relieved the promoters 
from their difficulties, and did much to aid the establish- 
ment of the foundation now known as the Lister Institute 
which has greatly enlarged our knowledge of the causes of 
disease. It is fitting that these services, briefly alluded 
to on Monday hy the President of . the . Royal College of 
Physicians, should he called to mind at .a moment when 
the Company has given further proof, of its friendlV feelin<^ 
towards tho medical profession and of its belief in medical 
research, 



870 May 19, • 192S] 


THE HARVE? TERCENTENARY. 


f Tiir BnjTi?H 
Meific^L Jocn'tii.- 


THE HARVEY FILM. 

The demonstrations arranged hj' tlie Royal College of 
Physicians in the Ph3'siological Department at Dniversity 
College (of which preliminarj- particulars were given in oiir 
last issue at p. 819) included a reproduction of Harrej-’s 
original experiments displaj'ed hj’ cinematograph. Soine- 
tliiug of the thrill which Harvey must have felt as he .slowly 
and cautiously traced the steps which led to his 0])0ch- 
inaking discoverj- was conven ed to those who, three centuries 
later, have watched the graphic unfolding of the argument 
by the art of the film. 

The familiar portrait by Cornelius Jansen of Harvoj- 
sitting at 'a table is first shown, and then the fingers 
slowly seem to come to life. They are next seen represented 
on an enlarged scale. First thej- turn the pages of Galen 
with a hesitancy which suggests doubt; then the effect 
of the disturbing observations of Vcsalius, Servetus, 
Fabricius, and Columbus is indicated. Thinking gives place 
to testing; the books are closed, and the bodj’ is opened 
that its secret maj’ be revealed. The hands pass from one 
animal to another as the various stages in the nrgument iirc 
built up. The rapid beating of the hearts of dogs and cats 
loses its m3-stery when the hearts of snakes and eels are 
exposed. Questions arise and are answered. What is the 
function of this contracting organ? Where does the blood 
go? Where are these alleged pores of Vcsalius to be fouml 
in the curiously tough ventricular septum? Where docs the 
blood come from in order to reach the heart, and what 
evidence is there of the existence of the “ natural ” and 
“vital” spirits postulated by Galen? Then the famous 
time calculation is indicated, and the discovery that in 
one hour the heart expels from itself a greater quantitv 
of blood than the body holds. So, irresistibly, the invisible 
reasoning which guided the testing fingere is driven to the 
idea that there m.ay be motion in a circle. Then in quick 
stages comes the revelation of the functions of the valves 
in the veins and heart, and with the experimenting fingers 
now applied to the human bod3' the great conclusion is 
inevitable. The last part of the film represents Harve3- 
turning the pages of his immortal work, ExercHafio 
Anatomica dc il/ofii Cordis ct Sanginiiis; his hands close 
the book and lay it on one side. The fingers become still- 
the hands are again those of Harvey in the portrait, sittiiiii 
at the table. 

This cinematograph film was more than dramatic; it 
was an education in itself, and a quiet rebuke to guesswork 
without experimentation. To Sir Thomas Lewis and Dr. 
H. H. Dale a very high meed of congratulation is due for 
a brilliant conception and for a perfect demonstration 
of how a great genius reached his greatest discover^-. This 
film might well be shown to evei-3- medical student; it tells 
more clearly than spoken words how knowledge grows from 
more to more, and how .alone error can be replaced by 
truth. 


EXHIBITION AT THE COLLEGE OF PHYSICIANS. 

On the afternoon of Tuesday, May 15th, delegates and 
guests and the ladies accompanying them were entertained 
to tea at the Royal College of Physicians. They were 
receiyed at 'the entrance to the Library by the President 
and an interesting account of the College and its treasures 
was giyen by the Haryeian Librarian, Dr. Arnold Chaplin 
who briefly traced the history of the corporation from its 
foundation by Thomas Linacre in 1518, and described the 
vicissitudes of the Library and the College houses. Books 
manuscripts, pictures, silver, and other objects of interest’ 
some of them relating to Harvey, were display-ed. The 
portrait of him painted by Cornelius Jansen, which hangs 
behind the President’s chair, is reproduced at p. 867 in oni- 
present issue. Other exliibits in the Large Library in- 
cluded the original Charter of the College, granted by 
Henry VIII in 1518, the first Book of Statutes, the first 
Book of the Annals of the College in the bandwriting of 
Dr. John Cains, the Signature Book of the Fellows, dating 
from 1647, and Sr’denhp.m’s Notebook, writteir with his own 
hand. There were also on view the first book printed in 
English by Caxton in 1474, and other incunabula, inclnd- 
iug the fir-st printed edition of Homer, many early and j-are 
editions and manuscripts, and three books saved from the 


Great Fire of 1666., On a sepai-nte table were laid out 
many’ of the earlier editions of Harvey’s work, I)c il/ofii 
Cordis, including the first edition published at Frankfurt 
in 1628, whoso title-page . wo reproduce at p. 869; also 
eleven autograph letters of Harve3-, a book with marginal 
notes in hi.s hand, the oboiy ])ointor used by him when 
delivering his Lumleian Lectures, and his Diploma of 
Doctor of Medicine in the University of Padua. In the 
Censors’ Room were displa3-od the silver plate helonging to 
the College, the ceremonial mace, the silver caduceus 
designed by Cains, and the famous gold-headed cane, whose 
imaginar.3- adventures were told by MacMichaol. Another 
object of particular interest was the catalogue of the 
library of the Marquess of Dorchester, who, after the 
destruction of all but 140 of the College’s 1,300 volumes in 
the Great Fire of London, bequeathed to it the whole of 
his books, amounting to some 4,000 volumes and com- 
prising one of the finest libraries of the time in England. 


. HARVEY AND ST. BARTHOLOMEAV’S HOSPITAL. 

Harvey’s connexion with St. Bartholomew’s Hospital was 
commomorated by a luncheon in the Great Hall on May 
15tli, wlieti Lord Sr.i.vjroitn, treastrrer of the Hospital, pre- 
sided. Sir AVii.siot HEiinixnii.vji delivered an address, 
which was subsequently described by the President of the 
Roval College of Physicians as one of the outstanding 
features of the centenary- celebrations. After paying tribute 
to the valuable historical research of his colleague Sir 
D’Arcy Power, Sir V’ilmot Heri-ingham recalled how 
HarveV, after taking an Arts course at Cambridge, 
studied at Padua for four years and obtained his 
doctorate there; he then returned to Cambridge and pro- 
ceeded M.D., and before the age of 27 came to live close 
to the Hospit.al in the parish of St. Martin, Ludgate Hill. 
A year or two later he was elected “ physician in rever- 
sion” to the Hospital, corresponding to the post of assistant 
physician to-day; in October, 1609, he was promoted fidl 
physician. Sir AVilmot read out the words of the charge 
given to Harvey on his appointment, with its references 
to the care of the poor and the collecting together of 
patients so often ns might be required for the investigation 
of their afUictions. He added that no record of Hai-vey’s 
work at the Hospital for the next twenty years was 
e.xtant, though during that period he was elected Lumleian 
lecturer at the Royal College of Physicians, and also 
physician to James I. The next apparent reference to him 
in the records of St. Bartholomew’s was his obtaining leave 
of absence to be with the Duke of Lennox on his travels 
abroad. Harvey accoiupanieil Charles I on his jouincy to 
Edinburgh for bis coronation, and, while the king was 
wrestling in argument with the divines, the physician went 
off to study the birds at the Bass rock. At a later date 
he appeared as a reformer at St. Bartholomew’s Hosiiital, 
introducing neiv rules and improvements. He suggested 
that no patients shoidd be admitted if they were suffering 
from trivial or incurable complaints. He advised that 
cases of venereal disease should be treated in a building 
separated entirely from the Hospital. No patients were 
to stay in the institution for more than a certain time 
witliotit special leave, while the disobedient and those who 
refused to take their medicine were to be di.scharged. 
The surgeons were not to allow their work to be done by 
their “ boys,” nor to admit patients without preliminary- 
examination. The surgeons should be restrained under the 
control of the phy-sicians, and should perform no operation 
w-ithout their counsel and advice. Sir AA’ilmot exidained 
that the suggested enactment implied, therefore, that opera- 
tive treatment ■ should bo directed by • the most skilled 
knowledge at that time. Harvey- himself in his Ltimleian- 
lectures covered the ivhole of medicine and surgeiT as it 
was then understood, and was an operator himself. In 
1636 ho went abroad again, this time with Lord Arundel 
in the vain attempt to regain the Palatinate for the nephew 
of Charles I. He was commissioned to buy pictures at 
A’^enice for the king, who was one of the leading art 
collectors of the period. In 1637 he returned to England, 
and two y-ears later was appointed physician to the king, 
with quaitei-s in Whitehall, an allowance from the kitchen, 
and a yearly- stipend of £400. He joined the king in the 




Mat 19, 1918] 


TETBA-ETnxri LEAD IN MOTOR SPIRIT. 


[ ■ Tnt CBmra 

tlCDICAI. JOCTBUAl* 


871 - 


Civil Wnv, «u(l eonscqiiotitly, in IG'IS, tlio Houso of 
Commons ordered him to Tjo expelled from St. Bartholo- 
mew’s Hospital, ilms tcnhiimtliig his counexiou with this 
institution. Sir AVilmot Herringham next emphasized 
points of interest in tlio clmractcr of ITarvoy, whoso will 
illustrated his liberal and warm-hearted nature. No member 
of his family cscapotl ’mention in it in tho most cordial 
terms, and all were given bequests. Harvey was generous, 
both in public and private life; ho was deeply beloved 
bv his friends, and a great favourite with Charles I and 
Lord Arundel, two of the most cultured men in Europo at 
that time. Ho was an intimate friend of tho learned and 
famous judge John Selden, with whom ho con.spircd on 
one occasion to euro a man who in.sisled that ho was 
possessed by two devils, which iiiHructcd him to destroy 
Selden. A parchment was given to tho patient, curiously 
inscribed and scaled, and threo mouths later the patient 
returned with tho inform.ation that the two devils had 
been successfully driven out, but that two others had arrived 
making the same demands ns regards murder. Selden and 
Harvey prepared another parchment, and it w.os explained 
to tho patient that, should there bo a reeurrcnce, tho only- 
two men in the world who could savo the sufferer were 
tho two conspirators, who thus ingeniously insured their 
lives. Harvey attended professionally Francis Bacon, of 
whom ho said, rather unkindly, that ho talked philosophy 
like a Lord Chancellor. Sir Wilmot remarked that Harvey 
might well bo described as tho first “ scientific ” man in 
tho modern sense of the word; ho obsoi-ved carefully, mado 
experiments, and drew conclusions. Ho would have boon 
at home in a modern physiological or scientific laboratory 
as no other man of his time could have been; Gilbert was 
his only possible rival in this respect. Harvey might not 
Imvo been so deep in his reasoning as his successor John 
Hunter, but ho was at any rate the founder of tho English 
school of physiology. For many years ho was passed over 
for tho presidency of ,the Royal College of Physicians, at 
first by reason of tho seniority of others, but later, in 
1641, ho was deliberately ignored, owing, it is supposed, 
to political feeling, which was then running- high in opposi- 
tion to tho king and those around him. When tho offer 
was eventually mado to Haiwcy, at tho age of 76, he 
was too old to accept it. His "houso had been destroyed 
in the Civil War and his papers were scattered ; yet his 
closing years were tranquil,, and ho passed them iiapiJily 
among bis books in tho family circle. 


TETRA-ETHni LEAD IN MOTOR SPIRIT. 

C0M31ITTEE OF Inquiuy. 

At the second public meeting* of the committee of inquiry 
on lead ethyl petrol, held on May 15th under the chairmanship 
of Sir FnEDERiat Wn-us, evidence was given by Dr. Myeh 
CorLANS. The witness submitted a pr6cis of his evidence, which, 
however, was not circulated to the press. Ho was questioned 
by the chairman and other mernbers on tho results of his 
investigations as published in the Dailt/ Mail, and in particular 
as to his medical examination 6f two men who had ” serviced ” 
cars using ethyl petrol, one of whom was found to be excreting 
a small amount of lead. Lead was also found on the overalls 
or these mechanics. 


Dr Coplans, in reply to Sir Frederick Willis, said that in h; 

these men spectroscopic exarain: 
t.on, which within limits w.as a quantitative as well as a qualiti 
VO test, was employed With regard to the overalls, lie suggeste 
that It was dangerous to send such articles to the laundry withoi 
some special notification. In liis-prdcis lie had referred to th 
p^sibihty of contamination of water supplies; ho had in min 
particularly the sha low wells used in the country for drinkin 
purposes Sir F, W.lhs asked whether, as a scientific man, i 
thought that the amount of work he personally had done justifie 
hys rather alaraist statements, to. which he replied that his wot 
w as borne out by more prolonged investigations in the Unite 
btates where a -number of aiilboritics 'considered that tl 
w ‘=°"stituted a public danger. He di 

exaggerated the dangers of exhaust gases i 
etii.-'i'^ agreed that he had imputed that the use < 

y pe ro for motor cars in this country might bo followed I 
course, such results depended upon tl 
^ ° cars, the congestion, and tho siisccptibilily of 


commiuT waf publisES" ou'lFay 


persons concerned. Sir F. ^Vi]lis said that if tho Daily Mail had 
been really anxious to got to tho bottom of this problem in a 
sciciitinc way ono would have thought that some of this American, 
work which told in the opposite direction W’ould have been nien- 
iioned, Tho United States Government committee, set up on the 
recommendation of the conference called by the Surgoon-Gcueral, 
had been unable to find any dcfinilc cases of lead poisoning, and 
held that at present there was no good ground for prohibiting the 
uso of ethyl gasoline of the composition specified as a motor 
fuel, provided its distribution and use arc controlled by definite 
regulations." Dr. Coplans said that wdiatcvcr might have been 
tho case with tho Daily Mailj ho himself had referred in his 
articles in the medical journals to. this American report. He 
agreed, in furtlicr reply, that ho had not controlled his results; ho 
had examined tho two mechanics in a garage w'hcrc ethyl petrol 
was used, but not corresponding men in other garages where it 
was not used. .His investigation w'as a private affair, and it was 
a question of money, and o( opportunity for making tests. 

Sir Charles Martin asked whether, if a person remained for 
an hour in a traffic block in Piccadilly, among cars using ethyl 
petrol, ho would run any risk of lead poi';oning from exhaust 
gases. Dr. Coplnns replied that this might be the case in a 
narrow street w'ith a great deal of traffic and in the case of a 
pci'son repeatedly subject to such conditions. Sir C. Martin 
thought such a pei’son would suffer from carbon monoxide 
poisoning far sooner than from lead. In an hour, if it was 
granted that a man might breathe 0.5 mg. of lead, ho would at 
tho same time he absorbing some 300 c.cm. of carbon monoxide, 
which would half saturate his blood. In reply to the suggestion 
that he had exaggerated the danger of exhaust gases in a con- 
fined area, Dr. Coplans denied any such intention, but said that 
it was tho ordinary practice in public health, in addressing the 
public, to speak not with scientific exactness, but in such a way 
that warnings would be regarded. Tho point was that lead was 
a cumulative poison, and the constant breathing of even one-third 
of a milligram per hour was a wrong thing to permit. Sir C. 
Marlin said that one would have to stand in a traffic block for 
six' hours, according to figures which Dr, Coplans had supplied, 
to get the 2 mg. of lead which were said by one authority to be 
i the industrial limit for a working day. Was anybody going to 
' stand six hours in a traffic block? With regard to tho mechanics, 
did Dr. Coplans fed justified' as a scientific man in drawing 
any conclusion whatever from the trace of lead in the faeces of 
one of them, when ho had not examined tho excreta before the 
man was so exposed? Dr. Coplans agreed that no proper con- 
clusions could bo drawn from one or two such cases, but he 
thought it justifiable to keep such a man under medical observa- 
tion. Asked whether, in view of th© fact that there must bo 
largo numbers of employees in America constantly exposed to this 
risk in garages, be knew of a single substantiated case of lead 
poisoning in America, apart from persons employed in th© mixing 
and manufacture of tetra-ethyl lead itself, he submitted a report 
of tlio International Labour Office of March last, and abo quoted 
from the Journal of the American Medical Association on 
February 25lh,.1927, which stated that the Standard Oil Company 
of New Jersey had settled tho case of certain tetra-ethyl gas 
victims by tho payment of 350,000 dollars. Professor W. E. Dixon 
said that ho had read that report, but ho thought the damages 
were paid for accidents in tho manufacture. 

In reply to Professor Dixon, tho witness said that he did not 
suggest that the mechanics he had examined had any signs of 

lead poisoning. He "was awaro that lead was used medicinally 

in great quantities in dysentery, for example — ^but the trouble 
arose when repeated doses were given over a great length of 
time, professor Dixon pointed out that there were other sources 
of lead poisoning besides tetra-ethyl lead, and asked whether, if- 
all these lead hazards were diminished, the danger of ethyl petrol 
would not be completely negligible. Dr. Coplans could not agree. 
A.skcd . whether, if a man took 1 mg. of lead a day, he, would 
get lead poisoning in five years. Dr. Coplans thought it more 
likely to be a few months, not five years. Professor Dixon further' 
suggested that the’ results of certain experiments with lead on 
his own skin, which Dr, Coplans had carried out, might be duo 
to a purely adsorption effect. Lead acetate, for example, put on 
tho skin, could not be washed away; it would have'to be scraped. • 

In reply to Sir William Willcox, the witness said he was awaro 
of Blair Bcirs” experiments with colloidal lead in the treatment 
of cancer, and knew that sometimes toxic effects resulted. The 
point about lead was that it was a slowly accumulating poison. 
It might be a matter of months or years before it was eliminated, 
whereas with carbon monoxide absorbed from exhaust gases in a 
garage elimination 'would be merely a matter of days. With 
regard to water contamination. Sir William Willcox pointed out 
that lead ethyl was a lipoid soluble, and the presumption seemed 
to be that it would stick to the oil rather than go to the water,- 
Dr, Coplans, however, said that the results of experiments proved 
that it went to the water. The last member of the committee 
to cross-examine Dr. Coplans was Dr. J.' C. Bridge, in reply to 
whom the witness said that he would certainly schedule lead ethyl 
as a poison. 






IRELAND, 


f TltE HRITUW 
Mrmcit JotrsNiL 


874 MAY ig, igiS] 


Ministry’s existence, !io said, tlie general dcatli rate of tho 
country had fallen from 14 per 1,000 to 12.3 per 1,000, anti 
infant mortality from 89 per 1,000 to 70 per 1,000 in 1927 ; 
but it was an unhap])}' and regrettable fact that the 
maternal mortality rate had for the pa.st twenty ycar.s 
remained practically stationary. It was_in circnmstance.s 
like these that it was tlic duty of tho Ministry to .stimulate 
all the efforts which were being mado to cojre with this 
blot upon their . civilization. Mr. Chamherlain then 
referred to the committee of investigation ho proiros'-d to 
establish to deal with tho causation of matoimal mortality, 
an account of which was given in the JnuriKil of April 
28th (p. 729), saying they hoped by this means to get 
available information which would throw new light on the 
dangers they were providing against. That they believed 
would he very useful to the Ministry in its cam|)aign 
against maternal mortality. What was needed was inoie 
supervision, both ante-natal and jiost-natal, more o|>])or- 
tunities for consultation, and more beds in maternity 
hospitals. Finally, there was wanted more education of 
tho public, which would then understand more of the 
instructions given, so that it would carry them out whole- 
heartedly. He then emphasized the importance of attract- 
ing into tho profession midwives of the' right type: their 
training was not so complete as in .some Continental 
countries. Accordingly he had just appointed a .strong 
committee to investigate tho training of midwives and their 
working conditions. The pressure and support of ])uhlic 
opinion would ho required if tho recommendations were 
to be carried into effect. Mr. Chamherlain concluded liv 
saying that he believed that in all tho fields of jiuhlic 
health there was no more noble or fruitful .section than 
that to which they were devoting their efforts. 

The London County Council and Compulsory Vaccination. 

Tho City Council of St. Albans has asked tho London 
County Council to support a resolution passed bv it to 
the effect that in view of the increasing prevalence of 
small-pox in this country the law should be amended so as 
to provide for compulsory vaccination and revaccination- 
further, that the medical officer of health should have 
power to isolate contacts or siisiiects for such period as he 
might deem necessary. The Public Health Committee of 
the Loudon County Council, however, considers that in the 
pre.sent state of public opinion it would not be wise to 
attempt to impose any further measure of compulsion in 
regard to vaccination. “ This does not iniplv that the 
value of vaccination is in any way considered In’ competent 
medical opinion as having diminished. The coiitram- is the 
case. But the whole question of vaccination is under 
consideration by a departmental committee, the report of 

ndttee Stal ® contacts, the Public Health Coin- 

f ^ -M 'f- outbreak of small-pox of a 

relat vely mild kind which has been prevalent -for some 
months IS being spread by persons of thi vagr ant class wl o 
frequent the casual wards of Poor Law institutions' and 
there are no powers of controlling adequately their move- 
ments in the present emergency. It is considered doubtful 
whether any strengthening of control would not defeat its 
own object, since it would lead to avoidance of the casual 
ward One objective of the Ministry of Health in dealii g 
with the iiresent outbreak is to keep all casual wards open 
mid thereby to have all tramps under close observation. 
The closure of the wards would disseminate rather than 
restrict the spread, and drive casuals into common lodirinn- 
houses. It is also iioiiited out that the present oiitbre-^ 's 
less menacing than previous, ones. It appears to lie a fixed 
variant of .small-)iox differing from the normal disease in 
many respects, of which the most significant is that it ' 
not fatal. It is frequently mistaken for chicken-pox', which 
in Paddington and the Port of Ixindon is alrcadv noti- 
fiable, while other metropolitan borough coniiciLs are con- 
sidering obtaining similar powers. Propaganda in regard 
^ matter jiriniarily for the sanitary authori- 
■ tbci/aw'’aT'’'T/'’''m'‘‘ epidemic diseases in 

eomicU officers of ihesc authorities and those of 

advice wdiir.! Vi co-operation, and anv assistance 
'•I' «>e co,iucil’s officei-s can afford is readily 


given. In all tho circumstanco.s tho Public Health Com- 
mittee i.s not prepared to advise the London County Council 
to support the St. Alhan.s jiroposal. 

Central AUdwive.s Boanl. 

The Central ' JIidwive.s Board for England and "Wales 
met on IVtiiy 3rd, with Sir Francis Champnej-s in the chair. 
The .sliindiiig committee reported that it had been in 
eonifniinication with the midwifery hoards of certain of the 
States in tlio Jlritish Empire concorning the eoncliisioii of 
reeiproeal arrangcnient.s for the registration of midwives. 
It was projiosed that the Engli.sh Board .should iimlertake 
to place on its roll the iiainc.s of midwives who iirodncod 
a eertifieale of registration granted by the State hoard 
concerned, after examination, jirovided that the State 
boards would .similarly accept tbe English qualification. 
The arraiigeiiicnt would not apjily to midwives holding tbo 
English Boavd’.s certificate granted by virtue of their 
having been in hoiia fide practice jirior to 1902, while the 
ai-cept mice of other certificates in England is govonied by 
certain conditions regarding training and ex]icrioiice. It 
was reported that a letter bad been received from the 
Xiiiises’ Registration Board of South Australia agreeing tn 
an iirrangcmciit on this ba.sis, and the Central Midwive-- 
Board tberefore adopted a rosohition giving effect on its- 
.side to tbo piojioscd reciprocal agrcciiiciit. 


Urdanii. 

Free State Afedicnl Registration. 

Mkiiicai. practitioners desii-oiis of Imving tlioir names 
pliKs-d on the Irish Free State Medical Register are 
reminded that ^fay 26tb is tiio la.st day for iccciiing 
applications for registration without a foe. After that 
date a fee of £5 will be ebnrged. Every pnietitioiior wliosc 
name appeaiis in the general illedfrid llci/isift befoio Mas 
26tli will be entitled to have bis or her name entered in 
the Free State Register if ap])lieation is mado within tho 
prescrihed time; those with Irish Free State addrcsses. 
will he placed automatically in the Irish Register, and 
therefore need 'not nmho personal application for registra- 
tion Details were given on Ajiril 21st (p. 686). Medical 
practitioners in Northern Ireland whose practice extends 
Into the Free State should have their names in the Free 
State Register so that they may have the legal right to 
'sue for R-es for treating patients resident in Sonthern 
1 rchuid. 

Lndy Dudley’s Nurilng Scheme. 

'The committee of Lady Dudley’s mirsing scheme, in 
the twentv-fifth aiiiuial report, states that the assured 
•iiiiniiil iiicome is seriously dejileted from now on bv 
the loss of a grant of £500 a year from the National 
He-dth Insurance Commissioners, through the funds from 
which it was drawn being entirely exhausted. The coni- 
mittee has, since 1918, had this £500 towards the work 
of six districts, and to rephiee the sum this year will require 
a eiiiisiderable effort. The Irish Peasantry Society has 
liieronslv promised £150 a year to cslahh.sh a nimso at 
B.-.., Mess’ county Donegal, on tho express condition that it 
fs onii Mvor as" the rciiiaiiiii.g twenty-five districts 

are kept open. A nurse is already installed tlicic, and hei 
Ic vk-e' aT deeply a,,prcciated. The heg.niiing of a new 
SCI I ices pniiiiiiittcc’s existence is regarded as a fitting 

decade appeal for fresh support. The 

M^iif £500 a ve^ --itioned above jeopavdizes the work of 
Hm t vent °six nm-ses already established, and along with 
B ^ ^mfxietv there are insistent calls for nm-scs in neii 
r f.- ts which cannot well ha ignored. 'These oiiianato 
paiticnlarlv from three areas; from Achill Sound the 
deiiS is’ for a return of tho nurse after oxperioiice of 
her ‘rrk in the years 1920^5, when it 

to close the district, partly owing to iiant of timcis aim 
nartlv because a suitable residence could not he found, 
CWt fiwm Sneem in county Kerry; third, from -Ma n. 
Head ’coiiiitv Donegal, for whose claim the cominitteo 
pleaded in it’s last report. In these districts there aie no 
people of .snhstance to assist tho movement, and any he j 
in the form of money must come from outside. 



876 May 19, 1928] 1 


COKBESPOKDENCH. 


[ 


Tnz bBfnn . 
iItVICXX, JoCBXiL 


Wright’s school, for severe infections, has been placed at 
1/500,000 mg., while the upper limits are somewhat similar 
to those of Dr. Crofton. 

Dr. Crofton’s figure 0.000000001 mg. is therefore 1/2,000 
part of AVright’s minimum effectivo dose, and Dr. Crofton’s 
system of dosage would appear to ho a variant of Wright’s, 
in the downward direction. 

AVhat these figures leally mean may ho realized hy 
an effort to visualize them. Tho quantity 0.000000001 nm-. 
of tubercle bacilli is an amount in bulk at least Uvo 
thousand times below the point of naked-eve visibilitv. 
lo cliauge the effort, one drop of Koch’s B.E. would 
require to bo added to a small swimming bath con- 
taining oyer JO, 000 gallo/is of wdicr in order to give in 
1 c.em. the equiyalent of Dr. Crofton’s initial “ potent 
theiapeutic dose,’ which “must not bo exceeded ns a 

tXreuios^s of cstablislicd pulmonary 

This method certainly ought to be safe.— I am, etc., 
WanilMvoith, lluj. 7th. ItODEllT C.MlSWr.ET,. 


DEAD AND INFECTED TEETH. 

Sneiotrof Ophthalmological 

ocietr of the United Kingdom I described some of the 
findings in 100 consocutivc patients, seen in private prac- 
tice, aho attained full normal vision after the pre.scriu- 
tioii of spectacles. I omitted from the series thirtv-iiiiie 
patients lyho did not reach this standard of vision owiii.r 
resuh"'’ pathological condition of the eves. 'J'lie 

results obtained have a bearing on tlie subject of “dead 

dcnc'ni 

suggestive of tLic absorption duetto 
piesence in the body -of some septic focus. I attempted 

thosp'X of tl'o focus if present. For 

defect crowned teeth, or other obvious dental 

..pW * radiographs and the opinion thereon of the 

cnsXV surgeon were obtained. In other 

cases the indication was to refer the patient to a surgeon 

fom- o'" “ operations being required in 

den A “dvice as to inedi^o or 

dental investigation, and in eight cases the examinntim, 

followsr™^’ ^ summarized as 

No. of 

Referred to denial surgeons ... 

Dental radiographs obtained ... .” „ 

Apical abscesses sliown by radio«»raDlm nnrl iU ^ 


Shown in radiographs 
Unerupted teeth, Mostly impacted ;;; 


prepared b/'£^GoIdweiraX Dr A11 *k " ere 

.strated at the congress bv Dr "^'e demon- 

College Hospital Dental School +A •, l ' King's 

holleagnes ift AVestmiXer 

and Mr. Frank Lawrence' I pvnroee i' Henry 

ness for lielp extending over several indebted- 

William Willcox, who spoke at turmeew’'’ ®‘'' 

■The paper will be published in the T,-„, • 
Ophthalmological Society, with full derails T/'”"*! 
the usual abstracts are being circulated +0 1 1 ’ 

journals, of which this lette? is arabl-evioi ® 
clinical results arrived at appear to bf of iXr' 
dental surgeons, as I suggest that the 100 ^eoXeenV^” 
private patients with full vision of my series ® 
considered as fairly typical of the social class which 
London consultants. hiploys 

At the meeting of the Section of Odontoloo-v of the IP„ 1 
Society on February 27tli I stated my belief that T 
breaking down of resistance to absorptloii of toxic mater -.1 
from the teeth may be detected at an oarlv sXe ' 
S ^ Pnmuorated some o^f £ 

S o>’s of toxic absorption in the eye.— I am, etc., 
I-onJou. W.l, May ^ -p 


Siu, It was with groat interc.st and hopeful anticipation 

If ViSi, mT'"" 

"With the first part of bi.s letter I am in entire agree- 
ment, for I know from cxperieiico that it is usually the 
wrong typo of case that is sent for extraction of all teeth 
as pai t of the treatment. I find that not a few medical 
men send their patients for complete oral radiograms, 
and uhcro aiij’ areas of rarefaction are scon about the 
roots advise extraction of these teeth. This advice is given 
without any supporting clinical evidence that tho teeth are 
pathological, or without consulting tho patient’s dentist. 
\\ iloii tlio patient later visits the dentist the latter is often 
placed in a very difficult jiosition. 

One would have thought that the stage where a:-ray 
evidence, unsiqiportcd clinically, was accejited had parsed'. 
I do not think that any practitioner would dare to order 
radical treatment in otiicr conditions on a:-ray evidence 
alone. I' nrthermore, I would rcsjiectfiilly .siigge.st that the 
ilceision with regard to the dental trcatiiiont necessary in 
any particular case he either left to tlio dental .surgeon or 
arrived at in coiisiiltation with him. AVhatcver jnoccduie 
is adopted I consider it wrong to send a jiatieiit to the 
dentist with iiistnictions as to denial trciitiiiciit. Shoiikl 
there he iiistnictions, the.so ought to be sent to the dentist 
direct, and not tliroiigh the niodiiim of the patient. This 
would avoid many an nnpIoa.sant situation, as I mentioned 
before, as frequently an explanation by the dentist will 
cause the medical nuiii to modify his opinion. 

This brings 1110 to the second part of Mr. Marshall’s 
letter — the part in which my hopeful anticipation received 
a sct-back. Ho refers to the treatment of teeth in which 
tho pulp cavity has lieen infected as a “ surgical heresy*.’’ 

I fail to see his reason for this. Surely it is not a “surgical 
heresy ’’ to render an infected organ aseptic and so enable 
it to bo retained as a useful member. The treatment of 
molar tcetli with septic imljis lias, by very many practi- 
tionci's, been abandoned as almost hopeless. This is owing 
to tlicir being ninlti-rootcd, the roots often being tortuous, 
rendering the proper cleansing and drainage of the root 
canals a practical impossibility. However, when it comes 
to teeth witli single roots — for example, the incisors or 
canines — and where a radiogram shows these roots to be 
suitable, these can be treated quite successfully. 

One would not expect a medical man to draw conclusions 
from sneb limited knowledge of any subject, such as I 
respectfully suggest the knowledge of dental surgery iiiiist 
be to a medical jiractitioner. A little knowledge may even 
be dangerous lo the scientific mind. — I am, etc.. 


London, ^V.I, Jlay 9 tli. 


George A. Cowan, M.B., B.Dent.Sc. 


THE CAUSES OF ALCOHOLIC INEBRIETY. 

Sin, — Long experience of inebriety in all forms makes 
me agree entirely with Dr. Carver (May 5th, p. 774) that 
the inebriate, wbetlier alcoliolist or morphinist, is in every 
case jirimarily the subject of a neurosis. Tho difficulty or 
otherwise of bis cure depends on tlio curability of his 
neurosis, together with the fact that lie has found the 
flight from his complex 'or complexes into alcoholism or 
morphinism so much easier and more satisfactory to him 
than facing reality*, though be knows from painful expe- 
rience the price ho must pay for bis temporary relief. 
Anyone who lias had any considerable experience of the 
alcohol inebriate must have noted what Dr. Carver points 
out, and’ what I have commented on elsewhere (I’aflio- 
logical Inebriety, Balliere, Tindall and Cox), namely, the 
inebriate’s disgust at the “ dojio ’’ lie finds necessary. 
I have often, unseen, watched the inebriate dally with a 
stiff dose of whisky for ball an hour or so before making 
up his mind to toss it off like a nauseous draft of physic, 
boaping curses on himself and “ the stuff ’’ meanwhile. 
I consider the causes of such inebriety', then, to lie : 
(1) neurosis; (2) the accidental discovery of the relief to 
be obtained in alcoholic or other narcotic euphoria ; (3) the 
depressant reaction of the narcotic, which is’ more dis- 
tressing or less bearable in the case of the neurotic than 
in a person of sound mental integrity, and so aggravates 
the already present urge of the neurotic complex as to 


srAV 19, 1928] 


CORRESPONDENCE. 


t . Inr nsmsii ■ fi77 

Medicad JocnjfAi. * ' 


make a rcsislniice io tlio laeiital and crave woll- 

ni'di irresistible. 1 cutiroly agree also vitli Dr. Cai-vor 
tliat tbe alcobol or inorpbino addict bas no desire to bo 
incanablv intoxicated, but is unable to control bis narcotic 
dosa-'o .so as to maintain just tbe desired cniiboria ivlueb 
ivill 'i-clievo distress ivitbout ovcrstep|nng tbe mark. 1 bare 
once only seen an addict ivlio was able to exercise such sclf- 
coiitrol over the dosage of niorpbine; I bale neiei sccii it 
in regard to alcohol. In this particular case the addiction 
was of fifteen years’ standing, during which period the 
addict had never exceeded 5 grains in the twenty-four 
hours, and had in consequence inanagcd to keep bis 
addiction secret oven from bis wife. 

In regard to heredity, I am of opinion that it is the 
neurotic constitution which is herodilary and makes the 
subject of it potentially, but by no means necessarily, an 
inebriate. — I am, etc., 

Middkton St. George, Stay 6th. * AsTI.r.Y Cooi'EK. 


SEA-STCKNESS. 

Sin, — ^tVhile there are few who wilt dispute Dr. Allan 
Bennett’s treatment for sca-sickness (Tllay Stb, ]). 752), 
Ihero are a great many who would join issue with him on 
the causal agencies of that disorder. 

The vast experimental evidence on the labyrinth, apart 
from the indisputable witness afforded by tratiuia and 
disease, makes the vestibular centre of fundamental iinpor- 
tanco in vertigo of all kinds. The liaplinKard ob.servatioifs 
regarding a punctured drum and double masloids are not 
pertinent, since in neither case was Dr. Dennett able to 
speak of the labyrinth, which, it is elementary to state, 
often escapes in such lesions. The vestibular centre is in 
certain types extraordinarily sensitive to all sorts of 
influence, both proprioceptive and cxtroccptive, and so the 
illustrations which suggest an independent coutro arc also 
not pertinent, since in none of .these is it denied that there 
may. bo almost any typo of stimulus acting as a signalizer, 
and operating singly sometimes, but none the less cffcc- 
tively. Tbe kinacstbetic, the optical, the olfactory, and the 
•psycliical may one and all be involved. It is therefore 
discursive to instance the' ease of the strong-minded person 
ascending a ship’s gangway being overcome with nausea as 
showing the relative •unimportance of the vestibular centre 
merely, because tbe kinaesthetic sensations are not directly 
involved. 

. There is no case of Dr. Bennett’s that docs not ulti- 
mately illustrate either the native sensitivity of the vesti- 
bular centre or how its threshold may not bo lowered. It 
is superfluous to deny the interaction of other nuclei, but 
it is poor observation to suggest the pneumogastric as a 
sort of independent centre. Sympatheticotonia and vago- 
tonia in* severe cases of- sea-sickness follow in disturbingly 
and antagonistic succession, or. mav in part act together, 
riiesc represent merely the overflow from the neighbouring 
nuclei, the • ultimate centre in every' case being the 
vestibular nucleus. 

Adi ice for the treatment of sea-sickness bas become 
trite, nei erthelcss attempts to close tho varying portals 
to signalizing stimuli depend for their success on a study 
individual case; it may, in fact, bo presumed that 
all Dr. Bennett had in mind was to emphasize what is in 
danger of being overlooked — that so far we have no remedy 
lor mat «c mcr. — I am, etc.. 


Cunanl Bviiltlinc, Liverpool, 
llay 8th. 


T. Gwyxne jMaiil-ind, 3I.D. 


Sir,— Very few ship surgeons wi]], I fancy, be able to 
agioe entirely with Dr. Allan Bennett in regard to sea- 
Mckaess. Driving patients out of their warm cabins into 
le flesh air on deck, “ however ciuol it may seem,” is 
a snid; In many instances in my personal experience — 
winch has been considerable— goingoiit on deck into the air 
has jest precipitated a had attack of mal dc mcr which 
might possibly have been avoided otherwise. The prostrate 
•.nif lielpless terms on the deck of a cross-Channel steamer 
on a lough day are sufiicient evidence of the inefficaev of 
the compulsory fresh-air treatment. ■ I have found .that 
egu ai daily action of the bowels, commencing with a good 


clcar-out before starting on tho voyage, plenty of water 
to drink, and tho. niinimizing of stomach acidity and 
moderate eating and exorcise arc about as useful as any' 
measures for proventiiig sca-sickiicss — if it can he pre- 
vented in any particular casc.s. 'When tho attack threatens 
and tbe patient begins to feel ill, tbe only thing tben to do 
is to go iinnicdiatcly to a warm and airy cabin and lie on 
tho flat of tho hack — not the side, romcinbcr 1 

Little sips of a mixture in solution oi oodiiiin hicarhonale, 
liquor morphiiiao hydroclilor., and sp. chloroformi and 
css. month, pip. will help matters. In had cases of 
acidity tho stomach certainly should ho washed out. Food 
and drink should not bo pressed at all for twenty-four hours 
if tho patient shows no inelinatioii. In any case dry ginger 
alc'(.as siiggo.sted in the annotation) I regard as one of tho 
drinks most likely to bring on a rocnrronco, and I have 
never permitted its use. Tho less aerated water a sea-sick 
patient has the better. 

As for jiiirgativos, salines .alone are perhaps host on hoard 
ship. Before starting the voyage calomel at night followed 
by a morning saline would bo preferable, but at sea tlio 
calomel is likely to cause a little too much liver disturbance 
and so produce nausea. Xcarly evoryono starting out on 
a long voyage feels sca-sick (“ livci-y,” they call it) for tho 
first two days or so, duo to changes of diet, exercises, and 
life in general, and, of course, also movement; but after 
this period is over only a vci'y small percentage ever feel 
ill again if they folloir tho ordinary' simple rules. 

Bromides and atropine should not bo relied on as pre- 
ventives, and it slionld bo borne well in mind that the 
frequent use of atropine may not only fail to prevent 
tho sea-sickness, but may ho harmful to tho patient besides. 
— ^I am, etc., 

Geo. a. Pesibehtox Weight, 

M.C.P. and S.Ont., L.-A.H.Dub., 

Late Stan Surgeon B.SI.S. Maiiretam'a. 


OBGAXIZ.-VTIOX ' OF DISCUSSIONS. 

Sir, — An amciulablo foaturo of tho highly successful 
Conference on Rhenmatio Diseases at Bath was tho rushing 
thi-bugh of tho papers. Alany important contributions, tho 
preparation of which must have entailed laborious hours of 
thought and work, had to he got through within a space 
of five minutes. This simply meant that tho various 
speakers had to deliver their addresses at such a rate that 
made it difficult for their audience to follow them to full 
advantage. Furthermore, considerable sections of many 
contributions bad perforce to bo cut out. This necessity, 
without previous warning, was obviously disconcerting to 
the speakers. Thus the continuitj' of the suhjccLmatter in 
many instances was lost. To take an instance; in the 
third session tho time which remained for a' general dis- 
cussion on the. subjects of three hours of mutilated papers 
was exactly five minutes. Small wonder that many whose 
views would have been of interest felt the futility of 
making any attempt. Surely the discussion, witli its inter- 
change of views and questionings of the principal speakers, 
should form an essential part of a “ conference.” 

The remedy would he to have the contributions, which 
are already in print for the convenience of the press, made 
up in the form of a paper-covered brochure. These, on 
application to tho honorary secretary a few days prior to 
the sessions, could he distributed to those interested. It 
would then be feasible to ask the speakers merely to deliver 
a precis of their ohsen-ations, and to show slides or charts. 
These latter would then possess a greater interest to the 
hearers, who would have had opportunity of digesting the 
subject-matter. In a tliree-hourly session this procedure 
would leave probably one and a half hours for the dis- 
cussion. 

As a former local secretary of a Section at an Annual 
Aleeting of the British Jledical Association, I would suggest 
■that if at the forthcoming meeting at Cardiff the Sections 
ivere conducted on these Hues, it would ho found to be 
of mutual advanta'ge to all concerned. — I am, etc., 

- Bath, May 14th. JamES LiXUSAT. 

V- If Hv, Lindsay bad been local general secretary of an 
Annual Aleeting he would know that wliat he siio-<fests is 
not quite so easy as it sounds. “ 


878 Miy i9i 1928] 


COBBESPONDENCB. 


r Tff£ nnmsii 
L Medical Jocceal 


BRITISH SPAS. . . , „ 

SiK— I read in your columns that the British Spas 
Federation held its annual meeting at Bath on March 8th 
and 9th, and that one of the chief points discussed xias 
tho necessity for propaganda, especially in English-speaking 
countries. Is thi.s shyness, lack of spirit of enterprise, 01 

complete misunderstanding of the situation . 

British spas will only be given due recognition when 
they atti-aet visitors from all parts of the world. It is tlic 
Continental patient they should first of all attract. I\ hat 
they would give., thorn' us regards accuracy 111 treatment, 
excellence iiv sports,' and the cnioyinoiit of British summer 
they would receive back tenfold. Imagine a I'rcnch colony 
invading Harrogate or Buxton with the merry detoininia- 
tion of having a cure and a good time together, llic %cij 
atmosphere of these spas would change, and the barometer 
would certainly go up a fow points. t> 1 

How much wo do approciato in Erance what onr British 
friends have done for onr spas! For instance, if Vich}' 
boasts of tho best-cqnippod sporting club iii the couiitiy, 
it is them we have to thank. It is in a feeling of gratitude 
that two Eionch hydrologists. Dr. Beboul and the under- 
signed, took the trouble to translate into 1* ronch, and 
present to French medical circles, Neville IVood^s book on 
British spas and health resorts; while in Paris and Lyons 
Dr. Villaret and Dr. Pierry, both professors of hydrology, 
have, each of them, devoted one of their curriculum lessons 
to British spas; and as hydrologj’ is an obligatory quiz 
for an M.D. degree, candidates have to look at the hydro- 
logical map of Great Britain and to know something of 
the indications of your spas. But we cnuiiot conduct pro- 
paganda on behalf of British spas witliout tho help of 
British spas. A'othing is more international than a spa. 
Nowhere will one more surely find out that he cannot 
get without giving, nor can ho give without getting. — 

I am, etc., 

Gust.we Monod, M.D., M.B.C.P., 

Past-President of the International Society 
Vichy, May 7tli. of Medical Hydrology. 

FBACTUBES OF THE CLAVICLE BTTH , 
DISPLACEMENT. 

Sin, — 111 his article in tho Journal of April 21st (p. 664) 
Dr. G. W. hlilroy calls atteiitioa to tho discomfort of 
plaster applied next the skin, and to the tendency of well- 
applied bandages to become loose, and he describo.s a modi- 
fication of Sayre’s method'whicli lias given him satisfaction. 

Another method, and one not involving the n.so of an 
axillary pad, is to apply John Duncan’s bandage (as 
figured, for example, in Thomson and Milos’s Manval of 
Siirgenj) with two women standing by with needle and 
thread, who, as soon as the bandage is on, descend upon 
the patient and proceed to sew him into it, paying par- ' 
ticnlai' attention to every crossing. When- they have 
finished, two broad circles of plaster, adhesive side inward, 
are applied on top of the bandage, one round the elbow 
and root of nock on the opposite side, tlie other horizontal 
and proximal to the wrist of the injured side. The women 
again fall to with needle and thread and sow the edges 
of the applied piaster to the 'Duncan’s bandage. Fixation 
is so good that an Arab boy, thus trussed up, will run 
about aud play the same da}*, and the combination wears 
well without attention. 

IVliore roll plaster is not available something unyielding 
required; I have used a horse-girth with an adult in 

J . L. Mabjobib.ikks, M.D., 

Lioufon.int-Coloncl I.M..S (ret ) 
Formerly in charge European General 
Hospital, Aden. 


is rcqmr , 
India.— I am, etc., 


San Kemo, April 24tli. 


of tho air-borno variety, 1 made special inquiries of the 
sister in charge as to Jmiidkcreliicf habits. She said tho 
handkercliiefs were for the most part oxtromcly dirty and 
Bcoiiicd to ho kept aiU'wliorc. Sho herself allowed none, but 
supplied paper or bits of linen and hiirnt them. Dus 
method sho considered successful as, except^ in tlio one 
casb of pneumonia that could not bo saved, there iioic no 
serious complications, and all tlio patients were well when 
thev were discliiirged to their homes. It wonhl be an 
interesting experiiiioiit to cstablisli “ hanky drill m .siicli 
schools, for nasal liygiciio was, in this case, the only braiieli 
dr: personal hygiene which did not reccivo attention. 

In certain .scliools whore the haiidkorcliiof is looked upon 
ns a valimhlo possession to guard tho hroatli of hfc the 
control of iiifertioiis disease scorns remarkable. An iiUiint 
elas.s in n .poor district had no loss of attendance or 
illne.ss for two successive years; the teacher had haiiK} 
drill ” dnilv, and kept a siqiply of siiitahle paper tor the 
children during scliool hours, this hoiug burnt at the end 
of thc liv. I-' t'tty school for girls, whore no one 

was allowed to ho without a handkerchief ami o 
in which it could bo kept free from 
had been no serious epidemic for seven years. 
he many factors in tho spread of air-horiio diseases tl 
cannot bo safcgiinidcd in such schools as those, so t'mt 
Kci-ms -is thoiK'li a deciding factor was the care and 
M tho lamlkerehief. In both schools there “anv 

children of an age when they are usually susceptible, jct 

*'llnndkciHiicf <1.111 comsists in clearing the passages as 
■nntisiblo. aftov "Waking. If tlie first clctaimg is 
accomplished with paper in tho lavatoiy the time spent 
in thc^di'ill at roll call is negligible. The ^ 

to. keep ho«ils o^en w. 0 nndjet^out aU tlmt 

momont.-I am etc., - . . ^ 3 ^ 3 g. 

Lomlon, MM, April 23 r.l. 

qTFBILIZATION of the FEEBLE-kllNDED. 
r.®" Vr.,11- notice of the hill passed m Alberta for 
sterilisation of tho feeble-minded shows some mis- 
a M ^ position of those who support this 
“"'u d'of attack on one of our disastrous social problems, 
"'I f should ho grateful if you will allow me to bring 
betre fur readers somo of tho facts at present far too 

’^trsf "ir'is Hot sufficiently realised that the ^ofects m 
^ A which caused the withdrawal or disuse of sterihza- 
UHitert States wore legal ami techme^ 
V mi hosed on any impracticability, or, so far as the 
"r i Xfi-ieiice of twenty years can show, want of 
fnnibirrcsiiHs. Tho conflict hotween Federation const.tii- 
tangible icsiilt^ constitution has, in the mam, been the 

S"’statnto!“nrfewor Hmf -five” States^md intro- 

Ff ‘ mitf aro'fforrtlm sfpr^mrCotl Sl/iufold Em 

wahf ortlicso statutes hinught up under that rccontb 

stronulv, Hmt sterilization can very seldom b 
preventing prooreatiou for khe reason hat 

Lfectives are satisfactorily dealt w ith ^3, 


INFECTIOUS DISEASE IN SCHOOLS. 

SiK^ Tho spring term has once more maintained its 

character for tho mass production of illness in the schools. 
In one high-class preparatory school 63 of the 80 pupils 
Sjiont some of tho time in the sanatorium — 43 for measles 
and 20 for influenza; there was one fatal case of double 
pi'onnionia. Tliis is a distressing record; yet the school is 
pnrticiil.ailv ncll situated, and great attention is fiaid to 
diet and other hygienic needs. 

Seeing that the disease.s causing these devastations are 


defectives are sarisracim ny < ,„.opovtio.i will 

*“ T.’SS"ki« « ~ ka ,m .!» 

tSly ^ean "Tfe^luch 'fhig "’'fuSrtiof of 

pH^s for mnidoymont require 

intelligence. In any ei ent, to-daj ^hnt it may well 

tions of oiir problem are so tremendous tha ^ n 
be argued that no “e"*ns slioulcnm spared t 1 
hiivfloTi for future cenerations. >> e knou ziuxi ^ 







Mat 19, 192S] ( 


■DNIVERSITIES AND COLLEGES. 


[ Titr.Br.m«?n ftRl 

MrDICAI. JOVJlXAt. O A. 


a\ual ca5C‘;. Timt was not a sunioionl number (o koepinfr 

tlio clinio^ open. A'« fai'" lio kno>s' tlicio were no nose and 
tiu'Oivt cases. 

.IhdrrtiJ KTaininotion of Pro^prrtirr /'iui;/ntnt.n to Cijontht . — 
Mr. .\MF.nY, roplvinj: to llaslam, on May Hlh, said llml in 
the fiWt four inoiil]i«s of IhK year 30,451 pei-sons \vere requested by 
tl»c Canadian nullmrilios to |)rcveut tlRinsidves for medical exam- 
ination with a view to tlunr settlement, in Canada. Of these, 
^,209 were examined. TIio ixunaimler would probably be examined 
during the coming moulhs. The numbers rojeeled on medical 
grounds, or uualne to attend for examination for loasons of 
distance, inconvenience, and expense, wore not yet known. Mr. 
ilASiJiM asked if Mr. Amery would get into touch with the Canadian 
nntborities and u^e bis influence to sec that no able-bodied man 
or woman wlio miglil be desirable was excluded. Mr. Amery said 
Uic Dominions Office was doing all it could. 

Siitr of Food nod Dniffx .lr/5. — On May 14t]i Sir Kixcsley Wood, 
in reply to Dr. Vernon Davies, said that tbe Sale of Food and 
Drugs Acts were adininislcrcd by the benlth authorities of certain 
counties. In some coimlies the public beallb commillec or the 
medical officer of licnllb, or both, took part in the administration 
of the Acts. He could not state the number of sucli counties. 

Ltpro'fp in l\ilrxtin'\ — Mr, Ameuy, rcplving to Sir R. Tliomas, 
on May i4tb, s.iid that in Febniaiy, 192^, it was e'stnuated that 
there were fewer than eighty lepers in Palestine. The disease 
appeared to be dying out natur.ally. In 1927 the Moravian Leper 
Hospital at Jonisalcm had on llic average 28.75 in-patients, and 
twenty-four lepers received out-pjiticnl treatment at Government 
dispensaries. The High Conimis^iioner was satisfied that sufliciont 
facilities existed in Palcstint: for the treatment of leprosy. 

ITraiffi of Prisoners in tin ^Solomon Ifhtndr, — A report to Mr. 
Amery on the condition of tbe Solomon Islanders m prison await- 
ing trial states that up to March 8lh five deaths had occuiTcd— 
two from dysentery and three from causes other than <lyscntcry. 
Majty of the prisoners were under-nourished and einucinted when 
they were brought in, ,t 11 were kept under close obsei v.atioii hv 
the senior medical officer, and their general health impioved as a 
result of a regular and substantial diet. Apart from the out- 
break of dysentery there had been little illness among the 
prisoners. 


0/ lirtn^tmr of DtutUr, — Sir Ki^'GSLEv Wood, leplving to 
Mr, Kolly on May ISlli. said that it was not the dutv of the 
X'ogistrar of deaths to ask questions in cases where the cause of 
(loath was certified by the medical pmclitioner who attended the 
(icceased person. Where the cause of death was not so certified, 
me registrar was required to refer tbe case to the coroner, and 
only to enter the cause of death according to information elicited 
} Iiimseli in cases where the coroner had deemed an inquest 
innccossary. Even wlicrc the camo of death was nu-dicallv certi- 
nctl, jt was Ibe duly of the registrar - to refer the case' to the 
mformation that dealli might ha-e been due 
calegorirs laid down by regiila- 
b>^vA categories included cases wlici*o death appeared to 

ba\c been duo to starvation or privation. 


recpiti^ *i<id borough asylums, pci-^ons : 

about 127 000 ibo wiedical relief only, and casuals, totallin 
Law relief^’ I"'} in of Poi 

of 1S27-2S was ^'ales on any Saturday in the wint< 

T i.255,251, on January 7th, 1923. 

open-aii- f-^ndon area \\lio attende 

202,930 widows' pensions an 
Included^udm granted in England and Wale 

allowants pensions ■ were "257.500 children 

31^* houses completed by Marc 

Sisting rates ' «thenvi.o eligible, qualify for subsidy at tl 


iHfiiirtr-ICtgni. 


A Iimv damages EOR a JrEDICAL MAN. 

to Dr. W s'^'^Hpnd^ovS’ ”” £1,000 d.image 

for the foilowing libellous’ p^sslee' ‘“.Sodbergh School 

by tbe father of a schoolbof to^tb?". 

In my opinion bis callousness w 

l. “ quite unsuitable for thf 

holds.** responsible position which ]i 

Ocqobe?"'l92'6‘“'irX%“n Sedbergh School ii 

Donald ’AcS-ev'"conte :d°scaXt‘^^^ '’T 

care Dr Hpnd#»rcr,i, tv,,, fever and came under In 

Mr E f telTevI^. ^ ^ December 16tb tbe faUiei 

bad examined the Tb’oy and J’'®. '''"“dmabter that two doctor 
Idp-joint. The letS . continued 

m, common complication ar shm ™ means a, 

makes Dr. Henderson’s easp ® Lom scarlet fever, so thi 
followed the wn vlo ''■01‘se than I thought.** The 

added that upon \be' issue oTtb 

1 1 sue of the writ in tbe action the seboe 


authority, taking tbe view that they could not Iiave their dirty 
linen washed in pub lie, -cal led upon Dr. Henderson to resign. 

Dr. Henderson, giving evidence, said that the boy liad some- 
liiiies complained of pains in his hips, thigh, kiicos, and cliest, 
and he considered they were due to muscular rheumatism, 
a . symptom sometimes found in cases of scarlet fever. Dr. 
AfaxwoU Telling, jirofcssor of medicine at Leeds University, 
told the jury that he would have made exactly the same 
diagnosis and advised tlm same treatment as had Dr. 
Henderson. 

The defence was a plea that the letter was Avritten on a 
privileged occasion, and a denial that it bore the meaning tlic 
plaintiff alleged, but there was no plea oi justification. 
A father's letter to a headmaster is w’litten on a privileged 
occasion, but it is only a qualified privilege, wbicli is lost on 
proof of malice, and the question whether or not tbe writer 
was actuated by inalice is one for a jury to decide. Here, as 
Afr. Aforiimer, IC.C., for the plaintiff, said, not only had the 
defendant abused the privilege by going further than lie ought 
to have gone, but ho had not even sought to justify the allega- 
tions he had made, nor shown any sign of repentance. 

Great sympathy for botli sides was expressed by Air. Justice 
Talbot in his summing-up to the jui-y. His Lordship pointed 
out that the evidence had domonstratiid that there was no error 
in treatment, with a possihlo exception regarding a rise in the 
boy's tempeniture on his last day in the .school infirmarj'. 

The solicitors for the plaintiff were Afessrs. Le Brasseur and 
Oakley, instructed by tlie London and Counties Alcdical 
Prolvctiou Society. ' 


Stnxiitrsittfs nntt ©olfigis. 

DNIVEESITY OF CAMBRIDGE. 

At acoiigregatiou beki on Slay 12tb tbe following medical degrees 
were conferred: 

M.T). — .T. P. W. .Tamle. H. Oftiusboroneb. ■ 

B.Ciim.— I j. J. l-Ruting. 


UNIVERSITY OF LONDON. 
liecent jycvelopvieuts tii Medical Education. 

The report ot the Principal Officer on tbe work of the University 
of London d\iring tbe year 1927-28 records » number of develop- 
ments ot some medical interest. Reference bas already been 
made to tbe pniolmse ol, tbe Bloomsbury site, whicb ^yns made 
possible by a very large contribution from the Eockofeller Founda- 
tion, That institution has also given £25,020 for the endowment 
bt the department dt pharmacology, and £90,000 for the endowment 
of the departments ot anatomy and pliysiology, all at University 
College. Fnrllier largo benetoctlons have been made to provide 
for tlie establishment of a chair ot dietetics, which will be at first 
ap.art-timc appointment and which, it is hoped, will be attached 
to tlie St. Tlioiiius’s Hospital Medical School. Begardiiig the 
medical education ot women undergraduates thereijort reters to 
tbe appointment, by the Senate, ot a committee to consider tbe 
question, and states that imioli ot tbe pretiminnrv work ot inquirv 
lins alre.idy been done. In tbe course ot tlie pa'st rear ncadomio 
diplomas in bacteriology and in biology have been iustitnted Tbe 
trust deed providing tor the Geoffrey E. Duveen Lectnresbip in 
Otology bns oeen varied to allow tbe establislimeut ot a travelliim 
post-graduate studentship in oto-rbiiio-iarvngology and of a fmwl 
for the promotion ot research in tliat subject. ‘ 

Cliangcs among tbe medical and associated teacbin« staffs imve 
been nnmerons. At King’s College Miss D. L. Jlaelrimim, 
succeeded Protessor.T. B. Huxley in the clmir of zoologv and Mr 


. — ir- jv uew uiii- 

held it the Westminstei- Ho3pltaT'Med%arScboo/b^ Dr^^j! a! 

Bi-axtoii Hicks. Eendevsbips in morbid anatomy and histofo"v 
aud m bactcnologv have lieen instituted at tlie Midd]ese.v Hospifa'l 
and University College Hospital respectively. Three chairs have 
been added to the eslablisliineiit ot ttie London School of Hvgiene 
and Tropical Medicine: Dr. W. W. Jameson bns been appointed 
professor ot pub ic liealtli. Mr. M. E. Delafleld proteUov of 
chemistry ns applied to hygiene, and the chair of biochemistry 
remains to he filled. Dr. G. S. Svilsou becomes reader in baoterio- 
logy and iinmnnqlogy. At tbe School of Phannacy the first holder • 
of the readership in pharmaceutical cliemistrv' is Dr W R 
Lmnell. n. n. 

LONDON INTER-COLLEGIATE SCUOLAESHIPS EOAED. 

Mcdicnl Scholars 1 ii 2 )s^ 

The London Inter-collegiate Scholarships Board annonncps 
an e.vaminatiou tor six medical scholarships and exhibilinno Vf 
aggregate total value of £513, will commence on Jnne 26tlf ’ 
are tenable at University College Hospital Medic.al 
Loudon (Royal Free. Hospital) School of Medicine for \Von\S ’ 
tbe London Hospital Medical College. Full particiilara 
forms may be obtained from the secretary of the Board 
Banner, M.A., the Medical School. Kind’s Coflew r’ S’ 
Denmark Hill, S.E.5. Jan-o s College Hospital, 


882 Mat 19 , 1928 ] 


OBITTJABT. 


[ 


Tnf UrtiTus 

SIkDJCAX. Jot7RHA& 


KOYAL GOrjtiBGE OF SURGFONS OF FNGLAKD. 

An ouniNATiY Council meeting was held on Alay lObh, whou the 
Presideut, Sir Berkeley jXoynilian, Bb., was in the chair. 

FcUou'ships. 

Mr. C. Tliurstaii Holland and Lieut. .General Sir Matthew H. 
Gregsou Fell, K.G.B., C.M.G., were admitted Fellows of tho 
College. 

John Hunter Mcda}.- 

Mr. Victor E. Negus was presented with tho John TTnntcr Modal 
in bronze and a cheque for £50 Cor his investigations into the com- 
parative anatomy and pliysiology of the larynx and tho anatomy 
of the bronchi in their relation to surgery. 

- , Membership and Diplomas. 

Diplomas of membership were granted to 152 candidates whoso 
names were among tliose noted as granted licences to practise bv 
the Royal College of Physicians in the list published on MayStii 
(p. 786). Diplomas in public liealtli were granted jointly W’ith tho 
iioyal College of Physicians to 18 candidates. 


ROYAL FACULTY OP PHYSICIANS AND SURGEONS 
OF GLASGOW. 

At the monthly meeting of the Royal Faculty of Physicians and 
Surgeons of Glasgow, held on May 7bh, George lIoiuV Kdington, 
]\r.L)., D.Sc., was appointed as the representative of tho Faculty 
upon the General Bledical Council. 


®Ij£ ^frbicts. 


TERRITORIAL DECORATION. 

The Ktkg has conferred tho Territorial Decoration upon the follow- 
ing officers of the Royal Army Medical Corps, T.F. : lion. Colonel 
A. Thorne, V,D., Major's N. M. Ferguson, J. F. Edmiston, T. W. S. 
Hills, J. A. Slenhouse, and F. H. White. 


NAVAL MEDICAL- COMPASSIONATE FUND. 

Tire quarterly meeting of tho directors of tho Naval Medical Com- 
passionate Fund was held on April 26th, when Surgeon Vice- 
Admiral Arthur Gaskell, Medical Diroctor-Gcncr.al of the Navy, 
tool: tho chair, and the sum of £175 ivas distributed among tho 
several applicants. 


©liituarg. 

We regret to announce the death, at the age of 92, of 
Dr. Hemit James Alfoud, .jwhich occurred at his homo 
in Taunton on April 17th. Ho belonged to a tvell-knoivn 
Somerset family, and his father, who also lived until over, 
90, preceded him in medical practice at Taunton, while dno 
of his brothers was a surgeon. Dr. Alford received liis 
medical education at University College, London; lie 
obtained the diplomas M.R.C.S.Eng. and L.S.A. in 1858 
graduated M.B. in 1861, and proceeded M.D.Lond. in 
1872. After spending some years in practice with his 
father ho was, in 1873, appointed medical officer to tlio 
old Taunton Board of Health. Dour years later, on the 
incorporation of the horongh, tho new council came into 
existence, and he retained the office of medical officer of 
health to that body, contimiing in this capacity until ]iis 
retirement after forty-six years of service in 1919, when he 
had i^achod the age of 83. Ho remained in service in a 
consultative capacity to the time of his death. He was for 
a considerable period consulting physician .to the Taunton 
and Somerset Hospital. Until a few months ago ho 
remained m good health. His devotion to his office and to 
the aitairs of Ins native town monopolized tho greater part 
of his time and energy, hut in his youth Dr. Alford gained 
some fame as an amateur actor, and throughout liis life 
took a keen interest in local dramatic and musical works 
ISlany years ago he was . received into, tho Roman Catholic 
comnnmion, and ho was .a, devout member of that Church 
The interment in St. Mary’s Cemetery was jireceded by a 
requiem service at St. George’s Church, Taunton, condnrted 
by -the Very Rev. Canon lies, and attended by tho mayor 
TOomhers and officials of the corporation, representatives 
of the medic.nl profession and of the religious coinmunitips’ 
with which Dr. Alford was associated. 


. ^Imthew CnnsH-vM ConxER, who died on April 25th 
in his sixty-ninth year, at his residence in Mile End, had 
Uiroughout his life been identified with work in the E.nst 
Hnd of London. The son of a medic.nl pr.nctitioner, he 


received hi.5 professional education Rt tho London Hospital, 
and in 1882 obtained the L.S.A.- After serving ns clinical 
assistant at tho East London Hospital for IVomon and 
Cliiidr'ori ho took over his f.nthor’s practice in the Milo 
End district, where ho remained until his death. For 
forty-two years ho was medical officer and lecturer to tho 
East End Mothcr.s’ Lying-in Homo, tho institution in 
connexion with which ho was, jicrhnps, best known, and to 
wliicli ho was latterly consulting physician. Ho was also 
for many years visiting or rc.sident medical officer to tho 
Tower Hamlets Dispensary, and liad at one time or another 
boon associated with the Royal Matcrnit}' Socictj-, the East 
London Mxirsing Society, tho "Whitecliapcl Dispensary, the 
Trinity Almshouses, and tho East End Emigration Society. 
Ho xvas honorary medical officer to tho National Children’s 
Adoption Association, and honorary consultant to tho 
Stepney ISchooI for Mothers. Dr. Corner iiarticipated 
actively in profcs-sional affairs, and was a past-iirosidont 
of tho North-East London Clinical Society. In tho British 
Medical Association ho had served as a member of tho 
Metropolitan Conntiev DrenMi Council and as chairman, 
from 1922-26, of tho Tower Hamlets Division. Hd was a 
justice of tho jicaco, and had served as chairman of tV.o 
Milo End Rettj' Sessions and as a member of the Shore- 
ditch Children’s Criminal Court. Among his public.ations 
may ho noted one, entitled A Defence, of East London,, 
which gives tho clue to his main interest in life — tho 
welfare of that district where he was particularly devoted 
to any service designed to liolp its mothers and its 
children. 


Dr. Josr.rn Hioiixs Fexn, who died on IMay 3rd at 
Rnsthall, 'Tunbridge Wells, at tho age of 60, was the thiril 
sou of the late Mr. Albert R. Eenn of Madrid. Ho 
received his medical education at tho London Hospital, 
and obtained the diplomas M.R.C.S., L.R.C.P. in 1897. 
Dr. Fcnn soon afterwards went to IMoxico, where he 
became well known as a surgeon in mining centres and 
travelled extensively. During tho war lie held a commis- 
sion as c.aptain in tho R.A.M.C., serving first on tr6o])ships 
to and from tho Mediterranean and Aii.stralian ports. Ho 
was later lransferrt>d to the Royal Herbert Hospital at 
Woolwich, and then to tlie Military Hospital .at Hounslow; 
as ho had made a special study of tropical diseases ho was 
subsequently aiipointcd medical officer in charge of tho 
Gravesend Military Hospital. After tho war, and until 
incapacitated by a" long illness, Dr. Fcim hold .an appoint- 
ment under the Ministry of Pensions in tho trojiical 
disease.s department. He retired four years ago to Rusthall, 
Tuuhridgo Wells, -ivlierG he patiently boro the increasing 
liraitotions and sufferings following upon encephalitis 
lethargica. His death is much regretted by his many 
colleawnes and friends. He was a memher of tho British 
Medical Association. 


Metrical JEtlus. 


The annual oration to the St. John’s Hospital Dermato- 
locical Society will bo given at 5.30 p.m. on Wednesday 
May 23rd, at, St. John’s Hospital, Leicester Square, by Sir 
John Bland-Suttou, Bt., ■whose snhject will bo “ Tiio debt of 
dennatology to optical glass.” On the same evening, at 
7 o’clock, the- annual dinner' will be bold at tbe Cafe Royal. 
Fellows intending to bo present are asked' to notify tho 
honorary secretni-y of the, society at 49, Leicester Square, 
W.C. 2 ,' not later than Tuesday', May 22ad. 

' Dr. Jane Walker 'will open a disemssion by the North- 
Western Tuberculosis Society on luberculosis and employ- 
ment at tho Tuberculosis Offices, Jodd'folfStreet, Hardimm 
Street, ■ Manchester; ou Thursday, May 24tb, at 3. o'clock. 
All medical practitioners interested are cordially invited to 
attend. . . 

The twenty-ninth annual meeting of the Lebanon Ilospilal 
for. Mental Disoa'ses, ■u’hich is situated at Asfuriyeb, near 
Beirut,' in Syria, will be held at Friends’ House, Bus! on 
Hoad, N.W., at 3 p.m., on Tuesday, May 22ud. Sir Wyudbam 
Deede's, late Chief Secretary to the Palestine Government, 
will preside, and a short address on The importauco ct 
treating early mental disorder ” will be given by Sir Mauiico 
Craig; Sir Robert Armatrong-Joues and Dr. Bedford Pierco 


MEDICAIj news. 


[ Tjir nnmsM 
MrUICAL Joi/RVAL 


883 


M.1Y 19. 1928] 


will also Bpealt. Tlio Lobauoii Hospital Is the only Instituliou 
ot Us Itlml in Syria, and provldos toaobiut* fncllltios for 
medical studonts at Eoirnt Dnivoraity. Its ndinlniatrntlon 
is on an international basis, wltli lioadtpiartors in London and 
nsaoclated committees in Holland, Switzerland, and America. 
Headers who are interested and who desire to attend tlio 
annual meeting may obtain particulars from tbo London 
olTlco, 139, Marylobono Hoad, W.l. 

Xhk opening ceremony in connexion with tbo Princess 
] ' T for Children will be performed by 

] ■ , . npaniod by the Queen, at 3.30 p.m., 

j ■■ ■■ hospital had its origin in a small 

dispensary started by a few medical practitioners in Church 
Street, Kensington, in 1840 ; in 1896 a small ward was added 
and the institution took’ the name ot the Kensington Dis- 
pensary and Children’s Hospital. l^our years ago it became 
clear that a greater need existed for the hospital in North 
Kensington, then in its original situation, and that it would 
require a very considerable extension to provide the desired 
facilities. . Under the patronage ot H.lt.H. Princess Louise, 
Duchess ot Argj'll— and largely at her instigation— a scheme 
was inaugurated which has resulted in the creation ot tho 
now hospital situated ot St. Quiutin Avenue, North Ken- 
sington, W.IO. The llrst building schemo, coiuprising tho 
out-patient department and one ward block, was started in 
November, 1926, and last siuniner tho board decided to 
proceed with tho second ward block. Out-patient work in 
the now hospital commenced in December, 1927, and tho first 
in-patients were admitted soon after. 

'i’nr: annual meeting ot King Edward's Hospital Fund for 
London was held at St. .Tames’s Palaco on May 15th, tho 
Prince of Wales iireslding. In his address ho stated that 
£1,800,000 a year is now voluntarily subscribed to London 
hospitals. 'I'be Fund last year distributed £247,000, while, 
in addition, special grants from tho legacies left by the lato 
Mr. and Mrs. John Wells of St. Albans liad been distributed 
since 1924, tbo total ot £255,000 having helped to provide 
1,600 additional beds. Tbo Prince of Wales said there were 
now in London 900 “pay bods” for tho professional and 
middle classes, and that the report ot tho committee appointed 
to inquire into the question ot this class ot hospital accom- 
modation was in course of preparation. A fuller account of 
the proceedings ot the meeting will bo given next week. 

THE summer session ot the South-West London Post- 
Graduate Association opened on Ifay 16tli, .and a lecture- 
demonstration will be given each week until .Tnly 12th. Two 
outings are included in tho progiaammc, these taking tho 
form ot visits to tho King Edward VII Sauatorium, Midhurst, 
on June 12th, and to tho Cassel Hospital tor Functional 
Nervous Disorders, Penshurst, on .Tune 27tb. Full informa- 
tion may ho obtained from the Imnorary secretary. Dr. B. 3. 
Saunders, 10, Lyford Road, Wandsworth Common, S.W. 18. 

The Fellowship ot Medicine and Post-Graduate Medical 
Association announces that on Friday, Jlay 25th, there 
will be two demonstrations : tho first, in gynaecology, by 
Mr. A. C. McAllister, at 10 a. in., at tbo Kojml "Waterloo 
■ Hospital, and the second, of the fundus oculi, by Mr. 
Lindsaj^ R^ at 8.30 p.m., at tho iu-patieut department of 
fte W^st End Hospital tor Nervous Diseases, Gloucester 
Gate, Regent s Park. Intending visitors to Mr. Lindsay Ren’s 
demonstration are asked to apply first to the Fellowship ot 
Medicine (Mayfair 2236). Special courses in June are ns 
follows : June 4th to l6tli, diseases of children; .luue 18tb 
to 30th, chest diseases at the Victoria Park Hospital and 
gynaecology at the Chelsea Hospital tor "Women ; June 25th 
^ July 21st neurology at tho West End Hospital tor Nervous 
Diseases, starting at 5 p-m. daily ; and a course in medicine, 
surgery, ami the specialties at tho London Temperance 
Hospital. This last-named course is primarily intended for 
practitioners who have little spare time, and it has been 
arranged to take place in tho late afternoons from 4.30 to 
6 o clock. Full particnlars and copies of all special-course 
iiro obtainable from the Fellow.sliip of Medicine, 
1, AVimpole Ltreet, together with information on the general 
course ot work. ” 


bonso and library of the Royal Society of Medicine 
will be closed on Satnrdtiy, May 26tb, and Monday, May 28lb. 

o LlTTDE, M.P., I, as been elected an honorary 

member of the Norwegian Medical Society. 

fi'^noral biMiness meeting of the National Incor- 
Mafqn, MM ^^‘"'ardo’s Homes was held on 

?it;iiii S showed that new admissions in 

mm’. 16^8 'verc permanent and 377 

cbildron in resideiicb 
S tffi iMMi . ? ^ ^ bonseliolds, and branches 

chi drp, 1 onv ™ 7,716; of these 

blind deaf mmm T ^ ‘’22 "were crippled, 

fm the vrar afflicted. The income 

ture was^ £521,499? was £o21,514 and the expendl- 


TOWAUDS tlio sum of £40,000 required for tho establishment 
in London of a clinic for the treatment ot rhenuiatic diseases 
£23,153 liad boon received by tlic British Bed Cross Society 
np to the end ot April. It is expected that the worlc of 
adapting and equipping the building chosen for the clinic 
will be bognn shortly. A treatment fnnd has been opened 
at tbo Instance of friendly societies and approved societies. 
The St. 3Iarylcbono Division of llie Brltisii Bod Cross lias 
inndo a donation ot £30 towards a Samaritan fifnd to assist 
those wlio cannot pay the fuH fees. 

Tub Treasury lias made an order under Section 10 of the 
Finance Act, 1926, exempting radium compounds from Key 
Industry Duty from 3Iny 15th to December 31st, 1928. This 
stop has apparently followed representations from certain 
hospitals to tho Cliaiicellor ot tho Exclieqner. Tlie imposi- 
tion of tho dnty has been attacked os the canso of difficulty 
in securing supplies ot radium salts, notably for the treat- 
ment of cancer. Very small amounts of radium aro produced 
in Great Britain, and the world’s supplies are obtained tor tho 
most part from tlie Belgian Congo. 

The annual medical cruise organized by Uie Jlntxclles- 
Jlcdical will start from Bordeaux ou the mail steamer r>rar,za 
on July 29tli. Visits will bo paid to Corunna, Vigo, Oporto, 
Madeira, Tcnerilte, Las Palmas, and Ajaccio. The x'ricos 
range from £45 10s. inclusive upwards. Farther information 
can bo obtained from the Section do Voyages de Bruxelles- 
Mdtlical, 29 Boulevard AdoliAe Max, Brnssels. 

An international congress ot open-air schools will be hold 
in Paris from July 8tli to 12th, under tlie presidency of 
M.. Paul Strauss, with Professor Nobecourt as jiresident ot 
tho Medical Section and Dr. Lesage as general secretary. 
Great Britain will bo represented bj' Miss M. MacMillan. 
Further information can be obtained from M. Lemounier, 
37, Avouuo Victor-Emmannelr Paris. 

A BILL to direct that the principal civil medical officer 
shall in future be known ns and styled the director of medical 
and sanitary services has been passed by the "Legislative 
Council ot Hong-Kong. The change ot title is being made in 
connexion with the reorganization of the medical and sanitary 
departments. 

"With a view to assisting German scientists In research an 
effort is being made by a German society to supply the 
nnivorsitlos and students of that country with medical and 
scientific literature ot tho war period and subsequently. 
Copies of the Rrifialt .Uedfcnl Jonrnnf and the Lancet for the 
years 1914 to 1924 are partionlarly required, single numbers 
being welcomed if complete sets cannot be obtained. Those 
who arc willing to assist in this are invited to notify the 
Notgemeinschaft der Dentsoben Wissenschatt, Berlin C.2, 
Sclrloss Portal 3. Expenses incurred in sending books and 
journals will be refunded. 

The bealtli section of the League of Nations Health 
Organization has issued n pamphlet containing a list otits 
publications down to March this year. The booklet serves 
as an index to the activities of this body, and research 
workers and others will find it useful as a bibliography of 
the many routine reports and special studies undertaken by 
its Commissions. Brief details are given of the scope of each 
publication. 

Tub late Professor Gilbert has bequeathed a series of 
medico-historical colleotious to the history of medicine 
museum of the Paris faculty ot medicine, with a sum of 
40,000 francs for their instalment. 


The iuternational congress of applied psychology will meet 
at the Palais-Royal, Paris, next October. 


The sixth international congress for combating tuberculosis 
will be held iu Rome from September 24th to 28th, under the 
patronage of the Italian Government and the presidency of 
Professor Eaffaele Paolucoi ot Rome, with Professor Leon 
Bernard as general secretary. Papers will be read by Pro- 
fessor Calmette on the filterable elements ot the tuberculous 
virus, by Professor R. Jemma of Naples on the diagnosis of 
infantile tuberculosis, by Professor Morelli ot Pavia ou the 
pneumothorax treatment ot pulmonary tuberculosis, by Dr. 
William Brand ot London on the organization ot antituber- 
culous jirophylaxis in rural districts, and by Professor 
L. Braner of Hamburg on the surgical treatment of pulmonary 
tuberculosis. The subscription for the congress is 100 lire, 
which is payable to tbo Federazione Nazionale Italiana 
Pascista per ia lotta coutro la tnbercolosi, 12 Via Toscana, 
Rome. An exhibition ot methods for dealing with tuber- 
culosis will be held during the congress, which will be followed 
by exenriious to Italian sanatoriuras. 


, iiiK secouu quarterly issue ot Seuclienielcampfuniq thi 
Viennese journal dealing with the ctiologv, prophj'laxis an( 
experimental treatment ot infectious diseases in man’ an( 
animals, is dedicated to Protessor Richard Pfeiffer ot Breslau 
the discoverer of the inflneuza bacillus, on the occasion o 
his seventieth birthday. i “ 


884 May 19, 1928] 


LETTEKS, NOTES, AND ANSWERS. 


r Tut JlnmiTK 

L UtDlCU. JOL’CXil 


Jiot£s, aitit 


All communica,tions in regard to editorial business should bo 
addressed to The EDITOR, British Modica! Journal, British 
Medical Assoclaticn House, Tavistock Square, WmC,U 
0111G11\.VL AUTICLES and LETTERS forwarded for publication 
are understood to be offered to the BuiTisn Medical Jouhnal 
alone unless the C9ntrary be Btated. Correspondents who wish 
potice to bo taken of their communications should authenticate 
them with their names, not necessarily for publication. 

Authors desiring REPRINTS of their articles published in the 
BaiTiSH Medical Journal must communicate with the Financial 
Secretary and Business Manager, British Medical Association 
House, Tavistock Square, W.C.l, on receipt of proofs. 

All communications with reference to ADVERTISEMENTS, as well 
as orders for copies of the Journal, sliould bo addressed to Iho 
Financial Secretary and Business Manager. 

The TELEPHONE NUMBERS of tho British Medical Association 
and the Biiitisn Medical Journal arc MVSEVM OSGl, VSG2 VS03 

■ and VSG^ (internal exchange, four lines). * * 

The TELEGRAPHIC ADDRESSES VLTQl 

■ EDITOR of lha Beiiise Meuical Jodhsal, Aitiotonv Woteent 

Loiirf.nn. *' • 


SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.!. Articulate Trcctccui I.outlnu 
MEDICAL SECRETARY. UcdUccra TTcctcrut, Loudon 
The address of t!.o Irish Office of tlie British Medical Association 
IS 16, South Frcdei iclr Street, Dublin (tcleiFranis • Ilacitlun 
DKihu; telephone; 62550 Dublin), and of the Scottish Office,’ 
6, Drumshough Gardens, Ediiihiirph (telegrams- Asinrlulc 
Adiniurp/i; telephone 24361 Edinburgh). Bams. Associate, 


QUERIES AND AKSWERS, 

“Co-SVAL" 06)56 Where he can fliicl the heat description of or 
treatise on, orthodiagraphy of the heart aud radioscopy of’ the 
chest and abdomen. He requires ancli an account as would 
card^'l0"V''^ seueral pliysiciau with a epeoial leaiiiug towards 

Hardening tre Eeet. 

(Winchcombe) writes in reply to “H. K” 
(May 5th, p. 787) : Soalcimj the feet in a 1 per cent, amieous 
solutiou of pici-io aoid liardeiis the slciii well, A friend of iiiinn 

eioeneut'resu’lts."’'^^ ”■ the war with 

VlTAGLASS. 

Dr. W. Colquhodn (Dmimurry, oo. Antrim) asks wliolher there 
\lTJi assertion that vitaglass. after hofng sub! 

jected to tlie suu s rays for some time, becomes discoloured nnd 
impermeable to the ultra-violet rays. aiscoloured aud 

iNco.ME Tax. 

Purchase oj Practice. 

“H. K.” bought a practice with a three months’ iutroduction on 

equal sharing terms ns from April 1st, 1928 and is la rim.°n 
partner as from July 1st, 1928, on a three-fifths nud^Huo nrn”' 
basis. How should his liability be assessed? ‘ 

The gross assessmeut should he bused on tlie nmonut of 
Ins predecessor’s earuiugs tor the previous year. This amount 
will be divisible thus: -ruis nmonut 

Former proprietor 1/2 Of 1/4... -ai/fl 

Self 1/2 of 1/4 + 3/5 of 3/4 ... ,=23Mn 

Incoming partner 2/5 of 3, '4 ... 

The appropriate personal allowauocs will, of course, be deductible 
from the respective sliares. H the profits of tlie r 

1928-29 should fall short of the' profits for 1927-28 from some 
specific cause then “H. K.” and his imi-tnor i • 

adjustment when the former amount is ascertained. ““ 

.. T TTT . , ^o^or Car Transactions. 

‘J. Y>. C. bought n car in June. 1924 fnr- rxnn .. ai . 

March, i928, for £60, huyhitf a car of 
Ho claimed depreciation £40 for 1926-27 a\id £30 fo^’wM-V? 

*.• He c.an claim “obsolesceiico,” hut not “ renewal,- „ a 
also dei.reoiatiou. The obsolescence claim shoulT L r ^ 
£300-£60-(£40-t-£30)=£170. (We are ■ assn nTing tw the 

• preciatioii was allowed, if it was uot allowed till. ni ' i 
he for£3M-£60=£240.) The Bepreciatiorctim ^i ^ on£"85 
at 15 or 20 per cent. ‘ -^185 

“ W. J.” bought a car in 1922 for £865 niid sold it in love r 
wiieu he hougiit aiiotiier for £1,922. He ImO 

mil. lilt, in 1014 (ni- £RSR On.l ,nl.l n no, .“““Ibl’ Car. wllicli 


hebouglit iiri914 lor £688 a7id sold in 1M7 

dai‘m7™^“‘' ■"'‘’at 'I'lowauceqMu^’j 

• . ’ Obsolc<ceucc allotcance (1) 'as an expense of the Tear im 

£863— £Ic0 — a. 713; (2) as an expense of the year 1927 £319 con 

£295. Depreciation allomiucc for tlie riiiaiicial year 19’27-28 £1 o 
at 15 per cent. ==£288, and for 1928-29 (£1,92‘2-£288=1 £i eje 
pi9-tliat is, £1.933 at 15 per cent., £293. It stionld, Imwew 
be stated witli reg.ird to the obsolescence allowance Hint in ti 
eircnmslanees the title thereto is not beyond dispute for ye ' 

maybe'omo?Sr“‘“°“ " claimed, and the claim for S 


Depredation on Car. 

“IIUSTICANUS” makes his accounts up to July 31et; ho bought 
n now car on Mai-cli 2911., 1928, and' has claimed depi-coiatTon 
nllowaiico for 1928-i;9 on tlie viiliio of that car. 'The iiisiicctor of 
taxes, howover, coiiBiders that tlie allowniico- should he made on 
the basis of the value of the car used at July 3l8t, 1927. 


*.* The course proposed by the inspector fa tho usual one 
and has been judicially apinovod. In this case, however, there 
are some grounds for the view taken by our correspoudeut-for 
e.xaniplo, tho niinaiial loiigth of time elapsing between the close 
of his accoiiiit and tho commencement of the year for which Ibe 
tiUowaiice Is made. In tho long run tlio difference should dis- 
npiioar, and the point is, perhaps, hardly worth pressing. One 
Jiicans of avoiding' the result that has hoen reached would be lo 
make the next xirofcssloiial account for tlie eight mouths to 
March 31st, 1928, aud apply for the 1928-29 assessment to ho 
made not ou tho agreed figures, but on tho amount of the profit 
for those eight mouths plus one-third of the profits for the 
lirevioiis twelve mouths. Ou that basis the new car would 
aulomatlcnlly come iuto tho depreciation calculatiou for 1928-29. 


LETTERS, HOTES. ETC. 

Thirty Years’ Suuvivai, aiter Excision of Tongue. 

Mr. .T. Macewen (Glasgow) writes: ’Tlie following extract from 
. a fetter sent iiio by Dr. J. Robson Turner, Paislev, is self- 
cxplaiialory, and may prove of interest to some of your readers. 

A patient told me he had been at tho funeral of R. E.. aged 81, 
who Jiad an operation n't your father's [Sir William Macewen] 
hands for cancer of tho toiigiio, thirty years ago. 1 thought 
tlio story so remarkable iti the success of the operation, and 
the longevitv- of the iiatieut, that I ought to draw youratteutioii 
to it. 

. The man referred to by Dr. Turner had an excision of the whole 
tongue, togetlier with tho glands in the neck, performed ns 
stated. He was said to have been of a silent disjiositiou prior to 
operation, but he became very loquacious after it, and was over 
ready to give the students o-xamples of his powers of speech. It 
was goiicrally believed in tlioso days that removal of the tongue 
rendered the victim mute, and this patient’s iierformniice 
accordingly created much surprise. In those days likewise the 
phonograph was a compai-ntivoly recent and marvellous inven- 
tion, and Dr. John MacIntyre of Bath Street, Glasgow, took a 
record of this iiinu’s speech ou a wax cylinder, using a recording 
needle, and, later, let my father and a visiting American surgooii 
friend hear the result over the telephone, which, likewise, was 
still something ol a novelty. 

Some Old Medical Books. 

There wore a few notable old medical hooks in Messrs. Hodgson’s 
sale at their Gliaucery Lane rooms ou May IBtli, 17th, and 18tb. 
li'oremost in point of interest, perhaps, was a first edition of 
. Peter Lowe’s “ The Whole Covrse of ' 
hrielly set dowiie tlie Cause, Sigiies, 

Ciirations of 'all sorts of 'Tumors, Wov 

Dislocations aud all other Diseases usually practised hy 
Chirurgioiis, according to the. opinion of nil our aiiucicnt 
Doctom-s in Chirurgerie," published by T. Purfoot in 1597. 
'This hook is uot recorded in the Short Title Catnlogiie,' so 
it must be extremely rare. There was also a copy of the 
“.Regimen Sanitalis Snlerni,’’ the English translation h.v 
Thomas Paynell, published in 1575; and another of tlio sixteenth 
century, probably earlier thau-tlio foregoing, was the “ Praotica 
Gerald! tie Solo siijier uouo.Almaiisoris.’’ Of tho seventeenth 
century maybe noted a late edition tlG2G) of Thomas Vicary’s 
“EiigUsh-niaiTB Treasure, with tho true Auatoniie- of Man’s 
Body, wliereiinto are annexed many secrets appertaining to 
Chyriirgerie ’’ ; W. Baley’s .“Briefe 'Treatise toncliiug tlie Pre- 
servation of the Eyesight ’’ (1654) ; “A Short Treatise showing 
the causes aud remedies of that General Disease . . . termed h.v 
many the Plague of Hie Guts j but it is very probable to be tho 
Dyseuteria, or Red l-'liix,” by N. H. (1658); “Pons Salntis, or 
the Pountaiu of Health Opened,’’ by T. Moiilaou (1665); aud ouo 
or two others of minor interest. 

Sea-sickness and Train-sickness. 

“M.D.” writes: To those who are prone to suffer from mal de 
voyage, whether in trains,, steamers, or in motor cars, thoro is 
one simple precaution which I can recommend — namely, that 
for several hours before and dm-iiig their travel they slionld 
avoid partaking of tea aud eggs. Several people by doing so 
have been able to undergo in comfort and even with enjoyment 
journeys which, taken after a meal oontaiiiiiig either tea or eggs, 
and, worst of all, both, have produced severe nausea and sickness. 

I hope this infoi-iuatiou may enable many others to enjoy 
journeys which in the past have been only paiutal necessities to 
he endured. 


.Vacancies. 

UOTIFICATIONS of otBccs Vacant in universities, medical colleges, 
and of vacant resident and other appolutmeuts at hospitals, will 
he found at pages 52, 53, 54, 55, 58, 59, and 60 of our adyertisernent 
'columns, and advertisements as to partnerships, assistautships, 
aud looumtenencies at pages 56 aud 57. 

'A short summary of vacant posts notified in the advertisement 
columns appears in the SiippIewieiH at page £19. 



MAT 26, 1928] 


rULMONARX ASBESTOBIS IN SOUTH AFRICA. 


[ TmEBsmnt QQR 


PULMONAET ASBESTOSIS IN SOUTH 
AFBIOA. 

[(WUli Special Plate.) 

BT 

F. W. smSON, M.B., Cn.B.Fn., 

PATHOLOGIST AT THE EOUm AFKICAH IKSTITUTE TOR llEDlCAIi EESEARCII, 
JOnANNESDOBG. 


It lias liGon Imown for some time that workers exposed 
to tho dustv ntmosphero arising from some processes in- 
volved in tlio preparation of asbestos materials suffer from 
pulmonary disability. Tho mining of tho mineral itself 
is probably not a source of danger, ns asbestos is mined 
mostly in open quarries. After sorting, there remains 
waste rock which still contains fibre in payable quantity. 
Crushing of this rock causes a considerable degree of dust 
exposure, and exposure to tho dusty atmosphere is still 
more exaggerated in tho carding and spinning of asbestos 
in the mills. _ ' - ■ • 

Very littlo concerning tho pathological changes in the 
lungs of persons working with asbestos has been found in 
tho literature, and it was thought that a record of the 
following eases might bo of interest. 

On September 2nd, 1926, the medical officer of an asbestos 
mine in Southom Rhodesia forwarded to tho South African 
Institute for Medical Research three small speeimens of lung 
from a i>ost-m6rtcm case for histological examination. 

Case 1 (Ko. 9026). 

. The subject waa a male adult native, who had worked for 
twelve months in the asbcs.tos mill, and, except for a short 
period before his death, had had a good record of health. 
For nine weeks before death ho suffered from acute tuber- 
culosis, and the post-mortem findings showed miliary tuber- 
culosis involving the lungs) liver, spleen, and pericardium. The 
object of the ■ histological cx.amination was to ascertain if 
there was any evidence of fibrosis in tlie lungs which might bo 
directly ascribed to the nature of liis employment, since workers 
in tho mill are exposed to a verj' dusty atmosphere. 

Apart from the tuberculosis and akociated fibrosis, sections 
of the lungs showed a certain amount of connective tissue 
change which had no obvious conne.vion with (he tuberculous 
process. It was also found that curious golden yellow seg- 
mented structures, with rounded' or club-shaped ends (Fig. 1), 
were embedded in this fibrous tissue, together witli very minute, 
doubly retractile particles, the latter presumably silica. 
Although the curious segmented bodies were remarked upon, 
no further investigation was carried out at the time, and the 
new-formed fibrous tissue was attributed to the presence of 
silica. 

. , _ Case n (Ko. 11016). 

It was not until September 29tb, 1927, when a portion of 
lung from a second case was sent by the medical officer from 
Uie same mill, that the foreign bodies and fibrosis were more 
fully investigated. This piece of lung was from a male 'adult 
native who had been employed in the mill for a period of two 
years. About SeptembCT, 1926, ho w-as admitted to hospital 
E^enng from pneumonia, and had a long illness. He was dis- 
charged, and later (September 19th, 1927) readmitted in a dying 
condition. He ivas very emaciated, and had the physical signs 
of pulmonary tuberculosis with fibrosis. At autopsy the lungs 
were firmly bound down by adhesions, the root glands enlarged 
ahd hard, and the lungs on section hard and fibrous with an 
almost leather-like consistence. The mesenteric glands were also 
considerably enlarged. 

Histological sections showed a generalized but moderate degree 
,, thickening of the pleura, trabeculae, and alveolar 

walls. In addition, there was n much more marked fibrosis 
awanged m irregular-shaped nodules, chiefly related to’ tho 
blood vaster system and bronchi. This fibrous tissue was 
cellnlar, the elements arranged in an irregular manner, and 
included some smaU lymphocytic accumulations (Fig. 2). There 
was no resemblance to the orderly, whorled arrangement and 
sharp definition of the silicotic nodule (Fig. 3). The bronchi 
were the seat of slight catarrhal changes, and many of tho 
mveoli contained dust cells ” filled with pliagocyted particles. 

^.2 ovidenco of tuberculosis or acute pneumonic con 
sohdation. Embedded in tho fibrous tissues, lying free i: 
alveoli (Fig. 4), and contained in phagocytio cells, there wore 
numerous golden yellow segmented bodies (Figs. 5 and 6), -a few 

arge angular bkack bodies, and very minute doubly refractin'^ 
partmles. Phagocytosis was o very striking feature. Large 
contained within ordinary mono- 

uclear cells and irre^ar-shaped multinudeated giant cells 


(Fig. 7). Phagocytosis was not confined to tho smaller particles, 
but even largo rods were Been completely enclosed and often 
bent in order to allow them to occupy tho space witliin the 
cells (Fig." 7). It was thought that these foreign bodies, 
together with the crystalline matter, may have been the cause 
of the fibrosis, as the connective tissue, both, in distribution- 
and formation, was very suggestive of changes resulting from 
n dust occupation of tho lungs. At the same time the liistoiy 
of pneumonia and protracted recovery must be taken into' 
consideration, since an unresolved pneumonia with subsequent 
fibrosis is not an uncommon occurrence amongst natives working 
on tho mines in South Africa. 

Cases in Axm rv (Kos. 6419 and 6751). 

Consultation of tho records and previous histological sections 
of material from the same mine has revealed two additional 
cases, both of which showed lobar pneumonia. There was very 
littlo connective tissue increase, but the unusual structures 
(Fig. 8) and refractilc crystalline particles were present. No 
hidoiy of length of service in the mill was obtained with cither 
of these cases. 

Further study of the golden yellow bodies showed a 
variety of shapes, hut the most common forms had rounded 
or club-shaped ends and a segmented body tapering to 
a finely pointed tail. They were non-refractiie to polarized 
light, soluble in strong acids, and, on raising to a red heat, 
turned black and tended to lose their outline. In sections 
treated with hot dilute liydrochloric ' acid and potassium 
forrocyanido they gave a well-marked Prussian blue 
reaction. No pigment except these structures giving the 
iron reaction could be detected in the sections examined. 
Strong hydrochloric acid, having been tested for the 
prcscnco of iron and found negative, was used to dissolve 
out iron from fresh sections. After treating the sections 
tho hydrochloric acid gave a very distinct red-pink’ colour 
with potassium thiocyanate, and the red-pink colour dis- 
appeared on tho addition of a solution of mercuric chloride. 
The sections were re-examined and showed that the majority 
of tho golden yellow bodies had been dissolved put. From 
these tests it was concluded that tho structures contained 
a largo percentage of iron. 

As controls, sections of lungs from a largo number of 
miners on the Rand who had died from silicosis and tuber- 
culosis were examined. Bodies such as have been described 
above were found in none of these, nor was the Prussian 
blue reaction or other test for iron positii-e except in those 
cases where the pigment was obviously of haomatogehoiis 
origin. A single case of a miner was also investigated; ho 
had worked for twenty-eight years in the haematite mines 
in tho North of England, and subsequently for seven and 
a quarter years in the gold mines of tho Rand, South 
Africa. Tlio cause of death was carcinoma of tho gall- 
bladder. jMacroscopically tho pulmonary root glands were 
enlarged, pigmented, and fibrosed. The pigment was dark 
rust-coloured and gave a marked Prussian blue reaction 
with dilute hydrochloric acid and potassium ferrocyanido. 
Occasional fust-coloured subpleural islets were visible. ' On 
.section the lungs showed a slight diffuse fibrosis and a 
few large areas of fibrosis. The whole lung gave a marked 
iron reaction. Histological sections of the large areas 
showed moderately well defined, but irregularly shaped, 
masses of well-formed acellular fibrous tissue (Fig. 9). 
Tho alveolar walls were slightly thickened, and there was 
a moderate degi'ee of connective tissue increaso round the 
blood vessels and bronchi. A largo quantity of pigment 
of a reddish-brown colour was contained in phagocytic cells 
and lying free in alveoli, alveolar walls, and between the 
-fibres of the newly formed fibrous tissue. Tlie greater'part 
of this pigment gave the iron reaction. In addition, there 
was another variety of pigment, in much smaller quantity-, 
in the form of crystalline refractilo particles. The latter 
was intimately mixed with the iron-containing dust. This 
lung was especially examined to determine, if possible, 
whether tho same peculiar bodies were being foi-med from 
a deposit of ferric iron dust as in the case of an asbestos 
dust which contained both ferrous and ferric iron.' A 
careful and thorough search was made, but lio particles 
with .a similar appearance were detected (Fif 10) At tho 
time of the patient’s death this case of ironstone phthisis 
was complicated by _ underground work in the gold mines 
on tho Rand, but in 1919- it simulated, bv a:-ray photo- 
grrphy and physical examination, an early case of kilicosis,’ 

[3516] 



886 May 26, igaS] 


PULMONAKT ASBESTOSIS IN SOUTH AFRIOA. 


[ Thk nr.iTiin 
Medical Jousnal- 


p.ml confirms the findings of Sir Kenneth Goadhy*. and 
Dr. Cronin.- 

In addition to the human lungs sliowing ashestosis. Dr. 
Mavrogordato of the South African Institute fdr Medical 
Research has supplied me with the lungs of a guinea-pig 
which died in December, 1927, from causes other than 
ashestosis. This animal was cx)rased to an asbestos dust 
atmosphere experimentally. The length of exposure was two 
hours a day on each of fifty dajs. The first exposure took 
place on February 4th, 1925, and the last on April 1st 
of the same year. The asbestiforni compound used for the 
experiments was a chrjsotile^ obtained from the mine in 
Southern Rhodesia. Histological sections showed a slight 
generalized fibrosis and an increase in pigment, but the 
interesting feature was the presence of the golden yellow 
bodies (Fig. 11), similar to those seen in the lungs of 
huinan pulmonary ashestosis. 

A comparison between the human cases and the experi- 
pental animal showed that the fibro-is was more rapid and 
(xtensive in the human cases than in the experimental 
animal. This is readily explained by the diffleulty in 
reducing the tough asbestos fibre to a uniformly find 
powder, and to the presence of a comparatively small 
proportion of the rock dust which is usually associated with 
asbestiforni comjiounds. For " dusting ” animals a limited 
amount of dust is available, and of this only a small 
jnoportion contains jiarticles of sufficiently small dimen- 
sions to permit of their reaching the lung alveoli. In 
silicosis^ the size of the majority of the particles' which 
roach the alveoli is between 1/r and 3p ; in the haematite 
lung, mentioned above, the particles appear larger, but 
oven hero are much smaller than the greater number of 
those prepared from asbestos for “ dusting ” experiments. 
In the working mill the conditions are very different from 
an asbestos dust atmosphere produced experimentally. Fine 
dust is continuously reaching the atmosphere, and only the 
very fine particles remain suspended for any length of 
time. These gradually increase in numbers until a maximum 
concentration is reached, then remain more or less con- 
stant during working hours. Thus it will bo seen that, 
in order to produce changes in experimental animals allow- 
ing the same degree of fibrosis in the same length of time, 
an atmosphere ap])roxiraatiug that of the working mill will 
have to be obtained. 

The amount of fibrosis in two of the human cases 
(Cases I and ii) was quite definite, and, if due to the 
presence of asbestos dust, the initial rate of production was 
rapid when compared with present-day non-infective silicosis 
on the Rand. It is difficult to state a definite time for 
the production of an appreciable degree of fibrosis in pure 
non-infective silicosis, but modern observation tends to show 
that it is in the neighbourhood of ten years. In Case i 
a moderately marked fibrosis had taken place after one year 
of work in the mill, but this was complicated by tuber- 
culosis. It is known that the rate of fibrous tissue pro- 
duction is v'ery much greater in dust diseases complicated 
by infections, but even allowing for this the connective 
tissue increase in Case i was rapid. In Case ii there was 
a still more definite fibrosis after two years of work in 
the mill with no evidence of tuberculosis. 

Before this work was completed Drs. Cooke,' Stuart 
McDonald, and Oliver^ published their papers dealing with 
pulmonary ashestosis, and previous to that a short article 
on the same subject appeared in the Lancet. The similarity 
between the case described and ours was suspected when 
the first article appeared, and our work goes far to confinn 
the findings. As in those recorded here, the asbestos dust 
responsible for the changes in the lungs in their case was 
a chrysotile. IVhether other asbestiforni compounds arc 
capable of producing these changes it is impossible to say, 
as there appears to be no record of any such cases in the 
literature. 

In the Union of South Africa*. and Rhodesia there are 
many asbestos mines, from some of which chiysotile is 

obt-ained, but two other interesting varieties are found 

namely, crocidolite and amosite. Amosite is a compara- 
tively recent discovery, the chemistry of which has not 
been completely worked out, but it appears to be somewhat 
siiuUar to crocidolite in composition. Both these com- 


pounds contain a largo peiccntago of ferrous iron. Analysis 
of four samples of amosite* showed between 32 and 44 per 
cent, of FeO, and' eight samjilos of crocidolite* between 
16.5 and 40.5 per cent. Up to the present there has been 
no examination of pott~mortcm material from cases of 
death among those working in mills where these minerals 
arc treated. No such material has bccii made available. 

Chrysotile or serpentino asbe.stos usually contains 2 to 3 
per cent, of FoO isomorphously replacing magnesia. The 
analj’sis of Dr. Cooke’s case showed 3 per cent, of FcO, and 
the Rhodesian mineral, according to Mr. A. L. Hall,* 
2.44 per cent. Dr. SlcCrao of the Government Chemical 
Laboratory, Johannesburg, analysetl the FeO content of the 
asbestos used by Dr. MavrogOrdato in his animal experi- 
ments, and found .i much lower percentage — namely-, 0.45. 
Apparently even with very small percentages of FeO the 
goldon yellow bodies are foi-med in tlie lungs. 

With regard to the unusual structure and chemical 
nature of the golden, yellow bodies found in the lungs in 
jiulmonaiy a.sbe.stosis, until many more cases have been 
examined and more ex])erimental work has been done very 
little can bo stated. There is no doubt that they are in 
some way associated with the asbestos, or, probably, more 
particularly with the FcO content, either of the asbestos 
itself or of the dust of the mill. This dust contains a much 
higher percentage of iron, which may bo derived partly 
from tho lode from which the asbestos is mined. 

Tlirco possibilities regarding tho formation of tho golden 
yellow bodies arc worthy of mention ; 

(1) In the form of a gel, as suggested by Dr. Stuart 
McDonald. 

(2) As jiarticles.of ferruginous quartz formed in the lungs 
under conditions similar to weathering, dr ferruginous 
quartz changed in composition as a result of combination 
with constituents of tho body fluids. In support of this 
it may be mentioned that crocidolite, which is an alkali 
silicate with ferrous iron, is .especially liable to decomposi- 
tion when exposed to weathering. Sodium is removed, tho 
iron oxidized and hydrated to form limonite, and silica 
set free; there then results a ferruginous quartz which 
possesses’the finely fibrous structure of the original mineral. 
It is extremely hard, and coloured a rich golden yellow. It 
is possible that a change such as this, occurs with the small 
quantity of ferrous iron associated with chrysotile, and tho 
colour of the bodies in the lungs is very suggestive. 

(3) Phagocytosis of these structures is a very prominent 
feature in the lungs, and it was thought that the action of 
th'cso colls may have been responsible, first, for some change 
in chemical composition, then a building up and moulding 
into the various shapes seen. 

Tho fibrous tissue change in tho lungs of tho above- 
mentioned cases -of workers in asbestos mills is probably 
tho result of a reaction on tho parts of the tissues to both 
the golden yellow bodies and a small quantity of silica. ■ 

Sufficient cases of pidmonary ashestosis have not been 
recorded to base an opinion upon tho liability to secondaiy 
infection by specific inflammatory iirocesses such as tuber- 
culosis but it is very suggestive that two of tlioso now 
recorded, which have been examined histologically, have 
shown tuberculosis complicating tho changes produced by 
an asbestos dust occupation of the lungs. 

Besides these cases thore is still further evidence in 
favour of tuberculosis being a complicating factor. 

Dr. H. M. Murray reported a fatal case in the Charing 
Cross Hospital Gazette in 1900; and in the United States 
of America, from one source,” during tho period ■ 1907 to 
1914 there were 13 deaths, 3 of which were from tuber- 
culosis. 

In 1910 Dr. Collis" reported on the relationship of 
asbestos dust to pulmonaiy tuberculosis, and found that 
5 deaths from phthisis had occurred in five years amongst 
a staff of less than forty workers employed at a factory 
where asbestos is woven. 

In conclusion, I wish to record my thanks to Dr. Mavrogordato 
for data and material from an experimental animal ; to Dr. 
Tri'inc, chairman of tho Miners’ Phthisis Medical Bureau, 
Johannesburg, for ^ material from silicotic cases and from tlia 
lungs of a haematite miner; to Dr. McCrae for his analysis of 
tho FeO content of a sample of asbestos; and to Mr. P. Longmora 
for his valuable assistance in preparing the microphotographs. 



M.U- 2C, 192S] F. W. SIMSON : PUDMONAEY ASBESTOSIS IN SOUTH AFRICA. 


[ The Bbitish 
Medicai. J^cbbax. 



Fig. 1.— Pulmonary nsbcJ-losis (Ca«o 1 ). Coition >ollo\v 
liodic> lyinir in the centre of a noilule of jounp tiluous 
tissue, (x 850.) 



Fie. 2. — Pulmonary asbestosis (Case 11 ). Irregular 
fibrotic nodule showing a moderate degree of cellularity. 
Tlic lK>die'< embedded in this tissue are just visible. 
( X 250.) 



arranppm7n®t‘'in'’i‘®i sliowinr; or.lcrlv whorle 

ch„.actcri.-,ic ol th, 



Elo. 4.— I umionary asbestosis (Case ii). Small pha«^o- 
cytes containing granular dust and golden vellow bodies 
One large body is lying free in the alveolus, (x 850.) ’ 



J-enow ?truciu”?Sutf„lp f 'V' ^'“'6'' 
<i>pering tow.-,.ds one en.° (" KO ) body 


Fig. 6.— Pulmonary asbestosis (Case m 
xellow structures with globular pnd<? 
body tapuiing towards one end, (x 850.) -e-.mented 



May 26, 1928] F. W. SIMSON; PULMONAK'Z ASBESTOSIS IN SOUTH AFEICA. 


[ 


The BnmsH 
Medical Jocesal 



Fig. 7. — Puhnonarj asbo^tovis (Ca«e li). .\1veohis 
sliowiii" Ffvcral large miiUinucleatcd giant tell? con* 
taimng golden yellow bodies, (y 850.) 


Fig. 8.— Pulmonary asbc'stosis (Cn'^c III). This lung 
showed acute jmcutnonlc consolidation. Golden yellow 
bt^ics in jdmgocvtic cells and lying free in an alveolus. 
(X 850.) 



Fig. 9 — llaematito miner’s lung. Sliowinp ^^e^•fo^lncd 
acellular tibrosjs and large masses of granular pigment. 
The gicaler part of this pigment gave the i»on reaction. 
(X ^h.) 





V •>; Tt ) 

■Y, -... 


miner’s lung. Showing appear- 
bodfes. absence of golden yellow 




# ^ 




'•'sv* 

•tfr 




: I 

. 

/ 


?IG. 11.— Luns of exporimental animat. 

How body and small phagocytes containing granti 
:st. (X 850.) 



May 26,.JI9i8] 


ABDOMINAIi PAIN. 


r TmrUniTJiH fift7 

t UeOICiX, JOCCNAI. 


RcrnnEXcns. 

J Oo'idbV Sir lui A Ctv'o of Irorislono Ththlsls. Lnneftt 1924, H, 75i ' 

scronhi,' A. J. : nu<:t liihaUtlou by llucmuUlo Miners. Journ. Inrfait. 

Fun'll NoIm on l!ic Asbojloi Occurroncos noar Knnr^o 
Uooji, In tho Barberton Bislrict. rrnlis. Ocol. ior. S. A/iiro, IKS. 

* McCone , Tht Ath of Silicotic Umos. Jolintinc'burir : PitWiratioM 
of tlio South African liwlituto tor Sledicnl Bwcnrcli. ial3 No. HI. 

• -olr, J. : On the Afld/rc oj the Dovbhj- 

• , ■ liicroscojifc Section* of Stlicolic h^unt, 

■ of the South African InsllUilc »or 
• VIL 

« ' hiincR <!uc to tho Inhalation of A&bc^tos 

DiiFt. nrtltsh Medical Journal, 

» Cooke, W. C., Stuart McDonaU!, nml Sir T. Oliver : Pulmonary 
Asbcslosls. britiih MftUcol JoumaU 1927, if, 1 Cl4. 

‘Hall, A. L, : in the Vnion of South Afrien. Gcoh Surrey, 

"Union of South Africa. Memoir Ko. 12, pp. 17, 18, 22. , 

•UofTman, F. L. : Mortalitv from Hcpnlraiory Direa^cs In Du.^ty Trades. 
2/uff. U.S. 2Inr. l^bor 191B, June, Whole Nutnher 231. 

CoUis, F. L. : Annual Hoport of tho Chief Inspector of Factories ona 
Workshops for England and Wales, 1310. 


ABDOMINAL BAIN AS EXEjMBLIFIED IN 
ACUTE APPENDICITIS: 

A Clixical and Biological Coysidehatios.* 

JOHN-MOKLEY, Cn.M., F.B.C.S., 

EONORARr ASSISTANT SUROEON, MANCHESTER ROV.^L INFIRMARV; 
HONORARY CON.SULTIKO SUKOEON, ANCOATS HOSPITAL; LEtTl'RER 
IN APPLIED ANATOMY, MANCHESTER UNIVERSITY. 


Tub Ea'olutio.n: of our Knowli^ige of ABDOiiiN'-\t 

PAI.V.f 

ALitosx tiio first considerable contribution to our kuow- 
iedgo of tho mechanism of abdominal pain was inado by 
J. Ross of Manchester' in 1887. Ross licid that there 
were two hinds of pain in visceral disease — true spluncbuic 
paiu, felt in tho nfTected organ; and associated somatic 
pain, referred to tho ccicbro-spinal nerves of Iho body 'vall. 
Lonnander® established tho insensibility of tho exposed 
gastro-intostinal tract to tho ordinary painful stimuli, and 
attributed all abdominal pain to stimulation of nerves in tlio 
sensitive parietal peritoneum. Mackenzie, whose views form 
tho orthodox teaching of tho current textbooks, accepted 
Ross's views on somatic pain, but rejected rplanchnic 
pain as uon-existent. Ho believed that painful stimuli 
])asscd from the viscera tlirongh tho afToront splanchnic 
nerves to the spinal cord, but ivero only appreciated by 
the brain as arising from tbo sensory nerves of tho parietes. 
Mackenzie's theories of a viscero-sensory and viscoro-motor 
leilex have been widely accepted, and will bo discussed 
later, Hurst^ in 1911 published observations which have 
'lestored our belief in true splanchnic pain; Iio proved that 
this typo of pain is produced by a single adequate stimulus — 
namely, increased tension in tlio muscular wall of the viscus 
concerued. Yet Hurst does not reject I^Iackenzie’s views on 
the mscero-sensory and viscero-motor reflex mechanism. 

My pui’poso in this paper is to discuss tho light which 
a study of acuto appendicitis throws on tho mechanism of 
abaominal pain; and since Mackenzie's theories were based 
0® his observations in cases of appendicitis, 
tm disease may reasonably bo used to test thoso theories. 


toaohing on tho pain in ncuto 
referred tn tlf attack is nshored in by pain 

it and tlnf umbilicus or a little above 

in tho riWit hocomes localized 


The Two Pains in Api’endioitis. 


in tho right iliac fossa 


or moves down into that region. 


Tlia firct or Central Pain, 

la<3 nrst point thii r ■ . 

initial pain is entimW '>‘»P''asizo is that tho 

modo of origin from tho^ fah?'!*'l 
Iliac fossa a few hours lain 
tho centra of tho abdomen ’ 

refer it to tlio mid-lino at or ''i patient may' 

describes it 'IS “ all across ° iimbiUcus, he often 
across the central region of ’.i, Ins hand evenly 

— 2 — “bdomcn. It is, in short, 


•A — 
JF.; 


■ Royal Infirmary, 
hoa been abrldjrea 


very imperfectly localized. The pain is often described by, 
tho patient as “ like an ordinary hellyucho, but mor« 
severe.” It is frequently griping in character and vario* 
in intensity; tho more sovoro spasms usually occur at more 
or less regular intervals, and last for a few seconds, during 
which tho patient moans and writhes restlessly in bed. 
This early pain is entirely unassociated witli any tender- 
ness on palpation, and tho patient may lub or press on hia 
abdomen in a vain attempt to soouro relief — a thing that 
he never does when tho second pain has appeared. 

This initial pain in . appendicitis is, I believe, a true 
splanchnic pain, and, like all true splanchnic pain, is due 
to increased tension on tho muscular wall of ' tho viscus 
concerned. Some degree of obstruction to tho lumen of 
tho appendix, causing retention of inflammatory exudate, 
distal to tho obstruction, is an essential factor in its pro- 
duction. Sometimes — in fact, it is almost tho rulo in the 
most fulminating cases — ^ivo find a hard, laminated faecal 
concretion engaged in tho relatively narrow base of the 
ajipeudix, whilo distal to it a collection of foul pus under 
great tension rams tho concretion home into the base. In 
this condition, so well described by Wilkie* as acuto 
appendicular obstruction, tho central pain in the umbilical 
region continues until general gangrene or localized per- 
foration of tho apjjcndix relieves tho tension within it and 
tho pain disappears. In other cases a stricturo at tho basc^ 
tlio result of somo former ulceration, gives rise to the samo 
soquenco of events. In others a kinking at tho base com- 
bines with inflammatory swelling of the mucosa to occlude 
tho outlet into tho caecum. In yet rarer instances a 
foreign body is tho occluding agent. A critical examina- 
tion of tho sjiocimcns removed in a large number of cases 
of early appendicitis has convinced mo that wherever this 
splanchnic pain is present some degree of obstruction to 
tho lumen, with retention of inflammatory exudato under 
tension beyond it, will bo found. It is possible that the 
inflamed condition of tho appendix lowers tho threshold of 
painful stimulation and allows a relatively slight disten- 
sion to cause pain; but without increased tension visceral 
pain is impossible. 

Under certain conditions recurrent attacks of appendicitis 
may occur in which this splanchnic central pain is the only 
ovidonco of tho disease, and great difhcnlty in diagnosis 
results. A striking instance of this difSculty was afforded 
by a man, aged 21, who gave a history of four sovoro 
attacks of epigastric pain, each lasting for a few hours, 
during tho course of four months. There had boon neither 
tonderncss nor muscular rigidity during tho attacks, 
lixploration a week after tho last attack showed that tho 
only viscus affected was tho appendix, which was swollen 
and congested in its distal portion. There was n narrow 
stricture at tho base, and, distal to this, a collection of 
thick yellow pus. In the ton months that have passed 
sinco tho operation there have been no more attacks. 

It is evident that this patient was suffering from recui- 
rent attacks of acuto obstructive appendicitis of too mild a 
typo to cause perforation, and that his pain was of tho 
pure splanchnic appendicular type. Tho reason for tho 
entire absence of local pain, and rigidity I shall discuss 
later, when dealing with tho second pain. The brief inter- 
mittent colicky attacks of central abdominal pain so 
common in children, and described by physicians as 
" umbilical colic,” are i-ory commonly due to spasmodio 
efforts to expel n concretion or a nest of threadworms 
from the appendix, and form another example of pure 
spianohnie pain. 

Although tho splanehnio pain in acuto appendicitis is 
felt in the umbilical or lower epigastric region, and not in 
the region of the appendix, it should not bo described as a 
referred or reflected pain, as no radiation of pain or reflex 
process is involved. Tho appendix is developmentally a 
part of the mid-gut loop. The brain can only appreciate 
painful stimuli arising from any portion of the mid-gut as 
vaguely situated in tho centre of the abdomen, and stimuli 
of appendicular origin are no exception to tho rule. It is 
characteristic of this splanchnic pain that it is dull and 
aching in character — as patients express it, “ like an 
ordinary bellyache” — and vaguely localized; in other 
words, it is a form of Head’s protopathic paia. 


888 May : 6 , 1928] 


ABDOMINATi PAIN. 


[ 


Tnv. 

MixicAt. Jocr.516 


The Second or Locdlizcd Poin. 

A few lioms after tlio onset of the arnte .attack tho 
second pain makes its appearance in the right iliac foss.a. 
The initial splanchnic pain is nsiially still present, hut it 
tends, either gradually or suddenly, to sink into insignifi- 
cance. Tho new pain is entirely dill'erent in character 
from its forerunner. It is localized, severely at first, to 
the right side. It has a shal^) or stahhing character. Any 
movement of the abdominal mnsch's, as in deej) breathing, 
vomiting, or coughing, accentuates the pain, and tho right 
iliac fossa bocome.s exquisitely tender on jialpation. .Tho 
patient no longer writhes in pain, but lies still in bed, 
resenting any movement and even complaining of tho 
pressure of tho bedclothes. The respiratory excursions 
of the lower abdominal wall arc now incrcasinglj’ limited. 

Since the cutaneous and muscular phenomena inter- 
preted by Mackenzie as the vi.scero-scii'-on- and viscoro- 
niotor ndlex have received such general attention, wo must 
now consider them in detail. 

CUTAS’EOC.S HyPEUALGE.SIA in AcVTn .VlTHNIUClTlS. 

Mackenzie’s theory of a viscci’o-sen.sory reflex was based 
on his observation that in certain abdominal diseases areas 
could be maiipcd out in which the skin of the abdominal 



I’/ie Viiliie of II;/pcralgcxia in Hirn/noi/.s. 

'I here is a marked discrepancy between the statements of 
diflorent ob.servcr.s as to the frequency of hyperalgesia in 
acute appendicitis. ISherren, in 124 cases, found hypor- 
alge.sia in 40, or 32 per cent. Robinson,' in 123 cases, 
found hyperalgesia in 26, or 21 per cent. Zachary Cope' 
found hjqieraesthcsia (not amounting to pain) in 110 of 
185 eases, or 59 per cent. Further, both Robinson and 
Cope differ from Sherren in finding that hyporalge.sia and 
h\'perac.sthpsia occur quite frequently with a gangrenoua 
or ruptured a])pendix, and with this opinion my own 
ob.scrvatioiis arc in full agreement. 

A plieiiomenon that can bo detected by different observers 
with a frequency that varies from 21 to 59 per cent, would 
appear to be of but little help in diagnosis. Fnless, given 
certain pathological conditions in the appendix, hyper- 
algesia can be detected as a eon.stant phenomenon, I hold 
that it is merely of academic interest. 

A fuithcr consideration which invalidates hyperalgesia 
as an aid to diagnosis is tho extreme freqiicney with which 
it can bo elicited over the appendix in the neurotic 
abdomen, or those c.a.ses simulating chronic appendicitis, 
where on exploration no evidence of organic di-seaso in tha 
appemli.x or any adjacent organ can be found. 


The -tfrehanism of Production of Hyperalgesia. 

All observer.s arc agreed that when hyperalgesia is present 
in acute appendicitis it is found, in the vast majority of 
cases, in some part of tho right iliac fossa only. If wo 
accept Mackenzie’s hypothesis that it is due fo stimuli 
arising in the np))endix and travelling by way of the 
splanclinics to tho sjiinal cord, wo should expect if, however, 
to be bilatemlly symmetrical. The appendix is a portion 
of tho embiyonic mid-gut loop. It becomes fixed in the 
right iliac fo.ssa rclativol)’ late in tho development of the 
embryo, and long after it has received its splanchnic inner- 
vation. As a devclopmcntally median organ its nervous 
connexions arc presumably with both sides of the spinal 
cord, and consequently Mackenzie’s hypothesis as to' the 
origin of the hyperalgesia would appear to bo at variance 
nith anatomical evidence. Zachary Cope, in tho artielo 
quoted previously, suggests that irritation of tho sonsitivo 
parietal peritoneum "may in many cases dotermiue flio 
presence of right-sided hyperaesthesia, yot he goes on fo 
ar"nc that some evidence is furnished by his eases to show 
that the appendix is supplied mainly by tho tenth dors.il 
segment; thns ho tacitly accepts Mackenzie’s vistcro-sensory 

reflex. . , ■ • „ 

My own conclusions are that the hyperalgesia is a 
plieiiomenon in which the splanchnic afferent nerves take 
no part. I believe that the nerves of tho exquisitely 
sensitive parietal peritoneum affect their cutaneous branches 
by radiation, and that the process is precisely analogous 



ritli the cutaneous hyperalgesia along 2 .)“ The 

ranial nerve so often present in lotion possible 

ommunicatioii or synapsis lendeiing n-^iittlia of 'tlio 

irobably takes place in tho however, 

lervcs concei-ned. On account of i‘?^'"™=|"*'J’“'Jedicine has 
he practical v.alno of hyperalgesia in clinic 
een greatly overcstifnated. 



ABDOMINAtj PAIN. 


t TiirUr.msn 
Medical Joubxax 


MAT 26 , igjs] 

I' r; - ' 

JIPSCW.AJ! lllalDITY IN AoOlT. AwKNDIClTIS. 

■\\'o linvo howcvof, in ('ouncxiou witli tlio localized pain 
oC acute appendicitis an objective plicnoincnon cf prime 
importance because of its constancj* under eoitain uell- 
defincd conditions. This is tlio deep tenderness on gentle 
palpation u-ith the flat of the band over the appendix, 
associated ivitli rcncx and involuntary muscular rigidity. 
In order to appreciate the extent and degree of tins 
muscular rigiditv it is necessary to have the patient lying 
at ease on his back, U'ith the head well supported on a 
))itloiv. Gentle pressure vith a narm hand on tlio un- 
atfected left iliac fossa through a full re.spirntory cycle gives 
a standard of comparison. The hand is then transferred 
to the area of pain in the right iliac fossa, and again 
exerts gcntlo jiressnro through one or more respiratory 
cycles. The hard, unyielding contraction of the affected 
area of the flat muscles, the corresponding immobility of 
the miiEclo in full expiration, and the marked tenderness 
on pressure over the contracted muscle can then bo rcadil}’ 
appreciated and the c.xtent of the rigidity determined. 
The area of muscular rigidity and tenderness corresponds 
accurately ivith the area to which the patient points when 
asked to indicate the position and extent of his pain. 

The Value of Muscular Bigidity and Tenderness 

■ in Diagnosis. 1 

By noting the exact position and extent of the muscular 
rigidity and tenderness in an early case of appendicitis, 
at a stage when the initial splanchnic pain has given place 
to the sharper pain in the right iliac fossa, but before 
perforation and spreading peritonitis have confu-sed the 
jiicture, it is possible to predict with the greatest accuracy 
the position in which the inflamed appendix will bo found. 
IVhen the appendix is curled up on the outer side of the 
caecum the maximum rigidity is found close to tho anterior 
superior iliac spine ; when tho appendix is pointing upwards 
towards tho s])Ioen tho maximum rigidity is nearer to the 
umbilicus than tho conventional McDurney’s point. In tho 
rare undesoendod caecum tho maximum rigidity is higher 
than usual, and corresponds with a point just below tho 
lower margin of the right lobe of the liver. Whore the 
appendix hangs over the brim of tho pelvis tho rigidity is 
in tho lower part of tho rectus muscle, well below and 
internal to a line joining the anterior superior spino and 
tho umbilicus. With a prolapsed caecum which has dropped 
low into the pelvis there may bo no rigidity or tenderness 
on palpating the abdominal wall,- but in such a case rectal 
examination will usually reveal marked tenderness on 
pressure by the finger from within towards the right side 
of the rectum. In this .early stage the accuracy with which 
the inflamed appendix can bo located is remarkable. One 
striking instance will suffice. 

A woman, aged 50 , became ill with pain in the umbilical region 
and vomiting. When seen fifteen hours after the onset there was 
no aodominal rigiditj' or tenderness, but on rectal examination 
pressure towards the right waU of the pelvis caused intense pain. 
I diagnosed an infiamed pelvic appendix. For domestic reasons 
some delay ensued, and I saw her again twelve hours later. 
She had now typical tenderness and rigidity in the right iliac 
fossa, while the tendemera per rectum had *3110051 disappeared. 

1 remarked before operating that she must have a very mobile 
caecum, which had moved up out of the pelvis between my two 
visite, dragging the appendix with it. Operation disclosed pre- 
msely that condition. The caecum was so loosely attached that 
it could be lifted through tho wound six inches above the 
abdominal wall, and the appendix, which W'as long and free from 
effective adhesions, was acutely infiamed and covered with flakes 
of plastic Ij’mpli. The appendix and caecum were found lying 
ni the diac fossa weU above the brim of the true pelvis. From 
the condition ^und I have no doubt that the change in position 
that I had predicted had actually taken place. 

The MECH-txisii of Reflex IMuscuictn Rigidity and 
Associated Beep Tfjcdehness. 

The arguments that I have^ advanced against Mackenzie’s 
Ikvpothesis of a viscero-sensory reflex apply with an even 
gieater cogency to the theoiy of a viscero-motor reflex by 
nhich he^ attempted to explain the phenomenon of pro- 
tective rigidity in appendicitis. The almost invariably 
iimlateral position of the rigidity makes the agency of the 
splanchnic neiwes improbable, because, as I have' argued 
above, the appendix is dcrelopmentally not a right-sided 

ut a median organ ; and tho far greater constancy of 

mscular rigidity than of cutaneous hyperalgesia .in acute 


appendicitis lends greater strength to this argument, 
jincicciizio liiiiisolf apprcKiiatccI the difhouUy, as lie admits 
in Ills work on Symptoms and their Interpretation, where ho 
says (p. 175, fourth edition): “I cannot satisfactorily 
account for tho predominant symptoms from the appendix 
being so distinctly one-sided, seeing that it is development- 
ally a iiortion of tho digestive tube.” But even if we could 
accept the tacit assumption underlying Mackenzie’s theoiy 
that there is a specially intimate connexion through tho 
splanchnic nerves bctivocn tho nppcndi.x and the right side 
of tho spinal cord, liow arc wo to rcconcilo it with the fact 
— which I have so many times verified — that the area of 
muscular rigidity aud deep tenderness corresponds exactly 
with the position of the appendix? If the viscero-motor 
reflex were a fact, tho muscular rigidity produced by it 
would be constant in position, since it would bo determined 
by the segmental innervation of the appendix, and would bo 
entirely unaffected b}' tho position in which tho appendix 
happened to bo lying in relation to tho abdominal waO. 

I find, then, that the clinical investigation of the distri- 
bution of muscular rigidity in appendicitis reveals facts 
that are entirely inconsistent with Mackenzie’s viscero- 
motor rcflox theory. Nor am I awaro of any physiological 
experiments which mako it jirobable that such a reflex 
exists, nor of any anatomical evidence of a communication 
in the cord between splanchnic afferent and somatic efferent 
norvo fibres. Tho whole theory appears to mo to be an 
unsound extension of Ross’s theoiy of somatic referred 
pain, based upon a mistaken interpretation of clinical and 
operative findings. Mackenzie did not ajjpear to appreciate 
tho exquisite sensitiveness of tho parietal poiutoneum to 
oven slight degrees of inflammation. Had he done so 
I believe that so acute a mind ns his would have perceived 
that in a peritonoo-musciilar reflex lies tho explanation of 
this protective muscular rigidity, and that tho splanchnic 
afferent nerves have nothing to do with tho reflex rigidity 
in appendicitis. 

The cumulative effect of correlating pre-operative 
symptoms with operative findings in acute appendicitis has 
convinced mo that the second or localized pain in the 
disease is entirely dependent on stimulation of tho sensitive 
parietal peritoneum. (Fig. 2.) In cases such as the first 
one quoted above, whore recurrent attacks of obstructive 
appendicitis gave rise to the epigastric splanchnic pain 
alone, the parietal peritoneum was shielded from the 
appendix by a fairly thick omentum ; and as the degree 
of inflammation was too mild to penetrate through tho 
thick walls of tho appendix and the omentum the parietal 
peritoneum was not affected. This explains the complete 
I absence of localizing pain or rigidity, and the difficulty in 
diagnosis. An appendix wrapped round by omentum ‘and 
coils of small intestine ns a result of some former attack 
will, in fat patients, often give rise to no cliaracteristic 
right-sided pain or rigidity until it has perforated. This 
absence of rigidity is particularly liable to occur if the 
caecum and appendix are lying low in the true pelvis 
But a degree of inflammation so slight as to cause but a 
little congestion of tho outer serous coat of the appendix 
and a trifling fibrinous deposit will, provided it lies within 
reach of the parietal, peritoneum, cause tho most accuratelv 
localized tenderness and rigidity. Should perforation occur 
the rigidity and tenderness extend pari passu with the 
inllammatiqn of the parietal peritoneum, while from the 
moment of perforation all the initial splanchnic pain 
disappears. 


The Pkihtoneo-Musculab Reflex and Pebitoxeo- 
Ctjtaxeous R.adiation. 

Since the parietal peritoneum is supplied by the same 
cerebro-spinal nerves as the overlying muscles' and skin, 
the accuracy with which an inflammatoiy stimulus from 
within the abdomen is localized can be easily understood. 
It is necessary, however, to insist that a time nervous reflex 
mechanism through the governing centre in the spinal cord 
IS involved. The tonic contraction of the affected area of 
muscles, recognized on palpation as a hardness that never 
relaxes during the whole respiratory cvcle, makes it im- 
possible for us to believe that we are pressing on tho 
inflamed parietal peritoneum itself. The pressure required 
to appreciate the muscular rigidity is too light to have any 



890 May a6, 1928] 


OPEEATION FOR PROIiAPSE OF RECTUM. 


Tnr nniTj^H 
SrpniCiL Jc)t;ii*;iL 


influeiico of that kind, and even on inspection alone the 
tonic muscular contraction may readily bo appreciated, if 
rve observe the limitation of respiratory movements in the 
lower rectus muscle. 

The peritoneo-cutaneous radiation is host appreciated by 
a consideration of the shoulder-tip pain resulting from 
stimulation of the parietal peritoneum lining the under- 
surface of the diaphragm. In some observations on this 
shoulder-tip pain® I have drawn attention to the fact that 
whenever the sensory terminations of the phronio nerve 
under the diaphragm are stimulated, either mechanically or 
by inflammatory exudate, a pain is felt over the corre- 
sponding shoulder in the area supplied by the third and 
fourth cervical nerves. This shoulder-tip pain is of special 
interest as proving a peritoneo-cutaneous reflection or 
radiation of the painful stimulus. By the descent of the 
diaphragm in the embryo this area of parietal peritoneum 
becomes widely separated from its corresponding skin area, 
and thus an embryological event, dependent on tho develop- 
ment of tho lungs, enables us to observe tho working of 
the pain-producing mechanism. IVhilo I have proved tho 
invariability of shoulder-tip pain whei'e tho diaphragm is 
stimulated, I have not found tho same constancy of 
cutaneous hyperalgesia as tested by light pinching over the 
acromion process. In some cases tho patients describe tho 
pain as akin to rheumatism in tho shoulder, and deny any 
tenderness on light pinching or deep pressure. In some 
instances tenderness is felt, but only on deep pressure on 
to the acromion process, while in others definite hyper- 
algesia is felt on light pinching. 

It cannot be doubted that a similar radiation or 
spreading of painful stimuli from tho parietal peritoneum 
to the skin overlying it via- tho spinal cord occurs in tho 
anterior abdominal wall, though tho proximity of skin to 
peritoneum has prevented its recognition. When the under- 
surface of the diaphragm in a patient under spinal anaes- 
thesia is stimulated by the insertion of a gauze swab 
between the liver and the diaphragm, tho patient complains 
of pam in the shoulder-tip area, but feels no pain locally. 
So, when the parietal peritoneum is stimulated I believe 
that the pain is felt in tho skin and subcutaneous tissue 
alone. The exact position in tho nervous system of tho 
synapses necessai^ to produce this radiation is uncertain. 
I ho teaching of Mackenzie and Ross would load us to 
expect to find it in tho grey matter of tho posterior horn 
ot the cord, but there would appear to bo a greater prob- 
ability that it lies in the posterior root ganglia. (Fig. 2.) 

It I have succeeded in proving my contention that the 
muscular rigidity m acute appendicitis is a reflex result 

apendicitis becomes a far simpler clinical problem 
Mackenzie himself, obsessed by his theory of a\dscero- 
that it was impossible to separate the 

prXed brttrinfl"'' ” 

LperLiL "in te.achSltL'Ji't'^^f ^rom my 

spiUd acceptance of t''® "'•'lo- 

an unnecessary difficulty Vnto^tbe 

lesions. The student of abdominal 

reflex from the iiiflamlT m-aan " 

afferent nerves, and conscioim tint .*1*® splanchnic 

similar effect, finds a hopeless -impossibilitv^in r 

distinguishing between the two processes" ind “ 
regard abdominal diagnosis as verv -larapTv^. 

But if he can bo taught that true reflex" •f"®®®"'®''!'- 
rigidity is the resuh of stimulation of the parX‘" 
toneuin, and of that alone, and that tho p.fi P®'*' 

felt in the gastrc-intestinal tract ts ^sX 1 P“‘." 

due to increased tension and ex^gm-ated pe bta.s- 
investigation of a case of acute abdominal dbeaso he ’ 
relatively straightforward. nseaso becomes 

T of -AlmosHN-Ai, Pain 

I 11 ill finally sketch in briefest oiitiino ivliot To* 
to be the biological or evolutionary aspect of abdomi^ 

"P"» *i.« pfriS 


from within by perforation of a hollow viscus, the parietal 
poritonoiim was endowed with nerves of exquisite soiisi- 
tivencss to mechanical or chemical insult. Stimul.atioii of 
this layer produced reflex guarding of tho overlying 
muscles, with pain felt in tho skin and on the surface of 
thoso muscles. At the same time another rcfle.x — not dealt 

with ill this paper, but al ’ j parietal 

peritoneum, tho splanchnic provided 

to securo rest to the inte.stinal tract and so to avoid the 
diffusion of septic material by peristalsis. 

Against tho danger of intestinal obstruction another 
mechanism bad to bo elaborated. Violent peristaltic efforts 
of myogenic origin attempted to overcome tho obstructing 
force, and their bcciirrenco was registered by painfnl 
afferent stimuli through tho splanchnic nerves, apineciatcd 
by tbo brain as spasmodic in character, and vaguely 
localized in tho centre of tho abdomen. This splanchnio 
pain would sceni to bo tho moro primitive in order 
of evolution. It is akin to protopathic pain in its dull 
character and in tho, absence of precise localization. More- 
over, a coiisiderablo stimulus is needed before consciousness 
of pain is produced. 

SuJisiAnY. 

1. Tho evolution of our knowledge of tho mechanism of 
abdominal pain' is summarized. 

2. Tho initial central pain in acute appendicitis is a 
truo splanchnic pain, duo to increased intra-appeudicular 
tension. 

3. Tho localized right-sided pain is duo to irritation of 
tbo parietal peritoneum. 

4. Cutaneous hyperalgesia is too variable in its incidence 
to bo of value in tho diagnosis of acute appendicitis. 

5. Tho mode of production of cutaneous hyperalgesia is 
discussed. Mackenzie’s viscero-sensory reflex theory is 
criticized. 

6. Tho mechanism of reflex museular rigidity and tho 
associated deep tenderness is discussed. Mackenzie’s 
visccro-motor reflex theory is criticized, and tho rolo of 
tho parietal peritoneum emphasized, protective muscular 
rigidity being ascribed to a pcritonco-musoular reflex. 

I am indebted to Professor J. S. B, Stopford, M.D., F.R.S., for 
his kindness in drawing tho diagrams illustrating this paper. 


ItmacjCES. 

> Lennond’erf K.'”A.\^!foiini.''^A*«ifr. Med. Attoc., 1S07. xli.T, 835. 

• «ihi»rrcn j : On tho Occurrrnco nnil Sipnlfiranc© of Cutaneous Hyper* 
niccsio in Appendicitis, /.aneef, 1M3, ii, 816. 

•nobmson, H. : Quart. Joiirn. of Med., i, 388. 

»Copc, Z. : Lanert, 1024, I, 121. 

•ilorlcy, J. : Clinical Journal, 1925, liv, 617. 


AN OrERA'llON FOR TEE CURE OF PROLAPSE 
OE TEE RECTUM .IN TEE FEMALE.^ 

BY ■ . 

FREDERICK J. Mc'CANN, M.D., F.R.C.S. , 

The aim of tlic operation herein described is to restore the 
muscular retentive mechanism which prevents the bowel 
prolapsing after each act of defaecation. 

In July 1913, a single woman, aged 51, came to see me; slio 
had undergone an operation for rectal prolapse four years pic- 
viouslv tho prolapsed portion .of tlio bowel being exnsod. 11 o 
opera&on was^ unfortunldely. a failure. Tho bowel st.ll prolap ed 
for nearly two inches and tho anal onfico surrounded by 
admitted^ throe fingers. She had complete was 

and was unable to earn her hving as a nurso. Hci 
deplorable, and her nervous system had suffered 
consequence. She was rcluct<ant to undergo anothei opciatiou, u 
ultimately yielded to persuasion. . 

Tho bowel was returned and the patient was plficetl X 
elevated lithotomy position; an incision was then made aro 


Tho bowel was 

evated lithotomy position; an incision was its 

the anal orifice Anteriorly and laterally for ,t'-''-«.-fourtI s ot us 
circumference. The perineum was incised in the middle m- 
the fourchelto to the anal orifice; this incibioii was luitiiei 
longed anteriorly into tho labium of each „-fioii 

and a half. Tlio lower end of tho rectum was freed -jj, 

anteriorly and laterally, exposing the levator am on ‘’“''A .(.(j 

whilst the lower portion of the posterior vaginal wall was a 
upwards for about two inches. A V-sliapcd piece was tlici — . 



BfAr ; 6 , 1928 ] 


OrEBATION FOB PKOC.APSE OF BECTaSr. 


f Tjrr iJRm'sff 
JlEiiiCAi. Jornsii,' 


891- 



of l)>o nnierior rcclnl wall and the antcriov margin of tlio anal 
orifice. The cut edges were united bj* catgul sutures, after tying 
the bleeding vc’^scls. The scar tissue sutrouuding tlio amis was 
dissected out, and the anal orifice reconstructed (o the requisite 
size by a series of catgut sutures passed so ns to take a grip of 
tlic sphinelcr nui, and to avoid the mucosa of the bowel. • A 
V“Slmped piece was next re- 
moved from the posterior 
vaginal wall, followed by Ibo 
put lire of tlic Icvatoros ani 
inuseles in front of the lower 
end of the rcclnm. The cut 
edges of the posterior vaginal 
wall were then .sutured 
together by catgut sutures, 
whicli wore passed through 
the united lovatorcs ani 
muscles, and when tied 
brought the latter in close 
apposition with the posterior 
vaginal wall. Silkworm-gut 
putures were pas«?cd through 
the perinon! tissues to coapt 
the divided perineal body, 
and further to coapt the 
alrc.ady sutured levntorics ani 
muscles. The sliin edges were 
finally united \vitb catgut, 
whilst a special silkworm-gut 
suture w'as inserted to nre- 
vent the anal orifice falling 
backwards. 

The patient iimdo a smooth 
recovery and regained com- 
plete control of her anal 
sphincter. She has, more- 
over, remained well up to Iho 
present date, and lias ex- 
pressed hoi^clf as being com- 
pletely cured. She 1ms been 
enabled to' discharge her 
duties as a nurse and to lead 
a life of unusual activity. 

The result of this operation ealisfics (he (imo (csl, for the patient 
has remained perfectly well up to the present date— that is, for 
thirteen years. 

_ On thinking over this operation I concluded that it was 
wiinccc.s.sary to excise a portion of the rectal wall and ana! 
margin (as that procedure only led to scar formation) 
instead of huilding up and .strengthening tlie anal 
sphincter,' which could bo done much better without 



Fig. 1.— The 5maUor diasi.'ini 
shows the prol.'ipf'O of the rectum. 
The lor;,'cr diagram ^]lOws the tine 
of ttic inci.*'»on after the prolapse 
has been returned. 



A, FiRt of n Bcries'^of^atgut suturti to ‘I 
», Silfavoi-m-gut sutures pasfed 

•skin on cacli side. O, F.sscial stTtnro. et J'>o 'ovator ani and 

furlhet united witli catgut! ’ catgut. Tlic Icvatorcs am are 

"I’y, tho bowel ; and although the fiinc- 

tiona rosnlt had hcon so good, vet I believed that avdiding 

oS.-'°ig24“a her sister' to mo 

annoarfto n ’ -Z ll * r® I performed on her 

ppcars to ho sintahle for the maioritv of cases TP:.! 
-Oman was 65 years of age, the motimi if tL-co "hild^! 


and had her last confmcinont twenty-nine yeans previously. 
She luid had .slight rectal jirolajise and loss of control ever 
sinco her last child was horn. AVIicn she presented herself 
for examination the rectum jirotrudcd for four inche.s, and 
she informed ino that the amount of rectal prolapse had 

been gradually increasing. 
Tliere was no evidence of 
ulceration. 

It is cs.sential that .sncli 
patients should have a 
]neliminai-j- period of rest 
in bed, not only for ]nir- 
po.scs of local cleansing, 
hnt hecauso congestion is 
diminished in those who 
have struggled to he 
about. The prolapsed 
bowel should ho returned, 
and if po.ssiblo retained, 
which still further 
diminishes local conges- 
tion. . 

During , the operation 
the elevated lithotomv 
position is employed in 
order to diminish the 
tendency to protrusion of 
the rectum. An incision is 
made around the dilated 
anal orifice anteriorlv and 
laterally for three-quarters 
of its circumference. A 
mesial incision is then 
made from the anal orifice 



Fic. 2. — Ty^vatorci ani rxpo'.i'fl tof^ofhoc 
wilh ibe e-pluDCtcr ani. The vaginal flap 
hna hfH?n rcflccte<l upwanl-'. Levator 
an*. B, Sphincter am. C, Vaginal flap. 


to the fonrehetto, which, when- deepened, splits- the 
•meal body (Fie. 11. Tin's incision is prolonged at 


perineal body (Fig. 1). 

its anterior extremity outwards and forwards into each 
Inhinm. The anal sphincter and the lower, end of the 
rectum arc exposed by dissecting away tho superjacent 
tissues, and the posterior vaginal wall is dissected Upwards 
for about two inche.s (Fig. 2). Catgut sutures are now 
intiodiiced grasping tho sphincter ani, being passed on one 
side from within outwards niider the sphincter muscle and 
avoiding the nnicosa, and in the reverse order on tho 
opposite side, and are then tied. A sufficient number of 
tlicso sutures are iiitrodiiccil to vestoro the anal orifice to 
the normal . size, and when a good grip of the sphincter 
muscle I.S taken by the sutures .this muscle is strengthened 
and .tightened and a normal anal aperture is consfructed 
Sutures of catgut arc fiii-thcr used to tighten the stretched 



minfn^ "'7'' and 

i^mfoicQ aiiv weak .spots. 

number of silkwonu-gut sutures are ne 
inserted; these pass mwards through the skin and lovat 
an. muscle on one side and outwards throS mtiscle a. 

SMii Oil tlio onnosito ctirle Tba luuhcie ar 

then united by catf^ut sutures A V Biuscles a 

from the posterio? vaginal wail 



892 May 26, 1928] 


SPIRIT iVND BIPP TREATSIENT. 


r TnrT>nrn<H 
t >rrni(:Ai. JoinviL 


tli6 Icvatoros ani muscles, in ovdei' to bving tl\oso muscles 
and tho posterior vaginal wall into closo apposition 
(Fig. 5). The skin edges aro next united with inter- 
rupted catgut sutures and tho silkworm-gut s\iturcs tied 
through small pieces of india-rubber tubing, thus com- 
pleting tho operation (Fig. 4). Tho last or most posterior 
silkworm-gut suturo is passed so as to prevent the anal 
orifice falling backwards, which is not infrequent after 
operations for complete rupture of the perineum. Catgut 
may also bo employed for this suture. 

A “ sacral anus ” is a complication which should not bo 
encountered where tho necessary precautions have been 
taken during tho operation to restore tho anal canal. 
After this operation I believe it is best to refrain from 
administering purgatives at least for some days in order 
that healing may remain undisturbed. Should tho patient 
be uncomfortable in consequence of tho bowel not acting, 
warm olive oil should bo run into tho rectum through a 
small india-rubber tube, and a doso of castor oil given b\- 
the mouth. Tho bowels should afterwards bo kept acting 
b}- a gentlo laxative. 

The result of tho operation described was completely 
satisfactory, tho wounds healed well, and there was com- 
plete sphincteric control. Tho patient has been enabled 
to bo about and lead an active life, whereas formerly she 
was more or less of an invalid, spending most of her time 
cither in bed or on a couch, and being forced to givo up 
her business in consequence of her physical suffering. 

When writing this paper I received unexpectedly a letter 
from this patient, in which she states: 

" I am writing to toll you tho operation has proved a perfect 
Euceess. It was some time before the bowels acted naturally, but 
now I am lifco another woman. I was a long time making up my 
mind to the operation, but I am glad I did, and I am very 
grateful to you for your care and skill. 1 only wish other 
sufferers knew tlio benefit. ’’ 

Although this typo of operation remedies the anatomical 
defects which seem to accompany this variety of prolapse, 
yet congenital predisposition is an etiological factor wliich 
cannot bo overlooked, for those two women were sisters, and 
I am informed that another sister and two cousins suffer 
from rectal prolapse. Exercises to cause contraction of 
the levatores aui muscles and sphincter ani should bo prac- 
tised after this operation, and such exorcises aro still more 
necessary in tho presence of congenital muscular weakness. 
Finally, this operation offers a prospect of cure, not merely 
to tho surgical derelicts cast adrift because of tho failure 
of other methods, but to those who bear their sufferin'’- not 
knowing that anything can be done for their relief, a ” well 
as to those who from knowledge of failures have lost faith 
in modern surgery. 


SPIRIT AND BIPP TREATMENT. 

BY 

N. L. MAXWELL READER, M.S.Loxu., F.B.C.S., 

BARRY. 


PnorESsow RuTnmirouD Mo-bison’s bipp treatment is not, 
I think, always clearly understood, and if employed hap- 
hazardly and without attention to detail may be dis- 
appointing. The following case, which recalls that of Dr. 
Alonica Bell and Professor Morison (December 10th 1927 
p. 1077), shows a remarkable result obtained by the uso 
of this procedure. 


On December 7th, 1927, a feeble old lady of 77 was knocked 
down by a motor lorry and sustained a severe compound com- 
minuted fracture of the lower end of the right tibia and fibula 
involving tho ankle-joint. She was brought into tho Barry Sur-’ical 
Hospital suffering from shock and haemorrhage. AltfiougTi a 
rough tourniquet had been tied round the leg the wouncl w.is 
still bleeding, and there was evidence from tho saturation of her 
clothes that tho haernorrhage had been profuse. A large dose of 
morphine and atropine was administered, and a mo^ efficient 
tourniquet applied. At the end of about one hour she was 
Bufficiently recovered from tho initial shock to justify operation 
Under gas and oxygen tho wound was freely opened up and 
tho bleeding points secured. The bone was found to be badlv 
comminuted, and many completely detached loose pieces were 
removed; other fragments showing a reasonable attachment to 

‘£tL"'wtph ^ c^ls^^eTe-fcisTdT an^tr]l:^'’l‘?e“ra'-^^^ 
S'.s3i2?o\-saTothVa"ni&bITL^^^^^ 


sti'ippcd by the viole nce of the injury, but remained in contimiitv. 
T1 i( 5 wonnd was now freely sv.ubhod out with mcthylalcd s-pirit, 
nflcr which it was carefully dried, one or two additional blccdiiiij 
points bein^ .secured at the sarno time. (There in always a fair 
amount of bleedin;» after tlic api>licatioii of spirit.) Tlic wound 
was temporarily packed willi dry gauze during the clianging of 
tho gloves and towels. On resuming, a small quantity of bipp 
was introduced into llio cavitv, and thoroughly rubbed into every 
4avnilnb!o nook and cranny. Ijcngths of thicic linen thread were 
carefully hipped, and by tl)cir means the skin edges were rou^lily 
approximated; owing to the loss of tiscuo accurate nppo'ution 
without tension was not possible or dcsiftablo. Tho dressing con- 
sisted of long pads of gauze freely soaked in spirit, each pad 
being liberally sprinkled with boric powder. TIio pads were laid 
along the wound and did not cncirclo the limb. A top dressing 
of wool was temporarily hold in position by a bandage. 

Tho plasters were applied as follow.s. Tlie first plaster extended 
from above the wound to above tho knee — tbo kneo being slightly 
flexed during tho application. Tho plaster was reinforced with 
thin laths of wood. Tlio second plaster encircled tbo foot below 
tho wound. Traction was now made on tho foot by means of a 
weight and pulley, and when alignment of the foot was perfect 
llio intervening spaco was rapidly filled in with the third plaster. 
Before tho plasters wero firmly set a largo window was cut out 
over the wound, and the wholo caso was divided longitudinally 
from (op. to bottom. This division was continued through tha 
wool and bandages until tho skin w.is exposed. . This step wa? an 
important ono in view of the pos‘?ibiHty of subsequent swelling, 
and tho very real danger of gangrene in a patient of this age. 

Tho patient stood tlio operation well, and returned to bed in 
a fair condition. Before leaving tbo theatre 500 units of anti- 
tetanic serum were iincctod. 1 would now also employ anti-gas 
fjancreno scrum, but I did not have a stock in readiness at tho 
time. 

J*roffnosif . — Tho prognosis given to tho relations was a bad 
one. Apart from the immediate dangers of shock and haemor- 
rhage, there remained tho possibility, of gangreno, and later of 
severe sepsis with osteomyelitis. At best only healing by granu- 
lation could bo hoped for, and a very* poor functional result. 

Progress . — The old lady remained very feeblo and debilitated, 
but no special pain was felt in the foot, and tho temperature 
caused no alarm. Thoro was somo trouble with tho bladder and 
bowels. On the seventh day — more from curiosity than necessity 

£ removed the dressing. Tho wound was quite dry. Tho skm 

was healthy right up to tho cut edges, between which lay a hard 
dry mass of congealed blood. I took out tho stitches and dressed 
tho wound with spirit gauze and powder. A week later a similar 
dressing was applied. From start to finish not a bead of pus 
or even serous oozing occurred. At tho end of a month tho 
splint was removed daily for massago, and a fortnight later 
discarded altogether. At tho present timo sho can bend her 
Icnco to a right angle, and can voluntarily move tho foot through 
30 degrees. The wound is healed and the fracture firmly united. 

Comments. 

Tho tcchniqno used in tin’s caso was almost identical with 
that instituted by Professor Morison at tho Nortlnunber- 
land AVar Hospital. Points to notice arc: 

1. Tho full excision of tho wound. 

2. Tlio liberal uso of spirit. 

3. Tho small quantity of bipp required. This must ho 

well rubbed into tbo exposed surfaces and no 
excess left. 

4. The use of bipped sutures; this prevents infection of 

tho ncedlo holes and tho spread of sepsis from 
tho skin to tho deeper structures. 

5. Tho dressing with spirit and boric powder. 

6. Tho absence of any encircling bands round tho limb. 

7. Tho infrequent dressing of the wound. 

Tho last requires courage, but is most essential if 
secondary infections aro to bo avoided. 


an atypical case of htperglycaemia in 

GENERAL ANAESTHESIA.* 

BY 

B. L. -MACKAY, il/.C., B.Sc., M.D.Glar. 

(From Uio Wolverhampton and Staflordshiro General Hospital.) 

The unusual extent of the increase in tho blood sugar 
during general anaesthesia in tho following caso, combined 
with tho absence of glycosuria or of any untoward symptoms, 
make it worthy of record. 

A woman, aged 50 years, was the subject of a major operation 
on account of gastric ulcer, hour-glass stomach, ami chronio 
appendicitis. She was prepared for operation in the normal 
manner, having no food on the morning of operation, ana • 
receiving 1/4 grain morphine and 1/100 grain atropine about- 
an hour previous to the administration of the anaesthetic. 

•This case is one of a series in a research towards the expenses of 
which a p>rnnf. hnq hppn modn hv the British Medical Association. 




May 26, 1928] 


H'JPEKGLyCAEMIA IN GENEBAE ANAESTHESIA. 


r Tiir. nniTun PQ.Q 
LMEDICXI-Jo'-TtSU. 


Ui'iiiarv tests before operation r, bowed no abnorm.iVily as 
regards the presence of albumin or of sugar. Induction of 
nnaostbc''ia was bv cbloroforni*ctlicr mixture^ and Incn ether 
was cniploved to' maintain tbe anaesthesia. Blood samples 
were taken' from the finger before, and at intervals during and 
after, operation, and the blood sugar content estimated Viy 
JlacLean’s method. At the end of operation, wliicli consisted 
of partial gastrectomy, gastro-entero.stomy, and remov.al of the 
appendix, since shock was jireseiit, she received a rectal salino 
injection, containing 5 per cent, glucose. The first two urines 
p.asscd by the patient after the anaestlietic were collected .and 
tested for glucose by the fermentation test and by l‘ohling*s 
test (Bertrand’s modification), 'flic result with each test was 
negative. ' Albumin, acetone, and diacctic acid were similarly 
found to be absent. The patient made an excellent recovery 
.from the operation, and w.as discharged later from hospit.al in 
a reasonable .state of health. 

The time record for this case is .as follows : 


wise, ill the two other cases the curves of which are shown 
hero, nlthough the renal threshold was exceeded for some 
considerable time there was no subsequent glycosuria. As 
urinary Rccretion is not iisimlly suppressed in anac.s- 
tliosia, curves .such as these load ono to doubt the validity 
of the renal threshold value, or to postulate for the anacs- 
tbeti'/.ed state tho existence of some other factor as yet 
unexplained. 

Siimviary. 

A case of anaesthetic hypcrglycaeniia of great extent, 
and unaccompanied by glycosuria, is described. 

1 wish to thank Mr. Dcancsly, F.R.C.S., honorary surgeon 
to llio SVolvcrhampton and SlafTordsjiire General Hospital, for 
jicrinission to record the details of this case. 

Rrrr.apNrr. 

JIacLcan (1925); Diagnmis anti Trraljnrnt of Ghjeomria anti Diabetes. 


Time in 
niiniitos. 

0 ... 

10 ... 
30 ... 

50 ... 

75 ... 

85 ... 

100 ... 
105 ... 

280 ;.. 


... Fii-sl blood sample taken— 0.150 per cent. 

Induction of anaesthesia begun with CE mixture. 
... Change over to closed ether. 

... Second blood sample — 0.181 per cent. 

... Tlnrd blood sample — 0.260 „ 

... Fourth blood sample — 0.350 ,, 

... Anaesihelic stopped. 

... Fifth blood sample — 0.386 per cent. 

... Rectal saline with 5 per cent, glucose. 

... Sixth' blood sample- — 0.220 per cent. 


• Commrntdvy. 

Tliis case, avbich forms one of a series in an investiga- 
tion into tho blood sugar changes in gcncj'al anaesthesia, is 
interesting for tho following reasons. 

First, it is an example of tho fact that general anaes- 
thesia, whether by chloroform, ether, or CE mixturo, is 
accompanied in practically every case by avt increase in the 
■concentration of the sugar in tho blond, manifest witbin 
a very few minutes of induction, and continuing, within 
limits, throughout tho period of anaesthesia. 


O'iOOr 



too /so soo zso 
^ T/rge. in Minutes. 

“S kere descrilird. Anaesthesia lasted 
after JMest‘h?s-m‘'''rau’ ''"‘I' 'before and 

SaiSl woh (hf unusuallr high, mav he com- 

FouTd m "hi mag™ a°naTsthf3iar'“ 

To-entprostom V, on a man 
nvp stenosis of tlie pylorus. Auaestliesia lasted for 

tittj ll'c minutes, and a rectal saline yvas civen as in Cose A Urine 
did not ferment with yeast after operation 
C. Blood sugar curi’e in a ca^e of h>datid disease of tho liver in a 

befo^rS^Kpolatron^^"''^^ 

Foi pui-poses of comparison tlicre line hron suuerimpo'ccl upon the 
ram'e <>' c.wve' D,"i]nch shS«3 the 

out by .UacLean (1925 ).® r'ucosc meal, as carried 


Second.y, this case demonstrates that the extent of tl 
mcrease may be far above that caused by the giving of 
50 gr.ams glucose test meal, as carried out bv MacLeai 
, comparison with MaeLean’s cun 

(cun-e D on tho accompanying figure) and the curv 
of two other cases (curves “B” .and “C”), in which anac 
lesia as -od for about an lionr. These latter curves a 
qui e 3 pmal of t.ie usual anaestlietic hvperglycaemia, ar 
differ only from the case here described in the degree ( 
Inpcrghcaemia recorded. 

lliiulh, in this case the unusual amount of hype 
glycaemia to O.086 per cent, would lead one to expect Mn 
uhseqiieiit degree of glycosuria, if the doctrine of a ren 

acennf^ 1 • is to 1 

absent in Tl Eiit such glycosuria was provi 

absent 111 this case by the two chief tests for sugar. Lik 


KUPTURE OF UTERUS EARLY IX THE FIRST 
STAGE OF LABOUR. 

BY 

GRACE STAPLETON, M.D., B.S.Loxd., 

MEDICAL SUPERIXTEKDEXT, DUFEERIX HOSPITAL, CALCUTTA. 

The following, case is reported because it is of interest from 
several points of view. In tlie firet place, rupture of tho 
uterus apparently occurred early in the first stage of lahour 
before rupture of tho membranes, -and without any of the 
usual causes, such as malprosciitation or disproportion 
between the size of the chiUl and the mother’s pelvis. 
Secondly, the jiatient had had ten normal labours pre- 
viously; all were of sliort duration and free from complica- 
tions. Lastly, she suit Ived the. rupture, though liystorcc- 
tomy was not performed until twenty-four hours had 
elapsed from tho presumed timo’of its occurrence. 

The paUent, a European woman, aged 36, was admitted to 
liospital at 12.50 a.m. on October 6th, -1927, for labour at full 
term accompanied by severe abdominal pain. - She stated that'two 
days prcnously sbe had not been feeling well, so took castor 
oil, which resulted in four motions, and at 6 p.m. slight labour 
pains commenced. At midniglit the pains were more definite, but 
were 'not* soTcrc enough to require medical aid of any sort. .At 
2 a.m. on October 5th, after two or three sharp pains, she 
suddenly 'felt an acute pain of a ditTcrent sort; after this the 
child seemed to alter its position to tho upper part of the 
abdomen, and within two or three hours its movements ceased. 
At the same lime bleeding began from the vagina, and pain was 
felt on taking each breath, A doctor was called in the morning, 
and after an injection she slept; the bleeding became less, but 
on waking she felt no better. She vomited several times during 
the day, and from 5 p.m. the vomit was dark brown. The bowels 
did not act that day. As her condition was becoming so much 
•worse she was brought to Iio.sjJital at midnight. 

The past- hisLorj* was that sho had had ten children, the last 
one .two and a half years pivviously. All the labours were quite 
normal and quick. She had never needed instruments. The last 
mcnsli’ualion had occurred in Fobruarj*, 1^7.> 

She was of medium height and nutrition, and was evidentlv in 
great' pain on admission, especially in the upper part of "the 
abdomen, which caused her to crj* out all the time. The pulse 
rate was 110, and the tension w'as fairly good. The temperature 
was 100.4° F. and the respirations 30. The .abdomen was markedly 
distended, especially above the umbilicus, where tbe outline of the 
dilated stomach was clearly scon; there was great tenderness all 
over it. The child was lying transversely across the middle of the 
abdomen, and was felt just under the abdominal wall; it could 
be moved about easily, but much pain was caused. No foetal 
heart sounds were heard. There was a small quantity of bright 
blood coming from the vagina. 

The patient was so restless that a little chloroform was given for 
satisfactory vaginal examination. The cer\*ix was found dilated, 
and the placenta lying above it was almost completely detached. 
The otherwise empty uterus lay on the right. On the left Iho 
membranes led out through a large tear in the lower part of the 
uterus and cervix, and the child could be felt h*ing in the unrup- 
tured bag of membranes among the intestines. Fresh bleeding 
was caused by tho examination. A catheter was passed, and 
. two ounces of slightly blood-stained urine were drawn off. 

' It' -was decided to open the abdomen, and the patient was pre- 
pared at once. By that time her pulse had risen to 132 and was 
decidedly weaker. She had vomited coffee-ground material once. 

. Saline injections were commenced, and a 6-incIi incision was inade 
in the middle line, two^thirds being below and one-third above 
the umbilicus. The child, a full-term female of normal size wai 




MEJrOBANDA. 


r Tnr.IlBnnsn 
L Jff'DrcAL JotrpWAX, 


895 


sG, 1928] 


blood calcimn was foiiiul to bo normal it was doxtblcd 
whether calcium therapy would be of any \ise, and this 
in spite of the work of Wright and Holt man and tho 
observations of numerous other authorities. Hcrzfeld 
and Lubowski’ observed hyporcalcaomia in 100 patients 
who suffered from neuralgia, chorea, tabes dorsalis, and 
chronic enteritis, yet calcium therapy has furnished 
splendid results in cases of neuralgia. Vergliano, Looft,* 
and Tsehiember^ liavo observed hyperealcaemia in a series 
of cases of tuberculosis; Loeper and llecliamp' in cases 
of nephritis, asthma, and pneumonia; ],ougo' in rickets, 
and Blum’ in a case of osteomalacia. In all these cases, 
however, calcium thern|)y wo\dd have produced entirely 
satisfactory results, in s]>ite of the contrary inferonco 
from tho state of hypcrcalcaemta. 

UirmnsTr-s. 

* Cf. 0«car Loew : Ver Knlihctlnrf ran Meufrh unti Tier, fourth edition. 
O. Gmciin, Mimicli. = Hrithh MrilirnI Jotirnnt, Oclohor 29th, 11^. Report 
of Discu&sion of tho Thornpeutic of Caleiiim Salt'’, p. 777 cl rcq. 
^ i7,’of. ittefl, ft'oe/i., 1323, p. 603. * (\ 11, Snc. (Ic Ilwlftfjic, 1924. * Ihitl. 
* Ibid., vol. 69. ^ II PoIicUnico, 1910, p. 495. ’ f'rrrse .Ifthf/rff/e, 19^, p. 225, 

MEDIGAIi, SURGICAL, OBSTETRICAL. 

PXKU^MOCOCCAL PKRTTONTTIS DURTXG THE 
PUERPERllTM: RECOVERY. 

The vnrity of tho oociinoncc of pucuniococ'cal infortions of 
the peritoneum would seom to justify puhlieatioii of a case, 
especially since recovery ensued, 

A woman, aged 24, was delivered of her first child on Mav 16ih, 
1927. TJic labour was conducted bv Dr. C. Fraser, who simply 
cased the bead over the perineum with forceps, under light chloro- 
form anaesthesia. The labour was othcr\Yise normal, and the 
placenta was^cxpollod lialf an hour after delivery. 

. after, delivery, (ho* temperature rose 

to 103.2 F., and the pnlso rate was 140. On tho following day 
I was called to see her by Dr. Fraser, and gently brushed over tlic 
interior of the uterus with a gauze swab on a* holder, but found 
*‘ctnined chorion; the uterus had scarcclv involuted at all. 
J injected an oiuica of sterile glycerin threagh a catheter into 
Uie utonuo cavity, after the manner of Rcmmgloii Hobbs. The 
patient \s-as also given 5, grains of quinine bilivdrocliloride intra- 
muscmarly, and 60 c.cm. of polyvalent antisfrcptococcal senim, 
since thc^oso looked hko'a streptococcal infection; but the report 
H I took from the ceiwix 

Li. Gram-nositivc diplococci, while from 

few Siforni diphtheroids, SUiphi/lhcoccus albv^, and a 

‘^“P“r?ture batl iallen to 99.4° F. and the 
Swfplf i veiy comfortable. I contonlcd 

a'T?r)thAr ? luithor 5 grains of quinine and injccling 

fn ‘"5” uferino cavitv. On Mav 26(E 

in the moimnp the temperature ag.viu rose lo 103° F. aiid the 

m“enint‘t’v'’lhr1nm,f^ hbdomcn. Towards 

tl'rpLlse waf m “onnfab^^^ bad set in, and 

cil r^kc^hreless*' st P^'itonitK and the 

the aMomeii and anacslbelic, and I opened 

tbhes aiM ovAril^ hnald''' "Lmtestine, as also the uterus, 

"AVt‘s^^30”a^^‘d°tr ffmp'Swtur^ 

tubbs.' Dr. Galt’s report of th^turbid^fluiTT b 

abdomen was that the film s loS ' • 

‘3x.,a‘"s,-;i.SS"" Sf.rT’l 

Sh?wal given aSwr“w IVn? or Anfi’fantip “'’''4’™'’“*' 

coming- freely through tlio drainage tubes. ^ 

tcmp‘'cralure drd"iorbec^r5ormM unHllbe‘’‘‘''V ’jf'’ 

abscess in the right forearm %dcl,a?sn n!n. ^ 
caeca,, was opened on June 16th. ’ st rt^orurgoJd 

peL^rtis'’dnrtn®'^r? Pneumococcal 

peritonitis during the puerpcnimi is rare. In raakincr i 

I have so far found only mib 
case, although tliere nui.st have been others no doubt 
where a bacteriological examination was not ’made This 

^ Gynicologic ft OhtUtriiUe, Tomeyi, 1922, XvT 


pneumococci were also found in tlie inoulli of tlic “ sage- 
femme ” tvlio nltendcd the woman in lier labour, uliicli 
may or may not iinvo been the cause of infection. No 
laparotomy tvas pci foiniod in tills case, but tlie necropsy 
revealed purulent endometritis, pneumonia, and peritonitis. 
The pneumococcus tvas found abundantly in the ascitic 
fluid, as in my case. 

H.tRot.D F. Seymour, M.D.Lond., F.E.C.S.Ed., 

Ilonorar}' Surgeon, Sussex Maternity ond ‘Wonien’g Hospital, 
Brighton. 


HAESrORRHAGE FROAt THE DEEP EPIGASTRIC 
ARTERY INTO THE RECTOS ABDOMINIS. 

Tiir. following case is of special interest in view of the 
diagnostic d/ifictrltj' c.vpericnced. 

A man, aged 55, was admitted to the Kettering General Hospital 
with a provisional diagnosis of acute intestinal obstruction. He 
had continued his work until the morning of the day of his 
admission to hospital, when ho had a sudden attack of pam in the 
umbilical I'cgion; tlio pain was definitely localized, increasing in 
severity with each respiration. On palpating tlic abdomen the left 
rectus *was found to be markedly rigid, and there lyas also a 
certain amount of general abdominal rigidity; a definite painful* 
area on prcssui*c was present about the middle of the left rectus. 
The bowels had acted in (he morning before the onset of pain; the 
abdomen w.as not distended, and the flanks were resonant. There 
were repealed attacks of feeling sick, but he was unable to bring 
anything up. The longue was furred and the breath foul. The 
icmpcratiiro was 98° F., and tho pulse 108 (6 An enema was 

given with good results. Operation was postponed, and the patient 
was kept under close observation. At 2 o’clock tne next morning 
the Icmpcralurc was 100.4° F., and the pulse 76; pain and rigidity 
still persisted. At 10 a.m. the temperature was 99° F., and the 
pulse 80. As the pain and tenderness persisted it was decided to 
operate. The abdomen was opened in the middle line above the 
umbilicus, and the middle third of tho left rectus was found to be 
the seat of haemorrhagic effusion with apparently no other patho- 
logical lesion. Tlie patient became worse under the anaesthetic, 
and, altbougli the operation was short, stimulants had to be 
resorted to tivice before he left the table. Death occurred on the 
fourth day after operation. 

At the necropsy the haemorrhage into the rectus was found to 
have increased. Tlic heart \*alves were apparently normal, but 
the myocardium was extremely friable; throughout the arterial 
system there was what appeared to be an advanced stage of 
general artcrio-sclcrosis. 

Donald AIacLennan, M.B., Ch..B., 

Resident Medical Officer, 

The General ITo.<ipital, Ketteriog. 


TINFA INTERDIGITALIS PEDIS. ' 

In bis recent atitircss on ringivorm and its treatment 
Dr. J. M. H. itacLeod mentions {British Medical Journal, 
April 21st, p. 656), among other varieties of ringrr’orm 
affection, a type of “ eezeinatoid ringworm of the 
extremities”— otlicnvisc tinea interdigitalis pedis. 'Wlthont 
discussing the question of wbich particular variety of 
epidcrmopbytoii is responsible for this most discomforting 
and intractable affection, I desire to question the wisdom 
of part of the treatment recommended for it by the 
lecturer— namely, the advice to soften the skin by soaking 
in salt rvater or wading in sea water; arid perhaps also 
the choice of medicament. 

This affection manifests eczematous characters and 
ahvays appears to be readily curable in cold climatic 
conditions, but recurs somervbat unaccountably in the 
summer time, - or more particularly under tropical con- 
ditions of living, when it is then most intractable. Anv 
such conditions which result in undue moisture of the skin 
betiycen the toes induce a fresh outbreak of symptoms, 
initiated by intense irritation and followed by vesication, 
painful fissures, and the appearance of white sodden 
patches of thickened epidermis between and beneath the 
toes. Moisture and wai-mth are the two factors neccs- 
sary to promote development of tliis fungoid affection, 
which seems able to remain unnoticed in the epidermis 
for raoiitbs before reappearing. Salt-water batbino- is 
harmful, because it usually leads to moisture remaining 
between the toes despite careful drying, and sea wading 
especially so, because in addition it means spreading of the 
toes, ivitli consequent causation of fissures made needlessly 
ivorse than they otherwise might have been. I would 
certainly dissuade any .sufferer from sea wading or walkinsr 
barefoot on a sandy beach if previous experience had not 
already made him wise. It has been demonstrated to me 
that a weeks indulgciKc of sea . bathing .in tlie summer 
can, precipitate the reappearance of- this affection afte^ 



May 26, 1928] 


INTBAVENOnS TBEATMEHT OF VABICOSE UECEBS. 


t ins BBmffii 
McdICAZ. JoUBKAlt 


8.97 


• sliowcd tlmt in n lavgo jn-opovtion of cases of scpticacmin 
' in aliicli a jnn'o cultnio of Blroptoeocci conkl be obtained 
: from tlie idood injections of incrcnrochroino were followed 

by a cine. Young had reported the clinical results in 
173 cases of septicaemia treated with nicrcuroehroinQ, with 
! a euro in 63 per cent. Tlie papers by Dr, Young and 
: his colleagxics shoa'ed so many remarkable cures that the 
; use of this remedy deserved a more extensive trial in this 
’ country. In septicaemia mercurochroino was given intrn- 
:• vonously ns a 1 per cent, solution in doses beginning with 
; 2 or 3 mg. per kilo; from one to five doses at intcivals of 

: four to five days might be required to clfcet a cure. In 
desperate cases of septicaemia or other infections where 
the patient might die in a day or two 5 mg. per kilo, 
or oven inoio, might be given. Tho objectiouablo rcsidts 
j which migiit occur were stomatitis and, with large doses, 
1 transient alhuminiiria, though tho latter effect was rare. 
i Tho weak point about raorcurochromo therapy at tho 
present time was its variability in toxicity, and, therefore, 
possibly in its therapeutic efficiency; for this reason tho 
maker should guarantee tho molecular weight and tho per- 
: centages of bromine and mcrcur 3 -, and should state its 

toxicity. Nevertheless, mcrcurochrome was not a dangerous 
drug to use, and its many users in other countries were 
convinced of its merit. 


conditions such ns stone in the ' common bile duct, or 
neoplasm, and in toxic and haemolytic jaundice, where 
there might be a direct reaction, or a bi-phasic reaction 
whoi'o an obstructive and a toxic process were combined. 
Ho added tliat tlie test was very valuable in latent 
jaundice, and in some eases of pernicious anaemia. In 
blood grouping, for transfusion it was very important to 
match the recipient’s .scrum against the donor’s red cells 
after the grouping process had been performed. 'riie 
blood calcium estimation ,was becoming increasingly 
popidar, especially in thyroid dcficionoy diseases. The 
value was low ns a rule in skin diseases, and might be 
very low in ca.sos of colitis; it was probably very high 
in arthritis deformans. The blood urea test was of great 
value to the surgeon as indicating the condition of 
tho kidneys, and whether there was much imiminnont of 
renal function, especially in cases of enlargement of the 
prostate. Blood sugar tests were of little value if taken 
without reference to the time of day .and to prerioiifi 
estimations. A glucose tolerance curve should always he 
constructed, comnieneing with the result obtained during 
a fasting period. Glucose .should then he gis'eii, and the 
dose be repeated half an hour and one hour afterwards. 
In this way the jiationt’s tolerance might bo determined 
at once and the necessary dieting prescribed. 


GUILDFORD DmSION. 

CLTxicAti Pathology axu GKKruALi PaACTicE. 

At a meeting of the Guildford Division on May 3id with 
Mr. H. B. BcTLEn in the chair, Dr. R. C. Matsox gave an 
address on .some .aspects of clinical pathology .as an aid to 
the practitioner. ' 

Dr. J^Intson first emphapizecl the great importance of the 
total irhite count in addition to tho differential ctnint in 
doterniining whether a morbid condition was septic or 
chiouic. Both results should be combinc<I to avoid u'rong 
conclusions.- Thus .a' dilfcrcntiai count of 44 per cent, 
lymphocytes might indicate a slight condition of no impov- 
taneo, but if the tbtnl white coll count was 15,000 to 20,000 
per c.mm., tho •prbh.ability was tliat an earlv Ivmphatic 
leukaemia existed;' thus by omitting the tot.al count an 
important diaposis might bo overlool:ed. It was nceessarr 
to remember that a physiological loncocytosis occurred after 
■? "•"s required, the doteianinations 

sho d always be made at the same hour each time. An 

^ anaemias a complete white count was as 
'' leukaemia might 

number f A ^u® ivas limited to the toLal 

toXx Tb- ^ -^’if und tbe colour 

as th; nX s"'*’'" of the acute leukaemias, 

.as the process was often so rapid and the nhy.sical siens 

to ubsciit, though the patient might be dead 

m a neek. Passing to Midal tests, the loctiirer warned 
a^m^ paying too much attention to the leiicopcnia in 

MTdarLstXXTl “ foooocytosis might oftcL follow. 

\\ idal tests should not he performed before the tenth day 

since the agglutinins were not in evidence previously For 
an e.arlier diagnosis than this a Wood cidtimo was reqnired 
and in the thud week of the disehto the urine andXXs 

should be oxammed. Patients, ' v.atiin.ated with T aX 

^sXhirr^""' ■'« their blood for si' Ion- 

as thirty ye.ars, and a period of seven years was ouite 
common. In those ivho had siiffererl f 1 as quite 

paratyphoid infections the blood might retain itoXgluttoa 
tion power for tho rest of life’ Tt was ® -Smtin,.- 

tnese infections 01 had been v.acciii.ated with TAB Thov 

sb^A^’ •■’SSlutin.ation of low titve' which 

sbonid arouse suspicion. If tl,p ' unicu 

a positive IVidal\eaction .a seeX^a^^ inf 

patrols should ‘Lais bo 0^^^ “ dXV'’'* 
den Borch’s reaetinu Ti,. ^ ’P*'’!™' Dealing with van 
determining the cause of' iaim i^*^ explained its uses in 
J‘ ndice due to hepatogenous 


Eeports rtf ^0£t£ttus. 

INTRAVENOUS TREATMENT OF TARICOSE 
ULCERS. 

At a combined meeting of the Sections of Dermatology 
and Surgery of tho Royal Society of IMedicinc, on May 
16th, with Mr. R. DAViE.s-Coi.LrY in the chair, a discussion 
was liold on the treatment of varicose ulcers by obliteration 
of varicose veins by injection. 

The CiiAiRsiAX, inlrodnoing Profes.sor vSicard, who 
initiated the method in 1916, mentioned that obliteration 
of veins had been attempted fifty years ago by tho injection 
of ferric chloride, hut tho method had been given up because 
it had proved unsafe. He added that Professor Sicard 
and Iiis colleagues had now removed the danger from this 
intravcuoius injection method, and had rendered it of groat 
practical value. 

Professor Sio.uiu reviewed the factors coiiconiod in the 
production of ulcoratioii in the lower limb. The influence 
of varix, age, licrcdity, and derangements of the cndocrino 
■SAstom were discussed, and tlie analogj- between tlio action 
of pituitary extract on the veins and adrenaline on tho 
arterioles was mentioned. These i-arious factors eaiwod 
weakness of the walls of the veins and of the snppoitin- 
perivascular tissues, with ihcompetpiice of the valves of the 
veins. Syphilis alono-or associated with anv' of these other 
factors was a fairly common cause of nlecratioii. Local ' 
factors, such as trauma, intiapelvic pressure, phlebitis 
infcctiiMi, and prolonged standing, played an import.ant ' 
part. Professor Sicard classified ulcers’ hi tbe lower ex- 
tremity in four therapeutic groups: (1) Post-iiblebit’ic 
ulcers with oedema of the limb. Tliis tiqic was eortainlv 
not suitable for injection, the only lines of treatment being 
lest, massage, and support. (2) Dirty serpiginous ulcers 
of long standiiig, with markecl local dystrophy, were also 
unsuitable for injection, and could only' bo treated bv rest, 
disinfection, vaccines, light, and surgery. (3) Ulcers with' 
raocleratc or mild loc.al disturbance, usually preceded bv 
local dermatitis, were i-ery much improveci by sclcrosin- 
combined Avith local applications! 
(4) Mixed sAqibilitic and varicoso ulcers, which u-ere cured 
bj- antisyphilitic treatment combined with local oblitera- 
tiA'e injections. With the aid of microscopic drawin-s the 
pathology of chemical A-cnitis and thrombosis was described 
and the firm adherence of the clot to the endothelium was 
demonstrated. Professor Sicard said that with his col 
leagues Drs. Forcstiw and Gav.gier ho had demonstrated' 
tho parage of fluids from the superficial to the deep vbtos' 
of the hmb on slight muscular contraction, bv means of the 
mjeetioii of opaque solutions such ,a.s JipioVjoI or 'sodium 
lodule into the superficial veins, followed by •stereosebpic 


898 may 26, 1928] INTKAVENOTTS TREATMENT OP VARICOSE UECERS.' [ 5lKDrcA JounsiXi 

X-ray photographs. ' Theso photographs wore shown, anil 
they illustrated clearly tho passage of the lipiodol into the 
deep veins on slight muscular movement. He therefore 
always performed the injection in tho supino position, 
instructing the patient to keep the limb absolutely still and 
flaccid. In this 'way the injected ' fluid remained in the 
superficial vessels and produced a much better thrombosis. 

Numerous lantern slides were shown of patients before and 
after treatriieht, to indicate the marked improvement in 
tile appearance of the limbs and tho healing of tho ulcers. 

Examples of venectasia, extending to the pubis and upper 
abdomen, were also shown. Professor Sicard pointed out 
that these cases were not suitable for injection, since there diicod a very marked immediate effect, and tho thrombo- 
was often obstruction to tho deep veins, and also because phlebitis occurred quickly. Patients, however, often had 
they were difficult to sclerose owing to the rapid stream cramp soon after tho injection. Quinine and urethane gave 
of blood through them. It was in theso cases that accidents Hso to littio' or no immediate discomfort, but about two 
were liable to happen. A 20 to 60 per cent, solution of or throe days afterwards patients complained of pain in 
sodium salicylate in water was tho most satisfactory; ho tho logs, even worse than that occurring immediately after 
gave 2 to 3 c.cm. in one dose, and he injected all tho veins sodium salicylate injection. The speaker objected to tho 
immediately proximal to the ulcerated area. Tho number massivo doses of glucoso necessary to produce offectivo 
and frequency of tho injections had to bo adapted to tho thrombosis. HO used tho horizontal position, but placed tho 
individual case. Other solutions, containing quinine and patient with the leg hanging downwards for injection of 
urethano, sodium citrate, glucose, as well as hypertonic tho smaller veins. To prevent leakage, he immediately 
saline, had been used with less success. In conclusion, applied an isinglass plaster to compress tho site of injec- 
Professor Sicard said that tho improvement was most tion. Rest and local treatment of the ulcer were also 
marked in the early cases; when eczema was a pi'edominant necessary, and a word of warning was given concerning . 
feature it rapidly improved. No complications had been tho use of quinine solutions during pro^ancy. 
encountei'ed, and relapse was rare; when this did occur Air. David Levi reported tho results of treatment of 
a second course of injections was invariably successful. 60 cases. Of theso 57 weio cured, but 3 failed to respond 

Air. Twistington Higgins based his observations on to injections of 66 per cent, glucose. Ho had had one case , 
200 completed cases of varicose veins, in thirtj’-fivo of which of embolus following threo injections of 66 per cent, glucoso, 
thero was active ulceration. He had used sodium sali- and another patient had transient pain in tho side. Mr. . 
cylate, quinine and urethano, and 50 per cent, glucose, and Lovi showed microphotographs of tho venitis- following 
found that sodium salicylate and tho quinine solution glucoso injection, and pointed out the looseness of the clot. ■ 
were equally satisfactory. Discussing the parts played by Ho therefore concluded that quinino solution was better, 
trophic disturbances, trauma, and infection in tho patho- Ho had failed to produce experimental obliterative venitis 
logy of varicose ulceration, he said that tho best results in a rabbit’s ear, oven after obstructing the, blood How, and 

were obtained by the injection method, in cases in which ho therofofo thought it was probable that, the thrombosing 

the trophic element predominated, and the poorest results effect of the injections only occurred in diseased veins, 

in those cases presenting a great deal of infection. Tho Dr. GoLDSsiixn pointed out that if was important to 
speaker considered it most important to disinfect and determine tho direction of. the blood flow^ in the veins in 
clean tho ulcer before commencing treatment, because any tho upright position. A backwarel (centrifugal) flow pro- 
risk of embolism was increased in the presence of a septic duced oedema and stretching of tho skin, with consequent 
focus. He commenced injection well above tho ulcer, and ulceration. Ho thought that it was rational to expect that 

noticed that, ow'ing to the great dilatation of tho vessels obliteration of such veins would aid the healing of tho 

usually present, many injections were necessary to produce ulcer. , He said that the advantages of the injection 

sclerosis, and that there was a greater risk of local necrosis method, over surgery were that injections could bo given 

since tho vessels were usually very thin-walled and near in cases of infected ulcer, and that the movement of tho 
tho skin. He had not met with a caso of embolism, but limb, allowed during the sclerosing process, played a very . 
from the investigations of Professor Sicard and his own important part in the relief of the aching and the oedema, 
observations on histological examination of a vein after If tho veins showed an upw'ard flow they should not bo 
injection, ho thought that the risk was very small, because injected, since they were not helping in the production of 
the clot of irritative endovenitis was very adherent. Ho oedema of the skin. A history of phlebitis wms also a 
mentioned that Professor Sicard had treated 2,860 cases contraindication to injection. Tho speaker only gave one 
without tho occurrence of embolism. To remove .any pos- injection at a time, ' since tho height to which the . 

siblo risk of this complication he emphasized the im- thrombosis extended varied very considerably. Ho pro-, 

portanco of preliminary treatment of septic foci and tho ferred glucose solution, since it was painless, non-toxio,- • 
avoiding of excessive muscular movements for about threo and did not produce local necrosis. Glucoso could be , 
weeks after an injection. Air. Higgins felt strongly that sterilized by boiling for half an hour without tho pi'oduction . 
the greatest uso of sclerosing injections lay in the proven- of toxio substances. He used a tourniquet in tho erect ' 
tivo treatment of varicose ulceration. Patients were position to demonstrate the vein, removing it after he had 
much nioro ready to submit themselves to the injection inserted the needle with the patient in ' tho horizontal . 
treatment at an early stage than they were to undergo position.'. 

ah operation. Tho out-patient department of hospitals Air. B. T. Payne said he had treated thirty cases of 
boro testimony to this procrastination, patients often only varicose ulcer with sclerosing injections of quinino and 
seeking treatment when a large and foul serpiginous ulcer urethano solution. All the ulcers were also treated with 
was present. Tho pre-ulcerative stage wms easily recog- calamine lotion, and tho patients were allow'ed to walk 
nizablo and tho injection of tho veins was of the utmost about during the course of treatment; all but one caso 
value in aborting tho atrophic changes and re-establishing showed signs of healing. Ho also used a tourniquet and 
tho nourishment of th.e tissues. The speaker, referring to compressed the site of injection for two minutes after with- 
p'erivenitis, necrosis, and cases with marked local reactions, drawal of the needle, and then applied strapping. Tho 
said that these sequels were often diie to faulty technique, speaker thought that all the cases of local necrosis and peri- 
though they sometimes occurred when the solution was venitis he had met with were due to this leakage of tho 
injected correctly into the vein. Such complications solution after injection. Ho said that not only was there 
occurred most often' in severe cases, in elderly patients, in a distal flow in tho veins, but that the capillaries shared 
thin-walled veins, and in veins over bony prominences, such in this back flow. It was the re-establishment of the capil- 
a's tho tibia and internar condyle of the femur. He thought lary circulation which was of importance in the healing of 
that possibly tho best treatment for these complications an ulcer, and this could bo attained by surgical extirpation 
was excision. General toxic symjitoms were rarely encoun- of the veins and by firm bandaging, or by obliteration of 
tered ; complaints of a lilllo giddiness after sodium sali- tho veins by injection. 


cylate wore sometimes received, and patients often tasted 
tho quinino soon after its injection. Air. Higgins had ono 
caso of vicarious menstruation after tho injection of 
quinino and urethane. Comploto failure, in' his expericrico, 
w.as uncommon, and a successful obliteration of tho vein 
could bo promised in every caso after repeated injections. 
Secondary dilatations did occur and under dosago produced 
thickening of tho veins without occlusion. 

Sir Sidney AnEXANUEn said that ho had used 40 per cent, 
sodium salicylate solution, quinino and urethano .solution,- 
and sodium chloride solution, but that ho had obtained tho 
best results with sodium salicylate. This solution pro- 



BKEliETAn METASTASES IN CAUOINOMA. 


[ Titr. npiTitn 
H^ntcAi. Jocasii. 


899 


MAY :6, It)j8] 


])i- Bfckk.tt-Ovv.uv said lie luid poi-foruiod 500 iiijnctions 
with ’siuliimi Mili. vlnte. Ho umIuIIv pvoducvd six to eight 
inches of thi-onihosis, and liad very litdo vonetion. Dr. 
Giii Y inontionod Unit toxaemia was Uie eliiof faetov in the 
pvodmtion of varicose veins, sincn they made their npiiear- 
ance during pregnancv heforo tlie uterus was large enough 
to obstruct the 'blood' veUirii. lie ado vcforred to Tloyd’s 
comparison between the. charaeter.s of the clot in throin- 
Iwsis and blood clot after bhaaling. 

Dr.FoHK.sTir.li, replving tor his colleagues Frofessor Sicard 
and i)r. Gaugicr, said' that the ulcers .suitable for treutnienl 
bv injection were. those with moderate di-.s-trojihie ehaiigc.s, 
and thc.se due to svphili.s as well .as trophic di.stnrTv- 
anec.s. rost-phlehitic'iileers and the large diity .serpiginous 
uleer.s were not suitable for treatment. Vmieitasia of the 
pubis and abdomen was also uiisuitnhio. He agieed with 
Mr. Twislington Higgins that the greatest use of the 
method wa.s in prevention of ulcernfioii. He never used 
a tourniquet, and had never failed to iiijest a vein. 
Tliere was a marked difTcreiiee between the pathological 
histology of chemical venitis and infoelivc phlebitis. Ho 
thought that at iireseut it was an opeui question whether 
there was any difTercnco between the thromhus produced 
by glucose and that )irndured by the oilier solutions, but 
ho added that the only fatal cases reported in the litera- 
ture followed the use of glucose. A'ei rosis of the .skin had 
not occurred siuc'c sodium bicarbonate bad been iliseaided. 
In conclusion, he I'lnpha.sized the importance of a thorough 
examination of the patient before Ireatmeiit, paying special 
attention to the blood pressure and to the examination of 
the mine for alhuniin. 


SKELElbVL METASTASKS IN CAHCINOMA. 

At a meeting of the Section of Surgery of the Iloynl 
Academy of ^fedicine in freland on Jfay 4tli, with br. 
M. R. J. Hayr.s in the chair, Mr. F. J. Ilr.xuv reported 
a case of extensive carcinomatosis of the skeleton in a 
woman, aged 49, who had fii-st nolicod a Inii.ji in tlie left 
brea.st about a year previously. 

Sfr. Henry said that six months later this lump began 
to ulcerate tlirougli the skin, and the patient began to 
sulfer from severe rlio'nmatic pains in the hack and aliout 
the sbonlders. She was in an extremely miserable <ondi- 
tion, being very carhcclic and searcclv able to move. A 
large fungating mass was present in tlie upper part of the 
left breast, and enlarged glands could bo felt in tbc left 
axillary and supraclavicular rogioms. A"-rav examination 
sbowed multiple area.s of rarefaction and erosion in the 
spine, ribs, and pelvic hones. I’hcrc was jironouneed 
angular deformity in the lumbar region, duo to cdlap.se of 
the bodies of the eleventh and dorsal, and possiljlv 

of tbo hrst Uiinbar vertebrae. Tbc gener.al appearances of 
tbe vertebral column were very unusual; they were attii- 
bated to decalcification and in some cases to condensation, 
probably broiigbi about by compression. .Secondaiw deiiosits 
uere also demonstrated in tbe bnmeri, scapulae, and 
femora. A blood examination w.ts made, but revealed none 
of tlie abnorm.ahtics described by Pinev as occurring in 
diffuse carcinosis of tlie bone marrow. ‘ 

Hi. M. R. J. H.we.s said that bo bad never .seen such 
extensive metastase.s as iii tbi.s’ c.T.se. He discns.scd tbe 
probable path of infection,' and .suggested that it might 
be a secondary infection ibiougl. the blood stream. He 
re eirei o bo care taken in America to iierfonn a 
complete oxaminatiom before an oper.ation fn eaUs of oar- 
cinoma of the breast. Tiip condition in which be bad found 
secondary deposits most common, and occurring at a voiw 
early date, was carcinoma of the prost.afo. 
siitrr' C- Stevex.sox tlionglit that one reason why 

casfrw.s"n /'“'V ri’ succeedod in cancerous 

the ^ g>«"’fh was rcniovod tbe poiver of 

he iratient to resist cancer was streiigfliciiocl. 

'vr T,- Uses o/ Hcidinm. 

SteyexsoXj in a pnpor on some STTrs^ical 

the Year 1927’’ oTtf'' 

nant disease and 120 Tr’om ^ Patients suffered from malig- 
conimnnication dealfcS 


that after cnucero.is cases had heen treated the effec.t of 
radium treatment oi cases mot with in ordinary .surgical 
or medical pracliie might well lie investigated. He had 
found that jirolougod ladiation with sniall aiuoiiuts of 
radio-iicitive material appeared to Ii.ave .a prononneed elfect 
in promoting tlie. ahsorptinii of iiiflaniir.ntnry products, 
curtailing the period of st-pvis-, and relieving pain. He 
iiistaiieed the case of ii l.arge '.welling in tlie neck which 
disappeared with mild radiation, the anioiiiit of pus forma- 
tion being minimal. A ease of ehroiiie otorrhoea of four 
years’ standing following a mastoid operation cleared up 
"within three or four weeks of radiation treatmeiiL for seven 
hours. Immediate relief of tlic* intense pain and rapid 
healing follmved mild radiation for five d.iys of an uher of 
the .leg of .about fifteen inoiitbs' duration following a com- 
pound fracture. The consol idatioii of a united frartnre 
of tbe femur in a rickety child appeared to be gr.s-.itly 
ba.stened liy radiation. He .statcal that with some of br.s 
colleagues rndiati-iu appeared to be tbe routine metiiod of 
treating tiiliereiilnns peritonitis; certain of these eases bad 
lioen treated after exploratory laparotomy wbcit very extru- 
sive disea.se laid been found. Mr. Stevenson tlionglit it 
probable that siiiiihir results would be obtained by a- ravs. 
i)ut be added that the csmtrol of tbe dosage of radium was 
mucli iK'tter tlian ;u the ease of .r ray.s, and be instaiin'd 
.0 case of recovc-ry from t iibercnloiis lung trouble wliiclt be 
bad radiated witboiil intermission for seven iiiontbs. 

Hr. M. R. .1. H.wk.s lielieved that in eases of tnlierciilou- 
peritonitis biparotoiny was tbe licst treatment ; lie wit-s 
always chary of applying radiation to aente inflammatory 
conditions. lu cases of ec'rvieal adenitis, if any of the 
glands contained pits, the patients slionld not lie tre.ated 
by radiation until an operation had been jierformed and the 
pus lot out. 

Hr. R. Stumpe said that the indication.s for tbe use of 
radium treatment and treatment by .e rays wei-e not .suffi- 
ciently known. It was possible by x-ray treatment in most 
ea.ses to get as good results ns were given by raclinin. In 
ease.s of keloid be preferred to use radium, and in eases of 
malignant disease of tbe mouth and oesopbagns be em- 
ployed combined treatment by radium and .r rays. He h.id 
treated eases of tuberculosis of the larynx, boils, eiTsipelas. 
and aetiiiomyeosis succcs.sfully by x rays. 


MANCHESTER PATHOLOGICAL SOCIETY. 

At the annual iiieeting of the Alanchester Pathologiral 
Society on Alay 9th, with Dr. T. A. GooDFELtow, the 
incoming president, in the chair, Professor J. S. Dtrxxinii.y 
gave a dcnion.stratioii of venomous and non-vcuoinous 
snakes. Tlie. meehniiisni of erection of the fangs and the 
action of the temporalis muscle in emptying tiic poison- 
scereting gland in venomous snakes were exjilaincd. The 
speaker added that the orcIinaiT teeth were prehensile only, 
the victim being swallowed whole. The nuizr.le of the prev 
was swallowed first, since ingestion was easier in this way 
than in any other. Owing to the absence of mastication 
the opening of tlie tiacbea was plated far forward in the 
mouth, choking of the snake during deglutition being thus 
prevented. Tbe venom cnntaiiiod a iienrotoxin, as well 
as a proteolytic enzyme and a liacmolvtie bodv; the poisons 
were, to a large extent, specific. Afr. F. H! IVestxi.ccott 
sbowed specimens and pbotograjilis from a ease of clironic 
bypertropbic pulmonary osteo-artbropatby, one of the first 
examjilos of this condition to be reported. Air. R, H, 
AIoTiiERsoim showed a specimen of a congenital bnccal evst, 
about tbc size of an orange; it was found lying on tbe 
mother’s perineum after delivery, with which it bad caused 
some interference. Tfie pedicle bad been attacbed between 
tbc lower lip and the' jaw of the child, who was alive 
and well. Professor Sii.tw Hr.x.v sbowed speriinens of nlcers 
of the ocsopliagn.s, among them two exaniides of decubitus 
ulcers of tbe pharynx, caused by the pressure of the cricoid 
cartilage against the vovtebral column. In one case this 
pressure iiad heen clue to a marked anterior cnn-atuie, the 
result of spondylitis. Dr. C. Poweli, AVuite demonstrated 
a numbor of niicropbotogrnpbs illustrating various points 
in tbc liistoTogy of tumours, including an adenoma and an 
adeiiocarciiionia of the rcctiiiii from tlic same patient and 
also an adenoearcinoina arising in tlie centre of an adenoma 


000 May 26, 1928] 


BEVIEWS; 


[ Tttr. nrtiTiPn 
SfKuicAT. JocnwAi. 




CLAUDE BERNARD’S. “ INTRODUCTION.” 

Mr. H. Copley Greene’s translation of Claude Bernard’s 
Introduction to the Study of Experimental Medicine^ will 
help to make English readers acquainted with a work 
that should bo in the hand.5 of evoryono who is engaged 
in medical research. The translation is excellent, and is 
preceded by an appreciative account of Claude Bernard by 
Professor Lawrence Henderson of Harvard and Paul Bert’s 
article written at the time of Bernard’s death. Although 
the Introduction made its first appearance in 1865 its 
value has not diminished in the lapse of years; indeed, it 
is difficult to believe that it will ever be out of date, 
because it expounds in a masterly way the fundamental 
principles of experimental research that hold for all time. 
It is, moreover, no mere philosophical dissertation, but a 
thoroughly practical guide to the research worker, explain- 
ing how discoveries have been and are to ho made. Claude 
Bernard is insistent on the practical aspect ; ho sets aside 
tlicoretical questions of deduction and induction as . uu- 
inafitable, and notes that although the Baconian induction 
lias been made the foundation of all scientific philosophy. 
Bacon himself did not understand the experimental 
method; the hapless attempts that ho made sufficiently 
prove it. Great experimenters appeared before all precepts 
of experimentation, as great orators preceded all treatises 
on rhetoric; Galileo and Toricelli admirably practised the 
experimental method which Bacon could never use, and it 
is the practice of experiment that Bernard explains in 
his book. 

The need for a work of this kind at the present time is 
referred to by Professor Henderson. Ho points out that in 
the composition of modern scientific literature it is the 
custom to adopt a formal, rigid, and impersonal stylo 
uhich affords no insight into the personality and behaviour 
of the writer behind the printed page. The same is true of 
lectures; they are formal, logical, and impersonal. Yet 
what the novice in experimental research requires is an 
understanding of the working of the mind of the great 
investigator, and this is at the present time practically 
shut out from him; he has to initiate himself into mysteries 
which no one will explain to him. Of the real disadvan- 
tages resulting from this defect Claude Bernard has no 
doubt ; he considered that the genius of inventiveness niigbt 
bo seriously diminished, or even smothered, by a poor 
experimental method. An inventive spirit and aptness of 
mind cannot be imparted by any means, but a good method 
enables such faculties as we posse.ss to bo turned to good 
account. 

In C'laudo Bernard’s Introduction to the Study of 
Experimental Medicine wo are shown what aro the essen- 
tials of a good method, and we have a vivid picture of 
hiinself at work by one of the most intelligent of .modern, 
scientists a man of genius and a great ijhysiologist. The 
numcious examples that he gives of his own experimental 
■ physiological investigations form an extremely instructive 
chapter, m which the working of his mind is. poi-tr.nyed 
in every detail- and stage of the process— from tlio first 
inception in some, often chanco or trivial, observation or 
hypothesis, and along lines often singularly circuitous 
and unexpected, up to the final goal of some important 
ditcovery. 

The book is unique; there is no other like it, and apart 
from it.s scientific value it .has literary merits which, at the 
time of its appearance, gained the applause of the French 
Acadeinj-. 


FUNCTIONAL REPRODUCTIVE DISORDERS 
IN AVGMEN. 

The book on tho functional disturbances of the female 
repioductivo system" by Professor Gaston Cotte is 
designed to show what can be done in restoration of func- 
tion, and does not concern itself with those conditions, such 


» .-In 2fiJrorf«c?i£>r» to the Study of Experimental iledicine. By Claude 
Bt-rtiard.' Translated by Henry Conley (ireone, A* 51. New and 

Ltmdon : Macmillan and Co., "Ltd. 1927. (.Med. 8vo, pp. .\ix + 226.) 

Troubles Functiounels de I'Appareil (f^nital dc la Femme, 
Colic. Paris: Mu*son ct Cic. 19.3. (.Sup; roy. 8vo, pp. 570; 
Uo Courts, 60 tr, cans majoration.) 


as cancer, that call for radical treatment resulting in 
destruction of function. 

Operations such as salpingectomy aro not discussed, hut 
tho.so such ns salpingostomy, wliich liavo for tlioir object tho 
restoration of function in a tubo scaled hj’ infiammatioii, 
aro included. Similarly hysterectomy as a motliod of treat- 
ment for non-malignant conditions does not como within 
tho author’s theme, save in so far as ho is concerned to 
advocate in women before tho mcnopaiiso tho subtotal 
operation, with conservation of at least ono ovary, when it 
is impossible to preservo tho integrity of tho re])roductivo 
tract. Ho has a very clear impression that tho after-effects 
of this method are much less trouhlesomo than those of 
tho more radical operation. 

Tho first, and much tho longest, chapter is devoted to 
menstruation and its disorders, opening with a section on' 
tho sox cycle in tho mammalia, which, taken as tho bio- 
logical foundation of tho menstrual cycle in women, is 
considered in detail. In view of tho author’s pur])oso 
n full account of the physiological a.spccts and meaning of 
this .function is given before going on to its di.sordors. 
These latter are confined to absence and deficiency, excess 
and irregularity of menstruation, .dysmenorrhooa being 
considered under disorders of innervation. Treatment by 
medical means, especially organotherap)’, and by physical 
and surgical i)roccdures is discussed. Ho decries tho exces- 
sive nso of tho curette, and in this plea will find nuieh 
support. When, however, he proceeds to advocate various 
interventions on tho ovaries largely based upon theories 
which aro as yet incompletely established, ho is on much 
more contentious ground. Resections of portions of ovarian' 
tissue aro advised, and it is suggested tliat if one ovary is 
found to contain atretic follicles and no corpora lutea, 
homoplastic grafting from tho other should bo practised. 
Many will liesitato to follow liim in adopting siieculativo 
procedures of this kind, oven if, as ho points out, an 
application of radium may ho tried in the event of a 
recurrenco of symptoms. Tho next chapter covers dis- 
ordered sexual relations — dyspareunia, -v^aginismus, and 
frigidity — and is followed by another on sterility and dis- 
turbance of embedding of the fertilized ovum, leaving aside 
tbo other disorders of reproduction during pregnancy, par- 
turition, and tho puerperium as being more particularly, 
ilio concern of tbo obstetrician. Chapter iv is concerned , 
with leucorrboea and disordered secretion ; chapter v with ' 
vascular distui-bance; chapter vi .with disturbances of 
innervation. The final chapter treats of ovarian insuffi- 
ciency and, the disorders consequent on castration. AVe ' 
doubt, however, if tbo method of treatment of dysmenor- 
rhoea and “ pelvic neuralgias ” by division of tbo. anterior 
jjypogastric nervo pf the sympathetic plexus after a deep 
dissection will meet with acceptance. . , 

Our criticism of the book is that, though tbo author has 
set out with an excellent purpose, he has allowed bis 
ontbusiasni for avoiding mutilation and needless destruction 
of function to lead. him to advance, procedures which are 
unsupported by adequate experience of results. 


■ the pneumothorax AND SURGICAL TBEAT- 
■ ■ ■■ MENT OF .PHTHISIS. 

'The pnqumotbofax. treatment of pulmonai'y tuberculosis is 
so important, and .still so new. and therefore subject, to 
revisions and improvements, that everyono interested in it 
must bo grateful for a second edition” of a book which has 
already -become, tbo; standard authority' on pneumothorax 
treatment in this country. In bis preface Dr. CuvB 
Riviere points out that the. original fourteen chapters 
have grown into nineteen by the addition of separate 
chapters on such subjects as the reduction . of adherent 
pleura, pleural contraction and its effects, tbo duration of 
treatment and its termination. In addition, such subjects 
ns tho division of pleura! adhesions, small-volumo pneumo- 
thorax, selective collapse, oleothorax, and pneumothorax 
in 'cliiidbood have, received separate and special attention. 
But what distinguishes the second from tho first edition 
most prominently is the addition of a second part dealing 


" The Pneumothorax ana baroical Treatment af Pulmnnary Tuher. 
culosis. By CUve Riviere, M.D.Lom!., T.U.C.V. Second edition. Oxford 
Medical Publications. London : Miltord, Oxford University Press 1927 
(Cr. Bvo, pp. xiii + 311 ; 16 plates. ICs. 6d. net.J * ’ 


MAY 26 , iqqSJ 


BEVJEWa. 


■f TiitCnmja 

LMeOICIX. JOTOSii 


v.iiu lUo sinpcal trontiiw-nt of pnlinonnvy tulx-i-ouln-iis 
i'lio }vullu>r has, of coorso, nvoidod IhoKo torinncal mui 
oporativo details which must inevitnhly heloi.g to (he sidiero 
of the suiReon, and he has 'confined liiinself to "ivnig ii 
general snrvev of the snhjeet for the hciicnt of the practi- 
tioner who, ‘in the interests of the patient, ought to 
know the indications and chances of .success of operative 
intervention. H is interesting in this tsnine.Mon to rend 
that “ in the e.stiination of the Matsons and Hisaillon. one- 
third of the ‘ no free space ’ cases, and one-third of the 
eases of ineffective partial lollai'se, are snitahle for tlinra- 
coplastv, and shonhl have this chance olfered to them.” 


operations or apparatus will he found in this work. Dr. 
I’ierre Marie, wlio has ivritten the jircfacc, welcomes this 
hook, indeed, as an attpin])t inade hv a phy.sician to annex 
a new territory in a domain which hitherto has almost 
entirely lielonged to snrgory. Those who annex, or tiy to 
annex, their neighhonr.s’ possessions are a))t to get into 
Ironhle, and Dr. Leri innst not ho surprised if surgeoms 
fail to admit his claims, since he has- not made them 
good hy cures without the help of surgeons. Indeed, in 
the case of. spina, hifida with incontinence of urine. Dr. 
Marie has to admit that the eollahoration of a surgeon has 
heen iiceilcd to achieve good result.s. 


rULJIOXAllY TiniKHCnLO.SlS. 

Dn. fi. T. HiainiT’s little hook I'lihiwiiiirij Tiilx'iriitii.w' 
is intended for the .senior student, the post-graduate, and 
the general practitioner. The first thing that strikes one 
about it is the peculiar arrangement of the snhjecl inatler. 
The fir.st chapter is headed “ Diagnosis " ; then come the 
u-sual chaiitcrs on jiathnlngy, symptoms, physical signs, 
and x-ray examination. Instead of these being followed hy 
a chn])tor on di.agnosis, the author has inserteil special 
chapters on pleural effusion and fibrosis; uinl when 
di.agnosis is con.sidered, tho two chaptef-s ihnotcd to it, 
headed “ Kvalnation of evidence” and “ Differential dia- 
gnosis,” are separated hy a special chapter on tiihcicnlosi.s 
in children. It is to he hoped that in a future edition a 
more logical order will Ik- arrived at. Apart from this 
fault of .structure, the hook is rcmarkahly good ; it i.s clear, 
direct, and dogmatic, as a popular texthraik should he, 
and is illn-stratod hy .some very useful diagrams. 'We note 
the inclusion of the old error, copied from one textbook 
to another for tho last forty years, that tlic Kmcgma 
Lacillu.s is decolorized hy alcohol. It is really time that 
this was given up; it is cpiito impossible to distinguish 
tho sapro])hytif acid-fast from tho tnhorele bacdli hy 
morphologiciil aiid .staining methods, and this should bo 
taught authoritatively. 


RAIIK DISH'ASMS or VKIlTEliRAE. 

Dn. Axonf. Lf.ni's volume on affections of the vertebral 
column* may be taken us a sequel or second part of Ids 
Imok, Efiidrs sar frs <i//frfions dcf o.s ct ties art irxihit ions 
{colonne vcrtchrnlc errcptcc), which also ap])eared in 1S26, 
and wa-s noticed in our ks-suc- of June 18th, 1927 (p. 1106). 
Those “ etudes,” like tho.se which formed the other volume, 
are all reprints from French jonnials, in many of which 
other authors have collaborated, some of whom aro highly 
distinguished, such as Dr. p^'erre Marie. The book is 
divid^ into five parts, the titles of which will give a clue 
to its subject matter. These are: 1, Anonialios and 
“troubles” (that i.s, di.sorder.s) of development; 11. Trau- 
matic affections; III, Ankylosing disorders of the spine; 
II , Localized vertebral rlieuinatism and Us consequences ; 
1 , Miscellaneous affections. Of tlieso, tho first occupies 
more than one-third of the book, and iiieliides inter- 
esting and often rare cases of maldevelojmicnt, such 
as saci'alization of vertebrae, lumbalization of sacrum, 
spina bifida, and various conditions which radiographs’ lias 
hronght to the front of late ycav.s. Parts 111 and IV, on 
ankylosing diseases and rheumatic affections, occiipj- most 
of the rest of the hook. Pott’.s disease is only roferre'd to in 
a few pages in Part \ on “ Pottic ” infantilism, in which 
will he fouiid^ some interesting ohserratioiis of cases of 
Severe kyphosis, in which, as is familiar to maiiv of us, 
there is some degree of arrest of sexual and ‘general 
doielopnient. 

Snell a volume as this, and its follow, is v.ahiablo as a 
Work of reference, in which the practitioner who has come 
upon an umisu.al case may find a record of others of a 
Bunilar kind, and some bints on their pathology and treat- 
ment. In general, however. Dr. Leri lav.s much more stress 
on patl-.o.ogy than therapeutics, for no descriptions of 


rxlrrctiiofis. Uv c, t. IWiorl M A M D Oxo 

1927:- (criJo, r'p ziz; 5 

rcrtchra?e. P.ir An<ir« !.< 
r»Ti5 . Msjson et Cw. (6 x 8J, jip vii -!- 526 ; 115 figures. 7s.6fi.net. 


AYUKVEDLST M.A.TERIA AfEDlCA. 

Mil. K. M. N.tiiK.MiM, the author of a well-known work 
oil liidiaii plaiiL. and drugs, has issued what ajijicais to ho 
a very complete Jiiitian .Ifo/crio Mcdirn'' — that is to say, • 
a materia iiiedlea oil Ayiirvedi.st liiie.s. Tlio hook will be 
of use to those who take an interest in native Indian mattei'.s, 
.since it gives an insight into one of the more favour- 
able and practical aspects of Ayurvedist incdieino. Reing 
restricted to Indian ilriigs its scojie is nccc.ssarily limited 
in some .slight degree, there being, for example, no mention 
of digitalis and strophaiithns. Tlie author, liowevcr, does 
not intend that his hook shall replace tho British materia 
mediea, but that it may ho used side by side with tho 
latter. He hopes that hi-s work may encoiirago the employ- 
ment of the ding- jireparcd in the native bazaars, wliich 
are vastly less expensive than imported drugs, and employ- 
ment of which would do something to meet the grinding 
poviwty of the people. The book is, as wo have said, frankly 
Ayurvedist, and the author cxprcssc.s a wish, in his preface, 
that tho Ayurvedist .system were more closely and syin- 
palhetieally studied. An article on, tho indigenous systems 
wins piihlisliod in this Journril in 1S23 (vol. ii, p. 477), and 
was written after an im))artinl .study of the subject, based 
solely on nintorial furnished hy a number of distinguished 
Aynrvedists. Tlic conclusion reached was that Ayuiwedism 
rcprc.sent.s a .stage in the dcvelojmicnt of medical science 
that is. centuries behind the present level of knowledge. 
This coiielnsioii imjilies no disparagement, for Aynrvedisni 
is admittedly a subject of very great historical interest; 
lYostern medicine has jiassed through a similar stage, and 
it must lie obvious to Ayiirvcdists that their Science cannot 
remain .stationary if it is to survive. It would he unreason- 
ahic to suppose that their ideas can be transformed in a 
day; the eliangc is hound to ho gradual, but of its impor- 
tance for tho welfare of the people of India there can 
ho no doubt. It is possible that the main obstacles to 
further advance arc the idea that science rests on antlioritv. 
rather than on ohsorvatioii and experiment, and a failure 
to recognize tliat tiic ipse dixit of an authority, however 
venerable, is almost certain to contain an admixture of 
error, and is not unlikely to he a mere legend or plav of 
the imagination. 


NOTES ON BOOKS. 

In T/cOvUifiiiff the Child: A Study in Mnhiutnlion.' Dr. 
FitANK HowAnn RicuAnnsox of Brooklyn, New York, the 
author of Ptjrrnfhnod and the ATierr Psychology and of 
Sinijilifying Motherhood, addresses parents, teachers, nuixes, 
and doctors, hut the simple, somewhat elementarr’, style is 
perhaps better fitted for the parents. Malnutrition, according 
to the editorial foreword, wJiicJi tells the reader that this book 
appeared as a series of articles in the Trained Nurse and 
Hospital Peview, is the great disease of the -American school 
child, and is shown by underweight for age and height, the 
latter being the more important ; in fact. Dr. Emerson, evho 
contributes the iiilrodnction, neglects the age factor altogether. 
The child has a pasty face with a tired, don’t-care expression, 
the chest is ilattened, the angles of the sc.apulae stick ont like 
rudimentary rvings, and the abdomen sags and is prominent 
from want of tone. Malnutrition is not ascribed to deficiency 
of food, but to five ■ classes of causes — faulty health habits 


* Thr Materia Medico. Edited and pnblishcKl bv K M 

Nndkarni. Bombay: K. M. Nadkarni. 1927. (Cr. 8vo; pp. xviii 1142 
+ Ixxxviiie IBs. net.) 

Itehniidinfj tlie Child: A Studr; in Malnutrition. By Frank I^ownr^^ 
Uichardson, M.D,, F.A.C.P. With an introduction bv W. R. .p Emf^rann ' 
^LD. London and New York : G. P, Putnam’s Sons/Ltd. IS^’ fCr firn 
pp. xxTl-b 319; 4a figures. 78.6d.net.) aro. 



002 may 26 ; 1928 ] 


NOTES ON BOOKS. 


t Tnr nniTi^jr 
Medical JounyAt 


faulty food habits, family . strain, school strain, and physical 
defects — which are discussed in separate - chapters. Tiie 
subheading of the chapter on faulty health habits js 
“ Americanitis." Among the directions given to parents id 
connexion with faulty food habits much stress is laid on the 
elimination from the diet of “ added sweets,” on stopping 
cream, and reducing the quantity- of butter to scanty propor- 
tions. The method of treatment advised is inculcated by the 
system of the nutrition class, which Dr. Eichardson had 
conducted for some years. 

Problems in Psychopathology,^ by Dr. T. W. Mitchell, is 
based upon a course of lectures delivered to an audience drawn 
from members of the British Institute of Philosophical Studies. 
Following a chapter on the earlier development of psycho- 
pathology, the remainder of the book is' devoted to an expo- 
sition and discussion- of the theories of Freud. The writer, 
who is evidently how an adherent of the psycho-analytical 
school, writes with the clarity which characterizes his other 
contributions to psychopathology — and it is assuredly not an 
■ easy task to make the more recent views of Freud in respect 
to the development of the ego and the nature of the instincts 
comprehensible to the uninitiated reader. In concluding his 
book Dr. Mitchell states that the fundamental conceptions of 
psycho-analysis are those of conflict and repression, the un- 
conscious, infantile sexuality, and transference; and he then 
proceeds to show how the post-analytical schools of Eivers, 
Jung, and Adler have arisen, and in what respects their tenets 
differ from those propounded by Freud. 

A fifth and enlarged edition of Dr. W. D. Bose’s book on 
Physical Diagnosis^ has now been published. This has been 
completely revised both as regards text and illustrations. 
Important changes appear in the section on the heart, where 
the clinical aspect of early heart failure^ has been especially' 
emphasized, and the section on endocarditis also has undergone 
a good deal of careful alteration. Eeceiit advances in the 
various methods of diagnosis have been incorporated in the text. 

The favourable reception accorded to the first edition of the 
work by Dr. Leeoux-Eobeet on high frCq^uency in oto-rhino- 
laryngology'" has justified the preparation of a new issue. This 
does not differ in essentials from the first edition, but the 
author has taken the opportunity of calling attention to 
improvements in the elaborate instrumentation necessary. The 
surgical aspect is well described ; this has established itself 
more firmly in England than the medical, which has perhaps 
been neglected unduly. The author again insists on the 
necessity of exact measurements in dosage. A work of tliis 
kind is necessary to those who employ high frequency in a 
scientific manner. To those who are content to work by rule 
of thumb it will not appeal so strongly. 

Lectures on the Biologic Aspects of Colloid and Physiologic 
Chemistry"- is a volume of half a dozen lectures given by 
different authors at the Mayo Foundation and the Universities 
of Minnesota, Iowa, Washington (St. Louis), and the Desmoines 
Academy of Medicine from 1925 to' 1926. Their general theme 
is indicated by the title. The lecturers have all made original 
contributions to knowledge in various departments of colloid 
chemistry or physics, and their remarks carry with them that 
freshness of tone and presentation which is almost inevitably 
lacking in a mere review of the work of others, however 
painstaking and thorough. Clearly, the appeal of the lectures 
to individual readers will depend to some extent on personal 
tastes and interests. Professor Chambers’s remarkably clear 
discussion of the properties of boundary membranes cannot 
fail to interest the cytologist; Professor Barton’s discussion of 
the ultramicroscope will appeal rather to the colloidal chemist 
and the bacteriologist. To the general reader, perhaps, the 
most instructive lectures are the first, by Professor Millikan, on 
" The principles underlying colloid cliemistry,” and Professor 
Bovie’s discussion on The biological effects of light.” ' 


chief object is to show that a large and attractive range of food 
can bo provided at the common table, and at no greater cost 
or trouble to the kitchen staff than tlio more monotonous 
stodginesses that arc too often found in schools and institn* 
tions. There are chapters that will be of help to the buyer,; 
and information is given about moat, side dishes, stock, pre- 
serves and pickles, bread, and pastry of various kind.s. There 
follow a calendar of seasonable food for each month of the 
j’car, hints on how to serve up the meat and fish, and finally 
the bills of fare of meals actually provided at the college for 
one whole year, day by day. An uncommonly attractive dietary 
is presented, good in balance, without hint of crankiness ; and 
if the serving of it proved to be as good as the thought 
expended on the arrangement, then the girls in that college 
must have been a well-fed and contented group. The book is 
a good e.xaraple of catering mixed with brains. 

The number of medical men whose hobby is fishing must be 
very large ; it is an excellent antidote to the cares of practice. 
The humorous novelist William Caine was a fisherman too, 
and his widow has collected into a' book,' Pish, Pishing and 
Pishermen," sundry articles of his which first appeared in the 
Picld, Punch, and other periodicals. Mr. Caine was a dry-fly 
fisher for trout— ho preferred to c.all tViem trouts — and ho 
regarded other forms of fishing as fit only for the baser sort of 
men. Even "daping” with the dry fly inspired him to an 
essay. As a fisherman he was justly indignant at the pollution 
of streams by the, manufacturer, and the fish-kiUing projien- 
sifies of the beet-sugar enthusiast would have aroused ’his 
wrath. In an article on bad form in fishing there is a comio 
diatribe against the man in the smoking-room who ventures to 
doubt the impressive statements of .” fact ” made by fishermen. 
Such a man is described as being at heart a “ gudgeon-killer, ”- 
who exchanges glances of the basest significance with his 
companion, ”, a doctor who dubs for eels by night with a ball 
of -worms and worsted.” 

" Fish^'Fishing and Fishermen. By Willlnm Cnine. London ; P. Allan 
and Cd., Xtd. 1927. (Demy 8 vo', pp. xii -l- 253; 1 portrait. 10s. 5d. act.) 


PREPAEATIONS AND APPLIANCES. 

A Mouth Gao., 

Me. Noeman M. Eadie, Eoyal Hospital for Sick Children, 
Ediiiburgii, has designed a gag for tonsillectomy and other opera- 
tions iu tho mouth whicli lias given great satisfaction. It 
embodies the following advantages. 

The teeth plates, with soft metal bearing surfaces, exert pressure 
on the molar teeth, which arc not liable to injury, as is tho 

case with the iucisors. 
The pressure being 
applied equally to both 
sides by means of 
easily adjustable tooth 
plates, the iuslrumeufc 
is rigid and cauiiot rock 
from side to side; for. 
edentulous patients 
this is a great advan- 
tage. Tho pressure 
being applied equally 
to both sides allows 
the tongue plate to 
remain accurately' 
placed upon tho 
tongue, which does not 
bulge out from beneath 
it The outer surfaces of the tooth plates act as effective cheek 
retractors. With tho moulded tongue plate sufficient depression- 
of tho tongue is obtained without undue tension upon the faucial 

r *''A?*anaestlietio tube is pro-vided; awhile the three sizes of tongue 
■ depressor give it an almost universal range. 

The gag is made by- Messrs. J. Gardner and Son, Edinburgh. 



The former occupant of the office of bursar and lecturer at 
King’s College for Women, Household and Social Branch, Miss 
F. E. Findlay Shlreas, has written an excellent little book. 
Aids to Catering," with special reference to institutions. Her 


• rrohlem) in Fsychopatholoffy. ,T. W. Mitchell, M.D. The Inter- 
n.vtioiial Library of Psychology, Philosophy, .and Soientiao Method. 
London; Kegan Paul, Trench, Trubner and Co., Ltd. 1927. (Demy 8%-o, 

Fh^sicai Diaiinusis, By TV. D. Bose, M.D. Filth edhion, revised and 
enlarged. London: H. luniptoll. 19^8. (6x93, pp. 819; 310 figures. 
J p5a?cs. 425. net.) ^ - » . 

Lti Haute Frequence en 
Robert. Deuxicnie tilition, re 
rraliiiuc?. Paris: Masbon et , 

(icuititf. 25 fr. sans inajoration.) • v • y,,. 

I.cclu}c 3 on the Biologic Aspects of CoUota and Pni/sioloaio Cnemtstry, 
I’bil.-xdeipUla nud London: \Y. B. Saundera Company. 1928. (Post 8vo, 
pp. 2J4; C5 figures. 1^. net.) 

fo Caterin'?. By F. E- Findlay Shirxas. Introduction by WalUr 
Ripnian. M.A. London: J. iL Bent and Sons, Ltd. 1927. (Cr. 8vo/pp, ix 
+ 1 : 5 , 5». net.) » V 


310 figures, 

■ Br. Leroux- 
ct Chirurpie 
sv + 216 ; 1J3 


AiT Aseptic Clinical Thermometer. 

\Vc liave received from Messrs. Coates and Cooper (41, Great 
Tower Street, London, E.C.3) a specimen of I'leir Simplex ” 
aseptic clinical thermometer, manufactured in this country. The 
thermometer has a small screw-top hojder whidh fits into a metal 
case. Into the lower end of the case is inserted. a moulded glass 
container, .which will hold enough antiseptic solution (such as 
2 per cent, carbolic) to bathe the lower end of the thermometer. 
There are slits in the outer case through which the presence of 
enough fluid in the container can be ascertained, and this is made 
easy if the solution is coloured. The whole appliance is no larger 
than a cigar, and has a clip for the waistcoat pocket. Tho 
thermometer can be unscrewed in a moment and withdrawn without 
removing tlie case from the pocket, and the antiseptic fluid can 
bo replenished^ almost as readily. Leakage is prevented when tho 
thermometer is in use by means of a rubber valve. A broken 
thormomeler can be replaced by heating the composition in the 
screw-top holder. Tho price to the medical and nursing professions 
IS Bs. 6 d. complete. 


MAV 2 f>, 1938 ] 


THE KEW PSYCHIATRY. 


,r Trrr . nn;j 

L ilEDlCiX JoCRJfAl. W U 


THE NEW PSYGIIIATIIT. 

JlAx;DSi.rY Lr.cicm; Sin .Toxin MAcriinnsoN. 

Tire JIaudsloy Lcctiiro, under ilio auspices of tlio Royal 
Mcdico-Psychologicnl Associalion, ivns delivered at tho 
British jMedical Association House, Tavistock Square, on 
OSIay 16th, by Sir John Jlacphorson, formerly Commissioner 
in Imnacy for Scotland and Professor of Psychiatry in the 
University of Sydney. . . , 

Sir John Maepherson defined psychiatry in its literal 
senso as tho medical treatment of mental disorders, which 
necessarily implied scientific investigation of their nature 
and causes. The commencement .of the twentieth century 
was marked hy tho advent of psychopathology, though its 
signific.anco did not at first attract much attention. For 
many years previously the medical world- had been interested 
in Charcot’s studies of hysteria, hut it was reserved for one 
of his pupils, Janet, to demonstrate that hysteria was a 
ment.al disorder and that its varied phenomena could ho 
interpreted in psychological terms. Janet’s contribution 
to psychiatry w.as tho concept of dissociation. In some 
respects his definition of hysterical dissociation was not 
'entirely satisfactory, because it implied a splitting up of 
consciousness and personality. It was highly improbable 
that there could ho such a splitting up, for tho cortical 
mechanism integrated ns a single system. The vital pro- 
cess called consciousness was one thing; tho outward 
expression of that process, which was called behaviour, 
was quite another. Behaviour might give the appearance 
of split consciousness because of changes in tho integration 
of cortical processes; in tho same way double personality 
depended upon different integrations within tho cortical 
mechanism at dilToront times. 

Dissociation was a comparatively new term, though fifty 
years ago a similar condition was described hy Hughlings 
Jackson, who taught tluat all morbid nervous phenomena 
were due to two factors — a negative factor consisting of loss 
of function at a higher level, and a positive factor con- 
sisting of over-function at a lower. Tho c.auscs of dis- 
Eoeiation resolved themselves into two co-operating groups, 
termed hy the lecturer tho causa causans group, including 
tho whole familiar scries of psychical and physical agencies, 
and the cniisn sine qua non group, which in tho present 
state of knowledge could only ho referred to generally ns 
tho inherent instability of tho cerebral mechanism. 

Freud and Orthodox Psychiatmj. 

It was in connexion with tho cause of dissociation that 
Freud joined issue, maintaining that functional dissociation 
was caused by conflict of opposing psychological forces, and 
that tho resulting symptoms wore duo to attempts on tho 
part of tho organism to adapt itself to altered conditions. 
Superficially such a statement appeared incompatible with 
contemporary views, but Freud proceeded to erect upon it 
a ^stem of psychology which in a remark.ahly short time 
had captured, if not the assent, at any rate the attention, 
of the civilised world. 

The Freudian theory and method were more finnly estab- 
lished than some people appeared to believe, for they wore 
unassailablo by direct argumenfor dialectic attack. To 
say that tho Freudian hypotliesis was embarrassing to 
psychiatiy was no more than the truth; to say that it was 
supplanting the . other was ' to exaggerate. Tho present 
position might bo more correctly' described as an imperium 
in tmpeno. Tlie field of psychiatry was infinitely wider 
than that covered -by Freudian doctrines, and its ralations 
with the. medical and cognate sciences were too close to 
allow tho possibility of the new psychology superseding it. 

Tile Foundations of Objective PsychoJogu. 

- After some discussion of the vital functions of tho cortex 
the lecturer wont on to consider, the foundations of objeo- 
ivo psychology. From Pavlov’s recent researches it was 
. inhibition (physiologicallv a state’ of 

rest) had a tendency to irradiate from its point of initia- 
tion and by a process of induction to cause excitation ‘in 
excitation arrested the spread of 
of tho cortex might bo visualised as a mosaic 

activ ^^^^tory areas within which the dynamic 

lu endlcs^”^ irradiation and induction acted and reacted 
lu endless variety.- Certain changes in cortical equili- 


brium resulted in sleep,' in a kind of hypnosis, or in actual 
mental perturbation; That tho depressed and exalted 
phases of tho manic-depressive syndrome depended upon 
states of cortical inhibition and excitation had long been 
believed, hut a more definite knowledge of tlio mechanism 
of these conditions was duo to tho rcsoarclies of Pavlov. 
Once the cortical equilibrium was profoundly upset the 
effect did not pass away immediately, but might last for 
weeks and months, as was known from cxporicnco, and also 
again from tlio work of Pavlov on dogs. 

Tboro was no singlo symptom in tho whole range of 
mental disorders which was not represented in the mental 
processes of normal people. Wo were dissociated from our 
surroundings when wo were engaged in any absorbing 
occupation, when wo forgot, and when we fell asleep. 

When wo dream, wo lire insane.” As wo wore neither 
omniscient nor able to see' into tho future wo were 
credulous, superstitious, and suspicious, and wd developed 
many harmless delusions, tho mechanism of which was the . 
samo ns that of tho delusions of tho insane. We were only 
saved from insanity because our more or less’ efficient 
cortical mechanisms were able to , correct our mental 
reflections and to inhibit bur tendencies to abnormal 
hehaviour. . ' ' 

The Question of Certification. 

It was abnormal hehaviour, the outward expression of 
cortical dissociation, that determined tho necessity or other- 
wise of certification. Tho person who certified ought to be 
able to do so, not on tho ground of abnormal behaviour 
alone, but also on tho nature and eaiise of the cortical 
dissociation. Therefore medical education and experience 
were required for certification; the statutory appointment 
of a layman to revise tho opinion of tlio medical certifier 
could ho regarded only as a device to allay public suspicion. 
If proof was needed ns to tho prevalence of public suspicion 
it could ho found in the provisions of the Lunacy Act, 1890, 
which showed loss concern for tho welfare of the insane 
than for tho protection of the sane. 

In any liuman system of the dimensions of lunacy 
administration it would be foolish to assert that mistakes 
and abuses could not occur; but tho lecturer thought thev 
must ho extremely few in number. In his own experience 
he had never come across a single instance of abuse of 
certification or detention, hut ho had had cause to deplore 
the hardship imposed upon patients and their relatives by 
tho reluctance of the medical man to certify. The same 
prejudices which influenced tho framers of the Act-of 1890 
could bo discerned in recent cases in the courts, not so 
much in the motives actuating the litigants ns in the 
atmosphere of vindictiveness involving the proceedings. 
He had happened to be in a distant part of the Empree 
when newspaper reports of these cases were forthcoming; 
there they were received with amused surprise — amusement 
that courts of justice should deliberate for weeks over 
issues which appeared to present no great problems to the 
man in the street, and surprise that the Mother of Parlia- 
ments should not liave devised less clamorous methods for 
the adjustment of disputes, involving such pathetic and 
morbid details. He praised, by contrast, the simple and 
elastic administration of lunacy law in New South Wales, 
where it had recently been arranged that every large 
general liospital should make provision for the treatment of 
patients suffering from mental and nervous disorders. This 
was accomplished without legislative enactment. 

Tho aims of the scientific spirit behind psychiatry, con- 
cluded Sir John Maepherson, could best he achieved by the 
admission of all cases of mental disorder to public hospitals 
without certification or judicial intervention. The great 
majority of patients and their relatives would welcome such 
an- opportunity. There was sufficient legal macliiiioi-y to 
deal with tho small recalcitrant minority who would refuse 
to enter a hospital or remain in it. In addition to the 
existing mental hospitals advantage should ho. taken of 
every opportunity of utilizing the many scientific facilities 
of general hospitals hy providing accommodation for the 
treatment of mental disorders in their vicinitv. Such a 
provision, on an enlarged scale, was specially desirable iii 
every centre of medical education. If ment.al p.ntieiits had 
the opportunity of such informal access to treatment as 
was accorded to patients suffering from other disease's 



CHRONIC ARTHRITIS. 


r iKthRmt* 

L Mkdical Jocnxii. 






904 


may 26, 1928] 


mental disorders would be robbed of some of the terror and 
opprobrium attaching to them; psj-chiatry also would bo 
brought into closer relations with general medicine, whereby 
its scientific spirit would be widened and its therapeutic 
cfllciency improved. 


CHRONIC ARTHRITIS. 

The publication of Dr. J. A. Glover’s report’ on chronic 
arthritis, with special reference to the provision of treat- 
ment, was mentioned in the Journal of May 12th| bnt in 
view of the recent conference on T’houmatic diseases” at 
Bath, in which Dr. Glover took part, we now give a more 
detailed summary of this official document issued bj- the 
Ministry of Health. 

This report, which is the third to deal with aspects of 
the problem of rlieumatism, has been written in fulfilment 
of a promise given by the IMinister of Health to a deputa- 
ton from various approved societies, and the Chief Medical 
Officer, Sir George Newman, in a prefatory note, stresses 
the need for the organization of an adequate treatment in 
efficient centres if the vei'y heavy claims on the funds of 
these societies are to be effectively reduced. Dr. Glover 
begins his report with a short section on the history of 
chronic arthritis, and then enters upon tho diffienltics of 
i lassification. Tho scheme used here is tho same as in tho 
jirevious report on tho incidence of rheumatic diseases, and 
comprises rheumatoid arthritis (ineluding infective jioly- 
aithritis), ostoo-arthritis, gout, and a fourth group' of 
“ chronic joint changes nnclassifiablc.” This scheme is 
amplified and discussed, and a table sots out tho main 
points in diffeiential diagnosis. The present report is 
mainly concerned w-itli treatment, but a summary of some 
previous work on incidence is included, dealing liarticnlavly 
with insurance statistics, hotli British and foreign. 


Ktiology. 

fn tho second section the moi’o important iirohlcms in 
the etiology of chronic arthritis are discussed. Dr. Glover 
does not dogmatize on the question of heredity and 
diathesis, but. quotes authorities supporting the various 
views. The prevalent idea is summed up in the statement 
that “the study of tho family history of parents f ? patients] 
will incline most people to the opinion that probably some 
liei editary influence does play a part in the production of 
clironic arthritis.” Tho rather curious .sex incidence ol 
tho various forms of the disease is next discussed, followed 
by some comments' on the age of onset. There appear to 
be certain factoi*s which play a pait as predisposing canaec 
in the production of chronic arthritis, and of these occiiiia- 
tioii, chill, dampness of houses or of localities, water supply, 
antecedent diseases, pregnancy, menopause, and mental 
stress are mentioned. Tho theory of focal sepsis is well 
asoiicd. Hero Dr. Glover obsevves; “We must regard 
c ironic arthritis as an end-result, which may be caused by 

v' * ’f •■''’I'oii of many different bacteria " 

After discussing the views of Timbrell Fisher, Hare, and 
oilier workers lie coiiclndos that “the role of focal sepsis 
111 the production of joint disease is not clearly known ’’ 
but “ the value of [the] theory of focal sepsis mu.st, lioiV- 
cver, bo mterpretod chiefly m the light of clinical results ” 
Disorders of motabolism are also held by authorities to 
play a part iii a group of eases m which some inborn error 
or some acquired fault of metabolism is the priniarv cause 
The results of various biochemical iiivcstigatioi'is this 
field are summarized under the headings of basal meta 
holism, uriiiaiw analysis, and blood analysis, while the 
occurrence of achlorhydria and endocrine "disturbances 's 
ulso mentioned. • 

Treatment. 

Coming to the main part of tins report, Dr.. Glover 
cinpliasizes from the start tbo iiiiportaiico of earlv d'ian-iiosis 
“ When a patient pi-cscnls himself or herself with any syninfo 
or sign suggestive of chronic arthritis tlie practitioner has l,” 
clc.tr and iirgcnl duties, the first to attempt to differentiate (he 
variety of arthritis pivseiit and tile stage to which the disease has 
progressed, and I'le second, even more important, hinisctf (o begin 
tiiat deiermiDe.l search for an infective "focus, in whicli later he 
may pio b.ebU- h ave to invoke specialist aid,’* 

Jferficol Joumalf May igih, *pp. 852-59. 


Tho next stops consist of a specialized search for focal 
soji.sis and tho measures to he undertaken for removal. 
In an analysis of Some 545 cases' it' was found tliat d.emoii- 
strnhlo ' foci wet e present in' 70 jier cent. In this largo 
group dental seji.sis was the iiredominating form, and tho 
whole question of tlie teeth in ehroiiie arthritic conditions 
is next dealt with in a tliorinigh iiianiier. The need for 
expert dentists and good dental radiograms is stressed ami 
the dangers of wholesale e.xtraction are not overlooked. On 
tin's point Dr. Glover wisely remarks: 

“ . . , whilst it lias been necessary to sound a note of caution 
about -v/holcsalo or numerous cvlractions, it must be rcrncinhered 
that dchlisls are on the whole conservative, and tlint one toolh 
with hidden .root sepsis left in the jaw may < be quite sufiicient 
to keep up a chronic artliritis.” 

Tonsillar .sepsis, nasal sinusitis, and intestinal infections 
are next dealt with, and also nrinaiy infection, especially 
in regard to tho analogy of gonococcal arthritis. Tho 
septic focus having heon dealt with, tho question of vaccine 
therapy next receives attention under the hcading.s of 
autogenous vaccines, stock vaccines, and non-iqiccific pro- 
tein therapy. The last, especially when carried out with 
T.A.B. vaccine, is urged by authorities for tlie early case, 
and certainly tho results liero set out a[)pcar to w'arrant 
its mine frequent use. Dietetic measures, in .some iii.staiices 
“ fce<iing-iip ” and in othei-s cutting down tho diet, aro 
described, and- tho theory of vitamin deficiencies is men- 
tioned. Drug treatment is summed up in half a page, 
and tlio absence of any comment on tliis is itself of 
significance. Ae.xt comes a long section on pliysio- 
therapevitio measures in chronic arthritis, whereby heat 
and “ other ■ insults ” may ho applied to the skin and 
joints. The principles of hydrotherapy and bnincotliorapy 
ave set out, and details of tho chief ‘methods employed aro 
given withv illustrations. Tho internal admiiii.stration of 
mineral waters is veiy fairly dealt with, and despite tho 
unproved doctrine of the specific action of mineral waters 
in the treatment of clironic arthritis, it is- concluded “ that 
spa treatment may and should play a very important part 
in tho treatment of chronic arthritis.”, Surgical measures 
required in chronic arthritis are aI,so discussed, and tho 
difficulties of assessing the results of tho treatment of 
clironic arthritis by any means are exjilained. 

The Provision of Treatmcni. 

It becomes obvious as the metliods. of treatment aro set 
out that the provision of a team of workers is necessary 
from the outset, and that apiiropriate treatment, -even if it 
can ho obtained, is a matter of very considerable expense. 
The existing provision of treatment in tho general hospitals, 
in the Poor Law infirmaries, and in the spa hospitals is 
discussed, and the urgent need for further facilities is 
manifest. Tho work already done by the general practi- 
tioner in' the past receives appreciative notice, and for tho 
future Dr. Glover writes : 

“ . . . Ibo general praclitionev will otlcn have tho opportunity of 
seeing such cases in the early stages when discovery and removal 
of the infecting focus and other appropriate treatment affords a 
greater chance than at tho later stages of effecting a speedy and 
permanent cure. If the general practitioner is not content merely 
to relieve immediate symptomsj if he recognizes the necessity of 
searching for the cause, and if he exercises the tact, patience, and 
energy necessary to persuade the patient to submit to tho 
necessary treatment, whether given by the practitioner himself or 
by others, invaluable time may be saved." 

The need for physical treatment centres, as outlined in 
the annual ' report for 1925 of the Chief Medical Officer of 
tho Hfinistry of Henlih, is insisted upon, and tho possible 
provision of. “ arthritis units ” to Kilfii tbo purpose of 
research - and observation as well as treatment is -men- 
tioned. Increased use -of the existing spa hospitals for 
early eases is also urged. The .out-patient clinics to he 
established, if funds permit, by the British Bed Cross 
Society and the British Committee on Riioumatism are 
looked" upon as the beginning of the provision of .such 
clinics tbrougbout the country., and the need for ednealing 
tho public in preventive measures, especially with regard 
to dental sepsis, is emphasized. 

In an appendix Dr. Fortesone Fox and Miss btai-gaiethe 
Mautner describe the treatment of - iheiiniatic diseases by 
physical methods in Germany. ’’ 


r Trrr.nntTnit 00^1 ’ 

L MtDtcAi. 


Mat sO, 1918] 


EATIIiY diagnosis of cancer of tee rectum. 


iHctitcal Sfotintal. 

SATURDAY, SI/VY 2GTH, 1928. 


THE EARLY DIAGNOSIS OF CANCER OF 
THE EECTUAI. 

TnK medical man wliosc pafionts can persnado him 
to give tliem ofTliand “ sonndhing lor piles ” sounds 
the dcatli knell of many .an early case of cancer of the 
rectum; for it seems cerlain that, of all the types 
of cancer with which, the surgeon has to deal, those 
occurring in the rectum and colon which arc dealt 
with by excision at an early- stage give better ultimate 
results tban those arising in almost any other part 
of the body. The importance, therefore, of early 
diagnosis cannot be over-estimated or loo often 
reiterated. Tlio Subsection of Proctology of the 
Royal Society of Medicine recently held an interesting 
discussion on this subject (of which !i report appeared 
in our last issue at page 846)', and if Ibere was one 
point .above all others made most abundantlv clear 


it was the imperative need for a routine digital exam- 
ination in every case presenting rectal svmptoms, no 
matter how trivial or unimportant they may appear 
to be. Everyone loiows that this precaution is fre- 
quently neglected — the. patient may resent it, the time 
or the surroundings may be inappropriate, the doctor 
may be hurried and overworked — and otdv too often 
the golden opportunity of recognizing a reall\ early 
and curable case of cancer has slipped awnv. It is 
but too true that in far too many instances the patient 
dees not consult a doctor at all until the growth has 
extended beyond all prospect of any curative treatment 
in our present state of knowledge, although it is 
satisfactory to learn that there is some evidence 
indicating not onlj* that patients arc coming to their 
doctors at an earlier stage of the disease, but that 
the medical profession as a whole is more alive to the 
necessity for earlier diagnosis and the value of earlv 
treatment. 

Whereas the great majoritv of malignant growths 
of the rectum and redo-sigmoid arc within reach of 
digital examination, and may therefore he classed as 
accessible or e.xtdrnal cancers in the same sense as 
giowtlis of the cervix uteri or buccal cavitv, yet there 
IS a proportion just beyond the reach of ordinarv 
examination, and the detection of the growth calls for 
a httle more care and skill; ; It is in just the e cases 
that the proctoscope has proved of such great value; 
well named an elongated finger with a human eye,” 
,it 13 BO simple m use, so easy and cheap to maintain, 
and so convincing in its demonstration of those 
dangerous three or four inches of the lower bowel just 
beyond reach of the finger, that it is matter for 
surprise that it has not yet fully taken its place in the 
paclitioner s armamentarium beside the otoscope, the 
laryngoscope, and the ophthalmoscope. It is certainly 
as e.asy to use as any of them, and there is further the 
om or ing leflectiou that the differential diagnosis of 
redo-sigmoid is simple, for all the 
p IS led figures indicate that if any chronic ulcer.a- 
tion IS detected this is very much more likely to be 
cancer than anything else. 

develops in a portion of the bowel 
• or the simple procro- 

nrec ’ / ^ demonstration and- its differential diagnosis 
present a more complicated-, problem, for the long 


BigmoidoBCope will ho ncce-s.sary, and its introduction 
may require an iiniiesthdic. Alorcover, even when 
the growth has been thereby visualized it may still 
bc*ncccsstiry to cstahlisli ils exact nature by micro- 
scopic examination, and its precise extent by moans 
of the barium enema and a- rays. The microscopy of 
small portions of growth, obtained by passing special 
punch forceps np Iho sigmoidoscope, has now been 
reduced to so fine an art tlial the pathologist skilled iri 
this work can not only give a very confident opinion 
ns fo the innocence or malignancy of the piece of tissue 
removed, hut can also in cancer cases form a full idea 
ns to the rohilivc degree of the maliguaney to ho 
e.xpcotcd. Dr. Dukes showed many .speciiiiens to the 
meeting Avhich well demonstrated the help ho had boon 
able to afford to his surgical colleagues at St. Mark’s. 

But. what of those regions of the bowel in which 
digital or ocular demonstration of the presence of a 
lesion is impossible? What of those extensive areas of 
the colon beyond the reach of the longest sigmoido- 
scope — the caecum, ascending and transverse colons, 
llic splenic fiexure, and the descending colon? Here 
one must to a large extent depend upon the careful 
weighing up of evidence less direct in character, and 
in doing so must not ncglcot-the histoiw to be obtained 
from the patient. As Sir William Wheeler emphasized 
in the paper with which ho opened the discussion, the . 
information to he obtained by careful cross-examination, 
of the patient may be invaluable, and the evidence 
upon wliich he laid most stress was the history of 
a gradual change from normal bowel action to some- 
thing abnormal. Persistence of such a symptom in 
spite of treatment should arouse suspicion, and 
point to the need for further detailed investigation. 
Examination of the abdomen may give no help, for 
it is only in the later stages, when obstruction is 
established, that visible peristalsis, “ ladder pattern ” 
of the intestine, or a palpable tumour becomes 
manifest. Naked-eye examination of the faeces may' 
also bo quite negative, for it is only in extensive 
growths or those low down in the bowel that obvious 
blood or mucus is to bo expected. Chemical exam- 
ination of the faeces is, however, a different matter, for 
most authorities concur in the belief that occult blood, 
especially if found repeatedly, is very strong evidence 
indeed of at any rate some kind of ulcerative lesion 
of the gastric intestinal tract; on the other hand, its 
absence proves nothing. 

What is the next step? The doctor is faced with 
a patient whose symptoms present nothing more 
strildng than the recent onset of some slight trouble 
with the bowels of rather indeterminate character; 
occult blood has been detected in the stools, and 
physical examination is negative. Is ho to wait and 
watch events, or is some further action necessary? 
Indubitably' the latter; and equally' without doubt it 
should consist in cai'cful ar-ray investigation by means 
of the barium enema, and not the barium meal. It 
seems necessary to be most emphatic about this, for 
the value of the opaque enema as compared with the 
opaque , meal is not yet sufficiently appreciated by 
-many' of those who send patients to the radiologist. 
A barium meal administered to a patient with vague 
'abdominal symptoms, and a report that “ nothing 
abnormal is to be seen,” may induce a wholly un- 
warranted feeling of security, for, as every radiologist 
knows, the passage of a meal may be hardly if at 
all delayed by a growth in the large bowel, which is • 
revealed at once in a barium enema by its typical 
irregular filling defect, found constantly in all jilates 
and at successive examinations. There are,' of course 
■fallacies, both positive and negative: the positive 



906 May 26, 1928] 


THE HARVEY TERCENTENARY. 


t TnsSRTTm 
Medical 


induced by faecal matter, spasm, or extrinsic tumours 
which mimic the appearance of carcinoma and must be 
guarded against by careful preparation of the patient 
and repetition of the photographs. I’hc negative 
fallacies are largely dependent upon imperfect tech- 
nique, insuflicieney of the enema, or lack of apprecia- 
tion of the fact that the ordinary photograph shows 
only one plane of structures like the colon and sigmoid, 
which have' no fixed anatomy. It is obvious that 
a filling defect in a portion of bowel whose axis is 
parallel to the path of the x rays might show nothing 
abnormal on the- plate. Dr. Graham Hodgson 
described how he had successfully overcome this 
particular difficulty by an ingenious method of taking 
oblique views. 

The trend of the discussion on May 9th made it quite 
clear that the more general use of the proctoscope and 
the sigmoidoscope, together with the development of 
the barium enema, have put the diagnosis of eaneev 
of the rectum and colon on a much more scientific 
basis. The combined work of the surgeon, radiologist, 
and pathologist has effected much, and will reach 
its fruition when the general public can be persuaded 
that not all rectal symptoms indicate “ only piles.” 


THE HARVEY TERCENTENARY. 

The celebrations of Harvey’s publication three hundred 
years ago of the immortal Excrcitatio Anatowica tic 
Main Cordis c.t Sanguinis in Aniinalibus have well 
illustrated the delectable doctrine that science knows 
no national or geographical boundaries. In March 
last the College of Physicians of Philadelphia, which 
rejoices in a wealth of Harveian treasures, paid its 
tribute, and was followed by Baltimore and Boston. 
Last week the Royal College of Physicians of London, 
as our columns have shown, organized a wonderfully 
successful celebration attended by delegates from 
twcnt}'-one countries; and during the present week 
the Acaddmie de Mddecine of Paris, with that talent 
for graceful acknowledgement of pioneers in science 
wliieh has in recent years been so much in evidence 
in generous recognition of British leaders such as 
Sydenham and Lister, has joined with her allies in 
commemorating the three hundredth birthday of 
Harvey’s great achievement, which corresponds with 
the three hundred and fiftieth anniversary of his own 
birth. It may be recalled that the tercentenary of 
Harvey s birth was marked by a memorial fund t-o 
erect a statue at Folkestone, where he was born, and 
b\ a dinner in the College of Physiciiuis’ Library, 
when T. H. Huxley delivered a eulogy on Harvey’s 
service to science and medicine. 

The organization of this month’s British commemo- 
ration was very appropriately in the bands of the 
Royal College of Physicians of London, whose chief 
glory is \Villiam Harvey, and it is specially fortunate 
that the Presiilent, Sir John Rose Bradford, whose 
early physiological work won him the Fellowship of 
the Royal Society, was able to correlate the activities 
of the College with tho.se of the physiolodsts. 
Harvey’s publication of his discovery of the circula- 
tion was even more important as inaugurating the 
jnodern method of experimental research, and the 
willing recognition by physiologists of this epoch- 
making event was a foregone conclusion. That the 
Fellows of the College are still obedient to the exhorta- 
tion “ to search and study out the seci'ets of Nature 
by wav of experiment ” was graphically shown by the 
convincing cinematograph films of Han-ey’s original 
pbysiological experiments as repeated by Sir Thomas 
Lewis and Dr. H. 11. Dale, and exhibited to enthu- 


siastic audiences at IJuiversily College on May 15th 
and 16th. 'Those demonstrations of the work which 
constituted “ the new birth of .physiology ” were 
supplemented by other demonstrations bearing upon 
some more modern worlc on the circulation, both at 
Univer.sity College, London, and at the meeting of the 
Physiological Society at Cambridge on May 19th with 
which a memorable week so fittingly concluded. It 
was a - happy thought to include in the proceedings 
a luncheon party for the delegates at St. Bartho- 
lomew’s Hospital (where Sir Wilmot Herringham gave 
a strikingly eloquent and comprehensive address on 
Harvey as a hospital physician), and visits to the 
two ancient English universities wliich also claimed 
Harvey at different periods of his active life. The 
•success of the Harvey celebrations and the smooth- 
ness, with which everything went were the result of 
much thought and attention to detail. The fact that 
this was a labour of love must not allow our debt to 
the Royal College of Physicians of London, its Presi- 
dent, and Officers — and especially the Registrar, Dr, 
Raymond Crawfurd, fit representative of. the seholar- 
physieians — to pass quietly into oblivion without an 
expression of gratitude. 

The historical aspect of the three hundredth anniver- 
sary of Harvey’s book has been admirably brought to 
the front by the publication of a facsimile of its Jirst 
edition, presented to each of , the delegates b}' the 
College of Physicians, and by the appearance of. two 
further works — one old, a reproduction of the first 
English translation in T653 of the De Motu Cordis 
(Nonesuch Press), and one new, A Bibliography of 
the Writings of William Harvey, M.D. (Cambridge 
University Press) — both duo to the scholarly energy of 
a member of our profession, Mr. Geoffrey Keynes, 
the bibliographical authority on Sir Thomas Browne, 
Blake, and Donne. 


RESEARCH BY .OBSERVATION. 

“ AVhen wo are reduced to observation, sclonce crawls,” 
said Lord Atoulton twenty years ago. ” AVlien and in pro- 
portion as you can use experiment, the science advances 
rapidly. . . In tlie early pages of this issue wo iniblisli 
ail account of an inquiry by Air. John Alorley into 
abdominal pain as exemplified in acute' apjiendicitis. 
Though the physiologists have taught us very much, yet 
for lack of adequate opiiortunity for experiment pain 
still escapes complete elucidation. Here, then, should be 
a leo^itimate field for research by observation, and wo have 
to-day a restatement of a particular case whidi was set 
forth by' Sir Henry' Head in our columns some years ago.* 
“ In the early stages,’.’ ho said, “ before perforation has 
taken place, widespread pains may be present in the 
abdomen, corresponding to the afferent supply of the upper 
parts of the digestive tract. Such pains are due to 
abnormal movements of the stomach and intestine, and 
express the reaction of normal parts to a lesion situated 
iu some allied physiological system. But when the appendix 
becomes perforated and inflammation of the peritoneum 
ensues, these referred pains are replaced hy local mani- 
festations, aoconipanied hy deep tenderness over inflamed 
parts.” Air. Alorley would confine the source of the initial 
yiaiii to tension in Hie muscular wall of the appendix itself, 
and' in his arguments in favour of local peritonitis as tlie 
exclusive source of the later rigidity' and local pain he 
omits one provided by Head, who noted that the absence 
of tenderness in tlie loin, both to superficial stimulation 
and to deep pressure, is proof that its origin is not seg- 
mental reference from the viscus. The second part of the 
thesis is au attempt, so far as the evidence from appen- 
I British Medical Journal, 1922, vol. i, p. 1. ^ ’ 


VuW' aG, igaS] 


INTBRNATIONAti CONTUOri OF DRUGS OF ADDICTION. 


f Tiiz nnmfla 0A7 

WEMCAI. JotTBKlt wUI 


tlicilis ROM, to disproTO U>o cxistouco ot nny visccro- 
Scnson- or viscero-niotor roflexcs. Localir.cd tcudcnioss and 
rigidity and localized pain',; siheo in appendicitis nnotlior 
explanation is forthcoming, aro not in iiis vimv'tlio expres- 
sion of such viBcoral rcilexes. Jlackcnzio, ho says. " did 
not appear to appreciate tho exquisite sonsitiveness of tho 
parietal peritoneum to even slight dcgices of inilamnia- 
tioii,” and accordingly failed to perceivo tho part played 
by a pcritonco-muscnlar reilex in protective jnnscular 
rigidity. But on turning up Symptoms and their Inter- 
pretation wo find, a few pages later than the paragraph ho 
quotes, this statement; “ . . . appendicitis may give rise to 
symptoms which are entirely eonfinod to tho reilex group, 
until tho inflammation extends to tho abdominal wall, 
when another series of symptoms may arise which are 
produced by a dilferent mechanism.” Doth ITead and 
jMackenzio were alive, it seems, to tho observations upon 
which Mr. Morloy relics, btit they wero less prono to 
gencr.alizo, and readier to admit exceptions to tho general 
•rules established by clinical obscn-alions. Most surgeons, 
wo think, will agree upon tho great frequency of corre- 
spondence between their own similar observations and 
operative findings, but few perhaps will not h.avo met 
disconcerting exceptions, even in appendicitis. Granting, 
however, that in general terms all illr. Morloy says is true, 
there are other observations to be considered. Is musenlar 
rigidity, familiar as a clinical sign of gastric and duodenal 
ulceration, dependent on stimulation of tho peritoneum? 
Surely not. Is there no muscular rigidity associated with 
tonic spasm of tho ureteral muscle, though the peritoneum 
in contact with tho ureter is not inflamed, and indeed 
belongs to what Cope calls tho ‘‘ non-demonstrativo ” area? 
What of tho riscoro-sensory reflexes associated with cardiac 
disease, with bladder and prostatio lesions? What of tho 
tondei-ncss in tho scalp related with visceral stimuli in tho 
whole Vagus field? If wo call in aid, to support Mr. 
blorley, tho deep tenderness over an area of pleuritic 
■ inflammation, there is still tho difficulty that with tho out- 
pouring of fluid this deep tenderness disappears, and dis- 
appears, it may be, only up -to tho level of that fluid. 
A point of weight is scored by Mr. blorloy in his insistcnco 
on the fact that muscular rigidity and hyperalgesia aro 
purely right-sided, whereas, if visceral in origin, they 
should bo bilateral, seeing that tho intestine is dovelop- 
mentally median. It is curious, however, that laterality is, 
sometimes at least, recognizable in tho caso of ulcers of tho 
stomach and duodenum; that we aro able to differentiate 
colic in the ascending from that in tho descending colon ; 
tliat tho areas of hyperalgesia of cardiac disorder show 
clear evidence of segmental distribution, with developmental 
scquenco, and yet are often unilateral. It is a case, then, 

• but not a conclusive case, that Mr. Morlej’ presents against 
these reflexes. There will bo a great measure of agreement 
with one deduction from these obseiwations — namely, that 
hyperalgesia is not a trustworthy diagnostic sign ; and 
there will be a considerable measure of sympathy with his 
expressed desire to simplify ’diagnosis for tho student by 
the elimination bf any reflexes that darken counsel. 


THE INTERNATIONAL CONTROL OF DRUGS OF 

addiction. 

Ro gieat satisfaction can bq derived from the discussions 
which took place during tbo sessions of tiie League of 
Nations Advisory Committee on the Trafllo in Dangerons 
I^ugs, held last month at Geneva. Tho Convention of 
1 25 remains unratilied by a sufficient number of the 
requisite Powers to bring it. into operation. The Control 
Board for which it provided, and upon which the Geneva 
ronferonces which drafted .that ' Convention set so much 
store has accordingly not been set up. Hence the mdehiierv 
chairman of tho second Geneva conference, 
itahle, declared three years ago' would initidto 


movement wliich will nccolornto from day to day and 
from month to- month,” still remains inoperative. Tho 
Haguo Opium Convention of 1912, which the Genova 
Convention of 1925 was to “ greatly strengthen,” is 
accordingly the only international instrument available 
for control of traffic in opium, cocaine, and similar habit- 
forming drugs.* Indeed, it was contended by Iho American 
delegates that tbo later Convention derogated from tho 
spirit, if not tho letter, of tho earlier pact of 1912 in tho 
mattor of limiting tho production of opium and in tho 
suppression of opium smoking. Tho Advisory Committee 
is reported to have hcon staggered and appalled at tho 
extent and tho extension of the illicit traffic in tho crude 
and the manufactured drugs. The chaotic state of tho 
central government of Chinn has been accompanied by tho 
rovorsion of tliat country to tho position of being one of 
tho chief producers of opium. Tho Government of tho 
Straits Settlements, it was alleged, was responsible for an 
increased consumption of smoking opium from 43,000 kilo- 
grams in 1025 to 55,000 kilograms in 1926, and tbo only 
justification vouchsafed appears to have been that if the 
Malay Government had liot supplied tho drug smugglers 
would not have failed to do so. Then, again, it was assorted 
that hundreds of kilograms of morpliino were being ex- 
ported from Franco, ostensibly to Gennany. The Gorman 
delegate, on tbo other band, maintained that such imports 
had not been roeoived, and it was suggested that tho con- 
signment had passed through Copenhagen to Russia for 
illicit uso. T)io records of imports and manufactures of 
cocaine in Japan likewise attracted attention, and wore 
said to amount to a total four times greater than tho world 
average. Tlio Japanese dolcgato somewhat irrelevantly 
reiilied that Burope had tried eighty years ago to convert 
Japan to opium smoking. .As regards the world production 
of opium, this had boon recently estimated at more than 
8,000 tons per annum, whereas tho most liberal estimate 
of tho “ legitimate ” need is less than one-tenth of that 
amount. Another disquieting feature was the extensive 
manufacturo of codeino. During the first Haguo Con- 
forcnco on Opium in 1911-12 a good deal of discussion took 
place as to whether codeine, like heroin, should be included 
ns a dangerous drug. Tho British delegates urged its 
■ inclusion ; tho German delegates opposed, and maintained 
that there was no evidence to show that codeine was a drug 
of addiction. One of tho British delegates promptly cited 
a case of " codeinismus " from tho columns of the KUnhche 
Wochcnschrift; but finally, to secure agreement, codeine 
was omitted from the Convention. Signor Cavazzoni, tho 
Italian delegate, again reiterated his distrust of tho “Board 
of Control,” proposed by the Geneva Convention of 1925, 
ns being too aloof from the organization of tho League of 
Nations to be effectivo and trustworthy. He also again 
pressed for governmental supervision or - ownership of all 
manufactories of dangerous drugs. An alternativo pro- 
posal by tho Gorman delegate. Dr. Anselmino, was the 
creation of a great international drug syndicate or trust, 
witli which tho League of Nations should enter into organic 
relationship by way of representation. All these proposals, 
coupled with the admitted fact that the situation as regards 
tho' international control of dangerous drugs and the sup- 
pression of illicit traffic therein is getting worse rather 
than bettor, seem to point to the principle which has been 
consistently advocated in these columns, which has been 
supported iiersistently in America, and which is implied by 
British legislation — namely: (1) that the use of opium, 
cocaine, their products, and similar drugs for other than 
modicihal purpose is an abuse and not legitimate ; and (2) 
that to prevent sucli abuse it is necessary to control produc- 
tion at tho source, so that there will be no surplus for 
non-modicinal or illogitimato purposes. 

> The ngreement mnclo between Powers Imvin- nos^essian-s in r... 
East, Eicaed at Geneva in Fcbniarv, 1925, 0.13 nuWisbea in 
Paper (Omd. 503o>, relates eiclusivelj- to " prepareS ” or Emokfng cpinS^ 


008 mat 26, 1928] 


THE CASSBE HOSPITAL. 


[ The Cnmn 
Uedicae Joui;5az. 


THE CASSEL HOSPITAL. 

In the report of the Cnssel Hospital for riinctioiial Nervous 
Disorders for the year 1927 the medical directorj Dr. T. A., 
Boss, continues his policy of discussing only patients who 
have been at least twelve months away from the hospital. 
As an attempt is made, with considerable success, to keep 
in touch with former patients b3’ getting them to rejwrt 
progress once a j'ear, the results described are well tried, 
and have among hospital reports a peculiar value. This 
year’s report, brief as it is, is full of interesting facts and 
suggestions. It furnishes, as in previous years, a striking 
justification of tiie methods of treatment cmploj-ed at the 
hospital. In the group of patients for whom this institu- 
tion is specially intended — the psj-choneurotic group, of 
h3’sterias and anxiety- states— the record is impressive, 
whether for jjercontage of impi-ovement, consistency of 
results from year to year, or permanence, and this in spite 
of the fact that the claims of recovery or improvement are 
made with great caution, and the results are te.sted at 
length by the only criterion that is of nearly unassailablo 
value — the test of the retuin - to e\-orvd.ay life. In the 
present instance, of 102 psychoneurotic patients treated in 
1926, 91 have so far replied to an inquiry about their 
health, and of those 70 reported themselves as well or 
much improved. This represents 77 per cent, of those 
replying, and contrasts with a percentage of 75 in 1925, 
74 in 1924, 77 in 1923, and 68 in 1922, u-hich was the fii-st 
year to bo so reported. Those are remarkably consistent 
and well-sustained results, and in evaluating them it sliould 
be remembered that they have been brought up to date, and 
so give evidence of durability. They irould ho still more 
impressive if some indication ivore given of tho duration 
of tho ilhie.ss before treatment was instituted. It 1ms to 
bo borne in mind that in some 'respects the Cassol Hospital 
population is a selected one — selected chiefly for its diffi- 
cuUy — for it is composed largely of patients who Imvo been 
ailing for years, many of them for the greater part of their 
lives, and who have had many treatments with fleeting 
Buciess. This may very well account for tlio pessimism of 
the report in regard to a small groiqi — the obsessional 
group— of which there have been only twelve in the hospital 
Biiice it opened. E.xperienco in private and out-patieut 
practice gives a more favourable impression of this typo 
of illness, especi.ally when it occurs in children and adoles- 
cents, than Dr. Boss has received from the Cassel Hospital 
material, which is mainly adult. From the figures quoted 
the therapeutic results in the chronic p-sy-choneuroses, which 
arc usually regarded so pessimistically, contrast very favour- 
ably with the results of treatment of other forms of chronic 
disalnhty. In this connoxiou we note with interest that 
it is found to be a useful policy to have some former 
patients hack fqi a brief second period of residence. Of 
24 patients who returned under these conditions, 17 are now 
much better or well, so that the experiment seems fiilly 
justified. Such patients return usually to discu.ss the effect 
of putting into practice in ordinary- life what they had 
learned in the Cassel Hospital, and to adjust any points in 
which they have failed to apply it satisfactorily. The idea of 
diagnosing dementia praecox in the early cases sent there 
has been abandoned; this is in accord with the most modern 
psychiatric teaching. It is not only unkind, but unscien- 
tific, to label patients “ dementia praecox ” merely because 
they- present certain symptoms; tho designation should be 
reserved for certain states of terminal demoniia. For all 
earlier cases of this ty po the term “ scliizopbrenic ” is 
wisely preferred at the Cassel Hospital. It is of consider- 
able interest that of the eight sebizoplirenics mentioned 
four are now well, and that most of them (Dr. Boss states) 
had to be discharged before recovery because they did not 
fit socially with tho rest of the population, which is, of 
course, mainly psychoneurotic. Ho deplores the fact that it 
w.'is impossible to provide special nurses to enable them to 


prolong their stay sulEciontly. Such patients undoubtedly 
feel themselves to ho different from tho psychoncurotio 
population, and the latter also are quick to recognize tho 
diffeionco. It would add still more to what is to be learnt 
from these very informative and constructive reports if 
moro statistics could ho given, such as tho duration of 
illness, the number of hours of treatment, tho length of 
the hospital rcsidonco, and tho age of tho patients. Some 
indication of tho rolativo permanence of tho results with 
each typo of p^chothorapy selected would further enhance 
their value. ■ • 


THE LIFE-HISTORY OF. EPIDEMIC ENCEPHALITIS 
IN THE CHILD. 

Finding that tho prognosis in epidemic encephalitis in 
children has been insufficiently studied, Dr. Mary M. 
Stevenson rccoi-ds in tho April i.ssiio of tho Archives of 
Disease in Childhood' the rc.stilts of her investigation of 
oighty-three cases, observed at intervals from 1918 to 1927. 
Twelve children had died, eight cases could not ho traced, 
and sixty-three had been rc-oxaminod recently by tho 
author. It was noted that 70 per cent, were hoys, and tho 
onset had occurred at ages varying from birth to 13 years. 
Tho disease began in most case.s suddenly; after tho 
aeuto illness there was a period of qiiiesconco, followed later 
by the appearance of new symptoms. Mental alteration, 
nocturnal excitement, conduct changes, respiratory dis- 
titrhaiiccs, the Parkinsonian syndrome, Joss of accommoda- 
tion, choreiform restlessness, myoclonic movement.s, and 
obesity occun-ed in that order of frequency. Fever was 
present at tho commencement in most cases, and lethargy 
was a pronounced symptom in the majority. Of the motor 
disturbances described tho most important wore convulsions 
seen in tho acute stage; choreiform restlessness, occurring 
both early and late; myoclonus, which appeared in both 
early and late stages and had persisted, for yoai-s ; and tho 
Parkinsonian syndrome, occurring in the late Stages only. 
Tlio prognosis of Parkinsonism is extremely had, tho 
majority of cases, being steadily progressive. The ocular 
sy-mptoras included diplopia, strabismus, ptosis, nystagmus, 
loss of the reflex on accommodation, inequality of the 
pupils, and disc changes. Among the pni-alyses that of the 
seventh cranial nerve was tho most frequent, and in six 
cases there were transient paralyses, of the limbs. Tho 
reflexes varied, and in twenty-tliree cases pain of a severe 
neuralgic character was present during the early- stages 
of the disease. E.xaminntion of the ccrebro-spinal fluid 
showed it to be under slightly increased pressure, hut clear. 
Durinn- tho acute stage there was an increase of the cells 
for two or three months. The colloidal gold test of Lange 
was usually positive during the acute stage, although in 
tho first week it was occasionally negative. During the 
chronic stage it was again negative. Nocturnal excite- 
ment with inversion of the sleep rliythm assumed a veiy 
prominent positron in the sequels seen in this scries; it 
lasted from ono month to five years, tho average duration 
being eighteen months. Derangements of respiration took 
tho form of (1) attacks of rapid and noisy breathing, (2) 
continuous rapid breathing with occasional attacks of noi^ 
respiration, and (3) apnoea. Eespiratory tics, such as 
frequent clearing of the throat, nose-blowing, and sniffing, 
wero also present. The onset of these respiratory troubles 
usually occurred between three months and three years 
after the start of the disease, and was a late manifestation. 
There is a tendency for these disturbances to disappear. 
Mental alteration was found in tho majority of tho cases, 
and tended to increase, in contrast with Shruhsall’s 
findings. Changes in conduct wore seen in forty-six 
patients; in most cases improvement has ot .irred. 

* Vol. 3 , No. 14. iKsued by the British Medical Association. London : 
B.M.A. House, Tavistock Square, W.C.l. Yearly subscription (6 numbers), 
259. Single number, ^3. 6i 


May 2G, 1928] 


ARTIFICIAL rRODUOTION OP A FOWL TUMOUR. 


[ Tire Bnmin 
MrcicAL JouutUi 


909 


Regarding tlio prognosis as to life, out of tho nntlior’s 
sorTes four children died during tho nento stago and eight 
.at varying periods after tlio acnlo illness. Only tlirco of 
tho whole series are norninl; many are seriously crippled 
and need institutional treatment, thus demonstrating tho 
seriousness of tho outlook in opidomio encephalitis. ' 


ARTIFICIAL PRODUCTION OF A FOWL TUMOUR. 

EvF.n -siucc Gyo and Barnard put forward their theory of 
tho cancer “ virus,” a gi'cat deal of attention h.as been 
directed to tho study of tlio Rous sarcoma of fowls, on 
which their argument wliolly depended, and especially to 
tlio naturo of tho filtcmhlo extract of these tumours. 
Gyo claimed to have demonstrated that tlio extract con- 
tained two factors — tho “ virus " and tho ” accessory 
chemical factor ” — neither of which was cfilcacious without 
tho. other; hut tho weight of scientific oiiinion has been 
unfavourable to this claim. It h.as even been doubted if 
the active principle of tho fowl-tumour extract is of the 
naturo of a virus, and Carrel has a-;scrtcd that ho has been 
ablo to produco tumours iudistinguisliablo from tho Rous 
sarcoma by injecting into fowls the pulp of chick embryos 
mixed with vciy weak solutions of ursenious acid or of indol. 
Carrel’s claims in turn have been disputed by others, but 
Brobner* states that ho has successfully repeated these 
experiments. But ho has gone further. Impressecl by tho 
discovciy of 'Warburg that tuniour.s, placentae, and 
embryonic tissues have, in contradistinction to most other 
tis.sue.s, a greater glycolytic than resi)iratoi\ property, he 
v.as impelled to try if tho combination of ]ilaceiital extr.act 
and chick embryo pulp would have a similar etfert to the 
Rous sarcoma extract. To this <'nd ho rcmovc'd two 
placentae from a rabbit at or about full term, minced them 
■finely, and mixed with them 10 c.cm. of viltiie. The 
mixture, after standing for thirty minute.s, uas centri- 
lugaliacd, .and the supernatant Iluid added to tho minced 
pulp of throe eigliL-day-old chick embn-os. This omulsion 
was injected into tho pectoral muscles of two foals. One 
of those foa'ls had developed a -nodule by the twentieth 
day, and by the end of tho forty-sixth day, when iho bird 
died, it had a largo nodule on tho left side and a smaller 
one on tho right. On dissection it a’as found that the 
tumours — grey-a-hito in colour, firm in consi.stoncy, not vei'y 
vascular — ^a-ere activelj- invading the musclo substances. 
Tliey showed no trace of emhi'j-onic tissue, such as cartilage, 
bone, or epithelial structures, ns one a*ouId expect to obtain 
fiom tho gi'owth of the material injected. There were 
nuineious metastascs, especially in the lungs. The micro- 
scopic appearances wore those of a sarcoma in which large 
cells picdominated, with abundant cytoplasm and somewhat 
pale-staining reticulated nuclei — cells which were probably 
of mesoblastic origin — ^but tho picture was by no means 
uniform, for dense cellular ai-eas existed side by side with 
iiij-xomatous areas, and there were a few giant cells and 
hmphoec-tes to be found. Tho metastatic deposits showed 
tho same characters. Tho tumour was successfully trans- 
planted into other fowls of the same breed, and had reached 
its fouith generation when tho paper was written. Tho 
tumours were alwa 3 s progressive, had the histological 
characters of the origiual, gave riso to metastascs, and 
proved fatal to tho fowls in thirty-flvo da^-s. Brcbner 
further states that ho repeated the experiments, using 
extract of guinea-pigs’ instead o'f rabbits’ placentae, and 
has produced similar tumours in six. cases. So far he has 
not succeeded in propagating theso tumours hv filtrates or 
by desiccate material as in tho case of the Rous sarcoma 
but otherwiso theso fowl tumonre are of a similar nature, 
c 0 doubt this new observation will be thoroughly investi- 
gated by others; if it comes successfully through the test 
It will throw .some light on the naturo of the agent causin g 

' ’ Canadian Sfed. Aesoc. daum., Anril, ,1928. 


theso iicculiar chicken tumours, and, incidentally, it will 
removo tho foundation on which Gyo’s thcorj' was 
constructed. 


B.C.G. AND NON-TUBERCULOUS INFANTS, 

At a recent sc.ssion of tho Academy of Medicine in Paris 
Professor J. Ligniercs, while spoalung in high terms of 
Ur. Cahnotto’s B.C.G., deprecated its uso for pro- 
immuniaing infants who wore not exposed to infective 
surroundings. Although ho was convinced that B.C.G. 
was a powerful help in tho struggle against tuberculosis, 
and ought alwn 3 'S to bo employed when contagion was to 
he feared, ho thought that tho introduction of a living 
organism into tho tissues led to an infection which, though 
never producing tho lesions of tuberculosis, might still bo 
harmful. Ho pointed out that there was a largo mortality 
in rabbits used for oxiicrimcnts with B.C.G.; that no trust- 
worthy statistics wore yet available on the vaccination of 
infants who wore not exposed to tuberculous infection; 
and that, in auj- case, pre-immunization led to a prolonged 
infection of tho lymphatic system bj' tho B.C.G. Dr. 
Calmette reserved his reply to Professor Ligniercs until tho 
session of tho Academy on May 8th. Apparently ho failed 
to recognize that Professor Ligniercs did not allege that 
the B.C.G. might produce tuberculous lesions in the 
vaccinateil, and his answer was based mainly on this mis- 
understanding. He asserted, however, that experiments 
had shown that tho mortality in rabbits was not due to 
injections of B.C.G., and ho made the remarkable statement 
that in vacciu.atcd infants tho morLility from all causes 
was less than in the nou-vaccinated. Professor Ligniercs 
again declared his admiration for the groat discovery of 
Drs. Calmette and Guerin; lie continued, however, to 
uphold his view that tho use of B.C.G. should ho avoided 
with licallliy subjects brought up in non-tuberculous 
surroundings. 


Dn. W. JI. IViULOUcnnY, who has been medical officer of 
health for tho Port of London during tho past twelve years, 
was elected on May I7th by the Corporation of London to 
tho post of medical officer of health for tho City, in succes- 
sion to Dr. IV. J. Howarth, who retired recenth- owing 
to ill health. ' 


Tnn first award of the Dalby Memorial Prize, for tho 
best original work in otology during the previous five years, 
has been made to Dr. Otto Mayer of Vienna. The award 
is in the hands of tho Council of tho Royal Society of 
Medicine, acting on tho recommendation of the president 
and vice-presidents of the Section of Otologj-. 


The annual general meeting of the Research Defence 
Socictj- will be held at 11, Chandos Street, Cavendish 
Square, IV. 1, at 3 ]i.m. on Tuesday, Juno 18th. Tho 
Stephen Paget Jleiiiorial Lecture will bo delivered by Sir 
Bernard Spilsbui'j-, his subject being the work and 
responsibilities of a pathologist. 


PnOFESson Hideyo Noguchi, of the Rockefeller Institute 
for Medical Research, died at Accra, on Maj- 21st, from 
jellow fever. Professor Noguchi went to Accra last 
November to investigate this disease, and contracted the 
infection in the course of laboratory work. 


SiK .STCXiAiu Thosiso.x has been elected a corresponding 
member of the Societe do Laryngologie des Hopitaux do 
Paris, of the American Stomatological Association, and of 
the Philadelphia Laryngological Society. 


910 HA? s6, 1928] 


r TiiKBrn-nnH 

tllKDtCXI< Jounxi^ 


‘3he ^arb^g ^etctntm^x'g. 


BANQUET AT LONDON GUILDHALL. 

The Harveian celebrations in London concluded with a 
banquet given by the Royal College of Physicians at the 
Guildhall on Wednesday evening, May 16th. The reception 
by the President of the College, Sir John Rose Bradford, 
took place in the art gallery, and the company of nearly 
BOO Fellows and guests proceeded to tables in the great 
hall. 

The President had beside him the German Ambassador and on 
his left the French Ambassador; other members of the Diplomatic 
Corps present were the Italian and Belgian Ambassadors, and 
the Austrian, Greek, and Finnish Ministers. The Government 
was represented by the Minister of Health . and the Under 
Becretary for Scotland; the religious life of the nation by the 
Archbishop of York, the Ai-choishop of Wales, the Dean of 
Westminster, the Dean of St. Paul’e, Cardinal Bourn^ and the 
Cliief Rabbi ; law by the Lord Chancellor (Lord Hailsham), 
Viscount Sumner, Lord Wrenbury, Lord Blanesborough, Mr. 
Justice Rowlatt, Mr. Justice Maugham^ Sir Ernest Wild, and 
Sir Thomas R. Hughes; industry and industrial science by Sir 
Alfred Mond, Sir Robert Hadfieldj and Sir Charles Parsons; and 
the arts by Sir Frank Dicksee, Sir Reginald Bloomfield, and Sir 
Johnston Forbes-Robertson. The University of London was repre- 
sented by Sir' William Beveridge (the Vice-Chancellor) and. Sir 
Gregory Foster; Edinburgh, by Sir Edward Sharpey-Schafef ; 
Oxford, by Sir Farquhar Buzzard; and Cambridge, by Sir -Humphry 
Eolleston. The three new Honorary Fellows who were able to be 
present (Sir Ernest Rutherford, Professor Pavlov, nnd Professor 
>Yenckebach) were grouped near the President, Otners at tbb prin- 
cipal table were Viscount Knutsford, Lord SomerIeyton,.tbe Earl of | 
Crawford and Balcarres. Viscount Chelmsford, Lord . Stanmore, 
Lord Riddell, and the High Commissioner for New Zealand.* The 
rcat majority of the others present were mcdiral men, including , 
ord Dawson of Penn; Sir Berkeley Moynihan, President of. the 
Royal College of Surgeons of England: Sir James Berry, Presi- . 
dent of the Royal Society of Medicine; Mr. H. W.- Carson, 
President of the Medical Society of London; Sir Robert Philip, ’ 
President, Sir Ewen Maclean, President-Elect, and Dr.’ C. O, 
Hawthorne, Chairman of the Representative Body of the British 
Medical Association: Sir George Newman, Chief Medical Officer 
of the Ministry or Health; Sir Thomas Barlow, Sir Francis 'i 
Champneys, Sir Anthony Bowlby, Sir John Bland-Sutton, Sir I 
Wilmot Herringham, Sir James Fowler, Sir William Hale-White, | 
Sir Thomas Border, Sir Maurice Craig. Sir James Purves-Stewart, 1 
Sir Robert Armstrong-Jones, Sir William Willcos, Sir Holburt j 
Waring, Dr. Graham Little, M.P., and Dr. F. E. Fremantle, M.P. 

** The Memory of William Barvey.'* 

After the loyal toasts had been honoured, the Phesident, • 
in few words, called upon those present to drink to ** The 
Memory of William Harvey," and the toast was honoured 
in silence. 

The Delegates." 

The Miotsteh or Health, proposing the toast of The 1 
Delegates, said that all would agree as to the gre.atness of the I 
occasion which brought together so distinguished a body of men, * 
including representatives from the universities and the learned t 
•societies of this country, of the British Dominions beyond i 
the seas, and of numerous foreign nations. Many bore names ' 
which were held in honour throughout the whole of the scientific ! 
world. He noticed with particular pleasure the presence of' 
Professor Castiglioni, representative of that University of Padua,' 
in which Harvey took his medical degree in 1602. Surely there ' 
could he no greater tribute to the influence of that wonderful 
treatise by Harvey. 'ban the fact that 300 years after its publica- • 
tion men of science' should come together from all .parts of the ■ 
world to do him honour and acknowledge the debt they owed 
to him. Harvey’s work was more than a discovery, it was 
a demonstration. So clearly did he state his problems, so 
skilfully did he marshal the evidence against the theories then 
current, so aptly did he illustrate by the results of his experi- 
ments the new theory which he put forward, that at one single 
blow he carried conviction to all his readers. Like another 
great scientist, Charles Darwin, he changed the whole current 
of men's thoughts. The present company had during the last 
two days listened to many appreciations of the work of Harvey 
from different aspects. The speaker .was present that evening 
as the ilinistcr for the time being responsible for the Depart- 
ment of Public Health, whoso duty it was to prevent and avoid 
disease. Looking at Harvey’s work from that point of view. 


it seemed to him that tho whole system of proventivo medicine 
was based and founded upon his discovery. For what was 
preventive medicine? Was it not the science and art of pro- 
viding for the population tho food, warmth, exercise, and 
recreation that were necessary to maintain a normal healthy 
circulation, and on the other hand to remove and avoid those 
factors which favoured the onset of disease and impaired tho 
resisting power of tho body, which was itself dependent upon 
the same circulation ? Harvey’s pre-eminent place in medicine 
was given to him because ho was tho founder of modern 
physiology, nnd all the services which were carried on in tho 
name of public health in this country, through tho local autho- 
rities, medical officers, sanitary inspectors, health visitors, 
maternity nnd child welfare centres, clinics and hospitals, tho 
health insurance system, even tho housing programmes, were 
just various methods of securing and safeguarding the physio- 
logical balance of the life of man. Mr. Chamberlain concluded 
by saying that of the various factors which were working to-day 
for the peace of the world there was none which was more 
potent than the brotherhood of the healing art. Diseases knew 
no. frontiers, took no account of nationalities, nnd those who 
were fighting in this great warfare knew full well that if they 
were to’win the battle they had to pool their resources and to 
regard medical men and sanitarians of all nationalities as their 
comrades in arms. It was in this spirit that ho welcomed tho 
delegates. 

Professor A. Castiglioni said that tho period during which, 
as a young man, Harvey listened with so much earnestness to 
the teaching of the greatest anatomist of the time, Fabrizio 
d’Acquapendento, was tho greatest and most glorious in tho 
history of .the University. Galileo Galilei had laid the founda- 
tioiii 6f c.xperimcntal science with his immortal words. Through 
the intelligence and foresight of the Venetian Hepublio the 
entire' University, enjoying complete freedom in matters of 
education, was influenced by the spirit of this earliest and 
greatest of experimental philosophers. At the same university 
Andreas Vesalius, student and afterwards Professor, had estab- 
lished modern anatomy, and for more than forty years Padua 
was the centre of anatomical research in Europe. It was into 
this environment that William Harvey brought his high intelli- 
gence and profound powers of observation, and here he came 
to know of the discoveries of Kealdo Colombo and Andrea 
Cesalpino. Italy could with pride testify that while England 
had the glory of being the country of William Harvey’s birth, 
it was the ancient University of Padua which afforded this 
famous man his course of instruction in physiological thinking 
which prepared him for his great discoveries. The glorious 
Italy of the Renaissance, which in letters and arts carried high 
the torch of beauty and truth to illuminate mankind, remem- 
bered to-day with pride the work of William Harvey as that 
of a beloved pupil. The speaker said that he was giving voice 
also to the feeling of all Italians who were tied to England 
in a bond of long-standing friendship. They did not forget the 
opportune assistance rendered to their land at all times by 
a country which they loved and admired. In commemorating 
the work of William Harvey of immortal fame he took tho 
opportunity to emphasize those ties' of friendship and unity of 
purpose, and to recall all those brilliant men, at one time 
students at Padua, who had held prominent positions in the 
Royal College of Physicians of London. He also brought 
greetings and good wishes from this ancient school, which 
followed with pride and affection the successes of its sons in 
another land, and in the name of the University of Padua, and 
also in the name of all those Italians who followed with such 
interest the progress and glory of British science, he greeted 
the President and members of the Royal College with the words 
** Vivatf crescatf fioreatl ” 

Professor W. H. Welch of Johns Hopkins University also 
responded to the toast, saying that it was difficult for him to 
follow the eloquent address of Professor Castiglioni, who repre- 
sented something very significant in the life of Harvey. - Ho 
himself could put forward no such claim, hut he did desire 
to express what he felt to be the good fortune of the delegates 
and cuBsts in being allowed to participate in that c'o.mmemora- 



May 26 , 19 * 8 ] 


THE EAKVEY TERCENTENARY. 


r TbkUritwh 
L Medical Jocrnal 


911 





tioil. Tlicic was soiuclliing stirring in tlip tliouglit that Uipy 
assomlilod at the invitation and nndcr tlio anspiees ol tlic Royal 
Golicge oi I’liysiciaiis to coVIinito an rvont nncxainpled in Uic 
liislorv ol Imman lliouglit. The celolnatinn ha<l been in every 
way wortliy of the event wliieh it ordehrated. Tlie delegates 
had been received hy the King, they liad p.irticipaU'd in sonic 
Iiighly impressive and interesting cercinoniev 'I'cy visited 
not only the Royal College of I’hyaieians, but Harvey’s old 
hospital, St. Bartholoinew’.s. and on tho following days they 
were going to Cambridge and to O.xford. lint In* thought he 
was voicing probably the sentiments of very .many of the 
delegates when be si’iid that on tJie previous day, during -the 
demonstrations at University College, tiny liad felt Uicuinelves 
most vividly in the jircsence of the living Jlaiwey. It was one 
tiling to read about the fact that Harvey made this direct 
appeal to nature, tliat Jio really introduced indepeadeut scientific 
inquiry into the biological sciences, that he stood for biology 
ill the same Jiosit ion as Galileo stood for the pby.sieal sciences, 
but to have this brought before the eye by ili iuonslration was 
a Eiiigiihirly iiiiprcs.sivc experience. 

He Ibongbt tb.at the prolonged 
applause with wbicli the delegates 
endorsed the Iribute jiaid by Uie 
Prisidcnt to Sir Thomas Lewis and 
Dr. Dale was more Ilian ordinarily 
significant j they felt that they 
were applauding really the jicr^nnn 
iiroj>r!a, as it Harvey bad been 
licfore them and bad conducted tho 
demonstration. The delegates bad 
also enjoyed the dcligblfully plain 
and simple and yet eloquent talk 
at Harvey's liospitnl by Sir Wilniot 
Heniiigbani about Harvey the man. 

They realized what a man be was, 
n gcnlleinan in every sense of the 
woial, one who did not love to over- 
throw -the spell of ancient .autliority, 
who did Ids work in a somewhat 
Ttiluctant, slightly regretful way, 
one who svas not altogether free 
himself from (ho Iramnicls of 
mediaeval liiought, one wlio was 
not engaged in vituperation and di<l 
not Jiglit-heartedly abandon the old 
authorities. The speaker desired 
only to add how grateful he and his 
fellow delegates were to tho Royal 
College of Physicians for having 
provided in so adequate a way this 
presentation of Harvey the investi- 
gator and Harvey Uie man. This 
visit would be one of the great 
experiences of their lives and an inspiration 
work. 

“ T/ie Ilonornnj Fcllovf.” 

The Pkesioent ne.xt proposed the liealUi of the newly installed 
Honorary Fellows, and repeated in substance tlie statement he 
had made at the reception at the College two days previously, 
which was reported in the Journal last week (page 867), explain- 
ing that tlio College had never iiad a roll of Honorary Fellows, 
(hough in history there were one or two wlio might by n 
stretch of language have been said to bear tiiat title. Four most 
appropriate names bad now been chosen for this honour ; the 
Earl of Balfour, who in many directious bad given great 
encouragement to medicine, Sir Ernest F.ntberford, the dis- 
tinguished physicist. Professor Pavlov, the doyeu of physiology, 
and Professor 'Wenckebach, a man distinguished for the kind 
of work peculiarly associated xvith the genius of Haivey- 

Professor W^'CKEBACtr addressed a few remarks in reply, 
modestly disclain^g any ability to speak for his great colleague 
Pavlov, but saying that Professor Pavlov'.s presence at that 
gathering was sufficient without any wm*ds. For his own part 
Piofessor Wenckeiiach felt himself singled out merely as one 
of a great army of practitioners in whose ratiks he had served, 
and that the honour done Jiim ttnis really intended for them 
all. He was one of the hundreds of thousands of physicians 
who stood indebted to Wdliam Harvey, and not to William 
Harvey alone, but to the profession of medicine in Britain nast 
and present. 



Sir Eunesx RiiniEnronD also aekiiotvicdgcd the toast in 
graceful terms, saying lliat it was an idiosyncrasy of human 
nature that it ajipreeiated most those marks of distinction which 
wore Ic.-tst de.scrved. He felt, however, that his admission to 
the F’ellowsliiji of the College was attended hy certain draw- 
backs, one being that he eonld no longer express his opinion 
of tile merits of the medical ]imfcssloii with the same candour 
as heretofore. Harvey, he went on, was tlte first man to ajiply 
jihysies to medicine. It was true, as others had said, that all 
the es'-cntial facts on which Harvey liased his great discovery 
were known before him. It, was known that the blood flowed 
ontw.nrds in one direction, and iinvartls in another; hut what 
he did, like Newton .and others of -whom the same twas true, 
was to make a great generalization. All honour to the man 
who h.ad the vision to do that! Harvey visualized the -applica- 
tion of dynamics to the circulatoiy system. Sir Ernest 
Riithciford ended hy asking his hearers what now scientific 
aeliievcracrrt they wonld most de.sirc to see in their lifetime. 
A former generation would have made varied replies, but now, 
with so maiiv conquests made — 
flight, and wiixdess, accomplislied, 
and television on the way — what 
remained but the achievement of 
the health of the comimmity, and 
who could doubt that the di.seiples 
of Hnivey would gain this also? 


^siciaiQ 


Certsor 

treasurer 


^ai'hPlu^Patt£c QwJxOiair 

(XOcc^icscG^ 


to tliem in futm-o 


" Tltr. Jloyal College of. . 
P/ijitician?.” 

The AncirBisHOP of Touk, In 
Xnoposing the last toast, tliat of 
“The Royal College of Physicians,’^ 
declared himself on that occasion 
to he a layman of laymen, who had 
had probably less to do witli 
doctors professionally than anj-hody 
else in that .hall. Yet, .after all, 
he might on that occasion represent 
the higlicst and most altrnlstio 
ideal to which the medical profesf- 
slon could possibly rise — ^that dl 
a humanity so healthy tliat , the 
occupation of tlte Royal College of 
Physicians would have gone. Ha 
had one link with tlie Royal College 
whicli he greatly valued. The 
principal founder and fiirt President 
of the College, Thomas Dinacre, 
became 440 years ago what he was 
happy to say he (the speaker) still 
was, a Fellow of All Sonls’ College, 
Oxford, and he hoped’ he might 
without presnniptiou he regarded 
as standing in the relation of founder's kin. That first 
Piesidcnt was Indeed the precursor of the great mau svhose 
name was in all thcii- hearts. It was but one hundred years 
before William Harvej' began the e.xperimental method of 
wliidi he was the greatest illustrator, and Dinacre as well as 
Harvey had the honour of graduating In medicine in the 
University of Padua, -wliicli had been represented with so much 
eloquence that evening. Linacre represented the union of 
medical science tritli letters and scholarship. He was the 
friend of Ei-asmus, Colet, and Tliomas More. It was to he 
hoped tliat the connexion between the physieiaii and scholarship 
and letters might he maintained. The study of humanities 
did give a unique distinction ; he trusted that that old associa- 
tion between medicine and letters, that old succession' of 
medical humanists who had done so mnch to give distinction 
to English life, xvould not he broken. Dinaere also reminded 
him of tlie union between medical science and the Church, for 
lie was during the last fifteen years of his life a clerk in holy 
orders. Tlieii, as now and always, Theology was the queen of 
the sciences, and, like other queens, was apt to be somewhat 
■jealous and dictatorial ; for a considerable time she held 
5Iedic5ne under a somewhat painful constraint. But those days 
■were pas.scd ; kledicine -was now free, though he hoped that as 
there had been no divorce there would not even he any separa- 
tion between the Church and Medicine, hilt a nmv coiVnadffiiiip 
based •on fi-eedom. They ought to he working together as fellow 
students in the spirit of science, with minds furnished as 


912 MAT 26, 1928'j 


THE HA.RVET TEROENTEN^BY. 


t Tfr* nnrrj^n 

Mri>;cAT^ JarnsAl. 


l^ecaine disciples of truth, and lie could "wish that the Royal 
College of Physicians would take the lead in a new scientific 
end independent inquiry bn the subject of spiritual Healing. 
He did not think there was any profession in the world where 
the connexion between science and humanity was more close 
than in the great profession of which the College was the head. 
There research, teacliing, and practice were all fused together 
in one common enthusiasm, and he liked to think that at that 
very moment there might bo, under the College auspices, some 
man, having the spirit of Harvey, on the very brink of some 
great new discovery. No sooner would any such discovery be 
made than it would be taken up by the great body of practi- 
tioners and applied in every cottage throughout tlie length and 
breadth of the land. 

The President contented himself with but a few words in 
reply, lie thought that those who had witnessed the demon- 
strations arranged at the College during that commemorative 
week would agree that tliis ancient foundation was not proving 
unwortliy of the trust which evidently Harvey in Ids time 
reposed in her; the Fellowship of the College included many 
men on whom the mantle of Harvey obviously had descended. 

[Our illustration is reproduced from the cover of the dinner 
rogramme, designed and executed by Mr. Emery Walker. This 
ust of Harvey overlooks the main elaircase of the College.] 


DELEGATES’ VISIT TO OXFORD. 

A large number of the delegates visited the University 
of Oxford on Thursday, May 17th, and were entertained 
at luncheon in Harvey’s college by the Warden and 
Fellows of Merton. The party reached Oxford by train 
and were met at the station by the Regius Professor of 
Medicine (Sir Farquhar Buzzard), the Dean of tbo Faculty 
(Dr. Ainloy Walker), and a number of other members of 
the University. Tliey wore conducted in cars to different 
centres, and the morning was spent in visiting tlio 
Bodleian Library, the Old Ashmolean Museum, the Lewis 
Evans collection, Magdalen College (hall, chapclj cloisters, 
and gardens), and Christ Church (hall, library, kitchens, 
and quadrangles). At the Old Ashmolean Museum Mr. 
[R. T. Gunther, curator of the Lewis Evans collection, 
spoke of Harvey’s work with Bathurst at Trinity College, 
where they studied the development of chicks in incubated 
eggs. At 1.15 p.m. the different parties re-united at 
Merton College, where they were met by the Professors in 
the Faculty of hledicine, and were received by the Warden 
and Fellows of tlie College. Luncheon was served in the 
College Hall to about one hundred guests. On a small 
table in the centre of the Hall were displayed some of tho 
College hooks relating to the period of Harvey’s warden- 
ship, and a bursarial account showing his signature was 
exhibited. After the loyal toast had been honoured the 
Warden (Mr. Thomas Bowman) expressed in felicitous 
terms the pleasure felt by the College in welcoming and 
entertaining the delegates. Sir John Rose Bradford 
(President of the Royal College of Physicians) replied on 
behalf of the guests, emphasizing the important part pl.-iyed 
by Oxford and Oxford men in the early history of scien- 
tific and medical investigation in England. Subsequently^ 
tho. visitors had the opportunity of seeing the College 
library and gardens, and proceeded in small jiarties to 
spend the afternoon in seeing some of the other colleges 
and University institutions. A short account of Harvey’s 
connexion with Merton, drawn up by Professor H. W. 
Garrod, Fellow of the College, was presented to each of 
tho guests .at luncheon. This recalled that Harvey went 
to Oxford with Uie King after tho battle of Edgehill, and 
was incorporated M.D. in the University on December 
7th, 1642. He was appointed Warden of Merton on April 
7th, 1645, but in the following Juno, when Oxford sur- 
rendered to Fairfax, Harvey ceased to be Warden. Merton 
possesses very few records of Harvey’s wardenship beyond 
two autographs, hut the College Register contains a f.rirly 
full account of his appointment as Warden and of the 
circumstances leading to it, together with a copj- of the 
letter of appointment. Four days after his appointment 
Harvey called tho Fellows together in the Hall and 
delivered a speech, exhorting them to friendship and good- 


will, Ho is believed to Iiave spent most of liis time at 
Oxford studying tho incubation of fowls. 

. On Saturday, May 19th, by tho invitation of Bodloy’s 
Librarian, tho members of tho Oxford Bibliographical 
Society viewed a collection of hooks exhibited to com- 
memorate the tcrccntbnai-y, at the Radclilfo (Science) 
Library, University Museum, ' and wore addressed by Sir 
Farquhar Buzzard on. Harvey’s discovoiy of tho circulation 
of tho blood. 


DELEGATES’ VISIT TO CAMBRIDGE. 

The last event of the week was a visit of tho delegates 
to Camhridgo on Friday, May 18th, where 0105 - were 
entertained at luncheon by the Master and Fellows in tho 
Hall of Gonville and Caius College, of which Harvoj- was 
a member, graduating B.A. in 1597. The guests were 
received by the Master, Sir Hugh Anderson, M.D., F.R.S., 
who welcomed them in tho name of the College, and 
recalled that its second founder, John Caius, was Prc.sident 
of the Roj'al College of Physicians of London in 1555-61, 
1562-64, and again in 1571-72. Tho thanks of tho delegates 
and other visitors were conveyed to tlio Master and Follows 
by John Caius’s successor in the presidency, Sir John Roso 
Bradford. Some of those who travelled to Cambridge by 
motor car turned off by way of Saffron Walden to Hemp- 
stead, Essex, in order to visit Harvej-’s sarcophagus and 
memorial in the parish church, of which an account 
appeared in our issue of May 12th (p. S16), fi'om tho pen 
of tho late Sir Dawson Williams. On the Saturday tho 
Physiological Society met in Cambridge and hold a luncheon 
party in the Hall of ’Downing College, in commemoi'ntion 
of tho Harvey Tercentenary, lilany of the delegates 
attended, and afteiwards took part ,in the scientific pro- 
ceedings held in the largo Botanical Theatre and adjoining 
laboratories.- Professor Joseph Bnreroft presided at the 
luncheon with Professor 0. Frank of tho University of 
Munich on his right, iSir John Rose Bradford on his left, 
and Professor Ivan P.avlov facing him. Tho large company 
present included also Sir Hum])hry Rolleston, Regius 
Professor of Physic, Sir- Archibald. Garrod, Sir Charles 
Sherrington, Sir F. Gowland Hopkins, Professor H. R. 
Dean, Dr. W. E. Dixon, and Sir. J; H. Widclicombc, 
Senior Tutor of Downing. Professor Barcroft reminded the 
visitors that tho Physiological Society was an informal and 
friendly body, whose members met chiefly to discuss work 
not yet ripe for publication. On this happy occasion, to 
celebrate the memory of the founder of modern physiology, 
the members welcomed their distinguished colleagues from 
abroad, and were delighted to have an opportunity of saying 
how much their writings and discoveries were appreciated 
in this countiy. After Professor A. V. Hill had given. an 
account of tlie arrangements proposed for the Pliysiological 
Congress at Boston in August, 1929, the serious business 
of the afternoon began. 


THE ROYAL SOCIETY CONVERSAZIONE. 

Tlie rooms of the Royal Society at Burlington House were 
filled with some interertiiig scientific exhibits for the usual 
spring conversazione ' on May 17tli, .when Sir Ernest 
Rutherford, O.M., Hoii. F.R.C.P., President of the Society, 
received the guests, among wdiom were many of the dele- 
gates to the Harvey tercentenary celebration. Although 
there were many novelties to he seen, the repetition of some 
old experiments alOT drew interested groups; for example, 
there were some experiments in stereoscopic vision which 
were described in Dr. Robert Smith’s Optichs in 1738, and 
again Faraday’s studies of the crispations formed on liquids 
lying on vibrating surfaces were repeated by Sir William 
Bragg. The Royal Botanic Gardens at Kew sent for ' 
exhibition specimens of the plants yielding chanlmoogra 
oil, which is used in the treatment of leprosy. This*oiI 
is obtained from tho seed of species of Tarahtogenox and 
SydnocarpMS, tall trees occurring in tlie dense forests of 
India, Burma, and Siam. The British Mosquito Control 
Institute demonstrated tho life-histories of various species 
of British mosquitos and the methods employed for 
controlling them. The Rothamsted Experimental Station 



THE IIAllVEY a?ERCENTBNARy. 


r Tjir. JlriTiTH OIS 

LMffDICAI. JoCIWlL 


MAY 26, 1928] 


ilhi'.tiatod tlio biolopicnl timiiol of iiisi'ct jx-sts aiul noxious 
plant-; Soinotliinu tvas sliotvn of tin- allonipl now In'ing 
made to eontrortlie Etivopean earwig in New Zealand 
bv tin; intradnclion in that ronnlir of it-, Eniopcan 
parasitic foes, and the destruction of noxious plants by 
iiwccts which attack them. Another exhibit of interest 
consisted of marine animals and bottom di-posits obtained 
bv the Difrorn-tf expedition.' These wi-re a eidicction of 
squids; cnis-taceans, and fish illustrating the development 
of Inminons organs in peliTgic animals, also tin- coix-s of 
deop-sea ooaes, obtaintxl with' a new form of hottoiii- 
sampling. apparatus, and preserved in the tnb'-s in which 
thev were collected. Tin- JIarine lliological Association 
showed a snbmarino photometer apiiaratns which has been 
used on its trawler to a depth of 70 metres. The Depart- ' 
meat of Zoologs- of the Rrilish Mnseiim contributed Romo 
very interesting natural history exhibits. One of the.s-e 
showed a portion of the intestinal wall of a whale heavily 
infected with ncanthocepbalan worms. It was mentioiieil 
that of a school of killer whale.s ree-i-nlly sli-aiuUxl in Scot- 
land,- every individual was found to be inf<-<-ted with this 
para.site, but oven when the intestiin- was almost blocked 
in' the worms the whale.s appeaix-d to be in giKxl condition. 
Other .specimens were the giant shipworin (Kuphtix 
nirncriii-i), which was obtained in the Solomon Islands, 
and anatomical preparations of the ostrli-h and allied hird.s 
to illustrate the structure of the feathers and (lx- arrange- 
ment of boUes and muscles iif the wing, and to show that 
• this family of birds are. derived from an<-cstors that had 
not acquired the power of llight. Ixird llayleigh demon- 
strated how the peacock’s feather fades if i-xposcd to nllra- 
rdolct light, the green changing to him-, and the colour 
disappearing altogether with long-eontinucd exposure, and 
Di. L. J. Spcnc-er showed the brilliant lluoiesienee of 
fluorspar and certain other minerals when exposed to this 
radiation. Dr. R. J. Lndford hronght from the labora- 
tories of the Imperial Caneer Resoarcli Fund a number of 
mierosi-opo exhibits to illu.slrato tell stria lure and intra- 
vitam staining in tumour-lK-aring animals. He stated that 
.mice given 1 e.cin. injections snlx-ntamHinsly of 1 per cent, 
trypan blue at intervals of a few d.ays could lx- kept plivo 
for several weeks. Within .some of the cells, sin-li as those 
of the kidney and liver, the dyo collected in the form of 
dioplets in tliat part of the cytoplasm which t-oiiuideil with 
the position of the Golgi a]>p3ratus. Areas of necrosis in 
transplanWd tuinonrs stained readily. There was a slight 
accuimdation of dye in living sarcoma cells, hut not in 
living carcinoma, cx-lls. Finally, there was a remarkahio 
exhihit from the School of Pharmacy' of the I’harmnceutical 
Society of Great Britain, consisting of specimens of the 
animal materia mcdica of the seventeenth centui-y. At 
that time entire animals, as well as parts and excretions of 
animals, were largely used medicinally. In the Lonilnn 
Pharinarojtncia of 1627 the bloods of fourteen aninmis, 
nichidiug that of man, were included. The Pharmaceutical 
Society recently came into jmsscssion of a nninher of these 
spccinimis, and some of the rarest and most inteie.sting 
were sliown. These induded iiowdered mummy, which 
was supposed to resist gangrene; hninaii skin, probahlv 
emplciyed as a ligature; powdered sliark’s teeth, used for 
scoipion bites; the ends of tails of scorpions, given as 
a diiiretie; callo.sitics on , the knees of liorsi-s, used for 
epilepsy-; liiinian blood, given as a'.sudoriric and diaphoretic; 
ealciih from t be luman bladder, given for stomach trouble; 
mid linman skull, poirdered, considered good for epilepsy'. 
Diinng the evening Dr. Stanley- Kemp gave an account 
of wba mg m the Antarctic, with lantern illiisti-ations of 
the scehei-y in the dependencies 
of the- Falkland Islands. • 


A BIBLIOGRAPHY OF H-ARVEY. 

Tnr. terrentenary- of tbc-imblicatfon of Hai-vey-’s Excrcifa 
Amdomica dc Jfofu Cardh ct Eanejuinh in Animnlihus 1 
been piously commemorated tmder tho auspices of .l 
Royal College of Physicians ol London, of w-liich, to qti, 
rom Mimk s lioTl, ho was tUo brightest ornament *'-.1 
hearing m mind the proverb “ JHera scripfn nuinet ” tlx 
IS every reason to .welcome tho three .volumes. wliich- In 
most appropnatcly appeared to' render the 'celebrations cc 


ph'te, and e.speeially Jlr. Cleoffiev ICoy-ncs’s boaiitifnlly 
printed .1 JIihl!i)ijrn]}liii oj'fhc IFi'i/inp.? of Willitnn llarrcij, 
M.l)., Di.icorcrcr of the. ('irrn/nfioii of ihr. BloodA This 
fine prodnet of tin' Caniliridgo Uniy-ersity Press by- a Cain- 
hi-idge graduate is- so extraordinai-ily- complete that some 
might like to imagine .some inspiralion from the late Sir 
William O.slcr, in w-lio'-,o study the first entry in tho 
Itiliiioyrii jihtj was iiiilde on Felniiary- 12th, 1927. . There are 
five Roetions, giving detailed acconiits of the Harveian 
yvi-itiiigs, w'itli iiiteicsting information alxiiit the actual 
resting jilaees of the rai'c editions. As is only- natural and 
right, nearly half the roinmc is oceiipiod witli the T)c Mnfu 
Ourdix; then the 1)c. t'irrvUiiinur SntKjtiinis (1649), or the 
Iw'o - letters to .Tnlin Riolan tho y-onnger, and tho l)c 
Grntrtdionr Animalium (1651) are simihu'ly deserihed. Tho 
•fourth section, Omnio Opera, deals with piihlications of his 
collected works, and tho fifth section, Jliscellaiica, c-on- 
tains notices of the neeropsy on the famous Thomas Parr, 
reputed to ho 153 years old. Sir George Paget’s publication 
of a letter from Harvey- to Samuel Ward, the Alaster of 
Sidney College, Camhridgo, letters snhsoquently- made public 
by- Dr. J. H. Ay-oling and Dr. S. Weir Mitclicll, and the 
well-known Vroirrtioncx, or notes for bis Liimleian Lectures 
of 1616, brought (Hit ns an autotype reproduction by the 
College of Pliysiciaiis in 1886. There is, in addition, an 
index of tho recorded eniiie.s, the British iMnseiini, w-itli 
35 entries, leading the College of Physicians of Pliiladelpliia, 
w'bicb has 31. 

Each section is inli-odiiced by a bibliographical preface 
full of sebolarly- lore— for e.xanqile, the details of the can- 
celled title-page of the l)c Circidationc Sanguinis — and 
tbcTc arc a niimboi- of well-oxeented illustrations and repro- 
ductions of title-pages. Tlic Dc il/otir’and the Dc Gencrn- 
tionc Aniinaliiim were both translated into English for 
tbo first time in 1653, but the responsible hand is unknown, 
and tlio .suggestion that it iras that of Dr. Martin 
Llcw-clyn, wlioso dedicatory poem to Hai-vey appears at 
the beginning of the latter translation, has not any 
evidence in its favour. The first English translation of tho 
JJc Mofu. Cordis has jn.st been edited by Mr. Keynes and 
issued by the Noucsueli Press. Of tho first edition of tins 
Dc illotn 17 copies have ijcon tracked dow-n; its Latin 
text lias been printed twenty times, the last occasion in 
ordinary type being in 1824; hut the College of Phy-sicians 
has now had 250 copies of a photographic facsimile of tlie 
original edition prepared to commemorate the tercentenary. 


ROYAL MEDICAL BENEVOLENT FUND. 


-At a recent meeting of the committee forty-nine cases yvere 
considered and £659 voted to forty-one applicants. Since the 
beginning of the ye.-ir £2,862 bus been made in grants to 
urgent cases of distress. The demands for help increase ; sub- 
scriptions are very- urgently needed, and slionld be sent to the 
Honorary Treasurer, Sir Charters Sy-monds, 11, Chandos Street, 
Cavendish Squijic, W.l. The following arc notes on a few- 
of the cases relieved at Oie last meeting. 


M.D.Durii., at tlie age of 76, with his wife blind and suffcrinfc from 
cancer, and without- ■ a penny saved, suddenly found himself ont 
of cmi'loyment. Xo provision liad been made for oid age, as since 
1912 he hod not been able to earn more than £300 a year. Before then 
ho had educated two sons for the medical profession ; one died during 
tlie war, and tile oilier is delicate .and is himself struggling to keep 
going. 'Pherc were also two danglitcrs to be educated. He will applv 
for the bid age pension. The Fund voted £40. ^ 

Widow, aged 69, of L.R.C.F. and S.Eel. The applicant's hnshand ilied 
of cancer, leaving her penniless. He Iiad been a sabiricd assistant, and 
on Ilia decease tlie widow received only £55, the salary due to his death. 
The sale of furniture and a small gift of £20 has bronglit iicr total 
capital np to £150. - The applicant is now Ii\-ing with a niece, the wife 
of a clergyman, who has only liis stipend and is unable to support her. 
Voted £26. 

yVidow, aged 77, of yi.K.C.S. Since her husband’s dcalli in 1884 the 
applieanC'haa maintained lierselt ns companion-housekeeper, but at 77 she 
is -unfit for. work, and her only income is the. oid age pension of. £26 a 
y-ear. Voted £26. 


The Royal Medical Benevolent .Fund Guild still receives 
many applications for clothing, especially for coats' and skirts 
for ladies and girls holding secretarial posts, and suits for 
working boys. 'The Guild appeals for second-hand clothes and 
•honsehold articles. -The gifts should be sent to the Secretary 
of the Guild, 58, Great Marlborough Street, W.l. . 


flibfioyrapAy of the irnlings of William Uarreu, M.l), Dhcoveri-r 
nf the ClTcnlatian of the Bloorl, 1G1S-IS2S. By Ceotfrey Kevnes yi y 
M-D.-,— F.K.<-'.8.- London-; -.CambridgO'.-UnLitrsiiy -Ptvfs 1958'' ’ fS v in'-’ 
pp. xii + 67; 8 illustrations and 12 reproductions of title-paec-i a-. neO 



914 Mat 26; 1928] 


LESSONS OE EAEE MALADIES. 


r Tfrrnrrnt*. 

L Mrnic4L JofuriL 


THE LESSONS OE HAHE MALAHIES. 

Annual Oration before the Medical Society of 
London by Sir Archibald Garhod. 

The Annual Oration before tlio Medical Society of London 
was delivered on May 21st by Sir Arohidald Garrod, 
K.C.M.G., D.M., r.R.S., whose subject W’as the lessons 
of rare maladies. Mr. Herbert "VV. Carson, President, 
was in the chair. 

Sir Archibald Garrod said that in rare diseases wore to 
be found the keys to not a few dark places in physiology 
and pathology. At the time of the First Empire, when 
the French universities were in the melting-pot, there 
were established in some of the medical schools professor- 
ships for the exposition of rare cases and diseases; and in 
the JDtctionnaire des Sciences Mcdkalcs (1813) there was 
an article by Fournier on rare cases which' extended to 
120 pages. In British medical journals and transactions 

the speaker had found only two addresses on this subject 

a series of Bradshaw Lectures by Sir James Paget in 1882 
and a previous oration to the Medical Society by Sir 
Jonathan Hutchinson in 1889. Paget observed; “Wo 
ought not to set them [rare cases] aside with idle thoughts 
or idle words about ‘ curiosities ’ or ‘ chances.’ Not 
one of them is without meaning; not one that might not 
become the beginning of excellent knowledge, if only we 
could answer the question— Why is this rare? or, being 
rare, why did it in this instance occur? ’’ The study of 
what might be styled Nature’s experiments was of special 
value, and many lessons which rare maladies taught could 
hardly be learnt in other ways. 

There were two preliminary questions at the outset: 
Was it needful to draw a dividing line between rare cases 
and rare diseases? and What was meant by a rare disease? 
The answer to the first question was in the negative. Any 
example of a rare disease was a rare case, and a rare 
syndrome might be due to a lesion of a common kind in an 
uncommon situation. With regard to the second question, 
he did not propose to include in the category maladies 
which were common in hotter countries, but r.are or 
absent from our own, nor infective diseases of lower 
anim.als rarely met with in human subjects, nor maladies 
the common occurrence or rarity of which depended upon 
the prev.ilence or absence of dietary defects. The truly 
rare maladies touched upon in this oration were such as 
were seldom seen in men living on any part of the globe 
or under any conditions of life. As to the criterion of 
between those common' illnesses 
. which went to fill the hospitals and those so uncommon 
that the recorded examples could he counted upon the 
fingers every degree of rarity was represented ; yet it 
seemed to him that the bulk of diseases fell into Lo or 
other of the more extreme categories, and that compara- 
tively fe^r Trere “ somewhat rare.*' ^ 


digits; others were functional mutations, and these, like 
interferences with a delicate and complicated machine, 
might bring about results which, however undesirable, 
threw valuable light on normal working. Thus from tlio 
study of some rare maladies much knowdedgo w*as g.aincd 
of diathesis, the constitutional factor in the caus.ation of 
disease. Idios^'iicrasies also — thoso special sensitivities to 
certain protein substances, to pollens, foods, and drug's— 
had a share in the causation of some raro syndromes. ° 

Addison’s Scscarches, 

The orator took, ns his first example the least raro of 
rare maladies, Addison’s disease, specially to call attention 
to_ Addison’s pamphlet (1855), which was a model of scientific 
clinical medicine, controlled by morbid anatomy^ In the 
preface to that epoch-making monograph ' in which he set 
forth his researches Addison described it as " a first and 
feeble stop towards inquiry into the functions .and influence 
of the' adrenals, suggested by p,ath61ogy ’’ : for it was clear 
to him that it was. the seat and not the nature of the 
lesions which determined tho symptoms. From that “first 
and feeble step ’’ had grown up our knowcldge not only of 
■tho functions of the adrenals, but also of the other endocrine 
glands, and of Gie hormones which they secreted. As more 
had. been learned about them they had been recognized 
as tiio regulators of tho metabolism of the tissues, also of 
height and weight, temperature, and blood pressure. It 
had become increasingly evident that tho several ductless 
glands, acting, some as mutual opponents and others ns ' 
allies, formed a balanced mechanism, which set limits to 
the various functions, and by readjustments of which the 
phenomena of puberty and of the climacteric were brought 
about. Tho most recent advances in endocrine studies; the 
isolation and synthesis, first of adrenaline Itself, and lately 
of thyroxine; tho study of their physiological actions, and 
the utilization of insulin, might rank among the greatest 
achievements of medical science, and all might be traced 
back, directly or indirectly, to Addison’s researches. 

Passing to inborn errors of metabolissn, the orator men- 
tioned alcaptonuria, a rare anomaly, which behaved as 
a characteristic Mondelian recessive character, and was 
wont to occur in several brothers and sisters, whose parents 
were usually normal but wore in a large proportion of 
cases first cousins. By the study of this malady from the 
standpoint of chemistry, and by the administration to its 
subjects of a variety of aromatic compounds, much light 
had been tin own upon the katabolism of proteins * it had 
also shoira how a metabolic product might have the power 
of staining cei tain living tissues in a selective manner, 
and, further, that, a trifling deviation from the normal in 
metabolism and the presence in the tissues of small quan- 
tities of an intermediate product, normally destroyed might 
so lower the resistance of tissues that, after the lapse of 
many years, there was develoimd, under the stress and strain 
of dfl-ily liiGj * 1 . charactoristic form of ostoo-artliritis 
Another still rarer malady was congenital porphyrinuria, or 
haeraatoporphyna, which stained the' bones a deep brown 
colour,, and had taught us much regarding the action of 
light upon the living organism. 


Departures from. Type. 

One of the chief reasons why rare maladies could teach 
so much was because they called attention to the ordinarv 
things otherwise accepted as a matter of course. We to k 
for gr.anted our own asymmetry— regarded it as natural 
that the liver should lie to the right and the spleen to the 
left. A case of transposition of viscera set us thinking 
pondering as to the underlying causo of the more usual 
arrangement. Many rare maladies had as their underlying 
causes more or less abrupt departures from type such as 
wore usually spoken of as mutations, which were transmitted 
to offspring, either as dominant or recessive characters 
Such departures often threw light upon problems of heredity 
on the development of the bodj-, or of the living processes 
of which the body was tbe seat, and on the liabilities of 
individuals to special forms of disease. Some unfavourable 
mutations were anomalies of structure, manifestin<i- them- 
Bclvcs ns malformations, such as claw-hand nr nf 


, The orator’s next example was taken from that group 
of tissue anomalies which included the familio-hereditarv 
affections of the nervous and muscular systems to which 
Gowers gave the name of “ abiotrophies.’’ These illus- 
trated a point upon which Hutchinson laid much,- perhaps 
too much, stress— namely, the affinities between morbid 
states and their tendency to merge into each other. Thus 
in a particular family tissue anomalies might crop up in 
different members, in one some form of muscular atrophy 
in another -myotonia atrophica. The muscular dystroph-i’ 
and myotonia had in the observed cases been limited to the 
-collaterals of one generation of a family, seldom develop- 
ing before the age of 25 ; but cataract, which was associated 
with the syndrome had been traced back through four or 
favo generations. Some recent investigators held that tlio 
underlying factor, in the disease undi dfscussTon was a 
— endocrine glands, and that what 
d was a pluriglandular syndrome. It 


May s6 , 1923 ] 


THE BIUTISU PHARMACOPOEIA. 


• r TiiK ni»m»« 915 

, L MrmCAL JOD»SA» Cf J.W/ 


miglit woll bo tlmt ollior nlTccUoiis of this proup, tlio 
nbiolrophirs, would prove to bo local nianifestations of 
much wider maladies, and that., tho link botweou tho 
calcareo>is deposits and tho digital anomalies in myositis 
ossificans might bo found in a generalized defect of tho 
mcscnchymatous tissues, of which theso were merely tho 
most conspicuous signs. 

Ho next tonched upon tlio very raio and curious diseaso 
first dc.scribcd hy Gaucher in 1882, and known by his uamo 
— a form of enlargement of tho sidcen, met with in a 
child, and characterized by tho prosente in the splenic 
tissue of numbers of large Iiyalino cells whith stained but 
feebly. Before long it was realized that this was no form 
of malignant growth, and that the changes wero by no 
means limited to tho spleen, tho liver becoming greatly 
enlarged and the haemopoictic ti‘-sue generally being 
involved. In recent years it had been 'iiown that tho 
peculiar Gaucher cells, found in all the airocted parts, owed 
their swollen and hyaline appearance to the presence in 
them of a chemical substance, kerasin, a member of the 
class of galacto-lipins. One of tho latest theories was that 
hcic one had a perversion of the jnctabolic process, and that 
kerasin was a product of abnormal metabolism. Tho sub- 
jects of such maladies as tho abiotrophies and (Jauchor’s 
diseaso furnished striking examples of constitutional 
liabilities. It was because they were uncommon individuals 
that they wero predestined to suffer — in other words, tho 
patient rather than tho malady was rare. 


THE ERITJSK PHARMACOPOEIA. 

Pnoi'os.ti.s ron .\ Standikg Coiutissiox. 

Tun report of tho subcommittco on the British Pharma^ 
coiiocia, appointed hy tho Committee of Civil Research at 
tho instanco of tho General Medical Council, was published 
on May 17th.' In its fifty-seven pages it gives a brief 
account of tho evolution and present position of this 
official publication, records tho criticisms directed against 
tho existing machinery for its production and revision, and 
submits a series of ])ropo.sals for its futuro conduct and 
constitution. 'Iho subcommittee, which came into being on 
July 19th, 1926, was directed in its terms of rcferenco: 

To make inquiries, to colirct information, to receive evidence, 
and to make recommendations on tho quesiion whether ,it_ is 
desirable to make anv, and if so, what, alterations in the existing 
law or practice relating to tho picparation or publication of tho 
Uritish Phitrmiiroimim and to its adaptation to the rcquiremems 
of the British Empire. 

Tlic members of tho subcommittco wero as follows : 

The Bight Hon. 11. P. Macmillan, K.C. (Chairman). 

The Riglit Hon. Lord Dawson of Penn, G.C.V.O., M.D. 

Sir Donald MacAlistcr, Bt., M.D., .President of- the General 
Medical Council. • , 

Dr. H. H. Dale, F.R.S., Director of Department of Bio- 
chemistry and Pharmacology, Medical Research Council. 

Mr, Edmund White, Past-President of the Pharmaceutical 
Societv of. Great Britain. 

Dr. H. GT Dain, Chairman, Conference of Representatives ot 
Local Medical and Panel Committees, British Medical 
Association, 1919-24, 


Maladies Still Ohsnirr. 

In conclusion, the orator spoke of soiiio laro maladies 
tho lessons of which had been Icanit only in part or not 
at all. Tho syndrome known ns intermittent hydrarthrosis 
bad features which might be dr.scribed ns uncanny. 
Effusion into the knee-joint hero recuried with a regu- 
larity comparable to that of some forms of niaUuia, and 
was clearly not connected with the life-history of any 
parasito. An exactly similar periodic hydrarthrosis was 
sometimes met with in cases of arthritis of various kinds. 
There was undoubtedly a connexion between the cutaneous 
lesions of tho o_ry-thoma group and nffeclions of the joints — 
witncs.s tho familiar serum sickness. Again, periodicity was 
met with in other maladies of tho anaphylactic group, in 
oi-ytheniala occasionally, in asthma often, and in Henoch’s 
purpura almost always; but in none of these conditions was 
thoro any such accurate periodicity ns in hydrarthrosis. 
Iho most likely explanation was that each attack desensi- 
tized tho patient tor a time, at tho expiration of which the 
trouble recurred. 

Another yoi-y uncommon syndrome was sulphaenioglobin- 
aomia, . clearly an acquired malady, with no indication of 
family or hereditary^ occurrence. Its chief problems still 
av. aited. solution , Chloroma was another rare malady 
which presented iniportaut unsolved problems. Another 
of the most obscure of ■ rare diseases was that maladv 
involving the bone marrow, of which the copious oxcretion 
of the Banco Jones protein was the diagnostic sign. Tiiat 
weird mixture of infantilism and preniaturo senility wiiicli 
Sastiugs Giuard described under tho name of ** progeria,*^ 
and tho developmental anomalies of bony structures, of 
which achondroplasia, oxycephaly, and ]i 5 'pertelonsm might 
be cited as examples, had not' yet revealed their secrets, 
but would repay investigation. Of all these it might bo 
said that Jhey tended to pi-ovo tho truth of Harvey's 
aictum that Nature is nowhere accustomed more openly 
to display her secret mysteries than in cases wliere she 
shows tracings of her workings apart from the beaten 
path. The orator hoped that there would ahvavs be some 
who would seek to guess the riddles and to learn the lessons 
or the rarer maladies. 


At the annual meeting of the Medical Society of London, 
which preceded the oration. Dr. John Walter Carr was 
elected president for 1928-29, Dr. J. E. H. Roberts a new 
vice-president, and Dr. Anthony Eeiling and Mr.^R. Davies- 
Colley honorary secretaries. It was stated that tho societv 
imw numbered 626 Fellows, including 15 lionorary Fellows 
The vote of thanks to Sir Archibald Garrod for his oration 
was proposed and seconded hy Sir James Berry and Dr 
J. W. Carr respectively. 


The siibcommitteo’s task foil naturally into two main 
branches — consideration of tho legal position of . tho 
Pharvwcni)ocia and consideration of tho machinery for its 
compilation and revision in tlio light of current difficulties. 
So far as tho first question is concerned, it concludes that 
no change involving legislation is necessary, and the bulk of 
tho proposals jmt forward thoroforo relate to the method 
by which it is considered tho Pharmacopoeia should be pro- 
duced, and tho considerations which should govern its 
composition. In view of tho fact that no change in the 
law is sngge.sted, the subcommittee states: IVe recognize 
that . . . the carrying into elfect of our recommendations 
will depend on their acceptauco by the General Medical 
Council, hut wo are iiopeful that tho scheme wliich wo 
propose will commend itself to the Council.” The scheme 
rcferreil to provides for tho appointment by* the General 
Afcdieai Council of a solection committee consisting of 
persans nominated by tho Council itself, by the three 
pliarniaceutieal societies, and hy the Medical Research 
Conneil. This selection committee will nominate a 
Pharmaeopooia Commission, a permanent body, which will 
bo charged, under the general direction of the General 
Medical Council, with the actual work of preparing future 
issues of the British Pharmacopoeia. Provision is mads to 
secure tho co-oiieration, -ivliere it is desired, of representa- 
tive bodies in tlie Dominions and in India. 

. , Difficulties in Securing Co-operation. 

At this point we may recall the chain of events which led 
to the institution of tlie inquiry now completed. At the 
auturau meeting of the General Medical Council in 1925 
it was announced that preparations had been made to 
proceed with a revision. of the British Pharmacopoeia, 1914. 
Communications had been addressed to the various Govern- 
mental authorities interested, at home and in the 
Dominions, and to universities and medical corporations 
in this counti-y, inviting relevant suggestions, while tho 
Pharmaceutical Society of Great Britain had been asked 
to co-operate by nominating members of a pharmaceutical 
advisory committee and a committee of reference in 
pharmacy. The Council, therefore, proposed to proceed on 
the lines wliicli, had governed the earlier revisions. Diffi- 
culty was experienced, however, in securing assurances of 
tho requisite expert assistance, and it became clear that 
pharmacists generally objected to the pei-petuatiou of a 
system which involved the performance by them of a lai-fo 
part of tho work required, wliile tho responsibility for 
editing tho Pharmacopoeia was retained hy a committee of 
the General Medical Council. An interesting account of 

Stationery Offico or through any bookseller. 



THE BRITISH PHARMACOPOEIA. 


t Tllr JlBITtt* 
HtpiCkX. Jovv.nis, 



916 MAY 26, 1928]' 


tlio position by Professor A. J. ' v ’ ' ' H 

sity (he thou lield the chair of 

College, Iioiidoii) was published in the Jintish Mcdtcal 
Journal ou January 2nd, 1926 (p. 30). In it ho gave a 
critical analysis of the methods employed in the prepara- 
tion of the Tiritish Pharmacopoeia and of the United States 
Pharmacopoeia, the tenth revision of which had just been 
completed. As a result of the criticisms directed against 
its procedure, the General Jledical Council convened a 
conference between the members of its Pharmacopoeia Com- 
mittee and lepresentativcs of various medical, scientific, 
and pharmaceutical bodies, and at a meeting on Fcbrnaiy 
23rd, 1926, a free discussion took place. Tlie outcome of 
these proceedings was the a])pointuient of the sidjcommittee 
whose report is now under review. 


Defects in the Present Sijstcm. ' 

This document surveys the evolution of the British 
Pharmaeopocia from the earliest times, giving partietdar 
attention, of course, to the jjart played 63- the General 
Medical Council in the execution of its responsibility for 
the production of this work under the Medical Acts of 1858 
and 1862. A review is given of the methods of prejiaration 
adopted for each successive edition from 1864 to 1914, in 
the course of which period the S3-stem now in the melting- 
pot was gradually built up. Reference is then made to 
certain developments which have taken place since 1914, 
such as the pa.ssing of the Therapeutic Substances Act, 
1925, and the subcommittee proceeds to comment on the 
machinery of the General Medical Council in this period, 
stating that : 

“ The functions of the Pharmacopoeia Conference and the com- 
mittees of reference set up to assist in the preparation of the 
fifth British Phannacoporia came to an end on its publication. 
The Pharmacopoeia Committee of the General Council continued 
to meet at intervals, and presented halfrjearly reports dealing 
with matters referred to above (e.g., the Therapeutic Substances 
Act), and any other topics arising which affected the British 
Phurmaropoiia. But no systematic or continuous work was under- 
taken with a view to the next revisal, and no digests of material 
were compiled. ... In 1921 the Pharmacopoeia Committee 
received an offer of co-operation in matters of common pharma- 
ceutical interest from the Ghahman of tiio Committee of Revision 
of the United States Pharmacopoeia, which was cordially accepted, 
and this was followed by the transmission of advance copies of 
material compiled by the United States Committee dealing with 
proposed omissions and additions, drafts of new monograph and 
the like.” 

-After giving .a surve3- of the more recent event-S men- 
tioned above the subcommittee submits a detailed study 
of the legal status of the Pharmacopoeia throughout the 
British Empire, and goes on to review the criticisms of the 
existing regime placed before it by interested parties. 
This criticism, the report states, was directed against 
both “ the method of production and the resulting pro- 
duct.” AVitb regard to the criticism of what may be 
termed the non-expert status of the Council the sub- 
committee remarks : 

“ It was pointed out that the General Medical Council has a 
number of most important public duties, judicial and administra- 
tive, to perfomi, and that its membere are selected not with a 
Tieiv to their fitness or capacity to take part in the production of 
the British Phai-macopocia, which is only one of their functions 
among others, but rather because of their general ability and 
professional standing.” 

The subcommittee found that one of the main objections 
to the existing sy-stem came from those who bad assisted 
in the production in the past, and who were dissatisfied 
with the status, accorded them in relation to their work. 
This was not confined to. the pharmaceutical societies: the 
complaint was general that the experts in the various 
hraiiclies of science whose collaboration was essential did 
not enjoy a responsible status such as they- claimed their 
services merited. 

The report proceeds to consider the nature of the 
Pharmaeopocia, introducing its discussion with the note: 

” In early times pharmacopoeias were little more than descrip- 
tive lists of medicines in use by Uie profession, and their com- 
pilation was generally the work of medical men. But a modem 
pharmacopoeia must 'be much more than this. It must contain 
not only a carefully scrutinized list of current drugs of repute, 
bat also authoritative standards whereby the purity and efficacy 
of these drugs may be tested.** . ^ 


The definition suggested by the British Bfedical As.so- 
ciatioii* is quoted : 

” The Phitrmarojiocia should contain, so far ns practicable, all 
those drugs ' and preparations whicli experience siiows to be in 
common use hj' medical practitioners and which in tlic interest 
of the public require a standard molhod of prcp.aration, or a 
standard of strength) or a .standard of purity; provided that such 
drugs and preparations have a therapeutic or diagnostic value, 
or arc pharmacouGcally ncces.sary.*’ 

The memhei'.s of the .subconimittee came to the conclusion 
that it was uiineees.saiy for thorn to discuss in detail the 
sphere of the Pharmacopoeia, as this was a mattef for those 
chared with the preparation of future edition.s, and they 
therefore coneciitrated their attention on the question of 
seeiiriiig that tliis work should he undertaken 113' tho.^e 
best fitted for it. The resailt of their deliher.atioiis on this 
m.atter has alreiul3- been indicated, and is given in gi eater 
detail in the snmniary printed below. AVitli regard to the 
period of publication, it is suggested that the revision 
should he so arranged that the successive issues of the 
British Pharmacopoeia should npjiear in tlic middle of 
the intervals of the issues of the United States 1‘harma- 
copoeia which is alrcadv* published oveiy ten years. 
Considerable weight is attached to the e.stahlislimcnt of 
an adequate secretariat with suitable staff and equip- 
ment, in view of the importance of co-operatinii with 
other parts of the Empire and with the IJuited States, 
and the growing international aspect of pharmaeontical 
enterprise. Tlie reiiort indicates that the ■subcommittee 
has been assured that the important work of research, 
often of a voluntary- nature, which has so frequently been 
provided in the past by experts with laboratory facilities 
nt their disposal, will he given to the jiroposed Pliarma- 
ceiiticnl Commission increasingh-, if it is established. 

Ill making investigation into the question of the adapta- 
tion of the Pharmacopoeia to the needs of the Empire 
commnnications wdre addressed to a number of the 
Dominions and Dependencies, and for the -most part their 
ansivors indicated that they were either satisfied with the 
existing 63-stem or were prepared to' accept a revised 
Pharmacopoeia without representation on the body respon- 
sible for its production. Various Canadian interests, how- 
ever held that Canada should have a voice in revision, 
hut the Canadian Gov-ernment, although twice approached, 
did not find it possible to appoint an authoritative repre- 
sentative to discuss with the subcommittee the best means 
of adapting the British Pharmacopoeia to Canadian 
requirements. General suggestions for adapting the 
Pharmacopoeia to regional needs are given in the report. 


Conclusions and Becommendations. 

The report gives the following summary of the principal 
conclusions and recommendations of the subcommittee : 

(i) That it is n°t necessai-y or desirable to make any alleratioiis 
in the existing law relating to the preparation or publication of 
the British Pharmacopoiia. 

(iil That the General Medical Council set np forthwith a 
Selection Committee to be cliarged witli the duty of selecting 
persons to form a new body to he designated ” The Pharmacopoeia 
Commission.” 

(iii) That the composiilion and functions of the Selection Cott>- 
mittee be as follows: (a) The Selection Committee should oomi.wt 
of four pei'sons nominated by the General Medical Council, three 
persons nominated jointly by the Council of the Pharmaceutical 
Society of Great Britain, the Council of ihc Pharmaceutical 
Society of Ireland, and the Council of the Pharmaceutical Society 
of TSforfcbern Ireland, and two pet'sons nominated by the Medical 
Research Council; the representatives in each case to be cliosen 
by the nominating body either from among -or from outside its 
membei”ship. (^) The chah'man of the Selection Committee should 
be appointed by the General Medical Comicil from among their 
four representatives, (c) Tlie Selection Com»iiittce so appointed 
should select persons representative of the various ' appropriate 
departments of Icnowledge and experience to form the Pharma- 
copoeia Commission, (d) The number of persons selected to foim 
the Pharmacopoeia . Commissiou sliould not be prescribed, but 
should be left to the discrotion of the Selection Committee, who 
should have power from time to time to select additional pei*sons 
for permanent or temporary membership, including representatives 


*X “watching'’ co^itlee was appomted by the British Medical 
Association in JuU’, 1926; a memora-ndum was prepared for presentation 
to the Euheoro-mittee, and evidence on behalf of the ABsociafion was given 
by Dr. J. tV. Bone and Dr. G. C. Anderson, Deputy iledical Sccretarr 



May sG, 192S] 


SCOTIiAND, 


Tir>; rnrn*!^ 
Medical Jult.xal 


917 



018 May 26, 1928] 


KNGLAND AND WADES. 


[ Tiir n«ms« 

tlKMCAL JacnyAV 


Bolam, M.D. (cliairman), Dr. J. W. Bone, D.aino Janet 
M. Campbell, M.D., Latly Cynthia Colville, Dr. AV. A. 
Daley, Dr. J. S. Fairbairn, Dr. T. Eustace Hill, Miss Alice 
Gregory, Blr. A. B. Maclaclil.an, Dr. P. Ti. Kay Alenzie.s, 
Mre. Bruce Richmond, and Miss Katherine J. Stephenson. 
The secretary rvill be Mr. AV. H. Homes of the Ministry 
of Health, to whom all communications i-elating to the work 
of the committee should be addressed. 

King Edward’s Hospital Eund for London. 

The Prince of AA'ales presided at the annual meeting 
of the King Edward’.s Hospital Fund for London, held at 
St. James’s Palace on May 15th, to which a brief i-efer enee 
was made in our last issue (p.883). After reading a message 
from the King, in which His Majesty expressed his gratiti- 
cation at the i-esmlts achieved by the special distribution of 
£255,000 received from the estates of the late Mr. and Airs. 
John AA'^ells, which had helped the hospitals of London to 
provide 1,600 additional beds and to meet other urgent 
reqnirernents, the Prince of AA^ales stated that the aeeorrnts 
showed a better resrdt than had been anticipated in 
November, wlierr the Leagire of Alercy annorrneed that it 
would give the Fund £17,000 instead of £15,000, so that 
the ordinaiy distribution could be increased to £247,000. 
This year thej- had already had a gift of £10,000 for gener al 
purposes fr om an anonymous donor-, artd their capital had 
been increased by a donation of £10,000 from Mr-. J. J. 
Crosfield. Referring to the statistical r-eport on the 
hospitals of London His Royal Highness said the total 
voluntary conti-ihirtions to the 140 hospitals amounted to 
something like £1,800,000 a year. In the repoi-t-, for the 
purpose of helping hospitals to coirtrol their expenditure by 
providing conrpar-ative figures of cost, quantities corrstimed 
were now given as well as money spent. The inquiry by the 
Pay Beds Committee into the question of hospital accom- 
modation for the middle and professional classes was near-ly 
finished, and the coneUrsioits would be based on a study of 
pay beds as they now existed in London. Grants from' the 
Wells legacies, which began in 1924, had for four vear-s 
enabled the Distributiorr Committee to take each rrigent 
scheme as it came along, at any time of the year-, and give 
it a grant. In addition to other work, three new hospitals 
had been built and four had been rebuilt on new .sites. 
In conclusiorr, the Prance referred to the loss the Ftrnd had 
suffered by the deaths of Lord Cave, Sir AFilliam Chinch 
— who was a member of the council for twenty-seven joars— 
and Sir John Craggs. Lord Revclstoke, honorary treasurer, 
presented the accounts, saying they had been able to carry- 
forward £2,700 as a balance to next year, and gave an 
interesting account of the origin of the AA'ells legacies. 
The report of the general eonncil submitted by the Earl 
of Dononghmore, chairman of the Management Committee, 
after referring to several matters already mentioned, stated 
that the total sum distributed during the last ten years 
including all special payments, was £3,360,688. Tim British 
Chanties As-sociation again gave £15,000 last year, while 
an .anonymous donation of £8,000 was received. Spcci.al 
consideration has been given to various aspects of the 
accidents prohlem, arising out of iucrea.sed road traffic and 
particular attention has been directed to the burden thrown 
upon hospitals provided to meet local needs by cases arising 
from this cause. The Fund is engaged in inquiries with 
a view to preparing practicable proposals to lay before 
a conference of the various parties concerned. A report 
on the now edition of the Fund’s statistical report was 
ajiproved. This edition is the first to be based on the new 
regulations under the revised uniform system of hospital 
accounts, and contains much valuable data relating to 
income, expenditure, and working costs in 139 institutions. 
The inoceediiigs terminated with the moving of a vote 
of thanlcs to the Prince of AAbalcs for presiding and for 
his continued interest in the Fund. 

The Hospital for Si-k Children and the Foundiing: 

Hospiiol .=ite. 

The need for the reconstruction of tlie Hospital for 
Sick Children, Great Oi-mond Street, London, has been 
recognized for some time past, and consideration is being 
given to tlic question of securing a new site. Eariyr this 
year the board of the hosiiital was approached bV the 


Foundling Estate Protection Association with the iirojiosal 
that the Foundling Hospital .site should bo inircbased 
jointly, the forecourt to bo pri-servcd as an open space for 
the public and the Cliildrcn’.s Hospital to he rchiiilt wliero 
the “ Foundling ” buildings now stand. Air. Stanley Hall, 
F.R.I.B.A., has reported that to rnbnild the .Sick Children’s 
Hospital on its present site would be attended with grav-o 
disailviiiitages as regards air, light, and Iiealtti conditions 
generally-, and at a general court of govcrnor.s on Alay l6tli 
it was stated that the Council of King Edward’s Hospital 
Fniid, in view of the architect’s report, would raisd no 
objection to efforts being made to secure a new site, jiro- 
vided that, the board was sati.sfiod with the prospect of 
.securing adequate funds. A committee lias been formed 
from the board of raaiiagemeiit and from the Foundling 
Estate Protection Association, which is in negotiation with 
the owner.s of the propeity, and if the result of these nego- 
tiations i.s satisfactoi-y an appeal on a largo scale will, no 
doubt, be lanncliod. Almost the only- critics of the schomo 
ncro described ns those who advocate other plans for the 
cxjiloitation of the Foundling Estate. 

Prevention of Tuhrrculosis In Childhood. 

In a incinBrandum of the tuberculosis group of the Society- 
of Alcdical Officers of Health reference is made to a useful 
form of preventive work which has been adojited in .Sbrop- 
sliirc. Infective tiibcrciilons women who are jiregiiant are 
admitted to a .sanatorium until just before labour, when 
they are transferred to a special opon-nii- ward at a 
maternity hospital. After her confinement the patient 
relui-ns to the sanatorium, and the infant is sent for one 
year to the County- Homo for Ailing Babies, whore four 
beds are resen-ed foi- these cases. Attempts are made at 
the end of the year to hoard out the babies for a further 
period with rclntiycs of the patient. Emplmsis i.s laid also 
in the report on the importance of tracing sources of 
infection, it being borne in mind that the notified case is 
often not the chief danger. Removal of potential patients 
from a soiiixe of infection is advocated, either, ns in 
France, by the Grancher system, or by making use of a 
residential open-air school. Attention is called to- the vnlii- 
ahlo work which the general practitioner can render as 
regards steps being taken for the prevention of infection, 
.and also for the education of the lay- public. A closer 
deereo of co-operation fs advocated between the tnlierciilosis 
department, the school medical department, and maternity 
.and child welfare centres. Tlio opinion is expressed that 
the pi-cvcntion of tnhercnlosis would be facilitated by 
extending Ins-nrancc Act benefits to the dependants of the 
insured. 




Aonointment ol DIsp’nsarjr Atedical Officers In the 
Free State. 

Under the Local Authorities (Olfieeis and Employ-ocs) 
Act 1926 a dispute has arisen between the Department of 
Local Goveniment and Public Health and the South Cork 
County Board of Public Assistance with regard to tbo 
appointniont by the latter body of a dispensary medical 
officer who was not one of its officials, and served under 
another bc.sltli antbority. In connexion with the matter 
the Local Government Department, in a letter to the 
local body, pointed out that as none of the existing 
medical officers in the employment of the Board was 
desirous of accepting the office, the vacancy should be 
rei>orted to the Local Appointments Commissioners. In 
reference to the minute of the Board requesting the 
Minister to sanction the appointment of Dr. Ny-lian, tbo 
Alinister desires to state that he is unable to meet the 
wishes of the Board. If it were possible for the Boai-d to 
nominate a particniiu- officer from outside their area, a 
condition of affairs would arise that practitioners generally 
woiild bo denied opportunity' for preferment on grounds 
of their expertence or attainments. After most careful 
consideration, the Alinister has decided, in the general 
interests, that, where an appointment is not proposed from 
existing officers of a local authority, the making of the 



May 26, 1928] 


CORRESPONDENCE. 


[ Tnr. PRrn^n * fll Q ' 
HeDJCAI. JoVI^Ui V-Lt/ 




nppoiiitincnii should bo plnccd iu lUo brvuds of tlio Tiooal 
iVppointmonts Commissioners, wlio luivo suitalilo mncliincry 
for assessing tlio vetnlivo merits and qunlifieations of 
eligiblo candidates. 

Alcillcal Benctlts (Northern Ireland). 

In tlm Norliiern IIouso of Commons wlicn n mono}' reso- 
lution in connexion with tlio National lloaltli Insur.anco 
Dill was proposed, Labour and NationnIi.st members urged 
tlio inclusion of medical benefits under tbo Act. Mr. Kyle. 
(Labour) said that unless they got an assuranoo that such 
boncfits would bo included, ho thought every mcasuro of 
this kind should bo opposed to tho utmost.. Thcro was 
nothing impossible about tho proposal, ho said, and tho 
Local Government Commission were within an aco of 
reporting in favour of it when they woro stampeded by 
mombers opposite in favour of tho dispensary system. Ho 
declared that under tho present system thcro was an in- 
ducement to doctors to certify peojilo who were not in- 
c.apablo of work. Mr. J. Devlin and Air. Ilealy supported 
tho proposal. Mr. J. At. Andrews, Minister of Labour, 
■s.-iid that at tho present moment it would be inadvisable 
to adopt tho suggestion, 'riicro wofo special difficulties in 
connexion with tho matter, and it would bo very foolish, 
in tho interests of tho poorest of their people, to luako any 
drastic decision. Ho did not think that tlio dispensary 
system was unpopular, and they must bo careful that in 
doing away with that system they did not do tho people 
an injury instead of a benefit. Tho resolution was agreed 
to, and tho Bill was carried through its romaining stages 
and passed. 

Return of Empty Atcdlctnc Bodies and Cases. 

At Cavan Circuit Court, Messrs. Evans Sons Leschcr and 
Webb, Ltd., Liverpool, sought to recover £26 9s. 9d., s'aluo 
of unroturned empties in connexion with tho supply of 
■ medicines, tho defendants being tho Cavan Board of 
Health. A sum of £15 was lodged iu court to meet tho 
claim. Eighteen dispensary districts wero involved, and 
sixteen doctors woro in <ourt. Dr. O'llourkc, Ballyconnoll, 
said that dispensary doctors .should not bo asked to return 
empties. It was not iu the terms of their appointment. 
There should bo soinothing in tho nature of a clearing 
linuso. A decree was given for £24 7s. 9d., with £5 
expenses. 


Cflri*iS|jontr£nc^. 

THE PATHOGENESIS OP ACUTE PRIMiVBY 
GLAUCOAIA. 

Sin, — In a paper on tho relation between capillary 
pressure and secretion, published in the Procccdinp.'i of tho 
Royal Society, May 29tli,1912, AI. Flack and I stated that 

tbo increased tension iu glaucoma is duo to increased imbibition 
and secretion of fluid, resulting from an altered metabolism 
of tlio ocular tissues,- leading to comprcs.sion of tlio veins, and to 
a rise in tho capillary-venous. pressure; and therefore intraocular 
pressure. . . . Acute glaucoma resembles an inflammatory con- 
dition in any other part of the body.” • 

Ilr- Maitland Ramsay, in his address published in tho 
Bnftaa J/cdical Journal of Alay 12th (p. V89), ascribes tlib 
disease to a toxin producing congestive changes — a similar 
view.^ Ho assumes that there is normally, both in the eyo 
and in tho glomeruli of tbo kidney, an excess of pressure 
sufficient to overcome tbo osmotic pressure of the plasma 
proteins and produco filtration. Tliis is a view com- 
bated by me and my co-workers, AI. Flack and J. McQueen. 
•Dukc-Elder, by his recent ingenious observations on the 
retinal venous and arterial pressures, has not, in my 
opinion, secured any evidenco which proves his assumption 
of the existence of a capillary pressure much above that 
of tho intraocular fluid. 

Tamura, in Japan, recently. has confirmed our view con- 
cerning the glomerular capillary pressure. -The excess of 
this ovm- that of the fluid in the Alalpigliian capsule does 
not suffice to produce filtration. The whole question of 


capillary pressure and filtration is dealt with in a paper 
now ready for puhlication by James AIcQueen and my.=olf. 
This will appear in tho British Journal of Experimental 
Pathology. 

Ry secretion of fluid wo moan tlio control of tho amount 
and nature of tho fluid by tho living cells and endotholi.al 
membranes. It is theso which aro altered by metaholio 
changes and toxins. It is not tho push of a capillary 
prc.ssuro, hut the pcnctrnhility of tlio endothelial membranes 
and tho pull of tho tissue cells, which is of first importance. 
— I am, etc., 

London, N.W., Jtoy 17 tl>. Leoxaud, Hill. 


Sin, — Tho interesting lecture by Dr. Alaitland Ramsay on 
the pathogenc.sis of acuto primaiy glaucoma raises of neces- 
sity tho problem of tho genesis of tho intraocular fluids. 
Let mo quote: 

“ " ' ‘hat tho tissue fluids como from tho 

lugli tho walls of tho capillaries, and 
that tho intraocular fluids obey tho 
sauio ph 3 *sico<liemical laws. Ho believes, tlicrcforo, that tho 
aqueous Immour is a dialysato, and has brought forward evidenco 
to prove that it is neither a secretion nor a filtrate. His wor.k 
has put tho physiology of tho intraocular circulation into lino with 
tho circulation in tho body as a whole.” 

This seems to mo to bo going somewhat fast. I am afraid 
there aro somo licdgcs and ditches in tho course, but I am 
ready to bo instructed bow' to take tlicm. Let mo state 
tho problems. 

As regards tho filtration theory, it rests on tho belief that 
tho pressure iu tho capillaries of tho eyeball is a filtei-ing 
pressure — ^that is, above 48 to 55 mm. of Hg. It is gener- 
ally agreed that tbo intraocular pressure is somewhat lower, 
by 1 or 2 mm. of Hg, than tho pressure in tho retinal 
veins. Taking tho intraocular pressure at 25 mm. of Hg, 
on tho filtration thcoi-y thcro would bo a loss of pressure 
(prossiiro gradient) between capillaries and veins of more 
than 22 to 28 mm. of Hg. Elsewhere in tho body the loss 
of pressure between capillaries and veins is 1 to 2 mm. of 
Hg. Loss of pressure in tho arteries is due to ehango 
of arterial lumen — its narrowing — and the main loss of 
arterial pressure in tho body is in the arterioles. There is 
no ovidenco of any peculiarity in tlie lumen of the capil- 
laries of tho eyeball to mako this enormous reduetion of 
pressure between capillaries and veins. It seems more 
probable that tho capillary pressure in tho eyeball is 1 to 
2 min. of Hg above tbo vein pressure, as elsewhere in tho 
body. Consequently no filtration pressure exists in the 
capillaries of tho eyeball. 

Tbo secretory theory denied tlio existence of a filtration 
pressure. Tho mechanism of secretion remained more or 
less a mystoiy. Now wo have the dialysis tbeoiy. A very 
notablo experiment in dialysis was carried out by Abel, 
who passed tho blood from an artery through collodion 
tubes to a vein, the collodion tubes being placed in a bath 
of saline. TIio salino solution is later anal 3 -sed for tho 
substances that Iiavo entered it from the blood by diffusion 
-^amino-acids, etc. It will bo noted that what enters the 
saline solution aro tho crystalloids it does not contain 
originally or contains in less concentration. Were the bath 
distilled water, all the various salts, etc., of the blood 
would pass through the collodion membrano. 

It is attractive to think of the tissue fluid as an Abel’s 
bath, and similarly with tbo aqueous humour of the eye. 
But the bath in the case of the eyeball must be renewed. 
Six eubio millimetres of aqueous fluid per minute Is 
estimated to bo made in tbo eyeball. Consequently six 
cubic millimetres of salt- or crystalloid-deficientwater has to 
ba made per minute in tbo eyeball from somewhere to allow 
of dialysis occurring ; and perhaps more, because the six 
cubic millimetres estimate does not include what passes out 
through tbo canal of Schlemm and what may bo absorbed 
into the capillaries of the eyeball, because if there is no 
filtration pressure in the capillaries of the eyeball, and the 
‘ pressure gradient between capillaries and veins is 1 to 
2 mm. of Hg, then the osmotic pressure of tbo blood in tbo 
capillaries is unbalanced practically, and water will pass 
into tho capillaries of the eyeball from the aqueous hninonr. 

I do not wish to undervaluo tho evidenco gained by 


920 MA.T 26 , 1928 ] 


CORRESPONDENCE. 


t Tjir 

StkMCii, Jovnxit 


experiments on imemorrliage. Tlicre the tissue cells 
mohilizo water deficient in salts which jiasses into the 
capillai'ies to restore blood volume. But if in the case of 
the eyeball the ciliary procc.sses, for examjile, ])roducc a 
salt-deficient water, the}’ might, it seems to mo, just a.s 
easily produce a normal intraocular fluid; and now we are 
hack again at a secretoiy theory. The most important 
bodge to be taken in the course is an accurate direct 
mtasurement of capillary pressure in the eyeball. But it 
is a pleasure to know there are workers in the saddle. — 
I am, etc., 

/iiilesowen, Hay 12th. J.\JIE.S M. McQuEEN. 


IMMUNITY EOULOIVING HERPES. 

SiT!, — Dr. Parkes Weber, for whose encyclopaedic know- 
ledge of the literature of disease I have the highe.st regard, 
expre,sses in your issue of May 19th (p. 875) doubt as to 
the possibility of second attacks of true herpes. I think 
everyone will agree that in the vast majority of cases one 
attack of heriies does confer immunity. Yet 1 have seen at 
least three cases of recurrence of true herpes. The first 
was a surgeon whom I saw many years -ago with an attack 
of herpes frontalis on the left side. There was di.stinet 
scarring. Twenty 3 'ears later I saw the same surgeon 
suffering from an attack of frontal herpes on the right 
•side, and, on my expressing surprise, he told me that some 
years before this attack, and after his previous attack of 
left frontal herpes, ho had had an attack of herpes in the 
deltoid region, and he showed me the scarilng which had 
resulted. 

The second case was that of a lady whom I saw in con- 
sultation with the late Dr. Lewis, a case of severe heipes 
in the distribution of the right fifth nerve. A year before, 
Dr. Lewis told me, she had liad an attack of herpes zoster! 
the scarring from which was still voi*y marked. 

The third case was a hospital patient who liad an exten- 
sive oi-uption of herpes zoster. When I told him it was 
‘ shingles ” ho said that ten i-cars before ho had had an 
attack of shingles in the neck, and on examining his neck 
I found marked scarring of the nature of which I could 
have no doubt. 

I may mention, jneidontally, with reference to the third 
attack experienced by the surgeon that bi.s daughter .a 
foitnigbt after the attack developed, became ill witli 
enic'ken-pox. — am, etc., 

London, AV.l, May 21st. JameS TaYlOH. 


VACCINES IN THE TREATMENT OF 

gonorrhoea. 

bin, --Dr. McCrea’s article on the above subject in the 
. mnmtl for M.ay Stb (p. 755) deserves the careful attention 
of the venereologist and for .a varietv of reasons, all of 

men'* the successful treat: 

ment of male gonorrhoea in the clinics working under the 
Ministry of Health scheme. ^ 

From my own experience when i„ charge of the venereal 
drseases clm.c at Warrington and in private pr.actice, I can 
thoroughly endorse Dr. McCrea’s general conclusion tlmt 
the routine administration of vaccines in acute male 
anterior gonorrhoea not only reduces the number of com 
plications, but materially shortens tlie time the patient is 
under treatment. 

At the Warrington clinic from 1921 to 1924 vaccines 
were given as a routine, and during that period there was 
not a single in-patient admitted suffering from gonorrhoea 
or any of its complications. During this time the vaccine's 
used wore those of the residual tj-pe, prepared by Dr. C E 
Jenkins, the pathologist to S.alford Royal Hoqiltal. In 
the year 1924, when vaccines were not given .as a routine 
thoro wore 119 in-paticiit days on account of gonorrhoeal 
complications. 

Dr. McCrea’s figures show; however, a surprisingly high 
incidence of posterior extension of the disease, both in 
the vaccine and the non-vaccine series — 81 per cent in the 
former and 88.5 per cent, in the l.atter. Under the routine 
treatment hereafter described tl.e proportion of such eases 
approximates 25 per cent., and on iuvestig.ation these .are 


found to have committed some indiscretion in freatment, 
exercise, or drink. A proportion of 80 per cent, is certainly 
not imii.siinl where reliaueo is jil.aeed upon the patient 
treating liim.sclf with a .syringe, and no vaccine is Miffi- 
eieiitly ])otont to counteract tlie damage wrought bv that 
most dangerous of all urological inslrninonfs. 

The routine treatment I adopt for a case of nciile 
anterior urethritis (duration two to seven days) i.s as 
follows : 

(1) Alkaline diarctic mixture. 

(2) Wearing of a proper .suspensorv bnmlngc of Ibe Ivpe mode 
and provided at the Cit}’ of Salford ^Iniiicipal Clinic, 

(3) Vaccines cycr}’ seventh day for nine weeks. 

(4) Daily iiTiyafions into thr^ hUtthlcr from the commt necnirnt, 
with the lowest pressure safficient lo oveicoinc the resistance of 
the sphinctci muscle. For tho first three weeks the irrigations arc 
of potassium 'permanganate, increasing in strength from 1 to 
3 grains to the pint twice or thrice daily. In the next three 
weeks the solution used is oxycyanide of mercury in similar 
strengths, given twice daily. In the seventh, eighth, and ninth 
weeks picric acid is used, increasing in strength from 1 lo 3 
gr.ain.s lo the pint, and administered once a day. In the tenth 
week silvei nitrate, 1 in 10,000, is used on nlternalc days, and 
during this week the urine and the prostatic secretion are examined. 
From the commencement of treatment, upon every occasion the 
patient attends, smears arc taken if available, and the urine is 
examined at each visit. During the eleventh and twelfth weeks 
Ircalmciit i.s entirely suspended, the patient merely attending for 
urine examinations daily. In the IhirlecnIIi week there Is given 
a provocative injection of vaccine or of aolan, and specimens are 
taken for examination in twenty-four and forty-eight hours. 

Criteria of cure arc ; ‘no discharge, no pn.s‘ in morning urine, 
no gonococci recoverable from mothra or prostate, no abnormal 
proslatic smear, nrcthra noniial ^ on iircthroscopic examination. 
I’ormission lo marry is not given till tho patient tias been negative 
for six months after the cessation of treatment. 

I have found that under this regime approximately 
75 per cent, of acute gonorrhoeas remain anterior in site 
.and are free from all clinical and hactcriologicnl signs of 
the disease bj’ the tenth week. In no such ease lias .a 
relap.se been observed in tbo six months succeeding tho 
ce.ssation of treatment. This is to be attributed to tbo 
following fnctor.s: (1) routine vaccines; (2) bladder irriga- 
tion from tlie beginning; (3) change of solution cvciy week 
as to strength and overj’ third week as to kind; (4) abso- 
lutely forbidding the patient to u.se a syringe; (5) irrigation 
at least once daily for tbo first four weeks; (6) if the 
patient is unable to .attend at least once daily be is pro- 
vided with a correctly designed homo irrigator, in the use 
of ivbicb bo is tborougbly and praeticalh- instructed. 

In jintients who appear with a discharge of two days’ 
duration or less, a more intensive line of tre.atmcnl is 
adopted. This consists of : 

(1) Routine vaccines; (2) during the fii-st week posterior irriga- 
tions with potassium permanganate (1 grain lo the pint) tlirice 
daily : (3) after each irrigation the patient lies on tlie couch and 
20 minims of wann iodargol are injected into tlie anterior nretlira, 
tlie penis clamped, and the iodargol gently massaged along the 
canal. Tliis is retained for at least fifteen minutes. In 50 per 
cent, of such early cases there are no clinical or bacteriological 
signs of the disease at tlie end of five weeks. The iodargol is 
discontinued at the end of seven days and the ordinary routine 
is carried out for the remainder of the time, except that from the 
fourth week onward the patient only irrigates once on alternate ■ 
days. 

I am convinced that the syringe is the m.uin cause of 
posterior involvement, and that in clinic treatment it 
should, as is the case in the Salford Municipal Clinic, ho 
releo-.ated to the museum. Treatment is available in this 
clinic for males and females every day from 8.30 n.ni. to 
8.30 p.m., and for four hours each on Saturday and 
Sunday. It would seem only possible to give tlie man with 
gonoriiioea adequate modern treatment in an establishment 
which is open twelve hours daily, and where the treatment 
is carried out by a whole-time staff of highly trained 
orderlies. Vaccines are decidedly worth while, but of mucli 
greater moment is the discarding of the syringe in favour 
of copious posterior irrigations from the beginning. 

The method adopted in this clinic for the examination 
of pus in the second urine after prostatic massage is that 
described by Dr. Cutlibert Dukes in the British filcdical 
Journal of March 10th (p. 391), any count over 100 being 
regarded as abnormal.— I am, etc., 

E. Ttilve Buhke, 

Venereal Diseases Sledical OfTicer for the 

May 7th. . City o£ Salford. 


May 36, 1928] • 


CORHESPONDKNOB. 


THE ORIGIN OF ISCITAEJIIC CONTRACTURE. 

S,n — Iscli.acmio conlracturo only oornis wlicro tight . 
hands’ h.avo boon applied round tho injniod part, never 
whero tho fragments Imvo boon luorely rc;placcd and kept 
at rest. In my view it is these tight bands which canso 
tho trouble, and I never use them. To reduce the dis- 
placement and then fix " tho arm up in full flexion by 
passing adhesive plaster round tho doublcd-up limb, ^ as 
was done fn tho case described, is a thoroughly bad method, 
though Professor Ilcy Groves, in his article published in 
the Journnl of Hay 12th (p. 807), charaetorizes it ns 
“ universally approved." It is this " universally approved ’’ 
method which causes all tho trouble. It .should bo entirely 
given up. Instead, after the displacement is i-educod, 
either by manipulation or open operation, tho wrist shoidd 
bo tied to tho neck in Thomas’s knotted sling, leaving tho 
arm, elbow, and forearm free. — I am, etc., 

P.tui, Uf.un.^hd Roth, 

OrlhnparKlic SuTpron, wilh Cbarcc of 
LonJon, W.l, Hoy 14lh. Fracture?, Miller General Jlo^pilaU 


THE INTRAVENOUS INJECTION OF INDIGO- 
CAHJUNE. 

Siu, — ^In tho JiritisU ^^c(lkal Journal of December 10th, 
1S27 (p. 1087), Jlr. IV. IV. Galbraith is reported .as employ- 
ing, in tho investigation of patients sufforing from renal 
tumours, “ an intravenous injcctioli of 5 c.cin. of a 4 per 
cent, solution of indigo-carinino,” 

Surely 4 per cent, is a mi.s-report for 0.4 per cent., since 
a 4 per cent, solution of indigo-carmine involves .a contra- 
diction in terms, indigo-carmine being soluble only vip to 
0.8 per cent. Tlio mistake should not ho allowed to pa.ss 
without remark, for othens might bo tempted to adopt tho 
stated technique; and, as this would have gr.avo risks, I 
hope that I may bo allowed to quote from a recent short 
article in tho Clinicnl Journal (April 11th, 1828), in which 
I reported tho only case which I have witnessed of the 
intravenous injection of 4 per cent, indigo-carmine. 

Tlio patient, “ a woman of 41, who was being cystoscoped 
under general anaesthesia, suddenly became of green-yellow 
colour shortly after tho intravenous injection of 2 c.c. of 
4% indigo-carmine, and bccaino collapsed.” Various 
rcstotativo measures were employed, and tho patient 
slowly improved. 


“ On coming round from the aimesthclio slio complained that 
she could not see, but this disquieting phenomenon fortunately 
disappeared within 24 boars. 

“ 20 e.c., or less, of 4% indigo-carmiuo may bo used for inlra- 
tnuscular injection in testing renal function, or in order to find 
tho ureteric orifices, during cystoscopy; but iho dye is wore com- 
monly and conveniently given intravenously ns a 0.4% solution. 
It should not be intravenously administered in a preparation of 
JTior strength than this, as it is soluble only up to 

u.O/o. In greater coneentration the dye is no longer in solution, 
but in suspension, and, although then suitable for intramuscular 
injection (since tho muscular tissues filler off the particles), is 
unsuitable for direct injection into tlio blood-stream, as embolism 
may occur . 

Macalpine, speaking of indigo-carmine, says that * shock, 
dizziness and pallor have been recorded as resulting from its uso 
at too great strcngliis, and cites two cases in which ‘ a 4% solu- 
1 by mistake. In addition to some slight vomiting, 
the skin specially around tho eyes and over tho scrotum — 
became a bright indigo blue. One of the patients also suffered 

,.nTv-oi a r^’i doubtless to minute emboli of 
undissolved dye lodging, in the cerebral capillaries.’ 

sncIi above quoted, recovery ensued, 

of 'mportanco of noting the exact position 

ecj a! point before administering intravenous injections.” 

— I am, etc., 

T 1 ®°cnE, M.D., M.Ch., P.R.C.S. 

London, May IQth. ^ ^ 


,* The report was printed in tho form in wliich it 
^ ^'ledico-Chirurgical Society of 


MEDICINE, LiVIV, AND THE PUBLIC, 
bm,— Some time ago a judge of the High Com 
up 11 aided and lectured a medical witness who asked fc 
his tee before lie was sworn. The learned judge must htiv 
known that the witness was within bis rights. The witnei 
presumably thought himself justified in asking to be pai 
betoro giving evidence. - ^ 


r Tor PiUTurt 001 

I Myoicit JOCBNAI. OOi 


Quito recently a jury lias gratuitously oxpressod tli© 
opinion that a defondant doctor sliould Iiavo called in 
another doctor to hear tho plaintiff refuse tho treatment 
advised. Surely this is importiiieiico in every sense of tho 
word. 

Now wo liavo .a coroner and his jury criticizing tho 
methods of ouo of our greatest hospitals in that a resident 
medical officer, on his own responsibility, sanctioned tho 
transfer of a patient to another institution. The coroner 
would pa.ss, without criticism, similar action on tho part of 
a practitioner outside tho hospital, hut in tho case of tho 
hospital ho recommends that such a transfer bo authorized 
by two resident officers acting in con-sultation and then 
sharing tho responsibility.- ' 

These three incidents call for reflection. IVhat is tho 
meaning of it? It is true that many learned judges of 
to-day',trcat tho "medical profession as one to bo respected 
and deserving of consideration. On tho other hand, there 
arc some higldy placed memhors of tho legal profession who 
resent tho riso and progress of our profession. For 
centuries tho law has had high places, largo emoluments, 
and good social status among its ' attractions,' while tho 
profession of mcdicino has been in a lowly state. Tho 
progress of mcdicino has altered the relationship, and it 
13 possihlo that tho profession of law resents tho 
cliaiigo. Can it bo what novelists and psychologists call 
tho “ inferiority complex ”? 

IVith regard to juries, wo have to remember that they 
avo composed of members of tho public. The public, when 
in good health, aro not in sjmpathy with doctoi-s. Their 
conversation in railway carriages and other places is largely 
about ailments. Remedies aro freely suggested, mostly 
; unorthodox. Osteopaths, chiropractors, herbalists, Con- 
■ tinontal charlatans are all recommended ns being so much 
better than our doctors at home. All classes drink patent 
medicines, advised by their friends or the chemist, for the 
cure of ailments that have not been diagnosed. These 
advisers would hesitate to recommend a particular motor 
car, on tho ground that they did not understand enough 
about it. .But tho much moro complicated mechanism of 
tho human body does not daunt’ them. So many of the 
public have learnt to road and so few to think. There, is 
tho risk of an ignorant valetudinarian public expressing 
unjustified opinidus from tho jui-y box. 

IVhat is to bo dono about it? Very little can be dono 
in court, and nothing can ho done -with the public. But 
the members of both professions who meet in friendly 
fasliion to discuss matters of medico-legal interest’ might 
consider tho matter. If a good example wero set bv the 
leaders of the legal profession it might permeate through 
all the courts, possibly even to the coroner’s.-^I am, etc., 

Mayetti. F.R.C.P. 


MEDICAL RESPONSIBILITY FOR LUNACTV . 
CERTIFICATION. 

Sin, — There has been not a little anxiety lately in the 
minds of tho medical profession regarding the risk of 
liability for tho certification of alleged lunatics. 

This risk would bo avoided if tho procedure were so 
altered that the doctor was not obliged to take upon liimself 
tlio invidious position of being tbo agent to declare that 
so-and-so is a fit and proper person to be shut up in aif 
asylum and deprived thereby of all civil and personal 
rights. Tlio doctor's true function is not to imprison 
people,^ but to give advice as to the treatment most 
conducive to recovery. 

As matters now stand, the doctor, when called in, lias 
in most instances to depend on hearsay evidence from 
those in touch with tho individual who is said to be 
affected. Ho has often but little opportunity of dis- 
covering for himself what amount of truth there is in 
tho assertions made. Not being himself a witness of 
what has occurred, he may have extreme difficulty in 
drawing up a certificate based on personal observation. 

In the memorandum presented by the British Medical 
Association to the' Royal Commission on Lunacy all cases 
of mental instability are divided into two classes : (1) those 
for whom detention is a necessity; and (2) those for whom 


- 922 May i 6 , 1928 ] 


MEDICO-tiEGA.ri. 


[ Tirr nnmta 
Memcal Jornyu. 


it is not; the criterion for certification being tliat tlio 
individual can be proved to have so conducted himself as 
to render detention a necessity. 

It is evident that the parties who can theinsolvcs give 
first-hand proof as to the conduct thev liavo witnessed nro 
the proper people to appear before the magistrate, and to 
state what they know. The magistrate can then weigh 
the evidence, thus carrying out the true function of a 
judicial authority, while the doctor is at the same time 
secured from liabilit}'. 

The individual concerned should, in faiijiess, be rej)ro- 
seiited by a friend; but there need ho no publicity in the 
matter. — am, etc., 

London, May 12th. S. E. WHITE, M.B., B.Sc. 


THE HAKVEY CHAPEL AT HEMPSTEAD. 

SrE, — May I add a note to my late friend Sir Dawson 
Williams's article on William Harvey? Ho stated that 
lapping in lead seemed to be peculiar to the Harvey familv. 
It was common to all the better class from Henry VII to 
about 1675. Henry VII, his wife, and Jame.s I aro all in 
shaped lead coffins in the vault in AVestminster Abbey; 
Sir Henry A^'ane is in a very much more elaborate ono in 
Shipbourne Church, near Tonbridge. I have seen one for 
a child so shaped that it would stand on it.s feet. The 
case was made by casting in two halves. After having 
been bandaged and sometimes embalmed, the coi-pse was 
laid in the lower half, and the body-shaped top was then 
soldered to this, and as a rule, a lead or silver inscription 
plato was soldered to the breast. The inscription on 
Harvey should read ; 

DOCTER 

AVTLLIAM + HARTET 

DECESED 4- THE 4- 3 
OF + lU.N'E -I- 1657 
AGED 79 YEARS. 

The bound volume of the 1767 edition of his works was 
encased in lead, and the hermetically sealed bottle contain- 
ing the engrossed parchment account of the day’s proceed- 
ings in another lead case. Both were placed at the foot of 
Harvey’s coffin in the sarcophagus. These details arc from 
the privately printed account (1883) of this second funeral 
of Harvey by the late Dr. AA’illiam Munk, librarian to the 
Eoyal College of Physicians. — I am, etc., 

E. AVilli.ah Cock, M.D., F.S.A. 

Ashford, Kent, May 16th. 


PHABYNGO-OESOPHAGEAL SPHINCTER. 

— I i'ave often deplored the fact that British dis- 
coveries frequently remain unrecognized and unappreciated 
until they are re-imported under a foreign uamo, Mr. 
Negus 5 letter (p. 879) seems to me to add ono more to tho 


ABhongh the discovery of this muscle has been attribute 
to Kilhan, Jackson, and others, it is, I believe, the fai 
toat It was firet described long years ago bv Sir Everar 
Home one of John Hmitei-’s illustrious successors, and li 
beautiful dissection of it can still. I think, be seen in tli 
Royal College of Surgeons Museum. 

; It is true to say that with the advent of oesophagoscop 
its clinical importance has been pointed out by Chevalic 
Jackson, but although I yield to none in my admiration fc 
Dr. Jackson and his work, I think that .the credit for i 1 
actual discovery must remain with Sir JEv-erard Home ~ 
I am, etc., 

liOndon, "W.!, May 18th. WaLTEU HowahTH. 


CAUSES or THE .DECLINE IN TUBERCULOSIS 
MORTALITY. 

SiTi, — Often in tho last seventeen years the British 
Mcdicnt Journal has published for me views in direct con- 
flict with what Sir Robert Pliilip enounced at Bath on 
April 20th.' I have urged that as against phthisis (bovine 
tuberculosis is another question) the statesman’s supreme 
weapon is the enhancement of the standard of living of 
— in two words, of real wages. Sir Robert .so far 
. ' See Sritish Jledical Journal, April £8th, p. <111. 


appoar.s to agree; wliero wo part company is that I argue 
that hi.stoi’v hej'o and elsewliero tenches that the best, 
perhaps the only, way of raising i‘eal wages is by tho 
policy known as Jaisscz foirc. TJioro are gaps in Sir 
Robert’s argument that seem wholly to invalidate it. ^lay 
I hope that bo will fcsolvo my doubts? 

1. Ho begins from 1871; why not from 1841? There is nothine 
in history to equal (though there are a score of instances of 
minor ilegreo corroborative) tho fall of llio phlliisis mortality 
which followed reel's daring reform of tho l.nriff from 1842 
onwards. As Koch has said, that fall wa.s greater before the 
cattso was known or anything public done than since. By 1880 
tho mortality had fallen by more than 50 per cent.; if tho 
decrease had really hceu accelerated the disease would have been 
extinct by now. Sir Robert tlius omits to quoin the most brilliant 
fiiicccs-s known, and that due to a di.stinctively laistsc: fairc policy, 
in its proper, as well as its vulgar, sense. 

2. Ho omits to mention the slackening of the rale of decline in 
this century. Tho rate had become practically slationarj* wli''n 
Professor Karl Pearson was able to prophesy a rise in 1915. 
So, in 1912, did I. Professor Pearson tells me that the inter- 
ruption of the war was fatal to his data; to mine it was an 
itntncnsc reinforcement. The crude death rate in 1917 was nearly 
double — in 1918 more tlian donhle—lliat of 1^5. 

3. He pointedly leaves out the war figures. 1 submit that you 

can find in tltem the .solution of tho problem. Tho tables of all 
countries which keep records show that an economic change— that 
is, of real wage rate — registers itself on the phthisis curve in tlie 
third year. Thus the long, slow fall of real wages from 1896 to 
1910 shows itself in tho gradual slackening of tlio decline of 
morlalily; the rapid fall from 1912 to 1914 in the ri^c from 1915 to 
1917, If Iho theory were correct, a fall should begin in 1918. It 
did, as iho Registrar-General points out. As if to clincli tlic 
point, the rale for the yoAr was raised above 3917 by the 
influenza outbreak of 1918; but the excess was due to deaths in 
itsylums, and the disease had picked out people uninfluenced by 
wage fluctuations, ns small-pox picks out tho unvnccinated in a 
school. The quinquennium is the only one in our records which 
fails to show a decTcaso on its predecessor; the increase is Iho 
biggest we have known, and follows ns the prophesied effect, 
or*^ at least — si faUor — Iho sequel of tlic biggest effort tho Slate 
has inadei . ... 

4 . Ho bases the tnumph of State nclivjly on the rates of 1919-24, 
and does not explain wl»y the great and sudden improvement had 
taken place. But the State was no more ncLive in 1919 than in 
1913, perhaps less so. In wages, however, there had been a 
startling cliffcrcnco ever since 1915. 

Wc who advocate a drastic curtailment of State 
activities do so because wo know from historj*. that State 
gifts to the poor are -always at tho expense of real wages 
and always tend to donioraiino. If this needed proving, the 
course of events this contuiT should .have made us wary. 
Only the otlier day the House of Commons took it for 
o-ranted tliat tlie- Insurance .Act had resulted in wide 
demoralization — tho only difference of opinion was ns to 
whether it was among doctors or patients — in the year of 
lowest mortality with tlie higliest morbidity. 

I submit that, when all the factors aro considered, tho 
question is whetlier State intervention, so far fi*om 
diminisliing plithisis, has not retarded the efforts of a 
greatly advanced science and the results of a vast improve- 
inent in social habits and conventions, which together might 
by now, of themselves, have extinguished the disease. — 

I am, etc., . ' 

Bath, Nay 2a6. B. G. M.-BaSEETT. 




MISDEMEANOURS AND PROFESSIONAL DISCIPLINE. 
The appeal of Pickup y. The Dental Board, "'hicli was dis- 
missed by a court consisting of the Lord Chief Justice, Air. 
Justice Avbry, hud Mr. Justice' Shearman on Slay 10th, has 
an interest for the medical as well as the dental profession. 
Again and again, in cases before the General Sledical Council, 
it "has been argued on behalf of the respondent that the Council 
has no power to erase his name on account of conviction for 
a misdemeanour when such misdemeanour is not of the class 
which is triable on indictment, but the Council has consistently 
overruled such objections, being advised that the word “ mis- 
demeanour ” in the Sledical Act is used in the widest sense. 
The case recently decided Avas an appeal against the order 
of the General Sledical Council, on the recommendation of tlie 
Dental Board, that the name of one James Pickup should he 
erased from the Dentists llegister on the ground that lie 
had been ' convicted of misdemeanours ivithin the meaning of 
Section 13 of the Dentists Act, 1878. The case ivas reported 
Avlien it came before the General Sledical Council in the 
Supplement to' our issue of December 10th, 1927 (p. 227). In 


May -.6, 1928 ] 


MEDICA.L NOTEB IN BARIiIAMENT. 


t TnEPnm«rT 003 

Mf.UICAE JoURNJlI, ^ 


dismbsiiiK tlio appeal tlio Lord Chief Justice said that the con- 
tention of tlio appellant that tlio expression ‘‘ niisdcmeanour 
in Section 13 meant niisdeincaiiour triable on iiidictmeiit could 
not bo snpiiorlcd. This was clear from the words of the 
section. Tlicro was a proviso to the section stating that when 
tho offenoes were of a trivial nature they might not bo held 
to disqualify a person from practising dcntistvy. Thus it seemed 
to bo contemplated th.st tho misdemeanours in tho section were 
not confined to indictable misdemeanours, but would include 
others, even those which, by their trivial nature, mado tho 
applic.ation of the proviso proper. Tho other jiiMicea concurred. 

In his address from tho chair of tho Dental Board on May 
8th, before this case had been decided, tho Bight Hon. Sir 
Francis Dyke Acland referred to this impending judgement, 
and said that ho trusted a judgement would bo obtained ns 
to tlio oFeiiecs which might properly bo termed misdemeanours 
and which would bo of service to tlio General Medical Council 
ns well as to tho Board. 


rOBGERy OP A DEATH CEUTIPICATE. 

At tho Old Bailey, on May 18lh, Charles Forbes, who was 
alleged to have posed as a registered medical practitioner in 
tho West Central district of London for seven years, pleaded 
guilty to forging and uttering a death certificate, and was 
sentenced to nine months' imprisonment, without hard labour. 
It was stated that tho certificate was issued in respect of on 
old woman wlio had been under tlio care of tho accused. Tho 
defence alleged that Forbes had qualified ns a medical practi- 
tioner, but that his name had been removed from tho Medical 
llegisicr thirty years ago after ho had been convicted of fraud. 
According to a statement mado in the course of tho earlier 
police court proceedings, Porbes described liimself to tho 
registrar of birtlis and deaths as a gradualo of Aberdeen 
University; the registrar, after supplying the accused with a 
book of certificates, came into possession of a letter which 
aroused his suspicion and communicated with tho General 
Medical Council. 


iitciJicd llotfs in ^Jnrlinnitnt 

[PnOM OCJl PAIUXUlENTAnV ConnESrOXDEXT.] 


TThe Currency and Bank Notes Bill was read a third limo in 
tho Houso of Commons on May 22nd, on which day tho House 
of Lords read tho Equal Prancliiso Bill a second timo after 
a division. Tho report and tho third reading of tho National 
Health Insurance Bill were sot down for M.sy 23rd. On 
May 24th tho House of Commons roso for tho Whitsun recess 
till Juno 5th, when tho Finance Bill will tome up for second 
reading. 

The Parliamenta^ Medical Committee met at tho Houso of 
Commons on Slay 22nd and considered questions to bo raised on 
the report stage of tho National Health Insurance Bill. It was 
reported that on the third reading of that bill Sir. Chamberlain 
might indicate that ho hoped at a future dato to propose tho 
provision of medical and midwife’s attend-iiice in childbed as 
a statutory benefit under tho national health insurance scheme. 


Ministry of Health Estimates. 

^ IStli, a veto to compicto tl 

b™ of £20,7(4.000 for thoSIimstry of Health was considered. M; 

that the Estimate showed an increaso c 
nearly £1,0(»,000 last year. Practically half of tho gro; 

estimato of £21,700,000 was’ needed for tho housing branch of tl 
Mmislry . M ith regard to slums, tho most urgent feature wj 
overcrowding. He Mw however, ground for hope in tho fact thr 
although on y 14,000- houses wero affected in tho schemes sul 
'v - ‘■hq war, every year over 500,0( 

houses weK .. , estimates stiowed a small increai 

-n '■■nnexion with which the Minislr 
’ i-'c:.' grants to- local authorities fc 
certain sen.cw., lutio ivcro tour of these services: treatmer 
of tuberculous (Usease maternity and child welfare work, venerei 
d^oase. and welfare of thq-blma. GenernllJ it might bo said tha 
the increases were due to the normal development of tho service: 
But this did not exhaust the functions of the Ministry of Healtl 
Ho had always regarded the Ministry as a sort of general heat 
■’ “"ert information regardiu 

the fight against disease and make it available to ail concerned i 
^ research had been carried on i 

TTinrtp'i-v^.f perhaps the largest -single cause c 

of research had dealt with the causes and treatmer 

abl^^o H'l 1? and abroad. Tliey had not yet bee 

wonlri thcir fingers upon any fact or series of facts whic 

SLctt-verv favtoom Problem c 

unon tlin '^but all the time they were encroachin 

tS knowMo-a^ Tho’M^o°7"’ advancin 

of Kf'mrtV^r ^ Ministry of Health had mapped ont a soi 

be dono to-day m the effecti^ 
treatment of cancer, and they had followed Hiat up with a cLef' 


nnd exhaustive inquiry into a largo numbor of cases of cancer. 
They had also dono somctliing to bring into promineneq certain 
motho^ of treatment which they had ascertained, from informa- 
tion derived from this country and abroad, had proved particularly 
ofTcctivo in Iho treatment of cancer. These were methods of 
radiology — tho uso of radium itself and so-called x-ray therapy. 
Tlicso methods wero costl}', and were not easily adopted by all 
authorities, but U\cy believed that by proper organization moro 
cfTcctivo uso could bo mado of tho equipment which they actually 
possessed. They wero keeping in tho closest touch with a great 
number of other agencies — tho British Kmpiro Cancer Campaign, 
tho public health authorities throughout the country, and tho 
local cancer committees working in some of tho great provincial 
centres. Whilo they could not say that they were even in sight 
of a euro or of a method of prevention of cancer, nevertheless 
they wero on tho right path, and ono day — no ono could say 
wlicQ — they might actually turn tho corner and find themselves 
in tho presence of tho goal which they sought. 

Bnccphalilis Ictharpica was a disease in regard to which central 
action was particularly necessary if they were to make progress, 
because this disease was fortunately not Bufiicicntly common yet 
for any hospitals or any private practitioners to hove seen very 
manv cases of it. During the past ten years there had been about 
1,500 cases a year in tliis country. The Ministry had instituted an 
exhaustive inquiry into about 3,000 cr.scs of sleepy sickness. It 
had been carried out by Dr. Parsons, ono of the officers of the 
Ministry of Health, and tlio results of the inquiry showed that 
only about 25 per cent, of the cases recovered; about 35 per cent, 
died, and tho remaining 40 per cent, wero more or less disabled 
mentally or physically. The valuable part of this inquiry was tfiat 
for tho first time they knew' what wero the proportions of tho 
persons attacked by this disease who recovered, died, or^ were 
pormaucnlly injured. They knew tho different forms of injury 
wliich sufforora from-cnccphalitis Icthargica might sustain; they 
knew how ihoso things proceeded, and they had got for . the first 
tirao some inkling of what wero tho best ways of treating tho 
disease. Tho inquiry came very opportunely after the passing of 
tho Mental Deficiency Act, because in tho light of the inquiry they 
might hopo that that Act might bo put to more effective use. 
Tho inquiry disclosed a considcrablo variety of cases, and it must 
bo understood that the treatment which might be effective and 
dcsirablo for ono case might bo quite wrong for another, Tho 
Mental Deficiency Act would cnablo them to classify cases and 
treat them in tho best manner. He thought that tho popular 
impression that encephalitis Icthargica was tending to decrease was 
correct, but. of course, sufficient remained to make it a very 
serious problem, because the effects of the disease were frequently 
permanent, and a person once affected remained a charge upon 
tho community perhaps for tho rest of his life. . . , 

Thoro wero really two distinct groups of uisoases which came 
under tho heading of rheumatism— aculo rheumatic fever, which 
60 often attacked children and which was frcq\tently associated 
with heart disease, and chronic rheumatism of tho joints and 
muscles, which frequently disabled industrial workers. Last year 
approved societies spent on sickness benefit and medical benefit for 
rncumatio insured persons £5,CXX)^000, and in the eame year 
5,250,000 weeks* work were lost owing to the incidence of rheum- 
atism among insured persons. They calculated that rheumatism 
accounted for oue-sixtl) of the wJjoId industrial invalidity of tho 
country. ^ With regard to rheumatism ho was told that the treat- 
ment which afforded the best hope was one of prolonged rest in 
institutions, and the Ministry of Health during the past two or 
three years had tried to encourage tho provision of hospital accom- 
modation set apart specially for this purpose. To-day, for tho 
first time, wo had actually got from 400 to 500 beds specially 
earmarked for the treatment of acute rheumatism. As regarded 
chronic rheumatism, the first thing required was advice, because 
tho causes of this rheumatism wore many and various, and it 
might, and very frequently did, spring from some local centre of 
infection. It might be the teeth that were wrong, or the tonsils, 
or tho intestinal tract. In tho absence of advice, people accepted 
rheumatism as tliough it wero a sort of act of God, which (»uld 
not bo prevented, and for which nothing could bo done. Yet 
under the advice of the . specialist, it mmht bo traced to . somo 
quite easily removablo 'cause, and the sufferiog might bo almost 
instantaneously relieved. A great deal was being done for that. 
In tho case of tho children there was the scliool dental service, 
which employed something liko 600 dentists, and was treating 
about 1,000,000 children a year. In tho case of tho elder insureu 
persons there was the dental benefit, to which approved societies 
wero now devoting some 000, 000 a year, with a result which he 
hoped would show itself in a lessened demand upon the funds in 
tho future -from rheumatism, and tho consequent incapacity to 
work, 'At present approved societies wero paying about £250,000 
a year to two hospitals for the treatment of their patients, and 
another. £200,000 a- year was being devoted to convalescent, homes 
in connexion with which, in some cases, there was now being 
developed spa treatment. But they felt that something more than 
this was required, and that there •were forms of treatment 
esp'ecially those connected with radiant heat and light, which ha^ 
shown very^ promising results experimentally, and which the 
Ministry desired to see extended for the benefit of a larger part of 
the population. The Red Cross Society was now trying to organize 
the setting up of an experimental clinic of this kind in London and 
as soon as that was ready he proposed, by regulation, to authorize 
approved societies to make a contribution to that clinic and to 
obtain treatment for their members there. The committee would 
realize- that the full development of a preventive and curative 
system in connexion with rheumatism must mean the exnenditnm 
of very largo sums of money It might be that in the present 
financial stato of the conntry A -was not possible to carrr on tlmt 
development aa rapid y as ive should -srish, hut rvo were at S 
besmnmg to realize the nature of the diseaso with which wo had 




r. 


924 Mat 26, 19281 


MEDICAIi NOTES IN PAELIAMENT. 


[ 


TfTEUnmrt. - 


to cope, and the extent to •which il was crippling our people^ and, 
as that knowledge became more widespread, he thought that wo 
should sec a willingness to devote to' I he improvement of tlioso 
conditions wliatcvcr money might be found necessary. 

The Ministry of Health had now been established for nine years, 
and as far as one could measure the progress of the public health 
by the general vital statistics the record of the Ministry -was not 
unsatisfactory. TIic general death rale in those years Imd gone 
down from l"4 per 1,000 to 12.3, and the infant mortality rate Jiad 
dropped from 89 Co 70 per 1,000. But there was one figure ■which 

showed no i- . ’ it concerned a very vital subject. 

That was th . • jrtality. It was a terrible thing to 

think that . ■ , . , ■ . ,0 mothci-s, one died in childbirth. 

That was not really the full measure of the injury that was being 
done. One must not only remember what happened to the family 
wlien the mother was taken away, but one must think of llioso 
other mothers ■who might not die, but who emerged from Ibeir 
confinement permanently iniurcd in thoir health and unable really 
to fulfil the full duties of motherhood. Ho felt tliat the time 
had come when a great new cfTorl ouglil to be made to bring down 
those figures of maternal mortality and to improve the health of 
these mothers. There ■were many things wc did not know yet 
about the causes of maternal mortality, but wc did know some- 
thing. We knew that these figures pc'i’sistcd steadily tliroughout 
the country, but, nevertheless, they were not universal. Thcro 
•were places wlierc wc could find much lower figures. They would 
be found in those cases where there was the most cai'cful ante- 
natal and post-natal supervision, and where the people themselve.s 
}ind the greatest opportunities of learning what was necessary for 
them to preserve their health and the lives of their infants. The 
Ministry of Health was taking up this question verv seriouslv. Ho 
now endeavouring to institute a new inquirv 'into (he ‘causes 
of maternal mortality. He was trying to enlist in that service (be 
general practitioners throughout the country, as ucll a« (he local 
authorities; and the Britisn Medical Association liad assured him 
that it was deeply interested in the question, and would us© all 
Its infiuencp to get its members to give every assistance nossiblo 
lo his inquiry. Under tins scheme a local medical officer of health 
would make inquiry into every case of maternal mortality which 
occurred, ■wherever it might oe, throughout the country. They 
■v-'ciild make this lucuury on a plan which would he laid ‘down bv 
m ‘ of Healtli on tlie linos of flic Canco'r 

Cornmittoo. Then' returns would como in quarlorlv lo that com- 
initleo tho information would ho classifiod, and 'the commiUco 
would draw what conclusions it was possible to draw from tho 
infqiniation obtained. All that infornialion would then co hack 
again to tlio local authorities, and would be made known to those 
responsible for the conduct of tlio infant welfare centres and (ho 
v,-as also setting up a commitUe to inquire 
into tho whole position of midwives— into their slalns Irainino 
and remuncralion After all, (ho .success or failure of any cZrt4 
conditions of childbirth in the count'rv must 

midwives, on whom a great resnonsibilitv 
rested. Midwifery was a hard and arduous profession; ft was not 
a well-paid profession; -and if we were lo get the rikt class 
'w "-e must maL tl.rconlitions fufh 

Umi this class of people would be aftrncted. If we could indicat<» 
confidence to the people of this country what ■were the 
precautions necessary to take if we were to remove this mcna^ 

improving. “ that the position ivas very elowly 

thaf - -“-^cd 

of the Ministry he had shown ni? onIv . 

(ration, but o? medicine, and a mastprv adminis- 

umipual in a layman. He felt that tho Ar fact quite 

unwieldy, and suggested that certaiil^ V® *^^comibg 

ferred to another^dopartLnt, porTapr'?hrV^’‘’'‘’''rvii'= 

nicdical service in conneiiou with the . Office. The 

removed from the Homo Office to the Minuir^ e might be 
they would co-ordinate, under the Mini^rv 'of 
health services of tho country. Witli re<Arfl , Oie entire 

were still spending some millions of pounds e vn., we 

of saimtoriums. However useful they mhih? hn 0 °° “pteep 

five point of view, or for the segregation of “ Preven- 

t hey were, from a curative point & vifw of h.H P'^P'®- 
portion of the money available might ns’efuIU- i,„ ^°me 

inveslig.ating other niefhods which, in (he ohiii.'en to 

medical members, offered a much better prospect of n several 
Mr. ScEYsiGEOUR asked if Dr. tVatls found 
evidence that sanatorium work was not producing 
mensurate with the expenditure on it. ° results com- 

Dr. 'Watts : From the curative point of view mo-i .s - . 

The sanatminin method, he said, could only show 14 ''Lr 

’""v ''■■'®reas other 'methods sifoweF 7n 
60 per cent, of mires. He also wished to call 
the senons increase of small-pox, and flic question of varffin,^- 

had t?|^r 'Sr'J'i^V,“ccS?Jdr bnt^haf ^ 

f suU was’’tha?-''the ^law Tn'u.Lf r?sp°e '"was’'™'' The 

w®®’ hoped that somelhiim would' ® 

bec.mso those of them who fcneu- snmlhpox'' i 

j-'tjx, ..nu \.cre acquainted 


I with i(A hislory, realized that previou*; epidemic.^ had' ahvavs 
been preceded by sporadic oulbreakH of a mild cliaraclor, which 
had suddenly bui-st forth into a virulent epidemic, wliich had 
carried away thousands of people and crippled thousands of 
olhci*s. That was a very real danger wliich lie aniicipaied if 
Vamnalion was not going to ho more general in lliis countrj'. 
This was the only country in the civilized world where vaccina* 
tion was not carried out. Ho had had an example of the ivay 
in >^'hich other counlric.s dealt with (his queslion when, last 
autumn, lie went (o Brazil with a delegation from (he Commercial 
Commiticc of the Hoiiso of Commons. Thej' wore freod fiom 
all (roubles in regard lo passport and customs cxarninnlion’?, but 
the Brazilian Amba'ssador paid to them : There is one obligation 
from which 1 cannot free you, and (hat is the obligation (o bo 
vaccinated.’* All the delegation had to he rovaccinated before 
leaving this counlry. 

Dr. Veukok Davies said that tho greater part of the debate 
liad been taken up with bousing and .slums, but very little had 
been said on the question of bealtb, yet that was fundamentally 
the duly of the Minister of Health. The Minister spoke about 
cancer and the progress that bad been made in it« treatment, 
referring particularly to radium (reatment. Ho framed to crento 
(be impression that tho Ministry of Healtli was anxious lo Iielp 
Iho radiologists to deal with cancer, and (hat it was very 
hopeful as to t!)c re.sults. Ho (Dr. Davies) wi«iie{I (o iinpresj 
upon the Hou.se and upon Ihc countn,* that thb only safe ti catmint 
for cancer was earlj* and comjdctc operation. In late and inoper- 
able cases radium treatment might prolong tlic life of the patient, 
or perhaps give him a little more ease. Whatever they did, they 
they should not get into their heads the idea that i-adium woultl 
cure cfuiccr. It could not do' it at the pi-cscnt time. It was only 
a help, nud he was afraid tlmt (he rather Jiopeful lone of lb*o 
Minister of Health might create a wrong impression in the country, 
and thus prevent sonic of lbc.se poor people from soekuig mediem 
advice in the early ^lngcs when something could be done. 

Ho was glad that the Minister dealt ivitli rheumatism. This 
queslion bad come to tlio fore lately, and all who read the address 
of the Chief Medical Olficcr of tlic ilinUtry of Hcaltb were very 
much impressed. It proved that tho Mmis‘ter Imd in Jus depart- 
ment a lull' knowltxlge of rbeumatiRm and of its bad economic, 
facial, and pliysical oiTect. The Minister said that there wore 
400 to 500 bods in^ the country’ earmarked for the ircatnient of 
rheumatism in children. Tlmt number was almost ludicrous 
when, they knew that with young children (be huge majority 
of lbo«c who got rheumatic fever or acute rheumatism developotl 
heart disease, and that it was cs.scntial that they should be given 
absolute rest for a long time. It seemed pitiable that, in tho 
whole of this great country, with the thoiLsands of free bed« in 
our Poor Law in.stitulions* something could rot bo done to sco 
that (bese poor children could be taken to ho'^pllal and kept there 
until they were fit for a more or less useful life. 

The question of maternity always roused the sympathy cf tho 
House, and lie was certain that the Mimsfer was' fully alive to 
the iinporlaiicc of lids subject, but be was not sure. that ‘they woro . 
using the material they had at hand to the best adranlage. They 
heard of a shortage of mid wives, but it must bo borne in mind that 
(bo midwife’s life was a very difficult one— a very hard life and 
poorly paid. Yet he had known of many cases Vhei-e midwivoa 
were thorougidy trained and yet could not gel n suffident amount 
of work for the reason that the better-class patients now went to 
nursing homes and the poorer-class patient.s went to Poor Law 
hospitals. He knew moie Umu one midwife who wa^ seriously 
concerned as to how she wa'? going lo carry on her livelihood on 
account of these claims at both ends taking away the patients 
which she previously had. That was a point which the Minister 
would iiave lo bear in mind, et^pcciall}* if be was going to increase 
the number of nddwives. Anollier question whicli ho wished (o 
bring before ibe House was that of milk. .A great campaign waj 
going on in the country by which evorj-body was advised to drink 
more milk, and overytbing was being doiio lo show people the 
advantages of milk, and, of .course, tlie Ministry Avere doing all 
in tlicir power in conjunction Avith the Miidstrv of .\giicnUure 
to impress these plans on the public. Thev had got ‘to know 
recently that milk was a perfect food, that it Avas rich in vitamins, 
and that it Avas the only suitable uourishmeut for young chiklrou 
or suckling children. It AA*as also a A*ery useful food for adults, 
and they Avei'e doing all they qould to see that this country pro- 
duced good pure milk at a cheap price. At present there Avas a 
great deal of milk adulteration going on. Tiie adulteration Avas 
of a JoAA'er standard in the toAviis than in the counties, and the « 
only conclusion he could come to Avas that in the counlics Ihe 
administration of fhe^ Sale of Food and Drugs Act was usually 
carried out by the police authorities, who acted by n riile-oF-tliumb 
method. They administered the Act rather from the point of A-iew 
of saving tlie*purchascr’s pocket and seeing that he got fnll^ A-aIno 
than from the point of A*iew of health. Tlmt Avns a grave mistake. 
The function of the Ministry of Health should be not to sa\*e the 
pockets of the people, but to look after their he.illh. ’SNMien ono 
considered that, A\dth the records in their department of tlio 
enormous adulteration that had gone on, they luul njiparcntly dono 
nothing, that fact must be weighed in the balamv agaiu.''t tlio 
many acknoAA'Iedged excellencies of tlio deparlnicnt. He suggested 
that the administration of the Sale of Food and Drug« Act in 
regard to foodstiiffs, and milk in pailiculiir, should be inkon out 
of the bands of tlic police and put in the liniids of tlie local health 
authority. . 

Sir Basil Peto said attempted abortion was n material con- 
tribution to maternal mortality. Septic perilonitH almost alwaA*s 
supervened upon attempted abortion. Jlc Mi^pcclcd that lho‘ 
^CA-alcnce of A'onercal disease was oKo clo‘'cly associated with it. 

He asked that the restrictii-c rcgnlntions for'AA«'lt'a»A' centres and 
centres should be relaxed nml that medical ofiieera 
in charge should have unfettered discretion to giAO or AviUihold 


JfAY 26, 102S] 


MEDICATj NOTjES in PARLIAIMENT. 


r TlTKnnitTTt 09 R 

JfKMCCL JOtrr.VAIi 


informnlion on liirlh control.^ ITo wn.s iold tluil, Ihouph tlirro 
^vns some iliniinnlion in pyplnli'?, Ronorrlioea ^vns on Uio incrcaso. 
Vof, <hn ofiicial system of (he Minisir}* rcfu-^cd (o allon* Hio civil 
population nccc‘^«i'to jirevontivo nirasnro'^ froju wlilcli in Iho army 
and navy admirable results bad followed. Could I bo Minister now 
declare, as hn bad done in 1925, that Ibo prevakuee of vcncrcu.1 
disoa'^o was diminislun^? 

Mr. PriniCK lAwnrscn a^ked wbat tbo Government bad done 
to classify the maternal dcalli rate. 3Iad they Hf^nres to show 
what deaths resulted froiti carelessness of doctor, midwife, or 
nurse; from poverty or mnlnntrition, or from the fact Umt sorno 
women ou^bt never to Imvo Iiad a child ai all? When it was 
certain that, if a woman bad a child, that child woidd he diseased 
or defective, or if that woman's lifo was goiuR to bo impcrillod 
by bringii’ig a child into the world, doctors in climes s^upporlod 
out of public money should liavo the rigid, to givo information. 
Women in all elass^ were determined to have this information, 
and if it could not bo given them scientifically by appointed 
officers of the Stale, (hej* would pet it in wavs less correct, and 
po'^sibly more injurious. Undesirable forms of information, when 
dfssemmnted among women, wero diflicult to rradiralo, and fiomo 
doctors now Iiad a grave problem in trying to alter what had 
been passed from one to another among tbo poorer women of 
tlio country. ^ 

Mr, UluVuell dissented, contending thrro was no evidence to 
show that (he failure of mafcrnnl mortality to diminish was duo 
to the failure of antc-nalal clinics to give information about birth 
control. 

Jlr, SenTMGEOur. asked whether there was to bo an outcome 
from the report of Iho Royal Commission on Lunacy. The prnctico 
of relegating pcopio Buttering from mental depression to an 
institution whero^ there wero others more seriously aflectcd was 
deleterious, Parliament was dealing with venereal disease in too 
timid a fashion. 

Sir Krxosurv Wopn said that, until the House of Commons camo 
to a contrary decision the ilinislcr of Health and tho department 
intended to maintain tho present fonmila that maternity and 
infant welfare centres shonla only deal with expectant or nursing 
niothcrs, that it was not. the function of an aiito-n.atal centre to 
give information on birth control, and that exceptional cases 
where avoidance of pregnancy seemed desirable on medical grounds 
should be referred to a private practitioner or to a hospital. It 
would bo a great pity if over 2,000 centres nltcndod by about a 
tmru of tho women who gave birth to children wero involved in 
this controversy. Sir Kingsley spent most of his speech in 
answering the criticisms of the Government’s housing policv. Ho 
a^lso dealt with allcgalion.s concerning tlio death of a cliild at 
Ch<^ter-|c-Slreot which had been alleged to bo hastened by 
niahiulntion. Ho contended that inquiry had not confirmed this 
•illcgation. 

Tho veto for tho Ministry of IlcaUh was carried by 209 to 99. 


Treatment of Mcntalhj Deficient rrisoncm, 

O'* 21st, considered, in Commitleo ol 

Supply, tho vote for £475,969 for llio expenses of prisons in England 
1 ®* 1 Rnvs Davies moved a reduction of (ho vote by 
asked how'_ many eases of encephalitis Icthargica there 
y^ro at tno moment in tho gaols. One of the biggest tragcdicfi in 
this country was that Ihcro was no appropriate institution to which 
to send eases of that kind. 

Sir VrviAK Hexdersok (Under Secretary to tho Homo Oflicc), 
to various questions raised in tho debate, said that every 
eft 01 1 would be made to improve the accommodation at the prisons, 
^ recreation and worksJjop fpcilities. With regard 
mcdicnl pnrt of the 1926 
‘’''""K ‘ho period undor 
during ilffAiitmn cncophaiitis icllinrgica occurred 

thnt ? m prison or .n any Borstal inslitntion. It showed 

w!' ‘^‘'“■cfully watched by tho medical 

bf Z of mental defect was con- 

.nrvwT. V. * ^ t medical officer of tho prison to exist, steps wero 
sDcciallv'adanted or those persons to a prison whicli was 

bam W?. ooo of tT "horc special treatment was given. Birming- 
fXwine Tn Ibis Commissioners were 

nnnarentlv s^iffertno *Jrom'°'' jt'TU'g to eliminate prisoners 

dpalt wUh vPTT* mi® ii defect. Such prisoners wero 

of tren Writ and received a^different typo 
tLy w^e lait “'‘‘'‘"“’•y Prisoner. Whetlir 

Klal''DeV.d:L"Ae^‘""4''‘^^^^ The 

to sel that wWo^ P''‘'’°"= o'-onr step was taken 

anolfior it was handed over from one man to 

» j" 

not ‘’hmeisr twSf”th!rt HT Particularly Ho“d?d 

££liFi r--|V “S.oTn-r’d“ob«r^f 

d^IrCo w^cl" 

would bo furthL deiebpef. watched, and, if successful, 

Tho amendment was negatived and the debate adiourned. 


Jlccommcvdiithn.n of the Doynl Commi.iFinn on Lunaci/.-^ 
Answering, on May 17th, questions by Mr. Snell and Sir ISicholas 
Grallan-lloylc, Mr. CirAjpiEKLAr.v fiaici he appreciated that early 
legislation was desirable in pui’suancc of some, if not all, of tho 
recommendations of tlio Royal Coir.nii'^^ion on Lnnacj' and Mental 
Disorders, but owing to the other coinmilrncnts ot the Govern- 
ment ho could not say v.’hcn it would be practicable to introduce 
a bill. 

Certification of McnlaUi/ Deranejed Versons. — On May 21st Sir 
Kinosixy Woon replied to Sir F. Hall, who asked if his attention 
had been called to eases wliich had occurred from time to timo 
in recent yean in which mentally deranged pcopio who would 
ordin.arily be under restraint had, owing to the liberty allowed 
them, committed suicide, ■ whether ho was aware that in somo 
of these cases doctors and magistrates had refused to sign certi- 
ficates owing to their fear of possible Ic^al proceedings, and 
vvhether ho would appoint a departmental committco to con- 
sider and adviso whether any amendment of the law relating to 
tho certification of lunatics was desirable. Sir Kingsley said 
that tho answer to^ Hie first part of tho question was "in the 
affirmalivo. Tho Minister of Health saw no necessity for tlio 
appointment of a departmonnl committee to consider the matter, 
as the Royal Commission on Lunacy reported upon difficulties 
of this kind and made a recommendation for an amendment of 
the law. 

Deport of the Voluntary Hospitals Commission.— Jlcp]ymg^ on 
May 17lh, to a question by Mr. Ltinn, Mr. CrrAxrBERLAnr said tho 
final report of the Voluntarj' Hospitals Commission, of which Lord 
Onslow was chairman, was in the printer's hands, and the work 
of tho Commis'iori would be concluded with tho issue of the 
report. KxchicHng contributions towards specific grant-aided 
services, the total Exchequer grants in aid of tiic general expenses 
of voluntary hospitals sinco 1918 amounted to £bCO,000; and tbo 
distribution of this sum by tho Commission was completed on 
March 51st, 1924. There had always been cases of voluntary hos- 
pitals in financial diniciiltics, but a great improvement had hap- 
pened in tho last few years, and in the absence of a further 
contribution from Iho Exclicqucr it would be no use to keep tho 
Commission in being. Colonel AcLA?;i>-TRorrc suggested that iho 
voluntary hospitals should be relieved of all rates. Xo answer was 
returned. 

^^otor Actidenfs and the Tohintarp Hospttal.^.S'T Kixcsexy 
Wood told Mr. Lunn, on May 22nd, that the Minister of Health 
hoped that the report of tho I’oluntary Hospitals Commission 
would bq issued this month. Tho Minister of Health must rcceivo 
and consider tho report of tho Commission before deciding whether, 
in new of tho great increa.«o in eases caused by motor accidents 
which had to bo dealt with by tho hospitals, he would call a 
confcrcnco between representatives of tho voluntary hospital^ 
insurance companies, and other organizations concerned, for tho 
purpose of drafting a scheme to cover the expenses of the trent- 
ment of cases caused by motor accidents. Mr. Lir^fx asked if Sir 
Kn?osLtT knew (hat last year there were more than 100,000 motor 
accidents, which co'^t voluntary hospitals more than £500,000, and 
that thousands of people awaited treatment for whom these hos- 
pitals wore created, but who could not be treated because of motor 
eases which wero going into tho hospitals and paying nothing for 
their treatment. Sir Kdcgslet Wood said that those facts might 
be true, and when the Ministry of Health received tho ‘final report 
of tho Commission he hoped it would bo able to give this 
matter further consideration, 

Fcc.s of Doctors Summoned to Urgent Casw.—Answering a 
question on May 16th, Sir Kikcsley Wood eaid he had not Been 
the evidence given at an inquest at Shoreditch on Ernest Mnrch 
of Rochford, Essex, at ^Yhich an allegation had been made that a 
doctor, summoned to atlond this man, refused to do so bccau'jo 
his fee could not be paid by tho person summonin'' him It 
appeared from a press report that tho coroner was not satisfied 
that the facts were os alleged, and the Minister of Health did 
not consider it desirable to introduce legislation making it com- 
pulsory for doctors to attend urgent eases and for their fees to 
bo paid from public funds. Sir Kingsley added that he did not 
think tho bborcditch ease was anything more than an. cxcentional 
ono. ^ 


Pensions Hospifals.^OnJlay 22nd Licut.-Colonel G. F. Staxlet 
told Mr, Robinson that tho staff employed in area war pension 
offices outsido_ London numbered 1,471, and that employed in 
Ministry hospitals and clinics in tho provinces, in Scotland, and 
Northern Ireland numbered 1,647. Arrangements had had to bo 
mado to vacate two hospRals—Craiglcith, Edinburgh, and Castio 
Leazes, Ncwcastle-on-Tyno, which were too large for their reqiiirc- 
mcntsn--pTovision being made for tho patients in substituted institu- 
tions of tho Ministry at Edcnhall and Dunston Hill. Apart from 
tlicsq cases, it was not possiblo to say what local offices, clinics or 
hospitals it might bo found necessary to closo during the present 
financial year. 


’ » I ettt. i/lCtUiJt Oir \>OOD, replying 

to Sir B. Peto on May 22nd, said that syphilis and gonorrhoea wero 
not compulsorily notitiablo, and the only information available as to 
their prevalcnco in tho civilian population was that obtained from 
tho' treatment centres provided by local authorities. The returns 
received from these centres showed that sinco 1920 there had been 
a considerable reduction in tho number of persons treated at tho 
centres, although tho figures for tho last two years showed a small 
increase over those for 1925, which was probably due to recent 
improvements in tho facilities provided at some of tho centres and 
to continued propaganda as to tho dangers of these diseases Ho 
was not aware that the present policy in dealing with theso 
diseases involved any denial of access to prevehtives tlirou-h 
chemists. The restrictions imposed by the Venereal Biseases A?t 





928 May 26, 1928] 


TJNIVEHSITIES AND COLLEGES. 


Tift I!arn?n 
SftMCAI. JorRYlI. 





Mat : 6 , 102S] 


MEDIOAD NEWS. 


[ Tifii nnm^n 

ULtilCAX, JOLDTAC. 


928 


Hotel Cecil on tho ovcnlnf! of June Ist. Fioin Jrny29tli to 
Juno Ist, in tlio Koyal Hortlcultnval Hall, llioio will bo a 
liORiiltals nmi institutions oxblbitlon. 

Tun Fellowship ot Jlcillcino and FosbGrnduato Medical 
Association amionncos that on Wednesday, Stay 30th, Jlr. 
Onloi- Ward will ttivo a clinical douionstratlon In urology at 
St. Peter’s Hospital; at 2 p.iu.,nn('l that on Thursday, May 
31st, at “1.30 p.ra.. Dr. H. C. Souiou will rItc a clinical demon- 
stration at the Royal Korlhcru Hospital. Special courses 
^Yill bo given in Tnno as follows : at the Children's Clinic and 
other hospitals a course iu diseases of children, June <1111 to 
Juno 16th ; at tho City ot Loudon Hospital tor Diseases ot 
tho Heart and Lungs, Viotorln Parle, a course in diseases of 
tho chest, and at tho Chelsea Hospital tor Women a course in 
gyuaccologjs both from Juno 18th to 30th ; at tho We.sl Knd 
Hospital for Norvons Diseases, a coui-se In neurology from 
Jnno 25th to Jnly 21st ; n practitioner’s course in medlclno, 
surgery,' and tho spoolnltlcs at tho London Tomporanco 
Hospital from Juno 18th to 30th, In the late afternoon. It 
maybe recalled that tho general course ot work continues 
throughout the year and may he begun at any tiiiio. Special 
arraugcraonts aro made for part-time study. Full particulars 
may' be had from tho Fellowship of Jlcdlcino, 1, Winipolo 
Street, W.l. 

A POST-QP.ADU.VTB courso iu gonlto-urinnry diseases, con- 
sisting ot weekly lectures on special subjects, will bo given 
in Jnno and July at St. Paul’s Hospital, Kndoll Street, W.C.2, 
whence details may bo obtained. No fee will bo charged and 
tho lectures aro open to any medical practitioners and 
students who may care to attend. Tho first lecture will bo 
given on Thursday, Juno 7lh, at 4.30 p.in., and subsequent 
Iccturesnt the same hour on either Wednesdays or Thursdays 
until July 2Gth. 

Tire annual meeting ot the Society for the Relief of Widows 
and Orphans of Jlcdicnl Mon was held on iMay IGth, when 
tho annual report and iluaucial' statement were presented 
and tho ofllcors wore elected for tlio ensuing year. The 
annual report showed that during 1927 tour members were 
elected, throe died, and one resigned. 'The society had. a 
total membor.ship ot 303, with Invested funds amounting to 
£139,400. 'The sum ot £4,782 was distributed Iu grants among 
the fltty-ono members and seven orphans, and on December 
31st fifty widows and one orphan were in receipt ot grants. 
A Bubcominitteo has been formed to consider the question ot 
menibetship ot tho society’ with a view to its expansion. 
Membership is open to any’ registered medical practitioner 
who at the time of his election is resident within twonty’-ono 
miles ot Charing Cross. Should ho remove outside the radius 
ho .nevertheless remains a momher ot tho society, provided 
he conforms to the by-laws. Further partlculnrs and applica- 
tion forms formemborshlpcan bo obtained from tho secretary 
of tho society, 11, Chandos Street, Cavendish Square, W.l. 

-At tho annual meeting ot tho Infants Hospital, Vincent 
Square, Westminster, on May 21st, It was announced that 
a big extension scheme, involving nn cxiieuditnro of £250,000, 
is to be undertaken. Ground has been acquired adjoining 
the present site, and it is hoped to commence rcconstructioa 
soon. The scheme provides for more than doubling tho 
nnmbor ot cots available, for creating a now maternity block, 
for enlarging and modernising tlio surgical section, for 
greatly' increasing tho out-patient accommodation, and for 
making new quarters for the nursing slalT. Sir Gomor Berry, 
chairman of tho committee of ninuagemenl, who presided, 
Intlniaicd that as a memorial to his wife he proposed to 
inalce a gift to tho hcspUal ot £50,00D, payable over tho next 
seven years, to cover tho entire co.sfc of a new maternity 
block. '' 


IHE opening of tho exteusiou of. tho Milduiay Mission 
Street, Bethnal Green, took place on 
, ^*dstock, who presided, recalled the origin 
ot the hospital, saying that more than sixty y’ears ago, 
when Loiulon was visited by a tciriblo plague ot cholera, tlio 
Rev. W. Permefather and a staff of trained deaconesses set 
Green a work ter the benefit of the 
suUenng. The mission then inaugurated was now known 
Un * Hospital. It was unique among 

hospitals m tliat it had sent out at least 75 doctors and 120 
mission field, and 350 women had 
'V' ft measure of practical training to 

lit them lor tending the sick at home or abroad. 'Tlio 
‘le^'C’ttod by tlio Bov. Colin C. Kerr, 
eel of Spitalllelds, and formally opened by Lady Coopei’. 
dho x-ray dep.artmout, which was tho gift ot Sir H. Percy 
opoued by him. Mr. Herbert S. Sliipton, 
himt-, council of the hospital, said that nobody, except 

the '"■'t'i owing to Dr; Henry White, 

The Hiss Woodhouse, thematrou. 
£2? 7’’’® Ueoes.sary to raise for this scheme was 

had’ been ” ig^osi” Previous evening tho amount received 


Tjik report ot tlio National Baliy Wcolc Coiiucil for 1927 
records tlio various lucasiues employed, willi coiisidcrablo 
success, b.v tills body iu the advaiiccinoiit of llic ideals for 
wliicli it stands. Jfaiiy ot its efforts liavc liecn duly noted 
from time to time as they occurred. Tlio number ot baby 
weeks, licaltU and baby weeks, baby competitions, and other 
lociil propaganda activities assisted during tlio year w.as 564 ; 
nn oxpcriiiient in propaganda worl: in rural districis, con- 
ducted by the Caiiibrklgcsliiie Federation of Women’s 
Institutes, yielded .satisfactory results iu spile of tlic difil- 
ctiUios attending such cIToits in thinly iiopnlafcd areas. 
Film displays, "tho use ot wliicli lias been considerably 
extended, Invi'o also proved valuable in liriiigitig lionie to 
those interested the need for instructed niotlicriiood. ’The 
council’s 1928 canipaign .’igaiii jirovides for the celebration 
ot National Baby Week during the first seven days of .Inly, 
in the courso of wbioli the usnal prograiniue of conferonccs 
and compotilioiis lias been arranged. As in former yeara, 
while regarding all aspects ot maternity and child wclfaieas 
important, Uie council nrgc.s that attoutiou slionid lie given 
especially to tlirce selected problems. These are: (a) inimu- 
nixatlon ns a means of protecling young children agaiiiRt 
disease; (5) prevention of maternal uiortalily, with special 
reference to ante-natal care and to tlio provision ot niateriiily 
homes and hospitals; and (c) new dovelopniouts iu maternity 
and child welfare work. 

The coinmitteo appointed bj- Ibe Royal Medico-Psyclio- 
loglcal Association lias received very eiicour.iging piomisc.s 
of support tor the memorial volume to the late Sir Frederick 
Mott, and it is liO[icd that the boolc may be ready iu tlio 
early autumn. The title suggested is “Contributions to 
Psychiatry, Ncinology, and Sociology. Dedicated to Sit 
Frederick Mott by his Colleagues, Friends, and former 
Pupils.” 'Tlio publication has been entrusted to Messrs. 
H. K. Lewis and Co., Ltd. 

Appucatioss arc invited by the Univor.sity ot Glasgow 
before April 1st, 1929, tor tlio Harry Stewart Hatebisou Prize 
of about £50, which is offered for the best original research 
in a branch of medical science relating to children. The 
prize is open to medic.al graduates, of not more than ten 
years’ standing, ot all British and colonial nniversitics. 
Further information with regard to this prize will be foniicl 
in last week’s advertisement columns. 

The Board ot Education has published iu pamphlet form 
a list ot certified special schools, recognized institutions foe 
tho training ot the blind and other detective children, and 
nursery schools in England and Wales. Tho schools are 
grouped according to tj’po and arranged in counties, details 
being given ot tho accommodation available and tho average 
attendance in 1926-27 in each case. Copies ot the list may be 
obtained from H.M. Stationerj’ Ofllco, price Is. 

Tire Cainbridge University Press announces for early pub- 
lication Part II of Professor Joseph Baroroft’s work on Tfia 
ncspiraiorif Fnnclion of the Flood and a revised edition of 
Dr. F. D. Drewitfs Fomaiice of the Apothccariee’ Garden. 

INFORM.VTION regarding tho special study tour for medical 
practitioners to tho spas and health resorts ot Italy, to 
whicli reference was made on May 5th (p. 787), may be 
obtained from the Italian Travel Bureau, 16, Waterloo Place, 
Regent Street, S.W.l, where bookings may be effected and 
all arrangements completed; The tour will extend from 
September 5th to September 21st, covering a number ot 
places ot interest , in Lombardy and Piedmont, including tho 
Italian Riviera and the Italian lakes. 

The eighth intomational congress of dei-mntology and 
syphiligrnphy, which was to have taken plaoo in 1915, three 
years after tho congress lield iu Rome in 1912, will meet at 
Copenhagen from August 5th to 8th, 1930.' Further informa- 
tion can be obtained from the general secretary, Dr.’ S. 
Lomholt, Raadhuisplads 45, Copenhagen.. 

The French league against the venereal peril will hold 
a congress at Nancy from May 29th to 31st, when the follow- 
ing subjects will bo discussed : the history ot syphilis, tho 
education ot the public, the antisypliilltic dispensary, and 
organization ot means for combating inherited syphilis. 
Further inforamtion can bo obtained from Dr. Spillmnuu, 
Facnlte de M6deoine, Rue Lionnois, Nancy. 

Dr. 'Paileens, professor of diseases of children at Lausanne 
University, has been nominated Chevalier ot the Legion ot 
Honour. Professor Manuel Quiutela, formerly dean of tha 
faculty ot medicine ot Montevideo, has been nomiiiatei 
officer ot the Legion. 

The 125bli anniversary of tho birth ot the chemist Justus 
Liebig, wlio was born at Darmstadt on May 12tb, 1828, is to 
bo celebrated by rebuilding with the original material the 
house in which he was born, and the addition to it of a 
lunscnni. 

Trachoma is prevalent in Tokyo, where there are now over 
330,000 cases in a population of about two millions. 





NASATi AND onAti FOCAIi SEPSIS. 


[ Tirr liniTi'^ft 

F nicA t. JonivAi; w 


June 2, 193S] 


COIisrrlmtinns 

OK 

ITASAL A^'ll 01 ?AL FOCAL SEPSIS IK THE ETIOLOCY 
OF GASTRO-INTESTES’AL AND POLHIONARr 
INFECTIVE DISEASES.* , 

BT 

PATIUGK ■\VATSOX-'\VILTiTAI\tS, M.D.Lond., . 

COSSULTIKG SUROEOi; TO THE EAH, KOSK, AKI> Tlir.O.AT DEPATiTMrKT, 
cnisTOi. r.ovAL iNFiuMAny; late trcrunin i.v ihpeavks of the 
EAE, K 05 E, AKD THROAT, CKIVr.RPlTV OF RRISTOLJ 
• AKD 

F. A. PICKIVORTH, R.Sc., AI.R., 
filKiCTOR or JOINT noAni) or nrsEARni ron hi'.ntal diseases or tde 
ti.vivEnsiTT or hiiiiiinoiiaji. 

(Pofliological Specimens etnd Jicporl.) 


.The term “ focnl repsis ’’ is iisiinlly r.pplicd in its 
clinical sense to established pyogenic iiifcelion such as 
occurs when an initiaPinfcctivo invasion, li.aviiig overeome 
systomio and tissue defensive reaction, persists as a chronic 
localized infection. Nevertheless in patients with nasal 
passages choked with polypus, or copionr. pnrnlent gingivitis 
round the neeks of living tc'elh, or periaiiieal dental 
abscess, one often looks in vain for systemic coniplicalions; 
the copious outpouring of polyniorphohuclcars seems a 
measure of successful local resistaiico to the focal infec- 
tion, Chronic bacterial toxaemia aiid subinfcction is most 
prone to arise from chronic latent focal infections, such 
ns frequently occur in nasal sinusitis, with relatively non- 
purulcnt discharge (sinus infection without pus in some 
degree docs not exist), or periapical dental sepsis, often 
with no pus at all. Hcnco the cxistenco of a causal focal 
sepsis in pulmonai-y or gastro-intcstinal infection is often 
.to bo discovered only by careful investigation. 

Sepsis of the mouth, phaiynx, and nose may affeot the 
mwer respiratory tract or gastro-intcstinal tracts (o) by 
direct spread of infection along the mucous membranes, 
through the larynx and trachea; (fi) by the blood stream 
or l^ph-vascular infection; (c) by inhalation of sejitic 
particles or secretions, or by the swallowing of enormous 
numbers of organisms. 


GASrno-lNTnsTix.M, Infections. 

_ Organisms Sxcalloircd. 

That patients may swallow immense numbers of septic 
organisms with impunity is certain, for the normal acid 
gastric secretion is a potent antiseptic barrier; but if the 
mass infection is continued it fairly frequently results in 
gas no catarrh or gastritis, with hypochlorhydri.a, constipa- 
tion, diarrlioc.a, or recurring colitis. It would seem likely 

mfection may originate local hastric or 
duodenal ulcers; -- b- • ■ • - - ^ relaxed 

sphincter of Oddi ' leiaxea 

I more 

. • \ “l’P^‘"f to happen, appendicitis. '.Again, such 

hi- tn-rnom'-^ may be 'indifcetly deterraiiicd 

i la uitli resulting endocrine exhaustion. 

CojiTci/cfl throngh fhc Wood Stream. 

i’- organisms apparently displav an 
'■'Sions involved-for Lample,- the 

have enn f adiich tlio researches of Rosonow 

have gone far to explain and to prove. ,d.- ' • 

in “ reasonable assumption that, 

nn in . ^''tonic - Bubiiifcctioh is comnionly set 

natinnA *! . oltbough in many a 

a' “ carrier renders him merely 

intereiirrei t f 1 ^ exposure to cold or some 

irreaPr a I* -I'etermines an , exacerbation of ivliat 

in 192(^ • andnig infection.-, IVhen eight vears ago, 
Lor?a’n ' - ? this society,^ I urged the 

aonendicif ° sinus infection as a causal factor in 

an^anflrsi'^' f"on “ S^^tric and duodenal ulcers,* 

nrartieef 1 ° 1 ^ consecutive cases of sinusitis in my own 

SdL r'‘=‘^ bad undJrgon^ 

^p dicoctoni), 2 had operation for duodenal ulcer, and 


2 patients Imd gastric uloor. Furtber oA'idenco was included 
ill my 1025 Semoii Lecture. 

• I now turn to quite recent observations, of tho general 
.surgeon and iibysician in support of my thesis that naso- 
oral focal Keiisis is to bo reckoned among tlio primary 
sources of gii.stric and duodenal ulcer, cholecystitis, and 
appendicitis. Air. A. H. ' Burgess,* writing on ^ chronic 
ulceration of tbo stomach and duodenum, after referring 
to tho work of Rosenow and of Wilkie, says tliat theso 
researches emphasized tho importance 'of a careful search 
for any focus of infection in tlio’ .tc'otli, tonsils, nasal 
siinise.s, or olsewhoro beforo operation.” Professor Wilkie* 
stresses tho frequent simxillancons association of gall- 
hl.addor and apiicndix infection, “ not cdiisccutivo hut 
simultaneous bhiod-horno infections, usually of strepto- 
coccal type.” Dr. Izod Bennett,* writing on tho treatment 
of gastric nicer, says that “ oral sepsis is probably tho most 
important cause of gastric and duodenal ulcer.” As long 
ago .as 1000 Dr. William Hunter* urged tho importance of 
oral and nasal sepsis as causes of serious gastric and 
iiifcstihal disease. How', can olio reconcile tlie largo por- 
ceiit'ago of gastric and duodenal ulcers that Hugh MacLcaii' 
cured by “ intensivo aihalino treatment ” ivitli the current 
view that absolute, or relative liypochlorhydria, and thero- 
foro diminution of tho .antiseptic harrier in the stomach 
normally onsnred by tlic free bydrocliloric acid there, leads 
to the uninhibited swallowed pyogenic organisms infecting 
the gastric mucosa or that of tho duodenum? Are there 
two distinct groups of gastro-duodenal ulcer — those duo 
to hypcrchlorhydria, non-infcctivc, with ulceration from 
tho ^surface, and those duo to blood-borne infection, in 
which, as in Pickworth’s specimens of G. S., the infecting 
organisms invade tho deeper Layers of tho gastric mucosa 
and not tho surface epithelium? It seems probable that 
n])pondix infection results from swallowed organisms, 
for tboro tlio intestinal contents are normally alkaline, 
while infective gastro-duodenal ulcers aro often blood-borne, 
and thus the frequent concomitanco of appendicitis and 
gastro-duodenal ulcers of infective origin might bo 
explained. 

Of tbo specimens of sphenoidal sinusitis that Dr. 
rickivortli brings beforo us to illustrate the purport of this 
paper, those from G. S. might be justly termed a " human 
parallel of Bosenow’s experiments,” for in this case a 
chronic diplococcal infection has been traced, invading 
tho sinus mucosa from fhc surface, aiid spreading to tho 
pituitary capsule and gland ; in the same case similar 
diplococci are also demonstrated in tho deeper layers of the 
evenly spaced haemorrhagic patches in the gastric mucosa. 
Furthermore, in this and other specimens tho diplococcal 
infection, traced to the pituitaiy, explains the evidences of 
endocrine disturbance, since the superjacent hypothalamus 
is the region hold to control many of the basal metabolic 
processes. (See Fig. 0.) These ohsen-ations of Pickworth, 
corroborating similar researches by Logan Turner, 
Boynolds, and others, point to infection bj- the blood 
stream as being tho most likely pathway of many siib- 
infections, rather, than infection by inhaled or swallowed 
organisms. IVhy organisms in the blood stre.am should 
liavo an elective affinity for certain regions or organs ive 
do not know, but that such elective affinity is shown 
Bosonow’s researches leave little room for doubt. Further- 
more, this same elective affinity of certain strains of infec- 
tiA’O organisms for certain tissues is supported by clinical 
experience — as, for instance, in epidemic influenza, which 
in one epidemic tends to involve tho lungs, in another the 
gastro-intestinal tract, and in yet another shows a pro- 
clivity to cerebro-spinal complications. 

Dr. Fichworth’s Specimens of Sphenoidal Sinuses and 
Gastric Slucosa. 

These demonstrate, macroscopically and microscopically, 
tho association of infective conditions of tho sphenoidal 
sinus with (a) lesions of tho stomach mucosa, and (6) 
changes in the pituitary gland. (Several other specimens 
shown are expluded by limitations of space.) 

Specimen O. S. — This shoAvs peculiarly evenly spaced haemor- 
rhages in the stomach mucosa. The haemorrhages are near tlio 
surface; superficial .tn small, thrombosed blood "vessels. 'The miicosa 

frT*m ' 'fllA linorr»nrrlinfr£>e'” at- ' r.f ...-I.. - * 



932 June a, 1928] 


r Tnz Ezmia 
I Mmcit JovEZiS 


jjTASAlj AND ORAL FOCAL SEPSIS. 


TCscmbUng a leopard^s skin (Fig. 1). Tlio llirombosed vessels con- 
tain diplococci (Fig. 2), although very sparsely distributed. Tho 
sphenoidal sinus (Fig. 3) shows a much thickened mcnibrano con- 
taining large masses of cocci invading the deeper tissues, usually 
■without, but occasionally with, lymphocytic infiltration (Figs. 4 
and 5). These cocci are apparently identical with those invading 
the stomach and also the pituitary capsule and gland. 

Specimen TF, J. (Fig. 6) shows haemorrhages in process of 
absorption, and represents an intci'mediato stage between llio 
above specimen and tho following. 



Fig. 1.— Stomach mucosa (G. S.). Multiple superficial haemor* 
rliagea beneath which wero thrombosed vessels containing 
diplococci. 

Specimen A. L. (Fig. 7) shows multiple deep pitting — really 
small ulcers — and an occasional dark area shading off into the 
surrounding tissue. This is probably an example of resolution of 
tho “ leopard’s skin ” condition, in which the hacmon’hages and 
thrombosed vessels have been digested with accompanying attempt 
at repair. 

Tho partial resolution seen in specimens TV. J. and A. L. indi- 
cate that the haemorrhages of G. S. are not merely a terminal 
condition. 

Specimens J, (?. and M. R. are examples of sphenoidal sinusitis, 
one associated with capillary haemorrhages (diapedesis), the other 
with multiple pin-head lymphocytic nodules in the gastric mucosa. 
(Illustrations of these specimens not reproduced.) 



Fig. 2 .— ocomacli (G. S.), showing organisms amongst blood 
corpuscles from thrombosed blood vessel. Thete organisms are 
of similar microscopic appearance to those seen in the sinus 
membrane. 

Pulmonary Infections. 

The vhinologist has long been familiar with the anaemia, 
cough, expectoration of mneo-pns, sometimes streaked with 
blood, loss of appetite, wasting, nocturnal fever, and sweats 
that may occur in chroiiio purulent nasal sinusitis, often 
with localized bronehitis, and while in earlier and less 
marked cases early tuberculosis is mimicked, in old-standing 
cases they rather suggest advanced pnlnumai'y tuberculosis, 
^loroovcr, tbeso chronic septic sinuses arc prone to cause 
recurrent pulmonary infections, till iu turn a subinfection 
of tlio lung becomes a chronic focal infection. Dr. Xoung’ 


says very truly: " Nasal .sepsis may give vise to symptoms 
and signs curiously mimicking those of early apical tubor- 
culosi.s — with definite signs in tho lungs, particularly at tho 
apices, which clear up when tho nasal condition has been 
oircctively treated,” 

My cxporionco of sinus infections loads to tho conviction 
that iu many patients with constant rccurrciico ot 
hronchitis tho source of infection lies in tho chronic sinus- 
itis, whore tho ' established infection with relative auto- 
immunization renders tho patient a sinus “cai'ricr”; in 



cour.so of timo tho samo seems truo of pulmonary sub. 
infection, when tho patient becomes a lung “ carrier.” 

AVo know that iu chronic pyogenic infections of tho 
mucosa of tho sinuses tho organisms may invade tho sub- 
mucosa and, with quiescent intervals without symptoms, 
activate from timo to timo under the influence of climatio 
conditions or the .symbiosis of a hetero-infection — as, for 
instance, influenza, measles, etc. There is reason to 
bolievo tho samo obtains in ]>xthnonaTij infections, and this 
explains some of tho pulmonary complications following 
general anaesthesia, which are not by any moans always duo 
to infection from above, but may bo duo to sensitization 



Fig. .. — OIU..S mc-.uOiautj o,;, auuwiug luaacea ut otguiiisms 
isvadiDg the membrane. 

of pre-existing lung infection, though any established 
focal sepsis in the nose and mouth is a constant menaco 
to the lower respiratory tract. It is hardly necessary to 
discuss the recognized fact that tonsillai- sepsis or tubercu- 
losis may spread to tbo hilum and peribronchial tissues of 
tho lung, and it appears certain that lung complications 
of a nasal sinus infection are often the result of blood 
stream infection. 

■ Familiar experience of tbo catarrhal infection known as 
tho common cold illustrates tho tendency of tho naso-oral 
catarrh to spread to the lower respiratory tract, particu- 
larly in certain individuals whoso colds always spread to thq 








Jose a,‘ 1928] 


NASA.T1 AND ORAD POOAD SEPSIS. 


MeDicii.JoaiiNil. 


cWst; in tlicso tlicro is often nn acquired liability to 
frcQucnt rccurronco, and, moroovor, in tho samo ]uumr>n- 
Krr ni-oa each time. Non-, ns Hatty Sbaw* observes, wo .nro 
not suro Ibo rcc.nrrcnt attacks in fiiieb vationts are tbo 
rosnlt of reinfection fron> outside, wliilo many becoim) 
cbronic broncbitics, and are, in fact, * carriers. ibd 

infection is a reinfection from within. , 

That broncliicc.tasis is very frequently dno to secondary 
infection from nasomr.al sejisiR is 
noiv accepted, and it is probablo 
that early and lcs .5 marked forms 
of broncbicctasis aro not seldom 
present, when signs and symptonis 
aro as vet too indefinite to permit 
of an exact diagnosis, pcrbaji.s dno 
to pro.ssnro in ' coughing acting on 
a bronchial niuscnlatnro and tissues 
weakened by infective, processes. 

It sbonhl hardly bo nece.ssai-y to 
empbasizo tbo importnneo of recog- 
nizing and removing focal infection 
of tbo month or noso in cases of 
pulmonary tuberculosis. lint Ihero 
would seem to bo good grounds for 
suspecting that sometimes iiaticnts 
with such focal infections, with pul- 
monary complications diagnosed ns 
phthisis, despite tho failure to find 
tubercle bacilli in tbo sputum, are 
in reality not tuberculous at all, but 
examples of sepsis infection. Sucb 
pulmonary cases may bo clinically 
indistinguishable from tho so-called 
phthisis without tubercle bacilli ; 
they benefit greatly, and may become 
cured by sanatorium methods; but 
' such methods are immensely assisted by tbo recognition and 
removal of tho causal focal infection," without which every 
method of treatment is prone to prove abortive. 

Cunously enough, reports on tho 6]iutum, uhich may bo 
teeming . with virulent pyogenic organisms, are usually 
returned " negative ” unless a few stray tubercle bacilli 
can bo identified, often only after repeated examina- 
tion. Yet, even, in ca.scs that aro truly tidicrculous, tho 
associatidu of other pathogenic organisms is by no means 
a negligible factor. In every case of clinical pulmonary, 
tuberculosis, whether tubercle bacilli aro dcmonstrablo or 



not careful inquin- for tho existence of focal infection- 
ought never to be omitted. 

The Importance of Case-History in Focal Sepsis. 
t is very instructive to observe lio^v a patient^s medical 
IB niy alone, taken over a long period, may in itself 
su . CO to suggest somo chronic septic infection, ever and 
anon ciqpping up, ivith quiescent inten’als duo to relative 
au o-immunization, but manifesting its existence by 
recrudescences which, on eacli of several occasions, have 
separately engaged tho’ attention of the physician^ the 


.surgeon, or tho laryngologist, yet seldom if over conjointly, 
Tho following aro three good examples in which tho case- 
histories suggested focal infection. 

Tho fn-st c.imo under my caro last October. He was a man, 
need 61, in active pursuance of his profession, ^Yb^cll brought him 
constantly beforo tbo public. Apparently fit when I saw him 
then, ho hnd on so many occasions of recent rears been laid up 
with nttneks of febrile nasal catarrh, which “laid him out'* and 
caused Ecvcro financial lo.ss, that bo was in constant dread of 
their seemingly inevitable recurrences. 
Twcnt 3 *-scvcn years previously, in ISOO, 
bo bad left antral cmpychia due to 
diseased teeth. These wcrc'cxtracted, tho 
alveolus opened, and a gold tube inserted: 
through this daily lavage was cai-ried out 
for about .ten j'cars, when, bein^ con- 
cidcred no longer ncccs.sar}'. the tube was 
removed and the opening allowed to close, 
two j'cars later, in 1912, ho consulted a 
colleague for sensations in the antral 
region, but transillurnination was negative 
and be was reassured. Again, four years 
later, occasional colds and lar^-ngitis and 
Blight cacosrnia made him seek a furl!ier 
consultation; but once more Uaj-s- 
illijininaiion and likewi^jo a skiagram were 
both negative. In 1921, with a se\cro 
hibrile attack abroad, he had a «/ pile 
abscess on bis foot, and again in 1922 and 
19^ slight cacosmia. 

In .January, 1923, he' underwent 
appcndicnctomV in London for acute 
appendicitis, and fiyo weeks lafrr an 
an operation on his gall-bladder was 
performed bv the same surgeon. 

In April, *1927, be felt and looked ill 
and ucuraslbcnic. He could not concen- 
trate, and had difficult}' in memorizing, 
which for liim in his work was most 
unusual. A few weeks later he had a 
Bevero feverish cold; he was in bed ten 
days, as bo bad a pneumonic patch and 
rusty sputum — streptococci were cultured 
from a pharyngeal swab. Regaining his 
relative aulo-immunization he returned to 
work; but six months later, though in fair health, be was still in 
constant dread of further breakdowns. 

Now the history of Ins recurring febrilo colds, appendicitis, 
cholecystitis, and phases of poor memory, pointed so strongly to 
a focal infection that, despite the absence of any nasal abnor- 
inalily or catarrh, using the suction syringe, exploration of the 
left antrum revealed a pure growth of pneumococcus with slight 
phagocytosis, though his right antrum was sterile. It would seem 
that lliis pneumococcal focus was the causal factor of his septic 
pneumonia, probably of tho previous appendicitis and chole- 
cystitis, and likewise of tho recurring febrile . attacks that had 
proved so disastrous in his career. Yet his various medical 
attendants had apparently failed to inquire for those data in tlie 
long history which, taken as a whole, seem to afford such a useful 
diagnostic guide. 



Fig. 7. — Stomach mucosa C^V. L.). Haemorrhages as in Figs. 1 
and 6, but showing luter stage of resolution. JIany liaeiuor- 
rliagcs have entirely disappeared, leaving superficial erosion 
and deep pits. . 

Hiss D., aged 46, suffered from chronic rheumatoid arthritis 
in shoulders, wrists, fingers, and knees, of twenty-seven vears' 
duration, beginning at the age^ of 14. »She also had chronic 
rhinitis of much the same duration, yet, although she consulted 
laryngologists, there was never sufficient evidence to warrant any 
operative treatment till 1916, when the sphenoidal sinuses were 
proved to be infected with Staphylococcus aureus and Strepto- 
coccus brevis. Meanwhile, however, she had recurring colitis, and 
removal of the appendix was followed bj' pneumonia. From the 
time her sphenoidal sinuses were opened and drained the arthritis 
definitely improved and her health has remained uninterruptedly 
good ever since, 



no, 5.— Sinus membrane (G. S.), showing organisms 
inMuhrig inuubr.nno with cellular reaction (tbo largo 
dark inas-jcs arc lymphocytes). 







~ ^^= =r -— ‘ Jo^.^ 

f7T?.»Trix, 


■ ®^^'^H:Aj\f-STjET\'-jii>m 

7r"''''“‘'"^®-"“'-«o.p., 

• "• <-™I>«^„.C.s., , 


r->o. 8_.s,„ V'"''~'?SsSfer I “ i’*'''i’“'‘'>tory scJiooI aJi "1 xUi 

Htm-ring iiifpf.+;„ ”1*^^ — ^°nip/etclv .. - P*>®>unouia 

'tir- 

"1 4.i! factor of iii m to ],„_ ,, ‘ '"e removal of 

°"-S<ac!e focal ijifoctio'i®'‘^' oT*"** 

I ^ ^ ^ P‘'o«)pt 



7 -«^.Xl.O.C5 

Qi* X? ' 

-tei novoPf:^t -"^^''-WcJ,, in ivLl.f - 

assomWed for fl.o .sun.mer!! 

Jater cases of feve,- i * ™ Sth. ‘''’ '■®' 

so till iMav29ff. ? ooonr i„?j ' ?.’'° '%3 

.‘l>roeeas?s ve lF 7'"’^'' 

dniigorotislv ill. Tlio T ’ ') '"*° those ‘ 

opidomio 00, dd 1,1:00 ^:/'“" of 

iv.o'’ ’-h^e 

suggested i>J„enw’^“''ijv’tF’ ^'o’ativfK sj,’'’ 

ri,? .'it"S”“' “ -F 

tl/fj/iosas B wns ol’,tah,wr^"l “Sglntinatio,, ‘fo^ 
save „ positi,.o grSrofU “ -'‘«rf pSofr; 

iras therefore clinched. ^ organism. Tiio^ diagnosis 


".^I'^hna'c ^’t",;!/'''-'’ OrS.',^ ^lIssJ 

re^ioa ol’T",'”f,„‘Up-oeoec. ,, 

lenioval may prevent tl ''’'’‘'"'>‘<'‘>1 ''>Po- 

o'ul .gastro-ii/tostina^I tra°t®"'""^^'^‘'ons of tl 
t'on ,5 trulv “a ujif for a Ht„ ’’"'"'onarv 

<^onId )Vm.et'%’’^ ^'othing.- ^^•''' ^nfe^ 
;<pf<e infections moro ''‘')oi,to<| !,^ reS;, «uieh 
eoinplications . ivithoiJt' '^^"'onic 

M,ri^ ''■aocCcr.',.to " "" "■“'• 

"ovo’r c:;L 

toer 26t]3, 2p^ 


to ho unnffeclod. in the and .sniritr'a ''“ 

of symptoms may bo m l V'^y stages this voL 

there a r4r, ami , ‘ t? ''omiting ''j„'^°’”l’'a”>ed of, 

other complaints. Tim * ' o-^'oeption of I 'i "as 

sudden; there wm-o ,„ the im"tvnl "o ’ 

ivas the rule anr! +i lu’odroniaj svnmt'.. iphoid fever ,ras 
tlic nature of the Vin '"°*'°us did not in”t7 ?°"®tipntion 
thielc irhitc cent al tongim ,va '° ^«t<-ay 

teniperatnrecf I054"’-;„1“ only «-ated iritl. 

^Vm &««?/, cm.__The ‘lcliri,mf„’ "''th a 

the fifth dav aft^.. ^"at spots an« 
u roscolar raki ennr I’or cent the end of 

flanks. In caL h'’ *“ '''° ohost.°!,, \‘° oases developed 
ho(ly ,ras co,-cred, n-ith " ‘’’® ®o" goncr^ll”’ "ufl 
foot, the hands, fac" If “ "^ooption^of ^'‘"t the 

n-hatover developed anf^ In 25 nf ''® °f the 
"•ns delayed till the'fourte” ?, ^^talcis 1^”*' ™"h- 

^'trexm._ln typical ' day. "oes.its appearance 

type for fonrtee^/ rf • “ ‘he fever ^- 

eightecn das-.s; in thef t'l some cases f reniittonfc 
fou days. Defe f forms if, aoi'cnteen f- 


JDSE 2 , 192S] 


AN OUTBREAK OP PARATTPHOID B PEYER. 


t TiTK BRinirti 05R 
Mewcai. JoimxAi, 


Tur^\T 3 >tr.ST AuorTr.n. 

TrcMinoiil \vns Imsi'd ou goxxorul linos. Tlio cliot wns not 
pxcC8sivclv it ronsis(«l of tliroc j.iiits of iiiillc, rein- 

forced witli plnMiion, liiseiiits and rusks, Invad-sind-liuttcr, 
custards, raw e{y;s, milk in>'''li''gS «>>‘l <* laldcsiioonful of 
etucoso. Ijcmouadc was freely given. 

Drugs.— A. 2!. minim capsule of oil of cinnamon was given 
every two lio\ns,' and 5 grains of nrotropini- tliree times 
daily. In order to covmtoracl llie constipation an ounce 
of petrolngar was giycn twice daily. At I lie termination 
of tlio illness the faeces and urine of each hoy were 
examined hacteriologically three time.s, and in only ono 
case was a positive culture of V. jxiraf B obtained. 


PjtrniBi’o.sixo C.\csi;. 

Tho limited naturo of tho outhreak, its occurrence 
amongst a proportion of tho Rchoolhoy.s, tho ah-ence of any 
other asccrtainahle source of infection', the pvohahilily that 
all twenty-three case.s were infected from the wimo sotirce, 
at the .same time, rendered it almost certain that .some 
article of food w.a.s responsible for the outhreak. After 
eliminating other po.ssihlc articles of food, suspirinn fell on 
ono partietdar Italian cream ehcc.se, which was cnti'ii on 
the day of assembly, May 5th. A very careful search 
for a possible carrier was undertaken, hut proved nsidcss. 

Two previous outbreaks of fever due to eating ihcesc 
have been recorded. Poard andlValker' record an I'pidemic 
of paratyphoid fever in Alkssouri; it consisted of loity-fonr 
cases and extended over tweut 3 '-eight dasss. Ma<aulav,= in 
the Dover epidemic of July, 1922, which" affected 126 indi- 
viduaLs in fortv-threo familio.s, cxiirc.ssos the opiuum that 
the infection was duo to Gacrtncr toxins contained in 
ihcese. 

Ij.tnnn.tTonr I.NvrsTio.tTioxs. 

Blood Cull m e . — Blood culture was iierfornu d in five 
instances, and was successful on tho fifth and eighth dav.s of 
tho illness. 

Scrum Agglufinoliun 'Tests , — The first batch of cases 
consisted of seven botts who had been ill for eleven dajs; 
the second consislcd of four boy.s, two of whom had been 
ill for five da\-.s and two for throe day-. The .serums of 
all the mmvo strongly agglutinated emulsions of II. imni- 
typhosus B when tested out on “ Garrow’.s agglntinomctor ” 
in dilutions of 1 in 10 upwards. The clinical appearance.s 
of the .sick boys coincided with the results of the agglutina- 
tion tests. I'ollowiiig uiKin tho outbreak, the blood of the 
lenmining jojs, together with that of the masler.s, domestic 
staff, and outside attendants (cightv-four iiersons in all), 
uas tested, with a negative result; "but in two apparently 
lea ij oys, ujio ;it the time were iilaviiic in the fields, 
the sernm was found to agglutinate D. pmvUjiiliosus B in 
d fi i'*?" ^ while the sideens of both wore 

nf fi" V Roth of these bovs, who, as a result 

t 1 1 m r " regarded with suspicion, developed para- 

typlioid B fever within the next five days. On the other 
4 ,^**i ’•t". case of eight other hoys who developed para- 
■d-l' *°'l ^ the ensuing five days no agglutination 

obtained; hut, after a further lapse of a fortnight, 
1 agglutination in dilutions of 

aiT.rlntin^f as obtained. In one instance a positive 

t^boid typi'ohl, paratyphoid A, and para- 

0 ’ 1 /* inoiiirv +f^ ** satisfactory to ascertain 

Bome two nmnH received a triple inoculation 

some two inontbs previously in Egi-iit. ^ 

in'^*ta^is^+f,°il an account of this eiiidcmic 

iuvcstitrntion f the technique employed, the 

the commnt” 1 outbreak can be concluded within 
i do^ tf .1 l 1 " “f forty-eight hours. If 

iimiortance c*** Id^^l ^i"^ other technique results of such 
SI The Tv ¥ with like certainty and 

110 ^ of this n (1) The trustworthi- 

amiliwl rtn o 1 . ^^croscopic agglutination when 

the blond so scale. (2) The fact that in two instances 
t' li B n"/* agglutination to B. para- 

the disease' dcVelo^f ’and* that "Turptoms of 
iueubarton period tht disTase^"®“^ 


Method of Dcfcrtiiiiiiiiq the Seiologicol licoefions of 
I'oiic.uls and Contacls in the J'lphlcmlc of 
J'araigjthoid 11 Fever. 

Agglutination tests were ]icrformcd on Garrow’s agglutiiio- 
meler, n method wo have practised with satisfaction since 
tho perfection of the apimratiis in 1916, and subsequently 
.wo employed it ns n moans of diagnosis throughout the 
great wam Tho simplicity of the instrument, and the ease 
with which nil the necessary material for performing 
apglutinatioii tests can be" carried about, rendered it invalu- 
able for use under condilions of active service. Garrou '.s 
agglutinometer’ is to .some extent based on Broughton- 
Alcock’s* slide niethod. This method of “ agglutination 
forceo ” alone makes jio.ssible the performance of a large 
number of tests in a minimum of time. The vcactioii is 
macroscopic and easily visible to the naked eye. 'When 
controlled by the tube method of agglutination it has 
shown itself to 1*0 equally specific, though it must be 
admitted that the “ end-point ” never reaches so high a 
litre as in the former method. False or “ pseudo- 
reactions " arc apt to occur only when very low dilutions 
of tho serum — that is, under 1 in 10 — are employed. 

The formalinir.cd bacillary emulsions used were prepar.id 
from type cultures supplied from' the National Collccti-m 
of Type Cultures at the Lister Institute, and were 
adequately tested, as regards their agglutinahility, before 
tho invo.stigation was commenced. 

Tho object of testing the entire school population for 
agglutinins of paratyphoid B fever was based upon the 
supposition that such a reaction will normally occur in a 
carrier of the infection. It is quite true that if a person 
has suffored from a mild attack of paratiqihoid B fever, 
and continues to excrete the organisms, his serum will 
probabh- agglutinato the parati'jihoid B liacillus, hut this 
does not necessarily take jiloce in the “ .svmptomless 
carrier,” who, though not showing any clinical signs of 
infection, nevertheless harbours the organi.sms, so that the 
agglutination test doc.5 not alway.s provide a sure means of 
detecting .such a '* carrier.” 

Tho serum of eighty-four individuals was .submitted to 
tho test, and the method of ap])lying it on such a large 
scale was as follows: The blooil required was obtained In- 
pricking the pvdp of the finger with a sterilized “ hare-lip ” 
noodle. B\- gentle massage along tho length of the finger 
sufficient blood was obtained to fill an ordinary capillary 
tube with a bulbous enlargement in its middle. 

The sick boys were visited in their rooms in order to 
collect tho samjde of blood. The remainder of the school- 
boi-s, masters, and domestic staff were paraded. As each 
individual came forward the finger was pricked and the 
blood collected in the cajiillarv tube. The tube ends wore 
then carefiilU- sealed with sealing wax, and finallv each 
lube was labelled with tho respective individual’s name. 
In this manner sani])les of blood from tho entire school 
were rapidlv obtained. The next steji consi.stcd in centri- 
fugalizing the blood in order to obtain clear serum. The 
capillary tubes containing tho blood were placed in both 
buckets of the centrifuge, so that the process of centri- 
fugalizing tho whole of the specimens was thus rapidly 
carried through. It may be jiointed out here that the 
amount of clear senini required for the test, when using 
tho Garrow agglutinomotcr, is l ory small, two drops being 
ample. 

After obtaining the scrum, dilutions were made with 
normal saline ; ono drop of the diluted scrum of each 
individual was placed in each of three adjoining divisions 
on the Garrow’s slab, and to these were added respec- 
tively one drop of tiphoid bacillari- emulsion, one drop of 
paratyphoid A emulsion, and one drop of paratyphoid B 
emulsion. Since tho slab is divided into thirty separate 
divisions it was possible to put up the seruins of ten 
individuals against the tyiihoid and paratyiihoid A and B 
emulsions at one and the same time. The slab was then 
transferred to the box and rotated for three minutes bv 
mcaiis of a special iiiechaiiisni, thus bringing the serum 
into iiitiniato contact with tho bacillari- emulsion. As a 
rule the results are sharp and clear. In "the case of a posi- 
tive reaction the mingled drops of baeillarv emuLsio'n’and 
serum are seen to contain innumerable whitish particles 



June 2, 1928] 


DUPrilOATION OK SUBDIVISION OF THE TESTICLE, 


[ Tne CmrTTrt 
ilKDICAL JoCBXil 


037 


wlio died uiid tlioso v'lio woro iiofc iinpio^cd tlio prmini^ j 
crowtli liiid l)POii nppnipntly clicckod nnd licnlod, bub tlio 
elandulnr deposits liud cbnlimied to progress. Of tlio 
8 eases deniiitoly improved, ono patient has boon treated 
bv irradiation aloiio and is apparently freo from rceui- 
rcueo over a period of three years nnd four months; in 
3 eases the uleer has honied, no rccurrenco ean bo detoeted, 
and niieroscojiicai examination of the scars left shoivs no 
tumour cells present. In 4 cases healing of tho ulcer has 
followed and the glandular deposits levelled in .size in all, 
completelv disappearing to palpation in 2. 

There. fan be no doubt that tho primary growth reacts 
better' tlian do the glandular deposits; this is certainly duo 
to tho fact that an inteuMvo'cross-firp aetion ean bo movo 
easily obtained. Small doses over a prolonged period of 
time aro preferablo to large doses acting for a .short 
period. The 5 mg. tubes aro ])rotmbly ton largo a doso 
for very jirolonged insertion, and a trial is to be made of 
less powerful needles. The best results are to be expected 
from growtlis of tho tongue itself, and especially thoso of 
tho anterior two-thirds; epitheliomata of the floor of tho 
mouth and tho pharyngeal portion of the tongue are 
especially difficult to treat on account of tho difficultj' of 
acce.ss nnd also of tho danger of necrosis. The warty 
exuberant typo of epithelioma gives a better residt than the 
ulcerative typo, which unfortunately is tho more common. 
No anaemia, .as shown by a scries of blood counts nnd haemo- 
globin estimations, has followed oven the most massive doses, 
nor has the cholesterol crnitent of the blood been aflected. 
Tho greatest care in rcgidation of the dose, .screening, and 
placing of the needles is essential to prevent radio-necrosis. 

It is possible that a combination of load colloid and 
radium repre.scnts tho ideal treatment, since the lead may 
help to check the glandular deposits while having le.ss effect 
on tho primary growth. An extensive recurrent growth 
treated on these lines improved eon.siderably. It i.s to be 
noted that all the caso.s treated were past all surgical inter- 
vention, nnd it is probable that earlier cases would react 
much more favourably thnu the above figures iudie.ate. 


RECTAL CANCER. 

The number of cases of rectal cancer admitted to the 
oopartment was 33. Of these, 26 were suitable for radium 
therapy and 7 were unsuited (5 were hopelessly advanced 
and almost moribund ; one was operable niul the growth 
wiis excised ; and ono was treated by lead owing to liver 
deposits). Of the 26 patients, 22 were males and 4 females. 
I bo .average age of the patients was 57. All were advanced 
and inoperable, in most cases there was extensive infil- 
tration of siirroiinding structures, espcciallv the bladder, 
prostate and perirectal cellular tissues. 

Microscopical examination of tissue removed showed the 
presence of adenocarcinoma in 23. In the remaining 
o patients sections were not obtained owing to the in- 
aecessibility of the growth.- All these were clinicallv 
tspical carcinoma, and in none of tho three did anv 
improvement occur under radiiim treatment. 


■ TllF..STJtP.XT. 

All patients were advi.sod to have a prcliminar 
colostomy for two re.asons : ■ first, to allow of exploratio 
(»r the abdomen, as it is obvious tliat secondary deposits i 
liver or peritoneum prohibit any local treatment such r 
irradiation ; and secondly, for tho pui-pose of keeping tb 
growth as clean as possible. ' 

Needles of 5 mg. and occasionally of 10 mg., screened b 
0.5 mm. of platimim were used. In 5 eases the cocev 
nas excised to allow of imiilantation of the radium needic 
directly around a posterior growth. In 16 cases soni 
needles were implanted deeply into the perirectal cellnla 
tis,snes by puncture of the ))eri„eum and ano-coccvgei 
laplie with a trocar. This procedure requires rigid asep.si 
and constant dressing if it is not to be followed by per 
octal suppnriition. This occurred in two cases, resuliin 

m. 1 1 I" "11 ""SPS needles wei 

mplaiitcd deeply into tl.e growth from tho rectal surfac 
in aclclition to t be two procedures 'mentioned previously. 

the large mass of these advanced rectal grmiTl; 
1 S^'ttlng nil intensive cross-fire actio 

twenty inserted, fifteen o 
fiiU 5-mg. needles being required. Xlie rectum toleratt 


thoso largo dose.s v.’oll if n proliminni-y colostomy has been 
performed nnd the tnhe.s are not placed too closely together, 
it has heon found mlvantageons to pack tho bowel lumen 
with ■ ruhher li.ssiio to keep the needles embedded in tho 
growth well apart. Tliis also hclp.s to protect tlio intact 
mucosa heloiv the growth from the effects of too close 
proximity to the iieedle.s, nnd also allows of tho free discharge 
of blood nnd infected fluid, s from the .surface of the growth. 

In all, tho 26 eases Imd forty-seven exposures, as follows: 

I had 4 o.vposiircs, totalling 15,300 mg. hours. 

5 had 3 o.’cposnres, with an nveiagc of 14,626 mg. liours in each 
case. 

8 had 2 exposures, with an average of 9,375 mg. Iiours in each case. 

12 had 1 exposure, with an average of 4,180 mg. hours in each 
case (ticalmcnt is not complete in all these cases). 

; Ru.sults .\xd llr.ji.iuKS. 

Of tlie'26 jiatieiits in this categofy, 13 aro dead and woro 
not im])rovcd in any wny, 8 are alive but sliow no improve- 
ment, 5 (19 ]ier cent.) aro dofinilely improved. Of tho 
5 showing improvement, 2 were irradi.ated- twice and given 
a total of 9,600 and 8,900 mg. lionrs respectively; 2 were 
irradiati-d on three occasions and given totals of 16,080 and 
16,920 mg. hours; ono was irradiated on four occa.sions and 
given a total of 15,300 mg. honr.s. 

In two of these eases the imiirovcment was most noticcalilo. 
In one caso, where the growth was very low down and 
easily accessible, a very comiilete irradiation was possible 
from all nnglc.s. The growth entirely disappeared, 
leaving a fine pliable scar, sections of which failed to reveal 
any tnmonr cells. Tho second caso was an exuberant warty 
adenocareinoma ; this also completely disappeared, leaving 
a fine scar. These two jiatients have been kept under 
observation for eiglitcen montlis nnd remain satisfactory. 
In tlio three remaining cases the improvement was slight 
lint clefinitc, the growth's becoming smaller, harder, and 
[ more fibrous ns comiinrod with iircvioiis sections. 

Cancer of the rectum is a mucb less favourable field for 
radium therapy than is the tongue. The reason for this is 
the difilcnlty of access and still more the intense septic 
clement which, in spite of the most careful preparation 
of the ])atient, is almost inevitable. Further, it is difficult, 
indeed probably imjiossible, to reach the upper jiart of 
the glandular field with any extension of tho surgciw of 
access, tho glaiid.s along the inferior mesqntoric arterj’ being 
quite out of reach. For any sati.sfactory result, then, the 
growth must bo early, low down, and the glandular field 
but little involved.’ 

I desire to acknowledge the help of my colleagues Dr. Lamb and 
Dr. Teall. Dr. Lamb lia.s undertaken all the investigation of 
pathological material and. Mias also investigated .-the blood before 
and after irradiation; Dr. Tenlf lias been of great. assistance with 
advice of- a Icclmical character. Without them' this work could 
not have been carried out. 


A CASE OF DUPLICATIOIsm OP SUBDIYISION 
OF TKE testicle; . . 

' ' - - BY ■ . - . - 

G. H. EDINGTON, D.Sc., C.M., F.R.F.P.S.Gl.vs., 

VISITIXG SVaOEOX,'. WESTERS. IXFIR5IAEY, 'GLASGOW; 

• ■'\yith'-Il!siu}ogica1 A’ofe hi/ 

J. M . S. BLACKLOClv, .jM.B., Ch.B.Gl.vs., 

LECTURER IS PATHOLOGICAL HISTOLOGY, UNIVERSITY OE GLASGOW. 

Durtic.ATiox, real or supposed, of the testicle would seem 
always to liavo excited considerable interest in both lay 
and medical circles. There is no doubt that the condition 
must in early times have been presumed on very insufficient 
grounds; within recent years even tho diagnosis has been 
made on a slender foundation. It seems a truism to state 
that authenticity can he established only by histological 
examination of the abnormal structure. It is now known 
that the condition does exist ; but whether authentic or 
presumed it must bo regarded as of very rare occurrence, 
and it, is for this reason that the following example is 
recorded.'. 

Clinical History. 

Tho P-Ttient, a Iic.iUby youth aged 16 years, employed as a 
telegraph .messenger, .ivas , sent into the Wesfem Infirmary in 
March, 1924, Avitli a swelling in the left scrotum. The swelling 


938 June 2, 1928] 


DUPLICATION OR- SUBDIVISION OF 'THE TESTICLE. 


r Tnr nnm*K 

SJr.DiCii. Jocnsfit 


was observed on physical examination for entrance to tbo JloyaX 
Navy, but its existence had been long known to the paticut-i 
and it had never caused him any trouble. 

On examination the right testicle was felt in the scrotum, and 
apparently was normal, A smooth, rounded, mobile swelling tho 
size of a marble was found in the scrotum above tho left testicle. 
Elements of the cord were felt passing to it, and it was thought 
to bo a displaced globus major, as the normal epididymis could 
not be demonstrated in tho subjacent testicle. At operation tho 
testicle and the abnormal swelling were found occup:^g a common 
tunica vaginalis. The lower body, regarded as testicle proper, was 
ovoid, and measured over 3 cm. in length by 2.3 cm. transversely, 
end 2.6 cm. antero-posteriorly. The upper body was globular, with 
a diameter of over 2 cm. It was freely mobile, and ojily indirectly 
attached to the lower by a pink strap-like structure Eove'ral 
centimetres in length and 0.6 cm. across. The vas deferens was 
felt arising from near the lower pole of the testicle. Tim tunica 
vaginalis extended up along the spermatic cord to well within tho 
inguinal canal, but it did not communicato with the abdominal 
cavity. The two bodies and intervening strap were covered by 
serosa -on anterior and lateral aspects; the upper body was more 
completely invested and was pedunculated. The malformed organ 
being of doubtful utility the tunica and its contents were removed. 
Recovery was uneventful, 
and he was discharged ou 
the twenty-first day. 

Dissccfion of Testicle, 

When ilic tunica was laid 
open and pinned out (Fig. 1) 
the upper body was seen 
to ho attached to it pos- 
teriorly by a pedicle, a 
hi tic over 2 cm. long, which 
passed upwards as a vascu- 
lar plica c.ttcnding to the 
upper end of the tunica. 
vSeated on tho lower part 
of this body was a small 
cup-Iikc structuie, 1.75 cm. 
by 0.75 cm., the expanded 
upper end of a strap, 4.5 cm. 
long, 0.6 cm. broad, and 
0.4 cm. thick, resembling 
noimal epididymis and pass- 
ing down to Ho behind tlio 
lower pole of tho ovoid 
testicle. This strap was 
attached to the tunica 
vaginalis posteriorly by a 
fold like a mesorchium, 
nieastiring in its greatest 
breadth 1.2 cm., and incor- 
porated medially with a 
vascular plica which ex- 
tended up from the testicle. 

Tho latter body, the long 



Fig 1. — Parts removed, viewed 
front lateral side with tunica 
vaginalis laid open, a, Spermatic 
cord; h, upper testicular body; 
c, strap-Iil<e epididymis; d, lower 
testicular body. 


axis of which was directed upwards and forwards, stood well out 
from the tunica vaginalis, to which it was attached posteriorly for 
about two-thirds of its length by a reflexion of serosa. From its 
upper pole a plica extended upwards medial to and blending with 
the pedicle of the upper body. Its postero-inferior pole showed a 
cup-like thickening, fully 1 cm. deep, which gave tho testicle tho 
appearance of an acorn. The lower end of the cpididymal strap 
seemed to be spread out on the lower pole of the testicle, and 
from this- pole the serosa was reflected in characteristic folds. 
Medially the serosa was. smoothly reflected over tho vas deferens 
and spermatic vessels; laterally it formed a deep gutter-shaped 
recess, about 2.5 cm. long, behind the lower part of the epididymal 
strap. , • 

Further dissection (Fig. 2) showed that the epididymal strap 
passed down behind the testicle and bent sharply upwards and 
inwards to become the vas deferens. Vasa efferentia were present 
as stringy connexions between the strap and the lower pole of tho 
testicle. The veins were arranged in two main groups : ono from 
the upper body with addition of a convoluted vessel from the 
epididymis, the other from the testicle, forming a looped plexus. 


Histological Report. 

Dr. Blacklock examined portions of the testicle, of the strap, and 
of tho upper body; and he reported as follows:, 

** Lower Swelling . — ^This is enclosed in a capsule composed of an 
outer layer of fibrous tissue in which are found numerous vessels, 
and an inner layer. of non-striped muscle in which the vessels aro 
less, numerous. Inside these structures composing tho capsule 
typical testicular tissue is present, and here and there evidence 
of spermatogenesis is found. Many of the gland spaces contain 
a mucoid secretion. The interstitial tissue and cells appear normal 
in character and in amount. In some of the sections small ducts 
corresponding to vasa efferentia are found between the terticio 
and epididymis. - . - • 


** Coni between Upper and Lower Swellings . — This Uructure 
shows ill its outer parts fibro-niuscular tissue in which arc present 
nmiiy small vessels (chiefly veins) and a fev/, nerves. Its central 
part is composed of typical cpididymi.s tubules lined by columnar 
ciliated epithelium, collections of spermatozoa being found in some 
of iho lumina. Non-striped mu&clo is seen whorling around 
the ducts. 

. “ Upper Swelling . — Tho part projecting furthest info the sac 
(tunica vaginalis) is composed of testicular tissue in all respects 
simitar to that in the lower swelling, though the evidence of 
spermatogenesis is not so marked. This part is aNo surrounded 
by an outer fibrous layer and an inner non-slripcd muscular layer, 
whicli make it distinct from tho outer part, wbicli is composed 
of typical epididymis tubes. In the epididymis part typical ducts 
lined by columnar ciliated epithelium aro present, and these ."iro 
surrounded by wliorls of non-striped muscular tissue in which aio 
some fino vessels. Between tbo inner (testicular) and outer 
(cpididymal) parts aro foiu.d numerous fine duels lined by a low 
columnar ciliated epithelium, and corresponding to the normal 
vasa efferentia. ” 


LlTERATUnE OF SurETlNUitFnAIlY TeSTICLE. 

Before commenting on tho findings in the above caso 

I would like to refer 
briefly to the litera- 
ture of supernumerary 
testicle. There is so 
wide a diversity in the 
cases i>ublislicd that li 
consideration of tlio 
literature entails a classi- 
fication of tho papers 
into difTerent groups, 
ranging from generalisa- 
tions to tho more pre- 
ciso investigations of 
more recent years. 

A. General. — Lucas-CImm- 
pionnibre,- in a clinical 
Iccluro delivered at tbo 
I16lcj-Dicu, reviewed briefly 
tlio subject of numerical 
anomalies from Icgomlary 
to scientific limes. He found 
that in proportion .as exact 
scientific observations caino 
to bo made tho numbers 
of caecs reported tended to 
diminish. He referred to 
tho legendary belief in tho 
snporcirility of individuals 
thus endowed. In 1911, 
somo cloven years after 
tho publication of this 
lecture, Conzette- wrote on 
tlio subject. Ho referred 
to Cruvoilhier and Sappey 
nob having met with a enso in fifty years, expressed his opinion 
as .to tho rarity of its occurrence, and then wont on to discourse 
upon legendary supervirility, to which, however, he seemed disposed 
to give credence. 



■ B. rscudo’dnplication. — Ma:'sh^ republished in 1911 a caso (origin- 
ally published in 1898) of a boy, aged 3 years, on whom he had 
operated for cpngcnital inguinal hcniia on tho left side. At 
operation two testicles in a common tunica vaginalis were found 
in the scrotum. The child died after operation, and post-mortem 
dissection showed one vcsicula scminalis, situated on the left side, 
and larger than , normal. . From it passed a very thick, vas to 
about half an inch from the internal ring, whoro it divided. 
Tho two branches passed down the inguinal canal into the scrotum; 
one to each testis. The right spermatic artery arose normally, 
but crossed the. middle lino and joined the left at the intenial 
ring to form a single vessel, which divided again into two beforo 
reaching the external ring, and passed one. to cacli testicle. Tho 
condition seems comparable with Lowe’s* case. In that caso there 
was no post-mortem examination, and it was considered by tbo 
Editor of the British Medical Journal as an example of true 
dichotomy of left with non-dcscent of right testicle. Banks^ has 
recently reported a caso similar in somo respects. Ho terms tho 
condition ** transverse^ ectopia ” of the right testicle down tho left 
inguinal canal ; and Keith, ^ wlio had an opportiinity of examining 
the specimen, considered it ^the result of fusion and pcrsistenco 
of the Mullerian ducts. Banks gives four references to cases 
rccoi'dcd by other observers. 

C. External Examination without Operation . — A certain number 
of observers have recorded cases on tho strength of external 
examination only. Davis,® in 1895, reported a caso with three 
testicles in the ■ left and ono in the right scrotum. All wero 
apparently perfect, with sensibility to pressure. Tomory^ described 
(1898) tho caso of a boy, aged 3^ years, with both testicles in tlio 
ecrotum, and in addition a rounded insensitive body in the left 
inguinal canal; the body, was larger than a testicle. Fischer,® 
in 1916, recorded a freely movable swelling in tbo region of tho 
right external ring. It was possessed of testicular sensibility, and 





[ Tint BRTTira flSfl 

SlEDtCAI. JoimXAt. 


JtfNE 2, 192S] 


DUPLICATION 'Oil' SUBDIVISION OP THE TESTICLE. 


i.ovonuM.t in tl.o nonnnll.v silnaled IcsUclo. U i.o M.hjwl 
S VP.II-: ot npc and tlic sciotmn contained two apiiarenll.v normal 
esics. 'nav»'’ reported, in 1918, a ca^c in wlncli tliero wore nvo 
,Ilc"cd testicles in tlio scrotum, and tie reproduced a pliotograpli 


■could lie pulled down into tlic fcrptum, willi a corresponding 
■movement in tlio normally situated testicle, 'i lie siilijecl was 
65 
ios 

of?i;e\iarlsrin"i92rAy7cr>»^P rlinical detail; of a case 

of .supernumerary liodv aliovo tlio left teaticlo. 'Icsticiilar sciisi- 
liilitv was pivsent, liolli globus maior and plolnis ituiior were fell, 
aiid’a distinct cord traced aloiiKsidc pf I ic normal as far as ic 
inlern.sl ring. A pliolograpli sliows (lio body 011 llie left of the 
peiio-scrotal .iuiiclion, and of smaller sue tban llie, normally 
situated testicle below. 


D. Drmnn.tlmtcd bv Oprrathn: A'a Jlhlnlnritrnl I'jrnwhiiilioii.— 
Turner,'! i,i 1900, recorded tlio case of a rliild aged 31 years. 
On the right side there was an encysted hydrocele of the cord; 
furl her down a snpermmicrary testicle svilh cord, which blended 
above with the spermatic coni; and lowest of all tlio losliclc 
proper vith hydrocele of its tunica va^finalis. In 1910 Dofraiiroschi^ 
reported a c.asc of trioiYhisinns in n youth apod 18 ycai's. The 
supernumerary body lay iu tbe upl>cr part oi Ibo left ingiunal 
canal, and its cord blended with that of the noiinal testicle. 
TIic body was removed and showed naked-oye characters of 
testicular’ tissue, hut it was mislaid hefop histological examina- 
tion could be made. ^Vidbahn'R case** difTcred from Ibc above, 
lie Imported, in 1911, a case of left-sided double testicle, ibc right 
IcsUclc being apparently normal. On the left side were : 

(1)' omentocelc, (‘^) two cysts of Ibo cord, and (3| hydrocele of 
the tunic^i vaginalis. On opening the tunica vaginalis two testicles 
were found side hv side, having n common epididymis and two 
\*asa dcfercnlia. Ooudert and Deroeque,** in 1924, reported an 
operation on a supposed strangulated left inguinal hernia in an 
infant aged 7 months. A violet-tinted tumour appeared, losembling 
strangulated testicle. The cord was dissected and showed two 
elements, one passing to the strangulated testicle and the other 
to the normal gland Tower down. Tlic supernumerary body, which 
was strangulated hy torsion of its pedicle, was removed. It 
showed complete macroscopic appearances of a tc‘;licle. Histology 
was not completed at the time of puhllcalion (nor has it yet 
appeared, August, 1927). 


"E. Oprrathn and lihtohfjical Krnminathv . — Wliilc (ho demon- 
slration hy operation is a step forward towards eslahhsihing the 
nature of unusual scrotal contents, the authenticity of super- 
numerary testicle rests on histological examination. Judged bv 
this .standard I have found in the literature only eiglit case** which 
emerge satisfactorily from the tost. In chronological order they 
are ns follows : 


(11 JSfCt, Lane.” Toulh, aged 17. Clicrry-sized hody ‘■iluatcd 
above right testicle, and suspended from spermatic cord by, a 
pedicle. Suponiunicrary body removed and sliowed micro- 
Ecopically tubules in Avhicb spermatogenesis was present. 

(2) Lessen*® (quoted by Haas, infra). In light-Mded 
iiydrocele sac of man, aged 28, two bodies, one above tlic other, 
9®9V. appearance of testicle and epididymis. Cord .'•bowing 
ppididymal tubules united Ibo cpididymes. Single vas defeteus 
passed of! from lower polo of lower epididymis. Both testes 
showed spermatogenesis. 

(3) Mariotli.*' In patient, aged 28, with ostensibly a 
large left inguinal hemin, two cords wore found after opening 
inguinal canal. The larger cord passed to a normal epididymis, 
the smaller ended in a bcan-siccd swelling which, after renicval, 
showed normal reddish testicular tissue supported hy fibrous tissue 
radialing from the tunica albuginea. The fibrous tissue appeared 
imder the microscope Ip be rich in cells and free from fibroblasts. 
(Unginal paper not available; above details from V.rutralhL /. 67<ir.) 


- meiivicai in 

cord; but operation showed it to ‘"be « 
t^ticle m an open processus vaginalis, and attached bv epididymis 
operma.ic cord, winch traced down to normal testicle, 
o vagmalis. Exainin.vlion of siiporniinierary body 

can:fof^pididyrs! ^P<=-»loz^id.s in tubules I 

Ii<.S,’;/*'i;;il,®f“^-'i "Seil 9 years, -w-itb double inguinal 

oana ;i,^re\*n Tv.® '''^spective inguinal canals. In left 

di^nLl frTm 11 ’i" “ pea-liko body ivilli vas deferens 

fwTn Wide*’ 1 ^ of testicle proper. Hislologic.al eiaminalion 
Bhowed highly atrophic' testicle and widely odcti enididvmis. 
Spermatogenesis is not mentioned, and was prcsunfably a*bsent. 

Loft inguinal hernia and pain- 

leh smaller lba’n”ri?Id* y®!*!'®- Both testicles in scrotum, 

‘ j j • iiohfc. Operation showed &uppo.«cd cv-sl to bo 

!* loaUcle. fipididvmis 
Histologically tissue was tosticu^av, Vith 

23 years, with congenital right 
scrotum On nnon*^ ivitii two normal well-developed testicles in 
found i,n,?n nc^T" ot Small olive, 

5 or 6 cm Ti .f » ^ from the spermatic cord 

afterwards' fnimrl In'* '® ®' n '’O subserous I'poma; 
organ' Hislnlnn:n-./°oTn® ■'* .".'"oil losticle resembling an ectopic 
Eperm'at^cnosis. ^ ‘=^“!o>'‘!'t!on showed testicular tissue without 

testidef'^ s^rnfnm "i ''*9 years, with two normal 

Supposed innninni i’.-tIT? “outo gangrenous process in left groin. 

o lymph gland excised and found microscopically 


to bo tosliciilnr (issue, with epididymis and vas deferens, and 
showing active sporniatogeiicsis. 

F. AlitJiiniinii! Suprrntimrnir!/ roitiVIc.— Ondeiidal’s caso,=!’ re- 
ported in 1922, tlioiipli hardly coming within the scope of ilie 
present paper, is of interest, and may tie briefly referred to. It 
was aocidoiitnily discovered during pii.il-tnor/rm examination on 
a subject, age not given, whose external^ genitals were apparently 
noriiinl. tVilliiii the abdomen was a third testicle, depending by 
a stalk from the ileum about 30 cm. aliove the ilco-caccal valve. 
The liody measured 18 bv 21 mm., and showed the liistological 
cliarncicrs of testicular tissue. There was no vas deferens, and 
.spermatogenesis was not observed. The accidental observation of 
.supernumerary testicle in the abdomen was later noted by 
Nieberie-! in the case of a gelded pig, aged about 9 months, in 
which iiodiile.s were scattered widely over the parietal and visceral 
periloiieiiiii. Sonic of llio larger nodules were in the mesentery 
of llie large bowel, otlier.s were irregularly distributed. Micro- 
scopically the nodules allowed the cliaractcrs of testicular tissue, 
without spcrniatogeiiesis. 


Itcmnrls on ihc TMcraturc. 

If tro confine ourselves to Class E, in wliich llie dia- 
gnosis was confinned by liistological examination, wo find 
only 8 cases, • Of tliosc, 5 occurred on tlic left and 3 on 
the right side. In only 4 was spcrmatogene.sis found; it 
was ab.sont in 3. and in 1 its occnrronce was doubtful. As 
regards the typo of malformation, tlio pedicle or cord of 
tbo supornumoran- organ sprang from the spermatic cord 
in 5 (I.nno, Lcra’t, Lcccno) ; it was presumably attached 
to Ibo spermatic cord in 2 (IMariotti, Haas) ; in 1 tliore 
was a sprcad-oiit epididymis (Los.son); and in 2 tbe 
epididymis and vas wore not identified. 

Tbe occurrence of abdominal sitpcrmimcrary testicle does 
not seem to be of clinical interest generally. It is only 
likely to come under notice if it be the .seat of inflamma- 
tion or neoplasm, and .slionld be kept in mind as a po.ssible 
finding in (be course of a laparotomy. 

In addition to the obsoi-yntion by Nieberle (supra) in the 
pig. mention slionld be made of Gerbartz’s-® two examples 
in Ivogs. In one tbe nctessovy organ discharged its secre- 
tion tbroiigb the duct of the main gland; in the other 
tbo accc.ssoiw liad no connexion with the main organ, 
altliongli the clevolopmcnt of the .sperm Jiad reached the 
same stage. 

As regards Class D, it is recognized that in some cases 
the diagnosis cannot be more than presumptive. Pre- 
.sumptiou may bo slrengtlconocl by a study of the records 
of siiecimens whose antbcnticity has been proved by histo- 
logical examination. 


Sum mary. 

Tbe specimen here recorded is an example of duplication 
of tbo body of the tc.stis. It is to bo regarded as an 
abnormal subdivision or duplication of that part of the 
interniecliatc cell mass which gives origin to the boclv of tlie 
te.sticle. TIic AVolflian duct has apparently developed nor- 
mcilly to form tbe vas deferens and epiclidymis, and the 
epididymis is elongated so as to serve the’ two separate 
masses of testicular tissue. Both masses show spermato- 
gencsis--a noteworthy finding,- since in a number of cases 
of duplication tbe supornumeiary organ has been found 
defective iu that respect, a condition of affairs comparable 
with what often occurs in ectopic testis: Tlie ,-pecimen 
would seem to be .similar to that of Lossen (vide supra), 
and one of the less ficc|ucnt varieties. 

ItEFnaEN'CES. 

* LiicnS'Cliampionniorc, J. r Jomn.' do wvd. e( cltir. prat., 19<X), Ixxt, 
ABl-491. =Conzetli*; (7<ro>i. wi-tl., 1911, xviii, 360. ^ p . jiritifh 

ficdical Journat, 1911, i\, 1551 . t Lowe : Ibiil., 1911, ii, 513-514 * Banks • 

IbUl., 1926, ii, 589. ®Davi«i, A. M. ; Med. Record, 1895, xlvii, 353. ^^Tomof.v* 
J. K. : liritirh Medicat Jovrnot, 1893, ii, 1149. « Fischer, 31, : Miinch. vic'd' 
Wach., 1916, Ixiii, 1824. ® Bay, G. U. : Joxtrn. Amcr. Med. Assoc.. 1918 
Ixxi, 2055. >®Ayyer, R. S. : Lau'cet. 1921, i, 223. Turner, G. R. • 
Ibid., 1900, ii, 174. 1 = Dofrancesebi, V. : Jteitr. z. lh‘n. Chir., 1910. Ixvii 
70-72. ** IVidlialin, F. ; TTfVn. wed. TT'or/t., 1911, Ixi, 1498. Courtort, E.[ 
and Beroeque, A.: JlxdJ. ct Mew. Auc. .-Inof. de Paris, 1924, xciv '< 86 ! 

Lane, IW A. : Tntxx^. £Ux\. !>oc. I.uxuh, 1895, xxviii. 59. Lessen, quoted 
by Haas (infra 3Iariotti, B. : Ref. Zexifralld. f. Chir., 3907, 1437. 

**LcraV,.P. : ItxiU. Acad. rop. dc Med. dc helg., 1910, 4S, xxiv, 932-334* 

Haas A'. : Rexil. 7,cxt. f. Chir., 1S22, clxviii, 1-5.- -0 Jeaunin and 
Dclater; lixdL ct Mvrn. Soc. Axint. de Paris, i9^, xciii, 677-681.- =1 Loc6ne 
P. : Ann. rPanaL path. w{‘d.-c1iir., 1924, i, 71-75. == Holder, H.* G. : Joxirn 
Urol.f 1925, xiii,. 555-564. Oudendal, A. J. F, : Virchnic^s Arch. f. path 
Anat. (etc.), 1S22, ccx.x^iii, 82-88. Nieberle: Ibid., 1023-24 ccxlvH* 
599-603. =*Gerhartz, H. : Anaf. Anz., 1906, xxviii, 522-5^. * * 



940 JUNE 2, 1928] 


DIAGNOSIS OP BEANCniAD CYST. 


r Tiir. DniTifW 
L UtniCAL JocuiriA 


'THE DIAGNOSIS OE BEANCHIAL CYST; 

^ViTH A Note oton its Remoyai.. 

BY 

HAMILTON BAILEY, E.R.C.S.Eno., 

GILLSON SCTIOLAR, society* of APOTnECAF.IES ; SUKGEON, DUDLEY* BOAD 
HOSPITAL, EIKMINGIIAM. 

It is common to find a branchial cj*st mistaken for broaking- 
down tiibercnious cervical glands. Eleven cases liavc come 
under my observation ivliere this error had been made, and 
in not a few of these treatment for tuberculosis had been 
persisted in. 

Branchial fluid, on being aspirated, looks just like tuber- 



culous pus, a coincidence which, combined with an implicit 
trust in the bacteriological report, is the fundamental basis 
of this confusion. 

“ No tubercle bacilli found; cultures sterile.” "Wo have 
■rightly come to look upon this familiar report as confirma- 
tory evidence of tubercle. But it shoidd bo borne in mind 
that branchial fluid is also often sterile. 

In _about 10 per cent, of cases tubercle bacilli are 
found in tuberculous pus. In such 
cases it u*ould appear ridiculous 
to suggest the possibility of an 
alternative diagnosis. The folloiving 
exceptional case proves tlio contrary. 

A branchial cyst was removed by 
operation, and its ivall, subjected to 
histological examination, revealed 
stratified squamous epithelium upon 
a basis of lymphoid tissue. The fluid 
aspirated before operation, and the 
contents of the specimen after opera- 
tion, showed numerous tubercle 
bacilli. Doubtless organisms can 
.penetrate • the epithelial envelope 
from its ensheathing ly*mphoid 
coY*ering, which in turn is con- 
nected up Yvith the cervical lym- 
phatic system. 

Breaking-doYvn tuberculous glands 
are exceeding!}* common. Branchial 
cj-st is comparatively rare. The 
difficulties Yvhich surround the 
diagnosis of the latter are ad- 
mittedly* formidable, but they are 
mountable. 

Clinical Features. 

Branchial cyst usually makes its first appearance in early 
adult life. Tlie onset is often curiously abrupt, after which 
the cyst begins slowly to increase in size. Recurrent 
attacks of inflammation in the cyst are usual. 

Branchial cyst is nearly always related to the upper third 


of the .sternn-mastoid (Eig. 1). It is usually found coming 
from the deeper planes of the neck around the anterior 
border of this muscle.* But as the sterno-mastoid is thinned 
and flattened over the cy.st this relationship is .seldom clear 
until the muscle has been rendered taut. 

If a swelling answering to the above description is found 
tho absence of cnlargoinent of the cen'lcal glands when 
the nock is sy.stoinatically palpated should raise in tho 
examiner’s mind tho quc.stion, " Is this a branchial cystP ” 
This question can bo promptly settled by tho following 
simi)lo confirmatory test. 

Confirmatory Test for Hranchinl Cyst. 

After the skin has been sterilized a little of the' fluid 



Fig. 2.— The cyst has been rendered dacotd by aspiration of half Ita 
coniciits, wiiicb considerably facilitates^ total enucleation. 


is aspirated. It will usually rim quite easily through a 
needle of an ordinary hypodermic syringe. A drop of the 
aspirated fluid is placed upon a slide, .and covered with 
a cover-slip. Tho slide is thou examined under tho mici'o- 
scopo with a one-sixth power lens. Tho presence of 
numerous cholesterol crystals at once makes the diagnosis 
certain. Fig. 3 is a photomicrograph of a drop of fluid 
removed from a branchial cyst for tho purpose of con- 
firming tho diagnosis. 





\- ' I'"- • ' 'tt'.y 


X 


Pig. 3 . — ^Photomicrograph of branchial fluid. Tho 
abundanco of choIeBtcrol crystals is characteristic. 


by 


no means msur- 


Itcmoval of a Sranchial Cyst. 

A branchial cyst should ho com- 
pletely roihoved by dissection. It. 
may ho conveniently exposed by a 
transveiEo incision following the lino 
of tho creases of tho neck. Except 
in small, superficially placed cysts 
it Yvill ho found best to divide tho 
stcvno-niastoid. Beneath this muselo 
the spinal accessory norvo will he 
found bearing a constant relation- 
ship to tho cyst wall.- Tho iieiwe 
should ho isolated. 

Branchial cysts often run deeply 
into tho nock, and may extend up- 
wards as far as tho haso of tho 
skull. Ill this respect they resemble 
an iceberg, for tho greater hulk of’ 
tho mass is beneath the surface. It 
is most clesirahlo to remove tho cyst 
intact. If the cyst hursts halfway 
through tho operation dissection is 
rendered difficult, surrounding structures hecomo en- 
dangered, and the end-result may prove unsatisfactory, for 
even a small piece of secreting epithelium left behind may 
give rise to a sinus n*hicli persistently discharges. Complete 
dissection of an intact cyst is almost always possible, and 
tho operation is very much simplified if the following 
technique is adopted. 

After carefully cleaning the superficial aspect about half 
the contents of the cyst are removed by asiiiration. The 


.y 




or 

Jdke s; igiS] 


TONSIti-SUOTION FOR DIAGNOSIS AND TBFATStENT. 941 


inuictiirc hole Gins mntlo i": rovcrotl with n piocc of panzc 
nhoiit the si/o ' of two postivgo staiui's. 'fl'e gauze aiul llic 
erst u-nll ai-e then piched up with n pair of spoiigc-iioittnig 
forceps (Fig. 2). Hio gnuze luininiizes le.ah.-ige ami ]n-c- 
veiits the forceps slipping. Gentle traction may ho made 
with the fnreop.sal first in this direction and then in that, 
and Mie evst wall is cleared hy gauze and hlunt dissection, 
aided here and there hy a few touches of the sealiiel. As 
dissection ])rocccds and the dce]> parts of the (yst are 
reached it will bo found convenient to apply a second ))nir 
of si)oiigp-hnlding forceps. Using these means the intact 
cyst may he complololy enucleated. 

nrrn:rr,cr. 

* Bailey, I/aiiiii‘'on : ISritisIt Journal of Svrumu vol, <0, 1923. 


TOJiSIL-SUCTION FOR DIAGNOSIS AND 
TREATMICIST. 

/ 

ur 

FRAXK: C. eve, AI.D.C.rN-r.tn., F.R.C.P.I.osn., 
EESiop. coxsi'LTiKO rjivsiciiK, covxL 2 xrin»tA«r, kill. 

I.vsiarcrto.v.s loti U.sk. 

' h\ J)ioriiiosi.i. 

The patient .sits facing a good light and lemovcs dentures. 
Tlio diagnostic lonsiksnckcr is wanned in hot water to 
prevent conden.sation. AYith the stem against the angle of 
the month the siiclccr is pressed firmly against the opposite 



squeezed, and then i-elcase 
yrvfe the fmger over the air-hole on the stem. The tons 
JS thus c.vtroveitod, and any pus in its crjpts is scen- 
yehow on the rod tonsil—msidc the glass funnel. The glas 
fnnncl is now given n combined pull and a slide toward? th 
chTOh, ^0 that the pus is picked off hy the incurved gla: 
edge; excessive snct.on will prevent the sliding niovenleni 
lemoml " Repeat to ensure tlTat all pns i 

an”? l'^”'''^’^'>seoped (for polymorphs and germs’ 

n^ahv .If it and smell it (it i 

is nocLsarv"^” funnel to convince that treatmen 


Tli'^ 1 yiie Thcrapcufic Tonsil-suclcr. 
hat a Sff funnel IS similar to the diagnostic one, but 
Wider month, thicker rim, and its edge is not 


incurved. A riihhcr fiiiger-slnll (niodium thickness) is 
wetted and slipped over the glass fiinnol. It should form 
a flat diaphragm aevoas the fiimiel mouth. On this the 
aiiti.septic cream is thickly spread; This is pressed against 
the tonsil and stioiig suction n])plied. The crypts of the 
extroverted tonsil arc thus thickly .smeared with the anti- 
septic cream. I’rc.ssnre is then relaxed (by opening the 
vent-hole); the tonsil .‘-nhsidcs into its usual shape, carrying 
the nntisejitic into the crypts and spaee.s from which the pns 
has been evacuated. This inaiiceiivrc .should he repeated 
thrice in rapid snci>ession heforo witlidrawal. 

After use the glass funnels should he cleaned and kept 
in the glass jar of weak carbolic provided. The rubber hall 
acts ns stopper to the jar. The finger-stalls can also ho 
cleaned and kept in this solution, and used again. For 
more rapid sterilization 1 use a sniicepan. 

Tlie iinthseptic cream contains increnry olcato, bismuth, 
Iceniscnc (for its creeping qualities), and vanisliing cream. 
BcttcrTormiilae are being searched for. 

As an c.xtia .safeguard, the portion of the glass tube 
which enters the patient’s mouth is enclosed in a sleeve of 
rubber tubing. 

Trcalmcnt is repeated at least once a week until no more 
]nis is found. Then the intcm-al can be lengthened to 
10, 14, 21,. of 28 da>T5. - Tlic course is usually longer in older 
paticiit.s than in younger, tliongli the health may ho 
heiicfitod long heforo the pns is all gone. Tiredness, 
pallor, anorexia, rheumatism, and other snbinfectij'e 
toxic .symjiloms often qniclcly disappear. In quinsy 
and acute tonsillitis it will probably he found that .septic 
fluid can lie .snekeil out and tension relieved - with - a 
larger glass fnnncl having a layer of cambric tied flat 
across its moutli. 


• Ilhistrafire Cnscr. 

Case i. 

Dr. X., aged 55. Had had tonsillitis after sleeping in a damp 
bed in 1919, 

Tonsillitis recurred trilh rhoumalic pain and swelling in ankles, 
fingcr-ioints, and back in March, 1927. I saw him first five months 
later; the fingers and ankles were eUU swollen, inth fiat feet. 
Though the tonsils looked normal I could so.ck liquid pus out of 
them Jiaving the same smell as Die nasty taste he was getting. 
This pus was largely composed of polymorphs, with only a few 
pnciunococci, baciUi, and dip1ococci_ 

At first 1 cleaned the tonsils twice a week by suction, later 
weekly, llieii monthly, and left various autiseptics in the crypts — 
for example, tliymol iodide and kerosene, bipp, iodoform and 
kerosene, and ung. liydrarg. roolle. The amount of pus rapidly 
diminished, and in about two months there was little or none. 
His rheumatism at'o quickly diminished, and he was able to do 
his practice throughout. 

On December 20th he reported himself as very well and without 
rheumatism; the tonsils contained no pus and' remain free (May 
2nd). He can (asio iodoform when lie drinks anything hot eight 
hours after treatment, pwing that the antiseptic' is buried in the 
crypts. He thinks this diagnostic and therapeutic method h.rs a 
great futuic. 

Case ir. 

Mi'S M., aged 32. Had poor health with frequent colds, sore 
lliroals, and abdominal pains and occasional rheumatism. In 
Kovemher, 1925, bc.ids of cheesv pus were sucked from both 
tonsils. On December 20th there was no pus. In December, 132B, 
two heads of pws were found in the icfl tonsil. In April, 1^, she 
could .squeeze beads of foul pus from her tonsils and could feel 
it accumulaUng. In May I started treating the tonsils bv suction 
ATilb culhjinoi aQu anstol. In July (oigjit treatments) fier rlicu- 
matism had gone and the tonsils were almost clear of pus, but her 
adenoids lyerc still sore and dirty. In September she had to have 
her adenoids out, and obviously this opportunity of removing the 
tonsils had to be taken, though tliev were clear of pus both by 
suction and in microscopic section. 


Case m. 

Mrs. A., aged 57, had suffered from rheumatic neuritis in the 
left arm for tliree years. Had *' always " had rheumatism in the 
hands and ankles, and frequent pain and swelling in the tonsillar 
glands. Had quinsies twenty years ago, and alt teeth extract^ 
ten years ago. Her father was crippled with rhenmatism for 
twenty years. Pus was sucked from the tonsils. Suction treat- 
ment was started on June 22nd (menthol, aristol, calomel 
glycerin). After nine treatments (.September 2nd) there was no 
pus in the left tonsil and the glands had ceased to swell. She 
looked well, but was still rheumatic. * . 

Between September 27th and Octohe'r Uth she was ejvcn three 
injections of contramine. On October 18th the pus in the rielit 
tonsif was nearly all epithelial debris; there were no polTmortTUs 
On Kovemhor Isl Uie rheumatism was wonderfullv easier and oii 
November 29th there was no pas in either right o'r left "tonsil 

On January 3rd, 1928, friends remarked on the wonderful chan'ro 



042 June 2 , 1928 ] 


INTKATEACHEAL ADMINISTRATION OF CHLOROFORM. 


t TffF nniTisa 
SIcmcaC Joubnui. 


in her condilion. On January 29th she had mild cholecystitis 
wliich soon yielded to hexamine. There was a little pus on the 
right, tonsil and slight rheumatism in tlic left shoulder, but 
nothing like it used to bo 

The chronic ill health and rheumatism of this patient was 
certainly very greatly improved qxiri passu with improvement 
in the tonsils. 

Case iv. 

Miss P., aged 23. This patient had chronic appendicitis. Pus 
was cleared from her tonsils in seven treatments during two 
months without influencing the kinked appendix, which was excised 
as soon as it was convicted. After an untreated interval of ihreo 
and a half months the tonsils were still clear of pus. 

Cage v. 

Miss H., aged 25, was a keen athlete, but now too tired, even in 
the morning, for anything. She had tuberculous dactylitis ns a 
child. There was offensive pus in both tonsils. I thought her 
tiredness was duo to septic absorption, presumably from the 
tonsils. The pus contained few polymorphs; no pathogenic germs 
were recognized. On November 26th treatment by tonsil-suction 
bismuth, and kerosene) was started. After much rest 
and five treatments she was much better and could skate: there 
was still slight pus in the right tonsil. On February 1st tho 
tonsils were clean. Ten days later there was a liltle pus, but her 
imT six months. On March 

outh she said she was “never tired there was very slight pus 
m the right tonsil. j b t « 

Besides rest, this patient had no other treatment except (later! 
ultra-violet rays and arsenic, so that it looks as if her ill health 
had been due to septic tonsils. 

Case vi. 

A woman, aged 50, with seven months’ constant asthma, which 
promptly vanished witli ono cleaning of tlio tonsils, and the pus 
almost cleared up m throe treatments. 

nolrenefited (solarr'* (complicated) are 

Conclusions (PnovisioMAu). 

Although pus may ho demonstrated by this method in 
manj- young adults in good health, yet it can hardly bo 
doiibted that, wlion they get older — to tho fibrositis -age — 
and less resistant, the infection will accumulate and conquer 
their resistance, and they will get rheumatism in some form. 

I have been using tonsil-suction diagnostically for three 
years, and should estimate that in patients with fibrositis 
pus can tiuis bo demonstrated in their tonsils in 90 to 
95 per cent, of cases, acting as a focus of subinfection. Tho 
tonsils may look quite normal and yet contain pus. The 
ordinary method of expressing pus with a spatula may bo 
far more painful ; one patient said it was agonizing, whereas 
my method was merely unpleasant. It is a more soarchino- 
method, and tho pus can he soon (and smelt) by the patienC 
That IS an important advantage. If there aro infected 
teeth or sinuses these should first be put right, as tho tonsils 
may then clear themselves. 

The method needs trying on a much larger scale and 
bacteriologically. I have been almost limited to private 
patients m a consulting practice; so that in these six 
patients alone has the treatment had a proper trial, 
except ,n one lady of 57, where the issue ivas confused 

In the septic tonsils of adults, the risk of serious 
haemorrhage after tonsillectomy should be minimized by 
a preliminary course of tonsil cleaning by suction 

Tho method is at any rato quito harmless; two of my 
cases indicate tho importanco of cleaning the tonsils after 
a quinsy (or tonsillitis?) and seeing that they remain 
clean. Six to twelve treatments have usually cleared tho 
tonsils of pus. 

My plan is to make tho intervals longer as soon as pus 
ceases to bo found ; but I cannot yet say whether a few 
treatments annually will ho necessary to keep the tonsils 
free from pus. Perhaps better pastes will bo more effec- 
tive. Evidently tonsillectomy is the best cure when possible 
and safe; but in adults it is practically a major opera- 
tion, and in many patients it is out of the question 
Painting tonsils containing deep pus is evidently fatuous 
Honco an altcruative is most desirable, and seems to bo 
provided by this method, which is available to tlio eeneral 
practitioner. 

i: funnels aro much moro subtle than they look— 

IVdRnI !.i‘' ^ ‘>>0 very 


INTRATRACHEAL INHALATION AND INSUFFLA- 
TION OF CHLOROFORM BY MEANS OP A 
FLEXIBLE M15TAL CATHETER, 
nv 

W. DAKIN hlART, B.A.C.ixx.in., M.R.C.S., L.R.C^P., 

SENIOn ASAESTIIETIST ANO LECTUREa ON ANAESTIIETICS, THE r.OTAL 
INl'IRMAr.Y, SIIErrlELD. 




E3 


SojfE fifteen years ago I wrote a paper on tho intratracheal 
instifilation of chloroform by moans of a gnm-elastio 
catheter. This catheter did not last long, and had to ho 
continually replaced. For some time now, however, Mr. 
AV. S. Kerr, honorary surgeon to tho nose, ear, and throat 
department of tho Royal Tnfirmary, ShcfTichl, and I havo 
used, instead of tho giim-clastic catheter, ono made for tho 
most part of flcxihlo metal, and this has given 
every satisfaction to both tho surgeon and tlio 
anac-sthetist. 

Tho method of administration differs somewhat 
from tho old procednre. Tho instnmients used 
iuclndo a flcxihlo metal catheter, an adapter, 
a Junker’s apparatus, eompleto with tubes and 
bellows, and an anaesthetic mask for induction. 

Tho flcxihlo metal catheter is made by Mayer 
and Phelps in two sizes. No. 12 and No. 16; 
it is rigid at cither end for about two inches, 
tho remaining part being flexible. (See figiiro.) 

Tho internal non-floxiblo part has an opening 
at tho side, in addition to tho end opening. 

Tho external non-ilcxiblo part, which during 
action is wholly outside the mouth, is a copy of 
tho internal, except that tho external end is 
somewhat funnel-shaped. Tho openings at the 
side aro of tho same hnnon as tho catheter, or 
possibly slightly larger. A blunt metal stiletto 
is provided, tho length of which is less than tho 
length of tho catheter; this provides rigidity to 
tho catheter during introilnction. 

Tho metal adapter (seo figure) is made to fit 
into tho funnel-shaped end of the catheter by 
ono end, whilst tho other end is attached to tho 
rubber exit.tnbo of the Junker apparatus. Tho 
lumen of tho adapter is either No. 12 or No. 16 
catheter size, according to which sizo is in use. 

Ono Junker’s apparatus has all its tubes No. 12 
catheter sizo, and tho other all its tubes No. 16 
catheter sizo, for employment with tho appro- 
priate sizo of cathetor. 

Tho following method is adopted to induce and 
maintain anaesthesia. 

Preliminary medication is by means of mor- 
phine and atropino, which should bo injected 
at least half an hotir heforo induction is com- 
menced. Anaesthesia is induced by means of 
chloroform dropped on to a mask; this should 
bo fairly deep, becauso otherwise tho patient 
may come round during tho introduction of tho cathetor into 
the trachea. When the patient is fully auacsthetized the 
cathetor is at once introduced into tho trachea with tho aid 
of a bronchoscope, the stilette being within tho cathetor. 

Tho catheter having been introduced through tho vocal 
cords, the stiletto is at onco withdrawn and tho cathetor 
attached, by means of tho adapter, to tho rubber exit tuboi 
of tho Junker apparatus. There may ho some coughing at 
this ^ stage if the patient has not been sufflciontly anacs-, 
thetized, but this can soon bo remediGd by placing tho' 
finger over tho hole in tho rigid portion of the catheter 
outsido tho mouth and pumping chloroform vapour into 
tho lungs by means of tlio bellows of the Junker apparatus. 

I usually at this stage give three pumps with the bellows, 
wliilo my finger IS over tho liole, and then remove my finger* 
so that tho patient may have a breath of air, and repeat 
this procedure until the patient is again completely anacs-' 
thetizcd. I do not think there is any danger, at this stage, 
to tho alycoh from excess pressure by this pumping, as 

Gio IS p enty of room outside tho catheter in tho trachea 
to act as a safety valve. 

The surgeon now completely plugs the throat around the 


Joke 2, 1928] 


MEMOnAKDA. 


r TnnPnTnra 04 ,Q 

L5rrMCAi.J0cr.yAi. 


catlictcr with sponges, so Uml tlio nlvooli now gel tho full 
effect of oiiy excess pressure from the Ircllous, wlnrli must 
1.0 nsod. lliorcforo, very lightly. In pmetioo it will ho 
found that ns soon ns thn sponges linvo hoen p need in 
position the pumping of chloroform vnponr into the lungs 
is no longer uoccssan-, ns the patient will draw chloroform 
•vapour through tho junker apparatus on insinrntion, when 
tlio finger is placed over tho external hole in tho catheter. 

I.thcreforo remove the hollows from the Junker apparatus, 
and tho patient insjuros chloroform or air ns desired hy 
'tho anaesthetist. Tho anaesthetist must never forget that 
'ho now has that which tho patient hronthes nhsolutcly under 
ihis control, just as is the case in tho administration of 
Initrous oxido and oxygon, lie has thoTOfore to find out 
itho ratio of air to chloroform vapour retpiired hy each 
■patient to keep them in a .satisfactoi 7 singe of maintenanco. 

I usually start, when the stage of mnintenanco has been 
readied, with three inspirations of chloroform vapour 
inhaled hy the patient through the Junker apparatus to 
ono insjiiration of air inhaled through the side opening 
in the catheter outside tho mouth; in other words, the 
finger is ]ilnced over tho side opening in tho catheter while 
tho patient takes three inspirations of chloroform vapour, 
and the finger is taken away from tho opening whilst tho 
patient takes ono inspiration of air. IVhat actually 
happens when tho finger is taken away from tho oiiening, 
after the three inspirations of chloroform vapour, is that 
an expiration is- the imui«liato rexult, followed hy an 
inspiration of air, then another expiration throngli the 
opening, and then the finger is again placed over it to 
permit the three inspirations of chloroform vapour, and 
so on. This I find is the average ratio of chloroform to air 
which suffices to keep a patient in tho stage of maintenance 
and in a good condition. Some patients, however, require 
moro air to keep their Wood a good colour than othor.s, 
and, on the other hand, there aro some who require a 


higgor proportion of chloroform vapour to air to keep 
them fully nnaeslhclized. Tho deeper tho anaesthesia tho 
lighter tlio hreathing. and the lighter the .anaesthesia the 
deeper tho hreathing during the stage of maintonanee. 

The anaesthetist should keep a constant watch on his 
Junker hottlo, in order that he may note tho force with 
which tho chloroform vajiniir is drawn through. This is a 
most oxcelleiit index of the force and depth of tho 
patient’s inspirations. , 'should the hiihhling of vapour 
through tho .lunker hecomc light I invariahly take this as 
an indication that the patient requires more air, find 
accordingly seo that, ho has it. 

Tho advantages of this method are: 

1. Tho maintenance of a ]x>rfcctly clear airway. 

2. The prevention of Wood entering the air pa.ssages 

owing to tho complete idugging of the throat 
around the catheter, 

3. The ahsolnte control of the amount of anaesthetic 

inhaled hy the jiatient. 

4. Tho jiatieiit inhales at each inspir.ation, hy his 

own c/fort.s, tho amount of anac.sthetic or air 
which tho anaesthotist thinks he requires. 
Pumping by moans of tho Junker hollows is 
di.spensed with. 

This variety of nnae.sthosia is undoubtedly tho best ’ 
method to adopt in all operations on the upper jaw or 
nose, and I have not the slightest doubt that anaesthetists 
who use it will he jileased with tho result. 

Ur. IV. !3'. Kerr, at whose suggestion the flexible metal 
catheter was made, and at whoso request I have written 
this paper, is very well satisfied with the results from the 
Burgeon’s point of view. My thanks are duo to him for 
Euggestions given to me in compiling this paper, and also 
to Messrs. M.ayer and Phelps for making tho c.atheter and 
adapter. 


^cinoraittra : 

■MEDICAL, SURGICAL, OBSTETRICAL. 

CONGENITAL HEAHT-BLOCK. 
iThe occurronco of two cases of congenital heart-block in 
ono family is so umisual ns to ffesen'O being placed on 
record. 

A married woman, aged 21, was delivered of her first child, a 
female, in 1922, This child has been under my ob^on'ation since 
-birth; 'her ventricular heart rate has varied from 40 to CO beats 
a minute, and tho pulse has always been regular in force and 
rhythm. During the first few years of life the child lacked 
energy, and was cyanosed at limes, particularly iu cold wcallier; 
Bho walked slowly^ refused to be hurried, never ran, and was 
quite content to he still for long periods. Thi^ state of affairs 
gradually disappeared, and now, at the ago of 6, she appeal's to 
the casual observer as an ordinary healthy child, able to run about 
and up hills with no more distress than tho average child. There 
is now. 'no cyanosis. The ventricular heart beat when last noted 
•was 42, and regular in force and rhytlim. The cardiac dullness is 
increased fo the -left, and the apex beat is in tlic fifth space, 
one inch outsido tho mid-clavicular line. On walking up and down 
stairs three times tho ventricular beat remained rcgufaV and did 
not alter; there was no apparent increase in the cardiac dullness, 
and the only effect of this exertion Avas a slight temporary increaso 
in tho respiratory rate. The systolic blood pressure is now 
115 mm. Hg; 1 have not been able yet to determine the diastolic 
rcssure in this child owing to the small size of the arteries at 
cr age. 

Tho heart has apparently accommodated for its slow beat by an 
increase in size and force of beat sufficient for the present for all 
ordinary purposes, but it would appear wise to conserve energy 
by avoiding as far as possible undue stress. 

Subsequent to tho oirth of Ihis child two normal boys were 
bom, each at an interval of two years. In March, when examining 
tho mother, who was eight months pregnant, I noted the foetal, 
heart rate was 59; at subsequent examinations the rate varied 
between 40 and GO. A female infant was born normally on March 
17th. Immediately after birth tho pulsation of the cord was 65 
and slightly irregular, with, occasional forcible beats ; this soon 
et^died to a regular oven rate of 48. The baby cried strongly; 
its weight at birth was 7 lb. There are at present no murmurs, 
enlargement of the heart, and no ej’^anosis, but tho« 
mother slates that there were frequent attacks of blueness during 
mo lirst fortnight. At tho age of 1 month the baby is doing 
wl ana appeal’s normal, except for the ventricular heart i*ate. 

■ 4 .ncre have been no miscarriages. Tho mother suffers from 


MiknUez’s — a chronic swelling of the parotid glands wiili 

occasional severe attacks of swelling of all the salivary glands, for 
no particular reason, hut so severe ns to need morphine for the 
relief of llio pain. She is slightly deaf as the result of middle-ear 
disease in childhood, but is olhenvise hcallby. The fattier is 
normal, except for ilie loss of n log, the result of war wounds. 
There is no histoi-y or oridcncc of any venereal disease, and 
no liislory of heart trouble among the relations. 

Apparently tlio dcvolopnient of congenital heart-block, or 
perhaps tho failure to develop normal conductivity, is 
developmental in origin, and it is pure coincidence* that 
two cases , of sucli a I’are disease as congenital lieail -block 
have occurred in tho same family. 

It. D. Aylvtakd, M.R.C.S., L.R.C.P. 

Tunbridge Well?. 


A CASE OF SOMATIC TAENIASIS. 

Dr. Robert Hutchison, on March 3rd, 1928 (p. 335), 
warned us against diagnosing rarities, but they do .-^ome- 
time.s occur, ns is shown by tlie following report of a case 
of gouevalized tapeworm infection. 

^ A strong young man became an invalid, his first complaint 
being severe lieadache. Malaria was thought of and elimin- 

• nte'd, blit early pernicious anaemia Avas considered possible. 
•The 'patient then said (hat his fingers and thumbs tingled, and 
’ pains ran down his legs; he staggered Avhen he A\alked. As there 

was nothing to account for his symptoms he Avas thought to 
; be raalingerihg, but he then became really ill. His left leg swelled 

• and his temperature rose, but after a fcAv days he recovered. He 
; commenced AA'ork, but shortly aftcrAA'ards • had a fit. These fit'; 

• recurred and Avere thought .to be hysterical, but I doubted this 
! etiology. His speech became hesitating. He, looked at times 
1 an iiiA'alid, but at other times I saw him Avallcing briskly and 
•. normally. . He then brought to my notice some lumps under hi': 
‘Skin, which were lender and abolit the size of a large pea. I 

• thought that these lumps might clear up tho mystery of liis 

1 disease. I was asked to certify him as insane, but- at my examina-’ 
i lion I discovered ho had double vision, and so I decided that the 
j case Avas physical, not mental, and this despite the fari that he 
; had auditory haUucinatious. At length a lump Avas excised, and 
I examined. The pathologist reported that it v.’as a cyst^ con- 
’ taining larval Avorins, probably the cysticercus stage of polk 

• tapoAA’orras. 

! Thus the uiystovy was solved: it was a case of A'isceral 
; costodcs. The rarity of tlii-^ condition is mentioned in the 
* article on diseases caused by cc-'itodos in Osier’s Texfhooh 


944 ; June 2, 1928] 


BCIENTIFIO FEOCEEDINGS OF BEANCIIES. 


[ Tiir lJnm<nl 
MrutcAL Jotnjfit 


of Medicine. . The diagnostic difficulty ivas considerable; 
in one of his “ fits ” tho patient .presented tho appearance 
of a case of acute heart failure. Had a lump been examined 
in' 1922, when the patient was in tho army, tliore would 
never iiave been any mystery. I^robably, they were taken 
for fatty tumours, which, I am told, are sometimes tender. 

Kilahurst, near Rotherhaa,. C. J. HinL AlTKEN, M.D. 


PEOFTJSE HABMATEMBSIS SECONDARY TO AORTIC 
AND MITRAL INCOMPETENCE. 

The case here recorded is^ I think, of sufficient interest to 
warrant publication. 

I was called one evening to a boy, aged 16, whom I found rather ; 
collapsed. Beside tho bed was a pail containing about eight I 
ounces of dark clotted blood. The haematemesis, 1 was told, had 
followed exertion; the patient had attempted to push a tram 
of coal, and immediately felt faint, and later began to vomit 
blood. He complained of little pain. He had never previously 
complained of epigastric pain, and had never sufTcred from dis- 
comfort or vomiting after food. I had treated bim for aortic 
and mitral disease, following rheumatic fever. There was no 
liisLory of haemophilia. 

Tho temperature was 98*^ F. and tho pulse (100) of Corrigan type. 
Epigastric pulsation was marked. There was no marked tender- 
ness or rigidity in tho epigastrium, and no tenderness anywhere. 
The lungs were clear. The heart apex was in the sixth interspace 
in the nipple line. A mitral systolic murmur, conducted to tho 
axilla, was heard, and also an aortic diastolic m the second right 
interspace; it w’as conducted dowm, and was heard loudest in tho 
mid-line in the fourth interspace. 

During the examination the patient had another attack of 
vomiting, consisting of dark clotted blood and mucus, amounting 
to about a pint, and complained of feeling faint. I administered 
morphine hypodermically, and ordered ice to suck, pending removal 
to hospital. About halt an hour later, in my presence, ho again 
vomited a lar^e quantity of blood (a pint to a pint and a half). 
Two hours alter removal to hospital he vomited six ounces of 
blood. Ho was collapsed, tho pulse 160, small and thready, Iho 
temperature 97® E., and the respiration sighing. 

Rectal salines were administered every three hours, morphine 
hypodermically, and ice to suck. The patient revived a little, but 
was very restless. Next day he again vomited a small quantity 
of blood-streaked mucus. The systolic blood pressure W’as 100 mm. 
of mercury, and the diastolic 40 mm,; pulse pressure 60. Normal 
lioise serum was injected, witli morphine, and salines by the rectum 
every six hours. On the third day a radiograph was taken, but 
showed nothing abnormal. 

Vomiting ceased after the second day, but the stools remained 
tarry for eight days after admission to liospitah The patient was 
given nutrient enemas as long as melaena persisted, and nothing 
by the mouth except ice to suck. After tho eighth day milk 
combined with barley water and calcium lactate was given, and 
this was followed later by milk puddings and fish. Ho had no 
discomfort. A fractional test -meal revealed no degree of byper- 
chlorliydria. . . , . 

An uninterrupted recovery followed. The patient was discharged . 
at the end of the third week. Before discharge another radio- 
graph was taken, but nothing was observed apart from slight 
dilaialion, of the stomach. 

Since discharge the' patient has never felt better; he has 
regained a stone in weight, does not complain of any 
discomfort, the murmurs have become less marked, and 
the pulse slower, but still of Corrigan typo, yet not 
so markedly water-hammer as before tho haemorrhaf^o 
occurred, ^ 

It may be worth while to mention that a claim was 
lodged by the patient under the "Workmen's Compensation' 
Act, but compensation was not granted. 

Gvvm, Jlonmouthsbire. F. O’SuLmVAU, M.B,, B.Ch. 


ISntislj Critical Assonatiun. 


CLINICAL AND SCIENTIFIC PROCEEDINGS. 


CAMBERWELL DIVISION. 

At a meeting of the Cambenvell Division of the British 
Medical xtssociation, held at tho St. Giles’s Hospital, 
Camhevwell, on April 24th, a discussion was opened by 
Dr. Gut Boxjsfield on methods of combating diphtheria. 


incidence in the elementary schools. Diphtheria notifications 
in llio borough, ho stated, numbered 8,120 for nil agc.s in this 
period, equal to an average attack rate of 3.0S per 1,000 (taking 
the 1021 census population), as compared with an average attack' 
rale of 2.7 per 1,000 for all London. There avero included in 
tliis total 2,632 cases under 5 years (attack rate 11.0 per 1,000) 
and 4,200 cases hebveen 5 and 15 years (attack rale 8.0 per 
1,000) ; for the combined ago group under 15 years tho 
Camberwell attack rale was 9 per 1,000, or slightly above tho 
London attack rate for tho decade of 8.7 per 1,000. 

During the ten-year period tho average annual death rate 
from diphtheria for all ages in tlio borough was 1.84 per 
10,000, tho rate for all London being 1.64 per 10,000. The 
avcr.ago yearly death rate in the Camberwell age groups under 15 
years was 6.2 per 10,000, against 6.0 per 10,000 for all London. 
In 1923, tho year of heaviest diphtlicria mort.ality in Camber- 
well, tho case mortality was as high as 20.6 per cent, among 
children under 5, being 5.1 per cent, in tho age group 5 to 15 
years, and 8.2 per cent, for all .igcs. In 1927 Ihc percentages 
had fallen to 4.2 in the age group under 5, 2.9 in tlio ago group 
5 to 15, and 3.16 for all ages. The year of the heaviest case 
mortality for all London was 1922, when it amounted to 
7.4 per cent. 

Incidence among School Children. 

Comparing tho attack rates in tho school population, Dr. 
Graham Forbes showed that thcro had been a considerable 
divergence between tlio experience of Camberwell and that of 
London as a whole, but that as a rule the incidence had been 
higher in tho borougli. Tlio average annual attack rate in 
Camberwell schools in the decade was 7.36 per 1,000, as com- 
pared svith a mean rate of 6.8 per 1,000 for all London. Tho 
disease had fallen far more heavily upon children in tho infant 
departments (between 4 or 5 and -6 or 7 years), with an averago 
annual attack rate of 12.45 per 1,000; among children aged 
7 to 13 years tho averago in 1918-27 was 4.69 per 1,000. Among 
older children the incidence of diphtheria in Camberwell had 
maintained a fairly constant level, but among infants tho 
attack rate had fluctuated between 6.7 per 1,000 in 1919 and 
18.9 per 1,000 in 1926. The steady rise in tho school inoidonca 
from 1921 to 1926 had been almost confined to the infant depart- 
ments,. where in 1027, although there had been a considerable 
fall in the incidence for all ages, the attack rate was still at the 
high figure of 15.38 per 1,000. 

Distrihution of Diphtheria in CamherwcU. 

Study of the incidence in tho four electoral areas into which 
■ the borough was divided, when viewed separately for the ten- 
year period, helped to focus local outbreaks peculiar to caclf 
of the four areas and their occurrence in the difierent years, 
as well as to show tho extent to which prevalence had varied 
i in each area, corresponding, it had been found, with tlie degree 
I of population density. Those differences were displayed in the 
j following table, arranged in order of highest school incidence 
I and population density. 


School Attack Rates per 1,000 School Population, lOlS-27. 


Area, 

Camber-. 

1 well 
North. 

Fockham. 

Camber- | 
well 
North- 
'West. j 

i 

Dulwich. 

■’iVllolQ 
Boro’. ’ 

Yearly averago : 
Inlanta 

1 UA 

13.2 

1 12.5 

9.4 

12.45 r 

Boys and girls 

' 5.3 

4.3 

4.2 

4.7 

1 

4!69 

Combined ... 

8.2 

74 

‘ 7.0 

6.3 

7.36 ' 

Population density* i 

177 

125 

120 { 

60 

• 

105 

i 


• Number of persons of all ages per residential aero. 


Diphtheria in Camhcriecll. 

Dr. Gn.tHXJt Foedes gave a survey, illustrated by charts, of 
tho prevalence and incidence of diphtheria in Camberwell* 
during the ten years 1918-27, dealing particularly with the 


.I'fY save a similar account ol dinhtheria 
Hampstead, a summary of ahich was published on June 25tb, 1^27 (p. 114' 


Dr. Forbes said he need not dwell on the obvious significance 
of the heavy toll levied among children of the infant depart-' 
ments. The facts spoke for themselves, and pointed to the 
need for the fuller use of the means of protection at that sus- 
ceptible period of life such as wai, being offered to parents at 
the infant tvelfare centre in Cainberwell. He wished, in con- 
clusion, to endorse the remarks of Dr. Bousfieid with regard 











JUNE 2, loss'] 


* f {M» 


NABCOliEifSI?. 


r TirrBnmsn 945 

L Medical Joctixal “ 


to tlio value and imporfnnco of the Schick tost and diphtheria 
itninunizatioii ns the means of prevcnlion, lieforc which all other 
measures of controlling the spread of the disease hitherto 
available- to the medical oineer of health hecamo insigmricant 
and futile. 

Proffrcff ill Prcvi'iitirc )Vorh-, 

It was most encouraging to watch the progress of the new 
preventive work in I^ndon, and to note that, whereas eighteen 
months ago only two out of the tweiity-nino metropolitan 
horoughs had ii'iti-oduccd it in their infant welfare -centres 
(Holhorn and Westminster), tliere were now no fewer than 
twelve or thirteen horoughs which liad begun or were shortly to 
begin the work. Others were recognizing its necessity as lime 
went on. In Camberwell, as they were fully aware. Dr. 
H. W. Barnes, the medical oflieer of health, was suceessfnl in 
obtaining the sanction of his council to start preventive work 
in the welfare centre at WO, Cainherwell Hoad in December. 1926, 
since when Dr. Bousfield had immunized some 1,200 children in 
the whole borough. That number represented only about one- 
twentieth of the most susceptible child population in Camber well 
under the age of 5 years, and it would -obviously tie entirely 
premature to c.viicct any inducnco on the general incidence 
and mortality of diphtheria from the immunization of so small 
a proportion of the nnjirotectcd children in the borough. In 
the protection against diphtheria, before any cficct on the attack 
and death rates in a community could he claimed or e.vpcctcd, 
it w.as necessary to achieve the immunization of at least the 
majority of those susceptible, and to allow considerable time 
to elapse before conclusions could ho drawn. Even in New 
Tork, where so much preventive work had been carried out and 
over 5tX),C00 children had been inoculated in the past ten years, 
there remained over a million children non-immunized and 
mainly of pre-school age. Consequently it ivas not surprising 
that in the marked recrudescence and severitv of the disease 
which 1927 had provided in the United St.atcs there should 
have occurred a rise in the diphtheri.a incidence and mortality 
above those .pf recent years, with so large a proportion of tho 
child population in New York and other cities stili un- 
protected. Immunization among the rcstricterl populations in 
residential schools, institutions, and hospitals in Great Britain 
and other countries of the world liad, lionever, afforded suffi- 
ciently sure results on which to rely when emphasizing its 
value and advocating its adoption and e.xtcnsion. 

^ employment in Great Britain for some ye.ars past of 
" to.void-antitoxiu,” and now “ to.-roid,” in which the to.vin 
had. by exposure to the action of formalin, been rendered 
harmless hut still potent to excite immunity response, had 
replaced the earlier use of toxin-antitoxin, anil safely insured 
against such rare accidents as had occurred ill the past 
in otlier countries where the latter was still being used. 
Notably was this the case with the recent disastrous events 
.at Bundaberg in Queensland, (be cause of which avas still under 
investigation by the speci.al commission. 


oi 


KAECOLEPSY. 

At .a meeting of the Section of Mcdioiiio of tho Roval 
Academy of Medicine in Ireland on May 12th tho Presi- 
dent, Dr. G. E. Nesbitt, showed a woman, aged 29, 
man led, with three healthy children, who exliibited 
t}picai s\mptoms of the remarkable conditions known as 
r»arcoJo2>sr, 


Dr. Nesbitt said that he wa.s indebted to Kinnier IVilsoi 
V. liose graphic description of three cases he had heard la 
year, for ability to recognize this case. The patient pr 
souted herself at his out-patient de 2 Jni-tmeiit with a liistoi 
of five or SIX years of attacks of “ loss of power in herself, 
cltu-ing which she became excited or laughed. Tliesc attad 
were followed by an uncontrollable desire to sleep. She lu 
dl, contracted influeni 
J .1 epidemic. Some time afterwards si 

I head violently against the fi- am© I 

the ^°^l°wod by almost constant pain : 

>e head, which she described as “ terrific,” hnd which w 


said to havo been relieved Inst year by- .a visit to a holy 
well. Soon after the injury the other attacks began, anti 
had persisted since. Dr. Nesbitt added that the patient 
was a Very intelligent ivoinan; she giivo a most pictnresqno 
and striking aeeoiint of her eiirions affection, w-hicli she 
Imd previously desjiaircd of making anyone understand, 
and she also quite appreciated its occasionally hnmorons 
aspect.- A strong emotion,- particularly langhtcr or mental 
absorjilion, hnt not fright, eansctl her to “ flop ” in a 
heap; her eyes shut and her head dropped. She lost all 
power in her liiiilj.s, and hcliaved “like an infant child 
when you stand if on tlic -ground.” Before she -actnally 'fell 
to the' ground the attack passed off, hnt it recurred quickly, 
each lime more severely. She finally had to sit down on 
the footp.ath or wherever she hajiiioncd to he, and had the 
greatest difficulty in getting homo. She felt exhan.sted and 
iiinst get home to sleep, which she did for a variable 
jicriod np to several Iioiirs. She had difficulty in rousing 
liersclf if she was distnrhed during this .sleep, hnt could do 
.so by a strong etfort. If wakened too soon there ivould he 
anol'lior attack. She soniotiincs suffered from attacks -when 
she wont to bed at night, hut these were slightly differont 
in character from the day attacks, probably due to the 
fact that she iras already in bed. inicn tho attacks 
occurred in tho daytime she did not havo tlicm at night, 
and she was not able to bring one on voluntarily. No 
abnormal physical signs had been so far detected in the 
case, which ajiponrcd to be one of the so-called idiopathic 
nart-oleiisy. Some theories of the disease wore then di.s- 
cnssctl by Dr. Nesbitt, including its relation to Pavlov’s 
tlicdi-y of sleep. He added that an excellent summary was 
to ho found in Jiniin, Part 3, vol. xlix (1926) by IV. J. 
Adic, who stated tbat the qniblishod cases numbered only 
about forty in all. 

Dr. E. T. FKEKJrxN i-eforied to a paper, by Sir James 
Purvos-Stewart, in wliieh it was suggested that the 
pituitary gland Iiad some connexion ivitli narcolepsy. Dr. 
Bni.ix "CnicMTOx mentioned tlio case of a gh-1 whose 
father had contracted cnceplialitis lothnrgica; about six 
months later she had developed enrions symptoms. IVhen 
amused she iras unable to control the facial muscles', and 
she constantly dropped asleep while sitting in a chair. He 
raised- the question of prognosis in these cases. Dr. C. 
Mimpiiv, referring to treatment, asked if Dr. Nesbitt 
thought that bromide and luminal, which w-ere so efficncions 
in the treatment of eases of eiiilcpsy, would be useful in 
cases of narcolepsy-. 

The PkEsiuext, veiilying, said that ho thought Dr. 
Ci-ic-hfou's case was one of narcolepsy. Tlie treatment was 
very unsatisfactory-. Bromide, luminal, and all medica- 
ments for epilepsy- iverc unavailing, and treatment bv 
suggestion also was useless. He had recently read of a case 
which h.ad been treated by strychnine,' opium, and caffeine, 
but iiithont any- effect. 

Coiigcnifal Pi/loric Stenosis. 

Dr. Bnr.vx Crichtox read notes on a case of congenital 
pyloric stenosis, and sboivod K-ray photographs. 

Mr. IV. PEAinsoN, who had operated on the patient, said 
that there were tivo types of stenosis; in one the iiylonis 
was very thick, pale, and vascular, and in tho other' there 
was no thickening of the liylorus and no onlai-gement, but 
tho iuiueu was thick. In the present instance the jiy-lorus 
had been situated right up in the liver, and lay vei-y far 
hack. Surgery- in this condition had not, until recent 
years, been veiy satisfactory, and a great many different 
surgical procedures had been adopted from time to time. 
The most roeent operation was that of Rammstedt, which 
was simiJle to iierforin. Tho patient had vomited for ,a fen- 
days after the operation, had then passed a mass of barium 
per rectum, and had not vomited again. He tlionght that 
it would have been wiser to havo washed out the stomach 
' before the operation, and got rid of the barium. 

The Pav.siDF.XT inquired about the operative mortality- 
associated with this condition, as he thought that in a largo 
proportion of cases the operation lias not successful. 

Refori-ing to tho alternative treatment— lavage he asked 

what action was to he expected from it oxceiit emptvinsr 
the stomach. ^ i - fs 


946 June 2, 1928] 


BTEEPTOCOCCAD CEEIiUrilTrS. 


r Tnr. r.nmn, . ■ 
L SIrmcAt. Jovftofju.' 


Dr. C. M. Saunders referred to n case lyitli visible peri- 
stalsis and constipation wliicli bad been treated on medical 
lines. The patient had been given fluid by the rectum,- 
and intraperitoneally with atropine and adrenaline; after 
about three months’ treatment sho recovered completely. 

Dr. D. J. Cannon said that ho had only operated on ono 
case of congenital pyloric stenosis. In this case ho had 
performed a gastro-enterostomy, and tbo child had died. 
Ho referred to a boolr bj' Dr. Barrington-IVard, in which 
there was a chapter on pyloric stenosis; it was stated that 
from 1907 to 1917 the medical mortality was 80 per cent., 
and that in 1925 tho surgical mortality was 25 per cent., 
but in 1926 it had fallen to 4 per cent. It was also 
advised that patients should have gastric lavago and 
infusions of 5 per cent, glucose before ojicration, and that 
gas and oxygen should bo used as tho anaestlictic. Ho 
i-eferred to the danger of intraperitoncal haemorrliago .in 
these cases. 

"Dr. Crichton, replying, said that tho mortality in 
Scotland was 44 per cent, for both medical and surgical 
treatment. He thought that Dr. Still’s figures wci'o more 
favourable for medical treatment. If tho child was seen 
in time, and was in a good condition, ho thouglit that 
tho chances of recovery by medical treatment were very 
favourable, but it must bo realized that medical treatment 
including two washings out daily, and some children did 
not stand this lyell. It must also bo remembered that with 
medical treatment some time was required to achieve a 
satisfactory result. Tho surgical mortality in these cases 
had fallen considerabl}^ in recent years. 

Mr. Pr-ARsoN, replying, said that if a c.-iso was going 
downhill on medical treatment he thought it was a great 
mistake to wait till the patient was moribund boforq 
operating. Some of these cases had been operated oti 
under spinal anaesthesia, but he thought that this method 
would be dangerous. 


Pituitary Jufaniilism. 

Dr. E. T. Freeman showed a case of pituitary infantilism 
of Jjorain-Levi type. 

Dr. Freeman said that this patient, who was a woman, 
aged 23, was 4 ft. 7 in. tall, with tho general appearance 
and physical development of a child of, 10 years old. She 
presented the following features (1) Skeletal undergrowth 
—the body was of childish stature and ossification, but its 
parts were in due proportion, except the noso, which 
was remarkable for its size and aquilinity; (2) genital 
inf.antihsm ; (3) absence of adiposity ; (4) normal or perhaps 
a slightly low sugar tolerance curve; (5) very small sella 
turcica; (6) normal basal metabolic rate; (7) normal renal 
effioien^ (blood urea 28 mg. per cent., uric acid 3.3 mg. 
por cent.); (8) no persistence of the thymus; and (9) a veiw 
severe anaemia. Dr. Freeman remarked that the firrt 
three features were constant and characteristic findings in 
the condition. The fourth showed normal or pbifaps 

pSrv lobe'^f T 

V .1 fifth ^as variable^ as a larce sella niiirlit 

bo the sito of a cyst whicli the; gland had atroph U 'Hie 
sixth was investigated to exclude a thyroid factor the 
seventh to exclude the possibility of renal dwarfism’' tho 
eighth to exclude lymphatism, while the ninth was appar! 
ently a complication. When tho c 

pallor was the outstanding featiire, ^nd she had 3 30o"o00 
lod cells per c.mm. with 33 per 'cent, .haemoglobin on 
treatment , with iron, , ai-senic, and live? tho^ rri ’ „n 
improved to-4,650;000 and the haemoglobin to 45 bm- op' f 
The^spcalmr added, that it was an iLresting fpLoS; 
liow far the anae;pia might be responsible fo® the unLi 
development, but five months’ treatment, while imnr.bdne 
the anaemia, had not altered the height or wein-ht\-n .1 
(.epee. Ho thought that the, anaemia was partly Ltribut^ 
^act that tho ppieiit scarcely ever left the house" 
Tho President asked what was the expectation of lifbTn 
those cases,, and Dr. C.- Mur.phy asked if there had been 
any change in the patient’s mental condition 
Dr. Freem.vn, in replying, said that tlieso patients 

throe to five v^ars, hut in such cases there was supnosld 


STREPTOCOCCAL CELLULITIS. 

At a clinical meeting of tho Devon and Exeter Medico- 
Chirurgical Society on April 26th, with tho iircsidcut, Mr. 

A. L. Candt.er, in tho chair, Mr. Wayland Smith showed 
a caso of streptococcal collnlilis occurring in a farmer 
aged 55. 

Mr. Wayland Smith said that tho patient had heen 
admitted to hospital with a .septic wound on the back of 
tiio loft hand, cellulitis of tho arm, and a temperature of 
103° P. Ijocalizcd abscesses formed suhscqiiciilly in the arm 
and axilla, and cultures from tho pus yielded a medium 
chained streptococcus; tho blood culture was negative. Ono 
month later tho man complained of sudden pain and 
swelling in tho right ankle and wrist, and there liad since 
hcoii limitation of movements in tlio wrist and fingers. 
Mr. Wayland Smith remarked that the condition in this 
hand had not been unliko tliat mot with in tenosynovitis 
of gonococcal origin, and thcro had been no sign* of pus 
formation. A special foaturo of this caso was tho tendency 
to fiaro up after,, nil tho inflammatory symptoms . hail 
apparently subsided. Tho intense toxaemia, as evidenced 
by deep cyanosis and delirium, -was also worthy of- note/ 
At tho present time tho wounded hand was, actually, in .a^ 
better condition than tbo other. ' 3Ir. Wayland Sniitli 
oniphasized the importance, from the point of view .of . 
prognosis, of identifying the typo of streptococcus in tlicsq 
cases. Ho added that as regards treatment lie was now ' 
relying on niassngo and radiant beat. 

Tho Pr'eside-NT recalled Roscmaycr’s vyovk on gall-bladder 
infections in connexion with tho selective properties; of ■; 
tho various streptococci. Ho quoted experiments, in which 
organisms recovered from . an inflamed gall-bladder, and 
also from a gastric iileor, had produced similar lesions when 
.injected into a dog. Jlr. Candler commented also on tho 
treatment of tho present patient, and said ho would ho 
very unwilling to wrench tho joints under an anaesthetic. 

■■ , Clinical Cases. 

Dr. Jackson showed a caso of tumour of the loft 
ccrcbollo-poiitino area. Decompression liad been performed 
by Mr. Worthington and tho patient was now in , fair 
health. Dr. W. Gordon disousscd''tuniours of. the auditory 
nerve and the very low malignancy which was a charnc- 
toristio feature. Ho commented on tho wisdom , .of 
trephining on tho loft side ns in tho present caso, so as 
to avoid disturbanco of Broca's convolution. Ho also cited 
cases illustrating depression ns a moans of presen-ation of 
sight. Dr. Fayle Seale showed three cases of infantilism 
of Mongoloid type; Dr. Eager and D>;. Gordon discussed 
tho value of thyroid troatmoiit in this, condition in con- 
junction with tlio necessary institutional supervision. Dr. 
Seale also showed a case of “hoi-moiial imbalance” in a 
girl.’ngbd 14, who had enlarged glands in tho neck and 
premature sexual development, menstruation having com- 
menced at the age of 10. Other diagnoses suggested were 
. Hodgkin’s disease and tuberculosis of tho suprarciials. Hfr. 

B. Dyball showed ' a, case of., hydronephrosis in a man 
aged 28. A- radiogram revealed tho right renal pelvis as 
being twice tho normal size.- ■ At tho operation it was found 
that the polv'is of the kidney was covered with a leash of 
varicose vessels. Mr. -Dyball also showed a doubtful c.ase 
of abdominal tumour in which the diagnosis lay between 
aneurysm' of the abdominal aorta, or of .the coeliac axis, 
pancreatic 'cyst, and'bqnq tumour. Dr. Gordon sug,geste(I 
sarcoma was niord probable, since tbo tninonr'had decreased' 
ill size and iv-as not tender; there was no modification in 
the pulses,, the murmur vyhich was. heard, over tho tumour' 
was slight, and ho could not detect definite expansile 
pulsation. -Dr. F. A. Roper showed a caso of marked 
cyanosis in a man, aged 45, which continued for some- 
twenty years. The heart was nuich enlarged transversely" 
and the liver was increased in size; Mr. Noraian Lock 
sho-n-ed a caso of mastitis in a youth aged 20. Mr. Dyrall' 
read notes on a' case of retroperitoneal fibroma in a woman' 
aged o7, and on a case of sarcoma of tho ilcnni which liacT 

: caused -intestinal obstruction. Dr. Roppr reported a ca.so' 

■ pylepldehitis, in which the, cause was found, on nccropsv,' 
to be a gangrenous aiipendix associated with multiplo 
abscesses of tho liver and general peritonitis- 


ju\‘r. 2, 193S] 


EEVIEWSr''^'''" 


/ Tnrn*»mw C)47. 

I IICDJCIL JoCBKlt ' , 


lUlnciiTS. 

HI IODIC AL IIIS'J’OIIY. 

In- liis Short liistnnj of MciUcinc, introdudvfi Mcdkal 
I’liiir.ipics to Sf\idriits ntul Koi\-J\fcdicn! Headers,' Dr. 
CiiAUi.Es SiNfiEU, ;v!io is so widely recognised ns n writer on 
this ^subjeet and on tho evolution of sciontifio thonght, 
follows his previonsiy, expressed ideal in treating medical 
history from tho" point of view of ideas and not hio- 
graphically and accordingly this worh tells tho .story of 
tho scientific elements in medicine, other nspccts hoing 
passed over in a silence which (as he p()ii\ts. ont in an 
eloquent preface) must not bo interpreted as the silence of 
contempt. Among .the graceful acknowledgements there 
is a rather retiring dedication of the work to Dr. E. T. 
'Withington. Dr. Singer is a vitalist, and this, ns he 
admits, may modify his treatment of the .subject matter, 
but others may feel that this is. rather a refreshing 
' attraction. 

The history is very suitably considered in six periods: 
Ancient Greece; the heirs of Greece, from 300 n.c. to about 
A. I). 200, including tho Alexandrian School, of course, and 
Galen; the Middle Ages; the rebirth of science, extending 
ficin 1500 to about 1700; then the period of consolidation 
up -to about a bundled years ago; and lastly, occupying 
inon' than half the s-olumc, tho pci iod of scientific sub- 
division. In an attractivo account of ancient Greek 
medicine, which grew out of tho ohsciiro Hliiioan civiliza- 
tion, Dr. Singer recalls that tho duration of progressive 
and scientific medicine lasted for eight hiindieil years, 
whereas our own system has been developing for little more 
than four and li half centuries. Tho wisdom of lliiipocratos 
is illustrated by selections from the Aidiorisms, and his 
honest accuracy’ of clinical description bv eases now recog- 
nizable as diphtheria and as showing Cheyne-Stokes respira- 
tion. Tho influence of Aristotle on hiological conceptions 
and his vitalistic view of the activity of the soul — which 
“ entelcchy,” and is here translated as the 
indwelling perfectibility ” or “ purposiveness ” — arc well 
brought out, and Haiwcy’s views on fertilization are 
slionn to bo practically identical with those of Aristotle 
too tlioiisand years before. Passing on to tho vebirtli of 
science and the rcnaissaiicn of medicine, which is of special 
iiilere« in this year of tho tercentenary of Han-cy’s Dc 
-loru Cordis, the revival of anatomy under tho independent 
nnnd of Leonardo tin Vinci is described, Harvey’s work is 
veil siinimarizcd, and tho’ subsequcnt influence of tho 
niicioscopo clearly shown. The period of consolidation was 
marked- by the rise of clinical teaching and of morbid 

■IvmT'i U. HloVgiigni, who is 
j'? ' ' '(^e'l led as introducing tho “ .anatomical concept ” 

?• 1*'*^ saw, tho carlv stiidv of vital 

statistics ; and Jenner’s vaccination. The difficulty of 
amiiig aiK dividing the several periods has been very 
' f i- perhaps more especially the last period, 

extending up to tho present time.' Dr. Singer’s admirable, 
era laces recent developments; for example, such 
■ u" f r?«"tive medicine,' cellular pathology, 

o3 n advance of surgery, the neV 

vitamins are 'passed in 

whb'on heautifiilly illustrated work closes 
needs 7'* "’hich the present-day tendencies, 

ami o , " rP considered in a ]ihi]osophicaI tone, 

ontiniisG^'eu® against.the adoption of too 

their ennelif 00 y Although data accumulate apace, 
t e.r corielation, which is the ciwing need, la^s; many 

vese:rch7as"';tle7or,''T general level of’medicii 

' must atlniiV In t' and there arc, as ereryone 
dele, v’ei 7“ in our. knowledge. That this 

it i 1 uUis ,ed and 

I^'^published at a most reasonable price. ' 


on! "'‘''n'v •Vfdicol PrincipUn 10 Sli 

I-!!.C.U, Oxford The Charles Singer, Jf.D., D.Litt.l 

+ ;M; .IW-ngures.. V^.ed ncT) " ^*8. (Demy’Bvo, pp. 


ioStu(lent$ 
Oxon. 
xxlv 


FOODS AND I'OOD ANALYSIS. 

Till; late Dr. A. 'Wvnteu IIlyth and Mr. Hf.' Vyntep. 
Ulyth’k textbook Foods; their Composition and Analysis, - 
pas.scd tbroiigli .six editions', the last of which appeared in 
1909, and now it lias been revised and partly rewritten by 
Air. H. E. Cox, jnihlic analyst for Hainjistead. Tho work 
is primarily intonded a.s a manual for tho use of analytical 
ehemi.sts, and the greater ])eition comprises detailed 
doscription.s of methods of analysis of foodstuffs and of 
tho procedures for detecting adulteration. Tiio first part of 
tho book iia.s a more genoral interest, for it contains a very 
interesting history of the ndultcration of liumnn food. The 
Iiistbry of this sordid aspect of commerce date.s back 'to 
classical times, but apparently adulteration of bread was 
a fairly cliroiiic social problem throughout tho whole . of 
Eiiropenii history.. This section concludes with a summary 
of the present law regarding adulteration, and in particulai 
the rcgidatioiis regarding tho use of preservatives (1924) 
iiro given in extenso. Tiic Acts regulating the sale of food 
niid drugs arc given in appendices at the end of the volume. 
Tho value of a work of this kind, whicli is a reference 
iiiaminl of practical technique, can only ho deterniincd hy 
expcriciico-of it in. practical use, hiit tho book appears to 
give n fiiU detiiilcd account of all the' import.ant methods 
of analysis,'! a'nd recent practices, such, as the' ■.elcctrol)-tic 
estimation of arscniCj^ liayc also liecn- iiicliided. Certain 
sections ivoidd, however, have been benefited hy a more 
drastic revision. Eor example, 100 pages arc devoted to 
milk, cream, and hnttor, In tliis section a mo.st interesting 
liistorv is given of tlie immoral theories of milk ioeretipn, 
and of such out-of-the-way subjects ns witches’ .milk. 
’J'hore arc’, however, searrelv half a dozen references to 
■ivork done siihseqiicnt to 1904. Alorcover, Koch’s views on 
bovine tuhorciilosis arc quoted in extenso, in particular the 
view that tho infection of liiiman beings hy bovine tuber- 
culosis is a very rare occiirrenco. Tho book states that 
this view is contested b.v other pathologists, but it would 
have been bettor either to give a proper presentation of the 
modern views on this Important subject, or else to liave 
omitted it .nltogctber. 

Oils, Fats and Fatty Foods,’ by E. 'K. Boltok, with a 
chapter on vitamins hy Professor J. C, DntritMox’D,' is a 
second edition of Fatty Foods, hy Bolton and Royis, which 
appeared in 1914. The author explains in tho preface 
that tho intensive study of fatty foods necessitated by tho 
fat shortage in the war roSnltcd in great progress in know- 
ledge, and particularly in a marked increase in the standard 
required for refined fats and oils intended for human 
consumption. Tliis advance has, resulted in a considerable' 
expansion of tho book, but the author points out that 
comjiaralivcly few new anah-tical methods have been' 
devised,- the advance liaving - consisted chiefly in the im- 
provement of existing methods.' Tho hook gives a full 
ac'couiit of all tho chief methods, both physicdr and 
chemical, employed in the testing of oils -and 'fats.' 'One' 
curious fact that is brought out is tho enormous variety 
. of fats that aro used in tlie pro'diictio'n of niafgafiiie.' It' 
; is "somewhat disquieting -todcai'n in regard to this (p. 110) 
■that there is in a. largo number of cases absolutelv lio' 

: method of arriving at proof that the constitution of aiiv 
' sample of butter fat is duo to sophistication and not to 
] natural causes.” The whole hook hears evidence of careful' 
[ selection, for full details are given of tlie best methods of ' 
1 analysis, and no space is wasted on nietliods that are solelv' 
, of historical interest. Professor J. C. Drummond contri- 
butes an interesting chapter on fat-soluhle vltaiiiins — 

, namely, vitamins A, D,- and E — and gives a short account ' 
. of the. chief facts tliat liave been established regarding tliese 
substances. Tliis chapter can be recommended to any who 
. want to find a short, clear, and accurate sunimarv of our 
present knowledge of this subject. 

’ -i'oof/a; their Compoeilion anrl Analpeis, Bv ' the late Alexander 
Wynter Blylli, M.R.C.S., F.I.C.. and Aleredith W.vnter BIvtIi, B..1.. -B.Sc 
F.r.C. Seventh edition ; revised and partly rewriUen bv Henrv Edwar'ti 
Cox, M.Sc.; Bh.O.Lond.. F.I.C. London : C, Griffin and' Co,, L'td 1907 
(Med. 8vo. pp. XXV + 619 ; 90 figures. 30=. net.) 

s Otis, I'ats ami Tatty Tootle. Bv E. Richards Bolton, FIC FCS 
■With a chapter on vitamins hy .1. O.j Briimmond, D.Sc., F.I C facino' » 
second edition of Tally Tooth-. By E. Richards Bolton and Cecil Revix 
, ®''°' PR- -’'I'i -I- 'lit : S'! fisurra. 



948 . June a , 1928] 


EEVIEWS. 


f Till nrnTi»7r 


.DEEMAT0L0C4\^ , . . .. 

^YE have, received .the fovii tli .edition of Dr.- D,Mni;n’s well- 
known Precis' db 'Pbrmdtoldgi'c'p iindou))tedl 3 -- one of tlio 
best textbooks on the subject in any liingnage. It lias noir 
been before tho medical public for just on twenty yeai-.s, and 
although grown in siao maintains its cbaracteristie.s-. YVo 
ina 3 ' remind our readers that it consists of two distinct 
portions, approximately equal in size, the first devoted to a 
description of the morphology of the lesions ivliich are tho 
fruit of pathological changes in tho skin; and the second 
(nosologj-) an account of tho cutaneous discuses of ivhich tho 
etiology is at all events in some mcasuro understood. This 
arrangement involves a certain amount of repetition, hut 
not so much as might be supposed, because tlioso numerous 
conditions of whose etiologj- wo aro entirely ignorant 
(psoriasis is the best example) are described only in tho 
first part. Dike Brocq, with wliom, no doubt, bo niUst oflen 
bare discussed these matters, Darior refuses to dignify such 
things as eczema, psoriasis, and urticaria with tho titio 
of diseases; he regards them as nioro clinical syndromes 
of doubtful, obscure, or complicated origin. Those patho- 
logical conditions alone are considered diseases, and worthy 
of a place in nosology, which have a definite eliologv, 
whctlier microhic, physic.al, or chemical. This arrangcnicnb 
at least avoids tho difficulties of , classification — always a 
bugbear to dermatologists — and iias permitted tlic author to 
write a lucid and instructive manual of his subject. 

Di-. Darier describes his book as a “ precis ” of dermato- 
logy, of which the nearest English equivalent is “suninmi-r-,” 
and states that ho wishes it to servo as an introduction to 
the anthoritative treatises (les traites magistran.v) on tho 
subject. This “ summary ” consists of over eleven hundred 
closely printed pages; how long, tlicn, should a treatise be? 
As a matter of fact, except for tho omission of roforcncos 
to original papers, this is a treatise, and a very good one. 
ilio only criticism we have to make is that the new edition 
IS somewhat awkward to handle, because tho thickness of 
the volume is excessive in proportion to tho size of tho 
page, which is tho same as in the first edition, tliougli 
that bad less than half tlio present hulk. Tho illustrations ' 
small ‘'"■e clear, though rather 


TRAEM.A AND COJIPENSATTON IN OBSTETRIC 
AND GYNAECOLOGICAL CASES. 

Ihehb aro many e.xoolieiit works dealing witli ohstotrics 
and gynaecology; Dr. LrND.s.\Y, in iiis book on Travma 
nnd Compensation in Ohstctric and Giinaccoloqical Cases ’ 
information and guidance not to ho 
nb w It must he almost unique for an 

o stetiician and gj-naccologist to have had the\advaiita"o 

as assistant to the professor of forensic mcdiciiio in 

relation to various gynaecological conditions. Urbook 
f ill of practical points- and well illustrated with cases Vo 
Strongly recommend it to anyone dealing with compSaGon 

ACUTE APLASTIC ANAEMIA 
In a monograph on Acnfc Aplastic Anacinia' Dr W 
Smith describes m full detail his daily notes 
pi-ossions on a case in 3 child of 2 vears 
that the activity of - tho bone marrow as a Jiarm '*^*'*j- • 
organ is controlled by a liver honimn:, "0^^ tb" 
pi imary fault in acutes aplastic anaemia’ is a toxin' aoi! ° 
on tho hver and inhibiting this hormone action Tn .n g 

^-'mcnlee. Paris f^ilSon et'^CioP^lsa 

cover, 85 fr.; bound. 100 Ir!j ■ ’ ’‘v.u + lKB; 


6s, net,) ‘ 


case tho deficient hornioiio was replaced hj- iiijcrtious of 
liver siihslanco which wore followed by an imniciiiate huiic- 
iiiarrow response and 'a quick • return to a normal Mood 
picture. C'Ic.arly all dcjicnds 011 the eorrectue-,s of tbe 
diagnosis, and a pleasing feature of the paper is the full 
ami eareftii w-iiy in wliieli tho blood oxamiiiatious by Dr. 
O. J. Y'oung arc recorded ; but not cverj-oiic will be ready 
to accept a diagnosis of aplastic anaemia on the absence 
on two occasions of platelets and |iolymorpli(muclt-ar lent-o- 
cylcs, when tho hiiomoglobiii value was only once as low 
as 58 per cent, nnd the jiaticut -was not sufiii-ioiitly iiicom- 
iiiodcd to Ijo ke]it in bed. Tlio luiflior realizes the danger 
of drawing concIusion.s from ono case, hut he points out 
that observatioii.s oii a siiiglo rare caso have left their 
impress on medicine. A short glossai-y is given at the end, 
hut no ono ivho needs to bo told tlmt Imomopoiesis means 
blood formation and that thromhocyto is a synonym for 
blood platelet can po.ssibly read Dr. Hayes Smith’s views 
-with any profit. In any future edition wc hope that tlio 
author , will correct tho slip tlmt makes iioxus ” tbo 
singular of “ iioxa.” 


ELECTRICAL DANGERS. 

Tiir. small hook on the accidents ami dangers of electricity,' 
by Dr. P.tnn Dtmnsi (electro-radiolo.gisto dcs Hbpitaux do 
Paris), gives a very ]n-actical and- concise account of tbo 
subject. Tbo author , was insjiircd to take up this work 
by tho accident to Dr. Jangcas, w-ho was killed instan- 
taneously whilst .conducting the screen oxaminatioii of 
a patient. Tho accident was camsed by tho formation of 
a .short circuit owing to the non-insnlaticfti of certain w ires. 
The author starts by discussing the physiological nt-tinn 
of olectriu eufvents,’ nnd pni-tieularly tho cause of death 
in electrocution. Tho text is illustrated throughout by tho 
citation of accidents w-hich have frequently, oct-ni-red from 
strange mid sometimes mysterious causes. Other chapters 
deal with tho etiology, the . .symptonmtologj', and tho 
results ■ and conqilientions -whicii may follow from a 
shock which docs not kill, Tho two concluding chapters 
arc on treutmont nnd on provoutivo measures. As 
regards tho latter, it is clearly shown that ignoranco and 
cnrelossncss play an important part in many accidents, 
but that defective wiring nnd apparatus have frequently 
much to answer for. ' 

Radiologists and clcotrologists will find a good deal of 
useful ami practical material in this hook, but it is by 
no means Written for them ami doctors alone; it should 
he useful, in these dajs of olectricity, to practically 
everyone. 


HARVEY’S WORKS IN ENGLISH. 

In -reviewing last week Mr. Geoitwey Keynes’.s ndmirablo 
bibliography of the writings of William Harvey wc men- 
tioned that ho had edited also, -with a view to the tcr- 
contenarj- celebrations, tho first English text of Harvey’s 
anatomical exercises. This charming yolumo has been 
printed and made in Holland with tho typos of Joan 
Michael rleischman and of Christophor van Dijck, and is 
published by the Nonesuch Press.* It contains Die English 
translation of the Dc Slotu Cordis and tho Vc Cirnda- 
tionc Sanguinis, of which tho first edition was published 
by Richard Lowndes at tho AVhito Lion in Duck Lane, 
Loudon, in 1653, and tho second in 1673. In preparing 
tho present text Mr. Keynes has collated these two 
editions^ and has done .such polishing as seemed necessary. 
Tho two plates illustrating the function of the valves in 
veins which accompniiiod the original Latin edition of 
1628 w'oro omitted from the' first ta-o English editions, 
although the references to them remained in tho text; to 
remedy this defect an excellent dr.awing has been mado 
from the life by Stephen Gooden for tho present edition,' 
and engraved on copper by C. Sigrist. These and other 
matters are explained in the editor's postscript and textual 


' AcciitcnU H Hangers de VSlecMciU. By Dr. Pawl Dulicm. Paris : 
Gauthier-Vniars et Cie. 1928. (5i x 8 ; pp. x + 74 ; 7 figures. 10 fr.) 

'JIui .Inatomtcal Szcrcises of Dr. lYtUiam Harcej/: Do 1/oiii Cordis, 

less ; Do Circulatione ■ — rst English text o! -'555 

riow newly editeU by on iho occasion of tho 

tercentenary cclebratior of the text of Do 3/o(u 

e^rdis by tha Nonesuc -(5x8),- pp. xvi -i-' 203. 


2Sb.1 


June 2 , 10 = 8 ] 


KOTES ON BOOKS. 


r Titr. rinrnw fldO 

L ITKDurit- Jocnxix Ota 


notes. The volume is ono which ovcryoiio who possesses it 
will value, both for what it contains and for the pious caro 
lavished upon its production b3- editor and printer alike. 
For eighty j'cars Bobert Willis’s Engli.sh rendering of 
Harvoj^s anatomical exorcises has held tho field ; now, 
thanks to Mr. Geoffrey Keynes’s scholarship and industry, 
wo have tho text of Uarvey’s own time, printed on good 
paper and beautifully bound. 


NOTES ON BOOKS. 

The 1927 issue of tho Ilandhooh to Britifji Mnlaya,'‘ edited 
by Mr. It. L. Geiuian of the Mal.a.van Civil Service, is an 
unusually attractive guide, and supplies, especially in the 
section on life in M.alaj-a, answers to many questions of real 
practical importance to aspirants for employment there which 
are too often overlooked in similar publications. The chapter 
on bj-gieno and sanitation shows the unusually high proportion 
of specialist appointments available on the European establish- 
ment of tho various medical departments. Apart from tho 
stall of the King Edward VII College of Meelicinc, Singapore, 
which numbers 11, the total medical establishment of 42 in 
tho Straits Settlements includes 9 specialist posts, and tho 
establishment of 91 in tho Federated Mahay States, 22. Entry 
to tho College of Medicine, avhich gives a full six j-ears’ course 
and confers a diploma registrable in the United Kingdom, is 
restricted , >lo candidates, born or edue.atcd in Malaya; the 
number of students in 1926 w.as 113. llegistration of births 
and de.aths is compulsory throughout British Malaj-a, and 
is in course of adoption bj- the native States. Vaccination 
is compulsory before tho ago of 7 years, and the effective 
operation of the Qu.arantine and Prevention of Diseases Acts is 
evidenced by the relatively low incidence of zj-motic diseases. 
Maternity and infant welfare work is now firmly established, 
both in Singapore and tho Federated States. Progress is being 
made with the prevention of malaria under the direction of the 
Feder.ated M.alay St.ates Malaria Advisory Board, and there 
is a Public Health Educ.ation Committee for tho spread of 
information of goncr.al health interest. Tho main causes of 
death are m.al.an.a — characterized as " preventable, but .at a 
cost venereal diseases, dj'sentcr}', and diarrhoea. Ankylo- 
stemiasis, ahnost universal among tho Asiatic population, gives 
rise to sj'mptoms in a relatively small number of cases, and has 
tho low death rate of 0.5 per 1,000. • Tho general health of 
the European population is said to bo good, though cases of 
neurasthenm have recently increased “ here as elsewhere." 
Tho book is lavishly illustrated with photographs of real 
beautj', and there is an adequate map. 


Alive to the importance of establishing definite knowledge on 
the distribution of those mosquitos which are vectors of human 
and animal disease, about which accumulated facts up to the 
present time are very me.agre, the Soutli African Institute for 
Medical Ilcscarch has had under consideration for some time 
a scheme for a mosquito, survey of South Africa. A beginning 
has been made, and the booklet now published by the Institute 
entitled A Mosquito Survey oj Certain Parts of South Africa,'° 
by Ikgu.mi and De Meillon, deals with the results of investi- 
g.ations made tn portions of the Northern Transv.aal and in the 
coastal belt of Zululand. The text is written very much in 
the form of a diary, and its v.alue lies strictly in its local 
fhe end descriptions arc given of now mosquitos 
collected in Zululand, and of tho larvae and pupae, not hitherto 
described, of certain other mosquitos. 


■ The pepartment of Health of Canada has published 
diamond jubilee ^ition of The Canadian Mother's Booh" (firs 
^ition 1923) ^ Dr. Helen Macjiuhciiy, chief of the Dominio; 
Division of Child Welfare. The book is printed in clea 
type with wide margins, and is illustrated by photogr.aphs o 
delightful-looking babies which arc certain to catdi the mother’ 
eye and to hold her attention. Simply and appealingly written 
it contains all information needed by an expectant mothei 
ihe right method of treating the baby when it arrives ar 
next de.alt with. Flam medical directions based on scientifi 
knowledge are apt to be dry ns dust ” when put into sirapl 
lan^age, but Dr. Macmurchy has succeeded in infusing a not 
of happy joy mto her little book. It is certain to arous 
interest and enthusiasm in all who have the maternal instinct. 


n'iied‘’bv'’r PuMished by nuthorltv and cor 

La X at-. pHsT; ill ^Bcnc 


(Part I). I 
iiicAiiwri, Aj.Jc. (Honourj 
Institute for Medical Research, K 
vn Institute for Medical Rescarc 


By Helen Macmurchy, M.H.Tor. 
Blue Books, Jlntlier’s Series, No. 1. 
1 , Canada. Ottawa : F. A. Acland.- 


■ The Handbook of Photomiernyraphy,'" by H. Lloyd Hind 
and W. Br.oucii Randles, which was first publislicd in 1913, 
has been revised, many sections li.aving been rewritten in order 
to bring the iiiforniation up to date. In giving an account of 
modern methods tlio practical requirements of students and 
medical practitioners liavo been carefully kept in mind. Such 
subjects as stereoscopic photomicrography, cincmato-micro- 
graphy, and colour photomicrogr.aplij’ liavo been treated siraplj' 
but enectivcly. 'I’lio wealth of illustr.ations indicates the wide- 
spread application of pbotomicrograpby to various sciences and 
industries, and it is plc.asing to note that British instruments 
figure very largcl.v. The book can be recommended to those 
who are concerned with a subject of increasing importance and 
interest. 

Dr. Minn CnAwronD has written a useful little Materia 
for NursesA^ Only drugs in common daily use are 
dealt with, and in addition to the important prep.arations, 
doses, action, and uses of each drug, a note is appended of the 
.symptoms of and Ircalment for an overdose of some of the 
more poisonous. Tlie book is clearly written, tlie descriptions 
of the actions of the drugs are made as interesting as the 
subject allows, and the author’s aim of producing a handbook 
useful both for examination purposes and for reference has, 
wo think, been achieved. 

Getting Well and Staying IFcf/,’* by Dr. John Potts of Fort 
Worth, 'fexas, is one more example of a tj'pe of book that has 
of lato years been growing very common in America — a book 
written for both doctor and patient. It deals, of course, with 
pulmonary tuberculosis. The great objection to this class of 
book is that it is too elementary' for the doctor and loo. advanced 
for the patient. On the whole, the present volume is better 
than most we have read ; but wo find it difhcult to imagine 
that any doctor in this country would put it into the hands of 
a lay person. 

Dr. Esdaile’s book Economic Biology^^ was written for 
students of social science who stud}' applied biology. It is 
really a kind of " materia domestica ’’ — a collection of facts 
concerning animals and plants which are, or may be, closely 
associated with man and Iiis household. It is not, however, 
merely a dictionary in which the angry householder may look 
up a method of exterinin.ating furniture beetles, but an orderly 
guide for systematic biological studies, the types chosen for 
special investigation being creatures familiar to us in our 
homes. 


Major Hassan Suhr.vwaRDy’s Manual oj First Aid for India, 
first published in 1925, Ims reached a second edition, and there- 
fore seems to have met a public want. As its name implies, it is 
specially ad.apted for use in India. It fulfils its purpose, and 
should bo of service to the class of workers for whom it is 
intended, though there is perhaps somewhat more anatomy and 
physiology than necessary. Fracture of tho lower jaw Is, no 
doubt, usually compound, but it is hardly correct to say (p. 74) 
that it is always so. The general get-up — plates, paper, and 
type — is good. No publisher’s name appears on the title-page; 
presumably tlie book may be obtained through the author at 
the office of the Chief Medical Officer, East Indian Railway 
Calcutta. 


Handtool- of Photamicroyraphg. By H. Lloyd Hind, B.Sc., F.I.C., and 
TV. Brough Randle?, Il.Sc. Second edition, revised. London • G Routiodge 
and Sons, Ltd. : New York ; E. P. Dutton and Co. 1927. fDemv 8 ™ 
pp. xii + 295 ; 76 figures, AH plates. 16s. net.) ' ' ^ ’ 

Materia Medica for Nurses. By A. Sliiir Crawford, 5I.D., F R F P S G 
London : H. It. Lewis and Co., Ltd. 1927. (Cr. 8 vo, pp. viii + 85 
3s, 6 d. net.) 

's Getting ITcli and Staging Well. A Book for Tuberculous Patients, 
Public Hcaltli Nurses,. nnd Doctors. Bv .John Polls. JI.D. Introduction hv 
J. B. HcKnight, M.D. London : H. Kimpton. 1927. (Post 8 vo, pp. 22S. 
Bs. 6 d. net.) 

■S Economic Bialogg, for Students of Social Science. By Philippa C. 
Esdailc, D.Sc. Part I, Harmful and "Useful Animals. London : Universitv 
of London Press, Ltd. 1927. (Demy 8 vo, pp. xv + 175 ; 150 figures. 
7a. 6 d. net.) 

** A Manual of First Aid for India. By Major Hassan Suhrawardv, M.D., 
F,R.C.S., D.P.H. Second edition, revised and enlarged. (Price R.l.) 


PKEPARATIONS AND APPLIANCES. 

ThEOSOL AJiT) Citobarytjm. 

We have received samples of the following drugs, which are sold 
in this country by Messrs. H, R. Napp, Ltd. 

** Thcosol ** is theobromine calcium salicylate (manufactured bv 
Messrs, Kuoll). The chief advantage claimed for this compound 
over the Pharmacopoeial compound theobromine and sodium 
salicylate is that the former is less soluble, and hence passes 
through the stomach to bo dissolved in the intestines. This 
obviates gastric indtation. 

“ Citobaryum ” is a preparation of barium sulphate prepared 
by Messrs.. E. Merck, Darmstadt. The special advantage claimed 
for tho preparation is tliat it is in a very finely divided stale 
Hence it forms, a creamy fluid, which is free from obieetionabto 
gnttines.s and sediments slowly. ^ 





JDSE 2, 192S] 

lonvard, but. medical licensing Iws, regT.-cttably, failed 
lo move in concert. In most Stales tlio iiTcgvilar 
healer is licensed on Hie same footing as tlio well- 
trained graduate, and the law may regard with equal 
favour the Zodiac-therapist and tlic tinished product 
of a high-grade medical school. It is little wonder if 
the citizen is in doubt as to what the brass plate — or 
its American equivalent — stands for, and needs the 
guidance of the daily press and wireless wlion he is 
choosing his medical attendant. Itlore than organiza- 
tion would appear to be required lo produce an ctlleicnt 
medical service in America. The question of licensing 
is fundamental, and' should he adjusted first. TTicrc 
should bo no place for Zodiac-therapy or oUicr forms 
of remedial magic in a country possessing the genuine 
medical resources of the United States. 


t TnJiEnmsrt - 
ITeWCAt JOURNAt. 

Prs. LttmscTeii and Stephens have found that, by combining 
tlio uso of hiitfsermn mtb adrcnalmo, about 50 per cent.- 
of rat sarcomata could bo made to disappear, and that the 
rat.s so cured u’crb immune to suhsequent implantation of 
sarcoma and also of i-at cancer. It airpoars that antibodiei 
specifically lethal to malignant tumour cells can bo pro- 
duced, and that local tr-eatment hy an implanted tumonr 
growing in a rat will yield a vaccino irhich canMs active 
tumoOT imninnity in the animal trc.atcd. Investigations 
of foot-and-month iTFseaso have been continued throughont 
tho year in a laboratorj' and animal house set apart for the 
purpose. Lastly, we may recall that (ns noted in our issue 
of ill.ay 5lh) tho Institute has accepted an invitation from 
the- Liternational Committee for tho Study of Infantile 
Paralysis to tahe part, with five other scientific bodies in 
America and Europe, iii a joint attack upon tho prohlem of 
poliomyelitis. 


THE Dis'risR ' institute. 


THE LISTER INSTITUTE. 

The iiniiiial general meeting of tho Lister Institute of 
Prcvciitivo lledicino was held on Slay 23i-<l, when the 
governing body presented its thitty-fourtb aiiiiiial rciiort 
to the members. In recording tlio death of I.:ord Ivcagli 
last October it is recalled tbiiL tho endowment of tho Lister 
Institute in 1898 was the largest of his benefactions for 
the advauccracut of medicine by rcseardi, and enabled the 
objects for which the Iiistitiito was founded to bo pnrsned 
ou a scale tliat had proi-iously been impossible. Bcfcrcncc 
is made also to tho death of Sir Dawson Williams, 
whoso place ns ropiesciitativo of tlio British Itcdical 
Association on tUo couueil has been filled by tho 
appointment of Professor W. E. Dixon. Tlio vartons 
sections' of tho ■ roiiort giro ovidonco of ccntina«l 
activity in all the many branches of research iindert.Tkcn 
m tho depai-tmcnts of tho Institute. Ackiiowlcdgcincut 
is made of the financial support given by tlio Medical 
Ecscarcli Council, the Dcpai tiiient for Scientific and Indus- 
trial Ecscarcli; and tho British Enipiro Cancer Campaign 
to skilled investigators working at tho Institute. The 
Jfcdical Ecseareb Council provides salaries for the staff 
of tho Ahitional CoIloction_ of Typo Cultures, and for three 
Workers in the Department of Experimental Pathology, 
and it has entrusted the Dopartracut of Biochemistry with 
a lengthy inquiry into tho vitamin content of Empiro 
products and the effect of preservation and storage thereon, 
tie cost heiiig defrayed by a grant from the Empiro 
j ai 'eting Board. In the Department of Bacteriology 
10 cssoi Ledingham has extended his studies on vaccinia 
ana ■variola, Dr. Eagles completed an investigation of rougli 
1 foims of streptococci from scarlet fever sources, 
in I special referenco to variations and virulence, and Dr. 

-img t s work on bacterial variation and the autigeuio 
structuro of bacteria lias been continued. Dr. Korenchevsky 
"’“I'kors have investigated testicular and 
pro a 1 C ormones and tho effects of lipoid ovarian extract 
an paia yroid extract on nitrogen metabolism. Further 
rcscardies have been made by Dr. Harriette Cliiok and 

' 1 ^ 1 active constituents of water- 

so u o VI amin B, provisionally cnlicd B, (tlie antineuritic) 
unc . (ho so-called " antipollagra vitamin). Their 
e^enmon s on nutrition indicate that conclusions 
biological value of casein and other 
ro cins MW stand in need of revision. Both vitamin 
and B, are present in yeast, and information is 
TOumu a mg regarding tho distribution of vitamin B, in 
1 oien w ole cereals and their constituent parts. Other 
tamins and their sources have also been studied during 
connexion tho biological action, of K^-| 
• s received close attention. In their work on cancel 


PROEESStONAL ORGANIZATION. 

It is liigbly dcsirahlo that members of the medical profes- 
sion should not overlook tho important and very interesting 
Herbert Si>enccr Lecture, delivered at Oxford on May 18th 
by Profes-sor A. M. Carr-Saunders, on Professions: their 
Organization and Place in Society.^ It has been published 
by the Clarendon Press as a booklet containing only some 
tliirty pages of reading matter, but these pages are full 
of wisdom and contain ronch food for thought. Tlie theme 
of tho Icctnrc and the general nature of its argument may 
ba -indicated by a short, but necessarily inadequate, sam^ 
mavy. A profession is defined as “ an occupation based, 
upon specialized intellectual study and training tho purpose 
of which is to supply skilled service or advice to others 
for a definite fee or salary.” Further, a profound distinc- 
tion. between manufacturers aud dealers on the one hand, 
and professional men on the other, is that the latter “ do 
not hny and sell material goods as an essentia] -feature in 
tho performance of their fvmctions.” It is useful to bear, 
this in mind w-hen claims are made, as is sometimes 
■the ease, that opticians, druggists, and pharmacists are 
nicmbors of “ professions.” Even chiropodists would seem 
to have a better claim unless any of them are vendors of 
boots, also. As soon as a profession emerges, its members, 
moved by common Interests; form a professional associa- 
tion. Moreover, -the tendency is towards the dominance of 
a single association in each profession. Minor rival asso- 
ciations always tend to- die out. This is apart from those 
associations which deal solely -with tho science or subject-, 
matter of their profession; these may be numerous. Two 
of tho chief objects of a professional association as hero 
understood aro “ to bring up the qualifications of all who 
hold themselves out as practising the craft , to a certain 
minimum standard, , and to enforce the rules of honourable 
conduct.” Some features of such codes of ethics are 
common to all professions; for example, (1) the rule 
against advertising; (2) “ making tho fee or salai-y paid 
fdr service rendered the sole remuneration or advantago 
which a practitioner receives”-; (3) prohibition of the 
alwogation of- one’s position as responsible advisei- in ordei- 
to facilitate and cover the actual delegation of responri.- 
bility to- an unqualified person. When examined, such 
codes or rules are found to ho entirely in the public 
intei'est. Some criticisms may ba made, “ but they are- 
small evils from the point of view of the public compared 
with the state of tiling wliicb obtains when the competent 
and responsible members of a profession fail to achieve 
these objects.” A third object of a professional association 
is to raise tho status of the profession, and “ it is impos- 
sible to ignore the fact that the status of the professional 


^Professima: their Organization and Place in Sac.icf.ij. By A. M 
Catr-Saumders, 5I.A., Prolessor of Social Scicnco In tho ioniversitv o' 
Liverpool. Oxford : The Clarendon Press ; London : H ililfnrd 
.Univeisity Press. 1928. (Med. 8vo, pp. 31. a. net.) ' ’ - ? - - 


962 June 2, 1928] ED-DCATION COMMITTEES AKP SAIiAEIES OP TJEDICAE OFFICERS. 


man must be dependent on the salary or foes which ho 
receives.” It is -easy to suggest that selfish motives aro 
Jjredominant in this connexion; but “if a just conclusion 
Js to be reached it must be remembered that tho activities 
of tho associations are restricted to raising tho minimum 
remuneration to a certain level. To tho public there is free 
choice of practitioner. It is merely sought to ensure that, 
when a practitioner' is engaged to perform a particular 
service, he shall not be paid less than a certain amount.” 
It may be argued that in some cases tlio minimum is set too 
high, but it is a legitimate claim and a useful tiling to 
attempt to fix minimum terms, to do this by collective 
bargaining, and to enforce it by joint action through 
an organization. ‘VSHien a professional organization has 
reached a certain stage a further motive and object appears 
— ^namely, to see the profession fully and adequately used 
vrherever it can be of service to tho State or others. “ Tho 
advancement of the status of the profession and tho exten- 
sion of the craft in the public interest do on the whole go 
together and “ a further development takes place when 
the State turns to professional associations for advice 
and assistance.” Professor Carr-Saundera goes on to 
examine tho charges against professionalism, which amount 
to this — that “ whatever may bo the declared objects of 
professional associations, in actual practice conservatism 
of outlook as exemplified by animosity against now methods, 
selfishness as illustrated by exclusiveness and by interest in 
status and remuneration, and rigidity of practice as shown 
by professional etiquette are predominant.” These, when 
investigated, are found to be based upon misunderstanding 
or upon a perverse insistence on some admitted defects. 
Tho nature of the defence has been indicated, and is 
further explored. Lastly, Professor Carr-Saundors con- 
siders the future of tho professions, the propriety of any 
professional register, and the desirability or otherwise of 
complete or some degree of closure to unregistered persons. 
He concludes that, as properly defined, there must bo an 
extension of professionalism for cotnmoroial and industrial 
purposes. “ Professional associations have something to 
offer towards the solution of certain of the problems which 
face commercial corporations. Towards the solution of tho 
problem of efficiency they offer tho ideal of adequate 
qualifications being demanded of those who undertake 
specialized functions. . . . Taking all in all, the growth of 
professionalism is one of tho hopeful features of the time. 
The approach to problems of social conduct and social 
policy luider the guidance of a professional tradition raises 
the ethical standard and widens the social outlook.” 


EDUCATION COMMITTEES AND THE SALARIES OF 
MEDICAL OFFICERS. 

It appears from the programme for tho forthcoming 
annual meeting of the Association of Education Committees 
at Bath that a motion will be submitted on behalf of the 
executive committee in the following terms: “That this 
association protests against tho action of the Ministry ol 
Health in withholding Government grant from local autho- 
rities if the demands of the British Medical Assooiatioii 
are not conceded. The association objects strongly to sucli 
a decision being arrived at without previous agreemenf 
with the local authorities concerned.” It is no part of oui 
business to defend the actions of the Ministry of Health, 
but this motion appears to indicate a wilful misunder- 
standing of the position. Tlie adjective is justified by th< 
fact that in the Supplement to our issue of January 28tl 
last wo published an article on the subject, in which ii 
nas explained that some scale of minimum commencing 
s.alaiies was agreed by the Ministiy of Health to be neces- 

tia^’ !!! ^°u ^j'listry and the British Medical Associa- 
-tma, as nell as local autborities, bad found that the publi. 


health service was not attracting medical practitioners of 
tho right qualifications and status. It was explained 
further that tho present scale docs not represent tho 
“ demands of tho British Mcdic.al Association,” but is a 
modified scale (in many respects lower than that originally 
suggested, and leaving a good deal of latitude, within 
limits, to local authorities), arrived at after consultations 
between representatives of tho Ministry of Health, of tho 
Association of Municipal Corporations, of other associations 
of local government authorities, and representatives of tho 
British Medical Association and of tho Society of Medical 
Officers of Health. Tho scale received in general tho 
support of tho Ministry and of tho Association of 
Municipal Corporations. Our article further set out that 
an offer of coufcrcnco with tho Association of Education 
Committees (inter alios) with a view to modifications of the 
Bcalo then proposed had been refused by that association ; 
and that an offer by tho British Medical A.ssociation to 
ngreo to an appeal committee consi.sting of representatives 
of tho medical profession and of local government auth'o- 
ritios, with a representative of the Ministrj’ of Health as 
chairman, with a dotermining voice, was turned down by 
tho Association of Education Committees and by tho County 
Councils Association. IVo havo no knowledge as to whether 
tho Ministry has actually withheld grant from any local 
authority on the ground that the scale has not been com- 
plied with; but it is true that the scale is now operating 
in more than 82 per cont. of the vacancies . occurring in 
: tho public health service, and that among tho remaining 
18 por cent, there aro a numbor of instances in which tho 
local authority is carrying on its service by moans of 
temporary expedients only. In those circumstances there 
would scorn to bo an element of pen-orsity in tho action of 
tho executive committee of tho Association of Education 
Committees, which might perform a more useful public 
sorvice by frankly accepting tho principle of a scale of 
minimum commencing salaries for public health medical 
officers, and either consentijig to the establishment , of a 
conciliation committee for cases referred to it- on cither 
side, or making practical suggestions for some reasonablo 
modification of the details of an accepted scale. Such 
suggestions would certainly receive courteous consideration. 


A TEST FOR PREGNANCY. 

Am, will agree with Dr. A. C. Siddall' that a simple and 
satisfactory test for tlie presence or absenco of pregnancy 
would bo most valuable, not only to tho obstetrician, but 
also to ■ every general practitioner. He remarks that at 
present perhaps the best-known test for pregnancy is that 
of Abderhalden, but ho agrees with Smith and Shipley, 
who tried to bring it -ivithin the realm of practicability, 
and concluded that it is of no value for the diagnosis of 
pregnancy. He mentions tho verdict of Do Leo that the 
■ epinephrine-glycosuria test, Kammtzer’s phloridzin test, tho 
dextrose test, and Fahraens’s red blood cell precipitation 
tost are merely of academic interest, and also the state- 
ment of Hunt and Long that no Laboratory method has yet 
been devised which is absolutely and infallibly diaguostio 
of tho presence or absence of pregnancy, with tho exception 
of radiological exandnation in tho later months. Experi- 
mental work in this field has been hitherto dominated by 
two ideas — namely, th.at pregnancy causes a specific protein 
(ferment) to appear in the maternal blood, and that during 
tho early montlis of ' gestation there is a tendency to 
glycosuria. Siddall suggests a test, however, which is 
based on a different idea from these. Early in 1826 ho 
advanced the hypothesis that if the enlargement of - tho 
uterus and breasts of a pregnant woman is due to tho 

'Siddall, A. 0. : A Suggested Test for Pregnancy, b.ased on tho Action 
ot Gravid Female Blood Serum on Mouse Uterus : Preliminary Keport. 
Journ. Amer, iled. Assoc., February 1928. 


June 2 , 1928 ] 


CAHblAC' MALi'ORMATIONS' AND ENDOCARDITIS. 


r Tnrllnrn« 
LirroiciDJociiNii. vuu 


prc.soiico of 11 hormoiio in tlio circulation, tlion cori«'-.|ion(tiii}; 
changes slionld occur in tlio uterus anil' tn’i'a'-t*- of a test 
animal which -.liad- received, injections of blood from tlio 
pregnant female, whereas the blond from non-pregnant 
women should give negative results. Hinz, in 1924, had 
observed that, after injecting femalo mice with tho blood 
of pregnant women, a transverse enlargement of tho 
mouse’s uterus resulted," and this re.sidt was conlirmcd 
towards the end of 1926 by Trivino and Fels. Franek and 
his co-workers, in a series of papers dating from 1926, have 
also demonstrated tho presence of the female •-ex horniono 
in tho ciiculation, not only during pregnamy. but also 
during the menstrual periods. These results .•-eem to indi- 
cate that tho blood of non-pregnant females might also 
have some effect on tho uterus of the test animals. Siddall’s 
ob.'crvations, however, shoiv that this is so small as not to 
invalidate, his method as a test for .pregiiaiuy. His test 
animals wero imniaturo non-caslrated virgin leniale white 
mice of less than 20,000 mg. weight. One cubic i eiitiinetro 
of the patient’s blond serum isrinjected subcutaneously into 
an immature virgin white mouse onco daily for four or fivo 
days. On the sixth (lay tho animal is killed, the weight of 
the mouse Is divided ;by the weight of the uterus pfti.s 
ovaries, and the resulting ratio provides tho criterion for 
a po.sitivo or hegative conclusion,- a Vatio below 400 being 
positive and a ratio above 400 being negative for pregnancy. 
Fifty-seven patients wero submilted to this test , of twenty- 
six pregnant patients, twenty-five gave a positive niouso 
tc.st, while of nineteen non-pregnant patients eighteen gave 
a, negative mouse test, and twelve were incomplcto case.?. 
Such evidence requires confirmation in a laig<r series of 
patients with controls, and it- is to bo hoped that further 
information wilt be forthcoming. 


CARDIAC MALFORMATIONS AND ENDOCARDITIS. 

It- malformations arise in tho development ot an organ, 
disease cither in that part of tho body or in closely related 
systems is a common sequel. Instances of this process 
are not far to seek. Congenital defects of the bowel or 
incsentcrv frequently conduce to acute abdoimnal con- 
ditions; a misplaced kidney or an aberrant aitery of 
supply may be tho first cause of hydronephrosis and ulti- 
mate destruction of the organ; and congenital stenosis of 
the pulmonai-y artery only too often results sooiiei- or later 
iu pulmonary tuberculosis. The recent work of f'lerc and 
Levy' has shown that congenital heart di'ca-e is respon- 
sible for many of tho recorded cases of hcart-bloik in young 
subjects, while French workers also liave been the chief 
adrocates of tho view that pure mitral stenosis such as 
occurs mostly in women without any history of acute 
rheumatism is due to a congenital cardiac defi-ct which 
has gradually increased. Although infection of the endo- 
cardium is generally regarded as a secpiel of valvular 
eformitics as distinct from other defects, it lias boeii sliowu 
by Hordor, ivlio in 1909 described illustrative case*;, that 
infective endocarditis may, arise in coiijuiictiou with either 
a defective intei-ventricular septum or a patent ductus 
arteriosus. The same writer, in his Lunileiaii Lectures^ 
no jears ago, diiected attention to the luiiiuto structure 
of the cardiac valves, particularly of the aortic cusiis, 
s rossiiig the likelihood that slight congenital abiiornialitie’s 
might bo iinpoi-taiit predisposing factors in infective 
endocarditis. Xumei-ous ohsen-ers over many years have 
remarked upon tho increased incidence of this disease upon 
congenita j abnoriiial valves, hut that this doctrine reiife- 
seii c( a est only a part of tho truth became apparent in 
10 years immediately following the war, when it was found 
la in ectne endocarditis in a siihacuto foi-iii was taking 
a u per, cent, of its , .victims from among the most robust 

3 n-'. • f Par/f -March Ur’S p 

Mrdical Journal. April 3^ lOlli, and 24ti.. 192^^’ - 


men who had served an nvorago of three yciirs in the most 
streinioUs military occupations. Conversely, altliongli this 
dicea'je.'.iii-civiliaiidife; wins. known to bo preceded iir perhaps 
half tho cases by cbronic simple endocarditis, few of the 
many soldiors at lionio or overseas prosenling minor valvular 
lesions developed tho .so-called endocarditis leiita. • With tho 
aim of elucidating tho part played by congenital abnor- 
malities in the production of endocardial infection, Gladys 
Waiicliopo’ has collected from tbc London Hospital records 
fifty-two cases of bicnsiiid aortic valves . and nine of 
pulmonary valve defects. Tlio latter wore found to be 
■comnioiily combined with more severe congenital lesions, 
and (lid not in tbeiiisolvcs conduce to ondocarditi-s. Aiiinng 
tho infections of the aortic group i-lieiiinatic endocarditis 
occurred five times, in each case affecting tlio abnoriiial 
valve, while the mitral was affected four times; in i-Iicuiii- 
atic endocarditis generally the incidence is greater on the 
mitral valve. Infective endocarditis was the cause of death 
ill .seven ca.ses; except in one case, whore the tricuspid 
valve only was involved, the abnormal aortic valve was^tbe 
0110 attacked. Tlicse redords brought to light, ■ therefore, 
an incidence of 11.5" per cent., as' contrasted with the 
•ostiinali? of 25 pci-' cent, by Lewis and Grant. ,Tlio lattcr 
• fignie is cotniiarable, since additional predisposing factors 
■wero present in some of the cases. While interest centres 
principally upon the liability of bicuspid aortic valves to 
infective endocarditis, it is hoteivortliy that in tho series 
under review ihciimatic infection, fibrosis, atheroma, and 
calcification .were found rather more often than in 
anatomically normal valves.--; Less than half of the patients 
lived nioro tliaii forty years, but, • on the other hand, the 
fifth decade showed a higher mortality than any other. 
The important dodnctioii from these observations is that 
a bicuspid aortic valvo does iiredisposo to infective 
endocarditis, and tho findings of earlier investigators go 
to show that other minor cardiac defects, congenital or 
acquired, are likcwi.se etiological factors. Since physical 
strain is clearly at times an activating agent, its pi-eveiitioii 
would seem to ho an important prophylactic measure in 
those wlioso hearts show signs of endocardial ahiioniiality. 
Because it is obvious that some, individuals with valvular 
defects arc attacked while others remain immune, it would 
bo a, valuable advance in clinical medicine if a means of 
(li.stiiiguisliiiig tile two groups could bo found. Identical 
organisms may in some cases of infective endocarditis be 
isolated both from tho blood and some source of sepsis in 
the body. The careful eradication of au}- possible focus is 
therefore an imperative pi-oph 5 -lactio measure in those who 
possess' congenital or acquired endocardial defects. 


THE GENERAL MEDICAL COUNCIL’S SESSION. 

The General Medical Council completed its session by 
sacrificing the whole of Bank Holiday to tho hearing of 
disciplinary inquiries. Our report of the proceedings is 
continued in this week’s Supplement. Had the Council 
adjourned orlei- Whitsuntide, as on a previous occasion, 
and assembled again at a later date, it would have incurred 
an expenditure of some hundreds of pounds for railway 
fafes,- and with a decrease of revenue from registration 
fees,- and income tax to pay, tho Council finds itself obliged 
to cultivate strict ecoiiom}-. The disciplinai-j- inquiries were 
unusually iinmerous,l 3 ut'iir the result only three practitioners 
had tlieir iiairies erased" from the Medical Segister — one for 
conviction for a felony, another for committing adiilterv 
■with a married woman with whom he stood in professional 
relationship, and a third for maintaining, also during 
professional relationship, a friendship of an improper 

character with a married woman. In two other cases 

duo arising out of convictions fo r drunkenness and the 
' ■ ^ Qiiaii. Journ'. jlcd.~ April, 1B23, p. ZS3. 


964 June 2, 1928] HtSTORICAL EXHIBITION AT' ftAifoiFF. 


[ 


Tjir rnms* *;/. 
llrDICAI. JotTRWAfc 


.ollit-r o'ut.of ladvortising to attract patients — tUo facts wore 
proved, blit judgement was .suspended until a later session. 
In two cases tlie charges wore found not proiTd, and in one 
other, although the facts were proved, mitigating circum- 
stances were allowed, assurances accepted, and the ca.se 
dismissed. . AYhatever may ho said about the discipliimry 
work of the Council, tho severest critic cannot deny its 
expeditiousness. Few courts of law could liaic dispo.scd 
of so much difticidt and delicate business in six day.s. 
Another thing to bo said is that no practitioner appearing 
btfox'6 the Council is prejudiced because he is nut leg.ally 
represejited. It conveys no reflection on the legal ])rofc.s- 
sion that while all three practitioners whoso names wore 
oiased were represented by counsel, two of the three who 
were successful in their defence liad neither counsel nor 
-.solicitor. Certainly no one will dispute the advantage of 
legal representation; if it docs not affect the result, at 
least it shortens tho hearing. But tho point is that this 
Council ’s indulgent to the practitioner wlio appears d:i his 
own behalf. A feature of recent sessions has la'cn tho 
increase in the number of cases in which the charge is 
.that of committing adultery during profesisional relation- ' 
ship. Tho Council applies no rigid rules to these cases, i 
judging each one, pioporly, on its merits. The session was 
.remarkable for the appearance of a dentist against whom 
it was alleged that ho had taken advaniago of his profes- 
sional position to commit adultery with a married woman. 
Iho profcssioi'al relationship was denied hj- tho jn-acli- 
tionei, but tho Council upheld tho findings of tho Dental 
Board and d..'.'etcd that tho name should ho erased. A sad 
ciicumalanco nnukod the end of the Council’s session. On 
his V, ay back to Edinburgh a very respected member of the 
(xnuicil, Sir James Hodsdon, died in tbo train. Ho liad 
spoken r.,orc than once in the Council on the day ])roccding 
his death. We hope to publish an obituary notice in an 
early issue. 


HISTORICitL EXHIBITION AT CARDIFF. 

T IS a debatable point wlietber men are most interested ii 
•tho very new or the very old; tile attitude of the lay pres 
and the piibho towards such things 'as the discoveries a 
Euxor and tho e.xcavations at Pompeii seems to sugvos- 
Tmn u"! ? Archaeological streak in most people 

Int-ankh-Amen had his day “ in tho nows ” ocjiially wit] 
Lindlmrgh and Adolphe Menjoii. It may be antic, -patod 
■aro+hp^*^ since medical practitioners aro'coiistitiited inuci 

"the 1 ■ + '^*^"1 ^ "'“’‘’®P‘'e.ad interest will be takciV ii 

the liistoncal exhibition which' it is proposed to 
in connexion with the Annual Meeiing of ti^ S 

men, practised medicine and magio An aee Y 
of ;tbe ontsfanding. manuscripts and "eBcr“veKt '"‘’T 
Welsh folk, medicine was published in the ' r 
March 24th (p,.509). and in the same 1 ^ 1,0 ^010 ^^ ^ 

a letter, signed by the President-Elect and- othere* 
for assistance, notably fiom practitioners resident in W 
in tho collection of articles suitable for this exhibit 
■ is being promoted by tho officers of «« 

Histoi) of aicdicinc Section, with the co-operation pf +i 
autlmrities of the National Museum of Wales and th\ 
National Library of .Wales. Information regarding th 
theory am practice of folk-medicine, luiman or animal 
and regarding the existence and ownership' of illustrative 


A SUJJOlGArt OUTPOST IN.-TJTE jruIiPTUES. 

HxTUN.SIONS .\T THK LuWIS ] [oRI'ITAI,, StOUNOW.W. 

In the extreiiie north-west of the British Isles, forming a 
curved breakwater wliieh .sbelter.s the mainland from the 
North Atlaiitie, lie tho Outer Ilehrides— a region de.sol.lle 
yet piclmrsqiie whore, in the ])hra.so of the country, “ The 
scii i.s all' islands and the islands are all lochs.” Tlic most 
northerly part of the chain — Lewis, and its apiicndngo 
Harris — eonlaiiis most of the iiopidation. On the cast 
coast of Lewis, soino six Iioiirs’ stciiiiiing from the mainlaiirl 
across the lempostiioiis Jliiiee, is Stornoivay, tho Ic.adiiig 
town in the i.shinds and tlio coiilro of the herring iiidu.Ury. 
Tho formal o])pning there on May 10th, ■ by -Dr. - Walter 
Elliot, Diidor Secretan- of Health for Scotland, of . ah 
extension to the Lewis Hosiiitiil, mentioned in the Journal 
on May 12th (p. 821), tnarked tho inauguration in its 
coinplele form of a surgical .service for tho Outer Ilchride.s, 
which was hegiin in 1024-hy the appointment of a consulting 
surgeon by the Scottish Board of Health; The development 
of this ■ serviee is of more’ than local interest, for it is a 
■departure in State mciircino. whicli may well Imvc important 
effects in tlie organiKalioli ' of tho profession throiighoiit 
tho country. 

To exiilain the, origin of the scheme it is nercssarv to 
go back to the cuinmcncoinent of national bcaltli insurance. 
AVhon this- came into ojicration it was realized that in tbo 
remoter jun ts-of Ibe Highlands most of the athiH population 
would not come under tlie system; croftcr-fislicfmcn could 
have no status as insured jicrsons ns they received 110 wages. 
In addition, tlie su))ply of doctors was limited. Tbo 
Highlands ami Islands (Medical Service) Commission, 1912, 
issued a masterly report which nimlysed tho entire medical 
requirements of this unique area. As a result of its reconi- 
mendations an increased inimbcr of medical practitioners 
were appointed, district nurses wore provided, ami it was 
contemplated that, when funds should suffice, improved 
liospitnl and dental services would bo instituted. The war 
delayed the fulfilment of these conceptions, hut in 1924, 
with the iqipointmcnt of consulting surgeons for Lewis and 
for Shetland, the first stage of a complete surgical service 
for tho Highlands was begun. 

-Tlio Board of Healtli’s nominee for the .surgical post in 
Lewis, Mr. J. Ewart Purves, E.R.C.S., by arrangement 
with its malingers, was made suiierintendcnt of the Lewis 
Hospital, Stornoway. This institution was founded by 
public subscription in 1896, and after an extension in 1912 
contained some twentj- beds. Both in staffing and in the 
character of tbo work done it was, however, essentially a 
cottagb hospital. Tho people of tbo island (who number 
nearly ’35)000) . bad a great repugnance to the idea of going 
to hospital; institutions 'werb regarded as the last refuge 
of medical treatment, and the removal of a patient as a 
sevefb asporsibii 'iipoir the hnmanity of his relatives. .The 
doctor who I'ocommen'ded it was. taken as giving a hopeless 
prognosis, and his advice was followed by lamentations froni 
the patient’s friends. ’In' fact, ibe. situation was much the 
same as that in tho cities fifty years ago.- Under tbo old 
iegimo the Lewis Hospital was not used to anything like 
capacity, and frequently it liad hb patients at all. A pre- 
vailing belief in those days was that there was no need for 
a modern hospital system. It was argued that the simpler 
habits of this pastoral people of "crof ter-fisliermeh . exempted 
them from tbo morbid conditions of tbo largo centres, and 
that apart from' the services of the practitioner (ivlio still 
has in- one paf isli some five thousand people to look after) 
no specialized aid was necessary ■ , 


- ■ -ilic.A’cu .-Hospifnl Arrangcmtnfs. 

- 'Within a few years the whole situation has ebangod. The 
presence of a surgeon consultant and tbo existence of a 
modern hospital has produced a supply of surgical condi- 
tions for treatment, and even with the institution working 
pressure there are as a rale two patients on tho 
waiting list foi- each bed. Compared with the savoUcti 
queues which line'the waiting rooms' in the city infirmar* 's 


JOSK 2, iqjS] 


A SUEGICAri OUTPOST IN- TOE HEBRIDES. 


[ Tnr. 

Medical. Jourvat. 


965 


tills may seem iiisighificniit, but many of Ibo island patients 
have \vaitcd long periods even before consulting their 
doctors. ■\Vith modern appliances nvailablo tlio number 
desiring admission is increasing gro.ally. 

, When tbo surgeon was appointed it was realized that 
for the iarger needs of a surgicai ciinic x rays and other 
diagnostic aids were ,cs.sontial, and at the same timo tbo 
increased staff and inoro elTicient management called for 
greatl 3 - improved quarters. AVitb Treasuin- assistance, tbo 
Board of Health authorized tbo managers to inocced tvitb 
a sebomo for enlarging tbo hospital and adding certain 
nccessai-y items of equipment. This extension is now com- 
plete and tbo building has been transformed from a small 
cottage liospital into a modern clinic — scientific, workable, 
and compact. It has not been found possible at present 
to incroaso von" greatU- tbo number of beds ; tbero aro now 
tivcnty-four, and four cots. 


Tlie new wing contains a larger kitchen and greatly improved 
quarters ' for the nursing and domestic staff. Owing to the 
e.vposcd situation of tbo building a steam beating svstem has 
been found necessarj'. An oil engine witli dj'iianio and batteries 
gives current, for lighting and. a- r.a.vs. The x-ray equipment 
consists of a “ universal ” conch wliicli can bo moved into 
any position for screening and pliofograpbing. and Philip’s 
" metalix ” tubes of fine, focus. There is a Poller-Bucky 
diopliragm, and the whole outfit consumes 5 kilowatts. The 
apparatus is housed in a commodiou.s room at tlic end of tbo 
building, with ventilating fan, annexes for developing, dressing 
rooms with shower-baths and lavatories. TIic National Physical 
■Laboratory has certified . tbo .entire s.vstem. There are two 
mercury vapour lamps for general irradiation, and appliances 
for both local and general diathermy aro installed. An enlarged 
and modern theatre replaces llio former cr-iniped operating room, 
and a laboratory’ of adequate compass 'will make clinical research 
more convenient than before. Under the present arrangements 
tlie medical officer of liealth acts as" nnacstliclist when necessary, 
and Uie \yholo forms a' complete surgical unit. Tlie general 
e.xperience of eases is said to bo similar to that in one of tbo 
largo infirmaries twontj* years ago, and some conditions are seen 
in a verj’ advanced form reminiscent of the older tcxtiiooks. 

Pigurcs of tile hospital work for two periods — before and 
after tlie ^appointment of tbo surgeon — illustrate the great 
ebango which the institution has caused in tfio medical practice 
of tlie island. For the ten s’cars prior to lfi2A an average of 
seventy patients were admitted cacti yc.ar. In the first whole 
\e.ar of the' now surgical service, before llic extensions to tlie 
building and the installing of tbo x rays, 376 patients were 
treated and 375 operations performed. In'tbis period, too, iliero 
were over 1,000 out-patient consultations — an entirety novel 
branch of the hospital’s activities. Patients aro seen upon the 
recommendation of their doctors ; surgical cases form most of 
the admissions, .although others aro not refused. About one- 
third of the admissions aro cases of cmcrgcncv. 

Eye cases avhich require operation' are sent to tho mainland. 
Abdominal work forms a major part of the clinical material, 
an j IS noteiyorthy that pneumococcal peritonitis is unusually 
common icre in children.- Malignant ■ disease/ unfortunately, 
m seen in the later stages, and gynaecology is a largo field of 
practice which is at present unexplored. Cases of difficult 
labour are beginning to appear upon tbo hospital list, and tho 
small private ward in the extended institution will thus prove 
iiseful In former. d.ays the treatment of tonsils and adenoids 
1.1 children as recoi^ended by the school medical officer was 
rardy undertaken, but this IS. now an important part of the 

work- among children. • - • • 


' Oommuniiation' Difficulties. 

The ide.amf.medical,_pr.actico. which prevails in Lewi 
IS one wh.cli IS largely colou?ed bj’ the times, hero no 
very far distant, when tbero were only two medical me 
to undertake the whole work of the island, and the 
tiavelled on horseback many miles over tlieii- professions 
domains at infrequent intervals. .In those days each docto 
was hter.ally a consultant, in that lie was only summone 
when the illne.ss had resisted the, efforts pf the local- wis 
men. Se\;eutli sons enjoyed peculiar .prestige in tho ,liea: 
VI® ‘ district even to-day there is some persb 

who IS regained as having special skill" in ti-e"ating frac 
tines .-.-id deformities. At tho present time, although eac 


parish has it.s competent doctor under tho Highland 
medical service, tho old traditions linger and it is riot 
unusual for a doctor to'ho .asked to''visit .a serious case only 
oiico in its currency. There aro no telcphonq cal! boxes 
or regular moans of communication, and the doctor is sent 
for by telegram, except at night, when some nbighb'our 
riiay sot out to" track many miles over the moors.- In such 
circumstances the work of a surgic.al specialist is "not easy ; 
tbero is a tendency for cases to bo sent in for operation 
only as a last resort.- 

It is difficult for .a doctor whoso praetico lies in, say, 
some pleasant suburb of Surrey, to contempl.atc how ho 
would feel if cut off from his friends by a tliirtj- hours’ 
journey from the mainland (including six hour.s’ .steaming 
over a villainous stretch of water), with no opportunities 
for medical discussion, no colleagues on the telephone, no 
opportunities for seeing other men’s operativd work. The 
city surgeon stops into his theatre and -finds all prepared; 
His mind is freed from extraneous considerations; In's solo 
concern is with the details of his -operative technique, and 
liis responsibility maj’ he lightened by collaboration- with 
specialists.' But the work "of- his colleague in the Hebrides 
is more varied and .strenuous. First tho" must ho 

seen' and any necessary dia^ostic test performed. '"The 
surgeoil may'then'liavo to spend half an hour in persuading 
tho relatives tliat’ operation in, say, a perforated gastric 
ulcer, -’is a matter of urgenej’. Having onco decided to 
operate ho must arrange for tho theatre — perhaps the 
water supply will be off — to ho made ready and go out to 
find an anaestiictist. '• (None of tho medical men in -tho 
island have tho telephone.)' This 'has proved 'so -difficult 
in some eases that local and spinal anaesthesia -have beeii 
developed iind aro now utilized whonever possible. Details 
wliich ill most mainland hospitals are -hardly noticed 
.assume hero great signincaneo. Success in sut'h a field 
is achieved 'only at tho cost of much effort in ways' which 
do not fall strictly within tlio realms of surgerj’. ’ On one 
occasion an operation was performed under novel circum- 
.stanccs. At night-timo and on Sundaj’s all tho telephone 
lines aro connected to the lighthouses at various points 
around tho coast. A message was received from one of 
these that the surgeon was required for an urgent obstet- 
rical ca.so. "Within half an hour his car was on the road 
with anaesthetist, trained sister, and operating equipment. 
After a journey of more than fifty miles over some of the 
roughest country in Britain, -including a gradient which is 
notorious, half an hour’s sea-crossing, and a few miles’ 
walk over the moors, the patient was reached, and a 
craniotomy performed successfully within three hours of 
the original telephone message. It is a sad comnieiVt upon 
a conflict of bureaucratic interests that on this occasion 
tho telephone was used irregularly. The correct procedure 
would have been to wait until ifonday morning and send 
a telegram 1 


.4 Threefold Success. 

In a great measure . the corispicnous . success of the 
service must ho ascribed to the confidence with which the 
surgeon has come to be regarded. The idea of anaesthesia 
is now taken" with more composure, and. .patients .appear 
demanding operations for the most unusual conditions. 
To ^an observer this undoubted triumph is the more inter- 
esting, ns from tlio very first it was tho determination of 
the present surgeon never to he content with less, than the 
highest pitch. of cfficiencj- in nursing, equipment, and his 
own. efforts. ‘His-policj’ has been justified by results. "It 
must- ho rave .that such a campaign of practical education 
has achieved its' nini .in so brief a -period. The successful 
establishment - of the service here outlined is a -threefold 
•triumph. Politically, it reflects departmental continuity 
in tho best sense — ^the surgical needs of tlie Highlands 
were first realized h}' a Liberal administration before tlio 
war; tho first surgeon was appointed under the Lahour 
Government; tho grant for tho further extensions' to the 
Lewis Hospital was made under the present Conseirative 
- 1 ?^ demonstration of our professional 

ndaptahihty, and shoivs that the influonco of tho State 
need not ha-vo a sterilizing effect. .Lastlji, it is a personal 
victory for the surgeon who has carried . .an - idealist con- 
ception successfully into the region of fact 




June 2, igiS] 


ENQIiAND. AND, "WALES. 


r TuF-BniTisn 
1 SlrDlCAl, JOURNlli 


967 


siiporintondwit, Sir lloiry CJniiv.niii, wlio will liii^olf giro 
tlip grcutor p.nit of tlio iccturrs .mid demoustrations, and 
will deal with hospital organization for snrgic.al tnhor- 
cnlosis, heliotherapy in surgical tnhorculosis, tuhorculosio 
of iho spine, tuherciilous ndonilis and peritonitis, etc. 
Dr. Jones will lecture on tuberculosis of tho hip, and Mr. 
Duke-Elder on tuberculous disease of tho cyo and treatment 
by ultra-violet light. “ Bactcriologj' in tuberculosis ” will 
bo tho subject of an address by Dr. Bannonuan, and Air. 
Eairbank will speak on dilTorential diagnosis of bono and 
joint lesions. In tho course of tho week thoro will bo n 
demonstration by Dr. "Wood at King George’s Sanatorium, 
Drainshott, including light treatment in adults, and tho 
closing day will bo given up to a ilemonstration at Sandy 
Point, Hayling Island, illustrating sea-bathing as a thorn- 
poulic measure. , 

Tho progranimo for tho Cambridge post-giaduato course 
has boon arranged by Dr. P. C. Varrier-Joncs, and an 
inaugural address will bo given by Sir Humphry llolleston, 
Dt. Professor J. 11. IJuxton is to provide a demonstration 
on tuberculosis. Professor G. Hi I’. Kuttali a demonstration 
of parasites, and Dr. G. S. Graham-Smith a lantern 
demonstration on flics. “ Chemotherapy and tlio tubcrclo 
bacillus ” and “ Tho mental factor in tuberculosis ” will 
bo tho subjects of lectures by Professor IV. E. Dixon and 
Dr. J. T; AlacCurdy respectively. Dr. W. Paton Philip 
is to speak on tho diagnosis of pulmonarj’ tuberculosis, and 
Dr. Louis Cobbett will' discuss tho inllucnco of diet on tho 
decline of tho disease. An alt-d.ay visit' will bo made to 
tho Papworth Village Settlement, under tho guidance of 
Varrier-Joncs, medical director, and at tho closing 
session on the morning of Saturday, July 7th, Professor 
H. E. Doan will demonstrate tho anatomical and micro- 
scopical changes present in tuberculosis. Information 
regarding the courses may bo obtained from tho Honorary 
Secretary, Joint Tuberculosis Council, Post-Graduato 
Courses, The Larches, Earnham Eoyal, Bucks. 


.any clinic. Alost of tho stnlls wero not Pjoudi.ans, hut 
behaviourists, and even in tho few cases where tho psychia- 
trists belonged to tho analytic school they did not think 
tho procedure suitablo for clinic conditions.” Tho Educa- 
tion Comniitteo is recommending to tho Council that tho 
offer of tho Child Guidance Council for the establishment 
of a clinio bo accepted, subject to certain conditions, that 
as an oxporiment for three years it bo recognized as a 
school clinio, that children bo referred to tho' clinic by 
tho school medical officer, subject to tho consent of their 
parents or guardians, and that visits to tho clinic by tho 
medical staff of tho London County Council bo allowed 
nt any time. 




Gifts to Scottish Hospitals. 

Two substantial money gifts to Scottish" ho.spitals, both 
for tho endowment of maternity institutions, have been 
announced recently. At tho opening by Lady Chamberlain, 
on Alay 17th, of a new nurses’ homo at tho Glasgow Royal 
Alatornity Hospital- it was intimated that Air. Archibald 
Walker of Newart Castle, Ayr, had given a sum of £40,000 
for endowment purposes to the hospital. The directors of 
tho Dundee ■Ro 3 -al Infirmary wero informed at a recent 
meeting that for tho further endowment of the new 
maternity hospital Air. F. B. Sharp,' a Dundee jhanu- 
faCturcr, who resides at Cupar, in Fifeshire,' and his sister, 
Miss Christina Sharp, had given annuity bonds of £14,000 
and £6,020 rcspoctivclj’. Last year tho two made an 
endowment gift of £28,000, and two years ago Air. Sharp, 
with bis brother, the late Air. E. B. Sharp, gave £30,000 
to build and equip tho hospital. 


1 Proposed Child Guidance Clinic for London. 

An offer has been mado to tho London Countj’ Council 
hj’ tho Child Guid.anco Council for tho establishment of 
a child guidance clinio in London to which maladjusted 
or delinquent children could bo referred with a view to 
tho establishment of harhiony between tho child and his 
environment. Clinics of this typo are already established 
in Canada and tho "United St.atc3. The London Education 
Lommittce, in considering the proposal, points out that 
tile ide.T IS not altogether new, and has been carried out 
m London and elsewhere increasingly of recent years. 
Special schools, were first of all instituted for children 
suuering from physical disahilitics, then" for tho mentally 
(letcctiye, with special classes for tho dull and backward. 

cliildren, it has been the 
° obtain reports frpm special officers, care cora- 
tw to arrange for special examinations 

y sc 100 medical officer, and perhaps by tlio psycho- 
logist employed by the Lohdon County Connell, and in this 
lZr '1 “Bsistan'ee, as Zo does the 

bldldVro residential school' to which such 

T*' /together, as much child guidance 
thonVh it ^ ° •'‘3 “"y city in the world, 

A t “S forhially as in some 

hStnrv -American plan the full 

witirthe ^ohi d f° enable those working 

finder udiil L^. V. ^ conditions 

of 'a tfiniV I c I ^ -a .*"cport describing tho work 

Ifiid befnr Cleveland, Ohio) was 

laid before the Education Committee by Dr, Letitia Fair- 

work k Uif ^ feature of the Americaii 

TOi imil orJfin ffi '°“^«eenTCs on cacli case. At these tho 
lentath-cs examined the case, repre: 

schnni toaolioro ° referring agencies, and perhaps tho 
a nla . ™“y be present; comments are made, and 

one if familv enir!^ r sometimes an elaborate 

^ complications are to bo relieved and hafmonv 

that ” in" Vim^ nT P’^rfeid repS 

in ,tbo yei'y lively dread of psycho-analysis 

ythi g approaching analysis being carried .out in 


Edinburgh Hospital for Sick Children. 

Tho annual meeting of the Eoj’al Edinburgh Hospital for 
Sick Children was held on May 8th. Mr. Colin AI. Black, 
W.S., chairman of directors, who presided and moved 
the adoption of tlio report, referred to the fact that' the 
hospital was unable to meet out of ordinary income the 
ordinary expenditure incurred in the hospital and con- 
valescent home, and that legacies and special' donation's 
had to be used in tho past year to make up a balance of 
£5,750. Tho report records the receipt of Tcgacies in the 
past year amounting to £8,840.' AVitli regard to the 
patients treated, tho average daily number durinn-, 1927 
was il4 and tho average duration of residence 17°days'. 
The total number of patients treated in the wards and 
in the out-patient department was 38,803, compared 
with 33,354 in tho previous year. In the hospital 1,106 
operations had been performed, and in the out-patient 
department 1,395 minor operations. A special feature h'ad 
been tho artificial sunlight department, where the total 

been 8,919, as compared with 
Z,6B8 in 1926. In the ear and throat department attend- 
ances had numbered 2,439, as compared with 2,106" in the 
preceding year. Attention is drawn in the report to a 
special study which is at present being conducted by the 
hospital into the problem of rheumatism in cliildhood and 
adolesoence, especially in regard to the production of cardidfi 
disease. ’ ' • ' 


Central MWwives Board for Scotland. 

At the recent examination of the Central Alidwives Board 
for Scotland; held simultaneously in Edinburgh, Glasgoa- 
Dundee, and Aberdeen, there were 129 candidates, of whom 
121 passed. Of the successful candidates, 20 were trained 
at the Eoyal Maternity Hospital, Edinburgh, 5S at the 
Royal Mateniity Hospital, Glasgow, 10 at tho Roval 
Infirmaiy, Dundee, 4 at, the Maternity Hospital, Aberdeen ' 
S-at the Queen Victoria Jubilee Institute, 7 at the Elsia 
Inglis Alemorial Hospital, 2 at Stobhill General Hospital, 
3 at Belslnll County Hospital, 2 at the Cottage Nfirses’ 

Training Homo, Govan, and the remainder St various- 
other institutions. yuuuus 




058 June 2, 1928] 


COBREBPONDENCE. 


C0rr£S|nm&£nru. 


MYCOSES. 

ith reference to Dr. Rupert Hallam’s ini erecting 
paper on mycotic infections of tlio hands and foot in votir 
issue of May I should like to bo allowed I 0 

emphasize the extoeme fretjtiency of these infections in 
the tropics, and in general in all countries with a warm 
moist climate, such as Louisiana and Mississippi in the 
■United States, certain parte of Southern Italy, Spain, and 
the Balkans. In New Orleans more than 30 per cent, of 
the medical students suffer in the late spring and summer 
from epidermophjdosis of the toes. The condition has, 
of course, been known for years iu Ceylon, Southern India, 
Singapore, and Hong-Kong, where it is known by a variety 
of names—" mango toe,” “ Hong-Kong too,” “ Cantlio’s 
toot-tetter, etc.— and a de.scription of it was given by 

Chalmers and myself in our Mamial oj Tropical Mrdicinc 
It IS caused, as proved by Sabouraud and IVliilfield, by 
the same fungi that cause ordinary dhobi itch ftiiiea 
cruris, tinea ij^uiualis), the principal species of thaso 
lungi being lipidermophyton cruris Castellaili, 1905 
7 Sabouraud, 1907), and Epidermo- 

phyfon rulrum Castellani, 1909. Both Ihcso organisms 
described by me in Ceylon in ca.ses of 
dhobi Itch. They are also the causative agents of certain 
cases of mycotic pruritus ani.i 

attention to another as vcl little 
kmown mycosis which is far from rare in the tiopie, aud in 

loSed” " !bis country, but is ifton over- 

fpyosis crvnT ^"'■““';"^°^'®.,.'=iTPtococcica vel moniliaca 
jpyosis ciyptococcica ye] moniliaca). I described this con- 
dition ceveva years ago,- and recently I a“ain gave a 

S rrjV f 

ts;. "> 

The condition clinically is often Lndistincuislmhlo from 
or^aiy furunculosis, the patient pre^entTe on varioTs 

identical with ordinary l^iils 
= chronic course. In some case tie 

thrfugf o^imitorn"’' dischaS 

aEoctod Teas falE oraito^ : The Jmir in the 

permanent, may be se^ ^ baldness, at times 

potassium Sde^toeri iii'fuli’dLe^'^T , to 

coccus vaccines. gball he f a V* staphylo- 

luterested in the s'ubiect witli n f^PPlv worhers 

isolated from various^caies.^S am*'“ote ^ 


TirrTiRTrmi 


L WrpiciL Jotmim 


Boss ^stltute and Hospital for Trooioal 
Diseases, London, May 22ndy ^ 


Aldo Casteixani, 


mE 

— Tbe report of Dr. Stanlev Ji 
published in the British MccuLT'T^t^’^ subject, 

p. 838), is a highly significant todee^ rsimni^v"^ 

ment, and as such calls - for some ' commcSl f"®’ 
^rtani past events into whicl. I need no? 
it -a matter of strange taste for Dr IVvard 1 ■'“ahe 

the field of criticism in ixi-ard to 0 ^ have e„te,^ 

bo doubted, in view of bis° oi^ljtom^’ 

Wyard ever seriously attempted to give Hie 

Sf Jst. t'Tss. i“ r| " « 

ss r'lStt 

conccirod. Tvork could liardly be 


• 1st, 1923, p. 1037. 

• Uygicnc, Decrem'bcr 1st, 1924. 


1. 'IVliv did Dr. IVyard use lead liydroxido after all our 
warnings to the eontrarv.t' 'j'ruo ho does not include the 
cases .so treated ii, his lahle of results; hut the impression 
produced on the miiul of an impartial observer, let alone 
lliat ot Dr. U yard, would liave been deplorable. No doubt 
his views coiiceruiug the clanger of the- method wore largelv 
mspircd by the effeets following the use of n yen- toxic 
HintcriAl. 

2. Tim method of preparation of the somallod " colloidal 
lead adininistorcd by Dr. Wyard, which he would have 
his renders holieve was himilnr to our ’ own, is groiesque. 
As J do not consider it ni-cessnrx- at the present jnnctiire 
to discuss the full extent of his errors, in this ro-smect, I 
anil inorcly remark tlmt shot are not composed of pure 
lead, hut contiiin •u'hat is hoHeved to ho an activator 
(ar.senic) of maliguaiit growth. This may siinirise Dr 
Vyard', imvcrUmkss, it is a fact. AVImt'a poor return 
for tile cEorts of Rrofe^sor Lewis and his a.ssociatos in 
1926 to teach Dr. IVyard how a lead colloid should bo 
prepni-ed ! 

3. The slnfcnmiifs are made that "Examination of the 
blood really helps yen- little,” and “ Wo found that the 
niimher of red colls showing piinctato basophilia was no 
c\-idcnco wliatcvcr for or against coiit iniiation of treat- 
ment "—statements whicli leave ns bewildered. Wo can 
only coiieliide that Dr. Myardk methods of observation 
are loss rermed than those of ourselves and others. 

4. On examination of the table of results wo note that 
of 56 patients treated with " colloidal lecid ” as many .ss 
ono-hair were under treatmont for less than seven ueoks, 
and of Ihesc, 17 died within that .short period. A number 
—it is impossible to say from the data given exactly how 
many, hut not loss than 14 per cent.— died after n single 
do.so. Forty-six of 56 patienf.s did not receive the 
mwhnvm complete cour.so <0.5 gm. Ph), and 40 of those 
46 received less than 0.4 gm. Pb. It is characteristic of 
Dr. Wynrd’s methods tlmt, in regard to the only case 
which appears to have boon suitable for treatment, and 
which lias improved to so great an extent as to merit 
-special comment, he should throw doul" on the diagnosis. 

As Dr. Wyard di-aws from this assciuhly of clinical and 
scientific errors the conchisioh tlint " there is no support 
for the statement that colloidal lead exerts a hcnoficini 
influence upon the progress of a malignant growth,” 
perhaps I may bo allowed to .state my own conclusion from 
the same data — namely, that Dr. AVyard is neither com- 
petent to treat cases of eanoor with lead nor to exjiross 
an opinion on this subject. — I am, etc., 

WvctttoI, 21st. W. Bmiu Belu. 


TREATMENT OF PROSTATIC ENLARGEMENT. 

Siu, — was mucli intere.stod in the letter from Dr. 
C. E. Dennis of Melbourne, commenting on mine, published 
in your issue of -<lpril 21sl (p. 691) and to note that his 
experience in the treatment of prostatic enlargement 
by -radiotherapy agrees ivith mine. 

It scorns to mo a most regrettable fact that British 
surgeons and practitioners do not recognize the great 
benefits that a:-ray treatments can give in suitable cases. 
It is the same thing in the field of gynaecology where 
menorrhagias, metrorrhagias, nionopansal haemorrhages, 
etc., are subjected to cnrolt.age, or a' major abdominal 
operation, before radiotherapy has been given the trial 
that, in suitable cases, is always suggested on the Conti- 
nent and in America prior to surgical intarvention. No 
a:-ray specialist of experience ciaims that radiotherapy is 
a panacea for all these conditions, but it Is so often 
successful in effecting a cure that I plead that piitieiits 
Bhoiild be given ilie chance of relief by the simple and 
p^less use of x rays more frequently than is at present 
he case. Regular consultations between the surgeon and 
the radiologist, and the mutual recognition by both of the 
exjmit^ knowledge in their own specialty possessed by 
eac^ IS tile only way in which the best interest of the 
patient can be attained. — I am, etc., 

J. Cuhtis Webb, 

ChoU»Tai„, Mae 21 sl. 



June ?, igsSj 


OORRESPONDENCB. 


LMehicie Joxjnsxi. 


DEAD AXE INFl'XTKD TEETH. 

SiHj 1,1 .mswering some points in ])r. Cowan's letter 

of Alay ISlli (p. 876) I fool it wonhl bo bc.st to confine 
my.solf'to practical and scientific isMics. With regard to 
instnicUons sent via tho patient, tho desirability of 
entrusting dental cleansing entirely to the dental surgeon’s 
judgement, or, in doubtful eases, of arriving at decisions 
in consultation with him, must surely bo obvious; it is 
certainly one’s own practice to regard a dental practi- 
tioner, not ns someone to wbom “ instructions ” aro sent, 
but ns n collcnguo to wbom oiio makes courteous requests. 
Tlio extraction of tooth on x-rni/ “ evidence ” alone, and, 
conversely, their retention simply because of its absence, 
should be condemned; tho widespread and growing sub- 
servience to radiography throughout tho whole range of 
mcdicino and surgery ns tho supremo and infalliblo 
diagnostic instrument is a grave mcnaco to tho clinical 
skill of the rising medical generation. 

It is not a surgical heresy to render aseptic a living 
organ ; it is a surgical heresy to retain in tho body a mass 
of ilcad tissue, diflicnlt primarily of sterilization (vido Dr. 
Cowan’s own admission), and, even if that bo temporarily 
aebioved, extremely liable thereafter for over to infection 
ns a locus rcsislcntinc minoris. There can bo no exception 
to the principles of tbo practic.al application of pathology 
in however small a branch of tho surgical art. I can only 
urge that tbo article leading to this correspondcnco should 
be re-read. — I am, etc., 

London, W.t, Jtay 22nd. C. JexXIXOS JI.insmLL. 


compared with tho pre.ssnro when on tho right side ; if the 
patient lies on tho left sido tho weight of tho liver comes 
into play and higher pressures than when on tho back ore 
found.) 

Tho clTicacy of this postural treatment seems to .support 
tho idea that a visceral circulatory disturbance is in play, 
tho offoct of administering glucoso further supports that 
conjecture. Glucoso, presumably, can have no effect on 
labyrinthino disturbances; that it greatly helps tho liver in 
its work, especially in states of impaired hepatic activity, 
wo know. Thus wo como to tho opinion that tho hepatic 
disturbanco is duo to a diminution of blood flow through 
the liver, occasioned by tho successive sudden falls of intra- 
abdominal pressure. At first sight, however, it would 
seem that a fall in epigastric pressure, by decompressing 
tho hepatic capillaries, would result in a greater capillary 
flow of blood through tho liver. But there is evidence 
which indicates that with decompression of c.apillary beds 
a corresponding constriction of tho supplying arterioles 
occui’s — limiting tho blood supply to tho insufficiently 
supported capillaries, and, conversely, that with increased 
compression of capillary bods, a reflex dilatation of the 
arterioles concerned is produced — allowing a greater blood 
pressuro to play upon tho capillaries. These, being now 
more compressed, can withstand a greater blood pressuro, 
and thus, unless tho capillary compression is too great, a 
greater blood flow through tho organ or part occurs. 'The 
portal vein and its branches are remarkable for their 
musculature: of what nso is this unless to control the 
blood flow through tbo liver? That the degreo of constri^ 
tion of these vessels, as that of the hepatic arterioles, is 
particularly related with tho blood pressure within tbo 
hcp.atic capillaries seems to mo a reasonable supposition. 
— am, otc., 

Rugby, May 19lh. K- H. PaRAMORE, P.R.C.S.Eng. 

PHARYNGO-OESOPHAGEAIi SPHINCTER. 

Sir, — In your issue of May 19th (p. 879) Mr. V. E. 
Negus writes to repudiate any connexion with what Dr. 
Hurst has called “ tho pharyngo-oesophageal sphincter of 
Negus.” Mr. Negus offers an apology to Professor Chevalier 
Jackson, implying that that distinguished endoscopist’s 
name ought to bo associated with that misnamed sphincter 
rather than his own. I doubt if Professor Jackson will 
bo flattered, as there is no such structure ns a pharyngo- 
oosophageal sphincter; and it is certainly not synonymous 
with tho crico-pharyngeus muscle, tho Continental name 
for the lower division of the inferior constrictor, the role 
of which in health and disease was originally elucidated 
by the late Professor Killian in 1908. Even seven years 
later, when Professor Jackson published his large work on 
Peroral Endosco 2 >y, ho had only partially grasped Professor 
Killian’s views on tho action of the lower (that is, the 
crico-pharyngeal) portion of tho inferior constrictor muscle, 
as ho nowhere in that work alludes to the sphincterio 
function of tho crico-pharyngeus, which Killian first so 
clearly expounded and illustrated. 

Neither does Mr. Negus, as far as I am aware, in so 
many words allude definitely to tho , crico-pharyngeus as a 
sphincter. This muscle is, of course, purely a pharyngeal 
structure — the lowest muscular band — and is the sphincter 
of the lower end of the phaiynx; it is altogether distinct 
from tho gullet, and is not incorporated with the circular 
fibres of the latter; and, moreover, the pharynx and gullet 
belong to two distinct types of musculature both morpho- 
logically and histologically, as the cirerdar fibres of the 
gullet are partially of the unstriped variety. AVliat is 
really, however, to tho credit of Mr. Negus is that he has 
made the suggestive pronouncement that a hitherto un- 
recognized function of the crico-pharyngeal portion of the 
inferior constrictor (which Killian called tho sphincterio 
portion) is to keep closed the lower end of the pharynx 

during inspiration and thus preventing aerophagia that 

is, the entry of air into the gullet at each respiratory intake. 

Mr. Walter Howarth (May 26th, p. 922) tbinte that 
credit should ho given to Sir Everard Home for having 
discovered tho crico-phaiyngeus, hut I may remind him 
that the anatomy of the .phaiynX, including its inferior 
constrictor muscle, with its two origins from the thyroid 


SEA-SICKNESS. 

Sir, — L ike Dr. Bennett (May Sth, p. 752) Dr. G. H. 
Oriel' has discounted tho labyrinthine theory of sca-sick- 
ncps. Ho found that a metabolic change was predominant, 
and that a “ condition of acidosis is ])rc,scnt before vomit- 
ing commences,” which gets worse ns vomiting sots in and 
continues. According to him tbo administration of glucoso 
“ causes diuresis, abolition of ncctonuria, and a fall in tho 
ammonia excretion, resulting clinically in tho rclicf of 
symptoms.” 

The change in tho blood, it seems to me, can only be 
explained by an impairment of tbo hepatic function, 
primap' in time. Either tho pnoumogastric nerve sends 
down impressions to tho hepatic cells, inhibiting them, tho 
reason and mechanism of which arc rather diffieult to see, 
or else the impairment is duo to a change in tho blood 
flow through tho hepatic capillaries, occasioned by fall 
of pressuro in tho epigastrium, tho result of tho sudden 
dc.sceiits with the ship pitching. Tho feeling one has when 
on board a pitching ship is tho queer .sensation, experi- 
enced cspcciall}' in the abdomen, of removal of tbo pressuro 
supporting tho body wben, after tho rise, tbo ship falls: 
it IS like the beginning of a descent in a lift. Even 
though ch.anges in the brain occur, tending to cause 
nausea and vomiting, changes in tho abdomen, produced 
locally, it seems to me, aro much more likoh’ to bo causal 
of these viscer.al symptoms. 

-In this lespect I note with interest the postural treat- 
ments advocated by Dr. Bennett, and by Dr. Wright (Jlay 
1 , p.^ 0/7). In sGvoro cases tlio former places liis 
patient in a warm salt-water bath for half an hour or 
an liour or more. “ The relief' is gi-cat and remarkably 
prompt. . The specific gravity of’ tho water is 1020, 
and the body is supported very lightly.” Aloreover, tho 
uaei, 111 virtue of its inertia, does not respond to the 
lolling and pitching as does tho bath itself. Dr. AVright 
also advocates warmth and postural treatment. The 
pa len is go immediately to a tvavni and airy cabin 
and ho oil tho flat of the back—not the side, remember! » 
I wonder iriiy the p.atient must lie on the back and not on 
-iff affect lab3'rinthine changes, or does it 

affect the pressure in the abdomen? It certainly influences 
atter, as observations of tho pressure in the rectum 
■ nc in the stomacli show that the pressure within tho 
when lying at ease on tho back than 

stomach, tins bolds when th e pressuro on the back is 
' Lancet, 1927, il, 81L 


060 June 2, 1928] 


COKBESPOKDENCE. 


r Tit HitiriTn 
L ^trincAi. JortivAt. 


and cricoid cartilages respectively, was tauglit to stiulonts 
of medicine in Italy’ and elsewhere centuries l)cfore Home. 
It was Killian solely’ who taught us the sphincterie function 
of the muscle and tho part it jihiys in pouches and in 
functional and other conditions. — I am, etc., 

London, W., May 24tll. ILLT.\^r IJlI.L. 


THEOMBO-PHLEBITIS MIGRANS. 

Sin, — Perhaps a lack of lucidity in my iirevious Idler 
accounts for Dr. Jeudwine’s presentation (May 12tli, ]>. 824) 
of my’ statement as an argument against— whereas I had 
intended it as an argument for — ^the ])o&sihIo infective 
nature of thrombo-phlebitis migrans. IVlien 1 .said that 
most of my cases of pulmonary thrombosis (infarction) 
occurred in close chronological proximity willi cases of 
such conditions as pulmonary’ embolism after operation and 
confinement, I meant that pulmonary embolism, whether it 
appears during an attack of influenza or after injury, 
operation, or confinement, has a habit of occurring during 
the epidemics of what we call “ influenza.” The inference, 
therefore, is that influenza or infection is connected with 
the thrombosis. 

Leaving out of account such questions ns whether the 
thrombosis is due to gelation of protein pai'ticlcs, and 
whether the thrombosis is always in sHu and is never tran.s- 
ferred (embolism), we still have to find out what initiuUtj 
causes the blood changes which lead up to the thronihosis ; 
what, in other words, is the “ primary condition ” of which 
Dr. Jeudwine speaks. There is only one such definite con- 
dition that I know, and this is the presence of lieart 
disease. Thrombosis, however, in the absence of tho latter 
may occur in any type of patient— last Juno I saw pul'- 
monary thrombosis in a girl aged 8. 

Dr. Jeudwine says that thrombo-phlebitis migrans cannot 
be regarded as primarily a bacterial infection, and that the 
true explanation is arrived at by the worli of Mr. J. E. R. 
McpoUagli. But surely Mr. McDonagh stated in his 
article that it is “ in all the intoxications and infeetion.s ” 
that some of the protein particles in tho plasma 

thrombo-iihlebitis it 

IS difficult to trace the original iiifectioii, in other cases tho 
follows^* observed. A few such cases are as 

,1 A man, aged 45 , had acute tonsillitis; (he tomnciature eunn 

improve, hut’ aftfrivard^ <o 

on Euddenly; he later 150 ^ c.vnnosis came 

sequent ly became jaundiced ^ On sputa, and sub- 
man had his pulmraw thrnmw ' ‘bis 

infarction after ovarbtomv woman had a pulmonary 

sputum, and died twentydivs laU^r haemorrhagic 

(3) A man, aged 28 had acmi f •It-?- embolism. 

Sixteen days afterwards there wa^ oUtis*^ "r Pebruary 15Ui, 1926. 
there was transient “ nephritil^ blarch 10 th 

30th there was pulmonary thrombosis March 

sputa.. Later tiifre was thrombosis In one' b'ood 
anaemia. “ “uo arm and intense 

(4) A woman pregnant for seven mneiv,. 1 i 

infarction with characteristic sputa- the ilfitisf P'l‘°?oPary 
? pneumonia,” Thirteen days later T ‘ ' ,‘®bol was 

an attack of influenza associated with a vmr locaUvod " 1 '°’ ‘‘"’’‘"g 

These two cases occurred during the maxim “ ,b>s wile, 

mnuenia in 1926. ^ inaxitnum prevalence of 

(5) A. woman wlio liad influenza flurinrr «. . 

linsband had influenza at the same time) ^deveLS’a 'nni'” 
Uwombosis and expectorated some blood 'sputa o^ the Snete'S 

woman, aged 39, had a slight attack of influenza 1 . t 
I emg confined. She died suddenly and uncxpectedlv on tte 
day of an aseptic puerperium. A partial necronsv dl^i 
anlr-mnrinn clot in the iliac veins The chest i 

there can he no doubt as to the cause of b«t 

I n as 111 those days sur- 


prised to find llie pnlieiits walking (ml on the teiilb day 
after no more lliaii .svniptoinatic treatment, in wliicli tho 
xtipply of nlerti-oii.s did not figure. 

I linve iiindo no loforeneo (o Ibo renal, cerebral, and 
iiieseiiterie tbroiiibose.s wliich I always see at tbe same 
Benscm.s as I .sei> tlie pulmonary lbionibose.s. 1 refuse to 
Imlicve that (heir otxmrrciico logellier in point of timo is 
nlwar.s a coincidence, and I believe it is to be explained by 
tlic ffr(X.t of some air-borne infection upon tlio blood. — 
I am, etc., 

Aherdarc, 3ioy 14t!i. Aytnnosr. M'. OwKX, M.D.Tiond. 


THE " CURE ” OF TUBERCULO.SIS. 

Silt, — Dr. Carswell iiinls tli.at 0.000000001 nig. H.T.S. is 
so absuidly KUiall a do.ve tlinl it could not be cfloetive. 
AVill ho give it and the .subsequent doses a trial P 

The do.se of ail antigen, as in tbe case of any other 
drug, depends on its potency, 0,000000001 mg. H.T.S; 
corrc.sponds to 0.0001 c.mui. -A.T. ; tlie equivalent dose of 
a potent strcplocoecal antigen is one million, approximately 
0.0003 mg. 

If Dr. Gunter adds to his good work by using autogenous 
catarrh antigens be will find that be will have to modify 
his third and fifth conclusions. 

I was most interested in Profc.ssor Greenwood’s paper. 
About twenty years ago Karl Pe.arson investigated the 
statistics of tuberculosis and pointed out that the fall was 
not as .signifieant ps it appeared to be, since the fall in the 
tuberculosis deatli rate was not .so great as that in the 
general doatli rate — in fact, the tuberculosis death rato 
was tending to rise in its relation to tlio general death 
rate. Is this Ibo case now? Some time or other an 
administrative area will be banded over for the practice 
of immunization methods of tuberculosis treatment. Thera 
will be an inevitable fall in the case incidence and 
mortnlitv. I should very mucli like to know from Dr. 
Greenwood what the proper method of correction of the 
.•ibsolute figures should be so ns not to give a false 
appearnnee of success. — am, etc., 

University Coll.-ee, Dublin. May 21«t. - CllOFTOX. 


INJFX'TIOX TREATJIENT OF VARICOSE VEINS. 

.gin, From this distance it is im])0S3ible to reply at once 

to ail tbe correspondence i-cgarding tbe injection trentiiieiit 
of varicose veins, but tlie three letters from Dr. Doiitliwaito, 
Dr. Ronald Tbovnliill, and Mr. E. \V. Dewey (JIarcli 24tli, 
p. 522) can be aiisiverccl'ns one. 

In the fir.st place I would say that tbe expense of the 
ollivl compoiiiids of arsenic is here not excessive, and even 
if it were tiie ]>ntionts would have no objection to tbe cost 
if tlicv cured varices. In my experience there is no danger 
in tiieiv use if the ordinai-y precautions are taken. 

The chief tlicnio of all the letters is to rebut my state- 
ment tliat varices of veins are of syphilitic origin. In any 
book on pathology it is stated that the diseases of veins 
are the same as tliose of arteries. Now only Dr. Thoiiiliill 
makes out any case as to some other cause for vnrieoso 
veins. He tabulates the causes ns prcssiue — iiniiich’, 
lirewiiancy, standing, . constriction of the limb (due to a 
tourniquet, I pvcsuuie), or simRar conditions. Surely’ Dr. 
Thornhill is not serious in suggesting that tbe pressure of 
pregnancy or constriction or standing is the, cause of 
varicose veins. They may be the determining factor, but 
never the cause in a healthy subject. Should the varices 
persist after the “ cause ” lias been removed, then certainly 
there must have been a predisposing cause, otbenvisc the 
tiicidcnce of varicose veins during pregnancy’ would bo 
appalling. The copying by antbors of causes of diseasc.s 
from ono book to another without sufficient analysis is well 
known, and it is only by personal observation with an open 
mind that ono can riarrew down the true causes of a 
disease. AVould any’one venture to state tliat the cause of 
pneumonia is catching cold if the pneumococcus is not 
present? 

Mr. Dewey’s case is quite compielionsible, but an argii- 
nieiit drawn from one case cannot be set against a general 
exporienco of a large ' number of cases dealt avitli and 


June 2, ig^s] 


OBITUABY. 


[ Tnr. Dr.msH 

Ur-DtCAX. JocnyiXi 


961 


cnvod witliout a siiu^Io failiiro. Would it bo nsicrted Ibat 
1 Imvo been tiufortunalo in mooting only sypliilitics? 

My mclbod is to inject nt Ibo very lowest point o£ tUo vein 
below llio last vnriv, anil obero it is of tlio vine-brancbetl typo 
to put Eonio of tlio injection into each branch at Ibo same aiUiiiB 
at tho lowest point always. I then bandago tho Innb, ns far as 
tbo varis extends, for a. few days, when it is found to linvo 
vanished, ^^’ith tliis I givo UntcUmson’s prescription for mercury 
bv tho mouth for three months. In vancoso ulcers I inject below 
tho ulcer with a very fiiio needlo and apply fomo simplo dressing, 
keeping tho leg olevated for fourteen days, when it will have 
healed up with tho formation of a strong scar, which does not 
ajjnin break down. 

Treatment by operation or “ embolic injections,” if 
I might nso tho term, throws tbo linrdon on to tho deeper 
veins. It has always been acknowledged that tlio result 
of operation causes tho varix condilion of tbo deeper veins 
to bo c-vnggerated. By tbo cnibolio treatment there is 
' always the fear that a' portion' of clot may break away, 
■sometimes with fatal vc.sntts, aiul tliero is also tbo pain 
which follows tlio injection. — I am, etc., 

Upinglon, Soutli.tlrlca,hpril2tlh. W. Jf. BoUCIlEnoS. 


TYNDALL v. ALCOCK. 

Stn, — I rend Professor R. W. Iley Groves’s article on 
this case in tho'Hritiah Medirnl Jniirnnl of May 12tli (p. 807), 
and I certainly fully agreed with it, and have mneh'sym- 
patliy with Dr. Arnold Alcock, who seems to mo to liavo 
don'o all that any of us have been taught to do in tlio sort 
of elbow iiijni'y described so graphically by Professor Hey 
Groves. Mr. P. B. Both now enters tho field (May 26th, 
p. 021), and, ns so often happens in onr profession, goes 
exactly counter to Professor Dey Grove.s, and I think witliout 
reason, beenuso Dr. Alcock never stated that ho treated 
liis case with acute flexion of the elbow-joint and tight 
bandages, etc, 

Isobacmio coiitmction is certainly a voi'j' rare accident and 
requires to ho carefully guarded against, of course ; but tho 
actual point at i.s.siio in Dr. Alcock’s ease is, Did ho, or 
■did ho not; oxorciso every rcasonniilc care in the treatment 
of tlio case for which bo was brought into court and mulcted 
in such heavy damages? I maintain, ns a hospital surgeon 
of very extensive experience, that be did nil that any of us 
were ever taught to do in a ease of the sort, that tlio 
verdict against him has boon most unjust, and that as a 
profession wo should .do all that can ho dono to see that 
ho receives fair pl.ay.— I am, etc., 

EnWAnn Tnosrr.sox, F.B.C.S.I., 

Mealb, May 2StIi. ■ Surgeon, Tyrone County Hospital. 


JIEDICAL FBEEDOJf. 

SiEj — Hemarks made at a recent inquest by a coroner 
about a doctor who was supposed to have refused to attend 
a dying man seem to call for sonio eomniont. According 
to tho Observer of May 6tli; 

, ‘ Be. Edwiu Smith, tho coroner, in returning a verdict of 
aeatli from natural causes,’ said : * / am not at all sure that 
ir ^^dtcal Couticil shotild not take up a case of this 

kind. A doctor is not, ’U 'is^truc, under n legal obligation to go 
to a person not already in bis cliargc, no matter bow urgent, but 
mere IS the strongest possible moral obligation when a case is ono 
of urgency.’ ” (The italics are mine.) 

Coroners, under the shelter of their court, frequently 
give voice to sweeping recommendations on matters funda- 
mentally affecting the State or somo of its members, and 
to some extent get the support of the uneducated p.art of 
public opinion. Dr. Smith in this caso admits that the 
doctor s action, if it was as ho was told, was neither 
criminal nor tortious, yet by laying stress on moral obliga- 
tion he suggests that possibly tlio General Medical Council 
might interest itself in this matter, and thus put tho 
doctor under the peril of losing his status as a registered 
medical practitioner. Although generally no other citizen 
'Iti practise his profession or occupation, and 

although at common law tho doctor ne^d not, yet Dr. 
omitli seeks to limit the freedom of the latter by calling 
into operation tho body ■U'liich governs the conduct of tho 
profession, and thus undemine the principle and wisdom 
or the common law. 

^°atoi;s are notoriously charitable, and there are 
lery few who ■would not fulfil, without fear of punishment. 


tho moral obligation suggested by Dr. Smith — so few, 
indeed, that limitation of their freedom to sell their labour 
like anyone else would, to that extent, place tho remainder 
in a position of quasnslavcry, contrai'y to the spirit of 
freedom natural to, and so wisely used by, tho average 
Englishman. — I am, etc., 

tVavlingbam, Surrey, May lOtli. W* S. tRusSELI, TnOM.VS. 


Oliiinanr. 

HIDEYO NOGUCHI, M.D. 

In tlio death of Hideyo Noguchi at tho early ago of 52 
medical science has lost ono of its most famous research 
.workers. His was a narno known to medical men throughout 
tho world, and justly so ; for his elaboration of the methods 
of culture of spirochaotes, particularly those of .syphilis, and 
relapsing fever, opened up to investigation fields which had 
not hitherto been explored. 

■ Born in Japan in 1876 Noguchi was educated at Tol^o 
University, and at tho early age of 25 proceeded to America 
to take up tho post of assistant lecturer in pathology at 
Philadelphia. 'Two years later he. was appointed research 
assistant to tho Carnegio Institute, and later joined the 
staff of tho Kockefcller Institute. Thero ho acquired for 
himself an international reputation and brought lustre 
on this great centre of medical research. 

Noguchi’s early work on tho blood, agglutinins, opsonins, 
haemolysins, snake venoms, and kindred, subjects led him 
to a study of tho serological diagnosis of syphilis, a line 
of research which culminated over sixteen years ago in his 
successful culture of Treponema pallidum, which spiro- 
chacto ho shortly afterwards demonstrated to he present 
in tho brain in general paralysis and in the spinal cord 
in tabes. These observations proved conclusively the 
syphilitic origin of theso diseases. The methods of culture 
were oxtondoif to all known pathogenic forms, in addition 
to others wliich are merely saprophytic, like those in tho 
mouth. Ho paid particular attention to the spirocliaete ojf 
Weil’s disease, many human and rat strains of which he 
investigated. For this typo of spirochaeto ho introduced 
tho name Leptospira, now in general use. In the midst 
of this work time was found for a study of the virus of 
vaccinia, it .being shown that a bacterium-free virus could 
ho cultivated in the testis of tho rabbit. 

Noguchi’s acquaintance with tho experiment.al side of 
leptospiral infections led him to Guayaquil in 1918 to 
study yellow fever, which had long been suspected to ho a 
spirochaetal disease allied to infectious jaundice. There, 
at tho end of 1918, and later in Mexico, Peru, and Brazil, 
bo cultivated from tho blood of supposed yellow fever cases 
a leptqspira morphologically identical with that of M’^eil’s 
disease. A long series of careful serological and animal 
inocul.ation experiments convinced him that tho organism 
differed from Leptospira icferohacmorrhagiac of infectious 
jaundice, and regarding it as tho long-sought-for etiological 
factor in yellow , fover . ho gave it the . name Leptospira 
ictCToides. Ho even believed that he had transmitted it 
from guinea-pig to guinea-pig by means of tho mosquito 
vector of yellow fever. A vaccine was prepared from 
cultures and an antiserum in horses, and reports sub- 
mitted appeared to indicate that these were protective 
and curative in outbreaks of tho disease. Doubts, how- 
ever, began to creep in. Other workers could not confirm, 
tho serological findings, and in West Africa particularly 
British workers failed to discover tho leptospira. Finally, 
the West African Yellow Fever Commission of tho Rocke- 
feller Foundation, oh which Adrian Stokes sacrificed his 
life, announced the susceptibility of the Asiatic monkey 
and the ahsenco of leptospira from human cases and that 
experimentally produced in monkeys. 'Though fully occu- 
pied with investigations on Oroya fever and verruga 
peruviana, and his recently isolated bacillus from cases of 
Mexican trachoma, which was giving experimental promise 
in monkeys, and though a relatively sick man, Noguchi 
proceeded to Accra in November, 1927, to study the African 
yellow fever on the spot. It was in the midst of this 
investigation, which ho was cari'ying out with his 
. accustomed thoroughness and care, that he was stricken- 


''.'OBITnAEY. 


S 62 June 2, ’1928] 




v.itU the disease, and died. Had ho lived lio would Imvo 
been the first to aimounco the results of his labours and 
to aeknowledgo any eriors of judgement lio may luivo 
made. With his unrivalled technical ability ho could not 
have failed to add to our knouledgo of, yclloiv fever, even 
if ho had had to withdraw from tho position taken up by 
him after his researche.s in South and Central Ameriea. 

Though at the present time the yellow fever rcsearehc.s 
appear most prominent, and undue importance is liahlc to 
be attached to the presence or ahsenco of a lejitosjiira in 
the disease — a disease which has been jiractieully wi])ed 
out from the New World as a result of data obtained 
before Noguchi even commenced its study — it ihiisl not ho 
forgotten tliat in many othc”- directions this indefatigable 
investigator made valuahle additions to .scienliric know- 
ledge. He studied the .serological and cidtural velation- 
ships of the various leishmniiia and allied insect flagellates, 
and was the first to differentiate these clearly by .serological 
reactions. Working with Ohira. he even found time to 
attempt with success the culture of the oral Trichomnjws 
of man. In 1923 he w.as investigating the serological and 
immunological reactions in Bncky Moiintain spotted fever, 
and from the transmitting tick of this disease cultivated a 
I'ickettsia-liko organism. In a series of more rec-eiit jjapors 
he described the cultivation of tho virus of Orova fever, 
and ]novcd by monkey experiment that tho causative 
organism, Tiartonclla haclllijormis, was common to this 
disease and verruga peruviana, thus cstahlishiiig, if the 
ohseiwations avo confirmed, the identity of the two diseases 
— a fact which has been tho subject of considerable con- 
tiovcrsy. He was .also snccessful in transmitting tbo 

infection bv means of the tick Vermneentor (iii(lrr.tr»ii 

an ohspixatiou which may throw light on tho etiology of 
the di.seaso in South America. Noguchi’.s latest researches 
had to do with trachoma, and only n brief reference to 
them lias yet appeared. In the midst of his work at tho 
Eockelollcr Institute — work in which his time was more 
than fully occupied — came tho results of tho Yellow Fever 
Commission in West Africa. All other work was put aside, 
and he sc-i out upon wliat has proved to he his last journov 
of investigation. 

Noguchi was a pioneer, and his output on original linos 
was enonnons; and though, like his conclusions retfarding 
the organism of yellow fever and those on rabies and polio- 
myelitis, some of his deductions may requiro (lualifiealion. 
Ins influence on scientific thought during tho past quarter 
of a century has been all to tho good, and has heon the 
^roet means of stimul.ating research in manv directions. 
Had he lived there is no knowing what important additions 
lie might have made to .scientific knowledge. His death 
appears to be peculiarly tragic, for in what must have 
been a futile attempt to discover Icptospira in West African 
yellow fever meilical science has been deprived of .a mhid 
l’i>Hicularly adapted and equipped for dcaliim 
111 th iiiaiiY of the problems confronting it to-dav. “ 


A. C. E. HAERlvS, M.B., F.It.C.S., 

Bivkciihcad. 

Wc regret to record the death, on Hay 18th, of Dr. Alfred 
Charles Mward Hams, at. the ago of 77 Br w *• 
recoived his medical education in EdinlmrMi Vi 
graduated H.B. in 1872 and ohtaiued the L B 
years later he became F.R.C.S. ' 

Ho went to Birkenhead some fiftv years o..,i 
built up one of the largest practices m'tho tonm ‘ hI Imrt 
various appointments, including those of honorary consnlt 
mg medical officer of the Wirral Children’s Hospital omi 
houor.arv consulting physician to the Borough Hospital H 
was for some time a meinher of the town council and 
been a nmgistr.sto since 1894. At one time he was’presideni 
of ihc Royal Hedical Society of Edinburgh and n 
surgeon of tho old Royal Naval Volunteer Rcscn'c. At tlir 
outbreak .of war be rejoined his unit and assisted ui tin 
examination of recruits. Ho .ahvays took a veiw activ 
interest in tho work of the British jiedical Association anc 

?:^ncil='l8^,- Bra^J 

Vice-president in ^ j f , he was 

I -menr in I 893 , and president in 1905. Dr. Harri: 


was ahso ehnirmaii of the Birhenhead Division in 1904, a 
vcpresoiitiitive in tho lIcpn“-entativo Body in ,1913, and 
deputy repiescutativc from 1918 to 1920. 

Wo are imlohted to Sir J.iJins Bnin for tho following 
appreciation : 

By tho death of Dr. A. 0. K. Harris of Birkenhead 
the iiicdicnl profc.s.sioii has lo.st a worthy niomher and 
1 have had f.ovorcd a warm and nnhroken friendship of 
over Imlf n century. He was n man of sterling mcrihs, 
iiieajiahle of any mean net, and was always highly rc.spectcd 
and esteemed by his profc.'.sioua! Inotliren. Dr. Harris 
retired from practice just heforo tho war 011 acrounl of 
failing health. AVhen, in October, 1925, I bad the plcastiro 
of moving tho eoiignitulatoiw address to liim on the iittaiii- 
ment of his jubilee of memhorship of tho Liverpool hlodic.il 
Institution, his stale, of health did not permit him to ho 
present, but the warmth of tho reception of my motion 
was most oiithusiastic, and he much appreciated the eou- 
gralulntiou.s of his fellow members. He was always a keen 
controversialist, an able deh.itor, and as an after-dinner 
•speaker he had few rivals. He took eoiisiderahle interest 
ill local ]ioliUcs, and for some time was a memhef of the 
Birkenhead • Corporation ; at one time he was an ardent 
Liberal, Imt with him tlu' wi'lfaro of the State was of 
inoro importance than that of party. As a Justice of the 
Peace ho devoted much time to the work of tho hench, 
especially after he retired from practice, and this work he 
continued almost to the cud. He had very few hobbies 
outside his professional work, and unfortunately hard and 
liersisteiit work was tho main cause of his breakdown in 
licalth. Ho rarely committed his thoughts to writing, Imfc 
ho was an omnivorous reader of all classes of litoraturo, 
had a well-stocked library, and kept him.self well abrca.sfc 
of all advances in incdicine. Of all tho practitioners 1 have 
mot in consultation ho was tho one I liked host. You 
could alway.s feel that he liad the confidcuco of his patients, 
and tlint the consultation was not forced on him, hut that 
iio w.as tho prime mover, and in tho selection of tho con- 
.snltaiit ho had only tho welfnro of the patient at heart. 
Dr. Harris was very happily married, and during his long 
Iieriod of impaired health ho owed much to ihc assiduous 
care of a devoted and beloved wife. He leaves a widow, 
a son, and three gvaudchildrou to momn their loss. ’ 


Dr. AVn.i-i.m SNOur.n.tss, who died in Glasgow on .Vpril 
23rd in his soventy-socond year, was horn of Scottish 
parents in tho United States. of America, but soon after- 
wards was brought to the Rciifrewsliiro town of Paisley, 
where ho received his early education at the John Neilsou 
Institution; proceeding tiioncc to tho University of Glasgow. 
Ho graduated M..\. in 1878, and hecaine a sehoolmastcr for 
a bnef period. Subsequently ho resumed his studies at the 
University .and entered upon his medical career, graduating 
M.B., C.M., with honours, in 1886. In 1900 ho was 
admitted to tho Fellowship of tho Royal Faculty of Phy- 
sicians and Surgeons of Glasgow. After spending some 
time in physiological study at Berlin ho was, in 1887, 
appointed Muirhead dombiistr.ator in physiology- at Glasgow 
University, and in this department he worked for ten years 
in close association witli Professor HcKendrick in a pavtner- 
ship xvhich resulted in several important publications; and 
ho was for somo years an examiner in physiology for the 
Royal Faculty of Physicians and Surgeons. Histological 
preparations made a special appeal to his orderly iiiind, 
and his thoroughness ns a teacher was widely appreciated. 
Dr. Snodgrass ultimately g.avo up this work to devote 
himself to his growing practice, which had developed 
rapidly. During his later years he took a prominent part 
in professional affairs. He was a member of tbe Royal 
Medico-Chirurgical .Society of Glasgow and of the British 
Hedical Association, in which ho served as a inemhev of 
Council for foiir years, from 1919 to 1922; he was also 
at ono time an active member of the_ Scottish Committee 
of the As.sociation, and had been chairman of the Glasgow 
North-AA cstern Division. Among his colleagues he enjoyed 
an affectionate popularity, and his death has caused 
general regret. Ho is survived by his widow and two sons, 
one being a practitioner in Glasgow. 




934 Jdne 2, 1925 ] 


MJJDICAt, NOTES IN PARLIAMENT, 


f Tnrr-BiriT* 
tSIrniCif. Jonixii 


of departmental regulations insfead. The profe'?‘>ion felt Hiai ji 
j^laiutovY provision was of much more value fo it. Tlio hill j 
.would enable a future Minister of Health to make regulations 
enabling the co-operative societies to start a clinic for oyes, cars, 
no .50 or throat, and then to appoint their own docfoi's. Tho | 
medical profession was anxioxis that the nalional 'hcaUh insurance 
scheme should he a success, and recognized that that could only • 
he secured I\y co-operation between the appi'ovcd Bociclics, tliC 
profession, an'?, tho State. _ , ' 

Dr. Drummonu Siiiels said tho bill did not go far enouglu If 
tho Royal Commission suggested a method by which speeiali*>t 
services could be carried out, why did not the Minister of Ifcullh 
.seek to carry it out? The Minislor had been guilty of lack^ 01 
courage in not tackling this qiicsUon. So long as these services 
wfcro nol provided tlio national licalth insuraneo .service gave Iho 
mass of the population an incomplete and itiadoqualc tnedical 
service. In committee tho medical members had tried to assure 
that the wives of approved poi’sons should have, iu courmcment,* 
adequate inidwifcrv service. At present maternity money payment ' 
was, quite naturally, often used for other purposes, ahd confine-, 
ments took place without medical or midwifery aUendnneo. Tlic 
Ministi-y of Health had in hand .sclicmcs dealing with this mailer, 
which the medical members had not pressed on the report Mago 
of the bill because they understood some elTort was being made l^y 
tho standing joint committee to achieve progress in this dircclioii. 
Tho problem of mafernal niortality was complicated and diflicult, 
hut evoryono agreed that one thing to bo done was to provide 
adequate midwifery attendance at the time of confinement. Dr. 
Shiels comrnented on tlio fact that dental benefit was not provided 
until an insured person had been a membev of an approved 
society for five years. By the school dental service a child could 
got dental treatment up to the age of 14, but then from 14 to 16 
ai?d up to 21 there u'erc seven years without an clTeclive dental 
service. Dental service should be given early. Ho had made 
representations to tho Minister, and ihey were being favourably 
considered. Could the Minister say whether anything had been 
decided on which would make it possible for vouug people to. 
obtain attention for their teeth immediately after they became 
iusuied persons? The bill showed a tendency to concentrate loo 
much on the financial side of the^ scheme and on money benefits 
rather than on providing an efficient and compiehensivc medical 
schcnio for Uie insured person. 

Dr. Fremantle said that medical mcnibor.s of Parliament looked 
at insurance bills not in relation to tlic pockets of tlic medical 
profession, but to the health of tl\c coiumuiiilv. In preventing 
disease and reducing sickness the bill of 1911 'had not been so 
successful «Ts was hoped. Tlicy had to remomhor tliat tho insur* 
bill was watertight, so far as finance was concerned, 

Hie House liad to do was to rearrange the distiibuUon of the 
tuna._ Members would find that tlic first seven of the new 
addiuonnl benefits weve cash benefits. All tlwougU the cash 
benefit loomed larger than the benefits in kind. (Labour members : 
vvny not.^) The original insurance scheme was a balance between 
financial relief in tune of distress and technical treatment for*tbo 
cure, and sUU more for prevention, of the -cause.s 'of Ibai dislreis.' 
i-hey were glad the Minister had appointed a committee on 
maternal mortality, but statutory benefit for matornKy, wlijclr 
was originally 30s. and no professional attendance, liad been, 
increased to an average of 4os. and still uo Iroatmout* It was 
not true that the people who received this mon’ey got the best 
treatment which could be provided. The Government in com- 
nuttee had opposed the, proposal that additional medical benefit 
^lould be given in nrpfessional attendance by midwife or doctor. 
Those Yfho looked after .the health of the community hoped (hat 
P'^‘>f®ssional and pi-opcr uso of the 
l^unds of the insurance scheme. In that hope tliey nclcomed tho, 

^^‘^’o^rdS^ '.o 

treatment. Sctiemes-in' existencS^idch wo^fpi ’ r®***?®' 

this biU-co-ovdinaled .maVer^ty; Sal "S?®? 

treatment. The Medical Sid’ Society had ^ 

hear . upon the Ministry hf - Saltli and 

medical services was no\/beuiB remmirt'-^ 

Tho hill was then read -a IhiKd time, ■"?" removed. , 

In, a reply, .to Mr. Ehys Davies; oi\ ijav 23va tt ' ' i . j 

that m 1927 the amounts of the Slate m-anl on slated 

hciiefits paid hy approved sdcictie.s in Enjdand^ and 

I?03pitafs £3^7M'’'coni 


valcseent homo treatment, £15,950- surirical .anni:-.n„ ’ An SS?' 

want or distress, £1,610 ; nursing, ’ £73o! provi5?nA S’ 

lioiiies, £720; repayment of contributions, *£220 

£559,300, against £226,620 in 1926 and £169,020 in 1925 

grant for dental benefit in 1925 was £97,150, and in l^Vownon® 

lor opldlialmic benefit, £12,860 in 1925 and £25 250 iiiiqZK a 

for hospitals £48,760 in 1925 and £37,090 in 1926. 


Tuli-rcutou's Patirntx in ,'imaIl-j>or HoxpiiaU. ' 

Mr. CiuMBEnnAU.- told Dr. Vernon Davies, on May 24(h - 

twenty-one small-pos. hospitals had been used during Die r,i"i 
tln-cc years for the treatment of tuhorculosls; in one case for .P 
Mimmer montlis only. Tnbcrculons patients liad been remove 
from these to provide accommodation for ' smaI!-poi ca-scs It 

dj-l 

tin- ^'-wVidomVaUonif hld Yo"^ 


Miiialorititn ncconunndatioii rouhl bo providcil for them, Mr. 
fI|iAMf»p.iii.\!N Miul .-oriio (lisadvautnge attaclH'd to the ii^e of ^mall* 
|> 0 -v lio-spilaK for t uberciilou.^ piilicnls, hul when if was iicceit«ary 
tor th‘->o hO'‘pi<aN lo rev^ut to fhoir original 11*^0 every cfioii wa«: 
inudc (o fimf oHkt nceorninodafion for flu* disjilacrd patieni**. It 
wi»s pviiuiiuly for the local nulhoiilies to cousider whal flcpH 
■.should be taken lo avoid fiomc of tbeso paticiifs having to return 
to (heir 'own bonic's. 

Dr. Pa'^'IES a‘'ki*d whotlicr Jlr. Clmrnberlaiu Ihouglif that if 
(ho Vncoiualion Ads were more rigidly enforced he would bo able 
to ti^c fome of Ibis accommodation for r.a'.os of tubercnlo-J'* which 
were of a more J’CMonH imtuie timn eases of .srnall-pox at jno^ent. 

Mr. CnAiinfiJii.AiN .said they could not entirely Jiegh-ct th^’ pn^d- 
bjlily of llie <H*ciiirenco of' Bmalbpox u's lo lie able to di^pcn5a 
with fimalbpo.t ho^pitalv. 


/,V7//co//on 0 / Mfiitdlln Vcfirirnt ami Ddicatc (IhWU'* u.'^(}\\ 
May 24(h, answering Mr, Iloflhm, Mr. CuAMnnRLAi.v said -.Uint of 
the 12^ local aulhovitirs under t\ie Mculnl Deficiency Ae\«^ 21 Ir.nl 
made direct piovision of instilutionnl nccommodalion for jnentnlly 
deficient children. Others' bad provided for Ibe nccoimnodation 
of Kuch .children b.v contracting \vilb Ihc mnnagei"s of 'privately 
owned in«'lilnlinn.s or with Poor Law authorities. All tuberculosis 
authorities included iu their schemes provision for the institutional 
(realnient of tuberculous children. ICducation was nroviirod for 
lubcveulous chiUben who made more than a brief ;Btay in a 
frtinnlovium, and education imd training Buited to their c.a])acity 
was provided for all mentally deficient children while in. an 
mstituHon. ' AirangeincniB existed between tho Ministry of Kdiica- 
iion, the Ministry of Health, and the Board of Control Tor co- 
ordinating the pervices in respect .of mentally defective, ’ delicate, 
and tnbcicnlon.s childicn. Of local education nidhoritic.s 2.5 per 
cent, provided nui'scvy schools, 3.1 per cent, vesidcntialf/open-air 
BchooK, 12.9 per cent, day open-air schools, 2.2 per cent, re.si- 
dcntial schools for mentally defective children, and 25.6'pcr cent, 
fluj schools for mentally defective children. In addition, jn .areas 
such as Lomlon and Manchester classes attached to . public 
elementary scliooh h.ad been started more or less on opcn-uir lines 
for young or delicate children. 

Siahilhatiria 0 } HVir fVn.t/ouA Hairs. — Major Tra’on (Minister of 
Pensions) announced in the House of Commons, on May 23rd, that, 
althoiigii existing rates of war pensions were safeguarded till 1931, 
the Govevnmcul was cousulcviug the conditions. \in,dcv which 
stahil'n^alion of pvoshnt rates of ail pensions and allowances under 
Orcal IVar Wnnnnls could bo olTcclcil. Major Tryon hoped to be 
able to make n full statement before., the .end. of the parhameatary 
se.ssion, 

}<hfrn Dip.— Mr. GiMNNESE, replying to fi quo^liou on May 23rd, 
said that so far ns he was aware there were no Home Office 
regulation'* rernuding workers engaged in the manufacture of siieop 
(lip or in dipping sheep. Ho’ 1101110 ” Office i-egnlalions or inslruc. 
(ions were given to persons purchasing sheep tlip^ the sale of which 
was .governed by legulatious made by (he Pnvy Council under 
ihc Poisons and Pharmacy Acts, Mr. Guinness summarized these 
regulations, and added that the Ministry of Agriculture, under the 
Sheep’ Scab Order of 1928, required lliat all packages containing 
dips must bo labelled with a label approved by the Ministry, 
tloting (he proportion in which the dip -should bo mixed and 
mentioning i* R contained arsenic. The Ministry had widely dis- 
tributed a leaflet' advising pc’i-sons how to use sheep dips. . . ^ 


iVoffs in Brief, 

The Belhlcm Hospital Bill, which has passed the House of Lords, 
was formally road a eccond time on May 21st and ^ent to the 
Committee on Dnopposed Bills. ^ • * 1 

- Tim largest number of cx-scrvicc men, excluding those in menial 
hosniUlft in receipt of hospital treatment at any one time during 
the fli'st quavtei' of 1928 was 11,400. 

On Deccriibcr Slsf, 1927, in Kngland and .Wales, 14,260,000 
nei-sohs 'rvere 'enlilldd to" benefit' under the National Insurance 
Acts. Of these, 9,210,000 men and 4,620,000 women were env ihc 
registers of appvoyod societies. 

■ Sskcd'abbnl the danger to the cmhan population of an escape 
of phosgene or of other poisonous gases, Sir William Joynson- 
Hicks Announced that .investigations were being made into tho 

Btorage of gases iihder . .' ..r . , 

- Hino- outbreaks ' of foot-and-mouth disease pccuimd (luring 
March' ft>uv during April, and elovch during Alic "first ’ {hrec .weeks 
of May. • Of- .were attributable to_ local ’ infection 
fioni oliier outbreaks, and the source of the 'vest remains obscure. 


SXnibfrsttifs aniJ (!l0ll£i5£S. 


UNn'’ERSITr OF OXFORD. . ■ 

Sin E, FATiQUiIAn Buzzatii>, K.C.V.O., H.D., Begins Professor of 
Medicine nud Sbndent of Cbvist Chiu*cb, has been elccl,(id loan 
honorary JTeilowsbip at Magdalen College', .6/.. which ho was 
formerly a commoner. • , 


UNIVERSITT OP CAMBRIDGE. 

Dr. Alfrud Ernest Barclay, of Christas College, has been 
appointed University Dectuver in Medical Radiology and Electro- 
logy wntil October 31st, 1930. • ... . • J 

- ATRcongregation held on May 25th the following medical degrees 
were co'uferrod : 

^ ■ M.D.^k. p. Uvek^. ; ^ ' 

M.B., B.Cnru.— \Y. J. Mooay, H. A. Clegff. 



JUKE 2, ig^Sl 


MEDICAti NEW3- 


r TTTTBBtTTfn flfi/l 

I U*DICit lODB'CiX. OUW 


ONIVEUSITY OF EONDON. 

■nuiVKiisiTY CoM.v.or.. 

Tnr. cT^nmlnnlion for tl.o Hncltnill SoliolarRl.ip (IGO Rnlnens) nml 
lor two cxliU)ilions tvftlno 55 Kmiienn one u will licKiii on .Mino /fatli. 
Tho Bubiccts of tno eMinlniUion mo cliemiHtry, pliynica, lurtmiy, 
mi.l 7 noloi>v Tho Bcholm-ahip niid tho two o^llihltiotl3 iiro t. imlilc 
nt Univorsitv UolloKo. Eon.lon. Entry forniR iniiy ho ohtalncil 
Irom tho Secretary of University Collci’o, ntul must bo In liia hmids 
not later than June 9lh. 


illofotica or public hoalfh. A special section, nioeting ab 
Kcndiitg UiiivorBlty on Utonday, July Znil, will deal with 
tiairy bncteriologleal tochniqno, tho snbjert for discussion 
being I ho rolativo valnct ot dlilerenc moriiods of tosting-tho 
clcimllnesa ot inillc. Membership of tho eongreas is open 
to Government olllcial ilelcgalOH, representatives of local 
anilioritioM ami nssoolatiotia, and others interested. Par- 
ticulars may ho obtained from tho organizing secretary, 
28, llnsRoll Square, W.C.l. 


XJNIVFillSITT OF LTVERl’OOE. 

Tnr. Connell ot tho TIniveralty 1ms received with regret tho 
resignation bv Professor J. W. W. Stevens of the Sir Alfred Jones 
Obair ot Tropical Medicino, which be baa held ainco 1913. 


licbs. 


Sm lYiLLTAM Beveridge, K.C.B., Ylco-Cha-cellor of tho 
Tlnivcrslty ot Bondoti, will dlstrlhnto tho prizes at St. 
Thomas’s Hospital Medical School, in tlio Governavs' Hall, 
on Wednesday, ,Tnno 20tli, at 2.30 o’cloelc. Academic dress 
will bo worn, and there will ho toa and music on tho terrace. 

Sir Maurice GR.UO will talto the chair at an “At home” 
In connexion with tho Nnrsch’ Missionary Iicagnc on Thnra- 
day, Juno 7Ui, at 3.15 p.m., in tho Church llonso. Great 
Smith Street, Westminster, when tlio Bishop of Blackhnrii 
will giro an address. Invitation cords can ho obtaliictl from 
Miss Richardson, 135, Ebnry Street, S.W.l. 

The Section of Urology of tho Royal So-’.lrtv of Medicine 
will hold a special mooting on Juno 28ili and 29th. On ibo 
Rftemoon ot tho first day tlioro will ho operations, nt St. Peter’s 
Hospital, and nt 8.30 p.m. Profossor .liirn"Z of Poznan will 
read a paper on movable UIdnoy, to ho followed by a dis- 
enssinn. On tho second morning' special instnimotits will ho 
demonstrated, and nt 2 o’clock Ihoro will ho operations at 
St. ’Pliotnas’s Hospital. 


Tub National Institnto for llio Deaf has arranged for 
a conferenoo ot delegates from nnlvorsillcs, edneation 
nnthorilies, special scliools, and wolfnro societies for tito 
tlenf to bo held at University College, Eotidon, on JniioSth, 
at 2 p.m., with a view to placing llio higher edneat'on and 
Inrther tcclinical training ot tlio deal nnd ilnmb on a more 
clleotivo basis. TVo referred on .September 18tli, i526 (p. 36). 
to tlio organiz-ation pf tlio National Inslltntc tor tlio Deaf and 
tho facilities tlien in existence for treatment, Fnrtlier 
Information may ho obtained from tiio secretary of tito 
Institnto, 2, Bloomsbnry Streof, AV.C.I, 

The annnal pond iifo and general tnleroscopicat cyh’hitlon 
of the Royal Microscopical Society will bo bold In tbo Icc'ure 
hall Rt 20, Hanover Square, W., on Wednesday, Jnno 6tli, 
from 7.30 to 10 p.m. 


Committee of Inquiry on Lead Ethyl Petrol conferred, 
on May 25tli, with Siirge.on General Cumming, bead of the 
PnbUc Health Service of tho United States of America. 
Dr. Leake^ono or tlio senior omcers of that Fcrvico. vran niso 
present. Tho extensive researches which have been con- 
Pnbllo Health Service and others 
"ir t,^n 1 "iRctfRlning whether there was any risk 

A^r °^''yl petrol were fnlly 

of Works St -win bo hold at tho Office 

TLJath ’n^ n S.W., on Wednesday next, 

Pnne R R J’''''" evidence from Sir William 

Pope, r.P.S., Professor H, B. Baker D Re P B c; nn<l 

pnbHc,^°'^ proceeding’s will bo open to ‘the 


Is ^G^hehl^in^ Pre World’s Dairy Congress, whic 

IS to be held m Great Britain this vear. is “ to efiect a 
international exchanjie of the latest knowleclfo of the scienc 

and Kodimts of the 4o o? mil 

orthe cJ^^°re\s dietao-.’’ The headquarter 

mitteo in London actim- in as“ odS 'IJ R spcobal coni 
Dsirv Fodoronnr, T.. 1 II u RR^ocintlon with the Internationa 
fr'oni^’fni^’sXv Jnnl PfiH? Central Hall, Westrainstci 

main work nVth. rnn? ’’ Saturday, Juno 30th, when Ih 
the following MoiKlaj'^nirTacsdr® ^ 

‘“o a^rjS-T«’seof.a!^l 

S-MWI.™.. air Co;- 

Consumnlion^ section concerned wilh. mill 

on Jnne 29th at tbn control, which will mee 

PRperrare soveial nt ■ Hall, Westminster ; among th 
f tors are seveial of interest to those concerned wltl 


Dr. D. S. Davies, who retired recently after forty-two 
years’ service as medical olTlcer of health for Bristol, was on 
May 24111 prcROntfil with an eair hnrean and bookcase from the 
meiiiliers ot tho stall of tlio health department. Tlio pre* 
Rontatlon was made by Dr, B. A. 1. Peters, who expressed the 
hope that tlieir former clilof, now that ho had retired, would 
ho nhio to give tho ini'dicnl profession tho horellt of bis very 
extensive Icnowledge of cpitlrmlology. In returning thanks 
Dr. Davies referred to tlio development in public health 
orgaiilzalion wlilcli liad taken place in his service. At first 
llic only hospilals helongiiig to tho hcnitli anthoilty were two 
wooden slieils clnso fogotlier in a stono yard, one labelled 
“ revets’’ and tlio oilier “small-pox.” When they first built 
their Isolation liospitnls thero was considerable difilcnlty in 
indneing parents to allow their clil’drcn to go; thty tlionght 
experiments wore going to bo inado on tho children. Tributes 
to Dr. Davies’s work and to his personal qualities were paid 
by reprcsent.alives of his torincr collcagnes, lay and medical. 

The Clinrtcrod Society ot Massage and Medical Gymnastics 
has published a register of members, covering the period 
iroiii its Incorporation by Royal Charter In 1920 to March this 
year, and containing tlie nniiies and addresses of all massenses 
and massonrs recognized as sncli by the society. Additional 
qnalillcatinns — lor examplo, in medical gymnastics, in 
nictllcal olcctrielty, or ns teachers — are noted, and the 
po=ses<-lon of other qualifications as nurses, midwives, dls- 
pen<-crs. etc., is indicated. As a snpplcment to tho alpha- 
betical lists lliere is a geographical list, giving the names of 
mt moers under the postal district or place in which they 
reside. Tho register Is puhllshod by the society nt 157, Great 
Portland Street, W.l, price 4s. 

The report of the school of mediolne of Shantnng Christian 
University for tho year rnding Jnne 30th, 19z7, contains 
a short aeconiit of tlio iTogrcss of medical edneation until the. 
end ot March in that year, when it became necessary for' all 
British and American subjects to leave. Tho school of 
medicine was closed 9iy the anlhorilies, hut Iho hospital was 
carried on imilcr Chinese management. Plans were well 
advanced for bnilding a new hospital, but it is thought 
milikely at present I hat the necessary money will be obtained. 
Emphasis Is laid in the report on the importance of inclntllng 
more Chinese medical nractilioners on the staff. Tho medical 
school was reopened in Feptember, 1927. with twenty new 
adinivsloiiH, as well as Iho majority of the old students, so 
that the work ot training tho Chinese in Western medical 
science is bring continued. 

A rosT-.GR.\DUATE coiirsc in malavlology will he held in • 
Rome fmiii Jnlv to September, which will include exenrsions 
to malarial districts. Fmih'-r information may be obtained 
from tho secret ary ot the Scuola, It. Clinica Medica, Policlinlco 
Umberto I, Rome. 

The Tn'crnational Congress of Oto-rhino-laryngology will 
bo held at Copenhagen, under Iho presidency ot ProfessoC 
Schniiegclow, from July 20th to August Ist, when the 
following questions will be disoussed: radical, partial, or 
palliative operations in snppnralivo otitis media, introduced 
by Neumann of Vienna and Tapia ot Madrid ; septicaemias 
of pharyngeal origin, introduced by Perrerl ot Rome and 
Ollenorde ot Marburg ; diathermo-chirurgical treatment ot 
mali.gnant growth, introduced by G. Holmgren ot Stockholnl 
and Dan Mackenzie of Louden ; anatomy ot the ear and its 
inflnenco on aural suppuration, introdneed by J. Monret of 
Montpellier, Portmann ot Bordeaux, and Wittmack ot Ham- 
burg. Further information enn be oht.a’ncd from the general 
secretary', Dr. Miejevillo, Place Vintimille 11, Paris, 9». 

During tho first twelve weeks ot 1928 more cases of 
meningococens meningitis were reported in the 'United 
States th.an Avere recorded dnring the corresponding periods 
of 192S and 1927, tho figures being 1,179, 562, and 698 respec- 
tively. Tho highest prevalence is reported for the Mountain 
States and tho lowest for tho South Atlantic States. 


As we go to press we learn with deep regret of the death 
from yellow fever ot Dr. William Alexander Tonng, director 
of tho Medical Research Institute of tho Gold Coast where 
Professor Noguchi was working at the time of his death. It 
is believed that Dr. Tonng contracted the disease in' the 
conrso of a necropsy upon Professor Nognclii. We hope to 
publish an obituary notice in an early issue. 



986 June 2, 1928] 


liETTERS, NOTES, AND ANSWERS. 


r 7iir. IJnrnn 
IfrntcjLi, Jovft5U> 


WetUvs, Jlotis, ait& ^nsium. 


can also claim to Jmvo tho personal and Bimilai* allowances 
Joi* 1928-29 t»mnled from liia other Incomo—by repaymeut, if 
iiccessaiy. 


All communications in regard to editorial business ehould bo 
addressed to The EDfTOR, British lYlcdtcat dournalf British 
A7ecf/ca/ /issoefat/.n House, Tavistock Scfuarxif W,C,1» 


OllIGINAL ATITICLES and LETTERS forwarded /or publication 
are understood to be offered to tlio British Medical Journal 
alone unless tlio contrary bo stated. Cori-cspondcnts who wish 
notice to be taken of their communications should authcnticato 
them with their names, not necessarily for publication. 

Authors desiring REPRINTS of tlicir articles published in the 
Beitish Medical Journal must communicate with the Financial 
Secretary and Business Manager, British ^Icdical Association 
House. Tavistock Square, W.C.l, on receipt of proofs. 

All communications with reference to ADVERTISEMENTS, as well 
as orders for copies of the Journal, should be addressed to tho 
hlnanclal Secretary and Business Manager. 

TIio TELEPHONE NUMBERS of the Brifish Medical Associalion 
and the British Medical Journal are MUSEUM OSGI, OSCZ^ VSCS, 
and OSGIf (internal exchange, four lines). 


Tho TELEGRAPHIC ADDRESSES fLTQ '. 

EDITOR of tho British Medical Journal, Aitiohay ]Tcgtcent 
London. * 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, etc.). Articulate Wc.ttcnit Loudon 
MEDICAL SECRETARY, Mcdisccra JVcstccnt, London. 

The address of the Irish Office of the British Medical As^^ocinlion 
is 16, South Frederick Street, Dublin (telegrams • TtacUlufi 
Dublin-, telephone: 62550 Dublin), and of the Scottish Offiec* 
6 Dramsheugh Gardens (tolcgiams : Aisociatc, 

Edinburgh-, telephone 24361 Edinburgh). 


QUERIES AND ANSWERS, 


■ MlGtUtNR. 

“ M.E.C.B.," who sntters sewrely from migraine, would bo elnd 
to hear from any fellow-snfterer wiietlior luminal is of use ns n 
prophylactic, and, it so, whether sodium bromide should ho taiccu 
at the same time. mni-u 


ClOAUETTES AND SUCKLING. 

“ A. E. S." nalis it excessive cigarette smokiiig on tlio iiart of n 
miralng iiiotlier would he injurious to a six-weeks-old iiifaiit 
and be likely to cause vomiting and general ill liealtli. “"““t 

Ultra-violet Rats for Acne. 

Dr. T. M. Guthrie (Rock Ferry, Cliesliire) aslts wliai form rj 
Tiltra-violet ray treatineiit is the best for oiiroiiio iiidurnled^ 
or back and slioiilders. Is n conrao of exZiwos it 
ouoaml ahalt to two minutes to ttie vaysofa miroiiry ™ i 
lampsuflioieiit, or issometlimg move stimulating iieeS suilf 
t^e^Kromayer lamp actually pressed on the skin ^r 

Angostcua Bitters. 

“wt^s', ani'wli'at’, "'?eo=t-n-a 

^ What are it-a pliysiofogiial or pathologicfa7ffe?tr^‘‘ 
there Riij Itiiowu authentic cases of i)oiaoiiin<f nhmv * * ^ Aie 

ocontTing as a direct resnlt of the o'l'rn^gS^ 

hark! also Vauiri clpar™ 
done on cusparia in times past and 1 , 11 , 0 ^' 
been found in it.but Aveare not a’wareot anyivlLu 
that the bark can be regarded as in any wiv 

formerly thoiiglitto have febrifuge and a/tinZ-Lni '''®® 

hnt its virtues are, in nil probability merely thn. ^ i t’^operties, 
bitter tonic. We have been nuabiettVai^r: 
of poisoning, acute or chronic, as the result '’t « case 

bark in any form. Two recipes for ango^L°'i,S"™*"8 the 
m Fharmaceuticnl Formulas, issued from tho office of 
nnd Druggist. Each contains aiigostura hark and r!.. 1 , 
principal ingredients, with cardamom seeds i, ®®®®! as the 
orange peel ns Uavonriiigs. The second formlila 
cinchona bark and gentian root. ^“oindes also 

Incosie Tax. 

Bcneical of Gar. 


‘A.C.R."B 0 ia hiscarinJnly, 1927,aiid'is being .allowed TKao 
hat amount wipes out liis Schedule D incS 
line, aiirl tli«>forrn.« i.,. ^ 


obsolescence; that amount ,,,03 om ,,,0 aciiecinio la • 
not bis entire taxable income, and ttiereforp i.e income 
bciientfrom the children’s and life nssiimnce allow 
bedspread tlie deduction over, say, tlie next two vears 

Tear - - 

expense ’r«d' dekirt'"tbat''nmouirfrom 

amount from the income of 1928, an 


Claim la Three Years' Average. 

“ J. BI.” commenced luactico on Sciitombur 39tli, 1924, Iiaving 
tcrmiunled fiis nssistanlsliip two moiitfis earlier. Ho was 
nsscssed for 1925-26 on tlie anioiiiit of fiis oariiiiigs for lliat year 
— presumably ns iiaving ciiniiiieiicod a new practice. Can lie 
claim to bo nsscssed on tlio basis of tlio tliroo rears’ average for 
1927-28 ? 

*,• Tlio average can bo cinimod tinder certain conditions liy 
** any person Aviio for liie year 1926-27 was assessed nnd cliargcd 
tinder Scliediilo D . . . niioii nil ivA’criigo of a period of llirco 
years or more. . . .” (Eiiiniico Act, 1926, Kcctioii 29 |3).) If, ns 
Avo iiiidorslniid, ” if. Bf.” Avns regarded for income tax purposes 
ns Iiaving started a now iiractice, lie v.-ill Iiavo been cliargcd to 
lax for 1926-27 011 the basis of liis fir.st year’s earnings and not 
on “an aA'crago ... of three jeers.’’ In siicli circumstances 
be is not witliiii tlio relieving section quoted above. 


LETTERS, NOTES, ETC. 


Br.ONCUO-i’NEUJIONXA IN CHILDREN TREATED DV INJECTIONS 

OF Emetini:. 

Dr.-T. Douglas Ross (Glasgow) writes : In j-oiir issno of Blnv 19lli 
(p.’844) Dr. C. Robertson Wilson recorded the resnits of ’trcat- 
iiiciit of IlftJ' c,asc8 of broiicho-pucumonia with injections of 
cmctiiio bj’droolilotido. Ho notes tlint, while in some cases tlio 
fefirilo period seemed to bo slioi teiicd by emetine, in others tlio 
drug lind no apiiaroiit effect, I suggest that his successful cases 
(apart from some that might Iiavo done Avell witli no iiicdiciiic) 
Avero o.xaniplcsof the liomoeopatliic action of cinotiiic, and that 
Hio cases Avliicli did not respond needed some oilier drug, 
according to tlioir pavticuliu- sjmptoins. Fifty cliildrcn witli 
bronclio-piiotimouia differ widolj' ouo from tlio other. One iiiaj- 
slioAv anxiety, restlessness, an aftor-midiiiglit aggravation of 
symptoms, and cxcossiA-o prostration— Imliciiting iirsoiiio. In 
another, inloiiso thirst for big cold drinks would suggest phos- 
phorus; If Avitli this tliirst tliore is profuse liend sweat, verutrum 
virldc is indicated. In my cxporicuco ipecacuaulia is needed 
fairij" frequently, especialij’iit tlie coiuinoiiccmciit of pnctmioni.a 
in ctiildreu, when nausea and A’omitiiig are proniibent, tlie 
respirations arc rattling from excess of mucus, and the coiigli is 
Biiasmodic, almost siiffocativo. When this rattling is present in 
cases nearly iiiorihniid, and tho cliild seems almost- siifTocated 
with its broiicliial secretions, tartar emetic is preferable, and 
often saves a life. 

Wholesale Extraction of Teeth. 

Dr. R. N. Burton (Iiviiiobaiik, Nortli Qiiconsliiiidj n-rites: Is it 
not time tliat a lialt was called in regard to tlio iiidiseriiniualo 
extraction of teeth on iiisnnioient grounds? On a iinniber of 
occiisions 1 liave Been patients urged to Iiavo all llicir teeth 
reuiovod, tlio only local indications being a slight retrnotioii of 
tlio gums ora sliglit gingivitis. A brief discussion Avitli aiij- 
patient who lias had all liis or lior teotli oxtraolod would, 1 am 
sure convince any medical man tliat tiiere arogriiA’c niecliiiiiioal 
nnd otiier disndvaiitiiges nttaclied to tlio Avearing of dentures. 
1 am convinced tliat in niiiiiy cases Avliere the tronbio is attri- 
buted to a patient’s teeth tins is a refuge nnd not a diagnosis. 

I would suggest tliat before advising the serious step of wliolesulo 
exti-action a doctor should satisfy tiimself that tho teeth in 
question are definitely loose, or that apical sepsis is clearly 
demonstrated by x rays. If there is any doubt as to tlie cause of 
the malady (and I submit that in many cases wlieio tlie patient’s 
teeth are 'blamed tliere is grave doubt),- instead of ordering a 
wholesale extraction of teeth the patient should he gii-eu the 
benefit of that doubt and treated on general lines, and iiistruoted 
to return in, say, six mouths’ time for aiiotlior examinatiou. 

Intravenous Treatment of Varicose Ulcers. 

At tlio combined meeting of the Sections of Derinatologv and 
Surgery of tlio Royal Society of Blediciiio ou Blay 16tli, reported 
in onr last issue at p. 897, the ohair Avos talten not by Jlr. Davies- 
Colley, but by Dr. 3. BI. H. MaoHeod, President of the Section of 
Dermatology. 


Harvey Tercentenary Banquet. 

PiiOTOGKArHIA, I/i-D. (17, Cheapside, E.C.2), nsit ns to say tliat 
their fiaslilight pliotograpli of the Harvej- terceiiteiiary banquet 
in the Guildhall may bo obtained in tliree sections. No. 1 being 
the centre section. No. 2 that ou tho piresident’s left, and 
No. 3 Hiat ou his riglit. 


Vacancies. 

Notifications of offices vacant in universities, medical colleges, 
and olA-aoant resident and other appointments at hospitals, will 
be found at pages 44, 45, 48, 49, 50, and 51 of our advertisement 
columns, and advertisements as to partnerships, assistautships, 
and locuratenencies at pages 46 and 47. 

A short summary of A-acant posts notified in the advertisement 
columns appears in the Supplement at page H35. 



JDNE 9. 1925] 


MATinmAIi jrORTAriTTY FROM PTJEnPER'At SEPSIS. 


r TiTT nntTtTn 
Mr.DiCAt. JoDHyiii 


ON* 

MATEENATj mortality from 

PUERPERAL SEPSIS." 

_^\_N An’ai.ysis or Tiir, Factous of, Contaoion, .liiAUAr.Vj, 

. ' ' anu Aoto-tnkkction. 

BY 

“ ' .TAJIKS YOUNG, 'A.S.O..'jr.r>., F.n.C.S., 

PltYStCTAA', EDISBtTItGII BOYAI. lUTERNITY' AITl) SIMPSON' AIEAIORIAL 
Iiosrmi.: ASSISTANT OYN'AI'.COI-OOIST, nOYAI. INTIIIMAUY, 
EIIIN'IlUr.GII. 

It is uniicccss.Try in tlicso d-iys <o oinpli.isizo tho tr.igic im- 
port.nico to tlic comnuinity of the largo mortality aiiiongst 
A’oiiiig women which is incurred yearly throngli child- 
iiearing and childbirth. In tlicso islands tho maternal 
death rate is about 4,000 each year ; between 1911 and 1926 
iiicUisivo there were 66,421 deaths from these canscs in 
Kiigland and M'ales. Septic infection is by far tho most 
important singlo cause. AcetTrding to the ofTicinl figures 
for 1926 tho total maternal mortality for England and 
TValcs was 5.14, and the sepsis mortality 1.60, per 1,000 
live births. 

• This loss, by death, however, is in some w.ays not the 
gravest consequence of child-bearing, for we have come to 
rcaliro that, for each mother so lost, there are many more 
.whose health is in varyiiif; degrees chronically undermined 
Tiy the damage they have sustained in childbed. Infection 
.and mcchaincal damage thus acquired are amongst tho 
main causes of the ficquont chronic ill health which dates i 
from childbirth. TVe can assc.ss within accurate limits the 
loss by death, but of the incidence of persisting invalidism 
of cliild-bcnring origin wo have tio e.vact knowledge. TVo 
know with certainty, however, that many of the common 
gynaecological disorders, the uterine liaomorrhages, the 
leucorrhoeas, tho pelvic pains, tho displacomcnts, etc., and 
many general disturbances, debility, indigestion, neur- 
asthenia, rlioumatism, etc., are to be traced to the lesions 
of childbirth. It is probably not an over-statement to say 
that about 60 per cent, of hospital gynaecology is a legacy 
from vitiated child-bearing, and of this a very largo part 
falls into tho categon' of infection. 

Septic inflammation of tho genital canal during labour 
or in the puerperium may, as a useful basis for analysis, 
ho considered as falling into one or other of three clinical 
types according as it is caused by (1) contagion, (2) trauma, 

• or (3) nuto-infcctioii. 

In tho case of contagion wo are dealing with an invasion 
of the passages by a virulent septic micro-organism, which 
is introduced from without. Hero, as in other infective 
diseases — for cxamplOj scarlet fever, erysipelas, typhoid, 
or tetanus — our etiological quest is dominated by the 
consideration of the nature, virulence, and source of the 
infecting microbe. This tyjie of puerperal infection is seen 
in its simplest form when it occurs after a normal, easy 
labour, with an absence of trauma' of the maternal passages, 
and in this category are to bo classed the epidemic scourges 
of the maternity hospitals of a former day. 

Puei^cral • sepsis due to travma is, in its essential 
etiological features, entirely different from that caused 
by contagion. Here tho factor which dominates the issue 
is a laror.iting or contasing claniage of the waifs' of tlie 
birth passages, and tho source and nature of tho infective 
organisms . become a matter of comparatively secondary 
-importance. By this is'meant that.it is the trauma of the 
soft parts that determines the risk of sepsis. The infecting 
microbes which can determine tlie infection in such a ease 
arc notoriously rridospread in nature. They may be con- 
sidered as being derived exogenously or endogenously; in 
either case they m.ay conceivably consist of micro-organisms 
uhich only cause disease when settling in devitalized tissue. 

he point of clinical importance, however, is that ' these 
somewhat theoretical matters concerning tho origin of the 
microbe are o'.’ersbadowcd by tho vital issue of trauma. 

1 / clinical typo of puerperal fever is that caused 

>\ auto-iu/cc<ion . Hove the micro-organisms which set up 

• Communicalcd to tho Edinbiirsh Obstetrical Society, Jtay 9tli, MfB; 


the pelvic inflammation arc, in 'some cases, present in tlio 
genital canal before labour begins — for example, in an 
infected cervix. In other eases they roach the genital 
jiassagcs from some distant source by direct .spread or 
by implantation — for example, from the bowel — or they 
may travel by the blood stream from areas of focal infec- 
tion in teeth, tonsils, etc. Auto-infection, like contagion, 
operates in its simplest forni-wlien it supen'encs in a normal 
spontaneous birth in which tbep. lias been a minimum of 
iiitcrforenco and trauma. . . . 

Tlio essential distinction between these three .iclinical 
types' of puerperal infection is'in no w.Hy underininod by 
tho consiArntion that, in somo cases, two of flic factors. 
concerned may ho operating togotlier. Where, for example, 
trnum.a has occurred the fact • of' contagion or of auto- 
infection may constitute an import.ant contributorj' agency. 
Before wo can hope to grapple .with the rnehace of- puerperal 
fever a knowlcdgo of .tho .manner .and degree in which those 
three factors operato is ncccssarj-. Until wo' .have this 
knowlcdgo much of our effort must bo largcly.-liapliazard. 
My purpose in this paper is' to draw attention to some con- 
siderations which,' although they'claim no finality, point to 
possible avenues of approach to this intricate .problem. . 

Auto-inttctiox. . 

Tho importance attaching to . this mode of infection 
hccomos apparent when we noto that within recent years 
manj- observers have attempted hr' its'.'meahs^to explain 
infection occurring in those 'spontaneous cases wliicli have 
not boon examined at any stage of labour.' 'Further, it is 
clear that, if operating in an appreciable ratio, it would go 
far to explain tlio pcrsisting'.liigU death rate from sepsis 
despite the application of the aseptic prin'cip'Io',' 'Victor 
Bonney and others have urged its importance with con- 
siderable force a'nd plausibility, and its possible sigiiificanco 
is referred, to in tlio recently' publislietl report of the 
Committbo appointed by tho British McTlicnl Association 
(Supplement to the British Medical Journal, April 28th, 
1928, Appendix iv, p. 165). Undoubted .examples of auto- 
genous infection can bo cited — for instance, puci'iieral fever 
arising during scarlet fever, erysipelas, etc. 

A consideration of the available data, however, suggests 
that ns n factor in tho death rate autogenous invasion 
probably plays a minor part. In a subsequent part of this 
paper 1 shall refer to some facts which emerge from a 
study of tho practice of tho maternity hospitals during the 
pre-Listcrian days, and shall educe evidence that in those 
old lying-in institutions puerperal fever was a negligible 
cause of death during those periods when contagion was 
obvioitsly in abeyance. Eqnalh- suggestive evidence mav be 
found in an analysis of the records of many extensive 
maternity practices at the present day. The extern prac- 
tice of tho Edinburgh Maternity Hospital shows a consecu- 
tive series of about 5,000 spontaneous births with 2 deaths 
from sepsis; ’the extern department of the Birmingham 
General Hospital records 888 cases with an absence of sepsis 
mortality; whilst there is the record of 47,503 deliveries, 
both normal and abnormal, in. tho unselected practice of 
the East End Maternity Hospital in London with 5 deaths 
from sepsis, nr 1 in ' 9,500. Tlio practice of tho Queen 
Victoria’s Jubilee Institute midwives is likewise instructive. 
During 1927 there were 53,502 deliveries' with 6 deaths 
I from sepsis in normal spontaneous births, or 1 in 8,900 of 
I the total. If wo include' all tho deaths in this record of 
53,502 cases which can directly or indirectly be attribxited 
to sepsis, and including normal and abnormal cases, we get 
a maximum figure less than 0.5 per 1,000. To the produc- 
tion of this figure all causes have contributed. 

. The fact which seems to emerge clearly from these dat.a 
is that tho very small sepsis rate in these large and un- 
selected bodies of |Women is an argument against self- 
infection operating alone being an appreciable component 
of the sepsis death rate in the rest of tho community. It 
is especially important that our ideas on this question be 
clarified, because much of the uncertainty and confusion 
in the minds of those who are anxionsh- seeking a remedy 
for the present state of affairs springs from the difficulty 
in assessing the true significance of this factor. 

Much recent bacteriological research has been direefed 
to the elucidation of these questions, more especially in an 

r.^5181 



iiATERNAI. MOHTAIil'i’Y Flioil -PUERPERAr, SEPSIS. 


r TiiKrnfTi-n 

L SfroiCit- JoLRXix, 


■968 June 9 , 1928 ] 


iiftenipt to reliite tlio v.agiii.nl ami cervical flora witli tlic 
incidence of inierpera! sepsis. As a ro.snll of tlii.s work wo 
must non- concede a comparatively frequent occurrence of 
streptococci in the genital passages of pregnant women, 
but, although it is established that puerperal infection is 
Voromonly caused by strains of streptococci, there is no 
evidence that the streptococci frequently jircscnt in the 
genital canal can play any part in initiating this infection. 
The fact of their frequent pro.sence, combined with the 
rarity of pucrircral sepsis in the ahsence of other factors 
whicli have a determining role, such as tranina, imjilirs 
that this streptococcal flora -possesses practically negligihle 
primary virulent propcrtio.s. Another finding which hears 
diicctly on this question is that, although .severe puerperal 
infection is usually caused by a haemolytic streptococcus, 
the ty]>e present so frequently in the genital canal is of 
the non-haemolytic variety (Bigger and Fitr.Gibbon,* 
Lockhart, - Colebrook^). Recently BiirtAVli ite and Armslrong* 
record the finding of streptococci of various kinds in the 
cervix of 40 per cent, of 55 pregnant women examined. In 
one only did the strain present the characters of Htrepto- 
rocCHs injogrnes^ the common cause of puerperal fever. In 
15 of these cases, including the one harbouring S', pijotjcncs, 
(he women were followed through their puorperium, and 
in none did symptoms arise. 

IVo thus seo that the consensus of haetoriologie.-il stmlv 
is against the view that tho bacteria of the genital camil 
play any prim.arj- part in luiciqjeral sepsis. These observa- 
tions are entirely in keeping with, and at tho same tiino 
eorrohorate, tho clinical ohsorvatioii of large .sciies of 
delivei ios to which I have directed attention. Whilst along 
such lines tho inference woidd .seem to bo well ostahlisUccL 
we must, however, not entirely slmt oiir luiiuls to tho 
Ijossibility that the normally iunocuous denizens of the 
genital canal may, under certain conditions, assume palho- 
gemc properties — for example, after trauma and dovitaliz.a- 
tiou ot tissue. 

Tho data, when so marshalled, would seem to warrant 
as a reasonably safe conclusion the view that auto-infection 
as a primary factor plays a quite unimportant part in the 
death rate from sejisis, and that in our search for c.sseiitial 
['.aiises we must addre.ss ourselves to tho remaining factors 
2 f contagion and trauma. ' b 


COXTAOIOX. 

Contagion is known to play a part in puerper.-il sepsis 

infection followiim 

-I 1 ’ m ‘’‘'‘^“swnally occur in maternity homes and 
siustattonlr, however, we have to turn to the reeor.k of 
discasl wore'"nTisrtvcn'T waves of tho 

tions. Eo,. ’example ‘'Tn'tha r 

tho patients confined in the hospital about half 

The striking lesson for us is that in ti,„ n . 
puerperal fever would seem to have been s ^ 
a matter of contagioh that other fnetm 
negligible. I have been stmngly improsJd witlTn ■ 

^vhat romarkublo fact thiriutr a recont stufN- f some- 

of tlic olil Etlinburgh Maternity Hosnital ‘ 

1844, out of 3,906 women delivered in this bospiS 75 ^t*i 
from all causes. The records arc not bomolntl ' ’ 
an accurate diffcrenti.al ,-inalysis of the caiises of death f'”’ 
tins whole period, but in one of his strikiim 
puerperal fever Sir James Yoimg Simpsoii^ A?er n '® T 
data for tho period from 1823 to 185?; wlJn 
7 deaths among 2,890 women delivered- 36 out of 

r 4 '\ tani to the records we find tin? + t1 

d^tnbution of tliese deaths is instrnctive \Ve 

that oO occiirml ^ ^nseover 

V. a s7Kr,, 


of fifleeii year.s, when contagion was eliininntcd, there w.ss 
litllo or no niortalily' from iinerper.ul fever. 

The records of other hospitals exhibit (he saiiio facts. 
Thus Collins, the master of the Dublin Lying-in Hospital, 
ri'ported a .sei’ie.s of 16,654 liirtbs during the seven yeais 
dating from Noveiuher, 1826, with 88 deaths from puer- 
peral fever, all ocenrring iliiring the first three years. Ho 
say's that “ for the four remaining years of iiiy mastei-bhip 
we did not lose a single patient from this disease,”' which 
implies 8,000 or more .successive cases without a death ffom 
puerperal fever. 

Ill retrospect it c.vnnot hut impress ns as remarkahlo 
that, despite the dangers lurking within the walls of these 
older hospitals, and the consequent ivliolesale sacrifice of 
women during tho eighteenth and uineteonlh ceuturlc.s, no 
widespread attcinjit to disestablish the system is apparent. 
Kvery now and then, it is true, a warning voice is raised 
ill roputnhlo medical circles.* ITirthermore, we know that 
the women inidwives engaged in a hitter contest with the 
ineii miUwivos on this and other questions. 

The fact lhal contagion was tlie dominating cause of 
puerperal fever in those days is hronglit out also by a 
study of tlio remrds of the outdoor practice of the lins- 
pitaK. In this cimuexinu the records of the Kdinimrgli 
Maternity Hospital from 1826 onwards, wliieli I have 
recently bad an iqqiortunity of studying, • are instructive. 
At that period the indoor department was limited to 
dcslilnte cases, ami the arrangement by a-)iicli .ahnonnal 
cases were removed to hospital did not come into operation 
till well heyoiid th(> time which tlio.se records cover, The 
outdoor practice may, therefore, he taken as representing 
the average type of midwifery of the class of women. con- 
cerned. This was carried out by the stiidchts attaclicd for 
service to the liospital and by the inidwives, who, as we 
know, at tins period bad little or no scientific training. 

Between 1826 and 1857 tbere wore 15,144 successive 
deliveries with. '61 deatbs-^that is, a rate of 4 in 1 , 000 . 
The cause of death i.s' given .in 44, and in 19 it is stated 
as jiiiei-peral fever — that is, .aboiit 43 per .ec'nt. If we 
.assume tiint this figure ajiplics' througliout the series the 
•sepsis deatlis- would represent under 2 i>cr 1,000 deliveries. 

1 have shown that, in flio indoor ilcpartmeht, there were 
considerable periods without atiy mortality from sepsis, 
clearly duo to the ehniieo nhseiieo of 'coht.agion. Tlic .same 
is true of tlie outdoor ]nactice. Thus there is !t record 
of 3,288 successive births during the nine years fr'oni 1839 
{o 1847 with 110 sepsis deaths. The elimination of this 
clement brings tbc total death rate during this period 
down to 5 ill 3,288, or about 1.5 per 1,000. 

The figures I liavc just quoted, embracing ns they do 
a fairly extensive record of what may bo taken as tlie 
aver.age niidirifcry in Scotland aljoiit n liundrcd years .ago, 
naturally challenge comparison with the practice of tlio art 
at tlie present time. Before .any legitimate comparison 
is possible; however, it must be recognized tli.at the above 
figures refer to deliveries and- abortions, and do nof. inclnde 
deaths from such coinplications of jircgnancy as' Inqicr- 
emesis and ectopic gestation, which appear in tho ordinary 
maternal mortality returns of the present day, and which 
constitute about 10 per cent, of the deaths in the Rcgistini-- 
GoncraVs Report for Scotland. Tho births in Edinburgh 
during the years 1924 to 1926 numbered 24,173,' and the 
maternal death rate was 5.6 per 1,000. By deducting 
10 per cent, wc get an amended rate of 5.-1 per 1,000, 
as against the comparable r.ate of 4 per 1,000 in the ease 
of 15,144 deliveries in the outdoor practice of tho Edinburgh 
Maternit 3 - Hospital about a centurj- ago^ 

-■The limited figures just quoted support the belief that 
during tbc past hundred 3 -cars there has been no deprecia- 
tion in maternal mortalitv-, and this is in accord with the 
national .statistics. ■ For Scotland the decennial mean fin-nres 
from 1855 to 1914 are 4.9, 5.1, 5.2, 5.3, 4.6, and 5.6 per 


Maternity Hospital, pccemlior I9th, 1845, a con/ribiitor to the Mnnthhj 
Pr'lirnl Science (vol. vi, 1845, n. 269) points 'out that the 
aeSil! 1'® ’“"in'fal wa--- 1 in 25 women (MivereU, nrherca.s tlie 


prnctico of the liospital was 1 in 331. lit 
question, therefore, naturally arires whether t\ 
aitf.nr. tu • ue;ter to improve the comforts of the poor wcmeu-at Imme 
uuimg tbcii confinoment rather. than advise them fo enter the hospital. 
•beWm^fo^ of propriety, as they are so ant tc 


JOKE 9. 1928! 


WATEnKAT. MORTALITY FROM PUERPERAL SEPSIS. 


[ Tm? narrm 

Mr.PiCAi. Jotnnr&£ 


g69 


1,0C0 birtlis, nnd ilic mmn for tlio period 1915 to 1S22 is 
6.2. Liko\vi>.e tlio proportion of dentils from sepsis during 
this period lins shoivii little clinnge iiniiiolr, 1.7, 1.8, -2.0, 

2 5 1.9 1.7 1.7. 

To rcalire the significniieo of tlie.se findings ivo must 
visunliro the ninhner ill ivliicli childhirth ivns inniuigcd in 
the prc-Listcrian dnys and how this differed from onr 
modern methods. The first fact of which wo must remind 
ourselves is that onr predeecssors had no knowledge of 
aseptic or aiitiseptie proeediiri*. It is ahiindnntly clear 
that it is to this wo must httrihiite in the main the 
r.avagcs of puerperal contagion, for they examined freely 
during Inhoiir, and, in c.a.ses of retniiied placenta, they 
had no hesitation in introducing the hand into the iitcrns. 
Alidomiiinl oxpre.ssion of the placenta hy the Credo method 
did not, in point of fact, come into iise till ahont 1867. 
The other important fart regarding the jiractice of those 
days is that it was hasod firmly njion the teaching of 
Harvey, Sniellic, Hunter, Denman, nnd others, who in- 
sisted that child-hearing was a physiological prnce.ss, which 
must he left to Nature, nnd whicli was apt to he vitiated 
hy iiiterfcrciiee on the part of the necotieheiir. This was to 
bo stringently withheld until Nature’s effort had iinmistak- 
ahly failed. Instruments of any sort were the last refuge. 
Simpson, for cxnm])lo, in the Edinhnrgli Maternity Hos- 
pital, used the forceps in 1 in 472 lahours, and other 
liospitals had a similar record. In studying those old 
records and noting what to us seems almost the extremity 
of patience, with which the tedious eases were managed, 
one is tempted to wonder how far the factor of exhaustion 
arid delay may have contrihuted to the frequency of infec- 
tion. This.' however,’ docs not seem to have been a factor 
of any moment, for Collins, in discussing this very point, 
reports that in 71 out of his 88 deaths from puerperal fever 
the labour was completed within twelve hours. 

These old records have a further hearing on the subject- 
matter of our discussion, for, as we know, there ivas little 
regard paid to the danger of repented vaginal examination. 
Despite thi.s, nnd the obvious nnd common contamination 
of the genital pas.sagcs which must have then occurred, 
there was a n-gligible mortality from sepsis except where 
virulent contagion was present. This suggests that the 
microbes introduced by such contamination had little in- 
fcctivqness in the case of labour conducted with a maximum 
regard to physiological needs. 

1 he records of these pre-Listerian times would seem to 
suggest that, although contagion was. a common cause of 
death, trauma was a factor which operated eiomparativcly 
rarely, and this wo must attribute to the principles which 
then undcri.ay the practice of the art. I have shown that 
.so strongly was this the case that at times the results 
obtained by our forefathers ivore such as compare favour- 
ably with the best practice of the present tlay. 

It would clcarlj- be to our advantage could wo analyse 
tlie factors that stand behind the present high r.ate of 
.^psis as .satisfactorily as is possible in these older records. 
Unfortunately in modern times the subject is hedged 
around with difficulties nnd uncertainties that make the 
study baffling in its complexity. 

Contagion an a Factor in the Present Sepsis Death Bate. 

' How far contagion or trauma, or both combined, are 
responsible for the death rate from sepsis at the present 
time we have no accurate means of discovering. If we 
address ourselves first to contagion we have, liowever, 
certain data which are worthy of analysis. In this con- 
nexion we have to remember that virulent contagion 
notonousl}’ may act where there is a minimum of interfer- 
ence, an^d the invasion of the genital canal may even occur 
V. len there has been no vaginal examination at all, the 
microbes being then conveyed to the vaginal opening on the 
lagers or dressings of the medical attendant or nurse, or 
111 some otlicr way. In pre-Listerian practice the high death 
A dependent upon such infection of the normal case, 
an the extent and severity of the danger were reflected 
^ r.atio of such cases involved. ' In any large 
p ac ice the criterion of the normal case provides a suffi- 
ciont index of the degree in which this factor is operating. 
TTinrit *1 that the omission of the abnormal and instru- 
a case from such an analysis docs not vitiate tlm 


result qua simple contagion. If the sepsis rate in such 
c.ases ho increased bcc.aiiso of. the major interference em- 
jiloycd it is legitimate to attribute such increased risk to 
the interference and the pessihle trauma incurred. 

Wo liavc, at the outset, to remark that the massive 
sepsis of the pre-Listerian days, when surgical contagion 
repeatedly overwhelmed the surgical and maternity wards 
and often spread into extra-hospital practice, is no longer 
with ns, nnd it would seem certain that the elimination of 
this virulent and .spreading contagion must nece.ssarily have 
led to a lessening of this contact factor in modern practice. 
Despite this, however, wo know that contagion does still 
o])orate — ns, for example, where the scarlatinal virus is 
transmitted to a parturient woman, or whore two or more 
women arc clearly infected from one common source. Tlie 
exact extent to which infection so conveyed is re.sponsible 
for modern sepsis is,’ however, more difficult to define than 
in the case of the older records. Whilst this is so, we 
are not altogether without evidence. The figures I have 
already quoted in connexion with auto-iiifcction are again 
of service hero. In the outdoor practice of the Edinburgh 
Maternity Ho.sj)ital, for example, during four years there 
have been about 5,000 normal deliveries ■with 2 deaths. 
During the year 1927 there were 53,502 deliveries in 
the practice of the inidwivcs of the Queen Victoria’s 
Jubilee Institute in England and Wales with 6 deaths from 
.sepsis in normal births — that is, 1 in 8,900 total deliveries, 
or about 0.1 in 1,000. This total figure refers, of course, 
to all cases, normal and abnormal. If wo exclude. the 
forceps cases wc get a figure approximately equal to 1 in 
8,000 or 0.12 in 1,000. lliis indicates the rarity of con- 
tagion in' the practice of midwives, and when we remember 
that in England and Wales over 50 per’ cent.-, and in 
Scotland over 30 per cent, of the maternity service of the 
community is in their hands, wo have ample reason for the. 
belief that, in this proportion of the country’s service at 
least, contagion is of comparatively minor import.anco. 
Then wo Iiavc a record of 47,503 successive cases in the 
outdoor and indoor practice of the East End Maternity- 
Hospital, with a total of 5 deaths from sepsis, or’ 1 in 
9,500 cases. It is, of course, not necessary to con- 
clude that all the sepsis deaths in these records are due to 
contagion. The figures are quoted with the , object of- 
indicating the maximum possible mortality from this cause 
when this is operating alone. 

I have given these data not because they demonstrate . 
necessarily any superiority in the practice of the institu- 
tions concerned over that obtaining throughout the rest of 
the community in respect of this matter of contagion, but for 
the re.ason that they constitute the only large series of figures 
.available. It is not easy to conceive any re.ason wliv this 
small ratio of contagion should be appreciably different in 
the rest of the community not covered by these precise 
records. In other words, such an analysis as I have given 
leaves in one’s mind the impression that contact infection 
while it does admittcdly’still occa'sionally’bperate to main- 
tain the incidence of fatal puerperal sepsis, is probably a 
factor of comparatively minor value, and that to explain 
the persistently high rate’ in modern pr.actice we have to 
direct our attention to other factors. 

Contagion in Present-day Eospifah. 

To the enduring benefit of labouring women we have to 
acknowledge' with ungrudging gratitude that the era in- 
augurated by Lister has brought assurance into obstetric 
practice, and in no way is this more strikingly manifest 
than in the enhanced s.afety- of the modern maternity- lios- 
pit.al and in the surgical procedures on behalf of the mother 
and child on ' which we now embark with confidence. At 
the same time the magnificence of this great new instru- 
ment is apt to blind us to tlie fact that even in the hospital 
system' of our own times there are still perpetuated in some 
degi-ee the risks with which our forefathers battled in vain. 
There is still intrinsic in it the danger incidental to the 
asseiiibling of numbers of parturient women within four 
walls. 'The reality of this risk is at. once apparent when we 
recall that, whilst tlie rimin’ practice of such hospitals is 
concerned with normal childbirth, it is also largely engaged 
in serving, and in attracting to itself, often. from a uade 
district, the abnormal, which is often svnonymous with the 



June (),'i9=8] 


• PUERPjeUAli SEPSIS. 


t .l^iDnmsn Q7l 

MXOtOlli JoCBNlXt W I A 


in this largo iiraotico is (Icpcnclont «iiou tho fact Hint the 
inidwivcs' cases arc to Bonio extent selected. js not 

denied, and that this selection is not iniionsiderablo is 
suggested bv tho very low death into in tho senes from 

l.uXrnernl convulsions and albuminuria— from 0.1 to 0.2 per 
1,000, ns contrasted with a death into over tho rest of tho 
eonimunitv of from 0.6 to 0.8 per 1,000. flaking exci^ 
nlloxvanco,' however, for tlicso facts tho record is full of 
encouragement, and points to the advantages to bo obtained 
from a wider extension of the midwife-doctor system. 

The signal advantages of such combination are even more 
convincingly demonstrated by such an in.stitution .as the 
East End Alateruity Hospital in London, where tho bidk of 
tho cases aro conducted by midwives, and abnormal cases 
nro treated by medical practitioners on tho honorary staff. 
This institution conducts over 2,000 cases yearly; about half 
being in tho hospital. There is a well-organized anto-natnl 
■ system, and tho forc-cps rate is under 3 per cent. Ee.spito 
tiio fact that tho practice i.s amongst tlio very poor, and 
that it is practically unsolccled, it has a mortality rate 
standing at a little over 1 per 1,000 cases. For four years, 

• in a total of about 9,000 cases, it sank to the extremely 
loiv level of 0.67 per 1,000. Sepsis is practically eliminated 
from this practice, and llicrc can bo little doubt that this 
is due mainly to tho excellent administration, the careful 
supervision, and tho low instrumental rate. 

It is to ho specially observed that tho admirable results 
obtained in the caso of thc.se extensive practices flow 
entirely from tho method and maebinerj- emidoyed. There 
is installed by comparatively simple means a .■-\stcm by 
xvhich — and this is especially noteworthy in such an institu- 
tion as tho East End Maternity Ho.siiital — tho pbxsiological 
management of labour is encouraged, tho abnormal case is 
seen betimes, and difficulty and danger nro thereby antici- 
pated. and prcx'eutcd. Tho record of this institution and its 
almost complete freedom from sepsis is one of tho most 
cogent arguments in sujiport of the contention that tho 
dominating factor behind sepsis in ordinary midwifery is 
trauma. So remarkably successful has this hospital been in 
its effort to expel from its doors not only sepsis, but also 
tbo other complications of labour and tho’ puerpciitim — for 
example, eclampsia — that wo might at first sight feel our- 
selves compelled to nttributo the result to some unduly 
favourable circumstanco in .tho material- of their practice. 
Against this, however, it may bo urged that the official 
records sboxv that the death rates of tho communities in 
xvhich this hospital carries on its xvork arc several times 
greater than that exhibited by the indoor and outdoor 
practice of this institution. 

: It cannot, I, believe, be denied tliat.thc evidence furnished 
-by an .enlightened and critical analysis of all tho various 
forms of-maternity effort xve liax'c revicxvcd goes to support 
the contention of Fairbairn’ and others that “ a country’s 
maternity service is best built on tho foundation of a 
senioe of midwives xvith medical help in difficult cases.” 
■.uefore this ideal can. bo universally realized much must 
.00 .done, in the way of education of tho publi'c and in 
.mo, reorganization of the present machinery of pi-actice. 
Doctors can do a great deal in both directions; and there is 
ample evidence to hand that in these objects they can count 
on tho help of tho central . and , local authorities. Tho 
problem in any area, can only be satisfactorilv dealt ivith 
by strenuous loc.al effort. 

The high death rate in some areas invites, the suggestion 
that on occasion the subject n;ay become eminently a matter 
for tile active interest and participation of the local body. 

Conclusions. 

1. Autogenous infection is a minor primarv cause of fatal 
puerperal sepsis. 

2. Contagion is probablv of comparatix-ely secondary 

fm))ortaii(e. The well-established risks of contact infection 
in hospitals call for caie in the extension of the hospital 
system of maternity service. ' ‘ 

. 3. ihere is eviueiice that trauma is the most important 
cause of tue death rate from sepsis. This is not entirely a 
problem involving the medical attendant ; it has implica- 
tions of a xvider nature. 

4. Ihe immediate need is an improved machinery for 
maternity practice based on a' midivife-doctor combination. 


From the standpoint of immediate policy tho importance of 
this ovcrshadoxv.s all other considcr.ations — for example, 
“ research " — and there is reason for tho liopo that by this 
moans alono a lessoning of tho death rate is possible.' 

5. Improved education of tho iiuhlic, tho midwife, land 
tho student, nnd tho nssi.stanoo of tho central and local 
authority, nro all iioccssaiy for tho creation and xvorking 
of a satisfactory imichino. 


REFrnrs'crs. - * 

BIgKcr nnd riliGililion ; lourn. Ohitct. and Gynaecol., vol. xxxii, 1923, 
p, ^6 nnd p, 310. 

, 3 Lockhiiri : Ibid., p. 49, 

‘ * Colcbrook ; I'ruc. Hoy, Soc. }Ied,, vol. xlx. 1933, Sect. Obstet. and 
Gvnnecol., p. M. 

* lUirl-XVIiitn nnd Armstrong : Ibid., vol. xxi, 1928, Sect. Obstet. nnd 

Ovnnccol.. p. 28, 

■ ‘ Slm'pson, Sir J. 3’. : Olttetrie n'orle, edited by Priestly nnd Storcr, 
vol. U. 1855, p. 18. 

‘Spencer, II. It.: The Hillary of Vritiih Midicifery from icyo to ISOO, 
London. 1927, p. 156. 

I Coliina : Hdinhuryh Hed. and Svry. Jonrn., vol. 47, 1837, p. 489. 

• Runacll, .Mocicnn, nnd Bourne : Joum. OVitet. and Gynaecol., vol. xxxii, 

1925, p. 201. 

•Fulrbairn: llrilitli lledical Journal; January 8tb, 1927, p. 47 


^ ^cchrrc 


on 



Delivered io tue Blackburn Division of the British 
Medical Assoclxtion 

BY 

A. REMINGTON HOEBS, M.D., 

MEDICAL SCPERJNTENDEXT, ST. MARY ABBOTS HOSPITAL; COKSULTIXG 
OYSAECOLOCIST TO THE ROYAL BOROUGH OF liEKSIKGTOIf. 


In considering the present state of affairs relating to 
puerperal sepsis, it xvould seem that during the last txventy 
•years no progress has been made, in spite of our knoxx'ledge 
of antiseptics nnd of bacteriological research. In support 
of this statement I may mention that — 

1. No fexver than 3,000 British mothers die ex-ery year in 
childbirth. 

2. Of a niimher of patients examined at n certain xx-elfare 
centre, 50 xvero still bleeding at the end of several xveeks, of 
xvhom 20 came from one hospital. 

3. At a similar centre 42 cases returned septic, of xvhom 
.28, had been treated by general practitioners and 6 at maternity 
hospitals. 

' 4. Dr. Harold Jliller’s investigations at Pittsburg show that 
of 1,000 xvomen ' examined as soon as possible after the sixth 
xvcck folloxving labour no fexver than 70 per cent, showed some 
degree of erosion of the cervix. 

5. Of the fatal cases, 80 per cent, afford a history of operative 

or manipulative intervention. ■ ' - 

6. Inflammation dating from some previous confinement or 
miscarriage is present in 70 to 80 per cent, of gynaecological 
cases. 

"What do xve understand by the expression “ puerperal 
sepsis ” ? In tliis connexion xve may consider the definition 
of puerperal sepsis enunciated, by the Ministry of Health 
and based on .the suggestions of the Royal Society of 
Medicine— namely, that.^ puerperal sepsis is (a) a fever; 
(6) a bacterial infection of the raxv surfaces loft after 
labour. 

Is it a fever? It is true. that some cases of puerperal 
sepsis may be attended bx’ pyrexia, but this is the exception 
rather than the rule. In support of this it may be sub- 
mitted that (1) all practitioners meet xvith many instances 
of yelloxv x-aginal discharge unassociatod xvith pyrexia; 
(2) in a large percentage of cases of secondary haemorrhage 
a high temperature nex-er develops; (3) a patient may die 
from secondary haemorrhage or gangrene of the uterus 
without any pyrexia; (4) of 340 patients delix-ered in a 
. maternity xvaid in 1926, 83 suffered from uterine sepsis— 
one-half of these septic cases exhibited pyrexia and tho 
other half secondary haemorrhage. 

Is it a bacterial infection of raw surfaces? If eo the 
inflammatory changes occurring as the result of retention 
of placental tissues or hlood-clot and lack of. free draina<Fe 
are lost sight of, and the significance of these changes Ta 
the etiology of uterine disease fails to bo recot^nized. 

Immediately after labour, or miscarriage a cascade of 
blood and serum exudes from the raw surfaces for a period 



‘072 JCKE 9, 1928] 


-PTIBKPERAI( ‘SEPSIS. 


[ Tits Cnmn, 
MzniciL JonRriA 


of some days’ duration. If there bo any interferenee with 
the outflow-, of this fluid symptoms and signs entirely duo 
to pent-up secretions will manifest themselves. 

I may summarize the main sites of obstruction as follows : 

1. in ihe Uterus ^ — The two main sites in the uterus are 
the wall and the cervical canal. As regards the uterine 
wall, the flow of lymph may be impeded by in(hininiatoi-y 
products, b}’ injury caused by the finger or curette, by 
the use of strong .styptics, or by too hot douching. Similar 
obstruction in the cervical canal may be caused b}- retained 
blood-clot, pieces of membrane, placental fragments, or tho 
swollen and congested cervical mucous membrane. 


nicnis of shed opithelinm, occasional Icncocytcs, and 
occasional orythroc)tes ; these contents connote chronic 
hiflnmnmtion. Tho stroma colls are much more widely 
sci>arated than normal by oedema. TTioro is n sli^t 
capillaiy enlargement and also small stromal haemorrhages. 
Lastly, there is a general .sprinhling of leucocytes, chiefly 
mononuclear, hut occasion.ally polymorphonuclear. 

TnEATaiENT. 

In tho first place let us consider tho nature of some of 
onr present methods of treatraont and tho reasons for their 
failure. 


2. Outside, ihc D ferns . — ^Interference with tho outflow 
may he caused by a loaded rectum, an overdistended 
bladder, oedema of the vaginal walls subsequent to pelvic 
cellulitis, and by swelling and oedema of the 2 >crincnm. 

A loaded rectum plays an important port in damming 
hack tho uterine secretions, the symptoms being due, not 
to absorption from tho bowel, but to pressure from tho 
loaded bowel preventing the secretions from being dis- 
charged. Tile following reasons may ho adduced. (1) An ; 
overloaded bowel must distend anteriorly' and not pos- 
teriorly. (2) On examination, tho flngor passes over a 
distinct hillock and tlie cervix is above and behind the 
lump. (5) In 200 cases the height of the uterus was 
measured before and after an enema. It was observed that 
the uterus descended on each occasion after the bowel was 
evacuated, (4) In 1918 tho records of 100 iiationts oxamiiiod 
in the maternity wards showed py rexia in 18 per cent, of 
cases hctweni the second and fifth days. In 1926 this ; 
percentage was only 5 following regular washing out of tho 
bowels for the first three days. (5) In tho case of one 
yratient in tho maternity' ward who had temperature and 
2 )ain the loaded rectum was emptied and 5 c.cm, of pus 
was drawn off from tlie uterus; an uneventful recovery 
followed. 


Pathology or PtjEnrEn.tL Sepsis. 

Wo now turn to the question of the pathology of uterino 
sepsis. It is probable that if every student .studied micro- 
scopical sections taken from cases of this disease he would 
arrive definitely at the decision that the uterus must bo 
drained. The following is a summary of what is found. 

1. Normal Endometrium . — In a noraial case tho surface 
is covered by a continuous line of columnar cells. Tho 
gland acini are similarly lined, are fairly uniform in size, 
and are more of less circular when seen in cross section. 
The gland lumina are emiity and their mouths openinc' 
into the uterine cavity are patent. The stroma is composed 
ot slightly elongated connective tissue cells with inter- 
cellular fibrils. The stroma cells arc loosely packed together 
n^ot wide y sep.arated as in an oedematous uterine wall! 
Ihe blood vessels are small and few. There is no evidence 
of haemorrhage or necrosis. 

■Kodomcfnfis.—Here the surface is devoid of 
covering columnar epithelium. In its place arc masses of 
fibrin and exudate together with large decidual cells, 7oml 
stdl living, others necrotic. There are small collectVoiirof 
extravasated blood and numerous ’ polymorph leucoc'vtcs 
The glandular elements are absent. In other words the 
mucosa has become necrotic and has lai-D-nt,- nr., j 

Hence wo find, immediately nnd«- this f5ev 
debris and decidual cells, the someivliat oeLniatofirfib^o" 
nuiseiil.ar wall of the uterus. Tliere is ereat i 

blood vessels, which appear much more niimerous'°t]ian 
usual, and some of these vessels contain nolvmbvnh T “ 
cytes and ary thrombosed. Tliore are niimeiniTs ' 
of polymoriili leucocytes studded about in the musJl-7'^T 
of these foci are virtually small incipient abscesses irl, i7^ 

lhan“usi‘;al.'^'’'^' more separated 

3. Tronic EndomctritU.~In this condition the eoverinu 
A:!;”' IS practicallv normal. The eland 

? 1 la'"'® dilated and larger than f 

which months of ™ose 

uarroivoTaAnAt CiAi; -e .somoaS 

empty, hnt contains inspissafed''”^ instances is no longer 
^ ated secretion, occasional fra"- 


1. Expcdnnt or Conservative Treatment. — ^This nicUiod 
has frequently caused hitter di.sappointinont. It leaves too 
great a task to Mature, because in more than half theso 
cases there Ls ovidciico of pont-iqi uterine secretion. It 
fails to keep tho cervical canal. clear. In tho caiinl may bo 
scon i>ioccs of blood-clot, placenta, or mombrano, wliich giro 
rise to tlie symptoms and signs of ohstnutioii. Mo one can 
say that tho bc.st method of treating .secondary hacmorrliago 
is to leave the uterus alone. Even with tho aid of drugs 
such as pituitrin and ergot, and of tho wcll-kimwn douelio 
tin, tho patient is frequently no bettor off. ' It is often 
followed by' intermittent pyrexia, and it leaves the uterus 
with no standard of cure. 

2. Curetting. — I cannot do better than quote the words 
of Sir Bernard Spilsbury: “ In all bad cases of uterine 
infection tlicro is presumptive ovidcnco of tlio introduction 
of somo material, surgical or other, into tho iitcnis.”- 
Tlioro aro too many' instances of a flaio U]i whore . this 
surgical method has been employed. Cases have been 
numerous in tho past wlicro tliis method failed .to stop 
secondary liacmonhngo. 

3. Dilatation and Sicahhing 'irifli Strong Styptics. — ^This 
method often fails becauso thero is a likelihood of severe 
.reaction following tho application of strong conosives. 

4. Douching. — It has been demonstrated that douching 
docs not roliovo tho uterus of its pent-up secretions. This 
was illustrated some years ago by tho caso of a woman 
w'hoso utorus was drained and suhscquontly douched; tho 
temporaturo rose, but sho was later cured by tieatment 
with glycorin. 

5. Hot Intrauterine Douche. — Tliis method i.s often 
followed by symptoms and sigms of septic absorption. It 
injures tho tissues niid i>rovcnts drainage. 

6. Scrums and Vaccines. — These seem to have no.cffect if 
tho tissues of tho uterus aro not drained. 

■ It therefore appeaix to he established that, judging from 
tlio niimhor of curettings performed, our treatment in tho 
past has left us without a proper standard of euro. What, 
then, is tho ideal motliod of treatment? Is there a method 
that can be applied again and again without being followed 
by an exacerbation of tho fever or disease; each ajiplication 
fulfilling the pnrpose‘ of an aid to tho drainage of tissues 
in a state of stasis — a method that allei'iates pain, relieves 
congestion, and by so doing stops secondary haeraon-hago, 
and finally restores tho functions of the uterus? I am 
certain tliat there, is,, and that iiiothod is tho mode of 
troatiiieiit by glycorin which I have described. 

Ill considering the iiidic.ations for treatment it is neces- 
sary' to think of tho ante-natal clinic, tho labour room, and 
tho lying-in ward. 

1. The .liifc-iiafn? Clinic . — ^It is important to see that all 
methods of investigation and treatment aro carried out. 
Tho necessity' of accurately measuring the pelvis is generally 
recognized, but there is also tho question whetlier any 
toxins aro yivesent, ns er'idenced by albuniiniiria. I wish 
particularly to enqiliasizo the importance of tlio jiresonce in 
certain cases of bacteria in the urinary' and genital tracts', 
this also ajiplics to septic conditions. If bacteria are 
present, treatment should he employed to eliminate them,; 
or, at any' late, to diminish then' ninnbor. If theso 
conditions are not fulfilled, pathological organisms may 
show their )>roseiice during labour without any vaginal 
examination having been made. 

2. The Labour Hoorn . — AVith regard to infection' during 
labour, there is a type of case in which labour starts with 




Juke 9 . ' 928 ] 


rXJERPER&^n' SEPSIS. 


[ Tirr.Bomtfl- 073 

MSDlCAl. JOm5AL VlW 


n liso of fomiicrnluro, often to n consulcrnl.Ic liciglit, nnd 
Avitli porl>nps n vipov, uud in nl.ich an acooinpai.ying 
uriuaA- infection may load to failure to recopn.ae a utcrino 
infection. Hero the false belief may arise that, because 
orRanisins and cells have boon found 111 tho nnne, tho 
diagnosis is comiilete. H thero has been any internal 
maniniilatioii ivo Jircvent .sepsis by admmistennp an intrn- 
uteriue iiiiectioii of 120 c.cm. of Rlycerni as a iirophylactic. 
In the case of retention of the )dncentn, if ordinary 
mcthoik have failed ivc inject 60 to 100 c.cm. of glycerin 
into tho uterus. In many cases this has aided oxjnilsion of 
tUo placenta ^YitUout vccoui'se to innnipulution. In tho 
presence of excessive lincmorrhagc miinnal removal must, 

' of course, ho jicrforined at oiiec. As regards jiosl-iiartnm 
liacraorrliage, ive employ tho same treatment, injecting 60 
to 100- c.cm. of glvci'rin into the lUerns, nnd have found 
this method most s'ucces.sful. If the Imcmorrliage shoivs no 
sign .of censing under tho treatment it is ndvi.sahlo to 
explore the uterus for retained iirodncts. 

3. The Li/lnff-in IVord.— In eoiinexion ivith sepsis a imich 
higher standard must he arrived at, and tlio fact must bo 
realized tliat not every case of .soiisis gives rise to pyrexia. 
If, hoivevcr, the patient shoivs, for example, a tempernturo 
of 990 F. and a pulse rate of 90, tho uteru.s should at once 
receive troatuienl. It is uinviso to look for some septic 
focus other than the uterus, and, having established 
a diagnosis of influenza, pneumonia, hacilluria, m.astitis, 
mumps, or femoral thrombosis, to treat tlic case ns such, 
forgetting tho uterus. It seems extraordinary that in just 
tho. feiv days of the early iiuerperium all these diseases 
should attack the woniaii, and that they should ignore her 
during tho remaining three hundred and sixty. A fciv 
illnstrnfions may ho advisable. 

(o) Influenza and I’nfuinonin. — I need not divell on the 
fact that .tivo of tho gravest complications that ivo have 
to.contend ivith during tho pucrpcriuui are influenza and 
pneumonia. IVo kiioir the severity of flic .symptoms nnd 
th.at patients often die ivithin a feiv days. Tho reason for 
this scorns, to ho that .the patient has .a double infection. 
It is difSciilt somctiiiios to decide ivhicli is the primary 
infection or ivhothcr a general infection is present, hut 
■ivo aro convinced of tho existence of tlio latter ivhon tho 
, lochial discharge is prolonged nnd ]irofuse; ivc kiioir then 
that tho patient has a poor chance of recovorv. AYe have 
seen several cases in which tlio jiatieiit has died during tho 
early puorperium, and on section ttie uterus has sliown 
acute inflammatoiy changes. 

(b) l^hthisin.’ Q*uite recently I was ashed to see a easo 
of phthisis. During pregnancy tlie patient had had no 
temperature, but on tho second day of the jnierperiiiiii it 
rose. The doctor who examined her tliought tliat her sym- 
ptoms were duo to her chest. She had'^tlirco .attacks' of 
shivering during the first week, nnd 011 examination tho 
lochia were found to contain II. coU and streptococci. Tho 
unno was sterile. 

(c) il/wmps.— t have found that when tho parotid gland 
becomes sii-olleii and tender during tho piierperiuni tho 
uterus generally escapes attoiilion. • On Jaiuiarv 2nd a 
patient was sent into hospital oii the tenth dav after 
delivery with swelling and .tauleriiess of the right 'parotid 

“?- • . ivpe day’s later this was followed hv enlargement 
and tenderness of the right breast. The uterus showed 
signs of sepsis. 

tl'is class of case we are 
accordingly ^ uterus is septic nnd slioiild be treated 

a «l>ort,time ago I was asked by 

li p’ ‘ ^ ending a caso of bncillurin complicating 

I t‘>«.Aciiipor.aturo failed to drop! 

; ..Qf, Denaldson had examined tho urine 

25 Pre^aiicy and Jmd found B. coli in 

lowpr n-nnifni ^ tiici'e -wns infection of the 

the iiterno w’fl ^'^'^1 . ®*’S^‘’*cd that be should wash out 

that tVin + * glycerin. This was done, with the result 

Scse cas™“'' ™ subsided. In all 

» 

mii^ cxn^eHput'r'f" i™*”* pronounced mastitis it is in 

infection aml it underlying uterine 

ccuon, anil it is advisable to treat the uterus. 


SioxiFic.ixcr, OF P.iik' ano Tfadf-UKesb rs' Hterike 
Sf.I’SIH. 

In n nonmil pucrporiuni, whether in a primiparn or a 
muUipara, there should not ho irregular contractions of 
tho uterus. Some years ago I was impressed by the caso 
of a iiuiltipnra who’ was stated to have had irregular pains 
during tho second niglit following delivery. Tlio vagina 
was Ihoronghly swabbed and the utoriis syringed out with 
givcorin, thereby getting rid of a considerable amount of 
blood-clot. Tho' pain disappeared ininiediately after treat- 
nienf. The only conclusion to be derived from this case 
was that ]iain is Uic cardinal symptom and tenderness tho 
cardinal sign of an obstructed visciis; in other words, the 
condition was uterine colic nnd obstruction. The cause 
of the obstruction was obviously tho blood-clot; moreover, 
pathologists state that the contact of blood-clot with raw 
surfaces for some Iiours produces inflammatory changes in 
a brief period. Tliis and other cases definitoly prove that 
after-pains are patliological and not pliysiological. 

Pain nnd tenderness aro not by any means .confined to 
the inaternity wards, but they tax all the. ingenuity of 
the surgeon iu the gynaecological department; numerous 
eases reach hospital labelled “ pelvic peritonitis,” “ abdo- 
minal influenza,” nnd “ appendicitis.” Given a case of 
well-marked peritonitis of tho lower abdomen it is, in tho 
exporionee of every surgeon, difficult to diagnose whether 
the appendix or tho tubes aro at fault, and on occasion 
one is certainly justified in opening tho abdomen.. But the 
point I wisli to cmplinsizo is whether we have brought every 
method of iurcstigation and diagnosis into play, because 
in many instances, after opening the abdomen, surgeons 
find not appendicitis, but an acute inflammatory condition 
of the uterus, tubes, and pelvic peritoneum. These cases 
.sliould bo approaclicd iu a careful nnd methodical manner. 
Tho history is of importance, since the origin of the trouble 
may date from some inflammation iu tho uterus left after 
labour, abortion, or gonorrhoeal infection. The points in 
tho liistoiy arc : 

1. If at any previous labour or miscarriage the lochia 
has persisted beyond the seventh day suspect uterine sepsis. 
This sign may have been present years before, and it 
connotes infection from an infected surface. 

2. Intermittent temperatures preceding or accompany- 
ing menstruation indicate an endometrium infected by 
organisms, nnd a condition of stasis. 

3. Dysmeiiorrhoea, whether appearing for the first time 
j or becoming progressively acute with each menstrual flow, 

indicates sepsis. 

4. Backaclie, discharge, erosion, and metrorrhagia follow- 
ing labour or miscarriage indicate sepsis. 

5. A visual examination of the cervix and a bimanual 
examination should be made. 


Typical Cases. 

I. A. woman came into hospital some weeks after a miscarria>»o 
with prolonged red lochia. She had been in the ward three days 
with a temperature of 99'iF. when one evening she was suddenly 
seized with acute abdominal pain and vomiting; the temperature 
was 105° F. and the pulse 120. ' The lower abdomen was acutelv 
tender, nnd there was rigidity. On bimanual examination the 
uterus was found to be enlarged, boggy, and tender, with impaired 
mobility and fullness in the lateral forniccs, especially on the 
right side. The mucous membrane of the cervical canal was 
swollen and oedematous, and contained thick mucus. There was 
obviously an acutely spreading peritonitis, and pain and tenderness 
of the uterus— the sv-mptoms nnd signs of an acutely inflamed 
viscus. It might he said that there were two wells of water 
being slowly fdled,' due in the uterus and one in the pelvic 
peritoneum. It is usual in these cases to watch the abifomen' 
for the .oycrfdliug of the second well, and then to operate; but 
it occurred to me that if I drew the water from the first well- 
in other words, penNup secretion from the uterus — the second well 
(the peritoneum) mipht bo able to deal 'with itself. I therefore 
gently washed out the cavity of the uterus slowlv drop by drop, 
using only about 1 c.cm. of glycerin. I put the patient back 
to bed and sat her up in the scmi-FowIer position. In two houre ' 
I found that the temperature had fallen to 99° F. and the pulse 
to 90. The acute abdominal pain had gone, but there was a feeling 
of soreness. The diagnosis could only be acute uterine colic and 
obstruction with adnexal inflammation. The patient slept for five 
hours and made an uninterrupted recovery without the abdomen 
having been opened. ’ 


... ..aj ccui, come momus alter conlinemeni 

as a ease of appendicitis with aihistorv of sudden pain in tbi 
right ihac fossa and vomiting. The. temperature was 101° F am 
the pulse 112.- Abdominal examination revealed pain and tc’nder 
ness low doivn m the right iliac fossa. Bimanual examinatioi 



974 J0NB 9, igaB] 


P'TJEllPEBir< ' SErSIS. 


r Tnc BntTtfK 
MrDjciL Jotrn'fix. 


Bliowed an enlarged, tender, and hoggy uterus with dislinct tender- 
ness in the right lateral fornix. A little glycerin was inicctcd 
into the uterus, and four hours later the temperature and pulse 
rate fell and the patient was free' from 'pain. 

, Anotlier factor of importance is tlio abnormal prolonga- 
tion or excessive degree of tho red iociiia, wiiicli is a 
significant sign, liable to nionaco licaltli or even to canso 
death. If the uterine jnoducts are expelled after tho third 
stage of labour, jirovided there is no sepsis, the red lochia 
should change from the fourth to tho sixth clay. Again, if 
tho uterus is empty and is tvashed out with glycerin lor 
the first few days, the lochia soon cease. 

I was much impressed by a caso of pneumonia compli- 
cating labour which was sent into liosiiital. Tho patient 
was delivered and died on tho fifth day afterwards. As the 
lochia wore excessive sections of tho ntorns were cut, and 
it was found to be full of small abscesses and most con- 
gested; in other words, the patient died not onlj' of 
pneumonia, hut also of secondary Imcmorrhago. It is 
evident, therefore, that if pneumonia and iiifiuonza com-' 
plicate the puerperinm there is usually a general infection. 
These events can explain at any rate one of the causes of 
tho high mortality in epidemics such as influenza. 

The importance of secondary haomorrhago is indicated 
by the following cases. 


A patient had been ill for eight weeks after her confinement, 
«io temperature ranging between 100° and 101° P. and the pulse 
between 110 and 120; she liacl a double fermoral tlirombosis. Tlio 
doctor who bad been called in said that tho uterus was normal; 
but the second consultant informed me that Itie patient had had 
two haemorrhages since her confinement. The surgeon look this 
to ho evidence of secondary haemorrhage, and tho uterus was 
immediately treated witli glycerin, with tho result that the 
temperature quickly fell. 


Another patient bled for six iveeks after her confinement; ihta 
sign IS evidence of sepsis. She was curetted, but the bleeding still 
persisted. A year afterwards she was curetted again, with tho 
same result. She received a:-ray treatment three limes a week 
tor three months, but the haemorrhage continued. She was then 
given a general anaesthetic and the uterus was washed out with 
sp. vini iiietli. and glycerin. She received half*hourlv treatments 
morning and evening, and tlie haemorrhage stopped ‘in five days. 
i>aily treatments were continued for another Ion days, and then 
sliq had her first normal period for two years. She has now 
quite recovered. 


As the result of these investigations I am convinced thal 
there is a dividing line where tlio red blood from a hcalthj 
Wound ceases and tho haemorrhage from an inflaince 
surface begins. It is difficult to bo sure wlien secondary 
haemorrhage commences, hut usually it is in tlio neighbour, 
hood of the fiftli to tlie seventh day. If women aro not fc 
. be allowed to fall into a state of chronic invalidism th< 
inflammatory surface must bo treated with a drug likt 
haemorrh " relieves tho inflammation producing tin 

Septic miscarriage is comparable with puerperal soiisis 
differing only in that the former is more liable to be'duc 
ictamed products of conception. No attempt is made 
to remove any retained products, except when ,"ecet 
piesont at tho os or there is severe liaemorrlmge. Bp /ai 
the worst cases admitted to St. Mary Abbots Hospital l.av 
beon , those where attempts have been made to romov 
retained products either by the finger 6r the curette Th 
canso of the rise of temperature is retained septic secrotffim 
and not necessarily the products themselves This f,ef 7 
often been demonstrated by draining the uterus when 
temperature falls before the expulsion of th^^^ontent? 

The following statistics illustrate the work carrierl ' i 
at St. Mary Abbots' Hospital. cairied oul 


Total number of patients delivered since 1921 
Cases exhibiting temperature 99° F. and over * 
Cases of secondary haemorrhage (past two yea're 

^644 cases) 

Number of deaths from puerperal sepsis 
Number of anaesthetics administered after third 
stage of labour 

(а) Dry labour — general peritonitis — lapar- 
otomy within 40 hours of delivery — recovery. 

(б) Secondary haemorrhage following 
manual removal of placenta — curetted for 
Totained piece- — m’Z found--^ report of curet- 

•- aeuto endometritis. 

C.™ «5. SS;;y 


1,657 

13<l 

102 

A’^il 


192 

104 

10 


CoNCnr.sio.vR, 

fVo Imvo nnived nt tlio following conrliisions a.s the 
result 'of tho rcseiirch work etirricd out nt St. Mnry Ahlxits 
Hospilnl tliiring the piist few yenis. 

1. TIio definition of pucvpoinl sojisis Inid down by the 
Ministry of Health is inadctiunto aiul erronoons, 

2. As regard.s tlio fir.sl part of the derinition, puerperal 
sepsis is not by any means invariably aceompniiicd by .a 
rise of teinpcriitnro, Pyrc.xin Is merely n .sign in the roiirso 
of a septic process, and tin's Is one of the nmin rea.soiis why 
a largo ntinibcr of cases of jiuorporal sepsis are allowed 
to pass tin recognized through our host maternity hospitals. 

3. Tho second jiart of tho definition ref|uires aiiiendiiig 
also. Inllanimatioir can ho ennsod by agents other than 
baclcvin. lletaiiied blood-clot and fragments of ineinhrniio 
or placenta will act as foreign bodies and will lead to 
inflammatory changes in tho uterus. 

4. Pain and tciulcnicss must ho recognized ns the coin- 
monccmeiit of iiteriiio colic and obstruction. Pain and 
tenderness are never jiliysiological, but aro invariably 
pathological after tho tliird .stage, Jforoovor, .so long ns 
tho syniptoiiis and .signs of aeutc utoriiio colic and obstruc- 
tion aro not added to the list of abdominal inflanimatioiis, 
and are not tre.-ited as soon ns these signs appear, so 
long will patients bo subjected to abdominal explorations, 
whereas they might have been saved. 

5. It will soon ho no longer tho fashion for women to 

bleed for weeks, months, or even years after their con- 
finements, hoenitso students will bo taught that glycerin 
will relievo tho inflammation which produces tlio 
haomorrhago. ' 

6. Tile utoriis never was, and never will ho, cloaiied in 
ono attempt. 

7. After enrotting and swabbing with strong styptics the 
ntonis must bo drained for the succeeding few days. 

' 8. Tho best time for troatmeiit is in the early days of tho 
pncrpeviuiii. 

9. Evci-j’ septic case following labour or miscarriago 
should bo investigated by tho hcnltli visitor and reported 
to tho medical officer of health. 

10. A special ward should he attached to every maternity 
hospital so that every scjitie case could ho transferred and 
treated, and, if necessary, treated after leaving tho hos- 
pital, since many women take their discharge on tho 
fourteenth day and before they are cured. 

11. A doctor who is skilled in tho detection of tlic early 

symptoms and signs of puerperal sejisis and tho modern- 
treatment thereof innst in fiituro bo attached to overj- largo 
maternity hospital. ' ■ ^ 

31 EPfTlEJJCE. 

* BritisJi Medical Journal^ Dt’cpmber 31st, 1927, p. 1223. 


PUERPERAL SEPSIS AND SENSITIVENESS ' 
TO STREPTOCOCCAL TOXINS. 

■ ’ BY ' '■ 

H. BURT-WHITB, M.D.Lond., F.R.C.S.Eng., 

SORCEON TO OUT-PATIENTS, HOSPITAL FOR WOMEN, SOHO SQUARE; 
ASSISTANT OBSTETRIC ' SURGEON, CITY OF LONDON’ MATERNITY 
• HOSPITAL. 


Tub aiioinalotis distribution of puerperal sepsis has Jong 
puzzled epidemiologists. It is stated .that women in good 
siivrouiKlings have suffered more frequently from this 
disease tlian the poor, and that rural districts show a higher 
hicidonco than towns. Tho numher of cases in hospitals 
and nursing homos is lilicwiso in excess of those occurring 
among women delivered in their own homes. True a 
greater number of abnormal cases, requiring manipulation, 
are to be found in institutions, and similarly the incidcnco 
of septic cases among priiniparao has been considered duo 
to the difficulties which necessarily attend a first labour. 

It is especially significant that great advances in obstetric 
technique have done little to lessen the incidence of inier- 
peral sepsis. Tliat puerperal sepsis is caused by tho 
Streptococcus pyogenes is now generally accepted, but a 
source of virulent pyogenes must he present beforo the 
disease may develop. Where is* it to ho sought? 

already shown in a recent paper by R. It. Armstrong 
and mj-sclf,^ streptococci are not by any means invariable 


JUNE 9, 192 S] 


PPERPEEAIi sepsis. 


f Tlir. IlRlTIfH 
irpniCAL JoCBVAt ^ 


iiihabitniits of the corvical canal during pregnancy. Tlio 
true virulent disease-iirodiicing .S', pyor/ciirs occnr.s very 
rarely in the female pass.ages, in all pwibalnlity only when 
a woman has been recently associated with u aonico of 
infection. It seems that infection is not necessarily by 
actual contact, altbongb the exact mean., of transference 
is at }n'esent obscure. Proof of this is furnished. by the 
clinical histories of local and institutional opidemic.s of 
puerperal sepsis. Again, our experiments iirove that a 
woman does not necessarily .sucaamib to puerperal se]>sis, 
oven though she be actually harbouring the infection. 

Neither'’first pregnancy, ‘difllcult labour, nor aggregation 
of . cases in. institutions .in. which the relative deii.sity of 

S. piiorjencs infection is inevitably high, will account fully 
for tho capricious incidonco of jiuerperal sepsis. Our 
general knowledge of infection and response suggests that 
in this, ns in other diseases, individual reaction and 
personal immunity against the infecting micro-organism arc 
important safognards. This view receives support from the 
work of Okoll and Parish', who believe that all the disease- 
jn'oducing strains of .S'. jiifOtfcnrs are identical, in the scn.se 
that .their main aggressive weapon is a toxin, which is the 
same for all strains." Hence an, attack, during her girl- 
hood, of slrcptococcal sore throat, of cellulitis, erysipelas, 
or oven scarlet fever, maj’ bo expected to have conferred on 
a woman a greater or less degree of ptoteclion against the 
most virulent and fatal fonn of streptococcal infection, 
puerperal septicaemia. It is a recognixed fact also that 
a woman who has onro .sutfered from puerperal sepsis is 
..seldom or never' attacked in subsequent pregnancies. 

Attempts in tho laboratory, witli experimental animals, 
to demonstrate and measure antistrcptococcal immunity 
have proved quite unexiicctcdly unsuccessful. Yet the 
value of somo foreknon-ledgo of the reaction of a primi- 
para to S. pyogcnc.i, with the implied possibilitie.s of 
prophylactic immunization before deliverr-, is beyond 
dispute. 

Tho investigation to bo described was initiated to test 
tlio reaction of pregnant women to the scarlatinal toxin, 
withont atij- preconception ns to rcsiilts. An ex])erimcnt at 
St. Bartholomew’s Hospital by .Sir Frederick Andrewes” 
on a number of hospitid students showed that a proportion 
U'cre sensitive to scarlatinal and other .streptococcal toxins. 
'This experiment did not altogether, make .clear the corrol.a- 
tion of toxin-sensitiveneiis with a past histoi'y of scarlet 
fever, or slreptococcnl infections. IVith tho accumulation 
of d.-ifa the test on women has come to assume positive 
significance, ns each has been followed through her 
pregnancy, labour, and puerperiura, 

A supply of standardized scarlatinal toxinp prepared at 
the IVellcome Research Institute, was kiudly furnished by 
T)r. C. C.-Okell, whose pioneer work on tho toxins of the 
Streptococcus pyogenes group is generally recognized and 
acclaimed. Tho preparation has been used in all tests. 
Four intradcmial injections, lespcctively one-fifth of a cubic 
centimetre of a dilution of 1 in 1,000, 1 in 3,000, and 1 in 
6,000 of toxin with control, were made into the skin of the 
palmar .surface of the forearm's. A positive reaction con- 
sists in the ajjpearance ivithin' tweiity-four hours of an 
erj-thematous patch, yai’ying somewhat in size with the 
intensity of the reaction and the dilution employed, from 
one-quarter of an inch in diameter to an area one inch or 
more in length. In about half the cases gradation in 
response is apparent, corresponding with the strength of 
toxin employed. But in many cases there is little to 
choose between the high and low dilutions. In general 
practice it inll. pyobably be found sufficient to employ onlv 
a dilution of 1 in 1,000 to discriminate between I'eactors 
and non-reactoi's. 

The tests were made on women at St. Bartholomew’s 
Hospital and the City of London Maternitv Hospital. Ono 
mndred cases have been tested, and tlieir labours and 
puerporia observed. Of these 100 women, 27 wore toxin- 
scusitive, while 73 did not react to any dilution. The 
cases may be grouped as follows. 


' (®) IFomcn Giving Positive Penefions. 

. ‘ ® experienced morbid 2 >iierperia, accordin 

10 tho Rritish Aledical Association standard. In on! 
cases were the cervices swabbed, but each yielded a pur 


growth of S. pyogenes. The high percentage (30 per cent.) 
of morbidity is remarkable when it is considered that 6 of 
tho 8 women pa.sscd through normal labours withont any 
interference, while the other two sustained only slight 
post-partum haemorrhages. The details of each case may 
bo summarized. 

1. rCormnl labour; morbid puerpcriiim. 

2. Normal labotir; posi-partum haemorrhage; temperature 
100° F.; second to eighth days, maximuirt temperature 102° F. 

3. Normal lahoiir; morbid piierperium; temperature 100.2° F., 

fourth and fifth days. ' 

4. Normal labour; morbid puerperium; ,S. jiyoffcncs isolated from 
cervix. 

5. Normal labour; morbid puerperium; post-partum haemor- 
rhage; .V. ppoijeors isolated from cervix. 

6. Normal labour; morbid puerperium. 

7. Normal labour; morbid puerperium. 

8. Normal labour; morbid puerperium. 

The remaining 19 women passed through normal 
puerperia; 18 of these experienced normal labours, ono 
was delivered by forcejis. 

(b) IFomcn who did not Jteaef. 

In this group there wmo 73 women. Two of these 
experienced morbid puerperia, but in each case tho con- 
stitutional disturbance rvas very slight, and in neither 
could S. pyogenes bo found in the cervix or blood.. The 
scries was of special interest in that it contained many 
abnormal cases in which sejisis was tO' bo' oxitected, yet, as 
will be scon from the summary below, no siich' event 
occurred. 

1. Severe post-partum haemorrhage; admitted pulseless. Manual 
removal of placenta perfonned after blood transfusion. Normal 
puerperium. 

2. Patient delivered on district; severe post-partum haemorrhage, 
associated with a morbidly adherent placenta which required manual 
removal. Patient collapsed for some hours. Slight rise of tempera- 
ture on third, fourth, and fifth days; lochia oSensive. ' Cerrical 
culture gave growth of .5. salirarius and staphylococci. 

3. Caesarean section; notmal puerperium. 

4. Caesarean section; normal puerperium. 

5. Severe tear of perineum; normal puerperium. 

6. Severe tear of perineum; normal puerperiura. 

7. Normal labour; temperature slightly raised in puerperium; 
haemolytic streptococci not found in cervix. 

8. Severe pyelitis of pregnancy; secondary anaemia, red blood 
corpuscles 2,400,000 per cjnm. Placenta praevia. Transverse lie; 
artificial rupture of membranes; later, internal version. Tempera- 
ture sliglitly raised in puerperium, maximum 100° F. on fifth and 
seventh days. No streptococci found in cervix. 

9. Concealed and external anie-partura haemorrhage; artificial 
rupture of membranes, vagina plugged; puerperium normal. 

10. A multipara with contracted pelvis. 'Interspinous diameter 

9 ill., intcrcristal 10 in., external conjugate, 6 J in. Transverse lie; 
external version; difficult delivery with forceps after lone second 
stage lasting six hours. Normal puerperium. ■ “ 

11. A case of severe post-partum haemorrhage; manual removal of 
morbidly adherent placenta. Normal puerperium. Cervical culture 
showed Staph, albus, B. coli comminii,«, and S. soUrarius. 

12. Case of ante-partum eclampsia; persistent right occipito- 
posterior, delivered as such with forceps. Puerperium normal till 
twelfth day, when rigor ocmirred; patient developed pyelitis and 
B. coli conimunis septicaemia. No streptococci in cervix or blood 
on repeated examination. 

13. A case of severe post-partum haemorrhage. Manual removal 
of placenta performed. Normal puerperium; cervical swab sterile. 

No case lias yet occurred, so far as is known, of a woman, 
.sensitive to toxin, who has harboured the S. pyogenes 
in her genital tract without developing puerperal fever. 
Since tire observations recorded above a morbid puerperium 
has occurred in a woman, who failed to react- to toxin 
from whose cervix the S. pyogenes was isolated. This 
woman, when tested three weeks before delivei-y and aeain 
at the time of delivery, was snifering from suppiiratino- 
scahietio sores of the hands and feet. These sores mav weR 
have been infected with pyogenic streptococci. Unfortu- 
nately cultures were not taken. 

The conclusion that toxin-seusitivcncss indicates suscepti- 
bility to puerperal sepsis is not disturbed by this observa- 
tion, however. There seems no reason 'to doubt the 
existence of a degree of resistance to ,5. pyogenes infection 
sufficient to neutralize the dose of toxin emploved for 


976 - JONB g; 1928] A TEMOW FE VEK VACCtKE. - 'tMrntciLjouRi*!* 


intradormal inoculation and to prevent a severo septic- 
aemia, but insufficient to prevent a local infection of tho 
uterus; just as every grado of susceptibility to scarlet 
fever or tonsillitis is "'oU recognized. 

No skin tests on women actually suffering from puerperal 
fever havo been made, but it is Jioped to undertake these 
as opportunities arise. , A' fatal case of 6'. 'pyogenes septic- 
aemia in a man, recently tested, proved vigorously toxin- 
sensitive. In a few instances toxins prepared from strains 
of N. pyogenes from puerperal sources have been tc.stcd 
simultaneously with the standard scarlatinal toxin, and so 
far with the same results, thus supporting Okell’s findings. 

It is realized that one hundred cases are insufficient to 
afford conclusive proof of tho sigjiificanco of tho toxin test. 
Tho investigation is being pursried, therefore, and it is 
hoped soon to havo further evidence. . Finally, it may bo 
stated that the possibilities of tho toxin-sonsitivo test ns a 
guide to preventive treatment against S. pijogCncs infec- 
tions havo not boon overlooked. If the conclusions reached 
receive support, tho time may come when prophylactic 
immunization of toxin-sonsitivo women will bo practised 
as a routine. But the indications for such immunization, 
tho optimum time in relation to labour, tho menns 
employed— by active dosage with toxin or by passive 
immunization with antitoxic serum — have yet to be studied. 

Summary. 

1. Of ICO pregnant women, £7 were sonsitivo to a 
dose of 1/5 c.cm. of a dilution of 1 in 1,000 scarlatinal 
toxin injected iiitradermally. 


2. Eight, or 30 per cent., of tho " toxin-.sen,sitive ” 

women experienced morbid puorporia. From tho cervices 
of thoso examined a puro growth of S. pyogenes was 
obtained. Bahour was altogothor normal in 6 of theso 
cases and normal in tho remaining 2, except for slight 
post-partuni haemorrhage. • ■ 

3. Of 100 pregnant women, 73 gave no reaction to 
scarlatinal toxin ; two of thoso exhihitod morbid puerperia 
(British Medical Association standard), hnt in neither caso 
could streptococci bo found in tho cervix or blood. 

4. Thirteen of tho non-rcacling women, or 19 per cent., 
sustained difficult labours but healthy puerperia; 6 of theso 
wero examined hnctcriologically, but in no caso was 

S. pyogenes found. 

' Conclusions. 

1. Tho optimum dose of scaidatinal toxin for intradcrmal 
tost is 1/5 c.crii. of a dilution of 1 in 1,000 strength. 

2. Women wlio react positively to intradcrmal inoculation 
of .scarlatina! toxin aro moro liable to develop puerperal 
sepsis than nou-re.actors. 

3. Difficult lahonr, with or without laceration, predisposes 
to pnerpoial infection only in so far ns tho risk of intro- 
duction of S. pyogenes is thereby increased, provided an 
oxtcriial sotirco of infection ho present. 

Tlio work was c-arried out during; tho second ye.ar of mv fcniiro 
of tho Lawrciico SclioJarship at .St. Bartholomew's Hosp/fat. Ify 
thanks aro duo to Dr. R. R. Armstrong for active collaboration anil 
ndviCQ throughout tiio inquiry. 

; lirrrnrxcT.s 

I prnc. Jley. .^nc. 1918, vol. xxi, p- 28, ~ T.nncet. April l-lli, 1928. 

p. 748. ^ St. Pat t/wtoi/ieifU J/onjiitat Journal. September, 1^, p. 181. ... 


A YELLOW FEVER VACCINE. 

BY 

TLVVTARV HINDLE, 

BHT MEMORIAL RESEARCH FELLOW IN TROPICAL SlEOiaN^. 
(From the 'Wellcomo Bureau of Scieotifle Bcscarcb.) 


Tot Urgent necessity of somo method of protective vaccin- 
ation against yellow fever has been strikingly demonstrated 
by the occurrence of epidemics of increasing severity in 
West Africa, and also by the recent tragic deaths of three 
distinguished investigators from tliis disease. Consequently 
it seemed of interest to see whether a protective vaccino 
could be prepared by using any of the methods employed 
in the case of other diseases caused by filterable viruses, and 
in particular those recommended by Todd (1928) for- fmvl. 
plague, Laidlaw and Dunkin (1928) for dog distemper, and 
Bedson, Maitland, and Burbury (1927) for foot-and-mouth 
disease.' 

Tho strain of yellow fever employed was isolated from 
n case at Dakar, and has been maintained by passage in 
rhesus monkeys and mosquitos until the firesent time (see 
Sellards and Hindle, 1928). Although tho minimal dose 
or Tii'Hs been estimated tho siihciitaneous inocula- 

tion of 0.0001 ^'am of the liver of an infected monkey 
produces death \n fonr to fivo days, and sixteen monkeys 
have been inoculated with the virus, with fatal results in 

(1928) in West Africa have also shown that tlid infection 
IS almost invariably fatal in rhesus monkeys, and therefore 
in tho following experiments the possibility of natural 
recovery from the disease need hardly be considered. 


Formalinized Vaccine. 

Part of tbe liver and spleen of monkey H 10, which had 
died from tho disease, was ground ,'up in' a mortar with 
broken glass, and the resulting paste mixed with five parts 
its Weight of normal saline, to which was added sufficient 
formalin to mako a strength of 1 in 1,000 formaldehyde. 
The emulsion was filtered through muslin and kept in tho 
ico chest at 0° to —3° C. until used. This vaccine has been 
tried on only one monkey, with the following results. 

I?fic,iii.s H is was inoculated subcutaneously with 1 c cm 
of formalinized vaccine on April 19th, 1928. It showed 
” ■t'’ three degrees on the fourth 

kut no, other obvious reaction. On April 
inoculated snbcutaneouslv with 0.2 gram^ of 
rnSected Uver from monkey H U, whidi had died Lm the 


disease, and after an incubation period of three days had 
a mild attack of yellow fever, with four days of foi’or 
followed’ by a subnormal temporaturd and thon_ a return 
to the normal. Two untreated control monkeys, inoculated 
subcutaneously at the same time, one with, 0.001 gram and 
the other with 0.0001 gram of the liver of monkey H 11, 
died of j’cllbw fever after fivo and five and a half days 
respectively. 

Tills vaccin.'ited monkey was again inoculated on May 
24th with approximately 1 gram of liver material from an 
iiifcictcd monkey, and again showed nothing moro than a 
slight fchrilo reaction, wliicli was prohahly tho re.siilt of 
tho largo dose administered. Furtlicr experiments with 
this vaccine are in progress. ' .... 

' Phenol Glycerin Paccine. 

Part of the liver, and spleen of tho same monkey (H 10) 
used iii tlid preparation of tho abovc-dcscrihod vaccino was 
treated in a different manner. The organs were cut up into 
small pieces and washed well with normal salino in order 
to removo all traces of blood. Tlie tissue was then ground 
up in a mortar with .broken glass, and tho resulting paste 
mixed w'ith four times its weight of tho following mixture : 

Glycerin 600 c.cm. 

5 percent, phenol , .... .100 c.cm. 

Distilled water ...' ' ... ... ... ‘ 300 c.cm. 

Tho emulsion was then filtered through muslin and kept at 
room temperature for seven days, after which it was placed 
in the ico chest. This vaccino has been tested on seven 
monkeys, with the following results. 

Rhesus if 12, This monkey was inoculated suhcutancously 
on April 19th, 1928, with 1 c.cm. of phenol glycerin v.iccino 
which had heeii kept in the ice chest for twenty-four hours, 
and, except -for one day, when it had a poor appetite, tho 
animal showed no reaction as a result of tho inoculation. 
Bight days later it received a subcutaneous injection of 
0;2 gram of infected liver material from monkey H 11, hut 
showed no reaction. Six days later it was again inoenlatod 
with 1 gram of infected liver, and on Alay 24th, five weeks 
after vaccination, received yet another inoculation of 1 to 
2 grams of liver material from two monkeys which had 
died from the disease. 

This monkey, tlierefore, has been inoculated on tlirco 
separate occasions ■with enormous doses of the, vims, but 

3® case was any riso in temperathi’o observed,' and tho 
has Temaincd in perfect health.. 

These results were to favqurablo that it was decided to. 



078 June g, 1928] 


ambulatory teeAtment'of varicose ulcer. 


r 


AMBULATOEY TEEATMENT op YAEICOSE ULCEE.* 

BY 

ROBERT GIBSON, M.D., 

HOXORARY DERMATOLOGIST, SALFORD ROVAL HOSPITAL; 

AND 

ALEX. E. SOMERFOED, M.B., 

assistant medical OmCER, MANCHESTER ROTAL INEIRMARY. 

Vamcose veins are met with in men and women in all 
guides of society, but varicose ulcer is almost entirely con- 
hnec to the wives of working-class men— women wiio, as 
a lule, have had large families, and who have to work 
a 1 the waking hours all the days of their lives. Bo inured 
aie some of these women to the pain that thev hesitato 
to have the ulcer healed lest some other and greater mis- 
fortune should overtake them. L‘<-<itei mis- 

Our e.\-perieuco, gained during the past twelve months 
go'’™! can be healed, an, rovm’ 

has rendered the nroimnsis fn; ‘-lire 

than formerly. P^° 2 nosis for varicose ulcer much better 

Th.-c I^'JECIION of AtARicosE Vei.\.s 

id tL&a°" P^tformed in the out-pationt clinioi 


THrD«iTi"Oi 
Alfiiirji. Ju( I'XAt 


-luid the following solutions are used 

1. Quinine hydrochlor. 

Urethane 

Aqua dest. ... ] 

2. Sodium salicylate 
Novocain 
Aqua dest. 


4 grams 
2 grams 
oO c.cni. 
Ill grains 

.5 grains 


. triciie 

Idiosyncrasy is observed d n.. •? ' ' “ " “o 

future sittings; TfsTclvisabletbo;?- ^ 

at each punctiu-e, and at intorvn/ given 

on the vein. The injections are given weeki;."' 

the foot'^of' t^e'*lerto'’be' trea^7 “‘"’^uitiit hciglit with 
■Aioction ispainted\w,Laine l;Va"^ tite^for the 

the selected site. When the needle^ of applied above 

duoed into the vein the tourniquet ^ iu*™- 

ot the left hand is placed on the ^ forefinger 

to, np, -ess the vein, the middle fineer Lef of -the needle to 
\ein above the ncSedle. The midfllf r, ? used to compress the 
^■om the forefinger so that tti ■ firralv separnled 

The inieolion is4adrand Vefore‘thr'""’f, ‘™Ptied 

passing along the .meedle tract Th Pe®'’®"* fhe solution from 

in position for three to four mm'i>tM* rf“'®®''® Pad are kent 

and collodion is applied to the punoturt" '•‘-'leased 

It is. not advisable to iniect 
lest infection of the thrombus sup“rvenp?' "u 
ulcois are. freely scarified, -and if oo t ' edges of 

there are aneurysmal dilatations ,5n f'appens, 

above tbo nicer, they .should, be onenerr‘“®i™“®‘'‘‘'‘tely 

bleed empty. . Following scarifieation^a d^v allowed to 

dressing is applied for twenty-four hours ^ anUSvool 

gebl, j.1^1 nine- 

end of this period -tlfe drtSng 

(caused, and a new dressing is applied is 

the zinc-gelatin is : ■ -f ■‘•“u formula, for 

Zinc oxide ... - . . 

Gelatin ... y,'. — - lOparts 

bfjycenn ... • - ■ *v ••• 6 - 

Aqua ... . ■“ “* ••• 14 *' 

This forms a .stiller dressing than the i.sn'el f ■ ' /’ ' ’ 

preparation and is strongi;Yeeomm™drd 

t <rAnt»/nc- 

the foot is plnccd on r’ res? Thf ^int “elnT'’“‘""‘ ' «"‘l 

• Koa.l iM.,„r,. O ^_ ^i, Warmed to m ake 

'•(.='a Medical .U^ociation. 


brn'Tmd‘'./’'e!;,^,",‘' “i" "i'® '®"- "''T'l an ordinary painP 

irum .md a g„u 2 c bandage is aiiplied-tv.o or three liivcus ,!i 

Liid.agc arc employed. It is important to nolo that Ihc^eiiti.i 
ulcer IS covered nitn tlic dieting, no window being left. 

liiose who have not tried tlii.s dressing often object to 
a discliarging ulcer being covered, but it can bo dimj 
nitli conlidciice and tlioiigb tbo ulcer mav, as fre(,ueiitlv 
Ii.ippcn.s, bo bathed with jiiis, wlion the drc,s.sing is rcniovej 
tlio edges of tlic ulcer will .show a tendency to Iital, wliiili 
"! ‘"•e.ul'Uully go on to complete euro. Siicli a procediiiu 
will rapidly euro varicose ulcers. 

A word of warning is neees.sary with regard to tbo 
injecticm of very small varices wliieli are met with in many 
patients. If sueli cases arc injected the patient slioiibl be 
put to bed for twenty-four lioiirs following the injection, ' 
snuo sjyclliiig ensues, and gangreno with the formation of ' 
.n .slow-JiealMig ulcer is linblo to occur. 

Wo liavo during tlio jiast twelve months treated nearly 
•vf-vciity ulcer.s, M'ith juarked .success iu every ea^e. Ulcei's 
of long .standing— in one case of tweiity-tbreo years— have 
healed, and still remain so. Patients are asked to report 
>u rcgul.ar intervals after discharge, so that wc may observe 
the result. 

THE TEEATMENT OF PROGRESSIVE aiUSCULiVE 
ATEOPUY BY PAEATIIYROID, CALCIUM, 

AND VITAMIN D, 

nr 

T. H. THOMAS, M.E.C.P., 

Captais- I.M.S. 


Jly- tbo administration of parathyroid extract, cnleiiim, and 
vitamin D - recently- in ih'o' Presidency -General 'Hospital' 
Calcutta, results have been cbtuinc'd in 'tivo-casc.s-"of oiont 
luetic progressive muscular atrophy which, while they have 
not attained a degree exceeding mediocrity, perhaps,- aio 
iiovcrUicless striking and gratifying. 

' The method of treatment employed at the outset was the 
liypodcrmio injection of parathyroid extract 1/10 grain 
daily, together with cpd-Ii'ycr oil 1 ounce twice daily by the 
inouth, and calcium chloride in solution 15 grains three 
tinies daily.' Later tins treatment was modified; ampoules 
were' snbstitiitcd for the tablet form of paratliyroid extract 
colloidal calcium took the -placo of- calcium chloride, ami 
osteliii, 4 .minims twice daily, was given in addition' to 
the cod-liver oil. 

Case i. 

Tbo first pnUont, ndmitted on November 26tli, 1927, -was nii 
Anglo-Indian, aged 34, wlio gave a history of .sixteen - years’ 
duration of gradually progressing muscular weakness and wasting. 
This caso was clinically of the piiro lower motor neuron Ivpe 
weakness and wasting being especially marked In the ulnar muscles 
of both hands and forearms, the biceps and triceps of both sides, 
the muscles uniting the scapulae to tho spinal column, tho muscles 
of tho back, and' tbo anterior Ubial muscles willi marked foot; 
drop. Weakness witbout appreciable waiting was present in the 
hamstring muscles of both sides. iV- somewhat remarkable fcatuio 
of the case was -excossivo wasting of tbo -sterno-ninstoid imiscles 
amounting to almost complete absonco. With tlic e.xception of the 
stcrno-inastoids all 'tho ' muscles reacted to faradism. The gait 
consisted of a peculiar goose-step, owing to the weakness of tbo 
hamstrings and tbo foot-drop. There . was considerable lordosis; 
the palieut had to be assisted to his feet, and could not walk 
unaided, 

.The treatment abovii outlined was begun on December 12th, 1927. 
About three weeks later he surprised all coiicerucd witli tlio state- 
ment that lio -was improving. It was found, however, tliat ho 
could dorsiflex both feet just a fraction of an inch. Further slow 
Prpgress occurred, and at the pfesoiit tiriio ho enn approximate his 
Brapulae m the mid-lme- posteriorly with the liitliorto completely ' 

both -rhomhoid muscles, exert quite an appreciable grip with' 
aoim'sl 1®'“' “'■"'s «t iTio elbow 

He-^ts f which- he could not do previouslv.' 

tie sits more erect in a chair; aiurthcrc is uimuestionablv rreat 
improvement, in general health and muScu L tone ‘ 

■ iud'hirsimowhat ''® with greater steadiness 

ground? greater facility m lifting his toes from the 

1. Tti +1 ^ Av Case ii. 

■ on Januarv^th *^1928®®?!’^ patient, a European aged 40, admitted 

|, more Japf/ Die’ fu st ’siv 0?™“’'®,“=^ '>“'1 been far 

. three 'years’ previouslv ^'Plflo F^-ikness having occurred less than 
I sclerosis witl? nrofoumi -iTn.fi ®'‘®®. amyotrophic lateral 

both hands, w?th ankvlos?s*’'f’ 

There was ’extreme gSM wa^n^® mctnearpq-phalaiigeal jo'int.s. 

fjLiieiai -ssasiing and spastic paralysis of tho 


jrEMOKANDA. 


[ TnT.Tinmn Q7Q 

Mkoicai. JovTcrtu, o t o 


June 9,.ios8] 


biiUiat- ll.c palnlnl reflex was absent.. Swallowins was xeij 

ilifficult, ami tlie jaw Iniajj pemleiit ; liquid food liad to be plareil 
inside the inonlli and was slowly pulped down, ibis was SHccccdcd 
by fits of eoupbinp when the food proceeded towards the air 
passaecs. The wasting of Ibo intercostal muscles was extreme, 
and respiration a as a painful proce.s.s. To add to t ile patient a 
discoSiforl tliere was a troublesome laryiigilis and l.roncbdis. 
Riving rise to an iiiccs.s.ant gargling noise on respiration. Tlic 
patient was entirely helpless, and beyond straigliteuing out Ins 
lena wlion they were flexed be could scarcely perform any volun- 
tary niovemcnt. He could shake bis liead for * no ojtd say 
“ all ” for “ yes,” otherwise lie tvas incapable of speech. He was 
naturally regarded as being very near bis end. 

Within ten days of bis starting the treatment Ins wife stated 
that she noticed 'an indefinable iinproyenienl in Ins condition, and 
within a inontli definite changes for the better had appeared. The 
patient was with some dimcully able to approximate Ins bps and 
to raise his head from the pillow, and could swallow his food with- 
out inconypnience. A conversation cotild be carried on with him 
with a certain amotinl of difTiculty. At the present time he 
cannot, phonatc welt, hut he can form even thrce-syllablcd words 
witli his mouth, and it is quite easy, if one has patience, to 
undorstaud wliat he has to say. The mo.st icinarkablo advance, 
Iiowcver, has occurred in the use of his jaw muscles. He can 
now chew his food withotit any difTiculty and sivallow quite easily. 
Another unquestionable iinprovemcnt is'manifcsl in the u.se of the 
.lower limbs, for he cati now flex and extemi both legs at the knee- 
joint, and can also dorsiflex both feet. 

The general nutrition of this patient has improved remarkably. 
The weight h.as not been recorded owing to the discomfort 
weiehing would li.ave caused, but the iinprovemcnt has been 
visihlo. On admission ho gave the impression of licing in immi- 
nent dangeb of death, arid the change for the better is beyond 
all doubt. 


These elinic.al oh.serv.atiou.s .apponr to intliente tlint there 
is an element in the treatment tvhieli is concerned most 
elo.sely with nervc-cell metaholi.sm. It will ho noted that in 
Iroth tho cases atrojiliy had procooded to sneh an extent that 
complete recovery could not he expected, for tn tho first 
there was a .sclerosis of neural tissue extending over a 
period of 'sixteen yenr.s, and in tho .second a progress to 
111111081 the terminal .stages of the disease in a relatively 
short ])Griod. There is no doubt that in early cases in 
wliieh wasting has only jiist commenced, and where fibrilla- 
tion is .still active in the weakened muscles, something 
approaching a complete cure might ho expected. Even in 
severe cases it appears feasible to suppose that the onward 
jirogress of the di.scaso may bo. arrested. 

Hiere is a group of eases of tjuito another nature in which 
a trial of this form of therapy would aiipoar to be ju.stified. 
T refer to the group of mental illnc.sscs, and especially 
to dementia praccox, in which the whole svmptoinatologv 
from tho beginning to the most distre.ssing end argdcs a 
cell atrophy which, invisible and molecular though it may 
be, is ncycrtlieless sufficient to cause complete disintegration 
of the higher association tracts. Paranoia might almost be 
included in the same category. 

I have to thank Major E, O’G. Kirwaii, l.Sr.S., the 
^igcon-superintcndcnt of tho Presidency General Hospital, 
Palcutta, for pennission to refer to tho cases concerned. 


^emorantra: 

MEDICAL, SURGICAL, OBSTETRICAL. 

LIGATURE OF THE INNOMINATE ARTERY FOR 
T .1 T, ,I^yOMINATE ANEURY'SM. 

In the-Thifish Journal of Sunjciy (vol. ix. No. 35) Si 
Charles Ballance collected the recorded cases of ligatur 
of the innominate artery; Im writes: “All the case 
recorded in the following paper, except mv own, are o 
ligature of Hie innominate for subclavi.aii or carotii 
aneurysm. His own cases comprised four, of which tiv 
patients died shortly. after operation, one died two and i 
mlf years later, and the remaining one could not b 
tiaced. Aneury.sni of the iiiiioniiiiate artery cured b 
proxini,. ligatuie of the artery is therefore siifficieiitl 
uncommon to make the publication of the present case o 
interest ; it is, moreover, the first successful case to b 
rei)orted from Leeds. 

of^thd^ 1” 1918 a bullet wound at the roo 

of llip claviVlp”^^ Tlllf immediately above the cenlr 
station fiom bullet was removed at a casualty clearini 

v:ouiid ranidlvSioalpli^'K end .of the clavicle, and lb 

P . healed, but a small hard swelling remained at th 


.site of entry, iind anollicr as large as a small egg in the notch 
above tiic lunnubriuiij slcrni. Since, being wounded he has laad 
a husky voice and freejuent attacks of pain in the nc-ck, and 
iicadnclic without vomiting. Jn 1925 lie suddenly lost the vision 
of the right eye, which partially returned later. 

A w'cek before Christnia*5, 1926, the central swelling began to 
enlarge rapidly, and this was accompanied by much pain both at 
(his place and in the back of the neck. He was admitted to the 
Ministry of Pensions Hospital in Leeds in January, 1927. There 
was n lender pulsating swelling as largo as a hi" pear filling the 
notch above tlie slcrnuni and extending in an ill-dofincd manner 
to both sides of tlie neck; the central part of this swelling was 
purple in colour and almost a.s thin as tissue paper. He com- 
plained of pain in the root of the neck, in the occipital region, 
and hohind both oars. There was difficulty in swallowing, 
especially fluids. Tlie right pupil was contracted, and the right 
radial and carotid arteries could only bo felt pulsating feebly; the 
huskiiioss of the voice w'as found to be due to rigid lecurrcnt 
laryngeal paralysis. There were no sensoiy changes in the hand 
or 'arm. lie was short of breath, had a pulse of 92, and a 
temperature of 99.4° F. As the swelling was rapidly increa.sing in 
size I decided to operate without delay, and performed the 
following operation on January 24th, 1927. 

The manubrium sterni was removed after carefullj* separating 
the thin nncury.smal sac, wliich was closely adhering to tho upper 
border. The aneurysm was found to spring from the innominate 
at its bifurcation, leaving rather le.«s than half an inch of the 
main trunk intact at its origin from the aorta. A ligature of 
No. 2 chromic catgut was passed round this pari of the innomi- 
nate and tied witli sufficient tension to approximate the walls 
closely. The recent acute symptoms were obviously due to a leak 
in the upper and right side of the sac. The clot was turned 
out. when vigorous bleeding occurred from tho distal end of the 
subclavian. A finger was applied to the open mouth wliilc sutures 
were being inserted on the inner side of the sac; after lying these 
all haemorrhage stopped. It was impos.^ible to obliterate the 
prcatcr. part of the sac, and inadvisable to attempt removal, as 
it was firmly adherent; it was therefore, packed. 

The patient stood the operation remarkably well, but the wound 
took some weeks to heal completely, owing to the packing. The 
right arm was useless at first, but lias since fully recovered, 
though tboro is, of course, no radial pulsation. When last seen, 
in June, 1927, he was very well, with no sign of rcairrence. - All 
that remained was a small hard mass where the aneurysm had 
been, and a depressed scar at the place from which the manu- 
brium sterni was removed. He has, of course, still the huskiness 
of his voice, and vision is limited to the central part of the field, 
in which he can only distinguish objects rather mistily. He is 
quite free from pain.* 

E. R. Flin'Tj F.R.C.S., 

Assistant Surgeon, Leeds General Infirmary. 


ACUTE APPENDICITIS FOLLOWING TYPHOID 
FEVER. 

The relation between aente appendicitis and typhoid fever 
has always been an interesting i)biut and the cause of some 
confusion in diagnosis. Acute appendicitis following typhoid 
fever must be a rare condition — I have no means here 
of verifying this— and the following case may jirove of 
more than ordinary interest. 

A young man was admitted to the Colony Hospital, Grenada, 
on April 21sti, 1927, with a history of four days’ continued fever. 
His doctor regarded him as a case of suspected typhoid fever, 
but was doubtful of the diagnosis, as. there was an old liiHory 
of (?) malignant malaria in Dcmerara several months previouslv. 
He was isolated and kept under observation, and eventually was 
notified as a positive typhoid case five days later. His illness ran 
a typical course up to the twenty-fourth day, a defen*escence 
by lysis having occurred. On the evening of tins day (Slay 10th) 
his temperature suddenly rose to 100.6° F., wdtii puls'e rate 
quickened to 114, and he began to complain of acute abdominal 
pain. It is noteworthy that his pulse rate ranged from only 
76 to 100 during the height of the typhoid fever. 

I ordered a soap enema and the result "was copious, but there was 
no relief from the pain; he was slightly distended. Palpation of 
the appendix region revealed a \vell-dcfincd enlarged appendix with 
bulbous extremity,* which was tender. The matron of the hospital 
palpated the appendix and could make out its outline distinctl}’. 
Oil the morning of May 11th I operated, and removed an acutely 
inflamed appendix with, ns wc had expected, an enlarged tip'; 
it was adherent in its whole length to the caecum. The wound 
healed by first intention, and thougli the patient ran a tempera- 
ture for some eight days afterwards his recovery was uneventful 
and he had no more pain. 

The patient’s prolonged convalescence was entirelv due 
to his enteric condition. No blood counts were performed 
during lus typhoid phase aior at the occurrence of the 
appendicitis; they might have been of interest, but the 
abrupt acceleration of the pulse rate was significant. I 
regard this as a genuine case of appendicitis occurring at 
the end of the third week of t^-plioid fever, and tlie wonder 
is that there are not more instances of the same condition 
to record. 

V. L. Ferguson,- M.B., Ch.B. 

St. Lucia, British West Indies 



880 .Tune g, 1928 ] 


MATERNAL MORTALITY DDE TO RDERPERAl' SEPSIS. 


[ 


Trr. JlRmtH ‘ 
Jlr-fi'cii. JocR-Tit 


Hfiptnls 0f 

MATERNAL MORTALITY DUE TO PUERPERAL 
SEPSIS. 

At tliG meeting of the Edinburgh Obstetrical Society on 
May 9th, with the president, Dr. IIaio Er.nousoN, in the 
chair. Dr. James Young read a paper entitled “ Maternal 
mortality' from pucrper.al sepsis: an analysis of tlio factors 
of contagion, trauma, and auto-infection,” uhich is pub- 
lished at page 967. 

Dr. Foudyoe, in the discussion following this paper, 
regarded the question of segregation of conllnomont cases 
in hospitals as an important one, and doubted whether 
it was advisable for normal cases to bo confined in hospitals 
where there was only a limited amount of space. Ho 
thought that forceps delivery in selected cases prevented 
the trauma which might otherwise bo caused by a very 
delayed labour. He regarded the statistics of puerperal 
sepsis of one hundred years ago ns not very reliable. 

Professor Hendiiy referred to three cases of pyrexia duo 
to extraneous origins — namely, infective rhinitis, com- 
mencing ahitlow, and a septic wound on tho skin of tho 
patient’s husband; these showed the importanco of con- 
tagion. He supported very strongly Dr. Young’s principle 
of separate accommodation in maternity hospitals for cases 
.sent in after intervention outside. AVith regard to trauina, 
pi imigravidao seemed to be more liable than inultiparac. 

Dr. Millwi showed by statistics of tho Royal Maternity 
Hospital that the incidence of pyrexia in patients delivered 
instvumentally Avas_ much larger than in those whose 
delivery had been spontaneous. Ho had found a marked 
variation in the bactericidal power of tho blood in pregnant 
women, which might explain tho variation in individual 
susceptibility to infection. 

Dr. J. M. Bowie regarded trauma as of great importanco 
m puerperal sepsis. He thought that the whole machinery 
ot maternity servie© in this country needed overhaulinfu 
Reorganization might bo effected in two ways : (1) by tho 
present system of trained midwives working alone in norninl 
cases and assisted by doctors in difficult cases ; or (21 since 
midwifery work appealed to many doctors a new race of 
spMialists might riso, who would confine themselves to it 
Dr. HEPriE Paterson attributed great merit to pro- 
longed antiseptic douching after delivery even in normal 
htter’vention greater value after manipulative 
..The Phesident thought that haemolytic streptococci 

sreretio." ‘hul • t>>e normal vaginal 

certain circumstances thev might repair 

dicater";t hiRl'“V “g-gation orcom" 

He did not tli’iiik ’““spital was required. 

^?er eXon Tince no instrileiital 

with very sevei’rtraum“ associated 

of midwives and medical piactitrorifarei^^-^^^^^ 

Clinical Reports. 

Dr. Cn.iRTERis Gn.iH.iM described in detail ten i 

Caesarean section which be had performed 
indications, such as contracted pelvis, eclamnsia r' 
ated sclerosis, and an impacted transverse lie ’ Attr^'"' 
was drawn to the number of cases of Caesarean J-"" 

coming under the notice of a busy coiintrv in-n 

m^rt^U?' attended .witl/aily maS 

wi^i; “ 

and diabetes respectively. In the ease nf “igica, 

patient developed the disease at the onset of labour ^1 
however, pas.scd off normally with the aid of “ t’w v’ul 
s OOP ” Tho child had no ilasli when bout and dTd^'f^ 

ITS 


licaltliy. The ca.se of diabetes was di.ognosed three months 
before labour w.as due, and the patient was treated with 
60 units of insulin daily until lahonr started. The lahoiir 
itself w.as rather liiffiiaiU, since the head had rotated into 
an occipilo-posterior position, and tho patient had to be 
kept niidor light cbloroform aiiae.stbesia for ne.arly two 
lioiirs before delivery was effected. Chloroform was not 
feared as the case had hceii .so tlioroiighly treated with 
insulin. The mother nnrsial lier child for six months 
without any detriment cither to herself or to tlie infant. 


NORTH OF ENGLAND OBSTETRICAL AND 
GYNAECOLOGICAL SOCIETY. 

At a meeting in Leeds of tho North of England Ohstetricnl 
and Gynaecological Society on April 27tli, with tho presi- 
dent, .Mr. H. Leith JIl'ihiav (Liverpool), in the chair, 
Mr. J. E. St.icey (Sheffield) described a S])eciincn of 
bilateral tarry ovarian ejAsts. Mr. Stacey said that tho 
histological cliaractoristics of tlio lumours were identical; 
marked liyperaemia and prodnclioii of numerous capillaries 
were a fealiiro of tlio sections. Tho cavity was lined in 
patches witli a poor typo of eolumnnr epillieliiiin, which 
gavo placo in sonio areas to a moro cndotbclial-liko 
cliaracter,' and was entirely absent in other parts. Deep 
to tho epitliclinl hiyer was a stratum of golden pigmented 
polyhedral cells with many of the characteristics of lutein 
tissue cells. Areas of this liad been stAincd by the Rnissiaii 
blue reaction, and in no ;;r.; t jl.jv.cd the jircsonco of iron. 
This layer of lutein tells ’..iis invaded irregularly by bands 
of hyaline tis.sao ari.ingcd radially to the cavity of tho 
cyst. In places the cells wore separated from one another, 
producing a mo.s.'.ic effect; in others they were .tightly 
bundled togetlier. No convoliiiion of the lutein tissue was 
pro.sciit in any pint of the wall. The clmracteristics of 
liitciii tis.suc cells in t’ao walls of these cysts demonstrated 
tiieir difference from the endometrial cysts described by 
Sampson, .and m.arked them out as folliculav in origin. 
But for the lack of c .nvolutions and of two distinctly 
defined tvpes of cell — g; Aiuilosa lutein and para lutein — 
Mr. St.acoy would bavo ;. laced this case in the third class 
of tariy lutein cysts de:.’ribed by AA’llfred Shaw — namely, 
tho tarry corpus Iiitcimi c;,st — since the hyaline clcgenera- 
tion in the wall, a marked f:.-.turc in this typo, was present. 
But in tho absence of the .e two primary charactcristies 
(convolutions ami two types cf cells) ho classed the case 
as 0110 of unusually largo tarry theca lutein cysts. Mr. 
Stacey thought that iiisufiicieiit attention had boon paid to 
AA’ilfred Shaw’s communication to tho sixth British Con- 
gress of Obstetrics and Gymiecol'.gy, held in jManclicster in 
1927. (Reference was made to t'.-is in our columns on Alay 
21st, 1927, p. 924.) A large part of this paper had been 
devoted to a consideration of tarry cysts of the ovary, and 
Mr. Stacey suggested that ondoniotrial implantation cysts 
bad very often been mistakenly so called when really they 
were of follicular origin. Shaw’s .three types were tho 
tarry theca lutein cysts, the tarry granulosa hitein cysts, 
and tho tarry cysts derived from corpora lutea. Each of 
these typos had boon described as possessing charaetcristio 
features, but from superficial losemblanccs between each 
Mr. Stacey thought it must require a vci-j- largo number 
of sections taken from many parts of an ovary, aiul even 
many areas of the wall of the same cyst, before it was 
possible to placo accurately any tarry cyst in its right 
groiqi. Moreover, tarry cysts of more than one typo had 
been found in tho same case, and in one specimen described 
by Shaw, complicating matters still further, an endo- 
metrial cyst of Sampson bad been associated with a tarry 
theca lutein cyst. Naked-eye appearances in no wa)’ helped 
in tho diagnosis between eiidornotriomata and tarry C 3 ’sts of 
follicular origin. Sampson had described no endometrial 
ejAst as largo as the follicular tarrj' C 3 'st hero recounted, 
but this was no criterion, since Dongal in 1925 had reported 
one 10 inches in diameter. In the case related tlio 
anatomical and clinical features were identical with nian 3 ’ 
another case described as endometrioma, and onl 3 " a careful 
histological examination in the light of Shaw’s and other 
recent papeiAS had determined the correct origin of the 



r TKrIiBrTi«?it QQl 

MeoTCAi. JovByii. oox 


aUKE 9| *928] 


BPONTANEOITS KUrTUBE- OF -tlTEniNE SAECOJIA, 


tumo<ns. In Sniuppon’s dosoriptiou (if cndninclnnl c\-sls l>p 
paid that in tlic final pondition tlipiv was voi y littlo loft of 
tho lining of the cyst beyond n few ireognlar cnbical cells; 
deep to tins ivas n-hnt remained of n didiTcntiated layer of 
BtTomn, and, when this was present, large pigmented colls 
wore fonnd in it. The aurronnding ovarian tissue was 
converted into a layer of hyaline tissue. ’I’his alone was 
sulficient to show how easy it conhl he to niistahe the two 
conditions of cndometrioina and follicular tarry c\-st.s. 


Sponfancoiis Ihiplurc of VUrliic !<nrcomn. 

Tho PnEsinrA'T and Mr. A. A. Gemjiv.i.i. (Inverpool) 
described jointly a , case of nlerino sarcoma which had 
riiplurcd spontaneously, giving riso to acute abdominal 
symptoms. 

A stcrilo married woman, aged 48, was admitted with the 
diagnosis of “ aciile abdomen ’’ to n eurgieal unit m the David 
I,ewis Nortliem Hospital, Liverpool, on Jtnrcli 7th, 1927. .She com- 
plained of aotilo abdominal pain with nausea and vomiting, and 
great frequency of micturition. The pain was referred to the lower 
abdomen, and bad been present for a few hours only; the bowels 
liad moved on the morning of _ admission. She gave a history of 
vomiting with pain in the right iliac fossa three weeks pre- 
viously; this soon passed off,' and' she bad been faitly well since, 
jlcnslruation bad been somewbnt irregular, altbough in no way 
excessive, for a year previously; for the preceding three nionths, 
bowever,-it bad been regular. The patient lay in bed with the 
abdomen much nwollcu and tho left leg flexed. The tempemture 
was normal, and in spite of the patn her puKo was only 80. 
,Bv edtliotor 34 ounces of tirino wero drawn off witiiout 
relief to the pain. Vaginal examination showed a rounded tender 
land apparently fixed swelling filling the pelvis. She was accord- 
ingly transferred to the ’ gynaecological unit. A diagnosis of 
ovarian cyst with twisted pedicle was made, but under an anaes- 
thetic tho ma-ss a-as defined ns uterine; it eocmed prolnahlc, 
therefore, that there was acute, presumably red, degeneration of n 
uleriiio fibroid. The patient apiicarcd healthy, auth a moderate 
amount of subcutaneous fat, 

.At operation the posterior wall of tho uterus presented an 
enlargcmcnl filling the pclvisj the mass a-as lightly adherent at 
one spot and had burst at its lower pole. There' was a small 
quantity of free blood in tho pcriloncal cavity, and some abso- 
lutely loOjio fragments, totalling probably liaU an ounce, in the 
pouch of Douglas. The peritoneum of the lower abdomen and 
pelvis showed no secondary growtiis. A subtotal liystcrectomy 
svitU rcmoviil of both appendages was rapidly performed. Tiic 
spcc'uncn weighed 12^ ounces, and even after removal was judged 
to bo a uterus containing a degenerating fibroid wliich bad burst 
I its capsrile. The rupture bad occurred over an area of about two 
.square inches: the peritoneal edgra were retracted and fully 
exposed tho sottish lobulatcd and apparently oedetnatous sub- 
stance of the growlli. The tumour was moderately firm — not 
in any way brain-hke — and it was slighlly yellowish. Micro- 
scopical examination proved it to he a mixcd-cellcd sarcoma 
(small round cells, spindles, and giant cells) with areas of 
necrosis. . The growth was dcfinltoly infillratiTO in tlio muscle, and 
at no point was any suggestion given of malignant metaplasia of 
a fibroid. The endoroelrial cavity lay distinct from the mass and 
was separated from it by a varying amount of tho muscularis. 
The loose fragments stained well and showed no necrosis. The 
patient left hospital on March H7th, and pelvic and abdominal 
examinations ^were then normal, but on April 15th she was 
readmitted with symptoms of threatened intestinal obstruction 
ana considerable cystic swelling of the lower abdomen. An 
e^loratory _ laparotomy Telnaied several pints of slightly blood- 
stained fluid and. showed innumerable nodules of ninl'ignancv, 
more particularly m the pelvis, but also in the abdomen, Scctroiis 
ot. several of thi^c demonstrated malignancy similar to the 
original _ growth. The patient, who had obvionslv lost ranch 
weight sinco her discharge from-liospilal nineteen days previouslv, 
went doynliilj .very fa.st, and without any further 'symptoms of 
obstruction died on May 12th. ' ' 


Mr. Gough said that the points of interest in the case 
were : 

1. The diagnosis of the nature of the tumour and tho 
reason of its extreme hardness. Bectal examination liad 
proved ot value. 

2. The tjtiostion of eorrect treatment. He had no doubt 
that in this case operation whs the right thing. 

3. The after-histoiy. The vomiting eontimicd after the 
operation as soverelv as before. He did not place anv 
value on the theory that .some caso.s of h.vjieromesi.s gravi- 
darum were reflex in origin, but ho was di,s.uppointod that 
tliore bad been 110 improvement in the condition. 


Imperforate Afiii.s. 

Mr. J. W. BuriNS (Eivcrpool) described a case of “ imper- 
forate anus,” 

A married woman, aged 31 years, Iiad had ilircc normal I.ahoiirs. 
Sho complained of tho womb'" coming down,” and much discom- 
fort on walking. On iir=peeling the v'- - ;; ,^^5 

seen llial exccpl for a small area o ' ■ nus was 

absenl. The \aitva, including the ■ .... normal. 

About one inch inside the vagina on the posterior rvall a trans- 
verse slit with crcnalcd edges was seen, which opened directly 
into the rectum. Above this slit there was a well-marked septum, 
which separated the vagina from the rectum. On bimanual 
examination tho uterus felt slightly enlarged, rctrovcrled, and 
fi-eely mobile; tho lubes .and ovaries were normal. Tbc cocc.yx 
was missing and tbe sacrum felt deficient. TIic tissue between the 
vaginal orifice and the pigmented area felt very thin. On straining, 
the iilcnis and bladder passed outside the sTilva. In spile of this 
condition the paticnl delinitcly stated that except on one occasion, 
when she was in the Maternity Hospital and had been given 
aperients, sho had never experienced any discomfort arising from 
loss of control over the bowels. ■ . . 

The c.ase presented a distinct problem as to the best lino of 
treatment to adopt so as to cure the procidentia and, if possible, 
provide a degree of sphinctcric control over tho rectum; Anterior 
colporrhaphy was performed and the bladder pushed up. Tlie 
cervix was 'amputated by removing n large cone of tissue, and 
tho raw area thus made was covered in by vaginal flaps. Next 
the lower two inches of the rectum were dissected free and a 
new anus was provided in the middle of tho pigmentation of the 
skin. The free end of tho bowel was drawn backwards through 
ibis anus and was united to tbe skin margins by interrupted 
catgut sutures. The perineum was then constituted by bringing 
llic lateral tissues togetber in the midline as in the ordinary 
perineorrhaphy. At the end of throe weeks, when the -vaginal 
wounds had healed, the abdomen was opened, the uterus ventro- 
fixed, and both tubes, cut across, ligatured, and arranged so that 
the cut ends of each tube were separated by tbe corresponding 
round ligament. The patient made a rai-y good recovery from 
both operations and left the hospital in excellent condition. She 
had very good control over the bowel and could retain a simple 
enema. 

Air. Burns said that it was somewhat difficult to understand 
how this control over tlie bowel had come about. Tho 
tissues of which the new perineum 'was constituted cditld 
not have contained much active muscle tissue, and he pre- 
sumed that the original sphincter ani must have been either 
absent altogether or else atrophied. Tho pulling backwards 
of the bowel might have kinked it so much that abdominal 
pressure was required to overcome the obstruction, and so 
a certain amount of control was acquired indirectlv. • 

Placenta Aecreia. 

Air. A. Gough (Leeds) described a case of placenta 
accreta. 


Parovarian and Ovarian Vysts in Prcynancy. 

Mr. M . Gough (Leeds) read notes of a ea.se of par- 
ovarian and ovarian cysts removed during jiregnaiicv. 


A married woman aged 32, had had one child four rears 
previously. The last mefistrual period finished January '4th, 
hes'in in Fcbruaiy and was severe. Aho'ut the 
w ™ ’j" ’nft si8e: there was 

’J • I“Pn/’nn showed a rounded swelling above the pubes 
more tli.-in haif-wav to tlie 
^ eoftish and fluctuant; behind and to tlie right 
tin. 11 was felt deep in the pelvis. On vaginal examina- 

anteriorly, and 
behind it was a hard 
n,?i P f'sb rery slightly movable. It felt 

Bliplit (vl-itf ^ diagnosis of sacral chondroma liad been- m'ade. 
Iherafni delected, and Str. Gough had 

wav of tumour wa.s so obviously in tho 

pSvcd%o hi decided on.- The tumour 

Douelas' adherent in the pouch -of 

4.® Tile annendnll f <>™i'.v- the size of a duck's 

, iiie appendage ana appendix were removed. 


A pnmipara, aged 28, had delay in the second stage of labour; 
Ihc child ^va3 easily "delivered with forceps. It was then noticed 
that there was no loss ot blood, and only after three hours* did 
there appear a slightly blood-stained discharge. TJiere ^-as no 
descent of the umbilical cord. After-pains occurred, but the uterus 
did not contract as usual into a hard round ball. Pituitrin and 
ergotin were given, and attempts were repeatedly made to express 
the placenta, but without success. Having recently heard of two 
disasters following, the removal of very adherent placentas — one 
patient dying immediately from shock and haemorrhage, the other 
a few daj-s later of septicaemia — Sir. Gough decided to leave the 
placenta in the uterus and to nwait events. The cord hangino^ 
from the mlva was kept dusted with boric powder. Ke.xt day 
there was no change, and the temperature remained normal* 
Credo’s method was again tried without success. On the third dav 
the temperature was 100° F., but the' patient’s condition was 
otherwise satisfactory ; attempts to express the placenta ' a^ain 
failed. On the fourth day the temperature had risen to 102.8° ^nd 
there was general malaise. The lochia were of average amount 
and not offensive: -It was then decided to empty the uterus 
Under ether anaesthesia tho placenta was found to bo adherent iii 
one or two places, -hut it was rcadilv removed. The uterine cavity 
was washed out with copious irrigations of a 1 in 300 solution of 


982 June 9, 1928] 


OTO-IjAMNGOL'OGY. 


f nir. Itnmnm 
c Mimcix JoL'ft!<iJb 


lysol. The temperature rose to 103.5° F., hut on the next day hail 
fallen to' 'normal and the patient made a good recovery. Soon 
aftenvards, however, signs of pulmonary tuberculosis appeared and 
she spent some months in a sanatorium; this might possibly havo 
had some etiological significance. 

Air. Gough thought it might ho questioned whether this 
was really a case of placenta accreta. It was clearly a 
morbidly adherent placenta, but perhaps not ono of tho 
most adherent. Generally tlio diagnosis of placenta accreta 
had been mado after an unsuccessful attempt at its manual 
removal. 'What was the proper course when tho placenta 
could not ho delivered in tho usual way? Most English 
textbooks stated that it must bo romovod manually after 
a certain time — ono or two hours. Any important post- 
partum liaemorrhago was, of course, an indication for the 
immediate emptying of the uterus. In this case, with no 
loss of blood for three hours and then only a minimal loss, 
tho safer course was the one adopted. Tho forcible sci'aping 
away of the placenta in fragments entailed a grave risk of 
perforation of tho uterus, shock, haemorrhage, and tho 
later development of septic complications. A risk of 
leaving tho placenta was, Mr. Gough supposed, that 
separation might follow and post-partum haemorrhago occur 
when no help was at hand; but it seemed unlikely that a 
closely adherent placenta would suddenly become detached. 
This fear might havo some weight when dealing with a 
patient in a remote country district, hut in an institution 
it could be entirely disregarded. Then there was tho risk 
of sepsis being favoured by tho retention: it occurred 
in this case, hut was evidently of tho sapraemic typo. 


Drainage in IVcrtheim’s Ilystcrcctomy. 

Professor Eletcher Shaw (Manclicstor) read a paper' on 
the valuo of drainage in Woriheim’s hysterectomy. Ho 
said that until recently his mortality from this operation 
was 20 per cent. Even a mortality of 12 per cent, which 
second series was a dreadful respon- 
sibility for any surgeon, especially since so many of tho 
patients who did recover had a very painful and proloncod 
convalescence. He had tried every suggestion for com- 
bating shook, sepsis, and urinary sepsis without much 
improvement until he found that Professor Wornor in 
\\ ertheim s old clinic in Vienna still drained tho pelvis hv 
a small wick of gauze running down into tho vagina. In 

qhawT ‘1 the universal pr.actico, but Dr. 

Shaw had ceased to do this after tho first few years hccauso 

tl.rfact’th ? a ureteral fistulao, dim probably to 

t le fact that a much larger quantity of gauze was loft in 

Professor Wornor. Sii co his 

.u ? ot Perforoiing this operation upon nine nationts 
all of whom recovered. He admitted tint +l.:vr -1 5 

patients. So, rUhouah ?bo f of these 

he should bring his experience' 'blf" thought 

of the societyf siuceTe bX/d JiVhLl°^ 
improvement from this small s+or. If “ ^ gamed more 
which had been suggested. ^ than from any other 

Mr. Carlton Oldfield said that 
employed the gauze pelvic drain He 
continued its use, and his results were Utter tbf ""7“'’’ 

Mr. Miles Phillips did not use the gauze ^7.™‘^''’y- 

Eidered the most important factor in sUcel v u' 
operation was absolute haemostasis. • ' tollowmg tho 


OTOLARYNGOLOGY. 

The summer meetings of the Sections of Lhrvncml ' 

• Otology of tho Royal Society of Medicine w ^ 

May 31st and the two following days, oi 
Mr. J. F O’Mallev presided ovfr thl seotron of 

presidents of subsequent meetin<r= ^ 

H, B.mwELL (Laryngology.) and%,L Sff (S, 

^'“^O’ao^or A;7ect;ons o/ tac Infernal For - 

motofaTeULs^rfh71nll7‘'r“""^’ P-^er'en v, 

disturbances could be regarded as7oUf’'o'f%^L7t1m; 


tanb patliological elements in internal car affections; 
they deponded directly on tlio sympathetic system. 
Recently, in association with colleagues, ho had cxiieri- 
nioiited on tho action of tho sympatliotio in refcrcnco to 
tho Inhyvinth, tho experiments consisting of cither peri- 
carotid sympathectomy or tho injection of vasomotor drugs, 
compression of tho vortobrnl and common carotid arterie.s, 
and tho warm bath tost. For a long timo otologists had 
been imprc.sscd by tho action of the sympathetic on tlio 
lahyrintliino circulation on tlio one hand, and on tlio other 
by tho secretion of tho ondolymiiliatic fluid. H.aving 
observed a typical .angiospasm of tho anterior labyriiitli in 
ft piitient with Raynniid’s disease, Lennoyez drew attention 
to tho similar strncthro of tho two situations (tho digit.al 
and tho labyrintliinc), and siimnicd up a particular laby- 
rinthiho affection ns “ tlio vertigo wliieli makes ono licar 
it .appeared to bo a spasiii of tho internal auditory artcrya 
Profe.s.sor Portiiiann submitted tho following cbiiiparativo 
tablo’ of tlid two conditions; 


- Mtln^^rc*8 DiPcnPi 
Good bearing, 
l^iuldoii vertieo. 
Sudden and decreasing 
-deafness. 

Slow recovery; 


Lcrnioycz’fi Syndrome. 
Good hearing. 

Gradual deajiicss. 
Sudden vertigo. 

Quick relum o^ bearing. 


Angiospasm could well explain tlio onset of vertigo and tlio 
disap[>cnrniico of tlio deafness, both depending on tlio 
removal of tho barrier of tlio Inbyrliitliino nrtciy. Tho 
patbogony of AIcniero’s di.scnso was still debatable; 
Menibro's own view was that it 'was caused by intra- 
labyrinthino hacmorrliago, wliilo' all who had tried to sqlvq 
it gave an important place in causation to v.asonibtor 
troubles. Many facts pointed to vertigo being essentially . 
ft piionomenon of irritation; it disappeared _with destruc- ; 
tion of tho labyrinth, and irritation of tho intern.al mom- , 
hrnnous ear or of tlio vestibular nervo was required to 
produce a giddy, sensation. A strident noiso by irritating 
tho original filaments of tlio cochlear nervo might also ■ 
cause vertigo rollexly through vaso-dilatation. How was 
this irritation of tlio vestibular noiwo produced? No satis-, 
factory answer could yot bo returned to this question, hut 
whatover tho mechanism, Mdnicro’s disease was closely con- 
ncct-cd with vasomotor phenomena, and thereforo with tho 
sympathetic cqiiilibriiiin. Vertigo was produced by tho 
sudden vnso-dilatation following tho spasm in tho syndromo 
of Lernioycz, but that whicli accompanied ischaemia of ■ 
tho labyrinth disappeared on sympatlioctomy, tho conso- , 
quonoo of wliich- was a vaso-dilatation of tho labyrinth. 
Deafness seemed to accompany ischaemia of tlio anterior ' 
labyrinth by vaso-constriction. Tho nngiospasmodic syn- 
dromo of tho labyrinth included tinnitus, deafness, 
vostibulm' liyqiorexcitability, • sympatlietic hypertony. Tho 
causes of vago-sympathetic troubles were very diverse, and 
might bo meehanical, cndocranial, toxic, or plainly psychic. 
Ho attached great iniportanco to the action on tho regu- 
lating apparatus of the endocriuo glands, especially tlio 
hormone of the suprarenal gland. 


•' Otosclerosis. 

Dr. Lowndes Yates road a paper entitled “ A working 
hypothesis for research in otosclerosis.” Ho said ho 
regarded as instances of this condition cases in whicli 
Bezold’s triad symptom-complex was present with a patent 
Eustachian tube and no denionstrablo ndhesivo process in 
tho middle oar or evideiieo of a former perforation of tho 
membrane. From tho point of view of audiography ho con- 
sidered that there were tliroo types of ear disease : (1) nervo 
or internal . ear deafness ; (2) otitis media , with . indrawn 
membrane, and limitation of its movements by adhesion to 
the' promontory ; and (3) acute otitis media, subacute otitis 
media', and_ otosclerosis, in which thoro could he observed 
a gradually increasing dejiarturo from tho graph. , 

Professor Otto Mayee- (Vienna), tho recipient of the 
Dalby Memorial Prize, in a paper on the pathology of 
otosclerosis', said that in this disease tlio original bone, of 
tbo labyrinth capsule became absorbed,, and bone marrow 
Was formed in which osteoblasts were plentiful; the new. 
bone, thus imperfect in character, overgrew the oval and 
the round windows. In otosclerosis tho lesions were 


June 9, 


OTO^ti^JNG.OTvOGy. 


[ Til?- nnmsn 

Jlff’DICAI/ JOCRjfAL 


983 


nniltii>li\ iiiul filiroiimtn in oVlu'r pivvls foulil iio lOKaixlcd 
as distant manifestations of tlio same in-oee.ss-. lie Imd 
foitiid in tiH’se cases a s.viieJiondiosis, also Iwniv pmrths on 
tin' vct' 0 '>s liono. In toil ont of fifty eases of dea(-m\itism 
examined iie had foniid' typical a?cas of oloseleiosis ; wliilc 
in fifteen out of tliirty eases of otoseleiosis llieee mas a 
maldeeelopnient of tlie inner ear, n*il)i anomalies of tlic 
eoeldenr frninework. Patliologioal investipation .showed that 
it was most proimhiy ii Iiercditary disease ; he opposed tfic 
view that it was inilammatory in oripin. 

Dr. A. A. Gii.\y said Iio aprecd with nearly all Professor 
^layer’s contentions. Ho, hoiioved the disease eo^^id only 
occur in a person wlio liad a personal tendency towards it, 
though it was not inherited in every ease. In further 
icseareh on the subject not only tlie temporal honc.s, but 
also the brains, shotdd ho included in the investigation. 
Mr. G. J. Jrkkins argued that otosclerosis was a diftei'ent 
disease from osteitis deformans, and that the former could 
not he reparded ns an atavism, since it progressed, and no 
, atavistic manifestation showed iirogre.ssion. Jlr. Someiivh.i.r 
H.\STJ j:oa said ho had scon cases of what was clinically 
middle-car deafness change into good examples of oto- 
sclerosis. Jlr. J. Ad,\m (Glasgow) illustrnteil tlie multi- 
plicity of lesions which otosclerotic.s bore by relating those 
1 occurring in a family, and including atheroma, scoliosis, 

I kypliosis of the .spine, and fragilitas o-ssiiim. Sir James 
D i'ND.rs-GiuNT deprecated a hurric-d diagnosis of oto- 
sclerosis, or taking too gloomy a vica* a.s to the outlook; 
he had known cases become stationaiy, and had even .seen 
improvement in some. The PiiRSinENT (Dr, Fra.ser) demon- 
strated on the epidiascope histological specimens in which 
he pointed ont, in otosclerotic en.so.s, areas which seemed to 
he obviously inflammatory, so supporting his view that this 
disease was of iiiflammatoiy origin. 


Diispltngia due fo.rharyugcal Vornh/sis. 

Mr. tv, JI. JIouusoN, in a, paper on dysphagia due to 
phaiTiigeal paralysis, said that patients frcciuently pixs- 
sented thcm.'.clvcs because of difficulty in sivallowiiig, but 
this was not often due to jiaralysis of the idiaryngcal wall, 
yet in the last few years ho had scon several such eases. 
Unfortunately the symptom could not bo treated with much 
chance of success. Complete unilateral paralysis of the 
vagus eansed unilateral iiaralysis of the palate, pharynx, 
and larynx, but there was only .slight ititerferencc with 
swallowing, yihen laryngeal ])arn!.vsis was complete the 
cord was flaccid, both adductors and abductors being para- 
ly,sod. It was possible to im.agino a small haemorrhage 
occurring in the middle of the nucleus ambiguus which 
woidd damage the fibres to the pharyngeal irlexus, and as 
the effects of the bleeding became localized, the effect might 
bo restricted to the palate, or to the [jharviix or larynx. 
The causes of phaiyngca! paralysis could be classified as: 
(1) central, (2) intracranial, (o) extracranial, and (4) peri- 
pheral, such as from diphtheria or load poisoning. Tlio 
prognosis in the condition when due to di])htheria rvas 
favour able, but it was gi'avo when the disabililv was caused 
h.' progressive muscular atrophy and amyotrophic lateral 
sclerosis; it was somewliat better in acute bulbar jraralvsis. 
Mr. Molhson gave details of the cases he had seen, 
including two in which the lesion was at the base of the 
skull, one from a bullet wound there in the war, the- other 
from tuberculous glands. 


Infiinsic Cancer of the Larynx treated hy 
Larynyo-fissurc. 

StClaik Thombox gave an account of the results ii 
70 cases of intrinsic lai-yngeal carcinoma treated br 
arr ngo-fissure. The series extended over twentv-eigld 
years, and he had been able to trace every case. His object 
remove all the tissue between tin 
subglottic space and the ventricular band, leaving only 
the external perichondrium. The danger area was 
undouhtedly, the subglottic space. Of the 70 patientr 
(only p of whom wore hospital cases) 34 were still liviiii 
Ti tnreG to muetoen veal's after tlieir Operations 

uoie eighteen deaths from causes other than vecuv 
patients died from bleedinj 
, appaiently, they fiad been given heroin; it war 


against liis wish and jiractieo that these patients .should 
be given beroin, morpbino, or similar drug.s. Hlcvcn of 
till* piiticnis developed jiinligiiniit disease elsewhere than 
in the larynx; most reenrrenecs took place within the first 
year. If in borderline cases (in wlricli there was a 
tciidoiiCy' to cxtei’inrization) there was a recurrence, he 
ndvi.sed laryngectomy. He regarded the outlook ns grave 
in .subglottic eases, arul when there .was fixation of the cord: 
far examiile, in nine cases in which the cord was fixed, only 
four patients lived more than three years after 'operation. 
It was possible to ])crform the operation tinder local 
anaesthesia; if a genera! anaesthetic was preferred, the 
narcosis should not' ho deep. He neither used cocaine 
Iicforehand nor plugged the larynx. Ho repeated the 
appeal which had been frequently urged that these casc.s 
should reach tire laryngologist at that earlier stage w.lien 
oi>eration was distinctly hopeful.’ 

Miscrlla aeons Papers and Discussions. 

Mr. A. T. Haki; I’cad a jiaper on ach.alasia and degenoi'a- 
tion of Anerharh’s plexus. Ho saitl that the vagus supply 
pi’oservcd the noi’inal oesophageal tone and supplied the 
cardiac sphineler. A lesion of the A-.agiis nerve fibres dis- 
turbed tbo ineclmuism of relaxation of tbe cardia, which 
must precede the enti’y of food into the stomach. In some 
ca.sc.s of .achalasia the ple.virs n-as about tri-ico the normal 
size, the whole str ucture being infiltr.ated Avith .small round 
cells. In the chronic stage there were ai'ound the fibi’ons 
plexus large blood vessels baring thickened Avails. He 
considerctl the conditioiA inflammatory, not A-asculav. 

Dr. AitTncR Ha'urt said that in some of the cases of this 
condition hypertrophy of the cai’dtac sphincter aa-us fonndi 
but not in all. It Avns, ho considered, jmrallcl to Hirsch- 
sprung’s disease in that thei’e avos an absence of normal 
spUiuctoric action. Dr. A. Buowx Keroy said the fibrotio 
changes in eases of cardiospasm Avere first domonsti-atcd 
hy Dr. Mirnro Cameron. Tire sjjoakcr thought that 
-Alcgenorativo changes in AAierbach's jilexns gave rise to inco^ 
ordination of the myotonic reflex in the regiorr involved, 
and that in consecjiience the distant longitudinal layer aa'hs 
not reached hy .stimuli. 

Dr. Loavxpes Yates road a jiajror on methods of esti- 
matiiAg the liability to jmst-operativo haemorrhage from 
unsutui’cd Avounds. He said that in three-fifths of the cases 
of spontaneous epistaxis Ire Jrad seen there was a consider- 
able prolonging of the clotting time from six minutes ns 
a minimum to as long as fifty minutes. The administra- 
tion of calcium Alid not reAhrce this. To a patient in this 
categm'y u ho .also had aeitlosis he griA’e sodium bicarbonate, 
and folloAving tbrrt tire clotting time became normal ; in 
epistaxis casi's ns soon as tbe sodium bicarbonate lind 
rendered the Arriue alkaline there Avas a like beirefit. 
lyben there nas a septic focus and this Avas removed -tlie 
clotting time again Irecame normal. Not every type of 
eornpensated ncidosi.s AA-as associated Avitli an alteration in 
the’ clotting time. Examination of tbe clotting time of 
blood taken from the ear before operating enabled him to 
take measures to pievent Avbat othoiAvise would be trouble 
from post-operative liaemorrliago ; moi-eovor, patients wlio 
had oxcessiA-e liaemorThage Avero more liable than others to 
secondary haemorrhage afterwards. Tlie latter Aias often 
[ attributed to the sui-geon Avhen the fault lay with the 
clotting time. 

H'"- D. 'WAT.sox-IYiLtr.AM.s, in a jiaper entitled “ Fnrnili.al 
infoctivity of chronic .sinusitis,” alluded to the fact thattho 
memhei's of some families seemed to liaA'e an inborn iirc- 
di.sposition to cafari'lial infections. M'hon a child in such a 
' family had chronic nasal sinus infection ho usnalh' also had 
enlarged tonsils and adenoids, and oven after these had 
been surgically removed lymjihoid tissue in other regions 
became infected and symptoms reciVrred. He sboAA’ed cliai-ts 
vif remarkable families Avitb multiple disabilities of the 
kind. 

Dr, S,\i,isinrRY SHAiiiT., in a paper on the influenza ear 
urged that in the bulging brought about by influenza anrl 
seen frequently during epidemics of that di.sease, mvi'inco- 
tomy ought to he carried out instead of leaving the sAA cIirnrr 
to Inu-st spontaneously, since early interA’ention preveuted 
secondary infection. Haemorrhagic mvriugitis he ret>avded 
as pathognomonic of iirfluoiiza as tbe causal aoent. ° 




986 June g, 1928 ] 


NOTES ON BOOKS. 


r Tirr rniTiTif 
JfrDicAL Jocnrib 


TESTS FOR COLOUR BLINDNESS. 

The type of test for colonr blindness based on tb.c metbod 
of Stilling is a well-known and exceedingly nscfnl metbod 
of detecting tho presence of this defect and eliciting its 
nature. The test consists in presenting to the sivbjcct an 
alternately irregularly arranged and confused a.ssortnient 
of coloured dots, among wbich, in another colonr readily 
tho confusion colours worked into tho peculiar pattern 
are a series of dots arranged in tho form of a letter or 
numeral. To a colour-blind subject whoso defect includes 
the confusion .colours worked into tho peculiar pattern, 
the whole appears an inexplicable maze; but if the ability 
to see and detect the colonr in question is normal tho 
subject will bo able to read tho hidden letter. 

There are many variants of the original tests of Stilling, 
two of the best known of wbich are those of Ishihara and 
Edridge-Greene. Professor HrnxEi, also has . devised an 
excellent series of these " pscndo-isochromatic tables for the 
testing of tho colour sense,” which has now coino out in 
its seventeenth edition.® If anything, these tests err on tho 
side of being too simple. They may be well supplemented 
in tho detection of red and green blindness' by tho tables 
of Dr. WbLFFLiN,' which are more difficult of analysis and 
are very well conceived. 


NOTES ON BOOKS. 

The scope of the International Health Ycar-Booh, 1027, has 
with its third issue,® been enlarged by the inclusion of reports 
trom a number of sources which had not hitherto contributed, 
and the 800 pages of this useful work of reference now contain 
particulars relating to health in twenty-seven countries, includ- 
mg the leading member-States of the League of Nations, the 
United States, and tho Union of Socialist Soviet Republics. In 
the sections devoted to the national reports there is a wealth of 
statistical detail relating to demography and vital statistics 
supplemented by accounts, -of varying length and value, of the 
hiiance, organization, and administration of public health 
services. Ihe details given relate to the year 1926, and it 
should be noted that the earlier issues bore in their title the 
year with which they dealt, while the present issue bears tho 
date of publication. Special sections are devoted to indiistri.al 
hygiene in Germany, Belgium, and Great Britain, and to 
certain international organizations, and tho concluding chanters 
give an account of the activities of tho He.alth Organization of 
the League of Nations in 192'? — this body is, of course, resnon- 
sible for the publication. It may be pointed oit ’tha? no 

The Irkh g'^^/^e^lding Scotland or Northern Ireland. 

■ the Irish Free State supplies its own indenendent rennet 
while that furnished by the Slinistry of Health related only to 

Wales"‘‘probablv 11 °'''" is, to England and 

th s hi lb/. u “""s.s'pii of any specific indication that 
this IS the case will not mislead anyone in Great Britain l.nt 

up to date by inclusion as f-r as Hamburg has been brought 
ture. The w^ork is divided “nto 

and smaller part being devoted to rr parts, the first 

the second part, whicl? forms the bulk^of^ bacteriology, while 
ceined witli the various groups of ba^teria^^Th'"'"'’’ 
appendices, dealing respectively with iv,!. ’ three 

viruses, .the most important pathogenic 
bacteria of definite regions and objects. P*°fo2oa, and the 

Latin Xames of Common Plants^o is on » ... 

book by Dr. F.- Dawthey Deewitt, who wroVe°’tn'"‘1® 
Romance of the Apothecaries’ Garden at Ghelslt n '"^'‘">•'>6 
15 distressed that botanists tread the footstens of „ ‘^;.°r®"'>tt 
into the morasses of false quantity, instead of f^i 
more pure-minded zoologist. Whyf lie asks, sliou°d° 'n"",^o.,ll',‘; 



• tiv'-o-ion + Sit; 39 figure' Jllft 

. H. t. uua G. ■.Vui,erb?;'''i9^> 


bo calloJ “ sipklymrn when C 3 'clc and c^'clono-bavc not become 
“sickle** and “sicklono”? I! liclium is rightly pronounced, 
why not heliotrope? ilfost dictionaries give the pronuncia- 
tion of ocnotliera correctly; but ono cnc^'clopacdia gives 
oenothcra. Such crror.s as Ij’copodiiim can oidj' be compared 
with tho medical mnn*s pronunciation paresi.s, instead of tlio 
equally casj' jiarcsis. Dr. Drewitt admits that the use of some 
false quantities has become so firnilj' ingrained that wo 
cannot expect alteration. Thus it is hardlv* likely tliat crouus 
will over conic to bo pronounced krtikfi.s. In other ca'ics 
rea.son maj’ he sliown why a word sliould not bo pronounced in 
accordance with strict classical Latin. T)r. Drewitt quotf.s 
Sargeaunt on the word “ gladiolus *' as stating that " nlUiough 
Tcronco would have pronounced it gladiolus, Quintilian, like 
Cicero, • would have said gl.adi6lus ** ; and Dr. Drewitt regards 
llio latter ])ronunciation ns a reasonable compromise, because it 
is grand, rolling, and mu.sical. Dr. Drewitt tells us that wo 
owo most of tlio Latin names of plants to Dioscoridc.s, Plinv, 
and Linnaeus. As two of these botanists belonged to cla.^^sic 
Romo, wc might at least trv to show* some respect for the 
language in which tlicj’ wrote. 

The Cenfeestom of a TendfTfont “ deals with 

tho life of a trader on the West African c'oast, and maj' he 
classwl among the lesser sort of travel hooks.- Mr. IIeniiy sets 
out simply to give his own experience, and in his first ten 
lines slates that his book will not add-to anybody’s knowledge 
of West African geology, fauna and flora, *br ethnology*, lie 
has, neverllitlcss, produced a tborougbh' readable volume, wliirh 
may be of special interest to some medical men in view of its 
candid account of the effects of life in Ibe tropics on the 
outlook and habits of Europeans, 

** The Conff»»ionn of a Tentlrrfooi " Coatler." By Wnrren Ilrnry. 
London: H. F. and G. Witlicrhy. 1927. (Dciny 8 vo, pp. 280; 6 plafc*. 
16^. net.) . - 


PREPARATIONS AND APPLIANCES, 

Appliaxcxs ron IifTAxmE Paiialysis. 

Dz. G. McCr.ACKLV (Leiccstop Isolation Hospital and Sanatorium) 
writes: Tlio following appliances may interest those' wbo have 
to deal, with post-febrile cases of infantile paralysis. 

ncltoid Shdf. 

In cases of deltoid paralysis when a good faradic response lias 
been obtained it is desirable to discard tbo abduction fraino and 
to cnconrago movements of tbo 
deltoid without causing slrotcli- 
iiig of tbo muscle fibres. This 
can be obtained eitlicr by sling- 
ing tile arm to an overhead 
frame or by supporting tlio 
limb on pillows. Both tbeso 
inetliods involve keeping the 
patient in bed. Tlio acconi- 
paiiyiiig photograph illustrates 
a simple method of overcoming 
this dimeuity. Tbo, shelf is 
made of poroplaslic supported 
by a flared strip of aluminium. 

A shoulder strap , fixed back 
and front helps to keep tho 
splint in position. Tbo shelf 
allows free antcro-posterior 
movements in the horizontal 
piano; it is easy to make, and 
can be worn, day and night. 

An Internal T-Strap. 

This internal T-strap is very useful in those cases in wliicli we 
have to deal with a weak tibialis anticus and flat-foot. It is a 
modification of Calot’s artificial tibialis anticus, 
and has tho advantage that it not only lelieves 
anticus of undue strain, but also supports. the arcli 
of -tho foot to such an extent that the child'walks' 
with tile foot in an over-corrected position. Another 
advantage is that there is no tendency for the 
origin of tho artificial muscle to slip' down tlio 
limb. It consists of a strap of soft leatlicr stitched, 
to the outer side of tbo solo of tlio boot. This 
passes across the instep, is continued up the front 
of the leg, and buckled to the outer side of a baud 
fixed below the bead of tho tibia by au outside iron 
from tho heel of the boot. This internal strap , 
supports a firm leather insole and is adjustable. 

Both appliances are simple in construction and 
have proved most satisfactory in practice.' 

I am indebted to Dr. H. Stanley Banks, medical superintendent, 
Leicester Isolation Hospital, for tho accompanying plio'tograpli, 
and his permission to publish tlicso notes. 






JUNE 9, igiSi 


POST-OPERATn’E TETANUS. 


POST-OPERiVTIYE TETANUS. 

Rkpout to the ScoTTi.'iii Bo.vr.n or irr.\i.Tii. 

The occurronce.of a scries of Mscs of po.st.opcr.Ttivc tctanm 
ill .-m institution led tlio Scotti.sli nonrd of Health to 
request Dr. T. .T. jllackic, In-ine Professor of Dactoriolog}- 
in the University of Edinburgli, to investigate the matter 
Sinco this infection 1ms in tlio pnst ]>con associatecl \\itu 
catgut, Profe.ssor ^laekio TN'as asked at the same time to 
report also upon tlio cffcetivcncss of tho means emjiloycd 
for stcrilis.ation of-catgUt in its manufacture, storage, and 
iiso in- hospital tho 'dangers attendant on its use in 
surgery; and tho host availahlo moans for effective steriliza- 
tion during manufacture, storage, and use in hospital. The 
report' of this inquiry has now heen pnhlished hy the 
Stationery Office, at the very low price of Is., in order 
that tho important conclusions reached may he availahlo for 
all .surgeons and medical schools throughout the world. 
Professor Slackio, who was assisted in the inquiry tiy Dr. 
G. S. JI'Lachlan, lecturer in hactcriologj- at Edinburgh 
University, heliovcs that tho investigation has not only 
elicited data of tho utmost significance in regard to the 
ivholo prohlcm of post-operative tetanus, hut has also led 
to an extended study of preventive methods which deserves 
tho most careful attention. The Scottish Board of Health 
expresses its full agreement with Professor Hackie’s 
assessment of the importance of tho facts now puhlished. 


lNCiDE>'cr. ,\>T) Etioloot. 

Tho report opens with reforenecs to tho literature 
.showing that post-operative tetanus has heen commonly 
attrihuted to catgut, though cases have occurred in which 
this material was not employed, and auto-infection was 
incriminated. Tho valuahlc suggc.stion is proffered that 
information should ho collected systematically regarding 
tho incidence of post-operative tetanus in all tho general 
hospitals in Great Britain, sinco at present it is prohahlo 
that many cases are not published. Jt is well known that 
71. tefani occurs as a commensal organism in the alimentary 
canal of various herbivorous animals, including the sheep, 
from the intestines of which surgical catgut is prepared. 
Other anaerobic sporing bacilli capable of producing serious 
wound infections 'are' also found in the intestine, and tho 
conditions prevailing in ■ abattoirs from which the raw 
material for making ca'tgnt is obtained render contamina- 
tion very easy. Subsequent .sterilization of tho catgut is a 
particularly difficult matter owing to tho resistant powers 
of the tetanus spores., , Post-operativo infections hv other 
sporing hactlli have also been reported, and this emphasizes 
Uio difficulty of adequate sterilization of tho catgut. 
During the .period in which tho cases of post-operative 
tetanus occurred at the institution in question, tho .surgical 
catgut employed jvd's -.supplied almost entirely from one 
source, mortly m Hie form of “ dry strings,” which had 
alrnady '?ndei;gonG some jiicasiire of sterilization but were 
sii )jected to furlber bactericidal treatment before beine' 
used in operations. During the investigation this supply 
of catgut was stopped. 


OfintcfiJ Dctaih. 

- ” . post-operalive infection in the instituti. 

ronsiuercd in the report ono'had occurred so long ao'o as 192 
m no instance was it possible to trace any connesiSn between t| 
catsat used for tho various patients, and the operations in t 
more recent cases were separated hy intervals of twelve, ninetec 
nine, and seventeen days. The highly significant fact was elicit, 
that in gynaecological repair operations a dnsiderablo amount 
catgut remained embedded in the tissues; it was eslimated 1 
one surgeon that .approximately 69 inches might be so left aft 
a repair oper.at.on for complete prolapse of the uterus. Moreov, 

Ihcr- was iff if' / 'iT® u demonstrate 

view'” II ^ about the diagnosis in any of the patients 

'Jew of llic clinical and patliolo^^ical data * 

-hi Jh c whole scries there were nine eases of definite tetan, 

I'aar," Keport to the 

i-T. net. T. J. iiaciie, M,D., D.P.Zf. lUI. Staihnery Om 


-r- X'frURtTTm - 

i SlrurcAi. Jotn'fAt- 


987 


one of gas gangrene, .and one of a sporing .anaerobe infection 
with muscular spasms. In five out of the si.v tetanus casc-s the 
infection followed gynaecological repair procedures; the operation 
in the siilli ease was oophorectomy combined with op’pendicectomy. 
The remaining three cases were associated respectively with a 
cholceyslcctomy, a nephrectomy, and a’ gastro-entcrostomy. In the 
gas gaiigreiio case an exostosis of tho leg had been removed, and 
the infection with the sporing anaerobe was the sequel of excision 
of the cervical glands. Ten different surgeons were concerned, and 
six operating tlicatrcs. All the patients died e.xccpt one, in whom 
tetanus Kupcrvciied after a repair operation for a retroverted 
uterus and a deficient perineum. Tlie incubation period m this 
caso was fourteen days, as contrasted with incubation periods of 
seven to twelve days in the fatal cases. The time of death after 
the onset of tetanus ranged from a few hours to five days. In 
tho tetanus cases the wound was apparently healthy in two cases, 
and septic in another two; there was gangrene of the tis.sucs 
in tlirce other cases, blood extravasation in one, and no evidence 
about tho wound was obtainable in the remaining caso. ./?. tetani 
was demonstrated in two cases, tctanus-Iike organisms were found 
in two, and other sporing organisms in two cases. No organisms 
were isolated in one case, and in two others no bacteriological 
examination was performed. Negative bacteriological findings are 
admittedly of litt/o significance in the diagnosis of tetanus eases. 
Five of the nine cases occurred after operations in one theatre 
v.diich was on tho ground floor and close to a main corridor. Con- 
structional work was proceeding in its neighbourhood, but no 
further evidence was obtained indicating that these local con- 
ditions were concerned in the infection. The possibility of auto- 
infection was carefully considered, but this explanation had to be 
dimiisscd in the absence of data. 


CoXT.XMlb'.tTED CaTCET ATtD TeT,\NTS. 

Profes-sor jradne mentions that the preparation of the 
catgut incliulcd : (1) twelve liours’ immersion in a watery 
.solution of meremy hiniodiilc; (2) heating at 160° C. for 
one iiour in oil ; (5) heating in anhydrous spirit in • a 
Jellctt’s sterilizer in boiling w.ater for one and a half 
hours; (4) storage in an antiseptic fluid containing a 
mixture of mercury biniodide and other antiseptics. The 
todiniquo of tho last three procedures was carefully 
revierved, and no evidence was obtained of any careless- 
ness or inexactitude. Tlie dry catgut strings were tested, 
and Avore found to contain sporing anaerobic bacilli of the 
group to Avhich 27. iefani belongs; these (27. tetani and 
IS. mcseniericus) wore used for testing purposes, and it 
quickly became obvious that exposure for twelve hours to 
the wateiy solution of mercury biniodide could have hut 
little efl-fct. A certain proportion of tho spores of 
77. vtcsentcricus survived heating in oil at 160°, and tho 
margin of the destruction of 77. tetani was verv narrow. 
The ineffectiveness in this respect of heating in a Jollett’s 
•sterilizer Avas completely demonstrated, and spores 
remained viable finally after storage in the mixed anti- 
septic solution. In onh- one -procedure was 27. tetani 
destroyed. Intermittent sterilization in heated oil was tried- 
hut was found to ruin the catgut, -as did also streaming 
steam sterilization and exposure in aii autoclave to super- ' 
heated steam. The efficiency of very many chemical bacteri- 
cides Avas tested hydrogen peroxide and iodine water proved 
to be the best, hut tho action of some reputed bactericides 
Avas found .to he surprisingly feeble. Details are given, 
of these tests and the results. It was concluded finallv 
that catgut “ ribbons ” could best be sterilized bv immer- . 
sioa in hydrogen peroxide (10 vols.) for twelve hours, the 
catgut strings spun from- these ribbons being further 
exposed for fourteen days in iodine water. These pro- 
cedures, which do not damage the catgut, can he employed 
in factories; it is suggested that, subsequently, the strands 
shoidd he .passed tlirougli two changes of spirit to remoA-e 
the iodine, and he stored in 50-75 per cent.' .alcohol con- 
taining 0. 1-0.2 per cent, iodine. It is added that those 
processes should bo controlled in operation bv bacterio- 
logical examinations. 

CoiIlTEXT. 

The great importance of this inquiry is obvious. Confirma- 
tion is necessary and the experiments require to be repeated 
under factory conditions; Profes-sor Jilackie’s data are set 
out so fully that this should be relatir-ely easy. An inter- 
esting point is that the invertigation arose out of a definite 
group of clinical cases, and it is possible that further- 



988 June 9 , 1928 ] 


BiRTlIDAY ilONOTJnS. 


t Tur rr.niCTi 
MrutcAi. JoLhNiX, 


discoveries in other directions await a similar lino of 
reasoning and research to ho adopted following (iinioal 
observations. Professor Mackie dc.scribcs the gradual 
progress of the reasoning eoncei'ned in the iiKjnirj- in a 
manner suggestive of the tracking down of a criminal, and 
there is much valuable evidence ])laced on record for U'-c in 
other connexions. In his conclusions ho calls attention 
to the fact that there is at present no control by any 
health authority over the manufacture of catgut such as 
exists over certain biological products. He believes that 
such a control is requii-ed, and he thinks that niann- 
faeturers would welcome aid in standardizing their 
methods of preparation and safeguarding their pro- 
ducts. He proposes also a collective inve.stigation of 
the general incidence of operative tetanus, of infections 
by other spore-bearing anaerobes, and of the varimi.s etio- 
logical factors concerned in these infections. He adds that 
the ofScial notification and investigation of Intnre cases 
wonld supply information of great value as regards projiliy- 
laxis. The possibility of anto-infection and the part 
played by carriers of B. tctani are also commended for 
study. For the ])reseut, at anj- rate, a ease seems to have 
been made out for the standardization of the methotls of 
preparing and sterilizing catgut; tlicrc can he little doubt 
that this will receive due consideration. 


Profe.ssor of Surg<Ty, 


BIRTHDAY HONOURS. 

Thu honours list issued on the occasion of His Afaje.stv's 
birthday included the names of the following memheis'of 
the medical profession ; 

Compmiion of Honour. 

Professor John Scon IUldane, M.D., D.Sc., F.R.S. 
Director of the Mining' Research Lahoratoiw of Birminglinm 
Urnver.sity, for scientific work in connexion with industiiiil 
disea.so. 

K.C.il.G. . 

Lirat.-Colonel Sir Wiixiaji Thomas Pnour, Kt., C.M.G. 
O.B.E., Senior Medical Adviser to the Colonial Office. ’ 

K.C. V.O. 

John ^ Mahnoch, C.V.O., Regius 
University of Aberdeen. 

K.B.E. (Militari/). 

1- Walter Holland Ogilvie, C B C AI fl 

^ua^irrs, IiMif.-’ 

■ Kiiir/Iits Bachelor. 

Atkinson Hoskek, J.P., Cliairm.in of the Bourne- 

sendees ?„”'B:u;r,ero„th“”"'‘'“"’ 
A,^:h:liau°’rmy“Si.d"cT;s 

Hospital. ^ iivuical Coips, Surgeon to the Adelabk 

... „ , (Mititari/). 

Depti^- K-H-P.. 

Colonel Harold Boultok, C.B E T nt V v'ir L 
Director of Medical Services. Deccan Distrkt, 

C.M.a. 

Dr. ,l0BN Hope Reford, lately Director of Ar„,ii i 
bcrviccs, Uganda Protectorate.^ • Medical and Sanitary 

C.I.E. 

Lieut .-Colonel Ernest William Charles Bradpield O B E me 

Ho^Ttab Mai™?"''’’ ®“P®ri-'‘®'>d?m;'Get-rai 

BUra;Pd°’Stssa^"'"^ ’ Bh.agalpnr, 

--Bieut.-CMonel George De.nne Franklin, O.B.E IMS r.i • , 
Medical Officer, Delhi. late Chiet 

' B'put -Colonel John Cunningham, I.M.S., Director 
institute, Kasauli. jinreror, Hasten] 

Dr. Hugh Gordon Roberts, Welsh Mission at Sliiilong, Assam. 

D 1 c.r.o. 

■ ALraro Bakewell Howitt (dated' April 21st, 1928). 

Coloiu-1 Howard EKsou’^n^h 

Depuly Dir^lor of MediSh Hte R.A.M.l 


roctor of iledii •• i late Jt.A. 

Captain James H?P.RaRT''i'ERo"ssoS’’ 


C./I.f;. (f'iiiV), 

Major .loiiK HAirriv Hriin, O.II.K., K.A.M.C.(ix{.), Director of 
Me^jical Seivicc**, Minifitrv of IViivion*?. 

Lieiif. -Colonel .loiix K. .‘ATaxTiiKAn?;, O.II.K., Warden of iho 
]fo«])itat of the Order of Si. JoJin of .Icrusalern in J\'tk*st!Jie. 

O.BJ:. (.Ifilitarj/). _ 

Major James IIlbhletuwaitk Mahtik rnbcrsiiEn, R.A.M.C. 

Lieut, -Colonel Hujiimirey Kuakcis Humi’hp.eys, J/.C'., l‘13rd Field 
Ambulatico, R.A^M.G., T.A. 

Major OennoK WiLbos, M.C., Il.A.M.C. 

Surgeon Cornrimndcr Duvax PiCKEiaxo Pick, P.N. 

0,/IJ:. (Cfr/T). 

Surgeon Cominaiidur WAETEir Kemi-sok IIopkikf, n.N'.(rct.), 
Medical Ofiicer, Boaid of Cu‘;lo»n‘; and Kxri*-!*. 

Profescor Albeet ViCTon ilKn.vARn, M.IJ.K., Medical Oflicur of 
nenllli, Malta. 

Manoaloas Vuriri'KiiAynAS Mehta, Medical Practitioner, Hombay. 

Dr. Geokge Pammell FoOTTftn, Director of the Oindurinan Ciul 

Kai Ibibndiir Dr. Kisnoni Lal CirArnmrr, M.B.K., As^ii'.tant 
Director of Public llealtb, United Province*. 

Dr. James Goofrey Lvon* Bkow.v for services in connexion witli tlio 
Kmergeiicy Voluiilecr Coips at ITankou'. 

-v./y./;. {jniitarj/). 

Fir*‘l-clas* As‘*i'*lant Surgeon Knss'Aun Hekhy Gileso::, Indian 
Medical Depai tincnl. 

MJi.B. {Cirir}. 

Dr. George Maclean, Sleeping Sickness Ofliccr, Medical and 
.^nnitary 7.)epartrncnt, Tanganyika Territory. 

Mrs. "Martha Isabel Garvice, Senior Ijady Medical Ofijccr, 
Kgyptian Ministry of Education. 

Dr, James I'REDEniCK Corson, ANsist.-int Bacleri(»logi«t, Medical 
and Sanitary Dcp.'ii tment, Tanganyika Territory. 

Dr. Kutii Young, Pei-sonul A'^istant to the Cliief Medical 
Oftk-ov, Women's Medical Sc*rvice, and Secretary of tlio rmids 
under the Presidency of Her Excellency the Lady invin. 

Honorary H.B.E. (Ciril). t 

Dr. Yeshua Siiami, Medical OITicer, Department of Health, 
Paleslinc. 

J\(ii.*ar‘i-Hini2 Jfnhil {First Class). ■ 

Dr. Christian Freperick Frimopt-Moller. Medical Superin- 
tendent. Union Mk^ion Tuberculosis Sanatorium, Madanappallc, 
Chiftoor Distnet, Madras. . -i i 

Dr. Annie Caroline SmitiTj m charge of the Zenana Hospittvl 
of the Churcli of Scotland Mission, Gujrat. 

Dr. Rodert Johnston Ashton, Kachwa, Mirxapur District, United 
Provinces. 

Jvipcrial .terrier Order — Companion. 

Khan Bahadur Ajimep Bakiisii, Assistant Residency Surgeon, 
Personal Assistant to t]\e Administrative Medical OfTscer in Central 
India and Superintendent, Central India Agency Jail, Indore, 


ROYAL 31EDICAL BENEVOLENT FUND. 


The total sum which lias been voted this year in grants to 
medical men, their widows, or orplians who have appealed for 
lielp amounts to approximately £4,744 as against £3,502 during 
the corre.sponding period of last year — an increase of £1,242. 
These figures definitely prove there is a greater demand being 
• made on the Fund this year than ever before. But subscrip- 
tions and donations do not show an equivalent increase over 
i the same period. To meet, an increase of £1,242 in grants, 
I suliscriptions have only increased hy £500. 

' An urgent, appeal made for subscriptions and donations, 
which should be sent as soon as possible to the Honorary 
! Treasurer, Sir Charters Svnionds, at 11, Chandos Strer:. 

; Cavendish Square, London, \V.l. 

I The following arc notes on a few of the cases helped at tiio 
1 last meeting. 


Dr. X, agcil 63, liail to give \^p practice throe and a half year? ago 
owiiif- to cataract on -bolh eyes*. Ho is loo blind to see patients and 
can do no work o( anj ^kind.. During thubo three ami a half jears hejuvs 
had ‘to li\e and m.u’ntaiu himself, his wife, and two young children on' his 
emaU capital, which is now oxhausted. An omevgency grant of CIS was 
made, and a further sum voted of J.AQ. Assistance is’ being souglit from 
oUier charitable funds. 

Dr. y, aged 78. Old ago and increasing deafness linvo prevented this 
applicant from continuing in the profession, and for some time be 
haa been foi-ced to live on capital. Other fninilv (loiible.s have made 
heavy fluaticia! claims UYinn the applicant, so that all liis life savings 
arc now e.xhaustod and he has had to apply for the old age pen^ion of 
1.26 a year. Voted £fl0. 

AV'dow, aged 55, of M.R.C.S. Owing to ill health t(ie applicant’s lin^iand 
•sold hi& country practice ton yeans befoio he died, and during this timo 
and np to his death he and his wife had to live on capital. At his death 
iJic widow founil there' was notliing left, lits life policies Iiad been 
*n<«t«ragod jears before, there were debts, and there was no money to pay 
•or the funeral. The wddow had to scU furniture and other private 
Vorecl^i^6^ order to pay. Her son can only contribute 10s. a we^^k. 

aged 59, of M.D. The applicant has been teaching as a 
, >orty-two years; now at her present age she cannot get 
In Her savings bring in- £50 a vear. Slie was not able 

FT keep her invalkl •molber for the li»5fc 

e jeara of her life. Voted i26. 



June o, 1928] 


PUERPERAti SEPSIS. 


r Tftr nm-nw QQQ 

L JfeDicAt. JouKNit. 0(jo 


Biittsi) iHctitcal JoiirnaL 


SATURDAY, JUNE Stii, 1923. 


rUERPERAL SEPSIS. 

Eaei.y in 1925 tlio Council of flic Brilish J^Ieclienl 
Association, recognizin'? the urgency of flic probloin 
of cliildbod infection, .set up a special committee to 
consider “ tlic causation of puerperal morbidity and 
mortality, and the administrafivc action, if any, that 
should bo taken in connexion with the matter.” An- 
interim report was issued within twelve months,’ and 
the Committee’s final report has been published 
rcconth' in our columns ns an appendix to the Annual 
Report of Council. = Towards the close of its delibera- 
tions the Committee held a conference with repre- 
sentatives of official bodies directly interested in one 
or other of the subjects coming within its reference, 
and a number of practical suggestions then put forward 
have been embodied in the recommendations with 
which the final report closes. It will ho generallj' 
agreed, we think, that the Committee has done an 
important service by drawing attention to the many 
factors ns yet unexplained in the incidence of puerperal 
sepsis, and by indicating' those in which further 
experimental research appears to be most needed. 
The intricacy of the problem, and the zeal with which 
it is, how being attacked by widely different routes, 
find expression in the throe papers with which our 
present issue opens. 

It will be observed that the Committee sot up by 
the British ilcdical Association accepts the common 
classification of possible sources of cliildbod infection 
into exogenous and endogenous. Dr. James Young, 
on the other hand, so far from entering the lists on 
behalf of either an exogenous or an endogenous origin, 
dismisses both as of secondarj- importance in main- 
taining the sepsis rate, and assigns the chief place to 
trauma from intervention. He considers that the 
question where the microbe comes from is over- 
shadowed by the vital issue of trauma, that the 
infecting organisms -maj- be either exogenous or endo- 
genous, and -sometimes of a type that causes disease 
only when settling in devitalized tissues. To some it 
may appear that Dr. Young has laid undue emphasis 
on injury as the determining factor in the risk of 
sepsis,- though there will be general agreement as to 
the important part it plays. Infection of the uterine 
cavity is an outstanding feature . of most cases of 
puerperal sepsis, and to its causation all internal 
manipulations, whether accompanied by tissue injury 
or not, must contribute, for the vulva, cervix, and 
lagiria cannot be - rtiade germ-free. All hospital 
records show increase of morbidity incidence with 
intervention, and the morbidity rate is greater the 
liglier up the genital tract the manipulation extends, 
re greatest risk of sepsis being reached with such 
iirtrauterine operations as manual removal of the 
P acenta when the fingers work in the bare uterine 
cavity. - 

~~^w'’,'TprU ^th'"rl8!''’'‘ Journal, January 9th, r926. ' -■ 


Though Dr. 31’oung adds a proviso that it must not 
be assumed that the main responsibilitj' is thereby 
placed on the medical attendant, he does not carr}' the 
matter further than b}' throwing out a suggestion of a 
po.ssible change in the fitness of the women of to-day 
for child-bearing, and hazarding a view that skeletal 
defects ma}' have increased owing to the -greater care 
of infant life and consequent larger survival of those 
who suffered from rickets in childhood. A reduction in 
infantile deaths entails also a corresponding reduction 
in the far larger number of infantile casualties that do 
not end in death. The incidence of rickets of all 
degrees of severity will rise or fall in correspondence 
with the place of rickets in the mortality rate. The 
most obvious change in the child-bearing women of 
to-d.ay ns compared with their predecessors of a few 
generations back is that they — and first of all those of 
the more educated and well-to-do classes — have learnt 
of the relief of pain and shortening of their , travail 
that anaesthesia and the obstetric forceps can bring. 
Their medical attendant is chosen largely with this 
relief in view, and he must steer a difficult course 
between the complete fulfilment of their desires by 
frequent interference with natural function or be 
thrown over for someone more compliant. Pressure 
from his patients, from their distracted husbands (like 
the one lately pictured in Pimc/i), and other relatives, 
together with the strain of his other work and all the 
circumstances in which family practice is conducted, 
have made it almost impossible for him to resist and 
sundve. ''t\’e -u’ould rather put the question thus. If 
the women of all classes in the country were prepared 
to have their confinements conducted as those attended 
by the mid wives of the Queen's Institute or in the 
hospitals whose figures Dr. Young contrasts with the 
national mortality rate, would the difference bet-n-een 
the rates remain at its present level ? 

Dr. Young mentions the need for educating the 
public, but he does not go so far as to suggest that the 
medical profession should teach their patients that a 
price must be paid for the relief in labour for which 
they crave — a price part of which at least is repre- 
sented at the moment by the failure to reduce the 
maternal mortality. His plea for concentration on 
the effort to secure natural delivery is timely, for the 
primary objective throughout Medicine — the main- 
tenance of normal function — ^lias to some extent been 
overshadowed in the practice of midwifery by the 
attempt to attain the secondary objective of relieving 
pain and shortening the time of trial for the woman in 
labour. Team work between doctor and midwife, as 
advocated in the report of the British Medical Associa- 
tion’s Committee (para. 34) and urged by Dr. I’^oung, 
has the great advantage of offering a better chance of 
lessening interference and the trauma on which he lavs 
such stress. Though much may be done to secure 
normal function in labour by a whole-hearted co- 
operation between doctors and midwives, the demand 
of the women for relief and, in the present state of 
our knowledge, the price of relief given on “ humane ” 
grounds will still appear in the national balance sheet. 
A lowering of the cost might be made were more 
known (as the report says) of “ the degi-ee and kind of 
immunity of the pregnant worhan.” 

Dr. Burt-White ’s preliminary report of an effort to 



990 June g, ig 28 ] 


PUEKPEKA.L SEPSIS. 


t Tlfl! Hrititk 
M roicAL Joi-Rxit 


unravel the capricious inciclencoof puerperal sepsis from 
tlio side of resistance to the streptococcal toxin records 
tile puerperal morbidity in a hundred women divided 
into two groups according to their reaction to the injec- 
tion of scarlatinal toxin. So far ns it has gone, his 
investigation shows that women who react to the 
scarlatinal toxin are more liable to develo]) puerperal 
sepsis than those who do not react. Once knowledge 
of this kind has been definitely established, and it has 
become possible to pick out those in whom resistance 
to infection is low, and still more when it is known 
how this low resistance can be raised, the risks of 
artificial aid in delivery will be greatly lessened. Dr. 
Itemington Hobbs’s paper falls into a different cate- 
gory, both because it is concerned with the curative 


rather than the prer'entive side of puerperal infection, 
and because Dr. Hobbs has widened his consideration 
to include tj'pes not discussed in the other two papers. 

We are glad to note that the Minister of Health, in 
pursuance of a policy designed by his department for 
grappling with this problem as a whole, has just 
appointed a Departmental Committee, wholly medical 
m composition, whose terms of reference ' arc “ to 
advise upon the application to maternal mortalitv 
and morbidity of the medical and surgical knowledge 
fit present available, and to inquire into the needs and 
direction of further research work.” 'I'hc names of 
this committee are given at page 998. It will bo seen 
that all^ branches of medical work in anv way con- 
cerned m the matter arc represented, an'd that two 
general practitioner!?— one from a counlrv town and 
the other from the East End of London-liave 
.ccepted membership. The persomud should there- 
oie command the eonfidonco of the profession and the 

Biitidi Jlodicnl Association on the lines of 'the 
Departmental Committee’s reference. 


T.. GORDON OF ABERDEEN 

SglS. this week . 

Wlioso Trcaiisl of Aloxa.ulor Gordo 

Ah.u-.U’cii was published iu ^1765 

of this pioneer has latelv -i, -t sjiiipathetic accou 

HorhirtShon..s of S iS"' r ® 
was bora at Straehan, a small’ Gordi 

south-west of Aberdeen, in 1752 V'Ai' to tl 

curly life, but ho took his decree of At T 
Colleso, Aberdeen, and subsequently b^.'i uL 
inedieine, first at Aberdeen IhfiVn-.rv i 
Edinburgh. Ho joined the navy as i Cii 
1780, and two years later olitainod the 3-“ ? 

In 1785 ho retired on half pay, and came “i 
ho liecame a rosidont pupil at the Lying i„ pi ’°’V 
Street, and attended left, ires on.niidwifen Tiy 4,®*° 
Eeniiian and Osboiii. He then became a’ 

Tliyniio, and attended lectures on sni-oory ‘ind T 
•at Uio AVestniinster Hospital under Jushunond. Vfter^u 
to Aberdeen and obtained 
the sl'oftly afterwards appointed physician 

cially f,,ver.s. r ’ t><^“t'»ent of acute diseases, es„ 

ii'iiimary, to the appointment to t 


12,925 ciise.s wore luliiiilted, he was oeeupied by a largo 
private praetico, in wliieh he devoted liini.self particularly 
to ob.stctric.s, and gave ail aiimial course of lectures to tlio 
iiicdieni .stmloiits. Four ycar.s before his death ho was 
called back by the Admiralty to aetivo duty in the navy, 
wlicre lie fidl ill with pulmonary liiherenlosis and was 
invalided home. His death took jilaeo on Oetohor 19tli, 
1709, wIifMi he was 47 years of age. Hr. Thoms cordially 
agrees with A. .W. Lea, who maintained that Gordon 
wa.s to Im credited with having first clearly demonstrated 
tho infectious nature of puerperal fever. Oliver Wendell 
Holmes was so much impressed with Gordon’s treatise that 
in his c.ssay ho quoted the following iinragrajih in capital 
letters: “By ohservation I plainly perceived tho ehaniicl 
by which it was iiropagatcd, and I arrived .at that certainty 
in tho matter tlmt I could venture to foretell what women 
would he alFeetcd with the disease, upon learning by what 
midwife they were to bo delivered or by what nurse they 
were to lie- attended during their lying-in, and almost in 
every in.stanee my prediction was verified.” AVith extra- 
ordinai*y honesty Gordon continues; ” Jt is a disagrecahio 
declaration for mo to mention that I myself was the means 
of carrying tho infoetion to a great number of women.” 
Ill another important passage Gordon shows the analogy 
between ])nci|)eral fever and erysipelas, in both of which 
the infections matter is readily ah.sorhod by tho lym|)hatics 
in the vicinity of tho wound. Gordon not only denion- 
str.atei.l tho infeetionsness of imerperal fever, but bad .a 
definite iilea of tho pathology of tho condition, whereas 
Ills contemporaries Hiilino and Lake pronoiiiiccd tho 
emcntiim to bo the .seat of tlie disease. Gordon by liis 
dissections .showed tlmt jincrperal fc\'or was a disease which 
principally alfcctod the peritoneum and tho ovaries. Lastly, 
lie laid ilown the following rides for prophylaxis: “Tho 
patient’s apiiarel nnd hedelothcs onglit cither to be burnt 
or tliorongbly purified, and tho nnrso and physicians who 
had attended patients nfTected with puerperal fever ought 
carefully to wash themselves and get their apparel properly 
fumigated hoforo it is put on again.” 


INTERNATIONAL HEALTH SERVICES. 

No one outstanding topic emerged at the twelfth session of 
the Health Committee of tho League of Nations, which was 
hold at Genova from April 30th to Jlay 5th, but several 
matters of considcrablo interest came under review, and 
the proceedings gave an admirable illustration of tho 
development of health measures in tho intornational sphere. 
It was reported, for e.xarapio, that the' Epidemiological 
Intolligonco Bnrean at Singapofo is now iii regular tele- 
graphic coinmnnication with 140 jiorts; the wccklj- Inillctiii 
based on tho information so gained is circulated by wireless, 
and an increasing mimher of stations transmit it, so that 
it is more widely available for ships at sea. Efforts aro 
being made to seenro tho collection, through tho bnrean, 
of information regarding quarantine stations and tlicir 
value, and it has ahso been sugge.sted that tho hiircan should 
securo the most detailed .s-tatistics possible on the seasonal 
prevalence of cholera and plague within its sphere. In 
various directions special inquiries are in progress dealing 
with particular diseases. Expert .subcommissions, at tho 
instance of the Cancer Commission, aro undertaking studies 
of occupational cancer and tho radiological treatment of 
cancer; tho investigation into tho incidence of small-pox 
in Eui'opo is to ho extended to North America and the 
piitcU East Indies, and aii inquiry into infant mortality 
is proceeding in Europe and South America. Tho report 
e the Sleeping Sickness Commission is to ho considered by 
an international confercnco composed of representatives of 
govonimonts interested; proposals aro put forward for 
ecuiing continnon’s study 'of tho disease, for tlid ’co-opera- 1 



Joke 9i lO’S] 


MEWCAti EXAMINATION OF CIVIWAN AVIATOKS. 


f TmjrBmsfl QOl 

LMzDICAL JoCKNiX. ^ **• 


{ion of worki'i's in various coiiiilrios, ami for flio .sy.stonialii; 
collection of information. Jfcasnres are now lioiiiij; talven 
to proparo n scliomo for an international impiiry into 
leprosy. The work of tlio Malaria C'oinniission is pro- 
cociling, ami, as in ]>rovio\m years, speifal eonrses have Iwcn 
arrangeil on malaria. This cininieratioii Jms not by any 
moans exlianst tlie tale of tlie Health Committee’s activities 
in this s;)Iiero, hnt it will Miffiee to "ivo an indication of 
one aspect of its work. The cstahlishment of .st.andarils for 
certain tliernpcntic .snhstanees is another of its fiinctions; 
the nnit for insnlin mlopted in 1925 has heen accepted 
nnivcr.sally, and the standard for pitnitary extract has also 
proved .satisfactory; work on international standards for 
antitetanie and antidysenteric sennas is now practically 
completed, and good jirogre.ss has heen made with anti- 
diidithcritic sennn. Two collective interchanges of pidilic 
health per.sonncl, arranged hy the Health Committee, 
will fake place this year. Memhers of the health 
seiwiccs of sixteen other conntries will visit Italy, 
.studying fust the central administration in Home, 
and then dispersing in groups to other centres to 
devote themselves to special snhjocts. The second inter- 
change is of a new type, and will he attended hy 
medical oflleers and sanitary engineers c-oneerned with 
health administration in rtiral ilistricts; they will he 
drawn from countries in Europe and .South .\merica and 
from Enssia, .and will visit .selected ureas in Enro;)e. Two 
examples occur in the report of the committee’s inoeeedings 
of the way in which the League organization ha*, heen aide 
to assist particular countries. The medical director of the 
committee is to co-ojierato with the atithorities in Greece 
in preparing a scheme for a campaign against tnherenlosis 
in Greek towns, while an otfer of assistance in dealing with 
the urgent health prohlem.s caused hy the recent disastrous 
earthtpiako in llnlgaria has heen accepts'd hy the Govern- 
ment of that country. It is prohahly ditTieult for most of 
us, accushimcd as we are to thinking in terms of ralativcly 
small nnificcl areas or of single highly spswialiaed services, 
to. gain an adcfinate conception of the work carried on hy 
the League agencies in connexion with health. Their 
activities are sridely varied, tlie aivas eoiicenicd are often 
remote, and tlio problems which engage attention are 
nsnally not of first importance in this emuitry, so that the 
a hole system is liable to impress itself hnt vaguely upon 
oui conseionsness. Perhaps, however, the Health Organiza- 
tion and the Health CViminittee of the League wdl seem 
more worthy of notice when we reflect that they m their 
spheie have achieved, it would seem, a greatei- degree of 
international unity and co-operation than the parent body 
las jet been aide to roach in the political sphere through 
the c/lorfs of the politicians and the dijilomats. Ilcprc- 
sontatiros of tho United State.s have playeil a coiisiilcrahle 
part in the work of the Health Committee, while officials 
lom ..ovict Russia will participate in the interchange visits 
arranged for this year. The two '< big exceptions " to 
niem lors n'p of tho League itself are therefore in cont.aet 
with the Health Organization. ' 


MEDICAL examination OF CIVILIAN AVIATORS. 

A snco.vD edition of T/ie Medical Examination of Ciriln 
Avmfars' has now been pnblished hy tlie Air Jlinistry aft 
a ap,.e o neaily eight years. AVhoii tho first edition w 
reviewed in tho Journal of Jlav 1st, 1920 (p. 608), o 
notice eoucUuled with the opinion that tlie pamphlet mig 
erve ^ a model when the international tests were deeid 
pon by the medical representatives of the rntcnmtioii 
ommi&sioii for Air Navigation, A snmmarv of the int< 
m tional medical rerpmements. in so far ^s they affe 
tiMhan aviators,, forms the first section of the ievis 
— tho sLindar d e.xacted does not vary much frt 


■ 11.3r.' 'Statimery Office. 1923. 


Price Is. 


that jirevionsly laid down in thi.s . country.; tho sjiecific 
methods of examination and tho minimal conditions of tho 
tesis arc left for tho present to tho decision of each connli-y 
until Iho International Commi.ssion shall arrange otherwise. 
As in former years, the Ilritish system lays greater emphasis 
upon the pre'-crihed general clinical examination and upon 
the imi«>rtanee of good family and jior.sonal histoiy than 
upon •• effieiemy ” te.ste, which nro given due recognition, 
hnt are tpnte definitely snhordiiiatcd to the general 
•sonitiny, emhodying a medical and surgical examination 
and investigation of tlie eyes, ears, nose, and throat. In 
raiinexiou with the personal history, guidance is given 
regarding certain disabilities which should ho regarded as 
indicating nnsnitahilitj- for air work. In otiior directions 
also the relation between tlie varion.s mental and jiliysical 
qualities, and the eharactcristics demanded of pilots, arc 
fully pxplninc’d, so that an examiner may readilj- appre- 
ciate the precise importance of his work. Diagrams ilhis- 
trato the apparatus emploj'cd in certain of tiic tests. Tho 
notes on “ assessment ” state that, apart from tiie elimina- 
tion of those who fail to satisfj- the reqnircmoiit.s in respect 
of sight and hearing, or who show signs of disabling organic 
disease, the a.ssessor’s main duty is to ascertain that tho 
accept e<l candidate possesses stamina and nervous stability 
eompatihle with tho safe landing of aircraft from any 
altitude, even in the case of prolonged and difficult flight. 
As an aid to decisions in this respect various tests of tho 
eardio-vasenlar, respiratory, and nouro-mnscnlar syrtems 
have heen devised, and a “ physical officioncy index ” has 
heen formulated. Tho standards for these tests have been 
set hy comparing the performance of pilots chosen as fit 
and successful svith that of pilots suffering from known 
defects impairing their flying capacity. Reference must bo 
made to tho importance attaehcel to vision. It is common 
knowledge that most flying accidents occur in landing, and 
it is remarked that lack of true ocular muscle balance has 
been proves! to ho tho most common cause of error in judge- 
ment in bringing an aircraft to the landing ground. -A.part 
from its value to those ongagotl iii performing one of 
tho most exacting medical examinations yet devised; and 
rightfy so, this little mannal will intcre.st medical practi- 
tioners geimrally. It reveals, for example, something of 
the deiiiaiids wiiich tho exercise of his art makes upoii the 
pilot’s mind and bodj'. It is also possible that .some of the 
tests doscriliod might be applied usefully elsewhere. In 
a modified form thej" would no doubt give a vorv clear 
indication of the capacity of motor drivers and others 
engaged in occiqiatioiis which j-eqnirc a considerable degree 
of nervous stability and co-ordinated muscular action. The 
anonymous authors are to he coiigratnlaitcd on producing 
a pamphlet whicli, in the space of fifty pages, not only 
admir.ably fulfils its express purpose, hut also embodies 
iiinch intere-sting matter of general application. 


THE LEISHMAN MEMORIAL AT MILLBANK. 

Ox Juno 2ud, two j'cars exactlj- after his death, a niemorial 
tablet to Lieut. -General Sir William B. Leishiiiaii, Iv.C.B., 
F.R.S., was unveiled in the cliapel of tho Queen Alexandra 
Militarj- Hospital, Millbank, and another in the patho- 
logical lahoratoiy of the Roj-a! Army Medical College. 
The unveiling of the foimior took place during a brief 
dedicatory service conducted hy the Cliaidain-Gencral to tho 
Forces (the Rev. Dr. A. C. E. Jarvis, C.iM.G.). The cere- 
mony of unveiling was performed by Licnt.-General Sir 
Matthew Fell, Sir AVilliam Leishman’s successor as Directoi-- 
Goneral of the Army Medical Service, who explained that 
the tablet was part of the' memorial subscribed for by the 
officers, past and present, non-commissioned officers,', and 
men of the R.A.M.C., and members of the military .nnrsin" 
6trvice.s, The major part of tho memorial consisted', ho said^ 
o.f,a medal wiiich had been struck and prizes wliicli would be 


092 JONE oj 1928I 


THE EABYBT TEECENTBNAET IN PARTS. 


r Tirr riMnw 

I Mr.D[CAt.i0CB1fi£ 


competed for bv officers and men of tlio corps. Sir Y ilUnm 
LeisUmau sen'ed the army for thii't)'-eight years, and won 
great honours, especially in the field of research in patho- 
logy, hut it was affection for the man as well as admiration 
for his work which had inspired this memorial. Ho was 
known to his officers of tho service as no other officer was 
known. Not only was he their teacher, hut their com- 
panion and friend. After the sei'vicc those present walked 
across to the Royal Army, Medical College, where Major- 
General Dixvid Harvey unveiled over tho entrance to the 
pathological laboratory the second tablet. Ho said that 
while tho memorial in tho chapel was intended to com- 
memorate Sir "William Leishman as a great Director- 
General, tho memorial in tho laboratory recalled him .ns a 
teacher, an eminent man of science, a research worker, and 
a discoverer of world-wide renown. Although the memorial 
had been erected at Millbank, it was only right to say 
that much of Leishman’s work was carried out elsewhere. 


The original discovery of the pai-asite of kala-azar was made 
in tho old laboratories of the Army Medical School at 
Netley; there also Leishman prepared tho stain which bore 
his name, and it was there he was associated with Almroth 
Upright and David Semple in work on tho typhoid vaccine 
— work which was subsequently to develop to such a 
remarkable extent in the army, to be tho means of s.nving 
thousands of lives of British soldiers in India and else- 
where, and to be adopted and adapted by practically evorv 
nation in the world. On the transfer of tho school to 
London Leishman became professor of pathology and put 
in very strenuous work. General Harvey described bis 
teaching carried on in that very room, and his gradual 
attainment to the position of a national figure in the field 
of research, so that there was hardly a piece of organized 
medical research with which he was not connected; but 
ho added that Leishman was not a scientist so absorbed in 
his pursuit as to he oblivious of the claims of family and 
friends. He was a devoted husband and father,* and 
nothing would have pleased him more than tho high 
degrees in science recently obtained by two of his daughters 
and the academic career of his son. “ Tablets will crumble 
in the course of time, but the name and fame of Ti'illiam 
Leishman will be passed on,” said General Harvey in con- 
c iision, “ from generation to generation.” The tablet in 
the college records the fact that Leishman carried out his 
researches on typhoid, kala-azar, relapsing fever, and other 

Tho tablet m the cbapel recites his many militaiy, medical- 

The ceremonies were attended 
by Lady Leishman and other members of the family am] 
bj a laigo number of past and serving officers, while imonc 
others present were Sir John Rose Bradford (President J 

Al' w I'"- Andrew Balfom SR 

Almroth Wright, Sir David Semple, Air Vice-MmsS 
D.avid Mnnro, and many more who came 1 rursiiai 

with Sir William Leishman’s life and work 'TliTBriHsl^ 
IMedic.al Association was represented by Br. Alfred O 
Medical iSecrotarv, - ' - '-'OX, 


British dclcgatc.s, omplmsized tho attention which Han-cy’a 
di.scover 5 ' had excited from tlie fir.st in France, not only in 
tho medical, hut also in tho philosopliical nml literary 
world. AVliilc the doctrine of tho circulation met with tho 
opposition of Riolan and Guy Pntin, it received tlic warm 
support of Descartes, who gave a detailed description of it 
in bis celebrated Discours dc Ja Mdihodc and his Traii6 de 
I’JIommc, whilo Boilcau and Molioro held up to ridicule 
tho opponents of tho now discovery, Profoksor Cliauffard 
expressed appreciation of liis reception in London as repre- 
sentativo of tho Academio do Medccine, and repeated tho 
address which ho had dolivored at tho Royal College of 
Physicians." Professor Glcy, who reminded his audience of 
tho commemoration by the Academic do Medccine of Edward 
Jennor in 1023 and of Thomas Sydenham in the following 
year, discussed the significance and development of Han-cy’s 
work, which was foreshadowed by iServctus, Colombo, ami 
Cosalpiniis, and hronght to completion by Pecquet, fiTalpiglii, 
and Locuwonliock in tho seventeenth century, Lamiiro and 
Berlin in the eighteenth, and Clando Bernard and ^tarcy 
in the following century. The proceedings closed with a 
short address from the general secretary. Professor Achard 
— in which ho expressed his best wishes for tlic progress of 
British science and tho prosperity of tho Royal College of 
Physicians — and tho jircsentation to its President of a 
Latin address, in which a eulogy of Hatwey was combined 
with an expression of goodwill to the College. 


DAWSON WILLIAMS MEMORIAL FUND. 

"We publish ■ this week at page 094 a further list of 
contributors to the memorial to Sir Dawson "Williams, 
Editor of the Drifish Medical Journal from 1898 to 1928,. 
who died on Fehruarj-^ 27th, last. Tho first list appeared 
in our issuo of March 17th (p. 461). l\c nie asked to 
call attention to tho fact that the fund will he closed 
on Saturday next, • June 16th, and that any further" 
contributions should therefore ho sent at once to tho 
Honorary Treasurer. The Organizing Committee is now 
cng.agcd'in preparing recommendations, and all snhsorihors 
will shortlv he snminoncd to attend a general meeting 
to consider them. Cheques should ho made, payable to 
Sir StClair Thomson, and sent to 64, Wirapole Street, 
London, W.l, the envelopes being marked “ Dawson 
Williams Memorial,” 


The summer dinner of the Australian and New Zealand 
Alcdic.al Association in England will bo held at the Trocadero 
Restauriinl, Piccadilly,' on Friday, June 15th, at 8 p.m. This 
will be preceded by a general meeting at’ 7.30 o’clock, which 
all visitors and] members arc "requested to attend, to elect 
office-bearers for the forthcoming year. Sir Anthony Bowlby, 
Bl., K.C.B., IC.C.M.G., K.C."Y.O., is the official guest of the 
Association. All medical visitors from Australia and New 
Zealand are invited to he present. The honorary secretaries 
are Mr. E. T. C. Milligan, F.R.C.S., and Mr. Philip- J. Jory, 
F.R.C.S., 86, Harley Street, W.l (Langham 2828). 


THE HARVEY TERCENTENARY IN PARIS. 

Ix tho week following the celebration in London of th 
threo hiindrodth anniversai-y of the publication of Han-ev’ 
great work a special meeting of the Academic de Medecin 
for the same object was held in Paris, when this country wi 
represented by Sir John Rose Bradford, President of tli 
Boyal College of Physicians, Professor Barcroft, who occi 
pics tho chair of physiology at Cambridge, and the Britis 
Ambassador. Addresses, of which the full text will I 
ound in the official organ of the -Academic,' were delirerc 
«lo\ Bcclere, and Professors Chauifari 

J c lard. Dr. Beclerc, after welcoming tl 


1 dc SICdccirte, May 22Dd, 1928. 


The annual report of the radium department of the North 
Canterbury Hospit.al Board, Christchurch; New Zealand, for 
the year ending March 31st, 1928, records that the total number 
of radium applications during the year was 498, On several 
occasions radium was taken out of the hospital for the treatment 
of patients in private hospitals or in their homes. Since the 
opening of the radium department in November, 1924, 234 
patients suffering from rodent cancer have been treated, of 
whom 203 are at present free from any -signs of this disease, 
and in the non-malignant uterine haemorrhage of middle age 
radium proved of special value. DUra--violet ray treatment was 
found to be very beneficial in certain cases' of disease of 
the nervous system. - - . 

' British Medical Journal, May 19th, p. 868. 



ARIUVAt. oil? !r&E ‘jTEWS lN ENGEAND. 


r TimI^RTTi*rt PQ5> 

t M>;t>tCAE JofCSAt 


June Oi iOs®] 


J^oba ft itefa. 


TIIK AinUVAL OF TJIK .IKWS IN ENGLAND. 

In a I'oiniiuitiicatioii to tlio Ih'iiifih MciJicid JoHiiialf 
Soptciiibci- 26tii, 1025, I , gave some oxaiiiplos of early 
cluivtors witnosscil 1 >y uu'u, lunl coiuiuoutru ou 

tlio raritv of incdioa! witncssos in p^oiiornl to niiciciit doods. 
Shu ‘0 11*kU date 1 liavo tonsuUcd tlio clmrtulnncs of I 
jHimoroiis lionso*;, and^ aUlioogli 1 liavo mot AvUb 

u certain nninbcr of medical \vitno''S('^, 1 soo no rcacou to 
modify the altitude 1 took u]i— namely, that it is uncommon 
to find a doctor acting as a witness. In two docunionts, 
taken from the Jlrinkhurn cliartulary, a still rarer 
jdionomonon is exemplified, a medical man being a principal 
party to early deeds. 

The Ilrinklinrn eharlularv w:k puhlislied hy the Surtees 
Society in 1892 (vnl. 90). in it is the reeort! of an agree- 
ment between the Prior and Convent and Henry the 
])hysieian of Kowcastle-on-Tyne ('oneerning a house in 
Newcastle. Tlio gist of this deed is as folhnvs. 

Know all men present ntul to come that this is the npreemont 
miule between IVillinin Prior of Itrinkhurn and the <pnvcnt of 
the i'nnic place and Henry the Physirinn of NcwcnMl<‘-ou-Tyne, 
viz., that the .aforo>nid prior and convent have let to fee firm 
to the nforosaid Henry a liou .''0 with appcrlepanoes m WcM^ato 
near the castlo ditch which they hold hy gift of Alexander of 
Gloucester. To lia\e and to hold to tlic afoi'^aid Hcniy nod lut* 
boil's or assigns, jews anti men of religion exccjiU'd fexceptis 
Judeis ot viris religiosis] of the pnor and com cut of nrinkhiirn 
for ever freely anil quietly. Paying therefor yearly to the prior 
and conveut two shilliugs* at Pthucco-^l for all set vices and dtces 
and heside.s the rent due to our I.fOrd tlie King. And be it known 
that if the aforewid Henry. and his heirs or assigns aic behindhand 
in payment of the aforesaid rent on the dales (hie, llio aforesaid 
land with buildings . IHterally principals] which shall have been 
erected on it shall ho taken into the Imnds of tftc prior and 
convent, until the said Henry and his heirs or his assigns shall 
have .salisfied the said prior' and convent. And the said Henry 
and his lioir.s or his. ns«igns shall keep the nfo^c^ald land and 
buddings in good repair ut his own proper i*ost. And the afore- 
•said prior and convent will warrant the said loud with appcvtcu- 
anecs^ to Hie said Henry and his heirs or his as-igns for ever. 
In witness of which we Imre fixed the seal of our chapter to this 
-chirograph script in the year of our Lord 1219, on the dav of the 
natirity of Si. JoUti the mptist. These being wituessi's. Domiiius 
Peter Scott, Master AVilliam the son of Hie Dean and others. 

A second deed i.'? .Xo. 216 in the sanio cliartulary; it 
is n grant of a rent' from the house iiicutionod in the first 
deed to John, son of Geoffrey Walonmn of HaliwoU, the 
mavviage gift tO'thc daughter, Y.sota, of the grantor. The 
gist of it is as follows. 


To all who shall see or hear this writing, Master Henry th 
Physician of XcwcasUc-on-Tyiic, greeting. Know that I have givci 
conceded and by lliis my prc.sent charter Imvc confirmed to Join 
sou of Geoffrey Waloman of Haliwell in free marriage with m; 
daughter Ysota an annual rent of 2/ of that house in Kcwcastl 
near (bo castle ditch of the same (own which formerly I Iicld o 

• r T> Convent of IJrinkbuni received yearly at Pcntccos 

• *1 I''® heirs or as5,igns. To have and to hot 

to tne said John and his heirs of the said Ysota iny daughlci 

• •. ' tf should happen to have no is.sue I will for me and nr 

Iicii-s that the aforesaid annual rent of 21 shall lomain to the prio 
and convent of Brmkburn for the health of my soul and of Alic 
my w^iic and all my ancestors in free and perpetual alms for ever 
And that my gut may remain firm and stable I liavc affixed m 
T? 1 ^ writing. 'These being witiies.scs. Dominus Euslac 

Delaval, Dominus Henry his brother and others. 

TIio clause in the fii*st of thc.so deeds excluding Jews call 
attention to an interesting liberty accorded to cei'taii 
towns in England^ ^tlie privilege that no Jew might dwel 
or stay in that town. Newcastle’s privilege is containei 
m a charter of Henry IJI. Alndorc, in his histoiy of th 
Exchequer (1/11), gives a copy of tlie King’s writ to th 
bhenfY. This I have translated as follows ; 

Tho King to the Slieriff of Northumberland greeting. Knoi 
that we liavc conceded and by our chailcr have eonfirmwl to ou 
tnjo men or Ncwcavtlc-on-Tyno i and their heirs that (hey ma' 
have this hberty, v«., that no Jew in our time or in that d 
om hens may remain or make any residence in the same town 
”1 f“''y conti^med m the King's charter which he ha 
ScHw I'r’P- « commanded to the r.ai, 

eon ,!.. V, i n publisli tile said charter through his whol 

KemIfnAon 4tt''jM Hin'o' 

Mjdox states tliat another town to have tliis anti-Jewisl 
privilcp was Derby, which was one of the famous fiv 
hoionghs of the Dames, tlie others being Lincoln, Leicestei 
nig lara, and Stamford. I do not know whether an 


of l!ie.se towns wt-ro granted the same lihorly. It miglit 
have been thought that tho documont transcrihed hy 
Jfiulox was forged, ns tho contents of it are distinctly 
nntisual, hut the first . of Dr. Henry’s deeds shows that 
tho privilege was a real one. AVhat tho unfortunate 
inhnhilanl of Newcastle did if ho wished to raise a loan 
I cannot toll.. 

The first entry of tlio Jews into this realm is an interest- 
ing jmint; donhtless some will ho ready to assert that our 
first .Towish resident was .Joseph of Arimallica, whoso 
thorn bloomed at Glastonbury, but this would seem to lie 
a myth. A friend i)f miiio Ims suggested to mo tliiit they 
may have aecompaiiiod the Plmenicians to Cornwall in 
their visits to this country in search of tin ; 1 have no 
jn-oof that this is the case, and I cannot help thinking 
that if they did visit England with the Phnenieinns, they 
inado no .settlement in Cornwall. Everyone knows that the 
Jews were hanished hy Edward I and that their TOtiirn 
to .settle in tins land was one of the many things we owe 
to Oliver Cromwell ; was it not stated the other day that 
he was willing to let them have St. Paul’s Cathedral for 
"a .syimgoguof A siiporfieial search of Kemble’s Codex ha.s 
not yielded any evidence of a Jewish section of the popu- 
lation in early .\uglo-Saxon times. In no Anglo-Saxon 
charter have, I seen the name of anyone who could bo 
looked upon as a Jew, either in the hody of th.o deed or 
among the witnos-ses. 1 do not find that 0.swald, tho 
saintly Bishop of IVortssster, granted any leases for three 
lives to any jtersons with Jewish names, but it is frequent 
to And in tlmt claiiso which was inserted to make the deed 
more binding tho \)ious hope expressed that if anyone 
j violates this gift may ho burn for ever with Korah, 

I D.athnn, and Ahiram I . . ; 

Towards the end of tho Anglo-Saxon era we have definite, 
cvidenco that there were .Tews in England. The laws of 
Edward tho Confessor declare tho King to he tho protector 
of all Jews. They counted ns strangers; they could riot he 
in hundred or tything as free men; and the protection of 
strangore being one of tho royal prerogatives, they belonged 
to tho Crown, ns did also a portion of their wergild (Ano 
for murder), and their jtroperty in case of death. So fai- 
ns my researches have gone, the Confessor’s laws give tis 
the, Arst definite evidence of the Jews in England. 

The Conqueror brought Jews from Eonen to London. 
William of JIalmcshury, speaking of tho doings of William 
Btjfiis, says: “ Jiidaei qiii Londoniae habitabant, quds 
pater c Eothnmago illnc traduxorat.” 

I do not think that tliere is any evidence in Domesday 
Book to show that there wore many Jews in England in 
1086. London, of course, is not included in the snn-cy; 
but, on the other hand, the Jews Agure largely on all the 
pipe rolls to which I have access. When the celebrated 
usurer, Aaron of Lincoln, died in 1186, his goods and 
debts wore taken into the King’s hands, and it is of 
intorcst to And that they do not appear on the pipe rolls 
till Avo 5 'oars later, so that it took a considerable time 
to wind tip an estate in those early times. Tlie Angeviri 
Kings kept a vei-y tight hold on 'tho Jews. Thev “were 
allowed to settlo in tho larger towns of the realm": they 
had the King’s peace — at a price — and were more often 
than not Aecced by him as they wore in tho liabit of Aeecing 
his .subjects. One may say that from the beginning of the 
reign of Henry II till 1290 the Jews afforded the most 
convenient means of raising money. Stubbs, in the Coii- 
siifutionaJ Hisfor>j of Jinqinnd, says that “ thev were 
exempted from the general taxation of tho coiuiti-y to be 
tallagcd by themselves; for the Jews, like the forests, were 
the special property of the King. . . . Henry II in 1187 
exacted a fourth part of the' chattels of the Jews; John in 
1210 took 60,000 marks by way of ransom ; Hen'rt- HI in 
1230 took a third of their chattels; and in 1255 he 'assimied 
the whole body of tho Jews to Earl Bieliard as seenritv for 
a loan.” In Frauee St. Louis expelled them from’ tho 
country in 1252. In England Simon do Montfort per- 
secuted them, and Edward I in 1290 banished them from 
the kingdom. 

Tho fact that tho Jews are with us to-dav in snclt 
numbers has always seemed to me a strono-' argument 
against .the rapid decline and fall of the British Empire. ' 

R. R. Jasies, P.R.C.S. 


994 June g, 1928] 


DAWSON WltitiTAMS MEJTORIATj. 


r Trrr*rrt't . 


Dawson Williams llkniorial fund. 

SECOND LIST OF SUBSCRIBERS. 


Since tlie first list of contributors to tlio Dmrson Williams jMomorial Fund iras published in fbrse columns, on Marcli 
17tli, subscriptions liavo been received from those ivhoso names appear in the list jirinted below. Tbosi> who may have 
overlooked the matter are invitqd to .send their subscription before Saturday, June Ibtli, when the list must bo definitely 
closed. The Organizing Cominittoo will then draw up recommendations for the dis])o.s:il of the fund, and all subscribers 
will short!}' afterwards be retpicsted to attend a meeting to consider tboni. Tlio honorarv treasurer is Sir .StClair 
Thomson, F.R.C.S., 64, Wimpolo Street, W.l. 


Abercrombie, Dr. Peter 
Aeland, Dr. Theodore Dyke 
Aitken, Dr. C. J. H. (Kilnlmrst) 

Auld, Dr. A. Gann 

Balt, Dr. Bernard (Bnry St. Edmunds) 
Bazin, Dr. A. T. (Montreal) 

Blenkinsop, Major-General Sir Alfred 
(Frensliam) 

Bond, C. J., F.R.C.S. (Leicester) 

Cameron, Dr. J. N. (Toronto) 

C affey, Dr. Wayland C. (Hove) 

Clow, Dr. David (Cheltenham) 

Clow, Dr. Alice Sanderson (Cheltenham) 
Cockill, Dr. T. T. (Milford) 

Collins, Sir William, F.R.C.S. 

Coupland, Dr. Sidney (Oxford) 

Crawford, Lieut.-Colonel D. G IMS 
(Ejling) 

Currie, frofessor J. R. (Glasgow) 

Davies, H. Morriston, F.R.C.S. (Ruthin) 

U arden Dr. W. F. (Old Traftord) 

Deymc, Dr. Henry (Virginia Water) 

Elliot, Colonel R. H., FiR.C S 
Fawsitt, Dr. Thomas (Oldham) 

Fletcher, H. N., F.R.C.S. 

Fox, Dr. T, Fortcscue 


Fraser, Dr. Louise (San Remo, Italv) . 
Fullerton, Andrew, P.R.C.S.I, (Belfast) 
Garrow, Dr. R. V. (Chesterfield) 

Gibbons, Dr. R. A. 

Goodbody, Dr. F. W, 

Goodfcllow, Dr. T. A. (Mnnclicslcr) 
Gordon-Taylor, Gordon, F.R.C.S. 

Gosse, Dr. Wilimm (Farkslone) 

Gow, Dr. A. E. 

Gray, Dr. A. M. H. 

Hamilton, Dr. C. D. (A(hcns) 

HcaUl, Dr. Ct B. 

Hempson, Mr. \V. E. (Tunl»rid»;c Wells) 
liughcs, E. E., F.R.C.S. (MancUe^ilcr) 
nutUer, Dr. William 
Jcx-Hlakc, Dr. A. J. (Knirolii) 

Keene, Professor Mary F. Lucas 
Kilroe, Dr. Lawrence (Roelidale) 

King, Dr. V. Ridman (Swindon) 

Lnslclt, Dr. E. Ea (Hull) 

Lawrence, Dr. R.'D. 

Lawrence, T. W. l\, F.R.C.S. (Tndwortli) 
London, Dr. A. A. (Adelaide) 

Lvnn-Tliomas, Sir John, F.R.(i.S. (Llcchryd) 
McCarrison, Robert, Licut.-Coloncl 
and Mrs. McCarrison (Coonoor, India) 


Mackenzie, Dr. S. Morion (Dorking) 
McVnil, Dr. Klizabcth 
Magnus, Sir Pliilip, Ut, (ChUwortb) 
Morlnnd, Dr, Egbert 
Motl, Ladv (Bournemouth) 
iVott, Dr. ll. W. (Guildford) 

O’Connor, Dr. Joseph (Woking) 

O’Kincaly, Lieut.-Colonel F. 

Ollcrcnslinw, Robert, F.R.C.S. (Manchcsler) 
Parker, Dr. Gcorgo (Clirlon) 

Patterson, Norman, F.R.C.S. 

Raynor, II. H., F.R.C.S. (Manchester) 
Richardson, Mrs, Sophfn, M.D. (Cheltenham) 
Samways, .Dr. D. W. (Mentone) 

Scott, Dr. S. Gilbert 
Shrubshhll, Dr. W. W. (Brighton) 
Thompson, Edward, F.R.C.S. I. (Oma"h) 
Wal.son, Dr. Chalmers (Ditm, East Lothian) 
Wafkins-Piteliford, Dr. W, (Bridgnortli) 
Wauchope, Dr. G. M. (Hove) 

\Vcir, Dr. J. W. (Ea.st London, S. Africa) 


Jncorrctihj ciifrrnl in Prci iotii J.i^t. 
Watsou-WiUiams,Kric, F.R.CJ5.,rhouId read 
Dr. Patrick Watson-Williams (Clifton). 


'I'HE VOLUNTARY HOSPITALS COMMISSION, 

Final Repout: Termination of the Inquiry. 

The final report of the Voluntary Hospitals Commission,’ 
Oealing with the requirements in respect of voluntarj 
liospital accommodation of Fngland and Wales, lias been 
presented to the Minister of Health. In April, 1824, it 

Mr / Chamberlain’s predecessor, 
Mr. John M heatley, requested the then existing Com- 
mssioii to institute an inquiry into this subject. A short 
mterim report was presented in July, 1925, and a summary 

fn i"' * Journal of August 15th, 1925 

(p. 0U5). The docuniont now under review is cquallv 
brief, occupying little nioro than five pages, with ail 

t 1 . The work of tlie Commission lias now with the 
conourreiice of the Minister, boon terminated’ and t e 
final report represents little’ more than a summary of 

coL’iiiiTirri'tiS Si",* ‘'"v". ‘t- 

Kxehoquer grant, or 7 seHe 

to £2,000,000 should be made to^heln =’™o>'ntmg 

expenditure for addition^ vohintery Imsilbl n""' 
tion, and that the Minister of Health 
ability to proceed with the proposal. Moaiiwhile'^'tlir fi ’"i 
report states, more iirogress has been made thLi’ was wn 
siderod probable. Tho report, apart from ■ survevV^ 
hospitals position, -deals ' mainly with fin.ance 
chides that tlicro is no ground for annrehenslon I- 

the ability of the hospitals to maintain such additiol"^ 
beds ns may ho provided,, directs attention to the growW 
importance of systems of mass contributions from tl^ 
uulustrial classes, and .suggests that this must he recardwt 
as the only quarter likely to yield any substantial crowti. 
of income. The Commission’s jiroposal for dealing titli n 
ditTioulty often referred to in these columns is that some 
form of compulsory insurance for motorists should he inlrn 
diu-ed to relieve tho voluntary hospitals of the burden 

=''vhtents'*‘’'Do/'-|’'"f S'vwing frequency of road 
— ; — — — I ^tails from the report a re given below. 

book.ellernS. 


The Tosh of the Commission. 

The Commission was instructed to inquire into and 
report 111)011 “ tho extent of' tho additional voluntary 
hospital accommodation - required in Kiiglaml and IVales 
.and tho host means of providing and maintaining it.” The 
final report hears the signatures of the following members; 
Tlio Karl of Onslow (ehaii nian) ; Sir llohert Bolam, AI.D. ; 
Sir John Rose Bradford, K.O.M.G., M.B., P.R.C.P.; 
Dr. B. C. Buist; Lord Clwyd ; Air. H. Wade Deacon; Dr. 
IV. K. Klliot, AI.P. ; Sir George Makins, G.C.AI.G.; 
F.R.C.S.; Mr. D. 0. Alalcolm; Dr. F, N. Kay Meiizies; 
Sir Ei Cooper Perry, AI.D. Lord Linlithgow, owing to liis 
absence as Chairman of the Royal Commission on .Agvicnl- 
ture in India, was not able to take part in any of tho 
Commission’s clolihcrations on tlia final report, and for this 
reason his name is not appended. The death of Sir 
Robert Hiidsoir deprived the iiicnihors of a' collcague whoso 
assistance had hccii of great value. 

The opening section of .the roqiort rec.Tlls the conclusions 
■prc.sented in the interim report, referred to above, and the 
reception its recommendations met with from tho Alinster 
of Health, stating tho position in the following, terms : 

' Early in 1926 you informed us th.at you had, with great reluc- 
tance, come to the conclusion that the financial situation of tho 
country was such as to make it impracticable at that stage to 
proceed with tlic proposals for a grant from public funds towards 
the cost of new construction on the lines of our recommendations. 
AVe received your decision with regret, though we were bound 
to recognize the force of tho considerations which led you to it. 
You have now intimated to us that our main task having been 
accomplished you do not feel justified in asking us any longer 
to continue our work as a Commission. While we cannot hut 
regret that it has been impossible ' to implement proposals to 
which we devoted much time and thought, we desire to take this 
opportunity of expressing our appreciation of tho confidence which 
you and your predecessors have reposed in us. 


liccent Growth in Jlospitat Accominoclntinn. 

A surrey of the present position is then gii-en based on 
a comparison of tho figures for Juno, 1024, and for the 
end of 1926. The expansion in available aceomiiiodation 
has been, it is disclosed, more rapid and more widespread 
than the Commission anticipated wlien ]irG]iaring the 1925 
veport. The figures prove that diirin" tho jioriod of two 
and a half years the liospitals liave shown marked activity 
in t tter of extensions, and during the latter part of 



Jdse 9, 19^8]. 


Tnn VOriUNTARY nOSPITAtiS COMHISSrON. 


r -Tur 

I MrorcAC JocBitu. ® ^ 


thnt porind tlio ralo of oxpaiiKioti Ims considcnilily oxfoodcd 
tlio provision required to Icecp pace iviHi tlio growth of 
the ]>opulatioii, AvilU the result that tho arrears of ine vai 
period nro liciiig gradually but appreciably reduced. 

Duo allownuco must, of eourso, bb made for the growth 
of pnputatiou, nud the report points out that the excess of 
bod accommodation available at tlio end of December, 1826, 
over tbo figures for .Tiitio, lE2d, must not bo tnlccii ns repre- 
.seuliug a net gain. At tbo timo of tbo 1624 sinwey tbo 
ratio of beds to population was 1.53 per 1,000. This ratio, 
bon-cver, was based upon a figure of accommodation which 
tbo Commission believed was 10,000 beds .short of what was 
reasonably necessary. If this deficiency bad not existed the 
ratio of libds'to population would have been 1.6 per 1,000, 
land this represents tlio riito at \vliicli the hospitals must 
•expand to keep pace with tbo growth of pnpnbitioii. Tho 
iiicrcnso in population in tbo thirty 'iiioiitlis between tbo 
date of tlio 1924 survey and tbo end of 1026 is estimated 
at approximately 638,000. On tiio basis of 1.6 beds per 
1.000 it was jicccssary, therefore, for the hospitals to 
provide 1,020 beds to meet this increase. 

Tho returns rcrcivtsl by tlio Coniiiiissioii from local 
vohiiitnr}- hospital committees, ■including King lulward’s 
Pnnd for London, showed that in this ]icriod 3,820 beds 
were actually provided, or 2,809 more than the number 
required to meet the growth of population. This repre- 
sents an average reduction of 'arrears at tlic rate of 1,124 
beds per niiiinm. TJiis the Coniiiii.ssimi regards ns less than 
is idc.ally satisfactory, but ns considerably 1 otter tlinii there 
was reason to anticipate, and it is stated that, taking the 
. nmoiiiit of money becoming available ns the tost, the 
position appears still more Iiopcfitl. It is |ioiiited out- that 
• in London the receipts for building puriioscs aiiiounted in 
1925 to £735,000, nud in 1826 to £479,000, as c-oiiijuirod 
w.illi an as'or.ago of £308,000 for the tliree i-ears 1922-24, 
ami it is further stated tiiat, aUhnugb Loudon is in some 
rcsjiccts in .a specially favourable position, and figures for 
the provinces are not available, there is groiiiul for believ- 
ing that tho amounts appropriated for buiUliug purposes 
have snbstantialJy increased, and that a further improve- 
ment in tile rate of progress may reasonably be I'.xpccted. 


T/ic Prohlcin of .Vuiiitraoiiee. 

In its previous report the Comiiiissioii expressed the 
opinion that tlioro is no reason for apprclieusioii as to 
tlio .ability of the Iiospitals to provide for the addit oiial 
beds. It was found that while in 1625 a Siiiistaiit.ally 
larger number of beds bad to bo niaiiitaiiiod tbaii in the 
previous year, the cxee.ss of income over cxpeiidiiiirt 
amounted to as nnicli as £734,000, or over £100,000 more 
than in 1624. Owing eliicfiy to the industrial couditioin 
prevailing in 1926 ilio dnaiieial position in that year was 
less fuvonrablo than lit 1825, but (iio Coiiiiiiission is coii- 
ndciit that \vitU .the return to more noniial conditions the 
position will again improve. The siicee.ss with wliiob the 
iiospitals met this crisis, it is' suggested, indicates the extent 
o a bicli the nnaueial'struetuvo of the system has rccovereil 
from tbo strain of the war period. 

f ^'“'''evor, that iio one should lose sight 
of the fact - that the views reported above refer to the 
-general position, and the Commission" evidently desires tc 
make it clear that the outlook, is bv'iio means entireh 
satisfactory. Referring. to this point the report' states: ‘ 

k mifnLni '‘l”, "• neb flic income of the I.ospit.ib 

IS insuuicient lo mcel the expendUure, and in which for thi« 

Sulito possible lo undert.akc extension on aii 

ho^niui PP 1^- areas conipnee some of tlic most important 

hospital centres m tbo country. Indeed, it i.s the larce cenera’ 

mamtpi\npp nltachcd in svhich thf cmW oI 

maintenance are higher than m ot!,cr hosnitals which find Iht 
i‘" ™'’frting tho funds necessary for carrying or 
lo soKp 11 " r '® .to Hie fullest extent. Foilurt 

iL'ifnf fn,f ““'"fenauTO and extension in tliose area- 

cannot fail eventually to react to the prejudice of tho voluntary 

■ /or J/oss Confn'bu/ioiis. 

Ucaliiig with the nature of hospital income, tlio Com 
nussion has found in eeitain a, 0 . 0.5 where fmancia 

tX.'t?’,, ®-''^tem of mass com 

1 biitioiis, and tho members have concluded that tin 
qiiaitcr whence any substantial increase in income 


may bo expected in tlio futiii'o. is from tbo indiis- 
trinl clii.s.scs. The report points.' out that legacies are a 
problematical element, and tliafc tbo proportion of intvmio 
from largo subscriptions i.s unlikely to iiicroa.se, while they 
feel that tbo interest of tlio middle-class snbscribcvs has 
been reiiinrknbly well inaintaihed having regard to the 
benefits they enjoy from tbo hospitals. The conviction is 
expressed that the fiitnro of tlio voluntary system depends 
in a largo nieasiirc fill its .success in .securing in one form 
or anolbcr tbo coiiliiiiiod support of tbo small contributor. 

In this coniioxiou tho Commission cmj'iiasiv.cs tbo need 
for recognizing that the framing of any sebeme of mass 
contributions calls for tlio cxereiso of groat caro to avoid 
tlio acceptaueo by tbo hospital of liabilities wiiieb cannot 
bo di.scimrgcd, or’ tbo creation in the minds of contributors 
of e.vpoot.stioii.s, wbieb may not he fuJfiJ/cd. Tho o/fcct of 
such Kchemo iijion tho govoniment of -the liosi>ttal and the 
relations of the medical stall must also, it is stated, bo 
taken 'into roiisidcratioii. The report proceeds : 

It is hoped that those local volnnUry hospital committers 
wliieli (lavo not (iiineil their .attention lo this prohlem will make 
a- reel efi’oit, in conjnnclion with ho.spilais, to establish, under 
adequate Kaftpuards, suth Fclicmcs wherever circumstanecs permit. 
Wo li.avo not" ill the past, pressed this' conclusion upon local 
committees liccauso we rcalired the manifest risks and difficnltics 
which- the sysuin entails. ]jut the experience of recent years has 
convinced us that this is (ho main source of new thconie, and 
while the ilangcrs’ nro" real we do not believe them ‘to be 
-msupcrable. ... 

• nofcrciieo is made to tlio fact that many of the local 
voliiiitniy eommitteos instituted on tlib recommendation of 
the Cave Committee are still in existence, and tbo Com- 
mission pbuc.s on record its indebtedness to those com- 
mittees for tlioif nssistiinec in its work. ' • 


Tho llosp'itiiU ftiid ilfofor Accidenis. 

Altoiitioii is finally called to tho effect of the increasing 
frequency of motor accidents upon hospital finance. Ho 
det.ailed iiive.stigation bins boon made, but tho Commission 
agrees that this is pkiciiig a heavy burden on many institu- 
tions, and exjnesses it.s" opinion on the matter in the 
following terms: • 

This charge ought not to f.sll upon tmids derived largely from 
llio goncrostiy of the cli.Tilnble, wlio«o gifhs are intended for the 
relief of pcrsor.s who ha c net tlie means to provide institutional 
Ircalmcnl at their own cost. While the possession of a motor is 
icry mr from licing evidence of adiuence, those who can afford to 
maintain a c.'.r would siillci' no hardship if by some system of 
compnltory ins; i-cnco Ihry were required to pay the' premium 
prohahly cotiqai.iti cly sit all, which would he needed to cover 
(l|c .Irciiii'.cnt of Iheif own injuries as well as those which may 
he cau.scd lo otlicis. The incidence of tliis burden is very 
unequally dkirilmicd, and it falls" with special severity' on tho 
Iiospitals whic'i nro siliwtrd on or -near" those now roads whoso 
excellence from an engineering point of view" affords a seemiiwly 
irresistible temptation to excessive speed, “ ^ 

It is reeogiiized that tho proposal would involve legis- 
lation, and ni.iy excite controversy, hut the Commission 
can SCO no other way of imiiosing the charge on tliose by 
whom in equity it should be borne. 


Hospital Accommodation Statistics. 

An appendix to the report gives details, by counties, com- 
paring the position in England and Wale-s in re.spect of 
voluntary hospital acconimcdation at the end of 1926 with the 
position in June, 1924. Tlie figures are' given for bed accomiho: 
dalion at each date; the miniber'of additional beds’ stated to 
In required in 1924; tbe increase in the period mentioned ; and 
the number of additional beds in course of provision at the end 
of 1926. For tbe country as a whole revised figures, prepared 
since tile issue of the previocts report, show tiiat there were 
available, in mid:1924 50,679 .beds, while 13,252 beds were stated 
t'i be required. By the end of 1926 the number available bad 
increased by 3,829 to 54,503, and 2,964 beds were in course of 
provision, so tiiat tlie deficit on estimated requirements had 
been reduced considerably. However, ,as the report indicates, 
allowance must be made for the increase in the population. 
It should be noted . that in its earlier report the Commission 
took the view that some economy could be secured in .{lie 
number of beds required by local co-ordination and other 
iiieans, and concluded that the then e.xisting requirements 
could be met by the addition of 10,000 beds. 

In London the revi.sefl figure for the avaiiahie accommodation 
ill 1924 "was 13,880 beds, and it was estimated that 2,088 addi- 
tional beds were required; accommodation had been incre.ased 
by 597 beds up to the end of 1926, and 1,150 more were in 
course o! provision, so that substantial progress bad beFtn made 



996 JXJKE 9, 1928] 


MEDICAL INSUK^CE AGENOT. 


r TifEnnmsa' 

L Mr.DlCAL JOCRHAX. 


The situation outside London was less satisfactory ; between 
dune, 1924, and the end of 1926, 3,232 additional beds had been 
provided, and at the end of the period 1,834 beds were in 
course of provision, while at the beginning of the period 
additional requirements were stated to be 11,164 beds. Wales 
and IMonmouth were stated at tlie first survey to need 1,102 
beds ; in the thirty months following 427 were provided, but 
at the end of the period only 43 more beds were in cour.se of 
provision. Some time has elapsed since the collection of these 
figures, but tliey serve to reveal the disparity existing in the 
extent to which the hospitals in various parts of the country 
have been able to increase their accommodation. 


THE MEDICAL INSURANCE AGENCY. 

Twenty-fihsi Anniversahy Dinner. 

The twenty-first anniversary of the establishment of tho 
Medical Insurance Agency was celebrated by a dinner at 
the Hotel Victoria, London, on May 30tb. Sir Husiriiry 
ItoLLESTON, chairman of the Committee of jManagement, 
presided, supported among others hj- the Chairmaii of 
Conneii of the British Jlcdical Association (Dr. H. B. 
Braekenhury), the Cliairman of the Hepre.sentative Body 
(Dr. C. 0, Hawthorne), and the Treasurer (Mr. Bishop 
Harman). The company included also many well-known 
men in the world of assurance and of mcdicai charitv. 

The health of the Medical Iiisnrance Agency was proposed 
by Mr. Arthur Digey Besant (Past President, In.stitute of 
Actuaries, and General Manager of the Clerical, Medical, and 
General Life Assurance Society), who said tliat it.s genesis 
might be traced to the special committee set up hv the British 
Medical Association at the time of the passing of the 
v\ orkmen s Compensation Act for the purpose of assisting the 
profession in the problems arising out of that legislation. The 
work of the Agency at first was more or less of a limited 
character, hut in addition to workmen’s compensation questioii.s 
It dealt with the insurance of motor-cars, although the age of 
the motor car had then scarcely begun. Incidentally, it was 
not always realized that medical men were pioneers in putting 

use. PreseiiUy the great insur- 
?nvfi picture. Some insurance men were 

advice a® to give 

technical questions involved. Insurance men, 
said the speaker, were naturally modest persons, but Uiey did 
recognize a golden opportunity when it came tlieir way^ On 
be one side were thousands of medical men, all immeiwed in 
t th ' ‘‘'cliiiation to de.al 

reorganized and sti-e™gUien^ management avas 

avith leaps and boLds^^ t<»>'''-ard 

started it had arranged life and tn ®1 Insurance Agency 

to one and a half raUlion endoavment insurances totalling 

whole of its business. In motor ’’j the 

hold, accident, and other insurances th*“’fi® 
impressive. That avas a avoiiderfnf * *'8ures avere also 
been effected in taventy^ine years The 
had always been service. A^the 

in 1907 it was resolved that the whole^l^f ^ trustees 

should be devoted to the benefit of the the surplus funds 
bad fallen on evil days, and though this If", 
m-entually, the cliaritable motive ^avas eonOn®^ l""* widened 
nncl taventy-one ye,ars ^ h ,'* , 

£18,000 had been contributed to medical charlttes’'®''®''®^’ 

pioneers, notably Radcliffe Crockerf tl," chnii the 
ceinniittee. Only lately one of the men most ff'"" I**® 

early days of tfie cnte'rpHse-Dr. J. A ‘he 

gathered to liis rest. Another avhose nassiii<f"tl'*~ I*®®" 
was Sir Daavson IVilliams. Mr. Besant’s^fimires mourned 
up to date. During the last ten hours money lml®L"°*' '’"'‘® 
winch brought the contributions to charities duri - ,1 'I 
^e years up to more than £20 Om t * ’® tw-enla-- 

College had b"een --ked to accepf “a’Tntr 
“hokarship w,th wliidi the name of fhe,V* . « 

Dawson V ilhams should be associated He .v '^®,\®‘'®‘I friend 
Mr Besant that tl.e reason avha tl fhUdS T ""Sgest to 
uad to chance its nolipv- '...■♦r ^ledical Insurance Acenc\' 

V"mbL® oft 


was left to distribute its surplus among those wlm lacked 
such prevision. Tho Agency valued very highly the cordial 
co-operation of tho various insurance corporations which Jiad 
aided in the work. The Agency held itself free to give tho 
best possible advice to flie profession ns to the iiive.stmcnts 
Us members sliould make in insurance on the merits of the 
case, and was not interested in the commission if it could find 
a better proposition where no commission was offered. 

Mr. L, I'EuniS'ScoTT, Secretary of the Agency, in n further 
res|)orise to the toast, compared tlic Agency to a stool witli 
four legs — namely, the companies tlirough whicli it worked, 
tlic^ medical profession whose interests it served, the charities 
which it helped, and, finally,- the statT of tlie Agency, who had 
helped loyally to build it up. He himself came in at tlie tliird 
septennium of the Agency’s existence, after the foundations had 
been well laid. But in the early years it was ncccssaiy to feel 
one's way, and those concerned, notably Mr. P. X" Adam- 
thwailc. the agent, had set themselves to lcarn about insurance 
from the very beginning. The companies were always most 
anxious to lielp the Agency; it was greatly lielped by the 
British Medical Association, and by the BritUh MvdicdJ Journal 
ami the Lancet. Very few concerns could possibly have been 
■ started or carried on under such favourable auspices, though 
possibly few had to v/ork in such difficult soil. 

Dr. 11. LA^•CDo^’-Do^Y^' pro|>osed the health of the guests, 
many of whom he mentioned by name. The Hon. Evelyn 
HunnAP.i), in responding, said that tlie company over which he 
had bad the honour to preside since tlic first year of the present 
century (the Guardian) was the first to come into alliance W’ith 
the Medical Agency. Tlie success of the combination had 
ivsuUcd from tho remarkable good feeling manifested on 
all side.s, and also from the skill and ingenuity with which 
insurance e.xperts had been able to devise special policies and 
termk of contract to meet the difficult and varving cases. He 
was a little doubtful about the practice of paying commissions* 
by the companies, though when confined to moderate limits, as 
in this country, it was almost free from objection, and in this 
instance the use which was made of the commissions— namely, 
their devotion to charity — deprived the critic of liis ground 
completely. Sir Charters Symonds (Treasurer, Boyal Medical 
Benevolent Fund), - who also responded, s,iicl that the .first 
contribution from the Agency to tli'e Fund was made in 1910; 
it was not large, hut it was sweetened by the promise that it 
would be repeated, and .in the TOui*se of eighteen years no les.s 
than £10,000 had gone from tho Agency to that Fund alonej‘lo 
tile inestimable benefit of members of the profession,' their 
widows, and families who had fallen on evil days. Not only so, 
but the Fund had gained greatly because it had imd Sir Bobert 
Bolam, Dr. Hawtliornc, Mr. Bishop Harman, and ^Ir. Ferris* 
Scott in its councils. ' . • 

Sir Squire Sprigge, in a very amusing speech, - proposed 
the he.nllli of the chairman, and Sir Humphry Bou.eston, in 
responding, said that ho thought anyone should be proud of his 
association with an agency of this kind, which had been of 
enormous benefit in the direction of providence to the medical 
profession ns a whole, by putting medical men in touch with 
the best possible insurance companies ; and, in the direction of 
charitable assistance, to those members of the profession and 
their families who had been less prudent- or less fortunate. 


^cotlaitiJ. 


Retirement of Sir LesIIe-Mackenzie. 

Silt AV. Leslie AIackenzie rctirud last tvock from tlie post 
of medical member of the Seottisli Board of Health. The 
Board has recorded in the minutes its ajipreciation of the 
services nhieh he has rendered as a medical officer of 
health, as a medical inspector on the Local Governnicut 
Board for Scotland, and, at a later period, as a member of 
the staff of its medical board and of the bodj- which took 
over its duties as the Scottish Board of Health. TJie 
minute continues that for the last quarter of a century 
Sir Leslie Mackenzie has exercised a profound influence 
upon public health administration in Scotland, while 
schemes which owed their beginning to his advocacy or 
design have been carried out with beneficial results, 
examples being the measures taken for the treatment of 
tubei-culosis, for the medical inspection of school children, 
and for the care and supen-isioii of mothers and young 
children. On May 31st Sir Leslie Mackenzie was the 
recipient of a presentation consisting of a handsome piece 
T plate and a gold pencil from the Board. Sir 

f'eslic has accepted an invitation to go to Kentucky to 
naugurate a new hospital which has been formed for 


JUNE 9, 1928] 


SCOTUA-mj. 


f Tii* unmrt 
Mex<]c^ Jc>p»y-U. 


.997 


st'vvico of Vl>o inov»\laii'o«s iwerts in tin; Allcghaiiy Sfotm- 
tniiis of tliiit state, nioclelted oil sclieitie.s in tlio HighJanils 
ami Islands of Scotland, in llio formation of which ho took 
a prominent part. Jiady Jlackenzio has also been invited 
to take part in the American visit on account of tho social 
work with which sho had hcon concerned in Scotland, and 
both .sailed for America from Soiifliampton on Jnno 5th. 
Tho choice of an oiricial of tho Scoltisli Hoard of Health 
to perform this ceremony may he regarded as a trlhnto to 
the Scottish Jicalth admiiiistratioii. 

Hnrvclan FesUval at Edinburgh. 

Tho 141st Ilarvcian festival was held in tho Tloyal 
College of Physicians at Kdiuhurgh on Jnuo 1st; this event 
has taken place annnally for nearly a century and a lialf, 
sinco tho foinidiiig of a chih to commemorato AVilliam 
Harvey on tiie instigation of Andrew Duncan in tlio year 
1787. On tho pro.sent occasion Dr. Hohert Thin, president 
of tho Kdinhurgh Harveian Society, occupied tlio chair 
and delivered an address upon Dr. Archihald Pitcairnd 
and his connexions with Harvey. Ho teminded his 
hearers that Pitcairne, in tho latter pail of tho seven- 
teenth century, had been distinguished as a poet, 
literary man, and .medical scientist, as well ns ,a 
Jacobite politician. In relation to Ifarvev, Pitcairno 
attracted great attention becairso ho was tho first 
to deinonstiate by a mathematical proof, similar to 
that used by Harve 3 * hiiilsclf, that tlio blood must pass 
fiom artorie.s to veins through capillaries; ho had made 
this demonstration even before iMalpiglii, with tho help of 
tho newly discovered microscope, bad seen tho corpuscles 
passing through these . ininuto vessels. As a result largclj’ 
of tin's research, Pitcairno u'ns called to tho professorship 
of medicine at Leyden.- After his return from Lej-deii ho 
was tho real founder of tho Kdinhurgh Jledical School 
upon which others had raised the superstructure. After 
tho address the members of the Harveian Society' and their 
friends sat down to a banquet in the Hall of tho College of 
Pliysicians. According to time-honoured custom ono of 
tho courses of the dinner consisted of Clear dc Bmii/ 
Harveian, .'Vftcr the toast of tho Imperial Forces had 
been proposotl by Mr. David lyccs,; and acknoivicdged by 
Dr. C. K. Douglas, “ Tlic Immortal Jlcmorj’ ” was pro- 
posed bj' tile Presiuent, and tbe niinufes of the preceding 
^ar s meeting were read by Mr. J. W. Dowden. “ Tho 
Health of the Guests ” was proposed by Professor Edwin 
Erainwell, and, a reply was made by the Very Itcv. tho 
Dean of the Thistle, after which “Tho Heiilth of the 
President was proiioscd by Dr. Ilobert A. Fleming, 
■President of the Koyal Collego of Physicians. The 

l’'''>'^<^edings wore closed with tho usual toast 
of Florcat res Hedica.” 

tis.t of the Lord High Commissioner to Edinburgh 
. Hospitals. 

nf High Commissioner to tho General Asscmbly 

thev^u'P,-e^.5 Vi° ^‘’^'•1 Infirmary of Edinburgh, where 
and of thn ificnibors of the board of management 

spiral hn, 5 “"d 

sill leal houses. Tho.KarFof Stair afterwards distributed 

■Ho romTrl tT’l ““PetitivG examinations. 

.Ho remarked that this training school for nurses bad been 

’•’■I ‘.''"11'"!“ « eiS 

'• x* ‘ > 1 recent institution of State exam- 

inations for admission to the State lle^ister of Nurses had 
emphasized ,tIio importance of, sj-steniatic studrin tho 
.nuiEcs cuinculum. The need was now recognized for 

rstsamft^tnfr adnTinistrativo 

wolt ^ ^1 t^^^^^PPointments as teachers, public health 

r... si 

annual distribution by the late Sir 

1 • most .m examinations, in work in the 

and in general efficiency and conduct throughout 


her wholo training. At tho Deaconess Hospital, which 
they visited on Alny 29th, tho lord High Coiiimi.ssioner 
ami Lady Stair were received by Lord Sands and other 
members of tho .hospital board and staff. A tour was made 
of tho various wands, Lady Stair, and members of Iier 
suilo speaking to each patient in turn.- Sho visited also 
tho newly installed x-ray department, whore sho liad her 
hand photographed while tho process was explained. Lord 
Sands, in welcoming tho visitors, stated that the, past 
yc.ar lind been n successful, one, for in addition to carrying 
out a largo amount of medical work in tlio. wards and in 
tlio out-patient department, the hospital had been able to 
hahiiico it.s accounts on tlio credit side, and had been able 
to install n new a-ray apparatus by the gift of ■.! private 
donor. Tho prizes were presented to tlio successful nurses 
by Lady Stair. V'isits were also paid during the general 
assembly, to tho Sick Cliihlren’s Hospital, tho Boyal 
3Iaternity Hosjiital, and ibo Hoyal Hliiid Asylum. 


Cameron Prize. 

Tho Cameron Prize of tho Univovsitj- of Edinburgh has 
been awarded tin's year to Professor C. Levaditi of tho 
Pasteur Institute, and ho will deliver the following two 
lectures .at 4 p.iii. in tho Medical School: Juno, 15th, 
Chemotherapy of bismuth; Juno 18th, Xcurotropic octoder- 
moses. The Cameron Prize was founded in 1878 by the late 
Dr. A. It. Caincroii of Richmond, Xeiv South Wales. It is 
a prize awarded, usually annualK', to a person who has 
recently made any highly important and valiiaWo addition 
to practical therapeutics. Tho list of prize-winnere com- 
inenccs with tho names of Pasteur and Lister, and includes 
such mames as Behring, Horsley, Fiiisen, and Ehrlich; the 
"last recipient was' Dr. Banting. 


Edinburgh Foot Clinic. 

Tho new promises established by the Edinburgh Foot 
Clinic, which has boon in existence for some four years, 
were opened by tho Countess of Stair at 81, Newington 
Road, Edinburgh, on May 30th. They include two operat- 
ing theatres ns well as ample waiting-room and other 
accommodation. The, demand for tho services of this clinic 
is inclic.atod bj' the fact that on tho days when consulta- 
tions are hold, from eighty to ono hundred patients are 
treated, while thoro is a waiting list for treatment of over 
1,600 persons. ' Lady Stair, wlien declaring the premises 
open, suggested that tho clinic should giro advico to 
young women against going to their work at which they 
would have to stand most of tho day wearing thin high- 
heeled shoes. Sho hoped that the clinic had a great iind 
useful fiituio befoio it. At tho annual meeting held 
prior to tho opening, the chair was taken by Air. C. A\L 
Cathcait, F.R.C.S. Tho annual report showed that in the 
past year the number of treatments had been 6,916, as 
compared with 5,335 in tlio previous year. There had 
been .an excess of income over expenditure of £43 Sub- 
scriptions and donations amounted to £166, showiiitr that 
the chnic wiis still dependent on the generosity of sub- 
scriber for tho continuance of its work. A special appeal 
.to meet the expense of alteration and equipment in takincr 
over the new premises was issued and the sum of £682 was 
received, but the building and equipment account stilt 
Hiowed an excess of expenditure ove'r income of £600 
John Fraser, F.R.C.S., in moving tho adoption 
ot the report; said that minor disabilities of the feet' 
formed one of tliOso collectivo maladies which received 
httle s 3 -nipathy and sometimes scant attention. The human 
foot w-as a- very perfect piece of mechanism -ivlieii it was 
considered how many miles it- was capable of travelling 
and liow miiii 3 ’ hours it had to hear the weight cf the bod 3 \ 
Napoleon, in his famous apliorisni, that an army marched 
on .its stom'ach, was. guilty of an' exaggeration, for the 
soldier on active service knew the truth in regard to the 
feet. Tho men who had been in tbe retreat “from AIoiis' 
could tell them that their clearest nieniorv was neither ot 
bodily fatigue, hunger, nor of merciless iboll fire hut of 
tho ceaseless ache of bruised feet. The foot parade of war 
timo was one of .the details which made for the efficiency 
of .the ssldier, and. tho same thing applied to the worker in • 



998 JUNE 9, 1928] 


IBELANp,;.,.,, 


[[ 


Inr: rnmw 
Mcuicai. Jortvif., 


tliese tlajs of competitive trade efBcicncy. Tlioy owed a 
debt of gratitude tp the experts who were giving their 
Berrices 'gi'atiiitousl 3 ' to this' deserving object. 

Glasgow Western Infirmary. 

At a meeting of the Board of Managers of tlie Glasgow 
AVestern Infii-mary licld on May 29th, tlie following new 
appointments were made : 'R. Barclay Kess, ^I.A., M.B., 
P.R.F.P.S., honorary consulting surgeon; George Allison 
Allan, M.D., F.R.F.P.S., M.R.C.P., visiting pln-sician; 
AV. ®. Snodgrass, M.A., M.B., F.B.F.P.S., assistant 
phj-sician; J. Gibson Graham, M.B., Ch.B., dispensary 
physician. 




Royal College of Surgeons in Ireland. 

At the annual election of officers of tho Royal College of 
Surgeons in Ireland, held on June 6th, the following were 
appointed for the ensuing year: 

Prcsldriii : Thomas Eagleson Gordon. 

Vir.c~Pi'c^idcnt : Richard Atkinson Sioncy. 

/Sccrcfaiy of the College: Sir F. Conway Dwyer. 

Council: Sir Thomas Myles, Sir Robert H. AVoo<ls, Sir AVilUatn 
Taylor, K. C. B. Maunsell, Sir AV. T. de C. AVIieelcr. Sir F. 
Conway Dwyer, Trevor N. Smith, Sir Arthur Ball, I,ouis A. 
Byrne, Andrew Fullerton, Seton Pringle, Edward Sheridan, 
William Pearson, G. E. Pugin Meldon, Howard Stevenson, Louis 
L. Cassidy, V/. Cecil P. Smyly, Arthur Chance, Palrick E. Hayden. 

The new President, Mr. T. E. Gordon, has served in the 
office of A'^ice-President for over two years. He is professor 
of surgery in the University of Dublin. During tho groat 
war ho hold the rank of colonel, and was attached to tho 
Dublin 83rd General Hospital, Boulogne. The now A’^ice- 
President, Mr, R. Atkinson Stoney, went to Franco with 
the French Red Cross in December, 1914; after working 
with tho French Red Gross he was given a commission in 
the French Arm}- Medical Service, and was made con- 
sulting and ojmrating surgeon to the 5th Section of the 
17th Region. He returned to Dublin in Juno, 1915, and 
went out again for the spring and summer months of 1916, 
1917, and 1918. After tho war he was made Chevalier of 
tlio Legion of Honour. 


McKisack Memorial. 

As announced in the Journal of April 21st (p. 686) it 
has been decided to establish a permanent memorial to the 
late Dr. Henry Lam-ence McKisack, consulting phj-.sician 
to the Royal A^’ictoria Hospital, Belfast, who died on 
March 26th, and in this connexion a meeting of suhscrihci's 
to the memorial fund was held at the hospital on Juno 1st. 
Mr. T. S. Kirk, chairman of the medical staff, presided, 
a^nd it was reported that coutribtitions amounting to 
£555 had boon received to date. The meeting decided to 
erect a bronze memorial tablet in the hospital and to 
employ the remainder of the sum in Iiand to constitute 
the nucleus of a McKisack Research Fund, the income 
from which will bo devoted to the stndv of diseases, in- 
jnries, and deformities in all their aspects, including tho 
study of the lysults of treatment. The fund is to ho 
kept open for future donations, with no limitation as to 
amounts, and is to be entrusted to the Board of Mamee- 
mont of the Boynl Victoria Hospital for adniinistra4„ 
the recommendation of the visiting medical .staff A com- 
mittee, consisting of Mr. T. S. Kirk, Mr. Edwin D Hill 
Mr. Stanley Ferguson, Dr. Robert Marshall anil Dr 
Andrew Trimble, was appointed to put into effect the 
uccisious of the meeting. 

Ths Medical Profession and the Public. 

At a recent iiieeting of the Statistical and Social Iiiciuh-j 
Society, held in the Royal Academy, Dublin, Dr. B J 
Rowlotte, re.ad a paper on the relations of the medicai 
profession and tho community. Tho General Council oi 
ileilical Education and Registration, he said, was nol 
necessarily composed of medical practitioners and was not 
elected by medic.al franchise. It was a grievance that Hit 
Iinqiialificcl practice of medicine was not more comnleteB 
prohibited. The Council existed for the protection of th'i 
publie aiul not of the profe.ssion. RcfeiTing to the Medica 
Iract.t.oiiers Act (Irish Free State), 1927, he indieatec 


certain departures from the British sy-Ktera. As to the 
degree of sanclitj- of professional confidence, lie drew a 
eoinparison hotween tlie privilege of legal and medical 
communications, and ]iointcd out .some anom.alics of 
incdic.al practice. Sir AA’illiam Thompson, in proposing 
a vote of thanks to Dr. Rowlettc*, said it was well that 
the jtuhlie. should know something about the work aad 
aims of the nicdical schools of the universities and 
colleges, and ahovit the amount of time certain members ot 
the incdieal profession gave to tin's work. It was only 
families who had incmhers in the medical profession who 
knew the nianv difficulties and adverse circumstance' 
doctons liad to coiitond with. The relation of the medical 
profession to public health was of evcr-incrcnsing im- 
portance, as the prevention of di.sease was now taking siieh 
an important part in tho life of the profession and the 
conimiiiiity. The nnioiiiit of voluntary service rendered 
by the medical jirofessioii was not siifrieicnth’ realized, for 
in hosjiitals, piihlie appointniciits, di.speiisaries, and in 
'private praetiee also, niiieli time was devoted to eharit.nhlc 
work. Dr. Moorhead, in seconding, extiresscd the I'icir 
that a doctor hronght lioforc the General Aledical Council 
or the Irish Medical Council on any disciplinary charge 
should have tho right of appeal to the law courts, if ho 
w.as dissatisfied with the decision. 


O^iTgljintF antr 


Maternal Mortality: Appointment of Departmental 
Committee. 

Shortly before tho AA’hitsuntido recess Mr. Chamberlain, 
the Minister of Health, ns a part of the measures designed 
to combat maternal mortality and morbidity, to which he 
referred wlien introducing the Estimates of the Ministrj' 
of Health in the House of Commons on May 15th,- 
appointecl a Departmental Committee to consider the work- 
ing of the Midwives Acts, with particular reference to the 
training of midwives and tho conditions under which they 
are emjiloycd. The ■ names of that Committee and its 
terms of reference were given in the Journal of Jlay 26th 
(p. 917). As a further instalment of the monsurca referred 
to Mr. Clinmhorlain has now appointed a second Depart- 
mental Committee, whose terms of reference are to advise 
upon the ap])licntion to maternal mortality and niorhiditj 
of tho medical and surgical knowledge at ])rcsont available, 
and to inquire into tho needs and direction of furthoi 
research work. The personnel of this purely medical com- 
mittee is as follows: Sir George Newman (cliairnian), 
Professor E. J. Browne, Dame Janet M. CainphcU, Sirs. 
Ethel Cassic, Dr. Leonard Colcbrook, Professor Archibald 
Donald, Dr. C. E. S. Flemming, Sir AA'altcr M. Fletcher, 
Dr. Harold Korr, Dr. AA’. H. F. O.xley, Professor Slile? H. 
Phillijis, Dr. C. E. Tangye, Dr. O. L. A^. S. do AA' csselow. 
The secretary of the Committee will he Dr. Slargaret ■ 
Hogarth of the Slinistrj- of Health, AVhiteh.all, S.AA’.l, to 
whom all conimiiiiicatioiis relating to the work of tho 
Committee .should he addressed. 

Wembley Hospital. 

The Duke and Duchess of York opened on Juno 2nd 
the new hospital which has been erected at AVembley at a 
cost of about £20,000. Tho building ■ is situated behind 
the main road on a site presented by Mr. G. Titus Barham, 
chairmaTi of the board of management, who also con- 
tributed generously towards the building expenses. At 
present there are twenty beds, but it will bo possible to 
double the accommodation at a cost of £3,000, and to extend 
the capacity of the institution to a hundred beds in tho 
future slioiild this become nccessaiy. Two wards, for men 
and women respectively, contain six beds each; there is a 
children’s ward of four beds, named after Princess , 
Elizabeth, and two rooms, each with two beds. A fuH.V 
np-to-date operating theatre and a well-equipped ar-ray 
Toom have been provided. The building opens free froin* 
debt, the necessary money having been collected — mostly 
locally, through a contribiitoi'y scheme — during the last 
three yeai-s. About £2,000 was obtained in large donations, 



June 9, 1918] • COBBEBPONDENCB, 


nud substaiitinl grants wore rccPM'cd from King Bdn-ard’s 
Hospital Bund. All tlio practitioners in tlio district become 
antomaticnlly members of tbo ordiiiniy staff of tbo liospitnl, 
and tbero is a consulting stafC nnmbering fourteen. 


r TnEBnmwi - Cl6b 

Wrcjcai, JocajrAlr OUO 


percentago of tboso adio liavo retired from tlieir pro- 
fession, especially as tbo fignro includes a' number who 
only retired after many years of active and successful 
medical practice. 


Presentation to Dr. B. E. A. Bntt. 

For manv years Dr. Hcrnard K. A. Datt bas rendered 
great service’ to tbo medical profession in West Suffolk. 
In bis capacity ns bonorary secretary to tbo West Suffolk 
Division of tbo British Jlcdical Association, and ns ebnir- 
man (previously honorary secretary) of tbo Panel Com- 
mittee, ho has dono an innnenso amount of work. At a 
meeting of medical practitioners held on !Mny 31st at 
Bury- St. Edmnnds Dr. J. S. llinnell referred in warm 
'forms 'to tlio appreciation of all medical men in tbo 
county of Dr. Butt’s activities in tbo interests of tbo 
inofession and of tbo AVc.st Suffolk Hospital and its 
patients. As a small mark of that appreciation bo banded 
to Dr, Batt a choquo representing donations readily made 
by. tbo whole of tbo local medical profession, and asked 
him to realize ilieir thanks for nil his good work. Dr. 
Batt, for onco at a loss on tbo matter beforo tbo meeting, 
nindo a brief reply, saying that bo had enjoyed tbo work, 
that it added to bis plcnsuro to know that bo was helping 
and that that help was- appreciated, but lio was unablo 
to find tbo right word to express bis thanks. 


Corrcsjjnntrcttcc* 


DIRECT REPRESENTATION ON THE GENERAL 
HEDICAL COUNCIL. 

Sir, — ^Prom your. report of tbo recent proceedings of tbo 
General Jfcdical Council it appears that tbero nro now 
two vaouncics , on .tiint body from among tliosc who arc 
elected to roprosont tbo medical profession directly, and 
an election to fill tlicso v.aeancics is to take place in tbo 
autumn. 

This give.s us time to consider carefully who aro to 
represent us, and I want at onco to press tlio view that 
both tbeso should be general practitioners with an intimato 
kiiowledgo of national bealtb insurance as well as of other 
branches of general practice. If two practitioners, still 
in active practice, can bo found to give tbo time, I hope 
they will be strongly supported. It would bo, of course, 
a turtlier.advantago if one of them is engaged in industrial 
and tbo otlicr in rural practice. At present Dr. Bracken- 
hury IS tlio only general practitioner on the General Medical 
t^oimcil, and, iiivalnablo as bis services aro, this amount 
is very insufficient. 

xr majority of the members of the General 

iledical Council aro teachers representing tbo universities 
witlinn°f many of them aro wiiolo-tinio officers 

iwrsonal cxperienco of the practising sido of 
nation/ between doctor and doctor 

“nos^ff nrLt oo sanations in different 

'rt P™°*’ae and differing circumstances, 
it seems essential that on a body cliamed ainonu its 

these /elation'sbin supeiwision and’ control of 

of the nractisinn-^l more sufficient representation 

ot the practising doctor should bo found.— I am etc 
Birmingham. Juno Hlh. jj;_ 

Brn — Tl ^^fPICAL CO-EDUCATION. 

ono whicb^mrifol?" co-education in medical schools js 
Women’s Fe’deration°'^b/^^iV^ of tbo Medical 

pr”.rUiat eertafn P'-onouncoment in the 

of. 50®per cent women, and the figure 

portion of those wb ” was given as tbo pro- 

eoW.m 4^?ng1/ tliriiX^.r 

WdmenWederation to V the Medical 

tbeso- statements A ' Qu^r'^ * ^*'’*'^* of 

tbousand members of ihh® /' o"® 
Isles. Tbo noiht of AVr "'*"S tbo British 

point of interest which emerges is the small 


Gcnernl prnctico 

40.6 per cent. 

HospilM or institutional work 

... 12.7 „ 

Consulting^ nml specialist: ../ 

.. 14.0 „ - , 

Hcscarch ... 

.. ■ 3.6 „ 

Public health 

.. 15.6 

Pctirotl 

9.0 

Not ascertained ... 

4.5 


Steps avero also tgkon to ascertain details regarding tbo 
women avbo bad qnnlifiod at six London hospitals. From 
tbo following figures it will be scon that instead of tbo 
“ 50 jier cent, or tlicroabouts ” stated to marry and so 
bcconio lost to tbo profession, tbo actual number is under 
10 per cent. 

Tbo number of women qualified from tbo Royal Free 
Hospital (for tbo years 1923, 1924, and 1925), and from 
Cbaving Cross Hospital, tbo London Hospital, St. George’s 
Hospital, StJ Mary’s Hospital, and ' University Collego 
Hospital, is understood to bo 644. Tbo following is an 
analysis of these : 


Doing ."iclivo medical work 

ncndiiig for higher qualification 

Travelling abroad 

Temporarily unemployed at time of inquiry 

Invalided ... ’ ." 

Died 

Not tr.aced 

Retired 


per cent. 


Tbo percentago of tboso who have married is 15.99 — 
namely : 


Married and still working S.36 per cent. 

Married and retired 9.63 ,, ' 

At a recent session of the Council of tbo Medical 
Women’s Federation a resolution in tbo following terms 
was unanimously passed : 

" That this Council of tbo Medical Women’s Federation, while 
welcoming tho public support wliich has been generously accorded 
to tho Cherts to retain tlio presence of women in co-educational 
schools, deprecates any attempt to put pressure oh the hospitals 
concerned by urging subscribers to withdraw their subscriptions.” 

On behalf of tbo Council of tho Jledical M’omen’s Federa- 
tion. — IVo arc, etc., 

Catherixb CmsHOLJi, President. 

CiimsTiNE M. Murrell, Past-President. 

A. E. Sakdersox Clow and Aiisox Hunter,’ 
Vice-Presidents. 

Jane H. IValker, Eon. Treasurer. 

F. May Dickinson Berry, Eon. Sccretarti. ' 

London, W., Jfay 25 th. . , ' ^ 


THE TREATJIENT OF AIALIGNANT DISEASE 
BY COLLOID-A.L LEAD. 

Sir,— Knowledge of tbo fact that colloidal lead is a 
" difficult and dangerous tber.apeutic method ” of tre.ating 
malignant discaso urged me to advise Professor Blair Bell 
to withhold details of the suspension • used in Liverpool 
until wo were satisfied that it was reasonably free from 
danger to life. I feared then that a premature revela- 
tion of our method would result in tbo promiscuous use 
of lead colloids of widely variable toxicity in cases of 
ad\ aiiced malignant disease wbicji were beyond hope from 
any treatment. Dr. Wyard’s paper in your issue of May 
19tli (p, ^8) fulfils in some respects my prophecy. He 
finds colloidal lead hydroxide, from bis experience with 
thirty-two patients, to be ‘‘extremely toxic”; I con- 
demned lead hydroxide to our Research Committee in 
1925, at the expense of two rabbits. Dr. Wyard suggests 
that bo followed latterly tlie original tcmlinique; if so his 
d^cription of it is faulty, and later ho speaks of making 
slight alterations and of using n reducing agent. As 
tbo pharmacologist of the Liverpool Aledical Research 
Committee it has been my duty to report on the relative 
toxicity of the ‘‘ many times changed methods of prepar- 
ing tbo colloid, and I can state that, before any modifica- 
tion of the lead colloid has been used on bninan beinus in 
Liverpool, it has previously been ’ tested repeatedly upon 
both rabbits and cats in doses per kilo far e.xeeedinn- those 
given to luiman. beings. I do not. find evidence that Dr 
"Wyard took such precautions. . . ’ 


1000 June 9, 1928] 


CORRESPONDENCE, 




Junk 9, 1958] 


CORUESt'ONDENCE. 


f The ntiiTitn 
t ^TeIjICAL JoCHMAt. 


ICOl 


gm,_TUoio will pvolinlily always oxist, ami always liav« 
to l>o coml.atotl, an unfortmiato incjiulico against tlio 
sccvctory tlu'ovy (ns opposed to tlvooiies of fdtvation, 
dialvsis, etc.). 'This pri>j\ulico arises on <|nito oxtranoons 

t moan nnsoiontilic — grounds. It is the idea that to don\ 

that the hohaviour of the living coll can ho dodncod from 
tho hoy’s (list hook (or any existing honk) of i)hysits is 
oqnivaicnt to investing tho coll with occnll powers. 

It cannot ho too .strongly assorted (though it is nausoating 
to Imvo to assort it at all) that tho secretory theory would 
not he a scientific theory if it .sought to conf(;r upon the coll 
any measure whatever of supernatural activity. It is only 
in the minds of those who have fainted upon tho scientific 
wav that the secretory theoiy has any connexion with 
“ vital force,” “ biotic energy,” “ ncovitalism,” or any 
such refuge of the destitute. 

To conclude on tho evidence nvailahle that rather eriido 
hypotheses like those of filtration, dialysis, cte., may (in 
view of the great complexity and delicacy of living matter) 
])rove to ho reductions to a simjdicity which is ahs\iid is 
peifcctly scientific, and, whether tho conclusion itself is 
right or wrong, it voices no greater heresy than docs tho 
suggestion that a man may act diffcrontly from a corpse. 

The secretory theory merely emphasizes tho fact that 
matter which has attained that peculiar degree of com- 
plexity which constitutes alivcncss is apt to hehavc other- 
wise than matter which has not this complexity. Mo 
metaphysical theory whatever is involved or implied, and 
not the slightest departure is made from that working 
hypothesis of absoluto materialism (or ahsointo objectivity) 
nbich is tho inalienable basis of all scientific knowkxlgc. — 
I am, etc., 

Liverpool, .Vnj 29 ih. BnilN.tnC Cu.WASBE. 


THE ORIGIN OF ISCHAptIC CONTRACTFRE. 

The Case of Tyndall v. .-l/coc/;. 

Sin, — 5Ir. Edward Thompson (Juno 2ud, p. 261) should 
not censure Mr. Roth (Jlay 26th, p. 921) for Ids comments 
on Professor Hoy Groves’s article on this ease (May 12th, 
p. 807). Mr. Roth at least suggests a valuable point which 
will help others to avoid tho advent of this nightmare — 
itchaomic contracture — which, as those engaged in. ortho- 
paedic practice know so well, is far Ics.s rare than Jlr. 
Thompson’s fortunate experience would suggest. Mr. 
Thompson’s note is merely a genuine expression of the 
sympathy which, of course; all of us feel for Dr. Alcock, 
but it adds nothing whatever to guide us in preventing the 
occurrence of this grave complication. 

Mr. Roth did not stress the point which I am sure he 
had very much in mind — namely, that ‘‘ full flexion,” as 
advocated in the books, is a factor equal in importance 
to tight bandaging in the production of ischaemic con- 
tracture. If the forearm in relation to tho upper arm 
? minutes past ” (to use a clock nomenclature) the 
evil rs likely to occur. On the other hand, 2 )Utting tho 
elboiv ui) at “ 7 or 10 minutes past ” — that is, fiO to 60 
degrees — will bo safe. 

Suptiorting Mr. Roth’s point, I wovild mention that one 
of tlio irorst cases I have seen followed bandaging of the 
upiicr forearm, for a graze, by a village nurse. Of two 
cases that have happened to myself, one followed “ full 
flexion” (“5 minutes past”) and tho other on tight 
bandaging of the forearm after plating a forearm fracture 
(without flexion), although, fortunately, being alive to tho 
possibility, I got in on the problem before more than a 
temporary damage liad occurred to the flexor muscles of 
tbe index finger. 

Professor Hey Groves himself, in his article, makes no 
very helpful deductions . to guide us in the anticipation 
and prevention of the condition. I agree witli him that 

10 displacement of hone fragments lias no importance 
production of ischaemic contracture. 
T *1*. ^ dangerous thing to flex a swollen clbow-ioiht 

^ if 'i admitted ; but he imts forward the old 
oV existence of the radial pulse is the index 

Iu> nil '1 r ^ sn.nre and a delusion, and, if T may 

coiiditTnr n teaching. I have had the 

occui under iny most intense observation while 


believing that nil was right us long ns the radial pulse 
could be felt. 

Tho threatening symptoms nro pain, pain, pain ! asso- 
ciated witli liv'idity and swelling, and disinclination for 
active movements of tho hand and fingers. Relievo thc.so 
symjitonis immediately, and if this is done within the first 
Iwclvo or twenty-four hours all will ho well. Have no 
regard for tho fracture; play for safety where the circula- 
tion is concerned. 'Tho fracture and the function of tho 
elbow can always bo relieved subsequently, but, in spite 
of Professor Hey Groves’s statement of Sir Robert Jones’s 
opinion on tlio improvement that is iiossiblo in tlio 
Volkmann complication, I maintain that present-day 
molliods in most eases can do nothing more for isclmemic 
contracture than improve the cosmetic aiipcaranco of the 
hand and forearm. 

Several other points in Professor Hoy Groves’s article 
nro open to discussion, and I should like to take them 
up with him; hut please save ino from going exactly 
counter, as so often linjipciis in our jirofession,” which, 
ns Mr. Tliompson maintains, Mr. Roth did “ without 
reason.” Mr. Roth had, indeed, cvciy reason to com- 
municato tho results of his considornblo experience for tho 
henefit of all those who have had to deal with these elbow 
fractures, and his remarks nro not lightly to be turned 
down by Mr. Tliompson, while tho subject is so fresh in 
our minds, as being beside the point, — I am, etc., 

W. H. TnETitoWAN, 

Cuj*s Hospital, and the Koynl Kalional 

London, Juno <lh. Otlhopaedlc IIospU’aL 


Sin, — ^M’ith regard to the origin of iscliaoraic paralysis, 
surely Mr. Roth will admit that a vascular lesion unasso- 
ciatod with fracture may produce this condition. 

A few months ago I was called to a young girl, whose arm 
was lying on a pillow, extended at tho elbow. On exam- 
ination 1 noticed that tho limb was cold, and found that 
she had no radial pulse. Tho supracondylar fracture was 
easily reduced, and tho arm treated in tho fully flexed 
position. A perfect anatomical and functional result 
followed, hut tho radial pulse had not reappeared eight 
weeks later. I take it that tho radial pulse may disappear 
at once by pressure of fracture ends or during tho next 
three or four days by thrombosis. It would be interesting 
to know if any ortliopacdic surgeons have statistics of the 
absence or disappearance of tho radial pulse in their wide 
experience of fractures about tho elbow.-^I am, etc., 

Livcrpocl, Juno ^tli. R* Henxox, F.R.C.S. 


TETRA-ETHYL LE.YD IN MOTOR SPIRIT. 

Sin, — In tho report of tho second public mooting of the 
Committee of Inquiry on Tetra-Etliyl Dead in Motor Spirit 
which appeared in tho British Medical Journal of Alay 19tli 
(p. 871) lliero aro several misquotations of tho evidence 
I submitted. Thus reference" is repeatedly made to two 
men (mechanics) who, it is erroneously stated, were 
medically examined by me. These men were examined, 
indejiendcntly, by their own private doctors, and also, 
indeiJOndently, by an exiiert clinician engaged in lead 
examinations of cancer jiatients undergoing lead chenio- 
therajiy. I was not consulted in these examinations, but 
I thought it proper to record, without comment, in my 
memorandum of evidence a statement of these indeiiendeiit 
clinical findings, for which I have no responsibility. The 
only submission I make in this connexion is that, in the 
circumstances of an additional exposure to lead, it Is 
justifiable in the interests of the men tliemselves that they 
ho kept under medical observation — ^tbe stricter the better. 
(I assume that these mcchauics aro habitually exposed to a 
small lead occupational risk.) 

I regret that my memorandum of evidence, of which, as 
specially requested by the secretary to the committee,' I had 
furnished a sufficient number of copies for circulation to 
tho press, was not so distributed; had it been circulated 
these misquotations could not have occurred. 

Numerous misquotations of tho evidence have appeared 
in tho lay press, and' tho Times, in its issue dated Alay 
16th, not only makes the above misquotation, but also 


[ Tnr r.nrnsif 
iIrptcxi.Jouuyii, 


1002 June g, 1928] 


THE SEKVICES. 


purports to give details of luy (alleged) evidence with 
regard to experiments on monkeys. 1 Inu'o carried out 
no animal experiment of any description in connexion 
with this investigation. 

The crux of the whole matter is that, in the recent expori- 
lucnts conducted by the Eesearch Association of British 
Motor and Allied Manufacturers with regard to exhaust 
gases from engines burning leaded spirit as a motor fuel, 
and also as the outcome of the investigation of the deposits 
found in three motor vehicles after a mileage of 11,000, 
the run being entirely with leaded spirit, it was found that 
not less than 80 per cent, of the lead contained in tho 
fuel was discharged into the atmosphere, and also that 
the exhaust gases contain not less than from twenty to 
fifty times the amount of lead per cubic metro ns was 
obtained in exhaust gases in the tests as described in tho 
DuUctin (No. 2661) of the United States Bureau of Mines 
of December, 1924. Also in 0110 of the tests recently 
carried out in England with a stationar}- engine it was 
found that the water vapour of the exhaust gases which can . 
he condensed from the end of the exhaust pipe is callable 
of dissolving practicallj- the whole of the lead present iii 
the exhaust gases. In sliort, with exhaust gases from an 
engine burning loaded motor fuel wo arc dealing with 
large quantities of water-soluble lead. 

IMay I correct a misapprehension which prevails as the 
outcome of the following sentence which appeared in tho 
Tiritish Medical Journal on January 14th, 1928 (p. 61) ;i 
“ The high toxicity of this compound naturally aroused' 
alarm in the United States, and its use was for a time 
prohibited in the city of New York.” The actual significant^ 
fact is that the sale of ethyl gasoline (ethyl petrol) is still' 
banned in New York City. — am, 'etc., ' ! 

Hendon, May 27th. AIVEH Cort.VNS, M.D. ' 


THE INTRAVENOUS INJECTION OF ' 
INDIGO-CARMINE... • 

Sin, — I noticed in the report , of a paper read by me 
before the Royal Medico-Chirurgical Society of Glasgow 
and epitomized in the Hritish Medical journal o{ December 
10th, 1927 (p. 1087), it is recorded that in the investiga- 
tion of patients suffering from renal .tumours I. i)Se -“an 
intravenous injection of 5 c.cm. of 'a 4 per cent. Soiution 
of mdigo-carmine.” This was such an o.bvious clerical 
crioi that at the time it did not occur to me to correct it. 
As Mr. Alex. E. Roche has called attention to it iu vour 
issue of May 26th (p, 921) and considers that others 
might be tempted to adopt the percentage ‘stated’ with tlio 
dire results he has brought to the notice of vour readers 
mv ft" 170W to correct it. The. original, iim'uu.scdpt -and 

SUT VS'th S' .i'l'iS’'* 


Jo\t a‘"' » 

0.4 per cent.— I am, etc. 
Glnsgow, Ma.v JDtli. 


percentage corio^tly— namoly, 
"Walter, '\Y, Galbraith, 


®Ijc ^triiias. 


INDIAN MEDICAL SERVICE DINNER. 

The annual dinner of the Indian Medical Service will he held 
at the Trocadcro Rcslauranl, London, on Wedne-sday, June 
20th, at 7.15 p.m., under the chaiiman.ship of Jlajor-Gencral 
Sir R. Havelock Charles, Bl., G.C.V.O., K.C.S.I. Price of 
dinner tickets, 16s. 6d. to snbscriber.s and £2 to iion-subscriiiers. 
Further particular.s may he obtained from the joint honorary 
secretary, Major Sir Tliomas Carey Evans, M.C., I.M.S.tret.), 
31, Wimpole Street, W.l. 


DEATHS IN THE SERVICES. 

Lieiit.-Colonel Dermot Owen Hyde, C.B.E., D.S.O., R.A.M.C., 
died at Jfavniyo, Upper Burma, where ho was in command of 
the station hospital, on April 19th, aged 50. He was born on 
December 1st, 1877,- the son of Licnt. -Colonel Robert Hyde, 
A.M.S., and educated at Trinity College, Dublin, where bo 
graduated as B.A. in 1896 and as M.B. and Cli.B. in 1899. 
Entering the army on April 25th, 1900, he attained the rank 
of lieutenant-colonel on December 25tb, 1917. He served in tlio 
South African war in 1901-02, receiving the Queen's medal with 
two chCsps, and also in the recent great war. In 1911 be was 
.appointed to the West Riding, Division of the R.A.M.C.(T.F.), 
and went out willi that division to France. In the battle of 
the Somme, in 1916, be commanded the 14tli Field Ambulance, 
from February, 1917, to April, 1918, he was iu command o£ 
No.' 1 Casnnitv' Clearing ' Station, and from April, 1918, to 
March, 1919, was A.D.M.S. of the 21st Division. After the 
\v.ar be served for three years, 1910-22, as senior medical officer 
at Bermuda; and in 19M was A.D.M.S. of the 28th' Division 
in the Dard.inelles. He was mentioned in dispatches in tho 
Tjondon dazctle of June ISth, 1916, and January 4th, 1917. and 
received "the D.S.O. and the C.B.E. for his services. In -1903 
iic.marricd Hilda Edith Richmond, daughter of^Lieut.-Colonel 
F; dc'R.' IMandiiit,' and leaves a widow .and tavo sons, 

Lieut. -Colonel Jame.s Haveloclc Ale.xandcr Rhodes, R..A.M.C. 
(retired), died at Pontnc, Jersey, on April pth, aged 71. Ho 
was born on Januara- 14th, 1858, took the M'.R.C.S. and L.S.A. 
in 1880, entered the . army as surgeon on February 6th, 1881, 
becanio lieutcn.ant-colonei' after twenty years’ service, and 
retired oh April 19tb, 1911. He rejoined for service during tho 
late war, fr'om'jVpril 14th, 1915. 

Major 'yMexander , Yates Reily, R.A.M.C.(rct.), died . on 
'.lanuary 2nd, aged 65. He was born at Dakkn, in Bengal, on 
'May 22hd,1862, and,w'as educated at Durham University, where 
bo 'graduated .'as'.^I.B. ,ahd AI.S. in 1885; also taking the 
M^K.'C.S. arid tlie L'.S.A'. in 1884, the L.R.C.P.Loiid. in 1586j 
■and hlic- F.R.C.'S.Ed.- in' 1889. Entering the R.^V.M.C. '.as 
-surgeon oh February 5th'; 1887, be became major -after twelve 
years’, service,, and retired on Juno 22nd, 1907. He served in 
.the . Sudan;, in the Dongola campaign of 1896, receiving the 
Egyptian medal .and the -Khedive's bronze star; in the .Sudan 
campaign of 1898, when he -was present in the battles of tho 
Atbara. River and of Khartum, was mentioned in dispatches 
in .tli’e Jjonilon 'Gazette of September 30lh, 1898, and received 
llie medal fol- that campaign and two clasps to his Egyptian 
medal; and in' the- South -African rv.ar, in 1902, iii operations in 
■Uie Transv.aal,- receiving the Queen’s medal avith four clasps. 
.He. also j-ejoined i for service in the recent great war in 
August,. 1914. ... . .. 


ARSENIC IN SUGAR. 

Sin,-~Some ye.ars ago, when medical officer of health 
district, I i-eceia-ed a request from tlie Ministiw 
Hcnlth to make investigations into a case of snspeci 
poison in sugar. s»o«peci 

The sack of sugar in question had travelled f.- 
London in the same truck as a drum of disinfectant 9 
groc-er who roeeived the sugar used one sack of tL t 
which constituted the c-onsignment, l,ut, noticing a sn 
alKiut the other, reported it. I followed up the drum 
.liMiifoc-tant and sent part of the contents to be amUs 
•also some or the sugar. The i-eport from the Mini^ 
came hack stating that the disinfectant was crude rarW 
acid, confannng no arsenic, and that the sugar was W 
uith ar.-=eiiic. and the sample sent contained sufficient 
poison the whole of the inhabitants of the i illae-c. 

I.iu-kily the disinfectant had imparted an oclmir to i 
sack against which it was iilaced. I was not !of 

of US contain arsenic in appreciable qnantitims.-lTJn el 

Totnv?, May CSth, T t ^ 

•1. -U. Jefferiss 


Stn:lT£i’5itt£s anb ®oU£g£s. 


UNIVERSITY OP OXFORD. 

Dr, Charles S. Myers, lias" been appointed HerbeH 

SpciiCer lecturer for 1929. =' 


UNIVERSITY OF CAJIBRIDGE. 

The followini' have been appointed members oC the Dci'ree 
Committee in tbo Faculty of Medicine : Dr. T. S. Ilele, Professor 
G. II. F, Nuttall, . Sir Jln^h. Anderson, Dr. W. L. H. Duckworth, 
Dr, E. D. Adrian, and Mr. H. Thurkill. 


SOCIETY OP APOTHECARIES OF LONDON. - 
The following candidates have passed in the subjects indicated : 

SORGERY. — K. Bryce. H. IH. Feldman. A. H. Honiiessy, N. C. R. 

KeuUenscbrijver, C. P. Madden, H, T>. K. Wright. 

Medicine.— K. D. C. Beckitt. L. J. Corbett, N. C. E. Keukcoscbrijver, 
A. ’A. Leiboviteb. L. W. Sanders. , 

Forensic aiEDiciNE.— A. C. Banerji, H. T. Jones, N. C. E. Keuken- 
schrijver. 

Midwifery. — M. K. Bi-yce, N. C. E. Kenkenscbrijver, ’A. E. Vnwsor. 

^iploraa of the Society has been granted to Messrs. K* 0* 
Heckitt, Tj,j, Corbett, H. I. Jones, N. C. R. Keukeuschrijvor, kud 
ij. W. Sanders. 



JUKK 9i >9’8'| 


SIR JAMES '■UbDSDO>T. 


r THRUhlTJBrt inOJ?' 

L JlM'lCAt JotUKAl. AWUU 


(Olulnnrir. 


SIU JAMES HODSnOX, M.H., F.K.C.S.Ed., 

Member of Ihc Grncral Me.liral Coimoil ; I'reM.b'Mt of the 
Itoyul College of Surgeons of Ldinlmrgli, lSM-17. 

As recoidoa tviUi regret in <iur lust issue, Sir James 
Hodsdoii died suddcf'le oiv Aluy 28tli, while letmuing to 
Edinburgli from Loudon after the .summer session of tlio 
Cienorul -Medical Council. For fomo yeans his health had 
given anxiety to his friends, hut ho seemed on tho da\ jne- 
ceding liis death to ho in ordinary health and vigoui. After 
retiring to his slcciring herth in tho train, 1 k> had laid 
down without undressing, and was found dtud hv the 
trairr attentlaut hetween 6 and 7 o clock next morning. 

James AVilliam lieeman 
Hodsdorr wa.s horn iir 
Bermuda iir 1S58, ami, 
coming to England at tho 
ago of 13, curir\iloted his 
school cducatiorr at Shcr- 
harne. After comnrencing 
medical study at Queen's 
College, Belfast, itr 1875, 
ho wont to Edinhni'gh in 
1877 arrd hccatno a liten- 
tiate of the Royal Callego 
of Surgeons in .188D. llo 
proceeded in 1883 to tho 
Fellowship of tho Royal 
College of Srrrgeons and 
to tho Jlemherslrip of tho 
-Royal College of Rhy- 
-Bicians . .of. . Ediiihiirgir. 

Mearttirnc, •■"'tir .-ISSl,;,' ho 
had g'l-aduatcd ALE. 'at' 

Queen’s Urrivei-sity, Bel- i 
fast. Ho hccamo, in tho 
sitnmrcr of 1880, houso- 
physiciarr to Dr. Brakcir- 
ridge, one of- tlio ])hy- 
sicians- in ' tho -Royal 
Infirmary, Edinburgh, 
having as orro of his 
fellow residents the late 
Dr. Alexairdcr Bruce, and 
a year, later, in . tho 
winter scssiorr 1881-82, ho 
hecaino house-surgeon to 
Air. Johtt Drrrrcart,- with 
whom he .maintained a 
close coirnexiori for ntanv 
years. , In tho meantinro 
ho had- acted as -a, re.si- 
dent physician in tho Sick 
Children’s arrd Alatcrnity 
Hosjritals, and. had sperrt 
a period in forcigrr strrdy, 
during which ho -visited ' ' . 

the medical schools of Vienna, Paris, and Londoir. Having 
a rratm-al bent towards sut-ger-y,. Atr. Hodsdorr acted as 
assistarrt to Air. Johrr Duncan arrd later- as atr extra-rnrtral 
lecturer otr sut-gory. Itr the latter capacity he was a highly 
succesiful-teaclier, being very popular with students in the 
ear ly year-.s of tiro present ceiitury as a clear arrd concise 
lecturer-, arrd atti-actiiig for marry- years a verv large class. 
Ayitilo acting as loctitrcr orr surgery' ho served at various 
times as examiner trt sut-gerv and clinicttl sitt-getv in the 
L'ntvcrsitte.s of Edinburgh', Dttrltat'n, and Belfast. lit 1886 ho 
was elected assistairt surgeon to the Royal Ittfirrrrary and in 
this capacity was agaitt- associated with Air. Johrr Drtrrcatr, 
and, after assisting-Irirn for-rnirny-y-ears itr private practice,- 
succeeded him as chief, medical adviser to the Scottish 
Irovident Insurance Cornpaiiy. Itr 1909 he contested tho 
appointment to the chair of snrgerv, vacant on the lesigna- 
Don of Professor Chieue, hiit .wds defeated by the laid 
rofessor Ale.xis Thomson, and. at that time gaye.up.Jris 
n^ly successful extra-mural class in surgery. 

r^ tire time of his election as an assistant surgeon to 
10 ojal Infirmary, Air. Hodsdou maintained a close 



coriuextoii with this institution, hecomin'g successively 
siii-gcon in 1907, consulting sni-gcon in 1922, arrd a memher 
of the hooi-d of iniiiiagement in 1923. 'The last appoint- 
ment he .still hold at tho time of his doatlr. He v.as a 
vei-y active incinhei' of the hoard, and took a great interest 
in the ai-rangeincnts non- in progi-css for revising tho 
agrceincnt in regai-d to clinical teaching in Edinbnrgli 
hetween tho maimgci-.s of tire Royal Infirmary, tire Uiiivcr- 
sitv, and the Scluml of Afedieino of tho lioy.al Colleges. 
A forv years ago he rlevoted a great deal of time ami 
cnci-gy on behalf of the Royal Infirmary to the reoigani-. a- 
tioii of the radiological department, visiting similar 
ccnti-cs ehewliere to investigate modern developments in 
this dii-eclioii. The new department in tho Royal Infit-- 
mary, which is regarded as one of the finest in the coiint-.y, 

was, to a large extent, 
his ci-eation. 

He had taken an active 
jiart in the dcliherations 
of tho General Medical 
Council since 19G6, when 
ho was elected to repre- 
sent on that body the 
Royal College of Surgeons 
of Edinbnrgli, of «-liicli 
from 1914 to 1917 he was 
president. Ho was also a 
inemher of the Dental 
Roard of tho United 
Kingdom after tho estah- 
lishinont of that body in 
1921, and for a ntimher of 
years had been chainn-an 
of the governing body .of 
tho -Sclio'oT of Alcdiciirli 
of the RoyaL Colleges at 
Edinbni-gh. 

Sir James Hodsdon^liad 
a long and intimate con- 
nexion with tho British 
Alcdical Association. Ho 
had been joint hoiiorai-y 
secretar-y of the Edin- 
hurgh Branch from. 1828 
to 1901 and ruce-chairiiian 
of tho No'rtri-AVost Edin- 
burgh Division for several 
years prior to the amalgat 
matron of ’ the ' .three 
original Edinburgh 
Divisions into one Kdiht 
hrirgh and Leith Divusioh 
as at pr esent. • Ho ■ rvas 
also' chaii-mau of the 
North - AVest Ediuhrirgh 
Division in 1905, a repre- 
seiitativo of this Division 
to the Airiinal Representa- 
tivo Aleeting in 1904, and 
its represeirtativo on tho Edinburgh Branch Council from 
1904 to 1907. In connexion -n-ith. the Edinburgh Aleeting 
of tho A.ssociatioii in 1927 ho took an active pai-t in tire 
orgairizatiou, being chairman of tho committee whicli 
arranged the aiinnal dinner- in the Alnsic Hall at Edinlnii-gh. 

In the midst of a busy administrative life ho found tiirre 
to make some contributions to current medical literatiire, 
and was the author of tho article on tho palate in the 
EnctidoimciVta .l/cdica. Ho contributed an article on 
exetsioir of the sigmoid for carcinoma, when that opera- 
tion was comjiarativoly new, to the second volume of the 
Edinhur<ih Hospital Iteports. Between 1888 and 1891 he 
llad-also contributed to the Edinhurgli Medical Jour ual air 
inquiry- into -the method of cure in empy-cma, and to tho 
Lancet an exporiinental inquiry into the iirflueirce "of the 
pulmonary blood pressure upon the collapsed lung. 

■ During tl'.o' war- he rendered, valuable services as a 
member of the, surgical staff of the 2nd Scottish Geiierar 
Hospital at Ci-aigleith. He was also for- some time the 
surgical nremher of the special iriodical board for Scotland 
■which reviewed the decisions of tho various medical boards 


Sir JiMES Hodsdok. 


1034 June g, 1928] 


GEORGE EDWARD SriUTTDEWORTH, M.D. 


t lirxDRiTm 
UeOICAL J9QRKA& 


in Scotland in regard to recruiting, and lie was, in ilio 
later stages of the war, a member of the Scottish Jledieal 
Service Emergency Committee. He acted for the iMinistry 
of Pensions as a member of the Advisory jSTedieal Council 
for the Scottish Area, and in this connexion arranged for 
the building, equipment, and staffing of the orthopaedic 
annexe at Tynecastle, Edinburgh. In recognition of tlie.se 
services he received the C.B.E. in 1919, and was created 
K.B.E. in 1920. 

He was a keen sportsman, and for more than thirty 
years his annual holida}' had been spent in sc.a trout 
fishing at Lochhois'dale in the Outer Hebrides. Another 
favourite relaxation was shooting. His administrative 
capacit}- was universally recognized, and his advice was 
constantly sought on difficult and intricate questions atfectr 
ing medical affairs. His death will he felt not only as a 
personal sorrow to many private and professional friends, 
hut will ho a great loss to the various public bodies and 
committees of which ho was an active and valued memher. 

Sir James Hqdsdon was married to Joan, daughter of 
the late Hr. William Baffin of Edinburgh, bv whom he is 
survived. The interment took place on Jlay 31st in the 
Dean Cemetery, and was attended by a large niimher of 
representatives of the medical profession and of various 
organizations, including the Roval College of Siugeons the 
Eoyal Infirmary, and the Royal College of Phvsieians, ’with 
which ho had beou ofEciallj’ connected. 

E<Unbmgh!“"' ''J A. Sw.an Watson. 

GEORGE EDWARD SHUTTLEWORTH, hl.D 

Formerly Medical Superintendent, Royal Albert Aiylu’ni 
Lancaster. ' 

It is with great regret that we have to announce the 

f’ o? age of 86, of Dr. 

G. E. Slnittleworth. Although lie retired from practice 

the ‘leading 

aut loritj m this country on ' mental deficiency, and tlm 
author of such a widely read book on this subject that 

world To' ,^1 ^“"1 .P®yp'“Atrists throughout the^ civilized 
HOI Id to iihom liis name is not familiar To manw 

loss 0 f\a warm ".carted fiTu i T the 

was ever ready to irive 'his ^ '^‘’""sellor, who 

needy and distees^el ^ t'‘°' oV the 

Xo^TXr^ielh '^lliT “ Edgbiiston on 

School, and on ’leaving there " '"i London 

London, Avhero ho graduated B ■+f 1 ^° King’s College, 
logy. He snbsoquently hhtained ihl'M rTs*'® 
diplonias, and the AI.D'. degree of W -Tu' 
working for a time at the Kilburn ’ , "^^ter 

appointed assistant medical officer to 'vas 

tnt.on for Defectives, the ■supertetenctnt 
knouai Dr. J. Langdoii-Down. Here Im the well- 

1870, when he was chosen,' out of a largo 
dates, to be medical superinteiidoi.t iff the rT-.T 
Asylum at Lancaster. He oeeunied + 1 ,; Albert 

twcnty-thiee years, and his intense* kebiiness 
. his wide knowledge and outstanding ahilitv his^^TuT^’ 
originating and applying .methods Tf tr ate’i.m 1 ' 

that institution into the first raiik of ostalTisbU, 
the care of the mentallv defective, and gahw 
reputation which attracted visitors' not nnl^ f ^ 

of the L-nitod Kingdom, 

iT' ''■+ T 1*’"" Shiittleworth’.s k-nowlodgc"‘nf T 
log^' stood him in good stead anrl t«- +i i ^ physio- , 
wore ha.od upon soinul nhvJ nl^ ^otliods of training 
received the wirm approva/of the principles which 

w paid a visit to thi [nstitut°L %Td T'- S<-goin-yvheu 


teaching, the pri!ici])lcs adopted nnd described at that 
time by Sogniii in America and Sluittlewortli in England 
arc tho.sc which are in use at the present dav. 

. On leaving the .Royal Albert A.syliim, Dr. 'Shuttlcwortlt 
c.oine to Loiulon and took up consulting work. His reputa- 
tion caused him to ho at once accepted as the leading 
authority rogiirding mental defectives. But he did iniicli 
more than consulting work. He had long realized that tlio 
unfortunate niciitally defective section of the comiminity 
had claims to lonsidcration and to care and training 
which, in the great inajoilty of cases, ivorc denied them, 
and he spent Jiis time and energy unsparingly in arousing 
prcfchsioiml and public interest on their behalf. In his 
work of advocating their claims, of organizing and spc.akiiig 
at. incctings, nnd iiistnicliiig nnd training teachers, ho 
had the enthnsiastic siqiport of a little hand of devoted 
..workers, chief among whom were Miss Ethel Dixon, Hiss 
Bertha Janies, and Afiss H. HcDowall. In time each of 
these disciples heenme a now centre for the training of 
those, who purposed to undertake the care of dofcctive.s, 
and there is no donht that a very large, proportion of such 
tonehers owe their knowledge, directly' or indirectly, to the 
work which was initiated liy Dr. Sluittlewortli. From' 
1899 to 1901 ho was medical examiner of defective children 
under the London School Board, and from 1901 to 1905 
medical expert to Bochester House Institution under the 
IMetrojiolitan Asylums Board. His unique knowledge of 
the subject made him a most valuable member of the 
Departmental Committee of the Board of Education, the 
report of which led to the passing of the Defective and 
. Epileptic Children Act of 1899. ! Ho also took a leading 
part in securing the passage of another vnlunhlo measure — 
namely, tlie Asylum IVorkcrs’ Superannuation Act of 1903. 

Dr. Slnittleworth was a member of the British- Medical 
Association of over sixty ycar.s’ (standing. He served on 
tho central Council from 1899 c to 1903, .'and had been 
President of the Lancashire hnd- Cheshire Branch in 1892. 
He was honorary soefetan- of the Section of Psychology at ■ 
the Annual Afeeting in 1883, and Vice-president of this 
Section in 1885 nnd again in 1006. He was a member of 
the Aledico-P.sycliological Association from 1877, and a - 
constant attendant at its meetings. He did a largo amount 
of ivork for tlic St. John Ambii]nnco Association, nnd -in 
1892, in recognition of this, he was. made an liouornry 
associate of tho order. Long after” ho lyas 60 years of 
ago his energy - nnd love for the! n-ork were shell ■ tluit. he 
contiiuiod to take ah active part. in the- affairs of many 
societies of which ho was a highly valued raenihcr. One 
of those in which he was especially interested, and where 
his knowledge and advice were highly esteemed, was the 
Central Association for Alontnl IVelfaro, of which ho was 
for ninny years a vice-president. Another, in wliicli he 
held a similar office, was the National Association for the 
Feeble-minded. Ho was also an active vice-president of 
the Child Study Soeiotj' and tlio Society for the Study of 
Inebriety. King’s College, London, eloefed ’hiiii a Follow, 
and in 1909 he was given the .freedom of tho City of 
-Ijondon. 

AVhiic perhaps Dr. Shuttleworth’s chief work was that of 
a teacher, and exponent of methods of training, ho never- 
theless wrote important articles in the 7(,'ii('i/rto/«ic<W(> 
Jl/crfiro, . Allhutt’s System, of Slcdicjnc,. Hack Tiike’-s 
• Dictionary of Psychological Medicine, and nnmoroii? 
journals. His most important contribution, however, was 
his . exceedingly valuable book on Mentally Deficient 
Children, the first edition of which a-as published in 1895, 
and the fifth edition, in conjunction a-ith Dr. AV. A. Potts, 

, in 1922. . 

■ To those a’ho did not knoa- him this account aill give 
some idea of Shuttlcworth’s ability, and energy. It is no 
■ exaggeration to say that the a-hole of his profe.ssioiial life 
a’as one of untiring devotion in the cause of mental 
defectives. In this work he was a pioneer, land he main- 
tainod his interest in it almost up to tho end. The iviitcr 
visited him only a short time before he died; in spite of 
his manifest feebleness his thoughts aero still on his life 
he exprcs.sed his satisfaction at tho recent pas-ing 
of the amended 'Alental Deficiency Act.- Those who .weire^__ 
oitiuiate enqjigh to knoa' him, hoa'ever, aill lememhcr 
nim for something' more and perhaps even greater. They 




,1006 JirNB g, 1928] 


MEDICAD NEWS. 


[ 


The BnttiM 
VSDtCAX. JOCEVU, 


Manufacture of Cocaine in England. — On June 5Ui Sh* P. 
Cunliffe-Lister told Mr. Feuby that the uianufaclure of cocaine 
and cocaine liydrocliloridc in substantial quantities had been 
carried on in this country for some limo under the anlhority 
of the Home Office. He understood that tliose inalrrials woiih! 
shortly be available for disposal, and the conditions for exemption 
from duty were, therefore, not. satisfied. . 

Adulteration of Milk. — On June -Sth Sir ' Kisgseev Woon, in 
reply to Sir Walter de Frcce, said that official Malistics 
indicated a progressive decrease in the aduUcralion of milk, (ho 
percentage of samples reported by public analysis as aduUcraied 
or below tho presumptive standards being 6.9 in 1927, as com- 
pared with 7.4 in 1926, and 9.3 in 1920. There was *no specific 
requirement as to the number of samples to bo taken annually 
a local authority, but it was the practice of the Ministry of 
Health to communicate from time to time with those authorities 
which did not seem to be taking a sufficient number to provide 
a proper check on adulteration. 

Manufacture of Sheep Dip. — Sir W. Jovysox-HiCKS, on June 
5th, informed Mr. W. Thorno that he was advised that the 
proce.sses of the manufacture of sheep -dip were liable to give 
rise to diseases of the skin but the niimhcr of such cases reported 
in the last few yeai-s had been quite small. Tho Factory Heparl- 
ment had not been able to trace any recent cases of ‘a ef-rious 
character at tho Barking Crock factory, and it uas presumed 
that cases to which Mr. Tliorno referred in Ins question had 
occurred some years ago. Tiic main precautions to ho taken were 
the provision of adequate exhaust ventilation and euitablo washin<» 
facilities, but these could be already secured in all cases wlicro 
arsenic was used under the existing provisions of the Factory Act 
and he was adnsed that no additional regulations were neccssai-y* 


Notes \n Briefs 

Officers of the Ministry of Health arc in consultation with local 
authorities about the improvement of tbe administration in the 
casual wards at Thame. 

Stalistics sliowing the totnl Bum paid in vales dmitm tl.e Inst 
U-O years by hospitals in England and Wales are not availalde. 


JEehical Jlelus. 

The net? snrgiwl block o£ the City o£ London Hospital U 
Diseases o£ ^e Heart and Lnngs, Victoria I>arU, E ^ will I 
opened by H.R.H. the Duke of Connaugbt on 
June 12tb, at 3 o’clock. The guests will be received attoi 
• wards m the grounds by the Lady Mayoress. ‘‘“O' 

As previously announced, the opening cororaonv of ti, 
Samuel Augustine Courtauld Institute ot BiSmiQim 
Middlesex Hospital, will be held at 3.30 p.tn., on Sldnr 
June 14th; Sir Archibald Garrod will deHvor nt. ’ 
o?‘«od "The place ot Bioohemist^rin Mediefno” of 
Middlesex students will be welcome on presentation o£ tlmi 

ot state andPresia^t o£ tile Secrotar 

music in the bospUa” gardens 

be^re^ratTbe'' Con^na°L‘ht wil 

Thursday, June 14th, at^^pm ^’ Queen Street, o: 

Leicester Square, W.C., on WednesLv 
A MEETING o£ the Biochemln.i P-w. 

tho Bothamsted Experim^to/ rhh°®*®‘^ '’e held a 

(Saturday, June 

"Will be made m the mornina ^nd tho m field* 

and communications will be held 1^ for husinesi 

2.15 p.m. The papers will include one nn™f?'® a 

a-radiation on vitamin D In irradiatofl .‘'^® o 

Morrison, P. B. Peacock, and S. Wright by E. ft 

An exhibition o£ old sporting pictures .•. i, i 

month in aid ot the Eoj-al Free Hospital It M thii 

gaUeries, 15, Old Bond Street. Messrs.-Khoedler’i 

The second international conference on ' 

medimne, surgery, and public health will ’‘oat ii 

from October 29fch to November 1st, 1928 af- ^ondoi 

Lonclon, South Kensington, S W 1 It *in o 

visits to representative%linics^nd an 

ratus and accessories for ultra-violet lirriif “ifiition of appa 

by the Brit 
Buildings, I 

medical praciiuoner on request. ' i-o anj 


gynaecology at the Royal Northern Hospital, and on tho 
ilay, at 3 p.m., Mr. MacCallan will domonstrato at the 
Royal Eyo Hospital, while on Tnesday, Juno 12tli, at 2 p.ia.. 
Dr. Anthony Foiling will give a clinical demonstration at tlio 
Hospital for Epilepsy and Paralysis, Malda Vale, W.9. Tub 
special courso.s, each lasting two wooks, begin on Juno 18th— 
at tho City ot London Hospital for Diseases ot tho Hc.art 
and Lungs, Victoria Park, E., and tho Chelsea Hospital for 
Women. Thoro will bo a goiicral practitioner’s course nt 
tho Loudon 'romperanco Hospital trom Juno 18th to Juno 
30th Iroin 4.30 to 6 piiii., and a coiirso at tho IVe.st End 
Hospital for Nervous Diseases from Juno 25th to July21st, 
consisting of cliiiicnl demonstrations on selected eases. 
Information regarding tho genoral course ot instruction and 
copies of all syllabuses may bo obtained from the secretary 
of tho FollowsUlp, 1, Wimpblo Street, W.l. 

A NEW posl-"i-adiiato conrso In gonito-urlnary discaso.s at 
St. Panl’s.no8pltal,EndeU Streot, W.C.2, opened on Juno 7th. 
On .luuo 13th Jtr. R. H. Jocelyn .Swan will lecture on tho 
trentment ot enlarged prostate. 'Xlio lectures will be con- 
tinued weekly and will terminate on July 26th, when Sir 
Thomas Caroy Evans will discuss stone in the bladder with 
special rotoroiico to treatment by litholapaxy. Cystoscoplo 
oxaminatlous. aro couduotod daily with tlio exception of 
Tuesday aiid Saturday, and urothrosooplo examination daily 
except Saturday. Operations aro porforraod on Mondays, 
Wednesdays, 'Thiiradays, and Fridays nt 2 p.m.;' Tlio course 
is fro'o to medical practitioners and students, who can attend 
any branch ot tho work in whlcli they aro interested. Tea is 
served nt 4 o’clock hoforo each locturo, 

A rosT-DRADUATE Iccturo demonstration on phj-Blothorapy 
will ho given by Dr. M. B. Ray, honorary secretary of tho 
British Committee on Rhouraatiara, ot tlio International 
Soelotj' of Sledlcal Hydrology, nt tho Epworth Streot Medical 
Baths, Beverley Road, Hull, on Friday, Juno 15th, at Sp.tiu 
All medical prnotltlbnors in tho district are invited. 

A POST-GRADUATE conrse onnowdovelopmontsinpodlatrics 
will bo hold in Paris nt the Hopltal dos Enfants Maindes 
from July 2Gthto August 2ad inclnsivo. Further Information 
may bo obtained from tho Secretary of tho Faculty of 
hlcdloino, 149, Ruo do Sevres, Paris XV'. 

A POST-GRADUATE course in tho diagnosis and treatment 
of cancer will bo hold at tho Cauoot. Institute in Paris," 
from July 2nd to tho 13th, under tlio direction’ of Professor 
G. Roussy. Tho courso will inoludo lectures and laboratory 
demonstrations; and, in connexion with lfc, n diploma will hd 
awarded by tho Faculty of Mcdiclno. Fnrthor information 
may ho obtained from Milo Hure, Sallo Bdclard; 12vEuo do 
I’Eeole do Mddooino, Paris VI. 

A comprehensive post-graduate conrso in oto-rhino- 
laryngology will ho. hold, uiidor tho direction of Protessor G. 
Cannyt, nt Strasbourg, from July 16th, to 28th. Fnrthor 
iiiformatidn may ho obtained from Professor Ganuyt, !, Place 
do I’HOpitnl, Strasbourg. From Octohor 8tlt to 25th there 
will .also be a conrso nt Strasbourg in titborculosls and tho 
diseases of tho respiratory passages. Further details may be 
obtained from Dr. Vnuebor, 8, qual Finkwlllor, Strasbourg. 

An intornational coutoronoo on tho physical, biological, 
and thornpcutical aspects ot light will ho hold at Latisauno 
from Soptombor 10th to the 12tlr, and tlio following day will 
bo spout nt Loysiu. . Tho subjects to bo dealt with iucludo a 
lecture on tho tUornpeutlc, prophylactic, and social aspects 
of hoilotherapy, by Dr. Rollier ; heliotlicrnpy in Belgium ; 
radiation of food ; a lecture on tlie sun .and artifloial light, by 
Professor Leonard Hill ; and pigmentation caused by light. 
Dr. 6. Murray Levick Js the genoral lionornry socrotary m 
England, but inquiries should bO addressed to the Seprotnriat 
Gdndral do la Premiere Contdronce Internationale de la 
Lumiero, Lausanne, Switzerland. 

The president ot tho Royal Free Hospital, Lord Riddell, 
and the treasurer, Mr. Albert Levy, have undertaken to give 
in equal shares the sum of. £ 100,000 'nooessary to secure 
the promised gift froth Mr. George Eastman, of the Eonnk 
Company, of £200,000 for the now dental clinic whioh, it is 
expected, will be completed within the next two yea.'?- 
AVith this provision assured for tho dental clinic efforts will 
now bo concentrated on raising tlie sum of £150,000 neeneu 
for other dovolopmouts,' such as tho robullding of tho palho- 
logical and maternity departments. 

The Scottish Board of Health has reappointed the Scottish 
Advisory Committee on tho Weliare ot the Blind for a furtne 
term ot olllce. The medical member is Dr. George Mackay. 

The Minister of Health has tor warded to’ county cbunci 3 

and local sanitary authorities in Eugland lists ot the f •„ 
rules and orders relating to tho new amending regulation, 
connexion with the notifloatioh of puerperal ‘ „ 

ophthalmia- neonatorum, ivUich comb into ttporatio 
July Isb next, from whioh date the procedure in „ 

these notiflc.atious will be the same ns that In force lo . 
notltioation of oases ot puerperal fever. 





1008 - JUNE 9. 1928 ] 


IiEXTEESi NOTES, AND ANSWERS. 


r THE iinm« 

L UrpiCAj. JocrnaXi 


I. YiTA ” Glass. . 

Journal (May 19th p. 884) by time “ vitft ” 

Bitot- beiug A ^mpermeBblo to the ultra-violet 

ylass becomes dtscolourea Bud exposed to the emt'e 

B poiut where 

matter liow mnqh loUoSv t g much quicker by 

Bevisiou) oI January 14th, 1928. _ „ „ 

* ♦ An article on this subject, by Dr. II. E. MacDormot, 
appears in the Canadian Medical Association Journal lor May, 

Income Tax. 

Wife Commences Practice. 

“ M N O "is a whole-time public official and has recently married 
a medical woman. If his wife practises and uses the car and 
a portion of the residence, can deductions be claimed, and liow 
should tlie statutory retnru be made if the professional e.xpeuses 
exceed the gross income ? , , , 

* * Deductions can be claimed ^so far ns reasonable — for 
example, “ M. N. O.” might have to fall back on an estimate of 
mileage cost for the use of car; if the amount of professional work 
is small be may have to take into account the assumption that 
the usual proportion of rent, etc.— tor example, oue-hnll~\vm 
not be allowed. The cash basis of oalciilatiug receipts will not 
be permissible in the Qrst two or three years. The wife’s Income 
should be stated separately, and the special personal deduction 
of £45 will be due in making any charge to tax. It losses aro 
incurred they can be carried forward to set against future 

profits. Purchase of Partnership Share. 

“ Y Z ” purchased, as from Jauiiary Ist, '1928, a halt share in a 
si’ngio-hauded practice. On what basis is he assessable for 
1928-29, and if on that of the 1927 profits, can he claim any 
special allowance, seeing that 110 bills were sent out for the first 
six months of the partnership ? 

The basis of assessment of the firm is the amoimtottho 
profits of the practice for 1927, and “ Y. Z.” will be liable to 
account for tax on one-halt of that assessiueut, less the usual 
allowauces. If the profits of the practice should fall short in 1928 
from some specific cause, the firm can claim some special relief, 
but presumably tliis is unlikely to happen. Tlie fact that, so 
far as “ Y. Z." is concerned, the cash receipts will fall short of 
his share of the assessment furnishes no ground tor relict. 

Expense of Assistants Board, etc. 

“ 0. B. T.” states that the local inspector of taxes has hitherto 
allowed £144 per aniiiim as representing the cost of the board 
and lodging of his nssislaiitr, but now declines to allow more 
than £70. 

• , • lYe.are not aware of any general regulation or agreement 
on this matter— indeed, circumstances must vary so widely 
between diflerent practices, that any fixed allowance seems 
impracticable. The only reply we can give to “ O. B. T.” is the 
not very helpful one that which of tlie amounts is nearer the 
trnlli must depend on circumstances not within oiir knowledge— 
for example, the general house expenses, staudnrd of living, etc. 
One point that may have been overlooked is that part of tlie cost 
of the domestic staff is allocable to the assistant’s accommodation. 


porooptihlo. (2) The second stop "’ks, the cslahlishmont, four 
years ago, of woll-oqnlpped oplithalmiq ollnlcB, coudnoted by 
specially trained modioal officers, in nil tlie “Y ‘llrv 

pWtionlnrly where trnolioma and its coniplioatlons ate very 
•prcvalont. ^ These clinics have done cxoclloiit work, and have 
really reduced tlie iiicidoiico of bliiidncBS ns far as Posaiblo. 
fnimiing tlie pnrnoso aimed at by Dr. Tlclio in his wovds- 

“ expert and timely treatment." 

» • tVo have referred more tlinn once to the valuable v.oili 
.carried on by the Govcrumoiit in rnleatiiie. For example, 
mention was made of those ophtlinlmic clinics In our columns 
on Febrimr}- 13th, 1926 (p. 295). 

INVEIISION.OF THE UTEIIUS. . 

Awivr. tliG reports in tlio Jountnl of cases of inversion of the 
u^e^us lAuuiist 270171927, p. 350; October 1st p. 595) I'vo fuY,''" 
ncchmila of cases of this condition have been received froii ■ 

hbroiid. • fSBrnwaki writes: In November, 1927, 1 was 

caUed a-yomig' bad 

?,for,teKa^d’aliM 

on tbo ° ’'".Yhichcs tb" coi-il "'as still attacl.ed tolhe 

‘c^^iVafiirtbo placenta 

There was vcij trouble 


BETTERS, NOTES, ETC. 


v’-, . 



(lo.om.pltuitrm nau oec.1 , j , n,B„ipuiatiou, and 

placon la I replaced tb6 ulor«3 nv m m 

inserted a l«vgo p'nS >>' ^Im jjaiavs allow any 

uneventful lecovc }^ in chilflbirtlb and tbo various objections 
European Intel leronco operation anv easier. -It bad 

tS bo’porffirmed in a native hut, where aseptic conditions are 
onllrcly lacking. ■ _ - __ . .--v Malay States) writes; 

Db.')Vinifiied H._ a bistorv of 

A woman, aged 2 a, le child at 4 a.m. 'The 

plqtoly w^^swllbbed vvitl. tiuotiire of iodine, and 

oxposort .irnAiiailv rcinvcrtcd. bv pressure on tbo 

then the ntoriis eosiirau‘4 witlioiit an nuaestlietio. 

fundns; '•’"® ''’’‘innXuoho wargivou and 20 0 . 0 m. of antistvepto- 
Abotiatcautcrinqdouono "as bi'u 6 p.m. the uterus 

ooocal s^runi inject again. It was refilaoed in the saiiio 

became with^icvillavino gauze, and morphine 

way, the ,lay it was ropaclied, 20 o.cin. ht "'i^i 

gr.i given- On tbo^iie- _ The nacUiug was removed 


OpiiTUALaiic Prophvlaxis and Tbeatment in Palestine. - 
Dll. N. A. IlAMZEU (Dublin) writes : There uppeared in the-British 
'Medical Journal ot May 19tb (p. 865) reiereuce.to a paper by 
Dr. 'i'icho (uot Tricbo) at the meeting ot the Academy ot Medicine 
in Jerusalem ou the incidence of ophthalmia iu Palestine, in 
vviiicb lie' , emphasized that improved general hygiene, with 
expert and timely treatment, would prevent blindness iu 75 per 
cent, ot cases. As a medical officer ot the Deparlmeut of Health 
of Palesliue, vvliicli is doing a great deal of work towards 
aUeviatiug eye diseases iu general, a fact vvhioli might have been 
.rec.a\lcd, i take the opiiortuuity ot pointing ont very briefly the 
.measures taken by tfiis organization iu this respect: (1) The first 
.anil most importaut step is the organized, persistent, and 

sy«lemalic Ireatmeiil ol the eyes ot Government school children 

,an.v in some p'^ces non-Governmentr-hy specially trained doctors 
ana nurses. Tlie ctlect ol this work has been very marked and 


CIS iiVi^Wornii Bhe “Yhe CrSI. An 

and large onn ol pilnitviu was injeotod intra- 

. donoho vyas g'' ^ ,,^,1 no more bleeding, hut ttoe clays 

muBonlailj. ihcpa .^.,,^.0 soon to he covered vvitli a 

later, the '’■'g'"? .,''"0 -Proatmeut with iodine douclies was 
.yelloWiBh weeks, when tlie iuembraue had complete y 

. coutlnuoil loi j n healtbjMoolciiig vaglua autl cervix, ana 

sloughed away , normal for fourteen days. The main 

the C St tlio case (Dr. Mitoliell adds) seem 

■featuroa of i iterest aoo^^^ the uterus after replasa™,®"^’ 

■ to be : (1) the — orfimgo ou tbo eigbtli day. As fbeie 
/4C-®„o“Se“nctB,^itm^ leave been due to secondary 

haemorrhage. ^ .Disclaimer, 

Mr. Victor puniorUto bo an 

morniug ’?eprodndiffi mv words. Many of the things 

interview vv. h me iej?ro n j,,o ot 

reported I nut nmi » 5 • private.' The message I perm ilted 
understaudiug my journey to New 

toIuK" o l-rool oUho intcude.! d.tiole wb 3 fiubm.llcd 

to me. — 

supporters of Emfdre jjP>;oauoe may. he - gl“Yn 

.Messrs. Lambe^^fi^^l^Yu^^ oalUiy lUwdeBmu 

brand of c.o , galisbury* the centre of tbe tobacco 

Virginia le . . coniitry. These welbina^e “ Kliobiftn 

*to new impressions. ‘ 

Vacancies. ^ ,««!!««;»» 

NOTIFICATIONS o£ offices vacant in 

and ot vacant resident and other appointment iv^rtiaemeui 
. be found at pages 45. 46. 47, 50, 51, and 52 o , our adv d bsemeu 
columns, and advertisements as to partnerships, assistanvau 1 
and looumteneuoies at pages 48 and 49. . n,„ „,ivpi-tisemenl 

A short summary ot vacant posts notified in. tlie ndveriiscm m 
C nllimMc; n miAfirQ in thp FiflDnlCDlCJlt at UagC !(i±7» ' 


June iG, 1918] 


nEA.UT ATTACKS. 


r TmtBiimrt 1009 


HJntislj ^ssaditiion ICrrtnrc 

oy 

HEAE.T ATTACKS. 

Dr.i.ivrjiKn to the C^Et.sA^ llivisiox, Ai’iiii. 25Tn, 1S28, 

■ ■ BY 

CAR FA’ F. COOAIRS, AI.R., F.R.C.P.Lond., 

rllVSICUN TO THE BKISTOt GENETIAL IIOSI'ITAE. 

The cliA-crsity of plicnomciin oUrilmlcd to c.Tidinc origin 
Tvill tio apparent from tlio following list of tliagnosps 
collcrlod during tlic past tlirco inonllis in cases labelled 
bv the iiaticnts tlioni.selvcs as licart altaclcs. First comes 
tlin group of troubles not actually couuorled with tlio 
heart at nil— gall-stones, epilepsy,- aural vertigo, iinrco- 
lepsv. Secondly, there arc dislurhnuecs of the heart Avithout 
evidence of orgauie disease. Of these' there arc two chief 
varieties — prcuiaturo bents and extracardinc arrhythmia, 
the latter manifesting itself oftencst ns speeding, but 
sometimes ns .slowing, of the heart. Last of all come the 
cardiac attacks proper, the symptoms of which are caused 
by organic disease of the heart. Angina pectoris, cardiac 
iiAfarction, acnlc oedema of the lungs, ami cardiac asthma 
.all come Avithin this group; so also do most cases of 
anricidar flutter, so far ns my oaa-u experienee has gone. 

The 'predominant .symptoms may be roughly divided into 
tAVo classes— the cardiac and tlio peripheral. The patient 
suspects his heart of heing the cause of his attacks, either 
because he feels something amiss in the region in Avhich 
ho believes this organ to lie, or because of symptoms clsc- 
AA-bcre AA'liicb common report lias taught liim to regard as 
cardiac in origin. SubjoctiA-cly considered, lliese attacks 
limy bo discussed under four hcadihgsj according to tlio 
predominant symptoms. ■ 


1. Pai.i’it.atioxs. 

Afore than a quarter of the patients seen in priA-ato 
practice for cardiac attacks may be classed as sAiffcriAig 
from palpitations. It imrst bo remembered, too, that these 
are more or less .selected cases; all bad passed through the 
hands of at least one medical man before seeing mo. If 
Avo were to consider instead the unsifted experience of 
an out-patient department or a family practice aao should 
find the proportion of functional cases even higher, foi', 
almost Avitliput exception, patients aaIio complain chiefly 
of palpitations are suffering from functional di.sordcr of 
the heart’s action. One' princiiAal reason for this is that 
AA'hcn^ the. palpitation is symptomatic 'of organic heart 
dUcasc-^s, for example, in sonio patients Avith auricular 
fibrillation-^there .are other symptoms, such as dyspnoea, 
AA-hich more urgently occupy tho, patient’s mind. When 
palpitation is the chief sonreo of' distress it is usually the 
subjectiA’o counterpart of one of tAA'o' kinds of disturbance 
or rhythm. In tlic first place, the heart mai' be accelerated 
by extraneous '.causes operating through 'the vr.go-svm- 
pathctic apparatus by .Avhiclr its speed is regulated. Often 
icso causes are psyeliical; and by no means obvious cither 
to the patient or to tho doctor. On little or no apparent 
provocation the heart’s speed rises to 120 a minute, and 
continues at this rate long enough to make the patient 
acutely uncomfovtab c. ■ Often, too, the attack is aggra- 
vated and prolonged by tbo fear ivliieli it arouses, this 
^ 1 ^ JJiaintain and increase tlio acceleration 

ortho heart s action. ■ Gradually- the attack dies away, 
01 or under the influence of. a reassuring prognosis or 
! spontaneously. -If the doctor is there in time i? will be 
noted that .the speed rarely exceeds 120 a minute, that 
f. IS mmenablo to such influences as 

deep breathmg and emotion, and that. its start and finish 
“Ot “brupt. Frequently, however, these 
i of .!r,m presumably as the result 

‘ ^ subconscious mind, and the 

( Evpn’ ^ ''kplo of the attack, escapes observation. 

! in tlie^ “early ahvays possible to detect 

* if ° Buscoptibility to external in- 

, absence’ the history of the '.attack, together Avith the 
c'nbVis c'- disease of the heart, makes tho dia- 

enosis Simple as a rule.' ' Usually the patient is a yo'ung 


adult, of- nervous tomperament; but, though this is a useful 
guide, it is by no means infallible. I have rcccntlj’ scon 
an old gentleman Avithin a montli of his eightieth birthday 
AA'hoso 'nocturnal attacks arc quite obviously of the variety 
I IiaA'c tried to describe; and oho of the AA’orst cases I ever 
saAV occurred in a burly f.irm labourer. 

Such cases are, of course, aa-o11 knoAvn, and it may seem 
that I am haying unnecessary stress on the cxistcnco of 
this sj-iidromm Rut it is not ahvays recognized even by 
the medical Anan, aAAil even when it is recognized it is by 
no means ahvays possible to persuade tho patient or her 
rolatiA-cs that the symptoms do not indicate serious trouble. 
I’arlicularly in medico-legal cases, AA-horo tho attacks aro 
supposed io'. dale from some strain, and thereby to entitle 
tbo patient to compensation, it is often impossible to get 
rid of ilio symptoms. 

Ollier influences beside emotion can quicken tbo action 
of Ibo heart by their operation tlirongh the vago-.sym- 
pallictic controls. For example, in the thyrotoxic stato 
palpitation is often an early SA'inptom, but it is usually so 
persistent that it docs not present itself to the jiationt in 
tlio form of an “ attack.” Once a girl aged 17 Avas 
bronglit to mo at tbo hospital for attacles of palpitation; 
.she had a pulse rate of over 120, Avbieli examination proved 
to be duo to Avidespread tubcA-culosis of the lungs. Similarly, 
tho Alinislry of Pensions found many cases of “ D.-A..H.” 
due to pulmonary tuberculosis. 

The other kind of disorder that giA'os rise to a complaint 
of palpitation is the premature beat or cxtra-.systolc. AYbcn 
this occur.s, as it often docs, in periods or bouts, the re.sult 
can be oxlraordiunrily disquieting". The patient feels a 
■son.sation as if Iiis heart g.'Avc a kick or 'turned oA-cr; or it 
may be the pauses tlmt be notices. If this sensation keeps 
on recurring it may bo enough’ to keep him aiv.Tko at night. 
Curiously, it is common among doctors, as Galli* has lately 
observed'. AVhen the patient comes for examination tho 
disorder may refuse to exhibit itself; but if you arc lucky 
you Avill catch at least one or tii-o premature boats, cither 
Avhen .the patient lies doAvn or Avlicii he stands up again, 
and by comparing notes Avitli the patient you Avill find 
.that it is this phenomenon, rcpoatcxl often enough to., 
accumulato into an attack, Avhich is responsible for his' 
bouts of discomfort. A number of these patients aro 
elderly, and tho arteries and myocardium maj- shoAv traces 
of AAcar and tear. In .sjiitc of this it is our duty, to rcassuro 
the patient, and to explain to him that, in the AA-ords of 
Sir James Alackcnzie,^ these disturbances mean no more 
than grey hair or a Avrinkled skin." . . ' . . 

Not infrequently both hciA-ous'accelcration and premature 
boats appear in the same patient. This may make the 
1 interpretation a little more, difficult, but it is- only rai-clv 
that a graphic record is' indispcn'sablo. In' • cither case, 
AA-hcn Avc ourseh'e.s are 'content that these" attacks have mo 
serious import, this A’iew must ho communicated to tbo 
patient, not merely , as "a nogatiA-o assurance that there is 
nothing the matter Avith his heart', hut also, as a positiAm 
statement attributing his symptoms to.a neiwous disturb- 
aiico Avhich he can to some extent discourage. AVIiencA-cr 
possible tho sources of the distiirhariecs . should he ascer- 
tained and laid before him. Much gdod is done not only 
:by abstaining from any prescription of medicine, but also 
by insisting on tbo value of exercise as a curatiA'c measure. 
AVo must not forget bow much this did for tho relief and 
euro of “ D.A.H.” in time of Avar. 

I do not “'ant to coiivey the impression' that an attack 
|of palpitation is noA’cr dependent on organic disease. 
Spraotimes a hian Avith a hypertrophied heart, the result, 
perhaps, of adrtiq regurgitation, Avill complain more of 
tho battering at his ribs that ho fools Avhen his heart^-is 
hastened by exercise than of any other - symptom. But 
this rarely limits itself -so neatly in point 'of time as to 
wnstituto an attack. I am thinking rather of those dis- ' 
turbaiicos of rhythm Avhicli, arising within the heart itself 
cause it to beat unduly fast — I mean paroxj-smal tachy- 
cardia, auricular fliitter, and auricular fibrillation jfs 
I have already remarked, the patient with auricular fibrilla- 
tion rarely complains of palpitation, because he is at tho 
same time nearly always suffering from dyspnoea duo 'to 
.organic diwase of tliq lieart. , In ^raro .. cases,. hoAvever, 
aunculai fibrillation appears, like paroxysmal tachycardia, 

[35 19] 


1010 JUNE l 6 , 1928 ] 


HEART ATTACKS, 


r TnEBnms* 

L Mscicti. Jormii 


aljnijitly and M-ithout any obvious background of organic 
disease, and after nnining for a brief poriot! disappears 
ns suddenty as it came. Again, ns in paroxysmal tachy- 
cardia, tliis may recur from time to time in bouts; or it 
may be an isolated attack, tlio origin of wliieb remains for 
ever unexplained. 

Far commoner is the ordinary attack of ])aroxy.smaI 
tacb 3 cardia. Hero also each attack begins and ends 
abruptly, the heart passing inimodiately from its normal 
speed to one twice as high, and back again to normal in the 
same way at the end of the paroxysm. Usually the patient 
can give a clear history of this kind of attack, and it is 
not difficult to recognize its meaning, especially if the 
pul.se, felt in an attack, shows a regular beat of IdO or 
oyer. In inaiu' instances there arc signs of organic heart 
disease. Usmallj- the patient can give no reason for the 
onset of tho attacks, which aristj as often during rest as' 
after exertion. I recollect the case of a young woman who 
said that her attacks were brought on b^’ stooping or by 
Jolts — for example, when riding pillion on a motor cych,‘ 
.she had known an attack jerked into being, so to sj)calc, 
on going over a pothole, and Jerked out again by another.’ 

Tlie onset and cessation of auricular flutter are usually 
less- obvious, and whei'cas tho bouts of paroxysmal tachy^- 
cardia often recur for many years without becoming worse, 
those of auricular flutter are less frecpient, but last loimcr 
when they do come. In flutter also tho high speed rhythm 
IS often broken into from time to time in such a way as to 
produce periods of irregularity. But apart from a graphic 
record It is impossible to bo quite suro whether a tachy- 
cardial paroxysm is duo to flutter or not; and it is often 

aTtacr' “M’ocially during an 

In, T- It IS not necessary to differentiate 

immediately between tho two. In both tho essential things 
arc to recognize that tho tachycardia is intracardiac ami 
not e.xtracardiao m origin; to see how far there is a hack- 
ground of organic heart disease to wliicli tlic muscle fatigue 

gendered by the rapid beating may add materially and 

SiltSs' •" •'»“ <" ‘""s •'» 

^As to the first, note that the speed is nearly .always bie), 

140 01 more; that it is regular, and uiiuilluencod by 

Uie T-’^l lii'cathiiig or emotion ; and tliat, 

It the high speed breaks off for a period the rate dro s 
at once to normal. The second aspect, that of prognosis 

;5I2 ■>' 

alte mtion ff Ft fs’ca l<igi'Iai-, exhibits 

.mci nation it it is carefully examined by means of tlm 

noiiniv ..-,,1 ini' .^1°. pntso piessnre becomes very 

.vn.. ... a 



Compression of the vagus in the up', 

- - - , - liave tried this often but « 1 recoin- 

these simple measures fail, the patientJwr"^- 
alarmed and uncomfortable— will domaiitl '+1 ’t 
more shall be done. We have then tn something 

to c onfide ill tlic digitalis group or to usF u "'‘“tl'ci' 

boim that it will Fecall the no’rmal i.l.ytl,?""'l I”!,'-" 

mvn o.xponcncc has accorded with the imlepn.poV "’J 

recently by Parkinson and Bedford = 'nTiu 

partial .success with digitalis or its Wlows t likelihood of 

that of complete success- with qiiinidine 

is a certain risfi a unit i;,. , ^ 

quinidiiic to a patient whose ventricle often 

-no clPgencrate, is beaming e^bans'eef by 1 1™ 7 

lor tbe^ riinons I prefer to eive i- ‘ ®imcd. 

It in largo and repeated doses-For exannde‘\a1?'‘ V 

CO *’"■ tmctnie every four bnn'rs -R it’ “ ffraclini 

59, wl,n..o fiiiUer hml resisted '* 

-vnous dose of ou.abai„ (0.5 m-^ , i'l 'FF 

0 -) icduccd the speed from 


180 to 100. A\ bat often liappeiis is that tbo regular beat 
of 160 or .so .a minute, cimracteristic of flutter, is converted 
under digitalis treatment to a totally irregular boat of 120 
01 .so, the flutter binug rejilaecd by fibrillation. This, again, 
may revert to normal, cither with or witlioiit tbo u.se of 
quiiiidinc. 

sVn attack of flutter is a serious matter. ICvcn if not 
dirc'etly fatal it make.s the jiatient ineajiablo of resisting 
contemporary stresses; and when it sujiervenes on gross 
organic disease of the heart it may jirovc the last phase 
of that disease, ft is, however, a rare ]ibenonienon, and 
my last word on this siibjoet of paljiitation i.s tb.at nearly 
always it i.s duo to fuiietional and not to organic tachy- 
cardia. 'Wlicn a patient dcscribc.s bis attack as one of 
palpitations tbo probability is that Ids trouble is functional. 
Tlii.s does not exclude, tbo jiossibility of an organic lesion 
of tbo licart coinciding but not otherwise 'connected with 
the functional disturbance — a combination that is difficult 
to handle, because it is hard to get the patient to hclievo 
that his sensations arc not dangerous. 

2. ir.rtXTixti .vxp Giddixkss. 

Dcciily rooted in the ])n1)lic mind lies a belief in tho 
cardiac origin of fainting attacks. It is, I suppose, a 
diluted edition of that other belief — that tlio. ])osscs.sor of 
a diseased heart is necessarily in imminent danger of 
sudden death'. If wo eonid dissipate these two misbeliefs 
maiiy ])co))Ie would bo delivered from a bondage of baseless 
fear wiiieli holds them in thrall. As a matter of clinical 
exporieiiec, hoiv iiianj- can recollect any case of organic 
di.soaso of the heart that revealed itself in the form of 
fainting attacks? I will speak of two or three examples 
presentW, hut first let me ask. How many times has there 
been found evidence of cardiac disease in a patient troubled 
by repeated faints? I .sec many patients who think tliej’ 
have heart disease hecanso tliey are subject to attacks 
of fainting, giddiness, or loss of consciousness. Among iiiy 
notes of these I can disecin three principal groups. First 
among them comes o))ileps 3 -. I imagine wo have all met 
the parent who is naturally and properly alarmed at the 
lapses of conscioiisnc.ss from which her child suffers, and 
is afraid Ics-t they betoken the proseneo of a diseased heart. 
Usually tho trutli is told her by the first medical man who 
secs tho child; hut occasional^ soino unimportant murmur 
or irregularity of the jiulsc is iibtcd and an indecisive reply 
offered to tho iiicvitahlo question about tlio state of the 
heart. If it were reniemhercd that loss of conseioiisucsj 
is practically never a symptom of cardiac disca’se in child, 
hood this mistake would bo avoided. 

A second kind of attack which is verj' iinturalK', tliougli 
crroneouslj', interpreted ns cardiac in origin is tlio verti- 
ginous syndroino of lahj'rintliiiiQ origin, often spoken. of as 
Meniere’s disease. It is a mistake wliieli is easily made, 
because tho giddiness which is the essential feature of the 
sj-iidrome is often ohseiired hj’ the faintness and collapse 
which accompany it ; and also because this state of un- 
certainty as to cquilihriuiii tends to breed a ueurasthenio 
ebiulitioii one symptom of whieli is palpitation of the 
nervous kind described uhovo. Tliat tho whole thing is 
aural in oi’igiii is nearly alwaj-s made clear by the dis- 
covery of deafne.ss with a histoiy of tinnitus, and bj" 
tho rccollcotioii' that circulatdiy failure cannot deprive a 
patient of tlio balancing function without also depriving 
him of conscionsness. 

'riiere is a third kind of fainting attack, whieli is of 
great interest, especially in connexion witli tlie ]>resent 
subject, because it is in part due to disorder of tho heart’s 
action. Sometimes tlio patient appears actually to lose 
consciousness, more often it is a jiassiiig bout of faintness 
which may ho associated with abnormal caidiac sensations. 
The two factors rosponsihle for production of tiiese attaclcs 
are a slow pulse and a low blood pressure. For example, 
one young ladj' exhibited a pulse rate varying from 48 to 
60, with moments of ratlier abrupt change from the 
quickened to tho slower rate, the systolic blood pressure 
being 110 mm. of mercuiy, and the diastolic 70 mm. A 
sudden change from the recumhent to the standing posture 
may provoke this kind of attack, and recently Ghrist and 
Brown* have recorded some reniarkahle falls in blood 
pressure with .such cliau'gcs in posture wliicli may hell) to 


r Tnr TJnmTO 1 AT 7 

L StFiiJCAi. JocnNix. Vi 


JUK''. Tv', 10381 


HEAKT ATTACKS. 


cxiibin tlirso ntlorl.c. Cottnii niul T.owis' fiirijislic'd the 
cioin'st ovideneo t!i:d fiiiiiliii;; mny he 

dirertU- (-niroii hv \\>'' «( ■ tlv<-s,o two ftudors 

in vnrviu'’- propoVlioiis. A Uiiowlrdce of lids fm-t. limy 
hp of creot vnhic i« ennhlint: us to fiiniisli n lo.svsiii-iiifr 
oxi.laimtion of ntl.sr);s uldrli nro very nliinidnp to those 
who wilucss thorn ns well »s to the siihjeel himself. 

■ Sudilcu fniutness mid giddiness iiuiy nlsu ovort.oUo 
chicrly mou, ns in two enses rceently seen. 

The one, n husiiio" imm of '3. Imt yomip for his vf.irs nml 
full of ipst for work, coiuiilninnl Hint, of l.sfe his shep Imil hron 
poor nlid that In- had horn suhirot to siiildeii nll.ioks of piildi- 
iipss, wliich thn-atcitcd him with lo's of roieriniisiie.s. It was only 
momentary and left him none the seorse,. hut ns he was tlnviiifr 
a ear a pood deal he was rafhtr perturhi-d ntiout it. llis heart 
was a little etilnrprd, his nrlerh-s palpnldo nml lorlunus_ 1ml his 
hloeil presstm' was only J40 mm. lip systolic and F.O mill, 
diastolic. The most noteworlliy poitil w.is lhal the pulse, already 
haiiiiiial/r .«l(iir— .nerapinp 51 a niiniite— was nl«o iiitrrrnpled hr 
numerous prenniiiri' heats with rompeii'iitery pinises. 1 think it 
is nrolialde that these, oeeasionally redtiritip liis elTertive henta 
to ^ a mimife. caused a temporary eerehral ischaemia and were 
thus responsihle for the piddy turns. 

The other patient, aped 71, nppe.ared to me to owe his 
.nUaeks to Ihe smineidenee of a very low diastolic pressuri. — only 
50 mm. lip — with n depenrrale .srleri.al Irrp. lie not only heeatne 
pi'hly, lull on more than one occasion acliially lost eonscioiiMioss 1 
for a few moment/!, j 

It li.as .spenied to me llml this /'.nintnes.s is more likely 
to happen when the blend is in the Kjilaiielmie nre.a, nfter 
a meal, and to he immediately preeipit.nted Iiy some i haiigo 
of posture, sneli .ns rising r(tiiekly f'lotti ,nti armeli.iir. 

In all these rather niiiisiml enscs we enii feriiiiilate soino 
Ihptiry to os|ilain the fniliire of eerolirnl cireiilation ; either 
through loss of nrterinl drive or through gups in the 
he.ari's rliyilim, or through .n cniiihiitniioii of hotli, a 
pataing nmnient of iselmeinia .sliow.s itself in dir.zine.ss or 
even nrln.al loss of ronseioiisiicss. Iltit how are wc to 
e.vplain sneh a r.o.'e .os this.® 

A man of 43, on Ihe slotil side and piviiip a hislorr of malaria 
and dyssajery, hut otlienvise in pootl health, was sitting up lato 
ere tn'pht talking to his friends when Im was seized wilh a 
sadden convulsive attack, in which he hee.ame eyanc-'od and then 
eeniatoso. ftr- was seen in the allack by a very aeriirate clinical 
oSserver, wdio noted the total arrhythmia of auricular filirillation, 
eezt inoniinp. when he had olherwu'se quile recovered, this irrepu- 
was still present, thoiipli the speed was onlv 76 a niinuto 
tperhans owing to a do’e of dipilalin wliieh had been piven the 
jugtit liefore). The nejf day .apaiii, however, Iho rliylhm had 
iioTOme iionnnl, there were no physical siptis of disease, and the 
tollowiag day ho exhihUed n nortnol cdectiowardiograin. 

I .ani not going to .nffomiit nliy expl.'Ui.ation of this 
tetrarkahlc story, hut will p.ass to n Considor.ation of tlic 
Stakes-.dd.anis .syiidroirc. Even hero there is room for 
speculation .and diror.sity of opinion .as to the precise reason 
'yhy the losses of eonseiousness that mark this condition 
diriihl occur at the mnmcnt.s when they do. Still, there is 
I'D room for doubt ahont tlie broad facts. The patient has 
a slow pulse, thanks to the failure of Ids anricnlo-vcntricnlar 
voinipxion.s, and that slowing of the pulse deprives the brain 
m Its necessary blood, with the result that there nro brief 
periods of complete unconseiousiies.s. If yon li.avo ever 
vatelipfl these attacks you will agree that the sequonce is 
^ery striking. Tlic patient is talking nntnrally when his 
aee turns 2 mlo, )d.s talk stops, and he falls asleep for n 
second or two. His face flushes and lie comes hack to 
eonseiousness, obviously distrc.ssod and apprebonsivo. This 
apprehension may defeat it.s own ends, for I have known it 
lioioko a doctor into dismissing the whole thing as an 

• ack of “ nerves ” demanding no other therajicutic 
■easnre than rousing advice. In this in.stanco, as in somo 

1 ^ condition wn.s sensibly alloviatod, though not 

• 0 islied, hy atropine, which lifts the inhibitory' action of 
e r.qgns off the aiiriculo-vcntricniar connexions, and niav 

urns save the staggering came! from a broken hack, 
nnf ” I " ‘"’^'^1 howeyor, it is safe to sav that when a 
he '^1 afraid ho has a had heart because 

(, tvouhlcd by faint or giddy turns, lie niav he reassured 

loss menacing than that 

"inch ins feai-s have suggested. 


O. J'AtX. 


stiiilv c timely address' on the cl 

of b 31 more respectful considci 

patient s description of In's sensations, espocia 


view of tile limifntions of pliysieal diagnosis. Kowliorc is 
this hotter oxeihiilified tliaii in the realm of cardiac disease. 
Often tho patient’s account of. his attacks rcndcr.s it 
certain that they are duo to organie disease of the heart, 
whatever tho resn/f.s of [ihysical e.xainination. By iv.ay yf 
o.xainplo, let me (junto tho words in which a man approach- 
ing 60 years of age rceently de.scrihcd to me tho attacks 
which lio had cxpcricimcd for some six months. 

After telling mo how regularly flieso attacks recurred at 
certain moments in his day — ^for example, nfter walking sixty 
Yards from the point at which ho alights from the bus that 
brings him home from liiisiiicss — and adding tliat at first lio 
llioiiglil it’Was indigestion, hcc,au.se exerlioii' directly after a nieai 
hroiigUt it on, lie went on to say that the onset of the attack 
was itccomp.anied Iiy tiie sensations associated with painful emotion' 
— for exaniiilo, the reception of had ncw.s, “ I know when it is 
eoming,” iie told me. " 1 linve a sort of uncomforlablq feeling 
ns if somctliiiig wore growing in niy chest, or as if something wero 
suppressed Ihero. It makes mo go slow, and I have to take short 
steps. K I do this it gets no woisc; hut if I were to hurry' — 
I couldn't hurry! — a very violent pain comes on licrc ” (poinlmg 
to tho iimer end of tho lliird and fourth left inler.spaccs) “ liko 
iieiir.algi.a. It makes mo liroak out into a sweat. Tliero may lio 
a tingling sensation, not severe, down tho left arm. It is 
gradually relie.ved if I stand .still.” He added that these sensa- 
tions were not accompanied by nausea or faintness, and that ho 
did not think any oiilookcr would guess that anything was amhss 
with him. Kxamiiintion discovered Httio lieyond a soft systolic 
murmur at ihe apex, tho sounds being rather weak. His blood 
pressure was 165/75, nml Ids vessels were normal Iq touch, though 
the retinal arteries were distinctly lorluons. The urine was normal. 

Now that is a common kind of attack. It is customary 
to think of it ns analogous witli tlio painful limji that 
sometimes reveals tho preseuco of sclerotic changes in tho 
crural vessels, and on this analogy tho syndrome has been 
Inliellod “ iscliacmia cordis intermittens ” (Bischoff), .and 
nserilied, on adequate grounds in iny opinion, to coronaiy 
sclerosis. It is well to explain to its victim tli.at Nature 
has set a limit to his nctivitic.s, and lips been considerate 
enough to provide him with an niitomnt'ic check to prevent 
him from attempting indiscretions. Caffoino or dinretin, 
with or without a small doso of potassium iodide, will 
nearly always decrease the liability to tliese nttacks. For 
the immediate relief of tho pain there is nothing liko tho 
nitrites. Nitvoglvccrin is, I believe, tho best of these for 
hahittml use. 'i'ho liquid form is more active than tho 
t.abella, c.spccially if a dose of not less than 5 minims be 
I given in combination with carminatives, such a.s capsicum 
and cardamoms. I’orsous with tin's degr(?e of pain may 
enjoy a fair measure of activity for years if only- they will 
rccognir.o the iucxor.ablo nature of the limitation imposed 
on them. AYbcn it is associated — ns so often it is — with 
a high arterial tension, great relief is often afforded hy 
a relatively small dccreaso in pressure, such as may ba 
secured by reduction of diet and stress, with little or no 
medicinal treatment. 

That wo do well to p.ay heed to such a history as this is 
exemplified by the following case. 

A man, first scon at tho ago of 41, said that for four months 
ho bad boon troubled by pain in the left chesi and arm down 
(o tlio fingers, coming on wilh exertion — ^for o-xample, walking up 
a slope — and relieved by rest. The pain in the chest was like 
a pressure. His arteries wero thicker tliau tlioy should have been, 
and his blood pressure was 180/100 in tiie ieft arm, 170/80 in tho 
right. Apart from a ringing accentnntion of the aortic second 
sound I found no abnormal physical signs. His electro-cardiogr.rm 
appeared normal, tho ai-ray screen discovered nothing beyond 
somo widening of the aorlfc shadow, and the IVassermann test 
was negative. I saw him from time to time, and his doctor and 
I wero gradually convinced of the ■ serious nature of his -troublo 
because wo found that no treatment was able sensibly to relievo 
him. About a year after lie was first seen a faint aortic diastolic 
murmur became audible, and a few months later he died suddenlv 
in an attack of severe pain. 

By way of contrast let mo give you a brief account of 
two patients who died ■ in or immediately after tiicir first 
attacks. 

One, a commercial traveller, aged 72, never ill before in his life, 
was taken ill about 10 a.m, at a country station twenty miles 
out of Bristol. Ho was seized with intense gripping pain, wliich 
began in the left side of the lower jaw and spread to tho ’eft 
arm and epigastrium. He felt loo ill to go on with his joiirnev, 
and came home. All day the pain persisted, and when we saw 
him in the evening ho looked pale, wilh bluish lips, and was 
obviously distressed. His cardiac sounds were weak, and there 
was a systolic murmur all over the precordium. There was a Uttia 
oedema" over the shins, but the liver was not swollen, nor wera 
rales heard at the bases. His pulse was only 72 and quite recnlar 
and his blood pressure was 150/80. While "we were preparing to 
give him morphine ho sank on his knees— we had been unabla 



1012 Juke i6, 1928] 


HEART ATTACKS, 


f Titn nnm^K 
IfruiCAXi JocRifUi ■ 


to persuade liini to lie down — cried out iliat the paiP was unbear* 
able, and pitched over on his face dead. His pulse beat at 72 till 
it stopped. ■ 

Tlic other patient was a clergyman, a very hard-working man 
of 60, whose doctor was called in ciglit days before vre saw him 
logether, on account of an attack of severe epigastric pain, in 
which he felt as if he were going to die. Tlic P^iin was not 
I elated to food, but he was belching wind and vomit ing mucus. 
It all passed off, but the pain recurred once or twice, and in 
several of the attacks extended inio the arms, tlic riglit more often 
than ihe left. On examination we found nothing indicative of 
cardiac disease, except that the first sound at the apex was 
occasionally doubled, but the cardiac natuic of the pain was 
proved by his sudden death a few days later. 

All these case-histories emiiha.size the diagnostic signifi- 
cance of the pain as described b}- the })atieiil. We nui.st bo 
prepared to recognize the cardiac origin of a pain oven 
when there is little or no objective evidence of cardiac 
disease to be gained by the most careful examination. At 
the same time it must be realized that .^igns of cardiac 
disease may accompany or follow an attack of jiain. As an 
example of the former I may quote the following case. 


A man, aged 37, is now under my care for aortic incompetence 
of syphilitic origin, on wliich it is probable tliat a slow endo- 
cardial infection has been engrafled. He has had several attacks 
of pain coming on without the least provocation, and described 
by my house-physician, Dr. J. C. Balt, as follows • 

“ Marcli 22nd, 1928. The patient was Iviiig in bed when lie 
was seized with a pain in the right shoulder. This pain came on 
when he was lying quietly in bed, and .at the time there was no 
exertion. The patient drew Inrnsolf upright and was then con- 
scious of a sensation of rapid palpitation over tlic precorditim. 
The pain in the shoulder was described as kiiifc-likc and stabbing, 
and spread over the precordium and all down the left side as 
far as the ilium, but no further. During the attack ho bad an 
expression of intense agony on his face. The whole affair was 
icbeved in about two minutes by amyl nitiitc. Sfiortly after Ibis 
the pain, etc., returned with equal severity about twenty minutes 
after the amyl nitrite liad been given, but on repetition of this 
drug relief was once again afforded, with no icturn of the pain. 

Annl 3rd (9.30 p.m.). The patient was sleeping after * his 
lost daj m hospital when he began to dream that sonic horses 
were chasing him. Just as he was about to fall over a cliff to 
escape them ho awoke with violent pain in the precordium. He 
sat up in bed with a ‘pained expicssion’ and placed his riebt. 

H pain radiated to the reft 

through to the back of the joint. Throughout the 
m, -j dyspnoea and the pulse rate went up to 124. 

iv), moved because tlio pain was apparently 

too se\ero m the shoulder, wliich during the attack *^was too 
tender even to be touched. Amyl nitrite again gave almost 
instant relief. The whole attack 'from time ®ot wfSfg laTed 

sti*ing%{i;?o“^“h"ht.S" - like^t^rfo 

His electro-cardiogram, taken by Dr. Bruce rorrv shows 
chanps vei-y suggcsl.vo of gross disease in the coronal vesSs 

att.ick o^cardfa ^ v'f syndrome consists of a severo 
a day or so bs followed in 

wall^of the heart ' Tim >««souIar 

attacks of pain boks 

obviously intense. Hsuallv "'it iT ’’’ 

Ijoliind the xipldstern, n o .d ';o'<!o™al, sometimes 
In some cases there is vomitinc '^’'“•“otor. 

location of pain, may insnirf’-,' p * P" opigastric 

Either at the time/ ol wHbi.l^ oolie. 

becomes rapid, often alternating ‘and ^somer"'’’ 

nith the total arrhv-thmia of m.rimda, ’n 

hasty action of flutter. If it remains ^'’"Upf'ou or the 

in systolic pressure is often noted wUh" f»" 

rednetion of tlie pulse pressure ’Th„ 1 oo^osponding 

found to be wealt and lantm’ir,g nd oT* 

friction is Iieard for a day or two’. The f * P^uaardial 

rises for a few davs, and tlicre is a leim “f ure also 

Mig and eharacto'ristic changes in the "e'le^r'*' 

Often follow in those who suivh e a„d 

Oil valiio 



■\VIinl i.s Iho connecting link hotwccii all these varieties 
of cardiac pain? To rejily fully to tlii.s would involve too 
long nn argument. Let it siifTieo to sny that evidcnco 
accnimilates in favour of the view that pain of this kind 
depends on intcrforenco with tho supply of blood through 
the coronary arteries to tho ivall of tho lieart, tho severity 
of tho pain vai-ying with tho degree of that intcifcreiicc. 

I niu.st refer briefly to three terms: pseudo-angina, vaso- 
motor aiiginn, and tolincco angina. The fir.st of tliese is, 
I am afraid,, a “ hedging ” form of words. Either a pain 
is cardiac or it is not. Often, it is true, cardiac pain is 
exaggerated and its true eharacter obscured by tho extrava- 
gant iieeoiint.s of it fiiriii.shcd by imnginativo patients. 
All vi.scoral pain is liable to ho thus misrepresented. But 
tho more carefully tho history is taken tho fewer will be 
tho eases of ])soiido-augiiia. Some of them appear to lit 
duo, ns Sir 'J'hoiiias Ilorder* has told iis, to .spasm of the 
ocsoi>hagcaI ciirdia; others are merely attacks of fiiiictiona! 
palpitation doeorated by tho jiatient with an account ol 
pain over what ho believes to bo tho position of liis heart, 
in all easc.s it is well to say to oneself, “ Either this iiaiii 
is enrdinc or it is not, and it is niy duty to niiikc np nij 
mind nhoiit it.” 

V.ssoinotor angina appears in the textbooks, hilt I nnisf 
con fe.ss that I do not see cases of it. Only 0110 can I recall 
that appeared to belong to this category, though occasion- 
ally there are vnsomolor pheiionieiin — acroeyniio.sis and the 
like — ill patients whoso pain is obviously duo to cardiae 
disease. 

Tohiicco angina is, it appears from tho experience ol 
othcr.s, an iiiidoiiiahlo fact; hut in most of tlio cases sc 
dc.serihod it seems to me that tho tohaeco is, at most, only 
partially responsible. 

A profcssionnl mnn consuUod me at the age of 55 because of 
pain behind the sternum, brought on by exertion. I could find 
no evidence of disease, and some months later ho told mo that on 
discontimiing the practice of smoking a pipe as he cycled to his 
work in tlie morning lie had lost the pain. Two or three ycai's 
later, however, he told mo that he still got tho pain if he went 
out after dinner to meetings This he attributed to the smoky 
atniospherc. Once or twice he had runs of tachycardia. I saw 
him at the tail end of one of these, and it appeared to be n true 
paroxysmal tachycardia, but I had no opportunity of verifying 
this liy graphic record. Eventually it was proved only too clearly 
that something more than tobacco was responsible for his attacks, 
for he dropped dead without warning. 

4. Dysi>noi;.\. 

As regards nttaek.s in, which dy.spiioca is the chief feature 
I will nioiition two varieties only — ■'the so-called cardiac 
asthma, and acute oedema of the lungs. 

The term “ cardiac asthma ” survives merely because no 
one has invented a more coiivciiient one. It is cardiac, but 
it is not nsthina, unless we decide to include within that 
word every kind of paroxysm of breathlessness. Tho cir- 
eunislances under which the attack occurs are remarkably 
uniform. Ainoiig the last twenty patients seen in private 
practice for symptoms of this kind all hnt one have been 
men, and only one of them under 60 years of ago. In 
every instnnee tlio attacks have occurred at night, in two 
only by day as well as by night. In three-quarters tho 
blood pressure was high, and in several of the others there 
was reason to think that it had been high and was now 
reduced only by having brought about ventricular defeat. 
That, indeed, is the outstanding fact about the clinical 
picture; it is the clinical picture that is associated with 
ventricular defeat siiperveuiiig on loiig-eontiinicd high 
arterial tension. There is evidence, of hypeitropliv of tho 
left ventricle, hnt there is also evidence that in spite of 
its hypertrojihy tl>e ventricle is no longer capable of sus- 
taining an adequate circnhition even while the patient is 
at rest. Consequently oedema is a common symptom. I 
noted its presence in eleven of these twenty iiatients. 
Cardiac pain, on tho other hand, is usually absent, or at 
all events not a prominent feature of tho attacks. Tho 
heart .sounds often betray evidence of ventricular failure 
in the shape of enfeebloineiit and gallop rhythm. Six of 
the.se patients showed signs of auricular as well as of 
ventriciiiar failure, the rapid irregular rliythm of the 
former contributing to tho completeness of tho latter. In 
&ix of the fourteen with a regular rhythm there was 
alternation of tlie pulse. 



JUKF. lO. IQlS] 


HADIOGRArnY IN OBSCURE DENTAL BEBSIS. [mS.c.^S*i. 1013 


Altlio\i-'li Uiis is ilic fully dcvoloprcl liiuUgrouiul of flipsc 
nttncks thov i))nv iirvortlu'Irss con^Ututo tiu* first \uirning 
of son'ous ili^oaso. It is .M)on iiftor goUnij; into bed llmt 
the luifioiil is coiiscioiis of (ly.spiioi-n. Oftoii it wakes 
Old of sleoj) aiif] keojis liilii from dvojiliiug ott ugatn, for 
as soon as lie does ro ho is soir-od hy the thioatj so io 
sneak and aiiiiaveiillv threatened with innuinoiit suffoca- 
tion, often iif tlic foi'm of terrifying dreams, lie cannot, 
lie down in hod; froqnontly it is impossihlo oven to rest 
.against a b.aiik of iiilloiv.s, and he has to sit up in an 
armchair. Sometimes even this iloes not Mifhee, and lio 
has tried to find what rest ho can hy leaning forward with 
his head pillowed on his arms, on the hack of a chair, or on 
a bed table. Indeed, one of tho essentials in treating thc.se 
attacks is to make provision, hy nioans of one or other of 
the.se .supports, for such small mea.suro of comfort ,n.s i.s 
left to the unfortunate victim. I donht whether there is 
any more distres.sing ex]>eriencc that falls to the lot of 
mankind than this, and it is most tantalizing to ho able 
to offer so little lieiii. Eoitniiately it i.s one of the many 
forms of agony in which the me of morphine brings relief. 
On the whole ! am inclined to think that the value of the 
morphine is enhanced hy combining atrojiine with it, but 
about tho value of tho morphine there can be no doubt 
whatever. By way of preventing rcenrrence of the attaclrs 
the best remedies to n.se are, I believe, the xantiiino 
derivatives, particularly caffeine and dinretin. In nomo 
instanco.s, when the siijion'eiition of fibrillation has 
precipitated the onset of thc.se noetnrnnl jiaroxystns, the 
use of digitalis may, for a time at all events, decrease 
tho overwhelming load home hy the ventricle and restore 
the patient to comparative eomfort. Otherwise, the chief 
indication is to mduco tho hlood pre.ssiire hy rest, dieting, 
and purgation, if this has not already heou accomplished 
hr tho failure of ventricular output. 

Aento sulfocativo oedema of tho lungs is rare in my 
experience. A brief note of a case recently seen with Dr. 
Paul Hodman, to whom I owe tho nccoimt of the attack 
itself, will servo hy way of desci'iptioii. 

Tho patient, a lngh.strung woman aged 60, had for some 
months experienced pain behind the sternum on exertion, roliovod 
by filoppinp still. Rceenliy she had also iiad attacks of dyspnoea 
at night. In one of tlieso Dr, Bodinan found licr cyanosod, Iier 
face appearing bloated and lioi, wliiic tlio exticmiiics were cold; 
she was iiiicnsoly dyspiiooic, witti buhiding icsniratioa. and was 
cpugliing up blood-stainyd Iluid. Her bead felt full, Iml the veins 
m the neck were not distended. Tho blood prcssuic in the attack 
was 180/110, wild eas at olher limes if wa.s not so liieli ; vet nitrites 
gave no relief. One curious fact .about llio .attack.s irn.s lliat tlicy 
were p.articularly apt to ocettr ou Sulunlays; atiollicr, that i»cforo 
tjie ouset of an attack site often felt remack.aidy weil; and also 
that in the ^tack there was otlcii an imperative call to i-elicvc 
the boirels. The atf.acks scorned io conic on when she bay doavn. 
Site found tliat in an hour or two tiie attack passed off, avitliout 
timcfi help from treatment. tVo decided to give her a course of 
diurelin, aud this was followed by a relatively long period of 
iiccdoin from tile attacks, which relapsed as soon as the drug was 
stopped. . ® 


Dr. Anthony Birrcll, who has lately published at 
account’ of some cx.aniples of this syndronie, ii.as foiini 
that venesection brings relief from the attack. He note 
that the blood flows centripetally — that is, from the open 
ing in the vein on the distal side of the incision. Thi 
observation may nitim.atcly prove significant in determin 
mg the nature of the attacks, the clinical background o 
vv ncli apjiear.s to he t)io same ns tliai of cardiac asthma 
une or two lessons emerge front a study of cardia 
attacks. J lie fir.st is the immense importanec of listenini 

0 what the patient lia,? to say; after all be has beei 
through the mill and may therefore be preMimed to knov 
some ling about it. ]t,ven if the attack is obvionsl' 
timetional it is probably the .source of inueh anxiety am 

istress for there is something inherent in cardiac sens.n 
tions of all kinds that appeals vividly to the instinct c 
*1-1' / 1 '*^ ' harm may be done bv an nnsvmpatbeti 
a itnde towards patients of this class and it is especial! 
miportaiit to avoid even the use of the word “ nerves J 
Uii the other hand, I Lelieve it i.s oven ivorso wistnk 

1 ^ patient whose attacks are really serioy 
T talking to him about sudden death. Usually Im is onl 
tot) well aware of the danger.? that tlire.atmi iiim, and i 

than good if the apprehensions that no 
mnaturally beset him are reinforced ratlier than allavoc 
the patient s .age is significant. Attacks due to orgaai 


heart di.se.ase are rare in young subjects, while those that 
are symptomatic of fniictioiial disorder are common. Coii- 
verseiy, cardiac .attacks .arising after 40 arc rarely func- 
tional" in origin. In a majority there is a ha.sis of organic 
disease, oven though this may ho overlaid hy a super- 
structure of functional iionrosis. It is in cases of this kind 
that one lias to he most careful, e.speeially as the patient’s 
relatives, to say nothing of one’.s own inclinations, are apt 
to urge a diagnosis of “ nerves.” I iniist confess that I 
know of no golden rule hy which errors of thi.s kind may 
ho avoided, except that which applies to every branch of 
diagnosis — namely, that of taking tronhlo over it. 

In conclusion, it must he admitted that mi.stakes aro 
hound to occur, and we must learn to take risks, alw.ays 
hearing in mind that it is the duty of the doctor to 
con.sidcr tho .safety and wcll-heiiig of his patient at tho 
e.xpcnse of his own reputation. 

nuTtirxrr.s. 

■ C.v1U : (Ifpli Oipril. <• iMIr Clin,, 1927, xlviii, Xo. 2D. 

’ Mnekenzic : Antjinn Pfctvrif, Oxfori] Mfilicu! Pnlilications, 1923. P.92. 
’ rarkiliFun anil ' bislford : Quart. Juurn, Mrd.. 1927, x.vi, 22. * Chrifct 
ami Drown: Anirr. D.mrii, J/rrf. Sri., 1928, i, 336. ® CoUoii ami ^;vvis : 
Ilcnrt, vii. 25. *n\lo: Jirihrh Mrilieni Jnurnal, 1928, i, 537. r rarkin.-'-'fii 
ami llviUata- t.nurri, 1928, t, 4. ‘ Itmlcr : Medical iVotri, O-vtoril 
Mdlical i'uhUcaiiotn, 2921, I>. 57. ’ilirrell; Mrietol iled.-Chir. Joitrrt., 
1928, xliv, 239. 


©Iisrrlrattons 

0!f THE 

VALUE OF RADIOGRAPHY L\ THE DIAGNOSIS 
OR OBSCURE DENTrVL SEPSIS. 

(TTif/i Npm'n? Plafc.) 

vs 

JAMES F. BRillLSFORD, AI.B.Bin.vf., AI.R.C.S.E.vc., 

Qvrw's nosriTAi,, bhiuixcimm. 


The value of radiography in tho diagnosis of obscure dental 
sepsis is now universally recognized. Physicians who, pre- 
viotis to the discovery of x rays, had urged that many of 
the " rheumatic ” group of diseases (arthritis, fibrositis, 
myositis, nonriti.s, and certain forms of heart disease) 
wore dne to dental sepsis, were faced with the .argument 
that those patients with the most obvious dental sepsis were 
the patients who suffered least from these diseases. Vfhen, 
however, it hccanio possible to demonstrate on a radio- 
graph deep-seated and unsuspected lesions, the piiy.sicians 
were able to .show tlint thc.'o “ rheumatic ” conditions, 
which had not shown the slighte.st rc.sponse to other forms 
of treatment, were ciiicd or their progress checked hy tlio 
removal of the teeth shown to he involved. 

Jtost medical men are familiar with the oh.stacles which 
these early vvorkers had to surmount, not only from tho 
members of onr own profe.ssion, but also from tho dental 
surgeons, who were not prepared to sacrifice iisofn] and 
” comfortable ” teeth without more evidence of their 
dangerous character. 

Patients siiircriiig from dental sepsis may he roughly 
divided into two groups ; (a) those in wlioin" the sepsis is 
associated vvith local pain; (b) those in whom the sepsis 
is unassociated with local pain. The patient helongiiig to 
Group (o) nsiiaiiy makes the earliest appointment with 
tile dentist, and in the majority of cases he is able liv his 
clinical examination to detect the sent of the pain, "in a 
few cases, ev'en after a thorough exaiiiiiiatioii, the cause 
of pain may not he detected, particularly as the patient’s 
localization is so poor, and frec|uentlv' tho pain mvsterionslv* 
ceases before or while the clinical tests are being applied 
and cannot he elicited bj' further testing. This may happen 
on several occasions. A careful radiographic examination 
of these cases may reveal tiie cause in the form of hidden 
or deep-seated caries, and save the dental surgeon much 
time and annoyance and tho patient much pain. The 
changes rci’ealed by the radiograph may be obvious or 3-ery 
slight, hut even so it may afford the only clue to the site 
of the p,ain. It is, however, chiefly with patients in 
Group (ft) that the radiograph is of tho greatest value 
because the lesion is often niisnspected by the patient and 
frequently is not, and apparently cannot be, detected by 
the most carofiiliy applied clinical tests; and it is not until 


1014 JUNE l 6 , 1928 ] 


EADIOGKAPHY IN OBSCURE DENTAIj SEPSIS. 


[ Tiir Jmmijf 

Ur.MCAL JOCKNU. 


tlio physician or surgeon finds signs or symptoms of a 
diseased condition iviiicli he knows to ho generally- duo to 
absorption of toxic products from septic teeth that tho 
teeth are radiographed and tho lesion demonstrated. 

There would appear to ho a very groat difloronco of 
opinion amongst dental surgeons as to the siguificanoo of 
the radiographic findings. It is theroforo advisablo that 
the radiographs ho interpreted by an unbiased observer. 
■Some still attach no importance to any radiographic appear- 
ance, however gross, if the teeth aro comfortable and appar- 
ently sound; others are prepared to treat lesions which show 
on the radiographs as dark areas (light areas on tho prints 
made from radiographs as in tho accompanying illustra- 
tions) of absorption of tho periapical tissues, but do not 
feel justified in “ sacrificing ” useful and comfortable 
teeth solely on “ slight ” radiographic evidence. Experi- 
ence has now proved that tho extraction of such teeth 
often relieves the symptoms of tho patient, and Price 
states that when such teeth, or cultures therefrom, aro 
inserted into experimental animals tho latter die of toxic 
absorption or infection. On the other hand, somo dental 
surgeons go to the other extreme and extract teeth tho 
best radiograplis of which show not tho slightest change. 
Yet Price says ; 

“ I wish to stress that wo have come to tho time when 
involved teeth can he so definitely differentiated from those that 
are not involved or with a sufficient limit of error that we aro 
not justified in condemning alt tho teeth for fear they may ho 
involved. I am seeing continually patients who arc suffering 
more from the inconvenience and difficulties of mastication and 
nourishment than they did from tho lesion from which their 
physician or dentist had sought to give them relief.” 

The important clinical manifestations of hidden dental 
sepsis wore described in 1922 by Dr. Leonard Mackey, 
whoso valuable paper is supported by all tho researches 
which have since been made. 

The RADioon.tPHio ArrEAUANCE or Septic Teeth. 

It must bo clearly understood that tho evidence which 
the radiograph gives is only a “ skeleton ” picture of tho 
pathological lesion. The actual lesion, certainly in bono 
pathology, is always of much greater extent than tlid 
radiograph suggests to an untrained observer. Therefore 
in dental conditions, where tho important changes are 
relatively small in size, it is important to have radio- 
graphs which will ^how these details. Fortunately the 
close proximity of tho radiographic film to tho tooth 
enables a sharp and detailed picture to be obtained which 
will permit of magnification, and as tho danger- of the 
lesion is not to be judged by its size, such magnification 
will not mislead by showing tho slight changes to bo 
definite irregularities. 

The outline on the radiograph of a normal tooth en- 
larged to the size of the radiograph of the femur head 
Is seen to be quite as regular as the latter whereas 
tho outlines of teeth which show “ slight ” changes are 
markedly irregular — a femur head so irregular would bo 
judged to bo gravely involved; 

Weston A. Price, who with a team of dental surgeons, 
bacteriologists, and laboratory workers has carried out a 
very extensive investigation on dental sepsis, considers 
that 10 per cent, of the teeth with septic roots give no 
indication of this on the radiograph; but even so most 
of tho process illustrations which he used in describing 
the ” failure ” of the radiographs show definite though 

slight” changes, yet process illustrations cannot give 
the detail of the original radiographs. ° 

There is no doubt in my mind that the figure of 10 per 
cent, can be considerably reduced by the skill in the 
radiographic technique and the care exercised in examin- 
ing and interpreting ■ the radiograph. Further, 1 am of 
the opinion that, every tooth which is producing systemic 
disiurhance shows definite changes on the radiograph 
Tho importance of this is apparent when we remember 
thiit tho clinical tests, oven when skilfully employed, may 
fail to reveal quite extensive lesions. ’ ^ 

Burchard and Inglis state that “ In cases of granuloma 
or blind chronic apical abscess there may bo no subieetive 
or locM ^mptoms of disturbance cognizable to patient or 


A patient suffering from a toxaemia was sent for an 
■ a:-ray examination of her teeth. She was annoyed at the 
suggestion that her illness was duo to her teeth, and 
informed mo that sho paid regular visits to her dental 
surgeon, who had recently carefully examined tho teeth 
and reported them to bo quite sound. (See Fig. 1.) 

Price, who has made an exhaustive study of the indi- 
vidual and family clinical histories, clinical, radiographic, 
and bacteriological examination of tho teeth of 681 selected 
cases ill a series of 1,400, has classified patients into tlirco 
groups. Ho says that dental infections tend to jiroduco 
tho same typo of tissue reaction around tho teeth of 
different members of the same family. 

Group A . — Tho radiographs of the tcelh of this group of 
patients show very extensive rarefaction around all the involved 
teeth, and often extensive pyorrhoea (as in Fig. 2). He 
regards this local bone absorption as a sign of a good reaction 
and resistance to tlio infection on the part of the patients. 
Such patients, ho says, rarely show symptoms of the rheumatic 
or dcgeneralivo disorders, and ho .accordingly classes them 
as having “ absent susceptibility.” Ncvcrthcle.ss, such p.atients 
come to hospital complaining of gastro-intestinal or other dis- 
orders probably brought about by the septic teeth. Clinically 
the gums show discharging sinuses, and the teeth are often 
loose, readily anaesthetized, and easily extracted ; the sockets 
Ileal with great rapidity and without discomfort or secondary 
infection. 

Group B.—ln this group of patients the radiographs of the 
teeth show similar changes to those in Group A, but the peri- 
apical areas of rarefaction are bounded by a zone of sclerosed 
and therefore denser bone (as in Fig. 3). . He regards this 
sclerosed bono ns a sign of breaking down of the local 
resistance to tho dental sepsis with tho entrance of the septic 
material into tho blood stream. Clinically there are signs of 
old fistulao and a history of former tenderness. An.iesthesia is 
less easily produced in patients in this group than in those in 
Group A. The teeth frequently are difficult to e.xtract, and the 
sockets do not heal so readily. He says that these patipts 
had acquired a susceptibility to the dent.al infection, and that, 
wliile no rheumatic symptoms were seen when the condition 
was acute, such symptoms had begun to appear, .and they 
cle.arcd with tho removal of the septic teeth. - 

Group C.—Tho radiographs of the teeth of this group show 
condensing ■ osteitis around tho infected root with little rare- 
faction (as ‘in Fig. 4). This appearance he regards as a sign of 
lack of local resistance to the dental sepsis. Clinically there is 
no evidence of fistulao; the teeth are seldom tender. They 
appear to bo more liable to caries, but are usually free from 
pyorrhoea. Anaesthesia of such teeth is -far from easy, and , 
they are often very difficult to extract. There is great tardiness 
in healing, and the sockets tend to become infected and pamfuL 
Price s.ays that these patients have an inherited susceptibility 
to the rlieuraatic group of disease. 

This classification tends to explain why somo patients 
with extreme and obvious dental sepsis have often few of 
tho symptoms usually associated with septic absorption, 
while others with marked rheumatic symptoms have often, 
no obvious dental sepsis, and the radiographs of their teeth 
show relatively slight changes— so slight that when indi- 
cated by tho physician or radiologist tho dental surgeon is 
loath to e.xtract tho teeth; yet it is often in patients with 
these “ slight ” dental lesions that extraction produces 
marked beneficial effects. As these important indications 
are rel.atively slight it is all tho more essential that tho 
radiographic technique should be good. 

Most physicians will agree that these dental groupings 
aro correct with regard to tho susceptibility to rheumatio 
infections, but few, I think, will agree with tho ideas on 
local resistance. 

An examination of the radiographs showing bone sepsis 
of different types permits of tho classification into three 
groups which resemble those indicated by Price. 

Group (o). — Patients with bono sepsis due to pyogenic 
bacteria. The radiographs in these eases show rapid absorp- 
tion or erosion of the infected bone, and frequently a large 
amount of pus is found. As the condition of the patient 
improves and his resistance is increased the rarefied bone 
increases in density and the p.atient shows little or no sign 
of rheumatic disorders, even tliough the degree of septic absorp- 
tion, as judged from the patient’s condition, was very severe. 

Group (li). — Patients who formerly showed radiogr.aphio 
changes similar to those in Group (a), but,. owing to the separa- 
tion of sequestra or the inclusion of some septic foreign ,0 y, 
healini; is very slow, and the radiograph shows that 1 1 


JUKE iG, 192S] 


J. P. BHAILSFOKD : RADIOGUAPHy IN OBSCIIRP DENTAB SEPSIS. [ 



Fio 1.— UadioRraph fliowinp larRn " cyft " (prolialily 
arisinp from llio root nilrd lilcuapl(i) wliich lias ormlcil llio 
apices of thn first bicuspid, canine, and central and lateral 
incisors. I’alicnt bad no local physical siens or symptoms, 
but a losacmia which cleared on c-ttraclInR teeth. 



Kifi. 2.— nmIio;?r.iph fhowinir extensive alveolar 
and periapical ab*orption. 



Fig. 3.— HodioprsapU fbowlnp a large 
apical abscess with sclcrosig of its bony 
wall and erosion of the tooth apex. The 
lateral incisor is root<niIe<l and there is 
a little erosion of its apex. 



Fig. Radiograpli showing small areas 
of rarefaction at the apices of the bicuspid 
and molars with sclerosis of the surround* 
Ing bone. Potient sulTcrcil from pains in 
the hack and along the course of the sciatic 
nerve a« well as in the shouldcr*jolnls. 



Fig. 5.— Radiograph of molar with ono 
root filled with opaque material, the other 
showing no sign of a nerve canal. There 
is sclerosis of the pericemental bone and 
secondary carles beneath the amalgam 
filling. ’ Patient suflered from neuritis, 
which improved on removal of the tooth. 



Fig. 6. — Radiograph showing retained Fic. 7. — Radiograph of incisor teeth showing 

stump with large abscess. destruction of the pericementum around the 

apices of the central and lateral incisors and 
extensive destruction of the cancellous bone 
around. There ia no definite boundary to the 
destructive process. Note the pulp stones in the 
central incisors. 




Fig. 9.— Radiograph showing “ bulbous ’* 
roots to root-filled molar with periapical 
absorption. 



Fig. 10. — Radiograph showing large area 
of periapical absorption with erosion of the 
apices of the first bicuspid, which shows 
secondary caries beneath the filling. There 
are similar but less marked changes in 
tlie second bicuspid. 


JUNE i6, 1928] J. F. BBAILSFOKD : EADIOGEAPnX IN OBSCURE DENTAL SEPSIS. 


t Tmc CRmss 
Mzdich. JoimzAi 



Fig. 11.— Radiograph showing 
sclerosis of the pericementum due 
to the large filling and a normal 
antrum. 



Fig. 12.— Radiograph showing 
rroMon of the wall of Iho antrum 
uiul <»f the appruximatcd rfK>t-fiHcd 
iucu''pid nericoinontmn with dim- 
nung of the antrum. 



Fjc. 13.— Radiograph showing 
apical absorption around centra! 
incisor, not sliown on "flat"^ 
rndiograpli. 


[i 


; i 



Fio. 14,— Radiograph showing root- 
filled lateral incisor and canine. 
On the bicuspid side of the canine 
the pericementum will be seen 
pushetl away from the side of the 
middle of the root. There is mathed 
erosion of the apices of both teeth 
and very little root-filling, which 
shows signs of shrinking and 
retraction. 



Fig. 17 . — Radiograph of root-filled 
upper molar teeth, showing re- 
traction and shrinking of prepara- 
tion in anterior root and erosion 
and absorption around the distal 
root, which shows calcareous de- 
posits. The floor of the pulp 
chamber had been perforated, and 
a deposit of calcareous material is 
shown on the projecting root -filling. 



Fig. 15.— Radiograph of root- 
filled lateral incisor and canine, 
showing retraction and shrink- 
ago of the root-filling prepara- 
tion. The nerve canals are 
shown to be much wider in 
calibre. There is also an area 
of rarefaction of the periapical 
bone of both teeth and erosion 
of the apex of tho lateral incisor. 



Fig. 18. — Radiograph showing root- 
filling in bicuspid roots; the filling 
projects beyond the apex in one, 
and an area of rarefaction has been 
produced in the surrounding bone. 



Fjg. 15.— Radiograph showing 
marked shrinking of the root- 
filling preparation and septic- 
erosion of tne apex of tho tooth. 



Fig. 19. — Radiograph showing* 
root-filling in bicuspid roots with 
areas of apical erosion and absor^ 
tion. A small fragment of an" 
instrument had been broken at tne 
ape.x of the root and is li’ing 1 
the rarefied area. 



jusn iC, loiS] 


nAWOGRAPHV IN OBSCURE DENTAL SEPSIS. 1015 


MHTOiiniiim? imno is sclwftsctl hikI v.’iy ilciisf. i Ins m-Ut(i.si.s 
ino.sl of us loiil: upon us of f\ic uaUuo of » pidtoc ivc roiulimi 
ncninsl a oUiouic infirtiou, nmt not as a l.i'ralulowii iii llie 
itsistanco of Uic natiolil, tlioiigli Midi (latiaiils ofloii <!« 
Rtailually (Unvlop ilunuualic syiiiptoms. tluc pnilnilily In Hit- 
long iK'i'ioil of slow septic alisoi'jilioii. , . 

Croup (r).~P.aficnts sufleviiig from imnspemfn- ■mfectnw 
avUiritis. The ladiogiMplis of ilic iufi-oti il joints ilo not suggest 
ordinavv Imne sepsis: rarofartinn, erosion, ami sclerosis may lie 
seen, ljut the rhanges .-ivc .slow to form. Thev lesenitile Urn 
changes in the leetii of Gronp C. Nnineroiis liaeleriological 
researches have hccn made to attempt to di.srover tlie e.iij.sal 
organism; various organisms have hern .suggested, lull the lack 
of nniformitv in the fnulinga suggest.s tlial the eonditioii is 
pioc'iiced eitiier hy dilferenl organisms or hy some haeteria or 
toxin which has not heeti discovered. 

Price lia.s .shown that septic teeth from jiniients in this 
grouji, even when hoiled, retain .some toxin whiih is fatal to 
oxpci'ijiiCJtt,’il .’iniinal.s. Ilo found, too, llml I'xtvnits Iron; 
such teetli jiassod 1111011011 a Jlerkefchl liltcr are nhso toxic 
to nninmis. 

One of the most important point.s that Prire has hroiight 
out is that the se|)tie teeth froin whieh nhsoriition is tiihing- 
plaec in jiatieuts with an inherited snseeptiliility to ihe 
rheumatic and degenerative di.soi'deis ]ii'Ofliiee very little in 
Ihe way of loe.al elinie.ol .signs, which arc siiiall in tnaginttid';. 
The fact that tiic patient has edeiitnhins gviiiis doe.s nut 
exclude the po.ssihility of hidden dental si'psis. U is n 
fairly common tiling to find that mkIi luitienls have a 
retainon stump whieh .sliow.s- marked periapit.il erosion 
indieative of .sepsis (as in Fig, 6). An r-ra\ examination 
may show definite evideiiee of .apical .sepsi.s of teeth whieh 
lihvc not heen filled and whieh .show no cvideiiee of i iivies. 
hi some casc<3 infection of the periapical area leads to the 
dcveloiimcnf of large cysts, which in tlie iipjiei jan may 
ho mist.ahcu for oxtensioii of the anlrnm (ns in Fig. 8l. hut 
they can lx> rcnilily distingui.slied fniiii the latter hy the 
fact that in the dental cy.st the apices are tlemideil of 
the pericementum, irhere.as with the aiitnim extension the 
wall of the latter appears to he folded around tlie apiee.s. 
Coiiconiitaiit with the periapical erosion liypereemeiitosis 
may oeciir, and the roots may as.siime a hidtjoiis appearanep 
on the radiograph. ..Such tcetli may he veiy didienlt to 
extract. Jn one case recently, where ihe r.'idiogrnph showed 
similar changes to Fig. 9, the dental Mirgooii luul great 
difficulty in e.xtraetilig the teeth, and ho told tlie patient that 
there had heen a mistake in the radiographic report as the 
tooth w.a.s* too firmly held to h.'ii'e heen tliscjiscd. Ilnituikcr 
reports that neuralgia, fnnetioiinl Idindiicss and deafness, 
chorea, epileptiform fit.s', paralysis, cardiac iinivalgia, in- 
sanity, and other ridated eonditiori.s have heen cured hy 
the extraction of hypcrcoinentoscd teeth. In cuiitradiVvine- 
tion to hypercementosis we Imvc erosion of the apices .a.s 
,a result of sepsis (as in Fig. iQ), 'Wlcen the infec-ted apex 
IS near the antrnrn tlie infection m.av imss into the .'iiitriim 
(as in Pig. 12). 

Radiographs with le.ss marked ehango.s are freqiientlv 
seen as lu Fig. 13, wliich sliow.s a large itrca of rnrefnetion, 
due to aeuto infection chiefiy to the lateral side of the root- 
filied fateral inciisoy. Tlio root-filling is not vc-rv op.aqiie. 
It ’y'i! be noted that the selcrosccl periecinental hone i' 

inped out about Italf-way to tbe .ape.v on thi.s aspect, 
and to a le.sser extent on the medial a.spcct of the lateral 
incisoi , Tho area of rarefaction niav not aliravs he at the 
apex of the tooth, since many teeth have lateral canals 
through winch the pencementmn m.ay he infected. 

A r Cl T I , PimimK.SK Tooth. 

‘ " deprived of it.s pulp has lost its 

eonfains within its unfilled 
three dentinal tnhnles (e.stimated a.s measuring 

bioiwht • length) dead organic matter which is 

threfenr '^“■^'dating hlood through 

i^en foramina, it i.s liahle," even if sterUo 

orsanisms o^'tirpatcd, to he infected hy any 

that ev \ 'fi the blood. It h.as heen shown 

Y V? T’?- e^t'^'idod a cinartev of the 

sooner the dentine towards tho pulp, approximately 

further tksf pnlps of Snell teeth are infected, and 

and the lice impossible, with tlie hiost .scrupulous care 

e use of- the best known bacteiicldai medicaments, to 


be certain Dint the iiifoelioii present lias been eliniiuatcd. 
It is prohahiy very rare for the nerve canals to ho eom- 
plelcdy filled, even tlioiigli Die canal he .sinqile and straight, 
as most Ilf the siihsljinc<-s nsei! cannot be made to fill the 
cauai avcnrately, and owing to ahsorption of the .solveiit.s 
iisiitl in the prep.’imtion the filling eonlraets and leaves a 
space whieh, with the dentinal tnlmles, i.s- iiiiprotrcted hr 
any vital agent.s and i.s liable to become the .stnra.ee pl.aeo 
for haeteria and toxins. Price says; 

*' tl IS to he rrmcmhcri’d lliat a smaii poriion of .-i gangrenous 
pulp hciic.'idi a rool-fillhig is cquiriilcMl to nil ciilirc gaugronoiis 
fillip .as li f.nise of pcn'ccmeiiiitis. The vast luajorily of case.s 
occur as a s^.qijcl to pntrcfactioo of the pulp, either before or 
after instrumciitalioii or as a rccsidt of infection of the apical 
tissue li.v inslriiinents eitber imstcrilized or reinfected by conlaet 
K-illi or.-il fluids, scpiic fingers, etc." 

When the nerve canal is delta-like, or has latoi-.Tl 
openings, the pulp remnants rannot ho removed, nor can 
the caiv.ils he snitahly filled even witli impregnation 
methods. To pel out of this difiiciilty some authorities 
vc'Secl tho apex cif tho tooth. 

Bnclvriolngiral exatninnlion has shomi th.at, no matter 
what ineilicainient is used in the treatment of infoeted 
apires, dressings loft in for forty-eight lioiiix are found to 
he infected, .nid that even when .oil c.Tre Im.s been n.scd 
vont-filted teeth way he a sonree of great rlanger to flic 
patic'iit. Experiment allv it has heen proved that siicb root- 
iillccl teeth limy contain haeteria or toxins which, together 
or separalol.v, piodnre toxaemia and death wlien in.scrtcd 
into aiiiinais. 

Mayo says; 

" AUhongli (lie possessor of a (ootli with dead pulp without 
local re.arlioii may be enabled to eat belter for, a time, ho is 
coiiihicling his beidlb on borrowed capital, a.s be may not bai-e 
a physieitto or denlisl nlio will appreci.-!te that the' diseaso or 
broken liealth (bat may develop is due to sudi an apparently 
trivia! can«e (liiit persons coniparalively well im.ay i.-ilor develop 
a vnriely of di.sease.s ibiit. dcslioy liealth and liappiiiess, it not life.'' 

IVliilo Iiiglis says : • ■ 

“At prrmil >1 looks a.s tbongli no root-filled tooth ran be con-. 
side-red other than as a life risk, srhilc sterile filled roots can he 
infected from oilier sources of infection, of which there arc 
many.” 

i RsPIOOII.CPHIC PlTjF.«.l.S. 

The errors in dental radiographic diagnosis mar be due 
to (o) fiinllv photogr.iphie and radiographio technique: 
(b) misiutorprotntion of the radiograph. 

AVitli regard to («) it can he said that the maniifaeturers 
Iiavc clone their best to produco an o--ray unit which is ns 
.simple in working as anv snap.shot camorn. It i.s common 
knowledge that with eitlier kind of apparatus the propor- 
tion of lilnis of good cpiaUty is dependent upon the care, 
skill, and oxperienre of the operator. Tho simplicitr of the 
apparatus will enable the most ignorant beginner to obtain 
chance snccps.se.s, and these chance snccosses ai-e stored and 
oxhiliited to give a sense of self-satisfaction which tends 
to prevent further progress. It is not to lie wondered at, 
therefore, that marks on radiographic films -duo to fairltr 
tochniquo may (1) Ijo interpreted as pathological changes, 
whicli are not found at subsequent operation, (2) nm&k a 
pathoiogiral lesion wliich is pro.scnt. I Iiave lcnown of a 
mimber of cases in which tho pathological lesion was missed 
Iiecanse the films were fiat. Fig. 13 is an example of such 
a ease. No ainonnt of clinical or pathological knowledge 
will enable anyone to-giro a diagnosis from a faulty film. 

jllirintcrprclotion of the Jindiogrnph. 

This is .due chiefly to: (1) lack of experience in inter- 
preting radiograpliic sliaclow.s; (2) lack of knowledge of 
general and dental pathologv. 

M ith regard to (1) every ladiologist who has correlated 
tho rntIiogra 2 >hic and clinical, operative or post-mortem, 
findings knows that the radiograph may show only slight 
changes even wlieu a massive lesion is present. Thus with 
acute inflammatory lesions of the skeletal tissnes the radio- 
graph mriv give no sign ; eren with the enormous develop- 
ment which one sees in some cases of periosteal sarcoma 
the radiograjih may show nothing abnormal or perhaps a 
little, localised thickening of the periosteum.-. • It can almost 
he said, pariicidarly in acute conditions, that tho more 
attractive the physical signs, the less the radiographic siirns. 


1016 June i6, 1928] 


SOME PROBLEMS OP GLXCOSURTA. 


[ T»t nsms* 
llrcicxt. JocK<«u 


111 the case of dental radiograph)-, as the lesions are often 
small, it is all the more important to pay attoiition to the 
finer details. 

As regards (2) there is no question that for tho he.st 
interpretation of radiographs tho ohserver must have a good 
knowledge of the normal and pathological anatomy of tho 
part. Most hooks dealing with tho radiograiihy of tho 
teeth instance tho interpretation of tho mental and palatine 
foramina and locnli of tho maxillary antrum as .areas of 
periapical absorption, so that these mistakes are hardly 
likely to be repeated except by the beginner; even if they 
are, tho worst that can happen is tho sacrifico of ono or 
perhaps two sound teeth. 

Tho result of tho wide Icnov, 'ledge of tho faulty inter- 
pretation of these foramina has no doubt been responsible 
for the much more grave error which is brought to ono’s 
notice from time to time — that is, tho interpretation of a 
definite periapical absorption as a normal foramen or sinus. 
It would almost seem that the larger tho cyst tho greater 
the possibility of it being interpreted as a’ shadow of the 
antrum. (See Fig. 8.) This is of great importance, hceausc 
the systemic disease from which tho patient is suffering, 
continues or increases in severity as the suspected cause 
has been overlooked and .allowed to remain — there being no 
local signs apparent to the patient or tho clinical observer. 


DiDUOcairnr. 

Burchard .and IngUs : Denial Pathology and Themnnitlee. Ifcnrv 
Kington, London, 1927. 

Co^er, J. F. ; Dental Surgery and Pathology. Longmans, Croon and Co., 

Onadby, Sir Kenneth : Dieeasei of Ihe Game and Oral .Mucont Jlemhrane 
Oxford Medical Press, 1918. 

Hess, Walter; The Anatomy of the Pool Canah of the Teeth of the 
Permanent Dentition. .John Bale, Sons and Dnniolsson, 1925. 

nopewoll-Sniith, A. : The Kormal and Pathological Iliitalogy of the Month. 
J. and A. Churchill, 1919. 

Howe, Percy K. : The Focal Theory of Infection in its Application to Teeth. 
hational Dental Asmc. Jonrn., vii, 1920, 635-641. 

Maehey, Leonard ; Deal.al Sepsis and Apical Infection. Drilith Dental 
Jonrn., September 1st, 1922. 

Mummery, ,r. Howard: The MierOteoyic and General Anatomu of the 
Teeth. Oxford Medieal Publications, 1924. 

Bfioe. Weston A. : Dental Infections— Oral and Systemic. Tlio Fenton 


Publishing Company, Cleveland, Ohio. 
Richert, W. G. : The .Status - - - - 


1170-1178. 


of Pulpicss Teeth. Dental Cosmos, l.xvill, 


SOME PROBLEMS' OF GLYCOSERTA.* 

BY 

GEORGE J. LANGLEY, M.D.Lontd., M.E.C.P., 

nONORAP.V PHYSICIAir, SALFORD ROYAL HOSPITAL. 


Yhe introduction of insulin in the treatment of glycosuria 
has en.abled us to overcome the urgency of diabetic coma 
in a way never before possible, hut many problems remain. 

Can the administration of insulin bo regarded as a 
replacement therapy? There is ranch evidence that such 
IS the case. It is usu.ally recognized that tho rcspiratoi-y 
quotient rises under its influence from 0.7, indicating meta- 
bolism of proteins and fats, to unity, indicating the meta- 
bolism of carbohydrates. Tho glycogen store has been 
shown to increase very materially under its use. The blood 
sugar curve ^tbat is, the amount of sugar in the circulating 
blood-is very materially altered; whereas the adniinistra- 
tion of glucose alone led in one case to a rise from 0.2 to 

0.4, the combined administration of glucose and 20 units of 
insulin resulted in a fall to 0.05. 

Regarding insulin, then, as an efficient replacement 
therapy, we are still left with very definite limitations. 

1. The amount of insulin required depends upon the 
amount of carbohydrate to he^dealt with. 

2. The insulin must be given at the finie of carbo- 
hydrate absorption. 

3. The duration of maximum insulin efficiency would 

appear to be only four hours. : 

4. The preparation must be given hypodermically. ' 

A consider.-ition of these factors at once shows tho very 

serious limitations of this lino of treatment.' ' The dailv 
life of most persons includes four meals, which vary iu 
tliemsclves, and frdm day to, day, as' to their carbohydrate 
content. A complete replacement therapy would therefore 
demand four . doses of insulin, g iven hypodermically, iu 

BrilUh’'Tc^ioal“ and Cheshire Branch of the 


qunntitie.s calculated to deal accurately with tho carlo, 
liydrnto content of each individual mc.al. This is quite 
. impossible, and it is found that patients are very reluctant 
to tolerate more than two h 3 -podcrmic injections daily. 
TIio diabetic patient under insulin treatment, therefore, 
finds himself still limited as to time, quantity, and qiialitv 
of food ; ho must bo on a diet as rigid as heretofore, 
although containing , material previously forbidden; and, 
in addition, must tolerate two hypodermic punctures every- 
day. Two of the meals will bo relatively, generous, wliilo 
tho other two are designed to contain tho minimum amount 
of carbohydrate. 

, There are two schools of thought in tho composition of 
diabetic diets. Ono believes that the best results are 
obtained by keeping the patient on tho lowc.st diet wliicli 
will maintain weight anil strength, and, in consequence, 
•tho minimum possible daily doso of insulin. The other 
.school holds that a generous diet allowing for plenty of 
availnblo metabolic material, with a relatively large do.so 
of insulin, is tho better line of treatment. A careful paper 
by Rabinovitch in tho Qttaricrhj Journal of Medicine, in 
which tho results of about 1,200 cases have been analysed, 
has led him to tho conclnsion that a minimal diet yields tho 
best ro.sults. This is tho typo of conclusion usually arrived 
at by a statistical method, but it is liable’ to omit tho 
human factor. It is a m.-itter of common experience that 
diabetics generally not only have larger appetites in consc- 
' qneiiec of tho dj.seaso, but that they have always liked or 
required quantities of food beyond the average. If this bo 
so, it is po.ssible that treatment including a generous diet 
will be more satisfactory to the patient and bo more likely 
to bo maintained ; ancl it will prove much less irksome 
than treatment along rigidly abstemious lines. It is 
possible that medical practitioners generally iindcrcstiniafo 
tho limitations from which thc.so patients suffer; the con- 
tinued dieting, tho regularity of their meals, and tho 
ever-recurring hy]iodormic punctures, with careful con- 
sideration of any food provided outside their own homes, 
make for a monotony which usually proves hard to boar, 
and the more rigid its limitations tho greater the mont.hl 
load. If insulin can legitimately be regarded as a replace- 
ment therapy, then, in my opinion, it should bo used to 
replace so far as it is practicable; the introduction of 
double strength insulin has enabled this to bo . achieved 
more easily than was tho case when only one strength 

was available. xi 

■ Tho relation of proteins, fats, and carbohydrates in tlic 
total diet offers a further prohlom to which no generally 
accepted answer has yet been found. Anything approaching 
Gio usual proportions of tho average meal in this country 
would involve the use of impossibly large doses of insulin. 
Even tho proportion found in milk (protein 3, fat 4, 
carbohydr.ato 5). requires relatively largo injections, but is 
probably a basis which -yields good results. 

.Ccrt.ain difficulties present themselves in relation to 
groups of cases. Tho man who has to earn his own living 
by h.ard labour obviously needs a more generous diet than 
tho well-to-do woman with no particular occupation. Tho 
dieting of diabetic children offers great difficulty, for they 
must be. given suitable f-ood in sufficient quantity to 
permit -of adequate growth, and they are nearly always 
.severe cases. It has been my experience that no satis- 
factory result can bo obtained among tho younger patients 
unless* three insulin doses a day are given. 

Changes in dieting when tho insulin dose has been estab- 
lished are from time to time necessary, tho commonest 
cause, qierhaps, being loss of appetite which rosnlts from 
some pyrexial illness. There is no doubt, that this consti- 
tutes one of tho greatest dangers to the diabetic to--dny. 
If tho patient does not take the carbohydrate part of ms 
diet tho insulin would appear to become unnecessary. It 
frequently happens that a diabetic patient contracts 
influenza, or some other disease associated w-ith a rise m 
temperature, and is put on a low diet without insulin. 
The .metabolic processes are incrca.scd with, the rise in 
temperature, the carbohydrates being the cliief soiiice o 
heat production; in this resiject the diabetic fails. com- 
pletely, .with the result that the proteins and fats ai a 
inadequately, split, a rapidly rising ketosis occurs, ant 
coma becomes imminent. The occurrence of pyrexia in a 



BO'ME rnOBIi'EMS Oir GriTCOSURTA.' 


r TfrrT!nrrr?:r 1017 
L M> nic%v J^rrvAt • 


June i 6, lo-S] 


fliiibctic is an indication for more insnlin and more carbo- 
livdrale not less. In mv own cases I l>avc found milk and 
ciucosc, u-itli snfficicni insulin to ovoid ocolono in the 
urine, a satisfactorv line of treatment, hut J have nhvays 
had the advnntage'of frequent blood sugar examinations, 
and have fufthet- aimed at keeping tho Idood -sugar u-ilhni 
reasonable limits,' but' at '.the cost of enormous doses of 
insulin. It i.s furtber" tenable that niuch inay bo done to' 
avoid coma bv the administration by the.mouth of -sodinni 
bicarbonate and sodium phosjibate, the action of tiio latter 
depending- upon the fact Ih/ii arid Kodluni phosphate is 
secreted ir. the urine. Jiiirge doses of botli salts can be 
added to each milk feed. 

The CNjiC'-imcnts of Allen with partially depancrealized 
dogs showed that plentiful cavhohydrnle with high hlood 
sugar caused early death, whereas carefully regulated di<“ls 
maintaining a Ion- hlood sugar allowed the dogs to lire 
considcrahly longer. Tlio question therefore arises when ' 
a diabetic with liigh hlood sugar come-s under trealmeut 
wlicther tlie maintenance of a imrnial Idood .sugar level wiP 
permit of any degree of paiicrentic recovery. It is in; 
experience wUli diabetics of middle life tliat if the di' t 
and insniin dose he correctly halaiiccd mid nmintained fo> 
some months the dose of insulin required for the same 
diet does f.dl. hut that the fall is slosv and grailual. No 
c.rse of s;onip!cfe rowivon- — that is to say, with a serioiislx 
ahnorinal response to 50 grains of glucose — has oeciirie.'l 
with sndicient completeness to show a normal hlood sugar 
curve after tre.stmcut ; yet a few ca.scs Imve given lemark- 
ahly satisfactory vosults, ■ more particulavly those avisiiig 
from septic absorption. 

Tho large amount of work on diiibotcs during tiie pa'-t 
fow years ha.s revealed a good many fallacies among our 
cherished beliefs. Most of ns were langlil tliat the dinbrlic 
was peculiarly liable to septic infection, wber,'a-- it is now 
generally rccogui-zed that septic infection is pvoiK> to give- 
rise to diabcte.s. Ilccently a woman, aged 32, was admitted 
to the Salford Itoyal Hospital with a carliuncle of tiie neck 
of seven days’ duration. Sugar was present in tho urine 
with much acetone, and nithongh the jmlient nns not in 
coma she was sutRcioritly sleepy to require runsing iK-ftii** 
she could take ,any notice. Tho slough was ri-morcd froin 
the septic area and the hlood sugar held in check hi 
insulin. At the end of a week it was found that the patient 
could take a diet of over 2,000 caloric.s, containing 85 graii.s 
of carbohydr.atc, without insulin and witiiout tit her gtveos- 
iiria or acetonyria. She wns discharged on a curtailc.l 
carbohydrate diet and witiiout other treatniciit. Anothe,- 
patient, aged 60, was known to have had a very extensive 
fistula ill ano and glycosuria for over (on years. Twu 
operations and a long period of _drc.ssiiig luoduccd a. 
complete healing of the fistula, and the patient was able to 
take, without glycosuria,- a diet restricted in earbnlivdratcs, 
but permitting a vijry fair, allowance of stout. Such chsos, 
pi-osnmably septic in origin, occur, in every diabetic clinic, 
■be origiviatiug sepsis can 

cat(!Jroiy^'°" ‘"® to mo to belong to a different 

llw mo«uf.°''No^!oca\ for soreness of 
tried iritliniif cV .»■ jiallint»vi«; wore 

sZo dotZ Z ’“’een in' robust healtb. 

found to contain-sugS-! ^The -same' dav XT 

urine beinf^' then Inndnd ^tin ‘ ® became unconscious, the 

•th irtv-six Rourn id Xto i .'".'d ■'eelonc. Tl.c coma iRslcd 
inmlfn ReeXery g?adua”nv'’fnsutd'Xd™hr?. 

patient was takiiw a rlicl Af i ^ *’'® 

wicrdi. Ir Alt (L ealqn” with 40 units of insulin 

SuUn lad'to bi cld..anv-'''"i "mamed unchanged, the dose of 
glvXm a uotil at-fb^ iccou, it of recurrent hvpo- 

colw be^taSh whbmft T.. r ■ we'oks.of Areatinent the. diet 

ncetOnuria* At the enrl nf”7 withouL cither glycosuria or 
m^tirsanie diet tu IhL f?"-’'.-* ‘"’’Pnent sbe returned home, 
'^ell with no plvcc«iivia enerpotic and 

proved too rnucli for her self later the fcstivilies of Christma:. 
the «rinrw™"loaded w;t&^ >!«.'•* of fo5?li?e 


d,"t c^lo" not disapti;^! 


r until tiro ' 
adhered to for ^ 


no lapse, and tho patient remains 

■diabetes -irresisfiblo to bcliev.o that 

origin- the • '"’S . 'has an acute and' infcctiv-? 

rirmioi,.^ tl-ese cases suggests it s 

f bis bo so, and they are adcquatelv treated 


from the first, to nvnid .my long period of raised hlood 
Kugnv, which is known to he so deleterious to tiie islet 
tissue, it i.s surely not too iniicli to hope that some of them 
w-ill netiinlly recover cninplefely, and so he saved from the 
dbeaso. 

Tie fca.sihiiity of oiierntion upon diabetic patients , has 
undergone comjilete chaiigo witli tlie iiilrodiiction of iii.suliii. 
The us'u.il metliod adopted is to ' give the '.patient an 
adequate diet end the required insulin dose to maintain 
freedom from glycosuvia for a woe!:. Oh the day of opera- 
I'cn the usiia', purging in preparation is dispensed witli, 
and the pnlicr.t liefore receiving the auacsflietic is given 
50 grams of glucose uud 10 to 20 units of insulin, depoii- 
deiif upon the amount of insulin required for his di'ct, as 
forming an e.slimate of Ihe severity of his jiniicreatic 
dcficiency. Chloroform ' is rnuntonh.a'ndod as ' an anaes- 
thetic, hut cflicr ajiprar.s to be quite safe.- . Past-anaestlietic 
v.mlitii'g nnd tbo geiioral-dietan'-upsct, consequent upon 
(bp anaesthetic, may occasioli .some dilht-ully in dotcnniniiig 
tho required insulin -doso^ for tlie fir.st'two or threo day.s 
after ti.o epeintion, othenvise this procedure causes little 
t .-,->iibic. - ■ 

Some time ago a woman, aped 38, who liad been known to have 
•linbetes for ton years, went into coma and remained unconscious 
for six days, in spite of very large insulin doses. Bbe ultimaiely 
nindo a %-ci-y good recovery,' nnd led a fairly nsefnl.life, taking 
about too unil.s of insulin daily; she wns regarded as a severe ease 
of- di.alieles, A year later slic was seized with severe abdominal 
pain nnd vomiting, and some boni-s later n gangrenous appendix 
was siireessfidiy removed by Mv. ifacalpinc. The patient- took tlie 
nnaesiheiic well, and made a remarkably good recovery- without 
anv signs of rorna. The w-ound healed up well, as in ordinary- 
e.sses. Slio unforlnnatclv developed femoral thrombosis, which 
rotpiircd prtdoiigcd rest I'li bed, but she is still alive and well and 
nldo to le.ad a normal life except for her dietary rcstrietions, 

Ti> uudoi-tnkc n Inp.arotnmy in this particular case 
appeared to ho courting tlisastcr, but very little trouble 
wis rvpei-ioncod from hot- diabclic condition, and 1 por- 
soual-y do not regard diabetes as a contraindication to 
tqior.atiou to-day. 

ft is now generally rccogni-/od that glycosuria does not 
nlwayi iimau diabetes, and renal glycoMtria in tvhich the 
kidney jiassos sttgar w-itli tho tirinc at an ahuormally low 
c'loceiitraiioii ;ii the blood is n fairly common occurrence. 
But tboi-c are throe other conditions tvhicb are perhaps not 
quite so froqnontly- looked for nnd tindoi-stood. The-oeenr- 
i-ouro of sugar in tbo urine after iiieutnl excitement is 
fn'rly c<iinm'«n. It was found in a considerable percentage 
of students during final examinations, and in. football 
te.ani's after exciting and important iimtolicsi and is believed 
to be due to tho physiological inobili-zation of sugar result- 
ing from increased adronnl secretion. ' Dnring the past 
year three cases have coinc under my notice in which tho 
diagnosis botwcon corobral hacinorihage and diabetic coma ' 
had t(> bo inado. All of tlioni wore yery c.xtoiisive ceiebi-al 
Imomorrlingcs, but all tho patients had glyoosiiria, pre- 
■RUiiiably caused by- the haemorrhago, as one of them was 
known not to have bad any urinai v sugar- on the morning of 
the .stroke. The third condition is the frequent association 
of dialictcs with exophthalmic goitre.^ .Iii-thc majority of 
liyperthyvoid cases the tolerance for. sugar is within’ tho 
iioi-inal limits, while in others 'thore "is a 'very definite 
iiitolei-aiicc, with abnormal .rise and slow fall in ‘the blood 
sugar i-ontpiit.' -Tli'cs’c ' cases '■ appear to bo mateiially 
improved, by insulin iroatineut, botli as regards their 
diabetes and tbeir liypertbyroidisiu. 

L,-itely- 1 have had under uiy care a patient with woll- 
iiiarkcd hyperthyroidism, who has ‘a very low lyiial leak 
point and slight enrbohy-drate intolerance. In spite of 
this.-tliveo-qnnrtcrs 'of the thyroid w .as ‘sneecssfnfty- removed 
'by “Air.- jetfersoh witiiout- any -nntowurd 'oventr and witli 
considerable benefit, but witb.out the help .otinsiilin. 

Some form of therapy wbicb can be administered by fbe 
moiitb, and witlr a longer period of activity than that of 
"insulin, is still being (liligcntlv sought. No such thing has 
ns -'yet been found, but two attempts have been made. 
Insulin can be absorbed in the stoinncb, but only in verv 
.snudl .quantities, if given either - with alcohol* or v.-itli 
sapohih.i but tho quantity is not sufficient to niako it 
pra’oticatile. Th.o other at+enqit depends iipon tiio'fact that 
'giiaiiidine wns thought by Noel Peton and-Findiav to'liavo 
a definite effect in Icwering the blood simar. -Th’e druo- is 
much too toxie to he employed, but various derivatives have 


1018 JCKE ifi, 1928 ] 


PULMONARY FIBROSIS. 


. r. Tiir HntTiMi 
L UrMrjL JoriutiLt 


■been tried, and sonic can be ■Inlerntfd. A [irodnet .of : 
■gi-onp knoivn as syntlialin is nmv on llie inarlut. It is I 
doubtful ivlietbcr it can bo adininislered in sullicinnl doses ' 
to ooiitrol the blood .sugar, lull there is no doubt 'that the 
drug does give rise to eonsidorable gastritis and wiiiio 
diarriioca. This is likely to iontrol the ainunut of food I 
ingested, and by so doing uill materially im]irovo iho 
middle-aged diabetic, who eats and driiiks too niueh. 


PULMONAEY PI,I3R<)STS : 

An Investig.miox into tiik Oukh.n .\sn Cnnisi;. 

BY 

C. VK^\^. KITCAT, AI.R.C.S., 

•BESIDEOT MEDICAL OmCEB, BKOJlrTOS HOSPITAL lOlt 1>I5I;A*^ES 

or TUE chest; 

AKD 

T. HOL3IES SKLLORR, Jf.A., R.iM.Oxox., 

CASUALTY SUimiCAL OrrlCEE, Alinm.ESE.S 'HOSPITAL ; G. H. lICNT 
TKAVELLING SCHOLAB, UKIVEBSITY OF OSPOBD. 


PuuiON.YnTr fibrosis in chihUiood indicts such a physical . 
handicap on its vietiins in later life that a short aecsinnt 
of our atteniiits .to iin-e.stigate the origin and subse(pient 
course of the disoaso may bo of goneral interest and lend 
to further study. The materials for the invesligatioii liavo 
benn gathered from the reeords of the Uroiupton Tlospitid, 
and ill tho main conCrm those recently pilhlished by Ur. 
Burton ^Vood.' Wo are using the term “ pnhnoimry 
fibrosis ” boeauso it is at present the must familiar de.signa- 
tion of the disease known as fibrosis, fibroid indnralioii, 
chronic broneho-pneumonia, ehronie basal pnhnoimry 
calarrli, and early bronchiectasis — wiiieli title.s, we believe, 
indieato phases of tho same eondition.' 

Pulmonary liliresis may he a ilisease entity per si;, but 
it i.9 commonly secondary to an attack of hroiiclio- 
pnoninonin, usually of the siihacnte varh'ly, following some' 
of tho infectious fovens, especially iiieasles and whooping- 
cough. Broncho-pneumonia Invariably produces .some 
degree of broiicliiolar dilatation, and persistence of tho 
inlliiniimition ])romotcs fibroid thiekciTuig of tho bronchioles 
and air cells; moreover, the slight dilatation is In it.self 
a cause of tho cough which tends in vicious .sccjueiiee to • 
increase tho weakness of the tubular walls. Pulmonary 
fibrosis begins in early cliildhood, a fact o.vplniiied partly ! 
by tlio special liabilitj' at that ago to infi'ctioii by ineaslcs ' 
and wliooping-coiigli, and partly by ceiTaiii peculiarities in ■ 
the anatomy of tho lungs — namely, the relatively large 
. calibre of tlie hroiiclii, the thickness of their epithelial . 
lining, -and tho thick, lint yielding, walls of the ah-coli ; 
these are embryonic and infantile distinctions wiiich Imvo 
disappeared in a healthy child by the fifth year. 

•Quito 'early in tho investigation wo found it essential 
to impose certain arbitrary limits to. oiir .search so as to 
Keep it wjtliiii rcasonaljlo bounds, and tluii'ofore niado use 
of only such cases as fulfilled the following conditions: 

(o) The age at tbe firsl cxaiiiiiialion must have been under 
lb yeai’S. 

(Jy) E*'tch,c:ise selected must, have been under observation for 
at least SIX months. * * 

(r) I’liysieal .signs niusL Imvo bocii picscnt at (lie firet 
c.Yaniiiiation and persisted over (bo whole period of alfeiidanec. : 

(il) At loa.st five years .must Lave elapsed since Uic last 1 
atleiidaiicc. 

Cases with any evidciico of luihnonary tiflierciflosis or i 
cstahlisliod bronchiectasis (at the first attendance) were j 
excluded. . i 

Aloro than 23,000 notes from the oiit-patient department j 
of tho Promplon Hospital were reviewed, and 259 patients j 
a|)pareutly suitable for investigation were followed up. Of 
these, 7 wore found to Jiave died and arc .not included in ■ 
this report, but .53 attended and form the basis of jnquiiy. , 
At our examination a full clinical survey was .made, with 
special reference to tho following features : (a) Clinical 
liLstoi-y since last attendance at hospital, (b) Symptoms .with 
liarticular rofercnco to normal life and work, (e) PJiysiquo 
an capacity for svork. (d) Physical signs in lungs. 


C'i..is.sirJc.\Ti 0 .v. 

Tlie B3 eases are classified from an ceonomio .staiidpiiiiit; 
wo use the lerm ’'fit” to imply tlio cajiacity of an 
individual for a normal iLsefiil life. .. . 

1. Tit, Avillioiit signs or symptoms — resolution 

lias liikcii plncc in flic interval 9 (17%) 

2. Tit, lull wifli pby.sical sigir — peniiaiicnt. 

injury to . bmp li«siio. but no. apparent 
impainnciit ol geiieial licaltli 16 (30%) 

3. Not ill and witli pli.i.sical signs — permanent 

iiijiiiy to'linig tissue aeeompanied Iiy some 
ilegreo.of const itiitioital ilisaliilily 23 (43%) 

4. Hi'oneliieelasis lias Mipcrveiied siiieo last 

cxamiiicrl 5 '(107o) 

CoMJtrxTs. 

Ciiiiijih:te Ih'sohtlioit . — This groiip is .siiiiill bid definite; 
tho Holes show that no iniproveineiit had iiceriiod during 
tin, period of treatiiieiit, and ft is iiniiossible to judge the 
ago lit which the induration resolved. 

1‘risisii'iit Si'jits, hill no S\i/in /i/oiiis . — -Tt is reinarkahle 
that n good pin siipii' and griienil health ciiii ho maintained 
ill s|iite of pernnineiit daiiiiige to lung tissue. 

■I’lTfisU-nl /•'/bro.siA.— Those (-ises aro tho most mmici-oiis, 
and, with the next groiiii, eoiistitiito a gras-c iiidietiiiciit 
of present treatment of tho disease. The syniptonis and 
.signs urn (onipatiblo in most cases; there is an inereased 
ieTideiiev to toiiglis ami colds; and the iiiajerity arc eon- 
fined t(> bed or house at freiiiieiit inlciwuls during the 
winter nieiiths. 

Itroni-liicriii.ih . — .As iiieiitloiiod |ncviously, we rejectea 
ca.sos whicli showed the i,re.seiieo of established hrenchieefasis 
while nlfemliiig liesjiital, and tins group only includes 'tlioso 
in which the (•omliiioii lias developed since last seen. Tlia 
nmulier is Miiiill, hut in addition the acc'oiiiits of the seven 
deaths suggested this us the terminal cinise. 

Nolle of tho piiticnts o.MimiiKxl exhibited 

clinieul evidoiiec of .syphilis.' 

Puhiwnm ij riil/erein'o.si.s.— All initients were I'xnimned for 
(ul»t*rcul()sis, find only one was fotincl to bavo ■tubcrclo bacilli 
ill tho spiitinii. This case is not iiicliidcd in our ligiiis'S. 


C.tr.s.tTJON. 


The primary causes were: 

Jicasles iiloiic 

AVlioopiiig-ooiigh alone 
Jlenslc.s with wboopiiig-coiigli 

" I’ncumoiiia " 

Re.arlct I'cvcr 


Cases. 

14 (26.5%) 
8 (15%) 
16.(30?;) 
14 (26.5?;) 
1 (2?o) 


All accurate histoiy of hroncho-pncimionin -following these 
fevers could not he definitely e.stuhlished, but was suggested 
ill the majority of eases. ■Broiidio-pncumouia js u Jroquciit 
and often fatal eomplication of micasles, and .among I lie 
poor or weakly is apt .to run .an irregiilar hut persistent 
ceiirsc. ft may last P.S long ns .sis weeks, or cvmi more, 
and ill such li case fibrosis will probably onsne. Bronclio- 
inionimmia is also tlio most EcrJous -complication of wboop- 
iiig-congli, and accounts for nine-fenths of tbo dciitlis from 
tho disease. Our cases support tho view that the.so two 
infections aro mainly responsible for tho production or 
pulmonary fibrosis. As tho severity of both deert-ascs with 
each vear after the second, tho fatalistic attitude of tliol.aity 

let them catcli it and get it over” — is to he deplored; 

siiico nftei- tho fifth year there .is littlo danger of severe 
pulmonary complications to ho feared from the infection 
or its sequel, every olfoit should -ho eiignged to .guard 
vouii" children from any risk of .contracting either, and 
osiiocTally should children T\-ith measles bo protected Irom 
wliooping-congh. -rncumoriia ” appears freqncntl}' in.tii.o 
histories and gives rise to some confusion, for lobar in- 
flammation is probably not intended ; it is not a frequent 
coraiilicutioii ■ of tho fevers, -and if present is alwa 3 ;s ot a 
lobular variety.' It would appear likely that a combin.Hio 
of impaired percussion note, weakened puerile nreat 
sounds, and crepitations occurring in a fehrilo clii i 
miglit well at first sight suggest a diagnosis of 1°““ 
piicuinonin, whereas actually the condition .ropresonts 
exacerbation in a fibrotic lung. 


BOIilTAItY vtJIiOEK OV THE EEADDEE. 


t Titnl\nrnfH 
MrDiCii. Jotrn^At. 


1010 


JUSE l6, 1928] 


SVMI'TOMK AM' SlONK. 

The following symiitoms nnd signs wcie found in paticnfa 
who were niifit. ‘Congh was invnrinhly an early syinptoni, 
aggravated hy cold and ilanip weathoiy and tending to 
hccoine worse vear hy yearj very lar.rhed liahiliiv to take 
cold was one of the 'most prominent features of the con- 
dition. If the congh hocamo i)crsistently ))aroxyMnnl n 
definite dilatation of the hronchioles was to he assnined. 
Slight hreathlessncss on exertion, and in advanced cases 
slight cyanosis, with parrot-hill clnhhing of the fingers, 
pofnted to right heart omharra.ssment. Contrary to tho 
prevalent opinion, we fonnd that the clnhhing tended more 
to tho early “ parrot-hill ” than tho " drumstick ” type. 
The .spntnm was scanty in quantity without characteristic 
peculiarity, nnic.ss hronchit'ctasis had intervened. Tho 
disease was almo.st nlwaiys unilateral. The configuration of 
the thorax was often alTccted, there heing .slight scoliosis 
with narrowing of tho interspaces and droojiing of tho 
shonlder; retraction to a degree indicating extensive 
pleural adhesion was not ohserved in any. instance, nor 
was the heart markedly di.splaced. llesiiiratory move- 
ments and .sounds were diminished over the diseased lung, 
and adventitious .sounds were occasionally present. .\'-ray 
investigation following lipiodol injection into tho hronchi 
would have heen desirahle, hut was iniprnctic.ahlc on 
account of the patients’ daily routine; radiograms were 
taken in some eases. 


Thuat.mkxt. 

AVilhont entering closely into details we wotdd like to 
point out that certain indications are clear, of which the 
need of more cfiicieht prophyl.ixis is the most prominent. 
Bfoncho-jincnmonia (wliether so-called ju'im.arv or secon- 
dary to measles and whooping-cough) is well known to bo 
the cause of a largo number of deaths in childhood, hut it 
is not so generally recognized that as a persistent sequel 
of these infections it leads to the' disability wliieli is tho 
subject of this investigation. Too much cMn|diasis. there- 
fore, cannot he laid on the aftcr-caro of cases of m<>asles 
and whooping-cough. In tho treatment of ineomplcto 
resolution attempts must ho made to reventdate the 
sclerosed areas hy means of hreathing exorcises; patients 
arc now being treated in this manner at llromplon with 
very beneficial results, but it is as yet too early to .speak 
of permanent benefit. In early eases reventilation and 
expansion of lung are desirable, hnt where hronchiolar 
dilatation has ocenvvod and appears to he hocoming.jierma- 
nent, natural or artificial methods of reducing tlic' .size of 
the thoracic cavity to allow for the ensuing cicatrization 
should he considered. If the cliild is vonng enough the chest 
wall will prohahly retract sufficiently for sonio degree of com- 
■pensation ; but when the thorax is too rigid more radical 
measures artificial pneumothorax, ])hrenicotomv, or more 
extensive .surgical measures— may he indieatecl. Failing 
emplocmeiit of such procednre.s, jiennaiieiice of signs and 
symptoms may be expected, and treatmeut ci\n on!v bo 
syiuptoTiiatie. 


Wusfrafivr Coitex. 

Gnoirp I. 

yf*ars. "W haopiugK^owgh one vear previous^ 
t "a"*' -well; pemistent cbupli, Exnmim 

rapaired pei-cussion note, weak bioatli sounds, an 
S 1 .= t lui .patient attended for si 

n ^ , end ot whwh time tlie signs were still persisting. 

i--^wff aged. 21 Has been very well for many vears, an 

•a L “ 'S P'‘-'®ieal signs completely Cleared 

" nneiimA ^easles two years proviouslv, followed b 

'^’.1 "’"‘^1 when be had bad constant cough and spatiin 
'mpaired note, weak breath sounds, and rich 
ltc°pTTTT,' 1 ^'asneaed as fibrosis of lung. Signs did not clear up 
lon^:r“pr”’:S?. well, “working. Signs S 


■ , . Gaocp It. 

vioasfe^ ^easlcs and whooping-cough three years pi 

anTcrentt^ff„p^‘'?w‘T.‘>'\“‘ Bxaminafion showe'd rhonc 

(ltd not^lear up ^ bases. Attended for seven months; sig 

®ealt’>5'-'ookmg woman; feels well a' 
breath sounds 1 sputum. Impaired note, we 

•it girl a red 7 ?^ ^t-tu^ivo crepitations at right base., 
when ne’r 5 is“rnf^i.„M three yeai-s previously, sir 

coUjjU. Examination shon-cd impaired note, vre 


hrcalU sounds, and crepitations at right base. Diagnosis — Pearly 
broncliicclnsis, Sign.s pci-sisted during attendance. 

Itp-cxainiiied aged 23. Has. been quite well for.ycni-s. Able to 
avbrk. Signs os before. No cough or .sputum. Not subject to colds. 

• . , Gaour III. ' • 

A girl, aged 5. Measles one year previously, since when cough 
and Uj'spnoea. ibcainimition showed numerous crepitations at the 
left base, and these persisled during six months’ attendance. 

Kc-exatnined aged 24. I’alo, muddy complexion. Always has 
cough and about half nn ounco daily of non-offcnsivc sputum. 
I'lxacerbation of symptoms occurs every two to four months, neces- 
silaliiig ridirement to bed. Able to work between attacks, but not 
complelolv fit, 

A boy,’ aged 12J. Measles and whooping-cough two years pre- 
viously,' .since when persistent, cough. Examination showed weak 
brcall’i sounds anil coarso rales at Iho right base. 

Kc-exaininod aged 20. Always lias cough with slight amount of 
spiitnin. l-’roquent colds, able to work, but not completely fit. 
Signs ns before. 

Gaorr lA''. 

A boy, aged 8t. Afcaslcs followed by whooping-cough when 
6 months old, since when persistent coug’li. Examination showed 
coarse rales nt bolh bases. The child never coughed lip any 
sputum, but I lie signs did not clear up. , ‘ . 

Tle-cxatnined aged 13j. Typical bronchiectasis with offensive 
sputum, confirmed by c-rny examination. 

A girl, aged 6. AVlioojiin’gaiougli one year previously, since when 
persisleiit cough. Exainiimtion sliowed numerous crepitations at 
tlio right liase. ■ Diagnosis — ? hroncliicclasis. ■ 

Ite-examined aged 14. Typical bronchiectasis with offensive 
.sptilimi. 

Co.xci.t;.siox.s. 

1. Pulmonary fihi-osis of noii-tiibereiilous origin frequently 
jiroduces grave disability and seriously reduces the subject’s 
economic cffieicncy; on tlio otlior baud, a reasonable pro- 
portion ostabli.sli an “ immunity ” and labour under no 
apparent disadvantage. 

2. Pnlmoiinvy fibrosis is a not infrequent ctinscquence of 
tlic jirotriuted form of bronclio-pneumouia which follows 
nicasle.s and whooping-cough. 

3. Protection against measles and whooping-cough in tho 
first five years of life would tend to prevent its incidence. 

4. Apart from prophylaxis, amelioration, if not ahsoluto 
cure, may he expected by improved methods of treatment. ’ 

It will’he noted that we have used iho term “ pulmonary 
fibrosis ” througliout ns a label for tho condition, but this 
is not altogether satisfactory, and there would appear to 
be a distinct need for nn official discussion with a view to 
i determining tho nomenclature. 

Our tliaiiks are duo to llie honorary staff of the Bromptoa 
Hospital for permission to moke use of fheir records, also to tho 
t lady almouci-s for their assistance in tracing cases; For suggestions 
' and advice we are indebted to Drs, G. E. Beaumont and AV. H. 

[ Lister. 

I Rtrcnixer.. 

I 1 boncrl, March 24lh, 1928, 


SOLlTxVllY TJLCEE OF THE BLADDER. 

BY 

GUY CHAMBERS, F.R.C.S.Exc.., 

iio;:or..vBV surceos, isle or -wigut covstv hospital; late clinical 
ASSISTANT, ST. PETER’s HOSPITAL FDR STONE. 


It is a matter of some interest that a review of the litera- 
ture on general and urinn\-y surgery reveals the fact that 
this condition is enshrouded in a certain elogree of ohseuritv. 
In some worlcs the disease fails to he identified as a clinical 
■entity from other varieties of chronic ulceration, in others 
it is not even mentioned. Certain well-known writei's, on 
the other hand, give the subject considerable attention and 
description under titles which appear to be synonj-mons. 

Rowlands and Turner (1927) describe the chronic or 
callous ulcer of the bladder, which occurs nearly always 
in young liien, but occasionally in women who have homo 
children. Haematuria is a fairh- constant symptom. The 
condition was mentioned hy Fenwick in 1900,* and again 
in 1904.= y. C. Hunt= discourses on suhmncons ulcers of 
the . bladder, advises their excision, and the treatment of 
septic foci affecting the tonsifs, teeth, nasal sinuses, etc. 

• Cabot describes a solitary nicer that may be either aciito 
or chronic. Ho mentions also an elusive ulcer that occurs 
chieffy in females and is associated with great frequency 
of micturition but without haematuria. ’’ 


1020 June i6, 1928] 


riARYNGBAIi DIPHTnERIA IN OtiD AGE. 



Frank Kidd, in liis work on urinary surgery (1010), 
gives a clear and concise description. Tlio causes of siniplo 
ulcer are classified as consecutive, spontaneous, and syin- 
jrtoinatic; tho consecutive variety being duo to mcebanical 
pressure of foreign bodies, stones, otc., tho spontaneous duo 
to bacterial infection of tho bladder wall, and tho syni- 
ptomatic occurring in tlio courso of diabetes or disease 
of the nervous system. 

The second variety, which is the tj-po under present dis- 
cussion, is subdivided into acute perforating and clironic 
solitary. It will thus bo seen that the nomonclaturo and 
description of this disease aro soniewbat varied, and that 
a brief account of its etiology, pathology, and clinical 
features may bo of interest beforo relating a caso which 
was sent to mo some months ago. 

Etiology. 

This is not clearly understood. There is cvidcnco in some 
cases of a toxic focus, such as pyorrhoea, septic tonsils, 
or sinus infection. Haematogenous infection is regarded 
as the probable cause. Comparison is made with tho theory 
of gastric ulcer from infective emboli through tho blood 
stream. Tho patients aro usually young males with no 
antecedent urinary trouble or venereal history. 

Pathology. 

The ulcer is single, submucous, and shallow. In timo 
it penetrates tho muscular wall, and, in rare cases, tho 
entire wall of tho bladder, with subsequent infection of 
tho pelvic cellular tissues or peritoneum, according to tho 
site of the lesion. Cystitis appears beforo long, and tho 
ulcer becomes encrusted with phosphatic debris. The ulcer 
i^s usually half to three-quarters of an inch in diaractcr. 
It IS situated mo.st frequently on tho posterior wall, abovo 
and internal to the ureteric orifice. Tho margin is slightly 
raised ; the base is somewhat shaggy and covered with fibrin 
or blood clot with, perhaps, some phosphatic encrustation. 

Clinical Features. 

The early symptoms are increased frequency of micturi- 
tion and intermittent haematuria. Later tho liaomaturia 
becomes more persistent and profuse, with strangury and 
liain referred to the penis. The. general health becomes 
undeiunmed in a very short time, with Joss of weight and 
a moderate degree of anaemia. Tho symptoms of cystitis 
are superadded. .r 

Differential Diagnosis. 

Examination by cystoscopy will, of courso, locaTizo tho 
source of the haemorrhage, and tho ulcerated area found 
in the, bladder must next bo differentiated from tubercle 
and neoplasm. Bleeding may be so profuse during instru- 
mentation as to make visibility difficult or inipossible 

nurno^s^'m-T^^l”*”™!’ 1°"' as well as curative 

^ Performed. Repeated bacterio- 

logical examination of tho urine is made to elimirato 
tubeicle. Colifonn infection should bo identified by tho 
same means. Adherent blood clot at the site of tho^ulcer 

wL"n^:ystRlt;Sr S-wth, especially 

The diagnosis is confirmed finallv + 1.0 
A ...lion of tlio nte, 

Treatment. 

Palliative measures are not, as a. mlo — r- r x 
Curettage of tho ulcer, and caustic applicatio4'1hrouYh 
a suprapubic opening, have met with varyine snepaff 
Treatment by diathermy through the cystoscope is suco^ssfui 
in early cases. Resection of the ulcer is the most 
factoi-y method. It should be done early.- The prese ^ 
of cystitis necessitates preliminary, drainage with^all^the 
attendant difficulties of a second operation later. An ul ” 
situated in tho trigone is best dealt with by the cautery. 

Case of Solitary Dicer: Partial Cystectomy: Cure. ' 
aot'ced Wood in his urine durine the 
U°o day .following exercise at rowSf earlier £ 

wa= a|ii„^p”Tont "l®, The next morai^nioo^ 

hacnaaturla 


as tho rondijioM was not improving under medical Ircalmcnt, 
1 was called m consultation by hi.s doctor with a view to furtlic; 
mycsligntion. Ills parents declared that ho' had looked tired aiid 
i • ° or tliico montliK. IIo had alwav.^ been 

ilclicatu Binco cliildhood. Ho "was, ho^vover, a keen atliletc, and 
played regularly at cnckct or football, and wa.s fond of rowing. 

last lilncsscs.-'JUi iiad tonsillitis and quinsy wJicn 3A years old, 
tuberculous glands in tlio neck, wliich were removed by operation, 
when ho was 7. and ty;r>lioid fever at 8 years of age. 

J resent Cojultiion, — IIo was pale, of muddy complexion, thin but 
wiry, and intelligent, TemneraLuro and pulso wci*© normal; blood 
pre^uro, 110 i/im, Hg. Tho amount of blood in the urine was 
vnriftblo each day, at times half to a third of its bulk, at 
others almost clear. Tlio haematuria was symotomless, but later 
ho complamcd of frequency of micturition and a feeling of dis- 
comfort at tho hnso of tho penis. Tho urine was free of casts, 
bacteria, and, apart from blood, showed no other pathological 
cell elements. Tho urea concentration test indicated good renal 
cflicicncy. 

Cystoseo'py. — ^Tliis liad to bo performed on three occasions on 
account of porsi.stcnt bleeding, it was only on tho third examina- 
tion that a clear view was obtained. Tlio ulcer was situated above 
and to tho outer side of tlio riglit ureteric opening. Its size could 
not ho clearly ascertained ns it was only partly visible, but after 
operation it was found to bo about three-quarters of. an -inch in 
diameter. There appeared to bo a small pouch or depression of 
tho wall surrounding tho ulcer, over the edgo of which several 
elrcaras of blood could bo seen trickling downwards like a cascade 
or waterfall. 

Operation. — On July 8lh I explored the bladder. Tho ulcer was 
bleeding freely; it was tho size of a sixpence, but well clear of 
tho right ureter. I resected a portion ot bladder wall including 
tho ulcer — approximately one and a quarter inclics by one incli — 
closed tho bladder, and drained by' a suprapubic tube for a few 
days. Tho prevesical space was drained also. 

Convalesccnco was normal. At tho end of three weeks the 
wound was quite licalcd and the patient passed water naturally. 
On July ^th he left hospital. 

During tho following two months tho urine was examined at 
weekly intervals and was found normal and free from blood on 
each occasion. Thcro was no pain or frequency complained of 
at any time. , , 

Before operation his weight was 6 st, 9 lb. On September 27Ui, 
two and a half months after operation, he weighed o st. He was 
then looking well, with a fresh and healthy colour, and stated 
that ho felt better than ho liad‘ done for several inoutlis. Ho was 
taking modcralo outdoor exercise. 

VatholooUal Heport (from tho Clinical Research Association).— 
** Tho section shows a superficial ulceration covered with partially 
organized blood clot. Tho epithelium is represented by a very 
snTali compressed fragment. There is inflammatory infiltration, 
but no sign of tuberculosis.'' ... 

RrPrRE,N'CES. 

» Vleeralion of the Bladder, • Ch‘»iicQl Cystoscopy, * Colleeled Vapers 
of the ilayo CUntc, 


LARYNGEAL DIPHTHERIA IN OLD AGE. 

. nir 

J. D, ROLLESTON, JI.D., M.R.C.P., 

ilEDICAL SDPEKIXTESDEKT, -WESTEBH EEVEE HOSPITAL, LOXDOX. 

Laiitnoe.II, diplitlicri.v is raro at any period of adult life, 
and becomes increasingly so with advance in age. In a 
paper published some years ago' I illustrated this by the 
fact that my experience had been limited to four examples 
of tho kind among 1,156 cases of laryngeal diplithori.a, 
with or without faucial and nasal involvement, admitted 
to hospital hotwoen August 17tli, 1899, and Deqcmher 31st, 
1915 during which period 11,313 diphtheria patients of all 
ages’ were admitted, 821 heing aged 20 years and over. 
Of the four cases, three of which were fatal, tho youngest 
was aged 24 and tho eldest 45. 

The present case is remarkable for the much greater age 
of tho patient, and is, as far as I can recall, the oldest 
example of diphtheria th.at I have seen, with the 
tion of a moderate faucial attack iu a woman aged 94, 
recorded by G. W. ' Ronaldson in this Journal. - 
Tho patient was a woman, aged 76, who was admitted to • 
hospital on March 20th on tho sixtli day of disease. On ’['I'V'®®’® 
tho tonsils and uvula were covered with membrane, wind iv 
also visible on tho tip of tho epiglottis.. The cough- was ciot py 
and the voico was lost. A culture of diphtheria ,'fJIn ■ 

obtained from tho throat. An intramuscular injection ot 
units of antitoxin was given on admission and repeatcu on i 
following day. No other active treatment, local or B'"'?!"',’,?'' . 
employed, and rapid disappearance of the me'”*”'''”® ■ . f Am ' 

goal symptoms took place. No complications ensued, apart i 
a trace of albumin in' the urine from the tenth to 
day, but in view of tho severity of the attack and tho “keU' . 
of subsequent paralysis it was considered advisable to 
patient in bed till the forty-second day. On her • 

hospital on the fifty-sixth day she showed no sign of pa j 
and the knee-jerks were active. 



June lO, ipis] 


TREATMENT OE EUA.CTERES OF THE CEiVVIGEE. 


r TnrnRtnfw \OOA 


Ai.nrt from Eio varHy of lovyupoul aipUllioria in 
aavnurcd life ilio oaso is of inlorost in t lo folloiyinp 
respects. Tho pernicious dortrino u’liicii has iwonod 
Bunport in Uvo of the most recent (exOioolcs on «/ 

tho throat— that antitoxin is of no value after tho fifth 
ilav of disoaso— is falsilied hv tho rapid hiihsidenco of tlio 
sviuptoms after injection of tho largo doses which tho 
liatieiit received. The ahsenco of any .serniii reaction was 
dtio partlv to tho use of a rcniicd .seriiiii and partly to tho 
fact, which I have ijtiistratcd on Ecveral previous occasions, 
that scrum reactions are often ahseiit or ill inarUcil after 
severe angina in spite of tho ndniinistratinn of largo 
amount*, of scrum. 

Becoverv was nil the more remarhahle as the prognoses 
of laryngeal diphtheria in ndnll life is nsnnlly iiii- 
fnvourahle. 

Lastlv the case is nn cNcollcnt examj)lc of wlmt 
C. Zocller,^ who has rocenlly recorded an attack of 
larynge.ol diphtheria in a middle-aged man, dcMrihcs as 
tho “ caprices of spoiitaneoiis imnninir.ation.” 

The great majority of town dwellers— especially those in 
capitals such as London and Paris, where diphtheria is eii- 
dcinic — undergo a process of occult siiontaiieous imiiiuniza' 
tion, and only a comparatively small minority contract 
the disease. In some cases, however, this process of 
Bpontancons iiiiniiinizatioii does not lake jihioo. Zoeller’.s 
patient was a colonel aged SO, who, in .spite of tho fact 
that ho had liccn living in Paris .and other comnuinitio.s 
where diphtheria was prevalent, had not heeome .spontane- 
ously iniiiiiiiiizcd, hut had contracted an attack of isolated 
laryngeal diphtheria followed hy oxteiisivo paralysis, the 
laryngeal involvement being altrihuted lo the fact that lie 
was a heavy smoker. 

In my patient tobacco could he excluded, and tho involve- 
ment of tho larynx was merely due to the natural course 
of tho disease. 

RcrrncxtTs, 

'Cliii. loiirn., 1916, xlv, J83. • IMIhh Mfillral Jniininl. 1925. i. 753. 
< Ek/I. ft Mem, Soe, Mril. IIOp. df Parh, 1929. Hi, 425. 


TBE1T3IEKT OE PRACTUBES OE THE CLAVICLE. 

DV 

H. H. GREFAWOOD, M.R., H.S.I.oxn., F.R.C.S., 

SCEGEOK TO TUE O.W.E. ItOSCITEL, SWl.VnOX. 


In the llrifish Mcdicnl Jnurnal of April 28th (p. 725) then 
was a comment on the tro.atnionl of fraetiire.s of tin 
clavicle, with a reference to modifications of the usual Sayro’i 
adhesive plaster method. Wliatever variant he employed 
adhesive plaster condemns a strong hairy iiiaii to a niontl 
or so of mild purgatory, and inflicts on the more tendei 
skin of a woman orya child an irritation that is wclliiigl 
intolerable; over the scene of tlie final removal of tin 
plaster it is bettor to draiv a I'cil. 

In tlie majority of cases of fractured clavicle the fractun 
is situated soiiiewlicro ivitbiii the inner two-thirds. Lcaviiif 
out those rare and tionhle.some fractures close up to tin 
storno-clavicular joint, and those near to tlic acromio 
clavicular joint, which present special ])rohleins in treat 
ment, these fractures can he adequately treated hv tin 
p.added ring method.. Tlii.s is no new idea, but the ring: 
v.liich I have used for the past tivo years in hospital ant 
private cases are, I believe, an advance on previous devices 
ihe rings are made of wash-leatlicr tightly packed will 
Xu' iHxvmg incorporated with the wool a spring 
they have been made for nio hy Mr. Walgrove, of 4 
tiiirchvick Place, Harrington .Square, N.'W.l. 

The method of application is important. TIio aiiterioi 
strap of webbing is drawn sufficiently tight to keep tin 
amerior part of the ring in' the sulcus'intornal to the heat 
a le humerus, so that on pulling back the rings pressiin 
uat'kivards is made on the outer fragment. The strap f 
lastened to the ring on each side by a .stout safety-pin, am 
™oukl then ho across the chest above the level of tin 
raammac Two straps' are irsed behind, and are drawl 
'y comfoit will allow; they. also. are pinned t 
rmg>. Generally ffc will bo found that on the next am 


succeeding day.s tho patient will tolerate further .shortening 
of the posterior .straps. When tlio rings are efficiently 
adjusted the arm of the affected side is placed acro.ss the 
front of the clie.st with tho hand jioiiitiiig towards the 
opposite .shoulder, and loosely fixed there by aiiy convenioiit 
iiicthod — haiidage or sling. The thiekiioss of tho ring acts 
ns an axillary pad, giving leverage outwards of the outer 
fragment. 




I have found this method far more effective than any 
plaster niothnd for the majority of cases, and as to comfort 
there is no comparison. In a bii.sy oiit-))atioi!t department 
the saving of time i.s coiisidcrnh'le. It is so simple that 
nnr.se.s quickly learn how to adjust tho rings, and tho 
paliont only needs iiis])CCtion hy tho surgeon hoforo being 
allowed to go homo. Ono youiig amateur jockey with a 
romiiiiiiuted fractvivo found himself so comfortable that at 
the end of a fortnight ho could ride at full gallop u’ithoiit 
discomfort — needless to say, without tho surgeon’s 
periiiissioii. 

From tho illiistrnlioiis it will ho scon that tho appliance 
loaves free tho breast in the female, iioithor pressing on 
nor irritating that organ. Usually it will be found that 
tho most ollettivo Icvoragc is secured by tightening the 
upper strap behind, xvliilo the lower strap -is only drawn 
sufficiently tight to counterbalance the pull of the anterior 
strap. 

In the earlier rings made for nio I tried a covering of 
vuhhcr sheeting, but this soon porisbod; it was move 
expoiisivo, it gave less secure jnircliase for the safety-pins, 
and caused unpleasant sweating in tlie axillae. 


PYREXIA DUE TO INEECTED DEAD TEETH. 

BT 

LEONARD G. J. MACKEY, M.D., M.R.C.P., 

IlONORXnV PHYSICIAN TO THE QUEEN'S HOSPITAE, niRlIINGnAJI, AND TO 
THE DIP.MINCHAM AND MIDLAND UOSPITAL POR WOMEN. 


Tur following tliroo cases are interesting examples of a 
prolonged fever arising from apical abscesses, and they 
liaA'o several features in common — namely : 

1. Tho fever was, considerable and of long duration 
in each case, and tenninatod at once on extraction of 
the infected tooth or teeth. 

2. Ill none of the cases is it known when the fei’er 
began; so it may have been of much longer duration 
than is shoivn by the charts. 

3. All three patients complained only of 3'ague ill 
health; they had no pain and there Avero no symptoms 
pointing to any knoivn disease. In Case i I had tho 
patient’s temperature taken most carefully to make 
sure tiiat she ivas not malingering. In Case ii the 
patient protested tiiat he felt well enough to he in 
his shop and resented being kept In bed. In Caso^III 
tho patient refused to remain in bed after two weeks 
and i-etuvned to his business. 


4. Ill all three cases the discovery of tho lesion was 
made by a radiologist. In Case i a solitary abscessed 
tooth was seen by the radiologist in skiagrams taken 
of tlie nasal sinuses. In Case ii the abse'essed stump 
was completely covered by clean healthy gnm In 
Case III the abscessed teeth were discoi-ered amongst 
several ^root-filled teeth by tiio radiologist. ° 


1022 June i6, 1928 ] 


PTREXIA DtTB TO INFECTION BT DEAD TEETH. 


[ Tnv RKm« 

UtDICAL J09t>lS 


- It is not improbable tliat some of tho apparently healthy 
possessors of abscessed teeth would prove to bo running an 
evening temperature if they submitted themselves to tho 
test of tho thermometer. It 
is also probable that a pyrexia 
which is attributed to tho 
patient’s illness is sometimes 
duo to an unsuspected root in- 
fection, and that if encoun- 
tered, say, after an operation, 
or after an attack of pneu- 
monia, or in a person with 
valvular disease, it might bo tho cause 
of much anxiety to both patient and 
doctor. 

It cannot bo too frequently stated 
that root abscesses aro quite common 
in tho apparently edentulous, and tho 
fact that a patient has clean empty 
gums docs not warrant us neglecting 
to advise an a-ray examination of 
them if tho patient’s clinic.al sj'mptoms 
are such as can bo caused by somo 
obscure focus of in- 
fection. 

Vague ill health, 
brachial neuritis and 
sciatica, fibrositis, 
weakness of the 
heart muscle, and — 
may I add? — pyi-cxia 
are- among tho least 
serious consequences of root abscess. 


C.\SE I. — Pyrexia for Scvcniccn 
. IFccbs. 

Tho patient was a middle-aged Indy 
whom I saw in consultation with Dr. 
L. Kirkby Thomas in 1921. 

Sho had had a febrilo illness for 
seventeen weeks, without any physical 
signs or symptoms that afforded tho 
slightest clue to tho cause of her high 
temperature, which at times roachod 
103°, as is shown in tho accompanying 
chart. All tho investigations usually 
carried out in such a caso proved fruit- 
less, including, I am ashamed to say, 
tests tarried out at my suggestion to 
discover if sho was malingering. 

Finally, we decided to havo her 
sinuses radiographed, .and, though they 
proved normal, the radiograph i-evealcd 
an abscess at tho root of a solitary 
tooth. 

With tho extraction of tho tooth on 
tho following day tho pyrexia ceased, 
and her health, which had been some- 
what affected by her long fever, rapidly 
improved, and has remained good up 
to tho present day. 

The temperature chart was made 
by the nurses in attendance on the 
patient. No one knows when the 
pyrexia began. 


Case ji.—Pyrema for Six Wceis. 
This patient, a middle-aged man, was 
under the care of Dr. G. C. Hartley, 
who was first called to "see him, in 
• January last because tho patient’s wife 
discovered' that her husband had a 
high temperature every evening. Dr. 
. Hartley, finding no obvious cause for 
the pyrexia except a suspicious tooth, 
had the tooth extracted ; in spite of 
the pyrexia continued. 

EvoDtually the patient was admitted into the Queen’s 
smtal, and I investigated his condition in the usual 


way; but all tests, including blood cultures and Widal and 
Wassormann reactions, proved negative. A radiograph of 
the patient’s gums, however, revealed a small abscessed 


Case ii. 

root of which there was no part visible from tho mouth. 
This root was extracted; and for tho first time since the 
discovery of the pyrexia tho temperature became normal. 
A few days later, on account of bleeding', tho socket was 
plugged, and the temperature immediately rose again. 
Tho next day tho plug lyas removed, and tho temperature 
foil to nornial and has remained so ever since. ; 

TJio acconipaU 3 ’ing tomperaturo chart was commenced by 
Dr. Hartley when tho patient was in his charge, and was 
continued by tho nurses at tho Queen’s Hospital. It is not 
known when tho p 3 -rexia began. . . - 


■Case hi. — Pyrexia for Seven TFccl's. 

A business man, aged 47, a patient of Dr. J. IM. 
HcQuccn, in September, 1927, complained of a vague ill 
hcallh and loss of weight and strength. His evening tem- 
porntnro was found to bo between 101° and 102°, but no 
cause for this could bo discovered, nor had ho any; symptoms 
which gave an 3 ’ clue to tho origin of tho pyrexia. 

Tho usual investigations and tests were made, but all 
proved negative till an x-ray examination revealed small 
abscesses at tho roots of three rooA -filled teeth. 

With tho extraction of his teeth the' p 3 ’roxia ceased and 
his health rapidly improved. ' ... 

Ho reports that ho has keen quite well since tho teeth 
were removed, and that there has been no further rise of 
temperature. . , - . . .... . . ■ 

Tho accompanying chart is constructed from notes kept 
by tho patient and Dr. JIcQueen. It is not known wlien 
tho pyrexia began. 


JUmorattira : 

MEDICAL, SURGICAL. OBSTETRICAL. 

EUPTURED IIALAEIAL -SPLEEN: SPLENECTOMY *' 
RECOVERY. * . . 

The follon'ing record may be of interest since rnptnre of a 
malarial spleen in Jamaica usually causes sudden death, 
followed by a coroner*s inquest. Moreover, the patient was 
not seen until thii'ty hours after the accident causing tba 
rupture. - 

A man, aged 37, whom I had known for several yc.Trs^ to bo 
suffering from malaria, with a large spleen, was on August 2fnd, 
1926, at about 11 a.m., thrown from a ouggy,” falling clneny 
on tho abdomen. Shortly after the accident ' ho yonnted twice , 
during tho following night ho had severe abdominal pains, ana 
passed two blood-stained stools. Ho was not seen by mo tin 
6 p.m. on tho following day (thirty hours after the accident;, 
.when ho was in a collap«ed condition, with a pulse of 120, ana 
complained of severe pain all over the abdomen, but most acuto 
in the h'ypogastrium and right iliac fossa. Tho abdomen was rigia 
and very tender all over, with dullness in the flanks; no super- 
ficial reflexes could be made out positively. , 

He was removed to hospital^ and at 7 p.m. his abdomen was 
opened through a right rectus mcision. The peritoneal cavity wa . 
full of -blood, for the. most part dark and clotted, but there w 
evidence of profuse fresh bleeding. The abdominal organs 
Quickly examined and the spleen was found to bo rupturea 









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CiSE III. 



anNi: i6, 1928] 


MEMORANDA. 


r Tnr. Bnm^ 109!^ 
L MrDiCAL JoUBKii 


runUiies V nml C (see pliologrnpli) IieiiiK ensily fell. Tins woiiiirt 
w's at once closed \vitli foi-ceps and an upper >efl lecliis 'neision 
nmde Imt as lliere evas some dimcidty in de . verms the sp ec,, „„ 
incUion was made nlonp the marpin of the lower rihs to "'cd 'U 
The spleen was then easily delivered, the l)e< icle clamped .and tied, 
and the organ removed. At this stage the patients condition 


w.a“ so poor that after rapidly c.leai.shig the peritoneal cavity 
tioth wounds were (iiiieklv sutured m single layers and a .Iran i..gc 
tube was inserted into the pelvic cavity.; this was reinovtd in 
fortvHjight hours. Saline injections were given co 
the operation, and rectal salines for thi; neat ti 
1 find it difliciill to give blood irniisftiMons m - 
the high incidenec of s.vpliihs and to the aversn 


io act as donois. 



The wouiuU showed hupcrficial for a fow diiy^; hu( for 

-this there was an uumtcmiplcd convnlo«ocnoc. The luan was 
discharged in four weeks from lio^pilal, apparently f|uitc well; 
he has not returned to mo with on attack of malaria, hut 
Tcponcd four weeks after wUU an attack of gonoviUoca. The 
spleen weighed 16 oz. on the morning after the operation. The 
ruptures labelled A, B, C, 11 in the accompanying photograph 
were on the outer surface; rupture E was on the innci surface. 

Conclusions, 

The liaomorrhago must have slopped temporarily, hut was 
renewed by the jolting over a four-mile rough road to 
hospital. Evidently 110 large vcssol was implicated. The 
two blood-stained stools may liuvc boon caused by a con- 
tusion of the bowel which did not ajipcar on the peritoneal 
surface, or have been duo to the common practice of the 
peasantry of dosing themsoivcs with calomel to remove 
“ bruised blood.” Another notable feature of the ease is 
the lack of shock, which I have often observed among the 
natives. 

D. LAriiKNCi: 'J’atk, F.R.C.S.Eo. 

Jlonltgu Uu) Ho'.pitaJ, .lamatca. 


PNEUMOCOCCAL PERITONITIS. 

The interesting case reported by Dr. Seymour (May 26th, 
p. 805) prompts me to describe another case of pneumo- 
coccal peritonitis, whicli eventnally recovered. 

A woman, aged 55, developed acute primary pneumonia in- 
volving the lower lobe of the left lung. The crisis occurred on 
the cightli day, with considerable collapse, vomiting, and copious 
evacuation of the bowels. Subscqucntlv the abdomen became dis- 
tended and a faint rash appeared on the flanks. A ^YidaJ test on 
the lUh day was negative. Distension of the abdomen progressed 
and constipation bocatne absolute; there was no vomiting, but the 
tongue was verjy dry, and the facies was Hippocratic. On the 
advice of Dr. Carey Coombs, pituitrin was ordered every four 
hour's. The patient became very collapsed after the third in- 
jection^ but the bowels were o'pened and gradually the acute 
abdominal condition subsided. The temperature, however, began 
to rise again, and repeated efforts ivere made to locate a possible 
empyema, without success. 

On the 21sl day the patient became suddenly collapsed after a 
navd cough; soon aftenvards the presence of a small quantity of 
ntiid was. demonstrated at the left base. The patient -also began 
o cough up pus; presumably a small interlobar empyema had 
Durst into the mam pleural cavity. After this episode the patient 
ntade progress and the signs in the chest cleared up. 
un the 44th day and again on the 60th day, the patient had 
of intestinal, colic. On the 66th day the colic 
peristalsis was visible, constipation became absolute, 
anti she began to vomit. ' 

anac^lW;?' fbe abdomen under gas and oxygen 

Through a median incision the small inlestine wa? 
idhe^ion. -n detended and densely matted with 

the pcliis. The large iiilcsliiie was not distended 


but was involved in the adhesioim in the pelvis; some adlie'^ions 
wore soft am! recent, otliem wore tough. Numerous adhesiona 
niid hands were <llvided, hut owing to the condition of tho 
paiicnt jejunoMomy had to be performed. 

After eleven weeks Ujc fistula was still discharging an excovial- 
iiig fluid, so a second operation was performefl by Xfr. C. O, 
ilodnmii, tin? scar of Uie picvions operation boiiifr excised. On 
opening the ])eritoMCUin it was seen that the adhesions wore less 
numerous than on the former occasion, but tlic last loop of the 
ileum was densely adherent to the dcptlis of ttic pelvis. The 
fistula was found to bo connected with the iippci end of Iho 
iioiim; this w;ui dissected away from the abdominal wall and 
annstomo:-ed witli the transverse colon. 

The patient made a satisfactory jocovery and was soen recently 
:i year after operation; she was in excellent lieallh and had 
snlieied no furilicr abdoniinal discomfort. 

Apparently nt the time of tlie crisis tlioie was a 
perilone.ul etFnsion whicli resolved, Ie;iving in. its wake a 
innSK of adhesions; tlirse, in course of time, eontraeted and 
eansotl the obstruction. 

I wisli to tlmnk Mr. C. O, Rodman, honorary surgeon 
lo tiie ]!rnee Wills Alemorial Hospital, for permission to 
record the details of this case. 

Fn.txK Bouman, M.B., 

AsstsiiiiU Pli\‘*‘ieiati, Hnii'f Wills Meinorinl 


Reports of ^odrttes.- 

JIALAIUAL TREATJrENT OF GEXERAI- 
FARALYSI^s. 

At a sjiocial mooting of tlio Devon and Exotoi- Alodioo- 
Cliinirgioal Sooietv at tlio Devon County Moiitid HoS])ital 
oil Slay 24lh, witli Dr. 0. C. Ciini.F.Y in tlio olmir, tlio 
inedteai .suporhitoiulont, Dr. R. ICvoKll, ojienod a disoil.'isiou 
on general jiaral.vsis of tlio insane, witli spceial reference 
to the trentinent by miilnriii, wbic-h bad been eondiieted 
for about two and a half ycar.s at this liospital. 

Dr. Eageu said that general jiaralysis was an organic 
disease of the cerebral cortex, wbicli gave rise to motor 
parnl.vsis and extreme mental deterioration ; tlic average 
duration from the incipient symptoms to death was four 
years. At jircsent it had to be considered incurable, 
although remissious might oeeur. PathologieaUy tho disease 
was ail invasion of the cerebral cortex by the spiroebaeto of 
syphilis, and, in addition to the SVassorniiinn and globulin 
reactions, diagnostic importance was nttacbed to the in- 
creased t-ell count in the eerobro-spinal fluid and to tlio 
colloidal gold reaction. Dr. Eager ompliasir.ccl the greater 
iiieidcnce of tho disease in the industrial centres as 
eompared with rural areas ; he cited his own experience 
at the Devon County Mental Ho,s])ital and the fall in tho 
figures since eases from Devonport had ceased to be 
admitted. Further, the disease was almost unknown in 
uiiciviliKod countries. As regards its incidoiico in .syphilitic 
infection, 3 per cent, was given ns tho average figure for 
the development of general paralysis; lightning pains and 
ataxia were not, as a ride, coneciinitant symptoms. Dr. 
Eager then discussed the three typical stages of the disease, 
anti showed a case under treatment at the hospital illustra- 
tive of each stage, lu the first stage, that of mental 
exaltation, appeared the classical ideas of grandeur; this 
was the most hopeful period for treatment. Next came loss 
of initiative, when, for iiistanco, the artist failed to secure 
tone for his pictures and the musician to gain lus accus- 
tomed encore. Later there followed untidiness and 
slovenliness of habit. At this period the physical signs 
present were frequently inequality and sluggish reaction 
of the pupils; tremors of the face, tongue, and hands; 
and an increase in the patellar reflexes. In illustration 
of this stage Dr. Eager showed a man, aged 40, who, on 
admission, declared himself to he the Prince of Romany, 
and claimed a flight from Australia in three uiimites. His 
pupils were unequal and the knee-jerks exaggerated ; there 
were tremors of the finger.s, and the tongue was protruded 
in the “ trombone ” fashion, lu tlie second, or congestive 
stage. Dr. Eager drew attention to the loss of facial 
expression and the tendency to sit “ huddled uij.” He 
showed trvo men in whom both characteristics wore evident. 
Some improvement had been noted physicallv in these 
two cases after malarial treatment. In the course of the 
third stage, or stage of extinction, there oceurrod the 



TREATMENT OF HARE-LIP, 


June iG, 192SI 


r Tnr JiBTTtim 
I MrnicAt lovuittL 


1025 


nftov tlio ilc'utli of lu'V Inisltnnd. Ho osUod why goiioriil 
paralvsis did iioi dovOlop in nil cii'-i”; of sy]iliilis. . • 

Dr‘ Kaoku, loplvinp, said ho Imd no oxpnionro of tlio 
dunl orcnnonco of poiionil i(iirahf.is in a man and Aoifo. 
It was possible that siiimchnotnl .strains existed with selec- 
tive qualities which accaumted for the coni|)aratn-ely low 
incidence of general paralysis in syidiilitic infection. Ho 
did not claim at this stage that nmtaria treatment was 
a cure for general paraly.sis, althongh .striking itnprovo- 
inent had followed .such treatment in some cases, and was 
at present maintained. 

Dr. RAi-vnainop., in reply to a cpiestion by Dr. Fleming, 
stated that he had not noted halhicinations in the patients 
under the malaria treatment. 


TUEATJIEOT OF nARE-LTP. 

Ar a meeting of fho Section of Surgery of the Royal 
Society of Medicine, on Jnno 6lh, with the Pre.sident, 
Mr. IV.vnnrA' Low, in the chair, a discussion was held on 
the treatment of haro-liji. 

Dr. Viciou Ve.vu (Paris) said that there wa.s always 
.snfScient tissue present in all types of hare-lip to allow 
of reconstruction of the deformity. He classified the 
cases into four groups: (1) simple unilateral cleft, (2) total 
unilateral cleft, (5) simple bilateral cleft, and (4) total 
bilateral cleft. The firet and second groups formed hy 
far the grcate.st nnmher of cases. Discussing the operative 
tcchlqnc in the treatment of the .simple tyiie of liaro-lip. 
Dr. Veau said that accurate sulnre of the nniscles AVa,s 
the most important detail in all oiierations for hare-lip, 
Bince these structures gave the thiekues.s and .shape to 
tile lip. He u.su.ally used ouo (or more) deep cutgut 
sutures for the. musele-s, which ho had c-arefully defined. 
Attention Avas next paid to tlio muco-<'Utancous junction, 
which ho sutured very acenratsdy with fine silk, Aising 
magnifying gla.sse.s. ' The .speaker iKiiiitod out that the 
prominence of the A'ormilion border of the lip added very 
considerahly to tlie cosmetic ro.sult. He desci ihed the 
incision he employed to i-ccon.strucl the “ Cupid’s how.” 
Manj- photograidis Avere shoAvn of case.s before and aftei- 
treatment; the i-esAilts in most iustancas had been 
escolloat. He mentioned that the skin svitures shoAihl 
lAOt be inserted deeply, otlienvise scarring Avas certain to 
occur. Dr. Veau eiinnAcrateJ the effects of poor opei'a- 
tioiAs, sAAcb as notebing of tbe fice edge of the lip, in- 
clusion of skin in tlio mncoAis portion, and inclusion of 
mucous meinbi'ano in tbo .skin rogioii. He described 
operations to remedy these defects, and again empbasi/-ed 
the importance of sutAiriug the mvAseles. In cases of auaI- 
lateral total hai-c-lip, the speaker said that tbe most 
clifficAiIt portion of the deformity to correct Avas tbe 
spreadiiAg out of the nostril oA-er tlie cleft. Retraction 
of the AipjAer lip following treatment Avas very Ainsigbtly 
aiAd sboAild he picvented. He did lAot icinoA'c the pAo- 
inaxilla, but if necossan- divided tbe bone and disj>laced 
it gently liaclcAvards. He recommended reconstruction of 
Die floor of tbe nose by tiij-jiing doAvn a muco-periosteal 
flap from tbe septuiu together Avith a small flap of iniieo- 
penosteum from tlio palate, aftiw CAitting the frennm and 
stripping up tbe lip. After repairing the liji, be passed 
a deep suture through tbe deep aspect of tbe defovUAed 
jvla on its oAiter side, under tbo floai' of the anterior nares, 
iiiiging it out through tbe skin of tlie face just external 
to the normal ala and tying it there. This suture pulled 
.in the flattened ala. The speaker slioAved photograj’hs 
illustiiitmg the good rcsult.s he- has obtained bv this 
•method. He said that the eailier tbe oiieratioii was 
oimed the better ivas the prospect c.t a good nostril. 
«e was certain that recomstruction of all the elements 
a 'ing part in tbe production of tlie cleformitA- ivas 
essential. 

classified bare-lip into three tvpes: 
partml nnilateral, and bilateral. He bad always found 
tliat the tissues ivcfo defective, .anil tlmt even in the 

uV deformed on that 

I 'e speaker carried his incision up into fho nostril, 
in chock on the outer side before suturing 

wifln*, ■'i H'c splaying out of the nostril, A 

a ” ptodvAced difScAAlties in speech, and excision of 

I on or the alar c.artilage had not mot ivith much 


success. Ho .said flint eversion of the ala could not ho 
corrected, and al.so that the apex of the nostril ivas usually 
depro-ssed. In hihileriil cases retraction of the lip pre- 
.seiitecl the greatest diffieiilty, hut an epithelial inlay and 
the vise of a lAVosthctic aiiparalns overeame the deformity. 

Air. T. PoMKitr.T Kii.xrn said that he and Air. Gillies 
had had most experience of tlie secondary oper.ations on 
cases witli iinor rc-sull.s from primary operations. He 
strongly recommciidpd tlie simple.st methods in tlie ])rimary 
proredni-e, corrcetiiig all the layers concerned and reducing 
raw .surfaces to ii minimum. Ho had not seen good re.sults 
from primary o)Aeratious, and ho condemned strongly all 
flaps and zigzag incisions. Alorc attention should he paid 
to the reinonhiing of the nostril than to tho production 
of an nrti.stic. vermilion border. Ho did not sacrifice any 
skin. Air. Kilner was in agreement with some American 
.surgeons concerning the importance of inonlding tho 
alveolar cleft hy stthmneons wiring. This produced better 
contour and more regular dentition, and obviated the 
necc.ssity for miiro-periostcal flaps. Ho thought that 
replac-emcnt of the prcmaxilla sliould ho gradually pro- 
duced. Ho used Logan’s traction how to relieve tension 
on the sutures, which were removed in three to five day.s. 
Roferring briefly to tlio secondary operations, he said that 
the epithelial inlay and pros-the.sis was the best treatment 
for the vcli-actcd upper lip foIloAviiig operations on cases 
of bilateral haro-liii; for readjustment of the lip he 
employed the “ Cupid's how ” operation, excising a small 
area of skin and .suturing the mutens membrane to tbe new 
skin edge, so prodneing a now and sbapely mnco-cntancoiis 
junction. Tbo nose was remodelled by fracturing the nasal 
bones, resetting tin- wbole nose, ami, if ncccssaiy, carrying 
out a eartitage graft from tbo ribs. 

Air. O. L. Anrnsox .said that tbo best time to operate 
was dtiriug tlio first few weeks. He tboiight tbe imme- 
diate result was a secondary consideration. Thei’o was 
no ncco.ssity for wiring tbe alvoolns if the lip was sntnroci 
early, for the gap gradually closed. The speaker agreed 
with Air. Faggo tlmt tlicro were always defective tissues 
pi-csoiil and tlmt the eversion of tho nostril could not he 
terrcctod. He disliked the method of reconstructing the 
anterior jiart of Hie floor of the nose, and also anv 
attempt at filling up this gap with other strueture.s. The 
epithelial inlay was an excellent method of tre.ating tho 
fiat rctvnetod liii. 

Air. C. W. G. BityAX* .said that ho operated at three to 
six weeks. He freed tlie sound .side widely, moving the 
sound no.stril inwards to help to mould 'the deformed 
side. He never sacrificed any tissue, and considered tho 
“ Cupid’s how ” operation a very Talnahle procedure. 

Air. C. A. R. XiTcii said that he operated at two to 
three months, since then tho ti,s.snes- vrerc stronger and 
a hotter hold coAild ho obtained. If the child was .soon 
early, lie instructed the mother to press the projectino- 
alveolus hack .several times a day. Tho effect was often 
remarkable after a month’s treatment. In severe cases 
ho fraetnred and wired the alveolus. He did Jiot Aindercut 
tho outer side of the cleft, only the inner; this .allowed 
tho columella to he moved inwards, and, after suturing, 
this was Iield hy the fixetl outer, portion of the cleft! 
Alany ojieration.s • were Aisnally ■ neccssatr in order to 
obtain a -satisfactory I'esnlt, and a realiv good nostril was 
never seen after repair of the deformity. 


pathological SPEGIMEjS'S. 

A MEF.TIXG of , the Section of Pathologj- of the Roy.al 
-Acadeniy of Aledieiue in Ireland was held in tlie Roy.al 
College of Pliysieians on April 27th, with the President 
Dr, T, T. O’P.MinELi,, in the chair. . 


Vivcrticnlitis. 

■ The PiiEsiDE-XT exhibited a piece of intestine which had 
been venvoved by Dr. L. G. Gniin from a man ao^cd 57. 
TAi-elve years previously a tumour of unknown natiTre had 
been excised from tbe bladder, and, one' year later a 
faecal fistula appeared at the site of the wound over the 
pAibes. The fistula bad .since altern.atelv closed and 
opened, .and during tlie last few years botli inino and 
faeces -liad beeii discharged tlirongli it. IVhen the patient 
was first seen by Dr. Gimiv there were three apertures' 



1026 JnNB i6, igjS] 


NEW GBOWTHS. 


t TnxriRmM 
UZCICIX. JoCBMift 


On cystoscopic examination the urine fi-oin tlio right 
kidney was observed to he cloudy, and thcro were two 
openings in tho posterior wall of the bladder; no faecal 
matter exuded from those and their exact relation to 
the rectum could not bo determined, though, on palpation 
there appeared to bo so'iuo connexion with tho .right 
ureter. Tho difficulty in determining tho exact condition 
of affairs was due to the presence of a large mass in tho 
right side of the pelvis, which suggested tho presence of a 
new growth of the intestine. The mass, in which was incor- 
porated a considerable length of tho pelvic colon, had been 
removed together with a small section of tho bladder wall. 
An anastomosis had been made between tho two cut ends 
of the intestine and tho rent in tho bladder had been 
repaired. Tho patient made an uninterrupted rccovoi'y, 
and since operation had passed urino and faeces in a 
normal manner. Tho resected intestino measured 11 cm. 
long (after fixation). When opened no ulceration was 
visible, but the muscular wall was very much thickened, 
the average depth being 1.5 cm. Transverse sections at 
several points showed many diverticula extending deeply 
into the wall, some almost reaching tho outer surface, 
llistological sections were made of several jilaces, but no 
evidence of malignant disease could bo discovered. Where 
diverticula were present they exhibited chronic inflamma- 
tion, plasma cells being abundant. Some diverticula 
showed no mucous lining, tho lesion being represented by 
a narrow channel surrounded by inflammatory cells, but 
distinctly connected with tho lumen of tho bowel. Hero 
and there were collections of inflammatory cells, repre- 
senting, probabh-, tho apices of diverticula. 

Ncio Growths. 

Dr. J. T. WiGH.\M showed specimens of a sarcoma of 
the spine in a boy, aged 8, who had been admitted to 
hospital on account of symptoms believed to bo duo to 
tho recurrence of a tumour in tho bones of tho spino. 
Ono eye had been removed two years earlier for what was 
stated to be an angiosarcoma. There was no recurrenco 
in tho affected orbit. The condition began as a gradually 
increasing tumour of the upper dorsal vertebra, extending 
backwards as a projection of a soft fluctuating mass, and 
forwards into the mediastinum, causing a cuiTaturo of tho 
spine backwards and to tho left; thcro was ))rogrcssivo 
paralysis extending from below upwards. Tho patient had 
no pain and his blood was normal except for anaemia; 
X rays showed the development of tho tumour, and tho 
soft fluctuating projections yielded no fluid. Ho died in 
a very emaciated condition. At tho necropsy no tumour 
was found below the diaphragm. A thoracic tumour had 
partly invaded tho lungs, but chiefly compressed them. 
In structure it was a small round-celled sarcoma, almost 
entirely composed of cells; in many places it was almost 
liquid, like thick cream, and sometimes bloodstained. 
The spinal cord was bent round a sharp angle ; it ivas 
compressed and degenerated, but tho tumour had not 
actually invaded it. It was not possible to be sure that 
the recurrence had actually taken place in the bones, 
which were greatly eroded. 

Dr. Wighain showed next a tumour of tho thyroid gland. 
Ho said that a gland removed from the neck had been 
received for investigation as to its nature. It wa's .approxi- 
mately spherical, about 2 cm. in diameter, and surrounded 
by firm fibrous tissue. It showed a structure of coarse 
Eomeivhat hyaline fibres, enclosing ^parate cells, many of 
whicli were- polynuclear. A diagnosis was made that it 
was probably some type of lympliadenoma. Shortly after- 
wards the discomfort duo to a swelling in the neck which 
proved to be an enlarged thyroid, began to increase, and 
a hard, largely adherent left lobe of the- thyroid ivas 
eventually removed. The thyroid itself, which clinically 
was undoubtedly malignant, proved to have the same 
structure as tho gland. In many places it was more fibrous 
and less cellular, but a kind of capsule,- which was stated 
to bo formed from the sterno-mastoid, showed no muscle 
but a more cellular structure than tho thyroid itself! 
There was ' practically no glandular appearance in the 
tumour, and, in general, the appearance was mure like 

‘=^ic>noma. Dr. Wigliam referred to 
Eain„s belief that nearly all the tumours described 


sarcoma of the thyroid were really carcinomata, but added 
that most of the malignant tumours of tho thyroid illus- 
trated in tho books of Ewing or other authors were vciy 
cellular struclurc.s, sometimes easily confounded with 
cxophthnlmic goitre, but not at all of the fibrou.s nature 
of this specimen. 

Dr. IVigham also showed a fibroma of tho tongue. Tlid 
patient had noticed a whitish nodule on the side of 
his tongue. From its position and general appearance 
it was thought to bo probably a secondary nodule of some 
inalignant tumour, although rather hard. On removal and 
incision it was found to be hard, white, and sharply marked 
off from the surrounding tissues.' It had never given pain 
or di.scomfort to tho patient. On examination it p.jvcd 
to bo a pure fibroma with hard hyaline fibres and very few 
colls, about 2 l)y li by cm. in size. 

Dr. L.tix exhibited specimens of a iirimary carcinoma of 
tho lung in a woman, aged 57,' who was admitted to 
hospital complaining of oedema of the left leg, a dry 
cough, weakness, and a gradual loss in weight. She was 
anaemic, and there was dullness over the front of tho 
right side of tho chest from tho third rib downwards. 
Thcro was slightly impaired vocal resonance over the area; 
Tho AVassermann reaction was negative. The presence of 
a tumour was confirmed by a:-ray examination. .-Vt tho 
necropsy a diffuse tumour was found occupying almost the 
enliro fling; it was soft in consistency and cream-coloured. 
Thcro was little fluid in tho pleural cavity. The liver 
contained a few superficial mctastascs the size of peas, 
and the spleen had ono deoii-seatcd secondai-j- deposit about 
.as large as a walnut. Doth suprarenal glands contained 
mctastascs, and tho tumour had involved the pericardium 
on the right side. No tumour was found in any otJier 
situation.^ On l.aboratory invcstig.ation the tumour u.as 
found to ho a priniai-y carcinoma of tho 
from tho alveolar epithelium. In its growth it had utilized 
tilling stroma in a remarkable way, tho tumoiir cells 
Wiic ffioiig tho alveolar walls and bronchi the striieturo 
of udiich was clearly definable. In places the groirtli filled 
tho alveoli with a solid mass. Tumour cells were a so found 
[nsido blood vessels. These cells were mostly ciiboida or 
else columnar; very often it was hard to distinguish then 
niitliiics and this syncytial character was most marked 
iif thr’seclion fiom\!io suprarenal gland. The etiolog>- 
of hill" tumours was discussed; tar taken into the- lungs 
udlli road dust and inhalation of the exhaust gases fiom 
motors were mciitioiicd as causes of the increased incideiito 
of pulnioiin.ry curciuoiiin. 

Tract wind Test iVcals. 

Dr- T T jMcGhath read a paper on fractional test nieiils, 
and ^htved hmtern slides. In liis paper he ana ysed the 
r^uH of tests which he had personally conducted m a 

to tu. « tto. « 
were untrustworthy in cases of gastric ulcei, but 
reliablo in cases of duodenal ulcer and of cancel . py 

T)r R, H. Micks said that test moa!s did not ^ y 
-doSrmin; the presence of a disease, but f 

ii-ithdnw hvdrochloric acid from the stomach. Tlu> uei , 
, i-ehtivelv safe as a means of making a diagnosis 

oroiophiai oitruction. Ho drew attention to the 
occasional disadvantage of analytical nmlectly 

;“o fottlog jolc-o U» olwt "■> ‘“I!” 

orTiialignant XJflelmann’s test 

achl of vei-y little use in clinical practice, and lie a un a 
Sed1w.7erric chloride test He i-s doubtfffi if^ - 

^^^r^Hrmu^h -IuHs^D;: ^Lean had^im;ffieffi 

•Gonsiderable amounts of blood were 

patients who had no ulcerative es.on rt„„c0 

^ Dr It A. Q. O’Meaba drew attention to tho m 
of making certain that hydrochloric acid was 
starting S tost meal, even ‘J. 

method was the best for diagnosis of 8“^ ^ least 
and it should, be possible in tins way to diagnos . 


BE VIEWS. 


Juke i 6, 1928]^ 

Ecbiclus. 


EPILICI’SV. 

Tiik uuiuoroiis problems of epilepsy, its iinture, its varieties, 
mul its possible causes bare lately been llio snitjeel of 
several important .contributions to tbo medical press, so 
that the JOnglisIi translation of Dr. Jlr.sKrN.s’.s nell-knoivn 
book* comes at a very opportune moment, llrilisb readers 
mill be grateful for tins opportunity of .studying a volume 
mbicb in many respects is uniquo of its kind. 

Dr. Jtuskens deals with bis subject on verv broad lines, 
appi-oacbing it by may of physiological experiment on the 
simple myoclonic reflex. The fimt ]>nrt of the book is 
devoted to a long and careful account of bis studie.s on 
mvoclonic reflexes and the myoclonic epileptic fits — studies 
in physiological experiment mbicb tbron- much light on 
the subsequent development of the author’s views on the 
etiology of the epileptic fit in man. The second part is 
concerned with the results obtained by various exjierimenlal 
injuries of the central nervous system in the production of 
epileptiform attacks. The third and largest section of ttio 
book deals with the epileptic di.sorders in man and their 
treatment. The neurologist, in perusing this section, will 
bo .struck by the evidence of the very careful and prolonged 
.study of his patients which the author has made over a 
period of many years, a study which clearly entitles his 
vicivs to the respect of all students of the di.sease. Great 
stress is laid on the occurrence of intm-paroxysmal myo- 
clonic minor convulsions, an obscrv.ation which was at one 
time much emphasized by llusscll lleyuolds, but which 
seems lately to have largely escaped general recognition. 
The value of the diseuxsiou on the more purely clinical 
aspects of the disease is enhanced by the detail.s of many 
personal cases, which are never too long or too numerous 
to interrupt tlie general flow of the argument. 

Traumatic epilepsy, with its own problems of causation 
and treatment, is fully described ; hut wo are a little dis- 
appointed to find that the subject of the status epile|)licns 
and its treatment hardly receives the detailed description 
which its interests and imjiortancc demand. Kiill details 
are provided for the general management and treatment of 
cases; generally speaking, the nuthor'.s methods of treat- 
ment may be regarded ns conson-ativc. There is hero little 
encouragement for those who claim success for nnv par- 
ticular method of treatment — for example, bv diet or pro- 
tein shock or psycliotherapy. A small but valuable appendix 
gives the composition of many of the secret proprietarv 
remedies for epilepsv. 

In conclusion, it may be fairly claimed for this volume 
that it represents a worthy inonument of the author’s 
poreonal experience and experiment.s, which can be cordially 
commended to all students of this complex disorder. 


n, , USES OF DRUGS. 

The book entitled Pharmacotherapcufic, Matcrh .Ifci/ic 
and Drvg Art, on,- by Dr. S. Soli.s-Coiiex- and Dr. T. S 
Githex-s, is an encyclopaedia of drug treatment whos 
scale maj bo judged from the fact that it comimiscs 2,00 

efif """ “"d scope ar 
clctmed in the preface as follows: 

is*kn“ow!rof °drue’ forth wba 
exact methods of^fndv — as ascertained b 

needs of practice, but ahvavs will, , nr, ’ a “ 
pliarmacodvnamicj. It ' has-been rtmmistry an 

detailed studv of individual dtues^aoO m S 

dBcussion of certain general ^ 

ma^rve to guide thf use of ^dnl^^'n^ot o^'l^'f^but' 


■ : .. out- ui uti c 

Sir^aS; , .S.' ’si.erringlon,''’'‘o vi ’'GnE' ''’ai'n ‘'T h q‘’''T 
SolQmoir's!rm!cJ|Jcn'' jfu 'Ynu''’Tr ^''"0 ‘iftinr 

}r,rk 1 ..n.i-n ■ n — ATrnlot...!* Thomas Stoteshurv Gilhens, 51,1) 
Mj. nek.) • ’'PP'rton and Go. 1928.- (Jlcd. 8vo, pp. m- 


r Tut nnmsn 'I flOT 

lJtrnicil.Jocii.xii. a-oci* 


of remedial agents. In tliis dbcussion are included certain aspects 
of llio iiciver developments in pby.'ics and cIicmLslry'; and stress 
is laid not onlv upon tbo adjustivc and adaptive powers con- 
sliliiling Ibo Felf-dcfcnce of tlio organism, but nbo upon the 
inonodynnmic conreplion of disease recovery; Ibat is to say, the 
view llial disease and recovery are not separate states or opposing 
forces, but one ronlimioiis, albeit coin])lex, process, in winch 

derangcinciil and rcsloralion arc fiom tlic fii-st as.sociatcd.” 

Ill the s|mce iit our disimsnl we can only indicate the 
main feature.s of a work planned on such eomprebonsivo 
liiie.s. I(s general arrangement i.s ns foUow.s. The fii'st 

quarter is devoted to a di.sciission of the general principles 
of drug treatment, with information regarding tbo sources 
of drugs, llicir standardization, and so forth. The 

remaining tlirce-quarter.s give a systematic account of all 
the driig.s used in mcdiciiio that are of any importance. 
Medieainent:,' arc divided into tliron main orders;' (1) 
“ anlipatbogens ’■ — that is, all the drugs used to combat 
invasion of the body by micro-organisms and other ])ar.a- 
siU's; (2) •“ tis.sue ’ alterants,” a term which includes 

domuleents, rubefneieiits, irritants, caustics, etc.; and 
(3) “ function modifiers,” comprising all drugs u.scd to 
iiilluoii'ce the fiinclion.s of the body. In the case of each 
drug its history, chemistry, materia mcdica, pbarmacology, 
and llierapenlics are described. 

The chief impression jiroduccd by a rapid glance tliroiigh 
the volume is one of admiration for the immouso indu.stry 
of tlio compilers — industiy of a type that hitherto many 
had thought to find only in Germany. Detailed study of 
a few scelions cboscii almost at random confirms -this 
feeling of admiration; for tbo authors give a very full 
necoiinl of modern views regarding tbo ))barmacology and 
tboraiieutics of each drug. It is indeed a remarkable 
actiievomcnl to have produced .so large a work .md to 
have kept the whole of it' up to date. Only a small jiro- 
portion of the space is occupied by details of materia 
luedica, and most of the text is devoted to a summary of 
tbo information available concerning tbo tberaiieiitic actions 
of drugs. Tbo size of tlio book is indeed a testimony to tho 
very largo amount of pharmacological knowledge that has 
lioon accumulated, and it is inloro.stiiig to note how largo 
a iiroportion of. the work referred to is of recent date. 

The volnmo appeal's to be .m excellent work of reference 
on drug treatment, which should jirove of great. service to 
the mcdienl profession, since it includes within a single 
cover masses of information that have liitbcrte been diffi- 
cult to obtain except from monographs. It is a book that 
can bo iccommended to all medical practitioiiei's who wish 
for a full and detailed guide to modern drug therapy. 
Dnfortunalcly no references arc given, but tho inclusion of 
any clfcctive hibliograpliy would have swelled the volume 
to an unmanageable size. As it is, the publishers are to 
be congratulated on having comprcs.sed such a large amount 
of printed matter into a single volume of reasonable bulk 
and weight; tbi.s has been aebioved by the use of thin 
paper. In conclusion, we may say that the price (three 
guineas) scorns very reasonable for a work of .such 
dimensions. 


laryngology. 

In the third edition of bis book on Diseases of the Larijnx,- 
for several years out of print, l\Ir. Baiiw et.t. has inciude’d 
eliaptci*s on the trachea, bronchi, and oesophagus, and 
endoscopy now finds an established place. The twentv-one 
years which have elapsed since tbo firet edition was'pub- 
lisbed have been a pci iod as full of ])rogress in laryngologj' 
as ill any other branch of medicine. The development of 
endoscopy, which has readied the stage of. definite rontino 
procedure, is largely, hut not, wholly, responsible for this. 
The management of eases of laryngeal tuberculosis is now 
very different, and there lias been advance in the control 
of malignant . disease in this region. All this is ■ fully 
described in Iilr. Barwell’s book, and in consequence tli'o 
whole outlook is ebaiiged. Nevertheless, be never loses 
sight of the fact that lan'iigology is based on the examina- 
tion of the laiynx by the indirect mcfliod with tbs 
laryngoscope. 

Textbooks on diseases of the larynx usnally include also 


UniverFit.v Tres.. 1928. (Dem.v 8vo, pp? XV+27S 




June iC, 19^8] 


NOTES ON BOOKS. 


[ Tuf Ubiti'u T 09,9 

JtKPICAr- JOfilSAL * 


pretovuWc iu- pnvlicxiV.M' pviKtucs Uvo ndvico Riven is 
iuvarinblv smiiid and valuable, and such advice musl 
nccc'Miriiv be based iiiioii peisoiial cNpeneiiec. Especially 
bclpful for tbo newly ipialified' pvactilioucr are llie 
ebapters on “ piircliasiiiR a praeUee ” and “ building a 
new. piaclice .many difiicultic.s will bo avoided if he 
follows, tlic delailed advice Ibereiti given. It may, li'ow- 
cvet, be doubted wliotbcr it i.s ahyny.s wi.sc to consult a 
local dentist, or even tbe local British IMedical Assoc-iation 
secretary, with regard to the character and suitahility for 
purchase’ of an individual practice, oven though such 
inquiric.s are made with the poriiiission of the vendor. 
Nor are wo sure that it is always be.sl, during the period 
of iiitixiduction, for the purchaser to " bear all expenses 
and receive all profits, paying the vendor the locum feo 
usual in the district.” Tbo advice, in a later chapter, 
to plan to do for oneself many of the simpler forms of 
laboratory investigation is, on many grounds, very wi.se, 
tboagli commonly neglected. An excellent principle for 
general' guidance is laid down by Dr. Briggs in tbe scii- 
icnce; “Tour patients .are your guests; make tlieiii at 
home.” • On the other hand ii may he that he goes too far 
in andercstimating his guests when he says, in a warning 
to the lieginncr against explaining too niiieli, “ There are 
no intelligent patients.” 


THE PROCESS OE EVOEUTION. 

Noihixg gives thonghtfiil men more . encoiii agcment than 
to see a demand for small hooks which handle serious 
subjects, such as those of tho To^lay and To-morrow Scries. 
Dr. Russbu. Bn.trx has written for this .series a readable 
and brilliant essay on a ncgleetcsl as|)ect of evolution.* Ho 
aceepts tbe theory of evolution as the only explanation 
of the world of life, hut believes we are .still- ignorant 
of the biological processes which bring about the transinnla- 
tioii and transformation of. species. In this nil who have 
examined the writings of Eamarcl; and of Darwin will 
agreec ” Those who object to noo-Dnnvinisni,” he writes, 
” on the score that it does not explain tiio facts, maintain 
tliat flic siinvUaiirnu!: auti lioniioiiioiM ndoptationnl irans- 
fovmafiotts required of evolution could not possibly bo 
produced by bapliazard mutations in' the time available.” 
To account for the evolutiou of man’s posture thousands 
of structural units have to undergo a corrolnted change 
at the same time — a possibility outside the bounds of 
elianco. Dr. Russell Brain is tlierefore of opinion that 
Dainarck’s conception, which was also Darwin’s, must be 
true, and that a way will yet Ire diseovcired of showing 
how fnnetioually wrought modification tan become heredi- 
tary. The school knot™ as neo-Darwinists has thromi 
this part of Darwin’s theory overboard. Dr. Russell Brain 
contends it must be restored; ollierwisc Darwin’s theory 
is devoid of a “ creational machinery.” 


NOTES ON BOOKS. 

lx lus monograph on the three-gland theory of urinnr 
secretion* Profepor PihTEn discusses the question, not froi 
the experimental point of view, tint from comparative stud 
of e.xcretory procreses in general as e.xlii(iitcd in the aninu 
series. His niyestigations lead him to tbe conclusion that fl 
renal function in man is best explained by regarding tbe kidnf 
as a complex of tliree glands. The primary functions of tl 
kidney being the removal of the end-products of met.abolisr 
of water, and of salts, be finds that in fishes and in mar 
worms these functions are subserved by cells of a single tvp- 
vbile 111 the .ascending animal scale there is a gradual separ 
tion of fnnction.s so that m mammals tavo distinct striicti.r, 
are differentiated for the excretion of tlie end-prodnefs ar 
‘’■'= involuted tiihiiles and tl 
in rlo! ’ »1 “'rubles Further, there develops in mammal 
iLiln- relationship Svith these two glands and from sma 
— structure, winch is also represented in amphib 

"•“‘O'- ‘o *■> oortain exte; 
morbed, a function analogous in a minor degree to that sh 


».M‘?Oxoi“’ JtE C P Lond hra 
Kopan Pftul, Trend/ To-Morrow Series. Londo 

net.) . Trubner and Co., Ltd. 1927. (Feup. 8vo, pp. 

Bciua; 'fi™ 3 - Von Dr. Aujusl PiUt 

O. aprin^cr. (Roj. Bvo, pp. jr + 173. 6 H.JI.geO.) 


served by the cloacal imicoiis iiiembrane of birds and many 
rciililes. A third eleiiieiit lreconic.s difTercntiated in nianinials 
ill the form of (he (bicker distal limb of (lie Joop.of, Hcnlc; 
this i.s called tbe “ siilt-glaiid ” by the author, its function 
being, ill bis opinion, ’to disclmrgc the salts of tbe ulkalino 
nielids ill a .state of high concentration. Tim second— di.stal— 
gii.up of convoluted tiiliiiles present in the human kidney are 
considered to have a function similar to that of the proximal 
groii)), altlimigb there is jirobably sonic differentiation, at 
prc.scnt unknown. ■■ 

Dr. Georges Giiiel has prepared an account of tbe treat- 
ment of epitlielioma of the skin and miiooiis membranes’ accord- 
ing to (lie method of radiotherapy introduced hy Dr. J. 
Costc, in which ti.se is made of tho less penctr,nting rays, 
no fiUratioii is employed, and a strong dose is given at a 
single .application. Dr. Gird discusses tho mode of action of 
the longer wave-lcngtlis on the tissuc.s, and tbe histological 
appc.ai'aiicc of the various tumours so dealt with. He describes 
in detail the toebnique be employs, and shows bow a relatively 
simple form of apparatus is sufiicient. A good bibliography 
is appended, and tbe book will, wc think,, be ■ivclconicd by 
those interested in this particular branch of radiotherapy. 


The liaiidv guide to MofgtiUo Jfcduclion and MalartaJ Pre- 
vention,'’' hi- Drs. J. A. CnAwroRD and B. S. Ciialam, medical 
ofiicers in cirarge of antimalarial measures in India, avas reviewed 
in these columns (1927, i, 881) less than a year ago, and has 
now pa.ssod into a second edition. The authors have now 
added an appendix on Paris green (aceto-arsenitc of copper), 
wliicli, when scattered on (lie surface of water, is swallowed hy 
the aiioplieliiie larvae and poisons them. It is insoluble in 
water, does not damage fish, aquatic insects, or ducks, and is 
diluted with fine road or clay dust. The mixture of 1 part in 
IM must be kept dry, otherwise it will sink. ' Modestly intro- 
duced, this is a very useful book for malarial inspectors and 
managers of tea gardens, ns. indeed, tho rapidity with which 
a second edition lias been called for would tend to prove. 

To the “ Notable British Trials ” Series has been added the 
Trial of Xamiifl Herlcrt Doinjal," wbicli contains the story of 
what was commonly known at tlie lime as the Moat Farm 
murder. As the evidence which led to the conviction and 
exeention of Dongal was largely circumstantial, and as the 
body of bis victim was identified mainly by her apparel, there 
is liot much of medico-legal interest in the trial itself. The 
main features from the m«lic.il aspect are probably the psycho- 
logical studies exemplified by Dongal, whose career ns a 
criminal and a ruthless woman-hunter was really remarkable, 
and by Camille Holland, who, at tbe age of about 57, after 
au .almost austere life, yielded herself to Dongal and met her 
death at bis hands. The strange association between this 
murderer and bis victim is handled with considerable skill in 
the inti-oduction by Miss Texxtson Jesse, the editor of the 
volume. 

I A further edition of Bow to Become a Kvree'" — the eleventh 
(o be published since this useful little book was first produced 
under tbe editorship of the late Sir Henut BuRnErr in 1899 — 
lias appeared, incorporating the most recent information avail- 
able on the subject covered by its title. The introdnetory 
ebapter contains much sensible advice to would-be nurses, 
while (he greater part of the book consists of a directorv of 
hospitals, etc., in Great Britain and Ireland, with details of 
nursing .salaries, terms of engagement of probationers, and 
status as training institutions. • 


In B iiineaiity ^ and Jjahour hi China'^ Dame Adelaide 
Axdersox describes a visit she paid to that country ^during 
the years 1923 to 1925, in the course .of which she made a very 
careful investigation of industrial conditions generally. A con- 
siderable ^ amount of information about different phases of 
Chinese life is set out in an interesting manner, and her dis- 
cussion of such questions as child labour and the general 
progress of industrial reform in China is illuminating. The 
hook is also attractive as a travel diary, and there is a pleasant 
description of the country through which she passed. 


* La Itoentgcnthcraine dec Epitficliomas Cutanei et Ctilniico-Viioi/riir 
par la Melliodr riu Dr. J. Caste. Par Dr. Georges Gird. Paris - Slasvnn 
et CiD. (Roy. Bro pp. 300; 8 piotes. Bs.) ' 

'•iUatavfro Reduction and llalarial Prevention: A Precis Bv T A 
Crawford, M.B., Cli.B.Ed., and B. S. Clialam, L.R.C.P and' R Ed 'ete" 
Second edition. London; Milford, Oxford XIniversilv Press. 1927' fc’r R™ 
pp. XV 4-' 107 : 17 figures. As. 6d. net.) * ■ t ■ o, 

» ‘1-*?''“.^ Script Douyaf. Edited by F. Tennyson Jesse. Notable 

British Trials. Edinburgh and London: W. Hodge and- Co Tfd • I OM 
(Demy Bvo. pp. xii - 1 - 236 ; 20 plates- 10s. 6d. net ) ’ .' 

*’ Row to Become a Kurse. Edited by the late Sir Henrv Burden K c B 
K.C.V.O. Eleventh, revised edition. London ; The Scientific PiiV^ rivi'ir'’ 
and Gw.ver, Ltd.) 1927. (6 x 7, pp. :^iii + 3«. - irM netO ^ ' 

"Rumanity and Labonr in China. Bv Adelaide Marv Andersn.. n » v 
M-A. London ; Student Christian Moi-ement. im P'®'®-, 

+ 285 ; 7 ptatea. 10s. 6d. net) PP- *v 




Jas’B iG, igiS] 


INTEKPRETATION OF GASTRIO SYMPTOMS. 


I.KCTDnr. 11. 

Pain occurring in nuillii)!o areas was inoro difficult 
classify, but the points wero u'orfliy of noiieo. Tlio pain 
frequently began simultaneously in all positions, .and when 
this happened tho timo of onset might ho taken as indi- 
cating the origin, as in the single pain areas. Tlio pain 
also often .spread npirards or domiiv.ards dni'ing digestion. 
■Upward spread usually meant a primary pyloric disturh- 
aiico, whereas rapid downward spread usually pointed to 
considorablo nervous instability. 

Sensation 0 } jnllntss, although primarily a symptom of 
body disorder occurring in 00 per cent, of cases with pain 
at tho cardiac end, was found al.so in 80 per cent, of cases 
of- pyloric pain. This was- c.asily to bo understood; tho 
■sensation depended on the volume of tho gastric contents; 
if tho irritable pylorus held up tho gastric contents a 
sensation of fullness would result; if, however, tho pyloric 
irritability showed it.solf late, when the contents had largely 
left the stomach, tho sensations produced were those of 
hunger. Absence of pyloric relaxation was not necessarily 
accompanied by pyloric pain, ns this only occurred when 
tho pylorus or adjacent part of the vcslibulo bccamo 
spasmodic, so that' there was yet a third type of pyloric 
irritability, which Was associated with tho sensation of 
fullness but without pyloric pain. There was no doubt that 
tbesQ pyloric types constituted tlio most important group 
of sufferers from dyspepsia. 

Iltlic/ 0 / Pain . — Tho symptoms of functional disorder of 
the stomach occurred at dilfercnt phases in functional 
activity, and ceased when tho work of tho particular part 
aficctcd Was finished. Factors causing tho disappearance 
of pain wore therefore as important as those causing it 
in explaining tho mechanical disorder giving rise to it. 
Three common w.ays of obtaining I'clicf wore by food, by 
eructation, and by vomiting. .t)f tho cases which were 
completely relievoij by food more than half fell into tho 
group of jiyloric pain (mid and loivor stcrno-umbilical areas); 
but on analysing the timo of onset it was found that in 
the largo majority of all cases whore pain was completely 
relieved by food the pain appeared late; so that it w.as 
probable that oven tlioso cases in whicli the pain was 
located in the cardiac or ocsoiitmgcal areas wore mostly 
.secondary to a primaiy pyloric disturlinnco. On the other 
hand, patients who wore not relieved by food were mostly 
tlio subjects of early and irregular pain.’ Two factors were 
involved in the causation of cardiac pain — tho irritant 
nature of the gastric contents and an ovcraction of tho 
noiiro-nuiscular mechanism. The taking of food brought 
into play, the mechanism for inhibiting muscular raovc- 
meiits seen during normal filling of the stomach; this 
inhibition was naturally less effective in cases where the 
central nervous system was unduly irritable, and as it was 
oesopliagcal cases in which such 
ond^+i 1 ^™* most common, theso wore naturally tho 
rl.ia . .' ** ® least relief by food. On tho other hand, 

gastric contents tended to 
wbon +1 ^ later stages of digestion, 

' 1 I'ad been 

-s IE; 

tbrfr^"foid’'if ’’preset!' neutralizing 

const.ant a symptom as to bo 
air sw.>llr. help; tlio gas was practically always 

however ‘t ’ tood, with saliva, or voluntarily; it did, 

system ’ T.’" "1’®” excessive, an unstable nciwous 

tile iiei-v ation of fluid was much less dependent on 
acid er ueTeK l'°lp- O'' the whole, 

cases anri "h'ro commonly with pyloric 

Shs ” ,! ^ O' tasteless eructation with cardiac or 
in the ^ ^ 'I'ft'nct'ou was due to the fact that 

as a Sr°up the function of the pvloric sphincter 

liyperaofdfc"’o'^f +T V*"- interfered with, and 

^ gastric contents resulted. 

a multitude o?'n‘''rcd so irregularly and in such 

imp^rtaiwe xr renditions as to be of little diagnostic 
imnorHnro. however, was of the greatest 

«Hes of 1 m 82 8 per cent, of the whole 
, cases, and was therefore much less frequent 


a syinplom than pain, and indicated a high degree of 
irritation of tho stomacli. To assess its significaiico it 
was essential to take carofui note of its origin and onset, 
for tho reflex tended to heroine more oxcitahio, ami the 
vomiting then lost its initial -clmractcr. It was also fre- 
quently induced by reflexes from all parts of the body, 
by nlfcctioiis'of the central n'cn-oiis system, and by blood 
poisons, so that the indiention.s of a gastric origin required 
close attention. It occurred in about the same proportion 
of cases in the pyloric and cardiac groups, hut much loss 
frcqiioiilly. in tho oesophageal group. The main cause of 
vomiting w.as pain. In 63 per cent, of his cases wliich 
showed vomiting the act occurred at tho height of tho pain, 
nnd in theso tlicro was rather a higlior proportion of 
pyloric cases than cardiac; oesophageal pain was the least 
likely to cause vomiting. Tho next ino.st active cause of 
vomiting was regurgitation of fluid from the stomach to 
oesophagus; 11.7 per cent, of tho cases wore due to tliis 
cause. TJio regurgitating fluid irritated the fauces and 
c.auscd retching; this condition was found much more 
frequently in oesophageal cases, and was especially common 
in neurotic subjects. Tho third cause was tho voluntaiy 
one in which the patient made himself vomit to relieve 
his ^iptoms. Sometimes the liabit was continued as an 
involuntary one, nnd tho patient then complained of it as 
his chief symptom. This group contained but few witli 
oesophageal symptoms. These throe factors — pain, regurgi- 
tation of fluid, nnd voluntary vomiting — accounted for 
85 per cent, of his cases. 

Il'asftnff was an important sj-mptom in cancer and 
pyloric obstruction, and nlso in certain remote diseases 
with gastric symptoms. Functional disturbances of the 
stomach, including nncomplic.nted ulcer, did not cause 
wasting; but tliis symptom might bo associated with it in’ 
three conditions: (1) severo vomiting, (2) voluntary reduc- 
tion of food to roliovo symptoms or 'becanse tbo patient 
was afraid to cat, (3) loss of appetite with nausea. All 
thc.so were indications of a neurotic individiml. The 
wasting impaired tho nervous System, and symptoms were 
aggravated. 

Appetite was good in most of tho pyloric cases; these 
included tho most robust individuals .and contained the 
smnllGst number of neurotics. Among cardiac and oeso- 
phageal cases about half had a fair or poor appetite. 

Sex of Patient and Shape of Stomach . — In males the 
pyloric region was affected twice as often as the body ; in 
females tbo pyloric region and the body were affected to 
an equal degree. With regard to shape of the organ it 
was not justifiable to look upon any form of dyspepsia 
as duo to any particular sbapo of stomacb. Normal in- 
dividuals varied .about a certain average .as reg.ards position 
and shape of stomach, nnd also as regards each of its 
functions; the typo of stomach affected must produce some 
modification in tho processes resulting from any disturb- 
ances, but all people, whatever the sex or tho shape of the 
stomach, were liable to .the same affections, and anv 
differences m individuals in liability to any particular 
affection depended on tho make-up of tho nervous svstem 
and the habit of the individiml. The. greater nervous' 
tendency of the fenDalo was showji by comparing tlio two 
sexes as regards the time of onset of . symptoms ; tho 
female showed in oveiy position of pain a’niucli greater 
toi^ency than the male to feel the pain quite early. 

Organic Lesions . — Gastritis and nncomplicated nicer were 
rtio only two organic lesions that need he mentioned. 
Gastritis was present in some degree in all chronic ulcers, 
but if It produced any symptoms they were indistinguish- 
able from those due to irritability of the 'body of tbo 
stomach, except by the typo of vomiting and examination' 
of the gastric contents. Ulcer, on the other hand, was of 
great importa'nco for the present purpose because wo knew 
the positiou, and could therefore locate the irritable focus 
producing the symptoms. Duodenal ulcers must be con- 
sidered with gastric ulcers, as whichever side of the' 
pylorus tho ulcer was situated the effect on. the 
pylorus was the same. In duodenal ulcer 87 ner 
cent, of cases of isolated pain exhibited pyloric pain 
12 per cent showed cardiac pain, whilst in eveen- 
tional cases there was no pain, but merely a soiisaiii . 
of fullness and regurgitation. Tliis entirelj- 00100 ^ wit 



1032 Jdhe i6 , 1928] 


INTERPEETATION OF GASTBIC SYMPTOMS. 


t TnxBirms 

IifEDI£.lL JocUAft 


tlio conception of ])yloric irritability previously described. 
Of 59 cases of gastric ulcer 23 wore found by the surgeon to 
be pyloric and 36 in the body ; in the, pyloric group tliero 
uas pyloric pain in 88.8 per cent., ■H'liilst in the' cardiac 
group there was pyloric pain in onl}' 40 per cent, and 
cardiac pain in 60 per cent. That a certain number of 
ulcers of the' body caused cardiac pain bad been noted by 
various people, tbo explanation being that an ulcer on 
tbo lesser curvature in tbo vestibule might give rise to 
irritability of tbo pylorus tbrougb tbo myenteric plexus. 
Tbe.se results indicated that tbo pain in idccr was not 
produced by irritation by gastric contents of afiorent nerve 
fibres in tbo base of the rdeer, as in that case the referred 
pain sboidd always indicate accurately the ))Osition of the 
ulcer ; latber tbo pain indicated the segment of tbo stomacb 
irritated. Duodenal and pyloric ulcers acted as a focus of 
irritation to tbo pylorus with secondaiy caidiac sj'mptonis, 
so that tbo pain was usually pylorie and oidy occasionally 
cardiac. IJlcer of the body irrit.atcd the cardiac' portion 
and pain was usually cardiac, but in a smaller ]>ropnrtion 
might by its position irritate the pylorus aiid produce 
pyloric pain. The pain of ulcer was thus of precisely the 
same nature as that of functional disturbance, aiid it. 
obej'od the same laws, so that it was impossible to separate 
them clinically. 

Reflex. Effects on the Stomach. — Oiir knowledge of rellc.x 
dyspepsia as a resrdt of disorder to some other organ was 
fragmentary, but from a clinical point of view the most 
important sources of origin of snob reflexes' were tbo 
biliary apparatus and intestines. With regard to gall- 
stones, be bad found that in a series of 59 cases that 
had been operated upon the greater number suffered from 
gastric symjjtoms originating in tlio body; this agreed wifti 
general medical opinion and was in conformity with a 
number of observations recorded on the gastric acidity in 
gall-bladder conditions. It was much more difTicult to come 
to any conclusion on tbo question of reflex irritation from 
the intestine; but, with regard to appendicitis, bo agreed 
with those who held that chronic appendicitis did not exist 
except as the end-result of an acute attack. In a series 
of cases of appendicectomy for gastric symptoms in which 
removal of the appendix produced no effect, an analysis 
of the position of the pain gave results not unlike those in 
whom operation bad been postponed for a supposed but 
non-existent ulcer. , , 

Leotuiie m. 

The symptoms of functional, disorder of the stomach 
could thus be classified jnto three groups or syndromes; 
pylorie, cardiac, and oesophageal, each connected with a 
different part of the gastric mecbanisni ; it remained to 
c-onsider what alterations in the mechanism were rcsjioii- 
sible for the production of these .symptom-groups and the 
cause of those alterations. 

PyJoric Syndromes. , ' 

The causes of these were : (1) Indigestible dnd irritating' 
food; the function of the pydorus was to bold up ' por- 
tions which required further, disintegration,' so tb.at the.se 
irritants led to deficient pyloric relaxation.' (2)' Hyper- 
acidity of gastric contents, wfiich licsUlted' froin delayed 
P3'loric relaxation itself,, maintained th'e ' irritability"; and 
induced spasm. Tlie facilit}'. with which' these two c.auses 
produced their effect . depended upon the stabilify 'of tiie 
nervous s 3 stem, which might bd affected 'adversely by 
(1) a direct effect upon the myenteric plexus by a chronic 
ulcer or veiy rarely by 'cancer; (2) by reflex dfritatioii 
from elsewhere in the alimentary system; and (3) general 
conditions, such as neurasthenia, although these produced 
their effect most often in the other syndromes. 

Effects of the pyloric irritability were the same wdiatcver 
the cause: the p3'lorus was interfered with in its double 
capacity ( 1 ) as a regulator of the output of food, and ( 2 ) 
as a regulator of tbc acidity of the gastric contents. The 
pyloric sphincter determined the rate at which food left 
the stomach ; at the beginning ' of digestion it relaxed 
enough to allow liquids and finely divided solids to pa^s, 
other material being shot back into the pyloric ve.stibule 
mor^."- ^'®’utegrati.on ; the gastric contents thus became 

>01 e irritating as digestion proceeded. If indigestible and 


irritating food wore taken the factons bringing .about 
pyloric relaxation became less effective, the p 3 'Iorus refused 
;^ii'oIax, and filially ■' became sptrsnimlic-; jieristalsis then 
'ihcrcased-in'vigonr,-hs’ in the case of- all ojijiosed niuscle's, 
so that the internal pro.ssnre was raised. If when tlio 
spasm came on the greater part of the food had left the 
■stomach the 'exaggerated inovements- of the stoimich were 
of the same nattirc as the normal hunger contractions 
of the empty stomach, and jiain was blended with the 
sensation of enqif incss or hunger. If the gastric contents 
at the time of pylorus spa.sm were considerable the puiii 
was associated with a feeling of fullness. As the cavdiac 
.s|ihiiicter I'claxed there might bo occasional rognrgitation 
of aehl fluid info the oosophagirs, with a burning sensation 
ill the throat, and the fluid might reach the month and 
he spat out. As the .second function of the pylorus in 
regulating the nci(lit 3 ' of the gastric contents by permitting 
the rogiirgilatioii of alkaline duodenal contonts had recently 
been -denied, it was neecssan' to give .i brief dcscn'ptioii 
of tbo foundations on wbicb llii.s idea was based. Bcanniont 
was the first to recognize bile in tbo stomacb, but no atten- 
tion was paid to if until Uoldyroff clearly establisbed the 
spontaneous regnrgifntion of bite and intestinal juices info 
tbo einpt 3 ' sfomnch of both dog and man. Boldyreft 
proved eonelnsively that if acid were introduced into the 
stomach it was nentrniized by regurgitation of pancreatic 
juice; bo tbougbt the process of regurgitation iieutralircd 
llie gastric contents down to 0.15 per cent. n.s tbe optimmn 
acidity for digestion by trypsin. That this neutralization 
.also occurred as a normal process in tbo digesting stomach 
in man bad later been demonstrated by estimations of tbo 
clilorides in tbo gastric contents after fractional test meals. 
In the iioniial subject tlie acid of the contents gradii.illy 
rose to somowbero about 0.2' per cent, at tlio height of 
digestion and then gradually fell towards zero as tho 
stomacb emptied; if g.astrio juice of constant strength 
continued’ to be secreted tlirougbout thy curve must con- 
tinue to rise steadily," but. if secretion stopped wlion tbo 
acid peak was rcacbod tbe acid concentration of tbc gastric 
contents would remain at that level and the curve would 
appear as a horizontal lino; if tbo gastric juice fell off 
in acidity the curve would lie between tlio two levels, and 
experiments by Rosoinan on dogs suggested that .such a 
fall in the acidity of the gastric juice did actually occur, 
but the lowest percentage reached was 0.319 per cent. HCl, 
so'that it was impossible! for gastric juice to act as a diluent 
of gastric contents wbicb had, on an average, only an 
acidity of 0.2 per cent. HCl. 

Tlio only other process which could bring down the acid 
of tbe gakric contents \Vas neutralization. Chloride c.sti- 
jnations by the fractional method showed that, as the acid 
enne fell, the curve of neutr.al chloride increased jmri 
Rajsii, the total chloride curve roraainiiig unaffected. The 
concli’ision was that tho true secretory curve was not the 
iicid curve, hilt followed clqselythe total chloride curve; and 
that the acid ciiive represented tho process of ncutraliz.-i- 
tioiij which in turn ' depended upon relaxation of the 
pyloric sphincter. Tlio hypothesis was formed that in 
pyloric irritability the pylorus refused to relax at tbe 
usual time and houtralization". failed to occur; tbe course 
of tbo acid’ curve- then- depended on the secretory activity 
of the stomach end the behaviour of tbo pylorus; it might 
co.ntinuo to rise as in the “ climbing ” curve, or it might 
draw!a bofizontal li’he', 'of, if the p 3 loi'us relaxed occasion- 
allV, it 'hiighf fall with caeli"' relaxation and rise again ns 
thd pylorus tigliterie'd' upi "Tliore were a number of facts 
eohfifming this cb.ncliisioii. 

1. BUe ahvaj-s appeared in the stomach from the beginning m 

the cases of excessive neutralization. . 

2. In oi-ganio obstruction of the p 3 'lqrus by nicer where regurgi- 
tation was prevented, the acid curv-o did not fall. ,1 „ 

3 ; Where the pylonis is cut out or after gaslro-enterostomy tuo 
total chloride curve is unaffected,' but achlorhydria is cstablisneii 
by free regurgitation. , ... v.Iati 

4. ” In .certain cases of pyloric hypertension atropine m aomiioi 

to diminishing secretion converted a climbing curve into a normal 
one by allowing pyloric relaxation. . . , , 

5. After recovery from dyspepsia the pylorus could be irritaicu 

by adding badly coofced split peas to the meal and a normal cuii 
be transformed into a climbing one. _ . ,, 

6. The rapid ups and downs that were sometimes seen m ui 
acid curve could only be explained by the vagaries of a sphiiicic 
muscle. 




1034 June i6, 1928] 


THE NINETY-SIXTH YEAR. 


r TjiK UniTurn 
MrtHfit, Jor RXAX, 


33rtttsi) JHctJtcal ^otirnal. 

SATURDAY, JUNE 16th, 1928. 


THE NINETY-SIXTH YEAR. 


Prep.vkations for the Annual Aleoting of the British 
Medical Association at Cardiff are now well advanced; 
the programme for the eighteen scientific sections, of 
which the provisional outline appears in our Snpple- 
ment this week, is nearing completion; and with the 
forthcoming publication of the- Supplementary Report 
of Council the full record of the Association for the 
1927-28 session will lie open to inspection.^ That 
record is presented primarily to the general body of 
members in whose name and by<whose authority the 
work is carried on from day to day, and to the elected 
representatives whose function it is to pass judgement 
on their behalf upon what has alreadj' been done and 
to lay down the lines of future advance. Beyond this, 
it should be regarded both as a challenge to the in- 
difference or antagonism of non-members, and as a 
manifesto to the growing section of the public which 
takes critical and sometimes captious note of the way 
in which the medical profession seeks to satisfy the 
increasing claims of the community for expert guid- 
ance^ in all that affects the common health no less than 
for individual help in sickness and accident. The 
record must_ be studied in detail to appreciate its full 
scope and significance, but something may be gained 
also from a cursory review that throws into relief the 
resources at the command of the Association and the 
manner in which they are being employed. 

Membership, a useful if not an exhaustive index to 
vitality, shows healthy progi-ess. The figure to-day 
stands at 33,700 — an increase of over 1,300 since 
December, 1926, and over 9,000 in the past five years. 
The progress of the Medical Association of South 
Africa as an integral part of the British Medical 
Association has amply justified the high hopes with 
which incorporation was accomplished in the opening 
days of last year; and the presence of Dr. Brackenbury 
at the South African Medical Congress in Bloem- 
fontein and the general success of his mission have 
demonstrated not only the strength but the practical 
value of the bonds established by the Association 
between the profession at home and overseas. 
Arrangements for the Annual Meeting of the Associa- 
. tion at IVinnipeg in 1930 are already in hand and 
preliminary consultations have taken place in London 
between delegates -from Canada (Dr. T. C. Eoutley 
General Secretary of the Canadian Medical Associa- 
tion, and Dr. J. D. Adajnson of Winnipeg, repre- 
senting .the Manitoba Medical Association) and the 
officers and officials of the British Medical Association 
'J’he report from Ireland' lays stress on the impetus to 
medical organization given by the Medical Secretary’s 
visit early -last year. Alike in .Scotland, where the 
Edinburgh office has been enlarged, and at the head- 
quarters in London, where the ground is being rapidly- 
cleared for the first part of the building scheme sanc- 
tioned by the Representative Body- last year, the 
Apociation is providing itself with homes in keeping 
with its status and activities. Meanwhile, lest growing 


’iSa .CounciJ for 1927-23, with Appendixe."!, r 

at oi April 28 


printeti Vrt Council foi' 1927-28, with . 

SuppicScnfary’penoVf Medical Journ . . 

rypls form the hIsiV fS? h,"'"!' ’“‘h. Tliese two d( 
„t Cordia from July rcth^t^^tr Annual Representa 


numhens and growing material resources should lend 
to the incrliii of instilulionalisin, tlie mticliincry of the 
Association is under constant scrutiny, and modifica- 
tions arc always being made to Itcep juice with fresh 
developments. Tlic inauguration in the past yctir of 
special groups of sjia jiractitionors and consulting 
pathologists has given the Association an opportunity 
to approach, by way of schemes for the spa treatment 
of insured per.sons and for the ordered development of 
pathological services, problems of real importance to 
the public and the profession in a manner which 
appears to justify this new phase of organization. 

Its primary object— the promotion of the nicdical 
and allied seienccs — the Association has served through 
the customary channels. 'J'he circulation of the 
British nicdical Journal still exceeds the growing 
membership, and there is abundant evidence of the 
care with which its pages ni'c studied by readers in all 
parts of the world. A larger amount of money, which 
includes a special grant to a supervisory centre for 
rheumatic children, has been distributed for the pro- 
motion of research, and more and more use is being 
made by members of Ihc imjjrovcd service now gifcn 
by the Association’s Library. There is also a steady 
demand front the Branches and Divisions for British 
Medical Association Lectures. The^special feature of 
the vear’s work for the advancement of medical science 
has been the inception of two schemes for collective 
research. This is a' return to — or rather a develop- 
ment of — an undertaking in which the Association was 
a recognized pioneer nearly seventy years ago, and for 
which it commands to-day resources hardly dreamed 
of by those wlio set on foot the modest venture of 
1862. The response to the recent inquiry into the 
after-results of gastro-entcrostomy has already sur- 
passed the most s.anguinc hopes; that on the treatment 
of varicose ulceration shows good progi-ess. 

In its special reports on lunacy and mental dis- 
order, on puerperal morbidity and mortality, on treat- 
ment by electricity and radiation, and on the possi- 
bility of formulating an international medical code 
for rise at sea — just as in the working out of a scheme 
for the- alternative provision of ophthalmic benefit 
under the National Health Insurance Acts through 
clinics— the main task before the British Medical 
Association has been to secure agreement on the best 
way to safeguard and extend the application of existing 
knowledge for the benefit of the community. It is in 
the preparat ion and discussion of such reports as these 
that the Association makes- its most .■.characteristic 
contribution to the education of the public in health 
matters, by securing a consensus of professional 
opinion upon questions in which the many con- 
flicting voices tend to confuse both- the administrator 
and the general public. That the more direct means 
of guidance are'not neglected is shown by the list of 
bodies, official and -voluntary, on which, the Association 
is represented and "with which it has conferred.. In 
the conference on the remuneration of nori-professori.al 
teachers and research .workers, attended by repre- 
sentatives of most of the medical schools in Great 
Britain and Ireland;.' in that on puerperal morbidity 
and mortality, at; which every type of expert -worker 
concerned in the problems of midwifery took part ; and 
in the discussion ' on contributory hospital schernes, 
attended by some 250 representatives of the medical 
staffs of hospitals throughout the country, those best 
qualified to speak on the several matters under review 
have been brought together by the Association. 
Progress has been made also with inquiries into psyoho- 
analysis and into encroachments upon the sphere _ot 
private practice,' although the reports of the special 



JONR l6, tgaS] 


INTEnPRETATION OF HEART SYJrPTOHS. 


r TiiFUniTtra 

L SlrntcAf. Jovnnix. 


1035 


coininittoes donling with those subjects will not bo 
available for discussion this session. 

Turning next to the largo and important field of 
inofossional life watched over by the Insurance Acts 
Committee, it should bo borne in mind that the re- 
vision of disciplinary machiner}’ has still to slarfd the 
tost of experience, and that the Committee's work 
arising out of the Insurance Bill whose terms arc how 
before P.arliamcnt is by no-means completed. Here, 
a.s in all that the Association undertakes, it may bo 
claimed that the economic basis of efficiency and the 
essential conditions of freedom and responsibility in 
every fonn of medical praef ice have been kept con- 
stantlv in view. One feature, only of the year’s work 
ca/fs for an admission of failure.’ It must be owned 
that the £4,000 or so collect cd by the Association for 
distribution among medical charities during 1927 falls 
lamentably short of- the annual income of £20,000 
which the Council desires to secure for this purpose. 
Lot us hope that the increase of more than £1,000 over 
the amount collected in 1926 may bo taken as an 
earnest of better things to come. 

Such in barest outline is. the record of the past 
twelve months. If it compares not unfavourably wifh 
that of other Ic-ss peaceful -years wo shall do well to 
I’ecall with gi'afitudc the many devoted workers whose 
capacity for service and for leadcrsiiip has brought 
pur Association to its iiresent security and pre- 
eminence. - In doing this wo shall think espociallv of 
-two who have passed from us so recently that their 
loss IS hardly yet realized, who finished their work 
TOi their profession during the period under review — 
J. A Jfacdonald, formerly Chairman of the Repre- 
sentative Body and Chairman of Council, and at the 
time of his death chairman of the Journal Committee; 
and Dawson Williams, for thirty years Editor of this 
Journal. 


THE INTERPRETATIONS’^ OF HEART 
SYMPTOMS. 

Im: study of Afedicino, as defined in the ofheia 
cuinculum, is a very wide and comprehensive enler- 
priss. It includes features which do not, at least tc 

iliro '’oynge, appear to have a very 

direct 1 elation to the main purpose of the journev, 
in the necessary discipline of the preliminary studies, 

S set me! Ptefical affah-s, is apt 

or later gratuitous obstacles. Soonei 

felt to bp "’hat he has throughout 

and t I study of the patient; 

throncrliniif 1 • ' that he is to be engaged 

fash? stated'.' The proposition is 

nrac«co^;i o’ application of it in life and 

-piactice IS one of the — — • ^ • 

meo and haiJiM P?''"*'"*’' 
a diaenostiV this necessarily rests on 

must“ nrocepfl , conclusion which, in turn, 

evidence Thiv: +i^ analysis and valuation of 

' of the^nmpfir ^ '^c'Sbmg evidence that the success 

part of th;« p,,;,! “ commonplace to say that 

which tliP npf provided by the description 

part hv fi ^ on4 sensations and 

h is iiot^thp^fir"!' observations of the physician, 
of these two p' V comparative value 

etiiSeVa differently 

the natLf primitive days 

Wilh^ flip and .easily .held the field 

''dh the development of physical methods of 


oxaniiuatioii and of extended methods of objectivs 
investigation, personal testimony from the patient 
suffered some eclipse; and the development of labora- 
tory tests made a further contribution to this result. 
Facts depending on the direct and first-hand observa- 
tion of the physician seemed to offer, tliomsclves as 
being in degree, and even in kind, testimony far 
superior to the stntcmcnt.s — often vague nnd,halting-rt 
contributed by the patient ns an account of his .own 
sensations. Undoubtedly' at one time there developed 
in practice a tendency to miniinizo, and even to dis- 
regard, the patient’s story', and to rest a diagnostic 
and prognoslic conclusion mainly or entirely on .the 
results of objective examination; and natur.ally. tins 
attitndc of mind p.articnlnrly expressed itself when 
.symptoms affirmed by the patient found no support id 
the physical faefs of the case. In recent years, liow^ 
ever, there has boon a decided movement towards a 
higher appreciation of the subjective evidence pro^ 
vided by the patient. In part this lias been due to 


a recogiiuion ol the trutli tliat physical methods of 
examination have their' limits, particularly on the 
negative side; wliilst another factor contributing to 
the same result is the doctrine that the beginnings of 
disease — the stage where treatment has its gi-eatest 
opportunity-— are to be detected by the. interpretation 
of symptom.s rather than by the changes which can 
be demonslratcd by physical signs. From these and 
other influences the patient’s story may now be 
regarded .-is cyidenco liaving a claim to a degree of 
attention that it has not always received. 

The general proposition here stated is often con- 
spicuously illustrated in patients who are, or on 
various grounds believe themselves to be, the subjects 
of cardiac disease. That the majority of fears of this 
order are ill founded is a familiar experience with every 
practitioner, but this does not exclude the possibility 
that a negative conclusion based solely on physical 
signs may be equally at fault. It is only by reviewing 
both symptoms and physical signs that a sure diagnosis 
and a confident prognosis can be reached. This i.s one 
of the lessons lucidly presented in the lecture by Drl 
Carey Coombs wbicb we publish on another page 
of this issue. Such symptoms as palpitation, extra- 
systoles, and fainting attacks naturally cause the 
patient much alarm, and often lead to considerable 
emotional disturbances, which in turn are reflected in 
stories overcharged with emphasis. Dr. Coombs shows 
t|iat the cJinicol value of such stories cannot be 
abruptly determined by the mere absence or presence, 
as the case may be, of physical evidences of valvular 
or other cardiac flaw. In other words, the stethoscope 
lo not a final court of appeal in the clinical interpreta- 
tion of the patient s sensations; it offei's a contribu- 
tion, and indeed an important contribution, to such 
a task, but its testimony is something to be added to 
the common stock, and to be considered in relation to 
the facts presented by tlie patient as a statement of his 
own discomforts and inconveniences. ^ ! 

lecture Dr. Coombs has set out in considerable - 
detail the clinical features of various forms of heart 
attacks, and his observations, we feel sure, w'ill have 
a wide range of helpfulness. They are evidently based 
on first-hand and careful bedside observations and the 
fact that m some instances the pictures fade awav at 
the margins, tliat they are not altogether mutu’ally 
exclusive, and that here and there some individual 
case escapes classification, only means that they are 
nature studies, and not, like the academic camel 
evolved out of the philosopher’s inner consciousnS’ 

SnSi eSSg ""iT '-of 


/ 



1036 June i6, 1928] 


OBSCTTRE DENTAIi SEPSIS. 


t Tnr. BniTinf 
MeojCAL Jon5Ui 


There are other features of this lecture that deserve 
cordial recognition. Granted that the study ' of the 
patient is thorough and inclusive, Dr. Coombs is all 
for the courageous and the confident conclusion. W'ith 
the “ hedging ” diagnosis he has neither patience nor 
sympathy, and he puts “ pseudo-angina ” into this 
category; “ vasomotor angina,” though honoured in 
the textbooks, he ‘‘ does not see ” in practice; and the 
welfare of the patient, he urges, has a claim which 
must take precedence of the practitioner’s desire to he 
on the safe side. If ‘‘safety first ” is to be the motto, 
it is safety for the patient rather than for the reputa- 
tion of the doctor. All this has a decidedly robust 
note. At the same time it is free from any encourage- 
ment to rash and hasty conclusions, for the decision 
for or against the existence of cardiac danger is to be 
a considered judgement on all the evidence, and not 
the outcome either of an easy optimism or of a 
vacillating mind. ‘‘ The pain is cither cardiac or it 
is not,” and it is the practitioner’s duty to ‘‘ make up 
his mind about it.” These are the stirring terms in 
which Dr. Coombs exhorts his colleagues to enter the 
valley of decision. 

It may be freely allowed that such an exhortation 
is not inappropriate to the field of cardiac diagnosis 
and prognosis. Doubtless nowadays cardiac murmurs, 
or at least some of them, have had their importance 
reduced, but even when this is allowed a suggestion 
of cardiac disease sometimes provokes a ‘‘ be on the 
safe side ’’ policy, and under this restrictions are 
ijnposed which are without justification unless cardiac 
disease is actually present. Unnecessarily to deprive 
a child of the activities appropriate to its age. or to 
leave an adult suffering from functional palpitation 
under the depressing verdict of ‘‘a weak heart,” is 
cerl-ainly not ‘‘the safe side” for the persons princi- 
pally concerned. The medical attendant mav some- 
times have to take a risk, and he will certainly make 
some mistakes. But, given the necessary investiga- 
tions and an informed judgement, the interpretation of 
symptoms having prima fade a cardiac significance 
ought to be undertaken with confidence and concluded 
with decision. 


OBSCURE DENTAL SEPSIS. - 
To the onlooker in medicine few things have been 
more impressive in recent times than the awakening 
of medical interest m dental and tonsillar sepsis as 
factors in obscure systemic infections. That there 
has been a gradual change of attitude on the part of 
the family medical attendant towards his patients’ 
teeth will scarcely be denied. How manv^ doctor's 
fifteen years ago thought of toxic absorption from I 
tooth socket when treating a case of sciatica or of 
unexplained pyrexia? In the early davs of enlighten- 
ment pyorrhoea alveolaris was thought to be of prime 
importance; now it is apical sepsis that holds the 

the pulpless tooth— the 
filled dead tooth - —is increasingly recognized as 
a menace to health. Bit by bit the evidence has 
been sought for, and pieced together, incriminating 
hidden dental sepsis as (to say the least) a predis- 
posing cause of general disease. The fruits of the 
pioneer work of Dr. William Hunter have thus in the 
course of a few years become a ' commonplace of 
medical _ practice. In this advance radiography has 
been of inestimable value. It is true that there is still 
a good deal of controversy about the interpretation 
teeth'' pulpless 

as to’the^trlltineh/''?^"^ surgeons are not yet agreed 
treatment of such teeth; but with improved 


technique luid growing nltention to the subject 
knowledge is aceuiuulating. 

A further effort towards systemnliziition in the 
diagnosis of obscure dental sepsis is made by Dr. 
J. 1’’. Brnilsford in the article illustrated with radio- 
grams which appears at page 1013 of our present issue; 
and the note by liis colleague Dr. Leonard klackey 
(printed at page 1021) gives three more proofs of the 
trouble an infected tooth root may cause until its 
inischievouK activities arc ' recognized and ended. 
'J’hesc papers, following recent communications bearing 
upon the same subject by kir. Arthur Bulleid* and 
klr. A. P. Bcrtwistlo," and the debate on the pulpless 
tooth at the Royal Society of Medicine;'’ indicate very 
plainly the new outlook on dental sepsis in relation 
to constitutional disease. Fresh light on the problem, 
leading to something in the nature of slandardized 
procedure, may be cxjjected in the near future if 
odontologisls and radiologists and pathologists con- 
tinue to work hand in hand; but it is all-important, 
we think, that physiciiins and surgeons and general 
practitioners should regard themselves as essential 
members of the team. That the ophthalmologist 
also is concerned in this matter was preached many 
vears ago by kfr. William Lang, who had noted 
and reflected upon the close connexion between 
some eve infections and dental sepsis; and at the 
congress last April of the Ophtlmlmological Society 
of the United Kingdom kir. A. F. klcCallan,^ when 
discussing the ocular changes observed in association 
with focal sepsis, reported that one in five of a 
consecutive scries of private patients coining merely 
for refraction u'cre found on radiographical examina- 
tion to have apical abscesses. In short, ns Dr. Patrick 
Watson-Williams wrote the other day, at the end of 
his paper on nasal and oral sepsis in the etiology of 
gastro-intestinal and pulmonary diseases, “ ‘‘ in medi- 
cine there is but one field, which ever calls for team 
work.” 


PLAGUE IN AUSTRALIA. 

‘‘ One tiaio with anotlior,” said Sir AVillinm Petty, “■ a 
l>lagae happcnotli in London every twenty years.”. Less 
fortunate than old London in this one particular, Australia 
sntFored a revival of plague in 1921 after a respite lasting 
for only half of the period specified by the Caroline sage. 
Di-s. Cumpston and klcCalluiu have made this recrudescence 
the occasion of collecting the scattered records of plague 
incidence in the continent, and presenting them as a con- 
secutive account in The Ilhton/ of Ptaguc in Ansfralia* 
In this volume we find perfect pictures' of typical epizootics 
and epidemics of .jilague, whicli fortunately occurred in so 
small a compass as to make a cfoso study possible throiigli- 
out. Jloreovcr, in some instances the earliest beginning 
of an epizootic were observed and traced to the actual ship 
responsible for introducing tbo infection. The close asso- 
ciation of human plague and rat plague was alwaj-s 
demonstrable, but tlie experience in certain of the out- 
breaks brings home to us how readily a r.-it epizootic may 
be overlooked, no sign of plague being noticed, nor any 
rumour of an unusual mortality reaching the authorities, 
until the sudden occurrence of a human case leads to the 
discovery of numbers of mummified rats, presumably dead 
of plague, in or near the premises affected. On the other 


1 BrjtisR Mciiical JournaJ, J.inuary 23th, 1928, p. 135. 

= Ibid., Anril 7th, 1928, p. 589. 

= lhid.. Unroll 3lBt, 1928, p. 548. 

•Ibid., Mav 19th, 1928, p. 876. 

• Ibid., June 2nd, 1928, p. 93L - „ , t r„Tnnt:ton. 

• The History of Plague tn Anstraha, 1900-1011. By J. IL I"-,, h 

ILD., D.P.H.,-'nnd P." McCallum, M.B., B.S., D.P.H., PT.M. »; 

Commonwealth of Australia, Department of 'Health. -SerA’ico Puhlica 
No. 32. Melbourne: H. J. Green. (Med. 8vo, pp. 238; 12 figure..! 



. lUND l6, igiS] 


PIiAGTJB IN AtJSTBAIilA. 


I Tint Dnmt* 
irrotCAi. Jocmjrit 


1037 


hmid, when extonsivo niul syslomatic trapping, combined 
with routino lahoratoi^ examinations, loads to tho early 
discovery of a rat cpir.oolic, thero may ho a cvnious free- 
dom from human plague for a considerahlo period. The 
1921-22 outhrealc in Sydney is parlicnlarly instructivo in 
this respect; rot plague, of ship origin, was detected in 
Septemher, 1621, and contiiuicd briskly for two and a h.alt 
months before it spread to man. Tho secondary foci 
of infection wero established hy somo means of transport 
which left the rats of the traversed interval unaffected, and 
it is interesting that in most of tho subsidiary outbreaks 
infection was dcrmitely centred around soino produce store 
or stable which had been supplied with fodder and the like 
from tho primary focus. The danger to man was cvery- 
whoro directly proportional to the ncccssihility of tho 
interior of httihiiugs to ruts, harirtg regard to tho fact 
that tho disease tended to pick out individual rodents, the 
majorit}- of tho colony being unafTceted (an inimniiity 
possibly dno to tlio low degree of flea infestation noted 
below), and tliat infection was active only in circumscribed 
areas, which were attacked in succession. On tho whole, it 
appears that Jinifiis rntfiis (both in its raiins and 
alcxandrhiux subspecies) and ItaHus ixorvegicus were of 
about equal im|mrtauco as sources of plague, but tho pro- 
portion of iiifi'ctcd mice was at times high. Thus among 
1,135 plagnc-infcctcd rodents captured in Sydney there 
wero 567 li. raftus (the common ship rat in Australia), 
397 1?. norrcgiciis, and 171 M. muscuhis, though in no 
instance were infected mice found except in association 
witli plague-stricken rats, and thero was nothing to suggest 
that mice of themselves served as an indepoudent focus of 
disease. As would ho assumed, If. r. raffiis and li. r. 
nhxandrinus wero found to interbreed readily, but all 
.attempts to cross H. rnttus and Jf. norvcgicus failed, for 
the doe of oacli species ropcllcd tho advances of tho malo 
of tho other, and the consequeut combat resulted in the 
rout of tho raftus malo or in the death of tho rallus 
female, tho fiercer norrcgictu, whatever the sox, holding 
the field. The Sfphoimptora, cxclusivo of flcsli-floas, taken 
from rodents were all embraced in tho genera XenopsyUa, 
LcptopsjjUa, Ccratophyllus, CIcnoccphalus, and Pulcx, in 
tho order of frcquonc}', with a genera! preponderance of 
tho species -Y. chcopis. Hats harboured a surprisingly liigh 
percentage of mouse fleas (L. muscvli), sometimes over 
40 per cent, of the total catch secured. The flea population 
per rat, as recorded, • was vciy scanty; in Sydney, for 
example, among 20,000 rats thero was an average of only 
one flea to every eight r.Tt.s, irliich suggests that somo con- 
siderablo number of rats sent for c.xaniination m.ay have 
been already dead and, deserted hy thcii' ectoparasites, 
nithin the same period. 8, 000 mice arc recorded as having 
laibourcd tho astonishing total of twelve fleas. Plague in 
Aiisti alia, both rodent and human, was strictly seasonable 
in its incidence, and reached its maximum intensity in 
summer, to die down again in winter— that is to say, 
;eepnig pace with the activities of tho insect vector, for, 
as ivas written centuries ago, “ Tlie flee . . . wexeth slowo 
an ajicth in colde tyme, and in somcr tyrae it wexeth 
quner [alert] and swyft, and spareth not kynges.” 


INCOME TAX: CHANGES IN PROPRIETORSHIP 

practice. 

CUING 10 past tivo or three years substantial cliangi 
lave een made in the general scheme of assessment fc 
income tax, it -is opportune to refer to ono alteration- 
name y, t lo fiscal consequences which now attach to 
c ange ni the proprietorship of a medical practice, i 
April 5th, 1928. Prior to the year 1927-2 
10 t nee years’ average” formed the basis of asses 
■On , no withstanding tho fact' that the result was i 
' igo a successor on the basis of the earnings of anothi 


man, but ns a check on tho hardship which that ride 
might have created, the siicce.ssor was entitled to liavo the 
assessment revised to tho amount of- tho earnings for that 
actual year, provided that ho could show that tho profits 
had fallen short from some specific cause since or hy 
reason of tho change. For tho year 1927-28 the three 
years' average basis -was replaced hy that of the previous 
year, hut tliis proviso remained in force. As regards 
changes subsequent to April 5t!i, 1628, the proi-iso dis- 
appears, and is replaced hy an entirely different rule. 
Unlike tlio former option, that now given to the taxpayer 
is such that it is unwise -to postpone its consideration ; tho 
matter has hocomo ono to ho discussed and settled at an 
early stage, preferably as part of tlie negotiations for- the 
purchase or sale of the practice or share which it is pro- 
posed to transfer. Tlio ciuingc may, of course, bo com- 
plete, as where a single-handed practice is transferred 
from one practitioner — or his executors — to another, or 
partial, where a share only is transferred and there remains 
in tho group of proprietors at least one individual iiieiiiher, 
who thereby gives partial continuity to the practice. In 
tlie htisincss world tho former is probably more common 
than in tlio medical profession to-day. In the former and 
simpler case tlio non' rule. Section 32 (2) of the Finance 
Act, 1626, is definite and conclusive ; the practice is to be 
dealt with ns if it had ceased and been rccomnionced by tho 
successor. Suppose, for example, that A sells his practice 
to B as from October 5th, 1928. In that case A's liability 
for tho year ending April 5th, 1929, will, so far as tliat 
source of income is concerned, he represented by his 
earnings during the six months ended October 5th, 1928 — 
not by one-half of the assessment for 1928-29, vrliicli 'vrill 
have been made on tho preceding year’s basis — and the 
revenue autlioritics will have the option of revising the 
assessment for 1927-28 to tho amount of the profits of that 
actual j'ear. So far as B is concerned, ho will bo charge- 
able for tho six months to April 5th, 1929, on the amount 
of liis earnings for that period, and for tho year to April 
5th, 1930, on tho amount of his earning-s for the year to 
October 5th, 1929, with tho option of having the assessment 
reduced to tho amount of tho earaings for the year to 
April 5th, 1929, if he wishes. In passing, it may be noted 
that in eases whore tho change has adversely affected the 
profits — not merely the cash receipts — of the practice the 
new scheme may prove to he a little kinder to the suc- 
cessor and a little more severe, to the predecessor than the 
former method of adi'iistmcnt. Coming now to a partial 
change in proprietorship — as, for example, by dissolution 
or tho retirement or admission of a partner, or where a 
single-handed practitioner takes another man into partner- 
ship with him— it is now provided that “ the tax payable 
by tho persons who carry on tho profession . . . shall, not- 
withstanding the change, be computed according to the 
profits or gains of the profession . . . during the period 
prescribed ’’—that is, during the year prior to the year 
of assessment. There is, however, a proviso (and to this 
matter we wish to direct special attention) to the effect that 
where all the persons concerned in the propi-ietorship, 
whether before or. after tho change, “require by notice 
signed hy all of them . . and sent to the inspector of 
taxes within three months after the change took place,” then 
the practice shall be treated as if it had ceased and been 
recommenced— that is, as in the case of a complete change 
of proprietorship-. The result of exercising such an option, 
both as regards successors and predecessors, will be seen 
from the illustration given above. It is clear that if the 
statutorj' grant of that option is to have any real value 
the question should he considered as part of' the matters 
discussed when negotiations for the transfer of the partner 
ship share are proceeding. Not only is that the most 
Hmveniont time, hut in view of its effect on both parties 
1 to tho transaction, if it is then overlooked or postponed 


1038 JUNE -16, 1928] NARCOTIC PLANTS. 


it may bo difficult, if not impracticable, to arrive at 
unanimitj- and give the necessary notice vitliin the .statu- 
tory time limit of,tln-oe months from the date of change. 
It is, of course, usual to make that change in a lu.mner and 
at a time calculated to interfere as little as possible ivith 
the normal flow of the practice income, hut that is not 
always possible, and it is not difficult to conceive of circum- 
stances in which failure to consider and exorcise the option 
in question would involve the parties to the transaction 
in the payment of a larger amount of tax than the full 
application of the law would have required. 


NARCOTIC PLANTS. 

In the appropriate setting of the old Physic Garden at 
Chelsea on June 7th, Dr. W. E. Dixon, E.R.S., reader in 
pharmacology at the Dniversit}- of Camhridge, delivered 
a Chadwick Lecture on the subject of narcotic plants. It 
was an interesting discourse on the various .specimens (in 
the green leaf) which were on the table in front of him, 
and was lighted up by a genial philosophy. One of Dr. 
Dixon’s observations was the curious fact that all over 
the world the national beverages containing caffeine were 
dojicndent upon plants without any characteristic smell 
or taste. Of all the alkaloids, he said, caffeine was the 
most widely used by man. It was found in the leaves and 
beans of the coffee tree, in tea, and also, in small quantities, 
in cocoa. It might be said that tea, coffee, and cocoa were 
not unicotics, hut that was because they wore not taken in 
large enough quantities. People of all races .seemed to 
crave for something which exerted on the brain a mild 
narcotic influence. This craving might he' understood 
among highly civilized peoples, accustomed to work or play 
at high prc.ssure and subject to the strain of modern life. 
In such circumstances anything might he seized upon which 
prpvfnted the exercise for the time of the higher faculties 
of the mind : but why should tho primitive peo)>le in 
Northern India smoke Indian hemp, which also produced 
a narcotic effect on tho nervous system? To some extent 
it was explained, as was the taking of opium, ns a social 
function. The natives sat round in a ring and practised 
this indulgence, passing into a state of languid case, 
obtaining an exalted sense of their own superiority, and 
losing their relationship to time and sjiaco, so that the 
minute became an hour. Such was the result which 
followed the use of the essential oils exuding from certain 
plants. Often these oils were closely allied, though the 
plants producing them were very different. Who would 
imagine th.at attar of roses, eucalyptus, and turpentine 
had much in common? Yet when any of the,se was taken 
by the mouth the person taking it smelt of roses. In the 
days of imperial Rome the maidens used regularlv to take 
a drop of turpentine so that the fragrance of the' queen of 
flowers might cling about them. Another essential oil of 
very powerful properties was exuded from tho iiiitmog ' and- 
in the early days of tea di-inking in this country the iiu'tiiieg- 
grater was an accessory to the teapot, a little of the' 
aromatic kernel being, used to give a fillip to the tea. But 
of course, the outstanding example of the narcotic plant 
is tobacco, whose innocent leaf Dr. Dixon exhibited to his 
audience. Incidentally, he said, it was a fortunate thing 
that we did smoke tobacco and not eat it or inject it' 
This led him on to the generalization that in all these 
matters, so long as we kept away from tho chemist, we 
were tolerably safe. Who ever heard of the juice of the vine 
doing any serious harm until the chemist came on the scene 
and practised his distillations? With opium, again, the 
great mischief was not done until tho chemist came along 
and extracted its chief narcotic iirinciple, morphine, and 
ofToved the byiiodermic needle. In tho same way, when 
tel'acco was used for smoking it was relatively harmless, 
lougU Dr. Dixon emphasized the evil effects of inhala- 


'tion, 2 )ointing out how the CO fixed tho haemoglobin, and 
how oven the non-smoker who had the, misfoi tuno to ride 
in a full-blast smoking carriage rvith the windows closed 
suffered with tho guilty and had a certain percentage of his 
blood put out of action. lint of nicotino it must he .said 
that its effects wore maiwcllous in that it seemed at the 
same time to .soothe tho irrilahility of the supor.sensitivo 
and to stimulate tho dull and apathetic. How to correlate 
tho.se two actions was a ta.sk which must be left to others. 
On tho general question of tobacco smoking and of narcotic 
indulgence Dr. Dixon remarked on the sad paradox that 
we .seemed to got our chief jileasurcs in life by escaping 
out of life. But in smoking he thought there were some 
values not often considered — for example, the ritual of 
.smoking, tho lenitive effect of its rhythms, and tho lialf- 
uneonscious occupations it afforded. 


THE VINEGAR EELiWORM. 

With fitting ceremony the Grocers Company has just 
celebrated tho five hundredth anniver.sary of the granting 
of its charter by King Honn' VI, though its history goes 
hack much further than tho fifteenth century. Long 
before tho Wars of tho Rose.s the grossiers, wholesale 
dealers in drugs and .sjiicos, were merchants of high 
standing in tho City, and even earlier they had been jirc- 
ceded bv the jieppcrors. From their ranks were recruited 
some of the merchant adventurers whose sailors' scoured 
the seven .seas — and discovered much thereby — in the scareli. 
for those condiments so earnestly desired by our forcfathei-s. ' 
Nowadays the Grocers Company has forsaken the high 
roads of commerce and polities for the quiet lanes of 
education; and it seems fitting that one of its research 
scholars in sanitaiy science should just have comiileted 
the publication of a trilogj- oh tho vinegar col-worm,-for 
if the jiciqicrs and spices of tho East have fallen somewhat 
fiom their esteem in thc.so days of cold storage, vinegar 
must still, above all, bo regarded as tho condiment of 
tlio )>coplc. The vinegar eel-worm has been known to 
naturalists almost since the discovciy of tho microscope. 
It was recognized by Petrus Borellus in 1656, and included 
by Linnaeus in his Systema jVntnrnc in 1765, with tho 
siiccific name of redirirom, a namo which indicated the 
jrrcvalent belief that the worms could revive after desioca- 
tion. Linnaeus had plaee'd tho worm in his eomprehonsive 
and npi)ro)U-inte genus. Chaos, froih the depths of whioh it 
has, we ho))C finally, been extricated (after a long forensic 
argument by jMr. PeterS) as Turhatrix arefid A few milli- 
metres in length, and just visible to tho naked eye as an 
active little hair-liko creature in the surface layers of the 
fluid, it .spends its entire life in vinegar; and in th.at 
unpromising material not only waxes abundantly, but 
manages to lay up a reserve of food in the shape of neutral 
fats and other substances. 'Whence it came no one knows. It 
is conjectured that it originally found its way from the 
slime moulds on trees, where its cousins are still found. 
Whither it goes is still obscure, but from Mr. Peters’s 
own experiments it ’ does not seem to take kindly to resi- 
dence in man, altbough that must surely bo a more • 
salubrious sjiot than a weak solution of noetic acid of 
doubtful purity. He has traced it through the entire 
process of the. manufacture of vinegar; it is found 
spasmodically, being absent now ancl again when tho tem- 
perature is too high or when the liquid must pass through 
filters ; it reappears in the most unlikely places, probably 
being transjrorted from one vat to anotber by the vinegai 
113 -, Drosophila sp. (a relation of that useful little insect 
which suiiplies our geneticists with much of their informa- 
tion and many of their theories), until it is finally found 
in the caslcs froin which the vinegar is drawn off in bulk for , 

^ B. G. Peters, Journal of Helrnintholoijij, Vol. ■ V, PP- D3-142. See 
also^pp. 183-202, and Vol. VI, pp. 1-38. 


V 


June iG, 1928] 


MEMOKIAD TO SIR DAVID FERBIER. ' - 3039 


gciioral consumption, Eomelirncs in stieli enormous concen- 
trations that 2,000 worms can l)o found in a single cubic 
centimetre — wliicli rcpt'cscnis about 1 per cent, of tlio 
volume of the vinegar! 'J'lio function of this nematode in 
our human seliemo of things appears to ho at least doubtful. 
It is a fascinating object of study for tho naturalist, but 
it cats the “mother of vinegar,” atttl is tiiercforo some- 
thing of a nuisauco to tho manufacturer. In tho past it 
has seiTcd as an aid to tho quack medicine vendors, and 
Jabez Hogg records that in, his day tho charlatan's dupo 
was often invited to view through tho microscope " a drop 
of fluid derived from his natural juices,” doctored un- 
beknown to him with a drop of vinegar containing tho eel- 
norms. IVcil, however, in 1881, suggc.stcd that it might 
act as a facultative human parasite when he found all tho 
members of a family suffering from a gastric disturbance 
sinjultnneously with a voiy heavy infection of tho household 
vinegar. The removal of tho vinegar coincided with tho 
disappearance of tho symptoms. Rut post hoc, ergo propter, 
hoc, and subsequent investigators have failed to confirm 
this suspicion; indeed, ilfr. Refers swallowed some seventy 
thousand in vinegar — slightly diluted and sweetened — 
with no ill effect, c.vccpt to tho worms I Ho concludes 
that tho public need not be unduly alarmed from tho health 
point of view bj- their presence in draught vinegar — 
curiously enough tho bottlcrl variety seems invariably to bo 
free. Tho complete eradication of tho worms from all 
stages of the manufacture of vinegar would bo difficult and 
costly, and tho end does not seem to justify tho ine.ans. 
A few additional precautions in a well-organized factory 
would probably secure its exclusion from the storage vats. 


0T0-UARYN30L0GY. 

In our last issue, at page 982, ue gave a general account 
of tho summer meeting of the Sections of Laryngology and 
Otology of tho Royal Society of Jlcdiciiic, held in London 
on May 31st and tho two following days. Tho outstanding 
feature of tho proceedings was the communication by Dr. 
Otto Mayer of Vienna on tho pathologj' of otosclerosis; 
tho microscopical iircparations and drairings which lie dis- 
played excited the admiration of all. Dr. Jfayei', as stated 
in our issue of .May 26th (p. 909), has received the first 
award of tho Dalby Mcmoiial Prize, for his work oil tho 
pathologj' of tlio internal car, and ho was the guest of 
honour at the banquet hold bj' the two sections on Juno 
Mt. Appropriately, the toast of his health was proposed 
■ y Sir Charles Ballance, who was mainly instrumental in 
funding the prize to perpetuato the memory of Sir IVilliam 
a J. Sii Charles vividly recalled tho pcrsoualilj' and 
sagacity of ono who is already little uioi'o than a name to 
nianj, and in welcoming Dr. Mayer reminded his hearers 
o 10 debt they owed to Vienna, and csiiccially to the 
teaching of Politzer, Drbantschitsch, and Alexander. 


vir I.' insurance AGENCY, 

week a report of the dinner held on 
celebration of tho twentj'-first aiiiuversai*y of 
Medical Insurance Agency. As was 
+ 1 ^^^ A ^ * on that occasion, the keynote 

® always been service. When thc-Com- 

mitteo of Managoibcht held its fust meeting in 1C07 it 
re„o ve t at tho whole of the surplus funds should bo 
evo c o the benefit of insured raomhers who had fallen 
c-' policy was subsequently widened, and 

inco tie Committee has distributed to medical 

ciaii les npnards of £20,400, of which by far the greater 
nTr' . Slants to the Royal Medical 

Guild and to the Royal Medical 
n a ion of Epsom College. During the twentv-one yeai-s 
I s existence the Agency has negotiated life and 


ondowmeiit- nssiiranco policies securing for mcrahci.s of tho 
medical profession capital sums in tho neighbourhood of ono 
and a half million pounds, and has arranged many thousands 
of sickness, accident, firo, liousoliold, and motor car insur- 
ances on behalf of medical men and women. The Jast 
seven years, in particular, have shown re'markablo progress. 
IVhcreas tho premium incolilo, in round numbers, 'ivas 
£30,000 in 1921, it was £80,000 in 1927, and tho animal 
amount of rebates to doctors insuring through the Agency 
has increased by £2,000, tho' total sum thus saved to 
members of tho medical profession being nearly ■ £29,000. 
Such figures speak well for the pvudcnco and foresight with 
which the affairs of tho Agency aro managed, AVo note 
with special iiloasnro a resolution passed by tho Committee 
of ilanagcmcnt at the meeting whieii preceded the dinner 
on May 30th. It was decided to offer to the Council of 
Epsom College, out of tho funds now standing to the credit 
of tho Agency’s hcnovolent account, £500 to establish a 
scholarship, to bo known as tho “ Dawson AVilliams 
Presentation Scholarship,” in momorj’ of tho late Editor of 
tho British Medical Journal, who was one of tho founders 
of tho Medical Insurance Agency. ' 


MEMORIAL TO SIR DAVID PERRIER. 

In view of his pioneer work upon the functions of the brain 
and of his scicntiftc eminence, nianj' of tho friends and 
oolleaguos of tho lato Sir David Ferrier, M.D., LL.D,, 
F.R.Sl, aro of opinion that in some way his momoiy should 
ho pcrjictuated. A committee of subscrihers is now being 
sot up, and will meet shortly to decide wliat form this 
memorial should take. "We are asked to -say that contri- 
butions, however small, from members of the medical 
profession will bo gratefully accepted and acknowledged. 
They may be sent either direct to “ Tho Ferrier Memorial 
Fund," AVestroinster Bank, 1, Cavendish Square, AV.l, or 
to Dr. Aldreii Turner, IS, Harley Street, AV.l, who is 
acting as treasurer. Tho other signatories to the appeal aro 
Sir Charles Ballanco, Professor AA'illiam Bulloch, Sir James 
Purves-Stewart, and Sir StCIair Thomson, 


AA’e publish in tho Supplement this week a full report of 
tho conferenco called by the British Medical Association 
on Juno 6th to discuss tho relation of hospital staffs to 
contributory schemes for hospital benefit. Tho attendance 
was very large, including representatives of the medical 
staffs of some 40 voluntary hospitals in London and about 
150 elsewhere in Great Britain and Ireland. 


The annual meeting of tho British Association for the 
Advancement of Science will bo hold in Glasgow from 
September 5th to the 12tli, under tho presidency of Sir 
AA illiam Bragg. Tlio Association has visited Glasgow four 
times previously— namely, in 1840, 1855, 1876, and. in 1901. 
Tho discussions will bo arranged in- thirteen sections, and 
the presidents of those more nearly related to medicine are 
as follows: chemistrj'. Professor E. C. 0. Baly; anthropo- 
logy. Sir George Macdonald ; physiologj’. Professor C. Lovatt 
Evans; psychologj-, Professor T. H. Pear; and botany, 
Professor R. H. Yapp. The subject of Sir AA'illiam Bragg’s 
inaugural address is “Modern developments of- the 'physical 
sciences and their relation to national problems.” Professor 
E. A. AA'cstermarck will deal with the study of popular 
saj'ings in tho Frazer Lecture on social anthropology, and 
Professor F. G. Donnan will speak on tho mystery of life. 
Numei'ous excursions and receptions aro being arranged in 
connexion - with the meeting. Membership tickets and 
further information may bo obtained from tho secretary, 
ai the office of the British ' Association, Bur]in<rton Hou'o’ 
Piccadilly, AV.l, ° “ ’ 


1040 JUNE l 6 , 1928 ] 


ANNUAL MEETING AT OABDIFF. 


[ Tmf. np.iniH 
BJrMCiL Jocnxic ' 


rsirsETY-siXTH AnrsuAE meeting 

of the 

British Medical Association. 

CARDIFF, 1Q23. 


FTBE an interval of forty-lhvoo years the British Medical Association will hold its Annual 
Meeting in Cardiff this summer under the presidency of Sir Ewon Maclean, M.D., I'.E.O.P., 
Professor of Obstetrics and Gynaecology in the Welsh National School of Medicine, who will 
deliver his address to the Association on the evening of Tuesday, July 24th. Tlie sectional 
meetings for scientific and clinical work will bo hold, as usual, on the throe following days, 
the morning sessions being given up to discussions and the reading of papers, and the 
afternoons to demonstrations. The Annual Eoprosontativo Meeting, for tbe transaction of 
medico-political business, will begin on the previous Eriday, July 20th. The names of the 
officers of the eighteen Scientific Sections aro published in the Sxtpplmmit this week, 
together wdtli an outline of tlio provisional programme ; further details will be announced from 
time to time as tbe arrangements for the work of tbe Annual Meeting take final shape. On 
the last day of the meeting (Saturday, July 28th) there will be excursions to places of interest 
in the neighbourhood. We publish below the fourth of a series of descriptive and historical 
articles, written for the occasion bj' Dr. Donald Paterson. The first appeared on December 3rd, 
1927, the second on January 28th, 1028, and the third on April 2l8t, 



Towr.n op Cardifp 
Ciir IIML. 


THE COUNTRY ROUND CAJiDIFF. 


ViMTons to Cardiff approaching it from the cast become 
aaaie of features which distinguish its surrounding scencrv 
from the rest of the Principality. Wales is ossontiallv nh 
upland region, with more than a foui-th of its area I'ving 
over a thousand feet above sca-lovel, and its main lines 
ot communication run from cast to west rather than from 

has largely determined 
escarpment of the old red 
Mudstone which forms the northern rampart of South 

VI* Bristol Chaiuiol on tho soutli, the 
country is nnliko tlie 

north and central xip- 
land in having a lower 
relief and the ]iossg 8- 
sioii of great mineral 
wealth. 'Within this 
area the county of 
Glamorgan presents 
charatTteristics of its 
own, -with two types of 
scenery wliich shavjjly 
contrast. Its northern 
two-tliirds is occupied 
hy the high ground of 
the coal - field, ' the 
southern edge of wliieli 
forms a' more or less 
hold escarpment — here 
and there rising over 
a thousand feet, ‘like 
tlio Gai'tli ■ Mountain 
that towers over the 
Taff Valley,- and divid- 





V** 



Llaktrissant, Glamorgan. 


iiig fhe hill country from the lower iindulatiii-r district nf 
ho- Vale. - The upland lOf the eoal-ffold, witlf flawippe” 
hills and deeply cut valloy.s, rises gradually northwards^ to 
the Brecon Beacons. Viewed from .-i lieight like Twm 
Bnrlwin, near Newport, it appears a vast ’ expanse of 
moorland clothed with rongh pasture, uncultirated dnd 
nniuhahited save by a few mountain ponies and sheep t-et 
It conceals within the folds of its vallevd a dense pmnL 
tioii often ovei-crowdcd.aiid affords h marked ^contrast to 
the hare uninhabited hills cunriast to 

country scats, white farnihm^ stieiin n ith old ehiirches, 
ainihonses, and mined castles. Gf 


the last-named it possesses perhaps .a larger number Bmu 
any district in tliis country, some still imposing in their 
grandeur, othcr.s in an advanced singo' of ruin or decayed 
into mere sites, eloquent witnesses to the fierce struggle 
that made life anything but pleasant in the March six or 
seven hnndred years ago. 

Glamorgan is ’a well-watered county. Its chief streams, 
charming in their variety, rim more or less parallel in a 
.southcrlv direction. Some rise in tho Beacons, otiiera 
within the coal-field, and flow rapidly throughout tlioir 

whole length to the 
sea ; few are navigable 
even .at high water. 
They breach tho .south 
rim of the coal-flcld 
in a series of gorges, 
which afford access to 
tho mineral wealth of 
tho valleys and detcr- 
jnined the position of 
the chief ports — 
Cardiff depending on 
tho gorge of the Taff, 
Nowjiort on that of 
the Ebhw. 

On the northern rim 
of the co.al-field, at the 
head of tho Vale of 
Neath, an interesting 
example of river cap- 
ture, due to rapid 
cutting hack of tho 
river Neath and tlio 
.divemion of several smaller streams, has given ns ono of 
the beauty spots of tho county. The capture has resulted 
in the formation of a ^ullloy of great charm, with almost 
inaccessible limestone gorges, lovely waterfalls, swallow- 
bbles, hnd underground streams, and tlio great Dinas Bock, 
within which, legend tells, Artliur still sleeps fully armed 
among his knights. 

Further cast the river Ely— after piercing the ridge 
upon which Llantrissant, one of the most picturesque of 
Glamorgan hill towns, with its ancient castle, sits astride 
flows down a valley of ))astoral hoanty and winds across 
the alluvial Leckwith' Moors to fall into the estuary of the 
Taff under tho headland of Peiiarth. The flooding to 





JUKB l6, 1928] 


0:013 bO-DNTRT ROUND GiRDIPP. 


r Tnrnnmnt 1041 ^ 


wliich it is siilijcct in its lowor roin-so lins liccomo n scrimis 
ninttcr no\v tlmt tlio moailows wliicli took its overflow hnvo 
liecn knilt over witli orowflea awofliiip lionses. On Us left 
bank, about two miles from Carfliff, St. Paean’K Castle, 
n se.at of tbe Karl of rivmontb, built in blliKabctlmn times 
tbe site of an oripinnl castle tben in ruins, ba.s a quaint 


vanaykwl ajipcaranro 
rcinul two sides of tbo 
frontage. 

The TaP, a rajiia 
stream tbrongliont its 
eourso; - emerges Unim 
the Brecon ' Beacons 
into a valley that had 
few equals in clmrm 
before industrial 
cliange transformed it. 
The river has been 
the good fairy of tlio 
city — a river goddess 
presiding over its 
destinies. From its 
upper readies it con- 
trilmtes the splendid 
water supply -wliich 
lias made tlio city tlio 
lie.aUbicst of towns ; 
from its valley and 
those of its tributaries 
come tile minerals 


from tlio sharply pointed gables 



Towk IfAi.t, Llaktwit IIajor. 


wliidi form the life blood of tbo port; its waters feed the 
great docks, whilst in its lower course, flowing between 
thickly wooded banks, with Castle CocU rising sentinel-like 
from the steep side of the gorge, and lower down tbo 
towers of the Catlicdrat .showing above the trees, it affords 
to the citisens a fair and pleasing prospect. 

To the cast the Rhymncy Biver, in escaping from tho 
coal-field, makes a winding detour and ends ns a tortuous 
stream flowing across tho Cardiff ^foors. Its valley, bare 
and more shallow in its upper part, opens out lower down, 
and at Caerphilly, whore it becomes a wide-spreading vale, 
tho eye rests tqion tho massive ruins of the old castle, the 
gi’eat border fortress 
that represented the 
high-water . mark of 
mediaeval military 
architecture, whoso 
“ concentric ” system 
of defences made it too 
strong to attack, and 
left it a history almost 
without feature. 

The Vale is watered 
by numerous short 
streams, u'bicli reach 
the sea through gaps 
in tho cliff. The Thaw, 
rising to tho north’ 
flows past tbo old 
walled town of Cow- 
bridgo under tho re- 
mains of Llanblethian 
Castle, with its fine 
gateway, and along 
by tho ruined manor 
house of Beaupre, 
wliich still retains its 
Renaissance porch, to 
fall into the sea at Aberthaw. Further we.st tho Ogmorc 
leaves tho mountains of the coal-field, passes through tho 
pleasant town of Bridgend, and, .joined by tbo Ewenny, 
oiras the eastern limit of tbe sandliills close to tbo sea. 
'wenny Priory, on tbo banks of tbo latter stream — “.the 
est specimen of a fortified ecclesiastical building rvhich 
^**^*''” can show” — with its massive tmver, embattled 
a Is, and magnificent gatehouse, has tho appearance of 
• cas lo rather than that, of a religious house. Lower down 

keep of Ogmorc Castle, 
P icsquely placed, and containing some of the earliest 
masonry work in tho county. 


Tho coast-lino scenery varies with tbo nature of tbo 
strata. To tbo east of Cardiff tbo flat shore of tho 
W'cntloog Level is lined by an expanse of mud. Part of 
tbo land is below bigli-watcr mark, and, protected by an 
embankniont, is drained by reens. Hero tbe m.ay tree 
flourishes almndnntly, and the pleasant meadows make good 
gracing ground. Nearer Newport, on the hank of tho 

Ehhw, lies tho well- 
wooded domain of 
Tredegar House, tho 
park of . whicli , is 
bisected by tlic main 
I'oad and overlooked 
by a hill topped by an 
ancient encampment. 

West of Canliff, 
from Penarth Head to 
tbo mouth . of tbo 
Ogmorc, tbo ’ greater 
part of tbo coast 
is bold, with cliffs 
ranging from 50 to 
100 foot, and attaining 
their greatest height 
-from Penarth to Sully 
and in tbo noiglibour- 
liood of St. Donats 
and at Dunraven. 
Though the regular 
bedding of tbo lias 
gives it an appearance 



St. Donats, Glamoroan, 


Umostonc of which it is formed 
somewhat monotonous, it is not by any moans tamo and 
uninspiring. Tho restless mining of tbo strong tides of 
tbo ‘Channel produces crumbling and slipping year by 
year, and tho constant change in the barrier has an 
interest of its own. At Barry and Sully tbe carboniferous 
limo.stono 1ms resisted tbo action of the sea, and leaves 
islands at liigb-wntcr mark. The same rock is seen in tbe 
Islands of Flat Holm and Stoop Holm, situated halfway 
belwocn Cardiff and the Somerset const. 

Penarth, whoi;o fine headland w'ith tho church on its 
summit makes it a well-known landmark, is a residential 

suburb of Cardiff, 
having well-kept roads 
and a promenade and 
jiier that attract 
summer visitors. 
Barry, fmthor down 
tho coast, in addition 
to its extensive docks, 
has developed along- 
side them, and yet 
distinct from them, 
tho sandy b.ay, of its 
island into a highly 
successful holiday re- 
sort. A fcAv miles 
west Llantwit Jlajor, 
a • picturesque little 
town with quaint cot- 
tages and inns, has an 
indescribable air of 
antiquity. It is re- 
markable for a striking 
scries of buildings and 
a clinrcb of absorbing 
interest. St. Donats 
. - - - Castle, two miles awav.* 

is t.amous for jts fine situation at tbo mouth of a well- 
wooded ravine running up, f,„m the Bristol Channel, and 
admnabJy cJioseii for defensive purposes. The extensive 
grounds, arranged in a series of terraced gardens leading 

fiZtle Sarnol.®‘^" appeuranee as viewed 

West of Ogmorc tbe shore is lined bv wide-spreading 
sand dunes or burrows as far as the estnarv of tile Tawo® 
e.xcept for a distance of three miles, where the rock emerges 
to carry the flourishing summer resort of Porthcawl 
Beyond Sker, the scene.of Blackmore’s romance Dm , pT ' 
ness of sand attains its greatest depth? Tud’ S KmffiT 



1042 Juke i6, 1928] 


TTNION OF SOUTH AFKICA. 


[ Tirt rpiTu* 
McMCAt Jocks ifc 


where it ovcrirJiclmecl the old town, tlio fragment of the 
castle protruding from the sand has I'cccntly hern in-ovcil 
bj the sjjade to he an upper iiart of a fine reetanguiar keej). 

A little further west, about two miles from the sea, are 
the ruins of Margam Ahhcy, a Cistereian foundation of 
the tnelfth centuiy. Rising behind is a range of liills, 
richly clad with oak trees and interseeted by a deep ravine 
concealing a mountain stream which supplied the fish 
ponds of the monies. The most interesting architectural 
remains are to ho fonnd in a polygonal ehajitor house of 
elegant proportion and unicjuc in character. 

The immediate neighbourhood of Cardiff, iu fact — tjiiito 
apart from the accessibility of the beautiful valleys of Wyo 
and Usk and the magnificent coast of Devon — is in itself 
attractive for its scenery, and is full of geological, arehi- 
tectural, and archaeological interest. The country further 
afield we propose to deal with in a future article. 


Mnim d ^frtca. 

[FkOM Ol’Ii Coral KSPONJ) ENT IN Pltr.T01!I.\.] 

fllEDtCAL MATTERS IN PARLIAAtENT. 

Medical, Dental, and Pharmacy Bill. 

The outstanding fonture of the ]ircseiit session of Parlia- 
ment is the success which is crowning the jiroloiiged elforts 
made by the medical profession in South Africa to secure 
satisfactory health legislation. Tlie Medical, Dental, and 
Pharmacy Bill, which has come before Parliamciit 
periodically during the past decade, lias at last been picssed 
by both Houses, Only formal proceedings now remain 
before the bill becomes law. On May lOth Uic Speaker 
read a message in the House of Assembly transmitting 
for information a fair copy of the hill to the Senate, 
printed on lellum, and forwarded to His lllxcelloiicy the 
Govenior-Oeiieral for his assent thoioto. The Aet «ill 
consolidate and amend the existing laws I'elating to 
medical iiractitioncrs, dentists, chemists and druggists, 
nurses, midwives, and massenrs; the keejiiiig and sale of 
poi.sons, and the importation, sale, luid uso of liabit- 
formiiig drugs. It will not only penalize any nnqnalifiod 
person practising as a doctor, dentist, or chemist and 
druggist, hut also any unregistered iiorson performing any 
act specially pertaining to one of the corresponding pro- 
fessions. It provides for the gradual prohibition of un- 
qualified midwifery and nursing, heginning witli the larger 
urban areas and extending throughout the Union as 
adequate trained assistance becomes available for all 
sections of the population. It also provides for the regis- 
tration of dental mechanics, health inspectors, hcaltli 
visitors, and other classes of persons, empowering them to 
use the title “ registered,'” and prohibiting persons not 
so registered from using that title. 

In previous sessions the bill has inrariablv liad to bo 
dropped because of the delay caused by tlie concerted 
efforts of persons not on the medical or dental registers 
of any of the four Provinces to become registrable. Its 
successfid passage tlirongh both Houses of Parliament is 
to be attributed to the persistence of the iirosent Mmister 
of Public Health, the Rev. Dr. Alalaii. At the end of tho 
last session of Parlianiout, when 75 of its 96 clauses had 
been disposed of in the Ckmmiittee stage, he ao-reed to 
its ]K)stponenient only on condition that it slmuld bo 
piocecdiHl with in the present session at the jKiint where 
it had been dropi>ed. As the most contentions points had 
already been settled the passage of the remainder was 
through comparatively smooth waters, and no great opposi- 
tion was cnconnterecl. On the passing of the bill through 
the Senate the organizing secretary of the Medical Asso- 
ciation of South Africa (B.M.A.),'ou the instructions of 
• the Federal Council, wiole to the jNIinister of Public 
Health, eoiiveyiiig to him the thanks of the Association and 
eoiigratidatiiig him on the passage of the hill. Dr. Malau’s 
private secretary, in reply, stated that the Minister 
thanked the Association mort heartily for the kind expres- 
sion of nppi'eciation and goodwill. Dr. IMalan desiretl 
111'? «l>prceiated verv higlilv the' 

tWirWartri’ profession, and ^speoiallv 

have 

® to accomplish Ins difficult legisla- 


tive task. He eiiine.stly hoped that the same eo-operation 
and goodwill would eontimio in future in regard to tho 
greater problems in connexion with public health with 
which South Africa was confronted. 

Public Health Amendment Dill. 

The Piililie Healtli Ameiidmciit Bill, loo, has reached 
the final formal stages. A slight verbal aiiiciidmoiit in the 
Afrikaans co|iy was made in Senate. This amendment was 
approved by tho Lower House on May 10th, and a fair copy 
of the hill was transmitted to the Sioiale during the s-imo 
day to ho certified as l•orI■oct and returned. Tlie first bill 
amending the Public Health Act was jiasscd last year; when 
introduced it included the substance of this year’s luoasme, 
lint when it hccamo n]i]iarent that the whole was liable to 
he dropped only the ehuises dealing with matters of siiccial 
urgency were proceeded with, and these .subsequently 
liecaine tlie Public Health Act (1910) Aiiieiidmciit Act, 1927. 
According to it the Mining Commissioner heconies the local 
aiilliority in any area proclaimed an alluvial diamond 
digging. It further provides for periodical visits by 
medical ollicers to jilaccs lacking medical aid where malaria 
or other di.sease is jirevaleiit, to he jlnid for out of pulilic 
funds. The rapid jiassagc of the prc.seiit bill was uii- 
cxpceled, as it eoiitaiiis all the contentions matter diO]>pod 
from last year’.s hill. Its ]irinci]ial objects arc to pravidc 
for the exeiuption of eoiiscieiitioiis objectors to vaccination 
against small-pox ; for the regulation and supervision of the 
piaetiee of midwivos, especially niiqiialified midwives, iu 
the interests of the )iiihlie health ; and for smnmaiy pro- 
cedure in regard to miisniices of an urgent nature. Some 
.•niibigiiities ha.vc been eleaied iqi, and several minor altera- 
tions in tlie Public Health Act, 1919, which experience 
has sliomi to he desirable have been made. 

Vaccination Problems. 

The’ Act of 1919 iiinde vaccination compulsory on all, and 
arrniigemciits were made for the sy.steuiatie enforcement 
of the leqnircmeiits for all races throughout the Union. 
Blit, from tJie fir.st, strenuous opjiosition was offei'od by 
conscientious objectors, especially in Natal, and during 
1921 a iiuiiihcr of ])roscciitioiis wore instituted iu various 
centres and <-oiivietioiis obtaiiiwl. Oiipositiou, however, 
stilfciiod, and in June, 1922, the Governinent gave instruc- 
tions that prosecutions of genuine coiiseiontioiis ohjeetors 
was to he discontinued. As there wcie no available nieaiis 
of diffcieiitiatiiig the genuine from the noii-gcniiiiie, this 
entailed the coiniilcte diseontiiiunncc of prosecutions, and a 
serious falling olf in the nninher of vaceiii-atimis was the 
result. The fall has been grc.atest among Europeaus and 
Eurafrieaus— that is, among tlic classes whicb register 
births. Ill maiiv native are.ns vaccination has also fallen 
oft considerably.’ Tliis has occurred iu spite of the provision 
of full facilities in both urban and rural areas tliroiiglioiit 
tho Union. Had this jiasition been allowed to coiitiiuie 
for a few more years large sections of the iiopuhitioii of 
all races would iiave been unvucciiiated, with the conse- 
quent serious danger of outbreaks of virulent small-po^ 
A large increase in vaccinations occurred iu 1926 and 1927 
as Hie result of an outbreak of small-po.x in Durban, from 
wliicli town the chief resistance to vaccination had coiue. 
In all, 57 cases occurred, of which 16 were fatal. Tho 
borough of Durban and the neighbouring local autliorities 
promi?tlv made vaceination compulsory on all non- 
Enrojiea'ns. T.iccination centres were provided, .and wero 
immediately besieged by a population deinnndiug to be 
vaccinated. The local hianch of the Autivaccination Leaguo 
took nil the attitude -that it did not object to vaecrnation 
per se, but only to eoinpulsory vaccination. A coimidcrablo 
number of conscientious objectors and their families were 
voluntarily vaccinated. The present bill makes iirovision 
for the exeiuption of conscientious objectors to vaccination. 
The procedure laid domi to obtain such exemption entails 
more trouble and foresight than to allow the cluld to ho 
vaccinated in the ordinary way. This, the Minster ex- 
plained, was intentional, as being the only reliable means 
of testing the gcniiiiicne-ss of the objections. No cxoin]> 
are, however, allowed in the face of actual or thrcatcnc 
outbreaks of .small-pox; nor m.ay inmates of institutions 
or persons landing at jiorts wlio liavc recently been cxi>osC 
to small-pox infection be exempted. 



Joke i 6 , 193S] 


TJNION or SOOTH ATBIOA. 


r Tirr ITnrn«n 
I Sfr.PicAi. JofBxii. 


1043 


Supcrvtston ot Mtdwivcs. 

Up to tlio pvcsont locnl ntiUiorilios liati practically no 
powers to siiporviso tlio iiraclico of nii(hvivcs. Provision 
for sucli supervision is now inado; it is provided that: 

Tlio Minislcr may, after eonsitUalion with tlio Medical Council, 
make regulations ns to the supeia-ision by the local nutliorily 
ill llio interests of tlio piililio liealtli of pers'oiia (other than regis- 
tered medical practitioners) practising midwifery within its district, 
and empowering llio local aiitliority to make and keep a list of 
such persons and to prohiliit any person whoso iiamo ia not on 
such list from so practising. Such regulations may empower the 
loral autliority to rcfiiso to enter on such list, or to removo 
therefrom, the namo of any person whoso practising ns a midwife 
tlio local autliority considers would bo prejudicial or dangerous 
to the public health. 

Provision is inndo for appeal to tlio Jfinistor of Public 
Health in tho caso of an uncortificat-cd midwife, and to 
tbo Medical Council in the ca.so of a certificated midwife, 
whoso decisions in cacli caso shall ho final and binding on 
tho local authority. Ilogulntions of this kind aro urgently 
nooded. Tho nnqiialifiod midwife in this country, often 
dirty and ignorant, levies a lipav3’ toll on tho mother and 
infant life of tho Union. Instances were quoted where 
whole series of pucqioral fever cases have occurred in tho 
practice of ono such inidwifo. This danse was tho result 
of a confereneo hotween tho Union Health Department, 
the four Provincial Jlcdical Councils, and a nurhhor of tho 
principal municipalities. 


Notification oI;.Vcncrcal Dlscnsc. 

Compulsory notification of cases of vciioronl disoaso by 
medical practitioners caused some dismay when it was 
®'^S 5 *^stcd. ..The principal _A.ct requires every medical 
officer of health or district surgeon who knows of a ease 
of venereal dise.nso which is not being treated to report 
such caso to tho magislrnto, wherenpon appropriate 
inoasuros may ho taken. Tho provisions proved practically 
unaorKahio. Apart from tho occasional eases that medical 
officers of health and district surgeons camo across per- 
lonallv tliero was no moans of informing them. No duty 
nas laid on tlio ordinary practitioner to inform tho medical 
officer of health, and if ono did so ho was liable to a legal 
action. Tlio amendment in tlic present bill requires every 
medical practitioner, ' who knows or who has reason to 
clievc that any person is sulforing from venereal disoaso 
in a communicahlc form, and is not under treatment, to 
in writing to tho medical officer of 
alth of tho local authority. Tho amondment does not 
tlieroforo represent any big advance in measures for tho 
eradication of venereal disease. It will not secure any 
ocneral notification of eases, hut will enable practi- 
Uoiiers comin^g across eases which aro not under treat- 
“'form the medical officer of health. Tlie 
nuwr? provided in tho principal Act for com- 

fece-'tlds''A^'t“”*' 'f.“oo“5ory can then ho brought into 

toTeuereal relating 

leueteal disoaso to be treated as confidential. ^ 

Tbo Wo Drugs, and Disinfectants Bill. 

pnno itVi Jind, Disinfectants Bill is designed to 

Tnd ieveliw T''- '“'V^ t>‘e iSng 

which are unwbrd^ importation or sale of food or drugs 
falsely desrribpil “““o or adulterated or incorrectly 01 - 
nreventimr tlm •’ regulating the labelling and 

re nc^Lt : o?“falser T ^-nfectants ®which 

second reading poI i' ‘fosenbed. It has passed the 
mittee It if noif o^A by Select Com- 
mittee stage Thomrh “'waiting tho Com- 
te end cant in JuVe f f f “ expected 

be done it fs vpi-ii i.T-’i ''1? f'*'®' ® is still much business to 
statute book do? ti^ that this bill will be placed on the 

pSsrlifSi ?= ^*”1 '» 

tho need for new nnd’efff fl, f ^®P®rts 

the adulteration of Ld anf d™ T^ .Prorenting 
in tho Provinces are innrfp ^ dnigs. The existing laws 
adulter'itinn ^ ^ ''^adequate and obsolete. . The old 

second ‘reading aimed^faif H i^inister on the 
health by prm-enW. b™?' 1 tho public 

are\^roV3'° The rTous adSants 

■ or vendor of adulteratedSeV efflt ^rmaSn": 


by selling spurious or misdescribed articles, or gciniino 
articles adulterated with cheap hut haiTnlcss ingredients — 
in other words, by defrauding buyers and consumers. The 
old laiv.s were not designed to meet tlicso modern condi- 
tions. Tho pnblio is being defrauded to a serious extent 
and the public health is being prejudiced by the sale and 
use of deficient, adulterated, or spurious food articles. 
Strong and repeated representations urging' tho need for 
amended legislation have hcon- made to tho Government 
for many years' by chambers of commerce niid other bodies. 
A bill to deal with tho matter was first prepared by the 
Secretary for Public Health in 1917, after special investiga- 
tion and inquiry. Since then tlio matter has been brought 
up annually when the Government’s programme of legisla- 
tion ivas being prepared, hut it was not . introduced to 
Parliament until last year. It is gi-catly to be hoped that 
tho bill will go forward during next session. 




Vital Statistics. 

TnE Bcgistrar-Gcncral for Scotland lias now issued the 
vital statistics for tho quarter ended March 31st, 1928. 
Births registered numbered 24,246, this being the smallest 
in any first quarter since 1919; tlie rate is equivalent to 

19.9 per 1,000. Of these births 22,485, or 92.7 per cent., were 
legitimate, and 1,761, or. 7.3 per cent., were illegitimate. 
Tlioro were registered 7,582 marriages, equivalent to a 
marriage rate of 6.1 per 1,000. Deaths Tiumhcrcd 19,385, 
being 2,445 more than last quarter, hut 52 less than in tho 
first quarter of last year; the quarterly death rate was 

15.9 per 1,000. In tho larger hovoughs tho death rates 
ranged from 21.1 in Greenock, 18.6 in Glasgow, 17.7 in 
Falkirk, and 17.5 in Coatbridge to 11.5 in DIotliorwcll and 
Wishaw, 11.9 in Clydebank, 13.3 in Hamilton, and 14.6 in 
Ayr. Tho deaths of children less than 1 year old num- 
bered 2,594, giving an infantile mortality rate of 107 
per 1,000 Tcgistercd birtbs. The rate is 3 loss, than in 
tho first quarter of last year, and 2 less than the five- 
yearly average for first quarters. In the larger bofouglis 
the infantile mortality rate ranged from 175 in Greenock, 
143 in Coatbridge, 141 in Falkirk, 137 in Glasgow, and 
124 in Dundee, to 82 in Hamilton, 86 in Dumfcrlino and 
in Motherwell and 'Wisbaw, and 88 in Perth. In Edin- 
burgh the rate was 94, and in Aberdeen 115. _ There were 
558 deaths from measles during tho quarter, -191 from 
diphtheria, and 431 from influenza. - 


wciiare 01 ine uiina in Scotland. 

The eleventh annual conference of the Scottish National 
Federation of Societies for. the Blind was held in tho toivn 
hall; Arbroath, on June 8th. ^ Ex-Baillio Delian (Glasiiow) 
read a paper entitled “A municipal experiment,” describing 
tho scheme managed by a joint committee of some twenty- 
three municipal and county councils in the South-west of 
Scotland, which had taken over tho administration of tho 
worlvshops of the Glasgow Asylum for the 'Blind. This 
involved a capital expenditure of nearly £32,000, .and 
though tho "workshops were not expected to he self-support- 
ing the deficit ■ last year had been comparatively small. 
Negotiations had taken place with the Outdoor Mission 
for tho Blind with the object of bringing all blind welfare 
^emes under unified control by municipal authorities 
The number of blind persons employed in these Glaseow 
works had increased from 278 to 500. Last year no less 
than £2,800 had been received in bequests to the municipal 
institution. Dr. J. Parlane Kinlocb, medical officer of 

r tv , an address on “ The prevention 
of blindness,” saying that this was 'simply a part of a 
great preventive service whose aim was to obviate a wide 
variety of injuries and diseases; the prevention of blind- 
ness was dependent on the advancement of this service as 
a whole. He stated that in 1927 there were 6 937 blmr? 
persons in Scotland but year by year the numbei of b nd 
children was steadily diminisliing. A careful aval,-.- e 
statistics showed that some SO per cent of of 

blindness in Scotland could havr^en ni-af ' 1 1 
right thing been .don,, at .thn^r tCel'^lf^S t 




1044' June i6, 1928] 


EHGLAND AND WADES. 


r Tnr. nrmw 
L SrrDicAL Journal 


accepted that the loiowledge as to -mothods of provontion 
of disease that resulted iii blindness was considerably 
greater than its practical application. The matter there- 
fore resolved itself into an extension of present health 
services, including the education of the pidilic in the 
prevention of disease. Out of 18 per cent, of cases of 
blindness due to injury only 5 per cent, nerc due to 
industrial accidents, while 11 jier cent, were duo to casual 
accidents to young people. The speaker emphasized the 
fact that the inexorable economic necessity of working 
within their financial resources handicapped local autho- 
rities, and was the cause of an apparent reluctance to 
provide an extension of services for blind iiersons. 

Pneumonia in Glasgow. 

Dr. Charles M. Smith of the Glasgow Corporation Public 
Health Department has issued a paper on pneumonia 
statistics in Glasgow, with special reference to children 
under 5.* Since pneumonia was made notifiable in Scot- 
land hj- regulation in 1919 cases of the disease have been 
removed in increasing numbers to the Glasgow fever 
hospitals. On the average about 50 per cent, of the i>neumonia 
in the city has been treated in those institutions. Dr. Smith 
finds that notification and ho.spital treatment have had no 
obvious effect in reducing the death rate from pneumonia 
in Glasgow. In the hosi)itals themselves the ease mortality 
has been stationary; it was 21.5 per cent, in 1919-20 and 
21.6 per cent, in 1926, with o.scillations between. Nor has 
there been any constant decline in the general mortality 
from the disease. In 1920 the deaths under 5 were 941, 
and in 1926 902, with wide excursions in the intervening 
years. Reference is made to the effect of environmental 
conditions on the pneumonia and broncho-pneumonia death 
rate under 5, which varies inversely with the .social status 
of municipal wards. It moves along with the infantile 
mortality rate, being a high fractional component of the 
respiratory death rate, which bulks large at different agc.s. 
This reference recalls Dr. Halliday’s inquirj- into measles 
prevalence in Glasgow, noted in the JouTnal of Slarch 31st 
(p. 560). A few years ago it was beginning to bo .said that 
the environmental hygiene of soil and water was disjrosed 
of and done with; studios like this of Dr. Smitli suggo.st 
that the environmental hj'giene of the air .still challeimes 
investigation. * ° 


O^ngktttt anir Maks. 

MacAIister Lecture on Medicine in Art. 

The second annual lecture in memory of the late Sir 
John MacAIister, secretary of the Royal Societv of 
Medicine, was delivered at the London Tcmperanco 
Hospital, under the auspices of the London Clinical Societv. 
"f Berkeley Moimihan, Bt., President 

of the Royal College of Surgeons. It was a popular 
lectuie to which nurses and a number of the lav public 
were admitted and was 0,1 the .subject of ‘•Medicine in 
ait. Substantially it followed the lines of the lecture 
which Sir Bm-keley Moynihan gave la,st antiimn to the 
St. Pancras Division of the Briti.sli Medical Association = 
He began with the gargoyles of Notre Dame and the 
■ Lincoln imp,” and showed what interest there was in the 
curious deformities, no doubt .shaped direct from models 
by the mediaeval sculptor, to those- who viewed thein with 
ail eye trained in medicine. Incidentallv, the.se fio„res 
often carried horns on the head, and there’ was also aliorn 
on the head of the most majestic sculptured figure in the 
whole world— the figure of Moses by MicheIan<relo so 
badly placed in the church of San P’i'etro in Vincol’i at 
Romp that few people realized what a masterpiece it w.as. 
The horn on the top of the head of Moses was supposed 
to be clue to a misreading of a passage in the Vulgate. The 
niost famous of all gargoyles was to be seen in the churcli 
of Santa iMaria Gloriosa at Venice, and was the subiect 
of an exquisite passage by Ruskin, in which he lamented 
the leering woekedness, the extreme of debasement, which it 

the “ 1 "* "Sited this church and saw 

- S i 0 ho said at once that it was exactly the kind 

‘JoiirTfoI 0 / Ilugirrtr, 1923 vol 'vrv{i •»' 

Supplo„„.,. unu.U 1927. a. 143. 


of hystero-ppileplie familiar to • the Salpetriere. Tlie 
hy.slero-ei)ileptic was considered in the Middle Ages and 
earlier to be the victim of “ possession,” .and the imago 
of him was put especially on the roof.s and towers of sacred 
bnildings to suggo.st that evil spirits had been driven out 
of (he church. Another deformity familiar to very ancient 
arti.sts was evidently nchondropla.sia ; witness the repre- 
.sentation.s of the great god Ptah of Egj’pt Bes of 
Memphi.s — the large-headed goggly-eyed ilwarf, with tbo 
short arms, the gross body, and heav}- buttocks. Sir 
Berkeley Moynihan touched on the representation of 
di.se.ased ))orson.s in some of the great piclnres by Raphael 
and otiicr.s, and of the emotional expre.ssion.s in the works 
of Velasquez, and he made the general remark th.at often 
.some quite inferior artists, whoso names were scarcely 
known at all, were far more correct in their details of 
subjects siiirering from di.seasc or deformity than were tho 
great masters, obviously hecanse tho former stuck more 
clo.sely to their models. Hu confos.sed that of all the 
pictures he had ever seen in Continental galleries the one 
which fascinated him most, and the one which he most 
coveted, was ‘‘ The contemjilation of ,St. Jerome ” in tho 
Louvre. The Louvre authorities were, .said to have refused 
to allow this jiictiiro to bo photographed, but a 100-frano 
nolo and tho promise of another produced the photogr.ajih 
which he exhiliitcd to the audience; it conveyed, however, 
little or nothing of the power of the original. In showing 
some photngra])h.s of ' mediaeval statuary. Sir Berkeley 
Movnihnn .said that it was the fashion to deride manj- 
antiques to-day from tho point of view of anatomy, but ho 
believed this view to bo entirely mistaken, and ho instanced 
to the contrary tho “ Dying Gladiator,” which brought 
into pl.av in a masterly manner tho accessory muscles of 
respiration. He conelmlod with some ancient works of art 
repro.scnting j)rimitivn surgical operations, and mentioned 
that the fir.st representation of a surgical opci-ation in a 
work of ai't in Europe — there were earlier examples in 
Eg\-pt and in Asia — was a fresco at Pompeii. 

New Institute of Biochemistry at the Middlesex Hospital. 

Tho opening of tho new Courtauld Institute of Bio- 
chemistiT at tho jMiddlcsex Hospital took place on June 
14lh when Mr. S. A. Courtauld formally handed over his 
gift,’ which was accepted by H.R.H. Prince Arthur of 
Con’naught on behalf of tho hospital and by Mr. S. G. 
Asher on behalf of tho council of the medical school. 
Before the ceremony an address was gii-en by Sir Archibald 
Garrod on “ Tho "place of biochemistry in medicine ” ; 
this will bo published in tho Journal at an early d.ato. 
The now institute is situated ou a site separated from 
the hospital by only the width of a street; tho lower 
part of the new structuro is devoted to hospital uses and 
contains tho central boiler-house and engineering plant, 
and, among other sections, a restaurant for students. 
Five stories, from tho first floor upwards, are given to 
tbo Institute. The first floor is occupied by a spacious 
laboratory for students, with tho usual auxiliary apart- 
ments, wliile tho second contains a clinical routine 
laboratory, throe examining rooms, and the secretary’s 
office- this floor is connected to the Bland-Sutton Institute 
on tho liospital site by a concrete bridge across the street. 
On the third floor is a largo chemical laboratory with 
combustion and balance rooms and a large-scale prepar.a- 
' tiou room. A library, an optical dark room, a standardiza- 
tion laboratory,- and the ])rofessor’s private room and 
laboratory are situated on the fourth floor, while on the 
fifth are tho animal houses. It is interesting to note 
that, unlike most similar existing establishments, the 
new institute at the Middlesex Hospital consists mainly 
of large spacious rooms which will be shared by a number 
of workers. Those responsible for tho plan, after review- 
ing many examples, have concluded that the advantages 
of this .sj-stem outweigh tho advantages offered by tha 
provision of a large number of small rooms in which 
each worker may have separate accommodation. It is 
contended that, under tho latter system, not only are 
tho difficulties of construction and ventilation enormously 
increased, but it is disadvantageous from an acadcmio 
lioint of view to segregate individual workers and so 
deprive them of the stimulus of contact and criticism 
given by colleagues engaged on other problems. 



Jung i6, 19:8] 


COKBESPONDENCE. 


[ T»rr }mtn*n , indfi 
MKMfiEJovRKii. • ' 


city ol tonilon Hospital tor Heart and Liinp : Opening of 
‘ New Surjjicnl nnd X-rny Block. 

A new suiKiral block nnd x-rny dcpnrtmcnl nt tlio City 
of Tiondou Hospital for Diseases of tho Honvt and Lruiga 
(or to givo it its local name, tlio Vicloria I'ark Hospital) 
ivas opened l)v H.K.H. tlio Diiko of Connaught on Juno 
12lh. The cluunnan of tho cominittco of managoincnt. 
Sir AloNnndcr Dnltorworth, addressing a distinguished 
company who had gathered in a inaniuco in tho hospital 
grounds, said that tho policy of tho hospital for some 
time past had not been to add to its total of boils uhicli 
had stood at 185 now for several years— but to spend 
availnhlo money in keeping tho huildiugs nnd eiiuipnicnt 
up to date.' This had somotimes meant additional building, 
bccauso modern developments in medical treatment and 
diagnosis necessitated tho creation of now departments, for 
which a homo had to bo found. This was tho case with tho 
new block or wing to lie opened that day. It consisted of ' 
an operating theatre, with adjoining rooms for tho surgeon 
and laiyaigologist, nnd a set of rooms for tho .r-ray dopart' 
meat, which had hitherto been very inadeqnalely housed. 
Tho oighticth anniversary of tho hospital had been colo- 
bratod bv an appeal for snlTicicnt money to placo tho 
hospital finances on a satisfactory footing. This effort, 
thanks very largely to the I.iord Mayor of Ijondou, had 
met with a fair degree of success, with tho icsult that tho 
building which His Iloyal Highness was to open was not 
saddled with any debt. tVith this new block nnd with tho 
new pathological laboratory and rc.soarch institute pre- 
sented Inst year by th» Prudential Asstiraneo Company, 
tho hospital .was in a bettor position to carry on its impor- 
tant work than it had ever boon before. Sir Ernest Birch 
added a few -words with regard to tho intorcst which tho 
Royal Family had always taken in this institution. Tho 
Duko of Connaught was'only a few months old nt tho timo 
when tho foundation stono was laid by hi.s father, tho 
Princo Consort, in 1851, and the Duko himself had been 
president of tlio ho.spital for tho remarkable (leriod of 
fifty-six years. Tho Duke of Connaught said that thcro 
had boon many changes in tho hospital during tho period 
■ of his association,- changes reflecting for tho most part 
tho general progress in medicino and surgery. It ivas 
essential for a hospital to bo abreast of tho times, however 
largo and- rapid tho development in tho methods of 
diagnosis and treatment might he. Diseases of tho chest 
caused moro deaths and more long-contimied ill health 
than any other catcgoi-y of illness. Nearly half tho deaths 
in this country were due to diseases of the heart and 
lungs.. Three things w'ero required to meet tho need — 

. namely, tho most skilful medical work, the most highly 
trained nursing, and tho best equipment. Tho first and 
second of theso had long been assured, but as to the third 
this hospital, like others, had had to struggle against 
inadequacy. Tho increasing uso of surgery in chest con- 
ditions and tho increasing uso of i rays for diagnostic 
pui poses ivould make the new surgical block and a:-ray 
department of very great value. His Royal Highness then 
pioceeded to open tho new premises, w-hich were after- 
uaids inspected by those present. Tho new- block consists 
ot two floors. Tho actual operation theatre and annexes 
aie situated on tho first floor, with tho x-ray department 
I 1 1 ^ connected w-ith tho hospital corridors 
J a lit lobby. The x-ray. department consists of a spacious 
loom, and tho -transformer and other apparatus are in a 
room a joining, from which leads are taken to tho couch 
or scieeniiig stand. The whole of tho fittings and equip- 
rnost up-to-dato chai-aotcr; the cost of tho 
*i°i been £7,500. In a hrochurc which w-as 

* 1 - ° each guest a history of tho hospital was given, 

■ u ing an account of tho stone-laying hv tho Princo 
“SO, at which wo read “Mr. 
-tVn.i;'* - T? ‘^e^’pCer of tho Great Exhibition then 

ilr-olrr, Park — “ also exhibited on tho platform 

tlm crystal sanitarium ’ in which tho purity of 

ficinl" fitt should be secured by a process of arti- 

hot'b ir, equable and pure temperature 

hv tnniinl'^"+”'+i ivintei-, the outer air lieing admitted 
s^ms in I, i ° The idea never 

windows lol'’ .adopted, tho hospital relying on open 

"muows and open-air balconies. • ■ - • 


Status of Tuberculosis Officers In Certain Counties. 

At a meeting of tho Joint Tuhorcidosis Council on Alay 
19tli Dr. Lissnnt Cox presented a memorandum on tho 
report of Dr. Peavso of tho Ministry of Health on tho 
co-ordination of tho public health services in tho counties 
of Essex, Hampshire, Glonce.stcr, and East Sussex. In 
view of tho fact that in tlieso districts whole-timo officers 
wore appointed to act as assistant medical officers of 
health, school medical officers, maternity and child welfare 
officers, and tuhcrcnlosis officers, tho council consideicd 
that such a plan would need to bo carefully safeguarded 
if it w-cro not to caiiso a serious deterioration in tho 
tuborctilosis service’. Tho assi.staneo in diagnosis or treat- 
ment of a consultant tuberculosis officer .should he avaihihlo 
for every' case of definito or suspected tuhorculosis. Dr. 
MacNalty had stated that it w-as tho policy of the Ministry 
of Health to carry out tho recommefidations of the Aster 
report. In rural areas the Ministry wore sometimes asked 
to sanction tho appointment of assi.stant tuhereiiln.sis 
officers W'lio wore also responsihlo for other public health 
services for reasons of convenience and economy-. In such 
cases tho Jlinistry advised the appointment of a chief 
clinical tuhcrcnlosis officer w-ith special experience, and 
also required tho assistant tuberculosis officers to have 
had a certain amount of expcricnco in tuberculosis. Pro- 
fessor Lyle Cummins, Sir Henry Ganyain, and Dr. 
Sutherland wero apimintcd to ropresont tho council at 
tho International Tuberculosis Congress at Rome. It was 
decided that a dinner slionld ho given to Canadian tiihercu- 
losis workois when visiting England in October next. 




THE WAR EMERGENCY FUND. ' 

Sin, — Tho activities of tho IVar Emergency Fund Com- 
mittco have now como to an end. Tho first case of 
.distress was relieved in 1915 by tho ' Royal Medical 
Bonovolcnt Fund, but it was soon found that a special 
subcommittee — tho IVnr Emergency Fund Coihraittce — had 
to bo constituted, and that an appeal for larger, funds 
was necessary. 

The War Emergency Fund was instituted to afford 
assistance to those members of tho profession who, in 
couscqucnco of having joined tho Medical Sei-vice of tho 
navy or amy, found themselves in temporary financial 
difficulties. Tho late Sir Alfred Pearcc-Gonkl, who died 
in 1922, was the first chairman. Amongst tliose who served 
on tho committee wore: Sir William Lister, 3Ir, T. P. 
Legg, Dr. Andrew Elliott, Sir D’Arcy Pow-er, Dr. Charles 
Buttar, Sir 'William AVillcox, Sir Chartei-s Synionds 
(honorai-y treasurer), and Dr. Newton Pitt (honorary 
secretary). 

Applications for assistance w-oro received from 297 
medical men; of theso, 160 cases wore relieved, and the 
other 137 cases wero cither ineligible or were assisted in 
other ways to secure tho help they, required. From 1S20 
most of tho applications made wero for assistance towards 
educational expenses. Assistance for education has been 
given to 75 hoys and 30 girls, who have attended the 
following schools: Taunton, Bournemouth, Cranwell, 
Harlow, ' Nottingham, Tunhridgo M’^ells, City- of Oxford 
School, AVestminster, Durham, IMalvern, AVollingborough, 
Sonthbourne, Ediuburgh, Bromsgrovc, Purley, Hunstanton, 
Woolwich, Epsom, Kelly, St. Paul’s, Colot Court, Ton- 
bridge, France, Denstone, Cardinal A’'aughan’s School, 
St. Peter’s York, Sunderland, Ampleforth, Afalton, AA’im- 
borno, Blackbcath, St. Anne’s, Holt, Bedford Trainin" 
College, Bury, Alderley Edge, Froohel, Littlehampton'; 
University College Hospital, St. Bartholomew’s Hospital, 
St. Mary’s Hospital, and Guy’s Hospital. Tho total sum 
paid m aid of education of the children of these medical' 
men was £18,9fl6 9s. lOd. 

Grants have also been made towards insiiranco rent 
maintenance, debts, and surgery requisites, and help has 
been given tovvards the purchase of practices, examination 
j fees. etc. Tho total sum raised was £32,458 16s 8d 


10 i 6 JUNE i6, 1928] 


CORRESPONDENCE. 


r Tnr.Bnrnw 
Mtmcu. JovnNUi 


TIio grants given vero : 

£ e. d. 

1917 290 H 0 

■ 1918 697 16 2 

1919 7,552 15 '2 

1920 ... 5,926 17 6 

1921 5,622 14 5 

1922 6,204 17 9 


£ e. <L • 


1923 ... 

'... 3,956 4,5 

1924 ... 

... 2,470 17 0 

1925 ... 

... .1,778 '4 2 

1926 ... 

291 4 4 

1927 ... 

85 0 0 


£34,876 14 11 


This letter is not written ]iriinarily to neqnnint tlie 
profession with the way in which the 'War Emergency Eniul 
has been administeredj hut to tell the story of the wonder- 
ful, long-continued, unobstrusivo, self-sacrificing labour.s of 
two members of the committee who investigated, visited, 
interviewed, and corresponded with applicants for grants. 
Their recommendations were almost invariably accepted by 
the committee, and without their aid and advice the fund 
could not have functioned without malring many mistakes. 
These facts we think should he known. The whole pro- 
fession will be proud to learn of the splendid .selfless service 
to their comrades in distress of Sir Charters Symonds and 
Dr. Newton Pitt. — are, etc., 

Thom.\s B.milow, 

President of the Royal Medical Benevolent Fund. 

Chakles Ballance, 

London, Juno 6lh. Chairman, War Emergency Fiaid Committee. 


MEDICAL REGISTRATION IN NEW ZEALAND. 

Silt, — The attention of the New Zcaliind Aledical 
Conncil, the registering body in this Dominion, has been 
drawn to a letter by “ Traveller ” appearing in your i.'.sue 
of J.anuary 14th (p. 77), Many .statements contained 
in this letter are incorrect. The whole tommnnieation is 
written from the point of view of one particular case, which 
po.s,sessocl unusual features, and the inference that the 
experience of this individual is repi'csontativc of all is 
untrue. 

It irill he well to state the normal procedure. Section 9 
of the Medical Practitioners Act, 1914, states : 

“ (1) Every person desiriug to bo registore'l under Ibis Act 
sliall c-ausc at least one montli’s notice of bis intciUioii (o 'apply 
for registration to be published in the (V’orct/c, and also in some 
newspaper circulating in the district in which the applicant inicuds 
to practise; and shall, at least one mouth before the dale of liis 
application for registration, deposit in the office of tlic Registrar 
nearest to the place whore ba .inlciids to practise bis diploma 
or other original evidence of his qualification, or a true copy of 
any sucli document certified as correct in tlie prescribed manner." 

Section 10 of the same Act explains why a medical man 
socking registration must advertise as stated above : 


(1) Any person who has rea-soii to believe that an applicant 
is not entiHed to bo registered or is not a fit person to bo 
tins Act may, at any time before lliat applicant 
‘9, ''®?'®terea, object in writing to liis registration, and shall 
specify the grounds of his objection.” .in n 


, “1'P^‘Chnt, having lodged an application, deposited 

his diplomas for inspection, • and advertised as required by 
the law IS asked to fill in a confidential form of inquirv, 
Oil uliicli the following particvilars are requested: - ‘ 


equested : 
been practising since 


you registered as a 


1. State consecutively >v)iere you havi 
qualifying. 

2. In what other country or countries are 
medical practitioner? 

3 . Has your name at any time been removed from ai.y medical 

regisler m any country where you have been ronistcrcdP ■ if 

so, on what date and for what reason? ii-„istcrca? And, if 

4 Give names of two or three peraoiis (both in New Zealand 
and elsewhere) to whom you could refer the Council for informa- 
tion as lo your character (if necessary). 

5. Vfhat were your reasons for coming to New Zealand? 


This information is obtained to enable the Jlcdical 
Council to satisfy itself, in terras of Section 8 (2) of the 
Act, tliat the applicant is satisfactoi-y from the point of 
view of good fame and character. Past experience has 
I'l'oA’ed the necessity for this procedure. 

As soon as the aiiplication is received it is the nsnal 
practice, if the documents' are in order, and without 
waiting to make any inquiries whatever, to issue to the 
applying doctor a provisional certificate of regi.stratioir, 
iihicli enables the applicant to engage in medical practice 
immediately if bg gj, desires. This provi.siona! certificate 
months, and is aiitoinaticallv reiie-wed 
The foe fnF at the end of that time, it necessary. 

Whig is £5, 

rue fee at present payable- in- Great 


Bi-itniii. ‘ ■ . - • Zealand Medical Gazette 

co.sts 5s., ■ ; 7.S. 6d. per ineli. 

-In the ea.se referred to- by “ Traveller ” the medical 
degree.? po'-,se,sscd by the lipplicaiit wore not olitaincd in 
Great Britain, and are not, now registrable in New Zealand. 
TJio apiilic.'iiil ignored repeated eomnuinications from the 
Alcdieal Council, and persisted in practising without any 
form of rogistnition irliatei-ei'. It was in- these circum- 
stances that the police aiitlioritics prosecuted him for 
.liraeti.siiig iritlioiit rcgi.strntion. 

If medical men possc.ssing qualification.? obtained over- 
.sea.s intend .settling in New Zealand they would be well 
advised to ascortaiii befoiebaiid wlictber tlicir degrees are 
registrable in this Dominion. If so, and if they bring with 
them .satisfactory i-ec-cnt reforeneos as to character, they 
need have no fear a.s to obtaining legistratioii in New 
Zealand. — I am, etc., 

C. J. Diiaice, 

Secretary tn tlie Aledicnl Council of 
\VcBingU»n, Mny New Ec«lantK 


- THE ORIGIN OF ISCHAEMIC CONTRACTURE. 

Slit, — ^Alr. Trctliownn (June 9th, p. 1001) writes that 
Professor Hey Groves in his article (May 12tli, p. 807) 
makes no very helpful deductions to' guide ns in the 
anticipation and prevention of the “ uightniaro ” of 
ischaeniic cbntracture. Actually, Profe.ssor Hoy Groves 
.says, “It should he clearly understood that it is always 
a 'most dnngertms thing to flex a swollen clhow-joint." 
The helpful dediiefion is obvious — don’t. Even- fracture 
aboht the elbow-ioint -is nccmiqianicd by swelling. 

For yc.a'rs it lias been taught on high -luitliority that 
fractures about the elbow-joint (excepting fra'ctnic of the 
olecranon) should be treated in acute flexion or full flexion,' 
niid all will be well. This teaching is widclv followed,; 
indeed, acute flexion has become almost a ritual in practice, 
and surprise is expressed again and again when it turns out 
that all is not well. 

‘It should be rridcly taught that to put up a i-ecent 
fi-actm-e -of the elbow in a position of acute flexion is 
a most dangerous procedure, especially as " acute flexion 
is so often taken to mean the impossible position of the 
hand on the shoulder of the same side. I do not for 
a moment mean to suggest that a reasonable nmoimt of 
flexion cannot he' emplnyod in many cases with impunity; 
hut the ritual of acute flexion and some of the fallacies 
assoeinted with it need to be suppressed. 

'Speaking iiartieiilai-ly of supracondylar fracture of the 
lower eiul^oV the humerus, it is commonly thought that 
acute flexion of the elbow-joint prevents, the formation 
of callus and of a bony block in front of the joint. Both 
the callus and the hon'y block arc due, not to the position 
of the clhow-joint, bnt'to faulty reduction of the fracture. 
Acute flexion is quite commonly thought to ho a mea"® 
of i-cdueiug th.c dis)ilacement of the lower fragment. This 
i.s mechanicallv unsound. "We see many cases in which the 
frairineiit has' been ' simply tilted forwards and its iipper 
eiid'^inade to project backwards by the blind jjroccdurc of 
acute flexion. H is thought that acute flexion is nccessai-j- 
iii order to mniiita'iii the, position of the fragments after 
rc'dnctioii. This again is wrong. Lastly, acute flexion does 
not eorrect or control the rotation deformity wliicli is so 
common in these fractures. i 

•Reduction of aii elbow fracture should bo enecteci oj 
direct mauipulation of the lower fragment under an anaes- 
thetic, with the elbow-joint preferably extended or niodor- 
atelv flexed. If this fails, the displacement should bo 
reduced by open operation. After complete reduction it 
matters little in what position the elbow-joint is placed; 
it- may be extended or flexed to a right .angle or more, 
as may seem best'. But to force an elbow into flexion in 
the hope that an incomplete reduction may he rendered 
more complete, or in the hope that the after-effects of 
incomplete reduction will he therehy minimiv-ed, is asking 
for trouble, . 

•What is really the best position' in which to put up tins 
fi-acture after reduction? It is admitted that, if there is 
little swelling, the elbow may be flexed to above a right 
angle with impunity, and this also has the advantage 
that the reduction can usually be maintained in tins 
position without the use of splints. But, apart from tlio 


CGHUESPDI^DENCE. 


r TneilRinw- 1A4V 

'Liitincax'Jocunu. -tw**/ 


June :i 6 , . 1928 ) 


iiigliiniiiro nf i‘,cl)n('iu;c ciiiilnii^tiu-o in cti'-c tin- (!c-{,'rof- of 
Ili'ximi Ims been ini-ijiulf-f-d, Ihorc sue 'other, if les-- M-rious, 
ili-^ndvniitngos of Oip ni’xocl position. 

1 Imvo jtlrondy poinlodsont lhal llexion dors not. ooutvol 
rotation of the- lower fnigment. OrUiop.oeilic surgeons Jriiow 
very well llmf. graJiml oxtensioii of Iho elbow J'rom Oio 
Itixod position does not nhvnys follow sinoollily according 
-to plan, and some residual contracture of llio joint is very 
eonuiion. Lastly. nivosiUs-oxsificans in this region is aggra- 
vated, if not caused, by injndieions altoin|its to cxleml 
the cibow-aiter it bus been lce[)( in tlio Ile.ved ])Ositioti. 

On ,tbo other band, given eoniplelo rcdnelion of the, 
fracture, very good resnlts can be oblained from troaiment 
with tbo elbow Ilexcd to a right angle or even fully 
extended. Tbo latter nccossitatc.s eonlincincnt to bed, but 
it .slioiild bo cnijiloyed when tbere is great swelling. Jiotb 
require some sort of splint, of wbicli by far the best is 
plastov-of-l‘aris, wliieb, liowcvcr, does not mean prolongeil 
fixation in one position. 

T would :\vU w'betiier the disadvantages of ‘‘aeule flexion ” 
bavo been fairly weigbixl againsf its alleged advanfagos? 
ft is “ ’Universally appi-oved iweanse it is so easy— —at -rir.st.. 
Isdiaemic conlrnetnre is .n mass vT enagnbition necrosis of 
tbo innselo fibres, and when -onee it has ots-nn-ed tbei*o is 
no going bnek 011 it. iVns 11 r. Kenmm givatly d.aviiig 
er did bo “ nisb in ” when, as be tells ns’(p. iODlf, be 
pntjr eoldJind pulseless limb into nente llexitin-'— I am, <"te., 

I.on(lon, W.l, .tuno lllti. A. S. Ill.C.VOItl.l. RcSKaKT. 


-sju, — '.Making some nsofnl eomrnents on traumatic 
isebaemia in your issue of June .Sib t).. lOOli, Mr. 
Tretbowan oiupbasizcs Uio value •of pain as a wnrniug 
.symptom. May I supplotucnt bi.s stab MHf'nt Iiy rcinurkitig 
ibnt the I'uiu of istlmouutv is rhov-noloristic aiul outike oUmu* 
-iVltlioiigli tlio FufTcrer niiiv lx* to <U'scriho 

}»is o.vcCjit iinOor ^soino sttcJi va|;no ])lira‘-o as 

a iiorriblo drawing -sensation,” yet Iio is Jikely to nndor- 
to nnswt'i' in the .iiffinuativo whon a^kod' 
11 \i IS at all Uko “ pins .and ncodWs.” 

Aiiotlioi* point IS wortli noting, iFcIiacjuic ('ontnicliiro is 
due to ^loe^ge of blood vos.M‘.N; and soon al'tor its main 
artery Las bocomo obsU'uctod the surfaeo tt'utporaturc* of 
tnc limb distal to tlio obstruction is usnallv rnisod, oven in 
tUo presence of imponding or cstablislu'd isebaenria of 
miisdos. riic anatomical and plivsiological j ra>on.s for ibis 
piienomcnoii arc apparonl; but tbo dangerous fallacv of 
I gaiaiug a warm limb tvs one with a pruvod siifficiem v of 
ciieulation is not y-ci extinct. A cold limb tliroateiis 
gmigrene rather tlmu iscbaemia .— 1 am, etc., 

I.ondon, N.6, Jmie Ulli. H.IHOI.r) JlmiloWS. 


THL TREATME.XT OF 3LALTGXAXT DISEASE 
c c , COLLOIDAJi DEAD. 

-Blair BolTs standing in the sphere of 
• ccr loscareh is well known and requires no comraent. 

‘•'■catmont -of nialiguaut di.seasc by 
eteenbo tbo luctbods of preparation of that 
in affirm that they aro tbo same as those used 

in J^neipool Jvo iiioro ca: cathedra Btatcmeiit to tlio con- 

on fib/ is 
klwn « . the difference lies. It is well 

neSent commeraal preparations of lead contaiu n small 
iiv of arsoniCj and it was for that reason that in 

wbicT.^ a specially prepared lead “ sliot,” 

carries b+il arsenic. .Aloreover, the criticism 

one dose patients received 

case thlbTmid.e 

than n Patient rcceivca more 

source 1 ol'taincA from Die 

Blair Bell binS. ' anpplying Professor 

^ r Professor Billing's letter, I cannot see how 
at il^T affect the mattdr 

Bell wi ^ %ff‘'oxido heforo Pj-ofessor Blair 

at pr^inrSfe 

Client T 1 *^ 1 ? ' enable others to repeat the experi- 

''hit I aUecl “"'“7 ''•arning/ but 

hi relation* to "'a'ghk to anything which Tie niav sav 
loiatioa to £hnrmacoIqar, I cannot admit that ho .is 


-an sinlliority from wlirun tlioro is mo appeal. 1 Therefovo 
‘decided ti> iest the matter for ny-sclf when I was. offei-ed 
the material by an expert in tbo ])roparaD'on of ciillnidal 
.Kuhstnnees. .In any case, I am surpri.sed that Professor 
. Diltiiig .sbonid complain of my action,; rather Jie 'sboulcl 
ho pleased, since hy doing so 1 fully ooiifirm his results. — 

I alii, etc,, 

lanidoii. S.W.. Juno 6 U 1 , St.V.\i,EV M'v.mn. 

Sill, — ff 0110 comqiai-cs the investigation undertaken hy 
1 lio Ile'soarch Committee of tbo General TTospital, Birmiiig- 
liam, into the Ireatmeiit -of nialignant disease , with lead, 
and the iiivestigiitloii by .Dr. Stanley Wyard reporteij 
in the liriti.di Medical Journal of May ASfli, one caiuiol 
lielp thinking that if all investigations in the treaDncnt 
of disease were cnrrictl out in tlio .spirit of that periorineil 
in Birniiiighnm the advance jji oiir huowledge would he 
greater and our waste of time wottld bo lessened. 

It is obvious that it i,s usele.ss to try any form of treaD 
iiieiit, apart from miracles, on pcoyile who -are dying of 
cancer, and I do not tliiiik that even the uiost enthusiastic 
c.\'|ionent of lead will claim niiraculoii.s hciiefits for this 
method of treatnieiit. 

fneludcd in the list given liy Dr. AVyard aro 21 patients 
svho did not -receive mioro Ih.sn 0.2 ^-niii of lead, and of 
ihr.so 14 died, 6 wcie in statu quo, and oiiCj who had 
oiily had 0.075 ginm of le.sd, nras said to be worse. In 
5 of those who -ilied the ti-me they -wore under treatment 
Is not iiicnlioiied ; in 7 it ivns as 'follows: 15, '45, -21, 35, 
o5, 2D, 36 d.oys. Three of those patients, it will lie noted, 
■did not survive more than three weeks. "Of Die throe 
■who f-nrvivenl si.x wcehs inio lived 107 days, one 176, and ' 
the third, who w.ss labelled -as “ worse,’.’ lived 166 das-s. 

From tlio results of this adniinistration—I cannot' call 
it invest ig.ation — Dr. M'yard expresses an adverse opinion 
on -tlic inetliod of trca-tnicni by load. It would ho fairer, 
surely, if ho had expressed an advei-so opinion on his 
iiiothod of D-entmont In- lead. Can any fair-minded 01 - 
■'IqgiCTl man say that anyo-ne is jn^ficd’ in drawing .con- 
clusions from material .sncli ,ns this? 1 cannot °tliinfc 
that -even ■ tlio most nTdciil opponents of the method' of 
Professor Blair Bell would care to quote sucli evidence. 

It is clear from both tlio Birniingiiani .and the Cancer 
Hospital repotts that the great drawback in the lead 
•treatment is the toxicity of the ■prepaiutions used. B'e 
■shall make little progiyss in the treatment of cancer if 
treatment can bo carried out -only in a limited luiniber 
•of qjlaces. A u idesiiread disease such as cancer' must 'ho 
attacked liy a large -nwinher of individuals, and a safe 
drug is essential to eiiabio them to do this. 

ALy cases of inniigiiaTrt disease are given a coiu-:o of 
lead as a Tontiiio practice, and no .harai lias come from 
this 111 the jiast two and a half years. I use Air. Patter- 
son’s colloidal lead iodido (British Drug. Hoiisei;, Ltd.)' 

I have never liad any serious load Boisonhig occur with 
this drug. A^iy injections have .hcon given in the out- 
patient depai-tmeut without any iU eJFccts.— I am, etc. 

toii-loa. W'.l, June Jltli.' Duxcix C. 'i; Pz 7 Y.wh.llams! 

T "" of 

.Juno 9th (p. 999), Professor W. J. Billing titates that, 

^ '? safe, but appears to be devoid 

01 iiilnoitory elfect in mahgnaii't disease.” 

I have been engaged in a escarch on' lead colloids, especi- 
ally The selenide, .since the autumii of 1925, and have been 
u^uig the ^ienicle on -advanced cancer since 1926; I tTm 
not in agreement with the .second of Profe^or Dillin^’s 
conclusions. About -sixty cases -of cancer in man and manv 
liuuctrcds of animals implanted with cancer have heed 
’D-cated. It IS found that lead selenide is' safe, and that 
it has a -decided action in causing Inhibition and some 
''"“S>ng ’’'Bout regression. of malignant groirths. 
.In addition, it has a definite, nnd often marked, action in. 
dinnnisliing tlie pam of advanced cancer 

The .jircpaiw^tiou we use is safe, h tlie mm-msted 
technique as followed -it would be difficult to fnimf fbe 
patient. It IS not claimed that it is a .cure h i 
it is .a useful and liojicful remedv. Further 
.progre.s.s,aud it .is -hoped that improVeme^iiH eontinZ 

The preparation using has been preseSed to {he 






1050 JONE l 6 , 192 S] 


tJNIVEKSITIES AND COLLEGES. 


THE MENSTRUAL FUNCTION. 

Sir, — I would like to couimont on tlio very intcrosl- 
ing iirtiele of Professor Beckwith, ■\Vhitcliou.so entitled 

Practical applicatioi^s .of recent ^’icw.s on the ineii.strnul 
function,” which was published in the Jouriial of Anril 
21st (p. 651). 

Professor AVhitehonse expre.sso.s the 0 ]>inion that the 
sangninons menstrnal discharge in the human female has 
a double causation — mamoly, the necrosis and consefjuent 
shedding of the ‘‘ decidua ” of the pseudo-pregnant v. and 
the pro-ocstrnal hyperaemia. Ho stiggosts, further, that tin- 
cutting off of ” ovarin ” is resjionsihle for the necrosis, and 
that ” ocstrin ” is the hormone resiionsihlo for the hvjier- 
aenne factor. In fact, according to him, there i.s, at the- 
onset of memstruation, a “ tele.scoping,” as Marshall ex- 
pressed it, of throe distinct events, namelv:(l) the termina- 
tion of a pseudo-pregnancy; (2) the ” acme of a pro- 
oestrum and (3) an oestrum. 

. seems to me unconvincing that the activities of 

two different hormones should coincide to iirodnce three 
resultant events, all at the same time, espcciallv since two 
ot these activities, which are sniiposed to take place 
passu, are, physiologically sjieakiiig, incnmpatihles. For 
while the terinination of jiregnancy is disruptive in it- 
natiiro-kataliolic-the “ acme of the pro-oestriim ” would 
mean the height of an anaholic process.. 

fsf «ivcn by Professor AVhitehonse 

foi 11 hat Im calls white iiiciistTimtioii ” is opnallv nneon- 
imcing. He asserts that the non-occiirreiico of' necrosis 
of pseudo-pregnancy is a more _primitive condition than 
IS 1 appeniug and he cites the merino sheep as an example 
of this primitive condition in mammals. That this is not 
he ca.S6 IS evident from the fact that we have a' dcL.ite 
so-called pseudo-pregnancy necrosis in the marsupial cat 

di/t'K'”"/ ’ much more pnmitivo in" its repro- 

ductii e functions than the merino, while we have this 


f TirrBnrn^n 

Mmii-ii. Jounsii, 


— ^1 ' ^Yl\ue wo iiavo tlik 

p.-endo-pregnaiit necrosis well marked in the dog, a mammal 
evoliuioimry of the same grade as the merino .shkoi! “p 
ii (as Professor AA^iiitehonse maintains) the menstnrd 

nddi,r tmCsTudf 

Con'tress^i7ig24'T aden^”''"; ^^'''*^<•<''1 

— l-ipothcs. of 

gl'uoahrmiXS’S’^- f-cti„nallv, .are 

that the ovarian 

and not vice versa. Hence the ]encn"‘^^f * activities, 

intrauterine pregnant cycle would !n' “ ™™Plete primitive 

of a complete ovariau cycle-^nanieli 

maturation and e.\-pulsion of an ovim, \ u'*' acquired for the 
about tweiitv-eighl davs The siiliso ’ \ L'’cl,e i.s even now 
ing of the intranterin-rgesllr Icnglhen- 

ovarian rhythm, which is phylogeiieticallv ill n” i ‘'‘e 

pace of a complete intrauteHne renmd , r ‘’''“I'”’' 
therefore be first set according to life ol v'’"' ® "’""'‘I 

rliytlim has still remained with its ■' prh^n k" ' *'”* 

generative changes, and in this sense \he wh 1 
menstruation is atavistic. ^ "Hole process of 

— I ain, etc., 

Capetown, May 24th. 


S. E. Ix.vitK, M.B., E.jx. 


HO time Im^n on sale'"? capsules have at 

tlmyjiaie not reconUy he?n 

muiestor.. gt^. g g FullEh! 


ctnilirvBilicr; nnii (jCoIhtjcs. 


UNIVEBSITY OF OXFORD. 

MT.,in.n,°e"n?xr'!''‘’" ’"'''I "" I^octor ol 

Medicliio (D.Af.) was coiifericd on A\ ; F. Sliiiife. 

UNIVERSITY OF OA JIRRIDOE. 

At a coiigrcgalioii held on .Imie Sth the following medical 
(legrec.s were conforrcH : , 

0. Ktricklantl. M. L. ynniu;.' 

M.It., IJ.Cnili.— C t. . 1 . O. It. D. Cm-rau, It. II T Itoa 

M. L, Itainpiinl. It. Itlaxill, K. Kc-llott. ‘ 

it.CHin.— c. Tj. rolu. 

Ml. tTobn Jlasi! Buxton, M.A., F.K.C.V.S., 1ms boon re-elected 
1 rofessor of Aiilmiv! I’ivtliolo'(y. 


UNIVKKSTTY OF LONDON. - 
Till-, following cniidicintcs have been approved at the examhmtiOD 
indicated ; 

Tiiiiin M.n.. n.B.-Ml. S. M. Harlow,.*! n. I..DoItch, IfEuima J. King, 
•in' ■" ’ '•f(tn!.,*fr.Jt.SlonaHold. 


on, I. Bakheb, Attt:uHta . 
rpontor, Doris D. Clay. 


*:n. C. Trowc 
Jlonnaril, fre % 

K. McT#. Gobi; • •' < 

• M. CuRtlen. S. ‘ . . 

FltzGIbbon, . ' . 

(lannor. Yetb. ' . , ■ 

A. C. Hancock, J. O. Qawksloy, R A. Hli ■ ■ 

KflioL. f»**i*‘- ' — . • :* ! 

.JV-Lfoy( ;" ■ ■■ A. M. McMastcr, R. H.' 

Mauito. ’ . * . N. T. Mencecs. Mary 

JI. Mollt , !. • , ' r. Notlos', Lois J. Ogle, 

Lvolyn D. Owrn. J. R.-Piorro, R. S. i’hlllins R. F. rhilllps. A. .M. 
Richards. Androy R. RnBRoli. J. R. Bavillo, Thtlma Sbopberd, 
Owladys V. Rmallpeicc, R. S. Rmith. K. H. Houthall, C. A. Stanlej*. 
Mar>* M. Tnlloch. U. L. Worthington. 

Gro«p J.— Sophia Anlonov.tch, \ Ii. Basham, A. C. H. Bell, 
Ruth Bocook. W. i*. hL Davidson. Helona M. do Harlog. Jlarjorio U. 
Dobson. Dorothy V. Dunolly, Dorothy E, Rgllogton, Grraldioe W. 
Kvorott. G.'S. Forraby. C. Oioss, Hnlcn M. Herbert, Alice D,‘ M. 
Hodge. E. C. n. Huddy, D. F, Kanaar, C. F. Moore, Mary E. Pease, 

G. C. Pother. .Gwynedd M. iMiilllps, Rdlth J. D. bmitb, E. B. 
Smllhard, E. 8. Vorgptto. , 

Orovj) Jf,— Mabel A Baker, S. Bornstolo. S. J. M. Do Narasauer., 

D. R. DonDlll. H. Evans R. V. Farr, A. McK Fleming. W. H, George, 
r )8, Gladys R. MoCabo, M. Mackonsle, ' 

- J *• . . • . S’icol.Q.D. 8. Phimbly, B. I. Paddy, 

. , " . Claiico A. bUidmoro, A. G. Watkins, 

P. C. Wickromeslnghe, Rlsio R. Wright. 

* Hononrs. i DlBtiDgiilsho'd In Mf^dlclno. 1 Distinguished in Pathology. 

I Dteiinguishod in ForonMo Medicine. S Distinguished in Surgery. . 

IT Distinguished in Midwifery. 


UNIVEKSITY OP BKISTOL. ' 

The following caucUdates have been approved ttt tUo oxaminatlon 
indicated; > 

Fikal M.B., Cii.B., Part l.fttjdwdtup Forciistc Medicine aud Toxica-, 
loffj;) : Row'ena M. Miokmau, April Doreen .lames,* Mabol F. Pottor, 

. 5N. Jj. Prico. In JPorensic Medichie and Toxicolopv onlv t Isabella 
J. Armstrong. 

Pat "" ■’ *fT. H. Berrill. B. J. Boulton, 

’ 'lurg cl, IT. B. Wansbrough. O roup II 
. D. E. 0. Andrew, A. J. McD. Grimston. 

• With Second Class Honours, t Distinction In Special Pathology. 

1 Dhtinotinn in Public Health. !! Distinction in ■ Obstetrics. 

9 Distinction in Materia Modica, Pharmacy, Pharmacology, and 
Theraponlios. • • 

SOCIETY OF APOTHECARIES OF LONDON, 

MdsterT/ of Miiliriferi/ : Kciv Diploma. 

The Society ot Apothecaries of London announces its Intention to 
iiistitiito a Mastery of Midwifery and to issue a diploma ninler this 
title denoting the possession of specialized knowledge of ante-natal 
care, midwifery, and child welfare. References to tlie proposal 
were made on several occasions last year, notably. ou August 6th, 
(p. 225), and the regulations are now available.* It is iiiteuded 
to hold the first oxamiuatiou in the autumn and to ■'make tiiis 
a severe teat,, so as to ensure a higli standard of professional 
knowledge. The diploma will, however, not bo registrable niider 
the Medicftl Acts. In initiating this qualification the Society has 
been moved by consideration of the need for organization and 
improvement In the practice of midwifer.v and cognate matters, 
and by a sense of its own traditions in proniotiug the advancement 
of medical knowledge among general pmctitioners. Admission to 
the new diploma is nob confined to licentiates of the Society, but 
Is open to all who have been for not less than a year in possession 
of aregistrablo medical qimlification. The regulations prescribe 
that, after qualifying, candidates must have held, for at least six 
months, a resident appointment in a recognized institution 
concerned with obstetrics, and must have attended, for periods 
of three months in each case, a recognized ante-natal clinic and 
arecognized infant welfare centre before entering thee.xaminntion. 
Until 1932, however, special conditions will applv to practitioners 
years’ standing. The examination will bo conducted by 
i!*- and by clinical and oral tests. Copies of tlia 

regniatious may be obtained from the secretdrv of tlio Society, 

B ater Lane, Queen Victoria Street, E.C.4. . * 






1052 June i6, 1928] 


JIEDICAr. KOTES IN PARLIAMENT. 


[ The URmw 
MrtHC&L JoCBTtl 


done in connexion ^viUl it by Sir Leslie iStacKcnzie, who Imd now 
retired, but who bad been rc.sponsibic for some very important 
Bcctions of the report for a good many years. He was glad to 
Ece that the question of river pollution was being taken up 
serioiisly bj the Board of Health. There was no doubt Ihnl both 
on aesthetic and health grounds that question was of considerable 
importance. In regard to tuberculosis, it was a matter for regret 
that the progressive fall in the death vale was not inaininincd 
during the last year, but probably the reason given in tho 
report— tlie very severe climatic conditions in Scotland last year — 
m^bt be part of tbc explanation. Undoubtedly they wcio still 
retaining in some of the houses in Scotland many cases in an 
infectious stage, and in so far as they did that they were i-cally 
wasting public money spent in other elTorts to get lid of the 
disease. He was glad to notice that there was a .slight fall in 
the death rate from non-pulmouary tuberculosis. In that con- 
nexion were the Board of Health quite satisfied (bat all that was 
possible was being done with regard to the milk supply? Tho 
milk supply in Scotland for a good many years was I'csponsildc 
for a considerable number of cases of non-pulmonarv tuberculosis. 
They had had, in recent years, the licensing SYstem, with tuber* 
culin-tested and graded milk, and so on, and tliorc was no doubt 
that this had provided milk which was a great improvement on 
any supplied before. But it had to be remembci'cd that licensed 
milk was dearer in price, and he was anxious to know whet her 
the average of the non-graded milk was not perhaps lower tiuin 
before the graded system was instituted. It was of great impor- 
tance that continued attention should be devoted to securing a 
pure milk supplj’. 

He agreed with Mr. Maepherson that the Highlands and Islands 
Medical Scrnce had done a very great work. He was glad tlmt 
the report called attention to the veiy serious jio'-ilion in regard 
to tuberculosis in the Highlands and' Islands. If they took tho 
15 to 34 age group, and looked at it in relation to Scotland 
generally, and the Highlands and Islands in jiarticular, they 
lound that the general average rate for Scotland was 12.2; fo'r 
the count} of Inverness, 20.5; for Ross and Cromartv (excluding 
Lewis), 26.9; for Shetland, 28.1; for Sutherland, 31; aiid for Lewis, 
37.1. Those were extraordinary figures. The report said that tho 
reason for this state of things was a matter for surmise, and 
tliat research was being conducted. Tliose who knew the High- 
lands and Islands did not need to look very far for, at least, the 
major causes of this condition. The fir.«t w'as housing; very iimuv 
people in the Highlands and Island.s were shockingly Iiouscd. 
Again, it was quite possible that some of thc«>e people did not 
got adequate food aud were not in a position to resist disease. 
Those figures boro out the need for the investigation wliicli was 
dealt with in tho House of Commons a short time ago, and it 
was to be hoped that general improvement in (he prosperity of 
the Highlands aud Islands would result in tho reduction of t'lieso 
very alarming and very unsatisfactory figures. 

He would like to have said sonielhiiig aliovil the Hairmvers 
Colony, and of that method of dealing with certain types of tuber- 
culosis. There was no doubt that such a labour colony was on 
right lines. The Middle Ward District of Lanarkshire' and the 
Board of Health were tj he congratulated on co-opernting in this 
effort to deal with tuberculosis on up-to-date lines. He a^ked the 
Under-Secrotary for Scotland, who was an authority on the .subject, 
how the light treatment ‘for surgical tuberculosis was proceeuiii" 
Did he consider that the facilities for that trcalnieiil, which it was 
now admitted was very successful in these cases, were satisfaclorv? 
In the report, reference was made to the number of dispensaries 
hemg fitted up with light equipment. The references to venereal 
disease in the report were also very iiiteresUug. They dealt 
with the general propaganda mcUiocts which were umfcvlaken 
with the encouragement of the Board of Health, and also 
rvith the possihihty of preventive methods. Thev said, in regard 
to those, that certain preventive methods might he conlributorv 
to the spread of the disease. He thought he had heard an echo 
of that m othe. quarters. It was not the opinion of the armv 
and narj. The army and navy had reduced their figures in 
connexion with these diseases by the methods which were' so 

shS ??v^.red ihei ‘“w" Trevcthh. CommiUce 

also favoured them. He was interested to find that the Board 
came to the conclusion that secrecy, which was so much slresSid 

‘of g.t\‘^mpo‘^la‘nc?.°''a\'’ tt'' 

One could see quite well that while the language used was'gua'i'dcl’ 
the Board of Health, as Ihoy had shown on several occasion! before 
were not convinced that the present arrangements and svsfems 
wove satisfactory or capable of dcaliiiL^ a§eainiM-»- 
serious diseases. This certainly juslified the attitude^ of the Min” 
burgh Corporation and other Scottish local aunimdlies in tlm 
matter. It was an appalling fact that last year in Scotland t e 
number of defaulters was 51 per cent. In view of the verv larlrp 
amount of public money spent in dealing with this subiect ti 
obvious that a great deal of that monev was wasted and' in I he 
name of economy, it humanity was not enough, somelhiim Ase 
ehoukl he tried. 

There was a rclurn in the report lo Ihc atlack made last 
year on Ine medical profession in regard to certification of 
people as unfit fer employment. He had hoped that thev had 
heard the last of that, because, in his opinion, that attack 
while it might have h-aen instilled in some cases, had been 
overdone. Altogether, an attitude was being taken up in regard 
to Uio medical proiession, and incidentally in regard to Their 
pnlients which wa*; quite unju';tifiahle. The report did not 
mi.arKiUly recognize that the condition of the people in ScotLand 

such, owing to uncmplo^Tnent, 
unforin^io forn.erlv to illness It was 

aid surcharge 

<-rccs, and so on, lucdicr.l men should have it suggested 


lo^ Ihein that they should cid down jnes-crildtig to the ^(•ry 
iinnitniini amount. Ho had never scon or Iieard of any iiux'sti- 
gation to find out if medical men were supplying sufficiently 
good medicines, toiiies, and Imilding-iip jiroparations, wliicli 
wore olten nece'-sary. So long a? the medicine was cnl down, 
and (he cost of prescribing was low, tliero was evidently no 
worry^ a** to whether the insured person was gelling proper 

rcinedh's. The whole tendency of tho system \\as to cau.«:c 

Iho doctor to ho afraid lo give wlml, in many ca<;e.% would 
only ho adcqualo for the nature of llio ca«;e. 

Sir R, Il.\Mn.TON ako drew allention to the enormou^' valuo 
of I lie work of llie Highlands and Islands Medical Service Fund. 
He «.aid lie did not believe that the aiimial contiiluilion lo the 
I'liiid of £42,000 a year had boon increased do meet the change in 
money valuer., hut the Fund was expected to do the same work 
(o-day, when costs were infmitcl}' higher, as in 1913. There was 
probably no fund in tho world more economically administered, 
and winch did a grynter amount of good. In a slibrt lime, unlC'S 
a further contribution was made, the work of the Fund could not 

he carried on, and it would have to come (o an end in eighteen 

months. Ho liad it on ihc be.st authority that another £25,000 
a year was required. He asked for an assurance from the Govern- 
tnonl that provisions would ho made so that the work of llie 
Fund .should not he allowed to he diminished. A hrancli of the 
work wliicli Imd been an outstanding success had been the appoint- 
ment of consulting surgeons in the outer islands. In Shcliaiid, 
particularly, when* a most excellent surgeon was appointed, the 
lesiilt was' that operations of importance could he performed in 
caves wliicli would otliciwise have liad to be sent south. As 
a result, patients were got under treatment early, and the hos- 
pitals in tlic south, whose beds were loo full already, had been 
relieved. 

Mr. .SmYSicnouR, referring to venereal disease, said that the 
Scottish Board had i.ssucd an excellent compendium of information 
on the various activities of the department, hut in regard lo this 
teiTihle tliseaso it put in veiled language evidence that it would 
like io do somelliing better, but was being held hack on account 
of the position of the English Ministry of Health. That situation 
once more proved the futility of trying to do anything in that 
connexion at all. 

Sir A. Sinclair, emphasizing what Dr. Shiols had said about 
harrying doctors for over-prescribing, said tliat there had been 
cases' in his constituency of well-known and vciy rnucli respected 
doctors who were accused of ovcv-pi escribing. They were iiio.sfc 
caicfui men, who licld important public positions in the country, and 
men regarding wliom sucli an accusation could not for a moment 
bo entertained by those who knew tlicm, He hoped that this 
action w’ould not ho resorted to in future. He n«kcd for an 
assiiranee from (ho Government that tho efforts of tlie local people 
to maintain and improve the equipment of the Bignold Hospital 
ill Wick, and the Dunbar Hospital in Thui-so, would he sup- 
ported, and, in particular, that they would bo able to obtain 
tho imich-needed .services of a surgeon. , . m 

Mr. Stepjilk complained about a paragraph m the report of the 
Scotlisli Board ol Health dealing witli the ccrlitication by 
doeloi's under the national health insurance scheme. - Ho 
challenged tlio implied reflection in it that doctors in Scotland 
were nUowing people to draw* sick benefit who wore not entitled 
to il. It was obvious that the paragraph was written to try 
to terrorize the timid members of the profession into sending 
people hack to work before they were fit to return, or to keep 
them from giving certificates to incmhei's of tho working classes 
w’ho through being unemployed and consequently unable to get 
piopci* food, had got into an unhealthy condition. 

Dr Elliot, replying to the debate, said that Mr. Stephen had 
spoken of I'enections and attacks on tlie medical profession con- 
Inincd in the report. The spoclncle of Mr. Stephen defending 
the medical profession against tho attacks of Sir Leslie MacKeiizio 
W'as one ilmt thev miglil well leave lo the delighted laughter 
of the medical profession in Scotland. Continuing, Dr. Elliot said 
that there wore nianv liouscs in Scotland which they not only 
regarded as unfit for 'human Iiabitation, but -whicli their fathers 
and grandfatliers would have classified as unfit.’ Those were tlio 
houses that the Board of Health w’ished io get rid of in the 
first place, but until they made a hegimung with them it was 
useless lo reclassify houses, and say tliat no houses w’crc satis- 
factory unless thcie were three rooms with hatliroom, water-closet, 
and other modern conveniences. Tliey had done their utmost to 
impress on the local authorities, who W’ere building liouses, that 
people at present were suffering acutely not only from unsalis- 
tactorv houses, hut from overcrowding. A cut liad taken place 
in the English housing subsidy, but none in that for Scotland, and 
Ihev had the assurance that none would be made until March 31sl. 
The subsidy for the Highlands and Islands Medical Service 
would have' io be considered. It w’as now £42,000 a year, hut 
Uic Fund was draw’ing on its uiicxpendod balances to make up 
au expenditure of £62,000 a year. The Secretary of Slate would 
again approach the -Treasury, and he had no doubt that he would 
succeed in getting a substautial increase in the statutory rate 
of tliat .subsidy. The report of the Scottish Board of Health 
Avas a rcvicAv of the work of the local authorities.- It pointed out 
many directions in which that w’ork needed to he expanded, and 
ill which it could he greatly advantaged by a better system 
of co-operatiou among the local authorities. All these things were 
being brought up, considered, and dealt w'itli in the great financial 
moasui’es now* before Parliament. 

The debate was adjourned. 


[Various other matters connected with medicine were discussed 
in Parliament this week, but the pressure on our space compels 
postponement of further reports.! 


June iG, 1928 ) 


WEDICAIi NEWS. 


r T»p immira 
L'lIcmcAE Joinvix. 


-1053 


iltcDiral 

Tnc annual general nicoting of the Ilcscarch Dofcnco 
Society will bo held at tlio liouso of Uio Medical Society 
of Loudon, 11 Chanclos Street, Cavendish Square, W., on 
Tuesday, .Tnno 19tli, at 3 o'clooU. The chair will bo Inkon by 
tho President, Lord Laiuiuglou. An addrc.s.s will bo delivered 
by Sir Bernard Spilsbury on ‘‘Tho work and rcfiponslbltics 
of a pathologist,” being tho second .Stopiion I’agot jifoiuorJnP 
Lecture. Tea and coiteo will bo served after tho mooting. 

A -MEETING of tho Z’aborculosts Association will bo hold on 
Juno 22nd, at 8 p.ni., at the Iionso of llio Itoyal Society of 
31ediciuo, 1, Wimpoie Street, IV. Dr. lA It. TValtors will road 
a paper on tho causes of breakdown in hoalth in pnlmonary 
tuberculosis. 

The National Council -for ^teutal Ilyglcuo has arranged 
a fmhiic meeting, (0 bo held in tiio C’ouncii Clianilier, Hir- 
miughaiii, on Tliursday, .Tnno 21st, at 5 o’clock, wlieu 
addres.sc.s on tiio (trevention of nervous breakdown will bo 
given by Sir MauHco Craig and Lr. II. Grioliton Miller. Tho 
, cliair will be tairen by tiio Lord ^luyor ot IJirniingiiani. 

Dit. Author IIopewei.e Smith will give a lecture, entitled 
‘‘The process ot ostcoly.sis: a liistologlcal .study,” at Guy's 
Hospital on .1 uno 2Gtli at 4 o’clock. 

The annual mooting ot tho British Hospitals Association 
will bo bold in.tlio Congiegational Schools at Southport on 
.Juno 21st and 22ud iiiidcr tho presidoacy of Sir Artliur 
Stanley. Sir 'I’lionins Holder will open a discussion on tho 
place of the voluntary liospital in rckulon to healtli service.s, 
and Mr. G. Q. lloborts, sccictary ot St. 'Tlionuis's Hospital, 
will open another discussion on the problems of tho voluntary 
liospital to-day compared wlth.tboso ot the past. Miss M. E. 
bparshott, lady snporiiitcndout of iiiir.sos, Manchester Ifoyal 
luiirniary, will open a discussion on tho placo of tho muse in 
tUo hospital. lurUier iuformatioii may bo oblaiiicd from 

G^rSTinmy;" ''• «o»thport 

atmivorsary dltinev ot tho Royal Society ot 
KeXt Hygiciio will bo bold at the Cafe Boyal, 

for®R Juno 20tli, at 7.30 p.m. 

lor B p.m., umloi* tlio cUaii-juansbin ot Professor J, W V,\ 
F’K.S., President of tbo Society, kpplica: 

11. Cl.andofs1r\d"°\vj?^ 

itnnmi Clnb will bold its 

“ 7 o'clock College on Saturday, June 23rd, 

in the ohair president, Sic Humphry Itollostou, 

Dr Y mooting will prcccdo tbo dinner. 

in^ ?s7ooal soI^'taoT’ Cambridge. 

BoberisoS” w^n'm announces that Mis. Tindal- 

graduates onir ^'7^i denionstralion, for women 

Newineton Canio , ° London Hospital for Women, 

Davb win 20tti, at 10.30 a.m. Mr. E. D. D. 

Juno 22udTnd af T „ Cross Hospital at 11 a.m. on 

.1 2 p.m. on tho sarao day Jlr. Dortell will 

nl Eye Hospital, Southwarlv. These 
* . “CO to medical practitioners. Tlireo 

m disea.ses ot the ^"“o 18th— namely, one 

Diseases ot tho Heart t''° Loudon Hospital for 

gynaecology at the riiel Jon P? 1 mtona Park, auotlier in 
afternoons” and some uform„?°®‘“‘P 

Bnrgery, and the speSueP’iP^H “ “mdicine, 

Hospital from 4.40 to 6 n m tv ^ t‘® Temperance 

West End Hospital (ot to July 21s6 tho 

course of clinical demons^Pt®”^ Diseases will hold a special 
four weeks. The following sJfop? f*'®'” ® P'®’ tile 

in July ; medicine i courses will take place 

N.E. London Post-Gr’adnafe Cn ’11 specialties at the 

Hospital), Totteuhaiu aUSv Ini?™*-® General 

course in prootoio^v at t-r instruction, and .a week’s 
all special course 'syllabusGR ® Hospital. Particulars of 
Qraduaie Medical Journal n,’ui ®‘;‘‘®®.“ ®°Py ®^ 
of work available for those nni?hP'“P °/ ijeneral course 
are obtainable from tlm "““’ilo to do whole-time stud 

1, IVimpole Streerw.l ®®"ctary of - -■ 


the Eellowsbip 

Of Ep?dmu?ologrMd^S®at?'MpiP^ Hogers before the Sectior 
Hcdieine, on tte Uicideuee^®‘?*®’®® ®' Royal Society o 
(reported In the Journal cholera in Xudi 

^printed trom the 1?26, _p. 784) has 


beei 


H^dic/ni;a^^aOTemoir(N“9('?f ‘^-^RO-Val feoeietrl 

Joiinmt of Medical llesearcl ,S??“ei=^iou with the Indiai 


Central Proviiios and Bciar, and in the Bombay and Madras 
Prc.sidciicic.s, the United Provinces, Biliar and Orissa, Lower 
Bengal, Assam, and Burma. It ni.ay bo obtained from tbo 
Indian Itesearcli Fund Association, Calcutta, price 7s. net. 

A 'CONKEitESCi: of dologates ■ from -various educational 
bodies and other organizations was licld in London on 
Juno 6th to consider the higher cdncaliou of the deaf. Lord 
Cliarmvood. president ot the National Institute (or the Deaf, 
was In tlic chair, and various speakers described tho existing 
provision and suggested iiiiproveincnts. Jfr. W. Carey Boo 
said that thcro was no public provision for tho post-primary 
education of tlio deaf, and outlined a scliome for the creation 
ot a residential college, with facillticB also for securing tho 
co-operation of e.visting colleges or technical institutions. 
The conteronco resolved ‘‘ that the time has arrived for the 
cxtousiou oC tlie national system of education for the deaf by 
the cstablislinient ot provisions for further education -lliaa 
can he given in tiio present schools for such children,” and 
decided to ask the National Institute to set up a committee 
to con.sldcr the proposnis pnl fonrard and to report to a 
further conierenco to be held later. 

The report of the IIoiiic Service Amhniauce Committee of 
the .Joint Coiiiicil of the Order of St. John and tbo British 
Bed Crass Society for the first quarter of the j'car contains, 
in addition to the usual statistics regarding work done, some 
inlercsiing practical notes on tho care and maintenance of 
nmbulunccH wliicli should receive the attention ot all con- 
cerned in thi.s imiiortant service. It is pointed out liiat tho 
comfort ot patients depends largely 011 the condition ot tlie 
car.s, and It is suggested that divisions and detachmciit.s of 
tlio organizations sliould make it tlioir hnsiiiess to remedy 
all structural detects which may develop. Boferriiig to the 
road service scboiuc adopted last year, which was de.sciibed 
on April. 7th (p. 603), tho report records an apiireciablc ex- 
tension in tbo number ot roadside first-aid boxe:--, first-aid 
stations, and patrols all over the country. La.st year H ivas 
noted that tbo presence of iinifornicd members of the Order 
and the Society on tlie roads served as a warning to innuy 
drivers and pedestrians ot tbo need for c.aution. Tho com- 
mittee suggests that units undertaking work on the roads 
sliould foiivard to the boadquartors ot tbeir organizations 
descriptions of tho scboiiies of working, adopted and an\' 
observations on ttieir experience, so that information may be 
marie available for the guidance of those taking up the work 
for the first time. 


iiiuuivi’i juis ueun tippointctl pijvsjcian* 
In-ordinary to II.B.H. Princess Beatrice in succession to Sir 
Alfred lllco-Oxlcy, resigned. 

Wells,- has been 

-adniitted a serving brother ot tlie Order of the Hospital ot 
;St, John of Jerusalem. * 

At a recent meeting of the Straits Settlements Legislative 
Council a bill was read for tbo first time designed to grant 
authorization to medical practitioners and certain other 
pci-Bons to possess and use dangerous drugs without licence 
so far as it is necessary for tho practice of tbeir professiL or 
employment, in the same degree as is lawful in England 
The Hong-Kong Medical Association gave a dinner 
April 21st to European practitioners and their friends • tho 
Governor, Sir Cecil Clemeuti, was present Dr Ten w’ , 
the chairman of tlio Hong-Koug Chinese HedioalAss^Ition 
welcomed the guests, aud Dr. Lee Shu-fan 
their health, expressed the hope that there would brstlU 
closer co-operation between Chinese and foroion ,n^-i- . 

practitioners in Hong-Kong He reoeminporioa®'^®’®® ’uedical 

Governor, replying, rtisenssed the hospital orglmratio J of 

Hopital Tarnier aud Acadgmie de Medecine? at the 

The following appointments bare i-ecetrtH- 
foreign faculties of medicine : Dr. Soiellmff 
dermatology at Jena; Dr. Steinhanser mo/essoro? 
at Greitswald; and Dr. Tanon, proS “w'r-^'®*®'®^^ 
preventive medicine at Paris in snccession tn T>r'^?^®'®“® 
Bernard, who has been appointed tim flrft’ ^f°fe.ssor Leon 
new chair ot tuberculosis. ^® occupant of the 



1064 Jdne i6, 1928] 


LETTERS, NOTES, AND ANSWERS. 


I Tifr nr.'mtir 
^frtitCAL 


Wdkvs, aittt ^nslircrs. 


All communications in regard to editorial business should ho 
addressed to The ED/TOR, British Mcdicat Journal, British 
Medical Association HousOf Tavistock Square, iV.C.f. 

OUIGINAL AKTICLES and LETTERS forwarded for publication 
are understood to be olTored to the British Medical Journal 
alone unless the contrary be stated.^ Correspondents who wish 
notice to be taken of their communications should aulhcnlicato 
tliem w'ith their names, not necessarily for publication. 

Authors desiring KEPIITNTS of their articles published in the 
British Medical Journal must communicate with the Financial 
^secretary and Business Manager, British ^ledical Association 
House. Tavistock Square, W.C.l, on receipt of proofs. 

All communications with reference to ADVERTISEMENTS, ns well 
as orders for copies of the Journal, should bo addressed to the 
Financial Secretary and Business Manager. 

The TELEPHONE NUMBERS of the British Medical Association 
and the British Medical Journal are lilUSEUM DSGl, VSG2, VSGS, 
and t)SGi (internal exchange, four lines). 

The TELEGRAPHIC ADDRESSES tiVQi 

EDITOR of the British Medical Journal, Aitiolofff/ TTcutcctit, 
Loudon. 

FINANCIAL SECRETARY AND BUSINESS MANAGER 

(Advertisements, ctc.i, Ar/ic«/ntc TTcs/fm/, Loudon. 

MEDICAL SECRETARY, Mcdiiccrn ITcRfcrnt, London. 

The address of the Irish Ofiicc of the British Mc<lical Association 
is 16, South Frederick Street, Dublin (telegrams: llnnllu^, 
Duhiin\ telephone: 62550 Dublin), and of llio Scottish OflTico, 
7, Drumsheugh Gardens, Edinburgh (telegrams: Associate, 
Edinburgh', telephone 24361 Edinburgh). 


QUERIES AND ANSWERS. 


tlio subject of n depreciation claim. So far ns our knowledge 
goes, that view is accepted generally throughout the country. 
There is no prescribed rate of depreciation; W'c should sug'.'est 
30 per cent, on the written-down value ns being at least fair to 
the ilcvcnno. 

*' O. A.’* iiuinircR what would bo a reasonable percentage for 
depreciation, and whetlior the value of articles liable to frc<|nont - 
renewal— such aa a:-nvy tnbe.s, .rnhhoi* gloves, etc.— shonld ho 
excluded ? 

Wo suggest, Bomewbat tentatively, 10 per cent. Wo 
are of opinion tlmt when rene\val takes place througli obso- 
Icscciico the nncxbauslcd value can bo claimed for, and thereby 
any ingnnicioncy in the dcjireciatioir- allow’ance ultimately 
corrected. .Articles which form an integral part of the plant 
should be Inciiidcd in tlio. value, even tiiongb subject to fairly 
frequent renewal— as, for instance in the case of motor car 
tyres; other articles, such ns rubber gloves, arc not proper 
subjects for the depreciation allowance. 

JJnhilitij for Hoard and Lodging. 

K. T.** was engaged as an indoor nssistint in 1921 at a salary of 
£40D. “ J'*or inconio tax jmrposcs the lns[»cctor of tnxe.s put 

down the inconio as £5(X) per year,*’ Is bo legally entitled to 
claim t1»e tax paid in error? 

No, any legal right could have been ]u*esen'ed only by 
lodging formal notice of objection to the incorrect nssessments 
when tlicy were notilied. But if “ K. I.‘’ can make It clenr that 
. the inspector of taxes knew that the salar.v. was £400 and added 
llio £1C0 for hoard and lodging through an oiricial error as to the 
law np))lica))lo it may be wurtli applying to the Board of Inland 
Itcveniic, Somerset Ilonsa, W.G.2, for relief as nn act of 
concession. 


W^HOT.K Blood Tuansfusion. 

Dn. Osborne Buownf. (Jamaica) writes: Can consangiiinons 

blood — that is, parents and clnldrcn, brothers and sisters be 

used without grouping and without risk ? Wlmt is the simplest 
method of grouping without the aid of a microscope? Some- 
times one would Idee to transfuse at sliort notice and in out-of- 
Ibe-way places, but the fear of group incompatibility acts as a 
deterrent. 

Cramp after Sciatica. 

With reference to the note by “ F. W. S.” on the treatment of 
cramp after sciatica, on March 24th (p. 534), it mav bo added that 
tlie preparation employoil w-as “ iodolysin,” obtainable from 
Messrs. Allen and Hanburys, Ltd. 


Income Tax. 

Payments for Capital Harrowed, 

“ E. "K. S.'\bas borrowed capital to pay out his late partner and is 
paying, iRicr nZ/a, interest, from which he deducts income lax, 
and an aiimia! sum representing the cost of a fidelity policy. 
IIow should he deal with these payments ? 

So far as the interest is concerned it cannot bo deducted 
ns an expense, and therefore is assessed on “ E. K. S.’* (ns part 
of his profits) as if it were his income, except that tnx is payable 
on that portion of the profits at the full standard rate. In that 
way the tax deducted by E. lx. S,” readies the It?vcnno without 
any specific ad hoc payment being made. The fidelity policy 
payments relate to a capital charge and are not allowable as 
-expenses, though presumably they arc part of the company’s 
profits and are assessed to tax accordingly. 


Gommeucement of Partnership. 

“ .?■ ® '■ m''® 'V0i-I(e,1 together foi- some ycave, B boiii" 

n “ sulanea paytnei;.” A deeil o( imi-tiievsliip was exeentort ni 
Jn.mia.ry, 1928, ‘ (liitiug tlie imrtnevsliip back to .lammry 1927 ” 
The income tax anti, orities will not a.lmit tliat a partnere! |> 
existed prior to January, 1928. l 

%* ■“ Pai-tnersbip ” is a special relation between the parties 
ami tlie fleeil of January, 1928, cannot have constitute, 1 tliat 
relation m 1927, tliongli, of conrse, it was open to A aiirt B to 
enter into any arrangement with regard to the payments to be 
made to B for bis work in 1927. “ J. K. S.” refers to B’s earlier 
status ns that of a “salaried partner”; we are not quite snre 
what precise meaning slionld be attnobed to tliat description 
but assume it to mean tliat B was a salaried assistant with a 
slinre in the firm in prospect. It so, tlien we tiiink that the 
additional payments made to liim for 1927 as a result of tlic 
partnership deed may properly be regarded ns liis remnner.ation 
for tliat year, and be cliarged on liim under Scliedule E and 
treated ns expenses in tiie accounts of tiie practice. 


LETTERS, NOTES, ETC. 


C05IPI.r.TM Ol)I.lTi:iI.\TION OF TIIF. YaGIN-J. 

Dit. F. Bokji: (llong-Kong) writes to record tlio case ofaCliincse 
woman, aged who was mlmittod to tit. I’niirs Jlospilnl, llong- 
Kong, with tbo following liistory. Higbteen montlis ago, wlieii 
about live moiitbs pregimnl, abortion started. At tbo time slio 
was living in tlio interior of China, and tlio old women of tiie 
village were called in to atlend to her. Tlioy cvidonlly did not 
think Hint tilings woio as they slionld be, and proceeded to 
remove tlio foe'tii.s liv means of “ metal liooks.” Tliero was 
a considornlilo amomit of Imcmorriiage, and tlie patient wis 
taken to a Cl, ineso doctor, wlio prooepilcd to repair tlie damage. 
The patient liad never menstrnnled since tlie abortion, un 
examination oi tlio place wliore tlio vaginal orifice slionld liavp 
been, lliero was tonnd a liavd mass of scar tissue at tlie liottom 
of a (iopre.ssion, witli radial ing soars towards tlio labia. Ko open, 
in- could lie found, oven witli a very fine probe, and tlie nterns 
■could not bo felt per rooliim. There liad also liocn extensive 
dama-'eto the poriiionm. At tlie subsequent operation performed 
bv llixBiitijo lio found tiiat a liliroiia cord of scar tissue repre- 
seiited tbo original v.iglim. and tills was traced up to a small 
atropliicd nterns. The cicatricial tissue on dissection wassliowii 
to lio as a partition between rectum and bladder.' 

TjNtisuAT. Pigmentation of Scalp. 

" X y Z ” writes: As tbo possessor of a “ piebald ” scalp I read 
br. ■\\’aiker’s letter, with Dr. Miildin-Davis’s comments, on this 
subject in voiir issue of l-eiirnary lltli (p. 243} witli great 
interest, and was surprised to learn tliat the alnioimality is 
considered so rare. However, I iet tlie matter drop. But iii 
j-eading Dr. Cooper’s note of Rlay 12tli (p. 832| my interest was 
again aroused, and tills time to a very bigli degree, by liis 
relorence to a case in Edinburgh (my native' place) twenty-five 
yovvsago: 1 liave little doubt tliat 1 am the person mentioned. 
From the scientific iioiiit of view I am sorry to say tliat 1 can no 
lon-'er oiler myself ns an interesting patliological specimen, 
alopecia liaving invaded tlie region in question almost to tlio 
entire exclusion of tlie blnok patch. Since my yomigor days 
other anomalies in tiie distrilintion and perniivnency of pigmenta- 
tion have manifested tliemselves, but tliat on tlie scalp was 
pi-essnt and unvarying from infancy. Wliilo tlie area was some- 
what larger tlian Dr. Cooper stated, I must congratulate him on 
the accuracy of liis description after all tliese years. 

Immunity foi.lowing Herpes. 

Dr. H. ■Willingham Gei.l writes: The personal experience of one 
of oiir in'ofcssian mav itself be worth adding to tlio record of 
Dr. James Tavlor (.Mav 26tli. p. 920). About twenty-five years 
n-o I bad an attack of typical herpes zoster. Bast year I bad a 
bad bout of lierpes frontalis; Of both I bear tbo soars. 


Depreciation Allntcance — X-Datj Appirntns. 

‘ E. P. D.” states tliat ills claim to a depreciation allowance has 
been refused, tbo inspector of taxes stating tliat lie is entitled 
only to renewal expenditure. 

.’ •* fio "ot agree. In onr opinion tlio apparatus comes 
^ witbin the category of “ plant and machinery,” as distinct from 
anch equipment as " tools,” and therefore can properly be made 


Vacancies. 

Notifications of offices vacant in uuiversUies, mo'lical colleges, 
and of vacant resident and other appointments at hospitals, will 
4>e found at pages 70. 71, 72. 73, 76. 77, and 78 of onr adyertisenienfc 
columns, and advertisements as to partnerships, assistantships, 
and locumtenencies at pages 74 and 75. i-carfianf 

A short summary of vacant posts notified in the advertisemenii 
columns appears lii the Supplement at page S63. . 



JONB 23» ^9=3] 


GASTKTC AND DDODENAD ODERATrONS. 


t Tirr TlRrn"fr 
Mkdicai* Jocitsi* 


1065 


llrsitlis 

or 

A SERIES OE GASTRIC AND DUODENAL 
OPERATIONS.* 

ny 

r. J. STRONG HEANEY, Jt.D., F.R.C.S.I., 

LtCTUHER llf CLISICAL SUnREKY, VKIVV.HSITV OY UVEUrOOL. _ 

Ik spito of the work which has I)con done and tlio volume 
of literature which has aeemuulntod during tlic last twenty- 
five years there are many points still unsettled in . tho 
surgery of gastric and duodenal ulceration, and eico 
surgeon is in duty hound to review his eases in the light 
of current liternturo and to bring his experiences, gveat 
or small, into tho coininon stock. I his must bo my 
apology for recording the end-results in a comparatively 
small scries of cases. 

Excluding malignant disease, I have notes on 183 con- 
secutive cases operated on by myself, mostly within the 
past four years, and I have endeavoured, with tho assist-^ 
once of my friend Dr. Aidcn, to follow ui) every case. IVo 
have succeeded in obtaining tho end-results in about 
90 per cent, .of. thchi. Pathologically tho cases may be 
classified as follows. 

33 

65 


1. Acute perforations 

2. .Chronic iluoiicnat nicer 

3. Chronic gastric nicer ... 


85 


Total 183 

I shall take tho different categories in tho order set 
forth. 

Acuti; Pr.nron.iTiONS. 

I have had 33 cases, 15 gastric and 18 duodenal ; the 
procedure followed was to repair tho ])crforation, insert .! 
a pelvic drain, and, if the patient’s condition permitted, 
perform a gastro-cntcrostoniy. Gastro-ontcrostomy was 'in 
fact porforincd in 31 out of the 33 cases. Of tho 33 cases 
7 died in hospital, but I caiuict discuss tho immediate 
mortality in relation to the number of hours which elapsed 
between perforation and operation as my notes are incom- 
plete on this point. A summary of tho results is as follows: 

Died in hospital 7 

Good cnd-rcsulls 17 

Good hut recent (under one year) ... 4 

Unsatisfactory ... 2 

Untraced 3 

Total 33 

Of the cases in avhicli gastro-ontcrostomy was performed 
I have been able to obtain the end-results over ono year in 
19 cases. In all cases save > one tho result was good. In 
that one the stoma became inadequate- and symptoms 
recurred.' At a second operation the stoma avas enlarged, 
and thereafter the course of the case was satisfactory. 

> ■ eases gastro-eiitcrostomy was not performed because 

of the -patients’, condition — ono a duodenal and the other 
a gastiiC case - In the duodenal case I learnt at the follow- 
up that lie was ■ admitted later into another hospital for 
duodenal symptoms, which were relieved by gastro-entero- 
stomach 'case' tho perforation which I was 
called ou to treat was a second perforation; the first 
occurred five years previously, and had teen treated else- 
where without gastro-enterostomy. On opening the abdo- 
men the viscera were matted together by adhesions and 
the patient s condition was so serious that I did not subject 
iim to the strain of a gastro-enterostomv, an addition 
*• "^ould have involved the separation of many 
adhesions. This case -is, of course, liable to a further 
repetition of ulceration and perforation. I do not know 
w le her in the duodenal perforation which was repaired 
without gastro-enterostomy, and which required a gastro- 
enterostomy later at another hospital, the operation was 
embarrassed by similar adhesions. Of the two unsatis- 
ac oiy end-results, therefore, one had no gastro-entero- 
stomy the other an inadequate gastro-enterostomy. 

“U Dm arguments for and against 
gastro-enterostomy, but will merely say that in so fdr 
Sjmj ^n experience goes I find myself in agreement with 


those who believe in taking the risk cf tho extra fifteen 
minutes required for a gastro-ontcrostomy unless there aro 
definite coutraindications. 

Ciiitoxic Duodkxai. UtCEh. 

I shall next refer to the cases of chronic duodenal ulcers, 
’riiern aro three schools of thought ns to tho ^manner in 
.which this condition should' be treated. (1) .Those who 
follow what I helicyc i.s the practice of the great majority 
of surgeouB-^performing gastro-enterostomy and removing 
any septic focus, such ns tho appendix. (2) Those who, 
accopting Ijcwisohn’s ■ figures as to the high incidence of 
gastro-jejuiial ulcer, and the ■ 

to iieutralizo or diminish ; . ■ ' 

and pracliso an extensive gastrectomy. In this country 
Jloynihan’s practice, I believe, is an approach to tho 
position of this school. (3) Those who accept Lewisohn’s 
figures but regard gastro-enterostomy as an unjustifiably 
severe' routine remedy for duodenal ulcer, and who have 
therefore nbaudoiied surgical treatment altogether. Lahy 
of Baltimore takes this extreme view, and no one can doubt 
his sincerity. His well-known clinic is organized for sur- 
geiy, but he pa.sscs all his cases of chronic duodenal ulcer 
on to a “ gastrologist an expert in tho practical applic.a- ' 
tion of the Sippey diet ns combined with alkalis. With 
^1 increased experience of this procedure he seems to havo 
become more convinced of its soundness. 

In all my cases I have followed tho more usual line of 
treatment— namely; gastro-enterostomy. At first I only 
removed tho appendix when it was definitely pathological; 
now 1 remove it when there is the slightest suspicion of 
past or present inflammation, and where tho paticnt’.s 
condition permits. The results may be summarized as 
follows : 


Good cnilTCRuUs 


.. 24 

Good but recent (under one year) 


.. 29 

Unsatisfactory 


6 

Untraepd 


.. 4 

Died in Jiospital 


2 

Total 


... 65 


The details of tho six unsatisfactory end-results were as 
follows : 

In ono (37) a gastro-jejimal ulcer formed after an interval of 
four years. -It was cured by partial gastrectomy (anterior Polya). 

In one |65a) a gastro-jojunal ulcer foi-med after an interval of 
three montlis. It was cured by partial gastrectomy (anterior 
I’olya)'. 

In one -^(74) tho stoma was found to bo functioning unsatis- 
factorily.' It has not yet been explored. 

In one (43) there is definite chronic appendicitis. 

In two. others (41 and 29x) the complaints made were slight but 
suggested chronic appendix trouble. The ' patients have, not yet 
presented tliemselvcs for further investigation. 

In iionc:of the six cases had appendicectomy been carried out 
at theyiriginal operation. " • . . 

It will, be noted that in the previous . group— ^tbo "acute 
perforations — there were no late symptoms of appendix 
troUble,'V although in none of them' had appendicectomy 
been performed. 

Various writers , have figured the x-ray appearances in 
gastro-jejunal ulcer, but as the condition -is not alwavs 
i-adiographically . demonstrable it may be of interest to 
show two ajiray. photographs (Figs. 1 and 2 in one of the 
above-mentioned cases — No. 65a). 

In the discussion of the causation of gastro-jejunal ulcer 
after gastro-enterostomy tho technique of the original 
operation and the post-operative medical treatment have so 
often been held responsible for the subsequent complication 
that tho technique employed in this series may be men- 
tioned. A vertical or nearly vertical stoma running into 
tho greater cun-ature at its lowest point is aimed at. 
No mucosa is removed and only absorbable sutures are 
used. In hospital cases, which constitute the majority of 
those noted and amongst which tho two ga.stro-:jejunal 
ulcers arose, a prolonged posl^operative dietary and medi- 
cation is found impracticable. 

Tho percentage incidence of gastro-jejunal ulcer in this 
series of gastro-onterostomies for duodenal ulcer works ot.+ 
at 3 3. While dealing with this group I would llle to 
allude to tho condition of acute duodenitis and gastritis 
which sometimes arises as a complication of chronic 
duodenal nicer, and. to cite three eases- of -this kind en“ 
countered within the past few months. Tho condition has 

[3S20] 



1056 June 23, 1928] 


GASTKIC AND DPODEHAD OPERATIONS. 


r Tnn r.Rmiit 

L ifrwcjA Joi'hvii, 


I)coii alluded to by Judd in one of bis enntribulions to tlio 
literature. One of my patients, a stout man with a long 
history of recurring duodenal symptoms, had, mheii I first 
saw him, continuous pain and vomiting. Tl>e pain was in 
the epigastrium, and ho vomited largo quantities of elcav 
brown fluid although only taking sips of water. At opera- 
lion the dnodonnm was rod, oedematons, and adherent to 
the liver. The redness extended be 3 'ond the duodenum 
over the lower half of the stomach. Tlio main feature 
of tlie case was the incessant vomiting, a picture not un- 
like the acute alcoholic gastritis one saw heforo alcoholism 
hecamc a rarer vice. In .spite of the dnodonnm becoming 
detached from the liver and its lumen being exposed in tlio 
course of the gastvo-cnlerostomr' he made a good recoveiw. 




Fio.t Fic, 2. 

Fiu I— DuoMiig from .i-tay pliotoanph in Casij po. 65i. SUowiiic 
(if outline of preufer curvature nt site of rtonin niui prup-e. 
lion of Lra^trO'jepmal ulcer bcyontl tlio lino of tiic prenier cunnlure. 

fu, 2 —Drawl m; from i-rny photograpU of same ciuse as I'ii;. I. 
.Sliouiitjr nsuiue sKv flours aflor barium meal anti projoetion vf the 
ga.titj-jejunal ulcer. 

Aly other two cases were .somewhat similar in clinical 
ftuitures and pathological findings. In one of them the 
vomiting was so stvero ns to cause a secondary aeetonuria, 
and ojfei ation had to he delayed some days while tho patient 
was tieated with glucose vcctally. lu this case tho slight 
tiactum employed in hringing up tho stomach for gnstro- 
eateio.stomy caused the rupture of au abscess and a flow 
of pus from the point whovo the falciform ligament, the 
liver, and tho inflamed duodenum came togotlior. Drainage 
was required, hut the patient made a good recovery. 

In .ill three cases there had been a long-standing duo- 
denal histoi-y and the acute condition had snpervened 
rather suddenly. One patient, x-rayed at the end of 
Xovemher, showed no radiological evidence of duodenal 
trouble; nevertheless in the three or four days following 
Christmas he rapidlj- developed the acute .sj-mptoms 
described. It is well recognized that a duodenal ulcer can 
evolve from the quiescent stage to perforation. It can 
with even greater rapidity develop an acute duodenitis 
and gastritis. Pyloric spasm doubtless plavs a part in the' 
incessant vomiting. 

The only other point on the subject of duodenal ulcer 
to winch 1 will allude is the unsatisfactory nature of x-rar 
minor degrees of the condition; it is fortunate 
that the chnical history and symptoms are as a rule more 
cnarnctenstic. In not a few cases, however where the 
clinical sympton^ and the x-ray appearances suggested 
cliiodena ulcer I have opened tlio abdomen and foimd .a 
doiihtfnliy pathological appendix or mid-lino ptosis I Imvc 
come to distrust, slight irregularities in form and behaviour 
of the duodenal cap, and, as is well k-nown, a six-hour 
remainder in the stomach of the opaque meal does not 
mean ovgaiiie disease, especially in the presence of mid-line 
ptosis. Frequently the patient has to ho told that both 
a)>iiendix and duodenum should he inspected, hut that 
piohahly the operation will resolve itself in an appendic- 
cctomy. Owing to the indetcrrainateiiess of tho ordinarv 
aiitero-po.sterior x-ray pictiiro and screen examination one 
must ask niore frequently for side-to-side and oblique views 
the etiology of gastro-jejiinal as well as of duodenal 
ulcer has been established on a surer foundation by the 
experiments of Alanii and AVillianison, resnltiiin- in the 
production of duodenal ulcers by abstraction of^the bilo 
and pancreatic fluid, and still more by the f.act th.at 
' applying Mann and Williamson’s findings, in fresli 

cxporimeiits, siiccixMlod liy duodenal drainage in producinw 
gastro-jejunal ulcers in 100 per cent, of cases 


The clinician still seeks to know what it is in pailicular 
clinical eases of gastro-jejunal nicer whieli eoircsponds to 
experimental duodenal drainagi — what it is in the cliniea! 
case which excludes or fiverwiiolms the normal duodenal 
effeet. If it is a hvqierchlorhydria, wliat is tiie cause of 
the liyperclilorliydiin? On this point we liave .still to fall 
hack on theories of nervous and nenro-imiseular influences, 
blood changes, and so forth. 

Cnnovit: G.istiitc Dr.cEn. 

I Imvo nofes mi cightv-five e.a.si's of chronic gastric 
ulcer during the period 1 have t.aken. In this group tlie 
clinical picture and the patliological findings at operatioa 
rniy so much from ca.se to c.asc that if the ond-re.snlts are 
to lie compared with aii_v degree of nscfnlne.ss .‘■omc further 
.snhdivision is necessary. I have nmghli' divided the 
eighty-five e.a.scs into eomi>licnted and niicomplicated. 

in the complicated group I have included the larger 
ulcers of the )) 0 .sterinr wall, cases of chroilie perforation 
with_ viosion of jiancreas or other neighhonring structure, 
cases of mnltiplc ulcer situated high ou the 'stomach, cases 
complicated ,h_v ptosis, cholciy.slitis, and’ hourtglass coii- 
tractidn." For the purpose of this sulidiyision I'.have not 
regarded a chronic appendix as a complication-. 

UveompUenied Gastric T'lcfr. 

•I will take tho uncomplicated cases first. In every case 
save one gaslvn-ontcrostomy was performed. This was com- 
bined in .some eases with excision of tho nicer, in otlieis 
with apjicndicectomy, in otlicns with both excision and 
appendici.-rtomy. In my earlier cases I did not excise 
small, uJeerK.:. I| now excise in everj- case whore the general 
conditioii of tho patient scorns to warrant the more pro- 
longed pi-nccdure. In one ca.so exci.sion alone wn.s done hc- 
causo a phv.sician thought that with the aid of niedical treat- . 
meut gastro-enterostoiin- might ho obviated. The result 
in thi.s ciiso was not satisfaeloiy. The patient, continued 
to h.avo svmi'tom.s until sho died of phthisis a j'car later. 

Of the" fifty-four uncomplicated cases operated on the 
following is the summary : 

Died in hospital ... ... 2 

Left hospital m good coaihlion ... , ... ... 5Z 

Traced (Ices than ono year had elapsed m ZO) ... 50 

Kcsnlfs in all traced cases were pood, there being no 
diffcrcnco in tho result whether the ulcer was excised or 
not. It is to ho noted, liowovcr, (1) that they were all 
simple uncomplicated cases, and (2) that some of thorn are 
still recent and li.ahlo to develop late complications. "1110 
immediate mortality was in each case duo to' post-operative 
pneumonia. 

Complicated Gastric Xncers. 

In this group of thirty aro roughly included all except 
the single small ulcer. Tho complicating factors here are 
varied and the mmihor in any group too small to speak in 
jicrceutagcs. 1 have therefore set fortli the list of cases^ in 
detail (sec accompanying analysis of cases). Glancing 
rapidly through it one sees: 

Group 1 — ^Each of the first two oases showed a p.vioric tumour 
suspiciously like malignant disease. On microscopic e.xamm.v 
tion both proved to be uon-malignant. One died ot pmt- 
operative pneumonia, and the other shows no sign of furtlier 
trouble although four years have elapsed. 

Group 2 . — The next group consists of fen large ulcers vita 
adlicsions .and erosion of neighbouring organs. In six a partial 
gastrectomy was performed (anterior Poljxi). In the otiicrs 
the ulcer was excised and gastro-entevosfomy performed. Jn 
one of these latter the ulcer recurred nine months after cxeisiqn. 
and I was obliged to do an anterior Poly.n operation, wifli 
satisfactory result. In this group there was one de.at i from 
post-operative pnenmoni.i; apart from this death and the case 
of recurring ulcer the results were good. Figures 3, 4, 0, and o 
show the history of the recurrent ulcer. ■ , • , 

Group 3. — The next is a case of a large ulcer Iiigh on tne 
lesser curvature ; the ulcer was excised and a gastro-enterosl^y 
performed .at the lowest point of the greater curvatnre. lac 
end-result was satisfactory. , 

Group — ^These are three cases of multiple ulcers. In flic nisr 
case a higli gastro-enlerostomy was performed without e.xcision; 
the result was unsatisfactory. In the second case there was 
an active ulcer and a quiescent ono; tlio active ulcer was e.xeise 
and gastrO-cnlerostomy performed at the lowest point ot i ■ 
great curvature ; result satisfactory. In the third case pai m 
gastrectomy was performed witli satisfactory en_d-re.sult. 

Group 5. — In these two cases mid-line ptosis existed in 




June 23 . 


r Tnu C*rn** 1057 

litnDicAuJonrJJi * 


'1 -.r. tn ilift fivst tUo ulcor lay Jiiglil pastro- 

extreme dcKroe. Jn Em l"- 1 j„],pr level tlmn usual with 

enterostomy the stomach concerned. 


r TnKP*m»» 

GASTRIC AND DUODEN Ati OPERATIONS. 

leer Kav Jiigli: Rnslro- Aiwlritif of 30 Cam of CompUcated Gastric Vlceri. 


rities Ibe troatmonl was unorthodox Ihc result ';\ns satisfactoi\ . 

group con.sists of two cases compheated by 

cliolecystitis; the end-resuUs were good. 



Hecord Condition. 

^o. 

>1 10 triccr with pyloric 

tumour 

135 Ulcer with pyloric 
tumotir 


Grotii>2 27fl Uartfo ulcer, lessor 
curvature 

GS UariJo paddlo ulcer 

78 rorforating ulcer 

(spleen and pan- 
creas) 

92 Perforotinc ulcer 

(pancreas) 

97 Pertorating ulcer 

120 liarcc pyloric ulcer 

223a Larue saddle ulcer 

126 Ulcer, adhesions 

les'scrsnc 

157 I»arKo ulcer, per- 

loratin#; nioso- 
colon 

150 Larfio saddle ulcer 


Operation. 

imirotlill 

Polya 

Polya 

Hinh G.E. and 
excision 

G.E.nnd excision 

G.E.and excision I 
G.E. and excision 


Died (pulino- 
narj'). 


Bccurrcd— . 
, piRs. 3. 4, 5. 

I and 6. 

I Good. 


Died (pneu- 
monia). 

Good. 

Good. 

Good. 

Good bat recent 
(slides). 

Goodbutrecerit. 


Group3 

29 

Group 4 

47 

85 

107 

Groups 

i 

49 

m 



Groups 49 Ulcer and ptosis HiRhG.E.,appcn- UnsatisfactoH'* 

dicectomy 

114 Ulcer and ptosis G.E. and Coffey's Good. 

operation 


Groups 81 Ulcer, adhesions G.E.. cholecyst- Good. 

and eah-stoncs cctomy . „ , 

no Ulcer and Sail- G.E., chotccysto- Good, 
stones stomy 


FlO. 6. no. 6. 

Fig. 3.— Dmwinp of ir*ray phcloRrapIi In Case Xo. 68. An ulcer which 
recurred after excision and gaslro-onlcrostomy. 

Fig. fl.—Drawing from ar-ray photOR-raph of same e3^e as Fir. 3- 
Showing condition three months after excision and luqh gastro* 
enterostomy. About this time symptoms^ began to recur. 

Fig. 5.— Drawing from g*ray photograph of same cnfc as Fig 3. Show- 
ing ulcer re-formed nine months after excision and gastro-enc»-ro 2 -toniy. 

FjG- 6.—Drawing from x-rar photograpli of same case a-4 Fig, 3. 
Showing end-result alter partial gastrectomy performed nine months 
after original operation, ^'o further symptoms to date. 

Group 7. — Thh consists of ten eases of non-mahgnant hour- 
glass stomach. The immediate results, it ^Yi^ bo seen, include 
three deaths. Althougli the eases were poor .surgical risks the 
results are disappointing. In the fir.st fatal case I .had no 
opportunity of seeing the patient after operation, hut was 
informed that she suddenly collap.sed on the third day. In 
the second fatal case the patient died of pneumonia. In the 
third case there was persistent vomiting in sjutc of repeated 
lavage of the stomach and elevation of the bed, and when 
I had decided to reopen the abdomen the patient une.vpcctedly 
^llapsed and died. The operation was an anterior Polya. 
Bightly or wrongly, death was attributed to acute gastric 
dila^tion. Rendle Sliort records eases where the opposite sides 
of the stoma stick or grow together, and thinks it Avorlh \vhile 
to hang a rubber dam between them before completing the 
anterior layer of stitching. This is the onlv ease I can recall i 
having lost in this way, and I hardiv think a rubber dam ' 
would have saved the situation. 

Looking at the complicated eases as a whole it will 
bo seen ; 

(1) The immediate mortality is disappointing : 3 patients died 
from pulmonary complications, 1 from acute dilatation of the 
stomach, and 1 from collapse. 

end-results after a year, of those that sumu'ved were 
as follows : All gastrectomy operations — good. All gastro- 
enterostomies and excisions — good, save one wliere the ulcer 
recurred, necessitating gastrectomy. Two cases of high gastro- 
enterostomy alone—unsatisfactory. TOiether it ^Yas the high 
position of the stoma or the non-excision of the ulcer that was 
esponsible for failure m the last-mentioned cases is not quite 
ear ; I hope to have a further opportunity of investig.ating 
present complaint is made of pain and flatulence, 
t there is some degree of improvement, and the patients 
6 lor the nioment reluctant to have any further a:-rai’ 
examination or treatment,’ 


38 Kon -malignant 

honr-class with 
gall-stones 

39 Non • malignant 

hour-glass 

62 >*on - malignant 
hour-glass 

71 Non -malignant 
hour-glass 

88 Xon -malignant 
hour-glass with 
large ulcer 

100 Non -malignant 
hour-glo-ss 

l$jF >'on -malignant 
hour-glass 

17x Ison - malignant 
hour-glass 

42x Non- malignant 
hour-gla'ss 

45x Nou-niiUgnant 
hour-glass 


Polya; cholecyst- Good* 
cctomy; appen- 
diccctomy 

Polya; appcndlc- Good, 
cctomy 

G.E. Good* 

Excision, gastro- Good, 
plastr, and an- 
terior G.E. 

Polya Good, 


Died (collapse). 

Died (pneu- 
monia). 

Died l?ncuto 
dilatation). 
Good. - 


G.E.-gastrc-entcrostoxuy. 

In gastric ulcer, as in duodenal and gastro-jejunal ulcer, 
jMorton’s <?xperijnciits have brought us appreciably nearer 
to an accurate undci'standing of the • etiologx', but have 
not brought us quite to the central point of the problem. 
Ho has for the first time succeeded in transforming an 
acute gastric lesion into a typically chronic ulcer. Again, 
the method employed is duodenal drainage, and again the 
clinician is loft with the question as to what in the clinical 
case of gastric ulcer corresponds to duodenal drainage in 
the experiment; and what is it in the clinical case wdiich 
corresponds to the experimental acute gastric lesion which 
duodenal drainage transforms into the typical chronic 
ulcer? 

In speaking in jSIanchester on the subject of gastric 
xdeer I cannot refrain from allusion to the discussion in 
which Manchester bore so important a part. In spite of 
the findings of the Manchester Committee and of the 
modified form in which Charles Maj-o recently stated the 
doctrine of the origin of cancer in benign ulcer, I see from 
the Mayo staff proceedings in January, 1928, that McCarty 
reiterates his conviction, that nearly all ulcers of a diameter 
of 2.5 cm. and over are malignant, and that in 12 per cent, 
of apparently benign ulcers a eytoplasia of cancerous 
nature — not to be recognized in sections stained by ordinary 
means, but recognizable hy special liistological methods— 
is present. The only aspect of tlie question on which I can 
, from my own cases express any opinion is the clinical one 












1058 June 23, 1928] TUMOURS OF THE FRONTA.D IiOBE OP THE BRAIN. 


URirTTil 



In none of the ulcers on uliich I liave operntod by siinplo 
gastro-onterostomy have wo found anything in the “ follow- 
up ” to suggest the suhsoquont development of cancer. 
Further, as will he seen from the tables, all largo ulcers 
and many of tho smaller havo been excised — sometimes by 
themselves, at other times as part of tho stoni.ach removed 
in partial gastrectomy. I havo not kept all mcasnronicnts, 
but in a good proportion of tho cases tlio ulcer was tho size 
T>f a five-shilling piece or half-crown (sco Fig. 7 ), without any 
histological ovidcnco of malignancy 
and without subsequent recurroueo. 
On tho other hand, all malignant 
ulcers which I havo onc.'ountcrcd have 
been of tho .size of a five-shilling piece 
and upwards. 

In no case of uleei*, large or small, 
has cancer subsequently develn|)ed 
where tho histological findings on the 
specimen removed at operation were 
non-malignant. 

Tho immediate iportality in the 
various groups is almost 0!itirely due 
to pulmonary complications. To what 
extent are tlic.so pidmonarv complica- 
tions tho ro.sult of the anao.sthi'tic.» 
^ The matter has been debated niany 
t mes. Personally! think tho anaesthetic is usuallv respon- 
smie 1 havo not had an opportunity of using ethylene, 
winch American surgeons find such a help. The dam-er of 
jmshing anaesthesm to tho point of complete relaxation, and 
le consequent difficulty in closing an incompletely relaxed 
n idomen, have been hold re.sponsiblo for many of tlio ventral 
hernias 111 the upper abdomen. Insomuch as this complica- 
tion is common to all abdominal operations 1 have not 

rPM,lti®f„ Po^st-operativo lioriiia as unsatisfactory 

lesiuts in tho figures abovo given. ^ 

,v m” “ site for tho abdominal incision which 

to + 1 ^°''- surgical dpiiiion is swinging hack 

to the mid-hno, whore the interlacing fibres give a secure 
gnp to tlio sutures. Personally I like to Reinforce tho 
contiiiuou.s catgut 111 the essential layer with “ fignro of 8 ” 
silkworm-gut sutures hold taut on a frame. Since adoiit- 
mg this method I have so far had no ventral henda iif any 
oOsti IC 01 duodenal case, although many times tho condition 
of tho patient did not warrmit pushing tlio anac.sthctic to 
oinplete relaxation, and in sonio cases, especially in porfora 
tion, the woiuid did not heal without some suppuration. 


LSfrDiciz. iouHxAft 


Fig. 7. — Drawing from 
ar-ray photograjih in 
Case No. 137. .An ex- 
ample of a large-sized 
non-malignant ulcer of 
the posterior wall.eiod- 
ing pancreas, and trans- 
verse mesocolon.. 


TUMOUES OF THE FEONTAL LOBE OP 
THE BEAIN. 

BY 

J. PURCON MARTIN, M.A., JI.D. MR CP 

ASSISTAHT PHYSICIAH to Tilp KATInp.r •) „ 

DISEASES, QOEEX SQUAEE- Pi4?icta 7 .rn 

TO THE seamen’s AND 

1 . . ; bolingbroke hospitals. 

Tusiours or tlie fi’oiital IoIip*: nf i • 

pre-central gyrus are notoriously d'fficuirto di.tnoL.*''’ Tim 

formed Vithhra perL^lpVlS'tha.ftL eT’'"^’ 

worth recording beeans'e they form .t groiip'in VhfcT' tl* 

was coiESiderablo siniilaritv and thev Omre 

lines.of a general clinical pieW • 

, h , . CAS.E I. . ■ ■ 

An engineer, admitted to the National Hosnita! n„ c 
had felt perfectly icell np till Marcli, 1926'. one 
inontii, after walking a few 3 ards from lii’s Iionse i"’"® m that 
mounted the stairs two at a time, stooTed to nfek nn ^ *’“'*• 

fe 1 unconscious. When his wife reached the room 
lafor he was still unconscious, was foamin.^ at the mmiTu 
h.ttcn his Kmguc; Ws.face ind jaw were ?Ucm-Sr bui“nol V-'’ 
limbs, atid there was no incontinence. U is “aid that ill "‘’f 
lasted ten to fifteen minutes; tho patient did not lhmf..io 
scionmcss. but appeared (o pas, into a sleep from 7hi7f i 
DoU he roused. After several hours of sleep Jio had aLtI 
described as “-most violent,” in which he “ stiail” ’> fit, 

cm,^iaint^oV7^?:rcr^;iaXt7.!■^Ifn'r 

unrcsciwcdly to the nro «fT commit himself 

covered considerably in a few da^^rbuf'l^fS'^ 


i’’”r rcl-'iiTicd to hi.s work and seems to have 

pciformed it normally for three months: at tho end of Uiat 
period ;,o had another fit. This, like the former, was a gLcral 
lo after this ho’ did 

^11 monlb.s ho was free from arms 

i^T'/p"'- ^'“^‘■c.waj some alight mental deterioration; he 
IwLir {'■"'-•“■•'e'y on his wife, and became so 

forgetful and alisciit-inindcd tliat he could not ho trusted to eo 
pill alone. Ife docs not seem to have been trooblcd with 
headaches dunng this period. On Cliristm.xs Day, 1926, ho had a 
severe licndache; this persisted llironghoiil ttic next day and led 
up to another fit in the afternoon of December 27tli. My first 
examination va?5 inado about ten days after- this third eciture. 
llic patient then had liad continuous headache, not, however, 
groat intensity, since tlic occurrence of the last fit. 

This cxaimiuitiqn in January, except for a certain ahnorma' 
mental ■ state and two objective signs to bo mentioned later, 
revealed nothing ahiionnal. No defect could bo discovered in tin 
motor or sensory functions; m particular, the optic discs wch 
normal as also were the visual acuity and tho visual fields. Tlit 
scii<!c of Kmeli wa** intact in both nostril*;, and odours could Ik 
distinguished and named. The rercbro-spinal fluid showed no ccllg 
and no cxcc.«s of protein: the Wassermann reaction was negative 
noth 111 the fluid and blood. An .r-ray examination of the skull gave 
no indication of any bony change The two slight signs referred 
to were an occasional fine ticmor of tho hands, such as is com- 
monly seen in nervous patients at a first examination, and an 
exaggerated flexor rcsjionsi- in tho plantar reflexes. The patient 
remained in Iio«?pilal lor four weeks, and during that lime had 
fn‘f|ucnt hnadacho.s, but after the lumbar puncture tlic hcadacho 
ceased for several days. After investigation he was allowed to go 
home (he said that ho “felt quite well"), and was instructed to 
report himself if any now symptoms developed. Bromide and 
luminal were given during tliis lime. After two months tho 

f mtient rctntaicd to tlie out-patient’ department, complaining of a 
OSS of ri«ion and the occurrence of “ petit inal “ attacks— 
momentary losses of consciousness about three times a week. It 
was found a week latai that tho visual acuity of tho left cve had 
diminished to 6/60 and that of the right to 6/9. Tlic left disc 
showed some doubtful pallor of its temporal half and-^the -right 
appeared normal; colour.^ of small objects could not be. distin- 
guished in any pari ct the field of tho loft eye. 

The patient was again admitted to hospiUl under iny care on 
April 9th, 1927. At that, time, more than a year after his flr«rt. fit, 
Ills condition was ns follows. lie answered questions and behaved 
inlcliigcnlly, and bad nu delusions or hallucinations, but he did 
not seem to realize fully the soriousnc.ss of the threatened blind- 
ness. He was probably somewhat deficient emotionally, and was 
slightly euphoric : there was lc«.s tlian the usual emotional modula- 
tion in iii.s voice. His speech was tremulous ahd slow, but there 
w.as no aphasia; his memory was had. The sense of smell was 
still normal on , both sides, Tho vision was seriously impaired. 
In the right eye Ihcro was a central scotoma, which was quickly 
enlarging, though the disc appeared normal. In the left eye 
acuity was reduced to counting fingers at half a metre, and the 
central and upper tcrnporal parts of the field were completely 
oblilorntcd; on the disc then? was some temporal pallor. The 
pupil rcaction.s and cyo movements were normal. The right pal- 
pebral fissure was w’idcr iban the left, suggesting slight weakness 
of tho right facial muscles, but such weatocss as there v.as did 
not alTcct voluntary movements. The remaining cranial nerro 
functions were normal. In the limbs no motor or semsorj' abnor- 
mality was found except that tho patient ^Yas at limes generally 
tremulous. This was a . fine irregular ti^or, not unlike that 
seen in early stages of. genei-al paralysis, and it affected his 
speech as well os Ins limbs. All the abdominal reflexes were brisk. 
TJic plantar reflexes A'cre peculiar in that they were very briskly 
flexor : the slightest touch of the soTo produced full and immcdialo 
flexion of the great toe, unaccompanied by any withdrawal of tho • 
foot.- The gait was normal and there was no incontinence. 

During May tho vision rapidly deteriorated and tlic temporal 
parts of both discs, became pale; the visual field of the right 
eyo was almost entirely obliterated by enJargement of the central 
scotoma. An o'-ray photograph of tho skull , now' showed some 
change about the pituitary fossa, ,and rather . open sutui*cs 
suggesting intraci-anial pressure. It seemed that there must he a 
tumour involving the optic chiasma and the optic nerves,, affecting 
the left side more than the right ; it was decided to explore that 
region by operation. -On »Tunc 22nd the operation was performed 
by. Mr. Sargent, - the exploration being made through a quadri- 
lateral. opening in the left frontal bone. Part of the temporal 
bonp io the .temporal^ fossa was extremely thin;, the dura was 
very tense, and to relieve the tension about 40 c.cm. of cerebro- 
spinal fluid were withdrawn by lumbar puncture. When the dura 
had been opened and tho loft frontal lobe was elevated a soft 
gelatinous-looking mass was seen protruding from imdcr tho 
frontal lobe, on tho _ outer side of tho olfactory bulb. It sur- 
rounded ilio left optic nerve and the chiasraa, and from tlieso 
siruclurcs a portion of ife was dissected off; the site of origin of 
this growth could not be determined. This operation resulted in 
a considerable improvement in the patient's vision, and tire wound 
healed uneventfully. 

A few weeks later definite weakness of the right side of th© 
face and right arm began to develop, and was accompanied by 
motor aphasia. At this stage (July 29ili, 1927) the plantar rofloes 
were still of .the same exaggerated flexor tj'po as before,, and 
stroking of the sole of the left foot caused flexion of the great 
toe on the right side as well as on tlie left; but by Oppcnlicim's 
method a feeble extensor response could be obtained on the _l<^ft'* 
During the last few weeks of his life the patient was emotional 
and very depressed. His gcncrcal \slale gradually dclerior.atcd, and 
ho died on August 28th, 1927. . : ' ' ' ^ , 

At tho necropsy a very hard tumour was found on the medial 



JCSB =3i 192S] 


•rUMOUBS OF THE FBONTAB LOBE OF a?nE BEAIN. ’ '[m,^'.cJ15Su. 1059 


surface of tlic left frontal lot.e; it readied lliu inferior surfaro of 
tlio lol'c in tlio region of tlie. olfactory tract anil l''''!n--(l back- 
lard? to, but (lid not involve,' tbo- ontic cbiasma. Jbo anterior 
clinoid processes woro eoinjdetcly eroded;, so Ibat tlicro was 11 
bolloiv in front of tbo ,)itnilary Vody. Wben 

after hardening, the left frontal lobe nns found to be filled nith 
a firin wbitisb tuinom-mn??, vvbicli shaded oft iiniieieentibly in o 
the wliile matter of the brain; it involved tlie bead of tlic caudate 
imcleus, and, medial to that, fiuined a rimiuUM boss on the 
internal asnect of tbo lateral vciitriele. It did not extend bigtier 
than the getin of tlie corpus callosum. Mieroseopically it was 
formed of a dense neuroglial network with ratber scanty small 
nuclei (asU'ocyloiua. lilji'iUatc). 


Sinmuurj/. 

Gradual dcvolojitneiit of mental Gyniptorns — loss of mental 
** sharpness,'' stupid mistakes, inability to supervise others, loss of 
memory later uleulioiial apraxia;, lioadaclics; tremor of tlio 
hands like that in general paralysis of Uic insane; tendency to 
fall Imckwarcis when standing and to deviate to the right v.'hen 
walking; excessively brisk flexor plantar responses; slight left 
facial weakness at rest and slight extensor jdantar response on 
Iho left side with persistent stimulation. 

The prcscnco of a bilateral frontal lohe tumour was verified 
after death. The alHonec of definite optic disc changes and of 
vomiting, of olfactory symptoms, aphasia, and all kinds of 
paralysis should he noted. 


Stimwarj/, 

On^ct of the symptoms \Yilh n severe convulsive nltack; ^Ight 
hut increasing mental changes of llie mature of n lo'^s of initm- 
live, lo!-s of memory, increasing reliance on others, insnflicicnt 
realization of Ins condition, euphoria; tnuiior of the hands and 
ill the \oico, not constant and not noticed when ihe^ patient was 
in bed; headaches; further convulsions and freqnenl 
allacks; a year after Die onset rapid diminution of vision and 
partial atrophy of tho optic nerves; flexor plantar responses of 
exaggerated briskness. 

' The necropsy confirmed the presence of n tumour m tlic left 
frontal lobe. *A noteworthy negative feature was the absence 
until the last stages of the illness of prnclically all ahnormnl 
motor plicnomcna except tremor; there wore no symplonis in the 
olfactory system, no speech sympioms, and no ataxia. 

I 

Case ii. i 

► An electrician, aged 34, ’seen by mo at tho London Temperance | 
Hospital, iiad been employed in Greece, wliero it was Ins duty 
to instruct and Rupcrvisc natiic workers. Seven month*? before | 
ins admission to hospital he bad l>cgun to make sUipid mistakes 
and had become useless ns a Piipcrvisor; he was forgetful, and 
was dismissed by the firm for “slackness.” Three or lour months 
before admission ho hcgaii to suffer from headaelics; he referred 
the pain chiefly to the right mastoid region, ndiere he bad bad 
an injury some years previously. He had never had a fit. There 
was no history of vomiting. At times lie was excessively drowsy. 

In giving hrs history he made inistnkc.s in dates and in periods 
of time. When 1 cxahiincd him on October 11th, 1927, he did not 
know the date, and had not even an approximate idea of the 
length of time ho had been in hospital. lie was sliglitly euphoric. 
He eeeinod to have little undci'standiiig of discipline, 'and broke 
the rules of the hospital in regard to smoking, hut evidently 
without any malice or appreciation of wrong-doing, or oven of 
the fact that ho was doing anything unusual. He was, in fact, 
very submissive when addrcs.'seS, Sometimes during examination 
he would do something other than ho was asked, apparently 
because he failed to fonii a correct Idea of the action wliich was 
required of him (ideational .apraxm). Itepoatcdlv when asked to 
show his teeth he put out his tongue, and he did not realize his 
mistake. Ho answered qiiestiohs iiitciligcntlv, and could read 
and describe what he had read, and could write, 
riiere was no loss of smell. The optic discs may have been a 
little blurred in the upper na«.i! quadrants,' but' were not dcfmilely 
pathological; the visual .fields responded normally to finger tests, 
and the pupils and eye movements were normal. . There was a 
slight ** smoothness " or emotional weakness of the left side of 
tho face at rest, but no weakness wa.s seen in voluntary move- 
ment. - The remaining cranial nerve functions were normal. In 
the arms jiower, sensation, tendon-jerks, pointing tests, and the 
control of fine movements ,Averc all. normal; there Avas no per- 
sisting hand-grasp. IVhilo' the patient was lying down flicro Avas 
usually no tremor of the hands, bill wdion he eat up there Avere 
frequent short attacks of gross irregular tremor like that of 
general paralysis, more marked,' if ' anything, in the left hand 
than jn.the right. - A)l the abdominal reflexc-s AA'crc brisk. In the 
lower limbs power; sensation; and tendon-jerks were normal. Tlic 
plantar rcfTcxcs AYcro-both brisklA'-flexor in an extreme degree; the 
1 merest touch of the sole causing full. and immediate flexion, without* 
any .withdrawal of ' the foot such as occurs Avlieit the sole is very 
' ■with persistent stimulation, the flexor response on the 

, leU ejde seemed to tire, and gave place to a slight extensor 
reaex, Avith some withdraAval at the -knee. When the patient 
stood up he tended to 'fall backwards, and Avhen Avalking lie was 
inclined to deviate to the 'right. . He -had incontinence (of the 
mental type) of both urine and faeces. The ccrebro-spinal fluid 
was normal in its cellular and albumin content, and the Wasscr- 
mann reaction was ncgatiAC . botli in this fluid and in the blood, 
iliere was a slight irregular rise, of temperature, and the pulse 
J'ate Avas consistently .about 60 per minute. Tlic opinion Avas 
expre^d -that the cause of the. symptoms was a tumour, or 
possmiy chrome abscesses, inA'olviiig both frontal lobes, but 
chiefly l\io light. . . . . ? » 

.On October flOlli the patient. had a conA’ulsion, and after several 
of Ainconsciousness be diedi Tlie nocropsA* Avas performed at 
^miguinclti. In the horizontal section of tho 
am, passing through the ^enu of the corpus^ callosum, there 
s a tumour on t.ie right side as largo as a pigeon’s egg, just 
anterior to and touching the caudate nucleus. It lay right in the 
tho fibres, of the forceps minor” radiating out into 
wati .Pi 1 from the corpus callosum, and at this IcA'el it 
intf fi but it extended doAvnAvards and forwards 

boundary' Avas less definite. On the 
^ mass of tumour, probably of later dcvelop- 
to fh® medial part of tho frontal lobe just anterior 

thaf <^^llosum; its outline was much less definite than 

Was n right side. Microscopically the groAvth 

was a polymorphocellular earcoma. f j & 


Case hi. 

All unmarried Avoman, aged 58, a boxmakcr, came to the out- 
palienls’ dopartuieut at the National Hospital, Queen Square, on 
November 1st, 1927; film was said to Imvc sulTcrcd from depression 
for about a year, but until July’ 15th chc aaus othcnvisc Avell. On 
that day she' had a fit, without warning, in the strecl. After this 
alio Avns “ not quite herself,” thougli she returned to her Avbrk and 
seems to have c.inicd it on normally. During this period it Avas 
ohscrA'cd that she often rubbed her nose as if it itched. She 
remnined at Avork until September 18lh, when she Avas more 
dcprcs.sod than usually, and during tho afternoon she fell down 
in a fit. This Avns the first of a series of fits Avhich In.slcd till 
11 o’clock the next morning, and the patient Avas more or less 
unconscious for forty-eight horns. Early in the attack she Avas 
removed to a liospilal ; when she recovered consciousness she had 
no paraly'sis or aphasia, and she left the hospital after a stay of 

five days. She Avas able to dress herself and walk to the car 

wliich look her home. After her return her manner was tlrange; 
fiiic w.ns ” absent-minded ” and confused, her memory Avas bad, 
and she could not be irusted to do ordinary things, such as to 
dre.ss licrsclf, because slic would make mistakes; she had to be 
directed couslauily and Avas very docile. About a month later slic 
began to ** worry about things Avhicli she ought to haA'r knoAvn 
were perfectly all right.” She had frcqucnl headaches and some- 
times complained of pain over the right eye. 

When t addressed a question to her at the out-patient depart.- 
iiicnt she did not an‘uver. but turned to her companion a.s 

though to shift the onus of answering on to her. But when an 

answer Avas required of herself she staled her name, age, address, 
and come of her complaints correctly. Only in nnsAver to one ques- 
tion regarding the cluiation of n symptom did she .«ay, *’ I don’t 
rcincmhcr.” aer speech Avas somewhat slow and monotonous, but 
there AA’as no aphasia. Vliy.sical examination rcA'caled no abnor- 
malities in the cranial nerve functions or any changes in poAver 
or sensation in the limbs. The tendon-jerks Avere brisk, the right 
plantar reflex flexor, and the left doubtfully extensor. There Avas 
a geneial rhytliinical Ircinor of the hands, and the patient volun- 
teered the statement, wliich Avas confirmed by observation, that 
the tremor was more pronounced in the left hand than in tho 
right; tlic dilTcrcnco was, hoAvcver, variable. All the abdoniinab 
reflexes Avcrc Aveak. Tlie provisional diagnosis was ” frontal; 
tumour, right or bilateral.” , 

She was admitted to hospital under my caro Iavo days later. 
Her general condition quickly became Avorse; she Avas \*cVy drow'sy,' 
(ended to become comatose, and Avas incontinent of urine and 
faeces. The ccrebro-spinal fluid Avas under high pressure 
(300 mm. aq.); it contained a very large number of cells 
(270 per mm.), of Avbicb nearly all were polymorphonuclears, and 
it had a A*cry high protein content (0.130 per cent.). Tliis ccrcbi-o-- 
spinal fluid nniuj'sis suggested the presence of an abscess, but 
sevoVal other features of the case Avero opposed to that vieAV. 
However, in case an abscess might be present, and in the hope 
of relieving the patient’s general condilion by cerebral decom- 
pression, it was decided to operate. On Novembex* 8th Mr. Armour • 
exposed the right fiontal lobe by a fronto-tempornl craniectomy; 
in the posterior portion of the second frontal convolution there 
Avos a small bromiish tumour, about half nil inch in diamelcr, ' 
slightly raised above tho surface of the neighbouring convolu-' 
lions, and this was -remoA-ed. After tho operation the patient* 
remained in- a very droivsy and feeble state for three days 
and then died. 

At the nccropsj', Avlien the brain bad been hardened, section 
rcA'calcd no other mass in the right frontal lobe, but in the left' 
frontal lobe there were several masses similar to that Avhich had' 
been removed from the right; ‘these masses extended almost to 
the lip of the lobe and across the genu of the corpus callosum. 
The whole of the left frontal lobe was much larger than its 
fclloAv. Microscopic section of the mass removed at operation 
showed that it Avas a glioma. The masses in the left lobe had a 
similar structure, and the remainder of the left frontal lobe Avas 
filled with gliomatous tissue unusuallA* rich in fibres. Such tissue 
Avould probably interfere little AA’ith' tlie functions of the nerve 
cells of the part. 


Summary. 

A Avoman, aged 58. suffered from unusual mental depression for 
several montlis/and then had a conA’ulsive attack; after an interval ■ 
of two months a very severe series of convulsions occun*ed. Mental ■ 
changes then became apparent — confusion, loss of memory, liability 
to make mistakes in everyday duties, abnormal reliance on others* 
headaches became frequent; tremor of the hands AA’as observed* ' 
Towards the end the plantar responses had become not flexor but * 
indefinite. , 


After death a tumour Avas found invoh'ing both frontal lobes 
The absence of signs and sAmptoms in the olfactorj' and visual 
systems and the absence of aphasia and of paralysis of everv kind 
are noteworthy. , 


1060 June 23' igdS'] TUMOURS Or THE EHONTAE LOBE OF THE BBAIH. 


The difficulty in the diagnosis of frontal innionrs lies in 
the paucity of the reliahJe pliysieal signs and s3-inptonis. 
Headacho, vomiting, and 2)a2)iIlocdema are still regarded 
as the cardinal signs of an establislied corohral tumour, hut 
in frontal lohe cases vomiting and 2'a2>illuedciua do not 
usually develop, and frontal tumoui’s must he diagnosed 
in their absence. The ahscnco of all recoguizahle. 2)aral3'sis 
and of aphasia has been noted in the foregoing cases. Onl3- 
when tho tumour lies towards the posterior part of the 
frontal lobe are such signs to be e-X2icctcd, the gmwth then 
being sufficientl3' near to tho 2)re-central convolution, or to 
Broca’s area or the insula, to interfere with the function 
of these parts h3- actual destruction or h^- oedema. 

Generalized headacho such a.s occurred in all three cases 
must he the result of increased intracranial 2)re.ssurc; it is 
therefore nnlihcH' to occur until the growth is largo enough 
to give rise to some dislocation of tho brain and consequent 
impediment to tho outflow of ccrebro-spinal flnid from tho 
ventricles. In none of theso cases was tho general headacho 
intense until other symptoms had been e.stahlishcd. In 
Case m pain over the left eye was one of tho 2>aticnt’s 
most frequent complaints; such local pains are probabl3’ 
due to a local stretching of the dura or to erosion of bone. 

Convidsions were an early s3'mptom in tvro out of the 
three cases, and were tho first definite indication of disease. 
They occurred at a time when nothing abnormal wa.s to be 
made out, except 2ierliaps some vaguo mental change. They 
were generalized attacks, associated with pi'olonged head- 
ache, and sometimes with continued unconsciousness. 
Attacks of such severit3’ and of such absolute suddenness 
are rarely caused by tumours in other paJ'ts of the brain. 
In one case typical “ petit nial ” attacks also oceun-ed. • 

Tho mental alterations mot with in frontal tumour cases 
are not specific for tumours of this localization; similar 
changes are common in cases of tumours in other part,s of 
the brain if there has been prolonged intracranial hy2)er- 
tension; but when they are encountered in tho absence of 
papilloedema these mental changes certainls- have a localiz- 
ing value. Tho most constant psychical modification — one 
which was met with in all these cases — is an abnormal 
submissiveness or docility, and a child-like reliance on 
others; with this goes a loss of initiative. Some loss of 
memory is frequent, and confusion may occur : tho 2>aticnt 
may become liable to make mistakes and omissions in 
everyday actions, and in this way. act indecently. Tho in- 
continence which occurred towards the end in two of theso 
cases is to be regarded as a S3-niptom of dementia and not 
as the result of any paral3-sis. The first patient of this 
group was somewhat euphoric; none of them showed that 
tendency to make a joke at every remark (Witzelsucht) 
which is probably more indicative of a frontal lobo lesion 
than any other single mental .symptom. These mental 
changes occur with frontal tumours of either side of the 
brain. 


Tremor was the only obsen-ed clinical sign except tlu 
mental changes which was common to all three of thes< 
cases. In the first patient it was a slight general tremulous 
ness, ivhieh at first attracted little attention, but it wa; 
more pronounced when the patient was seen in tho out 
patient department than when he was at rest in tho ward 

"7 '*1 sreatei- on ono side thai: 

on the other. In the second patient tho tremor was mosi 
pronounced, and in his case it was a coarse tremor occur 
raig m frequent short attacks each lasting a miniito or so 
pese attacks seemed to be more likely to come on wher 
he was sitting, up or standing than when he was Ivint 
down ; they usually affected both hands, but on one 
occasion, while in bed, he had a paroxy.sm of treniblinc 
affecting the left side only. The third patient’s tremor 
Jike that of the first, was a fine tremor, but it was more 
regular. It was more easily perceptible by palpation than 
by sight, and might easily have been overlooked ; moreover 
it was bilateral. A tremor affecting the side’ of the bod-v 
on which the tumour was situated was described in frontal 
lobe tumour cases by Dr. Grainger Stewart and it it 
graerally accepted that the tremor of these cases is homo- 
lateral. In two of my cases the tremor was bilateral, the 
wV bilateral also, but even in the third caso, in 

““fined to the left side, tho tremor 
affected both sides in some degree. So far as I am aw“re 


there i.s no reason for referring this tremor to destruction 
of any particular part of tho frontal lohes. 

Heflex cimngo.s in all these cases were few. Tho tendon 
jerks wore within normal limits; tho abdominal reflexa 
were I’tcscnt in all, and in tho first two wore brisk. Tlie 
2)hintar roflc.xes wore indefinito in ono caso, hut in tlia 
other two eases they wore pcculiarl3’ exaggerated. The 
.slightest touch to tlio solo of tho foot caused full and 
immediafo flc.xion of tlio groat too; the patients sliowe 
no signs of unusual seu.sitivcncss of tho sole of tho foi 
and made no voliinlaiy withdrawal or other movement. 1 
both cases the 2>hcnomonon was bilateral, and in tho fir 
case, ill which tho tumour was on the left side, stimulafic 
of tho solo of the right foot caused brisk flexion of tl 
great too, not oid3' on the riglit foot, but also on tbo Icf 
tho movoment on tho loft side occurring .a little later the 
that on tho right. Stimulation of the left solo cause 
flexion of tho loft toe onh'. Tho o.xnggerated plant! 
responso was ono of tho earliest abnormal signs in Caso 
being present at tho time of ni3- first examination of tl 
patient, when no other ahnormitl ph3-sical signs were to 1 
found. I liavo met this same phenomenon in two ofhi 
cases ill which there were meningeal tiinioui’s affecting tl 
frontal lobes h3’ 2)icssurc, but I am niiahlc to 503- whctln 
it is confined to cases of frontal lobe lesion. It is wortl: 
of notico that while this phenomenon was actuall3' preset 
an extensor rcsiionso could ho obtained in Caso i t 
Oi>i)enheim’s method, and in Caso ii after persistent stimt 
lation of tho sole, the flexor responso seeming to tire. Th 
observation of tho “ crossed flexor response ” in Caso 
was made b3' Dr. Ferguson, honsc-physician at the Xntion 
Hospital. Tin’s peculiar sign could be obtained constant 
from tho time when it was first noticed tq’ till the 2)atient 
death a month later; it is cvidoutl3* a further dcvelopmo: 
of tlio exaggerated flexor response, and its occurrence 
evidence that the exaggerated flexor response is definite 
a pathological sign. 

Of the .signs which ma3’ arise in the olfactory and visui 
S3-.stems little need bo said. A unilateral anosmia is.i 
more prcciso vnluo than almost any other sign of fronti 
tumour, but unfortunately it rarely occurs early, and, i 
the first caso described, it was entirely absent until otlif 
signs had 2>“t. tho diagnosis beyond doubt. Optio_ into 
fcronco, if nnilntoral, is also very valuable, but bilaterj 
visual defect such as occurred in the first of these cases hi 
so 1110113’ more common causes that it is likely to misleai 

Tho ataxia encountered in tho second case is a wel 
known sign in frontal tumours, but in my e.xperience 
onl3’ mot with at an advanced stage of the disease, an 
both for this reason and on account of tho difficulty < 
distinguishing it from tho ataxia of a cerebellar lesion, : 
is of little practical value for diagnosis. 

Differential Diagnosis. 

Even when one is faced with definite clinical signs _fl 
diagnosis of theso cases has to he iiiado from generi 
paralysis of the insane, cerebral syphilis, cerebral vascula 
disease, disseminated sclerosis, Schilder’s disease, an 
other forms of gliosis, and also from tumours of the ten 
2)oral lobe. The ‘V\’^assermanh reaction, tho age of, tli 
patient, and the general state of the circulatory systei 
may rule out tho first three of these. Disseminate 
sclerosis is likely to cause more reflex changes than front! 
tumour, while the other diffuse diseases are likely to b 
eliminated by the age of the patient or the rate of progres 
of the malady. The occurrence of severe generalized heac 
aches is a point in favour of a neoplasm, and the cerehro 
spinal fluid pressures measured at lumbar puncture ma; 
give more precise evidence of its presence. Temporal lob 
tumours usually bring about an homonymous visual fief 
defect, they cause papilloedema relatively early, and the- 
do not give rise to tremor. In tho presence of merely tir 
earlier signs of frontal tumour the most, difficult point ma; 
bo to determine on which side the tumour lies. The menta 
changes do not help to decide this, but the preponderant 
of tremor on one side indicates that the tumour is on tin 
same side; any visual, olfactory, speech, or motor sign 
are likely to settle . the point. • The great teuden^ q. 
frontal lobe tumours to become bilateral must be born< 
in mind. 


June 23, lojS] 


TUMOUR OF BRAIN SIMULATING ENCEPHALITIS. 


r Tin:Br.mw lOfil 

L JlEDJClL JounsAl. J*wux 


, S'li HI 711(1 ri/. 

Tiu'CO cases of frontal lobe tuuiour arc described, in tn-o 
of which the growths were hilatcral. 

The only obserrod cliuicJil signs which wore coninion to 
all three eases wore mental changes and tremor. 

In two eases severe gcneraliKod c'onvnisivc attacUs con- 
stituted the lii-st definite symptom. 

Attention is drawn to a peculiar exaggeration of the 
plantar refiexes cncounteretl in two of the cases. 


Tu:\iom{ OF THE braik si^iulating 

ESCEPHALITIS LETIIARGICA. 

BY 

S. McCLKMENTS, M.R.C.S., L.B.C.P. 

The raritv of a cerebral tumour giving rise to the clinical 
picture of encephalitis lethargica in its (airly and penulti- 
mate stages is so marked that the following case deserves 
attention. 

A man, aged 57, had a mild attack of iaflucnra in April, 1926, 
and was reported as completely well in the third week of the 
following month. Tour weeks later an insidious onset of drow.si- 
ncss and letiiai*gy began, and was followed in a few days by 
(Iimnc.ss of vision for near objects. The drowsiness gradually 
deepened for four weeks, and the patient complained of double 
vision; the temperature during the same period o^^cillated bet^v(^cn 
and 100® F. The period of stupor reached its height at the 
end of July, and was followed by marked improvement in the 
patient’s condition, as shown by lus taking an incronsing interest 
m his surroundinj»s and in the disappearance of diplopia. Except 
for spasmodic twitching of liis legs lie liad almost regained his 
normal health in September. In October and December, 1926, and 
April, 1927, he had relapses which were followed with marked 
improvement, athongh it was noticed that each successive ir^rove* 
ment left the patient a little more stuporous. In Juno, 1927, lie 
became markedly lethargic, and on July 13th ho was admitted to 
hospital for treatment, his condition having been dc/initoly 
diagnosed by a neurologist as encephalitis lethargica. On ndmis. 
sion his temperature was 98® F., and his pulse 7A He continued 
in a stuporous condition, but wljon awakened bis mental condition 
appeared quite clear and ho was able to answer questions in a 
rational manner. The face was smoothed out and cxprc^^'^ionlcss, 
the eyelids were in a condition of ptosi«, jjle voice wa.s monotonous, 
but not imlislincl, his right eye showed an internal strabismus, 
and on being questioned ho said he saw two fingers instead of 
one which I held before him. There was dimness of vision for 
near objects, the pupillary reflex to ligld was absent on tlie right 
side and sluggish on the left: reaction to accommodation was 
normal. The tendon, abdominal, and plantar rcncxcs remained 
uuauected. 

Although signs of iniprovemeiU were occasionallv manifested 
Uie stupor gradually deepened, and the vision of the right eye 
dinunishcd so rapidly that a more detailed ophthalmological 
examination was made. The (Kular reflexes had not altered since 
lue previous examination' there was paresis of the external rectus 
on the right side, a.«rsociatcd with well-marked pnpillocdcmu of 
1 retinal veins of the left fundus 

slightly swollen. These findings pointed to the probn- 
UvniJ ^ ^Gypla.sm localized to the riglit frontal region of the 
producing pr^sure on the right second and sixth cranial 
nerves and causing the papilloedoma. 

a cause of the mischief 

nositivp ^ performed; the reaction was 

(oflidp nnd treatment, in the form of potassium 

intrLusculLlv, '.'-astrarlcd’aT’onco noosalv-irsan 

nnd the p.^tieit died/on NcvctbT'^30 h hsarei^M 

the commencement of the treatment ' * "ccks alter 

a spherical tumour, two inches in diameter 

oT‘‘tif/\thrfro:tnTTob 

the tumoilr.antl the wall of the o"?,'”'""’'' Poslcnorly between 
ineh long and a quarter of an inch broL" '"" “ ^ "" 

The points of iiitcvest in the case are: 
droi-c' Pt'J' Jqr ®.'n7ptotns_i, amply, graclnally progressing 
oiid' diplopia, ptosis of eyelids, 

' s ight ises of tempprntiiro — were identical 

* 1 in a large group of eases of 

encephalitis letlnargica. ® ^ ^ 

nbgence .of boadache and vomiting, which are 
tnin^mir^*^' ^ ^ the later stages of cerebral 

thn pP^itbalmoscopic examination of 

npit-oi7 pointing. to a lesion of the central 

npirons system. 

exaniiiio/"'' ''®?^ottod that there was no liistological 

Pa'tholoU-"!' "*l / 7"”°'"' ’ PO’’i>ops an expert in nenro- 

the neoplasm" ' "" opinion as to the nature of 


ISOLATION OF B. TYPHOSUS FROM SEAVAGi: 
AND SHELLFISH. 

BY 

VV. JAMES MTLSON, M.D., D.Sc., 

rnovEsson or hvgikxi: and runi-jc in;Ai.Tii, QPEiaJ’s ukiversity, 

BBtrAST; WATER K.^ASinTER TO BELTAST WATER BOARD. 

Tun danger of eonsnnijition of scwagf’-contaminated Avator, 
shellfish, walereross, ete., is n cardinal article of the 
hygienist’s faith, hnt hitherto it has not hecn possible 
to find objective evidence by- the cultivation of the ts'phoid 
bacillus from tlie .sewage. By the nso of a new teebniquo 
] can now demonstrate on an average the jircscnco of one 
tr-plioid bacillus in oacli cubic centimetre of Belfast sewage. 
' Sir Alexander Houston' in 1913 and 1914 examined 23,353 
non-lactose fermenting colonies developing on plates inocn- 
Inted mainly with .saiiijilcs of London (Barking) or Hendon 
sewage, lin’d also with individiml samples from Dublin, 
Belfast, Ediiibnrgb, and Aberdeen. Ho was unsuccessful 
in isolating a single L’. t i/p/io.iiis, and concluded that tlio 
tvplioid bacillus is not nniformh' present in 0.00066 c.cm. 
of crude sewage, and that this amount of sewage contains 
704 excretal bacteria per cubic centimetre. Dealing with 
the difTiciiltios of the task Houston writes: 

“ Sewage contains such an enormous number of bacteria that 
it is quite impracticable to examine more than a very small 
amount of this material. For example, to examine one cubic 
ccnlimclrc of crude sewage for typhoid bacilli • by the direct 
plating metbod would mean making at least 1,000 special plate 
cultures and at least 20,000 primary subcultures, not to speak 
of llic secondary and other cultures for the pui-pdso of differentia- 
tion. It is, however, quite practicable to work with as much 
ns 0.01 c.cm. of sewage spread over from 10 to 20 special plates, 
and Ibereforc to make 200 to 400 primary cultures.” 

A'on-Iactoso fermenting organisms arc so common in 
sewage that many thousands or hundreds of thousands of 
such colonics would require to bo examined in order to 
isolate a single typhoid bacillus. For example, in Belfast 
sewage 1 find that on an nver.ago 400,000 to 500,000 
organisms dovelo]) from 1 c.cm. on AlacConkoy lactose bile 
salt agar plates, and that of these more titan one-half 
are non-lactose fermenters. In such sewage I have found 
about one typhoid hacillns in each cubic centimetre, so 
that, using the SlacConkoy medium, tliere would have been 
a chance of isolating the bacillus if 250,000 nou-lactoso 
fermenling colonies liad been tested. In all prob.abilitj-, 
even after such a -Herculean effort, failure would have 
resulted, as the chances arc that the typhoid bacillus would 
not have had a clear space on the plate to develop, and 
its growth would have been obscured and inhibited by tlio 
coliform colonics. Tlio addition of brilliant green to the 
medium would doubtlc.ss render the isolation of B. iyphosus 
from sewage not quite so difficult, but even so the chances 
against a non-lactose fermenting colony being composed of 
typhoid bacilli would be many thousands to one. In the 
examination of sewage for the presence of B. iyphosus I 
therefore made use of the glncose-sulphitc-iron-bisinuth- 
brilliant green medium of Wilson and Blaii-,= the efficiency 
of which depends on two original observations of mine : 

(1) B. Iyphosus in the presence of a fermentable carbo- 
liydrnte is able to reduce a sulphite to a sulphide, and so 
to foiTU a black colour' in the presence of an iron salt. 

(2) Bisinntb snlplute in the presence of a certain excess of 
sodium sulphite snpjircssos- the grorvth of most coliform 
baeiiu ; in the jnesence of brilliant green the selective 
action is intonsified. This medium has in 1113 ' hands ren- 
dered the isolation of B. iyphosns from enteric stools one 
of the easie.st procedures in applied bacteriology-, and 
recently by means of it B. A. Adams" has isolated the same 
bacillus from the excreta of seagulls. 

AYhen 0.5 to 1 c.cm. of sewage is poured over the surface 
of a plate of the medium and allowed to dry, and is 
then incubated for twenty-four hours at 37 ° 'C., -black- 
colonies witli a metallic halo are developed, and also lii^ht 
green colonies of B. proievs.- It is among the black 
colonies that B. typhosus is to he sought. All the black 
colonies, if subcultnred on AlacConkev or Endo modinm will 
be found to consist of non-lactose fernienter.s, so -that these 
media are not very helpful in distinguishing between 
colonies of S. typhosus and those of other reducing bacteria 
It was, found that a very large -proportion of the black 



1062 Jdne 23, 1928] 


ISOLATION OF B. TYPHOSUS FBOM SEWAOE. 


t Tne Hbittw 
3rf.nrC4L JoCR5At 


colonies simulating those of B. typhosus wcro saccharose 
fennonters, so that the nse of saccharose in a modified 
Endo medium enabled me to distinguish japidly between 
them and those of B. typhosus. The ])rinci])al organism 
forming these black colonies oh tho hismnth suliihite medium 
is present in most specimens of sewage, hnt has not so far 
been found by me in faeces. Tho chief characters of this 
organism, to which I have given tho name of B. cffliiviei, 
are as follows : A Gram-negativo actively motile bacillus 
with growth on agar resembling B. coti; in lif]ncf 3 'ing' 
gelatin and in being negative to methyl red and giving 
a positive reaction to the Voges-Proskauer test, it resembles 
B. cloacae, from which it differs in its reduction of sulphites 
aind in being a non-lactose fermenter. It grows in Koser’s 
citrate solution. It ferments glucose, maltose, mnnnite, 
saccharose, and starch, with tho production of acid and 
gas, and has no action on lactose, dulcite, and snlicin. It 
forms indol and digests inspissated serum. 

Tho B. cffluvici is prob.ahly related to the B. protcus 
group, although it ferments inannito and docs not decom- 
pose urea. 

Material Employed. 

Crude fresh-screened sewage was taken from the com- 
bined sewage of the upper and lower level sewers of Belfast 
on its way to tho sedimentation tanks. On three occasions 
the samples were taken at 10 a.m., on tho fourth at 2 p.m. 
The sewage was flowing along and was taken up in a 
sterile bottle, and may bo regarded as representative of tho 
ordmai-j- dry weather sewage of Belfast. One sample taken 
on Febiuarj’ 25th, 1928, gave the folloiring figures on 
chemical analysis : 


T, , ,, rartH per 100,000. 

rreo and saline ammonia 1,4 

Albuminoid ammonia *]* o!8 

Oxygen absorbed, two hours, 'at 80° F. 4 0 

Chlorine 25^0 

On bacteriological examination it showed 480,000 
colonies per cubic centimetre on a JIacConkey plate, and 
of these 218,000 were lactose fermenters and 262,000 
non-lactose fermenters. It also contained 200 spores of 
B, v'clchxi per cubic centimetre. 

The chief details in connexion with the isolation of the 
tj-phoid bacillus may be summarized as follows; 


Table I. 


Sewage. 

Date. 

Amount 
of ewagk 
Planted 
Out. 

NOi of* 
Blade 
Colonies 
Examined 

No. of 
Saccharose 
Fermenters, 

No. of Non- 
saccharose 
Fer- 
menters. 

No. of 
T> phoid 
Colonies 
Found. 

Belfast 

1928. 
Feb. 16 

4 e.cm. 

a 

27 

4 

4 

Belfast 

Feb. 25 

11 c.cin. 

67 

€0 

7 

2 

Belfast 

Mai*. 8 

10 c.cm. 

64 

50 

14 

7 

Belfast 

Mar. 12 

5 c.cm 

?1 

56 

15 

8 


The examination of 30 c.cin, of sewage resulted in the 
isolation of twenty-one strains of B. typhosus. The bacilli 
w^re not uniformly distributed in tho s-ewage, some of the 
plates jielding none and others several. Probably more 
bacilli were present than were isolated, and I am of opinion 
that at least one typhoid bacillus is present in each cubic 
centimetre of the ordinary, crude screened sewave of 
Belmst. ^ 


. Whether the sewage of other cities and towns would 
yield similar, results requires investigation. I niay state 
that Belfast, although at present comparatively free from 
ty])hoid fever, was at one time one of the most ti-phoid 
infested cities of Europe, and consequently would be 
expected to have many ' tj-phoid “carriers.” Prom the 
aiiiiual report of the superintendent medical officer of 
health for Belfast for 1926 I may take tho following figures 


Year. 

Population. 

1837 ... 

310.000 • 

1838 ... 

... 340,000 

ISOl ... 

... 350,852 

1£05 ... 

... 360,000 

19U ... 

... 386,449 

1920 ... 

... 413,000 

1926 ... . 

416,000 


Deatlis from 

Annual enteric 

typhoid fo\ er. 

nioitality rate 

.. 354 ... 

per 10*000. 

... 11.4 

.. 640 ... 

... 18.8 

.. 341 ... 

9.7 

.. 128 ... 

3.0 

.. 15 ... 

0.4 

.. 54 ... 

0.8 

6 ... 

... 0.1 


During 1926 there were 84 cases of enteric fever notified 
in Belfast. It would seem, therefore, that in a town that 
lias been exposed to outbreaks of typhoid fever tho ordinary 
sewage contains the tyiihoid bacillus, and that the sanitary 
policy which aimed at tho formation of a clean environ- 
ment — luiro watci', pure .soil, and tho rapid removal of 
oxcrctal matter from premises — was sound. In such a town 
our results show that tho specific infective agent is liable 
to bo pre.sont in ordinary seivago. Nearly all tho cases of 
typlioid fever notified are treated in an isolation ho.spital, 
tho sow.ago of which, bcfoio di.schargo info the city .sewens, 
i.s sterilized by steam ; of the 84 patients with enteric fever 
in Belfast in 1926, 82 were treated in hosjiital. Tho soiirco 
of tho bacilli in the sewage is thoreforo probably mainly 
“ carriers.” IVliilo tho bacilli remain in tho sewage ns 
such there is little danger of infection, hut there is the 
possibility of the return of tho typhoid bacillus to man 
again by contamination of tho soil, by leaking drains and 
.scwer.s, by contaminated water su|)plic.s, and by the 
consumption of shellfish living on sewage-polluted fore- 
shores. 

Shellfish. 

The facts relating to the isolation of B. typhosus from 
shellfish collected from Belfast Lough foreshore at Grccn- 
castlo are ns follows. On March 6th seven cockles were 
opened; tho liquor was collected on a sterile Petri dish and 
was then transferred to nine plates of the siiccial bismuth 
medium. Nino black colonics were studied, sei'en being 
sacelmroso fermenters and two non-saccharose fermenters; 
of tho latter one |)roved to bo B. typhosus. 

Tho bacilli which I regard as being ty])hoid bacilli were 
actively motile and Gram-negative; they fonned acid lint 
no gas in glucose, maltose, and inannito agar sbakc 
cultures. No fermentation of lactose, saccharose, dulcite, 
and .salicin occurred; indol was not formed, and gelatin was 
not liquefied. 

The bacilli wore ngglutinatcd to full titrc by four 
dilTcrent antityphoid scrums, and were not agglutinated 
by normal serums in dilutions of 1' in YO. That the 
organisms were typhoid bacilli was established by means of 
absorption tests.* It was found that those recovered from 
tho sewage and tho cockles removed from several anti- 
typhoid serums tho agglutinins acting on them and on 
gcnuiiio typhoid bacilli. 


> Houston. A. C. (1914) : Tcntli lieport on HcsoarcJi Work to Jlctropotilon 
Wotor nonril. r Wilson, AV. .1., ontl Blair. E. M. McV. ( 1927 ) ; ifwrn. of 
//y»(cnr, 26, 374. ’ Adams, B. A. (1928) : The Mctlical Otpeec, 39, 185. 


A CASE OF PROGIIESSIVE MUSCULAR ATROPHY 
OF THE PERONEAL TYPE ; 

Twenty-one of the Patient’s Relatives being also 
Affected, 

BY 

GKORGK PARKER, M.A., M.D., 

consulting physician, BRISTOL GENERAL HOSPITAL. 

■. Tins syutU'omo was recoj^uizecl as a distinct type, first by 
Charcot and JMario in 1886, and independently by Sir 
i Howard Tooth in a thesis tho same year. Several cases 
' which wero perhaps similar had been recorded previously, 

; such as Osier’s Star family in New York, and Meiyon’s 
! patient in 1852. - Herringham, ■ in 1887, published an 
1 account of a family where eighteen members were all 
, affected, Symonds brought forward one where nine sufferod. 
Collier one with eight, while Reevor, Bryant, Ormerod, and 
Seliultzo have each reported families with throo cases. 

Tho disease is transmitted both in tho male and in the 
female line;- and tliero is not the great preponderance of 
males affected that we get in pseudo-ln-pertrophic paralysis. 
As Williams has remarked, liowever, there are instances 
where no relatives are affected, and others where several 
brothers and sisters develop the disease simultaneously for 
the first time iu a family. It has several times appeared 
after a febrile disease, suoli as measles. It may commonco 
in childhood, more often in the second or third decade. 
Gcnoi'ally tlie first wasting is seen in the feet or ppronei on 
both sides, but occasionally it shows itself first in the liauds 


JDNK 23) ipzSj 


5«0GR.ESStVE MUSCULAB ATBOl'ill. 


r TiiK nnmsfl 
MeWCAI^ JotTT.KAI. 


10&3 


nui! foroavms. . The wustiiij; »iul ^v^.nkm■ss oxteixl very 
.rnulimllv- to the .mnx''' of the hnihs, and the 

mnsrles- of the tn.alc and face are rarely affeetod even after 
tliirtv or forty vearx. Bidhar symptoms are nnkimwn. 
it is'imi>ortaut to notieo tiiat the reaction of d, ■veneration 
can be found in some of the innsoles in pracfKally every 
case while there inav or inav not he erninps, pains, coldness 
aud’lividity of the shin, rdirdlary tremors, or slight sensory 
changes. 

Mv patient K. J., aged 53, mnviied, with one child, is a strong 
nnirothenvise hcalthv man, in whom the comlitinn first nppenn'd 
wlicn he was 19 veafs old. He was then an active foolhaltcr and 
member of a rowing clnb. Ho even now plays golf and finds no 
fatigue from a fivc-milc walk, though Iho disease has progrossed 
steadily. The feet wevo first ndected and then the hands and 
forc.arms followed. There is no history of any nrevions illness, and 
he has rarclv required niodiral treatment. Tlie gieat ape which 
many of his Velativcs attained, even when nlTeeleil like himself, is 
striking. His heart, kidneys, and lungs arc normal, the expansion 
of his chest is 3 inches. The nmseles of the trunk, face, eyes, 
throat, and tongue aro unnfTeclod. He can whistle and pout the 
lips. The iieiion of the bladder and how-els is normal. There is 
extreme wasting of Ihe muscles of the feel and lower part of the 
legs.-and intrinsic muscles of (ho hatid.s, and the forearms, and 
rlightiv of the thighs. There is no movcnn nt at all in the toes 
or at the aiikte.s; neither nhdiictioii nor nddiiction or flexion of 
the feet. Tlio gient loo and the others are flexed .and quite 
inofionles.' : Ihe arch of the foot is preserved, and his gait in 
walking is surprisingly good, though flighllv liigh-slr|iping. He 
flexes and extends the leg on the tliigli and the thigli on the hip 
freely, but hi gelling iin from the ground he likes a lillle .assisl- 
ance,' .such ns putting liis hand on his thigli, 1ml ho can liCnd 
down to touch the ground and rise up again easily. 

Though the rinall muscles of Iho hands arc ho wasted, the grip 
is strong, and he' has no difficnlty in hnltoning his clothes or in 
writing. Supination and pronalion have escaped, lint extension at 
the wrist is weak, and the hands when at rest t.ake Ihe claw 
form. There is lilllo or no fibrillation or imi-scul.ir iriilahilily on 
percussion. There is no ataxy. Ho stands ca.'ily with his eyes 
kUuI, and the pupils react to light. The knee-jerks are present, 
but sreak; (lie Achilles tendon-jerk is prc-sciit, but there is no 
plantar rcfle.x or clonus. He has no pain or cramps, and the 
sensation to light touch or pin-prick appeals normal over hand.s, 
feet, and trunk. There is no reaction to either current in feet, 
calvc.s, or" hands, hut some of the extensors at the wrists show 
reaction of _ degenoralion — that is, no faradic reaction hut good 
galvanic, with the positive pole equal to or greater than the 
negative. 

In this patient, then, wc pot wasting of the distal 
segments oi tlio limh.s with loss of powi-r, bogiiiiiinv in 
early adult life mid .steadily piogn-ssiiig. The rcflo.xc.s 
are diminislied mid reaction of dogoiicratioii is present. 
Finally, it apiiear.s from his statenieiit.s that eleven males 
and ten females of his family are siiiiilarly affected. In 
this family the fii-st case reeordevh is that of the patient’s 
grcat-grandfatlicr, mid out of fifty-four of his descendants 
twenty-one aro already affr'cted and others are not yet old 
ciiongh- The disease scenrs to pass rather more readily 
by the Wale line than the female, and if has little effeet on 
the duration of life- In a grau[i of'fivo lirothers and sisters 
affected, two ai'c alive aged 77 and 79, and three died at 
ages of 62, 82, and 86. 

One noiild like to know whether the affection did netuallv 
egm with the great-grandfather. It cannot have existed 
many generations back at the present rate of increase, for 
the district would he full of cases; whereas the disease is 
always a rare one. . 

• The type is clearly distinct from the mvopathies. Thus— 
iiV'-'i has’ neither the distal 

”ii rior the reaction of degeneration, 

muscles enlarged. 

distal myopathy, such as the one 
inv 1 a ^1 aii'pear to have the facial muscles 

inio led and no reaction of degeneration. 

bnirtkl® ^^prdnig-Hoffmaim tnm is roallv myelopathic, 

1 '** 7 ^ if® flic proximal segments during the. 

in t in t . f^'lows 
in thecn ®dactiou of degeneration is found 

in those cases, .and several may occur in one family. 


aftei begins at birth or soon 

distal srvmof 7 i"”! wasting, but paresis of the 
I think Him- rniprove if the patient sim-ivcs. 

heve but 'f.''” nffection of other members of the familv 
Ah- ofL mnv be present. 

The'nalwLf 

been imrtn *^.i "f type does not secin to have 

columns of f'nll ' nf fnto. The sclerosis in the 

'U'ns of Goll and Burdaeh, and the iesioi.s 'in the 


anterior horn cells and in the iieriplieial nerves, appear to 
vary in iiiteiisily in different ciise.s, but we are com|>lelely 
ignorant of the’ I'lnise which jirodncos them. ^Yhetlu■r it 
ho “ a dovelopmeiital wcaknc.ss, an iulieritod susceptibility 
to some toxin,” or a true infection, siiirocliaetal or other- 
wise, renmiiis to be proved. 

Rirrnrsrc, 

* Urilnh flcflicdl Jnvrual, 1902, ii, p. 89. 


PAUALYSIS OF ALL FOUR LIMBS CURED BY 
RF^MOVAL OF A SPINAL TTOIOUR. 

UY 

VALTER BROADBEXT, M.JXCant.ib., F.R.C.P., 

SE.S'XOi: PIIVSICIAK, 

AN’» 

G. AV. nKRKSFOKI), O.B.K., F.R.C.S-, 

ASSISTANT Si norON, nOYAL SUSSEX COUNTY HOSPITAL. 


A \YoM.\N, 51, \Yns ivtlmittetl to hospital iu October 

with complete parnly.sis of the right arm and leg and 
partial paralysis of the left arm and leg. She also com- 
plainctl of intense bcadaehe and gnawing and shooting 
pains in both iirms; these were so severe that hypodermic 
nuiriditne was needed to give her any .sleep. 

'The history given was that fourteen months previously 
she had fir.sf noticed mimbness in the right hand, but this 
(lid not bother her until in February she tripped over 
Mnncthing and had a lind fall, which shook her consider- 
ably. -After that slie began to lose the use of her right 
anil- By May the arm was so weak that she had to give 
up her work, and she was hcginiiing to drag the right 
foot. 'There was also then some aching pain in the .shoulders 
and rigid arm. Early in July the right hand had become 
nselo.ss, and tlie trouble in the right leg had advanced 
so much that she could not walk, also the left leg was 
affected. By the end of August the right arm and Jog 
were paraly.se<I, and she could only move the loft leg 
slightly, ami there was weakness in tlie left shonicler. 

On admission the right arm and leg were motionless; 
-slie could draw up the left leg slightly as she lay in bed. 
Slie could not abduct the left slioulder, hut could adduct 
and rotate it, and Hex the forearm. The grasp of the 
baud was very weak, and she could not feed herself with 
it. Both the tiiipezii were wasted, hut not the arm 
miiseles. Bcflexcs were increased. 

She complained of intense headache and agonizing shoot- 
ing and aching pains in both slionidors, and of “ pins and 
needios ” all over the body. The pain had been getting 
worse and irorsc for the past six u-eeks. Tliere u-as 
anaesthesia of the right hand and forearm, and diminished 
sensation in the same area on the left arm. Sensation 
over the legs ami body was less than noi-nml, and distinction 
hetwceii heat and cold was not ■ accurate. TJierc was no 
incontinence, hut it was difficult to get the bowels to act. 

Tlio neck could be rotated and flexed, and an a--rav 
pbotogiapb showed no disease of the bones. On lumbar 
imiictnro the cerebro-spiual fluid was not under pressure. 
It contained globulin in large excess, colloidal gold 
55544, 3o221, Feliliug reduced normally, no increase of 
cells. Tlie AVa.sscrniaiin reaction was negative. The 
cerebro-spinal fluid of the cisterno puncture contained 
only n very faint trace of globnliir, colloidal gold 
01110,00000, no cells. It would be interesting to know 
if this striking difference iu the cerebro-spinal fluid 
below and above tlie tumour occurs iu other cases. 

The diagnosis made was a lesion of the spinal cord about 
the level of the second cervical veitehi-a, and, on account 
of the intense pain, prohahly a tumour in the meninges 
jire.ssiiig on the back of the cord. Mr. Beresford was 
asked to do a t;istcrno piiiictiire and insert some lipiodol 
-Y-vay photographs after this slioived some lipiodol just 
above tlie level of the first cervical, and opposite the level 
of the first and second cervical vertebrae, 

-After the operation the movements of the left arm soon 
■ began, to improve, next those of the left len- Tt was 
nearly a month before the right • leg showed- signs of 
-recovery, and the right arm later still. JIassagh and 



1064 June 23 , 192 S] 


COMPLETE TRANSVERSE RUPTURE OF JEJUNUM. 


t tnr nnmtH 
M«ti'ciL Jovntit' 


i'uradism were used to linsteii tlie return of inovcnicnl. 
After ten weeks tlio ‘ patient could walk with a little 
assistance, spasticity not having quite disa]ipeared. Jlove- 
nients of tlio loft arm and liand wore ]u>rfect, and slio 
could lift a glass to her mouth with tho right hand. 

The operation described by IMr. Boresford : 

On November 8th, 1927, under intratracheal anaesthesia 
(Dr. Eccles), tho laminae of tho second, third, fourth, and 
fifth cervical vertebrae were removed. -The dura was not 
pulsating and felt hard in the second, third, and fourth 
cervical region. • On opening tho dura a tumour was seen 
in tho postero-lateral aspect pressing into tho right side 
of the cord. The tumour, which was attached b}' a pedicle 
to tho dura, was enucleated without difficulty, its appear- 
ance was rather like a large raspbenw, fleshy to feel, and 
not verj’ vascular. It measured 2.75 by 1.5 by 1 centi- 
metres. 

Tho dura was closed with continuous catgut, and, after 
closing the wound, the head, nock, and shotdders were 
supported in a plaster r.ast. The patient left tho theatre 
•in good condition, and got immediate relief from- her 
intense headache. Sections of tho tumour show it to bo 
an endothelioma. This tumour is said to be non-maligiiant, 
and thei'cfore the prognosis in this ease is good. 


COMPLETE TRANSVERSE RUPTURE OP TUB 
JEJUNUM WITHOUT EXTERNAL AVOUNJ). 

BY 

J. R. ARMSTRONG, M.R.C.S., L.R.C.P., 

LATE nESIDEirr MEDICAL OFnCER, NELSON HOSPITAL, MERTON, S.W. 


CojiPLiiTE transverse rupture of tho intestine is rare in the 
absence of external wounds. Moreover, rocovon- from such 
a condition is exceptional. The following detai'ls of a c.aso 
of such rupture of tho jejunum seem worthy of record, 
liarticularly in view of the satisfactory issue. 

A man, aged 46, was brouglit to the Nelson Hospital on .Tulv 
2qth, 1927, suffering from severe abdominal injury. Tlio liistory 
given was that while riding a motor bicvclo lie had lost control 
and' crashed into a wall, his abdomen striking a projecting corner. 

On arrival at hospital tho patient was in great pain and 
Bufrering from severe shock. Ho was in a cold sweat, and 
complained of intense pain in tho abdomen, which at times caused 
agony Tho pulse was 64, and tho temperature 
97.5° 1‘. Breathing was laboured with grunting expiration and 
almost entirely Ihoraoic; vomiting' did not occur. Tho pupils 
were equal and contracted, and reacted to light and accommoda- 
tion. The whole of- tho anterior abdominal wall was intensely 
rigid and motionless, while tho only external sign of injury was 
? discoloration or contusion just below the ribs in the 

bypochondrium. On palpation the abdomen was extremely 
tender everywhere, and a point of maximum tenderness could be 
elicited in the region of tho tin of the spleen. There was derinilo 
m n® o” s'do. but tho patient 

was so ill that slnfting dullness was not investigated. Liver 
present. The bladder was not distended; a catheter 
was passed and normal urine withdrawn. A diagnosis of crave' 
abdominal injiiry with rupture of a visciis, possibly llio -spleen, 
-jU-UbU’ uub the p.atient was treated for shock, T/2 com of 

Two hours later Dr. M.-irtin Randall opened the ' abdomcri • a 
largo left paramedian incision was used, w^ith the eeiiD-r^nosite 
the timbihciis No gas escaped on opening llie peritoneum Ind 
no fluid or odour suggestive of runturo of o i,oii„i ■ ’ 

perceptible. There was a large quantity of almost purl Wood"' ”n 
the peritoneal cavity. Examination of tho liver, splLn, Blomacli 
and pancrcK revealed no injury, but while the lastmameTwas 
being investigated a loose lorn end of bowel rami • 

This proved to be the jejunum, about flur Slhir i 
the diiodeno-jejunal flexure. Tho other end was fonild 
difficully, tho tear separating the two pieces of bowel 
a full Inch into, the mesentery. The edges of the sei-rod SoJTT 
were somewhat irregular, but it was practically a clean 
tear. Tho removarof about half afi inch on Inch sit 
to form a clean-cut Rclge for suture, and an end-to-end InasTiJ 
mosis w.as performed. Tho peritoneum having been 
guickly, the incision was closed, but a dfaina<^e Tube 
'u.„bb® luft loin and another in the pelvis, since somo 
still present in each of those situations. After the oTerfuon Thl 
temperature was 97.4° F., and the pulse 88. The Sell 

. rSm^'n*d®sXutfners??:™‘“ 4 th"l 

•At 6 a.m.. tho next, day be was given a further 1 /fl 0 -^-..;^. e 
during the day X drach'm of-b^randT Vih^fe^ L 


nil onenm,^ and ho pn-^sed a con«.idciablc qiiantily of flatus, with a 
slight notion of ilie bowolf?. At night ho was given 1/6 grain 
of inorphino niul nl 4 a.m. on tlic next day n furtlicr 1/12 grain. 
During I lie day ho scerned to Iiavo improved, tho temperature 
being 98.6° I*'., and tlio pulse 104; vomiting occurred four times, 
niid in tho evening tho ^tornnrh was waslicd out with Fodhim 
bienrbonatn, which nrrcslod this. From this limo onwards the 

C niiont continued to progrc«'S satisfactorily; distension wji.s relieved 
y tiirpcntino cncmata. Tlio toinpcraturo remained normal or 
slightly subnormal, and the puho ralo liad fallen to- 70 by July 
24tli. 'Tho patient siifTcrod from somo di.stro.ssing hiccup, which 
•however, responded to a simple mixture of bismuth, and he 
continued to progress until ho was discharged from hospital on 
August 27tli,- 1927, in good hcallh. 

A .series of cases recorded iiy l^fnssic^ at Guy’s Hospital 
between tho years 1899 and 1922 shows that rupture of the 
intestine occurred in 34 instances. Of these, 26 were situated 
in tho small intestine, and the jejunum was more commonly 
injured than tho ileum; of tlio 14 jejunal cases, T'oecurred 
within eighteen inches of tho duodcno-jojunal flexure. It 
was also shown that tho part most susceptible to injury is 
that part which crosses tho vertebral column, and tliat the 
second and tliird loops of tho. gut aro most frequently 
involved, ^fost of these lesions were partial, and nearly 
all casc.E wliprn tlio dutidonmii was involved ivcro associated 
with otlior .sovero injuries in tho upper abdominal wall. 
This. writer also points out that .wliercas cases of ruptured 
stomach and duodenum aro accompanied hy other injuries, 
pgncrally intra-abdominal, cases of rupturo of the small 
intestine aro .usually single, and arc not associatod witli any 
other injury. Tin's fact is borne out by the present case. 

Tho maiii symptoms and signs aro pain, shock, and 
rigi,dity. It lias been said that impairment of liver dull- 
ness is to he expected, but in the series collected by Massio 
this occurred in only 3 out of 34 cases; in tho present case 
tlicro was no impairment. Of 31 cases reported of complete 
ruptured small intestine tho mortality was- found to he 
78 per cent., and in 9 cases in which tlie rupture was 
complete tho mortality was 87 per cent. Tho high TTim-- 
tality in cases of complete rnptnro is said to ho due to the 
increased amount of shock as compared with cases of partial 

niptnic. . • i 

• Another sevios of cases, numbering 22, and occurring at 
tho London Hospital between tho years 1913 and 1922, is 
recorded bv Buddy. = • This writer emphasizes tlio impor- 
tance of early operation, tho significance of pain as- an 
indication for- operation, and tho fallibility of relying on 
tho pnlso rate— that is, not operating .hccavso it is slow. 
A"ain, such signs ns loss of liver dullness, sm'gical ernphy- 
soma, and distension are not of great- clinical value;'"tho 
latter is generally a lato result, and is often found 'witli 
other inini-ics, such as damaged kidneys or fractnfed pelvis; 
emphasis is also laid on tho fact that tho mortality increases 
with tho length of tho 'history, and that operation should 
not ho dol.aycd if thoro is no improvement after three 
lioni-s. In tho present ease diagnosis of grave internal 
injury was easy on accoinit of tho“Cxtremo rigidi^, great 
shock, and the doflnito, ovidcnco of effusion into tho 

peritoneum. • c 

Tha decision to operate depends on tho diagnosis of grave 
internal damage and not on a diagnosis of any exact form 
of injiirv, and tho earliest moment lit which tho condition 
of tho patient is such as to mako it possible should bo the 
time chosen for operation ■ . . - 

The points that seem to ho of special interest in this caso 
aro tlio following. On opening tho abdomen no gas was 
detected, nor was thoro any fluid or smell suggestive of a 
rupturo of a hollow viscus. Tho only fluid that escaped 
■ was blood, pos.sibly. diluted by peritoneal serous exudate. 
Nothing rescmhling food coufd bo found in the effusion, 
and tho inevitable presnmjition is that tho intestine was 
empty when injured; tlio sliock was -followed by a pyloric 
: spasm, which persisted until tho operation lyas pel-formed,- 
because thb storiiach was not empty, tho patient hatung 
had tea a short time heforo tho accident occ'iu'i'od. Tho 
success of the operation wa.s probably largely duo to its 
being . undertaken early. 

I Tim iiiflebtcd to Dr. Raiulall for assistance in describing Ibis 
case and for pci-mission to publish' it. 

•References.' • ' ■ 

'Masala: Laricet, 1923, ii, 640. s'Huddy: Clinical Journal, February 
-6th. -1924, p.- 65. - 


MEMORANDA.. 


r TjiEnnmsn 

I Mkmcai. Jov-nyii. J-UU a 


JUNE 13, 192S] 


lEtmorautia : 

MEDICAL, SURGICAL. OBSTETRICAL. 

CONGENITAL ABSENCE OF ONl^ OVARY AND THE 
CORRESPONDING FALLOPIAN 'JT'HE. 

Ox Novemticr 20tli, 1926 (]). 958) 1 piilili.'ibcd a cns.o of 
coiiiplclo atresia of tlio orsopliagus. Alon- rocoiitU- tho 
inollicr of tliis infant rct]nircil opovativo troalniont and 
tlio (levolopinental abnonnality Urns revealed seems worthy 
of recording. 

Tho patient, afretl 23, was sent to me with pelvjc Ironblo. In 
tho coui-se of n va^^innl examination nothin" idmonnnl was fell 
on tho right, side, but marked tenderness and u swelling were 
noticeable on tlio left side; after some local treatment surgical 
intervention appeared nece^san,*. Dr. Arthur Woo performcil 
tho operation and 1 asM^ted* him, Dr. Milward g^^^ng the 
anaesthetic. 

On opening the abdomen we found the left tube much 
inflamed, but no pus could he expressed frofu it. While seeking 
for tho right tube n most interesting condition was found; (he 
fundus of the uterus was quite free "ou the right side and there 
was total absence of tho tube and ovary. A long appendix 
reached across towards tho left tube, and since it showed signs 
of an lunammalory condition it was removed. Tho patient made 
an uneventful iccovcry. Tlierc were no signs of any previous 
operation, and Die Iiislory of tho patient, whoni I had known 
for many year.«, made me quite ccrt.niu that this was a ,caso of 
congenital absence of ovary and lube in a woman from whom 
I had dclivcrofl both male and female children, 

Tho patient was born in Lonrlon in 1901; she was brought to 
IIong-Kong wlicn she was 7 mouths old, and romainea here 
without going away until after her niarringe in October, 1922. 
She went to l-kigland in 1923, and while (here her periods ce.ascd 
for four to five months; she was examined and it was found 
ihat^tho cause was not pregnancy, Slie returned to Hong-Kmig 
in November, 1923, and became pregnant ; she was delivered of 
.a licalthy female child in August, 1924. In December, 1925, she 
was delivered of the apparently hfalthv male infant who was. 
however, found to Imvo no ocsop'hagus. In itay, 192G, the patient 
went to England, and seven months later was* delis-crcd (hero of 
a healthy fcmalo infant, She became pregnant again in 
September, 1927, hut had a miscarriage two months later, which 
sbo attributed to hard domestic work. 

She returned to Hong-Kong iu January, 1928, not at all well, 
ami. was admitted to hospital in Tebruary for the abdominal 
operation previously described. 

I consider this case most int^^rosting, ns wo Iinvo such 
nil undoubted history of n woninn witli ono ovnry bearing 
l)oth male and female children. There is also the point 
that a woman with an abnonnal condition gave hiidh to a 
child with a serious developmental deficiency, 

J. HKiiimiiT Sandeus, Sf.D., 

itfdical Superintendent, Matilda Hospital, Ifotig-Kong. 


.VN L'NL'SUxIL TYPE OF VICARIOUS 
AIENSTRGxVTION. 

Cases of .vicarious incii.striiation are fairly conunou, and 
aro mot viGx so frequently as to occasion very little 
comment. The liaoniorriiagc usuallj- comes from tho 
mucous membrane of tlio noso or iiasopliaiynx and more 
larely from the nipples. The folloiving ease appears rare 
enough^ however, to warrant publication. 


The patient, a young woman aged 26, is ono of an unhealthy 
of. «!<! members of which Iiavo died from puf- 
rlvini lubcrcnlosis. About a year ago sho developed imrais- 
disease. She refused sanatorium 
"'t' condition became progressively worae. Six 
Ik a^Q I nay sent for urgenllv, being told that she was 
roughing up considerable quantitiw of blood. For «omc weeks 
piCMous to this there had been slight haeraoplvsis, but onlv to 
the extent of there being occasional blood-stained sputum. 

^ patient’s house I was shoivn a vessel con- 
of bright rod blood, which the patient 
^ suddenly nnd unexpectedly coughed up. In the 

atintr hnf “'onlioned that she was menstru- 

^ not at that time associate the haemoptysis with 
tlm ersLn . ^ ^ cemeniber, pleasantly surpii-ised , bv 

to suMess of the measures I took to stop wliat seemed 

a mn. baemorrhage for on tho next day there was only 

this Inrl sputum and after two more days 

in there wns n well-mnrked cavity 


cWwbei'e'?n'^ul?i’'^i,'’^ fbo right lung and areas of consolidation 
emi,'” '’’’fl' bingB. i-xpectoration was free' and cop 
train “f F'^Pod tliere has been I 


ain of ’“ ri.'.' ii evtmu iiiere iias ucen I'le K.ime 

ents. On tho first day there - is a severe haemoptj-sis 


followed hv two or llirco ihiy.s of blood-slaincd spiitiira, and hy 
lii'c Iimo the inenstrual flow hn.s ceased tho sputum has, e-xcept 
on two occasions, been free from blood. I have noticed as llic 
mciislrual period approaches tlial the amount _of sputum in- 
cicascs nnd I boro is, so io say, a general moistening of the lung 
spaces, llclwccn tbo periods tlie cough is hard and rather dry. 

Since tlio severe liacmoptys;.s lias occurred only at the 
onset of jncnstrnation, nnd the last seven menstrual periods 
Imvc liad haemoptysis ns an acconipanimoiit, I think I am 
inslificd in labelling tho condition vicarious menstruation, 
though of an nncommori variety. 

1 ought to add, perhaps, that until this state of affair.? 
began, the girl had normal monstrnation, unaccompanied 
hy any niinsnal circiimslanco.s. 

I'.irtadown, frcijml. S- ClI.M’JrAX, AI.B., B.ClI. 


A CASE* OF EAR PRESENTATION. 

Tiir. following details of a ease of car presentation appear 
to ho of Kiiffieient interest to merit placing on record. 

A 2‘para, apod 27, was aflmitlod to hospit-al At 6 a.m. on 
April 25lh; labour hail cormnoncod in the early morning, and 
the membranes lind ruptured nl 4 o'clock. On admission a 
second verier pre«;entalion was diagnosed. Tiie mensnrcmcnls 
of tho pelvis were : iiilerspinous 8 in. and the intcrcrhtal 9A jn. 
Tho external conjugate was 7i in. There was full dilatation 
of tho cervix at 7.15 a.m., hut no .^d ranee in labour. Tlic 
palienl was in good condition, the pains occntring every three 
minutes. On examination a foetal car could be seen at tho 
vulva, while on vaginal examination tlio head was found to be 
lying in Iho transverse diameter, tho occiput to the right, and the 
head flexed laterally on the neck. 

1 tried manual rotation, at first without pucccss, but later, 
under a general anaesthetic, by pusliing the head tip into the 
vagina, I mnn.igcd to rotate it into an occipito-antcrior presenta- 
tion. Forceps were then applied, and a live child was delivered. 

Tho child had a large caput sncccdancnm on the left side of the 
face, o.xtcnding on to the car, and there was slight facial paralysis. 
It weighed 5 lb. 5 oz.. and bad the following measurements: 
Suboccmilo-brogmalic 3^ in., bitemporal 3 in., suboccipito-frontnl 
3] in., biparielal in.,*circnmfeTonce 13 in. 

The caput and the paralysis di'^appeared in four days. The 
mother had an uninterrupted puerperiuin, and was discharged 
on May 6th. 

The case of interest ns n marked example of Xncgeli’s 
obliquity which had not corrected itself. It is intere.sting 
to note that in 1921 tho motlier M-as admitted as an 
emergency case. Tbo condition then was a persistent 
occipito-postcrior presentation with prolapse of the cord. 
In 1925 sho Jiad a normal dcliv’cry. 

I am indebted to Mr. Louis (Maniac Kivcll for his permission 
to publish the case. 

C. G. 'W.VLKEit, AI.B.^ Ch.B. 

Queen Marj’s Ifo'jpital, Str.Ttford, E. 


Erparts nf 


THE TREATMENT OF ECLAMPSIA. 

At a meeting of the Section of Ob.stetrics and G^-uaccology 
of tho Royal Society of Jledicine on Juno istli, with 
IMv. CoAiYNS Berkeley in the chair, a paper bv Pi*ofessor 
At . Strog.anoff of Leningrad, an lionoraiw member of the 
Society, was read in his absence by' the honorary secretai'y'. 
Dr. AV. Gilltatt, who also anglicized what was described as 
tho author’s Anglo-Eussian. During Professor Stroganoff’.s 
visit to this coniitry iu 1924 he read a paper to the Section 
(Jiriiish Meilinil .Journal, July 12th, p. 55) in which he 
described his metiioii for controlling the fits in eclampsia. 
The cardinal principle in his treatment is that the fits can 
and must he controlled. All sources of irritation must 
bo removed, an injection of morphine be given immediatelv 
followed an hour later by chloral hydi'ate, and the adminisl 
tration of chloral hydrate repeated at intervals if delivery 
is delayed. The tecliiqne includes also the ap])!ieation of 
hot-water bottles, the giving of fluids to stimulate kidnov 
action, tho careful cleansing of the mouth, and tho ad- 
ministration of ox.vgen for asphyxia. 

The paper rend to -the Section' on June 15th wn.s almost 
entirely occupied with statistics.. Professor Stioganoff. 





JDNB 23, JOiS] 


BEVIEAVB. 


I JoCtlXJlX. 


1067 


^UbiciiTS. 


THE SIJIVEE GOITEICS. 
t, 1927, Colonel Ronr.iiT JIcCauimson i>iesent 
Hip InU'rnntionnl Coufei'oneo mi Goitre, he: 


esenteil a 
hehl at 


Ik August, 

renovl t-o Iho - _ . ^ • 

Borne under the auspiees of the Swiss Goitre Coinnussion, 
whieh he now publishes, in a slightly ain])lifiod form and 
with an introd notion of six pages, under the title of Jl>i' 
Simjitc Goilrcs.' It is divided into two parts, the text 
oeeiipying 59 jinges and the larger remainder eonsisting of 
illustrations, which are most s-uceesstully veprodiu-ed. 

There are, Colonel JIcCarrisnn insists, several forms of 
simple or non-to\ie goitre, and also several eaitses, each 
as important as the other. Undue inniortance has been 
attached to iodine defieieney, whieh, indeed, has been 
rogaivled as the one and only causal factor, and the value 
of the prophylactic administration of iodine has been 
exaggerated, whereas its failures have been regarded with 
a blind eye. IVhilo fully admitting that an adequate 
supply of iodine is essential dn preventing a certain type 
or types of goitre, the author is emphatic that iodine i.s 
not a panacea for all typo.s, and that it has not been 
proved that its deficiency is the ultimate cause of any form 
of goitre. The known goitre-producing influences include 
deficiency and excess of food, iodine defu iency. polluted 
water, gastro-intcstinal infection, and insanitary conditions 
of life. It should bo borne in mind that thyroid enlarge- 
ment, especially in young girls, is idiysiological, and .should 
not be described as “ incipient goitre,” ns apparently has 
been done in some goitre survei's. 

Three forms of simple goitre are described ; (1) the 
parenchymatous or chronic hypertrophie tyjie, wliich is 
endemic in mountainous regions, is c.xplained by a com- 
bination of infection and iodine deficiency — this fonn is 
considered at much greater length than the other two; 

(2) the diffuse colloid type of endemic goitre, which, on his 
own observations, the author tent.atively suggests may be 
due to a disturbance of .the calcium iodine balance in the 
food, and possibly in the gland itself — this is the form 
endemic in the Great Lakes district in North America: 

(3) the lymph-adenoid form, de.scrihed in 1925 by William- 
son and Pearce as the hypertrophic reaction of a jihysio- 
logieally insufficient organ with whieh there occurs a pre- 
ponderance of lymphocytic aggregates, fibrosis, and a pecu- 
liar atrojihy of the parenehyina. Experimentally, Colonel 
.McCarrison produced tin's form in rats fed on a diet 
deficient in vitamins A, B, and C, and iio argues that 
dins a physiologically siibnornial state of the tlivroid, and 
50 the production of to.xic metaholitis— and also a ])iiysio- 
logioally subnormal state of tlie gastro-intcstinal tract, with 
it^is and toxic absorption from the blood— result. 

unng his quarter of a century’s work on goitre the 
, laracj-ei , geographical incidence, and sequelae of goitre 
lave C langed, the grosser manifestations, even in endemic 
Aieas laio become loss common, and instead small goitres, 
more ''vn t spread gcograpliically and prone to be associated 
with thyrouoxicosis, have become more frequent. In 
describing only three forims of simple goitre the author 
modestly s.ys that be has but touched the fringe of the 

thoughtful 


iho .sclerotomy fistula produced by Lagrwigo's operation for 
glaucoma is so nbscuro that it might be anytliiiig or 
nothing. 

Tlio description of Lugrange’.s operation is oxcollent : it 
is to the work of that .surgeon that we are indebted for 
tbo basic idea of inndorn operations for glaucoma. His was 
the conception that a permanent filtration scar might be 
obtained by removing a iiiiiintc portion of tbo^ sclerc- 
cor'neal margin ; the ninny o])erations that hav'e been 
practised are no more than variations in the wor'^ing out 
of this idea. Some of tlicm certainly arc an improvement 
on Lagrange’s original method, for effective tliongli ''.bat 
was, it entailed a eon.siderablc woiiiuling of the eye. The 
merit of trephining — and most opbtbahiiic surgeons oniploy 
tbo method of Elliot— i.s that tliere is a iiiinimiiin of 
wounding to secure a full elfcct. In the description of 
tropliining there i.s a figiire in which the site of the bole 
is iiicorreclly gii-eii ; it apjiears there wholly in the sclera, 
whore it would ho inefTeetivo. 

The chapters 011 cataract operations are excellently done; 
■SO too are the doscriptions of the methods of dealing with 
obstinate aftev-catavaet. There are also good accounts of 
the several modes of removing cataract in the capsule’. It 
is curious to note that ivhereas ambidexterity scorns the 
rule for operators ill this country, so that the surgeon 
.standing hehiiid his patient’s head will incise the cornea 
upwards with the right hand for the right eye and with 
tlic left hand for the left eye, and make each section with 
equal ease and acturacy, it i.s otherwise on the Continent, 
wliere for the mo.st jiart the .surgeon still adopts tho 
riglil-handi'd method for each eye. 

Some critiei.sin might be made of tbe book owing to 
what apjiears a lack of balance. A relatively large 
jiortion is given to elaborate and detailed accounts of 
jdastic operation 011 the. lids and conjunctiva. As a 
matter of common ox]iericncc these operations are not 
everyday ojievations. and they do not conform to definite 
lines of proceiliiro. Nor is tbo margin between success and 
failure a hair’s brondtli as it is in cataract operations; so 
that there is much less need for detailed descriptions of 
the plmstie o|iorntions aud much more for ingenuity and 
re.soureo on tho part of the surgeon. ’Die forniuhition of 
rigid lines is inclined to evamj) his style and diminish the 
likelihood of .siiccc.ssfid ojieration. On page 591 there is 
an account, with two figures, of the perforniaiice of tho 
eoinmonest of all ojierations connected with the eye — save 
the removal of foreign bodies — the extirpation of clialaKion. 
AVc are .surjiriscd to find that it is recommended the tumour 
should lie removed through the skin of the lid by an 
incision parallel to tbe lid margin. This seems a most 
undesirable procedure; there will be a skin scar, slight it 
is tnio, but slower in healing than a mncoiis membrane 
incision. The correct mode of appro'ncli, both from aiia- 
tomical coiisiderntioiis and for rajiidity of liealiiig, is 
tliroiigli tlie conjunctiva by an incision parallel with the 
lino of tbe gland — that is, at right angles to tbe lid 
margin. By this method it is jiossible to remove tho 
eliiilazion so effectively that bleeding will cease in n few 
minutes and the patient can go away without a bandage 
over the eye. • ’ “ 


CLINICAL PATHOLOGY. 


A r.1- SURGERY. 

Professor Temiiek’s textbook of tl 
surgery of the eyo and its annexes has appeared. The woi 

or! enlarged,- and much of the earli, 

fiUfi les jccn lenriltcn. It is now a inassivo roliimc < 
646 pages with no fewer than 565 figures in the text. Moi 
tW ’’'f Orations are excellent, well conceived, and we 

armiL ^0 reproductions of phot, 

S +l, which piiiports i 

^j ^be bleb of tbe conjun ctiva dno to filtration tbronn 


r!Tui'v ’i-D., D.f 


• (Sup. roy. 8 vo, pp. viii -hC«; 555 lo'o fY'eanr.nuiorati« 


I’yur; >Ia5~on et 


■\ViiEN the fir-st edition of Todd’s Clinical Diagnosis hi/. 
Jjahoraforg Jllcfhods was 'first published twenty ^ years . ago 
the .subject-matter of .clinical pathology comprised little- 
more than elementary microscopy, blood counts, and a few 
sinijile tests wliicli could be ca'rried out without special 
tiainiug. The development of laboratory investigation.s 
during the past two decades, both in the province of 
biochemistry and of bacteriolog.v, has given, to clinical 
pathology an imjiortaiit place in the medical curriciihim 
Successive editions of Dr. Todd’s textbook have reflected 
this development of laboratory methods and provided a good 
working acepunt of useful tests. In tbo .si.xth edition^ Dr 
Todd has been assisted by Dr. A." H. Sakfoud. No sub- 
stantial alteration has heeii made- in the arraimemoiit of 


Ph.B.,M.D., and Arthur Hawlev Sanford, A.5I , ^ ' 

and rt^ol. ■ Pluhadr-lphia and London- W B .Salindo?- 

(Med. 8vo, pp. 743; 244 fit'ures. 28.. n^t j -Cnnipany, 1321 



1068 June 23, 1918] 


KEVJEWS. 


r' Tjtr, Uriti^u • 

L SrlKIitClL JoCRXiX. 


tha book, but a few sections liavo been rewritten, soino tests 
which further oxporicnco lias shown to ho of little value 
have been omitted, and others, such as the latest modifica- 
tion of Kahn’s ilocculation test, have been given a place. 
The book is of , a convenient size, well illustrated, and 
carefully documented. 

All laboratory methods that are useful in the diagnosis 
and treatment of disease have a right to bo grouped under 
the head of clinical pathology, and in their book'* with this 
title Drs. Panton and Maekack: have given them all a place. 
Thus they include not only the chemical and microscopic 
tests, which are part of the regular training of every 
student, but also sections on bacteriology and morbid 
histology. Though this may bo logical it is of doubtful 
expediency, for in a book comprising 450 pages, of which 
only' 80 are reserved for bacteriology and about 50 for 
histology and morbid anatomy, some of the information is 
bound to be “ scrappy.” But if the student is willing to 
learn his bacteriology and histology elsowhoro this should 
prove a useful book to him, particularly because of tho 
descriptions of chemical tests. Tho illustrations also aro 
good, and have been provided generously. 

The chief recommendation for Clinical Lahornfortj Pro- 
cedureSy^ by Dr. G. L. RonDENDUEo, lies in tho fact that tho 
author declares ho has used the tests recorded fo'r several 
years and found them reliable. Since personal experience 
must always carry weight, it is right that this justification 
for the present book should ho mentioned. For any other 
justification wo have looked in vain. Tho book is not 
divided into chapters, has no table of contents, is inade- 
quately indexed, and contains no illustrations. In the 
majority of cases no judgement is given of tho value of 
the tests mentioned, and the hook is nothing but an arid 
catalogue of how tho author docs certain things, though 
why he does them or what ho gains from them is not 
indicated. 

The third edition of Pathological Physiology of Internal 
Diseases^ has been i-oviscd and edited by nine of the hate 
Dr. Alhion WALTEn Hewlett’s colleagues at Stanford 
University, California— a task which they undertook ns 
a mark of respect for their former teacher. Dr. Hewlett 
was a trained physiologist who later in life concentrated 
his attention on clinical medicine. His book might bo 
called a textbook of functional pathology, for it deals 
chiefly with changes in function presented by patients 
suffering from various organic diseases. The two former 
editions were acknowledged to be valuable contributions to 
the scientific study of disease. In tho third edition the 
original form and order of presentation have been retained, 
and the book is brought up to date by tho inclusion of 
recent important advances in clinical physiology. 


industrial ACCIDENT INSURANCE. 

De. Paul Jottkowitz has had thirty years’ exporienco of 
accident piactice, and it was appropriate that ho should 
be asked to write a hook on the subject to succeed that of 
Golebiowski, which appeared in the year 1900, and which 
has become rather out of date owing to tho exporienco 
acquired in the war and to changes in the accident insur- 
ance law in this century. In this Lchrhuch dcr Vnfall 
hedkunde^ these regulations are discussed accordiim to tlieir 
actual effect in the middle of the year 1926. ° 

• The first part deals with the relations between the 
insurance laws and tho practitioner, and defines his 
duties in carrying out the law. The second part deals 
ivith tho connexion between diseases and accidents, and the 
third part treats of injuries and maladies of the several 
parts of the body and limbs resulting from accident but 

Clinical Pathology, By P. N. Panton, M.B., B.C.Cantab., and T t? 
^farrnck, M.D.Cantab. Second edition. London: J. and A 
1927. (5i X 9i, pp. viii +-^59; 51 figures, 12 plates. 150 . 

Clinical LahoTaiory Procedures. By George L. Rohde-nbur*^. MD 

Ma^nillan Company; London; ifacmillan and Co?. Ltd * iq ?7 
(.dcil. 8uo, pp. 2C6. 14s. net.) 

ratUoiog^al Physiology of Internal Dhcasen. Bv Albion W'iUai. 
nnn ^n**^** edition. New York and London: D. Appleton 

+ 787; 164 figures. 25s.) ^ppietoa 

((■i X 10. pp. *1 + 280; 267 J. F. Lehmann. 1928. 


loaves out of consideration llic Iiiglily specialized subjects of 
car and eyo di.s('a.s(‘.s and tlio.se ])eculiar to women. Tliis is, 
liowever, not a book on treatment, and tlierofore only in 
a few instances’ aro questions of treatment discussed, 
nltliough tho probahlo duration of disability, which often 
depends on treatment, iiccc.s.sarily occupies aii iinpoitajit 
place. Accordingly tho illustrations, of wliich there are a 
good many, aro iiitcndod to help diagnosis, and do not 
sliow splints or n])plinnccs or metliods of wound dressing.' 
As regards wouiurinfcction, it is pointed out how important 
iinmedinte treatment of sliglit hreaclies of .surface may be, 
seeing tliat it is only at fir.st that any attempt at steriliza- 
tion can succeed. A 10 per cent, iodine solution is reconi- 
mendod for this piirpo.se, ns well as the usual precautions 
against secondary infection. TJio anininr infections, such as 
anthrax, glanders, and rabies, and all sorts of diseases 
which may conlplicnto accidents or he incurred in tho 
course of duly, oven iiiclnding acromog.aly, aro considered. 
Tills last disease, it is thought, may lead, for inst.anee, to 
flat-foot, which may he com])Iaincd of as causing incapacity 
for work. All the usual clicmical causes of occupational 
(li.scaso and injuries of mnscles, tendons, hones and joints, 
and blood vessels and nerves, aro considered in tlicir general 
aspcct.s in Part 2. In tlio descriptions of local injuries and 
their results in Part 3 tho percentage of di.sahility in many, 
cases is stated, and some certain lines of treatment are 
recommended. This part is very well illustrated; in 
particular tho cighty-onc small figures' showing almost all 
tho possible nuitilntion's of the hand and fingers, and tho 
percentage disability of each, is likely to bo useful, if only 
for comparison with tho scales on which' onr own Slinistryof 
Pensions allots compcn.sation. A short section on amputa- 
tions and piostheses, and ono on tlio percentage disabilities 
of loss of limbs — including toes — ^coneliidcs tlio volume. 

Awards under tho German insurance law aro not neces- 
sarily guides for deciding cases under our Employers’ 
Inability Acts or tho Factory Acts, hut it cannot fail to 
bo iiislructivo to compare foreign methods and apjilicatious 
of first principles with our own. This book will enable its 
readers to do so to a great extent. 


ANNALS OF ]MEDIC-4L HISTORY. 

The first qnartorlv mimher of tho tenth volnmo of the 
Annals of Ulcdical Hisiortf contains ten articles in addition, 
to tlio editorials and tho reviows. Tho portrait on the 
cover is that of K. F. Bnrdacli (1776-1847), tho story of 
whoso life is related by Dr. T. H. Bast; in tlio course of 
his early struggles Bnrdacli in desperation invented .a. 
patent pill “ engone,” which not unnaturally for a. time 
interfered ivith his attempts to get a university chair; 
about six years later, in 1811, he scoured a professorsliip at 
Doi-pat, irtierc ho carried out original work, and in 1814, 
having in tho mcanwliilo declined a chair at St. Petersburg, . 
ho moved to Konigsherg, wliore ho puhlislicd his researches 
on tho nervous system and tho column which hears his 
name. Tlio frontispioco represents Dr. Philip Turner 
(1740-1815), who was an army surgeon for fifty-fivo years 
and took jiart in threo Ivors, eventually becoming surgeon 
general; Dr. 0. B. Graves says that tho latter part of his 
life was one long battle to secure ivhat ho believed to ho 
his rivlitful dues. In, his artlclo on “Robert Burns, his 
medical friends, attendants, and biographer,” Dr. H. B. 
Anderson concludes that tho poet’s death at the' ago of 37 
was not due to alcoholism, hut to rheumatic heart disease, , 
auricular fibrillation, and terminal bacterial endocarditis; 
tlio article contains portraits of medical men, including 
James Currie, who wrote- his life. John 'Weslo 3 ', the 
religious reformer, wrote, for the guidanco of the poor, in 
1747, Primitive ICnjsich, or an Pnsy and Hatural'Mcthod 
of Curing Most Diseases, and in his account of this work 
Dr. Baragar mentions that in tho edition of 1780 “ qninsey 
of, the breast ” is tho term used for tho angina pectoris 
described in 1768 by Heberdcii. Dr. A. H. Barkley shows 
that Constantine Samuel Kafinesquo (1783-1840), who was 
ono of the most brilliant men of his time, and did iiiiich to 


* Annals of Meilical Histor}/ fSprinc Number. 1923), vol. x, Eo. . 
Edited by Francis R.. Packard, 51,1). New York : Paul Iloeber, 
London: BailUere, TindaU and Co>-. 1923. (83 x 12i, pD. HO; illuMrait. . 
Subscriptions in Great Britain, £2 23. per volume of four number...) 



NOTES ON BOOKS. 


t lifE /^nrcTfX 
Ur.picAL Jot:iieiX> 


1060 


Jdne 23 , 192 s] 

tiilvnuco iiitclloolual .and Eciciitific devclopiueiif in Aiiiei-ic.a, 
was not a doctor, but bad an intiniatu Iviiowlcdgc of tbc 
.profession, cnied iiiinsclt of pnlnionai-y tnboi-enlosiB, and 
invented a remedy for it ealled “ pnlinel.” Dr. If. S. 
Iteiehlo contributes a .sketch of iimil Noejij^erath (1827— 
1895),. wlio practised with success for a time in Now York, 
but returned to liis native conntrj- ten years before his 
death. In his essay on fees in medical liistory Dr. 11. 
Dittrich gives examples from Babylon in 2250 11 . c. to tl»e 
i-eccnt past. Dr. It. G. Donglity tells the .stoi-y of the early 
struggles of tho medical department of the I'niversitj' of 
Georgia, wliich was st.arted in 1828, and the accomplished 
editor contributes somo excellent book reviews. 


KALA-AZAIl. 

In 1918 E. Afuir piiblislicd a small book on tho diagnosis 
and trentment of kal.a-.'izar; this reappeared practically 
as a second edition, much enlarged, under tho authorship 
of E. Jluir and L. E. Napier in 1923. The pre.sent mono- 
graph, Kitlti-azar,” by L. Evku.mu) N.wieu, winch now 
appears, though a lineal dcsccndcnt of the foregoing 
volitmcs, is in fact a completely rewritten book, Dr. 
Napier is in charge of kal.a-azar research at tho Calcutta 
School of Tropical .Alcdicine, whore ho and his colic.agucs 
have for the jiast three years been studying the several 
problems of this di.sc.ase, inclmling transmission. 

The book deals fully with epidemiologx', etiology, patho- 
logy, symiitomatology, diagnosis with laboratory nictho<ls 
and technique, and treatment. Though 1‘hlcholomns 
argcntipcs has been incriminated as tho vector of kala- 
azar, actual transmi.ssion by its agency has not yet lx>en 
effected. As tho transmission problem is thus unsolved 
it is discussed at length by the author. Tho rdtimatc 
solution will doubtless not be long delayed, and when this 
happens it shoidd give us one more example of the value 
of team work in dealing with such matters. The chajder 
on treatment will also be read with great interest, as 
since tho introduction of iicntav.alent compounds of 
antiniony the treatment of knln-az.ar has been nlmo.st 
revolutionized. ith the newer compounds the cure rate 
is now 95 per cent., tho minimum course of treatment 
has boon reduced to a quarter tho time fornierlv nccessarv. 
and tho relapse rate has been greatly reduced. 


NOTES ON BOOKS, 

It is not surprising that a second edition of Afr, ZXcHAitY 
Copes textbook on The Treatment of the Acute Abdoinea^^ luis 
been quickly demanded; the first edition was reviewed .sij 
lecently as I'ebruary lltb (p. 2^). Although the alteration.^ 
are not extensive they are minierous, and the additions include 
reference to the investigations of Williams and Brockman 
l^he to.xacmias of ileus and intestinal 
obstrnc ion. A fifth ^ition of The Early Diaynosif of the 
Acute Abdomen, by the s.ame author, has also r.apidlv followed 

The symptoms of peritonitis receive more 
.attention, 

-■ ■■ are dealt Willi in a short 

■ ; , obstruction of the small 

intestine has been e.xpanded. ' Both’ these, books arc verv 
valuable and can be strongly recommended bv reason of tliei'i 
practical outlook. • - 

The wid^piead interest taken in the injection treatment ol 
varicose veins is dlustra cd by the fact that n third edition ol 
Dr A. H. Douihvvmte’s little book>= has alreadv appeared, 
m contributed bv him tc 

? »i (P- 55d). and we noticed .at 

iw / his book on September 24tli, 

■w /P- cem.ams now to add that the new edition is 


eii*itfo°n“'Lonilt>? nbni^'r '^“'^'^1 11-11.0.8., L.R.C.P.Loncl. Sccoi 

'Medicaf Pnblfca^ionV Yf Xbrfonien.- .Second edition. Oxfo 

Umversity Pres. 1928. (Demr 8vo, pp.ziv+Zil 

0/ Porfeose reins. Bv A. H. Doiilhnaii 
Ud.'AP'e™; n^j''™^ H.-K.. Lends .nod C 


In the preface to Operative IJentistr;/,'^ which forms tho 
ninth volume of the scries Outlines of Dental Science, its 
author, Mr. Hajiiltok .Tamieson, tells ns that his guiding 
lirincipio has been to write only of sncIi things as he has 
Iier.sonal knowledge of. The ideas, experiences, and per.sonal 
ii'cthods of a colleague ho hopes may prove interesting to the 
busy pr.actilioiier and useful to the student. ' AVe think he has 
very well attained hi.s object, and that Ids little book will bo 
welcomed by members of the dental profession. In short sjiace 
and in simple wording lie 1ms covered the whole ground of 
“ operative dentistry,” including the ebairside work of denfuro 
construction. I’rom flic brevity with which “ pyorrhoea ” is 
treated wc gather that tho author is not greatly impressed with 
flic results of treatment, but we note with intere.st that 
s\-inmetrical extraction for relief of crowding is often 
ext'rcmclv hcncficial.” Tlic suggestion that an excess of over- 
refined carbohydrate food is responsible for many pyorrhoeas, 
owing, in part, to its efTcct in clogging the normal channels of 
elimination, seems a lilflc difficult to follow; and the idea 
that a labio-ccrvical carious cavity may be cine to an acid 
condition of flic body generally still more so. AVe may ask 
also what evidence the, author has of an acid state of the 
-saliva diiriiig pregnancy, dyspepsia, or rlicnmatism such as 
would cause hypersensitive elentine. As bearing on the vexed 
question of “ root fre.alment,” Air. Jamieson makes the 
inlerc.sting note that radiohiccnt areas, not necessarily infected, 
.are observed around the apices of tbc -roots of those teeth the 
pulps of wbicli have been removed under pressure anaesthesia 
rather more frequently than in similar c.ascs when arsenic has 
been used. The author li.as found " an interesting order of 
childhood wliicli has been appearing in increasing numbers sinre 
the great war.” From the illustrations we judge that these 
children arc the subjects of adenoids. 


The first edition of Advice to the Expectant Mother on the. 
Core' of Her JleaUh, by Professor F. J. Bbowne, appeared 
nearly two years ago, and was noticed in our issue of January 
15lb, 1927 (p. 106). The second edition,** recently published, 
has been revised and brought up to date. In his preface the 
author pa\-s a richly deserved tribute to the late -Dr. J. AAk 
Balbnlyne of Edinburgh, who (ns readers of this Journal well 
know) w.-is the first to advocate the necessity of ante-natal care. 
The paramount importance of this branch of medicine is now 
•so universally recognized by the profession that it is difficult 
to rc.alize that the lust ante-natal lied w.as endowed as recently 
.a.s 1902. There is still much need of education along these 
lines among the baity, and wo ni.ay confidently expect that 
Profes-sor Browne's useful ■ pamphlet of forty-eight pages will 
.agj.in justify itself and help to supply this want. 


Air. Enic Pabkeb’s reminiscent sketches in Field, Fiver and 
llill'^ are designed, with considerable success, to appeal to those 
«ho arc fond of the open air and of sport — more particularly 
fishing and sliootiiig. His hook is hardly one. to be read at 
a sitting, .consisting as it does p.artly of articles reprinted 
from various journals, but it will be v.aluerl by tliose whose 
professional responsibilities debar them, to their regret, from 
(he delights of the waterside and of the moor, and who will 
welcome a pleasant “ bedside ” hook dealing with these tilings. 
There is a richness of detail in the .author’s descriptions, based 
obviously on keen observation, which m.akes his work some- 
thing more than mere sporting gossip. He has ,nn eve for 
nature and for colour, and a knack of characterization 'which 
finds an outlet in his good-tempered little studies of men .and 
women. Eight reproductions of drypoint etchings of bird 
and animal subjects by Aliss AVinifred Austen add to the 
attractiveness of the book. 


” Opcralire Urnlislri/. Oiitliiier of Denial Science. Vol. JX' Bv J D 
If-ainiUon Jamieson,. L.D.S.Ed. Edinburgh : E. and S. Liviriestone 
1927. (Cr. 8vo, pp. vii 216 ; 27 figures. 7s. 6d. net.) 

>> .Irfrice to the ETi}ectanl Mother on the Care of Her Health. Bv F J 
Brt.wne. M.D., D.Se., P.R.C.S.Ed. Second edition. Edinburgh : E. and S. 
Livingstone. 1928. (Cr. 8i-o, pp. 43. 6d. net.) ■" 

Hirer anil Hill. By Eric Parker. London; P. Allan and Co.. 
Ltd. 1927. (Demy 8vo, pp. •x + 279; 9 plates. IC3. 6d. net.) 


PKEPAllATIOKS AOT) APPLIAIsCES. 

“ Eukodal.” 

“Eukodal** (ilessre. Merck, Darmstadt) is a derivative of- 
'thebaino, with the chemical name dihydroxy-codcinon livdro- 
chloridc. It was discovered by Freund and Speyer in *1917. 
The drug has been fbe subject of numerous investigations. 
’Schroder claimed that - it was a full substitute for morphine. 
.Ollier' observers found- that it was' of great value in- check inf' 
-excessive cough,, and _it was. also'.found. to have-a^ powerful 
analgesic and narcotic action. AU observei's .at'ree that the 
toxicity of the drug is low compared with thaf of -morphine 
-and that the chance of habit formation with cukodal is much 
'less than with morphine. The agents in this country are Messrs 
'H. R. Napp, Ltd. (5 and 4, Clement’s Inn, Kingswav WC2) - 


1070 J0NE 53, 1928] 


HABRTSON OP IGriT^A'^r. 


t 7nr. Bnrns* 

JoL'HTlt 


4^0ha tt llitura. 


HARRISON. OP IGIITIIAjr. 

A Village iVncnAEOLOGisT. 

Nestling imclor the Nortli Downs, on a trn)ntan' of flio 
lledwaj’, is tlio village of Ightlmin, niado fainons by its 
grocer — Benjamin Harrison. In the nortli wall of tlio 
parish cluireh is to be found an epitome of liis stoiy: 

" Benjamin Harri.son of Ighlham, 1837-1921, the village 
grocer and archaeologist, whose discoveries of colithic flint 
implements around Iglitham opened up a fruitful field of 
scientific investigation into the greater antiquity of man. . . . 
A man of great mind and of kindly disposition.” 

Man 3 ’ who wish to read tho full stoiy of this Kontish 
man will find it told h)’ his distinguished son. Sir Pdwnrd 
R. Harrison — told with modesty, restraint, hut most 
effectiveh-.i 

How did it como about that a hoi', horn in the ve.ar 
1837, of an ancestiy which had stood" heliiiid tho counter 
of a small village shop for generation.s, suddenly broke 
away from family tradition and devoted himself to" solving 
the problem of man’s antiquity? Undoubtedly the factor 
of heredity came in. His mother, Elizabeth Bigg.s, came of 
a stock which po.sscsscd inventii’e ability; tho eldest son, 
Tom, and the j-oungest, Benjamin, took over from their 
niother tho Biggs’s desire for knowledge; tho other members 
of tho family wero orthodox Harrisons. It was Tom, 
ten years senior to Benjamin, who led tho wav. AVhen 
Benjamin was a hoj’ of 13 ho listened to his schoolma.ster, 
Stephen Constable, discuss tho geology of tho weald with 
Tom — for theso wore (lavs when Lvoll’s 
Memenfs of GcoJngy and Chanihors’s VcsUgcn of Cfeallon 
wore moving all men of an inquiring disposition. Tho 
boy took to rea^ding Lyell, Chambers, . Gilbert. White, 
t anscll .s Popular Kducator; from tho pages of tho Gcoloqht\ 
taken m by Tom, ho learned what geologists of Ihb day 
were cloiiig. His master, Stephen Constablo, led liis hovs 
into tho weald to trace tho gravel drifts which had been' 
laid down bj' running streams in ancient times.’ In duo 
time Benjamin went behind tho counter to iio' packages 
and snuff candles, while his elder, brother Tom sailed for 
Australia, ultimately entering tho Patents Office Mel-' 
bourne, where he died in 1897. Without Tom thoro’ would 
hai’e been no Benjamin. 

We fiiKl this grocer’s boy, still in his ” teens,’’ construct- 
ing lehef maps of his native area of Kent out of- tho 
vaiious coloured papers theii used for sugar wiainiings. Ho 
developecl powers of drauglitsniansliip, e.ssential for every- 
one who takes to concrete science. Before he was 20 Im had 

RomaTrBrV I I'od been inhabited during tho 

Komaiio-British period; he had puzzled over “ pits ” found 

% "®'gbbouring wood, and finding a polished colt or 

me; whruslTsnch" '--s oTtlm 

Endand In dim i before the Romans camo to 

U e c^^e He was Ir™' ^ '>e 

ease. He was grocers apprentice durino: the dav hut 

in early mornings and late evenings ho Was hdanlt 
zoologLst, and geologist. Not a ditch Was a fouWla’ 

tion dug, or a gravel pit opened but bn +i ^ 
v-liat liglit they could thr^w on 

geological history of his homeland.. EsiWciauW h^'^de •'“"l 
to know when and how tho various deposits if grave]?lmi 
como to rest wdiere ho found. them. giaveis Had 

In 1863, when ho was 25 years of aee bn i-n - 1 ■ 
Geologist of the palaeolithic impleineifts wdiich '-Rn? i ■ 

'““l WW'' gravels of the Somme valWy 

Ahcady there had been announcements of the discovm-,, 
Similar stone implements in the gravels of tlm Tb^ 
valley. Ightham is situated on the^vateW.ed biWeen tlm 
upper tributariea of the Medway and of the urrmHh 
Haiiison inferred wfiat his gravels, especiallv tb^ca i ’ 
the hettoms of the valleys, sLnld .alsoTonjillfi 


lie .sc.arelicd for thorn, found them, ami began to foim 1 
collection of Kentish palaeoliths. jfcantime, his attentioi 
had boon di'awn more and more to Oldbury Hill, to tin 
west of Ightham; ho found flint implements there of ; 
curious tj-pe, which, in the teeth of expert opposition, h 
fiiiallj’ proved to Iio tho work of late palaeolithic man 
Tims at an early point in his career Benjamin Ilanisoi 
liad proved that Romans had lived in Ightham, neolitlii 
man in a iieighhouring wood, lato palaeolithic man h.n 
'shcltorod under tho rocks of Oldhui-y Hill, and that. earl 
palaeolithic man had occupied the neighbouring valley 
heforo tlic.sc had attained their present contours. 

Beforo tracing ids career farther let us look at hi 
domestic situation. lie married, and took over the liusines 
from his father in 1868, being tlicn, in liis thirty-first year 
hut it can hardly be expected that a.AuTlagc husinc.ss, how 
ever well cstahli.sliod, could tlirivo under a man who waken 
early in the inoriiiiig with geological problems “ ninninj 
through hi.s head,” and who early and late is out .soarchini 
hill and field and prizing the discovery of a palacolitli ahov 
tho addition of a new customer. Indeed, lie was mor 
intent on making converts of those who camo to his sho] 
than oil .selling tlioiii tea and sugar; ho was os.scntially i 
geological missionary, who desired to educate the workiiii 
moil in his district and to enlist their interest as helper 
in his self-imposed task — tho long history of Ightham .aiK 
Ighthaniitcs. His heaving hccaiiio impaired; in 1877 hi 
first wife died — it had been a happy marriage. Tiien, ii 
1879, he iiiarriod for tho second time, and evidently proniisn 
to turn over n new leaf of life; at least he di.spatelicd tin 
whole of his collection to tho nnisciim in Maidstone, deter 
niinod to coneciitrate on hnsiiicss. His old passion provei 
too strong for him; in ]o.ss than a year wo find him bac 
at hi.s old haunts— hut no longer content to search th 
more recent gravels along tho valleys. Tho palaeolitlii 
iinplciiioiits found thoro were tho work not of apprentice 
hut of skilled liands. To find man’s earlier work -tho olde 
gravels on tho ridges which soparato tho upper water 
of Medway and Darcntli had to bo searched. He searclici 
them; aiid found still older and cruder palaeoliths, but evoi 
they did iiot represent the , beginning of things. And si 
if came about, just ns ho was meditating his sccoiii 
marriage, ho began to search in the " gravel-spreads ” 01 
tho top of the' North Downs— infinitely older than tliosi 
of the weald — for man’s earliest attempts at making stem 
tools. Hciicc, after his second marriage, when the ok 
inquiring Adam in him had once more mastered his husincs: 
duties, wo fiiid hiin again searching the plateau gravels 
In 1881 ho hclicvcd ho had found a rude tool which sliowei 
definito evidence of human workniansliip ; in 1885 lio hai 
found others that convinced him of his eliscovery; by 188' 
further disciivcrics gave him tho feeling of certainty. Hi 
had conic into touch witli many of the loading geologisfi 
and' archaeologists of the time; but without tlio help 0 
Joseph rrcstwich, professor of geology at Oxford, ho conk 
never have succeeded in proving his case. ' jVltlioiigli lioldinf 
the chair of geology in the University of Oxford Prestwicl 
lived at Slioroliani, in the valley of the Daronth, eight mile! 
from Ightliani. In 1879 iio bocanio interested in Harrison’i 
work, and a'li ideal partnership was established between 
tho' two men. Prcstwicli bocamo adviser, mentor, and 
critic — for ho was Harrison’s senior by twenty-five years; 
lie insisted on Harrison siippljdng complete records of everv 
■find and convincing proof of every statement, and in diic 
time' was convinced that the plateau gravels of Ihe Nortli 
Downs did contain rudely chipped stone iiiiplenients, to 
which lio gave the name “ eoliths.” Harrison was au 
intensely modest man ; publication ho regarded as the duty 
of those wild occupied professorial chairs, not of tliosii who 
stood behind counters. So it came about that Harrison s 
discoveries iverc verif ’ ■' ' ’ ‘ 

lished, with all duo . ■’ 

at tho Geological Soci „ , , ' . , 

logical Institute in 1891. Tlie' announconient of Harrison s 
discovery met with a mixed reception ; cx])erts bccanio 
ranged in a series which extended from tho confirnicc 
“die-hards,” who rejected eoliths of eveiy kind and fqini 
as evidence of man’s existence, to tlio extreme optiims , 
who accepted every cliipped stone as the goimiiie r,yik 0 
human hands. Nor is the dispute now ended; it is tr®® 


Juke 23, i9=8l 


TIIK CAMPAIGN AGAINST LEPROSY. 


f Tne DBmra T f)?'? 


tint, in ilie lust fovtv voars oolifiis liiivo anultly giiinnl 
in favour ; tlicrc Ims'l.ron i gnnlnal movomont from 1 10 
,lii'-lmv(l to tlio optimist ond of the export scale, hut the 
hatllo for autiquitv is hy uo meatis yet decRtecl. Ilayrist.ii s 
cause was greativ advaiicxHl in 1010, when Mr. Ifcid Mo>r 
fust anuouuecd the discovery of rostrocariiiato iriipleincnls 
under the crag formations of East Anglia. He and Mr. 
lleid Jloir agreed that the Kentish eediths weiv more 
in imitivo in' Ivpe and older in time than the “ snherngs ” 
of East Anglia. Both discoveries indicate the existence 
of Pliocene man in England. 

The story of Harrison of Ightham has an interest for 


medical men; liis type is to he found in every jjnrt of 
England, and it is’ well that we should recognize and 
know them, for wo can learn much from them. There is, 
in all their lives, as in that of Beniamin Harrison, an 
element of tragedy; in 1005, at the age of 68, he ** I'etircd 
from hiisine.ss.” jn leality business had retired from liiin, 
and had it.imt heon for a small i)ciision from the Civil List 
and an aniinity from the Royal Society tiic tragedy might 
have hrcii a real one— to everynne except Harrison,- lor 
he was one of those happy men uho met the hnfi'etiugs 
of fate with i\ smile, and .sought only for the welfare of 
knowledge and of his fellow men. 


THI'i GA^irrATGX AGAKXST IrF.PKOSY. 

MTisgc it 'is realized (hat there nre prohalily about three 
million le])ei-s in the ftorld, and tliat about one-third of 
these aiv to he found in India niouo, it hceomes evident 
that the eradication of this sranrge is in great mcasnne 
a British problem. The annual report for 1027 of the 
British Empire lycprosy Relief .'Vssoeiation indicates in 
arresting words, statistics, and illnstraf ions uliat has 
already been achieved in this respect, and what remains 
to he done. Tlio most outstanding feature is imdoiihtedly 
the fact that cure i.s now possible if treatment is provided 
at the commcncomciit of the tfiscase, and tlie association 
has therefore addressed itself systematically to the impor- 
tant task of promoting an increasingly intensive search for 
early cases. Sfention is made in the report of the great 
advance since the di.s- 




covory of unirvitating 
preparations of sjdium 
hydnocarimtc. and of 
Muir’s antimony and 
potassium iodide treat- 
ment. Highly satisfac- 
torj' progress has been 
reported, not oidy in 
India, hut also’ in 
Sntith and East Africa ; 
it may he recalled that 
Mr. Frank Oldriove, 
the sctretaiy of the 
association, ’visited, in 
1^7, 1'ganda, Rhodesia, 

Kenya, Zanzibar, Tan- 
ganyika, aiulNyasaland, 
obtaining a verv large 
amount of valnahlo 
information. Among the 
natives eonfidence is 
growing rapidly in the 

treatment centres, which Cuizxgmai, Sjau. 

are financed partly or altogether hy the associ.ation. An ( there being 
appea IS made for such assLstaiico as will en.ahle this work 
to he extended still more n-idely. 

Sii l^nard Rogers, lylio is honorary scerrlaiy of tho 
assoc-ia ion, commenting on tlio importance of detecting 
and icating early cases, emphasi-zes the value of examining 
con ac s erers .six jnouths for five yeans. Ho believes that 
•”c " 7 ”' ®"'''>tantia\ reduction in tho incidence 

jpl'? 1)0 obtained. Dr. Robert Cochrane, 

' last year a survey of leprosy in India, 

to winch we referred on August 27th, 1927 (p. 362), has 
non made a second contrihutiou) to what is intended to 
become a world survey of leprosy. He outlines the present 



is now nsnally.considered very unsatisfactory, sinc-o early 
cases are thus driven into hiding and tho optimum time 
for treatment is tliorcforc uussecl. A modern equivalent 
Im.s heon devised in .some places in the form of leper 
centres in pleasant surroundings, wlierc a considerable 
degree of freedom is allowable. The plan is obviously 
capable of gre-at extension, .since it lia.s been estimated 
that less than 8 jior rent, of the Icj)crs in the British 
Empire are segregated. 

In this connexion wc have received an intcre.sti'ng report 
of the methods adopted in Siam, where, there are said to 
be about 20,000 lepers. In Chiengmai, in the north of 
Siam, an Aineriean physician, Dr. J. W. McKean, is 
ill charge of a leiicr a.syhiiii colony outside the city walls, 
where in ilic c-onr,se of the last twenty years more than 
1,000 lepei-s have been treated. Tliis asylum, of which we 
. print an illnstration, is 

one of tile two large 
ones in Siam, the other 
being ' at Prapadeng. 
The exist of mainten- 
ance of the Chiengmai 
a.sylum amounts to 
nearly £3,000, oius- 
third of which is bonie 
by tlic .Siamese Govern- 
ment and the remainder 
by voluntary contribu- 
tions, chiefly received 
through the American 
Jlission to Lepers. 
During tho earlier 
ycai-s of tho work of 
this institution con- 
sidevahle support was 
given hy British snh- 
scribers. In this leper 
colony the Siamese 
method of ■self-govern- 
ment is in operation, 
eighteen persons to 




position 111 .various jiarts of liuropo and the Middle and 
1 ’ devotes considerable attention to Africa, 
has been obtained in support of the view 
that infection usually occurs i„ childhood. The fact that 
pros} IS generally a house infection, and that, apart 
om is, close personal contact is usually necessary for its 
ftansnussion, brings up the diffienlt question of segrogatin. 
nfections rases and of protecting tiie children of leprou 


.isolation^^vldch"' proved 

lie measiiio in Europe in the fourteenth century, 
G. CKhlfn"' d/r/ra. I?}- R6l.ert 


G. Cocl.,-»n„ ’t7 .■'‘.""ne ami ^ear Eaul, anil A) 

trticc 2 I} ‘ .Press,. 1. Tmior Street, 


•LoiHlon, E.C.^.- 


homo guard of 
presor\*e <jnh*r, a samtary squad of eight, and a Melfare 
committee. Marriage is forhidden, and tho men and womoii 
live apart, hut olhorwiso there is no compulsion. The 
colony is open to all mccs and religions. Each small 
cottage accommodates tu'o lepers, and is surrounded hy 
a garden; the funushing of these cottages is very simple 
in order that strict cleanliness mav prevail. Dead .lepers 
are crematod in a hniiding approached by two stairunrs, 
church -with open doors is provided. Such con- 
ditions for living compai'e vei*y advantageously with these 
m the towns, where large numbers of crippled ■ and dis- 
figured sufferers obtain a scanty livelihood hy begging. 

fl c have nf^n referred to ‘the excellent work of the 
uell-Kno%vn British society tlm Mission to Lepers, whose 
journal entitled TTif^iotif ihc Camp supplies quurterlv a 
record of what is being achieved throughout tlio world 
It may also be mentioned that the May issue of the 27ic 
Mzssaon Bospifnl^ the monthly periodical published hr the 
Church JMissionary Society, is devoted to leprosy and cc 
tains an arfcic.e hy Sir Leonard Bogers on rece'nt ])roWn 

A\ith the advance of medical research thcio appraix to ho 
now a real prospect of . controlling, and 


con- 

•esa 


1072 JUNE 23 , 1928 ] 


INDUSTUIAIi FATIGUE HESEARCH BOARD. 


[ THRijumw 
MrolCAL JOORXU 


THE INDUSTRIAL FATIGUE RESEARCH BOARD. 

Bepokt Fon 1927. 

It is tho practice of the Industrial Fatigue Research 
Board to publish each year a suuiiuaiy of tlio work upon 
which it has been engaged. The iuvc.stigations, begun, 
continued, or completed during 1927, form the .subject 
of the eighth annual rojjort, which has just been issued. 
It is natural that the efforts of so young a handmaid of 
.science should be surrounded with difficulties; that much 
of the labours of tho Board should consist in exploring 
methods for attacking problems; and that in some cases 
the solution of a question submitted to tho Board has 
proved unattainable. Thus tho Advisory Connuitteo on 
Women’s Occupations asked tho Board to inquire into tho 
relation of school-leaving ago to well-being and proficiency. 
After two attempts- to define procedure suitable to tho 
subject, the Board, on tho advice of its Statistical Coih- 
mittee, was reluctantly compelled to dismiss statistical 
consideration of the matter, and to confino itself to tho 
investigation of the relation of ago to tho acquisition of 
dexterits-. In many of tho researches it has been found 
difficult to obtain sufficient comparable material for tho 
study of mass data. During the war many opportunities 
occurred for collecting such data, over long jieriods, relating 
to one specified product. In peace man’s demands for 
products are not limited in tho same way. iloreover, 
analysis of mass data can tako no account of tho personal 
and individual peculiarities which aro among tho most 
potent influences operative in industry. Consequently, 
wliile many of tho Board’s investigations, such as those 
dealing with sickness, are still stati.stical in tho sense 
that the investigator deals with data in tho collection of 
which he plays no part, tho procedure now adopted is 
often the intensive observation of comparatively few 
individuab. This technique has been applied to tho 
examination of woight-cariying by women, tho causation 
of accidents, and the effect on tho individual of ropotitivo 
work. 

Menstruation and Worhing Capacity. 

An inquiry of medical interest has been conducted on tho 
relation of the menstrual cycle to tho working capacity of 
women. Tho question was explored from two directions. ■ 
First, Miss S. C. M. Sowton, acting under Dr. C. S. 
Myers, made daily tests for several months of tho muscular 
and mental efficiency of thirteen university students and 
sixteen factory operatives, all of whom wero kept in 
ignorance of tho purpose of tho tests. In the second place, 
Miss G. M. Bedale, under tho direction of Professor E. P. 
Cathcart, made systematic observations for three months 
of the basal metabolism, body temperature, and other 
lihysiological phenomena in a single subject under strictly 
controlled conditions. Miss Sowton’s investigation showed 
that Die influence of menstruation was no greater than that 
of other occurrences of an accidental nature ; but that in- 
di\ idual w omen differed in their behaviour, some showing 
a worse performance of the tests about the time of the 
periods, others a better performance, while in others again 
no definite difference could be detected. Miss Bedalo found 
that, while there was a heightening of functional activity 
in the later inter-menstrual period and a fall at menstrua- 
tion, the fall was no greater than others which often occur 
accidentally. There was no evidence that a normally healthy 
woman was rendered physiologically ineffective during men- 
struation. Tho Board concludes that, while slight varia- 
tions in efficiency and functional activity during tho men- 
strual cycle exist in some women, the investigations support 
the results of an inquiry made in another connexion amomi 
welfare workers, from which it appears that very few 
women are so upset that they have to remain off work even 
half a day ; and that where menstrual trouble occurs at all 
the women merely lio down in the rest room for about an 
hour, and then resume work. 

Accident and Sichness Bates: The Personal Factor. 

The fact that under equal conditions of risk ono person 
m liable to incur more accidents than another has led the 
Board to the investigation of proficiency in certain sensori- 


motor tests. Such proficiency appears to bo a.ssociatod with 
n relatively low accident rate; and from data obtained 
from apprentices at tho R.A.F. cstablislimeiit at Halton, 
and the dockyard at Portsmoutli, it is Imped to throw light 
on tho rchitioii.ship between accident pronencss, sickness, 
and industrial proficiency. 

It njipcars that wide variations exist in the average time 
lost tlirongh sickne.ss in different factorie.s, and that these 
diffcrenees persist consistently. Sicknc.ss records arc, there- 
fore, lieing collected from .several largo firm.s, and it is 
hoped that it will bo discovered from those, and from 
examination of tho employees, how far p.sycho-ncuroses are 
a.ssociatcd with a high sickno.s.s rate. In such inquiries 
there is very great difficulty in relating cause and clfcct; 
but, ns tho report points out, though ono inquiry may 
merely suggest a tentative conclusion, repeated suggestions 
from many inquiries may establish a high degree of prol)- 
ahility. Such lias been tho case in ob.servations on tho rate 
of output on .short shifts; on tho beneficial influence of 
short rest pauses; and on tho importance of high illumina- 
tion in fine procc.sscs, an inquiry which had the additional 
advantago of leading to the adoption of .specially con- 
slructod glasses for tho relief of strain on the muscles of 
accommodation and convergence in workers. 

The M’orh of the Board. 

Tho total number of reports issued by tho Board has 
now reached fifty, of which seven were published in 1927 
and four in tho early part of tho pre.scnt year. It is 
evident that a vast mass of information is being gathered 
from experiment and observation, from which tho worker 
of tho future should derive much benefit; These efforts 
should provide an antidote to tho callous unconcern for his 
employee’s welfare which is siqiposed to have. characterized 
tho nineteenth century indusfrialist; to tho advantage; it is 
to bo hoped, of tho worker’s body, without debilitating 

his moral fibre. t-, i- 

At tho end of tho present report tho Industrial Fatigue 
Research Board gives an interesting account of tho 
organization used in its investigations. Superi'ision of the 
various researches, ‘and strictly scientific criticism of tho 
work generally, have been assigned to four committees : for 
statistics, for physiology of muscular work, for industrial 
p.sychology, for physiology of vision. In the study of in- 
volved and complex problems it has been found advisable 
(without impairing tho authority of tho four main com- 
mittees) to assign immediate supervision to special com- 
mittees of experts-with representatives of other Government 
departments interested. Lastly, in important technical 
questions, which can only be dealt with satisfactorily by 
those having a complete knowledge of the' industry con- 
cerned the Board has been fortunate in always being able 
to co-opt on to tho appropriate conimittoo, or to add as 
members of additional temporary committees, represe^ita- 
tives of employers or workmen interested in tho industiy. 
Eight of these special committees arc in existence. The 
place of Professor E. H. Starling on tho Board has been 
filled by the appointment of Professor E. P. Cathcart, and 
Dr. C. G. Douglas has taken his place on the committee on 
physiology of muscular work. - 


LONDON AND COUNTIES MEDICAL PROTECTION 
SOCIETY. 

Axnuai. GENEit.ro Meeting. 

Tub annual general meeting of tho London and Counties 
Medical Protection Society was held at Victory House, 
Leicester Square, London, on June 13th. 

Sir John Rose BnAUFOUD, president of the society, who ryas 
in the chair, said that there had been contiiincd progress during 
tho year. Ono gratifying feature was the large accession ot 
new members. The society had added to its strength by IJoh, 
and of lliis number 706 had applied for membership within a 
year of their registration. It still remained true, of course, 
that a very large number of practitioners, to their great risk, 
did not belong to any defence society. The work of the 
society had increased in even larger proportion than the member- 
ship, partly as the result of the extreme fondness of the public 
for bringing actions or claims against medical men. These cases 


June 23, 192 S] 


IiEAD TETBA-ETHIIj IN MOTOR SPIRIT. 


r TiiKHrimin 107.2, 

LMedicxl Jour.Nit ^ 


sliovvod that doctors eouki not bo loo cnrcf.il in (I.o in-ccon ons 
tlicv -took, especially in tlieir initial rctnlionsliips wilU tlicir 
patients. Scarcely » avcck pas-sed without the society Ir.arniiiB 
of some pi'ococdmgs t.aken or threalened owing to alleged 
negligence or wrongful act on tlie part of the doctor. 

The annual report of the council Avas adopled, and Dr. C. m. 
I'Toek moved Iho re-election of Sir John Rose Bradford ns 
president: after a Irilmlc to the .services which Sir John had 
rendered to llie society, he associated iiimself with the remarks 
just made about litigation. The colossal damages originally 
awarded in the Harnett ease had opened the eyes of the man 
in the street to the possihility of getting olicap money. Were 
it not for tlio resolute nltiludc of the society in fighting any 
such case where there was a chance of success, litigation would 
he still more frequent. The resolution, which wa.s seconded hy 
Sir William Halo-White, was cArHed by general acclamalinii. 

The annual report of the council stated that the meinhership 
of the society on December 31st last wa.s 10,872. (The society 
includes qualified dental pmctitioncrSj (hough not at present 
those registered as “ Dentjst, 1921.”) 7’Jic number of applica- 
tions for advice and assistance during the year was 1,008. In 
the majority of ca«es satisfactory results weix* obtained without 
litigation, and the ro.sults of most of the cases whidi went on 
to litigation were also satisfactory. Tlie solicitors’ report con- 
tained some interesting short summaries of cases dealt with 
during the year; they slate that the general piddic has become 
more critical and far more inclined to make complaints and to 
bring charges against members of the medical and dental 
professions. This is dijctiy nttrihutahlc, in their opinion, to 
tlie national health insurance scheme, the wider cducatioir of 
the piddic, the effect on the public mind of some spectacular 
cases in the last few years, and the lurid publicity which has 
been given to them. The national health insurance scfieme, 
under which complaints may be made against in.surance jiracti- 
tiquers, has, in the solicitors* opinion, awakened u far more 
cntic.nl nnd litigious siiirit in llic gcncf.il lioclv of the Dritisli 
pulOic, and has provided, with hut little ri^k of es}>ense to the 
patient, a J'fudy method of finding real or imaginnn- gncvancc.s 
against individual practitioners. 


LEAD TETRA-ETHTL IN' HIOTOR SPIRIT. 

CoiiitrrTF.T. or iNQuruY, 

Titr, coniiuitt€o which, iiiidor the ch.'tiniiuii.shiii of .Sir 
Ftikdehick Miu.is, is inquiring' into the tiso of lend 
tetra-cthy! in Tiiotor spirit held a ftirllicr meeting oti June 
Mth,* when Dr. J. P. Luke of the United States Public 
He.olth Serrico doscrihed the investigation eonijileted in 
1926 hy a committee appointed under the auspices of tlio 
Federal Government; ho was himself in charge of the 
exiicrimental work. 

Amebicak rnisuc HEtent Evidence. 

P“Tose of the inwstigalion was 
tactiwp dangers, if any, were involved iu (he mann- 
was felt to(ra.cthyl in petrol. It 

would not 'it. °f eiperimcnts on animal suhiecU 

of persons suhieclea to’^Titomo^e^^to- TO 

tff’27 iLr' simiU^roups. ot 

There was working where such petrol was used, 

workinff on nrunmiil f consisting of men, sneli as those 

other lead llarards The 

was no foiindation 

the men usino- tin's e(I i*"* ^"oSeslion of a previous witness that 
and took enM-ial me carerully warned beforehand 

^Lodt. Te 1 li>'' ei^-pcnment was 

spnHng'The’’™^! Ses"and 

X^srerti" r ^ rrti, atd’. "rr;: 

examinatiin was maU°'?or tJie^^'^V 

chemical exami^tTon fo7leaa h^f”^ 7'' 

Frederick Willis, the wilncs^ Sid ?hnf s'' ' s? ''' 

laige Broun of mm, ill ,, thought, over a 

factors- index of lend f “creta furnished a satfs- 

been usino the lead nro\ 7’™™ "'bmb of the men liad 

_ isin, me lead product and which were the controls, and 

Ar!?!*;, .'ffdf'col*Joanm7of b^e been published in the 

Jane 15th (p. 1033). ' ' ^ ’'“I' <?■ and 


thus anv suhjeelive error on his part was ns far as possible ex- 
cluded. ’ In Ihe ve.-ult this carefid clinical examination revealed no 
casc.s of lead poisoning except in Die fifth group — those definitely 
cxpo‘' 0 (l to other lend haznrcls. Among Ihoso some ca'^o- v-ero 
found, and tlieir discovery f'Cemed to prove that the tc-slb for 
(oxic action wore adequate. Tiio pos-ibillty w'as al«o borne in 
mind that employee** in (ho garages where ethyl lead petrol liad 
heeii used might have siifTcrctl from slight symptoms and havo 
loft the oinploynient or perhaps the neighbourhood, so that Iho 
men rcinaiiiing were -selected individuals who had gained a sort 
of imimmily. A very thorough effort wa*. made to seek out any 
who had been cxpo*“?d and had afierw'nrds loft the place, but 
no ca<;cs wore di'^covered ^s:hich gave any ground for the supposi- 
tion that among cx-workers unnoticed effects miglit hai'c been 
forthcoming. Further, owing io the great publicity ' whicit had 
been given to this .subject in tlio States, any deleterious results, 
were ci-en more likely lo be reported lhan di'^cases ordinarily 
notifiable. 

The roncluRion of the American commilteo was lliat drivers 
of enr-s using ctliyJ ga.soline showed no definite signs of lead 
nb'orplioii after exposuivs approximating to two years, that 
employees in onlinarj- garages miglit show n certain amount of • 
evidence of lead absorption — possibly due, ns the witness aficr- 
wartis explained, (o lead from the paint on the cars or on tiic 
tvi*cs— as indicated by lead in the excreta and stipple cell.s in the 
Wood, nnd that men at garages and Nations where ethyl lead 
petrol was u^^mI showed n somewimi inn‘ca‘^d amount of apparent 
absorption and storage, but this effect was small as compared, 
witli the effect on wortei.s who were .subjected to other definite 
le.'id hazards. The committee was of opinion that ai pvc*.ent 
there were no ground^ for prohibiting the use of lead teira-ethyl 
in motor fuel, provided its dirtribulion and use were under proper 
ivg«la(iofi«^. Tlie comniittoc had suggested four sets of regulations 
— namely, for the manufacture and blending of the product, for 
its mixing witli gasoline, for distribution, and for use in garages, 
service station's, and repair shops. These regulations were only 
of an advisory character, ns the Federal Govemment had no power 
lo make binding regulations for indhidual industries, and, so far 
as he knew, only one State had adopted them. But the Ethyl. 
Gasoline Corporation had agreed with tlie Surgeon-.Gcncral that 
tl\c regulations regarding manufacture, mixing, and distribution 
.should be carried out; so far a.s fbe fourth set.n^as conri?rneri,‘ 
affecting the garages, there was no machinery for its enforcement, 
but it was issued a.' a warning to those concerned. 

The witness added that since this inquiry further investigation 
ou the men had l>cen made, nnd they showed little or iio more 
lead ill the excreta than Uicy did when first examined. They 
had now been under the^e conditions for four years. So far there 
was nothing to indicate that even in twenty yeai-s any more 
unfavourable result was likely to occur, la addition, certain’ 
private investigation*, ami ini'estigations by State medical officers 
iiad been carried out. ami liero again the results had been 
entirely negative. 

In reply to Sir George Buclmnau, the witness said Uiat he 
ivas a whole-lime medical officer in the Public Health Service, 
and if he had any bias it wa"^ (he natural bias of the officer 
who would have to be ” sliot at ” should any calamity occur. He 
did not think it was likely that there existed any ' unsuspected 
form of clirouic poisoning, as had been suggested to the com- 
mUlee. Any such cases would certainly have been broui^ht lo 
the notice of those responsible for (he inquiry, if only on account 
of the publicity given to the whole question in. the States and 
to ihe instructions given to health officers everywhere to maintain 
a watch for such cases. The U'=e of ethyl lead petrol had now 
spre.'id so widely in America that it would be difficult in fiuuie 
to get coiiti-oU— that is. to find garages where one could be sure 
that none of the product had been u^d. lu reply to Sir William' 
W illcox, he agreed tliat be liad not examined iljo urine in the 
c.ascs taken, but only the faeces; be believed that the excretion of 
lead through (he kidney ivas more uniform than through the liver 
and other oigans. Sir William Willcox also put it to the witness' 
that whei-e any toxic sul>stance was acting in verv small amounts 
it might be extremely difficult to detect its cumulative effecU, 
as instanced in the long unsuspected clFccts on aeroplane workers^ 
during the war, of the tetraehlorethane iu which the Cellulose was 
formerly dissolved. The witness, in reply to Professor Dixon, 
said that so far as industrial medicine was concerned public bealtli 
conliol ill the States was not so well centred or so uniform 
as in this country, but from ihe point of view of the notification 
of unusual cases of disease or iniury he thought there was no 
marked difference between the two administrations. 

Sir Charles Hlartiu rcfened to a suggestion made to the com- 
mittee that cases of poisoning had occurred in America' and had 
been liushed up and compensated by the important intererts 
concerned Dr. Eeake agreed tfiat Dial migl.t be conceh-able 'in 
Die individual manufacturing plant, but so far as people ivorkinB 
in garages were concerned notbing of the kind could take nhre 
TIicsc people were in no wai- subject to control by tlie “ intere t ’> 
Industrial poisoning was compensated for bv law in 
wliicli bad a body of industrial legislation. ' 



,1074: June 23 , igiSl 


TUMOUE3 OP a?nE PRONTAIj r,OBE.' 


r - Tiir 

MroiciL JodixiA 


Britts!) JEetilcal journal. 


SAXUEDAT, JUNE 23kd, 1928. 


TUMOURS OF THE FRONTAL LOBE. 

The steady progress of neuro-surgery lins rendered the 
accurate localization of intracranial tumours n problem 
of urgent importance. As long as the surgeon could 
afford the patient merely a temporary reduction of his 
increased intracranial pressure by means of a cerebral 
decompression the precise localization of his tumour 
was of little more than academic interest. Modern 
surgical developments, however, are effecting as com- 
plete a revolution in the outlook of cerebral surgery 
as occurred in the surgery of the abdomen some thirty 
years ago. Owing largely to the work of Cushing and 
his pupils, the immediate mortality of operation for 
intracranial tumour is steadily falling, and in the 
most skilled hands is now less than 10 per cent. At 
the same time the technique of cerebral .surgery is 
becoming increasingly radical. In a progi'cssivcly 
larger number of eases the tumour is proving cap.able of 
removal. Histological studies indicate widely differing 
degi'ees of malignancy in the gliomas, many of which 
are slow-growing and relatively benign. Ilcmoval of 
such tumours may be expected to afford many years’ 
relief from symptoms, and the possibilities of post- 
operative treatment with radium are still almost un- 
explored. But it is obvious that improved neuro- 
surgical technique can offer its benefits only to a 
patient whose tumour has been accurately localized, 
lor, unlike the abdominal viscera, the cranial contents 
cannot be widely explored through a comparatively 
small incision. 

In _ view of^ these considerations any data which 
promise to facilitate localization are of value, especially 
in the case of growths in the so-called silent areas, and 
we publish in this issue articles bj' Dr. J. Purdon 
Martin and Dr. S. McCleraents dealing with the 
symptomatology of tumours of the frontal' lobes. 
Jirom the investigation of their cases certain facts 
emerge which are perhaps worthy of emphasis. Dr. 
klartin rightly lays_ stress upon the slightness of the 
classical signs of increased intracranial pressure in 
many cases of frontal lobe tumour. Increased know- 
ledge concerning the pathogenesis of these symptoms 
IS bringing with it a recognition that headache, 
vomiting, and ^papilloedema are by no means con- 
stantly present nor always - associated in cases of- 
cerebral tumour, and that- the presence or absence of 
these symptoms, taken in conjunction with the focal 
signs of the tumour, may have a certain looalizina 
value. Thus papilloedema, though rare with frontal 
tumours, is, as Paton showed, common with tumours 
of the temporo-sphenoidal lobe. Also swelling of the 
optic disc is usually an early sign of co-ebellar 
tumours, and in such cases attains considerable 
severity, while it is- often absent or late in appearing 
when the tumour is situated within the pons. The 
frequent absence of papilloedema therefore - distin- 
guishes a tumour of the frontal lobes from temporo- 
sphenoidal and cerebellar tumours, with both of which 
it may sometimes be confused. Vomiting, though 

ten described as a symptom of increased intracranial 


pro.ssuro, appears always to bo an indication that 
internal hj’droceplialus ' is present, and the frequent 
absence of vomiting in frontal lobe tumours is to bo 
attributed to the comparative remoteness of their 
situation from tlio ventricular and subarachnoid 
channels; licnce the unlikelihood tliat such tumours 
will cause obstruction to the circulation of tlie cerebro- 
spinal fluid until tlicy linve attained a largo size. 

Anollier point of practical importance which Dr. 
Martin mentions is that generalized convulsions 
occurred in all three of his patients, and constituted 
an early symptom in two, one of whom also had 
attacks of tlie character of petit mal. It is too little 
appreciated that an intracranial tumour not infre- 
quently gives rise to generalized epileptiform convul- 
sions without any focal or Jacksonian element, and 
that, more than any others, tumours situated in 
tlie frontal lobe arc prone to do so. Especially when 
generalized convulsions make their appearance for the 
first lime in a patient over the age of 20 the possibility 
that they may bo duo to a cerebral tumour should 
be considered. 

An important sign of frontal lobe lesions appears to 
have been absent in the cases now reported. This — 
tho grasp or grip rcflc.x-r-consists of an involuntary- 
flexion of the fingers in response to the moving 
contact of an object with the palm of the hand, 
especially with the cutaneous surface between the 
thumb and index finger. This phenomenon may 
bo discovered by the patient himself, who finds that 
lie is unable to withdraw objects from the band on the 
side opposite to .the lesion. The harder ho tries to 
pull away the object he is thus involuntarily grasping 
the more •firmly do his fingers gi'ip it. This remark- 
able reflex, which appears to be a regression to_ tho 
reflex grasping of the young infant, is present in a 
proportion of eases of tumour of tho frontal lobe, and 
appears to bo pathognomonic of a lesion in that 
situation. 

The mental changes wbicli so • often result from 
tumours involving one or otlier frontal lobe are of gi'oat 
importance in localization, and Dr. Ernest Sachs, iu 
a recent review of .tlie sjhnplomatology of these 
tumours, found them present in twenty-one out of 
twenty-five cases. He, like Dr. Martin, stresses the 
“ peculiar indifference " of these patients to their 
condition. That similar mental changes may be pro-’ 
duced by tumours in other situations is doubtless due 
to the fact that in such cases increased intracranial 
pressure impairs the function of the frontal lobes.. 
But then the signs of increased intracranial pressure 
are conspicuous, whereas when the mental impair- 
ment is due to a primary lesion of the frontal lobe 
these signs are slight or absent. 1 

Lastly, it should bo remembered that when clinical 
investigation yields an uncertain answer to the ques-. 
tion of the localization of cerebral tumour, we have in- 
ventriculograpliy ■ a valuable aid, of wiiich increasing' 
use is - being made. The injection of air into the 
cerebral ventricles allows alterations in their size, 
shape, and position due to the pressure of a tumour to 
be demonstrated radiographically. Tumours of the 
frontal lobe are'likely to cause deformity of the anterior 
horn of the homolateral ventricle, vath possibly a dis- 
placement of the opposite' anterior horn away from 
the tumour. Judging from the pathological reports, 
characteristic abnormalities would probably have been 
present in all three of Dr. Martin’s cases had 
ventriculograms been taken. Ventriculography is espe- 
cially useful when the clinical picture suggests that the 
tumour may be. either frontal or cerebellar, for the 



June 23 , 19 = 8 ] 


INTERPKETATION OF GASTKIC SYMPTOMS. 


r Tiir rnm^ 

jrri'icAt- JocRrAii 


1075 


cliaraclorisUc radiograpbio appearance of ilio latter 
is a gouoralizod’ distension of flic third and lateral 
ventricles, which can hardly occur as a result of a 
tumour of the fronl.al lobe. It must be added that 
both the injection of air within the ventricles and the 
interpretation of the' resulting radiograms arc prOr 
cedures requiring export knowledge, and vcntriculo- 
graphv should be performed only when cerebral 
decompression can subsequently be done without delay 
should the patient’s condition demand it. 


THE INTERPRETATION OF GASTRIC 
SYxMPTOMS. 

Apap.t from the typical syndromes presented by 
organic lesions of the oesophagus, stomach, and 
duodenum, very few symptoms or groups of symptoms 
are of much, value for the purpose of diagnosing dis- 
orders of the upper alimentary tract. Various names 
have been applied to diverse conditions thought to bo 
associated with "ahhormality of molilitj' or secretion in 
the stomach, bu't such terms ns " acid or hypersthenic 
dyspepsia ” and " flatulent dyspepsia ’’ are at best 
merely clonks for ignorance. That we are still 
very far from understanding this large group of , 
clinical conditions is evident, if only from the 
frequency with which they resist all forms of 
treatment. Indeed, from the point of view of 
cure it is far prefornblo to deal with a frank peptic 
ulcer than with some of the so-called dyspepsias. 
Numerous efforts have in the past been made to deter- 
mine the significance of symptoms which seemed to 
originate from the upper levels of the digestive tract. 
Notable among these attempts was the work of Head* 
towards the close of the last century on deep and 
referred pain, especiall}- that dealing with the dys- 
■ pepsias nccompnn 5 ’ing tjio various stages of phthisis. 
Mackenzie believed that* all visceral pain was referred, 
and cited the frequent occurrence of gastric pain in 
the region of the xiphisternum considerably above the 
actual level of the stomach. But the newer methods 
of e.xperiment erriployed by Cannon and Washburn 
and by Carlson, consisting in the investigation of 
pressure changes within a small clastic balloon at the 
end of a thin rubber tube introduced into the oeso- 
phagus or stomach, have necessitated the revision of 
older views. For example, the demonstration- bj' this 
method that pain in the upper part of the epigastrium 
often originates from the lower end of the oesophagus 
seriously weakens Mackenzie’s assumption I’cgarding 
the nature ''of such pain. ' - • 

Approaching the problem from its clinical aspect. 
Dr. Charles Bolton, in his Croonian Lectures (of 
which we gave a full abstract last week at page 1030), 
has analysed the position arid time of onset of pain 
in over one thousand cases of d 5 'spepsia. He 
described pyloric, cardiac, and oesophageal sjmdromes, 
the syrnptoms in each group depending upon undue 
irritability of th6_ rieurb-muscular mechanism in the 
wall of the viscus" or upon abnormalitj' of the gastric 
contents. In recent publications Bayne and Poulton" 
hnve amplified our rnodern conception of dyspeptic 
symptoms by an experimental investigation of pain, 
heartburn, nausea, “ sinking,” and hunger. For 
these experiments the patient was gi'adually accus- 
torned to the presence of a cylindrical balloon at 
^arlous levels in the upper alimentary tract; pressure 
changes wer e reco rded by water transmission to a 

; .‘Brain, 1896 , six, p. 153. . 

‘ Journ. Physiol.; 1927, xiii, p. a?, and 1928 ,- xv, p. 157.' ’ " 


smoked drum, and simultaneous records were kept of 
sensations experienced. These workers found that 
oesophageal pain was due to stretching of certain 
nerve-endings in the wall, and that such pain might be 
relieved cither bj' a peristaltic contraction relaxing the 
tension in the ivnll or by postural adaptation in- 
creasing the capacity of the visciis. Related also to 
the oesophagus is the sensation known as heartburn; 
this is 'associated with' peristaltic contractions of the 
organ and a rise of pressure ivif lu'n it. Heartburn may- 
be retrosternal, or epigastric, and in this connexion it 
may be mentioned that the position of an oesophageal 
lesion can often bo indicated with ease and accuracy 
by the patient. The sensation of nausea also is related 
to tension exercised on specific oesophageal nerve- 
endings, while (ho so-called ” sinking ” feeling is 
complctch- analogous, though arising from sensory 
nen'o endings in the lower part of the stomach. Local 
conditions of heat or cold produced by swalloiving 
liquids of varying temperature are capable of modifying 
'tone and activity in the oesophagus, as also may 
reflexes through the fifth nen-e or the cutaneous 
nerves supplying the sternal region. Pain is gener- 
ally accompanied by increased oesophageal tonus, and 
tho fact that the latter is diminished by counter- 
irritation probably accounts for the relief afforded by 
this therapeutic measure. In the upper abdomen pain 
is found to be commonly associated 3vith mo^^ements 
of the pyloric portion of the stomach, duodenum, or 
jejunum. Conversely, where postural tone is low, 
pain may accompany relaxation rather than contraction 
of tho muscular walls of the viscera. 

' These results may account in part for the spasmodic 
pain experienced in gastric or duodenal ulcer, and may 
in part also explain the more continuous discomfort 
so often felt in conditions of gastric atony as demon- 
strated by x-ray examination with the opaque meal. 
But it seems that there must bo some factor other 
than peristaltic contractions in the production of ulcer 
pain, since alkalis relieve it without inhibiting peri- 
stalsis. It may be that heightened tonus, as in other 
parts of the digestive tract, is responsible for the pain 
in this region. Hunger pains are referred by the 
majority of subjects to the lower and mid-sternal 
regions, but they were shown by Cannon and 'Y’ash- 
buriF to priginate from the contractions of the 
stomach, and also sometirnes' of the' lower end of the 
oesophagus occurring in conjunction -with increased 
tonus. These pains originate far ihore readily in the 
subjects of gastric or' duodenal ulcer than in normal 
individuals, a.fact 'which gives support to the view that 
the pain of peptic ulcer may he' more closely related 
to the postural tone of the affected organ than to active 
muscular contractions of its. walls. 


DAWSON WILLIAMS MEMORIAL. . ■ . . . 

Alij the subscribers to the Daxvson 'Williams Memorial 
Fund are inx'ited to attend a meeting to be. held at 
tho house of the Royal Society of Medicine (1, 'Wimpolo 
Street, W.l) on Tuesday, July 10th, at 5.30 p.m., to 
receive the treasurer’s report and decide on the form of 
the memorial. Tho Organizing Committee suggests that 
it should be a prize to be awarded ex-cry two or more years 
for the best xx'ork which had been done in pediatrics since* 
the previous award. The list, of subscribers will remain 
open until July 10th, and contributors are invited to send 
their cheques to the honorary treasurer. Sir StCIair 
Thomson (64, AVimpole Street, W.!) before that d.a'te 
when the list must be finally closed. ’ 

“Cannon: Bodily Changes- iti Fear,-Pam,'ani{Rage, 1915, p. 232 . .. 


1076 June 23, 19=8] 


DIPHTHERIA IMMUNIZATION. 


C TrtxKKmni , 
MfDICAL Jocsxit 


DIPHTHERIA IMMUNIZATION : THE QUEENSLAND 
FATALITIES. 

According to the correspomlent of the Times at C'ni)herra, 
the Commission appointed hy the Government of Aiistralia 
to inquire into the cause of tlio deaths of twelve children 
at Bundaherg, Queensland, in January, during an anti- 
diphtheria campaign, has now produced its roimid, whicli 
has been tabled in the House of Ropresoiitativcs. AYlien 
commenting previously on this fatality (February 4 th, 
p. 193 ) we suggested that it appeared likely that the pre- 
paration used for prophylactic inoculation was the toxin- 
antitoxin mixture; this is now shown to have been the case. 
The mortality is attributed definitely in the report to the 
absence in the sample used of tho antiseptic usually added 
to prevent the growth in the fluid of accidentally intro- 
duced micro-organisms; adverse comment is mado upon the. 
fact that there was no indication upon the bottle that the 
antiseptic was lacking. The Commission, which .admits 
that its conclusions arc based partly upon negalivo evi- 
dence, finds that pathogenic staph3-lococei wore' introduced 
somehow into the mixture, and all tho evidence is said to 
favour the view that living staphylococci wore the cause of 
the deaths. Tho way in which tho.so organisms ontored the 
mixture has not been defined with certainty; oontajiiina- 
tion of the In-podermic needle used may possiblv have 
occurred, or tho stajiliylococci mn\' have been air-borne. 
Tho absence of disinfectant from tho toxin-antitoxin 
mixture was intended ns a safeguard against such dis- 
sociation as has been known to follow the freezing and 
thawing of this prophylactic. The repeated use of such a 
preparation was obvioush- open to a danger which would not 
have existed had tho particular rubber-capped bottle been 
employed on only one occasion, as had been intended; tho 
absence of a label indicating that no antiseptic was present 
gave, however, the unfortunate impression that the mixture 
— apparently a culture medium for organisms — was safe- 
guarded from such contamination. The question, then, of 
tho advisability of using toxin-antitoxin in diphtheria 
prophylaxis does not arise, tho mortality at Bundaherg 
being accidental and having no real relation to tho compo- 
sition of the agent employed, Tliis point is important 
and should not be overlooked, since already erroneous 
deductions in this respect h.ave been drawn. Tho Commis- 
sion unhesitatingly lays the blame on tho absenco of an 
autiseirtic. Sir Neville Howse,' Slinister of Health, re- 
marked advisedly that such antidiphthorial inocuhation liad 
been used aU over the world without the procedure haviim 
been shown to be directly dangerous, and that this except 
tional fatality mdicated an unexpected complic.ation. He 
went further, and added that the action of the st.iphylo- 
eocci incriminated by tho evidence was so unusual that an 
extensive investigation would be made of the pathogenic 
possibilities of this group of bacteria. It is a mattw of 
common knowledge that staphylococci which in some past 
years were considered to have a very limited pathovenieity 
have latterly been shown to bo capable of causing wide 
spread and fatal morbid conditions. The unfortunato 
occurrence in Bundaherg is only ' another of h series of 
incidents all pointing in the saino direction. Apart 
from this, however, it is stated by the Times correspondent 
that the Queensland Health Department has been recom- 
mended by the Commission to .study the advisability of 
substituting toxoid (the Times report gives " antitoxin ” 
which is probably meant for “ anatoxine,” the confusing 
word used in French literature) or a similar modified 
immunizing agent for toxin-antito.xin. Reference has been 
made to this question on several occasions in our columns 
but it may bo mentioned again- that the emploj-ment of 
toxoid, and not toxin, in the mixture used in Fnjrland 
appears to afford a wide margin of safetv, provided that 
suitable antiseptic precautions arn tnt-on. 


I THE INTERNATIONAL CONFERENCE ON CANCER. 
Till; arrangements for the International C'onfereiice 0 
Cancer, organized by the British Empire Cancer Campaig 
for tho third week of Jidy in London, arc now practicall 
coniplcto. It promises to bo not only a large gatheriii| 
hut 0110 wliich may have f.ar-rcaching effects. The pn 
gramnio of disenssion.s and demonstrations planned is, 1 
say tho least, vciw comprehensive. On Jlonday, Juh" 16 t! 
tho inlornational and imperial delegates are to fie receive 
at Buckingham Palace by tho King, aiid iii the evening 1 
that tiny .Sir John Bland-Sutton, president of tho confe 
enco, give.s, with Ladi' Bland-Sutton, a reception at Broc 
Street. Tho business opens on tho Tuesday morning ; 
tho lloj-al Soriety of ^feelieino and in the assembly Ini 
of the adjacent College of Nursing. Tuesday and Thuisda 
niornings . are to bo devoted to • gener.al- discussions, an 
AYcdiiesday ami Fridaj" mornings to sectional meeting 
Tho principal general discus-sion is on the relative valiii 
of surgery and radiation in tho treatment of canci 
of the cervix uteri, rectum, breast, and buccal cavit; 
Dr. G. llegand, director of the Pasteur Laboratory at tl 
Paris Radium Institute, will contribute a general openin 
.address, and each branch of the subject will bo dealt wit 
sejiarately. .Another general discii.ssion will relate to tl 
etiology of cancer, to bo opened by Professor James Ewin 
of Cornell University, and this is to be followed by a thir 
on methods of treatment by chomothorajiv, with speci: 
referenco to lead, the opener being Professor Blair Bel 
On AYcdnesday and Friday mornings the confeience divide 
into its six .scction.s — namely, pathology, diagnosis, medi 
cine, surgerj-, radiologv’, and statistics and public health- 
under tho chairmanship respectively of Professor AA . £ 
Lazarus-Barlow, Sir Thomas Herder, Sir AA'iliiam Hah 
AA’hite, Sir Charlcs Gordon-AYatson, Professor Sidney Russ 
and Dr. F. E. Fremantle, M.P. In tho section on surgor 
the subjects to be discussed arc the classification and ti-eai 
ment of bono sarcoma, and, on tho second das-, tho earl 
recognition and treatment of cancer of the stomacli. Th 
sections of mcdicino and diagnosis unite in one moctiii 
for a discussion on some present-day medical aspects 0 
cancer, and, together with the patliologj- section, for a dis 
cu-ssioii on diagnostic methods. Tho radiologj- section is t 
cover the biological effect of radiimr and x rays, wit 
special reference to the factors of wave-length, intensity- 0 
radiation, and duration of exposure, and will also cousidc 
the effects of these agents on the blood, vascular, an 
lymphatic .systems, with special reference to malignau 
growths. The sections of pathology- and of statistics an 
public health combino for a discussion on occupationo 
cancer, and tho latter section is also ’to discuss gcographica 
and racial prevalence, and public action with regard to th 
disease. Tho afternoons aro to be devoted to demoustra 
tious at hospitals and research institutions. Among tlr 
institutions to be visited are tho Bland-Sutton Institute o 
Pathology and tho newly- opened Courtauld Institute 0 
Biochemistry at Middlesex Hospital, tho Royal College o 
Surgeons and its museum, St. Bai’tholomew’s, Guy’s, AYcst 
minster, St. Mark’s, and the Cancer Hospitals, the Liste; 
Institute, tho Radium Institute, and tho AYellcome Museun 
of Medical Science. Demonsti-atioiis, and in some place; 
lectures and operations, have been arranged. Tho out 
standing evening function is on AA^ednesday, when the Dido 
of York, President of the British Empire Cancer Campaign; 
will give a reception • at Lancaster House, St. Jiuuess 
About 0110 hundred delegates from European countries, 
the United States, and tho British Dominions have already 
intimated their intention of being present at tho con- 
foreuce, and tho list of these, with the much larger lis* 
of home delegates from the various hospitals and schools 
and public bodies, includes many names of national and 
international renown for work on cancer. Tlie official 


June 23 . 1928 ] 


THE EOTAE MEDICAE BENEVOLENT FUND. 


[ • Trrr nsmss 1077 

MrOtCAL JOCRNAt ■*-VI • 


Inngtingo.of tlio confcvciirc is Eiiglisli, but nrinngomont.<i ; 
have been ■ made for - tvaiislntions wbou desired. It is' 
intended aftcr\vards to arr.ange for tbe special publication ; 
of ns nuicb' of tbe prnrcedincs as is practicable. The; 
officers responsible, ndtlr the jirosident, foi this crent in. 
tho history of cancer research and control arc Mr. J. P. 
LocWiart-Mummory, chairman of the international con- 
ference committee' Jfr. Cecil Pmvntrce, chairman of the • 
escentivo snbeomriittee, and Sir Itichnvd Carton, honorary ' 
secretary. The offices, from ahich further details can be 
obtained, arc those of tbe Uritish Empire Cancer Campaign 
at 19, Bcrlceley Street, IV. 


THE ROYAL MEDICAL BENEVOLENT FUND. 

Tm: principal facts and rigurcs rebating to tho yenr’.s work 
of tho Itoyal Jlcdical Benevolent Fund were furnished in 
our report of the annual meeting in itlarch last (Journal, 
M.arch 31st, p. 564), but the annual report of the Fund 
for 1927 — the ninety-second to ho ptdilisbcd— which lias 
just come to hand, contains many other interesting details. 
It includes, for example, Bnmmaric.s of certain eases 
relieved bj’ the. Fund; some of these make very pathetic 
reading, but there is here and there — what must be very 
sustaining to the officers .and almoners — a vein of humour. 
Of the 150 jiages of this book, about 100 are occupied with 
tho list of individual and other subscriptions. It is 
gratifj'ing to note that the income for 1S27 was increased 
by £800 ns the result of allocations by the British Medical 
Association Charities Committee (as against £500 from this 
source in J926), and by £625 from the Medical lusuranco 
Agency, which has altogether contributed well over £5,000 
to tho Fund. The subscriptions and donations transmitted 
through tho British Medical Association have shown an 
almost consistent increase during tho last twenty years, 
and reached £1,271 in 1927. Certain Branches and 
Divisions of tho Association, one of them the hlalay.a 
Branch, also subscribed a total of £84, and a sum not far 
short of £250 came from medical societies and hospital 
staffs, and £225 from Panel Committees. This last is a 
growing source of revenue; five Panel Committees each 
subscribed twenty guineas or over. The Ijiverpool 
Cathedral collection on St. Luke’s Day re.sultod in £104 
for tho Fund. The historical retrospect shows that in tho 
first year of the society’s existence the income was £128; 
tho income Iasi year, for tho general fund, was £13,576, 
and, in addition, tho Guild, an invaluable auxiliary, had 
an income of £7,595; and as against the two cases relieved 
in 1 10 first year of operation, the number of grantees and 
annuitants is now over 600. With increased support from 
tlie profession at largo much more could be done for those 
applying to the Fund for help in their distress. 


. ACCIDENT SERVICES IN INDUSTRY. 
bEv-BRAi. points of some medical interest were brought ti 
Safety Congress, organized 53- tin 
ome Office and the National Safety First Association 
vhich was held in London on March 20th; a report o 
the proceedings has now been published.' Mr. E. J. Fox 
managing diicctor of the Stanton Ironworks Company 
Gscii 0 10 S3 stem eniplo3’ed 63' this concern for dealini 

1 1 acci cuts. Ambulance lioiises have been ostablishof 
at tho varions works, gnarries, and pits; first-aid boxe 
outside visitors are employed to keei 
n touch with men wlio have been invalided. Associatoi 
Rfl 1 4 -^^ service are tvo consulting surgeons, wlv 
1 ® t lem practicall3- every compensation ease 

oucl whose experience is available to tho men’s pane 
ctois in a consultative capacity. This facility. Mi 
"-as much appreciated by the local 'practi 
BefoiTiiig. to the staffing of tli o ambidanc 

Stalioacry Ofiico or Ihrougli any bootscller. 13S 


houses, ho insi.sicd on , tho importance of soenring 
tho bc.st possible por.sonnol — skilled trained hospital 
.nurses. To the early attention given in cases of injury 
at tho amhulanco houses is attributed tho substantial 
diminution which ha.s been recorded since their inaugura- 
tion in the mimlier of cases classified as serious. Another 
speaker expressed the opinion that it was futile to havo 
a safety organization without a well-equipped surgery, with 
whole-time attoudaiits, open throughout the hours of work 
in the factory. In the cstahlislimout which he represented 
they insisted that every inislm]), however slight, must ho at 
once reported to tiio surgery. Three years ago tlioy had 
discontinued entirely tlio use of fir.st-aid boxes previously, 
installed, and the result had licon an enormous decrease, 
in septic case.s. This, it will he agreed, is a significant 
ohservation. Sir Alfred Horhert, in a paper dealing with 
macliinc tool design from tho standpoint of safety, remarked 
that the oils, emulsions, or suds used on machine tools for 
cooling purposes in high-speed work seemed particularly 
prone to become contaminated 113' pyogenic bacteria, and 
workpeople exjioscd to contact with these fluids were vciy 
liable to develop boils. 


THE PRESENT POSITION OF PRE-IMMUNIZATION 
WITH B.C.G. 

Phe-immu.s'izatiox of infants hy tbe B.C.G. (Bacillus 
Calmcttc-Guerin) seems to have aroused but little interest- 
in this countiw-. It is different in other countries, where 
tlio tuberculosis problem is, perhaps, more acute. Thus, in 
a communication to tbe Academic do Medecino in Paris' 
Drs. J. Cantacnzeiio and Jonoscu Mibaicsti described- the 
results of tlio use of the inetliod in some of tlio poorer 
districts in Bnearest and some of tlio provincial towns in 
Bumania since the early months of 1826. It appears that 
tho inoculation of tlioir infants with B.C.G. was roadil3’ 
accepted by Rumanian parents, refusals being encountered 
in only about 2 per cent, of cases. In one town it is 
recorded that every child born was vaccinated. Bv tho 
end of last jMarch 6,083 infants had undergone the treat- 
ment in Bnearest, and 3,191 in provincial towns. Accord- 
ing to Drs. Cantaenzeno and Joposcu, tliero has been a 
.surprising reduction, not onh’ in the tuberculosis mortalit3% 
but also in tlio general mortality, amongst vaccinated 
infants under 1 3'ear of ago as compared with the mortality 
in tho non-vaccinated. Rates of 15, 24, and 26 per cent, 
in the latter are compared with rates of 5, 4.5, and 6.4 for 
infants who received B.C.G. The reduction applies to such 
diseases as bronebo-pneuraonia, in which the rate for tlio 
non-vaccinated is 5.5, while only 0.28 per cent, for the 
vaccinated, and “ congenital debility,” with the rate of 14.1 
as compared with 2.3. Tlio comparative death rates for 
vaccinated and non-vaccinated infants brought np in tuber- 
culous surroundings could not be obtained for the pro- 
vinces, but in Bnearest it was found that of 100 such 
infants 25 non-vaccinated died, and only 1 vaccinated. 
Tho observers regard the efficacy of B.C.G. as evident and 
its innocuousness as perfect. At tbe same .session of the 
Academio Professor Lignieres returned to his attack on 
Dr. Calmette’s belief in the liarmlessncss of tlie adminis- 
tration of B.C.G. to infants wlio are brought .up in non- 
tubercuious surroundings. Apparently Professor Lignieres 
produced no direct evidence in support of liis contention 
that harm arose from sucli administration, excejit that 
healthy inoculated calves sometimes bad a recrudescence 
of swelling at the site of injection, accompanied by a rise 
in temperature, and tliat some guinea-pig.s died unex- 
pectedly. In fact, tbe professor’s argument seemed to be 
that if a vaccinated child died of .any disease its end min-ht 
have been hastened by the Vaccination with a livTn" 
organism wliich was known to infect tlie Ivmpliatic 
S3-stcm. The other speakers at th o meeting contented 
i Bulletin de VAcademte dc Jledecine, May 15th, 19^9, 


1078 June 23, 1928] 


HARVEIAN SOCIETY OF LONDON. 


r The Cnm<R 
L ilrviCAL JotRxit 


tliemsolvos with jjoiiitiiig out that Professor Ligiiierc.s Jiad 
produced 110 evidence in sup])ort of this assumi)tion. Tlie 
chief defects in tlie ])rcsentation of their ease by Dr. 
Calmette and his supiiorters seem to he, first, the somewh.at 
startling assertion that ingestion of D.C.G. loads to a 
diminution, not only of tuberculosis, but also of general 
mortality; and secondly, the inadequacy, or worse, of their 
statistics. Those of Dr. Calmette were criticized in these 
columns by Pj-ofessor If.ajor Greenwood a few weeks 
ago.- The statistics of Dr. Jonesou are also unsatis- 
factorv, in that the general mortality of all children under 
1 year of age in Rumania is not stated. Jlorcover, it 
is astonishing to find that Dr. Jonescii is able to 
produce, as early as May 15th, statistics dealing «-ith 
infantile mortality and the use of R.C.G. up to the end of 
last March. Dr. Calmette claims to have discovered a 
method for the prevention of tuhcrculosis in the young 
which, if valid, might he described as epoch-making, llis 
discovPi 3 ' is considered worthv of much discu'-sion in the 
Academie dc Medecine in Pan's, and -this di.scu.ssion is 
usually laudatoiy of wh.at is rogaialed in h'ranco as an 
established truth. The method has been applied in ni.aiiy 
countries for the prevention of tuberculosis in cattle, and 
in soino counti ies to a less extent for the jire-iminnniza- 
tion of children. Fiom inanv of these countries cumnnini- 
cations have been made, .sometimes critical, at othci-s 
extolling the method. The British contribution to the 
discussion seems limited at present to criticism of Dr. 
Calmette's statistio, which are obviously defective. Jt 
would be interesting to learn whether anyone in this 
country has had experience of Dr. Calmette’.s method, and, 
if so, with what results. 


THE CORONER AGAIN. 

In an annotation on May 19th la.st (p. 864) dc.aling with an 
incident at an inque.st held by the coroner for South-Kast 
London we remarked that “ exomjition from the ncee.ssitv 
of attending before the coroner in future may be regarded 
tiom the personal aspect as a privilege rather than as a 
puni.shment.” A further incident has speedily justified this 
coininent. The body of a man who had committed suicide 
by cutting his throat was conveyed to the Lewisham 
Hospital. It was examined in the ambulance by one of 
the staff of that hospital, and sent on to the Lewisham 
mortuary. The doctor, giving evidence at the inque.st, was 
seriously blamed by the coroner for not having gone to the 
mortuary to examine the body there. On his stating that 
he thought such an examination was under the jurisdiction 
of the col oner, and that he had no directions to go there, 
the coroner exclaimed: “I have never heard such foolish 
words in my life from a medical man 1 The coroner is 
fortunate. Since, in the earlier case referred to, he had 
threatened pains and penalties to a-.doetor who -had been 
present at the examination of a body without his peniiis- 
sion, one can imagine what ho would have said in this 
case if the doctor had in fact made an examination 
without it. It is indeed difficult, on reading the account 
of the inquest in the Tioroutjh Kens of June 6 th, to seo 
how the medical witness was in any way at fault Ho 
had already testified that death was due to a lar'>-c throat 
woiuid, sloping downwards to the. right, deep, about, four 
inches long, and involving the larvnx and the jugular vein 
and that this was consistent with it being self-inflictcd” 
when the coroner told him, “ You don’t seem to know much 
about it,” and sent him to the niortuai-y. He returned 
tbiee-qnaitors of an hour later with the additional informa- 
tion that the “ section edges of the wound were rather 
raggecl.” This seems to have satisfied tl'.e coroner, who 
recorded his verdict; but medical witnesses, even in.tho' 
South-East London coroner’s court, have a right 'to be, 
tioatcd with court csv. . - ”• 

^ liriiitU Metlical Jonrtlai^ 31av 12 tli, p, 793 ^ ^ 


HARVEIAN SOCIETY OF LONDON. 

Tin; annual dinner of the I fa rveian .Society of Loudon was 
held at the Connaught Rooms on .June 14tb, with the 
President, Dr. Herbert French, in the chair. The medical 
guests included .Sir .John Rose Bradford, President of the 
Royal College of Physicians, .Sir E. Farqubar Buzzard, 
Regius Profe.ssnr of Medicine at Oxford, .Surgeon Vice- 
Admiral .A, Gaskcll, iMedical Director-General, R.X., 
Lieiit.-Geneial Sir Matlbcw r’ell, Director-General, A.M.S., 
Air Vice-Marshal Daviil Muiiro, Director of Aledical 
.Services, R.A.F., Sir AVilliam AVillcox, Sir .Tames Berry, 
President of the Roval Sordc-tv of Medicine, Sir. H. AV. 
Carson, Pre.sident of the' Medical .Society of Loudon, and 
the presiilents of several other medical societies. In pro- 
posing the toast of “ The Ilarveiau Secietr- ” Jlr. Carson 
rec.alled that it was within three vears of its ceiiteiiai’y, 
that it had in the past surviveil two veij- critical pcnoik 
for metlical societies, and that now, like 111 . 1113 - kindi-cd 
hollies, it was enjoying halcvon days of growing membership 
anil increasing prosperity. He jiaid a tribute to Mr. 
Buckston Browne, who, among other generous gifts, had 
endowed a ]irize in meniorv of his oiiK- son. In the 
cour.se Ilf his reply Dr. Herbert French announced that the 
socictr-’s membership was now 300 and its finance saund. 
The jire.sent llonrisbing condition he attributed to the 
keeniie.ss of the officers (more especially the treasurer, 
Dr. G. lie Bee Turtle) and to the iiarticipation of general 
practitioners in ever\- discussion. The Pre.sident adilMi 
that all those prc.sent that evening were the guests of one 
member who bad created a trust for the endowment of 
liiture dinners, and at his suggestion the health of this 
anonymous benefactor was toasted. Mr. C. AV. G. Bryan, 
viee-presiilent, welcomed tbe visilor.s in a witts- speech, 
and tbo Riglit Hon. Augustine Birrell, K.C., Surgeon 
Vice-Admiral’ A. Gaskcll, and Sir Henry Curtis-Bonnett, 
K.C., responded. Mi-, llirrell recalled that ho had s.at 
scores of times at the hospitable table of his old school- 
fellow Buckstone Browne, and chaffed previous speakers 
for omitting to mention the name of AVilliam Harvey at 
a dinner of the Harveian Society in the tercentenaiy year 
of the publication of Dc il/ofii Cordis cf Sanguinis, 
Speaking as a wi-itcr, he assured them that the circulation 
of his books quickened the circulation of an author’s 
blood. Admiral Gaskcll briefly expressed a .sailor’s feelings 
when put up to reply between two eminent law-yers, .and 
Sir Heni- 3 - Curtis-Bcnnett rounded off a cheerful evening 
with some topical allusions. 


THE INTERNATIONAL SOCIAL WELFARE FORTNIGHT 
IN PARIS. 

An International Social AA’elfare Fortnight will be opened 
in Paris on July 1st, and' four inqiortant combined 
, meetings w-ill attract a very large number of visitors. Tho 
i Frcncir Government is taking an active part in, aiTd is 
' helpino- to finance, this fortnight,' and the chairman of the 
executive is' a fornier Alinister of Health, M. Paul Strauss.- 
Tile mootings are: the? liiterhatioiial Housing and Toini 
Planning Congress, of which the secretary is Mr. H. 

' Chapman, 29, rue dc Sevigne, Paris ITT ; the International 

■ Congress on Statutory and A^oluntary Assistance, the secre- 
tary of which is M. George Rondel, 49, rue do Miioinesiul, 

■ Paris III ; the International Child AA’elfaro Congress, tho 
secretary of which is Dr. Lesago, 37, Avenue Victor 
Emiiiaiiucl HI, Paris AHII; and tho Iiiteriiational Con- 
fereiico oh Social AAMik, the .secretary of which is Dr. 
Rene Sand, The League of Re'd Cross Societies, 
2, Avenue Velasquez, Paris AHII. Among the subjects 
to be discussed at this last conference are social work ant 
public health; Dr. Kay jMenzics is among the vice- 
presidents, and Dr. C. J. Thomas will read a papci on 
sociill work and scliool hygiene. Special avrangemen 
have been made for reduced fares on tlie imilvays. 



.TUNH 23, 1928] -WORK AND BESPONSIBIDITIES OF THE PATHOLOGIST. _ 1079 


THE AVOlHv .VND HESPOKSl 131 IJTIES OF 
THE PATilOLOGlST. 

Siu Ukuxaki) Swi.siiuitY’.s Ai)i)itK.‘5K TO Tilt; Rr.sKAiicn 
Dkkknck Socir.TV. 

Tue SL'coml Stqilicn Pngol Mcinoi-ii\I Loclui o wos ddiverod 
at tlio annual meeting of tlio Hcseareli Defence Societj- on 
June IStli, bv Sir Beievaiid Si’n.smnn’, ivlio s|)oItc on “ 'j’Jie 
work and responsibilities of the iiatliologist.” 

At the outset Sir Bernard Spilslinry defined a pathologist 
ns a specialist in the study of the .seientifle asi>ecls of 
disease, including the essential cause, the changes, visible 
and iuicrosco])ieal, jirodneed, and the reactions provoke<l in 
the patient. Tlio groivth of scientific knowledge and of the 
laboratory method of investigation during tlio last Iift 3 ’ 
ycai-s had greatly increased the iiathologist’s labours anil 
Jiad brought about the division of the work between the 
pathologist (in the narrower sense of the term), the 
bacteriologist, and the chemist. 

Sir Bernard Spilsbuiw then gave a few illustrations of the 
achievements of pathoiogs- in the stmh- of the causes .and 
processes of disease. The first was what he called the 
“ romance ” of anthrax. This disease had been reeognizeil 
from very early times; the murrain of cattle recorded in 
Exodus was supposed to have been anthrax, fii the middle 
of the hast centurt- the observation was made that minute 
bodies were observed microsco|)ieally in the blood of animals 
sulTering from this dise.sse, and it was stated that the 
blood which contained these bodies would produce the 
disease when injected into the healthj' animal. The matter 
nas still in dispute when Koch, in 1876, then a eountrv 
practitioner in German\', devised a method of growing the 
oiganism outside the bodt* in broths aiul jellies, showed 
that these cultures liatl di.stinctive characters, and w.as able 
^ ropiodueo the disease in hcalth,v animals bv injection. 
Koch s proof of the cause of anthrax was utilized by 
Pasteur, rvho had alreadj- begun, his investigations on 
infectious disease, and ho developed a method of protecting 
animals against infection. He experimented witJi cultures 
of the anthrax bacillus until ho so reduced the vinilenco 
I '('joction of the attenuated cultures into tho 

icaltby animals, those animals developed protective powers 
which enabled them to resist sub.soquent injection of viru- 
lent organisms. Tlio result of tho widespread adoption of 
pio ectiie inoculation wa.s that the mortalitv in cattle .ajid 
Sheep from this cause had greatly dimini.shed; in France it 
had been reduced to onc-twoiitictli of what it was before 
inoculation methods were adopted. 

Another illustration was hydrophobia, where Pasteur 
tound that the A-inis Avas always present in tho siiiiial 

Id of rabbits used in experimciits, and that healthv 
from '‘Phil'Iy bo infected by injections made there- 

xrJfli l-oof* that -tlio A'inis lost its strength 

the wntil after a ti'mo it failed to reprodm-c 

ho advantage of tl!i^ fact, 

doc^ nrcl.t 1“*” "-bp liml been bitten by rabid 

rabbits ns'*^ spinal cord of the experimental 

ss, s “‘7"“' 1”" 

iiiYitm.ffnn- '■ i- P', 9^ iiicieasiiig virulence, thus 

to devdo®u The v"* u -•’•S”'‘-'rdi.sease had time 

in the pic+h . • pf this tioatnient carried out 

had boon tn re T '"arious pnrt.s of tho world 

ohhe patients treated! ^ I’®*’ ®®''t- 

in !lio Iirotoctivo poiver was resident 
of the serum 'of "eio treated by the injection 

against that ,mrf "1 '"■hich had been immunized 

been obtaino "l infection. Tho iniiiiiinizat.ion had 

containing the orgtinEin I'ritr"”"' T 

antliintorf ricocv,: bWSm o_i its specific toxin in carefully 
counteracted the’ t ^®.'’®'®1’®‘^ suhstaiice.s. w-hioh 

tions ef ce.., i \ ^''® '® most important applica- 

eWHv diplitheiia; it had been 

injection of the '"’ns gi'eatly reduced- by 

treatecf.tt an ‘eS 

infeHoi!! diagnose 

'nctious disease by the discovery of tlio organismsf but 


in some cases nlioroscopical e.samination of the suspected 
iimteriiil failed, and recourse bad to be made to animal 
oxperiniciif.s. In enrl3- nnd obscure c.a.ses of tuborciilo.sis, 
for example, to search for llie organism by iiiicroscoiiical 
ineaiis was liki' .searcliiiig for tlio needle in the lia3'stack. 
Ill .such c.a.ses- injection of su.spected material wa.s made 
ill tile gniiK'a-pig, wliicli after a time Avas killed, and if 
the tnberele baeillns had been at Avoik the eluiraeteristic 
eh.aiigos were found. Anotlicr difnciilt3- Avitli Avliieli tho 
pathologist had to eoiitcnd Avas that .some bacteria Avhich 
produced specific disease had their iiiiioc-oiit “ doubles,” 
and again it Avas animal expoi-imeiit AA-hich enabled tho 
prohleiii to he solved. 

A good deal of iiiisconeeption existed Avifh regard to 
niiiiiial inoculation. In tho A'ast iiiajoiity of cases the 
niiimnl suffered no wor.so effect at the time of introdiiction 
of tho iiiateriiiT than the soon forgotleii prick of. the 
h\-podennic needle. In some cases tho developniont of the 
disease led to sjiccdy death ; in others, as in tiihercnlosis, tho 
.Tiiinml Avotild prcsontl3' show slight sign.s of disease .sufficient 
to indicato that it .should he destroyed and its dead body 
oxnniiiied. It Avas only in a verA' small proportion of cases 
that serious- suffering in the sense of pain attended inocula- 
tion oxperinionts, and oa'oii then it Avas u.sually .shoi-t-livcd 
oAving to the rapid ]ii-ogi-oss of tho disease. 

.Sir Bernard Spilshiiiy then mentioned .some chemical 
prohlcnis Avhich Avero prc.scnted to tho pathologi.st, hoAv, 
for example, by nniinal ex|)erimoiit, tetra-chlor-ethanc Avas 
iiicriminateil as the liA'cr-damaging element in aeroplane 
“dope” dining tho war: also hoAv experimental methods, 
again on luiiimils, niforded tho information rcrjiiircd as 
to the h 3 -gienic measures to ho adopted in factories against 
poisoning by T.X.T. Again, tho experimental Avork 1)3' 
Dr. J. S. Haldane in connexion with c.arhon monoxide 
gas indicated the iiiochaiiism 1)3' Avhich this form of 
poisoning acted, and his experiments on mico demonstratod 
onco iiiitl for all the proper method of treating tho.se who 
Avere suffering fi-oiii its effects. 

Practieall3' the Avhole of hactoriological knowledge AA'as 
ha.sed upon expcrimentnl work — iiievitabl 3 ' so in the present 
state of affairs, for there wore no lueaiis of testing the 
suspected organism except 1 ) 3 ' tho reproduction of the 
disease in living animals. The same Avas true of the 
diagnosis of disease. Evci-a- pathologist who AAorked alone, 
ill a small hospital, found himself compelled to liaA-e a 
Home Office licence for vivisection if ho v.-as to do his 
duty to the patients in tho diagnosis of ohscure disease. 
For that reason, in recent 3 'ears, the number of licences 
granted to ])athologists all oA'or the couiitr3- had greatly 
iiiereascd. But chemical problems also required - animal 
experimentation in such matters — for example, as the tot- 
ing of HOAV drugs.’ The pathologist Ai-as a medical practi- 
tioner, Avho, like his clinical colleague, had to apply, his 
skill and kiioAvledge to the best adA'.Tntage on behalf of 
tho patients. He must aA'oid cn-or as far ns possible, and 
must employ exact methods, including, at present, animal 
experiment. The scientific adA'.mces of the last fifty yeai-s, 
A-eiy largely based oiT experiment, had gone far to" revolu- 
tionize the treatment of disease, so that there A’.'cre some 
di.sea.ses, foinierl 3 ' fampaiit, with AA'liieli the modern practi- 
tioner wius scarcely acquainted. If only our forcheai-s of last 
eeiitui'A* could see the work Avhich had been done in modern 
.science and medicine, Iioaa; they Avould exclaim at the 
ciioi inons amount of .suffering AA'hich, had the3’ possessed 
the knowledge in their daA’, Avoiild ha\’e been prcA'ented 1 


-iiiriri viscction rroiiaganda. 

In proposing a vote of thanks to Sir Beniaid Spilsburs' 
Lord Kxtit.sfoud read to tho meeting a, postcard whicl 
had been sent out to tho memhei-s of tho British Hnioi 
• for the Abolition of Vivisection. The postcard st.-ited tha1 
! the Govci-nment, having remoA-'ed the ban on the broad 

■ casting of controversial matter, tho British Bi-oadcastiur 
Corporation was iioav in a position to .-illow “ oiir side” 

.of the question of vivisection to he heard. But tliev Avould 
:douhtles.s only do .so if there Avas a sufficiently" stronn 
demand from the public Jrembers were therefore ur'r^d 

■ to write immediately to tlio -Director of Talk<. nsl-!,, l- 
to invito Dr. Hadwen to state the 

The postcard continued:. ” You «ced «ot°kTy’ tha^y^f a."; 


1080 June 23, 1928] 


SCOTTISH BOAUD OF HEALTH. 


[ 


Trr nniTTsa 
3lKt)IC.tL JoVAViA 


a member of the British Union.' Yonr letter will probably 
have more influence if the B.U.A.V. is not inentioned ” I 

Lord ICnntsford added tliat ho tlionght it a very regret- 
table action on the . part of the antiviviscctionists at 
Eastbourne tliat they should tiy to persuade jieople not 
to subscribe to hospitals which had a jiathologist on their 
staffs. It was impossible to treat patients projiorly without 
such service, and if a hospital had no pathologist on its 
staff it must simply apply to another hospital which had. 

At the business meeting of the Research Defence Society, 
which was presided over by Lord Lamington, one of the 
speakers was Mr. J. F. Peart, F.R.C.S., formerly a member 
of the staff of tho Battersea General (Anti-Vivisection) 
Hospital. Mr. Pe.\ht said that as a member of the staff 
of that hospital he had signed a declaration that ho would 
not assent to experiments on animals unless thoj’ were for 
the benefit of the animals concerned, and he had to under- 
take not to use any serums which had been prepared from 
living animals. He wished now to take tho opportunity 
of publicly recanting his' signature to that document, 
though he thought that he had “ whitewashed ” himself 
by the letter with which he accompanied it. On getting ,a 
case of tetanus into the hospital he found that ho was 
not allowed to use any antitetanio serum. He appealed to 
the chairman of the board. Lord Tenterdcu, who did 
eveiything in his power to help him to get round tho 
hospital statute, but in vain. Ho was forced to resort 
to using antitetanio serum surreptitiously. Ho felt very 
strongly that to send an accident case, which might bo 
tetanus, to that hospital was like sending it to its death. 


SCOTTISH BOARD OF HEALTH. 

ANNUAL REPORT.' 

The ninth annual report of the Scottish Board of Health, 
for the year 1927 , recently issued, deals comprchensivclv 
with many vital questions of administration. It is pointed 
out that this will probably be tho last report to be sub- 
mitted by the Board, in consequence of tho proposal before 
Parliament to establish in its place a Department of 
Health for Scotland. 

Housing. 

The year 1927 marked a record in the historj' of house nro- 
duction in Scotland, the total number of working-class houses 
erected having been 21,660; it is anticipated that these results 
v ill be equalled in 1928. As 10,000 houses have been estimated 
?o non ,''eq“irement in Scotland, it follows that neark- 

1^,000 liouses have been made available during 1927 towards 
the reduction of the housing shortage. The 2,000 steel houses 
mentioned in the last report were completed during the vear 
and readi y obt.ained tenants. Further houses of this tvprare 
being built on the Springboig site in the vicinitv of Glasgow 
During tlm year five improvement schemes for slum clearance 

of Aberdeen, Fort IVilliam 
Glasgow, and Kirkcaldy, while two Edinburgh schemes were 
under consideration at the end of the year. The nSer of 
houses to be closed was 11,935, and the schemes, wldXare to 
be carried out by the local authorities with the aid of a 50 ner 
cent, grant from the State, are under the inspection of an 
officer of the department. An Art rlp<;;.rno.i “peciion or an 

accommodation for agricultural workers ^received™thp^*R'^’"^ 
Assent in December 1926, and by December, 1927 schemes 
under this Act had been submitted bv sixtv tUi-oo i , 
rities and approved. ^ sixty-three local autho- 

PimiricATioN or Rivers. 

The problem of river pollution is stated to _ 

pressing each year; over 800 instances of river uolIiiHoo”^® 
Scotland liad been investigated. This situaHoo’^ u V 
brought about by the hasty methods of sewage dispo'saf avhirh 
avere adopted over a hundred years ago. The Srt ^ 

the history of the different methods of seavage purifiLtion wWch 
have been introduced from time to time in more recent ve-irT 
and summarizes the conclusions avhich were reached bv tb 
Royal Commission on Sewage Disposal that sat from 1901 
1915. It IS intimated that, avith the concurrence of The^ Seerl 
tary of State for Scotland, an advisory committee of 
members, representative of all tlie interests concerned in Ihe 
pioblcm of preventing river pollution, has been appointed to 
polYuUon.'' ""'‘■'sures desirable fw reducing 

T 11 aooc Diseases. 

death rYe-ToO^eVLo-o^otr aT/otni- VtS^^^ 


the same figure ayas repealed for 1927; fhe expected continued 
fall ava.s not realized, avliilc the iiiilnioiiary death rate actually 
rese from 69 to 71. An investigation was made of the treat- 
ment of tiiberciilmi.s cases by the .lluppel antituberculosis 
.serum (osmoserin). 9'lierc ava.s no evidence that the serum 
exerted a heneficial act ion in ea.ses of noii-piihnoiiarv tuber- 
culosis, aUliuiigli it proved, on the whole, to bo an innocuous 
.agent. With regard to venereal diseases, the report dnaws 
attention to the iinporl.ancc of education, hoth for the public 
and for medical atiidenis and practitioners, in this matter. 
The provision of facilities for treatment in Scotland may ho 
reg.ardcd as rcasonahly complete. Attention is drawn to the 
innwirt.ant arriirigemeiits made hy varioii.s local aiitlioritics of 
combining to cst.ablisli ceiifrc.s or to utilize tliosc cst.abli.sbed in 
central towns. Tlie report .slates that, with very few excep- 
tions, the records kept in the Seottisli clinics "arc of liigli 
excellence. Complaints are from time to time received from 
various centres regarding iialicnts svlio b.avc received inefficient 
private treatment at a stage while disease is still in a curable 
form, and tlie report emphasizes the necessity for training 
mcdie.al students so that they may be able to treat the ordinary 
forms of these diseases with confidence and efficiency. The 
minilicr of patients treated at venereal disease centres during 
tlie year ended May, 1927, was 24,751, including 13,976 new 
palioiits, while llic total miniber of allendaiicos w.-is 397,611; 
tile total cost of tlie scbeincs was £76,000, of wliicli threc- 
foiirllis was paid nut of imperial taxation and onc-foiirtli by 
local rating. Willi regard to oilier infectious diseases, there 
svorc 155 C.SSCS of .small pox in Scotland during 1927, the largest 
number in any year since 1920. All these cases occurred in 
Dundee or liad hocii infected from a source in this town. 
Tlic disease was of a mild type, and all cases recovered. There 
was a considerahlc reduction in the niimhcr of cases of measles 
reported from the sixteen principal towns of Scotland, hut 
this w.ss coimlcrbnlancod hy a rise in the miniber of c.sses of 
wliooping-coiigli. Dipbtlicria sliowcd 7,548 cases in 1927, as 
coinnared with 6,021 in 1926, but scarlet fever showed only 10,609 
cases in 1927, as compared with 13,667 in 1926. Tlie practice of 
tc.sling persons for susceptibility to scarlet .fever and to dipli- 
tberia; and of imimmiziiig susceptible persons ngai list these 
disca.scs, contimied to .spread. It is pointed out that general 
practitioners who desire to immiiiiizo cases against these 
!lise.ascs should collect them and inject a number at one time, 
bec.iuso the material for immuiiizalion very rapidly deteriorates. 
Tho onthreak of influenza in Scotland during Jamiarj , 1927, 
and the subsequent months was the severest since 1924, although 
the disease was of a milder type than in the earlier year. 
Cases of encephalitis lethargica notified in the sixteen principal 
towns showed a considerable fall— from 260 m 19-6 to po 
1927* cases ai)poave(l in a sjKn’adic manner, witnont any 
outbreak of eonsidorable dimonsions. Manv cases, however, 
aro very .slight, and do not secure medical recognition .yid 
official iiolification. The problem of dealing with c.asp m the 
later stages lias given considerable anxiety. The parish council 
of Glasgow made ariangeiiicnts in 1925 for the accommodation 
of fifly"c.ascs in the iiospital at Stobbill, but the si nation wms 
nL"sa^isSor" as tlici!; was a waiting list of 
numbering 161. Some provision lias also been made hj the 
parish council of Aberdeen for the reception ° 
number. Infective jaundice, winch was made notifialilc in 
tho Lotliians in February, 19^, wlien 19 “"‘jS 

and wliicb liad subsequently been made notifiaWe t irougbout 
Scotland, with a notification of 52 cases in 1925 and 27 cases 
in 1926, produced only 1 notification in 1927. The results of 
a soecial investigation of Scottish cases carried out by Dr. 
George Buchanan have been published by the Medical Research 
Council. It has been confirmed that tlie rat acted as an animal 
reservoir of tho spirocliaeto. but it has also been discovered 
that the organism c.xists in fungal slime banging from the root 
of certain coal mines and 1)^ !!!“!. of 



parts of Scotland made infection with malaria a definite P?!''’: 
bility. The total number of cases qf infectious disease notinea 


in 1926 in the counties, with a total popu ation of was 

17.549, while in the burghs, with a population of 3,3UU,UUU, me 
corresponding number was 51,012. Tiieso are analysed m an 
appendix to the report. ^ 

Co-operation in Hospital Services. 

The report points out that there are in Scotland 25,000 Peas 
for the hospital treatment of sick persons, excluding 
disease and hospitals provided by Government depar - 'j 
Of these 9,000 are in voluntary hospitals, 10,000 ^ 

by .public health local authorities, and 6,000 are in Poor li« 
hospitals or buildings. Voluntary authorities t ’ 

general hospitals, of which 26 have more than 100 beds, wi 
local authorities maintain 230 hospitals, of which 23 have 
than 100 beds, and in ten cases Poor Law hospitals 
100 beds. The six great - teaching hospitals associated 


JDNF. 13. 19=3] 


SCOTTISH BOABD OF HEAIiTn. 


r . Titn n«m%0 : , infll 

L Str.nicAt Jocn.vAL A vOX 


ineKlical -sclwols provide more tlian n tliird of tlio yoluyliirj 
liospital accommodation in Scotland; 'I he prtmarj; duty of the 
local anthorilv in the provision of hospital beds is the oblipa- 
tion to maintain hospitals for infections diseases, and tiio 
accommodation for tuberculosis alone accounts for A.Otra beds, 
of whicli Uic greater number have been provided m Hio las', 
ftftecu years. The Mackenzie Committee of the Board of Ilcaltli 
reported that the additional bods required for voluntarf 
hospitals amounted to 3,600/ vrhilc the defect of the Poor I*a>v 
provision was more a matter of inadequato standard than of 
numbers of ■ beds. ‘Abordceit Parish Council has handed^ its 
hospitals over to the public UealtK local autboritios for adminis- 
tration, and these have been brouplit into relation with the 
teaching school of Aberdeen. Kdinburgh Parish Council lias 
under consideration the reorganization of its hospital provisiorij 
with the intciition of providing a service of high quality. The 
report points out that there arc numerous ^vunls of contact 
between (ho hospitals of different categories, and that there 
is nothing that ouglit to differentiate (heir funrtionj ns recent 
c.vamples the • new infirmaries at Stirling and Falkirk are 
pointed out; both provide bods for niateniity eases and for 
venereal disease, by agTccment ^Yilh the local authorities of 
the areas served. liirntion is made of the .scheme under which 
llic Gl.asgow Parish Council, in its hospital at Stobliill, makes 
available a considerable numlior of beds lo the Glasgow 
2ilatcrnity Hospital for confinements; these are regarded as 
being an integral part of tbe latter institution. A pmcHce 
which has grown up whereby iiulividual members of tlie teach- 
ing staffs of the medical schools are employed in outlying 
hospita^ has important results in keeping the standard of .such 
hospitals in line with the host modern pi-aclice. Any effort, 
the report concludes, towards a heller integral tun of the 
hospital service in an area must take into account iFie medical 
centre towards wliich these service.s are orientated: grouping 
should be considered in relation to the nfjpropnatc medical 
centre^ rather than to territorial divisions, siuli as c^otmty 
boundaries. On the invilnlion of •the Secn^tary of Slate for 
Scotland a liaison commilteo of siv representatives of vohiti* 
Inry hospitahs has been nptKiintcd lo keep the department in 
touch with voluntary hospital opinion in the five regions grouped 
round medical schools into whicii Scotland is naturally divided- 

^Iaternttv SF.nvicn axd Child WEtrvnE. 

By the end of 1927 schemes of maternity service and child 
welfare were in operation in areas representing 93 per cent, of 
the total population of Scotland. The minimum provision f>f 
anj; approved scheme included home visitation by a health 
visitor; in many eases tlie part-time services of the district 
nurse .have been utilized for this purpose. The number of 
ytsitors employed by local autlioritios ui 1927 was 136 
whole-time and 450 part-time, equivalent in all to 230 wholc- 
light inslallatiotis had Ikk^ii approved 
at 23 centres for the treatment of mothers, and children under 
o years of nge- Much anto-natal work had been done, and 
tlie experience of the 10 ante-natal clinics in Glasgow is quoted 
wner^ during 1927, the primary attendances numbered 5,983. 
ine Board of Health, considering that an important factor in 
the reduction of maternal mortality in Scotland was the pro- 
vision of trained nurses wuth specialized midwifery training. 

0 ered a grant of £20 per nurse to assist trained nurses to 

® certificate of the Central iHidwives Board, this 
^ emg conditional on tlie nurse undertaking to serve two 
3cars in bcotland on maternity work. Thirtv-niuc applications 
.^'Pproved during the year. The number of practising 
1007 ou March 31st, 1927, was 4,250. During 

Tion ’ Scotland through diseases of pieg- 

1 nm ^■cP^esciitiug a dcatli rate of 6.4 per 

^ fhis year being the same as the 

Ilnf 'fi ^ ^ years, notwithstanding the fact 

infantile mortnlitv were both 
in^n 96.669 births ivere registered in 
compared with 20-9 for 
children -imder 1 year of age who 
of fiq ^ infantile mortalitv rate 

5 f Tlie pre-school child under 

7.3 per cent, of the total 
TPBr rra\ ^ Hd the death rate in this age gi’oup during the 
year gave a rate of 11 per I^OOO, the same as for 1926, or 
Out nf ratra of the preceding ten years, 

dun In n 4,103 in tin's age group 1,095 were 

4 monia, 434 to measles, and 393 to whooping-cough, 

ritip? fn,. °.t ^0,000 was distributed to local autKo- 

the nnr.t specific putposc of Securing greater efficiency in 
oceorriTur'^*' 'i^m of measles and wliooping-cough 

particul'fril" under 5 3-ears of age. This was secured 

ffiseases'tn\n ? Jarge number of cases of these 

in Scotland fre.-itmcnt. There were 26 day nurseries 

wluch ■ Were iu Glasgow, Edinburgh, and 
of the lano-o there was a large increase in attendance. Most 
g local authorities had developed arrangements for 


imitlicr-crafl classc.s and for short tour.scs of Iiealtli lectures 
and dcuioii.strations for women at their cliild welfare centre.s. 

PuEIUTni.tL SeI’SIS. 

Out of llic 622 maternal deatlis during 1927 in Scotland 184 
were duo to puerperal sepsis. This luimhcr. it is stated, giye.s 
no idea of the inorbidit3' resulting from thi.s disease, v.hieh 
ought, to be to a largo extent prevcnt.-iWe. The death rate of 
6 mothers per 1,000 births still remains much the same as 
it was a generation ago. The report considers poh'valent anti- 
slrcptococcal serum to he veiy u.sefiil as a preventive, lint 
up to the prc.scnt time the chief method of dealing with the 
problem has been lo encourage ante-natal supervision. Frequent 
snpcrvi.sion of pregnant women is regarded as an important 
dnt\- of tlic hcaUh visitor. Stafislic-s have shomi that in 
industrial areas there is an increasing tcndc-icv- to engage the 
services of a midwife rather than a doctor for c-nnfinements. 
and it is pointed out that, tlie midwife is prevented he- law 
from undertaking any nursing or other duties which are likeh- 
to make her a cavrieV of infection. . The report states that 
one of the most urgent requirements for a successful midwifers' 
.service is a great increase in the numher of beds available, 
althongh most local authorities have made some provision in 
this respect. 

Food Scvts-v. 

Much has been done under the Milk and Dairies (Scotland) 
Act, which c.ame into operation in September, 1925, to seciiic 
improvement in the milk siippK- of Scotland. It is recorded 
that, outbreaks of milk-horno infection continued to occur in 
1027. An outbreak of illness due to tlie Bacillus citfcritiilii 
Gacrtncr occurred in Dniulcc in October, and affeefed some 
200 persons, the outbreak being traced back to a cow suffering 
from mastitis of the same form which had, in the previous 
year, caused an outbreak involving 370 cases of the same 
nature. During 1927, 2,240 cows were dealt with nndcr the 
Tuberculosis Order, and it is considered that the removal of 
so mans- potential sources of infection must have had a great 
effect on the purity of milk supplies and on the health of the 
coraimmits-. The Sale of Food and Dnigs Act, 1927. has intro- 
duced some important regulations, and boric acid is now pro- 
hibited in all foods. 

CoNTIUDUTOTir PeN-SIOSS. 

The economic position of the people of Scotland has been 
greath- affected alread3- by the scheme of contributors- pensions. 
Tlio number of persons m respect of whom weekls- payanents 
are being made, including children, is estimated at over 1£0,000, 
equal to 3 per cent, of the population, or one person out of every 
tsveive insured. It was expected tliat in Scotland about Sl.COO 
persons would qtialifs- for an old age pension, pa3-able at 65 on 
the commencing das-.’januars- 2nd, 19^. ’ • . . . 

Xatioxae Healtii Insuran'CC. 

Dental benefit is said by the report to have improved b}' 
reason of the gratifs-ing reception from Scottish approved 
societies of the scale of dentists’ fees, conditions of semice, 
etc., prepared towards tlie close of 1926. This has been 
adopted hr- 67 societies and 331 brandies wiLli a total member- 
ship of over 1,200,000, or appro.ximateU- GO per cent, of tlie 
membcrsliip of Scottish units giving dental benefits. The funds 
allocated to ophthalmic benefit appear in general to hare been 
sufficient to proride grants to all claimants on the basis adopted 
b3- societies. The district medical officers hare been increas- 
ingly employed because the hcav3- claims experience of societies 
frequently made it desirable to .obtain second opinions on the 
condition of claimants for benefit. During the r-ear 34,558 
pci-spns were referred by societies to the district medical 
officers. AVliile women comprise onlr 33 per cent, of the 
insured population, they account for 57 per cent, of the refer- 
ences; during the year 40 per cent, of the women examined 
were pronounced to be c.apahle of work, as compared a-ith 
'03 per cent, of the men. Ont of the total numher of references 
.only 510, or 1.4 per cent., were made 03- practitioners, and 
surprise is expressed that greater advantage was not taken hr 
insurance practitioners of Uie facilities provided by the district 
medical service for obtaining, free of cost, second opinions in- 
cases which, may present difficnlt3-. During 1927 insurance 
committees reported twent3--fivc complaints against insurance 
practitioners bir- insured pei-sons or societies. Generaliv charges 
of neglect were found to be unsubstantiated, but in two cases 
fines of £10 and £50 were imposed. For charging fees to 
insured persons one practitioner was fined £5. One practi- 
tioner was fined £5 for failing to produce on request his records 
and other fines were imposed for failure to transmit the medical 
records of patients whose names had been removed from th 
lists of practitioners. Some 40 out of the 2,000 nractitione,-= 
in insnvance practice were surcharged on account of over-ure 
amount involved aggregating approximatelv 
£700. The surcharges had been imposed mainh- in respect 
ot unnecessary prescribing ot ftavoutW rrTara 

elaWatipn of ingredients! and rontme^Trex^”:.!^"^^ 
gredients where cneaper ingredients uere available. ^ 


1082 June 23, 1928] 


INDIA. 


C ‘ Tfir Cnmw 
MrntCAL JOCBKAI 





mEIilND. 


f Titr Bnmtn 1 OfiS 

LMtWCAl/JOClVSlt ivuu 


June 23, 102S] 


of tlio mbilical profession conld Ijo bvousUt to vcnliKo that 
ninny of tlio widows of tlicir former cnlloagucs are living 
in penury, that in some cases hunger Imunts tlic orphans, 
and that hrokon and infirm medical men lack the minor 
comforts which would tend to amcliorato their lot, tho 
apathy which exists towards the. work of tho Benevolent 
Bund year after year, noted in its reports, would vanish, 
and that tho society would receive, move general support. 
Thoso who know its work help it generously, but there is 
need for propaganda throughout tho land to gather in 
now supporters. Tho iei>ort irns adopted. Sir John 
'William Moore announced that Hfrs. Hepburn had left 
tho society a suhslautial legacy running into four figures. 

Health ol School Children In Northern Irclanl. 

Speaking at a meeting of tho North Antrim llogional ■ 
Education Committee, Dr. Patrick of tho klinistry of Homo 
Affairs said that in this area they had 5,000 school children 
on an average in attciulauco. It had hocii fouiul iu other 
areas that there had heen a verj* largo numher of minor 
ailments among these children which could easily ho 
renvedied onco tho necessity had heen hronght before the 
liarents. It was largely a matter of education, since when 
it was explained to tho people why Ihcso things were 
necessary the children would hcncrit. ’ It was found in other 
areas in N'orthern Ireland that about 50 per cent, of the 
children were suffering from defective teeth, and this was 
really the most pressing problem. Moreover, about 30 per 
cent, of the cliildreii were suffering from throat diseases — 
serious conditions which ought to bo remedied. Belwcon 
15 and 85 per cent, of tbo cbildren had bceit discovered to 
bo yerniiiious; from 3 to 6 per cent, certainly, possibly 
10 per cont., were suffering from minor defects of the eyes 
atid were not able to 'read tbo school books ; the parents 
did not realize os a rule that their children’s eyes wore 
defective. It was agreed to undertake tbo proliiiiinary 
inspection of cbildren, and for this purpo.so it was decided 
to arrange a conferonco with the dispensary doctors in tho 
district to settle terms. 


The Trafnfng and Examination of Nurses. 

• Dr. Edward Thompson, F.R.C.S.I., Omagh, in a recent 
couiinunicatioii to the press, refers to a Belfast iiewsiiaper 
report of tho observations made by some of the Lurgaii 
guardians about tbo failure of most of the probationer 
nurses trained in Belfast to pass their examination. Out 
of forty-two candidates only cigbtceu passed, and those 
were all being trained in Belfast institutions. Dr. 
Thompson states .that he is not surjirisod .at the faiiures, 
because some of the questions put would puzzle many 
qualified doctors and nurses. Ho quoted tlirec of these 
Bescribe the coronary heart circulation ; 

' / . ^bo internal secretion of the ovaries consist 

ot and wh^ has it on the other organs of the 

r i - 1 . • the cranial nerves and give their 

distribution. He had a record ot many btlier questions 
ir ^ probationer and senior nurses sent forward from. 
tJie lyrono County Hospital, but the examples he bad 
giien were enough to demonstrate the severity, of the 
examination these young girls bad to face. He .admitted 
hat the institution of these nursing councils had raised 
no standard of nursing, but there seemed a danger that 
If candidates were exposed to such exacting questions and 
lere were so many rejections, they would become dispirited 
3iiu tliGii nuiiibGrs Would bo greutly reduced* 

Dispensary Doctors and Midwives (Irish Free State). 

A letter with ■ reference to the duties of dispensary 
wedicai officers 3ias heen received hy the Clare Board of 
ealth, writing M’ith reference to an applicatiou from 
a ispensary- medical officer for payment of 8 guineas for 
ac mg as lociimtenent for the local niaternit 3 ' nurse, the 
1 inistor for Local Government stated that he presumed 
us claim- was in respect of the period during which the 
iiirse had heen on- holiday, and for which period tho 
DC or had agreed to do her dutjx Such claim, continued 
tT.'.fi- 1 entertained. A dispensary 

leal officer was responsible for the • treatment of sick 


poor ill his district, who wore entitled to gratuitous 
medical relief, and the services of a. midwife did not 
relievo tbo iiicdicnl officer of his responsibilitj-, but ivere 
placed at bis disposal to ciiublo him to release himself 
from tho necessity of attending ca.scs in which no difficulty 
arose. If tbo services of a niidwifo wore authorized for 
a dispensary district, niid sbo was not available, for any 
particular reason, to attend a patient, it was tbo duty of 
tho medical officer to attend such patient, or, if necessai^-, 
to requisition tbo assi.staiico officer to procuro tbo seiwices 
of a temporaiy midwife. 

St. Ultan’s Infant Hospital, Dublin. 

Tbo niiniml general meeting of St. 'Dltan’s Infant 
Hospital, Cliarlcmoiit Street, Dublin, was bold on Slay 
31st. Tbo report indicated the great progress made during 
tbo nine j-ears of its existence, and stress was laid by 
tho speakers on the importanco of the extern dcparlinent 
in a ]io.spital of this kind. During tbo past j'ear 4,210 
• patients under 5 bad been treated in this depai-tmont, 
in spito of tbo difficulty duo to. building operations; tho 
new wing, when completed, would provide much needed 
facilities. After tho meeting thoso present visited this 
new wing, now nchring completion. Tho gi’ound floor will 
bo oeciipicd by the out-patient department, which includes, 
among other special features, extensive accommodation 
for peranibiilators. On tbo upper floor there is a 
theatre block, a now diet kitchen, and small individual 
wards for premature infants opening on to a special 
balcony, Tlio new wing is glazed with ‘‘ vita ” glass, and 
last November tbo western windows of the main building 
were glazed similarly. This hospital, which was opened 
in 1919, admits to its wards no patient over 12 months 
ot age, and in this respect differs from all other hospitals 
in Ireland. 


aittr Maks. 

Welsh Board of Health. 

The Minister of Health has approved tho following 
arrangements for tho organization and conduct of the work 
of tho 'Welsh Board of Health, consequent upon the retire- 
ment next week of Sir Thomas Hughes from the public 
service. Tbo Board will liencofortli consist of three 
nicmbcis; Mr. John Rowland, C.B., Dr. Llewellyn 
AVilliams, and Sir. Howell E; James. Mr. Rowland and 
Dr. Llewellyn Williams will continue to exercise the fuiic- 
tioos heretofore assigned to them as Deputy Controller of 
Insurance and Sledical Slember of the Board respectively. 
Sir. Howell James will become a member of the Board, 
and will cease to be secretary and ex officio member of tbo 
Board. Sir. Rowland, as senior member of the Board, 
or, in his absence, the member next in seniorit 3 -, will 
preside at Board meetings. Sir. Rowland will succeed Sir 
Thomas Hughes as deputy for the Welsh member of the 
National Health Insurance Joint Committee. 

The Courtauld Institute of Bioch;niistr3'. 

A- description was given in our last issue (p. 1044) of 
tlio new Samuel Augustine Courtauld Institute of Bio- 
cliemistr 3 '' at Sliddlesex Hospital. The opening ceremony 
on June i4tli, at which Prince Arthur of Connaught pre- 
sided, was notable for the aniioiincemeiit of another 
generous gift by Sir. Courtauld of £20,000 for the mnin- 
tenanco of the Institute, in addition to the £40,000 he has 
already given for its construction and equipment. Sir. 
Courtauld explained that ho had heen led to make this 
gift partly by the recollection of a cottage hospital in 
Essex, started and maintained more than halt a century 
ago by his parents. As a small child he was taken to 
inspect the surgical instruments, which no doubt would 
bo judged antiquated to-day, kept under the care of a 
motherly nnrso equally antiquated. But another reason 
had prompted him to this gift— nanielv, that during liis 
business life the success be hud attained liad depeu'cled 
largely on the application of science to industry Very 



1084 ■ June 23, 1928] 


ENGIiiND AND WADES, 


/ Tnt IJRmts 
L'Memcil Joma ' 


often siidi research ended in failure, .soniclime.s in success, 
and sometimes in a negative! result, wliicli u'as still valuable 
because it nariowed the fieltl of fnrtber inquiry. ]fe bad 
a profound sense of the value of research, and lie quoted 
a lino from Virgil, “ b'clij; qiii poitui rcruux cognosrcrc 
cavsas, Clique mctu.i oiimcs ct iitexorahilc fciixnn Mthjccil 
pedihus," and added that perhaps one might say, more 
blessed still was he who iva.s enabled to hnow .something 
more of the .science of medicine and to overcome the ills 
of hnnianity which were due to pain and disease. Prince 
Arthur of Connaught, as chairman of jMiddlcscx Hospital, 
accepted the Institute on behalf of the hospital with 
appropriate expressions of gratitude, and Mr. Asher did 
the same on behalf of the medical school. The latter 
said that the building was linhed hj- a bridge and a suhwav 
to the Bland-Sutton Institute of Pathology, hut it was 
linked also by something much more substantial — the coi dial 
co-operation of the professors in the difi'erent dejiartments 
and the sjiirit of endcavonr which gave ])romisc of great 
achievement. Tlie Institute, said INIr. Ashci-j represenled 
almost a magical combination of the right moment, the 
right place, and the right design. In the course of the 
proceedings Sir Archibald Garrod gave an address on “ The 
place of hioehemisti-j- in medicine,” which we hope shortly 
to publish in full. A vote of thanks to the lecturer was 
spoken to by Sir John Dland-Sutton, who described him 
as the natural successor of William Prout and Henry 
Bence Jones, and by Professor Dodds, wlio said that after 
hearing Sir Archih.ald Garrod describe what had been 
accomplished by the old phj-sicians who had, in or near 
their consulting room, a shelf with a few bottles, a spirit- 
lamp, and some test-tubes with which to prove certain 
chemical e.xaminations, ho was appalled to think what 
would be expected of tlmt great institute of which tho 
shelf was the prototype. 


A Plea for Biologj'. 

The annual conference of education authorities, held 
recently at Bath, was noteworthy for a striking address by 
Professor Julian Huxley, in the. cottrso of which he made a 
strong plea for tho making of biology- a central subject in tho 
educational eurriculum. Biology, ho said, was just attain- 
ing its maturity. Each of the many branches of the subject 
now had it.s repercussions on every other branch. Since 
1800 groat strides forward had boon ‘made. The whole of the 
essential mechanism of heredity transmission had been dis- 
covered; also the essentials of that mysterimts problcjn 
the determination of sex. An enormous advance had been 
made in the study of the chemistry of life and its Ijcarin"- 
upon physiology and medicine, and innumerable gaps had 
been filled up in the study of evolution, especially from 
tie Gxaimnation of fossils’. The science of deveropinent 
had been lifted from what was a chaotic and rather' 
mj-sterious re,alni into something where at least <evtain 
principles ^uld be aiqireciated. The twentieth 
ccntur>, Piofessm; Huxley continued, seemed likely to be 
the century of biolo^- and its applications, as the pre- 
ceding century was the emitury of chemistry and physics 
and their applications He reminded his midiencl that 
many Government deimrtnients were clamouring for .trained- 
biologists to go into the Empire and take clnii-ire of work- 
in entomology,- agiiculture, fisheiies, animar breedimr 
various applications of biochemistry, as well as hyiriene 
and tropical medicine, this at a time when, in a'nnlied 
chemistry and engineering, the market was overstocked 
He stated further that the knowledge of biolon-y was 
becoming more and more necessary as a basis for citiEen* 
ship. To have a .sound and sensible judgement of sucli 
problems as population, the unfit, birth control and 
private and public health, it was necessary to have a 
loiowledge of the scientific principles which such problems 
involved — that is to say:, the biological sciences. Professor 
Huxley ’predicted that in another decade any reasonable 
and informed discussion of the political problems of the day 
would demand tlie biological liackground if the discussion 
W.as to be effective. He then went on to ask what the 
doing in respect to biology. The public 
saw largely because they found it neces- 

ou'to medicai’'5„.r saliolars who were going 

.>• In the secondaiy schools, however,- 


lie found very- little biology in tho inodern ■sense of. tl 
word; holiiny- and geology wore taught, and a few otlii 
siilijeeis, hilt tho intorconne.xion was not nindo jilain. Tl 
dilhctilty was to find space in tho ouriiculnm. l’hv.si( 
and chemistry, owing to their .siicce.ss during the ia: 
rjiiiirter of a century-, were standing in tin; way of hioloj 
finding its projier place, just as classics and history stoc 
ill Iho way of physics and chemistiy thirty- years ngi 
AVhat was wauled, .said Professor Hiixky, was genoi’i 
hiologieii] tcacliiiig for tho average child — not merely tl 
.selioinr.ship child — not dollops of botany and slices i 
geology, hiit biology as an interconnected whole. A bur 
of coal was geology-, botany, cheinisti-y-, and economic 
,Tlio hiiinan eve was phy-siology, phy-.sical optics, and evoh 
lion. Bacteria were botany-, clioinistry-, hygiene, .an 
ecology-. H’lieii he said that biology- mu.st ho a cciitn 
subject in education ho explained that ho did not nica 
that it .should ho the largc.st .subject, only- that it .shoul 
lie central in position, hocausc it was a subject whicli linkc 
up Ml many- others. It was tlie only link Ixitwccr. tl 
science of matter-^tlmt is, pliysics and chemistiy — and tt 
.seieiiee of mind — psychology; and it was the basis of agricii 
tiir.al, veterinary-, and iiieilical .sciences and sociology. Mi 
T. Dovedav, tlie vic-c-chaiiecllor of Bristol University-, wb 
presided on the otrasion of Pi-ofo-ssor Huxley’s lecture, sai 
that tlie iiuivorsitics were haring a surplusage of me 
who were tr.aiiied in mathematics, physics, and cliciiiistn 
and at Bristol every- opportunity- liad been taken t 
” orient ” men towards the biological sciences, in wide 
there were more ami more openings every year. 


Inquests in the City nnd Southwark. 

In Dr. E. J. IValdo’.s . annual report for 1927 it i 
.stated that 545 inquiries were hold in districts for whid 
be is coroner — namely, tlie City of Dmdon, includinj 
Hollowny Prison, and Southwark. Xceiupsies wore per 
formed "in all except twenty-seven cases. Of six hodic 
recovered from the river, five were identified by moan 
of the special City formalin preserving apparatus. Th 
notion of the fonnalin— apart from its disinfecting pro 

,,^.,•^ies is to render jircvionsly nnrccognizablo bodie 

reco'uiizahlo. Verdicts of death fiom suicide wore roturnei 
in twenty-fonr cases (19 males ,aiid_ 5 females). Tho oos^ 
of tlic inquests amounted to £794 in tho City, o'nd £65' 
in Southwark. It is noted that 63 fatalities wore dm 
to road vehicles, and that in 20 of these eases death wni 
caused hv commercial motor vans or lorries (all 11-1111011 
side guards, which are compulsoiy in the case of omni 
buses). Ono inquest only was hold on an infant acci 
dciitallv suffocated while' in bed with the parents; ii 
this instance there was no room for a cot or cradle 
Inquests were held in 21 cases of sudden deatli caused 
or accelerated, by the administration of anaesthetics 
necessary surgical operations. Ether was given in li 
cases, chloroform in 3, a mixture of chloroform ant 
ether in 1, gas and oxygen in 1, and in the romaiiiing 
case death was caused by an accidental overdose of carhor 
dioxide. A^^leroas, in former years, a largo majority- ol 
these deatlis were attributable to cldoroform or a mixtiirt 
containing chloroform, in recent ycai-s ether generally 
has taken the place of chloroform as a fatal factor in this 
class of case. The Coroners (Amendment) Act came intc 
full force on May 1st, 1927 ; ono result of the new Act 
has been to increase largely tho work and exqicnscs of the 
coroner in both tho City and Southwark. 

St. 'Mary’s Hospital Medical School. 

At tho presentation of prizes and awards by Lady Iveagh, 
M.P.,'at St. Mary-’s Hosiiital Medical School, on Juiio 14th, 
several references were made to Dio relations between the 
public and the medical schools. Tho dean. Dr. C. M- 
'Wilson, mentioned that Lord and Lady Iveagh have been 
for many y-ears associated with the work of Sir Aliiii-oth 
'Vl'^riglit, and said it was fitting that slie should be present 
when preparations were being made to build a permanent 
home for his department. They needed, he said, £100,000, 
and he reminded his hearers that not ono penny' that was 
contributed to the hospital was available for the school. 
Their fii-st contribution was £20,000 from an anonymous 
donor interested in Sir Almroth "Wright’s work; Sn 



aUNE I3i ’928] 


CORBESPONDENCE. 


r Tnr.Unmsn lORR 

(.MtlJiCAZ. JoC7tyiIr AVUO 


Almiolli’s committoo hnd promisoil llicin £20,000 subject 
to certain conditions, and tliey bad now £51,000 towards 
their fund, although they had hardly begun to ask for 
money. They wanted to convince public opinion that 
opportunity for medical education and rosenreU supported 
propbvlv was tlio best iiivestnient the nation could make. 
Liiuly iveagh said that tho public had no idea of their 
duty to medical education; many thought that in con- 
tributing to the voluntary hospitals they were contributing 
to tho medical schools. 

The Tuberculin Dispensary. 

The second annual report of tho Tuberculin Dispensai-y 
Benevolent Society states that work at tho dispensary 
at 32, Fitzroy Street, Fit/.roy Square, Loudon, W.l, 
has made steady and satisfactory jirogrcss, though 
not rapid enough to satisfy its jiroiiiotcrs. Kcforcnco 
is made to tho lack of snppoib hy medical prac- 
titioners, and attention is drawn to tho economic 
advantages of tuberculin tlierajiy, particularly in the 
case of tlio poorer patients, who arc able to remain 
at tlicir usual occupations while being treated. Increased 
funds nro required for tho dispensary, and regret is 
expressed that more support has not been forllieoiniiig from 
public authorities. Buviug tho year under review 110 
patients visited tho dispensary, but many were in too 
advanced a condition for treatment to bo undertaken 
hopefully. Fourteen cases wliicli had been diagnosed as 
having early signs of tuberculosis wero proved negative 
on testing. Dr. Camac IVilkinson niciitioiis with regret 
• that only in one iiistaiico was assistance received from any 
of tho friendly sociotics. Ho invites an unbiased and 
judicial investigation of tuhorciiliii trcalnicnb on tho lines 
employed at the dispensary. At tho annual meeting of tho 
Tuberculin Dispensary Benevolent Society it was agreed 
that stops sliould bo taken to tcriiiinnto its oxistcnco as 
a friendly society and to reconstitute it in its earlier form 
as an indopciidont tuberculin dispensary for tho poor. 

The Victoria Hospital for Children. 

Increased activity is recorded in tho annual report for 
1927 of tlio Victoria Hospital for Cliildrcn, Tito Street, 
Chelsea. Tho daily avCrago number of occupied beds 
was 105.22, against 89.13 in 1926," wliilo the number of 
diildren resident during tho year was 3,753 against 1,677 
in 1926. This incroaso has boon duo largely to tho fact 
that the now special ward, for tonsil and - adenoid cases 
was, for the first time, open tlivougliout tlio year. It is 
interesting to note that tho average cost per iii-paticnt 
per week has been reduced by over 4s. 6d. to £3 Is. 3Jd. 
In. the out-patient department tlio work done also showed 
some expansion; the numlicr of new patients was 12,338 
attendances 82,563, as compared with 
,163 imw patients and 75,029 attondaiicc.s in tho previous 
addition to tho hospital’s facilities, 
in the lovm of the artificial light cxten-sioii, which was 
opened early m 1927, brought about an iiicrcaso in the 
eraand 01 its .services. Tlio convalescent homo at Broad- 
staiis continues its useful work as an adjunct to the 
lospi al. In its finances the hospital has been faced 
with a deficit on the year’s working, the cost of mainton- 
?'IV above tho incoino for the year of 

’ ’ '"'J' there Was a bank overdraft at the close of 

le jeai of oyer £4,123. An appeal is iiiado for further 
annual subscriptions, and this report points out that 
specia 'I' ® involve additional expendituro and yield 
ua'ture " ' egarded as of a temporary 

. to Dr. Iris Fax. 

, is being raised to erect a permanent memorial 

bos who died from septicaemia 
oiitractcd in the course of her work at tho Royal Free 

career was published on 
j,, *’ 1926 (p. 222). It is intended that the 

mpnf “Seriated with tho pathological depart- 

ent at the Royal Fi-eo- Hospital, where Dr. Fox^ was 
exlmP pathologist at tho time of her death. The 

and Iho department is now under consideration, 

hoped that enough money may bo raised by the 


subscriptions of her friends and former students to build 
and equip a laboratory or librai-y for research, to hear 
lier name. Donations should bo made payable to tho “ Iris 
Fox Memorial Fund," and sent to bliss Lord Goodfcllow, 
lionorary secretary and treasurer, Flat 3; 28, John Street, 
Bedford Row, IV'.C.l. It' may bo added that in con- 
nexion with tho general appeal for funds for tlio extension 
of tlio pathological department a circular letter lias been 
addressed to past and • present students of tho London 
School of Medicine for Women, pointing out that support 
from tho general public is difficult to obtain since few 
ap])rcciatc tlio importanco of pathology or the extent to 
which it contributes to successful treatment. 


(Knrrcsijottilinrr. 


ABDOJfIXAL PAIX AS EXBJfPLIFIED,IN ACUTE 
APPEXDICl'TfS. 

Sin, — Under the heading of “ Research hy ohsevvation,” 
ill tho' Journal of May 26tli (p. 906), you make some 
pertinent editorial comments on a paper of mine in the 
same issue (p. 887) dealing with abdominal pain. In the 
course of tiie.se eommciits you montion certain observations 
which are difficult to reconcile with the observations and 
the thesis set forth in my paper, and I would ask your 
iiidulgcnco that I may deal with some of the points 
yon rai-so. 

You ask, “ Is muscular rigidity, familiar as a clinical 
sign of g.astvio and duodenal ulccrhtion, dependent on 
stimulation of tho [parietal] •peritoneum? ’’ In my expe- 
rieiico true reflo.x involuntary muscular rigidity, strictly 
coiiiparahlo with that found over an acutely inflamed 
appendix, is not a feature of gastric or duodenal ulcers, 
unle.ss there has been a slight leak from a pin-point per- 
foration, or perforation of an ulcer on the anterior wall 
is imminent, and I feel sure that where met with it does 
signify stimulation of tho parietal' peritoneum. But deep 
tenderness, a-ssociated with a slighter degree of muscular 
resistance or “ guarding,” is frequently present, and tlve 
evidence from the examination of theso ulcer cases under 
tho fluorescent screen is quite definite. The tender spot 
is almost invariably found over tho actual ulcer crater; 
Xow wo know that tlio stomach and duodenum are not 
.themselves tender on pressure, even though ulcerated. 
My conclusion is that when the radiologist elicits a tender 
spot on pressure over the ulcer ho is pressing the sensitive 
parietal peritoneum into a position in which it receives 
some dogroo of irritation from contact with the ulcerated 
area. In this connexion it should he remembered that 
Mackenzie’s observations on the areas of tenderness asso- 
ciated with gastric and duodenal ulcers were made before 
tho modern developments of radiological technique, whicli 
have altered so profoundly our conception of the anatomy 
of tho stomach in tho living patient. 

You also mention tho difficulty of muscular ri^^'iditv 
associated with tonic spasm of tho ureteral muscle” and 
of tho viscero-sensoi-y reflexes associated a-ith bladder and 
prostatic lesions. My paper was an attempt to establish 
the mechanism of paiii in the gastvo-intestinal tract, and 
I do not think that we are justified in arguing from the 
urinary system. There are certain fundamental diiforenoes 
between, tho two systems which invalidate any such argu- 
ment hy analogj’. One is that the bladder and prostate, 
unlike the gastro-intestinal tract, are very sensitive to 
direct mechanical stimulation, as any surgeon knows wlio 
has opened a bladder under local anaesthesia of the abdo- 
minal wall alone for suprapubic drainage and explored the 
upper surface of, tlio prostate and base of the bladder with 
his finger. Peuile-tip pain is at once felt. Another 
difference between .the urinary and gastro-intestinal tracts 
is the strictly extiaperitoneal position of the urii 


system. 


rinary 


Again, m reply to your mention of the viscero-sonsorv 
reflexes of cardiac disease, I believe that the argument 
by analogy from the cardio-vascular to the gastro-intestinal 
system IS dangerous and tends to confusion of thought 
Much of Mackeime’s theory with regard to ahdominaTSin 


1086 June 23, 1928] CORUESPONDENCE. 


[ 


The Dr.tnfli 
SfrciciL 3oiT.ru, 


was undoubtedly based on liis* observations of cast*s of 
augina aud aneurysm, and 1 suggest that this train of 
thougiit led him astray. ' 

Tile “ tenderness in tlio scalp i-clated ivith visceral 
stimuli in the whole vagus field ” is a phenonienoii with 
which 1 have only a textbook acquaintance. j\I_y lack 
of any clinical experience of it leads nic to helioye that 
it is a rare iilieuomeuon, and tliorefore not one on which 
an important physiological argument can lightly he based. 
I tried in my paper to argue from plicnoincna such as 
are met with in the routine clinical work of any general 
surgeon. 

In reference to the deep tenderness over an area of 
pleuritic inflammation you find a difficulty in the fact that 
with the outpouring of fluid this tenderness disapjiears, 
though it may be only up to the level of that fluid. 
I am bound to accept the pleural cavity ns germnno to 
the argument, since it is developed from the ))eritoneal 
cavity, but the fact that you mention seems to me not a 
difficulty but a confirmation of my thesis. As the fluiil 
collects it separates the visceral from the parietal idenra, 
and so stops the friction of the parietal pleura, which 
is the source, by plcuro-cutancous radiation, of the deep 
tenderness. 

A theory such as Mackenzie’s theory of referred pain 
uhen once it has become orthodox dies hard, and it is 
right that we should be very critical of ncu- and ])ossibly 
subversive doctrines. But 'if the unity of tbe gastro- 
intestinal tract be granted I feel confident that an unbiased 
study of the clinical and operative phenomena available 
will lead to the general conviction that we have been 
trusting to a theory of reflexes that doe.s darken coun.sel, 
and that the true mechanism of abdominal pain is simpler 
than Mackenzie believed. — I am, etc., 

Manchester, June 8th. JoUN JfonLKV. 


PATHOGEXESIS OF ACUTE PRIMARY GEAUCOMA. 

Sin, — Tlicre are one or two points in Mr. Uuke-KIdcr's 
letter (June 9th, p. 1000) which call f;or reply. He has 
mstaueed the wide differences of measuromeutj but those 
methods used for measuring capillary pressure which give 
high readings are open to the criticism that they stoj) tbe 
flow, jjrodueo banking up, and so measure the pre.ssure in 
the arteries — kinetic energj' of flow being converted into 
static energy. The least equivocal methods give the low 
readiug.s — for example, that of finding the counton-ailinir 
pressure which stops bleeding from a small cut in the 
finger, such a cut undoidrtedly severing arterioles as well 
as cajiillaries. Also the method of introducing a quartz 
micro-pipette into a branch of a capillary network, and 
finding the pressure which jirst prevents entry of blood 
coipuscles into the pipette. Ifoth these mcthod.s’ have been 
applied to human .skin. Landis introduced such a pipette 
into what he calls arterial capillaries fouiid in the 
mesentery of the frog. The.se are straight vc.ssel.s; usually 
unbranched, and like arterioles. He has measured th'e 
systolic picture by forcing a dye into the vessel. Now tbe 
pipette both occupies room in the vessel and obstructs 
flow, and banking up is produced by injection. The 
systolic pressure so measured is mucir too hiali ' but it 
comes into his calculation o! the average normal lateral 
pressure of the capillaries p also introduced the .Pipette 
mto a branch of a net of what he calls venous eapill.aries 
Tins would give a much more accurate reading, but not 
differeiitiatiiig one set of readings from the' other be idves 
to average of them all, aud this must therefore be too Iiieli 
His method of measuring the passage in or out bf fluid 
from a capillary is no less open to criticism, as shown in flie 
papers by J , McQueen and myself, which are aiipearinn- hi 

0/ Ax/icrhacn/nl 

One important factor generally left out of reckoninir is 
the counterbalancing pressure of the tissues. The capillary 
pressure can' rise to consideriiblc heights under eertaiu coii 
ditioiis, .such as obstruction of the veins, but as the tissues 
aio confined by membranes the tissue pressure rises con 
eoptantly. In the eye the pres.snre of the- hnnionrs 
TO inteibalances that of the minute vessels, and a very small 
excess suffices to maintain velocity of flow. If Uie 


fluid be let out and tbe abdomen bo conqircssed the iris 
Mvclls up, and the niinute'blood vc,s.scls, no longer siqqiortrd 
by the foiinterbalancing ))rc.ssurc, may bnf.st. Jn the 
kidney the fluid in the cajisulcs counterbalances the 
pre.ssure in the glomerular ca])illaric.s. 

. Tbo nu'thod which 1 use for incaKuring capillary prc.yuiro 
i.s the same as that used in measuring blood pressure in the 
arm by me.ans of the pneumatic cuff and inanoiiictcr, tho 
only dillerence being that the indices of cajiillary pressure 
arc observed luidei' the microscope. There is ahimdant 
proof that this mclhod is fairly accurate, and I a|)ply it to 
liiglier animals, .miie and bats, no Ic.ss than to frogs and 
loads. The lajiillary pre.ssuie in the minute capillaries of 
the fat in the mesentery of a mouse i.s lower than that 
in the big capillaries of a frog. — 1 am, etc., 

Ijonilen, N.U'.J, Jmu- ]8tli. Leox.MID HiLL, 


Sill. — Mr. IV. .S. Buke-Elder, in the opening paragraph 
of his letter (June 9th, p. 1000), states: 

“ I>r. Itanira.v Rtiegc.stcd iliat the evidence was in favour of the 
foiiimlion of this lltml by dialysis in the Kanie manner as the other 
tissue lliiids, and to this Dr. McQneen objects on two grounds: 
first, that there is not a Rnfiicieiit pressure in the capillaries of the 
eye to allow anch dialysation, and secondly, that the aqueous 
limnour is foirncd in quantity too great to be "accounted for in this 
way,” 


Mr. Bnke-KIder’.s pariqihrase of niy letter is quite an 
erioiicons one. I did not confuse filtration with dialysation. 

By filtration is meant the pas,sngo of fluid through a 
nicinhrane as a rc.snit of a difference of hydrostatic iircssnrc 
on the two sides. (IViiymonth Reid in Sehiifor’s Teribooh 
of I'by.iiojopt/, rol. i, p. 280.) Dialysation or dialysis does 
not imply n difforenee of hydrostatic pressure on two sides 
of a inemhranc. Krogh (1922) is ahso misquoted. 

Landis, in 1027 paper (Amcrienn Jouriiiil of I’hysinloyy, 
rol. Ixxxii, p. 217 cl seq.), which is the important paper 
dealing with passage of tissue fluids, never found how much 
the prv.ssure in the arterial capillaries” was ahovo the 
tissue jiressurc hccnuso .lie never measured the tissue 
jircssure. The osmotie pressure of tho tissue fluids in the 
frow would not bo oyereomo by 145 mm. of H„0 as stated 
hv'^Mr. DnkcUCldor. As regard, s tho suppos'ed ])ro.s.siiro 
g'radient of 22 to 28 mm. of Hg in the capillaries of tho 
eyeball, I did not argue from analogj’ solely, ns anyone rail 
see who rends iiiorc oi tho paragraph than lilr. Dukc-Eldcr 
qnotos. — -1 otc., 

1I.IC-OWC... June isih. James M. McQuef.v. 


THE FUTURE OF OBSTETRICS. 

Sill, In India little girls of 6 years old arc maiTicd 

to men of 40 years of age, and many little children join tlio 
cruel and awful ranks of widowhood before they have 
meii.strnated. This is done, and apjiroyed of, in the .sacictl 
name of religion. In England ineii and women arc allowed 
to qualify and try to peifoiiii tho most difficult operations 
in obstetrics in tiic most iiufayoiirahlo surroundings, after 
having completed at most two months of practical niid- 
Vvifery and after having delivered perhaps Ic.ss thaii ton 
casc.s. People can get used to and ap23rove, anything. 

Tho maternal 'death r.ato in, Siam is ten times as great 
as that of England (at least 40 per 1,000). The point I 
want to make is this : althoiigli every law of hygieiio 
is broken, although cloves and rags and filtby nails 
ai'o ’scra]ied around tlie vagina and sometimes even into 
tbe utcru.s, yet 950 out of 1,000 women siiryivo. The 
canyer.se is equally true. Because only 4 women out of every 
1,000 die ill England it does not mean that the other 996 
had a safe confinement. I. am firmly convinced that no 
woman who has to siihmit to any form of interference has as 
safe a confinement as possible. . Eveiy vaginal, examination 
is potentially dangerous, and they are absolutely unneces- 
sary in over 90 per cent, of all cases. It is jirccisely those 
cases of labour which are normal, or vary, but little from the 
normal, which require so many months of the student’s time 
to master, and which are so liable to lead him into excessive 
interference in his practice. 

The whole crux of tho matter is that tho student is prac- 
tically ignorant so far as midwifery, is concerned when he 



JUNE 23, 1928] 


OORRESPONDENCB, 


r Tnr.Tinxnm 10^7 
LafEDICXt JotJDVU. 


nvinVifies. Tt is liigli lime Unit overy unit of tlio mediral 
profession faced tlio facts am! insistol on a longer and inoro | 
]u-nclical course in oljstetrics. 11 will llicn Im realized that 
until aliout' tln-co times as many beds aro available for tlio 
iiistrucUou of medical st'ndouts tlio desired improvomont 
is impossible. The necessary hospitals might bo built by 
private companies, foi I am 'suro they could bo run at a 
profit, or they might bo obtainwl by tbo convejsion of exist- 
ing infirmaries. The important point is that tbo medical 
profession should bo unanimous in demanding that they 
should bo obtained and tliat tbo ridicidously inadequato 
training in obstetrics should bo recognized and altered. ' 

Fiohssor iHcflroy in your issno of ilfarcli 17 tli (p. 467 ) 
writes that “British midwifery is tlio admiration of the 
world.” I am sure sbo has adequate ovidenco for tliat 
statement. IVhntovcr it is tbo world admires it certainly 
is not the institutions, for wo have none that can compai’o 
with the admirable clinics of such places ns Leipzig, Berlin, 
or Vienna,, or even, ns far ns equipment goes, with tbo 
Government Hospital, Jlladras. I do not thinh that either 
wo ourselves or tbo world c.'in ndmiru our results or the 
amount of research worh carried out in Great Britain on 
obstetric subjects. I^ct us rather determine that British 
obstetrics slialt again bo tbo admiration of tlio world, ns it 
onc.o was. 

Wo spend enormous sums of money on cancer research 
which may or may not bo tbo means of s.sving lives. Shall 
we refuse to spend money in preventing the wastage of the 
mothers of England just becauso wo hnow the causes of 
their deaths and could prevent them? Tbo plain un- 
riirnishorl truth is that there is not tbo money, there aro 
not the institutions, and there arc therefore not the facili- 
ties for adequate instruction or clfectivc research. 

It is because Dr. Crossy, in his courteous reply (Jfarch 
10th, p. 412 ) to my letter published in your issue of 
Fobruai-y 18 th (p. 284 ), failed to answer my two questions 
that I have ventured to refer once again to what, I am 
suro, is tho root of our obstetric evils. — 1 am, etc., 

G. W. TireoiiAim, 

. Profossor of Obslrlrics aiul Gynaecology, 

Siam, May 22n(3. llant'kok. 


Mcdifnl Joiininl. ,Tuno 9 t 1 i, p. 974 ), describes normal cases, 
under skilled modern snpervi.sion, that have had morbid 
pnerperia, whilst Dr. James Young (p. 967 ) is so impressed 
bj’ the danger of grouping parturient women within four 
walls that bo urges that no maternity homo should bo 
without its isolation block. 

The.so facts taken together seem to show, as Dr. Y^oung 
himself suggests, that her own homo is the safest place in 
which a woman nmy ho confined, unless, perlmps, some 
exceptional difliciilty is anticipated. If fever should occur 
tho isolation difficulty does not arise, while if surgic.al inter- 
vention should hceomo necessary sho can ho moved to a 
hospital or nursing iiomo ns casiiy as from a maternity 
home. ■ - 

In a speech tho other d.ay the Minister' of Health pro- 
posed, in .addition to an increased number of maternity 
iioinos, ah “ improved ” training of niidwives. If by this 
bo meant that be hoped that in future all pupil midwives 
wotdd bo taught to make oul3’ rectal (instead of vaginal) 
examinations in normal cases, 1 think few will disagree. 
Blit' if it is proposed to add to their intellectual burden, 
then the results will certainly bo disappointing in more 
wa3's than one. 

Another not unimportant point arising out of Mr. Burt- 
AVbito’s paper is relative to the position of tbo practising 
midwife. At present tliore is a tendency at least to hint 
that a morbid ])iierpcn'nm is tho result of some failuro in 
her aseptic technique: in some instances .she is made to 
fool that sbo is sitting on the edge of a precipice over which 
the first “ temperature ” ma3’ push her. It is to bo hoped 
that one result of 3 Ir. Burt- White’s observations will bo 
genornl recognition that liowover skilful, however careful, 
and however conscieutions a midwife ma3' bo, untoward 
complications may appear, jnst as they do in surgical and 
medical practice, and that, when the3’ do, sho needs 
.S3unpnUiy and help rather than blariieT Moj-eovor, if an 
investigation is conducted in the spirit of helpfulness, she 
will be much more ready to assist than if sho feels that any 
ovidenco sho may give is likol3' to be used to her own 
disadvantage. — I am, etc., 

Syilonlinm, S.E., .Tuno IJtli. PE^-^•T. 


Stn, — In reference to tbo training of midwives and the 
cdiication of medical students in midwifery I wish to 
suggest that tho bigger midwifery schools should confine 
themselves to tho training of medical students and gradu- 
ates, and that the smaller midwifciy training schools 
should receive the pupil midwives. This would leave a 
much wider’ scope for tho belter education of medical 
students and doctors. I do not suppose there is one of us 
who, when called out as a A’ouiig graduato by n midwife 
for an omorgenc3’) did not regret at some time or other 
having had so little experience in his training school, both 
in ante-natal work and in deliveries. An abnormal case 
can bo made normal during the ante-natal period : .a iiornial 
case c.an be made abnormal during labour. Tho .adoption 
of nn- suggestion would mean that the borger schools, find- 
ing themselves short of nursing staff, would have to 
employ a gre.atcr number of staff nurses. A staff nurse’s 
post is equivalent to a post-certificate course to her. Thus, 
in effect, tlio larger schools would train medical students 
V’?^'fy'ug examination, and would provide 
doctors with post-graduate experience, and staff nurses 
with post-certificate experience. Tlio smaller .schools ivould 
train pupil niidwives for their certificate examination, — 
,I am, etc,, 

SliildleBbrough, June llth. G. H. GlFFEX DunDAS. 


PDERPERAL SEPSIS. 

Sm, ^It IS the universal experience that many a Sairc 
amp, with no knowledge of nail-brush or ly'sol, worJciu 
nuclei- tho least favourahle surroundings, has 3’et been abl 
to Sliow a spotless record. I myself can think of moi 
lan one such whoso cases “never go wrong.” TVe Icnov 
00, that it is common for difficult cases, attended li 
trauma ending oven in manual removal of the placenti 
comlucted m the most unsuitable surroundings, still to I 
0 owed by an uneventful convalescence. 

iuti". 5’® Bnvt-Wbite, in bis mo: 

icsting and, to m3- mind, important paper (Britis 


THE TREATiMEXT OF MALIGNANT DISEASE BY 
COLLOIDAL LEAD. 

Sir, — I cannot help thinking that Dr. 'IVA-ard has been 
ill advised to invito me to demonstrate fnrthci- and com- 
pleteK- the fntilit3’ of his work and report, which reflects 
not only on Iiimself, but inevitably also on the institution 
with which ho is connected, for ho states that the so-called 
investigation was a concerted effort in the Cancer Hos- 
pital. However, as ho is unwilling to accept . m3- “ cx 
cathedra statement,” wliich it was to bis advantage to 
do, I shall talco tho trouble, which I would rather have 
been spared, of exposing tbo full extent of his errors in 
respect of -tbo method of preparation of his so-called 
“ colloidal lead,” of which .lie says “ I . . . affirm that 
they are tho' same as those used iii Livorpool.” From Dr. 
■\Vv.ard’s accdniit of bis various methods the following 
points omerge. 

1 . Dr. IVAjard’s^ preparation rv.-is made b3- sparking ... in 
a medium of distilled water. Aftcrirards he added the gelatin 
and electrolytes. We Ep,ai-k in a medium containing the gelatin 
and clecli-oiy-tes. So far as one can say, without wasting the 
time' necessary to' investigate something which would be value- 
less to our work, a" heavy, direct current such as that which 
appears to have been used would produce in distilled water 
lead hydroxide and large- particles of metallic lead; there would 
certainly be v’ei-y little colloidal suspension of lead. It is of 
primary importance to spark in the medium containing gelatin. 
In this respect, therefore, the method empIo3-ed at the London 
Cancer Hospital is diametrically opposed to our own. 

2 . Dr. Wyai-d used isoelectric gelatin in some of his prepara- 
tions. This is acid, and would, therefore, lead to the foimatinn 
of lead -ion (Pb ++), the very thing the method is designed 

fn fivnul • 


9. liie preparation used by Dr Wyard at the London Cancer 
■Hospital does not appear to have been centrifuged ; conseouenflv 
It would conta.iy large particles of lead-partfdes’ Im-ge ^004 
to block capillanes-cspecially- when made as described ° 

S t,', z ? 


1088 June 23, -1928] 


CORRESPONDENCE. 


r Tnr T5rmsK 
LMrotcJit. JocBXiL 


of lead ion, which is toxic, and but little lead in colloidal 
foim. 

5. Dr. Wj’ar.d admits the addition of a reducing agent — pre- 
sumably sodium hydrosnlphite. Professor Dilling found this 
reducing agent caused the preparation to have a S]>ecial toxicity, 
and, therefore, it rvas not used by us. 

6. Animal investigations as to the toxicolngic.al and chorio- 
tropic properties of Dr. Wyavd’s preparations were not coi\- 
ducted. As to the toxicological effects, Dr. Wy.ard’s comiuents 
with reference to my colleague Professor Dilling make it 
appear that he has neither tlic conscience to care, nor the 
ability to appreciate, Professor Dilling’s gently convoyed rchidie 
to the effect that the sacrifice of a number of human livc.s is 
deplorable when information might have been gained, as 
Professor Dilling gained it, at the expense of two rabbits. 

7. ^yith regard to the question of “ shot ” — this word means, 
to a sportsman at any rate, shot used for shooting. Dr. \Yyard 
states that he used “ specially prepared lead ‘ shot.’ ” This is 
an " cx cathedra statement,” and, therefore, I am told by 
Dr. Wyard himself, is of no v.ahie. Iff were further intcrc.stcd. 
hut I am not, I should require him to go into dctail.s, and 
inform me of the maker. I had this in mind when I wrote my 
letter, but I did not think that even Dr. Wyard would ho 
so foolish as to go to so much trouble wlicn he could have 
obtained at once what we have always used — namely, “ granu- 
lated lead,” which is pure, and offers a larger surface than shot. 
To make sure, I telephoned to the manager of a large chemical 
firm, and w.as informed that, if asked for lend fhot he would 
always supply the commercial article used for .sporting |mr- 
po.ses. and, if asked for pitrc lead, ho would send “ gramil.iled 
lead.” Even in this mattei' Dr. Wy.ard has missed the point. 
It is, I a^ree, well known that “ commercial prei)aratioiis of 
lead contain a small percentage of arsenic ” as an impurity, 
hut it does not appear to be equally well known, even by 
Dr. Wyard, that arsenic is added to the alloy of antimony and 
lead from which shot are made. In whatever way Dr. M’yard 
proposes to get ont of this difficulty — and I hope he will not 
try to extricate himself — the fact will remain that alternatively 
he misled his readers by using the word ” shot " without 
qualification or even inverted commas, and he must, therefore, 
excuse my scepticism regarding the explanation he now gives. 

8. Lastly, since Dr. Wyard lias not received any colloidal lead 
from us, aud we have always used only that made licrc in the 
laboratories of my colleague Professor W. C. JI. Lewi.s. tlie 
assertion of Dr. Wyard that most of his ” doses were olilaincd 
from the source which was, and I believe is, supplying Professor 
Blair Bell himself,” is simpl}’ untrue. I suppose Dr. Wyard 
has inferred that we have used choriotrope supplied commercially 
by the British Collosol Co. This is not so. We have advised 
this company regarding the maniifactuie of this preparation, 
but have done no more than test it om-selves. 


I hope I have now finished with an analysis of Dr. 
.Wyard’s methods, and that he will not encourage me 
-further to waste time I can ill afford. I have felt it 
necessary for once to demonstrate clearly that when I 
•make an “ ex cathedra statement ” it is at least wise to 
suspect that there may be some foundation for it. In 
this case there were, apparently, six or seven foundations, 
all supplied by Dr. Wyard himself. 

^br- Duncan Fitsai’illiaius and I myself have demonstrated 
the absurdity of the clinical investigations condiictod at 
the London Cancer Hospital. 

If my lemaiks have been strongly* ivorded no one has 
regretted the necessity of forcible comment more than I. 
I have felt, however, that if I allowed to pass unnoticed, or 
to pass.with gentle irony, such a report as that of the Cancer 
Hospital, our work might stand condemned by default- 
for Dr. Wyavd’s conclusion — a conclusion endorsed I 
suppose, by his colleagues at the London Cancer Ho.sjiital 
- — of tho effect of lead on malignant di.sease, based on 
what I judged to be an almost unparalleled example of 
unsound work, was very- definite and unqualified. Manv 
wlio read such a paiier, aud were not conversant with the 
details involved, would natni-ally jump , to the conclusion 
that the matter was therein settled. I sineorely hope 
that we may he spared such baseless aud valueless criticism 
in the future. 


Sir. Fitzwilliams has very adequately e.xpressed what 
must have - been - the opinion concerning this -report of 
.those, who have knowledge . of . the methods, _.of. the dis- 
appointments and difficulties associated with it, and of 
the encouragement that is vouchsafed to ns from time to 
time; and Mr. PitzwilUams has, ciirionslv enough, inde- 

d" WrnLm mLo .^^“temeut similar to that uttered bv 
Dr. Wdham Mayo the early days of our work-namely. 


that to treat very advanced caso.s of cancer is tantamount 
to e.xjieeting niiraclos, not cures in tlie usual sense of 
tho word. 


T am glad to know, from the evidence received from 
Hritisli, eohiiiial, and foreign eliiiic.s, that the pro|ihecy 
of my friend Professor Carter AVood has not been entirely 
fulfilled. AA'hen he .saw the endless trouble und thought 
cxpoiuled on eiieli ease in Liverpool, he assui-od mo that 
no one else would get results eoiuparahlo with our own; 
and there was nnieli in what he said, for to-day, with our 
nnmorons patients, we find it dillienlt to bestow the same 
liewsonal cure on caeh, yet wo strive to do .so. Still, it 
is eviiloiit there was inueli truth in this prophecy, and 
with Jlr. Duiiean Fitzwilli.ams I feel that at the beginning 
of Kueli a tremendously diffieult jiroblom the results ob- 
tained will depeud largely on tho personality and sym- 
imllictic understanding of tho investigator. Is it not 
li'iie, indeed, that in tho results of oven wcll-estahli.shcd 
mi'cliauical iiroccdurcs, such as thyroidcctomv, ovcrrthiiig 
ch-peuds oil the iudividiinl operator? I have iu mind 
tho work of that mastor-surgcoii Crilc, with his twenty 
thyroidectomies iu a morning; his 10- to 15-ininutc, yet 
perfcel',' operations, and his mortality rate of 0.7 per cent. 
So with anll.sepsis and.' asepsis in tho early Listcrian 
period — ns flic kind of ninn, so tho result. 

It is only with patient, laborious work, and much 
stniiibling and confusion on the way 'that tho clicmo- 
tliernpciitical method — tho ideal choniothcrapoutieal method 
: — for the treatment of cancer will roach some degree of 
fool-iiroof certainly; it will never he infallible. AA'e know 
no prciiaration of load in use so far — and I suppose we 
ounsolvcs have tried about one hundred — that ai>proxinintcs 
to the ideal. Thus with our Icad-scIenium iircparat'ioiis 
wp have used stable, non-toxic materials made under 
Profe.ssor AV. C. M. Lewis’s direction. These were found 
to he no heftor than otlicr projinrntioiis tried in regard 
to choriotropie aud neoplnsitropic properties; so for the 
present thov have been put on one side. Kiis is wliat 
Professor Dilling stated in his letter. ATo' are none tho 
less very ' glad to hear' of tho good results that have 
attended' tho n.se of a lead-selcninm material in the bands 
of Dr. A. T. 'Todd. He may be using better preparations 
than those we have "employed. So with the load" iodide 
of the British Drug Houses Company, which Mr. 'Patterpn 
originally made on m.v instructions when lie was working 
■for us in Liverpool. 

It is, liowcver, to ho remembered, as I -have previously 
stated. Hint eveiy load preparation appears to have some 
effect, and in certain cases can arrest tho growth of 
ihaligiiaiit disease with the disappearance of pain. The 
point is 'that no preparation of lead yet employed is so 
good that we can nllord to hesitate in onr search for 
sometliiiig' better, oven at tho cost of f^od statistics, 
which for tho present arc of little value in enabling ns 
to assess tho estimate that will he placed on this method 
of treatment in the future. 

To- have made a start is something; now — to emphasize 
Mr.' Fitzwilliamshs i-emark — wo want the help of everyone 
wlio has the facilities, and will go to work in the right 
.spirit and in tiie riglit wav. AA’e are not so egotistical 
and stupid as to think that wo alone are capable of 
developing the ideal preparation, although, of coni-se, we 
should like to finish what wo have begun and have so 
widclv explored. Novorthelcss, as some alread.v know, 
we desire to enlist as colleagues all who wish to work on 


the lines wo have sought to establish, and to help, as we 
have in tlie past -hj- -any means in our power. Life- is 
short, the problem vast, aud time is pressing. — I am, etc., 

, , . ., .AAh Bl.vir Bell. 

Liverpool, June IBtu. _. . 


Sm,_i-In Ins letter, wiiich yon publish in your last issue, 
Hi-. Fitzu-illiams makes the egregious blunder of assuming 
rhat the duration of. life after the commencement of treat- 
nent -is identical with the duration of treatment. D 1- 
ihvious that this is.iiol 'necessarily the case. . Iii iiiy .report 
;o which' he refers, “ duration of freatiiieht ” alwaj-s • 

lie interval between the first and last injection of collowla 
end, and has no relationship whatever with the duration 
>f life.— I am, etc., - 

London, S.W., June.lStm St.VNLEY A\ Y.VUD. . 




June 23 , igiS]! 


cokrespondbncb: 


r The Bnmsn 
L Medical Joxmyix, 


1089 


SBA-SIGKNESS. 


Sir,— I noticed with interest Mr. R. II. Parnnioro’s 
letter (Juno 2ml, ]). 959), in which ho ngrccs with Dr. 
Bennett in disconntin|.>; the ‘‘ Inhyriiithino ” theory of son- 
sickness, nnd centring the hlnnio on liver functions. 

■ Lust February I took a voy.ogo ns teuipornty ship 
surgeon on the -Ifnum'o to Halifax and New York. I was 
sea-sick for threb or four days, nnd took notes of iny own 
symptoms. After my sea-sickne.ss had gone tho rest of tho 
voyage was most exhilarating, and I returned feeling much 
fitter. I came to tho conclusion that this condition is duo 
to “ waves of pressure ” in tho corebro-sjiinal fluid, sot 
up by tho motion of tho .ship. Theso “ waves of prosstiro,” 
transmitted to tho brain by tho cdrehro-spinnl fluid, upset 
tho nonnnl function of tho brain cc\itrcs to such an extent 
in certain [>eoplo that the brain inhibits tho blood supply 
to tho abdominal viscera, and thus chocks seriously tho 
general metabolism, niitil it reinstates itself in its now 
environment. Tho stomach then has no other courso of 
action than to expel its contents, nnd other signs of 
disturbed metabolism appear, such ns acidosis. 

With regard to treating tho symptoms it is goucrally 
agreed that lying on tho back, warmth, fresh air, nnd tho 
administration of glucose arc excellent. Tho relief of 
.symptoms which follows lying on tho back suiiports my 
theory of waves of pressure in tho corcbro-spinal fluid, for 
in that position the head nnd spinal colninn aro kept 
most nearly at rest. As soon as tho erect posture is 
assumed, particularly with a tall person, tho swaying of tho 
long vertical axis must cause waves of pressure in the 
cerobro-spinal fluid, both laterally and vertically. Tho 
chief dosiro of tho patient then is to get tho head down 
flat on the ground nnd to let it remain there; vaso-con- 
slriotion of tho abdominal blood supply is thus allovi.atcd 
at once. After a few days tlio brain becomes educated 
to deal witli its now environment nnd is not upset by tho 
waves of pressure; it thus ceases tlio inhibition of tho 
normal blood supply to tho abdominal viscera. If sea- 
sickness was caused by “ hepatic disturbance duo to a 
diminution ^of blood flow through the liver, occasioned bv 
iho successive sudden falls of intra-abdominal pressure ” 
as suggested by Mr. Paramoro, it is difficult to understand 
how sea-sickness can be overcomo in a few days, since the 
abdomen is not a subject for education, whereas the 
brain is. 


Bhcn sea-sielmess is considered from tho broad aspeef 
of its meaning it will be seen that it occurs for a purpose 
namely, education to a now environment. When tlk 
land-liver goes to sea there is such a complete change ir 
Ills whole environment that Nature decides that ho must 
bo put into bodily order for tho struggle for cxistonco. An 
attack of sea-sickness cleanses tho stomach and 
t Z a contents generally; at the same 

1 up and improvement of the 

the natient'™^'^ 1® attained 
n~ fu •nodcrato meals, and to 

extronLly wSl.^^"*^^ ^ wciglit and feels 

foi^°a nurnneo’ ■'’omiting, is present with ns 

we can^ but urevent ■‘I "‘‘f b “s- Alleviate it 

ne can, but prevent it-~nover.— I am, etc., 

Soulbampton, Juno 8th. ^V. A. EtLlOIT, M.B., B.S. 


Sir, Your correspondents on tho subiect of sea-sickno< 
are evidently unaware of the cndolymplTtheory wMch"S 

ast It published so long ag 

of tho vestibular branch of the a re 
i nkatfon wl ' «P°“- the counteracting of thi 

brltTof .^mmoni™ ‘ 

«wangcmcnt of the iMer ear“ and 'wat 

from “ sirl-nooo I, , that it is quite distinc 

;;£• •« a. <l.go,*ire »<! lb 

“Ui, Juno MthJ Norman Babneit. 


IMMUNITY FOLLOWING HERPES. 

Sir, — ^In view of tho recent correspondence on this 
subject from Dr. Parkos IVebor (May 19th, p. 875) and 
Dr. James Taylor (May 26th, ii.'920), I venture to record 
the notes of thfeo cases of apparently genuine rocufrcuce.s 
] of herpes zoster. 

I saw a patient in April with severe herpes ophthalmicus 
and, to my surprise, she stated that this was her tliird 
attack of shingles. A few days later I saw her next-door 
neighbour, who inquired after her, and expressed deep 
synipathy as sho had had throe attacks herself. The same' 
day I met a third lady who knew both of the others, and 
lyas astonished to lionr that sho liersolf had twice suffered 
from tho same complaint. 

This coincidence seemed to merit further investigation, 
and I obtained the following details. 

Case 1 . — In 1B77, when 20 years of ago, tho patient had her 
first attack of shingles — apparently true zona on tho left side. 
In 1897, ivhcn aged 40, sho had a second attack,' which aftccled 
tho left, shoulder and arm. In 1928, at tho ago of 71, sho had 
severe herpes ophthalmicus, on tho right. Sho was seen by 
a doctor ou each occasion, and has no recollection of having had 
chicken-pox. 

Case S . — This patient, in 1885, when 36 years old, had a very 
painful eruption round the waist on tho left side. She saw ilb' 
doctor, but tho diagnosis was subsequently made by him on' 
hearing her story. In 1902, when 55 years of age, she had aimore 
severe attack at tlio back of tho neck and shoulder— side unknown, 
but seen by iicr doctor. In 1922, wlien 75 years of age, slie had 
a third attack, whicli alTcctcd tlio back nnd waist on the left 'side. 
The attack was a severe one; and was seen by her doctor.. She 
attributes tho attacks to severo shocks, and has no recollection 
of chicken-pox. 

Case 3 . — ^This patient liad Iier first attack, which aiTcctcd tlie 
left side of the trunk, in 1894, wlicn sho was 39 years of age. 
In 1911, wlien sho was 56, slio had a more severe attack, again ' 
left-sided. SIio was seen by a doctor on both occasions, and 
has had chicken-pox. 

It is clearly impossible to confirm theso statements; but 
I feel that they are in all probability genuine recurrences.' 
The interval in each case of a period of fifteen to twenty 
■years seems of interest; might it bo considered the limit' 
of a period of immunity? — I am, etc., 

Cambridge, June 6lb. H. E. NOURSE, M.B., B.Ch. 


A PLEA FOR THE OPERATION OF 
LITHOLAPAXY. 

Sir, — For tho past three years I have witnessed a 
number of oper.ations for stone in tho urinary bladder 
performed in various London and provincial general 
hospitals' and infirmaries; the operation was invariablv 
removal of tho calculus by the cutting method of “ snpra'- 
pubic cystotomy,” nnd in all cases the stone was small and 
tho bladder was clean. 


Experience forces me to conclude that the operations 
wore unjustified in that they involved an unnecessarv : 
cutting of tho bladder wall, resulting in the patient’s 
detention in hospital for many weeks and, at tho best 
in his being discharged with the bladder adherent to the 
anterior abdominal wall— surely a serious disability. I do 
not think it can he contended that, in the circumstances, ■ 
the urinary organ after such an operation is quite as good 
as formerly. This is tho argument from the patient’s 
point of view, but the expense to the State in after- 
treatment and hospitalization for many weeks is very ’ 
considerable as compared with what it would be were the 
operation of litholapaxy to come into general vogue. 

Up to tho latter part of last century perineal lithotomy 
was universal in India for tho removal of bladder calculus 
until Bigelow introduced tho operation of litholapaxy, con- 
sisting of tho crushing of the calculus in situ and the 
evacuation of tho fragments through a cannula at tho same . 
time. Since then this procedure has entirely displaced the • 
cutting operation. I am safe in saying that if a surgeon 
proposed to an Indian to remove his stone by cutting he 
would not get the work to do— and the Indian ' would be 
right in hia decision. Public opinion in India has been 
formed as the result of a great mass of experience ’and 
therefore, arguments which oncle.avoiir to prove that* the 
cutting operation, as generally practised in this coiintrv ■ 

IS as good as or superior to the crushing operation cannot 
be sustained. I can remember only a few instances of ' 


1090 JUNE 23, 1928] 


COERESPONDENCE. 


f Tur.JtnmrK 

L MrMcii. JoL'P.^Ui 


calculi so iaige that they could uot bo rouiovcd hr tlio 
operation of litholapaxy. 

AYhen 1 was civil surgeon of Hyderabad, Sind — at a 
hospital famous in India for stone, where' as many as five 
to seven hundred stone operations have been performed 
per'annum — it was no uncommon event during the “ stone 
season ” to have six or eight operations in one daj-. All 
would be dealt with by litholapaxy during the morning, in 
addition to the usual work. The patients wore not admitted 
to hospital ; their operations were carried out in a special 
theatre, and lasted from ten minutes upwards, depending 
on the size and hardness of the stone. The patients were 
then removed to tho hospital verandah till the effects of 
the anacstliotic had passed off, after which they .stayed 
the night at the adjacent rest house. Next morning they 
were usually able to report fit and return to their homes, 
undertaking long journeys hj’ road or train. Their 
bladders had suffered in no way, as shown by absence of 
blood at time of operation and their well-being afterwanls. 
From tho point of view of the patient, tho Ic.sscr mortality, 
and the minimum of expense for after-treatment, it cannot 
be gainsaid that litholapa.xy for bladder calculus is im- 
measurably the superior operation. "Why is it, then, that 
in this country litholapaxy is practically abandoned by 
general surgeons as the operation for vesical calculus P 
Can it be that the teachers at tho British medical .schools 
have not the experience and the data at their dispo!-al to 
warrant their recommending the adoption of trealineiit by 
this method? In unpractised hands the operation of litlio- 
lapaxy is certainly most dangerous, a.s it rcfpiirc.s much 
experience to obtain tho necessary “ tactus crudilus.” 

It is not sufficient excuse for the general surgeon to 
continue to practise the inferior operation of suprapubic 
lithotomy by saj-ing that ho gets so few opportimitics 
that he feels quite unequal to tho task of performing 
litholapaxy with satisfaction to himself or .safety to his 
patients. If ho is to continue to operate for vesical 
calculus he should, in justice to bis patients, take .a two 
months’ cold weather trip to India, where ho would bo able 
to observe exjierts at work, who would gladly instruct him 
in the art and give him opportunities for practising the 
technique, in the same way as tho American ophthalmic 
surgeon visits India to perfect his technique in the 
operation for cataract. — I am, etc., 

L. P. SiEraEN, M.A., M.B., F.B.C.S.Ed., 

Grimsby, 5Iay 18th, Liciif.-Colonel, I.5f.S.(rcf.) 


INJECTION TREATMENT OF VARICOSE VEINS. 

Sir, — Dr. Borcherds’s letters are ahvays interesting, but 
some of his statements are rather startling. If, as he says, 
all varicose veins are of syphilitic origin then everv family 
must snller from the luetic taint, as.it is doubtful if 
a family ever existed where one member has not at some 
time suffered from varicosity either of the limbs or anal 
canal (piles). I cannot agree with him that intravenous 
mjections of arsenical compounds cure varicose veins. 
During the past fifteen years I have given over ten 
thousand of the latter, chiefly to women (at the London 
lioclv Hospital), irhose ami veins are occasionally so small 
as to be almost imperceptible, and the injection has then 
to be given elsewhere, usually in a varicose rein. I did not 
observe that the varicosity disappeared following the injec- 
tion, of the arsenical compound. The possible explanation 
of Dr. Borcliords’s apparent success may be as follows 

The calibre of veins is regulated by the smooth masele 

in their walls. This muscie is controlled by the sj-mpathetic 

and it is by means of the latter that the veins dilate 

or constrict. Excitation of the sympathetic leads to a 

diminution in the calibre of tho veins. It was first pointed 

out to me by Professor Sicard (originator of tho sodium 

salicylate sclerosing method) and Dr. Gaugier at the Necker 

Ho.spital, Paris, that simple insertion of the needle into 

the vein, even without injection, veiy • often causes a 

romaikable constriction of the vein, the pniieture acting 

as an .oxcitor of the sympathetic. This constriction mar 

bo Borcherds states that 

cRvatcfr ««er injection and 

to .Ik expected that cousideroi 1'^ " 

at cousidci-ahle improvement wUI result. 


due to rest nnd t'oinprc.ssion, and not to the arsenical 
compounds. If ho did not handiige and rest the limb 
immediately after injection be would see tliiit vaso-coii- 
.s'lriction would soon give place to va.so-dilatation and the 
former varicose condition reass<;rt itself. 

Dr. Borcbords .speaks of the .sclorosiiig method of treat- 
ment as one of " embolic injoefions.” This is a grossly 
misleading dc.scrijitioii. The e.sseiilial of emholism is that 
the clot must ho loose; an einboliis is n clot that has been 
“ transported ” by the blood sticani. The most remark- 
able eliarneteristio of the clot jnodneed by .sclerosing 
injeclions is the tenacity of its adherence to the vessel 
walls; it is almost impossible to pull it away from the 
latter. Embolism only occurs when tho clot is infected; 
if suitable care in sclceting eases is exercised and the 
iiijeetion given with correct technique ami aseptic pre- 
cautions, coiaplclo ohlitoration of ibo varicose veins will 
result with iierfcct .safet}-, and emholism will not occur. 
Professor Sicard and Drs. Gaugier and Eorostior stated 
recently at the Royal Society of Medicine that in over 
300.000 injections given at the Necker Hospital, Paris, 
not a .single ta.se of emboli.sm resulted. 11 is only in rci.'cnt 
veurs that 1 have interested myself in treatment of variceso 
veins of the limb, hut I have employed selcrosing injection 
ill .selected cases for jiilcs during fifteen years and liave not 
had a single ease of emholism. 

Iiitinvcnons arsenical injections occasionally cause ana- 
phvlaxis, hut I think Dr. Borcherds will agree that it 
would he mi.slcading on that account to refer to the treat- 
ment as one of " anaphylactic injections.” — I am, etc., 

P'. KE.N.VEDV Muuriiv, 3I.A., 31. D. 

London, W.C., Jane !rd. 


Sin, ^In the last paragraph of Dr. Borcbords’s letter 

in vour issue of June 2nd (p. 960) bo rises a term nhich 
is ‘most ))nzzling— “ embolic injections.” Would Dr. 
Borcherds ])loa'se give his definition of tho word einholius. 
If he is oinploy/ng it in the sense generally given it in 
patliologv tlien I suhmit that in this instance it is , a 
inisnomc*!* nnd very misleading, Eo substance non in us^o 
for the iiijcMion "of varicose veins ever produces cmholi. 
It was the use of such substances ns tinct. feyri perclilor., 
liq, iodotnii., etc'., that for seventy-fivo years (to within tho 
last ten or twelve years) rendered these injections so 
daimcroiis. l^vcn then those drugs did not cause eniboli, 
but 'the soft, fi inble clot formed by them, together with 
infection, often caused fatal emboli. . 

Dr Borcherds’s term would seem to he most unfortunate, 
as it was, and still is, in a moasuro, tho bugbear not only 
of the t»encrnl public, but also of some members of the 
|)rofes.sion at the present day. This fear of embolus (now 
proved to he more theoretical than real) all workers 011 
the subject now agree to be groundless with modern 
methods in use, but I would suggest that there is possibly 
more chance of embolic formation with arsenical injections 
(Goiigcrot) than with the uso of any of the other sub- 
stances now emplovod, and this apart from other obrioas 
objections to the method used by Dr. Borcherds. I do not 
follow him when, he says that these ‘‘ embolic injections 
should " throw the burden on to the deeper veins.” In 
what way does his arsenical injection differ in its action 
and how does he prevent the dce))or veins from being 
affected, as ho affirms is tho' case with tho use of “ embolic 
injections”? Is the vein obliterated or not after this 
injection? If it is, in what way doe.s it differ from veins 
blocked by. other drags ? How are the deeper veins not 
likewise aifcctcd by his injection? . 

I venture to suggest that if .Dr. Borcherds were to 
employ the drugs in n.sc hero and on the Continent ho woaUl 
get just as good results as with tho arsenical injections, 
for if ho will consult Sicard’s articles ho will see that this 
authority ascribed tho bloclriug of the veins to the sodium 
content of ai-seiiical preparations and not at all to the 
arsenic, nor to its curative effect on the element .sypInhS' 
should it exist. The veins were blocked, (where disease and 
varicose conditions wore absent) at the site of tlio injec- 
tions, and this seems to be all that is necessary for the 
cure of this prevalent .and disabling infirmity. I submit 
that Dr. Borcherds is curing liis eases by sodinni only, 

■ given, in a very- complicated way. .1 think he-wiH 'bavo 



June 23, 1918] 


■WILWAM JAMES .HOWARTH, M.D. 


r TnKnnmsn 
1. 5I1.I1ICAI. JoLTtNAI, 


1091 


frrcat aifficuRv in conviucin?; those conversant, ."‘th tl>o 
treatment of this comiilnint of the proi.rioty of hi.s niothficl 
•IS coinnared with tho simple, methods now goxmvaUy m wso, 
esnoeiallv as tho cnn.so of varix docs not seem to ho 
syphilis,* at least in this connti-j- or on tiio Continont.— 

1 am, etc., „ ,, 

T. H. Tnr.vr.s B.xiunm, B.fcc. 

London, S.XV., June 3rJ. 


Sin,— I am afraid Dr. Borcherds (.Tnno 2nd, p. 960) 
lias not quoted my letter in your issue of Ixlarch 13th 
quite correctly. If lie will read my letter once more ho 
will notice that I do not say that " tho pressuro of 
pregnancy " is a cause of varicoso veins, hut that I havo 
made two distinct- factors in “ pregnancy and increased 
intravenous pressuro from utcrino causes.” Jfy reason 
for doing so is evident when one considers that tho onset 
of varicoso veins in pregnancy is most commonly observed 
long before there can bo any question of increased inti'a- 
uterino pressure. 

L. Gaugier has decided that tho cause of tho varices 
of pregnancy » nt cndncrvnn orvgvn nnd Wmh the pvtwrtvv’ry 
gland is predominant in their causation. Ifeiscn beliovcs 
limt they are probably tho result of toxins acting on tho 
u'alls of tho veins, which toxins are caused by tho tem- 
porarily subsided function of tho ovaries. At any rate, 
modern evidence goes to show that in most cases some 
endocrine deficiency is tho “ fons et origo ” of varicoso 
x-oiiis, and I cannot disagree with Dr. Borcherds if ho 
says that syphilis is at tho bottom of .a certain number 
of cases, but I certainly do not feel that all arc syphilitic 
in origin ns ho suggests I am, etc., 

London, tV.I, Juno Vlh. lloX.ALD TnOnXniLL. 


NBPHRO-DRETEBAL ANASTOMOSIS AFTER 
COMPLETE AITJLSION OF THE URETER. 

Sin, — In tho Journal of October 2nd, 1926 (p. S89)i I 
reported a case where, following complete avvdsion of tho 
ureter and absenco of any firm tissue witli which to make 
a pelvi-uvcteral anastomo'sis, tho urctov was joined to tho 
kidney by threading over an inlying catheter. 

' Tho procedure was apparently a success, but I have 
just ascertained tlio subsequent history of tho paticutj 
liich throws a different complexion on the matter. About 
year after tho operation a perinephric abscess developed, 
nd nltiraately tho kidney had to he removed, when it ''ms 
ound that the lower part 'vas liydronophrotic. Tho ureter 
ad apparently successfully drained only the upper two 
alyces. 

I consider it nccessai'y to make this furtlicr report, which 
lodifies considerably the value of such a procedure.- — I 
m, etc., , 

R. C.vJirnF.LL Bncc., 

Wellington, Mny 5th. 


health and school medical officer for tho county of Kent. 
In December, 1912, ho was elected medical officer of health 
for tho City of London on tho retirement of Dr. "W illiain 
Coilingvitlgc. l^viring tho wiw- ho served with the rank 
of Major R.A.]M.C.(T.) as lionorary medical administrator 
of tho Fishmuiiger.s’ Hall Hospital for Officers, and as 
chief rationing officer under tlio London and Homo 
Counties rationing .scheme ; for these services ho was created 
C.B.E. in 1919. Dr. Howarth’s intimate knowlodgo of 
meat inspection led to his appointment as chairman of 
tlio Meat I'rcsorvation Committco of tlio Food Investiga- 
tion Board, and as a member of the Meat and Slaughter- 
houses Committco of tho Ministry of Health; he Was also 
a university nomiiieo upon tho Board of Management, of 
tho Low Temiioraturo .Bc.soarch Station at Cambridge, 
and had served on tiic Ministry of Health’s Insanitary 
Areas Subcommittee. In 1917 ho was Mili'oy Lecturer 
before tho Royal College of Physicians of Loudon, taking 
as his subject “ Meat inspection, witli special reference 
to tho developments of recent years.” The.5o varied and 
responsiblo activities, with tho accumulated knowledge 
•kEvAv s.’i'il.v w twiaessbOT. of Qffi.<ila.t pasi-tiAuA a£ iiec.fissity 
implies, gave him a wide acquaintance with men and 
I affairs, and his forceful character and statesmanlike out- 
* look put him in tho forefront of many of tho advances 
in preventive mcdicino during recent tiroes. He was for 
nianj" years a zealous and highly esteemed member of 
council of tho Society of Medical Officers of Health, holding 
office ns president in 1921-22. In tlio latter year be 
presided also over a conference of medical officers of 
health during tho congress of tho Royal Institute of 
Public Health at Bournoiiiouth. 

Throughout his career Dr. Howarth was inspired by 
high ideals, always upholding tho good name of his pro- 
fession and tho sanctity of •English law as expressed in 
tlio various Public Health Acts and Regulations. He 
was opjxised to scctionnlization in medicine, and during 
tho past ten years took an active part in tlio work of 
tho British Jtedical Association, believing, and acting 
upon his belief, tliat its organization and aims made the 
Assoeiattow pavticwlayly well fftted te bring into eloser 
touch general practitioners and medical officers of healtli. 
Ho was for some time a valued member of tho Public 
Health and Insnranco Acts Committees, and served on 
a number of special committees and subcommittees at 
headquarters. He had been appointed president of the 
Section of Public Health for tho Annual Meeting of the 
Association at Nottingham in 1926, hut was compelled 
by sickness to resign that post shortly before the meeting. 

After struggling against ill healtli for. many months die 
at length handed in his resignation , to . the Corporation 
of tho City of London, and in March last a resolution 
expressing deep appreciation of his. valuahlo seiwices as 
medical officer of liealtli for the .City was passed 
unanimously at the instance of the Sanitary Committee. 


©lixtxmrg. 


We are indebted to Dr. H. B. BnACKE.viiLTtr, Chairman 
of Council, British Medical Association, for the followiii" 
tribute: . - . . » 


WILLIAM JAMES HOWARTH, C.B.E., M.D., 

, Late Medical Officer o£ Health for the City of London. 

Ve havo to announce with groat regret that Dr. ML J. 
lowarth, for fifteen years medical officer of health for 
lie City of London, died on Juno 15th, at Gerrafd’s 
•TOSS, m his sixtieth year, after maiiv months of illness. 
IS death removes a distinguished and much-respected 
world of -prevontivo medicine. 

^ \\ liham Jnmes Hon-arth was educated at Manchester 
Owens College, Manchester, and in 
of .L.R.C.P. and S.Edin., and 
Mt.i'.P.f^Glas. Ho graduated M.B. and Ch.B. at the 
^lotona University of Slanchester in 1891, proceeding 
, : “93, and taking the D.P.H. in 1896. After 

I aining Ids firrt qualification ho became in turn housc- 
.nvgeon to the Mancliester Royal Infinnarv and to the 
General Hospital. In 1896 he was appointed 
npdio^i health for Bury, Lancs, and in 1898 

lor officer of health for Devhx, wbdve, l\w vwvswvvwid. 
years until his appointment as medical officer of 


ine long luncss ol Ur. M'. J. Howarth has heen a great 
loss to the British. Medical Association, and his death 
has now made that loss irrecoyerahlo. He was greatly 
interested in many of tho Association’s activities, and a 
strong and influential supporter of tho Association’s main 
policy in matters relating to public health and to tho 
methods by which private practitioners of all kinds should 
take their part in the health work of local authorities. 
Even before lio was president of the Society^ of Medical 
Officers of Health in 1921-22, his services had been sought 
as a member of certain special central committees dealing 
with matters such as these, and ho afterwards consented 
to servo upon otliers. It was a great regret to him as 
to all thoso who had lioped much from his counsels that 
ho found himself unable to take a more reo-ular and 
energetic part in tho work in which he was anxious' to 
share. Ho held very strongly that the real solution of 
many health problems would be found in tho extension of 
. a national health insurance scheme to the denendants 
. of msmted pavs.Qu.s., tbws. wwxbMwg modfi o'r fi.e " clinic ” 
1 work of local authorities to be done away with- and that 



1092 Juke 23, 1928] 


OBITUAKY 


r TnrnftTTHH 
L lIU'lCAt JcrCBSAL 


nieantime this clinic work could most profitnhiy for all 
concerned be placed in the hands of private ])ractitionci'S. 
Ho had a far-seeing mind, and inany statesmanlike qual- 
ities; and his sanity of outlook and great experieuco of 
health jirohlems were very valuahlo assets which tho 
-issociation will sadly miss. ' • 


A. MASON JONES, M.D., F.R.C.S.En., 

Surgeon, Ear, Nose, and Throat Deparlinent, CardiJ Roj'al 
Infirmary. 

We have to record with mwh regret the death of Dr. A. 
Mason Jones, one of the vice-pro, sidents of tho iScction of 
Laryngology and Otology at the forthcoming Annual Meet- 
ing of the British Medical Association. Although he was 
the subject of a valvular heart affection from boyhood he 
had carried on his work with cheerfulness and spirit tintil 
three months ago, when auricular fibrillation supervened, 
and he died on June 11th. 

Archibald Mason Jones was a native of Glamorgan, 
having been born at Skewen, near Neath, in 1883, niid 
received his medical education at Edinburgh University, 
graduating M.B., C.3I. in 1809 and proceeding M.D. two 
years later. In 1920 he was admitted a Fellow of the 
Royal College of Surgeons of Edinburgh. After qualifying 
be was engaged in general practici* for four or five years in 
South Wales, and thus gained an invaluable training and 
introduction to the special hranch of work he took up later. 
During the war, though his disability prcvenled him from 
spiviug overseas, he held a commission in the ll.A.M.C., 
and did excellent service in this country. When tho war 
ended he took up the .study of laryngology and otology, 
and became later successively liouse-surgcon and cliiiii’al 
assistant to tho ear and throat department of the Cardiff 
Infirmary, to which ho was ' appointed assistant surgeon 
in 1923. --tt the commonconiont of this year ho was pro- 
moted surgeon, and became head of-tho department. His 
work was characterized by soundness and devotion, and 
his kindliness made him popular with his patients. Ho 
had acted as demonstrator of anatomy at the AVclsIi 
National Medical School for some .years, and was inirnl 
specialist to the Cardiff ICdiication Authority, while his 
services brought him also into association with tho Cardiff 
City Mental Hospital, the King Edward VII Welsh 
National Memorial Association, and tho Maestog and 
Morrison Hospitals. He was a loyal colleague, and all who 
came in contact with him mouim his passing when on 
the threshold of a promising career. 

Mason Jones took an active .interest in the affairs of the 
British Medical Association, having been joint secretary 
of the Cardiff Division for four years, deputy representa-' 
five in 1926, and representative "in 1927. He looked for- 
ward to the coming of the Association to tho capital of his 
native Glamorgan, for which he cherished a warm affection, 
and it was a great grief ' to him, when laid aside, that 
he could no longer take his shave in the work of iirepara- 
tion. He IS survived by his widow and two children. 


J. A. MacDOUGAXL, M.D., F.H.C.S.En., 

Consulting Surgeon, Queen Victoria Memorial Hospital, Nice. 
Dn. JOHX Ayjiebs MacDougali. died on Juno 12th at 
Balenio, in Midlothian, where he had made his home in 
the years since his retirement. His deatli, at the ao-e of 
83, reniove.s a link with some of tho most notable figures 
in tile medical life of Ediiibiirgli in "the last century. 

Born ill July, 1844, he was the son of Dr. George 
MacDougall, a medical practitioner in the Scottish border 
town of Galashiels, and received his early education at the 
High Scliool of Edinburgh, proceeding, in 1861, to the 
University, wliere he commenced the .study of medicine. 
Four years later ho graduated M.D., along with his friends 
John Chieiio, John Wyllio, and W. Allan Jamieson, of 
whom the two former came in due time to fill profe.ssorial 
rtimrs in their alma mater. In 1875 lie was admitted 
-1 ? reference should be made to the men 

V lie taught lu the medical school in an interesting period 

"iionf only 

eight sniiite of the sixty-three who graduated with him-1 


wore fortunate in receiving tlieir instruction from a 
ifinnrkahle group of men. John Goodsir, John Hughes 
Bciiiiott, Sir Bohert Christisoii, and Sir Janies Young 
Simpson, among others, occiiiiiod chains in the Medical 
Faculty. In the Royal Infirmary James Syme and Thomas 
Laycock were clinical profcssor.s, while Patrick Heron 
Watson, Daniel Rutherford Hnhlaiio, and William Ruther- 
ford Sanders were members of the honorary staff of tho 
lio.spitni. John MacDougall, as a dre.sscr, came into close 
toucli with Janies Syme, for whom ho retained throughout 
his life a profound admiration, and whoso teaching and 
|>raclice of siirgoiy ho closely followed in after years. In 
1866 he hocami‘ honso-surgeon to .Tames Siiciicc, who had 
lalely been ajipointed professor of systematic surgery. 
.Toseph Lister during thi.s jieriod was working in Glasgow, 
and, althongh ho did not pnhli.sh until 1867 his epoch- 
making paper on lii.s first .series of eases of eonipound 
fracture treated by his new method based on the “ germ 
theory ” of Pirstciir, riimoiir.s of the now learning had 
filtered through to Edinhiirgh from tho medical scliool in 
the west. 

Returning to his hirthiihice on the completion of his 
training. Dr. JIaeDoiigall settled in general jiractico, hut 
after nine years of a busy life in Galashiels In- crossed flic 
border in 1875 to Carlisle ami hecanie surgeon to tho 
Ciimherlaiul Infirmaiy, wliere ho wa.s able to develop his 
ta.ste for surgery, in which he was intensely interested and 
highlv olficient. In 1885, however, the state of his health 
led him to .sc-ek a loss rigorous climate, and ho accordingly 
removiHl to Cannes. For twpiit%--nine years he coiulncted 
an extensive inaclico as ])hysicinii and surgeon there, liis 
services being in great demand along tho whole of tho 
French Riviera. He was latterly consulting .surgeon to 
the Queen Victoria Memorial Hospital, Nice, and surgeon 
to tho Asilc Evangelitpu', Cannes. Ho retired from active 
work at the age of 70, in 1914. 

A colleague writes: A' largo circle of 'friends, both 
within and without the profession, monrning his death, 
will retain the memory of a very lovable man. MacDougall 
was a horn iiliysicia’n, and iiossesscd in an exceptional 
decree tho clinical instinct; he was an acenrato ohsen-cr, 
and his powers as a dingno.stici.an were Tomarkablo. Ho 
liad the "ift of establishing between his patients and him- 
self a strong bond of syniimthy and friend.slnp. His friends 
were attracted by Id’s high integnty, his great personal 
charm, his obvious sinecritj-, and the gentleness of his 
nature. 3Yiih an excellent and accurate memory, his 
reminiscences of tho Fklinlnirgh Medical School of sixty 
vears a<m and more were always interesting and instnictivc. 
To the end of his life lie kept liimsolf abreast of progress in 
medicine and surgery, and just before his doatli had com- 
menced to prepare for publication recollections ot ms 
fornicr and revered teacher James Syme. The sympathy 
of many friends is with ids widow and danglitcrs in thoir 
bereavement. 


Dr. RonEBT Johnson Pibie, who died .suddenly on 3Iay 
:2iid at his rc.sidenco, , Slnrrayficld, Pittenweem, in Ins 
ixtv-sccond year, received his medical odneation m tlio 
cliool of the 'Royal College of Surgeons of IMiulmijh, and 
a 1889 obtained’ the diplomas L.-Tl.C.P., L.R.C.S.Ed. and 
i,R..F.P.S.Glas. He then spent a period in .stndr’ at 
(erlin, and soon afterwards commenced prartice in Pitten- 
roem,’ becoming, in tho course of ids tidrty-five vmvs 
rork there, one of the best-known practitioners m li-ast 
i’ife. He took a considerable interest in local .atfairs and 
a the work of Ids profession, and was a member of the 
^ifo Branch of tlic British jMedical Association. For some 
imo past be bad not been in good' healtli, but liad been 
ble to cari-y on Ids practice witli the assistance of one 01 
lis daughters, wlio is also a medic.al practitioner. Dr. 
’irie is survived Iry bis widow, two sons, and tour 
laujrbters. 


Tlio death occurred on June 4th of Dr. Vince, 
Theodobe Gabruthebs, a ■ well-known practitionei 
Dundee; he was taken ill while swimming at the coipora- 
tion batlis, and died soon afterwards from heart tai iir . 
Born in 1880, he was sent to Toiihridgo School, nn 



June 13 , 1928 ] 


■ UNIVERSITIES AND COtLBGES. 


r TnRpRmm 1093 

t Sfr-PicAi. JovRXWi J. uc/u 


rocoivocl his medical education at the XJnivoi'sity of Iitdin- 
burgh, gradiintiiig Sf.H., Oi.H. in 1G04 nnd proceeding 
J[.U. in 1S21. In 1308 Iio nos ndniiUed to t)io FcDowsliip 
of tile lloyal College of Surgeons of Kdinburgli. After 
gvadwntiug" be was for n time house-surgeon to Sir 
Montagu Cotterili in the Edinhurgh Ilojal Infirniaiy, and 
was subsequently appointed to a connnission in tbo 
R.A.M.C. During the war ho served with various medical 
units in Franco, and after, tlio armislico was attached to 
the Army of tho Illiine. Ho was finally employed as 
surgical specialist to the Scottish Command, and retired 
from tho army with tho rank of major. lIo resided for 
some time in Derby, where ho was olistctric physician to 
tho Nightingalo Iiistilnte, and later commenced practice 
in Dundee. Ho was a meinlior of tho British Medical 
Association, and tho author of a numher of contrihutioiis 
to various medical jo.nrnals. Ho is survived hy his widow 
and two daiiglitcrs. 


pore, Ceniral Provinces, India, aged 52. Ho was horn on 
Ocloher 28lli, 1875, and WaS educated ' at ' Trinity College, 
Dublin, where ho graduated as B.A., M.B., B.Ch., and B.A.O. 
in 1899. Entering the army as lieutenant on January 29th, 
1901, ho liccamo brevet lieutenant-colonel on .lanuary GSth, 
1923, and got that rank substantively on March 31st, 1925. H< 
served in the Soiilli Afric.an war in 1901-2, taking part in th« 
operations in the Transvaal, Orange Biver Colony, and Capi 
Colony, and received tho Queen’s medal with five clasps, and 
also in tlio recent great war. At the time of his death he was 
in command of tho Jnbbulporo Station Hospital, in which ho 
died. - • 


StiiilicrsHifs n;n& (SoIItgcs. 

BOTATj OODDEGE OP StJRGEONS OF ENGDAND. 

A>J oitDiKAUY ConoctI meeting was held on .lime 14tb, when the 
President, Sir Udrkeley Jloynilian,' I5t., was in tho chair. 


Da. Fa.VNXis AV. Squaiu of Culls, Abordconshiro, died , 
suddenly, on, June 13th, whilst responding to tlio to.ast of 
his health at a dinner of tho Fawcett Lodge of Freemasons 
at Scaham Harlionr. Ho was educated at Ahordeon Uni- 
versity, where ho graduated M.B:, Ch.B. in 1902. After 
practising at Scaham for a year or two he migrated to 
Greenock, but returned to Scaham in 1909. Ho hold a 
commission as major U.A.3I.C. during tlio war, and sub- 
sequently became attached to the B.A.F.M.S. with the 
rank of flight lieutenant (honorary .squadron leader). He 
had also served as D.A.D.M.S. Slst ('J'lio Highland) 
Division, T.A., and as visiting medical attendant at the 
Greenock Infirmary and Dispensary. Dr. Sqnair, who was 
a inombcr of the British- Jlcdicnl Association and a Fellow 
of tho Boyal _ Society of. Atcdicino, had for some timo 
Bufi'ered from indifferent health. 


Ft’Umrthip. 

It was reporlcd that 115 cainliilates had presented themselves for 
the Fellowship exaniinatioo, of wlioni 34 (iiicindiiig two women) 
were sncccsstiil. 'I'lio diplooia of Fellowship was conferred upon 
the following candidates : 

A. J. tv. Ahern. P. G. .Allan. *7. C. Anderson. Xi. H. Ball. J. Brumwell. 
J. Carver. A. At. "■ ” ' " Klgood. lJ. M. B. Evans, 

C. W. flemniln ’ Gaii-drfcr. .1. Grav. tV. A. 

Gvay, P. Hack. ■ ■ E. Holmes, G. H. HowelF, 

H. .Inckfon. .7. A. .iiinics, i . u. i. junieR, Jj C. Enneaster, E. 17. 

.Eo.Souof, A. C. MftcEcoiE Glnclj's H. tlnrchant. At. O. Nlniatnllah,- 
E. W. C. Nortlihcld, Constanco RI. Ottley. S. SI. Power, B. G. 
Schotehold. 7- H. Thomnson, J. II. SI. SValkcr. 


Tho diploma of Fellowship was also conferred upon tho following 
caiididales, who liiid previously passed tlie exaininntinii and lind 
now aUnined tho required age ol 25 years; J. Gove, B. L. Ho'.t, 
F. T. Uidley. 

Memhmliip. 

The diploma of SI.K.C.S. was conferred upon the following 
candidates, who had p.asscd tlio requisite e.xnmiimtions and com- 
plied with tlio by-laws: 

D. tv. Cmrie, Yotia Glmpelson. B, Natarajan, Sfargaret E. Peokcr, 
Edith J. E. Smith. G. N. Unnitban. Elsie E. tVrieht. 


AVe regret to announce the death, in his 43i'd year, of 
Dr. Eodfjit Koceii of Jrnsivcllhrook, Xow South AVales, 
which occurred in a London iiiirsiiig homo ou Jiiiio 10th, 
only a month after ho had arrived ou a visit to England. 
Ho received. his medical odiiealioii at tho Uiiiversitv of 
Sydney, graduating M.B,, ClnJI. -in 1909, and, after 
practising at Scono and JLirmndi, settled down in 1915 
at Muswcllbrook, wlioro ,lio shared an extonsivo iiracticc 
with two partners. Although of a retiring disposition 
ho was -well . known to -momliers of the medical profession 
tliroiighoiit the northern district of Xow South W.alcs, 
and .among them he ivas hcld in high esteem. Dr. Bogcr 
was a memimv of tho Xcw South Wales Branch of tho 
British Medical -Association, About .a fortnight after his 
arrival in England ho contracted influenza and later 
pneumonia, and empyema developed. Ho is survived by 
Ins widow, one son, and two daughters. 


Tho following' oxomlners were oppointcH lor Ihe ensuin'; year: 
Denfnl Snrofru (i^nrcical Sef^Hou): Tj. B. H, S. C!oeg; T.P. 

Lcf!f!, n. J HowanJ. G. E. O, Williams, C. H. S. Ernnkau, J. Alnrray, 
Fi. U. Cavlinr. aiuiiLTnii nnd Phvsioloov /or thft ■FelJou;s7tij): 
Anatomy, 1’. G. Persons, W. E. Lo Qros Clarlc, C. P, G. ^YalteleJ^ 

V. N. B. Otlj^ers ; PhvRiology, J. B. Loathes, H. E. lioaf, C. A. L. 
Evans, It. J. S. McUowulK 

TTniler the Conjoint Exumininf; Bonn! : 

EUm'Ufnrv Jilolcov: T. W, Shove. J. P. Hill. Anatnmv' J. B. Hnmo, 

W, .WnRht, It. B. Green. Phitsioloov: G. A. Hnckninster, E. B.- 
Verney.' Mt(hoifr7y D. W. Boy. H, H..WhUchonse. C. White,-T. B, 
Davies. Vsplmna in PuhlicUenWi : Part I.’Il.T. Hewlett; ParfcIIi\ 
O. W, Hutt. Divlnjnn tn Ttnjyicnl Medicine and Hvoicne: Patho- 
locvanil Tropical HAgiene. W. P. MacArthnr; Tropical Medicine- 
and Surgery, P. H- Manson-Bahr. Diploma in Ophthalmic Medicine 
and Siirgerv: Pnvt I, C. B. Goulden, H. W. Lyle; Part II, R. A. 
Grooves. Diploma in Psyrludogical Medicine : l-\ L. Golla. 
Diploma in Laryngnloav and Otoloov : Part I, W. M. MoBison. 

• N. Patterson ; Part II, S. R. Scott. 

Mr. R. H. Dowscttaiul Jfr. A. IT. Pitts were' rc-elecfeil membei-g 
of tho Dental Section ot the Boanl of Exainiiiers iu Dental Surgery. 


^crbicts. 

TTI . Q deaths IN THE SERAHCES. 
lleet Surgeon Charle.s Francis Newland, R.X.fret.), died 
R. 76. Ho was educated at 

ti" in-f ^ ^I-K-C-S. in 1875 and tho L.R.C.S.Ed. 

1877, and allained Iho rank of 
-IV --T ’^'hho ■ serving as fleet surgeon on 

. 'V,'®'. esciis he took part in the punitive n.aval expedition 
to Benin, Mmmanded by Rear-Admiral Kawson, C.B.,- in 1897, 
of Benin city on February 18tli, 1897, 
c ho general African medal, -with a clasp for Benin. 

dipd f PI • C.M.G., D.S.O., R.A.M.a(ret.), 

died at Chisledon Camp, Wilts,, on May 10th, aged 56. He was 

Hen-:.T„f . "7 tho son of the late Rev. George 

Pnlln ' r Cork, was educated in the School of the Royal 

1895 ^T?ni t>>e L.R.C.P. and S.X. in 

becamo^nlnn»l® T lieutenant on July 27th, 1898, he 

Hr^etved tT and retired on June 3rd, 1927. 

Oueen’-s mpA-il ^ '^^^ican war in lfiOl-2, receiving the 
menUnned ^ ’i" 19M-18, when he was thrice 

1915. Alav 29th^^iq?7'^^~'v Gazette of June 22nd, 

tbe-Tl R n • December 30th, 1918, and received 

rccentiv'Mtfr-! .Ernest -Parkes, R.A.JI.C., died 

y an operation in the Station Hospital -at Jubbnl- 


. Primary Fellowship. . , . 

At Iho recent primary examination for the Fellowship 160 
cainlidates presented themselves, of whom EO were approved anil 
110 rejected. The following were the suocosstnl caudiiiates : 

K. L, Almond. M. E Ashmawi. SI. B.acliwell, J. S. Batchelor. SV. D 
Bedford. H. S. BillcIiH, J. D. H. Bird, D. .A. S. Blair. H. A. Brittain, 


Slason. St. V. Slodi. H. S. Slnrton, A. B. Stowlem. J. H. SInlligan. 
G. H. Newni. C. W. Olsen. SI. D. Patel. .7. B. Pennybacker, P. N. 
Raj-, J. G. Beid, A. H. Richardson. N. H. E. Ridlej-.-SI. C. Rons 
A, Simnson-Smith. G. .1. Sonhian, V. Krinivasan, F. S. Tait H S* 
Thomas, T. F. Todd, C. K. Vartan, A. L. SS'ebb, T. H. Wilson.' 


ROYAL FACULTY OP PHYSICIANS AND SURGEONS 
OF GLASGOW. 

The following have, alter examination, been admitted ns PpIIowo' 
ot Facnity: J. Craw, S. B. 'Tvivedi, A. M. Yoniig. 


LONDON INTER-COLLFGIATE SCHOLARSHIPS BOARD 
The following awards of enlrance soliolarsliips ami exhibitioiia 
have been made: Umversity Coffege-sledical Soliolarshin 
IV veni* lor three years, to C. Oiiist.- Jiinn\ CniUr,^ w ^ 
Medical Scholarsbipr,, £30 a year each for fon^Vears 
Jarvis and .J. C. 'Winteler; Samhroolte Scholarshin in srid- 
• Science, £30 a year for three years, to G. B DaWs k' r^i 

H^Kirmam'*’'^' ^“^olarsbip in Science'’ 


1094; June 23, -1928] 


MEDICAL KOTES IN PARLIAMENT. 


[ Tire Dnmrt 
Ur.DiciL JorcKiA 


iiti&ical Jlotfs in ^3nrltami;nt. 

[From our Parliamentary Correspondent.] 


On June 19tli Mr. J. H. Wliiiley resigned the Si)oakor.ship 
of the House of Commons and the House took farewell of Inm. 
On the following da}' Captain E. A. Fitzroy, niemhcr for 
Baventry, was elected Speaker. The otlier cliief Imsiness of 
the House during the week was the Committee stage of the 
Rating and Valuation (Apportionment) Bill. The ifouse of 
Lords read the Equal Franchise Bill a third time on June 18th. 


fncliire, storage, sale, import, niid export of p1jo«gcnc, intended 
for war piirposes, >vas ■foi’bidfleii. Tlie manufacture of plio^gcne 
intended for iitdnslrial purpo*-es was confined to three lactorics, 
and the machinery for producing the gas in each of thcs<5 
factories was limited so ns to fix the total maximum output’ 
at nine Ions a day. No n^stiiction was placed upon the export 
or storage of phosgene so produced for industrial purposes. Tho 
facts hitherto brouglit to light afforded no-proof that the Gcnnan 
Goyerimicnl had failed to ensure the ohscrvaiicc of these con- 
ditions, and tho British Governinonf did not consider tliat any 
action on their part was required. If there was any suspicion 
of an infringement of the treaty the League of Nations v.ji3 
entitled to hold an inquiry. 


National Health Insurance Bill. 

The House of Lords went into Committee on Juno 14lh on the 
National Health Insurance Bill. Tho Chairman, Lord Bonougii- 
MORE, remarked that tlicro was only one amendment to the First 
Schedule. Lord Askwitei moved that to the additional hcnefit.s 
allowed by tliis schedule there should be added “ allowances in 
respect of dependants of insured persons in receipt of Mckness or 
disablement.” He said that 124 women’s sociclie.s lliroughoiit the 
country had approved this proposal. Lord Gage,- for the Govern- 
ment, said that not only the Ministry, hut the approved societies 
considered that the surpluses should be devoted principally to 
benefits in the nature of treatment. If the amendment ucre 

E assod and adopted by the approved societies, little money would 
e left for dental and ophthalmic henefits. From 1911 to fhc 
present time no representations had been made to the Minister of 
Health that the approved societies favoured lliis proposal. Tho 
amendment was withdrawn and the bill was reported without 
amendment. It was set down for third reading on June 21s(. 


Do(j-i Act (ArnciKhrivtit) liiU. 

In Committee, on June 15lh, tho Ho\isc of Coiiimons considered 
the Dogs Act (Amendment) Bill, introduced by Mr. Briggs. On 
Clause 2 (delivery of stray dogs to tho police) Mr. Briggs moved 
new words which provided that the finder of a stray dog should 
it to its owner or take it to tho nearest police station. 
If the finder desired to keep the clog lie must receive a certificate 
from the police and bo under an obligation to keep it for not loss 
than one month, Mr. Briggs* added that tho hill was an agreed 
one. Sir Robert Gower supported the amendment, which w.as 
inserted. The bill was then reported and read a third time. 


Training of the Deaf and Ditmh. 

In the House of Lords, on June 18th, Lord Ckarnwood called 
attention to the position in industry of the congenitally deaf and 
dumb and of those wlwlly or partially deafened in later life bv 
disease or accidents. He also referred to the limitations of the 
present provision made for their training, and for securing enmlov- 
ment for them, and asked thcr Government to set up an inteV- 
Departmental Committee to inquire into the whole matter. 

Lord Gage said that before the Ministry of Health came into 
existence a great deal of work on behalf of the deaf was done 
bv vojuntaiy associations, whose work was still being coiitmncd 
Ihe Minister had no intention of interfering with that magnificent 
work. If they Avere to apply the analogy of the machinerv 
.^P 1® deal with the blind to all congenital afHictioiis the 
Ministry would have a great financial load put on it. The in- 
Brard of Education went to show that deaf 
«n 'fo provided by the Board 

up to the age of 16 were able to obtain and retain reasonablv irood 


; Storage of Poisonous Oases. 

Sir Laming Worthington-Evans told Mr Tlmrtlp nn cn 
that small quantities of phosgene gaf ind '"imIiarcXonnds 
were kept^by the British. Aimy for use in ^^npounas 

mental' work. On the same day Sir' Vivian HENDEEsmf 
Secretary of the. Home Office) told Commander ^^wortliiP that 
no regnlalions were in foi-ce in the United Kingdom for prt 
venting the storage of poisonous gases near largo centres of 
population. The use made of phosgene and other poisonous 
gases m industrial processes necessitated the storage of tliP« 
gases in the factories concerned. At Hamburg, where uhoso^pn 
gas was accidentally released, the containers appeared *to hav 
been,' of much greater capacity and liable to far greater 
than the containers generally in use in this country. InquiriS 
by the. Home Secretary had shown that the containers in use 
here liad a -wide margin of safety, and that the position generally 
was satisfactory. A committee of the Scientific and Industrial 
Research Department was inquiring into the storage of such 
gases, .and .the situation would have to be reviewed' in the lielit 
of its findings. The supply of gas masks to the police would be 
considered, but -hardly appeared necessary. 

On June 11th, Mr. G. Lockkr-Lampsok, in reply to Sir W 
the obligations assumed bi' ' the German 

raannfacrnre t I'V ‘o the 

bad been defmod by^^prpf'Ti util^ablc as- poison gas 

botvseen the ox-allied p‘oWi pS i *1” subsequent correspondence 
Po^ei-s and-that Government. The manu- ' 


Trnitnifnt of lUnsiotts Patimts. 

On June IBtli IMajor Tuyon informed Mr. Ouckworlli that it was 
the duly of the proper medical officuis of the M»iii‘«try of Pensions 
to piescribc wliatcver form of treatment tliC'V miglil consider 
necessary for ex-seivicc pensiouruK suffering from chronic dis- 
abilities. In a case where no special treatment beyond aflcnlioii 
from a general practitioner was required, (he pen.s-ioner was 
advised to consult the practitioner wliO'^c services were availahlo 
to him under the Ileallli • Insurance Acts. This was the long- 
standing practice of tlie Ministry, and he would not he justified 
in requinng, ns Mr. Duckwortli suggested, tlio provision of 
hospital treatment in all cases. 

Colonel Stanley, replying to Mr. Johnston, on June 18tli, said 
no instructions had neon issued to local* medical officers of the 
Ministry of Pensions urging the curtailment of treatment allow- 
ances paid in respect of ex-service men suffering from tnberculosi.s. 

Mr. R. Morrison a.sked wliy it seemed almost impos-sible for 
ex-service men to get treatment allowance except by going into 
a Ministry of Pen.Mons hospital. Colonel STArarv said that that 
depcnded‘cntirc]y upon whctlier the treatment that tlic man wa.s 
to undergo would prevent him from working. Lady Astor asked 
whether one of the real difficiiUics was that men who got treat- 
ment came out before their tientment was finished. Ckuild not 
some wav he* found of guaranteeing that (hoy should stay until 
tliev weiV dk-cliarged ns practically cured? C-oloncl Stanley ‘^aid 
liie’ Ministry had no power to keep a man if ho did not wish 
to stay. 


J)r. Voronoff and Grafting Kxl>trin\(.n1if. ^ ... 

Mr . Briant asked the Horae Secretary, on Jiinc 14th, if a 
permit had been given to Dr. Voronoff to visit this country; U RO, 
lor whal period it was available; ami if sucli a permit would 
allow him to carry out experimonU of tbo nature of grafting on 
human beings. Sir William Joynpon-Hicns x'eplied that iJr. 
Voronoff was given leave to land in tlie United Kingdom on May 
22nd. and no time limit was imposed. His object was to give 
certain lectures at Cambridge University and elsewhere, but no 
licence of any kind had been given him to experiment in this 
coiinlrv. Mr. Brtant asked the Home Secretary if Dr. Voronoff 
could niako expeiimcnU without a licence. Tlio Biilish public were 
cxlrcmclv anxious to know tlial lie should not have un oppovtunitv 
of coiiducling dangerous and disgusting operatons, which included 
the transfer of the organs of propagation from an ape to a tvoman. 
Sir W Joynson-Hicks : It is quite impossible that he should 
conduct mn- experiment involving vivisection or cutting operations 
on any animal witlioul a licence, and that licence 1 have not 
granted and do not propose to grant. Dr. Frk.manti.s asked it a 
Uumati being was not an exception, and if . lie 
himself for experiment if ho liked. Mr. ItAnronn asked if it would 
be possible for some oilier licensed person to make an operation on 
an animal and to leave it to . Dr. Voronoff to complete tho 
experiment on a human being. Did the Home Secretary not tiiiiik 
that it was a violation of everything that was decent in our 
constitution that this man should be allowed to conduct such 
experiments in this country.? Sir W. Joynson-Hicks: Bo such 
experiments are conducted in this countr3- at all, and the sugges- 
tion that it would be possible to have an operator who has a 
licence would not work, because I am most careful to inquire into 
11... 4 Ivo rtnornfinnis; rondiinlf»d luidpr n lioonce. 


.PU/s. 

. TIio Representation of the People (University of Reading) Bill, 
which proposes to include Reading University in the combined 
English universities constituency, was passed through committeo 
of tho House of Commons, on June IStli, and read a ( ard lime, 
Tho Solicitors Bill, to prevent persons struck off the' rolls 
solicitors from practising fraudulently, was read a second and a' 
third time in the House of Commons on June 15lh. 

Tho Petroleum (Amendment) Bill was considered on the report 
islage by the House of Lords on June lltli. Tliere was no 
reference during tho discussion to lead tetra-cthyl. The bill 
was read a third time by the House of Lords on June 14th. 

The Food and Drug (Adulteration) Bill, which is one of a 
number of consolidating measures being canied by tbe Ministry 
of Health, was read a second time in the House of Lords on 
June 11th. 


State Grant in Aid of Medical Benefit. — Mr. CnAaiRERLAiN 
told Mr. Smedley Crooke, on -June 7tli, that the State grant 
in aid of medical benefit to aged friendly society mombci'S was 
less than £1,000 in 1926 and was rapidly diminishing. ^ it haa 
to be distributed among 7,000 approved societies and branches, 
and the cost of distribution far exceeded the sura to be dis- 
tributed. ‘He had decided that continuance of the grant was 
not' justified. ' The' Consultative Council concurred.' 


June 23, 192S] 


MEDICAti NOTES IN PARtilA-DiIEMT. 


r Tnr ‘ 1095' 

LMyoiCAt^aoT^pNAt. J-VOcr 


Xattoiull UiCiHh Jm^itmurc Iii ^ p ( ctor -' f .- — ^Ir. Ciiambkulai 5 t 
nniioimced, on Juno 71li, llml, lio Imil decided to rrensL llio 
dntict ot men nnil %vomon national lieaUn in>inianco mspoclors 
on a common basis. iTliiinint' for tlio present sepnrnto seniority 
lisls for moil ami women. 

Vurrinofion Tlr. Veruou Davies was informed by 

Mr. CiiAMPEnLAiK, on June 7tli, tlmt -Ibe report of llio commitlce 
on vnccinnlion had been received and would shovtly bo published 
as a command paper. Mr. Chamberlain stated that in 1926 the 
pprccnlago of successful vaccinations to birtlis in NcwcasUc-on- 
Tync was 68; in Dirminpbani, imlndin/? IVrry Harr, 61; in 
Manchcslcf, with Pailsworth, 60; in Liverpool, with part of 
Seflon, 72; in the part of SUelBeld witliin SbeflieUl Union^ 57; 
in Bradford, with Clayton, Dcnholrno, and DriRhlington, 32; in 
Leeds, 60; in Warrington^ 65; and in Darlington, 23. 

Vohnitnry //ospifnfs <7onnniA.*ioM. — On June 8tt\ Dr» Littlc 
asked tlic Minister of Health his i-cnsoiis for discharging llio 
Voluntary Hospitals Commission; and if lio would reconsider Ids 
decision, "in view of the regret expressed by the Commissioners 
that they were disabled fi-om implementing propo'-als to which 
liicy had devoted (irno and attention. Mr. Chamekulaik answered 
that, ns stated in paragraph 2 of the final report of the Voluntary 
Hospitals Commission, the veasous, with which the Commission 
concurred, for which the work of tho Commission had been con- 
cluded were. first, that there was no prospect of an Kxchequer 
grant in aid of capital expenditure hy voluntary !io«pitals on tho 
provision of new beds; and, secondly, that in the abscure of eiicli 
a^ grant it would not be justifiable to make furtlier calls on tho 
time and .services oj the nicmhcrs of the Conind‘‘'-ion coHcclively. 
He was not aware of any ground for reopening tlie matter. 

Dtci^faa.s of the Pnifion.^ Appeal Trihuual. — Lieut. -Colonel G. F. 
Stanley, answering Lieut. -Colonel TJiom, on aIviic 22th, said that 
the decision of the Pensions Appeal Trihunal was by -tatntc final, 
and the provisions of tho War Pensions Act, 1919, <Iid not admit 
of a roiiearing hy tho trihuual of cases once decided. The 
Ministry had liccu enabled, in exceptional eu'^es whero fresh 
malerial evidence was pmduced, to reconsider n claim- If fucIi 
evidence was produced in a cave where an appeal had been made 
and had failed, it was the practice to consult the president of tho 
tribunal itiformally before making any recommendation for a grant, 
in order that no point in favour cf the claimant might lie overlooked. 
Lieut.-Col^oncl Stanley said he agreed on tlie <U'sirabihty of 
ma.king final awards in nil eases as early as [ios<il)|e, but it 
would not be iustifiablc, nor in the inlci'csis of pensioners, that 
such aa*ards .should be made without proper medical consideration 
I 11 **'^V'’*dnal eases. Warning nnout the operation of the 

statutory tinio limit had been given l>y the exhibition of poslci’s 
ni all post office.s, and in all the local otTlccs cf (he Ministry. The 
tinio limit expired seven years after discharge from service, and 
in’ any event not later than August 31st next. 

rrorfcmtn't Compeafatinn for SiUeofin.—Ow .Itiiio 12th Sir W. 
Jov.vso.v-Hicks told Mr. Rennie Smith tliat ilic Departmental 
^.ommittec on viorkrncn’s Coitipeii«ation for Silico«U was directed, 
uudw us m-ms of reference, to advise on anv proposals wliich 
tne Home Secretary miglit refer to it for sclicnies of compensation 
: liable lo tlio disease. Tbo coimnitlee was iiiquiriiii; 

pottery industry, and lie liad asked it, as 
-«-i inquiry was eompleted, to advise on a scliciiie for the 

nfio™.!.'"?® industry. TJicro was a question eoiniiig on soon 
aitemards with regard lo, silicosis in sandstone quarries. If 
it r ^ coniinillee was siiniciciit, lie iiail powers already 

-«.,i sctiemc. under tiic Workmen’s Coiiipeiisalioii Act. Ho 

: ^ oqt say, witliout notice, wiiotlier tiie cominitlec would 

industry ^''.‘oosis among tlio workers in ilic Iirick-making 

Tuhcrculosis.—On .rune 19lli Captain 
and Wales ® blie total expenditure in England 

treatment nf” oarrying out of the approved sclienics for the 
ended March oaoli of tlio Inst four years 

evcludim^ ennifnl^*^’ figures were 'at present available, 

in 1S25"'’£3 fq'7 KOI £2,881,062, in 1924; £5,034,600, 

in XbdD, 4^,157,694, m 1926; and £3,294.991, in 1927. 

Vernor'l)avL'''on Bsldwi.v told Dr. 

--Sir'"]SGSLEV^^Wnnn Persons ami Viiccimidon. 

1.0 was^t aw-,.n nf ’ told 3Ir. T. Williams tliat 

been nrccbided* f mm sufferers from tuberculosis had 
Se.ded tnW iw ‘■“'"‘'•"’g sanatorium treatment unless they 
to that effert nfr a“‘* bo had not sanctioiiod legulatioiis 

was't^arf tbit fn'tlS .'‘O”’ Sent'eman 

as^ed if ho was^to undcriTanf'tbaf’l?™ ar 

?rat 1 ustlafdro^“’'‘““" Ir-I^iLsTS "wlon': 

On June 


'lUi^^Mr^^^Chrmborh'iif^n^ Vnir/s Acts . — ' 

Lharabeilam pi-onnscd to consider - - — 


Dr. Vei-nnn ■hnx';Vr*‘2u consider a suggestion from 

local authoviUes to th^^\ should draw the attention of all 
sanitary insucctoi-s medical ofitcers of health and 

Salo of^Food^and procure samples under the 

these ofiicers mifriif prosecute offenders, although 

tboso Acts in tfieir areas? authorities for administering 


Footaiml-Jfoiith Visiasr.—On Juno lltli Jlr. Guinness informed 
Sir R. Tlionijis that for some years it had been known that the 
scrum of animals wliich had recovered from foot-and-moutli 
discrfsc when injected into stiscepliblo animals would protect them 
for a few days against the disease. Tlic Fool-and-Moutli Disease 
Research Commit tco and scientisis on the Continent were actively 
trying lo discover a practical method of giving animals a lasting 
inmninity from Iho disease, Inifc the task presented very great 
diflicuUics. 


Hospital Officers tn the Prhoti Service . — Sir William Joynson- 
lIiCKS stales that there are 130 nieri hospital ofiicors and 10 women 
hospital officers in tho prison service; of iho men, 38 arc regis- 
tered by tho General Nursing Council as nurses, 9 as mental 
nurses, and G aro registered tinder both heads; none of the women 
aro registered. Tlicro arc, however, 33 fully trained women 
nurses employed in iho prison service, all of -whom aro Slate 
registered, 31 being on tho general register and 2 on the register 
of mental nurses. 


Afcdiral luspcrttcni of Casaah.^^On J.imc 18th Jfr.^ CnAJiUERLAiN 
told Mr. Shepherd that, he was afraid that tho varying conditions 
of sla/T* and accommodation in - the different casual wards, and 
tlio late hour of nri'ival of some casuals, made it impracticable 
to arrange that hoards ot guardians should be instructed to 
have tho medical inspection oL casuals carried out in tho evening, 
before risk of infection of clothes and bedding. 

J/afcnioi .l/orfnh"f.M »» ChildhWth. — On Juno IBtli Hr. Cilambet»- 
LAiN told Mr. Tasker that no complete statistics were available 
on tho percentage of deaths of molbcrs in childiiirth where doctoi*s 
attended tlic hirlli of children with unccrtificatcd midwives in 
attendance. Asked the percentage of deaths of mothers in child- 
hirth when allendetl by certificated midwives only. Hr. Chamber- 
lain referred Mr. Tasker lo page 42 of the recent report issued 
by bis department on live “ Frotociion of Hotberbood,” which 
siimmarixcd an analysis of the midwifery work of the Queen 
Victoria Jubilee Jn.stitulo over a period of ycai'S. 

Use of 6/roff>« Oil in .Hrnfnl Insiitulions. — Hr. Citaulcton a«ked 
the Alinistcr of Health, on June 14th, whether the recommendations 
made by tho Koval Commission on Lunacy and Mental Disorder, 
1926, for the control of the use of croton ort, whether for medicinal 
or ptinitivo purpo'^os, in mental institutions, were receiving 
attention; and whether ho proposed to take auy administrative* 
or other action. Mr. C/iamberlaik answered that tho rccom- 
mendalion of the Royal Commission had received consideration, 
but tbo report did not support the suggestion in the question 
that tho drug was used for punitive purposes. The administration 
of drugs of this character was the subject of frequent consultation 
between tho Medical Commissionci’s of the Board of Control and 
tho medical 061001-5 of mental hospitals, and lio was advised that 
no further action was at present necessary. 

Dispensers in the D.A.M.C. — On June 12t}i Sir L. IVoRrin.vcrojr- 
Evans told Sir Wilfred Sugden that provision for the enlistment of 
dispensers was made in the establishments of field ambulances and 
general hospUals of ibe Territorial Army. Sir W. Suonux asked if 
these pharmacists were invited or desired to serve in tlie Royal 
Army Medical Corps. Sir L. Wortuington-Evans replied that tlicy 
certainly would bo -eligible, if they^ desired to enlist. Replying 
to r. further question by Sir W. Sugden, Sir L. WoRniiNGToy- 
Evans said tliat drugs and medical supplies were only sloi-cd in 
military hospitals in quantities sufficient approximately for the 
current six months? requirements. Instruction in their storage was 
given as part of the course of dispensing, which all soldiers of the 
Royal Army Medical Corps had to pass before attaining- the rank 
of sergeant. Tlic examinatiou at the oud of the course was 
conducted by a board of medical officers. 

Dhptnsivs in the Ttrritorial Army. — In a scries of replies, on 
Juno 15lh, to Sir Wilfred Sugden, Mr. Durr CoopEa (Financial 
Secretary of the War Office) said quartermasters of- llie R.A.M.C. 
(T.A.) were nominaUd by the officer commanding the unit, 
after consultation with tho County Association. None of the 
quartermasters at present in tho B.A.M.C.(T.A.) possessed 
Iho qualification of pharmacist. If a qualified pharmacist were 
recommended for appointment as quartermaster his claim would 
bo gladly considered by the War Office, but at present tbeve 
ucro no vacancies. No dispensers in the Territorial Army held 
tho qualification of pharmacist. 

Cost Aecounis of A'aval and Alilitm'}/ ffo.’cpitah, — Answering Dr 
Vernon Davies, on June 13tli, Mr. A. M. S.aaiuei. said cost 
accounts in a common form had been compiled for a period of 
three months at one naval, one n.ilitary, and one Air Force 
hospital, and had been considered by tho" Joint Medical Services 
Commilleo of the three departments. The modifications required 
ill tho common form before it would bo suitable for general 
adoption had not been decided, “ 


Lack of Hospital Hrrvicc in A'orth Uist . — On June 12th Sir J.*' 
Gilmour told Mr. MacKenzio Livingstone that lie was aware 
that there was no hospital in North Hist. The provision of an 
adequate hospital service was complicated by transport difficulties^ 
by the comparatively small population to be served, and by tbo 
position, of the Highlands and Islands (Medical. Service) Fund 
which was mortgaged to present commitments. Tho matter wa«’ 
however, receiving consideration. 


CiXamimtiwn oj £.ninjv(UHs to ijanaaa. — Un June 18lh Sir R 
TnojiiS asked it Mr. Amevy knew that Ikere were widespread 
complamls t'lat the new system of medical inspection Iiid 
aiitagoiiizocl tlio British medical profession and creat^ an atmo 
sphere nnfavourable to emigration to Canada, and whether lie 
would discuss tins with the Dominion' Government Mr A'tpy 
said he had seen press statements of the kind, but he ’wS. not 


1096 June if, 192 S] 


MEDIOAIj news. 


I T;rr r.iimw 
MhtJlCiL Jovusii 


prepared at present to express any oj)inion on the cfTcel of ilio 
new system of medical inspection on tl»u inovcmenl from iliis 
country. From the latest information in tlic press he fjalhcred 
that it was proposed materially to modify the new system. 
From Jamiaiw Isl to April 30ih ilic Canadian Government doctors 
rejected 1,740 persons in the United Kingdom as unfit for emigra- 
tion to Canada. 

Noisr of Motor VihicUa (nnl Xirvouf: Cout]‘Jaiiit(t , — On June 6tli 
Sir Kingsley Wood told Sir Kobert Thomas that tlie Minister 
of Health had no particulars of the mjml)cr of patients who 
underwent treatment for nervous complaints in London hospitals 
each year from 1920 to 1927, nor in the fn st quarter of 1928. 
Sir Robert Thomas asked whether those responsible for hospitals 
and nursing homes in London did not think the trouhlc was duo 
to the noise caused by the absence of silenccr.s on motor cai*s 
and motor cycles. The Speaker, intervening, said Sir Robert was 
putting his own views. In a reply, on June 7lh, to Sir Robert 
Thomas, Captain Margesson, answering for the Home OITicc, 
said that during the last six months of 1927 there were 0,622 
prosecutions of motorists in the Mctropolilan police district for 
excessive noise, and from January 1st to Aniil oOlh, 1928, 4,150. 


A’o/f.i iti Jfrief. 

A scheme for provision of separation wards in Lambeth Hos- 
pital is being considered by the guardians. 

The calves at Hendon are killed on the same day on which the 
lymph is collected. The carcass and internal organs are fully 
examined by a veterinarj surgeon for an}* morbid condition, 
including tuberculosis. 

The report on post-operative tetanus submitted to the Scottish 
Office is still under consideration, and, on June 13lh, the Secretary 
for Scotland could make no statement on it. 

The provisional number of notifications of small-jiox in England 
and AValcs in the thirteen weeks ended June 2nd, 1928, is 4,239. 

Commander Kenworthy picsented in the House of Commons, on 
June 6th, a petition signed by 26,031 pei-sons. asking for the 
prohibition by law of experiments on living animals. 

There were 240,392 pei'sons in receipt of relief in Scotland on 
January 15tn, 1928. The number of lunatic poor has not varied 
much from May 15th, 1927, when it was 18,322. 

Under the Refractories Industries (Silicosis) scheme fovou com- 
mittees had been set up to decide compensation to workers in- 
capacitated by silicosis. 

Sir Kingsley Wood slates that it is not possible to make a 
reliable estimate of the present shortage of houses in England and 
Wales. 

The number of deaths classed as due to chiidbirth in the 
boroughs of Kensington and Southwark in 1927 were respect ivciv 
2.26 and 2.57 per 1,W0 live births. 




His Majesty the King will open tlio Now Uni vorsitj- College 
BuiUlings at Nottliighani, evected by Sir Jesse Boot, Bt., on 
the aitemoon of Tuesday, July lOtb. 

The annual general meeting of the Eoyal Society of 
Medicine will be held at 1, Wiuipole Street, on Tuesday, 
duly 3ra, at4 o'clock, when the olflcers and council for the 
session 1928-29 will be elected, aucl the renort of council will 
bo presented. 

The prizes and certificates of tlie London (Bos'al Free 
Hospital) of Medmine for Women will be presented by 

Dr. Artbur G. Bhcar, C.B., on Thursday, June 28lb, at 4 p.m.; 
the cliairwill be taken by Lady Barrett, C.B.E. After the 
aistrilmtiou of prizes the memorial porch in the north-east 
of tlie quadrangle will be. unveiled by the Bb'ht Hon Sir 
Francis Acland, Bt. ° ' 

The Fellowship of Medicine and Post-Graduate Association 
announces that , a clinical demonstration will be eivnn nn 
Tuesday, June 26th, at 2.30 p.m., by Mr. Roeyn- Jones in the 
out-patient department of the Boyal National Ortbrnnorii- 
Hospital, and on Wednesday, June 27th, at 3 p.m^ Mr^ 
Biokerton .will give a clinical ophthalmic demonstration at 
the Royal Eye Hospital. From June 25th to July 21st there 

.will ho a course of lecture demonstrations on the diagnosis 

and tieatuient of common diseases of the nervous system at 

tlio AVest End Hospital for Nervous Diseases. Special courses 
will take place during Jnlj' and Augustas follows: medicine 
surgery, and special departments, Prince of Wale.s’s Hospital' 
July 9th to 21st; proctology, St. Marir’s Hospital, Jnly 9tb 
to Mth ; medicine, surgery, and special departments 
Queen Mary’s Hospital, August 27th to September' 8th • 
diseases of the chest, Brompton Hospital, Jnly 30th to 

I ‘ 1 ‘seases of infants, Infants Hospital, August 13th 
1st ' nH'^'- A” Hospital. August 7th to Sertembm 

raav bo obtateeri'Jl"'' 5'.“^ information on the general course 
™ Wimpote Sreot™ 7.1.'“= tecretary, Fellowship of Medicine. 


TflH treasurer of King Edward’s Ho.spit.al Fund for London 
has received a gift of £10,000 from an anonymous donor. 

The Minister of Health has appointed Lord Blancsbmgh to 
bo clialrman of tlio Advisory C’ommlttco on tlio Welfare of 
the Blind in siicccssion to tlie late Mr. G. H. Roberts. 

The Mini.stor of Ilcalth has appointed Mr.s. Barton, .7.P., 
ns nn additional iiiombor of tlio Departmental Coiiiinittce 
wlilcli, ns recorded on Juno 9th (p. 1006), he set up shortly 
before Whitsun to con.sidcr tlio working of the Midwives Acts 
and conditions of oinployincnt of mldwlvos. 

Dn. I'liANK Gower Gardner has boon elected county 
director of tlio Brltisli Bed Cross Society for O.Kfordshite, 
vice Colonel Slauior Waller, resigned. 

The following have been elected Fellows of the Royal 
Sanitary Institute : Dr. Cyril Banks (Halifax), Dr. Henry 
Josopli Milligan (Rending), and Dr. Andrew James .Shinnio 

Comtnomorntion Day ccrcinony at Livingstone 
College, Leyton, on JimclStli, tho chair was tniieii by Dr, G. 
Carmichael Low, senior pliyslcinn, Hospital for Tropical 
Diaensos and Seamen’s Hospital, who gave a brief addre.ss on 
tho development of tropical medicine. Dr. Low described 
tho progress made in tho treatment of such diseases ns 
innlarln, yellow lever, knln-azar, and plague, and emphasized 
tho raluo of some training in tropical mcdicino for all who 
went abroad. Many of tlio students of the college, ho said, 
were treating j’aws, sleeping sicUness, and leprosy under tho 
direction of tlio Government iiicdicnl services in Africa and in 
other lands. Tho Southern Rhodesian Government wore now 
making raoiioy grants to tlioso who had had tho full training at 
Hviugstone College, to iiclp them with their dressings and 
medicines. Mr. ,S. Peake, a ml.ssionary wiio has been working 
In South India for the past twenty-nine years, referred to the 
value of teaching missiounrio.s to care for their own Iiealth 
and Hint of their coilcagnes when far from qualified medical 
aid. Dealing with work among others ho said ho had treated 
nearly 100,000 people at his disponsnrj’. Tho principal of the 
college stated that 1,020 students h.sd passed through it for 
training, and asked for tho support of jiiissloiiary societies 
by sending their candidates for training. Tlio college requires 
tho sum of £^00 to enable it to close tlie financial year without 
R doliolt. 

Messrs. H. K. Lewis, the wcll-liiiown medical puhlisher.s 
and boolcscllcr.s of Gower Street, have issued a small 
pamphlet giving details of tlio service iviiich they liavo 
built up as a result of eighty-four ycar.s’ spoeinlized 
cxporlonco. Tlioir publications have incliidcd tho works of 
such men ns Jonner, Lister, and Osier, nud to-day cover 
nvory widn Held, wliilo the bookselling department maintains 
a stock comprising every important new English hoolc on 
medicine or surgery, besides many other sciciitiflo and 
teclinleal works, and its resources include arrangements for 
obtainin'’ foreign publications. Lewis’s circulating library 
offers facilities for tho most persistent borrower, and is 
provided with a reading and writing room, where books may 
bo inspected nud works of roferenoo cousnltod. 

Two further pamphlets, forming parts of tho EncyclopacHia 
of Intlvslrinl Jlcnllh, Which is being Issued seriatim by the 
International liabour Oflice, and wUl ultimately appear also 
in volurao form, have been published. One of these (com- 
prising Brochures Nos. 95 to 100) deals with electricity as 
a cause of industrial hazards; flax and linen industry; 
phosphurotted hydrogen; goggles; hemp manufacture; 
odours. Tho other (Brochures Nos. 101 to 108) relates to 
arscnobenzol ; artificial flowers and artists: liftmen; the 
stone industry; sulphate of soda; sulphuretted Iiydrogen; 
nitrogen; am’inophcnols ; anisidines; anthraquinoue; anti- 
moniuretted hydrogen, and apoatropine. 

Dr. Emid Abderhaeden, professor of pliv’siology at Haile 
University, has been nominated an honoraiy mciiibcr of the 
Chinese Fhy.siological Societj' at Pekin ; Dr. Paul Schuster, 
professor of- neurology at Berlin University, has been 
nominated an honorary member of the .Sociota Italiana 
Otomeuro-Oftalmologica ; and Dr. Karl Scheele, professor of 
Surgery at Frankfort, has been nominated corresiionding 
meniberof the Societa Italiana di Hrologia. 

The following appointments have recently been made m 
foreign facilities of medicine: Profe.ssor Giuseppe Caroniiq 
director of the pediatric clinic at Rome, lias been traiisferrca 
to. the chair of infectious diseases of children at Naples : 
Professor Lnigi Spolverini has been appointed director of tho 
pediatric clinic at Rome; Professor Rocco Jemma has been 
nominated director of the faculty of medicine at Naples , 
Professor Nojons of Louvain lias succeeded Piofe.ssor 
Zwaardeiiielier in the chair of pliysiology at Utieclit; Di. 
Erich Preihei. von Redwitz has been appointed professor ot 
surgery at Bonn, and Professor R. L. Porter dean of tliq 


^London). 
AT tho 



3uNE S3, igsS] 


BETTERS, NOTES, AND ANSWERS. 


f TscBRmts infl7 
L Mxoicix, Jounub 


faculty of modioino at Sau Francisco ; Professor von Economo 
of Vienna, professor of nonroloj^y at ZflrlcU ; Professor von 
Ilaberer of Graz, professor of surgery at Dilssoldort; Professor 
von Gaza of Gottingen, professor of surgery at Rostock; Dr. 
Angiola Borrlno, professor of clinical pediatrics at Sassarl, 
Sardinia; and Dr. Karl Lindner, professor of oplitUalmology 
at Vienna in succession to Professor Dimmer. 

The report of tUo Huntingdon Memorial Hospital for Cancer 
Research and the associated laboratories, controlled by the 
Caucer Commission of Harvard University, for 192G-27 con- 
tains an interesting account of tho inorcaso in facilities 
for tho diagnosis and treatment of cancer in tho State of 
Massachusetts. Rofcronco is made to tlio opening of sovernl 
now voluntary hospitals and clinics dealing with this disoaso, 
and to tho establishment by tho Doparlmontof Public Health 
of six caucer clinics and a State cancer hospital. Tho 
•publicity secured by these developments has led more people 
to seek advice for incipient or suspected cancer. In tho year 
192S-27, in spite of tho creation of so many now institutions, 
tho number of cases dealt with at tho Huntingdon Hospital 
showed a considorablo Increase. Tlicro is, in connexion 
with tho laboratories, a free diagnosis service for pathological 
material supported by tho Massachusetts Public Health 
Department and available for every registered medical 
practitioner in the State. , 

Ax Ordinanoo to'mako provision for tho medical inspection 
of school children in Trinidad and Tobago has received tho 
Governor’s consent. Under this Ordinanoo tho Governor is 
empowered to appoint members of tho Sledlcal Board of 
Trinidad, and such olllccrs as he may consider necessary for 
the purposes of tho Ordinance, to bo' school medical oQlcers. 
A school medical olHcor has tho right to enter and inspect, 
with or without notice, any school during school hours, and 
must repotfon his inspection to tho Surgeon-General. Ho 
may arrange for tho medical inspection of all pupils attending 
any school. The Governor in Council may make regulations 
prescribing tho nature of tho medical Inspection of pnplls 
attending school, and tho forms and records to bo used In 
relation to snoh medical inspection. 

The jubilee of tho Queen Eiisahoth Sanatorium, BndaUcszi, 
which was tho first tuberculosis sanatorium in Hungary, is 
being celebrated by the laying of a commemoration stono and 
the unveiling of a statuo of tho founder, tho late Professor 
Baron Frederick von Koranyi, who was also tho founder of 
tho Budapest society now responsiblo for tho institution — an 
organization devoted to tho provision of sanatorium facilities 
for persons of limited moans. 


The area of Hungary was reduced by tho war from 125,40 
square miles to 35,870. Its prcsont-d.ay population is 7,980,141 
Prior to tho war Hungary was a constitutional and hereditar 
monarchy. In 1918 King Charles abdicated, and a repnbll 
was declared. After a brief experience of Soviet misrule th 
national government was restored, and Hungary is now 
monarchy with a vacant throno under a regent. Tho loci 
administrative areas are counties and boroughs, tho forme 
subdivided. , Tho Minister of Labour and Social Wolfari 
Who is respous^iblo for health administration, is advised b 
Health Council, whoso members nr 
1 '^Tr° workers in the medical professioi 

n to tho Ministry supplie 

had been countings of the poopi 
IRRC- m'**' Vi'* '"O^nrn census of Hungary was i 
riAAAAAiof ° V*®” census has been talicn at approximate! 
rlArT^A‘A‘®"^!®-A S'^Ristration began in 1784, when th 
nliAid registers. In 1894 it wa 

davR nnh hf* fi! ®lrtiis mnst be declared within sove 

EnhRtUn?A^ti V*? former by the father or hi 

attendariAi ^Ar ”C3'rest relative, tho doctor i 

fn 197I' os a'*?'* household. Tlie birth rat 

sKthfcc^l Anhli 17.1. There are seven 

Freuph ' printed in Magyar, German, an 

with n’lnonA diseases are uotilinblo,togGth( 

mb pellagra, ankylostomiksis, an 

primarily respon.sible ft 
bv loral A, °^l”leetlous disease mnst he reporte 
Welfare m Labour and Soci. 

nation Rnh hours of their occurrence. Vacc 

pmso?v 'rnhIvAni‘rV°“ °“aer 12 years of age are con 
paign ^ subject of a special can 

1 000 • in 1925 was 2.4 p< 

now "ethniAAi'in^^vT^^'' of the people of Hungary ai 

predominates.^ Hungarian, and the Hungarian languaf 


As^sTCia^ion^hL h**'“*’’ ^‘‘esident of the British Medict 


aittr ^nsiuxs. 


AI! communications in regard to editorial business should b« 
addressed to Tho EDITOR, Brltlvh lYIctJlcal *Journctff British 
Medical Association Houso, Tavistock Square, W,C.1, 

ORIGINATi AUTICTjES and LETTERS forwarded for publicntion 

. aro understood to bo offered to t!io Bkitisii IIedical Jourhil 
ftlono unless tlio contrary bo stated. CoiTes])ondcnts wlio wish 
notico to bo taken of tlicir communications should aulhciilicato 
them with their uanics. not necessarily for publication. 

Authors desiring REPRINTS of their articles published in the 
Bcmsii MEDicAf, JounxAL must communicate with the Financial 
Secretary and Business Manager, British . Medical Association 

■ House. Tavistock Square, W.C.l, on rcccipt'of proofs. 

All ccminunications with reference to ADVERTISEMENTS, as well 
as orders for copies of tho Jouruat., should bo addressed to tho 
Financial Secretary and Business Manager. 

Tho TELEPHONE NUMBERS of tho British Jlcdical Association 
and the Bamsii Medical Joitrsal are MUSEV2I OSOl, 9S6S, 9S0S, 
and bsO^ (internal exchange, four lines). 

Tho TELEGRAPHIC ADDRESSES are i 

EDITOR of tho British Medical Jocrital, Aiitolopp Wcstceni, 
London. 

FINANCIAL SECRETARY AND BUSINESS MANAGER 
(Advertisements, clc.j. Articxilaie TTcAfccnf, London. 

MEDICAL SECRETARY, ilcdtsccra Wcstccnt, London. 

Tho address of tho Irish OfRco of the British Medical Association' 
is 16, South Frederick Street^ Dublin (telegrams : ffncilltts, 
Dublin; telephone: 62550 Dublin), and of the Scottish Office, 
7, Drumsheugh Gardens, Edinburgh (telegrams: Associate, 
Edinburffh; tcTcphono 24361 Edinburgn). 


QUERIES AND ANSWERS. 


Status Epilepticus. 

**H. C. B.** asks for suggestions ns to tbo treatment of thia 
conditiou in n child 9 years old, subject to fits from infancy. 
The ftltacks aro extremely severe* the violent (convulsive) stage 

> hours, and forty^eight honrs of complete 

4 • • They are preceded by n scries of 

• . * , ow hours between each. Of late tho 

child has had nn attaci: about every fortnight. Bromides, 
chloral, and paraldehyde per rectum, even in large doses, do noi 
have any effect. Neither chloroform nor morphine has been 
employed, and information ns to the adAtiufages and dangers of 
these would bo much appreciated, and also as to any electrical 
or mechanical treatment. Whatever its cause, there is obviously 
in status epilepticus a tumultuous and uucontrolled discharge of 
nervous impulses. It does not seem unreasonabJe to think of 
tapping and short-circuiting these by means of some appliance 
to the head and spine, or of influencing them by the passage 
through the body of an electric current. * 


V.. V/AXAiULU, 

Dr. J. van Millikgen (Havlesden) writes;! would advise ** 0 f! »• 
(Mayr'“‘'-.r "r-*- 

Done’ • " ■ • ' . * V 

in ba« u» wen u-y lo clean out a hou^e bv 

pouring a bucket of water through the frpnt door and out at the 
back. Sprays have the ^me disadvantage, as they do not reach 
the various chambers and passages of the nasopharynx. He will 
find iusnraatjon by far the roost effective method; it has civen 
me most satisfactory results during the last five years of mv 
pmctice. I have practised it in about eighty cases, some of 
which have been exceedingly chronic. Among these were three 
ofatrophic rlumtis. which so far improved as to be free from 
two most omectionable features of this disease— namely, ozacun 
and a constant desii'e to free tlio nose from the obstniction- 
two true hay fever cases, in which no attacks occuned diiriuc 
the period of treatment, and one patient wlio had liad seventeen 
Eeasonal attacks, completely escaping during the period of treat- 
ment ; and three patients with catarrhal deafness, one of whom 
recovered completely in a fortnight and tlie other two so 
improved, after life-long deafness, ns to be very gratified wRh 
the result. It is immaterial what powder is used, but it* is 
important that one should cease using any particnlur powder no 
soon as unpleasant symptoms supervene and then chocse anothev 
powder having n totally different action. Treatment should he 
from one to three mouths; most of my cases showed imnroiv 
meut in two or three weeks. The powders recommended 
lodol, orthoform, and 10 per cent, euflavine in casein fO>f 
(soluble). Insufflation rendersv it possible to detect caseq nl 
fieepev EigaiQcaace than nasal cata^h, lor those which are no 
cleared np by this methoa should be sent to a snecialist 
further investigation and treatment. ^ ciaiist lot 

, . . Mjgeaine. 

“ M; D." writes to say that “ M.R.C.S. ” vrhnai 
on June 2nd. will find in the SritUh appearet 

1927 (p. 700), a note on the treatment of 



r Titr ■nnrn'oc lAQQ 

UtrrucAi, Jocnwit J-viOO 


Juki; 30, i9=3] 


THE PLACE OF BIOCHEMISTRY IN MEDICINE. 


3^.11 ^tibrrss 


THE PLACE OE BIOCHEAIISTRY 
IN MEDICINE. 

Dkuvfrf.d at Tin; Opkniko of tiii; Couutaui.d In.stitctk 

OF BlOfHF.MISTIlY AT TIIF. jMlDOl.F.snx lIoSl'ITAI. 

. . OS'- Jfs'K IAtii, 

Sin ARC'HIBAii) GARROl), K.ci.M.G., D.IM., F.R.S. 


Fon more tliaii a century past every medical man 1ms had, 
in his consulting room or near it, a shelf rvith a few bottles 
of reagents, a spirit lamp, and some test tubes, with which 
to carry out certain simple chcmic.al investigations which 
form part of clinical routine. That shelf is the prototype 
of this great institute, with which the munificence of Mr. 
Samuel Conrtauld has enriched the Middlesex Hospital; 
and the contrast between prototype and acliiovcment is no 
greater than that between the medical chemistry of a 
Imndrcd years ago and the biochemistry of to-day. 

Indeed, the year 1828 marked an epoch, for in it the 
German chemist AVbliler, afterwards the fellow worker with 
I.iebig, obtained that most abundant jiroduct of animal 
cbemistrj-, urea, as a result of a reaction in the laboratory, 
and so began the removal of the barrier which was believed 
to separate organic from inorganic coni])ouiids — the 
chemistry of living things from the chemistry of the rocks. 


Eorbj Assoridtion nf Chciiiislri/ vitli ifrdiciitc. 

But the association of chemistry with medicine dates 
back much further. Even the alchemists tried to prcimre 
the elixir of life. In the early part of the sixteenth 
ceiitnn' lived that eccentric genius who called hinnsolf 
Par.acelsns. who looked upon medicine from the standpoint 
of chemi.stry: and in the sixteenth century was born 
van Helmont. who has been called the father of chemical 
physiologA', of both of whoso contributions you may read 
in Michael Foster's Lectures on the History oj I’hysiology. 
In the .seventeenth century our couiitryman 'riiomas IVillis 
discovered glycosuria. Many of the iiionecr.s of chemistry 
"ere medical men, some of whom occupied chairs both of 
medicine and of chemi.stry; and so medicine has played an 
important part in the building up of this, as of -other 
branches of pure science, and often provided the early 
chemist with a means of gaining his livelihood. In return 
chemistry has rendered immense services to the advance- 
ment of medicine. 

M herever a medieal seliool was founded a professor of 
c lemisti-y was appointed, and in Edinburgh, at the end of 
le eigiteentb century, there ivas a remarkable group of 
e iemist-pbysicians, which included Cullen, Joseph Black, 
the discoverer of latent heat, and Daniel Rutherford. In 
lo^e (ia^s numbers of future physicians, niul amongst them 
iI'V f “’‘•''^hiatec of Oxford and Cambridge, went to 
vlV"."-'® 'i ^ i^^hnical training, and some of these, 
inning to London, brought with them the current teach- 
ings of the school. Amongst these was Alexander Marcet, 
•'>'»d afterwards physician to Guy’s 
I ' niade some valuable contributions to pure 

ciemistn- as well as to chemical pathology. A slightly 
older contemporary was 'lYilliam Hyde Wollasto.T, a 
a of the ductility of platinum, 

tVnll ° 1 '"“'.''Robing A'alue to chemists and physicists, 

to riV"; nodical practice after' failure 

■bln so.f i «oorge’s Hospital, devoted 

0 ^ oD r •■■■’'> gained distinction in phvsio- 

tlmfi -a F '’Otany. He'w.as 

c Wfiili* ^ scientific study of the comoositioii of 

Tu V.r.ni of these, and like Marcet 

tHod to n'i'!' T ^Villiam Proiit, who is en- 

Pbv.iolm f '‘.'"S'' P'^oo among the fonnders cf chemical 
in tie 'I'^ooverer of bvdrocliloric'-.'icid 

plivsinln "0 ,piicc_a vital finding in connexion with the 

Chen ist of digestion. Ho won fame as a 

leniist also, for Ins celebrated hypothesis that the atomic 


weights of other elements arc niultiplc.s of that- of hydrogen 
and that from hydrogen all other elements arc derived 
has over since set chemists thinking, and has inoved a 
powerful .stimulus to rcsenreh. 

'J’lie gcneiation which sneroeded these men in London 
producoil another group of chemist-physicians, whoso work 
was carried out in the middle years of the la.st century. 
Among them Hcnn- Bcnco Jones may claim a prominent 
place. He was a jnipil of Thomas Graham, who first investi- 
gated the colloid state, and of Liebig, and a friend and the 
biographer of Faraday. His best remembered contribution 
to medical clieniistry was the discovery in urine of the 
peculiar jirotoin substance which bears bis name. Among 
his contemporaries, and also a pupil of Thomas Graham, 
was my father — not to refer to him in this connexion 
would be the outcome of a false modesty. He, in 1848, by 
means of n tost of extreme simplicity, but which c.-ills for 
some skill to carry it out, demonstrated the pre.soncc of 
uric acid in tbo blood of gouty subjects, and estimated 
approximately its amounts. Thus was eberaical examina- 
tion of tlio blood of living persons first made available 
as a means of diagnosis; and the developments of such 
methods, in the bands of Bang, Folin, and others, are 
familiar to students nt the present day. These modern 
methods yield, with small quantities of blood, drawn 
from a vein or even from the lobe of tlio ear, results 
of great accuracy and diagnostic value. Somcwliaf younger 
contemporaries wore 'J'liiidicbnm, whoso work is now 
better appreciated than formerly, and Frederick AVilliam 
Pavy, wiio devoted much time tlivoughout a long working 
life to the study of dinhotes, but did hot live to see the 
discoverj- of insulin. Ho it was, also, who first described 
cj'clic albuminuria. It is told that one of bis colleagues 
nt Guy’s Hospital, himself a great plij-sician, expressed 
.surprise that Pavy sboiild devote all bis best energies to 
the study of an iiienrable m.Tlady; but granting that even 
now wo cannot cure diabetes, the advance made towards 
that goal shows that tbo time and energy of those who have 
workcil at the subject have not been wasted. 

Meanwhile, in a wider sense, and in a far wider field, 
tbo study of animal chemistry was advancing steadily. 
Much of’ the advaiico was due to the teaching, influence, 
and opportunities of research provided by Justus von 
Liebig in bis laboratories at Giessen, and later in Berlin; 
and there come to mind the names of other groat bio- 
chemists of the nineteenth century, among them those of 
Pasteur, IVnrtz, Hoppe-Soylcr, Karl Sclimid^, Emil 
Fischer, Hiipiiert, and Arthur Gamgee, to mention only 
a few. 

Nowad.ays very different conditions prevail. A consider- 
able number of those who obtain medical degrees or qualifi- 
cations turn aside from the path of practice and devote 
themselves to laboratoi'y work in the medical sciences, as 
pathologists, physiologists, biochemists, or pbaniiacologists. 
For these men it lias been necessary to provide adequate 
accommodation. Tlio Institute of Physiology no longer 
houses both biophysics and bioelicmistry ; patliolog}- has 
split into several branches — namely, bacteriologj-, morbid 
anatomy, and jiatbological chemistry. In biochemistry 
far more work is being done, and those who pui’sue it 
are almost all able to devote their whole time to it. Tbo 
names of living biochemists who liavo done or have sur- 
passed such work as that of onr forefathers referred to, 
form a I'erj- long list, in which onr own countrymen 
occupj' a place of whieli wo may he proud. Centres of 
biochemical teaching and research, such as that over 
which Sir Frederick Hopkins presides at Cambridge, are 
now being formed in various universities in this country 
and we are met together for the inauguration of the 
latest of these to-daA-. 

Bacteriology and Chemical Pathology. 

It must not he forgotten that the aims and raetliods 
of tlio several branches wliicli are included under the 
collective name of pathologA- differ considerably; and thi.s 
is specially true of bacteriology and chemical' patliolon-v 
although in the field of iramnnitr they overlap and must 
collaborate. The bacteriologist studies' the afctual agents 
of disease, the stone which, as it falls into the- pool ruffles 
Its surface, whereas the biochemist studies the ’rinnlpc 
which spread outwards in increasing circles, from the 

[ 3521 ] 



1100 JDNB 30, 192S] 


THE PLACE OF BIOCHEMISTRY IN MEDICINE. 


f Tut: KnmTif 
LMEDICALJoCliXlt ■ 


point of impact of tlie stoiio — in otlicr word"!, tlio dis- 
turbances of the metabolic processes wliich result from 
the bacterial invasion. 

Of recent years, under tlie spell of tbc advances of 
bacteriology and protozoology, wo liavo tended to ln_Y all 
the stress upon the invading malady and to pay too little 
attention to the reaction of the organism invaded, but 
thcio are signs that the pendulum is returning from the 
limit of its swing, and in its modern dress the revived 
doctrine of diathesis will rest largely upon a chemical 
basis. 

The newer biochemistry docs not restrict itself any 
longer to the older problems of chemical constitution 
and the products and methods of metabolism. I'he pby.sico- 
chemical aspects of the subject are receiving more mid 
more attention. Wo may hope that, important as those 
aspects are, they will not so engross attention that the 
older problems will be. neglected. 

Not only does the modern pathological chemistry embrace 
a far larger field, but the .simple methods of our pre- 
decessors no longer suffice for its ref|uiremcuts. E.samina- 
tions of greater and greater delicacy are called for; 
apparatus is needed which requires ample laboratory .space, 
and which is itself often costly. No wonder that the 
cost of liospital equipment and uphci'p has increased 
greath-. Fortunately donors arc heginniiig to realize that 
by providing a great hospital with .such au institute ns 
this they aro rendering as much, or more, aid to the '•ick 
and suffering around n.s as hy the addition of so many 
more beds. Ihe value of a hospital depeiuls not onlv upon 
the number of patients treated, but also upon the quality 
of the relief given, and, as I shall hope to couvinco you, 
the value of such a hospital ns this, and the good w'hich 
it does, is not limited to the area in irhich it is situated, 
nor even to its wider clientele; but, .so far as it is a place 
in which knoiyledgo is increased, its iiifluoucv extend.s to 
wherever medicine is taught, and those who are trained 
hero diffuse its teachings all over tho world. 


The Importance of Biochcmisinj in flic Diayno.il.i, 
Prognosis, and Treatment of Disease. 

Let me try, then, to set before you wherein the im- 
portance of biochemistry to medicine consists, and why 
such departments as that which has been opened here 
to-day aro desirable, or even essential, parts of the equip- 
ment of such a hospital as this. Lot me speak finit of 
the more strictly practical aspects of my subject, of the 
aid which biochemistry affords in tho diagnosi.s, prognosis 
and treatment of disease. ” ’ 

Tlieio are a few maladies the diagnosis of which rests 
upon chemical evidence, or in which ■ ■ ■ 

the chemical processes is usually the , 

IS often the case with diabetes, 'which is not iiifrequeutlv 
tirst detected on examination of the patient for life 
insurance, and the earlier tho recognition of the malady 
the better is the prospect of treatment. Indeed, all 
through the course of diabetes chemical tests are of 
value, as iiulicators of relapse or of rcs])onse to treatment, 
as well as of the inimiiieiice of. danger from aeetoiiaeinia! 
The estimation of glucose in a few drops of blood is of 
special value, especially in distinguishing betwdeii true 
diabolcs and varieties of glycosuria which are apnareiii/lv 
harmless, which call for no restrictions of diet and in 
which such restrictions may be undesirable. From .such 
examinations also the effects of dietetic and insulin tre-vt- 
ment can be determined, -\gain, the reducing power of 
tho urine may be due to sugare which are not ejucose 
and have quite different significance, and- these '^an be 
I’ecogiiized by various chemical tests. ' - 

Tho inodern niothods employed in these examinations of 
glycosuric 'paticnts demand techniciil skill in the exainiiier' 
.and a variety of iiiaiiipiihitioiis which are best carried out 
in a laboratoiy. 

Another disease which has always bc’cii classed as a 
disoixler of nietabolism is gout. It' looms le.ss Jamelv oil 
the popular, as well as on the medical, horizon tlmii* was 
the case twenty or thirty yeare ago. Two factors combi, ‘lo 
to bring tins about. First, a large number of conditions 
fovmovly cbwscd as gouty arb now referred to othercaT 
gorios-oral sepsis or ivbat not; and secondliy owing 


.sumahly to change of hahits and modes of life, true gout, 
the podagra of the ancients, is much less common in Loiulon 
than it used lo he. How rarely do wo now see the chalk- 
.stones upon the hands, with which our forchoars' were falsely 
reported to have hecn able to .score iqion the cloth of tho 
card-tahlo. Now that. wo can measure with accuracy the 
amount of uric acid in .small quantities of hlood wo can 
exclude the cases which do not fall into the strict c.ategoiy, 
and iucludo others tho goutiness of which is apt to cause 
surprise. 

There arc various rare conditions for tho recognition of 
which testing of tho excreta is c.ssential ; and by such 
chemical te.sls it is often possible to detect a drug which 
has been adminislcretl. .Some poisons also aro found by 
examinntiou of certain tissues, such ns ai-senic in hair. 

Chemical tests may afford most ini|)ortiint evidence as to 
the functional efficiency or otherwise of certain organs, and 
these tests have bt'on multiplietl and greatly elahorated in 
recent years. 

In most cases a diagnosis consists of two parts — namely, 
the nature and tho seat of the di.sease — and it is with the 
.seat that we aro at this momont concerned. Tho detection 
of alliumiii in the urine is one of tho oldest means of 
detecting damage to tho kidneys, but,' n.s with glycosuria, 
not all albuminuria is of evil omen, lii more recent years 
the tests- of renal efficiency have been greatly multiplied, 
and have become more delicate: by the administration of 
urea by tho mouth and the .study of its excretion we may 
measure tho efficiency of the renal njipnratus; hy the 
administiation of coitain other suhstances we may obtain 
information as to which part of tho renal apparatus is 
chielly at fault. Sloreovcr, by estimation of urea in the 
blood or ccrcbro-spinal fluid wo can learn about the effi- 
eicnev of tho kidneys from tho other side, so to speak, 
and gain information as to accumulation in tho blood and 
ti.s.sues of substances which it is the function of tho kidnevs 
to get rid of. So wo can estimate the risk of uraemia in 
a patient whoso kidneys are diseased, although urea is 
not the cause of uraemia, and wo do not yet know what 
is its cause. 

Tests on somewhat similar lines, such as- administration 
of levuloso by tho mouth, and estimation of the tolerance 
of that sugar, which is more readily excreted in tho urine 
when tho liver is diseased, or by tho determination of the 
sugar curve in' tho hlood after its administration, affoid 
valuable cvidcnco as to tho functional efficiency of the 

liver. . 

One of the most important, and at the same time most 
elusive, of our organs is tho jiancroas. Deeply seated iis it 
is, it is almost out of reach of direct clinical examination; 
oi’ily ill comparatively recent times was tho part played by 
this gland in connexion with carbohydrate metabolism dis- 
covered bv von Alohring and Minkowski. Act, hy putting 
two and "two together, by tho cumulative evidence of .a 
.scries of tests, it is often possible to reach a correct din- 
gno.sis in cases of pancreatic disease. Those tests are for 
the most part chemical, and the determination- of the 
nature and amounts of the fatty substances discharged 
from tho intestine is tho most important of them. 

To Front’s discovery of hydroeliloric acid in the gastric 
juice I have already referred, and in recent years methods 
of increasing dclicacj' and efficiency have been devised, and 
are in common use, for the chemical examination of the 
gastric or duodenal juice obtained after a test meal or 
by passage of a duodenal sound. 

The metabolic processes at work in the lii ing organism 
are of almost infinite variety ; special enzymes aro entrusted 
'with each small metabolic task, and if one fails, or is 
lacking, more or less conspicuous derangements result. 
AVe can no longer regard tbo body as a siinple furnace 
in which the food supplied is burned without discrimiiin- 
tioii. Nevertheless it is soinetimc,s useful to doterinine t.ic 
sum total of tho chemical .activities of which the- body is 
the seat, and this may bo carried - out without niiicb 
difficultj-. For cxamiilo, the metabolic fires burn up, o' 
burn low, according as the -thyroid gland is fiinctiou.auy 
overactivo or supplies too little of its hormone; and ’T 
determining the amount of oxygen utilized we may cstini.i o 
the well-being or. otherwise of tho thyroid gland. 

It is true that these tests can .seldom be carried out 


JuNv; 30 , i 02 S] 


ACUTK NECROSIS OP THE PANCREAS. 


[ Tnr 

Medical Jocrnix. 


1101 


1 : — — 

jn doctor in l)tBV inactico; Iml it is one of the <'Iiiof uses 
of siicli n department ns tliis to help the practitioner as 
well ns the liospitnl .stnfl', by reporting upon inaterinl .sub- 
mitted to it. In tills way the benelils of the biochemical 
department rcaeli a mncli wider circle than the, staff and 
patients of the hospital to which it is attached. It may 
bo objected that tho more elaborate investigations must 
iiced.s take time, whereas medicine is alwny.s in a linrry, 
and cannot wait. Crave disca.se often strikes (jnickly. and 
it m.ay he necessary to net before a report can be received. 
This is true in some eases, lint in the majority there is no 
snch urgent haste; and modern diagnostic methods would 
prove a ciirje i-athcr than a blessing if the jnaet it inner, 
trusting to them, neglected to ac(|iiire a thorough know- 
ledge of the older methods of diagnosis, uliieli rely u)ion 
tho use of hands, eyes, car.s. and nose. These instruments 
ho has with him alwny.s, and, when propel ly used, they 
|Sorre him veil. 

I might go oil to .speak of the use r.f cliemiral tests 
in prognosis, which is perhaps the most difheult provinee 
of medicine. This is well seen in eoiiiioxioii with diabete.s. 
Ill tho domain of treatment, also, hioehcinistrv )ilays an 
important ])nrt. A . better knowledge of tlie eon.stitnents 
of diet, their ntilir.atloii, and needful proportions, together 
with the discovery of vitamins, is revolntionizing the 
scieiico of dictetiesj or rather is creating stieh a icieiue. 


parts played in the anininl economy by such ehoniical 
.substances as lionnones and vitamins. If all this ho truo 
it is obvioii.s that a chemical outlook is iicodfnl for tho 
comprelieu.sion of morhid jiroccsses, and that there aro 
unlimited openings for lesenreli in bioehcmistiy. 

Here young iiive.stigators will ho guided and instructed 
in tho methods of re.spareh by the ])rofossor and other 
experienced teacher, s, who will eiicoiirago and help them to 
jinrsno jnoniising lines, and will e.vtract them from the 
hliiid alleys down which they are so a]>t, in their inexperi- 
eneo, to wander. 

Iict us wish, then, to all who work within these walls, 
whether ns tenehei -., Icarncts, or invrsiigators, good success. 
Let us wLsh, too. that the numher.s of those who shall 
engage in hioehomieal re.^eareh may he as birgo as the 
aeeommodation proviiled admits, for so will knowledge and 
wi.sdoni he increased; aiul in the book of AVisdom it is 
nritton ibni “ the miiltittulc of the irisp is the velfnrc of 
the world.” 


ACUTE KECROSIS OF THE PAA'CREAS. 

■Rkiokt or A SmtiKS of C.ises. 

BY 

J. AV. GEARA' GR.ANT, E.R.C.S., 

IIONOB.IRV SVRGEOX, BOVAL IXFIRMAKY, CARDIIT. 


Fii)ic/io)i.s 0/ Jiiorhcmirnl Liiborn/ories. 

I trust th.at I have .said enough to make it clear that tho 
practical applications of hiochemistry are of great use for 
tho solution of tho prohloin.s which confront ns at tho 
bedside; that they help in the diagnosis, jnognijsis, and 
itro.atmont of dispn.sc. That in it.self is enough to justify 
'the estahlishincnt of hiochemieal lahoratories in eomiexion 
with all hospitals. But if tliat were all wo should feel 
much satisfaction, hut not the cnlhnsiasm which is experi- 
enced to-diiy by all who have the welfare of this hospital 
and its medirnl sehool at heart, on tlie oeeasion of tho 
opening of this splendid in.slilnte. 

There are two much greater functions which the institute 
will perform. In it generations of stndont.s will learn from 
competent teachers biochemical methods, and how to carry 
out the various tests which arc so helpful in eliiiital work. 
It is true that many of them may not, in after-life, have 
the opportunity of liorformiiig these tests for themselves; 
hut it is hardly noecssarv to insist on the jioint that he 
who acts on, tho result of a test should know how it is 
earned out. If he has himself learned how to do it ho is 
i'blgo of its value and significaiicc. 

Ihe students of the London schools tlistriliiitc themselves 
ovei the world, and carry tho tcarhing which thev have 
received into remote parts of the earth. OlivionsK' toaeh- 
ing IS one of tho chief functions of this institute, 

“"‘I mind its most 

+mn + ''•'f ’ It is now recognized that, in addi- 

ciiiA .°i" ^ cue img every university and place of advanced 
7 -ecr.s ns one of its duties the furtherance of original 
hntFtJ ^ ■'’'i'’nnocd teacher will do his work 

Siho taci?es ^ knowledge of tho subject 

looked tipon from several distinct 
is*se^.nni +’ 'n'portaiice, tho chemical Standpoint 

from ^ none, ns is heconiing more clcarlv recognized 
■inebmfnor Bi'>'^l>o>"istry is not merely a nsefnl 

K m 4 stiuly for the jnedical man, blit 

1 ; ^ ° leiy ossonce of his .science, and, through 

itiis science, of Ins art. 

Inf^ni'mo?'' different genera and species 

struetiir'e P niits chffer from each other in chemical 

that no fir ^ nAO™'oal life, and evidence is accuiiiidating 
in'ehomi " ninnls of a species aro aiiv more identical 

a cWoa‘l'’-''l It would seem that there is 

are sMed n.f f 'lopartnros from type which 

iTabilitfi of ^ hoiieve that the 

from corf • •ndividnals to, or their imiiinnity 

—hare ^ called tlieir diatlieses 

which the had .^"J^nnbtcdly the iiicchanisiiis by 

or poisons feZ V T*' '^ooterial inyasioiis 

nnd it is not ■ lor the most part, chemical; 

0 It IS not necessary to point out the importance of tho 


.VenTn pancreatitis, althmigh 0110 of the raver causes of tho 
acute abdomen, in some of its loss acute and dramatic 
manifestations is jiossibly more conimoii than is generally 
realized. In rending records of reported cases it is obvious 
that it is frcijneiitly diagnosed prior to opovntioii as intes- 
tinal obstruction, jiorforation of a viscus, etc., by com- 
petent surgeons. 

It has happened that in the past two years six cases of 
this condition have come under my personal observation — 
two in private nnd four under my care in tlio Cardiff Royal 
Infirmary. Prioi' to tin's period I bad only come across or 
recognized one nndoiibtod ease, and in tho above period, 
after a careful soarch, I have only been able to find 
records of fii'o otlior ease.s in charge of the other surgeons 
of the liospital. Ry their courtesy I am permitted to 
inelmlo these in the following series. As several of these 
case.s present some one or other feature of interest, aiid ns 
tho diagnosis is always difficult and early diagnosis is of 
vital iraportaiico, I have thought them of sufficient interest 
to record. 

In Zachary Cope’s Iferhj Diagnosis of the Acute 
.•Uxtovicn' it is .stated that “ pancreatitis is a rare con- 
dition seldom diagnosed correctly before operation, .occurs 
most commonly in men, and for the most part is on’ly mot 
with in those over middle age.” In the following 'series 
of tivclvo case.s no fever than ten oceurrecl in irdmon, and 
in seven of the.so their ages ranged from 20 to 33. ' ’ 

A brief niiah-sis of tlie.se cn.ses shows: Alalos, 2 case.s; 
agcs^55 and 69. Females, 10 cases; ages 20, 22, 25, 26, 29’ 
32, 33, 54, 72, and 63: It is .Seen that whilst tlio 'ao’e of 
tho males is iii agreement with that usually stated, '’’that 
of the females shows a striking- proportion of veiw young 
women, and in 3 cases where the sexual history ‘is ‘gii eii 
parturition had taken place one month, six weeks, and 
tlireo months respectively prior to the on.sot of the attack 
and III the last case symptoms of gall-bladder trouble 
dated immediately from childbirth. 

In 10 cases stones wore found in tho gall-bladder, and in 
2 of these in the common duct, and of the latter one was 
round impacted in the ampulla of A'ater, the common duct 
being greatly distended. In this case tho patient died as 
the abdomen was opened. 

At operation fat necrosis was found in 10 cases, haemor- 
rhagic fluid in tho abdomen in 2 eases, “ beef broth ” fluid 
in 2, and straw-coloured serous fluid in 2 cases Broco’ 
states: “ des deux phenomenos qni la earacterisent, 

1 Iiemorriiagie et la necrose graisseuse, senl le premier est 
constant.” In my series fat necrosi.s was the almost con- 
stant sign whilst liaemorrimgic fluid free in the abdomen 
was found 011 only two occasions, and beef hrotli fluid on 
two other occasions. 

In 2 eases suppurative cholangitis was found: . In one of 
these (No. 4) small stones were present in the comiLn 


■ 1102 JONE . 30^ 1928] 


ACUTE NECROSIS OF THE PANCREAS. 


‘1 


Tni! CRinsv 
UeDICAI. JOCRNiA 


duct, but 110 signs of iiivolvomcnt of tlio ijiiiicreas. At 
necropsy, t\v6 days later, however, fat necrosis around tlio 
pancreas was found, and muco-pUs in the duct of Wir.siing. 
In tho other case (No. 5) the jiaticnt, aged 72, liad under- 
gone cholecystostoniy for gall-stones several years' pre- 
viously, and had boon fre.e from syin])toins until tho niglit 
before admission, when she was seised with jiain that she 
described as worse than anything she had oxj)orienced with 
gall-stone colic. At operation tho only sign of imncrcatic 
disease was one patch of fat necrosis in tho gastro-colic 
omentum, and on pal|)ation the pancreas appeared normial. 
The main ducts wore distended, readil3' admitting the index 
finger, and coirtained mueo-pus, but no sto\ies were found, 
either in tho ducts or gall-bladder. At ni;cropsy, some days 
later, the pancreas was found large, led, congested with 
numerous necrotic areas, and fat necrosis in surrounding 
tissues. 

In Case I haemorrhagic fluid was tlio one .sign which 
might have pointed to pancreatitis, hut was attributed to 
bleeding from the omentum, which walled olf a perforation 
of the gall-bladder. A week later, when tho wound was 
opened up, the pancreas was found lying as a black slough 
in an abscess cavity. 

In Case 11, after an indefinite illness following child- 
birth three months previously, where an operation on the 
gall-bladder was declined, a few days after leaving hospital 
tho tj'pical symptoms of a fulminating pancreatitis 
developed, with agonizing abdominal pain, constipation, 
tenderness, rigidity, and cyanosis. At operation a slough 
of the pancreas 3 inches long was picked out of a large 
abscess in the lo.sser sac. 

The mortality in this scries of cases was excessively high. 
As regards tho operative procodures adopted : 

2 patients recovered after simple drainage of -tho gall-bladder. 

2 recovered wliero tho gall-biaddor was slated to liavo been 
normal and the pancreas -n'as incised and a drain placed 
in its neighbourhood. 

1 died after tho same procedure. 

2 died after drainage of the common duct for cholangitis. 

1 died on tho table as the abdomen was opened. 

3 died after cholecystectomy for perforation or gangrene of 

tho gall-bladder. 

1 unoperated on. 


The views of Denver and Maugeret, that pancreatitis is 
due to infection from tho biliary tract via the lymphatic.s, 
may theoretically be hold to indicate tho removal of tho 
focus of infection in the gall-bladder, and may havo influ- 
enced one in removing it. In tho light of my present 
experience, even with a gangrenous g.all-bladder, I should 
never attempt its removal if signs of pancreatitis were 
present, but content myself with drainage. The question 
of drainage of the common duct where with a shrunken 
gall-Maddor this is not available is more difficult to decide. 
Holding the views of Opie, Moynihan, Brocq, and othere, 
that the cause in most of these cases is the entry into the 
2)ancreatic duct of infectious bile or of bile during active 
digestion, if the common duct were distended and tho 
technical difficulties did not entail too long a prolongation 
of the ojjeration it would seem desirable to lower the 
pressure m the biliary system by drainage. 

I feel, however, that in all cases where there is reason 
from the presence of haemorrhagic fluid, or. any areas of 
fat necrosis to suspect pancreatitis the condition of the 
pancreas should be inspected by direct vision after dividing 
tbe gastro-colic omentum. It is usually impossible to detci^ 
mine its condition by palpation only. If signs of oedema 
or haemorrhage are found it should be incised and 
drained. 


Case i. — Acute Haemorrhagic Pancreatitis. 

A minister of religion, aged about 50, a year previous to his 
present illness, had an attack of gall-stono colic, for which ho 
was treated at a spa with mineral watere. 

On March 2nd, 1926, he was seized with violent abdominal pain 
and was treated by injections of morphine without much relief’ 
I saw him in consultation on March 3rd, at night, in the country* 
He was obviously in very intense pain, in the epigastrium, and was 
jaundiced moderately deeply. A diagnosis of acute obstructive 
cholecystitis was made. Ho was brought into Cardiff and operated 
on at 10 a.m. tho next day^ 

Opci-ation.— Right paraniodian incision. The abdomen contained 
blood-stained fluid which was thought to comfv 


tuho [las-sed down to the stump. The pancreas was not explored, 
all' tho syjnnloms being attributed to the gangrenous ana 
perforated gall-bladder. 

For Unco or four days the jialicnt’s progress was satisfactory, 
then ho was suddenly .seized with abdominal pain and passed into 
a slate of collapse. About two pints of glucose saline were given 
intravenously, and this was repeated the next day and the stomach 
was washed out. Ho rallied. The abdominal wound was opened 
up and pus escaped. Tho urine was found to lie loaded with 
sugar, which pci’SisLcd.* He gradually sank and died in four days. 

At a limited poxt-movtaa examination the whole pancreas was 
seen to form a black sloiigli lying free in an abscess cavity. Tlicro 
was extensive fat i^ccrosis in the omenta and mesenteries. 

Cask ii. — Acute Panerratir Xccro.'fin. 

A married woman, aged 26, mother of one child, was admitted 
to tho medical side of the Uoyal Infirmary on March 24th, 1925, 
for severe and pcmslent vomiting of three weeks’ duration, which 
began a!)6nt a month after the birth of her child. Vomiting 
camo on ten to fifteen minutes after food, was copious, and was 
preceded by pain in the epigastrium pawing back to between tho 
scjmulae. . 

On April 19th I saw her in_ consultation with the physician 
in charge with a view to operation for cholecystitis. She did not 
appear to ho very ill,’ and there wero IJien no physical signs, 
tenderness over the gall-bladder region, or rigidity, and it was 
almost impossible to get anything but of her regarding her 
symptoms. It was arranged to operate on her for cholecystitis, but 
sfio went liomo at her own request, refusing operation. 

A week later I was called in by her doctor to sec her. She 
presented llio picture of an acute abdominal disaster. The 
abdomen was rigid all over and acutely tender. The pulse was 
about 160. There was a cyanotic tinge on the face. Her con- 
dition was desperate, but sho was removed to a nursing' home 
and operated on at oncc^ 

O/urttfioii . — Right paramedian incision. An abscess was found 
pointing through the gastro-colic omentum, anti when opened a 
quantity of thick pus with faecal odour came away, together with 
a black slough of the pancreas four inches by olic inch in sire, 
lying freely in the abscess cavity. The retracted gall-bladder was 
so snrunken that it appeared impossible to drain it, and it was 
removed. It contained numerous small stones. A largo tube 
brouglit out through the main wound was na.ssed into the ah«ecss 
cavity. It discharged quantities of pancreatic juice, which digested 
all tho'lissucs witli which it camo in contact and set up a sevevo 
dermatitis, although every cITorC was made lb prevent this. 

She lingered on for a week. 

Case hi. 

A woman, aged 32, had been in good health until two years 
ago, when slic began to have attacks of pain and vomiting, lasting 
Two to three days, willi varying intervals of sometimes months. 

On February 28th, 1927, sho had a much more sevci*c allaci: 
of pain in the epigastrium, radiating to the right costal margin, 
to tiio right inguinal region, and to the back. The pain was 
accompanied by vomiting. She was sent to hospital by her doctor 
as nil emergency, but was not admitted. Slic was then sent fo mo 
as a case of gall-stones and was admitted on March 10th, 1927. 
She was very obese, and on admission did not appear to be very 
ill. The abdomen moved on respiration; there was no rigidity, 
but some tenderness in the gall-bladder region. Temperaturo 
101® F., pulse 120, respiration 28. Urine, sp. gi\ 1020, nothing 
abnormal. A diagnosis of gall-stones was made. . 

Operation, March JSth. — My house-surgeon remarked that lie did 
not think much w’ould bo found. On opening tho abdomen 
sivo fat necrosis was found in omentum jind mesenteries. There 
was no free fluid in tlie abdomen. The gall-bladder was buried in 
adhesions to the transverse colon; when these were separated an 
area li inches in diameter was found on the left side of its wall 
(gall-bladder) to be completely gangrenous. It w*ns aspirated and 
then opened, and a quantity of a dirty brown bile w'as evacuated 
and two colonics of calculi, one being small round yellow stones, 
the other larger and faceted. The mucous lining was entirely 
gangrenous, and it was decided that it had to he removed. This 
was difficult owing to the depth of the wound and to the liver 
not rotating. The common hepatic duct was opened and a tube 
sutured in. Corrugated rubber drains were passed down to 
Morison’s pouch and to the neighbourhood of the pancreas below 
the transverse colon. A probe was passed through *the ampulla 
of Valer into the duodenum, meeting no obstruction. Ono pint of 
glucose saline was given intravenously. Pulse 140, temperaturo 

100® F. , 

From the date of operation to March 16th her pulse ranged irom 
124 to 134. Her temperature kept about 99® up to 100® F^ 'nitil 
the 19th, when it reached its highest, 101®, with pulse 140. -She 
felt very ill, with constant nausea, but no vomiting. 

Case iv. 

A married woman, aged 29, was admitted as an emergency 
case with pain in the right hypochondrium passing to tho right 
scapula, and vomiting of four days’, duration. Sho had had nvo 
similar attacks during the previous nine months, accompanied by 
jaundice, and at times frequency -of micturition. Her expression 
was anxious. The abdomen moved freely, but there was tender- 
ness and slight rigidity in the right upper quadrant. Tho gall- 
bladder w’as palpable, the tongue moist and clean. There was no 
jaundice, but bile was present in the urine. 

Operation.— Under chloroform and ether a right paramedian 
incision was made. The liver was proptosed. The gall-bladder 
■was the size of a small pear* very tense, witli distended pouch 
of Hartmann adherent to the common duct; it was removed from 
the fundus towards the ducts. The comfnon duct was opened and 
found to contain thin, bile and flakes of muco-pus; two stones 



JONE 30, 19=8] 


ACUTE NKCKOSia OF THE .PANCREAS. 


[ Tnc Pnms* ' 

ilKDtClL. JOUIINAI. 


rtf nn nir1\ in tliamclcr were removed with n scoop, 
r^lch black pum l)bii{;ics wore passed witli dinTicultv through tho 
sn" le er of O.l.H, mid tlio duel wni wnilied.oiit with r.Hine. No 
fat necrosis foeii or Mood-stained ftiiid in Iho ulnloineii. The 
common' duct was drnined. • 

The nalionl died on Docoinhor 2ntl, IJci. 

Accroniv.-Aciitc innamiiialioii in rcKioii of liver and numerous 
■ndhcsioiis.' Cominoii lute duel" much ' mnamed and, ncerolic m 
narts. r.ancrc 3 (ie duel also inflamed and contaminjr muen-i.uru: 
lent cxiulalioh. ranrroas cidargcd and lirm niid fat in ncighbom- 
hood Ehowing neerosis. Sidccn fofl. 

Cisi; V. — .Ici/fc I'diirrintir AVnoji.i. 

A married woman, aged 72, on whom I had performed 
cholccvstotomv several vears previously. She hatl had several 
attacli of biharv colie, ’hut since the operation no trouble \vhat- 
ever until the 'night before admission. Gall-sloiu-s had been 
removed. .... ... . , . , 

On September 30lh, 1927. in the middle of the night, she was 
seized with a sudden attack of agonizing nluloininnl pain, which 
pile described "ns being far woi'sc than anything slio liad had in 
her previous attacks of gall-stone colic. Sho was admitted as an 
emergenev with generalized abdominal pain. 

Opern/roa.— The gall-hladdcr was distended and ndlierent to the 
abdominal wall; adhesions were separated with diflicully. Dense, 
adhesions of liver to diaphragm were not interfered witli. Tho 
cystic duct and common liilc and liepatic ducts were greatly dis- 
*lcndcd; the latter was the size of the indc.x finger, ihm-wnllcd. 

* and of a green colour. It was aspirated and then opened: it 
*. contained imico-pus hut no slonc.s. A probe passed down would 
not enter the duodenum A tube was sutured in the duct. The 
gall-bladder was opened: it contained muco-pu.s but no stones; a 
tube was sutured in. The pancreas was not felt to ho enlarged.. 
There was an area, 1 or It inches in diameter, in the lesser 
omentum of fat necrosis. 

• For some days she appeared to be doing well, and bile drained 

• from the tubes. The pulse ranged from 80 to 100, hut not higher;, 
the temperature remained normal. She died on October 10th, 
1927. 

iVeerop.^v. — Stomach dilated, containing large amount of .almQst 
faecal fluid. Gall-bladder contained a small amount of pus, and 
duels all showed intense inflammation. Liver friable. Pancreas 
large, red, congested, with niiincrou.s necrotic nrca.s. Fat necrosis 
in surrounding tissues. Rile taken from gall-hhuldcr at operation 
gave no growth on culture after three davs. 

Post-niortcm diagnosis: acute cholecystitis and cholangitis, acute 
pancreatic necrosis. 

Case vr. 

A married woman, aged 20, mother of one child. 1 month old, 
on August 23th, 1926, went for a walk for tho first time after 
confinement. Slio^ was seized with sudden violent pain in the 
right livpochondrium and epigastrium, and vomited. Tlic pain 
radiated to the right iliac fossa, back, and shoulder. The 
.symptoms continued throughout the following dav, and on August 
31st she vomited four limes. 

She was admitted lo the Infirmary on Soptemhor l«t, at 9 p.m. 
Examination showed rigidity of both upper iccli; Murpliy's sign 
was present; the abdomen moved freely on respiration, hut was 
tender all over. Tho face wa.s anziou.s and pale. Pul.«c 103, 
temperature 9^4° F., The urine .was loaded with sugar. 

. Opcmtioa. — On September 2nd the patient looked ven* ill; she 
had vomited twice in the night. Glucose was administered bv (he 
rectum.. Temperature. 99®, pulse 116. . 

A right paramedian incision was made. A quantity of blood- 
P T , present and on the omentum several patches: 

?, necrosis about an inch .in diameter. A verj* tense gall- 
bladder 4 in. long by IJ^ in. at the fundus, mottled yellowish- 
wlute, was found and incised. • Brown bile under * pressure 
escaped with small light yellow non-facctcd calculi. It W'as 
Mashed out witli'salinc, and showed a typical strnM’bcrrv appear- 
ance, bcing .a- brilliant scarlet M'ilh yellow dots of lipoid*. A tube 
Mas sutured in it and a corregated drain to Mori.son’s pouch. Tho 
abdomen vras quickly closed, with through-aiid-through silkworm 
gut. One hour after the blood sugar was 0.188 per cent., pulse 
140, temperature 101° F. i » t 

On September 5th the urine contained 1 per cent, glucose, and 
acetone was present. - i e. j 

On September 27th the patientrM'as convalescent. 

. . . • . Case vii. 

... married woman, aged 63, had suffered from 

constant epigastric pain and vomiting for six months. In the 
rly morning- of I^cbruary ^st, 1927, acute cpigaslrx poin and 
miting set in. She mxs admitted rs an emergency case and 
operated ^ at 1 a.m. on Februan- 22nd. Pulse 138; slight 
cjanosis. The abdomen was distended, slightly rigid, and fender, 
vei^^iir^^ sugar m the urine. Loewi's test positive. Patient 

anaesthesia. Abdomen conta'necl fluid 
rtf omentum duty grey in colour, with areas 

nafipni the size of a threepenny piece. Owing lo 

.condition Iho abdomen was closed with through-and^ 
fo^,, rv:"?! “ft®"- ‘'■■aiiis down to the 

died 01**3 'a nT *''*^ li ansvcrse mesocolon. Sho 

Cso’ecfallv Scattered foci ' of fat ncirosis, 
lafffpd pancreas. No peritonitis. Pancreas on- 

bla?V ’-.r ^ ^ cut into widely necrosed with 

faceted eifculb No sines fe”l**ifd^te™‘“’"''’® *!*****""".“**-" 


Case vm. ... 

A married woman, aged 25, was admitted as an emergency case 
for n sudden nltnck of abdominal pain of twenty-four hours 
durnlion. Partiiiition r.x weeks previously. She was verj' stout. 
Tho uhilomcn u'as lender and slightly rigid. 

Ojnrittioii — General injection -of intestines, free serous fluid m 
nbdomcji. Grontly thickened omcnliim with areas of fat necrosis. 
Lesser sac opened through gaslro-colic omentum. Pancreas bulged 
forward like a cyst. Punctured; two or three drachms of fluid 
like water} 'hilc escaped, ' No growth on culture,' Drained. Gall- 
bladder iiormaL Tlie patient recovered. 

Case ix. ^ 

A married woman, aged 33, Mas admitted M-ith a history of 
attacks of abdominal pain and vomiting, Milh slight icterus in 
some, of Im'o years’ miration. Flatulent dyspepsia. Four day.s 
before admission, on December 29th, 192G, she had a more severe 
at lack. / 

On admission she was in great pain and looked very ill : her 
skin M*ns yellow. Temperature 97.6° F., pulse 74. There was no 
. distension* or rclrnrtion of tlic abdomen. Movement impaired; 
tcmlerncss over the right upper rectum. 

Operntiou (January 5rd, 1927). — Omentum ' and- mesenteries 
sludded M'itli areas of fat necrosis standing out prominent!}’ OM'ing 
to bilc-slainih". The pancreas was palpated and found to be 
somewhat swoHen, especially the licad. The gall-bladder M'as not 
enlarged, hut contained small .stones estimated at 4,000. Cholc- 
cystotomy was performed. 

The patient recovered. 

Case x. 

A man, aged 69, was admitted as an emergency, 'wiCli pain of 
nine days' duration referred lo the M’holc abdomen^ Constipation 
had been present for four days. The abdomen M*as distended. 

.Opci'afton . — Large quantity of straw-coloured 'fluid in the 
abdomen. The patient died on the table. 

k'xainintttiofK — Extremely fat, slight icterus. Fatly 
heart; atheroma of coronaries. Acute inflammation of gall-bladder, 
M’liich contained several large faceted stones. Common bile duct 
distended, contained a small stone in the ampulla of Vater. Acute 
liacmorrhagic pancreatitis M'itli fat necrosis in retro-peritoneal fat. 

Case xi. 

A woman, aged 22, was admitted on February 11th, 1928, as an 
emergency case. 

During* tho past two years she had had three attacks of 
abdominal pain and vomiting, lasting about tM*o days. She had 
been getting thinner for the last six months and suffered from 
backache and severe frontal headache. She M’as a domestic 
servant,' and had been out of Mork for hvo years on account of 
illness. 

Oil admission sho had had pain in the abdomen and back for 
Uvcnty-foiir Hoiii-s and had vomited. Later she had generalized 
abdominal pain, M-hicIi doubled her up. Tliat 'morning she had 
cramp in both' bands, and bad vomited four times.- Sbe was pale, 
thin, and anaemic, and looked ill. The abdomen ‘did not move 
on respiration. Tho whole abdomen was rigid and lender all 
.over — tympanitic; spasm of muscles caused flexion of Mrist and 
extension of fingers (query t-stany) Temperature 93.8® F., pulse 110. 

Operation (Fcbnmiy 14th). — Marked fat necrosis in the omen- 
tum, and in appendices cpiploicao. Whole abdomen filled with 
odourless brOM-nisli fluid; pancreas exposed, appeared as a con- 
gested, .purplish. tense" SMclling; incised, and swelling collapsed. 
Abdomen mopped out. cigarette drain inserted to pancreas. Gall- 
bladder appeared normal. 

On February 17th there was no discharge from the Mound and 
the drain was removed. 

On -February 27th she M-as convalescing, but the temperature Mas 
SM-ihgiug from normal to 101° F., pulse 100. 

Case .\rr. 

A mtirricd womnn ng'cd 54, Imd a sudden attack ot epigastric 
pam on May 7tli. 1928, followed- bv vomiting, after wliicli tlic 
pain pa^cd off. Both pam and vomiting recurred the following 
day. bho was admitted as an emergency case on May 9tli. but 
was too ill lo be operated oh. She died on May lOtb 
iTccropsy.— Liver, numerous pale areas on surface, fatty; gall- 
bladder, numerous stones. No stones in common bile duct or' 
evidence .of iiiflaramafion. Fat necrosis in omentum, round the 
pancreas and pcrirenar fat. Pancreas enlarged, with numerous 
linemorrliagcs,' one longitudinal, one at tail. 

In reporting these cases I have endeavoured to shoiv 
tliat in spite of tlieir extreme gravity, tlie early symptoms 
are iipt always sucli as would iead one to suspect tho 
condition, and that, even at operation, in certain cases 
it is possible not to recognize it. If one onlv thinks of the 
classical symptoms of a fuliniuating pancreatitis operation 
may he delayed unduly. 

I desire to thank my colleagues on the staff of the Cardiff Roval 
Infiimary for their courtesy in permitting nic to include a report 
of the cases under their care. - pore 

Referexce^;. - , 

• The Tarl;, Diagnoeii 0} the. Acte Ahih'in'en ‘nrA 
0.vford Medical rublication-i - Les Tan'crcatitee '‘'‘.^“>'>..1222, 

par Pierre Brocq,_ Masson et Cie, Paris, ig£6^ jq- ^ 


1104 - JUNE 30,' 1928] ADRENAr.iNB-W‘MEiyicAIi' A'lvjb' 'sUR'GicXt PRACTICE. 


r. TnerKiTiw 


THE USB OE ADRENALINE IN 3IEDICAL AND 
SURGICAL PRACTICE. 

BY 

W. M. BEAUJIOXT, 

BATH. 

The service of atlrcnaliiio in nicclical and surgical practice 
is apt to be overlooked. And yet the information to bo 
gained from its instillation in tbo eyo is often of groat 
value in c.stimating tlio integrity of the syinpatbctic 
system . 

Tlie supposed danger of producing glaucoma was founded 
on a series of five cases in wbich tbat disease was tliouglit 
to be aggravated bj' tbe instillation of adrenaline.* Sub- 
sequent investigations have not confirmed tlie accusation. 
On the other band, it has been advocated that adrcnalino 
is not only liarmless, but also tbat it is useful in glaucoma. 

Grandclement in 1904" insisted tbat bj- tbe use of it 
glaucoma maA- bo cured without operation if tbe disease 
has not advanced too far. Sydney Slcpbenson in 1908’ 
recorded tbat adrenaline bad sboivn itself of service in 
tbo treatment of glaucoma. 

O. Loewi in 1907 proposed tbat tbo mydriatic r«‘sponso 
to epinepbrine should be used as a diagnostic .sign in 
Basedoiv’s disease and in pancreatic iiisufficicncy. ' 

f 'oope* also supports the A’alne of tbe responso in tbo 
case of acute pancreatitis. According to 'Watanabe and 
Kato tbe sensitiveness ajipears to be somewhat increased in 
cbronic nephritis. 

lleltzcr and Auer in 1903 pointed out tbat an increase 
of excitability to epinepbrine occurred in degenerating 
structures of the car vessels. 

Lewandowskj- in 1898 showed tbat. tbo mydriatic effect 
occurs after degeneration of tbe .syinpatbctic. 

Joseph demonstrated that epinephrine w.as to some 
extent counteracted by pb3-sostigmiue ; and Gitb'ens and 
Aleltzer state tbat pituitary extract also counteracts the 
nivdriasis in liealtlij- animals. 

Tbo intraocular tension, according to Rupert, is first 
lowered and then increased. 

Solliiiann’ reeords that this mydriatic effect •occurs 
readily in frogs, but only in ipamnials under sjieciallj' 
favourable conditions. 

Tbe m3-driatic response in bcaltln' frogs is e.specially 
strong, and 0103-, it is said by Ifcltzm- and Auer, be 
produced by .systemic application, in extremely diluted 
solution, of adrenaline (1 in 100,000). 

Post* has noticed dilatation of tbo pupil after instilla- 
tion of adrenaline in oases of glaucoma and keratitis. 

H. Straub in 1919 found tbat ni3’dria.sis occurred if 
Rie excitability of tbo .sympatbetic is increased as in 
Graves s disease and in acute pancreatitis. Later it was 
round that m3-driasis occurs in all tvjies of byperaemia. 
The sensitiveness is also increased in cbronic nephritis. 

-A .103 diiatic ra.sponse may be obtained a few days after 
excision of tbe superior cendcal ganglion. In many of 
these cases the in3-diia.sis was accouipanicd In' other 
ei ideiices of ocular stimulation, such as sepai’atioii -of the 
lids, and protrusion of tbo eyeball. 

* U. Schultz lecords that in inaiiim.alia ni3'driasis 
only follows after large doses given intravononslv • and 
adds tbat mydriasis may be obtained if tbo oculomotor 
tone is low, with weak illumination. 

In man the effect is 01113- invoked in exceiitioiial cir- 
cumstances, and then it usually signifies a lesion which 
involves the .sympathetic. Straub state.s tbat it may 
occur if absorption is hastened by conjunctivitis. 

Tbe signification of a dilated pupil in irritation of the 
cervical S3'mpatbetic from wounds or growths is ivell known 
but that dilatation can sometimes be produced bj- adrena- 
line in such diseases as acute paiicieatitis and exophtlialmic 
goitre is apt to be overlooked. Given a nonnal svmpa- 
tlietic system tbo power of adrenaline over tbe iris in man 
is ntdl. 

Allis drug, so frequently used by ophthalmic surgeons, 
Eliould not 1)0 banned from the arsenal of the genera] 
pliA-sician. I have never seen any ill effects following its 


U.SO as a test, nor can I find any reports of cases in which' 
trouble ensued. 

Foster Moore,* quoting from do Sehweinitz, writes:! 

“ Instillation of ndronaliiie, ordinarily inactive in causing 
dilatation of tbo pupil, becomes exceedingly aetivo'wlien 
tbo sympatbetic is cut, or llio superior gniigliou is I 
removed.” , ] 

In conclusion it is to bo noted that tbe response docs not 
alwav'.s occur in the nimicrons diseases mentioned ; and 
therefore, while a jmsilivo reaction i.s valuable, a negative 
one does not cxcliulo tbe snspected diso.asc. 

Mrllnul nj — Ono or two drops of a solution 

of cblorido of ailreiinliiio (1 in 1,000) arc dropped into one 
03-0, llie otlior being reserved for comparison. Tbo light 
should 1)0 subdued, as a glare is likel3' to impede dilatation. 
The conjunctiva will immedintel3’ blanch. If flicro is no 
dilatation of tliu pnpll in ten minutes tbo in.<-tillutiou should 
bo rejjcatod. A dropper that has once been used for 
atropine should never bo emplo3'cd. 

ntroicxcr-s. 

• Tf'DiiA. Oiihthnlm. S>or,, 1903. p. 371. , * ODnnlciun' iil : ,Lil Clio. 
niihlnliiiiil., 190). ’ Oiihthnlnioicnpe, 1S08, p. 785. ' t'.-.npf. I!.: DiagMIil 

of Poorrrntic 1927. ’Sollmnnn : MntionJ of i’l/iritiacologff, 19-6, 

p. i))0. • I'o-'.t .* Ofifilhnlitmiicofif, vol. vi, p. 7oS. ^ lleore, Fester: 

Mcitical Ophthatnivlofftft p, 95. 


TJIE 1927 EPIDEMIC OP DENGUE IN EGYPT. 

»Y 

H. ICAMAL, ]\[.B., B.S., M.R.C.S., L.R.C.P., 

COVICXME.N'T reVEK UOSTlTAL, CAIHO, EGITT. 


fOS\ 




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Fon several years I'lgJ'pt ivas practically free from dongno; 
the la.st epidemic, prior to that here recorded, occurred 
in 1906-7 at Port .Said and tbo Suez Canal zone. 
Last vcui', liowovor, a sudden epidemic affected the whola 
country from the shores of tbo Meinterranoan to the 
extreme south of Uiiper Egj'pt, preceded by equally 
sudden climatic cba)igcs. Thunder-storms, winds, and 
rains su'cpt the whole country, and were followed 
by the appearance of dengno and other afflictions, such 
as tbo invasion of tbo Nilo Valley by locusts, ' wbieli 
constituted, a very serious danger to ngricnltin-e. Tbo 
■ci)idauic started at tbo end of September; daily admissions 
of 30 or 40 cases of dengno were warded in the Government 
Fever Hospital, Cairo, ivhilo thousands 
of patients wore attacked in the town 
ivith remarkablo rapidity. Groups of 
policemen on duty in certain streets ivero 
attacked as a whole. 

Thanks to tbo experiments organized 
by the Jfcdical Departmental Research 
Board of the U.S.A. army and others, 
we now know tbat a patient with doigno 
fei'cr can infect Aedcs aegypti {Stego- 
mijia fascinta) during, at any rate, tbo 
fu-st three da3'S of bis illness. Tbo dengno 
virus appears to lemain in tbo infected 
inosquito for about eleven days before the mosquito can 
transmit it to uoii-immunes, and tbo infected, mosquitos 
coiitiuuo to propagate tbo disease probabl3" throughout tbo 
remainder of their lives.* 

The PliHippitie Journal of Science published ■ in • 1926 
most important infoi-mation concerning tbe insect vector 
of dengue. It was proved that the vector is Aedcs aegypfi 
{Stegomyid fasciata) aud not Culcx quinqucfasciaticus 
(0. fatigans). It lyas also proved that a deiiguo patient 
might infect mosquitos during a period from a few houra 
heforo tbe first sjinptoms appear to tbe cud of tbe second 
day of the disease, aud po3sibl3', though with less certainty, 
for another twenty-four hours or so, after wliicli mosquito 
infection fails.** 

Tbe A'irus of dengue is at one stage, at least, an ultra- 
microscopical filterable one, and is present in the patients’, 
peripheral circulation up to tbo third day of illness. It 
is also tran.smittcd b3’ blood or filtrate to non-imraunes. 
Tbo piroplasma-liko organism of Graham is probably an 
artefact. The incubation period is usually from four to 
seven days. 


ChihtI.— . tbortiva 
type. Duration ot 
fUnesg before 
oilmirsion one 


3DSK 30, ig:3] 


AN EPIDEMiaOF. DENGUE JN. EGiTT.,. 


r Tnr.rRmin 1105 

<- LMrIUCAD JOUESfiX J-J-ut/ 


The mortiilitv of tliis cj)i(1eiiiic in Kgy)>t was luV anil the 
immunity vni i-.hlo. Tlie loilowing wove tlie cinef dmvaflor- 
.istics of the epiiiemio. 

iS'iyiiipfoiiis fUK? iS'iyiis, 

Piodromal svmptoiiis woie ohsevveil in many cases, 
lieatlaclie malaise, ami anorexia hying the chief complaints. 
The onset was nsuallv smUlen. The patient while on 


and lasted from a feiv hours to one week. It -was either 
niorliillifonn, searlatinifonii, or petechial (like tliat of 
relapsing fever). When it heloiiged to the first two types 
it was not so height.- Over the extensor .surfaces of the 
legs and forearms it was decidedly more pinkish. The rash 
apjieared first on the dorsal asjiccts of the forearms and Ieg.s, 
then on the face, neck, chc.st, trunk, and upper and lower 
exlroinitics (iiiclnding palms and soles), Init it was some- 



Chu:t 2.— Irifoiinittont tyj>c. Pmation oi 
Itctnru atlnii*-'ion ono <lay. 


4 ' * 
^0^ 4 

j : 
1^ — 



■nuaHwiararaHHn 

i 




CUvr.T 3.— IntfrnnUont Duration of 

illness iK'fou* iitlmt'-ttifni two 



/06 

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mamwmm 


HHIllInliimiil 



C'lnEiT -1.— Intermittent type, nurntion of 
Iirffire ail!nis..if*n thro'* 


duty deioloped high fever, preceded at times by rigors; 
he suffered from severe frontal headache, vomiting, and 
excruciating jiain in the himho-sacra! re;poii, and over the 
joints of Imtli liiiihs. Pome patients became niicoiiscions 
and remained so for a period ranging from a few hours 
to two days. Many were .semi-conscious and drow.sy; 
others were mentally and fihysicnlly tlcincsscd, although 
their temperature wn.s not high. The face was tosnaily 
congested and sometimes swollen ; the eyes appeared sleepy 
and photophobia was frequent. 

The fever lasted from three to seven dasTi, and was 


times ahsont on the trunk. De.sqnnmatioii was not the 
rule, hiit when it occurred it was of the branny type, 
aeconipatiied by .severe itching, and lasted for a few weeks. 
This rash is the mo.st characteristic feature of the disease. 

Cirniliiforji •Vyiapfoiii.'!. — Prccordinl distress was noticed 
in a few r-ascs. No heart Ic.sion could be traced to dengue. 
Haeniatemesis, hacinatiiria, and haemoptysis were rare. 
Tile pulse was iismiDv .slow throughout the dise.a.se, hut 
more .'o townrd.s the end of the fever, ninety heats being 
the average nnmher ]>cr niimito, with a temperature of 
390 C., and fifty beats when convalescence started. There 



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CiUTTT S.—Hi'niittent or tyjir. 

Duration of lii*fore adinihaion otiu iKu. 


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C»i\nT 6.— Tlomitls nt or FadilUMnick 
Jliiration of Ituforc a(imi?^K•n one <!uy. 


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XiunT 7. — RemUl'.-nt or t-oiltllc-back type. 
Diinitjon of ilJntjis lH*forc nflnl^fr^^on two 
daNM. 


usually of tlio .saxldlo-liack type, V cry rarely patients 
were afohrile tlinnighout the disease, and such wor<-, 
therefore, a eomstant meiiato as potential .spreaders of the 
malady. Tile following were the types of pyrexia noticed : 

1. Abortive t.vpr in which pyrexia lasicd from one to three 
da.vs ■ (Clmrl 1). 

2. InleriniUent type in which pyrexia dasted usually for seven 
aavs; the interniRsions were sometimes separated hv n period 
ot normal temperature for one or two day.s (Charts 24). 

3. Saddlc-haek type or remittent temperature (Charts 5-7). 

4. Conlnmous tj-pe with fehrile plateau (Cliart 8). 

(Chart'Qj irhich fever continued for leu to fifteen days 

The degree of 
fever was in no 
relation to the 
severity of the 
attack. High 
temperatn res 
were ' sometimes 
accompanied • by 
mild symjjtoins, 

■and vice versji. 

The, onset of 
fever and it 



Ch\rt_ 8. — ContinuouB type. Dura* 
tiou of illness before admission one 
ua3’. 


dcx:line were hotli by crisis; rarely the pyrexia ended by 
l.Ysis. The fall of fever was accompanied by various 
phenomena, of which the, chief were diai’ihoea, 'dy.sentoric 
stools, ejiistaxis, haeniatemesis, haematuria, heart f.iilnre, 
and, rarely, syncope. 

T/ic Iiki.i/i .— 1 ho initial rash, which was nothing more 
lan a flushing of the face and sides of neck and chest, 
vas rather common. It appeared usually on the first day, 
and lastecl from one hour to thi'ec clavs; it was freqnentlv 
accomjianiccl by inflammation of the throat. The secondan' 
as 1 appeared about the fifth- or sixth clay of the illness, 


iiavc been cases where the jnilso was rn]nd at first 
(120 iier miiinte). hut most of these onclecl in hradycardiii. 
Cnltni'cs of the virus from the patients’ blood were not 
sncco.S'.fnl at onr laboratorv. Examination of the blood 
sliowed an average Icucopenia-of 4,000 to 5,000 per c.inm. 
as a constant feature. This decrease in the mimber of 
leucocytes affected the ]iolymor]>houncloars most. A redative 
increase of cosinophilia and largo lymphocyte.s was also 
noticed. 

Except for the occasional congestion of the nose, throat, 
and larynx, the respiratory eonqdieations were rare. Pni- 
moiiary congestion was only seen in a very few cases. 

No enlargement 
of the lymphatic 
glands was 
noticed, .although 
it is mentioned 
That, in some 
epidemics a con- 
siderable propor- 
tion of patients 
develop enlarged 
glands. 

The pains were 

mostly mnscular m origin, and thei-efore aggravated on 
contraction ol the affected nniscles. Nearl^v all mnscles- 
wei'e affected, tlie most common being the ocular ilio- 
qisoas, quadriceps, biceps hrachialis, intercostals,’ and 
supra-, intra-, and snh-scapnlar muscles. The degree of 
pain varied from slight aching to excrnciatiug pains which 
moiqjhiiie alone could alleviate. TJicre were no joint lesions 
Headache was a prominent symptom in this epidemic- in 
one instance it lasted over seven davs, during which ’the 
patient could neither sleep nor obtain ease irithout drims 
. Gastro-wte.tinaJ Symptoms.— Fetid breath was noted in 



Cn\nT 9- — hong t\-pe. One day ill before ndtnission. 




IIOG Junk 30 , igiS]' 3DTJPLICATION OF THE SPINAL CORD. 


TtcrBnjTif* 
Alrt.lOiL. JUL'K'TAI. 


n fow discs. Tlic tongue ivns iiciuly ahiiiys emtied nl Ihe 
clor.sum iiiul red iit tlic nmrgin.s. 'roiisillilis iinil |)liiirvMgitis 
wei'C fairly connnoii. No iiarotilis was nu t with. Nausea 
and vomiting were usual at tlio eomnieneenieni, hut rarely 
persisted tlirougli'ont the disease. Coiwlipation was tlio 
ndc, and was,followcd hy ilinrrhoea at the lerininal crisis. 
Dy.sontcric tymptonis were ])icsent in a few eases throngliont 
the nialadj". No changes were ohsmved in liver or .spleen 
that could bo attidhutcd to dengue. 

UiiiKinj Sijstciii. — Allmminuria was eonunon but Iran- 
.siont. One ease of acute nephrilis was reported. Chronic 
kidney disease is likely to end by uraemia as the result 
of an attack of dengue, lliahetic patiimls when atlai-ked 
sometimes developed a fatal coma, even during eon- 
valcsconeo. Epididymitis, orebitis, cystitis, etc., were not 
met with. 

Coinplicalioiif:. — 'riiese were rare. Those met with were; 
pharyngitis, ihinitis, gastritis, enteritis, nephrilis, and 
throndiosis. 

Scquehtc. — Itching of body, irritation of palms and 
soles, mental depression, veitigo, motor jinri'sis, peripheral 
neuritis, staccato speech. 

Cliildren were just as liable to be atlai'ked by deiigui' 
as adults. Males and females wore affeeteil equally. No 
deaths oeeurred among chihlren. 

Convalcseonee may ho short or long — one <lav to three 
months. Patients lose weight, and iKually suffer from 
mental depression, debility, loss of appetite, bradycardia, 
migraine, ami neuritis, llelapses arc rarm 

Diaijiw.ii.t. 

In this .seasnn (lleeember) in Egypt dimgiie has to be 
diagnosed from tho following diseases; 

(a) Jlalaria; by CNamination of blood films, size of 
Bpleen and liver, time ineidoneo of febrile attacks, and 
rapid pulse. 

(h) Measles: starts less suddenly; ])rcscnee of TCoplik’.s 
spots, coryza, absence of pains, rapid pulse, and deep red 
rash. 

(e) Influenza: is usually aceompauied by respiratory 
involvement, rapid ])ul,so, and absence of rash." 

(d) Scarlet fever ; diagnosed by pri'seneo of throat sym- 
ptoms, rash, rapid pulse, absenco of pains, and blood 
oxamination. 

(e) Small-pox: in tho first throe day.s of dengue it is verv 
difficult to differentiato it fioni small-pox. Later on the 
course of tho malady soon manifest.s its nalurm History 
of vaccination may help. 

(/) Articular rheumatism : diagnosed by history of 
malady, pre.seuoe of acid .sweats, and joint lesions. 

The treatment is symptomatic ami prophylaxis involves 
antimosquito measures. 

UnFFinFNFrf^ 

iitia''i9»‘ rf m"* 2711.; 1025, r. nss, = iimi., .So|.ionii.cr 


DUPLICATION OF THE SPINAL CORD. 

BY 

F. PARKES WEBER,, M.A., M.D., P.R.C.P. 

An excellent review of tho known cases of partial doubling 
of tho spinal cord was written in 1006 by A. Urueo 
Stuart McDonald, and J. H. H. Pirie' ; for the refereneo 
to it I am indebted. to Dr. Kinnicr Wil.son. Nevertlieloss 
the following case perhaps deserves a note. ’ 

Tho palicaL a wcll-clovelopocl man, aged 51, w.as admiUed ,fo 
hospital on March Z9tli, 1928, wiUi a spaslio parotic ataxic iraifc 
and sipns snfrgosling conihincd degeneration of the spinal cord 
Ho liad a pale, sallow face; tho liver was consiilorably enlarged 
and tho spleen could bo felt, rcarliiijfj just below tbo ribs, Tlio 
gastric contents after a tost, brcalcfast contninod no freo' hydro- 
chloric acid. Tlic crylhrocvlc counL was 3,332,000 and Uic hacnio^ 
globin was 70 pbr cent. Tlic while cells wore *17,800 (polvmorpho- 
luiclcars 74 per cent., lymphocytes 17 per cent., monocytes 9 per 
cent.). The Wassermann reaction was nofi:ative; There was a 
litllo irregular pyrexia, and npparcnlly a remnant of pneumonia 
in the middlo part .of the ri"ht luiiff, wliieh possibly explained 
»m* presence of a polymorphonuclear Icucocytosis. Accordiiifr to 
ivUl, ‘ml”?’ ,'’V‘!»>'wd the miticnl, Imd iiolicrd somctliiiig wron.- 
h.!on Pfccmlwr, 1927,^ he had 

Insult of tfio or i ‘'"’'y ^0‘‘ nuncmia. The 

weaUnesa ia hie “diSoS”*’’ 


Til Iho hos)nlnl, in spile of liver did, de., (he v.-cahne-s ;n 
the Ic.gs im-reavi'd, panidoxieal incontinence of in inn and cyslilii, 
wiflt hcdsoi'c^, del doped, and dcnlh occnri'ed on April 25ili. 

Tim lu’cmpsy iiiid micrnscniiical exiimiii.-itimi confiiincd 
Ihe iliiiguosis nf cnmliiucd dcgcnenition of Ihc .'.|iin!d coni; 
hut iluriiig the mncroscopicid exiimimilioii it was iioticcil 
thaf, close along Ihc leftside of fho lower jiait of flic spinal 
cord, there wiis nnoiher eord-like liody of the snine enn- 
Kisteiice ns the cord, hut .smaller (ahout 1 cm. in diameter) 
and withmil nerve roofs prnci'cding from it. Its iipiier eiiil 
aio.se from the .sulisfaiice of the cord hy a ha'-e somewli.'it 
over 1 cm. in diameter, the uppermost part of its insertion 
lieiiig 7.1 cm. ahnve the formiiml point of the cqims 
termiimlis. At its lower ffree) end it lapered to a |mint, 
which was II cm. ahnve the lower end of the tomis 
terminalis. 

Transverse miernscopical sections of this macriiscopically 
iiimoiir-Iikii appendage of the spinal cord showed it to lio 
qnilo olivionsly !i fairly wcll-dcvelopcd duplicate cord with 
e. central canal, clc. Thi.s was kindly confirmed hy Dr. 
•I. (1. tlreenfii’ld, who also rniifirmcd the fact that the 
duplicate cord siiowed well-mnrk-ed signs of tomhinc;! 
.degmicratioii, just as did tlio main spinal cord (from whicli 
the caiida equina arose). 

When I .saw tin- long iiolyjioid Inmonr-like appomlapc 
lying along the left side of tho lower portien of the spiinil 
rord, I at first thought that I had madi- a mistake in the 
diagnosis, and that the pationt’.s jiaraplegin, efe., might 
liaiv been due to a tumour; but mleroscoplcal examiiintloa, 
as already stated, romidetcly cleared up the nature of tho 
tumour-like structure, jiroving it to be a rongeiiHal nbnnr- 
malitv a doubling nf tbo lower part of file .sjiiiial eon). 
One may wonder wbeiber in Ibis ense, lipiodnl would liavo 
been partially arrested at the site of origin "f the duplicate 
eord bad it been used to ascertain the site of a jinssible 
tumour. 

Urrriir.vcr. . . „ , « ... 

1 K Scconil Ones nf Pnrlinl liimtitiig of flic .Spinal Coni, /fci’. .iciir. 
(01(1 I'fyth., KiliolmrRli. ftOj. i'S P. k. 


THE ETIOLOGY OF MONGOLISIM; 

With a Cask op filnxcoi. Twix, 
ty 

HUBERT ARMSTRONG, M.D.Vict. and Livimr., 
scNion iioNonAiiY rJiY.sici*N, ilOYAL mvanrooi, cmi.niti:N’s iiosriTAi,. 

Tiik oeeurreiico recently, in my hospital praclice, of a 
ense of twins, one of whom was a Mongolian imhoede, tho 
othor not, stimulated investigation into the etiology of 
that distiossiug and inerea.siugly common type of menial 
deliclcnev. Rut tho vUimatc cause of Moiigoh.sm is, 1 
suppose, ‘as yet uiikimwii, nor can I find imich to elucidate it. 

The pociiliar history so often ohtained— namely, Hint, 
tho child is either tho’first of a very .young mother, or, ns 
often hapiiens, is horn many years after the previous one, 
ami- most frequently of a mother ueaiiing tho inenopausc-- 
warrauts the assumption that this devoloiimciitnl error is 
ill some way' due to imnmlurlty or exhaustion of her pro- 
creative iiowcr.s.i At what stage in the development of tho 
ovum or foetus this makes itself felt has heen the suhjcct 
of a good deal of argnm'ciit. . 

Tho prolilem is this: Is fifongolism inherent in tlio 
unfertilized oviim, or is it acquired after fertilization? 
A third proposition might ho that jMoiigoli.sm js impnrtcil 
to tho ovum ill fertilization, were it not that tho history 
apponis to iioint to the maternal factor so constniitlj'. As 
n generality it may ho a.ssumcd that paionts are approxi- 
mately tho same age, the father being -on the nVorngo a 
j-onr or two the elder. This would make the odds even nS 
hetweon the two parents, were it not that there is no evi- 
dence, known to mo, that tho children of eldcrh' men tend 
to Jlongolism otherwise than, when their wives are npin onch- 
iiig tho nicnopansb, Novoitholoss, this possihio factor 
cannot be entirely brnsbod aside witbont ronsidcratioiii 
An'nrgnmciit in favour of tbo post-fertilizniion cmlnyouK! 
tlicory is that jMongols are so often tbo subjects of otber 
coiigonital abiiormalitios.' - Of these -tlio‘ l-.•mmqnoot ■ are 
.malformations of the heart; -followed a long waj'. bcliino 
by congenital cafnrnct — defects , whicli obviously cannot 



JUKE 30. 1928] 


THE ETIOLOGY OF MONGOLISM. 


[ The nniTiW 
Klr.DtCXL JODRKJLX. 


occm- till cmbnonic development has proceeded far enough 
to ''tart the formation of the orgaiis im])lK‘atc(l ; and tho 
heart for example, is perfectly formed, though in luima- 
turo hv the cud of tho seventh veek after couceptiou.- 
Bv aualoev it is argued that similarly the IMongolian 
characteristics (which arc in effect congenital malforma- 
tions) take their origin in the oinhryonic" period of tho 
first six weeks of intranterino life. This may he countered 
hv the argument that an ovum already the subject of an 
inherent defect (of a nature which is wonderfully true to 
tvpe) is more likely to go wrong in other diiections tliaii 
one which is not. 

David M. Grcig, in a recent long and erudite article, 
favours a theorv that Mongolism is a defect of foetal 
growth, though he concludes that this must have started 
in the emhrvonic period mentioned already, fie liases on 
his minute' and fully recorded ohsen-ations on thiee 
Jfongolian skulls the 'deduction that jMougolism “ seeius 
rather to ho a defect in growth (foetal) than a defect in 
development (embryonic).” He states that " the main 
defect in the skull is want of growth of the fat ial hones, 
chiefly the maxillae and of the alveolar processes 
anteriorly,” with various conscquenecs to tho adjacent 
hones, into which I need not enter; As an interesting aside, 
however, it may he mentioned that although obliquity of 
tho jialpehral fissures and nearness of the eyes are charac- 
teristic of the Mongolian facies, there was no ohliquit 3 - of 
the superciliary margins in these skulls, nor any undue 
approximation of the hon\’ orbits. 'With regard to tho 
reported arrest of development of tho skull base ho goes 
on to say: “ Deficiency of tho anterior wall of the acoustic 
meatus, imperfect closure of tho foramen ovale and 
foramen siiinosum, flatness of the occipital condyles, and 
in tho r-oungest skull an indication of the component parts 
of the occipital hone, arc evidences of delayed development, 
hut are not features which Imvo interfered with the growth 
or siac of the skull-haso. If any arrest of dovolo]imcnt has 
occurred it is in tho brain, not in the bones . . ; and 

later, “ Before the ago of 16 the growth of tho Jlongors 
brain has ceased.” He states as his final opinion that 
“ oven from the skull alone there seems evidence that 
development normally begun has mapped out all structui'os 
and features in the omhrj-o, hut has failed to lead them to 
perfection during foetal growth.” Pointing out that the 
first appearance of ossification in the , skull appears in the 
maxillae on the thirtj-niiith daj', followed bj‘ the pre- 
maxilla three days later, and tho nasal hones on tho fifty- 
soventli day, lit* says: “ Obviously it is during this period 
that the departure from normal growth shows itself, and 
this failure in tho boiic-S is accompanied or followed by 
defective gro^rth clsowhoro, notably in the noiwous system.” 

For myself, though open to conviction, I believe tho 
maternal inlUiencc, which appears to bo almost xindcniablc, 
and wliatever it may be, is exorcised upon tho ovum during 
its maturation, and thoroforo before fertilization lias 
followed and segmentation started. 

The chief argument in favour of this theory is tho 
occasional occurrence of twins one of which is ^longol and 
the other not. niis proves beyond a doubt that no 
niatcinal influence is present after cmbiyonic development 
las begun; or that if there he any such influence it is 
selective in a manner highly improbable, though I recognize 
Ins argument is a two-edged sword. It has no bearing 
on the question of responsibility as between the parents, 
01 obviously if one ovum can he inherently INtongol and 
10 other not so, the same should hold good of the male 
0 einonts. Known cases of twins both of which were 
-longols are so rare — only some three in number — and 
their original records so inaccessible that altliougli they 
tieic of the same sex complete proof that they residted 
n-om uniovular pregnancies is wanting, but the assumption 
la it uas so is warranted. There are also three cases on 
ecoul whore the twins were of the same sex, one being 
- ongol; but thcro^ is equally no proof that these were 
Tft picgnancies. But on no occasion has it vet been 

that twins of different sex were both Mongols, 
^ A? Ill accordaime with the mathematical probabilities 
tho thcoi'y does not prohibit the 
f twins being IMongols it must be 

eied that, apart from the six twin cases above 


mentioned, and admitting tho fact tliat the jMongol is 
often the last prcgiiancy, more than one Mongol in a family 
is almost, if not quite, unknown. But we are still as fai- 
ns ever from solving tlio problem of tho malign influonc'e 
dooming the ovum to ^Mongoli.sm, and the corollai-}* of 
prevention. . 

In January, 1923, Hnlbertsina of Haarlem^ collected 
fifteen cases of twin pregnancies of which one twin was 
Mongol and the other normal. Occa.sional additions to this 
list have .since been made, and to these 1 am able to add 
I another instance. 

I Ou December 25rd, 1926, C. F., aged 4 months, was brought to 
Iho Royal Liverpool Cliildrcn’s Hospital because “ lie Avas not 
coming on.” He was one of twins, the other being a girl, who, 
at my request, was brouglit on a subsequent occasion for com- 
parison, and proved to be a normal and healthy child, though 
small for her age. The boy Iiad the typical Mongolian cranial 
attributes and facial appearance, with tne other characteristics 
of the Mongolian imbecile, including the loud bruit and the 
03*aiiosis of a congenital heart lesion. This cliild further complied 
" with The frequent Mongolian lii.story by dying of measles, con- 
tracted when he was 14 months old.* The sister recovered. 

IlCFTREXCES. 

* Shnttleworlh, 0. E. : Jirid^h JoiirtiaJ, 1909. ii, p. 661. 

-Carpenter, C. ; Weiphtman Lecture, 1909. Ihit. Journ. Child. Vie., vi, 
337. ^ Ballantyne,' J. \\\ : 1/nnun? of Antenatal Path, and Hygiene, 
Tho Embryo,* 1904, iii. * Edin. Med. Jonni., xxxiv, Kos. 5 and 6. 
^ Amer. Journ. Die. Child., xxv, 352. 


A CASE OF PRIMARY ACTI2s"0MTC0SIS 
OF THE LHNG. 

or. 

HERBERT SHARPE, M.R.C.S., L.R.C.P., 

MEDICAL SUPERISTEXDEST, WARE PARK SAXATORIUM, HERTS. 

Owixe to the fact that patients aclmittccl to tukcveulosis 
saiiatoriunis have niostlj- been tliagnosecl before admission 
one is apt to be biased in favour of tuberculous infection 
and to take for granted that the diagnosis is correct, 
in.stcad of approaching the case with an open . mind. 
During the course of tlic illness of a certain patient one 
or two complications onsiiod whicli raised some doubt as 
to tho diagnosis of pulraonai-y tuberculosis being correct; 
hence I have thought it worth while to publish an account 
of the case. 

rreriotis HJrtorti. — Up to the age ol 18 the patient had lived 
in Sontli Africa, where, after leaving school, he was an apprentice 
in a lithography works. He came to England for a few montlis' 
holiday, and then went to Australia witli a friend to search for 
gold. After a few months of unsuccessful prospecting tliey botli 
I worked on a ranch, sheep farming, for about eighteen months 
or two ycai-s. Tho patient then joined the army soon "after 
tho outbreak of war. He was sent to England and thence to 
France, wlicrc he was “gassed” in March, 1918; ins war service 
amounted in all to three and three-quarter years' when he was 
( demobilized. He then joined a Government tug boat and 
remained at tins work for four years. He returned to England, 
and after three months’ iioliday" worked as a bricklayer for five 
moullis, later returning lo Iiis original work as a lithographer. 
His health gradually deteriorated, but lie remained at work 
until June, 1927, wlien he complained of acute pain in ttie left 
side, anorexia, and loss of weight. He was first seen by a 
tuberculosis officer in October of tliat year, who, after havin'' 
carefully watched tlie temperature .(99.2°-102°) for a few days 
diagnosed the case as anaemia ’ and pleurisv with effusion, and 
recommended - sanatorium treatment. The' sputum had been 
examined a month previously, -witli a negative result. Tliere 
was no significant family history and no previous illness of 
importance. 

Voniition on Arlmission.— The patient was admitted to tlie 
Hcrlfordshiro County Sauatorimn on October 2-ltli, 1927. He 
gave his age as 35, was very anaemic, and looked exceedingly ill. 
Ho had .lost about 2^ st. in weight, and had not had a ‘good 
night’s rest for a fortnight. His temperature was 100° F., pulse 
118, and respirations 24. He complained of pain extending from 
tho right shoulder down the outer side of the arm, as far as 
tho elbow,, but since no definite lesion could he found to cause 
the pain, it was attributed to neuritis. On examination of the 
chest the left side was found lo he dull on percussion tlie 
dullness being most marked at tlie left base posteriorly There 
was also slight impaii-ment of the note at the right apex Tliere 
were moist crepitations throughout the left side, and m addition 
diminished breatli sounds at tho base behind with amnliorie 
breathing— signs compatible with pleurisv with a small effusion 
His liver was palpable and slightly tender; the abdomen othei-l 
wiso revealed no abnormalities. The urine contained no albumtn 
or sugar; the specifie gravity was 1020 and the reaction acid 

Subaeguent H.sloru.— The pain down his right arm was treated 
with metliyl salicylate and a neuralgia mixture wis 
Nepenthe 20ni was ordered, and the next dav he appeared to 


■ ( 1 , 






1108 JUNE 30, 1928] AN -ADJUSTABIiE BOABD-BED. 


r 


Tiir finm»Tr 
Mri/joi Jf-i hvit 


be somewhat easier. Between November 1st and .December 24tb, 
ten abscesses developed in various parts of the body, most of 
which wero aspirated or incised 'under novocain. On' two occasions 
pus was sent for bacteriological examination and inoculation of 
a guinea-pig requested. The first report was as follows: “Thick 
grumous blood-stained material. Microscopic.ally non-celhuar 
apart from red blood corpuscles. Tubercle bacilli could not bo 
found.” No other organisms found. The second report stated: 
“Microscopically it is essentially structureless, only a few cell* 
outlines being seen. Tubercle bacilli could not bo found ciUicr 
by direct films or by concentration^ methods. No other micro- 
organisms were found on microscopic examination and cuUnres 
remained sterile. Animal inoculation of the material for tubercle 
bacilli is bciug proceeded with.” 

During this time the patient’s tcmpcratui'c and pulse remained 
about the same, his general condition seemed to be improving, 
but the signs in his chest were unaltered. The AVassqrniann 
reaction was negative, as also were blood tests for typhoid and 
parat’*r?’'oid infections. On December 12Ui his Icniperalure began 
to subsiae, it being 98.4° F. in the morning^ and 100° F. in tlio 
evening; between December 18th and 22nd it remained between 
97.2° F. and 98.8° F. .On December 23rd it became subnonnal, 
and remained so until his death six days later. The pulse rate, 
on the other hand, never dropped below 100, ranging between 
100 and 120, with respirations constant at 24. 

Special features as regards the case from n difFerontlal 
diagnostic point of view were: (1) all the abscesses deve- 
loped veiy quickly; (2) they caused great pain; (3) after 
the first bad been incised tbe pns, ndiicb was quite 
innocuous, became so fetid that the patient had to -bo 
removed from the ward into a separate shelter; (4) the 
relief experienced after incision and aspiration was very 
considerable. 

A post-mortem examination was performed on December 
30th hy Dr. G. H. Priugle and myself, and the following 
obseiwations were made. 

There wero adhesions on Iho left side between tho left lung 
and chest wall, becoming denser towards tbo base. A largo 
abscess was found in tho base of tlio loft lung, which sltowcd 
collapse. Both lobes on tho left side and tho two upper lobes 
on tho right contained numerous small nodules, which proved to 
be abscesses. The heart was small, and there was an ounco of 
greenish fluid in the pericardial sac. There was slight atheroma 
of the aorta, a little thickening arouud tho pulmonary orifice, 
and a small abscess in the wall of, tho left ventricle. Other 
abscesses wero found in the following organs : two in the liver, 
which was congested and fibrous; one in tho left kidney, round 
which were adhesions; a perinephric abscess, whicli communicated 
with the one in the lower part of tho left lung througli an open- 
ing in tho diaphragm (tho right kidney was normal); and ono in 
the spleen, which was slightly enlarged and friable. There were 
a few small flattened greyish nodules in the mesentery, but no 
peritoneal adhesions. 

BorLions of the abscess tissues from tho liver, lungs, and heart 
were examined histologically, and tho organism rcsponsiblo for 
the condition was found to bo tho acUnomyecs. The tissue was 
remarkable in showing a largo number of granules, which is rare 
in human actinomycosis. Tho guinea-pigs inoculated showed no 
signs of tuberculous infection, and tho pus was presumably, 
tliereforc, freo from tubercle bacilli. 


My thanks are duo to Dr. H. Hyslop Thomson, county 
medical officer of health, for permission to publish this 
account, and for his assistance, also to Dr. G. H. Pringle 
for his help in the investigation. 


AiSr ADJUSTABLE BOARD-BED. 

BY 

LEONABD HEABN, M.B., B.S.Dmin., 

LATE RESIDEXT MEDICAL OFFICER, HULL TUBERCULOSIS SANATORIUM, 
COTTINGHASI, E. YORKS. 


Tuberculous disease of tho hip is ■unfortunately only too 
often met with for the first time when the condition is well 
estahlished and the joint is more or less fixed, with the 
limb in a bad position of adduction, inward rotation and 
flexion, and usually a certain amount of shortenino-. Tho 
bed splint to' bo described has been used with excellent 
1 csnlts ; it is designed to correct the deformity vei-y 
gradually and obtain tho desired position, with a quiescent 
condition, before the limb is put up in a plaster splint. 

All tuberculous lesions improve as tho general condition 
of the ' patient grows better, and these cases should be 
placed on the open verandah day and niglit in all seasons. 
This bed splint enables the patients to be treated .under 
open-air conditions; tliey are really only confined to bed 
liKo pyrexial pulmonary cases, and enjoy a 
amount of comfort, thus benefiting ' botli 


maximum 
morally and 


hinToiut' thrPu*.!!?' tuberculous disease of the 

U.p-jomt the hmb is fixed in plaster, or in a Thomas’s hip 


splint, in a more or less good ])ositioii, hut this unfor- 
tunately may ontiiil a compensatory lordosis of the spine, 
witli subsequent permanent deformity. 

This apparatus is essentially a “ board-lied,” liingcd in 
tho iiiidille so that tho lower half .supporting tlio legs ni.iy 
bo raised or lowered at will by means of a suiiport on a 
ratchet similar to tho method of fi.xiiig an ordinary (leek 
chair. Si.x hoards form a ho.x framo for retaining tlio 
liaticnt in position, and these swivel from tlio toiitre line 



of tho bed; tiioy arc kept in position by mean- of pegs in 
rows of liolcs at tho foot and head. The lower end of the 
framo can lie extended to fit any length of jiatieiit. and, 
the hoards being 3V to 4 inches liigb, cradles are unneces- 
sary. Pulleys adjusted by means of tliiimb-crews carry 
tho extension weights, and move to any position on tlio 
.lower edgo of llio frame.' 

At tho commoncoment of treatment tho S])ine is placed 
in its natural position, with the limbs raised and with a 
siiit.ablo extension weight apjilicd, tho afTocted joint is 
gradually abtliictcd, and tho leg is lowered as required, 
tlio position of tlio spine not being allowed to vary, so that 
lordosis is never preieat. 

The case shown is a typical tnbcrcnlous arthritis of tlio 
left hip ; this joint was held in a had position of flexion and 
adduction, with two inches of shortening. Tlicre were 
present also ail tlio symptoms of active disease, such as 
pain, heat, and pyrexia. 

Tho first pliotograjili demonstrates tlie nnionnt of eom- 
pensatory lordosis which was present wlien tlio affected 



leg was kept flat to correspond with the soniul leg; this 
is tho position in which .so many limbs, after aliduction and 
external rotation, arc finally fixed in a p!aster-of-Paris or 



Thomas’s splint. The second, photograph shows the patient 
in position at tho commencement of treatment, ■ with tlio 
spino in normal position. In tlie third the corrected limb 



is seen after use of the board-bed and ready to be liu 
up' in plaster-of-Paris, after having bccn’.snbmitted to r cij 
gradual lowering and extension, dependent on the position 
of tho spine. 



memoranda. 


TiiK CnmBK 11 DPI 

. MrDZCAl. Joc«K*4 ±x\/fJ 


This pati('nt aviis iiovor oft nn open VL*r:nulah. His 
uouoral (.‘omlilioii is oxc-ollent iu every vuy: there is iio\\ 
no pain or tondevncps, ;uul tlie poise and leniperatnre arc 

'quite normal. . . , i 

.The api)aratns is simple to use; it ran he qiuekly adjusteil 
in anv dirretion hy the lucdical oUiccr from time to time, 
and it vender.s nursing easy. Tims a l»od-pan is used hy 
iiiorclv lionliing U]> the extension weights and sliding Ihe 
patient up the bed;. he fits buck into position when tlic pan 
is removed, iind the weights again hang free. The splint 
will Jie oil auv ordinary bed and fit any [lationl. rliild or 
adult. Cradles, wliich cause draught and discomfort, are 
rendci-ed unnecessary. 


shot up to 105’^ but dropped to 9S° T. Iiy 8 p.m.; after this 
convalescence was rapid and uneventful. 

Tlic facial paralysis had almost entiiely cleat cd up by the 
beginning of may, wlien sht' '.vns able to take walks of two to 
four miles, hut (he diplopia pcrsi‘~ted for about another montb. 
Sonio pramiialions had to bo curcUed out of the right canal. 
The discharge soon cleared up. As soon as the membranes were 
BOiiiidly iioulcd gentle politzcnzalion was used, and this was later 
MtppicniGiiied by massage, rrom time to lime all treatment ivas 
stopped for a week to leu days. 

Tlio hearing in both ears is now practically normal; there is 
no narrowing of (ho right extenial auditory canal. The patient 
is again leading her normal life, and lias resumed hunting. Head- 
aches, or other sequelae, are nhseut. 

AV. J. Haruisox, Af.B., B.S. 

fiurgf'on, Ear, No«r, and Throat Hospital, 
Newcublle-oii^Tvne. 


^tcmoraitlta : 

MEPICAL. SURGIO^VD. OBSTETRICAL. 

FRACTURKD BASl-: OF THF SKULL FOLLOAVKD 
BA' ACUTE AIASTOID DISEASE: RECOAHCRY. 
Acute mastoid disease is nn unusunl sequel of fractured 
base, and the following details of such u case seem to bo 
worthy of record, especially since almost complete recovery 
followed operative treatment. 

\Ylulc hunting on February 1st, 1926, a l.ady was thrown from 
her horse, widen rolled ovci'* her. She was unconycious on being 
picked up, and was bleeding from both oars and from the nose. 
Both clavicles were broken, and there were injuries to some ribs. 
She was coniplctx'ly unconscious for twelve hours, and only parliallv 
conscious for the next four days. It was noticed that she had 
right facial paralysis, and on recovering con^iciou^ne^s more com- 
pletely it was found that she had paralysis of the right sixth 
nciTO, can‘?u)g doulOc vision. 

Tlic external^ auditory canals weiv kept clean by swabbing with 
1 in 20 carbolic solution. On the cightli day there was earache 
on the right side; a discharge appeared ftom both cars on the 
tenth day, and her (emperaturo rose to 100= F. On the twelfth 
day she complahied of earache on tlio left side. There was eon- 
sidcrable swelling around the upper part of tlic rigid mastoid, 
extending above the car into the temporal rogion, and in front to 
]usl below the zygoma. This had appeared very sliortU after the 
awidcnt. There was a free discharge of pus from this cur, and 
when the canal was cleaned out it was hniiid to be lorn across 
close to the memln'ane. wlitcli could not ho seen properly owing 
to narrowin^^ of the canal. The left canal contained some dried 
blood "and disch.argc, but no perforation could be seen iu the 
inembraiio, wliich was not reddened. Both masioids wore verv 
tender to pressure, and this liad always been the case since she 
recovered consciousne.ss. Air conduction was diminished, but l»ono 
conduc^n was nonnal. Tlio tomperalurc was 100.6-^ F., and tlio 
pulse SZ. She answered questions inlclligcnilv, but when not 
spoKcii to lay in a drow.sy condition with her* eves closed. The 
„ day^ the pulse and temperature wore normal, and 

frt-n '”'^-**.^** hours, when the tcmpcratuic again 

LaA »» being 88. On the sixteenth day she 

Knmn car and mastoid, and there was 

the swelling in tliLs region, the car being pushed 
lonvard; the temperature was 101.8= P., and the pul^o 100. The 

il.n dwcharging slightly, and it was obvious that 

me right mastoid was infected. 

usual incision was made, and a fracture 


the bone* tliiQ Arne i vrocar was used lo make a hole ixi 

use of Ijuir? -11111 1 trocars, and b,- gentle 

fouiul in the'rell. ''olo "as enlarged. Some pns was 

in tlic bone aftcr'heb?.T througli the anditus, and tbe cavity 

lightly packed“-with brpp^l'’Ealr‘‘Tl'fi‘'T,e'’r"‘’ •’’‘'’Fi'''’ 

pulse 86 but bv 8 o clock tbe temperature w.as 93.4° F. 

Sulse 132- tbe bieatb^.""' ‘W™tHre bad risen to 103° F.l 
uideed. There were no ' Pry >>• 

tlie question of a commencing “ater'al^^M;"''^^ 
fmous abscess bad to bo .of, • 1 sinus infection or a pen- 

of the tte^s bi the “ deep infection 

By the eWuiF ( 1,0 hi the line of the fiacture. 

IM. -and Z “was dn m’Si b"; 100.6° F., pulse 

teniaincd below 100° ¥ m (jfo ‘7 'Bhe temperature 

rose to 101.40 F at R a ‘'.ay, wlieii it again 

The swelling in' the tcmnA'rai"'^ ^ P-™- hay. 

marked, the ri-^ht eyelid region became more 

closed ; ’somo Stna mid f^ddo^""™’ “o-'"'-’' 

catoiidiiig to the left side over the forehead appeared, 

Z The t^mporaT,’'^^^omatlc‘°Zd''sid'''''® ''•n '°“’P°''.“' region, 
explored with a verx iZo C® „ T ''Cg'ona were 

A fuillicr free iiicis'ioii m tbf ."“hie, but no pus was found, 
lomeiitations were applied Too uoZ"!'®' 

1 1 a. i.iic next day the temperature again 


PNEUAIONIA AVITH ACUTE ABDOMINAL SA’^iIPTOJIS 
AND JIULTIPLE rVBSCESSICS. 

Thk simiil.atioii by pni'iinionia of an aouto abdominal 
condition is not yen- nncoinmon, but tbe following case 
pixjsenls some nnusnal featuies and seems, tberoforo, to 
bo worthy of record. 

A young lasc.ar was ndniiltcd to the British Collage Ho.spilal at 
Algiers, on l-’cliriiary I6II1, complaining of anorexia and great pain 
below tile liver running down the right side of the abdonicn. 
On palpation muscular coiilraclioii prevented exploration of the 
subjacent viscera, but no tympanites was present and the ab- 
dominal respiration was unimpeded. The temperature was 101°. 
The liowels were loose, but nothing abnormal was found in the 
faeces; it was decided that there was no necessity for immediate 
inlerv-:‘iilion. 

He began lo cough considerably two days after admission, and 
examination showed diilliicss over the upper lobe of the right 
lung exiemling into the nxilla. The sputum was not particularly 
viscid and did not present the cbaractcristic colour of pneumonic 
expectoration. Puncture of (be pleura over the dull area brought 
away only a few drops of blood-stained fluid rich in pneumococci. 
At flic liack rc.spiration at the upper part of the lung was Wowing 
and llicre wa-s podoriloquy. The crisis occtirred on Vcbniary 25th, 
■ when the temperature returned lo normal and did not subse- 
quently rise. 

The patient improved and began to lake food readily, but he 
complained of pain in the back of the neck on movement in 
any direction. Notiung abnormal could bo made out in that 
situation by palpation, but there may b.avo been pneumococc.al 
arliirilis; Keriiig’s sign was absent. Then swellings appeared 
on (be arms — one on (be outer aspect of the right forearm 
and two on tbe outer aspect of tbe left arm, the uppermost 
just below the deltoid. The swellings ranged in size from a 
filbert lo a wahiin, and fluctuated freely. On being opened 
they gave exit to creamy pus containing a pure culture of 
pneumococci. The patient was given three intravenous iii- 
jcclions of antipiieiimococcal vaccine; these were not followed 
hr any rise of lemperatiirc, but he bcc.amo noisy and had to bo 
placed in a separate ward. He ultimately made a good recovery, 
the abdominal svinploms having cleared up spontaneously in the 
course of four or five days ; (be stilfncss of the neck subsided gradually. 

Jiulwiug from tlio litcfntufo of tlie subject the [iroguosis 
iu eases of ])iicumococcaemia before the iutrochietion of 
vaecincs was extremely grave, but this is my second case 
in which the use of an aiitipneiimococeal vaccine appears 
to have exerted a favourable influcuce. 1 reported a case 
of piienmococeal iiolyarthritis in the British Medical 
Journal of Septcraher 13tli, 1924 (p. 455). 

The interesting feature in the present instance is the 
patient's admission ns an acute abdominal case. The fact 
that pneumonia may simulate appendicitis has long been 
knomi, and this is particularly the case iu infantile pneu- 
monia. Danssy, in 1913, collected notes of a numhex* of 
such cases for his Paris thesis. Ho points out that while 
some patients treated for pneumonia were found after 
death to have had appendicitis, on other occasions patients 
operated upon for ajipcndicitis were found after death to 
have had pneumonia. He concliuled that pneumonia, 
especially in children, might ho accompanied by an abdo- 
minal syndrome resembling that of appendicitis. This is 
not due to an ahnormal localization of the pneumococcus; 
it is quite possible, of coui-se, for the two affections to 
coexist, and it is obvious that an attack of appendicitis 
may pxedispose to an attack of pneumonia. He divides 
these cases into two main groups — namely, (1) those in 
which the piiciimonia suon dominates the scene while the 
abdominal sjinptoms spoutaneously clear up, axxd (2) those 
in' which the a]ipeiidicitis becomes and remains the prin- 
cipal feature, the puenmoniii onlv being reemrnized later 
on. The cases helmiging to the first group are nsnallv 
mild, hut the prognosis is not so good in the second 
The moral to he drawn from his observations is that in 


r TirrTlKmf* 
MrMCit JorBxiC 


1110 , JUKB 39,^ t 928 ] 


THE INTESTINATj Al^roEBAE OF MAN. 


|•"^’ctico wo ought to look after the appoiKlix in our 
puouniouia patients and keep an eye on the lungs in eases 
of appendicitis. 

Algiers. Alvked S. Gunu, IVI.D. 


PTJLMONARy SILICOSIS. 

The following case would appear to ho worthy of record in 
view of the question of compensation that arises. 

A stone borer, aged 42, had worked in a coal niino for iwciily 
years; there was no liistory of any previous illness or a family 
history of disease. Before his employment in the mine he had 
worked in a quarry, boring with a pneumatic drill and hlasUng 
away the hard rock aboro Iho co.al scam. I am told that tins 
rock is so hard that no other method hut explosive will BufTico. 
Last August lie complained of an irritable dry cough, \vhicli 
resembled a bark. There were no definite signs then in the hiiig, 
and a tuberculosis officer excluded this disease; the T-ray photo- 
graph showed mottling, but there was no wasting. In tact, the 
man said he felt quite fit, but tlio cough tired him out. 

examination by a laryngologist led to the suggestion of 
there being pressure on the recurrent laryngeal, witli silicosis ns 
the probable cause. The Wassermann reaction was negative. The 
was seen by the regional medical officer, who agreed wilJi 
the diagnosis of silicosis Several specimens of sputum wero sent 
to the county bacteriologist with negative results. Dr. Ifor Davies 
saw the case and also diagnosed silicosis. Early this year the 
patient had an attack of acuto bronchitis with .signs of'bronchi- 
cardiac insufficiency and oedema supervened, ending in 
death. Four or five sputum examinations were made during the 
for tubercle bacilli, but proved negative each 

I do not think tliero is iniicli douht as to tho diagnosis. 
The patient )iad been seen by six iiKlopondent medical 
practitioners, ivlio agreed as to tJio naturo of tlio condition. 

I am infornied that silicosis is not on tho schedule: 
consequently this man’s widow and children rccoivo nothing. 
Tenosynovitis and minors’ lioat hand como within tho 
scope of tho Workmen’s Compensation Acts, wlicn in niy 
opinion a damaged ” lung is a condition with a much 
less probloniatic etiology. Compensation is paid should 
tuberculosis supervene in a previously damaged joint at 
work; why should it not bo available if tho Ituif^ is 
damaged through tho hazard of occupation? ° 

„ , Gwilvm L, PiEncE, L.R.C.P., ‘ 

Penrluwceiber, Glamorgan, L.R.C.S.Ed., L.R.F.P.S.Gla?r. 


Erporfs of 

THE IXTESTIXAL AMOEBAE OF MAN. 

At the meeting of tho Royal Society of Tropical Medicine 
and Hygiene on Juno 21st, witli Professor J. W. W. 
Stemexs in the chair, a paper on “ Tho differentiation 
of the intestinal amoebae of man ” was read by Professor 
L. Brctmpt, of tho Laboratoiro do Parasitologic, Faculte 
de Medicine, Paris. 

Professor Brniiipt said that English authors had hcen 
tile brst to demonstrate tlie frequency of ocfiurronco of 
four-nucleated cysts of Entamoeba in individuals who had 
never boon in tropical countries. These cysts had been 
considered .as invp-iably identical with those of the real 
E. dysentmae, discovered by Quincke and Eoos in 1893 

nn w nrS" identification that 

.all wiitors had published tlieir statistics. TIio statistics 
demonstrated the peculiar fact that four-nucleated cysts 
u ere encountered nearly as often in countries where 
.amoebic dj-seiitery was unknown as in those where it was 
e.xtensive. It had yet to be explained why amoebae were 
pathogenic for man in one of four persons of the 
Philippines, one in ten or twenty in various narts nf 
Hclia and IiKlo-China, while in England, Fr.-iice, and 
Holland, where millions of cj-st-spreadors existed onlv a 
few cases occurred each year, and among those c.ases 
contagion from exotic carriers was usually deiuonstrahl© 
In tho speaker’s estimation most statistics iiad been ostab- 
lisliod on a false basis. Ecarly all authors bad considered 
iill four-nucleated cysts as belonging to E. dysenicriae 
but in fact these cysts wero produced by three different 
ontainoebae— naiiiely, E. dispar, E. Bartmanni, and E 
dysenteriae, and in that order of frequency. E. hartmanni 
was a small amoeba, found in ail parts of the world and 
ono winch did not soem to he pathogenic for man’ He 


had hoon taken for E. dysrntcriac in tempov.ato comitrics— 
in England, for instance — was much more difficult to 
■identify than E. hartmanni, for it differed from E. dysen- 
tcriac only in a negative character. It stood out from 
E. (hjsr.nl critic by its natural and experimental ImVitat, 
its gcograpliical dislrihution (whicli oxtonded hc 3 -oncl that 
of E. dy.scnlcriac), by tho way in which it fed in natural 
hosts and in culture, and by its p.athogcnic power. This 
amoeba, dwelling in tho largo iiitcstino, lived probably on 
tho surface of tho epithelium without producing m.ncro 
scopio lesions. It was incapablo of producing liver 
abscess, tlioiigh, like E. hartmanni, E. dispar probably 
gave rise, when numerous, to various sligiit digestive 
troubles. This parasite was widely sjircail among indi- 
viduals who seemed to tolerato it quite well, while in 
post-mortem examination lesions of tlio gut caused by it 
had never hoon observed. Differentiation could ho made 
by injection of tbc cysts into cats. When the agent was 
tbo dysenteric amoeba Ibo cat died with tbo usual lesions; 
if it was E. dispar any infection produced w.ns only mild. 
Professor Brumpt considered that tbc dyscntoric infections 
reported during tbo war by Yorko and others as occurring 
among recruits who had never been out of England wero 
infections in which E. diipar and not E. dysenteriae was 
implicated. If amongst cyst-bcarors — and tliero were 
several millions in England — only ono or two cases of 
dyscntoiy occurred oacli year, it was bocauso these many 
cyst-bcarors wero infected ■n'ith B. dispar and E. hart- 
manni and not with E. dysenteriae. 

Professor WannixaTOX Youke said that Professor Brumpt 
liad offered a very simple explanation of a pnMling 
phenomenon — namely, why a dofinito porccnt.age of appa- 
rently healthy people should harbour a pathogenic organism, 
or vvlm.t niitil tliat evening most of tboso present had 
believed to bo sucli. Professor Brumpt had said that it 
was ilifncult to difforontinto tlicso species, E. dispar and 
E. dysenteriae, on tlioir inorpliologieal characters, but tho 
spc.akcr confessed himself ono wlio still clung to morphology 
as offering the soundest b.asis for classification. Tho onus 
of proof lay on those ivho stated that things -which appeared 
to bo tho sanio wero really diffcicnt. With regard to^ the 
woi’k wliicli ho and others had dono in 1917 on recruits 
who had never left England, it was noteworthy that in 
at least two of these cases infections were produced in 
cats which wero not to bo distinguished from those resulting 
from similar experiments with tho excreta of chronic 
dysenteries. In certain circumstances amoebic dysente^ 
could bo contracted in England in indigenous cases, and it 
was possible that if signs of amoebic dysentery among tho 
population of temperate zones wero sought for by skilled 
observers they would bo found much move commonly than 
at present imagined. Why certain persons should harbour 
E. dysenteriae and exhibit no signs of tho disease was not 
known, but tho explanation might ■n-cll bo that befovo 
E. dysenteriae could produce any diseaso some additional 
factor was necessary, such .as susceptibility of tbc alimontavy 
canal. The lesoarches of Adams and himself had sliown 
that cysts of E. dysenteriae passed by different individuals, 
or by tho samo individual at different times, differed 
markedly in numbers passed in a daj', the stage of develop- 
ment at which tliey wero passed, and their viability as 
judged by cultural methods. 

Dr. H. D. Duke ■ instanced tlio parallel with regard to 
trypanosomes. The dualist view was that 2’. rhodesiense 
and T. hrucei had very little to do with ono another; ai 
recent investigator had linked up T. rhodesiense and 
T. gambiense as tho same species appearing under different 
guises, and T. briicci was regarded as a trypanosome which 
had no use for man. The unicists, of which he was one, 
regarded T. rhodesiense and T. hrucei as very nearly allied, 
and he himself thought that T. gambiense was a variant, of 
T. hrucei wliich had become a specialized parasite of man, 
having been forced to utilize man as its final host owing 
to tho decrease of game in the regions where man and the 
t^tse fly came into close contact. There was a parallel 
between the situation in the trypanosomes and as Professor 
Brumpt had sketched it in the amoebae. Tho speaker prit 
forward the hypothesis that there was one polyniorphio 
species of amoeba, a parasite of man, but differing in its 
adaptation to man in different circumstances, and that occa- 
sionally this adaptation broke down, resulting in dysentci-y. 



JDNE 30 , igiS] 


ElJINCUlian OBSTETJttlCAL SOCIETT. 


T Titr, Bnmin 
t SfKurcAt JocnsAt 


lUl 


Dr OoitiioN" TuohsoS felt tlie siil)ji,'i.t to lio I’xli'enipjy 
difficult because so many unbnoun taclors in U.c Ivans- 
mission of amoebic dv.scntciT neve cyvdeutly at woyU One 
important factor was tbc mass of infc. tin- .luyo, wliicb was 
probablv iicgli-iblo in a country like Kiiglaiul, but in 
]->vnt, \vbcre there were large numbers of llies, and where 
faeces wore deposited all over the giouud, it was veiy 
considerable. 

Dr. C. 31. 3Vr.xyox pointed out the einbarrasMucnt to 
clinicians sltonld rrofcssor Drnmpt’s view find acceptance. 
Hitherto, on the presence of fonr-nncleated cy.sts of the 
histoJylifii tyiic being rci>ortiHl, tlio imticnt was. put on 
emetine, but now' tbc clinician wonitl have to aw'ait a 
further verdict, to bo tested on the eat, as to whether 
tbc agent was Tj. (Visjtar (in wliieli ease llie patient should 
bo left alone) or E. hutoUjUai. Dr. 11. 31. llASseiiKi.r., 
taking uiv this bast remark, said that if I’l-ofcssm- Hiumpt 
stayed tlie routine rush to emetine lie would liave done a 
great deal of good, because it was (luile clear that amoebic 
.dysentery was not ab.solutcly constituted or demonstrated 
merely by the fact that in the stool n fonr-nncleatcd cyst 
liad been found. Dr. Sr.iwri.iN spolro of cxiu-vieme in two 
tropical eonntries — 3Icxico and Central .\friea. In both 
these countries there was a consideinble fic(|uen<y of 
amoebic dysentery, but liver absrcs.s. wbicli was excei dingly 
eommoii in 3toxico, was com])ai-.itively lai-e in Central 
Africa. One differciitialing factor was |>erhaps flics, of 
which there were a largo niunbor in 3Ic.xieo, but hardly 
any in tlio Congo, wliero dust was more likcli to be 
the principal menus of traustuis.siou. 

Professor BauMi'T, in reply, spoke of the great difrii iilty 
in identifying species on a moipbological Iiasis alone. 
Morpliobgy was in a state of cvofiition, and wa> not 
infallible. Indeed, it was somcliuics not po'-'-iblc to dis- 
tinguish moiphologicaJly between certain finite coniplieatcd 
organisms, \\ itii regard to liie rrcfjuoney of liver abscess 
among dy.scuterie individuals, tliis wms ucuerally, in wliitc 
men, m the jiroportion of one in si.x,'hut racial factors 
came in, and it was possible that in 3Icxico there was a 
mixture of w'hitcs and Didiaus, which would alter tlie 
iucidenec. 


EDIXClTKCn OBSTETRICAL SOCIETT. 

At a meeting of the Edinburgh Ohstctrieal Society held on 
June 13tU, with the president, Dr. H.iio Ffmocsox, in the 
chair, a paper by Professor \V. STUouANorr entitled “ A 
pica for the treatment of cciampsia bv tlie improved jiro- 
^i.rlactic method ” was read by the socrctaiy, Dr. 
Uocr.i.\s 3lrLLEn. The paper followed much the same 
linos as that communicated to the Section of Ohstcfrics 
and Gynaecology of the Royal Society of Sfcdicine on 
June 15tb, and reported in tlie Drifish Medical Journal 
of June 23rd (p. 1065). 


_ , „ of Eelampxia. 

Irofessor Stroganoft hegan by giving statistics to show 
tlmt eclampsia still remained a great menace to etiild- 
bmnng women, and wa.s accountable in Russia, the United 
States of America, and England for a maternal death rate 
of nearly 8,000 women and orer 14,000 ciiildrcn every year 
oni,!- mortality could, in’ his 

menf T f" adoption of hi.s treat- 

^ of 360 cases of 

1“^ '■oported a 6.6 per cent, maternal mortality 
Toi mortality. This compared 

mniLvr ^ treatment.s, where the 

Si^t o'-or 20 per cent. During tbc last 

Prof^sor Stroganoff bad treated 300 fnrtbci 

at dVolt,- -I? four patients arrived 

*scnki<^ and t^o died from pnenmouia ami 

sinrtp' r-ni 1 • 300 -cases there was not a 

single convulsion after the beginning of treatment; ir 

15 ner^,?^ “‘If ^ 3 scfmires, and only- in 

of xV ® «'«o. In d large numbci 

hour's brf *'“^'^1 ' 1 ”^ convulsions for twelve 

sm^ ■' mortality among children -was a relativeh 

C illiCn if premn' 

cbUdion -weighing. less .than 3,000 ^ ams be excJiided 


the foetal nioitality i.s rodncod to 6 t’cc cent. There was 
not a .single niaterniil death due to treatment, ivliereas 
in tlio old days, wlieii accoueboment forte was the method 
of treiitmcnt, 4 per cent, of the mothers died as the result 
of the ojieratioii. There w.as a relatively small mimbcr of 
operative delivcric'*, and rapid recovery of the patient lyas 
general. Of late. Professor Stroganoff had A'isitcd clinics 
in Vienna, Berlin, and liondon, but tlie number of eclamp- 
tic cases scon in these cities wore few and not up to 
expectation. Tlicse visits, however, had not been in vain, 
.as the.!' taught the rainc of the prophylactic method, .and 
there had boon .a definite improrement in the mortality 
rate in the various e.linics. In cases at a distance the 
Icleplionc could be ii'icd to instrngt tlie medical attendant 
as to the treatment to bo adopted. This had- been done 
in one ho.spital where 176 cases of eclampsia had been so 
treated. In his last series of 85 cases of eclampsia tre.ated 
over tlie telcjAhone there was onlv 5.6 per cent, mortality. 
Professor Stroganoff deprecated the operation of Caesarean 
section in the troatment of eclampsia, as such a treatment 
not infrccpicntly contributed to a fatal is.sue, and fti 
nearly all cases inynred tlio woman for no good purpose. 
He did not consider his mctliod ideal, and believed Diat 
even now furtlicr improvements could be made. 

Oraiiaii ErtracI after Arlijichd Menopause. 

Dr. TV. T’. Hm'i-tain read a paper on tlie value of 
ovarian extract after an artificial menopause. It had hern 
his practice for the hist five years to administer ovarian 
extract oiuliy in 5-giaiu doses for six months in casc.s 
where liotli ovaries had to be removed at operation either 
with or w-itlmut the uterus. The method of atlrniiiistration 
was to decrease the dosage giadually, the patient begin- 
ning with 5 grains tliree times a day for the first two 
mouths, twice a day for the third mid fourtli months, and 
once a day for tlie fifth and .si.xth montlis, hut if the 
symptoms became severe at any time the dose was imme- 
diately increasi'd. In order to’ discover if there was any 
advantage in this treatment Dr. Haultain scut out a 
quesliouary based on simUar questions asked, by J. "U'. 
Bride, when ho was investigating “ the further results 
of removal of the uterine appendages in hysterectomy.” 
The questions a.skcd were: (1) TVas the general health 
improved? (2) Had tlic jiatients become stouter since the 
operation? (3) Had they become very depressed? (4) Had 
they bad severe fiusTiiiigs, for liow long did the flusbings 
last, and were they still present?' (5) Did they suffer from 
beadacbe? (6) TVere there any marked nervous .synijitonrs 
following operation? In all 31 replies were received, and 
of these 31, 24 had taken ovarian extract for one montli 
or more. In those who had taken ovarian extract the 
results foiiiparcd voiy favourably with Bride’s results in 
185 ra.-es, as it was noted tliat the extract seemed to liavc 
helped tlie patients with regard to adiposity, hcndaelics) 
nervous symptoms, bnt chiefly in regard to flushings. -Ts 
the tieatmciit hud been given principally to try and relieve 
flic flushings the results were very gratifying. The imme- 
diate result was very little better tlian iii "Bride’s cases, 
but at the cud of twelve montlis only 33 lif-r cent, of the case.s 
contiunod to bare any flushings, whereas in Bride’s cases 
64.6 to 75 per cent. mTficred from flusbings after twelve 
months. Among the h'ysterccfoniie.s only 20 per cent, bad 
flushings after twelve months. xVbont n year ago it was 
jxornted out to Dr. Haultain that injections of ovarian 
extract might be more beneficial than the oral adminutra- 
Hon, .aiicl for the last year he lias treated all his cases by the 
injection of 1 c.cm. of whole ovarian extract twice a 'week 
combined with the oral adiniuist ration of 5 grniii.s once 
nightly. He bad treated in all 13 cases for a sufficient 
time to estimate the value of the method, and from a. 
short simiiiihi'y of the cases he showed dearly that until 
further injections the flushings became very sliglrt, and in 
many cases entirely disappeared. Several patients had 
been operated niion some niontlis iirovionsly and Imd 
suffered severely from flushings; when injections were 
started the flushings in practically ereiw one of .sudi cases 
were much improved, and in a large nnmber entfrefv 
ceased. "Dr. Haultam therefore recoinmended tins treat 
inent for a period of tlireo months at least, espedallw'iii 
younger women uhere both ovaries had had to be removed 




June 30, 192S] 


HEYIEWi?. 


[ Tnr numfTT 
Mi uical Jot'Ksxt. 


1,113 


tvo points, however, in tl.o French hislorv- whore, in mu- 
opinion, . improvements might have t.cen ma<te. in tho 
matter of illustrations wo fiml 100 maps ami 27 figmos 
spread over tho foiir volumes, and while tliesc. aro clear 
and devoid of unnecossarv detail, a more plentiful supply 
of actual photographs would have considerably mcreasetl 
tho reader’s interest. Tho only inde.v conies at the close 
of tho last volume, and takes tho form of a tahlo of 
Synopsis, which seems hardly adequ.ato to the importanco 
o‘f the work. A list of abhrevialioiis use<l throughout the 
text and an explanation of tho signs employed in the maps 
aro given in tho first volume onl}-; a repetition in each 
volume would have been preferable. Hiese are, however, 
small points- compared with the' achiovemont of tho author, 
whoso work brings credit to himself and his country, and 
will amply repay close study. 


PERNTiClOUS anaemia. 

TnE success of liver diet in the treatment of pernicious 
anaemia has stimulated fresh interest in tho nature and 
etiology of this hitherto fatal disease, and Dr. Cou>;f.i.i,’s 
monograph on Fcmiciom Anarmiii- appears at a very 
opportuno moment. Although the classical signs and sym- 
ptoms of this disease aro now pretty generally recognired, 
there is a large mass of information which has been 
collected bit by bit and been published in v.arious journals 
and monographs all over tho world, and which has hitherto 
only been available to those with the opportunity to hunt 
through an extensive literature. Dr. Cornell has brought 
this information together and has succeeded in turning 
what might easily have been merely a useful catalogue 
into a most pleasantly readable and extremely useful book. 

In a volume that is full of odd and ajiparcntly unex- 
plained observations which give much food for thought 
it is impossible to do more than note one or two of the 
points that will be of general interest ; of these, the pages 
on the geographical distribution of the disease, the critical 
consideration of tho diagnosis in those instances that have 
been reported in young children, tho points in differentia! 
diagnosis from other diseases which may occasionafly show 
a similar blood picture, and tho interpretation of the newer 
methods of diagnosis by tho measurement of tho red colls 
nnll all find a geiiorat welcome. The historical survey of 
of tho disease is einincntlv fair and 
™ iind tliroughout the hook, although the 

fiuictly indicates his own views, tho various hypo- 
cses that li.ive been advanced by others all receive a 
JIK appreciation. Summing up the observations on tho 
e 10 ogy of the disease Dr. Conielf concludes that it is a 
ipers ructure of blood system and nervous system changes 
uporimposed on an unknown foundation, and that tho 
1 ; 1 involvement and tho peculiar mass of 

ftmrinmlnt Support tile view that tho underlying 

•The ^’®fhrhanco of metabolism. 

that mav liei-uf '' for non-medical readers 

, • ^ . P® ^0 of more value in its country of origin 


than l,ei-e. 1 vuluc 111 US country or origin 

shows the 'i * ''l *”’’I'ography which not only 

also lavs nil s+ has gone to its making, but 


CLINICAL PEDIATRICS. 

TiedS5;c<r° **ti sories of monographs on clinical 
HATmis^hr -‘‘l editorshfp W Dr. R. S. 

and tven t e • “ 'oviewed in these columns, 
apnear to linv^Tvl concerned do not 

as a whole tl, this subject. It may bo said that 

no'Ae fit. “d "’bile the price may 

Biiteeu ■shniings'fstx3./ftyttl“^-®’ °d 

half this.ngmber 0 ^,1^:- ‘ ^oL T’o^ pL^Zi 


laW;niUnh^reitj"p™s"' *tB. lajndon ; Com- 
J Clinical PelUalrici Sii JrvLl' ®™v'’.P- ; 6 fiRurcs. 20s. net.) 

ri'.n.. H.D. v5s i. ii. ii^v "“y*' stores Haj-neJ' 

London;. D Appleton and Co -Vt'-.^v. fTeiv Tork and 

fisnres; voV. it* Vp "^.1 +258 b Pr- xiv + 211, AT 

figures; vol. r, pp‘^.xiv + 242 64 1°'- PP- xviii + 429, 82 

2 Pjotes; Tol.’xi,P PP xiii imo ™' ’'b PP- -1 233, 5 figure, 

^figares; rol. xiY,*pp. itiit + 415 = ' Ol ■ pp. xvil 178, 

^ figures, I 63 ; net eich vol.) ; 7 " Psurcs-, vol. xv. pp. xxvi + 330, 


Care, by Dr. R. IV, Lohcnstiiio and Dr. IT. C.'Railcy, 
is specially disappointing — an nnsatisfactorv mixture of 
obstetrics and pediatries discussed in a very .superficial 
manner. Dr. C. O. Gvuloe and Dr. B. E. Bouar deal with 
The jVewboni in two volumes, numbered ii and iii, of the 
scries. The former is devoted to physiolog)- and care, and 
the latter to diseases and abnormalities. This distinction 
is artificial, however, and leads to a great deal of over- 
lapping.' For example, the volume on ph3-siology incTiides 
avlielcs on asphyxia neonatonim and the haemovrhagic- 
disenscs of tho ncwlj- horn, while a discn.ssion on the 
physiology of the nrinary tract would ho much more useful 
if it accompanied the ac-eoiiht of di,soider.s of this .sj-.stcni 
instead of appearing in a separate volume. A section on 
breast-feeding i.s iiieludcd,' although vol. xii, by Dr. H. B. 
IVilcox, is devoted cntireK' to Infant and Child Feeding. 
This is one of the verj- short volumes already ine.ntioned; 
and while in general it follows orthodox lines it cannot be 
considered satisfacton-, in a series intended for the general 
practitioner, to deal mainly with artificial feeding, while 
hrca.st-focding is considered only iii the two final chapters. 
Dr. Bronson Crothers writes on Disorders of the Nervous 
System in Childhood in vol. v, and this appears to be 
a very good contribution to the series. Ho regards the 
proble-m of exact classification as iSf academic interest only, 
and devotes liimsolf to the more practical aspects. Can 
disorders of tbo nervous sj-stem be arrested? Is the lesion 
progressive? Can education be carried out if the process 
is no longer active? These are some of the questions he 
attempts to auswef in a stimulating and provocative hook. 
Dr. IV. P. Lucas and Dr. A. H. B’ashbum consider 
Diseases of the Flood and Blood-htiilding Organs, and tho 
degree of overlajiping present throughout the .series is 
clenrlj- shown liorc; the haemorrhagic diseases of ilie newlj- 
born are again discussed when the subject has been dealt 
with fully in vol. ii, with a brief summarj- in vol. i. It 
is unfortunate, too, tliat these accounts differ on certain 
points. Infective mononucleosis (glandular fever) is not 
mentioned except in a table. Tho account of purpura is 
good, and the discn.ssion of such difficult subjects as splenic 
anaemia and Banti’s disease is adequatelj- presented. Dr. 
F. B. Talbot writes on The Internal Secretory System and 
Metabolism in a vorj- satisfactorj- tliough small volume 
(xiii of the series). The normal metabolic processes and 
their pathological variations are well described, and defi- 
ciency diseases are discussed, with good illustrations, 
although one and a half pages seems a ver_v small allow- 
ance for an account of the etiology- and sj-mptomatology of 
rickets. Here, again, overlapping is shown,..for cretins and 
Afongols iiavc already been described in detail in other 
volumcs. Infectious Diseases of Infancy and Childhood, 
by Dr. H. L. K. Shaw, forms vol. xiv; it is a valuable 
exposition of modern views on those disorders; the question 
of prevention is kept well to the front, and each disease 
has the relevant American public health regulations .set 
out at the end of tho appropriate chapter. Rheumatic 
fever has been included, but only ten jmgos are allotted 
to this subject, which deserves fuller treatment. Dr. R. IV. 
Bolling deals with Surgery of Childhood in vol. xv, 
e-xcluding orthopaedics, which forms the subject of another 
volume already mentioned in these column.s, and excludiiin- 
also, apparently, diseases of the car, nose, and throat. The 
omission of -this latter “ specialty ” results in such troubles 
as the consideration of cervical adenitis or acute retro- 
pharyngeal abscess without any reference to tonsillectomv 
as an important measure in their eventual cure. Othei^ 
wise the volume gives a clear account of the special features 
of surgery as applied to the period of childhood. 


FOOD POISONIN&. 

Misconceptions still exist about the nature of food poison 
ing in circles well informed about other infectious diseases 
For instance, it is common for illness to he ascribed to 
ptomaine poisoning in spite of the fact that every nroDer 
investig.ation of such illness has proved the cause to be 
Salmonella bacteria or their toxins Dr i t 

Food In/cefions and Food IntoMnsA dV 

l.ohrn'*: 'nlS 

figures, 18 plates IBs. net.) f PP- 'iii + 260; 13 


1114 June 30 , ,igj 8 ] 


I , , . BEVIEWS., 


■ iY.r: . ■ 


f TiipHRITI!* . 
L‘M» DicAi. Jonjxus- 


summary of present views on food poisoning, and it is 
to 1)0 hoped that it will ho widely read. Tho essential 
difference hetween tho old and tho new point of view 
lies in this — that it was formerly believed that a poisonous 
chemical substance was produced during tho natural decom- 
position of food, whereas tho truo view is that tho toxic 
substances aro produced by tho growth of a well-defined 
group of pathogenic bacteria which cause disease in 
domestic animals, from which sourco human food becomes 
contaminated. This commonest of all types of food poison- 
ing is well described by Dr. Damon, though it is to ho 
regretted that ho omits references to tho hfinislry of 
Health Reports and tho Food Investigation Board Reports 
published sinco tho year 1620. 

Tho other, and much rarer form of food poisoning, 
botulism, is classified by tho author amongst tho food 
intoxications, and finds itself grouped with mushroom 
poisoning, grain intoxications, potato poisoning, and shell- 
fish poisoning. Tho only feature botulism shares with 
those other intoxications is that tho s 3 ’niptoms aro duo 
to an organic chemical poison. Botulism differs from 
theso poisonous foods in so many respects, notably in tho 
fact that tho germ injui-es food otherwise wholesome, that 
its separation from other bacterial diseases seems an 
artificial distinction. This second part of tho book, headed 
“ intoxications from food,” is worth special mention 
because of the information it contains about such subjects 
as mushroom and shell-fish poisoning, which do not tisually 
receive much attention in public health textbooks. Tho 
third part deals with tho larger animal parasites trans- 
mitted by food and tho method of diagnosis of helminth 
infections. Tho author docs not mako anj' claim to 
originality in tho contents of this book, but ho has done 
a useful service in collecting together in one volumo in- 
formation about tho different agents which inako food 
poisonous, derived from books on medicine, public health, 
bacteriology, chomistrj', and biology. 


OPHTHALMIC OPTICS. 

Oriics aro a necessary part of tho training and equipment 
of tho ophthalmie surgeon. Compared with tho fascination 
of clinical work, optics aro dry as dust except to a vciy 
small minority of those who aro mathematically minded, 
and who revel in equations that do not seem to equate I 
There has been much improvement in tho teaching of optics 
of recent years. Teachers have clarified their own minds, 
and have been able to give clearer indications of simple laws. 
A recent book of American origin is a good exemplar of 
improv'od methods of teaching. Tho Introductory Course 
m Ophthalmic Optics,^ by Dr. Alfhed Cowan, assistant 
professor of ophthalmology in the Graduate School of 
Medicine of tho University of Pennsylvania, is an excel-, 
lent piece of work. Ho has aimed at giving a Working 
knowledge of ophthalmic optics to medical students and 
practitioners. Ho has tried to construct a system that can 
bo followed by one having only an elementary knowledge 
of mathematics, but a system which is scientifically correct, 
and not inconsistent with tiio’ronghness. Ho has certainly- 
succeeded in his endeavour. He proceeds from considera- 
tion of the elementa^ laws of light to reflection and 
refraction at piano surfaces, and then at spherical surfaces; 
thence to lenses, and the dioptric system of tho eye! 
Myopi.a, hyperopia, and astigmatism are considered, then 
accommodation,' and finally tho clinical methods 'of 
ophthalmometr)’; ophthalmoscopy, and retinoscopy. 

In each section the author not only gives the theory and 
mathematical demonstration of tho subject under considera- 
tion, but there aro experimental demonstrations which can 
be verified by tho student, and which will convey to the 
least mathematically minded a conclnsive proof of tho pro- 
position under examination. Tho rationalo of tho clinical 
instruments for the examination of tho eyo aro stated 
with an enviable precision and directness. Retinoscopy is 
explained in eight hundred words and three diagrams, but 
tho explanation is complete and accurate. It is a pleasure 
to come across a teacher of ophthalmology who tells his 
student that- in retinoscopy it is tho light reflex which is 


M.D. riulaatHo 

111 tigaics. 3 .Cj 


in Ophthalmic Optics. Uy Alfred Cowon, 
DaviS Company. 1927. (Leiny 8vo, pp. 262; 


tho proper subject of observation, and that ho should 
follow tho movements of tho light, and not of somo 
dcltisivo shadow. 

Tho book is beautifidlly printed, and tho diagrams aro 
ndniirablo. In many of these tho ground plan of tho 
problem is given in black ink and tho answer to it in 
coloured inks — a method of printing that is without doubt 
expensive, but most imptessivo. 


THE ALCOHOL PROBLEM. 

Dn. H. M. Veunon, in his book on The Alcohol Problem,* 
gives a judicial survey of two important aspects of tho 
question ; ono is tho effect of legislation in this and other 
countries upon tho consumption of alcoholic liquors, and 
tho other is tho experimental ovidcnco at our disposal con- 
cerning the action of alcohol on tho human organism. 

In his consideration of prohibition in tho United States 
tho author is careful to point out that this was of 
gradual growth, and not a mcasuro thrust on the country 
suddenly in a wavo of war-time c.xcitcmcnt. IVhilo tho 
press in tho United States, as in this country for tho most 
part, is strongly anti-prohibitionist, medical opinion in tho 
United States is strongly in favour of prohibition. Under 
the' prohibition law any doctor who wishes to prescribe 
alcohol for his patients may do so after taking out a 
.special permit, but it appears that only 22 per cent, of the 
medical praetilioners in tho United States hold permits 
at all. Although tho law is flouted in tho largo industrial 
areas' and tho big cities, where in recent years there has 
been an increaso in tho nnmbci- of deaths from alcoholism, 
in tho ae-ricultural districts and small towns;, which contain 
tho majority of tho population, prohibition is accepted with 
complacency. Dr. Vernon , is inclined to think that tho 
real test of the efficacy, both in America and in Finland, 
of prohibition should come in twenty or thirty years' time, 
when tho present generation of young people will have 
reached maturity and power. Ho next considers tho 
system of partial prohibition in vai-ious countries, such as 
Canada, Australia, Now Zealand, Sweden, and Norway, 
and comes to tho conclusion that tho principle of avoiding 
absohito compulsion is tho correct ono, especially if it 
is coupled with an unrestricted sale of com])aratively 
innocuous beers containing 3 per cent, or less of alcohol. 
The methods for controlling tho production and salo of 
alcoholic liquors in this. country during tho war aro next 
considered, cspeciaily thoso relating to tho hours of salo . 
and hiefi taxation, and a chapter, follows on tho English 
public house as it is, in which Dr. Vernon acknowledges 
liis indebtedness to ^Ir. E. Selloy’s work (sco Journal, 
September 17th, 1627, p. 466). , 

In his chapters on tlio ' physiological aspects of the 
problem Dr.' Vernon, vvho has made so many valuable con- 
tributions to' tho subject, discusses the. effeiit of .moderato 
quantities of alcohol, oil cfficicnc 3 %‘ tho . extent to uhich 
food. and .dilution modify the effects of strong drink, and 
tho influcnco of alcohol on length of life. . He maintains, 
ill opposition to Professor , Raymond '. Pearl, ‘ that it, will 
never bo. possible to obtain clear and conclusive evidence, 
though ho is inclined to agree that the effects of moderato 
drinking bn longevity' are- small. Although wo find no 
discussion of tho relation of liquor to povertj',' crime, and 
prostitution, nor any reference to tho place of alcohol- in 
therapeutics, and might for theso'reasons'regaid tho titlo 
as somewhat too wide for tho contents, this book is of 
value as setting out tho impartial views of a physiologist 
oh a matter of outstanding importance. 


NOTES ON BOOKS. 

The first 'edition of Dr. A. Piney’s Ucccnt Advances in 
Haematology was reviewed in these columns on August 13th, 
1927 (p. 269), and already a second edition' has appeared with 
considerable additions, such as a glossary of technical words 
likely to cause difficulty, among which is " pseudo-lcukaenna, 
witli tho comment “ a term best left to undergo atropliy from 
disuse.” There is a new chapter on the spleen in various 


* The Alcohol Prohlcjn. By IT. 51.. Vernon, 5I.A., M.D. Witli a 
by Viscount D’Abernon. London : Bailliere, Tindall and Cox. 
(2»emy 8vo, pp. xv 4- 252; 24 figures. 9s. net.) n n* 

^ Recent Adianccs in Raematulogy. By A Piney, M.D., 
3r.Il.O.P.Lonil. Second edition. London : J. and A. Churcliill. 
(^tra post 8vOj pp. x + 318 ; 4 plates, 18 figures. 12s. 6d.) 



Jdnb 30, 1928] 

infections, and additions liave been made in Ibo otlier chapters 
—for example, in connexion with the liver heatincnl of 
ptrnicioiis anaemia. The chapter Iicadcd Ilaeniorrliagic 
diatheses” includes Wcrlhof’s disease (as ho prefers to call 
purpura thrombopenica, inasmuch^ ns the iniplicatjon of anj 
etiological hvpothcsis' is thus avoided) and aplastic anaemia. 
Here will be found also an account of David’s disease— a 
haemorrhagic disease so far observed only in women, without 
evidence of infection or constant thrombocytopenia, and 
regarded as possible due to endocrine disturbance. In the 
preface Dr. Piney replies with some spirit to criticisms in 
reviews of the first edition, but considering the interesting 
character of the work as a whole he should perhaps regard 
these as compliments to be silently accepted. 

■ Various clinical methods, routine procedures, and therapeutic 
measures have been collected together into a ^t/inicnf Handhooh 
for J/esidents, l^'urscs and Sludentt' by Dr. Vicron M. 
CorrLEsox, . who edits the volume which members of the staff 
of the St. Vincent’s Hospital, Sydney, have written. There 
are a large number of iiroccdures, often handed down by 
tradition among the resident workers in a hospital, which arc 
seldom adequately dealt with in books, and it is certainly an 
advantage for the young house-officer to know something of 
the ways in which encmata arc given, for example, and of the 
general management of special cases, such as ophtlialmic, ear, 
nose, .and throat, and gynaecological patients. The chapters 
on sterilization, minor surgic.al procedures, imisoning, and 
anaesthetics are especially valuable, and it is evident that 
throngliont the book all the methods described are in everyday 
use at the hospital to which the anthors are .attached. 

Clinical HamlbooT: for IlettidrutJi^ yurte» and Sluilrntt. Edilctl by 
Victor M. Copplo*ion, M.B., Cb.M., F.U.C,S. Svdncy, Australia : Cornstalk 
Publishing Co. 1928. (^i x 7, pp. IM.) 


i • . 

I r Tnr narrrtn 111 

LSfrDtCAr.JorP.XAt, 


PUEPARAnONS AND APPLIANCES. 

" Ambidex ” TOisf SjditK. 

Dn. Heobek IjEvi.vsox (Goodmayes) sends a description of 
a simple modification of tlic Carr splint for Colies’s fracture 
which he has. devised. He writes: At present a separ.ate 
splint is required for the right and left Iiancls. Tlic ease with 
wliicli one somehow always succeeds in unearthing the right- 
hand splint avhon the left is required, and vice ver.sa, is too 
well known to need enlarging njioii, and it eonscquently 
occurred to me tliat a splint which would be suitable for either 



hand would be a very definite advantage to the busy medical 
practitioner and to medical officers of hospitals. In’ the Carr 
splint tlic hand-grip portion is fixed to the head of the splint, 
but in my modification the band-grip is arranged on a hinge, 
wliicli thus makes it possible to swing tlie band-grip over from 
one side to llie other for cither right or left liand, as the case 
may be, the faces of the splint being shaped accordingly to 
take the thenar eminence. This new splint is produced by 
S. Jlaw Son and Sons, Limited, 7-12, Aldersgate Street, London, 
E.l, under the name of the " Ambidex ” wrist splint. 


PAPWOBTH vibXiAG'E SETTLEHENT. 


PAP’^ORTH VILLAGE SETTLEMENT. 

CLiFFonn Ali.uctt ME.MoniAL Cqtt.aof.s. 

As a memorial to the late Sir Clifford Allhutt, who was 
president of the Papwortli Village Settlement from 1918 
to 1925, two cottages liarc been erected at the settlement 
from funds subscribed by memlicrs of tiio medical pro- 
fession. Photographs of the cottages .and of the inscribed 
stone which records the significance of the memorial aro 
reproduced on this page. 

The .opening ceremony at the cottages was performed 
by the Prince of "Wales on the occasion of n visit to 
Papwortli last month, when ho spent about three hours 
in making an informal but very complete tour of the 
settlement, under the guidance of the director, Dr. P. C. 
Varrier-Jones. At the opening of the Clifford Allhutt 
memorial cottages a brief address was given by Sir 
Humphry EoUeston, the present president of Papwortli, 


•' i 

' j 

:’1 


. . -'to ftif. 

, THE K!0HT-HGN..S!?,,IC’i.!rrORD AlbEUTT 
■ ■ 'i. fC.C.B.- aVd." f 'R.S ■ '• 

OF physic. EM Tdc'.' . V 

. rr.EsiDE.Hi.cr. the PA rwopTii vin<cs settle-v-enT' ' • ■■ 

. miS-inis. V 

S'T:'r 

The llemorial Stone. 

■fnd Lady Allbutt ^vas prc^ientod to His Royal Highness. 

le cottages are being occupied by tuberculous ex-service 
laen uho, after treatment in the Papvrorth sanatorium, 
tesiie to settle in the village with their wives and families, 
and work in the industries. 

twelve years since operations were commenced 
Ti ^ ' ?tth the erection of two shelters in a garden, 

n-i'.t . course of his visit, saw a community 

patients are being treated, while 
: 'ous iiubistrics have been built up on a sound footing 

Tlin largest village settlement in the world, 

mine: Papworth Hall, the former 

mansion, "-hich now contains the' main wards for men and 
9Q , gi.ounds of udiich are chalets to accommodate some 
n patients. From the wards and tlie chalets the 


men pass out into hostels, where the unmarried remain, 
while the married arc housed, with their wives and families, 
in cottages when these can be provided. 

For women patients tlic prc.sent provision is inadequate; 
there is available accommodation for only five cases, and 
it is desired to create a similar system to that existing 
for men. A sum of £4,000 is needed, and up to the 
present £1,500 lias been secured. 

The Papwortli Settlement is, apart from otlier considera- 
tions, notable for tlie development of many crafts and 
industries among its patients. TVork is begun ns soon as 
their condition permits, many of the workshops having 
been started to provide occupation for patients who alreadv 
possessed a knowledge of some trade or other when thev 
entered the settlement. Among tlie industries carried on 



CliHord Allbutt ^.lemorial Cottages, Papwoith. 


are carpentry, leather work, printing, and iqiliolsteiy, hut 
there are many others. The working day is restricted to 
six hours, and conditions are carefully regulated to suit 
tlie physical state of the workers. To the " provision of 
facilities for useful activity is attributed the cheerful 
atmosphere which ohsei-vei-s have noted as characteristic 
of the patients at Papwortli. Many of them are men who 
at the onset or with the progress "of the disease had not 
expected to he able at any time to resume work. 

It is interesting to note, moreover, that the financial 
results Lave been far from unsatisfactory, when the physical 




1116 June 30, 1928] 


MENTAIi HTGIENE. 


[ Tmk 

MtMCAL JoraviA 


status of tlie workers and limitation of tho hours of 
lal)our, among other' things, are taken into consideration. 
In the industries carried on, under tho management of tho 
tuberculous patients themselves, there has been, during tho 
past nine years, a turnover of about £220,000, and tho loss 
has boon the comparatively small amount of £2,000. As 
it is, therefore, tho industries havo been practically self- 
supporting. Amrarently thej' havo boon hampered by lack 
of adequate capital resources, and it is believed that if 
this deficiency could be overcome there would bo no loss 
whatsoever. 


MENTAL HYGIENE. 

The Prevention of Nervous BnE.\KDOWN. 

A WELL-.VTTENDEp public meeting, arranged by tho National 
Council of Mental Hygiene, was held in tho Birmingham 
Council House on June 21st. A letter was road from the 
Minister of Health, Mr. Neville Chamberlain, oNpressing 
warmest sympathy with the objects of tho council, and 
regret that duties in the House of Commons iircvented 
his attendance at tho meeting. Tho Lord Jf.ajor (Alderman 
A. H. James) presided, and, in opening the meeting, 
described mental disorder as one of the most serious 
problems affecting the countiy, either on its social or 
economic side. In 1926 tho cost of maintenance, super-” 
vision, and treatment of patients amounted to £8,000,000. 
The not cost to the Birmingham local authority last j-car 
was £181,546 for tho treatment and care of 2,655 patients, 
and this was equivalent to a rate of_,8d. in tho £. 

Addressing the meeting on “ The prevention of nervous 
breakdown ” Sir Maurice Craio said That physical health 
had long been the special care of municipalities, bub, except 
for tho care of the insane, tho mental health of tho iioopio 
had been almost entirely neglected. Tho word “ mental ” 
was considered synonymous with “ insane,” but now ideas, 
such as that the prevention of disease far outstripped in 
value the treatment of disease which had become estab- 
lished, must bo developed. In the matter of tho insane 
they had contented themselves with housing those who 
reached an advance state of mental disorder — a state which,.' 
in many instances, need never have been reached had the 
early phases of the illness boon recognized and proper 
treatment boon available. There was no fundamental differ- 
ence between physical and mental disease. For exanijilo, 
one person might react to stresses, of whatever kind, on 
the physical side, whereas another might react to similar 
stresses by some change in mind. Tho importance of having 
general and mental hosiiitals working in close co-operation, 
and of having a mental clinic in every general hospital, was 
becoming evident. Mental disorder was not a bolt from the 
blue, as so many thought ; serious disturbance developed, as 
a rule, slowly, and it was in the early days that it was 
important to discover what was causing it, and to treat it, 
and prevent its further development. The minor mental 
disturbances were of importance,^ and should never be 
ignored. It should be remembered that mind had many 
attributes, and that emotion was one of tho most valuable 
attributes of mind. Emotion must be understood, for if 
it was allowed to run riot it might end in bringing about 
mental ruin. Passion — extreme emotion— could devastate 
the mind for the time being, so that the person so affected 
might bo incapable of reasoned action or judgement. But 
lessor disturbances required serious consideration. A child 
whose emotional reaction was unstable might be almost 
uneducable. Again, disturbed emotion might lead to false 
reasoning, and false reasoning might give rise to altered 
behaviour, or to some other failure of adaptation to 
environment. 


Importance of Early Treatment. 

There were two important factors in early treatment: 
(1) tho proper understanding of mind and its activities 
liy laymen ; and (2) tho ^wider teaching regarding minor 
disturbances of the mind in medical schools and hospitals. 

ttiat they were appreciating that mind and its work- 
m.Tnir+t. integral part of wSat was called health, so 

Tt' S of mS it become to see that the 

Stuclj Ot mind nns not divorced from the teaching of 


general medicine. , The emotional reaction cf a patient 
might delerininc the ultimate sueccss or failure of a surgical 
operation, and this was equally true of discace. It was 
being .shown by increasiug and overwhelming evidence that 
mental fatigue was in many instances a matter of even 
greater importance than physical fatigue among the workers 
in great industries. Jlonotonous movement might exliaiiit 
tho mind in certain types of person to a far greater degree 
than it fatigued tho muscles employed in performing it. 
jroutal hygiene, again,' should play a very im2)ortant pait 
in education, not merely with defective and “ ])roblem ”■ 
children, but with tho highly- intelligent and brilliant also. 
Living as they did in times when scholarship Aras so impor- 
tant a factor in education, they should never forget that the 
strength of tho human brain lay in its slow development,- 
and that if the central nervous system of a growing child 
Avero oA’cr-stiimdatod infinite harm might be done from 
Avhich the child might never rccoA'cr. ' • ' 

In conclusion. Sir Maurice Craig said that tho subject 
of mental hygiene Avas a A-ery largo one, toui hiiig all mental 
activities from the cradle to tho gr.avc. It brought a fresh 
interest to iiarcnts Avatching tho development of their 
children, Aihilc the Avorker Avould understand better Iioaa- 
to get tho best value out of his Avork and bow to avoid 
tho too common minor, but crippling, disabilities. Ea'cu 
in tho iircsent slalo of knondedgo, if this Avere used to tho 
full tho number of tho insane could bo greaily diminished.' 
Tho task now Avas to put into action the knoAvlcdge already 
possessed, for it AVas far better to spend money cn pre- 
A'cntion than on building big institutions. The present 
methods aacio economically Aiasteful ' viened' frOni tho 
standpoint of medicar science they aa'CIO deplorable, .snd 
AA'bcu measured in terms of human suffering it Avas difficult 
to find AA'o'rds strong enoiigh to condemn them. " 

Xced for Education of the Pithlic. 

Dr. Crichton JIii.eer said it Avas an incontrovertiblo 
fact that in affairs of the mind, as in afl'airs o{ the body, 
prevention was the only royal route to eradicate ineffcc- 
tiA'cncss. It did not matter Avhethcr ono Avas dealing with 
early tuberculosis, or a knocking in the engine of a inotor 
car, or slight irritability on the part of a daughter-in-IaAv, 
in each case tho remedy must be applied earlv to be 
successful. From the point of vicAV of good citizenship 
“ mental hygiene ” meant a great deal ; the phrase AA-as 
coined in America for something that bad not hitherto 
been thought of. People had lived with the impression 
that mankind Avas more or less tho same except Avben mad, 
and that madness Avas a special problem unlike any 
other. If insanity happened in the family circle the 
other’ members hung their heads for shame. The Avholo 
question of mental hygiene, and the idea of keeping tho 
mind he.althy instead of regarding the pioblem as ono that 
presented itself only Avhen the mind Avas diseased, had bad 
very little attention, and the public must bo educated. A 
nation’s interest lay in keeping its minds healthy. The 
old phraso Mens Sana in corpore sano had been misinti'r- 
]>retod to imply that if tho body Avero kept healthy tho 
mind Avould remain healthy. That never Avas true, nor 
was it intended to mean that the mind necessarily remained 
liealthj'. If tho' problem Avero faced in this country as 
it was being faced on tho other side of tho Atlantic, tins 
would make for national efficiency in a very remarkablo 
waj'. In mental hygiene nothing like tho same progress 
had been m*.do as with tuberculosis. It was not possible to 
impart such accurate, full, and adequate information as 
the specialists could about tuberculosis, but an indication 
could be given on hoAV to iiroAent nervous and mental 
breakdoAA-n to a certain extent, and it Avas possible, Avith 
the co-operation . of the public, but not Avithout it, to do 
something useful in that direction. 

Then in order to impress upon his audience the Avay 
in which this problem of mental hygiene affected good 
citizenship,-- Dr. Crichton Miller gave a number of telling 
instances, draAvn from the daily life of ordinary people, 
showing hoAV many difficulties of teunperament and 
character were due to long-past troubles vrhieli might havo 
been OA-ercomc if only tho person concerned had been 
treated at the right time by somebody trained in the 
methods of iisychotherapy, ' ■ ' 



JUN’E 3')." 1038] 


^'ATI0NAT. ni^ATuTn INStlR'A.^CE ACT, 1928. 


r Trrr Unmrt 

MrmCAL JODHHAt 


1117 


Bn'tisi) iHrtJtcal 


' SATURDAY, ,TUNK 30th, 1928. 


THE NATIONAL HEALTH INSURANCE 
AMENDMENT ACT, 192S. 

.The A.-ifionnl Hcnlth Insurnnco Amoiiflmcnl Hill w.is 
n-iid a thii-fl time .and passed in the ITonse o{ Lords 
on June 2lKt. . In our parliament nrv notes we have 
from time to time reported the speeches made in con- 
.nexion with the various stages of the bill, and have 
indicated the more important changes that have been 
.introduced during its passage through the House of 
Comhions. IVe'liave commented on its provisions on 
two previous occasions (ilpril 21sl, p. 677, and May 
12th, p. 811), and now that the bill has bden passed in 
its final form it may bo well to recall some of (ho main 
points to which attention has been directed in these 
columns. There are, as we have said, many things 
in the Act — .such as the simplification etTocted in some 
of the insurance .arrangements, and the establishment 
at last of a real insurance scheme for deposit contri- 
butors who, owing to ill health, are refused member- 
ship by approved societies — with which (he medical 
profession is in hearty agreement; l)ut (bore .are 
others which have excited groat misgiving, and which 
will need both vigilance and firmness on the part .of 
the profession if their ofTcct i.s not to bo detrimental 
to its liberties, traditions, and interests. Some of 
these dangers were set out in the two articles to which 
reference is made, and they have not been removed bv 
any effective amendment of the bill. 

In the first place, the Act i.s one more exaniple of 
the practice, severely condemned bv the Lord Chief 
Justice and many others, of legi.slation by the indirect 
method which authorizes a Government department 
to maKo Regulations and prescribe conditions under 
winch various actions may be taken. There are said 
to be in this comparatively short Act no fewer than 
feixU -SIX occasions on which such words as these are 
.used giving the Minister of Health power to impose 
. ns will III a manner not specified. Parliament ought 
by this time to know its own mind in the matter of 
+*1?^ T,' l<^S^lation, and to those who need it 

U Statute Law is better than 

1 i.at .affoided by Regulations. Our second criticism is 

witb ? been quite fairly dealt 
hi I i measure. Before the 

lie; .7 mtroduced the British Medical Association 
oftlpifi assurance from the Ministi^ 

whiel.'nff '"'outft he little or nothing in it 

lined me Peal profession. The fact has 

iifi-nr. f * ^^^‘***^ contains provisions of the 

■insiltmr'’" ''?P^°i«»y-to those practising as 

iroS r. 1“ this way the best 

■noitifa vn.^'^i representations on these 

the bill lehiif when it was discovered that 

the Act ‘of ^‘^^tion 75 (5) of 

the infei'f the only effective safeguard against 

.profesiir'Tiii ?«'^'‘^ties with the medical 

-benefit- ii r, '"Rh additional treatment 

Sfn ami the . Ministiw ' that the. 
onlv aridlf tRis repeal were that the 

applv'lnd Wn 1 to which, the section ' could 

Pl'b had been removed- fi-om the list of such benefits; 


and it -was left for us subsequently .to discover tlinf 
words had been introduced into oilier , specified 
additional benefits placing them now' in a category 
to wbicli the section would have applied if it liarl 
been allowed to remain. Again, when after discussion 
with the jilinistry an ninendnient had boon agreed to 
ensuring tliat any scliemc by which an approved 
society' contributed towards treatment of its members 
at a clinic should at the same time make provision for 
Ibis to be available from practitioners elsewhere than 
at the clinic, and it was pointed out that the particular 
amendment adopted by the Ministry offci-ed these 
forms of treatment ns alternatives so that clinic treat- 
ment by itself could still be adopted by a society, 
no attempt was made by those in charge of the bill to 
remedy this defect and carry' out the arrangement 
which had been accepted. These arc grounds for 
complaint, even though some of the points may yet 
be safeguarded by Regulations. 

It is true that much of the dissatisfaction with the 
Act .arises from what it omits to do as well as from 
what it does. Lord Gage, moving the second reading 
in the House of Lords, on behalf of the Government, 
said'; “ Mr. Chamberlain would have liked the adop- 
tion of the Royal Commission’s recommendation that 
the surpluses of approved societies should be p.a'rtinlly 
pooled to enable speci.alists’ services to -be made a 
sl.atutory benefit. The suggested pooling was the only 
method whereby tlie necessary funds could be obtained 
without recourse to the Exchequer. The approved 
societies liavc, liowever, so set their faces against this 
that Mr. Cliamberlain lias been prevented from making 
this necessary and desirable extension.” In the 
Hou.co. of Commons Sir Kingsley IVood had already 
said that ” but for the opposition of the approved 
scciolics it would be perfectly possible to put into 
oper.ntion the .scheme for specialist services without 
bringing any additional funds into the national insur- 
ance system at all.” Thus the approved societies 
h.avc boon discovered, and unequivocally declared, to 
be a gigantic obstruction to the main advance, most 
urgently needed, which ought now- to be made in the 
public health services of the nation. This cannot bo 
forgotten, and should be proclaimed and emphasized 
at every suitable opportunity. Whatever the useful- 
ness of the societies. in some other directions, this 
remains true. At the same time the Ministry and 
the Government have shown themselves weak enough 
to tolerate this obstruction, instead of insisting, at 
the cost of a little time and courage, on clearing it’ out 
of the way. It is claimed that the metliods°o£ the 
new -Act in this regard are an alternative, even thoimh 
they are unsatisfactory and heed an apology. In fact 
they are not an alternative at all. To” tinker with 
additional treatment benefits for a certain number of 
privileged insured persons— who, on the whole, need 
these less than those who do not get them— by permis- 
sion of the more prosperous approved societie”s .and bv 
means of Regulations reflecting the differing views of 
successive Ministers, is in no sense a substitute for a 
publicly, organized specialist service for all insured 
persons alike. When it is found, moreover, .that under 
the proposed system an approved society or a combina- 
tion of societies will be able to influence -strongly and 
m.ay even be able to control, the provision, the e’qiiip- 
ment, the administration, and the staffing of clinics 
institutions, or schemes for providing consultant and 
specialist advice and treatment, it is imperative ‘for 
-the medical profession to express, its opinion of le-is- 
lat-iou which makes this possible, and -to rrive “uo 
countenance to any such action. The Council of the 
British Medical Association at its last meetiii- 



1118 J0NB 30, 1928] 


HEALTH OP THE COLONIES. 


Mt n;c IT, JoiT.ru, 


declared that “ it is essentia], if the medical profes- 
sion is to talte part in the provision of additional 
treatment benefits, that those, as is the case with 
statutory medical benefit, shall be administered in 
such a fashion that the services of the medical practi- 
tioners who elect to give advice and treatment in 
connexion therewith shall not he under the control of 
any approved society or societies,” and that tliis 
position ought to receive statutory recognition. It- 
has not received statutory recognition under the new 
Act. The word “ control ” in the Council’s resolu- 
tion is admittedly of uncertain connotation in some . 
respects; but it must be remembered that control 
is often insidious, and may, in fact, be acquii'cd by 
a minority. Freedom from the administration and 
control of approved societies, even though this were 
to be governed by Eegulations made by a Alinislcr, 
was won for general practitioners at an earlier stage. 
It is equally the duty of the medical profession to sec 
that consultants and specialists are not faced with the 
alternative of either abandoning a legitimate sphere of 
practice or submitting to conditions which the expe- 
rience of the profession in former times has proved to 
be intolerable. 

Under the new Act the Hfinistry of Health has 
secured for itself many increased powers, which the 
present Minister may use wisely and others possibly 
not so wisely; but it has done this by weakening the 
position of the medical profession, and in some 
respects by enhancing that of approved societies. It 
should be made clear, in those circumstances, that 
consultants and specialists will only be willing to offer 
their services under conditions which safeguard their 
liberties and traditions and assure that they are 
in no sense the seiwants of the representatives of 
approved societies. 


THE HEALTH OF THE COLONIES. 

The principal speaker at the twenty-first anniversary 
dinner of the Hoyal Society of Tropical Jledicino and 
Hygiene on June 20th was tho Secretary of State for 
Dominion Affairs and for the Colonies, Mr. Amery, who 
gave an interesting review of the position in tho colonies, 
more especially in the tropical dependencies, from tho point 
of view of public health. Tho Colonial Office, ho said, was 
one which combined many functions, but none was of 
greater importance than the function of Ministry of 
Health to the tropics. There was a timo when tho diseases 
of tho tropics were regarded as tho inevitable result of 
the climate, and only within tho last generation rvas it 
learned that these diseases were no more inevitable than 
diseases in temperate regions. The first British statesman 
to realize clearly the implications of tropical hygieno was 
Joseph Chamberlain. In his famous dispatch in 1898 Mr. 
Chamberlain informed the Colonial Governments that he 
had had under consideration the important question of 
reducing the mortality among white people resident in tho 
tropical zone. After consultation with leading medical 
authorities he decided upon two main lines of action. One 
of these was the establishment of a school of tropical 
medicine in Loudon (which was soon duplicated at 
Liverpool, thanks to the generosity of Sir Alfred Jones), 
where medical officers proceeding to tho tropics coidd ho 
given special instruction in the control and treatment 
of the diseases encountered there; the other was the 
encouragement of scientific research into the causes of 
tropical diseases. Mr. Aiuory reniarked that his famous 
predecessor was more immediately and directly concerned 
with the white administrators and traders, hut it had since 
come to be realized that the problems of health for whites 


and natives in tho Empire wore ono. Tlio mosquito .mid 
tsetso fly wero no respecters of races. Mr. .-tmery then 
gave somo figures showing tho expansion of the colonial 
medical soi-vices since Mr. Chamberlain’s iutovvention. Tlie 
number of medical officers on tho Gold Coast had increased 
from 21 to 100; in Nigeria from 7 to 161; in Ceylon from 
54 to 363; in Fiji from 8 to 68. Tlio colonial medical 
services now had a strength of over 1,700 officers, and were 
gi-owing every year; tho salary and status of these officers 
had improved also. Jiist heforo tho war tlio ordinary 
salary of medical officers in West Africa and in East Africa 
was from £400 to £500; it was now, in lYcst .-tfrica, from 
£660 to £960, and in East Africa from £600 to £900. 
Mr. Amcry expressed tho hope that before many years had 
passed it would bo possible to cicato something in the nature 
of a singlo colonial medical sorvico, tliorchy enabling tlio 
best brains in administration to bo available to tlio colonies 
which most needed them, irrcspcctivo of what a particular 
colony could afford immediately to pay. He claimed con- 
fidently that tho general level of medical work in the 
colonial empire had novor .stood as high as at prc.sont. Tlio 
increased mnnbcr of officers available enabled more atten- 
tion to bo paid to prevention and research, and thus tlio 
officers wore not left, ns before, continually struggling with 
tho problem of * overtaking disease after it had occurred. 
The Colonial Sccrotaiy ahso touched on tlio cst.iblishinciit 
of the hospitals at Singapore, at Accra on tho Gold Co,ist, 
and at Alnlngo in Uganda, and then spoke of the various 
special campaigns and inveestigations conducted with the 
encouragement or under tlio auspices of tho Colonial Office. 
Among these ho mentioned tho investigation on sleeping 
sickness begun by tho Lcngtic of Nations, also tho very 
important work done on inalnria. Ho quoted some striking 
figures to illustrate the great improvement in tho health 
of tho tropics. In fVest Africa in 1904 tho death rate of 
European officers was 27.3 per 1,000, and in 1926 it had 
fallen to 8.6; in tho same period the invaliding rate fell 
from 67.2 per 1,000 to 19.2. In East Africa tlio death rate 
botwcon 1910 and 1926 fell from 14.9 to 5.6 per 1,000, and 
the invaliding rate fiom 24.5 to 4,4, It was not possible 
to givo exact figures with regard to tho native population, 
but there was no doubt about the steady improvement here 
also. Tlio last medical report for Uganda furnished an 
instructive comparison. In 1920 a sum of £61,000 was 
spent on medical services in that country ; in 1926 the 
amount was £128,000; tho number of new cases among 
natives treated at tho medical centre increased from 
62,000 in 1920 to 380,000 six years later. Finally, Mr. 
Amery spoke of the co-ordinating and other work at head- 
quarters. He said tlmt when ho first took cliaigo at the 
Colonial Office he endeavoured, to remedy certain deficiencies 
in this respect. Two years ago ho appointed a chief 
medical officer at tho Colonial Office, whoso business it was 
to keep the importance of tho subject before the various 
administrations. A medical and sanitary advisory com- 
mittee, a colonial medical researcli committee, and a bureau 
of hygieno and tropical disease wero all functioning. On 
tlie periphery wore tlie Committee of Civil Ecscarcli, 
which linked np tho Colonial Office with alt tho other 
research activities of tho Government; also the great 
schools of tropical medicine in London and Liverpool; and, 
not least impoitant, tlie Royal Society of Trojiical Medicine 
and Hygiene, whoso health it gave him great pleasure to 
propose. Dr. Andrew Balfour, who replied, mentioned 
that the fund for a memorial to Sir Patrick Blanson had 
now reached a total of £3,324. Lient.-Colonel AY. P. 
MacArthur proposed in haiipj- terms the health of the 
guests, to which Sir Squire Sprigge responded, and tho 
final toast was the health of the chairman — Professor 
J. W. AV, Stephens, president of the societj' — which w'as 
proposed by Dr. Manson-Bahr. 


June 301 ^ 9 =®] 


KXPEEniENTS ON ANIMALS. 


• r TitEPr.mxn - 1110 

LMrmc*L.TouRrAi. A Aiw 


experiments on animals. 

In- last weck’.s .Tourniil (p. 1079) wo icpoiTod tlio second 
Ptephen Paget Steiiiorial I.cetnro delivered liy Sir Pernard 
Spilslmry, who spoke on “ The work and responsihilitics 
of the pathologist ” at the annual nun-ting of the Pesoarcli 
Defenco Society. Some excellent illnslrations were given 
hv Sir Bernard’ Spilslmry of the aehieveincnts of pathologj- 
in the prevention and cure of disease hy means of experi- 
ments on aniinals, not merely by immunization against 
particular infections, hut in other ways also, and not 
merely in the human race, Imt also in shei-p and cattle and 
domestic animals. It is important that clear and simple 
illustrations of this sort shoidd from time to timo ho given 
to tho public, even though their reiteration may seem 
wearisome to the well informed,' for there is no relaxation 
in the campaign of prejudice and misroprc.scntation which 
is being conducted by tho British Union for tho Abolition 
of Vivisection, and even by more rcspretablc Imdic-s. An 
interesting example of a better method of discussion is to 
ho found in the recent corrcspondenco in the Thiir^ between 
Sir Bernard Sjiilsbury and Irfird Dawson of Penn on the 
one hand, and Mr. Stephen Coleridgo on tho other, though 
even hero it is unfoi-tunato that one or two letters of an 
altogether different calibre of iutelligcjicc have been allowed 
to appear, and that Mr. Coleridge has been unable to 
suppress an unaorthy but characteristic method of coii- 
trovor.sy by implying that Ijord Dawson is not truthful 
when ho gives a particular instance (ncce.ssarily anony- 
mous) in which tho use of a mouse has heon of service in 
tho case of a boy at one of our public schools. Tho corre- 
spondence began through tlic complaint of n general 
hospital that it had some difEculty in getting subscriptions 
oa'ing to tho agitation of certain persons against tho 
holding of a Homo Office licence for vivisection hy tho 
pathologist on its staff. The claim is that, as Lord Dnw.son 
saj-s, “ tho ads'antages which accruo to mankind by tho 
use of animals in tho study, diagnosis, and treatment of 
disease can bo determined only hy those jiossc.ssed of tho 
necessary special knowledge,” mainly scientific and medical 
workers; and that, so far as these advantages exist, those 
who are willing to profit by them should not bo deprived of 
their opportunity by tho exertions of those who have corac 
to tho conclusion that it is ethically wrong so to do. Mr. 
Stephen Coleridge is, of course, right when he claims that 
to many people it is not a question of medicine, but a 
question of ethics and conduct.” It is not open to tho 
inexpert to deny the advantages; but it is open to them 
consistently to refuse to accept or use them if they believe 
them to bo achieved by methods ethically wrong. Some 
such persons (we accept Air. Coleridge’s st.atemcnt that he 
IS one of them) do refuse treatment by inoculation, but we 
doubt whether they do, or can, refuse tho benefits of much 
other knowledge gained by moans of experiments on 
animals. But even putting tho code of ethics Of Air. 
Coleridgo and his associates at its highest, it is not open 
to them to impose this upon tho medical profession or upon 
1 10 far greater number of patients, whether in hospital or 
elsewhere, who, when faced with tho quite simple altorna- 
ues offeied to them for alleviation or cure, do not feel 
that there is any ethical difficulty whatever. 


collect and collate information regarding tho world supply 
of drugs, and to pronounco whether a State is in any 
given year exceeding tho amounts to which it is legiti- 
mately entitled. Considerable delay has been experienced 
in securing tho ratification of the convention, and it is 
only recently that satisfactory progress has been made. 
The position when tho Advisory Committee’s x-eport xvas 
drawn up xx'as that fifteen States in all had ratified,' 
including four States members of the Council, two being 
permanent members, ns required by the convention. Tho 
Netherlands and Rumania hax'o since formally signified 
their adhesion, and wdien tho Council met the Canadian 
ratification was reported to bo imminent. .Several other 
Slates are taking steps to conform to tho movement. The 
committoo xvas therefore able to .state that there is ex-cry 
prospect of tho conx-ontion being in operation before the 
end of tho year. From accounts given to the committee, 
to xvhich xx'o juado reference on ALay 26th (p. S07), it is 
obvious that energetic and highly organized action is 
needed if tho traffic in dangerous drugs is to be kept xvithin 
bounds. Great inqiortanco is attached by tho committee 
to the collection of full, prompt, and accurate information; 
there has been some improx-ement in this respect, but 
certain producing countries, such as Bolivia, Greece, Pern, 
and Persia, are not yet gix-ing tho desired details, xvhile 
some di.scrcpancics have been noted in the figures received 
at Genex’a. The Advisory Committoo dox-oted considerable 
time to a discussion on tho constitution of tho proposed 
permanent central board to 'bo .set up under tho 1925 
conx-ontion, but in tho result most . of the details xvero 
left to bo sottlexi at a later session. A recommendation 
xvas rcceix-ed from tho League Health Committee that a 
number of morphine compounds, knoxvn as e.sters of 
morphine, of xvliich benzoyl-morphine is an example, 
shoidd bo brought under tho convention, since tliey may bo 
abused in the same xvay as morphine. Tho convention 
permits tho addition of fresh products to the' list of those 
subject to its control. 


FINE WORK AND EYESTRAIN. 

L.xst year a report w-as issued by the Aledical Research 
Council on tho effects of eyestrain on the output of linkers 
in tho hosiery industry; in this xxork the detail to be dis- 
criminated is so fine that, however high the illumination 
prox-ided may be, the eye must bo kept quite near the 
object, xvith the result that some degree of continuous 
strain is imposed on tho muscles of convergence and 
accommodation. Tho investigation clearly showed that 
benefit xvas to be gained from the use of spectacles, xvith 
xx-hieh this strain was i-elieved and output increased. In 
a new- report* published this xveek the ' investigation has 
been carried a stage further; each operative bi-ought into 
the inx-cstigation has beeii examined by an ophthalmic 
surgeon. Air. T. G. Clegg, and for each approjiriate glasses 
have been provided, gix-ing tho necessary correction for any 
error of refraction and muscle balance, together with tho 
additional correction for tho relief of the excessive con- 
vergence and accommodation. Particulars of the glasses 
ordered aro given, and these show- that a considerable 
range of error of refraction was found. Part of the xvoi 


INTERNATIONAL CONTROL OF THE TRAFFIC 
, . . 'N OPIUM. 

r 16 lecent meeting of the Council of the League 0 
Nations a report from the Advisory Committee on TralE 
in pium and Other Dangei-ous Drugs xvas receix-ed, to tb 
Tf expected that tho Geneva Opium Conventio 

1925 will come into force in the near -future. The lie’ 
coiix^iit.on IS ijesigned to strengthen the Hague Opixu 
for 11 notable feature is the provision maxi 

lor tho establishment of a permanent central board t 


was connected xvith xveaviiig and part xvith nioxintino 
electric lamp filaments; both processes are very fine- both 
demand not only perfect illumination, but po'xver also on 
the part of the operative to get close up to the xxork for 
prolonged iieriods. No work more likely to cause cyestraiii 
could bo chosen. So far as these tests have gone— and 
their only weakness is the relatix-ely ' small number' of 
operatives tested— there is strong evidence of the x-alue of 


n-ort. By H. C. XX-cston ami S. .Xdams Xledical 

Industrial Fatiguo Research Board. London: H^I ^tationarv°m 

192 a. Pp. 2S. Prica Is. 3d. neL ■ ijtationcry 01 


1120 June 30 . 1928 ] CENTENARY OF KING’S COiiEFGE, LONDON, 


Tnr TsniTna 
JIrr'Ti.AL 4urR«»it 


tlio glasses. The relief and assistance tlnis afforded to tlio 
workers onahle them snhstantially to increase their rate of 
output, tho amount varying, in individual cases, from 
about 8 to 26 per cent, for drawing in . (weaving), and 
from less than 1 per cent, in an exceptional case to nearly 
20 per cent, for filament sorting and mounting (Lamp 
making). These figures refer only to experienced workons, 
and there is evidence that a still greater increase may he 
expected, in .the case of learners. It is believed that with 
them . tho use of the glasses would shorten the period 
rcciuired to attain jjroficiency. Particulars are given of each 
set of experiments, and of the nature of the illumination 
jn ovided, with graphs of tho results. The ro]mrt concludc.s 
that: “It is, therefore, obviously dc.sirahle, in the interc.sts 
of worker and employer alike, that the sight of candidates 
for fine work should he tested and any defects properly 
corrected.” 


THE “DRINK-MORE-MILK” CAMPAIGN IN THE 
UNITED STATES. 

The Danish export on nutrition. Dr. M. Hindhede, Ims 
rcccntlj’ returned from a voyage of discovery, or what 
would he more accurately described as a tour of critical 
inspection, in the Fnited States. His i7upressions are 
recorded in the journal of the Danish Medical Association, 
Vijeshrift for Lacger, for May 31st. The heading of his 
paper, “ The American milk agitation,” gives a clue to 
his own opinions of the efforts made there to induce children 
to drink more milk. To thg casual observer this movement 
might seem to be inspired by undiluted iibilanthropy, hut 
Dr. Hindhede has a wonderful scent for the sinister and 
the dramatic, and his suggestion that capitalism and the 
farming interest are bejiiud this movement is not to ho 
dismissed offhand. His criticisms fall into two categories: 
the first may bo disposed of in a few words, for in telling 
such stories as that of the unnamed woman professor who 
uas obliged to resign her appointment because she taught 
that milk is decidedlj- not good for any child after a certain 
ago he is not supported by any serious documentation. 
Also, such vague statoment.s as “ I could toll a good deal 
more of tho same kind ” aro unconvincing. More inter- 
esting, and perhaps to some people moi'o convincing, ai'c 
his criticisms of Professor K. V. McCollum’s book The 
Niifrifional Value of Milh. This work records experiments 
in an institute for negro children, some of whom wore kept 
'on the institute’s original diet, while others were given this 
diet with the addition of milk. According to Dr. Hindhede, 
as much as 96 per cent, of this original diet was practically 
vitamin-free ; 3 per cent, contained an uncertain amount 
of vitamins, and only 1 per cent, contained a more or less 
amj^lc supply of them. Almost ai7y combination of foods 
would give good results compared witb those obtained with 
such an unsatisfactory diet ; by reducing the vitamin-free 
proportion of a diet to 52 per cent., and making 42 per 
cent, of it rich in vitamins, the result, comparatively 
speaking, must be good,whctber the addition of vitamin-rich 
substances be of milk or of potatoes phis other vegetables. 
Incidentallj-, Dr. Hindhede points out that, in Professor 
McCollum’s experiment, together with the addition of 
milk to the original diet, other vitamin-rich foods were 
increased -five times in relation to the calories. Indeed, 
the milk-fed children received 22 per cent, more calorics 
than those on the original diet. This inequality was, it 
is true, made good at a later date, but the caloric value 
of the original diet was brought up to that of the milli 
diet by tlie addition of still more vitamin-free foods such as 
white bread and sugar. Dr. Hindhede suggests that Pid- 
f'ssor McCollum would have obtained the same results as 
'"tb the milk diet bad he dispensed with milk, reduced tho 
Ilia ration of the original diet, given wholemeal bread 
greatly increased the quantitv of 

tur^oacb child” ''®Sctablcs. A litre of fresh milk a dav 
oacb child IS liable to .q,,et the budget of a workiim- 


class family, and tho inclusion of much milk in a dietarj’ 
containing normal quantities of proteins is calculated to be 
injurious. Referring to Professor McCollum’s work and 
the recent investigations of Dr. Cony INtann (criticized 
by him in an earlier communication'). Dr. Hindliedc con- 
cludes: “Thus, I cannot sco that any jiroof c.xists in 
favour of the teaching that it .should in general be profit- 
able to give children a large supplement of Jiiilk. The 
American experiments aro just as unconvincing as the 
English experiment already discussed.” 


CENTENARY OF KING’S COLLEGE, LONDON. 

One hundred years ago, on June 21st, 1828, at a meeting 
convened by the Duke of 'Wellington and the Archbi.sliop 
of Canterbury, the movement which led to the institution 
of ICing’.s College, London, now an integral part of the 
University of London, was initiated! Soon afterwards the 
Crown granted the site adjoining Somerset House in the 
Strand which the college still occupies, and the new 
addition to the educational facilities of London came into 
existence. The illu.strious sponsors of tho project . were 
moved, perhaps, more by tho fear that tho neivly o)iciied 
University College, an institution of Radical and Non- 
conformist colour, might-bo tho means of luring the youth 
of the “ Church and St.ate ” party in the rising middle 
cla.sscs from their allegiance than hy any passion for the 
democratization of higher educ.ation. King's College w.a.s 
originally, therefore, a very definite rival to the sister 
institution in Gower Street. The two colleges are -still 
rivals, but in a healthier fashion, and the old party and 
religious division.s were soon forgotten in a disintere.stod 
enthusiasm for learning. In tho development of educa- 
tion in tho metropolis and in the advancement of science 
tho college has played a large part ; it has changed in form 
and constitution with tho establishment of tho I niversity 
of London, the erection of tho theological department into 
a separate school of tho University, and tho organization 
of the advanced medical school and the hospital as an 
independent body. These developments were referred to 
at a commemorative dinner given at tho college on Juno 
21st, when tho principal. Dr. "W. R. Halliday, in replying 
to the toast of “ Tho College,” spoke of tlio number of 
groat institutions which it had nursed to maturity and then 
launched to success. Dr. Halliday added that the tiir.a 
would come when it would be necessary to ajipcal for 
funds to carry on the work of tho college and to extend 
its capacity for service. Though flourishing in numbers, ho 
said, it was jnactically unendowed. Capital expenditure 
for building which could not be postponed must necessarily 
be met. and so long as the work of the college was wholly 
dependent on a fluctuating income from fees, it could not 
carry on its work as it would like that work to be done. 
He wanted to convinco all members of the college of the 
overwhelming importance of the present opportunity. 
Upon their success in turning it to account would depend 
tho future of the college during the years which lay ahead. 
Great institutions dared not stand still ; but — it was best 
to face the facts — without a very largo sum of money they 
could not go -forward.- In the course of. the proceeding-s 
reference ivas made to .the loss sustained by the college 
through the death of Lord Hamblcden, described as 
“ the greatest of- its modern benefactors,” who was 
chairman of the delegacy of the college. Lord Hamblcden. 
it will be recalled, was also keenly interested in the welfare 
of the voluntary hospitals in London, notably in connexion 
with King’s College Hospital, in the administration of 
which he played a leading, part for , many years. Ho 
participated . activclj- in the . business of .the British 
Hospitals Association, and was for a time honorary 
treasurer of that body. 

‘ llijeBlrijt fur Larger, 1928, p. 92. 



June 30, 1928] 


THE KOYAE SOCIETY CONVERSAZIONE. 


[ Tnr IlRrnsH 

SfFDTCAL JorSNiL 


1121 


MUSEUM OF THE ROYAL COLLEGE OF SURGEONS. 

The CoiiiciviUnr, in liis loport for tlio ycnr ondiiig Jnno, 
1928. notifios Hint llio nddilions to tlir imi'icuin of Hio Roynl 
CoHoge of Singoons of Rnglnnd will lie on view in Room I 
from .Tilly Stii (tlio dato of election of new inemlicrs to tlio 
eoiiiicil) until .Tnly 28tli. Ono of tlio Inrgcst doimliona 
dining the year wa*; tlio Strangownys collection, coii'ii'iting 
of several liiindreds of siiecimens of cliroiiic arthritis. 
TIicso have hcon handed over to the College hy tlio trustees 
of the collection, and, with Dr. Strangewnys’s inanuscripts, 
liavo hooii eutrustod to Jlr. Lawford Kiiapgs for investiga- 
tion and revision. The nioro important research work 
carried out at tlio miisenm includes investigations on nervo 
Mitiire and nervo fegcncration h\- .Sir Charles Rallancc, on 
Hie pathological changes in eases of colitis h\- the Con- 
si-rvator, on the evolution of tho Ijunphatic system hy Hr. 
R. H. Riinie, and on tho anthropology of eertaiii native 
.tfrican races hy Mr. L. S. R. Leaks’. In the pathological 
department the curator, Jlr. Cecil Beadles, reports the 
addition of 150 new specimens, and refers more espcciallj' 
to specimens of papillary tuberculosis of the Fallopian tube, 
careinotna of tho m.'ilo urethra, old gunshot injury of 
the brain, necrosis with ossification of tho muscles of 
the thigh following suppuration, tho hones from a c.osc 
of craniocleidodtsostosis, malignant ondoHiclioma of tho 
tibia, adamantinoma of the' infundihuluni, torsion of tho 
gall-bladder, a largo lymphadenomatous tumour of tho 
Uiyimts removed In- ■ operation, and a fine series of 
.specimens of Recklinghausen’s disease showing extensivo 
alfoction of the cranial, spinal, and sympathetic nerves 
and tho rare condition of involvement of tho periosteum 
(ol the tibia) in tho hyperplastic process. In a nuinher 
of specimens (tho gift of Dr. William Hunter) from 
cases of pernicious anaemia arc shown tho glovsitic, 
gastritic, and enteritic changes which ho has described 
as tho starting point of that disease. Two interesting 
preparations of tho alfercnt vessels of tho lymplmtic 
circulation in tho cod illustiato Mr. Burno’s researches 
above referred to. Numerous additions Iiavo been 
made in the department of ostcologv, tho most iinpor- 
taut being an exact cast of tho Taungs .skull, the gift of 
lofessor Raymond Dart, whoso description of the original 
appeared in Xafiirc (February 7th, 1925). In connexion 
tlie coin^nlatiou of t!ic new catalognc of ostcologx', 
iss TiMeslo}' contributes .some interesting notes on skulls 
n-om the Aiulaman Islands, ' tlio Dutch luist Indies, the 
Ihilippinos, Xeiv Giiiiioa, and tho Torres Straits, The 
Dcpartinoiitj which was closed for structural 
lopaiis last year, is now open for the use of students; 
lain at itioiis ha^e been made to the collection, including 
T. iiboiit 100 in munber, presented by Sir. 

allies * uptrating the operative measures adopted 

in the treatment of cleft palate. 


A n royal Society conversazione. 

- T le summei conversazione held last Aveek at Burlingt 
^ i>cientific exhibits in many instances had alrea 
Previovis evening function lield 

(.>‘'■ 012 ^' ’ofT'- T’® issue of May 26 

rlnn X- mterest were the m.nuisciipt of J 

fiiU'^. rt’" TV “"cipia and his marginal notes in t 

tiaii 1 ^' Broiik gave a demonst] 

Hon of H.6 impulses travelling up sensory nerve fibres wi 

iniiio impulse is acco 

five bii Tfl ® ^i'^cH'ical discharge lasting about 
ebam^P ^ second, tlicv amplified the elect: 

mnw’ when a skin-nci 

touched hv 1 ™-® “ppvopriate electrodes u 

viont to no - mir hrush the magnification was su 

urn \bl t 1 loud-speaker. Sensory messa. 

xhus be transformed into sound-waves, and the sa 


method can ho used to domomslrato tho electrical changes 
accompanying muscul.ar nctivitj’. Tlio Marino Biological 
Association of tho United Kingdom gave an iiiterc.sting 
dcmoiistration of tho modc.s of ro.spiratioii in living iiiariiio 
animals, showing how in tho varying conditions of exist- 
ence tho animals develop mcchani.sms for continually 
hriiiging fresh .sea water in contact with their bodies, a 
Wood circulation with spcciali’/.cd respiratory areas, and 
respiratory pigments (compounds of iron, copper, vanadium) 
in the Wood to iiiereaso its oxygen content. T)i\ Pearson 
and Jfr. Hopwood showed specimens of tho teeth of fo.ssiI 
animals found in the rocks in China — ^tho so-called 
“ dr.'igoiis’ teeth ” of tho Cliiueso rcodiciiio men, who uso 
them as charms to cure all nianner of diseases. Pei haps 
the most iiitercstiiig exhibit of all, and certainly ono 
that attracted iiinch attention, was the demonstration by 
Me.ssrs. Colour Photographs, Ltd,, of their new procc.ss of 
colour photograph}-, uhich will s.ioii he put on tho market. 
Tho method would seem to bo .simple and- .straightforward 
enough to he’ carried Out hy the average amateur pihoto- 
grnpher, and when it is ro.alir.ed not oiilj’ that natural 
colour traiisparoncic.s can he taken hy the ordinary caiiicra 
without colour filtcis or multiple exposures, hut that they 
can bo printed on paper in true colours with very littid 
trouble and repiodueod as often as is desired, it i.s probable' 
that the process will hccoiuo very popular. In order to 
obtain tho negatives a three-ply film pack is inserted into' 
tho dark slide in the usual way. Tho pack is composed of 
three celluloid films, oaeli about ono tlirce-tliousaiidth of an 
inch in Ihicknes.s, which arc coated with gelatin oiinilsions 
of selective colour sensitiveness, and they are arranged in 
.such an order that tho front film, uhieh is bluo-«eiisitivo, 
lias its uiicoatcd surface towards tlio lens; next conics tho 
ycliow-sensitive film, with its coated side in contact with 
that of the first; and then behind conics the rcd-sciisitivo 
film. For all practical purposes it may he .said that tho 
sensitive surfaces Ho on one plane. Tho photograph 'of 
the object is taken in tho usual way. It was stated that 
most of the exposures, ccrtninlv for tho portiaits, were 
made with half-watt lighting and took about three seconds 
each. Thus tho plate is very speedy in eomparison with 
autochromes, and it is possible that snapshots could be 
taken outdoor with good lighting. Tho triple negative is 
developed, and tho three parts appear like ordinaiy nega- 
tives Avithout colour. Kach constituent film is inserted in 
the usual printing frame with a .special sensitized trans- 
parent celliiloso tissue, wliich is thin hut very touEh, and 
they are printed out hy direct exposure to light, so that 
ono obtains a yellow, a red, and a bine print from tho 
respective negative iilms. Tho printed tissue is simply 
washed and fixed and hung up to dry. In order to obtain 
tho finished result tho rod print is wetted and “ squeegeed ” 
on to a sheet of paper, a ccmciitiiig fluid is rubbed over it, 
tho yellow print is siqieriiiiposed and easily registered, 
more cementing fluid is applied, and lastly the blue print 
is put on top, and all of a sudden the true colours emerge 
and the composite picture is finished. Prints can also he 
made from paiicliroiuatic plates wliieh have been exposed 
through three coloured filters, and probably this method 
uould giA'o sharper detail. 


OXFORD OPHTHALMOLOGICAL CONGRESS. 

The full programme of the eighteenth aiiiuial meeting of 
the Oxford Ophthalniological Congress lias now been i.ssued ; 
pi-climiiiai-y details were given in our issue of March 17th 
(p. 460). Accommodation has again been offered at Kehl© 
College, and memhers will assemble there informally on 
tho evening of IVedncsday, July 4th, at dinner. Tlie 
meetings ivill be held in the Department of Human 
Anatomy at the University Museum, and concurrently 
there will he an exhibilion of ophthalmological instruments 
and apparatus. On July 5th tho congress will bo opened 



1122 June 30, 1928] 


THE! POST^EKCEPSAIilTIO PATIENT. 


• T , JTnt Birnm 
L UcflCXL JOVftMiA 


by Mr. Pliilip H. Adams, tlio Master, and Professor 
Leonard Hill n-ill introduce a sym|iosiuin on “ The idtra- 
violet ray,” followed by Mr. IV. S. Euko-Eldcr and otlicre. 
Subsequently Mr. G. It. de Beer will give an address on 
“ Recent experimental work on the development of the eye 
and associated structures. :The afternoon will he devoted 
t.o a series of demonstrations on various aspects of 
ophthalmology — devices for tests and operative treatment, 
pathological specimens, drawings illustrating diseases, and 
the like — and in the evening the annual dinner of the 
congress will be held in the Hall of Kohle College. Pro- 
fessor Arthur Thomson will deliver the Doyne jMeinorial 
Lecture at 11 a.m. on July 6th, his subject being 
“ Observations on the eyes of birds.” Before this a series 
of short papers will be given, Lieut.-Colonel Henry Smith 
dealing with “ The nutrition of the lens and vitreous — 
a speculation,” Mr. Burdon-C'ooiier with “ Spectroscopy of 
the crystalline lens,” and Mr. George Young with “ Double 
sclerectomy as now performed by the author.” During the 
last hour of the morning se.ssion a paper on “ Sympathetic 
oidithalmia ” will bo read by Mr. T. Harrison Butler. 
Arrangements have been made for the nicnibers of tho 
cengress to visit the Morris motor works in the afternoon. 
The closing session, on the morning of Saturday, July 7th, 
will be given to reports of clinical cases, contributed bv 
seven ophthalmologists from various centres. Copies of 
the programme and other information may he obtained 
trom the honorary 'eenJary. Mr. Bernard Cridland, 
Salisbury House, Chapel Ash, AVolvcrhainpton. 


The Sheffield Aledical School will celebrate tho centenary 
of its foundation on July 11th. Among the C'Cremonies will 
bo a congregation at the I'nivcrsity, when the honorary 
degree of D.Sc. will be conferred upon Dr. H. H. Dale, 
Piofessor Arthur J. Hall, Sir Frederick Gowland Hopkins, 
Sir Thomas Lewis, and Professor Otto AVarburg of Berlin. 


AjioxCr tho recently elected foreign members of tho Royal 
Society are Dr. Albert Brachet, professor of anatomy and 
embryology in the University of Brussels; Emeritus 
Professor Richard Friedrich Johannes Pfeiffer of tho 
University of Breslau, celebrated for his discovery of 
tho bacillus bearing his name, and for his genei-al 
researches in bacteriolog_v, immunology, and proto- 
zoology ; and Dr. Richard AA’illstiitter of Munich, well 
known for his researches in organic chemistry. Lord 
Melchett (formerly Sir Alfred Mond) and Sir AA'^illiam S. 
McCormick, chairman of the Advisory Council on Scientific 
and Industrial Research and of tiie University Grants 
Committee, have been elected Fellows of tho Society. 


THE POST-ENGEPHALITIC PATIENT. 

Report by De. Alb.vx P.\esoxs. 

Tjiat mysterious and distressing inaladv encephalitis 
lethargica continues to elude the attacks of the research 
worker; and the clinician is in no better case since 
diagnosis is hampered by the protean manifestations of a, 
disease which was stated by Sir Farquhar Buzzard to be 
“ almost defiant as to treatment and prognosis.” It is not 
surprising, therefore, that Dr. Allan C. Parsons, a medical 
officer of the Alinistrj- of Health, has found his path beset 
with difficulties in reporting an inquirj’ undertaken by 
him into the after-histories of persons attacked by encephal- 
itis lethargica.' Dr. Parsons was largely responsible for 
a conqnehensive report on the epidemiology and clinical 
features of the disease, published by the Ministiy five or six 
years ago, and discussed in the British Medical Journal of 
Octolier 7th, 1922 (p. 654). His former efforts are admir- 
a.ily supplemented by tho document now before us, which 
1ms been issued by the Miuistiw this week. 


0,Sco*:“’J‘r'ico''Ss.' fid."”" 


The first part of Dr. Parsons’s report contains an 
analysis of data concerning some 3,600 patients, about one- 
fifth of tho total number of cases notified from Januaiy, 
1019, to December, 1026. Tho analysis shows that in 
every 100 cases investigated three years after tho primary 
illuoss 25 patients, on the average, will have sur- 
vived without serious comsequcncos, 35 will have died, 
while 40 will have become more or ' loss disabled in 
mind and body, or both. It is with tho ultimate fate 
of the forty that tho rest of the report is mainly con- 
cerned, in tho hope of riveting attention on the- serious 
consequences of tho disease and tho necessity for special 
consideration. 

Defective Nolificatiun of JCiiicjdialHis Lethargica. 

The first difficulty upon which Dr. Parsons lays stress 
is dcfcctivo notification. For this many reasons can be 
assigned. There is the comparative novelty of a condition 
which was first described by von Economo of A'ienna in 
1917. In tho following year in this country Dr. AVilfred 
Harris and Professor A. J. • Hall simidtanoously directed 
tho attention of the medical profession to series of cases, 
“ presenting somewhat remarkable features,” which had 
been observed by them in London and Sheffield rc.spectively. 
The innnlfcstations of a disease which has only been 
described so recently, and tho incidence of which, in terms 
of population, is not great, aro still unfamiliar to many 
practitioners. Tho onset is often insidious and tho early 
symptoms slight. Epidemicity hardli" exists away from 
largo centres of population, and positive baetcriologic.sl 
tests are not obtainable. Then, again, many patients 
consult a doctor for tho first time when they arc already 
siifforing from late eft'ects of tho disease, and many of tho 
missed cases, when ultimately recognized, aro not formally 
notified. Tho Health Department of tho London County 
Council recently discovered 269 children suffering from 
late effects of encephalitis lethargica who had never bceii 
notified. Dr. Pnr.sons estimates that for every 100 cases 
notified 50 to 75 cases arc not officially reported. 

The causes of imperfect notification help also to explain 
local differences in mortality. Taking the year 1924, which 
was noteworthy for a very marked epidemic form of the 
disease, though by far tho least fatal of the nine yc.irs 
under review, Dr. Parsons explains tho low mortality 
figures in Sheffield and Glasgow, as compared with New- 
castle and Lancashire, by differences in the extent to which 
mild cases of tho disease were recognized. Intensive study 
in the former towns meant not only the bringing to light 
of a larger number of mild cases, but also the excluding 
of some other fatal conditions from the encephalitis 
lethargica list. 

After-Effects in .idults. 

There is tho further difficulty that a patient after 
recovering quickly from a mild attack of the disease, and 
remaining well for months or sometimes years, may develop 
sequelae which in tho end may oven prove fatal. In pro- 
portion to tho comparatively small number of persons 
attacked there is probably no infectious or contagious 
disease in this country which produces so much consequent 
ill health and disablement as encephalitis lethargica. And, 
though tho results of the disease in children are deplor- 
able, and have attracted much attention. Dr. Parsons is 
concerned to show that tho effects on a wage earner or on 
his wife aro no less dejilorable. The case of the dribbling 
“ old man ” of 15, hunched up in his chair, impassive and 
slowly di'ing of Parkinsonism, is set beside that of the 
intelligent workman who loses job after job and eventually 
drifts into a Poor Law institution or an asylum, and that 
of a housewife wlio becomes lethargic and melancholy, 
incapable of attending to the needs of her husband, her 
children, or herself. Tho pathos of these pictures drawn 
by Dr. Parsons in his report is relieved to some extent 
bv tho account of the female Parkinsonian patient at 
AVest Park Mental Hospital who, taking part in some 
athletic sports, c.ame in first in tlie 100 yards race ! As 
Dr. Parsons says. Vires acquirit eundo. The variability 
of this symptom or' syndrome, which occurs' in perhajjs 
30 to 40 i)er cent, of those suffering from sequelae, i.s. 
shown by the record of the young woman whose case 
seemed hopeless on account of severe Parkinsonism wJio 
eventually earned her living as a dancer. 


June 30, 191S] 


TUB FOST^ENCEPHAIirTIO FATIENT; 


r TnrjJRms* 7123 
L JllRDICir. JoCBKi* X J. ^ u 


Classification of Mental .•Sequelae. 

The Into mental manifestations of encephalitis lotharpiea 
liavo been describe<] under many heiulinps. Dr. MtipoUier 
broadly classifies them into (a) inoibid rcstlessue-ss, (b) 
deinoraliantion, (e) “mental aneisia.” Ttcstlessiicss ho 
tli'inUs cliurnctcristic of cnt>cR iu «elu\tlvou u^ulcv 8, dcnioial- 
ization in juveniles hotivecn 8 and 20, while mental niiergiii 
is most common in thoso over 20 years of age. Dr, Parsons 
setms to prefer a broader grouping into tho depicssed 
and the excitable, and quotes a writer who puts post- 
encephalitis patients into two groups— “ tho irritablo 
group of patients who got into troiiblo with tho police or 
try to throw theinselves under a train, and tho apathetic 
group, content to stay at home and look at tho lire.** 

About 27 per cent” of those who suffer from sequelae 
show symptoms of menial impairment. Sleep disorders 
aro troublesome, and especially the insomnia which turns 
night into d.ay— tho “ inverted sleep rhythin ** so common 
in children. ' A curious occasional sequel is abnonnal 
fatness. A fortunately raro sequel in bedridden sufferers 
is bedsores. In summing up tho differences between the 
effects of encephalitis lethargic.a on adults and children. 
Dr. Parsons says that children show more signs of restless- 
ness and excitement than do adnlts, whoso reai lions aro 
more passive and negative. Conduct perversion is common 
in the former, confusion and the usual symptoms of in- 
sanity in the older patient. Some pln’sicians state that 
children nve, generally speaking, more piono to mental, 
and less to physical, sequelae than aro adults. 


After-Care and Control, 

In dealing with tho after-care and control of disabled 
patients Dr. Parsons points out that tboro is Iittlo difficulty 
iu securing treatment for tlioso in tho aculo stage of tho 
disease. General hospitals aro quite willing to admit such 
patients, tiio risk, of infection to other patients or tho 
nursing staff being very slight. The rislc, however, appears 
to bo not euinplctoly absent, and instances of infection have 
been noted in Lancashire and at Portsmouth. 

Vhcu tho acuto stage passes olf a time arrives when tho 
general or. the fever hospital finds tho patient no longer 
v.'ckonse, and his bed is required for moro urgent cases. 
Yet tho patient is not fit to resumo bis uonual occupation, 
and in many cases is unfit to resiuno homo life. It appears 
from the report that a variety of institutions and bodies 
exist to whoso care such a patient can bo entrusted; and 
yet tho position, according to Dr. Parsons, is not satis- 
factory. Tho Guardianship Society at Urightoii may board 
tho sufferer out in a carefufly chosen family, or assist in 
obtaining training and enijiloymont suitable to his capacity, 
and by visiting tako a friendly interest in his moral and 

I'^lfavc. The local education authority may allo- 
cate for further caro and education children whoso training 
las been impeded hy mental or moral deterioration, or 
may transfer a child to a “ special school.’* Tho Metro- 
poli ton . Asylums Board has an “encephalitis Icthargica 
unit at its I'Torthern Hospital at 'IVinchmoie Hill, and 
0 101 institutions such as Darcnlh Training College. If 
10 mental condition of tho patient is such that ho can 
10, ceitihed, ho will come under the caro of the Board of 
on loi; vrliilo tlio Poor lijvw autbovities aro largely con- 
. coined with poor persons who suffer from tho after-effects 
or encephalitis Icthargica. 

failing .all these agencies, a number of post- 
cop lali^s patients arc bound" to como under tho purview 
m- • ^o'oe Ofiice, owing to their appearance iu a 
innii''” ) ^ ; P^'sens summarizes the various 

iiivenU^ * 0 ?^ udmg whipping — ^Yhich aro applicable to 
niT shows how frequently offenders 

k '■f°™**’torics or Borstal institutions. It 

of some cases the diseiplino 

vonnir ' ,a markedly good effect on the 

ovtr^tf patient. The fact remains, how- 

'rbicii onf’ the long list of institutions to 

I’arsons ^<*>'.“ftev-caro and control. Dr. 

exist in ,lnpli '“t eoiisiderablo administrative difficulties 

er even ernun ® satisfactorily with certain individual eases 
Bttu groups of cases. 


Disposal of DifJicaU Cases. 

Tho question of disjios.oi is governed hy two considera- 
tions: (n) tho ago of tho patient; (b) tho nature and 
extent of his incapacity, csiiccially a.s regards niontal 
changes. At tho scliool-going ago tho attention and dis- 
cipline of tho normal children arc distracted hy association 
with a post-cncephalitis child. On tho other hand, the con- 
duct changes in such a child impose severe strain upon 
teachers in schools for backward children. In many cases, 
therefore, committal to a reformatory or an industrial school 
becomes necessary; and during tlio year 1924 it was found 
that in about 8,000 cliildren and young persons under 
dotoiiiion there were at least 26 with a histoi^ pointing 
to encephalitis lotliargica. Bj- tho end of the following 
year 87 such children had boon admitted to these schools. 

Ill adolescents tho apache post-encephalitic presents a 
difficult case. IVhcn his period of detention and reforma- 
tivo training is over, his rotiini homo is liable to lead to 
relapse. If ho is transferred to a Poor Law institution, tho 
guardians, iiiilos.s they adopt him, have no power to retain 
him unless ho wishes to bo retained; and the power of 
adoption only applies so long as the patient is under 
18 years of ago. 

In tho ni.ojority of older patients tho problem, though 
tragic, is gcnorallj’ domestic. From tho medical sido tho 
degreo of mental disablement is the detennining factor in 
tho disposal of tho patient; and iinfortiinately ccrtific.'ition 
is rarely possible except after a lengthy and miserable 
period of progressive mental or physical deterioration. 

Dr. Parsons concludes that tho great difficulty lies with 
patients who, by reason of profound nicnt.il disturbiinco or 
in consequence of serious moral delinquencies, roquire 
special supervision and control iu the interests both of 
tliemsclvo.s and of society. It is especially with the case 
of tho juvenile in this class that tho difficulty arises; and 
it is noccssavy to consider not only tho probable effect of 
any particular kind of institution upon tho patient, but 
also the patient’s effect upon the imstitution — its normal 
inmates and staff. 

In addition to these troublesome sufferers, consideration 
has also to bo given to tho problem of those w-ho have 
beconio iiieapablo of fending for themselres, arid, wiiiie 
not attracting the same public attention, cause much 
domestic anxiety and expense. They aro often.' helpless 
and apathetic creatures, erratic in their behaviour, and 
absorbing much of tho time and cuergj' of their relatives. 
Such patients tend to wander in and out of a vavieiv 
of different institutions, tvithout any benefit to themselves 
or permanent relief to their friends’ anxieties. 

Special Institutions ; Merits and Defects. 

It is evident that Dr. Parsons leans to a solution of the 
problem of tbo treatment of tlio post-encoplialitic bv the 
ostablisbment of special institutions. In his ’ view' siich 
institutions would not only lead to improvement in the 
condition of some of tho patients arid provide suitable 
supervision for the rest, they would also serve as valuable 
clinics for tho study of the after-effects of the disease. 
Ho admits, howover, the existonco of ari opinion that the 
association of all classes of cases in such an institution 
might ho too close, and that individual patients might 
Euft'or in consequence. And tho experience at IViuchmore 
Hill has already suggested that one of the functions of a 
special institution should bo the preliminary sorting of 
patients. It is noted also that those in chaige of the 
French encephalitis unit — La Colonie de Perray-Vauclrise 
—receiving boys from 6 to 16 years of ago, are doubtful 
about tho value of establishing special institutions for such 
patients, and consider that they would be bettor treated 
under arrangements already existing for backward or 
mentally impaired children. 

It will bo gathered from what has been said that Dr. 
Parsons’s inquiry forms a valuable addition to .the reports 
on public health and medical subjects issued by the 
Ministry of Health ; it sets forth ably and in an interesting 
manner the difficulties connected with tho treatment and 
disposal of the post-encephalitic patient; and it srmgests 
I for discussion a possible solution of these difficulties °° 


1124 June 30, 1928] 


scon:.AHD. 


t Tirr Hums* 
BIcbJCAL Jurr.six, 




Scottish Hospitnl for Crippled Children. 

A PUBLIC meeting^, iindoi- the chairmanship of tho Lord 
Lieutenant, was held at Peebles on Juno 19th, in connexion 
with tho scheme for building a hospital for cripple children 
to supply the needs of tho soutli-cast area of Scotland, 
which was outlined in the British Medical Journal of 
May 19th (p. 873). Sir David Wallace, F.R.C.S., who 
described the proposals, said that one criticism that had 
been heard was that one or other of tho present hosjiitals 
might be used for this scheme, but tho answer to that was 
that a central special hospital was essential to co-ordinato 
the whole scheme. In this there would bo a competent 
surgeon to deal with all the cases, and in it all tho e.ssen- 
tial work woidd be done. In the cottage hospitals of 
outlying districts the patients would bo treated after tho 
necessary stay in the central hospital. Tho surgeon of the 
central hospital would also visit outlying districts and give 
advice. They were asking from the charitable public a 
sum of £75,000 to carrj' the scheme into clTect, and, after 
this, maintenance of the patients would be provided by tho 
local authorities and from Government grants. Tho scheme 
would also be of great service in helping to reduce the 
waiting list in connexion with large institutions, such as 
the Royal Infirmary of Edinburgh. A committee w.as 
appointed to secure support for tho hospital in Pcoblessliiro. 
Donations amounting to approximately £27,000 have 
already been received for the hospital. 

New Home for Blinded Sailors and Soldiers In Qlasgow. 
The Lord Provost of Glasgow, Sir David Mason, on 
June 11th, opened a branch of tho Scottish National 
Institution for Blinded Sailors and Soldiers at 2, Queen’s 
Crescent, near St. George’s Cross, Glasgow. Tlie institu- 
tion has since the war been accommodated at Newington 
House, Edinburgh, where tho headquarters still romam, 
but it has been found desirable to open a worlisliop in 
the West of Scotland, and the now quarters will provide 
accommodation for nineteen men. The Rev. Dr. Thomas 
Burns, chairman of the institution, who presided, said 
that since the institution was inaugurated in 1915 oi-er 
£166,000 had been contributed to its funds. Tho occupa- 
tions in which men had been trained included boot 
repairing, basket, brush, and mat making, poultry farming, 
and pig breeding. The men, after conclusion of their 
training, had been settled at various places throughout 
the country and had been assisted with a settlement 
allowance of £150 in each case. In all 140 men had been 
trained and most had done well afterwards j some, how- 
ever, had found great difficulty in. obtaining orders and 
were handicapped by lack of accommodation in their 
homes for the work. The conmiitteo had in operation 
workshops in Edinburgh and Glasgow, where tho nlcn not 
only <»uld carry on their occupations to advantage, but 
had the benefit of c-ompauionship and daily intercouree. 
In the worlcshops at Newington House, Edinbiirgli fliirtv 
trained men were now employed, and it was hoped that 
similar success would attend the Gkasgow branch Lord 
Provost Mason, in declaring the branch open, remarked 
that the hardship imposed by the necessity of travelling 
woidd be minimized. Tho work at Newington House 
Edinburgh, had proved a great blessing, and w”as deseiwine 
of whole-hearted public support. He hoped that the 
citizens of Glasgow would give their cordial support in the 
way of orders to the men employed in the local workshops 

Larbert Colony for Mental Defectives. 

A meeting was held at Larbert House on June 16th 
under the auspices of tho Royal Scottish National Institu- 
tion, Larbert, with the object of enlisting public support 
for the industrial colony sclieme for the care of mental 
defectives. Sir Alexander Gracie (Glasgow), chairman of 
directors, presided, and said that in purchasing the large 
estate at Larbert House the directors bad undertaken a 
great responsibilit3-, but they hoped to be able soon to 
Eccuro the necessary amount of money for the erection of 


tho litiilding.s. 'J'ho .schomo had hecn largely supported in 
Edinburgh, 1ml Glasgow hod dono relatively less for it than 
any other jilaco. Dr. R. D. Clark.son, medical supeiin- 
toiulciit of the ihslifution, also addressed the gathoringj 
and explained tliat it was very neecssaiy from the Scottisli 
ii.ational point of view that the scheme should bo completed 
as early as possible. The vi.sitors afterwards inspected tho 
maiLsion lioii.se, wliieli is at prc.scnt being used for thirty-six 
case.s wlio.so relatives can afford to paj’. A number of the 
children performed musical games and gave demonstrations 
of plij-sical exercise.s. This institution is tho only national 
voluntarj- organization in Scotland for mental defectives; 
it lias hecn in existence for tho past sixty-eight years, 
providing a homo and training for over 500 defective.' 
under 21 3-cars of- age for a considerable time past. Tlicrc 
i.s, however, at prc.sent no proper provision for many 
defcclivc-s over the- age of 21 yearn, and it is to reinedi' 
this that the directors of the institution have purchased 
Larbert House and estate with the object of building np an 
industrial colons- for such defectives. A sum of £5O,O0O is 
.still mjuired before the selicme enii bo completed. A 
eomineneemcnt is to bo made with tho erection of some 
of the buildings at an early date. 

Hospital Accommodation In Edinbargb. 

Considerable interest lias been rcccntU- taken in the future 
of Craiglcitli Hospital, Edinburgh ; it w.as used during^ the 
war as a inilitar3- hospital, and afterwards I)\- tho Minfsiri- 
of Pensions, and reverted to its original proprietors, the 
Edinburgh P.arish Council, on lMn3- 28th last. Tlie matter 
was considered by tho Parish Council on Juno I8th. It 
was pointed out that the hospital and’ children’s homo 
could be made available for occupation in a very short 
time and that the tw-o present Poor L.aw hospitals at Craig- 
lockliort and Seaficld were much overcrowded. It was 
decided to remit the whole question to a committee, with 
full powers to arrange for the reconditioning and occupa- 
tion of the children’s homo, which is adjacent io 
hospital, and for the reconditioning and use, immediate 
and future, of the main buildings. It was intimated that 
approximately £11,000 wa.s available, representing the sum 
w-liich had been received by the council from the Scottisli 
Command in respect of strnctural reinstatement of tlia 
buildings, and which had been held in 'suspense since 1921. 

Npisc in Relation to Health. 

Tho Public Health Committco of the Edinburgh Town 
Council rcceiith- considered the qiies-tion of noises 
the night in relation to their effect on health. The 
matter was hronglit up on-a letter rcecivod from the 
Ediiiburgli and Leith Division of tho British bledieal 
Association, recommending that tho local authoriti- should 
seek greater power to suppress iiniieccssarv noise in the 
niglit, by having it declared that any noise between 
11 pjn. and 6 a.m. wliicli is capable of being prevented or 
mitigated, and wliicIi is dangerous or injurious to lioalth, 
should be a luiisaitce ivitbiii the meaning of the Public 
Health Acts. B3- this means it was considered that the 
public health aiitboritv would obtain poivers to deal w-itb 
such disturbing factor.s as discordant noises produced by 
motors, noise and vibration caused by lieav5- vcbicular 
traffic through ' residential areas, uncontrolled barking of 
dogs, and the iiois3- dispersal of evening parties. It was 
reported to the committee that there w-as no evidence to 
show that ordiiiar3- noises of the street had a prejudicial 
effect upon the organs of hearing, althougli interference 
n-itli natural sleep and detrimental effects on the nen-ous 
system, should bo considered as tho more important effects 
of noise and excessive vibration. The report of the 
Division w-as minuted In- the Public Health Committee for 
further action. 

Proposed Crematorium for Edinburgh. 

Tho Edinburgh Cremation Society, which has been in 
existence for a number of years, has now- obtained an 
option from the town council to purchase tho house and 
grounds of Easter AVarriston as a site for tho erection of a 
crematorium. Arrangements are being made to form a 
public company w-itb a view'to raising tho capital required. 



June 30, 1928] 


ENGIiAND AND WALES. 


[ 


Tin: Ebittstt 
MEO tCAt loCBNlX, 


1126 


Tho grounds nro very nltrnctivc, niid -tlio Iioitse is .1 
liiuulsomo stono building in good condition. Sir Robert 
Lorimer, R.S.A., luis luopnrcd plnns for .odaplntioii of II 10 
liouso with clinpol, columbarium, roliring rooms, incinerat- 
ing chambers, etc. Tho site occupies two acres and lies 
immediately to tbo east of Warriston Cemetery. 

ChIropodIst.s' Confcrcnc". 

Tho Scottish liraneh of tho Incorporated Society of 
Chiropodists held its summer conference in Edinburgh on 
.Tuno 16tb. TIio morning session of tho conferenco was 
hold at the Edinburgh Eoot Clinic, in Newington Road, 
where 3[r. C. W. Cathcart,' F.R.C.S., welcomed the dolc- 
g.ates. Ho remarked that they were trying to get a 
register ns a definite body, and said that even if they wore 
disappointed for a time ho would advise them to hold on 
and continuo trying, and bo bad no doubt tb.at in tho 
future a definito register of chiropodists would bo formed. 
Ho gave some intoresling personal reminiscences of Lord 
Lister, under whom bo bad been a student, and described 
in detail various of Lister’s operation motbods. Dr. 
Cranston Low, pbysicinn to tbo skin department, Edin- 
burgh Royal Infirmary, gave a Iccluro on sonio skin 
diseases affecting tbo fool, illustraled by wax casts, and 
at tbo evening session of tbo conferenco Hiss Gertrude 
Hcrr.feld, surgeon to tho Roy.al Hospit.al for Sick Children, 
gave an address on somo problems in tbo diagnosis of foot 
conditions. - . 


(Snjlantr aittr Males. 

The Order of St. John and the British Red Cross Society. 
(Steadv progress in most of its activities is recorded in 
tbo eighth report on tbo work of tbo Joint C'ounoil of tho 
Order of St. John of Jcnisalom and tho British Rod Cro.ss 
locioty. . Tho rcjiort covers tho period from April 1st to 
December^ 31st, tho joint councii having decided to closo 
us financial year on tho. latter date instead of on March 
31st as formerly; future reports will deal with the work of 
tno calendar year. Tlio mimlior of c.ascs helped hy tho 
auxiliary hospitals for ofiTicors now totals 
hoing cx-officors suffering from tuhorculosis. 
grants for hedsido occupational work wore made to nine 
Ho.spitals, SIX being institutions under tlic Ministry of 
cnsions, and tho value of these grants, as reflected in 
10 ou ook cf the patients concerned, has been considor- 
‘ f'. Reposed to chaiigo the nanio of tho fund 

making this provision to tho “ IVard industries fund.” 
, 1,000 men benefited from tlioso grants 

review, and teaching and training 
schenli.™'^' w handicrafts. Tho emergency help 

assistinn''^c,vv"”'^i 1 ° exceedingly useful work in 

daiit- ivbn ' Oisahlcd ox-servico men and their depen- 
sai rc; obtain , relief from any other 

Whilo'thk 1927. 

tbo amount a” tbo previous year’s total, 

it is' exnectod 'll grants was considerably less, and 
decrease Til 

raised diirincr +1 available are tbo residue of resources 
year bv vear Tt being heavily depleted 

form for ROTTi« W'ork, perhaps in an amended 

the report aErain^nt^^’ recipients of relief, 

tarv refimds^nf ^®® ' satisfaction, bavo made volun- 

rep"ai5l“l927 “''''.®"®®''- O'’®® “ 

Home sLico A l®‘'®"®®^’® to tho work of the 

this period nntall" ®-"®® ^kimmittco, whose activities in 
sciwicron tL rl l^ tbo development of a firs^aid 
7th (p. 6031 The rri’ vf*® *'®^‘®"’od in tho Journal of April 
cmploved anrf nltl ** 'J® kas boon increasingly 

'vovKl- T nnf ^’’® primarily intended fl 

as far a, c„mb“d’ ‘I year been sent 

Tu^reulosis (MmLtL that rLelf'^ 


iiiromo, but exact coniiiarison witli-tlio previous accounts is 

not possible, owing to tbo change in the accounting period 

and tbo fact that somo classes of incomo are seasonal in 

their recniTcnco. 

\ 

The Winsley Sanatorium. 

Tlio niimhcr of jmtieiits received in 1927 at the M’insley 
Sanatorium for Consumption, near Batli, was 354, 
this being above tbo totals for tbo two preceding years, 
but considerably below the number of admissions in tlio 
years 1022-24. In tlio later years, it is interesting to 
note, tbo* average time spent in tho sanatorium by patients 
treated to a conclusion lias gromi apprcciablj-. In bis 
report the senior resident medical officer, Dr. J. D. 
Mncfie, discii.ssing tlio value of graduated labour as prac- 
tised at IViiislcy, regrets tbo teiidcney in certain qnai-tors, 
notably among tlio j-omiger nieclical superintendents and 
tuberculosis officers, to decry this. Dr. Macfie holds that 
tbo ps}'cIiological factor is of tbo greatest importance in 
llio trc.atment of pulmonary tuberculosis and, if finance 
permitted, bo would liko to see tbo gi'adc system fnrtbor 
developed at IVliisley on tbo lines of the Papworth Colony. 
During tlio year tbero was a largo incrcaso in artificial 
jiiiciimotborax eases; this procedure was attempted in 
tliirt}' cases, in tbreo after a spontaneous piieumotborax 
bad taken place. Tbero were three failures, and in four 
eases tbero was only a partial collapse, while in the 
remainder a good collapse was obtained. Sanocrysin is 
now- bciiig employed at the sanatorium, and a trial is 
being made with zomine, a preparation invented by Pro- 
fessor Charles Ricliet of Paris, regarding which Dr. Alacfio 
slates that Iio has not had enough cases to offer any final 
opinion, but that so far Iio is satisfied with tho results. 
Tuberculin has been used occasionally; the only patient 
it seemed to suit was a pulmonary caso complicated with 
•tuberculosis of tho kidney. , . 

Reconstruction of the Altddlesex Hospital. 

The foundation stone of tho west wing — the first part 
of tho reconstruction scliomc — of tlio new Middlesex Hos- 
pital building was laid on June 26th by tho Duke of York. 
Prince Arthur of Connaught, tho chairman, stated that 
the entire cost of tho reconstruction would be £1,001,670. 
Since tho launching of the scheme three years ago they had 
received £405,500, so in the course of tho nest five years, 
tho period needed to finish the work, they had to obtain 
the sum of £596,170, and £137,700 was required by tho 
j close of tho present financial year. Tlie governors had set 
tliomscivcs to build a new hospital, a fully equipped out- 
patient department, and special departments. They would 
iiavo to endeavour to provide a block for paj-ing patients, 
as it was certain that in the near future no hospital would 
be consiiiercd np to date unless its service was so extended. 
In bis speccli after the ceremony the Duke of York, who 
was accompanied by tlie Duchess, recalled that for moro 
than 170 years tho Middlesex Hospital bad ministered to^ 
tbo needs of many thousands of sufferers. Tbreo years 
ago the governors were faced with a gi-ave problem ; serious 
defects in tbo fabric of the building were found, and the 
board was called upon to make a momentous decision. 
They now saw tbo firrt result of these careful deliberations 
ill the laying of tho foundation rtono of the new hospital, 
of which that wing -was only tho first section. There was 
ample evidence that the courageous policy of the board 
was endorsed and approved by the public, who had already 
contributed vei'y largely to tho rebuilding of the hospital. 
Tbo contributions of tbo anonymous friend who gave £200,000 
for a new nurses’ home, and of Mr. S. A. .Courtauld, who 
has provided and' partially endowed the new biochemical 
institute, referred to in our last issue (p. 1083), the Duke 
described as “ magnificent.” ' Continuing, be said there 
was every justification for the' view that the public was 
becoming moro. keenly aware of the value of good health 
both -to the individual and to the commiiuitjk Those who. 
took part in the rebuilding of the hospital would be sharin" 
in this great national work. Ho trusted that the new 
Middlesex Hospital might prosper in tbo noble task that 
lay before it. Tbo Duke and Duchess afterwards visited 
the medical school, the Bland-Sutton Institute, and the 
Courtauld Institute of Biochemistry. 


1126 June 30, 1928] 


IREIiAND. 


[ 


Tiir I?niTJn 
3lr&;ciL Joctxu. 


Ir^ajttr. 


C0ms|joniijiitrc. 


The Local Authorities Dili.' 

The Local Authorities (Officers and Employees) Bill uns 
introduced into the Bail recently by Mr. be Valera, its 
object being to amend the Local Authorities (Officers and 
Employees) Act of 1926 in one particular. That Act 
provided that appointments under local authorities should 
bo made on the nomination of a central board set up by 
the Government, the Local Appointments Board, only one 
nomination being made in each case. Mr. Be Valera |)ro- 
posed that, instead of naming one pei'son to he appointed, 
the Board should submit a panel of names from which the 
local authority should choose one; his argument was that 
the local authoritj’ should not be deprived of all power 
of choice in the selection of its officers. In opposing 
the bill Mr. IV. Cosgrave, President of the Executive 
Council, said that the Act had been introduced for one 
main purpose — to secure in the appointment the best 
qualified person. Under the bill now before the House local 
authorities were to be invited to ask for a panel of not 
less than three, which would mean that canvassing and 
local influence would be resurrected. The ])urpose of .send- 
ing down more than one name could only he to invite the 
local authorities to appoint someone other than the best 
qualified candidate. Ho further stated that the standard 
of applicants lor the various posts had been good. Mr. E. 
Blythe, Minister for Finance, agreed that an inquiry into 
the working of the Act might be extremely useful. One 
of the results of the present system was that there had 
been great numbers of candidates coming forward, which 
showed that they had confidence in the methods by whirh 
they would be appointed. Ho saw no loason why officials 
should be chosen by a particular local authority, just as 
he saw no reason why civil servants should ho chosen 
by a Minister, because officials wore no more the servants 
of the council or local autliority than civil servants were 
the servants of the Minister. Br. T. Hennessy said that 
before the passing of the Act it often happened that a 
■candidate — a medical candidate — passed his final examina- 
tion one day, had his degree confciTcd, and then went 
down the day afterwards, and was elected to a position. 
Professional experience had mattered little so long as he 
had enough influential friends on the local board. Br. 
Hennes^ added that no defeated medical candidate had 
yet invited any body charged with the defence of pro- 
fessional interests to investigate the facts of an appoint- 
ment on the ground that ho had been unfairly rejected. 
It is expected that the bill will be defeated. 


School Medical Services. 

I At a conference of national school teachers held reeentlv 
in Carlow, Br. Robert Condy, medical officer of health, 
stated, in connexion with the medical inspection of school 
children, that it was the riglit of every child that his scliool 
life be ■ passed with the greatest possihle freedom from 
physical defects. If every child entering school received 
a thorongh physical and mental examination, and was then 
dealt with according to his particular needs, from the 
infant up to the highest standard, the ro.siilt would, in 
almost all cases, he .a firsLclass health certificate when 
leaving school. Education without health was useless. Tlie 
health of the growing child in nearly all cases determined 
the health of the adult. Br. Condy suggested that no 
scheme for the treatment of school children could be com- 
plete. unless consideration were given to those children 
nuder school age who were knowai to be defective, and 
the condition remedied without waiting until the child 
became of school age. The location, structure, and iiiaiiage- 
meut of school premises and playgrounds was of nnieh 
importance. A healthy, clean, sanitary environment, the 
betterment of home conditions, and the -education of the 
l>arcuts and children in the i^revention of disease were most 
essential objects. A 'well-trained scliool nurse was a link 
between school physician and teacher. The teacher needed 
the advice pf the scliool nurse, and together they formed 

bound to have a far-reaching 
eUcet on the health of the children. 


OA.STItIG ANB BUOBE.VAL OPEKATIOX.S. 

Sill, — In to-day’s issue of the Jirilish Mciliail yJoiiriiai 
(JtiiKi 23rd, ]). 1055) Jlr. Strong Heaney e.xpiciscs Iiis 
“ belief ” that my practice in regard to tlie surgical tieat- 
nient of duodena! nicer is an approach to that of II 10 
advocates of gastrectomy. 1 wonder win"! 

1 do not pel-form ga.sti cctomy for duodenal nicer. 1 hare 
not Imrboiired one thought, uttered one word, written 0110 
line in its favour. 1 think it needlessly severe. Hie puli- 
lished experiences of those wlio perform it leave me quite 
11 neon vi need by their advocacy, and deeply confiniied in 
Illy contciitnicnt with simpler, safer, yet equally effcctivo 
methods of treafincnt. — I am, etc., 
l..-«l-, Jimc Mill. BnnKTI.EY 3rOY.VIIU.N. 


IMIBMTFEltY MUBTALITY. 

Sill, — I would lihe to snhniit the following ohsen'aiions 
for flic consideration of your readers. Tliis incrcaicd 
iiiorlality, if it is real — 1 bavc-no statistical infovraatioa 
on tbc matter — is due to the sbort-siglitedness and stupidity 
of a body of medical men, who advised the Govenimcnt 
of fho day, when the Midwives Bill was introduced, tliat 
it was desirahlo to e.i-tablish a licensed body of iiiidwivc', 
a Iraiiied body, to take the place of the nnlraiiied aiul 
ignorant women who acleil in the capacity of nurses, hut 
who did nothing — did not attonqit to do anything — excejit 
wail by the bedside of the lahonring woman: the responsi- 
bility "tor any examination, ojiinion, or iiitcrfeieiiee, was 
laid upon tlie doetnr. 

In those days Die doctoi-s attended a large number of 
coiifmcnicnts (100 to 200 jicr annum) for relatively sinnll 
fees — £1 Is.; in some districts 10s. Tliese confiiicnieiits 
constituted the hackhonc of a general practice. They 
were the criterion upon which its value was determined: 
tho reputation for efficiency of the niedicnl practitioner 
was popularly as-sessed by his skill in conducting midwifery 
cases; tho loss of 11 maternity case, e.s]iecinlly from pner- 
peral fever, was the most .serious thing-tliat could happen 
to hhii. Tlie very large expcricmce he acquired, together 
■With the advice and assistance' ho received from his clch-r 
brethren, very soon rendered him highly offieiont. His 
income from liis midwifery pi-nefice was from a sixth to 
a third of his total receipts. 

All tills has changed— partly owing to tho Insurance Act, 
mostly to the establishment of a body of midwives who 
are licensed to attend cases, who are quite good as far 
ns they go, hut who are totally unfit to take the resjionsi- 
bility thrown upon them. Their existence has taken 
away from the medical practitioner a large mass of expe- 
rience and a large slice of his income. He is now oid.v 
asked to see the 10 per cent, of ahnonnal cases, while at 
tho same time he is deprived of tho experience wiiicli 
alone can enable liim to distingnish tho normal from tho 
abnonniil. If he is a wise man he will not- attend mid- 
wifery cases at all if he cannot make £100 out of 100 
simple and difficult cases; it is better for his' i-cpntatioii 
not to attend any. He cannot ask ten guineas for tho 
difficult 10 per cent, of the cases. But still more serious 
is the fact that the redne-tion in the number of his cases 
has resulted, or must result, in rendering him inefficient — 
ho has no longer the cxpei-ience which . alone can make 
him efficient; this is what the original advisors of the 
Govcmnient of tliat day failed to see. It did not matter 
for ten" or fifteen - years-^tbere were plenty of efficient 
doctore then;:that- is not tho case now, or it will not he 
soon. Very few medical men now have an experience 
of 1,000 cases, which, in’ my ophtion, is necessary to make 
a man efficient in any part of his work. 

• In more ways than cine the airthorities appe.ir to he 
losing siglit of this fimdamental fact. There is a tendency 
to create, for various piuqiascs, bodies of whole-time doctqra 
whose services are not available to the genoi-al public. 
From an administrative point of view tliis is jn-obahly 
the easiest and the best method, but it must have the 
evil effect of rendering less efficient the practitionei-s who 
are available to the pnblic. ' .... , 


COnRESrONDENCE. 


r Tnr BniTinn 
I Mfoical JocnKiti 


1127 


June 30, 192S] 


This is too serious i\ iliattor to lie ignored. Tl was 
ignored wlien tlio Midwives Bill was passed, with tho 
m-csent or coming result that, tho public will have at then- 
command a body of practitioiiors who cannot get, the 
cxporicncQ iwvist huvo i-o rciuloi them ofitc ioiif-, nud 
a body of midwives whoso professional training cannot 
lender them capable of bearing tho rc-spousibility thrown 
upon them. — I am, etc., 

, , , c, I) .win Roxurnen. 

London, Juno oUj. 


rUERPERAL SEPSIS. 

Sin,— I read with pleasure three articles on puerperal 
sepsis in j-our issue of Juno 9th, The .address by Jlr. ,Iaine3 
Young of Edinburgh interested me most, chiefly because 
of certain eonelusions he arrived at.. 

In tho first plaeo, Dr, Young say.s Ihoio i.s evidenco that 
trauma is tho most important cause of tho death rate 
from sepsis. I have long hold this view. During tho past 
twenty-six years I have, in general practice, attended 
slightly over four thousand confinomonts, and years ago 
I noticed how important a factor trauma was in pnorpernl 
sepsis, I do not recollect having a ca'O of puerperal sepsis 
without it. Many times I Jmvo removed an adherent 
placenta by introducing tlio Imnd into tbo utoriis, .and have 
performed this operation in surroundings far from ideal — 
a dirty room, with a patient who bad rarely enjoyed the 
luxury of a bath, lying on an unclean bed — and never with 
a bad result. Such cases always caused ino much less 
anxiety than those in which trauma existed. 

In tlio second place, Dr. Young concludes that there is 
need of an improved luacbincry for niafornity practice 
based on a midwife-doctor combination. .Such a combina- 
tion is, undoubtedly, all-important. For several years I 
have insisted on belter-class patients going to a nursing 
home to he contiuod, and tho poorer classes I Lavo rctus-ed 
to attend unless with a certified luidwifo co-operating. 
Since following this custom I have not had a single case 
of puerperal sepsis. 

1 am convinced that most cases of puerperal sep-is are 
due to trauma folloiring the improper use of forcep*-. Tho 
doctor is busy, tho patient impatient, and instrunionts aro 
applied hurriedly and too early. IVith a compotont mid- 
wife present this does not happen. ,Sho .soothes the patient 
.and her relatives till tho timo is ripo for tho physician’s 
appcaraiieo, and very often such cases end naturallv, 
whereas if tho doctor is working alone, or with tho aid 
ot olio whoso only (lualification lies in tlic fact that sho 
'if ^ dozen,” forceps aro applied early', 

ah® usual lacerations and accompanying perils. — 


DuiiJw, Juae isiii. Hii.vnr Dpisr, M.R., CIi.B.Ed, 


-YE AESTHETICS AIsD DIABETES, 
fn lilcdical Journal of Juno 

nnmi rVi w-‘ ILangloy, in discussing opoi-.a 

manded “Chloroform is con 

sZ” ®t>'or ®l>P®-ars to ho 

m-obablv of ethc 

ulttaSrSr ■ also' considers 

wrUos.’'®fff 

a serious eoLltior’’ Dr'^’ 

-asf in tbt ?bJ -d 

after oneratinn tolerance threo m 

showed a iim-L-nrl ,• i'**... '®*' d’as used as an anaesti 

ihetics ' writpc ‘f ^adfield, in Practical A 

».”ta 

spaS if at al el',’, sbonid be 

Jn thll.’ * I ’ oWoroform never.” 

eltect of tbo'* ™aesther " is present the delete 


aRo «f tho opinion that otlior should not bo employed 
unless it is c.s.scntinl for tho operation. With the advaiico 
in tho tochniqno of local and spinal anaesthesia such 
circninstanco.s should rarely occur. Gas and oxygen is con- 
sidered to ho proforahlo to other although not freo from 
objections. — I am, etc., 

Londnn, N.W,, Juno 251, j. ' S. Levy SiMrSON. 


IMMUNITY FOLLOIVING HERPE.S. 

Sin, — In rogai-d to tho recent corresimndcnce on tins 
subject — by Dr. James Taylor (Sl.ay 26tli, p. 920), Dr. 
H. \V. Cell (Juno 16fh, p. 1054), and Dr. H. E. N'onrso 
(.Tiino 23rd, i’. 1089) — it must bo admitted that reenrronco 
of genuino horpes zoster is occasionally seen, but I 
think that ca.scs of typical “ recurrent herpes ” of the 
Inittoek or clscwhoro should not bo admitted as evidenco 
ag.aiust tho teaching that triio herpes zoster ordinarily 
confers immunity iinlc.ss, indeed, it can ho shown that 
tho causo of recurrent herpes is tho same as that of 
true horpes zoster. Amongst cases of “ recurrent horpos ” 
which have been described as cases of recurrent true lierpes 
zoster I would include that of \V. Richter,* partly owing 
to tho actual illustration of tho eruption that accompanies 
tho description. The illustration shows a vesicular erup- 
tion in tho lower loft part of tho abdomen of a woman, 
aged 46 years, and a similar eruption recurred during 
fourteen years in that situation whenever menstruation 
was much delayed on the day when tho period should 
have commenced. Quite a number of tho cases of “ roeiir- 
rent menstrual licrpes ” liavo been of gluteal distribution. 
Tho earliest reported case of recurrent gluteal herpes, 
according to Adamson, was th.at described by Bortholle in 
1876. It was in a man aged 48, and may be compared 
to that in a man aged 32 years recently described by 
Dr. 31. Obermayer ns ono of recurrent true herpes zoster. 
I have referred to many cases of “ recurrent horpos ” of 
tho buttock or thigh in a recent paper. — I am, etc., 

London, tV.t, Juno 23rd. ff. P-^EkES Muilini. 


GLAUCOMA AND THE CAPILLARY CIRCULATION. 

Sin, — It interests mo iniich that Dr. JIaitland Ramsay 
regards tho state of tho kidney in glomerulo-ncphritis as 
analogous with the state of tho eye in glaucoma, for, 
working on tlio renal state in eclampsia, I have looked 
at glaucoma as an exaroplo of a similar pathological 
process. Not that these two states, in their genesis, 
aro comparable, but in their end-results. Tho increase of 
intraocular pressure causes blindness by interfering with 
tho nutrition of tho essential cells of tho retina (by affect- 
ing tho retinal capillary bloocT flow) : in the pregnant 
woman, tho rise of pressiiro on and within the kidney, by 
obstructing tbo blood flow through the kidnei-, causes 
degeneration and necrotic changes of renal tissue cells. 

I liavo maintained for some years that tho visceral state 
in eclampsia is an cxamplo of ischaemia: tho condition of 
tho retina in glaucoma seems another example of this 
very common condition — witness tho present discussion in 
your columns on “ ischaemic contracture.” 

Dr.' Ramsay believes that both these conditions — that is, 
glaucoma and glomerulo-nephritis — are due to a toxin. - 
According to him the toxin causes a dilatation of the 
capillaries and an increased permeability of the cajiillarv 
walls. I do not think this view can be maintained. In 
tho case of tho kidney, eclampsia occurs so often in the 
best typo of pregnant woman, the lioaltiiiest and strongest, 
that the impufatioii of a toxin is unreasonable. In the 
case of glaucoma, although a toxin or an inereaso of 
waste products in the blood may always bo present and 
bo the predisposing cause, it does not seem to explain 
tho condition in tho way supposed. If the toxin acts 
primarily on tho capillaries, causing their dilatation, etc., 
then if tho supplying arterioles remain patent and tho 
veins aro' not obstructed, however penneahlo the intra- 
ocular capillaries . become, a continued blood flow not 

a stagnation— through tho eye must occur. Tho intra- 
ocular capillary blood flow must be contiuued because of 
tho (up to now normal) press-aro within the eye, which 

* Dent. mol. TTncfi.. 1925, H, p. 127^ : 

> Jlci/ical Press, 1928, clsxvi, p. 500. 


1128 June 30 , 1928 ] 


COBRESPONDENCE. 


Tifr Htmia 
Mriirrit. JorB'rtft 


■“ supports ” tho capillaries, and tends to prevent an 
undue dilatation. There must bo some faelor other than 
a simple dilatation of the capillaries: that faelor Kcems 
to be an increase of pressure within tho eye, and that 
increase of pressure tho result of a chemical change. 

“It is not tho push of a capillary . pressure,” says 
Leonard Hill (p. ,919), “but tho i)cnetrability of the 
endothelial membranes and tho ])ull of the tissiie 
cells, which is of first importanco ” — in the genesis of 
glaucoma. Dnke-Kldor (p. 1000) agrees. “ Changes in 
tho vitreous,” says the latter, “ are probably the mo.st 
important factor,” causing tho increase in penetrability. 
IVo have only to assume that tho osmotic pressure of tliO 
vitreous rises (for which, porhaiis, there is reason) to see 
that an increase in volume of the vitreous and a I'ise in 
intraocular pressure would occur. Tho lens must thus be 
thrust forward, which woidd result in the exit of tho 
aqueous into the canal of Schlcmm being obstructed. Tho 
result must be an increase of pressure on the retinal 
capillaries, an obstruction to tho blood ilow, and an 
impairment in function of the retinal cells. Thus, in tho 
case of the eye, if a toxin be present it would seem to 
act by affecting tho vitreous, raising its osmotic pressure; 
in the case of tho kidney of a pregnant woman about to 
become eclamptic no swclr toxin is. nccctsovy to explain 
tho renal state. 

It is clear that tho flow of blood through the 
capillaries is of paramount im])ortance for the he.alth of 
the tissue cells, and it is at least reasonable to believe 
that the tissue cells, in respect of their varying activity, 
determine and control the blood flow through tlie related 
capillaries — doing so always except when pressure conditions 
arise interfering with tho mechanism. Man consists of 
a mass of tissue cells, for which tho blood and tho ca|)illaries 
exist; tho tissue cells, not the endothelial cells of capillaries, 
are the master cells of tho body. The pressure of tlie tissue 
cells upon their related capillaries must, as Leonard Hill 
has consistently taught, always bo approximately the .same 
as the pressure of tho blood within tlioso capillaries. The 
capillaries are such thin-wallcd structures that if the 
pressure outside them, caused by the activity of the tissue 
cells — for example, in gland and muscle — bocomc.s greater 
than the intracapillary blood pressure — as, for instance, 
during systole of the heart — tho capillaries become oblitcr' 
atod, the contained blood being compressed into tho veins. 
If the pressure of the tissue colls upon the capillaries 
becomes much less than tho pressure of the blood rvithiu 
the capillaries — if the arterioles do not constrict — an 
extreme dilatation and oven a rupture of tho capillaries 
with exudation of blood must occur. Tins hapjicus in 
“ shock.” It is stated that in shock the dilatation of 
the capillaries is tho jirimary change. In my view, the 
lirimary change is in tho tissue cells. Tho Ilougot cells, 
found on capillaries, imjjuted to act as dilators, possibly 
are sensory, not motor, in function. Tbcrc must, at least, 
be some mechanism correlating the state of tho capillary 
blood pressure with the state of the supplying arteriole — 
that is, with the aortic blood pressure. 

Tho pressure within any capillary bed, necessarily de- 
pending (in the normal) on the activity of the tissue in 
question, and upon other internal and external conditions, 
must bo constantly changing, and in different organs or 
body parts, at the same time, groat differences of capillary 
pressui-o must exist. The pressure on the pulmonary 
capillaries, and thus the pressure within the pulmonary 
capillaries, at tho top of Mount Everest is obviously greatly 
less than when at the base of that mountain. The pressiu-e 
on the glomerular capillaries in the state of diuresis is 
obviously much greater than the pressure on those capil- 
laries during a state of renal quiescence. So also must 
the pressure within the hepatic capillaries vary. 

Tho arterioles of the several capillaiy beds react to the 
changing demands and to tho physical conditions to which 
the body is exposed. At the top of Mount Everest the 
pulmonary arterioles must be constricted, obstructing the 
blood flow through the lungs, explaining tho fearful fatigue 
experienced by individuals attempting the final stage of 
tho climb. Otherwise, the pulmonary capillaries would 
burst. Luring diuresis, the renal arterioles dilate, allow- 
ing an excess of pressure to play upon the glomerular 


capillaric.s, thus causing tho blood to flow on ra|)idly into 
the tubular capillaries and auay — without ivhich urim! 
could not be formed ; the rise of ]n-cssui e in Ilownuui’.'! 
cap.sides su|>pnrting the glomerular expansion with a 
pre.s.sure <-(jual to or almost equal to the blood pressure 
within the glomerular capillarie.s — the kidney hetoming 
.swollen and tense. It is ])lain the arleriolos do not present 
the only ))eriphcral resistance to the flow of blood; the 
great fall of incssure seems to occur at the outlet of the 
arteriole, where it exiiands into the (•.■qiillaiy bed, but 
this fall only occurs during resting slates. During activity 
of a part the cajiillary pressure within that part is con- 
siderable; but the pressure of the tissue cells now is raised, 
.so that in the normal the integrity of the important part 
of flic v.'iscular inecliani.sm — the part which inalfers— is 
conserved. — I am, etc., 

Hiici.y, June 9tii. R- H. P.Mt.\3roitK, F.R.C.S.Eng. 


WAR EMEROEXCY FUND. 

Silt, — In their all too generous tribute to the Ilonoraiy 
Tre.-isiircr and Honorary Secretary of tbo above Fund 
(Uritiah Meilirtii Journal, June 16lh, p. 1045), Sir Thoniaf 
Rarlow and Sir Charles Uallanco omitted to mention that 
the Fund owed its origin to the foresight of Dr. .Sainiiol 
Wc.st, at tbnt time. President of the Royal Medical Renc- 
volent Fund. ' Ho recognized that Territorial medical 
onicer.s — at the time mobilized for the annual training, 
and many unable to return home to make arrangements 
for a long absence — must .suffer financially. It was fhn^ 
that tho Fund came to bo administered by the ufficiah 
of the Royal Meilical Rencvolcnt Fund. Racked by the 
immediate ro.sponse of the profession to the aiipeal for 
funds. Dr. West, through his iiersonal inflneiico, obtained 
a grant of £10,000 from the Prince of Walc.s’s Fund. By 
his dentil the eomniiltco lost the guidance of a wi.se 
counsellor, and one who knew, perhaps bettor than anyone, 
whore relief was most needed. — I am, etc., 

Cii.rtiTKns J. Symonds, 

Uonilon, W.l, June 22nil. Honorary Treasurer. 


LITHOLAPAXV. 

Sin, — J think Colonel L. P. Stephen, in his letter in the 
Journal of June 23rd (p. 1089), has touched on a very 
important .subject, both from the jioint of view of the 
jiatient and of the State. 1 think that there can be no 
doubt of the advantages of litholn])nxy over suprninibio 
cystotomy for the treatment of vesical calculus. There 
should be no need, however, to go to India for two months 
to learn a method which .at tho beginning is not devoid 
of risk to the jiatient, and which is becoming more and 
more out of date — at le.ast, outside India. Litholapaxy 
with the cystoscojiic litbotrite is safe, sure, and .speedy, n 
jiractised by one expert in cystoscojiy. At All Saints 
Hospital, in cases of uncomplicated .stone, no other method 
is ever used. The operation is rendered easier by employ- 
ing the Ryall cy.stoscopic evacuator, 'and is easily per- 
formed under sacral niiaostliesia. In the teaching hos- 
pitals litholajiaxy is neither taught nor practised, and it 
would be to the advantage of patients if all cases of ve.sical 
calculi wore transferred to the special hospitals dealing 
with this type of case. — I am, etc., 

F. McG. Lougiix.ink, ■ 

liOntlon, "W.!, June 24lli. ARsistanl Surgeon, All Saints' Hospital. 


GASTRIC SECRETION OF NEUTRAL CHLORIDES. 

Sin, — May I bo allowed to defend the paper on “ The 
origin and significance of gastric chlorides by F. S. 
Hansinan, Emily M. Day, and R. Clifton (from the 
Department of Biochemistry, Royal Prince Alfred Hos- 
pital), which was criticized by Dr. Goodhart in the British 
Medical Journal of March 24tlt (p. 521). Dr. Goodhart 
misrepresented our iioint of view in several details. 

Lu the first place, we took caro to state definitely that 
we do not deny that fluids secreted by tho duodenum, 
pancreas, and liver may gain access to the stomach, but 
wo maintain, and since writing the article are more than 
over convinced, that all the neutral gastric chlorides 
cannot be accounted for on the assumption of liydro- 


Metl. Jonni. of Auttrnlta, - vol. 2, July, 1927, p. 6. 




1130 June 30, 1928] 


MEDICAL NOTES IN PARLIAMENT, 


[ Tiir. Bnm«m 
MrMCAL Jocemi 


^ibical i^otcs in l^arliamcnt. 

[From our Parliajientary Correspondent.] 


In tile House o£ Lords, on June 21st, the National Hcallli 
Insurance Bill was read a third time without debate. TJiO 
House of Commons has been chiefly concerned with the Finance 
Bill this week. On Tliursday it was asked to set up a limc- 
iable for the remaining stages of the Bating and Valuation 
(Apportionment) Bill. The issue of Air. Neville Clmmbcrlain’s 
circular to local authorities, outlining the proposed rcarrangc- 
nunts of their areas and powers, was expected at the end of 
the week. 


Parliamentary Mcilical Committer. 

The Aledical GouumUec of the House of Commons met on 
June 26th, with Dr. Fremantle in the chair. The chairman, on 
behalf of tlie committee, congrafiijatcd Sir Thomas Watts on 
receiving the honour of Lnighthood.- Tlie committee decided 
not to urge a reduction of tlie tax on petrol used in doctors* 
cars, as no comparable concessions were being made. It was 
decided that the committee should meet specially when tlio 
report of the Committee on Vaccination was published. The 
committee regretted that publication had been delayed. A dis- 
cussion followed on the changes which the Government were 
contemplating in local government as these would affect 
hospitals, and also on the projected introduction of block grants 
which might cover both health and the maintenance of roads, 
with the consequence that money might be diverted from tuber- 
culosis services and venereal disease measures. The possibility 
of Poor Law hospitals being transferred to the control of 
county councils was also mentioned. As Mr. Chamberlain’s 
circular to local authorities was not before the committee it 
took no decisions on these topics. 


Infanticide BUI. 

In the House of Lords, on Juno 21sl, Lord Darling moved the 
«ccond reading of the Infanticide Bill, to meet a legal anomaly 
defined by Mr. Justice Talbot thus : ** It is a felony to procure 
abortion and it is murder to take the life of a child when it is 
born, but^ to take the life of a child while it is being born and 
before it is fully born is no offence whatever.” Lord Darling said 
there had always been this gap in The law of England, yet the 
Court of Criminal Appeal had reaffirmed the doctrine 'of Sir 
Edward Coke that if injury were inflicted on a child during birth 
and after that injury the child was fully born and existed ns a 
separate creature, then the .person inflicting the injury might bo 
punished. In the proposed codification of the criminal law pre- 
pared in 1879 a clause was included to deal with this defect of the 
law. ■ Twenty years ago Lord Robert Cecil bad introduced a bill 
to remedy the defect, and that .bill had passed tlirough second 
reading and committee, but had lapsed. 

Lord PRiLLiMORE supported the bill. 

The Lord Chancellor (Lord Hailsham) doubted whether many 
cases of this offence had happened without piuiishnient. Still the 
gap should be closed. The bill would make it an offence wilfully 
to kill a child in the act of birth. Tliere were 'cases in which a 
doctor had to choose between losing 'the life of tlio mother and 
wilfully destroying the life of the child which' was being bom.' 
'^uch a state of affairs must be safeguarded and prolcclcd hy* 
legislation. He was not sure that that matter was covered bv the 
bill as diawii. He understood that Lord Darling was willing* that 
the bill, if read a second time, should be referred to a select 
comnultce, whicli could consider such points. 

Lord Darling said he realized there was anxiety, on the part of 
those who had to assist women in their accouchement lest tliev 
should be obliged, in order that two lives might not be sacrificed 
intentionally to sacrifice that of the child. That case was pro- 
vided for by a clause in Lord Robert Cecil’s bill as it emer^-ed 
from the standing committee, and Lord Darling promised to^’do 
all he could to get that provision included in the present bill 

The House of Lords tlien read the bill a second time and *;cnt 
it to a Select Committee. 

On June 26th, on the motion of Lord Darling, the following 
peers .were constituted a Select Committee to consider llie 
Infanticide Bill : The Earl of Desart. Lord Pliillimoro, Lord Dawson 
of Penn, Lord Hewart, Lord Merrivale, Lord Darling, and Lord 
Haiiworth. ’ 


Xaiional Health Insurance. 

Mr. Hore-Belisha asked the Minister of Health, on June 12tli 
whether lie was in a position to make a statement regarding the 
reconmicudations of the Consultative Council in respect of the pro- 
po'sals made by the Royal Commission on National Health Insurance 
that the scope of the benefit should be extended to include a 
consultant and specialist service, and that the necessary funds for 
this purpose should bo obtained by a partial pooling of future 
surplu'jcs of approved societies. Sir Kingsley Wood : The recom- 
mondatious of the Royal Commission to which the hon. member 
lofcrs were very fully considered by the Consultative Council, who 
unnnittiously cndoi-sod the recommendation that the fi!*st extension 
of the statutory benefits of national health insurance should take 
tho form of widening the scope of medical benefit to include a 
epecialjct and consultative service. The Council, however, by a 


largo majority, declined to endorse the rccommcnrlalion of the 
Royal Commission tlmi tbo cost of this extension should be met 
by' means of a partial pooling of future sur]iluses of approved 
Bociclics. 

In England and Wales, according to an answer given by Mr. 
CiiAMnEKLAiN ou Jiiiie 2lKt, twenty-two approved Fociclics and 
275 branches, witli a membership of 317,389, arc not giving addi- 
tional benefits. Such benefits arc given t)y 923 societies and 6,156 
branches with a membership of 13,015,180. Mr. Oiambcrlain is not 
considering any action to Bccurc equal benefit for all persons 
coini»tilsoriiy insured. 


Sie.all-j>vr. 

Answering Air. W. Baker, on June 21st, Mr. Chamberlain said 
(hat 6,(J07 case*, of srnall-pox were notified in England, including 
Monmonllisliirc, during 1928 up to June 16lh.- The number of 
deaths up to the end of May in which Finall-pbx was medically 
certified as the cain-e or one of the causes of death was 46; (he 
figures vfcvc pvovisioual. No small-pox had been uoUfied Ihi- 
year from a port sanitary district. lie had no slati*-lics to show 
what percentage of persons suffering from small-pox were casual^. 
Answering Dr. Veinon Davies, Mr. CuAMBr.rxAiN said that the 
total number of cases last year was about 14,000. It did-not seem 
that this year tlien; had l/ecn any great change in numbers. Dr. 
Fremantle* asked wlicn tlio report of tlio Departmental Committee 
on Vaccination would he published. Air. . Chamberlain answered 
that it was in print, and would he published within tho next week 
or two. In reply to Mi\ Smith Carrington, Mr. Chamberuin 
said the inmihcr of cases of small-pox among casuals had recently 
shown n tendency to decrease. 

In reply to a* question by Mr. Robinson, on June 21st, Mr. 
Chamberlain said lie Iiad received a report regarding the death 
of II Keighley hoy', aged 10, wlio was vaccinated as a condition of 
going to a hoys’ camp. The Alirnslry' of Health liad communicated 
with the certifying practitioner. No examination 

was held, and llic eerlilicd causes of death were: (1) («) acute 
meningitis, (b) tonsillitis; (2) vaccination. 


Hhim Charance Srhemcf:. 

In the IToiiso of Lords, on Juno 20th, tho IJishop or SorrirwARK 
opened a discussion on slums. He asked how manv persons wouia 
bo nffccled by slum clearance scbcmc.s approved ov tho Minisiry 
of Health but not yet carried out, and whether the 
had nnv proposals to hasten the abolition or improvemcnl ot sium 
propcrl‘v. They were told that in London, apart from co,wj 
people who had been or would be dealt with under shun clc^5wi 
schemes adopted by the London County Couiicil, lU least 
people w’crc living’ under insanitary conditions. He 
Govcnimcnt would, in the near future, do its utmost to remote 
Iho fclums. iiiP 

Lord Gorell quoted from reports by medical officers to lu 
effect that the housing sliorlago and the slum pi-oblcm were a 
acute ns ever. . , . * n .v uef 

Lord Gage, replying for tbo Government, said tl^ JR (be 
yenr for which statistics were available over l,0w,tXX) bou* 
wcrc inspected for defects; 15.260 were found to bo unfit for btunai 
linbitntion and 352,645 were found unfit in minor respects. AS a 
result of action by local authorities in 1926, 6W,(^ houses ne 
repaired and put into a correct sanitary condition, ouicc in 
annisUco 6(,600 now houses liad been completed to replace boiK > 
demolished’ or to be demolished. Tlieso new lionses would ' 

modatc 29,0(X) or 30,000 persons. Since the war 123 slum scbcnics 
Iind been , submitted and 115 confirmed. In the vast I 

clearance schemes considerable work had already been .^briaed oui. 
Of persons displaced by such schemes, about 39, (XX) had still i 
be provided for. . 

Lord Beauchamp spoke of tho prevalence of overcrowding in 
districls. Infantile mortality, ho declared, was 20 per cent. i 
bad areas and 11 per cent, in good areas, ^ 

Lord Salisbury said he would convoy’ to the Minister of Beau 
the suggestion that tho Town Planning Acts should be cxlendctt 
to existing liousos to prevent overcrowding by tho conversion oi 
dwellings into places of business. The Government was 
ing wlicthcr they' could not find a hotter remedy than the vast 
schemes of slum clearance and rebuilding. The reconditioning oi 
suitable houses would be cheaper and more speedy. ^ 

Sir Kingsley Wood, on June 25lh, replying in the Hoiisc oi 
Commons to Mr. Hurd, said the Ministe’r of Health had not 
received from the roceut conference of local authorities on liousiUc- 
.a resolution asking for a return from local authorities of lowj 
standard working-class dwellings in their areas, distingmsnnip 
between those houses capable of being reconditioned end (bose 
w’liich, because of total unfitness, should be condemned. He wo. 
reluctant to add to the burdens of local authorities in the prcpai'n- 
tion of returns. 


Welsh Board of Health. _ 

In reply to Sir C. Kinloch-Cooke, on June 25th, Sir KingslCT 
Wood said that on the retirement of Sir Thomas Hughes from the 
cUairmansliip of tho Welsh Board of Health, the position was 
reviewed, as was the case from time to time with all sections o 
the Ministry’ of Health. This review showed that' the bulk o 
the Board’s work was done satisfactorily by the mcmbci’S m 
their individual capacity, and meetings of tho Board for collcctivt: 
deliberation were rarely held. In these circumstances the Alinistor 
of Health felt that the employment of four higher officers on the 
Board was no longer jiistiliod, and Hint the vork conid he done 
by three. The ■Ministry’ of Health Act, 1919, empowered the 
Minister to appoint such officers as he thought fit to constitute a- 


jnxE ,30 , i 9 js] 


uniyehshtes And colleges. 


[ 


Tnr nrmflft 

5 I» LrCAL JflURVAL 


1131 


l)o;\r(l of hcaUIi in Wnics, ami 1 nmllior n|.,'ol,o,l nny miinboc 
nor laid donn that ti.rro rhonid bn nnv .■ha.nnan. Sn' C- 
KiM.ocu-CooKr. a«kcd if Kir Kinuficy Wood wns invaic hat 10 
abolition of this poH was rarMnjr imUp.natmn, and whothor tUn 
Mini'itor of Health would rreoivt' a di'putntion on (he Fuhjcci. 
Colonel WooPOOCK a<5kcd what savinj: would he rffeetod hy the 
abolition of this Sir KiNGM.rv Wood vuul ho believed there 

■would be a pavinp of about £1,6C0 n year. If nny indignation hnd 
arisen over the action of the Mini‘?lor of llenltli it was due to 
inisapprciicii'^ion. J'oplvinjx to Mr. Morri'^, Sir KiNCsi.rv \\oon 
f:aid the effect of the aholition of tho po<t wns not to placc thc 
Welsh nation under the jurhdiction of the Kiiplish Commissioners. 
The Wcisli Hoard liad met on an average only throe limes yearly. 
The Minister of Health believed Ibat Hie duties of the ofnee 
would be carried on clficicntly. 

On June 26lli Sir Kikusi.ky Wood stated ibat Ibo savinp realized 
by tho recent reoi^anization of the cslablishmcnt of tho Welsh 
Board of Health wns £1,628. 


Liq7!or {Difintcrr.^frd Ofrnrr.tAi/i a«f7 }fnnafinntJ}t) TiiU. 
Speaking on June 26tli, in the House of LoisN, on a motion 
for tho second reading of tlie Liquor (Disinten'sted Ownei<hip and 
Management) Bill, moved by Ixird Balfonr of Ihirlcdgh, Lord 
Dawsos of Pfnn said that llie principle of local option carried 
with it certain disadvantages, not to '•ay dnngns. The institu- 
tion of elections for this or that matter mn«t clirnprii elections in 
'the eyes of tlio people. ‘Kxperirneo in regnul to eli-rtions for 
boards of guardians and under Hie Srottisli Temperance Act 
showed that relatively small numbers of pi'oplo went to the polls. 
Evci’yonc interested in social reform rejoiced Hint they hml the 
valuablij experiment at Carlisle, but after twelve yenr«, with every 
advantage, it could not be said that Carlisle was an out'Jtanding 
succor*!. He could see no end to tliecf* ad hi>r bodice, Pcesibly 
tlicy would have the New Health Society asl:ing to have local 
option in the use of^ brown bread. J.egislation on drink had 
proved. that unless legislators carried Hie people wuli them they 
defeated their own objects. Education and sna'^ion bad done far 
morc^ than legislation to promote temperance in tins country. 
The improvement in temperance began long before tlie war, and 
the figures slmwod a steady improvement m that, reaped among 
^ the massc^ of the people. Kotliing was more striking than the 
rapid and progressive improvement in the temperance of the 
people. He w'ould give one set of figures which showed tlial in 
a largo fully licensed house in I/ondoii 75 per cent, of tlic people 
WHO sat there on one evening were consuming no alcohol at all. 
Inc only place where dninkcnncss seemed entrenclied was from 
lime to time behind the motor wheel. The statesmanlike course 
to pursue if they wanted to increase temperance wns to stndv 
worked for temperance, and further them 
possible. Among those causes was the growth of know- 
* ^^‘^tieation. The educational propaganda of the 
lifft ^ AnoHior cause was 

of recreation and games. Above cverj'- 
thl Tberc 

W .'“f S<>0<1 nlcoliol war, in it-, riglil place ami 

UD 1 ® drink too much, and tiiore was growing 

bad brrl ^ temperance which left little to lie desired. Tliore 
counfri' *^P*‘0'’cmcnt in the public houses in this 

In som#» nf "cnt, with the exception of the slums, 

nrovidpd' houses around London food and coffee were 

and tho* ”on-alcohohc drinks, with games and amuscmcnls, 
amount commission on Hie 

to proceed drink. Along such lines as these they ought 

67''^ol(?to“24.^“'^ reading of tlio bill was defeated by 


TIio „f""t7Atrr of Antmnh (Srollnor!) nil!. 

of AniS^t&onan'dt’???/ 'oxsidcred llio Slanglilc 

reactin',. Ti'io bill nil.?' ’ PH^sed it throudb report and thin 
eompuf-on- for fbe use of tlio liumano kilic 

andlLb? buLokof 1" Scotland of ealtle, calves, sheep 

and calves to lio kinell"!' '(i" “"’cn'in'cnt to allow young lamb 
CHARTca.r referred to "as defeated. Genera 

veterinirv omcer of Pai u “pcnnient, conducted by the cbie 
rcientists\f Edinbur^li''^'''rf'’’ attended by two independen 
from the Umo Xn W. '■ r ^ <lotcrmined ll.a 

bullet from tho canttvl ’’’ft'?'’ ?f f'*® ®bin was made by th 
”^oro than four-rif*^'c ^ instrument there elapsed n 

supervened \V,*i n Vif^ • r complete unconseionsnes 

reconds With tho T "“s thirty-three and onc-fift 

indent, o„Xp‘uVpXs,‘iSan‘;Xs''.' 
'X“'’^SS^X7TbJX'nyo{hcX1iZl 

■regarded tlio hill oil Scotland) said tlic Governmen 
tho United Kingdom of legi.slatioii applicable t 

Jfaclean, - Sir* 'W.” Jovksow"^*^" ^ 26tli. in reply to Mi 
13,871 experiments on aoirm'?"^n tliat in 1927 there ' wei 
anaesthetics. The Mter ’’ '‘'’aesthetics and 279,431 wittioi: 

t'ons and feeding exnerimlnre ^ CMicnmcnts were mostly inoculi 
procedure mpre severe tlrnn ifmo'i"'’- "* '}° opnralii 

anaesthetic. I.i 1927 ihoro' 'nociilatioii allowed witliout a 

’"S experiments ill X^Xtion ‘'I, registered for eoiiduc 

induct them; 7,647 -oTnA^rviV^^ persons were licensed t 

(that is, where*' 

Jhli^ation .to.kiil tho animn^l cxpenraciilcr is relieved from tl 
>*-tic). Of from.the-anae 


Trnitmvnt vi Tuht rculoux Pnadotit vx.~\i\ a reply, on .July 21st, 
to Sir Wilfred Sugdoii, Major Tuyo?.’ said treatment for pensioners 
RufTeriiig from tuucrculosis was fccurcd tlirougli Hie local IicalHi 
nulhorities, who normally made use of their ov.n sanatorium?, 
approved for the purpose by the Mini.stry of Health. This prac- 
tice ensured that local facililie.s were utilized to Hie full and was 
also consistent witli tho policy of treating pensioners, as far as 
possible, near their own homes. Cases of Hiis cla«s likely to bo 
suitable for, and to bcnetit from, ultimate residence in a village 
settlement after any coui'se of treatment required, would be in- 
creasingly few among pensioners whoso tuberculosis wns directly 
traceable to their war service, having regard to the stage of their 
rotnplaiiil, age, previous occupation, habits of life, and other 
factors. When such rases aroso treatment in a sanatorium 
attached to a village settlement might bo preferable to the normal 
arrangements of treatment in the sanatorium of the local health 
niiHiorily, and he wns prepared to continue to give reasonable 
facilities for Hio treatment of suitable eases. Tlierc were' excellent 
local sanaloriums in tho North of England, and the Ministry' of 
ilcalHi desired to make full use of them. 

Death af a Datliofjrftphf r from Cancer. — Dr. YEnJ.'or; Davtes, on 
June 25Hi, asked the Prime Minister wdicUicr, in view of the facts 
disclosed by the inquest held on June 19th at Deptford, on the 
i)ody of Arthur Augustus Parsons, radiographer at the Seamen's 
Hospital. Greenwich, for over twcnlj* vcai*s, and. for six years 
previously at Wcslminslcr Hospital, who died from .carcinoma 
contracted in the course of liis duty, ho would, consider recom- 
mending some appropriate method by wbich Hie State could show 
its appreciation of- such work for Hie public good. Mr. Baldwin' 
said that if Dr. Davies sent him full particulars of this ease he 
would look into it. 

Vetrot Tax. — The Houce of Commons, in Committee, on June 
25Hi, considered the petrol tax. Mr, Snowden moved to reduce the 
tax from 4d. to Id. This amendment was resisted by Mr. 
Churchill, and defeated by 237 voles to 115. 


111 Brief. 

On June 25lb Mr. Bahl\vin stated that it was not proposed to 
make atiy alteration in the status- of the Ministry of Pensions 
during tlic life of the present Parliament. 

The cITect of coal dust in causing clicst diseases among surface 
workers at collieries is being investigated. 


Stnilirrsitits nn& Colleges. 


UNIVERSITY OF OXFORD. • 

Jladcliffc Price, 1920. 

Tnn next award for tlic Uadcliffe Prize will be In tho year 1929. 
*riic tirize, of the value of £50, is awarded by the Master and 
Fellows of University College, Oxford, every second year for 
research in nny brancli of nieilical science compriKed under Hie 
following licads; human anatomy, physiology, phavmacologv, 
pathology, medicine, surgery, obstetrics, gynaecology, forens'ic 
medicine, hygiene. It is open to all graduates of the University of 
Oxford wlio have proccedpil, or are proceeding, to a medical degree 
in the University. Candidates must not have exceeded twelve 
veils from the date of passing the last examination for tho B.A. 
degree, and must not, at Hie date of application, be Fellows on the 
Foundation of Dr. Joliii Hadcliffc. Candidates must send in their 
memoirs to the Secretary of Faculties at the Uiiiversitv Registrv, 
Oxford, by December 1st, 1925, The award will bo made in March, 
1929. No memoir for wliicli any University Prize has already been 
awarded is admitted to competition for tho Uadcliffe Prize, and 
the prize wiiluotbeawarded more timuouce to the same candidate. 


UNIVERSITY OF CAMBRIDGE. 

At a congregation held on Jmie'lSth the degree of Doctor of 
Medicine was conferred on W. D. Keyworth, 

A coiigregiition for the conferment of degrees in medicine and 
surgery will be held on July 21st, at 2 p.m. *'■ 

Tlie A. R. Graham prize in medicine has been awarded to 
J. Metcalf. 

The foJlowing candidateshavebeen approved at the examinations 
indicated: 


THinn M.B.. B.Cma— (Part D Suraerv,Mid%vifcru,a''d Gvnaecdloav 
M, E. Albury, N. R. Barrett, H. F. Bateman, W. A. G. Bell, F. Bash* 
S. S. Chesser. E. Clayton-JonoB, G. C. Bewep, A. J. Dix Perkin! 
w T n. ^ Elkinglon, W. A. Elliston, P. H. Fox, 

Hodkinson. S. H. G. Hnmfrey, S. D 
A; Lankester,- Pr G.'Iievick. J. 0. f! 
"ly. A. A. Mites, .7. K. ilonro.. J. R 
Peacock, I/. S. Penrose, .7. B A. Reynolds, A. M. Rhyddsrch, A. M 
Roberts, W H. Scott-Easton, C. W. Shaw. H. J.' Simmons^ W. Hr 


Pathologv. atid Phannacoioov “ , Ashh^^K^' 

Barrett, D. H. Belfrage, W. .. jj. t! Cox 

W. J, G. Drake-Lee, J. StC- Elkiiibt,uii it,, vt. newer, T O GarlAnri* 
R. M. Gilchrist. F. H. Gillelt.7. C.’ Gordon. R. A. P Gmv L 7* 

Haxdon.J. H Hoppei*. M. C. Hounsfield. L. R. Janes. T E 

J, M. Dees. E. W. Dindcck. W. J. Lloyd. R, A. ijeCanci n t 
M flcMyn. W. E. Masliiler. A. A. Miles,- T. St. M Norris ’ M* -n* 
Nosworthy. B. E. M. -Pilcher. -7. G.O.-Poole, E. J. PyewsSfeh P n 
Recor on.A.M-.Rhyddercli F.A.Tliehai-^B a 


Stewart, H. H. Stewart. G: S. Btorrsl J- Rt-ETTo^erR^'H^'^ 

Women: A.'G. Clogg, C. P. Giles, E.'m. Hoskii^S! p! SaackS^^^”'' 


1132- Juke 30, 1928] 


MEDICAL NEWS. 


f Tn*Ilimf« 

L UKDiCiL JorftXU 


UNIVERSITY OF LONDON. 

Sir Gregory Foster has been elected Vice-Chancellor for 1928-29, 
iu succession to Sir 'William l3everidj»o. 

The degree of D.Sc. iu Anatomy has been conferred upon Miss 
I. C. Mann, and that of D.So. iu Physiology upon IMr. C. II. Dost. 

Dr. J. Fitwcett has been appointed the represeutiilivc of the 
University at the fourteenth annual conference of the National 
Association for the Prevention of Tuberculosis, to be bcltl iu 
Loudon iu October next. 

UNIVERSITY OF GLASGOW. 

A GRADUATION ceremony was held on June 20th, -when the 
following were among the degrees conferred : 

Hon. LL.D. — Professor G. W. Crile, F.R.C.S. (Cleveland, Ohio). 

M.D.— F- R. Startiu. 


QUEEN’S UNIVERSITY, BELFAST. 

The results of Queen’s University final examinations, held iu 
June, show an unusually liigh percentage of passes. For llio 
degree of M.D. seven candidates w’ere Biiccessful, representing 
75 per cent, of the total uumber of candidates; wliilo forty-live 
candidates were awarded the degrees of JI.B., B.Ch., B.A.O. — 
approximately 70 per cent, of those who sat for the examination. 
The following is a list of the successful students : 

M.D.— W. Black, ’♦j. S. Camnbell, iJ. 0. Davison. 71. Ilarrio. 

+W. F. T. M’Matb, R. A. Reynolds, L. Walker. 

H.B., B.Ch , B A-0. — *A. J. P. Alexander, IF F. Kano, W. Bapsolt. 
IIJ. H. Biggart, li J. A. D. Deeny I'Eiloon M‘C. Hill, 'iH. C. Lindsay. 
S. Anders-on, T. H. Baillio, Martha 13. Cantloy, F. W. II, Canghay, 
H. M‘B. ( hisholm, H. H. Collier, J. Do Largy, G. B W. Fisher. 
J. H. Getty, A. D. Glasgow, M. J. Gordon, s. K. V. Gordon, J. 
Gourlej', Margaret M. Hosoy. Mary E. Houston, T, 8, Hoy, D. .T. 
Hurrell, M, Ji ffers. Elizabeth H J. Kelly, .1. M. Kennedy. .T. 8. ICylo, 
A. E. Lavello, K. N. Lavelte, W. J. budlow, W. K. Lyster. C. B. 
M'Carthy, W. N. M’Cullougb. \V. H. M‘Ilrath, I^Iargt. M. MacNcUl, 
Jane E. M’Neill, W B. .Morton, Alice I. Muir, .7. Pitt, M. Rosseufield, 
W. J. Stewart, Nora E. Btoape, A M'O Wallace, F. L. Wynne. 

Gold modal. + With comniondation. 

J First-class honours. II Second class honours. 


SOCIETY OF APOTHECARIES OF LONDON. 

The following candidates have passed in the subjects liullcatcd : 
SuROERT.— K. J M. Graham, T. A. P, Proctor, A. F. Qnarmby, S. M. 
Rahman. W. Zlv. 

Medicine — P. C. Basu. H C. Cliflord.Rmith. S, M. Rahman. 

Forensic Medicine.— M. K. Bryce, A. F, Quarmhy. 

Midwteery — H, H, Jachson, C. P. Maddeu, H. Murkis. 

The diploma of tlie Society has been granted to ATcssrs. K. J. M. 
Graham and W. Ziv, 


®lj£ ^iriricts. 


INDIAN AIEDICAL SEEA^CE. 

Annual Dinner in London. 

The annual London dinner of the Indian Medical Service was 
held at the Trocadero Eestaurant on Juno 20th, wlicn Major- 
General Sir R. Havelock Charles, Bt., G.C.V.O., K.C.S. 1., 
was in the chair. The following is a list of the officers pre.seiil : 

Majoi'-GeneralK : I!. N. Deare, C.I.E., A. A. Gibb., K.H.P., G. F A 
Ilarris, CJS.I., R. W. S. Lyons, Sir R. C. JlacWnlt, C.I.E., J. B. SmitlL 
c.n., c.i.E. 

Colonels*. ,T. CTimmin, V.C., C.B., O.I.E., V.D., 11. M, Cruddas, C.M.G., 
O.B.E., C. M. Goedbody, C.I.E., D.S.O., T. A. Granevr, C.M.C., C. R. Al 
Green, J. A. Hamilton, C.M.G., H. Kcllock McKav, C.B., C.I.E., A. .7 


Connor, D.S.O., A. G. 

R. H. Elliot, G. H. Fro‘ 

E. C. Hodgson, D.S.O., 

S. P. James, Davenpor I 
• Hlacrae, O.B.E., J. Mast . 


51. Craw'ford, O.B.E., 
. C.I.E., E. C. Hopper, 
J. B. liunter, O.B.E., 
'.V, H. Leonard, T. 51. 
51iUer, F. O'Kincaly 


C. I.E., C.\.CV, .7 S O NeiJl, ILC., Sir Leonard Rogcis, C.I.E., F.R.S., 

E. R Rost, p.RE., S. Biownmg Smith, C.M.G., R. Steen, Aaliton Slrecl, 
U A. Sykes, D.S^., D. V. Sutherland, C.I.E., C. Thomson, G. Sloane 
Tliomson, W. H. Thoinhlll, E. L. Ward, C.D.E., D. P, Warhker A C 
Younan. ' , . . 

5Iajop : Norman Briggs, Sir T. J. Carey-Evans, 51.0., IT. S. Comiack, 
5I.C., A. Duncan, P. K. Gilroy, 5LC., N. H. Hume, 5L L. C Inine 
J. C. John, O.B.E., R. N. Kapadia, M.C., U. Rif^uv L\nn 1> S O v’ 
5lnhadcvan, N. B. 5Iehtn, R. V. 5Iorrison, 51. A. Nicholson. 5f J* Onirko 
M. A. Rahman,- J. Rodger, JI.O., E. CL A Smitli, fl. T«it CaUhvell’ M n F 

D. R. Thomas, G. Y. Thomson, F. R. Thornton, 5I.C. 

Captains: 51. P. Atkinson, D. P. Bhargava, J. E. Grav, A. C Ua\den 
Lieutenant : F. T. Harrington. 


COMMISSIONS IN THE R.A.M.C. 

The "War Office announces that a limited number of commis- 
sions in tlie Royal Army Medical Corps are being offered lo 
qualified practitioners under 28 years of age. There will be 
no entrance examination, but candidates will be required to 
present themselves in London for interview and medical 
examination. Applications should reach the "iVar Office not 
later than July 20th. In the .meanwhile, all information as 
to .conditions of service and emoluments may be obtained from 
the Under Secretary of State, \Yar Office (A.M.D.l) 
Whitehall, London, S.WM. ^ 


— Dektai. Officers R.N. 

on entry as dental officers R.H 
been awarded lo . Holgate, surgeon lieutenant (D). 




The FclIowHliip of Medicine anil rost-Grafluatc Medical 
As.socintion nnuounces tliat on Tuoselny, July Jrd, Mr. G. 
Perkins will f;lvo a donionstration at the Brockloy Hill 
Conutry Orthopaedic IIo.spitnl at 11.30 a.tn. If not less tlian 
ten posl-Kradiiato.s notify tlielr intention to bo present by 
telephone to Mayfair 2236. Demonstrations will be given at 
tlio Itoyal ■Westminster Opiitlialinic Hospital oa Thnrsdnj-, 
July 5tb, Rt 3 p.ni., by Mr. M. L. Hiiio, and at Charing Cross 
Hospital oil Friday, July 6tli, at 2 p.m., bj- Dr. I’. G. 
Chandler; tlioj’ are open freo to nienibors ot the ipedical 
l>rofossiou. Tliero will bo a special wlioie-day course at the 
I’rlnec ot Wales's Hospital in medicine, surgery, and tlie 
.spcolaltlos from July 9lh to 21st, and a eour.so in proctology 
from .Tilly 9lli to 14th at St. Marie’s Hospital. Later stnuiner 
cour.scs are ns follows: At the Qncen Mary’s Hospital in 
medicine, surgery, and tlio specialties from August 27tli to 
September 8tb ; in diseases of tlio cliest at llic Broinpton 
Hospital, July 30tb to August 4tli ; iu diseases ot infants at 
t lio Jiilniits Hospital, August 13tb to 25tli ; in urology at the 
All Saints’ Hospital, August 7tli to September 1st. Full 
parliciihirs, sylinbiiscs. etc., may bo lind from the Fellowship 
at 1, Wimpolo Street, W.l. 

'I’llE aiinnal meeting ot tlie Royal Medico-Psychological 
Association will bo held on July I'llli, 12tli, mid 13tli at the 
West Riding Mental Hospital, Wakellcid, under the presiilcncy 
of Professor J. Shaw Bolton, M.D. On the niternoon of the 
Hast day tbo president will give liis address cntitleil “The 
evolution ot n mental hospital — Wiikelield, 1818-1928,” and 
tbo Gnslcoll medal and prize for 1927 will be presented to 
Dr. Elizabeth Cassoii, and for 1928 to Dr. F. R. Martin. The 
m'oruitig and attonioon sessions of July 12th and 13th will he 
given up to papers and domonst rations. The general socictary 
is Dr. R. Worth, Springfield Mental Hospital, ur. Tooting, 
S.W.17. 

At a special meeting ot tho Royal Anthropological InstUiile, 
to bo bold at 52, Upper Bedford Place, Rnssell Square, M .L., 
at 8.15 p.m. on Tuesday, July 3rd, Dr. E. II. Hunt ■"'''' U"'® 
an address on the rock-liown lomplcs ot Ajauta and Ellora. 
On the afternoon of that day, from 2 o’clock, a seriM oi 
cxliibits illustrating the paper — photographs, iiiaps, etc. 
will bo on view at tbo instiliito. Among tliom will be pholo- 
graplis ot solf-mntilation coremonios and implements ot the 
Kalla fakirs ot Hyderabad. 

j\ COMFLETF. post-gradnato conrso iu dermatology and 
vouoroology will be bold at tlio clinic for cutaneous anti 
syphilitic diseases at Strasbourg from Septouibor 17tu to 
November 3rd. Tbero will also bo a laboratory course, 
including twenty loclnros and practical work. 'Tho fee lor 
each course is 300 francs. T'urtlicr Information inay be 
obtained from Professor D. M. Pautrier, 2, Quai St. Nicolas, 
Strasbourg. 

According to a report issued by tbo Health Organization 
ol tho League ot Nations, there has been a great decrease 
in the incidence ot small-pox iu European countries during 
recent years. Tlio only exception to this general rule is 
offered by Great Britain, where tlioro has been a 
increase in tbo uumbor of cases otllciallj’ reported since Is-U- 
InT927Fbero were 14,931 cases in Great Britain, as compareu 
with 6,841 in the rest ot Europe. The disease is coinnioa 
only' in a mild form, known as alastrim, but this mild fonn 
has been notably absent from Continental Europe, 
exception of Switzerland, whore between 1921 and 1926 it 
persisted in epidemic form. In 1927, however, no cases were 
reported in that country. Despite the largo number of cases 
iu Groat Britain, the mortality 1ms boeu very low, no deatus 
Jiaving occurred in Scotland between 1922 and 1927, and opiy 
49 deaths in 1927 in England and Wales. During tlie 
under review tlie disease was limited largely to the N°tth oi 
England and tbo Midlands. Ot 10,141 cases reported in 192b, 
10,070 were reported from Durham (6,645), Torksbire (liztuji 
Derbyshire (982), ■Nortbuinberland (843), Nottingbainsbiio 
(191), and Lancashire (139). During the winter of 1927-..b 
a wider BiHusion of infection occniTod ; 4,711 cases 

reported from 38 counties iu England and Wales in the ur.s 

quarter ot 1928, but the mortality has boon almost negligible. 
The report states that vaccination within ten years 
to give complete immunity to the disease. Thus in 19- - 

there was not a single case among children below 12 
years of age who bad been vaccinated in infancy, wbereas 
there were no fewer than 3,930 cases among children belou 
12 years of age who had never been vaMinated. 
part ot the report dealing with Russia .shows a reinarkao 
decrease in the number ot cases since tbo war. In lyi 
there were 186,755 cases, which gives a rate of 30 for every 
10,000 iuhabitanls ; in 1926 there were only 16,547, or l.i j 
every 10,000 iuliabitants ; in 1913 there were 4 cases t 



JUKn 30 ,*"l 92 S) 


r,ETTER3, NOTES, AND ANSWERS. 


t Mbmcai. Joca.tAfc 


every 10,000 inliabltants. No ease of Bina^H-Rox was roportoa 
In Bninarin, CzeclioslovaUIn, Doniunrk, Glljrattar, lluut'ary, 
LUlinanln, liiixoinbourfi, MaUa, or JRuuianIa la January or 
February ot this year. 

TUn aunnal National Conforcnco on jratornily and Infant; 
■WeltMQ will bo hold at tlio Guliaimll, London, on Jnly Stli 
and 6th. In addition to Sir Goorgo Nowman, Daino Janob 
Caiuphell, and other roprescutativos ot tho Ullnisti-j’ ot Health 
there will bo present Dr. Ilclon MacJfurchy, clilof ot tho 
Child Weltaro Division ot tho Canadian Dopartmout ot 
Health ; Sir Frodcclclt Trnhy Kind, director ot child wolfaro 
tor New Zo.aland; Dr. Janishyd Alunsill, chief ot the Public 
Health Dopaninout, Bombay: and Dr. Bnth youiij; ot tho 
All-Iudia IjoagHo tor Jlatormty and Child Welfare. Wo 
understand that so groat has been tho demand for tlolcots 
that all tho seats in tho council chamber ot tho Guildhall 
have been allotted. 

The Hampstead Garden Suburb, which, with other more 
or less similar schemes for the doliborato creation ot now 
social and communal units, has oxercisod a cousidornblo 
influence on tho ideas associated wllli town-planning, is now 
celebrating tho twenty-first anniversary ot its Inauguration 
with a week ot entertainments and other festivities. Tho 
Earl ot Ly tton portormed tho opening ccromony on J uno 23rd, 
when Sir Philip Cnnllflo-Llstor presided. 

The Austrian State Pablishliig OIIlco (Osterroiohlscho 
Staatsdrnckerei) Wlori I, Scilorst.atto 24, has published in 
the German language a roforonco book on Austrian spas, 
which is obtainable direct or through nliy bookseller. It 
contains tnneh intormatlon concerning tho various spas, tho 
corapositiou ot their mineral waters, and their thorapontical 
effects. Tho book has been compiled by well-known 
Austrian anthoritlos, snch as Professor Viktor Conrad, Dr. 
Karl Diem, Dr. Josef Knctt, Professor Hans Horst Moyer, 
and Dr. Siegfried Stoclmaycr. 

Cross Society in April ofilclally closed 
im lellot work for victims of tho Mississippi Valley floods, 
the largest task it has over undertaken, after a year ot 
strenuous ondeavonr. In all over 600,000 refugees camo 
under the society’s care, and practically nil tho relief land 
raised, amounting to about £3,400,000, has boon expended. 

M. Mas Hcber, a Judge ot the Permanent Court ot Inter- 
national Justice at the Hague, has boon elected to snocood 
tuo late M. Gustavo Ador ns presidcut ot tho International 
Red Cross Gommittoo. 

(Ibo Eight Hon. Neville Chamber- 
J Surrey County Sanatorium at 

^ 5 *day, Jnly 20tb, at 3.30 p.m. Tho sanatorium 
a designed to accommodate 300 patients and stall at 

a cost ot about £200,000. 

French Bopuhlic has coiifcrrcd tho 
Nnffnii Ibe Legion ot Honour on Professor G. H. P. 

I’rofesaor P. Eondopoloulos ot Athens, 
nom?n,» and La Grice Midicalc, has been 

rarv ^ Chevalier of tbo Legion ; and Dr. Trnc, Uono- 
hopn Montpellier Faculty of Medicine, has 

been nominated Commander. _ ’ 

I^ONSCOMBE, assistant medical offleer of 
Inner Temple”^ called to the Bar by the 

otSnrrpnn^^®/? “dvertisoment pages tbe Association 

scbolMshin applications for a surgical 

SeptemLr 30tb 17. Wimpole Street, W.l, by 

iiriim has^ip^n'? yP'nwo of tho Archiv fxir Verdaxmnrjsliranlc- 
' the occasin^n/^P^*“'^^®‘^ Professor 1. Boas, on 

volume or thp w*”® birthday. The sixty-eighth 

has been Tsyciiialric itnil Neuroioyic 

on his sKrieri, editor. Professor K. Bguhoefll-, 

paia bv ^ compliincuti Uas been 

Eric Xffmami ° Zcitsciiri/i to its editor. Professor 

Ihr(in„roTa“;r Avalny Jiir 

to Professor JT ''®®“ dedicated 

luent of Hip t ■ "ho medical depart- 

Eamoage. ' ' - attaining the 

ba?£;^,f of ?red!ca'^I Offleers ot Missiouai-y Societies 

InslTOc/ions for (the fourth) of its pamphlet. Health 

uqprni rnf the Tropics^ which conveys 

Women ^ there is a brief supplement for 

of tho as?ocUatio'lfV*’w^‘““l^'° ‘‘'® honorary secretary 
is-Por dozen (inIam^pJstfreeT 


'aSi’era ’'^tllett have been promoted 

uueis in the Order ot the Hosniml nf Rh k. 


E-nnshavebe^ppoItS,^^^^^^ William Owen 


WetfevSr MoteSr mth 

AH , commimic.sf ions in regard to editorial business should B* 
addressed to T/io EDITOR/ British Motllcal tiournal, British 
njeeflcal Ascoclat/on Houso, Tavlstoch Square, W.C.U 

ORIGINAL ARTICLES and LETTERS forwarded for publication 
arc understood to bo olTcrcd to tho Barrisn Medical Jonaaia 
alono unless tho contrary bo elated. Correspondents who wiih 
nolico to bo taken of their commnnications should autbentiexta 
them with their names, not necessarily for publication. 

Authors desiring REPRINTS of tlioir articles published in thf 
Barass McDiciL Jouesal roust communicate with the Financial 
Secretary and Business Manager, British Medical Association 
House. 'Tavistock Square, W.0.1, on receipt of proofs. 

All communications with refercnco to ADVERTISEMENTS, as well 
ns orders for copies of tlio Jocesal, should bo addressed to tha 
Financial Secretary and Business Manager. 

Tho TELEPHONE NUiyiBERS of tho British Medical Association 
and tho Bnmsn JIedical Joursal are MVSEVil SS6I, iSU2, SSC3, 
and OSC', (internal exchange, four lines). 

Tho TELEGRAPHIC ADDRESSES ato : 

EDITOR of tho British Medical Jourkal, Aitiology ircsfrcnf, 
Loadon. 

FINANCIAL SECRETARY. AND BUSINESS MANAGER 
(AdvcrLiscDicnts, etc.), Arficuinfe TTcsIcent, Lamloii. 

MEDIC.Uj secretary, Jfcdiiccra TTeslcciit, London. 

Tho address of tlio Irish Ofiico of the British Medical Association 
is 16, South Frederick Street, Dublin (telegrams r nacillus, 
Dublin; telephone : 62550 Dublin), and of tho Scottish OBicc, 
7, Drumslieugli Gardens, Edinbnrgh (telegrams : Associate, 
Edinburgh; telephone 24361 Edinbnrgh). 


QUERIES AND ANSWERS. 


INCOHE Tax. 

“ P. G. D.” bought a car in 1921 lor £596, and lias now replaced it 
by a sligUtly different typo ot car at a cost ot £295, less £17 
allowed for tbo old car. What claim can be make 7 
*,* For the ye.ar 1928-29 he ehonid claim the depreciation 
allowance on tho written-down valne neat December 31st, 1927, ol 
tbo old car— say, £220 at 15 per cent., £33. Tins wiR lielp to pave 
the way for tbo allowances to bo claimed for 1922-30, which will 
be (1) obsolescence allowance — tlint is, £295-£17— £33=£245, and 
(2) depreciation allowance, £295 at 15 per cent. — that is, £44. 

Gift of Car for Professional Use. ‘ 

" H. B. L.” bought a secoud-haud Hillman conpii in 1922 for £385. 
In 1927 be rooeived os a present a Hillman all-weatlier (1925) car 
ill exchange for tlie coupe. The value of tlie former when given 
was £170 and tlio latter was sold immediately for £60. The 
depreciation allowed on tho conpe has been; 1925-26 £42, 
1926-27 £35, and 1927-28 £30. Wliat shonld he claim as the 
depreciation nllowaucc for 1928-29 ? 

Apparently the last depreciation' allowance reduced the 
wrltteu-down valne to £170. On that basis the^ depreciation for 
1928-29 will bo as follows : 


Value of car brought forward 

Deduct Tealizatiou value of Car replaced 


Add valao of car acquired ... 
Allowance at 15 per cent. 


£170 

€0 


£110 

170 


£280 

£42 


Cash Receipts Basis, 

“ T. H. G." bought an additional practice ns from April 1st, 1927, 
ami took in a partner, who acquired one-tbird share in tho 
combined practices. Book debts were not taken over on either 
purchase. Past returns have been on the cash basis. Are the 
expenses iuenrred in connexion with the proprietorship changes 
nllownhle ? 

■*.* The cash basis is jnstified by convenience only, and is 
■ applicable only where tl-.e amoiiut received in the year is pro- 
bahly equal to tberafiic of the gross bookings. In the circtim- 
slances stated “ T. H. G." cannot require his “cash basis" 
returns to be accepted, and the accounts for 1927-28 should be 
based on the gross bookings for that year less a dednetion 
which shonld bo caretnllj- arrived at after n specific valuation of 
each outstanding debt, for probable losses by bad debts. Cash 
received tor pre-.VpiU, 1927, bookings is not liable to tax 
because ca hgpotkesi the tax on those e.aniings has already be*>n 
accounted for— on the basis of the assumption that the cash 
receipts represented the true earnings ot past years Tii 
expenses of purchase and formation of the partnership Ire nof 

aRowable; they are of a “ capital” nature. 



Asfistant hecomes a Partner. 

“ J. L.” was an assistant in tlie empioyinent of A and 1? nnlil 
January 1st, 1928, when ho hecamo a partner, talcin}; one-fonrtli 
share of tlie profits. On what basis shouiil his return lor 1928-29 
be made ? - 

*.• Tile change in status involves a radical change in Iho 
assessment. For 1928-29 ho is no longer assessable under 
Sclioiiulo E as an employee of the firm, but for the whole of that 
year uudeivSobodule Diu respect of profossioual prolits. Strictly 
it is the firm of A, 11, and J. jj. wliicli is hliargeable; bo is. not' 
individually .assessable. Consequently the new firm will rctiirn' 
and be assessed on the basis of the profits of the old linn lor 1927,' 
and one-quarter of that will be attributable to “ J. L.” and will; 
represent his gross liability. The firm gain, because “ J. L. ’a 
salary will have been deducted in calculating the profits for 1927, 
but it will uot bo assessable for 1928-29. 


the pnenmonia is evident. The case was that of a young man 
admitted to liospital tliirtccn hours after an nicer near the 
liyloric end of the stomach bad perforated. As it was high up in 
the portal fissure it was closed with dilliculty, omentum being 
required to seal it over; drains 'were inserted laterallv into 
lllorrlson’s and sniirapubic pouches on second day. Consoliilntiou 
of the left lower lobe appeared, wliile the riglit lower lobe was in 
a doubtful condition. A few hours after tlie first injection ol tlie 
vaccine tlie patient had talten a turn for the better, bis shin v -s 
moist, and lie expressed jiimsell as feeling much better, il i j 
could only get some sleep.' This was procured by a liypodermic 
injection of heroin; otiior two doses of tlie vaccine were given 
on Buccensivo. days. Tliercafter his recovery was rapid anil 
nnevcntful. Inquiry lora furtlier supply ol this vaccliio resnltecl 
in the inforniation lliat the. inahcrs (Messrs, rarlte, Davis anil 
Co.) Iiad discoiitiiined Its inamifacture ; llierc was sucli a small 
deinaiid for it that it did uot pay for the cost ol production. 
This is very uiilortnunto. 


‘ Status Epilupticus. 

“ H. C. B.’s ” inquiry regardiug the treatment of this condition 
in a child, published. ou June 23rd (p. 1097), stated, tlirongli an 
error in traiiseriptiou, that the violent (coiivnlsivel stage of 
the attaohs usually lasted two hours; this should have read 
“ tweuty-four hours.” 


LETTERS, NOTES. ETC. 

Lead Tueatmunt of Malionant Disease. 

Da. J. McNamaua (Kensington, W.) writes: May I appeal fora 
lair trial ol Professor iilair llclPs lend treatineiit of caiictr? 
That tieatmeiit is tlie result of over twenty vears' investigation 
and there is no getting over or explaining' away the statistics 
given by Professor Cunningliam in a paper read at tlie Notliii''- 
ham meeting of tlie Britisli Medical Association and publislicti 
in the British Medical'Jounial of Kovemtier 20tli. 1926. Iholcssor 
Cunuiiiglinm sliowed that ol 227 patients suffering from malig- 
nant growths between 30 aud 40 were cured by load. Soino 
time ago 1 board tliat tliero was to be e.xliibited at a medical 
meeting in a Loudon hospital a patient undergoing the lend 
treatment. Having a special interest in the treatmeiit, I went 
to see the patient before the mceiing aud learned all the detads 
At the meeting the patient was shown by a young man, who 
simply said, ” This is a patient undergoing the now lead troat- 
meut, aud all 1 cau say is tliat it lias done no harm and has done 
no good.” He never mentioned that the treatniont had oiilv 
just begun and that tlie (ireparatiou of lend used was differen't 
from tliat used by Profoaior Dlair Bell. Is this fair? Ideas 
originating outside Loudon do not seem at first to bo ncoop'tod 
with mneb enthusiasm in tlie metropolis. Witness the struggle 
of Listerism to get a footing In the capital. When Dr. Golov 
Ol the Cancer ilqspitnl of How 'i’orlt came over hero and 
published Ins claim ttint his fin d could cure at least 10 or 12 per 
cent, of otherwise liO|ioless cases of sarcoma a linlf-liearled trial 
was given to the treatment, but the Iluid used was made iii 
London and was uot Coley s Uuid at all 1 The lesult, of course 
was disaiqiointiug, and gave in ibis country a knooU-out blow to 
the treatment, from wliicli it has not yet recovered. Nevertlie- 
' less, Coley’s claim is, beyond all doubt, valid. A' near relation 
of my own suffering from round-celled sarcoma of the breast 
which recurred after operation, was saved bv it. In Sir Joiiatlian’ 
Hutchison’s polyclinic 1 saw two cases 'of largo iuoperablo 
sarcomas cured by Coley’s fluid.' Qir 'Victor Horsley once' said 
Bometbing atiout our being different from wlint we were 
foniierty. He said it used to take twenty years to get an idea 
into our heads and now it ouly takes ten, 

Mr. j. Hatieiison (Crouch End, N.8| writes: Iii-the British Medical 
Journal of June 23rd (p. 1C88) Professor Blair Bell says that 
I originally made my lead iodide iireparatiou ou bis iiistrnctioiis 
whe.n l was working for btm in Liverpool. This is iiot acciirato’ 
I first made my lead iodide preparation in May, 1920, more tliaii 
SIX months before I gave up all other work to go to LiveiV.oo 
to take sole'Chai-ge ofthe chemical work of hls'cancdr i-SK 
^ofessor Blair He I suggested to me tlie preparation of ^lead 
body, and I tried the iodide. This preparation was us'ed Su 
. patieuts at I, iverpool before 1 joined bis staff tliere • Since 
leaviug Liyerpool-With regret expressed iu writing -iiy^botli 
■ .parties to tlie separation— 1 have succeeded iu improviii- mv 
preparation. Su h success ns I have attained is largelv .bie ra 
the kindness of Dr. Drakeley, bead of tlie cliemical department 
Hortlieru Polyteobnio Institute, wlio put at my disposal all the 
resources oMiis department. He also gave me free access to bu 
owu private reageuts. “ 

- Pneumonia after Operation for Gastric and Duodenat. 

. IJlcicus. 

Mr, R. Chalmers, M.D., F.U.C.S.Ed. (Assistaiifc Surgeon Green 
Bank HospUal, .Darliugton), writes: In tlie British 'Uedteal 
Journal of June 23rd (p. 1055) Mr. Strong Heaney’s report o?i the 
results of operatJoii in a series of the above cases emnliasizes 
again the dreadful toll that chest complications, particiilaHv 
pnenmonia, takes of these cases, aud robs tlie surgeon of tho 
success his efforts and slciH deserve. I wish liere to record tht 
very successful, almost dramatic, results which followed inn. 
case of pneumonia after operat.ou for acute perforating nicer of 
* flpTT»n] V®® ^ vaccine made from Wiiiu’s 

loimula, aud giveu m the large doses lie recommeuds. as eoou as 


A SuroicaTa Poutrait Group. 

Dr. a. E. M^inter (11, Oakficld Koad, Clifton, writes: 

U'hirty years ago I had prepared for mo a photogravure from the 
picinfo of tlie* Council of tlie College of tinrgeons (J8S4) aud 
(liBtribiited fifty of the copies over the Hinpiro gratis. There arc 
n few still remaining, whicli cm be obtained from mo forscliools, 
nniycrsitics, or Institiites of medicine wltli Rtudents in the 
Knglm}ps)>eaking world, preferably those of Africa or America, 
' since tlie JCnipiro Ims already many. Tlie portraits iu the group 
iticludc Sir Spencer Wells (abdominal surgery), Bord Josepli 
Xiistcr (aseptics, antiscjUics), and \V. G. T. Wells, Boston, U.S-A. 

’ • (aimeslhclics), who roiiresent and 63 *mbolizc the advances made 
iu surgery during the Victorian era. 

Endocarditis in Young Children and Lambs. 

Dr. G. Ardour Sthpiiens (Swansea) writes: I desire to drav; the 
nttcuUoirof provincial members of tlie Asaociation ton condition 
of the heart fonml ni tnidcniuiirislicd lambs, in thcdiopc tliat 
some of them may test iny observations. In jarge flocks it n 
well known that many Iambs arc iiudcrnourislied because, at 
a lime when they are* unable to cat much gras-s, tliey cantiol 
obtain a proper BU))ply of milk from tbeir mothcre. 
c.xamining tlie hearts of sneb Iambs 1 have found Unit there is 
an inflammatory fringe on the edge of the mitral valve nudfj 

smaller one on the tricuspid, while the heart muscle is pnio ami 

sorter than normal. , nt 

Milk, ns a lime-containing food, is necessary for 
bones and the dcvclopmontof blood, and, if Ibo supply isrcduceu, 
both suffer. ’ Tho fact wliicli X have been trying to f 

imincly, that heart diseaijo occurs only in children who no nos 
got milk (while possessing a perverted appetite for acids sneu ns 
vinegar)— scorns to bo corroborated by my 
. connexion with lambs. In both cases tlio blood laoks 
iiounsbment, with the result tliat the iiiternclion 
leucocytes and the ondotbclinm of the blood vessels of the vni 
■ is BO interfered witli ns to give rise to an inflammatory cxiinaii^o 
•• there. To wliat extent the lowerml vitality of tlio Iambs unuei 
tiicso conditions must bo associated wiih a poison 
' nii Insect or an intestinal parasite I am not c'erlam, tnong 

Iain satisfled tliat such has undoubtedly a marked determu a 

influence in connexion with the development 
' This is made very evident by examination of badly uounsu- 

cbildreti who have been bitten by insects such as midges, uai'ea 

bugs, or even fleas, at tho end of the summer; many J . 
children are ill from tho biles and. oftcu show evidence e 
endocarditis soon alter. 

Vicarious Menstruation. 

Dr, S. Wand (Birmingham) writes : Dr, Chapman’s nota 
(Juno 25rd, p. 1065) regarding vicarious moustniation promiHS 
me'to menlioii a case I had some time ago. Tlio jmtieut.agu 
of 17, had frequent and fairly profuse haemorrhages from her 
respiratory tract. Tliey wore more marked at or about her 

periods. I had her examined by physicians, laryngologists, mm 

radiologists, but nothing was found. 1 tried a good many drug- 
•anil found that. calcium lactate and thyroid combined preveuteii 
the bnemorrliages for. a few mouths. Later (two years ago) she 
. became pregnant, and she has liad uo rccurreuco. 

Medical Golf. 

The, summer meeting of the Medical Golfing Society was held ou 
Juiie 19th at Walton Healtli. All competitors were again the 
guests of Lord Riddell. Tlio’ weather was One and the course m 
excellent condition. The results of the competitions were m 
follows: 

Laveet Challenge Cup. — T. A. Torrance, 3 up. 

Uemv Rlorrix Ohnlleng' Crijj. — T, A. Torrance, 11. T. P. Kolesar, 
H. Chappie. ■ * ■ 

Jiftlsom Bet “ 

Claxa l.—l Kolesar. tiod 

at 1 up. Be. , fagRcr, H. V. 

Gillies, tied at 2 up. 


Vacancies. 

Notifications of offices vacant in universities, me Beal colleges, 
and of vacant resident and other appointments at hospitals, will 
be found at pages 41, 42, 43, 46, 47, and 48 of our advertisement 
' columns, aud advertisements as to partnerships, assistantships, 
and locumtenencies at pages 44 and 45. 

A short summary of vacant posts notified in the advertisemenfi 
columns appears in the Supplement at page 2SS, 



S TJnPPLE MEN T 

TO THE 

BKITISH MEDICAL JOURNAL. 


LONDOJ^, SATUUDAY, JANUARY 7tu, 1928. 

CONTENTS. 


rAGE 

trbo British Medical Association nnd Colloctlvo 


Investigation. Past II 1 

CURRENT NOTES : 

The Nuusisg Homes (REOiSTnATiox) Act 2 

Civil Servasts and MEMSERSiiir or the H.M.A. 3 

The IIempson Prize 3 

SuBscRinioss roR 1928 3 

ASSOCIATION NOTICES 3 

MEETINGS OF BR.VNCIIES AND DIVISIONS 4 

ASSOCIATION INTELLIGENCE AND DIARY 8 


PACE 

NATIONAL INSURANCE : 

Tho Provision of Dental Benefit 5 

CORRE.SPONDENCE : 

OpiiTiiALMic Clinics foe Insured Persons 6 

WILLIAMS-FREEMAN PRESENTATION FUND 7 

NAVAL AND MILITARY APPOINTMENTS 7 

VACANCIES AND APPOINTMENTS 7 

DIARY OF SOCIETIES AND LECTURES 8 

POST-GRADUATE COURSES AND LECTURES 8 

BIRTHS, MARRIAGES, AND DEATHS ;. ' 8 


THE BRITISH MEDICAL ASSOCIATION AND COLLECTIVE INVESTIGATION. 


Part II.— A NEW VENTURE.* 

T\r' j* 1 ^* Roprosontativo Cotly of tho British 

iuedicnl Association npprovo<l at tho Edinburgh mooting 
n Bciicmo of - colleotivo investigation to bo carried out by 
Hio Association. Tho prcliminaiy work upon tbo scbonio 
ans done by a special subcommittco composed of repro- 
lentativcs of tbo Science Committoo nnd tho Insurance 
Acts Committoo. Under tho cliairniniisliip of Ur. 0. E. 

oiiglas^ Uns. subcommittco oxnniiiicd tho records of 
iiimlar investigations conducted by the A.ssociation in tbo 
pm, tlio nature of tlio growing demand for a fresh 
R mpt to find in tlio colleotivo cxpcricnco of tho profes- 
1 to questions which daily confront the 

rnnd * . i^souiccs available for tho 

uct of tho proposed inquiries. Tho general object in 
IT was found to bo identical with tliat sot boforo tho 
+ 1 ,^*^''*”..™ r committee appointed to consider 

nro 'l’'®®tion in 1880; the difficulties inherent in its pui-suit 
cssontially similar to those encouiitorod in tlio course 
£ ‘^^poriment then made; hut the resources available 
wtoT. 'll"” . '"“"ipArably greater than tliey wore 

far nr '°i membership of tho Association did not 

pivnr “|U00, and the Divisional machinery which to-day 
liaH means of access to tho individual member 

roani? f ii devised. Under the schomo adopted ns a 
twD P*'®l'minary survey it was decided to initiate 

varinncn'^^i*^**^ forthwith — ono into tho treatment of 
caEtrn-nnt And tho other into the aftor-offects of 

the fvirri: The scliemo ns finally elaborated has 

in a loff* AAPPort of the Minister of Health, expressed 

Novembornh.^igt?. Ts^fonowL”^ Association dated 

Dear Sir Robert PniLip, 

tion aflnr'^nr^*^u interest that tho British Medical Associa- 
te institute a rMi -with officers of my Department, is about 

problems of disease” “T^^'-'S'ltion into cert.iin highly important 
the co-oDoratinn nf ™ '“tention, as I understand it, is to secure 
and down the rr “ number of medical practitioners np 

and so u team work on an extensive 

®t experience ^I neeH^^L*''*m of many varying kinds 

promises to threw i; ’’“rdly say that this endeavour, which 
urgently for rolution^ disease that press 

t^iUbe^hrougrt'toT’suc^sS^.rsr”'^ 

Yours sincerely, 

N. CHAMBEELAIK. 


^ ^ AS. 

4tst, 1927,’ page Printed fa the Supplement for December 


Tho method of approach has boon carefully adjusted to 
tho particular problems chosen for inquiry. In tho case of 
varicose ulceration tho object is to obtain a general con- 
sensus of opinion as to tho most offectivo method of treat- 
ment. Every Division of the Association has been asked 
in tlio first instance to obtain the names of os many 
memhors as possible who will undertake to share in the 
investigation. Tho names of all those willing to co-operate 
will then bo communicated to tho Head Office by the 
honorary secretaries of the Divisions, and the remainder 
of tho work will bo done by tho individual, the records 
being passed to tho Hoad Office, where expert assistance 
will bo available for thoir collation and evaluation. A 
memorandum explaining the object and scope of the 
inquiry will ho sent to all those who show an interest in the 
Bubjcct, together with a set of questions to be .answered in 
respect of every case recorded, nnd a request for general 
observations nnd conclusions based oh individual experience 
in treatment of the condition. The memorandum and 
questions aro printed in full below. In the case of gastro- 
enterostomy the object is to obtain a sufficient number of 
reliable histories to establish the relative values of tho 
short-circuiting operations when ' performed for ulcerous, 
cancerous, or other conditions of the stomach or duodenum! 
In this problem the starting point is the surgeon’s record 
of the exact nature of the operative procedure undertaken, 
and accordingly the memorandum and questions have been 
issued in the first instance to the surgeons of every hospital 
of more than one hundred beds throughout the country. 
Where the after-history of tho cases has been followed 
up by ^ the surgeon himself, he or the surgical registrar 
authorized by him to record particulars of his casM will 
be ablo to complete the full record. Where this cannot be 
done an attempt will bo made to secure from tho practi- 
tioner into whose care each patient has passed the parti- 
culars of the after-history of the case. The inquiry is 
limited to cases operated upon during the period 1920-24 
inclusive. Tho memorandum and questions are printed in 
full below. ... V 

It is not intended to limit the inquiry to the cases 
returned by those to whom tho memorandum has, as a 
matter of practical convenience, been addressed in tho 
first instance, and it is hoped that any surgeon who' is 
willing to co-operate in the work wiir apply to the Head 
Office for the necessary forms without ddlay, whether 

p^rtffiulars. for 

[1224] 



2 Jan. 7, 1928] 


Tho Association and Colicotivo Investigation, 


r BVPTLEiOVT to tn 

LCnrrxiB vxstcxL Jotrutifc 


INQUIRY INTO 

THE TREATMENT OF VARICOSE ULCERATION. 

jMemohandum. 

Varicose ulceration is a common e.\perlcnce in mcclir.il 
practice, and every general practitioner is frequently called 
upon to treat it. It is accompanied by much pain and di.s- 
comfort,^ and is responsible for a l;u.’ge amount of disability, 
especially among women. Its treatment is tedious alike to 
practitioner and patient; the' results .sre often disappointing, 
and relapses are common. It is a disease mainly within. the 
province of the general practitioner, for it is he who scc.s 
the cases from beginning to end, aud it is with him that the 
provision of treatment rests. 

The treatment of varicose ulceration therefore appears to be 
peculiai'ly suitable for a collective investigation and record by 
general practitioners, and the collection and co-ordination of 
their experience would afford a valuable contribution to clinic.al 
knowledge. At present there are many methods and many 
claims. By a comparison of results it may reasonably be hoped 
that the most suecessful methods will be secured. 

It is to this end that tho accompanying qnc.stions have been 
arranged and are now submitted for your co-operation. Tho 
questions provide for the record of an individual ease, and 
any number of cases may be reijortcd. In addition, you .aro 
invited to record the conclusions that you have reached from 
your general experience of the treatment of varicose ulceration. 

Questions. 

1. Patient (name or sj-mbol). 

2. Sex. 

3. Age. 

4. Occupation (precise nature). 

5. Is patient insured under National Health Insurance Acts? 

6. Has ulceration caused inability to work? Givo approximaic 
period. 

7. xVt what age did ulceration first occur? 

8. Indicate on tho diagram on back page tho por-ition of I he 
ulcerated surface and its approximate size before trealnicnt 
commenced. 

9. Has the course of ulceration boon— (i) continuous, (ii) Iicaling 
with relapses? 

10. Suggested cause of ulcer. 

11. Wliat treatment gave tho best results in this cas-c?— namely : 
(i) Local— (ff) bandaging, strapping, etc.; (5) natuie .and strength 
of medieaments used, (ii) Intoiaial, (iii) Postural, (iv) Operative 
(give precise nature), (v) Treatment b.y injection. 

12. For what period, if any, was rest in bed with leg rai.sed 
adopted; or was treatment ambulatory throughout? 

13. By whom was tho ulcer usually dreased? 

14. If ulcer has at any time been completely healed, w-erc any 
measures adopted to pi-ovont it breaking down again? If so, what? 

15. Condition after (period of treatment), 

Genekal OaseaVATioss. 

(1) Please indicate from your experience what conclusions you 
have arrived at on (i) the preventive, (ii) tho curative treatment 
of varicose ulceration. 

(2) Have you^ found benefit result from administration- of calcium 
salts, or otlier iuteinal treatment? 

INQUIRY INTO 

THE AFTER-HISTORY OF GASTRO-ENTEROSTOJIY. 

IMEiroRANDtnir. 

It IS desirable to obtain infonnation as to the after-hislory 
of those wlKy have und^eirgonc’ the operation gastro’-enterostomy 
during the peidod 1920-24 inclusive, and many generaf pracCi^ 
tioners arc- doubtless in a. position io. supply Uiis" information. 
Surgeons regi'ct that in many instances they are unaware of Ifie 
history of patients after these- have left the hospital, and if 
reliable information of this order could be obtained it would 
serve to establish the relative value of the sliort-drcuitin*^ 
operations -when performed for ulcerous, cancerouS;^ or other 
conditions of the stomach or duodenum. * 

Tlie accompanying questions provide for an individual case 
and any number of cases may be reported’. * 

The questions are divided into two sections. Section A 
deals v-ith the operative and immediate post-operative history;: 
Section B with after-history — that is^ after the patient- has 
ceased to be an in-patient at the hospital. It is recognized 
that, generally speaking, Section A only of the form will be 
completed by or on behalf of the surgeon, however 

the surgeon is in possession of information relative to after- 
history, it is requested that he ivill also arrange- for the com- 
pletion of Section B of the form^ Wliere Section B is' not so 
completed it is desirable to obtain the name and address of the 
practitioner into whose care the patient passed after leaving 
ho-spital. The individual case ivill then be followed up by the 
Association through this practitioner. 


Questions. 

Siction A : Operative History^ 

1. Patient’s name and if possible address. 

. 2. Occupation. 

3. Sex. 

4. Age. 

• 5. Dale of operation. 

G. What type of operation v;a.s performed (r./?., gastro-cntcro* 
stoiny anterior or posterior)? 

7. Briefly, what condition was found (r.y,, site and size of ulcc? 
or gi'ovrth)? 

8. Reason why the operation was performed (r.i?*, for iclicf ot 
pain, bleeding, vomiting). 

9. What was the condition of patient after operation? 

10. Did a lest meal or an x-ray examination show any change? 
n. Name and address of practitioner into whose care patient 

nas'sed (if patient died in hospital please say so). {Tliix information 
#.t o/»/y desired to ciiuhlc the case to hv followed vp tcherc the 
surf/con is unable to supply information rdatirc to aftirdtistory. 
If the surprun is in posstssion of this inf urination, it is requested 
that he. icill also romphtc Hiciion Jl.) 

Section It: After-History. 

.12. Has the patient sufTered from pain or other discomfort after 
food? if so, give* particulars. 

13. Has patient sttfiered from diarrhoea or constipation? 

14. Is patient able to enjoy every kind of food? If not, wliat 
sort of. food is avoided? 

15. How long was it after operation before patient returned 
to work? 

16. Has patient been able to do full work «jncc tiieii? If not, 
what has prevented patient from working? 

17. Has patient gained or lost weight? 

18. Has there been a general improvement or impairment of 
health and well-being since operation? 

19. Mention any subsequent treatment found necessary. 

20. If case bas terminated fatally give: (o) dale of death, 
(6) cause of dcalb. 

Tho Medical Secretary will bo glad to answer any 
questions and givo full information in regard to both 
inquiries. All who are interested in cither subject are 
asked to- apply to him at tho Head Office of tho Association, 
Tavistock Square, W'.C.l, for tho ucccssoiy forms and 
iiist ructions. 


Hfiritislj iJtrtrirnl ^ssonirfion. 


CURRENT NOTES. 


Tho Nurslim Homes (Registration) Ret. 

The Nnvsiiip; Homes (Registration) Bill was veiul a tliird 
time in tlio House of Common,s and was agreed to without 
a division. .Vlniost at tho last niomoiit an ameudn’cnt was 
\rat down to exclude Christian Scioiiee homes from tho 
scope of the bill. The matter was brought before tho 
Council of the British Sledical Association as one of 
urgency, and it was unaurmouslj’ agreed to oppose tlia 
clause, even if such a step led to the wrecking of tlio 
measure. Steps were at onee taken to oppose the clause-, 
as it- was undoratood that if there was any objection to tho 
bill it would not come up for discussion, being a priyato 
member’s bill. A strong protest was sent to the Minister 
of Healtli personally, aud tho decision of the Council was 
made knoivn- to the medical members of Parliament. 
During the discussion on the bill tlio argument was 
adduced, by the Mfnistei- tliat if tliese homes c.ame within 
tho scope of the Bill they would be obliged to have trained 
nurses on their staffs and qualified doctors in attendance, 
a thing which in the circumstances was absurd ; and that 
the only alternatives were either to close them down-^an 
act which- would bo regarded as religions pereecntion — or to 
make ft plain that these institutions were not iiurs-fng: 
homes. On the understanding that the amendment wonld 
bo altered “ in. another place ” to provide that these 
institutions should he described as Christi.'ui Scieiico 
houses ” and not homes, the House agreed to the amend- 
ment, as it was thouglit that this designation would pre- 
vent persons going into them under tho impression that 
they were ordiiiai-y iinrsing- homes. A perusal of the debate 
(ropoi-ted under Medical Notes in Parliament in tho last 
two issues of the JounNAU) shows that several speakers 
were not altogether satisfied, and it' is manifest , from the 
report of the proceedings in the House- of Lords that, as is 





4 Jan. 7 , 1928] 


Meetings of Branches and Dlvlslona, 


r BxrrrLF.irKifT to tm 
Lrr.iTiBii iir-DiCAL JoPBm 


SuRRET Branch : Croydon Division. — A meeting of tlio Croydon 
Division will bo held at the Croydon General Hospital on Wednes- 
day, January 11th, when Dr. G. Lewin will privo a lantern 
demonstration on Bazin’s disease. Tlio meeting will bo preceded 
by tea at 4 p.m. 

West Somerset Branch. — A clinical meeting of tlio West Somerset 
Branch will bo held at tho Taunton and Somerset Hospital on 
Tuesday, January 24th, at 3.30 p.m. A paper open to discussion 
will bo read by Dr. W. H. Maidlow (Ilminslcr) entitled A to 5^. 
Subjects of interest to tho general practitioner.” Tea will bo served 
at 4.30 p.m. 

Yorkshire Branch : Dewsrury Division. — A meeting of Iho 
Dewsbury Division will bo held at tho Batley Hospital on Friday, 
January 13th. Mr. L. R. Braithwaito (Leeds) will read a paper 
on chronic pains in tho right iliac fossa. 


Yorkshire ■ Branch ; Wakefield, Pontefract, and Casti-efoRD 
Division. — A meeting of the Wakefield, Pontefract, and Castlcford 
Division will bo held at tho Great Bull Restaurant, Westgate. 
Wakefield, on Thursday, January 12th. Dr. G, B. Hillman will 
give a Iccturo on tho iusuranco practitioner and somo of his 
relationships. Supper {2s. 6d.), at 7.45 p.m., will precede tho 
lecture. 


iiti£tings of ?6ranclj£s anil iBilTtsions. 

Edinburgh Branch : Edinburgh and Leith Division. 


Metropolitan Counties Branch : Lewisham Division, 

A MEETING of tho Lcwisham Division was licld at tho Town Hall, 
Catford, on December 20tli, 1927, when Dr. W. E. Hallinan occu- 
pied tho chair. 

Dr. Rose Jordan, tuberculosis ofilccr for Lewisham, read a paper 
on the dilTcrcntial diagnosis of pulmonary tuberculosis. She said 
that in LewLsham, w’ith its area of 7,015 acres and population of 
187,800, tlio death ralo was 10, and tho dcatlis from tuhcrculosii 
in 1920 numbered 162, of which 135 were due to tuberculosis of the 
lungs. She showed charts illustrating tho steady fall of tlio tuber- 
culous dentil rate in this borough and in tho county generally. 
Important diagnostic points were the personal and family history 
anu tho general appearance. In tho physical examination tho 
patient should bo stripped to tho waist and palpation performed 
with tho Hat hand. During auscultation the patient must hrealho 
through tho mouth. Children were much more dirficult to diagnoeo 
lliaii nduUs, and it was hard to detect tuberculosis when the chest 
was full of adventitious sounds, ns in bronchia! asthma. Tho 
bronchitic chest was usually symmetrical, * and in cardiac cases 
eotinds were heard at the bases. Bleeding seldom came from tho 
throat and was then always amall in amount. Young adults with 
hacmorrlmgo often did very well, aince they had few other 
symptoms. 

Dr. E. OfTNnriM described Verne’s test, ns applied to the dia- 
gnosis of tuberciiIo*;is, and said that there wero three known 
fallacies — namely, the presence of early chancre, advanced cancerous 
cachexia, and ncuto lobar pneumonia. 

Drs. F. H. Evans, G. Jones, Beattie, and Hallinan joined m 
tho discussion^ and a vote of thanks was passed to tho lecturer. 


Reception to New Graduates, 

A reception was given by tho Edinburgh and Leith Division on 
Deccmberl5th,1927, to medical studcntswno had recently gradii.alcd, 
and Mr. David Lees delivered an address on medical ethics. After 
referring to the great traditions of the Edinburgh Scliool of 
Medicine, ho compared them with tho historic rules of conduct 
associated with the name of Hippocrates. Mr. Lees then dealt 
with the ethics of medicine, with special reference to tho conduct 
of general practice. He said that ethics defined wliat a man ought 
to do and be; its rules were based on a threefold conception of 
duty— namely, to |iatients, to colleagues, and to tho laws of tho 
State. Daily association with patients required the possession of 
a sense of duty, conduct, and character which included a dccisivo 
mind, self-control, and consideration for the views and opinions of 
others. Professional rivalrv should bo encouraged, being always 
in the interests of individuals and of medicine; professional jealousy, 
on tho other hand, brought medical practice into contempt. Mr. 
Lees then gave an indication of tho course to be adoptca in tho 
matter of transference of patients from one doctor to another. 
Ho referred to his recent visit to India, and commented on tho 
prevailing lack of any ethical codo among many of tho graduates 
of tho younger universities in tho East. Ho believed that this 
resulted in harm to the profession and to patients, and detracted 
from the respect which should bo accorded to a medical practi* 
tioner. Mr. Lees referred briefly to tho work of tho Cfcncral 
Medical Council, and urged tho members of his audienco to make 
themselves familiar with all their statutory obligations. 


Lancashtre and Cheshire Branch j Rochdale Division. 

A MEETING of tho Rochdale Division was held at tho I^ccuit), 
Rochdale, on December 14th, 1927, when Dr, E. H. Cox, D.S.O., 
the chairman, presided. 

A resolution of condolence with the widow of tho lato Dr, Jamcj 
M^vin, sen., was passed, all the members standing in silence. 

Dr. L. Kilroe was elected secretary in place of the late Dr. 
James Melvin, sen. 

Dougal, lecturer in obstetrics and gynaecology al 
the University of Manchester, read a paper on “'Haemorrhage 
about tho menopause : its investigation and treatment.” TJi< 
address was followed with great interest by the meeting, and 
after discussion. Dr. Dougal was heartily thanked for his lecture. 


^Ietropolitan Counties Branch s City Division 
Annual Dinner, 


The annual dinner of tho City Division was held at the Trocadero 
Restaurant on December 1st, 1927, when Dr. Philip Hamill was in 
the chair. Among the guests of the Division were Dr. W. Lanedon 
Brown, Professor Hugh Maclean, Dr. N. G. Horner (the Assistant 
Editor of the British Medical Journal), Dr. Anthony Foiling 
Dr. R. Bronte, Mr. Capps, and Dr. Lucey. An excellent dinner 
was enjoyed by tho eighty members and guests present, and tho 
latter part of the evening was pleasantly passed enjoying tho 
toasts and musical entertainment. ^ 

The toast of “ Tho British Medical Association ” was admirably 
proposed by Professor Hugh Maclean, and replied to neatly and 
shortly by Dr. Horner. Dr. Kendal proposed the toast of ** Tlio 
Guests,'* which was replied to by Dr. Langdon Brown. Tho toast 
of “ Tho Chairman ** was proposed by Dr. Harold Latham and 
acknowledged by Dr. Hamill, and many compliments were paid to 
tho honorary secretary. Dr. W. E. A. Worley, for his services to 
tho Division. 


The ^ musical entertainment was provided by Mrs. Westerma 
the wife of a past chairman, and Mr. Sterndalo Bennett w 
gave sketches at the piano. The Division owes a deep debt 
^atitudo to Mrs. Westerman for her kindness in enabling t 
tonccr°tl^ EiDEing of a character not obtainable at smW 


Metropolitan Counties Branch : Willesden Division. 

A MEETiTfO of the Willesden Division was held at the Willesden 
General Hospital on December 21st, 1927, when Dr. N. R. Beattie, 
assistant medical officer of health for Willesden, read a paper on 
public education in health. ^ ^ 

Dr. Beattie alluded to tho favourable statistics of puerperal 
morbidity in the Willesden area in the previous year, and he notw 
this ns a striking proof of tlic value to the community of the 
health services. Ho pleaded for tho greater co-ordination and 
centralization of llic many official and unofficial health services now 
oncraling. Ho envisaged all medical services tinder the control of 
tho Slate ns tho ideal towards which tho present services wero 
inevitably, if slowly, evolving. Dr. Beattie criticized the prwent 
teaching of hygiene in tho medical schools in view of tho clentcDlarT 
character of the inslrnclion and tho uninspired manner 
this branch of medicine was presented to tho student. BeaUie 
ofTcred several suggestions for educating tho lay pnhhc, ino 
teaching of hygiene in schools should be given a prominent place 
in tho curriculum, and should bo efficient: the present practice was 
negative in both these respects. Secondly, the Churches should uo 
explored regarding the popsibilily of their facilitating tho propaga- 
tion of knowledge of hygiene : co-operation between the priest and 
tho doctor in a pint effort for tho dissemination of this knowledge 
was very desirable. Tho utilization of tho press for the same pur- 
pose, if intelligent and on organized lines, could become a most 
effective channel for instilling into tho public mind tho laws of 
health. .... . 1 • 

A very interesting discussion followed the rending of this paper, 
and many of tho obstacles to be overcome in forwarding a sdicmo 
of health education were considered. Dr. Beattie was accorded a 
licarty vole of thanks, and the question was referred to the 
Executive Committee. , , 

Dr. W. Lock presented the report of tho Dinner Committee, and 
was warmly thanked for making the arrangements for a very 
successful evening. 


South Wales and Monmouthshire Branch : Cardiff Division. 

A meeting of tho Cardiff Division was held on December 15th, 1927, 
when Professor W. E. Dixon, M.D., F.R.S., Reader in Pharmaco- 
logy in tho University of Cambridge, delivered a British Medical 
Association Lecture on the trend of thought in modern therapy, 
wliicli was attended by about a hundred members of the Division. 
Professor Dixon was in his very best form, and spoke for fully ao 
hour and a quarter. He dealt with many aspects of modern therapy, 
and the lecture was thoroughly enjoyed and much appreciated 
by tho audience. At its conclusion Professor Dixon was enter- 
tained by the Division to supper at the Park Hotel. 


Ulster Branch : Fermanagh Division. 

As already briefly reported in our issue of December 24th, 1927 
(p. 1203), Dr. Leonard Kidd invited, on December 15th, the 
medical profession ith Donegal to dinner in 

Enniskillen for the the Fermanagh Division 

of tho British Med ■ , »f meeting Dr. Hennessy 

(tho Irish Medical Secretary). A large and representative company 
was present and enjoyed Dr. Kidd’s hospitality. The toasts of 
“ The King “ and “ The British Medical Association ” having been 
duly honoured, Dr. Hennessy gave a very interesting and instructive 
account of the working of the British Medical Association and tlio 
great part it played in the medico-political, scientific, and cconqniio 
life of the profession. They were all aware of the benefits derived 
from membership of such a powerful Association, and it was 
unnecessary for him to dwell unduly upon this point. He instanced 
tho financial improvement in tho salaries of many medical men 
brought about through the instrumentality of the British Medical 




JAN. 7, M28l 


Provision of Denial Bonofit, 


r BXJTPLEiTVl^T TO TOB 
LnniTisii Mkdicxl Jonns'ii. 


B 


Association. Tl.o Bamsit MroicAi, JouRNAt., which inctnhors receive.} 
weekly, was one of the leading medical jo.irnals of the world, and 
would always keep members abreast of current clinical, ecicntifio, 
and medico-political thought. He was delighted to have availed 
himself of Ur. Kidd's hospitaliU- and o ho amongst them n 
Fermanagh that evening. Ur. Kidd and ho had been very o d 
friends-their common dcsiro (though perhaps .liffering slightly 
in their methods) had always been tho promotion of tho best 
interests of the profession. Ho sincerely hoped that tho Division 
would bo established on a sure footing m county I crmanagh, and 
ho wished Dr. Kidd and his fellow workers every success m their 
undertaking. 

The following officers were then elected : 

Chairman, Dr. L. Kidd. rfcc-Chafrman, Dr. T. C. Tevylor. Secretary. 
Treasurer, Dr. J. Itaguire. 


Dr. Kidd eubscqucntly referred to tho report of tho Poor Law 
Commission (Northern Ireland). Ho deplored tho fact that thcro 
was no mention of a Minister of Health, and criticired various other 
defects in the report. -He drew attention also to the form of medical 
certificate required by eick jurors at present in Northern Ireland— 
whereon tho precise cause of the illness had to he staled. Dr. Kidd 
thought that tho form should bo altered, and advised their repre- 
sentative to bring up tho matter at the Branch Council. 

Dr. T. A. Smyth said that the educational commitlcoa (regional) 
now required medical certificates for children when absent from 
school through illness. In tho ease of dispensary patients and thoso 
unable to pay, tho committee had made no attempt to pay for 
medical ccrtiucatcs. Dr. Smvlh had invariably refused ccrtihcatcs 
in these cases, and would Btill continue to refuse them (unless tho 
committee made some^ arrangement with llic doctors about pay- 
ment). This was an important matter, and should bo raiscu in 
the proper quarter. 

Hearty votes of thanks. were accorded Dr. ITcnnc^^sy for his 
interesting address, and to Dr, Kidd for his kindness and hospi- 
tality. Tho general consensus of opinion was that this had been 
one of the most enjoyable and profilablo evenings ever spent by 
the profession in Fermanagh. 


ilirtionttl Hlnsurnnci;. 

THE PROVISION OF DENTAL BENEFIT. 

Tihue can bo littlo doubt that if Parliaraont wero now 
^ablishing tho national licaltli insurance system with 
tho advantage of present c.\-porienco, tho position of dental 
benefit and of what aro now called additional trcatinent 
benefits would bo fundamentally altered. Thcro can bo 
no justification in any national health scheme for making 
on a treatment and certain forms of special medical treat- 
ment available only for some, and not for nil, insured 
persons, irrespective of their needs and of tho fact th.at 
a alike pay the same insurance premium. Thcro is really 
0 excuse for tho continuance of this state of things when 
•'"s .'men disclosed ns tho result of tho 
rr,nrr 'plnatlonsj and tho only explanations aro tho 
f inertia of Parliament and tho obstinate 
nf "* ' societies have clung to tlio whole 

lunds and refused a partial national 
on Id.5i refusal which, it seems, cannot bo upset 

tion n* ‘^•an have not the slightest justifica- 

is tbr." ^"7- ground whatever. So manifestly unjust 
of that tho continued obstinacy 

^'=e'nning to undormino their whole 
that smnir opinion; and tho superior foresight of 

been f “inority of approved society officials who have 

rton,ir“,"?n ° Partial pooling of funds 

^Oium nded by tbo Royal Commission for these purposes 

Thm.nl 1^7 ^<='7 long. 

^^ailabiHt in their paii-ial and haphazard 

tenefit-? i^enefit and tho additional treatment 

sdminKt 'r ^ another as to their provision and 

Ihewliotn m defined as “ the payment of 

Ihe addif; dental treatment,” and 

Echemos rcatment benefits are described in sanctioned 

” cprtn: P^jment of the whole or part of the cost 

services t'^ treatment or ancillary 

Societies ^ ° similarity of definition, approved 

O'^miiiistraf ! provision and 

**olil to bn medical treatment, as this is 

administ 1 of medical benefit,” and there- 
oot by annrn ° Insurance Committees and 

s separate e 7*^ societies; where.as dental benefit being in 
ategory in the schedule of additional benefits, 


tho provision and administration of dental treatment may 
legally bo undertaken by ajiprovcd societies themselves; 
This distinction hetweon tho provision of tho cost of some 
fonns of niedicnl treatment and tho provision of tho treat- 
ment itself is obviously very thin, and it is more than likely 
that if the profession had been in a position boldly to 
chalicngo this departmental distinction at tho outset in tho 
law courts, and to carry tho case to tho House of Lords,; 
tho result would have justifiod the action. It is a question 
whether it is now too lato to make such an action woi-th 
while. 

As things are, however, tho dental profession is in a 
difforent position from tho medical profession in relation 
to tho approved societies. In tho latter case, direct 
negotiations with regard to terms and conditions of servico 
have always been refused; in tho former case such negotia^ 
tions were cloai-ly a necessity if thcro were to ho any 
degreo of uniformity of bonoCt or collcctivo influenco on 
tho part of dentists. Such negotiations took place last 
year under tho auspices of tho Ministry of Health and 
tho Scottish Board of Health by moans of a joint committee 
composed of fourteen dental representatives and a like 
number of representatives of tho societies. Fortunately 
for tho dentists, certain principles and precedents have 
been established by tlio Medical Benefit Regulations, which 
it was agreed to follow; some important points had thus 
been safeguarded by tho previous action of tho medical 
profession. Tho result of tho work of tho joint committee 
is a schomo which, though not binding upon any particular 
approved society, and always limited by the amount of 
money disposable in any year for tho purpose of dental 
benefit, has been accepted by societies covering about 
95 per cent, of tho insured persons concerned. Particulars 
as to what exactly is included under the term “ dental 
treatment,” ns to tho procedure to be followed when such 
treatment is claimed, and as to tho terms and conditions 
of servico of dentists in connexion therewith, have been 
communicated to approved societies and to dentists from 
time to time by means of circulars and professional 
journals, and certain aspects of the scheme were com- 
mented upon in our columns (Sutplement, October 9th, 
1926, p. 161) some months ago. There is still, however, 
a good deal of ignorance or doubt in connexion with the 
scheme, and tho joint committee lias just issued a “ Dental 
Benefit Handbook ” (His Majestj’’s Stationery Office, prico 
3d.), setting out in convenient form such details .and 
explanations as seem necessaiy, and giving, in addition, 
a summary of tbo principal decisions of .the interpretation 
committee and certain selected decisions of the investiga- 
tion committee, such committees being in tho nature of 
courts of appeal. 

Tho medical profession is no party to these negotiations 
or arrangements in any sense whatever. Its interest in 
them is indirect, and may bo said to be of a threefold 
character. First, practitioners may wish to know sufficient 
of tho scheme to help their patients to obtain any dental 
treatment to which they are entitled. Secondly, the pro- 
visions with regard to anaesthetics in connexion with dental 
benefit may have some bearing on medical fees for the 
administration of such anaesthetics. Thirdly, it is possible 
that certain features of tho scheme should be noted, as 
warnings or otherwise, when any extensions of the insur- 
ance medical service come to be discussed in more detail. 

Not all societies provide dental benefit. Ev'en when a 
society does provide it a member does not normally 
become entitled to such benefit till the beginning of 
January in tho fifth year after that in which he last 
joined the society. The only obligation of an insurance 
practitioner is that, if he has advised his patient to obtain 
dental ti-eatment, if the patient’s society has notified tho 
practitioner that the patient is entitled to such treatment 
and if the patient is already under certification, he must' 



jAsr. 7, 19281 


WHIfams-Frceman Proaontatfon Funcfs 


r BUPrLnMEiTT to nm • ^ 

LBRITIHII MCDICIZ. /oOBKlt. " 


tlm cdncAtion audio- 
certalir Iinurri ra 


iiri'mises and apparatus are ’“f 

lilies and tho diddren cart be dealt with 
he I rnip. To compare flie two is to suggest that the aocictiea 
shall set up clinics and work on (lie same system, winch would 

Iw disastrous. . , . . . . . 

We have pot to get our living and to protMt our profession 
from being exploited. Doe.s the writw of tho letter consider 
the fees suggested as suitable for clinic work to bc at all 
satisfactorv? I think they are an insult. The rmiilt of starting 
clinics wifi bo to lower the whole status of ophthalmic work. 
How futile it is to suggest tlrnl the menibcrs should pay tho 
difference between the clinic fee and that of an oplitlialnnc 
surgeon if they want the latter! At the present d.ay working 
men are out to get everything for little or nothing. How many 
will p.ay the extra fee? 

Then, in the last paragraph, tho writex states : " At present 
those who do not like the clinic scheme need not undertake 
the work.” This is to E.ay that if a clinic is established in the 
town where I reside I am to lose all my ophthalmic work if 
I do not join the clinic. That is a nice brotherly position 
to t.ako up, is it not? If the clinic .system is adopted the 
societies will obtain control, put in the medical man who is 
willing to do the work at the clicaix’st rate, and the rest can 
go to the devil ! 

If hosp'tal ophthalmic surgeons arc so foolish as to do work 
for nothing, for which they would he paid if they went about 
it in tho right w.sy, it is only another examfile of the lack 
of business aptitude of medical men. Every hospital o[ilithalmic 
surgeon sliould pul his fool down and say, " I will not tre.st 
members of societies at Uic hospital. ’’ If thej- do not do this 
they arc acting unfairly to themselves and to otlicr colleagues 
who depend partly on ophtliahnic work for .a living. 

I trust that clinics will not lie eslahlishod. It is by far the 
best plan to stick to the guinea fee and see tlie patients at 
our own rooms, making a modificil charge for simple cases, such 
as presbyopia, or letting them go at their own risk to an 
optician. 

I am afraid the Ophthalmic Committee of the British Medical 
Association has too many oplilhalmic snrgeoiis as members to 
the exclusion of those who are familial- with panel work and 
know the conditfons of general practice in connexion with tlic 
panel. There are many men who have taltcn tip refraction 
work as a sideline; these slionld be roiircsented. — I am, etc.. 
Hasting., Dee. 27tli, 1927. ARTUVn E. LaukINC. 

^nLLLOIS-FREEJIAN PRESEXTATIOX EUXD. 
Tire following is tho fonrtli list of subscri ptions received 
response to tlio letter published in our columns of 

October 1st, IhS? (p. 139): 

Amoimt prcTioosly acknowledged 

Cor’i'nitlrc Co,t!rihulwn.i. 

Midlothian Panel Conmiiltee i," 

Li'iic^^lU™''i'rT‘^ii^^* Medical and Panel Committee 
Herifn,! m Panel Committee 

^'5 Medical and Panel Committee 

Middlesex Panel Committee 

Ureicnn- 

dauiiiauir^nsuranee Practitioners' 

Dr O Contri&iit/ons. 

D^ ToS Torrington, Devon 

Dr a B ttmllington, Devon 

Dre To™ 

Drs'. Devon 

Devo? ’ *^‘bus, and Shaw. Barnstaple, 

^ Luckh'ani, Saiisbu^ 

Drs. Langran and*Crnct?'''.F'^A'’' Molswortliy, Devon 

d" |-bes,'‘sheS^eTf - 

■ ■ 

twining and Moore, Salcombo. Devon i'.'. 

W'eques sl.mil 1 (morning) £1,661 18 6 
^‘■Rortation^iimT^ “ado payable to the Williams-Freeman 
Treasurer c/o thn'^M ^o Dr. D. G. Greenfield, 

Asneiatirm Bi-ftish Secretary, Bntisli Medical 

®V>aro, Smlo? W.Ca ^^"b^btion House, Tavistock 


£ s. cl. 

1,267 17 6 


29 9 
25 10 
2 2 
33 2 
5 5 
10 10 
43 8 
8 18 
3 0 
5 5 
15 14 
20 0 
24 0 
61 10 
75 18 


10 
2 2 


i^nlittl nn& iHiIttar)i ^ppoitttntcnls. 

nOYAn XAYAL .MEDICAL SERVICE. 

Surgeon Llcutcnmit CumttianiJcr.H F. (J. Hunt to the Tamar for ITong- 
Kong Doctyari; 1*. H. Vey to the f’lWory for Porttrnouth Dockyard r 
0» T. Ilyntt to th<» rir/ef. 

Surgeon Lieutenants I). Duncan to tho IVrnnn ; J. IT. Nirolson- to tho 
7’iy**r# toiu|ioniTy, niu! to the Cormcall on cornmistnoning witli full coniplc- 
moiit ; S. U. WjUIon to the Mecto, temporary. 


14 2 er 


ROYAL ARMY MFJDIC^VL CORPS. 

CoIonoH Ci. M. Colflfiiuith, C.B.E.^ and 11. D. Packer, C.I.E., lato 
ILA.M.C., retire on rcthed pay. 

Colonel R. If. LIo3d, Into R.A.M.C., Is placed on half pay under tho 
provhion.H of .Articles 139 ami <86, Rovnl Warrant for Pay and Promotion, 
i3:!6. 

Lientonant-Colonels from R.A.3I.C. to be Colonels: E. McDonnell, D.S.O^ 
vice Colonel tJ. M. UoldKinllh, C.H.E., to retired nay; Rrevet Colonel A. IL 
SnfTort!, vice (Lionel U. )T. Llovd to half pav; Brevet Colonrl J. W. West, 
C.M.O.. K.ILS., vice Cf.InncI iL D. Packer. O.I.E., to retiretl pay. 

Lleut.-Cotonet A. Mc.Munn, O.R.E., having attained the age fixed for 
compubory retirement, retires ort retired pa3'. 

Majors fo Ih; Llcuteimnt-ColnncU ; K.. Low, D.S.O., O.B.E., vice Licut.- 
Colonel E. McDonnell, D..S.O., promoted; A. N. Fraser, I>.S.O., vico 
Llont.»Cofone1 mid Brevet Colonel A. U, Soflord, promoteil ; R.. U. L. 
Conlner, vice Lioul.-Colonel ami Brevet Colonel J. \Y. West, C.3I.G., 
K.ILS., promoted. 

Captain O. T. Gimlctte to ho ^fajor (prov.). 

Tcmporar3* Lieutenant O. A. Owen-FIood (Lieutenant, Regular Array 
Reserve of Ofilcers, Royal Irish Fusiliers) relinquishes Iiis temporary 
commission. 

ROYAL ATR FORCE SfEDICAL SERVICE. 

The promotion of the following officers is annonneed in the Supplement 
to the Loiuion (inzrttc of Jonuar3' 2nd^ containing the list of New Year 
Honours, etc. Wing Comm.ander E. C. Cle.mcnts, O.B.E., to be Group 
Captain : Flight Lieutenant (Acting Squadron LeaiTcr) J, ?». SlacDonald 
to W Honorary IVhig Commander, 

Flight Lieutenants 0. J. Griffiths to R.A.F. Station, Bicester; D. B. Smith 
to Station Hcadquaitcrs and Storage Section, Andover. 


INDIAN- jrEDICAL SERVICE. 

The services of Lieut. -Colonel G. W. >rnconnchic have been placed at tlio 
di«i>o‘*al of the Government of Bihar and Orissa, for employment as 
Officiating Inspeelor-Goncral of Prisons, Bihar and Orisva. 

On reversion from the cadre of Agenev Surgeons under the Government 
of India In the Foreign and Political Department, the services of Major 
C. J, Stocker, M.C., arc placed temporarily at tlio. disposal of the 
Covernmrmt of the Central Provinces. 

The service.^ of Capt.ain M. T. Khandwalla are placed temponiTiJy 
At the dispo-al of the Government of Jladros for employment in the Jail 
Department, 

Lieut.-Colonel W. 11. C. Forster to be Colonel, vico Colonel A. Fenton, 
rotired. 

Lieutenant ,T. H. Clapp tn 1v» Captain. 

Lieut.-Co!oncls T. .S. Novi*-, V.H.S., and W. F. ITnrrej*, • C.I.E., have 
rcllrc<l from tlie service.. 


TACAXCIES. 

HouaxntocDi : Rovn. Viaonii and Wrsr ITintt? IIoctital.— nouse-Surgeon 
(male) for the Bopcomb.* Bninch. Salarv’ £120 per annum.' 

CnNin-iL LontjoN’ OpjiDDUric nosPiT.it, Judd Street, W,C.1.“(1) Two Out- 

S aticnt Officers; remunci ation at the rate of £150 per annum. ^) 
iinior House-Surgeon ; salary at (lie rate of £"50 per annum. 

CnoYDOx County BoROUcn^A.«si«4(ant Medical Officer of ITeallli and 
Assistant School Jlodical Officer. Salary £600 per annum. 

DnnBYSmnE Royal iNnRiHRY, Derby.— Honorary Gynaecologist, 

E:tKTKn : Royal Dhvon and Exeter TIospit.al.— S enfor House-Surgeon (male). 
Salar 3 ' £200 per annum. 

Freoiasons Hospital and Nursing Home, 237, Fulham Road, S.W.3,— • 
Resident JTcdical Officer (male). Salar}' at the rate of j^O per annunr! * 
Glasgow RoyauCanceu Hospital. — R esearch Worker. Salary £800 to £1 000 
per annum. * 

Hospital for Consumption .and Dise.ases of titf. Chest, Brompton, S,W3 

Two Hotiso-riiVsfoians. Honorarium £50 for six months. > » . - 
Ipsvncii ; East Suffolk and rpsRTcn HospitALl— C asuaRy Officer fmalel 

Salary £150 per annum, rising to £200. , 

Kr-NsiNCTON, Fulham^ .and CnELsnv GE-neral Hospital.— H onorary Dental 
Surgeon (raale). 

Leeds Public Dispenstry.— J unior Resident Sfcdical Officer. Salary £150 
per annum. 

Lincoln t Tin: Lawn.— S lcdical SuperintendenL Salary £700- per annum, 
LoCircinnoN PAiiisn CouNaL, Ross-shire.— Medical Officer and Publio 
Vaccinator. Salary £135 per annum. 

Lowestoft and North Suffolk Hospit.au— H ouse-Surgeon (male). SaTarv 
£120 per annum, 

Manchester r Ancoats IIo^piTAt.— House-Surgeon (OrUiopacdic).* Salarr 
£100’ per annum. 

MAxaiESTCR Royal Eve Hospital. — ^T wo Junior House-Surgeons. Salarr 
£120 per annum. 1 

SIaxchester Royai. lNFiP.AtARV.— Assistant Medical Officer. Salarj* £35 pet 
annum. 

3lANCHfSTERi St. M.ap.y's HOSPITALS.- Two Honsc-SiTTgeons for the Whit- 
worth Street West Hospital (Maternity). 

Manchester Union, — J unior Resident Assistant Medical Officer (female) at 
the Booth Hall Infirmary* for Children.. Salary at the rate of £^5 per 
annum. 

MAr.GATE : Roy.al Sea B athing Hospital. — ^T wo Male House-Surgeons. Salarr 
at the rate of £200 per annum. * ‘ ^ 

Metropolitan- Asylums Board : TrurjiccLOsis Serytti:.— J unior Assistant' 
3Icdical Officer (male) at St. Ltike’s Hospital, Lowestoft. Salary iSOO’ner 
annom. . 

KORWicii Cnr.— Clinical Tuherculosrs Officer, Assistant Sfedical Offim-r. 
Healthy and Assistant School Jledical Officer. Salary £750, 



© jAk, 7, 3528] 


Correspondence, 


r SUPPLEIIEXT TO tWI 
IBBmsH Urojcii, JocBXU 


ent«r ou tho next regular certificate issued to the patient 
a statement that dental treatment is recommended. But 
most practitioners will be quite willing, ercn without 
diarging a fee, to help their patients in this regai-d without 
any narrow insistonco on this limited obligation. The 
benefit ordinarily consists of payment by the society of tho 
whole cost of oporatire ti-eatment and not less than half 
the cost of dentures; but owing to lack of funds set aside 
for this purpose certain societies havo been authorized to 
pay only 75 per cent, of tho cost of operative treatment; 
and some havo been obliged temporarily to suspend tho 
benefit altogether. This treatment may be obtained by 
tbo patient from any registered dentist wbo is working 
under tho scliemo. In order to obtain a gi-ant tho member 
must ordinai’ily, before any treatment is begun, havo sub- 
mitted the dentist’s estimate to the society and have 
obtaiuerl the society’s authorization. 

'The scale of charges agieed upon is no concern of the 
medical profession. There are some indications that at tho 
moment it is more satisfactory to the dentists than to tho 
societies. Tho scale of charges for anaesthetics is, how- 
ever, of some interest. It is not binding ou any medical 
man, and has, in fact, been i-opudiated entirely by tho 
British Medical Association. It contains two provisions 
jvhich arc of an extraordinai-y, not to soy ludicrous, 
character. One of tlicso is that where there are extrac- 
tions from both jaws the anaesthetic foe is to be higher 
than if the extractions arc from one jaw onh'. The other 
is that only one administration foe is to be charged to each 
patient, even if that patient requires more than one adminis- 
tration. No explanation of these remarkable provisions 
has, so far as we know, ever' been vouchsafed. The actual 
fees prescribed are; fl) simple administration of nitrous 
oxide or similar anaesthetic, one jaw 7s. 6d., both jau-s 
10s. : (2) prolonged anaesthesia whei'o not less than twelve 
teeth are extracted at one opciation, £1 Is. Tlicso are 
tho fees ou which the dentist must estimate, and which will 
ho paid to him if tho society accepts hi.s estimate. If he 
employs a medical practitioner as anaesthetist it is to he 
presumed that ho will not he very willing to pay the 
anaostheti!5t larger foes than he will himself ho allowed, 
and he is not allowed to chaigo his jiatient any larger fees 
than those. If, however, tlie patient himself asks to have 
his own medical attendant as anaesthetist, and tho fee is 
in excess of those mentioned, tlie dentist may arrange this 
with tlie doctor and charge tho excess to the patient.* 
Tho choice of an anaesthetist rests with tho dentist. A 
knowledge of the conditions set out above may be useful to 
medical anaesthetists arranpng their fees with tiie dentist. 
In all cases of prolonged anaesthesia the anaesthetist must 
he “ eithci a medical practitioner or a dentist (other than 
the dentist performing the extractions) skilled in the 
administration of a suitable general anaesthetic and in- 
duded ill a list to be approved by tbe Dental Benefit Joint 
Committee." As we prorionsly pointed out, tho obvious 
ambiguity of this provision would be completely avoided 
by tbo insertion of a comma after the words medical 

* Tliis statement is in accordance Bilh the paragraph in tlie body 
of the “ Dental BeneEt Handbook,” page 16 : “ kuquiries havo 
been received as to the proper procedure in eases of ■simple adminis- 
tration in whidi insured persons desire to have their own doctors, 
either to adminislcr tho general anaosthetio or to be present »l Us 
administration bj the dentist. It has been agreed that in the first 
typo of case the payment of the doctor's fee is a matter for 
arrangement between the patient and the dentist, tlie patient paying 
to the dentist the difference, if any, bcl-irccn the doctor’s fee and 
the administration fee payable by the society, and the dentist then 
making himself responsible for the payment of the whole fee to 
the doctor.” But see page 50, under “ Summary of the principal 
decisions of tlie Interpretation Committee ” : 

” Case Ko. S55. It a patient desires to employ his or her own medical 
attendant to administer ordinary oitrousositie gas, and is wilKog to pay 
the tee, is lids permissible under tlie sc.sle? — Decision r If the patient 
desires to employ his or her own nnaestJwtist for the ordinary ndminis- 
tration of nitrous ovide the patient is liable and must pay tlic onaes- 
thetisfe fee, the dentist ebarginc only the male fee for the extraction." 

Borne further explanation seems called for. 


practitioner.’’ For some reason the Joint Committeo have 
preferred not to insert the comma, but to explain elsewhere 
that the proviso applies only to a dentist and not to a 
medical practitioner. Even so, the explanation is expressed 
incorrectly. The handbook states (p. 15) “ any registered 
medical practitioner, therefore, is entitled to receive tho 
fee under Item 5 (5) (ii) irrespective of the inclusion of 
his name in the panel.’’ The medical practitioner, it 
cannot ho too cle.ar!y understood, has no rights or duties 
under this scheme at all. M’hat is meant is that the dentist 
has the right to employ a medical practitioner as anaes- 
thetist and to receive tho prescribed fee in rcqieet of tbe 
administr ation. The difference is not negligible. 

■Thero are two 2 ’oints worth noting 'in connexion n ith 
possible dovelopinonts of tho medical insiwanoe sendee. 
One is an important difference of function between tho 
regional dental officer and the regional medical officer. 
The former may be (it seems, usually is) requii-cd to judge 
of tho propriety of the dcaital treatment which liis pro- 
fessional colleague jiroiioses to give his patient, and of 
the quality and success of such professional work' after it 
has been given. This seems, on the face of it, a lilglily 
undesirable state of affairs, and if it must be aceejited by 
the best dentists as a regrettable necessity with regard to 
dental work and in the pre.sent conditions of the dental 
profession, it cannot be too empliatieallj' stated that inspec- 
torial functions analogous to these would never he tolerated 
for a moment by the medical profession. The second iioiut is 
the statement of the joint committee irlth i-egard to dental 
clinics. Tho coiuniittco docs not express any' definite 
opinion on tho question of the general institution of dental 
clinics, but “ recommends that an experimental clinic or 
clinics be set up in a suitable area or areas, if jiossiblo 
under tbo supervision of tho Minister of Health or the 
.Scottish Board of Health,” and says that ‘‘the steps 
nccessaiy to give effect to this recommendation are now 
being taken by the eomroittee.” H’o made some comment 
on such a proposal in tlie Jotoxaii of Augtist 27th, 1927 
(p. 355). 


ffiiirrrsp0n65n«. 

Ophthalmic VUnics for InsxiTcd Persons. 

Sm— The letter ic the Supplement of Pecember 24tb, 1927, 
from ’Pr. Bickei'ton is so misleading that I feel 
reply to it. I do not ngree with the policy of the Ophthalmic 
Committee of the British Medical Association; in my 
they are making a fatal mistake in advocating dimes. Already 
there are signs that some societies are taking advantage ot tne 
favour shown by the Briti&li Medical Association to Hie clinic 
system and are actually starting climes fhemseives, winch are, 
as might have been expected, entirely controlled by these 

societies. . , , 

It is all very wen to divide societies into good and naa, 
but it is a false division. A society foimed from members m 
a nood social position has a far lower, sickness rate luan one 
fonned from members of an unhealthy trade. The surplus 
varies in different societies. One can afford to give its members 
extra benefits, whereas another finds itself with no surp ns 
funds. Are we to label the latter a bad society J;''’’ 
account? It is no good to argue that as tiiCTc is n 
of over one hundred millions in the National Insurance 
therefore the societies can afford to pay the 
feS are paid by indiviaual socictiei and not by the national 

^'"rhe fault of the whole matter is that we have not consented 
to let certain varieties of defects of sight, mainly , rases of 
ureshvopia, go to opticians. It is ridiculous to send every 
patient, ^vithout any discrimination to 

The Panel Conference recognized this, and %otecl accomiOoV- 
The dictum, ” Send all caste to an ophthalmic surgeon, must 
modird. As was stated to 

representative of the Ministry, it is impossiW^e to pay for this. 
rZZlh- other way of overcoming the difficulty is to treat 
cases of Vreshvopia at a lower fee than the guinea. , f . 

To compare’ school clinics with those that arc proposed for 
societies is^a very poor argument, .School children arc all under 
;ne authority, and are treated in most areas by whole-tune men 
« a part of their dnty as school medical officers. Suitable 


J.w. 7, IMSl 


WltHams-Frceman Proaontatfon Puna. 


f fiPPriEilEST TO- THE 
iDittristi UcoicAi. Xoc&nAt. 


7 


Tirpinises nnd atiiwratiis aro .nroviilod Iiy llin edncation aiillio- 
rilics and tho diildren can U dealt with at certain hours in 
the lump. To compare tire two is to suggest that tire Eocicties 
sliall set up clinics and work on the same system, which would 
he di.sastrous. 

Wo have got to get our liriiig and to protect our profession 
from being cxTiIoitcd. Doc.s lire writer of the letter consider 
tho fees suggested n,s siiitnhlo for clinic work to ho at all 
satisfactory? I think they arc an insult. The result of starting 
clinics wifi ho to lower the wholo status of ophthalmic work. 
How futile it is to suggest that lire memhers should pay the 
difference between the clinic fee and that of an ophthalmic 
surgeon if they want the latter! At the present day working 
iiipii are out to gel everything for little or nothing. Uow many 
will pay the citra fee? 

Then, in tho Inst paragraph, tho writer states : " At pre.scnt 
tliose who do not like the clinic scheme need not undertake 
tire work." This is to say that if a clinic is estnhlislred in the 
town where I reside I am to lose nil my ophthalmic work if 
1 do not join the clinic. Thai is a nice hrolhcrly position 
to t.skc up, is it not? If the clinic system is adopted the 
societies will ohtjun conlTol, pul in tire medical man who is 
willing to do tlic work at the clicapc.st rate, .and the rest can 
go to the devil ! 

If hospital ophtlialmic surgeons are so foolish ns to do work 
for nolliing, for which they would he paid if they went about 
it in tho right way, it is only another e.x, ample of the lack 
of business aptitude of medical men. Kvery hosjutal ophthalmic 
surgeon slionld put his foot down and say, " f will not treat 
memhers of societies at tfic hospit.al." If they do not do this 
tliey arc acting unfairly to tlicmselvcs and to oilier collcaguc.s 
who depend partly on ophthalmic work for a, living. 

I trust that climes will not ire estalili.siicd. It is hy far the 
best plan to stick to the guinea fee and see tlie patients at 
our own rooms, making a modified charge for simple ca.'-es, such 
as presbyopia, or letting them go at their own lisk to an 
optician. 

I am afr.iid the Ophthalmic Committee of the Ilritisli Medical 
Association has too many ophthalmic snrgeons as memhers to 
the exclusion of those who arc familiar with panel work and 
know the conditions of genera! practice in connexion with the 
panel. There are manj' men who have taken up refraction 
work as a sideline; these should be represented. — I am, etc., 
lla'.tias’, Dee. 27tli, 1327, Ar.TUCn E. Ltl’.KlNC. 


'\YILLI.MIS-FREE3fAN PRESENTATION FUND. 

Tire following is the fonrtli li.st of subscriptions rccoivod 
in responso to tho letter ptibli.shcd in our columns of 
October 1st, 1 Sj 27 (p. 109); 


^nliol itn& ^iliiorji ^ppoitdotcnls. 


KOVar. NAVAL .UEDIC.tL .SERVICE. 

Surgeon Lieutenant Commniulfr'i T. G. Ifunt to the Tamar for Hone- 
Ifonjr 1\ If. Vey to flic Victor!/ for Portsmouth Dockyard: 

C. T. Hyatt to Om 

Surgeon LicutrnuntH IX Duncan to flic Vernon; J. IT, Kicol.^on to tlio 
fi*iu|iorary, and (oftljc Cornicall on commisaioninff wUli full compic' 
mciit ; S. G. WeUlon to the Atectn, temporary. 


nOYAL AUMY HEDICAL CORPS. 

Colonels O. yi. Coldsmitli, C.D.E.r and 11. D. Packer, C-I.E., lato 
R,A.M.C., rcllTc on ri-tircil pay. 

Colonel 11. ir, Ltoyd. lafe R.A.Jf.C., is placed on half pay tinder tho 
of Article*! 139 and ^85, Roj-al Warrant for Pay and Promotion, 

Llcutcnant-ColoneN from K.A.M.C, to be Colonels: E. McDonnell, D.S.^ 
vice Colonel G. M. GohUniith, C.ll.E., to retired pay; Brevet Colonel A. lu 
Snftord, vice Colonel H. IT. Lloyd to half pay; llrevct Colonel J. Vi. West, 
C.M.C., K.II.S., vice Colonel If. D. Packer, C.r.E., fo retired pay. 

Lietit.<^CoIonel A. Jfe.UtTrtn, O.B.E., havfnp^ attained the fi.red for 
compuhiorr retirement, rriire» oa retired pay. 

ilajors fo bo Llcuteimut-Coloucls : K- Iasw, D.S.O., O.B.E.T vice Lieut.- 
Colonel E. McDonnell, D.S.O., promoted; A. N. Fraser, D.S.O., vice 
Llcut.^CoIonel and Crevot Colonel A. II. Soflordr promoted; R.. IT. L. 
Cordner, vice Liout.*CoIoneI and Brevet Colonel J. W. West, C.il.G., 
K.II.S., promotcfl. 

Captain Q. T. Cimlettc to he Srajor (nror.). 

Temporary Lieutenant O. A. 0\ven«FIood (Lieutenant, Re^jular .^nny 
Reserve of Olheers, Royal Irlnh Fusiliers) relinquishes his temporary 
commission. 


ROYAL ATR FORCn MEDICAL SERVICE. 

The promotion of the followinp oflTcers is announced in the Supplement 
to the London dazrttc of January 2ndr containing; the list of New Tear 
llonours, elo,t Wln^r Commander E. C. Clements, O.B.E., to be GrouTr 
Captain : Flight Lieutenant fActfnp; Squadron Leader) J. }». IfacDonald 
to be Honorary Winf; Commander. 

Lieutenants 0, J. Grifiiths to R.A.F. Station, Bicester; D. B. Smith 
to Station Headquarters and Storaprr Section, Andover, 


INDIAN- XtEDICAL SERVICE. 

The services of Lietit. •Colonel G. W. Jtaconachie have been placed at llic 
disposal of the Government of Bihar and Orissa, for employment as 
Ofhciiuin;; rnspector-Ccnoral of Prisons, Bihar and Oris«a. 

On rcvcision from (ho cadre of .-Ipcncy Sorjroons under the Covernmenfc 
of India In the Foreign nnd Political Department, the services of Major 
C. J. Stocker, ^i.C., nre placed temporarily at the disposal of the 
Covernmont of the Central Province;*; 

TIjc services of C.'iptaiu 31. T. Klmn(lv,-alla are placed temporarily 
at the disi'osal of the Corernment of Jtadrae for employment in the Jail 
Department. 

Liciit.-Coloncl W. If. C. Forster to bo Colonel, vice Colonel A. Fenton, 
r.'tircd. 

Lieutenont J. II. Clapp to lie Captain. 

Lleut.-Co!oncI;r T. S. Novir, V.rt.S., and W. F. ITarrev, C.T.E., have 
retired from the service. 


VACANCIES. 


£ f. <1. 

1,267 17 6 


29 9 
25 10 
2 2 
33 2 
5 5 
10 10 
43 8 
8 18 
3 0 
5 5 
15 14 
20 0 
24 0 
61 10 
75 18 


14 2 e 


Amount previously acknowledged 

Local SI edicat and. Panel Commiilrc Contrihulivn.t. 

J orccslcrsliirc L^l Mctlical and Panel Committee . 

Somerset Panel Committee 

ir „ ,, „ , •• 

I Medical and Panel Committee 

-u 11 - T , ^ f*""' Committee 

anfi Fund Committee ... 

Merf^S''¥L^l“'aomm?tL^“"’=' 

Middlesex Panel Committee 

An^SeriiLf^t^’lfte^e°'“' ■■■ 

Brecon Pane! Committee „ 

KoUiiigJiamsIiire Panel Committee 

Hainpsliire Panel Committee 

H.impshire Insurance Practitionem 

T, . C (Previously acknowledged, £4 45 j’ 

East Sussex Insurance Practitioners ... 

■n 11 ^"^‘^’‘'^jL^aatrihutions. 

Dr. G. . Candler, Black Torrington, Devon 

Drs Todd _^d Smalley, Gmllfngton; Devon i" i" 

■n ' ^ Bif ton, Devon ... 

Drs. Toye and Wilson, Bideford, Devon 

bfvo?'"'’ Bitinslaple; 

Dr. L. S. Luckliam,. Salisbury 

E, O. and C, IT, Kingdon 'n^Tf/aU 

S^!-A':“plSes,“"^reffie°lf D-" - 

Di-s. Twining and Moore, Salcomhc, Devon 

January 2nd (morning) £1,661 18 

Pr^'oT?-® ^>’0 VTiliams-Freemi 

Tr^as?,!- “xr addressed to Dr. D, G. Grcenfiei 

Sccret.ary, British Hecli, 

St-c Unc?o?W.OA Tavisto 


10 6 
2 2 0 
110 
110 


BouP-xaiouTii : Royil Virromv .ind West Hiatts ITosTTriL. — TTou?i;*Siirsron 
(male) for the BG«coml>' Bninch. Salary £120 per annum. 

Ckstr-U. LONDON’ OPiiTK.iLMie ITosPJTiL, Judd Street, W.C.1.-“(1) Two Ont- 

S aticnt OlTicers; n-nuincr.’itioiT at the rate of £150 per annum. (2) 
unior irou«c-Surpeon ; salary at (he rate of £50 per annum. 

Croydon County DoRoucu.^Aj'sistant Medfcal Ofliccr of Health and 
Assistant School Jlrdical OfHcer, Salary £G00 per annum. 

Dn^iBYsniRR Roy.^l iNnait^av, Derby. — Honorary Gynaecologist. 

E^ett.r : Roy^l Drvo.n ind Exeter Hogpira.— Senior nousc-Sur{;eon (male). 
Salary i:26o per annum. 

FncrjincONs Honpitai. and Nursing ITojn:, 237, Fulham Road, S.IV.3.— 
ncsidertt Medical onieer finale). Salary nt tho rate of £250 per annum. • 
Glasgow Royal Canter Hosm iL.—Rescarcli Worker. Salary £300 to £1,000 
per annum. 

IIOSHTAL FOR CONSUMPTIO.N AND DISEASES OP ITTE ClIZSTw Brompton, S.IV.3.— 
Two lIouse-Fh\?ictans. Honorarium £50 for six montbs. 

Ipsw^Cll: East Suffolr anit rpswiaX TTospit.au— C asuaRy Officer fmale). 

Salary £150 per annum, risiu" to £200, , 

Kensington. Fin/nAM,. and Chuse-V GENErai, ndsrmL.— Honorary Dental 
Surpeim 

Leeds Pujlic DisPENS’Ar.Y. — Junior Resident Medical Officer. Salary £150 
per annam. 

Lincoln : Tjte Lawn.— 3redical Superintendent. Salary £700- per annum. 
LocnciRitON PARlsri Coungh., Ross-ehire. — Bfcdical Officer and PubHo 
Vaccinator. Salary £I3J per annum. 

LowKroPT AND NORTir ScFTOLK IIOcriTAL. — Hoxtse-Surgeon (male). Salary 
£120 per annum. 

Manchester r Anioits ITo^pitai,. — H ouse-Surgeon (Orthopaedic). Salary 
£l0d per annum. 

Manchester Roy.al Eye Hospital.— Two Junior House-Surgeons. Salary 
£120 per annum. 

Manoiester. Royau iNnRJLARY.— Assistant Medical Officer. Salary £35 pet 
annum,. 

ilANCHJSTCR; St. JLary’s Hospitals.— Two House-Surgeons for the Hhit- 
•worth Street West Hospital OfaternitjO- 
Manchester Cnton; — J unior Kc?ident Assistant Jfedical Officer (female) at 
the Booth Hall Inflrnrary for Children. Sa]aTy at the rate- of £^5 pet 
annum. 

SrARCiTB; Royal Sea Bathing Kosphal. — ^T wo Male Honsc-Snr;;eons. S.alary 
at the rate of £200 per annum. 

■MEtRQPQLtTAN AETCTTMiJ BOATTO : Tceercthosis SERYTrE, — Junior Assistant 
Medical Officer (male) at St. Luke^a Hospital, Lowestoft. Salary £5Ca per 
annum. 

Hoiwnai Cnr.— Clinical TuhercuIosTs Officer, Assistant Sfedical Officer of 
Health, and Assistant Scliool Jledical Officer. Salary £7^ 





SXn’PLE^NCElsrT 

TO THK 

BRITISH MEDICAL JOURNAL. 


LOXDOX, SATURDAY, JANUARY I'Jtu, 1928. 


CO^s TENTS. 


BRITISH MEDICAL ASSOCIATION. 

CURHEXT NOTES : 

IU.VSTr,.lTIOKS IS THE " JoiIESAL ” 

Si'Bscr.inioss ror. 1928 

ASSOCIATION NOTICES 

CORRESPONDENCE 

ASSOCIATION INTELLIGENCE AND DIARY ... 


P.MiE 


NATIONAL INSURANCE : 

R.vsce or MEmc.lL Seevice ... 


... 9 NAVAL AN*D MILITARY APPOINTMENTS 

... 9 1 VACANCIES 

... 9 { DIARY OF SOCIETIES AND LECTURES 

... 11 I POST-GRADUATE COURSES AND LECTURES.. 
... 12 1 DIRTIES, MARRIAGES, AND DEATHS 


page 

.. 10 
.. 11 
.. 11 
.. 12 
.. 12 
.. 12 


18ritislj IHtbirnl ^saannlion. 


The following rules from two contemporaries indicate 
the view taken hy other editors and printers: 


CURRENT NOTES. 


Illustrations In tho "Journal." 

DcRtXG tile Annual Representative Sleeting in Edinhurgh 
a motion was brought fonvaid hy the Edinhurgh and Leith 
Division requesting the Conneirto consider the possibility 
of improving tho general quality of the illustrations 
appearing iu the Biimsu AIv.dic.sl JoniMt.. After an 
explanation had been given by the Chairnuui of the Journal 
Committee, iii tho course of which he cmiihaMr.cd tho 
expense involved in reproducing pictures on spcci.al art 
paper, tlie motion was withdrawn. 

This is a matter to which a great deal of attention has 
been given, and the efTorts to obtain good results uill not 
ho relaxed. I’en-and-ink drawings that can be roprodneod 
in line bloclrs are easily dealt ivith. Tho loot of tho 
difficulty is that nowadays most of tho jiictures submitted 
are pbotograpbs, and that tlioy are not taken with a view 
to reproduction on a rapid press, as arc tliose produced 
by journalist-photographers for the daily pro5.s. Tho situa- 
tion was discussed again at tho last mcotiiig of the Journal 
Committee, when the opinion was expressed that some 
good might be done if an apjieal were made to contrihutors 
to' realize that some of the difficulties iu the way of satis- 
factoiy reproduction of photographs in the Jounrc.iL can 
onlj be overcome if they will give their assistance. 

Mauj of the illustration.s seut for rcproductiou are very 
far from being suitable. Snapshots taken ivith a hand 
camera are a veiy severe test of a photograplier’s skill; 
feu amateurs can in this wa}- produce a print suitable for 
i epvoduction on the printed page or even on special art 
paper, lor photograplcs of patients it is best to use a 
poitiait lens. Usually it jg preferable to cmploi' a plioto- 
giapher accustomed .to portrait work. Care ‘should be 
taken, that the subject is properly lighted and shown 
against flat uniform .background . The uliole effect of 
photography is in tho contrast between the black and 
unite. Ill most cases a smoothly stretched sheet, ivliitc 
or grey, gives the best contrast; an ordinary wall with 
fittings in or upon it, or a curtain hanging in folds, ore 
most un&uitahle. Satisfactory process reproductions of 
anatomical details or of posf-moyfcjii ajipearances can 
seldom be obtained from photographs; drawings iu black 
and white without a wash will usually give all the details 
lequisitc, and ai-e preferable to photographs or wa.sli 
t.i.nriugs. It IS often as difficult to get ,n good result 
lorn a wash drawing as from a photograph. Descriptive 
details should not he written on a" iihotograph or a 
drawing; reicrenco lettere in the margin, with lines to 
le point to wluch it is desired to direct attention, should be 
pencilled m faintly, and tbe description given in the legend. 


The Sioehcmical Journal: " Illustrations and curves accom- 
panying panel’s must be carcinlly drawn, _ about twicc^ the size 
of flic finished block, on smootli white Bristol boards in Indian 
ink. Any lettering on these drawings should be lightly inserted 
in pencil." 

The Journal of Phyitotogy ; " Figures should bo ready for photo- 
graphic ((hat is, process) reproduction. Diagrams should bo, in 
Indian ink, and plain white or faint blue-lined paper only should 
be employed; letters, numbers, etc., should be written in pencil.” 

Subscriptions for 1928. 

Jtombors of the British Medical Association are reminded 
that subscriiitioiis fall due on Januan- 1st in each year, 
and that if each momher on receiving an application for 
his or her stihscription from the Head Office would send the 
amount to tho Financial Secretary without delay the work 
of the office would be very considerably lightened. Members 
arc also reminded of the cl.aims of charity. The amounts 
at the disposal of those who administer medical benei-olenco 
aro altogether insufficient to deal adequately with the cases 
needing help, and the Britisli Medical Association Charities 
Funil was formed in order to assist. Contributions are 
urgently needed, and all members are asked to add to their 
ne.xt p.aymcnt a sum for the credit of that Fund. 


^5sanafj0R ^aims. 


BR.ANCH AND DIVISION MEETINGS TO BE HELD. 

Border Cou^•TrEs Bbakoi ; Dumtries and GALLO^VAT Division. — 
The next meclin" of the Dumfries and Galloway Division will be 
held in the Koval Infirmary> Dumfries, on Friday, January 27th, at 
4 p.m., when finance, hospital accommodation, ethical questions, 
medical charities, and other important matters will be considered. 
The Executive Committee will meet at 3 p.m. Professor Bramwell 
has fixed February 21st as tlie date of bis lecture, the subject of 
which will be announced later. 

Border Counties Braxcii : Excusn Division. — A meeting of the 
English Division will be held at Sfaryport on Friday, January 
27th. Dr. J. K. Douglas Smith will read a paper on the early 
Ircainionl of puerperal sepsis. 

Ca^ibridce AJrn Huktixgdox BuAycn. — A ineetiug of the Cam- 
bridge and Huntingdon. Branch, in conjunction with tlie Cambridge 
Medical Society, will be held at the Addenhrooke’s Hospital, 
Cambridge, to-day (Friday, January 13th), at 2.50 p.m. The 
meeling will be devoted to the exhibition of clinical casc^ and 
pathological specimens. 

Dorset and "West Hants Br-vnch : West Dorset Division. — 
meeting of the West Dorset Division will take place at the County 
Hospital, Dorchester, on Thursday, January 19th, at 3.30 p.ni. 
Agenda : Ca'jes; election of representative and deputy representative 
for 1^8-29: Tea will be served by the courtesy of the medical and 
Mirgical staff of the hospital. Mr. P. Jenner Verrall will deliver a 
British Medical^ Association Lecture entitled ‘‘Manipulative 
surgei’y,’* at 4.50 p.m. Criticism and. discussion are invited. 
Members unable to gel to tlie meeting by Ok 30 p.m. will if 
hoped, attend the lecture at 4.30. . ^ - 


[1225] 




Jan. 11, 1023] 


Nava! and IVJHitary Appofntmonis, 


r svrrLr.Mr.sT to TnE 

iDniTisir Mldicil Jocns'ir. 


11 


right of n pracliliouor to charge a fee. V\c douht not that in a 
proper case— for cxarnplo, wliorc the local surronnilings arc wholly 
unfavonrahlc — the iloctov conUl justifiaUly that, while 

charging no fee for the Fcrvico, Ijo should ho permitted to operate 
under more favourahlc conditions.” 

On the question of local custom and tlic weighty* that should 
ho attached thereto, the referees e.xpress the view that no mere 
agi'cemcnt among local practitioners to regard a particular oj)era* 
tion as outside their contract can hy itself give rise to a local 
custom. Such an agreement would constitute them the arbiters 
in the very issue which arises in these inquiries. 

” On tlie other hand, it is clearly ncres<;ary to recognize n differ- 
ing standard of skill in operative work in accordance with local 
conditions— for cxamnle, in a manufacturing district, say twenty 
miles from a hospital, a higher htaiulard ot skill may reasonably 
he attributed to the practitioner than to one whose experionco 
is limilcd by the rla«s of persons ho attends, and to a certain 
extent by the local facilities for expert Ircnlment. And in this 
respect the camparalivc rarity of the occasions on which (he 
neccsMly for this operation arises in the Blackpool area must he 
taken into account. 

“There arc, however, operations of such a simple character 
(hat it would be unre.asonnhlo, if not unnecessary, to invoke the 
provisions of Clauso 8 (4) of the Terms of Service as .atTccting 
ihc main test laid down in Clauso 8 (1). Tlicre appears to us 
to he some danger in using Clause 8 (4) to narrow the nmhil of the 
services to be rendered by an insurance practitioner except in 
cases in which tlio operation itself may bo legarded as on the 
hordcr-Hne of difficulty — that is, when’ the fkill of on average 
general practitioner is in question ns a criterion. 

^ “ The ncccs«ity must arise on occasions for an operation of 
simple character to be performed ns a remedy for some complaint 
which may in the particular di.slrict bo of rare occurronre. In 
such circumstances wo suggest that, if the operation, as measured 
hy the main test, is comparalivclj* easy, contentions as to a local 
custom should ho examined with sonic caution. A too ready 
iusi«itoncc on such custom would seem to us to ho harmful to 
the broad principles upon which medical service under the National 
Health Insurance Act is founded.” 

Applying the foregoing considerations to this pnrticuhar case 
the referees have, on the whole, come to the coiuUision unani- 
mously that the contcnlion.s advanced hy (he Minister should 
prevail, and that this particular service was witlnn tlio range 
of medical service as laid down in the opening words of 
Clause 8 (1), 


Comapoit&cncc. 

Oplilhohnic Clhiics for Itisurcd Per^ntu^. 

Sin, — I was glad to see from various letters on the above 
subject that many ophthalmic surgeons arc against the proposed 
clinics. For the past seven year.s I have had experience of 
dimes for school children under two cducatijn committees. In 
one case I am paid on a sessional basis, and in tlic other 
on a capitation basis. I find that, in the ca.so of the clinic 
paid on the sessional. basis, in order that at least eight “ new *’ 
cases shall be present at each session, many more than eight arc 
written to to attend and, as a consequence, the average attend- 
ance of new cases is twelve or thirteen. 

I fear that the same thing -will happen in ophthalmic clinics 
for insured patients, and we shall he fortunate if the payment 
works out at 09. per person examined. If an ophthalmic .surgeon 
nnas more than eight “new” cases at these clinics and he 
objects, 1 am afraid that the societies will bring pressure to 
pear to force him to examine as many cases as they care 
to send to the clinics. After all, if one should find ten or 
twelve cases at a session, one cannot very well go “ on strike ” 
after seeing eight cases and refuse to sec the remainder. 

1 T'? 1 . clinics, let us be paid on a capitation basis, 

^ ^ btisis he at least half a guinea per case. As Dr. 
sittings says, the Ophthalmic Committee of tlie British Medical 
Association seems determined to have clinics; but I suggest 
that before the committee goes any further it circularize the 
ophthalmic surgeons on the British Alcdical Association list, 
and ask for replies to the following questions : 
system? favour of the present system or the clinic 

(2) If clinics are established, do you prefer to be paid on 
a sessional basis or on a capitation basis? 

If the cominittee does that, then let us be content to abide by 
the decision of the majority. — I am, etc. 

' Another Ophthaljiic Surgeon. 


liabal antt ^UUtary ^ppomtincnis, 

n IJiVVAL MEDICAL SERVICE. 

M-nUam; anA '''• >>’e“bitt, A. D, Sinclair. E. R. P 

short scrvirA^nmi' entered as Svwgcon Lieutenants loi 

of Instructioiu”^ appointed to the I ictory for Haalar Hospital for courst 


Itovu. N’u'u. VoLi;.sTr.Ea Usseryp. 

Surgeon Ccinmarwler H. L. .Murray to be Surgeon Captain. 

Surgeon Commander (retired) It. ‘Wilbond, \.D., to be Surgeon Captain 
(retinal). 

Surgeon Lltulenant Commanders L. C. D. Irvine and A. G. V. Elder, 
D.S.C., to bo .Surgeon ('ormnanders. 

Surgeon Lieutenant It. Hall to be Surgeon Lieutenant Commander. 
Surgeon Liciitenanti T. A. brand to the Benhotc for training; F. E, 
Stabler to the Victorj/ for H.N. Ilobpital, Haalar, for fourteen days* 
(raining. 

Probationary Surgeon Lieutenant R. L. Stubbs to be Surgeon Lieutenant. 
To ba probationary Surgeon Lieutenants: C. C. Ungley, attached to 
List 2 01 Tyne Division; U. D. Owen, attached to List 2 of Bristol 
DivUion. 

To be probationan* Surgeon Sublieutenants: E. P. Davies, E. G.' 
Thomas, and D. 0. Evans, attached to List 2 of Bristol Division; D. A. 
Williams. 

Rovil Austriliin* Ntvv. 

Surgeon Commanders W. E. Roberts to the Victorp for R.N. Barracks; 
A.'S. Mackenzie to the Victori/ for II.M.A.S. Au^fraho for trials. 


ROYAL ARMY 5IEDICAL CORPS. 

Major-Generals Sir Maurice P. C. IloU, K.G.B., K.C.M.G., D.S.O., late 
R.A..M.C-, nnd Sir .Samuel 0. Guise-Moorc*', K.C.B., C.M.G., retired pay, 
late R.A.M.C., to be Colonel Commandants, vice jrajor-Gcneral Sir 
William Maophcr.«*on, K.C.5I.0., C.B., and Lieut. -General Sir Arthur T. 
Sloggclt, K.C.n.. K.C.M.O., K.C.V.O. 

Lleut.-Coione! A. C. AtUlcrIey, D.S.O., half-pay list, late K.A.3I.C., 
retires on re(ire«l pay on nccoiiht of ill health. 

Major H. H. A. Tlmerson, D.S.O., to be Brevet Lieutenant-Colonel. 

Major B. H. H. N’cvcn-Spcnce retires on retired pay. 

Lieutenant (on probation) T. F. M. Woods, from the seconded list, is 
rc>torcd <0 the c<'tablishment. 

Temporary Lieutenant S. M. Burrows to be Lieutenant (on probation), 
am! relinqni<Iics the rank of temporary Lieutenant. 


ROYAL AIR FORCE MEDICAL SERVICE. 

Squadron Leaders R. W. Ryan and F. E. Johnson to R.A.F. Depot, 
U-xbridge. 

Flight Lieutenants C. V. D. Ro«e nnd T. V, O’Brien to R.A.F. Depot, 
Uxbriilge ; L. C. Palmcr-.Ioncs to N’o, 2C8 Squadron, Sliddle East. 

Fljing Oificer J. Jlngner to Aircraft Depot, India. 


COLONIAL MEDICAL SERVICES. 

Dr. R. T. B. Green appointed Second Pathologist, Tn.stitute for Medical 
Rc«oftrcb, F.M.S. Dr. R. A. Palhster appointed Health Office, Slalayan 
Medical Service. Dr. R. Sluppel appointed Government Medical Officer, 
Fiii. Dr. R. I*. Crawfnnl is confirmed in his appointment as Medical 
Ofiicer, Nigeria. Dr, William E. Glover promoted Senior Medical Officer 
in Nigeria. Dr. A. S, Westmorland appointed Senior Jfedical Officer. 
IMtblic Hospital. Kingstown, Jamaica. Dr. H. 0. Hopkins appointed 
Malaria Research Officer, Institute for Sledical Research, F.M.S. 


VACANCIES. 


Bctii.vu. Green IlosPita, E.2.— Assistant Slcdical Oificer. Salarj' i350 per 
annum. 

BiRMiNGiiiM CORPOr.moN.— Senior Assistant Medical Officer of Health. 
Salary 11,100 per annum. 

Blytii Borough.— M edical Ofiicer of Health, ‘ School !Mcdical Officer, and’ 
Port Medical Officer. Salary £800 per annum, rising to £900. 
Bournemouth : Rova Victoru ano West IUnts Hospital.— H ouse-Surgeon 
(male) for Boscombe Branch. Salary £120 per annum. 

Brighton : New Sus-^ex Hospital for Women ANOXHaDREN.- (1) Honorary 
Radiologist. (2) Honorary Surgeon to the Ear, Nose, and Throat 
Department. 

CAMBrauGE : Addencrooke’s Hospital.- House-Physician (male). Salary 
at the rate of £130 per annum. 

Central London Ophthalmic Hospital, Judd Street, W.C.l. — (1) Two Out- 
patient Officers; remuneration at the rate of £150 per annum. (2) 
Junior House-Surgeon ; salary at the rate of £50 per annum. 

City op Ia>.\DON Hospitil for Diseases of the Heap.t and Lungs, Victoria 
Park, E.2. — Physician to Out-patients'. 

Coventry Cm'. — Deputy Medical Officer of Health. Salary £750 per 
annum, rising to £1,000. 

Croydon County Borough.— Assistant Sledical Officer of Health and 
Assistant School Jledical Officer. Salary £‘600 per annum. 

Durham County Council,— Sledical Officer of Earl’s House Sanatorium 
for Boys, Sa^ry £450 per annum, rising to £500. 

Freemasons Hospital and Nursing Home, 237, Fulham Road, S.W.3.— 
Rcsulenl Medical Officer (male). Salary at the rate of £250 per annum. 

Gordon Hospital for Rectal Diseases, Vauxball Bridge Road, S.W. — 
Resilient House-Surgeon. Salary £75 per annum. 

Hemel Hempstead: West Herts Hospital.— Resident ilcdical Officer. 
Salary £150 per annum. 

Hu.ntincdon County Hospital.— H ouse-Surgeon (male). Salary £100 per 
annum. 


Liverpool: Royal Liverpool Children’s Hospital,— (1) Resident Medical 
Officer at the Heswell Branch; salary £120 per annum. (2) Two Resident 
House-Physicians anti two Resident 'House-Surgeons at the City Branch; 
salary £60 per annum. 

LOCHCARRON PARISH COUNCIL, Ross-shirc. — Medical Officer and Public 
Vaccinator, Salary £133 per annum. 

London Fealale Lock Hospital, 283, Harrow Road, W.9.— Second House- 
Surgeon. Salary £150 per annum. 

JLanchester : Ancoats Hospital. — Resident Sledical Officer. Salary £150* 
per annum. 

Mansfield and District Hospital. — Senior House-Surgeon (male). Salary 
XTOO per annum. 

Margate: Royal Se\ Bathing Hospital.— Two Male House-Surgeons. Salary- 
£200 per annum. 

Metropolitan Hospital, Kingsland Road, E.8. — Ophthalmic Surgeon. 

Midlothlan, West Lothian, and Plebuis Counhes.— iledical Officer of 
Health. Salary £900 per annum. 

Mildm-ay 3I1SSION Hospital, Austin Street, E.2. — Junior Resident Sledical 
Officer (male). Salary £100 per annum. 

Ministry of Pensions Hospital, Grangethorpe, Manchester —Junior 
Medical Officer (unmarried). Salary £300 per annum. * - . 



12 JAX. 14, 1928] 


Association Intetllgence and Diary, 


r suppLmrE^t^T to tick ' 
LBbitisu slEjiiCAt. Journal 


/ 


KoTTJNCHiM CniLpnE-N'.s no5PiTit.“Hei.idcnt llousc-Sar^'con (woman). | 
Salary at tlic rate oJ i.'150 per annum. 
lvO^’.u^CH Cltw— C linical TuliejcuIoJ^is Officer, Assistant Medical Officer of 
lleaUli, and Assistant School Medical Officer. Salary X750. 

House Mental 112, Pcckham Rnad, S,E.15.— Junior 

AsMstam Medical Oflicer (male, unmarried). Salary comnicncinir at 
£250 pel annum. 

Por.TsMorTH PinislT.— Third Assistant Resident Medical Officer for 
St. Mary's Infiimary, Institution, and Ctuldrcn’a Home. Salary £^0 
per anjium. 

IvtcisMOUTH Roy.iL PoP.TSJiouTH HosPiTiL.—Casuiilti' Officct (male). 

Sal.a> at tlic rate of £100 per annum. 

Ruva Wm'.iaoo Hospital for CniLDHEX AVo.'itux, M'alcrloo Road, S.E.I. 
— ^'f*a-I^e^ldent Casualty Officer for Out*pallent Department. Salary 
£150 per annum. 

St. JonN’s Jlo.-mtis Lewisham, S.E 13.— Casualty Officer (male). Salary 
at tlir i.iir of £100 per annum for six months, rising to X125 per annum 
foi lhie«* months. 

SE\MKs’'t IfdSJ-niL SociciY.— Honorary Assistant PJi.vsician at the Hospital 
fur Ttoptcvii Diseases, Endslcigh Cardens, W.C. 

SiianuLD Ro\ \L HosPinu — RtMdent AnaestUctibt (male). Salarj £80 per 
annum. 

SuMEPSFT C'nrxTY GounSil.— ( 1) Assistant Tuberculosis Officer. (2) Tuber- 
culosis Officer for Bath City. (3) Tuberculosis, Officer for Western Area. 
Salary £600 per annum each. 

Sri^NEY Pinisiu— Pathologist and Bacteriologist. Salary £450 per annum. 
Stockton ud Thoenady Hospital, Stockton*on*Tecs. — Junior Resident 
Medical Odir-rr (male). Salary £150 per annum. 

Stoke-on Trcn r • North SnffonDsUiRE Royal iNFinM.AUY-.— House-Surgeon. 
Salary £150 i>er annum. 

Swindon Bonotcij. — ^Asshtant to Medical Officer ol Health (male). Salary 
£600 per unnum, 

Taunton and Somyrsct Hospital. — S enior and Junior Medical Officers. 

SalaiA 1150 and £100 per annum respectively. 

Wakefield City. — A ssistant Medical Officcj (woman). Salary £600 per 
annum. 

IVn-T End Hospital for Nervous Dise-xses.— S enior Housc-Phvsician. Salary 
at the latc of £150 per annum. 

Certifying Factory Surgeons. —T he following v*;— •* •! 

anaouncA'd • Kilwinning (Ayrshire), Kirkby * ’• * . ■ • 

Applications to the Chief Inspector of Factorie? 

S.W.l. 

7'ht$ bst cj lacancicj compiled from our advertisement edlumnSf 
isherc full pariicuhrs will be found. To ensure notice in this 
column adveriiscmcnU must he received not later than the first 
post on Tuesday morning. 

DIARY OP SOCIETIES AND LECTURES. 

, _ Royal Society of Medictke. 

Soodl Fi< Mon , 8.50 Reception by the President and Lady 

9.15 j).ux . Address‘< by Dr. Jane Walker: Saints,, Medicine, and 
iHusliations). E.vlubits lent by the Wellcome Ihstoruml 
MofUcal Mu>i.um and b> Miss Marie Leon will he on viciv. Music and 
hglit iefK"=!hmcnts. 

CVufini Mrctiny of FcHoii'S —Tw?-, 5,30 p.m., Ballot for Election to 
1 cllossship. 

Section of Tues., 8.30 p.m., Pro{es>sor J. McIntosh. Histology 

of Some Virus Infecrioms of the Central Nervous System; Mr. A 
Fleming: InHucncc of Temperature on the Agglutination of Bacteria; 
Dr. F. T, Ridley: A New Mixing Machine. 

Scctnui of VcimalalQqii. — Thurs., 4 p.m., Cases. 

Sfcthni of OddetWcv*.— Fri., 8 p.m., Professor J. B, Cleland (LTniAorsitv 
of AdiOaidc): Difficult Labour in a Pure-blooded .Australian Aboiiginal 
Momiin; Mv. 0. F. Gibbci’d : Results of Albuminuria during Pregnancy, 

"d' 'if ■ • 7 * * p between Pregnancy Kidney 

ano ‘ ‘ . . J 

Sectit . ■ p.m., Discussion; Diathermy 

‘ : , particularh m High Blood 

1 rcfcsui’c, etc. To be opened by Piofessor Sidney Russ and l)r. T. F. 
Cotton, foUowcd by Dv. Justina Wilson and Dr. Agnes Savill. 

RoyxL College op Sunoi.nvs op England, Lincoln's Imx Fields, W.C — 
lluntenan Lectures by Xir Artlmi Keith. Jlon.. Bed., and Fri.. S p.m , 
Factors counectcil in the Giowth of the Uuuxan Boilv 
Royal Min;c.M-ori(;\L Society, 20, Hanover .Square, M'.l.— -Wed., 7.45 p.m., 

1 resulential A«hlre^s by Dr. James A. Murrav ; Staining and Structuie 
of.Tiioncd, Medk-ixe and Hvgiexe, II, Chamlos Strci-t, 
p.m.. Surgeon Commander D. H. C. Given R.N • 
Health Oigvinization on lL3f. Naval Base, Singanon*. and its. ReMilt.s 
C’lDXSEX Clinical Society, ht. George’s Hospital.— Tucs., 8.30 pm Clinical 
Meeting. * '' 

lU'NTT.RiAN Society, The ^fansloii House, E.C.— Mon., 9 nm n,,nterinn 
Lecture b\ Dr, Howard Kelly (Bnllimorc) ; Rubbing and Rca'.oning 
SoriETY or JXhDioiL Officf-Rs op HEu.m. 1, upper Montague Sti-eet WCl — 
Fxi.. 5 p.m.. Rerenl Adiances m the Knowledge of Food. Spcakeis : 
Captain Waher LHioi, M.P., and Piofe^.-or R. H. A. PUmmer. * 

POST-GKADUxVTE COURSES AKD LECTURES. 
FixLOxv.smr («.«^ Midiclne and Post-Graduate Medical ^Usocution —L ecture 
at Medical Sociidy, H. Chando^ Street, W.l. Mon.. 5 p ni * Acute 
Dnmkennc'^. Uoijal Eye Jlotpitni, St. George’s Ciieus, S.E.l • Clinical 
Dcmonj-tralAon, Thurs., 3 p.m. The above arc opr-n to members of the 
medical profe>->ioa without fee. lifthlan HoyaJ Ilotpital, St. George’s 
Fu'M-, S.E.l ; Cour-c in Psychological 3fedicine; Lecture Demonstra- 
tions on Tin-^. and Sat.. 11 a.m. : U'c Cl Is. for sciic'* of eight. Prince 
o} General llo'^pilal, Tottenham. N.15 : Course m Medicine 

Snrgcri. ami the Spi'cialtica; Dcmonstrationj-, Lcclm\-.«, Wanl Rounilsl 
arul OjH'ratjnris daiU', 10.20 to 5.30 p.m.; foe £3 Sv. for the w'cek. 
C'hihfre;r< CfiMic. and other hospitals: Post-graduto Course in Diseases 
ot CUikltcn, occupMUg morning- and some aftcrncoui ; j-ccond week. 
Cevtral Lonuo.v Throat, N*o?e, and Eir Hoshtal, Grab's. Inn Road, 
Wf.l.—Mon.. 1.30 p.m.. Hearing Teds. Med., 1.30 p.m.. Examination of 
the* Ear. Pti., 4 p.m., Demonstration of Mu«cuin .Specimen*-. 

Ho-tital ror. Sick Childefn, Gr.-.'it Onnond Street, W.C'.l.— Thurs., 4 p.m., 
stive Dij-turbanccs in Infancy and tbeir Tivatnu*nt. 

London S''ikkc. of DiRMiTOLOGY, St- John's Ho.-pjtal, Leiccs-tcr Square, 
W.C.2. — Tu' *'., 5 p.iu., Erstlicma Multiforme. Tlmrs., 5 p.ra.. Pathology 
Pcm'\n»lralion, * 

Noatir-Ki-T Lontka?.' ro^^T-GriDCiix College. Prince of Wales's General 
lIo«pi;ah Tottenham, K.15.~Mon., 2.50 to 5 p.m.. Medical, Surgical, and 


C-. ". ' ■ * ■ • !. Tucs., 2.30 to 5 p.m., Medical, 

:• : • • ■. * • CUnicy; Operations. Wed., 2.30 to 

‘ ;■ •' ‘ ( •■lies; Operationg. Thurs., 11.30 a.m.. 

** • . 1 ’ „ : ■ " lical. Surgical, and Ear, Nose, and 

: « ■ . ' . 10.30 a.m., Throat, No'?e, ami Ear 

I' ; . ' • ■ Mcilical, and Childrcu’e Difecates 

Oijnics; uperatiQn?. ' 

Roy.al Institute;^ op Publtc Hkilto, 37, Rn&scII Square, IV.C.l.— M'l'd., 
4.30 p.m.. The Medical I’raciitioncr in Relation to the Adminii-tralion 
of Justice. 

Roy.al NonniEi’N Hospital, Ifolioway Road, K. — Tucs., 3.15 p.ni., Clinical 
Manifestations of Parentcric Infections. 

Wi:sT Londo.v Hospital Post-Graduate Couece, Hamraersmitti, M'.6.— -3Ion., 


Ward Vi 
T hroat, ' 

Medical 
logy; 2 

1 p.m., ‘ 

Eye an 
10 a.m. I 

Depart m . , 

Chcmica' ].*. ■ 
Medical . • • 

Glasgow * ■ 
IVcd., 4.:.. -.v . • 
Maxchestel : . *' 

Fn., 4.3C-.* a: 


Medical Wauls, 
i.m., Children’s 
Medical Pathu- 
rs., 10 a.m. to 
itures: 2 p.m.. 
Ward. Fri., 
and Elccttical 
. lu x-ui i/epauiuent ; 4.30 p.m., 
lustration). Daily : Operations, 
p.m. 

•Tio.v.— At Western Inni-m.ary : 

*1 'hitworth Street West Braneli : 

, and Treatment. 


?8iitislj ^fbiral ^ssonation, 

OmCES, BKITISU MEDWAE ASSOCldflOX U0VSh\ 
TAVISTOCK SQUARE, Jl'.C.J. 


Dopetrtmonts* 

ScBSCRiriiONS AND ADVERTJSEirE.vTB (Financial Secretary and Business 
Manager. Telegrams ; Articulate M'estcent, London). 

Medical Secretary (Telegrams; Medisecra Westcent, London). 

Editor, British Medical Jotirnaf (Telegrams; Aitiology Westcent, 
London). . . , j. , 

Telephono numbers of British Medical Association and British Medical 
Journal, Jiuseum So61, 9862, 9863, and 9864 (internal exchange. 

four lines). — , 

Scottish Medical Secretary ; 6, Drumsheugli Cardens, Edinburgh. (Tele- 
grams; Associate, Edinburgh. Tel. r 24361 Edinburgh.) 

Irish Medical Secret.ary : 16, Soutli Frederick Street, Dublin. (Tele- 
grams: Bacillus, Dublin. Tel. ; 4737 Dublin.) 

Diary of tho Association* 

January, 

13 Fri. London: Public Health Committee, 2.30 p.m. , 

Cambi'ulgc and Huntingdon Branch: Addcnbrookcff Hospital, 
Cambridge, 2.30 p.ra. 

City Division; Clinical Meeting, 4.15 p.m. . « «, 

Chesterfield Division : Maternity Hospital, Chcsterneid. Jir. 

W. W. King on Dysmenorrhoca, 8.15 p.ra. 

DcAViburv Division : Bailey Hospital, Mr. L. R. Braithwaue 
on Chionie Pains in the Right Iliac Fossa. 

Tyneside Dn'ision Dinner. 

17 Tues. Lon<lon ; G- • ' f’ ‘ ' '*'*■' a.m. 

Lonilou: ' ' • ’ , r. t 

Crovdon . • ' Hospital. Dr. Edward 

Bach on Intestinal Toxaemia, B.30 p.m. „ . 

Lewisham Division : Clinical Evening, South-Eastern 
Children's Hospital,. Sydenham. o,. l* x 

Stiatford Division: Educational Offices, The Grove, Stmtford. 
Dr. Tlicodorc Thompson on Examination of C.'vscs for Life 

IR \Vi‘d ! ”■ ’ ■ Committee, 2.15 p.m. 

10 WA.U, ^ ^ ^ TavATAtou on 

Cithopacdics in General Practice, 4 p.m. 
ilarylelonc Division: Wellcome Hibtorical ShAScum, 54 a, uig- 
moiti Sticct, W.l, 8.15 p.m. « i i 

Wilksden Division : Willesden General Hospital, Harlcsdcn 
Read, N.W. Dr. Christine Murrell on Nursing Homes for 
Middle-class Patients, 9 p.m. , , 

19 TJiurs. London: .Tounial Committee, 2 p.m. (olietafiuu of Jt me). 

Jersey Division : General Hospital. Dr, H. 1\’. JIarett uims 

cn ‘Heredity, 8.30 p.m. _ ^ v, 

South Wales and Monmouthshire Bianch: Clinical ilccting, 
Royal Gwent Hospital, Kcivpoit, 4 p.m. 

South-lVostern nraT|.ch : Royal Devon and Exoler Hospital. • 
M'est'Doisct Division; County Hospital, Dorchester, 3.30 p.m. 
B.3LA. Lecture by Mr, P, Jsnner Venall oir Jlunipulative 
SurgerA', 4.30 p.m. 

24 Tues London : 'international Medical Sea Code Committee, 2.30 p.m. 

26 ThwKs. London ; Psvcho-Analysis Committee, 2 p.m, 

27 Fri. London : Private Practice Committee, 2.15 p.ra. 

February. 

8 Wctl, Council, iO a.m. 


BIRTHS, MARRIAGES, AND DEATHS. 

The charge for inserting announcement of Births, MarriageSf and 
Deaths is Os., which sum should he forwarded with the notice 
not later than the first post on^ Tuesday morning, in order to 
ensure insertion in ike current issue. 

biuths. 

I.MrEY.— At Capetown, on December 29th, to Dr. and 3Irs. R. Lance Impey, 
a son. ^ 

Walker, — On December 31st, 1927, at “Saxtead," MaishalJs Road, Sutton, 
Snm*v, to Svbil (nee Hwmmel), wife of Frederick Oliver Walker, 
M.R.C'.S., L.RIC.P., of 40, Yx'orple Road, Epsom, and Iloiton 3Iental 
Ho*ipital, Epsom, Surrey, a son. 

IVEnsTER.— At 1, Carden Terraco. Aberdeen, on Ncav Year’s Day, 1928, 
to Grace, wife of A. U. Webster, J/.C,, M.B., Fraserburgh, a son. 

MAREIAGE. 

Rain — CnorAXin'. — -\t St. Patrick’s Church, Sobo Square, London, W.l, 
on December 21st, 1927, Ian Stnian Robert.'^on, JLB., L.R.C.P., i-on of 
the late- Ex-Provnst John Bain of Bridgt-of-.Mlan, Scotland, to Frances 
Mary, daughter of the late IVilUara Crowley of Cork, Ireland. 


rnctcJ ari.j ruWishcO bj the British Jtedical Association, at tlicir Office, Tavistock Square, in the Parisli of St. Pancras, in the County oi Lonaon. 



STJPPXjEMEjSTT 

TO TUB 

BRITISH M EDICAL JOURNAL. 

LONDON, SATURDAY. JANUARY 218t, 1928. 

COTS’ TENTS. 


BRITISH MEDICAIi ASSOCIATION. 
Annual Mcotinff nt Cardin’— Provisional Programme: 

Ontirn or JIiistxkss 

OiTictRs or SrcriOKs 

CURRENT NOTES : 

RRiTisn SltmcAL AsfocrAxioN’ Ilonsr E.'CTtvsiov 

Some IVoek or the Week 

’ABSOCTATION NOTICES 

MEETINGS OF BRANCHES AND DIVISIONS 

CORRESPONDENCE : 

’ OpnrnALMic Bexeeit cxnER the Txsuraxce Act 


PAGE 


... 13 
... 13 

... 14 
... 15 
... 20 
... 21 

... 22 


PACE 


Tho Mlddlo Years. An Address by Sir SaniEE Sprigce, M.D., 
F.R.C.P., F.B.C.S 

Btrtlis and Deaths Registration Act. 1926. Procedure roR 
Delivery or Death Oertiticates 

NAVAL AND MILITARY APPOINTMENTS 

VaVOANCIES and APPOINTMENTS 

DIARY OF SOCIETIES AND LECTURES 

POST-GRADUATE COURSES AND LECTURES 

ASSOCIATION INTELLIGENCE AND DIARY 

BIRTHS, MaVRRIAGES, AND DEATHS 


15 

22 

23 

23 

24 
24 
24 
24 


NINETY’SIXTH ANNUAL MEETING, CARDIFF, JULY, 1928. 

Patron: His Majesty the Kikg. 

President: Siu Roeert IV. Philip, M.D., LL.D., F.E.C.P.Ed., Consnlting Physician, Royal Infirmary, Edinburgh. 
President-Elect: Sm Ewen J. Mac'leav, M.D., F.R.C.P., Professor of Obstetrics, "Welsh National School of Medicine. 
Chairman of Jlcjircscn/aftve Body: 0. O. Hat^thorne, M.D., F.R.C.P. 

Chairman of Council: H. B. Brackenbhry, M.R.C.S., L.R.C.P. 

Treasurer: N. Bishop Harman, BI.B., F.R.C.S. 


PBOVISIONAIi PEOGRAMIME 


E incoming President, Sir 
Ewen Maclean, Yvill deliver 
his address to tho Associa- 
tion on Tuesday, July 24th, 
nt 8 p.m. 

Tho Annual Representa- 
tive Meeti.ng ■will begin on 
Friday, July 20th, at 10 a.m., 
and bo continued on the three 
folio-wing week-days. The 
Representatives’ Dinner will 
take place on Friday evening, 
July 20th, at 7.30. 

Tho statutory Annual 
General Meeting will be 
held on Tuesday, July 24th, 
nt 2 p.m., and the adjourned 
general meeting at 8 p.m. 

Tho Annual Dinner of the 
Association will take place on 
Thursday, July 26th. 

The Conference of Honorary 
Secretaries will be held at 
2.30 p.m. on Wednesday, July 
25th, .ml the Sscrctaries’ Dinner at 6.30 the same evening. 

The official Religious Service will be held at St. John’s 
Church, Cardiff, on 'Tuesday, July 24th, at 4.30 p.m. 

The Annual Exhibition of surgical appliances, foods, drugs, 
and books will be open for inspectiou on Monday, July 23rd, 
from 2 till 6 p.m.; the formal opening by the President 
■will take place on July 24th at 9.30 a.m. The exhibition 
will remain open on July 25th, 26th, and 27th from 9 a.m. 
till 6 p.m. 

Saturday, July 28th, will he given up to excursions to 
places of interest in the neighbourhood. 


THE SECTIONS. 

The Scientific Section will meet from 10 a.m. to 1 p.m. for 
papers and disenssions on Wednesday, Thursday, and Friday, 
July 25th, 26th, and 27th. 

The fol/owlng Sections will meet on Three Days, 
MEDICINE. 

President: Sir Thomas Lewis, O.B.E., M.D., F.E.C.P., F.R.S. 
(London). 

Vice-Presidents: Ivor J. Davies, M.D., F.R.C.P. (Cardiff): 
A. B. Gow, M.D., F.R.C.P. (London); A. Fergus Hewat, M.D., 
P.B.C.P.Ed. (Edinburgh); Cyril Lewis, M.D., C.M. (Cardiff); 
Professor T. Gillman Moorhead, M.D., F.R.C.P.I. (Dublin), 
H. Letheby Tidy, M.D., F.R.C.P, (London). 

Honorary Secretaries ; Abel Evans, M.B., M.R.C.P., 3G, Newport 
Rond, Cardiff; Anthony Feiling, M.D., F.R.C.P., 52, Montagu 
Square, London, IV.!. 

SURGERY. 

President ; Professor A. W. Sheen, C.B.E., M.S., F.R.C.S. 
(Cardiff). 

Vice-Presidents ; H. G. Graham Cook, C.B.E., M.D., F.R.C.S." 
(Cardiff); C.H.Fagge,M.S.,F.R.C.S. (L ondon); Professor Andrew 
Fullerton, C.B., C.M.G., M.Ch., P.R.C.S.I. (Belfast); J. VI. 
Geary Grant, F.R.C.S. (Cardiff) ; "William Martin, M.B.. C.M. 
(Cardiff); Albert J. Walton. M.S., F'.R.C.S. (London). 

Honorary Secretaries : D. J. Harries, D. Sc.. F.R.C.S., 106, New- 
port Road, Cardiff; R. St. Leger Brockman, M.B., M.Ch., 
F'.R.C.S., 79, Upper Hanover Street, Sheffield. 

OBSTETRICS AND GYNAECOLOGY. 

President: T. 'Watts Eden, M.D., F.R.C.P., F.R.C.S.Ed. 
(London), 

Vice-Presidents : MARGARET M. Basden.M.D., F.R.C.S. (London); 
Arthur E. Giles, M.D., F.R.C.S.Ed. (London); Professor 
■W. Fletcher Shaw, M.D., Ch.B. (Manchester); Professor 
H. Beckwith Whitehouse, M.S., F.R.C.S. (Birmingham). 

Honorary Secretaries; B. K. T. COLLINS, M.D., F.R.C.S.Ed., 
12, 'Wind'so'r Place, Cardiff; Everaed Williams, M.D., 5, Wimpole 
Street, London, W.l. 

[1226] 



Towtu OF Si. .toil.s's UllUllCH, 
Cardiff. 






Jan. 21, 1028] 


Tho Mlddto roars. 


r BUPPLr.m:KT to the 
LD nixisii iivmcih Jovksal 


IS 


■which is inndo nml iloitiils of tlio !ivrni\KCinouis for lessening 
tho iiironvcnioiiccs for memhers of tho Associhtion during 
tho period of rohiiildiiig. 

Some Work of tho Wook. 

During tho week ending Jumiary 14th incotings were 
hold hy tlio Control IClhical Commitlco, tho lilnternily and 
Child IVolfaro Snheommittoo, tho Hospitals Comniittoo, tho 
Insnrnnco Acts Conimitto.o, the I’nhlic Honllh Coinmittoo, 
and tho Public Education in Health Coiuuiittoo. Tho main 
event of tho wook was, howovor, the conforonco on puer- 
peral morbidity and mortality, which took place on January 
11th. A full report of this will appear in an car}y issue 
. of tho SuiTI,r.JIK.N'T. 

Dcx-cJopmctif of Hospital Policy. 

On January 11th tho Hospitals Committee had heforo 
it ntv interim report from the Bubcommittoc on tho 
co-ordination of hospital pror/.sion, and framed answers 
to tho questions on this matter suggested by tho Ministry 
of Health for investigation by voluntary hospitals, hcaltli 
. authorities, and boards of guardians. The principles Laid 
down by tho committee in these answers will como before 
tho Council of the Association for ratific.ation next month. 
Tho committee also had under consideration tho amend- 
ment of paragraph 2 of tho Hospital Policy, to provide 
that practitioners permitted to treat tiaticnts in private 
wards or nursing homes attached to hospitals Khali con- 
form to certain specified criteria, and much time was 
given to a review of tho various contributory schemes, tho 
. conditions of which have hcon reported to tho ofiico. It is 
felt that the time has arrived to call another conference 


OK 

THE mDDEB TEARS. 

DiarvnRED to toe St. P.\NcnAS Division or the DitiTisn 
Jrr.nic.tT. Association, Januaiiy IOth, 1928, 

BT 

Sin SQUIRE SPIHGGE, M.D., 

EDITOR or TUE “ LANCET.” 

"When your- secretary gave mo . tho flattering invitation 
to address you, and asked mo to suggest a name for this 
discourse, I choso the. title of “ Tho hliddle Years ” without 
quite envisaging what the title might bo taken to mean. 
1 meant to talk mainly of the plight of Lister's immediate 
predecessors; but -I came to see. that their plight is, and 
should be, one that wo are all of us in, and that tho 
position of ^ the men of that jiarticular date was only' a 
striking episode in tho general story of medical progress. 
After choosing my title I found that Hciry James Ifad used 
tho same title, not only in his later biography, but for ono 
of his short stories, which had escaped my attention, and 
which, noting the complete absence of refei'cnco to it in 
the critical estimates of that much discussed author, I 
believe to have escaped the attention also of many. I read 
the story, and as it is illustrative to some extent of what 
I had proposed to Bay, as well ns of a good de.al else, a 
brief cpitorao of it may bo used as a convenient text. 

Heniyr James's narrative is concerned with an author 
who in his youtli^ has splendid ideas, and in his middle age 
still has a ^plentiful supply of them, and also a perfected 
tochniquo in which to oxpres? them, and a larger expe- 
rience by' the light of which to ei'aluate, support, or 
reject them. Those were the middle years for Henyy 
James s boro, who at this point dies — conveniently for the 
mor.al which Heni*y’ James was pointing, hut not for any 
convincing reason regarded medically. Henry Janies, so 
particular to conduct his stories with regard to probabilities, 
msido the strict limits which he laid down for himself. 
Was not a sound observer of medical hapi>onings. 

The hero thus does not live into the third phase .of 
activity— or tho reverse— in an author’s life, when tho 
tiesbncss of the ideas is lost, while tho writing m.ay have 
ecome mannered, and tho philosophy' stereotyped tlirough 


of tho medical staffs of A'oluntary hospitals to consider 
this and other dovolopmouts, and tho Hospitals Committee 
is recommending the Council accordingly'. A suggestion 
that tho A-ssociation should adopt a standard method of 
case-taking was rejected hy tho committee as impracticable. 

Insurance Acts Committee. 

Tho main busino.ss before tho Insurance Acts Com- 
mittco on January 12th was consideration of the draft 
alterations in tho Ilegulations put forward by' the Ministry 
of Health. Tho more important changes are those designed 
to put into force tho disciplinary procedure agreed between 
the committee and the Ministry and ajjprovcd by tho 
conference. Tho draft Regulations were, generally 
speaking, approved ns satisfactory, but several points 
W'cre rcson'od for further discussion with the Ministry. 
Difilculties have been, and are likely to be, experienced in 
connexion with the 'Regulation embodying tho revised pro- 
cedure for change of doctor, and the committee approved 
the draft of a letter to local medical and panel coin- 
ihittccs dealing with this subject. Tho committee also 
approved a jn-oposal by its chairman for ah alteration of 
its constitution so ns to provide for two extra repre- 
Eonlntives. It appointed a subcommittee to report on. the 
compilation of a National Formulary, and . considered the 
report of an infomal conference between rcpresentativc.s 
of tho committee, the Retail Pharmacists’ Union,- and the 
jMinistry of Health on the compilation of a list of iirepara- 
tions which should not ordinarily be regarded as medicines 
for the ]>urposes of tho National Health Insurance Act. 
This last matter will be discussed further with the Retail 
Pharmacists’ Union and the Ministry. 


reiteration. Tho pathos of the story is that ho dies in tho 
flower of his talents — in the second stage, his middle years. 
His successes now' give him the sense of progress; the good 
start is being jn.stified, which tr.agedy prevents him from 
pursuing. But his life, so far ns it was lived, is illustrative 
exactly of the growth of evei-y branch of science, as well' as 
of tho life of every scientific man. In the accomplishments 
of an individual we have the same time .stages as occur in 
tho development of a science, though it is noticeable that 
in our own calling the middle phase is often prolonged, so 
that wo see veterans displaying no sign of lost freshne.ss 
and no diminishing capacity either tor receiving or im- 
parting impressions. Remember Clifford Allbutt. For 
these fortunate few the third jihase is never reached, but 
anyhow that phase is negligible, for it means that the 
w'orker is no longer old-fashioned, blit obsolete as far as tho 
world is concerned. 

Tho analogy between the .development of the individiial 
and tho development of the particular art or science 
concerned is complete if we remember that in neither case 
will progress cease, for tho .'art or science will always be 
living and developing in a^ociation with that part of the 
work, done by the individual, which lives and develops 
when ho has passed away. No tenn can bo set to the 
progress of a doctor, for medical science will incorporate 
from the individual’s activities his essential contributions 
to the wisdom of the world. No real worker dies. He 
dies as a man, but that part of his work which adds to 
tho wisdom of the W'orld lives, whether he is associated 
with it bv name or no. Gentlemen, we may all be im- 
mortal. With evei'y -human , activity, and, very exactly, 
with the science of medicine, we are always in the middle 
years, passing from the stage of unsupported imaginings 
into the stage when experience leads to the confirmation 
of tho ono thing and experiment to the rejection of 
another; and only in this way can orderly progrcs.s con- 
tinue. The tentative and orderly progress of to-day will 
conduct, us to the organized position of the future. 

E.aulv' Medical Procress. 

Orderly progress is a phrase much on our lips, but all 
who have realized something of tho ])robiems of heredity, 
cither in the practice of medicine, in the laboratory, or 
in the profuse literature of the subject, know that the 
term "orderly progress” requires any amount of definition. 


16 .Tax. -21, 192^1 


The Middle Years. 


r TB»-. 

iBBSTxan UKoiCAZ. Jovhnai. 


ansi to tliiit Jitoratiirc i -may rofiM- you,- as woll -as -to say Hint -no .surgeons or iloctors tliii-ing the -n%ole -period 
yoiir practical knoivlcdgo. ‘It is sufficient -to .say tliat -pro- -aere-enllcd upon -to revise .seriously -the teaching that ihgy 
gross will at one time he -in accordance with a pattern had rceoived I'rom Galen, founded upon that -of -Hippowates, 

which can bo perceived and anticipated, and at aiiothor and not improved. The- position tvliich medicine in con- 

time it -may proceed by fits and starts, ii hafons rumpus nexion with the .study of natural science had reached in 

instead of with roulcmcni, the di'uin-roll -being replaced by the time -of the PtolemD 3 -s is comparable to its position in 

the tattoo. It is b\- the stages of abrupt change that we the .sixteenth century- — nothing between these dates occurred 

become .most aware of the orderly progress wliicli is always that eoidd bo i-egarded as progressively- revolutionary, -and, ' 
going on, but wliieb might otherwise escape our attention, as a matter of fact, -no -marked changes even 1:11011 occurred 

so miieh do wo take progress for granted-, it is hy the ■generally -or 'rapidly. Many -isolated ohservntions were’ 
lapid transitions, as they ocenr, wliether in professional recordotl which 'have since fallen into their proper places, ’ 
life or in scientific accomplishment, that we become aware but Whose significance at the time went unrecognized, 
tliat ivo are always in the middle years— always using the Along certain clinical jiaths Hippocrates was an uji-to-date 
IcnoH ledge of the past to make laws for the present, with physician until Harvey’s discovery, and when the Eenais- 
the belief that the knowledge of the present, throngh sauce arriicd, .while additions were being made to our 
which we may fannulate new laws, will bo revised for the therapentio knowledge, the scientific thinkers were .actually 
formation of the law.s of the future. . lo.ss ready for the doctrine of the circulation of .the blood 

Tliei’O is a groat difference in the way in which new than they- would have been nearly two thousand y-oars 
itleas aie received, and when the term “ old-fashioned ” earlier in ihi.stor.y-. Harvey arrived .with liis grand demon- 
is employed wo should be quite clear what we moan by it. stratioii of the mystery of the circiilation of the blood 
For the last thirty or forty years in the obituary notices in 1628, and had hard work to convince his own 
of a good many physicians and surgeons, all of whom acre colleagues that he a-as right; he. might have found it easier 

well knoa-n in tlieir day, and some of aliom have earned to discuss the .mechanism of the circulation a-itli the great^ 

a sccuro place for over in our annals, the phrases have .anatomists of Alexandria than with any of the eoiitcm-’- 
oectirred that a-rth sueli a one “ a tyjie of the older poraiy mystics. 'In adiat arc called the Middle Ago.s‘ of ilio 
school” or "one of the last of his day” has gone, or aorld — that is, in mediaeval days — scientific -progress -a-as ■ 
" a link with the past has been snapped ” — some'hoa- or in many directions imperceptible. 

otlicr the impression is conveyed that the sub.jeet of the It may bo noted tliat the colloquial use of the terin ^ 
obituary notice was “ old-fasbionod,” But, seeing the Middle -Ages, in contradistinction to Hark Ages, as' 
jienod of unlimited retrospect wbicli such aords as “ the referring to the fonrteontli, fiffeentli, and sixteenth ceiiT' 

[lavt” signify, a-e may ask wlmt is meant by "old- turies exactly bears out a-liat has been already suggested— I 

fashioned and we shall find that -those to a-hom tlic namely, that it is only when a big revolution of tliougbt 

I'pitbet is applied will usually be tbo.se whoso most, .occurs that the iact becomes obvious that we are living nil 

prominent a-ork was done, and a-hose cliiof claims to the middle years of a progressive state. Historians regard 
remembrauce a-erc established, just before one of tbo.so tlie Middle Ages, .roughly speaking, as covering the 
fits or starts occurred iu the progress of tlio scicnoe; just thousand years between the fall of ’the last Emperor of the 
wlien the roll of the drum is replaced by the tattoo AVest and the fall of Constantinople. 

we become aa-are that wo are iu the middle yoar.s — a-c speech ac have taken to apjilying the -terra Middle Ages 

find with a shock that things are moving. The epithet to the last quarter, or .less, of that jicrioil of n thousand 

" old-fashioned,” as commonly used, seems .to put a term years. TJie reason, of course, is that it was during t-lns 

to the period of antiquity, and to suggest that hy tom- closing eiioch tlmt revolution of thought 'made .so drnniatic 

parison a-ith the length of time which might have been g, shea- the period alien the thinking a-orld be.came awaie 

brought into discussion, the range to bo considered is brief. that it* was . in its middle -years. The belief that notmiig 

Wbcu the old-fashioned .doctor is spoken .of, while we itappoiicd at all worth counting , in the ovolntion of socie y 
imply that he is one whoso methods are out of immediate outil the liumauisiu of the •Eenaissance was easy : 

date, wo also imply that those auetliods have distinct researeh has .shown that this -view is superheial -aiiu .tn. 

affinity with the procedures of our time, Xo one would the -progress of European society has been -contimioii , 
allude to Hippocrates as old-fasliioiied ; and when, leaping .nltliongh not 'nniform. During dhat thousand y ears -le wee 
not merely Roman civilization but the Dark Ages, we the disappearance of ancient learning -.with 'the .collap o 

come to Han-cy, we should still find the epithet inapplieablo .the Roman ’Empire .and its recovery’ .or rcdiscovoiy .ns . 

to Hai-vey. Xeither of these men is of niir time; each basis upon a'JiicIi the social liistoi-y >of 'fbe laoi < ^ 

is an immortal. On the one band, their technique bears elevelop, the mental activities of man were -not a lo y 

lui relation to modern methods; and, on the otbor hand, absorbed by the struggles .between barbarian ** 

<mr toelmique is the result of discoveries and iiiveiitioiis later were they .wholly mtider the spell of aouual me. 

often closely- related to their work. And while we seem ' ecclesiastical authority. In science, bowover, .compai i 
too far aa-ay from -the era of tlie historic protagonists of a-ith political advances, .but little .did happen tin oiigioi 
medieino iu our daily routine or our practical procedure the aholo period known to historians .as -the Mideie j gv > 

to make it suitable to call them merely old-fa.sliioiied, wo .and -it -is a fair generalization to rsny, using "1'^ 1’“™ 

should bo more wrong to call them obsolete when we find 'to cover the a'liolo thousand years, .that.miedmevnl 

constantly that cyclical rocurreuce of thought may render goneriilly inconsequent and amcritica! au scicini 

some of .their observations pertinent to existing conditions. matters. ’The weal middle years of -.niedidine as » '"■”1’'° 
For this reason the exponents of early pathology should (a'hen the learning of the .past was being correlated ant i 
bp approaelicd with real respect, for in the light of -nea- t],c work of the present to form the developments 

lact.s discovered and new exporiances formulated the fancy f,rturo) occurred at the end of that thousand years, -unt 

of the past .may become the fact of tlic present; the tben -no marked diffeicnce. could have been perceived, citii 

dogmatic statements of our predecessors a-e may discover their colleagues or by' the public, between the tenets . 

to' have been not necessarily incorrect becaii.se they were one physician and those of his immediate predecessor o 
saddled in their day with explanations -which have since :),is immediate successor. In a loc.al school .of tbougnt a 

proved to bo erroneous. This position ae shall see a-ns yashion might prevail a-bicb -.would for a time p''®. 

noticeable after Han-ey’s discovery, when sound cHiiieiaiis appearance of old fashion to those who -did not iml uu® 
found that thev had been fiirni.slicd a-ith logical grounds ii„e ; but there a-as no disturbance of •fundament.als, and 
for wlmt they had been doing .already empirically. ty,is q,oppcns those who are just behind -their immc- 

Tlie whole of what are eallgd the Dark -Agc.s present in diate date liave little to warn them of their plight, nor is 
most directions a period in which Die middle years of their slowness much detected by others. The progress that 
lunimn reasoning were marked by no universal I'evolution has been going on in bbeir science has. been gradtiallv and 
of thought. Until the Renaissance, and the Reformation iargely concealed, and the lormor leaders -can remain in 
oivnrred tlie leaders of thought progressed along such close intellectual touch with the developments due to the 
traditional lino.s as had not been absolutely destroyed in the work of their followers, .for this work has been the logicaf 
fading out of the Roman Empire; and, remembering that outcome of .Dieii- own teadung, which was accepted in the 
wo are here thinking only iu terms of niedicine, wo may main. Evei-y time that revision is called for soiiiothing is 


JAN; 21, 1023] 


Tho Miditio Ycarsi 


r BvrrLrAtKirr to xn* 
LBniTIHIt M£UXC4L JOCnKAl 


rr 


suporsctli'tl ; bnt tlic more Ui:>l siu li suporsussiwus takc iilac-o 
graiUially. the more will it sooiu that a pause has oceurrod 
in. the puraiiit of knoa-ledgc; ami wo are only brought to a 
sense that the pause is imaginary by some drainatic- and 
fundanu'ntal diseovorj' — soniething which arises dc iioro, or 
is. a late fruotifieation of ideas sown earlier and arriving 
at maturity perhaps by aceident,. just as aeeident may have 
checked earlier development. 

It has- often been pointed out that between discovery of 
the burning glass and tho arrival of the miernseopo about 
two thousaml years elapsed ; if Areliimetle.s bud discovered 
the microscope the history .of the world wotild have been 
altered. 


Tnr. RrxKnios or IIauvky'h DiscovriiY, 

Xow the history of medicine was definitely altered by 
Harvey’s discovery, incidentally without the aid of the 
miernsc-Qpe, for bo had to assvnne the existence of tho 
e.ipillary connexion between tho arteries ■•md the veins 
which was demonstrated a few years later by Halpigbi. 
Harvey’s discovei'y was made and proimdgated in a fault- 
less way. lleforc.hc was ready with the exact demonstra- 
tion be taught publicly in accordance with his theories, 
and although so radical a rearrangement of all physiology 
was not, and was. not likely to lie, accejited by all and 
immediately, ho had. on his side throughont some of the 
greate.'t tliinkcns. Here wa.s no .snspoiision of one tech- 
nique for another, no isolated improvement in thcr.xpeutics, 
but a complete revolution, reudoiing immediately those 
who did not jiractise medicine in accordance with tlie iieir 
physiology not merely oUbfashioned (in the sen.so that they 
wor^, di.srcgarding some, fresh reading of an obseiwed 
phenomenon or were neglecting the ii.so of .some more 
effective remedial measure), ’Imt obsolete from the point 
of view of scicjitific mcdiciuo; tVo may see how the dis- 
covery was received by obseiwing what auticipatioii' U'bered 
it in, and what re.sults immediately followed. con- 
venient way to do Ibis will be to look at the medical science 
of two acknowledged' heroes of medicine jvluise dates cover 
the period antecedent to and just posterior to Harvey’s 
discoveiy. Ran-cy was honi.in 1578 and <lied in 1667, and 
aimonnccd his discovery of the circulation of the blooil in 
the treatise l)c il/o/ii Cordis cf‘ Sunijuiois in tho year 1628. 
Lfuacre, the founder of tlic Royal College of iMiysicians. 
tyas bone in 1460 and died in i524 — that is to say, fifty 
veal's bcloro Harvey was born, while his fame may bo 
said to have readied its apex about one buiulred years 
bC'foie the Vc Jfofii was published. Sydouham was liorn 
in 1624— that is to say, exactly a hundred years after 
Linatre's death. Ho lived till 1689, and his active caicer 
■ eoveicd the whole of the period of llarvev's iibysiologival 
"vvorK. 


liinacre was more of a scholar than a seienti.st, althougl 
ho appeal's to have been considered a great clinician. lb 
uas certainly a fine classical' schol.ir, bnt llis comidot 
reliance on tradition is shown by the fame which lie obtainei 
for bis translation of the works of Galen into Latin. Tin 
translation was acclaimed by Erasmus as being a botto 
lersion than Galen’s original Greek, work, and there seem 
no ica.son to suppose that Linaci'e considei cd that incdiein 
demanded more from liim than a translation into tin 
Jtoman dialect of the writings of tho Roman antlior win 
pie ciied to uso the fashicnahlo Greek tongue. Linacr 
certainly pei*racd a great litcraiT exploit, for it i 
sc om indeed that a translation is able to do real jnstic 
to- an original He also founded' the Roval College o 
1 liysiriam.. ol London, ami iii so doing Imd a fine con 
cep 1011 tor the organization and elevation of the medica 
pio e.-.ioii. He- was full ol tlio dignitv and virtue of hi 
caUuig: l,„t those who have studied' his work do not seci! 
0 laie icc'oided to bis credit any mission to change tb 
ovf* as it Iiad.'conic down from Hippo 

tbiniigli Galen; Ho bad no knowledge that be wa 
time.s, and medicine generallv followe 
infi almost exactly the same time a 

f • g'''^;Rpr person than Linacre, Rabelais, was man: 
woe”!-? ‘‘.f.'a’.aV content with oxi'sting knowledge. Rabelai 
ami -''Cientific knowledge of bis eiJOcl: 

unnu 11 1 medical lectures at Montpellie 

10 Moiks of Hippocrates. If there had been, anythin 


subver.sive of the early Greek doctrines contemplated by 
mcdicino Rabelais would have known it, and would have 
exulted in pnhlishing it. 

And if Rabelais and Linacre bad no prophetic glimpses, 
ire need not be mnch siirpri.scd that the doctors of Harvey’s 
day, save those in his immediate contact, were equally 
nnprcpiired'; Sydenham, Han'ey’s contemporary, seems 
not to have recogni'zcd the significance of Harvey’s work. 
This is curious in. a man who recorded his disapprohation 
of those who disliked all that is- now and who reprobated 
the iiroimdgatioii of doctrines to the public which they 
bad 'not ])revionsly beard of. But Sydonbam may have 
been in no mental contact with Harvey. He appears to 
Inivo been no student of anatomy, but a great clinical 
pby.sieiiin ; thus be was able to act empirically upon lines 
wliicli the new learning would have justified. Possibly be, 
like Sbake.s))carc — or so it is often alleged — may have bad 
some sort of knowledge that the physics of the circulation 
ivere .soon to be made the .subject of some drastic dis- 
covery, bnt tho argnmonts for Sbakcs]ieai'o’s prevision 
scorn nntrnstwortby. Shakespeare died tho very week 
that Harvey inaile bis aiinonnccmi'iit, and' the pivsbiige 
in Coriohiiuis, wherein be is held to have fore.sbadowod 
tho circulation of tlio blood, is based upon a fable in 
Ao.sop. And so far from believing that the arteries 
eontaiiiod blood, be spcalcs of them as eontainiiig spirit.s. 
Sbakesponre bad some niicx]iccted anatomical knowledge 
— for exaiiqile, bis references to the pia mater — and this bo' 
may have gained from seeing, the illustrations to Helkial, 
Ciooke’s Anofomy, wbicli was printed, according, to Sir 
Beiijarain IVard Ricbardsoii, next door to the Globe 
'I’boatrc; bnt Crooke’s work brings together all known 
anatomy of the arterial and venous system to the latest 
point before Harvey’s discovery, to which no allusion is 
made. Jsotbing that Shakosiieare wrote can be strained 
to moan .tliat lie had an acquaintance with Harvey’s pre- 
liminary studies; and Sydenham was in similar condition, 
and busked in the title of the Englfsb Hippocrates. 

How did tho exponents of medicine take 'the unpresaged 
and therefore unexpected revolution in their science? They 
responded well to tho shock' wbicli they liad received, con- 
sidering that .they were not well adapted to bear it. It is 
true that the discovery produced this situation among prac- 
titioners- of medicine — it compelled those who did not 
accept the truth to remain dependent upon, ompiricisiu 
instead of upon reasoning, but — nil important rosorvatiou 
— it did not dojirivc them of their .valuable knowledge. 
The leaders of medicine after Harvey’s discovery did not 
ill any .serious way clialicngo it, bnt they adapted tlieii- 
dinioal methods in accordance with the new teaching, and, 
to the enormous credit of the old fathers and ancient 
))ro))bots, no great alterations were needed in day-by-day 
I'ontino. In a largo incasuro the medical men. succeeding 
Harvey found themselves supplied with reasons for what 
they bad previously been doing upon traditional grounds. 
This, of course, is a veri' general statement and becomes 
less and less- accurate as the leforeiice is to periods further 
aiul further away from 1628. Xliey showed', that the 
medical man who cannot immediately get into intimate 
touch with modern, dcvclojimcnfa does not lose bis pbiJo- 
sopbie insight into his calliiig, where he is the licir to 
a long lineage of experience- and research; foe ho 
knows that many truths, when enunciated, have escajicd 
attention or been buried under irrolovancies, and be can 
console himself with the assurance that the e.sscntials, 
to which be bolds tenaciously, are the things that count 
for the good of mankind. 

'Vt’beu, ill the drawn-ont story of intellectual progress, 
there comes a discovery which revolutionizes coiitcmporari- 
tbonglifc, the whole situation is changed. A new e.ssential 
— not a new piece of technique — is added, and, as far as 
the profession of medicine is concerned, all those who ai'o 
. unable to carri- on their work in accordance with the 
discovery, and in association with its relations to their 
, tlieorj- and technique, will become old-fashioned. But 
those who find' tbomselvos- in this plight will he oh-solete in 
such measure as previous equipment enables them, or docs 
not enable them, to. adapt tho teachings of the old essen- 
tials to the differences entailed by the new learning The 
■ medical men of the seventeenth century gave a good 


18 Jan. 21, 1928] 


The Middle Years. 


r BUPrLi^iir.NT Tc Tin 
-.BniTISU ilEDICAL J>UftyAl, 


account of themselves when the}’ became suddenly aware 
that they stood in the middle years — between the iirecepts 
of the past and the learning of the future. It was a large 
gap that was suddenly bridged for them — in time a thou- 
sand years, and in biology the whole mechanism. They were 
asked to accept the new doctrines unprepared by any 
warnings ; there bad been no general advance in physics 
to helj) in the comprehension of the new physiology ; and 
there was no medical or scientific literature having any 
cii’culation. They did well. 

The Reception of Listeb’s Wobk. 

The next great revolution that occurred in onr science 
was, of cqurse, that brought about by Lister. In attempt- 
ing to estimate the position of the exponents of medicine 
seventy-five years ago, when thej’ became aware that they 
wore living in the middle years of a progressive science, 
wo must remember, it seems to me, certain things which 
counterbalance each other. On the one hand, we have the 
rise in general learning that had taken place, e.specially 
in physiology, associated with names, from Hunter 
onwards, that need not be recapitulated, and this made the 
acceptance of the new learning easier. But, on the other 
hand, the challenge was more direct, and hero the position 
of the acknowledged leaders of medicine, when their funda- 
mentals had altered, was rendered much harder, because of 
the medium of profuse literature and the rapid intercourse 
"hich had taken place between populations, national and 
international. These had changed all the circumstances of 
the world. In Harvey’s time slow infiltration of new 
knowledge was the only method for its spread, but in the 
middlo of the nineteenth century gospels could be propa- 
gated with remarkable speed, and the medical mind had to 
bo made up quickly. This was vei-y difficult for those who 
might have been compared with Lister in professional stand- 
ing — his coevals — or those who were a little senior to him- 
self, some of whom had been his teachers. While they had 
pui'sued theii' jirofession in accordance with traditional 
doctrine, he had been working intensively and for many 
years with his theory before him. They did not know, or 
at any rate had not followed in any detail, that woik; 
while he, when he delivered his great message, had not 
perfected his techniquej and had not envisaged wholly what 
his discoveries might imply. Few people, indeed, among 
his seniors or oontemporaries had the training to enable 
them to put the new doctrines to proof, even when they 
understoocl what was their aim; while Lister and his 
personal lieutenants were instructing the modern medical 
world, there was no one to instruct those whose education 
had ceased when the discoveries in Glasgow and Edinburgh 
became widely known. 

Tbe attitude taken up by the medical profession, save 
for a very short space of time and with very little dissent 
from those- W’hoso opinion reall}’ counted, was commendable. 
The senior men, educated along traditional lines, laboured 
under the drawbacks of unfamiliar procedure, and even 
when unable to become scientific exponents of the practice 
the}' realized its ideals and were insistent upon it in tlieoi'y 
and word. Speaking of surgeons alone, with their great 
heritage behind them and their responsible work to do at 
the leading hospitals of the world, the extended scope of 
treatment was welcomed; depreciation was found only in 
a few quarters. Certain practical criticisms were met by 
alteration in the original tenets, and the only sign amon" 
any of tho seniors of a sense that they wore being suj” 
jilanted was manifested by tbeir tendency to point to 
their own good results before the introduction of antisepsis. 

Wo should recall these facts for two reasons, ono of 
which is more important than tho other. Tho unimportant 
I’cason is that to some extent the medical profession is 
damaged even now by tho persistent and ignorant assertion 
made by all critics of our profession — and heaven knows we 
have enough — that Lister was impeded systematically and 
relentlessly by tho medical profession in his work; in short, 
that antiseptic and aseptic surgery arrived in spite of, and 
not because of, tho medical profession. It is usual for our 
critics at this point to make great play with the fact that 
Rastcur was not a doctor. Ho was not ; bo was an extra- 
ordinarily able chemist, and his researches canio as a 


revelation to Lister in some cases because they indicated tho 
support of discoveries made by himself quite independently 
of Pasteur. Pasteur both inspired and confirmed Lister; 
wo have here a perfect illustration of the convergence of 
science, and no question of priorities arises. Such ojipo- 
sition as there was in the medical profession against the 
teaching of Lister was limited and, considering tho 
sweeping nature of tho changes w'hich adherence to his 
doctrines postulated, lasted for an extraordinarily short 
time. 

But depreciation of the medical profession is unim- 
portant, because it is so volatile. The second reason why 
it is well to remember the open-mindedness with which the 
medical profession received the teaching of Lister is a very 
solid one. Wo may all find ourselves in the position of 
those who, in the sixties, threw in their lot with what 
they could not thoroughly understand, because they could 
appreciate the honesty of the work and the splendour of 
the prospect opened out. 

•The main difference, then, between the reception of the 
new teaching of Harvey and the new teaching of Lister 
was determined by the circumstances of tho world’s general 
progress. Iii the days of Harvey intercommunication was 
slow; in the days of Lister it had already become quick and 
easy. The consequence was that a more highly educated 
class of medical men, familiar with the results of a vastly 
improved chemistry and a greatly extended biology, was 
rapidly made acquainted with Lister’s claims and called 
upon to take a side with regard to them before any slow 
permeation of their meaning was possible. Thus, there 
were places of individual opposition, not necessarily all 
occurring exactly at the same moment or with regard to 
exactly tho same points ; and in this way intelligent doubt, 
which was legitimate at tho time, came to be regarded 
as obscurantism when it persisted. 


The Reception op Peofessional Changes. 

It is in tho obituary notices of Lister’s immediate seniors 
and of some of his contemporaries, as they from time to 
time occurred, that the frequent appearance may be noticed 
of tho epithet “ old-fashioned ” ; but I cannot recall that 
it had to be said of any of them, save on one or two 
occasions, that they were more than old-fashioned. They 
did not continue to remain opponents of the germ tfieoiy 
of disease, and so become obsolete; They obtained the 
epithet not because they had resisted the new learnmg, 
and thus become obsolete, but because the lines of their 
practices continued to rim in accordance with the more 
leisurely methods of their early training. ■ They continued 
to place before themselves as the pattern for the conduc 
of practice the family doctor, from whom they had received 
their earliest professional upbringing as apprentices, it 
was not so much the new developments of therapeutics o 
the vistas of operative surgery or preventive medicine wi 
which they found themselves in ill accord, as tho dis- 
locations of daily habit brought about by social progress. 
A confusion was produced in this way, for men udio were 
looking back at tho past in matters of daily J®' ® 

held to be unable to look forward in matters of 
Those who argued in such a way wouM have bee 
wrong at this date, though usually right. • 

thought commonly bring revolutions of conduct in ti e 
train but it happened that, for the medical profession 
in the nineteenth century, tho professional changes 
preceded, as well as accompanied, the scientific ones. 
Before Lister’s doctrines had been published numerous 
practitioners had found themselves unable to appreciate 
the public benefits which had followed upon the passage o 
tho Medical Act. Tho virtues of legislation here were so 
patent that real opposition ceased almost as soon as it 
had begun, but for many years tho falling into desuetudo 
of the apprenticeship system, the prolongation “f the 
medical curriculum and, later, the abolition of unqualified 
assistants, and finally the Act for the registration of mid- 
wives, produced qualms among many. All these things 
seemed to them to detract from tho status of the general 
practitioner as they had estimated it, honestly believing 
that the substitution in a measure of hospital teaching 
and of multiplied examinations for the training given to 



JAN\ 21, 1028^ 


T/)0 Middle Years, 


r BXTPPLEirEirr lo tub 
Lnr.iTisu Ukx>icxz« JocsKiO 


19 


pupils 01- nppionticcs by indivlihml pinctilioners was not 
adding to tlio wisdom of tim profession or turning 4 )ut a 
liiglier class of inddic scrranl. Tlicrc was inueli Hint must 
command our sympathy in those views, for many excellent 
practitioners wore bred on tlio old pattern, just ns wo 
must sympatliizo witli tlioso who seo to-day in tiio 
encouragement by tlio State of public medical activities a 
rcgvettablo limitation to tbo '’■'llucnco exercised by tbo 
practitioner, despite official manifestations to tbo contrary. 
The broad purposes for tbo futuro escape attention, 
altliougb they aro directed to making medicino a 
co-operativo career, with tbo public inking its sbaro of 
responsibility ns well ns of benofit. Thoso who advocate 
a State mctlicnl service as a remedy for certain undcniablo 
Iiardsliips do not trust tlio course that progress is taking. 
.■V mpidly changing milieu compels us always to accommo- 
dato ourselves not only to a new scicntifio outlook, but 
also to new professional habits — lo face changes in the 
conduct of practice: "one dam thing after another." 
Xow, in tbo latter half of the nineteenth century many 
doctors found their profc.ssionnl life ns much tbo subject 
of change as their scientific equipment. Their own know- 
ledgo and sincerity, and tbo passage of time, dealt swiftly 
with tbo scientific dilemma, so that opposition to Lister 
quickly becamo negligiblo; but changes in professional life 
were harder to meet. When tbo itcdical Bcgisler w'as 
established and tbo General Medical Council camo into 
boing all tbo medical men .in tbo United Kingdom who 
bad earned their position as doctors by acquiring a degree 
or a diploma from a university or a cor])oiation were 
eutcrod upon a roll call, on which, in tbo eyes of tbo law, 
tbero was no differcnco between themselves and a largo 
body of practitioners who bad not undergone tbo ordeal 
of professional examination. This they resented, though 
tho bitborto unqualified men bad conducted tlicir practices 
according to traditions received from tho masters to whom 
they had been apprenticed; they bad walked hospitals, and 
as in their day there was no great competition for a 
qualifying hall-mark, its non-possession, though a bar to 
any exalted position, was no bar whatever to tho earning 
of a reasonable income. This many of them were obtaining 
when their professional recognition came under tho Act, 
mainly in tho position of unqualified assistants. And if 
many practitioners disliked parts of tho great 5 Icdical 
Act, in hospital circles it also bad its critics. Hero 
measures directed to tho suppression of coiiipotitive 
quackery had been desired rather than a higher 
standardization of general ■ medicino. Tbo educational 
reform entailed by tbo. Medical Act was viewed with mixed 
feelings by many members of hospital staffs. Although a 
peiiod of active reform had set in hero, and appointments 
were no longer given in a barefaced manner to young 
1 elatives or to feo-pn3-ing apprentices, many ornaments of 
10 nietropohtan medical schools, at any rate, must have 
considered httlo short of shocking their inability to mould 
tbo educational activities of tho institutions with which 
ley wero connected in accordance with their own ideas 
fi fact, much of tho public value of 

tho Medical Act escaped tbo attention of tho wholo pro- 
fession in those days, and it seems that it still escapes the 
comprehonsion of many who write to-day about the dis- 
ciplinary functions of tho General Medical Council. Thoso 
who considered that things had been running smoothly, 
and noticed that many additions had been inade to tho 
profession s general wisdom and technical skill, did not 
allow that the point was reached at which standardization 
"as necessaiy. But with the passage of tho Act many 
abuses which had previously run side by side with tho 
geneia piogiess became patent; tbo need for confining 
practico to tlioso who had received, and could prove that 
they had received, adequate professional training was 
lecognized, and tho grievance against tho admission of 
miqualified persons to the first Hee/htcr quickly died down, 
io-day, tho person who makes it a hardship that he or she 
cannot practise before gaining a legal status because of 
i : having had. no professional educa- 

if to 't-n y except in thoso sill3' circles where 

It IS still behoved that the .liealer ivlio works by the light 
P'^PisossGs some ktiowledge that is unrevealed to 
0 simply attend hospitals and pass examinations. 


Those who continue to point out that because the appren- 
ticeship S 3 '.stem had its virtues wo should return to it aro 
n littio in simihir ca.se. Thcio i.s no doubt that tho system 
worked wcdl before medical education was standardized, 
and tlicro i.s equally no doubt that, from the day when tlio 
Geiieriil Sfcdical Council camo into existence, with the 
rospoiisibiIit3’ of admitting to tlio llcgistcr onl3- thoso wiio 
could pfovo tbo regularity of tlicir training, tlio system 
was doomed. Tho Council took over tbo inspection of tbo 
examinations wbicli gave access to tho roll which it was 
its function to keep at its proper standard. This it 
was perfectly nblo to do wlicn dealing with universities 
and corporations, anxious to co-operate in raising medical 
education to a high general level and in preventing any 
dowiigrado competition between their various selves, but 
it would ho cntiicl3' impossiblo for a similar scrutiny to bo 
instituted of the toiicliiiig which apprentices derived from 
musters of vai^-ing capacities and ideas. 

So tho men of tlio sixties were faced with vast altera- 
tions in fundamentals, both in science and practico; they 
met the situation bravely, and progress in both directions 
proeooded, wherever possible, with tlieir active support-. 
Tho occurrcnco of grievances and sometimes of real hard- 
ships must bo common to these revolutions. Many wero 
offended at the inchisioii of non-qualified practitioners upon 
ilio first Ucgislcr; many were seriously embarrassed by 
loss of apprentices and later by tho inability to employ 
unqualified assistants; and, later still, many felt that the 
registration of midivivcs was an encroachment upon pro-^ 
fcssional tcrritor3-. It is fair, also, to remember that those 
who had been practising medicine without qualification, 
and who proved unablo to obtain the necessary testi- 
monials, found exclusion from the first professional roll 
a severo blow. Tbo necessity which all men feel to-day for 
the co-opcratioii of tbo public in the progress of medicino 

and this is a prime object with the Ministry of Health 

— is presenting iis now with problems of a similar sort; 
and will present us with more. These are things which, 
every wliit as much as startling advances in science, recall 
us to tlio fact that we are living in Sliddle Years. 

I will bring to 3'our attention ono man, because his 
scientific and professional attitude was typical of that 
assumed by the best practitioners of the day throughout 
the country, while he would inevitably have been called 
old-fashioned by those who judge from exteriors, or who 
write careless obituary notices. When I first joined the 
staff of the Lancet, now over thirty years ago, what might 
ho called tho ethical side of medical practice was watclied 
over for ns by Dr. James Grey Glover. Glover, of small 
stature, ivitli large mobile fe.atures framed in side whiskers, 
wore ahva3-s the customary black suiting of the professional 
classes in tho sixties and seventies, and drove to the office 
in a typical doctor’s phaeton on certain appointed days. 
He was courteous in manner, precise in speech — no word 
of slang ever soiled his lips. His leading articles — he wrote 
ono every week for more than a quarter of a centuiy* — were 
solemn, for ho took his re.sponsibilitics seriously, but his 
judgements wero charitable even though bis tolerance did 
not extend to certain classes of offenders. On Saturdays ho 
pla3'cd bowls on a beautifully kept lawn in the suburbs. 
It would have been impossible for the casual observer to 
guess that this exterior wont with great clinical knowledge 
"carefully kept up to date, with an unerring appreciation 
for the professional difficulties of colleagues, and with an 
intimate perception of the circumstances which brought 
these difficulties about. Glover sat upon the General 
Medical Council as one of the direct representatives of tho 
profession from the year 1886 , when they Avero first 
appointed, until his retirement fifteen years later, and 
during the whole of that time he showed himself able to 
appraise correctly the changes that wero taking place. In 
welcoming the measure for the registration of midwivea 
he was held by many of bis constituency to liai-e mis- 
represented their views, but Glover was firm in believing 
that tlio interests of the medical profession were only 
vested when it was clear that to disturb them would also 
be opposed to the public weal, and he pointed out that 
tho midwifei-y service of tho country was a scandal to 
remove which many sacrifices would be properly endured 
Thoso of us who had to read the Andria for matriculation^ 



20 Jan; 21,. 1928] 


Association Noticesi 


r suPPLEiirsT TO Tint 
LnniTisn KlCDicii. Jovavtx. 


or wlio liappened to- see- the Westminster play this year, 
well know that nearly two thousand years ago the raid- 
wife’s hahits were held to he a source of grave danger 
to Homan women, so that legislation to deal with grosser 
abuses at the close of Queen Victorials reign cannot ho 
called hasty. Glover found that it had been undid}' 
delayed. Ho was a- pcrfeet example of the way in whicli 
the medical men of his day met a difBeult situation, where, 
in the cause of the public good, they had to press forward 
in trying circumstances and overcoming logical reluctance. 
In attitude and manner he was of the older sdiool, hut 
from the beginning lie was an ardent convert to scientific 
progress, and gradually he became a champion of pro- 
fessional icforni. We may want such men in the coming 
time. 

The Heception or Futuhe. Reve.u.inos. 

May I pull together the threads of a rambling discourse? 
I have attoinjited to point out that medicine has gone 
always forward, but that this continuity has been marked 
by fits and starts, which especially bring home to us that 
we are ever in the middle years of jirogre-ss. These may 
react painfully upon us, through troubles both in scien- 
tific work and professional routine. The practitioner has 
responded finely, realizing that he was receiving proofs, if 
Iiainful iiroof.'!, of progress ; and where it has proved im- 
possible for him fully to appreciate the significance- of 
the changes, there ha.s been no long- re.-^ontnient of them; 
on the whole they have been welcomed enthusiastically, 
and many who remained old-fashioned on the surface were 
among the heaitie-st converts to new doctrines. We have 
had fine examples, and it may behove us to imitate them in 
circumstances that will bring us similar troubles. 

It is an ei-ror to-iiold that any jicriod in the world’s course 
ha.s been unprogressive, although- sometimes tho progress 
has been unnoticed because uiipunctuatcd by any striking- 
happening. As far as physios, phy.siolog}-, and their medical 
accompaiiimonts are concerned, a real period of stagnation 
occurred in the Dark Ages ; what is usually termed tho 
Middle Age.s being tho time wlien tho world woke up, not 
only to a .sense of the past, but a vision of tho future. 
Even in the Dark Ages, however, the cause of medicine was 
bettered indirectly by the progress that had been always 
going on in sneiety generally, for inquiring and ]ihiloso|)hic 
minds were encouraged thereby. Wo receive hei-e a proof, if 
one were wanted, that the .science and art of medicine 
draw sustenance from all knowledge, general or special. 
Progre.ss i.-; noted whenever the evolution jn-oceeds by a 
short cut 01 - mutation, and then those bred of the older, 
doctrines may find it hard to adjust their views. But often 
their scientiiic adaptation is more rajiid than their accept- 
ance of new professional methods, and wo must be careful 
to discriminate between the old-fashioned man and the one 
who is jmsitivoly unreceptivo of scientific revision. 

Those are tho things I have attempted to bring out, and 
partieulai-ly for this i-eason ; Many irisc and thoughtful 
persons believe, from work ivith which they arc personally 
coucerned, that we are on the edge of big things, and it 
may bo diffu-nlt to estimate tboii- signific-anro solely by 
knowleilgo that wo ourselves may have acquired. We '.shall 
have to i-ec-ogiiize more fnily tlic signification of the growing 
connexion between- chemistry — that is, hiocheniisti-v — 
biology, and iisychology as they may he reflected in thera- 
peutics. Jfuch which wo consider to bo medicine proper 
may take its place in a large synthesis, when we must bo 
willing to make use in a fuller way of the additions to 
knowledge made by workers along other s|iec-ial lines than 
onr own. Sncli work we must regard as reinforcements, not 
om-i-oacliments. Distor Iind a better field than Harvey, 
because the medical constitueney was better educated. AVe 
skould do better even than Lister’s couteinporaries. 

That the middle years in which ice live, and in which 
tile progress has been steady, and indeed woudcrhil. may 
shortly he marked by another such move forward as the 
seventeenth and nineteenth centnrie.s saw is the strong con- 
yiciion .shai-cd by many scientific men. Tiie .sort of con- 
yergence bet ween physics, hiolog}', and psi'chology to wliich 
allusion is ticinp; made must influence both tliouglit and 
social i-nstom. if it occui*s; for its significance is nothing 
less than a belief tlrat we arc clearing up mysteries on the 


way to. the solution- of basic problems of life. Investigations 
into inanimate matter have hitherto constituted practically 
all our researches, hut it would seem that when wo look 
into tho nature of tlio processes whioh underlie radiation 
and chemical combination we may he enlarging tlie .scope 
of our inquiries indefinitely. Wh'atevor the inquiries may 
lead to in- which physicists, are at prc.sent engaged when 
studying the emission of liglit by tlie atom the results may 
have a- message to biologists, and thus to those whos’e 
researches- arc directed, towards the central nerroiiB .sy.stom ; 
while psycliologists are attempting to analyse the structure 
of- mind by procuring, evidence obtained from the messages 
of light to tlie brain. May I refer you- to Archim.e.dcs, the 
latest voliime of the admirable 'Eo-day and To-morrow 
series, wherein. Mr. L. L. AVlivte- sots out the daring 
aspirations of modem physics. Tliis small volume indicates 
that the fundamentals of physic.s ami psychology are being 
disturbed in tho same way as the fundamentals of medicine 
and .surgery were disturbed by tlie work of Harvey and 
Lister. We may have a liarder task tlian either tlie con- 
temporaries of Harvey or of Lister, heoanse of the little 
time tliat may he- left for hesitation and the wide range 
of laiowledgn- that will be presented for assimilation. To 
Harvey’s contemporaries the new.s filtered tlirongh slowly, 
and they adjusted them.solve.s slowly. To Lister’s con- 
tempofarics it was presented more rapidly and in greater 
volhme, hnt they were prepared to receive it by the 
levelling up of their scientific eqni[)meiit in. their own 
subjects. But if. tiie new jump comes, ns some predict, tlie 
iiiforinatibii will reacli ns tlirongh channels where medical 
learning, . as we now define it, will- not suffice for its 
appraisement. Old-fashioned then wc may become, hut 
let ns not he found resisting the truths as they emerge, 
and as we become painfully aware that we are in middle 
years. ____________ 

^ssoriaiiBn fitslms. 


PROPOSED BUXTON DIVISION. 

NOTICE is hereby given to all concoruefl of tlie following, 
proposal made by the Council of the Midland Branch : 

Xhafc there be formed a Buxton division of the Midland- 
. Branch, of area as follows: Tho municipal borough of 
Buxton ; tho urban districts of New Mills and Bakcwcll; 
and the rural districts of Chapel-cndo-Brithv Bakewell; 
aud Hayfleld ; and that the area of the Derby Division 
be modilied accordingly. 

Written notice of tbe-proposal has been given to the Derby 
Division, and the matter will be determined in due course 
by the Council of the Association. Any member affected' by 
the proposed change, and objecting thereto,, is requested to 
write, giving reasons therefor, to . tho Medical Secretaix 
British Medical Association House, Tavistock Square, London,. 
W.C.I, not later than February 21sfc, 1928. 


BRANCH AND DIVISION MKETINGS TO BE HELD. 

Bath and Bristol Brakch. — A meeting of the Bath aud Bristol 
Branch will be held at the University of Bristol on January 25th 
at 8‘p;m. A debate on liospital policy will be opened by Professor 
E. W. Hev Grovc-s, and the opposition' will be led by Dr. B. G. A. 
Baskett. "The motion- is : That tlic needs of tlic comninnity 

require *a belter hospital service than that provided by tlic vohm- 
tarv SYslem." The chair will be taken by Professor Francis Francis, 
Pro-Yice-Chanccllor of the University of Bristol. 

* Bikmingham BnAKCif : Coventry Division. — A meeting of the 
Coventrv Division -will be held at the Coventry and 
shire, fiospital ow Tuesday, Febniavy 7th. Dr. BraiKfoid 
(Birmingham) will read a paper on cholecystography* 

CiRMiNCHAM Branch: Nune.<ton anh TA^rwonm Division.— A 
meeting of the Nuneaton and Tamworth Division will he heid at 
the Nuneaton- General Hospital on Wednesday, February oth. 
Mr. C. A. Raicon will read a paper on surgical conditions ol 
the biliary tract. 

Border Counties Brancjt ; Dumfries and Galloway^ -Division.-— 
The nest meeting of the Dumfries and Galloway Division will he 
held in tlic Koval Infirmary, Dumfries, on Friday, Ja'nuaiy 27th, at 
4 p.m., when "finance, hospital accommodation, ethical qu^lions, 
medical charities, and other important matters will he ctmRiucreu. 
The Executive Committee will meet at 3 p.m. Professor Bramwell 
Ii.os fixed February 21st as the date of his lecture, the subject or 
which will be announced later. 

Border Counties Bn.tNCn ; Enccisit Division. — meeting of tho 
English Division %vill be held at Maryport on Friday, •January 
27th. Dr. J. N, Douglas Smitlr will read a paper on the cany 
treatment of puerperal sepsis. 


JAN. 21, 102r] 


Mootings of Branches and BMstons. 


r BUI^PLnMPh’T TO .Tlffl 
DSlTIsn 3IBDICAL JOCCTAL 


2f 


Ksskx llnANCii ; T^onTii-I^^ST Ks'jkx Diviptox. — A clinical nJcetiog* 
of tiic Korlir-Kn^t i>scx Division Avill he held in Die out-nnLionts* 
hall in the Ks^cx County Hospital, Colchester, on Tlnu-sday, 
January 2Gtli, at 8.15 p.m. Prolcssor "\V. P. Pi.xon will give an 
address on the known cfTccts of alcohol in llic human body. 

Fife Puaxcti.— A clinical meeting of thn Fife Hranch will bo 
held in 'the Maternity TIomo» Townsend Ci-esccnl, Kirkcaldy, on 
Thursday, Jommn' 2Glh, nt 3.30 p.m. Bir David Wallace will give 
an address on mluopacdic Irealmcut and orguinzatiou in the Kast 
of Scotland. 

•Kext BnAKcn : DAKTronn ;Uivisiox.~A meeting of the Dartford 
Division will ho held nt the King Kdward llo'Jpilal, West Hill, 
Dnilford, on Wednesday, January ^(h, nt 3 p.m. Dr. liindsay W, 
Batten will give n British Medical As.soeiation Lecture on the 
medical aspt> 2 ts of child welfare clinic work. 

LAKCAsninc akd CiiEsiiinE DnAxai : Hyue Dryisiox. — A clinical 
meeting has boon arranged by 'the Hyde Division for Thursday, 
Jnmini'y 26tli, nt 8.30 p.m., in the Hyde Child Welfare Centre, 
when cases will he shown by memhc!*s of the Division. It is 
hoped "that cYcr^’ member NviU endeavour to show at least one 
ea'^e and, if possible, more; they need not necessarily he rare 
cases, a well marked type is often of greater clinical interest. To 
facilitate the arrangements mtunhci’s arc requested to notify the 
Eccretary not later than Saturday, .Tinumry 21sl. 

Metropowtax CouxTiEs Brakch : City Drvisiox.— A meeting of 
the City DiviMon will he held -at -the Metropolitan ITo^pilnl, 
Kingsland Road, F., on Tuesday, iFchruarv 7th, at 9.30 p.m. Dr. 
H. C. Semon will discuss diagnostic pitfalls in dcnnatology. 

■Metropolitan Coukties DnAxar : Finchley Division.— A meeting 
of the Finchley Division will he held' at the Finchley Memorial 
Hospital on Tuesday, February 7th, .at S.'-IS p.m. Dr. F. M. R. 
Walshc will give a Icclin-c on Vaith healing. 

Metropolitan Counties BRANni : Hampstead DmsioN. — A meeting 
of Hie Hampstead Division will he Iicld at the Hampstead General 
Hospital on Thursday, Fcbniarv 9tli, at 8.30 p.m. Dr. 6. Monckion 
Coponian, F.R.S., will discuss inoporahlc cancer. 

Mbtropoutan Counties Branch : Lamreth and Southwirk 
Division. — A luccUng of the Lambeth .and Southwark Division will 
be held nt the Lambeth Carlton Club, CoUlharbour Lane, S.W:9, 
on Wednesday, .Tanuniy 25th, when Dr, A. G. G. Thompson, 
the newly appointed medical ofTiccr of health for Lambeth, will 
rcjd 'a paper-on the -Schick test. 

Metropolitan Counties Branqi : North Middlesex Division. — 
At the meeting of the Kortli Aliddlescx Division to be held on 
■^Vcd^csday, January 25th, Mr. T. II. C. Banians will read a 
paper on local immunization and antivirus therapy. 

Metrotolitan Counties Bp.anth : St. Fancr-^s Division. — A 
meeting of tlio Si. iPancrns Division will he held at the British 
Medical Association House, Tavistock .Square, W.CJ., on Tuesday, 
Irbruary 14lh, at 9 p.m. Dr. Alfred Cox, O.B.E., Medical 
Soerelnry to the British Medical Association, will give an address 
medical man iu .public life: his duties and rospon- 

fiihilities.’* 


Metropolitan Counties Branqi : Wandsworth Division. — A 
meoimg ot the Waudsworlli Division Avill be licld at Stanley’s 
B^taurant, Xavender Hill, on Thui'sdav, January 26th, at 
P***k*» ‘"hyu Dr. Brinckcr, senior mehical officer in charge 
of Llie mf^cciious diseases department of tlic London County 
Connell, will 'lecture on diphtheria and diplithcria irnniiiiiizatioii. 

North of England Bp.anch : Bishop Auckland Division. — A 
meeting of the Bislion Auckland ‘Division will be held at the 
BiMiop^ Auckland, on Friday, January 27th, 
at 6 p.m. Dr. J. C. Spence will give a lecture on medical 
j'nicrgencic« in -children. 


Kortu^f England Branch-; Stockton Division. — At the inocling 
ff.‘ Division to he held on Friday, January 27th, 

-M** . 1 - ^-'‘‘^kinson i(Newca.stle-on-Tvnc) will read a paper on 
the Umgnosjs of pulmonary tuberculosis. 

i^ORTii OF England Branch ; Sunderx.and Division. — The annual 
dance arranged by :tlic Sunderland Division in aid of B.M.A. 
'Charities will lake place on Tliuisday, February 2nd. 

Dxford and 'Keadino Branch : Oxford Division. — A meeting of 
.\A 7 1 Division ^11 ;be .held an -the Radcliffc Infirmary on 

Wednesday, January 25lh, .at .2.30 p.m. -Dr. T. Izod Bennett will 
lecture on recent advances in -pcniicious .anaemia. 

Southern Branch; Fortsmouth Division. — A meeting of the 
To.UnioulIi Divnioii -will be dicld on Thursday, February 9tb. 
A Bntisli Medical Association Xccture will be delivered by 
1 iDiessor Hugh Maclean on j'enal disease and high blood pressure. 

- Surrey BitANim : Croydon Division. — A meeting of the Croydon 
Division will be held at Uic Ciovdoii General Hospital on 
Wednesday, .January 25lh. Dr. .H. W. Southgate will give a 
cctuie (lemQnstiation on modern laboratory metbods as an aid 
to clinical medicine. Ficccdcd by 'tea at 4 p.m. 

Surrey Br.ANar : Guildford Djvision.~A meeting of the Gmld- 
fon Division will bo held at the Boyal Sun-cy cSuiity Hospital, 

GmUlford on I'hursdav February .2iid, at 4 o’clock. Sir D'Ai*cv 

i^t 3*45 p ni **** address on the history of medicine. Tea 


Yorkshire- JIrakot,: Dew’scury .Division. — A meeting of tho 
Dcw.sbury Division will he held at the Dewsbury Infirmary on 
Friday, February 3rd, at 8.15 p.m. Dr. G. Cooper (Leeds) will 
read a paper on radiotherapy. 

YoRKSinRE Branch : ’Leeds Division. — A meeting of the Leeds 
Division will he held in llic General Infirmarj*, Leeds, on Friday, 
Fobniary 17th, -at 8 p.m. Dr. John Parkinson will give a British 
l^tcdical Association Lecture on common difficulties in cardiac 
diagnosis. Lantern slides will ho shown, and there will be a 
disctisston after the lecture. 

Yorkshire Branch : Wakefield, Pontefract, .and Castleford 
Division. — A mceling of the Wakefield, Pontefract, and Castleford 
Division will ho hold nt the Great Bull Restaurant, Westgate, 
Wakefield, on Thursday, February 9lh. Mr. A. Gough, surgeon .to 
the Women’s and Children's Hospital, Leeds, will lecture on 
menstrual diseases and the menopause. Snppcr (2s. 6d.) at- 
7.45 p.m. will precede the lecture. 


Meetings' of Slrattcljcs anbf Btlrtsions. 


Cambridge and Huntingdon Branch : Cambridge and 
Huntingdon Division. 

Dixcti.fsion on Facilities for Maternity Worl:. 

The last general meeting of tlic Cambridge and Huntingdon 
Division was held at Addenbrooke’s Hospital, Cambridge, on 
December 23rd, 1927, when Dr. Apthorpe Webb presided. It was 
called primarily to di«cti63 the provision of new facilities for':tbe 
treatment of maternity cases in the town and county of Cam- 
bridge. Owing to the fitormy •weather there was only ,a small 
atlendauec. • 

After some discussion arising out of the minutes of -the last 
mceling, Dr. Stevenson opened tlie discussion on maternity treat- 
ment by moving ; 

That this Division favours a public rnaternitv' liorae, not in 
connexion witli tlic Jiospilal, for the treatment of maternitj* eases 
in the town of Cambridge. 

Dr^ Young formally seconded the motion. Dr. Stevenson urged 
the necessity of a move being made by the Division in a matter 
about wliicli public fooling was very strong in Cambridge. He 
outlined a scheme which ho thought would meet -present require- 
ments, although probably the county would Xave to make 'Special - 
arrangements. 

Dr. Ellis moved the following amendment : 

That this Division favours on arrangement between the -public 
health authorities conccrncti and Addenbrooke’s Hospital for the 
.provision of nn untc^natal department and maternity -home, to -wbicli 
may l>e admittotl for confinement those eases in which abnormality is 
expect!^ or is known to c.xist, cases from homes which -ore con- 
sidered insanitary or othenvisc unsuitable. 

He favoured one single scheme for town and county (although 
the two resolutions were not necessarily antagonistic), and .wen5 
on to describe past and 'present conditions, and tho futile efforts 
which, nt dittcrent times, had been made to improve them. 

Dr. ApmoRPE Webb fonnally seconded. 

Dr. Canney (honorary surgeon in charge of .the gynaecological 
and obstetrical department at the hospital) gave his views, and 
urged fhat nothing should be done in a hurry. He -admitted -the 
past and present unsatisfactory arrangements for treatment of 
pathological cases at liospital, but prophesied a big improve- 
ment within the next few* mouths. The basis of any scheme was 
the ante-natal clinic, and bis ideal would be a home, rim in 
connexion with the hospital (not of necessity within its 'pre- 
cincts) with .about twenty beds, a pre-natal idepartment, and -an 
*' out ’’-district, so that students and midwives could be trained. 
The expenses should be divided among the .authorities concerned 
according 'to Ireatment received (or beds occupied). 

Dr. Robinson described the Oxford scheme, which seemed to 
work well. It was an csscutial part of the Radcliffe Infirmary. 
•He advised making use of existing institutions -bcfoi-e beginning 
to build. Both lie and Dr. Laird had no desire to see the worS 
taken out of the “ family doctor’s ” hands, and tlicj* urged that 
any scheme should be limited to “ the treatment of necessitous, 
abuomial, or filthy cases," roughly. 

Most of those present took part in the discussion. It was 
pointed out that the -Ministry of Health would favour, and help 
to support, a scheme run in connexion with the hospital. 

The general feeling was in favour of Dr. Ellis’s resolution, but 
as the attendance was so poor, and as the question was important 
and merited more interest being taken in it, on the motion of the 
Ciwirman the discussion was adjourned until January IHh. 


Nyasaland Branch. 

A WELL attended meeting of the Nyasaland Branch was held at 
the Masonic Hall, Zomba, on November 5th, 1927. Interestin'^ 
papers were read by Dr. W^ Milne Tough on some suggestions for 
the improvement of the African in Nyasaland, irom the medico- 
ccoiiomic point of view; by Dr. W. SIcFarlane on the treatment of 
malaria by intravenous injections of quinine; and by Dr. H. M. 
-Shelley on recent theories on the biochemical patholoo’v of 
nephritis. It is hoped to hold regular meetings of the Branch*^€very 
three months. ^ 


Bnn^T clinical meoling of the West Somerset 

Tue<:t]'iv^V and Somerset Hospital on 

will ^ paper open to discussion 

^r** 4*1 (Tlminster) entitled " A to Z. 

at 4^30 pm general practitioner.” Tea will be served 


Southern Branch : Fortssiouth Division. 

The annual dance arranged by the Portsmouth Division in aid of 
medical .oharifics look place at the Savoy. Cafe, Sonthsca on 
January 10th, when there was .an attendance of about 450 *Thc 
function was in every way a striking success, and the A^cooiAfinTi’a 
Charities Fund will benefit in consequence. ® 


■ 22 JaK. 21, 1928] 


Births and Deaths Registration Act. 


[ SUPPLEJfJiNr TO TH» 
DniTisn uepiciz, Jomtfkt 


BIRTHS AND DEATHS REGISTRATION 
ACT, 1926. 

Prooedtoh tor DELivERr OF Death CERTrFic.WEB. 

Aa a result of the Births and Deaths Registration Act, 
1926, inquiries have been made by members of the British 
Medical Association as to nhat risk, if any, they ran if they 
handed death certificates to informants instead of obseiTing 
the usual method laid domi in the Act — namely, of sending 
tho certificate by post in a sealed envelope to the registrar 
of births and deaths. 

The Medico-Political Committee of the Association 
decided to ask the Registrar-General to furnish a state- 
ment on the subject for publication in tho British Medicai, 
JouRN.tt, and he has complied vith that request. The 
statement is as follows. 

Statement by the Registrap.-Generai,. 

The Births and Deaths Registration Act, 1926, requires that 
a certificate of cause of death given by a certifying medical 
practitioner shall be " delivered forthwith ” by him to the 
registrar. The Act does not, however, prescribe tho means 
or method of delivery, or limit a practitioner as to the course 
which he may adopt for discharging his obligation to deliver. 
He is presumably entitled, therefore, to employ any means 
available to him of delivering tho certificate — for example, by 
handing the certificate in person to the registrar, by employing 
a messenger, or bj' posting it. 

It has, however, been generally taken for granted that the 
method of postal delivery is that which practitioners would 
normally adopt; and for this reason representations were made 
during the passage of tho bill on behalf of the medical pro- 
fession that free postage should bo conceded in respect of tho 
postal transmission of such certificates. This concession was 
accordingly made, and arrangements are in force for the supply 
to practitioners of postage-free envelopes. But, as already 
indicated, practitioners are not restricted by law to delivery 
through the post; and it is thus open to them to adopt other 
means, provided that such means do in fact discharge the 
practitioner’s duty of delivering the certificate forthwith to 
the registrar. 

Cases have, however, occurred in. which it has appeared 
that the normal method of postal delivery might involve some 
hardship to the relatives of the deceased, and that such hard- 
ship could be obviated if the relative, on visiting the practi- 
tioner immediately after the death, could receive the certificate 
and convey it at once to the registrar. In such cases the 
Registrar-General has expressed the opinion that there is 
nothing to prevent a certifying medical practitioner, if he 
thinks fit to do so, from making use of the relative as his 
messenger for the delivery of the certificate. Emphasis has, 
however, been placed upon tho fact that the responsibility for 
delivery forthwith ” will still remain "with the practitioner, 
for the following reasons : 

Where this course is adopted the procedure will bear a strong 
superficial resemblance to the procedure in force prior to the 
1926 .\ct. Under the pre-existing registration law the duty 
of a certify ing medical practitioner was strictly limited to a 
duty to hand the certificate to the relative or other person 
qciclified to be informant of the death. A separate duty was 
placed upon the person receiving such certificate to deliver 
it in his turn to tlie registrar. It has thus appeared possible 
that if a practitioner adopts a means of delivery so closely 
rcsembliug the old procedure an erroneous impression might arise 
that his legal duties in: the matter were identical with those 
under the old l.aw. This is not, however, the case. Under the 
old law the practitioner’s responsibilities were at an end upon 
liis handing the certificate to the relative. Under the present 
law, however, if in the circumstances described above the 
practitioner bands the certificate to the relative, be merclv 
entrusts it to liim as to bis agent, and himself remains respon- 
sible for the delivery “ forthwith ” of tlie certificate to tlie 
registrar by his agent. 

With regard to the consequences of any failure in the 
prompt delivery of the certificate, the Eegistrar-Gcner.al is 
advised that where delivery is by post, Section 41 of the 
Births and Dc.aths Registration Act, 1874, would apply. The 
efiecl of that section is that the date on wliicli the letter coii- 
taiiiing t!,e certificate would he delivered in the ordinary 


course of post to the registrar is to ho deemed to bo the 
date on which it is received ; and a practitioner who proves that 
tho letter was “ pre-paid, properly addressed, and piit into the 
post”. at a date which satisfies the requirement as to " forth- 
with” is thus protected against any postal miscarriage of the 
certificate. No such protection attaches, however, to any other 
methods of delivery; and in this sense a practitioner adopting 
any other method does so at his own -risk. If lie commits a 
breach of his obligation to deliver forthwith, he ' is liable on 
summary conviction under Section 11 of the 1926 Act to a fine 
not e.xcceding forty shillings. But the question whether he took 
reasonable steps to ensure delivery forthwith would doubtless 
be one of which full account would be taken before any pro- 
ceeding.s were instituted, and which tho court, in the event of 
proceedings being taken, would consider in deciding what was 
the appropriate penalty. 

The Registrar-General has expressed the hope that practi- 
tioners ■ would adopt the method of delivery through tho 
informant in particular c.ases where hardship would arise if. 
delivery were made "by the normal postal method. He has 
thought it. necessary to draw attention to the legal aspects 
of the adoption of the alternative method, however, for two 
reasons. In the first place, it has seemed desirable that practi- 
tioners adopting that method should not he misled by the 
similarit}' between that procedure and the procedure prescribed 
by the pre-existing law. Secondly, it has appeared undesirable 
that, owing to any such misapprehension or for any other reason, 
the profession should he gradually led to adopt that method in 
normal circumstances in preference to the metliod of postal 
transmission. The system contemplated by the Act' under which 
the certificate reaches the registrar from the practitioner without 
the intervention of the relatives is one which has long been 
advocated by the medical profession, and is supported by 
weighty advantages. Moreover, the present form of certificate, 
it will ho remembered, contains some provisions which depend 
for their utility upon direct transmission. It would thus be 
regrettable, in the Registrar-General’s opinion, if postal trans- 
mission as a normal practice in ordinary cases were substantially 
departed from in favour of delivery through the informant, 
however necessary and desirable that course may he to avoid 
inconvenience and hardship in occasional instances. 


(jpomsponbfttrf. 

Ophthalmic Benefit itnUcT Ihflnsvrqnct Act. 

Sir— I t is high' time that finality should be reached in this 
matter; and, above all, the scheme must be simple. This is 

f‘sseTitial for smooth working. ‘ . ui ' * ii. 

The half-guinea fee would no doubt bo agreeable to the 
approved societies, and would immediately solve their problem. 
But wuld it satisfy the oculists? I think- not. A large number 
of the besrmeu o^bject to anything fees than one guinea; a 
larger number still would he satisfied with ‘7, 

on one condition-tliat every 'vas referred to t ie ocuUsts^.^^ 

I do trust that no clinics will be established. T y . 
money they will have all the disadvantages of the outpatient 
rp”aTtmen7of the hospital-namely loss » , ^d 
to the workers and “ members, leading to noise ana 
to haste and hurried work. I tr"st the choice w be^^^.^^ 
of “clinical evenings at the A Equipped, 

already in existence, and are comfor ably ^linic, con- 

Six cases would be . quite Already had a hard 

sidering that both p^ient and ‘ ^ 7meal. Thus 

day’s work, and be saved and this saving 

the extra expense of a clinic woulcl be saieo, 

could be added to the fees. . rnnveniently for tho 

The oculists are already placed ®7ents do not care 

patients throughout the kingdom, . P“ e-mes; it adds to 
{o he dragged to clinics away j'lTvenings the fee 

the cost and inconvenience. On these ® • to make an 
would he the flat fee, but »"y, Pf t”! on condition 
appointment at other times should a) o guinea. Many 
that he personally makes up the flat fee save their 

would .avail themselves of this advantage, ® . examination, if 
time and allow them the privilege of a fuller e 

"'"A^There must be cases (though few in oTThe 

a consultation with a second oculist, a and these 

highest authorities in ophthalmology should TJicv should 

oculists should be paid a higher fee, say /i^^onilals and 

all be on Ihe honorary full staff of ^emld also 

be recognized as the “ highest trihunal. * ^ ^ 

belong to the ordinary panel, if they so deciclca. 



Jan. 21, 102S] 


Naval and Military Appointments. 


r EVPrLmir.h'T TO tnr. 

Medical Journal 


Then I think the i>nro oculists should bo on a scpnralo panel 
from Iho general practitioner oculist. It must bo obvious that 
men making a side-line of ophthalmology can hardly bo equal 
to those wlin spend their whole lives on their specmlt}*. Some 
will claim, doubtless, the reverse; but we must rememhor that 
every medical man (specialist or general practitioner) has had 
a full education in the whole range of inedicino and surgery. 

As regards the higher fee for the highest authorities; at 
present they are doing these , consultations at the hospitals, 
without feej and I think it is unfair on them and ungenerous 
of prosperous societies to accept this charity. At all events, the 
first consultation should bo paid for. I niav add I am not quo 
of these authorities, in ease anyone may think I am pleading 
myo^vn dmso; but I am ashamed of getting tlicir help without 
any fee being paid them, for under no condition can these 
societies bo described as poverty stricken,” and the highest 
members of the profession certainly deserve their reward. 

To sum up, I advocate that : 

(1) .Vo clinics he rstnblifhcd^ They will fall into tlio hands of 
some corporate body, and probably, end. up by being absorbed 
into the hospital system, as the Iiondon County Council school 
clinics have been in many eases, to the loss of freedom of the 
medical ofliccr. 

(2) Clinical hoitrs to he arranged at oculists’ houses to suit the 
convenience of the local insured (proh.ahly evenings). On these 
evenings the flat fee to bo charged. 

(3) liy special appointments (at the desire of the patient) at 
convenient times, the patient to bring up the flat fee to one 
guinea. No oculist to use any kind of pressure. 

(4) A special class of consultants to ho fonned for extreme eases 
needing a second opinion, to be paid a higher fee, and these 
consultants to bo drawn fi-om the honorary .*-tafrs of the hospitals. 

(5) Lastly, the ad\*antagc of having opticians present at tlie same 
time as the oculist is, I tiiiiik, greatly exaggerated. There is little 
extm trouhlc in going aftcrrk'ards to the iioaicst optician on flic 
panel; he can be seen at all hours of the day. I do not think 
it would help the oculist much to have him alwavs present. 

— I am, etc., 

London, \v. * Erkest C. Ar.Noi.D, F.R.C S.Eng. 


iiabal anti iftilitani Jtppainiincnts. 

. nOTAL NAVAL .MEDICAL SERVICE. 

Snrgwn Captain J. R. Muir is phiccd on the retired list with the 
rank of Surgeon Rear Admirnl. 

Surgeon Captain W. W. Keir, C.M.G., to the Tamar for R.N. Hospital, 
Jlong-Kong. (Amended appointment.) 

Surgeon Commander* L, R, Warlmrton, O.B.E., to the rietort/ for R.N. 
Hospital, Haslar; A. G. Taylor to the Cyclops \ .7. R, .V. Clark-HaU to the 
Mctlic.'il Department, temporary, frupernumcrary : G. D. 
Walsh to the tolumbinn for' Port Edgar Base: 0. Malcolm to the 

/resident for course at R.A.V. 31cdical OiTicers* School of Instruction. 
Surgeon Lieutenant Commander A. II. Harkins to the Delhi. 
burgeon Lieutenants' J.' 0. Holmes to the Harebell: F, W. Bc-'lev to ( 
Jiroke. 

, ROYiLNiv.iLA'pLONTEEr.-Rnstnvr.. 

Probationary Surgeon Subliciitenantfi T, F. Tiernev to the Calliope 
for training; F. Davey to the Ark Hoyal for training. 


^ . ROYAL ARMY 3IEDICAL CORPS. 

D.S.O., from the seconded list, is restored 

to the establishment, ' 

Captain L 11. Ba>dey, 3I.C., to be Major, May Ist, 1927, with precedence 
(substituted lov notincatiou in the 

Lieutenant W. D. Speedy resigns his commission. 


royal air force medical service. 

(Rouorary Squadron Loader) E. F. N. Currey rclin- 
commission on completion of service, 
r light Lieutenant F. K. M jlson is transferred to the Reserve, Class D ii. 
ri,.ir^ J’ ^^nd'.I. M.agnor to’ be Flight Lieutenants. 

FKing Officer G. T. 0 Brien to Home Aircraft Depot, Ilenlow. 

REGULAR ARXIY RESERA'E OF OFFICERS. 

Royal Ahmy Mojicil Conrs. 

on^a™o:mt'ornn.caUlf “■= 

11 ^^' J'?’*""! havinit attained the ajte limit of 

liability to recall, ceases to belong to the liesenc of Officers. 

INDIAN JIEDICAL SERVICE, 
fliti,.? of Captain T. R. Kbanna are placeel temrorarilv at -the 

* “! Gorernraent of JIadras for employment in the Jail 
sen.iecs of Captain G. If. Fraser are placed at the 
diM o=al of the Government ol the United Provinces. 

'ervd C.I.E., V.II.S., has retired from the 


be 


territorial ARMY. 

' ‘ Army Medir^l Corp?. 

T.A. Reserve of OITicers, to 
'*^3 precedence aa from October 6th, 1923. 

?.* A® confirmwl in his rank. 

'^ith W. M. Brown, late R.A.M.C. (Special Reserve), 

D/K.'oSS;':r„^ac.g™ I-ieutenants'A. C. Crawford. 


Lfciitenant R. M’alkingshaw, )I.C., resigns his conmiis-rion. 

To he Lieutenant : C. C. Ryan. 

Snperniiitterary for Serdcc irith O.T.C . — Captain J. F. .Sniitli resigns 
his cominissioi), 

COLONIAL MEDICAL SERVICES. 

Dr. \V. E. Burton appoinlinl Principal Jlcflical Ofilcer, British Ilondaraa. 
Dr. C. T. MneCarthy appointed Medical Officer, Federated Jlalay States. 
Dr. D. Duff appointed an .\ssi^ta^t Director of the Medical Ser\'ice, Gold 
Coast. Dr. S. L. Brolilcr appointed a Senior Medical Officer, Gold Coast, 
Dr. K. K. Grieve appointcil a Senior Jlcdical Officer, Nigeria. Dr.- 
IV. E. Clover appointed a Senior Jledical Officer, Nigeria. Dr. R. B. 
Hawes, jr.R-C.P,, appointed Profes«or of Medicine in the College of 
Medicine, Singapore. Dr. V. L. Ferguson to bo Cliief Medical Officer, 
St. Lucia. 

The foUov/ing appointments Jinvc been made by the Secretary of State 
for the Coloni*:s during tlie month ended December 31st, 1927 : Jlessrs, 
J. 1*. M. Donnelly, W, S. Tbonia.s. and Reid appointed Meilical Officers, 
West African * .Med iiLal Stafl. Dr. A. V. G. Price appointed District 
Medical Officer, Britidi Solomon Islands Protectorate. Mes’srs. E. C. 
XTorrla and W. B. Holmes appointeil Sfcdical Officers, Federated ilalay 
Stales. 3IifiS V. E. K. Stuart apnointed Lady Jledical Officer, Federated 
Malay States. Lieutenant E. L. Robert appointed 3IedicaI Officer, Straits 
Settlements. 

VACANCIES. 

BlllKKNIlctD (:Exr.r.lL IIOSPITII. — Casually Ifouse-Siirgcon (male). Salary 
£100 per annum. 

nmsnxCHiM Conron iTiox. — Senior .(ssistaiit Medical Officer of Health. 
Salary £1,100 per annum. 

Rlytii Ronoccil. — iledical Officer of Health, School Medical Officer, and 
Port Mcilical Officer.’ Salary £800 per annum, rising to £SOO. 
nouiixEMOL-ni : RovtL Vjctorii txD West Hixts Hosfitu.— M edical Officer 
to the Venereal l)irea.«cs Treatment Centre. Salary per annum. 

niiiciiTOX : Rova Sussex Cou.xty Hosrmi.— (1) Honorary Dental Surjieon. 

(2) Honorary Assietant Dental Surgeon. 

Dri-STOE GlilRDl.txs. — .Second As-sifitant Medical Officer at the Southmead 
Hospital. Salary 1200 per annum. 

Cimbridce: ADDEXDP.ooKr.'s HospiT.ii.— (1) House-Surceon (male). (2) 
House-Physician (male). Salary at the rate of £130 per annum. 

CiROirr Roi ' ■ '2) House-surgeon- 

Surgical . A'l) Two House- 

Pliysiiclam . ^ala^y at the rate 

of iso per nnuuni. ’ ’ ‘ . 

CovilvtRY City.— Depul.v Jlcdical Officer of Ileallh. Salary £7o0 per 
annum, ri.«ing to il.OCO. v, , . 

Durham County Council*— M edical Officer of Earls House Sanatorium 
for Boys.* Salary £150 per annum, rising to £500. ' • * 

Edinburgh: Royal EniNBuncn Hospital for tSicK CmLDRc??.— Honorarv' 
.Vssistant .\urol SAirgeoji. 

ELitABCTii Garrett A.NDEn£ON* Hospital. Eiislnn Road, N.-W.—fl) Assistant 
RadioloWvt (part time); ilOO r<>*‘ annum. (2) Assistant Pathologist 
(part time); J.150 per annum. IVomen. 

Evixjna Hospital for Childrex, Southwark, S.E.L— House-Physician 
(maic). Salary at the rate of £120 per annum. 

German* Hospital, E.8.— Honorary Assistant Surgeon. 

Great Ou«eburn’ Isolation CoMinTTEE.— Sleclical Officer of the Isolation'- 
Hospital. . Retaining fee £5 r«r annum and £1 for eacli ease admitted. ■ 
Great Ousiijurx U.nios.— ifediral Officer and Public Vaccinator for the 
Acomb District, Salary £43 15s. per annum and vaccination fees. . 
Hemel Hempstead ; West Herts Hospital.— R esident Medical Officer. 
Salary £150 per annum. 

Hockley Provident Dispensary, Birmingham.— 3Iedical Officer (male).: 
Emoluments lost year £960. 

KnatALLic Parish Councte— 3Iedical Officer -and Public Vaccinator. 
Salary £100 per annum. 

Leicester Royal iNnp.UARV.— Casualty House-Surgeon.^ Salary at the rate- 
of £125 per annum. 

Lochcarron Parish Council, Ross-shire. — iledical Officer and Public 
Vaccinator. Salary £135 per annum. 

London Feuale Lock Hospital, 283, Harrow Road, W.9. — Second HouTe- 
Surgeon. Salary £150 per annum 

Manchester Roy.al iNnRiLARY.— .\ssistant Jledical Officer. Salary £35 per 
annum. 

Metropolitan Hospital, Kingsland Road, E.8.— Ophthalmic Surgeon. 
Oxford: Kadclifpe iNnniiARY and Col’NTy Hospitae — (1) Honorary 
As^Jistant Orthopaedic Surgeon. (2) Assistant .Surgeon at the IVingfield 
Orthopaedic Hospital, Headington; salary £600 per annum. 

Preston: Roy'al IsriRii.ARV. — ^House-Surgeon (male, unmarried). Salary 
£150 per annum. 

Royal Waterloo Hospital for Children .and M’omen, M'atcrloo Road, S.E.L 

Non-Resident Casually Officer for Out-patient Department. Salary 

£1^ per annum.' 

Sr. Albans : Hill End Mental Hospital. — S econd .Assistant Medical Officer 
(male, unmarried). Salary £450 per annum, rising to £500. 

St. Bartholomew's Hospital, E.C.— .Assistant Surgeon. 

St. John’s .Hospital, Lewisham. — .Assistant Physician. 

St ALary’s Hospital for AVomen and Children, Plaistow, E.13.— Resident 
ifedical Officer and Assistant Resident Medical Officer. Salary at the 
rate of £175 and £130 per annum respectively. 

St Pancr-AS Parish. — J unior Assistant 5Iedical Superintendent at the 
Higiigatc Hospital. Salary £325 per annum, rising to £375. 

Salford Cmr. 3Iedical Officer of Venereal Diseases Treatment Centre. 

Salary £750 per annum. 

Shanghai Municipal Council. — .Assistant Radiologist in the Public Health 
Department. Salary 700 taels a month. 

Sheffield Royal Hospital.— Resident Anaesthetist (male). Salarj* £80 per 
annum. 

Somerset County CouNnL.— (1) Assistant Tuberculosis Officer. (2) Tuber- 
culosis Officer for Bath City. (3) Tuberculosis Officer for M’estem Are*. 
Salary £000 per annum each. 

Stoke-on-Trent : North Staffop.dship.e Royal Intip.mart. — (1) Honorary 
Assistant Surgeon. (2) Honorary Anaesthetist. (3) Honorary Assistant 
Aural Surgeon. (4) Honorary Assistant Orthopaedic Surgeon. 

Tonbridge Union.— Resident Assistant Jlcdical Officer at the Institution 
at Pembury (unmarried). Salary £273 per annum, rising to £350 
and fees. - _ 



24 21 , 1928 ] 


Association Intelligence and Diary. 


r BUPPiElfEJJT TO TUB 
LBniTjBn Medical JonnKiL 


Tnuno : Roval CoIlK^YALL iKTirviiAnv.— House-Surgeon. Salary £170 per 
annum. ^ 

iT^'OLvnniusrrTON* akd Midund Counties Eye iNnRMAnT.— House-Surgeon. 
Saiarv £200 o rear. 

i^^ooEAvicir AKD DiSTP.iCT Wau JlEMOBia HOSPITAL.— C^) Radiographer. (2) 

Dispenser. 

Cebtjpyin’G 
announced : 
deenshi 
tions 
S.W.l. 

Medic.al Referee under the Workmen’s Cosn’ENSATroN Act for the Bath, 
Caine, Chippenhatn, Devizes, Frame, Hungerford, Malmesbury, Marl- 
borough, Melksham, Kewbury, Swindon, Trowbridge, and Warminster 
County Courts (Circuit No. o2). Applications to the Private Secretary, 
Home Office, S.W.l, by January Slst, 

r/tw list of vacancies ts compiled from our advertisement columnSf 
lohere full particulars will he found. To ensure notice in this 
column advertisements must be received not later than the first 
post on Tuesday morning. 


APPOINTMENTS. 

Page, Miss Hildo W., M.R,O.S,, L.R.C.P., a member of the Honorarv 
Medical Staff of the Willesden General Hospital, Harlesden Road, 
N.W.lO. 

Bourasky, a., M.B., Ch.B.Leeds, P.R.C.S., Assistant Ophthalmic Surgeon, 
London Jewish Hospital, Stepney Green, E. 

Btallman, J. P. H., M.B., B.S., P.R.C.S., Honorary Surgeon, Children’s 
Hospital, Kingsholm, Gloucester, 

Westminster Hospital.— Howsc-Pliysfcinn ; S. Segal, M.R.C.S., L.R.O.P. 
Housc-Surpeons ; P M. Robottom, M.R.C.S., L.R.C.P., and p. A. M. 
Boutter, JI.R.C.S., L.R.C.P. . 

.Citifying Factory Surgeons,— S. Bolton, M.D.Ed., for the Halifax 
District, York; R. W. Davies, M.B., Ch.B.Ed., for the Rushden District, 
Northampton j L. C J. Edwards, M.R.C.S., L.R.C.P., for the Braintree 
District, Essex; C. P, Oliver, jun., M.B., B.Ch.Camb., for the Maid- 
stone District, Kent; 0 . H, Warner, M.D.Lond., for the Southwell 
District, Nottingham. 

DIARY OP SOCIETIES AND LECTURES, 

_ ^ ^ . , Royal Soctety of JfEDiciKE. 

Section 0 / Oaonfoloffy.— Mon., 8 p.m., Mr. Arthur Bulleid : Apical Infection 
Mr. H. P. Baylvs; Necrosis of the Mandible. Mr. "W. Rushton : An 
Abnormally Small premolar, 

Seaton of Medicfne.— Tucs., 5 p.m., Discussion; Cardiac Infarction 
(Coronary Throinbosish To be opened by Dra. John Parkinson and Evan 
Carey Coombs, Geoffrey Hadfield. J. A. Rvlc. 
and B, T. Parsons-Smith. ^ * 

Seoti‘on ^ Tropical Diseases, Dermatology, and Comparative Medicine^ 
Wed., 6 p.m.. Special Discussion : Cutaneous Mycoses in the Tropics 

mitflel“dP(De™a\olo^Vl- Dr. A. 

Section 0 / Bolncoloov.— Thurs,, 5 p.m., Dr. Adolph Schott (Bad Kauhoiml : 

f Carbon Dioxide Thermo-saline Springs in the Light of Stodorn Research 
ection of Urology.— Thuts., 8.30 p.m., Ciinical Pathological Eveninir 
cction of Disease in Children. — Fri., 0-30 p.m., Cases. - 

<’t Epijiemiologu.— Fri., 8 p.m., Dr. J. E. McCarlnev and Dr. 
William 0 . Harvey : Observations on Diphtheria Cartiers. 

Royal CoLUor. or Surgeons of England, Lincoln’s Inn Fields, W.C2 — 
Mon., Wed., and Fri., 5 p.m., Hunterian Lectures by Sir Arthur Keith i 
Factors concerned in the Growth of the Human Bodv, 

MraiCAL Society of London, 11, Chandos Street, W.i,— Mon., 8.30 pm.. 
Discussion ; The Treatment of Pernicious Anaemia. To be opened bv 
Professor F. R. Fraser, followed by Sir William WiUcox and Dr 
Herbert French. 

Medico-Legal Society, 11, Chandos Street, W.I.— Thurs., 8.30 p.m., Mr F 
LlewcUyn-Jones, B.A., LL.B. : Drunkenness and Civil and Criminal 
Study in Comparative Law, to be followed by a 

® ®‘- •'*'''= Hospital. Leicester 

oquarc, w.c.<;.— Fri., <1.15 p.m., Clinical Cases. Tea at 4 p.m. 

POST-GR.\DUATE COURSES ANI) LECTURES 

Memcm AssociTOox.-Lecture 

Detect and its Imt^rtance t^thl Community^’ qIiTcp Ifarg™’ 

The above lecture and demoaslratlons a?e opS tS ro?mbe?s ‘S*'the 

len't’on apphe" lilm ” ’^'^'’I’"“oaate tees payable, and syllabus 

CEKTR.U, LOXDOX THROIT, KOSt, *XD ElR HOEFIIAL, Gray’s Ina Pond mn 
-Mon., 1.30 p.m.. Examination of the Pharynx and N^Jhar™;' 
Wed.,, 1.30 p.m.. Examination of the Kose. Fri^g p m , JlStU^e ifasai 
oinusitis. 

East London Hospital for CnaDREX, Shadwell, E.l— Thur «5 a 

Borne Congenital Deformities. ^ 

Hospital for Sick Children, Great Ormond Street, W.c.l — Thura a r, « 
Rectal Prolapse In Childhood. -^nurs., ^ p.m., 

London School or Dermatology, St. John's Hospital, Leicester 
W,C.2.— Tues., 5 p.m.. Exfoliative Dermatitis. Thura., 5 p.m., E?^tro^ 
therapeutics. 

North-East London Post-Gr.addate College, Prince of Wales’s Generii 
Ilnsnitnl- Tottenham. N.15. — Mon.. 2.30 to 5 D.in.. Sredionl. s,rvrr:»..i J 


Clinics; Operations. 

Royal Institute or Petue Health, 37, Rus«ell Square, W.C.I.— Wed 
A.30 p.m., Tests for Drunkenness, particularly in relation to Motor 
Accident^. 

RoYiL SoRTnrr.N ITosruvL, Holloway Road, X. — ^Tues., 3.15 p.m., Indigestioiu 


W’r.st London Hospital Post-Graduate College, Hammersmith, W.6.— Mon., 
10 a.m. to 1 p.m., Genito-urinary Operations, * * 

"Wards; 2 p.m., Surgical Wards, Gynaccologl 
Tues., 10 a.m. to 1 p.m., Medical Ward Visit, ' 

Diseases; 2 p.m., Medical Wards, Throat, > 

Wed.. 10 a.m. to 1 p.m., Children’s Medical Out-patients, Medical 
Wards, Demonstration in Medical Pathology; 2 p.m., Surgical B'ards, 
Eye Department. Thurs., lO a.m. to 1 p.m*., Neurological Department, 
Demonstration of Fractures; 2 p.m., Eye and Genito-urinary Depart- 
ments, Gynaecological Ward. Fri., 10 a.m, to 1 p.m., Gynaecological . 
Operations, Dental, Skin, and Electrical Departments; 2 p.m., Throat, 
Nose, and Ear Department; 4.30 p.m., Carbohydrate Tolerance Tests 
(Demonstration). Daily : Operations, Medical and Surgical Out-patients 
nfc 2 p.m. 

Glasgow Post-Graduate JIedical Association.— A t Eye Infirmary : Wed., 
4.15 p.m,, Cases. 

Manchester; St. Mary’s Hospitals (Whitworth Street West Branch).— 
Fri., 4.30 p.m., Intestinal Indigestion in Children. 

Sheffield University Post-Graduate Clinics. — A t the Royal Infirmary : 
Fri., 3.30 p.m,, Eye Cases. 

5 Britislj ^cbiral. ^ss 0 cifttiott. 

OFFICES, DTilTJhU MnVJCAL ASSOCIATIOy UOVSE, 
TAVISTOCK SQUARE, IV.C.:. 


Depayimonts* 

SunscRlPllONS AND ADVERTISEMENTS (Financial Secretary and Business 
Manager. Telegrams : Articulaie IS’cstcent, London). 

Medical Secretary (Telegrams: Bledisecra Westcent, London) 

Editor, British JIedical Journal (Telegrams: Aitiology ueslcent, 

rShM. number, of Drilish H/cilical Association and ■’''''''f 

Journal, Museum 9351, 9862, 9363, and B8M (internal exchange. 

Sco-msn MroniiL SEcnET.iiiY ; 6, Drumslieugh Gardens, Ediaburgh. (Tele- 

crams • ■ : 24361 Ed'dl’iirfili.) 

Imsfi itoic “ 

grams: Dublin.) 

Olat-y of tho Association, 

J,A\lTARY. 0 YO n m 

24 Tues. London : Inlernattonal 3Iedicnl Sea Dr. 

IVcsl Somerset Branch : Taunfon General Practi- 

W. H. Maidlow on Subjects of Interest to tnc 

25 Wed. Londlfn*; OpiShalmic Committee. 2-30 j t Oel,atc on 

Bath and Bristol Branch: Universitj oi 
Hospital Policy, 8 P-ni. HosnUal. Hr. H. W’. 

Croydon l^iYision: Croydon Genera) B P» Clinical 

Southgate on Laboratory Methods ns an 
Medicine, 4 p.m. he Dr Lindsnv W. Batten 

Darltord Division: Wpifate Clinic B'ork. 

on the Medical Aspects of Child pc Carlton Club, 

Lambeth and Southwark * q q, Thompson on the 

Coldharbour Lone, S.u.s. L»r. a, u. 

Schick Tc't. , \tt. T TT C. Benians on Local 

^ImmunizatfoTand'^ T. Uod Bennett on 

Oxford Division: R?dc)me Infirmary, i^r. 

Pernicious Anaemia, 2.30 p.^. o « m 

25 Thurs. London : rsycho-AnaIvsis Committee 2 p.m- jj Townsend 

26 Thurs. Branch : Olimcnl on brthonaedio 

?J?^rm”eit''ind'=“organ®i'/atrtn\he East of Sootland.- 
division: Clinical Mooting, Hyde Child IVcUare Centre. , 
Ko®fh-S‘ Essex R'llixo^il nn'the KMwn 

Ss“^} 4jr?s”i?e°1S'n?ilft,^'Lavender Wll 

''Brl’M'nrte^’on’Dipbtho^^^^ diphtheria Immunmatmn. 


27 Fri. 


London’’;'"Frivate mclice committee. 2.W P.-™;_ ^ A„eh. 

’’I'anJ’. dT’j? a ^peMO Sn S?edical Emergencies m Ctuldrcn. 

and" Galloway Division: Royal Infirmary, Dumfries, 

'i"js.ra. B«9h*‘7h‘l.j"™count?e?’Brnneh): Haryport. Dr. 

?y!‘"fr"LioKSn on Puimonary 
-.rviT^nTi Division : Dr. '' . 


Stockton 

Tuberculosis. 


February. , , . ttnr. r’/bnimitlce, 2.30 p. 

1 Wed. London : idvn^y, s[irr\y^ County Hospital. 1 

2 Thurs. Guildford ^piviS)on Ro>a^ 


Sir 


5 Fri. 
8 Wed. 


London : Lunacy. Law i ....ncv - • 

““li!i'r^-;^?,^^fo“n"iue7st'orrof jedioine. 4 p.m- 

b&”Sar.v. Dr. G. Cooper on 
Radiotherapy, 8.15 p.m. 


births, marriages, nna 

ensure insertion in the current tssue. 

BIRTHS. -iv to 

D.ivwson.-On January llfh, 1528 “t 6, t™«'s''Ed^’a"s’on. ^ ’ " 

tho wifo of Norman Davidson, O.^E., F.R.aS.M., “ to 

Davidsox— O n January ^2m, at j Davidson, a ^on. 

Dr. Jessie R. Davidson (n^c Brash), wife of vr. o. 

Bell,— A t The Green, Lockerbie, on December 31st, 1927, Janet Turner 
Douglas, wife of Dr. John Stothnrt Bell. t- cordon Brown, 

Brown,— O n January 15th, 1928, at Past Master of the 

M.R.C.S., late Surgeon of the City of London loiice, au t 
Society of Apothecaries, aged 65. ^ 


l-ruucd anu publuhecl Lj the Oritlbh Medical .\EiOciation. at fbcfrOaSerTavStocirSquatc. in The Parish of St. Pancras, inlheCouaty of Lonaon. 


STJPPL3B]]NdDE]SrT 

TO THE 

BRITISH MEDICAL JOURNAL. 

L" ■■■' ■■ ' ■ ■ — - ' ^ -J f 

LONDON, SATURDAY, JANUARY 28Tn, 1928. 


COTS’ TENTS. 


PAOE 

THE rUBLTO HEALTH SERVICE SALARY SCALE 25 

CURRENT NOTES 1 

SiE Dawsos Williams 26 

Some Work or the Week 26 

. Remuneuatios or Nos-PnorEssorjAL TnAcnEP.s akd Reseaeoi 

WORKEES 27 

The B.U.A. asd Medical CnARiTiES 27 

The Halt-yearlt Isdexes 27 

ASSOCIATION NOTICES 27 

MEETINGS OF BILVNCHES AND DIVISIONS 28 


THE PUBLIC HEALTH SERVICE JIINIMHil 
SALARY SCALE. 

ATTiinDC or tite Bnirisn Medic.il Associ.ation'. 

Oun coiitomporaiy Education, the official organ of tho Asso- 
ciation of Education Committees, in its last week’s issue 
printed a leading article lieadcd "Education and medicine: 
a question of renuincration,” which sliows a snrjirising 
forgetfulness of history, and some misnuderstanding of tho 
facts of the caso, wliicli is perhaps not so surprising. It 
may tlicroforo be of some ndvantago to take note of the 
article in question, in order that tlio position may bo more 
clearly uiulorstood. 

Tho British Medical Association’s present “ Scale of 
Miniimim Commencing Salaries for Afcdical Officers in tho 
Public Health Soi’vice ’’ is not a wanton, illogical, hastily 
conceived scheme adopted merely with a view to enhancing 
the material interests of such officers, or of memhors of tlio 
Association. On tho contrary, it is tho result of rcry 
prolonged, almost painful, consideration in all its details, 
^e first official move by the Association in the direction of 
improving tho salaries of these medical officers was taken 
in November, 1918. 'Tlio matter was brought definitely 
before tlie Bepresentative Body in the following year, in 
1020,. in 1923, and in 1924, and it was not until 1925 that 

scale was finally adopted. Those unfamiliar with the 
Biitisli Medical Association’s machinery may' be informed 
t at, in accordance with the Articles of Association, on all 
these occasions tlio operative resolutions had boon given 
two months puhlic uotico and received endorsement by a 
two-thirds majority. The scale, moreover, within the pro- 
fession, has received the unqualified approval and support 
of the Society of Medical Officers of Health, of the Women’s 
Medical Federation, and of influential and independent 
persons connected with tho medical press. 

Moreoi or, throughout tho whole of their deliberations, 
extending over this period of six years or more, and 
since, tho Council and Bepresentative Body of the Associa- 
lon liave had even more regard to the interests and 
requirements of public health than to tho emoluments of 
tho ofiiccrs concerned for their own sakes. Indeed, it was 
An part the anxiety of the Alinistry of Health as to the 
c ass of medical practitioner who was entering the public 
ea t 1 service that mado tho matter so important and 
Airgent. Tho Assoemtion found tliat “ uot only is tho 
seivice not attracting promising graduates, but that 
requentiy medical meii give up public health work and 
0 in o general practice hecauso they are imahle, even 


PACE 

CORRESPONDENCE i 

A EEPEREirooM OK OrimiALiiio Besetit? 31 

NAVAL AND MILITARY APPOINTMENTS 31 

VACANCIES AND APPOINTMENTS 31 

DIARY OF SOCIETIES AND LECTURES 32 

POST-GRADUATE COURSES AND LECTURES 32 

ASSOCIATION INTELLIGENCE AND DIARY 32 

BIRTHS, MARRIAGES, AND DEATHS 32 


after years of experience, to make an adequate income as 
a puhlic hc.alth medical officer.’’ Tho seriousness of such 
a state of affairs with regard to pvihlic health administra- 
tion is too clear to need emphasis. It was agreed by all 
tlio medical organizations concerned, and by tho Ministry 
of Heaitii, tiiat an improvement in the salaries and pro- 
spects of these officers was necessary, and that in order 
to effect this, and to break down the narrowing tendency 
of many local authorities to look only to their own staffs 
when any opportunity of promotion occurred, it was desir- 
able to systematize salaries, and to convert the public 
health service ns far as possible into a co-ordinated whole, 
in whicli wider prospect of advancement would he given. 

Furtlier, it has never been the desire of the Association 
to “ impose ’’ upon, or “ demand ” from, a local authority 
submission to its scale of minimum salaries, or to "fix the 
romnneration without reference to the employing autho- 
rity.” Over and over again, almost from the very 
beginning, the Association has made it evident that it 
wished rntlior to iicrsuade authorities of the reasonable- 
ness of its Ecalo and of the public considerations on which 
it is based, to give opportunity for the observations of 
authorities, and to meet their representatives in conference 
before the details of the scale were fixed; to modify those 
details in any or every particular if found necessaiy as tho 
result of such oh.s6rvatious or conference; and to insert 
an arbitration clause under which, if there were dispute 
between tho professional organization and tho local autho- 
rity in individual cases, the matter should be placed before, 
and determined by, the Ministry of Health. 

In May, 1923, a letter in this sense was sent to the 
various associations of local government or education bodies 
inviting tlicir comments and promising them consideration. 
From these several associations either no reply was received 
or it was intimated that no scale of any kind would receive 
their countenance. Nevertheless, the Bepresentative Body 
still asked the Council to meet, if possible, the representa- 
tives of these associations, and authorized it to make what- 
ever alterations in the scale might he necessaiy. In 
October, 1923, with great difficulty, a conference attended 
by certain representatives of some of these bodies was got 
together, hut it was entirely unsatisfactory. No discussion 
took place, as the representatives of the British Medical 
Association and the Society of Medical Officers of Health 
were at once met with a statement from the cliairnian that 
no scale would be acceptable, and therefore the matter was 
at an end. Tho patience of tho British Medical Associa- 
tion was not oven then exhausted. In Febrnarv, 1924 
under the auspices of tho Ministiy of Health, which had 

[1227] 



26 JAN. 28, 1928) 


Current Notes, 


r ■ BVPPLBUSNT TO m 
LBBiTien UEvicu, Joruris 


become tlcfiiiitcly alarmed at the condition of rocniitiiig 
for the public health service, the profession’s representa- 
tives began a series of conferences with ineinbcrs of the 
councils of the County Councils Association, of the 
Municipal Corporations Association, and, later, of the llnral 
District Councils Association and others. As a resrdt the 
scale was materially modified. Among other things, some 
difi'erentiation was made in favour of certain api)ointincnts 
in rural aicas, a wider latitude was given to ajipointing 
authoj’ities withijr certain limits of salaiw, and it was 
an anged that in order to militate against making respon- 
sihlo appointments straight from tho medical school a 
certain amount of oxpeiicuce after graduation would he 
icciuircd before the minimum salarj- should be asked for. 

In the end tlio scale, so modified, received the sanction 
and support of tho Jlinistiy of Health, was regardoel by tho 
Association of Municipal Corporjitions as not nnrea.sonablc, 
and commended by them to tlicir constituent authorities 
as a guide when maldng appointments, and was approved 
by the Council and Representativo Body of tho British 
hfodical Association. It is unfortunate that agreement was 
not complete, but it is clear that abundant ojiportunity was 
oirci-ed, and it is manifestly too late now, when the scale 
has been operative for more than two years, with success in 
some 80 per cent, of tho vacancies which have occurred, for 
the .Association of Education Committees, which persistcntlv 
lo'luscd the opportunities for consultation ofl'ercd it, to .say 
“ it should not be beyond the wit of representatives of 
final authorities and representatives of the medical )n-ofes- 
si.m to frame a scale of romuncration for members of the 
medical profession engaged in tho education service, in 
which such factors as preliminary training, fpialifications, 
experience, and conditions of service would have due con- 
sidoratiou, and which would bo acceptable to both parties.” 

The British Medical Association is quite unable, in the 
public interest, to regard the school medical service ns 
other than a part of the whole i)uhllc health medical 
SCI vice, or to enter into any sopai-ato, negotiations for a 
ciifferout scale with education committocs as such; hut it 
ma_> bo desirable to say .something with regard to the con- 
tention of the editor of Education that it is unreasonable 
and inconsistent to ask for an assistant school medical 
officer a commencing salary of £600 a year. The main 
reasons for such a salary are set out in a circular letter, 
d.alcd Slay, 1925, which slioidd ho cpiito familiar to our 
contemporary. They are, iu effect: (1) that such officere, 
hefovo appointment, aro required to have .passed through 
tho full medical curriculum and obtained their registrablo 
qualification ; that in addition it is veiw desirable, and often 
compulsory, that they should further have taken tho course 
for and secured the Diploma of Public Healtli ; that they 
should have had at least three years’ oxi>ei’ienco iu tho 
practice of thoir profession subsequently to qualification; 
and that therefore they are on appointment commonly 
about 50 years of ago and can very rarely he less than 27- 
(2) that the number of higher appointmente iu tho service 
which they have a chance of securing is c.xtraordiiiarijy 
small ; (3) that only too often there is no advancement of 
any kind, and that their maximum salary remains the 
same as their minimum, or rises veiy little above it. 

It is-quito true, as tho leading article with which wo are 
concerned suggests, that in such a matter a comparison 
n ith tho emoluments enjoyed by other empToyces of a local 
authority, and by practitioners engaged in other spheres of 
medical work, is quite legitimate. IVo believe that within 
tho education service tho proper comparison can only he 
xvltli tho male graduate teacher of like ago in a secondary 
.school, who liolds a post of special responsibility. Even 
this comparison must be profoundly modified by reason of 
tbo considerations abevo stated, and scveml others. Tt 
must bo remembered, too, that in tbo teaching profession 


almost the whole cost of training — itself materially smaller 
than with thc^ medical profession — is often borne by puhlio 
funds, and onlj- to a small extent by tbo individual trained; 
and wliilo this is true the two professions must, in soma 
respects, be on different planes. 

TIio comparison with otTier hraiiches bf the piofession 
did not, of course, escape tho attention of those concerned 
with tho framing of tho scale. Indeed, it was precisely to 
bring tbo piddic health sorvico into proper comjiciitioii with' 
these other branches that tbo scale was adopted iu its 
present form. Tho remuneration and prospects over a 
number of years will not bo found out of proportion. The 
comparisons which our contemporary makes with such 
appointments as those of liousc-surgooii aro euticelj- in- 
apjjropriate, and v.itli those of an assistaJit in private 
practice largcl)- .so. Tho former are invariably of a 
temporary, and largely of an educational, character; the 
latter, in tho main, aro of the same nature. Hospital 
appointments in tbo public sei-vicc aro provided for iu the 
scale itself. Tho Association has made, and is continuing,; 
efforts to improve the ])osition of assistants. It lias laid 
down by resolution conditions which it dc\iics ' to see 
fulfilled, but tbo eircum.stanccs of a.s.sistaiit'-bips vary so 
greatly that uniformity is impossible to enforce, and it 
is highly desirablo to encourage recently qualified practi- 
lioiior.s to take such positions for a time as perhaps tho best 
introduction of all to tho prfvato practice of their profes- 
sion. Both these classes of appointment are totiilly different 
frour tho pci-manont position of responsible assi.stant school 
medical officer, which is to bo regarded as the first (often, 
alas ! the last) step in a service offering a career. 


50 r:tisfi iJlcbiral ^ssadfdian. 


CURRENT NOTES. 


Six* Dawson Williams. 

At its last meeting, on Thursday, January 19th, the 
Journal Committee, on the proposal of its chairman. Dr. 
J. A. Iilacdonnld, passed tlie following icsoluliou, with 
acclamation, and ordered it to ho entered on the minutes: 

“ Tlio Journal Conunittee, meeting on tho day on 
which he relinquishes the position of Editor after thirty 
years in that office, wishes to place on record its deep 
appreciation of tho great services rendered to medical 
science and tho medical profession by fcir Dan son 
tVilliams during his long and brilliant editorsbiin its 
giatrtndo for all be has done to advance the BntisJi 
Medical Association in every braneb of its worit; and 
its liigb regard and affection for him personally. 

The Committee tnists that iu tho leisure earned by 
fertv-soven years of unselfish devotion to the 
.Vcdicai Joiinial, during which he has raised it to tlio 
great position it occupies to-day, Sir Dawson n illiaras 
will renew his health to enjoy the honour and esteem 
in whicli he is universally held." 

On the evening of the .same day Sir Dawson R 
the guest of his senior colleagues on tho staff ot tiia 
Association and JouiixAP at an informal dinner m tlio 
Hotel -A'ictoria. After dinner Sir Dawson was presented 
by Dr. Cox, on behalf of those prc.sent, m'tli a namea 
photograph of himself taken in his room at B.Jl.-A. 
Tavi,stock Sduare, where, bv his consent, it will be bung. 


Some Work of the Week. 

J/cdtco-’Pofificfil Comniitfec, 

The Medico-Political Coininittce, which met oji January 
18th, is making rccoininondations to the Council as to the 
conditions of service of assistants in mental hospitals, ana 
with reference to tlie infant welfare ceutre.s winch aro 
being promoted by lay persons for mothers who can afford 
to pay for such a sendee and are said to desire it. Both 



‘ ixsitr*'’ • 


Association Notices. 


• 5DTr7,j[:5/r.Yr to Tim 
.CniTisii Mr-DicAr, Jocenal 


27 


T'ld t-. ^ nn ; •,• •. . r 

these <iui"-tiim-' have liecii Ihoioiiglily explored by suh- 
comiuittee^. The CoiiimUlee is in eoinmnniealiou wiUi the 
Cculrnl ^tidwives lionrd nnd the Jlinislry of Heattli on the 
snbjeel of the detailed ante-natal reeords ivhieh inidreives 
arc recpiired to fill np. Other matters under consideration 
verc the a|i])()intment by the Oovcrninent of Canada of 
Canadian pear titioners tvho are in hdure to examine all 
intending emigrants for Canada before they leave this 
country, and the position of a doctor uhos<! detailed report 
to a eorouv'r obviates the need for an inquest. AVith regard 
to the fir-t point the Committee is informed that the 
Caimdian doctors trill bo nholc-time civil .servants nnd trill 
not 1)C permitted to eng.age in any form of private ]>ractice. 
On the second point the Committee decided to inform the 
Divisions of the steps to be talcen to secure a fee for 
reports given to coroners in such circumstanees. 

Increased fsielncss lienejii Claims. 

On .Tannary 19th the representatives of the Insurance 
Acts Committee discussed tvith representatives of the 
Ministry of Hc.ilth the present position u ith regard to the 
substantial increase in claims for'sickness benefit under the 
National Health Insur.ance Acts. A special subcommittee 
has been appointed by the Insurance Acts Committee to 
explore the ivhole question ivitli the representatives of the 
Ministry, and to determine, if possible, whether the in- 
ci’ease is natur.al and incvit.able, or due to some emuse 
over whii’li t-uc profession may have some control. 

Kemunoratlon of Non-Profossortal Teachers and 
Research "Workers. 

For some time there has been evidence that dissatis- 
faction is felt by a number of univereities nnd medical 
schools with the scab adopted by the Association in 1926 
foi* the rcinuuprat iou of V'holo-tiiru* nou-profes^-orial medical 
teachers and medically qualified research workers. The 
Bc-ale was originally the work of a committee largely com- 
posMi of rojivcscntatircs of medical sdiools, and it was 
lealizcd fixim tho start that it tos bv no moans casv to 
Imiidlo this matter judicionsly, since* tbo mine of these 
appointments is determined hy a number of eonsidcratioiis, 
among lyhieh the .actual eahirv, however important, is not 
necessarily lii'edomiiiant. In view of eritioisms recently 
^ccivcjl Irom the deans of several medical schools the 
Loniicil has now decided to review the whole position in 
tho light ol the experience gained during the past eighteen 
months, and to this end has invited a medical representa- 
tive from each of the medical .schools in Gre.at Britain and 
Irelaml to attend a coiiferenee at the House of the 
Assocmtioii ..11 Friday, Fehrnary lOtli. It is hoped that 
this disenssiiin iiiay result in .some solution of the diflienlty, 
111 11 Inch both tue material intorc.sts of an important class 
o iiorkei and the traditions and resources of the medical 
schools will be safeguarded. 


The E.M.R, and Medical Charities, 

Tlie -Association has received from Dr. A. J. Copeland, 
of tl>0 JIalaya Branch, a draft for 
~ob lOs 2d., collected from members of the Branch and 
intended as a donation to the Koval Medical Benevolent 
iitiicL Last year the same Branch sent £26 3s. 2d., and 
Dr. Copeland announces that he hopes to make a still 
greater impi-ovement next year. This is a notable and 
most iieleomc gift, and Dr. Copeland has been warmlv 
thanked for Ins efforts. 


^**0 Half-yearly Indexes. 

Ibe usual balf-yearly indexes to the Joni.N.ii. and to tb 
nppLEMEXT and Epitome liave been prepared and will t 
reads sliorUv; they will, however, not bo issued wit 
a 1 copies of the Jotox.cl, but only to those readers wb 
as" tor tbeui. Any member or subscriber who desii’es t 
pave one or a.l of the indexes can obtain wliat he wants 
post free by sending a post-card notifying his desire to tli 
1 inancial Secretary and Business Manager, British Medic: 
^sociatioii House, Tavistock Square, AAkC.l. Tlios 
' > ^ ^ receive the indexes regularly as iiublisTie 

should lutimato this desire. 


^ssociaiioit iloiirns. 


BRANCH AND DIAMSION MEETINGS TO BE HELD. 
UinMiNGHAM BRA^Xlt : COVENTRY DIVISION. — A mcclinp of the 
Coventry Divi*'ion vill be held at the Coventry and WanWek- 
shire Hospital on Tuesday, Fcbniarj* 7th. Dr. Brailsford 
will read a paper on cbolccysto^rapliy. 

IhRMiNCitAM Branch : Nuneaton and Tamwortii Division. — A 
mccthig of -the Nuneaton and Tamworlh Division will bo held at 
the Nuneaton Goncral Hospital on Wednesday, February 8lh. 
Mr. C. A. Bai'jon will read a paper on surgical conditions of 
the biliar 3 ' trad. 

Birmingham Branch : West Bromwich Division. — The annual 
incctiii" of l!ic West Bromwich Division will bo held at the West 
Bromwich -and District General Hospital, Edward Street, West 
Bromwich, on Tuesday, January 31st, at 3 p.m. Agenda: The 
retiring chairman Avill give a summary of the work of the 
Di^'ision dur/iig 1927; programme and election of officers for 1928; 
education of the public in health matters; question of courtesy 
calls; inquiry into tlic treatment of varicose ulceration; ^airman’s 
address. 


Boeder Counties Branch : English Division. — A meeting of the 
English Division will be lield at Alai^'port to-day (Friday, January 
27lh). Dr. J. N. Douglas Smith will read a paper on the early 
Ircalmcnl of puerperal sepsis. 

East York and North Lincoln Branch : East York Division. — 
At the mocHng of the East York Division to be held on Friday, 
Fcbruaiy* 17lii, Dr. Ritchie Rodger udll read a paper on foreign 
bodies in the air passages, etc. 

Glasgow and West or Scotland Branch : Ayrshire Division. — 
A meeting of the Ayrshire Division will be held in the board room 
of the County Hospital, Ayr, on Friday, February* lOlh, at 
4 p.m. An address will be given by Dr. J. A- Wilson of Glasgow 
on diagnosis of pulmonary tuberculosis of the young adult. It is 
hoped that there will be a good attendance of members. 

Lancashire and Cheshire Branch : Med-Cheshiee Division. — The 
annual meeting of the Mid-Cheshire Division will be held on 
Sunday, January 29lh, at 4 p.m. in the board room of the 
Altrincham General Hospital. Tea will be served at 3.45. 
Agenda: Annual rejoort of tlio Executive; election of officers; 
charities; branch periodical, 

Lakcashjre and Cheshire Branch: Southport Division. — A 
meeting of the Southport Division will be held on Friday, March 
oOtli, when Dr. E P. Cumberbatch will deliver a British Medical 
Association Lecture on the use of ultra-violet rays in general as 
well as in skin disease. It is hoped that there will be a large 
attendance of mcmboi*s. 

Metropolitan Counties Branch: Camberwell Division. — A 
mcelhig of the Camberwell Division will bo held at the Bonnondsev 
and Rotlierhilhe Hospital on Tuesday, February 7th, at 9 p.in. 
Mr. A. E. Webb-.Tohnson will give an address on liaematiuia. 


Metropolitan Coujcties Branch : City Division.— A meeting of 
the Citv Division will be I»cld at the Metropolitan Hospital, 
Kingsland Road. E., on Tuesday, February 7fch, at 9.30 p.m. Dr, 
H. C. .Semon will di'^niss diagnostic pitfalls in dciTnalology. 

Metropolitan Counties Branch : I'inchlet Division. — ^A meeting 
of the Finchley Division will be held at the Finchley Memorial 
Ho«:pilal on Tue=iday, February 7th,* at 8.45 p.m. Dr. F. M. R. 
Walshe vill give a lecture on faith healing. 

Metropolitan Counties Branch : Hasipstead Division. — A meeting 
of (he Hamp^lcad Division will be held at the Hampstead General 
Hospital on Thursday, February 9th, at 8.30 p.m. Dr. S. Monckton 
Copemau, will discuss inoperable cancer. 

Metropolit.kn Counties Branch : Hendon Dia'ision.^ — The next 
clinical meeting of the Hendon Division will take place at Hendon 
Cottage Hospital to-day (Friday, January 27th), at 8;30 p.m., Avheii 
Dr. Archibald Leitch (director of the 'Cancer Hospital Rcseardi 
Institute) will deliver an address on modern views on cancer. 

Metropolitan Counties Branch : St. Pancras Division.— A 
meeting of the St. Pancras Division will be held at the British 
Medical Association House, Tavistock Square, W.C.l, on Tuesday, 
February 14tli, at 9 p.m. Dr. Alfred Cox, Medical Secretary of 
the British Medical Association, will give an address entitled 
“ The family doctor on his trial.’" 

Midland Branch : Chesterfield Division. — A meeting of the 
ChesleiTield Division Avill be held at the Maternity ^Hospital, 
Chesterfield, on Friday, February lOtb, at 8-15 pjn. Professor 
A. J. Hall (Sheffield) ivill discuss certain points in the use of some 
Gverj'day drugs. 


North or England Branch : Sunderland Division. — A meeting of 
the Sunderland Division will be held to-day (Friday, January 27lh) 
at 8.30 p.m. at tlie Sunderland Royal Infinnarj*. Agenda : Minutes ; 
annual report ; election of officers; any other bu-sincss. Tlic annual 
dance in aid of B.M..4.. Charities whi be held in Meng'^ Rooms 
Sunderland, on Thui-sday, Februaiy 2nd. Reception 8 p.m., dancin^ 
8.30 pjn. to 1 a.m. Tickets 10s. 6d. each, early application for 
which should be made to Dr. MacMuia-ey, North 'Grange Stockton 
-Road, Sunderland. * 


Southern Branch: Jersey Division. — A meeting of the Jersey 
Dirision will be held at the General Hospital on ThiiT^rla-t' 
February 16th, at 8.30 p.m. Mr. A. S. Ferguson will road a naner 
on focal infections of the head. * ^ 






Jan. 2S, 10281 


IVIcottrigs of ' Branches and Divisions.' 


r EUTPtr.iiEST TO Tim - no 

LPiiiTisit Medical JocesiIi 


timl)i!ical hernia hoforo operation. (3) Case of doublo intussimccp- 
tion. (4) Case of branchial cysls. (5) A hoy, u"cd 9, who had 
nniltiplo pyarniic nWossrs followin" a splinter ni llio fool — trcaled 
witij intravenous injection of pcrchlorido of mercury and aulo- 
cenoua (staphylococcal) rnecino. 


MirmoroLm?? Co^^TIE3 BnANOt i Lewisitam Division. 

A Mxn’iJ.'O of tljo Lewisham Division -was licld nl the South-Eastorn 
Children’s Hospital, Sydenham, on January 17t.h, when Dr. W. B. 
Hallijcak took tlic chair. 

Dr, n. Stevtaiit showed i-ray plates fro»n a ease of fibro- 
cystic disease in a hoy n^^cd 6 years. Dr. O. RrcitAUDSOv described 
a ca*:o of fibrocystic disease in Iho right ulna of n woman. 
Dr, C. E. Carpmael showed x-ray plates and a sonucstrum from 
a child 7i years old, with acuto ostcomyelilis of llio metacarpal 
bone; it imd been opened under the impression Ibat it was a 
whitlow. The tcmpcraluro woa 103® F. and Ihcro was vomiting 
and conslinalion. 

Dr, G. UiciURDsoiT described a caso of volvulus neonatorum. 
A malo child was admitted wlicn 4 days old and weighing 
81b. 8 oz.; it passing blood per anum continuously, ana 
vomiting was persistent. Tho abdomen was soft. At the necropsy 
thcro was slight distension of tho abdomen ; tho bowel was black 
and distended with blood. Tho stomach and duodenum wero 
normal, but tho'vrholo smafl inteslino Avas loose, without any 
mesentery, and there was anticlockwiso rotation of tho bowel. 
Death had occurred on tho sixth day. 

Dr, Corslet described a ease of nephritis in a child aged 6» 
with a history ^ recurrent pyelitis, scarlet fever in 1926, and 
toi^jJIectomy jn December, 192?, followed by pyrexia, albuminuria, 
and hacmaturia. ^ Ho also showed a child, aged 5, admitted in 
October, 1927, with a history of .gastro-cntcritis. Tlicro was a 
mmp over tho rmht temporal region, and bruising of tho eyelid. 
Tho child was ill, fretful and lost weight. Exophthalmos and 
ecchymosis developed, and tho abdomen increased in size. Tho 
showed a sarcoma of tho adrenals with hydronephroma; 

^Iso sarcomatous. 

4 x' SAixp?AK, CrrARSLEY, Beattie, and Davies joined 

.“.u BooiAS proposed, and Dr. Halujian 
B oconded, tho vote of thanks to tho hospital staff. 


A hfET RopouTAtr CouiTTTEs BnAircn : MAnixEBOKE Division. 

Dhision sras held on January I8th, 
^toriil S- Welleomo, nt tho Willcomo 

m^atli “I "'S”?™ Street. Itr. Malcolm, llio 

^saum ®«nd eoncral arranReincnt of tho 

which wnymr,.?/ o^ects of interest in tho various sections 
A roT^o? thnnPf members who attended. 

Hosvz°* ^'^.®"coino, proposed by Dr. Jobsos 

Tho museiim*^n^,!n^ Dirision, was carried by acclamation. 
interSt an?I Af? Ar“i col ection of spccimeiis of historic.il 

and that ^as.open every week-day, 

welcomo to visit'?t°i profession and their friends were always 
weicomo to visit it on prcsonUilion of their visiting cards. 


Metoopolit^ Counties BiuKca : Willesden Division. 
tofsTS-E Division on January 18Ui Dr. 

homes for middle:c]as® pltieSta'!'^'’'''^ 

Ei?at!^”Tled ?or°the middli“‘^ nursing homo facilities wero very 
lower middle classes fn ^ olasses, and more particularly for the 
gen»a”hbspita!s was acceptance ol charity from tho 

were not intended whom these institutions 

thes'epaUen"uU;ti,“srSenhl,‘if^ ^7 

homes should be kept withirf ti, „ ‘'m charges made by such 

patient. Several .suggestions for® 1 ?““ 

modation had been^t forward -'f’T “ccom- 

was that the general hospSa^hn.fM™®"^'^ consideration. One 
beds in their wards for should segregate a proportion of 

inadvisable and inadequate on va?ious"^L‘''a® ^a' D'cught 

was that hospitals s}iould equip ^ A. second suggestipn 

. services of Iho hospital would homes where the 

ns a geneml appi^lionT was IhouEhf'’,'® patients; this, 

hospitals could not obtain build J®" 

hospitals had already reached so moreover, tho larger 

would entail such difficulties^ of wganiLtten^H®Vn 
patient would be increased rather [fan P'^v 

m tho nursing homo under such Vested interests 

become established. Dr Murroil® ®™?mq would almost certainly 
that whatever scheme of nurS hoT/ . strongly the point 
prmciplo of continuity of treatmij.®!™® nJopted, tho 

should be in chargo^of tho p“ttent'H,®E ®^^i ‘ physician 

homo, should Be steiotly adhered to Dm 

tie in tho best interests hnlh that this principle would 

Neither.of tho themes alluded ‘’towouhTiir'’ ®^f n® P’'.?<=‘’tioner. 

this principle. A third su4est?oir hid h®’" °fn‘'’i® 
nursing homes of comprehenlfvo size I'®®? independent 
nncillaiw services, should bo erected’ and ®™taining all nece^ary 
basis. Dr, Murrell thmicyiif ^ profit-making 

?“h a venture financially Lund In^dt ?h“°'' “?■¥ 

the purpose for whlrlT if same timo accomplish 

0 mimfng alSimmodatL te iV" ‘® « Deneo-namcly, the supply 
Dosses at" prto Tifid*®”,,,!'? ‘''® mujority of the liwer middle 
fcllcma .V . . b^ir moans. Dp. Tlftvrroll ctifr«yp«+o/I a 


the nursing homes thus provided should bo run by suitably cboscu 
comiiiiitccs. A resolution urging the necessity for the provision of 
middle-class nursing liomcs was pas'sod by the meeting. 

A hearty vote of Uiauks to Dr, Christine Murrell for her 
iuicresUng and stimulating address was moved by Dr. William 
Bateiisok, seconded by Dr. G. W. R. Skeitb, and was passed 
unanimously. 

Nortit of England Branch : North Northumberland Division. 

A MEETING of the North Northumberland Division was held in tho 
Infirmary, Alnwick, on January 10th, when. Dr. Lawrie was Jn . 
tlio chair. It was unanimously decided that a letter bo sent to - 
each member of Iho Dinsion asking him to eubscribo £I fo tho 
B.M.A. Charities Fund, those present at the meeting agreeing to 
pay that amount forthwith. At the closo of the business meeting 
a most ^ interesting and instructivo address on abdominal 
emergencies was given by Mr. Hamilton Barclay, for which ho 
was very heartily thanked, on tho motion of Dr. Scott Ftjrves. . 
Tea was kindly provided by tho matron after tho lecture. 


Southern Branch : Portsmouth Division, 

A MECTiNQ of tho Portsmouth Division was held at tho Queen’s • 
HoM, Souilisca, on January 12th, when Dr. Lttlb was in tho 
chair. 

Dr. E. Matother, medical sunermtendent of Maudslcy Hospital, 
gave an address on the possinlc co-operation of tho profession 
m Iho treatment of mental disorders. The speaker indicated tho 
general practitioner as tho only possible observer of the genesis 
and early development of mental disorder; his obligation to ensuro 
suitable hospital Ircalmcnt for tho poor, when available ; tho 
grc.itcr likelihood tliat early treatment would bo accepted by tho 
well-to-do if it remained chiefly in his hands; and a possiblo 
solution of difiicuUics by association of clinics for voluntary 
treatment of curable cases in the poor, with paying homes for tho 
well-to-do under tho care of their own doctor. 

An interesting discussion ensued, in which Mr. Inman, Dr. 
Mearns Fraseu, Dr. Beaton, Dr. Bosworth Wright, Dr, Montague 
Wat, and Dr. Stevenson took part. A very successful meeting 
was brought to a closo by a cordial vote of thanks proposed by 
Dr. Philip Green, and seconded by Mr, Lumb. Tiie attendance 
at iho meeting was over 50, of whom 34 sat down to supper. 



South Wales and Monmouthshire Branch. 

A CUNICAL meeting of the South Wales and Monmouthshire Branch 
was held at tho noya) Gwent Hospital, Newport, on November 
19lh. 1927. 

Professor A. W. Sheen demonstrated two eases of cyst of tho 
roandiblo, illustrated bv plaster casts and skiagrams. Tho first 
patient was an edentulous woman, aged 51, with a swelling of 
eight weeks’ duration outside the left lateral incisor and canine. 
The second patient was a lad, aged 18^ with a swelling of the samo . 
duration outside tho position of the right first and second molare. ' 
In both cases the bony walls were removed, the contents of, tho 
cyst evacuated, and tho cavities healed eventually. The first case 
was regarded as osteitis fibrosa cystica and tho second as a dental ' 
cyst. Professor Sheen then discussed twentv-one cases of pelyio-, 
injury seen during fivo years in the surgical unit at the Cfardifi 
Royal Infirmary. 

Mr. Lambert Rogers showed a ease of spinal tumour (meningioma) 
in a girl, aged 17, who was completely paraplegic' and incontinent. 
Laminectomy was performed and the tumour removed; there had 
been no recurrence during eighteen months, and the only remaining* 
symptom was a very slight limp in walking, due to some spasticity 
of the right leg. 

Lieut.-Golonel W. K, Beaman showed a case of oedema of the feet 
and legs in a woman, aged 55, believed to bo early parenchymatous 
nephritis with little involvement of the kidney, no cysts being 
present in tho urine. 

Dr. P. C, Ingram showed a case of aoHic aneursym of syphilitic 
origin, which had r^ponded well to silver saWarsan and khar- 
sulphan with collosal iodine. He also described the thallium method . 
of treating ringworm of tho head, a single dose of not less than' 8 
or more than 9 mg. for each kilogram of body weight being 
administered by the mouth in some sweetened water. About tho • 
seventh day the hair began to loosen, and by tho twenty-first had 
completely come out, with the exception of a downy fringe above - 
the forehead, which, apparently, was never infected w'ith ringworm. 
Parasiticide ointment, consisting of ono part of phenol and two ' 
parts each of sulphur ointment and unguentum hydrarg, nitratis, 
was rubbed into the scalp night and morning to prevent reinfection 
of the new hairs, which soon began to grow rapidly. Toxio 
symptoms were frequent, and consisted of pains and occasional 
effusion into a ioint, drowsiness, malaise, and, rarely, albuminuria. 
Tho joint trouble was relieved readily by salicylates, internally 
and externally, while the drowsiness yielded to thyroid.extract. 

Dr, T. I. CJandt showed three radiograms of a condition of thd 
fibula discovered while examining a man, aged 24, who bad been 
injured while playing football. Three minute cysts appeared close 
together at the site of injury, and callus was proauced around 
them subsequently. The cysts invaded the callus, and a diagnosis of • 
myeloid* sarcoma was rnade, necessitating resection of the ‘middle ■ 
third of the fibula. The unusual features of the case were that 
tho patient was unconscious of pain or swelling until the timo 
of tho injury, and tho underlying morbid condition would haro 
been easily overlooked but for the clarity of the first radioCTanb • 
revealing the minuto cysts. . ® 

Dr. IT. .CiCTo gave a demonstration of pathological Ecclions of 
microscopic slides, indqding tho invasion of the (Jest, ■trail ' 

epithelioma primarily situated in the hand; carcinoma of tha 



30 JAN. 28, 192S1 


. IVIeetingszpf. ^Branc^es Titnd DMslonpr.z:: 


r EUPPLEtirNT TO TUB r 

LirmiTiSfi' BinoiciL 'Jounsii.'i 


sigmoid colon, producing complclc occlusion; malignant endo- 
carditis of IIjc left auricle, with freedom of the valves from 
disease; and actinomycosis of the Fallopian tube. 


South Wales and ■Mokhoxithshiiie Branch : Cardiff Division. 
The annual dinner and dance of the Cardiff Division took place 
at Cox’s Cafe, Cardiff, on January 18th, when Dr,. T, W. Thomas 
(Caerphilly) xH'Osided. The Lord Mayor .and Lady Mayoress and 
Mr. J. Alicock (city treasurer) \Yere among those present. 

After the loyal toasts had been honoured, Principal A. H. Trow 
of University College, Cardiff, proposed prosperity to the British 
jNIedical Association. He said that the members of the medical 
profession were more individualistic than those of any other pro- 
fession. Though inclined to agree with the old saying that two 
doctors would never agree, he was sure that on the question of 
the British Medical Association they were all agreed. He I'cgrcttcd 
the relatively slow j:atc at which Vescarch in medicine was being 
carried on, and felt convinced that it could be greatly accelerated 
by closer association and collaboration with those engaged in tlie 
realm of pure science. He was quite sure that the important 
researches on cancer and other diseases would make much more 
rapid progress if the medical profession would adopt a greater 
degree of team work with workers in other sciences. He con- 
gratulated the Cardiff Division on the fact that the British Medical 
Association was to hold its Annual Meeting there this 5 'car. 

Sir JSwEJT Maclean, in responding, said that every medical man 
cordially cndoi-sed Principal Trow’« plea for greater co-operation 
in their researches with other sciences. It was, he said, forty-lwo 
years since the British Medical Association had held its annual 
meeting in Cardiffy with a membership numbering 9,000, whereas 
this year it was around 35,000. There would be a very dis- 
tinguished gathering at the meeting in July, including . eminent 
members of the piofession from Ibc fringes of the empire, as 
well ns from Europe and America. There would be eixteen 
scientific sections, which would meet in the University College, 
Cathays Park, which Jiad been practically put at the disposal of 
the Association for the week. Among the unique features of the 
meeting would be au exhibition in the National Museum of 
ancient Welsh medical relics, and lie was hoping tlic display 
would include the first gold medal presented by the British 
Medical Association, whicli was awarded in 1877 to Dr. H. A. 
Davies for ins skill and bravery in the T^uiewdd Colliery disaster. 
They were proud that Dr. Davies’s son was a member of their 
Division. 

Dr. W. E. Thomas, wlio also responded, expressed liis admiration 
for the work of such a democratic body as the British Medical 
Association, which had improved the status of the profession in 
the army and navy, and Iiad upheld the position of medical 
practitioners under the National Insurance Acts, 

pr. H. G. Cook proposed tlic toast of The Guests,” coupling 
with it the names of tlic Lord Mayor and Mr. John AUcock. The 
Lord Mayor, in responding, stated that he had promised to do all 
he could to make the Aiuiual Meeting of the Association in Jiilv 
ti success. Mr. Allcock, who also acknowledged the toast, said 
that the Cardiff Corporation would leave no stone unluimcd to 
makc_ the forthcoming Annual Meeting of the BritHi' Medical 
Association a memorable occasion. 

Dr. T, W. Thomas responded briefly to the toa<{ of “ Tlie 
Chairman,” proposed by Dr. Colston ■^^'rLL^AMS. 


South Wales and Monmouthshire Brancti : South-West 
Wales Division. 

A MEETING of tho South-V/est Wales Division was held on January 
lltli at the Cariuavlhcnshirc Infinnary, CarmarUion, when a Jarsc 
and very appreciative audience heard a nio'^t excellent and instruc- 
tive lecture by Dr. Frederick W. Price (Londou) on ^omc recent 
advances m the diagnosis, prognosis, and treatment of licart 
disease. 

The lecUivcv dealt with his subject in a most interesting fashion 
afid by frequent blackboard diagrams illustrated points of difiicullv 
in a most jileasmg manner. It was felt by all present that Ihev 
lind derived veal help m a subject full of dimcuUies for prncli- 
i loners far removed from a teaching hospital. * 

At the close of the lecture a hearty vote of’thanks w.as conveyed 
fo Dr. Price by Dr. D. H. Penn.ant, D.S.O. (cliairman), ami seconded 
by Dr. A. Thom.<s, who said that he and othci-s had conic over fifty 
miles to hoar the lecturer, and it had been well worth their trouble. 
Dr, Price having responded, tea was served. 


South-Western Branch. 

An inlormediate meeting of the South-Western Branch was held 
in the library of the Boyal Devon and Exeter Hospital on January 
19th. There* was a modernto aitcndance of twentv-two, an*d 
Colonel Hansom IhcKAnn, C.B., was in the chair. 

Mr. Norm.in Lock lead a paper on some remarks on puerperal 
fever. He gave a vciy Interesting sketch of the difficulties that a 
surgeon has to contend with in such cases, and by illustrations 
from his own case< showed that these conditions are frequciillv of 
a fuhiiinaling typ<>« A vigorous discussion followed tlie reading 
of tho paper. " ^ 

Dr. It. it. Traill read notes on a case of macerated foetus with 
gas gangrene, which served to shen* the odds that general 

pracutioners very frequently arc up agamsl. particularly in the 
conntn,*, and iUustralca the heroic measures that may be necessary. 
Dr. R , V. Solly gave a long paper on some observations of 
fluids. He "pomted out the great frequency with 
*‘*^,.<*xport examination of tho spinal fluid might* be of 
t^xlrenic. diagnostic value. 


't'.*. - ‘ : ’rf , . rr :: rpTTTTT 

Surrey Branch : Guildford Division. 

An ordinary mcoling of the Guildford Division was held at the 
Ro^'al Surrey County Hospital, Guildford, on December 1st, 1927. 
Mr. H, B. Butler was in the cliair, and a large number of members 
w6re present, including some dozen members of the Midwives 
Association branch of the Midwives Institute. 

Address on rucr2>cr{tl iScpsis. 

Dr. James Montague Wyatts assistant obstetric physician to 
St. Tlionias’s Hospital, gave an interesting address on puerperal 
ecpsis.^ He commented first on tho fact that the mortality from 
this disease had not appreciably declined in the hist sixty yeai'S. 
The Ecgistrar-Gcneral’s figures for 1847 to 1881 showed a death rate 
of 1.8 per 1,000,^ and for 1916 to 1920 of 1.48 per 1,000, which indi- 
cated tliat in spite of the great, advance in antiseptics with regard to 
general surgorj', a corre-spondiug advance had not been shown .in 
regard to obstetrics. Tho chief organism concerned was the 
haemolytic streptococcus, which was found in from 75 to 80' per 
cent, of rII cases. The question was, WJiat was the source of the 
organism? It had, in the past been considered that it was present on 
the examining finger or on instruments introduced into the vagina; 
but that would not account for cases of infection Uiat occurred 
when no examination at all bad been carried out. Other possible 
6ou!*ccs might be the mouth of the attendant, or the mouth or 
vagina of the patient concerned. Investigations on these lines 
were now being carried out by Dr. Wyatt an comicxion with liis 
work on .puerperal infections for the Metropolitan Asj'lnras Board. 
In regard to predisposing causes, there seemed "to be no doubt that 
the resistance of each individual iiatient was a potent factor, and 
that the resistance was undoubtedly lowered by such conditions 
as prolonged . labour, -diQicult or instrumental delivery, extensive 
laceration of. the soft parts, and ihacmorrhngc. The toxaemias of 
pregnancy and previous ill health of ihe pabent from causes other 
than the pregnancy had to be considered. The results of infection 
varied considerably, and there seemed to be no means of deciding 
what the condition was wliicli caused tlio variation. In the first 
place there was a local infection of the vagina and uterus, whicli 
in ;thc past had been termed “sapraeraia.” Then there were cases 
in wliich the infection in the Fallopian tube spread to the peri- 
toneal cavit^*, producing usually a localized peritonitis, but eomc- 
limcs a general peritonitis. Thirdly, there was a general infection 
of the blood stream; and, lastly, those cases not manifesting 
themselves until tho tenth or fourteenth day of the puerpen'mn. 
'Other conditions mentioned were ihi'cmbosis of ihe femoral vein 
and pelvic cellulitis. „ , , . ^ i* ^ 

With regard to treatment, in ca.ses of local inrccUon tiioie 
seemed to bo no doubt tlmt the Jess the interference the better 
the results. Vaginal douching with one of. ihe antiseptics of tho 
chlorine croup, the promotion of drainage by Fowler s position, 

STihe n<lni?nistratU .of on - *Xrl 

active principle generally proved 

delay in -the condition settling, . . , ^ 

Hobbs’s method of -intrauterme glycerin injections! vias of gieat 
lielD. Iiitraulerine manipulation, except in cas« of incompleU' 
abortion, should be avoided. In cases of pcritomtis, pronded the 
condition remained localized, exjieclanl treatment again appeared 
(o give the best rcsnlls; but il iliore was any evidence of Hie 
condiiioii becoming generalized, then laparotomy and drainage 
Sid be carried out at once, and, combined with this, niassiye 
inicctions of anti-/?, wcldiii scrum, ns advocated by I^lliams in 
ids paplr in tlie Jouniat of .S’mprry. With regard to genera 
iiifcc’tion of the blood stream, the oul look was not at all 
ebeerfu" tbore was at present no specific treatment at all. At 
fiirw^lVonolitan Asvlums Board’s hospitals various preparations of 
‘rscnl ami inercu!^ bad been tried, but -no good results J.ad 
ice™ obtained. However, it -was only by prolonged pemeveraneo 
oetu uutiiwt. diseases bad been found, and it was to 

KopcdMmt U.e same good results might eventually be obtained 
111 S treatment of sopticiienim At p.resen therefore,, p.o- 


Fleming, Parker, 

G M Bluett, took po***^- 
quesVionf aildr^cd to him, was accorded 


s»rmed to be' of tremendous importance The inlro- 
pujiu.i!. .-e clinics had undoubtedly reduced Hie number 

ofeult Taws an^ ‘l-o number . of severe eases of 
ol Uinieuiv laoo number of Hiese clinics increased, and wiHi 
to-xaemia, and as Uic numoci 

it the pioficicup t-ikcn" during the actual confinement, and anv 
great care must be "patient or attendant, cspcciall - 

source of “fed'on, ciUi.r 

from the mouth and ^ ^vhich Drs. Lawton Moss, 

An instructive bono.ravr^ secretary. Dr! . 

nart Dr. Wyatt, having replied to the 
I liim was accorded a very hearty vote of 

tlianks-for-his kindness in TcUlioTeS.*"' ™ ’ 

an iniporlunt subject to mc ^cal prv 

Ulster Branch: Portadown and West Down DmsioN. 

A MEer,.vc of tlie Porladown and West 

Ibc .Swan Cafe, Armagh, on January. 1811 , ’^.wber and the 
members were present, which, considering the veathci 
distances to he travelled, was very g^ 9 *^d. Itif' moetiii" 

The CHAinM.iN (Dr. W. J. lustJtncd hv 

referred in feeling terms to the loss the Divi. io ^ ♦ 

the death of Dr. J. Singleton Darlmg, who 

meeting, and moved that the sympathy nasseil 

on the minutes and also conveyed to Mrs. Darlmg » ‘ P ^ ’ 

all present ^landing. The chairman also ref^red I® 
dcatli of Dr. James Taylor, Tandragee, one of the scnioi /nemlicrs 
of the Divi^iion. . , c 

Dr. Deote and Dr, T. B. Fedlow reported some cases of suigwai 
Jnleiosl and showed palhological specimens. . 

Mr. Howard Stevenson (Belfast) read a papei’ on methods ol 


^ Hritisii llEDir.a Jourkil, DfM;cml»cr 31*t, 1927, p. 3223. 








STjnppxjmnvDEi^T 

TO THE 

BEITISH MEDICAL JOURNAL. 

LONDON, SATURDAY, FEBRUARY 4Tn, 1928. ' 

CONTENTS. 


FACE 

BRITISH MEDICAIi ASSOOIATIOH. 

Conforcnco on Puerperal Morbidity and Mortality. Tnr 

Pkevestive Aspect or MiDWirEnv 33 

ASSOCLVTION NOTICES 38 

MEETINGS OF BRANCHES AND DIVISIONS 38 

SVILLIAMS-FUEEMAN PRESENTATION FUND. Fn-rn List 
or SuBSCRirrioHS 38 


%ritislj ^Itbiral Association. 


CONFERENCE ON PUERPERAL AIORBIDITY 
AND MORTALITY. 

THE PREVENTIYE ASPECTS OF IIIDYVIFERY. 

A CONTHRENCE OR puerpoml morbidity and mortality, called 
on tlio initiatiro of tlio British Medical Association com- 
mittee entrusted with that subject, was held at the Asso- 
ciation Hous’d, Tavistock Square, on January 11th. In 
addition to members of tlio committee, those attending 
included representatives of tlie Ministry of Health, tho 
Scottish Board of Health, tho Royal College of Physicians 
of London, tho Royal College of Surgeons of England, tho 
Royal Society of Mcdicino, the Central Midwives Board, 
and tlio Society of Medical Officers of Health, and there 
wore certain other medical men present by invitation. In 
tho uiiavoidablo absenco of Sir Ewen Maclean (chairman 
of the committee). Dr. T. Watts Edkn presided, and the 
first part of tho proceedings was given up to the reading 
of four short papers dealing with distinct aspects of tho 
subject, after which thero was a general discussion. 

The Chaihsian sketched briefly tho objects of tlie com- 
mittee and tho nature of its uncompleted investigations. 
Its desire was to encourage tho medical profession to view 
the preventive aspects of midwifery in a more serious 
light than hitherto. Despite tho noteworthy increase in 
midwifery beds, the progress towards a solution of the 
yiholo problem had not boon as great during tho last fow 
years as might have been hoped, and the question was 
whether tho best use was being made of tho means avail- 
able. He hoped that that conference would bring forth 
some practicable suggestions. 

Co-operation of Medical Practitioner and Midwife. 

Dr. J. S. FAmBAiiiN, in an opening paper, recapitulated some 
of the points discussed by him in a previous paper published 
in the British Medical Journal (January 8th, 1927. p. 47) 
M to why the midwives of the Queen Victoria Jubilee Insti- 
ute were able to attend some 50,000 confinements a year and 
declCTa a mortality rate below half that of the country as 
a whole. Ho explained that in his view it was because tho 
medical man called in to midwifery cases had to do more than 
Eecnre normal fnnction--he had to relieve the patient. It was 
re lef that tho parturient woman asked' from her medical 
a tendant, and this was nsnally given by anaesthesia and a 
Epee y and artificial end to labour. But, as hospital records 


FACE 

Tho Provision of Ophthalmic Benefit. Address by Dr. H. B. 


BrjICKEMBUET 36 

NAVAL AND MILITARY APPOINTMENTS 39 

VACANCIES AND APPOINTMENTS ' 39 

DIARY OF SOCIETIES AND LECTURES 40 

ASSOCIATION INTELLIGENCE AND DIARY ! ... 40 

BIRTHS, MARRIAGES, AND DEATHS 40 


showed, all internal interference involved an increased 
morbidity. Under good conditions the risk was very small, 
but in total, spread over thousands of cases, it accounted for 
an appreciable addition to mortality. On the other band, the 
class of women attended by midwives, with medical assistance 
available for difficult and complicated cases, showed a lower 
mortality because of less interference. Incidentally, Dr. 
Fairbairn e.vpressed his entire disagreement with the . policy 
of the British Medical Association in seeking to prohibit the 
use by midwives of such simple sedatives ns laudanum and 
chloral. The commonest causes of weakening of uterine powers 
were fatigue and the emotional disturbance from anxiety and 
recurrent pains. To remove the cause was the first principle 
in preventive medicine, and to treat a condition at its very 
beginning was the second. A dose of laudanum sufficient to 
give relief and rest for the time would often secure a natural 
end to labour. He differed also from the Association’s Maternity 
and Child Welfare Subcommittee in its attitude towards the 
ante-natal record card issued by the Central Mid'wiv.es Board 
for the use of midwives. If pupil midwives were taught ante- 
natal work they must be expected to carry it out in practice, 
and, in his opinion, the more that could be done in the .way of 
ante-natal work by the midwife the better ; it would all help 
to narrow the mesh of the net. It was the midwife rather than 
the doctor who might often hove the opportunity of going 
through the obstetrical part of the ante-natal examination of 
the woman. He hoped it would not he long before there came 
about the gradual adoption of the midwife as one of the team 
in private practice. The chief difficulty in the way was that 
of attracting the best type of trained women into practice. 
Not one-quarter of the women who took the C.M.B. examina- 
tion practised as midwives, and of those who did so very few 
were the highly trained. Something might be done to attract 
a better class into the service if the posts of health visitor or 
inspector of midwives or other whole-time jobs in the health 
service were awarded to those well trained ■women who had 
borne the burden of day and night in the rough-and-tumble 
of midwifery practice. 

liaeteriological Investigation. 

Dr. Leonard Colebrook raised the question of the practic- 
ability of preventive immunization against the risk of puerperal 
infection. Unfortunately, no satisfactory evidence was as yet 
available from lying-in wards that women could actually be 
protected in this way. The haemolytic streptococcus as tho 
cause of puerperal fever had been known for many years, but 
the results of most workers along this line of inquiry had been 
negative. Nature was niggardly in her ^ arrangements for 
killing these organisms. Certain experiments with vaccines 
had, however, been made abroad for which encouraging results 
were claimed. He showed a chart gi-ving the results obtained 
by Jotten in Germany, relating to something like 1,500 women. 
This worker, starting with small doses of a vaccine, . found an 

[1228] 





34 Feb. 4, 1928] 


Conference on Puerperal Morbidity and MoriatHy', 


Increase in jihagocytic power ami a steady decrease in tlio 
percentage of morbidity as the dose was given in larger 
quantities. The speaker also cited figures by ilaroudi of 
.iVlbens, comparing 1,200 inoculated cases with 780 cases un- 
inoculated. Here again there was a suggestion of benefit. In 
the inoculated group there were no deaths and only two local 
streptococcal infections; in the. non-inoculated group there were 
seven deaths and eight local infections. This was all the 
evidence the siieaker had been able to find in literature. It 
was certainly iiremature at present to suppose that the par- 
turient woman could be successfully immunized. Certain diffi- 
culties came to mind in connexion with this prophylactic work. 
M'hen was it going to be carried out? If before labour, would 
the immunity be lost should labour be del.ayed ? And if iluring 
labour, was there any possibility that harm might be done or 
that the immunity might not be conferred in time? He thought 
the committee might usefully consider whether arsenical drpgs 
could not hopefully be employed in prophylaxis. With regard 
to treatment, there were two schools of thought among research 
workers. One school, having in mind the recent work on 
scarlet fever, looked upon puei-peral fever as primarily a 
toxaemia — in other words, that there was a specific toxin 
produced by the streptococcus which must be neutralized. 
The other school thought it not proved Unit to.xin wa.s the 
essential feature, but rather that the micro-organism itself 
appeared to find conditions for multiplication and jirolifera- 
tion in tho patient’s body, and that the problem was to kill 
the micro-organism. Dr. Colebrook inclined to the latter view, 
and pointed out certain distinctions between scarlet fever and 
puerperal fever. The object should he to help the body to kill 
off the streptococci rather than primarily to neutralize the 
toxins. Hera came in tha usefulness of organic compounds of 
arsenic, which in nearly all patients increased the power of tho 
blood to kill streptococci, and in all of them incren.scd tho 
power of the serum. He emphasized the necessity of getting 
the cases at the earliest stage, and Uie advisability of arsenical 
treatment in every case that developed even a small temperature. 

MidwifcTy and tha General Practitioner. 

Dr. C. E. Douglas, a member of the B.Itl.A. Committee, in 
a further paper, touched upon the ve.xed question of instiu- 
mcnlal intervention. His impression was that the midwife of 
to-day, in many parts of the country at any rate, held on to 
her case till she felt that it was not going to do alone, and 
sent for the doctor really that he might give the relief that 
was desired. Therefore, a high proportion of cases would 
necessarily he forceps cases. This might be contemplated with 
perfect equanimity if men would observe two simple rules : 
perfect antisepsis, and withholding of the forceps until the 
second stage had gone on for over two hours. In thirty years’ 
practice, ont of 1,620 cases lie had .applied forceps 283 times. 
'I'heio were no deatlis, hut during that time ho had two 
deaths from sepsis in specially easy cases. Aiiotlier question 
hearing on the point of co-operation was whether tho midwife 
sliould give drugs. Strictly speaking, she slioiild not. .She 
was allowed only to undertake normal labonrs, which should 
not require drugs. But of late yeare there had come .a change 
in practice. For many years it ^Yas considered bad form 
give opiates. At present this was not the case, l.argely by 
rc.aEon of the so-called ’■ twilight sleep ” method. If midwives 
were to he encouraged to adopt a waiting altitude they should 
certainly be trained in the nsa of morphine and ciiloral • 
pituitrin he tlionght pretty dangerous, even in other Iiands 
(hail theirs. With regard to medical cchic.ilion, there was an 
impression that the medical student was being imperfectly 
trained. The available dinic.al material was limited, and had 
now to he sliared with the growing class of pupil midwives. 
Another tiling to he said was tliat if it w.as desired to send 
out competent and reliable men this would not be done hy 
putting “ the fear of death ” upon Uiem it they so much as 
dared to apply forceps. Men should he trained and w.anied, 
not frightened. Ante-natal care had immense po.ssibilities. 
The ofTert of the recommendation of the Scottish Departmental 
Committee — that this bo made compulsory for studeiil.s — would 
be tar-rcaching and beneficial. It was surprising — ^vidc that 
report — that tho watcli for eclampsia sliould require emphasis 
at this late day. Since 1899 watch had been kept by him on 
every woman who had engaged him for her confinement, and he 
had liad no^ case all these years. As a general scheme for the 
uture nothing could he better than that ante-natal care should 


ho with tile doctor, the actual confinement under the midwife/ 
wiUi liio doctor in reserve for emergencies, and hospital treat- 
ment for exceptional cases ; and that the doctor sliould see, byi 
post-natal examination when requisite, that the woman was 
restored to functional efficiency. 


The Hole of the Medical Officer of Ueidth. 

Dr. Dl'XStan Bhewer discussed the subject from tiie point) 
of view of the .special duties of tho medical officer and his staS 
which boro upon tiie reduction of maternal morbidity. These 
duties, he said, were of three kinds — those relating to the people 
themselves, to liis profc.ssioiial colleagues, and to scientific 
investigation. Tlie duties under the first head were to ensure 
that all jicrsons in his district could obtain such medical skill 
as was available, and that they did in fact obtain if, and ohtaiu 
it in lime. His duties to liis colleagues were embodied in the. 
Jlidwivcs Act and the Puerperal Pyrexia Order. The pro- 
visions of the latter had given rise to some objections, duo 
entirely lo misunderstanding. About one delivery in fifty was 
followed by pyrexia as defined by the Order — an average of 
two notifications by every practitioner in a year. The notifica- 
tion form allowed the practitioner to ask for certain facilities 
it he reqii’red tliem. It was for the practitioner to say what 
he wanted, and for the medical officer to see that it was forth- 
coming. With regal'd to the third part of the medical officer’s 
duties, the investigation of maternal deaths conld be undertaken 
only by the public medical service. These inquests required 
great tact, and were impracticable unless the medical officer 
was on the most friendly terms with the practitioners in his 
district. In his own experience . in his district he iiad not 
discovered a single ease of a mother who had lost her life 
through lack of medical skill, though many had died hecausa 
that skill was not avail.Ahlo until too late. The roidwives were 
occasionally to blame, hut the patients themselves were (he 
chief oflcndci-s, occasionally from stupidity, more often from 
igiiovatice. Tiio public health service might also not be -iviOiout 
fault for failing to supply facilities wliicli it was its duty to 
siipplv. If the coiiipuksory notification of pregnancy ■''fAo 
feasible and properly carried out, and sound adramstration 
founded upon it, it might pnt a stop to maternal mortality. 
At present such a provision was not practicable, but nithout it 
much miglit bo done to prevent fatalities by supervision m 
pregnancy as far as possible, involving niachineiy 
ipmi medical skill without difficulty, forniahtjv or do « J . and 
other macliiiicry, non-medical m al’/racter, whose mam func- 
tion was to watch and to detect immediately an> dep.irture 
from a state of health when medical intervention mu.st bo 
sought. 

Genebal Discussion. . 

Professor Beckwith Whitehouse (Royal ^ 
said that during the last few years there had heci , ' 
iiexion witli tlie Maternity Hospital at 

mental clinic with a team headed by a sister who icllj kn<^^ 
her job, intent upon securing sufficient ® ^ 

some of the worst districts of the city. <roing on 

attended in their own homes, none hut aalec e w-is onW 

to hospital. In the first 1,000 cases the ^ 

2 per cenl..^ and only one woin.an ^ „ 

ruptured uterns-bnt she as baJ 

he Imd discovei'eTr’a ffigirdass maternity 
incidents, all happening within one month, were vo , j j • 
the matron and sisters-namely, a refusal to bav ohstetrio 
forceps iKjiled, a refusal to wear a stcrihzcd g S 

labour, the placing of sterilized instruments “P , 

sterilized area, and the use of silkworm gut direct ■ 

without sterilization of any .kind. Kone of he “ 

■wrong, hat tliat was a ivonderful testimony to the resi 
the patients. As a constructive measure he urged t ic p 
post-gradu.Tte training of certain genei-al practitioners, i- 
cularly to imbue them with “ surgical sense" , i 

them obstetric .specialists, and that the possibility mig i o 
considered of obstetric work in any area being in ch.Ti-go o 
men who held a post-graduate diploma, and who would nana 
over normal cases to the midwives and pass on to iii.Tteruity 
hospitals casfs of grave obstetric difficnlty. Something mns 
bo asked also from the midwife. Ifore care might. v.e!l ho 
taken to cUininate unsuitable women ; the training of iiiidwivcs 
might bo improved by tlie greater concentration of tr.niiing 
centres, so that the best teachers would he more generally .avail- 



Filn. 4, 1023]^^^' Prcvcntivo' Aspects dT'M/divIfery, rDBITtSU MEDICAX. JoUBKAL 35 

W'le : 'iii'st-graduato training iniglit bo made universal j and an lying-in inslitutions should bo of sufficient size to have resident 
lago' limit for retirement from the service imposed, llo also medical officers working under tlie supervision of skilled 
Suggested the provision of depots where sterilized gowns, towels, obstetric teachers. The multiplication of small maternity 

"and gloves would be available for obstetric purposes. An ante- homes was not for tho good of obstetric teaching in the 

matal reiilro would be tlie ideal place for this, and the cost, in long run. 

the case of the {loor, might be defrayed from maternity benefit. Mr. E. B. TiutN’En (B.M.A. Committee) g.ave some interesl- 
Anotber .suggestion was that the committee .should dr.aw up a ing details of his father’s practice in Dorset, Esses, and 

form, to he completed by the practitioner called out to a case ],cndon from JSdl to 1882, during which tinie he treated 

of ])yre.\ia during the pnerperium, and forwarded to the nearly 2,000 midwifci-y cases, under all sorts of conditions, 

inspector. A little care was ncce.ssary lest there be any loophole and did not lo.se one of them: also of his imcle who, qualifying 

in the ]iiierper.al pyrc.xia regulations. in 1836, jiractised until 1886, and had nearly 4,000 cases of 

Dr. M.vnrr, Rsmsay (B.M.A. Committee) asked why Dr. midwifeiy, with only seven deaths, five of them in one month, 

Celetirook had rcconunended arsenic. She laid had good resuH.s due to a scarlet fever infection. He was not advocating 

with colloidal silver in about fifteen ca.ses, treated with do.ses a return to the conditions under which those men worked, 

of 10 to 20 c.cm. but he thought there was something in the success of those old 

Mr. '\Vr.\Tr pointed out the wide field for investigation which practices which, if it were studied, might bring very near a 
remained in connexion with tlie sources of infecting organisms. solution of the present problem. 

Until the source and mode of conveyance wore known it was Dr. CnniSTixr; JIumieli, (B.M.A. Committee), speaking as a 
difficult to advise midwives and praclitiouer.s bow to avoid general practilioncr, said that there did not seem to be suffi- 

pucrpcral infection. It could not be doubted that in a great eient cvidcnc-e that puerperal sepsis was due entirely to intro- 

niany eases (here w.as mouth infection, bacniolytic streptococci duclion from without. This question would not be tackled 

being brealbcd by the obstetrician into the vagina. In general satisfactorily until all the various and obscure sources of septic 

surgery no ono would think of opening the abdomen witlioul infection were investigated. She also spoke of the importance 

we.aring a mask. With regard to treatment, ho was not quite of ante-natal inspection. Every woman ought to have during 

so hopeful of arsenic as Dr. Colcbrook. He liad seen no really licr pregnancy at least one inspection I>y a doctor. The qiies- 

encouraging results with this agent, though lie could speak tion of cxpeu.se loomed large, but she thought that to proceed 

only of a limited number of cases, and tliorefore pcrb.aps be along these lines would be more remunerative than other 

.was not in a position to judge. expenditure suggestions which had been made, such as the 

Dr. htiDOLETOX' Mautin’ (Society of Medical Officers of iirovision of depots for sterilized garments. 

Ec.altl!) spoke of the conditions in Gloncc.stersbire. with a Dr. H. B. BnACKENmimv (Chairman of Council. British 
population of 330,000, where, when the Jfid WIV0.S Act came I Medic.al Association) took up Dr. Fairbairn’s complaint of the 
into operation, there were 250 untrained women and 25 trained. Association policy in denying the right of midwive.s to 

These figures were now reversed, hut, so far as ho could administer certain drugs. The resolution in question included 

ohsei-vc. there had been little clmngc during these twenty-five ,opium and pituiirin, and with regard to the danger of the 

years in tho incidence of disease. In 1927 there were .sixty- latter lie thought everybody was agreed. But so far as opinm 

Eeron cases of puerperal fever notified in his area. An analvsis, was concerned also he was of opinion that tlie Association's 

■which was immmplete, bora out Dr. Fairliairn's point that it po.sition must he maintained. Drugs of this kind could not be 

TOs not only in cases where there had been intem-ention that safely placed in tlie liands of other than medical men. He saw 

these conditions arose. Out of 46 cases analysed, there h.ul no practical difficulty about the matter in those areas where 

been no intervention in 20. Despite the most elaborate pro- the doctor’s services could easily he obtained. If the condition 

cautious, infection was in some way introduced. Was it neccs- of allairs wa.s sucli that the midwife thought Uie patient ought 

sary to assume in puerperal cases that there iva.s an introdne- to he given a drug of this kind the doctor should he called in 

tion of organisms from witlioul? Much could he learned and the drug given, if at all, on his responsibility. There were 

and much could he done by following up the sliglit cases. His cases in .sparsely populated areas where to bring in the doctor 

experience of the svork of midwives, especially those con- for this purpose might he difficult, or even impossible, hut 

netted with the_ county nursing association, had been favour- surely it was better to lay down a general rule of prohibition, 

auJcj lie admired their patience and conscientiousnc.ss. oven if very rare exceptions liad to be admitted, than to 

1 250*^ ■''* « Icrge area like Gloucestershire— advocate, as Di-. Fairbairn apparently did, Hiat midwives should 

, "ii ^ spread the niacliincry so that no he allowed to use drugs ivlienever they pleased. With regard 

tl'*^f tl . neglected. It was important, he thoiiglil. to antc-iialal examination by midwives, again, surely nobody 

la leie .should be a room in every cottage liospit.al to which hut .a qualified medical pr.actitioner could give a guarantee that 

e pre^iaiil woman coiiUl go, nothing was wrong with the patient, and that was the object 

statist' s (Royal College of Surgeons) gave of aiifc-nalal examination, which, as Dr. Fairbairn himself had 

In tV'^^ ' ■ no'*’ “ hospital ante natal service. said, ivas medical work, and, if it was thoroughly done, was 

avas dono'^^m ^ ^ “ Sood deal of ante-natal work to be regarded as of the same category as examinations for 

th»re we' '"a oncf ' systematized as it became later, insurance or for admission to tlie Services. To place such a 

with Pn ^“■patient and 12,365 out-patient deliveries, rcsponsiliilily on the midwife was utterly wrong, and it was, 

wlin tlifil Of the 20 patients in f.acl, the best midwives who objected to having to make 

Tieioliliniiiin 7‘f i- been sent in by doctors or came from the record to wiiich Dr. Fairbairn liad alluded, and to take this 
resnniisil le ^ which tile service itself was not re.sponsibiiity, while those least qualified did it most readily, 

were d ' t^° 1 ^ ™°™cnt of admission. Ten of tlie deaths IVitli regard to inedieal students, almost all the teaching bodies 

1922-26 'fl ° sepsis. In tlie iieriod were giving attention to the question of tile training of students 

deliver^e I I ' hi-patient and 8,348 out-patient in ante-natal work. The General Medical Gonncil was hu.sying 

Seven nt lf" t° * deaths numbered 13, or 0.099 per cent. itself at present in seeing how far the obligations in this 
nat illv *!■ cases were cmergcncie.s, nith whicli, ante- respect were being carried out. Di-. Braokenhury uttered a 

one was' 1 had nothing to do. Of the 13 deaths protest against the idea, put forward again in the present 

primariiv "d* 1° sepsis. This was conference, that no qiialified medical man was to ho allowed 

rhieflv il *1 service, supervised by medical men, to practise in any particular direction in his profession unless, 

work on *1 The extreme value of ante-natal after his qualification, he had taken a post-graduate course 

ortranize r ^ oniphasis. In the cases covered by a well and obtained an additional diploma in that particnlar branch 

to arire ' w'es rare for a quite unforeseen emergency of his profession. It was a false idea. There might be, for 

tioners ii "-‘fl propaganda among pracii- example, doctors who were imperfect in their treatment of 

natal work^^* d "h ^ '^®Sard to the value of systematic ante- pneumonia; bnt was a special post-graduate course going to 
sho'nhl hitf’ V " 1° extremely good antiseptic technique, be made compulsory before medical men were allowed to treat 

was a necessary. He did not agree that there cases? He thought it was quite absurd to require these super- 

dealii ” int^^H teachers to put the “ fear of numerary diplomas in this, tliat, or the other department of 

haviiw s\vu°n- *"'*1 foreep.s, hut the pendulum medicine before a man could he considered a duly qualified 

it Avas lint direction of operative intei-vcntion, medical practitioner. With regard to the great desirability of 

statin^ tlie n teachers tried to correct matters by securing ante-natal observation, and, if necessary,’ ante-natal 

o otner case. He thought it most important that treatment by a registered medical practitioner for everx- prci^nant 


36 Feb. 4, 1928] 


T/jo Provision o9 Ophthalmic BencTit* 


r svppLF.yrr^r ro tiib 
LDnmsil Mku:s..i. iovnsu 


■woman, the question was how this could be done. The class 
of women -who could pay for their private • practitioner could 
be reached only by a process of education and persuasion. 
Even if there were compulsory notification of pregnancy, 
compulsory ante-natal examination would have to be added 
on to it beforo any good could be done. The insured rvoman 
could be reached through the insurance medical service, and, 
by way of maternity benefit, the wife of the insured man not 
herself insured. There would remain a small number, many 
of whom might bo reached through the work of the ante-natal 
centres. What the profession had to say was that it was out 
to secure, by State aid where necessary, or by persuasion, 
ante-natal examination of every pregnant woman by a medical 
practitioner during pregnancy, and it could not tolerate the 
taking over of this work by the midwife, because that would 
be clearly a second-best procedure, and in the present state 
of public opinion and public affairs insistence on the second 
best was a distinct obstruction. 

Dr. T. F. Dewar (Scottish Board of Health) agreed with the 
general trend of the discussion, which indicated the realization 
that normal cases were the sphere of the midwife, and that 
abnormal midwifery, more strictly than ever, should go to the 
practitioner. He spoke of some recent inquiries in Scottish 
cities which showed that quite a large proportion of women 
— 30 per cent, was mentioned — were receiving some ante-natal 
e.vamination. The investigation of every maternal dcatli had 
not yet been brought about, but hejlared to hope that it 
would bo. " 


Lady B.\nRExi (B.M.A. Committee) realized tlio difficulty of 
demanding a post-graduate diploma from all who practised 
midwifery, but she thought that a period of assistantship 
under a trained leader of an ante-natal clinic would bo very 
valuable. One lino of investigation which might bo fruitful 
was to endeavour to find out what it was that made the vast 
majority of women resist infection. It would show what an 
extraordinarily powerful thing was normal resistance. 

Dame JattEi Campbell (Ministry of Health) said that the 
Ministry desired to do all that it could from the administrative 
point of view to secure co-ordination between the various 
agencies concerned in the solution of this problem. No one 
body, whether of practitioners or midwives, could solve it 
alone. There was need also for central co-ordination, for the 
number of cases in any one district or hospital was too small 
for conclusions to be based upon them. Especially was it 
necessary to obtain help from the general practitioner, who 
saw these cases in their early stages. A committee charged 
with investigation on the bacteriological and clinical sides of 
the question might be very useful. An inquiry into every 
maternal death would also bo helpful, if carried out in the right 
w.ay; it could bo done quite confidentially, and without hurt- 
ing anybody’s feelings. JThero were also many cases in which 
tho practitioner concerned was unaware of the facilities which 
were available for his assistance. There was room for more 
cooperation in ^is respect between practitioners and medical 
officers. The difficulty of ensuring a medical examination for 
ewiry pregnant woman was that of cost. The woman could not 
afford to pay for it, and the doctor could not afford to do it 
for nothing Some modification of the insurance maternity 
benefit afforded almost the only hope of bringing the maiorily 
of women— 84 per cent, of women were insured or the wives 
of insured men — into sudi a scheme. 

Dr. Fairbairn, briefly replying to Dr. Brackenbury still 
affirmed that midwivcs might bo trusted to administer certain 
drugs which it was necessary should bo given at an e.arly 
stage when tho woman began to show signs of fatigue. There 
had been no case of abuse beforo tho Central Midwives Board 
From tho point of view of preventive medicine, if the midwife 
was not taught tho use of something to avoid fatigue there 
would bo more calamities. With regard to tho ante-natal -work 
of tho midwife, ho thought her rolo could bo very much like 
that of a sister in a ward — carrying out the instructions of the 
medical man, making observations . for him, and relieving him 
of a great deal of unnecessary work. From tho point of view of 
tho lying-in ho thought ante-natal training essential to tho 
midwife. 


Tho conforenco ended •with a vote of thanks to the 
Chairman, who remarked that tho views ei^ressed would he 
of great uso to tho committeo in carrying through the 
further stages of its inquiry. 


THE PROVISION OP OPHTHALIillO 
BENEFIT. 


ADDRESS BY DR. BRACKENBURY. 

A FtiLL meeting of the Ophthalmic Benefit Committeo was 
held at tho Hastings Hall of tho British Medical Association 
House, on January 31st to hoar an address by Dr. H. B. 
Brackenbury, Chairman of Council of tho British Jledical 
Association. Mr. H. L. Eason, and afterwards Dr. G. W< 
Kend.all, presided. 

Dr. Brackenburv, at tho outset, instituted a parallel between 
the present ophthalmic position and the dental position previous 
to the passing of the Dentists Act, 1921. At that time it was 
clear that tho supply of properly qualified dentists was inade- 
quate to tho public needs, and similarly it now had to he recop 
nized that in tho country ns a whole tho supply of properly 
qualified ophthalmic service was inadequate. It was interest- 
ing to consider how tho public was supplied with such 
treatment as it received — he was thinking chiefly of refraction, 
but also of the treatment of more or less minor eye troubles. 
To a quite considerable extent the needs of the public were met 
by a commercial supply of cheap spectacles. The dimensions 
of this business were surprising. In one of tho cheap stores, 
which ho named, a million and a quarter spectacles were sold 
in a year. People went into these stores, picked. up spectacles 
from a tray, and tried them until they found the glasses which 
suited them best. No doubt this resulted in a certain amount 
of harm to individuals, though there was no evidence that it 
constituted a grave public evil. 


' Tlic Sight-testinij Optician. 

Tho second w.ay in which the public supplied its needs was 
by going direct to tho sight-testing optician for defects , of 
vision. Tho three representatives of tho sight-testing opticians 
on Uio Departmental Committee contended, not merely that 
tho opticians’ work was better than tho medical practitioners 
work in general, but that it was better than the ophthalmic 
surgeons’ work so far as refraction was concerned and inings 
incidental thereto. The ideal of the sight-testing opticians was 
to ho placed in the same position as the dentists, wlieieas the 
medical view was that they should be placed m a position 
mialogous to that of the dispensing chemist. The opticians 
dcsire^d to have a Board which would prescribe a course of 
S approximating to the medical curriculum, with special 
refCTcnco to eye diseases, in exactly the same way as the dental 
student went through a truncated medical cumcMum and then 
devoted himself to certain special subjects, and |ot a registrable 
diploma in dentistry. Ho was bound to say that, leaving out 
school children and^ those who received attention at hospitals, 
t^ great majority of the British public were receiving atten- 
tion ^for defects of vision from sight-testing opticians rather 
than from medical practitioners. That being so, it was argued 
that thrpublic should bo protected by a State repster tou- 
sistinVof those opticians who really dil know spmeU.ing a^ut 
their lob, sVas to enable them to bo distinguished from others 
-rdmHtedlv a large numben-who knew little or nothing 

The medical evidence beforo defects* o^ 

things : first, that there were appreciable 

vision being dealt with by those who had not a complete 
medical education; and secondly, that there was - FOspect in 
the not distant future of the medical first 

slipply the public with the facilities which a. 

rate treatment. These were propositions which “F' 
proved if the claim— on the face of it, in t''® 
of affairs, not an absurd one^that there should be a Sta e 
register of ophthalmic opticians, following 
curriculum, was to be -withstood. ^ ronnirp- 

The third way in which tho public got its 
roents was through the school medical service, 
and the private practitioner. Bnt unless it could ho , ^ 

the medical profession was able to supply the public y 

a first-rate service the case of the sight-testing op ic 
unanswerable. If, in fact, the public could bo supphe ? _i 
the second-best way it was right to distinguish that speona-Dcs 
way. from a third-best way by the setting up of a register, i no 
medical evidence beforo the committee on tho Registration ^ 
showed that there was danger in the second best, and that 
was a reasonable prospect of the first best being supphedi 
and this was accepted by the committee. 

Tho problem was to supply the first best by an adequate 
service of medical men ana women competent to gi^o ophthal- 
mic treatment. The General Medical Council was doing some- 
thing to help, and, partly owing to tho greater concern of tho 
public about cyesignl, partly to the demands of tho sight- 
testing opticians for recognition, and partly to - the giving 
of ophthalmic benefit by approved societies, there had been 
recently an awakening on tno part of the medical profession 


FEn. I, ' 


T/ie Provision of Ophthalmic Bcnoflt. 


r sxTTPLr^irEST to tub 

IfRiTISQ SICDfCAL JoCBhAC. 


37 


to its iliitirs nml opuortmiilics in Hu's respect. The new 
ciirrieuitim laid down liy tlio General Jtedical Council some 
years ago, in wliich cmplia,sis was laid npoii tlio study of 
oidithalniic conditions, was only now maturing, and llicro was 
clear evidence that a large number o£ Bcnior students in the 
medical schools did intend, whether ns general practitioners 
or not, to continue the sliidy of ophthalmic surgery and to 
practise it. There was thus an increasing supply of medical 
practitioners interested in and willing to practise specially 
— not entirely — in this direction. How to pet them distributed 
properly over tho country was a more diincult problem, but 
no supposed it would bo solved by financial arrangements made 
for tho people in ibo more sparsely populated areas. 

The Ajtprovcd Societies. 

Another factor in tho situation 'was that tho approved 
societies in supplying ophtlmlinic benefit were now handicapped. 
Earlier valuations had shown surprisingly largo surpluses, but 
in 1926 thero wero enormous claims for sickness and disable- 
ment benefit, which were put down to tho peculiar circum- 
stances of that year — tho gcncr.al striko and tho coal deadlock. 
But in 1927 tho claims were vastly in caccss of thoso even of 
1926, so that it looked as it thero was some underlying and 
eontinuing c.ansc. If this was so, tho next valuation would 
rcvc.al for many societies no surplus at all, and therefore no 
ophthalmic or other special benefits would ho possible. The 
societies were right in saying now that thej’ could not afford 
to pay a guinea for each ophtlialmic ease. All the societies, 
except one — though that ono was tho largest — had said frankly 
that they would prefer to have treatment for their members 
hy registered medical practitioners rather than by opticians. 
Tho Prudential, on tho other hand, was inclined to the e.xtreme 
view of tho sight-testing opticians, that they could do the 
job better than the doctor. Some of these other societies had 
thought, ns did the representatives of tho medical profession 
at tho time, that a guinea fee would bo satisfactoi-y j but it 
iv.as now plain that for tho bulk of them this amount was 
beyond their means, and their means, so far from improving, 
wore apparently going to ho aUcmialod further, unless tho 
underlying cause of the increased claims could ho discovered 
and_ proved to bo romodi.sblo, which ho doubted. 

What, then, was to ho done? Some offer had to ho made 
to tho public which would approximately halve tho present 
cost of ophthalmic benefit. The Departmental Committee 
clearly saw that the public interest called for a State register 
of sight-testing opticians as tho second-best thing if tho first- 
best tiling was not forthcoming. 


The Proposed Ophthalmic Clinics. 

Ono way of meeting tile position, advocated in letters to tho 
Bninsn llnpiCAi, JounsAL, was tho simple plan of reducing 
the guinea fee to half o guinea ; but it appeared that lliat 
proposiUon would not bo acceptable to a considerable propor- 
tion of tooso on tho British Medical Association list, and if 
they withdrew, the available facilities, instead of enlarging, 
uould dimmish. It had thcreforo been suggested that condi- 
tions should be arranged, primarily in tho largo towns, by 
which the work of the ophthalmic surgeon could bo eased so 
that in the new circumstances ho might bo willing to set apart 
a certain time for a pnaller fee, reserving to himself otherwise 
0 right to charge tlio guinea fee under tho conditions origin- 
charge his ordin.ary private feo. In 
f 'F®^’°'' uertain offers had been made for tbo cstablislunent 
of climes, as they had been loosely called. Offers Iiad been made 
premises, with full equipment, clerical and 
mg assistance, and the presence of an optician for me.asnr- 
ig, e c., so that the ophthalmic surgeon woiud have everything 
done for him short of the actual examinatiou. It w.as taught 
' 1 1\ ®^sbt set apart a session at which cases 

1 °'? a guinea. It was further sug- 

^ connexion TOth tliese clinics in large centres 

certain faciUbes should be provided at stated times in 
idch a ° and assisl.anco would bo fur- 

equipment^ surgeon would probably take his own 

®i^ other large towns, had 
wbtl, i , ae National Insurance Beneficence Soiiety, 

. 1 , the approved sotaelies under another form, techni- 

I ofgamzation. The British Medical Associa- 

1 these clinics, but the society had come 

ho “ P*“n could bo agreed upon it would 

bo prepared to finance and extend them further. The dispensing 
1 , for'vard with a similar offer. Thert 

w ° ’if u'^Pices— unless the British Medical 
admrn' ( f^c’iaok tho financial responsibility and 

nlan Tvhereby tho position could be met. Tho 

Minifttfvv ^ preferred by the representatives of tho 

medical profession was that of tho 
be set nr? °Pi'’';'uns. In effect, the plan was that there should 
p a central committee on which the medical professioUj 


lliroiigli (ho British Medical Association and such other organiz.v 
lions of ophthaliiiic workers as might seem desirable, would 
bo represented ; thero would bo also an entirely medical sub- 
commilleo, to which all medical questions should be refen’ed. 
The dispensing opticians would finance tho establishment of 
tlieso clinics, which, of course, would not appear all at once, 
but would spi-cad gradually in various centres. The medical 
men, on their part, would undertake to put in tlie requisite 
number of afternoons or evenings a week at these premises, 
which would ho properly equipped and attended, and to do the 
work, not at a sessional fee, which was at first proposed, but 
at a feo of halt a guinea per case. 

This method was not intended to supplant other more private 
methods of supplying ophthalmic treatment. There w-ould be 
an option — indeed, lie thought that it would he in most 
places tho rule— for ophtiiaTmio practitioners to hold such 
se.ssions in their own houses. In that case, of course, 
they would supply their own equipment, and the dispensing 
optician would attend for tho purpose of measuring the patients 
for spectacles, and so on. There would also remain a pro- 
portion — it must bo recognized that it would probably be a 
diminishing proportion — of cases in which the patient would 
prefer to go quite privately and have attention at the guinea 
fee, half of this being provided possibly by the society. 

At tho moment, therefore, the position was this — that the 
profcs.sion should supply to members of approved societies 
entitled to opliOialmic benefit, at half a guinea per head, the 
ophthalmic scrvico required, and that this should be accom- 
plisbcd either b 3 - a session in the private practitioner’s house 
or by a session in a separately established clinic, at which 
certain arrangements had been made with regard to equipment, 
nursing, and so forth. 

In conclusion Dr. Brackenbnry begged that the ultimate' aim 
in view might not be forgotten. The continnance of ophth.tlmic 
benefit to members of approved societies as such was not the 
ideal at nil. What it was desired to carry out was the plan put 
forward in tho evidence of the British Medical Association to 
the Eoyal Commission on National Health Insnranco and recom- 
mended bj- tho Commission — an e.xtension of medical benefit to 
include specialist and consultant treatment, of which, of course, 
ophthalmic Ircntmcnt would be one branch, and would be- on 
Ibo same principles and terms as all other specialist and 
consultant services, this to be the right of the whole of the 
insured population, and not dependent upon the accident of the 
societies' surplus. 

Questios'S. 

At tho close of Ills address many questions wero put to Dr. 
Brackenhury. In reply to one question he stated what were 
the recommendations on tho snbject which were being made by 
the Ophthalmic Committee of the British Medical Association 
for presentation to tho Council on Fehru.a^ 8th. The Council 
had authority from the Representative Body to ' sanction a 
scheme of tho kind he had outlined if it approved the con- 
ditions and the auspices under which the scheme was run. 
Tho Oplilhalmic Committee was recommending approval of the 
scliemo subject to its conformity to certain conditions laid 
down. If the scheme went forward it would mean that the 
conditions under which men and women had placed their names 
on the British Medical Association list would be materially 
.altered, and therefore they would have to be consulted on tlie 
matter. It was hoped that the list would be e-xtended; it 
should have at least 1,000 names, some 200 more than at 
present. 

In answer to further questions. Dr. Brackenhury said that 
tho dispensing opticians had stated that they were prepared to 
start the scheme with a number of clinics in large centres, 
and as tho need arose tliese would be multiplied, though in 
most parts of the country there would be, for the present at 
all events, no question of a separate clinic. The selection of 
medical men to take sessions at a clinic, supposing there were 
more men available than sessions arranged, would be a matter 
for friendly adjustment between themselves, subject to the 
right of appeal to the central medical committee in the unlikely 
event of anj-ono feeling himself aggrieved. 

Asked if there would he room for free choice of doctor. 
Dr. Brackenhury pointed out that there could not be free 
choice at a particular session, but that the principle of freo 
choice was preserved by the fact that the patient could go to 
any doctor in tho area who chose to say, “ If j-on come to 
me at a certain time I will see j-ou for half a guinea." He 
added that it should be made clear that the position of anyone 
who desired to remain on the list, but was not willing under 
present conditions to see any patient except at a guinea, was 
not prejudiced. He need not take part in the work of tho 
“ clinics " at all, although, of course, such a practitioner must 
recognize that a proportion of what had hitherto been his 
clientele might be drawn away through tho effect of these other 
provisions. 

At the close of the questions a hearty vote of thanks was 
accorded to Dr. Brackenhury. 





Feb. 4, 1928] 


Nava! and .MiUtary AppoTntmenis* 


X BUPPiximi^T TO Tim 
LBniTisir iTKDicAXi Joun^rxii wiF 


^irbttl mtb ilttlitnrg ^ppcrintnwnts. 

ROYAL NAVAL 5IEDICAL SERVICE. 

SuTPccn Commanders T. C. Paltcn*on to tlic PrcfttUni for MctHcal 
Department, tomporarv; 0. E. Creoson to the Victor;/, Eebrnary 6lh, and 
to the troulent for’U.M, Experiments Station, I’orton, for courso of 
instrnotion, Fci>runry 15th, ntiil to the Victori/, Marcli 12th; H. M. 
Draithwatto to the Egmoni for H.K. Iloipltal, Malta. 

Sur^c«m Lieutenant Commander W. J. Colbornc to the Vic/d for R.N. 
Hospital, Plymouth. 

Sun^x'on Lieutenant 0. S. Rutherford to he Surgeon Lieutenant 
Commander. 

Siirpcon Llmdcnanls J. W. Simpson to tho VoL’anf; R. W. Higgins to 
(he impregnahlc. 

RoY.tL Nival VoLUNinT. Rr^rnvr. 

Vrolationary Surgeon Sublieutenants D. C. Llving><lon and D. R. 
G*Mdfenow to ho Surgeon Sublieutenants. 

H. SheUwoU haa entcrc<l as proKitionary Surgeon Lieutenant, and 
is attached to List 2 of the I/Dndon Division. 


ROYAL ARMY ilEDICAL CORPS. 

Licnf.-Colonel II. IV Shea, D.S.O., h.aving attalneil tlm age limit for 
eompul'ory irtlremenl, retire'* on retired p.ay. 

Jtajor li. St. M. C.artcr, D.S.O., to In? Lieutenant-Colonel, vice Lieut.- 
Colonel 11. F. Shea, D.S.O., to retired pay. 

Major B. 11. 11. Ncven-Spencc In re-employed under .\rtlclc 507 (6), 
Roj'al Warrant for Pay and Promotion, 1926. 

C.iptains W, Millerick, M.C., and It. Johnson, M.B.E., to be Majors 
(prow). 

Temporary Captain J. W. Darling, M.C., ^cllnqui^he*^ his commission 
anti retains tho rank of Captain. 

Lieutenant on probation P, C. Rcntlif resigns his commirsion. 

n. G. Rees to be temporary Lieutenant, 


ROYAL AIR FORCE MEDICAL SERVICE. 

Lieutenants E. G. ITowvll to the School of Army Co-opcralion, 
Old.Saimnx; D. R. Smith to R..\,F. Station, Cppcr ncvford; II. Penman 
lliR*^* ^ Squadron, Catlerick; G. 51. Anderson to R..AJF, Station, Biggin 

9; ‘Tr S- O’Malley to be Flight Lieutenant. 

•rliing Omcers N. I Smith to fltallon Headquarters and Storage Section, 
Andmer; J P. Hcilemian to R.A.F. Depot, U.\bridgo; E. A. Rice to 
R.A.F. Station, Worthy Doivn. 

REGULAR .VRMY RESERVE OF OFFICERS. 

Ti *r.i , r, Joyit Conns. 

I Goddard, I).S.O., having attained (he age limit of 

liability (0 recall, ceases to belong to (he ne2}rTc of omcoi«. 


INDIAN JfEDICAL SERVICE. 

5IaekIo, O.R.E., Director of the IlnlTkine InMitiitc, 
^baj, appointefl an Honorarj* Surgeon on the personal stafl of His 
if V 'iccroy and Covernor-General of India. 

Captains P. 5cr«lon and J. M. Shah, M.U.E., to b^ Major-. 


TERRITORIAL ARMY, 
iv <ir •. Ar.iiY MnmuL Con.rs. 

rrr«i»riirT,^«'«} Rwcrvc of OlTlcors, to be Captain, with 

precedence as from March 30th, 1910. 

Janniiry''Sst T92^' Captain, witli procfdi'iicc as from 

n. N. Kinnison to bo Lieutenant. 


TERnrroKLVL Aiurr re-serve of officer.s. 

Vaini- n T- AnstY MCDICIL COW.S. 

coSio"na^ia^re&swr?fn^ "S” 

to“c^L7JntenanE’''"‘'“^‘™‘'“"‘ Cnrrcll. from fl.c active list. 


, . , VACA2fCIES. 

* ralfin “■/m'Jr '^“'TO-bms.mY DismsES.— (I) Honorarj Con- 

Registrar. ^ Officer. (3) Ilonorary Surgical 

^ Salary Assiatant House-Surgeon (male, unmarried). 

Medical Officers for the Public IFealtli 
?aTe"50’rS‘^nSSm!^^ unmarried). Salary at the 

^sXrilSO^p'S'annum!'^ irosrmL.-IIouso-Surgeoa (male). 

Assistant Surgeon to tbe Ear, Nose, 

" ■■ ;■ dical Omcer as nonse- 

tho^atc of £155 at mVnt 

Officer os Junior liouso-nnysic.an ; salary at tho'rati of^M per annim! 
^alarfll5o“e?anS?”’ Croytlom-Medical Officer (V.D.). 

^'Srk' <«’ ihe Hdirt and Ldxgs, Victoria 

annuni*^'^~” (male). Salary at the rate of £100 per 

Hosmit, City Road, E.C.I.— Assistant Resident 
Medical Officer. Salary at the rate of £80 per annum. 

a , S’?, BOROUGII.-Depnly Medical Officer of neallh and 
Dtpnty School Metlical Officer. Salary £780 per annum. 

M^tmT'ris^n^t^Ilwy^™"”'' O'”''''’'' P" 

MospitaL and Eye Ixfirmary. — .A ssistant House- 
Pni , (nnmarnnd). Salary at the rate of ‘£50 -per annum. 
sSgron" JfEMoniAb Mateukity Hosi’iTAL.-Tao House- 


Eni,XDimGii Hospitai. ron IVojie.v axd CmuntEx. — (1) House-Surgeon, 
(2) Ilousc-Pliyslcini). (3) Junior House-Surgeon (non-resident); 
remuneration at tlio rate of X'25 per annum. Females. 

Edinouroh i Royal EoLvaunen Hospital for Sick Cihloro. — F ivo 
Honorary Resident Slcdlcal Officers. 

EDiNBUfioiT Royal iKrmMARY.—Scntor Clinical Assistant and Clinical 
Tutor In* the Ophthalmic Department. Emoluments £145 per annum. 

EXETcn : Royal Devon* and Ryotr Ho.'ipital.— R esident Casualty Officer 
and Ilouso-l’hyslci.an to the Radium, A’-Ray, and Electrical Department 
(mote). Salary at the rate of £100 per annum. 

GufiCOAV Evk lN*rin.M\RY.— (1) Resident As^iFtant House-Surgeon; salary 
£75 per annum. (2) Visiting Snrgcon. 

Grcit YARMOUTn ; OrN’CiiAL Hospital,— H ousc-.Surgeon (male, unmarried). 
Salary £150 per annum. 

GuiLDPORD U.vio??. — Resident 3Iale Assistant Medical Officer at tlio 
IiistiluUon. Salary at the rate of £150 per annum. 

Hertford County Hospital. — Honorary Assistant Surgeon. 

IrsAVicn Partsji. — .\F slstaiit Resident Ifedical Officer (female) at IToatli- 
flelde Infirmary, Ilcathflchl House, and St. John’s Home for' Children. 
Salary £250 per annum. 

ISMY : P.inisii OP'KiLDiLTON A>n) Oa.— J lcdical Officer and Public Vaccinator. 
S.alary from Pnrisli Council £100, and grant from Highlands and Islands 
(^ledfcal Service) Fund £180. 

LniCESTER Roa'al l.vrjRsrARY.— (1) Honorary Physician. (2) Assistant 
Honorary Physician. 

Lr.wi’^li.iir BoROcen Council. — A aslstant Medical Officer and ilatcmity 
and Child M’clfaro SIcilieal Officer. Salary £650 per annum, rising to 
£750. 

LivcnrooL r Hospital for CoxsushmoK ant) Diseases of nin ClrcsT.— 
A-«slstant SIcdical Officer and Pathologist (non-resident). Salary £150 per 
annum. 

London Scttool of Hyctent: akd TnonciL Medicwe, Endsleigh Gardens, 
W.O.— Rescarcli Sludentship In Protoroologj*. Value £250 per annum. 

Lokdotj CxrvLTSiTY.— University Clinir of Pathology, tenable at the 
London (Royal Free Hospital) School of Medicine for Women. Salary 
£1,0(^ a year. 

MAN’cnESTFR AND Salford Hospit.al FOR SiOK DISEASES.— Housc-Surgeon. 
Salary £100 per annum. 

MiDDLr.sBnoucn County Borough. — ^Assistant to Medical Officer of Health 
(male, unmarried). Salary £450 per annum. 

Middlesdroocii : North Riding Lntirxlary.— S enior and Junior Resident 
Surgeons (male). Salary at the rale of £200 and £150 per annum 
respectively. 

Ministry op Health.'— M edical Officer (male). Salary £600 per annum, 
rising to- £1,100, and bonus, at present £176 7s. 

Preston County Borouoh.— A ssistant School Medical Officer (male). 
Salary £600 per annum. 

Oueen’s* Hospital for Children, Hackney Road, E.2.— (1) Resident ^ledicaj 
Officer. (2) Casualty Officer, Salary £200 and £100 per annum respeo* 

R^ietcr: St. Bartholoxteu-’s Hospital.— House-Physician (nnmarrlcd). 
Salary at the rate of £175 per annum. 

Royal Fred Hospital and Londo.n (ILF.H.) Scho^ol or MmiQNB ‘for 
M'omen.— Anacsthetibt for Obstetrical and Gynaecological Unit. 
Honorarium £100 per annum. 

Royal National Orthopaedic Hospital, 234, Great Portland Street, W.I.— 
(1) House-Surgeon. (2) Ilourc-Surgcon at Country Branch at atunmorc. 
Salary 1T50 per annum each. 

Royal Northern Hospital, Holloway Road, N.7.— Ophthalmic Surgeon. ^ 

St. John's Hospital, Lewisham, S.E.13. — Assistant Physician. 

St. Tnojws’s Hospital.— P hysician in charge of Ont-patientff. 

Seamen's Hospital Sohety.— H onorary jVfisistant. Physician at the Hospital 
for Tropical Diseases. Endsleigh Gardens, W.C. 

SiiEnnvTCK County Borough.— Lady ^\saistant Medical Officer of Htalth 
and Assistant School .Medical Officer. Salary £600 per annum. 

Somkilset County Council.— C ounty .Assistant Medical Officer. Salary 
£600 per annum. 

Stokeon-T»r:;t City.— ^fedical Officer of the Venereal Diseases Centre. 
Salary 1850 per annum. 

Truro: Royal Cornwall iNriRXLARY.— House-Surgeon. Salary £170 per 
annum. 

tJnivep.'ITV College Hospital JIedical School.— R adcliffe Crocker Travelling 
*Schoiarship in Dermatology. -Approximate value £280. 

Warwick County Mental Hospital, Hatton. — Assistant ^Icdical Officer. 
Salary £300 per annum. 

West London Hospital, Hammersmith Road, W.6. — ^Honorary Obstetric 
Registrar. 

West Riding County CouNai. — School Oculist. Salary £600 per annum, 
rising to £700. 

Wilts County Council.— School Dentist. Salary £500 per annum. 

M’olvep.hampton and 3IIDUND Counties Eye Infirmary.— House-Surgeon. 
Salary £200 per annum. 

Cep.tifytnc Factory Surgeon. — Tlic appointment at Middleton-in-Teesdale, 
CO. Durham, is vacant. Applications to the Chief Inspector of Factories, 
Homo Office, London, S.W.l. 

Medical Referee under the Wo • ■ . ••• * t, 1925, for the 

- - .-IT,... J 'aim). Applica- 

' ? " ■ London, S.W.l, 

This list of vacancies is compiled from our advertisement columns^ 
where full particulars will be found. To ensure notice in ihts*^ 
column adverfisemenfs must be received not later than the first 
2 )ost on Tucsdai; mominQ. 


APPOINTSIENTS. 

Lucas M- G., 3I.B., Ch.B.Ed., Honorary Anacstlictist to the Hull Royal 
Infirmary. 

Minton Malcolm, M.D.Glas., D.P.H.Camb., Jledical Officer of Health and 
School Medical Officer, ^Yood Urban District, vice W. E. Porter, M.D.Ed., 
D.P.H.Camb., retired. 

Marshall, C, M., Ch.B. New Zealand, Re-sidenl Medical Officer to tho 

lYccmasons Hospital. 

Reid, E. Neil, M.B., Ch.B.St. And., Assistant Deputy Medical Officer for 
Durabarlonsiiire. 



40 


Feb. 1928 ] 


Association intclllgohco and Diary. 


r supPL^iiENT to m 

LBHITIBB UEDIOU. JotXBKifi 


DIAEY OP SOCIETIES AND LECTURES. 

ROTAI. SOCIETT OP llEDIOIKa 

«tX Bomhard Baron Inatltnt, 

of Pathology, fflon Hoapitai; E.l. Tuea 8 30 P-®-. Dmonatrattons 

^ " usfdW Loolon" of S^poro 

mental Herpca^ln^the - . . Uenal Funclfon; 


Glasgow Post-Qiuotjati Medical AasocuTiOTU— At Ear, Koso and Throai 
Hospital; Wed., fl.lS p.m., Cases, , 

MANcacsTr.a’; Bt. Mary’s Hospitals (Wiutworth Shiest West Brakch).— 
Frl., 4.30 p.m., Obstetric Operations." 

SnEFFicLD University Post-Ohaudatb Clinics.— A t the Royal Infirmary; 
Frt., 3.30 p.m., Clinical Cases. , . 


Method; A. B. Bratten : 


Tetanus; H. D. Kay a 

lithologfcafsMoiiiiMls: K. Ih laiienuau; “I 

Membranes ; / R. Merrack : Osmotic Pressure of Sen m ProtclM m 
Kophrllis ; ’p. Flldes : Motility and Germination of B. fofanf. 

Section of knrgery - SvbiccUon of Frocloloyii.— Wed,, 6.30 p.m., BIr. r. J. 
McCann: Operation tor Prolapse of the Rectum the Female, 

Zachary Cope : Treatment of Irreducible Sigmoidorectal 

in Old People! Mr. W. B. Gabriel : Five Cases of Small Gut Obstruction 

round Colostomies; Dr. '' '■ • ^'‘monstratlon of Sigraoldo- 

Boopic Appearances of , ■ Origin, o „ 

Seotiont of Ophthalmolog), 8 p.m., Caaea. ®*20 P.“., 

Special UlacuBSlon : Ocular Complications oi Encenhalttls Lclharglca. 

To be opened by Dr. Joraes Collier (Kcurology) and Mr F. A, WlUiamson* 
Hoble raphthafmology) ; followed by Dr. A. felling, Dr. J. B. Perdrau, 

Hr 3L L, nine, Mr, R. Foster Moore, and Dr, W. J. Adle. 

Clinfcol Section.— FrL, 6 p.m,. Cas es. 

Royal Colleoh or StmoroNa o? England, Lincoln’s Inn.— ^ton., 6 P;ro*» 

Sir Percy Sargent : Surgery of the Posterior Cranial Fossa, wed., 

6 p.m., Mr. Q. Grey Turner : Treatment of Congenital Defects of the 
Bladder and Urethra bv implantation of the Ureters Into the BowcL 
Frl., 5 p.m., Mr. J. H. Sheldon : An UndescrIbed Disease of Bone. 
Biochemical Society, Lister Institute, Chelsea Bridge Road, S.W. — Mon.,- 
6 p.m, (i) H. Jepheott and A, L. Bacharach : The (^antltative Estima- 
tlon of Vitamin D; (il) A. L. Bacharach and E. Allchorne: The 
Vitamin B Content of Malt Extract; (HO M. Q, White and J. J. 
Wlllaman: The Alcoholic Fermentation of Pentoses by Fuearium Uni; 
(It) a. V. Hill : Increased Anaerobic Metabolism In Muscle following 
Stimulation; (r) D. Jordan Llovd and W. B. Please; The Eflect of 
Nitrates on the Absorption of Waler bv Gelatin ; (vi) H. W. Kinnetsley, 

B. A. Peters, and V. Reader ; Metabolic Constancy In the Pigeon ; 
?Tili R. T. Brain and ft D. Eay ; Phosphate Excretion; (vHI) R. P. 
Cook and B. Woolf ; The Deamination and Synthesis of l*Aspartio 
Acid In the Presence of Bacteria; (ix) R. Robfson and E, M, Soames; 
Calcification in vitro, 

UsDKWL OmCERs OP ScROOLa AssoaAHON, 11, Chnndos Street. W.I.— Frl., 

6 p.m., Dr. A. A. Mumford : The School Medical OiTiccr of the Future. 
West Kent JItdico-Chirurgical Society, Sillier General Rospital, Green- 
wich Road, S.E.10.— Frl.. 8.45 p.m., Dr. R. Travers Smith : Tho Origin 
and Diagnosis of Punotional Cardiac Murmurs. 

POST-GRADUATE COURSES AND LECTURES. 

Fellowship op BltDiaNE and Post-Graduatb Medical AssoaATTOK,— Leefura, 
Medical Society of London, 11, Chandos Street, W.l : Mon., 6 p.m., 
Secondary Forms of Mental Deficiency. Paddington Oreen Children*$ 
Rorpitfll, W.^ : Frl,, 2 to 3 p.m., Clinical Demonstration. Sf. J/orfe’s 
Hotptlal, City Road, E.C. ; Mon.. 2.30 p.m., Clinical Demonstration. 
Ropai wettmineter Ophthalmic noppffaf. Charing Cross, W.C. : Frl.. 

5 p.m., Clinical Demonstration; Cataract. The above are free to medical 
practitioners. Paddington Green Ohtldren’i Hospital and PictoHa 
Hospftal for Children: Combined Course In Diseases of Children. 
Mornings ond afternoons, Lectures, Demonstrations, and Operations; 
fee £3 as, for two weeks. St. John's Uoepital for Diseases of the Skin, 
Leicester Square: Course in Dermatology every afternoon; Pathology 
Course arranged. Bethlem Roval Hospital, St. George's Fields, S.E.l ; 
Tues. and Sat. mornings, Clinical Demonstration In Psychological 
Medicine. Roffonal Hospital, Queen Square, W.C.l ; Course In Neuro- 
logy every afternoon ; Demonstrations ; Lectures at certain times. 

Central London throat. Nose, and Ear Hospital, Gray's Inn Road, 
■W.O.I.— WeA, 4 p.m.. Consultations and Demonstrations of Interestinj 
Cases. Frl., 4 p.m.. Early Mastoid Operations, 

East London HoariTAL por Children, Shadwell, E.I.— Thurs., 4 p.m.. Heart 
problems In School Children. 

HoamAL for Sick Children, Great Ormond Street, W.O.I.— Thurs., 4 p.m., 
Oyitoscopy. 

London School or Dermatology, St. John’s Hospital, Leicester Square, 
W.C.2.— Tues., 5 p.m.. Lichen Planus. Thurs., 6 p.m., Lupus 
Erythematosuo. 

National HosmAt. Queen Square, W.0,1. — Mon., Tues., ThurSy and FrL, 

2 p.m., Out-patleni Clinics. Tues, and Frl., 9 a.m., Operatlona; 

5 p.m., Methoas of Examination of the Nervous System. Mon., 3.30 p.m., 
papilloedema. Tues., 3.30 p.m., Diagnosis of Spinal 'Tumours. Tbum., 
3.30 p.m., Neuro-syphllls, Frl., 3.30 p.m., Demonstration of Re-cducatlvo 
Methods. 

North-East London Post-Graduate College, Prince of Wales’s General 
Hospital, Tottenham, N.15. — Mon., 2.30 to 5 p.m., Medical, Surgical, and 
Gynaecological Clinics; Operations. Tues., 2 p.m,, Special Demonetra- 
tion of Ear, Nose, and Throat Coses ; 2.30 to 5 p.m., Medical, Surgical, 
Throat, Nose, and Ear Clinics; Operations. Wed., 2.30 to 6 p.m.. 
Medical, Skin, and Eye Clinics; Operations. Thurs., 11.30 o.m.. Dental 
Clinics Special Demonstration of Medical Cases; 2.30 to 6 _p,m,. Medical, 
Surirical, and Ear, Nose, and Throat Clinics ; Operations. Frl., 10.30 a.m. 
Throat Nose, and Ear Clinics; 2.30 to 5 p.m., Surgical, Medical, am 
Children’s Diseases Clinics; Operations. 

TtnTii Institute or public Hraltk, 37. Russell Square, W.0.1.~Wed., 

^ 4 M p.m., Some Problems of Forensic Psychiatry. 

Royal Nor.TiinRN HosmAL, Holloway Road, N.— Tues., 3.15 p.m.. Lichen 

' St^^Kul's Hospital, Endell Street, W.O.2.— Wed.. 4.30 p.m., Tho Enlarged 
Prostate. . J ...v 

RnnrrNlVcST LONDON POST-GPADUATE Assoctatton.— Wed., 3.30 p.m.. Visit 
^ to^WellcomenistoTical Bledical Bluscum, 54a. Wlgmore Street. W.L 
TTf-^n- London Hospital Post-Gr\DUate Col^e. HammersmUh, W.e.—Mon., 
10 a m to 1 p.m., Oenito-urinary Operottons,_ 

Wards: 2 p.m.. fufcmal "nrds, GjmaccoloRi 
Tues.. lo a.m. to 1 p.m.. Medical art ' lait. 

Diseases; 2 p.m., oledical Warts, Thyoat, 1 
Wrt 10 a.m. to 1 p.m.. Children s Med 
Wards, Demonstration in Medical Pathology 

S'mon'^^rotl'on''o! ^Tirturra- 2 Eye and Cenlto.urinary Depart^ 

SeX G?na«om~ieS Vri.. 10 i.m. to 1 p.m. Oynaecolo^ioal 

Operation., Dental. .Skin, and Electrical Departments; 2 p.m., Tl.roat 
j;S-e. and Ear Department. Daily : Operations, Sledical and SurEical 
Out-patients at 2 p.m. 


©litislj iHcliical ^ssonation. 

orncEs, EuiTthu hbuical association uodss, 

TAVISTOCK. SQVAUB. IT. 0,1. 

OOfjartments , ' 

BDBScniPJJOSS AKD ADvaiTisindESTa fFlnanclnl Secretary and Buslncsj 
. 1 ........ Tnl.e. ■ — don). . _ 


"don). 

• nt, Loodon). 

. Aitiology Wcslcent, 


relmi/mns' number, of BrUiih UcdioafAstopIotJon pni Mt>$hJledUal 

^ * < ■# 'noc.1 - oofLO nOAT 


Manager. Tclcgr 
Medical Secretary 
Editor, British 
London). 

Rmnisn - ' ® '’-""’sheugb Gardens, Edinburgh. (Telis- 

BCOTTISII Jiar ^ Edinburgh.) 

Inmf. MCDK ■ Frederick Street, Dublin. (Tele- 
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Diary of tho As60Gfation» 


Z Ftl. 


London ; Ultra-V 
Cambridge and 
Dr. S. Fraser 


■ 3.30 p.m. 

enbrooke'a Hospital, 
and tho Jledical 


6 Mon. 

7 Tuc3. 


Deli'S^f D.“v'.eKS Cooper on 

Co^enTrrDfv^aloi^ (iJo^ntry and Wanvlekshlra Hospltnl. Dr. 

FiSjhiif Divi."a?“Flffii"& nospltab Dr. F. IE B. 

Wnlslio on Faith Healing, 8.«S p.m- 

Portsmou” Division = QS’on°rtenaTDlsease and High Blood 

Division : Great Bull 
Wftkpfield, Pontefrael, and Cast c Gough on Menstrual 

gfSses «d’1bl''Menop’;use.- Supper preceding lecture. 
T ’•^ln'’••'cou^ereuee of Representatiye. d Medical Schools with. 
10 Frl. ^Committee, 2 Ayr. Dr. J. A. Wilsou on 

T WOE 

W Tues. S‘b 

,5 wed. ®'^feln"e RoU Brl^htcn,^5-«„^^^^^^ • A. S. Ferguson, 

16 ■Thurs. jepey^, •^LVeSn. of the Hetd.jf “ „„ j.„,elEn Bodies 

Protcsslon, 8 p.m. , jj^^ly Qualified Practitioners 

Sirf&eSniau^ of Puerperal Morbidity and 

Mortality. 2.30 p.tu- 


births, marriages and 

”"„?eTns^J?rn niu Ke /urreni t«ua. 

MAnuIAOES. Church East 

iawson of Celot. Epping. n-.TH 

, taih 1923 Bartholomew. Hospital. London, 

**^TS^r'^owclirw.l^. F.li:C.S.Ed.. aged 60 Peees. 


17 Frl. 


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' SUP3?XjEl]NJ^EISrT 

TO THE 

BRITISH MEDICAL J QURJ^AL. 

LONDON, SATURDAY, FEBRUARY llin, 1928. 


CONTENTS. 


BRITISH MEDICAL ASSOCIATION. 

cur, RENT NOTE.S : 

Lokoos CYmc ror. Rheusiatic Dise.kses 

Committee IVoue or tiu; Week 

Anseal Session or the Amie».ic.ak Medical AssociAXiON 

MEDIWL ArrOlETMEHTS Adeoad 

MEETINGS OF 15RANCHES AND DIVISIONS . 
ASSOCIATION NOTICES 


PACE 


... 41 
... 41 
... 41 
... 41 

... 41 
... 42 


NATIONAL insurance : 

Loxdo.v 1xslt.asce Committee 

liOSDOx Taiiel Committee 

A'AVAL AND MILITARY ARPOINTMENTS 
VACANCIE.S AND AITOINTMENTS 
DIARY OF SOCIETIES AND LECTURES... 
ASSOCIATION INTELLIGENCE AND DIARY 
BIRTHS, MARRIAGES, AND DEATHS ... 


PAGE 

. 42 
. 43 
. 43 
. 43 
. 44 
. 44 
.. 44 


IBritislj litciJiral ^ssocintioit. 


|!tc£iin0S rf BSrantljts anti Bifaisions. 


CURRENT NOTES. 


London Clinic for Rhcumntlc Diseases. 

On* seeing tlio report of the inaugural inecting of this 
clinie,’ tho Medical Secretary of the British Medical 
Association UToto to Sir Arthur StanleVj chainnan of tho 
;,exceutivo committee of tho British Red Cross Society, 
asking u-hat is to be the method of access of the public to 
the clinic. The Medical Secretary asked whether the clinic 
is to he open to anyone atIio likes to go and pay a fee for 
treatment or is it intended only for patient.s aho are sent 
Tvitli a medical recommendation ; and ho imintcl out that 
unless the cases arc sifted hoforehand tlic clinic may 
easily he flooded with all Innds of Tinsnitahle patients: and, 
moreover, the medical profassiou would regard with grave 
suspicion any medical institution which opened its doore 
to all and sundry wlio miglit think it worth their while 
to tiy a course of treatment. Sir Arthur Stanley has 
repli^ saying that tho point is an important one, and 
that the procedure to he adopted has been referred by 
the clinic committee to the medical suhcommittcc for con- 
sideration. He adds that the Association may rest assured 
that the recommendations of the suheommitteo will bo 
satisfactory to it. 

^ Committee Work of the Wcek- 

Tho Coraniitteo on Puerperal Morbidity and Mortality 
met on .fauuaiT 31st and discussed the suggestions put 
forward at tlie recent coiifereiice, a full report of rvliich 
nppeared in last week’s SurmnsreNT. On February 3rd the 
special subcommittee appointed by the Scienco Committee 
to considoi- tbe effect of tho growing propaganda for the 
goueral use of ultra-violet light and the indiscriminate 
^’•pparatus for the purpose to tho lay public mot, 
and after revio^ng the existing position in this respect 
formulated detailed recommendations for the consideration 
of tho Scienco Cominitteo at its next meeting. The special 
liunacy Conimitteo also met during the wcolc. 

Annual Session of American Iffedlcal Association. 

Tho annual session of the American Medical Association 
is to he held in Minneapolis, Minnesota, fi*om June llth 
to 15th, 1928. The Medical Secretarv would he very glad 
to he informed at the earliest possible moment of any 
member of the British. Medical Association who is propos- 
ing to attend the meeting at Minneapolis. 

Medical Appointments Abroad. 

The head office of tho British Medical Association has a 
good deal of information placed at its disposal by its 
Branches overeeas, which maj’ be very useful to those 
proposing to accept medical appointments abroad. Practi- 
tioners are cordially invited to apply to tlio Medical 
Secretary', B.IRLA. House, Tavistock Square, W.C.I. for 
any information that may ho available regarding oversea 
appointmen ts in which they may be interested. 

^ Biutish SIedical Joukkal, January p. 152. 


Jamaica Branch. 

Tjie monthly mccliDg of llie Jamaica Branch wa.s held in Toft 
Maria Public Hospital on January 19th, when Dr. LscEsm: read a 
paper on eclampsia. He also prascnled three cases of ectopic gesta- 
tion for discussion. 

Tho St. Mary members enlcrlamcd the Branch to lunch at tho 
palm Beach llotcl, and the afternoon was spent at the Robin’s Bay 
golf bouse. 

Oxford axd Reading Branch : Oxford Division. 

The first meeting of Iho year of the Oxford Division was held 
in the Radcliffc Infirmary on Jamiarj' 25th, when Dr. Montgomery 
was in the chair and forty members were present. 

Mr. .H. WurrELOCKB read notes of a case of prolapse of bowel 
through a persistent umbilical fistula, through wliich faeces had 
passed regularly tlireo or four times daily since birth. When tlie 
infant was four weeks old about eight inches of intussuscepted 
bowel protruded through the opening, and was reduced by opera- 
tion. The convalescence was complicated by pneiunonia, but four 
weeks after the operation the wound was well healed and tho 
child was putting on weight. 

Dr. E. \Varjho Tatlor reported the case of a child, aged 11, 
who was first seen in May, 1924. The patient then had what 
seemed lo bo an ordinary attack of chorea, with marked and 
universal movements of all her limbs, and was at that time suffer- 
iag badly fi-om want of sleep, a 6}Tnptom very difficult to relieve. 
Treatment was given on ordinary* lines. The condition continued 
for somo nine weeks, when a gradual improvement set in. Tho 
child was son( away fo the seaside, whei*e she appeared to be 
normal in health. At the end of August, however, in the same 
year, she relumed liome, and had then a marked Parkinsonianism, 
with a very emotional nature. Tliis condition became steadilv 
worse, and "she passed into a condition of spastic rigidity, with 
very marked tremor. The original diagnosis of chorea, althougli 
entirely incorrect, was at first supjiortcd by a history of “growing 
pains.*'’ There was never any definite cardiac lesion or any 
symptoms pointing to a rheumatic infection. Dr. Taylor added 
that it was difficult to see how the diagnostic error could have 
been avoided, even though the subsequent course of the illness 
proved it to he a clear case of encephalitis lethargica. 

Dr. R, IV. Crujckshank and Dr. IV. T. Collier showed two 
cases of cow-pox. The first, a boy aged 15, had complained of 
distinct illness on January 15th — namely, headache and genera*! 
lassitude: lie seemed to be feverish and perspired a gooS deal. 
He remained in bed for the next two days, and an inflamed «pot 
appeared on his right index finger. He had a crack in the 
skin behind the lobe of the right ear due to frost and cold. 
On January- 18th there was much swelling and thickening around 
iliis crack, and a crusted scab was found around tliis. The glands 
under the angle of the jaw were enlarged and tender, so also 
were the axillary glands. On January 22nd the finger showed a 
bluish-black scab and the tissues immediately round this were 
ulcerating; a thinnish discharge of purulent appearance was oozing 
froni under the scab. The ear lesion -showed much the same con*^ 
dition. There was also a spot on the left wrist — ^first a papule, 
then a vesicle, and lastly a dark umfailicated scab. 

On January 14th a man, aged 22, complained of “ sore throat *’ 
and enlarged submental and maxillarj- glands; he looked flushed 
and ill, and the throat and tonsils were slightlv congested. The 
temperature was 101° F. On the inside of the left nostril, at tlie 
junction of the skin and mucous membrane, there was a papular 
swelling which, on January 16th, showed a black crust; a purulent 
fouI-smelling discharge oozed later from under tlds. Both 
the patients were employed at the same farm and were 
looking after and milking cows -which had been suffering from some 
eruption and sore places on their teats. Dr. Cruicksbank added 
that ii was interestmg to note that the first patient had not been 
vaccinated in infancy and that the second one had only been vacci 
ualed as an infant. In the unvaccinated lad the infection was 
multiple, and in tho one vaccinated in infancy infection was sinirle 

Dr. IzoD Besnot read a very interesting paper on recent 
advances in pernicious anaemia. An unusually large number of 

[1229] 





Feb. 11, 1928] 


Nava! and MUHary AppofntmcntSi 


r STTTPLr.iTEirr to the 
LnniTian Uedicaz. Joubkat^ 


43 


ncconlnnco with tho instniction**, tlio Minister would Imvo no 
oltcrnativo but to withhold a sum whicli, if tho dcfccla were 
serious, might be substantial. TIio Minister nointed out that tho 
practitionei's were not dealing fairly with their colleagues, who 
might afterwards have to treat these same eases, if they failed to 
fulUl their obligation to furnish a continuous medical history. 

Th« Final Certificate, 

Mr. H. Mills, chairman of tho Medical Service Subcommittco, 
said that in eases which had conio before tho subcommittco 
complaints had been made against practitioners because tho 
insured person had not been able to get a second opinion when 
his practitioner had — improperly, ns the insured person thought- 
insisted on giving a final certincato. Ono insured person asked 
leave to go to the regional medical officer, but that was refused by 
his society, which iield that the regional medical officer was 
brought into existence to protect tho society against its members. 
There was a diffcrcnco of opinion as to wlicthcr tho society was 
justified in that attitude. It was suggested that if some method 
could bo found whereby tho insured person would know what was 
his proper course under such circuinstancca it would simplify tho 
work of tho Medical Service SubcommiUee. In a brief uiscussion 
some astonishment was expressed that any society should rcinso 
its members permission to go to tho regional medical officer, 
bccauso tho nltcrnative, ns to which the society had no option, 
was tho clumsy proccduro of arbitration. It was agreed that tho 
chairman and another member should sock an interview with tho 
DtTicials of tho society which had witlihcld consent and endeavour 
to discover some compromiso. 

Chanr^e of Doctor, 

Tho total number of notifications by insured persons of their 
desire to chango doctors in the same district received m London 
Juring tho last llirco months of 1927 was 5,834. The greatest 
number on any ono day was 107 on November 3rd. The number 
of irregular transfer acceptances sent in by practitioners and 
\*eicctcd during tho same threo months was 2,198. 


ROYAL AIR FORCE JIEDICAL SERVICE. 

Flight Lieutenants J. J. Clnrko and B. Pollard aro transferred to tho 
Be*!crvo Class Dli. 

Flying oniccr N, 1. Smith to bo Flight Lieutenant. 

FlVing OlTiccrs V, V. Brown to No. 5 Flying Trolning School, Sealandi 
M. Clancy to No. 1 Flying Training School, Netheravoii; F. E. Lipscomb 
and 0. P. O’Toolo to R.A.I'\ Depot, Uxbridge; S. B. S. Smith to Electrical 
and Wireless School, Flowercfown; G. H. Williams to Aeroplane and 
Armament Experimental Establishment, Jlartlesham Heath; D. A. Wilson 
to Headquarters, Air Defence of Great Britain, .Uxbridge. 

RcsERvn OP Air Forch OmccRs — M edical Brakcii. 

Flight Lieutenant G. R. Nodwell is transferred from Class Di to Dii. 


VACANCIES. 

BiRinKCiLtSt AND SIiDUKD EtR AND Tiiroat HOSPITAL. — fl) Second House- 
Surgeon, (2) Third House-Surgeon. (Non-resident.) Salary at the rate 
of 1153 per annum each. 

Birminoiiam: Queen’s Hospital. — Medical Registrar. Honorarium £100 per 
annum. 

Birmingham Union.— Technical Laboratory Assistant at Selly Oak Hos- 
pital (male). Salary £4 per week, rising to £5 

BucKDURN County Borough. — SIcdical Oificer of Health and School 
Medical Oificer. Salary £1,000 per annum. 

BooTin Borough Hospital. — (1) Senior Medical Officer. (2) Two Junior 
Medical OfTicera. ilatcs. Salary £150 and £125 respectively. 

Bristol Gener-vl Hospital.— House-Phys*~*'*“ n-.. r.. q Resident 

Obstetrio Officer, House-Physician and Depart- 
ments, Casualty House-Surgeon. Salor, • , ^ • annum 

each, rising to £100 if reappointed. 

Bristol Royal Infirmary.— (1) Two House-Physicians, (2) Four House- 
Surgeons. (3) House-Surgeon to Ear, Throat, and Nose Department. 

t 4) Ilousc-Surgcon to Gynaecological, Ophthalmic, and Dermatological 
iepartmonts. (5) Obstetrio House-Physician. (6) Casualty House- 
Surgeon. (7) Assistant House-Surgeon and House-Surgeon to Ophthalmic 
Deportment. (8) Denial House-Surgeon. Salary (1) to (7} at the rate 
of £80 per annum, but If candidate had previously held resident 
appointment in Infirmary £100, and for (8) £80 per annum if resident, 
and £116 If non-resident. 


LONDON PANEL CO:MiriTTEE. 

At a tncGling of tho I^ndon Panel Committoo on January 24th, 
Dr. H. J. Cardale presiding, Dr. W. L. Templeton was iippoinicd 
a member to fill a vacancy in tho rcprcscnlatiou of Isliugton. 

Alleged Canrcwin^ for Patients, 

Tho case of a practitioner who, it was alleged, had contravened 
the waraing notico in regard to canvassing for patients camo 
again before tho committoo. At its last meeting tho commillco 
decided to report tho caso to tho registrar of tho General Medical 
Council. A letter was now read from tho registrar asking 
whether, in tho event of an inquiry, tlio coraniittco would bo 
prepared to lay tho facts before tho Council at tlio hearing. 
After discussion, tho committoo decided that its funds did not 
permit it to appear before tho Council in tho role of prosecutor, 
and that it would bo^ tho moro proper course to refer tho matter 
^ tho Medical Service Subcommittco of tho London Insurance 
Coi^iUeo to bo dealt with as a complaint, and then it would 
bo for the Insurance Committee to decide whether the caso should 
go^ forward to the General Medical Council. It was agreed that 
tins should bo done. 

* . - ProT)riciary Preparations, 

On tho question coming forward as to whether certain pro- 
prietary preparations should bo allowed at tho cost of iho Drug 
bundj a member complained that there did not seem to bo any 
intelligent system whereby ono proprietary article was admitted 
and another refused. Tho Chairman replied that primarily every 
practitioner “VSt bo a law unto himself in this matter. There 
was no fixed list published, but from time to timo lUo question 
of certain preparations came before tho Panel Committee, on tho 
request of the Insurance Committee, as to whetlicr it was con- 
sidered that they_ should bo paid for out of tho Drug Fund. 
A number of opimons by tho Panel Commiltco were now on 
record; but tho whole question was ono of common sense. If 
a practitioner thought that a certain preparation suited his 
patient better than a preparation in the Pharmacopoeia^ it would 
be comparatively easy for him to justify it before the authorities. 
A practitioner had only to say that in his experience he had 
found tho proprietary article do his patients moro good than tho 
usual prescription, and his point of view would almost certainly 
bo accepted without further question. The Loudon lusuranco 
to notify practitioners of all preparations 

definitely turned down. 

.. c lifedical Service, 

At a meeting of the committee of tho London Public Medical 
Service, which followed the meeting of tho Panel Committee, 
It was announced that the number of subscribers was now 8,434. 


^abal anil IKiUtar^ Appo:titiJ«nts. 


Buxton : Devonshire Hospital. — Assistant House-Physician (male). Salary 
£150 per annum, rising to il75 after three months. 

Cantcrdury ; ‘ Kent and Canterbury Hospital. — (i) Honorary Assistant 
Physician. (2) Two Honorary Assistant Surgeons. 

Children’s Medical Home, V’addon, Croydon.— Medical Oflicer (V.D.). 
Salary £150 per annum. 

Church XIissionary Soctett.— Medical Ofllccr for Church Slissionary 
Society Hospital, Omdurman. 

Croydon County Borough.— Deputy Medical Officer of Health and 
Deputy School Medical Officer, Salary £780 per annum. 

Cyprus.— District Medical Officer. Salary £600 per annum, 

Derbysiurb County Counql.— W oman Medical Officer. Salary £600 per 
annum, rising to £750. 

Dewsbury and District Gd>er.il Hospital,— House-Surgeon (male). Salary 
£20^ per annum. 

EDiNDURCn: Elsie Incus Memorial Maternhy HosmiL.— Two House- 
Surgeons (females). 

Edinbiiroii Hospital ron Women and Children.-^CI) House-Surgeon. 
(2) Houve-Physlclan. (3) Junior House-Surgeon (non-resident): 
remuneration at the rate of £25 per annum. Females. 

Edinburgh Royal Infirmary.— Senior Clinical Assistant and Clinical 
Tutor in the Ophthalmic Department. Emoluments £145 per annum. 

Guildford Union.— Resident Jlale Assistant Medical Officer at the 
Institution. Salary at the rate of £150 per annum. 

Hospital for Sick Children, Great Ormond Street, W.C.I.— Assistant 
Pathologist and Research Fellow, Salary £450 per annum. 

lifORD Emergency Hospital. — Senior and Junior House-Surgeons (male 
unmarried). Salary £110 and £90 per annum respectively. * 

Ipswich Parish.— Assistant Resident Medical Officer (female) at Heath- 
fields Infirmary, Heathfield House, and St. John’s Homo for Children. 
Salary £250 per annum. 

Kensington, Fulham, and Chixeea General Hospital, S.W.IO.— Senior and 
Junior Resident Medical Officers. Salary at tho rato of £125 and £100 
per annum respectively. 

Leicester Royal Infiiuury.— Two House-Physicians. Salary at tha 
of £125 per annum. 

Liverpool and ©istrict Hospital fob Diseases op thb Heart— H ou«e- 
Physician. 

London University.— University Chair of Biochemistry tenable at the 
London School of Hygiene and Tropical Medicine. Salary £1 300 a vear 
and allowance of £200, ’ ^ . 


aiANUHUjitli A.MJ ... .v... 

Salary £100 per annum, 

Middlesbrough: North Riding Infirmary. — Senior and Junior Resider 
Surgeons (males). Salary £200 and £150 per annum respectively. 
3IiLDM.\y Mission Hospital, Austin Street, E.2.— Junior Resident iledlca 
Officer (male). Salary £100 per annum. 

Ministry op Health.- 3Iedical Officer (male). Salary £600 per annun 
rising to £1,100 and bonus, at present £176 73. 


- — — 


Queen’s Hospital for Children, Hackney Road, E.2. — (1) Resident Medical 
Officer. (2) Casualty Officer. (3) Two House-Physicians. Salarv for m 
£200 and for (2) and (3) £100 per annum. •' 

Richmond, Surrey : Royal Hospital. — Junior Assistant House-Surgeon 
(male). Salary at the rate of £100 per annum, rising to £lw on 
appoihtment as Senior. 


ROYAL NAVAL StEDlCAL SERVICE. 
ortJSh " ^ °- '5lven to. tlio Victor!, for R.N. Barracls, 

Surgeon Lieutenant T. G. B. Cranford to tho Concord on completing. 


IT. ARJIY JIEDicAL CORPS. 

•I Ueutena S-ColoMh"^ granted tho rank 

Major C. JI. Rigby, retires on retired nav 
Captain T. C. Bowlo to bo Major. ^ 

relinmii.n temporary Captains and temporarily 

D- Merrln and J. B. WoodrSw. 

P ary Lieutenant I. MaotV, Bourko relinquishes his commission. 


Rochford Union.— District Medical Officer and Public Vaccinator of the 
Southend-on-Sea (West) District. Salary £120 per annum and usual 
medical and vaccinaiion fees. 


Royal College op Surgeons op England. — Member of Court of Examiners. 
Royal National Orthopaedic Hospital, 234, Great ‘Portland Street W’l.— 
(1) House-Surgeon. (2> House-Surgeon at Country Branch at Stamnore. 
Salary £150 per annum each. 

Royal NoanrenN Hospital, Holloway Road, N.7.— (1) Ophthalralo Sarc-Mn 
- (2) House-Surgeon ; salary at tho rate of £70 per annum, ** , 

Bt. George’s Hospital, S.W.L— Assistant Ej4iologist. Remuneration mk 
the rato of £110 per annum. “ *• 

St, John’s. Hospital for Diseases of the Skin, Leicester Sauarp wn ' 
•Honorary Medical Registrar. ’ J>quare, W.O,-i 

St. Thomas’s Ho£PXTal.— Physician in charge of Out-patients- 


44 FebI 11, 1928] 


Association Intelligence and Diary, 


r EUPPjji:m:KT lo to* - 
LCciTien HsDicxi. ^ourkil 


blocKPORT I.NTIRMARy.— Eesident Surgical Officer. Salary £250 per annum. 
Bioio! AKD WoisTAirrox Union.— .\5?istant Medical Officer at the London 
Koad Institution. Salary £250 per annum. 

Etoke-ox-Trcnt Oitv.— Medical Officer ot the Venereal Diseases Centre. 
Salary £850 per annum. 

TKvno • Eor.iL ConnwALL iNnaMir.v.— Honorary Assistant Surgeon. 

.Warwick CooKry Mental Hospital, Hatton.— -Assistant Medical Onicer. 
Salary £300 per annum. 

.West London Hospital, Hammersmith Eoad, W.6. — Honorary Obstetric 

WesV Norfolk and King's LYaVN Hospital.— (1) Resident Sur;:ical Officer. 
(2) Assistant House-Surgeon. Salaiy £400 and i.100 per annum lespec- 

York Maternity Hospital.— House-Surgeon (female). Salary at tlio rate 

of £350 per annum. 

Certifying Factory Surgeons.— The following vacant appointments are 
announced: Aberayron (Oardiganshire), Rothesay (Buteslure). Applica- 
tions to the Chief Inspector of Factories, Home Office, AMiuehall, S.W.L 

This list of vacancies is compiled from our advertisement columns, 
where full particulars will he found. To ensure notice in this 
column advertisements must be received not later than the first 
post on Tuesday morning. 

APPOINTMENTS. 

Eddison, Herbert W., M3., B.Ch., D.P.M.Camb., Medical Superinlendent 
of Wonford House Mental Hospital, Exeter, vice W. B. Morton, 
JLD.Lond., deceased. 

Clegg, R. Ashleigh, M.D., D.P.H., County Medical Officer of Health to the 
East Sussex County Council. 

Jones, Archibald M., M.D., F.R.C.S.Ed., Honorary Surgeon to the Ear, 
Nose, and Throat Department of Cardiff Royal Infirmary. 

SIarley, J., M.R.C.S., L.R,C.P.Lond,. Certifying Factory Surgeon for the 
Hoylake District, county of Chester. 

Robinson, J. S., M.B., B,Cli.Dub., F.ILC.S.Ed., Consulting Surgeon to the 
Tewkesbury Hospital, 

Roxburgh, A. 0., M.D.Oantab.. M.R.O.P.Lond., Physician in charge of 
Skin Department, St. Bartholomew’s Hospital. 

DIARY OF SOCIETIES AND LECTURES. 

Royal Society op Medicine. 

Sccfion,— Mon., 5 p.m., Surgeon Commander S. F. Dudley, R.N. : 
Some Aspe* * "■ ‘ ' * 'typhoid Fever in the Royal Navv. 

Section of P 'at the Maudsley Hospital, Den- 
mark Hill . (tea at 4 p.m.). Discussion : 

Prognosis of Acute Schizophrenia: preceded by display of series of cases. 
Social Evening. — Wed., 8.30 p.m., Reception by the President and Ladv 
Berry. 9.15 p.m., Address by Lieut.-Coloncl w. P. SfacArlhur, R.A.M.C. : 
Some Medical References in Pepys (with illustrations). 
iSccfJojj of Dermatology. — Thurs., 4 p.m., Cases. 

Section of Ohstetrics. — Fri., 8 p.m., Dr. Bethel Solomons: Two Uteri 
removed for Puerperal Sepsis; Mr. J. Ellison: Two Extreme Cases of 
Multiple Myomata in Sistcis of under 25 years; Mr. Frederick Roques: 
Enccphali' * ‘ * ” 

Section of • , Cinematograph Demon- 
stration b including the Action of 

Irradiatio j . 

EOY.4L College op Surgeons op England, Lincoln’s Inn Fields, W.C.2.— 
Mon., 5 p.m., Dr. Adolphe Abrahams : Physiology of Violent Exercise 
in relation to the Possibility of Strain. Wed., 5 p.m., Mr, A, Fleming: 
Lysoz^ne. Frl., 6 p.m., Dr. Ida 0, Mann : Regional Differentiation of 
the \ ertebratc Retina. 

Royal Soctety op Tropical Medicine an*d Hygiene, 11, Cliandos Street, W.l. 
—Thurs., 8.15 p.m., Dr. A. R. Paterson, Deputy Dir-ector of Sanitary 
Service, Kenya : The Provision of Medical and Sanitary Services among 
Rural Populations in Tropical Africa ; preceded at 7.45 p.m. by a 
demonstration. 

JIedical Society op London, 11, Chandos Street, W.l. — ^Mon., 8.30 p.m., 
Discussion : The Use and Abuse of Ultra-violet Light Thcrain-, To bo 
introduced by Professor Leonard Hill, Dr, O’Donovan, and Dr. C. B. 

- Hcald. 

POST-GRADUATE COURSES AND LECTURES, 

Fellowship or Medicine and Post-Graduate Medical Assoclation. — Lecture 
Medical Society of London, 11, Chandos Street, W.l, Mon., 6 p.m.. 
Hysterical Breasts. West End Hospital for Nervous Diseases, Wclbeck 
Sfrcft, w.l : Clinical Demonstrations, Mon., 5 p.m, St. Veter’s Hospital, 
Hennelta Street, W.C.2 : Clinical Demonstrations, Fri., 5 p.m. Itoyal 
TT eslmmster Ophthalmic Hospital, Charing Cross, W.C. : Lecture Demon- 
stration : The Clinical Application of Perimetry, Fri., $ p.m. The above 
aro open to all members of the medical jirofcssiou without fee. 
St.- Johns //osptfttf. I^icester Square, W.C. ; Course in Dermatology 
every afternoon; Patholc^ Courw arranged. National Hospital, Queen I 
Square, \\.C.l: Course in Neurology every afternoon; Demonstrations, i 
Lectures at certain times. 

Central Lo.ndon Throat, Nose, and Ear Hospital, Grav’s Inn Road WCl ' 
— Fri., 4 p.m.. Dysphagia — Pain in Swallowing. 

East London Hospital por Children, Shadwcll, E.I.— Thurs., 4 p.m.. Acute 
Abdominal Emergencies. 

Hospital for Sick Children, Great Ormond Street, W.C.I.— TJnirs., 4 p.m. 

Jlodorn Methods of Contr • c' ••• ^ ' •• '^'seascs. * 

IxiNDON School of Derma* . Leicester Square. 

W.C.2, — Tues., 5 p.m.^ ' . , Thurs., 5 p.m., 

Pathologv Demonstration. 

Xatidnal ilosriTAL, Queen Square, W.C.I.— Mw., Tues.,- Thurs., and 
Fri., 2 p.m.. Out-patient Clinics. Tues. and Fri., 9 a.m.. Operations* 

5 p.m., Examination of the Nervous System. Sion., 12 noon, Pathology 
of the Nervous System ; 3.30 p.m.. Cranial Nerve Palsies. Tues , 3.30 p.m 
Cranio-cerebral Topography. Thurs., 3.30 p.m.. Cranial Nerve Palsies 
Fri., 12 noon, Anatomy and Physiology of the Nervous Sj-stem ; 3.30 'p.m.. 
Muscular .\trophies. ’ 

Nop.th-East London Post-Gp.aduate College, Pnnee of Wales's General 
Hospital. Tottenham, N.15.— Mon., 2 p.m., Demonstration of Gjuaeco- 
logical Cases; 2.30 to 5 p.m.. Medical, Surgical, and Gynaecological 
Clinics; Operations. Tues., 230 to 5 p.m., Jledical, Sunfical, Throat 
Nos,', and Ear Clinics; Operations. Wed., 2 p.m., Demonstration of Ea'c 
C ases; 2.30 to 5 p.m.. Medical, Skin, and Eye Clinics; Operations 
Thurs.. 1130 a,ni.. Dental Clinics; 230 to 5 p.m., Jledical, Surgical! 
and E.ar, No-^e, and Tluoat Clinics; Operations. Fri.. 10.30 a.m„ Throat 
Nose, and E.ir Clinics; 2.30 to 5 p.m., Surgical, Medical, and Cliildren’s 
Diseases Clinics; Operations. 

Royal Chf^st Hospital, City Road, E.C. — Tues., 3.15 p.m.. Early Diagnosis 
of Pulmonarv Tuberculosis. 


Royal Institute of Public He-altk, 37, Russell Square, W.O.I.— Wed., 

4.30 p.m., Mcdico-Lcgal Aspects of Jcwisli Life. 

St. Paul's Hospital, Endell Street, W.C.2.— Wed., 4.30 p.m., Retention of 
Urine. 

Souin-WcsT London Post-Graduate Association, St. James’s Hospital, 
Ouselcv Road, Balham, S.W.12.— Wed., 4 p.m.. Blood Transfusion. 
WF.ST London Hospital Post-Graduate College, Hamraersmilh, W.b.— Mon., 
10 a.m. to 1 p.m., Genito-urinary Operations, Skin Department, Surgical 
Wards; 2 p.m.. Surgical Wai-ds, Gynaecological and Eye Departments; 
4-30 p.ni., Special Lecture: Tho Anxiety Neurosis. Tues,, 10 a.m, 
to 1 p.m., Medical Ward Visit, Demonstrations in ’^cncreal Diseases; 
2 p.m.. Medical Wards, Throat, Nose, * ' 

Wed., 10 a.m. to 1 p.m., Children’s Medic 
Wards, Domon.stration in Medical Pathology; 

Eye Department. Thurs., 10 a.m. to 1 p.m., *■ 

Demonstration of Fractures; 2 mm., E^-c an 
mcn^, Gynaecological Ward. Fri., 10 a.m. i 

Operations, Dental, Skin, and Electrical Dept ' r, - , 

Nose, and Ear Department; 4.30 p.ra., Special Lecture: Surreal 
Emergencies. Daily : Operations, Medical and Surgical Out-patients at 

CLASOOAi' Post-Graduatb Medical Association.— A t Royal Maternity and 
Women’s Hospital : Wed., 4.15 p.ra.. Obstetrical Cases. 

Manchester: St. Mary’s Hospitals (Whitworth SinEur vest Branch).— 
Fri.. 4.30 p.m., Congenital Pyloric Stenosis. 

Sheffield University Post-Gradu.atb Clinics.— A t Royal Infirmary: Fn., 

3.30 p.m., Surgical Cases. - 

58 ritislj iRtMcal ^ssoriotion. 

OFFICES, liniTISn MEDICAL ASSOCIATION HOUSE, 
TAFISTOCK SQUARE, W.C.I. 

DcpartmcntSrn 

Subscriptions and Advertisements (Financial Secretary and Business 
Mana‘'er. Telegrams: Articulate V estcent, London). 

o '“isf, Jlrr’-- • Gardens, Edinburgh. (Tele- 

’ ■■reSclf‘'s?r«tf Dublin. (Tele- 

Diary of the Association. 

10 Fri London ; Conference Kr«entatires of Medical Sebools with 

,4 Tuea. NowiS.uW^o’’|fe '’’SK 

Nortli if Nerroursyphilis. 2-'l5 P-"'- 

Hj?glirDiv^"lonfFas\&^^^^ »>r!’ciiflord Wh.te on 

br. Alfred ^ox o" the Famdy Doc o^on.U ^ Meeting, Royal 
Shropshire and Barnes on Simulation by Func- 

aV6uo^d??-o“orgnn'irD?aS’of .be Nervous lystem, 

15 IVed Brlg^do^^bivislont Clinical Meeting. Sussex Eye Ilosp.t.ul, 

■ Queen’s BrigMon, paadington. ’Dr. 

’'■ aT' K eu^i’nglon Cobbs on Holcl!’ Jlargate. 

16 Tifurs. I->e^oi^Thauot f.-'ji^'S.^obo'JSp”^--:; S. Ferguson. 

^=Fo 7 a, Sons of;£D-d pun.^_ 

Lincoln Division : Lincoln 4 p m. ^ 

Luce. 1\I.P., on the Future oi iio&mi Meeting, Gray 3 

Northern Counties ‘>i,^°eVdacli'*L D on Oral Sepsis- 3-30 P-n'- 

Hospital, Elgin. Dr. Sluacli, g^jj^dcriantl. Dr. Alfred 

General Hnspital. Harlesclen 

Road, N.W.IO, 9 Disorder Committee, 2.30 P-™- 

17 Fri. Dr"'Ri°hie Rodger on Fore.gn Bod.es 

‘in the Air Passages. r^cds. B.ILA. .Lecture by 

os Common Difficulties .n Card.ao 

Diagnosis, 8 p.m. ,, w'indsor. Discussion on Hie 

^’b‘iill"orYe^™Sa?an’a To^ay; to be opened by Dr. 
A. W. Sikes, 6.15 p.m. -pni-al Albion Hotel, Brighton. 

18 Sat. Brighton and the Med.cal 

I 21 Tues . Lo^nSfr:"^?^dirstudent, and Newly 

Subcommittee, 2.30 p.m. j puerperal Morbidity and 

28 TiicS London : Committee on Causation oi 

. Mortality, 2.30 p.m^ 


BIETHB, JLUmiAOliS. A™, ..J 

ensure insertion in the current issue. 

DXRTBS. 11 Ilf n 

E Claude TJiomos, a daughtcr. 

DEATH. „ ^ - 

at 5 Airlie Place, Dundee, on January 25tl., 1S28, Annie Gertrude, 
of Dr? ciiaxles Kerr, O.B.E. 


S XJPPXjEI ME T 


TO TUB 


BRITISH MEDICAL JOURNAL. 


LONDON. SATUUDAY, FEBHUARY ISth. 1928. 


COTS TENTS. 


PACE 

EnITISH MEDICAE ASSOCIATIOH. 
Ecmun(sra‘!on of Non-profossorlal University Workers 45 

LEICESTER PURLIC MEDICAL SERVICE 47 

CURRENT N0TF5 : 

CossuETixo PATnot-ociSTS Gr.ocr 51 

. The Hempsos Triee 51 

Askcai. Session or the Americas Medical Association ... 51 
The HALr-A-EARLA- Indexes 51 


ASSOCIATION NOTICES; 

Election or Memrers or Cocncil ... 
CoNSOLTISG 1 ’aTIIOLOCISTS GrODP ... 


PACE 

Indian Mcdloal Servloo! Recrnltmont for Permansnt 


Commissions 47 

MEETINGS OF BRANCHES AND DIVISIONS 52 

CORRESPONDENCE ... 54 

NAVAL AND MILITARY APPOINTMENTS 54 

VACANCIES AND APPOINTMENTS 55 

DIARY OF SOCIETIES AND LECTURES 56 

POST-GRADUATE COURSES AND LECTURES 56 

ASSOCIATION INTELLIGENCE AND DIART 56 

BIRTHS, MARRIAGES, ANTI DEATHS 56 


?Jritislj itlcbtcal ^Bsociation. 

REMUKF.RATION OF KOX-PEOFF.SSORIaVL 
UMYKIISIIT WUIIKFRS. 


CoNTEETiNCi: OF RErnPKE.VTATivrs OF JIrntc.ir. Schools ivith 
THF. Sc^F.^•CE Committee of the Associ \tion. 

A coNFFHEAXE of rcproRontfitivos of mcdiciil schools ivitli the 
Science Committee of the llritibli Medical ARsocintion mas 
held at the Hoiiso of the Association on Febniarr 10th for 
the purpose of discussing the question of the icnnincration 
of non-professorial medical teachers, laboratory workers, 
and research workers at the universities. Mr. H. S. 
SoUTT.vn, Chainnan of the Science Committee, presided, 
and was supported by Sir Robert Philip, Piosident of the 
Association, Dr. C. 0. Hawthorne, Cliairman of the Repre- 
Bcntative Body, and Jfr. Bishop Harman, Treasurer. 
Almost all the medical schools of Groat Britain and Ireland 
were repre.scntcci, in the majority of eases by their deans. 

The CiiAinMAv, after thanking those present for their altend- 
once, said that it might be asked what was the interest of 
the British Medical Association in a purely university matter. 
In the first place, many of those svho came into the category 
just staled Avere members of llie Association, wliose interests 
had to be safegu.arded, and, in the second place, the Association 
Avas bound to exercise a A-ery careful control over the adA-ertise- 
ments of appointments in its JounN.AL. The Association had had 
to put up a certain sc.ale of salaries for medical officers 
employed by local authorities, and to scrutinize advertise- 
menls by public bodies AA'ith this scale in vieAv. It was 
admitted that laboratory AAorkers employed by universities 
might come into a different category from similar officers 
employed by public bodies, and that considerations other than 
the mere question of salary might arise in their case which 
did not arise in others, hut the difficulty of making any such 
discrimination in regard to adA'ertisements for posts AA’Ould be 
understood. As long ago as 1919 a subcommittee was formed, 
under the leadership of the late Sir Clifford Allhutt, to go 
into this matter, and it Avas upon the report of that subcom- 
mittee that certain resolutions Avere adopted by the Representa- 
tive Body in ensuing years, and folloAving subsequent dis- 
cussions the policy of the Association in this respect Avas framed 
m 1926, AA’hen a certain scale was adopted at the Annual 
RepresentatiA*e Meeting of that year.' This Avas reported to 
tlie governing bodies of the uniA'ersities, and certain criticisms 
lad been receiA'ed, ^from Avhich it appeared to he the opinion 
o some that the uniA'ersity point of vieAV had not had sufficient 
consideration. Hence the present conference. 

t -r representing the University 

o dmburgh, said that it Avould hai-e been all to the good had 
such a conference been summoned earlier. The interest of the 
^socmtion in the matter had been truly stated by the 
'j fiuty of the Association lo 

. — und .Avide outlook on the whole question of the 
JomiN.lL SUPPLIURENT, 


July 24ih;‘i9s; 


April 24tli, 1926, page. 143, and 


training of the profession. The Association had perhaps 
restricted itself too sharply to the immediate financial interest 
of individuals. The junior teachers attached to medical schools 
AA'cro from certain aspects a remarkably privileged class; their 
misfortune was in being attached to institutions AA-ith A’ery 
limited resources. They were in a sense apprentices or pupils, 
not EO much officers as sons, and their remuneration might he 
considered r.ather from the point of A-iew of the filial lelation 
than from that of the hireling. The uniA-ersities — at least those 
of A\-hich he had cognizance — Avere not able, like other public 
bodies, to enlarge their resources by an additional penny on the 
rates, and they Avere compelled to " spread the butter " care- 
fully. They made as many posts as they could, and rewarded 
them in sAich manner as they Avere able to afford. At Edinburgh 
many of these Avorkers Avero on temporary engagements, and 
regarded it as a privilege to serve for a time under the head 
of a department Avliose scientific eminence ga\’e their experi- 
ence an added A-alue. Another consideration aa’bs that there 
AA'cre other faculties in the uniA'ersity employing similar assis- 
tants Avho, if the scale tinder consideration Avere enforced in 
the medical faculty, would feel that they had similar rights; 
and these men in the other faculties would go on to a career 
in which the remuneration was not so high as the positions 
at which many of the men in the medical profession Avere 
aiming. The dilemma AA-as therefore a A-ery real one. One 
practical suggestion he AVOuld make was that in the adA-erlise- 
menls for such university posts it might not be considered 
necessary to state tlie salary at all. 

Dr. A. JIacGillia-hat (St. Andrews) said that when this 
m.atter came before the Dundee Branch of the Association in 
May, 1926. a recommendation was arriA-ed at nnanimou.sly that 
the Council should he empoAvered to exempt from the operation 
of the scale any appointment with regard to which it Avas 
satisfied that the e.xemption was justified by the financial 
position of the school or by other special ' circumstances. 
Although St. Andrews was the oldest university in Scotland 
it had the youngest and smallest medical school. This did not 
mean that its staff was unduly reduced, for it had actually fiffy- 
seven teachers, a great number of whom, of course, were part- 
time men, AA'hose case did not arise in the present discussion. The 
adoption of this scale' at St. Andrews would mean a diminution 
in the number of posts; the professors and full-time" men 
AA'ould ha\-e much more teaching AA'ork to do, and consequentK- 
less time for research. Insistence on the scale would handicap 
the university considerably. It Avas true that the universitv 
got a Government grant, but a large proportion of this had to 
go into building dcA-elopment. 

Professor E. Faavcett (Bristol) said that it Avould be useful to 
know AA-hat unu-ersities had adopted the grading system sug- 
gested by the Association of University Teachers some A'earii 
ago. Some, he kneAv, had adopted it with the full financial 
obligations attached to it at that time; others had adopted the 
scheme Avithout those full obligations. At Bristol the principle 
of the scheme had been adopted, and aU the full-time people 
AA'ere graded. 

Professor J. R. CtmnrE (Glasgow) said that grades had been 
■•■Adopted at GlasgoAv not verj- different from those proposed by 

.[1230] 



46 Feb. 18, 1928] Remuneration of Non-professorlal University Workers. 


tlu' Bl'itisli Medical Association. Tlie crux of the question 
rel.ated to the nngradetl assi.st.Tiits. These people were ofteo 
anxious to come to the university to gain e.xperience and do 
research;- sometimes tliere was a personal link between the 
as.sistant and the head of his department, and the' question of 
salary was not very closely regarded. These people came in 
order to prepare themselves generally for their profession, and 
some of them afterwards went into the public service and 
others into special hranches of medicine, or into ordinary 
general practice, all having derived heneflt from the proba- 
tionary period in the university. In Glasgow it was felt that 
if these scale.s were insisted on the field would be encumbered 
by another class of person less suitable. He also wished to 
suggest that there was no true parallel between the junior 
assistants at the universities and the junior assistants in the 
public services, in spite of a certain similarity in the character 
of their work. In the public services, with their huge exten- 
sions into tuberculosis work, maternity and child welfare work, 
and the school medical service, despite the fact that the he.ids 
of the various administrations were highly paid (at least in 
comparison with professorial posts), these highly paid positions 
were not numerous enough to give the junior officer much of a 
chance of being anything other tlian a junior officer; yet in the 
ji nior position a man was doing important and necessary work 
for the community, and therefore the Association was right in 
(htermining to maintain his status and remuneration at certain 
levels. If such officers did not get promotion — and few of them 
did — they would be permanently in the lower-grade work to 
11 Inch the scale rightly .applied. On the other hand, the 
junior at the university was there for a short time only, 
chiefly with the object of gaining experience. 

Dr. t . 0. Hawthorne said that the university appointments 
of which Professor Currie had been speaking were donie.stic 
aiiangenients between the professor on the one side — with the 
nominal covering of the university court— and the individual 
sliulent on the other. The Association had no desire to inter- 
fere with arrangements ivhicli were domestic and personal. Such 
aiq ■ointments, neither permanent nor advertised, did not come 
under this scheme. On the other hand, a man who was 
.sppointed a lecturer, unless his lectureship iva.s limited to a 
certain duration. Had an appointment which involved the quality 
of permanence. 

Profe.ssor T. E. ELLiorr (University College Hospital) .said 
that the resolutions, if insisted on, would interfere with the 
responsibility of all the univeiisities in Great Britain. To clear 
th .1 ground he urged that teaching posts he excluded from the 
ambit of the resolutions. 

Professor Currie, in reply to the Chaihjian, said that at 
Glasgow the grades were in force for those whose work might 
be described as senior, though their tenure of the posts was 
teinporaiy; their duties were to lectuie, and they were gener- 
ally attaclied to a department, where they had departmental 
duties also, and did research. A few of these men remained 
until they got into Grade I, “ hanging on ” chiefly in the 
hope of a chair, which was sometimes realized. The graded 
woikers were appointed for a term of years; the ungraded from 
yeni’ to year. 

Professor A. W. Sheen (Welsh Xational School of Medicine) 
said that in his university it had been found almost impossible 
to work to a scale. The contingent future advantages of an 
aiipointmeiit were not to be disregarded. In the departmeiit 
of pathology, for example, the professor was desirous of 
having two demonstrators, and two qualified people were 
appointed at a salary of £250 a year. Both were perfectly 
satisfied, and were doing good work; the salary in such cases 
was not the primai-y consideration. In the departments of 
clinical medicine appointments might lead to the hospit.al staff 
and to consulting practice in the district. On the physiology 
side larger sums had to be paid, because the class of men 
needed were not so readily forthcoming. He thought it would 
b-.‘ an advantage if there were no scale at all. 

Sir HI'III'IIIIY Rolixston (Regius Professor of Physic 
C-ambridge University) said that it was obvious that what was 
laid down for Grade III (coiiiprising those who were junior 
V inkers temporarily employed on probation, remaining in the 
grade for not more than two years at a minimum s.alary of 
£300 for the first year and £350 for the second) would have 
to be rcfcriod back to the Scieiicc Committee. 

Dr. lI.tWTUOr.NE thought that the conference might reasonably 
feel that there was a case for reconsideration. Tile very fact 


that the confereiico had been called was an indication that 
thc.se primarily re.sponsible for the policy of the Briti.sh Medical 
Association recognized that in conne.xion with academic appoint- 
ments some alteration of the scale had to be made. But those 
prifcnt would appreciate how difficult it was for the Associa- 
tion to insert an advertisement in the JoURNAE offering £600, 
.say, for an appointment in the public health service, and 
another offering £300 or £350 for an .appointment in the 
academic service. No doubt the academic people felt’ that 
their appointment invoh'cd large opportunities for the future, 
hut the public health people svould s.ay e.xactly the s.anic thing. 
The public health people would not agree tlnat any a|ipointmeut 
of theirs svas necessarily one which led to an impasse, nor 
vould they agree that every' junfor university appointment did' 
effectively carry with it .a reasonable clianec of promotion; 
Possibly Sir Hobert Philip’s suggestion was a practical one, 
that advertisements for academic appointments need not specify 
salary, but Im hoped that other practical suggestions would be 
ferthcoming. 

Professor W. J. Dileing (Liverpool University) said that 
it would be helpful if representatives of universities whicli 
had a grading .system would say what grades e.xisted and the 
salary attached. In Liverpool it had been found 116008 x 017 to 
divide Grade 11 (laboratory or research workers), or teachers 
permanently or c.xchisively employed as such) into two cate- 
gories, with certain variations as to the scale, the first category 
including a nnniber who, while very good teachers, were not 
likely to advance beyond that grade. 

Professor Kay Ja.mieson (Leeds University) said that in the 


faculty of medicine the majority of the staff were on Mieir way 
to other lines of professional work, and the same was true in 
other faculties. Few were permanently on the academic staff. 
Those who had pcrmaueiit positions had been sifted out from 
the others who were moving on. The university deliberately 
made as many positions available as possible in order to afford 
men e.xperience fitting them for v.arious lines of profe.ssional 
life. It was scarcely necessary for the Association to lay down, 
rigid scales in the interests of its own members in the univer-| 
sities. The universities wore doing their best for their staffs;' 
moreover there was a considerable number of persons on the 
academic staffs who were not in the profession at all, and not 
;iffected by any action of the Association. 

Professor J S. B. Siopford (Manchester) said that 111 Jlan- 
chester the adoption of Grade III with the salaries stated would 
h,ave the effect of quite definitely reducing the staff. 

Dr. -Ain'ley Walker (Dean of the Faculty of Medicine, 
Oxford University) said that at Oxford Grade III would cori-e- 
spond to a class of persons who were called departmental 
demonstrators; they were not appointed by the univei-sity, out 
by the professor himself, for a nmxmmm period of three ye.ars; 
they could be reappointed for a further three years, but 

Professor DoET.EAS (Sheffield) said that at Sheffield no system 
of grading had been adopted in any faculty. He agreed with 
the remarks made by Professor Jamieson, though there was 
this difference between Leeds and Slieffield, that at the latter 
university the junior people were not as a rule appointed for 
any definite length of time. 

The CHA 1 I 13 IAN thought it was now possible to draw some 
definite conclusions from the discussion. TJie confereiice seemed 
to be generally agi’eed that the scales of salaries suitable for 
puhiic appoiiitnieiils were not directly applicable to academic 
appointments, that the Association required more mforniatioii 
with regard to the salaries of laboratory woikers throughout file 
kingdom, and that it would be an advantage if sakary was 
iiot-'’mentioiied in advertisements of academic appoiiifmenls. 

Mr. Bishop Harman trusted that no Iiope.s would he lielu 
out that' advertisements could be insei-tod in the JocRNAE 
without a .specific statement as to salary. He felt sme tliat 
this would never pass the Represent.ative Meeting, “e '•‘lad 
the re.solulion of the Annn.al Representative Jleetiiig, 1919, Jo 
the effect that no advertisements of public appointments should 
be accepted unless tlie s.al.rry was definitely stated m tue 
advertisement. Dr. MacGillivriy suggested that ‘ public 
appoinlmeiils ” meant appointments by a body of men elected 

by the ratepayers. . 

Sir Roeeri’ Phirip put foi-ward tentatively the foIiouuMo 

rebolutioii : ... 

This eoutcicnce, having Iiad evidence of ttie vanaliqiu iJJ 
lO'-pcct of privileges of non-profeS'Orial jnetheal 



rKii. isrissf] 


tndidn' Motiioctt Sorvic'o. 


r SUPPJ.KMVi^T TO TITS 
LllRlTlSn ^lEDICiT. JOL'n^*A^. 


47 


tht' diffcrcnl tituvorsitios niul incdioal »schooU, ik of opinion 
that scale*? of salary suitable for public nppohitmcuN fire 
not dit'cctly applicable to acadetruc nppointiucuts. 

The conference Avould n«k the Science Coruinitteo of tlie 
Kritisjj Medical A^'^ociation lo consider the desirability of 
I'ccoinmcndinp to the Association: (1) to exempt such aS'*iMant- 
fhips from tlie application of n fixed scale of salaries; (2> to 
allow advertisements hearing on such appointments to appear 
in the nnmsii MmiCAi. doURNAL without a s^aletnenl of Iho 
salary payable; and in (he meantime to obtain further 
information as to (lie salaries anti eomlitions in force at (he 
dilTerenl universities and medienl rcliool'-. 
lh\ M\cOiixiy]iav dcnnirreil to the last danse, and staled 
that universities, especially in iScotlaiid, would not be inclined 
lo furnish figures. Tlio salaries were jnivate and could not 
lie given.- Professor Cuniin: also said ih,nt bo could not commit 
his university (Glasgow) to give the iiif<»nnation. Dr. 
Hawthornk pointed out tliat it Avas .‘idministratively impos- 
sible for the Council to coiusider each individual advertisement 
on its merits, and therefore a standard Iiad to lie set up for the 
guidance of the oflicials. 

After some further discussion the laitci portion of 
the resolution was dropped, and the remaindei uas carried 
uiianinioiisly. as follows : 

This conference, having had evidenrt' of tlie variation in 
rc«pcrl of privileges of non-nrofe.ssorial medical assistants 
in the different umvoi-sitics ana medical fchools, K of opinion 
yial scales of salary suitable for ]ntblic appointments arc not 
directly applicable to academic npjiointment?. 

The conference, would ask the lienee Committee of the 
British Medical Av^ociation to consider the desirability of 
iccorarncnding to the As.'.ociai ion the exemption cf such 
nssistanUliips from the application of n fixed fcalo of salaries. 
Ihe Cn.MUMAN, in closing the conference, reminded those 
present that the organization of the British Medical Association 
was a comple.x one, and that the jiowors of notion of the 
Science Committee without further reference wore strictly 
liinilcd. However much tlic commitlee niigiit agree with what 
Iiad been put forward, it was finally controlled by (he Repre- 
sentative Body, Avbose endoi'scmcnt of anv non procedure must 
he sought. 

vote of thank.s was accorded to Mr. Sonttar for his 
senices as cliainnan, and the conference terminated. 


LUICESTER rUBLIC JIEDICAL SEimCE. 

The report of tlic hoard of inanagcmciil of flie Leicester Puldii 
w 1927, in recording tiny tcsignnfiori of Di- 

a acp Henry from the lioard, calls nttontion to the fact that 
K lad played an outstanding and distinctive part in laying 
le oundation of the service, and rendered invaluable servio 
lor many years. Jn recognition of his work Dr. H^illace Heiin 
la.s )ccn elected president and an cx oIJiciv member of tin 
board of management. 

J^ubscriboi-s to the various sections of the scrvic< 
T ^ ^kc year and 4I,9J2 for the sccoiit 

and OrlHfp^inJ-'*^^''- ®|®l^’insured members of the Forester? 
iho T ft* » Tr Societies and some insured members ol 

hriM Friendly Societies’ Medical Association \ver< 

linnpi ■ ri As might bo expected, the con 

hoaiH dcprc'-sion adversely affected tlie receipts. Th( 

nnil tiift r.’***^*4 V*^ •'U’>‘angcmcnts with the People’s Dispeiisan 

■n-pvp Medical Association, whereby medicines, elc.j 

TTipniliftfc^ .1 1 ^ Fublic Medical Service branches for Ihost 

the veav '2^ non themselves of the facilities. During 

? ‘ P*'^<^nptions were dispensed. The ophthalmic 

t n * 10 o ica . and dental departments Avere continued, anc 
st^scribers took gr^.t advantage of the facilities afforded bv tin 
«• with the Ministry of Healtl 

nt Ml., * ig iccni _'Mth wailing room accommodation was provider 
ofTmer- D'spciisary for tlie regional medical and dciita 

I eirest’er was also provided fo. ll.e City ol 

m-'ni f ^y^P^'dmeiit in connexion with the dental treat' 

ihe motliers. Accommodation, by arrangcmenl wilt 

^ Leicester and the Leicestershire Malcniitj 
hospita'l ' P'O'ided also for the ante-natal clinic of flic 

Leiioiolciit Fluid, established for assisting nniiisurcd people 
a o^^.i ''T T “'■diParv prices to obtain it a) 

g 5 I'c need co^l, proved very useful in a number of cases. 

fiWv of I lie Fiiio.i of Medical Practi 

loeMTiif niecsier Subdivision) states that the scheme of collective 
during holidays and sickness, iiiaiignrated in 1919 
ui'ide"'i"^'^^*'^v ■' 1 donations amoniiliiig to £113 -were 

Itvlin *1 cliarilies, while £193 Iiatl been credited to tin 

se'iilaiJc’ Trust and £48 to the Jledical Repre 

mentation of Parliament-Fund for 1927. 


INDIAN MEDICAL SEDTICB. 

RECRUITMENT FOR PERMANENT COMMISSIONS. 


IVk piiblisliod in tlio Jouhn.m, of .Tainiary 28Ui (j). 160) an 
iniiioiiiicoiiii'iit that tlio Scciotniy of State for India tvonld 
.shortly nnilcc a iitiinhor of ajijiointnient.s to permanent 
oonimissions in tlie Indian IMcdical Service. For some 
\'cnr.s past, it will ho rempmhored, reernitmont for the 
l.M.S. has heen by way of tomjiorary commissions. 

A Alcmoraiuhim on the terms and conditions of appoint- 
ments to permanent commissions has now been issued 
from the India Office, and as the matter is of great 
importance wo reprint this document below, snbbtantially 
in full. Comment on the condition^ stated in the Alcmo- 
randuiu must be deferred until after the Naval and 
Afilitary Committee of tlie British Medical Association lias 
mol and considered it in all its bearings. 


AIeMOR.VNDUM on ArrOINTKENT TO THE l.M.S. AND 
Conditions or Service. 

1. The condition*; contained in this Memorandum arc those in 
force at the present time. They are subject to any alterations 
that may be determined on. For detailed regulations reference 
should he made (o Army Regulations, India. 

iJethod of Appointment. 

2. Since the open competitive examination held in July, 1915, 
for admission to the I.MJS. no similar examination has been held, 
but such appointments as have been retjuirod to meet the needs 
of the service liavc been made by nomination by the Secreta^ 
of Stale. This method of recruitment will continue to be in 
force until furtlicr notice. To assist him in making appointments 
the Secretary of State has appointed a Selection Committee, who 
will summon and interview such applicants as may appear to 
be prima facie suitable and make recommendations for appoint- 
ment. A similar committee has been appointed in India to 
investigate applications and forward recommendations to the 
Secretary of State. Applications from Ruropesns resident in 
Europe ‘should be addressed to the Secretary, Military Depart- 
ment, India Office, 'NVhitehalb S.W.l. Other applications should 
bo addressed to the Director-General, l.M.S., Simla (or Delhi), 
India. The application? of all Indian candidates are considered 
by the Selection Board in India, and no useful purpose is served 
by such candidates presenting themselves for interview before 
the Selection Board in London. Applications from Indians in this 
country to appear before the London Selection Board wull only bo 
entertained where the Board is of opinion that the circumstances 
arc exceptional. All correspondence regarding applications should 
be marked “ Medical Recruitment ** at the top left-hand corner 
of tlic envelope. 

(jtnrnil QituU fixations and Limits of Agr. 

5. E%'cry candidate must be either («) a British subject of 
European' descent in the male line, whose father was, at the time 
of the candidate’s birth, a British subject, or (^») a British 
subject whose father was, at the time of the birth of the 
candidate, cither a British subject domiciled in British India 
or a subject of a State in India. In either case, such father 
must still be, or have continued lo be to his death, a British 
subject or a subject of such a State in India. Provided 
that a subject of any State .in India, in respect of ^Yhom the 
Governor-General in Council has made a Declaration Note, under 
section 96a of the Government of India Act, shall be deemed to 
be eligible. Every candidate must also be of sound bodily health, 
and, in the opinion of the Secretary of State for India in' Council, 
ill all respects suitable to hold a' commission in the l.M.S. He 
may be married or unmarried. He must possess a qualification 
regislei'cd in Gicat BriUin and Northern Ireland under the 
Medical Acts in force at the time of his appointment. Candi- 
dates must be under 32 years of age at the time of application. 

Di chii'iition lo he Submitted. 

4. Candidates must subscribe and send in to the Secretary, 
Military Dcparlmcnl, India Office, Whitehall, a declaration in lha 
terms printed on the form of application. 


5. This declaration must ' ’lowing docu- 
ments : («) Proof of cifjf\ ' ’s certiCedto 

or, where such certificate ' . , lidate’s own 


statutory declavaiion, forms for which can be obtained at the 
India Office, supported, if I'equired by the Secretary of Slate, bv 
such evidence as he may consider satisfactory. A' certificate of 
baptism which does not afford proof of age will not he accepted 
(A). A, recommendation and certificate of moral character from 
each of two responsible persons — not being members o'f the candi- 
date’s own family — to the effect that he is of regular and steady 
habits and is likely, if appointed, to prove in every respect 
creditable to the l.M.S. (r) A certificate of having attended a 
course of instruction for not Jess than three months at an oph- 
thalmic hospital, or the ophthalmic deparbnent of a general 




4s Feb. 18, 1928] 


/. M. S. c Recruitment tor Permanent Comm/ssfons ^ '' 


Jiospital, ichich course shall include instruction in the errors of 

refraction, {d) Evidence of registration under the Medical Acts 

m force m Great Britain and l^rtliern Ireland. 

6. of, each candidate is determined by a 

Board of Medical Officers appointed by the Secretary of State 
tor Jndia, Detailed regulations as to the physical requirements 
are printed separately, ^ 

Courses of Instruction. 

appointment, attend such courses of 
V- Secretary of Stale may direct, eiUier in tho 

“'’iu" subjects mentioned below. 

subject to his attainine a 
reasonable standard of efficiency in any examination that mav 

Sld dne™“t3^^lHt‘’”^'^^ %iene;V) milituTand tropTca'l 
meaicme, (3) military surgery ; (4) pathology of diseases and 
injuries incidental to military and tropical service; (5) midwifery 
and diseases of women and children; (6) military medical nSnfs^ 
tration : _(n) internal economy; (6) Army Service Corns siihieci«. 

|c) eqmtation ambulance drill; 

1 H officer is also required to attain a certain 

^andard of proficiency m Hindustan? in the early part of his 

R /ppoiiitmcnt. War Service, anil Antedates 

candida?e‘'tm°47c^s“‘”tlm“cou'lrse “of ‘“nstr';icUon‘’"r T 

ratln%o“j raVdfis 

Sred"“i;y“L\rer’m“ay““bfc“ort‘ed“®““‘^^ 

fc^4™S:fhf'cou°n?e?t' fer^F/ 

Kingdom or in India may he a " hospital in the United 

one year, provided th^t^ ^ anted an antedate not exceeding 
of th^e hos^iUI ind 'thi tcrminalioS 

wiir'“counJt co“mm”?s“''seSe“ir“1li”“''‘*"- 

gratultf T ^SatrwhTat^hrtim?*'^^ ‘but’’“nT“f^ 

be seconded for the npriof? oi in India, may 

ho holds the appointS^^n^ WhflP 

pay from GoyF?nmer funds but th^leriod "T"® 

•t «; tCrdarii.* •s's*' » 

fimt c^omiSssion hi! Jetenlifn ther“eir??" “'1 of his 

Service previous to appointment Tn', n oonsidered undesirable, 
the I.M.§. will not cou^n'^t ft^hts purpos^e commission in 

du\%Mnel^m1y of 

liable for niilitay or civ™ emnlo^.n? 1“*'* 'f'hey will be 

are required to perform be required, but 

to permanent appointment before they can^bl^^rn'^ s'J ®ohaequent 
for civil employment. With a yjew to Dossihl„ ? ®’‘eh’Io 

to civil employment, each officer will hp^ntt' /"fu™ transfers 
following civil areas : til MpTp,® T.,i Lo one of the 


r nVPPLlillF.tiT TO Tn* 

InuiTiflii Medical Jocrxil 


follow ngd'iu^^eks’. til A?aT® '"’‘i ?i® ‘o one o fth^ 

Aden; fj) Upper pioiLe“luiat "“h 

and Central Provinces* fd^ T nura*. t> ’• Biovinces, Puniab 

and Orissa, and Assam! '^e allOTat?oll“?r’offl*^ .®®VP'> ®'har 
of employment will be determined officers to these areas 

the circumstances, including as far ^ consideration of all 
own wishes. Offi^icrs Franffe JJf ^'hle the candidate’s 

ordinarily employed within the area to wI.M. though 

assigned, remain liable to emplo^ent else ®n * ’®^ have been 
exigencies of «ie service. On t?M™er to Y'*®—’, =‘®cording to the 
Officer IS placed on probation foV a period^of ““ 

11 rrur. 1 r and Promotion 

11. Tho ranks - of officers in - the I M ^ . 

namely <1) Major-General, f (2) Colonel mimHer-^ 

(4) Major, (5) Captain, (6) Lieutenant ’ ^ f'*cu*-euant-ColoneI, 

12. A Lieutenant is normally promoted to r-o.,* - 

of three years’ full-pay service, if he has preJimi'sK®" ®°™J>>etion 
promotion in such manner as may be prescribed ^ lualified for 
to permanent appointment in tho Indian Med!L.i®o'®®.P®®’'>°“® 
peimitt®d to account for such purpose (see paragraph's?'® *’®‘'’® 

13. A Captain, if m all respects qualified and rY.„ "h 
promoted to Major on- completion of 12 -years’- 

subject to the same condition as regards service nrevfo'Jif |c*''''ce, 
manent appointment in the I.M.S. ®A11 officers bef-l ® f° P®*’’ 
to Major will be required to attend the senior officer?' 
tho Royal Army Mediral College, Millbank, and qualifY T'tn* 
examination held on its conclusion. An officer wl,i fJ.Y "1 *"0 
fust attempt will be allowed a second trfah AtTindan?e A’’-® 
course will be regarded as duty and will carry with ?f 
passage to and from the United Kingdom. ' * m a free 


. 'f , hi all respects qualified and recommended is 
on completion of twenty yclirs’ 
full-pay service,- subject to the same condition as regards service 
previous to perniaiieiil appoiiilment in the I.3I.S 
o«r„ ®“oo‘)hig one year) passed on the temporary noii- 

effccLive list, 111 the case of an officer placed llicreoii on account 
of medical unfitness caused by duty, military or civil reckons as 
service for promotion and pension. 

16. Promotion from the rank of Captain to the rank of Major, 
or froin Major to Liciitcnant-Colonel, mav bo accelerated by not 
more than six months in tho case of officers -who produce satis- 
lactqry evidence of progress m any branch of knowledge which 
is^ likely to increase their efficiency. A certain number of 
Lieutenant-Colonels are specially selected for increased pay for 
ability and merit. 

17. All promotions from the rank of Lieutenant-Colonel to that 
ot Colonel, and from the rank of Colonel to that of Major-General 
are made by selection for ability and merit. 

18. 'The tenure of office of Major-Generals and Colonels is 
limited to four years, subject lo the limits of ago as laid down in 
par.agrapli 45. 

19. Colonels, if not disqualified by age, are eligible either for 

emp oyment for a second tour of duty in the same grade or for 
tlmrcd?'""'*^ ^*'® ^‘'^'’®'' Sradc of Major-General by promotion 

20 Absence from duly for longer than eight months consccu- 
tively involves the vacation of an administrative appointment of 
limited tenure. 

21.^ Officers of tho I.M.S. ore eligible for the military dis- 
tinction of tho Order of tho Bath, and for other Orders, British 
and Indian, and for good service pensions. Six of the most 
meritorious officers on the active list are appointed Honorary 
Physicians, and sir Honorary Surgeons, to His Mjijcsty. On 
appointment as Honorary Physician or Honorary Surgeon to His 
Majesty, an officer below the rank of Colonel may be promoted 
to the brevet rank of Colonel. A Captain after at least six years* 
service, a Major, or a Lieutenant-Colonel may be promoted to the 
next higher rank by brevet for distinguished service in the field, 
or for meritorious or distinguished service of an exceptional 
nature other than in the field. 

7*aj/ and Jlloiranccs. 

22. Officers on appointment will receive an outfit allowance of £50. 

23. Pay will normally commence from the date of appointment 
and is issued monthly in arrear in this country up to tho dale 
of embarkation at the rates of leave pay shown in paragraph 31, 
except lliat during the course of instruction referred to in para- 
graph 7, tho R.A.M.C. rates of pay and allowances are admissible. 

An advance of two months’ pay at the rates shown in. paragraph 31 
is also made before embarkation, if desired. ITiis advance will be 
recoverable from the officer’s pay in India. 

24. Tlie following arc the monthly rates of Indian pay payable 
from the date of arrival in India : 


Bank, 

Service in Bank, 

Basic 

Pay. 

Overseas 

Pay. 

Year 
of Total 
Service. 

1. 

2. 

3. 

4. 

5. 



Eb. 

Es. 





’ 150 

1st 

Iiieut. 



500 

150 

2nd 



150 

3rd 




150 

4th 

Captain 

(i) During first 3 years’ service 

650 

£ 


ns Captain 


15 

5th 




15 

6lh 


(ii) "With more than 3 and less 

750 

f 25 

7 th 


than 6 years’ service as 


1 25 

8th 


Captain 


( 25 

9th 


(iii) With more than 6 years’ 

850 




service as Captain 


( 30 

12th 

Major 

(i) During first 3 years’ service 

950 



as Major 





(ii) With. more than 3 and less 

1,100 




than 6 j’ears’ service as 
Major 





(iii) With more than 6 5’eurs' 

1,250 




service as Major 

*■-. 30 


Lieut.-Col. 

(i) Until completion of 23 J’ears' 
total sen'ice 

r.500 

and over 


(ii) During 24th and 25th j'ears’ 

1.600 




Beri’ic’e 





[iii) After completion of 25 years’ 

1,700 




total service 




[iv) When selected for increased 

1,850 J 



1 

pay 





♦A candidate may. if he vishes it, underiro a Dreliminnrvrtir, • - : — 

as lo his physical fitness by the Medical Soard^ at The India OffC-T''’” 
payinent of & fee of two pmnea-.. Particulars reeardinir such riamin,#® 
Sto.® ® Under Socretao- of State, lodm Office, Thite'larfi 

t The Hircctor-Cenernl, I.M.S., will rank either ns M-iior 

SUt?Tor"iadirm'co“ilX ^ ®“^® ot 


Note. — (1) Until the completion of 23 years’ total service, basic pav is 
' regulated according to rank and ser\’ice in rank (columns 1 and 2); which; 
owing to the system of accelerated promotion, maybe in advance of the 
time scale of promotion. 

(2) Ovei^eas pay is admissible onlj' in the case of officers who, at the 
date of their appointment to the I.M.S.. had their domicile elsewhere 
than in Asia, and is regulated solely with reference to'length of total 
service. 

25. In addition to the above rates of pa}’, various allowances are 
admissible to officers holding special appointments, such as : 

(a) Command pay drawn in addition to pay of rank by 
Indian 'Medical Service officers for the command and second 


xdiAiaii Au.cuik.ai ucivicc uiiiucx:, iui x.ue cuiiiiXic 

in command of Indian Military Hospitals : — 


Isl class Station Hospital ... 
2nd class „ ,, ... 

5xd class ,4 


Command. 

HP. - 

240 

380 

120 


Second in 
Command. 
HP. 

120 

90 



so Feb! IS, 1928] I.M.S, : Recruitment, for Rermapent Commissions. 


Ordinary” Leave Rides for Officers with Asniiie Domicile. 

Lcaro is calculcited in terms of “ leave on average pay,** and 
the amount of “ leave on average pay ” with whiclj an officer's 
leave account is credited is two-elevenths of the period spent on 
duty. Subject to certain maxima and minima, and to the limita- 
liojjs noted below, an officer may draw, at liis option, leave 
salary equal to the average pay of the last twelve months of 
completed duty or to half such average pay. All leave ^ on 
average pay and half the period on half average pay is debited 
in the leave account. An officer may take his leave on average 
pay, on half average pay, or on a combination of the two. 
provided that his continuous absence from duty docs not exceed 
twenty-eight months, and that the amount of leave taken on 
average pay_ does not exceed, at any one time, four months, 
if taken without medical certificate and spent in India or 
Ceylon, or eight months, if taken on medical certificate or spent 
elsewhere than in India or Ceylon. The maximum amount of 
leave admissible during an officer's career, expressed in t«rms of 
leave on average pay, is two and a half years, plus one-elevcnth 
ot the period spent on duty, of which not more than one-clcventli 
of the peri.id spent on duty may actually consist of leave on 
average pay, provided that, in the case of an officer who cither 
takes leave on medical certificate or spends his leave elsewhere 
than in Inrlia or Ceylon, leave on average pay up to a maximum 
of one year, 2 du 8 one-eleventh of the period spent on duty, is 
admissible. 


lions arc, therefore, laid down governing tho grant of passages 
during the early years of an officer’s service : 

(а) No concession passage will bo granted during an officer’s 
first five years of service. On tho completion of that period 
an officer becomes cligiblo for concession passage, provided 
that ho has not given notice of his intention to retire with a 
gratuity in accordance with the terms of paragraph 45. On tho 
completion of eleven years’ service he becomes cligiblo for a 
second concession passage, subject again to jus not having 
given notice of retirement. The remaining passages duo to 
an officer may bo taken at any time during tlic rest of his 
service, subject to the exigencies of the service. 

(б) An officer invalided homo on sick leave during his first 
tivelvo years of service will be provided witli a passage, but 
any such passage granted to him will count against any con* 
cession passage or passages to which he may subsequently 
become entitled. In the event of his retiring otherwise than 
on account of ill healthy before becoming entitled to full 
benefits under the concession passage rules, lie will be required 
to refund tho cost of any passages granted to him on sick 
leave. 

(c) An officer who retires with a gratuity at the end of 
either six or twelve years’ service in accordance with tbc terms 
of paragraph 45 will be provided with a free passage to the 
United Kingdom for himself and his family* 


General R>:lrs, Applicable to both Special and Ordinary Leave. 

Leave not due and carrying half average pay (or subsistence 
grqnt as indicated below) may be granted on medical certificate 
and within certain limits, for other reasons. Such leave, except 
for a maximum period of three months in all during the officer’s 
s«r ic^, expressed in terms of leave on average pay, is debited 
in the jpnve account, and an officer will not again be^in to earn 
l''nve until the expiration of a fresh period of duty sufficient to 
a credit of leave equal to the leave taken before it was duo 
and debited in the leave account. After twenty-eight months* 
a v'f.ncc from_ duty an officer draws subsistence grant. Leave 
^ry IS ordinarily payable in rupees if tho officer spends his 
leave in Asia, and in sterling if lie spends it elsewhere. 

Study Leave. 

A study leave) may be granted to officers 

dc of pursuing special courses of study. These courses must 
Sr courses of poH-graduate study at a recognized institution, 

or of study ordinarily associated with post-graduate work, and must 
by the Director-General. I.M.S., or by the 
Medical Adviser to the Secretary of Slate for India. (Courses of 
oLi'fin"*; preparing for their primary medical 

?-c'l apnrovecl.) The .satisfactory completion of 

SC) appro) ed courses is taiccn into consideration for the purposes 
of accelerated promotion under tho terms of paragraph 16. Tlie 
p nod of study leave will bo calculated at the rate of one-twelfth of 
prrsjon service, but will not exceed twelve months in all during 
nro -Mcrr f if 7^)®' leave may bo combined with other leavo 

on,*' occupied in study is not less than two 

riv P®"®^ ®f ®tudy leave taken by itself is 

‘he course of study, study allowance, at presen? 
on V '®i-''‘'‘*®. ® ‘*’® Uhiled Kingdom, £f a (lay 

Europe, and £I 10s. in the United States o^ 
nrortuvH’„"* f*"® ®“®'' ?L‘® ®®™pletion of tho course on the 

T? 7 satisfactory certificates, as required by the Study 

^7 ®^ ®‘®‘‘y,'®!i''e will count as service tor pr'omotion anj 

ncco^^iarv Vn ^anv exigencies of the service make it 

occasion during his service for the PurposFSf tfking ftud™ leave."® 

01 . An oOiccr on appointment is nrovifl-«ri « e 

to India, normally by transport. ^Tho 

ofkccrs who are married prior to tlie date of Uie families of 

lien on first appointment to the I.M.S will ako ^ 

fro-' passage to India. provided with 

77. Subject to the limitations in parasranh 4n nn r 

Asi-ic domicile at the date of !appo"imPme„\°’ fo" M s"®"? 

r;-.i..Ied during liis service to pass.ages of a total value imiai to 
‘ a cost of the iiumucr of passages between Bombav and 
by 1>. and O. 1st Class B., shown below : ^ “ London 

I. Tor the officer himself: If innlcr 31 years of age, four refnm 
r“jsap'5; If 31 years or over, but under 38 ycarS, ’llwce HtSS 

If. Tor his wife, ti'.e same number ot return pasraacs to whlcl, (l, 
oliicer iiinncit is entitled; provided that in the case of an oflice? 
who li.as been married after tlie dale of his entering In'dian Seia-ie. 
Ibo scale ot benenis tor liis wife siiall be os follows ■ If the 
act- at d.atc ot marriage is under 31 years, four return passaces- 
if 31 years or over, lint under a8 years, tlirce passages - it 36 veari 
or over, but under US years, two p.assages; if 45 wars or over on^ 

III. For cacti child, one single adult pas-^age. 

40. 'Hic scheme of concession pass.ages slated in Ihe previous 
patagraph is based on the assumption that an officer continues in 
the service till qualified for pension. All officers, however, possess 
the option of retirement on a gratuity, and tho following condi- 


Pcnsions and Gratuitic.f. 

41. Officers of the I.M.S. are allowed, subject to the right of 
Government to suspend retirements in times of emergency, to retire 
on the following scale of pension, on completion of the required 
periods of service for pension i 


After 17 years! service 

»» »» ** 


Per annum. 
£ 

400 

4:o 
4:o 
500 
540 
580 


After 23 years* serv 

:: n :: 

:: f? 


Perannum. 

/ 

... 620 
... 660 
... 700 

... . 750 
... 800 


These rates are subject to ’alteration on account of a rise or fall 
in the cost of living as compared with the year 1919. With effeeft 
from July 1st, 1927, a reduction of 4;^ per cent, on this account has 
been made from the amounts shown above. A further revision 
may take place on July 1st, 1930, and every three years thereafter, 
to an e.xtent not e.Tccedjng 20 per cent, in all, , , , 

42. Service for pension reckons from the date of commission, 

and includes leave taken under the leave rules, time passed on the 
temporary non-effective list (if the officer is placed thereon on 
account of medical unfitness caused by duty) up to one year, and 
previous war service. , , 

43. A Major-General, after three, two, or one years scrvlw m 
the substantive rank, is entitled to retire upon a pension of £^0, 
£315, or £285 per annum respectively, in addition to tho pension 
to wiiich he may be entitled under tho above scale. 

44. A Colonel, after four, three, two, or one years’ service in tho 
substantive rank, is entitled to retire upon a pension of £250, £185, 
£125, or £65 per annum respectively, in addition to tlie pension 
to which he may bo entitled under the above scale. 

45. An officer is entitled to retire on a gratuity at any timo 

after tho completion of six years’ service from tho date of per- 
manent appointment to the I.M.S,, provided that ho has given 
notice of iiis intention to do so twelve months in advance. - The 
amount of tho gratuity for an officer with over six years’ and less 
than twelve years’ service is £1,000, and for an officer with twelve 
years’ service or over is £2,500. Privilege leave will bo allowed 
to count towards service foi a gratuity, but not ordinary furlough 
or sick leavo. ^ , •, nr • 

46. Officers of tho rank of Lieutenant-Colonel and Major aro 
placed on the retired list ' when they have attained the ago of 
55 years, Colonels when they have attained tho age of 57 years, 
and General Officers when they have attained the age of 60 years. 

47 An officer is liable, after retirement on pension or with a 
gratuity after not less than twelve yeai-s’ service, to recall to 
military duty in case of emergency up to 55 years of age. Officers 
will bo recalled to duty only in tho event of an emergency^ ansuig 
which exhausts the reserves permanently maintained in civil 
employ in India. , . , . i 

48. An officer who, before completing seventeen years’ service, has 
become permanently incapacitated for further service in India on 
account of unfitness caused by duty may bo granted an invalid 
pension varving from £60 to £370 per annum, according to length 
of service. 'Provision is also made for tho grant of additional 
disability pensions of from £20 to £100 per annum. 

49. Officers placed on the temporary non-effective list are granted 
temporary invalid pensions at the half-pay rates of the British 
Army — namely : 

’’ Rales of IIalf*i>ay. 


Per diem. Per annum. 

£ 9. d. £ s. (1. 

Colonel - 1 1 9 6 ... 538 7 6 

Lieiitcnant-CoTonel, after 3 years’ scr- ^ ^ ^ crM i»t a 

vice as such 1 7 6 ... 501 17 o 

Lieutcnant-Colonel, under 3 years’ Ecr- ^ >,« ‘o o 

rice as such ... ... J i "* a q 

Major 0 ^5 ? - iV, 1 ? A 

after 5 vears’ ser\'Ice as such ... 0 18 o ... oo/ o 

Captain ! 5 

Lieutenant 0 8 '0 


214 8 9 
146 0 0 


Tlicso rales are subject to alteration on account of ® 

Q tho cost of living as compared with the year 1919. A> ith cil c 



51 


Fnn. IR, mVj 


CWfrini N^tos. ' 


r i^VTVi.r.t^TT.'^T to rnn 
LUritish Mkdicai. Journ'al 


from July Isi, 1927, n rodrclion of 6 per cent, on this nccount ha*? 
iiccn made from tlio amounts shown above. A furtlier rcvmon may 
take placo on July 1st, 1930, and every throe years thereafter, to an 
extent not exceeding 20 per cent, in alt. An ofTiccr of less than 
three years’ service, although ho may bo transferred to the tem- 
porary non-etTeetivo list ?inder the general conditions of transfer, 
will not bo gr.anted any temporary invalid pension \inlcss his 
unfitness has been cause«rby dnty. 

50, Tho claims to pension of widows and families of officers aro 
treated under tho provisions of such Itoyal Warrant regulating tho 
grant of pensions to tho widows and families of British officers as 
may be in forco at the time being. 

51. Tho widows and families oi ofTicers are nho cnlitled to pen- 
sions under tho Begulntions of the Indian Military Widows* and 
Orphans* Fund. Sunscription under these Regu'ations is a condition 
of appointment, except in the caso of Indians, for whom it is 
optional. 


ISrxtislj iHrbicnl ^ssociniiott. 


CURRENT NOTES. 


ConsuttfniT Fatliclo^lsts Group. 

Tiik Council of tho British ^loclical As.socintion, at its 
meeting on Docembor 14lb, 1927, approved the formation 
of a Group of Consulting Pathologists, to coniprisc all those 
members of tho Association (not being members of the 
Pxiblic Health Sendee) adio arc working in institutional 
or private pathological laboratory engaged in examining and 
reporting on specimens for clinical purposes. TIio official 
notice summoning the first mooting of the memhevs of this 
Group for Friday, March 2nd, at 2.30 p.ni., appears in tho 
adjoining column. Xt is hoped that all members eligible 
for inclusion in tho Group will inako a special effort 
to aflend. 


The Hompson Prize. 

Mr, W. F. Hcmpsnn has placed at tho disposal of tho 
Conned, upon his retirement in March next from the post 
held by him for thirty years of Solicitor of tho Association, 
and as a mark of esteem for tho Assnc’ation and appre- 
ciation of his happy relations thcrewitli, a sum of twenty- 
fivo guineas, to be awarded as a prize for the best cssav or 
treatise on some phase or branch of public health. Tho 
subject approved hy tho Council for the prize is “ A study 
of personal experiences in tho inspection and treatment of 
school children under tho auspices of any elementary educa- 
tion anthonty,” The following conditions govern the award 
of the Tinzo! ^ 


9 Association aro eligible to compete. 

be sent to the Medical Sccrolnrv, British Mcdic.T 
1928 flTifl iiirt ^V.C.l, not later than December 31st 

of jhe AssociaFrorj'ManXIto im® 
whcre“viU 

such point shall b^final. ^ ^^' ^"^cision of Uio Council on an: 

tinwnis^hed a mnH kypewriUon or printed, must be dis 
envelope marked must bo accompanied by a sealct 

name and address. motto and enclosing the candidate’: 

Medica? Secrelaryt^^'^ prize should be addressed to th) 


Jtmerlcan Medical Asscc’ation. 

is tn bp lipbl ' Medical Associatic 

to 15th, 

+n bo 1 i "‘CUical Seerc-Lary would be very gla 

membpr nf f) O P°®sible moment of ai: 

inn to nttPTi 1 +1 V Association who is propo 

tug to attend tlio meeting at Jlinncapolis. 

, 11 1/! Half-yearly Indexes. 

ScppiFinix^T ^ indexes to the Jounx.iL and to tl 

Lwevpr P--i"ted, they wil 

oX tr’tbol ® JovnsL, b, 

snlfscHbPr wb r*'? Any member , 

obtain wlnt bo^^"^t indexes c£ 

nott vin " wic- ^^■’ding a postca, 

Hanacer Br'f 7*^11? 7*^ rnioncial Secretary and Busine 
Square Tavisto. 

o y published should intimate this desire. 


Association flotircs. 


ELECTION OE MEMBERS OF COUNCIL BY BRANCHES 
OUTSIDE THE UNITED KINGDOM. 

TiiR following is n list of tho nominations received for the 
election of tho Council for 1928-31 by Branches outside the 
United Kingdom : — 

Mr- T. P. DUNllll.L, C.M.G. (London), Sonth Australian, 
Tasmanian, Victorian, and Western Australian Branches. 

Sir Ji;kxeii Veriiai.i,, I-L.D. (Leatherhead), New South IValeS 
and Queensland lirAnclies. 

Dr. G. CbARK Trottek (London), New Zealand and Fiji 
Branches. 

Hong-Kong and Chinn, and Malaya Branches. No nomina- 
tion. 

Dr. .r. B inrr.orr Akdeuson G^ondon) and Dr. W. MUtkins- 
PlTCllFOnn (Bridgnorth, .‘■'alopi, Border ^outli Africa), Capo 
Eastern, Capo Midlands, Cape Western, Egyptian, Gibraltar, 
Griqnniand West, Kenya, Alalta, Mnsbonaland, Matabelc- 
Innd and Nortbern Jth'dedan, Natal Coastal, Natal Inland, 
Nynsnlnnd, Orange Free State and Basutoland, Preioria, 
Sierra L"cne, Soi.th-M'est Africa, Tanganyika Territory, 
Dgai da. Witw-ter rand, and Zanzibar Branches. 

Voting papers for the Afr'can Group of Branches were 
posted from tlio Head Ofllce on February 11th ; they are 
returnable not later than Mondays, April Idth, 1928, to 
the Alcdlcal Secretary, British Medical Association House, 
Tavistock Square, London, W.C.l. 

The candidates referred to in the remaining Groups, being 
the only candidates nominated for those Groups, aro hereby 
declared elected inombors of the Council for 1928-31. 

The following is tho position as regards the other Groups of 
Branches outside llie United Kingdom : 

Lieul.-Co oncl Asutok Stheet, I M.S.(ret.) (London) (le-s 
elected Jor tl-e three yenn I0S7-S0), Assam, Baluchistan, 
Bomb IT, Burma, Ci ylon, Hyderabad, Mesopotamia, Northern 
Bengal,’ Pniij b, and South Indian and Madras Branches. 

Dr. F. .1. GcMEZ (Soutli Petherton) (was elected for the three 
yeare lOS'-OO), Barbados, Bermuda, British Guiana, Grenada, 
Jamaica, Leeward Islands, St. Lucia, and Trinidad and 
Tobago liranehes. 


CON.5ULTING PATHOLOGISTS GROUP. 

A 5IEETING of the recently formed Consniting Pathologists 
Group of the .Issoolation will he held at the B.JI.A. House, 
Tavistock Snnaie, Loudon, W.C.l, on Friday, March 2n.I, at 
2.30 p.m. 

Tho Group comprises all those members of the Association 
(not being members of the Public Health Service) wlio aro 
Working lu an Institutional or private pathological laboratory 
cng.iged in examining and reporting on specimens for clinical 
purposes. 

The agenda of the meeting is as follows l 

(1) E’ect a chairman. 

(2) Elect Group committee of six. 

13; Con ider arrangements to be made for provis'en of 
pathological service in connexion with National Health' 
Insiirince. 

(d) Any other relevant business. 

Alpked Cox, Medical Sccrctahj, 


BRANCH AND DIVISION MEETINGS TO BE HELD. 

Boeder Counties Branch : Dumfries and Galloway Divisiox.— 
The next meeting of the Dumfries and Galloway Division will bo 
Iicid in tile Boyal Infirmary, Dumfries, on Tuesdav, rebruary 
21sl, at 2 p.m., when Professor Edivin Bramwell Vill give a 
lecture on some clinical aspects of pain. As the lecture is espe- 
cially for the general practitioner, and as tho hour fixed is to 
suit tliose from a distance, it is hoped that ail members and 
their friends will make a special effort to bo present. Tea will 
be served. 


East York and North Lincoln Branch : East York Division. 

tho meeting of the East York Division to be lield to-day 
(Friday, Pebruary 17th), Dr. Ritchie Rodger will read a paprr on 
foreign bodies in tho air passages. 

Edinburgh Branch. — The -winter clinical meeting of the Edinburgh 
Branch will be held in the Royal Infirmary, Edinhun-h on 
Wedn^day, February 29th. All members of tho profession’ are 
™™>ally invited. Senior medical students desirous of attcndini- 
will be admitted hy card, obtainable from Mr. W. A. Cochrane^ 
24, Walker Street. The museum will be open from 10 a.m to 
6 p.m. Arrangements will be made for holding special cli''-=c 3 
during the day. The clinical meeting will be held at 3.30 n in 

TllOSR wnn linvA Tinfipnfc «TyAr»jrr*pnc! Af/» #, 1 .^ * 1 


mi ® V ■ ---- - — '-*'***0 .1*44 uo liciu at o.oj p.m. 

Those -wlio have patients, specimens, etc., to show are recuesterl 
Le with Mr. . A. Cochrane by February 18tli 

Ar will bo fnk'An in flio TVav+U oi-a* . .■*. 


to communicate 4141 . »». v-ivcmaue uj I’enruary • iBtli 
7.15 p.m. dinner will bo taken in tho North British Station TTofAl. 

l”"’ welSmck 

Membep are asked to notify the honorary secretaries by February 
pii whether they intend to bo present, and ahethor they will 
be accompanied by ladies or other guesta* ^ 




S2 Feb. 18, 1928] 


Meetings of Branches and OMsions. 


r RUPPLr.^rrs’T to t«k 

LDRITrSIt llF.DlCAr. JOURKAL 


Glasgow and West of Scotland Brancti : Lanarkshtre Division. 
■ — A meeting of the Lanarkshire 'Division will he held n-t Ihc 
County Laboratory', HamiKon, on Wednesday, February 22iid, at 

3.30 p.m. Dr. James L. Brownlie -will read a paper on ilio 
bacteriological laboratory 'and the practitioner. 

Lancasiurd and CiiEsniRE BRANcn.-— A science meeting of iiie 
Lancashire and Cheshire Branch will be held at the Salford Boyal 
Hospital on ThiU'sday, February 23rd, at 3 p.m. The following 
short papers will be read : — (1) Mr. Garnett Wright : Volvulus of 
the sigmoid ; (2) Mr. B. Ollerenshaw : Fractures in the region of the 
elbow joint; (3l Dr. G. J. Langley: Some problems of glycosuria; 
(4) Mr. J. B. Macalpine and Mr. K. D’A. McCrea : Stricture of the 
urethra. After tea there will bo an exhibition of cases, a display 
of exhibits from tlie pathological laboratory, and a demonstration by 
Dr, R. Gibson on tlie treatment of varicose veins by injection. 

Lancashire and Cheshire Branch : Hyde Division. — A meeting 
of the Hyde Division will be held in the Dukinfcld Town Hall on 
Tiiursday, Februaiy 23rd, at 8.30 p.m., ^yhen an address will bo 
delivered by Dr. A. Corsar Sturrock. 

. Lancashire and Cheshire Branch : Southport Division . — A 
meeting of the Southport Division will be held on Friday, March 
30th, when Dr. E. P. Cumbcrbatch will deliver a British Medical 
Association Lecture on llie use of ultra-violet rays in general ns 
iveil as in skin disease. It is hoped that there will be a large 
attendance .of membei’s. 


Lancasihre and Cheshire Branch : Warrington Division. A 

meeting of the Warrington Division will be held at the Infirmary 
Kendrick Street, Warrington,' to-day (Friday, February 171 li) at 

8.30 p.m. Mr. E. Fox will give a lantern demonstration on 
radiography as an aid to diagnosis. 

Metropolitan Counties Branch : City DivisiON.—The next 
meeting arranged by the City Division will bo held at the Metro- 
politan Hospital, Kingsland Road, E., on Tuesday, March 6th at 

9.30 p.m. Mr. Norman Pattei*son will read a paper on car 
trouble in general practice. 

Metropolitan Counties BnANar : Finchley Division.— A meolinH 
of the Finchley DiWsion will be held at the Finchley Memorial 
Hospital on Tuesday, March 6lh, at 8.45 p.m. Dr. J. W. McNee 
will discuss the clinical features of thrombosis of branches of 
coronary arteries. 

METEopoLmN COCKTIES Brancii ; Let^-ishak Dn-isroK .— a meeting 
of the Lewisham Division will bo held at the Town Hall Catforif 
on Tuesday, February 21st, at 8.45 p.m. Dr. J. Slanlev While 
will road a paper on some recent aspects of biolocical ‘(lier.mv 
illustrated by laiitoni slides and a film, “How biological moducU 
m-e made.” Dr. .Tane Hawthorne having had to Teavc for M e 
Conlinont the addiess on March 20th to iRe Division at the Town 
Hall, Cattord, will bo on the general practitioner and the prevention 
of voiieroal disease, by Mr. Wansey Bayly. 

Metropolttas Couhties Branch ; South-West Esse.v Division — 
A meeting of Die boutli-Wcst Essex Division will be held at llie 
yiupps Cr^s Hospital, Leytonstonc, on Tuesdav. March 6lli at 

3.30 p.m Dr. .T. C. Uuh-, medical snperintendent id 1 Ji -e a 

clinical demonstration. ^ * 

Metrofoeitan Coucties Branch : Stratford Division.— A nicclin» 
of tlio Stratford Division will bo held in the Board RooirT 

Ediication.aI Oflices The Grove, Stratford, on Tnesdav, February 
21st, at 9.15 p.m. Lecture by Mr. W. Rowle,v Bristow, orthopaedic 
surgeon, St Thomas s Hospital; Common disabilities of lbe^|-iice- 
]oint, and their treatraenl. 

Mideanh Bkanch: Chesterfield Division.— A meetin-' of the 
C.csterhcd Division will be held at the MaternTv Hosnital 
C iesterlicld on Friday, Mamli 9th. at 8.15 p.m, Mr (Traham^ 
Simpson will discuss the value of operations. t,raiiam . . 

I'Tokth of England Branch : Bishop AL'CKLArn riivTSTa*- a 

iKaemorrlunge. ^ ^ lectuze on uterine 

the'sToeWonDDlSn 

p^a'^rXis^"" <Newcastle.on-Tyne, will gi^^Yn S^'rl^^-^onni-fanS- 

South Midlact Branct ; Bedpordshire Division. — A TOneral 
raeeimg of the Bedfordshire -Division w 1] |,e held Rf the if iV , 
County Hospital on Wednesday, Febn.aiv 2Ld If 
Agenda: Lettei-s and -communications (a) from the ai^iL 
re undulaut fever; (6) from the Leicester Personal Heib if X* 

cialion and from the British Medical AssociMiof on „ n r ' 

education in lieallh. Discussion : The treatment of PV*'**® 

ulceration, to be opened by the chairman. Dr. H. D. Pollard”*^***^ 

Surrey Branch : Ceoidon Division.— -A meeting of the 
Division will be held at the Croydon General Hospital on TnoZi ” 
Fcbriiary 2Lst, .at 8.30 p.m. Mr. A. E. HaywarS Pinch 
superintendent of the London Radium Institute, will read a pan 
on radium. On February 22nd a Iccfinv-demonstration win 
given by Mr. E. T. C. Milligan at tlie Croydon General HosniM 
on practical points aliout rectal diseases, wliich will be nrecpHiWl 
by lea at 4 p.m. ^ 

Surrey Branch : Guildford Di\hsion.— A of tho 

Guiltlford Division will be held at the Roval Surrev Gounlv 

ITo^ipital, Guildford, on Thursda^^- Murrh Isf* at 4 o’clock Sir 

Tboma*; Lewi=? will give an address on the rhetunatie Iieaii. in 
children. Tea will be served at 3.45 p.m. 


Sussex Branch : Chichester- and Worthing Divusion.— A meet- 
ing of the Chichester and Wortiiing Division will be held in the 
BurlmgLon Hotel, Marine Parade, Worthing, on Wednesday, 
Febi'uary 22nfl, at 6 p.m. Business : Communication from head 
oiTice about the inquij*y' into the treatment of varicose ulceration; 
organization of medical charities; paper by Dr. R. Biooko 
(Chichester) ; The modern operative treatment of liornias, illus- 
trated by lantern slides and cases. Dinner will be served in the 
Burlington Hotel at 7.30. 

Yorkshire Branct ; Wakefield, Pontefract, and Castleford 
Division. — A meeting of the Wakefield^ Pontefract, and Castleford 
Division will bn held at the Strafford Arms Hold, Wakefield, 
on Thursday, March 8tli. Dr. R, A. Vcalc, physician- in charge 
of the akin department. General Infirmary, Leeds, will give a 
lecture on common skin diseases. Supper (2s. Bd.), at 7.45 p.m,, 
will precede the lecture. 


iKctlinrjs of 56randj£s antt iBtbisions. 


Birmingham Branch : West Bromwich Division. 

The annual mcctiug of the West Bromwich Division was held on 
January 31st. The report -of the work of the Division during 
1927 staled that the chief matter of intei'cst was the appointment of 
medical ofliccr of* health for West Bromwich, which was successfully 
nc^oliatcd. The contract rates in the Tipton area had been 
rearmed and brought up to the recognized scale. The members 
of Parliament for West Broniwich, Smethwick, and Wednesbury 
had been written to and asked to vole against the Dogs’ Protection 
Bill. 

The following ofijccrp were appointed for 1928 : 

Chairman, Dr. D. 31. Spring. Vicr-Chairman, Dr. E. .Ashton. Ilonorart/ 
Sccrcfart/, I)r. A. F. Adamson. Itrpresciitatirt in Reprrsentatire Ilotiy, l>r, 
.1. M. Mitclieil. Dcpntjf licpt citentaticc in Jleprciientntire Dotlp, Dr. I>. M. 
Spring. 

Tho' Executive Committee will meet at an early date Id arrange 
p. programme for 1928. 

It was decided to cousull with the medical officers of health before 
taking any further steps regarding the education of the public in 
hcaiih matlci*s. , 

Drs. Spring and Davidson agreed to supply the information as 
required for the inquiry into the treatment' of varicose ulceration. 

The new chairman, Dr. Spring, showed a case of rodent ulcer 
which was cured under treatment by ultra-violet rays, and luso 
a case of carcinoma mammae which was steadily improving under 
the same treatment. ^ 

Bombay Branch. 

\ meeting of ihc Bombay Branch was held on November 22iul, 1927, 
at the Pathological Laborntory of the Grant Medical College, when 
Dr. R. Row was in the chair. ^ . /tt • ...» 

Dr. Arthur Swain, who had passed many years in FIdiir and 

was in India only temporarily on account^ of the unsettled con- 



iht'^i.ino.0 r, 1.10.1. .ana ■bolioS'.S “i'l^ fboir 
social habils.. Tluoughout he showed impavliaht} and an appie- 
elation ot Ibc Chinese point, of view, witbont any ridicule o'' 
icmpl. Ho could not discuss the political aspect for want of 
tim^- blit be g.ave. a good account of tbo medical aspect. The 
Cliiiieso relied greativ on llie clmracter of the pulse for tlicir 
Siosis and if was ‘described in the Cbineso books as exhibiting 
more than a lnindred difforeiit varieties. From the treatment 
point of view tlieir slrongbold • was dietetics. Tliiougboul atl 
fheSr methods a very great amount of superstition and cnl spirits 

DOn'row thanked the lecturer for his diseonrae and «P';«';;0d 
the hope tliat Dr. Swam would be able to address the Branch 
a-rain on the siibiect during his slay in India. .... 

'br Turner showed two samples of coloured mine that ho was 
asked to examine during the last few months-one was pmk ""d t 'O 
other blue. Neither case showed any other .ahnormaliD . H'c 
nink colour was proved ultimately to bo due to plicnolphlliaton 
proLt in chocolax that the cfiild was fond ' of taking. T 'o 

other was duo to methylene blue m some preparation that the 
other child was taking. 

Gloucestershire Branch. 

A MEETING of the Gloucestershire Branch w.as hdd at the 
Hospital, Cheltenham, on January 12th, with Dr. J* G. * 

vice-president, in the chair. r i .xmet Avas 

The adjourned discussion on new the bi east 

continued by Dr. Curtis \\ebb, who recommended the haidcst 
possible for post-operative treatment, and others. _ in 

Mr. J. S. Kellett Smith read a paper on ^®^cal 

adults, dealing. chiefly with those cases r(^iU:ng from 
strain connected with lateral curvature. He said that V ^ ‘ f 
of tenderness and pain in such cases were .ints 

in the joints/ostoitis and periostitis set up by tension 4^,.. 

and bv direct pressure between bony points, and painr . - i 
tonus ‘of the spinal muscles. This last factor was } 

lant, and might be the chief element in the fi'ouhl^* 
factors named were often active and formed a its 

vicious circle. The reason for a lateral curvature T- • P _j,(j 
appearance in the adult frequently demanded a nn^hiral 

radiological analysis. ’ Films were shown dcniqnstratm„ P 
curves associated with such conditions as sacra. ization o 
lumbar vertebra and renal calculus. ..Special stress was • I 




54 Feb. 18, 192.8] 


* Corrospontfcnco, 


r PVPPTXMES'T TO THh . 
LUniTISIl UEDICAL JOOBKit. 


empowered lo con?uU with all local bodies inlcrcstcd in the public 
hcallh — namely, the county council, borouj^h councils, dislricL 
councils. National Health Insurance CoininiUcc, and the coni- 
inillcc of the "West Suffolk General Hospital. 

The SECKETArA’ gave a brief explanation of the nature of the 
collective investigation into varicose ulceration and the kind of 
form that would be required to be filled up. Several members 
undertook to take part. 

Dr. Bird suggested that the Division should send out a circular 
staling the fees to be charged for various •services, such as 
examinations for life insurance, woi-kmen’s compensation, etc. It 
was agreed that the revision of the circular i<!snod by the Division 
some years ago sliould be undertaken at a later date. 


Ulster Br.knch. 

A GENERAL meeting of the Ulster Branch was held in the Medical 
Institute, Belfast, on January 19lh: Dr. W. Poster (Porlir.sh), the 
president, occupied the chair, and provided tea for the mombei's. 

Dr. F. M. B. Allen read a paper on llie use of acidified milks 
in infant feeding. He said that though breasUfeeding was the 
most satisfactoi-j', it was sometimes impossible for various reasons; 
proprietary or patent foods were of use occasionally. But in four 
out of every five cases in artificial feeding cow*s tnilk was used, 
and cow’s milk required the addition of more hydrochloric acid. 
Acidified milk was exemplified by the use of buttermilk for very 
many years in Holland, and of Bulgarian koumiss. Alkalis slowed 
down the emptying stomach. Two and a half years a«^o, as the 
result of suggestions in American journals, DiC Allen ^had tried 
acidified milk in the Queen Street Hospital for Sick Children and 
had elsewhere explained the process and his success in its use. 
Ill one of his cases the mother had asked for a return to lactic 
acid after a change to the citric acid, stating definitely that the 
child was better with the former. Dr. Allen outlined the indica- 
tions for the use of acidified milk and the melJiod of nrenarntion 
which could be undertaken by auv intelligent mother. Diarrhoea* 
wasting and vomiting were cured, and he did not see- wbv 
rickets, tetany, and cochac disease should not improve- cod livcV 
oil and fresh fruit juice might be added. ' 

^.^JcFadden read a paper on the production and treat- 
ment of obstetric paralysis. He showed a large number of cases 
ilhisliatmg variations m the affection; and with Iho aid of 
mimorous diagrams explained the direct and predisposing causes 
and how some of the methods, sucli as twisting the head round’ 
which were admted to expedite delivery, might bring about the 
complicatiou. He added that- some cases of sudden dealli of the 
infant were due to injury to the medulla. 


®omsp0ni(£ttcc. 


Change of Doctor. 

Sib,— Like mo-st of the doctors iiitli whom I have discussed 
the matter, t object to the cumbersome new regulations for 
change of doctor in national health insurance. The worst 
feature of the whole business, however, is that of the signing 
ot die pink slip which the Insurance Committee altaclies to the 
iiiMoe of the insured person’s card after lie lias taken his 
card to the committee’s office and notified his desire to 

i 1 *'’®. is then letiuned 

to tl e insured person, who is requested to take it a'rain to 
the “new” doctor lo be signed by him. As the inZ-ed 
“'ready sat for perhaps an hour in a crowded 
ins/"'® waiting to see the “ new ” doctor in the first 

bring’ Uie^card^rikl'd Ifm? 

cqnlirmatoiv pink slip pf course unsigned up^toulat dale 
m:!: not^l.^lerHte^”'^.,. is 

Darlington, Feb. 1st.* t t- 

O. i\]RK. 

Ophthalmic Benefit and Clinics 

Sin,-One, aspect ot the subject under discussion lias not 
been noted by your correspondents— namely tbo lovlla ^ i 
of patients who need repeated attention .and to be^ecT'verv 
often. I have just gone through inv card indev fr,- 11 '.:. 1; 

.and find that I have seen 22 persons un.lcr the oclfl™?" ' 
benefit sclieine. Of this number "^nly 11 we./ ..eteltiln'^'s^r 
J no otlicrs were as follows : " 


Two p.atients each with two large Jtcibomi.an cv.si..-. v.liith 
were cyaciiated under cocaine: seen once. 

Corneal abrasion : seen four times. 

Severe interstiti.al keratitis : seen first in .Scpte.mber an,! 
twelve times to date. 

Acute iritis : now cured, hut seen ten times in nil. 

Angukar conjunctivitis and Idepharitis : .seen thrtM*' times 

Cliro'iic glaucoma : I have operated oii one eve sucee-s.sfnljv 
niid I hrivc seen the patient in all .seven tiine.s at uiv 
house, besides attendance at hospital; I shall hr 5 ,eein’'> 
liim again. ° 


Severe kidocyclitis ; been six limes to date. 

Deep septic nicer of cornea : seen, so far. twice. 

Two patients with neglected foreign lK>dy on cornea, wit 
rosnlling ulcer and keratitis : one seen three limes an 
now cured; the otlier had considerable keratitis wlie 
first seen, and has been seen three tinies lo date. 

The glaucoma patient liacl already been to two optician' 
the .second lime bav'ing been .sent by bis society. Six week 
ot most valuable time bad thus been wasted. I bad to e.xamin 
field.s, e.xamine him again after intensive cserine treatment 
do toiiometfic readings (tliey w-ere 40 and 50), and see Iiii 
three times before I took liim into hospital; I luive seen liii 
four times since. In course of time I hope lo receive on 
guinea for my work from his .society, vdio might liave ha( 
to pay him sick benefit for years, it does not seem to b 
vealiml that the* fee of one guinea . covers all case.s. It Avil 
be seen that 1 have received anything from eighleenpence t< 
one guinea per attendance, and that a, total of sixty-tlire' 
attendances divided into twenty-two possible guineas works ou 
at not quite 7s. an attendance for the average, but is reall.' 
less, as some of the cases are not finished. Also, most of tin 
inflammatory casc.s were sent as emergencies by their medica 
men. and had to be treated, the application for benefit beiiif 
sent in after I bad .seen the patients. In .some cases the benefii 
may be rcfu.sed. Kot long ago, by the time a septic ulcer hac 
healed the patient received a form from his society to take tc 
an optician “ who would then say wlietlier lie needed to set 
a specialist.” The ulcer was then healed and he was told that 
li !.5 society could take no responsibility for my fee, as he had 
not waited for instructions before applying to me. So I speali 
of possilile guineas.” That reduces it down to a probable 
5s. per attendance. Writers in the Jouhnai., and others whn 
do not know what a busy ophthalmic practice is really like, 
apart from a Wc.st Knd consulting room, would like to reduce 
the fee to 10s. 6d. per case. That brings the payment for 
the above attendances down to a probable 2&. 6d. Now the 
average lime for those attendances, I think, would be twenty 
minutes to half an hour. It is necessaiy to allow not less than 
lialf an hour for a lefixiction case, and a glaucoma case took 
an hour on one occasion; the suggested fee of half a crown is 
absurd. 

I may add, perhaps, that I am acquainted with West End 
practice as well as “suburban ” practice, and that the above 
cases were seen at my home address in Surrey just outside the 
London ai*ea. Before the ophthalmic benefit scheme was began 
(Ihere is no settled scheme yet) I used to see the above type 
of patient for no fee. or for a reduced foe, at the request of tlie 
patient’s medical man, and they knew that they were bying 
seen under exceptional* circumstances.’ Now it is suggested 
that, if my name is on the “ophthalmic benefit list,” they 
will have the right to see me for a total fee of lOs. 6d.. which, 
as I have pointed out, is probably about 2s. 6d. per attendance. 
Is it surprising that some of us feel inclined to witlidraw our 
names at once, and see patients who. are poor, and sent by 
their doctors, in the bid way? 

■ The medical man who' takes up O})hthalmology and expects to 
receive “ specialists’ fees ” must have had at least as good 
a training in his special line as the dentist has for his life-, 
■work. Within a few years such a man will find that he Ims 
as much work as he can manage, that 40 per cent, of his cases 
are not refraction cases, that half his time is taken up hy 
medical and surgical ophthalmic cases, and. that he must be 
something of a neurologist. To hear and to read some of the 
discussion about “ ophthalmic benefit ” it might be supposed 
that an ophthalmologist did nothing else but correct pres- 
byopia. Let us endeavour to remove this impression . from 
the minds, not only of insurance officials, but of medical 
practitioners who should know better. — I am, etc., 

London, W.l, Jan. 31bt. M.D., D-O.jM.S. 


iJalral ant) ^tliiarg ^ppontimettis. 


ROYAL NAVAL JIEDICAL SERVICF.. 

Surpoon Coimnancleib "W. J. Slorrie to the Dragon' W. F. Peattic 
CoufjueH; L. S. O.K.E., to the Suffoll- on commii-'-ioninff; ;• 

O'Jliordan to tile Vulcan ; R. P. Ninnis to the Venihrole for R.N^ Barrac . , 
Chatham; W. H. Mnriay to the Fruhisher on recommisaioning and 
Squadron Medical Ofncer'on transifer of flat:. , „,.m, 

Surjfcon Licutenantb C. B. Fo’^ to the Vivid for R.N. Ho«phal. . 

Icmporarv; G. \V. Garde to the Centnriou', O. Watt'on to the 
commissioning; E. R. Sorlnv to the Vcmhrokr for R.N. Barracks ’ 

«L B. Patrick to the Fiobhhcr on rccoainiissioning; A. S. Burns to 
CaUiopc, ~ , 

^ Messrs. R. A. Graff, T. L. Cleave. G. D. J. Ball, E. S. Bollon, f*,;;; 
Lord have entered as SuTfreon Lieutenants for short service anil appoi. 
to the Victori/ for R.X. Ifospital, Haslar, for coiir-e of instruction. 

Roval Xvv^l VoLUNTEEr. Reserve. 

Surgeon Commander F. H. ’U’alson ie placed on tlic retired list. 



Nava! and -Military AppolntmontSm 


f !^VrPLi:'iTEST TO TIIF 

LBkitisu Medical Journal 


55 


Feu. is, 


ROYAL ARMY MEDICAL CORPS. 

Mnjor \\\ r. T^o^nl^on, D.S.O., rotlres on rclirotl pny on Recount of 
ill licAlth nnd H ;rr.tnto‘I the mnk of TAc\j(onnnt-CoIonrI. 

Captain J, C. Rurn'*, linlf*]»ay lift, late lUA.Jl.C., rttnx's on rclirtnl I'ay 
oii'aivoujit of ill In'aRli contractcil on nctivo service. 

l.icntrnanl (on probation) W. R. C. Spict'r, from iho EOCondcU list, is 
rc'lorcJ to the cstablislnncnt. 


RDYAL AIR FOUCB MEDICAL SERVICE. 

Flight Lirnlonnnt O. J. Oriinth.** is Iransforri'd to the Reserve, Clas<iDII. 
Flxnng Otlicei-s to Ih’ FHirhl Lieutenants : n. K Chnieh and E. J. Jenkins. 
Filing Oniceis D. A. Milson to R..\.F. Station, Rieester; J. Kemp, B. B. 
KenncNiv, j. J. jlne.\ndre>\->». U. F. Macl.atchy, J, R. Murphy, J. U. 
Nfely, F. A. O’Connor. L. O’Connor, and J. J. Quinlan to tlie* Medical 
Training Depot, Hnlton, and nj»pointment to sluut service commission?. 


LSDLVN MEDICAL SERVICE. 

Colonels R. M*. Knox, D.S.O., and A. Fenton and Lieut. -Colonel Ij. T. R. 
llutchin><'n have retired from the Serviee. 

Consequent on the appointment of Brevet Colonel S. R. ChrDtophers, 
C.T.E., O.R.E., Pirpctor, Central ne*eareh luslltute, Knsnult, a.s Member 
and Secretary of the Me<UcaI Reseftrcli Institute Committee, ('aptuln 
K. R. K, IxVnger. .XK-sistunt Director, Central Res-'nioU liiNtiliile, is 
appointetl to'oJTiciate as Director of the Institute. 

Licut.-Colonol F. E. XViNoa, an Agency Surgi*on an»l Civil Surgeon. 
Quetta, is apnointisl to ofliciatc as Rr.sidencv Surgeon and Chief Jlctlical 
ttiheer, Raluclii^tan, in addition to his own ilnties. 

The services of Major M. (J. Rhaudarl nie placed pormanontlx at the 
di>po«.al of tile Government Of Bombaj* for employment in the Jail 
Di'partinent. 

The fcerviees of Major K. B, Rharucha arc plaes'il jicrmnnentlv at the 
di»-ro<xl of the Government of Bihar and Orivsa for emplovmeni in the 
Jail Drpaitnient. 

Tlio services of Captain Som Diitt, M.C., are plneed at the di'<pO'al of 
fho GoxTrnnicnt of Bengal Icmiwrarilv for ernploiment in the Jail 
Department. 

Captains S. A. I'hatak and R. Warters to l>r Majoi'S. 


TERRITORIAL ARMY. 

Royil Army MrpicxL Cunr.s. 

^lajqr If. E. S. Richards, ,M.C., T.D., having atfaine<l the a^e limit. Is 
retinsl, ami retains his rank wltli iiermi^vron to wear the lue-eiilied 
uniform, 

ainjof (prqv.) A. If. Fullerton is connime<l in his rank. 

Captain \\. Luniley, late IL.X.M.C., to be Captain, x.'ith precedeneo I'S 
fnim July 26tb, 1921 

Ijculciiants to Iw Cnl'toins ; F. N. Fuslor, K. Ilolmi"?, F. A, Sninifiii, aii.l 
F. C. Lewis. 

To bo Licutonaul. ; Liculcnant J. S. FliKon, lole R.F. (Snicial 
ReemO, niul A. 0. Kin?. 

S'niirniiiiiierari/ fm- Srrrirf u-itU O.r.f.— <'iiiitain W. R. Martino from 
nist. T.A., to In- I.iiMttt'iinnt uitli orrcotlonco os front .Iiilx 24tli, 
JS25, i.npetnnini'rnr.T for sent(x> witli Motlicnl Unit, K<linbnl?Ii UnivelMiy 
Contingent, Senior DiviMon, O.T.C., and relinquishes the rank of Captain. 


TERRITORIAL ARMY RESERVE OF OFFICERS. 

Rovil .XpiTT SlFmciL Conr?. 

'1* Jamiefon, T.D., and Major J. A. D.nxies, haxinj 
fri *1 *^*’R/c^Jrcd and retain their rank, with penm^Mor 

to wear the proscrilKxl uniform. ‘ 

nnmmlJjJl Dolroxd, hiivitig atlaincil the age limit, rclfnquislies liu 
commission and retains his rank. ‘ 


COLONIAL MEDICAL SERVICES. 

Senior Metlical Oniecr, Masindt. Ucandn 
M,*,! appointed Diptrict Medica 
OffiOTs, Ihibende and .Arna LWnda. rc-xilcctivcly. Hn.. C. J. Macqtiillai 
' ■ Metlieal OfTiccrs, Tanganyika. Dr, W, C. SmitI 

Maallh, Nigeria. Dr. G. V. .Mien, Senio 
KpA-P-iroii r.»iotraf«.f Bacteriologist, Institute for Medica 

intpmw nl V t O*** ”• C- ‘Wilkinson, Medical Super 

Dirt?-to?^Af V* 3'onorial Ilo.spital. Dcrninda, appoints 

tS fnllnVla^. Department, Hcrmtitla. 

foJ^Uie eSmnie. dSS SL ft," ’ *>y tile Secrelary of Slat 

wLlaee ^aXriofoJi.t® 3Irt : Captain J. .11 

.s„,‘ Research, URanila. Dr. U. Jl 

Aledkirt t?ffleer°.Ve^^^^ ‘V,'''™" Jiedical Staff. Dr, D. AV. McT.nrcn 

ATrte^n Afldieal'suB Vt"''''?.* D""' F. Kane, Medical Officer 

Gold Coas? LipiilS’an? ^ Strallon, Lady Medical Officer 

Lady Mctiieal Officer, Gold Coit. Jlr W ?r 

Staff ‘"Dr'^‘'n‘^*c'“^'.rt?s^‘ M ^“i'D-Dompbell, \Vert African"j?ediM 
LmnriS ilospitS, E T rSw?™'" 

Schools, Federated Jlalay Stile/ ' Medical Inspector o 


tacajtcies . 

^ S™EMn!‘’sa^ir’./ilM 'Jiir 'nnnuni'f Sltpcrintcndent a 
BjP.MlNCinM X%Ji MIDLIND E.in l\n Tirnn.-r TT«r. /-ix C. » Tt 

“MeS%S°cS"sa?aT?lWl,"y“^ o''Dea..., and Sel.t 

H„.,se.St.r?cons.- (2) Don, 

s\7r?eonf‘}"3f^T„f/s’'!iT,V7£l '^V"""^'--F'DHeians. (2) Fonr Hon: 
(1) lionep Siirr-ofATA in^r« Throat,- and Nose Dcpartmei 

l»A-irTm^n* " ^ rsx f Ophthalmic, and Derm itoJogii 

Sn‘r^o™-"m If „Donse.Phyrtciati. (6) Casualty hSu 

®<T'artmcnt VfiX *n^Af^oi Ti House-Surgeon to Ophtbaln 
t-rttnent. (8) Dental Housc-Surseon. Salary (1) to (7) at the r; 


of £80 per annum, but if candidate bad prcvlou-^ly licdd resident 
appointment in Innrmniy £100, and for (8) £80 per annum if resident, 
and £116 If rion-rcsidcnt. 

BnisTOL; W.iLKm DcxBir. PiiiviTn lIosrxr.iL ron XVomen* axd Children'. — 
Honorary AXiuiestlief ist (female). 

Bi'RY Txtirmirx'. — S econd House-Surgeon (male). Salary at Uic rate of 
£T75 per annum. 

CiMrntwiXL: Ptnjsir op Sr. Gili:s.— L ociimtcncnt Assistant Jlcdical Officer, 
Salary £7 7?. per week. 

Cxxcm Hospital, Fulham Road, S.M’.3. — Surgical Registrar. 

CmninsTER : Royil 'We.-t Kussilv lIo.srniL. — Junior IIolls^e-Surgcon (male). 
Salary £150 per nnitutn. 

Ciiunrir Missio.viny Socilty.— Medical Olflccr for Cliurch Missionary 
Society Hospital, Omdurman. 

Cyprus.— D istrict ^ledical onieer. Salary £‘600 per annum, 

Ilrp.riORD County and City Mkxtxl Hospital.— S econd Assit-tant Medical 
oniccr (male, iinmaiTicd). Salary £350 per annum. 

lIURTi’ORD County Hospitil.— ( 1) Resident Surgical Officer. (2) House- 
Physician. Salary £250 and £150 per annum respectively. 

Hospitxi. ron Srcic Children, Great Ormond Street, XV.C.l.— (1) Assistant 
Pathologist and Research Fellow; halar3' £450 per annum. (2) Part-time 
Junior Casualty Officer for six months (non-resident). Salary £75. 

JoitiNNCsnuRG : U.NIVERSITY' OP WiTWiTCRERiND. — Senior Lecturer in Physio- 
logy. Salary £516 per annum, rising lo £726. 

Kent County Opiirniunu ,and Aur\l Hospital, Maidstone. — Ophthalmic 
House-Surgeou (male). Salary at the rate of £200 per annum. 

LrirrsTEiisHinn County Council. — .X hsistant Medical Officer for Maternity 
nml Child Welfare and Assistant Scliool Medical Officer (female). Salary 
£600 i>cr annum. 

Leicester Roy^l InfirM-IRY. — Two House-Physicians. Salary at ILc rate 
of £125 per annum. 

Lincoln City and County Borough. — M edical Officer of Health. Salary 
£1,000 per annum. 

Lincoln County Hospitil. — .J unior House-Surgeon (male, unmarried). 
Salary llM per annum, rising to £200 after six months’ approval 
nciwicc. 

Liverpool : S^mirjun Hospitil fop. Women. — U o««’c-Siirgcon. Salary at the 
rate of £100 per annum. 

Liatjipool: St.inley Hospital.— (1) House-Surgeon. (2) House-Physician. 
Salary at the rate of £100 per annum each. 

London Temperinck IIos-pitil, Hampstead Road, N.W.l. — Resident Medical 
Officer. Sularj at the rate of £175 per annum. 

Millet. Ceneril Hospital, Greenwich Rond, S.E.IO. — (1) Resident Jlcdical 
Officer. (2) Hou>-c-Physician. (Males, unmarried.) Salary £250 nml 
£125 per annum respectively, 

Nottincium .and Midland Eye iNnnmr.T.— lIouFc-Surgeon. Salarj- £200 
per annum. 

O.xroRD : RADcxirrE I.VFm'iiRV and County Hospital.— ( 1) House-Physician. 
(2) IfoiL-c-Surgeon. (3) Casualty House-Surgeon. (4) Obstetric' House- 
Physician. Males. Salary at tho rate of £1^ per annum. 

Plymouth : Homoeopathic and General Hospital.— H ouse-Surgeon (male). 
Sal.ary £100 per onnum. 

Pri.vit of Wales*.s CF.N^^^AL Hospital, Tottenham, N.15.— Radiographer. 

Queen Charlotte’s Matf.rntty Hospital, Maryleboue Road, N.W.l.— (1) 
.Vssistoiit Resident Medical Officer (male); salary at fhe rate of £80 per 
annum. Hsing to £100 on appointment ns senior. (2) District Resident 
Medical Oflicer; salary at the rale of £^0 per annum. 

QuEEx’d Hospital ron Cittldren, Hackney Road, E.2.— (1) Resident 3Iedical 
Officer. (2) Two House-Physicians. (3) Clinical Assistant in the Ortho- 
paedic Department for Out-patients; honorarium 5s. per attendance. 
Salary for (1) £200 and for (2) £100 per annum. 

RiaiMONU, Surrey : Royal IIospital. — J unior Assistant House-Surgeon 
(male). Salary at the rate of £100 per annum, rising to £150 on 
api>ointnicnt as Senior, 

Royal Chest Hospital, Citv Road, E.C. — Assistant Tuberculosis Officer' 
(non-resident). Salary £60o per annum. 

St. Geop.ge’s Hospital, S.lV.l.— Assistant Radiologist. RenVancration at 
the rate of 1110 per annum. 

St. GeorgCs Hospital 3Ikdical School, Hyde Park Coiner, S.lV.l.— M’hole- 
time Worker in Research Department. Initial salary £500 per annum. 

St. John’s Hospital for Diseases of the Skin, Leicester Square, AV.C. — 
Honorary 31ed!cal Registrar. 

Samaihtan Free Hospital for Woii^, ilarylebonc Road, N.W.l.— House- 
Surgeon. Salary at the rate of £100 per annum. ' 

SHiarriELD : Jessop Hosfital for Wo.mkn. — ^.\8sistant House-Surgeon (male). 
Salary £300 per annum. 

Southend VirioniA Hospitat.. — Junior House-Surgeon (male). Salary at 
the rate of £150 per annum. 

Tundridge Wells and County General IIospiT.a.— House-Surgeon. Salary 
£169 per annum. 

WF.STEIIN Ophthalmic Hospital, Marylebone Hoad, N.lV.l.— Senior and 
Jiuiiur Honorary' .-Vnaesiheti&ts. Honorarium £1 Is. per visit. 

Wc?r Ham Union. — .A ssistant Medical Officer at the IVhipps Cross IIospitaL 
Salary £300 jior annum, lising to £250. 

Wkst Nortolk and King's Ly-nn Hoepital.— ( 1) Resident Surgical Officer. 
(2) As-^islant House-Surgeon. Salary £400 and £100 per annum respec- 
tively. 

WiLLEsOEN Municipal Hospital. — Residenl-ifedical Oflicer. Salary £150 per 
annum. 

AVoolwich and District IVar JIemorial Hospital, Shooters Hill, S.E.18.— 
(I) Honorary Senior .Anaesthetist. Tivo Honorary .Anacsfhetisfs. 

Honorarium 50 guineas per annum e’ach. 

Certifying Factory Surgfons.— T he follovAing vacant appointmerifs are 
aiinnuuc'eAi : Whitehaven (Cumberland), Chepstow (ilonmoiithBliirc), 
Chderweu (Pembrokeshire), Montgomery (3IontgoraprA>liire), Oakhnni 
(R'utlandslure), King’s Lynn (Norfolk), Newburgli (Fifcsbire). Ai>pli. 
cations to the Chief InspLCtor of Factories, Home Oflice, Whitehall, 
London, S.AV.l. 

JlELMCAL Referee under the Workmen’s Compens ition Act, 10:5, for tho 
Di^triet8 of Che*tcr (Ciiciiit No. 7). Holywell and Flint, and 3Iold 
(Circuit No. 29) Coiintv Cnurt«. Applications to the Private Sccretarv 
Home Office, Wliite!«ull, S.B.l, by March 3rd. 

This list of vacnncicz is corupiled from our adicrihcnunt columns 
where full particulars rcill be found. To ensure notice in this 
column adeerttsements must be received not later than the first 
post on Tuesday tnormiifff 



STJPPXjEMEjSTT 


BRITISH MEDICAL JOURNAL. 


LONDON, SATUHDAY, FEBKUAKY 25 th, 1928. 


COIs TENTS. 


PACE 

BRITISH MEDICAB ASSOCIATION. 


Procccdin^B of Council ..^ 57 

SlEnico-I’ouTicAt. Business 58 

Tublic Health Business 60 

Hospitals Business 61 

Ophthalmic Clinics ... 62 

GURUENT NOTES ; 

CoNsULTiNO Pathologists Gnoup 63 

The Assoctatiok's Collection or Autogp-aphs 63 

The Halt-Yearly Indexes 63 

MEETINGS OF BRANCHES AND DIVISIONS 63 


page 

Bill for Control of Yenereal BlBcase In Edinburgh 66 

ASSOCIATION NOTICES 65 

CORRESPONDENCE 67 

NAVAL AND MILITARY APPOINTMENTS 67 

VACANCIES AND APPOINTJIENTS 67 

DIARY OP SOCIETIES AND LECTURES 68 

POST-GRADUATE COURSES AND LECTURES 68 

ASSOCIATION INTELLIGENCE* AND DIARY 68 

BIRTHS, MARRIAGES, AND DEATHS 68 


PROCEEDIiVaS OP COUNCIL. 


IVediicxrifUj, Fchmary SIh, 1P2S. 


A MnETi.vG of tlio Council of tlio British Moclicnl As.socia- 
tion ivas liold on Wcdiicsilay, Fobniarv 8lli, at Tavistock 
Square, wlion Dr. H. B. Br.ickknduuy was in tlio chair, 
and the following wore present: ' 

Sir Robert Philip (President), Dr. C. 0. Hawthorne (Chairman 
of Representative Body), Mr. N. Bi.sbop Harman (Treasurer), Sir 
Ewen Macioan (President-Elect), Dr. A. Lvndoti (Deputy Chairman 
of Represenlalivo Body), Sir Robert Bolani (Immediate Past 

• of Council), Dr. ,1. Barcroft Andcr.son, Dr. J. Armstronp, 

• 7 * Baildon, Sir Alfred BIcnkinsop, Dr. J. \V. Bone, Dr. H, C. 
Bnstmv^ I>. Q. F. Buchan. Dr. H. G. Dain, Dr. C. E. Douglas, 

P- Banhill, Mr. W. McAdam Eccles, Dr. F. W. Goodbodv, 
Dr.R.-MaRaco Henrj-, Dr. G. B. Hillman, Dr. ,T. Hudson, Dr. I. W. 
Jolinsom Dr. R. Langdon-Down, Dr. R. W. Leslie, Dr. E. Lewys- 
1 Loudon, Sir Ricliard Luce, M.P., Dr. J. A. 

Macdonald, Dr. Morton Mackenzie,* Dr. O. Marriott, Dr, J. C. 
■Matthews,-Dr G. ly. Miller, Dr. Christine Murrell. Mr. A. W. 
Nutball, Dr. W. Paterson, Dr. J. R. Prythercli, Dr. F. Radcliffc, 
Dr. E. H. Snell.'Mr. H. S. Soutlar, Dr. E. A. Starling, Dr. John 
' Lnai^-Colqnel Ashton Street, Dr. IV, E. Thomas, Dr. 

G. Clark Trotter, Mr. E. B. Turner, Sir Jenner Verrall, Dr. J. F. 
Worlev* ivilliara AViiocIer, and Dr. IV. E. A. 

Ap^ogi^ ioT absence were received from ; Mr. R. -G. Hogarth, 
' Pl-D- .E- ^nlay. Dr. T. Fraser, Dr. F. J. Gomez, Dr. E. K. 
Le Fiemiufr. Dr. ,T- G. Tv_ * n 


. Prclimmnry -Duslncss. . 

The Chairman said that since the last meeting a colleagui 
who had been present at tlie Council on that occasion Iiac 
'passed away-^Sir Percy Bassett-'Smith.' Sir Percy was a mat 
greatly esteerfied -by all ^Yho knew him. In the work of tin 
Council, though primarily interested in liis own special depart 
medical practice, he had shown a catholic sj’mpathy 
. The members, by a standing vote, authorized the Chairmai 
to forward a letter of condolence to the family. 

le TOngratulations of the Council were accorded to Sii 
. Rercy S^gent, a member of the Association, and to Sii 
r eric Hallett, an honorary member, on (heir recent honours 
American Medical Association to sene 
<3elegates to the annual congress, to bi 

■ I" . Iinneapolis in June, was considered. It was stafec 
1 Li Pf^sident of the Association might he able to attend 

• but that 'lomestic reasons made it somewhat doubtful, and thal 

■ Philip yould like some deputy to be appointed 
' . ® m-T ter was left in the hands of tlie Officers of the Associa 

ion. somewhat similar course was taken in respect to thi 
th^ the Faculty of Sledicine, Cairo, anc 

1 orna lonal Congress of Tropical Medicine and Hygiene 


to take place in Egypt next December. The President hoped 
to he able to ntlend. 

Dr. G. F. Buehon and Dr. I. Johnson, members of the 
Council, wcre,nppointed delegates to attend the Royal Sanitary 
Institute Congress in July. 

Election of Future President. 

A communication was received from the Manchester Division 
intimating tli.at it desired form.ally to nominate Mr. A. H. 
Burgess, F.R.C.S., lionorary surgeon to the blanchester Royal 
Infirmary, and professor of clinical surgery at Victoria 
Univer.sity, Mancliester, as President of the Association in 
1929-30. The Council unanimously agreed to a motion by the 
Chairman that a recommendation in this sense be made to the 
Representative Body. 

Vice-Presidents.- 

The Chairman also moved that it be recommended ’.to the 
Representative Body that Sir Robert Bolam and- Sir Dawson 
Williams be elected Vice-Presidents of the Association in 
recognition of tlieir services as Chairman of Council, 1920-27, 
and Editor of the British Medical Journal, 1898-1928, 
respectively. This was carried unanimously. 

Sir Dau'son Triffinnis. 

A further recommendation to the' Representative Body, that 
-Sir Dawson Vvilliams be offered' the title of Emeritus Editor of 
the British Medical Journal, was also unanimously adopted. 

The Chairman said that on the report of the Editorial Staff 
Committee, to be brought up later, there was a resolution 
passed by that committee placing on record its profound appre- 
ciation of Sir Dawson Williams’s great services. He thouglit 
the Council would desire that this resolution should be adopted 
as its own, and he proceeded to read it as follows : 

The Council of the British Medical Association, at its 
first meeting after his retirement from the position of 
Editor of the British Medical Journal on completin"- 
thirty years in that office, wishes to place on record its 
profound appreciation of Sir Dawson Williams’s great 
services to the Association and the medical profession 
. • during the past forty-seven years. The Council recognizes 
with gr.atitude the high position the Journ.al has attained 
under Sir Dawson Williams’s direction, and offers to him 
on behalf of the Association its warmest wishes for a 
renewal of health in the leisure he lias so well earned bv 
his long and devoted service. ^ 

The Cliairman having moved this from the chair as the 
e.vpression of the feeling of the Council, it was seconded bv the 
President, and carried unanimously and lyith acclamation.' 

[1231] 





58 Feb. 25, 1928] 


Proceedings of Council. 


r fiiTPPXEWEwr to THi 

IBBXTISEX JOVMMkb 


Election of Overseas Members of Council. ! 

It was declared that the following, being the only nomina- ' 
tions received, were duly elected members of Council for 
the years 1928-31 : Mr. T. P. Dunhill (South Australian, 
Tasmanian, Victorian, and Western Australian Branches); 
Sir T. Jenner Verrall (New South Wales and Queensland 
Branches) ; Dr. G. Clark Trotter (New Zealand and Fiji 
Branches). 

Appointment of Solicitors. 

The Council considered the appointment of a Solicitor to the 
Association for the period April 1st, 1928, to March 31st, 1929. 
!Mr. W. E. Hempson had intimated his decision not to .seek 
rcai^pointment. After discussion it was tlie opinion of the 
Council that there were certain advantages in appointing a firm 
rather than an individual, and on the motion of Sir Robert 
Bolam it was agreed that Messrs. Hempsons, of Henrietta 
Street, W.C., the firm of which Mr. W. E. Hempson has been 
for many years the leading member, be appointed Solicitors 
to the Association for the period stated. 

jMEDICO-POLlfICAL BUSINESS. 

Contract Hate for Juvenile Oddfellows. 

Dr. Bone, chairman of the Medico-Political Committee, said 
that his committee had been approached by the Jklanchestcr 
Unity of the Independent Order of Oddfellow.s with the sugges- 
tion tliat the Association should consider the adoption of a' 
standard fee for medical attendance and medicine supplied to 
juvenile members of the society. In the course of a conference 
it vas stated that the board of directors of the Order was pre- 
pared to advocate general acceptance by all juvenile branches 
of a standard rate of 8s. 8d. per head per annum for medical 
attendance and medicine, with a slightly lower rate for excep- 
tional areas, where, owing to economic conditions, the standard 
rate was not feasible, free choice of patient by doctor and 
doctor by patient to be safeguarded. A recommendation in 
this sense to the Representative Body was accordingly brought 
l»cfore the Council. 

Dr. Starling said that this raised a question which had been, 
before the Representative Body, as w’ell as the Divisions, on 
many occasions. It was well known that medical attendance 
on children and young people was much more onerous than 
attendance on adults. This matter ought to be considered very 
closely before a capitation fee was fixed at a lower rate than 
under national health insurance, where the fee was for atten- 
dance alone. In 1925 the Council of lus Branch was approached 
by a local juvenile lodge of tlie Independent Order of Odd- 
fellows, and asked to suggest a .suitable capitation rate for the 
medical officer. After discussion and negotiation a capitation 
fee of 9s. for medical attendance and the provision of drugs was 
suggested, and was accepted by both the doctor concerned and 
the lodge, and he believed it still obtained. If the present 
recommendation were passed it would make a difficulty for 
medical men in other circumstances in holding out for more 
than 8s. 8cl. 

Dr. TUdeliffe asked whether it was not the policy of the 
Association to oppose all contract practice, in spite of the 
National Insurance Act. Dr. Bone replied that it certainly 
was not. 

Dr. Jolinson opposed the Tecommendalion. If he interpreted 
aright the feelings of his brother practitioners of Lancashire, 
this proposal would receive universal condemnation. 

Dr. Walker asked within what ages these juvenile members 
came, and wliether they were examined before admission. He 
nmiinded the Council that this was not a question of treating 
with individuals, but with a society which liad lai^e reseiwes 
ai-ciuiiulated to a considerable extent owing to the wrelclied 
fees paid to medical men in the old daj"s. 

Dr. Bone re])lied tliat the children might be of any age from 
birth up to 16 years, and he believed that it was not customary 
to have a medical examination before entry. 

Dr. Hawthorne thought that before the Council decided on 
this proposal the opinion of the Iiisiu'ance Acts Committee 
should be ascertained, as, if such a decision were made, it 
uculd have an important bearing on the fee to be paid for 
dependants of insured persons if and when these dependants 
were brought into national health insurance. He nios'ed that the 
rccc.mmcndation be postponed niitil after consideration by the 
In-urancc Acts Committee, and this was seconded by Dr. 
London, and carried. 


Tiic Chairman pointed out that what W'as intended here was 
not to encourage tlie extension of contract practice, but to raise 
the fee from the more usual- 6s. 6d. to 8s. 8d. 

It was agreed tliat the matter should be reported to tlie next 
meeting of Council after the Insui’ance Acts Committee had 
considered it. 

A^Aatanf Medical Officers cit Mental Hospitals. ^ 

Dr. Bone brouglit forward certain propositions with regard to 
tlic .salaries and emoluments of assistant medical officers to 
nieiilal hospitals. The policy of the Association in this matter 
uas laid dowji in 1915, and therefore the figures did not corre- 
spond with the present cost of living. The Council now agreed, 
on Dr. Bone's motion, to express the following opinions, not 
with a view to recommendation to the Representative Body, 
but as a m.'itter of record : 

(i) That all assistant asylum medical officers should be ablc'lo 
look forwai’d to a salaiy which with emoJuraents would amount 
to at least £600 per amumi after some five years* service; that 
this end could be attained by a provision that assistant asylum 
medical officers should be given a minimum commencing .^alarv 
of £350, willi annual increments of £25 a year rising to £450, with 
cmolunients in addition valued at £150, whicli should include board, 
lodging, laundiy, and attendance; 

(ii) iliat assistant asylum medical officers should be encouraged' 
to take a Diploma in Psychological Medicine; 

(iii) that (liaving in mind the view expressed by the Royal Com- 

tnissioii on Lunacy that in a large number of institutions tlio 
medical staff should be enlarged) a whole-time medical officer of 
a mental hospital should not take cliargc of more than (rr) 50 
acute cases togetJier with 50 convalescent patients, or (h) 400 clironic 
cases, as understaffing of hospitals means that the patients therein 
receive insufficient treatment, and this entails a corresponding low 
recovery rate; . . , . . . 

(iv) that pi’aclitioners who are acting as clinical assistants m 
menial hospitals should not be required to undertake the duties 
of junior assistant medical officers; 

<y) tliat practitioners engaged in tlie trying -work of comiuuous 
attendance on mental patients in mental hospitals should Jiavo 
at least four weeks’ leave each year, and that they should not oo 
obliged to take more than two weeks of this consecutively. 

The Council also agreed to recommend to the Representative 
Body that tlie minimum commencing salary be as set out m 
paragraph (i) above; that officers who possessed the diploma 
should receive an additional £50 a year; that temporary 
medical officers should not be employed on the staffs for mora 
than tliree months, except as relief during holiday periods or 
when a member of the pci’manent staff was .incapacitated by 
illness, or had been seconded for any purpose; and that every 
mental hosjiilal should contain a separate house suitable for a 
niarricd assistant officer, or two sudi houses wheio the hospital 
had four or more assistants. . • . 

Dr. Bone added that it was proposed at once to^send copies 
of these, lecommeiidatiqns to the County Councils Association 
and the Association of Municipal Corporations for comment, 
and to all the county and county borough oouncils. It waS the 
desire of his committee to consult the important a'^socialions 
just named before the policy had become -stereotyped, and tho 
Council would have time to consider any co^ents before too 
recommendations came up to the Representative Body. 

It was agreed also to consult any other representative 
associations, such ns the Parish Councils Association of Scotland, 
whose views might he useful. • 

Tieatmcnt of Employers of Ordnance Survey Department. 

The last Annual Representative Meeting mstru-jted tho 
Council to approach- (he authorities concerned witli a view 
to obtaining an 5nciea.se in the fees paid to doctors for casua 
cases in the Post Office Telegraph Survey Department, 
been ascertained that the persons referred to were eniployea 
by the Ordnance Survey Department. Dr. Bone gave an 
account of the foes offerod to practitioners, and said tJiat, 
although inadequate, they were le.ss so than fees paid hy oei-lam 
other Government departments which were accepted “ 
profession, and his committee thought that no action should j 

taken in the matter. , o firl 

Dr. Walker said that tlie fees were very inadequate— iis. on. 
for consnltation and medicines, 3s. 6d. for visit and nicdicmes, 
•while night visits, for which there was a slight addition, nera 
supposed to he vi.sits between 10 p,m, and 7 a.m,, " 
implied that the pi-actifion'er’s working day was from i a. . 
to 10 p.ni. It was a poor reason for taking no action i. 
other case.s were worse^ and he moved the reference >ac ^ 

The Chairman said that in other connexions the .Association 


■Fi:b. 2."), 15)28] 


Pro'ccodtngs 'of Council. 


r firppiEifE.vr to inE 
LDsinsn aJEorcux. JovBXit S>if 


had Micoocdcd in establishing the hours fro:n 8 p.m. to 9 a.in. 
ns the ** night ” period, and lie hoped that tliesc would bo 
estahlished in every connexion ns the prop»''r hours. 

Br. Bone said that he was not out to defend the scale; hut 
the fact was that here, ns with otlier Oovernnicnt dejmrtinenl.s. 
there were always practitioners who were jna'parcd to accept 
the scale. There was a scale of fees for attendance on seamen 
away from their sliips, and another for attendance on soldiers 
at homo, hy civilian practitioners, wliicli wore not such good 
scales ns this. There appeared to he enough prnclitionei*s in 
every area to give attendance on these terms. 

It was agreed that the views of the coinmilteo he loported 
to the Bepresentntivo Body, hut not in the form of a ret'om- 
mondalion. 


Poi/hiff Centres for Infant 

A long discussion look place on ceitain rec ommetulalions 
arising out of the recent promotion of scliemes for the eslnh* 
lisliment of infant consultation centres for hotter class families. 
Kcprescnlations lind heon made to (he Association hy die Asso- 
ciation of Infant Welfare and fraternity C’cntie.s. putting 
forward the strong feeling amongst a sccUon nf the middle- 
class public that the mothers of this class should lie able to 
get tliat instruction which was provided for a difrerent dass 
of the population hj’ the municipal maternity and child welfare 
clinic.'*. Tliese mothers were willing to pay for the instruction, 
and at one institution of llic kind, Irnown as the Choksea 
Babies’ Club,” the charge propo.sed was five guineas a year 
for each diiUl. It had been stated hy a dopulation which mot 
the JIaternity and Cliild Welfare Subcommittee of tite Associa- 
tion that many private practitioners were imahlo or unwilling 
to give the kind of instruction required. It was not proposed’ 
at these centres to give medical treatment. 

Br, Bone said that his committee wa.s not desirous of enconr- 
extension of Ihcso centres among well-to-do people, 
but at the same time it believed there wai a good deal of 
truth in the assertion Uiat many medical men wore !iot specially 
interested in this hraneh of work, and that a case liad been 
made ont for the estahtislmient of the centres under discnssion. 
TJie ladies w'ho had brought forward llic matter allachcd 
gieat importance to those clubs, asserting that they found a 
rehiclanco on the part of the ordinary practitioner to give de- 
tailed advice on the feeding and manageme'iit of small children, 
Ti I 1 t'lnt tliesc centres should he formed, 

la being the case, it was neccssaiy to consider ways in which 
ley should be run. He llierefore moved the first of several 
recommendations to the Representative Body as follows : 

education of all mothers in preventive nicdiciiie, 
iiome^ ic the conditions of the 

exist - considered that there already 

attainprl- ^ these objects may be partially 

cenfrfv; Kuinii I ^*i{' establishment of special paying 

panda and not purpose of education and health propa- 

motliers nrpfnr f M treatment; and (iv) that should 
that atfpnd'inpft P^Vhig ccnlx-es it is desirable 

knowledge of 

.Jp|'’>son said that this was to his mind one of 
le mos prep^ eroi»3 propositions that had ever come hefore 
the ^onnea. The committee appeared to have been unduly 
s\\aje j le representations of a few ladies from Clielsea. 

pparcntly the ordinary medical practitioner was fudged not 
to be capable of advising on the care of tlie baby. ' 
r t* i- .6xpre.ssed strong dissent. How was a 

IS me ion o e made between medical advice and medu-al 
treatment If these centres were established there would be 
con 1 C le ween ^ud the private practitioner. He thought 

ns was with which the Association ought to Iiave 

nothing to do. ® 

Chaiiman said that he imagined the opponents did not 
S I o iiega i\e a le propositions set forward in the rccom- 
len a ion, an if liey wished to saj' that the Association 
should not countenance the establishment of such clinics it 
' rJ. T^i ^oi*ward an amendment in that form. 

Imi ^41 esued to move to proceed to the next business, 

starve ^^in-man declined to accept such a motion at tliat 

siirlr* Starling thought the encouragement hy the Council 'of 
' ^*1 down in the recommendation was 

tionov '*'^“h^gcons. The work of the private practi- 

>“ a lea j suffered sulTicient inroads without this fresh 


one. His experience AV«as that .a large number of general prac- 
(11101101*1) Were much interested in the nianagenient of infants 
and anxious to give advice on the siiliject. The distinction 
helwecii advice and ircalincnt would ho very linrd to draw. 

Dr. CJjristine Murrell .said that there was more tlian one 
middle-class centre already in existence. She believed that 
when itifaiiL welfare centres for the iiidustrial classes were 
started ilui attitude of the Council was somewhat similar to 
that which had been e.xprcsseci hy (he previous speakers. But 
was the Council really acting in the intorest.s of the gener.al 
practitioner when it washed its liands of this thing? Was 
it not better to take an interest in and to guide the early 
stages of this movement ? The movement miglit be dangerous, 
but it was moie dangerous to ignore it. 

Dr. Bristowe felt that, wlietlier llie Asstn-ialion discouraged 
(»r approved them, tliese centres Jiad conic to stay. The w’isest 
thing the Association could do was to tiy to guide them into 
the right paths. 

Dr. J. A. IMacdonald considered that each one of these 
dovrlopineiits w*as a stcfi towards the establishment of a State 
medical service. 

Dr. Radcliffe supj>ortcd the opposition, urging that it was 
impo.ssihlo for any medical man to give the mother the best 
advice unless ho was acquainted, as the private practitioner 
was, with the home surroundings, the econtmiic situation, and 
other circumstauce.s. 

Mr. K. B. Turner said that while he siiaiod the feelings of 
others with regard to these movements it was necessary to 
face such a fact ns this, that one nf these centres was started 
hy a lady who had asked her practitioner how* to manage her 
baby, and lie bad told lier that he knew very little about these 
things. It was not a few ladies of Chelsea, as Dr. Jolmson 
Inul said, w*ho swayed the committee, hut tlie accredited repre- 
sentntive.s of an organization wliich covered the whole kingdom 
— namely, the Association of Infant Welfare and Maternity 
Oentro.s. Some of these centres were already in existence, and 
momhers of the profession wlio belonged to what he called the 
” publicity brigade ” had addressed them. But the whole 
qnoslion was largely in the hands of tlie members of the pro- 
fession. If they cliosc to do this work in tlic ordinary course 
of their private practice the need for such centres would not 
arise. 

The Chairman reminded the Council that the Representative 
Bod\* had committed it to a campaign in the direction of health 
ediicalion and propaganda. It miglit he said that n tiling of 
this kind was not a right method of propaganda, hut it was 
not for the Council to oppose education and propaganda in 
comiexion with infant hygiene. If there was a demand for 
public information and education with regard to infant hygjene 
— a demand not completely met by private practitioners — then 
some such organization as this was a proper tiling, but it 
ought to he confined to that particular sphere of education and 
propaganda. 

Dr. Johnson having moved that the whole matter he referred 
back, 

Dr, Bone said lie could not agree that these careful recom- 
mendations shonkl he scrapped. The committee did not como 
to its decision lightly, and the deputation which it received was 
not a local affair, hut representative of a national body, on 
which, by llie way, the Council of the British Medical Asso- 
ciation itself was represented. All the arguments advanced 
that morning, such as the difficulty of distinguishing between 
treatment and advice, were equally applicable to the municipal 
clinic-s which for some time now had had the approval of the 
Council. Ho sometimes thought that the interests of the pro- 
fession Avere looked after a little too minutely; its monetary 
interests Avere considered to the disadA'antage of the Avider vicAv. 
That seemed to he the underlying consideration of the dis- 
sentients AA'ho had spoken. Even on this ground lie did not 
think that any money Avas going to be lost to the profession 
because this A\*as entirely neAv AAork, Avhich had not been done 
in the past. It seemed evident that ladies Avould not be 
Avilliiig to pay five guineas a year for each child if thev could 
get the information from their’ family doctor. It appeared 
therefore, that tliovc Avas a need for these centres, and if there 
Avas a need they Avould ho forthcoming. Could the Association 
CA-eii if it Avished. do anything to stop them? And if not, why 
not try to guide them in the right patli? * 

Tlie amondmcnl to refer hack Avas lost by 20 \-otcs to 11. 




Proceedings of Council. 


r SCTTPLEifEWr TO THIS 

LBnmsir medical JocnKit 


ei 


Fr.n. 2,->, 102Sl 

T^octmv. on education in liealtli. These were agreed to, and the 
names (»f possihle lecturers .nnd chairmen were suggested. 


Coinhiti((l Appointmniii*. 

Dr. Hawthorne brought forward a report of a joint meeting 
of the Medico-Political nnd Public Health Committees whicli 
had been lield to consider the question of combined appoint- 
ments of wbolc-limo medical onTicer of health, Poor Law 
mwlical ollicev. and public vaccinator. 'I’he occasion of the 
joint meeting arose out of what is known as tlu Cludstone case, 
diMUSScd at the last meeting of Couneii.‘ 'I’lie joint meeting 
hioiiglit forward a recommendation for submission to (he 
Pepresontalive Body as follows ; 

(i> That domiciliary attendance should, in the )»cs| interests of 
the patients, be provided by private pmclitionoi's in (he area con- 
cerned and not- by a whole-time medical ofTicer; (lii that the adop- 
tion of the above rcsolutioii leaves luiprejndicod (ho portion of 
any medical otTicci's at pi-cscnl holding whole-time appointments 
in which doniirniarj* attendance is one of the duties; (lii) that if 
theiT are in the area uo. practitioners willing to nndcrlakc the 
domiciliary work on suitable terms, the resolution (paragraph (i) ) 
shall not apply. 

He said that it was felt that it would he unfair to make the 
pit»jK>.sition retrospective, ami, nior«'ovcr, the possibilities indi- 
cated in pavagrapli (iii) had to he home in mind. 

Dr. ^loiton Mackenzie asked whether tlie (hidstonc case was 
mvered. Dr. Hawthorne replied that this was « recoiumenda- 
lion to the Bepiesentative Body, and if it uas passed it would 
i>egin to operate from the date of its pa.ssing, so (hat the 
Godstone and other apjHiintments .would then be ct»vered by 
paragraph (ii). 

Dr. Morton Mackenzie then moved, and Dr Lyndon 
seconded, that words be added in paragrapb (li) “ prior to 
the origiii of the Godstone ca.se.” This anicndinent was lost, 
and Mr. Harman moved the deletion of the whole of p.iragraph 
(iij. and Dr. Mackenzie seconded. Dr. Hawtliorne urged that 
this would ho unjust to individuals, nnd this amcndinciit also 
was lost, and the recommendation as it .•■tood was agived to. 

Dr. Hawtlioruc further mow'd as n recommondatton to the 
Bepiescntative Bwly ; 


That there is no objection in principle to (he combination in 
anc ami the same whole-time appointment of the duties of medical 
3mccr of hoallli and those of Poor Law in«>titulionaI medical 
om^r, but Ilia application of (his principle in any individual 
in'.tauce nuist bo governed by local circum«tances and bv ihe 
opinion 01 the Division or Divisions concerned.” 

ibis was agreed to, and Dr. Hawthorne furtlier movt-d that 
there was no objection in principle to the combination in one 
ami the same whole-time apixiintmenl of the duties of medical 
officer of health or of Poor Law institutional medical officer 
and those of pubVie vaccinator, subject to tlic same provision 
^^ilh regard to the local circumstances. This also was agreetl to. 
Dr. Morton Mackenzie moved a re.solution regretting the 
sIl 0 ^Yu 1)y the Council of tlic Society of 
. eulcal Officers of Health in not urging its members to posl- 
^.nc applying for the pot,l recently advertised in the public press 
*c * 1 *^ Lodstone board of guardians. He reminded the Council 
of the Godstone ca.se and of the fact 
^ meeting, confirmed the Issue of an 

inpoi an i o ice. Six application.^ were received for this post, 
from wltid. three selections wore made. Two of the three 
app lean 3 wit idreAv, and the third was appointed. An appeal 
A\as ma e ® ^ applicant to witlidraw Iiis application, but he 
refused, .nnd based lus refusal on a letter from the Society ef 
" 1 ^^ 1 ^^ ^ H*^^»lth,in whose hands lie Iiad placed himself, 

wliieh stated that no decision was taken bv the council of tbc 
.l' Important Notice issued by the 

11 In 1 * e tea . ssociation, and that the council had passed to 
* thonglit that this was falling 

^, 1 *- 1 ^ I ^ Diight be expected from the sister .society, 

'' ” ^ w * soocia ion had supported, incurring some odium in 

so doing. Here was a case in Avhieh the local profession felt 
\er\ s long \ an yet the society could give their own member 
no positive advice on the su\>ject 

Dr. Starling seconded the resolution. The area in question, he 
.1 , was wi iin le constituencA' which lie represented on tlie 
?2r: "'"O- strongly indeed hy a large 

wn^nV ** whom he came into contact that all 

nnri'f^ taken to preserve the jnactice of private 

^actdiouei-s. It had always bee n bis objecl to try to gel the 

‘ SeiTLrjiEsi, DfX'ctnhcr 24th, 1927, p. 213. 


two branches of tbc profcs,sion to work togetlier in harmony,, 
but be thought the Council should register its regret at what 
Iiad buppened in Ibis instance. 

Dr. Snell regretted to see sueli a resolution as fbi.s on the 
agenda. At the ])revious meeting of the Council there wa.s 
cniisiderable diflerence of opinion over llie Godstone case, and 
after a long discussion tbc resolution was carried only Iiy 
23 voles to ID. To base on a resolution so carried a resolution 
of regret or censure relating to anotlier society would be quite 
out of place. Similar appointments Iiad been held by wliole- 
lime odicers for over tliirty years, and there was no e.vpressed 
ptilicy of tile Association on record. But in 1911 tlie policy 
w.as laid down liy the Annual Representative Meeting tliat the 
Association .should do what it could to make all medical officer' 
of liealtb appointments whole-time appointments. If tliis 
Godstone advertisement Iiad offered opportunity for general 
practice to lire man appointed it would Iiave contravened the 
policy as stated in 1911. In 1910 a memorandnm was issued by 
the Loc.il Government Board in support of the combination 
of appointment.s with a view to securing wliole-time medical 
officers of health, and the Council had not e.vpressed a contrary 
opinion. Tlierefore when tfiis advertisement was on the Asso- 
ciation’s books tlierc was iiofliing laid down by tlie A.ssociation 
directing its member.s not to apply for such an appointment. 
With regard to the rclationsliip between general practitioners 
and tlie medical officer of health, it.miglit be of interest if lie 
staled that he, an M.O.H., had been a member of the Asso- 
ciation for nearly forty years, and whenever be had expressed 
a desiie to attend the Annual Representative Meeting his 
Division Iiad always sent him. He moved that the Council 
procecil to the ne.vt business. 

Mr. lYebber seconded, anti the motion to pass to the next 
business was carried by 17 to 13. 

Hospitals Business. 

Co-onI hint ion of Ho>pitai Provision. 

Several impoilant recommendations were brouglil forward 
lie Mr. McAdam Eccles on behalf of the Hospitals Committee. 
Tlie first related to the co-ordination of hospital provision. 
Tlic Minister of Health, Ire said, was in correspondence with 
tlie British Hospitals Association with regard to this matter 
of co-ordinaf ion, and the Hospitals Committee, hearing of tliis, 
had thonglit it well that the Britisli Medical Association should 
look into the matter also, and a sniicommittee was appointed for 
this pur|X)Sc under the chairmanship of Sir Richard Luce. Tlie 
Hos-pitals Committee considered tliat the .rtssociation should 
take an active part in attempting to guide any legislation 
which might be the outcome of any of the principles adopted 
as a result of the consideration of the answers to the questions 
whicli Iiad been suggested by the Minister of Health. The 
policy of the Association should be framed before any bill 
was introduced by tbc Minister into Parliament. The .sub- 
coiiimitlcc had prepared a scheme, but it bad not yet been 
before the full committee. In the meantime, however, the 
committee Inougbt foi-ward certain recommendations iii order 
to gauge the feeling of the Council. The first was ; 

That all hospitals in a given area should be grouped round a 
parent or primavv hospital, which liospital, in view of the existing 
-slate of alfaii-s, will generally be one of tlie bigger voliinlarv 
general hospitals. In any area of co-ordination in which llierc 
is a hospital willi a recognized medical school attached, such 
teacliing liospital must ncccssai-ily be the hospital round which 
the othci-s are grouped. 

Mr. Eccles added thal the committee was quite aware that 
some .so-callcd Poor Law; — in future probably to be called 
nniiiicipal — ^Irospitals were exceedingly good in their buildings, 
equipment, and staff, but they had not got the same facilities 
as the larger voluntary liospilals, particularly those with medical 
schools attached, for research work and other matters. 

Sir Robert Bolam suggested that the term " primary hos- 
pital ” might cause confusion with some similar term in the 
leirort of the Consultative Council. On tlie underetanding tliat 
the phraseology in tliis respect might be made plainer, the 
recommendation was agreed to. 

Air. AIc.Adam Eccles then brought forward some replies whicli 
he suggested might represent the Association’s point of view in 
answer to (he questions which the Jlinister of Health had sug- 
gested tliat volnntaiw hospitals should examine in conjnncfion 
with local authorities. The discussion in the Council on these 
answers was almost entirely devoted'to terminology, particularly 
the description of what was variously termed the primary or 



62 Feb. 25 , 1928 ] 


Proceedings of Cownc//. 


r surrLKMKXT to m 

LBnmsiI •MKDiCil, JoOBKiXi 


parent Iiosi^itaT or base hospital. The term “ central or base 
hosjjital ” appeared to find most favour. The Ministei**s 
questions {Q) and the proposed replies (* 4 ), as agreed to after 
the discussion in the Council, are set out below : • 

Q . — Having regard to the nature of the hospital accommodation 
available in the area, both in voluntarj' and public hospitals, arc 
there any categories of cases which should, so far as practicable, 
be allocated to one typo of hospital or the other? 

A . — No class of case other than infeefious or insane should be 
excluded from the central or base liospital. Certain categories of 
cases might, according to local circumstances, bo allocated to other 
liospitals of tlio area, provided they were still available for 
teaching purposes when necessary. 

<?.— -Ts it possible, after taking stock of local needs, to agree on 
any line of demarcation between the province of the voluntary and 
public hospitals in the area? 

■ 4 ; — The lino of demarcation must depend upon the slafiing and 
equipment of the hospitals concerned. 

^•“■■^ssuming that some understanding is reached as to the line 
of demarcation between the voluntary and public liospitals in a 
given area, to what extent would this modify schemes of enlarge- 
ment in hand or in contemplation? ** 

■d.- The public hospitals must provide accommodation for those 
cases which arc outside the province of the respective voluntary 
hospitals, but the public hospitals should not develop in compcli- 
tion nuh in i;... . jii • *- 


1 *1. - co-ordination and co-operation with the volunlaiw 

hospitals, tyherc a voluntary hospital is already liolding llio 
leading position, and is progressive and locally supported, it 
siioula maintain this position, and any futher developments which 
are necessary should bo mado in co-operation with it. 

‘T shortage of voluntary hospital beds, in wbat 
respect is the shortage most serious — for example, is it a shortage 
medical beds, gynaecological or maternity 
beds, 01 orthopaedic? Is there vacant accommodation in public 
hospitals suitable, or capable of being adapted, for the typo of 
caso for which accommodation is specially needed? 

beds must vary in 

aifferent locahties. In mdustrnvl areas tlio sliortago is cliieilv in 
beds (in surgical beds parlicniarly for 
H a?. which the urgency depends upon industrial rather 

f on tho other hand, it appears 

m fl'ortago IS partly m general medical and surgical beds 
^ m bods for special departments— for example, throat 
whi nrnb^F,r‘)° 's vaciint accommodation it 

H o ‘ f ^ necessary to adapt such accommodation to meet 
tho spccia needs, and to provide adequate and efficient staff. 
n=i,li a “ “ clearing house” arrangement bo cstab- 

nutboriW^e.“°t™'^f’°r ^ between the voluntary hospSals and tlio local 
distrfh.iVinn en^':fn'ns) wliioli would oiisuro a bolter 

distribution of patients and the more rapid admission of cases 
requiring institutional treatment? -on oi cases 

-itp'Tun •>0“se that is, a central bureau- to co-ordin- 

hosnitsk requiring admission to the various 

iiospitals would be essential under a system of co-ordinaliou aF 

mdmatv should work in close connexion with the 

n ''°®P*^o'.,and bo situated near it, or oven within it but 
should be under the control of a central cimrailb - " ’ 

hospitals of the area. It 
ambulance transport of the area. 

extent and under what conditions could the medical 
nl rL hospitals undertake responsibility for cases, 

miknt '"'"‘ber ot beds, in public hospitals, so that the 

whctIicr”]?Yrli’F,i®‘’‘^'“^'^'^ special type of experience required, 

ho oc-nniF] without regard to whether the bed 

lie 0C..UP1CS IS under voluntary or public management? 

hosnit,ils staffs of the existing volunfary 

Sp als in one o? . ho f u P“blic 

to the nublic hosnitok^ r/T"’® visiting consultants 

o ]o,i.F,“ of tho active staffs of 

of 


committee of co-ordinated 
It sliould also corordinate the hospital 






1 4 1 extension of this work to tho care of those for 

whom the Government and local authorities make themselves 
responsible must bo remunerated, and it is considered tlmt tho 
remuneration .should lake the form cither 5 "Sod slry or of 
an bonorai 111,11 for dehmtc services .and respon.sibility. It is esLn- 
tial that such visiting staff have the right of accL directly w 
indirectly to the governing body of the particular hospital, ^ 

Dr. Radcliffe desired to delete the words " or indirectly ” 
from this last paragraph. Mr. Eccles pointed out that the staff 
of a public hospital, in exercising their right of access to the 
governing body, would do so in all save very exceptional 
cases indirectly through the medical superintendent. But there 

might he circumstances in which they desired direct access 

that is, over the head of the medical superintendent wdiich 

would probably lead to very severe friction. Xo staff would 
go over the head of the superintendent unless it had first-tried 
the more ordinary means and had failed. 

Sir Robert Bolam hoped the chairman - of the • committee 
would accept-tlio amendment. - The normal routine of the -hos- 
pital did -not contemplate access -to the governing body, -hut 
it was essential in the last resort that members of the visitin" 
staff should have direct access. — • - t_. 


It wiLS agreed that the words “ or indirectly ” be omitted. 
The recommendations were then approved, and it w.as .agreed 
that they should he communicated to tho Ministry of Health 
at an appropriate time. 

Other matters brought forward in the report of the Hospitals 
Commiltco included a recommendation to the Representative 
Body laying down certain criteria for practitioners treating 
patients in private wards or nursing homes attached to hos- 
pitals. Mr. MciVdam Eccles said that when practitioners were 
desirous of treating their patients in paying w.ards or nursing 
homes attached to hospitals the authorities might reasonably 
ask for proof that the -practitioners were really competent to 
do the special service required by the patient, and the proposal 
was to amend tho hospital policy by setting out tho conditions, 
one or more of which should be satisfied by the practitioner, 
in a special case of this kind before undertaking the treatment. 
Tlio motion, as a recommendation to the Representative Body, 
was agreed to. Mr. Eccles said further that the contributory 
schemes for hospital benefit were being watched, and he asked, 
and it was agreed, that the Hospitals Committee might hs 
empowered to convene at an appropriate time a conference of 
representatives of medical staffs to consider this subject. 


Ophtiulmic Clinics. 

Dr. AYallace Henry brought forward a report of the Ophthal- 
mic Committee embodying certain principles for incorporation 
in any scheme for tho provision of ophthalmic e.xamination 
and advice through clinics. Ho detailed , the recent history 
of this subject as set out at greater length by Dr. Brackenhury 
in his recent address to the Ophthalmic Benefit Committee 
(SiirrLEMENT, February 4th, p. 36), and said that the matter 
had a certain amount of urgency in view of the report of the 
Departmental Committee on tho registration of sight-testing 
opticians. ^Yhcn ho and Mr. Bishop Harman and tho Medical 
Secretary, as witnesses for tho Association, gave evidence before 
that committee a largo part of the cross-examination turned on 
the question whether it was possible for the medical profession 
to provide a sufficient number of men to do tho ophthalmic work. 
The Association’s witnesses practically pledged the Association 
that it would take every possible step to provide medical 
ophthalmic treatment. 

Tlio recommendation set out the conditions as to representa- 
tion of tho Association on the central hoard of management, 
tho composition of an entirely medical executive committee ia 
deal with medical questions, and tho methods under which 
treatment should bo provided— namely ; 


(i) Clinics cstablislicd apart from tho practitioners _ private con- 

sulting rooms whero necessary, the practitioner receiving IDs. oa. 
per ciTso for opliUialmie examination and advice. ... 

(ii) Arrangements ■whereby ophthalmologists on the hst might 
SCO patients at their own private consulting rooms at fixed fioura 
on terms similar to those applicable to patients seen at climes, 
provided that the proscriptions wero forwarded to the optician at 

*' 7 iii)‘A“’conliniianco of tlio existing arrangements whereby an 
ophllialmologist upon tho list will only soo patients at ius own 
privato consulting rooms at a fco of one guinea, Pjyablo bj the 
Approved society, or, allcrnatively, will accept a fee o/ h“'f » 
guinea from the society, the balance being obtained fiom t o 
patient, provided that Hie proscriptions wero fonvaided to ilia 


It was also laid down that practitioners wishing to servo 
should bo chosen from the British Medical Association list by 
the Medical Executive Committee, that the central board oi 
m.anagemeiit should be responsible for all apppintmentsT hot 
as regards ophthalmologists and dispensing opticians, .and slioum 
make arrangements where necessary for a suitable service m 
salellito towns, and that the arrangements for attendance at 
sessions at the clinics must be primarily a matter for arrange- 
ment between the area ophthalmologists tliemselves. 

'The recommendation was agreed to, as also were^ fui le 
rocommendations approving the scheme of the Associa ® 
Dispensing Opticians, subject to the cbmmittce being sati.siica 
that the sclieme complied with the general principles just state , 
and another empowering the committee to approve any 
for the provision -of oplitlialmic benefit which salisn ics 
piinciples. ' ' .... 


Other CosDrrrrEE Business. . • 

On the motion of Dr. Dain, it was agreed to recommen o 
the Representative Body -that the Insurance Acts .Commi • - 
enlarged by the' addition of '-two ‘members- so as to aci i a 



FEI3. 25, 1928J 


.. . ..Current Notes . ;• 


r xvprLrMr-KT to tub 

LnniTlSn aiEDICAL JoUEKlt. 


63 


n rcarrangcniciit of tlio groups of .oroas, wlicrotiy Wales wouW 
become, a group by itself iustoail of being, as liiilierto, linked 


illii£ttn05 of ?8ranrIj£S an5 BiUisioits 


avitli Clicshire. 

It avas agreed that a History of the British Sfediral Asso- 
ciation should bo prepared, to appear about the time of the 
Assceiation’s centenary in 1932, and that Sir Hawsou Williams 
bo asked to eonsider the inaltcr, and to give his views on the 
best an'angcnients for the production of such a history. 

It was announced that Dr. Andrew Balfour, director of the 
London School of Hygiene and Tropical Jlcdieiue, had compiled 
a handbook dealing in full detail with the way in wliich to 
obtain education and qualification in public health and tropical 
diseases. Dr. E.alfour had offered to edit and give it to tho 
Association if tho Association would publish it. Tho Chairm.an 
stated that this was a most valuable and laborious piece of 
work, and ho thought the offer .should bo gratefully .accepted. 
Tho Council signified its assent by applause. 

Several committees prc.scntcd routine or interim reports which 
g.avo rise to no discussion. Among .these were the Puerperal 
Morbidity and 3rortality . Committee, tho Central Ethical 
Committco (on whoso recommendation an amendment of the 
regulations relating, to Important Xoticcs was agreed to), the 
Organization Committee, tho Privato Praclico Committee, the 
International Medical Sea Codo Committee, and tho Lunacy 
and Mental Disorder Committco. ' 

On tho rising of tho Council at 7 p.m., Sir liobert Bol.am 
expressed to tho Chairman, Dr. Brackeidmry, the wishes of tho 
Council for a successful and health-restoring voyage to South 
Afric.a as tho Association’s delegate at the South African 
Mcdic.al Congress to bo held in Bloemfontein ne\t month. It 
was apeed by tho Council that tho Chairman of the Repre- 
sentativo Body (Dr. Hawthorne) .should act as Chairman of 
Council during Dr. Brackonbury’s absence. 


?0riti5lj ^tcbical ^ssocmitott. 
CURRENT NOTES. 


— ConsuUIn£f Pathologists Group* 

Tke CoxiTicil of tho Britisli ^fcdical Association, at its 
mooting on Doeomber 14th, 1827, approved tho formation 
of a uroup of Consulting Pathologists, to comprise all tlicsc 
w Association (not heing momhers of tho 

i nolle Healtli Service) who are working in an institutional 
or piir ato pathological laboratory engaged in examining and 
repoi mg on specimens for clinical purposes. Tho official 
no ice summoning the first meeting of the members, of this 
roup or Fiiday, March 2nd, at 2.30 p.m., appears in the 
a joining column. It is hoped that all members eligible 
to inclusion in tho Group will make a special effort 


T ■ T, JlBsocIatlon’s Collection of Auto^ratihs. 
in December last we announced that tho British Jfedical 
f begun a collection of autographs which was 
T i+tlo 1 presented through Mr. Muirliead 

^ slaughter of tho late Sir 

Bennett, President of the Royal College ef 
Dn\ will ho gratified to hear 

nvpsnntl 1 through Mr. Muiihead Little 

n miro ^ lutorestiug series of autograph.s, including 
riini-fo 11 uianuscript of The Origin of Species by 
nntnr!r Council would welcome the gift of 

autographs of (n) persons who havo held high official 

4®^®';‘'*tion, (6) celebrated medical men 
with +lip°”mo^r 1 pei'Soiis in some way connected 

w,™i„ • r ri or medical affairs. Anv 

?rt'tho Itoariam'^" 

SuTrLr"’ and to the 

bnwpv have been printed ; they will, 

0 ^. t 'Vl" of the JouRX.ii,, but 

snWr°l y them. Any membm- or 

notlf,-; 'i^' '®."®”ts, post free, by sending a postcard 

Manatrpr "b Financial Secretary and Business 

Snarl ’w C l ^““-■•'tion House, Tavistock 

fmruhr’lw pc ' to receive the indexes 

S s y. ®.P.ihhshed should j intimate this desire,' .. 


Metropolitan Coitnties I^rancii : Westminster and Holborn 
Division. 

On Jamiary 19ih Piofo^j^or Frederick Hobday, C.M.G., F.R.C.V.S., 
iViiicipal of tho Royal Vctcriiiaiy College, London, road a paper 
before the Westminster and Holborn Division of the British Medical 
Associalion on “The value to the public and ourselves of an 
oflicieiit liaison between tho medical and veterinary branches 
of medicine.’' Tlic paper was illustrated by photographs and 
specimens. 

Commenting on the similaritie.s between tbo two professions, 
or rather, the two branches of tho same profession, Mr. Hobday 
pomlcd out that veterinary surgery had to be conducted under 
llio same antiseptic precautions as human surgery, but that 
generally— except in animals kept as pets — it was necessary for 
tho vclcrinarj* surgeon to consider his patient from the economic 
point of view as well as from the humane. If, for example, tho 
fractured limb of a horse would (ako three months to set, and 
then would leave Iho animal lame, it was probably better to 
destroy the hoi^c at once. Anacstholics were in use for animals 
in the same way, and with the same precautions, as for man. 
Cliloroform and A.C.E. mixture were the favourite general, and 
procaine and iiovocaifi tho chief local, anaesthetics. Cocaine was 
cxcellonf, but dangerous to use unless tho doses were accurately 
gauged. 

Dental and oral operations gave more trouble than most other 
operations because of the difliculty of working with an inhaler 
in position. It was interesting to note that the horse breathed 
Ihrongli (he nostrils alone under natural conditions, not through 
the mouth. Dental treatment was an important branch of equine 
surgery, especially in early adult life, as tho colt suffered greatly, 
)u«t as did cluldreu, from teething troubles. In dogs, too, 
teething fits and convulsions were often seen, while pyorrhoea was 
as common in old pet animals as in man. The latter disease was 
ccldom seen in liorsos and cattle; yet few pet dogs reached 6 years 
without signs of it. Ho believed that this was almost entirely 
a question of improper dietary — sloppy food and no hard bones 
or biscuits to clean tho gums and use tho teeth. The disease 
•was a .rave one in working sporting dogs kept un^er hardier and 
more natural conditions. Once the teeth had gone they could be 
replaced by artificial teeth— a rare, but not impossible, feat. 
X rays were of use for diagnosis, not only in dogs, but also for 
larger animals, particularly horses. Ultra-viclet rays,’ too, had 
proved valuable for ulcerating wounds and for certain forms of 
eczema in animals, as in man. 

Among the medical diseases there was much in common between 
buinan and vcterii^ary medicine. It ^yas in tbo prophylaxis of 
disease, however, that tho two branches came closer together.' 
In the horse group tho two most important diseases were glanders 
and mange — tho first of which had now been eradicated from 
Britain and the second would be, in a few years. Yet twenty-fivo 
years' ago nearly 2,000 horses were being destroyed annually 
because of glanders, and during tho South African war tons of 
thousands were affected. The Royal Army Veterinarj” Corps, by 
the use of mallein, had eradicated the disease from the British 
Array within tho first two years of the great war, and had kept 
it out ever since. Among cattle the most important diseases were 
tuberculosis and anthrax. Tuberculosis was too big a subject to 
discuss, but its eradication was being gradually undertaken on 
lines similar to the glanders campaign. Anthrax was exclusively 
a disease of animals and their products. Other diseases briefly 
mentioned by Professor Hobday were ringworm in calves, cats, and 
rodents, Malta fever in goats, and rabies and mange in dogs. Ho 
was thankful to say that rabies was now non-existent in Britain, 
but caiiiiic mange was still present, and not infrequently trans- 
mitted to man. Ho suggested that this, too,' like mango in tha 
lioi*se, ought to bo scheduled as a notifiable disease. 


Birmingham Branch : Nuneaton and Tamworth Division. 

An ordinary meeting of tho Nuneaton and Tamworth Division was 
held at Nuneaton General Hospital on February 8th. 

After preliminary business Mr. C. A. Raison read a paper, which 
was illustrated by diagrams, specimens, and radiographs, on 
surgical ’conditions of tJio biliary tract. Following some intro- 
ductory remarks and a short sketcli of the anatomy of tlie biliary 
tract and the function of the gall-bladder, Mr. Raison entered very 
fully into tho pathology of cholecystitis and cholelithiasis. In dis- 
cussing the probable loute of infection he referred at some lent^th 
to tho recent work of Wilkie at Edinburgh, which appeared to prove 
that the blood stream was by far the most usual route and a 
streptococcus mucli tho most frequent causal organism. Dealing 
•Nvith symptomatology, Mr. Raison emphasized the usualiy very lon5‘ 
prodromal stage of' dyspepsia, and suggested that if patients*^ cbul3 
be seen early in this- stage- medicinal remedies would sooner or later 
bo discovered which would often obviate tho nece««iitT for a 
cholecystectomy. Speaking of cholecystography, he diiussed the 
striking advance in radiodiagnostic investigation Hy the intro'duclion 
of the tctraiodophenolphthalein method,- but-staled his conviction' 
that this method ivas far from being freo from ris£- Kl looked' 


64 Feb. 25, 1928] 


r f!VPrjXiiF.i;T to TKt 
LlsciTiKu Medical Joudmal 


Meetings of Branches and Divisions. 


forward to tlio time when some Ic.'-s toxic cliomical would be 
discovered to supplant this salt as, in pyelography, soduiin bromide 
had supplanted the irritating silver salts. , , , 

Mr. Itaison compared the operations cholecyslolonn and cliole- 
cvstectomy, and referred especially to some of the difhcultics and 
dangers of the latter operation— for example, haemorrhage' from the 
cvstic artery, damage to the common bile duct, leakage of bile into 
the lesser sac or into the general peritoneal cavity, l.aematemcs.s 
and melaena. He referred to the slow convalpseencc often noted 
after cholecystectomy, and to the occasionally disappointing results, 
and siiKg<^ted the probable causes. . , • r 

In concluding his paper Mr. Eaisou emphasized the following 
points ; (1) Cholelithiasis is probably but the cnd-rcsiilt of a long- 
standing cholecystitis. (2) Cholecystitis is probably secondary to 
some other infective focus elsewhere in the body. (31 Cliolccyslilis 
probably starts in most cases in the walls of the gall-bladder, and 
not from within. (4) In most cases, when gall-stones have been 
formed, the walls of the gall-bladder cease to be of any functional 
value, but rather are encumbrances to the cholesterol metabolism. 
(5) In cholecystography we have a valuable adjunct to early dia- 
gnosis, but a certain risk is attached to it, and it must he n.sed with 
raiition. (6) While, at the moment, cholecystectomy probably otters 
the best prospects in the treatment of cholecystitis, it is to bo hoped 
that the future will open up means of curing the disease and yet 
at the same time preserving a useful gall-bladder. 

discussion followed, and a hearty vote of thanks was accorded 
to Mr. Eaison for his interesting and suggestive paper. 

After some general discussion it was agreed to hold the annual 
dinner at the Newdegate Arms Hotel, Nuneaton, on May 9th or 
I6th, and n small committee was appointed to make arrangements. 


East Yobk anp Nonxn Likcolu BaAifcn ; East A'onK Divisiok. 
The East York Division held a well-attended dinner on January 
27th, to which Professor D. P. D. Wilkie of Edinburgh came as 
..itnlrmun Tlr HlATTivsnu AIackav. Tpnlvinp to llie 



represented in tne oauge oi me AAssouiatiou, uhai oneivo a suggestion 
with regard to its symbolism. He showed how the two Greek terms 
for the serpent referred to its unwinking eyes, M'hich seemed to 
quality it to act as a guardian, whether of fruit, of a fountain, 
or of a fleece, as in different stories. Dr. Mackay remarked that 
similar functions were performed by the British Medical Association 
and by medical practitioners in guarding the profession and the 
publio' generally from dangers. He proceeded to suggest that the 
reason for the adoption of the serpent ns the emblem of medicine 
was its connexion with the celebrated “ Python,” which was 
destroyed by the infant Apollo with his fii-st arrow; he thought 
that tile staff round which the serpent was twined might represent 
this arrow. 

Essex Branch : South Essex Division. 

A LAROE meeting of the South Essex Division took place at the 
Queen’s Hotel, Westclifl-on-Soa, on January 10th, when Mr. E. C. 
Hughes of Guy’s Hospital gave a most interesting address entitled 
" Our surgical mistakes.” Various membois took part in the 
subsequent discussion, notably Dr. Sells. ' On the motion of Dr. 
Cleveland Shith, seconded by Dr. Floyd of Grays, a hearty vote 
of thanks was accorded to Mr. Hughes for his address. 

On February 14th Dr. A. S. Woodwauk, physician to the West 
minster and Koyal Waterloo Hospitals, addressed a very full 
gathering of members on the modern treatment of diabetes. The 
address was listened to with great interest by all present. Dr. 
Hocking, clinical pathologist to the Westminster Hospital, gave a 
practical demonstration in the modern methods of performing the 
blood sugar tests, which was very much appreciated. The warm 
thanks of the meeting were accorded to Dr. SVoodwark and to Dr. 
Hocking on the motion of Dr. GaosvEXOit Hinks, seconded by Dr. 
VicToa Hodgson. 


strablo pathological cause, the possibility of artefact should always 
vcceivo consideration. An inquiry should always be made into the 
patient's employment and hobbies, aiid the question of drugs and 
local applications ought never to bo omitted. A patient with 
pustular acne wliich refused to yield lo ir-ray treatment was later 
found lo bo taking bromide pi escribed by a colleague for some 
functional form of dyspepsia. On this being omitted the acne 
immcdiatclv cleared up without further application of x lays. In 
writiim certificates for cases of ringworm of the scalp the wording 
should not be too dogmatic, and the word “ cure ” might well be 
replaced by some such periphrasis as that, after repeated examina- 
tion, no evidence of tinea capitis could he found. \\ hen the 
diagnosis was in doubt the best plan was to send the patient away 
for a week or ten days, with strict iniiinctions lo be isolated and to 
applv nothing to the scalp. The signs of tinea wqiild be very 
dclinitc bv the end of that lime. Eingworni infections m o her 
sit nations' were discussed in some detail, and it was asserted that 
lliis type of cutaneous infection probably gave rise to more errors 
in diagnosis than anv other. at the present time. • 

Tlic paper was highly appreciated by those present, and a rerj 
hearty vote of thanks was accorded to the lecturer. 


Metropolitan Counties Branch : Lambeth ano Southwark 
Division. 

A CLINICAL meeting of the Lambeth and Southwark Dii-ision was 
Ld“ rrebruar/ Bib at the Belgrave Hospital for. Children 
rianliam Road S'W.9. Dr. N. H. Hill showed many interesting 
mediia" cases, ’the ciiicf being: (1) a boy, aged 6, who had been 
. , I r-_ .i:-betcs for the past three veal's, and uos 
(2) a boy, aged 7, who presented charac- 
-• three cases of congenital. licai.t disease of 

varying severity; (4) a microcephalic idiot; (5) a ghl with cerchra 
pal4’; (6) d "'>1'' liibei-culous glands of the neck. 


Metropolitan Counties Branch : Tower ^iLns Division 


regurgitation;. (3) 
members participated. Di 
moved a vole of thanks to 


Metropolitan Counties Branch : City Division. 

A MEETING of the City Division was held on February 6th at the 
Metropolitan Hospital, when Dr. Philip Hamill was in the chair 
and tliirtv -eight mcmbei-s were present. 

Dr. H.'C. G. Seuon read a paper entitled “ Diagnostic pitfalls in 
dcrmalologv,” in which ho emphasized the supreme importance of 
coricet diagnosis in two diseases ivith cutaneous manifestations — 
namely, variola and ■■ Be"' - rvere dangerous for the 

individual and might serious consequences in 

the patient’s famfly i . . The other niistakc.s in 

diagnosis ol' dermatological conditions affected only the indii'idual 
patient and the doctor’s reputation. As illustrations. Dr. Semon 
oted the case of a young mineralogist, who, having been put to 
bed and dieted for eczema for six weeks, eventually succeeded in 
demonstrating the acarus of Ecabi« from a digital burrow on a 
slide under his own microscope. One lady who was treated -with 
X ravs for two years tor alternating prnrifns of the amis and vulva 
was cvcntuallv proved to be suffering from tinea cruris. Almost 
.anv dermatosis could occur on a syphilitic basis, and the Wasscr- 
mami lest was onlv of really positive value when it supported the 
clinical findings, or in a case of suspected secondaiy syqihihs, when 
it was nenative Self-inflicted eruptions often gave rise.fo errors 
of diagnosis. Dr. Semon suggested that .an artefact should be 
suspociod when the eruption was of no recognized patliological type, 
ami when come of its elements piesented straight line bordcre or 
angular contours. The civil cases lyere usually young girls, will, 
prSnounced hvstcrical stigmata, such as hcmianacstliesia contrac- 
turi-s. or paraplegia. In two cases quoted the self-niutilations had 
ullimalcK- involved amputation through the shoulder-joml. IVhen 
inivaclablc ulceration occurred in such subjects, •without anj aemoii- 


Midland Branch : Nottingham Division. . 

the treatment of during the last- hundred 

Professor Wjum „ “ived reduclion in most infectious 

years there increased, and w.as the most wide- 

•fevei-s P»— f ’•liaTRses ln iRjl-Js. This uhs 

spread and fatal ot aii vortcirflpfl as a conlacxous disease, and nof 

bccnusc it had not bee «ardcd_^^^^ infection: The proof of 

precautions bad been i; i ^ho time had come wlicn 

Uugion-;ncsshadbecncs^ andpatieuN 

•it shonid be Ves ^diphtheria, typhoid- fever, or 

bo jsohvicd njc Irealincnt of pneumonia il nas 

ccrebro-spinal of imnumity, .md the hop.e of a 

necessary orlnlitv lav in specific Ibcrapy: Ibis must 

reduction of the , 'since its object was to control 

be started as caidj ns ,,and. and to prevent tlio 

Iho infection mg Earlv diagnosis was thcvefoic 

development of was' not made until consolidation was 

necessary,; too "em'lv svmptoms should, lead to 

preseuL. whereas the St. iknig.^eau ^ 

recognition of the emergency in which delay migh 

Si 

”ird\li^“n!“fmimitydegonded^^^^^^ 

niost important weic Uic n^lf'r^vise fatal dose of pneumo- 

.I;-.™;-'. bSa. 

pneumonia there ‘ ,i this lack of icsisling powei 

tho blood of. the patients, and "‘treatment there was 

associated wilh a septicae • acemes ' The various forms 

lXTthrpredt«™“of proi^^^^^^ 

^^llKl’s t’reSmm of P--^ 

;^rso"n'r^vf.o“;^o^sSJe.f speciL^ '.J^a^heSo’/e fi^in 

pneumonia specific antibodies uoie absent, . ^ .i^rgc numbci of 

Soidd be saf&y used in the '^’tbe act iSn of vne«n;» 

temperature charts were shown to \Vul results obtained 

in various stages of pneumoma. T'’" '“"f umiicd to P"™"'"’”?,’ 
by tbc early injection .of '^'L^tims hi which a diagnosis 

} but could be obtained in olhei acute . pcnsitircd. Cba 

I could bo made early and before the pahcnl was sc 




66 Feb. 25, 1928] Bill for Control of V eneroaf Dtseaso In Edinburgh. [ Unmsn’^'MVuji^ jocitsit. 


Association Lecture on the nsc of iiUra-violet rays in general as 
ivcll as in skin disease. It is lioped that there will bo a largo 
attendance of members.' 

IMetropolitan Counties Branch : City Division.— The next 
meeting arranged by the City Division ivill be held at the Metro- 
politan Hospital, Klngsland Road, E., on /Tuesday, March 6th, at 
9.30 p.m. Mr. Norman Patterson will read a paper on ear 
trouble in general practice. 

Metropolitan Counties Branch : Eihchlev Division. — A meeting 
of the Fincldcv Dirision will bo held at the Finchley Memorial 
Hospital on Tuesday, March 6th, at 8.45 p.m. Dr. J. tV. McNcc 
will discuss the clinical features of thrombosis of branches of 
coronary arteries. 

Metropolitan Counties Branch : HAiiPSTEAn Division.— A meeting 
of the Hampstead Division will bo licld at the Hampstead Gcncial 
Hospital on Thursday, March^th, at 8.30 p.m. Dr. G. A. Sutherland 
will discuss the heart in acute infections. 

Metropolitan Counties Branch : liEwisHAM Division,— A mecling 
of the Lewisham Division will be held at the Town Hall, Catford, 
on Tuesday, March 20th, at 8.45 p.m., when Mr. AVansoy Bayly \yiH 
deliver an address on the general practitioner and the prevention 
of venereal disease. ♦ 

Metropolitan Counties Branch : St. Pancras Division. — A 
mcolm» of the Si. Pancras Division will be held at the British 
Medical Association House, Tavistock Square, AV.C.l, on Tuesday*, 
March 13th, at 9 p.m. Mr. Sidney Boyd will give an addre.ss on 
the diagnosis of surgical emergencies occurring in general practice. 

Metropolitan Counties Branch ; Souto-AYest Essex Division. — 
A meeting of tlio Soutli-AA^est E<;sox Division will bo held at the 
AYliipps Cross Hospital, Leytonstone, on Tuesday, March 6th, at 
3.50 p.m. Dr. J. C. Muir, medical superintendent, will give a 
clinical demonstration. 

Midland Branch : Chesterfield Division. — A meeting of the 
Chesterfield Division will be held at the Maternity Hospital, 
Chesterfield, on Friday, March 9th, at 8J.5 p.m. Mr. Graham S. 
Simpson will discuss the value of operations. 

Southern Branch : Jersey Division. — ^The next meeting of the 
Jersey Division will be held at the General Hospital on Thm-sday, 
March IStli, at 8,30 p.m, Mr, C. A. Halliwcll will read a paper 
on the treatment of peritonitis. 

Surrey Branch • Croydon Division. — At the meeting of the 
Croydon Division at the Croydon General Hospital on AVodnesday, 
March 14tli, Dr. J. AA'. AA’ayte will give a lantern dcmoiistiiition 
on liaomalurin. U will be preceded by tea at 4 p.m. 

Surrey Branch : Guildford Division. — A meeting of the 
Guildford Division will be held at the Royal Suircy County 
Hospital, Guildford, on Thursday, March 1st, at 4 o’clock. Sir 
Thomas Lewis v.*ill give an address on the rheumatic heart in 
cliLldi'cn. Tea will be served at 3.45 p.m. 

Yorkshire Bp.anch : Doncaster Division. — A meeting of the Don- 
caster Division will be held at Parkinson’s Cafe, High Street, 
Doncaster, on Thursday, March 22nd, when Professor G.. Lovell 
Gulland, Edinburgh University, will give a British Medical As«ocia- 
tion Lecture on the significance of heart murmui*s. Dinner, at 
8 p.m., will precede the lecture. 

Yorkshire Branch ; AA'akefield, Pontefract, and Castleford 
Division. — A meeting of the AA’^akeficld, Pontefract, and Castleford 
Division will be held at the Strafford Arms Hotel, AVakcficld, 
on Thursday, Marcli 8lh. Dr. R. A. Vealc, physician in charge 
of the skin department. General Infirmarj*, Leeds, will give a 
lecture on common skin diseases. Supper (3s.), at 7.45 p.m., 
will precede the lecture. 


BITJ. FOE THE COXTEOL OF VENEREAL DISEASE 
IN EDINBURGH. 

Tills hill, which lias ah’cailv hocn laid hefore Parliament, 
asks for the ' eonfcrinent of “ furtlier powers iiiioii the 
Corporation of tho City and Royal Burgh of Edinburgh 
in relation fo venereal diseases and for otlier imrposes.” 
It eoiisists of four sections, three of which arc taken up 
witli tlio preamble, short title, and expenses of the Act, 
Section 3, wliieli is the operative section so far as venereal 
disease is concerned, is printed below. 

After tlie hill as presented to Parliament had been put 
iiito type we leeeived a pamphlet entitled “ Statement for 
the Corporation,” in wliieh considciahle alterations aro 
jiroposcd. These alterations aro included in our leprodnc- 
tioii of the hill : omissions from the original hill are placed 
wilhin stpiare brackets; additions aic printed in italics. It 
will he noted that the original Snhsi'ction (3) has been 
deleted; that Subsection ( 4 ). with alterations, becomes 
(5), and that new sVihsections have been added. 

5. V nun cl Dnnnc. — (1) ■When the Jledic.d Officer of Health 
lias reason to believe that any pei-son is suffering from venereal 
dhe.is- and liable to infect oilier persons and such person 


neglects or refuses to undergo treatment by a medical pnicli- 
ticner or at a treatment centre for venereal disease established 
by the Corporation {hereinafter referred to. as “ a troalniciit 
centre ”) or to continue .such treatment until he is cured or unlil 
it has been certified as atteinientioned that lie is unlikely to 
cause infection the Medical Officer of Healtii [shall lie ontiliyd 
to] may give notice in writing to such person requiring him 
within a reasonable time to ho specificxl in the notice to consult 
a medical practilioiier or to attend a treatment centre and 
(unless [he produces] within a time to he specified in the 
notice he 'proftitrek to the Metllcal Ofjicer of Health a certificate 
from [such] ei medical practitioner that he is not suffering from 
venereal disease) to undergo treatment by a medical practi- 
tioner or at a treatment centre until certified by the medical 
practitioner or the Medical Officer of Health to he cured or 
unlikely to cause infection. 

(2) 'Where the ))cr.son believed to he suffering from venereal 
disease is under the age of sixteen the notice reterred to in 
the imnicdiatelv preceding subsection shall he given to one of 
tho parents or 'the guardian of such per.son and such parent or 
guardian shall be responsible for carrying out any requisition 
of such notice. 

[(3) ■Where it is certified by the Jledical Officer of Health 
that a pcihon is suficring from venereal disease and liable to 
infect other persons and that it would he expedient for tlio 
purpose of preventing the spread of infection that such person 
sliouhl he removed to and detained in a hospital or other place 
provided hv the Corporation for the treatment of venereal 
disor.se (hereinafter referred to as “a hospital ) it shall bo 
lawful for aiiv macislrate or .inclge of police on the application 
of the prosceiitor in tho police court and on .production ot siic/i 
cerlifieale or on being satisfied by medical evidence of tlio 
ncco.s.sitv or desirability in the public interest of the removal 
and detention to grant warrant to remove such person to a 
hcspilal and to detain him therein until he is certified by tbo 
MtAical Oflicer of Health or a medical practitioner to Jje ‘'U"" 
or iinliltelv to infect other persons Rrovided that the Loi- 
noration siiall in every case cause the removal and detention to 
he effected without cliargo to the person removed Provided 
further lliat proceedings in the police court under this section 
si al he' conducted in private and no person except the peiso 
to whom the pioceedings relate the IMedical Officer of Health 
and Xi meSicid witnesses and the legal representatives of 
the CorporaXi and ot such person shall he present without 

the leave of the court.] . . « • 

rf4n (5) Wliere niiv child under the age of sixteen is suffering 

shall 10 ° entitled to give such parent a notice in writing m tho 
terms referred to in Subsection (1) of this section.] 

in It •‘hu'l hr. m the option of any pcifon to nhom a not tee 

hi^ias^tttl-en mich steps us he considers reusonahk for the 

(7) Proceedinys in regard to an 

proceedings under Section oi of the Pn i venereal 

Act JS97 where such proceedings relate to a case f 
disease shall he conducted in private. lorrc at 

(S) The provisions of Act nnlc‘> 

the c:x:pirafio 7 i of five years from the pass nj j j 
the same shall have been continued by Order mai 
Secrelari/ of Stale for Scotland which Order 
empowered to nial.-c. . ,..ii,ie.s,sion 

[(6)1 (.0) For the purposes of this ■’\'-t.„eic.al 

venereal disease ” has tho same meaning as ,„.-,r.titioner ” 
Uisc-a.se .-^ct 1917 and tlu; expression mcdic.il p • 
niFans a erud luediial practitiouev. 


Feb. 25, 1028] 


tiava! and Military AppoIntmontSi 


r svptTjT^itest to tot 

LBniTisir SlEDiCAi. JounsiL 


67 


(Eomsponticttci. 

Orffiiiiizntwji <’/ t!‘C Profcfiioii. 

Sm, — I nm asking my Division to amsidor the following 
motion, and wonld ask other Divisions to give tho matter their 
earnest llionghl. 

" That the oiganization of tho profession on present tines is 
tcjidinp to tlio depreciation and degradation of tho general 
practitioner.” 

Hospital provident societies and pnhlic clinics aro rapidly 
destroying the confidence of the community in tho knowlcdgo 
and skill of the general practitioner, and diminishing his field 
of work. 

Some alter.stion in hi.s field of work may he necessary in the 
fnrther efforts of tlie commnnily to ohtaiu tho host medical 
service, hnt immediate consideration should he given to the 
future position of the genci-al practitioner in the final scheme. 
—I am, etc., 

Southciul-on-Srn, Fob. Mill. FEIiniNAND Rees, M.D. 


Driifjs and Appllanccf Jor Jiittircd Patiatts. 

Sir., — Jlay I ask space in the columns of the SurrLEJiENT to 
give publicity to an example of the way in which an iiisnraiico 
practitioner is h.ampered in treating his patients by officials 
with no practical knowledge of tho issues? 

I spent considemble time and trouble in leaching two of my 
panel patients suITering from diabetes to carry out their own 
tests for sugar. The advantages to tho patient arc obvious 
(vide The Pinbctic lAje, by R. D. Lawrence). I ordered them 
Feliling’s solution for this purjrase, whicli w as duly supplied by 
the chemist. Some time afterwards I received a letter that 
Fehling’s solution was not “on the list,” and had been dis- 
allowed. And yet it is st.ated that “it is the duty of tho 
iiisuraiico practitioner in attendance to see that all appropriate 
and nccessarj" drugs and appliances aro available for the needs 
of his patients ” ! — I am, etc., 
loniinglon. ■natils, Feb. 15th. XevillE M. GOODMAN'. 


ilnbal anl> iRiltlarg ^ppoiiitincnts. 

EOr.tL .V.W.tL .MEDICAI, .SERVICE. 

SurjTon Commander A, DavJd>on is plaoetl on ilio retircsl li>t witir the 
rnnk of Surffcnn Capt.ijn. 

Snrjjt'on CVimmander F. J. Conans (o the Vrcfid^nt. 

.Surpeon Lic^ifenants If. ir. Fit-licr to the AfhU\ E. V, Harncs to (he 
” Quarters, Dartmouth. 

» A •‘'ntennl os Surpeon Lieutemaut for fthott set^ ice am! 

oppointcKl to the T tciory for Ifaiilar Ifospital for cour'-e of instruction. 

^ ItOYAL AIUIY AIEDICAL CORPS. 

DeS.O.. liavlup nttaiiiod Oic apc for 

*'ctiros on r«*tired jiay, and is prantc<l the rank 
^Oi, IS'S (MiliNtltute'd for nolillcation in (lie London 
(ftizftte ot January 27th, 1928). 

fu f»e Major vi'ili prcccdcuce next below 
Captain C. IE C. B%me to be Major (prov.), 

^ ^'ilroy arc Rcconiletl un<Irr (he pro- 

\ p. Article 2^ Royal WairaiH for I’av and rromotinn, 1926 . 
t; temporary Lieuteiiant.’ 

_ ro be Lieutenants oil imilmtion: C. L. Dai, C. T. U Aielier. D. R. . 

0 r-l i^"ycr, K. JlcXcill, R, Burke, V. \V. A. 


Agncw,‘j. C, Gilroy. 


Gnr.iT Yaiuiol'th : Gexeril IIOi'nTAL. — ^House-Surgeon (male, unmarried). 

* Salary JL150 per atinum. 

Ilr.ttTi'OUD COUXTV JIo^iriTa.— (1) Resident Surgical Ofilccr. (2) House- 
rhj-sicinn. Salary £250 and £150 per onnura respectively. (3) Honorary 
.AiiacstlictihiR. 

Hospital pou Coxsumptton axd Disfasps op the Chest, Bronipton, ’S.ML — 
Rcfidcnt Jledical Ofllcer. Salary £350 per annum. 

Hospital ron »Sick Chilhken, Great Ormond Street, M\C.l. — (1) .Assistant 
Rathalo^ifit and Re-sc.arcli Fellow; Ralary £450 per annum. (2) Part-time 
Junior Casually OfRcer for six months (non-resident). Salary £75. ' 

Knrrimixo \xd DisniicT Gexeril Hospital. — Resident Medical Officer 
(male). Salarj* at the rale of £175 per annum. 

JiiMcrrit Boiitu qp Guoinuxf^ — Mole Junior Assistant Medical Officer for 
tho Lamhclh Parish H(>^pital. .Salary £200 per annum. 

XntMiXCTON Spa : Warnepord GEXERtL Hospital. — Rc.sidcnt House-Surgeon. 
Solar}* £165 per annum. 

LEicESTi:r.£iiiRC County Council. — A ssistant Modical Officer for Matemily 

. and Child Welfare and .\s:si^tant School Medical Officer (female). Salary 
£600 per annum. 

Lintoln Gnr .and Couxty Borough. — Medical Officer of Health. Salary 
£1,000 i>cr ftnnnni. 

London XfiHPnRANrn Hospital, H.-impsleud Road, N.W.L — Resident 3Iedical 
Oflieer. Salarj* nl Uio rato of £175 i>cr annum. 

Miller General IIospitil, Greenwich Road, S.R.IO. — (1) Honorary Fliysician 
to Chihlren’iJ Depaitment. <2) Resident Jledical Officer. (3) Housc- 
Physlcinn. Salary for (2) X250 per annum, and for (3) £125 per annum, 

XORTiitMPioN General Hospital. — (1) House-Pliysician. (2) Two House- 
Surgeons. (3) Two Assistant House-Surgeons. Salary at the rate of 
£150 per annum caeli. 

Norwich : Jenny Lind Hospital for CinLDREN.— Resident Jledical Officer 
(male). Salary £150 per annum. 

Nottinchah Guneril Hospital. — House-Surgeon. Salary at the rate of 
£150 a year. 

Perth: James Murray’s Royal .Asylu^t. — A s-sistant Physician (male, 
unmarried). Salary £300 per annum. 

Plyniouth : Homoeopathic and Geneilal HosniiL.— House-Surgeon (male). 
Salary £100 per annum. 

Rochford Union. — A’- sis'lant Resident JIcflicaT Officer (Ladj) at the Poor 
Law Hospital. Salary £200 per annum, rising to £250. 

Royal Minoikter L'hildren’s Hospital, Pcndlebury. — (1) Resident Medical 
Officer. (2) Resident Snrgic.a! Officer. £3) Assistant 3Icdical Officer 
<nou-rcsident). Salary for (1) and (2) £125 per nnnum, and for (3) £150. 

Roy.al IVaterloo Hospital for Children, M'aterloo Road, S.E.I.— Honorarv 
Medical Registrar. 

St. Petcr'.s Hospital for Stone, etc., Henrietta Street, "W.C-S.— Honsc* 
Surgeon. Salary at the rate of £75 per annum. 

Salford City.— Senior Orderly at the Corporation’s Tenereal Diseases 
Trcatmcul Centre. Salary £4 per ivcek. 

Salisbury: GiL\ERAL7Nnr.M.ARY.— House-Surgeon (male, unmarried). Salary 
£150 per annum. 

Samaritan Frfj: Hospital for IVomen, Marylebone Road, X.B'.l,— House- 
Surgeon. Salaiy at the rate of £100 per annum. 

Seamen’s Hospital Soouty.— Assistant Medical Officer at tiie King Geoi*ge*3 
Sanotorium for Sailors, Lipbook. Salary £200 per annum. 

Southampton : Royal South Hants and SouniAMPiaN Hospital.— Casualty 
Officer. Salary £120 per annum, rising to £130 on ■appointment as 
Junior IJouse-Surgeon. 

Torquay; Torbay Hospital.— Honorary Medical Officer in charge of Ear, 
Xo?e, and Throat Department. 

West Ham Union.— .\ ssistont Medical Officer at the "Whipps Cross IIo>pitaI. 
Salary £300 per annum, rising to £350. 

IVest Lo?hx)N Hospital, Hannnersmilh Road, W.6. — (1) Honorary ^fedical 
Registrar. (2) nousA'-PhysIcian. (3) Two House-Surgeons. (4) Honorarv* 
AiiacsUietist. Honorarium for (1) £100 per annum, and salaiy at the 
rate of £100 per nnnum for (2) and (3). 

WiLLESDUN JIu.NiciP.AL Il 0 STiT.\i,— Resident Medical Officer. Salaiy £150 per 
annum. 

Certifying Factory Surgeon.— Tiio appointment at Sutton-in-.Ashfield 
(Notiinghanithipe) is vacant, .applications (o the Cliief Inspector of 
Factories, Home Office, IVhitehall, S.AV.l. 

3IED1CAL REFERrE UNDEP. THE WORKMEN’S COMPENSATION ACT, 1925, for the 
Orkney District (Sheriffdom of Caithness, Orknev*, and Shetland). 
.Applications to the Private Secretary, Scottitsh Office, 'Whitehall, 
London, S.W.l, by JIarcJi 14tli. 


vi- n T- . -'lit ronCE MEDICAE SEHVICE. 

Thf w AI.C., to B_\.F. Station, Snrtli Weald, 

ill the vault »tSf«l -*^r are granted permanent commiiMons 

VuTne Offiee?'^ “"'t > Smith, 

tion^ Dbl Sai'im,'*' , • ''*?'v‘‘"i>n to remain at Seliool of -Army CVopera- 
iiMlfie. I- W <■’ J'-'-T- li-tliridge. ni prcrmnali 

Ifftlton, ’ ■ ’ it- F. McGovern to Mcalicld Training Depot, 

TERRITOniAL ARMV. 

Lieut -Cotniiel F T ■''I’"' SlmilWL CORrS. 

■Rererw S OffleeJ; Th ''■™' General List, R.A.M C., T.A., 

fWeldO PJulfi Ami ’,/” ^*** £*cu(pnaut-C«lonel and to cuinmnitiJ the ISBth 

(Brevet CO, one,) C. L. Isaac. 

MaioVs''’'R''Vtr,l,?' Colonel. 
rVnk-\viHi T.D., rF.sigiii Jiis eoniniHsiou and retains bis 
Ylaior n PK^crilHid uniform, 

and regains ^li^'r-ink v m attained the ago limit, is retired 
r-intain ’• '’/il to woav tlio prescribed uniform. 

Uiptam (Bre\ct Major) h. h, GilKou, D.S O to be 3Ujor. 

fEuSivireiffor enr7'~F' '’C Licuteimiit, .laniialj 20th. 1925 

(Eubslit.ded loi notification m (he London Gazrlle, Janiinrv 39lh, 1926). 


A'AGANGIES. 

Rm'iol^i'h.nfat Dm 'rate S'iuS^er f (female), 

® ilousc-Snrgeons. (2) nomse- 

Cliief Assistant ifcdical Officer of Hraltl 
o^i®****^?' Officer (male). (2) L.ndv As>i».tani Mcdiea: 
5 for ( 1 ) £800, rising to £1.000, and for ( 2 ) £750. 

.Alice lIO-spinu-TJunior Resident Housc-Surgeor 
t. c, unmarried). Salary at the rate of £100 per nnnum. 


This list of vacancies is compiled Jrom our advertisement columns, 
where full particulars will he found. To ensure notice tn this 
column ndvertneme7its must he received not later than the first 
post on Tuesday morniny. 


APPOINTMEOTS. 

Hern, J. B. B., 3I.A., B..M., n.Ch.O.\on., 3r.R.C.P.Lond., Ont-patient 
rii\.-ieian to the City of London Hospital for Diseases of the Heart 
ami Lmig^. 

JLarsh-ALL, John, Jf.-C., Sf.B,, Ch.B.GIas., F.R.P.P.S., D.0.3r..S,, Visiting 
Surgeon, Gla«gOAV Eye Infirmary. 

St, Thomas’s IIospit.al. — (’mualtu Officers and Resident Anaesthetisu ; G. C. 
Babington, M.B., B.S.Lond., M. D. Nosworthv, M.R.O.S., L.R.C.P., R G 
ApUuiipe, M.B., B.Ch., C. G. IVimlsor, M.B., B.Ch., F. J. ililward. 
M.B., B.Gh., A, H. Lankestcr, 3LB., B.Ch., J. A. Hartlev, M.B., B.Cli., 
A, I*. FaiTnrr, 3[.R,C.S., L.R.C.P. Resident Eousc-Pht/gicians : R. Oddie, 
3T.B., B.Ch., J. B. George, M.R.C.S., L.R.C.P., G. R. N. llenrv. 

-D t> o IT T.' -M IJ Tim, Z7., >. n... D7. „ n'L 


M.B.. n..S., H. K. Goailh.v, M.B., B.CIi. Iten'ilcnt Hoiisr-Phynicittn (fir 
Cltittlren): .1. B. Gniinell, M.R.C.S.. L.R.C.P. JlpxuJcnt Honf^r-Surneons : 
C. L Tiicl-ett, M.B., B.tHi.. G. E. Parker, M.B., B.Cll., G. M. Fitrgjbbon, 
M.n.C.S., L.R.C.P., R. W. Butler, M.B., B.Ch. Rf^iilciil Honte-.Vi;r7coi;«.- 
(Enr) .1. C. D. Carothoiv, JI.B., B.S. ; (Throat) R. G. Thomas, M.R.C.S., 
L.R.C.P, ; (Ortliopacdic) It. W, L. .Bay, M.B., B.Ch. Obttrtric Uausc- 
Pliil^icianit: (Senior) ]1. Blaxill, M.B., B.Ch.; (Junior) G. W. Walker, 
11.11., B.Cll. OphtUahulc Hoii^r-Sariji-ons: (Senior) J. F. L. Barnes, 
Jt.R.C.S., L.R.C.P. ; (.Iniiinv) T. Edmunds, M.R.C.S., L.R.C.P. (’/„>? 
.Iw/efniit, fihit I’lhtical : (Oplitlialmic) R. G. Ilodder, A!.R CS 

L.R.C.P.. 31. R. Dovie, M.R.C.S.. L.R.C.P.; (Ear) 11. 1. Matrincr 
F.R.C.S.Ed. (Oiiet Assidant), D. B. ytimihy, M.R.C.S., L.R.C.P., R M 
Wilcox, M.R.C.S., L.R.C.P.; (Throat) U. F. A. Xcilson, F.R.C.S. (Ciiiet 
Assistant), .1. F.' Stent, M.I1., B.Ch.. F. L. n. Volier, AI.ILC.S., L,R C P 
(Skin) II. T. Barron, M.l). (Chic, Assistant), A. Bevan, 3 I.D., IL g! 
llarver, 3LR.C.S., L.R.C.P., .1. E. Saville, M.R.C.S., L.R.C.P.; (Dent.ll) 
P. Lloyd Williams, .M.R.C.S., L.R.C.P., L.D.S. (Chiet .Assistant): 







STIPPIjEMENT 

TO THE 

BRITISH MEDICAL JOURNAL. 

LONDON, SATURDAY, MARCH 3itD, 1928. 


COTS’ TENTS. 


rACE 

Private Moaical Practice. Ilv E. llo^vLA^•n roniEcciLL, 

M.H., n.S .' 69 

MEETINGS OE BKANCHLS AND DIVISIONS 70 

ASSOCI.\TION NOTICES : 

Table or Dates 71 

BnAsat AND Division Meetikgs to be Helo . 71 

BOOKS ADDED TO THE ASSOCIATION’S BIBUARV ... 72 

COnnESl’ONDENCE 74 

ASSOCIATION INTELLIGENCE AND DIARY 76 


FACE 

BRITISH MEDICAI, ASSOCIATION. 

Annual Meeting at CardllT— Provisional Programme; 


OniiEF. or BosiKEiS 73 

The Sctentiitc Sectioxs 7i 

NAVAL AND MILITARY APPOINTMENTS 75 

VACANCIES AND APPOINTMENTS 75 

DIARY OF SOCIETIES AND LECTURES 76 

POST-GRADUATE COURSES AND LECTURES 76 

BIRTHS, MARRIAGES, AND DEATHS 76 


PRH^ATE MEDICAL PRACTICE. 

BY 

P ROWLAND FOTHEUGILL. M.U.. B.S. 


The Roprc.scutative Body of the British ^lodual As-^oc-iu- 
tion in July Inst year adopted the following rosolulion: 

That the Representative Body, viewing with consideinblc 
concern llic in.<>idioiis inroads contimmlly being made on 
private medical practice under the auspices of the State, 
voluntary bodies, and others, and being of opinion that this 
ib not only dctnrnental to the hUcrcsls of the individual 
members of the medical profession, but uUinmlcly to all 
clas'ies ill the community, instructs the Council to watch 
all such developments and actively to interest it«elf in safe- 
guarding private practice amongst all groups in the medical 
profession, and to develop througli the' Branches and Divisions 
coser co-operation with the local medical luofcssion for (hat 
purpose. 

riiis resolution very incompletely voices the grave anxiety 
wliidi IS now felt in all groups of the medical profe.ssiou 
uitli regard to wliat obviously is taking place and which 
las been drawn attention to from time to time. It was 
nn or nun^ Hot allow of a general di.s- 

cnssion and elaboration of the issues involved, and that the 
ince mg lad to be satisfied for the time being with an 
nnmeia ion of certain encroachments and a few comments 
leieon t mil be useful to name a few of tliose men- 
tioned. They included: 


National health insurance 
Additional insurance benefits. 

meilt<\nd ' deSardlealc?"*mcnW^ luborculosis (4501 cance, 

dit^scT’ viriiLs'U"S';;p:edics? 

Clinics foi- lie.-itmeiit of school childvci (1 ]90) 

Rheumatism and heart disease in child" on. '' 

(2?2IX)),'and (5)‘^middle claSr 
Consultations for puerporM pvreEia 
Ante-natal work and niatermiV r.n ' j • 

Pathological facilities ‘ attendance by midwives. 

work!*^^^ State medical officers engaged in domiciliary clinicJ 

rad'iiUe^^'^for^the™^’ ■'’olmitarv hospitals, 
fees for fn nnd insurance or pavment o 

incindin-^ single pci°onLvhh*i »t voluntary hospitals 

-Anaesthetics by registered dentists. 

ISnn of tile items iinknotvn Iicfor 

cnc™nr.h,n V «oce.ssariIy follow that liet-aiiso a: 

into i'd i "" ’'7-7fle in one or aiiotlior dircctioi 

itself i', IH-arfice in tl.e past that that i, 

to siicro-nci'* ’ I i-" PP''I'Gse of this comniunication i- no 
o . - so II ions to the various prohlcins in(lic.ate( 


above and now confronting the profession, but rather to 
draw attention to the direction in which such solutions 
may he looked for. 

Dr. C. E. S. Flemming, in an able article in tho 
Sn’rj,E.Mr.NT of December lOtli last (p. 221), advocates that 
tho private practitioner should eonio forward and' take part 
at cHiiics and centres where noiv medical treatment is 
being given. To do tliis may or may not he a good tiling; 
hut lie does not state how doing this would fit in witli 
any fnndnmontal principle which should guide the private 
practitioner’s actions, or even if there is any fundamental 
prineipio at all involved. One reads tho essays of others 
who demand' “ a policy,” and ask that “ a lead should he 
given,” and in particular “ that the Association should 
wake n]i and do something or other.” As the Association 
is, after all, formed of the individual members, that does 
not cai'rv us far; and to “ announce a policy ” or to “ give 
a lead ” before being sure of our “ fundamentals ” will 
lead only to destniction. It would seem to he necessary, 
thorofore, to re-examine old conclusions and to revise oiir 
preconceived notions. 

Undoubtedly profoniiS changes are taking jilace in tho 
thoughts and h.-ibits of British people, and the medical 
profession cannot expect to he unaffected. Because we arc 
all in the midst of it, and are ourselves subject to it, we 
hardly realize what is happening, and are consequently 
ill-fitted to co])e with the situation. The medical profession 
has long since left its position of isolation, and, whether it 
likes it or not. has been brought during the past twenty- 
five year.s into the most intimate relationship with tho 
movements of public and Jiarty thought and oijinion. To 
look around over onr broken-down fences will prove a 
profitable and illuminating employment. 

The .speculative re.stlessnoss of some medical practitioners 
desiring to know “ whither away ” cannot bo hilled by 
stiiteinents that all is well. It is contradicted by their 
experience, and their common sense will not accept it. 
Others wonld seem to he keen to plunge at once into the 
conllicting currents and to endeavour to readjust this or 
that, or to guide hither dr thither, all without any previous 
consideration having been given to what is not necessarilv 
on the surface. And then we have the average medical 
praetitioncr. ever an eager, single-minded (often simple- 
minded) seeker after truth, fully concerning himself with 
the individual, and hardly to he expected to he capable of 
getting away from this attitude of mind and to assist in 
determining ivhat is best to ho done. Ho finds himself 
ass.ailed by the ardent reformer and the astute adminis- 
trator, He detests the bureaucrat, tyith his silent hut 
ceaseless and plausible encroachments on his libertv and 
private practice, who in turn resents him as a personalitv 
which cannot ho made to fit itself into a set of statements 
on a printed form. He recognizes that things are changing 


70 KARCH 3, 1928] 


Private Medical Practice. 


t RVmr.irr.sT to Tn» •• 
nniTJBii SiKnicAL JounvAt 


but lie has the foggiest notion how it is coming about and 
of tlie fundamental principles on which he should act. He 
longs for them all to leave him alone and allow him to 
pursue his way, continuing in that liberty and indepen- 
dence which ho was led to expect, and in which those wlio 
jireceded him so usefully functioned. 

Wo have those who openlj- state that the decay of homo 
life is now proceeding, and that the homo and all its 
tahoos are being brushed aside. If this is so then the 
private practitioner goes also, for his place has alwaj-s 
been in the homes of the people. Again, it is becoming 
all too apparent that the present-day management of 
democracy — and this consequently involves the medical 
profession — is by means of inner rings, part}- cliques, and 
legislation by reference ; and that the centre of gravity of 
public health administration has shifted from the environ- 
ment to the individual, who is being encouraged to look 
elsewhere than in his home for the medical attendance 
which he is being educated to think that he has need of. 

The private doctor in his difficulties hopes to find assist- 
ance in formulating his opinion and in coming to a decision 
by inquiring what other nations may bo doing, and how 
they may have dealt with similar iiroblems, especially in 
relation to medicine. Such an inquin- would be interesting, 
but it must be appreciated that developments of other 
national forms of medicine cannot be made applicable to 
the “ atmosphere ” of the British peoples. National dis- 
positions, personalities, and faculties must be recognized 
and allowed for; and to be too closely guided by the con- 
sequences in one nation for conclusions as to possible 
consequences here may lead us astray. So wo come to 
wonder whether what is going on is all a development or 
whether it is a revolution, and where it will all end, and 
how wo can best manage to deal with our own difficulties. 

If the profound changes in the thoughts and habits of the 
l>eople we hear so much of, especially in their relation to 
medicine, can be shown to preserve the idea or typo of the 
past, with a continuity of principle — changes that allow of 
assimilation and are a logical sequence and free from lop- 
sidedness — then it is reasonable to conclude that these 
changes are developments. But even development may not 
moan progress; all things develop for bettor or for worse. 
What would seem to be necessary in the development is a 
power of adjustment with the utmost mobility. Is this 
so at the present time.!* Incidentally it may bo remarked 
that this power has proved to bo very pronounced in the 
organization of the British Medical '.Association. But is 
it so in the outside medical world? The medical profession 
docs not ask for permanency of idea, but it does ask for 
adaptation, and not destruction; and as a scientific pro- 
fession it welcomes criticism, is willing to admit error, is 
imbued with the spirit of adventure, and is attracted' by 
truth and is eagerly in search of it, whatever the public 
may think to the contrary. 

Is it possible, therefore, to find one common factor, a 
necessity, which would appeal to the medical profession 
and to the public--toward which both could move, animated 
by a conimon object, and which should be preserved at 
every cost if the two are to continue to co-operate and the 
British nation is to progress — a fundamental principle to 
govern all conclusions, and on which the medical profession 
can come into line, formulate a policy, and look for the 
loaders asked for? 

The home, with its influence on conduct and character 
has made England what it is. The private medical practE 
tioncr has been the guide, philosopher, and friend in the 
past in those homes, influencing them in main- wavs hardlv 
appreciated now, bringing to bear on them,' and' thi-oimii 
them, those jiowers which he is peculiarly trained and 
suited to apply. If these statements arc correct, then it 
would seem that the home and the family doctor’ must be 
continued and the closest co-operation be developed. The 
caso could then bo stated thus : 

(o) In the home alone is formed, and can be discovered the 
environments of circumstances and character so necessarv for 
successful medical practice of prevention and cure. 

(A) The family doctor, aided In- medical and lay co- workers 
should direct and be responsible for the personal health 
services required in the home, making himself fully acquainted 
with these environments. 


(c) If for any reason it is found necessary or desirable that 
the people should be removed from their homes for medical 
treatment, that treatment should be given by the family doctor; 
or, if not possible, then in close collaboration with him, his 
knowledge of the environments being put at the disposal of 
his colleagues. 

(d) In all matters of health affecting the people and their 
homes the family doctor should be consulted and be given the 
opportunity to co-operate with the State for the maintenance 
of the homo and the happiness of those who form it. 

To many this idealistic attitude ma)- not appeal. 
Practical reforms alwa3-s lag behind the vision of the 
idealist, and even when action is at last taken the result 
is commonl}- a compromise between w-liat the idealist and 
his followers demand and what the average of medical and 
public opinion will accept. But that is not to say that 
tlio idealist has not proved to be the very salt of progress. 
Anj-how, one would suggest that the appreciation of these 
fundamental principles and their application to each aspect 
of the several problems as they como to confront tho 
medical profession will bo of some assistance in their 
elucidation. 

Get medicine aivay from tho “ bottle of physick ” and 
the herd treatment of individuals, with its flat denial of 
differing personalities; convince public opinion that sound 
medical treatment cannot be carried on effectively detached 
entirely from, and independent of, the knowledge of home 
conditions and of the various personalities therein; then 
tho swarming throngs ever exhausting the facilities of hos- 
pitals, clinics, and centres will at last come to see tho 
delusion, this decadence in treatment, and ivill demand an 
efficient medical service, based upon and carried out in 
homes made fit to live in, as the one essential for health 
and happiness. 

Tho medical profession at this juncture clamours for a 
policy and demands leaders. If those wlio are fitted to 
lead can seize the ideal, and, whilst throwing into tho 
common stock their several personalities, will develop for 
the family doctor that sympathy and support ho rightly 
looks for and richly deserves, then medicine can again go 
fonvard with confidence and assurance to further triumphs, 
having helped to recover the homes of England and their 
influence for good. 


of HBrancljfJS anb Bilnsions. 

Kenya Bhancoi. 

i meeting of the Kenya Branch was held on October 1927, 

it tho Municipal Council Offices, Nairobi. Dr. C. J. Wilson read 
i paper on tuberculosis amongst African natives, which was followed 
i)y a discussion in which many members took part, and a vote of 

Jianks was accorded to Dr. Wilson. 

A further meeting of the Branch was held at the Municipal Offices, 
^Tairobi, on November 9th, 1927, when the President took the chair. 
Or. H. L. Gordon read a paper on mental instability in Kenya. At 
Jio conclusion of the paper there was a discussion thereon in winch 
jevcral members took part.' A vote of thanks was passed to Dr. 
aordon. Mr. Daubnay, deputy chief veterinary research oflicer, 
.vas elected a complimentary member of the Kenya Branch in 
•cco<'nition of his distinguished scientific work and the assistance 
10 h*as always given to medical men in the colony. 

At a meeting of the Branch held at the Municipal Offices, Nairobi, 
m Wednesday, December 14th, 1927, Dr. J. B. Clarke read a paper 
m civil mobilisation for war service. A -di-^cnssion, in which several 
nembers took part, ensued, and Dr. Clarke replied. A vote or 
ihanks was accorded to the lecturer for his address. Arrangements 
vere made for the annual meeting of the Branch to be held on 

fanuary 20th and 21st. 

Metropolitan Counties Branch: Camberwell Division. 

\.N ordinary meeting of tho Camberwell Division was held at the 
3ermondscy and Kotherhithe Hospital on February 7th. Owin„ to 
;ho unavoiiablD absenco of the president Dr. Cox, Y,”® 

aken bv Dr Heard. Mi\ Alfred Webb-Joiinson, suigcon to the 
iliddlescx Hospital, read a paper on haematuria. ^lic various 
:auses of tho condition were enunciated and m.my "se'ul mms 
n treatment given. The address was illustrated 
nloresting x-raj- films and hy some excellent .-j 

lathological specimens. The lecture was much 
vas followed bv a keen discussion. A hearty vote of thanks to 
dr. ■\Vehb-JolmsDn for his address was earned unanimously. 

Hetropolitax Counties Brancu : Hampstead Division. 

t MEETIKC of the Hampstead Division w.^ J'*''.rl'TO,vT^=?Nv'as 
Jencral Hospit.-ll on February 9th, wlien Dr. J. S. NaOTUTO 
n the chair. Dr. S. Monckton Copemas, F.R.S., gaic an . 
llustratcd by lantern slides, on inoperable cancer. form 

Dr. Copeman defined the term “ inoperable c^ihcor ‘ - what 
if the dLase in which it was no longer possible to -perform viiai 





72 mECH 3,' 1928] 


■Boolcs Added to the Library. 


r suPTLEiTEirr to m 
LCRiTiim Medical JocBiriL 


Essex Braxch : Mid-Essex Divisioir. — The Jinnwa! g'cnrral meeting 
of the Mid-Essex Division will be hold at the Bell Hotel, Chelms- 
ford, to-day (Friday, March 2nd), at 3 p.m. Agenda : Report of 
year's work and accounts; election of officers for 1928; discussions: 
U) re attendance of medical practitioners at road accidents; 
{Z) chronic varicose ulceration. 

Fife Braxch. — A clinical meeting of the Fife Branch wilt ho held 
in the Maternity Home, Townsend Crescent, Kirkcaldy, on 
Thursday, March 8th, at 3.30 p.m. Dr. W. D. D. Small (Edinburgh) 
will give an address on the medical treatment of gastric and 
duodenal ulcers. 

Glasgow and West or Scotland Branch : Lanarkshire Division. — 
A meeting of the Lanarkshire Division will be hold at St. Enoch’s 
Station Hotel on Wednesday, March 14th, at 3.30 p.m. A paper on 
teeth in relation to health (with lantern illustrations) will be read 
by Dr. Charles Read. 

Metropolitan Counties Branch. — Tlie Metropolitan Counties 
Branch has arranged a meeting to be held at the British Medical 
Association House, Tavistock Square, W.C.l, on Thursday, March 
22nd. Dr. E. Graham Little, M.P., will deliver an address on 
** The future of medical practice : an address to *500101 students 
and young practitioners ” at 5.30 p.m. Fourth and fifth year 
medical students and newly qualified practitioners aro cordially 
invited; tea and coffee at 5 p.m. 


lecture demonstration on various hip cases, in the place of Dr, 
J. W. Wayto. 

Sussex Branch : Hastings Division. — The next meeting of tho 
Hastings Division will take place at tho Queen’s Hotel on Tuesday, 
March 6th, at 8.15 p.m. Dr. A. E. Larking will give an address 
on hospitals, general practitioner.s, and others. Tho annual 
dinner of tho Division will bo held on Friday, April 20th, at tho 
Royal Victoria Hotel; tickets 10s. 6d. 

WiLTSimin Branch : Trowbridge Division. — A supper arranged 
by tho Trowbridge Division will be held on Wednesday, March 7th, 
at 7.45 p.m., at tho Roundstono House Hotel, Trowbridge.^ An 
address on hoarseness will be given by Mr. E. Miles Atkinson 
before tho supper. The representative of the Division in the Repre- 
sentativo Body will also bo appointed. 

Yorkshire Branch : Wakefield, Pontefract, and Castleford 
Division.— A meeting of tho Wakefield, Pontefract, and Castleford 
DivHon will be held at the Strafford Anns Hotel, Wakefield, 
on Thursday, March 8th. Dr. R. A. Veale, physician in charge 
of the skin department. General InfirnjKiry, Leeds, will give a 
Iccturo on common skin diseases. Sup^r (3s.), at 7.45 p.m., 
will precede the lecture. 


Metropolitan Counties Branch : City Division. — Tho next 
meeting ai'ranged by the City Division will be held at the Metro- 
politan Hospital, Kingsland Road, E., on Tuesday, March 6th, at 
9.30 p ni Mr. Norman Patterson will read a paper on ear 
trouble ill general practice. 

Metro.'’olitan Counties Branch : Finchley Division.— A meeting 
of tho Finchley Division will be held at tho Finchley Mcmori.'Tl 
Hospital on Tuesday, March 6th, at 8.45 p.m. Dr. J. W.. McNec 
will discuss the clinical features of thrombosis of branches of 
coronary arteries. 

Metropolitan Counties Branoi ; Hampstead Division.— A meeting 
of the Hampstead Division will be hold at the Hampstead General 
Hospital on Thursday, March 8th, at 8.30 p.m. Dr. G. A. Sutherland 
will discuss tho heart in acute infections. 

Metropolitan Counties Branch : Hendon Division. — The next 
clinical meeting of the Hendon Division will take place at Hendon 
Cottage Hospital to-day (Friday, March 2nd), at 8.30 p.m., when 
Dr. J. M. H. MacLeod, physician for diseases of the skin. Charing 
Cross Hospital, will deliver an address on somo observations on 
ringworm and its treatment (illustrated by lantern slides). 

Metropolitan Counties Branch : Maeylebone Division. A 

meeting of the Marylebone Division will bo held at 11, Chandos 
Street, Cavendish Square, on Thursday, Marcli 15th, at 8.15 p.m. 
Agenda : (1) nomination of candidates for election to Central 
Council; (2) election of seven representatives and deputy repre- 
sentatives to Representative Meeting; (3) a lecture, with lantern 
^lustrations, by Dr. Percy Flemming : Tho Thames from London 
Bridgo to iLambeth, with a note of London’s early water supply. 
Members aro cordially invited to bring ladies and friends. 

MmopoLiTAN Counties Branch : St. Pancras Division.— A 
meeting of the St. Pancras Division will be held at the Britisli 
Medical Association House, Tavistock Square, W.C.l, on Tuesday 
March 13th, at 9 p.m. Mr. Sidney Boyd will give an address on 
tho diagnosis of surgical emergencies occurring in general practice. 

Metropolitan Counties Branch : South-West Essex Division.- 
A meeting of the South-West Essex Division will be held at the 
\\liipps Cross Hospital, Leytonstoiie, on Tuesday, March 6th, at 
... P;™* Dr. .T. C. Muir, medical superintendent,* w-ilt give a 
clinical demonstration. ® 

Metropolitan Counties Branch; Westjcn'^ter and Holborn 
Division,— A meeting of the Westminster and Holborn Division will 
bo held on Thursday, March 22nd, at 8.30 p,m., at Romano’s 
Kcstaurant, btrand, preceded by a dinner at 7.30, Mr. P. B Tustiri 

Jl^itinent of S.' '‘"d 

Metropolitan Counties Ekanct : Willesden Division.-A meeting 
the 3\ille5don Dmsion will be hold at the Willesden General 
HespiLal, Harlraden Road, on Wednesday, March 21st, at 9 p.m. 
It "111 bo a ]omt meeting with members of the dental profession; 
?'’d -yi- H. L. Jtessenger, L.D S., will read a paper on focal 
infection ; discussion on matters of mutual interest to follow. The 
following liirther meetings have been arranged - Anril 18tli Hr T 
Bright Bannister : Ante-natal work; May ®16lh, a'^inual nleeUng; 
J uno 20th, Dr. Margaret Lmslie : Caro of the infant. 

Midland Branch : Chesterfield Division.— A meetinfr nf flro 
Chesterfield Division will be held at the Maternity Ho^nital 
Chesterfield, on Friday, March 9th, at 8.15 p.m. Mr. Graham *s’ 
Sinipson will discuss the value of operations. 

Southern Branch : Jersey Division. — The next meetin*^ of the 
Jei-sev Division will be held at the General Hospital on 'nnir« 5 f 7 iw 
March 15th, at 8.30 p.m. Mr. C. A. Halliwell will read a paper 
on tho treatment of peritonitis. ' - • ‘ 

. Southern Branch : Portsmouth Division,— The next meeting of 
the l ousmouth Division will be a dental night; it will therefore 
bo an opportunity for members to invite their friends of the 
dental profession as private guests. No official invitations will be 
issued. The meeting will be held at the Queen’s Hotel, Squthsea 
on Thursday, March 8th, at 9.30 p.m., preceded by supper at 
9 o’clock (cost 3s. 6d., including gratuities). Dr. A. Livingston, 
M.D.S.Liverp., director of dental studies at King’s College Hospital* 
has kindly consented to give the address. * 

Surrey Branch : CRO^mON Division. — At the meeting of the 
Croydon Division to be held on Wednesday, March 14th, at 4 p.m., 
at the Croydon General Hospital, Mr. A. H, Todd will give a 


BOOKS ADDED TO THE LIBRARY. 

The following books were received in llie Library of tho Association 
during tho months of December, 1927, and January, 1928. 

Annnis of Medical History. Vol 9, Part 3. 1927. _ 

\nnals of tho I’lckctt Thomson Research Laboratory. \ ol. 3. 1927. 

Arr.t. L., and Fulls, II. i^Rbntgen Rays in Dermatology. 1927. 

Astier: Formidaire. 1928. ‘ 

nailcv it • Physical Signs in Clinical .Surgery. 1927. 
llalv E C 0. : Spectroscopy. Vol. 2. 1927. 

Boii'ekaert, J. P. : La patliogenie ct le Traitcment du' Diabetc. 1927. 
nradlev D. C. : Topographical Anatomy of the Dog. 1927.' , 

Biixlom P. A. : Repcarcbes in Polynesia and Melanesia. Paits 1-4. Medical 
Entomology. 1927. , 

• IaO xMal Hereuitairc. lyii. 

cS^kc, \V. E., anti E. Ponder ; The Polynuclear Count. 1927 
CroAsJn IT S : The Diseases of Women. Sixth edition. 1927. 

Crow, E. A*.: Tho Ear, Xofee, and Throat in General Practice. 1927. 

^WhA^^shalTthc^ do for the Fceblo-minded? 

Du Ibo/s, E. F. : Basal Metabolism in Health and Disease. Second edition, 

PoiiSf’s • :iranuol of Hygiene and Sanitation. Eighth edition. 1926. 

and Post-Natal Cliild Hygiene. 1927. 
Gilchrist, T. C. : Outlines of Skin Diseases. • 1927, ' . 

Gordon R H. : The Neurotic Personality. 7927. 

Tialiwliite. Sir W. ; Bacon-Giibcrt-Harvey. The Harveian Oration. 1927. 
Harvey Lectures. 1925-26. 1927. 

llriV'X^V^’Muscn/ar^Cvcmen^s'rn^ 

IK: f F.'"; VKu^srituironal Factor in Disease. 1927. 

Ks VI \ IfeKS^L^offNav^'^urgeon. 1927 

Kvlbi -^Der' brhault des BiStes au Ualzium und K“h'»n- 1927. 
Lawrence, n. D.': Tho Diabetic Life. Third 

itoir ' k Stment of Renat 

tho Thyroid Gland. 1927. . 

sloSe (’iu'N. C.')" nS A V.“ Joncord : .V JIanual of Emergeneies. Second 
ilumVo-' O^^'PuImonary Tuberculosis : Its Etiology and Treatment. 

Second editiim.^ Evolution of Preventive Sledieine. 1927. 
TOnNooulen and' S. Isaac: Die Zuckerkranklieit und ihre Belinndkmg. 

8 Aufl. 1927. vT 1 TC57 

8?“a l??^Pra’'ctioI?’'Tr''elSi?i on Diseases of Skin. Third edition. 

?dS?'G':=«t^r'li?;l^ 1927. 

?S"!’ L:/'ticmSi” o'’ CdtiSr’a? Concetto dci Circoli Viriosi in 
Robrek” A^ A. :’ThG Psychology of piaracfer. 1927. 

RomKVnd MUoheier:‘‘’Mo'^^^^^^ Praitice of Surgery. Vols. 1 and 2. ’ 

RosSu, 5L J. : Preventive Medicine and rTygicne. Fifth edition. 1927. 
Ruddiinan, E. A. : Whys-in Phiwmaoy. 19K. 

Schalek A. : Fundamentals in Dermatology. iy<iD. t t .n iQ?fi 

Schilling, V, ; Das Blutbild und seine kliniche ^ erwerlung. 5/Vufl. 1-26. 

Scholes P V G. : Diphtheria, Measles, Scarlatina. Second edition. 19-7. 
Smith, ’h.‘ E. : Applied Refraction. . 1927., ^ 

Solomon, I. : Precis de .,0— 

Spencer, H. R. : Histor; 1927' 

Steiner, E. B. ; Eradica , - p. o .i' Suinn 1927 

Stevens, E. B. : Textbook of Therapeutics. Seventh edition, 

Thomson. J. A. : Towards Health. 1927. _ , . „ iVnrld 

United States War Department. The Medical Department in 
War. Vol. .XI. Surgery. .1927. 

University College, London : Centenary Addrrsse.s. Women’s 

Webb, C.: The Woman with a Basket. The Story of the women 
Co-operativo Guild. 1885-1927., 

Webb and Ryder : Overcoming Tuberculosis. 1927. 

Whitman; Orthopaedic Surgery. Eighth edilmn. iaZ/. 

Williams, J. F. : Hygiene and Sanitation. 1927. „ 

Wilson, F. P, : Plague in Shakespeare’s London. 19*A 
Woollard, H. : Recent Advances in Anatomy. 1927. 



3rAncn n, 'l928] 


Annual Meeting at Cardifr. 


r suTFLEymyr to ths 

LDRITISII MKDtCXL JOUllIflL 


73 


SJiitrslT IttuMral ''^wdvAxm. 

NINETY-SIXTH ANNUAL MEETING, CARDIFF, JULY, 1928. 


Patron; Ills Majesty the Kino. 

Frrsiitcnt; Sir. HonEiiT “W. PniLip, M.D., LL.D., F.R.C.P.Etl., Consulting Physician, Eoyal Infirmary, Edinburgh. 
Prcaidcnl-Tilect : Sm Eiven J. JIaclean, JI.D., F.R.C.P., Professor of Obstetrics, Welsh National School of Medicine. 
Ghainiian of PcjJrcscnfative Body; C. O. HAlvTnonNB, M.D., F.R.C.P. 

Chairman of Conncil; H. B. Br.ACKENnunY, M.II.C.S., L.R.C.P. 

Treasurer; N. Bisnop IlAnsiAN, M.B., F.R.C.S, 


PROVISIONAL PROGRAMIME. 



flE incoming President, Sir 
Ewen JIaclean, Tvill deliver 
his address to the Associa- 
tion on Tuesday, .Inly 24th, 
at 8 p.m. 

Tho Annual BEParsENTA- 
TivE JIeeting Tvill begin on 
Frida}’, .Inly 20th, at 10 a.m., 
and bo continued on tho three 
following weeU-days. Tho 
Representatives’ Dinner will 
taho place on Friday evening, 
July 20lh, at 7.30. 

Tho statutory Annual 
Geni'.kal Meeting will bo 
hold on Tuesday, July 24th, 
at 2 p.m., and tho adjourned 
general meeting at 8 p.m. 

Tho Annual Dinner of the 
Association will taho place on 
Thnrsday, July 26th. 

Tho Conforonce of Honorary 
Soorotarios will bo hold at 
2.30 p.m. on Wednesday, July 
25th, and tho Seci'etaries’ Dinner at 6.30 tho same evening. 

The official Religious Service will bo held at St. John's 
Church, Cardiff, on Tuesday, July 24th, at 4.30 p.m. 

The Annual Exhibition of surgical appliances, foods, drugs, 
and b^ks win bo open for inspection on Monday, July 23rd, 
° p.m,; the formal opening by the President 
will take place on July '24th at 9.30 a.m. Tho exhibition 
wi 1 remain open on July 25th, 26th, and 27th from 9 a.m. 
till 6 p.m. 

Saturday, July 28th, will be given up to excursions to 
places of interest in tho neighbourhood. 


Towcu or Si. .ioiik’s Ciiuiicii, 
Oinnirr. 


THE SECTIONS. 

Scientific Section will meet from 10 a.m. to I p.m. for 
Juyr25thf26t“r27H^.'^®^“®"^‘^y’ Tl>uraday. and Friday, 


77io foIiowJng Scct/ons will meet on Threo Days, 

73-7 o- rv, MEBICIKE. 

(Londonh Lewis, C.B.E., M.D., F.R.C.P., F.R.S. 

A.’E"(fow"M d"' p R C P F.R.C.P. (Cardiff); 

F R O P A. FEnGUS Hewat, M.D., 

H B C (C-diff); 

H. Letheby Tidy, M.D. P r 0 p jt A'-R-C.P.l. (UuDimj, 

IlS'TaSiff • M!B!rli.R.C.P., 36, Newport 

Square?Lonaontw.L'’"^ F.R.C.P., 52,’ Monfaga 

r, . T, . SURGERY. 

(Carfiff)'" ■' A- W. Sheen, C.B.B., M.S.. F.R.C.S. 

C.^a^raGGE"*’^S M-B., F.R.C.S. (Cardiff); 

FuLi.FRTnv r p (London) ; Professor Andrew 

GeS? gIa’nt P R CS P-B-C.S.I. (Belfast); J. W. 

Vof^TioIa %Zrdia-' R^'st D.S 0 .‘, F.R.C.S.', 108, New- 


OBSTETRICS AND GYNAECOLOGY. 

Pres!, lent ; T. Watts Eden, M.D., F.R.C.P., F.R.C.S.Ed. 
(London). 

Virr-Presulents ; JfAEGAEETM.BASDEN.Sr.D., F.R.C.S. (London); 
Authuu E. Giles, JX.D., F.R.C.S.Ed; (London); Professor 
W. Fletcher Shaw, RI.D., Ch.B. (JIanohester) ; Professor 
n. Beckwith Whitehouse, M.S., F.R.C.S. (Birmingham). 

Honorary Seerclanes ; B.K.Tenison Collins, M.D. .F.R.C.S. Ed., 
12, AVindsor Place, Cardiff ; Everard Williams, M.D., 5, Wimpole 
Street, London, W.l. 

MENTAL DISEASES AND NEUROLOGY. 

Pretiilent; Edwin goodall, C.B.E. , M.D., F.R.C.P. (Cardiff). 
Vice-Presidents: E. D. Adrian, M.D., F.R.C.P., F.R.S. (Cam- 
bridge) ; G. H. R. GinsoN, D.S.O., M.D., F.R.C.P .Ed. (Edinburgh); 
Bernard Bart, M.D., F.R.C.P. (London); W. F. Nelis, M.D. 
(Caerleon, Mon.); N. R. Phillips, M.D. (Abergavenny). 

Honorary Secretaries; Edward Le'Wis, F.R.F.PiS., Drymma 
Hnll, Skewen. nr. Neath, Glam. ; W.R.Eeynell,M.D., M.E.C.P., 
87, Harley Street, London, W.l. 


T/>o following Soctlons will meet on Two Days. 

PATHOLOGY AND BACTERIOLOGY. 

President; Professor B. H. Kettle, M.D., M.R.C.P. (London). 

Vice-Presidents; Professor JOHN Cruickshank, 3I.D. (Aberdeen); 
Sir Thomas Houston, O.B.E.. M.D. (Belfast); W. Parry Morgan, 
M.D. (Cardiff); A. F. S. Sladden. M.D. (Swansea). 

Honorary Secretaries ; J. B. Duguid, M.D., Department of 
Patboiogv, Welsh National School of Medicine, The P-.rade, 
Cardiff; ’Lawrence P. Garuod, M.B., M.R.C.P., 68, Gloucester 
Terrace, Hyde Park, London, W.2. 

ORTHOPAEDICS. 

President; Sir John Lyn.n-Thomas, K.B.E., C.B., C.JI.G. 
F.R.C.S. (Llechryd). 

Vice-Presidents : A. Rocyn Jones, M.B., F.R.C.S. (London); J. J, 
McIntosh Siiaiv, J/.Cf., M.D., F.R.C.S.Ed. (Edinburgh) ; S. Alwyn 
Smith, D.S.O., O.B.E., M.D., F.R.C.S.Ed. (Cardiff); P. Jenneb 
VerraLL, M.B., F.R.C.S. (London). 

Honorary Secretaries ; J. BERRY Haycraft, JJLC.,M.B., F.R.C.S. 
31, Cathedral Road, Cardiff; Eric Ivan Lloyd, M.B., F.R.C.S., 
33, Wimpolo Street, London, W.l. 

DISEASES OF CHILDREN. 

President; Alfred Howell, M.D., M.R.C.P. (Cardiff). 

Vice-Presidents; B. A. COCKAYNE, 3I.D., F.R.C.P. (London)* 
Herbert Thomas Evans. M.D., M.R.C.P. (Cardiff); Charles 
Leonard Isaac, M.B., F.R.C.S.Ed. (Swansea). 

Honorary Secretaries : D.aniel Thom.as Davies, 3I.D., 3X.R.C.P., 
24, Park Place, Cardiff; Hilda N. Stoessiger, M.D., II, Belmont 
House, Candover Street, London, MM. 

OPHTHALMOLOGY. 

President : F. P. S. Cresswell, M.B., F.R.C.S. (Cardiff). 

Vice-Presidents; Herbert Ougeu, M.B., li’.R.C.S. (Sheffield)* 
L. V. Cargill, F.R.C.S. (London ) ; R. J .Coulter, M.B., F. R .C.s.i! 
(Newport, Mon.); F. Griffith Thov- ” ' 

Honorary Secretaries ; J. W. TUD' 

I, Park Grove, Cardiff ; F. A. JuLER, " . ' . , 

Place, Loudon, W.l. 


LARYNGOLOGY AND OTOLOGY. 

President: Donald R. X’aterson, M.D.„C.M., F.R.C.P. (Cardiff) 
Vice-Presidents .- ALBAN Evans, M.R.C.S., L.R.C.P. (Swansea) ' 
E. D. D. Davis, F.R.C.S. (London); Archibald Mason Jones’ 
M.D., F.R.C.S.Ed. (Cardiff). ’ 

Honorary Secretaries ; A. A. Prichard, M.D., 14, Windsor Piece 
Cardiff; D. F. A. Neilson, F.R.C.S., 40, Queen Anne Street’ 
Loudon, W.l. 

TUBERCULOSIS. 


President; Hugh Mobriston Davies, 3I.D., M.Ch. FRCS 
(Ruthin). ■ 

Vice-Presidents ; Alf.xandeu Brownlee, M.D., F.R.C S Ed 
(Fairwaler, nr. Cardiff); Dan Arthur Powell, M.D. (Cardiff. •’ 
Cecil Wall. M.D., F.R.C.P. (London). li. (waraiu^, 

Honorary Secretaries ; J. C. Gilchrist, M.D., Tuberculosia 
Inetitntion, AVelsh National Memorial, Cardiff: J c Hnvif 
M,B., B.S., 28, Malcolm Street, Cambridge. -ciorLE, 



74 March 3, 192SJ 


Correspondence, 


■ nvprT,rsrr:yT to nm 

• lil'ITISII MFDICAL JoCB^tAt. 


RADIOLOGY AND PHYSIO-THERAPEUTICS. 

President : OWEN Lewelhn RhYS, M.D. (Carditfj. 

I'icc-Prrsideii/s ; T. Garfield Evans, M.!)., D.M.R.E. (Carilifti; 
0. H. IlF.iLD, C.B.E., M.D., M.R.C.l'. (London) ; (Thomas Marlin, 
BI.D., D.M.H.E. (London). 

Hon irnrij Secretaries ; T. I. Candy, M.B., H.Ch., 202, Stow Hill, 
Newport, Jlon.; A. J. H. Iles, M.R.C.S., L.E.C.P., Sluitterno 
House, Ttiunlon. 


The following Sections will meet on One Day. 
PHEVENtriVE MEDICINE. 

President: Edward Colston H'lLLrAMS, M.D., E.R.C.S.Ed. 
(Cardiff). 

Vice-Presidents; W. W. Jameson, M.D„ M.R.C.P. (London); 
Pavid Llewelyn Williams, fl/.C.'., E.R.C.S.Ed. (Cardiff); C. A. 
Erigstocke. M.R.C.S. (Haverfordwest). 

Honor, tnj Secretaries : H. W. Catto, DI.B., B.S., 198, Slow Hill, 
Newport, Mon. ; D. C. Kirkiiope, M.D., Town Hall, South 
Tottenham, London, N.15. 

PUBLIC HEALTH. 

President ; R. M. E. PiCKEN, M.B., Cb.B. (Cardiff). 
Vice-Presidents ; D. T. Rocyn Jones, O.B.E.,M.B., C.M.fRtimiiov, 
nr. Cardiff); J. D. Jenkins, M.H. (Rhondda); S. G. Moore, M.f). 
(Hnddersfie)d). 

Hoiiornnj Secreteiries ; Thomas Evans, M.B., Pnhiic HenlHi 
Department, Swansea; R. P. Garrow, M.D., Health Office, 
Saltergate, Chesterfield. 

MEDICAL SOCIOLOGY. 

President: William Evans Thomas, M.D., C.M. (Yslrad, 
Rlioudda). 

Vicc-PresiiUnU ; Letitia Denny Fairfield, C.B.E., M.D. 
(London); EVAN Leyyys-Lloyd, M.R.C.S., L.R.C.P. (Towyn). • 
Honorarii Secretary: E. Y. I>eaP.son, M.R.C.S., L.R.C.P., 
18, Cnvys Road, Cardiff. 


TROPICAL MEDICINE. 

President: PHILIP H, Manson-B.ahr, D.S.O., JLD., F.R.C.P. 
(London). 

Vtce-PicsUUnU ; J. B. Christopherson, M.D„F.B.C.P., P.R.C.S. 
(London); Lient.-Colonel A. G. McKendricR, M.B., Ch.B., 
E.R.C.S.Ed., I.M.S. (ret.) (Edinburgh). 

Honorary Secretaries: Ernest Henry Price, L.R.C.P.I., 153, 
CaUiedtal Road, Cardiff ; H. McCormick Hanschell, D.S.C., 
M.R.C.S., L.R.C.P., 35, Weymouth Street, London, W.l. 


HISTORY OP MEDICINE. 

President; WALTER G. SPENCER, O.B.E.,M.S.,F.R.C.S. (London). 

Vice-Presidents: Thomas Wallace, M.D. (Cardiff); T. P. C. 
Kirkpatrick, M.D., F.R.C.P.I. (Dublin); Professor J. A. Nixon, 
C.M.G., M.D., F.R.C.P. (Clifton); Charles Singer, M.A., M.D., 
F.R.C.P. (London). 

Honorary Secretaries : H.R. Frederick, M.B., Ch.B., 42, Victoria 
Road, Aberavon, Port Talbot, Glam. ; Kenneth U. Hay, O.B.E., 
M.B., 47, Hill Street, Berkeley Square, London, W.l. 

THERAPEUTICS AND PHARMACOLOGY, 

President: W. L.ANGDON Brown, M.D., F.R.C.P. (London). 

Viee-Peesidents; Professor W. J. DlLLiNG, M.B., Cli.B. (Liver- 
pool); Philip Hamill, M.D., D.So.. F.R.C.P. (London); W, H. 
Maxwell Telling, M.D., F.R.C.P. (Leeds). 

Honorary Secretaries: J. P. H. Davies, M.B., ‘'Cranmoor,” 
Tlie Green, Llandaff, Cardiff; J. H. Burn, M.D,, Pharmaceutical 
Society of Great Britain, Pharmacological Lahoratorv, 17, Blooms- 
bury Square, London, W.C.l. 


DERMATOLOGY. 

President ; Sir Robert Bolam, M.D., LL.D., F.R.C.P. (Nowcastle- 
on-Tyne). 

yice-PresiiJenU ; JAips Beatty, M.D., M.R.C.P. (Cardiff); 

M.R.C.P. (London) ; Henry Semon, 

M.D., M.R.C.P. (London). 

Honorary Secretaries: R. H. Enoch, M.R.C.S., L.R.C.P., Roval 
Infirmary, Cardiff; J. E.M. Wiqley, M.B., M.R.C.P., 132, Harley 
Street, London, W.l. 


The Honorary Local General Secretary of the Annual 
Meeting is Dr. G. I. Stkaohan, 20, IVindsor Place, Cardiff. 


PATHOLOGICAL MrSECJI. 

The coinmittoo appointed to organize the Pathological 
Mnsenm in connexion with the .\nnnal Sleeting of tlie 
British Medical Association at C.nrdiff next July proiAoscs 
to arrange the inatorial under the following heads: (1) 
Exhibits bearing on discussions and [lapers in the various 
Seetions. (2) Specimens and iilnstrations relating to any 
recent research work. (3) Instruments concerned in clinical 
diagnosis and pathological investigation. (4) Individual 
specimens of special interest or a series iHn.stratiiig some 
special subject. (5) Exhibits of general interest. Tlie 
committee appeals for the co-operation of the profession 
in making the museum n success. It will he easy of access, 
being situated in the same building in which the Sections 


will meet; it is hoped to make arrangements for exhibitors 
to demonstrate tlioir siiotimon.s. Every care will ho taken 
of the exhibits, and the contents of the museum will he 
iiLsurod. Tlio lionoraiy .secretaries (Dr. .1. D. Diignid and 
Dr. J. Mills, Dcpai’tmcnt of Pathology and Bacteriology, 
AVelsli Mutiimal School of Medicine, The Parade, Cardiif) 
ask intending exhibitors to notify them as soon as possible. 


CCoriTsponbcncc. 


Infant Jlyr/ienr Centres. 

■Sir, — Dr. .Bone states (SurrLEMENT, February 25th, p. 59) 
that this work is entirely new worli whicli has not been done in 
the past. If this is so, the general practitioner has allowed 
others to steal a march on him. The general impression con- 
veyed by your report of " Proceedings of Council ” is that the 
gener.al practitioner, like Gallio, caves for none of these things. 

Actually the aver.age general practitioner does not possess 
the necessary knowledge to advise. Such points ns the optimum 
frequency of feeding, the .stimulation of failing lactation, the 
value of supplementary feeds, the modification of milk 
mixtiirc.s, the results of altering the ratios of sugar and fat, 
the indic.itions for the different proprietary foods in v.arying 
condilion.s — all these and many more are hidden mysteries. 
Yet he will find that the “ Truby King ” nurse can give him 
.sound advice on .all these points. If ho is losing the oppor- 
timitv for tlii.s class of work it is because he has failed to 
answer the public demand for it. The public will get what it 
w.ants, and if the right kind of advice c.annot be obtained from 
the doctor the public will consult the expert nurse, or write to 
the .saarious lay journals or manufacturers’ bureaus where such 
advice is available. 

Surely, Sir, an anomalous stale of affairs c.visls when the 
gencrar practitioner lacks such fundamental knowledge as_ the 
dietetics of the young of his own species. It is not surprising 
if the man in the street, or rather the wom.an'in the house., loses 
confidence in her family doctor when she discovers such a 
notable failure in tlie oracle. Adequate instruction is the proper 
remedy. Objections will be raised to further straws on tlia 
breaking b.ack of an overloaded curriculiim; but if the student 
could sp.are some of the hours .spent .in the- theatre wiitchmg 
dramatic maior operations wliich ho will never he called upon 
to perform 'himself, and devote those hoars to the more 
- of the infant welfare clinic, he couUl 


humdrum experiences 


provide himself witli a - foundation of accuv.ate knowledge 
which might go far to counteract Die pre.sent tendency, .so 
deplored by Dr. Rees (Supplement, p. 67) ” to the depreciation 
.and dcgradatiDn of the gener.al practitioner.”— I am, etc., 

, Frank BodmaN, M.B. 

Ciillon, Feb. 25lli. ■ • 


Ceilificiition under the Insurance Acts. 

.Sir —T he report of the parli.amenlary discussion on National 
Icaltii Insurance certification and excessive sickness henetit 
February 25tli, p. 330) moves me, .as a panel doctor, to a tew 

^First'^^Dr Vernon Davies bit the nail on the liead when be 
aid Uial the difficulty arises at the end of an illness, in decuhng 
■ hotlier the patient has become fit for work or not. I lie 
.atient may say he does not feel fit and would like another 
reeroff The^dootor thinks, ” If I were in that condi ion 
should work; but is it fair to apply such a criterion ‘o ‘I ns 
ran””’ It he is sent back and relapses the expense will he 
mrc than that of an extra week. So the man gets his 
erlificate. The real, and only, remedy here is a second 
pinion easily available. In theory' this is to be had in the 
bane of the regional medical officer; in practice a special foim 
ms'^to bVfiUed up, and this may not be & hand. 
im doctor has to ’inform the patient o! his doubt, and to be 
resent at the regional medical officer’s examin.ation. Tins 
isTTs the cldef oLt.acle; it is nsnally onnecessa^v, and mey 

11 a busy season he impossib e. Some 

mnerative Why cannot Die doctor— in a doubtful case— gne 

ire^^TerUfirate an";! mark it in some way-for examp e, put a 

‘D ” in the corner? The society, on receipt of tins marKc 
erlificate, could promptly refer the case to the "g'onal med c t 
fficer for a decision. The regional medicxil officer "oo’d t 
he doubtful cases much more effectively than be does at pr . , 

nd there would be no friction between doctor and pot’om- 
Secondly, we are . told we ore lax m oortificalion , l i ^ 
curc-s produced are too general and do not touch tli 


MAncii 3, 1023] 


Nava! and Military Appointments, 


r SUPPLEMENT TO TIIE 
LBniTisii Medical Joursil 


75 


doctor. Cnnnot oacli man's sickness rate bo ^vor]^od out periodic- 
ally and a local list circulated privately? Wo should then know 
wlierc \vc stood in relation to our colleagues. "Wc foo educated 
men, and threats and penalties strike us as rather childish. 
Tlie spirit of competition is more in us, and. if stimulated, 
would be productive of better results. Wo might also be told 
once a quarter what our prescriptions have cost. The sum of 
our sick pay jilus treatment cost per patient would bo an 
interesting figure, which we w'ould try to keep lower than our 
neighbour. — t am, etc., 

Loiuloii, S.AV., Fcl). 2GtIi. 


Sin, — Regarding the recent parliamentary debate in wliich tho 
iniquities of tho panel doctor came under the lash of the 
zealous guardians of the public purse (or rather, that of tho 
approved societies), the following details may prove of interest. 
Of the last thirty cases of mine referred to the regional medical 
oHicer the subsequent developments wero : 

“ Failed to attend 5 

“ Declared fit for work ” 3 

“ Declared unfit for work ” 19 

** Received declaring-off certificates ** 5 

Of tho " failed to attend ** one (a w’oman) was by no means 
fit for work, but was afraid that some dire consequences would 
result if she presented herself for c.xamination before one whom 
she regarded as “the Government doctor,” whom she con- 
sidered had already unfavourably prejudged her case. Of the 
“ declared off ” contingent four of them had already been at 
work for periods of from five to ten days before receiving the 
notice to attend (not very good “ team work ” tliis ou the 
societies’ part). Of the three ” declared fit ” one was a man 
I had been endeavouring to “sign off” for several weeks; 
No. 2 went back to work, but subsequently broke down .and 
returned to the status guo; No. 3 endeavoured to join the army, 
but \vas rejected on medical grounds I Surely tliere must be 
something wrong in tho alleged high porcenlagc of ” lead- 
Bwmgers.”— I am, etc,, 

LfcicLAtershire, Feb. 27th. B.Ch. 


ilnlial anti iHititarn ^Appointments. 

^ „ koyal xaval volusteeh heserve. 

Sifuu'oSlcnant? Sublieutenant E. C. ■«’. >ra.\well to bo Surgeon 

and- a‘jtaehL'iS'i:!Jt"2rLomirDfvU^^^^^ 

aUae & "“LLt’rof'?irELrSe'’,^lUh‘Diwriol“^‘''”^ Sublieutenant and 


•n,. r„ii ' ■ ^ SO'fAt ARMY MEDICAL CORPS. 

BO^O, T. ^B.^Bea^'l^^(pUg^ Majors; C. A. Slaughter (prov.), 11. A 

aud™s‘’grtmed“lhr?ani; commissioi 

restored to tho^csUblishmekt. ‘‘‘c seconded list, i 

renaqS^S" the “t™p^"r“y 'rin’k^o^Lieu^en^^ 


Squadron Lea^def U SERVICE. 

Area. * Starkey, O.D.l,., to Headquarters, Coasts 

Resen e, Hendon^;” Superintendent ( 

Flight Lieutenant’ IT R.A.F. General Hospital, Iraq, 

this rank. ' is granted a pennaiiont commiision i 

■to R.A.F. ^^neral^osuif-lf^T'*^" *t Repbt, Uxbridge; M. O'Rcga 

ueneral Hospital, Iraq; J. Hill to StatioL Headquaiteri., HinaVd 

RKGUL^^ ARliv RESERVE OF OFFICERS. 

(Brevet .lajo 

to belong to the Reserve M liability to recall, ceas 

R. W. .4gnew to bo Lieutenant. 

SUPPLEMEKTARV RESERVE OP OppTrrnc . -n.. . 

A. Roberts (o be Lieutenant. 


T . . , I^»D^AN MEDICAL SERVTp-p 

Colinol'Gco^ge’BrowJc^D S O ‘"retVr - *<> Colonc 

To‘bo‘c\p^-aiS^“']v T'i" V‘{ 

To be Lieutenants: J.'h.- C lapp’, Vv. i.'A?CoTcS’re“amVand llTl 


’TERRITORLIL army. 

Mivn.. n T» . Army Mpdicil Corps. 

'* " ranlf With limit, is retired 

rank, With permission to wear the nrrseril.M nni 


retains his 
Captain u. 
Anghan) Div 


i rank whh ^ . “^*^cd the age limit, is retii 

D C ’ wear the prescribed uniform, 

Mvision - 'o '<» Divisional Adjutant. Mt: 

JUlsion, Mce Major E. Phillips. D.S.O.. JI.C., R.A.M.C. 


Mth (I 


VACANCIES. 

RiRMINGIHM TN'D JilDUND ElR .AND TUROAT HOSPITAL. — ScCOnd HoilSe- 
Siirgcon (non-rcsidcut). Salary at the rate of £150 per annum. 

Birmingham Maternity Hospital. — Junior HouFc-Surgcon. Salary at the 
rate of £75 per annum. 

BinMiNGHAM UiViON.—Rcsident Assistant Jfcdical Officer (female) afc 
Slonyhull Colony. Salary £-250-£350 per annum. 

Brighton County Borough.— Resident Medical Officer at the Borongli 
Infectious DIf'Cnso Hospital and Sanatorium (male, unmarried). Salary 
at tho rate of £350 per annum. 

Brighton : Su.«se.v Maternity and AVomfn's IfosPiTAL.— Resident House- 
Surgeon (mole). Salary at the rale oI £130 per annum. 

Carlisle: Cumberund Ineir.mary.— (11 Resident Jledieal Officer, six months 
an House-Physician and six months as House-Surgeon ; salary at the 
rate of £155 and £175 per annum rc.spcctively. (2) Resident Medical 
Officer ns Junior House-Surgeon for six months; salary at the rale of 
£135 per annum. (Males.) 

ChestrufIeld and North Derbyshire Royal Hospital.— (1) Junior House- 
Surgeon. (2) Casualty House-Surgeon. Salary at the rate of £100 per 
annum each. 

Hertford County Hospital. — H onorary Anaesthetists. 

HERTrORDsiimn County Council. — .V ssistant Jledical Officer of Health. 
Salary £700 per annum. 

Hospital for Sick Children, Great Ormond Street, W.C.I.— Part-time 
Junior Casualty Officer for six months (non-resident). Salary £75. 

Isle of Wight: Hermitage Sanatorium.— R esident Medical Officer (male). 
Snlary £3W. 

Kensington Board op Guardians.— Resident Medical Secretary and Regis- 
trar at St. Mary Abbott’s Hospital Salary £300 per annum. 

Kettering and Distuict General Hospital.— Resident Medical Officer 
(male). Salary at tlio rate of £175 per annum. 

King's College Hospital, S.E.5.— (1) Two Junior Surgeons. (2) Sambrooke 
Medical Regibtror; palnry £175 per annum. 

Leamington Spa : Warntjord General Hospital. — Resident House-Surgeon. 
Salary £165 per annum. 

LntRTOOL ; Ministry or Pensions Hospital, Mossley Hill.— Junior Medical 
Officer (unmarried). Salary £300 per annum. 

Liverpool Open-Air Hospital for Children, Leasowe. — Junior Medical 
Officer. Salary £200 per annum. 

Manchester: .\ncoat.s Hospital. — Clinical Assistant to the Ear, Nose, and 
Throat Department Out-patient Clinic. Fee 10s. 6d. per clinic. 

Manchester: St. Mary’s Hospitals.— Two House-Surgeons each for tho 
Whitwortli Street West Hospital (Maternity), and for the Wlritwoith 
Park Hospital (Gynaecological). Salary at 'the rate of £50 per annum 
each. 

Miller General Hospital, Greenulch Road, S.E.IO.— (1) Honorary 
Physician to the Children’s Department. (2) Resident Medical Officer. 
(3) House-Physician. Salary for (2) £^ and for (S) £125 per annum. 

Neavcastle-upon-Tyne City and Cou.xty.— Assistant Medical Officer of 
Health. Salary £750 per annum, rising to £900. 

Northampto.n General Hospital.— (3) House-Physician. (2) Two lions**- 
Surgeons. (3) Two Assistant House-Surgeons. Salary at the rate of 
£150 per onnum each. 

Kottincuam Gf«\eral Hospital.— H ouse-Surgeon. Salary at tho rate of 
£150 a year. 

Nottingham and Midland Eye iNnRiLARY.— House-Surgeon. Salary £200* 
per annum. 

Plymouth Poor Law Institution.— R esident Locumtenent for^three weeks. 

Royal Dental Hospital of London, Leicester Square, W.C.2.— House Anaes- 
thetist. Honorarium £200 per annum. 

Royal Manchester Children’s Hospital, Pcndlebury.— (1) Resic^nt Medical 
Officer. (2) Resident Surgical Officer. (3) Assistant Medical Offic**r 
(non-resident). Salary for (1) and (2) £125 per annum, and for (3) £150. 

Royal Waterloo Hospital fop. Children, Waterloo Road, S.E.I.— Honorary 
Medical Registrar, 

St. Peter’s Hospital for Stone, etc., Henrietta Street, W.C.2.— House- 
Surgeon. Salary nt tlic rate of £75 per annum. 

S.ALFOr>D Royal Hospital.— (1) House-Surgeon attached to Orthopaedic 
Deportment. (2) House-Surgeon. (3) Anaesthetist, Salary for (1) and 
(2) nt the raie of £125 per annum, and for (3) £1 Is. per morning 
session. 

Salisbury : General Infirslary.— House-Surgeon (male, unmarried). Salary 
£150 per annum. 

Seamen’s Hospital SoaETY.— Assistant Jledical Officer at the King George’s 
Sanatorium for Sailors, Liphook. Salary £200 per annum. " 

Southampton: Royal South Hants and Southampton Hospital.— Casualty 
Officer, Salary £120 per annum, rising to £130 on appointment as 
Junior House-Surgeon. 

Stepney Parish.— Pathological and Bacteriological Attendant at the Mile 
End Hospital. Aggregate salary £4 43. 6d, per week. 

West London Hospital, Hammersmith Road, W.6.— (1) Honorary Medical 
Registrar, (2) House-Ph>sician. (3) Two House-Surgeons. (4) Honorary 
Anaesthetist. Honorarium for (1) £100 per annum, and salary at the 
rale of £100 per annum for (2) and (3). 


Certifying F.actory Surgeon. — The appointment at Saltcoats (Ayrshire) 
is vacant. Applications to tho Chief Inspector of Factories, Home 
Office, Whitehall, London, S.W.l. 

This list of vacancies w compiled from our advertisement eolumnst 
where full particulars will be found. To ensure notice in this 
column advertisements must be received not later than the first 
post on Tuesday morninff. 


APPOINTMEKTS. 

Owen, Robert Davies, JI.R.G.S., L.R.C.P., F.R.C.S.Ed., Honorarv Aseistant 
Surgeon to tlie Ear, Nose, and Throat Department of tlie Cardiff Royal 
Infirmary, 

WlLLLAMS, R. Lester, M.B., B.Ch.Camb., F.R.C.S.Eng., Honorary- Surireon 
to tho Passmore Edwards Hospital, Wood Green, London. ' “ 

Certifying Factory Surgeons.— C. S. Carter, .M.R.C.S., L.R C P for ilp 
Kenninghall District (Norfolk); I. Thoma?, M.B., Cb.B.Livern” for tlio 
Pontrhydygroea District (Cardigan); P. S. Henderson. M B Ed ’ for fl « 
Fyvio District (Aberdeen). ' 


76 MabCH 3, 1928] 


Association intelligence ana Diary. 


r EtrPFLFAlEKT to tHl 
LDBiTian Mkdical JonaxAt 


DIARY OF SOCIETIES LECTURES. 

„ , ^ Rovvl SoaETY OF Medictxe. 

Sectioii of prlhopaedics.—Tiies., 8.30 p.m., Discussion: Tlie Treafmcnf of 
AciUo Osteoraychtis. To be opened by Tdr. Harry Platt, followed by Mr. 
Alexander Jlitchell, Mr. Erie Lloyd, 5Ir. Whitchurch Howell, and Mr 
H. Ogilvje. ' 

Section of Pathologii.-Tms., 8 for 8.30 p.m., Laboratorv JIoctiiiK at the 
Lifter Institute, Chelsea Gardens, S.W.l. G. H. Eagles and I). UlcClenn • 
On the Grmvth of I accinia in Tissue Culture ; B. 3V. Fairbrothcr ■ 
Cholera Antipns from the Prophylactic Point of View; J. ft. Orr and 
m' Ti A<ition of IT etf/iii toxin on red cells in ritrn- 

7 "V* °i ■ Behaviour of a Protozoon exposed to Acriflavlne • 

J. C G Lediiighain and D. JteClean : Piopagation of Vaccinrv.n,. in 
Rahil, t Dermis; H. Chick, Jl. H. Roscoe. anj JI. A. Doas ; PcWra-lii" 
Cotirlitions in Rats (demonstration). Ji*e 

of History of 3le(lictne.~\\c<[., 5 p.m.. Dr. Robert 7I«tehi.on • 
James Wylie, Rt., 51.0., a Medical Adxen- 
urci , Mr. F. Prescott : Louis Pasteur and Fermentation 

‘ hi dV't ^ Calcetnmy. ' To be opened 

^ P-™-’ Di«-iit.sion : The Value of Marine 
D? Poir^.se'’,'„‘ S Refeicnce to Children. To bo opened bj . 

followed hy Dr. Perev Lewjs (Folkestone) Dr W 0 
Uilougliby (Lastbourne), Dr. Colhs HaJIowos (TorqnaO Dr () R 

a.a" - >- 

Clintcal Section.— Fri., 5 p.m., Ca.e.i 

a.''rp.l.'''(¥e'a”irS)“c;een“ H-'PHal 

Di»«lc'Rea'il?cT“' ' r-pec,' of ?;m,:,'::','i;i‘'ri!i 

VnniciL SociETV or LOXDO.V, 11, Cliando^ Street, IV 1 — IVed 9 n m Tl.ie.1 
ChilZiS" l-o.'"'™: m>eiimatic Heart'^b7i;™.c'i ' 

Radium TikaSVcanceVof'C'cenix 

vei.o, POST'GHADUATE courses and lectures 

R&T,!/ Kroi?''Goide™'s '’ Ji;?'<'Ognipiit.j.’'‘‘ IIo,vnfT’%",' 

“a AHl S^t4et 's*W 3'“-®sSei';^'i"?lJ,‘ C/iei.ra ,Tr 

immmmM 

the Fello-.v,7hin of ifalicitiA 1 ivimno/e stlei rv i .“Pl»l<i“‘'»n to 

St'iig.^TeTi^t Tp S-"-.9.-lVed., Clinical 

of ReR^Uon^nJ'sqmn!:”'^™^-'’’ 4 P.m., Errors 

"AMom.nal Pa‘i^.*^"‘“'’‘^'’ "•.C.l.-Thnrs.. 4 p.m., 

'ISSSiS'SSx£F" 

•Voiitk-E,u.t Lo:?Dorposr Gr'im-'.Tr T, , W 
11 — .• eSn "'“Rs’s General 


Exophthalmic Goitre 
C...M,..-At Royal Infirmar^i.Fri.. 


5 SritisI; iitfiiiral Jlssoriaiion. 

0F//67;.S’, BJlITISll MT.BWAh ASSOCtATlO'S IlOUSE^ 
r.lI 7 .ST 067 v ir.C.L 


Doparf/nentff. 

(Financial Secretary and Busincaa 
\Ve&tcent, London), 
discern Westcent, London). 

iHcaicai Journal (Telegrams: Aitiology Westcent, 


3fcdRaV-Sk;g;cair'a„d“S 

Fri., 10.30 a.m., Throat, Nose ’am?‘E^r Clin? <^Perations. 

of Medical Casc^ (Children); 2.3o ‘to S n nV ^ 

Children s Diseases Clinics ; Operations Suigical, Sledical, and' 

Royal CirF.ST Hospital. Citv Road, E.C—Tnes 

Cases in the IVarcls. ' P-m., Demonstration of 

Institute or Public Hr.\LTa. 37 -Rn^von c.. .. 

4.30 r-m.. Some Problems in Sledico-Lcgal Prnolio^^"'^*^^’ H .C.I.-.R'cd., 
^^*1 Endcil Stieet, W.C2— T/tcit^ am 

the Upper UrinarA* Tract and it> Treatmenh Stone in 

South-West Lonpox Post-Graduate a^-sociatiov <i* i 
Onscley Road, Balliam, S.lV.12.-\\ed.. ‘I p.m., Tim Mcd?c'?rn 
Vi^T Loxdox IIosriT.iL Posi-GninriTE Collfc- ‘ ‘ ' ®-'’*P<^Ps>as. 

10 a.m. to 1 p.m., Genito-urinarA- Operations 
JUrds; 2 p.m.. Surgical Wards. Eve and 
Departments; Special Lecture at fl.30 p.m,. C 

y, Jo 1 P-"'" Mrtlical IVnrd-. Venpre.al Diskiire ’ 

Electrical nopartmont ; 2 p.m.. Medical IVnrcls Throat v 
department. ‘ MVd.. 10 a.m. to 1 pmi., Chkal (vand P^l“"^^ 
dciiionslratioii; 2 p.m.. Surgical Wand. Eve Departmcifl ”’‘^5’"'™' 
10 a.m to 1 p.m.. Neurological ncpartmciil. MaJsage 1)1.0.]™™,'- , . 

Eve Ilcpartniciit, pcnlto-nrinar.v IlcpartmciK, Gi iiae??WM ’ay 
y J’;*”.-’ **’*'*” Pcparliiienl, Mc'dical IParil. 

-ledical Trc.)tmeiit Clinic. Eieclrical nepanmont Clinical 
t.nn; 2 p.ni.. Throat, Note, and Ear I)cpartmcnt; Sne]i]? 

D.-paitment. Tlmxat. No<c. ant 

2 p.m.. Medical anil Snrcifal (except Sat.) at 

CLA'COAV ^’O^T-G^ \DU ate ^ 1E''1CAL AcsrvruTTnx- * a» ii- i -w 

MVd.. 05 r.m.. Venereal " Infirmary: 


SuDscr.rp .■ 

Sfaneg 
Mbdical ' 

Editor, jjuim/i 
London). 

'’(,i!^r'''j!,‘,''^4ifico; Aseociotion anil Srittsh Hleillcal 
ioutuL-,)' ® “"‘1 S864 (internal exchange. 

Scottish JItdicii, SrcnT,T\p,v : 6, Drunifhcugh Gardens, Edinburgh (Tele* 

■ “ : 24361 Edinburgh.) 

Il.lsil Jirpicil. ‘rcdcrick Street, Dublin, (Tele- 

Dublin.) 


grams : Cac 


2 FrL London 


S Mon. 


Ofary of tho Association. 

March. 

.... Consulting Pathologi.«,t.s Group: B.M.A. Hou-e. 
luvislock Sipiare, W.C.l, 2.30 p.m. 

Cambridge and Huntingdon Bianch ; Medical Schools, Downing 
Street, Cambridge. B.M.A. Lecture by Mr. Alc.xander Flcinine 
on \ uceme Thcrap>-, 2.45 p.m. 

Hendon Division : Hendon Cottage Hospital. Dr. J. M B. 

Mel/cixl on Ringworm and its Treatment, 8.30 p.m. 

Slid-Essex Division : Annua! Meeting, Bel! Hotel, aiclm'-ford, 
3 p.m. 

Lonilon: SI. Pancras Church, MemoTial Serrice for Sir Damon 
WiUinmx, I.i5 p.m. 

London : Lunacy Drafting Subcommittee, 2.10 p.m. 

0 Tuc 9. Bournemouth Division: Annual Dinner, Roxal Bath Hotel, 

• 7.30 )>.m. 

City Division : Jlefropolitan Ho>pita!,E. 5lr. Norman Patterson 
on Ear Trouble in Generni Practice, 9.30 p.m. 

Covcnrrv Division : Coventry and M'arwickshirc Hoopital. Dis- 
cussion on Dental Sepsis and Internal Medicine, 8.30 p.m. 
FlneUlcy Division : Finchlev Memorial Hospital. Dr. J. W. 

McKee on (Coronary Thrombosis, 8.45 p.m. 

Hastings Division : Queen’s Hotel. Dr. A, E. Larking on Uos* 
pitoJs. General Practitioners, and Others, 8.15 p.m. 

South-We«t Essex Division : Whipps Cross Hoapttal, Levton* 
stone. Clinical Demonstration by Dr. J. C. Muir, 3.30 pirn. 
London : Propaganda Subcommittee, 2.15 p.m. 

Trov/brUlgc Division: Ronndstone House Hotel, Trowbridge. 
Mr. E. Miles Atkinson on Hoarsenesg. Supper afterwards at 
7.45 p.m. 


7 


Thurs. London : Cluiritics Committee, 8.30 p.m. 

Fife Branch : Clinienl Meeting, Moternitv Home, Townsend 
Crc'^cont, Kirkcaldy. Dr. NV. D. D. Smafl on 5Iedical Treats 
ment of Gastric and Duodenal Ulcers, 3.30 p.m. 

Hampstead Division : Hampstead General Hospital. D 
Sutherland on the Heart m Acute Infections, 8.30 p.n 
Kuneatoa and Tamworth Division ; Tamworth Generni 1 
Portsmouth Division : Queen’s Hotel, Soutbsea. 

Livingston will give an itdtlress, 9.30 p.m. Supper 9 
■Wakefield, Pontefract, and Castlcfora Division : S 


9 Fri. 


13 Tues. 


14 M’cd. 


ure'^coni, KirKcaiay. ur. \\. u. u. smaii on Aie 
ment of Gastric and Duodenal Ulcers, 3.30 p.m. 

Hampstead Division : Hampstead General Hospital. Dr. G. A. 

Sutherland on the Heart m Acute Infections, 8.30 p.m. 
!^unentoa and Tamworth Division ; Tamworth Generni Hospital. 

' - • • - ----- Dr. A. 

- - p.m. 

■Wakefield, Pontefract, and Castlcfora Division : Strafford 
Army Hotel, Wakefield. Dr. R. A. Vealc on Common Skin 
Diseases, 7.45 p.m. 

London : Science Committee, 2.30 p.m. 

Chesterfield Division ; 5Iaternity Hospital, Chesterfield. 3Ir. 

G, S. Simpson on the Value of Operations, 8.15 p.iu. 

London ; Committee on Causation of Puerperal Morbidity and 
3Inrf/i)ilv, 2.30 p.m. 

London ; Central Ethical Committee, 2 p.m. 

T — U7.1. nr. Ilf.,.. 2.15 p.m. 

Hospital. Mr. A. H. Todd 


London : Hospitals Comniiltee, 8.15 p. 

Cioydon Division : Croydon General iiuo>.iiu4. 4.4». .x. 
on Various Hip Cases, 4 p.m, 

Lanarkshire Division : St. Enoch’s Station Hotel. Dr. Charles 
Read on Teeth in Relation to Health, 3.30 p.m. 

T_rtnr1r»T> - Tvxu.t rf» n no Anfa UAmmiltoo 19 norto 


Read on loeiii lu jveiunAMi lu rieunii, o.o 
Thurs. London : Insurance .^cts Committee, 12 noon. 

” ■ London ; Lunacy and Jfental Disorder Committee, 2.30 p.m. 

Border Counties Branch : Storms Farm Dairv, Kesw'iok. 5 


Fri, 


Border Counties Branch : Storms Farm Dairy, Kesw'iok. Mr, 
J. A. Spcdiling on the Production of Coitified Milk, 3 p.m. 
■Wed. London : Mcdieo-Political Committee, 2.15 p.m. 


BIRTHS, 3IARR1AGES, ANU DEATHS. 


7'hc charffc for inaertinff finnourrcmcnt of Dirtha, Marriur/cSf and 
Deaths is 9s,, irhirh sum should he forwarded with the notire 
not later than the first jiost on Tuesday morninr/, in order to 
ensure insertion in the cun'cnt issue. 


BIRTHS. 

Cheltenham, on Fcbiuary 11th, 1928, to Dorothy Collett*. M.B., 
id. (mV Millar), wife of' Lieut. -Colonel G. F. CoHotf, D..S,0., 
n. 

IX. — Cm February 28th, 1928, to Dr. and Mrs. T. R. fJordon (i/fV 
>thy 51. Harris, Jf.B., Ch.B.), of 39, M’cllwood Road, GofidmaACS, 

X, a daughter. 

LUM. — On February 2l5.f, 192S, at the CVremont Nni.sing Home, 
..—-gow, to the wife of Gavin McCallum, 5I.B., Ch.B., 16, Nottingham 
renue, Glat-gow, \V.2, a daughter. 

PiXG.— On January 15th, 1928, at 64, Binscarth Road. Toronto, Caiiad.i, 
Agnes II. Topping, 31. B., B.S., and Victor Topping, 31. C.C., a 
cond 8011. 


fr.n.; 7 l^n,. r„bl. 7 hea by .hr BrilM, nt iha?O mee;^.i;(^i;Fs 5 ir 


Collett.— A t ... 

Ch.B.Sl.And 
a son 
Goruox. 

Dorothy ..i. 

Essex, a daughter. 

McCallum. — O n February 2l5.f, 192S, at the CVremont Niii.sing Home, 
Glasgow, to the wife of Gavin McCallum, 3I.B., Ch.B., 16, Nottingham 
Avenue, Glasgow, \V.2, a daughter. 

Toppixg.— O i ’ " — 

to Agnes ... 
second son. 

DEATH. 

M’illtams.— O n Fcbiuarv 27th, 1928, snildonlv. Sir Daw-on Williams of 
Marlow Cottage, Bourne End, Bucks, late Editor of the BRITI.-H MFDinL 
Journal, aged 73. Funeral at Little 3failo\v Ccnioter.\ , Friday. .Mnieh 2nd, 
nt 3.30 p.m. No flowers. 


lare, in the Parish of St. Pancras., in the Coimt\ of London. 



STD PPXjEMBNT 

TO TUB 

BRITISH MEDICAL JOURNAL. 


LONDON, SATURDAY, AIARCH lOrir, 1928. 


CONTENTS. 


i-ac;e 

Tho Future of Hospital Services. .\n .\(Ulro>s by Sir 

r.icuAnn n. Luce, K.C.M.G., I'.R.C.S., M.P 77 

CURRENT NOTE.S : 

CONTEREVCE or CoKSm.TIJJ<i rAmOLOfilSTR 81 

Medicai. OrncEE to Gexeral Post Orrin: 81 

.\SS0CIAT10N NOTICES : 

Table or Dates 82 

BsAsen ASD Division' Meetiscs to se help 82 


rAGE 

NATIONAL INSDR.ANCE : 

Increase of Claims for Sickness and Disability Benefit. 


■ Attitupe or the Iksurasce Acts Cosijiittee 83 

NAVAL AND 511 LIT ARY APP01NT5IENT,S 83 

VACANCIES AND APP01NT5IENTS 83 

DIAItV OF SOCTET1E.S AND LECTURES 84 

ASSOCIATION INTELLIGENCE AND DIARY 84 

BIRTHS, 5IARRIAGES, AND DEATHS 84 


THE FUTURE OF HOSPITAL SER’STCES.’' 


Sm RICHARD H. LUCK, K.C.AI.G., C.R,, 

F.R.C.S.. 5r.P., 

rOEMEELY SUEGEOjr to the DERBY ROYAL IKEIRMARY. 


I DO not think I need apoIogiEo for tho sulijcct of thii 
address. Tho press has recently hecn full of it. and all ol 
us irho are interested in tho troatinont of the si<k aiu 
m the effect that any changes which tho future may hriiif 
forth will haro on the health of tho people and on tin 
medical profession will have been thinking about it durinf 
tho last few months. I confo.ss that, as cliairmaii of i 
miucommitt''o detailed by tho Hospitals Committee of tin 
British IMedical Association to try and work out a police 
on the subject from the professional point of view, it hai 
seldom been absent from my mind, and tiiat I have feh 
a heavy responsibility in a very difficult task. 

Ihero IS no doubt that a cliaiigo in tlie position o: 
lospitals has been going on for .some yoai-s. Tlio develop 
men of institutional treatment as against lioine treatmeiu 
las advanced by leaps and bounds, and the demand foi 
accommodation in hospitals is increasing out of all pro 
portion to the increase of population. 

ihe reasons for this are not far to seek. The complexiti 
modern metliods of treatment, corabinct 
nT.T-D, '^'^pendence which those metliods have on skillei 
r.'iviln.L it almost impossible for them to bi 

tn rlr. +l.n'*i pr'Yate house. Even among tho quite well 

morlorii I lias made the conversion of tin 

bminra./ “S >“1’“ “ '■“T 

rt'rrs' “™i- 

* •' ” means of the ordinarv lioiischolder. More 

humanity of tin 

affovd it' ^ success of the treatment thei 

tionsVb- D entirely removed that dread of institu 

many of ut ®''®n witliin the memory ol 

firt'tbnt'sDl medical thought that regrets tin 

driftino- "i t p'Sp n proportion of medical work should be 
tDste^f 4 .0 would like to make an efforl 

‘ viou vlUob T something in thii 

it is' imnnss'I I ndmit, most of us would agree tlia 1 

nedlsTD : must be faced, ^and the 

civetmtaros!"'"" the’ chaugin. 

eountrv ’ foutulo 1^''“ majority of tho hospitals of this 
have iiepu o ' + i 't charitable institutions 

mnneemeut contributions. The 

__^^ 2 ^ait by the regular annual subscribers to the 




.. Division of 
Society. 


fiinels, though for some years there has hoeii increasing 
representation on tho hoards of those workmen who make 
weekly subscriptions. Since the war, owing to the vmstly 
incrtMi-.eil cost of maintenance, most of tho hospitals have 
passeel through a time of groat financial stress, and for a 
year or two it looked as if the voluntary funds would not 
bo sufficient to keep them going. 

This fear has for the most part proved to be groundless 
owing to tlie wonderful way in wliich tho working classes — 
those who benefit by the hospitals — have come to their 
rescue. Tin's lias been done in a number of ivays which 
have varied considorahlv in different parts of the counti'y. 
In .some jilaces it lias been effected by a system of 
graduated ]).Tvmi'nts for treatment received; in others by a 
great increase in the subscriptions of the working classes 
through their .Saturday funds and tho like; and .within 
tho last two or throe years by the introduction of definite 
contributory schemes by which the contributor of a weekly 
sum is cxcm]itod from any charge for treatment and 
obtains a sort of right, though generally without any 
definite contract, to receive treatment, when ho requires 
it, in tile hospitals covered by his contributorv scheme. 
This comes very near to being an insurance against those 
forms of sickness whicli require institutional treatment. 
But it is not quite an insurance, liecaiiso no definite 
promise of accommodation is made, and tho premium is 
hardly ever sufficient to cover the whole, cost of main- 
tenance and treatment of tho patient. A considerable 
proportion of tho cost has still to he borne out of 
the charitably .subscribed funds and endowmoiits of the 
hcspital. 

The Hosi’it.m. System and the State. 

At the same time a great development of State medicine 
has been going on which brings it into direct relations with 
the hospital system. 

The State has always recognized some responsibility for 
the niodical rare of the poor. It has provided a Poor Law 
medirai service- for those who arc certified to he nnahle to 
provide medical treatment for themselves, and Poor Law 
Iiospitals, for sick and infirm paupers, in coiinoxlon with 
the workhouses. It has for many years also ■ provided 
institutions for the insane and for those who are suffering 
from infectious diseases. But in recent years still further 
advances have been made. A succession 'of Acts has been 
passed in which State responsibility has been admitted for 
new cla.sses of cases. Tlie pregnant mother,' fhe j-oung baby, 
the. school child, the tuberculous, thososnfforing from ve'ncro’ai 
disease, and the cx-soldicr have all in turn been declared 
to bo objects for State responsibilitv-, and public bodies 
Imv-e been authorized to provide treatment for them in- 
cluding hospital treatment when this is ncce^aiy In some 
cases tliis has been dono by arrangement with the existing 
voluntary lio.sjntals ou a contract basis, but in others the 
rc.si,on.sib!c bodies have provided their own iustitiitioiis and 
Bcn’ices. 


rT 244 l 





‘cannot' C V'“ t L ° P‘-ovcnt ‘^nd tin 

I P''a'-ent it. P'-o^sm-o ttfv 7 "'® 

/^;S“S5’?-S;t^^rr* 

I ^atecl th I IID f? for f -j . 

, P«/ted K-f «'?'-o ,r«T atatS,*^af„i,„f‘ anougA to 

I ^^adica^^°f"'Hyilj,,^^" of t;.o data ‘■*''"ard/t3?";\«aed for 

f •'*«ap>ces of nt ?. ^^'"'an o, ' ,’’’/''aJ' it t! "1 "*«- 

"“''■ “-"Sgl S4,?vS«- 



TiUncu 10, 1028] 


Tho Future of Hospital Services, 


r RVPPJMir.xT TO THE 

LURITISH MEDICAI. JOCRXAt. 


79 


invasion of now l)i-nnclios of niodioino, and l>y tlio dovclop- 
niont of tlio Poor Law liospitals into pjoncval hospitals, 
they luo coining into direct compolilion with tho voluntary 
hosjiitals. 

This is an insidious forco and one which is ditRciilt to 
harness and direct. Tho pro])osed reform of the Poor Law, 
now probably postponed for a time, but inevitable in tho 
near future, with tho abolition of tho guardians and tho 
niunicipalii'.ation of all their medical and hosiiital respon- 
sibilities, would at once raise tlio f(uoslion in an acute 
form. iCven at present a good deal of worlc is going on 
in the direction of improving old guardian hospitals and 
building new ones, which, with bettor cr|uipnient and 
increased staffs, arc already undertaking a good deal 
of the medical and surgical work which was previously 
done almost e.xclusively by tlio voluntary hospitals. It is 
only natural that this should happen, and, if it goes 
undirected and uncontrolled, the movement may eventually 
have a serious clTcct on tho voluntai-y hospitals. With the 
public purso behind them, and tho not unnatural de,iro on 
the part of tho local government managers to make good, 
they will provo very fomiidablo competitors. There is the 
po.ssibilily also that when they see that the State autho- 
rities are providing a hospital service out of piddic money 
raised by taxation to which they are forced to contribute, 
tho public will bo less and less inclined to subscribe 
voluntarily to voluntaiy hospitals also, and that the sources 
of voluntary and charitalilo contributions will be dried up. 

This is a very real danger, and unless sometbing is done 
to direct tbo new development and demarcate tho respec- 
tive functions of voluntary and publicly supported hospitals, 
tho rivalry is lUtcIy to go on and eventually cripple the 
voluntary system without any real wish on tlic part of the 
public that this should happen. 

A contingency tliat would effectively seal the fate of the 
roluntary system is tlio possible a'dvout of a Liihour 
Government dctorinined to carry out its avowed policy of 
cstablisliiug a complete medical sctwicc. Sueli au event 
is on the knees of tho gods, or, in view of impending 
legislation, on tho place wlioro tho laps of tlie goddesses 
used to he. At a non-i)olitic.al meeting there is no need 
to discuss this contingency further, and tlio method of 
proveuting it is obvious. 


Should the Tohiiitai'ii Uospiteds come under Slate 
Control? 

The present Minister of Health, Mr. Neville Chamberlain, 
has, I tbmk, realized the position of affairs as regards the 
hosjiitals, and is anxious to do sometbing to remedy tlie 
present confused position lest, in view of tlie possililo 
contingency to wliich I have icfcrred, a worse tiling should 
happen to them. 

In his own repeated statements in Parliament and else- 
where ho has made -it clear that he fully appreciates the 
good iioints of tho voluntary system, and wishes to incor- 
porate ■what he can of it in any future developments that 
may have to bo undertaken by the Government. In the 
Honse of Commons, on December 1st Inst the following 
question was asked: 


WhcUicr in bis proposals for the reform of (be Poor Law and 
TCorg.anization of tbe healtb services of fiie coimlry, i lio Winisler of 
Heallb contemplates that the voluntary bospilals should or would 
come under the control of the State -- 


or the local authorities. 


issued by tbo Ministry to tbo British Hospital Association 
for consideration bt- voluntary hospitals in conjunction 
with local authorities. They deal with the following very 
important points, and are to bo answered in accordance 
with local conditions. 

(1) Tho practicability of allocallng special categories of cases, 
according to tho liospital accommodation in the area, to voluntary 
nnd public liospitals respectively. (It is to bo understood that by 
public liospital Iio means guardian or municipal hospital.) 

(2) Tlio possiliilily of co-ordinaling and demarcating ilie pro- 
vinces of tlio two classes of liospital. 

(3) How such co-ordination or demarcation would modify any 
echeiiics of enlargement in liaiid or in contemplation. 

(4) In what respect, if any, is the shortage of beds most 
serious — for example, surgical, medical, gynaecological, maternity. 
Of orlliopaedic? Is tlicre vacant accommodation in public hospitals 
suitablo or capable of iietng adapted for the type of case for 
wliicli accommodation is specially needed? 

(5) Tho i>ossit)iliiy of ostablisliing by agreement between the 
voluntary liospitals and (lie local authorities some clearing liouso 
to .assist ill tile co-ordiiiaiiou. 

(6) To wliat extent nnd under what conditions could the medical 
slaffs of tlie volnnlary hospitals undertake i-esponsibilily for cases 
or a defmilc inimbor of beds in public hospitals, so that tlio 
patients may lie secured of the special type of experience required. 

These qtic.stions r.aise tbe whole matter — namely, tbo 
possibility of detailing special functions to the newly 
developed local government hospitals, of co-ordinating the 
work of tbo individual hospitals in their respective func- 
tions, and of ensuring that the local government hospitals 
shall bo able to obtain tlic services of tlie same class of 
.consultants that tbe voluntary hospitals have at present. 

It is tlic duty of tho medical inofc.ssion as one of the 
interested parties, and ns being probably the body best 
able to give an opinion on the subject, to formulate their 
ideas and to be in a position to give tlieir opinion to tho 
Minister. 

In trying to do this, it is well to consider what we heVievo 
to be the essential medical sendees for the needs of the 
country. 

The Essexti.il Meuiwu Seuvices. 

These arc well considered and laid domi in tbe interim 
report of the Consultative Council on Medical and Allied 
Services published in 1922, known as Lord Dawson’s Report, 
with its ]Jiimary licaltli centres, secondary centres, and 
supplementary services. Tlie proposals of that report aro 
pcrliajis elaborated in too great detail, and the eanying 
of them out would require very considerable new additions 
to j>rc.scut jnovisions and a too great dislocation of existing 
ones. The essential requisites, us it appears to me, are : 

(1) Tliat there shouid he for every locality an eflieient pulilio 
service of preventive medicine dealing wilh sanitation, epidemics, 
•and oilier group diseases. 

(2) Tliat every individual sliould liave access to a general medical 
prac(itioncr, wlio will liavc personal charge of his hcaltli as an 
individual, and who will have at his disposal some form of 
iiislilulion in which he can treat that individual when he cannot 
he adequately treated in his own home. 

(3) Tlial there should be within reasonable distance a group of 
consultants in all the ordinary specialties wliosc services will be 
available to lielp llie general practitioner when he needs lieip. 

(4) That tlicre .sliould be, also witliiu easy access, an institution 
to wliicli the individual can be sent for special advice, investigation, 
and treatment wlien liis case requires it. 


■ To Ibis iMr. Chamberlain roplied ; 

Ko, Sir. On tho contrary, I regard the pveseYvatiou of tho 
t-oluntary hospital system as a matter of essential importance 
rn tlio licalth mtcr«ts of tho country. lYliat lias been impressed 
on my mind is the absence' as a, general rule at present of 
any systematic arrangements for co-operation in the various 
areas of the country between the voluntarv hospitals and tlio 
iiospitals and institutions carried on bv tlio local authorities. 
!■ have therefore^ suggested^ that it is advisable that there sliould 
he consultation in tlie various areas with a view to arriving at 
an agreed Pjan for institutional provision which would enable 
each Kind of liospital to play its proper pai-t in meeting flie 
o\er-mcrcasing need of the people for hospital necommodation. 
1 sliould anticipate that under such a plan the position of tlie 
voluntary hospitals would bo slrcngthened and not weakened, hut 
i have_ never contemplated putting any compulsion upon them to 
^mo into an arrangement, their participation in wiiich would 
he a matter for then- own determination. 

The consultation took tbo form of a scries of qiiestiona 


The cottage hospitals, wboro they exist, and at jircscnt 
tUoy exist only in country districts, furnish tbo institutions 
for tbo gonoral practitioner, and tbo general liospitals ot 
our big towns jjrovido tbe more fully equipped institutions 
for special consultations, investigation, and treatment, and 
tboy have ns tbeir staffs tbo gioup of consultants needed to 
assist tbo general practitioners. 

Tbe public health part of tbe sclieme is .already well 
developed, and corresponds with tbe local governincnt areas. 
The individual part, tbongb already largely existing in 
most parts of the country, is incomplete, ill-defined, and 
practically not at all co-ordinated, nor does it correspond 
usually with existing local government areas. Moreover 
from the haphazard way in wbicli tbo voluntary hospitals 
have grown up, there are often subsidiary liospitals and 
special liospitals in addition to tlie main general hospital 


so March lO, 1928] The Future o9: Hospital, Ssrv/ces. 


in any given area, and now there is arising tlio added 
complication of municipal and guardian hospitals, which 
are beginning to undertake the same sort of work that was 
previously dono in tho voluntary general hospitals, and to 
coma into competition with them. 

Unless some sort of co-ordination and demarcation of 
function can be brought about, there will be increasing 
confusion and overlapping. 

It seems, therefore, that tho time has como to try to 
bring some order out of this chaos, and, without destroying 
those elements of voluntaryism in management which wo 
consider to bo so essential, to introduce a scheme on which 
tho whole of tho hospital services may hang together. This 
can only ho done by the establishment of some central body, 
which, while having tho confidence of all tho parties con- 
cerned, and having sufficient authority to inako its influence > 
felt in a co-ordinating capacity, will at tho same time 
carefully refrain from interfering with tho individual 
units and allow them to manage their own affairs and 
develop along their own lines with tho greatest possible 
amount of freedom. 

A Central Hospital Council. 

The first step would bo to form a Central Hospital 
Council, appointed by tho Ministry of Health. Its func- 
tions would bo to advise on the general policy of hospital 
development, and to act as a communicating body between 
tho Ministry and the local hospital committees of areas. 
The Voluntary Hospitals Commission already existing, 
though no longer functioning, could form tho basis of this 
Council if it were reorganized to represent tho other 
interests that will have to be brought into tho scheme, 
such as the local government hospitals. 

Local Area Committees. 

The second step would be to map out the country into 
areas and appoint Local Area Committees. Tho areas 
should be largo enough for their committees to deal with 
all tho local governing bodies and all tho hospitals in the 
area. They would probably, though not necessarily, corre- 
spond with county areas, as this arrangement would greatly 
facilitate their organization. The existing voluntary 
hospital local committees, adapted to suit their new , 
functions, might form the basis of tho hospital area ! 
committees. j 

There would be some difficulties in tho employment of tho ' 
county as the basis of the area, as in many cases the 
existing voluntary hospitals go well outside their own 
counties for their patients and spheres of interest. Tho 
local areas, on whatever basis they were formed, would 
probably contain more than one big general hospital, and 
would have to bo subdivided into groups of hospitals, each 
with its own administrative subcommittee, 

Tho raison d^etre for tho formation of such a group 
would be ; 

(a) Tho needs of tho population as ascertained by 
experience. _ •' 

h existence of a suitablo central or primary general 

(c) Tho position and grouping of the secondary hospitals 
round it. r 

Tho qualifications for a hospital to become a central or 
primary one would bo: 

(a) That it is of adequate size and of sufficient superiority 
as regards staffing and equipment. ■' 

(h) That it acts as a consultative centre. 

(c) That it is able to deal with tho investigation of the more 
difficult cases. 

(d) That it undertakes tho more specialized methods of 
treatment. 

A hospital with which a medical school is attached would 
naturally fulfil these requisites, and they would bo fulfilled 
also by most of the general hospitals of our provincial 
towns. Under existing conditions tlio primary ]iospit.als 
would generally ho ono of our bigger voluntary general 
bi.spitals. In some cases there may be existing municipal 
hospitals which with somo development will he suitablo to 
tako their places as primniy hospitals. In other cases, 
especially in newly developing centres of population, whero 
cxperionco shows that n group should bo formed, but in 
which there is no existing hospital suitablo to take its 


placo as a primary hospital, such a ono will have to ha 
developed. 

.Tho duties of tho group hospital suheommittoes would 
have to ho carefully defined and limited so as not to inter- 
fero with tho autonomy of tho individual hospitals, and 
would not includo intorforenco with internal finance, 
management, or tho election of governing bodies and staffs. 
Its functions, chiefly advisory, might include tho following : 

(а) Tho co-ordinat.jn of tho admission and transferenco of 
in-pationls. 

(б) Tlio establishment of a clearing house or bureau to 
carry tliis out. 

(c) To adviso on and direct tho development of new 
hospital accommodation for tho area. 

(dl Tho co-ordination of tho ambulance transport service. 

’ ’ (c) Tho insurance of a uniform - system of accounts and 

records. 

‘ (/I'Tho organization and distribution of massed voluntary 
contributions. 

ig) Tho distribution of any Government grants-in-aid that 
may become available. 

Co-ordination of Hospitals. 

In any attempt to co-ordinate tho various hospitals in 
an area, and possibly to demaveato separate functions to 
individual hospitals, tho most important point to remember 
is tho educational function of tho primary hospital. In 
those liospitnls with whicli a recognized medical school is 
associated this function is obvious, hut it is by no means 
confined to them, because every general hospital is a school' 
inasmuch ns it is tho training ground of its staff. The 
residents are all in reality advanced students learning 
tho practical work of their profession, and the honorary 
staff themselves obtain their experience and train them-’ 
selves and ono another in their particular specialties ill 
them, and can only really reach the requisite standard to 
become tho consultants of their area by tho practice they 
obtain in tho hospitals. 

It is essential, thcref .re, that a primary hospital shall 
not be debarred from dealing with any class of cases that 
may be useful from an educational point • of view. It 
is likely that the primary hospitals will be used more and 
more also as centres for post-graduate and refresher work; 
for those practitioners of the area who care to tako advan- 
tage of them. 

Ono of the most difficult parts o£ tho work of co-ordina- 
tion will be the fitting' of the secondary hospitals into 
their position in tho general scheme. 

The place of cottage hospitals is simple. They will be 
general practitioners* hospitals, and will be equipped for, 
and cater for, tho work which can usefully be done by them. 

Special voluntary hospitals ha-ve grown up in a somewhat 
haphazard way to fill the gaps and provide tho additional 
beds required in tho area for their specialties; and without 
in any way making them subservient to tho primary hos- 
pitals, or interfering with 'their complete freedom as units, 

1 think much can he done to prevent ‘overlapping and to 
ensure that they too may servo a useful function by 
carrying on their special work and by making use of their, 
material for educational purposes. 

■ Tho question of the new and newly, developing publio 
hospitals is more difficult, hut it is in order to do something 
to bring them into line with -the scheme and to prevent 
their becoming competitive and overlapping that tho 
co-ordinating machinery is really necessai-y. As already 
stated, a few of them, such as some of the big Poor Law 
and municipal hospitals of London and some of tho biggest 
towns, are already almost fit to ho primary hospitals, and. 
others may be developed so as to become so, but the majority 
will only be needed to coihplete and fill in gaps of the 
work of the existing voluntary primaiy hospitals. 

These institutions will still have to provide accommoda- 
tion for those chronic cases which have never come within 
the scopo of the voluntary hospitals, and in future, with 
better equipment and more complete staffs, they will also be 
able to deal with a great mass of surgical and medical -work 
■which cannot at present be carried out by the voluntary- 
hospitals owing to lack of beds. 

Tlioro is no doubt that to enablo them to do this many 
of them will have to bo remodelled or rebuilt, and 
will have to bo staffed on a much more ample scale. Bu 
I see no reason wliy this should not bo done, nor why they 








MAHCII 10, 1923] 


Naval and Military Appolntmonts. 


r SUPPLEiTEST TO THB 
LDRITISII AIEDICAL JOUBNIL 


83 


^Intionnl Sfiisumncf. 


INCREASE OF CLAIMS FOR SICKNESS AND 
DISABILITY BENEFIT. 


aro eccondcd under the provisions of Art. 205, no 5 *al Warrant for Pay and 
Promotion, 1026. 

Tho following have been granted commissions as Lieutenants on 
probation : 0. Tj. Day, 0. T. L. Archer, D. It. W. Burbury, P. J. h. 
Capon, P, Dwyer, K. McNeill, M. R. Burke, P. W, A. Agnew, J. C. 
Qllroy, J, W. Kendall, W. A. R. Ross, P. V. ilaeGarry, and J. G. Weston. 


Attitude of the Insurance Acts Committee. 

The following letter 1ms been addressed by tho Medical 
Secretary of tho British ^Icdical Association to tlio Secre- 
tary of tho ^linistry of Health dealing with tho remarks ! 
made by tho Minister of Health about tho responsibility 
of insurance medical practitioners for the increase in tho 
number of claims for sickness and disability boneht, and 
tlio interpretation put on tboso remarks by certain news- 
papers. 

Sir, — At its meclini; on February 23rd tho Insuranco Acts 
Commiltco directed me to say that tho Committee liad been 
greatly disturbed by the interpretation placed by tlio la.y press 
of tho country upon some remarks made by the Minister of 
Health at the luncheon of tho National Conference of Approved 
Societies held on the 20th ult. In his remarks tho Minister 
apparently made special reference to tho increase in the number 
of claims for sickness and disability, and is construed by the 
press as having emphasized as a specially prominent cause of 
this increase tho failure of practitioners to bo suflicicntly 
particular about certification, and as having suggested that this 
■was probably duo to a fear that persons refused a certificate 
might go to a competitor. 

You will have noted the way in which certain newspapers, 
some of a responsible character, have utilized these remarks 
in accusing panel doctors as a class, of being (vide tho Times 
of February 23rd) unsuiled to arrive at judicial decisions 
about the working' capacities of their patients — a cliarge which 
the Committee considers to bo a very grave reflection on tho 
honour and moral and intellectual stamina of tho medical pro- 
fession. This is only one example. There arc others in whicli 
tlic words of the itinistcr are being used, perhaps with less 
responsibility but with more venom, in attacking insurance 
practitioners as a class. 

At the present time, and at tho request of the Ministry, 
representatives of tho Insuranco Acts Committee and of the 
Ministry are together exploring a position whicli even pre- 
liminary* investigation has shown to bo very obscure and 
complex. Such exploration must needs bo made even more 
difficulty if an impression is created, and allowed to persist, 
that the Minister (and possibly liis advisers) has already 
decided where the burden of culpability lies, 
y The Committee' would earnestly request the ^linister to take 
immediate steps to combat the unfortunate construction placed 
upon his remarks, which is conveying tlic impression tliat he has 
^ready made up his mind that tlio increase of sickness claims 
IS due in the main to the fault of the doctors in tho service. 
If this were indeed his opinion it is unnecessary to point out 
^ you how utterly futile it would bo for the Insuranco Acts 
Committee to continue^ ■with you the discussions, already begun 
_at the time of the Minister’s speech, whicli we believed were 
to constitute a serious scientific inquiry into a difficult and 
complex matter- — I am. Sir, your obedient Servant, 

Alfred Cox, 

March 1st, 1928. Medical Secretary/, 


Jlabal anb ^Rtlttarg ^ppointmints. 

„„ „ NAV.\1, SIEDICAL SERVICE. 

iSriH 

Commander. Surgeon Eieutena 

Pemlfuke for“R Beaufort ; G. Rorison fo t: 

for RK Barracke, Chatham; J. w. Nesbitt to the liUro. 
A. Kingston to tho Aeflelt; J. a. K. Fitzgerald to the riindcT!. 

„ , „ EOTil Nu’ll, VOLCNTEEn RESERVE. 


Tl > r 1 , T JIEDIC.VL CORPS. 

Umit“for^?o°moi,Isorv‘r't^'^ O.B.E., having attained the 0 

“fio'r“Ws;ry?e«^ P®'-- 

on ^cou?*: oVui h’eam'/e^Sed'b^ wounV'^-'^-’ 
ar.l^rdlSiK |e'°r?nlfo,”nro“v. sfaTo? 

Buis°h Captains to to Majors : D. Crellin, 5I.C. (prov.), a 

^®P°o^d3 relinquishes his commission. 

Tho foffio.? S. Littlepage and G. L. Grieve. 

^ W UavwiT^ 2® probation are confirmed in their ran 

Carer M r n ’ t’ 1 0-Dwver, H. A. Ferguson, do 

wFa.^H “linl O-Sullivan-Bearc. 

. Ro_s and P. \. MacGarry to bo Lieutenants on probation, a 


ROYAL AIR FORCE MEDICAL SERVICE. 
Hying Officer J. E, Foran to Palest ino General Hospital. 


INDIAN MEDICAL SERVICE. 

Colonel O. Browse, D.S.O., and Licut.-Colonel W. W. Jeudwlnc, C.M.G , 
faavo retired from tho sendee. 

Llcut.-Coloncl F, E. Wilson, Civil Surgeon, Quetta, Is appointed to 
officlato ns Residency Surgeon and Cliief Medical Officer in Baluchistan, 
in addition to his own duties. 

LleuL-Colonel R, W. Anthony, Officiating Surgeon-General with the 
Government of Bombay, is confirmed in that appointment. 

Licut.-ColoncI L. J. M. Dcas to bo Colonel, vico Colonel R. W. Knox, 
D.S.O. 

Major O. H. Smith. O.B.E-, an Agency Surgeon, on return from leave, 
Is posted as Agency Surgeon in Bundelkhand. 

To bo Captam: A. J. C. Culhanc (senioritv September 10th, 1923). To 
bo Lieutenants : E. G. Xlonlgomery (seniority July 22nd, 1925), G. F. 
Taylor (senioriW April 29ili, 1926). (The notification in the Gazette of 
August 6th, 1927, in so fnr as it relates to these ofTicers is cancelfcd.) 

Tho provisional promotion of W. Lawie to the rank of Captain, as 
notified in Army Department Notification No. 1225, dated September 2Ath, 
1926, is confirmed. 


VACANCIES. 


Atr Couxtt Hostital. — ( 1) Senior House-Surgeon. (2) Junior House- 
Surgeon. Males. Salary at the rate of £100 and £80 per annum respec- 
tively. 

BiRSOKcnAM AND MIDLAND EiR AND Throit HOSPITAL. — Second House- 
Surgeon (non-resident). Salary at the rate of £150 per annum. 

BlRMlNGUAM AND MIDLAND HOMOtOPATIIIC IIOSPIT.AL AND DISPENSARY.— (1) 
Honorary Anaesthetist. (2) Honorary Consulting Ophthalmic Surgeon. 

Bournemouth : Royal Victoria and West Hants Hospital.— Honorary 
Medical Officers to the Out-patient Department for the treatment o‘f 
Nervous Diseases. 

Brighton County Borough.— R esident Medical Officer at the Borough 
Infectious Disease Hospital and Sanatorium (mole, unmarried). Salary 
at tho rato of £3W per annum. 

OniRiNO Cross Hospital, W.C.2.— (1) Assistant Surgeon. (2) Surgical 
Registrar; honorarium £150 per annum. 

Connaught Hospital for Walthamstow, Wanstrad, and Letto-n.— ( 1) 
Honorary Radiologist. (2) Senior Resident House-Surgeon. (3) Junior 
Resident House-Surgeon. Salary for (2) and (3) at the rate of £100 
per annum. 

CossitAM Memorial Hospital, Kingswood, Bristol.— Resident Medical Officer 
(male). Salary £150 per annum. 

Croydon General Hospital.— Casualty House-Surgeon. Salary £125 per 
annum. 

Herepord County and City Mental Hospital. — S econd Assistant Sledical 
Officer (male, unmarried). Salary £350 per annum. 

Hospital for Women, Soho Square, W.I.— Resident Medical Officer. Salary 
at tho rate of £100 per annum. 

Kino Edward VII Hospital, Windsor.— Honorary Ophthalmic Surgeon. 

King’s Collegf. Hospital, S.E.5.— (1) Two Junior Surgeons. (2) Junior 
House-Physician for Diseases of (Children. 

IiiVERPOOL Open-Air Hospital for Children, Leasowe. — Junior Medical 
Officer. Salary £^00 per annum. 

U-ANcuester: Ancoats Hospital. — Clinical Assistant to the Ear, Nose, and 
Throat Department Out-patient Clinic. Fee 10s. 6d. per clinic. 

Manchester: St. Mary's Hoshtals. — Two House-Surgeons each for the 
Whitworth Street West Hospital (Maternity), and for the Whitworth 
Park Hospital (Gynaecological). Salary at the rate of £50 per annum 
each. 

Merthyr General Hospital. — Resident House-Surgeon. Salary at the rate 
of iHOO per annum. 

Kewcastle-dpon-Tynr City and County.— Assistant Medical Officer of 
Health. Salary £750 per annum, rising to £900. • 

Newcastle-upon-Tyne ; Hospital for Sick Children.— (1) Junior House- 
Surgeon (non-resident). (2) Resident House-Phvsician. (3) Resident 
Senior House-Surgeon. Salary at the rate of £100 per annum for (1) 
and £95 per annum for (2) and (3). 

Nigeria : Medical Research Institute. — Biochemist and Prctozoo]ogi«t. 
Emoluments £800 per annum, rising fo £960, together with senioritv 
allowance, also staff pay at the rate of £150 per annum if possessinr' a 
medical qualification. ° 

Palace Sanatorium, Montana.— Assistant Phj-sician. Salary £400 per 
annum. 


Rochdalb INFIRM.ARY AND DISPENSARY.— Junior House-Surgeon (male). 
Salary £200 per annum. 

Royal Gwent Hospital, Newport, Jlon. — House-Surgeon. Salary at the 
rato of £125 per annum. 

Royal Northern Hospital, Holloway, N.— (1) Hoiise-Phj'Stcian. (2) 
Obstetric House-Surgeon. Salary at tbo rate of £70 per annum eacli. 

Rugby: Hospital op St. Cross. — Senior and Junior Resident Medical 
Officers (males). Salary at the rate of £150 and £100 per annum 
respectively. 

St. Mary’s Hospital: Institute of Pathology and Researcti, Paddington 
\\\2 , — ^Research Studentship. Honorarium at the rate of £200 per annum.’ 

Salford Royal Hospital^— (1) House-Surgeon attached to the Orthonaedie 
Department. (2) House-Surgeon. Salary at the rate of £125 per annuni 

• each. 


Seamen’s Hospital Soctety.— Assistant Medical Officer at the King Georre’a 
Sanatorium for Sailors, Liphook. Salary £200 per annum. ** 

Sheffield; Royal Infirmary.— Ophthalmic House-Surgeon. Salary £80 
per annum. 

■Wist London Hospital, Hammersmith Road, W.6.— (1) Honorarv ■Medical 
Registrar. (2) Housc-Physician. (3) Two House-Surgeons, (fll'lionorarv 
Anaesthetist. Honorarium for (1) £100 per annumT and salary ^t tlm 
rato of £100 per annum for (2) and (3). ' ^ 

Westminster Hospital, Broad Sanctuary, S.W.I.— Assistant Su- rirtiX 
Registrar. Honorarium at tho rato of £50 per annum. 





SXJ PPLE3N4DE JSTT 

TO THE 

BRITISH MEDICAL JOUBNAL. 

LONDON, SATURDAY, MARCH 17Tn, 1928. 


CONTENTS. 


rACK 

Pay Beds and tlio Future or the Voluntary Hospitals. 


liy C. M. WiLsoK, JI.D., F.R.C.r 85 

CURUF.NT KOTES ; 

B.M.A. ScnotAr.smrs .tsii Gsasts 87 

JIeDICAI. ClIAIilTlES 87 

SciEXCE Committee 87 

Sir Charles Hastings Lelti're 87 

ASSOCUTION NOTICES 88 

MEETINGS OF Iin.ANCHES AND DIVISIONS 89 

CORRESPONDENCE 90 


PAGE 


NATIONAE INSURANCE : 

Proposed Changes in Administration and in Treat- 
ment Bcnoilts 89 

■ Increase of Claims for Sickness and Disability Benefit ... 90 

NAVAL AND MILITARY APPOINTMENTS 91 

VACANCIES AND APPOINTJIENTS 91 

DURY OF SOCIETIES AND LECTURES 92 

ASSOCIATION INTELLIGENCE AND DIARY 92 

BIRTHS, MARRIAGES, AND DEATHS 92 


PAY BEDS AND THE EUTUJIE OF THE 
YOLHNTAHY' HOSPITALS. 

BT 

C. M. AVILSON, M.C., M.D., F.R.C.P.. 

PHYSICIAN TO OUT-PATIENTS, ST. MART’S HOSPITAL, AND DEAN OF THE 
MEDICAL school; COKSDLTINO PllYSICTAN TO THE PADnlNOTOX 

infirmary. 


The need for these beds is, I sHppo.sc, no longer hi (jiicstion. 
It is a general and oven-day cx])oricncG of pliysiciaiis in 
practice that ivhilo the homes of the middle class arc ill 
adapted for the treatment of grave maladies, this class can 
no longer afford nursing homo fees. It is not so much that 
tho average minimum ivoekly fee — nine or ten guineas in 
Central London and eight guineas iu the suburbs — is 
prohibitive, as that tho cost of acccssoiy investigations, 
such as a: rays and laboratory tests, makes tho whole pro- 
codnro impossible. Accordingly this class is seeking insti- 
tutional treatment, and tho qiiostioii at issue is really 
whether this will bo provided in paying wards of existing 
hospitals or in special paying hospitals built expressly for 
that puipose. I am not here conconiod with details, which 
are the province of those who have had o.xporienco of such 
beds in practice. It is my present ]iurposo only to argue 
that the teaching hospitals in London will bo driven to 
espouse the first alternative, alike for the proper discharge 
of their educational mission and to safeguard their very 
existence. 


The Position if the Vghinf-ary Ilospitah Hold Aloof. 
Consider the position that must arise if the voluntary 
hospitals fail to make provision of this kind. The middle 
class will build its own paying hospitals, and will build 
Uicm, as we are told by an ofiicial of King Edward’s 
Hospital Fund for London, for two million persons. That 
figure IS the estimated number of tho middle class in 
London, but it is probable that in the future this tendency 
wm not be confined to the middle class, and that all 
sections of the community will eventually seek institutional 
rcatment m grave illness. This view is based on certain 
figures which, in tho absence of a register of nursing 
homes I had prepared for the Pay Beds Committee of 
ung Edward s Fund. As a result of systematic inquiries, 
of the first half of the 410 nursing homes in the Buff 
lelephone Book it would appear that there are in the 
mirsmg homes of London between three and four thousand 
leds, that one-tliird of these hods have no operating theatre, 
lat less than a quarter are seiwed by a lift, and that 
a most u itliout cxcoptioii they h.ave no a;-rav apparatus, no 
a oratory, and no resident doctor. From my oivii expe- 
these homes 1 am impressed with their efficiency, 
"Ufild he the first to admit that, owing to these 
I f fitioiis, those who use nursing homes must eventually 
” choice between the same two alternatives 
non coiifroiit the middle class. Either these homos will 


become centralized into large pay hospitals, or jiay beds in 
existing liospitals will expand and serve the class now 
using nursing homes. Tho change will no doubt come so 
gradually that individual hardship will scarcely arise. In 
brief, if the voluntary hospitals hold aloof they must bo 
prepared to see springing up at their doors other institu- 
tions that will enjoy the support of all those who can afford 
more than tho maiiiteiianco fee now charged by most 
hospitals to those who are able to pay it. 

AVhilc this is happening the Poor Law infirmaries will 
become municijinl hosjiitals, only differing from tho volun- 
tary hospitals in tho financial attractions they can offer to 
the resident and visiting staff. This change may seem to 
many a leap into tho future, but to those of us who aro 
intimately associated with these institutions, and who are 
aware of’thc change in their character since tho war,, it is 
only a matter of time. Mr. Neville Chaniherlain may fail 
for the moment to persuade tho Cabinet to father a bill to 
place the infirmaries under tho London County Council, 
hut that measure cannot bo long delayed. Further, it is 
perhaps not generally understood that the development of 
the infirmaries into municipal hospitals, speaking generally, 
will not bring up tho stumbling-block of capital expenditure. 
Ill tho main it will mean increasing the iiunihor of resident 
medical officers, enlarging the existing arrangements with 
consultants, and altering the rules of admission of patients. 
In the present temper of the democracy it is not concoivablo 
that these municipal hospitals, charged with the caro of 
the sick poor, and with the rates behind tliem, will he 
content to stop short of cfficienc 3 - if that depend onlj- on 
an increase in annual expenditure. 

If this view of the future bo correct, a volimtar 3 - hospital 
miglit find itself between a large municipal hosiiital with 
well-paid consultants and residents and a large pa 3 ’ 
hospital providing institutional treatment for all those 
who can afford more than maintenance. Tliose who are 
friendh- to the volniitaiy system could not view such a 
contingency- without misgiving. On the financial side they 
might reasonably fear that once the sick poor are efficiently 
provided for out of the rates, snpiiorters of tho voluntary 
hospital, harassed b 3 - increasing taxation, ma 3 - feel relieved 
of further rcspoiisibilit 3 - for their caro, wliile 1 ) 3 ' their 
failure to provide within their walls for those who can 
afford to pa 3 - for treatment they would have lost a golden 
opportunit 3 - of attaching subscribers to their fortunes by 
new and more personal bonds. There are, in short, 
sound financial grounds for the view that if the voluntary 
system yvith its precious spirit of service is to survive, it 
must no longer confine its ministrations to one section of 
the community-. 

But apart from financial considerations, if a situation 
of this liind should arise it ivould prohabh- undermine tho 
efficiency- of the volimtai^- ho.spitals in other wavs. Tlio 
prestige yvhich they now enjoy depends mainly on their 
poirer to attract picked men to their staffs. IVIicthor that 
power will ho imjiairod if these men can acquire experience 
in municipal and paying liospitals without tho long hours 

ri234] 



86 March 17, 1928] Pay Beds and the Future of the Voluntary Hospitafs. 


anJ years of unreramicratire, or at any rato not directly 
rciiniuerativo, toil is at least open to question. An argu- 
ment of that kind, which opens up tho whole sources of 
consultant practice, is beyond tho scope of this discussion. 
This much may, however, be said. It is not wrong ethically 
that doctors should wi-ite on disease in tho columns of the 
lay press, but it is inexpedient, because it is an attempt 
to enlarge their practice by appealing directly to an 
ignorant laity, and not, as in tho past, to a critical body 
of general practitioners. If the custom became prevalent 
it would undermine the necessity for building up a sound 
reputation in the profession and woidd put a premium 
on those who possess only a flair for tho frailties of a 
democracy. It is therefore of some importance to tho 
future of medicine that consulting physicians and surgeons 
should continue to look to tho teaching hospitals as tho 
direct avenue to practice. Plainly the growth of largo 
paying hospitals altogether independent of the teaching 
hospitals, with tho opportunities they would offer of acquir- 
ing practice without the intervention of tho general 
practitioner, together with the creation of municipal 
hospitals paying considerable salaries to their consultants, 
offer, an alternative to the method by which consulting 
practice has hitherto been built up — an alternative that 
must be jealously scrutinized if tho standards of practice 
are to be preserved. 

Practical Pifjic’uUies. 

Tho needs of the middle class have been widelj' venti- 
lated of late, and in such discussions general principles 
have tended to become submerged in a confusion of detail. 
Siieakers have been busy with measures to i-cstrict tho 
scheme to tho middle class. They have been preoccupied 
as to who shall decide it the patient is financially eligible — 
whether the secretary of tho hospital or a special com- 
mittee — and whether the yearly income shall be declared 
and the fees charged reported to tho coinmittoo. But in 
fact there are but two practical difficulties in opening pay’ 
wards in existing voluntary hospitals; the first is con- 
cerned with tho source from whicli the initial capital out- 
lay will come, and tho second with tho position of the 
general practitioner in any such schemo. Probably financial 
difficulties will be ovorcomo by. public appeals for the 
necessary funds, and I believe that when the report of the 
Pay Beds Committee of King Edward’s Hospital Fund for 
London is published it will be found that these appeals 
will receive the blessing of this Fund. This endorsement is 
so vital that it is perhaps relevant to give reasons for this 
view. It would appear from the experience of hospitals 
which have paying wards already that a weekly charge of 
five guineas meets maintenance without profit or loss if 
rent, lighting, and the like are charged by that hospital 
against these beds. The present proposal provides that 
the middle class should get at cost price everything that' 
the hospital can provide except medical attendance, and 
Uioso wlm are responsible for tho administration of tho 
King’s Fund have therefore to inquire what are the 
advantages to tho community and to the hospital which 
justifi’ a section of tho community in receiving medical 
lodging at cost price. They may conclude that the increased 
supiiort which may bo reasonably expected from this large 
section of tho community would react very favourably on 
the subscriptions to the voluntary hospitals, and indeed 
that their trust on behalf of the public health is not dis- 
charged while such a large proportion of tho community 
is denied the benefit of institutional treatment. They 
will certainly decide that there is no real difference in 
principle between taking patients paying three pounds 
or thereabouts, as is not unusual in the wards of voluntary 
hospitals at present, and taking patients into those hos- 
pitals who should pay five guineas as now proposed, if the 
hospital makes no inofit. Tho difference is one of degree, 
not of kind. It may bo said that if tho doctor is paid 
that in itself constitutes a departure in principle, but it 
must be remembered that medical opinion is shaiqily divided 
already whothcr medical men should bo paid for treating 
those jiaticuts who now pay for their maintenanco in part 
or ill whole, or have this paid for them by tho State or bv 
muuiripal bodies. The question of principle is involved 
only it money collected for tho sick poor is spent on 


another class witliout this indirectly benefiting tho sick 
poor by increasing subscriptions to tho voluntary hospitals. 
But apart from tho olfect on subscriptions of tho desire 
to provide institutional treatment for the middle class, tho 
authorities of tho King’s Fund may find a moro consider- 
able argument for providing accommodation in existing 
institutions for members of this class, and it is this — that 
this stop may have a decisive effect in safeguarding the 
future existenco of tho voluntary hospitals. 


Pay Beds and the General Practitioner. 

It is, however, the second practical difficulty which 
threatens, if it is not handled with insight, to wreck tlio 
whole scheme. A measure of this kind and scope must 
ultimately stand or fall by its success in winning the 
support of tho general practitioner. Existing schemes have 
been on too small a scale to arouse his interest or opposi- 
tion, but if pay wards are to become general the matter 
would take on a different complexion. Indeed, in siiito 
of tho consensus of opinion that these bods arc urgently 
needed they might bo difficult to keep filled if the general 
practitioner was opposed to them. It is not, however, on 
grounds of expediency, however weighty, that I base my 
view that practitioners must be in the future more closely 
associated with hospitals, but rather on broader educa- 
tional grounds. The day is coming when these pay beds 
will bo found in every institution, great or small, when 
every doctor in tho land, and not a mere fraction of the 
profession as now, will have frequent opportunities of 
treating his cases under hospital conditions, where his 
diagnosis must often pass the test of half a dozen labora- 
tories before it is established, where now knowledge is 
automatically put before him in tho process of proof, and 
where tho cold wind of criticism blows upon credulity. He 
will remain in contact with his hospital not for a few years, 
before ho has obtained a diploma, but throughout his pro- 
fessional life, with incalculable gain to himself and to the 
whole practice of his calling. I say deliberately that a 
change of that kind, coming quietly as a side issue to a 
now demand upon tho hospitals, might, by raising the 
standards of professional efficiency, do moro for tho healtli 
and ’ happiness of the people than many years of con- 
sidered legislation. Holding thi’s faith-that ultimately no 
competent practitioner will bo excluded from hospital prac- 
tice— I yet believe that it is only fair to examine tho 
question from tlio angle of those who are naturally jealous 
for the fair name and established reputation of tlm volun- 
tary hospitals. Those institutions are responsible for what 
happens within their wails, and it is plain that even if 
my view found sympathetic consideration, measures must, 
be taken to safeguard existing standards of treatment and 

diagnosis. • ■ • i a 

It is tempting to seek a comproinisc, to lay down,, 
for example, that general practitioners should be barred 
from surgery, but should be allowed to look after medical 
cases, which they already do at the houses of patients. 
This would probably meet the general practitioners 
view, for perhaps few of them unconnected with hospitals 
do much surgery in London. It would be accepted as 
reasonable, but it would evade the real difficulty, and it 
could not meet tho higher interests of the profession in 
safeguarding - the standards of hospital medical practice. 

I am not disposed to support that assertion by cohibatiiig 
in detail the prevalent view that the treatment of medical 
cases is necessarily more simple than that of surgical cases. 
Those who subscribe to such a view are perhaps bettor 
aware of the standards that may reasonably be expected 
in surgery than in medicine. To be precise, tho con- 
sequences of a technical error in abdominal, surgery are 
more dramatic — shall we say moro blatant?— than tho pro- 
duction of coma in the treatment of diabetes through 
ignorance of the laws of metabolism. Tho medical mis- 
creant is sometimes ignorant of his crimes. The arguiiieiit 
goes deeper. Unless the existence of medical consultants 
on the staffs of hospitals is an anachronism, their exist- 
ence inijilies that additional yeais of study are necessary to 
acquire tho standards of hospital medical treatment. If> 
in an attempt to exclude the weaker tj'po of piuctitioncr 
so as to safeguard tho reputation of tho hospital, the 
pirivilcge of attending the medical pay wards is extended 








90 March 17 , 19281 


National Insurance. 


r ni'rrT,r,iiF.2!T to th* 

LliKITIHM 2Ir.llICAL JOUBKAL 


continiions period, aFcragiiig t^vo yoavs and nine months, 
hefore his insurance can be terminated, and if he returns 
to employment before the end of this period lie avoids 
any break in the continuity of his insurance, both for 
health insurance and for pension. Provision is also made 
to prevent genuine unemployment causing persons to lose 
their title to old ago pension, and for placing voluntary 
contributors on an equally favourable footing ivitli that to 
be enjoyed by others. Power is to be taken under the 
bill to make regulations under which no penalties will be 
attached to arrears of any member which are due to 
genuine unemployment, and provision is made to give 
financial assistance to societies to assist them to boar the 
resulting additional burdens. It is stated that the maxi- 
mum additional cost to the Exchequer is approximately 
£40,000 a year. 

Several clauses are designed to prevent the recurrence 
of known abuses of the existing Act. Where benefit is 
being withheld from an insured person hy reason of his 
receiving maintenance in a hospital, it is provided that at 
least part of the benefit shall be paid to his dopolidants, if 
any. Such action is at present left to the discretion of 
the approved society. Money not required for the above 
or for other purposes accumulating during the stay of 
persons in institutions must not be paid, it is proposed, in 
lump sums (except in the case of maternity benefit), but by 
weekly instalments, and the total must not exceed £50, any 
balance going to the central fund, which is a fund avail- 
able for liquidation of deficiencies of societies on valuation. 

The 1924 Act provides for the recognition, under certain 
conditions, of medical institutions through which insured 
persons may elect to receive medical benefit instead of under 
the normal arrangements from insurance practitioners. The 
Act also allowed insured persons in certain circumstances 
to make their own arrangements for medical benefit, and in 
a few cases, it is alleged, advantage has been taken of the 
latter provision to permit of tlie existence of medical 
institutions which have not been recognized under the 
former provision, and which do not in some rcsiiccts satisfy 
the requirements of the Ministry. To meet this, the bill 
provides that the original recognitions shall all be annulled, 
though institutions now recognized will bo entitled, within 
a prescribed period, to apply for fresh recognition, and a 
clause has been put in the bill to render the abuse named 
above impossible in future. In hospitals and similar institu- 
tions whore the nursing and domestic staff obtain their 
medical treatment from the medical staff, a saving clause 
will permit the continuance of the “ collective omi 
arrangements.” 

Neio Additional Benefits. 

At present approved societies are allowed to make sub- 
Bcriptions or donations to hospitals or similar charitable 
institutions out of the general benefit fund, and Insurance 
Committees^ have a similar right. In addition to retaining 
as an additional benefit the right of societies to make 
payments towards the cost of the treatment of their 
members in hospitals, the bill provides a new additional 
benofit undoi which the societies may^ out of any disposable 
surplus, make payments to approved charitable institutions 
in respect of any treatment of members that is provided 
by the institution for the prevention or cure of disease, 
not being treatment within the scope of any other additional 
benefit or of medical benefit. Societies havin'^ no dis- 
posable surplus may also make occasional smair subscrip- 
tions to hospitals or other charitable institutions out of 
the ordinary benefit fund, subject only to the consent of 
the hlinistcr. The right of Insurance Committees to make 
similar payments is retained, subject to the consent of the 
Minister. Further, provision is made for societies to grant 
out of a disposable surplus occasional subscriptions or dona- 
tions, up to a proscribed maximum, as charitable gifts to 
hospitals or similar charitable institutions, or for medical 
research. It is proposed to strengthen the power of the 
Alinistcr to secure the maintenance of a proper standard 
in the administration of additional treatment benefits, 
which are now being given to the c.xtent of about £4,000,000 
a year. 

The position of deposit contributors is dealt with in 
a clause which proposes the creation, for those who prove 


that the}' are unable by reason of the state of their health 
to secure admission to an ap])rovcd society, of a special 
group (the Dejiosit Contributors’ Insurance Section), in 
which they will, foi- most jnirjmsc.s, be on the same fooling as 
members of .societie.s, receiving the. ordinary benefits, but not 
the additional benefits, and will bo freed from the dis- 
abilities they have hitherto .suffered b}- reason of their 
inferior insurance status. As this section will be composed 
entirely of “ bad lives,” special arrangements are proposed 
to secure its solvency. 

Other changes proposed include the addition of two new 
classes of workers within the .scope of compulsory insurance, 
and a provision that insured women who cease work on 
marriage shall receive sickness benefit at the normal late, 
and not at a reduced rate as at present, and that there 
shall ho no reduction of maternity benofit for arreax-s. 

An impoi'tant “.additional benefit ” under the 1924 Act 
— namely, medical treatment and attendance of dependants 
of insured persons — is not retained in the bill. 

The Act' is intended to come into opei'ation on July 
2nd, 1928. 


IjS'Crease of claims for sickness and 

DISABILITY BENEFIT. 

Po.siTiox or THE Minister or Health. 

The following letter has been received by the Medical 
Secretary of tho British Medical Association from tho 
Ministry of Health in reply to tho letter by the Medical 
Secretary, reproduced in last week’s Supplement, request- 
ing tho Minister to take stops to combat the construction 
placed upon bis recent statement regarding tho increase of 
claims for sickness and disability benefit, and the responsi- 
bility of tho medical practitioners concerned. 

,$ir,— I am directed by tlie Minister of Health to refer to 
your letter of Iilarch Isl, expressing the concern of the 
imsuranee Acts Committee at the interpretation placed in some 
quarters upon certain remarks made by him at the hmclieon of 
the National Conference of Approved Societies on February 
20th, and to state that it will be observed from the report in 
tho issue of the A’aftonof Insurance Gazette, dated February. 
25th, that in that part of the speech to which, apparently, 
reference is made, he gives three possible reasons for the 
increase in sickness claims. , . 

The hlinister has not himself seen statements m the press 
which liavo particularly referred to his observations as the 
foundation of any general charge against general practitioners ; 
he is aware that such charges have been made, but he thinks 
that they are based upon other statements than that to much 

attention is drawn in your letter. . , „ A. m 

Tho Minister believes the Insurance Acts Committee nonm 
aereo that, as he said, some practitioners have not been 
as particular as they might be, but the best answer to any 
charge tliat such laxity is widespread would be the report of 
the joint investigations of the Insurance Acts Committee with 
officers of the Ministry which are now in progress, and which 
-■■e in themselves tho best proof that neither he nor his 
Iviscrs have already made up their minds about tho problem 
•*•••• ■ .-'—A--! .j gji;^ your obedient servant, 


diich is being investigated. 
March 7th, 1928. 


W. A. Robinson. 


ffiomspon&fitrc. 

Private Medical Practice. 

Sir —I have read Dr. FothergilTs article, with its concluding 
anthem of “Homo, Sweet Home,” and at the same time 
I had just finished reading an article on Thomas Paycocke ot 
Coggeshall, clothier, by Miss Eileen Power. In it I read : 

“It was characteristic of 'the period in which ho lived (''•1500) 
llrat somctliiiig like a miniature factory systom-was 
itself in the midst of the new outwork system. It wi« as '''Oiigii, 
long before it established itself in England, they bad a. prevision 
of the factory system, and of the worker no longer owning eitlicr 
his raw material, liis tool,- his workshop, or the produce of ms 
indnstry, but only liis labour; the master weaver dwindled lo 
a hired hand.” . , • t d. 

Industry was organized in the eighteenth and nmctccnrn 
centuries. I believe the medical profession is now undergoing 
a similar organization into clinics and hospitals. The community 
insists on haring the best medical treatment. The clinics an 
the hospitals have been, and are now, driving it into us ora 
that tiicy are the only people who can do this hy * 
organization .md eqnipment. Village and small town ”1®. 
been changed by railways, motors, electricity, etc. noun 







SUPPLEMENT 


BRITISH MEDICAL JOURNAL. 


LONDON, SATURDAY, MARCH 24Tir, 1928. 


CONTENTS. 


BRITISH HBDICAIi ASSOCIATION. 

The Sir Chailos Hastings Populnr Lecture: The Founda- 
tlotta of National Health. Rv Sir Gtorce Newm.^x, 
. K.C.B., JI.D., r.R.C.V 

CURRENT NOTES : 

Tuk CiiAinMAx or Coukcil ik South ArnicA 

Association Pbizes tor Essays by Students . . 


93 


98 

98 


S^Ijc I^nstings Ijopiilar ICrrtmc 

ON 

THE foundations OF NATIONAL 
HEALTH. 

DEI.IVF.nED IN THE GllE.lT H.AI.I, OF THE BuiII.-HI MkDU'.M. 

As.sociation on M.Mtfn 21 st 

BY 

Sm GKORGE NEIVJUN, K.C.B., If.D., F.R.C.P., 

CHIEF SIEDICAL OITICER TO THE BOARD OF KDUC.STIOK AND TO TUB 
SinHSTRY or ItEALTIt. 


This locturesliip commemorates Sir Cliarles Hastings^ the 
* British ^Medical Association. Ho was born 

in 1794 at Ludlow in Shropshire, the old walled town which 
aas formerly tlie seat of govornmoiit in the borderland of 
the Alarcbes. AVlion 16 3 'oai*s old bo was ajjprcuticod to a 
cloctor at Slonrport, and graduated in modicino at Edin- 
uigh in 1818, in the illu.strions time of Sir IValtor Seott 
and L(^d JefTroy. Ho settled at 'Worcester, and in the 
oard Room of the old. Infirmary there he started in 1832 
a medical society which was to becom^ the British iMedical 
sso^ution. Quite apart from this particular acliievemcnt 
I . larles Hastings was one of the small but remarkable 
gio ip o who, almost unconsciously, became tlie 

pi on eel so the national bealtli in the great age of the 
Reform Bill. o » 

rri OF Kngland in 1832 .^nu 1928. 

I 1°'^ Bngland was then very different from 
. «i 1 w lie 1 Me are familiar .a century later. Even tlio 
oppearance of the country uas ('lifferent. In 1832 
fn.. r ft*-' ^ "!'* u Clreat Britain, then tu-eiitv millions, had 
t; ' f ti**"'^ iT" ®^aadily collecting in toMiis; the deser- 

advanced ; the -Stockton and 
• ’Hd on lai w.i\ tiain had heen running for seven vears; 
the ancient iron industry had been moving from the south 

leirl"* '"J'* ' ““^5 Brindley and Bridgeu-atcr 

Wn 1 iT" MaeAdam and Telford roads; the 

Enn-h 1 l^^'u *•"' * ’’apidiv, and the majoritv of 

Englmhme i dwelt in mean streets “ divorced froni nature 

Us Zl Ti^-' t'>« mass of people life 

tile soil 'f" *^'^a'yi and “drink and religion strove for 
hml nrri? r"v Great Divide 

nliilosU, 1 '>ad handed on his 

mid thr.''^T\rH Soutlnrood Smith, Chadivick, 

amlinted. p /• Law Commission- had been 

iuciniries in vt-"'' commenced its famous series of 
Reform -Rill I *.? ooiulition of the English people; and tho 
P'-ofoiind plr passed. From these four sources 

I ‘oiotind changes M-ere to ai-ise. ■ ■ -- - 


ASSOCUTION NOTICES- 

JIEETINGS OF BRANCHES AND DIVISIONS 

I'AC.VNCTES 

DIARY OF SOCIETIES AND LECTURES 
ASSOCIATION INTELLIGENCE AND DIARY 
BIRTHS, MARRIAGES, AND DEATHS ... 


FACE 

99 

99 

100 

100 

100 

100 


To-day rve look upon a very different Britain. The popula- 
tion is 43 millions, of M-hom 21 millions are enfranchised. 
InffrcoDiiiuiiiiidlion has increased almost beyond belief; 
tlioro are 20,000 miles of railwaj" and 180,000 miles of road; 
there has been enormous development of shipping, of postal 
service, and of ncu'spapei'S ; there is non' also tho telegraph 
and teicplione, tho acrojilane and u-ireless. These methods 
of intercommunication, being world-M-ide, har-e revolution- 
ized industry and changed tlio face of our civilization. For 
improved intercommnniention has made actual tho enormous 
potential u-enlth and capacity of the country. It has 
enlarged tlio social life of the people and brought them 
into the snnliglit and fresh air. It lias carried them to 
and from their Mork. It has furnished their tables ivitli 
nourishing food, and spread noivspapors and hooks before 
tlicm, filling their minds M'ith new interests and enabling 
them to enter a wider citizenship. It has changed both 
Avar and peace, and “ covered tho ivorld ivith a network 
of M’ondorful hours.” It is the first great contribution to 
tho saving of iife and the postponement of death. Then a 
compulsory .system of Kdiicafion for all classes has heen 
introduced over tho length and breadth of .the land; an 
aiiiple and varied food supply comes to us daily from tho 
ends of the earth ; tho conditions of labour, and the oppor- 
tunities of leisure, liave been immensely improved. Above 
all, there has been an amazing transformation in the health 
of the people, for ivimm life is rvider, better, and longer, and 
death is more remote. Though tho iiopnlation has more 
than doubled, tho general death rate for England and 
AVales has heen halved since 1838; tho child -mortality' 
under 5 for London is non- about one-third of ivhat it rvas; 
tlie nniuber of deatlis .under 50 years of ago is non- 38 per 
cent., as compared with 71 per cent, in 1838; and the 
expectation of life at birth has heen extended by as innch 
as tMclve years for hoys and fourteen years for girls. In 
other words, the premature, deatli of little children has 
been enormously reduced, the infectious sickness of adults 
lias heen more than halved, the great fatal pestilences of 
cholera and small-pox liaA'c vanished, and life has heen 
prolonged. 



General Deatli^ 
Ba'.e. 1 

Infant Mor- 
tality Rate. 

Deaths 
Under 5. 

1 Deaths 

1 Under 

1835-9. 

1926. 

! 183S-9. 

1926. j 

1838-9. 

1926. 

: 1833-9. 1 

1 j 

1926. 

: I 





Per 

Per 

Per 1 





1 


cent. ' 

cent. 

cent. ^ 


England and 

: 22.0 

11.6 

150 

70 

39.5 

15.8 

71 

38.2 

■Wales 1 









London .. j 

28.1 

11.5 

174 

64 

40.2 

14.6 

73.6 

37.3 


arrived. 

“ The great source of the misery of mankind is not their 
numbers but their imperfections, and the w-hnl" of control over 

[ 1235 ] 


94 March 24, 1928] 


Hastings Popular Lecture. 


r BVPrLmrr.nT to tiib 
iBniTiaii Mkdical Joursal 


tho conditions in which they live,” said Dr. Farr of the General 
Register Office. “ Without embarrassing ourselves with tho diffi- 
culties which the vast theories of life present, there is a definite 
task before us — to determine from observation tho sources of 
health and tho direct cause of death in the two sexes at difierent 
ages and under different conditions. Tho exact determination of 
evils is tho first step towards their remedies.”* 

Farr revealed to tho nation that a vast increase of popti- 
lation was going on in a small island which conld not 
itself expand; that a rural people were becoming urban, 
an agricultural people becoming industrial; that tho 
ravages of pestilence were competing with the evils of 
social degeneration, and that both of them must bo brought 
under control ; that there is a definite relationship between 
the price of wheat and tho death rate, between poverty 
and disease, between personal conduct and health. 

More important and far-reaching than the actual doings 
of the time was tho new spirit of tho nation after tho 
Reform Bill, which showed itself in a wonderful period 
of constructive statecraft. We have had a century of it. 
Observe what has happened. Predominant political power 
has been transferred from -an hereditary aristocracy and 
the middle class to tho nation as a whole. Government of 
tho people, by the people, and for tho people has 
hrour/hf io the front the vital and domestic issues 
of life. The centre of gravity has moved from the 
interests of dynasties to the well-being of tho people. 
“ Power has only one duty,” said Disraeli, “ to secure 
tho social welfare of the people.” There has been an 
enormous extension of the conception of tho State and of 
its sphere of operation. We have witnessed the enthrone- 
ment of the scientific spirit. Wo have seen tho discoveries 
and inventions of science allied for the first time with 
industry and commerce, and insurance against risks of 
every kind has extended and ramified in a truly extra- 
ordinai'y way, becoming oven a subtle international agenc 3 ’. 
Lastly, wo have seen an intenser humanitj’ towards 
children, animals, victims of disease, criminals, and all 
men and women in need of succour. During tho century 
there has thus been an astonishing growth in human know- 
ledge and contrivance, almost beyond tho power of tho 
mind to conceive; a growth and a spirit by which a small 
nation renewed its youth, spread its infiucnco all over the 
world, huildcd an Empire by confederating both alien and 
kindred races, and at the same time learned for itself more 
and more of the supreme art of how to live. It is indeed 
one of tho most moving stories in the history of mankind. 

The Sooi.\l Factor. 

Let us consider and look around. These great achieve- 
ments depended on tho survival, health, and capacity of the 
body and mind of man. “ Inquiry what the event actually 
was,” said Lord Morley, “ its significance and interpreta- 
tion, becomes secondary to inquiry hoiv it came ahoiit.” 
How did it come aboxit? Why, in fact, was human life 
a longer and a healthier thing in the nineteenth century 
than in the fourteenth? I think tho answer is twofold. 
Social and Scientific, and it is important we should fully 
understand it. 

First, there was the social factor, tho vast improvement 
in the ordinary domestic life of the people. More than 
two thousand years ago Hippocrates had taught the 
Influence of the external world of air, water, soil, and 
climate on health and length of human life; but it is only 
in modc-in times that we liave learned that the genius of 
agriculture, of engineering, of industry, of trading, and of 
commerce, all the world over, are intimately concerned 
a'ith tho maintenance or impairment of human health. 
For it is by these means wo get our food, our coal, our 
clothing, our houses, our lighting, our water supply, and 
our wages. Nor are these alone. There has been tho all- 
pen-ading and transmuting effect of social custom and caste- 
of tradition and religion; of occupation and emploj-ment- 
of c.ating and drinking; of fashions of dress and personal 
appearance ; of recreations and amusements (golf, tennis 
cricket, football, athletics, swimming and dancing, winter 
sports); the week-end habit; gardening; countiy rambles- 
mountain climbing; enjoj-ment of tho seaside and seal 
bathing; tr.avol and change of air; the manifold uses of 
leisure-— all these daily occupations, avocations, and 
amenities have plaj-c<l a largo and primar 3 - part in tho 


creation and inaintonanco of personal and public health. 
We must give up tho idea that health is comprised in 
sewerage, disinfection, tho suppression of nuisances, the 
burial of the dead, notification and registration of disease, 
fever hospitals, and endless restrictive by-laws and regula- 
tions. Health springs from tho domestic, social, and per- 
sonal life of tho people. It is, as tho Greeks said, the fruit 
of tho more abundant life. 

The .Scientific Factor. 

Tho second great influence in tho rise of tho national 
health in tho nineteenth century was tho extraordinary 
adv-anco in scientific discovery and tho adoption of the 
Bciciitifio spirit. Put down on a piece of paper some of 
tho great political and social events of tho last hundred 
years — the Reform Bill, tho abolition of slavery, the factory 
system, tho repeal of tho Corn Laws, penny postage, the 
newspapers, free education, tho trades unions and the 
co-operative movement, , the four extensions of tho 
franchise, tho reform of criminal law, old age pensions, 
and tho immense cultivation and extension of literature; 
and then put. down by their side some of tho landmarks of 
science — tho application of steam to ships and railways, 
tho electric telegrapJi, tho great exhibition of 1851, tho 
Atlantic cable, spectrum analysis, the Suez Canal, the 
telephone, tho internal combustion engine in 1835, 
Marconi’s wireless, tho discovery of tho North Polo and 
tho South Pole, tho aeroplane, Darwin’s Origin of Sjiccics, 
and the incompaiablo advance of medical science; add up 
the account and see where tho balance lies. Tho store of 
tho relation of these scientific advances to the health and 
happiness of man would read like a fairy tale, but it 
would have the advantage of being true. Let me remind 
you of two examples, arid let us be sure that we understand 
..them. . . 

In tho Origin of Species Mr. Darwin told us of the origin 
of tho nature of tho human body-, and the laws which directly 
control it — the Law of reproduction and growth, tho Law of 
heredity, tho Law of variation (owing to “use or disuse ”), the 
Law of natural selection. There is, he said, no escape from 
the operation of these four laws, for they are universal.” 
They are the principal contributors to the cosmic process 
as it concerns man, a process of which the human species 
forms part. It is these laws and this cosmic process which 
gives man the body in which ho lives ; and this body is set 
in tho midst of nature, subject to many external influences. 
“In every case,” said Darwin, “there are two factors— 
namely, tho nature of the organism and the nature of the 
conditions” under which it lives; but, he added, “the 
former seems to be much tho more important.”” A genera- 
tion later Huxley reminded us that “ much may be done to 
chango tho natui o of man himself ” by the control or modi- 
fication of his internal and external conditions.” Indeed, 
tho character of these conditions, what has been called 
nurture, is the factor which is most under our direct control 
in improving tho body of man. 

Here,- then, wo have, according to Darwinj tho -two 
fundamental things, the nature of man and his nurture — 
tho impress on his nature of all tho factors and all tho 
influences wliicli ’ affect him, his total environment. The 
growth of our knowledge of physiology in modem times 
has immensely expanded our understanding of man’s 
nature, and the potential capacity of tho functions of tho 
human body and of its extraordinary powers of defence 
and repair. Nor must we overlook or set aside social and 
ethical factors which play a part, and, as civilization 
grows, an ever-increasing part, . in tho nurture of man. 
Human life at its best is, therefore, a balance between 
nature and nurture, a harmony of , all the functions and 
faculties (whether physical, mental, or moral) moulded and 
directed by nurture. The body is not merely a machine, 
what the engineer would call an “ assembly of its parts : 
it is something much more .than the sum of its parts-— a 
unified living adaptable organism, with a potential 
capacity, always susceptible of growth, development, or 
degeneration. 

For in practice we know- that there is often disharmony, 
which may be duo to inborn defect, or accident, or 
neglected nurture, or disease. AVhat is disease? 4Fo have 
not yet found tho full answer to this question. But wo 



MAlictt i'l. 102sl 


The Foundations of National Health, 


r sVTVLr.^^rEKT to tfie . 

iDRlTtSII SIEDICAI. JOCR.VAL 


SS, 


have . loi! rued tlint clireas-o is not soinetliine arliiti iirv, 
capricious, or occult, hut due always to definite causes; 
and we Jemnv it i.s not an e.\ternnl entity or agent — a .sort 
of hlack dragon outside our.solves wliich we have to slay 
or exterminato. Tliore is no external thing which we can 
call disease. It is something within the living organism. 
U if iU( rcnr.iion of the human body to irrryulnritief or 
aycnricf in itf environment to which it has not hecome 
Imhituatcd, and which if ))rolonged may lead to an actual 
altovafion or degeneration in the tis.sues of which the body 
is constructed. It is the disturhanc-e of the hnnuony of 
the body which is dis-ease. It is, as JletchuikofT said, a 
“disharmony”; or again, it ha.s hecn well dc.scribed as 
“the dissociation of the functional unity” of the body. 
There may be (n) inhorn flaws or defects in the structure 
of the body, irregularitic.s in asscmhling the parts, even 
inherited taints and blemishes; or (b) in the ordinary 
stre.s.ses of life. ])arf.s of tho machinery of the iinmaii body 
may ho strained, impaired, or even broken; or (c) owing 
to faults of nurture, habit, or way of life, the functioning 
of tho body and even its strnctnro may have hecome 
misdirected or ill-formed ; or, lastly, (d) the body may 
he invaded by the agents of infection — parasites. These 
are examples of tho kind of injurious influences and 
conditions to which tho body is liable, and in tho 
presence of which the body itself reacts, producing the signs 
and srnuptoms which wo coll disc.asc. . 

j In short, when wo think of tho foundations of health, 
Darwin and his disci))lcs have taught us that we 
have two main groups of facts to consider — namely, the 
body of man with its natural powers of i-eproduction and 
resistance; and tho laws of Katuro as tho governing factors 
in its sun-ival. Hygiene or provontivo medicine depends, on 
|tho other hand, upon (i) the knoivlodgo and practice of the 
(iitirfitic of tho body, and (ii) tlio organizorl prevention or 
wntrol of the external agencies injurious to it. Thus there 
is a Science of Life (biology) which includes our knowledge 
of tho Xature of Sian and tlio laws and conditions under 
which ho can live and flourish as a jiart of tho cosmic 
process; and .there is a, practico of Health (Hygiene or 
Preventive illedicino) which includes our Icnowlcdge of the 
positive nurture of man and tho negative prevention of 
injurious influences acting upon him. lYe must not expect 
apprehend cither the science or tho practico from 
hucksters’ tips or from tho “ hits and hobs ” of propaganda 
in an adreitiscmont of a patent medicine. Wc must learn 
to look upon the whole business as a science, concenicd with 
no less a subject than the Evolution of hlan, governed by 
tho immutahle laws of tho univeree, and demanding from 
us patient learning, vigilant understanding, and strict 
1 c penalty of the Court for disobedience of 

0 lavs of Nature is a degeneration of true or an earlier 
death sentence. ' 


The Advaxce of JIiidicixe. 

This leads me to tho next step we must consider- 
^amo 2 > ‘a outstanding advances of medical science. Tli 
- J, nineteenth centuries were exceptionally rid 
' 1 ‘^aovey, familiar to us all. John Hunter’ 
ing pa m ogy, Jonner’s vaccination, the work of Si 
ump ir} aij and Sir James Simpson on the abolition o 
p in } anaesthesia, that of Louis Pasteur and Rober 
+,.%^ ' t causra of infective disease, Lord Lister’ 
fl/ ication of that laiowledgo hv tho intre 

° c antiseptic snrgen-, and the development of th 
, ^ evcntivo medicine — ^theso are six of the epoch 

1 ‘ aoraiiccs winch, with the Darwinian liypothesis 

foT- ? "J’j. J outlook upon, and new power 
for, the control of disease, the relief of suffering, and th 
prolongation, and betterment of life. Thev have mad 
bp.i-,>**i' constructive the period in which we live 

1 ot er centui-y. Thev mark the gi-cates 

and art of medicine? 

t *1 Uimecessary to describe them, it is appre 
First toution to two facts in regard to tlieir 

• on ti.’p ' ° discoveries originated in previous wor 

fiebl subject, .and each of them has opened up no’ 

in ^oowledge and life-saving applications. Pc 

, Jennei s work showed .not only that vaccini 


could he traiisfei red from tho .calf to man, and from man 
to man, hut he proved the validity of the proposition that 
vaceiiiia in man dimiiiisrhed the liability to attack by 
sm.all-pox. In .so doing he introduced an artificial method 
of producing iiiinii,niti/,-\yUk-b has since been applied for, 
the prevention or cure of many other diseases. He opened 
a door which is always opening wider; lie proved a secret 
of Natiiro’.s ways to lie true. Sir Aliuroth Wright’s dictum 
that “ the physician of the future will be an immunizator ” 
is a logical deduction from the over-growing juactical expe- 
lieiK'o of medicine. Furfher, the study of immunity has 
.shown that in many infective diseases substances appear in 
the liiood which are antagonistic either to tho inr-ading 
micro-orgaiiism or its toxins, sugge-sting both that a process 
of immunization is going on in the body during the attack, 
and that it i.s due to antibodies developed by the reaction 
of tho tissues to tho invading infective agout. In other 
uords, the study of natural iiniuunity has revealed the fact 
that the healthy body itself fosters defrnsire properties and 
icsistaiit potcnti.alities. These are four in number. 

(i) Thc' resistant power ari.sing from the physiological 
! re.soiTe of health, thc power of hypcrtrojihy, and of 

increased functioning and metabolism in emergency. 

(ii) There is thc control by the “ vasomotor ” nerve 
system, whieli regulates thc blood supply of any given 
part of the body. Hushing it on demand with tho 
refreshing current of the blood stream. 

(iii) TIkmc ' is a defence established by means of 
cells in the blood, lymph, and tissues, which have the 
rcmarkahle power of first, catching and then absorbing 
into their own substance any invading germ or foreign 
element with which they come into contact. 

(iv) There are the newly discovered biochemical 
powers vepvcscntcd partly by the normal secretions 
of tlic ductless glands (hormones), and partly by tho 
group of antitoxins which follow in tho wake of toxins 
and are the direct reaction of tho healthy body to 
their presence. 

Those four separate lines of defence are powerful, but 
if must he romemhered that they never act in isolation. 
Tiiey arc mutually interrelated, they co-operato together 
under a unified command, and they depend for their vei-y 
existence upon a healthy and well^nourished state of tho 
bodv. ITlieii, therefore, an infecting bacillus attacks man, 
it sets lip, automatically, a chain of natural defences — 
(a) inciTa.sed functional activity; (i>) a fuller blood siiijply; 

(c) tho stimulation of the catching and absorbing cells 
(phayoeytosis) and the excitor .secretions (hormones); and 

(d) a new formation of cells and substances antagonistic to, 
or assimilative of, the toxic products of the bacillus. 'When 
we ponder upon this array of defences called into operation 
by the act of infection we cannot bo surprised that oiie 
attack of a disease is not followed by another, and that a 
natural iinmimity against certain diseases may bo estab- 
lished. IVo begin to see the true philosophy of the action 
of antitoxins and vaccines; we understand a little better the 
survival of man’s body in Nature; and wo learn once and 
for all the necessity of bodily health as tho strong and 
primaiw foundation of Preventive IMedicine. 

Secondly, each of these six momentous medical advances 
has not only won triumphs in it.s oa n sphere of tho medical 
or surgical treatment of disease,- hut it has indircctlv 
furnished new methods and confirmations in regard to the 
foundations of health itself. Their principles have been, 
in fact, applicable to the creation and maintenance of 
health as well as to the treatment of disease. Pasteur 
not only elucidated the cause of fermentation and particular 
infectious, but bis work changed the whole attitude of 
men’s minds to the relation of cause and effect in all 
forms of infection and bodily condition. " lYhat hopes 
seized upon me,” be said, “ when I realized that there must 
be lan-s behind so many obscure phenomena.” Lord Lister 
not only taught the antiseptic principle and method of 
dealing 'with surgical wounds or compound fractures, but 
tho supremo importance of similarly attacking all forms of 
septic poi.soniug--in fact, to the necessity of cleanliness 
I and asepsis to a liealUiy body. 


96 March 24, 1928] 


Hastings Popular Lecture^ 


f RXJTPLEirrKT TO TW 
LBniTisH Medical Joukkaa 


The Nurttire of the Body. 

Tlio fundamental iiroblem of lioaltli, then, is the wise and 
Boiontifio nurture of the body. Now can wo say in plain 
and categorical terms in what such nurture consists? Hero 
is your body with its nature, its heredity, its variation, its 
inborn instincts, impulses, and organic functions, the 
instrument of emotion, intellect, and will — a living 
organism of long biological ancestry, the whole man — can 
wo define the best nurture for it? I think wo can, but 
only in genera! terms. Perhaps indeed one term, nutrition, 
is tho answer. It is when we attempt to bo prescriptive 
and dogmatic in detail that we go astray, for each human 
body is, as Galen pointed out, individual in its “ prepara- 
tion ” for health or disease. Yet some general rules of 
nurture mankind has learned through thousands of years of 
experience. Tho trouble is that he will not practise them. 

The elements of nutrition for the body are six in number : 
Food, Fresh air and sunlight, Exerciso of tho body. 
Warmth, Cleanliness, and Rest. If these necessities bo 
provided we may have some “ approximation,” as Emerson 
called it, to full physical life; but if they are withheld or 
inadequate we shall assuredly have insufliciency, poor 
physique, disease, and oven premature death. Though this 
knowledge is as old as tho history of tho human family, 
it is still only partially applied to tho building of men or 
tho rearing of a race. For though the general proposition 
is simple, its application is complex and variable. AVhat 
is the ideal form of nutrition in any given climate or for 
any given age of life, and how can wo follow it? How can 
wo live in the open air if wo also live in houses and in 
cities? By what means can we secure sufficient exci'ciso, 
and of what nature should it be? And how can wo escape 
tho condemnation by Galen of tho over-specialization of 
Greek physical culture? The answer to these questions 
comes only by education and experience. For, given a 
“ living wage,” and given a sufficient yield of the proper 
food necessary to man’s health — and, speaking generally, 
these desiderata are available in this country — there can bo 
but one answer: People do not live tho healthy lifo because 
they lach knowledge. As the Duke of Devonshire said in 
1904, ” the people perish for lack of knowledge.” It is 
ultimately a matter of the instinct, education, and 
experience of the individual. 

Food. 

Let us consider for a moment the most important of these 
six — Food. The products of digestion enter tho blood from 
tho alimentary canal, and thus all parts of tho body are 
nourished. It is of vital importance to eat tho food which 
will build, repair, warm, and energize tho body. Ignorance 
of a sensible dietary is the direct cause of much preventable 
disease, and more people suffer from eating too much than 
too little. It is common knowledge that man’s diet should 
bo mixed ^ and varied; should be sound in quality and 
sufficient in quantity; consumed at regular intervals; and 
appetizing and digestible. It sbould contain some proteins, 
such as occur in meat, fish, milk, bread, cheese, eggs, peas, 
beans, lentils; some fats, as in cream, butter, suet, lard, 
dripping, olive oil, etc. ; some carbohydrate, as in simar, 
bread, potatoes, rice, and starchy foods. The body also 
needs mineral salts (calcium, iodine, magnesium, sodium, 
and potassium), contained in milk, cheese, eggs, green 
vegetables, and fruit, tho last two furnishing a consider- 
able bulk of fibrous material valuable in stimulating 
alimentary movement. Lastly, there are certain substances 
essential for growth and nutrition known as vitamins 
present in extremely minute quantity in various foods, ’ 

Several principal kinds of vitamins aro recognized, and arc 
called vitamins A, B, C, D, etc. Vitamin A, found especially in 
milk, butter, checso, yolk of eggs, and green vegetables is 
necessary for growth and the maintenanco of body resistance 
against infective disease. Vitamin B, found mainly in cereals 
pulses, and yeast, is also nccessarj’ for growth and for tho main- 
lenhiico of nervous stability. Vitamin C, found in various fruits 
and leaves, but especially in lettuce, cabbage, and oranges is 
cfTcctivo in the prevention of scurw. Vitamin D occurs richly in 
cod-liver oil, oily fishes (such as lierrings), and egg-yolk; jt is 
concerned in tho proper development of bone and teeth, and its 
absenco may lead to rickets. 

Goitre may follow insufficiency of intake of iodine, ns 
stunted growth may result from poorness of proteins or 
oxcessivo or unbalanced cereals (which should always bo 


associated with milk, eggs, and green vegetahles). It 
should bo remembered that tho vitamins exerciso joint and 
intordopendent action and may bo destroyed by over- 
cooking. A plentiful supply of sunlight to tho skin will 
make up for certain deficiencies. In addition to theso 
various requirements of living protoplasm wo must add 
water. Tho transmission of all nutritive substances to 
parts of tho body is dono by “ water transport.” So, too, 
excretion of wasto. 

But merely to deviso ideal dietaries is not enough. If a 
chemically ideal and model food bo prepared in tho labora- 
tory with tho proper amounts of each essential constituent, 
and then it bo sterilized, dried, or otherwise ‘‘ preserved,” 
it will bo deprived of some or all of its vital and natural 
principles. Hence, dried foodstuffs, preserved vegetables, 
proprietary foods, overcooked foods, and tinned moats,’ 
though possessing some practical advantages, aro I’educed 
in valuo as foods. Fixed foods bccomo 011 x 111017 only, for 
they aro deprived in some measure of their vital elements 
of appetite, of tasto and disposition, and of variety of 
composition. Moreover, nutrition does not consist only of 
pabulum, tho food. There must bo healthy activity of those 
physiological processes which havo to do with mastication 
and' preparation, with absorption and assimilation, mct.T- 
bolism and excretion. Healthy and complete nutrition is 
infinitely more comprehensivo than mero feeding, inero 
filling of tho stomach. It connotes a healthy body in all 
respects, a brain and neiwous system in tone, a hcaltliy 
muscular and digestive system, circulation of blood and 
lymph. Now, when we turn to tho dietetic conditions of 
tho great mass of tho workers wo find a talo of ham and 
beef, of beer and broad, of tea and pickles, of tinned meat 
and proprietaiy foods, or a weary round of bacon and 
herring and cheese— and of an unstable digestive system 
and an impaired physique. But variety, mixture, appe- 
tizing cookery, freshly prepared or natural food, the healthy 
conditions of sound digestion — these aro the essential things 
so often ignored. This is partly duo to our medical neglect 
of rational physiological feeding, which is worth more than 
all tho drugs in tho market; partly to the vicious custom 
of tho sedentary worker to combine an excessive consump- 
tion of unsuitable food with an entire lack of daily exercise; 
partly to ignorance and bad habit. 

Finally, there aro some food rules which it is expedient 
to adopt, (o) Strict. and persistent moderation in diet 
tends to longevity, and excess tends to early mortality. 
(&) Nature has provided that food should be masticated, 
should reach the 'stomach slowly, and not too frequently, 
(c) The number of meals taken daily is ’a matter of indi- 
vidual practice and custom, but for persons over forty 
years of age they aro usually too frequent, (d) No food 
should bo taken between such regular meals, as eating 
promiscuously gives the body no rest, (e) A small quantity 
of beverage with the meal is desirable, but there sbould bo 
no excess’ of alcohol — alcohol is not in ordinary circum- 
stances necessary to health; there should be, as a rule, no 
alcohol before meals or between meals, and none for 
children. (/) There should bo no activo exerciso imme- 
diately after a meal. 

Fresh Air and Sunlight. 

I have not time to discuss at tho same lengthy tho other 
essentials of true nurture; but each of them is important. 
Flesh air is almost as valuable to health as food. It is, 
indeed, another element in nutrition,’ for the living pro- 
cesses carried on in every cell of tho body require oxj-gen. 
This reaches the body through tho nose, passes to tho lungg,’ 
enters the blood stream, and is thus carried, like the pro- 
ducts of digestion, to all parts. Breathing sbould always 
bo through the nose, in order that the air may bo properly 
filtered and warmed before reaching the lungs. The fresh 
incoming air conveys oxygen and expels tho used-up air of 
the lungs. Its physical properties of coolness and movement 
are valuable as conducive to the increase of metabolism and 
stimulation of the skin arid the appetite. There can bo 
no more far-reaching or beneficial method of improving the 
health of the people as a whole than the wider practico of 
tho open-air life. As AValt Whitman said in the Song of 
the Open Itoadi 

“ Now I see the secret of the making of the best persons. 

It is to grow in the open air,” 










STJ PPXjEMIENT 

TO Txra 

BRITISH MEDICAL JOURNAL. 

LONDON, SATUUDAV, MARCH 31st, 1928. 


CONTENTS. 


BRITISH MEDICAIi ASSOCIATION. 


PAGE 


The Future of Medical Practice. Address by Dr. E. GitinAM 


Little, M.P 

CURRENT NOTES : 

The Ciuikuah or Coukcil is Sotnn ArnicA 

IssuRAscE Acts Committee ... ... 

Hospitals Committee 

Cardifp Assual Meetiko : Reduced Railway Fares... 
The Hcmpsos Peieb ... 


B.M.A. CHARITIES FUND 

GRANTS IN AID OF SCIENTIFIC RESEARCH 

ASSOCIATION NOTICES 

MEETINGS OF BRANCHES AND DIVISIONS ... 


101 

103 

103 

103 

103 

103 

101 

101 

105 

106 


GENERAL MEDICAL COUNCIL i 

Executive Committee 

DENTAL BOARD : Retestios Fee for Dektal Registrahos ... 
NATIONAL INSURANCE : 

Cost or Prescribiso. Abolition of the “ PnARMAC0P0F.iA 

Cestriensis " 

Local Medical and Panel Committees 

CORRESPONDENCE ... 

NAVAL AND MILITARY APPOINTMENTS 

VACANCIES AND APPOINTMENTS 

DIARY OF SOCIETIES AND LECTURES 

ASSOCIATION INTELLIGENCE AND DIARY 

BIRTHS, MARRIAGES, AND DEATHS 


facx 

103 

109 


109 

110 
110 
111 
111 
112 
112 
112 


SCrxtislj l^ttbiciil Association. 

METROPOLITAN COUNTIES BRANCH. 


PEGEPTION TO STUDENTS AND THE KEW-LY 
QUALIFIED. 

A jtEETixo to rrliicli fourth- and fifth-yc.ir students and 
recently qualified practitioners were invited was lieid by tiio 
Metropolitan Counties Branch on March 22nd in tlio Great 
Hall of tho Association’s House. A very largo number 
were entertained to tea, and wore afterwards addressed 
by Dr. Graliam Little, M.P. 

The chair was taken by Mr. E. B. Totintu, F.R.C.S., Branch 
President, who first of all presented to tho prizewinners from 
^e l.iqndon schools the certificates and prizes nw.irdcd by the 
l^unoil of the Association for competition essays by final-year 
students. Ihe full details of the results of tho competition were 
pubiisned in last 'VTcek's Supplements Those who received Ihe 
prizes on this occasion were Mr. A. Gilpin (Kina’s College), 
It i' ,V (Guy’s), Mr. G. E. Lewis (The London), 

(ol' -S' (University College), Mr. C. E. Dolman 

(bt. amry s), Jlr. W. Linton-Bogle (St. Bartholomew’s), and 
a 1 ■ (Westminster). All were he.artily 

applauded as they stepped forward to the dais. Mr. Turner 
said that he had been informed that the standard of work 
/.F competition was e.xceedingly Iiigli, and every one 

Bnf gained a prize thoroughly deserved it. 

SmnJdin the greJl value of the 

competition was not the winning, but the striving. 

the future of MEDICAL PRACTICE. 
Address by De. E. Geaham Litixe, M.F. 

a Little said, was furnished by the 

tho onn^nnoh'^'^'^^ Annual Representative Meeting on 

■frtn fi iftrsry private practice. It had been obvious 

ho ^ that the position of the general practitioner had 
®“htle and insidious changes, owing in part 
■in a'‘- and in part to the progress 

in aimplexity of medicine in this generation. The outstanding 
tn hY? education was, the multiplication of subjects 

an in the undergraduate stage. A large proportion of 
w/on oh“ him was groaiiing under a 

nnd Fho ,, S'^icration'of practitioners never knew, 

f fl Pi erage period of study at the present time demanded 
in medicine was stretcliing well into 
nrtonrUa h ^ ''rJ' ^0^6 than thirty subjects was already 

P hy the General Medical Council, and public opinion 

advant-fJo for more. In some ways it had been an 

inrtiVnto^ 1° catholic training which this curriculum 

tafnS ^h misgiving, widely enter- 

imnoss’ihlo ♦ allowed for individual subjects made it 

re^iiiFtmoit r,®®J mastery of any of them, and that some 

made of enh^ ®ome selection would have to he 

bjects which -were regarded as of primary importance. 


A Ghrlficd Casualty Medical Officer." 

The object of the future might well be to equip the medical 
practitioner by his first qualification to undertake something 
of the duties which were now performed by the casualty medical 
ofiiccr of a great hospital. The general practitioner would, in 
fact, bo a very glorified casualty medical ofiicer. His function 
would he largely to sift out cases and to instruct the patients 
who passed through his hands to consult the jierson or depart- 
ment most able to diagnose and treat individual conditions. 
Tho lecturer saw no reason why the general practitioner of the 
future should object to such a role. The casualty medical 
officer was one of the most important cogs of the hospital wheel. 
Upon him rested the responsibility for detecting disease in its 
earliest stages. He sorted out the cases in which diagnosis was 
unusually difficult, and sent them to the appropriate department 
for further investigation and treatment. The waste of time, 
and quite often the loss of real opportunity for service, when 
patients went in the first instance to consultants without having 
had the advice of their general practitioner in the choice of 
consultant, was often to he deplored. 

Dr. Graham Little wished particularly to avoid the sngges- 
tion that there was any conflict of interest between consultants 
and general practitioners. They were all riiombers of one body, 
and the one could not exist without the other. 'While ho 
thought it on extremely mischievous tendency of the public to 
go to consultants without first receiving the advice of their 
family practitioner, he thought also that the family practitioner 
was sometimes unnecessarily reluctant to seek the advice of the 
expert in cases where he himself was not personally qualified 
to make a diagnosis. ’That golden quality of reciprocity was 
clearly indicated here. The interest of the public was' the final 
law. . It was to the interest of the public tnat early diagnosis 
and treatment should, be obtained from the general practitioner, 
and, if doubt existed as to diagnosis, early advice from the 
consultant was equally important. With this conception of tho 
part to be played by the general practitioner of the future the 
curriculum would obviously undergo some change. Many 
subjects would be dropped so far as the undergraduate stage 
avas concerned; the. period of undergraduate study might even 
be profitably shortened, and those who wished to take up 
some special subject .Vvould he able to add to it by way of 
a post-graduate course. The broad basis of a good general 
education must be insisted upon as an entrance to the profes- 
sion. He had always, set !his face against the too early 
teaching of the medical sciences. Again, competition in 
medicine had become so severe that it was more and more 
important that the student should, at the very outset of his 
career, recognize the importance of taking the examinations for 
a degree in one or other of the universities in preference to 
the qualifications of colleges, however eminent, which could not 
give degrees. In London the choice usually lay between reading 
for a University of London degree and for the diplomas of the 
Royal Colleges; many students took both as a sort of re- 
insurance against failure. The medical degrees of London 
University were perhaps the best in the country, and the 
examinations were not much more difficult to well-trained 
students than the examinations for the diplomas of the Royal 
Colleges. When .applying for appointments the young medi^ 
practitioner usually found that candidates with’ degrees were 

[1236] 








Maiicii .11, 


Association Notices. 


r SVTPLrifEI ^ Tt> tSB 
DniTisn MEDICAL JoDB^rxt 


fOS 


^ssorirttiou Hotircs. 


Itavl2, SaL rnhlication In Up.itish 


^lar 15, T«c^ 
Mavis, Sat, 


TABLK OF DATES. 

April C3, Sat. Annual Itcport of Council nppcnra in Bninsti Medial 
JOimKAL hUrriXMENT. 

I.a't clay for receipt at Head Ofllcc of nnmlnntion'c : (1) l»y 
n Division or not loss than 3 inenil'ors for election of 
Cl members! of Council by prouped llrnnchoH in Itritlsh 
Isles; and (W) for election of 2 Public Health Sendee 
memhers of Connell, and Representatives of Public 
Mealth Service In Representative Rodv. 

Mr.Dica JocnNiL SurrtrMnsT of 

■ eleo.llon of (i) inemlkcrs 
' Jlr.anelies Jn Rriti.sh Isles; 

' vice members of Council, nntl 
■ * ■ bile Health Service in Repre* 

Yotinp papers posted from Ilond Ofllcc, ^\herc there are 
contests in al>o\‘e elections. 

Motions by Divisions and Branches for A.R.M. apcmla on 
mailers of which two months’ notice must be given 
must be fcceiir<i at O/Iice by iiiis date. 

Ln5t day for receipt at Head Ofllcc of voting papers for 
election, where there are contests, of (i) 24 n»eni*>ers of 
CKutncIl by 'groiipetl Branches In British Isles; and 
fii) 2 Public Health Seiwdco Members of Council, and 
4 Representatives of I'ubUc IIc.iUti Sendee in Repre- 
fentaiive Body. 

Publication In Br.msn Mrtiita JovnvsL Surrir.MrsT of 
motions by Divisions and Branches for A.R.5f. on 
muUera of which two montlia' notice must be given. 
Representatives and Deputy Reprc.sentntive.s must l)e 
clecle*! hr this date. 

Publication in BtUTi«ii Mr.mctL JouriNiL SumuMrST of 
result of election of members of Council by grouped 
Brandies, and of result of ejection of members of 
OiuncI! and Representatives in Representative Body by 
Public Health Scr\dce hicnil>ors. 

^‘^jitation papers nvaiiatde (on appHenfion at Head 
Ofllcc) for election of 12 members of Council by grouped 
Representatives (British Ulos). 

Jvames, of Rcprc-'cntotives and Depute Repro.^entatives 
must b6'recci\cd at Hoad Ofllcc h\ this date. 

Council, 

Meetings of Constitucnclo.s must be held b<*tween this date 
and Jufy 20th to fn*tnjet Repre.sonlatues. 

Supplementary Report of Council appears in Bnmsti 
. JlrDicvL JouRNii, .SfrrLuMn.\T, 

Amendments and riders for inctii.sion fn A.R.Jf. agenda 
must be received at Head Olfleo l»v this date. 

Annual nevrermtatire .Vcdnig, Cardiff, 10 a tn. 
AomJnaf-Joflf for election of 12 member' of Council bv 
pront«d Reprwentatives muat lie rocciTc<l (nt A.n.M;, 
Cnrdia) by Ibis dnlp, 2 p.m. 

Annual Htpreien/alirr Jlecting, CnrdtR. 

Coii/ifil, Cnrdifl. 

Annual tlrprerrnlallre Mertlng, CnrdilT. 

Annual rajiraranlatirf Mrcling, Cfli-difl. Annual General 
Meeting, Cardiff, Pre,idenfs Addres,. 
tnuncii, CardIfL Conference, of Honor.iry Secretaries, 
CaidIfL ' 

ofeefingt of ^fCthnr, etc,, CardifT. 

Mrflintjt of Seetinuf, etc., CardifT. 

.Vccfiii^s of Seciiont, etc., CardifL 

Alfred Cox, Medical Secretary, 


Juno 2, Sat. 


June?, Tliurs, 

Juno 13, IVed. 
June 21, Thnrs 

Jano30, Sat 

Joly 4, TTed. 

July 20, Frt 


July 21, Sol. 
July 23, Mon. 

July 24, Tuca. 

July 25, Wed. 

July 26, Tlutrs. 
July 27, Fri. 


Metropolitan Counties Branch : Finchlev Division. — A meeting 
of (ho Fiuchicy Division ivill bo held at the Finchley Memorial 
Hospital on Tuesday, April 3rd, at 8.45 p.ra. Mr. W. S. Herman, 
L.D.S., will read a paper on tlio dental treatment of fractured jaws. 

Metropolitan Counties Branch : Hendon Division. — A combined 
clinical meeting and dinner of tlio Hendon Division will be held 
at (ho Brent liridgo Hotel to-day (Friday, March 30th), at 7.45 
for 8 p.m. All address will be given by Dr. W. Langdon Brown, 
ph^'sicinii to ^ St. Bartholomew’s Hospital, on organotherapy in 
general practice, to be followed by a aiscussion. All medical prac- 
lilionci*s arc cordially invited. Dinner tickets 8s.. 6d. 

^fETROPOLITAN COUNTIES BRANCH : LeWISHAM DIVISION.— At tlie 
nicctiiig of (ho Lewisham Division (o be held at (he Town Hall, 
Catford^ S.E.6, on Tuesday, April 17th, at 8.45 p.m., Dr. AV. Y. 
Gold'smith will read a paper on pigmentation of the skin. 

Mittropolitan Counties Branch : St.Pancras Division. — A meoiing 
of the St. Pancras Division will be held at the British Medical 
.\R‘'ociation House, Tavistock Square, Y’^.C.l, on Tuesday, April 10th, 
nt 9 p.m. Dr, Donald Paterson will give a lecture on tlic prevention 
of summer diarrhoea. 

Metropolitan Counties Branch : “Willesden Division. — ^At the 
meeting of the Willcsden Division to be held at the Willesdon 
General Hospital, Harlesdcn Road, on Wednesday, April 18th, Dr, 
J. Bright Bannister will give an address on ante-natal work. 

Midland Branch: Chesterfield Division. — A meeting of the 
Chesterfield Division will bo held at the Royal Hospital, Chester- 
field, on Wednesday, April 18th, at 3 p.ra,, when there will be a 
scries of clinical demonstrations. 

SfiDLANTi Branch : Hollant) Division. — A meeting of the Holland 
Division will be held .in the White Hart. Hotel, Boston, oul April 
12th, nt 3 p.m., when an address will be given by Dr. J. Wilkie 
Scott (Nottingliam) on some aspects of vomiting. Members of 
neighbouring Diidsions will be welcomed. 

Norfolk Branch. — A meeting of the Norfolk Branch will be held 
at the Norfolk and Norwich Hospital on Wednesday, April 11th, at 
3.30 p.m. Sir Hamilton Ballance, K.B.E., president of the Branch, 
will he in the chair, and a paper will be read by Dr- Ian D. 
Dickson on neurnslhcnia in general practice. 

North or Engl.and Branch : Sunderland ' Division.— A meeting 

“ ’ ■* ■ •' will be held at the Royal Infirmaiv, 

*' April 18th, at 8.15 p.m. Dr. A, F. 

paper on the present status of the 

jaundice problem. 

Southern Branch: Jersey Division.— A meeting of the Jersey 
Division will be hold at the General Hospital on ^ursday, April 
19th, at 8.30 p.m. Lieut .-Colonel P. J» Marett will read a paper 
on some lung afTcclions. 

Southern Branch : Portsmouth Division. — The final address of 
the winter session of the Portsmouth Division will be held at the 
Queen’s Hotel, Southsca, on Thursday, April 12th, at 9.30 p.m., 
preceded bv a supper at 9 p.m. Dr. J. Stanley White will give 
an address ‘on some recent aspects of biological therapy, illustrated 
by a cinematograpli demonstration of research work carried on in 
Messre. Parke, Davis and Co.’s research laboratories. This will be 
tho last address, preceded by a supper. The business meeting will 
be held on May 10th, at 9 p.m., and the annual dinner on May 16th. 


. branch and division meetings to be held. 

BiRMiNGnAM Branch: (^ventrt Division, — A clinical meeting will 
Wr. ' ^ DivLiion al tlio Covcnlry and Warnickslure 

Hospital on Tuesday, April 3rd. at 8.30 p.m. 

Bats-cn : Dtini.EY Divisiok.— A mccUng of tlie Dudley 
In Hospital, Dudley, on Thursday, 

Anminl Iinnrn, I ^.-^Souda 1 Elcctiou of reprcsentaliye al 

cases, etc Afcctmg, and demonstration of clinical 

TAsnvoRTn DIVISJOS.— At the 

Se K.fnnn^nn Tamworth Division to be held at 

C F Eudd till renS”' Wednesday, April 18th, Dr. 

t.. F. Kudd svtll read a paper on an ophthalmic snbject. 

^’htisn Ditisiok. — ^A meeting ol 

HoS’itnl Wliitehaven and West Cumberland 

Programme: Paper on tho Whitehaven 
rfrntin'r. Dr. G. B. Muricl ; demon- 

F w V. W. Maxwell, and 

iiosnitai, including demon- 

5^0 m ten ‘bv by the honorary medical staff; 

D p.m., ten, by invitation of the matron. 

A BaAscn ; Lahakesbiee Divisios.— 

TTnfel nn Division will be held at St. Enoch 

will vnn^^ ®>lnesday, April 11th, at 3.30 p.ra. Dr, John 

4n ilnnn^vi ^ P®P®r ou tlio commonor Bjo affcctious as 
, occurring in general practice, ■’ 

Dmsios,_At a meeting of the Ashford 
W^« 41 ..v ^ -i' ?L‘}, “‘i y’® North Street Club, Ashford, on 
’ P-™-- J’r, J, IV. McMeo of Univereit; 
and t^pTt inert of ® o®. .r'®^ Work in the diagnosis 

is <vT-ton*,ic 1 H hepatic and biliary diseases, A cordial invitatioE 
.IS extended to all members of the Kent Branch, 

Division.— A meeting ol 

KincSind Eo\d n ^ Metropolitan Hospital, 

:^ngsla«d Koad, B., on Tuesday A«ril 3 vd nt Q ^ n m Drs 

U^bojough and T. H. G. Shore will discuss the tr^aT^ent oi 


Suffolk Branch : West Suffolk Division.— The Y^est Suffolk 
Division lias arranged, with the a^istanco of tho committee of the 
W'est Suffolk General Hospital, the following jiost-graduate coni'se 
of lectures .and clinics at the 3Vest Suffolk Hospital : 

March 31st. 3lr. .Vlcck W. Bourne. Lecture: Tho Action of Pituitrln 
and of Ergot. 

3Ir. C. IV. G. Bryan. Lecture : The Acute Abdomen in 
Cliildhood, 

Clinic : Surgical Cases. 

Dr. R. D. Lawrence. Lecture; Simplicit}’ in the Treatment 
of Diabetes, 

Clinic : Coses of Bi.abetcs. 

Jlr. T. H. Just. Lecture : Diagnosis and Treatment of 
Acute Inflammatory Conditions of tho Ear. 

Clinical Demonstration. 

Sir Thomas Plorder. Lecture : Etiological Factors fa 
Fibrosis and their Bearing on Treatment. 

20tli, Clinic ; Jlcdical Cases, 


April 14th. 

„ I5th. 
!. 21st. 


May 


22nd. 

5th. 


6lh, 

ISth. 


The lectures on Saturdays will bo given at 8.45 p.m., and coffee 
will be served at 8.30; the Sunday clinics will begin at, 11 n.m. 
Tlie courso is open to medical practitioners in West Suffolk and 
anv guests they may care to bring. There is no fee, but donations 
will be in^dted .towards the cost of organization. Members are 
invited to bring any cases of interest to the appropriate clinic, 

Surrey Branch i Croydon Division. — A meeting of the Croydon 
Division wil) be held at the Croydon General Hospital on April 4th, 
at 4 p.m. Dr, G. E. Bra-vnc-Nicholls will give a lantern demon- 
stiation on tuberculosis of the bowels. It will bo preceded by tea 
at 4 o’clock. The annual dinner of the Division will take place at 
tho Grej-bouud Hotel on Y’ednesday, April 11th, at 8 p.m. 

Surrey Branch •, Guildford Division. — A clinical meeting of tho 
Guildford Division will be held at the Royal Surrey County 
Ho^ital, Guildford, on Thursday, April 5th, at 4 p.m.; tea served 
at 0.45. 


Sussex Branch ; Hastings Division,— Tho next meeting of tho 
Hastings Division will be held at the Queen’s Hotel, Hastings, on 
Tuesday, April 3rd, at 8.15 p.m, Dr, E. I, Spriggs, director, Ruthin 
Castle, will give an address on divcrticulosis. The annual dinner 
will take place at the Royal Victoria Hotel on Friday, April 20(h 
at 7.15 for 7.30 p.m. Tickets 10s. 6d, Members are* requested to 
notify the honorary secretary as soon as possible how many 
tickets they will require for themselves and their friends. 



106 Maech 31, 1928] 


Meoiings of Branches and Divlsionst 


r BxrrPLFMEirr to thi 
LDRiTisTr Ukoical Joosiri& 


YoRKSimB Branch: ‘Wakefield, Pontefract^ and' Castleford 
Division. — A meeting of the Wakefield, Pontefract, and Castleford 
Division will be held at tho Strafford Arms Hotel, Wakefield, on 
Thursday, April 19th. Dr. J. le F. Burrow, assistant _ physician, 
Leeds General Infirmary, will 'givo a lecture on the diagnosis of 
acute cerebro-spinal diseases. The lecture will bo preceded by .a 
supper at 7.‘15 p.m., price 3s. The annual meeting of tho Division 
will take place on Thursday; May 10th. 


iitwiings of JQraitcljts anJt IBiijisions. 


Birmingham! Branch : Nuneaton and Tamworth Division. 

An ordinary meeting of the Nuneaton and Tamworth Division was 
held at Tamworth General Hospital on March 8th. Mr. F. B. 
Gilhespt read a paper on the tonsils. 

After some remarks on anatomy and methods of examination 
Mr. Gilhespy referred to’ the difficulty sometimes experienced in 
determining when tho tonsils were . septic. Ho thought tho 
presence of pus^ or muco-pus, which could be expressed from 
under the anterior pillar, was a good criterion. He referred to 
the largo number of diseases in tho development of which 
tonsillar^ infection was now believed to be a determining factor, 
mentioning tuberctilosis, rheumatism, and diseases of the respira- 
tory, gaslro-intestinal, and urinary tracts. Ho thought that 
chest conditions such as bronchiectasis and abscess after tonsil 
operations were perhaps more frequent than was suspected. Ho 
warned against promising too good results from tonsillectomy, and 
in this connexion referred to the weedy child with enlarged 
tonsils, glands in the neck, and persistent slight rises of tempera- 
ture. Tho results of tonsillectomy were often disappointing in 
these cases. In children with nasal discharge and enlarged tonsils 
ho thought that, where possible, the maxillary antra should bo 
examined by transillumination before operation. 

Mr. Gilhespy mentioned the various diseases affecting the tonsil 
and their diagnosis^ and compared tho guillotine operation with 
tho operation by dissection. He believed that the pendulum had 
swung too far in favour of dissection, and' held that tho guillotine 
was more suitable in many cases. Ho thought that in young 
cliildren, when it was necessary to remove adenoids, it was often 
advisable to leave the tonsils unless there was some very definite 
indication fer their removal. 

The paper was followed by a discussion in which many members 
took part. Mr. Gilhespy replied, and a hearty vote of thanks 
was^ accorded him for his address. 

Circular D 15, regarding reports by medical practitioners at tlio 
request of coroners, was considered, and after some discussion the 
secretaries were instructed to take action on the lines suggested. 


Edinburgh Branch. 

The clinical meeting of the Edinburgh Branch was held in tho ’ 
Edinburgh Iloyal_ Infirmary on February 29th. Demonstrations in 
tho various fecial departments were given by members of the 
Infirmary staff from. 9 a.m. At a clinical demonstration at 3.15 p.m. 
In the surgical theatre there was a large attendance of members, 
guests from other branches, and senior students, the theatre being 
well filled. Interesting cases were shown bv members of tho staffs 
of the Royal Infirmary and Royal Hospital for Sick Children. It 
was generally felt that the meeting was one of the most successful 
arranged by the Branch. 

A dinner was held at the North British Station Hotel at 
7.15 p.m., whcn.thcre lyas a gathering of sixty members.and guests 
under the chairmanship of Dr. John Stevens, president of tho 
Branch. The toast of “ The City of Edinburgh,” proposed by 
Sir Robert Phtlip, President of the British Medical Association, was 
acknowledged by Bailie Nasmyth. The toast of ” The British 
Medical Association,” proposed by Councillor Peter Given, was . 
acknowledged by Dr. Alfred Cox, Medical Secretary, who, on rising 
to reply, received a cordial tribute. Dr. W. R. Mabtine proposed 
the toast of “Tho President of the Branch,” to which Dr.- Stevens ‘ 
responded. Tho toast Floreat Res Medica,” proposed by tho ' 
Chairman, having been duly honoured, those present joined in 
singing ” Auld Lang Sine,” after which “ God Save the King ” 
was sung with great enthusiasm. 


Lancashire and Cheshire Branch, ^ 

A SCIENCE meeting was held at the Salford Royal Hospital on 
February 23rd. Tho chair was taken by Dr. J. H. Monks, presi- 
dent of tho Branch, and there was an attendance of about 
1^ members. The programme took the form of a series of short 
paners, followed by an exhibition of cases, a display of exhibits 
From tho pathological laboratory, and a demonstration by Dr. R. 
Gib?on on tho treatment of varicose veins by injection. ' 

Mr. Garnett Wright, in a paper on volvulus of the sigmoid, 
referred to the comparative rarity of the condition in this country 
compared with Russia and Eastern Europe, adding that a large 
number of tho cases in Great Britain occurred in mental institu- 
tions. Tho. anatomical predisposing factors. .were a .long meso- 
sigraoid and a narrow attachment of the meso-sigmoid to Iho 
abdominal wall. Mr. Wright regarded constipation as a result 
rather than a causo of the condition. In most cases careful 
inquiry showed that acuto obstruction bad been preceded by , 
symptoms' of a chronic and recurrent nature; hcnco the presence 
of visiblo .peristalsis in most instances. Mr. Wright' .recomtoendeH .j 
excision of the sigmoid in two stages; less radical measures were’! 
very liablo to bo followed by recurrence. I 


Mr. R. Ollerenshaw showed a series of cases to illustrate 
various types of fracture in tho region of tho elbow. A fracture 
of tho olecranon was first shown, and Mr. Ollerenshaw expressed 
himself os being in favour of non-operativo treatment in most 
fractures of this nature. Tbo details of treatment by full exten- 
sion fo.r six weeks, followed. by. flexion, with careful control of the 
fragments, under an anaesthetic at the end of that period was 
demonstrated. Cases eliowing fracture of tho head* of the radius 
followed, illustrating tho results of conservative methods and of 
cxscction of tho head of tho bone for severe .smashes. Tho more 
common , injuries of tho lower end of tho humerus were then 
shown, and a case in which tho fracture had occurred a week pre- 
viously;' where gross displacement had been -pre.scnt and reduction 
had been ofTected under the x-ray Bcrccn, was demoii.^tmted. Fivo 
other cases showing tho frequent association, of peripheral nervo 
injuries wxtl? elbow fractures were exhibited. In two of these tho 
musculo-spinal nervo had been completely divided and subsequently 
sutured; m one, tho ulnar; nervo had been transposed forwards to 
remove it from bony pressure; in another- tho median had been 
torn" by a fractiiro dislocation. In the fifth case a crushing of the 
posterior interosseous nervo had necessitated a tendon transplanta- 
tion, which provided excellent furclion. • ■ , 

Dr. G. J. Langley contributed a paper on some problems of 
glj’cosuria. After referring to the general conditions of the insulin 
treatment in diabetes, he expressed tbo opinion that the best 
rt^ults wcro obtained with a - minimum diet combined with small 
but adequate doses, of insulin. He admitted that the patient 
usually desired a larger dietj but was not willing to undergo tho 
moro frequent injections of insulin which, a harger diet required; 
a compromiso had often to be made. Dr. Langley then emphasized 
tho importance of recognizing that tho recurrence of pyrexia — for 
example, influenza — in diabetes required immediate increase of 
carbohydrate and insulin. Operations could now be undertaken in 
diabetes without hesitation; ether was the best anaesthelic, and 
should bo preceded by glucose and insulin^ Dr. Langley then 
referred to renal glycosuria, and expressed tho opinion that this 
was fairly common. Ho also called attention to the occurrence of 
glycosuria under other conditions— after mental strain, after 
cerebral * -^mc cases of exophthalmic goitre.' 

Mr. E * ‘ • >sed tho treatment of urethral 

stricture and tho aftcr-carc of patients 

operated jsults of 160 men treated by him 

personally in tno gemiu-uunuiy department of tho Salford^ 
Hospital. Ho considered that the best results were obtained if 
instrumentation was always carried out by the same surgeon, who 
carefully regulated tho attendance of each individual; ^ forcibly 
dilatation was condemned. Three points were emphasized in treat- 
ment: first, urinary infection must bo guarded against; secondly, 
overdilatation must be avoided; thirdly, tho intervals between 
attendance must bo so regulated that contraction was not permitted 
to progress. Ho concluded that the present operations for stricture 
should -bo regarded as palliative, not curative, and must be 
followed by dilatation at longer or shorter intervals. Careful and 
well-regulated dilatation co^d maintain health and prevent the 
development of sequels. 


Lancashirh and Cheshire Branch : Rochdale Division, 

A meeting of tho Rochdalo Division was held m the Lyceum, 
Rochdale, on March Mth, when Dr. E. H. Cox, D.S.O., was in tho 

F. Holt Digcle (honorary surgeon, Manchester Royal Ear 
Hospital, and honorary aural surgeon, Aiicoats Hospital) read a 
paper on some factors in the prevention of deafness. He gave a 
lucid and instructive account of tho measures necessary in cases ot 
catarrhal otitis media and suppurative otitis “ledia, in which 
groups most of Ihe cases of- preventable deafness may be said to 

°^On’the motion of Dr. Jefferson, seconded by Dr. Ramsbottom, 
a vote of thanks was unanimously accorded to Mr. Diggle tor his 


JjETKOPOLITAir COUNTIES BeANCU I CaMBEEWELL DIVISION, 

A MEETING of tho. Camberwell Division was hold at tho Bermondsey 
and Botherhitho Hospital on March .13th, when Dr. Cos was m 

*^^Dr*' aiKKNESS demonstrated and discussed the diagnosis of an 
uriusiiarcase of abdominal neoplasm. Members shouted a keen 
interest and expressed' their opinions as to its origin. Dr. 1'Oeman 
showed tlio following cases : (1) pernicious anaemia, with signs or 
subacute combined degeneration; (2) two cases of aortic aneurysm; 
(3) syringomyelia; (4) abscess of lung'. The cases were illustrated 
by a^ series of excellent x-ray films, those dealing with the case 
of abscess being of especial interest. The focus had been clearly 
identified, enabling a sureessfiil operation for drainage of the 
cavity to be carried out. Dr. Evans showed a girl with Schlatter 3 
di'-ea'se in which signs followed two months after a slight injury to 
the kn4e, and an elderly woman with myxoedema. 

During tlie discussion which followed members were cntertainett 
to tea by the matron of the hospital. A vote of thanks to the 
staE was carried with acclamation. 


Meteopolitan Counties Bbancu : Lambetu and Southwabe 
Division. 

t 5IEETINO of tho Lambeth and Southwark Division '"'ha 
ho Lambeth Carlton Club, Coldharbour Lane, S.Vf.9, on February 
2nd, when Dr. V. S. Paktkidge was in tho chair.- 
-Mr. -F.-M cG.-Lougiinane read. a detailed paper on the “ 

lia^riosis of liaematuria.' Mr. -I-oughnano enumerated -tbo ebuaea 

if liaematuria under tho headings of renal, uretene, vesicai. 





Mootings of Branches and Divisions, 


r SUPPLr.MK>iT TO TnB - 
LDRITIWK iiKDICAL JOC’H-VAIi 


■for 


MAitcn 31, 


1928] 


pro?laU(', aiul urethral; ho pointed onl that haematnvia duo to 
some nlTcction of the kidney vns tlio rno*;t Ukoty to occur. In Iho 
ca 5 o of renal calculi haemorrhago might follow sorno jolting move- 
ment, and would bo preceded by colic; wberens if a malignant 

f rowth was present (ho bleeding would como beforo tho colic, 
’yurla was slight, unless pyonephrosis was present. Diagnosis \ya3 
m’ado by radiography and pyelography; cystoscopy gave liiilo assist- 
anco.in a ca^^o of renal calc-ulus, since tho ureteric orifices changed 
only when a stono was impacted in tijo vesical intramural portion 
of tho ureter. Tuberculosis of the kidney caused slight bleeding, 
but considcrablo pyuria; and cvsto^copy might rovcal tubcrclcs’or 
ulcers in tho bladder, and a golf-holo ” urctor. A pyclogram 
would shoa* worm-eaten ” calyces. ' A renal neoplasm gave rise 
to serious haemorrhago only rarely; it was usually moderate, inter- 
mittent, capricious, and uninfluenced by movement, pyelography 
usually enabling a diagnosis to bo made. In adults hypernephroma 
and papilloma were tho commonest tumours, and in infants 
embryoma, a palpable tumour being alwnj’s found in tho loin in 
t’lQ last caso. “.Ksscntial hacmalr.ria should only bo a Icntalivo 
diagnosis after tho elimination of 'all knoivn causes. Aneurysm of 
tho renal artery was rare. 

The source of vc^ic.al haemorrhage was readily detected by cysto- 
scopy, and was usually a papilloma, except in elderly men, wlicn 
a malignant growth or an enlarged prostate niiglit bo concerned. 
A clear medium for cystoscopy could bo obtained by using liquid 
pi raflin or a 1 in 400 dilution of hydrochloric acid. Urethral hacma- 
H in children was generally ouo to impacted calculus or to a 
body; in adulU to infection, papilloma, or enlarged prostate, 
llio speaker emphasized tho importance of cniploving modern 
methoas in Iho diitcrcntial diagnosis so as to ensure Ihe detection 
t disease; no patient with constant or recurrent hacniaturia 

should bo kept very long on medical troatineut only. 

On tho motion of Dr. K. Coyne, seconded hy Dr. J. Mellotte, 
a V 0..0 of tlianks svas accorded to afr. Loughnano for liis address, 
and to Mr. E, Canny Ryall for tho excellent illustrations ho 
provided. 


A clini^l nKoling of tho Lambeth and Southwark Division was 
held at tho Relgrayc Hospital for Children, Claphnm Road, on 
March 7th, when Mr. R. A, Ramsay showed tho tollowing cases: 
* swelling of tho upper end of tlio femur in a child 

aged A year 5 months; (n) a case of dermoid cyst on tho temporal 
region; (uO d case of congenital atresia of tho external auditory 
^ congenital 'hypertrophic pyloric stenosis, 

successfully operated on, and treated afterwards with intramuscular 

cerricaUdeiiiU 3 l“ ° empyema; (vi) a case of 


llETBOPOLITAK Con.VTIES BrAKOI : IfARYLEnOKE DtTtSIOK. 
Rtrpjf”w’i ‘'-i? ^,»7jo>Jono Division was licid at H, Cliandos 
of tl .0 Dh-ision,“reswi(I. ’ eUairman 

Hm' appointed reprosonialives in tlio Rcprcscnla- 
Tlmolo year: Drs.- Hawthorne, Roxburgh, 

WesFon n Geaham Liltlo, M.P., Gcorgo 

Mm “n<> Dr. Jobson Horne, Sir. McAdam 

representatives' Darman, and Mr. Soultar were elected deputy 

tho .lecture witli lantern illustrations on 

a noto on Doudon Bridge to Lambetl: in old days, with 

intereslinn early water supply. The address was extremely 

imeresting and was mueii appreciated. 


A Do u 1 lEs Brakch ; Sooxn-'WEET Essex Division. 

Cross Hosn?tal''nn^xi'*^*’i^S^ Essex Division was held at Wliipps 
Medical Secretarv “ communication from tho 

info tlie treatment of concerning the collective investigation 
agreed to take mrt !n ulceration. A number of members 

Dr Arnm P • '•'le investigation, 

interesting casM''?nc*udtFF*^i“^ tlio hospital, showed a number of 
souism totlowS Fncenh^i- ? if 

caries very closely- simulated cervical 

Wassermann reaction •'^a r,nnr^° ,*’'‘gbs. .associated with a positive 
ture of tho femoral ’artpr^P ‘■"‘®“0'sm organizing after liga- 
angiosarcoma of tlio fcm,,n ““Putation at tho liip-joint for 

in tliQ region of tho tliird'^n ? a coxa vara; a tumour 

and slow Spontaneous deconFpFcFsFon.’" “ ^D'droceplialus 

Dr. and Mrs. Mui*ia° ‘“'^®^'ng a hearty vole of thanks was accorded 

The annuaFd^npr = MonrETn Division. 

in tho Queen’s Head Hn^ Morpeth Division was held on March 9th 
in tho ehal. Tile gS'^ ’fi?''^ °r. Hugh Dickie was 

(Newcastlo-upon-TynlF Tim*^ Harvey Evers 

Association was ^oroDospdK “The British Medical 

Dr. Frank Beaton^ Datotyside and replied to by 

year’s president of’ the Nor?h oT En'"? “a** 

lion. Tlicro w.ns a « i. -bngland Branch of the Associa- 

from other DivisioL.^WmF'lon™’ members being present 

enjoyable evening was snont ®tory, and sentiment a very 

the best yet heldr ^ Pnnetion being declared one of 


The • D^igh and Flint XIitision. 

.reorganizafioii' ri? f hn' 71 ^ and Flint Division ainco, tbi 

ChS“ on March 3r?‘'''"T Qheen’s Hotel 

r. on.JUarch 3rd. In tbo unavoidable absence (througl 


influenza) of Dr. Kaiharino Drinkwatcr tlie ' chair was taken by 
Dr. .T. 0. Davie?. 

With regard to reports by medical practitioners furnished afc 
tho rcqiicst of coroners, it was decided to follow tho suggestion 
from Iho head offleo to write first to tho coroners and sub- 
sequently to approach tho county councils by letter. 

It was proposed to circnlarizo tho members of the Division to 
ascertain if they would havo their names submitted for tbo 
inquiry into the treatment of varicose ulceration. 

Tho proceedings ended with tea provided by tho chairman of 
tho Division, Dr. Kaiharino Drinkwater, and much regret was 
expressed at her absence. • 


Sierra Leone Brancit. 

Tira annual meeting of tho Sierra Leone Branch was held on 
December 30th - in tho Medical Offices, Water Street. In the 
absence of iho president and vice-president Dr. Wood, the senior 
member of tho Council, took tho chair. After tho minutes of the 
last meeting had been adopted tho president-elect, Dr. Peacock', 
took tho chair, and expressed his higir appreciation of tho honour 
of being elected president for the second time; he proposed a vote 
of thanks to tho outgoing officers, vfhich was adopted. Ho said 
that in tho absence of the rcprcscntAitive, Dr. Iriness, he had had tho 
pleasure of representing tho Branch at tho Annual' Meeting of tho 
Association at Kdinburgh last year, and expressed the hope. that 
it would bo possible to find a representative for the 1928 meeting 
at Cardifi. 

Dr» Peacock referred to the severe loss sustained by the Branch 
and by tho colony in tho death of Dr. M. Jackson, w’ho had possessed 
in a remarkable degree the confidence and affection of the com- 
munity; botli European and African. On the motion of Dr. Peacock 
an expression of condolence was directed to be sent to Dr. 
Jackson’s relatives. 

Tho following officers wero elected : 

President-Elect, Dr. McDouall. Vice-Prefidentf Mr. Quintin Stewart, 
llonorar!/ Secretary/ and Treasurer, Dr. Wright. 

Tho Secretary reported that the Branch had thirty-two members. 
During tho year three scientific clinical meetings had been held, and 
tho financial statement showed a satisfactory credit balance.^ • 

A circular with regard to tho election of a representative on 
tho Council of tho Association was considered, and it' was decided 
tliat the Sierra Leone Branch should not register a vote on account 
of its small size compared with tho Branches with which ifc was 
grouped. 


South-Eastern op Ireland Branch. 

An ordinary meeting of the South-Eastern of Ireland Branch was 
held in Kilxcnny on March 10th, when tho president, Dr. Myles, 
was in tho cliair. Tho annual report of tho Branch was 
unanimously adopted. 

On tbo motion of Dr. D. Walsh, seconded by Dr. Myles, it was 
unanimously resolved : 

That having learned of tho serious illness of Dr. R. O’Brien 
(Clonmel), the honorary secretary be directed to convey to him tho 
wishes of tho Branch for bis speedy recovery. 

Dr. O’Brien has been a very old and esteemed member of tho 
South-Eastern Brancli. 

Dr. R. Row’lette (Dublin) delivered a British Medical Association 
Lecture on tho medical treatment of gastric and duodenal ulcers, 
illustrated by a lantern demonstration. The lecture was very rnuch 
appreciated, and the following members took part in the discussion ; 
Drs. Denis Walsh, Myles, D'Abreu, and Drennan. 

Cordial votes of thanks were accorded to Dr. Rowlette for his 
most instructive lecture, and to Dr. Grace for arranging ifc. 


Southern Branch ; Portsmouth Division. 

A meeting of Iho Portsmouth Division was held afc the Queen’s 
Hotel, Southsea, on March 8th, when Dr. Lytle was in the chair. 
Mr. Oed, in tho absence through illness of Dr. Livingston, gave 
an address on the dental problems of medicine to a mixed 
audience of dental surgeons and doctors. 

Tho speaker thought that ifc was difficult to Ijelieve that 
pyorrhoea was of much importance in -tho causation of disease, 
but Mr. R. W. Henry of Leicester, speaking for ophthalmio 
surgeons, referred later to certain diseases of the eye in which 
pyorrhoea was an important factor, and Mr. Stanley Hillman 
thought that if, in pyorrlioea, the teeth were removed in the early 
stage of joint aud other manifestations, further trouble would be 
avoided. Apical root trouble was considered to be of importance, 
but it was thought to bo unwise to extract many teeth at a 
time, since a temporary exacerbation of joint symptoms might 
follow. It was emphasized that where organic change had taken 
place no obvious improvement would result from extraction. The 
advisability of using, local anaesthesia in these cases was doubted. 

The use of the tooth brush w’as questioned, but most of the dental 
surgeons thought that there was nothing to lake its place. Mr. 
CROor, however, advocated vigorous la^-age of the mouth with 
water^ and Surgeon Commander Given supported him froih his 
experience of the Chinese, among w’bom there was said to be very 
little pyorrhoea. Their method of cleansing was by lavage and finder 
friction. It was suggested al-^o that consideration of vitamins mi^hfc 
bo neglected, since most people obtained enough in their food, Eufc 
Dr. OnTiNQS believed that an appreciable percentage of the popu- 
lation 'suffered from mild forms of scurvy. Dr. Lytle called 
attention to tho condition of tho mouth in Vincent’s angina 

Mr.* Warren, president of the Portsmouth Dental Association 
proposed a.voto of thanks to Mr. Ord, and Dr..McAsKiE, secondin*’^* 
expressed tho hopo-that a dental evening would bo an ‘annual 
event. 


yos mnCH 31, 1928] 


Genera/ ATccf/ca/ CouncU. 


t BVPrixin:}& to 
D r.tTisn MEDICAL Jourkia 


South Wales aio) MoNMOurnsinEE Bbanot : Swansea Division. 

A meeting of the Swansea Division was held at the General 
Hospital, Swansea, on March 15th, when Dr. Daniel E. Evans, 
chairman of the Division, presided. 

Mr. T. E. Hammond of Cardiff gave an admirable address 
entitled “ Infections of the urinary tract : their diagnosis and 
treatment.” A vote of thanks was accorded to the lecturer for 
his lucid and helpful address. 


SuFFOLH Branch. 

The spring meeting of the Suffolk Branch was held at the Angel 
Hotel, Bury St. Edmunds, on March 6th. Dr. Malcolm 
Donaldson of London read a paper on the uses of radium in 
gynaecology. He dealt in a most able and clear manner with the 
work at St. Bartholomew's Hospital in both innocent and malig- 
nant conditions. He pointed out that without some knowledge of 
the physical properties of radium no treatment could be really 
efficient, and that many of the poor results obtained in the past 
were due t-o the fact that people had not realized this fact, and 
had used it indiscriminately. Having described some of these 
physical properties, he then passed on to' the radium treatment 
of non-malignant conditions found in gynaecology. He dealt with 
the treatment of haemorrhage during abnormal menopause, and 
emphasized the necessity of an early correct diagnosis in such 
cases^ 60 as to exclude malignant disease: and the advisability of 
keeping the radium in position forty-eight to seventy-two hours, 
rather than the twenty-four hours which was the common practice. 
Ho then discussed the treatment of fibroids by means of radium, 
and the type of case in which it was indicated. Turning to the 
treatment of malignant disease of the female genital tract, he 
dwelt at some length on the treatment of carcinoma of the 
cervix.^ He pointed out that the statistics from English sources 
of patients who had survived five years were not yet sufficient to 
make a comparison between radiotherapy and Wertheim^s opera- 
tion, but that if the figures from Continental eources were taken 
it w^ obvious that thei-e was very little difference in the results. 
In the case of radiotherapy, however, an additional 12 to 16 per 
cent, of the inoperable cases could be saved for at least five years. 
Fiu*thermore, he pointed out that, owing to the very simple 
technique required, the mortality by this method of treatment 
was less than 1 per cent., whereas that of Wertheim’s liysterectomr 
was in the neighbourhood of 10 per cent, in the case of most 
operators. 


Tanganyika Branch. 

A SCIENTIFIC meeting of the Tanganyika Branch was held on 
JiTnuary 9th at the European fespital, Dar-es-Salaam j the 
Director of Medical and Sanitary Services, Dr, J. 0. Shircore, was 
present as a guest of the Branch. 

Mr. McHurdy, Governmen * interostm*^ 

■paper on the distribution and ' --cs-Salaatm 

Drs. J. Williamson and ' ' • jmonstrated 

four clinical cases — an old African woman with a fungafing mass 
in the right breast and pathological fractures of the right humerus 
and femur; an African boy with a hard, ill-defined swelling in 
the quadriceps of the right leg; an Indian woman with hepatic 
and splenic enlargement, associated with continuous fever, which 
had’ not yielded to quinine; and a young African male with 
obscure meningitic symptoms. Much discussion followed, and Dr. 
Shircore suggested that the first case, while superficially suggest- 
ing carcinoma, was in reality a combination of tertiary yaws with 
osteoporosis. 

Dr. W. K. Connell described a method which he had devised 
for obtaining a complete and satisfactory cutaneous investment 
for the penis after the radical operation for elephantiasis of the 
.male external genitalia.- His method consisted of embedding the 
penis temporarily in a subcutaneous tunnel on the inner aspect 
of the thigh, and subsequently liberating it by means , of a simple 
flap .operation. He demonstrated a case which had been treated 
by this method. 


Torkshire Branch: Wakefield, Pontefbact, and Castleford 
Division. 

A MEETING of the Wakefield, Pontefract, and Castleford Division was 
held at the Strafford Arms Hotel, Wakefield, on March 8th when 
Dr. T. Gibson was in the chair. A message of sympathy was sent 
to Dr. Tcalc, who was unable to lecture owing to indisposition 
Dr. J. T. Ingram, dermatological physician to Leeds Infirmary 
gave an interesting discourse on skin diseases, based on persona! 
study and experience, stating that in his belief the skin was more 
often offended against than offending, and that rest, rather than 
attack, was the proper line of treatment in the majority of cases. 
Ho emphasized the necessity for the general examination of the 
patient, and exposure of the whole of the body in dealing with 
fikin diseases, and advised early epilation for sycosis. He con- 
sidered vaccines to be of definite value in the case of boils and 
acne vulgaris, and thought that boils were a definite' indication 
of ill health, and that a holiday or, failing that, artificial sun- 
light, influenced treatment verj* much. He dealt with general 
skin diseases commonly experienced, and with industrial dermato- 
logical conditions, pointing out that many skin diseases had a 
psvchological basis. 

His address was very much appreciated by the members, and in 
tho discussion Drs. Gibson, Butler, Lister, Stev-en, and Thomas 
took part. 


GENERAL JIEDICAL COUNCIL. 

Executivi: CosniiimE. 

A siEETixo of tlic Executive Committco of tho General 
Medical Council was hold on February 27th, under the 
chairmanship of tho President, Sir Donald MacAltsteh, Bt. 

General Medical Council Finance. 

The sums received for registration fees during 1927 were 
£5,813 by the English Branch Council, £2,675 by the Scottish 
Council, and £1,467 by tho Irish Council, together with £1,135 
received by the General Council in respect to colonial and 
foreign medical qualifications. Fees and expenses for attend- 
ance at meetings of tho General Council and- its committees 
amounted to £2,723. 

An Italian VcgTce. 

At its session in May, 1927, .the Council decided that tho 
entry of tho name of a practitioner in the Foreign List of tho 
Medical Register in virtue of the M.D. Pavia was incorrect, 
and must bo erased. Since then communications have been 
received from the Slinistry of Foreign Affairs at Rome 
announcing the anmillment of tho decision of the Royal Univer- 
sity of Pavia that tho degrees granted to cei-tain American 
practitioners by that university should bo considered as equiva- 
lent in every respect to degrees in medicine, and surgery 
granted in Italy. Two other .applications for' registration in 
virtue of the P.avia degrees were before the Council, and tho 
Registrar was instructed to refuse them. 

Rcciprocitg with Ontario. ■— ■ 

Reciprocity with Ontario ceased at the end of 1927, hut 
some correspondence was brought before the Committee on tho 
subject. In ■ a previous communication the Registrar of tho 
College of Physicians and Surgeons of Ontario had instanced 
the registration of a certain practitioner resident in Ontario 
as one of the causes which led to reciprocity being brought 
to an end, and referred to the “ humiliation ” of having to 
grant this practitioner his registration following upon his 
registration in the United Kingdom. On this communic-ation 
being brought to tho notice of the University of Western 
Ontario, Dr. Howilt, of the staff of the medical school, wrote 
an account of the circumstances, -which was stated by the dean 
to be more accurate than that given by the Registrar of the 
College. Dr. Howitt’s letter, which is printed in full in the 
Committee's minutes, alleges grave unfairness in the treatment 
of this practitioner by the Ontario Medical Council,^ especially 
after he had willingly incurred great financial loss m meeting 
;a condition which the Council had imposed. 

British Doctors in Madeira. , 

From some telegraphic correspondence between the British 
Consnl at Funchal, Madeira, and the British Amhass.ador at 
Lisbon, it appeared that a notice to discontinue practice w.ts 
niven by the chief of police to foreign doctors in hladeira on 
February 16th. The Consnl protested to the acting- civil 
covernor, who had been proceeding on suggestions — not haying 
■quite the force of instructions — from the Portuguese Minister 
of the Interior. The governor, liowever, was induced grudg- 
ingly to promise that no action should be taken pending an 
appeal to Lisbon, where the matter is now being taken up by 
the Ambassador. It is stated that British doctors have amended 
British residents in and visitors to Madeira since 1866. 
Madeira has become practically a hospital for convalescents 
.and persons needing sun and sea bathing. Thousands of 
British subjects visit Madeira annually, many of whom would 
not do so but for the fact that British qualified doctors are 
in attendance .at the hotels. [This matter is referred to by 
Dr. Michael Grabham in a letter published m this week s 
Journal at page 571. J 

Colonial Legislation. • ■ ■ 

An amendment of the law relating to dentists in the State 
of Victoria lias been made. It was reported to the Committee 
that one effect of the new legislation is that persons registered 
under the Dentists Act, 1921, are no longer remstrable in 
Victoria which was one of the few dominions where, owing 
to the -wording of the previous law, they had hitherto been 
able to register. This conforms to the custom in the Uniteu 
Kingdom of declining to register as dentists persons registered 
in the dominions solely on account of previous practice or 
apprenticeship and without a qualification obtained ailcr a 
recognized course of study and curriculum- 

Vniversity of Calcutta. 

The University of Calcutta sent a communication stating tliai 
transitory provisions had been made by the senate whereby 
the new mediral regulations would become immediately appne- 


Maucii 31, ib'isl 


National Insuranco : Cost of Prescribing. 


109 


eblo to existing students ns desired by tlic General Medical 
Conneil. Tliis followed niion a resolntioii of the Executive 
Comniitleo of the Council at its previous inecling relating to 
tlic recognition of the luedicnl degrees of Calcutta. Colonel 
Needlinm reported on tlio provision.s that they complied with 
the Council’s requirements, although certain anomalies inevit- 
able to a change-over period remained. Thus, while the Final 
Exiunination under the new regulations would ho held for the 
first time in April, 1928, the old Final Ex.aminalion would bo 
contiuued until November, 1929, so that senior students would 
have the option of taking either the old or the new Final. Tho 
Committee agreed that on tho receipt of a satisfactory report 
from an approved inspector as to the conduct of tho new 
Final Examination to bo held in April next, the Council would 
bo prepared to consider an application for tho recognition of 
the degrees of tho university granted under the new regulations. 


Applications for Incorporation. 

Following upon a communication considered at tho last meet- 
ing of tho Committee with regard to an application to the 
Board of Trade for tho Society of Actinology and Actino- 
therapy to be registered without the use of the word “ Limited,” 
a letter was read from Sir Henrj’ Gauvain, president of the 
society, stating that tho application was unauthorized. A 
journal interested in the subject with which tho society dealt 
—that is,, tho physics and physiology of light — had offered to 
bear tho expenses of formal incorporation, but this assistance 
■had been declined. - 

The Committee also considered an application which had 
been made to tho Board of Trade on behalf of tho British 
College of Obstetricians and Gynaecologists to bo registered 
without the use of the word " Limited.” The Commilteo saw 
no objection, provided that tho memorandum and articles of 
?^°cmtion included a provision that every certificate or diploma 
issued by tho body should bear an intimation that it did not 
confer or purport to confer any legal qualifications to practise 
gynaecology or midwifery. . . 


. , Adminiifrolion of Drugs hy MiA wives. 

I n ? ?tinistry of Health had forwarded to the Committee a 
leaflet issued by tho Central Midwives Board concerning tho 
drugs which might properly be carried and administered by 
midwiye^ The Committee resolved to inform tho Ministry 
that It did not think it expedient in tho public interest to 
distribute to midivives for use in their practice such a schedule 
ot drugs as was set out in this memorandum, and was of 
opinion that the rule of the Board requiring the midwife to note 
In her register each occasion on whicn she applied a drug, with 
other details, should incorporate tho wording of tlio corre- 
^oiiding rule as framed by tho Central Midwives Board for 
^otland.i The revised rules of the Scottish Board were also 
considered by the Committee, and no objection was taken. 

Danoval of Name at Practitioner's Own Pequest. 
ine Committee considered an application from Harold 
Bearden, registered as M.R.C.S.Eng.l911, L.R.C.P.Lond.l911, 
removal of his nnmo from tho Itcglftrar on the ground 
ohtLnL P''actise. Tho Royal Colleges had no 

to^accede’ Committee agreed to recommend tho Council 


DENTAL BOARD. 

The case of T^Ue^an ’'dll ^ 

Justice T which Wsis decided by Mr, 

liabililv of -i 20lh, was a test case on the 

Dentaf Board dentist to pay a retention fee to the 

fof Tbo^retention'^of ^a^na that a fee may bo charged 

Board thereunon made on the Register, and the Dental 

failed to pl?h“s“ tenl?on''P'“PT registered dentist 

ceding that for wliiS it IhnnI i a .C'O ®bd of the year pro- 

whereupoii, if he contin might be removed, 

himself' open to prosMuS Practising dentistry, he would lay 
England such prosecutions 1 ,?'' “n “'^registered practitioner. In 
of cases. In Scotland nmsilm® undertaken m a number 

Board but onlv hv fiia Prosecutions cannot bo instituted by the 
prosecutions the Lord following upon some 

fiscal that they were not issiftd mstructioiis to procurators- 

becn rcmoveFmerelv fL where a name Imd 

Lord Advoc'itc nn of a retention fee. The 

his view, but said that subject, adhered to 

were decided in the*^ opposii? cp reconsider liis decision if a case 
A friendly action was coinT^PVp^^v^. ^ ^udge of the High Court, 
in pjirtn^hin imf^pr n two dentists who were 

Qpen to prosecution by the Board the 


distinction as Committee's resolution makes 

jnciuclcs sitnplo aperients schedule, wh 

brandy, aa SropluiS such as lysol. stimulants such 


partnership would bo dissolved. One of these dentists failed to 
pay his retention foe, wijoroiipon tho other gave notice of dissolu- 
tion of partuciship, and on the first refusing to accept such notice, 
brought an action for a declaration that the partnership was 
dissoTi-ed. 

Mr. Justice Astbury, in giving judgement, held that the use 
of tho term ** retention fee ” implied that unless a man paid this 
fco his name was not (o be retained on tho Jlcgi.ifcr^ and, further, 
that tho regulations made by the Board for erasure from tho 
Ilcyistcr were valid and binding. It followed, in his lordship's 
opinion, that if tho name of the defaulter was erased from the 
Itcgister and ho continued to practise ho would bo liable to 
prosecution. 

It was reported to tho Dental Board, at a recent meeting 
** in committee of tho whole Board,’* that tho Lord Advocate 
had accepted this decision, and had given fresh directions to 
llio procurators-fiscal. 


!lns«ranrr. 

COST OF PRESCRIBING. ' 

AnOUTION OF THE PlLAItirACOPOEIA CeSTRIENSIS.” 

The following letter has been addressed to the Clerk to the 
Insuranco Committee of the County Palatine of Chester by 
Dr. Lionel -J. Picton, on behalf of the Local Medical and 
Panel Committee. AVhile his primary subject is the abolition 
of the Phcirmacopocia Cestrxensis, the letter is of interest as 
embodying tho views of the Cheshire Panel Committee on the 
current discussion on increasing costs of prescribing. Dr. 
Picton’s letter reads : 

Tho Panel Committee accepts, with misgiving and regret, the 
suggestion of the Insurance Committee that the Pharmacopoeia 
Ccftricnsis ho done awav. 

Tho Drug Fund is fixed at a figure inadequate to meet the 
chemists* tariff charges j the chemists, though receiving the whole 
fund, arc losing tho dilTcrcnce. That is a state of afifairs which 
can only bo brought to an end by less or cheaper prescribing. 
It is because it recognizes these facts that the Panel Committee 
acquiesces. Us misgiving and regret proceed from the knowledge 
that tho step is backward. The Pharmacopoeia Cettriensis was 
based on the well-known pharmacopoeia of a great hospital. It 
was pruned, altered, and enriclied in the light of the experience 
of a group of general practitioners; it set a high standard; it was 
adapted to supply broadly the whole range of general practice. 
On its issue the British Medical Journal spoke of it more highly 
than of any comparable publication. It met the need; now that 
it is to be scrapped the need will not be met. 

Tho report of tho Insurance Committee's subcommittee on the 
** revision ** — which is to result in the destruction — of the 
Pharmacopoeia Ccstricnsis speaks of . the medical merahers 
agreeing that the substitution of a list of a few mixtures, etc., 
printed on a card *' will not in any way ho detrimental to the 
interests of tho insured persons.** They have been misreported, 
What they said was that the alterations proposed in the par- 
ticular mixtures selected from the Pharmacopoeia for retention in 
the list would not be detrimental to the efficacy of those par- 
ticular medicines. The Panel Committee would have no objection 
to, indeed would welcome, similar alterations in any other items 
in Iho Pharmacopociay were it possible to retain it. The nature 
of the nltcrntions is the omission of spirit. This is on account 
of the present high duties on it. Concentrated infusions were 
requested by tho authorities when the Pharmacopoeia was drawn 
up, as being cheaper; but as they are made with spirit they 
are now dearer. The Panel Committee never -wanted them and 
welcomes this revision, but their satisfaction ends there; if the 
whole Pharmacopoeia, so revised, could bo retained it would b© 
a matter of congratulation. 

The financial impasse will not permit of this. By an Act of 
Government^ a rigid Hmjt is set, and cheaper treatment alone 
can keep within it. It is on that account the Panel Committee 
has misgivings. Cheaper treatment will inevitably mean dearer 
illness — ^not always, but often enough, and commonly enough, to 
tell against the patients and against the funds which the societies 
administer. The arbitrary imposition of a cost limit to pre- 
scribing tells against the freedom of medical treatment. TJiat is 
tho gravamen of the charge. If a doctor knows he will likely be 
surcharged if ho^ orders so-and-so, he won’t order it — a quixotic 
or rich doctor might. But no doctor can be the first long unless 
he is tho second, and few are that. In a recent Cheshire case 
a doctor was accused of using cod-liver oil and malt too often. 
“ It is hard to give convincing reasons why you should give it 
to one and not to another,” he told the referees. ” Thev find it 
does them good, and come and ask for it. I find it does good 
to a large class of patients. Now I am telling them that exception 
has been taken to its prescription, and I don’t prescribe it.” 
That is an example of the effect of sudden and restrictive economy 

Before the present new phase of Governmental activity the 
Panel Committee was engaged in working out a sj’stem of 
criticizing and curbing extravagance, which was applied domes- 
tically, within its own walls, so. to speak, and would, tho Com- 
mittee believes, have issued in enhanced adherence to the prin- 
ciples which should guide doctors in spending the Drug Fund 
moneys to the best advantage. ' Real economy was in siohfc 
Further, the Panel Committee has always, from the early Jays 


110 March 31, 1928J 


Correspontience. 


r fJVPPLTSrEKT TO TH* 
LUniTiaK Medical Jouesal 


•when it issued its o-wn special drug list with stipulations as to 
quality, had its e-^'es fixed on the freshness, standard, and purity 
of the drugs useii. 

Now all these endeavours go by the board. There seems no 
room for local effort in the system. I am to write frankly to the 
Insurance Committee, as above, in order that it, as i*eprcscniing 
the insured people, may bo made aware of the light in which the 
Panel Committee views the recent developments in connexion with 
the Drug Fund. They may be inevitable, but they arc not 
satisfactory. 


LONDON PANEL COMMITTEE. 

A MEETING of the London Panel Committee took place on 
February 21st, with Dr. H. J. Caudale in the chair. 

Proprietary Preparations and the Drug fund. 

A long discussion took place on the question whether various 
proprietary preparations formed a legitimate cliargc upon the 
Drug Fund. The committee agreed to inform the Insurance 
Committee than in its opinion feenamint and formamint tablets 
should not be allowed at the cost of the fund, but a similar 
recommendation with regard to spliagnol ointment was referred 
back, Dr. H. Roberts protesting that if the committee sought the 
exclusion of any preparation it should at least suggest an allowable 
equivalent. 

It was reported that a letter had been received from British 
Drug Houses, Limited, protesting against a recent decision of 
the committee that radio-malt should not bo allowed at the cost 
of the Drug Fund, The committee, however, after further dis- 
cussion, decided to adhere to its previous decision, pointing out 
that tliis was a new preparation and that its therapeutic value 
could only be ascertained by experience. Dr. V. S. Partridge said 
that the sole question that the committee had to consider was 
•whether radio-malt was a food or a drug. It was true that cod- 
liver oil and malt were allowable, but those preparations had 
occupied a special position in national insurance dispensing, dating 
back from the days of sanatorium benefit. He added that the 
committee was in no w«ay concerned with the cost of a preparation, 
and that the fact that a preparation was more costly was no 
reason for its exclusion. 

The next case considered was that of the proprietary prepara- 
tion known as bynogen. The committee had previously decided 
that bynogeu should be classified similarly to extract of malt, but 
it was now reported that in the view of the Minister of Health 
bj'iiogen should rank -with sauatogcu, -witli regard to •which both 
the Panel and Insurance Committees had agreed that it was of 
the nature of a food and uot allowable at the cost of the Dru" 
Fund. It appeared to the Minister to be clear that the malt 
and wheat in both these preparations were included for their food 
value, and that it would be difficult to contend that the small 
amount of special soluble malt extract which byiiogon contained 
could have been added for any medicinal value it might possess. 
The committee therefore decided, in. view of tlie information 
supplied by the Ministry, to regard bynogen as a food and as 
a preparation not allowable at too cost of the Drug Fund. 

A letler from the Insurance Committee was read asking that the 
Panel Committee should enter upon a joint discussion witli itself 
and the Pharmaceutical Committee on the wliolc question of 
proprietary preparations, but the Panel Commillec reaffirmed a 
previous decision that there was no reason to interfere with the 
discretion of practitioners generally in ordering proprielai*j* pre- 
parations for their patients, as adequate machinery existed under 
the regulations whereby practitioners could be called upon to 
explain what might appear to be excessive prescribing. The 
Chairman said that every case of this kind had to be decided 
on Its merits. All practitioners received notice of certain prepara- 
Uons whicli were not considered allowable at the cost of the Dm*' 
Fund, but he thought that if a_ practitioner from liis own cxperi^ 
cnce ill practice was able to justify the use of a pi*oprietary 
preparation as against some more orthodox remed 3 ' no penalt^v 
would be imposed. 

Prescribing by Insurance Practitioners. 

The committee had before it the Memorandum on prc^cnbin«^ 
for the guidance of insurance practitioners’’ issued by theTnsur^ 
ance Acts Committee, but after a brisk little discussion durin«^ 
which Dr. Chase complained of the Panel Committee’s use of 
language which was unnecessarily provocative, the committee 
agreed by a majority to a resolution acknowledging the receipt 
of the memorautium and informing the Insurance Acts Committee 
that for some years it had issued a booklet on this subject M'hich 
it considered or greater value to its constituents tlian the one now 
presented. 


BIRMINGHAM PANEL COMMITTEE. 

A MEETING was licld on Fcbruaiy 21st at the office of the committee 
nheii Dr. Dain presided over a good muster of membei-s. Drl 
Puirges was congratulated on his election as vice-chairman of the 
Biiminghara Insurance Committee. The Ciiairaian drew attention 
to the great amount of useful work in connexion -witli health 
insurance which had been done by Dr. ‘Williams-Freeman on 
behalf of the panel doctor, cspecialh' rural practitioners, and it 
wa's decided to contribute twentj* guineas to llie 'Willi.ams-Frecnian 
Testimonial Fund. An appeal was made for subscriptions to the 
B.M.A. Cbarilics Fund, and it was decided to appoint a .secretarv 
to carry out a collection. 

Tlic letter from the British Medical Association -with regard 
to the new method of changing doctor will bo circulated to all 
panel doctors in the area, and their attention spociallv drawn to the 
cotilonis. A letter from the Pharmaceutical Committee containin”’ 


euggestions making for economy in prescribing will be brought to 
tho notice of all panel practitioners in the area through the medium 
of tho Birmingham Midical hcrir.w. Comparison of the areal 
figures for November and December last showed a more favourable 
position of affairs. An invitation to the committee to appoint 
a representative to Ibc Birmingham Hospitals Council was received, 
but as it was considered that one I’cprcscntativc was not biifficicnt 
the appoinlraent was deferred pending correspondence on the 
subject. Claims for emergency, anac.slnetic, and special service 
fees were considered. An appeal was again made to panel doctoi-s 
to send to bcaclqimrlois statistics of practice receipts and expendi- 
ture; forms for ihi.s purpose maj' be obtained from the Secretary 
of tho Panel Committee. 154, Great Charles Street, Birmingham. 
Tho comraitlee expressed an earnest hope that a good proportion 
of the doctors would respond, so that the case of the Insurance 
Acts Conunittec (acting on behalf of tho doctom) might he 
strengthened in pos<5iblc future discussions with the Ministo' of 
Health. 


WARWICKSHIRE PANEL AND LOCAL MEDICAL 
COMMITTEE. 

A MEETING of the Waiwickshire Panel and Local Medical Committee 
was hold at Leamington on FcbruaiT 23rd, when Dr. Herbert Mauns 
presided over a good atlcndancc. A considerable amount of routine 
business was transacted. In the cour.se of a discussion on the 
working of the new “ change of doctor ” arrangements divided 
opinions were expressed ns to whether the procedure was satis^- 
factory tmd equitable, and it was agreed that the matter should 
receive continued review so that the committee’s suggestions 
thereon could be prepared in good lime for the autumn Panel 
Conference. The Phaimaccutical Committee put forward a list 
of proposed alterations in the Formulary adopted by the West 
Midlands Conjoint Group of Panel Committees; these suggestions 
mainly tended to the clicapcning of certain mixtures. 


®omsp0nltjnr£. 

The Worhman'f Vnhic? 

Sm —It soems -woi-th -while calling attention to the following 
interesting details connected with the payment by Government 
of the only unbiased examiner into an accident taking place in 

Haviim taken over the appointment of surgeon under the 
Factory Acts in this district, I was requested to proceed to 
a factory about one mile distant, examine into tlie cause of an 
accident, examine the machine responsible for the accident, 
interview the persons concerned, and altogether spend the best 
nart of half to three-quarters of an hour at the factory. 1 ^yas 
then asked to furnish a full report of the case after examining 

For \hese services .a cheque for Ss. was forwarded from the 
Home Office. I wrote and asked what the 3s. \vas for = it 
for car hire one way, or what? When requested to render my 
account I put down .a guinea as the charge for the jepoit 
as the usual fee in similar cases not under Government. 

The whole appointment is not worth 30s. a year, and is, no 
credit to anyone concerned. But roy point is this : the only 
unbiased opinion in a case of a working man losing his hte 
is Given by an educated professional man, who is paid 3s. tor 
a journey of about one mile and back, half an hour at the 
factory, and furnishing a full medical rejiort. The cheque for 
3s. is pinned up on the wall, but what it is for I do not know. 

am, etc., , Jefferiss, 


TflUl. 


Wi-rlinal Officer of Ilealdl. Tofnes. 


Fvime of Hospital Services. 

I have not seen any comments on Sir Richard Luce s 

address on the future of hospital services, published in the 
Supplement of March 10th (p. 77), and I suggest that some 
points arising out of it deserve attention. 

^ There will be general sympathy with his appeal foi tne 
maintenance of the voluntary system. At Hie same time, any- 
one who knows anything of the pipnecr work done under Roor 
Law, and the sacrifices made, will feel the injustice oi Jus 
remarks about that service. . 

It seems clear, however, that he drew a contrast between 
system that is knoA\Ti and another that is little loiowii. He 
fears that the voluntary system will be swallowed up. I 
is evident from his quotation of the Socialist programme, ana 
anxietv as to the permanence of financial support given in 
recent' years. Stress was laid upon the funds now being raisca 
by -workmen. Is it realized that increasing numbers are going 
into Poor Law hospitals from, choice, not necessity, and that 
the amount paid into Poor Law funds rivals the amount 
contributed bv patients to voluntary hospitals? 

Would it not be well tliat all the facts obtainable shoulU ho 
sought? Authoritative statements are made, for example, tna 
so many thousand sick beds in the Poor Law service are 




112 MAEOH 8l, 1928] 


Association Iniegllgcnco Diary, 


T BXJPPLVUtl^T TO Tin! 
iDniTisn Mkoical Jour.KAi. 


BftnTAi. Frakcak, 172, Shaftesbury Avenue, W.C.2.— 0 Physician to 
In-patlenta. (2) Physician to Out-patienta. (3) Junior Resident ileciical 
OOKier (male, unmarried). Salary for (3) £100 per annum. 

Hospital for Oonstjmption akd Diseases op the Chest, Brompton, S.W.3.— 
House-Physicians, Honorarium £50 for six months. 

Hospital for Epilepst and Paralysis, Maida Vale, W.9.— p-) Resident 
Medical Officer. (2) House-Physician, Salary £150 and £100 per annum 
Tespectively. 

Hospital for Sick Children, Great Ormond Street, ’W.O.l,— House- 
Surgeon, House-Physician, and Assistant Casualty Officer for bjx 
months. Salary £50. 

Hospital for Women, Soho Square, W.l. — ^Assistant Anaesthetist, 

Kkockando Parish. — Parochial Medical Officer and Public Vaccinator. 
Salary £46 per annum. 

Leigh Infirmary, Lancashire, — Resident House-Surgeon (male, unmarried). 

Salary at the rate of £150 per annum. 

Liverpool Eyb and Ear iNnnMABY.— Third Honorary Anaesthetist, 

London Fever Hospital, Islington, N.I.— Honorary Surgeon. , 

Lucknow Ukivbrsitt. — Professor of Anatomy. Salary R8.1,450 per mensem. 
Manor Housb Hospital, Golders Green, N.W.ll, — House-Surgeon (male, 
unmarried). Salary at the rate of £^0 per annum. 

UiLDMAY JIiSBiON HOSPITAL, Austin ‘ Street, E.2.— (1) Senior Resident 
Medical Officer (male). (2) Assistant Casualty Officer f^non-resident). 
Salary at the rate of £140 and £100 per annum respectively* 

Hiller General Hospital, Greenwich Road, S.E.10. — Casuolty Officer (male, 
unmarried). Salary £150 per annum. 

Ministry of Health. — Deputy Regional Medical Officers. Remuneration 
£800 per annum, rising (o £1,100. 

Paddington Green Children’s Hospital, W.2,— (1) House-Physician. (2) 
House-Surgeon. Males, unmarried. Salary at the rate of £150 per 
annum each. 

Prince of Wales’s General Hospital, Tottenham, "N-IB.— (1) House-Surgeon. 
(2) Special House-Surgeon. (3) House-Physician. (4) Junior House- 
Surgeon. (5) Junior House-Physician. Salary at the rate of £120 per 
annum for (1), (2), and (3J, and £90 per annum for (4) and (5). 

Princess Louise Kensington Hospital for Children.— (1) House-Physician. 
(2) House-Surgeon, One will be appointed Resident Medical Officer and 
be regarded as senior with salary at the rate of £100 per annum, the 
other will receive £75 per annum. 

Queen’s Hospital for Children, Hackney Road, E.2.— Physician in charge 
of Sklu Department, 

BnoNDDA Urban District Council.— Assistant Jfedicnl Officer of Health 
end Assistant School Medical Officer, Salary £600 per annum. 

Royal Nmional Orthopaedic Hospital, 234, Great Portland Street, WX— 
Medical Registrar. Honorarium at the rate of £150 per annum. 

Bt. Vincent’s Orthopaedic Hospital. Eastcote.— Resident Medical Officer 
(male). Salary at the rate of £150 per annum. 

Wakefieid : County Council op thb West Riding of Torkshire.— Third 
Assistant Medical Officer (resident) at the Middleton-in-Wharfcdale Sana- 
torium. Salary £250 per annum. 

Wals.!LL County Borough. — Clinical Tuberculosis Officer, Assistant Medical 
Officer of Health, and Assistant School Medical Officer (male). Salary 
£750 per annum. 

Walsall General Hospital.— House-Surgeon. Salary £125 per annum. 
Walsall Union. — Resident Medical Officer at the Poor Law Institution. 

Salary £600 per annum, plus vaccination and certiftcation fees. 
Weston-super-Marr Hospital.— Resident Medical Officer (male, unmarried). 
Salary £130 per annum. 

West Hartlepool : Cameron HosPmL.— House-Surgeon (male). Salary £150 
per annum. 

Medical Referee or Referees under the Workmen’s Compensahon Act 
(1) for the districts of the Northampton and Towcester, Newport Pagnell, 
and Leighton Buzzard County Courts (Circuit No. 23); (2) Ophthalmic 
Specialist for all County Courts in Circuits 1 and 2 (Northumberland 
and Durham). Applications to the Private Secretary, Homo Office, 
Whitehall, S.W.L, by April 7th and llth respectively. 

Certifying Factory Surgeons. — The following vacant appointme'pts are 
announced : Aberchirder (^Banffshire), Rlnmie (Aberdeenshire), 

Tyldesley (Lancashire), Fakenham (Norfolk), Kingston (Surrey), Citv 
of London. Applications to the Cnlef Inspector of Factories, Home 
Office, Whitehall, S.W.I. 

This list of vacancies is compiled from, our advertisement columns, 
where full particulars will be found. To ensure notice in this 
column ndi'crf/scmenfs must he received' riot later than the first 
post on Tuesday morning. 


APPOINTMENTS. 

Pierce, W. J., M.B., Ch.B.Llverp., Junior Medical Officer, Liverpool Open- 
air Hospital for Children, Leasowe- 

Queen Charlotte’s Maternity Hospital, Marvlebone Road, NWl— Sentor 
Rerfdrnt Medtcal Officer: George A. Ross, M'.D., Cb.B. Aesiefanf Resident 
?tedical Officer: Heniy C. Lowry, M.B., B.Ch., B.A.O., P.R.C S Ed 
liistrict Reeident iledical Officer: Miss Q. JI, B. Morgan, M.B., B.Ch. 

Bt. John’s Hospital for Diseases of the Skii^ Leicester Square, ■\V.0.2. 

Senior Honorai^ Medical Registrar: Henry CorsI, M.B., F.R.C.S. Junior 
Honorary Medical Registrar: Lazare Hartston, M.B., B.S.Lond. 
Certipyikg Factory Surgeons.— T. Clapperton, M.B., Ch.B.Aberd., for the 
Oakham District, Rutland; L. E. Hughes, M.R.C.S., L.R.C.P.Lond., for 
the Cirencester District (Gloucester); T. E. Jones, M.R.C.S., 

L. R.C.P.Lond., for the Aberayron District (Cardigan) * R. Lawson, 

M. D.Ed., for the Hipnenholmc District, West Riding, Yorks; J. W, 

McIntosh, M.B., Ch.B.Ed., F.R.C.S.Ed., for the King’s Lynn district 
(Norfolk); J. J. O'Reilly, M.B., N.U.Irel., for the Chepstow District 
(Monmouth). ' 

DIARY OF SOCIETIES AND LECTURES. 

Royal Soctctt of MEUiaNE- 

Sectinn of Orthojianlics. — ^Tucs., 8.20 p.m.. Dr. Charles Scudder (Boston, 
Mn'-».) : The Treatnu-nt of Recent Fractures bv Operation, To ^ 
followed by Sir Robert Jone®, Mr. E. W. Hey Groves, Mr. IL A. T, 
Fairbank, and ilr. W. A. Cochrane. 


58rittslj iltcbiral ^Bsoriatioit. 

OFFICES, nniTisn medical association uovsb, 

TAVISTOCK SQUARE, IT.C.Z. 


Dcpat^monta0 

Subscriptions and Advertisements (Financial Secretary and Business 
Manager. Telegrams ; Articulate Westcent, London). 
tlCDicAL Secretary (Telegrams: Mcdisccra B'esfeent, London). 

Editor, British Medical Journal (Telegrams:. Aitiology Westcent, 
London). . 

Telephone numbers of British Medical Association and British Medical 
Journal, Museum S861, 9862, 9863, and 9864 (internal exchange, 
four lines). 

Scottish Met*"** . a n...,r«eL«upj| Gardens, Edinburgh. (Tele- 
grams ; ; 24361 Edinburgh.) 

Irish Medic rederick Street, Dublin. (Tele- 
grams : , Dublin,) 

Diary of tho Association, 

JIarch. 

30 Frl. • English Division (Border Counties Branch) ; B’hitchaven and 
West Cumberland Hospital,- Whitehaven, 3.30 p.m. - 
■ Hendon Division ; Clinical Meeting and Dinner, Brent Bridge 
Hotel. Dr. W. Langdon Brown on Organotherapy in General 
Practice, 8 p.m. 

Southport Division : B.M.A. Lecture by Dr. E. P. Cumberbatch 
on the Use of Ultra-Violet Rays. 

April. 

3 Tues. I/Ondon : Standing Ethical Subcommittee, 2 p.m. 

Cit^ Division ; ‘ Metropolitan ' Hospital, Kingsland Road, E. 

Discussion on Treatment of Fibrosis, .9.30 p.m.. 

Coventrv Division : Clinical Meeting, Coventry nnd W’arwick- 
Bhiro Mospltal, 8,30 p.m. ' ■ T.f t. 

Finchley Division; Finchley Memorial Hospital. Mr. W. S. 
Herman, L.D.S., on the Dental Treatment of Fractured Jaws, 
8.45 p.m. „ , 

Hastings Division : Queen’s Hotel, Hastings. Dr. E. I. Spriggs 
on Diverticulosls, 6.15 p.m. 

4 Wed. London: Psycho-.\nah-8is Committee, 2 to 4 p.m. . 

Croydon Division : (Jroyrion General Hospital. Dr. G. E. L. 
Brayne-Nicholls on Tuberculosis of the Bowels, 4 p.m. 

5 Thurs. Dudley Division : Guest Hospital, Dudley, 8.30 p.m. 

Duildiord Division : Clinical Meeting, Royal Surrey County 
Hospital, 4 p.m. . . ^ ,,..-,1 

10 Tucs St. Pancras- Division : B.M.A. House. Tavistock Square, B .O.L 

Dr. Donald Poterson on the Prevention of Summer Diarrhoea, 

11 IVcd. T-onSo?’: Council, 10 n.m. , o 

Ctovdon Division: Annunl Dinner, Greyhound Hotel, 8 p.ni. 

. c, Enoch Station Hotel. Dr. John 
»• c Affections, 3.30 p.m. ^ ^ 

* • ind Norwich Hospital. Dr. Ian D, 

• in General ,Prncuce, 3.30 p.m* , . 

10 TN..M • Hart Hotel, Boston. Dr. J. Wilkie 

“ ° ' Vomiting, 3 P.m. 

' sllnnd Branch : Clinical Meeting, 

Port5mou\h*Div!™on : Queen's Hofeh Southsea. Dr. J. Stanley 
White on Biological Therapy, 9.10 p.m. V 

17 Tuea. ®ms.on^ Town^ 

18 Wed. Ashford'"D!’vis"on I'^Dr." J. W. McKee on Hepatro and Biliary 

d^sterfield^Drvision : Roval Hospital, Chestcrfi^eld, 3 p^. 

• Nineaton and Tamwirtl. "DivisioA : Nuneaton General Hospital. 
Dr. 0. F. Rudd on on Op hthalmic Subject. ^ 

POST-GRADUATE COURSES AND LECTURES. 

Hosrmi. FOR SICK Ciiildrek, Great Ormond Street. W.C l.— Thurs., 4 p.m., 
^ Some Complications of Acute Spcoifio Fevers in Children. „ , 

NonTH-EisT LorooN POfT ^Demonstrati™ of Medical 

(iflRps* 2 30 to 5 p.m., MediCtil, BKin, ant 
Thu^:, nlio a.m., Deital CliniM 

and Ear, Nose, and Throat Clinics; Operatic ^ 

Nose, and Ear Clinics ; 2.50 to 5 p.m., Surgi , 

wSToKDorHosVm'l"pos™URinmra CoLiEGE._HammersmIth._W^-Mpn.| 

.. : 

GUOToirk°?-GRADn"ra 'medical AssoouTioK.-At Ophthalmic Institution: 

MSs^V^’iScGA^rii™, -Thurs.. 4.15 p.m.. Treatment of Hemfa. 

M.«™Vo«Li™nv Tu^ 4.1^5 P.m., Lecture: Pseudo-eo.valpio 
and Allied Conditions. Tea at 3.45 p.m. 

BIRTHS, MARRIAGES, AND DEATHS. 

The charge for in!:crtina annouacement 

Deaths is 9s., which sum should be forwarded iq 

nof later than the first post on Tuesday morning, m 
ensure insertion in the cuiTcnt issue. 


DEATH. 


MniR SjnTH.-On March 26th, suddenly, at aVed'lS! 

Road, Eastbourne. William Muir Smith. M.B.. C.SI., 


peflon 


ITinted nnd published by tjje British iJedieaJ Association, at their OSie^^ ravjetoct Sguare, in fie Purish ol St. Pancras, in the County of London. 



ST 3 PPXjEMEI^T 

TO TUB 

BRITISH MEDICAL JOURNAL. 

LONDON, SATUllDAY, APBIL Vrn,' 1928. 


CONTENTS. 


PACE 

BRITISH UEDICAIi ASSOCIATION. 

CnRRK.\-T NOTES: 

Jltmco-PouTicAL Committee 113 

CoSSlILTING rATlIOLOGISiTS GrOUP COMMITTEE 113 

Election or Central Cogncil ... 113 

NOTICES OE MOTION FOR THE ANNUAL REl’RESENTA- 

TIVE MEETING AT CARDIFF 113 

GRANTS IN AID OF SCIENTIFIC RF.SEARCH 113 

Association notices ii4 

B.M-A. CHARITIES FUND 114 

MEETINGS OF BRANCHES AND DIVISIONS 115 


SJrUisl; lltcbicnl S^ssocinttou. 

CURRENT NOTES. 


MEdlco-Polltlcal Committee. 

MtoNo other iiiattei's of interest tlio Alcclico-Political 
Committee, on Alarch 21st, liad before it the draft regula- 
tions drawn up by the Jfinistry of lloaltli under tiio 
Nursing Homes Registration Act, 1927. This Act .comes 
into force on July 1st next, and tbo precise wording of 
the regulations is important to iiicmbors of the medical 
profession, for tbo Act affects the medical ns ivcll as tbo 
lay owners of mirsiiig bomes. Tbo Committee has suggested 
for tbo consideration of tbo Alinistry of Hoaltb certain 
amendments in tbo draft submitted to it. Tlic Committee 
lad a ISO uiidor consideration at this mooting certain diffi- 
culties reported as arising in connexion with tbo new fomi 
ot death certificate. It seems that delay has been found 
0 occur in cases in which doctors aro not familiar with 
® addresses of tbo registrars of subdistricts 

Tj ^ practices. This matter has beefl referred 
®?'®^’'“’’'^‘^'’eral, who has replied that the regula- 
tinnor ^ “ay registrar rcceiA'ing from a practi- 

roruiii-oA ^“rtificate which has reference to a death 

+. ^ rfg'stered in some other subdistrict shall 
it rolitnc tbo registrar to whoso subdistrict 

nt^n tn^ i* '*"? d«ty of supor- 

tho -ieo-!ctri^'^ print from time to time a list of 

statiiio-'’tlio:,.^ “.’’‘i <3eatbs within the district, 

liourc'of att nffircs, etc., and approved dnvs and 

distrjpt ° c;fnnc i practitioner practising within the 

relsie of oX l-‘f® taken to ‘ensure that on the 

Act such lists should indudoTddT ^bf 

l.ra“rieTV^uv3' ,tln>se arrangements will for all 
practical pmposes meet the difficulty which has arisen. 

Tim Group Committee. 

BuWn/„^U,owf t'le recently constituted group of con- 

Sx'i.SSt svkfr'iy'-', 

ferenco on March 2nd i “““ting of the group con- 
ivas eluoflv ocoLmied ii a ^°t''’ P’ 

of such local Nr-botvmo ^ preliminary revieiv of the details 
prov sion o n Tn, in operation for the 

feealth Ins^raiClcT 


page 

NATIONAL INSURANCE : 

London Insurance Committee 118 

London Panel Comjiiitee 118 

Birmingham Panel Committee 118 

CORRESPONDENCE 119 

NAVAL AND MILITARY APPOINTMENTS ... 119 

VACANCIES AND APPOINTJIENTS 120 

DIARY OF SOCIETIES AND LECTCRES 120 

ASSOCIATION INTELLIGENCE 120 

DIARY OF THE ASSOCIATION 120 

BIRTHS, MARRIAGES, AND DEATHS 120 


BlcctloD of Central Council. 

The attention of Division and Branch secretaries and 
merahors generally is drawn to the announcement in .the 
Table of Dates under “ Association Notices ” {Supplement, 
p. 114) that nomination papers for election of the twenty- 
four members of Council by the grouped Branches in the 
British Isles aro now available on application to the 
Medical Secretary. 


NOTICES OF MOTION BY DITISIONS FOR THE 
ANNUAL REPRESENTATIVE MEETING, 
CARDIFF, 1928. 

Membership and Aeccpiance of Post which is Subject of 
“Important Notice." 

By North JIiddlesex ; That no medical practitioner shall 
bo eligible lor memborship of the Association who has 
obtained and holds a position to which ho was appointed 
whilst it was the subject ol an “Important Notice” in the 
British MedicalJouintal, 

Medical and Dental Examinations of Insured Persons, 

By Windsor : That in the opinion ot this meeting the 
establishment ol periodical medical and dental examinations 
ol all persons insured under National Insurance laws is 
urgently called lor as an economic proi>osition, having reganl 
to the return so to be obtained in health and productive 
elHciency ; every such insured person, when accepted as a 
patient on a doctor’s panel, shall be by that doctor medically 
examined, and the resnlt ol that examination placed ou 
record. Preliminary examination should apply also to dental 
examination, when that additional benefit is included and 
available under the National Insurance laws. 


SCHOLARSHIPS AND GRANTS IN AID OF 
SCIENTIFIC RESEARCH. 

Scholarships. 

The Council of the British Medical Association is pre- 
pared to receive applications for Research Scholarships as 
fellows: An Ernest Hart Slemorial Scholarship, of the 
\ahie of £200 per annum, and three Research Scholarships, 
each of the value of £150 per annum. These Scholarships 
are given to candidates rvhom the Science Committee of 
the Association recommends as qualified to undertake 
research in any subject (including State Medicine) relat- 
ing to the causation, prevention, or treatment of. disease. 
Each Scholarship is tenable for one year, commeneinrr on 
October 1st, 1928. A Scholar may bo reappointed fo” not 
more than tuo additional terms. A Scholar is not neces- 
sarily required to devote the whole of his or her time to 

I 1237 ] 




114 April l] 1928] 


Association Notices, 


r BVPPLFAfEJn' TO T*1 
LCniTisu mkdicai. Jouurib 


the ivork of research, hot may hold a junior aiipointnicnt 
at a university, medical school, or hosioital, provided the 
duties of such appointment do not interfere with his work 
as a Scholar. 

Giants. 

Tlie Council of the British Medical Association is also 
prepared to receive applications for Grants for the assist- 
ance of research into the causation, treatment, or preven- 
tion of disease. Preference will bo given, other things 
being equal, to members of the medical profession and 
to applicants who propose as subjects of investigation 
problems directly related to practical medicine. 

Conclitions of Award: Applications. 

Applications for Scholarships and Grants must be made 
not later than Saturday, Juno 2nd, 1928, on the prescribed 
fonn, a copy of which will be supplied on application to 
Ibo Medical Secretary of the Association, B.M.A. House, 
Tavistock Square, London, W.C.!. 

Applicants are required to furnish the names of three 
referees who are competent to speak as to their capacity 
for the research contemplated, to whom reference may bo 
made. 


^ssoriaiiott 0.atms. 


A CALCUTTA BRANCH. 

Notice is hereby given to all concerned of the formation by 
the Conncil of the Association of a Calcutta Branch, the area 
of the Branch to comprise that portion of Bengal which lies 
to the south and west of the Gauges, the Branch coming into 
existence as from the date of publication of this Notice. 


Aprir28, Sat. 

Jloy 12. Sat. 

Jlay 15, Tues. 
Jlay 19, Sat. 


June Sat> 


Juno 7, Thurs. 

June 13, IVcfl. 
June 2T, TImrs. 

Juno 3C, Sal. 

July 4, Wed. 

July 20, Fri. 


July 21, Sat, 
July 23, Moa. 

July 24, Tues. 

July 25, Wed. 

July 26, Tliurs, 
July 27, Fri. 


TABLE OF DATES. 

Annual Report of Council appears in Bninsii 3 Iedical 
JOUR.NAL Suppr.EME.vr. 

La&t day for receipt at Head ORlce of nominations: (i) by 
a Division or not loss than 3 inomber.s for election of 
24 members of Council by grouped Blanches in British 
isles; and (ii) (or election of 2 Public ITcalth Service 
members of Council, and 4 Representatives of Public 
Health Service in Representative Body. 

Publication in British Medicil Jourkil Scpplfmemt of 

'* ' . ‘'jctlon of (i) 24 members 

, •' • •'ranches in British Isles; 

Ui . ■ . . . members of Council, and 

tntaUvcBody.' ' '' ' 

Voting papers posted from Head Office, where there arc 
contests in above elections. 

Motions by Divisions and Brandies for A.R.M. .agenda on 
matters of wliich two nianths’ notice must be given 
must be received at Head Office, by this date. 

Last day for receipt at Head Office of voting papers for 
election, where there arc contests, of (I) 24 msmijers of 
Council by grouped Branches in British Isles; and 
00 2 Public Health Service Members -of Council, and 
4 Representatives of Public Health Service in Repre* 
sentative Body. 

Publication in British Jlsnicii. Jotir.sii. Soppijihent oI 
motions- by Divisions aiul Branches for A.R.5L, on 
manors of ivliicli two months’ notice must ho given. 

^elcSed‘byThis d'n'te.®"’”^^ Representatives must be 

British Ifnnicil. Journ.h. Scpplejirnt of 
result of election ot members of Council by grouped 
Counc members of 

Public Representative Body by 

Representatives (British Isles). ^ groupeti 

Names of Represenlntives and Deputy Reprcscntalives 
must be received at Head Office by this date 
Coxnicil. • . > . 

Meetings of Constituencies must be I, eld between tins date 
and- July 20th to instruct Representatives 
Supplementary Report of Council appears in British 
JlEDiciL JounxiL Supplement. 

Amendments and riders for inclusion in A.R M ap-pofia 
must be received at Head Office by this date. * ' 

Annual liciircsentatice Meeting^ Cardiff, 10 a m 
Nominations for election of 12 members of Council bv 
grouped Representatives must be received fat \ n 
Cardiff) by this date, 2 p.m. ^ 

Annual Jlcpreer-ntatirc Meeting^ Cardiff. 

Councilj CariHfL 

Annual licprescntatire fleeting, Cardiff. 

.•InmmZ Uepresentatire Electing, Cardiff. .fVnnual General 
3Teeling, Cardiff, Tresident's Address. 

Council, Cardiff. Confercnco of Honorary Sccrclariee 
Cardiff, ‘ 

^Uctiiigf of Sections, etc., Cardiff. 
yieetingi of Section*., etc., Cardiff. 

21eetingi of Scctionx, etc., Cardiff. 

Autred Cox, Zlcdtcal Secrciary. 


BRANCH AND DIVISION MEETINGS TO HE HELD. 

Birmingham Branch : Nuneaton and Tatuwortii Division. — At the 
meeting of the Nuneaton and Tamworlli Division to be hold at 
llio Nuneaton General Hospital on Wednesday, April 18lh, Dr. 
C. E. Rudd will read a paper on an ophthalmic subject. 

Cambridge and Huntingdon Brancii.-^.A meeting of the Ciim- 
bridgo and Huntingdon Brandi witli tlic Cambridge Medical 
Society will be held at Addenbrooke’s Hospital on Friday, 
April 13(h, at 2.30 p.m. • Mr. Arthur Cooke ; Tlic' results of treat- 
ment of gastric and duodenal nicer; Mr. W. H; Bowen and 
Dr. Ff. Roberts : The operative treatment of oblique fracture of 
tho femur; Dr. Ff. Roberts: Localization of a golf-ball in a dog 
by tiio barium meal. 

Glasgow and West or Scotland Branch : Lanarkshirf/Division.-— 
A meeting of the Lanarkshire Division will be held at St. Enoch 
Station Hotel on Wednesday, April lllh, at 3.30 p.m. Dr. John 
Mortimer will read a paper on tlie comnioncr eye affections as 
occurring in general practice. 

Kent Branch: Ashford Division. — At a meeting of the Ashford 
Division to bo held at tho Nortli Street Chib, Ashford, on 
Wednesday, April 18Ui, at 4 p.m.. Dr. J. W. McNcc of University 
College Hospital will give a lecture on new work in tlic diagnosis 
and treatment of hepatic and biliary diseases.: A cordial invitation 
is extended to all members of the Kent Brand). 

Metropolitan Counties Branqi : City Division.— The next 
clinical meeting of the City Division will be held on Friday, 
April 13lh, at the Metropolitan Hospital, when Mr. F. M. Heath 
will show surgical cases. Tea at 4.15 p.m., meeting at 4.30. 

Metropolitan Counties Branch : Lew'isiiam Division. — At the 
meeting of tlio Lewisham Division to be held at the Town Hall, 
CalfonT, S.E.6, on Tuesday, April 17fh, at 8.45 p.m., Dr. W. V. 
Goldsmith will rend a pnper on pigmentation of the skin. 

Metropolitan Counties Branch : St. Pangeas Division. — A mccliu^ 
of- the St. Pancras Division will be held at the British Medical 
Association House, Tavistock Square, W.C.l, on Tuesday, .\pril 10th, 
at 9 p.m. Dr. Donald Paterson will give a lecture on the prevention 
of summer diarrhoea. 

Metropolitan Counties Branch : Willesden Division.— At the 
meeting of Oic Willesden Division to bo held at the Willesden 
General Hospital, Harlcsdcn Road, on Wednesday, April 18di, Dr. 
J. Bright Bannister will give an address on ante-natal work. 

Midland Branch: CiiESTERriBtD Division.— A meeting of the 
Clieslerfield Division will bo held at the Royal Hospital, Chester- 
field, on Wednesday, April’ 18th, at 3’ p.m., when thevo will be a 
seru's of clinical demonstrations. 

• Midland Branch : Holland Division.—A meeting of the Holland 
Division will be held in the White Hart Hotel, Boston, on Apnl 
12th, at 3 p.m., when an address will be given by Dr. J. >^llKIe 
Scott (Notlingbam) o)i some aspects of vomiting. Members or 
nci‘'hbouring Divisions will be welcomed. 

Norfolk Branch.— A meeting of the Norfolk Branch will bo held 
at the Norfolk and Norwich Hospital on Wedn^day, April nth, at 
3.30 p.m. Sir Hamilton Ballancc, K.B.E., president of' Gic 
will bo in tho chair, and a paper will be read by Dr. Ian D. 
Dickson on nenrasthenia in general practice. • 

North of England Branch : Sunderland Divihon.—A meeting 
of the Sunderliuiil Division will ko hold at tho 
Suudciland, on Wednesday, April 18Ji. at 8.15 p.in. Li. A. 1. 
Bernard Shaw will read a paper on tho present status of the 
jaundice problem. - ■ » - t — 

SooTiiEKN BnAKcn; Jeusey Divisioh^A meeting of the Jcisey 
Division will ho held at tho General Hospital on Xhmsday, April 
mil;' .at 8.30 p.m. Lieut. -Colonel P. J. Marott will read a paper 
on some lung affections. e. y e 

Southern Branch : Portsjiouth DivmoN.— The final address of 
Hie winter session of the Portsmouth Division wil be heW at ae 
Queen’s Hotel, Southsea, on Thursday, April 12th, at 9.30 p.m., 
preceded by a supper at 9 p.m. Dr J Stanley White will give 
an address on some recent aspects of biological tlierapj, illustiated 
by a cinematograph demonstration of research work carried on m 
Messrs Parke Davis and Co.’s research laboratories. This will be 
the tet address, preceded by a supper. The business meeting 
will be held on May lOtli, at 9 p.m., and the annual dinner on 

May 16th. ‘ , c ii 

Suffolk Branch: "'Vest Suffolk Division.-A meeting of the 
West Suffolk Division will be held on Saturday, April 14tli, at 
8 45 p.m., when Mr. C. W. G Bryan will give a Icctme on the 
acute abdomen in childhood. Coffee will bo served at 8.30. 


B-M.A. CHARITIES. fund. 

N the list of subscriptions and donations to tlie B.JLA. 
■haritics Fund published on page 104 in the Supplement ai 
larcli 31st, tlie sum of £1 15s. 6d. was entered as fiom the 
Censington Division. This sum should have been credited as 
ubscriptions from Surgeon Hear- Admiral W. G. Axfoid, C.B., 
Jr. Mary A. Silcock, and Captain Arraitage L. Forlie.s. 

in addition to the amount of £1 15s. 6d., subscriptmns had 
leen received from the folloAving members of the division 
,nd these have been entered in tho individiml names . Aiiss 
Jorothy Wood; Dr. Katlierina A. C. Gillie, I’’’- 
Jr. G. Denton Winston, Dr. AV. G. 

lolonel W. G. Pridmore, C.M.G., Dr. A. S. Herbeit, and 

)r. Foorcl Caiger. , . , c,.r>m thft 

A subscription was shown as having been received^ A,winver 
liidover Mental Hospital. This should have read Antiover 
Var Memorial Hospital.” 


Atom, 7, 1028) 


Mootings of Bronchos and Divisions, 


r BUPFI.r.MT.ST TO inE 

InriTlSII aiKDICAL JOtTBXXL 


115 


i^trriiugs of ^SrnnrlKS anb Hibisions. 


AuKUnnr-v I}«AK*cit : Ani:r.nrn.v D/vrsioa*. 

I'jlE Dxecntivi' Comniittoo of (lie Ahordoen Division on Marrh 27lh 
rntorUiiR'ti io loa the medical prniluands of Aboidoon University. 
Out of a total of twenty-seven (here were present Iwcnly-onc. 
f^opies of tlic lUimJhook' for Jircfuthj Quulifinl MnJintl 
thners, issued liy the British i\Tcdical Association, were distributed 
to (lie new jjiad'nands, and the chairman and vice-chairman of the 
Division, Dr. Skinke?. and Dr. Thomas rnAsra, addressed the 
pucsts, and cxiilained the advantape of jnininp tlie Association. 
The meclinp was informal and was penerally \oted a success. 


BlnMl^'GnAM Bhakcii : llnoM^unovi: Division’. 


(ho Icp bones. IIi; had luid many fractures. The ripht tibia and 
niuila had become bent at a right anplc. Dr. Horton had per- 
formed a wedge-shaped osteotomy of the tihia and plated it in 
pood 2 >ositioii. TJie wound hnd now lieaJcd. Dr. Horton exJjihited 
n section of an cncapsjiled tumour removed from the pcctoralis 
major of a male patient; the section show'cd myeloid sarcoma. 

Dr. PitinifAM showed a lad. aged 19, presenting the Parkinsonian 
syndrome following cnccphniitis Iclharpica, 

After l•efrc>hfuents Jiad been served Dr. T. Colley read an 
intere.stuig and practical paper entitled “ Some acute eye con- 
ditions met w'ith in general practice.'’ He discussed the diflercn- 
lial diagnosis and tiealment of acute glaucoma, acute iritis, and 
acute conjunctivitis. 


Es.snx Braxcii : Mid-ICssex Division*. 

A MEETiKCt of the Mid-Kssex Division Avas held on March 2nd. The 
following ofliccis weie elected for 1928: 


GF-XKRAL mcelinp of tlie Bromsgrove Division was h»*ld at the 
Smallwood Hospital on Maicli 19lh, Avhen Dr. V,. A. Smith was 
in the chair. 

The rules of organisation of the Division, us suggested by (be 
Central Council, were discussed and adopted, with a few minor 
inodificaticus. 

A circular from hcndqunrlei-F regarding linspitol conlrilAitory 
schemes was discussed. As the Birmingham ho<pitnK ronlrtlmloiw 
schenio has now conceded the llnTc main items in the British 
Medical .\ssociation policA’, further discu-s.*'iou AA*n.s considiTed usele.ss. 

It Avas decided to ash tlie Dudley Division to soli*ct a repre- 
sentative to the Annual Roprcsentalivo Meeting this year. 

With reference to the inquiry into the treatmeni" of A-arieose 
ulcers, the sccrctan* was instructed to suhmit (hr iinme-i of Drs. 
Prothcroc Smith, Mitchell, ami Lewis of Iledditch, and Dr. Dodger 
of Stiullcy- 

A discussion took place on a nicmor.andum from lu'adqtiarlers 
rcgarditig reports of practitioners at (ho-rcquerl of coronei^. The 
secretary Avas inslniclcd to write to the Biimiugliam Branch 
suggesting that the county councils concerned should be approaclicd 
by the Bi-nnch, ns having more weight than the Diaiskui^. 


Border Codxties Braxcit. 

A CEN’EKAL meeUng of the Border Gountle? Branch Avas held at 
Morins larm, KesAvick, on March 16tli, at the invitation of Mr. 
J. A, Speudmg, More than fifty niemhcrs and fnciids Avcrc 
present, the latter fncluding leading memln'rs of the Bordei 
Louiuies Blanch of (ho Association of Vcteiinarv Surgeons. The 
v.hqlo proc^vs of -the production of certified milk aa-rs demon- 
strated, and after tea Mr, Speddixo gaAe an address on pure milk 
production ami grading, 

Mr. B. Sixipsox, cnief^ rcterinary officer to the Cumberland 
Lounty toiincil, read an inslructivc and interesting paper on the 
sumect of milk pi^odticlion ami bo\*ine tuberculosis in relation to 
rnibhc hefiHii. After referring to the . food value of milk, be 
i^Tnarkeci that hpctcnal contammalion was to a large extent pre- 
Aent^le if suitable methods Avore employed, though the position in 
T?« 1 tuberculous mfcclion was still far from satisfaetorv. 

Keccul legislation Avould bo prodiiclivo of good, provided that 
uniform ndministrution throughout (ho 
coimirv. J he education of the- public Avilh regard to the A*alue 
be intensified in order that recognition of (he 
nf I induce people to pnv tlie Jjigher cost 

Simpson insisted that (lie oliminution of 
ID mnn must to a very large oxlcnl he dependent on 
ttii' ''here it was sbll ven* prevalent ; in 

then T-ffnSo,!^ was by far tbe most important animal disease. He 
re^ard^ th^ falM improvement in Newcastle ns 

mflk m oil^‘ Jr ! P'^^^er of samples collected of tuberculous 

^nd ^ W.ri ’n difficulties in tracing infected calllc, 

■special rcforcnct lo%e^atron'"an°l m'’™"' 

the lines on whirl, A’anous orders, indicating 

t HO) lines on " h’cli further dovelopmont slionld proceed: 

considered tlie snh?^’f officer of healtli for Cumberland. 

''Ir^*^!md'jli°'snetHino'f” votes of thanks were passed to 

A resolution of rondolenc7warsenT'to“]l‘^'’ “"l'' 

Dr. William Scott of HuUm-St p'esiyeliT^f Uiett 

A J^aAxai : West Dorset Division. 

at tlie Wcvmoiith Division aahs held bn March 20th 

Council ^oSnlng 
orissed, and it was Sec Ld fo 

Uivisionalnrca.andtoasccHaiX^r^^^^^ “■ ‘ 

usual s^Voms''of“Mo^g'Slm’’h'c'’^haT‘* Ih' addition lo the 

and fourth fin<Ters bnfhhnnJ^^ j Avebbmg of the middle 

Dr.°HoaToK sS^iwcTa Tad ’ a"ed'‘ iT“T od 

sufferrtl frnn, i •’ 17, Avho, fouv Veal'S ago, had 

now cured. Sub^eouently tlie lSrfo°" 

B sinus: nnrnrd ^ r i torcarm became sAvollen and 

Towed tnl ci^ulo T^^ pl'o‘»K>aph 

had sulTereVl frnT u'uu- Earlv in 1928 he 

The left humerus appea^rto he onl ’‘'“i 

ffrapli showed neriostitis TiT .uujurged, and an x-ray photo- 
^10 pus but n ^ » pci’i0-‘5tcum was incited; there Avas 

vecovered A* ^oiiffux and a colifoi-ra bacillus were 

iiml no cJdnnrr. of pcnosteum shoAved fibrous osteitis 

showed -I > 1 ^^^ tuberculous or malignant disease. Dr. Horlor 
. Avho suffered from fragilitas os<5ium affecting 


'(’hnifinaii. Dr. .f. P. WVIN. Secretary ontl TreOfurcry Dr. I{. If. 
Veicoc. Itepicemlgtirc in Rc)nr!ii’)ttafirr Holly, Dr. H. C. L. Haynes. 
lieynty Iteitrerentative in Jicprcirntnlirc lioily. Dr. R. II. Vcicoe. 

The SECRirrARY reported on the year’s AA’ork and account.s of the 
DiA'ision. After a discussion on attendance of medical praclitionei's 
a( road accidents, it airs decided that the onij’ liopc of being paid 
for attendance at sudi accident.s Avould be for legislation to be 
" itori'^ts to be insured to coA'cr accidents to 
1 C cost of medical treatment, ambulance, 
. ^ Some <Iiscu«sion took place on (lie treat- 

ment of chronic Auricese ulceration in general pi'ncUco. Various 
methods of treatment were discussed, including ultra-violet light 
and injections into ihc veins of sodium salicvlatc. Several members 
offered to complete case sheets if sent to tbem. 

A leltcr from ihc Medical Secretary on reports furnished by 
medical practitioners at the request of coronei-s was read; it Avas 
decided to write to the Branch Secretary asking him to notify the 
county ronncil that lOs. 6(1. Avas considered a proper fee for such 
report?. 

Dr. Lyster asked if there wore a ruling as io a fee for dental 
gas given by a medical practitioner. He v-as informed that the 
accepted fee* avrs 10s. 6d., although the Dental Benefit Joint Com- 
mittee under the National Insni-nnce Act had approved a fee of 
7s. 6d. in certain cases. 


Laxcasthre and CriESiriRB Braxcu ; MiD-CiiEsniRE Divisjoy. 

A MEETiXG of the Mid-Cheshire Division Avas held at the Altrincham 
General Hospital on March 20th, Avhon Mr. Sampson Handley gave 
a lecture on radium lu carcinoma. The lecture Avas illustrated by 
lantern slides, and Avas mucli appreciated by thirty-five members of 
the DiA’ision, and by nine non-membei's, who had also been invited 
to be present. 

At the close of the lecture an engraved silver inkstand and a 
blotter Averc presented by members of the DiA’ision to Dr. 
T. W. H. Garstang as a token of esteem and in apiircciation of 
his ‘.services lo this Dii’ision and to llic British MMJcal Associa- 
tion. The CiiAiRM.AN (Dr. Chisholm) appropriately described these 
services. Dr. G.arstaxo, in thanking the members, said that he 
was aUvaA’.s ri'adv to adAise them in case of any difficulty, and 
that he Avoiild ne.vt autumn sivc them a Jeetarc on his personal 
experiences in organizing British Medical Association AA-ork. 


Metropolitan Counties Branch : Cm* Division. 

A meeting of the City Division was held on March 6th, Avith Dr. 
Philip Hamtll in flic chair, when Mr. Nop.man Patterson, 
dermatologist lo the Royal Northern Hospital, read a paper on 
dinicuUies''in diagnosis in connexion with throat and car trouble. 

Mr. Norman Pattor^on began by pointing out some difficulties in 
connexion Avith diagnosis of certain conditions in the mouth. One 
of these AA'a? sublingual cellulitis. Patients suffei'ing from this 
complaint, owing to restricted opening of the mouth and the 
apparently large size of the tongue, Averc difficult to examine, and 
the correct treatment, which generally consisted in making a free 
incision from the outside, Avas not aliraj'S adopted. He mentioned 
submaxillaiy calculus, and described the best nietliod of palpating 
for a small stone; a second calculus Avas sometimes present, as 
indic4v(cd by a facet of the first calculus remoA'cd. He discussed 
(he diagnosis between acute tonsillitis and diphtheria, and pointed 
out (he** importance of examining for the Klebs-Loffler bacillus in 
patients shoAA'xng paralj’sis of the palate or suffering from other 
si*»ns of posl-diphthoriLic paralysis. As sccondai’v syphilis of tlie 
tlu'oat Avas frequently mistaken for an inflammatory condition, 
stress Avas laid on the special features of the former disease. 
A case of parah'sis of one vocal cord resulting from secondary 
sj'phiJis Avas mentioned, and the diagnosis between Vincent’s 
angina, diphtheria, and syphilis discussed. The likelihood of mis- 
taking a gumma of the soft palate for an acute inflammation A\*as 
mentioned. The necessity in some c.ases of examining infants for 
retro-pharyngeal abscess Avas stressed, as symptoms might some- 
times be misleading. Many deaths had occiin-cd from ihis disease 
without anv suspicion having arisen in the mind of the practi- 
tioner lhat'such a condition was present. ^ Tlic diagnosis between 
keratosis pliavyngis and follicular tonsillitis was discussed. Some 
remarks were inadc on the search for a primary growth in a case 
of malignant glands of the neck, and three cases Avere referred lo 
in which an insignificant primary tumour had given rise to massive 
secondary tumours. In one case the primary growth Avas repre- 
sented by a .slight area of roughness on the tonsil, and in another 
there AA’as a liny localized area of induration in the same region. 
The importance of examining the nasopharynx for a primary 
groAA’ih, and the difficulty of locating such a ‘grOAvth should it be 
Bituated in the pjTiform fossa, at the back of the longue, or /a 



116 April 7, 1928] 


Mootings of Bronchos and Divisions, 


r svrrLKyrr^fT lo nm 

IrniTISn aiF.DICAL JOOKMUi 


tlio hypopliarynx, was remarked on. Any obstructing mass in tlic 
nasopbarjmx occurring in a child need not necessarily bo adenoids; 
other conditions, such as a polypus, tumour, or congenital occlusion, 
might bo present, l^mphasis was laid on tho cxlrcmo imporlaiico 
of diagnosing epithelioma of the vocal cord in its early stage, as 
tliG operativo results in early eases wore better than those obiainod 
in any other part of tho body. Tho speaker insisted on Iho impor- 
tance of investigating most thoroughly any ease of hoai*scncss 
occurring in patients over 40 and lasting tor more than a few 
weeks. Misleading symptoms in association with carcinoma of the 
oesophagus were mentioned, and tho diagnosis of carcinoma from 
other conditions atTccting tho gullet was considered. Tho impor- 
tance of a correct reading of tho laryngeal picture was discussed 
in connexion with such diseases as aortic aneurysm and locomolor 
ataxy. Consideration was given to the mistakes likely lo occur in 
eases of foreign bodies in tho pharynx, larynx^ etc., and special 
mention ivas made of pitfalls in connexion with foreign bodies 
located below tho level of tho vocal cords* 

Continuing, Mr. Norman Patterson stated that in swellings in 
tho neighbourhood of tho orbit a thorough examination of tlio 
nose was necessary. Very many of these eases were in some w'ay 
connected wuth tho nose or nasal sinuses. A coloured drawing of 
0 case of primary sore of the nasal vestibule was shown, and the 
diiTcreniial diagnosis discussed. Tertiary syphilis of the nose was 
often misinterpreted. Tho chief clinical signs wore alluded to, 
and suggestions were made with regard lo avoiding crroi-s in 
diagnosis. Tho characteristic appearances of simple nasal polypi 
were described, and the importance of cocaining tlio nose in order 
to bring into view polypi which otherwise might bo invisible, and 
of examining tho nasopharynx, was emphasized. Distinctions 
between nasal polypi and malignant disease were mentioned, and 
it was pointed out that polypi might conceal a malignant growth. 
The ciiaracteriskics of malignant disease wlicn afTccting tho nasal 
sinuses were passed under review. ‘ The spcakci* remarked on tho 
symptom of referred pain in nasal sinus disease; ho also con- 
sidered tho differential diagnosis between antral suppuration, 
dental cyst, and polypus in tho antrum. False conclusions might 
bo drawn from transillumination. The necessity for a caroTuI 
examination of tho noso and a bacteriological report in cases of 
rhinitis occurring in children was emphasized. 

Turning to the question of the car, Mr. Patterson dealt with 
tho distinguishing features between acute conditions of tbo 
external auditory meatus and thoso affecting tlio middle car and 
mastoid. Cases were mentioned in which serious intracranial 
complications had developed in the presence of what appeared lo 
bo a practically normal car. Tlio diagnosis of various conditions 
of tho e.vtcrnal auditory meatus, tympanic membrane, and middle 
car was discussed. Two eases wero mcnlioiied in wliicli herpes 
had been mistaken for mastoiditis. TIic importance of always 
examining both cars was insisted on, and tho speaker concluded 
by referring to tho differential diagnosis of lateral sinus disease 
and cprlain other conditions. 

A lively discussion followed tho reading of the paper, and the 
meeting terminated with a very hearty vote of thanks lo tlio 
lecturer for a most instinictivo evening. 


MrinopouTAN Counties Branch ; I/Ewisitam Division. 

A MEETING of the Lcwisliam Division was licld at the Town Hall, 
Catford, S,E.6, on March 20th, when Dr. W. E. Hallinan was in 
tiio chair, and Mr. H. Wansey Payly gavo an address on tho 
general practitioner and the prevention of venereal disease. 

Mr. Bayly said that the public health department and tho 
specialists had failed as regards prevention, which consequently 
devolved upon the general practitioner. Tiie law decreed that only 
a qiialificd medical practitioner could give advice on prevention, 
60 it was now impossible for chemists to sell preventive packets 
with instructions such as were used in the army during tho war. 
Prophylaxis was very successful in the army and navy, and would 
produco 90 per cent, decrease in venereal diseases. Syphilis was a 
cause of more deaths than was shown by the rogistrai-s' returns. 
Tho method advised was lo swab with a 1 in 1,000 solution of 
potassium permanganate, a s.alt, which was cheap, n on-poisonous, 
and could be obtained anywhere in any country. Calomel ointment 
might also be used. 

Drs. Gilchrist, Halltnan, G. Jones, H. Evans, Beattie Bain 
and Buchan joined in tho discussion, and a veto of thanks was 
passed to the lecturer. 


Metropolitan Counties Branch ; ^YILLESDEN Division. 

A clinical meeting of tlio Division was Iicld on March 22iid at 
the ^Vi^csdcn General Hospital. This was a joint meeting ivitJi 
tlio dentists of tho north-western district, Hfr. H. B. Mes^encer 
ai.C'., L.D.S., read an interesting paper on focal infection which 
was followed by an instruelivo general discussion, ^fr. Messenger 
dealt particularly with dental sepsis and its sequelae. He <nit- 
liiicd tho pathology of dental sepsis, which he divided into two 
types — the closed, as typified b}* a root abscess in a dead tooth 
and the open type, as seen in pyorrJioea aivcojaris. Emphasis was 
laid on tlio greater danger from the closed type. Such conditions 
as arthritis, endocarditis, and iritis undoubtedly arose from septic 
conditions of tho teeth, and eases were quoted illustrating their 
occurrence; but Mr. Messenger pointed out the difficulty in many 
cases of excluding other probiblo foci in tonsils and intestinal 
tract which were tho real sourco of infection, tliough associated 
with a dental infection. Many eases in which the teeth were the 
alleged sourco of infection had failed to show improvement after 
c-xtraclion, and Mr, Messenger deprecated the casual manner in 
which extensive extractions were often done in various chronic 
infections when other possible foci were insufficiently invesli»»atcd. 

In tho discussion which followed Dr. Daugherty outlined the 
radiographic appearances in dental sepsis, and indicated some 


of Uio pitfalls in tho interpretation of Uie plates. Other speakers 
discussed tlio importance of provenlivn measures in the treatment 
of dental infecnons, the education of the public in the caro and 
hygicno of tho month, and in dietetic matters, particularly in iho 
ca.so of children. It was observed that medical men occasionally 
ordered extraction of teeth witliout reference^ to the dental 
surgeon, and sometimes in opposition lo the opinion of the dental 
surgeon; such practico was considered to bo ill advised. 

A vote of thanks to Mr. Messenger for a very enlightening paper 
was moved by Dr. G. W. R. Skene, seconded by Dr. C. de Boudrt 
Thomson, and carried unanimously. 


Northern Counties of Scoti.and Branch. 

A MEETING of the Northern Counties of Scotland Branch w^ held 
at tho Northern Infirmary, Inverness, on March 15Ui. Dr. T. 
Macdonald, president, was in the chair, and tJiero was an attend* 
anco of thirty-two members. i -n -p 

Tho first part of the programme was a paper by Dr. E. h. 
Mackenzie on some views upon midwifery practice. Dr. Mackenzies 
views were based on his experience at 865 confinements which ho 
had attended during the last twelve years. Careful notes had been 
kept by him of all liis eases, and the result was a very interesting 
and informative paper. After the paper there was a free disaission, 
in wJiich Drs. D. G. Campbell, J. \V. Mackenzie, Kelly Dickie, 
W. D. MACKINNON, and tlio President took part. 

Mr. A. J. C. Hamilton gave a demonstration of surgical eases, 
which also proved very interesting. Tho eases shown were as 
follows : • 

(1) CasQ of Perthes’s disease of right hip: A girl, 9 years o' 
limn and occasional pain in hip since Docemher, 1925; x rays, [d) 
of KOhlcr’s cliseuSQ (tarsal scanhoiditis) : Child 6 to 7 years of age. 
and some swelling in foot for a fortnight ; x rays. (3) Case oI opdlieli^ia oj 
lip: A male, 24 years of age; Wassermann test negative; piece 

for examination; radical operation-three stages September to 

1027— (a) excision of glonifa right side. of neck, (61 ° 1 

lower lip and plastic repair, (c) excision of glands left side of necK, 
fourteen days l.elwecn cncli since. (fl.Cnro «rc.noran of peU.c 
A woninn, oped 55; proRrcssivo constiimtion.of several months dutnuen. 
niirmoido'-comc c.vominnlion iicgntivc; linrium enema; Serterohex stOi 
1927, Inhoroiomy and tlirec-stnpo operntion ol Mikulics imUatcd. (5) 
of empyemn treated hy Sorest cannula : Patient, nRed 64, had left sioci 
empyema amt mi.vcd infection of streptococci and pnoomococci , 

P-Viip.inrv 18t) 1928 : X ray. (6) Calculus from pelvis of left half ol a 
Imteffi ktdney: Vpceime^o only; (7) Case of hydronephrosis; * rsjs 

*"Aflcr Iho iticcUng lea was provided by tlio matron of iho 
liospital. 

Nonin or Englaot Bhanoi t Blyto Division. 

'Tup nnnunl dinner ot tlio Blytli Division was hold on March Zlstj 
Tho tSmTs' of "‘Tho KinB,;-"“ Tho British Medical Assoerntm^ 

oYortinal\.S"de^kMfbf so^^^^ Mr. Manghun, Dr. Brown. 

""rViY^o"t""dfmmr‘’theTollow^^^ -ero elected for tho 

craip (Bndle;). rieo.Chofrman, Br. Brown (Bedllngton,. 
o/e^ 'we i;sUlJ;-d duo ceremony by the outgoing 

‘=’'D‘r™a?rp" ose\\Tcd"r?ho Dh^^^ 

•‘'D.^’XLn'aving raisod tho question ot ruiuers’ levy for tho 
dolors? tho honovarl secretary was instructed to deal with tho 
ruallcr. 

South Indian Btianch. 

appoiiucu loi „ Social Hygiene Conned. A paper 

M^ftt"N^^mber"Ve^^ 

it“ai"reve“;' propaganda 

“eh nssiTtant for work on iodine a.jd fcmd.cj 

mbiects. Tho financial statement showed a credit balanc 
R 5 .a, 52 l' at tbo end of tbo year. 


South Wales and MoNJtouTHsniRE Branot. 

CLINICAL mooting of tho SouU. Wales =‘”<1 "'“iU,'' the 

as held at the Aberdarc Hospital on March 22m ^ 

■esidcnl, Dr. J. Morgan Rees, in lb° “a su^s 

nco the Branch met at Aberdare, and tho ipeotin. was a 

Slrl^'^VmL^ASi Everett demonstrated eases “”.'1, ®'liaai''''trac°! 
section 'for malignant discaso of tho gaslro-mtc 


JLt'nir, 7, 1923] 


Mcotings of Branches and Divisions. 117 


(1) A specimen from a v,onmn, nped Gl, showed a Inrpe columnar 
carcinoma filling ilio pyloric nnlnnn, with herniation ot tho growth 
into Iho (liiocienmn, nut witli arro‘;t at tho pyloro-duodonal junc- 
tion» Billroth’s No, 2 operation had hocn performed more than 
two years previously; tho patient was now fit and well and had 
gained over a stone in weight. (2) A man, aged 46, had undcr- 
gono an ilcodiepatic resection for columnar carcinoma of tho 
caecum fivo years previously, tho carcinomatous ulcer having a 
diameter of three and a lialf inches. There had been no signs 
of recurrence. It was explained that llio prognosis was much 
inoro favourable in resection for cancer of tho caecum than for 
a similar growth in any other part of tho colon. (3) An inter- 
esting specimen was exhibited of a fungating columnar carcinoma 
of the transverse colon which Iiad become adherent to tho 
descending colon with tho formation of an intorcolonic fistula. 
Hcpato-pclvic resection had been performed witli subsequent relief 
for eleven months. (4) A woman, aged GO, liad been operated 
on Ihroo and a half years previously for carcinoma, abdomino-pclvic 
resection being performed. There had been no recurrence, and 
tho patient had gained and maintained an increase in weight of 
over a stone, A feature of this case was the control of the bowel, 
tho patient having an evacuation regularly cacli morning; the 
artificial anus was then dressed with absorbent paper and covered 
with a flat celluloid disc kept in place By an ordinary corset. She 
led an active public life, and was able to attend to all licr duties 
without inconvenience or discomfort from tlic colostomy, 

Br, H. Bakks demonstrated (1) a Ircphino ho had devised for 
uso with Albcc’s motor for opening tho medullary oavit)' in acute 
osteomyelitis. Dr. Banks thought that the use of chisel and 
it ^ from possible danger in an acute infection 

e kind. The Ircphino perforated the hone with a minimum 
of ciTort ; a series of trephine openings were rapidly made, tho 
f 1 being easily levered out, (2) lie then showed a ease 
of bilateral pneumothorax in a man working underground who 
been run over, both clavicles and several ribs being fractured, 
ilo was adraittcd in a slate of extreme collapse, witii extensive 
surgical emphysema of neck and chest extending from the level 
1 ij .to below tho pectoral muscles, and across the 

siioulders. ilespiraiion had almost slopped. A trocar and cannula 
introduced into the chest, and was followed by an escape of 
immediate improvement in the respiration^. A similar 
r ®thcr side, the lividity disappeared, 
improvement in tho brcalliing was noted. The patient 
oxcollcnt recovery and resumed his work. Skiagrams 
four ribs were fractured at their angle on one side 
other. (3) Dr. Bank.s showed next a ease of 
A man, aged 53. had been 
in September, 1927, with marked anaemia 
tjic blood count showed variation in size and 
• 2lf&iwi AjP <-‘ells, with occasional polycliromatophilia, and 
wftss ? pcr c.mm. were present. One pound of liver 

lisrlif^ 7 ^ ^ ^ ,pound being raw, and half a pound 

was orange juice. A fortnight later tho patient 

inerGa-^P^ ?« feeling much better; the red cells had 

annSrpd , The man had returned to work, 

Dr DiJIJ was stiU taking half a pound of liver a day. 

under liic (Swansea) described some cases of anaemia 

• Ho had been found unsatisfactory', 

bo eiven bulhxk’s Jiver gave the best results; it should 

added bffbtly grilled, and- orange juico could be 

einco * anhlnt-f^*? ^ iruit juice might bo the beneficial factor, 
a°aW often present. Dr, Evans warned 

considerablv^°#rr^/^"^*^”’i treating these eases, which varied 
How tho ifrpr continued for several months, 

but ^nmp acted in pernicious anaemia was not understood, 
to maturp present which allowed tho red corpuscles 

tho disadra«f« were several liver essences on the market, but 
Cook (Cardi'ftf“*i preparations. Dr. H. G. 

of <Iiabetp<{ compared the empirical treatment 

injections. insulin and general paralysis with malaria 

oneratpd*iiiSl°r*® showed a case of carcinoma of tho breast 
discoverprl , ? “vo and a half yeare ago. The condition had been 
breast patient reported with an abscess of the 

also showpd^J”^ confinement. There had been no rccurrciice. He 
bad been notip^pT^^^S^ boy aged 9. A swelling 

no discomfprf ^*bs on the right side, which caused 

with ^ ^bo boy was brought to hospital 


appe of 

drain^e^. * opened and tho cyst evacuated and 


‘ acute abdomen 


brought to hospital 
tho swelling had dis- 


Bccoiery had been_ uninterrupted. Dr. Tiiomas gave 


^ case of stricture of the urethra to show the 
ment was discussed complications. The operative treat- 

binaural (Llanelly) demonstrated a modification of the 

plug-in which he had devised. This consisted of a 

attached ivliich various types of chest-piece could be 

hospital members were entertained to lea at the 

departm’cnt nspected the new children's pavilion and light 


South Wales and Monmouthshire Branch : South-West 
A /. Division. 

29tii at^Thp ^yaIes Division was held on 

Ewen J Carmarthen, wl 

tion, and fbe British Medical j 

Medicine ^one^Prl ^.'^wifery, the Welsh National Sc 
morbidity. P ^ ^ discussion on maternal mortalit 

Elato present unsati: 

morbiditv Imi’c? ^1 ' ^ ^’gb the maternal mortal 

omit} still stood in this country. Even though Qur s^ 


compared very favourably with tho.so of tho United States of 
America, Canada, and New Zealand, there was a very serious 
problem to bo faced. He urged those present to take an active 
part in any investigations which might be made in the near 
future. 

Many took part in the discussion, among them the CnArRiLor, 
Dr. D. II. Pennant, Dr. C. A. Briostocke, Dr. Oscar Williams, 
Dr. T. J. Jenkins, Dr. E. Jones, J.P., Dr. Williams, Dr. Neilson, 
Dr. Jean Mackiktosif, and Dr. A. ,H. D. Smith. There seemed 
to bo unanimity on tlio lack of careful ante-natal supervision and 
on llio necessity of providing facilities for dealing' with cases 
which ante-natal examination had shown to need special care. 
A strong plea was made for inidadves with full hospital training, 
though somo of the rural practitioners who worked in areas where 
no midwives practised said they would bo satisfied with the 
ordinary trained midwife. Dr. 'Mackintosh produced statistics 
from tho Llanelly borougli health department, covering the last 
seven years, and said that in this area the general practitioners 
had for many years shown great zeal in ante-natal work; tho 
average mortality figures for the last seven years was stated to 
be 2.6, while the average mortality rate from puerperal sepsis 
was 0.13. Unnecessary uso of the forceps was considered by 
all to bo a causo ot increased mortality and morbidity, but 
opinion was divided as to whether forceps application was now 
ns frequent as in the past. The opinion of all speakers was that 
Iho profession as a whole should make an early and earnest effort 
to deal with this very important subject. 

On tho motion of tho Chairman, seconded by Dr. Brigstocke, a 
verj* hcartv veto of thanks was accorded to Sir Ewen Maclean, 
who suilafdj' responded. After tho discussion members were 
entertained to tea at the infirmary. 


Sussex Branch : Hastings Division. 

A well-attended meeting of the Hastings Division was held at 
the Quccu’s Hotel, Hastings, on March 16th. Dr. A. E. Larking 
read a paper entitled “Hospitals, general practitioners, and others/' 

Dr. Larking dealt first with the relations of medical practi- 
tioners to tho public and to each other, and later with the 
hospital question, Tho profession, he said, had allowed certain 
encroachments into private practice to be established ; school 
clinics and tho so-called hospital benevolent funds were instances. 
These were both helped by practitioners acting on their own 
behalf and without any consultation with tho general body. They 
must endeavour in future to have every project dealing with 
medical matters fully discussed in a general meeting before any 
individual member supported it. They were being exploited in a 
most flagrant manner. In twenty years the general practitioner 
would be a very poor creature, treating onfy tho most trivial 
complaints; all other cases would go to hospitals. It was quite 
time they recognized this and did something to prevent it. They 
must educate the public to realize that a general practitioner 
was just as competent to treat cases as those at the hospital, unless 
skilled nursing and major operations were required. 

Tho greatest diWculty was in dealing with the men on town 
councils and other public authorities, which were often under 
the thumb of a clique who took no notice of opposition or protest. 
If .the medical men of a large town were to determine to take 
actiou in any public matter they could 'wield a tremendous influ- 
ence. But it was essential for them all to meet together and 
discuss matters beforehand; tho pity was that there were men 
in tho profession who apparently took no interest in medical 
matters. There .were many members^ of the British Medical 
Association who never attended a meeting and did nothing what- 
ever to promote the general interests of the profession. It was 
a great misfortune for any town if tho men on the staffs of the 
local hospitals did not take an active part in helping to promote 
professional union. With the health insurance scheme they were 
all becoming more or less civil servants, and with the extension of 
tho Act providing specialists, consultants, and pathologists, it was 
most important for all of them to unite. - 

The work done at the voluntary hospitals was not at all fully 
appreciated by tho general public. Few of them realized that all 
the work at the hospital was done by the doctors quite free of 
cliarge. There was nothing comparable in any other profession 
or industry to this voluntary work. Many men devoted much 
more time to hospital work than they could afford, and the time 
would come, sooner or later, when they would have to be paid. 
Hospitals were being boomed so much that there was arising a 
view among’the general public that no treatment was of any good 
except hospital treatment, yet hospitals that were short of funds, 
instead of economizing and limiting the work, tried to get money 
to open new departments. The wholesale treatment of anybody 
at hospitals was a public scandal. Many serious eases were kept 
on tho waiting list for lon^ periods in consequence. All motor 
accident cases ought to he charged full maintenance fees. 

Hospital committees were composed mainly of people who knew 
very little about hospital management. Many took up the work 
as a hobby; the general practitioners of the town were not repre- 
sented on the committee as a whole. Tho few who were on it 
were members of tho staff and were prejudiced. If tlic general 
practitioners were represented as a whole, by selected medical 
men there would be mudi more chance of stopping hospital abuse. 
The so-called hospital benevolent funds were all very, well in their 
place, and if kept to the right people, but there were many who 
thought that by joining the fund they were entitled to bo treated 
free and could claim admission. They also had no idea that tho 
medical men did not get a penny of their money. 

Hospitals and general practitioners should not bo antat^onistie 
but should work together for their common benefit and “that of 
their patients. Tho present method of electing certain general 
practitioners to the staff of tho local hospital, except in very lar»o 
towns, was all wrong. It was not fair to select one man and not 



1 1S April 7, 


19281 


National Insurance. 


r suppjj:irr.NT to th* 

LDniTlSU ll£t>lCAli JOUSKAL 


Bnother All senei'a! practitioners slioiild be allowed to attend 
tbSr patiOTtslt the hospital if thej- wished. If all were on the 
it would increase the general efficiency of the profession 
ti-emendously. The greatest drawbach to general practice was 
oFten. its deadly dullness; the treatment of trivial ailments palled. 
Without speciil work or hospital work many became apathetic, 
ilcoenerate, and lost interest in their profession. Hospitals slioii d 
5 ilher be staffed by pure consultants or erery practitioner should 
to allowed to be on the staff if ho wished. When there was a 
specially selected staff, not only should tliev be the best qualihed 
men, hut they should be the men most likely to work ainicablj 
with the general pracUtionei's of the locality. 

Many patients were kept in hospital far too long, and the long 
waiting lists were a very serious blot on the present mclhods: 
laro-c uumbei’s could be sent t-o the Poor Law infirmary when ■con- 
valescent if they had no home suitable^ for thorn. There Avas a 
growing desire on the part of the public to cover every risk by 
lusurauce, and the profession shonld bo able to meet the need. 

A public medical service adapted to all classes would do much 
in this respect; it would demand some effort and trouble to 
start, but would result in great benefit and avoid many had 
debts. It Avould diminish the number of tJie out-palicnls at the 
hospitals considerably. 

Dr. Larking said, in conclusion, that in the past the Bnlish 
Medical Association had done an immense amount of- useful work 
for the profession; the sooner it took up the ■question of hospital 
abuse the better. It was urgent and brooked no delay. Private 
practice must be -presci'yed, and the rush for hospital treatment 
checked. The medical profession demanded good healtli and a 
strong constitution. At times the anxiety and respon«ihiHtr \vcre 
loo much, and Avhen financial liAiubles were added it became 
unbearable. If they could do anj'thing to ensure that private 
practice could give a man a good income and freedom from 
financial worry, they would have done a good work. 

A very keen discussion follcrwcd the reading of the paper. 

■\Vest SoMuasET BuAKcn. 

A MEETI3TU of the West Somerset Branch was held at the Taunton 
and Somerset Hospital on March 27Lli, when Dr. E- N. Jvpi*, the 
president, was in the chair. 

It ivas decided to send a lettca' to the Somerset County Council 
asking that authority be given for the payment of a fee of IC?. 6d. 
to practitioners who supply to coroners written reports in con- 
nexion with a death. 

There Avas some discussion of the question of recommending a 
definite fee to bo paid by boards of guardians to their medical 
officers for the inspection of casuals -at ivorkhouscs in pursuance 
of the Ministry of Health Circular S59 — ^smaU-po.x among casuals. 
It AA'as decided to take no action in view of the fads that the 
average number of casuals inspected in the A*arious Avoikhouscs in 
the area varied largely in nnmbore, that the guardians w'ould not 
bo agreeable to payment on a case basis, and that some medical 
officers had already*^come io a satisfadoiw arrangement Avilh their 
board of guardians. It Avas left to each individual doctor to make 
his oAvn arrangements Avith his board of guardians. 

The suggested scheme of the Somerset Insurance Committee oT 
health lectures by practitioners to their patients Avas considered; 
it was decided to no action in the matter for ihe pi'cscnt. 

Dr. L. H. Birkbeck, honorary surgeon to the Taunton and 
Somerset Hospital, read a very interesting paper on his experience 
during the last tAventy-fiA'e years as a surgeon to the hospital. 
In a discussion that folloAved many sug^gestions avctc made by those 
I^resent for the improvement of hospital service from the point of 
view of the iicighbonring practitioners. 


Rational Snsiiranrc. 


LOHDON INSTJEAHCE COSOIITTEE. 

Chairmavship vf Medical Service Suheoniinitttc, 

At tlio meeting of ihe London Insurance Committee on 
March 22nd many tributes were paid to the work -of tlie 
late Mr. Heniy Mills, J.P., who at the time of his sudden 
death Avas A*jc(^chairman of the committee (of which he liad 
been a member for fifteen ycais) and chairman of the Aledical 
Seivlce Subcommittee. Mr. W. EpAS'Aans, chairman of the com- 
mittee, proposed that in appointing a successor to Mr. Mills 
chairman of the Medical SerA'ice Subcommittee a departure 
from precedent should be made by' selecting someone who was not 
a member of the committee. He submitted Ibe name of Mr. 
R. Harris, secretary of Uie London School of HA-gicne and 
Tropical Medicmc, and formerly on tlic staff of the iVIrnislry of 
Health, where lie gained a close acquaintance Avith the administra- 
tion of nation.al health insurance. The nomination ivas supported 
.hr Sir Neill, and, on behalf of the medical meml^rs, bA* 

D‘r. H. J. CArmiiLU, and Avas agreed to unanimously. The regula*- 
lions provide that an outside ohairman may be appointed, pro- 
vided he is not an insured person, an officer^ (otlicr than a trustee) 
of an approA-ed society, a practitioner, or a' registered pharmacist, 
and he may attend tlW meetings of the full committee ?nd speak, 
but may not vole. 

Drugs and Applvmcfs. 

A rctuni was submitted to the committee comparing the 
total nimibcr and cost of prescriptions dispensed by chemists 
for insured persons in the county of London during the ji\-e 
A-ears 1925-27. This shoAved that the number of prescriptions 
had ri-en stcadilv from 6,132,356 in the fii'st of these years 
to 8.743,249 in the last, that the total cost had lisen from 
£205,619 to £297 .©IS, that the average co^t per piescription had 
Bone Aip slightly from 8.05 pence to 8.17 pence, and that the average 


cost per persoh liad gone up more markedly from 30.9S pence to 
4016 pence. In the fifleon years -since ihe commeuccmcut of 
national insin-ance administration the prescriptions issued and 
dLspensed for insui-cd persons in the committee’s area liaA’c in^- 
bej-cd 86.641,690, and the total cost has l)ocn -£2,803.050. Dr. 
Cardale pointed out that the increase .in Uic number of insured 
persons from 1923 onwaixls bad an impoiUiU bearing on the 
totals "iveu. It was also reported that during 1927 the chemists 
on the*’ committee's list dispensed 10,533 prcscriplioiis for insulin 
at a cost of £3,824, and 2,219 prescriptions for serums and vaccines 
at a cost of £555. 

LONDON PANEL COMMITTEE. 

A ■JiEETiNC of the London Panel Committee Avas held on March 
20tli Dr. H. L Caeiialt presiding. A .sympathetic tnbulc Avas paid 
to the Avork of the laic Mr. Henry Mills, chairman of the Medical 
SerA'ice Subcommittee, who, Dr. Cardale said, had occupied lliat 
position, Avhich lie took on at a time of great difficulty, m sucli 
a wav as to gain the entire confidence of the mcmbcis, AAhetiicr 
rcprcscnlaiTvcs of approved societies or of practitioners. 

Lirttirrs in M(flical Stvdnits. , ,, 

A su<^gcstion Avas considered that the Panel Commit Icc should 
undorlakc a series of lectures io students at medical schools upon 
iiational health insurance practice and contract practice 
It Avas fcU however, that the committee must -001111110115011 to 
iuMiraucc practice only, and it was agreed to convoy to tkc deans 
of the London medical schools the opinion that 
witli the problems of insuronce practice could usefiillA. bo dcluereil 
annually to senior students. 

Tuvmnii for Kfiiirrfnicy Trcatmait. , ^ 

A siibcommiltee'reconiineiiacd tlial a H-c for a 

for Citicf'-eiicv trealmciil slioiild be disallowed. Hr. Pai-Mjni said 
Hial be bad a good deal of syinpatby with Ibc praclitioner «ni- 
wriied because L bad Inken much trouble in coiiuMion witli tbe 
case wbicli was one of acute abdominal pain. He tboiigbt A 
unwise to discourage a practitioner from seeing a patient a second 
in Bucli circiinistHUCDS. Hr. rAnTRipar, however, hoped the 
committee avould not bo led away into any niismlerpretalion of 
TblT^vnrd “emergency.'” The first ntteiidaiicc was properly an 
llie word cmcig .1 ^ arranged to rc-exarame Uir 

ilS"be 

^ Tlie^ recommendation disallowing the second fee was earned. 
Jhhisal nf Vrnint Vu»f a1 HmpiUih. 
n „ of the fubcommiUces has bad ils attention drawn lo .Uie 
One of in refusing to admit serious cases requiring 

action of chanmnii of the siibcommitlee reported 

immediate attention, xnc -fiffv cases in Avhich patients 

Ibatbebadobtamede^cnreof^^^^^^^^ 

were ic/uscd admittance. imsnitals was one wltieb was likely 
this action on the Hierefore bad directed llio 

to bniig tbcm of the hospitals eoiicenicd to the 

secrclary la djfw f 'J.a Io request iiifoi-matioii as 

cases I not “ted’: The comrure approved this 

aclion\akcii by the subrommitloe. 

Certifimns and rajHlap!<- , , . 

The leUef from his^ociely pointing out that the dates 

of the approved society eoiicc^^^.^^^ regulations. A reply 

Ihat this lusuiance Committee was received iiiforming 

from the clerk of the 1 ^p^ssarv that certificates slionld be 

him that i: uiar of the week be was advis^ to issue 

given on any particular n j nsunl pav-dai-s of approved 

rcrlificates .11 order^^to confoim^to q neo 

societies nds sSoii of the clerk, wbicli vras thought to be 

a «rreSt interpretation of the regmations regarding, 
certification. 

BIRMINGHAM TAHEL COMMITTEE. , , , „ 

lie Birmin“liain Panel Committee was held on 
Tuc'^da™Mnreli 20111 "S’Dr. H. G. Dsik- presided over a good 

attenda'uce. . detailing arrangements approved 

It was Ibive ™e under which paymenls made by 

efeTei “SSigha'^ Hospitals Council. An ab-aUon m Urn 
composition of the ' rvlre pa^sfd, and area 

suggested, emergency and jaouarv 1927, srerc compared, a 

figures for January, 19 “, and January , a , ^ 

slight reduction in cost cbaii-e of doctor, and 

bv panel practitioners of forms faciliUtn g ,, “^e^ional medica 
aUo on t4 number of Pal.enls " yOr wo.k teSk place, and 
officer who are certified by }’™ Ociiaiii steps in tliese matters, 
the secrclai-y was instructed to take ccilmii p j nuniiaily. 

It was decided to ask the liisuraiico Committee to supp^_^ 

'to each practiUoiier, the figures showing mdividi ml ai cra^e 
4««v.4i.r.v -wiih the aA'CraEes for Uic artu. 



Correspondence, 


r ^cTpimrirEXT to ueb 

LButxsu MU>ICAL JOC&SAI* 


ri9 


Arnir. 7, 1023] 


ComDponticnet. 

Oyththnlmk Jh nrjif. 

Sin, — I Imvo just r»'coivt*<I n lon^ printocl letter froni fl>o 
British Metlical As'^ociiiliou on the suhjfof of ophthnhiiic henefit 
for persons insured under t!»e Xalional Insuraneo Acts. In 
this letter the Association states that the j)resent scheme for 
ophtlialiuic henefit has heeii a partial failure owing to its 
lum-support hy the leading approred societies. 

The original scheme was that insured persons desiring to 
have their eyes examined should apply to their panel doctor for 
a certificate, this certificate stating whclhei: the doctor tFiouglit 
the services of an ophthalmic surgeon or optician wore neces- 
sary. The approved ‘ociety then made an appointment with 
the snrgiwn or optician as the c:is«‘ might hr. A special panel 
called the Ophthalmic Tanel was formed, including practically 
all the ophthalmic .s»rg<*ons in Great Britain — ahont eight 
hundred in number. Thrs**^ agreed to see pane! patients in their 
private consulting m<mis for a fee of one guinea. As might 
liavc heon expected, large nnnihers of persons <lesired to sec an 
ophthalmic surgion, there being about fourteen milUon insured 
persons in the country.- The funds of the approved societies 
avaitahle for ophthalmic henefit were speedily c-xhausted. 
The larger societiivs htrgan sending all their rases to opticians 
in the first instance, only rcfcri'ing to ophthalmic surgtwis those 
cases to which the opticians could not manage to give satis- 
faction. Tlie approved societies report that the scheme has 
worked well,' and then* have been few conijdaints. 

In the past, when the ordinary man was troutded with some 
defect of vision he went either to an optician or to a hospital. 
A small percentage of the comnninity vi.sttctl an ophthalmic 
surgeon first. >Ve .must rememher that Great Britain contains 
forty-five million inhahitants. Tlic insured class ntimliers about 
oiie-tliird of this total. The remaining two-thirds still act as 
they did in the pa.st, visiting opticiaiLs and hospitals. At an 
outside figure there may he about one fliousand doctors prac- 
tising ophthalmic surgery, and perhaps half tins number may 
bo on tlie sUfis of various hospitals, rresumably there arc 
no more, as the country does not supply a livelihood to a 
P’cater number. It is usnall 3 * compiUetl tliat a town of 50,000 
mhajiitants can support one ophtlialmic surgeon only. 

\vo are all agreed that it is the ideal that every man having 
trouble should Ire examined by an opbllialrmc surgeon in 
the .first instance; but tliis is a counsel of perfection. It is 
as reasonable as the demand that even* wntnaii in her confine- 
ment should be .ittendeil by a gj'iiaocologist. The ideal nuy 
be attained in tlie future, hirt not in our day. 

1 believe that th»*re are ahouf 14.0C0 dentists in England, 
and these suffice* for the’ dental needs of the rountiw, both 
insured and uninsured. Perhaps a man m.u* not have to see 
.someone about his e\'es as often as about fiis teeth, hut a com- 
parison of the uumlier of ophthahiiic surgeons as compared with 
demists .shows that the number of ophthalmic surgeons would 
laso to he .ninltipHefl nian%' limes before Ihes' could give an 
Ideal sersnee to the communitv: and who is going to pay for 
their remuneration? 

Now, what is the British Medical Association’s remedy for 
IS i,tate of afiah’s? It projioses, fii*st, that ophthalmic surgeons 
laJt reflucc their fees for seeing insured pei-sons to half a 
guinea. I do not think that this will be agreed to. It must be 
reniemuered that .specialists are being employed. It is the fii'st 
ime that this has been done for insured patients. The 
specialist can usually' c-ommand a fee of two or three guineas, 
he beginner at a specially may possiblv accept less at fii-st. 
is, Is he worth itf 

-the Association’s other proposal is that a committee shall 
le formed consisting of representatives of the approved societies. 
Of ophthalmic surgeons, and of the Association of Dispensing 
/pucimis (it is to be noted that the vast majoritx* of ordinary or 
opticians are thus left out), and shall found a series 
1 climes throughout the country at which groups of patients 
s lall be collected for examination. The disadvantages of these 
Clinics are, to me, obvious. ' Tliey will be nothing more than 
^VP5.*^cir hospital out-patient departments, with all their dis- 
abilities, such as prolonged waiting before being seen, hurry 
and lack of individual attention, and without the right of 
admission to wards that obtains in an ordinary hospital for 
cases needing it. In fact, if a person requires in-patient treat- 
ment a visit to a clinic will be simply a waste of time, as 
be mvestigation will have to be carried ont again at the 
Gspital. It must be remembered that these proposed clinics 
bia\ have to deal with a much more difficult tj’pe of case than 
un ordinaiy school ' clinic, which only deals with refractions 
* r school clinics can be dealt w'ith quite 

junior men with a knowledge of refraction 
<^1', but without much general ophthalmic knowledge. 

say, let the present sj’-stem remain. Insured patients much 
ppreciate the right to a private consultation at an ophthalmic 


snrgeon’.s rooms bj* appointment without the delays of hospital; 
they feel that a personal interest is being taken in their case. 
But I do say that, if an approved socrclv refers a case to an 
optician, before aii^* spectacles are ordered a certificate should 
be .sent to the socictv* stating the strength of the lenses to be 
supplied, and that normal vision was obtained in each eye with 
(hc.se lenses, and tliat no obvious ocular disease was present. 
It would he worth while for the larger .«^ocieties to employ 
medical asse.s.soi*s to review opticians^ prescriptions witJi a view 
of referring doubtful cases to ophthalmic surgeons. It should 
ba remfndH*re<l that main* of the societies pax* a small sight- 
Usting fee to the opticians. 

Lastly, let us as a profession ce.ise our opposition to the 
rfgistration of opticians. Chemists are registered, and we do 
not object to it in spite of the fact that we know that a laige 
amount of prescribing and doctoring goes on across their 
€000101*5. We never hear of architects or engineers objecting to 
the registration of plumbers. If opticians are registered their 
knowledge will tend to improve, as some of them are very 
ignoiiint now. Proper safeguards can be introduced in (he Act 
of Pailmnient limiting them to sight-testing and the manufac- 
ture of 5pcc(acles, prohibiting them from dealing -with ej'e 
diseases or the use of mydriatic drugs, with penalties for 
infringement. Proliibiting them from prescribing for elemen- 
tary* school children would not be unreasonable. I have recently 
come across a case of an optician who had been prescribing 
glasses for a small child with squint for many months. — 
I am, etc., 


Lontlon, VT.l, March 25tri. 


Adkxan' Caddy. 


Ejcptoiiation. 

SiK, — ^TFir letter nnder the heading “ Tiie workman’s valtie ” 
in tlic Sii/iiifriiirnt of llarcli 31st (p. 110) reveals the shocking 
ertent to whicii the medical profession is being exploited Ijy 
certain CTOvernmcnt departments. Almost on a par with tlie 
c.xperience recorded by Dr. Jefferiss may be mentioned that of 
any practitioner who is called upon by the head teacher of the 
local elementary school to e.xaraine one of his or her pupils. 
He mxist find ont what tlic child is suRerlng from and certify 
as to the probable period of enforced absence from school, for 
which service lie is oEered the Iiandsome fee of Is. Ijy the 
county education committee. 

Is it qnite ont of t)ie question to approacli the departments 
coiiccriicd. so that what is obviously a gross undervaluation of 
our services, and the slight to the profession resnlting therefrom, 
may be swept away? l\’e pride ourselves on doing a gi-eaf deal 
of gratuitous work : but are we, on that account, to let 
officialdom use onr disinterestedness as a bait for any indignity 
it may wi.sh to offer us ? — I am, etc., 

Greeiihitti'*, Kent, lUarcti 31.t. STAXDtXY. 


|ia&al aii& ^ilxtaro Appointments. 


R0V.\I. N.WAI, MEDiaVL SERVICE. 

Snrt:«’on CVmmantrcr E. L. .Markham, 03.E., fo the Pre^idenC for course 
at n.il. E.Ti>*rnmcntaI Station, Tocton. 


ROY.A.L AR.MY JtEDIC.VL CORPS. 
Captain .7. A. Crawford to bo Major. 

Liouteuaiit J. M. Johnston resigns his commission. 


H0y.\L AIR FORCE 3IEDICAL SERVICE. 

Squadron Leaders II. L. Burton to Central ^fedicaf Ertabifshment ; C.- P. 
Barbo to K-V.F. Base, (JosTTort- R. W. R-j iau to No. 3. Flvinf: Trainin^T 
School, Grantham ; F. E. Johniou to School of -\rmy Co-operation, Old 
Sanini. 

FHpht Lieutenants R. L. C. Fisher to R..\.F. Hospital, Cranwell; M*. D. 

to 45 Squadron, JliiUUe East ; J. P. Ileclermaa to R.A Jl 
Uepot, Vxbridgc. 

Flight Lieutenant G- E. Church is granted a permanent commission 
in tilts, rank. 

Firing OtTiccrs R. J. T. Bell to No. Ill Squadron, Sutton's Farm ; R. G. 
Frecmaa to Ofllcerb’ Hospital. Uxbridge; J. O. PriestToy to Princess 

JIarv’s R.A,F. Hospital. Haltnn: F. E. Lipscomb to R..\.F. Station, Kenlev; 
J. lintchicson to R-\.F. Training Depot, Leuchars; J. Kemp to Princes 
Jlarj-V R..\.F. Hospital, Ilalton ; B. B. Kennedy to Depot, Uxbridge; 

J J JlacJVndrews to .A^eropl.’ine and Armament Experimental Establish- 
ment, 3ranleshani Heath; R. F. iracExtchy to the Jfarine .Aircraft E^ri- 
mental Establishment, Felixstowe; J. B. Jlurphy to No. 1 Flying Training 
School, Nefhernron; J. C. Nelly to R.A.F. Station. T’pper Heyford ; 
F \ O’Connor and Leo O’Connor to R..\.F. Station, IT.xbridge. 


INDLVN MEDICAL SERVICE 

LieuL-Colonel P. E M’d^oii appointed Residency Surneon and Chief 
3I«?tlical OFfcei* in Baluchistan, and to officiate as Civil Surtrron,- Quetta, 
in addition to his own duties ^irh effect from January Ist, 1328. 

' Lient.-Colonel C. A. Sprawson, C.T.E, ha.=J liocn apixiintcil Honnrarv 
Snc*mon to the Vio-my and Governor-General, vice -Lieut. -Colonel F. i\ 
EIwls, C.I.E.. Tclirc-J. 

Liciilenaot S. P- Jn^Iii to he Captaiir. 

“ Tlic r^motion to Ills prr^ent rank -of Jfajor S. H- Ptal! is antedat*-)! 
to rebruajv IBtli, 1527. 




% 


ST)'X-»3?XjE.ISlElSr T 


TO TUC 


BKITISH MEDICAL JOURNAL, 


LONDON, SATURDAY, APRIL 14in, 1928. 


CO iS TENTS. 


BRITISH MEDICAL ASSOCIATION. 
EETINGS of HKANCIIES AND DIVISIONS ... 
;SOClATION NOTICES; 

Tihle or D*te.'; 

Bniscn asd Division MrrnKos lo nc iict-n 
;SOCI.\.TION INTELLIGENCE AND DIARY... 


r.\oE 

CORUE.SPONDENCE .- 

121 CoLLIEnY SunC.EOKS Asn Ukempeoyment 


NAVAL AND MILITARY APPOINTMENTS 
... 122 VACANCIES AND APPOINTMENTS 
... 122 DIARY OF SOCIETIES AND LECTURES 
... 124 I BIRTHS, MARRIAGES, AND DEATHS ... 


P.kGE 

... 123 
... 123 
... .124 
... 124 
... 124 


lEcctings of SJraurljcs onij Bibioious. 


Donsrr akd West Hasts BnxNcn : BoLT.KEMOUTir Divimok. 
iiErriyo of the Bourncniouth J)ivi«;ion vas held on March 29th 
St. Pcler's Hall, Boumemonth. 

Dr.^ Astck, who was in the chair, cxptt^'cd the ‘sonow of the 
vision at the loss by death since the last niccung of 
embers—Hrs. Davidson, Marrincr, Prcnlicc, and Saberton — all 
whom had laVen an active part in the work of the Djiision. 
Dr. G. G. A^^)ERSo^% Deputv Medical Gccrctarv, gave a very 
tcrcsting and lucid account of the activities of \l>c Avvociation. 
e grouped his remarks under the headings of (1) inainuMmuco 
professional standards of pro- and i>o«il-graduate education; 
') promotion of sciculiCc rescarcli; (3) influence of the Associa* 
on on the dc\’clopmcnt of the national henith policy. (4» odvo« 
icy of reforms in Lunacy and Mental Dcflcicncv Acts; ( 5 > public 
Jucation in health matters; (6) hospital poUev of the Association; 
i) medical charities. 

After the address several memhers look part in a dtscus^^ion. 

^ 'otc of thanks to Dr. Anderson for coming to 
WEATnERi,v said tliat he had l»cen a nic«d»er of 
ae British Medical Association for more than fifty yeai's. and hcvcr 
efore had he heard such a yoi*v clear and interesting account of 
^'ork of the Association. Mr. Vcukox, s<*conding the vole, 
aid that he had listened to all Dr. Andercon had said nith very 
real interest*, he regrelled that there had not been a much 
irger attendance of members. 


, Kexta BnAKcn, 

the Kenya Branch wa® held at the Xativt 
osiniaJ, Nairobi, on Januarv Mth, and the annual dinner a' 
no .TSairoui Club on .TnnnfiT^. mi.:.. 4i.« in..ri n\ 


uturc yeare. 

ictrei^for'^lSa'^-^^ “eeling Hie following were cleclccl .is olBcc 

•fc7-I'rfJlknt'’n: Preii.hni-Elect, Dr. C. V. IV. .\naor.-or 

olmsfnnn Sequeira. Honorar}/ ^rrrrfop//. Dr. F. J. C 

'arman WoHurori/ rrrasHrpr and Attielant Secretaiy, Dr. J. A 

foT the meeting reassembled for the readin; 
1 ^- P^pers-^ne by Dr. J, H. Sequeira on some diseases cansei 
nlterable viruses, the other by Dr. J. L. GitKS giving a medica 
eyew of Kenya during 1927. » ° 

^ dinner there were present thirtv-seven membei'S 

i? With Uie guests of the Association, including the Governor 
Grigg* the Chief Justice. Sir JacSb Barth; tli< 
Secretly, Sw Edward Denham; the Chief Native Com 
' A Maxwell; the Mayor of Nairobi, Mr 

Associated Chambers of Com 
Cenva Ar' 5 i^hc president of the Law Society' o 

' ^r' • ‘-rf president of the Velcrinar 

^ S* ^rassey-Eda-ards. In the absence of tin 
T X III® Branch Uie chair was taken Vvy the vice-president 
'ErsmpS* ioast of “The King." the Vice 

he Bntish 3Ie<lical Association," recountin' 

^nra. in As5^alioii throughout the world, and h 

len??*’ i Vvi followcd bv “The Health o 

)r T ' T ^ r ^“'cctor of Medical and Sanitarv Services 

hJ medi^ol n speech Dr. Gilks reviews 

•apcr rrnil year, mainlv on the lines of hi 

co^nomr vnlL fn day. Dealing with th 

department ni\1 the work done by the medica 

mm a letter reserves, he quoted the following passag 

f^enva'- “I ^ Ini’S® estate 11 

state Will ranch Ihe future ^ th 

ione iu rServe of the work now beini 

me resene. This is having the effect of helping to ge 


labour locally — and healthy labour at that." In conclusion, lie 
referred to the scheme now under consideraHon for regulating 
subsidies to medical missions and lo the valuable work of the 
Lady Grigg M’^clfare League. The toast was replied lo by the 
GovERKORy who expressed his appreciation of the work done by the 
medical profession in Kenya, and his cordial intereH in their 
activities. The health of the guests was proposed by Dr. C. J. 
WiLSoK, and replied to by Mr. E. K. Figgis. 

The niimial golf competition for tlie Gilks Challenge Cup was 
held on Jamiarv 21st at the Nairobi Golf Club, which had extended 
hospitality lo the Association. Considering the state of the coui’se, 
tho winner, Dr. 3f. Mackinnon, put up a very fine performance in 
finishing square with bogey. Tlie nmncr-up was Dr. J. B. Clarke. 


North or Ekolako Brahch; Cossett Divisioj?. 

The mcnibci*s of the Consett Division held their second combined 
ordinary and social meeting of the winter session iu the Imperial 
Hotel, iitanlcy, on March 28tb. After the items on the agenda 
had been dealt with, there was an animated discussion on matters 
of local interest relating to colliery practice. 

After the meeting the niembei*s enteiTained Mr. Koiman 
Hodgson, Iionorary assistant surgeon, Newcastle Royal Victoria 
Infirmary, lo a complimentary supper, the president, Dr. \Y. M, 
Morisox of Catchgatc, taking the chair. 

Mr. Hoiwsox subsequently addressed the meeting ou injuries 
and infections of the hand, describing fu*st the essential features 
of its anatomy, with a brief reference to the recent investigations 
of the laic Dr. FiGcld and othei's. He discussed the treatment of 
%Youm!s and infections of the hand in general, ahiraadverting ou 
indiscriminate poulticing and the prolonged application of boric 
fomentations, for which, he said, spirit or drv dressings should 
be substituted as early as possible. Various injuries and infec- 
tions wciv then considered, and the most effectual incisions for 
dealing with them were described and illustrated by photographs 
and diagrams. A vote of thanks to the lecturer for a most 
excellent and practical address brought to a elese a very enjoyable 
evening. 


North of Exglaxo Braxcii : H.\rTLEPOOLS Drv’isiox. 

At a meeting of the Haitlepools Division on Februarv 22ud Dr. 
\V. M'arxer Cook being in the chair, Mr. Norm.xk Hodcsox (Ncu - 
caslle) gave an address on infections of the hand. 

Mr. Hodgson reviewed the i*cccnt anatomical work of Knarvcl 
and Fifield, and indicated its bearing on the spread of infection 
in the hand. He referred to the part played by the fibrous bands 
which, running from the skin to the periosteum, formed com- 
partments ^ in the terminal phalanx, and showed how, by a 
crescentic incision, free drainage could be obtained, and necrosis 
of the terminal phalanx be prevented in most cases. The value 
of a general ana^Uictic in facilitating adequate incisions and 
the proper inspection of the affected area was emphasized. The 
after-treatment and the importance of fixafion in order to antici- 
pate any resulting stiffness in ihe fingers were discussed. Tl\e 
address \vas illustraiod by recent dissections, diagrams, and 
pathological specimens. 


North of Exglaxd Braxch : Tyxeside Divisrox. 

The annual meeiiug of the Tyneside Division was held on March 
^rd at the Tynemoutli Victoria Jubilee Infirmary, with Dr. H. 
Ai>.\ms in the chair, and Dr. Harvey Evers as the guest of the 
evening. 

The following officers were elected ; 

Chan man. Dr. H. Adams. Vice-Chaii matu Dr. E. Gofton Ilonoraru 
Srerttanj, Dr. N. B. Rawson. Eeprefentative in the Hepre^entativc Jiodt' 
Dr. Williamson. • ’ 

Dr. Stoxier reported that the Golf Committee had fixed the 
meeting lo decide the representative in tlie Treasurer’s Cup 
competition for May 13th at Hexham. It was decided lo hold, als 
in the. previous year, a dance in October, a diuuei* in January and 
•two clinical evenings; meetings would be on Tuesdays and I'ridavs 
alternately. ‘ ^ 

[1238] 


122 April 14, 1928] 


AssGdatson . Notices, 


r RVPPLK^rEKT TO TH* 

inniTisic. Medical Joubkal 


It was resolved to raise a voluntary levy of 5s. per member 
toward tlie out-of-pocket expenses of tJic representative in the 
Representative Body, and other incidentals. 

After refreshments, provided by the matron, Dr. Hauvey Evers 
gave a carefully reasoned and very instructive address on the 
indications for curettage of the uterine cavity. An interesting 
discussion followed, and tho evening closed with a hearty vote 
of thanks to Dr. Evers. 


Staffordshire Brancit, 

A MEETING of the Staffordshire Branch was held under the chair- 
manship of Dr. J. A. M. Clark, the president of the Branch, at 
tho General Hospital, Walsall, o'n Marcli 29th; forty-ffve members 
were present. 

Dr. S. C. Dyke read a paper on tho liver treatment of per- 
nicious anaemia, and exhibited a large number of charts. He 
expressed tho view that pernicious anaemia was a disca<ie in 
which tho bone marrow gave rise to red corpuscles, which, on 
account of their immaturity and concomitant faulty foi-mation, 
were immediately destroyed by the organs of tho reticulo- 
endothelial system, notably the spleen, the function of this 
system being to destroy red blood corpuscles after they had 
become effete. In pernicious anaemia, however, tho red blood 
corpuscles produced by the bone marrow wero so immature that 
they wero readily destro^'ed by the reticulo-cndothelial system; 
their sojourn in the circulation was so short that a marked and 
rapidly increasing anaemia was produced. Dr. Dyke stated that 
the success which he had had from tho use of liver was very 
great, and that in some cases tlie results obtained were actually 
dramatic. The observations which lie liad made included red 
blood counts, estimation of the haemoglobin and bilirubin per- 
^ntages, and calculation of the proportion of rcticulocx’lcs. 

had come to the conclusion that liver therapy was only 
effective for pernicious anaemia. He believed that liver substance 
had a specific effect upon the cells of the red marrow, enabling 
thorn to produce mature and properly formed red blood cells 
instead of the immature forms characteristic of pernicious 
anaemia. The reticulo-endothelial system was not able to destroy 
these mature cells until they had become effete; they thus had 
time to function, the patient had a normal supply or red blood 
corpuscles, and his anaemia was relieved. Dr. Dyke exhibited 
vaiious propnetary preparations of liver; he stated that equallv 
good r^ults were obtained with fresh liver and with anv of the 
pioprietary preparations ho had tried. 

Dr. Jolly opened a discussion on tho small-pox of to-dav. 
and recounted the clinical features of a number of cases of mild 
small-pox he had seen, emphasizing the fact lliat for all practical 
purpo^, except severity, the so-called mild small-pox ot to-dav 
was the same as tho disease generally known as variola. Ho 
raised tho question whether the same precautions were necessary 
in the prevention of the disease in its present type as were con- 
sidered requisite for combating the old-fashioned and more lethal 
variola, alluding to tho disturbance of business and general life 
which resulted from anything in the nature of a small-pox scare. 
The subsequent discussion centred round tlie efficacy of vaccina- 
both types of tho disease, tho supervision of 
small-pox contacts, and the spread of the disease by vagrants. 

1 ... .• 'i Edge, in a paper on some points in gvnacco- 

logjcal surgery, r^orted many unusual cases which had wcurred 
in Ills practice. He showed how a thorough routine examination 
prevented a scepnd condition from being missed, wlien a moro 
superficial examination suggested tliat^ only one abnormality was 
present. He instanced, in this connexion, a most interesting case 
of incompleto abortion combined with a ruptured tubal gestation. 

the geography of the “blind spot“ of the 
indicated kow the existence of this led to difficulty in 
diagnosis. He emphasized the necessity for care in making ud 
normal saline solutions for rectal infusion, recountino- his exp^ 
rieiico wiUi some solutions which were hypertonic. Ho deprecated 
Uic use of milk as a food immediately after abdominal operations 

results which were^obtained 
bj allm\ing the patient as soon as she had recovered from the 
anaesthetic, to have water glucose solution, and tho cup of lea 
which had such a beneficial effect upon the feminine mind. 


SuiuiEY Bkakch : Guildford Divisioif. 

Ak oidinarj- moeling of (he Guildford Division ivas held al tl, 
Royal tjurrey County Hospital on March 1st with Mr H 
Butler m the chair. In the unavoidable absence of Sir’Thoma 
Lewis, Dr. E. T. Grant, lesearch worker in the eir,Uoe 1 
inciit of University Colleg-e Hospital Medical School^ gave a mos 
mteresUng lecture on the diagnosis of subacute infective endocardith 
Dr. Grant said that this malady occurred more frequently tha"^ 
was commonly thought; it was often overlooked, and yet in moJ 
cases it was easily recognizable. The infection tended to de-eloi 
in those who already suffered from chronic valvular disease o 
tho heart, and was one of the factors which rendered pro^nosi 
of this malady uncertain. When its onset was recognized^in 
case of valvular disease a fatal ending within a few months couji 
bo foretold almost with certainty. Dr. Grant then summarize, 
the main pathological features of the disease : (1) the infectin' 
organism was usually Strvptococcuft viridans; (2) large vegetation 
weyo found in the valve cusps; (3) the valves showed also as 
rule, either old disease of the rheumatic’ type or congenitai mal 
formation; (4) tho vegetations tended to spread over the cusp am 
on to the nei|;hhouring parts of the heart wall: (5> streptococc 
were present in the vegetations; (6) the heart muscle, as a ruk 
was not involved. -Associated findings were enlargement of tk 
spleen, glomerular nephritis, and embolism of various organ 


without suppuration. The lecturer then dealt in some detail with 
the clinicAil findings on wliich diagnosi.s was based, and empha- 
sized particularly tho age of tho patient, usually between 20 and 
40; tho existence of valvular disease; the insidious onset; the 
prcsciico of pallor, petcchiao, and Osier’s nodes; tho clubbing of 
tho fingers; tho enlargement of the spleen ; tlie occurrence of 
embolism; tho fever, which was usually low and irregular; the 
presence of red blood cells in the urine and of streptococci' in 
blood cultures; in addition to other signs. Negative blood cultures, 
when tho otlier signs were clear, did not Iiinder a diagnosis from 
being made. The courso of the disease was not always steadily 
downhill, and there mi^ht bo periods of remission. The average 
duration was five or six months, but it might be only a few 
weeks, or two or three years. Diagnosis and treatment were 
hopeless. Dr. Grant concluded by giving tho histories of five 
representative cases. 


Association i^otircs. 


April 28, Sat. 


May 12, Sat. 


May 15, Tuca. 
May 19, Sat. 


Juno 2, Sat. 


Juno 7, Thurs. 

Juno 15, Wed. 
June 21, Thurs. 

Juno 30, Sal. 

July 4, Wed. 

July 20, Fri. 


Julv 21, Sat. 
July 25, Mon. 

July 24, Tucs. 

July 25, Wed. 


July 26. Thurs. 
July 27, Fri, 


TABLE OF DATES. 

Annual Report of Council appears in British Medicai. 

JOUR-Va SUITLEMENT. 

Last day for receipt at Head Office of'nominations : (i) by 
a Division or not less than 5 members for election of 
24 members of Council by grouped Branches in British. 
Isles; and (ii) for election of 2 Public Health Service- 
members of. Council, and 4 Representatives of Public, 
llcnltli Service in Representative Body. 

Publication in British Medical Journal SurruMENT of 
list of nominations for election cf (i) 24 members 
of Council • by grouped Blanches in British Isles; 
(iil 2 Public Health Service nTenibcrs of Council, and 
4 Representatives ol Public Healtli Service in Repre- 
sentative Body. - . . 

Voting papers posted from Head Office, where there are. 
contests in above elections. 

Motions by Divisions and Branches for A.R.M. agenda on . 
matters of whfcti tvs'o monl/is’ notice mtt‘t bo given 
must be received at Head Office by this date. 

Last day for receipt at Head Office cf voting papers far 
election, where there arc contests, of (i) 24 members of 
• Council by grouped Branclies in British Isles; and' 
(ii) 2 Public Health Service Members of CouncH, and 
4 Representatives of Public Health Service in Repre-’ 
sentative Body. , 

Publication in British Medical Journal Supplement oi 
motions by Divisions and Branches for A.R;M. on 
mutters of which two months’ notice must be given. 

Representatives and Deputy Representatives must be 
elected by tills dale. , 

Publication In British Medical Journal Supplement of 
result of election of members of Council by grouped 
Branches, and of result of election of members of 
Council and Representatives in Representative Body by 
Public Health Service members. a ,» i 

Nomination papers available (on application at iieaci 
Office) for election of 32 members of Council by grouped 
Representatives (British Isles). _ * i- * 

Names of Representatives and Deputy Representatives 
must bo received at Head Ofiico by this date. 

McetSnea of Consfituencies must be held between this date 
and Julv 20th to instruct Ileprescntatives. 

Supplementary Report ot Council appears in DalTlSH 


•R.M. agenda 
e. 

.m. 

f Council by 
(at A.R.M., 


MCDIC.AL Journal supplement. 

Amcndmen 
must be i 
Annual Hc} 

Nomination 
grouped 

Cardifl) 1., . 

Annval liepresentativc lleettng, Cardiif. 

Council, Cardiff. . 

Annual Reprenentatire Meeting, Cardiff. 

Annual Representative fleeting, Cardiff. Annual General 
Meeting, Cardiff, President’s Address. ’ . 

Council, Cardiff. Conference of Honorary Secretaries, 
Cardiff. ^ 

Meetings of Sections, etc., Cardiff. 

Meetings of Sections, etc., Cardiff. 

Meetings of Sections, etc., Cardiff. 

Alfred Cox, Mcdtcnl Secretary. 


branch and division meetings to be held. 

BmAiiNGHAAi Brahch: Nuneaton and Taaiwortk Division,— .4n 
rdinary meeting of Urn Nuneaton and Tai^-orth 
eld at the Nuneaton General Hospital on Wednesday, April 18th, 
t 3 30 n m Dr. C. E. Rudd will read a paper on oedema of the 
velids Agenda: Minutes; rules of organization; reports bv 
ledlcal practitioners at request of coroners; Treasurers Cup golt 
impetition; election of representative and deputy representatii e , 
;tter from secretary ot London Public Medical Service. 

C.AMBRIDGE AND HUNTINGDON Brancii.— A meeting .0/ 
ridge and Huntingdon Branch with the Cambridge Medical 
Dcicty Avill be held at Addenbrookes Hospdal to-day (I nday, 
pril 13lh). at 2.30 p.m. Mr. Arthur Cooke : The results of treat- 
Lt ot gastric an'd duodenal ulcer; Mr. W H. Bowen and 
r. Ff. Roberts: Tho operative treatment of 
lo femur; Dr. Ff. Roberts: Locaiization of a golf-ball m a oog 
y the barium meal. 

Glasgow and West of Scotland Branch : Ayrshire 
he annual meeting of the Ayrshire Division will be n m. 

ifirmary, I^marnock, on Monday, April 25rd, ^ 
genda : (1) Election of office-bearers; (2) appointmen 



Arniii 1-1, 192^1 


Corrospondcnco. 


r SUTPLESrEXT TO THE 
LBRITISn JIEDICIL Jocuxilt 


Fcnlativcs (o (f{) Hranch Coanril, (6) ilio Koprosontativo Kody, 
(f) Counlv Maternity and Cliild WVIfuro Coimniltcc; (3) nnniml 
report ; (1) Kodak, Ltd., will sliow live medical cine- 

matograph fihns at- 4 p.in. 

Kest Hiukcii : Asiiroan Division. — At a mrctinp of the A«;hford 
Divi«ion to ho held at the Nortli Street Clnh, Ashford, on 
Wednesday, April 18th, at 4 p.m.. Dr. J. W. McKee of University’ 
College Hospital will give a iccttire on new work in the diagnosis 
and treatment of hepatic and biliary diseases. A cordial invitation 
is extended to all inemhett! of the Kent Hranch, 


Kekt Br.Axat : Kociiestek, CirxTirAM, an'd Gillincjiiam Divistok. — 
The annual meeting .and dinner of the Rochester, Chatham, and 
Gillingham Division will take place at the Bull Hotel, Rochester, 
on Wednesday, April ISth, at 7.30 n.ni. Agenda : Election of 
ofliccrs for the current year; post-graunatc lecture by residents of 
St. Bartholomew’s Hospital. Mr. K. Cecil Harris, coroner for llio 
Sittinghournc Division of Kent, has ncccptc<l an invitation to dine, 
and will speak. Tliose intending to bo present are asked to notify 
the honorary secrctarv ns soon ns possible, and not later than 
Monday morning, April 16th. 

Metropomtan’ Counties Brakctt : CAiinEnwEix Division*. — A 
meeting of the Camberwell Division will ho held at St. Giles’s 
Hospital, Camberwell, on Tuesday, April 24th, at 9 p.m. Dr. Guy 
Bonsficld (St. Giles’s Hosnital)* will read a paper on modern 
methods of combating diphtheria. 

Metropolitan’ Counties Bp.axctt : City Division*.— The next 
clinical niccting of the City Division will he held lo-day (Friday, 
April 13th), at the Metropolitan Hospital, when Mr. P. M. Heath 
will show surgical eases. Tea at 4.15 p.m., meeting at 4.30. 


Metropolitak CoLfN*TiES Bp.ancii 1 Lewishaji Division. — A meeting 
of the Lewisham Division will bo held on Tuesday, April 17lh, at 
8.45 p.m., at the Town Hall, Catford, S.E.G, when Dr^ W. V. 
Goldsmith will speak on the diagnosis and treatment of pruritic 
skin conditions. 

Metropolitan Counties Brancti : St, Pancras Division. — The next 
meeting of the St. Pancras Division (postponed from April lOlh) 
“C held on Tuesday, April 17th, at 9 p.nu, at the Association's 
House, Tavistock Square, W.C.l. Dr. Donald Paterson (physician 
Hospital for Children, Great Ormond Street) will deliver an 
address entitled “ The prevention of summer diarrhoea^” 
Metropolitan Cou.vties Branch : Willesden Division. — At the 
meeting of the Willesden Division to be held at the Wil)c«dcn 
Uenoral Hwpital, Harlcsdcn Road, on Wednesday, .\pril 18th, Dr, 
J. Brigiit Bannister will give an address on ante-natal work. 


Midland Branch: Ciicsterfield Division, — A meeting of the 
uicstcrficld Division will be held at the Royal Hospital, Clicslcr- 
neld, on >\edncsday, April 18tli, at 3 p.m,, wlicn tlicrc will be a 
seiios ol clinical demonstrations. 

Korth ^y^Es Branch.— The spring meeting of the North Wales 
Branch will bo held at Llandudno on Tnesdav, May 1st. The 
Branch sccretarj*, Dr, E. Lewys-Lloyd, Rhianfa, ^fowyn, Merioneth, 
will be glad to receive names of mcmbci’s willing to read papers or 
show eases not later than April 20tli. 

Northern Counties or Scotland Branch. — The third clinical 
meeting of the Northern Counties of Scotland Branch will be held 
t liic District Asylum, Inverness, on Thursday, April 19th, at 
^ paper will be read by Dr. T. C, Mackenzie 
entitled Some notes of the epochal insanities.” This will be 
oiiowed by a demonstration of eases by members of the Branch. 
Members w'lllmg to show cases are asked to communicate with 
ine honorary secretary of the Branch by April 16tb at the latest, 
^frangements can be made. Tea will be served at the end 

Vif^iri 1 \ fourth clinical meeting is being arranged to bo 
held at Golspie on May 19tlu 6 b o 

Division. — A meeting' of the Jersey 
iqUi D 3 n keld at the General Hospital on Thursday, April 
nn Licut.-Coloncl P. J. Marett will read a paper 

on some lung affections. 

Suffolk B; 

West Suffolk 

R je; „ 1 — *’*;f*'^*^ iieia on oaiuruay, Apiij xHir. 

Mr. C. W. G. Bryan will give a lecture on ur 
abdomen in cliildhood. Coffee wdll be served at 8.30. 

' Brighton Division. — A conjoint meeting of th' 
Division Avith the Sussex Law Society will be held a 
^ Dispensary on Thursday, April 26tli, at 8.15 p.m. 
p , ^®.,,"*^horary secretary of the Brighton Division, Dr. L. A 
^ paper on criminal abortion, with special refer 
?f Collins.- It is hoped that the subsequen 
elicit the views of both professions. The next clinica 
Division will be licld at the Lady Chicheste 
■no^pital, Hove, on Wednesday, April 18th, at 3,45 p.m. 

• Hastings Division. — The annual dinner of tir 
msUngs Division will take place at tlie Roval Victoria Hote 

for 7.30 p.m: Tickets 10s. 6d 
requested to notify the honorary secretary as soon a 
their friends tickets they will require for themselves am 

Dl^?sTn«'"'A PoNTErKACT, AND CaSTLEFOKI 

D Wakefield, Pontefract, and Castlefor, 

Thp,4d^,- A lolv StralTord Arms Hotel, Wakefield, o) 

Leeds il: P- Burrow, assistant physician 

acut- will give a lecture on the diagnosis o 

sunuer diseases. Tlie lecture will be preceded by 

will^ annual meeting of the Dirisioi 
take place on Thursday, May 10th.- 


Suffolk BR.^cir ; West Suffolk Division. — A meeting of th( 
>lk Division will bo held on Saturday, April 14tl', a^ 


(Komsponbiitci. 

CoUicry Surgeons and Unemployment.' 

Sm, — •! have seen no reference to the grievous losses colliery 
surgeons sustain because they arc expected to, and do, attend 
the dependents of unemployed miners witlioiii any remuneration 
whatsoever. I do not know* the arrangements made in England 
and Wales, but in Scotland the employed miner is at present 
p.Tying (he arrears covered by the strike period, and will be . 
fully paid up in October. Tlie fact, however, is not generally 
known that with a large increase in unemploy’ment tlie colliery 
surgeon.s, even with the temporarily increased offtakes, are 
actualh’ receiving less than they did before the coal stoppage, 
so that the remuneration for attendance upon miners’ dependents 
during the strike period must simply be written off as a bad 
debt. Afaltcrs will be aggravated when the arrears are fully 
paid. With a further immediate extensive closing down of the 
pits — and every closure means a further deduction in the 
colliery surgeon’s income, though his work remains the same — 
there will be a very marked reduction in his emoluments. In 
Scotland after October the diminished sum will be reduced by 
one-third. I find that by that time my colliery fees will 
have fallen to about 50 per cent, less than before the stoppage. 

I suggest that tlie colliery surgeons in each area should meet 
logether for joint action. We cannot be expected to pay 
assistants and procure new cars if this present situation con- 
tinues. Only an appeal to the men is needed to secure dis- 
cussion of ways and means for putting the matter on a proper 
basis. Three solutions, more or less practicable, have been 
suggested to me : (1) Continuation of present increased payment 
by the men employed unt« the coal trade revives, the employed 
paying for the dependents of the unfortunate unemployed; 
(2) the formation of a joint club run by colliery surgeons, the 
unemployed to make a small contribution weekly, less than tliat 
paid by'thc employed; (3) the Government to grant facilities 
for a 'small deduction from the unemployment benefit. As 
rogai’ds the second proposal, when members of other trades 
are unemployed tliey continue to pay into our clubs, but not 
so (be miner. 

I feel certain that the British Medical Association will ^ive 
us support in our efforts to improve the condition of colliery 
surgeons in stricken areas, where the young men at least suffer 
in silence. — I am, etc., 

Fife, iLirch 31st. COLUERY SuRGEON*. , 


^afaal anil iJttlitarg ^ppoininwnfs. 


ROr.AL KAVAL MEDICAL SERVICE. 

Surgeon Commander P. M. Rivaz to the Victory for R.N, Barracks, and 
for duty with Jledical Officer-in-charge, Haslar Hospital, and as Naval 
Health Officer. • • 

Surgeon Lieutenant E. O’Reilly to the Constance. 

Surgeon Lieutenant Commander E. B. Kelley to rank of Surgeon 
Commander. 

Royal Naval Volunteer Reserve. 

Surgeon Lieutenant J. B, Hutchison to the Valiant for training. 

Probationary Surgeon Lieutenant C. A. Mason to the Rodney for 
training. 


ROYAL ARMY JfEDICAL CORPS. 

Lieut.'Colonc! A. E- B. Wood, Regular Army Reserve of Officers, to be 
Major whilst re-employed, and relinquishes the rank of Lieutenant- 
Colonel. 

Jlajor E. C, Stoney is re-employed. 

Captain R. le G. Worslev to be temporary Captain, and temporarily 
relinquishes the rank of Captain. 

Lieutenant E. H. Hall Is seconded for duty with the Sudan Defence 
Force. 

J. E, Swyer to be Lieutenant on probation. 


ROY.VL .-VIR FORCE MEDICAL SERVICE. 

Flight Lieutenant H. W. Corner to R.A.F. Hospital, Cranwell. 

Reserve of Air Force Officers : Medicil Br.anch. 

Hon. Flight Lieutenant W. G. Weston is promoted to the rank of Hon. 
Squadron Leader. 


INDIAN MEDICAL SERVICE. 

Lieut.'CoIonel .K. W. C. Young retires. - . . 

The services of Major N. Briggs, are placed permanently at the 

disposal of the Punjab Government for employment in the Jails Depart- 
ment, with effect from Maich Z4th. 1925. 

Captain W. E. R. Dimoncl to be Major. 


TERRITORIAL ARIFY. 

Colonel M. B. Ray, T.D., having attained the age limit, is retired on 
completion of his tenure oi appointment as A.D.il.S., 47th (2nd London) 
Division, and retains his rank, with permission to wear the prescribed 

Lieut.-Colonel (Brevet Colonel) L. D. Bailey, M.C., TJ)., from General , 
List, R.-\.-M.C., T.D., to be Colonel, with precedence as from December • 
6th, 1926, and to be A.D.M.S., 47th (2nd London) Division. -- - 




t 24 April 11, 1928] 


Association Intoltigcnce and Diary, 


r RvrrLr.itKST lo ra* 

InitITISH MKDICiL JODEirib' 


Roy.al Arjiy Medic \l Coiu-s. . 

' Jlajor A. E. Evans to be Lieut. -Colonel and to command the 140tli 
(County of London) Field Ambulance. ^ „ , • n 

Captains (piov.) W. Simpson and G. F. Ivealin^io arc confiimcd in (lioir 

^^Lieutenants to be Captains: P. J. Stokes, A. Su indale, C. A. Cowie, 
\V. 15, A. Lewis, F. R. Sandford, M.C. 

IL B. Tiumpcr lo be Lieutenant. 


STANCLiir, 3frs. Isabella Morison, M.Ik, Cli.B.Ed., Tcinporarj’ AFsistant 
Medical Oincer for Schools under the Govcininent of lIonR-Kon". 
WcbTJiiNSTEU IIoseiTAL. — Uceidciil Uini^e-Vhyt'icindf : J. II. Wainwripht, 
L.R.C.P., M.R.C.S., A. M. .McGiath, L.U.C.P., M.R.C.S. Jlnident 
llouhc-Sunjeun : T. ^V. Mor^ran, L.K.C.P., M.R.C.S. Itetklenl Obilelric 
A9s>hi<tut : C. U. Greene, L.R.C.i'., M.R.C.S. 


CrntirYiNG Factouy Rurcf.ovs. — W. L. Tulli^, M.D.St. And., D.P.TL, for the 
Nc\Nhuriih Di.strict, co. Fife; T. \V. Howie, JLlk, Ch.R.Glas., for tlio 
Rot!le^ay District, co. Bute; A. G, Wallei, .M.R.C.S., L.R.C.P., for the 
Wallingford District, co. Berks. 


YACANCIES. 

Addexdrooke’s Hospital, Cambridge. — House-Surgeon (male, unmarried). 

Salary at the rate of £130 per annum. 

Ashford Hospital, Kent. — House-Surgeon. Salary £160 per annum. 
Bmuow-iN-FuRNESS : North Lonsdile Hospital.— H ouse-Surgeon (male). 
Salary £130 per annum. 

Beit Memorial FELLOWsinrs for ^Iedicil Rf.sc.\rcii —J unior Fcllow.'-hips bf 
the annual value of £400. 

BiRJiiNGn\si Union. — H ouse-Surgeon (male) at the Dudley Road Hospital. 

Salary at the rate of £200 per annum. 

Bolingbrokk Hospital, Wandsworth Common, S.M’.ll. — Out-patients* Oflicer 
for the Ophthalmic Department. Salary £65 per annum. 

Bradford Royal Infirmary.— H ouse-Physician and two Housc-Surgcoijs 
(male). Salary £150 per annum. ‘ 

Bury and District Joint Hospital Board. — R esident Assistant to the 
Medical Superintendent. Salary £400 per annum, rising lo £450. 

Devon Mlntal Hospital, Exminstcr. — Junior Assistant iMedicul Officer 
(male, unmarried). SalarA £300 per annum, rising to £350, 

East London Hospital for Children and Dispensary for Women. Shadwell, 
E.l. — (1) Resident House-Surgeon. (2) . IVJiole-time Casualty Officer. 
Salaiies at the inte of £125 per annum. 

Farringdon General Dispensary, Holborn Circus, E.C.4.— Honorary 
Phjsician for Electrothcrapeutic Clinic. 

Gloucestershire Royal Intiruary and Eye Institution, Gloucester.— Assis- 
tant IlouseSurgeon (male). Salaiy £120 per annum. 

Glasgow Royal Infirmary. — D eputy Superintendent and Senior Medical 
Resident. Salary £200 per annum. 

Guildford Union. — R esident Medical Officer. Salary £500 per annum. 
Hospital for Epilfpsy and Paralysis, JIaida Vale, 'W.O.— (1) Resident 
Medical Officer. (2) House-Phjsician. Salaries at the rate of £150 and 
£100 per annum respectively, 

Leeds : St. James Hosphal.— House-Physician and Surgeon (male). Salary 
£200 per annum. 

Leicester Isolation Hospital and Sanatorium, Groby Road.— Resident 
Medical Officer. Salary £350 per annum. 

Liverpool Eye and Ear Infirmary.— T hird Honorary Anaesthetist. 

Lord IMayor Treloar Cripples’ Hospital and Collfge, Alton, Hants.— 
Second Assistant Resident Medical Oflicer (male, unmarried). Salary 
£300 per annum, rising to £400. 

Loughborough and District Genfjial Hoopital and Di«pensary.— R esident 
House-Surgeon (female, unmarried). Salai\A £125. 

Manchester Royal Infirmary, Central Branch, Roby Street. — Junior 
Housc-Suixeon (lady). Salary, eight months' at £100 per annum, and 
four months at £200 per annum. 

Ministry op Pensions: BiRiiiNOHAM Pensions Ho.spitals Committee.— 
Resident Junior Medical OlRcor at the Highbury and Uflculme Hospitals. 
Salary £300 per annum. 

NoTTiNOHAJt General Dispensary, Broad Street, Nottingham.— Resident 
Surgeon (male, unmarried). Salary £250 per annum, rising to £300. 
Por.TSJiouTH Parish.— F irst Assistant Resident Jlcdical Officer. Salary' 
£350 pel annum. 

Rotherham Hospital.— H ouse-Physician (male). Salary £180 per annum. 
Royal Chesi Hospital, City Road, E.C.I.— (1) Resident Medical Officer. 
(2) House-Physician. Salaries at the late of £150 and £100 per annum 
respectively. 

Royal College of Surgeons of England.— E xaminers for the Fellowship 
and under the Conjoint Board. 

Royal Waterloo Hospital for Wosien and Children, Waterloo Road, S.E.I. 

— House-Surgeon (male). Salary at the rate of 4100 per annum. 
SAitLAUiTAN Fref. HOSPITAL FOR WOMEN, Marylebonc Roail, N.W.l. — Registrar. 

Salary £100 per annum. * o • 

Seamen's Hospital Society : Dre.adnought Hospital, Greenwich.— (1) 
Anaesthetist. Honorarium 50 guineas per annum. (2) Surgeon with 
charge of out-patients, 

Sheffield Royal Hospital.— Resident Anaesthetist (male). Salary £80 per 
annum. 

West Cornwall JIimers’ and Women’s Hospital, Redruth, Cornwall 

Radiographer. 

WF.ST End Hospital for Nervous Diseases, 73, WelbecU Street, Wl — 
Registrar (male). Salary £200 per annum, 

Windsor : King Edward VII Hospital. — J unior House-Surgeon (female! 
Salary at the rate of £i00 per annum. ' ■ 


Certifying Factory Surgeons. — The following vacant appointments are 
announced: Finedon (Noithamiitonshiie), 4! ivenhoe (Essex), Accrington 
(Lancashire). Applications to the Chief Inspcctoi of Factories, ^me 
Office, Whitehall, S.W.l. 

Medical Referee under the W’orkmen’s Compen.'-ation Act, 1925, for the 
Districts of the Aylsham, Downham Jfnvkel, East Dercham, Fakenliam 
Holt, King’s Lynn, North Walsham, Norwich, Saaflliam, Thetford, and 
Wvmondham Couiitv Courts (Circuit No. 32). Applications to the 
Private Secretary, Home Oflice, London, S.W.l, by Apiil 25th. 


diary of societies and lectures. 

Royal Sociitty or ^If.dici.nt. * , 

deucral Mfclimj of Tiics., 5.30 p.m., Ballot for Election to the 

Arnrobiz/v.- Thnrs., 8 p.m., Clinical Meeting 
Hospital for DlseaM'.s of the Nervous System, Out-patients Department, 
rect, 11.1. ••r.. • riA 



POST-GRADUATE COURSES AND LECTURES. 

Meiiical Cnscj*. _ 


iibtiical Association. 

OFFICES, ERITISII 3IEDICAL ASSOCUTIOX UOVSE, 
TAVISTOCK SQUAUB, W.C.l. ' 


Departments. 

n u.Hn ’tM • 4737 Dublin.) 


•ublin. (Tele- 


Fri. 


Tucs. 


Wed. 


’’■'"gVam“'‘'B.cXrDubiinr'Ter^ 

Diary of the Association, 

C»mbvidgc nnd JIuntin^g™o'n Brand. : Addenbrooka’s Hasrital, 
City” division ; Clinical JIcetinR, Metropolitan Hospital. 

®'far':'Donald”pato‘^on oVu^hrevonUon of S.unmcr Diarrhoea, 

5(ti:£Di^ktnfDr?T“v"Ve“o'’-o"'n Hepatic and Biliary 
Br^r’Dlv^s™;.: Clinical Meeting, Lady Chichesto. Hos- 

siPsiiipr^ 

Meeting. Bull '^Gencral"Hospitnl, Harlesdcn 

'''i‘S'"Dr“‘j 'BHi-l.t Banm-sk Work. 

ness Dr Division ; Strafford Arms 

■H’.akcfleld, urrow on Acute Ceiebro- 

liSci, 

7.30 p.m. 


Fri. 


Mon. 

Tues. 


— 

A«shi?o"'Diviaion : Annual Meeting. Inlirmary, Kilmarnock, 

Division- St. Giles's Hospital, Gambcrwell. Dr. 
Giw Bonsfi^ld on Combating Diphtheria, 9 p.m. 


births, marriages, and deaths. 

Silci Si <»■ f’" f" •• 

Sn.rrtion in the current issue. 


This list of vacancies is compiled from our adrertisement columns, 
rchcrc full particulars trill be found. To ensure notice in this 
column adrertisements must be received not later than the first 
post on Tuesday morning. 


APPOINTMENTS. 

Cook, Miss Eva D , M.B., B.S.Lond., ITouse-Surgcon to the New Sussex 
Hospital for Women and Children, Brighton. 

Hunt, Elixabclh. M.D., Cli.B.Liverp., Honorary Senior Jledical Officer, 
Liverpool Hospit.'il for Cancer and Skin Diseases. 


MAIIIIIAOES. , „ ,, 

nDOU-Konvvso..-At Cl.anaral. Chili on Aprn^ 

»a‘’i!i^e !?o"r::.rM.B:rc%:"4|.H.; |dcfsl ^^fughtcr of Mr. and 
ilrs. J. K. Norwcll, Ardcniea, Perth. (By cable.X Anrii 4th bv 

Y-WooD.— At Union and Rei^ 

lev. David Rycroft, assisted bv Rei. J. l\hitaker 

3. Evans Watson, L. Ward Ivay, Jf.B., Ch.B., 2 , T^eyiy n ; 
o Annie, only daughter of Mr. and Mrs. ■\\ alter Mood oi di y 

DE \TII« 

.RTT On lifarch 18th. at 67, Wanslead Park Avenue, E.^, Arthur 

nrv mT’ B.S.Lond.. Ph.C.. L.S.A.Eng., aged 63. 


Printed and published by the British 3Icdical Association, at their Office, Tavistock Square, in the Parish of St. Pancras, in 


the County of London. 


STD PPLEMEISTT 


TO TUB 


BRITISH MEDICAL JOURNAL. 


LONDON, SATUKDAY, APRIL 21st, 1928. 


CONTENTS. 


rAOE 

BRITISH HEDICRB ASSOCIATION. 

BrocccdlnSa oT Council: 

Tue I'ihasce or the Assoctatioh 125 

The AsSCOATIOK PROrESSIOXEU-E I^•TEn^•ATIOKAEE DES 

Meoeoss 126 

Peovisioh or Spa Theatueht ron Insueed Persons 126 

CossTTruTioN or the Association 127 

The CuAHimN’s Visit to South AriticA 128 

liUKACT AND MeKTAE DiSOEDEE 128 

POEEPEEAL MoeBIDITY AND MOETALITV 129 

ASSOCIATION NOTICES 132 

aiEETlNGS OF BRANCHES AND DIVISIONS 134 


PACE 

CURRENT NOTES : 

SiE Dawson Wileiams 132 

CONTEEENCE Or llEDICAL SlArPS Or VOLUNTAET HOSPITALS ... 132 

Middeemoee PniZE, 1929 132 

BOOKS ADDED TO THE LIBRARY 135 


NAVAL AND JIILITARY APPOINTMENTS 135 

VACANCIES AND APPOINTMENTS 136 

DIARY OF SOCIETIES AND LECTURES 136 

POST-GRADUATE COURSES AND LECTURES 136 

ASSOCIATION INTELLIGENCE AND DIARY 136 

BIRTHS, MARRIAGES. AND DEATHS 136 


PROCEEDINGS OF COUNCIL. 


IVcJncsda;/, April lUh, 1038. 


A stEKTiNO ot tlio Council ot tlio British ^Icilic.Tl Association 
was licld at tho Association’s House, Tavistock Square, on 
April nth. Dr. H. B. DiiACKr.NuwiY, who was warmly 
■welcomed on his return from his visit to Soutli Africa, was 
in tho chair, and the following were presoiit: 


.,1^: C. 0. Hawtliorno (CiiairmEn of Representalive Body), Mr. 
A. Bishop Hannan (Treasurer), Mr. R. G. Hosartli (Past President), 
mr Ewen Maclean (PrcsidenUEIecl), Dr. A. Lyndon (Deputy 
Chairman ot Reprcsciilalivo Body), Sir Boh ~ 

Past Chairman of Council), Dr. J. Barer 
Armstrong, Dr. F.- J. Baildon, Sir Alfred 

Bone, Dr. H. C. Bristowo, Dr. G. F. Buclian, Dr. H. G. Dam, 
Dr. C. E. Douglas, Mr. W. McAdam Eccles, Dr. D. E. Finlay, 
I'^'aser, Dr. F. J. Gomez, Dr. F. W. Goodbody, Dr. 
R. Y allaco Henry, Dr. G. B. Hillman, Dr. J. Hudson, Dr. 1. IV. 
Johnson Dn R. Lanodon-Down, Dr. E. K. Lc Fleming, Dr. R. W. 
Deslie, Dn E. Lowvs-Lloyd, Dr, J, Livingstone Loudon, Sir Richard 
Mwlon Mackenzie. Dr. A. Manknell, Dr. O. 
Matthews, Dr. Christine Murrell, Mr. A. W. 
Nuthall, Lieut.-Colonel P. O’Kinealy, Dr. W. Paterson. Mr, J. 
Patrick, Dr. R. c. Peacocke, Dr. J. It. Prytherch, Dr. F. Kadclifte, 
T', E. A. Starling, Dr. John Stevens, Lieut.- 

Colonel Ashion Street. Dr. W. E, Thomas, Dr. G. Clark Trotter, 

Mr' AM^VebbTr' '''<=‘'‘■^11, Dr- J- D- Walker, and 

J”’’ absenco were received from Sir Robert Philip 
Dunhill, Dr. J. A. -Macdonald, Dr. J. G. 
McCutcheon, Dr. G. W. Miller, Group-Captain N. J. Rocho, Mr. 
D. b. bouttar. Dr. Lockhart Stephens, Dr. D. IValshe, Sir William 
« heeler, and Dr. W. E. A. Worley. 

■p"''*'® '*^aass of Dp. J. A. Macdonald was reported, and the 
Council sent a sympathetic message. 

The Chairman said that since the last meeting of Council 
the death of Sir Dawson Williams, Editor of tho Sritish 
mc(l:cal Journal, had taken place. He could only draw 
attention to the large number of personal tributes to the late 
Editor which had been printed, several of them by members 
ot the Conncil, and he knew that the Council generally would 
endorse all that had been said with regard to the personality 
anc work of a great journalist, a great medical man, and 
a sagacious counsellor. (“ Hear, hear.”) 

le Council had also to deplore the deaths of Dr. H. W, 
Langley Browne of West Bromwich, Dr. James Davison of 
Bournemouth, and Dr. Henry L. McKisack of Belfast, former 
Council, and Dr. James Wheatley, president of 

We Society of Medical Officers of Health. 

tnu ° Council, by standing in silence, signified its desire that 
laUers of condolence be sent. . . 


Sir G. Lenthal Chcatle, K.C.B., was appointed delegate of 
llie Association at the forthcoming annual meetings of the 
Canadian Medical Association and the American Medical 
Association; Professor W. E. Dixon, F.R.S., was appointed 
to represent tho Association on the Council of the Lister 
Institute in place of the late Sir Dawson W'niiamsj and 
Mr. .Bishop Harman was asked to continue for a further period 
of tiircc years as representative upon the Professional Classes’ 
Aid Council. 

TAe Financt of (he Aseocia(ion. 

The Treasurer presented the financial statement of tlie Asso- 
ciation for 1927. The year, he said, had been one of very 
successful working ; the expense of maintaining the full 
activities of the Association had been well met by the sub- 
scriptions, the receipts from advertisements in the British 
Medical Journal, and other revenue, and there was a surplus 
on the year, which surplus had eased the task of the Finance 
Committee in dealing with the anticipated liabilities and 
responsibilities of the Association. On the expenditure side 
there was an increase in the cost of the Annual Representative 
Meeting, due to the distance from headquarters (Edinburgh) 
at which it was held last year. The year 1927 was the first 
normal year of housekeeping in the new premises, and the cost 
was shown to he about £2,500 a year more than at 429, Strand. 
But the family was larger and required more accommodation, 
tho Association’s earning powers were greater, and its vitality 
was enhanced. He read the auditors’ report, and then moved 
that the financial statement be approved, which, after a few 
questions liad been asked and answered, was agreed to. 

Mr. Bishop Harman then went on to report on a matter 
referred to the Finance Committee by the Conncil — namely, 
the question of the payment to members attending Council anil 
committee meetings of out-of-pocket e.xpenses in addition to 
railway fares. Tliis was the subject of a resolution at the last 
Annual Representative Meeting, which instructed the Council to 
consider the proposal. Mr. Harman said that to pay a sub- 
sistence allowance in these cases would involve an e.vpenditnre 
of £1,000 a .vear. The Finance Committee look exception on 
financial grounds to sucli a proposal. Dr. AYallace Henry 
thought that tliere might be reasons other than financial for 
whicli the Council could not approve the proposal. Dr, Buchan 
asked, in view of the excellent financial condition of the 
Association, what were the financial grounds on which the 
coimnltleo had turned it down. Sir Robert Bolam tliought it 

[1239]° 



126 APElIi 21, 1928] 


ProcoBflings of Council. 


I BXTPPLF.UBST TO !■» 
LBniTisn UKiiicii. jouBXAA 


best that it slioultl simply be stated that the Council, having 
referred the matter to the appropriate committees ^the Organiza- 
tion Committee had also considered the matter, hut submitted 
no recommendation), deemed it inadvisable that this expense 
sbould be undertaken. The Chairman pointed out that 
“ financial considerations ” involved something more than 
financial abititj- or otherwise to draw a cheque for the amount. 
The subject then dropped. 

The Association ProfessioncUe Internationale tits hledccins. 

The question whether the British Medical Association sbould 
join the Association ProfessioncUe Internationale des Medecins 
came forward again on a report by the Finance Committee, 
embodying • a note by the Medical Secretary concerning the 
financial commitments ' of such a proposal. The expenditure 
involved would be £250 a year, and it was reported that tlio 
voting in the Finance Committee on a motion “ taking exception 
to this e.xpenditUre ” was equal, whereupoir the chairman of 
the committee gave his casting vote as taking exception. 

Dr. Lyndon now moved a resolution affirming .the opinion 
that the estimated expense of joining tliis international body 
was in no way exce.ssive, and furtlier, that oidy by so joining 
could the British Medical Association make its influence felt 
with the International Labour Office, the League of Nation.s, 
and other organizations concerned with social insurance aln-oad, 
and afford much-needed lielp to the medical profession in other 
countries to obtain ju<t and equitable conditions in relation to 
insurance law. He felt that ti.e po.sition taken up by 'some 
members of the Finance Committee was rather parochial. 
A great body like the British Medical Association was big 
enough to help members of the profession on' the Continent 
wlio were in a less fortunate position than their British 
colleagues. Tlie profession in some countries of Europe was 
most anxious to have such help iu fighting for those rights 
which iiad, happil3’, been secured hero. Moreover, it was only" 
in this way that the Association could get into official contact 
with the League of Nations, which was increasing in importance 
every year, and the International Labour Office, a veiy 
ijiiportant factor where social legislation was pending. 

Dr. C. E. Douglas seconded tlie motion. He said that this 
uas not a matter to bo decided on financial considerations 
almie. It should be looked at from a larger point of view. 
By joining this body the Association would be able to carry in 
a sort of missionary fashion its great ideal beyond the bounds 
of its own nation. There had been an attempt on the part of 
tlie Gennan representatives in this movement to get the British 
Medical Association to “ come over and help us.” Iiitcr- 
iiatioiially that was a gesture of great importance, the rooro so 
because, if the British Medical Association stayed outside, the 
German element would be predominant in Europe in medical 
matters. In the matter of State sickness insurance the Associa- 
tion could make a contribution of great importance from the 
e.xperieiice of this country. He also mentioned that the 
approved society movement was now taking an inteniatioiial 
orbit, and he thought it would he rather a sorry position if the 
British Medical Association were left ontside. 

Dr. Bone moved : 

That the Council is not willing in present coiiilitions to 
become a constituent member of the A.B.l.M. ; but wishes to 
put on record its willingness at all times to furnish other 
medical associations, whether national or inlenialional, with 
any information which may he at its disposal by reason of its 
experience of social legislation in relation to medicine. 

He said that this international organization was not connected 
at all with the League of Nations. Its object was the collection 
of information by the issue of questionaries to the constituent 
bodies. The annual meeting was held only to decide what 
questionaries sliould be issued. 

Dr. Dain, in seconding this amendment, disclaimed any 
parochial spirit, but asked what practical use this organization 
was likely to be. He thought the British jtledical -Association 
could best help other countries, while remaining apart, by 
improving and maintaining its own standards as an example 
of what might be done and an encouragement to others. 

The Medical Secretary gave some details of the organization, 
and said that the annual conference in Paris, which he had 
altcnded, was concerned with much more than the discussion 
of (piestionaries to he sent out. By far the gieatcv part of Uie 
time was spent over answers to questionaries and in general 


discussion. As to the connexion with the League of Nations, 
at the hist meeting in Paris a representative of the Institute 
of Intellectual Co-operntion, which was a League organization, 
alfcnded, and it was probable that representatives fron, the 
international medical body would be invited to Geneva next 
June to give certain information. 

Afv. Bishop Harman reminded the Council of the origin of 
the international association. It was said that the Asso- 
ciation if it joined could withdraw at any time, but, of course, 
ill common 'decency it'could not do so. This international body 
in its present infant state would cost the Association £250 a 
year, which represented a capital sum of £5,000, and if it grew 
to lusty youth it would cost very much more, perhaps £1,000 
a year. Such. movements bad a tendency to grow piion them- 
selves. 

Dr. Ilawtliornc said that Dr. Bone rejected this proposition 
because the international body was so small, and Jlr. Harman 
because it was likely to be so expansive and expensive. No one 
would deny that it w.is in harmony with the tendency of the 
limes and tho spirit of the age to organize intenialiOnal 
co-operation for purposes of -mutual benefit. It might be said 
that under this arrangement the Association would give more 
than it received, but in so doing it would earn the promised 
blessedness. In addition, it was now certain that this organiza- 
tion would have a voice in the League of Nations. Tho 
speaker was much influenced iu this matter by Dr. Cox’s 
judgement. 

•The Chairman pointed out, iu reply to observations by Dr. 
Barcroft Anderson, that tlie decision of the Dominion organiza- 
tions was to postpone consideration pending the decision of tho 
British Medical Association. 

Mr. B. B. Turner spoke against the proposal, though not 
on financial grounds. He was afraid, after long experience of 
international orgaiiizalioiis, that there was a fundamental differ- 
ence as to ideas of procedure between Continental nations and 
oni'selves. He thought the AsMciation should watch this 
movement, but not join it, at all events at present. 

Dr. Bone’s amendment was carried by ,30 votes io 11, so that 
the proposal to join the international body was negatived. 

Piorision of Spa Treatment for Insured Persons. 

■ ’i'bis matter arose on the report of the Insurance Acts Com- 
miltcc, which incorporated a scheme of the British Spa Federa- 
tion for spa treatment of insured persons which had been before 
the Spa Practitioners Group Committee. Dr. F. G. Tbomson 
of Bath was present at the meeting of the Council during tins 
discussion in his capacity as chairman of tlie Group Committee. 
The Group Committee asked that the proposed scheme miglit 
be recommended to the Kepresentatlve Body for appvovab 
subject to the incorporation of certain conditions which were 
set out. Tlie full details of the scheme will be embodied m 
the -Annual Report of Council to be published next week. 

Dr. Dain, chairman of the Insurance Acts Committee, said 
that this was the first occasion on which the chairman of a 
standing committee had presented the report of a group. His 
committee liad not itself expressed any opinion on some of 
the inatters in the report. . 

The Chairman of Coniicil drew attention to reference in the 
broposed scheme to " clinics " That provision should ho 
made under the scheme for each locality keeping medical 
records at the clinic,", etc.— and asked what was meant liy 
this. Dr. ' Thomson said that the idea was that some place 
must he -provided at the spa for the treatment of these people, 
who were of the out-patient class. It was felt that some 
special consulting room should be provided. 

The Chairman said tliat tho Representative Body had been 
very emphatic that in any extension of insurance benefits ah 
endeavour should he made to maintain the private practiifoncr 
character of any specialized treatment. He thought it would 
be better to emphasize the ordinary methods of consultation, 
either at the house of the specialist, the general practitionei-, 
or- the patient, rather than any special clinic. That was the 
general system the -Association had laid down, and he %yantca 
to know how far the Spa Practitioners Group had taken it into 

consideration. i i II 

Dr. Thomson said that it Iiad not been considered -A a b 
because it was felt that the great organization connected ni 
this work of spa treatment provision could only I>e done a 



Arnib 21, in2s] 


ProcccdinQs of^ Council. 


r slTPPLr.^rE!7T to thb 

LrRITXBII MRDICAI. JOUBHAD 


/27 


some central coimiiUinp room, othorwiso Rpparato records would 
Imre to bo kept by every iirnctitioncr. ll bad been suggested 
that the clinics might be. run ns a sort of out-patients' depart- 
ment to the mineral water imspitals, but tlic hospitals did noi 
see their way to undertaho the responsibility, and bo it was 
suggested tlint a clinic should be instituted by the governing 
committee composed of the physicians and the spa nuthorities. 

Sir Kohert Bolam said that this point was of importance 
because it seemed rather to prejudice tlio kind of consulting 
and specialist service that would bo set up under tbo national 
health insurance scheme when the authorities saw fit to put 
such a scheme into operation. This would inevitably be used 
ns an illustration of the way to conduct a particular Bpecialist 
service, and the clinic idea would bo given a general applica- 
tion. He. thought there should be a clause put into tlio scheme 
rendering it possible for tbo advice of the spa physician to bo 
obtained apart from tbo clinic. Ho did not see any provision 
in the scliemc at present for the bedridden patient. 

Dr. Dain pointed out that in tbo extension of insuranco 
benefits which were of a Irealmont character — dental, for 
example — it Imd been agreed (hat clinics were a suitable 
method of administering the benefit; there was nothing 
new in the clinic idea. Sir Hobert Bolam said that he 
was not objecting to clinics, which in certain cases wero an 
economical method, hut lie was concerned that any group 
should say tliey were the only method. There were spas whero 
it might be belter to deal with these patients privately. 

Sir Ewen Maclean said that in the evidence given by the 
Association to (he Itoyal Commission on National Health 
Insuranco the clinic was suggested as a niotliod when other 
methods failed. 


Eventually it was agreed, on the motion of Dr. Wallace 
Henry, Dr. Thomson concurring, that a paragraph should be 
inserted declaring that rheumatic cases whicli wore considered 
suitable under this scheme sliould be treated either at private 
consulting rooms in the locality or at clinics established for 
ic purpose, and tliat wherever the clinic was mentioned in 
1 C s lemo the phrase should bo “ consulting room or clinic.*' 
r. Dain thou moved the following definition of spa treatment 
for submission to the Representative Body : 


defined as treatment at a place 
thpr'inftilr? ^ of natural mineral waters of known 

value with facilities for their application. This 
IrainflfT i existence of suitable buildings, apparatus, and 
thcrapeuUc depallmcnll^^^^ balh-l.ouscs and other pl.ysio- 


uliri !i ®t)me sncli definition was necessary inasmucli as 
treaf Pfoposed scliemo of the Spa Federation contemplated 
nnrt ^ clinic recently cstalrlislied in London 

ei le aegis of the British Red Cross Society evidently had 
ctmnexion with treatment at spas. On the suggestion of 

" 1 . word “reputed” was substituted for 

hnoToi m the definition. 


Afsociation Prizes. 

broimht^ “'■fon Mackenzie, for the Organization Committee 
schnoU f “ scheme for the regrouping of the medica 

vear f Pttfpose of the prize essay competition hy final 

25 in "timber of students competing — onh 

in Ilia n rather disappointing, and this was due 

It was ® opinion, to the inadequacy of the prize (£10) 

nrizps t '.poc proposed to divide the prize money into si: 
siv srr^ ®ach in place of fifteen prizes of £10 each. Thi 
nrovi^ j avere tavo for London, one for tin 

one one for Scotland, one for Ireland, ant 

faetnra^^ "'■^'■sea schools. The grouping aa-as not entirely satis 
60n as regards Scotland, avhere approximateh 

30(1 anu annually, as compared avith hetaveei 

avas av ■ other home groups, hut the sdiemi 

"as expenmental for one year only. 

iirnirm- Harman thought the proposed scheme avas ai 
prize ^1'® existing one, but he still believed th. 

mm ,. 1 '^^ wrong m its incidence. It aa-as an inducement ti 
and hr *°. he stria-ing for qualification to turn asid. 

of ^ 11 bile on some special subject in the hop' 

in 5 trnrt”('i° ''^^appmtion prize. He moved as a rider t. 

o( alfer* . ^SaPmation Committee to con.sider the ada-antag 
mg le status of candidates eligible for this prize t 


posf-graduntes instead of undergraduates. Dr, Douglas seconded 
this rider, which avas agreed to, 

The Oonsiiintion of the Association. 

Dr. jMorton Mackenzie, in bringing forward a recommendation 
regarding the grouping of Homo Branches for representation in 
(he Representative Body, involving the creation of three neav 
Independent constituencies, said tliat his committee recognized 
that the avliolo question of the size of the- Representative Body 
\a-as getting ripe for discussion. In recent years the member- 
ship of the Association had increased by 40 or 50 per cent. It 
avas proposed to ask the Organization Committee next year to 
explore (he situation. 

Ho next proceeded to move a series of recommendations for 
the adjustment of ttie articles and by-laavs. The only really 
new matter comprehended was a provision for the possible 
formation of groups aaitliin the Association, but advantage aa-as 
iiihcn of the opportunity to substitute in about forty places 
the term “ Great Britain and Ireland ” for the noav obsolete 
term “ United Kingdom.” The only discussion arose with 
regard to Article 9, relating to termination of membership, 
avhero it avas proposed to e.xtend the present wording to read 
“ upon erasure on the ground of professional misconduct from 
any McAical llcgistcr for the time being established for the 
Irish Free State or for India or any British Dominion, Colony, 
or Dependency, or any Province or State forming part thereof 
respectively, or for any British Protectorate or Mandated 
Territorj-.” As at present it read “ any British Colony or 
Dependency." 

The Chairman mentioned a case which came before the 
General Medical Council in 1925 (Supplement, December 12th, 
1925, p. 204), in which a practitioner at Lagos had been removed 
from the Nigerian Register, but appealed to ■ the General 
hicdical Council, who decided that there had been a miscarriage 
of justice, and refused to erase his name. The Chairman 
thought that if Article 9 was altered at all the matter ought 
to be considered in its widest aspects. It w-as a matter for 
the Association Council to determine whether, if a member was 
not erased on the instruction of the General hledical Council, 
hut Mas removed only from some local Register, his membership 
of the Association was affected. 

It Avas agreed to refer the whole question of this article to 
the Ethical Committee. 

On a by-law- dealing with the reduced subscription of members 
engaged whole-time in medical instruction. Dr. Hawthorne 
sought to have (he word “ private ” inserted before “ medical 
practice ” in the following proposed clause : 

“ Any member who is not _ engaged in medical practice, 
whether as consultant or otherwise, and is a whole-time member 
of the teaching slnfi of a university or medical school, and has 
signed and transmitted to the Treasurer a declaration to -the 
foregoing effect in relation to the year for which the subscrip- 
tion is due ... 2 guineas.” 

Dr. Haw-lliorne said that he was thinking of the young 
medical man who received a fixed salary, his duty being to 
take part in teaching and research work, but who vi-ould be 
excluded from the benefit of this scheme as it stood because 
he attended in the out-patient department, for which, of course, 
he received no pay. 

Mr. Bishop Harman opposed the amendment, and indicated 
certain classes of practitioners who might, if the door w-ero 
opened in this w-ay, come in at a reduced subscription when 
such w-as not the intention of the scheme. 

The amendment to insert the w-ord “ private ” before 
“ medical practice ” w-as lost, 9 voting in favour and 11 
against. 

In concluding the report of the Organization Committee, Dr. 
Mackenzie mentioned that more new' members for the Associa- 
tion w-cre being obtained in proportion to registrations this year 
than last. 

The Chairman’s Visit to South Africa. 

Dr. Brackenhury said a few- words at this point about his 
recent visit to South Africa. He was only tw-entv-si.x <l,ays 
actually in the country, but w-hen everybody conspired to make 
one see as much as possible quite a large amount of ground 
could he covered in that space of time. He was able at one or 
otlier of the places x-isited to get in toucli with all classes of 
practitioners— Government officials, medical officers of health, 


128 APBin 21, 1928] 


Proceedings of Council. 


[ BTJPPL'ElIEliT TO TH* 
BniXISK M£DIC1L JOUB:flli 


specialists, men engaged in research work, and general practi- 
tioners, including among the last several in tile most i-ural 
districts. In each of the four large towns visited a si>ecial 
meeting of practitioners was called, which he addre.ssed. 
Fortunately for him, the subject in which they were 
interested was national health insurance. [An article on this 
appears in the body of the Journal at page 673, and a report 
of tile Congress at page 684.] National health in.surance and 
hospital policy were the two big things they were concerned 
about ; with regard to tlie latter they were passing through 
at present the stage reached by the Association at home 
some three or four years ago. In addition, he saw quite 
a number of influential members of Parliament, and one 
or two important civil servants, and gave evidence before 
a Parliamentary Commission appointed to consider schemes 
of pensions and sickness and unemployment insurance. The 
Congress in Bloemfontein was not numerously attended as 
compared with our own meetings, but was very successful. 
There were only thirty-five practitioners all told in the 
capital of the Orange Free State and its neighbourhood, 
and the numbers attending the Congress were perhaps 
200. The Congress was to some extent upon the lines of an 
Annual Meeting of the Association at home, witli a number 
of quite interesting — some of them very valuable— papers. 
The accompanying entertainments were excellently organized. 
Dr. Brackenhury thought the object for which the Council had 
asked him to go out had in fact been accomplished. Tlie unity 
of the profession in South Africa, already achieved, had been 
placed, as a result of this Congress, on firm foundations, and 
to this end the action of the Association at home in sending 
representatives had contributed. (Applause.) 

Lunacy and Mental Disorder. 

pr. Langdon-Down, Chairman of the Lunacy and Mental 
Disorder Committee, brought forward a memorandum on the 
report of the Royal Commission. [This will appear as an 
appendix to the Annual Report of Council in the next Supple- 
mint.] He said that tlie memoi'andum was long, not because 
it covered many topics, but because it dealt very fully with 
the topics that it did cover. This was done 'in order that 
members of Council and members in the Divisions and the 
Representatives might thoroughly understand the i.ssue. Tlie 
Council had already had recommendations from the committee 
with regard to one important question— namely, the protection of 
tile certifj-ing doctor. The reason for dealing with the report 
of the Commission piecemeal was that they were given to under- 
stand that the Government had in view the introduction of 
a short measure to pva effect to two parts of the Royal Com- 
mission’s report which were believed tO be non-controve’rsial 

namely, the extension of the provisions for voluntarj' boarders 
in mental hospitals so as to enable a public institution to deal 
with them, and the question of protecting the medical man ; 
but, in fact, he had seen no reference in the programme of the 
Government to any such measure this session. His committee 
rcg.arded the report of the Royal Commission with mixed 
feelings. It was very appreciative of the report, but was 
strongly opposed to certain parts of it because they failed to 
achieve the great objects in view. The committee did not and 
C(.alcl not agree ■\vitli the proposals for bringing patients under 
treatment by what was called the Provisional Treatment Order. 
In so far as the Commission extended the facilities for volun- 
tary boarders it carried out the plan, which the Association’s 
committee supported, of treatment without certification; but 
what the committee had greatly hoped and desired was’ that 
these facilities for treatment without certification should he 
greatly increased. In fact, the proposals with regard to the 
Provisional Treatment Order were in no degree less rigid or 
formal th.an in the case of the ordinary full certification order 
of a justice. IVhy was it that the machineiy for cariyin-^ out 
the principle of treatment without certification had not been 
provided? The committee believed that the Commission had 
taken a wrong basis for classification of cases. The Commission 
persisted in classifying patients into two main groups — ^r'olnn- 
tary and involuntary, and took as the basis for the classification 
of tile latter the probable duration of the illness — a most 
vague and impracticable criterion. What the committee said 
was that the basis of classification whicli should deteivnine the 
intervention of leg.al machinery was, in the nature of things, 
the mental attitude of tlic patient towards treatment; hut in 
regard to"those people who were incapable of expres.sing an 


opinion, there was no need to bring in the justice. 
The committee was of opinion that for all patients brought 
under treatment there should bo a preliminary month of trial, 
the authorization for treatment being supported by two medical 
recommendations. In that way tlie hesitation of people to 
place themselves under treatment would be overcome, and it 
might be hoped that patients in the early acute or early mild 
stage would be ready, all proper safeguards having been taken, 
to come under treatment. In addition, such an arrangemeut 
would provide some intermediate ground between full freedom 
of treatment of ordinary mental ailments and formal certifica- 
tion by a justice. He was glad to s.ay that the memorandum 
had carried with it substantial agreement in his committee; 
there was substantial agreement also with the Royal Medico- 
Psychological Association ; and he claimed for the report and 
its recommendations that they carried out to a practical issue 
the general principles which the Royal Commission had laid 
down more nearly than did the recommendations of the 
Commission itself. He believed that in this memorandum there 
was cinhodicd a policy which was worth putting before the 
country as promising a real reform in the treatment of mental 
cases in the future. 

Dr. Hawthorne agreed that the report of the committee now 
brought forward rested upon well-defined principles. The 
thesis which it announced w.as, he took it, that in the issue 
as between sane and insane in the individual person reliance 
had to be placed upon the judgement and opinion of the 
medical profession, and that the intervention of a legal official 
was unnecessary, and might in certain cases be harmful. To 
put tlie doctrine in other words — for a decision whether as a 
method of treatment the patient’s liberty ought or ought not 
to be restricted the medical profession must be trusted, not 
the judgement of the lawyer. He would go further than that : 
ho recognized that this doctrine was consistently and thoroughly 
applied in the report, which thus became a document capable 
of legal defence. Once again, tlie report did recognize that 
there were limited circumstances in which for practical reasoiis 
the thesis for which it stood could not be applied, and it 
defined those exceptions by means of argument. Therefore, if 
this report were the only voice with which the committee' had 
spoken to the Council, he would have been ready to maintain 
that no one was in a position to contradict its argument, unless, 
indeed, ho was prepared to challenge the whole principle on 
which it was based. The report, however, was not the first 
report whicli had come to the Council from the committee. To 
go back to tlie beginning, what was the basis of tlie com- 
miltee’s cvidonco given on behalf of the Association to the 
Royal Commission? It was that no patient should have Ins 
liberty taken away except upon the approval and warrant of 
a legal representafive. It' was agreed that this might not 
hold°good in occasional circumstances of emerge.ney and for a 
temporary period, but that was the broad position for which tlie 
Association stood. In its evidence the Association endeavoured 
to make this principle still more effective by proposing certain 
changes in the laiv. It was argued that the magistrate slioiild 
be compelled in every case to examine the patient, and th.-it 
the emergency certificate should be shortened from seven days 
under the present law to three days, once ag.ain indicating 
that in the Association’s judgement it was law and not medicine 
which was responsible for restricting the patient’s liberty. It 
was upon this claim for prompt and universal legal intervention 
that the committee had proceeded to argue that the position 
of the doctor in tliese proceedings was tliat of a witness, and 
that the instrument rvhich restricted the patient’s liberty was 
the magistrate’s ordei-, not the opinion ' of the doctor, wlio, 
bein'' a witness, should enjoy the immunities of a witness. All 
these doctrines had now been thrown overboard, and,' swinging 
to the opposite e.xtreme, the committee now proceeded to say 
that, except in those cases where the patient deliberately 
or by resistance or violence opposed the doctor’s intervention, 
the great majority of patients should be admitted to an asylum 
-^and might be kept there by means of renewed certificates for 
two vears or longer — upon the recorded wish of the .■datives 
supported by certificates from two medical practitioners, and 
without any legal knowledge or intervention in the whole pro- 
ceeding. The present report preached the full-blooded medical 
doctrine that insanity was a form of illness which, like other 
forms of illness, required medical opinion. That wa.s not an 
unattractive doctrine — far from it; but in adopting this lepor 
the Association did give itself an awkward corner to tiiin 


Antlt. 21, 1928] 


f f^vrrT.Kx^r.:,’T to nsz ^ r» a 

Utr.nirH >!l mcAL JOCKNIL 1 mf' 


Proceedings of CounctL 


lound. ll must j^o forward wiUt a lillU- lo*.'- n»nndcn( (oiio. 
The chainnan of the committro (Ih*. Lanj'dond^own) had 
criticized the Koval Coinmi'^sion for the tono^ and conditions of 
the Provisional Treatment Order; lie had ohjectod to the 
presence of the magistrate, to tin* ^ignatme of one dodor, nnd 
to the temporary duration of the certiric.ito or (uder. It was 
an excellent piece of dc.stnntivc criticism of ^^hat tlio Uoyat 
Commission had proposed, hut what the Koynl Coniniixsion had 
proposed was exactly what t!ie Ai'iceiation had suggested to 
it that it should projiosr iii tAe evidence given at the outset. 

It would hoconic tlio As.sociution to adopt a somewhat c(»iilrite 
tone, even if not (ho full penitential dress. At (lie Inst I’epre- 
sontalivo Meeting the proposal which was made f(»r the pro* ' 
toctiou of the certifying practitioner inchided three possi- ' 
hilities ; n change of onus in eases where an application for 
a slay of action was being lionrd; a medical assessor sitting 
with the judge who heard such application ; and the counter- 
signing of the original cerlificatc by the magistrate at the 
outset as a proof Uiat the doctor Avas acting in gfvul faith. 
But a smaller inc.asure of protection would now be proposed 
to the PiCpresentativo Body than on the last occasion. He (Dr. 
Hawthorne) was concerned only to point out in advance the 
diflicuUic.s wliich must arise Avhen this report w'as presented. 
He was. liowcvcr, going to vole in favour of the report because 
it did meet to some extent the views he had pressed upon the 
Council and the Beprescnlativc Body. He wa.s jirejiared to hold 
that there were certain avenues for discussion and modification 
and change in this report. Ho did not think it ahsulutclv shut 
the door upon the possibility of gaining full protection lor the 
pvaclitioner.^ He himself wonld have liked to bring in the 
magistrate in these transactions in an administrative, not a 
judicial, capacilj*. 

pr. Langdon-Dovrn agreed that the altitude on this question 
taken up by the committee had changed, though not to the 
extent Dr. Hawthorne had suggested. When those c-oncerned 
nist took up this question they had to educate themselves and 
one another in many aspects of lunacy law and procedure. He 
did not think they Avero bound for all time bv Avhal tliev bad 
rccommeiidod Avhen the Royal Commission Avas silting. Had not 
^f.. ^o^^ission itself swept away many donhih and diffi- 
n circumstances Avove cmirclv different in the light 
ct tiiG Royal Commission’s report and in view of the dis- 
cussions at the Animal Sleeting at Edinhnrgh and el.seAvlicrc. 
Approval was given to the report unanimously. 

Puerperat Morhiilitt/ and .VorUditj/. 
frn *** ^liiclean, chairman of tiie Committee on the Causa- 
n o uerperal Morbidity and Mortality, brought forward 
subject Avhich Avill be printed as au appendix 
le .* nnual Report of Council in next A' cek's 
e suggested a revised Avording for the last paragiapli in the 
f^port, before the recommendations, as follows ; 

that there should be a medical investigation 
invAtj;!! deaths has found some support. Such medical 

should be carefullv controlled bv th^ 
of letter of the Council to the Ministry 

ron/iiir.i fhc cfTcct that the invcsUgalion should be 

ilm r., ^ wnipetciit and experienced medical ofTiccr, and for 

of scientific inquiry and the advancement 

p- said tliat there must he no censorious form of inquest AvitU 
o^equent possible imputation of blame to indiA'iduals. 

r. Manknell thought that, in a'icav of the popular prejudice 
I 1 regard \o poxt-mortc7n examinations, the fact of such an 
- anuriation might be regarded as a prima facie case against 
the doctor in attendance. 

Chairman pointed out that vhal Avas intended A\as a 
i re V medical and scientific examination, not a compulsory 
r-o^(-mor/,m examination. 

thought that the doctor might not be in a 
position to object to a necropsy if such Avere suggested. 

Ew paragraph be altered in the Avay Sir 

tinier ” ^^^lean had suggested, and certain of the recommenda- 

report Avere agreed to.Avithout 
iricntil doAVn the objecth'es of further experi- 

U'edkM * need for incre;ised facilities for training 

cases '* further provision of beds for maternity 

Practif!^ institutions, for the keeping of regular records by tlie 
condii; inidAviferj^ cases, and the desirability that a 

‘nn oi the paymient of maternity henefit should be that 


the mother had had at least one anlc-nalal examination by 
a medical practitioner. On a furtlicr feconimoiidation that 
a standing coinmitlee of tiic A.ssociation should be set up 
to Avatch the course of cA’eiits, Sir Kwen Maclean said he 
thouglit it necessary that some body sliould be charged Avith 
seeing that the A.ssociation and its great machinery Avero used 
in the right direction. The proposed committee should include 
tile Officers of the Association, repre.sentativcs of the bodies 
Avhieli took part in the ronference at tlio House of the Associa- 
tion in tiamiary la.st, nnd general practitioners. 

Dr. Dain said that this Avas an extremely interesting and 
hope-raising rejiort, ljut it Avas also disappointing because it 
did not offer under the nuthorily and with the appro\ml of the 
British Medical Association those ndA’antages Avhich were noAV 
Itctng enjoyed by the patients of tlic external departments of 
the midwifery schools Avho Avere confined in their OAvn homes. 
It w.is not necessary lo await the results of research or the 
practicability of the extensive provision of beds. It had been 
.shown that by adopting certain simple measures tlie mortality 
rate could he reduced considcrablj-. The CoimcH would 
stultify itself by letting such a report as this go forward 
without some effective recommendations. Bj' organized mid- 
wifery, involving co-operation between qualified midwives, 
doctors, and local authorities, it was possible to reduce 
markedly the mortality rate ; and xvhy should the Association 
wait until this fact was grasped by the Ministry of Health? 
lie had had the oj)porlunify of talking over the matter with the 
professor of midwifery at Birmingham University (Professor 
Beckwith Whilchouse), who was satisfied that if provision were 
made for one ante natal medical examination, and for tlie folfil- 
nicnl of certain other simple conditions, including the pro- 
vision of sterilized towels and gloves, the question was within 
measurable distance of being settled. In this system, following 
the ante-natal examination, the doctor wonld place every 
patient in one of tliree categories : (1) the healthy and normal, 
including the great number of multiparae and a certain number 
of primiparae : (2) those with certain complications who were 
not to he safely confined withont a doctor present ; (3) those 
of whom it could he said at once that they were enses for 
institutional treatment. Tlie women in the first (sj these 
classes were handed over to tlie midwife, iiith the instruction, 
of course, that she would call in the doctor if any unforeseen 
event occurred : the women in the second class were seen by the 
doctor again, and as often ns necessary; and for the wnmen in 
the third class arrangements were made for their admission to 
institutions. This meant that doctoi-s would get into touch 
with a uuiiibcr of cases which were on the borderline, and 
would know beforehand whetlicr there were definite risks or 
not. Willi regard to cost, in many areas the patient was 
invited -to pay 5s., and it did not seem as though ft would 
require any very large increase on that sum to provide for the 
necessary ante natal treatment. It was mainly a question of 
the organization of a sound working scheme. If sncli a scheme 
were forthcoming he thought that objection by the patient to 
ante-natal examination woidd be veiw slight. He hoped that 
before this rejiort went forward to the Representative Body 
it would carry with it some such recommendations as tliese. 

Sir Ewen Maclean said that what Dr. Dain had pat forward 
was practically gathered up in the report itself, but on the 
question of making detailed recommendations as to the method 
of conducting a confinement there had been serious considera- 
tion by the committee, which had decided not to make' such 
recommendations. 

Dr. Dain desired that a committee of the Association might 
be set np to formulate a scheme which wonld make available 
for all parturient women the advaiitage.s now obtained in the 
external departments of the midwifery schools, and he hoped 
tliat the publication of this report would be delayed mitil such 
scheme had been submitted to the Council. 

Dr. Bone pointed out that there were diEereut schemes in 
diHerent midwifery schools, and asked also what Dr. Dain 
pioposed for the cases remote from the area which any such 
organization could cover. 

Dr. Dahl said he quite appreciated that there were areas 
out of reach of .such organized efiovt, hut in those areas the 
number of coiifiiieineuts also was small. The fii-st thing was 
to provide for the needs of the big urban populations. He 
added that if he had reserved until the Representative Meeting 
_ the speech he had just made, he might have been regarded as 



130 April 21, 1928] 


Proceedings of Council. 


r BOFPLEimST TO THl ^ 
LDr.lTlsn MEDICAL JoCBXAfi 


throwing some discredit on the committee. He hoped that 
some such suggestions as he had made might be incorporated 
in the report before it was given to the profession and the 
public. Above all things, this question could not be left in 
the air. The report should be taken back and brought up again 
at the June meeting of Council, when it might be made to 
embody some such scheme as he had outlined. 

In reply to Mr. Bishop Harman, who asked whetlier the 
adoption of such a scheme would mean the promulgation of an 
orthodox ritual of childbirth treatment, Hr. Dain said that he 
was not himself an expert in this matter. What he had said 
had been gathered mainly from conversations with the professor 
of midwifery at Birmingham University. His whole idea was 
tliat something practical should be offered to the profession and 
tlie public. The crux of the whole matter was organized mid- 
wifery and effective ante-natal examination. 

Hr. Bone said that Professor Beckwith Whitehouse was not 
the only man in this country wlio had a scheme. He thought 
it would be a difficult problem to formulate a scheme wliicli 
would command general approval and be applicable everywhere. 

Hr. Christine Murrell agreed with Hr. Bone. There were 
other schemes than that put forward by Professor Beckwith 
Whitehouse, and other points of view, and it would be unwise 
at the present moment to lay down the matter as definitely as 
Hr. Dain proposed. 

Sir Jenner Verrall said that in his view the committee had 
not left this matter in the air. Its recommendations were, 
briefly, that there should be research, that there should bo 
vigilance in view of the possibility of new discoveries and 
opportunities, and that the subject presented so many varied 
conditions that the opinion of the profession at large should be 
elicited, and experience and results from different parts of the 
country compared. He thought this was not the stage at wliich 
the views of the Council should be crystallized with regard to 
a detailed scheme. 

Sir Robert Bolam said that one of the great points in Dr. 
Dain’s argument was that there should be initiated amongst all 
women a system of ante-natal examination and classification. 
Would it not be advisable to introduce into the recommenda- 
tions something which would suggest a campaign to educate the 
public in the need for ante-natal examination ? 

Dr. Dain’s amendment for the referring back of the report 
to the committee, with a view to incorporating in it and pre- 
senting to the next meeting of Council a scheme which would 
make available for as many parturient women as possible the 
advantages now obtained in the external departments of the 
midwifery schools, was not carried. In place of the recom- 
mendation that a standing committee of the Association be 
set up to watch the course of events and to keep in touch with 
research work, and of a further recommendation that the 
Divisions and Branches should arrange a series of meetings 
to be addressed by consultants and specialists, it was agreed 
to send the report first to the Representative Body, and that, 
if approved, a further resolution should be put to the Repre- 
sentative Body tliat a committee be set up to formulate 
measures designed to bring about a reduction of maternal 
morbidity and mortality, to keep in touch with research, and 
to assist Divisions and Branches in arr.anging for education 
and propaganda as to the value of ante-natal services, metliods 
of dealing witli confinements, and the care of the mother and 
infant. 

It was also agreed that the allocation of additional grants 
of money by the Association to promote research in this subject 
should be considered, and the report was approved for recom- 
mendation to the Representative Body. 

Dr. Bone brought forward, on the Medico-Political Com- 
mittee's report, the question of the forthcoming issue by the 
Minister of Health of a circular to local authorities in con- 
nexion with the investigation into maternal deaths. It was 
understood that the Minister proposed to insert a clause to the 
following effect : The British Medical Association has already 
been consulted and has expressed general approval of the objects 
of the proposed investigation, understanding that it is intended 
to use the results exclusively for scientific and public health 
purposes.” This was almost precisely the wording of the letter 
sent to the Ministry from the Council in April, 1926. 

The Chairman said that the Council could not object to — 
indeed, could only welcome — the insertion of such a statement. 


Contract "Rate for Juvenile Oddfellows. i 

Dr. Bone again brought forward, on behalf of the Medico* 1 
Political Committee, a recommendation for approval by the ; 

Representative Body of a standard rate of 8s. 8d. per head ' 

per year, including drugs, for tho remuneration of medical * 
practitioners for medical attendance and medicine for juvenile ’ 
members of the Manchester Unity of the Independent Order of ’ 
Oddfellows. The recommendation added that the Council bo 
authorized to approve a slightly lower rate than 8s. 8d. per 
head per year, for a time to be definitely stated, for application 
in any area in which it is satisfied that, owing to economic 
conditions, the standard rate is not feasible ; and that it be an 
essential part of this arrangement that there must be free 
choice of doctor by patient and of patient by doctor. This 
recommendation had been before the Insurance Acts Committee, 
which had appi-ovcd it. 

Dr. Johnson, who entered a strong protest when this matter 
was previously before the Council, repeated his objectio'ns. 
Practitioners in Lancashire to whom ho had spoken were unani- 
mously against the proposal. They had accepted insurance 
practice because they felt that it included a class of case which 
hitherto perhaps had not had proper care and treatment; it 
was not altogether a financial arrangement. But this was purely 
a financial matter, and the element of sympathy did not come 
in. Tlicse people were of the bettcr-off artisan class, and 
a fee of 6s. 6d. (after deducting the proportion for medicine) 
was wholly inadequate. 

Dr. Walker thought it would be a fatal error to pass this 
recommendation. He was sur^irised to hear that two com- 
mittees of tho Association approved it. There was no demand 
whatever from tho medical profession. The request came from 
the Manchester Unity, which was naturally anxious to conclude 
a good bargain. If this were passed it would spread like 
wildfire to other societies. When the question of dependants 
under the Insurance Act came up, or when the Insurance 
capitation fee was to bo readjusted, how would the pro- 
fession stand after accepting a capitation fee of 6s. 6d. 
in this instance, for attendance on persons, including - 
young children, who required more attention than the 
average insurance patient? 

Dr. Douglas supported the protest, and considered the figure 
ridiculous in comparison with that paid by the Post Office 
(8s. 6d.), remembering that this latter was for attendance on 
a favoured population who had passed an entrance medical j 
examination. Dr. Manknell said that the Association had put 
the clock back for fifty years. Other societies would soon bo 
demanding the same privilege. Dr. Wallace Henry said that 
in the vast majority of lodges the proposed fee of 8s. 8d. 
would mean an increase — in many a considerable increase — on 
tho fee hitherto obtaining. It had always been made clear 
that the profession was seeing these dependants at a lower rate 
because they were not receiving State aid. The vast" majority 
of tho members of the profession who were doing this work 
would be advantaged by what was now proposed. Dr. Stevens 
joined in opposition to the proposal. It was an extension of 
contract practice against which the Association should set 
its face. 

Dr. Dain said that the Insurance Acts Committee decided 
in favour of this with only four dissentients. It had to be 
borne in mind that a great deal of minor ailment work among 
children was now covered by the school clinics. Among this 
class of persons there was not — as there was in insurance 
practice — an increasing number of disabled persons drawing 
certificates for years. There were no certification rules, and 
there was no disciplinary procedure. His committee had felt 
that it would not be difficult to combat any suggestion that 
this fee was in any respect a standard for tho fee to be paid 
in national health insurance. 

Dr. Bone said that this fee was in the interests of the doctors 
primarily affected. It had been argued that acceptance might 
prejudice negotiations with the Ministry of Health in respect 
to the insurance capitation fee, but he felt that he would have 
no difficulty in arguing that the fee compared favourably with 
the 93. fee, having regard to the fact that the Oddfellows fee 
was for a restricted service, there were no certificates, no 
questions of discipline, no records, and that these juveniles 
between the age of 6 and 16 did not' require an attendance 
equal to the average required by the population at all ages. 




■ Arrtir/21, 192fll 


Prhcoodfngs of Council 


r SUPPLF.MEiJT TO THU' < o ^ 

LBnmsu aiedicax. Jou&mxl /o7 


Among this clnsa of persons llio inciilcnco of sickness was less, 
not greater. Tlic recoinmendntion was approved. 

Jtailiation and Eleciricnl Treatment Inj Untrained and 
Ungntdified Persanf. 

The Science Conimittco hronght forward .a comnnmication 
from Dr. C. B. lleald urging llio need for consideration liy 
the medical profession of treatment by radiant energy and 
electricity. 

Dr. Hawtiiorne, who .aeted in the absence of Sir. Soult.ar, • 
chairman of the committee, said that the report on tliis subject 
boro both on tlio need for giving medical .students instruction 
in these methods and on the risks involved to the public wlien 
such methods were employed by untrained and unqualified 
persons. 

On the first of the committee’s recommendations, that .a 
communication bo addressed to tho General Medical Council 
pointing out tho need for giving medical students some such 
instruction. Sir Robert Bolam thought this an unnecessary 
recommendation, as tho General Medical Council had been 
insisting for two years on tho necessity of this particular thing 
in this particular way. Mr. McAdara Ecclcs said that in most 
of tho London schools lectures were given on these methods. 
Dr. Hawthorne, in view of what had been said, withdrew tho 
recommendation. 


77ie Co-ordination of Hospital Provision. 

Mr. McAdam Ecclcs, chairman of the Hospitals Committee, 
presented to tho Council a memorandum [to be printed in tho 
Annual Report of Council in tho next Supplement} setting 
forth .a schema for tho co-ordination of hospital provision. He 
said that tho schemo was for the co-operation of voluntary 
hospitals with municipal hospitals, and he desired that tho 
Council should acknowledge the great amount of work that Sir 
Richard Luco had put into this report. The Hospitals Com- 
mittee had set out certain definite resolutions which it hoped 
might bo for tho guidance of tho Government, but at that 
l.ito hour in tho Council’s proceedings ho would not do more 
than ask tho members to study the report for themselves. There 
was one small point — a matter of nomenclature — about which 
ho was not quite happy — namely, tho term “ central or base 
hospital " to describe tho institution around which other 
hospitals were grouped. The Council had in a previous dis- 
cussion expressed a preference for this term rather than “parent 
or primary,’’ but the word ’’ central ’’ was considered still not 
very suitable, while “ base ’’ had a suggestion of the great war. 

It was agreed by tho Council that the scheme he adopted and 
submitted to the Minister of Health, together with the resolu- 
tions of the Council at its previous meeting [Siip-plement , 
February 25th, p. 61) in connexion with any legislation that 
tho Minister miglit propose to introduce on the matter. 


-'Vnothcr recommendation, after some sliglit revision, was 
carried, asking tho Representative Body to express the opinion 
that in view of the risks to tho public involved in tho use of 
electricity and radiation as methods of treatment by untrained 
and unqualified persons it was desirable that suitable courses 
of training should bo organized under medical direction for 
persons who wished to administer this form of treatment, that 
persons who had satisfactorily followed such a course should bo 
entitled to have their names entered on an approved roll, that 
one of the conditions attached to admission to and maintenance 
on tho roll should bo alistcntion from tho treatment of any 
pa lent except on the responsibility and under tlio general super- 
vision of a registered medical practitioner, that tlio treatment 
n every case should bo under such supervision, and that 
pa lents requiring such treatinent should bo referred only to 
persons whoso names are on the approved roll. 


Pemuncration in Certain Academic Posts. 
witi!'^ Council ronsidered a report of tho recent conference 
'■opresentatives of medical scliools on tho question of the 
uneratiou of non-professorial medical teachers and laboratory 
Vt, [Supplement, February 18th, p. 45). Dr. 

the" Science Committee saw the forco of 

presented at tho conference that tho universities 
in salaries on tho lines suggested 

were ^ "^r^'ral Assb'ciation’s scale, and that there 

noi remuneration, which did 

was si ^ ° a™dar posts under public health authorities. It 
iiini'nr recognized that tho academic bodies were paying 
juniors more than formerly. 

t was proposed by the Science Committee : 

recommended to tho Eepresc-ntatiro Body that 
teTBl.o™*®! u eu'aries relative to non-professorial medical 
to research workers should not apply 

whero appointments in universities and medical schools 

whern n, appointments aro of a temporary character and 
with ti.y° duties attached to tho posts aro in direct connexion 
exDprlBBB “.“'’aucement of tho practitioner’s knowledge and 

proposes to 

Iioped for an assurance tliafc there would 
policv ,, of the word ’’ temporarily ’’ in the 

Gra^o IIT .Association relating to what were known as 

temno M ’) comprising those who are junior workers 

Doinf '^*"^* 1 ,^ emjDloyed on probation.” He also discussed other 
^ ’ fidwever. Dr. Hawthorne said, were not raised 

Dr B *^ 11 , What tho conference had to answer, said 

miici i^'^r simply ; What are the conditions whicli 

mpnt r before tlio Association will accept advertise- 

to an academic posts? The comraitteo had endeavoured 
Wonla%^*^ question, but ho hoped that Sir Robert Bolam 

whlai, ^ memorandum relating to the other matters 

o ad advanced. The recommendation was agreed te>. 


The Charities Trust Fund. 

Dr. J. F. Walker, for the Charities Committee, hronght 
forward a recommendation, among others, that the sum of £300 
bo forwarded to tho Council of Epsom CoUege with a request 
that £200 bo utilized for the purpose of contributing towards 
tho education of the son of a medical woman, understanding 
that this would secure the admission of tho son of a medical 
man as an e.xhibition scholar. The circumstances of the case 
have already been set out (Supplement, March 17th, p. 87). 
A medical woman, whose husband (a layman) had had to retire 
fiom business on account of ill health, was unable to obtain 
admission for her son as an exhibitioner at Epsom because the 
Act of Parliament governing the constitution of tlie college 
does not provide for the admission as an exhibitioner of the 
son of a medical woman by a lay husband. There was the 
greatest goodwill on the part of Epsom College, which. Dr. 
Walker had every reason to believe, would agree with the 
conditions on which this sum was voted, hut in awarding its 
ordinary exhibition scholarships it was bound by tho terms of 
the statute. ' 

Dr. Lyndon said that Epsom College could only alter the 
position by a new Act of Parliament, which would bo a very 
serious matter. There were complications which arose ont of 
this question — for example, whether the widower of a medical 
woman could put in a claim for a grant or pension. 

The recommendation was agreed to, and further amounts 
were allocated to other charities. Dr. Walker remarked that 
the relations between the British Medical Association and the 
governing bodies of tho various medical charities were now 
most friendly, and any feeling that the Association was 
encroaching on their preserves was passing away. 

Other Business. 

Reports were made by the Ethical, Naval and Military, and 
Office Staff Superannuation Committees which gave rise to no 
discussion. An important report of the conference with the 
Society of Medical Officers of Health, which involved the 
question of the modification of the scale of salaries, was post- 
poned until the next meeting of the Council, because the two 
members of Council elected by the public health service 
members were not then in their places. The chairman of tho 
Science Committee (Mr. Souttar) and Dr. Wallace Henry were 
appointed, at tho invitation of the Standing Committee (General 
Merchandise) of the Board of Trade, to confer with tliat body 
on the question as to whether imported surgical instruments 
and dental supplies ought to bear an indication of origin under 
the Merchandise Marks Act. 

It was left to the Chairman of Council and the Afedical 
Secretary to adjust tho draft Annual Report of Council in 
accordance with the decisions of the day’s meetin"-, and the 
Council rose at 7.30 p.m., after a sitting which, with two short 
intervals, had lasted from 10 a.m. 



132 April 21, 1928] 


Current .Notes* . 


r suppLrirrsT to tok 

LPhITISJC IIF.VICaL JOURKlt 


5Srftislj iRtiJird ^ssonation. 


CURUENT NOTES. 


Sir Dawson Williams. 


Thank-offering to B.M.A. Charities Fund. 

A inomljcr of tlio British I\Ioclical Association iviio dcsiics 
to he anonymous lias sent a chcqnc for £50 to tile Sir 
Charles Hastings Euiui, as a thank-offering for tiventy-fivo 
years of health, hapjiiiiess, and reasfinahle success in 
jiracliee. 


Sympathetic reference to tlie death of onr late Editor 
appears in the Journal of the American Medical Associa- 
tion for March 31st. After briefly recalling Sir Dawson 
,‘lVilliams’s long connexion with the editorial work of the 
British 2[cdical Journal, onr contemporary says: 

“ Sir Dawson had done much to develop the periodical 
to tlio high place that it Iield in medical journalism. In 
medicine he was recognized as omniseient, and his ability 
to develop the writings of others was the subject of 
universal comment. In a recent number of the British 
Medical Journal leading medical men from all over the 
world pay him the tribute that was his due for his con- 
tribution to the promotion of medical knowledge. To these 
tributes the Journal of the American hlcdical Association 
wishes to add its recognition of his notable work. His 
constant willingness to bo of assistance in campaigns against 
fraud and folly and in promoting the friendly relationships 
which should and do exist among intelligent .scientists on 
both sides of the Atlantic was an inspiration.” 

Conference of Medical Staffs of Voluntary Hospitals. 

The recent rapid growth in the numbor of contributory 
schemes for hospital benefit all over tho couutrv is giving 
much concern to the Council of the Association. Hardly 
a day passes but some new .scheme is reported or some 
new and unexpected development is comiilaincd of. It 
is clear that the direct and indirect effects of these 
sohemes on the hospitals, on the public, and on the whole 
medical profession are far from being appreciated as 
they should be. Tho Council has therefore deemed it 
advisable to c.ill a conference of the medical staffs of 
voluntary hospitals in order that various pj-inciple.s, 
dangei-s, and difficulties involved may be discussed bv 
those of the profession who are most intimately concerned. 
I olnntary hospitals (including cottage hospitals) are being 
asked to send representatives to the couforcnce in the 
following proportion; Up to 100 bods, 1 representative; 
100 to 200 beds, 2 representatives; 200 to 300 beds, 
3 representatives; 300 beds and over, 4 representatives. 
The conference will bo held in the Association’s House 
Tavistock Square, London, W.C.l, on 'IVodnesdav, June 
6th, at 2 p.m. 

Iffiddlemorc Prize, 1929, 

The Middloniove Prize consists of a cheque for £50 and 
an illuminated certificate, and was founded by the late 
Richard Middlemore, F.R.C.S., of Birmingham, to be 
awarded for the best essay or woi'k on any subject which 
tho -Council of the British Medical Association may from 
time to time select in any department of ophthalmic 
medicine or surgeiy. Tho Council is jirepared to consider 
an award of the prize in the year 1929 to the auttwr cf 
the best essay on the following subject: ‘'The clinic.al 
study of the vitreous body, its .swellings, contractions, 
opacities, and reactions to toxic invasion; with special 
icferenco to glaucoma and detached retina.” Essays 
submitted in competition must reach the Medic'al 
Secretary, B.M.A. House, Tavistock Square, IV.C.l bv 
December 31st, 1928. Each essay must be signed with a 
motto and accompanied by a sealed envelope, marked oii 
the outside with the motto, and containing the name and 
address of tho author. In the event of no essay being of 
sufficient merit, the in-izo will not be awarded in 1929. 

Election of Central Council. 

The attention of Division and Branch secretaries and 
members generally is drawn to tho announcement in tho 
Table of Dates under “ Association Notices ” (Supplement 
p. 133) that nomination papci-s for election of the twenty- 
four members of Council by the grouped Branches in the ' 
British Isles are now available on application to the I 
Medical Secretary. ... . . . 


^ssanatiou 


ELECTION OP REPRESENTATIVE BODY. 

The Council has formed tho Divisions into the coustitu* 
cncies for election of tho Representative Body, 1928-29, shown 
belovr. 

It is a matter for tho Executive Committee of tho Division 
(or, where tlie Consfciiue/icy compr/ses taoto than one Division, 
for a joint meeting of tho Executives of tho Divisions) to decide 
whetbor the Ropresentative(8) and Deputy-RopvesBnfcativc(s) 
shall be elected by a General Meeting of the Constituency or 
by Postal Voie* The meeting must bo called (or, whei'e tho 
election is by voting papers, these must be issued) by tho 
Secretary of tho Division (or, in tlio case of Constituencies 
comprising moro Divisions than one, by the Secretary of the 
Division containing tho largest number of members). 

The Representatives and Deputy-Ropresoutatives mnsfc be 
elected not' later than Saturday, May 19Lh, and their names 
forwarded to the Head Oifice not later than Thursday 
Juno 7th. 


CONSTITUENCIES FOB ELECTION OF REPRESENTATIVE 
BODY, I92&-29. 

(I) CONSTITUENCIES IN THE BniTISH ISEES, 

{Divhions hrachelcd totfetherfonft one ConslHnencij>) 


ADEnnEEN— 

( Aberdeen 
OrUnoy 
Shetland 

Bath akd Biustol— 

Bath 

Bristol 

BinMINOHAM— 

{ Bromsfirove 
\ Dudley 
Central 

Coventry ... 
Nuneaton and TaniTrorth 
J Rngby . 

( Werwicic and Beamington 
West BromTvich 

BotiDEit Counties— 

Dumfries and Galloway 
Bnalish 

CAUnniDGE AND Hdntinqdon— 
1 Cambridge and Huntingdon 
I Isle of Ely 
East Hertfordshire 

Connaught — 

( Mid-Connaught 
North Connaught 
South Connaught 

Dobret and West Hants— 
Bournemouth 
M'est Dorset 


EabtTouk and North Lincoln- 
Eaet York 
North Lincoln 

Edinburgh — 

Edinburgh and Leith 
Lotbians 

South-Eastern Counties 

Essex— 

Mid-Essex 
North-E as t E SB ex 
South Essex 

Fife 

Gi^qow and "West of Scot- 

EAND— 

Argyllshire 
Ayrshire 
Dumbartonshire 
Glasgow Central 
Glasgow Eastern 
Glasgow North- VTestern 
Glasgow Bouthom 
Lauark.<ibire 

• Benfrowshire andButeshiro 


Gloucestershire 

Kent— 
j Ashford 
1 Dover 
(Foiltestone 
Bromley 
Dorlford 
Isleof Tliauot 
Maidstone 

Rochcst(-r. Chatham, and 
Gillingham 
Tunhrtdgo IVsi’ls 

LANCASHIRE AND CHRSUIRE— 

J Ashton-uuder-Lyno 
1 Glossop 
Biri.enhoad 
INnnifbiirn 
J BlacUiool 
llslo of Man 
Bolton 
Burnley 
Bury 
i Chester 
\ Crewe 
f Hyde 

■j Stockport, MacclosQoId, and 
[ East Cheshire 
7 Leigh 
\ Wigan 
Liverpool 
Manchester 
Mid-Clioshiro 
Oldiinm 
' Preston 
Rochdale 
St. Helens 
Salford 
Southport 
W'arringlon 

Leinster— 

Dublin 
EastLelnslcr 
/Mid-Leinster 
J North Leinster 
1 North-West Leinster 
vSouth-East Leinster 

Metropolitan Counties— 
Camberwell 
Chelsea 
City 

Finchley 

Gr«enwicli and Deptford 

Hampstead 

Harrow 

Hention 

Kensington , 

Lambeth and Southwark 
Lewisham 
Morylehono . 

North Middlesex 
St. Pancrae 
Soulb Middlesex 


April 21, 1028] 


Assocfaiton Notices, 


r • BVPPLEilEST TO TOT 
InniTisn Uksicll JoumrAC 


133 


HETnoroT.TTAN CorNTino (coti* 

S0Ulh-\VC5t r.S^CX 
Stralfonl 
To^cr IlamlcLs 
Wontlswortli 
West Ilorlfortlshiro 

V* .* »•’ * ** 


Wool^rldi 

CUc^torflolcl 
{ llnxtoa 
1 Derby 
Holland 
Kcfto%Tn 

Lcicestcrand Rntland 
Lincoln 
Koltinsliam 
ilCNSTTr.— 

i lSorthMnnslcr 
South Munster 
WestMuuslcr 
NonpoLK— 

DastNorfollc 
Konvlch 
West Norfolk 

NoTvTiiwiN CocKTirs or Scot- 

iaNT> — 

Banff, Moray, and Naim 
Caithness and Sulhcrland 
Invercess 
J Islands 

InosT and Cromarty 
NoTiTn LxN'CAsninn jlxi) SotiTii 
WnsTifoniiXXD— 

Fomess 

Kendal 

Lancaster 

North or En-olarti-. 
finsIiopAucIiliBil 
I Durhana 
JBIyth 
( Morixith 
Cleveland 
JConsett 
I HcTham 

Darlington 

Qatesbeod 

IBatUepoole 

iSto^toa 

e5lS 0 jn berUn d 

South Shields 
Sunderland 
Tyneside 
Nojtm Wales— 

DenbiaU and Flint 
g. tEOTarron nnd Anslcscy 
b-Caniarvon nnd Merioneth 
OaoUD AND RkadIXO- 
Oxford 
Heading 
Windsor 

PERTn 

SimopsninDANDjrro-WAi.ES 

Eoyru-EASTms or Inr.LAvn— 

SonTHEp.K— 

Jersey 

Portsmouth 

Southampton 

Mincbester 


SOCTIT MinLANT)— 

Hcdfonl 

IluckluRlmTnshIro 

Northamptonshiro 

South W’ali'.s art) Monmouth- 

Btiiui:— 

Cardiff 

^^onmouttr5llI^o 
North Glamorgan and 
ntrcknock 
South-West Waloj 
Swansea 

SocTii-M’i'RTrnN— 

Harnstaplo 
East Cornwall 
Exeter 
riyinoutli 
Torauny 
West Cornwall 

STArronnsninr:— 

North Slaffordshlro 
South StolTordolitro 
Walsall and Llchdold 

STtPLlRO 

SUPrOLK— 

North Snfloll; 

South Snffollc 
Wosl SiiffoU; 

StntRrr— 

Croydon 

Guildford 

KingstOD-ou-ThauK 8 
Ucigato 


Sussex— 

Brighton 

f Chichester and Worthing 
( HorNlmm 
East!>otirDO 
llastinga 

.I;cv.*csflud EastGriaslcad 
Ulsttu— 


^ North-East Ulster 
t Dciry 
Belfast 

( Fcrmatiagh 
Mouagbon and Cavan 
Tyrone 

Portadown and West Down 


West SoMunstrr 


WiLTSTTnur— 

f Salisburj* 

\Svrindon 

Trowbridge 

WoncusTunsninE axd FTkre- 

roiiDSimiE— 

IFcreford 

Worcester 

YonKsmnn— 

Barnsley 

Bradford 

Dewsbury 

Doncaster 

Halifax 

narrogalc 

Hnddcrsflcid 

Leeds 

Bolberham 

Scarborongh 

Sbcflicid 

W’akefield. Pontefract, and 
Castleford 
York 


The Outside the British Isles. 

onlside made each Division and Division-Branch 

to elect on Rn independent Oonstitnency, entitled 

seutatives ^ -“^P^Rsentative and one or more Depnty-Repre- 


June 2, Sat. 


June 7, Tliurs. 

June 13, AVed. 
June 21, Tliurs. 

Juno 30, Sal. 

July 4, We<I. 

July 20, Fri. 

Jtilv 21, Sflh 
July 23, Mon. 

July 21, Tuc?. 

July 25, WetL 

.Tuly 26. Tlinr?. 
Jui\ 27, Fri. 


Council by grouped Branches in British Isles; and 
(ii) 2 Fnhlic ITeaith Service Xfombers of. Council, and 
4 Ilep!C!;cntative3 of Public Health Service in Hepre- 
fonlative Body. 

Puhlicalion In Hp.msii Midic.il Jourrm, Supplement of 
motions hy Dtvisiom and Braiiciics for A.I1.3I. on 
matters of whicJi two mouths’ notice must be given. 

ncprcseiilativcs and Deputy .Representatives must be 
eWted by this date. 

Publication in Bi’.nisii Mediuil Journil Srrw.niKNT of 
rcautt of election of members of Council by grotxped 
Bratiehe?, anti of result of election of members of 
Council and Representatives in Representative Body by 
Public Health Service members. 

Nomination papers available (on application at Head 
OflJee) for election of 12 members of Council by grouped 
Renrc-«entativcs (British Isles). 

Names of Rcpre'cntatives and Deputj' Representatives 
must ho received at Head Onicc by this date. 

Cow«c«7. 

Meetings of Constituencies must be held between this date 
anfl July 20th to instruct ‘Repicsenlatives. 

Supplementary Report of Council appears in 
Medtuxl Jocr.N'u, Supplemext. 

Amendments and ridets for inclusion in .i.R..M. agenda 
m:i«t he received at Head Oilb.’e by this date. 

Annual Rrpmrntatice M/teCiiuf, Cardiff, 10 a.m. 

Nominations for election of 12 members of Council by 
grouped Rcpre-yeiitativcs mujt be received (at .\.RI.AL, 
(’aniift) bv this date, 2 pm. 

Annual ne'preseritaticc Meetfitff, Cardiff. 

CowuWf, Cardiff. 

Annual R^jfreirentatire -Verfjny, Cardiff. 

lUpres/mtatirc Jleetiiuj, Cardiff. Annual General 
Jlccling, Cardiff, President’s .\ddress. 

Cauucilr Cardiff. Conference of Honorary Secretaries, 
Cardiff. 

Mr.rtings of Section^, etc., Cardiff. 

2Ii'ftingf( of etc., Cardiff. 

3Ifctiiuj$ of Sectiojn, etc., Canliff. 

Alfred Cox, iledtcal Scertfanj. 


BRANCTI AND DIVISION MEETINGS TO BE HEED. 

Dorset and West Hants Brancii : West Dorset Division.— 
sooial merlin" of the West Doi-set Division will be held on 
Tlmrsdav, .\niil 26th, at Corfe Castle, at 3 p.m., when Dr. 
G. Dru Drury will briefly describe the hislorv and architecture of 
tlio castle. Visits will be paid also to the parish church of 
St. Edward the Martyr and to Church Knowle and Barnslono 
Manor House. 

Glasgow and West or Scotland Branch r itmsniRE Division. — 
The annual meeting of the .\yrshire Division will bo held in the 
Infirmary, Kilmarnock, on Monday, April 23rd, at 3.30 p.m. 
A"cnda: (1) Election of officc-bearci-s ; (2) appointment of repro- 
scTilalivos to (a) Branch Council, (b) the Representative Body, 
(f) County Maternity and Child Welfare Committee; (3) ennnal 
report; (■}) Messrs. Kodak, Ltd., will show five medical cine- 
matograph films at 4 p.m. 

MErnopoi.iTAN Counties Branch : CAiiiERWELL Division.— A 
meeting of the Camberwell Division will bo held at St. Giles’s 
Hospital, Cambenvcll, on Tuesday, April 24th, at 9 p.m. Dr. Guy 
Boiisficld (St. Giles’s Hospital) will read a paper on modern 
methods of combating dipIiUieria. 

Metropoiitan Counties Branch : Chelsea Division. — X meeting ■ 
of the Chelsea Dirision will be held on Wednesday, April 25tli, 
at 4 15 p.ni., in the Fulham Town Hall, when Dr. Carey Coombs, 
phv.sicion to the Bristol General Hospital, will give an address 
on" heart att.acks. Tea at 4 o’clock. 

Metropolitan Counties Branch : Hendon Dij-ision. — ^Tho annual 
meetin" of the Hendon Division takes place on Friday, .4pril 
27ih, at 8.30 p.m., at Hendon Cottage Hospital. 

Metropolitan Counties Branch : Kensington Division. — A 
elinical meeting will lie held by the Kensington Division on 
cmucai _ p ^ ^ St. Mary Abbott’s 

firmary), Marloes Road, W 8, (three 
High Street Station). Agenda : (1) 
Minutes; (2) election of representatives in Representative Body 
and on ' Branch Council, and nomination for Central Council ; 
(3) cases will be shown and demonstrated by the visiting staff. 
Dr. Remington Hobbs, and the assistant staff. 

North Wales Branch.- The spring meeting of the North Wales 
Branch will be held at Llandudno on Tuesday, May 1st. 


April 28, s.it. 


May 12, gat. 


May 15. TuM. 


May 13. Sat. 


table of D-LTES. 


Annual Report of Council .appears in Briiisii JlEmaifc 
JovilNIL bcrPLEMENI. 

receipt at Head OlTice of nominations : (i) by 
•>1 ^^^*1°** less than 3 members for election of 

V® Council by grouped Branches in British 
rnlmi. election of 2 Public Health Service 

I of. Council, and 4 Representatives of Public 
Reprcsenhitive Body. 

list in British Medical Journal Supplement of 


(i) 


British Isles; 


nf lor election ' 

fill 5 STouped Branches lu AAA.»,A.a.A 

a .Health Service members of Council, and 

^.ntatf^^Body'^'^® Public Health Service in llcprc- 

' from Head Office, where there aro 

Ifn? elections. 

Branches for .1..R.3r. agenda cn 
Tiin«5f Xvp. » which two months’ notice must be given 
Last lleiil Office by ibis dale, 

election Office of voting papers for 

ction, "Where there are contests, of fi) 24 mcni'jprs of 


Oxford and Reading Branch: Windsor Divtston.— A public 
addrc<^s entitled “ Some facts, fads, and fancies concerning food ; 
what should wo cat? ” will be given by Dr S H Daukes at the 
Guildhall, Maidenhead, to-day (Friday, April 20th), at 8 p.m. 

South-Western Branch.- An intermediate meeting of the South- 
Western Branch will bo held at the Royal Cornwall Infimiai-y 
on Thursday Jfay flUh. JVill members kindly infonn the 
honorary secretary as soon as possible of any cases, notes, papers. 
SDcciineiis or notices of motion they may wish to bring forward 
in order that they may be placed on the agend.a paper? It is 
advisable tliat papers should be as short as possible. 

Sussex Branch : Brighton Division. — A conjoint meeting of tiie 
Bri-liton Division with the Sussex Law Society will be held at 
theQueen’s Road Dispensary on Thursday, April 26tli, at 8.15 p.m., 
when the honorary secretary of the Brighton Division, Dr. L. A. 
Parry will read a paper on criminal abortion, with special referi 
ence to the case of Dr. CoUins. It is hoped that the subsciiucnt 
discussion will elicit the views of both professions. 

Sussex Branch : Hastings Division. — The annual dinner of the 
Hasliii"s Division wilt take place at the Royal Victoria Hotel 
to-day '’(Friday, .4pril 20lli), at 7.15 for 7.30 p.m. Tickets 10s. fid. 



»34 April 21, 1928J 


Meetings ' of Branches and Divisions, 


f BVPPLr.T^tr.liT TO Tiri 
Lnnixisn Medicai. jouekaii 


iK«iin0S of IBranrljis anb JBiWsions.. 


Gloucestershire Branch. 

A MEETING of tlie Gloucestershire Branch was held at the General 
Hospital, Cheltenham, on March 8th, when the president, Mr. C. L. 
CooDE, occupied the chair. 

Dr. Allman Powell showed the following cases. (1) An unusual 
case of glycosuria in a man who had undergone a cataract opera- 
tioUj who had been reduced to 600 calories per day, and was 
receiving 180 units of insulin in twenty-four hours. On the fourth 
day he became unconscious, but quickly came round on glucose and 
adrenaline. He was apparently the pituitary type of case, and 
could now take 2,000 calories per day with 80 units insulin, and 
remain sugar-free. (2) A girl, aged 23, with combination of 
psoriasis and arthritis. The nail beds were much affected with 
psoriasis, pushing the nails off. When the psoriasis was cured the 
arthropathy disappeared. Tlie Wassermann reaction was negative. 
The main treatment had been chrysarobin and ultra-violet light. 
(3) A woman, aged 31, with profound secondary anaemia. An 
opaque meal sliowed nothing, but gastric analysis revealed complete 
achlorhydria. The Wassermann reaction was negative* 

Mr. J. S. Robinson showed the following cases. (1) A girl after 
open operation for fracture of the trochlear process of the lower 
end of the humerus. The fragment had been attached simply by 
a tag of periosteum. The result had been very good. (2) A case of 
one variety of “ tennis elbow,*’ where the orbicular ligament had 
been nipped and adhesions formed. This case was speedily cured 
by manipulation. (3) Two cases of Pott’s caries. The first patient, 
thirteen months after a spine-grafting operation, was able to walk 
four miles without support. The second showed the type of support 
required four months after a spine-grafting operation. (4) A man 
after intrapelvic rupture of urethra, caused nine weeks previously 
by being crushed against a wall by a motor car. An operation was 
performed within five hours, and no trouble was now expe- 
rienced by the patient in pacing urine. (5) A man aHer 
open operation for bad fracture of patella, which had been stitched 
with catgut. The great increase in size of the patella after opera- 
tion was very noticeable. (6) A man after operation for recurrent 
dislocation of the shoulder-joint. The dislocation was so easily 
and frequently produced as to be a serious disability. Claremont’s 
operation had been performed with complete success. 

In the discussion which followed tho President mentioned a recent 
case he^ had seen of dislocation of the sacro-iliac joint and 
symphysis pubis after accident, one half of the pelvis being ilircc- 
quarters of an inch above tho other. No treatment had been 
attempted. 

Mr. J. S. Robinson then read a paper on three acute abdominal 
conditions of^ childhood — namely, acute intussusception, pneumo- 
coccal peritonitis, and acute appendicitis. Many points in differen- 
tial diagnosis were brought out, and the treatment and prognosis 
were discussed. 


Hyderabad Branch. 

At the annual |:eneral meeting of the Hyderabad Branch on March 
9th, at the Residency Hospital, Hyderabad, the annual report and 
the accounts for 1927 were adopted, on the proposition of Dr. 
Coorlawala, seconded by Dr. Waghray. 

The following members were elected as officers for 1928 : 

President, I'rofcssor M. G. Naidu. Honorary Secretary and Treasurer, 
Licut.-Colonel W. M. Anderson, C.I.E., I.M.S. 

An interim report on the proposal to construct a tuberculosis 
sanatorium was read, and as it was shown that the Addigamct site 
would not be available, the Council was asked to search for another 
suitable site. 

On the proposition of Dr. Lateef Sayeed, seconded by Dr. Taylor, 
Dr. E. H. Hunt was appointed as a representative of the Branch 
to attend the Annual General Meeting of tho Association at Cardiff 


Lancashire and Cheshire Branch : Blackburn Division. 

At a meeting of the Blackburn Division Dr. Remington Hobbs gave 
a lecture on puerperal sepsis and its treatment. There was a good 
attendance, and the lecture w’as appreciated by all present. The 
vote of (hanks was proposed by Dr. Jeffrey Ramsay and seconded 
by Dr. Aitiien. 


Metropolitan Counties Branch : South-West Essex Division. 

At a meeting of the South-West Essex Division on April 3rd a 
letter was read from the secretary of the Loudon Public Medical 
Service concerning an offer made through Uie Medico-Political 
Committee of the British Medical Association by the directors of 
the Independent Order of Oddfellows of 8s. 8d. per head per 
annum for medical attention and medicine supplied to juvenile 
members of the Order. In the view of the London Medical Service 
this was inadequate. 

Dr. Panting explained the reason which induced the British 
Medical Association committees to agree to the scale, and it vias 
decided to tako no action in the matter. 

A letter was read from Dr. Ambrose, H-M- coroner, regarding 
the payment for reports by medical practitioners at the request 
of coroners. As_ such reports are very seldom called for in the 
area, it was decided not to approach the Essex County Council on 
the matter at present. 

Dr. R. 31. Bronte then gave a most interesting and humorous 
address. He discussed cut throat, and emphasized the impossibility 
of •distinguishing w'hether the wound was homicidal or suicidal. 
Some remarkable photographs of cases were shown. In one the 
wound — proved beyond doubt from collateral evidence to be self- 


inflicted— -was circular, penetrating between the skull and atlas, 
and causing a haemorrhage between the' cerebellum (which was 
partly exposed) and the spinal cord. No wound in the throat was 
too severe to be suicidal or too trivial to be homicidal. He dis- 
cussed criminal abortion, pointing out that it was quite possible for 
a woman herself to introduce an instrument into her uterus. He 
told of a case where, on examining a woman very shortly after lior 
death in a bath, ho had opened tho abdomen and found the end 
of a gum-clastic catheter projecting through tho uterine ^Yall. The 
importance of always opening the stomach when making a post- 
mortem examination wag emphasized. 

After a general discussion a warm vote of thanks was accorded 
Dr. Bronte. 


Oxford and Reading Branch ; Oxford Division. 

The second meeting of tho year of the Oxford Division was held 
in tlio Radcliffe Infirmary on March 28th. Dr. Montgomery was 
in t)je chair, and forty-two members were present. 

Dr. Collier, sen., related an incident in the life of the late 
Dr. C. H. Bloxsome of Fairford, as far back as 1887, concerning 
tho diagnosis of anthrax on the forearm of a journeyman butcher, 
and tho controversy that raged in tho neighbourhood over tho 
diagnosis, which was subsequently confirmed by independent 
examinations (sec British Medical Journal, March 17th, p. 476). 

Dr. Stobie showed a woman, aged 26 years, on wdiom, following 
three and a half years of illness, two of which had been spent in 
bed, thoracoplasty in two stages had been performed by Mr.' 
J. B. H. Roberts at tho Brompton Hospital five months previously 
with, to date, satisfactory results. .The sputum was much 
diminished in amount since the operation^ and no longer yielded 
tubercle bacilli on examination. . The patient was able to be up 
five to six hours daily and to walk about half a mile at a time. 


Recent Aspects of Biological Therapy. 

Dr. Stanley White gave an address on some recent respects of 
biological therapy. Following the exhibition of a cinematograph 
film depicting in a graphic way the manufacture of diphtheria and 
other antitoxins, the preparation of vaccines, and .the manufacture 
of calf lymph, he elaborated certain points in connexion witli 
recent advances in biological therapy. He explained the method 
utilized in tho concentration of antitoxin, and proceeded to discuss 
at some length the Schick and Dick tests. He pointed out that 
tho work of tho Dicks in showing for the first lime that the 
streptococcus can be made to give up its toxin was perhaps the 
greatest advance since the principles of blood scrum therapy were 
first put forward- by Behnng in 1891. Dr. White discussed the 
recently introduced scarlet fever antitoxin, and having explained 
that these streptococcal toxins were very difficult to differentiate, 
stated that it ‘had been possible to prepare not only a specific 
erysipelas antitoxin, but also a specific puerperal streptococcic 
antitoxin. Having briefly referred to measles and to tlie recent 
work of Ferry, he went on to speak of vaccine therapy, particularly 
in re'^ard to the treatment of rheumatic conditions, and also ot 
respi^torv affections. He referred to tho w’ork being done ^ in 
several largo public schools in regard to active immunization 
against influenza and its sequelae, niid also touched upon the 
question of non-specific therapy. In this connexion ho was of tho 
opinion that T.A.B. vaccine offered perhaps the best means ot 
introducing a definite amount of foreign protein into the blood 
stream, because the doso and the reaction could be careiuUy 
controlled. , , « ^ i -n ■ 

Tho lecturer then referred to the work. of Hordor and kerry zn 
their attempt to prepare an ideal antigen. These products, which 
had been designated immunogens, differed from vaccines in that 
they contained practically no protein or toxin, and. were free from 
bacterial cells. Their antigenic value, however, was very high, as 
demonstrated by the complement fixation and agglutination tests. 
Clinically, also, the product had been shown to bo very uschil, 
notably in acute conditions. This was no doubt due to the fact 
th«Tt they were rapidly absorbed, and, if necessary, a second dose 
could bo given in twelve hours. . , , , . , , , ... 

Dr. White next made a rcfez'ence to tuberculosis, notably with 
regard to the diagnosis of the disease, and at the same time 
briefly J*eferred to sanocrysin as an interesting example of chemo- 
therapy; at least, this was what 3Ioellgaard hadrin mind when lie 
originally introduced this gold salt. Recent experience, however, 
suAested that sanoerj-sin was probably not a direct bactericide, 
and may produce its results by a tuberculin reaction. He referred 
to the work of Dr. Stobie at the Osier Pavilion, and agreed with 
him that in certain forms of pulmonary tuberculosis, notably the 
exudative type, sanocrysin did appear to be of considerable service. 
Dr. White devoted the remainder of bis lecture to a brief descrip- 
tion of the so-called ** toxic idiopathies.” He discussed various 
forms of allergic diseases, and explained Iiow it was possible to 
immunize against such conditions as horse asthma,- hay fever, etc. 
The lecture was profusely illustrated by lantern slides, which 
added considerably to the interest of the occasion. 

In the discussion which followed Dr. White’s paper, Dr. Collito, 
Dr. Isabella Little, and Professor Gunn took part, and on the 
motion of Professor Gunn, seconded by Mr. Counsell, a unanimous 
vote of thanks -was accorded to the lecturer. 


Southern Branch : Portsmouth Division. ^ 

meeting of the Portsmouth Division was held at the f 

jtel, Soulhsea, on April 12th, when the Anal address 
nter session was given by Dr. J. Stanley Wiiite ' j 

pects ot biological therapy; it was illustrated by 
icmatograph. Tho discussion turned largely on , , 

ising out of some of the new methods of treatment, ^n I 
oposition of Colonel Buooe, seconded by Mr. Mautis, a loto 











Ai-fiir. 29, ms] 


OhHuarym 


** BVPVix^tT.^T TO me 
LnniTrxii MriMCAt< JcofiiikX. 


139 


Dr. Henry Lawrence _ ' 

McKisuck. 


Hr. Vighr 3I,ickoiirie 

■ Mncpliail, O.B.B. 
3I.ijor-Gni. Sir 3Vin. Grant. 
Macnlicrson, K.G.M.G., 
C.H., LL.D. 


Hr. kVin. Herbert Lister 
V ' . JIarriner. 


Dr. Thomas Jtelhoitnie 

Jl.arlin 

Dr. James Melvin 


Dr. -Vlexanilcr Cameron 

Jlillcr 

Dr. Hobert Arthur Jtillijran 

Dr. Kichartl Wilson Mnllnck 

Dr. Albert Edward Norbnrii 

Dr. Ale.xaHdcr Wellcslcy 
_ _ Einch N'ove.s. 

Dr. Edward Albert Ofticer 

Dr. Wiiltei- Charles Oram ... 

Dr. Landcl Hose Oswald ... 

Dr. Francis Barclay Wilnicr 

■n TT' Plullijis. 

Dr. Wa. Smith Porter ... 

Dr. llcginald Wickhaui 

■n -r , T, . Prentice. 
Dr. John Prjor Purvis ,,, 

Dr. Fiedcrick Augustus 

Ilovrtch. 

Dr. Wm. Scott, J.p. 


Dr. Edward Colby Sharjiin 

Dr. Gerald Theodore 

Sylvester Sichel. 
I)i. •Tanios Silver 

Dr. Charles L.awson Smith 

Dr.,D.avid Turnbull Smith .;. 

Mr. Sidney Maynard Smith 
C.B. 


Dr. tVillinm Muir Smith, 


J.P. 


Dr. Andrew Stewart ... 
Lt.-Col. John Baglan Thomas 
Dr. Biclmrd Francis Thomas 

' .••• . y . 

Diet. Wm. Thelwall , Thomas. 


Member of Conneil, l!i()3-inon. 
Honorary Local Secretary, 
Annual Jlceting, Belfast, 
1000. A Chnirmnn of tho 
Belfast Divi.sioii. Vice- 
Pre.sident of Section of 
Aftslicinc, XdlO. 

Prciidrtil of the St. Lucia 
Branch. 

Member of Conneil, 1920-192G; 
MemlHr of NavnI and Jlili- 
tarv Comniitfeo, nnel Chair- 
innu of Sjiecial Committee on 
Tests for Drunkenness. 

A Vice-President of the Dorset 
.and Weal llant.s Brancli, nml 
a Cliairmaii of the Bonriic- 
inouth Division . 

.A Chairman of tlie Smith 
Shields Division. 

For many years Secretary and 
Representative of the Roeb- 
tlale Division ; a Vicc-Piosi- 
(lenl of the L.aneashire and 
Chc.shire Branch. 

A Meinher of the Scottish 
Committee. 

I’re.sidcnl and Trea.vnrer of 
the South Atidland Branch. 

A Chainnuu of the Xorih 
Suffolk Divi.sioii. 

A I’rrsidcnt of the Bath anil 
Bristol llranrli. 

Honorary Librnriau of the 
Victorian Dniiicli. lUOO-lOlo. 

A President of the We.stern 
Australian BraneU. 

Secretary of Section of Elect ro- 
Therapeulics, 1912. 

President of Section of Kenrol- 
• ogy and Psychological Medi- 
cine, 1912, 

A Alcmbor of the .‘south 
Midland Branch Council. 

Vice-President of Section of 
Afedicinc, 1908. 

Alcmhcr of Dor.-et .and W'est 
Hants Branch Council. 

A Cliairniau of the Greenwich 
and Dejitford Division. 

Member of the Executive Com- 
niiltee ot the Tunbridee 
IVcIls Division. 

Member of the Border Counties 
Branch Council ; a Chairman 
of the Dumfries and Gatto- 
iray Division. 

A Member of the South Mid- 
land Braiieh Council. 

A Renreseutativo of the Guild- 
ford Division, 

MeinWr of the Executive Com- 
wittoe of the PortsTnouth 
-Uivisiou. - 

A Chairman of the Ea*( Hcrt- 
lordslurc Divisiou. 

4''® Dancashirc 
and Chcslurc Branch Council. 

A Member of the Metropolitan 
Bi-ancii Council. 
Genera Secretary of Special 
Masting, Loudon, 
1J19. Secretary of Section of 
Children. 1908 

For 21 jrc.nre Secretaty of East- 
boi^e Division, and Bepre- 

the^ Dil - 

too Division. A Vicc-Prp«; 
dent of the Sussex Branch. 

'^n ®®P,''asautative of the 
.Queensland Branch 

of Maval 

A Section^ 

A. Chairnian of 

and 


and 

1907. 

the North 
Brecknock 


Glainoi'"an 
Biviaion. 

Local Secretary 

. Sen^Si?'^ 

, Section of Siirg-erv. ' 


Dr. Wm. Tibbies 

Dr. Alfred (tindsfonc Tribe 

Dr. IViii. Jo.sepb 'J'ysoii 

Prof. F'rancis Wm. Underhill 
Dr. James Whe.illey 


Diverjxml 
Seerctj 


Mr. Bichard Henry .Anglin 

Whitclocko. 


Dr. .Samuel IVillinms 


A Member of (be Alidliind 
Briiiicli Conneil. 

A Alember of tbc Executive 
Committee of tbe Xorth 
Olaiiiorgan mid Brccknoek 
Divibion. 

Member of Council, 1897-1908 
, and 19I2-19l:t. Secretary of 
Section of Public Afcdicine. 
188G, and Vice-President of 
.Section of Medicine, 1907. 
Member of O.xford and Itcadiiig 
Branch Council. 

A Member of the Public Healili 
Committee and a Pre-ident 
of tbc Sbropsbirc niid Mid- 
Walc.s Hr.anch. 

A President of tbe O.xford and 
Heading liraneb; Vicc-Prcjii- 
dent of Section of Surgery, 
190}, and A'ice-Piesidcnt of 
Section ot Diseasc.s of Child- 
ren, 1922, 

A Member of tbc Sontlr Wales 
and Monmontlisliirc Branch 
Conneil and a Chairman of 
the .Soiith-Wc.st AValc.s .Divi- 
sion. 

Lt.-Col. Thomas Samuel A Atoiiihcr of the AIcIrotioIHaii 
Beauchamp Williams, Counties Branch Council and 
I.Af.S. (ret.). of the Executive Committee 

of (he Wc-tniiiistor and 
Holborii Division. 

Dr IVni David Adams, Dr. Joseph Barllett .Addison, Dr. 
John Aitkcii, Dr. Charles Me.Artbnr Allan, Dr. John Allan 
sVrmstrong. Dr, Httgh Lowrie Askham, Dr. Thomas 
Edwarrl .Atkins, Dr. John B.ircl.ay, Dr. .Tnrncs Samuel Freden'ck 
Barnet, Dr. Franei.- Barton, Dr. James Clement Baxter! 
Dr. George Albert Berkeley-Colo, Dr. Thomas Hill 
Bi.shmi, Dr. D m. Hodgson Boazmiin, Dr. Bohort Bowci, 
Dr. James Cmrn C.vrsnn Boyle, Dr. .Andrew John Brady; Dr 
Edgar Brandon, Dr. Hewlett Breton, Major Charles Hildrc.d ' 
Brodnbb, I.M.S., Bet., Dr. Henry Grav Brown Dr 

Hohert tilbnrv Bromp 
Tomblcson Brmivate, Dr 
Lewis ^lom^ 1- rarer Biwett, Dr. Edmond' Patrick 
Burke, Dr. ‘Thomas Burrow, Dr. D.avid John Stewart 
Burt, Dr. John Miller Hopkius Caldwell, Surg. Ll -Col 
Lewis Cameron, I.M.S. Bet.. Dr. Peter Campliell. Dr. Olive- 
St. Ledger Campion, Dr. Samuel Burns C.arlislc, Sen Dr 
John Wm. Stirl nw CiinAlm. Dr. Thomas Wm!^ Clav Dr 
Deins J«eph Cofeman, Dr. John Cotton. Di' ^Henrv 
Lovett Cumimng. Dr. Wbii. .lames Davies Ti va"- 
Lonixe Deiiltle, Dr. .loscpli Dcunr Dr Josenl ’ 

Dickson, Dr. John Donald. All ’ ^ ^ 

Jo'’''iV ‘rl'ff ^'m■nmn Dowling. Di- Patrkk 

Meredith Earle, Dr. Lionel Enipe Edinendcs 
Guy Etches, Dr. Henrv Wm. Evans M C * I'll’ vv 
Evans, Dr. Emstace ' Wm. Ferguson C ni "xv' 

Ferguson. K.A.M C Dr T',-. i - 1 ’• ''i! Haig 
Bichard Fifield, Lt. Anth'onv'’ Kemint Lionel 

R.A.M.C.. Dr. Gerald Fit" ieraid Dr^ k 
Dr. lA'jii. Forrest, Lt.-Col ” Bohe'rt jio Fletcher, 

I.M.S.. Dr. Andrew Fowler 

Wemyes Fulton, Dr. K.ihani ^Alexander 

Gibhe^s. Dr. Tbonm^ C^pa GHd mist nv^"' 

Gordon, Dr. Henry BnsheirGore Carman 

Govim, Dr. James^Mne are nV -I® Maitland 


Haynes, Dr. AVm: He„r7 Dr j2, yf 
WMi Gasfcell 'Higginson 

Hill, Dr. Albert Hod"-c^D'r Herbert 

Victor Cyril Houcvbounie", B A Vi 'p Alajor 

Hown^ Dr. Wm.' Hornsby D. t , «oorgc 

Dr. Trevor Howell AfC^’ n.. Patrick Howe 

Dr. Robert Edward' Inmaii Dr' Imrio’ 

tuoh 



i40 APrii, 28, 1928j 


Report of Council! 


"Dr. Ealph Albert 
Dillon .Lawson, Dr. John 
Leach, Dr \^lter Lawrence Liston, Dr. Win. Cameron 

Dr '^Edi^i’rrf ?/’ L®'' McConnell, Dr. Colin McDonalrl. 
Dr. Edward Patrick McDonnell, Dr. Joseph McGrath, Dr 
Douglas Bower Mclnto^i, Dr. Ewen MacKenzio, Mr. George 

Morham . MoLachlan, Col. 
John M-if Maclean, Dr. Shon Walker Maclean, Dr. 
John MacMillan, Dr. George McIntyre Maggs, Dr. Vincent 
M PI Michael Joseph Mahony, Dr. Angus 

McPhcc Maiohall, treorge Balfour Marshall, Dr. Thomas 
Ml bourne Martin, Dr Samuel James Mathewson, Dr. Max 
Mehliss, Dr Kenneth Wm, Miller, Dr. Henry Wm. Mills Dr 
James Mitcheh, Dr. Eobert Duke Monson, Dr. Cyrus Murray 

Morrison/ Vr Geo^go 
Jackson Muller Dr. Henry Chester Nance, Dr. Wm Henry 
Eichard Neckles, Dr. Edith Neild Til 
Albert Hmry Lowman Newstead, Dr. Cyril James Stanley 

Packman ^D^ AKrT?' """m ^^'^^'’^ cYarlesTnguitfs 
r acaman. Dr. Alfred James Meyrick Paget Siirg T f ^ w«. 

fir.?BSw?“ss Bi H Ir • 

Dr. Alfred George Clarke 

Eeid®’ d'’’ Hay Pulipaka, D?. Chaf cs ^W^ 

te;:;, bs'' “:■ is, rr 

gw, B.„,« ■M|S‘'sSh.“”c;'i'' j’rXjur'i'Mi' 

Attendances. 

Appendix I.) -a-.it.M., 1»J7, to April, 1928. {See 

Chairman of Coitnciij. 

Dr.^H^B.^Brackenbu^y Clmirm A" 

.years 1927-30. The thLS of th^ rl ^"“‘=>1 tlie three 
the late Chairman, Sir i^bert Bolam “?nr 
highly appreciated work as Chairaan durinJ'his^"”''"’*' 
of ofSce, a period which iucluded^the acnnS-}- years 

opening of the present House of the Assom-attn“ 

Editor of the “ British Medicau Journal " ’ 

M^D.^amt; as^'’Editrr^l?c SrilS 

Dr. Horner has been Assistant Editor since 1916 . ^ Journal. 


r SUrPLKME\t TO TH* 
LnntTlSII MliDICXL JOVBKlCi 


History of the Association. 

13. At yarious times suggestions have been „ , 

the effect that a History of the Association sliould^be' nr^ 
pared in readiness for its Centenary in 1932 The Cnim 
of opmion that this is very desirSile and it h^e??o have 
had the guidance of the late Sir Dawson Williams than Jh 
no one wmiild have been more competent to edit such a boT 
hinn® i’^“o "p'" "“‘•er consideration and the Coiincii 

th? ^ *‘’ 1 *’“ to report that the preparation of 

the History has been taken in hand. ' 

B.M.A. House AREANOiaiENTs. 

If Certain changes in the arrangements for the accommo 
dation of members at the B.M.A.-House hare been mad- Th- 
Members Lounge is now called the Members’ Coaimoiriloom 
as being more in accordance with its real usaoe: steps have 
been taken to prevent its use by unauthorised perscis- and 
some additional periodicals have been provided. The fa-i.’ities 


bv"^ aTfeiAly’"”'’’'®'’" taken advantage of 

by a steadily increasing number of members. 

The Association has established a collection cf portraits 
which has been catalogued by Mr. Muirhead Little, P.E.C.S.. 
and has now been labelled; it also has a collection of aiito- 
graphs, due A-cry largely to tho personal efforts of Mr. 
Muirhead Little, and it is hoped to add to it from time to 
time autographs of those persons, both medical and lay, who 
ilflve been associated in some prominent way either with the 
Association or with the medical profession. ‘ 

South African Medical Congress, 1928. 

15. In response to the cordial invitation of the Executive 
Council of the South African Medical Congress, 1928, the 
first to be held in South Africa under the ajgis of the Medical 
Association of South Africa (British Medical* Association), 
that tile Council should appoint delegates to attend the Con- 
gress, the Chairman of Council (Dr. H. B. Brackenbury) was 
appointed official delegate to the Congress along with Sir 
Prank Colycr (London), Dr, H. B. Densham (Stockton-on- 
Tece) and Dr. C. D. Hatrick (New Barnet). 

1928 Annual Conference op the New Zealand Branch. 

16. In response to the invitation of the New Zealand Branch 
tho Council had tnuch pleasure in appointing Mr. Victor 
Bonney its official representative to the Annual Conference of 
the New Zealand Branch held at Hamilton, North Island, 
February, 1928. 

Centenary op Granting of Charter of University op 
Toronto. 

17* The Council appointed Sir John Bland-Sutton, Bt., to act 
as the official delegate of the Association to the Centenary 
Celebrations of the Granting of the Charter of the University 
of Toronto', held in that city in October, 1927, when Sir John 
Bland-Sutton presented an Address .from the Association to 
the University of Toronto. 

Artist's Original Model of the Hastings Prize. 

18. Tho 'Et. Eev. Bishop Williams, son of Mr. 'Watkin- 
W’illiams (wjio in addition to having been General Secretary 
of tho Associiitiou (1803-72) was a close personal friend of 
Sir Charles Hastings the founder of the A830ciation), kiudlj 
offered to tho Association the aitist’s original model of the 
** Hastings Prize *' of the Association which was presented 
by the artist , to Mr. Watkin Williams. The Council accepted 
the offer and expressed the thanks of the Association to Bishop 
Williams. The Hastings Prize referred to was, apparently, 
founded in 1860, the intention being to give annually one or 
two gold medals as prizes for essays or papers, the first such 
prize, being given in 1864. Further awards of the medal were 
made in "65, "66, "70 and *73 when tho award of tlie Prize 
apparently fell into abeyance. 

Medical Representatives on General Nursing Council. 

19. In response to an enquiry from the Minister of Health 
as to whether the Association desired to recommend any 
persons for the Minister’s consideration in connection with 
the appointment by tlie Minister of Health of five members to 
the ** General Nursing Council for England aud Wales,” the 
following names were submitted : Lady Barrett, Dr. A. H. G. 
Burton, Sir Ewen Maclean, Dr. Christine Murrell and Mr. 

A. M. Webber. Lady Barrett has been appointed by the 
Minister, 

Harvey Tercentenary, London, 1928. 

20. In response to an invitation from the Royal College of 

ViyiTcFir.{qTic jif T.rvTirInn ncViiiCT flip' A eorkf»tnf irtTi fp ■nrtTr»i«'«+o cptup 



of Harvey’s epoch making uook, jjc luoru uorais ' to ue 
celebrated in London in May, 1928, the President, Sir Robert 
Philip, was appointed to represent the Association, 

International Union or Medical Organisations. 

21. In the Supplementary Report' of 1926 and in the Annual 
Report of 1927 the Council reported the formation of the 
Association Professionelle Internationale des Mcdecins, tho 
object of v/liich is to establish an international union and 
bureau for the interchange of information and ideas con- 
cerning the social and political’ aspects of medical practice. 
After consideration the Council decided not to adhere formally 
to this body, but to send the Medical Secretary as an observer 
to the first Annual Conference, which took place in Paris, in 
September last. The Council lias given-very careful attention 
to the detailed report which the Medical Secretary placed 
before it with regard both to the’work'bf the A.P.'I.M- during 
the past year and to the proceedings at the Annual Conference, 
and has decided not 'to join the . organisation, it being of 
the opinion that there is no sufficient gain to the Association 



Al'Mb 28, 1023] 


Ffnanco. 


r Rnrri.Kstnrr to rat 

IpClTlHIt 


141 


frow -.ftfmljcrsl.ili of Huh intori.alio.u.t liorty wLicl. f »'>«}><> 
tct off no-ainst llu' c,v]U'IUoh of smoui'i mcmliorsUni 
coml;iiio<fivit5i Hic iIpuuukIh on t\'o *i"'o "f 

Kwv and 0U,cr inoTobors of U,c atoff. 'I hv On.no.l In 
Bocrclnrv of tlu- A.IM.M. t .nt ,t ,s xv.llrntr n 


of Hio Mt^lical 
\ ns 

infoimc-d Uu* Boorclnry of tUo A-IM-.M. inn. ii is «l 

ti'l tines to filrnisli oilier nu'dioal nN-ootaUmis, ouUor iuAk'""' 

0 ^ iidcrniUionnl. with imy infonr.ation winch imi.Y jKr at it« 
disj) -sal hy rcirson of its c.vi-<ncnce jn t-ocinl Icirula.ion m 
rcinlion to medicine. 

.tVHr«i. Myitiiyo on CAN.«.;u.tN Mr.iuMt, Ahsoi ltV2S, 

Ay.: -A t. Be-ysiok or AmtoiChS Mviucm, Anrori.YTio;:, 1023. 

2l'. The Council luis liecu invited to eeiid » rejue-entati.e or 
‘ rci'festnl.ttive.- to the Aotuinl Ctuifereucea of the Cnmulinu 
M-'dirnl UsOvintiri; niu! the Amcrieaji Me(iic;i( Ao.Hocmi lott 
vhmh arc lo bo hetd in June next in Ch-vrl tlrtowii, I'nnco 
lldwaiA Island, and Minnciij'Ois re.sjieelivcly, and m gu'd 
to be nolo to rej'crt tlint Bir I.enthal Cbeatic, C.lt.C.B., Imn 
eoi'i^entod la attend holK cv*ufercncoa ns the dclc^nte^ of t o 
Associ.atioa ni.d to jirc.scnt to I'oili bodies the good w.slic.; of 
the Association. 

CEXTEj;.\Rr CcLCKR.moss or Ff.cot.TV' or Mr.rucixE, Caiko. 

23. In resjionso lo au iiivilalion from the Egyiitinn O'o.crn- 
Pienl, thrniinh the ilini.sler of Ijdncnl ioii, for I he Aicsocialioii 
to fend » delcg.ato to take p.arl in the Ceiitciiury Ccicbr.itionii 
of the F.acnlty of hlediciiic, Cairo, and the IntcrnatioanV 
Congress of Tropical Medicine and Hygiene, extendiug fro.ai 
Joth-26'th December. 1928, and midcr tlic patronage of Ifis 
Majesty King Pound I, the President, .Sir PoiktI I'liilip, iras 
appointed ofiicial delegate of Ihe Awoeintion. 

Arrni>-TsiExT Dceino Yeae cr REVEraEsTATivcs or Assort atiox 
o.v < trrstnE Bonjw, 

,24. The following appointments linro been made by the 
Conncil during the year: — Board o! Govoriior.s, CniTersity 
College, Hull, Dr. Inathcson hvacKay; Ceutrnl Cs'^nctl lor 
ihe Caro of Ctipplcs, XIr. \V. 'McAdam Eccle.s and 
Mr. P. jenner VerrEll; Child Cfnidnr.rc Council, Dr. 
B. Imugdon Down ; Connell of Knciilty of Injarauco, Dr. 
H. B. Braekcnburyi Conncil of the Smoke Abntcnicnl licagoe, 
Mr, Bishop Harmnn; Council of Society of Mcdicnl Oi'errs 
^ Health, Dr.- H. B. Braefcenbury and Dr. \V. Paterson; 
Howard League for Penal Rcforili ; Conference on Young 
Offenders Report, DVs. G. F, Buchan, B. G. Gordon, B. 
^ngdou-Down nnd IV, A, Potts; Joint Tnbcrcnlas'e Council, 
Drs. A. Lyndon and C. O. llawtUorne; Cottncit cl i,ister 
Institute, Proferscr II’. D. Dixon ; Prcfeicsionai Clar.ses 
Aid Conncil; Mr. Js. Bishop Parninn ; Roval Sanit'”'Y 
Inetitnte Congress, 1D28, Drs. G. Buchan and I. TP. 
Johnson; Seventh Internati"nal Congress of Photography, 
London, 1928, Dr. Gilbert Smith. 

Souciion or Associatio.v. 

25. Fotlowiiig the rctircinent of Mr. IV, E. Hempsou wliiob 
was jEoreshadowed in tlic last Annual Report of the Council, 
"I Hempsons, London, lias been npnoinlod S.'licilors 
to the Association. 

Council l.as expressed to 3Ir. IV. E. Hempsou its 
ALftcsVir 1 neatly scTvicros rcndcrod bv liim to Ibe 
tlfp 'wished him in 

wiettf f rv A^ociation muuv voats of bnpnv rctire- 

.laent from tho cares o! olBce. 


Finance, 

Venr from f2i<. Financial Statement for the 

yeai ended 31st Decerabetv 1927, which is set out in det.ail in 

tl’fr “fo?- Supplement, Mav 5th, 1928), the 

'fidancialYv ^•'"'P^'Inble to' the AssociaUo-u, 

in X Although many of the item^ 

in the forecast presented Ismt year t«re e.xceedcd, the result 
is not one calling for regret. The AdYcrtisement revenue for 

ImhS only pBd to the 

aciditional M lie Journal, including a Iteavv increase in 

FutnlS^ ^ estimated 

well for the future, and P«tiolrV iof 
mrnediate future wJicii the oxtensiou ' af 4i;p 
^ouse involve the Britisli MprliVnl Ac ' ^s-ociatious 
^tdexalAe enpital expemltoro Afsoetat.on in eon- 

Af^clation, .and foTthTs^purpofe a sunfof £ 

Tfh's Iras' now been htlllzed ° o- Y aside. 


Tl.e nmotiul required for tltis purpose .hiring 1027 was 
£1,094 19>. 2il. net, future picmiuiu-s being £1,191 ios. mi. 

*'*mj**Hiider Ibe term,, of the I.eime of Ibe Tavit-tock S.inaic 
nw’.'ssarv to carry out periodicjil redi'iX)r.itions, 


pmperty it is nw-.-ssarv to ca.ry ..... j... T-i: ,. 

kml tbe sum of- £1,500 inn, l.eeu set aside to meet this Imbilitt- 
.20. The Reserve Fund for the exlemuon 
l)remme.s of tlie A.s.soei.'ition hii.s been iiicrcn-ed l.y X-nOOU, aiKl 


premi.se.s 

now nt.siids in tlio books at £‘31,052 10s. 

31 Tlie bnlnnee of Income over Expenditure cariie.l 


io 


, 11 . J lie ii.v-....- ,o. m,. - 

Burntns Accimut for the year 1927 nmoHuls to £l.y.i-> 18-'. ion.. 
the total nt which tliis necount now stands being 

,£•190,110 r,s. 10(1. , . o— .to, 

32. The meniticrsliiji inereasetl during tlic year by itm 

Inl III 31st Decemtier, 192", being 33£;‘i5. 


total 
33. The 
foBowK : 


Income for the imst three years has been as 


1925 

1926 
1027 

The Expen.liluie 

1925 

3925 

1927 


£ .s. d. 

151.767 4 -5 

136,357 14 4 

; 143,293 18 7 

’iir tile .Slime three veais; was : 

£ s. <1. 

131,003 IB 1 

154,434 13 Z 

141,357 19 9 


B.M.AXCE Sheet. 

LlaUHiiict. 

.31.- The Sundry Creditors hIiow nu increase of nenrly £2,000. 
mainly in connexion with jiapcr and postage for the /ourr.nf, 
and adverUseincnts pai.l for in advance. 

The Reserve Account has been increased as set. onl- above. 
Tho market value of tbe stocks taken in the B.slantsi Sheet ,sl 
£23,612 lO.s. wns, on the 31st December, £25,494. 

Tile Icmpor.sry overdraft of £29,146 from the Westmitister 
Bank was repai.i in tlic early part of the ye.sr, but tosrard.s tlie 
end of 1927 it was found advisable again to have rcroiJr.se to 
a lemponiry overdraft of £19,522. TTii.s had been romplclely 
repaid by the end of Keiiniary, 1928, when a sum of £3, COO was 
placed upon deposit willi tlie Bank. 

ArscU. 

33. Leasehold I'rcntiscs. — The depreciation rate was iiiain- 
tained at £2,000 for the year, 

HenUith Ilotiie. — ^Tho adjoining house, jCo, 7, Dnim.slieugh 
Gardens, licld also upon fen charter, has been jinrchascd hy Iho 
Associntioii, and is now Wing converted tor the use of 
■members. DciiTvscinlion has Ijccii increased from £200 to 
£41C 7s. for the year 1927. 

/nrfsimrnis. — Tile investments of the Association rtniain .-.I 
the figuvo in the Balance Slicel at 31sl December, 1926, and 
have not been written up. 

Paper Stock. — Tlic stock of paper for the British Jfcdieal 
Journal ha.i been increased at tlic end of 1927. 

Subscription? in .Arrcnr. — The subscriptions carried toward 
as in arre.ar iinve increased slightly in value, the numlier being 
1,652 at 31st December, 1927, as against 1,564 ,at the end of 
1926. 

Tbe item of £2,595 is represented largely bv snbscriptioiis of 
overseas members wliicb may have been paid to Hie Breiteb 
Svcrelaries ahrond, but bad not readied the Head OITice before 
the end of tbe year, (See also note rc subscriptions in Income 
anrl Expcudituve Account.) 

Sundrif Dritori for Advcrli.scments:~Tho Reserve to’ Bad 
Debts and Discounts is considered ample. 

iHCOltE AND E.VPE.VDITCTtE AcCOtrNT. 

36. Subscriptions. — Tlie' subscriptions due for the current 
year show mi increase of £3,060 Is. lUl., due to the iucicase 
in membership dtiriDg 1927 and to variations iii the elasse; to 
whtdi members belong. 

The snliscripHons due for previous years and recovered 
in the year under review Ji,ave again been shown scnavatelv 
m order to demonstrate that the amounts shown i„ (L 
Income, and Expenditure Account as “ Subscriptions written 
on , are by no. means lost. Of llie sum of &,262 7s 3d 
carried fonrard in the Balaijcc Sheet of 51st December 1^' 
as Subscriptions jn arrear,” no Jess a sum than £1 976 7s m’ 


was recovered during 1926. The balance of £285 19? Od 

InMnrlnrl in ♦!»»» -i? ifV» /s - „ J-tf.S, t/Ci. 


included in the amount of £3,122 8s. 4d. written oR 'n ^ 
Income and Expendilnre Account at ‘51st 
A further sum of £157 10s. was received durinn- IQoy’^’ 
together with the £1,710 7s. 7d. collected bv he 
respect of . 1926 .subscriptions written off;’ Tml S O^^d" 
recovered jn respect of previous ’ = > . ■■ 

,r.f » 7 QT ..-.r • .. 


Jia ^ o r, ^ V, .T ^4 f • .1 . 


now the properfv of 

on Die balance of 


Government, wbicli, hoireve^rp^jw' interest - 






Organization^ 


r fffTr/j:.v;:.\T to twt. 

LnilITttOI Mlll'ICATi J0UK*<AL 


/43 


APr.u. 2S, 19233 

On-ov-VocKirr Exn-.NKKS or Mkmiii.hs AiTn.vM.vo Jlirimsoff. 

IG. Tlio Council linvinp referred the followiMs; Aliiiute 39 of 
the A.K.M. 1927, to the Orpunisntion mul I'iiinnee C'oiumit- 
tce> : — 

.lliniiic 33.— Itesolved ; That the C'ouiieil K' iiistrnelcd 
to consider the tnfcinp of .such .s(e)>s ns nre necessary to 
seenre that nieinlteis ntlendino nieetino.s of Council and 
Central Coniinitte-es he jiaid re.r-on.dile ont-of-jioeket 
exjienses in addition to railway fares. 

and havinp received the reports of these Coiiiniittee.' thereon, 
does not eonsider it de.sirable that the expense likely to he 
incurred in earrying onl the snppestion in the Minute should 
he nndertaken by the Association. 


Organisation. 

Mr.nciaismp Finriin.';. 

47. In 1927 there was a net inerease in the nieniher.ship of 
the Association of orer 1,200, and dniinp the live years, 1923-7, 
the net increase has been over 9.000. The Council rvelcoines 
this recognition by the profession of the vnliic of the work of 
the Association. The moat fruitful sources of recruitment in 
the year were: — central activities, 1,.735>: by oversea Ilranehes, 
050; by Home Divisions and Branches. 39."), 

The following i.s a snmmarv of the change.s in the 
membership during l!l27 (the figures for 1920 are shown for 
comparison) : — 


liBK been n steadily inereafing demand for the book on tho 
part of the ncwlv (jualilied, nnd its section na to po.st- 
gradiintion study "amt epccinl diplomas lias been found of 
grent liclp by post-graduates visiting this country. 

Ei.kctjo.s- or ]!i:riii;.sKNTATivj: Boot, 1928-9. 

J>iri.ri()n.T in Jtrillsli Isles, 

51. Tlic Comieil lias, subject to one or two adiustinents, 
re)) 0 .atcd the 1927-8 groitjiing of the Divisions in the BriDsh 
Isle.s for election of the Itcprescntntivc Body, 1928-9. The- 
romplelc list of Constituencies will be found in the li.M.J- 
Supplement of April 21fit, 1928. 

JJit'isions otUsirlc Vritish Isles. 

Each Division and Division-Branch outside the British 
Isles has licen made an independent con.slitncncy. 

DtrcinoN or Coc.xcit., 1928-9. 
lUtilics in JiriH.sh Isles. 

52. riirsiianl to the standing authority conferred on it by 
tlic Hepre.scntative Body, the Council lias grouped pis 
Bianelies and constituencies in 'tlic British I.slcs for election 
of the ‘'2t’’ nnd '•12” nicmhers of the’ Council for 1928-9 
in the same w.sy as for 1927-8 (sec Annual Handbook, 1927-8, 
page 48). 

I.odies outside British Isles. 


(19-2fi. 

Now mcinbews 
Bttid arrears 
Kcsigimtions uitli- 
drawn 

Besignatioos 

Deaths 

Arre.rrs 

Erasetl niider .Article 

0 W (1) ... 


Inoreaso .. 


1927 


2,s7-2 

Xow memher.^i .. 

•2,. -.78 

814 

I’uid arrears 

1.0U7 


Kesigiiaiions ^vitli 


39 

di*awn... 

33 

3,7‘2.-> 


3,(178 

4(17 

nC'Aigimtious 

.000 

29G 

Dfcatlis . . 

.3.71 

1,1.34 

Arrears 

1,48.0 

2 

E.^peUed.. 

1 

— ^ 1,899 


2.403 

I,.820) 

Increase . 

1.27.7 

icenibcr Sl.st, 19-20 

32,350 

cccmbcr 31st, 19-27 

33,025 


Tlie numbciu of new registration.-. (British Isles) in 1920 and 
192, were 1.942 and 1,700 rc.spcctivoly. 

.IVoltK Doxi; EY THE DlTIStOX'S, BltANCHES, AND FEDERAL 
Coujiittees. 
majority of the Divisions and Brandies in the 

^ippleme of "FOcMdfny%uhHd3e‘r1^ 

,1.. M-u, 

40 P I'ewlt Qualified Peaciitio.nebs. 

:ofta^ m1d“i'f 

munection with the scheme inaynr 

nlercsting final-rear medical slnOe. t"''' |<»1 

iractitioners in the work of the A “owly qnahfiec 

hose gratifying activities is seen One result ol 

.'iSriS 

'cliools in larger groups and rmH** ^ grouped the niedica’ 
Thus, there will %.ow* 1^2 grouVs greater value, 

for. the Provinces and lVa?es^ 8eol 1 ^° ^ 

3veraea.s. A prize of £25 wfll f.p /‘'‘’•“"d, anc 

well CToiip. The subject for ■ th ” essavs 1098 

symptoms and Sequel® of Encenhilitis^T^n ' 1928-9 is Tin 
"hpropriate Treatment,” and ?hVei1rs SrTt 

Jniniary 1920 ^ require to he received 

practitioners 

^coiea. PriSierT'^onSroVeTt a^rld” “'led^-'S 


Tlie Braiichc.i oiil,.ide the British Isles have been gronjied 
for election of the " 7 ” memhers of Council. 1928-9, in tin- 
same way ns for I!i27-S {sec Annual Handlxiok, 1927-8, page 49). 


Kf.vision or Auticles and By-laws. 

53. A'arioiis qiie-tioiis of adjustment of the Articlc.s and 
Bv-laws of the Association have lately arisen. The existing 
Articles and By-laws proposed by the Council to be revised will 
be found in Appendix HI to this Hoport {sec II.M.J, feupple- 
nicnt of May 5th, 1928). llcfcrenecs in the llccommcndatioiLs 
to lineage of Articles nnd By-laws, ate to tiiat of the printed 
booklet of the Memorandum,' Articles nnd By-laws. 


Title of Dominions Committee. 

54. -As much of the work of the Dominions Committee is 
concerned with matters affecting the medical services, etc., in 
the Colonics, the Dependencies, and in India, tlic Council is of 
opinion- that the title of the Committee should be brought 
into line with this position by naming it the " Dominions, 
India. Colonies and DeiXMulcncies Committee." 

Rccommcntlation : That By-law 73 bo amended by in- 
serliug, in the 2nd line, after the word " Dominions,” 
the words “ India, Colonics, and Dependencies ” ; and 
that tlic Schedule to the By-laws ns to the Dominions 
Committee be amended by inserting, in the 1st columir. 
after " Dominions ” ; — “ India, Colonics and' De- 
pendencies." 


Constitution of Insurance Acts Committee.- 

55 The Council submits tlic formal proposal for amendraer 
of the Schedule to tlie By-laws as to the composition of Ih 
Insurance Acts Coniimttec. which is dealt with in sTcate 
detail ill para, 122 under National Health Insurance. ^ 

Bccommontiation ; That , the Schedule to the Bv-law 
relating to the Insurance Acts Committee be amende 

by substituting, in line 14 of column 5, 

„ ^3 the same column. 


'29 

‘25 




S"=«rrs'.K 

4 members should be apnoinW bv tb« iiT, ’ '’""f' i 
viz., 2 by the English PfP^e-=enta;.ve Be 

Representatives, and 1 by . 

members should be appoU ' ■ ' ■ tn: 

Association’s. rcpreseiitativ . - . 

and on the Committee of Manawemeut nf t),„ w' , 

Benevolent Fund should be menXrs of H B«yal.Med 

officio, 'rills proposal wns .apnrovPf] hr- m 

the Council now‘ submTlVTlfeTcys^.sv 

By-laws. ' nccess.iry amendment of 



744 Apbil 28, 1928] 


Report of Council 


r SUFFLESIi:XT TO TOT 
LDaiTIBII MKDICAl. JoOBKit 


Recommendation : That th6 2nd, 3rd, 4th, and 5th columns 
of the Schedule to the By-laws, as to the Charities 
Committee, be amended to read as follows : — 


Additional Members 


Appointed Members. 

ex-officio. 

By R.B. 

By Council 

Otherwise appointed. 

The representative or 
r< Mresentatives of 
tlio Association on 
each of the follow- 
ing bodies, viz, : — 
The Council of 
Epsom College and 
tiie Committee of 
Management of the 
Royiil Medical Be- 
nevolent Fund. 


2 . ‘ 

2 appointed by tho 
Hepreseiitntivca of 
Constituencies in 
England (excluding 
-Monmouthshire) ; 1 
appointed by tho 
Representatives of 
Constituencies in 
Scotland ; 1 ap- 

pointed by tho 
Representatives of 
Constituencies in 
Wales (including 
Monmouthshire). 


Term “ United Kingdom “ in Articles and By-laws. 

57. The Council has considered the question whether the 
Articles and By-laws of the Association should be adjusted 
as regards Ireland, in connection with the term " United 
Kingdom.” So far as the Articles and By-laws of the Asso- 
ciation are concerned, that term ineludes the Irish Free State. 
The Royal and Parliamentary Titles Act, 1927, provides that 
the title of His Majesty the King be : — 

" George V. by the Grace, of God, of Great Britain, 
Ireland, and the British Dominions beyond the Seas, King, 
Defender of the Faith, Emperor of India.” 

(instead of — ■ • 

“ George V. by the Grace of God, of tho United King- 
dom of Great Britain and Ireland, and of the British 
Dominions beyond the Seas, King, Defender of the Faith, 
Emperor of India.”) 

As matters stand, the, Articles and By-laws are in this respect 
in conflict with the B.M.A. Handbooks,' tho forms of applica- 
tion for membership, the requests for subscriptions, etc. The 
Council considers that the Articles and By-laws should bo 
adjusted so as to bring them into line with the actual new 
position in respect of the Irish Free State. It should bo 
understood that the merely verbal alteration will in no way 
affect the position of or the subscription payable by members 
resident in Ireland. 

The Council submits adjustments of Articles and By-laws 
accordingly. 

Recommendation : That the Articles and By-laws bo 
amended so as to bring them into line with tho 
position created by the formation of the Irish Free 
State, and, as so amended, be approved and adopted, 
and that the Council be instructed to submit the 
Articles to Extraordinary General Meetings of the 
Association, as follows ; — 

Article 3 {Eligibility): Tn let, 2nd, and 8th lines, for the 
United Kingdom,” read : — ” Great Britain or Ireland.*' 
Article 10 {Expulsion) : In 14fh and 15th lines of para, (a), 
for ” the United Kingdom,” read “ Great Britain and 
Ireland.” 

In 2nd and 3rd lines of para, (b), for “ the United 
Kingdom,” read : — “ Great Britain and Ireland.” 

In 1st and 2nd lines of para, (c), for “the United 
Kingdom.” read: — “Great Britain or Ireland.” 

Article 12(1) {Incorporation): In title, and in 2nd and 3rd 
lines, for “ the United Kingdom,” read : — “ Great Britain 
or Ireland.” 

Article 13 {Formation, etc., of Divisions): In 2nd line, for 
“ the United Kingdom,” read ; — “ Great Britain or 
Ireland.” • 

A I tide IG {Federal Councils): In 2nd line, for “the United- 
Kingdom," read : — “ Great Britain and Ireland." 

.Iiticle 28 {Annual Scientific Meetings) ; In 8tli, 9th, and 10th 
lines, for the words “the United Kingdom or abroad. 
When held in the United Kingdom ....,” read 
“Great Britain or in Ireland or elsewhere. When held 
in Great Britain or Ireland . . . ." 

Article 37 {.Affiliation): In 3rd line, for “the United 
■ Kingdom,” read : — “ Great Britain and Ireland." 

.Article 42 (1) {Expenses ) ; In 2nd and 11th lines, for “ the 
United Kingdom,” read ; — “ Great Britain and Ireland." 


By-law 1- (3) {Interpretation) : In last line, for " the United 
Kingdom,” read : — “ Great Britain or Ireland.” 

By-law 5 {Election by Branches) : In Ist lino of para. (1) and 
1st Tine of para. (2), for “ the United Kingdom,” read : — 
“ Great Britain or Ireland.” 

By-law 11 (1) {Amount of Subscriptions) : In 2nd line of 
Section E. for “the United Kingdom,” read: — “Great 
Britain or Ireland.” 

In 1st and 2nd lines of Section C, for “ the United 
Kingdom,” read : — “ Great Britain and Ireland.” 

By-law 14 {Special Subscriptions to Divisions and Branches): 
In 8th line, for “ the United Kingdom,” read : — " Great 
Britain or Ireland.” 

By-law 15 (1) {Subscriptions to Branches not in United King- 
dom) : In title and 4th line, for “ the United Kingdom,” 
read: — “ Gre.at Britain or Ireland.” 

By-law 16 {Incorporation of Branches not in the United 
Kingdom) : In title, for “ the United Kingdom,” read :— 
“ Great Britain or Ireland.” 


By-law 18 (1) {Local Management : Branches) : In para, (a), 
1st line, for “ the United Kingdom,” read : — “ Great 
Britain or Ireland.” 


In para, (c), 1st line, for “ the United Kingdom,” 
read : — “ Great Britain or Ireland.” 

By-law 22 (1) {Branches not in United Kingdom : Special 
Powers) : In title and Ist line, for “ the United 
Kingdom, read : — Great Britain or Ireland.” 

22 (2) : In 1st line, for “ tho United Kingdom,” read :— 
“ Great Britain or Ireland.” 

In 1st and 2nd lines of para, (vl, and in 3rd line of 
para, (vii), for ‘'the United Kingdom,” read: — "Great 
Britain or Ireland.” 

By-law 23' {1) {Federal Councils): In Ist and 2nd lines, for 
“the United Kingdom,” read Great Britain and 
Ireland.” • ■ • 

By-law 27. {Divisions not in the United Kingdom: Special 
Powers) : In title, in 1st line, and in last line but one, 
for. “ the ■ United Kingdom,” read; — “Great Britain or 
Ireland.” 

By-law AO' {Number of Bepresentatives) : In 1st line of para. 
(2), for "the United Kingdom,” rend: — “Great Britain 
or Ireland.” 

By-law 53 {Composition of Council) ; In 5th and Cth lines of 
para, (a), 2nd line of para. (b). and 5th and 6th lines of 
para, (c), for “tho United Kingdom,” read Great 
Britain or Ireland.” 


By-law 55 {Mode of Election by Groups in Untied Kingdom ) : 
In title, and 3rd line of para. (1), for " the United 
Kingdom,” read : — “Great Britain or Ireland. 

By-law 5G {Mode of Election by Groups not in United King- 
dom): In title, and in 2nd line, for “the United 
Kingdom,” read;— "Great Britain or Ireland.” 

By-law bi) {Qualification for Election as Member of Council):^ 
In 3rd line, for “ the United Kingdom,” read 
Britain or Ireland.” 


Great 


By-law GO {Terms of Office of Members of Council) : In 2nd and 
3rd lines of para. (1), and 2iid line of para. (2). for 
“the United Kingdom,” read : — “Great Britain ol 
Ireland.” 

By-law 85 {Expenses) : In 4th line, for “ the United 
Kingdom," read : — “ Great Britain and Ireland.” 

Schedule to By-laws (Duties, Powers, etc., of Central Ethical 
Committee): In 2nd para., 8th .md 9th Tines, for “the 
United Kingdom,” read ,: — “Great Britain or Ireland and. • 


Schedule {Dominions Committee) : Under “ Additional Mem- 
bers ex-officio," and “Duties, Powers, etc.,” for “t**® 
United Kingdom,” read : — “ Great Britain or Ireland.” 


Subscription of Members Engaged Whole-time in Medical 
Instruction or Medical Besearch. 

58. By-law 11 (1) n (iii) provides for a reduced subscription 
of two guineas in the case of — 

" (iii) Any member who is engaged on a whole-time 
basis in the work .of medical instruction or medical 
research and is not engaged in tho practice of the medical 
profession either as consultant or otherwise.” 

This clause, introduced into By-law 11 in 1922, has. been giving 
rise to considerable difficulty, many members having paid, 
or applied to pay at the reduced rate in respect of whom 
it was doubtful whether they came within the clause. 

'The clause as it stands was the outcome of a projiosal 
that some concession as regards subscription should bo m.ado 
in the case of members of the profession " engaged in teaching 






At-ntt. 23, 1(I2S1 


Organ !za tioh. 


r svppi.r.yrr.vT to thk 

LrrtiTitiJt aiKniCAf. Jot'RXAJ* 


145 


or l('^ca^cU Iml not in 5 )racUce.' 


On consUlenitiou of that 


iiroiio^al in li)22, tlio Council came to tlin conclusion Hint 
there slioultl be a rciluclion of Bubscripllou lu the case of 
(hoie inombers of the nrofession who were engaged at the 
universities or nicdical schools in teaebiug or. scieuiiuo 
lesoarch, but who were not engaged in consulting iirncfico, 
basing its dcciaion on the facts fa) that the interest of such 
persons in tile general work of the Association dincred from that 
of other lucmbors of the profession; (b)that tiieiv remuneration 
was often inadequate, and (c) tliat it tva.s desirable that the 
Association should include within its ranks ns ninny of them 
ns possible. Counsel, instructed accordingly, diafted Clause 
(iii) in qne.slion, quoted above, wbicli was lulopled by the 
A.E.M.. 1922. 

Tile clause deals with memliers engaged in whole-lime 
medical iustruclion, and with luembcrs engaged in whole-time 
medical research, llillicnllics have arisen in respect of botli 
categories. As regards the former, there have been doubt 
and difficulty in njiplying the clause Irocnnse of the vagueness 
of the term “ medical instruction.” Mitch more serious 
difficulty has arisen in respect of " whole-time medical 
rosearcli.” The term is wide and vague, null it hecame 
apparent that in sonic cases there were U.M.A. members in 
one and tbe same dop.srtnioat of one and the .same i list i tut ion 
or service, tome of whom paid the ordinary .1-guinca and 
■some the 2-"ninoa rate. As a result of the difliculties niid 
anomalies which have thus arisen, there have naturally Iiecn 
comphuiifs of unfair discrimination ns liotwceti one member 
and another as regards the ainouni of subseriptioo payable. 

_ The Council regards the position n.s difficnlt, if not 
impos.siblc, to Btrnighteu out if clnn.se (iii) is left n.s it .at 
present Rtaiids, and tberefore proposes that lly-Iaiv H be made 
more explicit as regards the definitions of " whole-time medical 
mstruction ” and “ whole-timo medical research.” The 
r ""v'' the question of abolishing the reduced rate 

of subscription in rcsjiect of such work, a course for wliicU 
tlieie IS a good deal to be said, but came to the coiicliisiou 
that the arguments in this connection which weighed with 
the Council and It.Jf. in 1922 still hold good. 

Recommendation: That By-law 11 ( 1 ) B (ill), as to the 
suhscrijition of members engaged wliole-tiine in 
medical mstruction or medical re.scarcli, be deleted, 
following substituted therefor; — 

(iii) Any member who is not engaged in nicdical 
practice whether .as consultant or otherwise and is 
a whole-time member of the teaching staff of n 
imivei-sity or medical school and has signed and 
transmitted to the Treasurer a declaration to the 
loregoiiig clicct in relation to the rear for which the 

subscription IS due .* ... 2 guineas. 

(iv) Any member who is not engaged in medical 
practice whether as consultant or otherwise and 
vaose w-hqle time is occupied in the investigation 
loi,' problems ns distingnislicd from routine 
aboratory work and has signed and transmitted 
cLci •. I'"*' 'loclaratiou to the foregoing 

Sp 1 ; K "'"d 

guineas." 

re-mimbeiSd”*' being 

le uumbei-cd, consequentially, “ ^v) •’ amt •• (vi;.- ° 

59 IifToo" f'<e lirilhh Isles. 

Braucb rute's,' Provide that local 

the British Isles ira additln / Branches not in 

io become efTective,' iinr>rl siibscription, do not. 


Britain 
omission 


lu juecome eiiectivp ai. ' — u,u jiui, 

the time when tbat By-law wn the Coimcil. At 

that By-law 22 (Sneeial ™ if escaped notice 

or Irelaniyteouirc^l "" Branches not in Great 
should be reetTfied^ eonsequeutial adjustment. This 

"'“mKS"”"’ lira ip .-.a.a p. 

to such approval ^ 15 


and 

, of any^ ada^o^^aTru^s^^riS^-^^ 

bsequent, paras, being renumbered consequentially 


or By-laws, or to the policy of the Aixsocintion in nialtcra 
(ilfcctiii" the honour or interests of the medical profession 
mul is carricil by a majority of not less than two-thirds 
of the votes given tliercoii in tlic manner prescribed bjr the 
By-laws, or wliicli relates to any other businc.ss within 
the powers of the Bcpre.seiit.ative Body, and is carried 
by a simple majority, shall be deemed to be a decision of 
the Association." 

By-lnw 47 provide.s ; — 

“' 47 . The Imsine.ss of the Animal lieprcsentativc 
Afeeliii"- shall be .... to make new By-law.s, and alter 
and repeal B.V-laws, and to consider any re.solntioii rcl.atiiig 
to the promotion of the medical or allied sciences, or the 
maintenance of the Iiononr or interests of the nicdical 
profeasion or of the As.socialioii which .shall have been 
adopted by any Division or Branch; provided that any 
BUcli resolution proposing material aller.ation of the con- 
stitution or policy cf the Association shall have hcen 
jmblished in the journal for the consideration of nil .the 
ilivisior.s not less than two months previously.” 

A»v propo.sal for eiiimcialion of jiolicy upon which the 
lieprcsentativc Body has not previously c.vprc,sscd an opinion 
must he eonsidered’lo come under the category of “ material 
nlteralion of the policy of the Association," and as such, to 
require 2 months’ notice <B.v-law 47) before it can be ndoptod 
iiy an Annual lleprcscnlalive Meeting ns valid policy of the 
Association. Tlie question having been raised, tlic Council 
considers that Article 33 (1) and By-law 47 should be anicudcd 
so .as to m.akc ibis iiosition clear and plain. 

RecommCTiuation : (i) That Article 33 (1) be nrociidctl by 
inserting, in 1st line, after “ Itegulations,” the 
words; — "or the By-laws”; and that By-law 47 bo 
iimended by inserting the words " or addition to,” 
shown in ifnlirs below: — 

" . . . . lo make new By-laws, and alter nnd 
repeal Ev'-laws, and to consider .any resolution 
relating to tbc promotion of flic mwlic.al or .allied 
scitnce.s or tl;e maintenance of the honour or 
interests of the medical profession or of the Associa- 
tion which shall have been adopted by any Division 
or Brancli ; provided that any such resolution 
pioi«>sing material alteration of or addition lo the 
coii.stitiition or policy of the sVssociation shall have 
been iniblislicd in tlie Journal for the consideration 
of all tbc Divisions not less than two months 
2 >rcviousIy." 

nnd (ii) that the Council he instructed to submit the 
foregoing .amendment of Article 33 (1) for completion 
by Extraordinary General Meetings of the Association. 

Possible Formnlion 0 / Groups wilhin the Association. 

Cl. The Council has considered the follovring Min. 30 of the 
A.K.M., 1927 ;— 

“Minute 30. — Besolvcd; That, ns amended by Mins. 27 
and 28, the lioprescntativc Body approves the scheme for 
formation of Groups in the Assocnation (B.M.J. Supple- 
ment, April 23rd, 1927, page 158), and instructs the Council 
to prepare the necessary amendments to the Articles and 
By-laws for submission to tlie A.It.M., 1923, it being 
agreed that the Council, should the need arise, mav give 
immcdi.ate provisional effect to the echeme.” 

Pnrsmant to the authority thus given, the Council has 
formed 2 Groups, namely, a Spa Practitioners Group 
the members of whicli arc those members of the Associa- 
tion who regularly prescribe the miiicrn] waters or baths of 
the spas in which they reside or who are on the staff of a 
hospital or clinic whore the use of the local miner.al waters 
IS part of the routine treatment; and a Consulting Patholo- 
psts Group, composed of members of the Association (not 
being members of the public health service) who are working 
in an institutional or private pathological laboratory eno-a^ed 
in examining and reporting on specimens for clinical purm^s 
Both Groups are now in active being. ^ 

In tbc opinion of the Council, shared by Counsel tn\ the 
amendmeut of the Articles and By-laws sh^nTd 'sTmpiJ''^ 
tUc.forar of giyrng general power to the Connell to form snrt 
special Groups under such rules as the rnneeii ” 
from time to time determine; and (b) the Coiinc^rlbnn?J 
adopt, rules, and/or standing oilers accordinllv 
come into force inso /(icto Avitli the non* 
subject in tlie Articles and By~ln^vs Tbe^ ^ 

accordingly (a) a new Article 19x *’ * (h\ tlmf 
42. .and 45 h\ 'adjusted ; .and (e) a new ^By- ary 
recommendation below). ' ‘ ' 

provisionally adopted on^hc'^'lubj^cri V 

with the dr.aft scheme .approved by the AS.ri 927 rbut?in 


CoU^^UJ- 


gUi 


Article, .--^ yircd- , .,^„j- s"'='^^o,,oid « 

’“ii'S-K =?,» K*?,;\^X'“"l>-''“'' " , • 
si?-* 

ilcctir'g^" -, 

. , -tvBoAlCal 


-,s o£ “‘•‘iVoin t'®c ^';' 

^s;ts mcy '■°cumstanccs 

A ..title ^■'•'■'' fei'sionai ^“".a in sUcU cii „,,(! 

Sj;S ’■ 

'“J--- “ “ 

« Regulal-^®' ^ (Ejc,)cn'ics''^-jj._ ■^\th\n 

Article ^.r [2], ■’ .,,«d £« utorcsa' 

nAiijjberc ex^c"®*^®’, xvelc"‘^ Jf 

oUending Cotn»t'^"nbora to 

.. b. ® 

-^Vstiug itii Viac ;-- 

‘^riS/ds 

.. and sevar.'tc ,. 

tbcreot . • lines : ^ 

nbcd or ^ 

.. picscUOC'* ^ 

(^'ctc Bl/'l®'’' ” -MciiEt:®®- 

Gnotirs , r niciabc’^® 

PV^.^-Ser-ct'*- ® i)cJov»cd °£ d i,<.ing 

at Groups way 1 intereAs a 

ti'®" InTation oi tl'®®® . sball 

XCpTCSC ■Rvalicli-C®' t G,r)CCl^^ ^ _«v tO 

sions .;oi^ oi to opp^^tc fi«a\ 

«.«5 ftsrs'oi -ris %st"iHssJ‘ 

X.lcciwg® w^iatcs cud 

SiSvS'w- „, c..— 5“t',T;...“"r'Si 

,-= Tcris'on w ..> 

fn?ges\®.,onctti3- 



Arniri 2S, 1929] 


"British lyiodlcat Journal.” 


r srrrtrymsT to Tiir 

UlltlTIMI MKlUCAr. JOUIlNAt. /^/ 


Prcsidontml Addrof^s, proccrdinf^fi in ilio ■Rcj>r(*P('nta- 

tive Meotiiijr, tlu; stnlutorv Aniuni! (U'lioral Mictinp. and the 
various conforonccs hold ‘at Kdinbur;;h, occupird 'J1 })ag:os; 
tliift makiu'^ in all pajjrs. Notwillistaudiii" the very 

large luniibcr of Seclioiis in 1027, j)U])licntir,u of tlie full 
reports of the Fcientific j)ioroedings was one:; again coni])loU*d 
by the Inst issue of Decembor. Apart from the two Annual 
Meeting issues of the Anpp/enirri/, those wliich contained the 
Annual* nnd Supplementary Itcnoits nt Council, \t.e .uiiinnl 
Keport of the Insurauce Acts Committee, nnd the rcjiort of 
the Ahmml ranel Conference, were oxccptionnlly large. A 
considerable amount of ^^pace in the body of the ,/onriinI was 
again devoted to British Medical Assoriation Icctnroa and 
papers of scientific nnd jiractical interest rend to the Divisions 
.nnd Branches of the As-sociation. On several occasion.*! the 
Kpitomc of Current Medical Literature was enlarged to six 
pages, when other demnuds U))on hp,u<* made thi-i piacticabio. 
in accordance with custom no Kpitomc or »^npplemenf appeared 
in the Educational Kumhor jmblishcd on September IJrd. 


IliUTSTR.VTIONS. 

G7. During tbo year twenty-five sjn^cial jilatos were devoted 
to the reproduction of illustrations wbicb w<»uld not have 
given good results if printed in the text on the ordinary’ paper 
by rotary macliincs. One of these nrt-pajicr plates (n portrait 
of Lord Lister, published in connoclion with the Lister 
Centenary celebrations), was in colours. The cor^t of a special 
two-page plate on art jiajicr, apart froit. the co^t of engraving 
blocks, Is for an issue of 37,000 copies about XliO (paper £20, 
Juaciiining, binding, etc., £-10). A largo number of ligure-s, 
executed in line or half-tone, wore printed in the text, and 
efforts to improve the general standard of reproduction of 
Uic.so blocks have boon mainlainetl. Altogether. -130 illustra- 
tive blocks were engraved in 1927. A Current iNote, paintimr 
out the difficulties in the way of reproducing pjiotcgraphs' 
aiiQ giving hiub^ to cniitrihulors on the preparation of nicturoi, 
“Pl’^'^ted in the Sujiplemcnt of October i.MIi, 


MSS. AKt) Books. 

th^Wl coiitriiiutinns received in 
limi^Pd fP m very largo and the si-aco available 

muoh considered in cnci, ca.e .h not sc 

its ^ 1 ° material wlitcl; would justift 

fi’ '"crits and its general interest 

In ^ sliould bo chosoii in iircteronco to oliiera, 

nuenth-^inpv1ton°"‘®T>‘^‘^ ^ reaching a decision is conse- 
more thin '■wel'c moiitiis tindor review 

nanerromf^s/'^T" addresses, Annua! Jlecting 

furgtcal and obstetrical memoranda were 
•the.?MR<! “ Publication in the Journo/. Oi 

orWn^ ‘bo insertion of 500-203 

memorandn^''^ mu Annual Meeting pairers, and 192 clinical 
for review bocks received from rublislicrs 

tor review was 99o, and notices of 477 books appeared. 


tlip consetjiienlial loss, due to witlidiawnl of fnrllior advrit 
iiig iiiallcr from llie same (innrlcrs, cannot bo taknk'.tc:!. 
Xovcrtliolcss, tliis jioliey of cNclnding niidesiraidc ndverti-o- 
iiieiits from its odleinl organ is a duty the Assooialion o...'s 
to its iiioinbprs and tlirongli liieni to tlic public, and tlx bettor 
cliiss of ndvcrlisors welcome it, recognising its advantagc.s to 
llicmscives. Wbilc tlie neecptnnco of nn advert ircnxnt for 
publication in the JoiiriutI is not to bo nndorstood as rec'in- 
mending or giiaranloeing the aiticlo ndverlie-cd, yet the 
ajipenranco of nn ndvertisemenl indicates tlial no oiijectioa of 
principle lias bi’cii taken to it. All new adverli-enieiits lu’j- 
mittcu for piililiention arc serntinifod in tlie Financ"' nnd 
Medical llepnrtmciits of tlie AH<ocinli(,n, and tlioso con.fidcrod 
primii facie to lie misleading or olbenvi.se objcctionn'ile are 
referred for fnrtbcr inquiry and consultation. Tlic Council 
has from time to time laid down general rules goierniig 
tlie acceptance and rhfmal of edvortisemcnls but |9c 
application of llicse nilc.s in particular cases lends to become 
more difliciilt. Details of advertisements suspended or reft's d, 
and of tlic grounds for tlie action t.akeii, are periodically laid 
before Ibe .louninl Committee, when tlic eiicnnislancrs of each 
case are reviewed. The Committee reappointed the Foods aii l 
Drug.s (Advertisemciils) Siib-Commitlec to advise its Clinirn.a'i 
in regard to doubtful advertisements of phaniiaceiitical nnd 
dietetic preparations. Tlie claims made for pailicalaT sub- 
stances have been reported on by pbnrraacological and 
analytical experts. 

" Ancnivr.s or Disease ix Childhood.” 

71. In 192G the Council decided, in ri’s]xntc to icpre.=ent3- 
tioiis made bj- many members intcreslcel in dise.'..scs of 
children, to issue a periodical which would worthily represmt 
the British seliool by recording the iiivestig.ntions and conclu- 
sions, clinical and jmlliological, of all its workcr.s. For iliii 
carrying out of this purpose the Council appointed a General 
Committee, representalive of all jiaits of Great Britain, with 
Dr. Hugh Thnrsficld and Dr. Begiiiald Miller as Editors. Tiuy 
are assisted hj a small Editorial Committee of practitioacio 
p.irticiilnrly interested in the subject and resident in Lor.do.n, 
Edinburgli, Glasgow and Eiverpool. The first number of tlie 
.trchifcj of Discncc in Childhooil was issued in February, 192(i, 
and tlic second volume was completed with tlic twelfth number, 
dated Dcceiiibor, 1027. In the papers published the Edito.s 
have maintained n very high standard and many cxco.leiit 
illiislralions liiivc aeeomjmiiied them. 'I'lio appeal < t liie 
drchtrc.v is world-wide, for it is addressed to all those at homo 
and abroad, in every sphere of work, who, realise tlio import- 
ance of this rapidly growing department of medical science 
and practice. The Archtvrs appear six times a year, and the 
subscription (pest free) is 258., payable to the Fin.ancial 
Secretary, Briti.sli Medical Association, Tavistock Square, 
W.C. 1. The snhscriptioii for Canada and tlie United States is 
six dollars (post free). The price of a single mimher is 4s. Cd. 


- Cost op Phoduction and Distriiiution. 

Stali!mcnt^Bhows'’tW published in the Annual Fiiianeinl 
bution of the Britiih production and distri- 

and »• proportion oMlx Joiirnol, including all editorial 

1927. Siceipts from adv‘crG^f3^ ciepensos, was £09,4 12 in 
amounted to £ 55,694 so tw non-members, etc., 

members of the AsscHoHOi* * -Journal to 

the whole year iBcludino- “ ^ead for 

of producing a single com^of^thO the gross cost 

a member was prleticaul 8’ supplying it to 

approximately IJ pence- L n kim was 

Ireland the price^ of a “ "““'“ember in Great Britain or 

!?■ 4}d. S.ales ol Journals /iddeTIo 419 postap w.ns 
sidered highly satisfactory in idew Of ’ thO 
membership of the AesociTtina steadily increasing 

field for ci?eulation of the the 

charge for postage of the Jonra Jt uon-members. The 

of the total expfnditnre on th^ 100 °"“? 

£13,547 in 1927 as compared iph ip/"”'-. It amounted to 
1925; £10.635 in 1924 •^£9 foo-J ooo ^H-SSO in 

£7,261 in 1921. The increase in .'u 1922; and 

to the continued growth in memOn i costs is due mainlv 

-n WI Censoeship op ADVEnTisntE.\TS 

and It was. found necessary to rOfus» or Imff pahlicatien. 
did not conform to the polici- and reo^ "J' ’"•'"ch 

ciation. This strict snp?^ sion rntl-? -Asso- 

-veiuie to the Journal^. 


.. Journal or rsEUROLOGT and PsYCnopATnoLOCY.'* 

72, As stated in the last Report of Council an applie.-ition ' 
W.-IG received early in 1926 by the Britis'n'Mcdicnl Association 
to take over the publication of the Journal of Ncurologu and 
Psychopathology, then in its sixth volume. From tfie firal 
luimbcr of the seventh volume iJnly, 192G) it has been issued 
by the British Mcdicnl Association. The aim of this pGriodi'*al 
IS to supply up-toHlate information on the subjects named "in 
its title. This 18 fulfilled by publishing short original com- 
munications and editori.al articles, together with abstracts 
and critical reviews; and the scope and arrangement of the 
.loumal of Neurology arc such that it fills a place which no 
j pubhslicd in English exactly occupies. It is 

„ w®^ .*^1’ IliHHicr Wilson, with the assistance of nn 

tditonal Committee, all of whom are nicmhers of the British. 
Medical Association. It is published quarterly, and the snb- 
scription 19 30s. a year, payable to the Financial Secretary. 
,1110 price of a single number is 8s. Gd. (post free). 

Science. 

Scientific Woek op Annual Meeting, 1928. 

Council has arranged the following Sections for 
fhe forthcoming Annual Meeting at Cardiff ThZ.. J 




A-Wir, 23 , 192 Sl 


Sclonco. • 


r f!arrr,rsrf:!.T to nnt 

InniTtblt itr.PiCAL JOORKiC. 


f 43 


The operation of tliis scale liaa given rise to very con- 
siderable difliciiUy anti it becamo clear to tbo Council that 
some iiiodification vras called for. In order to obtain the 
views of tlie medical scliools on the subject, a conference of 
representatives of the schools with the Science Committee was 
convened by the Council in Pcbniarv l.ast.' Almost all the 
medical schools in Great Britain and Ireland were represented 
at the conference, in the majority of cases by tlicir deans. 
Ihe conference was strongly of opinion (i) that the univerai- 
tics were not in a position to pay salaries on the lines 
Buggc.stcd in the above scale, and that the enforcing of the 
sc.sle (as.suming that the Association was in a position to 
enforce it) would mean the diminution of the number of 
poaU, or the transfer of many of them to iiersons other than 
qtmlifjcd medical practitioners; (ii) that the appointments 
were almost invariably not of a permanent character; (iii) 
that there were many considerations ether than remuner.ation 
in the arademic lino of work which did not npplv to npnoint- 
ments under public health .authorities, and tliat a iunior 
appointment in the academic field when it did not le.ad to a 
I’Bofh-'sorinl post w.as often a stepping stone to 
remunerative employment in other walks of life. 

vto ^*''1 ^““"Bil has given careful consideration to theso 
views and recommends : 

Recommendation : That the scale of salaries rel.ative to 
non-profcs.sori,al medical teachcr.s. laboratorv and 
rcsc.arch workers, should not apply to academic 
appointments in universities and medical schools 
lore these .appointments are of a temporarv character 
and where the duties attached to the posts arc in 

advancement of tho 

knowledge and cxjjcricnco in the 

cultVvat” which lie proposes to 

BT HaDIATIOU AND ElCCTOICITT. 
riste to'^tbe^nuhv" tl>« Council has heeu dr.awii to the 

cLmittee report from a special Sub- 

BciencPQ,mmu'‘tei:!!’^°''"'" of the 

mcChods^haTm^irh^- ■^•'^'^tro-thorapcutic and radiation 
proSe that^n^ ’norchsed in recent years and it is 
Knt tnembers of tbo profession have not 

forms orapprr^tJm ^ f “otlorn procedure and 
sometimes nres^^fh^A of tliis kind is 

specific dircJtio"^ ^ 

beinl°cnUivat”ed‘'u!!rf ‘''catment arc 

medical education ^ person.s who liavc had no 
there is tlnm rTsrto^^e" puE*" 

ot^sucli powerfid* a^encies^*'^'^*'”]' 'I" nerson 

diathermy and uhra.v'oLtTighr 

anVlierc in particuHr must ’1 serious misciiief 

development of „ltra^•ioTet lVbf 

amateur and domestic uppar-atus aud its .sale for 

iWhile allowing that these dantpr‘’i ’ts dangers, 

some cpiartcrs, they Ldoubtrcflv o’ Oferetated in 
th.at the apparatus in individn?) "i"^ admitted 
quiescent plithisis pnlmonal is 7 “'='^5vc a 

damage to the eycsi|ht. dtl er serious 

reason why this form of trcaVn.o^?’'®! good 

properly trained persons. ®“‘“ont should be confined to 

(e) Similarly diatb«rmv fcom r 1 . 
produce burns which are very sW t ?PP’*oation may 

■ :i’diS. 

(!) Electricity therefore in it- - • 
several methods of radiatim loo ond the 

agencioa which may adversclv afr„*t Iiands, 

conditions, may make aetloo ^ • o®oct existing diseased 
. positive^a"ma|o“^l'\^,‘ 5 “.^oe„t disease'’ and may 
death have been traced to these methS'.’' 


opinion, both professional and lay, against the use of 
powerful rcmedinl n'gcncicn by ignorant and untrained, 
persons. ... . . 

(i) The medical schools .arc not unaware of the thera- 
peutic values here considered nnd arc arranging cone- 
eponding courses of instruction for medical students. 

The Council recommends : — 

nccommcnclatlon : That the Hcprcscnt.ativc Body express 
the following opinion, namely, that in view ol the 
risks to tho public involved in the nso of electricity 
nnd radintion ns inclliods of treatment by untr.ainetl 
nnd unqualified persons it is to be d-sired (1) that 
suitable courses of training sliould be organised under 
medical direction for persons who wish to administer 
this form of treatment; (2) that persons who bave 
satisfactorily followed such a course filioiild be 
entitled to have their names entered on an approved 
Boll; (3) Hint one of the conditions attached to 
admission to, nnd maintenance on, the approved Boll 
should he abstention from tho treatment of nnj' 
patient except on the responsibility and under the 
general supervision of a registered' medical practi- 
tioner; nnd (4) that patients who require electrical 
or radiation treatment should bo referred only to 
tho.se persons whoso names are on the approved Boll. 

The TjIbuaiit. 

82. Increasing tiw continues to be made -by members of 

the facilities provided by tlie Association's Library; Tbt 
number of books borrowed during tbo years 1023-27 has been 
respectively as follows : — 

1023 ... 4,803 

1024 ... 7,200 

1925 ... 7,300 (Library closed for several weeks.) 

102G ... 0,810 

1927 ... 11,017 

In order to meet these increasing dem.ands, the Council h.as 
made further provision for the expansion of the Icndiii'v 
library facilities. ” 

Tlie Council desires again to acknowledge the valued 
services of tbo Honorary Librarian, Mr. W. G. Spencer. 

Inquieies into the jVnxn-HisioRr of Gasteo-Entebostout 
AND Tnr-tT.ME.NT OF VAnicosE Glcehation. 

83. Tlie A.B.^I., 102/, approved of collective 'investi/rations 
being conducted by the Council into the Aftcr-Historv of 
Gaetro-Entcrostomy and the Treatment of Varicose Elku-a. 
tion. The interest taken by the Alinistrv of ncalth in the 
suggested method of research is indicated in the follow nw 
letter which was addressed to the Bresident of ' lU" 
Association .- — 

“ Ministry of Health, 

Whitehall, S.W. 1. 

•n e- v> 1 i -n? -I- November 7th, 1927 

Dear Sir Bobert Philip, ■ . 

1 ]c.ani with much iuterest that the British M-di al 
Association, after consultation with officers of n-.v Hera' 1 
ment, IS about to institute a collective invcsti-.^tion’intl 
certain highly important problems of d;se'’asc Tl.; 
inten 10 . 1 , as I understand it, is to secure the c-o-’c-a'don 
of a largo number of medical practitioners up and do vu 
the country in a scheme of team-work on an exte liv- 
scale, and so bring together the results of many var -i I;: 
Linds of experience. I need hardly say that tli"? c!r 

Tours sincerely, 

(Sgcl.^ Cii«i7iiberlain. ” 

Many rorgeons have cordially welcomed ihe fn-* 
Enterostomy inquiry nnd Imvo exDressed wJiK ^"® p“-t'o- 
part in tho invlstigations. As rSs 
treatment of Varicose Ulceration, the names of a c^rid r 1 1 '" 
number of members have been received frlm Tlf ® 
throughout the country. The Council attnM,» Pitisions 
ance to tins inquiry and it hopes tliat Hinco Unport- 

have not yet indicated their wlCilncL lo 
scheme of investigation, will do so at an cariv dat!? 

"n.. A -D T-.a- 1 Utue. 


— — uHce. 

work o/eo^'rdTnari^ the tpull toX^InJuirief.""'"’''" 


the 



150 Apeil 28, 19281 


Report of ■ Council I 


r SDPPLElTEJUT TO THl 
British Mkdical JooBSUi 


Medical Ethics. 

Instruction of Newly Qualified Practitioners in Medical 
Ethics. 

84, The Council has considered the following Minute 46 of 

the A.K.M., 1927;— ' ■ 

Resolved : That the Council be instructed to consider 
any further steps which may be thought neceisary for the 
instruction of senior students or newly qualified practi- 
tioners in medical ethics. 

As the question at issue is clearly one which concerns tho 
General Medical Council, the Council has asked tho ' direct 
representatives of the profession on the G.M.C, to raise the 
question in that body. In point of fact, some years ago 
a report was presented to the G.M.C. by its Education 
Committee as to the instruction which was being • given 
to medical students on tho duties which devolve upon 
practitioners in their relationship to the State and on tho 
generally recognised rules of medical ethics. Tho report 
showed that while satisfactory action appeared to bo taken ' 
by a considerable number of the medical schools, the situation ; 
as regards other schools was either doubtful or unsatisfactory. 

The Council has suggested that a further enquiry on this 
subject should be addressed by the G.M.C. to the medical 
schools and that the lectures on medical ethics should be given 
by practitioners who have had experience of private' practice. 

The Ethical Work of the Association. 

85. A great amount of the work of (he Central Ethical 
Committee and of the Standing Sub-Committee concerns 
matters which cannot very well he made the subject of report 
Advice IS frequently sought on matters of ethics and disputes 
between members of the profession. The Central Ethical 
Lommittee, acting for tho Council, has adjudicated in se.cral 
disputes between members where a satisfactory settlc- 
ment has not been possible without bringing the parties 
together at a hearing. It is evident from increasing corres- 
pondence that the advice on ethical matters which the 
Assomation is able to give through its central office and by 
tho Ethical Committees, both local and central, is much 
aiipreciated by members. 


Ethical Ehles. 

88. In pursuance of the standing instruction of tho 
Hepreseutative Body the Council reports that the following 
bodies in Great Britain have not vet adonted tl-.. - 

Ethical Buies -.—Divisions : Argyllshire, Chester, Dumbarton- 
mure, D^ham, Edinburgh and Leith, Halifax, Salford. 
Branch-. Edinburgh. 


Medico-Politioal. 

Consultations under Puerperal Pyrexia Regulations. 

87. Arising out of paragraphs 113 and 149 of the Annual 
Report of Council, 1926-27, the A.B.M. 1927 passed the 
following resolution : — 

Minute 148. — Resolved : That it is desirable, owing to 
the fact that^ puerperal pyrexia may be due to causes other 
than obstetric, that a panel of consultants which may be 
instituted under the Regulations should include competent 
physicians, surgeons, and pathologists, in addition to con- 
suiting obstetricians; further, that some standard of 
competence should be adopted, such as membership of the 
staff of a local general or obstetric hospital, , or the 
possession of special qualifications or experience by private 
practitioners. 

, This resolution was brought to the notice of the Ministry 
of Health which stated that some local authorities had 
already made arrangements for the establishment of a panel 
of consultants, and the Minister would have regard to the 
view expressed by the Representative Body in the event of 
further proposals for the constitution of such panels being 
submitted for his approval. The Council regards the position 
as satisfactory. 

Medical Officers of Public Schools.. 

88. Minutes 106 to 140 of the A.E.M. 1927, dealing with the 
romiiiieratioii and conditions of service of medical officers of 
iniblic schools, have been discussed with representatives of 
the Incorporated Association of Headmasters and the Associa- 
tion of Headmistresses, but as a result of a communication 
from the Medical Officers of Schools Association (on whose 
representations this matter was first taken up by the 
Association), further action in this matter is delayed. 


Reports by Medical Practitioners at Request of Coroner.!. 

, 8U-,Tlie A.R.M. 1927, in the following I’csblution, restated 
what was already the policy of the Association : — 

Minute 153. — ^Resolved: That there should be a fee 
VY^ierc a report has been requested by a coroner from a 
practitioner who has not performed a post-mortem 
examination and who is not called to give evidence. 

In connection with the Coroners (Amendment) Act, 
1926, when the Association attempted to obtain legislation 
to provide for such a fee, a deputation from the Association 
w.as informed by a ropreschtativc of the Home Office that it 
was legal for local authorities to pass resolutions authorising 
the payment of a fee to medical practitioners who, at the 
request of coroners, provide reports but are not subsequently 
asked to perform the post-mortem examination or to give 
evidence at the inquest. The Council has urged the Divisions 
and Branches to endeavour to obtain the support of their 
local coroners to this projiosal, and tlieii to urge County and 
County Borough Councils to adopt the necessary resolutions. 


Death Certification. 

90. Representations were made to the Registrar-General 
pointing out tliat tho delay necessitated by medical practi- 
tioners foi-warding, in accordance with the Act, certificates of 
the cause of death by post to Registrars, some of whom only 
attend their offices on certain days, causes considerable 
inconvenience to the relatives. 

The reply of the Rcgislrar-Gcneral is contained in the 
B.M.J. Supplement of 21st ' January, 1928 (p. 22), and is, 
briefly, to the effect that in certain cases a practitioner may 
hand the certificate to a mes.scnger for personal delivery to 
the Registrar, nlthoiigh in so doing the practitioner does not 
divest himself of responsibility for the loss of the eertificate. 

Alleged Encroachments on the Domain of Priv.4te Practice. 

91. The Council, arising out of Minutes .101, 163, 166 and 

220 of the Ammal Representative Meeting, 1027, has set up a 
special Committee to consider the question of the alleged 
encroachments on the domain of private practice resulting 
from medical services rendered by the State, local health and 
education authorities, voluntary bodies and hospital contri- 
butory schemes. . . , 

' With a view to obtaining exact informatimi on the 
subject the Council, with the co-operation of the Society of 
Medical Officers of Health, has issued. a questionnaire to all 
whole-time Medical Officers of Health in England, Scotland. 
Wafes and Northern Ireland, enquiring as to the number of 
whole-time and part-time medical officers employed in t^se 
services and how far hospital services arc made use of. Iho 
Medical Secretary is also making detailed personal investiga- 
tions into tho health services in certain areas which 
specially selected on account of the different methods of 
administration prevailing. A considerable amount of attention 
has been devoted to the question of the inroads into private 
practice occasioned by contributory schema for hospital 
benefit The Council does not propose to report on this very 
important subject until its enquiries are completed and an 
adequate report can he presented to the Representative Body. 

International Medical Sea Code. 

92. The Council, being of opinion that there exists a 
vrimd facie c.-ise for the establishment of an Iiitemational 
Medical Sea Code, has had before it reports on this matter. 
A considerable amount of work has already been done .lij 
other countries and organisations in the direction of improving 
the facilities ' for inter-communication between ships at 
and between ships and land stations, for medical purposes, 
inasmuch as the League of Red Cross Societies has the mattci 
in hand and the Belgian Government has earned out .a senes 
of experiments to test the Medical Intelligence Service 
organized for seamen in Denmark, Norway and Sweden, me 
expressed opinion of many of those who have made 

tive tests ou tlie merits of transmission of .messages by epac 
or in the ordinary manner is that the latter is the mure 
advantageous. 

The object of tbe Council is, if possible, to Help to hriug 
about a state of affaire which will facilitate matters from tbe 
surgeon's point of view when he is asked by the master , ot a 
ship other than his own for advice as to the treatment oi » 
patient, and the Council is of opinion that any system wmen is 
to he of inlcrnatidnal value must be based on a code. It iias, 
therefore, been decided to make an eifort to draw up 
questionnaire on the signs and symptoms of disease for tne 
Use of Master Mariners when seeking medical advice by ^^^9" 
less from n surgeon ou another ship or on shore, J 

proposed at a later date to approach the Board oi , 
with a view to the questionnaire being translated into c 
foT incornoration in the International Code of Signals. 





152 Apeil 28, 19281 


Report of Council t 


r svrrurmisT to tk* 

LUlilTlHn 3IEIHCA1. Joun.VAl 


tip of the maternity and child welfare clinics. has undoubtedly 
BTOused a much g-reater interest in pre-natal and child welfare 
work. 

The Council recommends : — 

Recommendation A : (i) That the education of all mothers 
in preventive medicine, as applied to the care of the 
infant and the conditions of the home, is desirable; 
(ii) that it is considered that there already exist 
means by which both of these objects may be partially 
attained; (iii) that any ftirther establishment of 
special paying centres should be for the purpose ot 
education and health propaganda and not for the 
purpose of treatment; and (iv) that should mothers 
prefer to avail themselves of paying centres 
it is desirable that attendance at such centres should 
be with the knowledge of the family medical 
attendant. 


Recommondation B : That with reference to paragraph (ii) 
of the foregoing recommendation, in view of the 
recognised importance of preventive medicine at the 
present time, it is felt that the private practitioner 
with his knowledge of the family and home conditions 
is the best person to give such advice and should be 
strongly urged to undertake this important duty. 

Recommendation C : Th.at any body of persons considering 
the formation of a Paying Centre for Infant Hygiene 
should communicate with the local profession, pre- 
ferably through the local Division of the British 
Medical Association, with a view to obtaining their 
co-operation. 

Recommendation D : That the local medical profession 
should be represented on the Committee of Manage- 
ment of all Paying Centres for Infant Hygiene. 

Recommendation E : That it is for the Committee of a 
Paying Centro for Infant Hygiene, on the recom- 
mendation of the local medical profession, to decide 
whether the medical staff of a Paying Centre shall bo 
selected from among specialists or general practi- 
tioners, whether from those practising in the area in 
which the Paying Centre is located or from thoeo 
who are practising outside that area. 

Recommendation F : That the remuneration of the 
medical staff of Paying Centres for Infant Hygiene 
must be a matter of arrangement between the Commit- 
tee of Management of the Centre, and the local medical 
profession, preferably through the local Division of 
the British Medical Association. 


Recommendation C i That the following be suggested as 
Model Rules for Paying Centres for Infant Hygiene : 

(i) That the object of the Paying Centre for Infant 
Hygiene is to give education and advice to eubscribera 
on the general welfare of children, up to 5 years of 
age; 

(ii) that it is desirable that any mother wisliing to 
attend a Paying Centre for Infant Hygiene should 
inform her family medical attendant of her intention 
.^nnd obtain liis co-operatiou ; 


^ii) that should any case of illnes.s be discovered at 
\ Centre for Infant Hygiene, the subscriber 

shall be referred to the famiy medical attendant; 

(iv) that the medical officer of a P.aying Centro 
for Infant Hygiene shall not be at liberty to attend 
the children of subscribers in case of illness, except 
m consultation with the private medical attendant 
of tlie family; 

(v) that in no case shall medical advice be given 
by correspondence, or on the telephone, either by the 
medical officer or the nurse-superintendent; and 

(vi) that subscribers must not bring to the Centre 
children who have been in contact with infectious 
disease or children who are actually ill. 


Peotectiox op Unborn Chii,ijeen. 

9G. The Council reports that the Public Health Section of 

the Annual Meeting, 192G, passed the following resolution : 1 

Resolved : That the Council be requested to approach 
the Government with a view to securing legislation to 
protect the unborn child against intentional viol.-nce until 
all parts of it are completely born, i.e., during its passage 
from the mother’s body. 

In the discussion in the Section, it was stated (i) that 
there was no statutory definition of live birth in English law, 
only a formula accepted by what is known as " commen law,’’ 
nnd (ii) th.at the rulings laid down by Judges, and now 
generally accepted, were to the effect that in order to be bom 


alive a child must show some signs of independent existence 
I after every portion of its body was free from the mothcr’i 
parts, and that fherefore the killing of a child during the 
process of bh-th, and before it was fully Imrii, was not an 
offence under the present law,‘ a.s, in order that murder could 
be perpetrated, the victim must have had a scjiaratc existence. 

In view of the fact that the Births and Deaths Regis- 
tration Act, 1926, which came into operation on 1st July, 
1927, perpetuates this legal position the Council is of opinion 
that no useful purpose would bo served by sn attempt, at 
any rate at' the jircsent time, to take action on the lines 
suggested in the above-quoted rceolution of the Public Healtl; 
Section, 1926, and which would require fresh legislation. 

WoRKSIEN’S COIIPENSATION. 

97. The Council has considered the following motion by 
Chestei-field ■nhich the Annual Representative Meeting 1927 
(Minute 150) referred to it : — 

That the Association is strongly, opposed to tho 
pr.actico of some intipectors, not being medical men, 
acting on behalf of Employers’ Liability .Insurance 
Companies, of requesting or suggesting the removal 
of properly applied dressings, when visiting injured 
workpeople, in order that they may see the inju^, 
nnd instructs tho Council to enter a vigorous .protest with 
renresentatives of tho Compensation Insurance Companies. 

> The Division, in submitting tliis motion to the Repre- 
sentative Body, had in mind the fact that one of its member* 
had found that tho dressings he had applied to a patient had 
been tampered with ’oy a lay inspector of a Compensation 
Society. Enquiries were made cf the ■ society and it was 

■ ascertained that it vias the practice of their inspectors to 
ask to see the injuries in order to satisfy themselves that 
there was a cause for incapacity, but that the inspectors did 

I not interfere with' dressings .applied by doctors or-nurses or 
insist on seeing the injuiy if tho workinau objected. •' 

As there is no body of evidence that Compensation 

■ Insurance Companies’ Agents remove dressings which have 

been applied by doctors, only one sucli instance having been 
reported, tho Council is of opinion that there is no case -for 
action on the lines suggested in Minute 150 cf the A.R.M. 
1927. • 

' Registration of Nursing Homes. 

98. 'Under the Nureing Homes Registration Act, 1927, which 
will come into operation on 1st July, 1928 (and which doe* 
not apply to Scotland or Ireland), tho main points which affect 
the medical profession are (i) that nursing and maternity 
homes are required to bo registered, the only exceptions being 

(a) any hospital or institution not carried on for profit; and 

(b) any nursing home c.arried on in accordance , with the 
practice nnd princi 2 )lcs of the body known as the Church of 
Christ Scientist— a condition for the exemption of the latter 
being that such home shall adopt and use the name of 
Chriltian Science House; (ii) that the local supervising 
auOiorities shall be fa) for the County of L-ondon, the London 
County Council; and for the City of London; the Common 
Council, the London County CouncU being empowered to 
deleo-ate any of its powei-s under the Act to metropolitan 
borouo-hs; oud (b) for the remainder of the country, the 
County and County Borough Councils, the former being em- 
powered to delegate any of their powers or duties under 
the act to District Councils ; (iii) that the certificate of regis- 
tration shall be kept affixed in .a conspicuous place in th* 
nursing home; (iv) that the local supervising authority may - 
make By-laws : — 

(a) prescribing the records to be kept of the patients 

received info a nursing home, ' and in the case of a 
maternity home, of any miscarriages occurring iA 
homo, and of the cliildren born therein and of the children 
so born who are removed from the homo otherwi^ than 
to the custody or care of any parent, guardian, or 
relative; ' 

(b) requiring notification to be given of any death 
occurring in a nursing home ; 

(v) that the M.O.H., a qualified ‘nurse or other 
authorised by the authority may at all reasonable times 
enter and inspect any premises used, or believed to bo used, 
as a nursing home and to inspect records, other than mediMl, 
required to be kept; and (vi) that the Act contams tho 
following definitions; — - j 1 

“ Nursing Home ” means any iiremises used or intended 
to be used for the reception of and the providing o 
nursing for persons suffering from any sickness, 
or infirmity, and includes a maternity home, but does n 
include — 

(a) any ho.spital or other premises maintained or 
controlled by a Government department or i 



!V!cdicO“Poimoal. 


r firrrT.r.iTT.ST to mr. 

Uir.iTiBii jiKtiicii, Jocns<r. • 


Al'UIt. 28., 10281 


mitliority or by ony othor body oC porso.ts conflUKttol 
by special Ad of I'arliiinieiit or incorporated by iloynl 

Cliartcr: ' ,,,, ,, _ 

(b) any insUlnVion tor Iw'nlics tbc tueaning 

of tUo tiunacv Ad, 1S90; . ■ ‘ 

Many cc.difictl insfitiitioii, rcrlibcd boiisc or ap- 
proved home oitbin tbo ineaimig of Uic McnVal 
ilcficicDCy AcV, lbl3. 

"MoternUy Eoiuo " weans any premises used or' 
intended to bo Used for tbc rceeplion of pre^rnant women 
or of women inuncdiatcly after cbildbirtb. 



bad before tbe conunenecmcnl of tbia Ad. completed tv 
three years’ course of training in a hospital wliicU was 
during tbo period of lier training, or subsequently 
became, n training scbool npproved by tbo Generat 
Kursino Council for England and Wales, or tlic General 
A'ursing Council for Scotland, or the General Nursing 
Council for Kortlicm Ireland, for tbo purpose of admission 
to tbc general part of tbc said register. 

The Council has considered the draft model by-laws ■ 
whicb tbo Ministry of Health proposes to issue to local 
Eupervising autborities unilcr tbo' Act and bas suggested 
certain amendments. 

PosmoN OF Docrons' IIocsr,s -cunna Nonsiuo HosiM 
Itr-oiSTRATiou Act, 1927. 

99. As questions will undoubtedly nri.se in (he near future 
as to tbc position of doctors wbo take one or two patients 
into tbeir private bouses, tbc Council lias made cuquiTies 
as to what their position will be under the Act. It is 
dilBcuH to dogmatise but it appears tbnt, generally speaking, 
the position will bo governed by what llie doctor imdcrlakeB 
to do for such persons ns ho receives into his house. 

If ho habitually takes in p.Tlients and provides nursing 
it seems likely tluvt be will liavo .to register, but the question 
is one whicb must be settled by the local authority, nnd any 
•doctor who is in any doubt as to his position would be well 
advised to discuss tbo matter with the local Medical Ofliccr of 
Health. It must not be forgotten that the Act lays down in 
its definition of a nursing home " any premises used or 
intended to be used for the reception of, nnd the providinp 
0 / nursing for, persons suffering from any sioknos.s, injury, or 
infirmity," and from this it would apiwar that the habitual 
provision of nursing is the guiding lactor. 

Ante-Natau Br.conn Ponst for 'Osn nr Midwives. 

100. 'Ondcr.tlic 1927 Itulca of the Central Midwives Board it 
is laid down that “a midwife must keep notes of he.r' ante- 
natal risi^ in the form approved by the Central Midwives 
Board.' This form involves the use of tlio stetncscope and 
• pelvimeter both of which instruments the Council considers 
jnidwives are not competent to use. The Council has pointed 
S?.,’ . bhioction to tbe Ministry of Health and the Central 
Midwives Board. 

EXAMIKATIon' OF EstlORAKTS TO CANAHA. 

£, }??■ If'® Oversea Settlement Oincc (now tbc Oversea 

j. of tbc Dominions Office) prep.arc3 a 

practitioners for the medical examination of 
‘'‘® Overseas IJomimons, tile fees 
hpiin 1 candidates for such e.xaminations having 

TW.Snt -lEsociation and the MigratioS 

Departaents of the various Overseas Governments. ^ 

s\“Vr a’-.'/sire 

debarred from entorin^ into* nrivn+n rSr • " ^ 

!" S“® Tfi-'SliS G.™™; 

g: «■!„?:, tuTSr «' dSS.i.'E'-iS 

ll.,re i, differEnc. J pJotession,! 

constitutes mental defectiveness! luTthera 
il. to give tbe emigrant the benefit 

arrival ' 

. For these reasons tbe Canadian Government ba= toi. 

SUiTA'" Sr,'lK 

tu.. 5”»bj SS i) °L'Kr«" 


Examination or Emiorants to A-cstralia.' _ 

102. It has been nsccrfaiiicd (hat thc_ Government of 
Aufitrnlin has followed, bo far ns London is concerned, tbo 
example set by tbo Canadian Government and has appointed, 
for a trial period of 12 months, 3 wliolc-fime. Australian 
medical practitioners to work in ami around London in 
cxinnining emigrants for Australia. This means that London 
practitioners whose names arc on the roster drawn up by the 
Iloiniiiion Governments for the examination of emigrants arc 
lo.sing tbc work. Meantime, practitioners on tlic roster are 
iieing asked to give a good deal more detailed information 
in their reports than they were asked for when tlie Association 
mgreed io Die fees lor the examination, and the mailer m 
being taken up witU the Chief Medical Officer at Australia 
House. 

Thaw. Disputts anh Trade 'Dnions Act, 1927- 

103. The ilinistry of Health has informed the Association 

that in the view of the Treasury there is nothing in 
tbe Civil Service (Approved Associations) Hegulations, 
1927— made by tbe Treasury in pursuance of the Trade 
Disputes nnd Trade Hnions Act. 1027— to prevent an cetab- 
lislicd civil servant hclpngiiig to the Association. ■ 

Conthact Hate for Juvenile Oddfellows. 

101. The Alancbcstcr Unity of tbc Independent Order of 
Oddfellows Biiggc.stcd tliat the Association .should consider 
the adoption of a standard fee for medical attendance on and 
tbc provision of medicine for juvenile members of the Society 
tlirouglioiit tbc whole country, nnd the question has been 
discussed between represcntalivcs of the two bodies. 

The policy of the Association as regards medical 
attendance on nnin.'uircd persons is as follows and was adopted 
by the Annual Hcprcscntntivc Meeting, 1920 : — , 

Minnie 109. — That tbe Hcprcscntativc Bcdy adopt tbe 
following principles ns essential to tbe formation of any 
Bcbcmes for tbc provision of medical attendance and treat- 
ment of uninsured persons : — 

(1) Tbnt, in general, in considering tbc necessity for 
obtaining the approval of the Council for schemes for 
the treatment of uninsured persons upon contract terms, 
the following principles and conditions must bo adhered 
to : — 

(a) Free choice of doctor by p.iticnt nnd of patient 
by doctor; 

(b) Hemuncration to bo not less than that which is 
deemed by the Council to be equivalent to that paid 
in respect of insured persons; . 

(c) Persons with a total income from nil sources of 
£250 per ntinum or upwards, or tbc dependants of 
any such person, not to be treated under contract 
terms at all. 

(2) That the Eeprcsent.atiTe Body realises that- tbo 
• conditionB in certain areas will not allow of tbc above 

' terms being obtained, and that in these circumstances 
the approval of the Council may be given provisionaliv 
to a scheme involving a less payment when tlic local 
profession can show that the economic conditions in the 
area demand it. 

(3) Tliat one of the conditions necessary for the 
approval of schemes containing lower rates of payment 
shall be, the inclusion amongst the Tulcs. in a prominent 
position, of a statement that ap 2 )rov.al by the Association 

^ • has been given to the rates only because of special 

economic conditions. 

will be seen this policy makes no difTerentiatibn 
between juveniles and adults, but as a matter of actual 
practice it bas been found that tbe fees obtained in respect of. 
juveniles are almost universally lower than those ob 
tivined in respect of adults. The proposal which was 
eventually made at tbe conference referred to above 
Avas that a standard rate of Ss. 8d. per head per 
annum including the provision of drugs should bo adopted 
as the remuncTation of medical practitioners for medical 
attendance on and the supply of medicine for juvcuile membeU 
,ot the fcociety. The age limits of the juveniles concerned 
vary, but in many branches of tbe Society tlie awe is fro-n 
birth to 1C years. The Directors of the Order a« prepared 
fsubjcct to confirmation at the Animal Conference^ ot the 
Order to be bold 28tb May-2nd June, 1828) To advocate 
genera] acceptance by juvenile branches of tbo society of tbi, 

8s.-8iL% cStaWy ’TTvTr'Thif^th!’'llion^^ Health 


154 April 28, 1928] Report of Council: [n.,m»rSSjj„S5,T, 


Insui'ance capitation rate, is of opinion that there are com- 
-paratively few areas in wliich contract attendance with 
medicine on juveniles is paid for at a higher rate. Moreover, 
the position of the juvenile differs very materially from that 
of the insured person inasmuch as the latter is subsidised as 
regards his medical attendance both by his employer and by 
the State, whereas the whole cost of medical attendance 
on the juvenile falls on the parent who is often in poor or 
comparatively poor circumstances. Again, the service provided 
for juveniles under the proposed new arrangement would differ 
materially from that given to insured persons — it would bo 
subject to no regulations and the bugbear of certification 
would be almost eliminated. For these reasons amongst 
others the Council favours the adoption of the proposal of the 
Society, and recommends; — 

Recommendation : That the Eepresentativc Body approve 
a standard rate of 8s. 8d. per head per year 

including drugs for the remuneration of medical 
practitioners for medical attendance and medicine 
for juvenile members of the Manchester Unity 
of the Independent Order of Oddfellows; that 
, the Council be authorised to approve a slightly lower 
rate than 8s, 8d. per head per year, for a time to bo 
definitely stated, for application in any area in which 
it is satisfied that owing to economic conditions the 
standard rate of payment is not feasible; and that 
it be an essential part of this arrangement that there 
must be free choice of doctor by patient and of patient 
by doctor. 

Conthidutoky Schehes fob Hospit.\l Benefit in Efxation to 
Education Authoeities. 

105. It has been ascertained that some education authorities 
which have hitherto paid fees for medical attendance on 
school children are talcing advantage of the existence of 
contributory schemes for hospital benefit by advising parents 
of children who need medienl attention and who arc contri- 
butors to one of these schemes to send their children to the 
hospital either direct, or after consultation with the family 
medical practitioner, thereby obviating the necessity of fee's 
being paid for them cither by the education authority 
or by the parent. In the opinion of the Council it wa's 
never contemplated that contributory schemes for hospital 
benefit should cover the provision of treatment for children 
found defective on school medical inspection, these services 
being already provided for by the education authorities 
in most areas. In any existing contributory schemes for 
hospital benefit where treatment for children referred by 
school medical inspectors is not excluded, the Council advises 
the Division to endeavour to get the scheme amended in 
this respect, and in those areas where contributory schemes 
for hospital benefit are contemplated, the Council advises 
the corresponding Division to urge that the scheme shall not 
include these children. 

Further ; — 

• (i) that medical practitioners should be warned that in 

their own interests -they must take the necessary steps 
when hospital contributory schemes are being set up to 
SCO that the three fundamental principles enumerated in 
the Hospital Policy of the Association are enforced, 
namely : — 

(a) that membership of a contributory scheme should 
be governed by an income limit; 

(b) that except in emergency a contributor to a 
scheme should only be admitted to hospital on the 
recommendation of the attending practitioner; 

(c) that financial recognition should be made of the 
services of the medical staff of the hospital attending 
members of a contributory scheme; 

and that, with reference to the last paragraph, the 
Council wishes to make it clear that in regard to operations 
on school children (where such fail to be excluded from 
the scheme) the words “ financial recognition ” should bo 
understood to mean cither a percentage of all contributions 
made by the contributory scheme, or the fees which have 
been laid down by the Association for medical practitioners 
employed part-time in school medical work, which should 
be secured from the hospital authorities; and 

(ii) that the medical staffs of the hospital should refuse 
to perform operations, without a fee, on any- children for 
whom the education authority makes itself responsible. 

Blind Peesons Act. 

lOG. Consideration has bceii given by the Council to the' 
question of fees for the various certificates called for under 
tlie above -Act. It appears that in connection with arrange- 
ments for the welfare of the blind in England and Wales 
medical certificates of blindness may 'be required for .the 
following purposes : — 


(a) to support a claim for a pension under the Blind 
Persons Act, 1920; 

(b) to support an application in respect of a blind 
person by a local authority or voluntary agency for grant 

.out of public funds under the Eegulatious made under the 
Act, for grant for the welfare of the blind, or under the 
Education Act; 

(c) to obtain evidence of blindness before the registra- 
tion of a blind person; and 

(d) to support an application for assistance to a 
voluntary agency by a blind person in respect of whom 
no gr.ant out of public funds is available. 

If the Minister of Health in considering an appeal 
arising in class (a), either by the aiiplicant or the Pensions 
OlBccr, deems the evidence of blindness submitted to ho 
sufficient to establish a claim, a claim is allowed. If not, the 
case is referred by the Minister to the local Eegloiial Medical 
Officer for examination. If the case appears to be one of 
special difficult 3 ' it may be referred, with or without previous 
reference to the Ecgional Mcdic.al Officer, to an ophthalmic 
surgeon for examination and report, and a fee of i3. 3s. Gd. 
is paid bj’ the Exchequer for this service. 

So f.ar as cases coming under ahovo category (d) arc 
concerned the Council docs not see fit to make any suggestions 
as to the charging of a fee. 

So far ns fees for the other cases are concerned the 
Council recommends : — 

Recommendation : That except in cases of special 
difficulty which are referred by the Ministry to an 
ophthalmic surgeon and for which a fee of three 
guineas is paid, the Council is of opinion that the fee 

. for medical certific.atcs of blindness for anj- of the 
following purposes should he one guinea : — 

(a) to support a claim for a pension under the 
Blind Persons Act, 1920; or 

(b) to support an application in respect of a blind 
person by a local authority or voluntary agency for 
grant out of public funds under the regulations, for 
grant for the welfare of the blind, or under the 
Education Committee; or 

(c) to obtain evidence of blindness before the regis- 
tration of a blind jxjrson. 

Medical Defence: X-Eay Examinations. 

107. Arising out of correspondence with .the York Division, 
the Council has considered whether or not it is possible to 
define a group of injuries to bones or joints, the diagnosis and 
treatment of which can be said in advance not to require 
examination by X-rays. 

■ The Council recommends that the E.B. should make the 
following pronouncement : — ^ 

Recommendation : That it is not po.ssible to define a 
group of injuries to bones or joints the diagnosis and 
treatment of which can be said in advance not to — 
requii'e examination by X-rays, and that w’hethcr such 
an examination is or is not necessary in an individual 
case can he judged only by the practitioner concerned. 

Clinic foe State Teeatment of'Eheu.matis5i in_ London. 

108. The British Committee on Eheumatism of the Interna- 
tional Society of Medical Hydrology, in conjunction with 
the British Red Cress Society, decided to build and equip 
in London a 'clinic for the physical treatment of rheumatic 
diseases, for which object a public apjreal was issued in 
March, 1927, for tha necessary funds and supported, amongst 
others, by Lord Dawson of Penn, Sir Thomas Border, and 
Sir Humphiy Eolleston. Although the- Association was 
invited to support the appeal, time did not permit of the 
matter being submitted to the Council at its April meeting, 
with the result that the Association took no part in the 
appeal. 

It would appear that the proposed clinic is the' outcome 
of a visit to Germany, on the invitation of the Geriuan 
Minister of Health, of representatives of approved societies, 
indnstrial managers, and physicians, to inspect the various 
industrial clinics for the 'treatment of rheumatism in that 
country at which both in- and out-patients are treated. Some 
of these clinics are run by private companies, some by the 
State, and' a large number by State insurance sick funds 
which, in Germany, are administered on a territorial basis. 

It has been ascertained that no patients will be treated at 
the proposed London clinic except on the recommendation of a 
duly qualified medical .practitioner, and that both insurra 
and non-insured persons, able and willing to paj' a reasonable 
fee for treatment will be dealt with while at the same .tnc® 
continuing in their normal occupation. Eventually i - 



Arnit, 2S. ires] 


Lunacy and Mcniat Disorder, 


f SVPTLF^ST TO nt* 
LnniTiRii sirwcit. Jouewiti 


1SS 


hoped to inntce tbc clinic Hclf*s«]>jmrHup. Ccrtnin infonnalion 
hub been obtained nnofTicially to the principles iipon wliicb 
the clinic will be run, nnd the.se .‘>eein sntisfnclorv. In these 
circumstances the Connell has thought U well, as xi first slop, 
to approach the Coininlttce oT the clinic with a request that 
the Associnllon be rojireseiiied on the Goveijilnij Body of the 
clinic. 


Ckstril EMEnci:\*CY Fund, 


109. This Fund was created in 1003 wltli the object- of 
n^istin" mcmlwrs of the Association to inaintnin the inlorc.sts 
of the jirofession against orp^anised tmdies, by pTr^TUts which 
c^not be made out of, the funds of the Association. The 
Fund is ndniiinstored by the xnombors of the .Mrdiro-Political 
Comnnltco who act ns trustees, and is entirely supiwrted by 
voluntary contrilmtions. ^ n j 


Grants arc n.'oially ^ivon if a doctor has sufTcred 
nuancial loss as a of snpjiojiin/: the policy of tbo 

A>?oc.iation. Thoii|'h recently no dcmxnuls have hi»cir made on 
the I nnd p.ut cr])cricncc shows that the Ihind is a most 
useful weapon to have in re.^erve. The Council therefore 
recommends it to the support of mcnibers. 


Causation o! Puerperal Morbidity and Mortality. 

Council to report 

tl . r^erperal morbidity and inortnlitv and on 

tliD ndministrahrc acHon. if anr. that should be 'tden in 

investipaUons. 

St SR F<-l>r«aiy. 1928, p.ioos 

Jaunnry 19‘’3'\pVn^ ” conference hold on lltli 

aTTMortaltt^’^i.!-H*’'® ''»''«>ciaUonV rucrporal Morbidity 

Collooc ot Inr^inL f Plir^d.sns of London. U.o Ilornl 

J. S. PairSrm morbidity,” by Dr. 

XiTnernc™! propbyl.iyis and 


o ijjv wjutTcnce. 

Appendix ^lortality be 


Causation 
adopted (s 


I'Tinaoy and Mental Disorder. 

consider 

Mental Disorder (as TcooTii^°r?' Commission on Lun.icy 
Tins Committ ^ Engbind and Wales). 
rpsolnlious of the con.sidered the foHoi 

referred to it;^ Pfc-entative Body. 1927, wliicli 

the Lunacy^ Law^nd' ^’ tl 

Memorandum on the for 

Lunacy Law and Men^l^- j iloyal Commissio 
• ?'''* request the Coun^l to 
instnietions to tate whit., tl*® Committee 

, what the Beport of the Bovol possible to sc 

■fair.” namely, that ‘he t 

. be ashed “ to perform profession should 

menace of litig.afen which «• ' P“t under 

financial or professional niin.”" ""successful may , 

Council to 'consider t^e'' dcsirlb^l^^^ it be rcferreci 

Legislature that the judicirrautb^ “pen 

Act of 1890 must issniir 1",^“’*^^ “’‘tier the Lui 
commitment of a person , r^pensibility for 

and (u) ijiat judicial -.n'tln ““^oimd nr 

Court Judge or a f either a Cai 

*"ch as a medical bOTtst^ ^ ‘ cinaUf.cat 


Minnie 190. — Hesolvfd ; Tlml it be referred to the 
Council to consider the need for the proyision of 
‘‘Observation Ward.s ” to which p.aticiiLs c,tii he com- 
jnilsorily e.cnt where conditions, whilst doubtfully 
justifying certification, arc sucli as make them a nuisance 
or danger to thcmKchc.s or others. 


J12. With referenre to Aliiiute J8G of (he Annual Bepu- 
isentatirc Meeting, 1927, the Mcmorandiitn of Kvidence whirli 
was rmbmitted by fie Council on bcb.alf of the Association' to 
(he Boyal Commi.siiirin on Lunacy and Mental Disorder on lltli 
Jnnunry, 19‘25, cIiiMiied for prnetilioners who signed medical 
cerlificatcs under the Lunacy Acts the immunities granted to 
medical witnmwcs in courts of law, the p.aragrapli of the 
evidence dealing with the malter reading as follow.s ; — 

CS. While it is dc.sircd to guard against the eleyntion 
of the medical certificate to a position of authority wliicli 
it docs not jio.s.sc.ss, there is no wish to undcpcsliroale the 
great importance of the certificate ns cvideuce. 

Indeed, it is desired to insist upon it.s being given very 
definitely the status of cvidcncci nnd, therefore, that, 
tlic protcelion which witiicssp.s in courts of law are 
entitled to receive shall be extended to the practitioner 
who aigns a certificate under the Lunacy Acts. 


The Boyal Commission in paragraph 90 of its report 
atnted : — 

‘‘ The British Medical Association submitted proposal.' 
designed to secure that the doctor's certificate should be 
trented simply as cridcncc upon which the judicial 
authority makes the operative order, and that the doctor 
should enjoy in respect of the contents of that certificate 
the same immunity as a wituc-ss testifying in a court of 
law. Tliis, of course, would provide the liighcst possible 
privilege, involving complete immunity even for a medical 
prncHtioner who gave n certificate negligently or in bad. 
faith. The medical witnesses, liowc\-cr, have made it 
clear that they haiu no desire to protect a practitioner 
from the consequences of such conduct. In our view, the 
provision of absolute privilege could not he defended, but 
wc consider tliat the certifying doctor should not be 
exposed to an action in rmpcct of anything done under 
the Act, unless the plaintifi can first satisfy a Judge in 
Chambers that there is primo facie ground for an orici'a- 
tion of want of good faith or reasonable care.” ° 

and recommended that the law. bo nmendod so as to provide 
that medical practitioners nnd others in the bona fide dis- 
charge of their duties under the 1890 Act slionld not be liable 
to civil or criminal proceedings unless it could bo shown that 
they had acted in bad faith or witiir.ut rea onnijlc eaie, me 
terras of tlic recommendation of the Eoyal Commission beiii'i' 
no follows : — ° 


‘‘We recommend that Tor the more effcctiTo protcction o'; 
medical men and others in the bona Jiac discJiarne ot tlieir 
duties iindcr the Act (i.c., Lunacy Act. 1890), Sjction 330 
Buould be BO nTnenaod to provide that any .fneh person 
shall not 1» liable to civil or criminal proc^iiigs unless 
he has acted in b.id faith or witnout roasoa.iolo care; 
and that any procecding.s taken against such a person shall 
be elayed upon a summary application to the IligU Cou-t 
Cluambers unless the Court or Judwe is 
satisfied that there is substantial ground for nllcginAhat 

carl”“ roasonablo 


from (he Assopialion, at (Jie invitation 
of tlie Board of Control, discussed tlio subject-matter of the 
foregoing recommendation of the Boval ^Commissimi with 
representahres of the Board and was informed that the 
Miiviuced ot the need for the further 
1 °^ practitioners who signed certificates under the 
Lunacy .^t, was considering the drafting of a short ‘Pa-lia 
.mentary BiU dealing with voluntary boarders' and incor'oor' 
nting this recommendation of the Boval Commission' .^^Pi 
matters dealt with in tl.e Beport of the EoyaTcZmif 
being loft over until a later date. The Chairman of nZu a 
said that if any Bill dealing with tL pZc’tiL^ "f 
practitioner were to h.avo a chance of becoming Kw if, ‘ 
be non-contentions and stated that if tUo A... must 

for a provision that tlZ JuZ i„ Vl on,f 
Court hearing a summary adfecatioif Z ^ 
should take the uvidenc/ of^an'^’indcnemlpn^” f -Appeal 
practitioner appointed for the purpose bv tbo^’r medical 
the Bill would become contentioiS and s+an.i ^ i Loverumoiit, 
of being passed into law, H^aid ?baf rtf 
inclwtTc such a prorision in its B 11 biZ^° Bo-Yd could not 
Association migfo put down iHi aZ. ®"SS.''='Aed that the 


fse Apbil 28, 1928] 


Report of Council! 


r SVPFLKULKT ID rm 
LBniTisn MEDICAL Jocexal 


Tile Council tliereupon adopted tlie following resolu- 
tion : — / ■ 

That the following recommendation of the Eoyal Com- 
mission on Lunacy and Mental Disorder, namely : — 

" Wc recommend that for tho more effective protection 
of medical men and others in the bona fide disenarge of 
their duties under the Act (t.e., Lunacy Act, 1890), 
Section 330 should be so amended as to provide that 
any euch person shall not be liable to oivil or criminal 
proceedings unless he has acted in bad faith or without 
reasonable care; 

and that any proceedings taken against such a person 
shall be stayed upon a summary application to the High 
Court or a Judge in Chambers unless the Court or Judge 
is satisfied that there is a eubstantial ground for 
alleging that such act was done in bad faith or without 
reasonable care,” 

affords adequate and reasonable protection to the certify- 
ing medical practitioner, provided that the Judge in 
Chambers, or the High Court hearing a summary applica- 
tion, or the Court of Appeal, shall have the assistance of 
an independent expert medical practitioner who shall be 
selected from a panel of practitioners appointed for the 
purpose by the Government, and that eteps bo taken to 
secure, by consent, that effect be given to the views 
expressed above in any legislation on the matter that may 
be introduced into Parliament. 

114. With reference to Minute 188 of the A.ll.M., 1927, the 
Council reports that it is not able to endorse the suggestions 
contained therein because, with regard to part (i) it has, as 
stated above, adopted the policy set out in relation to Minute 
186 of the A.E.M., 1927, for securing the protection of medical 

E ractitioners and has based that action partly on the widely 
eld opinion that for tho more effective treatment of those 
suffering from mental disorders, it is desirable, if possible, 
to avoid the necessity of bringing in a judicial authority; and 
with regard to part (ii) of Minute 188 of the A.K.M., 1927, it 
is of opinion that it would be impossible in many areas to 
obtain in emergency tho services of the persons specified in 
that resolution. 

115. Minute 190 of the A.R.M., 1927, is dealt with, as are 
tho other relevant resolutions of 'the A.E.M., 1927, in the 
appended Memorandum dealing with tho Beport of the Eoyal 
Commission (see Appendix V). 

Recommendation : That the Memorandum (Appendix V) 
on tho Eeport of the Eoyal Commission on Lunacy and 
Mental Disorder (as regards England and Wales) be 
adopted. 


Fublio Health and Poor Law. 


Status of Disteict , Tubeeculosis Officees. 

115a. The' scale of minimum commencing salaries for whole- 
time public health appointments does not contain any defini- 
tion of “ District Tuberculosis Officers ” and as there are 
several areas which now appoint officers with that designation 
the Council has considered what definition should be adopted 
by the Association in order to determine the application of 
the scale to such appointments. As the general application of 
the scale has the approval of the Ministry of Health the 
Ministry was consulted on this matter ond has approved tho 
substance of the recommendation set out below ; — 

Recommendation.: That in order more closely to define 
the status of district tuberculosis officers under ■ the 
scale of salaries, it be laid down that all tuberculosis ■ 
officers whose clinical work in areas is not subject to , 
detailed supervision by the chief tuberculosis officer 
be considered, for the. purposes of the scale of mini- 
mum commencing salaries, to be officers in charge of 
departments, and thus entitled to the minimum 
commencing salary of £7o0 per annum. 


Puouc Education in Health. 

116. The A.B.M., 1927 (Minute 198). approved a memoran- 
dum on the action which could be taken by Divisions and 
Branches in assisting in the education of the public jn health 
matters and instructed the Council to take all necessary step* 
to put the proposals into operation. Copies ^ the memoran- 
dum were distributed to all Divisions and Branches of the 
Association in England, Scotland, Wales and >orthem 
Ireland on 14th October, 1927. together with a covering letter 
ur-’int- that the units of the Association should lose no time 
or'’oppor.tunitv in getting their local authorities to take up 
tho matter of'thc education of the public in health matters in 


accordance with their powers so to do as contained in the 
following section 67 of the Public Health Act, 1925 ; — 

67. — (1) Any local authority or county council may 
arrange for the publication within their area of informa- 
tion on questions relating to health or disease, and for 
the delivery of lectures and the display of pictures in 
which such questions are dealt with,- and may defray the 
whole or a portion of expenses incurred for any of the 
purposes of this seetion. 

(2) Tho Minister of Health may, for the purposes of 
this section, make rules prescribing restrictions or condi- 
tions subject to which the powers conferred by this section 
may bo exercised. 

Eeports received show that many Divisions have taken action 
and ate co-operating with their local authorities. The Council 
trusts that this important sphere of activity will be regarded 
as one of the regular activities of each Division. 

The Council in its Supplementary Eeport for 1926-27 in 
dealing with this question stated its intention of assisting in 
this work by promoting lectures to the lay public on the 
lines of the Hastings Lecture, 1927. The Council, therefore, 
arranged for such a lecture (to be known as the Sir Charles 
Hastings Leeturc) to be delivered in the Spring of 1923. 

The Lecture entitled “ The Foundations of National 
Health ” was given on 21st March, . 1928, by Sir George 
Newman, K.C.B., M.D., Hon. D.C.L., F.K.C.P., Chief Medical-- 
Officer of the Ministry of Health and the Board of Education, 
with the Et. Hon. Lord Cozens-Hardy, D.L., in tho Chair. 
The Lecture was published in the S.M.J. Supplement of 24tli 
March, 1928. The Council has conveyed the thanks of the 
Association to Sir George Newman. 

Pathological Eepoets. 

117 Consideration has been given to the' following Minutes 
of the A.E.M., 1927 

Minute 54.— Proposed by the Chairman of the Science, 
Committee : That tho following Eecommendation of 
Council (Suppt,, 23rd April, 1927, p. 145, para. 96, third 
lecommendation) bo adopted : — 

That in the opinion of the Eepresentative Body, 
public health authorities should neither provide for 
pathological examinations nor furnish pathologiml 
reports "on individual cases, except (i) in cases which 
directly involve questions of public health, or (ii) whore 
provision is made for such reports by statutory right, 

■ or (iii) when the patient is stated by the practitioner to 
be, in’ his opinion, unable to pay a fee. i 

Minute 55. — Whereupon an amendment by Brighton 
(L. A. Parry) 

That the third recommendation in paragraph 96 of 
the Annual Eeport of Council be amended by -the 
deletion of paragraph (iii). ' 

The amendment was lost. , 

Minute 56. — ^Whereupon an- amendment by H. S. Sonttar 
(Council), seconded by W. McAdam ' Eoclcs (Council);— 
That the words “ wherever other pathological facili- 
ties are available ” bo' inserted after the words “ That 
in the opinion of the Eepresentative Body.” 

The amendment was carried. 

Minute 57. — On being put as the substantive motion 
an amendment by E. A. Lystor, seconded by C. E. 
Douglas : — 

That the matter be referred back to the Councils 
The amendment was carried; also as the substantive 
motion. 

The Council recommends : — 

Recommendation : That the work of laboratories estiib- 
lished by public health authorities should, in the 
opinion of the Eepresentative Body, neither provide 
for pathological' examinations nor furnish reports on 
individual cases, except (1) in cases which directly 
involve questions of public health, or (2) where pro- 
vision is made for such reports by statutory right; or 
(3) when the patient is stated by the practitioner to 
be unable to pay a fee; provided that in parts of the 
country where facilities for pathological examinations 
and reports are not afforded either bv private piacti- 
tioners '(pathologists) or by the service of the local 
hospital, the local public health laboratory 
properly make examinations and furnish reports as 
these arc required by practitioners for patients who 
are in a position to pay the usual professional fees- 



Arnin 28 , 1928 ] 


Public Health and Poor Lawm 


I EVrPLF.Hr.ST TO THE 
nniTlBlI UCOICAL JOCftfCiL 


1S7 


VaCCINATIOK PnOrAGAMJA. 

118. The l!cprc.<!entaUvc Boily in July, 1927, tin the inolion 
E Southport, passed Uic lollowing resolution : — 


118. Ihe licprcsentalivc llouy in .inly, ]U2i 
bt Southport, passed Uic lollowing resolution ; 

iliuutc 200. — llcsolTcd: That the Council he n.skcd to 
arrange with tho Society of Metlicnl OlTiccrs of Health 
that, in areas where cases of small-pox are known to exist, 
special propaganda work for a-acciniitiou should he 
organised. 

' It was also suggested to the Council that the Associa- 
tion’s pamphlet "Facts about Sinall-pox niitl Vaccination ’’ 
should be on sale at all bootcstalLs ann stationers in ui.siricts 
affected, but the Council is of opinion thnt in oi^er to ensure 
the efficient distribution of raceinution literature ninongsl 
the population it would be necessary for it to be iieuted free 
of diarge, and this would entail the expenditure of a con- 
sidemhlc sum of money. Ijocal nnlhoritiiu- might rca.sonaliiy 
be expected to bear any expense incuricd in their localuiea in 
this propaganda, but ns a uiiniber of local nnthnrities arc not 
in favour of v.accination the necessarv projiiigaiida will 
probably not bo carried out in the areas wli'ere it would be most 
needed. As vaccination is a protection which should alwnya 
be in operation and not only when an epidemic of small-pox 
IS raging, the Council is of opinion that a ginat resiKuisibililv 
rms on the family practitioner who.se dutv it is to advise 
Ills jinlicnts that efficient and sy.steniatic v.-icciiialion and re- 
yaccinalion is tho best iirophylactie for sninll-iiox. As rerrards 
general propaganda tho Council rceoiiimcnds : — 

Recommendation : That in areas where cases of small-pox 
- arc known to exist, propaganda work in favour of 
vaccination should be carried out bv the local 
aiithonty; that where this is not done the Iocs 
Biiision should endeavour to stimulate the nuthorit 
to do the necessary propaganda work or it.self do who 
It can to supplj the dcficicncj*. 

Men, CAP OrncEU o 

tiEALTa, Pooh Caw Medicap Ometn and Pcnuic Vaccnatoi 
the iioei^Ho? fo"’ UU.S s - i.i-d , 

sucli appointments so tb'n ccmbination c 

be dealt with dc noto T„* “i • n ‘'‘,TW»dion luid t 
general policy the Couieil^sj ^o^ulution of 

tion of the AR.lf., 1911 hcforc it the following rcsoli 

public hLlth’nnd'rf'tht mldT* l" ^*'7 iuturests c 

(i) that Medical Officer, of p 

without prejudice to tho/ should, ns a rule (an 

appointmLtl), be rMu'wed "ai l>.'irt-trm 

official duties- Oil ttmi n° their whole time t 

Bhouldbc ad,’ni(l*p“ d iist 

necessary to make tL? nr^ot- *i i grouped wher 

Officers of Health sb on Mu i^'.l 

a Government Superann^n^r participation i 

Medical Office,^ of Hea th ? -lud (iv) tliat al 

proper dischawe of tw Protected, in th 

dismissal or rrfuction of salaries”' enpriciou 

^d the followinty extnrf r 

December, .1910, issued' bv tb, 7"' a meraornudura, date 
Bnpport of the combinatiM of , .^irernmcnt Board i 
Becunng whole-time Medical „ J‘I’P°‘"‘rM"ts with a view t 
The Home Secretarv ’ - =” ' 

■ Factory Surgeon', and^ *“7*’*" Certifyin 

combination with the the Board favouf it 

Other public offices whffih th m'T- 
may be allowed to hold are thi„ ^ealt 

Vaccinator, District Medical nm^ 
of the Workhouse, .“'^“"pul Officer, and Medical Office 

analyses Ld '’barierlolorici cx^^' “ak 

bacteriological examinations W water, an 

The Conheil is of ® diagnosis of diseas, 

“s rvell as of the medTral^B^fe” ‘I' 

that work of a domiciliary ''"desirabl 

make up a salary for an ■annn7-r,7*'^*'^i elmuld be thrown in t 
of a public health and adSdnistStive''n\'7’" “ PJ^dominanti 
that a , practitioner will be recured iwlik-el 

capable in' the two lines of work wwf, ■ «q«all' 

he mute easy to get the domie;n.l!^r ® “esl areas it wil 
practitioner, and .at the same -irork done by a loca 

other suitable plaii, to recure^n eombmation of areas o 

Medical Officer of Health "'in uttract a 

oxperience are of a public heS nahme''. «“< 


The Council recommends : — 

Rocomnicndntlon A : (ij Thnt domiciliary attcndauce 
should, in the best interests of tlic patients, be jiro- 
vided by privnle practitioners in the area concerned 
- nnd not by a wliolc-liiiic medical officer; (ii) Hint flic 
nilojdion of the above resolution leaves unprejudiced 
the position of ,auy medical officers at jircsent bolding 
wliolc-lirac apjioiulmcnls in wliicli domicilinry aUend- 
uiice is one of Ibc diitie.s ; (iii) that if there .are iii the 
area iio prnclifioncrs willing to undertake the 
domiciliiiiy work on suitable term.,, the rc.solution 
(parngraph (i)) shall not ajiply. 

120. Rub-pnrngrapli (iii) of the foregoing itocommendation 
wns inserted ns the Council considered that circum.stancia 
might arise with regard to appointments in which the action 
of the Associntion could not be governed by .a litoral inlor- 
pretation of siib-paragnipli 7i), n.s, for example, where no 
local practitioner wu., nvail.able, or where an obvioii.sly iin- 
siiitnblc praclitioiicr wn.s the only practitioner nvnilabfc. or 
ivlicre the only local, practitioner nvailablo was taking 
ndvnntnge of that position to demand a salary obviously di?- 
proportionatc to the dutic., of the po.st. in .suen circuo„ianccs 
the action of the A-stocintiou would have to be guided bv the 
opinion of llic local Division. 

Rccommondatlon B ; Tliat there i.s 110 objection in princ'iple 
to' the combination in one and the same wbolc-tiroc 
appointment of the duties of a Medical Officer of 
Hcallli and of those of a Poor Law Institutional 
Medical Officer, but the application of this jirinciple 
in niiy individual instance must be governed by local 
circumstances nnd by the opinion of the Division or 
Divisions concerned. 

Recommendation C : That there is no objection in principle 
to the combination in one and the same whole-time 
nppointmeiil of the duties of a Medical Officer of 
Health or of a Poor Law In.stitulional Medical Officer 
nnd those of a Public Vacc’nator, but the application 
of this principle in nny_ individual instance must bo 
governed by local circumstances and by the opinion 
of the Division or Divisions concerned. 


Co-ornjiATioN with SoacTT of Medical Oiticebs of Health. 

121. 'The Council of the Society of is.cdic.al O.-ficers of I caitli 
has invited its Brnnehes to keep the Association fully informed 
regarding practitioners who apply for or accept undcsitablo 
posts and 1ms also asked its Brnnehes to advise 'Medical. 
Officers of Health to consult tho Association in any ense in 
whicli they arc doubtful about tho record of a cantlidate 


National Health Insuranoe. 

CoxsTiTOTioN OF Insurance Acts CoitJxirrEE. 

122. Members of the Representative Body .are aware that a 
majori^ of the member., of Uie Committee is com^.M^,7F 
noraiii^ sclccUd by the members of Local Medic.^a^PaneT 
Committees. For this purpose the country hns ^“"diS 
into groups, e.ach group selecting from on- fn m 
T cnlatives, Scotland being a groun W itretf 
Wales has been combined wHh Cheshire 
continued agitation acrainst thi*? nottiffn.,, t* n i-esuU of 

Cheshire, nnd particiilarly by the^latter ^ 

disfranchised ijy being griped ^ h re’, « 
Conference directed tbf Tiisnra^ Am ^^«cent Panel 
some way out of the difficulty. It it feIt^h^rtV'’%-^° 1“^ 
come when Wales, like Scotland shm.M 
for this purpose. This will entail a It,. ^ 
remaining groups ncccsitatino- ® ,^?j?'^''“hgemeut of the 

'for EnglLd\and'mir ^t^fm^Li^on^ 

country, Scotland is iindcr'-renr^n^ 

considerations together, the ^uncil 

direct representafives on the ^mSlttre ° 110^- 

from the present 23 to 25. The Ponr.,.;' 11 , increased, 

mends the requisite alteration in the^Sched'ule'to'^n'^^T^^I”®' 
(Ace under Organization Section, para. 55). ““ * B.v-laws 

123 "'■“ KnOTTL.VT,ONS. 

1^. At the dote of the Al?. M too? t-i t 
C ommittee wns completing negotiations with - 

Health for the revision of tho discinlina,.,, Ministry of 
the K.H.I. Acts. Tlio suggested new nTo,-' machinery under 
to the Coiifereiiceof Rep?e^tati>es of^al x? a’-®’’, P”’»ntoa 
Committees in October, 1927, ^ 

tnodificaHou. The resolutions were without 

of October 29tli. 1927, in the report B-M.J. 

Snbscqnently, the bn£inc.ss of expSw tL Conference, 
the wording of regulation has ^eeu proeredTD^nd*i^"1,o'" 


•I I V 



158 April 28, 1928] 


l?eporf of CouncU 


r svrrLr.iirF.KT to th» 
Lbriti**!! medical Jotityit . 


completed. • It . is expected that the . new regulations will 
shortly come into operation, and the Committee is satisfied 
that under them the medical service for insured persons will 
run more smoothly and efficiently. . .... 

Altehation in Proceduee for Change of Doctor. 

12i. One outcome of the discussions Which took place in the 
early part of 1927 between the' Ministry of Health aiid the 
Association as to the greatly increased sickness benefit claims 
e.xperieuced by .approved societies during 1926 was ' the 
bringing into operation on October 1st, 192?, of a new regula- 
tion allecting the change of doctor by an insured person. 
Prior to that date an insured person was able to change his 
doctor at any time. Under the. new arrangement an insured 
person is able to change immediately at any time where both 
ractitioners concerned agree, or at any time after a fortnight 
y giving written notice to the Insurance Committee of his 
desire to change. By this means it is. hoped that time will 
be given for a reconsideration of the position by those insured 
persons who, finding themselves in disagreement with the 
practitioner, of their choice in the matter of their capacity 
for work, decide to transfer to another practitioner’s list. ' 

Peescribiko. 

125. The continuous rise in the cost of providing medicines, 
etc., for insured persons has been receiving the attention of 
the Insurance Acts Committee, and in an effort to impress 
upon insirrance practitioners tlio need for care and eikmomy 
in prescribing, a memorandum has been issued to each of the 
14,000 insurance practitioners which it is hoped will be found 
of assistance in understanding the Drug Tariff and in pre- 
venting waste. 

Sickness Benefit Claims. 

126. Considerable anxiety has been felt by the Ministry of 
Health and approved societies with regard to the greatly 
increased sickness benefit claims experienced during 1926 
and 1927, The Insurance Acts Committee, r^lising 
the responsibility placed upon 'insurance practitioners 
in the certification of incapacity, has accepted an invitation 
from the Ministry to consider with its representatives the 
causes of this increase. The results of these deliberations will 
be published later. 

National Health Insurance Bill, 1928. 

127. A Bill to amend tlie 1924 N.H.I. Act was introduced 
by the Government into the House of Commons on 5tli March, 
1928. The greater part of the provisions do not affect' medical 
benefit hut there are new provisions to introduce into in- 
surance certain types of workers' now excluded, and to modify 
considerably the administration relating to those kinds of 
additional benefits which -may. be -described as treatment 
benefits. These proposals are being carefully scrutinised. 

Scheme of the Spa Federation for Spa Treatment of 
Insured Persons. 

128. The first Group Committee, namely, the Spa Practi- 
tioners’ Group Committee, was inaugurated under the new 
group scheme of the Association in December, 1927. The 
first piece of work which the Committee found awaitino- 
consideration was a request from the British Spa Federation 
for the views of the Association upon the medical aspects of 
its scheme for the provision of spa treatment for insured 
persons. 

In order to assist in the consideration of this cjuestiqn, 
it may he well to refer to previous history. A coiifer'enco 
was held at the B.M.A. House on March 4th, 1927, at which' 
were present representatives of the various bodies interested 
in the provision of spa treatment for insured persons, 
including British spas, approved societies and the Association! 
From that discussion there appeared to be very little likeli! 
hood of definite action being taken in the matter in the 
immediate future, although a small Committee was elected to 
draft and submit to a further conference in the summer of 
1927 a scheme under which steps should be taken to provide 
ns soon as possible increased facilities for diagnosis and 
treatment of insured persons suffering from rheumatism. No 
further action, however, wa.s taken in ■ view of a statement by 
one of the approved, societies’ representatives present at_ the 
conference to the effect that the Joint Committee of Approved 
Societies intended to discuss the question with representatives 
of other associations of approved societies and of the British 
Spa Federation. Notwithstanding the intimation sent to the 
Association that in view of various circumstances- societies 
were not likely to be able to' embark upon general schemes 
for the treatment of rheumatic persons at the spas, the' Joint 
Committee also appointed a small Sub-Committee to explore 
the possibilities of individual action by societies and report 
to a later meeting. Arising, apparently, out of the latter 
discussion, the British Spa Federation drafted a complete 


nnd definite scheme whereby spa treatment for rheumatic 
diseases might bo brouglit within the reach of the insured 
members of the " societies taking part therein or of any other 
societies with available' funds ; and being anxious that its 
scheme should commend itself to , the whole of the medic.al 
profession at the respective spas asked that the draft scheme 
should bo considered -by the Association and for- any obser- 
vations the Group Committee might desire to make thereon. 

The Group Committee,' after considering the proposed 
scheme and having, arrived at various decisions as to its 
medical aspects, discussed the matter , with representatives 
of the Federation who attended the meeting of the Committee. 
Various suggestions by the - Committee for the - amendment 
of the draft. scheme were favourably received by. the Federa- 
tion representatives who undertook to give them, careful 
consideration with a view to incorporation .in. their, scheme. 
It was explained that the decisions of the Group Committee 
were only provisional pending adoption by the Association, 
i The proposed scheme does not take into account the 
question of the position of the spa hospitals as there appear 
to bo difficulties in the way of ''those hospitals combining 
directly in the scheme, but -it contemplates- the treatment 
of, cases cither at private consulting rooms or at- clinics 
established for the purpose. The question of the degree of 
association between the scheme and any spa hospital is left 
for local determination. 

i It is not thought desirable to refer to those details of 
the scheme which do not affect the medical profession. , Briefly, 
the proposal is a skeleton scheme under ■\vhich an approved 
society taking advantage of it may pay an agreed sum per 
week in respect of any of its members sent to the spa for 
treatment, such sum covering the cost of board, lodging, 
treatment and administration exp^'i®<-‘s, and to be reviewed 
if necessary after twelve months’ working. The National 
He.alth Insurance Acts provide that an insurance practitioner 
shall advise' any special treatment which ho considers his 
patient requires. Any insured person advised that his con- 
dition requires treatment at a spa will presumably apply 
to his society for this special form of benefit, when the 
society, if it approves the application, will communicate with 
the authorities of the spa to which it is desired to send the 
insured person. 

The Council recommends : — 

Recommendation : That the Eepresentativ© 'Body be 
recommended to approve the proposed scheme of the 
British Spa Federation for the provision of spa treat- 
ment for insured persons at the various British spas, 
subject to the incorporation therein of the fol- 
lowing : — 

Selection of Cases. . 

' (a) That if bo made clear- that rheumatic cases 

which are considered suitable by the spa physician 
shall be treated either at private consulting rooms or 
at clinics established for the purpose. 

(b) That prior to the insured person being accepted 
at'- the spa for treatment the spa physician be 
- , ' ■ furnished by t-he patient’s private practitioner with a 
brief resume, as follotvs, of the medical history , of 
any patient recommended by the approved society for 
spa treatment — 

For7n for a Practitioner to Seport the Case of an 
Applicant for Spa Treatment of Chronic Pheiimatism 
’ in hisured Patients. 

I . . ■ - 

Name. ' Age. . Married or Single. 

Occupation. Hesidence. 

1. Disease. 

2. Duration of Disease. 

3 . Present condition. - 

4. Is the patient crippled. If so, to what . 

extent? Can the patient get' up and 
down stairs unaided and can he wash 
: 'and dress and feed himself? 

' 5. Does ■ the patient suffer from advanced i 
cardiac, pulmonary, or renal disease?. ■ 
(Please answer as, fully as possible 
because such cases of advanced disease 
.mav be unsuitable for treatment.) 

6. Does the patient suffer from epilepsy, 

hysteria or any mental disorder?- 

7. Does the patient suffer from - ulcers, 

suppuration, di-ensed boric, or con- ^ ■ 
tagious' skin disease? . 

8. ' AVhat is the condition' of the teeth and j 

throat? 




Report of Council: 


r eUPPLESTEI/T TO THl ’ 
LDniTiffH Medical JotrsKit 


160 ■ April 28, 1928] 


quently the Dispensing Opticians saw representatives of the 
Ministry with regard to their proposed scheme, after wliich a 
conference was held of representatives of the Association, (he 
Dispensing Opticians, and certain important approved 
societies, when it was found that tlie approved societies’ 
representatives were favourably impressed with the scheme, 
but asked the Dispensing Opticians to clear up certain points. 
Discussions proceeded between these two parties, when the 
Association of Disirensing Opticians found that before they 
could go further it was necessary that they should he in a 
position to inform the approved societies not only that their 
scheme had the approval of the B.M.A., but that the B.M.A. 
had secured the co-operation of a number of ophthalmologisis 
sufficient to make the scheme work. 

A set. of conditions was accordingly drawn up by the 
Council subject to which the Association, on behalf of the 
medical profession, declared its willingness in conjunction 
with the Association of Dispensing Opticians, to supply 
ophthalmic examination and advice for insured persons (.n 
lines already described. 

A very important factor which moved the Council in 
approving this scheme was the attitude of tlie Departmental 
Committee on the Sight-testing Opticians (Eegistration) Bill. 
When the witnesses of the Association appeared before the 
Committee they were strongly pressed as to the jiossibility 
of provision being made of the services of ophthalmic surgeons 
ut a rate which would fit the economic circunu.tances of 
insured persons and others in like economic condition, and 
the Association’s witnesses practically pledged the Association 
to co-operate with any suitable body in an effort to' make this 
provision. The Majority Eeport of the Departmental Com- 
mittee is against State registration of oplicians, but goes on 
significantly to say that unless within a reasonable lime 
suitable provision is made by an adequate niinihcr of qualified 
ophthalmologists throughout the country a re-consideration 
of the question of some form of State registiation of sight- 
testing opticians will be justified. That is to say if the Govern- 
ment adopts the findings of the Majority Ecpoct the medical 
profession, as represented by the Association, is to be given a 
reasonable time in which to show that an adequate service 
can be provided over the country at reasonable terms for 
insured persons and others of similar economic position. The 
value of the opportunity thus given can scarcely be over- 
estimated. If it can be utilised not only will the pretensions 
of the opticians to occupy a field the medical profession deems 
to be mainly medical be defeated, but a large amount of 
work hitherto done by opticians, or gratuitously at the 
hospitals, will accrue to ophthalmic surgeons, with great 
benefit it is believed to the public! 

In furtherance of the aboye action the members of the 
profession on the Association’s old “ Ophthalmic List ” were 
circularised as to the new proposals and practically ail have 
expressed their willingness to fall in with them. 


Hospitals, 

VOLUNTAKY HOSPITALS AND BeCOVEBY OF MONEY. 

131. The A.B.M., 1926, passed the following resolution 
■which was incorporated in the Hospital Policy of the 
Association : — 

. Minute 59.— Eesolved : That in all cases of accident 
where medical attendance is given at a voluntary 
hospital, and such medical attendance is covered cither 
directly or indirectly by insurance, the hospital authori- 
ties should recover from the insurance company the full 
cost of maintenance and treatment of such patient. 'Tliat 
where patients who would ordinarily be considered as 
private patients are admitted to hospital solely on account 
of accident or ergency, they should be considered as 
. " private patients,” 

and the Council reported to the Eepresentative Body, 1927, 
that in view of the doubt which existed as to the legal position 
of a voluntary hospital recovering from .patients the cost of 
maintenance and treatment in the. circumstances detailed in 
the 1926 resolution, it was obtaining Counsel’s, opinion on the 
position. Counsel’s opinion is appended hereto (Appendix VI.) 

In view of the following paragraph which appears in 
Counsel’s opinion : — 

“ In my opinion where an accident has been caused by 
negligence, and the victim receives emergency treatment 
in a hospital, the victim alone can bring an action against 
the person responsible for the negligence and he cannot 
include in his claim any sum in respect of the expenses of 
the hospital unlees he is himself legally liable in contract 
to the hospital for the amount of the expenses, which — 
in such a case — can rarely be the fact. If the victim is 
legally liable to the hospital he can claim the amount for 


which ho is so liable as part of his damages but this gives 
no right to the hospital, whose only right of action is 
against the victim, its own debtor. If and when the hos- 
pital has obtained a judgment against its own debtor, and 
its own debtor has been awarded damages against the 
person responsible for the accident, the hospital may be 
in a position, as a judgment creditor, to make the award 
of damage available to satisfy its own judgment debt, but 
it will only be in the same position for this purpose as 
any other judgment creditor of the victim, 
the Council considers that Minute 59 of the A.E.M., 1926, 
should be amended by the deletion of the words " from the 
insurance company.” 

The Council recommends : — 

Recommendation : That above Minute 59 of the A.E.M., 
1926, bo amended by the deletion of the words " from 
the insurance company.” 

“Bay Beds Cojimittee" of Kino Edwaed's Hospital Fund 
ron London. 

132. His Eoyal Highness me I’rince.of IValcs, as President 
of tlie King Edward’s Hospital Fund for London, appointed 
a special Committee, .the persdnriel of which was Yiscount 
Hambleden (Chairman), Sir John Hose. Bradford, Sir B.einaril 
Mallet, Mr. V. IVarrcn Low and Professor Winifred Cullis, 
(Mr Leonard' L. Cohen and Major Harold ' AVeruher, 
Hon’. Secretaries; and Mr. H. B. Maynard, Secretary^, 
“ to inquire and report upon the question of hospital accom- 
modation in London for peiwons prepared to pay more than 
ordinary voluntary hospital patients; and to report the 

conclusions at which they 'may arrive.” 

The Association gave evidence, based on the policy of 
the Association, before that Committee on 5th October, 1927, 
and the evidence was supported .verbally by the Chainuau 
and Deputy-Chairman of the Ho.spitals Committee, the 
Treasurer and the Deputy Medical Sccretarj . 

The Eeport of tliis Committee will, it is expected, be 
made public before the meeting of the Eepresentative Body. 

Hebtfobd BsiTisH Hospital, Pabis. 

133 In paragraph 170 of its Annual Eeport for 1926-27 the 
Council stated that it had enquired into the circumstances 
connected with the dismissal in September, 19-4, of the. 
Resident Medical Office'r of the Hertford British Hospital, 
Paris ' (who is a ' member of the Association), . and the 
ersequSi .resignation of .the other Brit.^' members 
of the medical and surgical staffs of that hospital, 
and that the Board of Management of the hospital and the 
Association (acting on behalf of the late medical and surgical 
staff's) had agreed ■ to acceiit the decision of Mr. \au,,liaii 
Williams K C., who had liien appointed by the Government 
to consider the whole of the evidence and ^’ocule wheUier oi 
not the Commmitte of the Hertford British HospitM h^ beta 
unjust in dismissing the late Resident Medical Office . 

In the conclusions arrived at by Mr. Vaughan Williams 
he stated (i) that the Committee of the hospital was ontuled 
to terminate, the contract of the Resident Medical Officer, 
(ii) that, notwithstanding the excellent services rendered by 
the Resident Medical Officer, it was not iii the interests ot 
the hospital to rctaih-his services; (iii) that in not examining 
the Dcrson whose rejection as- a patient culminated- in tne 
disraL.al of the Resident Medical Officer. that officer made an 
error of judgment, although the condition of the. jwlicnt 
justified refusal of admission; (iv) that the reeipiatmn o 
the medical staff constituted no breach of contract, but was 
not justified by tlie action of the Committee or bj . 
interests of the hospital and patients, and the dismissal of the 
Resident Medical Officer was not adequate grounds for resig- 
nation of the staff, neither was the^ dispute as to the 
administration of the hospital a justification for siicu 
resignation. 

The late medical staff considered that Mr. Vaiighan 
Willianis’ report exonerated the late Bes'dent Medical Oince^’. 
The Council forwarded a copy, of that report to the late 
■Resident Medical Officer' and nothing further has been nearu 
of the matter. 

The • Committee of the hospital has agreed to submit 
suggestions for revision of the rules of the hospital and has 
in fact already submitted part of the rules, upon ■which’ several 
suggestions for variation have been made by the Association. 

• Middle Glass Hospital Policy. - • 

134. The Council is considering the forim’lnt'on of a Middle 
Class Hospital Policy^ pursuant to the following resolution 
of the Annual Representative Meeting, 1927 : — 

jjfinufe 210 . — That the Representative B<>dy inst^ct* 
the Council to consider the formulation of a' Middle Class 
Hospital Policy. ' ... 




ffOSpftnfSm 


T KTrprr>r?rn.vT to tti* 
IDr.iTiHtr 5ii:i»icAi. Jocnyit. 


161 


AtMI. 18, 1023] 


Co-Ordinatio.'<’ op UosriTAi. rnovjsiON-. 

155. TJic 5Iini.s(cr of Jlc.iJlli lia.'s ■•iiigijMfod Dijit yoliiiitftry 
hospitals should examine in conjunclion local anUiuntics, 
including Boards of Guardians, the following- <i«estions 

1 Haviiie- regard to the nature of the liosjntnl accom- 
modation in-ailablc in the area, both in voluntary nud 
nuhlic hospitals, arc there any categories of eases winch 
should, so far as practicable, be allocated to one type of 
hospital or the other? 

•2. Is it jiossiblc, after taking slock of local needs, to 
agree on any lines of demarcation between tlic province of 
the voluntary and public hospitals in the area? 

3. Assuming that some nndcr=Vandiug is reached as 
to the line of demarcation between Ibe voluntary and 
public hospitals in a given area, to what extent would 
this modify schemes of cnlargeincnt in hand or in 
contemplation? 

•1. If there is a shortage of voluntary hospital beds, in 
what respect is the shortage most serious, e.g., is it n 
shortage of general surgical or medical beds, gynreeo- 
logical or maternity ' beds, or orthopaedic? Is there 
, vacant accommodation in public hospitals suitable, or 
capable of being adapted, for the type of case for which 
accommodation is specially needed? 

• 5. Could not some Clearing Bouse ” arrangement bo 
established by agreement between tlic voluntary hospitals 
and the local authorities (including the Guardians), 
which would ensure n better distribution of patients and 
the more rapid admission of cages requiring institutional 
treatment? . . 

G. To what extent and under what conditions could the 
medical staffs of the voluntary hospitals undertake 
responsibility for cases, or for a definite nuroher of beds 
in public hospitals, so that the patient mav be secured of 
the special type of experience required, wlicthcr medical 
or surgical, without regard to whether the bed he occupice 
is under voluntary or public management? 

The Council,, considering that the Association should 
take an active part in attempting to guide any legislation that 
may be the outcome of any principles adopted as a result of 
the consideration of the answers to these questions, has drawn 
. up the following scheme which it submits herewith to the 
Bepresentativc Body for adoption. 

Recommendation : That the appended scheme of co-oper- 
ation of voluntary hospitals with municipal hospitals 
for the co-ordination of hospital provision be adopted 
and submitted to the llinistcr of Health (jec 
Appendix TII). 

Ceitebia Peacijtjo.vebs Teeatixo Private Patiexis in 
Peivate Wards qe Huusiso H-Oues AvtAcnED to Hospitai.s, 

136. The following paragraph 22 of the Hospital Policy of 
tne Association •* 

22. Where it Js desirable that special accommodation in 
tUe nature of a nursing Udtne should be provided in 
connection with voluntary hospitals for the reception of 
private patients, there should be provided as follows : — 
(a) Private patients should be admitted to such 

““'y cncommendation of a 

private_ practitioner,, except in cases of emergency. In 
the latter circumstances the patient's own medical 
should bs mforiDcd 

he open to a private patient to select 

■ ? Jf^'stered medical practitioner as his attendant, 
(c) The scale of charges for the private patient foi 

Tthc h,ip4k"’‘' 

"f Wmeht for professional services 

■ fete BO^navabirto established; the 

ices BO payable to remain, as at present, a matter of 

IIS”;” '“"I 

Kg-^ered medical practitioner as his attenllr 
such ward or home. W^the CouncU c^^Liders 
Pt^titioner should be allowed to ri a oatient ^ “"f 
reasonable rpoui^ment w 

the institution concerned to exotet V,“ 

hetore it the criteria “?tter the Council has had 


service.-! requiring special skiil and experience. Thc.sc criteria 
were arrived at with the help of the As-oci^ion and they 
have Ijecii found fo stand the test of time. The Council is 
llicrcforc reromiiicnding that these criteria, with certain 
verbal modifications, should be adopted by the Association 
ill lliis respect also! 

Tho Council recommends 

Rccommcndalton : Tlint paragraph 22 of the 'Voluntary 
Hospital Policy (United Kingdom) be amended by 
tbe insertion of the following, as sub-paragraph (c), 
prc.scnt Bub-paragraplis (c) and (d) being renumbered 
(d) and (c) respectively : — 

(c) If tbc treatment of the patient involves the 
npplication of speci.al skill or e.vpcricnce of a degree 
or kind whicli general practitioners as a class can- 
not reasonably be expected to po.sscss then the 
attending practitioner before undertaking the 
treatment should satisfy one or more of tbc follow- 
conditions : — 

(i) that ho holds or has held ho.spital or other 
appointments affording special qpjiortiiiiities for 
acquiring special skill and experience of the kind 
required for the performance of the service to be 
rendered, and has had actual recent practice in 
performing the service to be rendcicd or services 
of a similar character, or 

(ii) that he has had special academic or post- 
graduate study of a subject which comprises the 
service to be rendered, and has had actnal 
recent practice as aforesaid, or 

(tii) that he is generally recognised by other 
practitioners in the arc.-i as having special pro- 
licicncy and experience in a subject which com- 
prises the service to be rendered. 

CSoKnaiCNCE re CoxTRiunroRT Schemes' for Hospitai. Benetit. 

.337. Tbc Council has, from time to time, brought to tbe 
notice of hospital staffs tho following three fundamental 
principlco which underlie tbc Association's policy as regards 
contributory schemes for hospital benefit : — 

(a) Tliat only persons ^loir a definite income, limit 
should be entitled to join a contributory scheme for 
hospital benefit. 

(b) That (except in emergency) a centributor to a 
echeme should only be admitted to a hosjiital upon the 
recommendation of the attending practitioner. 

(c) That recognition should be made of the services of 
the medical staff. 

A large number of these schemes are being adopted, but 
in very few have all these principles been given effect, 
and the position is viewed with very- considerable concern bv 
the Council in view of the importance of safeguarding the 
position both of the medical staffs of hospitals and of private 
practitioners. ‘ 

The Council is therefore convening on 6th June 1D2S 
a conference of representatives of mcdicat staffs of voluuta*rv 
hospitals (to be held at the Headquarters of the Association) 
in order that the policy of the Association in regard to the4 
schemes may be explained and discussed. ° ' 


, Naval and Military. 

Repbesertative op Roeai. Kaval Uedicai. Sehv-ice ox the 
CocNcin. 

133 TAc regretted death of Surgeon Rear-Admiral Sir Perev 
Bassett-Smitb, the representative of tlie Royal Aaval Medie 
'“s deprived the Association of an 
odyser ^vliosc help was of great assistance in respect of all 
laaUeTB cOTCCTwvng Service. Sir Percy Bassett-Smith's 

eoner"Ha\\!"c.I^G!! l!K°^°(ret5f“bf ekried ^the 

Mprtecntative on the Conucil of the Hoval Naval 
Medical Service for the period 1928 - 31 .' ' 

ArPOKTHESTS TO THE IXDIA.V MedicAI. SERVICE AHI> CON-mTIOVl 
OP Service. ^ 

139. The whole question of the ronrt>^ani«atinn fi.„ t t 
M edical Service is now under aetiv? censideratio^ “ 

Government of India, and the Council hopes shortlv to 
possession of tho new proposals. Therriias alre-iri^ 





r nvPPiy'^WST TO Tnir 
LnUTTir\T« Wr.PIClX^ JOtJttXAL 


April 2S, 19281 


Scotland^ 


163 


' Isnjoi-Nous SySTRMS or Mwicisr in Cevlon. 

116. A CoininitU'p uppoiiitod by tlio Govcruuiout- <if Cojlou 


llic colulitions'of tfcnieo, but that there ih in BOine districts a 
iocui winch cnil« special cxamiiiatioii by -the 

Brauches aud Divisions conecriicu. 


to cohsiflcT — 

(a) wlicthcr it is prnclicablo for the Govormnciil to 
assist financially or ofhernisi. — 

(i) in the training ot those seeking to rjUalify them- 
fclvcs ns practitioners of tiic indigenous sysleins of 
medicine;- 

(ii) and in the investigation of the medicinal vidua 
of drugs used liy lliose practising sncii syslcnin; and 

(b) if practicalilc,' to prepare a detailed sclieiiic of such 
travuiug and investigation for file coiisidoratiou of llie 
Qovermneut; 

reported^ in its Majority Jicporl, in favour of flic recognition, 
umler certain conditions, of the indigenous systems of 
medicine. tVlicroupon the Council informed the Coloni.sl 
Oflicc and the ticncraV Medical Connell that it considered that 
such official recognition nould be a retTogiado otep. Tlic 
Kegistrar, of the General Medical Council stated that the 
Council ivas advised that “ having regard to matters in India 
at the present time it is not ailvisahie that the Council should 
intervene at this stage in a innltor of this kind,” and the 
Colonial Office replied that the Secretary of State had not. yet 
received the rejiott of the Comniittcc appointed hy the Covorn- 
inciit of Ceylon tiivough official clianncls hiit when this lyns 
received the vieus of the Ceylon Govcrimicnl and llie opinion 
of the Council of the Association Mould he borne in niiiid. 
The Ceylon Branch has passed the folloiving resolutions; — 

That a Snb-Coniniittce of mcinl)cr.s of this Association 
be appointed lo take .such slejis as are necessary to bring 
to the notice of the parent As-sociation the detrimental 
effects that the adoption of the recommemlntions of tho 
Majority Report would have on the progrcs.s of scientific 
medicine, both curative and preventive, in the Colony, 
and that copies of the Snh-Commiltec's findings be sub- 
mitted to the Ceylon Government for its on-n information, 
and for transmi.ssion to the Secretary of Slate for tho 
.Colonics; 

That the Ceylon Branch of tlic B.M.A. strongly support 
the Minority Report of tho Indigenous Systems Com- 
mittee; 

and has fonrardod detailed criticisnjs of tiic Majority Report 
of file Government Committee. Tlic Council has again urged 
the Colonial Office not to approve action on the lines of tho 
Majority Report. 


Scotland. 

Extension or the Scottish House of tiu; Association. 
147. When tlie Scottish House was ncipiircd in 1925, it .seemed 
likely to be adequate for all purposes for some time to come 
” shoivn the need for a larger and better 

ventilated hall than could be provided in the existing building. 
\Micn the adjoining property at JTo. 7, Driimsheugh Gardena 
came into the market, tlie Scottish Coiumittco thcretoro 
recomniend^ to the Council that it be purchased, a proposal 

by tho Building Committee, 
f ® property was acquired in Decoinbor, 1327, and 
the wort of reconstruction was at once begun -and is now 
ncaniig completion. By combining tho first lloors of the two 
p operties and removing the staircase and partition wall.a, 
it h.TS been found possible to provide a good, well-ventilated 
and well-lit ball capable of seating 250 porSins .and, in addition, 
n committee loom and a common room. Tho office n-ill bo 

wuf SI®' ® floor of No. 7, and tho 

Association Will thus occupy a co ‘ 

, unit. Access to the remainder of t 
from No. f>. and the whole of this 
let at good rents. 

• On behalf of the membership in Scotland, the Scottish 
. Committee has tondered its thaiiks to tlie Council and re 
corded Its belief that the action t.aken will hear fruit in 
niereascd usefiilne.ss and activity. 

Conditions or Service of Pabochiai. Medical OrricEBs, 

148. 1 arious complaints having been received by the olfic 

med enrSo «Pl'«<‘iitn.ent of paroehis 

tncdic.nl officers, it was decided to . institute an iiinuin 

for particulars was addressed to airsnc 
officers 111 ticotland, numbering over 800 ; to this onlv Ifi 
replies were received, of which 61 e.vpressed deffm-fe^ cl® 
terms of appointment. As a result lli 
fS r tlmre is no evidence from 

P e» of any general discontent throughout the country wit 


-T. 


Pees to ruACTiTiONEus Called in hy MinvaVES. 

119. In 192.5 the Scottish Coiriniittec reported that the 
Iconl miviscr.s to tlie Board of Ucallh had ruled that 
ill lernis of the Miilwivca (Scotland) Act ^ery ^ fee 
paid covers one siilwccjiient visit, and tho Cominillcc 
asked tliat the scale should be revised, or. alternatively. 
Hint the Act should he amended. The Board' adopted 
the latter coumo and inserted an anicndiiig clause 
in the Midwives niid Matoruily Ilomcs (Scotland) Act. 
Kegoliaiioiis" were entered info with the Board, and an 
auiciided scale has liccii agreed to which is on the lines of 
the corrcsjioiiding Eiigiisli scale. The fee for attendance at 
parturition has been raised from Al. 17 b. Gd. to A2s. 2s. Od. 
and now iiicliidc.s necessary visits during tlio first 10 days. 
Tile Ice for visits under tlio old scale was .Os. Cd. for a day 
visit fliiil 7«. Cd. for a iiiglit visit, and the Coiumittco pressed 
for tlie.se fees to be raised to 5s. and 10s. There was cou- 
siderahlc ojijtosilion to this on the pArt of the Board and 
'local aulhorities, and in the end a coiiiproniisa was agreed 
iijion whereby tbo fee lias been fixed at 5.s, (day) and lO.s. 
(night) for a first visit, and tor subsequent -visits in the 
satno illness Ils. Gd. (day) and 7s. Gd. (iiiglil). Tlic other fees 
payable under tlic scale are unaltered and are the same as m 
tlio English scale. 

HosriTALS Policy. 

150. Tlie Conueil has given careful cousidcratioii to the 
situalion which has arisen in Scotland through the action of 
the Scottish Begionnl Committee of the British Hospitals 
■Association in setting up Regional Committees in five logion.s 
of Scotland, with the object oi exploring the needs of their 
areas and considering the possibility of co-operation between 
statutory aiithoriticB and Hie voluntary- hospitals. These 
Committees are composed of represeutatives of the uianawc- 
ment of voinntiiry hcopitnls nn(\ contain no direct representn- 
j tires of tlic medical profession. The Secretary of State for 
' Scotland hns commenued the appointment of tliesc Committees 
and, in addition, has nppointed a small Liaison. Committee to 
keep them in toudi with representatives of iiis department. ’ 
Without committing himself to details of a liospitol policy, 
ho hns indicated that lie looks to co-operation hetween the 
voluntary hospitals and tho public authorities for tlic future 
development of the liospital services; that the co-operative 
arrangement sliouUl centre round roluiitary hospitals, and 
that it must be part of a hospital policy to develop the poor 
iaw hospithls up to the standard of the voluntary hospitals. 
In view of tho cstnblisliincnt of these Regional Committees, 
the Council is of opinion that corresponding Medical 
Committees shonld bo set up in eacii of tho five regions, on 
tho Hues of parngraph 3G of the Association's policy affecting 
hospitals, and is necordiiigly arranging, in conjunction with 
the Branches concerned, for meetings of the Branch Councils 
with tho medical .staffs of voluntary hospitals in cacli of the 
regions, tho business of tho mootings being to consider the 
appointment of Regional Medical Couiinittccs. 


Ireland. 

Ge.nbral Organisation. 

151. Tlie outstanding event of the year was the visit of 
Dr. Cox, Medical Secretary, to Ireland. He arrived in 
Kingstown on Ajiril 2ath and remnined for ten d.rys. During 
his vdsit he had a strenuous time travelling and attending 
meetings of the Branches accompanied in each case by the 
Irish Medical Secretary. He held his iir.st meeting in 
Belfast ou April 20th, where he received a very warm we}conte 
and the meeting was a very decided success. On May the 
3rd, he visited Cork, and was present on the same cveninw 
at a well attended meeting of the Munster Branch. A large 
number of the medical students from Diiiversity Collecm 
Cork, .attended tho meeting and they much appreciated the 
udyice given them by Dr. Cox. Successful meetings of the 
^euister and South-Eastern Branches were also attended bv 
the Medical Socret.ary, and ou February Gtli he was nreseiit 
at an exceptionally well attended meeting of the Irish Com- 
mittce. He made the most of his -many opportunities to 
explain the many and different w,rys the Association could 
be made helpful to its Irish members. The Irisli Committee 
and tUe Irish Branches -WDro very likfised with ihn t.o 
reception extended to Dr. Co/ evSYwherf ),p 
M embers who had not attended a meeting^for' years mide'll®^^' 
journeys to meet him and thus showed ifiiHlSr' 
of Ins services at all times for the profession U Ireland 



164 April 28. 1928] 


tleport of Council! 


r !!urrTJ:3rnsT lo to* 

lTlr.JTI«n JIKDICAI, JotrKXAt 


On tlie otlier hand. Dr. Cox -was nnmistakably impressed with 
the popularity and the keen appreciation of tlie Association 
and its work in all parts of Ireland. 

Arising out of a suggestion from Dr. Cox arrangements 
are being made for holding B.M.A. lectures in the different 
Branch areas. Dr. Eobert J; Eowlette, P.E.C.P.I., Professor 
of Materia Medica, Medical School, ’ Dublin Dniversity, 
delivered at Kilkenny to the members of the South-Eastern 
Branch a lecture on G astro-duodenal Dlceration, which was 
very much appreciated by the members. This new departure 
of providing for lectures by loading men in the profession will 
undoubtedly be a source of attraction and benefit to 
members. Since the Medical Secretary’s visit the Irish 
Blanches have certainly become more active. For many 
years the Leinster Branch has not had ro many well 
attended meetings, with the result that the seating 
accommodation of the Irish Office had to bo consider- 
ably increased. The Organisation Committee invited Dr. J. B. 
Shanley, Honorary Secretary of the Leinster Branch, and the 
Irish Medical Secretary, to its meeting in London on February 
28th, when the question of recruitment of newly qualified 
medical practitioners in the Free State was discussed and it was 
decided that the Irish Medical Secretary ' should arrange for 
meetings of newly qualified medical practitioners in Dublin 
and in Cork. In this connection the' Irish Medical Secretary 
has been in correspondence with officials of the different medical 
schools and has been promised their as.sistance. 

Medical Affairs in Northern Ireland and the Free State. 

152. In the course of the year three important Eeports 
dealing with medical questions of unusual interest to the 
medical profession in Ireland were published, namely, (1) 
Iteport of Departmental Commission on Local Government 
Administration in Northern Ireland, (2) Heport of Committee 
of Inquiry into Health Insurance and Medical Services in 
the Free State, and (3) Eeport of the Commission on the 
Belief of the Sick and Destitute Poor including the Insane 
Poor. These enquiries meant a good deal of work for the 
various medical associations’ with regard to the preparation 
and presentation of the medical features involved in the 
enquiries. 

153. The Departmental Commission for Northern Ireland was 
appointed in February, 1925, and finished its report in 
SejEember, 1927. Professor E. J. Johnstone, F.R.C.S.(Eng.), 
M.P., acted as chairman of the Commission. Of the thirty- 
nine members of the Commission, eight were members of the 
medical profession. This report, with regard to public health 
adminiatration recommends that the present local public 
health authorities — urban and district councils — bo retained 
as the primary authorities but that tlie county council, acting 
through a county health committee, be the supeirvisory 
authority in each county area The report recommends that 
the county health committee (in Northern Ireland) be com- 
posed of ; one member appointed by each urban and district 
council in tlie county; members by the county council equal 
to the total number of urban and rural representatives; six 
co-opted members, of whom at least one should bo a medical 
practitioner and at least two should be ladies. The functions 
of the county health committee recommended by the Commis- 
sion arc as follows ; — 


The report states that the demand for medical benefits applic 
with greater force to urban and industrial than to rura 
areas, and tliat a considerable section of medical practitioner 
in Northern Ireland . were opposed to the system. Fror 
'figures produced it was shown that about GO to 70 per cenf 
of insured persons cither do not. or are not eligible to, rcceiv 
treatment under the Medical Charities Act, and, that tlies 
persons liavo to provide privately for their- own mcdica 
attendance. The Commission came to the conclusion that 
scheme of medical benefits should not be established fo 
Northern Ireland. In a Eeservation, nine of the thirty-nin 
members gave reasons in detail why medical benefits shouli 
be introduced forthwith.- The Commission having decided no 
to recommend the inclusion of medical benefits make severa 
suggestions for the re-organisation and improvement of th 
dispensary medical service. Tlie report recommends th 
provision of post-graduate courses for dispensary doctors h 
order to enable them to keep abreast of modern development 
in medical science. The report deals more or less exhaustivcl; 
with several aspects of medical treatment including th 
, treatment of tuberculosis, administration of hospitals 
maternity and child welfare schemes, etc. 

154. The fin.al Report of the Committee on Health Insuranci 
and Medical Services - in' the Free State was completed ii 
February, 1927. Of the nine memliers who constituted th- 
Committee of Enquiry seven signed in f.avour of the extensioi 
of medical benefit to insured persons throughout the Frei 
State with an increase of 2d. in the existing weekly con 
tribution rates to bo borne equally by the employer an( 
employee. One of the representatives of the Department o 
Local tiovernment and Puiilic Health, with the representativi 
of the Department of Finance, signed a minority repor 
stating their rc.asons for not agreeing to the inclusion o 
mcdica! benefits under , the Insurance Act. Tliis minorit; 
report goes to the extent of formulating a scheme by wliicl 
the voluntary hospitals would provide medical treatment fo: 
insured persons amongst others. In support .of this recom 
mendation the two signatories, who are civil servants, refe: 
to the grants made by the State to; certain Dublin hospitals 
To give this scheme effect it would bo necessary tlmt thi 
medical ;Jtaffs in the voluntary hospitals would bo agreeabh 
to undertake such work — which is very improbable. Dr 
■ Robert J. Eowlette, whilst signing the majority report ii 
favour of medical benefits for the insured, in a separate noti 
goes further and' recommends that a comprehensive scheme o 
medical services should be established— the scheme to applj 
to insured persons and to t]iosc linvo a to treatmen 

under existing legislation. Dr. E. F. Stmilienson. ' Chid 
Medical Officer of the Department of Local Government aac 
Public Health, cxplain's in a Eeservation his attitude toward! 
medical benefit whilst signing the majority report. In the 
report is published a letter from the Irish Medical SecreUrj 
in which it is stated “that the Committee (the Irish-Medical 
Committee) docs not think that the medical profession of the 
Free State would be willing to provide treatment at a lower 
' figure than that paid in Great Britain Nor does the Coin- 
nutteo think that it is desirable on the grounds of public 

policy to offer lower Temiiiieration than is. given for similar 

work in Great Britain. A service that thinks itse f 

does not attract the best doctors and it is not likely to give 

efficient service." 


(1) Administration of. PubEc Health and allied Acts 
at present administered hy the county council including 
the Tuberculosis Acts and School Medical Inspection. ^ 

■ (2) Administration of Medical Relief and Hospital 
Services. , 

(3) SupErvision of all local public health authorities 
in the area of the county. 

(4) Appointment of health officers for the discharge of 
the functions allocated to the county health committee. 

(5) Administration of Vaccination Acts. 


Medical Legislatioh. 

155. In the way of legislation the, most important 
;atutes were (1) the Medical Practitioners Act 
hich provided for the esUiblishment of an Irish .Medical 
ouncil and registration of newly qualified practitioners in tna 
ree State, and (2) the Dentists Act, similar in its provisions to 
le Medical Practitioners Act. Both tliese Acts were the resuL 
• agreements between the British ^“'T.'T^on 

1 the one hand, and the Government of the Free State on 

H. B. BEACKENBHET,- 




ATRIIj 28, 1028] 


Apponcticos t — IV. 


r gVFPLT.irr.rrr ro rta inn 

LDniTISIl VEOICAL JOCfiKAb / 


APPENDIX I. 

Return of Aittcndances. 

At Council Meetings, from Uio termination of Annual 
Reprcsentalivo Meeting, 1927, up to and including 
April 11th, 1928, 

COUNCIL. 

Chairman : II. B. BiiACimNiiunv. 


NAME. 


PrcsMcjit: rhiUp. SirRot)crl, Kdlnbiirgh . .. .. 

Prcjldcnt-Elcct; Maclean Sir Kwen I'anlift 
Past President: Hoprlli, P. 0.. Kotiincbam. 
Chairman ot Council : Urackcnljary, II. M., London 
Immedbte Past-Chainnan of Ueprcsentatnc l3otly : 

■ BoUm, Sir Uo\«:rt. NcvrcasUe-on-lync .. 
Chairman of ltcpresentati\c I^y ; llan'iliornc, 

C, O., London 

Deputy . Oiaimmn of. RepresentaUvQ llody: 

Lj-ndon, A., IlintPiead 

Treasurer: ilani)«n,K. BUhop. London ‘ .. 


Anderson, J. Barcroft, I^ndon.. 


IVme, J. \Y., lAilon .1 • .. 
Brintytre, IL C., WrinKtou 
_ Buchan, Ci.F.,I-®udon .. 

' Dalnril. G., Blrmingliam 
DoufKa*, C, H, bt, Andrew Hfe 
DunbiU, T. l\, l/indon .. 

Eccle*. W. McAdwn, iAsndbn 
Finlay, D. E. , Gloue-cster ' . . 

Fraser, T., Aberdeen 
Goodbody, P. W., London 
Gotuez, r, J., South Pciherton 
Henry, B. Wallace, Leicester 
Hillmao,0. B.. WaVefieM 
Hudkon, J., 5?ewrcaatle*on,Tvne 
Johnson, L W., Bury * .. 
LanjjdoO‘Down, It ,Teddinpton 
Le Kleiuinp, E. K , Wimborne .. 
LesUe. JL W., Belfast .. .! 

l-e\fys.LIoyd, E.,Towyn . 
l^adon. J. Urinffston, HaniiUon ■ 
Luce, Sir HicharaH., London .. 


I’. ■ 

r 


oath 


Oftinealy.K, J^iidon . 

Pateraon, W., London 
Patrick, J., Glasgow ** 

Peacocke.K C.,Blackrock 

Prytherch,J.R:Ll?ngSi - 

Eadcliffe. Frank, OMmmi 

Roche, N. J., SoutWa 
Snell, E. H., Coventry »** 

SoutUr, H. S., London 
Starling, E. A., Tunbridcc WelV* 

Mmornh 


■Vtiijll. Sir ciiner. Leatherheiii 
W.tkrt, J. P..So,.thcnd.o„'s“'‘ 
TValshe Denis. nnuKuen-iminagh 

Ti^hlier, It., Nottincham ^ 

JVhteler, Sir \V. <le Courcr. Dn'bltn 
Worley, iV. E. A., London .. 


ATTENDANCES. 


Actual. 

Po«ibIf. 

4 

6 

c 

6 

2 

& 

4 

£ 

C 

5 

1 

S 

5 

£ 

6 

t 

6 

5 

5 

& 

5 

6 

•4 

r> 

5 

c 

& 

G 

4 

5 

5 

6 

fi 

S 

3 

5 

5 

5 

3 

5 

4 

G 

6 

G 

4 

fi 

6 

6 

4 

C 

5 

C 

5 

6 

6 

5 

i 

5 

5 

5 

4 

G 

6 

G 

4 

5 

a 

G 

3 

G 

6 

r. 

3 

5 

4 

6 

5 

G 

3 

3 

3 

5 

S 

6 

4 

5 

5 

G 

3 

5 

4 

f, 

5 

6 

5 

5 

0 

G 

5 

K 

4 

G 

5 

5 

2 

G 

4 

6 

5 

6 

5 

G 

5 

6 

5 

G 

4 

5 

G 

5 

1 

5 

5 

5 

o 

5 

3 

5 


appendix ii 

(For 1927 Financial Statement, see B.M.J. Supplement 
Map oth, 1928.) 


appendix III. 

Existing Akticles and By-laivs ivhich the Councu, 

MOEOSES SHALL BE EeVISED. 

{See B.M.J. Supplement, May oth, 1028.) 


APPENDIX IV. 

IIEPOIIT ON CAUSATION -OF I’UEUI’ERAL M01U3IDITX 
AND MOIlTiVElTY. 

PnmtBLB. 

1. On 18th Fcbru.'iry, 1925, tho Council set up a special Com- 
mittee " to consider and report on the Causation of Fuerpcral 
Morbidity mid Alortality, and on the administrative action, 
if liny, that should ho taken in connection with the matter. • 
This Committee js.sned an Interim Itcport, ivliicli iva.s pub- 
lished in tho B.M.J. Sujiplcuiciit of Oth Januarj-, 1920, and 
that rciiorf, together ivitli a tiucstionuaire, referred to in 
para. (3) below, was circulated to Divisions aud Branches of 
the Association. 

2. In presenting tho final rojKirt the Council submits tho 
following general observations : — 

(1) The ready courtesy with which the ofiici.als of tho 
Ministry of ncallh and the Medical ll.eearch Council,- amongst 
other public bodies, and also many i)r-ctilioner,«, have suj.plied 
vaiunblo data, or replied to the inr[uiricB addressed to them, 
has revealed a very general desire to render assistance aud 
n widespread recognition of the profound importance of tho 
problem wliicli is being dealt witb. 

(2) Facts obtained from the overseas Branches of the Asso- 
ciation, have been taken into account. Special mention must 
be made of the Interim Report on Maternal Mortality aud 
Morbidity in Victoria by It. Marshall Allan, . M.C,, M.D., 
P.n.C.S.E., Director of Obstetrical Bcscarcli, University of 
Melbourne. 

(3) A questionnaire devised to elicit first hand information 
was issued to the Divisions and Branches of the ..Vrsociatiou 
and to a number of individual practitioners, and tbc informa- 
tion obtained has been of considerable assistance. 

(4) A very important and helpful Conference was held on 
11th January, 1928, at the House of the Association, between 
the Committeo and representatives of tho following bodies all 
directly interested in tbc problem of puerperal morbidity and 
mortality : — 

Ministry of Health; 

Scottish Board of Health; 

Medical Be.scarch Council; > 

Royal College of Physicians of London; 

Royal College of Surgeons of England; \ 

Royal Society of Medicine; 

Central Midwives Board; 

Society of Medical Ofiieers of Health. 

At this Coufercuco (n Beport of which was published in the 
Supplement to tho British Medical Journal of 4th February, 
1928) valuable papers, ns follows, were read : — 

“ Co-operation of midwife with general practitioner with 
a view to lessening puerperal morbidity,” by Dr. J. S. 
Fairbairn. 

" Some points in connection with prophylaxis and 
treatment of pncrpcTnl lever,'" by Dr. Leonard Colebrook. 

" Midwifery and the general practitioner," by Dr. C. E. 
Douglas. ’ ’ 

"The role of tho Medical Officer of Health in the 
elimination of maternal death,” by Dr. Diinstan Brewer. 

A general discussion followed and the problem was viewed 
from all angles, aud several useful suggestions for adminis- 
trative or other action emerged from tho debate and have been 
emtjodied in tlio recommendations sefforth at tho end of this 
report, 

(5) Of the various sources of inforiuntion available to tho 
Committee, certain publications— the reports on " Maternal 

Protection of Motherhood'' 
(192() by Dame .Tanct Campbell for the Ministry of H^aitb 

Morbidity and Mortality ’’ 
^924) by a Departmental Committee of the Scottish Board of 
Health— mast, on the administrative side of tho problem, tako 
a very prominent jilace. * 

3. It is imfortuuate that the Report on "Maternal Mortal-'ty"* 
(1924), probably owing in part at least to its clinical detail in 
the cases under review, has been taken to indicate that tho 
persistence of a high puerperal mortality rate may ho attri 
bated mainly to imperfect .attendance at childbirth anrl 
specially to the dcf.aiilt of general practitioners as a’hodv 
The value of the evidence m many of these cases appears to 
be debatable,, and a careful study of tho eases cited %pears 
to show that in only a relatively small number can any sWnd 

as^sH^r* ’^“sed upon the facta 

4. The contention (page 32 of th.at Report) that "the averarro 
death rate among midwives’ cases is certainly lower than tkt 
among doctors’ cases" is clearly not borne out by tlm fVures 


lee APRUi 28 ,' 1928 ]' 


Report of Council : 


f SUrpLKUrKST TO TW 
LURiTisn Medical Jodemai 


of the puerperal sepsis factor in doctors’ and midwives’ cases 
as set forth in the table on page 110 of that Report, where, 
the percentage of- infection is higher in inidwives’ than in 
doctors’ cases. The authoritativ.e status given to any such 
report by issue from the Ministry renders its statements and' 
implications far-reaching, as the correspondence published in 
the British Medical Journal and elsewhere goes to show. 

5. One of the most ' frequently quoted statements of tliat 
Report occurs in its opening paragraph, and is to the effect 
that whilst the general death rate has been reduced by one- 
third and the infant mortality rate halved since the beginning 
of the century, the maternal mortality rate is little lower than 
it was twenty years ago. 

6. Whilst there is a desire to urge all branches of the pro- 
fession concerned to aim at improvement in maternity practice 
this observation is calculated to disparage the substantial 
efforts which have already been made and to convey au 
erroneous impression. The table which appears on page 3 
of the Report on “ Maternal Mortality ” (1924) shows that as 
between the first and last years taken (1900-22) the reduction 
in the maternal (sepsis) mortality rate is 33 per cent.; in 
“other causes ’’ maternal mortality rate 19 per cent.; in total 
maternal mortality rate 25-5 per cent.; and that these reduc- 
tions are at least comparable with the 29.6 per cent, reduction 
in the general death rate. It is true that the two years 
compared are high and low in figure value as well as in their 
tabular position, but taken by the stricter criterion of 
quinquennial periods a very appreciable improvement is also 
shown. 

7. The view is taken that this extraordinarily responsible and 
difficult branch of practice is conducted by the profession as 
a whole conscientiously, carefully, and skilfully up to the 
limit of the knowledge and facilities available, and that to 
discredit the whole by reason of the shortcomings of the few 
must inevitably create resentment amongst the predominant 
part of the medical profession in whose hands the application 
of the standard of midwifery practice — whatever in the li^ht of 
new facts and with administrative aids that may be— mimt, in 
largo part, remain. 

8. In “ The Protection of Motherhood ’’ (1927) Dame Janet 
Campbell quotes figures showing total mortality rates since 
1891 and says : — 

" From these figures it is evident that there has not 
been much variation in puerperal mortality since the early 
years of the present century, though the' death rate has 
never again reached the figure of 4-27. which was tne 
average rate for 1901-05 (the Midwives Act came into 
operation in 1903), but the average rate for the next 5 
years was 3-74, a lower rate than we find in the next two 
quinquennial periods, and only slightly above that for 
1921-25. In 1904, when the first effect of the Midwives 
Act was probably operative, the maternal death rate was 
3-88; in 1920 it was 3'87. Since 1922, indeed the rate has 
been slightly but steadily rising. 'The rolati'n between 
the death rate from sepsis and from " other causes ’’ has 
remained fairly constant, and such reduction as has been 
effected since 1890 has been due chiefly to a reduction 
in puerperal sepsis.’’ 

9. The further reduction of the rates of puerperal mortality 
and morbidity involves the operation of factors ether - than 
those directly concerning the practiLioncr, and which* the 
Government reports quote as essential for and complementary 
to the application of professional competence. It involves, 
too, the elucidation of that not inconsiderable group 
of cases to which the facts set out in the Report indicate 
that more prominence should have been given, but which is 
represented in every series of puerperal infection tables, where 
labour has been spontaneous and normal with no traceable 
interference by doctor, midwife, or other attendant (25 per 
cent, in a series of 356 cases in the Report on “ Maternal 
Mortality ’’ (1924)). 

10. These points serve but to illustrate the complexity of 
the problem and the need for further research in regard to its 
various aspects. 

The Council is confident that all branches of the pro- 
fession concerned with the advance of obstetrics will gladly 
co-operate with the administrative authorities in devising 
and applying any agreed scheme to minimise the incidence 
of the diseases and accidents of* childbirth. 

PuEnpEBAi. Sepsis. 

11. Investigation of this dominant f.actor of the problem 
brings to light common experiences which are worth noting as 
evidence of the fact that in certain directions there is still- 
a great deal to be learned. That there is some factar at 
present not fully known is fully evident, for whereas on the 
one hand cases of women delivered under the worst possible 
hygienic conditions often show nothing abnormal, other 


women delivered in hospital under the most stringent aseptic 
conditions sometimes develop pucrper.al sepsis. 

12. Sepsis occurs not infrequently' in cases in which the 
child has been bom before the arrival of the doctor or midwilo 
and in others in which ho vaginal examination has been made. 

' The as yet unanswered question is IVliy is this so?” The 
solution may well lie in the determination of the kind and 
degree of immunity of the pregnant women for there are 
factors in her defensive mechanism which obviously require 
further investigation. 

The essential nature of puerperal infection is a problem in 
bacteriology, and requires the co-operation of specialists in 
that branch. 

13. Tlte principal facts may be briefly outlined. 

Bacteriological examinations, in many clinics, have revealed 

the fact that in most cases puerperal sepsis is due to 
streptococcal infection. Streptococci are widely distributed 
both in the body and outside it. In the body they are fre- 
quently found in the mucous membrane of the pharynx, tonsils 
and nose, and even of the vagina and cervix uteri. - 

14. The possible sources of infection rluring childbirth 
are ; — 

(a) Exogenous, such as, any infective conditions of the 

patient or the attendant, the fingers, gloves, instruments, 
etc. ; ... . 

(b) Endogenous, such' as, the cervix uteri, or erabolio 
from a primary focus elsewhere in the body, the organisms 
resting in devitalised' .tissues (c.g., osteomyelitis). 

PnopHViAxis OF PoEupEnAL Sepsis. 

15. Information on this ■ subject may be derived froni the 
Report on Puerperal Sepsis compiletl by a Committee of the 
Scetion of Obstetrics and Gynaicology of the Roj-al Society ot 
Medicine, and is based on an analysis of 249 reported cases. 
It is noteworthy that no prophylactic measures are mentioneU 
even in the record of cases of long and difficult labour. 
Evidence furnished in the above-mentioned Report and in 
the equally valuable Report of the North of England 
Obstetrical and Gynrecological Society shows that in roost 
cases' the luemolytic variety of streptococcus pyogenes is tho 
infecting agent. 

1C. The prophylactic measures which are necessary to 
combat infection may be summarised as follows: 

• (1) Strict antiseptic or aseptic measures, in order to 
diminish the risk of conveyance of infection. 

(2) A minimum of obstetric interference, which is 
especially dangerous after rupture of the membranes. 

13) The intelligent anticipation of complications likely 
to occur during labour by efficient ante-natal super- 
vision. 

' (4) The eificierit treatment of any complication of 
labour should it arise. 

17. Efforts have been made to determine the degree to which 
sepsis may be attributed to perineal tears. It has not been 
found possible to obtain from indh-idual doctors a sufficient 
■volume of reliable data on which to. base a definite conclusion, 
but the following example of institutional ' investigation is' 
worth' noting. , 

18. .In a series of 888 confinements dealt with by the Bir- 
mingiiam General Hospital Extern, Department there were 95 
cases of perineal tear. In 72 of thcM 95 cases the trauma was 
due to natural forces, and in the remaining 23 the trauma was 
mainly attributed to forceps delivery. Eight cases only 
exhibited pyrexia and the most severe case was associated with 
a simple first degree tear due to natural expulsion. Irome- 
diatc repair by suture is indicated, however small the tear. , 

19. The elimination of sepsis is an ideal to be aimed at; its 
reduction is a matter ' of practical politics though it is un- 
doubtedly the most difficult part of the problem. There arc 
many elements of difficulty, some due to incomplete scientific 
knowledge and others due to factors which at present arc not 
under the control of the medical practitioner or the midwife, 
for example, the occurrence cf sepsis where no definite reason- 
can be assigned. 

20. Administrative action has been taken which should go a 
long way to enable doctors and midwives to cope with cases 
of sepsis in the early stage, namely, the compulsory notifica- 
tion of puerperal pyrexia, the provision of a - consultant s 
opinion, and the increased provision of beds for serious cases. 

21. It is for the medical profession to take full and early 
advantage of these facilities. Every case of a rise of tempera- 
ture, unless it is clearly explained by some morbid condition 
unconnected with the pregnancy, should be regarded as scnou.s 
and dealt with promptly from the start : it is dangerous to 
wait until the condition is so ra.arked as to be unmistakable. 
The necessity for this cannot be too strongly insisted upon. 



ArniL 28, 1028J 


Appendix IV. 


r EVPrLi'.sins'T 70 tiik 
InniTiHK Mf.dical jonnvAt. 


167 


Should the home surroiindinfjB be puilablo niid cflicient 
nursihs nvnilnble, it is jirobubly belter Umt the case should 
bo dcaft with in the home, but in the nbsenee of ouch fucililicJ, 
icmoral to au institution is ceseuliat. 

Antb-N’atal ^V0ItK. 

22. In any cfTort to u’dnce inieiperal niorlnlify and morbidity 
aiitc-uatal 'sniicrvision must take a prominent place. An 
examination of tlie causes of deatli in slalislics connected with 
maternity work shows that many of these deaths mi"ht havo 
been avoided and that it is throxigh ante-ualnl supervision that 
this can bo accomplished. 

23. Deaths directly due to childbirth may be divided into 
three main classes, namely: — 

(1) Toxannias; albuminuria of prconaucy and its 
terniiii.d complication, eclampsia; byperenn is graviuarnin ; 
acute yellow atrophy of the liver. 

(2) Accidents of pregnancy: ha'ninrrhnfjcs; uipture of 
the uterus; pulmonary embolism. 

(3) Septic infectious. 

There arc other conditions which may lead to a fat.al 
termination at or about the lime of co’ulinement . such ai 
tuberculosis, valvular disease of the heart, Drighfs disea-e 
and^ diabetes. In suelt cases tae pnolie i..ay legatd 
the death as due to the childbirth rather than to the paiticnlar 
diseaso and the doctor or miduife, or both, are unjtisllv 
blamed. 

Ante-natal examination, supervision, and triatment can ilo 
much to reduce the number of dealh.s from hueb associated 
conditions. 

In class (1) there is a great field for antc-natnl work. 

24. The cause or camsos of the lo.v.'emias of pregnancy 
remain largely unknown in spite of world-uide re-oarch. 
it has been estimated that in Great Dritain the vneidcncc of 
cclamjieia amounts to 3,000 cases auuuaily, and that it is 
csponstble for COO deaths, mo.st of which occur among young 
others. That eclampsia is a preventable disca.«e the work of 
tcstiiiionv. iVitli the routine 
•I'lring prcgiiancv, the systematic 
nna ^ Wood prcssuic when albuminuria is discovered, 

Ireatmenl when the warning 
would practically disappear. The 
‘ Committee of the Iloyal 

Medicine hare shown th.at the number of cases in 

any warning signs is very small indeed. 

urine” is^so^imte^ re|>ealcd o.vaminalion of the 

stress tL poin" ^ ^ recognised that it in nniiccossary to 

necfion^the^fl?!'^^ value of ante-natal work in this con- 
worth recording”— *‘SUrcs supplied to the Committee are 

Birmin^hanf Infirmary Maternity name, 

Institiifinn ' there were 1,21/ confinements in the 
observafinn those patients who had ante-natal 

those w7m 1 ,., 1 ™ cases of cclamiwia while among 

one death ' observation there were 9 cases wTtli 

had receive/i'^* I>084 confinements. Among those who 
rclamnsfa there were no coses ol 

® cases but no”dcath"*’ ^**°*'’ dealt with there wore 

mortality^ ami ®"I>crvision can do nnicli to roduc< 
• hages, by the defa'^*- oorly treatment of baimorr 

nnd tho reco<miHn,?”f” rectification of mal-prcsontations 
labour. Svstpnnf! conditions likely to lead to delavcc 

''!■ parturition to n work will reduce the accident: 

factor of humoral. ®“nll figure but can never eradicate tin 
our knowledep ,lno nor in the present state o 

unexpected df possible to eliminate such snddci 


27. In clas 


as deaths due to syncope 


Pnerperai iiifection™i!'^'^ lessen tho risk < 

Already existino- discovery of septic conditioi 

With them before 1 aba”'* prospective mother and by dealin 
“Ay he mentioned conditior 

AArs, septic ulceratinna "'fcctions of the nose, mouth an 
septic vaginal discliMees”^ 

'■csponsible for about oeo 1 ^’a® I’™" shown that sepsis 

^ntc-natal supervision rm, '“'i maternal death 

■» tte attack on this aspeetlflbe" proWTm"" 

“Ant vvoman M^c'omMsted'* * condition of the pre: 

^oman. There areTounds Tor hr ‘t® “"^Presnatc 
“> her bio-chemical and hel ‘’“‘'“''.mg that changes occi 
no her. endocrine conditions and tt 


results as regards increased or decreased immunity and 
susceptibility to sepsis seem to afford an important field for 
research. 

29. So far as private iiractitioiiers arc concerned the replies 

to the (iiicsliiinimire sent out to DiviHioiis and liranches of the 
Association show that while women arc seeking niilc-natal 
ndviec in increasing inimbers there are still very many who 
do not. The movcniciit is still in its infancy and no eubslaii- 
linl progress will bo mndo until every woman, whether rich 
or poor, is examined at least once in her pregnancy by a 

ipialificd medical practitioner, and further that tho uniio 

bo oxaiiiincd at regular intervals during pregnancy. The 

tendency of patients to postpone consnlting a doctor or 

midwife until bate on in pregnancy sboiild bo disconr.ugcd. 

A general adoption of the principle wbicli will rosnlt in ante- 
natal examination becoming the rule r.allicr tlmii the exception 
can only be altainod by a persistent c.-impaign of education 
niid it is for the profession and the inidwivcs, whose opportuni- 
ties for propag.anda work are unrivalled, to educate their 
patients. 

30. It is notewortliy as evidence of the need for further prop- 
ag.inda work in (he value of ante-natal Mipervision lhat in 
answer to the (jucstioii, “ Do many women seek ante-natal 
advice and treatment?” of 104 of tho Associiition’s Divisions 
sending in replies, half replied in tho afiirm.ative and half 
in the negative. 

This would not be so were women aware of the importanco- 
of ante-natal supervision, and it rests largely with the medical 
profession to educate public opinion on this point. 

It is only when financial difiicultv i.s cxpcriciiccil ill meeting . 
the cost of necessary examinations that there should be need for 
the local authority to set np clinics under the Maternity and 
Child Welfare Act. 

31. Fignios showing niimistakably the value of ante-natal 
work arc available and if only they can be put before the 
public in an nttr.ictive form they cannot fail to cbiiviiicc. Tlie 
tollowing examples .speak for tliemselvcs : — 

2,000 confinements of women wbd, with one exception, 
bad been antc-nalally examined took place in the Louise 
Margaret Hospital for Women at Aldershot in the four 
years 1920-1923. Tlicrc were only two deatb.s : one from 
mitral disease in the woman who bad no nntc-natal 

• cxaniiiintion and one from pulmonary cmb.lism. A 
inorlality rate of 1 per 1,000 against the normal rate 
of 3-81. 

883 cases were dealt with in the Isxtcru Midwifery Clinic ■ 
of the Binniiiglinin General Hospital. The cases were 
delivered in their own homes in some of the worst slums 
of the City. There was only one death and this in the 
case of a woman who only registered on tho day of her 
coiilincmcut. The case was one of hydrocephalus and the 
uterus ruptured. 

Experience at the Dudley Dead Infirmary, Birmingham, 
shows that the percentage of abnormalities during labour 
and the jiucrjicrium in the case’ of those who have not 
attended the ante-natal clinic, is more than double the 
percentage of tlioso who Iiavc attended. 

The records of the Glasgow Eoyal Maternity and 
Women’s Hospital for 1926 show that tho percentage of 
deaths was less than half in tliose cases which bad bad 
ante-natal supervision as compared with tliose which had 

• not. 


32. From vvhal has already been said it is clear that ante- 
natal supervision is a powerful weapon with which to 
attack the problem. Apart from the education of the public 
by the doctor and the midwife, in regard to its possibilities 
further means may bo devised for increasing the prevalence of 
nutc-untnl supervision. 


In Australia there is a Maternity Allowance Act ' This 
provides for a payment of To to a mother on the birth of 
a child, and in 1926 the Boynl Commission on Healtli of that 
country recommended tho amendment of tho Act to provide 
tlmt application for the allowance should be made at least 
five months before childbirth : “ no payment to be made unresa 
a medical certificate be produced sliowing that the mother has 
had ante-natal supervision.” 


unaer tiio jsatioiial Mealtli 


, xusuranco Acts an insured. 

woman gets a maternity benefit of T2 on production nf 
evidence of the birth of a child; if her husband L also insured 
she can claim au additional T2. 


The Boyal Commission on National Health 
recommended that the National Health Insurance Eeinla«ou° 
be amended so as to make it a condition of payment 
recipient has bad at least one thorough elSatinn L ® 
qualified. medical practitioner during ¥er pregnancy L"r 
this service no special payment need be proviJed in thfcuo of 


fSS APETIi 28, 19281 


Report ,6f Council! 


r KP/’Prr.vr.vr to tct 
LT lriTiHn Mudical Joubn 


pomcn insured under tlie National Hcaltlt Insnr.ance Acts, as 
bnte-natal examination is regarded, as part of the duty of the 
insurance practitioner. Of those remaining it may he assumed 
that many could afford to pay,.or, if they could not, could avail 
.themselves of the ante-natal clinic. In view of the admitted 
Inadequacy of midwifery fees generally the extra work in- 
volved in the extension of ante-natal care would appear to 
taisc the question of appropriate remuneration. 


The Need or Beds for Maternitt Cases. 

33. An important element in the armament for an attack m 
maternal mortality is an adequate supply of hods for mid- 
wifery cases. It is difficult, if not impossihlc, to obtain a 
comprehensive analysis of the beds definitely set aside for 
maternity cases in all parts of the country, hut replies by 
the Association’s Divisions to the question, “ How many 
maternity beds are there in the area?” confirm what is 
common knowledge, namely, that there are not sufficient beds 
for midwifery cases evenly distributed throughout the 
country. Twenty replies out of 118 indicated that there were 
no beds specially allocated to midwifery in their areas. 

In London the available beds for maternity cases in regis- 
tered lying-in homes, municipal, maternity liomc.s, special 
hospitals, general hospitals and poor law infirmaries would 
permit of 43 per cent, of the total births within Ihe area 
taking place in institutions. 

There are no data available to show the total number of 
confinements which take place in institutions in this country, 
but the percentage cannot be very high. 

Wliile it is not considered necessary that all maternity 
cases should be institutionally treated it is regarded as essen- 
tial that there should be an adequate supply of beds for 
certain classes of cases, viz., those with obstetric or other 
complications, and those whose home circumstances are 
unsuitable. 

The provision of bedsjn many areas would probably be more 
feasible if provided by a combination of local authorities, 
rather than by individual authorities. 


Comna>TS. 

34. It has already been shown that ante-natal work can do 
'a great deal towards the reduction of morbidity and mortality 
by the detection and rectification of abnormalities. Its 
utility might be carried still further by ciassification of cases 
into those which are normal and those which are abnormal 
allocating the former to the midwife, whose function it is to 
attend normal cases, and the latter for the supervision of the 
medical practitioner. 

No such ideal can be accomplished without full and cordial 
co-operation between doctor and midwife. There is here a 
field for team work comprising ante-natal .examination by 
the doctor in the patient’s home or at the clinic, the con- 
finement being carried out by the doctor or midwife or both 
With the specialist and bacteriologist available in cases of 
special difficulty, and, in certain cases, institutional 
treatment. 

3a. An organised attack sliould be made in towns and rural 
areas in winch it is common Icnowledge that the sene-al 
maternal mortality rale is persistently much hio-her than the 
general rate for the whole country. There would seem to be 
here a great opportunity for the Divisions of tbe Association 
to inaugurate a campaign. It lias not yet been explained whv 
in certain industrial towns a death rate as high as 6 or even 
8 per 1,000 is met with. There iiiiist bo some special cause 
to account for this high rate, possibly bad housinrr, -f, poQj. 
standard of living, or faulty methods of attendance. The 
results obtained by an organisation working in the East End 
of London which deals with a large number of con'lnc-.iinnts 
annually and which for four years lias kept its mortality rate 
down to 0-67 per 1,000 give good grounds for optimism. 

3G. With regard to the apportionment of blame for the 
admittedly unsatisfactory morbidity and mortality rates it 
seems that no useful purpose is to be served by an attempt 
to lay it at the door of either doctor or midwife. Both are 
doing their best under very difficult circumstances. There is 
ample evidence that in the present state of scientific knaw- 
Icdgc and iTitb the lack of proper facilities for*dealing with 
cases of grave difficulty a quite appreciable proportion of the 
trouble is outside the control of either. To create a fcelinir 
of dcspondeucy or lack of confidence in themselves would uol. 
be helpful. Far better is it to promote a spirit of co-operation 
between them to let them feel that they have tbe confidence 
and support of tbe public and. to stimulate them to renewed 
efforts to improve midwifery pr.actice. 


.37. There is need for a great educational campaign thro 
out the country, in which the' Association should take a i 
important part in consolidating medical opinion am 
directing the lines upon which progress may best be mr 


As a special means to this end it is suggested that a 
mittce should bo sot up to watch the course of events. Su 
committee would have under review the various irca; 
wbicb are proposed or adopted for general improvement oi 
position, would keep in iouch with rcsenrcli work and v 
initiate activities designed to bring about a more satislac 
state of affairs. The committee should be a committee oi 
Association censicting of the r,r-ojficio officers, other mem 
cf the Association and representatives of other bi 
concerned. 


38. A matter of ccnsiderable importance is the shortat 
material available fer i-.structional purposes and it is ol 
utmost importance that such material ns c.-ists shouli 
turned to the beet account. Cases arc ret only requiroc 
instruction of medical rtiidenti but .also of midwivos. It 
wcll-lmown fact that Ir.rao numbers of r.nrs's take fb: L.i 
ns an additional qualification witbant any inlcntioi 
practising midwifery, tbe result being tbet a large am 
of the availal.'lc materia! is wasted. It i.s p^ossiblc tlii 
longer and more strenuous course of training for the L.i 
certificate might deter those who ha-c ro inter,, loi 
practising miefwifery from taking the c-rlifie.a_tc and 
problem is ccrt.cinly der-mneg rf tb" clere attention of t 
responsible for the training of both doctors and minwives. 

39. The Ministry of Hcallli is precsing upen (lie Ieer.I aut 
itics the necessity cf an investigation in every area i 
competent and c.vpcricnccd medic.cl officer cf all m-atc 
deaths and all cases of puerpere:! fever, with a view 
nseertaining more exactly the actual causes winch Icai 
maternal mortality, in order lo . provide fnrthc. luc.ns 
prevention. The Council, _ cn being .asked for its s-ipp 
jKTeed that such an investigation would be useful if ^-ref 
controlled by a competent r.rd cxponcnced medical c.:ice. 
if the results were used e-clusively for scientific ‘--I pi’ 
health purposes, and urged that it was most rmpo-rtant 
whore necessary such an investigation should be fallowed 
tlic offer of expert advice and assistance, ii^titvtiqnai 
otbeTOiso. Tbe Council would press on the Divisions, 
on members of the profession generally, Cio r.ceessity 
c?ving all tbe assistance they . can_ towards making 
fblorfai ions secured by such investigation as accurate 
comnlete ns possible under the conditions named. 


Rccommendalions. 


40. (1) That steps should be taken to determine by furl 
xpcrimenlal research : - ■ ^ 

(a! The factors which constitute and the condili 
which vary resistance to disease, particularly as rega 
pregnancy and the p-jorperium. 

(bl The best specific prophylactic measure to emj 
for the prevention of infection by streptoooc 


pyogenes. 

(cl The 
immunity 
immunity. 

(d) The 
antiseptic 


length oi lime required to acquire si 
and the degree and ' duration oi si 


therapeutic value of specific as opposed 
measures in the treatment of scplicsei 
caused by streptococcus pyogenes. 

(2) That increased facilities should be provided for tr: 
,g medical students with special reference to ante-n; 


(3) That a condition of the payment of maternity ben 
under the National Health Insurance Acts should be that 
mother has had at least one ante-natal examination bi 
qualified medical practitioner during her pregnancy. 

(4) That members of the medical profession should 
encouraged tb keep regular and careful records of th 
midwifery cases. 


.(5) That there is need for further provision cf bi 
specially set aside for maternity cases in institutions. T1 
every maternity home should provide for the compi 
isolation of septic cases. 


(6) That the Association should consider the allocation 
additional grants to promote research Into the prokle 
raised in this report, including especially the questic 
raised in the first recommendation of this report. 

(7) That a Committee be set up to formulate 
designed to bring about reduction in puerperal morbid 
and mortality rates, to keep in touch v/ith research woi 


Arnir, St*, 1928] ■ ■ 


Appendix y. 


r /itTrr.r.vr.vr to nrr. 

iTiniriffn iSr.PiCAV JovnsAP 


169 


and to assist Divisions and Branches of tho Association In 
arranging for education and propaganda tvilli regard to 
ihe value of ante-natal service, the nactliod of dealing with 
confinements and the post-partiim care of the mother and 
care of the infant. 

JlrcoitMKSDATiONs Thit Havk Ai,nn\oT BncoMK ErFrcrivK. 

41. Compulsory notification of pucr^n'ral pyic.vin. 

frovision of compensation to inidwivcB who arc nnable to 
c.iirj on flicir work owing to having been in contact with 
a septic case. 


APP]^ND]X V. 

MEllOHANDUM OS BEPORT OF ROVAL COMMlSStOX 
OX LtJXACY AND ,MEXTjUi DISORDER (AS REGARDS 
EXGLAXi) AXD ^YALES.) 

XoTE.— References marked " 11 ” arc to pngcj in the Report 
of tho Royal Commission; fho.se marked "31" to 
paragraphs in the present Memorandum. 

iNTRODUCTOnY. 

1. In many important respects the Report of flic Roval 
toimnission on Lunacy and Alental Disorder (as regnrd.s 
England and Wales), published .Tuly, 1020, is in liarmony with 
the principles advocated by tbe A.s.sociatiou in tlic evidence 
xvUicU it tendered to tho Conimiasion. 

2. In particular, the CorahuFt^ionera report unauiinously : 

(.a) "that tlio treatment of mental disorder should 

approximato as nearly to the treatment of pliy.sical nil- 
ments .as is consistent with the siiecial safoguiirds which 
arc indispcusablo when tho liberty of tlie subject is 
nfnnged" (Ris-V. tlnat "the keynote of the past 1ms 

nreven1r'^‘'‘“”i’ 1 . of the fiitiiro should bo 

picventiuu and treatment. ’’ (R 17) 

not’'l'n!!‘s-t',"‘'‘'''r''“-" resort and 

cerMca?L!\‘r'i‘* facilities for freafment without 

lawie 

TNitliont the necessfty tor full certification.” (R I.37) 

r boarders miglit bo received in anv 

Se'r^Si b"on"^ 

M ft “ ^ “cme, or in single care.” (R 157) 

tionlrsl to oat them [medical practi- 

■with tlia Limacy Act! nndor"tV“^ [iK connection 
which, even if c 1“ ("ciiaco of lifig.ation 

eioiial ruin ami “Kr' financial or profoa- 

b« given to midical leu^^Tn H ‘a''- »''o«id 
professional duties in rrfoHo, J of their 

(!\ *1 .7 relation to insanity.” (R 24) 

enggestion that the nresent L "r ' ““t support the 

ceitificatiou if proi^rFv oW ®o[ogUards against ivroiigfui 
" that in none^ot the^eats inadequate ” (R 1I7); 

w«e we satisfied 0,1 the evidinc^iT^ f® by is 
bad been suffered, while tim '"’Proper detention 

received on this subiect evidence wliicli we 

“ that in practice instLce^of ” (R 87): and 

fully certified or impronFrlv “''"i P'"'®®"® being wrong, 
occurrence,” (R 87)^ ^ ^ retained must bo of the rarett 

. (g) that " a considerahln ■ 

IS urgently needed, . amt after-care work 

of closer touch between thi. i «stablislimcnt 

tiitions and the general oLfw ®f“fi of iiieiital insti- 
after discharge would prove'’ attending patients 
improving the after-care s^ysteni.” i" 

3. TIio Council welcomes tlm ■ ■ ' 

substjnitially in agreement with stated 

issQciatiou before the Roval .P'’.’‘fsnc« given by the 

■ckiiowledges the courtesy and 'care^tf®'”'!’- gratefully 
ias heeu received. There are h'ow«rv^ - ^'’’s evidenci 

conclusions from*wliich Commissioners’ 

omiiellcd to dissent. Thosrrrilf ?o"’mittee finds itSff 

;y which Patientsfailing n of menW ’r “" hoi 


The Council projiO'Cs in tho present Mcnior.andiim both to 
imliciito in what rcsjiccf its vicirs on (he above topics diflcr 
from those of the Royal Commission and to offer certain 
nlteriiativcs to the procedures the ConimiBsion has Buggested; 
also to comment on .some other matler.s that seem to cal! for 
special remark. First will bo considered tho methods by 
which tho interests of patients suffering from various degrees 
of mental disorder can best bo secured, nnd later the 
Arcmorniidiim will deal w’itli tho protection of members of tbo 
medical profession from vexations actions at law instituted by 
pntientH wlio believe tlienrsclvcs aggrieved. 

AnnAsor.MLKTs ron nniNoixo trs-nra Theatjif.nt Peiisoks 
surrmir.vo raojt AfevAr, Di,sonDEn. 

(a) Menial Cases outside the Lunacy Act. 

4. The Council desires to cmplinsiso the existence of 
forms and degrees of mental disorder which need not bring 
the patients under tbe Lunacy Acts or w’itliin tlic cognisyinco 
of tlio Board of Control. Thc.so patients arc conscious ot some 
decree of mental disorder and desire to bo treated, but do not, 
cither in their own interests or in tho intcrcsis of the public, 
require compulsory restriction of their liberty. They can 
bo satisLactorily treated at out-patient departraciit.s, or in 
general hospifnl.s, or by private practitioners in their own 
houses or in iinrsiiig homes. A.s a fact, tlicy are so treated 
at the present day, nltlioiigli the existing provision for 
treatment of this order, and especially for tho poorer patients, 
is quite inadequate .md ought to be increased. If the sug- 
gestion on pago 1.30 of the Beport regarding arrangements 
for Irenlmcnt “ without certification ” is to be rend as a 
proposal to bring these patients in any way under tho Board 
of Control, then the Council is hound to disagree. Sticli 
a formality, with the consequent prospect ol oIRcial visits on 
bclinlf of the Board of Control, is quite unnecessary and 
would certainly deter many patients from accepting tho 
medical treatment they require; nnd similarly, the mnungers' 
of general hospitals and other institutions might well be 
jeliictaiit to receive pafient.s who appeared to bo Tcg.ardcd 
oflicially ns of unsound mind. ° 

The CommissioDcr.s rccogni.se (R40) that Section 315 of tho 
Luii^y Act, 1890, puts some difliculty in tho way of treatment 
of thCM slight .and cur-ahlo cases, nnd recommends that tho 
pronsion need.s considerable amendment." Ttio Council 

Ef SpiS" " »' 

” ns used in the Commi.ssioners’ 
Beport IS not quite free from ambiguity. Probably if 
generally means " full ” cei tificatiou of the patient a^ of 
unsound mind and Uio proper subiect of t. 

Order. But it might bo held {o iuclX^lf L^wlm 
dfsoFacr.'"' treatmeuf for mental 

The Council reiMiats that there aro patients who sufiev 
from some degree of mental disorder but who need r,oUi 
a formal " recommendation for treatZnt ” nor n f 
‘ certificate " and therefore ought not to ho w 
tho purview of tlio Board of Control -When 
doeiimciits is required the Council of coukc^ F 
that the lunsdictioa of tho Board of Control at omS^^pplfM! 

(b) -Vciifa! Cose, under the Lunacy Act. 

come withni tbe provisions of "S’LunacY^ASt”tf 

may be rcco^iised, namely:— ® ff^oups 

mental' disorder r^niks’er may 7emuvTt'"^t 
institution wliero restriction of FiberTv ^ trcatnient in an 
who to this end voluntarUy suLwder^fl ""'I 

from momal 

care and treatment or for' rim '/“teS'':? 
treatmentT: ° ‘^<^»’’'^'’''tely objcc^'t'^Mjet 

nieUnf disIvdev°wMclFneo^/s*'insri 

whicii prevents them giving either n rU ^ treatment but 
a reasoned objection, to tlm defeiitinv 
w-oiild place them in tiie " Volitional " 
class respectively). °r Resistive ”■ 






170 April 28, 1928] 


fteport of Council! 


r KVrn.T.lIF.UT TO TH» 
|.r.RJTIHIl Mi:DlCAL JODBHiL 


Louses, general liospitals, nursing homes, and in single care, 
llie Council'* is in entire agroonieiit. The Commis^jioners 
prescribe a written application from the person wishing to be 
received as a Voluntaxy Jioarder; presumably the application 
would have to be addressed to the Superintendent of the 
hospital or other institution concerned, and it would bo well 
to indicate this precisely. 

7. In contemplating the possibility that the mental con- 
dition of a Voluntary Boarder may, during his residence* 
deteriorate, so that he is no longer capable of volition, the 
Commissioners advise that sliould this condition continue for 
a month he should no longer be regarded as a " voluntary 
patient but should be placed under certificate. The alterna- 
tive would be to claim that as the voluntary entrance implies 
surrender of personal liberty for the purpose of treatment 
this surrender should continue even though the patient^s 
mental capacity to express it hod for the time being failed. 
The Council fully recognises the importance of keeping 
faith with a ‘‘ voluntary patient. To receive such a patient 
under the guarantee that he is at liberty to leave on a few 
hours* notice and then to put him, while in “ voluntary ** 
residence, under compulsory detention would be hard to 
justify; and in a system which sanctioned such a procedure 

voluntary patients would not place their confidence. Tlio 
Council is of opinion that n distinction should be made 
between two groups. The patient who, received as a 
Voluntary Boarder, becomes mentally inert and acquiescent 
may be continued on a ** voluntary ** status, but he who is 
resistive, and demands his freedom in the terms of the 
bond, should be discharged, although this action may have 
immediately to be followed by certification and compulsory 
detention. 

Resistive Patients : Reception Obders and Emeroenct 
Procedure. 

8. The more or less sudden and actitc manifestation of 
mental disorder creates a very difficult situation. Unless 
forcibly restrained, tlie patient may harm liimself or others, 
or may destroy property, and in those circumstances careful 
medical examination may well be impossible. As the law 
now stands, if the doctor certifies the patient he runs the 
risk of an action for damages by an indignant convalescent; 
if he declines to certify and the patient harms himself or 
others there will be public reproach and the cbancc of censure 
by a Coroner’s jury; while, in a doubtful issue, should the 
patient bo placed in an ordinary nursing home, Section 315 of 
the Lunacy Act, 1890, may provide heavy penalties for all 
concerned 

9. The Commissioners recognise that in some of these cases 
law rather than medicine must take ilie initial step. Hence 
they advise that if a patient suddenly develops acute symptoms 
at home, rendering medical examination impossible, or is 
found at large in a condition that requires instant restraint, 
a constable, relieving officer or overseer should* be empowered 
to remove him and place him under control, (1157) Should, 
however, a patient be detained in this fashion proceedings 
must be taken within seven days to secure an authoritative 
warrant in the ehape of a provisional treatment order 
or a reception order. (R 57) Unless this is done further 
detention of the patient will be illegal. 

10. Procedure somewhat different from that just described 

is proposed- (R 57) when the development of dangerous symp- 
toms is not quite so acute. Here an order signed by a 
relative or friend or public official and supported by a medical 
certificate to the effect that ** it is expedient for the welfare 
of the . patient or for the public safety that he should be 
forthwith placed under, care ” will justify the reception and i 
detention of the patient in an appropriate institution. But 
once again, proceedings to obtain a provisional treatment i 
order or a reception order must be taken if detention beyond j 
seven days is contemplated. Tlic procedure is tliafc of the , 
existing “ Urgency Order.” j 

11. Tiiore arc yet other patients who require forcible j 
removal and detention. Less violent and urgent perhaps than I 
those mentioned in -the two preceding paragraphs, they may ' 
none the less be dangerous to themselves or to others; and as | 
thcT deliberately I'efuse advice and resist treatment force is 
the* inevitable remedy. Under the present law such a position j 
can be met by the existing Reception Order granted by a 
macristtato after consideration of a Petition presented by a 
relative or friend and supported by two medical certificates. 
The present . medical certificate, describes the patient as '*a 
lunatic, idiot, or person of unsound mind,” but in the new 
form the reading is to be a person ** of unsound mind and a 
proper person to Iw taken charge of and detained under care 
and treatments^’ Tliis amendment of the ** certificate '* adopts 
the proposal made by the Association in the evidence given to 
the Royal Commission. 


12. The Commissioners suggest certain modifications of the 
present Reception Order. TIiuh they alter the rule which 
instructs the two doctors to act independently, and recommend 
that the doctors be entitled to consult together. The 
Council wclcomoB this proposal. Another recommendation is 
that tlic Reception Order shall apply only to patients who 
aro’ not likely to recover 'within a period of six months, niid 
this must be stated on the medical certificate; the Council 
cannot endorse this proposal. Obviously, one result will bo 
that at fhe outset of institutional treatment the Reception 
Order will rarely bo used, for in so uncertain a region as the 
progiic-sis of menial disorders the doctor will be reluctant 
to suggest an unfavourable outlook and the prospect of 
unlimited detention. The Council thinks that this time- 
clause should be .omitted and the doctors loft free to judge 
in each case which form of procedure is the more suitable. 

Another suggested modification of. the Receprion Order is 
that the magistrato must see the patient and any available 
relatives; also, if ho thinks it necessary, one or both doctors. 
Ho is further to exercise a ” directed discretion ” whether or 
not to inform the patient of the allegations ” made regard- 
ing his conduct. Later in ’ this Memorandum the Council 
will argue that the Reception Order, andi the intervention of 
the magistrate, as here advised, should apply only to certain 
cases. In such cases the activities of the magistrate as pre- 
scribed by the Commis.sion may pcriiaps be of valne. 

The Council questions the Commissioners’ demand that the 
Petition shall be accompanied by ” a disclosure of the patient’s 
property, if any.” The immediate distress inflicted on the 
relatives by the necessity for certification may well claim soihc 
postponement of a matter tliat can hardly be described as 
urgent. 

33. There is one other position for which provision must 
be made. According to the existing law, when a Justice of the 
Peace is informed Uiat a person deemed to be a lunatic is not 
under proper care and control or is cruelly treated or 
neglected, the Justice shall direct two medical practitioners 
to examine the alleged lunatic and shall on their report order 
tile detention of the patient if he judges it fit so to do. : In 
such cases the right of entry of the doctors may be contested 
and tlic Justice ought to be empowered to secure this. 

14. Subject to the criticisms presented in the above parn- 
oraphs the Council agrees with the proposals of the 
Commissioners Tclativc to mental patients who arc 
‘"rcsistire” in the sense defined in this Memorandum. (M 5(b)) 

Non-Toeitional Patients ; Provisional Treatment Order. 

15 The Commissioners take the view that cases of mental 
disorder should be classified in two categories, namely, (a) 
voluntary, (b) iiivoluntaiy. The voluntary group consists of 
patients who enter a mental institution on their own initiative 
as Voluntary Boarders. All others are “ involuntary ’ and 
can be placed under compulsorj' treatment only after medical 
examination and on the order of a magistrate. If recovery 
is anticipated within si.x months a single medical examination 
is sufficient, but if the outlook is less promising two medical 
certific«'ites are inquired.’ The instrument justifying the 
shorter detention is tho Provisional Treatment- Order, while 
that for the longer - period , is the Reception Order. Such, 
essentially, is the scheme outlined by the Commission so far 
as the formal procedure governing the admission of mental 
patients to appropriate institutions is concerned. 

36. The Council, with great deference, and assuming 
that the ends desired by the Commissioners are to be obtained, 
cannot acccp*i as a practical scheme the classification of 
cases adopted by the Commission; nor can it agree that the 
intervention of a judicial officer prior to institutional treat- 
ment is invariably desirable. On the contrarjs if the early 
treatment of mental disorders is to be realised,- then, in the 
view of the Council, such intervention should be limited to 
cases in which the patient is capable of volition and definitely 
refuses or resists institutional treatment — cases, - that i3» 
where the use of force is necessary either for the patient a 
welfare or for the protection of the public. "What has to lx? 
recognised is that between the Voluntary Boarder ' 

extreme, and the recalcitrant or deliberately resistive naticnt 
at the other, there are numerous patients in whom the wiH 
is in abeyance (non-volitional patients). The incapacity maj 
be associated either ivitli the irresponsivencss of stupor oi 
melancholia, or with a state of mental confusion and in- 
decision; in either event the patient is manifestly beyon 
the point at which' any appreciable degree of judgement or 
choice is possible. Such patients are numerous, and many 
them made an early recovery; hence they ought. ’ 

to be saved from the stigma of formal certifiration. ^ 
Council’s claim is that these patients can 
admitted to an appropriate institution on an “Autlion. 



APRir- 28. 1028] 


Appendix V. 


r nvrrLrMT.ST to tub 
Lurn 


CniTiRit ilroicin Joccxii. 


171 


for Treatment ” given by i\ relnlivc or friend and supiiorlcd 
by a “ recommendation *’ signed by two medical practitioners. 
The intor\’cntiou of a judicial nutliority in tb.cse cases the 
Council regards ns unnecessary and possibly liarmful. 

17. The contrast between the two positions above discussed 
may be briefly stated. Iloth the CommiH.sion and the Council 
limposo a Itcccption Older and a ib-ovisionnl Treatment 
Order, lliongli the Council would prefer to name the latter 
instrument an “ Authorisation for Treatment.” Ilolh agreo 
that the Reception Order ix'tpuroH two medieal ccrliticales and 
the warrant of a magistrate. Rut wliile tlic Commission 
applies this Order when a jjatient is not likely to recover 
vithin si.v months, the Council projxises it when n patient 
capable of volition resists treatment, or, when a limited term 
of detention having failed, prolonged or even pernmnent 
detention ajipears inevitable. Again, tlie Commission*H 
Provisional Treatment Order is to be snp])orlocl b}* only a 
single medical ” recommendation ” and a magisterial 
authority, and is to be used when the patient is deemed likely 
u) recover within six month«. On the other hand, the 
Couiicirs Provisional Treatment Order or Authori-'atiou for 
Ircatracut needs merely the ” authorisation ” of n relative or 
friend or public ofiicinl and '* rccommciidatioiiH *’ from two 
medical practitioners but no magisterial intervention; it is 
offered as appropriate to all eases in which the patient either 
can be persuaded to submit to institutional treatment or 
exhibits evulences which show him to be incapable of volition. 

18. To put tlic position in other words, while the Com. 
m^ioners I'rovisional Trc.itnient Order is (lie licception 
Urter made by n magistrate but limited to n period of si:t 

"T'lical certificate, the 
•orfriel.8 for 'Treatment is made bv a relative 

for 28 d^'v^ I '’T " "'•■'pistratc)," is clTcctivc 

medial capable of extension, and in supported bv two 
“heme no ^^ooording to the Commissioners’ 

instkiition^i J ^ “ Voluntary Boarder can receive 

wli lo thr Conin'- ‘>'0 ni'proval of a magistrate, 

aent wiiLnt ^ available sucl! treaU 

eaber yi^ d I thf for all patients wl.o 

magistrate on a f^ooption Order, granted by a 

iliit it differs from A J’rcsented by a relative or friend. 

(a) it requires one Ececptiou Order in tbreo rc.spccts, 

(b) thr- "ecommenTal!n"‘.r but one only, 

mental condition U such'tlnt^f*^ state Uiat “tlic patient’s 
or for the wclf.^re of JS c-xiicdieiit for his welfare, 

under observation care amf t rl,‘7 slionld bo detained 

effective only for a montli “"'f (c) Ibo Order is 

recovered at the end of ' Ko'vcvcr, the patient lias not 

«asonable prospect of 'f » 

osteuded fora fnrtPe; <latc, may be 

extension a judicial auA^nrU-t ^7*^ months. To secure this 
the original Order! mnsf ^ (preferably the one who signed 
mendation for “ roLTal ““^n's f “ Patient, and a roeom- 
medical practitioner or " "xlcpendeiit 

public mental hospital nr Li ““^.‘oal superintendent of a 
service,” The te™ “ "fboor in the public 

definition, and again it is not*7ll^'”^ I needs 

or would not sanction a reni ■'vbether the proposal would 
medical superintendent of jp J 5 <=°'nmendation ” by the 
bed spent the previous montii Tl. " 

but in practice the exact ‘ nee points of detail 

authoritative explanation ‘“‘"Fetation of them will need 

20. The following are in +i 
unwelcome features of the Pn^ • °f ^‘0 Council, 
ment Order; — Commissioners’ Provisional Treat- 

ca^e^ of th?' Vohmta^ '’srard'’^ treatment, e.xcept in the 
• legal official on every paHpn'7’ mterveutiou of a 
treatment; in this respect '"'b? "ceds institutional 
of the existing law. There is fbc formalities 

to what the Commissioners dcs rf' fbereforc, no approach 
tion of the treatment of mental v the approxima- 

ot bodily ills. Again, treatment 

dislike the publicity and sti^nn °f ‘bo patient 

the presence of a magistrmc associate with 

measures as long as possible and ''7' postpone active 
hopeful treatment, which the Comm;f^““ 
to encourage, will be prejudiced 

eZ?““‘ detention under a ° 

empliaslises m the public mind the cf* '^arrant 

, tion; it is this feature of the certiiica- 

muoh resented. .. TJ^^uot practice that is so 


to bp played by the I.aw in the treatment of mental 
patients. 'They tbns fnrtlier depart from the ideal towards 
wliicli nmendnionis of the existing law ought, as they 
tlicmsolvcs urge, to be directed. 

(c) 'Tlic Order can bo continued only for a period of 
si-x inontlis; if at tlic end of this lime further detention 
is ndvis.able nnd the patient refuses fodiccoine a Voluntary’ 
Boarder, be inn.sl cither be diseliargcd or placed under a 
Itcccption Order. The Insl-mcntioncd course must mean 
anothor legal interview and fui-tlicr nicdic.al certification. 
As opposed to this tlio lle.xibilily of the Council’.s 
Authorisation for Treatment would avoid tlic.=e multiplied 
adiniiiistrativo complications, nnd would meet the position 
both of patients who may be cxixicled to recover promptly 
nnd of those for xvliom the outlook is less promising. 

(d) 'riicsc increased legal activities will be unweleoine 
to the patient nnd to bis friends. The Comniiasioners, 
conlcmpbating the necessity for tlic removal of a patient, 
write, “ in such a domestic crisis the first and natural 
concern of doctors and relatives alike is to obtain for the 
patient, with the least possible delay and the least possible 
publicity, bis necessary removal to' a place of safety and 
treatment. 'The unfamiliar formalities of legal jiroccdiire 
may well jirove an ndditionnl cause of distress in such 
circuinstnnccs.” (R 20) And yet, on the Cominissioner.s’ 
advice, “ legal procedure ” is to become not less but more 
formidnblo than in the present practice. Again,, a 
multiplication of legal interviews will put a cons'ideraiilc 
burden on magistrates and, what is more inipartant, cn 
the medical officers of mental hospitals. Tiii.s ]>ositioii 
becomes all the more evident when it is realised that the 
great majority of patients will, under the Commissioners’ 
Mlicnie, enter institutions under the Jfrovisional 
Treatment Order. The belief that tlio medical practi- 
tioncr can confidently estimate the probable date of the 
patient’s recovery nnd thus sliarply decide between a 
Provisional Treatment Order on the one hand and a 
Reception Order on the other, is not well-founded. The 
uncertainly of the future, the pressure of relatives, and 
the natural inclination of the doctor towards a hopeful 
prognosis, will combine to select the less forbitlding 
course, and the Provisional Treatment Order therefore 
will usually be adopted. This will mean that everv 
patient wlio enters an institution through this avenue will 
have au interview with a magistrate before lie enters a 
second interview after a month’s interval unless 
bo has recovered, and a third five months later 
If, as Will sometimes happen, a period of treatment 
extending over more than six months is refniired 
Both magistrates and medical officers under ^ sucli 
a scheme will find their burdens much increased. This 
also must be said, that the procedure hero considered ^ 
largely superfluous, seeing that the patient during bis 
residence enjoys the supervising and protective actifitks 
of the Board of Control ; and so efficient h.avo these 
activities proved that he Commissioners in tho course of 

Sop^rdefen W of 

■ oiil'^m^S'-^rellm^ndattr'’ Tn“ead 
“ certificates.” the new Provffiioual Treni. 
present to the patient and hiq fn*n» Order will 

difference from the present Rcceptio^ Order”'’ irwiir^ff"^ 
the same obstacles to early treatmenf nV„i *for 

same objectionable stigma^ To Ztest t1m7 

mean full certifintion ” P™test that it does not 

the patient is removed and dpt'i'*'°*i that 

JustL he is unSer the p^ent nractte^T^'^-''^ 

subject of legal deten&nnd not ^“'".oponly the 

consolation and mav possiblv t*nrdly afford 

to cl,,, 0. ... .lloiopt 

Prom this the Council strongly' Snts ^^“““‘ioner. 
an acute emergency and as a merely -^^oopt m 

while a more formal warrant is h'eint expedient 


an issue bo 


:c formal warrant Irfi .’^o^Porary expedient 

21 . Altogether the Pniinoii •« j . ctors concerned, 
tlio conditions of the pronosed ^*®eult to reconcile 

with the expressed de3';r:'’rf "hfTo’Z’-''’- ^reatmeiR 'ffi 
cation should be tho last resort • certifi’ 

a necessary 





Arnir, 2S, 192a] 


Appendix V. 


r. 


svrrTXar.XT to rmi ^ 

rniTIBlI Mr.t>fCAL JOU&HAri • 


Acts. Those, niul parallel ])ljrases, show that the CointniR* 
s.oiK'i's were satislicil that “ the exi.^thi'j lunacy cculc bristles 
with precautions . against iinproper detention” (It 19); that 
they did net in the course of their investigations discover 
even a single instanco of iin])ropcr cortilicalion or detention; 
that medical practitioners in undortakiiig respon.sibilitics 
Mider the Lunacy Acts arc j)laced in an unfair position by 
their liability to vexatious and unrensonnblo litigation; 
that in conse(|Uoncc of this risk practitioners are, not un- 
naturally, becoming relnctant to sign Iniiacy cortilicatcs; and 
that both nalicy and justice demand that doctors should 
rccone further protection against the menace of unjuatifiabte 
litigation. Furtlicr. on the subject of the iinjiortanco of tho 
part played hy the medical practitioner, the Commissioners 
write — 

(a) that ” the more mental illness is assimilated to 
physical illness the more tho public mu.st rely ou the 
medical profession.” (U 20) 

tb) that ” it is remarkable that in the case of a form 
of disca‘;o pnihably more subtle and dinicult of diagnosis 
than any other, tho layman should insist ou Ids right to 
sit in judgement on the o.xpcrt.” (U20) 

it is ‘‘’’aid and done reliance niiist 

levitably be placed at some jmint ou tho ekill and 
inlognty of the medical man,” (U 20) 

of llif.se rmdiiijrs. is bound to claim 
Tt fonsational riiiiiours ami sufrpestions which have 

hLl /V" administration of the law have 

enoni^ Sf" "Ifo, that the most searchins 

anSliMtii f 'T)'” t ‘‘■'‘"■"'ff 0" i'"I>ortant part in the 

fl/od ^ '"<',|ical profession has 

“or in sound judgement. The 
great f^ L '"p"- " “““onty of eases, are 

S defi„i?L' . 9°»™>“>o“or3 well sav, “ insanity is not 

noofw nvf It is .a 'matter of\legree, 

To^mtn." (R 19)“"“^ disjeno^ 

PnOTECTmX or THE IfEDICAt, PnACTITIONEK DlSCUAROtSO 
"T Tl.^ P “''“SOASCE or THE LU.VACV ACTS. 

tcetion" wWcr?he “ f»rthcr pro- 

medical practitioners^^ should be given to 

duties il relation to insanity Iirofcssional 

one. Sent^*ca« 3 ^n " p « most nnsatisfacton- 

tioner who has 'siirnwl * "'‘own tliat a practi- 

liable to a ch^“lion'mn‘^,?‘“ 

event, and on the plea that ? y'*'*”' 

and in good faith^ ttV 

evidence from mental iucxcascd by 

a certificate tliounh justified in cliallenging 

months or years f * ""‘ii 

instance the Tssue for tL "‘’''"r 

Was the doctor ea,ets bat^ t7 substance been, ncit, 

at the date of certification? ’ TI r P“*>oni of unsound mind 
long after the event to 1“’^ « asked 

the spot; and, if nnf ° "i^^dical judgment made on 

diagnosis, to draw tZ accuracy of the 

without due care. AVlietlier doctor has acted 

or not, it is hardly reLonClJC^''?"'*' appropriate one 
authorities differ on a 1*'“* ''vheii two 

sarily guilty either of cawl~°““ 1® neccs- 

pf. these faults. As n„Ce" X"vn%°" °f b®“' 

insanity is not a dcfinitel^ from the Royal CommiEsion 
matter of degree upon which' .^®®^‘“‘“‘''ble st.ate. It is .a 
honest difference of opinion.’^R igj ^® for 

of the certifying practitioCC'?n^'*' •^^® farther protection 
an Order authorising the detenp^^”’^? *'‘® 01“'“ fbat when 
magistrate it is thm le=-al ? P“fl®“f is signed by a 

certificate that assumes °resMasib;rr‘ medical 

follows the contention that 'tlm ' i “ corollary there 
Structing the certificates are Practitioners in con- 

the magistrate may or mav nnr o evidence which 

are witnesses and the Talistrafe 

Some colour is lent to tlds a^L deciding authority, 

magistrate may call for oHie/ fl‘“t the 
evidence undor^the sanction of a?“"T “5'^ “•'‘y ‘“t® all 
m the procedure which leads to thp''*^i’’f *'^® doctor 

bas the status of a witness, he ou-^ht to 

of a witness, that is to sav, that unle°= i^ ^ *'‘® ^“'‘nitics 
no civil or criminal proceedings can be tak° ““““'fa perjury 
the evidence he has o-iven Hn ?i“ against him for 

bat merely gives to tS '^epreslfatlvo “f •““‘'■““ify 

“a fho technical question^rt Tssue vf.! “■I'"''' “Pi“ion 
by the law; with the law, therefore; mu^rert "respoSy^ j 


Of coiisidorablo intorcsl in rclntioii to this nrginnenl is a 
jiidgcincnt delivered in a recent enso hy Mr. Justice McCardie. 
The learned .Tudge said that if he liad been freed 'from 
mithorily ho would have thought that tho effective cause of 
the dcieiitiou was the order of tho Justice and not tho certifi- 
cate of Ur. D. The decision under Section 10 of the Lunacy 
Act, 1890, lay with the Justice and not with the doctor. Tlio 
.Tustico could decide ns he pleased, whatever the certificate 
stated. The doctor’s certificate although an, essential require- 
ment was a mere opinion which possessed, of itself, no 
opcrnlivc force. Apparently, the learned Judge felt himself 
bound by n previous decision of one of tho superior Courts, 
hut it is nolcworlliy that even the judicial bench gives some 
measure of sunuort to the claim that not medicine but tho 
law is rc.sponsiule for the detention of a certified patient. 

32. Tho A.s.seci.af ion’s witnesses before the Royal Commission 
prcscnled the case just stated. Tho Commissioners, however, 
did not accept the claim; they rejected it on the ground that 
it vvoiild protect a practitioner “ who gave a ccrtificato 
iii'gligently or in bad faith.” Upon this it may respectfully 
be suggested that when the l.aw appoints an official to decide 
nyo or no on the proposed detention of a citizen it is tho 
duty of tho qlficial to appraise the value of the evidence 
before ho decides to act on it. Again, according to tho 
existing law, the two doctors who take part in a Reception 
Order must not he in partnership with one another nor related 
to one another or to the patient, and in these circumstances 
a deliberate conspiracy oii tho part of two independent medical 
practitioner.? to net carelessly or in bad faith is difficult to 
imagine. Once more, when, as is the rule, one of the certifi- 
cates is signed by tho usual medical attendant of the patient 
or of his family it is against the interest of the doctor to 
send the patient out of his own care into an institution; in 
such circumstances the law forbids the f.amily doctor to act as 
the regular medical attendant of tho patient, and the same 
principle applies even when the patient is placed under “singlo 
care.” tVorthy of consideration, too. in this respect, is 
the failure of the Commissioners, cither on enquiry or visita- 
tion, to find a single instance of improper certification’ or 
detention. Altogether, the feer of the negligent or disloyal 
practitioner seems decidedly over-stressed; if lie exists, liis 
opportunities are certainly severely restricted by the condi’tions 
here defined. 

33. There is in tho Lunacy Act, 1890, one protecting clause 

for tho beaefit of those who with due care and in good faith 
undertake any duty in pursuance of' tho Act, This is Section 
3.30, which provides that if any proceedings are takca against 
any person for doing anj-tliing in pursuance of the Act, such 
proceedings may be stayed upon summarj- application to the 
High Court or to a Judge thereof " if the Court or Judge is 
satisfied that there is no reasonable ground for alleging want 
tif good faith or reasonable care." Under this°prWsion 
a doctor against whom an action lies been entered ma?- nrnilv 
to the Court for stay of the action. But to succeed ho 
must satisfy the Court, not only that there was no caielcssness 
or want of good faith on his part, but also that tfie-^- was no 
ground for alleging cither of these faults. , The doctor 
applies to the Court and the burden of proving a uenati?-o 
IS placed on his shoulders, ^uch is the extent of thi W 
tcction afforded by tho existing law. ' 

34 The Commissioners agree that "further protection” 
must be given to medical practitioners; and to Veure this ' 

to'^air'yr® * certifying doctor should not be exposed 

to an action in respect of anything done under the Anf 
unless the plaintiff can first satisfy a judge in chLw H.at 
there is prtma facie ground for an sllnrmflr,-, ““P®*^ tliat 

carclcssnLs oi-° of htd‘ faith rt”ts 'the ^doctor “'in °tho° 

rnrsf £ 

support of such an allc>ratiou SlinnlV I,J 7 " i / ® 

Court this respect thettion wiU 'be s?aj“ed. 

35- As the alteration of Section Ran of n. t 
proposed by the Commissioners ??m transfer tfi^on?'^ 
from the defendant to the plaintiff it m^t 
matters. There is considerable donhl 7 .'^ possibly improve 
Itself such ail alteration will be sufficie’nt whether in 

in view. E?-cry now and a"ain snmo ■ “““'"'O object 

tnrbancc, in the future as ° ? victim of mental dis- 

Hmself to have been wr’onged by rproc'edurf 
him in a mental hospital, aSd will se?k a 1 a 
of the, law and at the expense ot tL T/ ““ 
conceruEd. The defendant pStioner ™ ''““‘or® 

of the action, and may, per^mprimder^l ^ “Pply for a stay 

.... .„ 4 ,; 




Report of Councils 


r sc;pri.r.vr*vr to xrre 

LPRlTISn JlroiCAL JOURVIL 


174 April 28, 1928] 


application (and the standard of %vliat is judged to l>e satis- 
fying evidence is likely to vary) the decision will piesuniably 
be suloject to legal review^ witli resulting expCMise and anxiety 
for the doctor. 

36. The Council, therefore, while recognising the good- 
will of the Commissioners and their desire to assist Ihe 
medical profe- sion in a difficult Mtuation, yet doubts Avhclher 
the mere modification of Section 330 -wiH' give an adequate 
degree of protection to the certifying practitioner or will 
secure that willingness of the medical profession ” (It 23) 
without which, as the Commission recognises, anv system 
that can be devised must ultimately break down. 

37. What the Council sugec.-its is that the recomnicucla- 
tion of the Commission on this point should bo suiiplcmcntod 
by a step which would place toclinical knowledcp at the 
disposal of the Court when an application for a stay c.f an 
action is being heard. This aim would be secured bv retniii- 
rng the Court, before refusing such an application," to hear 
the opinion of an impartial expert competent to advise the 
Court on the teclinical values of the affidavits, or other 
evidence that may iie submitted. Tlie Counci! i.- of opinion 
that tlie Association should jiress this propo.sal on the Govcni- 
ment and the legislature in the hope that if adopted, ton-ether 
with the suggested modification of Section 33ft ir will 
conimaiid tiie goodwill of the profession To ’meet the 
Councils proposal oil this point a panel of "medical expcrt.s 
should be set up by the Govenimeiit. 

38. The Council recognises that as tlie claim f,,,- tlie 
comiilcte protection of the certifying jiraefitioncr Vm 3(t) 
presented by the Association’s witiiesse,s to the Roval" Com- 
mission has not been approved by the Commission, the clmL ■ 
of securing legislative sanction for it is not a good one If 
this assumption proves to be correct the doctor will as a) 
present, continue to bear the respoiiaibilily for the p.atient’s 
detention, that is, so far as the doctor ‘is concerned the 
magistrate will have no protective value. Tlie Com- 
missioners’ Report (R.36, 37) shows that in the jud<romeiit of 
many experienced p^sons the magistrate is i-alueless also 
to the patient. Whether the more active and more 
inquisitorial duties which are to bo imparted to him will 
afford added efficaw m tl'is direction may be open to debate, 

tJ'at these new aetivitic.s will not m.ake him 
more welcome to the patient’s friends, and they mav in 
individual instances he prejudicial to the patient.' lu "face 
of these considerations the Council urges (i) that in very 
m.auy cases, as explained in this aiemorandiim, magi.steriai 
intervention is quite unnecessary, and (ii) that the interests of 
such pnt'ents will be best served by leaving the decision cm 
methods of treatment to a medical judgement. This arrauo-e- 
ment may seem, although there is no real change in this respect 
® ^ore manifest the responsibility of the doctors con- 
cerned. Be this as it may, the Council belie-es that the 
profession will be prepared to meet the resiiousibility provided 
(a) that in an application for the stay of .an action against 
a doctor the onus of proving an allegation of carcle.ssucss or 
of bad faith shall be on the plaintiff who affirms it, and (bl 
that when such an appliention is heard tlic Court shall have 
the opinion of mi independent medical expert on the technical 
values of tue affidavits or other evideuce submitted. 


Additional Notes. 

39 The Eoyal Commi^ion has considered the apiioiutmeiit, 
by local health authorities, of special ’■ certifying medicai 
officers . who would in whole or in part remove from the 
family practitioner the responsibility of lunacy certification 
and the Commissioners rather encourage this view in respecl 
•at least to one of the certificates in cases where two of tlie-ie 
documents are ret|uirc(l. 


The Council doe.s not favour .siich apiioiiitmeiits. An 
official announced as a “ public certifying officer ” woiilel be 
avoided by the public as long as possible and certainly would 
not be welcome as a substitute for the trusted aud confidential 
family practitioner. It miglit. liowcver, be jio.ssible' for cacli 
health authority to provide lierc as iu other case.s (c.f/., the 
notification of Puerperal Pyrexia) a jiaiiel of experts any one 
of whom would meet the f.-imily doctor wlien a consultation 
was desirable and the patient’s circumstances did not permit 
thc'p.ayment of a consultation fee. 


40. A small but convenient improvement to each medical 
recommendation Or certificate would be the addition of a 
footnote drawing the doctor’s attention to the fact that if he 
signs the document he cannot act as the " medical attendant 
of the patient ” while the patient is in a ment.al hosjiit.al or 
ill single care. Tliis restriction exists under the picseiit law, 
and presumably will be continued. If the friends desire tlmt 
the usual medical adviser shall continue as medical attendant, 
not he, but some other doctor must sign the official dpeiiment. 


I . ' u 

APPENDIX VI. 

COUN,SEL’S OPINION IN RELAITON TO THE LEGAL 
POSITION AND POWERS OP VOLHNTARA' HOSPITALS 
AVITH REG.ARD TO THE RECOVERr OF JfONET FOR 
THE TREATMENT OP PATIENTS. 

Counsel was requested to advise the Association upon the 
following specific questions : — 

(1) A hospital, .supported in whole or in part by volun- 
tary contributions aud rendering gratuitous service... to 
those unable to jiay for hospital treatment makes special 
provision for more affluent patients on the basis of pay- 
ment upon a scale determined with reference to tho 
financial resources of individual patient.s. It also agrees 
with a local authority .to treat certain classes of patients 
for a definite fee jiayablc by the authority for every 
jiaticnt so treated and with a provident association to 
treat mcnihcrs of that association at a certain r.ite. Is 
that hospital, 113 - reason of the fact that it is a charitable 
institution, iiiiahle to recover (a) from the individual 
patient, (b) from the local authority, and (c) from the 
provident association, the amount of the charges laid 
down in respect of the treatment rendered? If so, on 
what grounds and for what reason? 

(2) Where the victim of any accident receives emer- 
gency treatment in a hospital, and c.stablishe.s a claim to 
damages in an action for negligence against a third 
party, is tliore an 3 - means by which the hospital concerned 
can recover through such patient any sum on account of 
the expenses incurred by such hospital (a) if the victim 
falls W'ifliin the class not tre.ated gratuitously by the 
hospital, (b) if hf falls within the class normally eligible 
for gratuitous treatment? and 

(3) Generally -with regard to the subject-matter -of this 
case for the giiidaiieo and assistance of the Association. 

Opinion of Mb. J. H. Stamp. 

(1) A hospital, supported in whole or in part by voluntary 
contributions and rendering gratuitous services for thos'c 
unable to pay for hospital treatment, which makes special 
provision for more .affluent patients on the basis of pa 3 -ment 
on a scale determined witli reference to the financial resources 
of individual patients and wliich agrees with a local aiitlioi-ity 
to treat certain classes of patients for a definite fee payable by 
the authority for every patient so treated and with a 
provident association to treat members of that association at 
a certain rate, is not in my opinion by reason of the fact 
that it is a charitable institution unable to recover (a) from 
the individual patient, (h) from the local authority, or (c) 
from the provident association the amount of the charges laid 
down in respect of the treatment rendered. 

Except in the case of any incorporated institution which by 
the terms of its incorporation might be prohibited from 
charging for its services or from suing for moneys owing to 
it (a case which so far as I am aware is who!l 3 ' imaginary 
and not likely to arise in fact) the question wliother a hospital 
can recover charges for its services depends upon the ordimirv 
law of contract and wlieiiever there is in fact a contract witli 
a hospital by a person or body capable of entering into such 
a contract for the payment to a hospital of charges for 
services to be rendered by the hospital and the hospital 
renders services pursuant to the contract the hospital can. 
in my opinion, recover the agreed charges from the other 
contracting part)-. 

Where a charitable institution such as a ho.spital differs 
from a conimercial iiiidertiikiug is not iu relation to the cu- 
forcement of a contract which has been in f.act entered into 
with it, but iu relation to the question whether or liot there 
is iu fact 303 - contract between the parties, and tlic differc-ncC 
is this, viz. ; — ’Th.at wliere a person invites or knowingly 
accepts services from a commercial undertaking in the course 
of its business a contract will be implied for pav-inent of a 
reasonable price for the services 60 rendered. . and when an 
implied contract for payment has arisen the amount to be 
jjaid can lie subsequently agreed or determined bv aii action 
at law; but a charitable institution habitiialU* renders R-s 
'seri'ices gratis, so that the mere acceptance of services from 
such an institution raises no implied contract to pa 3 ' for 
them, and even a promise to pay foi- the services after they 
have been rendered is not in law enforceable because there 
is iu laiv no consideration for it, the services being past 
services and no implied obligation of pa 3 'ment having arisen 
from them. But where the services are in fact rendered ))iii- 
suaiit to a contract, including a term requiring that payment 
should he made for the services, this difference of course 
disappears; and an cxpre.ss reepicst to he admitted to a 
’* pa 3 -ing ward ” or “ as a paying patient ’’.would prium /«cic 







Ariiir. *23, I92s] 


Assoc/at/on Notices^ 


r /^DrrLrsrr^rr to m 
LnniTijirr Mi^dical jouuxit 


177 


3. The work Fuljmitlctl inusl indutlo personal observations nntl 
experiences collected by the candidato in general prncticci and a 
hi^b order of cxccUcnco vrUl be required. If no essay entered 
is*of sulTicicnt merit no award will be made. 

4. Essays, or whatever form the candidate desires Ins wmrk to 
lahe, must bo sent to tlm Tlrilisb Medical Association House, 
Lonaoii, AV.C.l, not later than Decernher 3Ist, 1928, and the 
prizo will be awarded at ibo Annual General Meeting of llio 
Association to bo held at Manebester in duly, 1929. 

5. No study or essay that has heen published in the medical 
press or elsewhere will he considered cligihlo for (ne prize, and a 
contribution ottered in one year cannot be accepted in any aubse- 
qucnl year unless it includes evidence of furtber work, 

6. If any question arises in reference to the cligihtlily of the 
candidate or the admissUnlilv of his essay, tho decision of the 

..Council on any such point shall he final, 

7. Each essay must be typewritten or printed^ must bo distin- 
guished by a motto, and must be accompanied by a Pealed 
envelope marked with the same motto, and enclosing llio candi- 
date’s name and address. 

8. The writer of tho essay to nhotn the prize is awarded may, 
on the initiative of the Science Committee, be requested to 
prepare a paper on the pubjcct of his essay for puhlication in the 
Barnsn Medical Jourkal or for presentation In the oppropriato 
Sec^on of the Annual Meeting of the Association. 

9. inquiries relative to the prize should bo addressed to the 
Medical Secretary, British Medical Association llouse, Tavistock 
Square, Eondon, W.C.l. 

Medical Appointments Abroad. 

The bend ofbee of tbo British Medionl A.^^ocmtion )ins 
n good deal of information placed at its disposal by its 
Brandies overseas, which may bo very tiseful to those pro- 
posing to accept medical appointments abroad. Practi- 
tioners are cordially invited to apply to the ^fodicnl 
Secretary’, B.M.A. Honsc, Tavistock Square, W.C.!, for 
any infonnation that may bo available rogarding oversea 
appointments in which they may ho interested. 


Associaliou lloticcs. 

i^tEJlBER OF CENTRA. 7 J COUXCIE 
AFRICAN GROUP 

1'OU‘loo. EufilancI, txncl Dr. W. 
mTiabs-PiiCHFORD, Briilgnorih, Saloj), EngJaml, harlsg 
been uominateil in respect o£ tho election to the Council ot 
a timber to represent tho Arricau Group ot Branches foe 

‘ro'u HoaA Ofiico to 
volinrt Branches In tho Group. Ot the 518 
292^r-'’T 5 Avero spoilocl; ot tho romainacr, 

ol Dr -R ^''at'““s-Pitchford auil 221 iu favour 

W Dr. Bai'orott Anflevson. 

dt th'o^^ntrifi thorehy heconics elected a member 

the African Gronro” Benches”. 

18th 1928 Journal Supjilcment ot February 

Association outside the United Kifc ’"' 

Tm toSnJ^H^ ^’ROWBRIBGE DIVISIONS. 

takes^effeotalfrorttodat Council, ana 

Tlmf the aato ot publication ot this notice : 

from the area'-ot ''y‘‘'^“>“ster be trausterred 

Division. Salisbury to that ot the Xrowbridfie 


May 12, Sal. 


table of dates 

«an5 Tua,. ■ ‘'-0 

““r 19. sat. ta^r ly° 

gaclion, al;cre there are^con^c® s! ol fn '24*^nf“,Sf” 

. airi'k’tiu/Sti'; sSirei 

4 Represontativea of PuMlo^ f^®uncil. and 

sfiitatiyo Body. Service in Repre- 

mot^ons^^by^D^wJiong 

■ ''T on 

'Representativea ond BeDutv*^n»Sv piven. 
elected by this Bepicsentatircs must, be 


Juno 2, Sat. 


Juno 7, Thura. 

Juno 13, IVed. 
June 2}, Thi/M. 

Juno 30, SaE 

July 4, IVcd. 

3\My 20, Fil. 


Jiilv 21, SftU 
July 23, Mon. 

July 24, Tucs. 

July 25, IVcd. 


PuMlcntlon in IiruTiPir MnniciL Jolt.nu. Sfrrr.r-MrjJT of 
result of election of members of Council hy grouped 
Branclics, nnd of result of election of members of 
Council nnd Ucprc«cntntivcs In Representative Cody by 
CiibJfc HenUh .svrvicc member. ^ , 

Kominntlon papers nvnllnblo (on apnilentinn ot Head 
toT viveUon ot 12 members ot Council by grouped 
Rcprc.vnlnlfvcs (British Isles). 

Names of IteprL^cnlatlves nnd Deputy Rrprcrcntalivcs 
must bo received at Head Ofiico by this date. 

Mcetlner'i of CoriflUt/cncles mitfi be held Ijetvrccn thfs dat<3 
nrul Julv 20lli to instruct Representatives. 

Bnpplemchlary Report of Council appears In British 
lU.Otca JOURNAL Suitleme?.!. 

Amendments nntl ritlers for JneJnsJon in A.R.M. agenda 
must be received at lleotl Olficn by this date. 

.4nnU«t Rrprf«enf<i(fre Jfreftud, CardIfT, 10 o.m. 

XomCmtfons tor election of li members of Council by 
grouj)c<l Rcpresenlntlvrs must l>c received (at A.R>3h, 
CaftblT) by this dale, 2 D.m. ^ 

Annt/ol JleprfjrrnlQtirc 3/eelinp, Cardlli. 

Couneil, CardIfT. 

dnniiQl Urprffentntfrf Merftnp, Cardlfl. 

Anttuo! Rrprr^enfflfire ,1/eefini;, Cartlifl. Annual General 
Meeting, Cardlfl, Rrcsltlcnt’s Addrefs. 

ConitcH, Cardlfl. Conference of Honorary Secretaries, 
Cardlfl. 

Altiito Cox, Mcdtcnl Secretary. 


BRANCn AND DIVISION MEETINGS TO BE HELD. 

MmtorouTAS CoUNTir.s Batsen: Lewisham Divisiok.— A meeting 
will bo hclil nt Si. .lolm’s Hospital, Morden Hill, Lewisham, 
S.E.I5, on Tuesday, May Isl, at 8.45 p.m. Clinical c-i-ses sviil be 
shown hy Dr. E.' Openheim ond oilier members ot tlie staR of 
tlio hospital. 

SlmtopoLiTAN' Cou.vriES Beakcii : St. Pakckas Drvisiosr. — ^Tho 
annual general meeting of llic St. Pancras Division will be held 
III tho British Medical Association House, Tavistock Square, IV.C.I, 
on Tuesday, May 8tli, ol 9 p.m. 

MctllOrOUTAN COUSTIES BltAJICn : IVESTMUfSTEIt ACT HoLEons 
Division. — T he annual general mceling of Ihe. Division will be 
held to-day (Saturday, April 28lh), ot tho BotUing .Works of the 
United Dairies at Scnihbs Lane, Willcsdcn._ Tho United Dairies, , 
Ltd., have kindly invited members of fhe Division and tlicir wives 
and friends to a demonstration ot modern metliods ot milk collcc- 
lion, treatment, and bottling. Tea will he provided after the 
demonstration, and tho .innual general meeting will follow j'mmc- 
diatcly. Transport, by clmrabanc, will be provided by the United 
Dairies to and from tlieir works. Tlio clmrabanc will leave Con- 
naught Place, Marble Arch, at 2.15 p.m. Members are asked to 
moko uso of llio transpoit provided, ond not travel by their 
own eats. , 

llfETnorouTAS Counties BoANai ; Willesoen Division. — T he 
annual meeting of tlio Willcsdcn Division will bo held on May 
16th. Agenda : Election of officers and committees, and considera- 
tion of Annual Report of Council. 

MinLAND BaAN-ai : CjiESTEnnixD Division . — X meeting of tlia 
Chcstcrrield Division will bo held nt tbo Maternity Hospital, 
Chcslcvricld, on Friday, May 11th, at 8.15 p.m. ~A British Medical 
Association Lecture sviil be delivered by Professor Louise Mcllroy 
on tho management of labour. 

Nonxit or Engl.wd Branoi ; Bishop Auckland Division. — A 
meeting of the Bishop Auckland Division ivill bo licld in the 
Cottage Hospital, Bishop Auckland, to-day (Friday, April 27th) 
at 8 p.m., for tho election of representative to tho Annual Repre^ 
scnlalivo Meeting. 

North or Enguxd Branch : Blyth and Morpeth Divisions 

A clinical meeting of tho Blytli Division will be held at the 
Thomas Knight Memorial Hospital, Blvth, on Wednesday Mav 
2nd, at 8.30 p.m., when Dr. W. H. Dickinson (Newcastfe’-upon- 
lync) will speak on some practical points in the diagnosis of 
pulmonary tuberculosis, and will show films. 

South-Western Bsaxct.— A n intermediate meeting of the South- 
Meslern Branch will be held at tho Royal Cornwall Infirmary 
on Thursday. May 24tli. Will members kindly inform Urn 
lionqrary secretary as soon ns possible of any cases, notes, papers 
specimens or notices of motion they may wish to bring forward 
in order that they may be placed on Hie agenda paper? It is 
advisable that papers should be as short ns possible. 

SuiTOLK Branch : West Suppolk Division.— O ne ot the series of 
post-graduate lectures arranged by the West Suffolk Diinsion wfll 
bo giieii by Mr. T. H. Just on diagnosis and treatment of acute 
inflammatory conditions of the ear, ot the West Siiffnlt r „„--i 
HospUaton Saturday, May 5th. at 8.45 P m. Se win he^served 
at 8.30 p.m. A clinic will bo held on Sunday, May 6th at 11 a m 
Sell- gJJesk*^ practitioners in West SuIIolk and 

rd*Cisfnr;:^nS®T„’?S°":? '"celi„g of tlm Guild- 


demonstration's.” ® Patbolegicai 

Yorkshire Branch : 'Wakepieid, Fontepract act 
Division.— The annual meeting of tlic Wabefi^o d . Caetle.voed 
Castlcfom Division will bo ifeld at the sfr J’ ^""‘efract, and 
Wakefield, on May lOtli, preceded bv a scene Hotel, 
A. Manknell (Bradford) will give an P'™- 

Association and its wo 4 for the genera' practUione®''“‘"'‘-^‘'^'‘'^‘ 



178 April 28- 1928] 


tvieetings of Branches and OS^^IsSonSi 


r BVPPIXilEllT TO THl 
LBeitisii medicil JoMiru ' 




NOTICES or MOTION BY PmSIONS FOB THE 
ANNUAL RBPRBSENTATIYE MEETING, 
CARDIFF, 1928. 

Proprietary Sledictnes. 

By Aberdeen : That, in the opinion ot the Representative 
Body, stops should he taken, in view ot the very great number 
ot proprietary medicines which have been put upon the 
market in recent years, to set up at Hoad Office a department 
to investigate these proprietary medicines and to supply 
iutormation regarding them to members, either on request or 
in the Journal, or as otherwise deemed expedient ; or, it this 
is considered impracticable, the publication entitled Secret 
Itcmedics should be brought up to date. 

Position oj General Practitioners in rctnfiou to Hospitals 
and Clinics. 

By Aberdeen : That it be remitted to the Council to con- 
sider and report to the next Annual Representative Meeting 
upon the position ot the general practitioner in relation to the 
voluntary and rate-supported hospitals and clinics. 


iltcjtittgs of BBrattrljts imb iBHrisiotis. 


Aberdeen Branch : Aberdeen Division. 

A MEETING of the Aberdeen Division was held on Apii/ 12th, Dr. 
Rorie, chairman of the Division, presiding. iDr, Tliomas Prascr 
^vas nominated as member of Council for election by Group 
Branches. Mr. F. K. Smitli and Dr. John Craig were elected 
representatives, and Mr. G. H. Coll and Dr. Charles Forbes 
deputy representatives for the forthcoming Annual Representative 
Meeting. Tho Model Rules (Organization and Ethical) were 
adopted by the Division. 


Bomb.ay Branch. 

A MEETING of the Bombay Branch was held on April Snd a( the 
Pathological Laboratory of the Grant Medical College, with Dr. R. 
Row in the chair. 

It was agreed unanimously that the recommendations of (ho 
subcommittee of the Branch on the question of registration of 
midwives in the Bombay Presidency be approved, and that a copy 
of these recommendations should be scut to tlic honorary secretary 
of the Women’s Medical Association, 

Opening a discussion on the question of public hospitals and free 
treatment, Dr. Yodh said that copies of the letter of Dr. 
Sandilands, who had opened the question, wore sent to the super- 
intendents and honorary staffs of nine hospitals in Bombay. 
Replies showed that the opinion was practically unanimous that 
the public hospitals should be reserved for the poor. Only in 
cases of emergency should well-tO'do pei'sons be admitted, and 
they should be charged on the same scale as they would have to 
pay to private medical practitioners or in private nursing homes. 
After discussion the following resolutions were adopted by the 
meeting unanimously : 

(1) That the public hospitals should be reserved for the poor only. 

(2) In emergency anybody might be admitted, and, if not poor, he 
should be charged fees at least on the scale as laid down b^ the 
Goveruroent resolution. 

(3) That it was desirable that small paying wards should be eslab- 
lished in all the public hospitals as in* the case of the Nowrosjec 
Wadia JIaternity Hospital. 

That a copy of these resolutions be sent to (i) the Surgeon with the 
GoVciiimcnt of Borubaj ; (li) the President ot the Bombay Munici*' 
palitv and Dr. Sandilands, the executive health oflicer, thanking liim 
for diking up this question. 


• Lancashire .^nd Cheshire Branch : St. Helens Division. 

At a general meeting of the St. Helens Division held on April 
18th the payment for reports to coroners was discussed. A letter 
from Medical Services, London, was read with reference to 
contract practice for juvenile; the terms were considered inade- 
quate, and disapprobation was expressed of club practice being 
restarted. Three names were submitted for the inquiry into 
varicose ulceration. A letter from St. Helens Hospital was dis- 
cussed, and the meeting, in view of the offer to leave to practi- 
tioners the option of attending their patients as at present, decided 
to a^^sist in the appointment of a surgical staff. The secretary was 
asked to call a meeting when he had any more information. 

' Reference was made to the dcallis of Drs. J. Cotton and J. H. 
Don, .both past chairmen of the Division. 


Metropolitan Counties Branch : Lambeth and Southwark 
Division. 

A CLINICAL meeting of the Lambeth and Southwark Division was 
held at the Bclgravc Hospital, Clapham Road, on April 18th, 
when Dr. H. M. Oddy sherwed the following *ca»;cs : (1) tuber- 
culous cervical glands; (2) congenital morbus cordi=; (3) rickets; 
(4) clnonic p.arenchj'matous nephritis; (51 tuberculous glauds in 
ccrvncal region and axilla, ]iossibly Hodgkin’s disease; (6) a 
i of cretinism; (7i a ca^c of enlarged liver and spleen. 


Korttortt Gohhties or Scotland Branch. 

A meeting of flic Northern Coiintic.s of Scotland Branch was held 
in the District Asylum on April 19tb, under the chairmanship of 
the president, Dr. T. Macdonald. / 

Dr. T. C. Mackenzie read a paper on epochal insanities, in 
whicli he classified them as insanities of puberty, adolescence, the 
climacteric, and senility. He dealt ver>' fully with each, describing 
Uic salient features. Ho read case’ histones illustrating the 
different forms, and showed two striking examples of senile 
lusamty. 

Mr. A. _iT. C. Hamilton show'cd a typical case of Kohler’s 
disease, with skiagi*ams of the affccted"^foot. 

Tea was served at the end of the meeting. 


Sierra Tjeone Branch. 

The fourlcojilh scientific meeting of the, Sierra Loono Branch was 
held on March 8th at the Connaught Hospital, with the president, 
Dr. Peacock, in the chair. 

Dr. E. A. Renner showed a case of trypanosomiasis in an adult 
African with a history of six months’ illness. On admission to 
hospital the patient was dull, lethargic, and slept all day, but 
could easily be roused- After three intravenous injections of 
(I’yparsamidc lie bccauic brighter, more active, and hardly slept at 
all during the day, but subscrjucntly he was sent to the asylum 
as he showed marked signs of insanity. T. f/ambiense and Loa loa 
were found in the peripheral blood. Dr. Renner also showed a 
case of lymphadenoma in an African girl, aged 18; the illness had 
lasted for fifteen months. The ccr\ical, right axillary, and the, 
right and left inguinal glands were all markedly enlarged, and' 
tlio spleen and liver were both palpable, but the blood picture 
•was not striking. Treatment witli novarsenobillon did not. effect- 
any improvement, and the patient subsequently returned with 
oedema of both legs. 

Dr. M. C. Eassion showed four leprosy cases to illustrate the 
common types: an adult male, typical nodular type; an adult 
female, typical anaesthetic type — one 'digit missing from left foot, 
and numerous light-coloured areas on trunk, face, and limbs, 
which were anaesthetic; and two youths, very early cases, the 
nasal smear examination being negative in both, but in one there 
was very early thickening of the lobes of both ears. Lepra-likc 
bacilli (acid fast) were obtained from the serum from these 
lobules. Both patients^ had pule areas on the face and apparently 
anaesthetic incisions at the back of the heel. Di\ Easmon sliow'ed a 
photograph of the back of a chicken-pox case illustrating an unusual, 
complication in some of the pustules. After maturation and com- 
mencing to dry, a large ring of very superficial vesicle forma- 
tion about the SV 20 of a penny appeared around some of the 
pustules. If protected from scralcliing there was no involvement 
of the true skin, and in a few days 'the dried blister scales 
dropped off. Dr. Eaemon algo showed a skiagram of a hip-joint 
for diagnosis. From infancy the left leg from the knee down- 
wards had been a little smaller in all dimensions ^tlmu the right. 
The patient was now 23 years old, and for the last tw6 or three 
years had complained of excessive pain, after walking or standing, 
in the ’ ’’ ' ..-1 it - knee, and back. The pain- was 

never loint. The skiagram was not a good 

one, a . to arrive at a definite diagnosis, 

althougli there was obviousl}- some abnoi'mality about the hip» 
joint. The great trochanter liad not yet ossified on to -the rest 
of the femur. ^ .. 

Dr, R. M. Gordon exhibited larvae and adults of A, smithtt, 
also infected salivary glands from the same species. The infec- 
tions had been obtained by feeding bred v adults on ci-escent 
carriers. A.^ smithii liad ' not previous!}' been shown to be a 
Iraiisniittor of malaria. He also showed microfilaria of Z^a 
from a West African native suffering from trypanosomiasis; the 
patient had never been outside the colony of Sierra Leone.' 

Mr. JQ. Stewart showed a patient who had had partial gastrec- 
tomy for suspected carcinoma of the stomach, Moynihan’s modi- 
fication of the Folya operation being used. Tlic patient was a 
Liberian woman, 32 years old, who had lived in Freetown for ^ 
year. The symptoms pointed to pyloric obstruction, arid there was 
a marked peristaltic w’ave in the epigastrium. The, specimen 
showed a large saddle-shaped ulcer on the lesser curvature jast 
proximal to the pylorus; the edges of the ulcer were markedly 
hypertrophied and hard, and enlarged hard glands were 
aicng the lesser and greater curvatures. • Mr. Stewart said Ihat 
he had only seen two cases of gastric cancer in six years .in B’esl 
Africa. In regard to' the queslron of diet and the apparent loi'* 
incidence of cancer amongst African natives,, it was interesting *p 
find that tinned foods had entered largely into the diet of this 
patient. He «aIso exhibited a rj^diograph of the humerus from a 
young man with a history of the arm giving way when he 
using it to aid him in rising from a chair. There had been slight 
pain in the arm for one month previously. The radiograph showed 
a fracture with marked loss of bone substance. The important 
point was the diagnosis, so that the proper treatment could be 
applied, and Mr. Stewart was inclined to the diagnosis ? 
central sarcoma A third case was that of a child, aged 4, witli 
marked genu valgum and olher signs of rickets, the intci’csting 
point being that rickets should occur in Freetown, wliorc so’inucb 
sunlight was present. i)r._ E. J. Wright had, however, shown that 
the diet of the mother in these cases was deficient in vitamin 
content. . . • _ 

Dr. Wright- showed a -case of tumour of the dower jaw in a 
pregnant African woman, aged. 20. She gave a history of pam m 
the second left premolar two years previously, but 
caries of the 'tooth, which loofened and came out. - .^Ytci * 
quiescent period of rwo months 5hc noticed swelling oi the n 
about tlio region fioin which the tooth had been extruded. 



AmiD 23, 1928] 


Naval and MitUary ApFioinimcnts, 


T r;u^vIJ:^TEHT to rmt ^ ^ 

IrniTtmi liKiur.AL Joc&Kit. 1 /if 


steadily increased in fire until it readied ilv «5 present dirnensionF-^ 
oboni tho sito of i\ fowl’s Tho x-rny pliologrnph Bhown was 

con*:istcnt with a (Unpnosis of inyclonin. 

The Pkbside.st wdeotned^ Dr. J. Jlcrin^er, a puest at the 
incctinf:, remarking that it was through tho elYorls of Dr. 
Itoringcr tliat tho Sierra Lcono Itrancli of tho Association had 
come into being. 

.Tamxicx BuANCTr. 

At a recent special meeting of the Jamaica Ilranch at tho Public 
General Hospital Dr. Onr. described (ho methods of making 
tuberculin injections for diagnostic purpose*; and their value; 
ten case*? were shown. Dr. Opio answered numerous questions 
from Drs. b. Jf. Afoody, Vino, Hronstorph, Gifford, and Allen, 
niid, on the proposition of Dr. L. M. Clarke, seconded by Dr. 
Girroan, bo was aworded a vote of thanks. 

At another meeting of tlio JnniatVa Hraridi, on ^fardi 15 th, Dr. 
boYU doUverod a IccUiro on iimlarial surveys, and afterwards gave 
a dcmonslratjou ou anophclinc mosquitos and larvae. 


-South Wales axu MoxiiountsitiRE Hranck : Swan'ska Divisios*. 
At a meeting of tho Swansea Division on Mareh 29 th, at the 
Swansea General Hospital, a Jeeliirc was given hy Mr. IT, K. 
nNakefiilu on marvels of insect life, ilUistialed In* lantern slides 
from original photographs by himself. Mr. Wakefield, one of the 
leaaing naturalists in South Wales, gave an admirably lucid Jeclure, 
and tho thanks of tho meeting were accorded him by Dr. J, S. H. 
J*03E«rs, Dr..J. if. iloRRis Neatif, and ifr. 11 . L. Quick. 


STAVrop.nsTnr.E EaAV’cn ; Kortu STArronnsmnE Division. 

A 2 iEinKc of the North Staffordshire Division was held on April 
lain, when Dr. Gordok HoLiiES gave a most interesting address 
on acute infcctivo diseases of tho nervous pyslcm. A dinner was 
iKlii m tho evening. 


CDomsponticttcc. 

An A-pfTovt.d Socichfs AttituiU towarih Ophthalmic 
- Tf T • Jlcntjxt. 

1 ventilate in your columns a grievance wliicli 

Kncinecrinn^fln'inn .■•‘■sued by tlio Amalgamated 

a^Ielter in optician, and gave him 

side.- he nnd con- 

an onhthalmir enr^ examination and treatment bv 

, exists*'! '« ■" 

to examiuo your eyes Tiu 

your case is Sond l.i, ^ opliciau is ot ipiuiou that 

for glasses iu Part 2 Form^O fo g>''o an estimate 

inslructions^n^\,lo'k^]pf "liicli ended tvitli the 

surgeon is neccs 5 ary,*^Vill'''f^i,* J'l" O-vamination by an opbtimimic 
by letter before estimating conimunicalo with tho society 

for recommending same? *' glasses, siating tho specific grounds 

■f shared the patient’^ «• 

should be ignored, or whii-ii ”> 2 ’ recommendation 

revision or approval bv an subject to 

of the optician. As the^natio,,?^”*^"* ^ .i*' 8 onthority— that 
with tho Panel ComhiitUe of ^ communicated 

that, as ophthalmic benefit is ti i informed 

no action they could talcn i„ additional,” there was 

recognized. ® remove tlio absurdity they 

In tho words of a colleague ■■ T 1,.^ 
recommending my patients to an .'*^®,"0 more intention of 
mg my gold w-atch to a Wactsmif)!'” ^ ®ofrust- 

lent upon nio to attempt to delnd ^ or do I feel it incum- 
tiuiikmg that my ktiowledEe iff ^ a" “PP''ove >3 society info 
using the euphemism “ retinitis great hj- 
" v,‘? ' beyond my ken. ^ describe any condition 

for examination hy an ^oph’tha?mTo'"sT‘^ patient in question 
out to our fiombined satisfaction buf if^r''’ carried 

that an optician’s advice slmnlri i **" 'a a very real grievance 

‘he pteWoetorTaft 

P?P®> P“‘m"ts are treated The 


SKs'-;-w-r-" 

Tlie teL ■^•;dd^?.?'’f«-'^**^y 


- bis is a*-!!;;:;? ,'o‘‘persisr"T,ri"P’" 

« fey rv^urf;:" he^^dtspeniJ’?' 

•f- K. Emd, 3I.B., ch.B. 


iifibal atiJt iltiliinrn Appoiulincnts. 

nOYAIi XAVAb MEDICAL SERVICE. 

Surgeon Commnndcr R, J. Inman to tho Mar/lioroi/17/i ; A. J. To7>r to 
tlio licton/ for R.N*. nnrrack^ rorUmouth; A, O. Bee to yjc Champion*, 
il* /’rnidcnt for three months* post-graduate course; 

1 . b. ScargJII to tho Nctfon, temporarily. 

.Surgeon Commander C. II. Dawo is placed on tho retired list, with 
tlio rank of Surgoou Captain. 

Surgeon LIcutermnIs 0 . Rorlfon to tho Scuroh; W. D. M. Sim to tho 

\\. W. Darley and I*. C. M. 'B.imford to bo Surgeon Lieutenants. 

Jloni/ KlV.lL VOLinVTTXR Referve. 

Surgeon LIcntrnnnt C. MeCoiilI to Imj Surgeon Lieutenant Commander. 

Surgeon Lieutonniit If, Willoughliy to the Champion for training. 

Surgeon SubUculeuaut F. T. llotimnn to the Suffolk for training. 


nnVAL AIR FORCi: 5IEDICAL SERVICE. 

Lieiitcn.ant O. J. S. O'irallcy to Headquarter?, R.A.F.. Mtddlo 

bli’idi’nanM A, Briscoo in ne.adquartcr?, Aden Command; 
O. 6. Strachan to Headqunrlcr?, R.A.P., Inriia, 


iXniAN' MEDICAL SERVICE. 

Ljcut.-Colonel J. W. D. Mrgaw, C.l.E., Director, School of Tropical 
IloipuSli Punjah^'^ Calcutta, (o' bo Inspector-General of Civil 

Llrut.-Cojonel T. 0 . McComhie Young, an ofllcer of the Medical RcFearcIi 
i)ep.arfme/it, i? placed on foreign £cn*/co under the Indian Research 
Hind Association. 

Con-Muent oa (lie crant nf leave (o Drevet Colonel S. It. CliriFtorlicrs, 
■!. CunniiiKham, Diteelor, Pasleiir Institute of 
Inilia, hasaiill, Is appolntetl to oAieiato ns Director, Central Research 
5 r'ew’r''T“';"A "ml Major R. II. Malone, Officiating Af.Malt 
Director, ^nlral Research InMUule, Ka-auli, is appointed to officiate as 
Director, Pasteur Inslilule of Inrlia, Kasaull, uiucinio as 

Tlio sen-iees qt Captain K. R. K. Ijcnger are, from April Ilth 1028 
D^ie?‘el’M,e'lr‘’!''' of t>'c. Co'crnmeni of Mailrns for dppointment Is 
Director of tlio lastcur Institute of Soutrern India, Coonoor, 


TERRITORIAL FORCE. 

Rovil Ansiv Jlr.DitM, Conrs. 

lo he .Major, uilli prccodcncc ns from July Iftli, 

iL W. Is Xicliols, lalo n.r..\. special Reserve, to bo Lieutenant. 


YACAXCIES. 

RtmtstcT sxp tv.tCTnFLD Joint Si.vuoniiiM Cosrstmrr— Assistant 
rising pe?‘ann,'rn?: 

”’oSVT.^.;,e^'''LKriSo’;'? 7 ^ 

(tonal XIOO n year while acting os ralhologist!’ * * nddi- 

UvncY UOROUOIT. — AssDtant Meciiral OffJrpr * nr rrn>>in> e , 
female). Fco II IZs. 6d. per session of Uo houi, twi?o weci'if 

S"I"cy fSOO per annum. 
”o"E."'^'aPa'^?’i^efa^?’J^f“ nosPirsus.-Tliird Assistant Medical 
“sabTil 2 ?%'‘;-annur HoNriTsu-CasuaRy nouse-Siirgeom 

Of tho Museum, 
i" charge of ibe Ear. 

BonxiEY : Vicionu Hosmtiu— I louse-.Sureeon Seise- nos 

Cexihii, Lo.vdov Tiiroit Xosc s-n rr ““'"CJ £125 per annum. 

\V.C.l._Rcsident Housjlsurgwn (mal§ SalarvTt’ ^oad. 
annum. ^ M“aioj. Salary at tho rate of ITS per 

S; ^cti.e.-AIediea, Super- 

's^ar/So5 P°rlTn;rJ'Z;%1KZ' “"-licol'officers of Uealth. 

ts; otS nouse-Surgeon 

risine'’'lo'^i; 7 a''’ ^‘“‘''‘ct Medical Officer. Salary fSM per annum, 

‘’(mn%.®S^^£10o'p'er^^^’um^ ^ Hosrmn, Wi-Ifousc-Surgcon 
^^^vS^ur‘^era^o%°ut^pa‘tienlI.“^ I-osBou Hosniu, Haverslock imi. 
risine'^to jn-)jSJJ''‘^’^v.-ProfcEsor of Physiolo-y. Salary £800 a year, 

rato of £130 jjer anium IIouso.I>liys.e.an (male). Salary at (l,o 

PUBLTO DisPEVSIPY TT/s 

ri’®™*® SocEcon. “OSi.ii.ii,._nonorary Assistant Ortho- 

mensem payable in EnglJni ®'’““ plus ’’so "pi? 


180 ApEIL 28, 1928] 


Association inlcf/tgence and D/ary, 


r svppLrymsr to xitr. 

LIJIIITISII JlLDlCAL JoL'E.N \L 


Middlcsbuough : T^oniii Riding Ixnr.MVDY. — Honorary AssUtant, Stirffcon. 
PnixCK OF Wales’s Gexeril lIosnivL, I’ctlenliam, N.15.— Clinical Assistant 
in 3[e(Hcal Out-pntiont Department. 

RoTiiEr5ii\^ii HosriTAL.--HouPe-riiy?ician (male). Salary 1180 per annum. 
Rov\l Free Hospital. Gray’s Inn Roatl, "W.C.l. — (1) Oplitlialniic Surgeon. 

(2) Assis>tant I’hjsician. 

St. BmTHOLOMEiv’s IIospjtil.— A ssjst.ant Pliv'^ician to the Ci»ihlren’s 
Department. 

St. Pn:£:p/s IIosPirtL fop. Stone, ITcnricUa Street, ■\V.C.2.— Third Auncs- 
ilietist. Honorarium £25 per annum. 

STiFfORDSHir.B Genewl Infirjup.y, StnUord. — Iloupc-Surgcon (male). 

Salary at tho rate of £200 per ann\iin. 

Stoke-on*TrfjsT : Kortii STtrrohDsiiiRE Royal- Infirmary.— ( 1) AP'^i^Uant 
House-Pliysician ; salary £125 per annum. (2) Honorary Anaesthetist. 

(3) Honorary Assistant' Aural Surgeon. (4) Ilonorary Assistant Oitho* 
paecUc Surgeon. 

SuDvN Oovf.rn.xient.— M edical Officer for the Sudan Medical Service. 

Pay £E.720 a year, rising to £E.1,200. 

SuNDERL\Nn: Royal Infirmary.— S enior Resident Medical Officer (male). 
Salary £200 per annum. 

Walsall Gexeuai, Hospital.— S enior House-Surgeon. Salary £200 per 
annum. 

West Ham County Borough.- A ssistant Resident Medical Officer at 
.Dagenham Sanatorium. Salary at the rate of £250 per nnnttm. 

York : County Hospit.al. — H ouse-Surgeon (woman preferred). Salary £150. 
York Dispensary. — R esident Medical Officer (female). Salarv £150 per 
annum. 

Cep.tifying Factory Surgeon.— T lic appointment at Carnwalh (Lanark- 
shire) is vacant. Applications to tlie Chief Inspector of Factories. 
Home Office, B7fite2i«», S.IV.I. 

I’fiis list of vacai\nes*is compiled from our adi'crtiscmcnt co/wmn#, 

. iphcrc full ^xi^'ticulara icill be found. To ensure notice in this 
column advertisements must he received not later than the first 
post on l^ucsday morning. 


APPOINTMENTS. 

Si vuerland Royal iNnr.MARY.— //ousc-Sitr^rons ; L. D. Nelson, M.B., BS, 
T. F. Jarman, M.B., B.S. IlouBC-rhysicion, Children's litanch: Miss 
C. MrLcoy, M.B., Ch.B. 

Certifying Factory Surgeons.— I. H. ^faciver, ^t.B., Ch.B.Ed., for the 
Fou Yilliam District (Inverness); J. A. Mlivte, M.B., C7i.B.AlK‘rd., for 
the .Micrchirdcr District (Banff); J. A. Mulligan, M.B., Oh.B.Abcrd., 
for the Bervic District (Kincardine); J. McKenzie, M.B., Cli.B..\berd.. 
for the Rhyme District (.\bctdccn). 


DIARY OF SOCIETIES AND LECTURES. 

Royal Society op JlEDiaNF., 

Secfmn of Ortl/opaprlies.— Tues., 4.50 p.m., Cases. 5.30 p.in., Annua) 
General Meeting : Election of Officers and Council for 1928-29. 

Section of Uistory of Medicine. — Wed,, 5 p.m.. Annual General Mooting : 
Election of Officers and Council for 1928-29. Papers will be read dealing 
with tho sources of Harvey, as follows : — Professor F. J. Cole : The 
History of Embryology; Dr. «T. F. Prendergast: Galen. 

Section of Tropical Diseases.— Thurs., 8.15 p.m., Annual General Meeting • 
Election of Officers and Council for 1928-29. Demonstration by Sir 
Leonard Rogers ; Climate and the Incidence of Small-pox, Cholera, and 
Plague: Forecasting Epidemics. 

Seetton of " ' - Cases. 5 p.m., Annual General 

Mooting ; ■ ncil for 1928-29. Comnutnicalion 

by Dr. R. Discussion of cases shown at 

March Mec ■ y Mr. Leslie Powell, Mr. IdolHson, 

and Dr. Dan SicKenzic. 

Section of Anaesthetics. — Fri., 8.30 p.m., Annual General Meeting: 
Election of Officers and Council for 1928'29. Discussion on Late Ether 
Convulf-ions. Opener : Dr. C. F. Hadfield. 

Section of Olnlopi/. — Sat., 9.30 a.m., Cases. 10.30 a.m., Annual General 
.Meeting: .Election of Officers and Council for 1928-29.- Papers 
John P. Stuart: The Hislo-palhology of Mastoiditis; Dr. R. Graham 
Brown : Case of Spherical Bulging of the Floor of the Third Ventricle, 
Secondary to Internal Hydrocephalus and Simulating a Pituitary 
Tumour. Cases and Specimens. 


Royal Collece'OF Physictai^s of London, Pall Mall East, S.W.I.— Tucs. 
and Thurs., 5 p.m., OUver-Sharpey Lectures by Dr. E. P. PoiiJton • An 
E.vperimenlal Stud^i of Certain Visceral Sensations. 

FOST-GKADUATE COURSES AOT LECTURES. 

Fellowship op Medicini: and Post-Graduate Medical Association.— Mon., 
Ajuil 30th, to Fri., May 5th. 2?o»/al Waterloo Hospital, Waterloo Road, 
S.E.l : Tues., 3 pm., Clinical Demonstration; no fee. Hupal London 
Otdithalmic Hospital, Citv Road, E.C.l ; Tiie?., 1 p.m., Clinical Demon- 
stration; no fee- Mauthiey Hospital, Denmark Hill, S.E.5 : Course in 
^^ychologica\ Medicine, Lecture^, Demonstrations, and Clinical Instruc- 
tion; one montli, fee £5 5s. St. John's Hospital, Leicester 'Square, 

W C 1 * ■ ' ‘ ^ Dermatology, Clinical Instruction Uajlv 

jn‘ ih« Lectures; fee .£1 Is. Practical Patho- 
logical ' arranged if desii-ed; fee £4 4s. Itopnl 

WalriJo S.E.l: Third week of Post-graduate 

Course in Mcdicnic. Sui-gery, and Gynaecology. liotjal Free Hospital, 
Cray’s Inn Road, W.CM : Wed., 5.15 p.m.. Third Lecture Demonstration 
* ■’ London School of Jlytjiene and Tropical 

.C.l : Tues. and Thurs., 2 p.m., Lecture 
cliciue. Copies of all syllabuses sent on 
leral course of work. AppU Secretary, 
• pole Stieet, W.l. 

J ■ D E\n lIOTiTAL, Gray’s Inn Rond, W.C.l. 

Larynx. 

St’. Jolm's Ho'spifal, Leicr.«tcr Square, 
W,C.2.— Tiie?., 5 p.m.. Eczema. TIiuts., 5 p.m., Acne Vulgari.«. Fri., 
5 p.ni., Walt'-. 

KoRTfi-EASi IxiNDOV Po^r-GKADLiTE CoiJ-EGE, PriDcc of B alcs’s General 
lio>piul, Tottenham, N.15.— Mon., 2.30 to 5 p.m., Medical, Surgical, 
and Gvnaecological CHnlc=;; Operation*. Turs., 230 to 5 p.m., MeiUcal, 
Snrr»ical, Throat, No^c, and Ear Clinioj;: Operations. Bod., 2.30 p.m., 
DenTonslration of Ej-o Cases; 2.30 to 5 p.m., aiedical. Skin, and E 3 ’e 
Clinics; Operations. Thurs., 11.30 a.m.. Dental Clinics; 2,30 to 5 p.m., 
Metlical, Surglc.al, and Ear, No^e, and Throat Clinics; Operations. 


Fri,, 10.30 a.m. Throat, No^e, and Ear Clinics; 2.30 p.m., Demonstratioa 
of Surgical Cases:- 2.30 to 5 p.m., Surgical, Medical, and Children's 
Diseases Clinics; Operntions, 

IVest London IIo.spital Post-Gkaduatk CoLUxjn, Hammersmith. B'.— 3Ion., 
10 n.m. to 1 p.m., Ocnito-urinarv Operations, Surgical Wards. Skin 
Department; 2 p.m. to 5 p.m., iJyc and Gyrmecological Denarlmenfs. 
Tnes.p 10 n.m. to 1 p.m., Medical IVurds, iJemonstration ot Venereal 
Disca'i'CS, Electrical and Dental Departmontv; 2 p.m. to 5 p.m., Gynaeco- 
logical Operations, Thiitat, No«p, and Ear Department. Wed., 10 a.m. 
to 1 p.in., Children'.^ Medical Department, Jlcdical Wards, Patho- 
logical Dcmon>trallon ; 2 p.m. to o p.in., Eye Department, Surgical 
Wards. Thurs., 10 a.m. to 1 p.m.. Neurological and Mab'-agc Depart- 
ments; 2 p.m. to 5 p.m., Eye and Genito-urinarv Deportments. Fri., 
10 n.m. to 1 p.m., Skin, Dental, and Electrical bopartments, Jledical 
Wards, Clinical Demonstration; 2 p.m. to 5 p.m.. Throat, Nose, and 
Ear Department. Sat., 9 a.m. to 1 p.m., Medical Wards, Throat, Nose, 
and Ear Operations, Medical Children's Departmcnl, Bacterial Therapy 
Jlepartment. Daily nt 2 p.m., Oi>crationK, Mc<lical and Surgical Out- 
patient Departments. Special Lecture TiiPbilay, 3lay 1st, at 4.30 p.m.: 
Skin Diseabes Due to Protein Sensitization. 

CbAFGOAY Post-Graduate SIedical Association.— .\t Royal Ho'^pital for Sick 
Children : IVcd., 4.15 p.m., Surgical Cn'-cs. 

Liverpool University Clinical SniooL Ante-Natal Clinics.— Royal 
Infirmary : Mon. and Thurs., 10.30 a.m. ifaternity Ho>pilnl : 3Ion., 
Tues., IVcd., Thins., and Fri., 11.30 a.m. (Fee £2 for three months' 
attendance.) 

M.AXCiiESTn’. Royal Infirmary.— Tues., 4.15 p.m.. Lecture : Some Pitfalls 
in Radiology, l^ri., 4.15 p.m., Demonstration of Ophthalmological Cases. 


^CiTtislj ifitbical Association. 

orricEs, nr.tTiSH MaoiCAL associatiox house, 

TAVISTOCK SQVAllE, W.C.l., 


DepartmontSt 

Sucscr.iPTio.NS AND Advep.tisements (Financial Secretary and Businew 

• Manag * ' * Westcent, London). 

Medical *' Hbecra Westcent, London). 

Editor, ‘ ' ■ (Telegrams ; Aitiology B'cstcent, 

London). 

Telephone numVers of Tirilish Medical Association and "British Meatcal 
Journo/, Museum 9861, 9862, 9853, and 9864 (internal exchange, 
four lines). ' 

Scottish Medical Sfcretarv : 6, Drumsheugh Gardens, Edinburgh. (Tele- 
grams: Associate, Edinhurgh. Tel.: 24361 Edinburgh.) 

Inisif Medical SccnEnni' : 16, South Frederick Street, Dublin. (Tele* 
grams: Bacillus, Dublin. Tel.: 4737 Dublin.) 

Diary of tho Association, 

April. 

27 Fri. Bishop Auckland Division : Cottage Hospital, Bishop Aiicklano, 

Hcnilon' Division : Annual Meeting, Hendon Cottage Hospital, 
8.M p.m. 

23 Sal ‘Westminster and Holborn Division: Annual Meeting, Lnitecl 
Dairies B'orks, Scnibbs Lane, IVillesdcn. Conveyances leave 
Connaugiit Place, 2.15 p.m. 

May ■ 

1 Tucs. LcAvishain Dii’ision : St. John’s Hospital, Jlorden Hill» 
Lewisham, S.E.i3, 8.45 p.m. . ^ 

North Wales Branch : Spring Meeting at Llandudno. 

2' BVd Blvth and Morpeth Divisions: Clinical Mooting, Thomas 
Knight Memorial Hospital, Blytli. Dr. W. H. Diekin^'On on 

...» ^ -jQ 

X Thur« iiBiUce, 2 to 4 p.m. 

. Jfoeting, Royal Surrey Coanty 

A t*ri 'ists Group Committee, 2.30 p.m. 

jjcwsuui.v Meeting, Dcus-bury' Infirmary, 

5 Sat Weiit^Sunolk Division: West SuITolk General Ilo'spital. Uc. 

T. H. Just on Acute Inflammatory Conditions of the Ear, 

8 Tuc*! St ^Pnneras DiA'ision : Annual - Meeting, B.3I.A. House, 
Tavistock Square, W.C.l, 9 p.ni. 

10 TJiurs, ■Wakefield, Pontefract, and Castleford Division : An””*; 

Meeting, Slraflord Arms Hotel, Wakefield. Dr. A. Macknell 
on the British Medical Association and its Work for the 
General Practitioner. Meeting preceded by supper, 7.45 p.m. 
16 B*cd. IVillesden Division : Annual Meeting. 

23 B’^cd. London : Private Practice Committee, 12 noon. 


BIRTHS, 3IARRIAGES, AND DEATHS. 

T/ic charge for inserting announcement of Births, Marriages, 

Deaths is ^s., ichich sum should be foncarded icith^ the notice 
not later than the first post on Tuesday morning, in order lO 
ensure insertion in the current issue. ' - 


BIRTHS. 

Bailey.— On April 1611i, at 37, Wheats]ieaf Road, Edgbnston, Birmingham, 
to the wife of Hamilton Bailey, F.R.C.S., a son. 

Brade-Birks.— On Sunday, April 22nd, 1928, at Doriscourl Nui^inv 
Upper Chorlton Road, ’Manchester, Hilda Kathleen Bradc-Bnk", M>c., 
M:b.. Ch.B., D.P.H.3fanch., L.R.C.P., M.R.C.S., wife of the I?e^ 
S. Graham Bi*ade-Birks, Jl.Sc.ilanch., D.Sc.Lontl., of Buxton. 
shire, and Wve, Kent, of a daughter (Mary Kathleen). . 

CoRMicK, — At 18, IValkcr vSticct, Edinburgh, on April 3id, the yvife oi 
Captain R.'Pairman Cormack, R.A.M.C., R. of O., Uganda, a daughter. 


MARRIAGES. 

Anderson^tiR'K. — .Vt Overden IVesleyan Chapel, on Tliurstln.y . .^pi il 19‘h, 
bv the Rev. J. Stainer B'lJkinson, 'James Stirling Antlei?on, 

D.P.It., of Aberdeen, to JIary Stirk, M.R.C.S., L.R.C.P., daughlei oi 
Mr. and Jtr's. Edmund Stiik of Halifax. 

ClarkE'Bullmore.— A t St. Oswald’s, Millhouses, Sheffield, on 
19^, hv the Rev. H. C. Foster, George Cyril Wlitteley’ Claikp, -^•^•’-'•‘-■5 
L.R.C.P., of Sundial House, Rotlicrham, to Ethel Rhocla Bullmore 
Nether Edge, Sheffield. 

LEIKEY-r 



X’rintcd and published by the British Meclic.ol .\s«ociation, at their Office, Tavistock Square, lo Dm Parish of St. Pancras, in the County of London. 





182 -Mat -5. • 19281 


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surPLnyir.h'T to this 

HrITISH 3IED1CAT* JOURNAL 



Katherine Bishop Harman Prize Fund, 

{Holding £1,000 New South Wales 5% Slock', 19.}!j-0S.) 



British Medical Hssociation Charities Fund. 


192 Mat 5, 19281 


Report of Oounci! s 


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r /^urrLr.yrrsT to tiw 
iIDiitihxi air:oiCAb JooKKAt. 7 


APPENDIX II r. 

EXISTING ATmCl.lIS AKD BY-LAWS OF THE ASSOCTA- 
TIOX I’UOrOSEn by the coilnoil to be bevised.’ 

{Sec AmiuaJ Jl( port of Council, B.M-J. SiJi'ri.r.Mi;\T, of April 
28IA, 1923, po'jc. 193, para. 53.) 


nmnlf'nnintc, Kubdivido and modify DiviBiona and Brandies 
and llio local areas thereof. Nevertheless, not less than ono 
month's notice in nil eases shall he given (in the manner 
nrcscrihcd hy the By-laws) to any Division or Branch in whoso 
Imnndnrics or area any change is proposed, and in the case 
of a Corporate Branch no alteration in the boundaries or 
area thereof or of any Division thereof shall be made without 
the consent of tliat Branch.’! 


AllTICtK 3. 

" Eligiliilily (for Mcmhcrihip), 

3. Any Medical Practitioner registered in the United 
Kingdom under the Medical Arts, and any Medical Practi- 
tioner who does, not reside within. the area of any Branch of 
the Association and who, though not so registered, is posi-essed 
of any qualification entitling him to he so registered, and 
any Medical Practitioner residing within tho area of any 
Branch of the Association not in the United Kingdom, who 
is so registered or jwsse.sse.'i sncli medical qiialiiitation ns 
shall, subject to the By-laws, he jirescrihed hy the Bales of 
the said Branch, shall he eligible as an ordinary Member of 
the Association. Subject ns aforesaid, the mode and condi- 
tions of election to membership shall from time to lime he 
determined hy or in .accordance with the By-lnwri." 


Annci.n 10. 

"Crptiltion, ■ 

10. (a) The Council shall have power, on the representation 
of any Division or Branch, and nfter due empiiry, of which 
not less than fourteen days' notice S[>ecifying a time and 
place at which he may he heard in his defence shall have hcca 
served on the Member in the manner prescribed hy the 
By-laws, finally to expel from menihersliip of the Association 
any Member of such Division or Braiicli whose conduct shall 
be held hy the Council to he .such as renih'r.s him liable to 
espulsion 'mder par.agraph (d) of tho last preceding Article, 
rovidcd that no such representation shall he eiitertainod if 
made by a Division or Branch witliiii an area outside tho 
United Kingdom for which a IVlcral Council has Iwoii formed 
under the Articles and By-l.aws where lliat Federal Council 
Article'" of paragraph (c) of this 

BrSew' fl'all hare power on the application of the 
S a r" Kingdom for 

Till ArBelsr^nfi n”'!'""' <»• " 'Jbing formed under 

the bowers Ky-Iaws to invest that Federal Council with 
,? sncceeding paragraph of this Article. 

KinVom haviirn'l"','' “i ‘'■’I'-'' >" United 

not beiVwithi^iL ‘'''''D’ and 

the powere^f .i,: * ° '' Federal Council invested with 

two Members of 6110 ^^“'* V the -representation of any 
invested with ° “'“1 (”) any Federal Council 
rentatioii of n fx this paragraiih, upon the repre- 

have poTe? area of that Council sliall 

Federal Connrii »i!“* ^bcting of the Branch Council or 
than ono mnnlb'. »• ® "’“F tic) convened at not less 

lees than twentv after due ciniuiry of which not 

time and nhre nt notice in writing, specifying the 
have been iHven tie heard in his defence, shall 

the Association am- w t° expel from mcnibersliip of 

ehall be held hv '^binlier of such Branch wliosc conduct 
(as the case mav lm\ tl°”"uil or the Federal Council 

Kpulsion under ' *0 render him liable to 

paragraph (d) of the last jireceding Article. 


... Ahticle 12 (1). 

12. ttrniiclics not in flic United Kingdom). 

P't'nt for the ''Memhem “ •^'''’tl !>« <=0™- 
Kingdom to procure thlm branch not in the United 
aare with the law in w incorporated (in necord- 

^,"ame indicating that thl 1 ° 1 '’“ branch) niidci 

' the Association A »<> incorporated -is a Branch 

«|'»ed to as a CorporhtrBTarch."“’"^°""‘"'^ ' '‘“""naftei 


"To 


13. 


i-r,.,- Ahticle 13. 

'“a, Alteration, Dissolution, 
Divisions. 


etc., of Branches an 


n't United Kingdom^tn^lb^ of Divisions and Branclic-s not 1; 
n^itti the CoweiT «i® By-Ussn, it shal 

and declare hv rnT 1 t''“® *0 determini 

It bodies of Mcmbcrs^fhall '’i'“*T?-”-f“^’'®^'®‘' *''® Jo'iTna: 

d gtonps.Qf_D:„i ; ho TLvisions, and what Division 

hri ,e^ shall be the local'*' of the Associatioi 
® f the Council shall 1 **' ® 'Ko'i Division,' and aecort 
“ nave full power from time to timd t 


. Ahticle 1G. 

" Federal Councils. 

IG. Federal Councils representative of tho Branches in any 
nrc.a outside tho United Kingdom defined and approved liy 
the Council may he formed in the manner and for the purposes 
specified ill the By-laws." 


AhTICLE-S 22 AND 23. 

" Erlraordinarg General Meetings. 

22. The Council may, whenever it tliinke fit, and it shall, 
upon a requisition made in writing ns hereinafter provided by 
any 100 or more Meinhers, convene an Extraordinary General 
Meeting for the purpose of transncfiiig nny such businc.ss as 
hy .Statute or hy the llegnlalioiis or tho By-laws is appointed 
to ho transacted hy a General Meeting. 

23. Any such requisition shall state the object of the 
Meeting proposed to he called, eucU object being to transact 
sonic husine.ss which hy Statute or hy the Begiilntions' or the 
By-laws is required to be transacted hy a General Alecting, 
and the said requisition shall ho left at the registered office 
of the Association.” 

Article 28. 

" .liiniinl Scientific Meetings. 

28. The Council shall at least once a year arrange Meetings 
or Coiifcrcncei», nlonc or in conjunction with other bodies, 
which it shall he open to every Member of the Association to 
attend, for the purpose of receiving addresses or other cbm 
miinications relating to tho Medical or Allied Sciences, and 
discussing such subjects pertaining thereto as the Council m.ay 
think proper, and tho Council may arrange to hold such 
Meetings or Confcronccs in tho United Kingdom or abroad, 
ivhen held in tho United Kingdom, one ench Meeting shall 
he convened at tho same place as the Annual General Moctirig 
of the Association and in connection, hiit so ns not to conflict 
therewith. For the more convenient consideration of the 
matters to he discussed, the Council may provide that they 
shall he considered in Sectional Meetings, nnd the Council 
siiaii appoint a I’rcsident and other Officers of such Section 
ns well no readers of nny addresses that may he given.’-' 


Article 33. 

" Kesolutions (of Kepresentative Body). 

33. (1) Subject ns provided hy the Bcgulations, a resolu- 
tion of the Kepresentativo Body (not being a resolution 
inconsistent with the provision of nny Statute or of the 
Memorandum of Association) which affects the funds of the 
Association, or relates to the Bogulntions or By-laws, or to 
the policy of the Association in matters affecting the honour 
or interests of the medical profession and is carried hy a 
majority of not less tlian two-thirds of the votes given thereon 
in the manner prescribed hy the By-lnws. or which relates to 
any oilier husiiicss within Uio powers of the Bepresentative 
Body nnd is carried hy a simple majority, shall he deemed to 
ho a decision of the Association. 

(2) Provided that no resolution of the Bepresentative Body 
to'inakc any addition to or any aniendmeut, alteration, or 
repeal of any Bcgulation or By-law, or to make any new 
BcViilation or By-law, shall have nny operation unless a 
proposal to make the same shall have been previously 
approved and submitted to the Bepresentative Body, • either 
hy the Council, or by a Branch or by a Division, and shall 
Iinvo been published in the Journal, not less than two months 
before the Annual Bepresentative Meeting, or one month 
before the Special Bepresentative Meeting at which such 
resolution is passed.” 

Article 34. 

" Referendum. 

34. In respect of every resolution of a General. Meeting of 
the Association (except a resolution capable of being con- 
firmed. as a special resolution or a resolution confirming as 
a special resolution a resolution previously passed, or an 
ektrao'rdinary ■•resolution or a . resolution relating colely to 
the procedure of the Meeting), and in respect of every resblu- ' 


794 Mat 5, 1928] 


Report of Councils 


r RurpLEitnuT to th» 
LnrtiTxsH Mkuicai. JouMit 


tion of the' Rein-esfintativc Body, except as otlienvise provided 
iu the Regulations, the following provisions shall have 
effect : — • 


Article 37. 

'! Affiliation^ 

37. (1) The Association may admit to affiliation with it 

any medical Association oi similar body established outside 
the United Kingdom, on such terms and with such privileges 
as may in each case be approved by resolution of tlie Eepre'- 
sentativc Body, passed after consideration of a Eeport by the 
Council. • ■ 

(2) The Association may terminate any such affiliation 
(after due notice ' on either side) by resolution of the Eepre- 
sentative Body passed after consideration of a like Eeport. 

(3) Any resolution of the Eepresentative Body under this 
Article shall be final and shall not require to be approved 
under Article 34.'’ 


(or such longer period as the Branch may by its Eiiles 
prescribe) after the date of the said notice. A Branch may 
require that eaclr candidate for election shall furnish a certi- 
ficate signed by two Members (either of the Association, or of 
the Branch, pr of the Division in which ho resides, as th.e 
Eules of the Branch may prescribe) stating that Iroin ])crsonal 
knowledge they consider him. a suitable person for election.- 

(2) In the case of a Branch not in the United Kingdom, 
the mode of election shall bo such as may, with the consent of 
the Council, be prescribed by the Eules of (he Branch.” 

By-law 11. 

" Subscriptions (Amount). 

11. (1) On and after the Ist of .Tanuary, 1023, the Annual 

Subscription to the Association shall be Three Guineas. 
Provided that in the case of Members of the classes or descrip- 
tions mentioned in column 1 of the following table the said 
subscription shall be reduced to the extent appearing in 
column 2 thereof. 


Article 42. 

“ Expenses. 

42. (1) The expenses, as defined in the By-laws, within the 

United Kingdom of Members of Council and Eepresentatives 
of Divisions attending any Eepresentative Meeting shall be' 
defrayed out of the general funds of the Association. 

Attendance of Eepresentatives of Divisions for this purpose 
shall be construed to mean' attendance at each Session of the 
Eepresentative Meeting, unless the Couneil shall be satisfied 
that good cause existed for absence from any particular 
Session or Sessions. The expenses, defined as aforesaid, 
■withm the United Kingdom of all, Members attending Meet- 
ings of Council or of Committees and of all Members 
authorised by the Representative Body or by the Council to 
attend, and attending, any Confcronce shall be defrayed in 
like manner. 

(2) The Council shall (subject as hereinbefore provided) 
determine what shall be considered an attendance for the 
purpose of this Article.” 

Article 45. 

" By-laws. 

45. Save so far as determined by Statute or by the Regula- 
tions the constitution and mode of government of the 
Association, the rights and obligations of every Member and 
separate body of Members thereof, the appointment, duties, 
powers, and privileges of all Officers, and of all Councils, 
Committees, and governing and administrative bodies ■■both' 
of the Association- and of every Division and Branch, shall b'e'- 
such as may from time to time be prescribed and determined 
by or in accordance with the By-laws, and the By-laws may 
from time to, time be added to, amended, altered, or repealed 
by the Eepresentative Body, subject to the provisions herein- 
before contained with re.spect to a resolution of that body 
for the purposes .aforesaid.” 


By-law 1. 

" Interpretation. 

1 . In these By-laws (where not rejiugnant to the context)— 


1 

Members ontitled to Reduction 
of Subscription 


A. Anv Officer on the Active List of the 
Boyiil Naval Medical Service, the Koyal Air 
Force Medical Service, the Medical Service 
of the Regular Army or the Indian Medi- 
cal Sendee, wherever resident 

B. Members of the following descriptions 
resident in the United Kingdom and not 
falling within class A above described 

' (i.) Any Member of nob less than 40 

years’ standing ns such 

(ii.) Any Member of not less than 10 
years’^ standing as such who has defi- 
nitely and permanently retired from 
the active practice of the medical pro- 
fession and has signed and transmitted 
to the Treasurer a declaration to that 
effect 

(iii.) Any Member who is engaged on a 
whole-time basis in the work of medical 
instruction or medical research and is 
not engaged in the practice 'of the 
medical profession either as consultant 
or otherwise 

(iv.) Two Members jointly being -a 
- husband and his wife residing together 
{v.) Any Member admitted to member- 
ship before the expiration of two years 
from -the date of his registration 

under the Medical Acts 


2 

Reduced Subscrip- 
tion payable 


Two guineas 


Two guineas 


Two guineas 


Two guineas 
Four guineas and 
a-half , 

One guinea and a- 
half until Uio 31st 
December next oc- 
curring . after the 
expiration of four 
yearsfromthe date 
of such* registra- 
tion • * 


L' Member resident outside the United 
' I 1 flincQ A 


One guinea 
a-half 


and 


(3) The expression ‘ Public Health Service Member 
means a Member of the. Association wlio -is perma- 
nently employed in the whole-time medical service 
(other than service at a lunatic asylum) of the Council 
or Education Authority of any County, Countv 
Borough; Municipal Borough, Metropolitan Borough', 
Burgh, Urban District," Enval District, or Parish, or 
Port Sanitary Authority in the United Kingdom.’ 



■A a thiit anv Member, wherever resident, -who is 

iTtl^^ln or”after &t July -in any year, shall pay only 
f. his current subscription for that year. . . 

, 'rxf fliitj Bv-law a Member shall bo 

!) For lace in which his ordinary place of. 

de is° BiUmte at thJ^ time at which according to the 
!!.i„Hnns-his subscription . is considered due. 


By-law 5. 

" Eleetion by Branehes. 

5. (1) In the case of a Branch in the United .Kingdom, 

the mode of election of members shall he as follows : — Every' 
candidate who resides within the area of a Branch’ shall 
forward his application to the Association at the Head Office, 
and every such application shall forthwith be notified to the 
Secretary of eaeli Branch and Division concerned. Notice of 
the proposed' election shall be sent by tlic Branch Secretary 
to every member of the Branch Council, and the candidate, 
if not 'disqualified by any Regulation "of the Association, 
mav be- elected a Member of the Association by the Branch 
Council at any Meeting, tbereof held not less , than seven "days 


■ - ■ By-la-w 14. 

” Special Subseriptions to Branch 

.4. It shall require .a 

special privileges to ito Memo „vail tbcin- 

jscripfcion from tliose Members who likewise be 

ves i.f eucli special privileges, subh spedial 

npetent for, any Division or Brancli to 

iscription as it m.ay think ^ -nivision or Branch 

'mbers; but no'Ordinnry Member of an} D 

the United Kingdom shall be called "P“" J ^ 
■thcr subscription than that paid '‘’ o' . of 

idition. of -enjoying any ordinary privilege P 

1-1 ’ r»T* -Rrnnrli.^’ 



Appondix Ilf. 


MaV 5, 102.^1 


Uy-iji\v IT). 

"Subscriptions to JIntnclics tint in the United Kingdom. 

15. (1) It fliall niBo bp conipplpiit (n) fur miy Cdriior.nte 
BotcIi to fix .oml from timo to time nitor tin- nin’oiints of tlio 
sabscriptions to be ji.niil by ito Momliors. niid (h) for nny other 
Branch not in the liiiiteil Kingdom, by Itulo (niiprovcd nn 
hcreinnfter ineutioncd), to ri'iiuiro nieh Mrmber of micU 
Branch to pay (in addition to bis Kub.Bcription to tlip Ap.-.ocin- 
tion and to nny special onb.Boriiition) nii nimiml onbicriptioii 
of such amount ns may be decinod by kucIi Hrancli to bo 
ncccssarj- for defraying expenses occasioned by tlie ppecial 
circumst.ances of sneh Jlranch, and not enpahle of b.'in^ 
defrayed out of nny prnnt from the fnnda of the Associntiou 
nade in pursuance of the Uy-lawa. 


Tm.n or Hr-ijiw 1C. 

Incori>oration of IJrnnchcj not in the United Kingdom.’^ 


Hr-uw IS (1). 

" Local Management : Jlrtinohoi. 

JL of flio nffnirs of enrh Hraiich 

(other than a Cor|)ointe llmnch) oliall. rave as otberwi.sc 

KiatiLv- I'orson.s (beiiifr jncml)er.s of the 

tWe'nf''".? Ki»?dom 

tl, ^ * (bereinnftor in. ntioiied) of 

by thrii" T ‘'''■'‘'■'f <"s lioiTinafter provided) 

t^e BmnT'i r Jirnnehes to yyliicii 

■ Annual pi of O.iistitiienries at tho 

area of tlmBranlli"® 

Tublic Hoaldi I'inRdom a 

Semico <’'• I'nl'lic nmlth 


f:tn>Pu:nrKsr to tu** 
.TiniTlKIt JlKlJlCAL JOL'n.VAt. 


195 


(vii) Any other ninttcr ns to yyhicli the Council mav, from 
time to time, nnlliorieo the TiranclieH not in the" United 
Kinsrdoin to make Jtulcs without the aiiiiroval of the 
Council.” 


Bv-laxv 2.3 (1). 

, " Federal Councils. 

.“•f; 0) ^lie Hranclic.s in any defined area outcida the 

United Kingdom which Hlinll be approved by the Council for 
tho jiiirpose may form a Federal Council, consisting of 
Jlember.s of (ho As.sociation representing each of the Branches 
concerned, for the imrposo of carrying out -the objects of the 
Asoocintioii on belinlf of those Branches collectively within the 
nreii so defined and approved. Subject as hereinafter pro- 
vided, nny micli Federal Council may be corporate or 
unincorporntc.'’ 

Bv-i,aw 27. 

" Divisions not tn the United Kingdom ; Special Powers. ' 
27. A Division not in tho United Kingdom shall (subject 
in the ease of a Division forming part of a Corporate Branch 
to nny directions or regulations given or made by that 
Branch) be competent from time to time to adopt, by tho vote 
of a General Meeting of tho Division, and wit'lioiit the, 
approval of the Council, Itiiles dealing with all or any of the 
following matters, which lliilcs shall be binding upon the 
Members of the Division to which they relate 


(iv) Anj- other matter ns to which the Council may, from 
time to time, authorise the Divisions not in the 
United Kingdom to make Rules yvithout the approval 
of the Council.’! 


Bv-i-aw 40. 

“ Ktimber of Itcprcscntativcs. 

40. (1) Each Constituency shall be entitled to elect one 
Representative. 

(2) Each Constitnency in the United Ivingdom having not 
less than 150 Members (according to tho Annual List in force 
at the lime of the election) shall bo entitled to elect one 
additional Representative for each complete number of ItIO 
Members in excess of fifty Members.” 


" . Br-uw 22. 

patent ‘iae'tVtL'e to’'''?'",'"? ^ 

Meeting of the BranriT ''J’ vote of a C 

^tacil, and njj th'-’n”'''' ■"'itliout the aii[iroval 
benefit, or’for lb; " >ielnbcrs a 

taps authorised br tho iirnfossioi 

Mtamment of anr if X “f Association 1 

Bland, ng such moans ^'''•‘'=‘!iation, nc 

™I1 not for the tim i • have been adopt. 

P'-'rally, but wUhr. '''■‘"K bv the A°lo 

to pledge the credit of tboT “"v liability up 

« . matter or thing in c'onneclio.r 

adoption or user” < pursuance of, or arisinir 
“tified to tho Coundl ion shall fori 

P) A Branch , . ‘ Branch. 

ot°the‘B " ‘"i to"adon?bv G be com 

dp,.- ^Banch, and withni^l ** General M 

S f “B uuy of tb^f"{’i‘’‘'°''“' Council, 

be binding upon^the Mo matters, which 

The number and , " =” 

(“) The number i of the B: 
p the Branch, provided^tl‘'‘^f olficc-b 
times have an HonorarVq'e*' V'® ^'"''"'='1 shall 
°®eial medium of com^,® ’ 

tion and vrith other n '"^itb the As 

'“‘'The holding of “"'1 Divisions, 

business to be “‘'.‘'"gs of the Branch an. 
conflict with the^Ee^ra?-' “‘ercat, but so as 1 
DiTismng ® -ttegubations as to the autono 

The voting bv nr 

uny Meeting of the^Pm ** such Meeting a 
Semb'^ Kingdom ^for'^'eirt"® registered i 

^^nch’l^othf^than Membership c 

"mvened for the conBidewnf"®''^ ‘'’*‘<="‘1 Me. 

ration of Association bus 


By-law 47. 

‘‘ llusincss of .Innual Picprcscntative Meeting. 

47. The businers of tho Annual Representative Meeting 
shall bo to elect a Representative of a Constituency as' the' 
Ghairman of the Representative Body, and also a Eciircsenta- 
tivc of a Constituency as Deputy-Chairman ; to ' elect a 
Fresideiit of the Association; to elect such Members of the 
Council, and sucji other Officers and such Members of 'Com- 
mittees ns by the Regulations or By-laws may be required 
to be so elected; to consider the election of Honorary Members 
when recommended by the Council; to apjioint a place at 
which the next Annual Representative JMeeting shall be 
held; to consider the Annual Financial Statement and Balance 
Sheet presented by the Council; to consider Reports of the 
Council, Reports of Committees instructed to report to such 
Meeting, and Reports of Branches and motions relating to 
the adoption of such Reports in ■whole or in part; to make, 
new By-laws, and alter and repeal By-laws, and to consider 
any resolution relating to the promotion of the medical or 
allied sciences or the mainten.anee of the honour or interests 
of the medical profession or of the Association which ehall 
have been adopted by any Division or Branch; provided that 
nny such resolution proposing material alteration of the 
constitution or policy of the Association shall have been 

£ ublishcd in tho Journal for the consideration of all the 
livisions not less than two months previously.” 


By-law 53. 

'* Council; Composition of. 

53. The Council shall be composed of the Members ex 
officio mentioned in the Regulations and of Members elected 
in manner following, namely : — 

(а) Twenty-four (being persons who have been' Members ' 
of the Association for at least the period of three 
years immediately preceding their respective elections) 
by the Branches and Divisions of the Association in 
the United Kingdom, which shall bo grouped for that ' 
purpose as hereinafter mentioned. 

(б) Seven by the Branches of the Association not in the 
United Kingdom, which shall be grouped for that 
purpose as hereinafter mentioned. 


r SUPPLEMENT TO TM ' 
LDmTisu Medical Jodekil 


196 Mat 5, 1928] 


Report of Councils 


■(c). Twelve . (being persons who have been .Members of 
the Afisociation for at least the period aforesaul) by 
the elected Eepresentatives of the Constitncncies 
comprised in the Branches and Divisions of the Asso- 
ciation in the United Kingdom, wliich Branches and 
Divisions shall be formed for that, purpose into twelve 
groups as hereinafter mentioned, the Representatives 
of all the Constituencies in each such group being 
entitled together to elect one Member of Council. 

: ' , “ ' Bv-LATr -55. . ' . . 

“Mode of Election, by Groups in the United Kingdom: ; 

55. (1) The elettioli of twenty-four 'Members of 'CouhciT 
by the Branches or Groups of Branches and" Divisions in the 
United Kingdom shall be by means of voting papei-s sent by 
post by the Association from the Head Office to each Member 
of every Branch comprised in the Group. 


By-law 56. 

“ Mode of Election by Groups 'not in the United Kingdom. 
56. (1) The election of seven Members of Council by the 

Groups of Branches not in the United Kingdom shall’ be 
conducted in the manner prescribed by this By-law. 


By-law 59. 

“ Qualification.- 

59. No person shall be eligible for election as a Member 
of Council to represent a Branch or Group of Brahehe's in the 
United Kingdom (whether the election- be by the -Branch or 
Group or by the Ilepresentatives of Constituencies) unless at 
the time of his election he shall be a member of that Branch 
or of a Branch comprised in that Group.” 


By-law 60. 

“ Terms of Office of Members of Council. 

60. (1) Each Member of Council elected by a Branch or 
Group or by the Eepresentatives of Constituencies in the - 
United Kingdom or by Public Health Service Members shall 
hold office for one year, and at the end of that time shall be 
eligible for re-election. " Provided that a person who has 
served as the representative on the Council of one and the 
same Branch or Grou]) of Branches or group or class of 
Members for six years successively shall for one year be 
incapable of being elected as such representative. 

(2) Each Member of Council elected by a Branch or Group 
not in the United Kingdom or elected to represent the Eoyal 
Naval Medical Service, the Eoyal Air Force Medical Service, 
the Army Medical Service, or the Indian Medical Service, 
shall hold office for such period not exceeding three years as 
the electing body, may determine, and at the expiration of 
such, period shall be eligible, for re-election, provided that no 
such Member shall be re-elected so as to make his period of 
continuous service as the Eepresentative on the Council of 
one and the same Branch or Group exceed six years.” 

By-law 78. 

Committees and Standing Committees, 

78. Each Standing Committee except the Scottish, Irish, 
Welsh and Dominions Committees shall appoint from its own 
number a Meniber of Council as Chairman. Each such 
excepted Committee shall appoint from its own number a 
Deputy-Chairman, as well as a Chairman, and ' either the 
Chairman or the Deputy-Chairman or the Honorary Secretary 
of that Committee shall be appointed from amongst Members 
of Council.” 

Bi'-law 85. ■ 

“ Expenses. 

85.. The expenses of any person which in pursuance of the 
42nd Article of Association are to be defrayed out of the 
general funds of the Association, arc the first-class travelling 
expenses within the United Kingdom of that person.!’ 


Schedule to By-laws, as to Duties, Powebs, etc., of Cestral 
Ethical ’ Cojijiittee. . 

. »C- - ‘ 

Provided that,, notwithstanding the foregoing provisions, 
the Committee shall not adjudicate upon or entertain any 
such (piestion ns aforesaid which has arisen in a Branch not 
in the United Kingdom having a membership of not less than 
thirty, except upon the request of the Council of that 
Branch; 


Schedule.- TO By-laws, as to Appointjiext of Members to 
Insurance Acts Committee, other than (1) Members theeeop 
ex officio, (2) Mejibers Appointed thereto by the Hepbesenia- 
. . . TivE Body OR . Council. . 

“Appointed Members . . . 

Otherwise appointed. 

■ Bcgistcred medical practitioners appointed as follows ' 

5 such practitioners (being Members of the Association) 
clecteil (in- the manner prescribed by the Ilepresentativ* 
Body), by. the. elected Representatives of the Constituencies 
formed for Great Britain under By-law 39, namely, 4 by- 
all tlie elected Representatives (acting together) of the 
Constituencies so formed for England and Wales, and one 
by all the elected ■ Eepresentatives (acting together) of 
the Constitucncie's so fo’rmcd for Scotland together -with 
27 practitioners (whether Memlxirs of .the Association or 
not) to be nominated or qualified as under, viz. : — 


23 to bo selected so far as possible on a territorial 
basis from among practitioners nominated by the Local 
Medical Committees and Panel Committees formed in 
Great Britain under the Insurance Acts; . 


1 (being a member of the Staff- of a Voluntary 
Hospital) to be nominated by the Hospitals Committee 
of the Association; 

1 to be nominated by the Medical Women's Federa- 
tion; 

1 to be nominated by the Society of Medical Officers 
of Health; 

1 to be nominated by the Poor Law Medical Officers 
Association of England and Wales; - .... 


with power for the Members of the Committee'" appointed 
ns above provided to co-opt as additional Members such 
number (if any) of non-panel . practitioners as shall he 
reciuired to secure that 4 such practitioners _ shall bo 
Members of the Committee, 1 of whom shall be in general 
nractice in an industrial area.” ^ 


Schedule to By-laws, as to Charities and Dominions 
Committees. 


“ Name of 
Com- 
mittee 


Charities 


Additional 

Members 

c.v-officio 


Appointed 

Members 


|« >.1 

' © o 

'•2 5 

■** c 
C s 
'S “ 

Oa u 

cu 


O 3 

.sa 

o 

Of 


© 

.2 © 


o 'S I 
cul 
ri, 


Duties, Pow( 


|to direct the atten- 
tion of members oi 
the medical pro- 
fession to the finan- 
cial and educa- 
tional posit i one 
which arise as n 
resultof misfortune 
falling on members 
thereof ; to appeal 
for contributions to 
meetthesepositions 
and to advise the 
Council on the ad- 
ministration of the 
CharitiesTrust 

J ysF A cc/\. 


Dominions 


‘'All the Mem-j 
bers of the 
Council whore- 
present Bran- 
ches not in the 
United King- 
dom. 


To consider^ ques- 
tions specially re- 
lating to 'the 
Brunches not in 
the United King- 
dom.” 




i 

i 



Mat IPJS] Annual Moot/na, 1928 1 Provisional Programmo. if 97 


IBrxtfelj iEctiiral ^ssariaitnn* 

NlNETY-SfXTH ANNUAL MEETING, CARDIFF, JULY, 1928. 


P(ifro:i ; His Maaksty Tnn Kiko, • 

President : Sir. nonr.tiT Sv. Piiir,ir, M.D., LL.D., IMl.C.P.Kil., Consulting Pliysicmn, Poynl Infirmary, Edinburgh. 
President-Elect: Sin Ewr.s- .1. Macuias, >1.1)., r.ll.C.l*., Professor of Obstetrics, Welsh National School of Jlcdicine, 
Chninnnn of Itcprescntextivc Ilodtj : C. O. IlAAVTitoiiNr, iM.D., F.R.C.P, 

Cliairniaii of Cortneil :■ II. P. PnACKns’nonv, M.II.C.S., E.U.C.P. 

Treasurer : N. Ih.sHor JIaiiman, >f.H., F.P.C.S. 


PROYISIONAL PROGRAMjME. 



/fsr' HE iucoiuiug 
M ‘ Eavi'.n Maci.i: 
VJ'i his nddriRs I 


President, Sir 
AN, Avill deliver 
to the Associa- 
Tuesday, .Inly 2Alh, 


To"rr. or Oicr.a,, 


lion on 
at 8 p.m 
Tho Ass'uai. Itr.rr.Ksr.NTA- 
Tivi; Mr.r.TiNii will begin on 
Friday, .Inly 20tli, at 10 a.iii., 
and le conlimtcd on tho three 
following wcohdays. Tho 
IteprcscntaUvcs’ Dinner will 
l.alte place on I'riday evening, 
July 20th, at 7.30. 

The statutory ANNU.it, 
■ Gr.SFi!Ai, MnirriNC. will bo 
held on Tuesday, .Inly 24th, 
at 2 p.ni., and the adjourned 
general niccting at 8 p.in. 

Tho Annual Dinner of tho 
Association will talco place on 
Thursday, .Inly 2Gth. 

Tho Conference of llonomry 
Socrctaric.s will bo held at 


25lli as,i o ■ , . . _ 2.30 p.in. on Wednesday, .Inly 

tL it .® Dinner at 6.30 the sauio evening. 

Sorvieo avill bo held at St. John’.s 
The I r; <‘1 ^-30 p..n. 

and bok”s''Sl of surgical appliances, foods, drugs, 

from 2 till 6 ™ tnspection on Jlonday, .Inly 23rd, 

will ialrn nin, formal opening by the President 

remain 00 ^°“ exhibition 

6 p.in OQ Jnly 25tb, 26Ui, nml 27tli from 9 a.m. 

''sees of mtorcst 8>'’cn up to excursions to 

mrorcst in the noighbonrhood. 


Th 0 • . Of.UJ'JONS. 

'“pets anTat!.! from 10 a.m. to 1 p.i 

'"'y2Stb, 26tb, Ina 27°ir''‘'^““'^‘''’’ 

lowing Sections will moot on Threo Days 

PeesUltnt • Si,, rr MEDICIME. 

iAioaon). ■ Thomas Lewis, C.B.E., M.D., F.It.C.P., I 

; Ivon t rv 

^Gow, M.D., F n r F /? P-P.C.P. (Cm 

.•U.C.F.f.a rp,iLl!‘'-V-P. (Lontlonl: A. rirw,.,. 



^“te, London. TV . 1 . Ieilino, M.D., F.R.C.P., 52, 

"y'di/ 's5ja''''in arrange 
So'y, To "^0 n?-™- r : Disease 

° opened by Dr. George A 

I^j“®“‘otD^phtherii^° T^i, Discussion; The Prevei 
r^M ^obeopenod by Dr.J. D.Ki 


SUPCERY, 

Presiitenl : Professor A. W. SiiEiiN, C.B.E., M.S., F.R.C.S. 
(Cnrdlg). 

Vtcf-VresultnU : IT. G. Cook, C.U.E., M.D., F.R.C.S. (Cardiff); 
C. 11. Fagok. M.S., F.R.C.S. (London) ; Professor Andreat 
l-|lI.l.EltTON. C.ll.. C.Jf.G.. .M.Ch.. P.R.C.S.I. (Belfast) ; .1. W. 
Gearv Gr.int, I'.R.C.H. (Cardig) ; Wii.i.iam JIartin, JI.B.. C.JI. 
(Cardiff); Ai.iiert.I. Wai.ton. .M.S., F.R.C.S. (London). 

Ilntinrnni Secrehnirf : D. .1. Harries, D.Sc., F.R.C.'S., lOS, New- 
I'ort Ro.a(l. Cardiff; J!. Sr. IjEger Brockman, SI.B., M.Cli., 
F.R.C.S., 79, Upper llnnover Street, Sheffield. 

The following provisional programme has been nrr.angcd : 
IIVdnf.*diiy, Julij •Jjlli.—lO a.m. Discnssimi ; Tho Diagnosis and 
Treatment of S|>intil Cord Tumours. To ho oiiened by Mr. 
DoNAi.l) .1. Ar.MOER (London), followed by Dr. George RinnocH 
(I.rf)ndon) and Sir Pj'.rcv Sargent (London). 

Thuriitaij, July Sdlli.—iO a.m. to 12 noon, (.Joint meeliiigwith 
Section of" Radiology and Pliysio-Thcrnpeutics.) Discussion: The I 
I'allncy ot Rays in Ab iominal Diagnosis. To be opened by .j 
Air. Jlr.nnnnT .1. Pateiuson (London) and Dr. F. Hernam.an- 
.Toiin.son (London). 

12 noon. Diecmsioii : Tlio Treatment of Gangrene. To be 
opened by >tr. W. Samp.soN IIanpley (London). 

J'ruhiy, July 27lli.— 10 a.m. Disciifsion: Pancreatitis. To be 
opened bv Sir Berkei.ev Moyniuan, Bt. (Leeds), followed by 
>lr. .1. W.’Geary Grant (Cardiff). 

12 noon. Ditenssion : 7 bo Diagnosis of Ureteric Calculi. To be 
opened by Professor Andrew Fullerton (Belfast), followed by 
Dr. E. B. C. .M.AYns (Belfast). 

OBSTETRICS AND GYNAECOLOGY. 

President: T. Watts Eden, M.D., F.R.C.P., P.R.C.S.Ed. 
(London). 

Vice-Presidents : AfARGARET JL Basden, M.D. .F.R.C.S. (London); 
ARTHUR E. Giles, M.D.. F.R.C.S.Ed. (London); Professor 
W. Flktciikr Shaw, M.D., Cb.B. (Manchester); Professor 
ir. Beckwith Whitehouse, Jt.S., F.R.C.S. (Birmingham). 

Honorary Secrelartes : B. K.Tenison Collins, M.D. .F.R.C.S. Ed., 

12, Windsor Place, Cardiff; Everard YVilliajis, Jf.D., M.R.C.P., 

5, Wimpolo Street, London, W.l. 

The following provisional programme has been arranged : 
llVcfncsihiy, -hily S'dii . — 10 a.m. Difcit.^siou ; Unsuccessful 
Forceps Cases. To be opened by Professor W. Fletcher Shaw 
(Manchester), followed by Professor .Tajiks IIendry (Glasgow) and 
Dr. DougL-AS A. JIillkr (Edinburgbj. 

Ttfirsday, July SGlU.—lO a.m. Discussion: The Diagnosis and f 
'I'rcalmcnt of Sterility. To bo opened by Di'. A. E. Giles ,jj 
(London), followed by Dr. Sydney Forsdike (London) and Jfr. !{ 
Kenneth M. YVai.keu (London). 

Friday, July 2Tlh. — 10 a.m. Papers: Professor R. Vaudescal 
(Paris), Myomectomy during Prognniicv ; Professor W. W. 
CniPJiAN (Montreal), Acute Conditions in the Lower Abdomen of 
tlio Female ; Mr.EVERARD M’illiajis (London): The Acute Pelvis. 


MENTAL DISEASES AND NEUROLOGY. 

President: Edwin Goodall, C.B.E., M.D., F.R.C.P. (Cardiff). 
Viec-Presidenls : E. D. Adrian, M.D., F.R.C.P., F.R.S. (Cam- 
bridge) ; G, H. R. Gibson, D.S.O., M.D., F.R.C.P. Ed. (Edinburgh);' 
Bernard Hart, M.D., F.R.C.P. (London); W. F. Nelis, M.D. 
(Cacrleon, Mon.); N. R. Phillips, M.D. (Abergavenny). 

Honorary Secretaries: Edward Lewis, F.R.F.P.S., Drynima 
Unll. Skewen, nr. Neath, Glam. ; W. R. Reynell, M.D., M.li.C.P., 

87. Harley Street, London, W.l. 

The following provisional programme has been arranged : |i 

V'cdnesday, JiiDl 25th. — 10 a.m. Discussion : Antotoxacmia as a \li 
Factor in tlie Causation ot the Psyoheses. To be opened by /( 
Professor W. Weygandt (Hamburg), followed by Dr. E. Mapother 
(London), Dr. J. P. Porter-Piiillips (London), Dr. M.vry J}. 
BaRKAs (Loudon), Dr. A. Helen A. Boyle (Hove), Dr. D. p 
RAJIBAUT (Nortliampton), and Dr. P. A. Pickworth (Birm'in'*- 
ham). “ 

Thursday, July 2Gth. — 10 a.m. Discussion : The Differ“ntial 
Diagnosis and Treatment ot Cerebral States consenueut nnnn 
Head Injuries. To be opened by Dr. C. P. Syjiond.s (Londmi) 


198 Mat 5, 1928] 


Annual Mesting, 1928 ; Provisional Programme^ 


1 TO THI 

LBHITISH MeDIOIL JoDRKAti 


followed by Dr. O. R. Wohsteb-Dbought (London), Mr. Wilfbed 
Tkotter (London), Dr. R. D. Gillespie (London), Dr. D. 
McAlpine (London), and Dr. G. Riddoch (London). 

Fritlay, July 27lh. — 10 n.m. Discussion :• The Early Treatment 
of the Rsychoses and Psychoneuroaea. To be opened by Dr. A. 
Helen A. Boyle (Hove), followed by Dr. E. Mapotheb (London), 
Dr. E. D. Gillespie (London), Dr. MAuy R. Baiikas (London), 
Dr. R. G. Gordon (Bath), and Dr. JoiinR. Rees (London). 

The following Sections' will moot on Two Days , V 
PATHOLOGY AND BACTERIOLOGY, 

President: Professor B. H. Kettle, M.D., M.R.C.P. (London). 
Vice-Presidents: Professor John Geuickshank, M.D. (Aberdeen); 
Sir Thomas Houston, O.B.E., M.D. (Belfast); W. Parey Morgan, 
M.D. (Cardiff); A. E. S. Sladden, M.D. (Swansea). 

Honorary Secretaries ; J. B. Duguid, M.D., Department of 
Pathology, 'Welsh National School of Medicine, The Parade, 
Cardiff; Lawrence P. Garrod, M.B., M.R.C.P., 6S, Gloucester 
Terrace, Hyde Park, London, W.2. - 

ORTHOPAEDICS. 

President ; Sir John Lynn-Thomas, K.B.E., C.B., C.M.G. 
F.R.C.S. (Llechryd). 

Vice-Presidents: A. Rooyn Jones, M.B., F.R.C.S. (London); J. J. 
McIntosh Shaw, M.O., M.D. , F.R.C.S.Ed; (Edinburgh); S. Alwyn 
Smith, D.S.O., O.B.B., M.D., F.R.C.S.Ed. (Cardiff); P. Jenner 
■Fereall, M.B., I'.R.C.S. (London). 

Honorary Secretaries : J. Berry Haycraft, M.G., M.B., F.R.C.S. 
31, Cathedral Road, Cardiff; Eric Ivan Lloyd, M.B., F.R.C.S., 
33, Wimpole Street, London, W.L 
Tlie following provisional programme has been arranged : 
Wednesday, July 25lh, — lOa.ra. Discussion: Low Backache and 
Sciatica. To be opened by Mr. W. A. Cochrane (Edinburgli). 

Thursday, July 26th. — 10 a.m. Discussion : Volkmnn'slschaemio- 
Contracture, with special reference to Treatment; . To be opened* 
by Sir Robert Jones, Bt. (Liverpool). • - • 

12 noon. Cinematograpli Demonstration by the Prf.sident of 
the Section on Methods of Treating (1) Colles’s Fracture, (2) Frac- 
ture of Femur, and (5) Clubfoot, as practised by Sir Robert Jones. 

DISBASBS OP CHILDREN, 

President; Alfred Howell, M.D., M.R.C.P. (Cardiff). 
Vice-Presidents; E. A. Cockayne, M.D., F.R.C.P. (London): 
Herbert Thomas Evans, M.D., M.R.C.P. (Cardiff); Charles 
Leonard Isaac, M.B., F.R.C.S.Ed. (Swansea). 

Honorary Secretaries ; Daniel Thomas Davies, M.D., M.R.C.P., 
24, Park Place, Cardiff; Hilda N. Stoessiger, M.D., 11, Belmont 
House, Candover Street, London, W.l. 

Tile following provisional programme has been arranged ; ' 
Wednesday, Ju'y 25th.— 10 n.m. Discussion: Chronic Spleno- 
megaly in Childhood. To be opened bv Dr. Robert Huiohison 
(London), followed by Mr. L. E. BahringtoN-Ward (London). 

Thursday, July 26-h. — 10 a.m. Disctissiou; Olironio Nephritis in 
Childhood. To be opened by Dr. J. C. SpenOB (Newcastle). . 

OPHTHALMOLOGY, - - 

President; F.P. S. Cresswell.M.B., F.R.C.S. (Cardiff). • - 
r/cc-Presidents .•^■Herbert. Oaiger, 'M.B., F.R.C.fL (Sheffield) - i 

,.(Nowp ■ ... I 

' Horn g , 

' L Park Grove, Cardiff; F. A. JuLER, M.D., F.R.C.S., 14, Portland 
i iace, London, W.l. 

The following provisional programme has been arranged : 
Wednesday, July 25th.— 10 a.ral Discussion: Visnal Efficienov 
. and Working Ability. To be opened by Dr. A. Freeland Fergus 
(Glasgow), followed by Sir J. H. Parsons (London)' and Mr N ■ 
Bishop Harman (London). ■ , 

Paper: Dr. T. H. Whittington (London), The Examination of 

■ the Eyes and Eyesight in.Young Children. ■ .* 

Thursday, July 26th.— 10 .a.m. Discussion: The. Etiology of 
.Glaucoma. .To.be opened by Mr. W. S. Duke-Elder (Lohdou) 

■ followed by Dr. H. M. Traquair (Edinburgh), Mr. Thomson 
Henderson (Nottingham), and Mr. N. Bishop Harman (Londonl 

. Piiper-.'Mr.'A. H. Levy. (London), TelesoopicSpectaoles. . . 

LABYNGOLOGY AND OTOLOGY.' 

President: Donald R1 Paterson, M.D., G.M., F.R.C.P (Carflim 

Vice-Presidents : ALBAN Evans. kr.RlC.R.. T..P n p ’ ! 


Vice-Presidents ; ALBAN Evans, M.RiC.S., Ij’.R.’cVp.MSmin^a 

s, F.R.C.S. (London); Archibald Mason Jones’ 


E. D. D. Davis, 

M.D., F.R.C.S.Ed. (Cardiff). 

Honorary Secretaries ; A. A. Prichard, M.D., 14, Windsor Plare ' 
Cardiff; D. F. A. Neilson, F.R.C.S., 40, Queen Anne Street’* 
Loudon, W.l. ’ ■ 

TUBERCULOSIS. ' 

’President; Hugh- Morriston Davies, M.D., M.Ch. F.R c S i 
(Rnthiii).' I 

.Vice-Presidents; Alex.4NDEp. Brownlee, M.D., F.R.C S Ed 
(Fairwater, nr. Cardiff); Dan Arthur Powell, M.D. (Cardiffi- ■ 
Cecil Wall. M.D., F.R.C.P. (London). ' *’ ’ 

Honorary Secretaries ; J. C. Gilchrist, M.D., Tuberonlosis 
Institution, Welsh National Memorial, 10, The Parade, Cardifl- 
J. C. Hoyle, M.B., B.S., 28, Malcolm Street, Cambridge. ’ 

The following provisional prograihme has been arranged : 
Wednesday. July 25th. — 10 a.m. Discussion: The Relation be- . 
tween Trauma and Tiiberoulosia, especially from the noiut of 
view of Compens-ition and Accident Insurance, To be opened by 


Dr. Norman Tattersall (Leeds), followed by Mr. Robert Milks 
(L ondon) and Dr. Otto.May (London). 

Papers on Factors in the Bioobemistry of Tuberculosis: Dr. 

L. S. T. Burrell (Loudon), The Tlierapeiitio Value of the Heavy 
Metals; Dr. J. C. Hoyle (Cambridge), Tlie Serum Calcium in 
Experimental Tuberculosis ; diid Dr. IV. H. Tytler (Cardiff), The 
Tuberouliii-aocive Fraction of the Tubercle Bacillus. 

Wednesday Afternoon. — Demonstration of After-results of 
Surgical Treatment of Tuberculous and other Diseases of the 
Lungs.- Speoimons, lantern slides, anatomical preparations of the 
phreiiio nerve, etc., will bo on view in the l^ntbological Museum' 
during the meeting. 

2.33 p.m. There will be an Explanatory Demonstration. 

4 p.m. Cases will be shown in tlio A'-ray Department, Cardiff 
Royal Infirmary (by the courtesy of Dr. Owen L. Rhys); and Dr. 
R. Cecil B. Wall (London) will give a Physiological Demon- 
stration. 

Thursday, July 2Clh. — 10 iKn. Discussions: (I) After-effects of 
Surgical Procedures on Cases of Pulmonary Tubercnlosis. To be 
"opened by Mr. A. Tudor Edwards (London) * and- -Dr. F. G. 
Ohandler (Loudon). (2) Tuberculosis as seen by the General. 
Practitioner. To be opened by Dr. R. Cameron (Cardiff), and 
others. 

radiology and PHYSIO-THERAPEUTICS. 

President ; OwEN Lewellin Rhys, M.D. (Cardiff). 

' Vice-I^residents ; T. GARFIELD Evans, M.D., D.M.R.E. (Cardiffj; 
C. B. Heald, C.B.B., M.D., M.R.C.P. (London); Thomas Marlin, 

M. D., D.M.R.E. (London). 

Honorary Secretaries : T. I. Candy, M.B.,B.Ch., 202, Stow Hill, 
Newport, Mon.; A. J. U. Iles, M.R.C.S., D.R.G.P., Shutterne 
House, Taunton. 

The following provisional programme has Ween arranged: 
Wednesday, July 25th.— 10 a.m. Discussion: Ultra-violet Rays 
and the General Pnblic.- To be opened by Profess ir W. E. Dixon, 
F.R.S. (Cambridge), followed by Dr. G. B. Hb.ald (London). 

• Thursday, July 26th.— 10 a;m. to 12 noon. (Joint meeting with 
Section of Surgerv.) Discussion: The Fallacy of A' Rays in 
Abdominal Diagno'sis. To bo opened by Mr. HERBERr J. 
Patterson (Loudon) and Dr. F. Heknajian-Johnso-V (London). 

The following Soctlons will meet on One Day , 

preyentiye medicine. 

President; Edward Colston Williams, M.D., F.R.C.S.Ed. 

^*^P’icc-Prcsidc)ils : W. W. Jameson, M.D., M.R.C.P. (London); 
David Llewelyn Williasis, J/.6'., F.lf.O.S.Ed. (Cardiff); 0. A. 
Briostooke, M.R.C.S. (Haverfordwest). „ „ „ 

Honoruni Sccreturics : H. W. Oatto, M-B., B.S., 198, Stow Hill, 
Newport, 'Mon.;. D. 0. Kirkhope, M.D., Town Hall, South 
Tottenham, Loudon, N.15. 

The following provisional programme has been arranged; 
Wednesday, July 25tli.-10 a.m. Discussion :'--Tlie Value of the 
Present Methods of Control f.ifeotious Diseases: (n) The 
Control of Small-pox. To he o, eiiod by Dr. B..J. RajchMaNK 
(Geueva),' followed by Dr. J. Middleton Martin- (G loucester), 
Dr. T. Eustace Hill (Durham), - Dr. R. P. (Saruow 

Dr Ri^BuuoE Low (Oardiffj, .and 

(Leicester)... (ii). Tlie Control- of Scarl 

Dr 'j.' G^KAlIAJl'^FmiBES (London), Dr.-B. A. I. PETERS (Bristoll 
and Dr'. E. H. R- HarrieS (Birmingham). 

PUBLIC HEALTH. 

or chdiffl ■ J. D. JEKKIHS, M.D. (Rhondda) ; S. G. Moore, M.D. 

SSfeii rT-cS=: K.', 

Saltergate, Chesterfleia. ... ^ 

t M i-iY-nviRional programme has been arranged. 

Hygiene: (. 1 ) the Child and tlie Adolescent.- To be 

oSby' Dr A. ElcSmoLZ (London); (c) To the General Public. 
(Opener will be announced later.) 

medical sociology. 

Presides; WILLIAM EVANS THOMAS, M.D.. C.M. (Astrad 

^^i^f-Ihl-sidents : Professor F. W-W,^M.^. Ph-D.JE^^^^ 
burgh); Letitia « C P. (Towyn) ; The Rev. Sit 

Evan Ekivys-Lloyd^M.R.C.S.^J^h-j^, ^ j, jLonaon); Mrs. O. 

: '^^°°‘y“*'pearson, M.R.C.S.. . 

18, erwys Rood, CariBff E lizabeth Casbon, M.D., D.P.M., 
Hollowav Sanatorium, Virginia Water, Snirej. 

The following pr.oviBi6narprograthme has been arrange^.. * 

Friday, July Li.scussioii :-^The Fallino, opgued by *, 

Various Aspects : (<i) The Pp'searoli Department, *. 

Professor F. A. E.Ciiew (Animal Breeding Reoejiro^.^^ , 

University of Ediiibnrgb). (h) Wales), ic) The , 

opened by Professor 3V. J. HORDEIt, Bt. , * 

Medical Asoect. To be open^ed by mr THOMAS 
(London), aiid Lady BARRETT (Loudon). •! 


MAY 5, 1038] 


Annual Mooting, 1928: Provisional Programme. 199 



TROPIOAIi MEDICINE. 

I’lirur U. M.ANSOS.ll.Mlli. D.S.O., Jl.l)., F.U.O.P. 

(I/iniioii). 

I’lff-IV 
( 1.011 lion) 

f 

55, Weymouth Street, London, W.l. 

Ihe following provislounl iitaiinAmnie Ima liccn i\trau(!cd : 
IMiirdfiii/, Jiilv lOn.ni. JUfriirfinnt : (ll Itecent Advancca 

in Dinenos'ffi nnd Tio.itnient of llnnmn lIolininlliiaNiR. To ho 
cmiicd bv Licut.-Coloncl CLAYTON Lani:, LM.S.(ret.) (London). 
l2) Transmission of Kala-arnr. To he oponed liy Dr. C. 51. 
IVtxvoX (Iioniion). 

An exhibition of nntlioIo(tic.aI specimen') nnd prcimrotions 
illoslrating tropic.il discuses will ho on \ lew. 

HISTORY OF MEDICINE. 

• ProMfiit; WAI.TKU A’t.SruNei’.u.O.lJ.L., M.S..r.U.C.S. (London). 

I’Kt-FrmUnu ; TnoiiAS W.At.r.ACi:. 51. D. (C.irdlrf); T. P. C. 
KiF.KrATiucK, 5I.D., r.U.C.P.I. (Duhlin); Professor .1. A. Kixon, 
C.M.G.. M.I)., P.U.C.P. iClifton); CiiAi'.i.ns SlNoi-.n, M.A., M.I)., 
F.R.C.P. (Ixmdon). 

Ifcnernn) .SVcrrlnrio : ILR.l'r.r.nniiiA'K.M.lA., Ch.lL. 42, Victoria 
r.oacl, Aberavon, Pert Tnllmt, Glam. ; Ki:ssr.Tlt !t. llAV, O.P.K., 
5I.B.,47, llill Street, llcrhelcy Square, I.ondon, W.L 
' The following provisional proErainme has been nrmnEcd ; 

irrdnM.hi/y.hdy ij(h.— 10 a.ni. Jii-i-ii'rinii: nistorical Annccta 
ilHeas regarding the h'ature nnd Treatment of Dropsy. To he 
:pcnedbyl)r. J.D. CoMhii'. (Kdliihurph). 

Piiprs: Dr. E. Roland Wit.n.A'its (Mncnclochop). Welsh 
Physicians ami the Rciialssauce; Dr.J. D. Itoi.msTON (Loudon), 
Tim History ol Scarlet I'ever; Dr. P. Divmmr.s (SwanFoal, Tho 
Welsh rhvsician In the Middle Apes; .Mr. C. J. S. Tlio.'ir.so.v 
(London), The History nnd Lore of Ciiicliona Rarlt. 

o collection illnstrativc of tho theory nnd prnctico of folk- 
rnedicine, human nnd nnlmal. In Wnle« will ho housed in the 
national Jlnsenm of Wales, Cardiff. (Bco Jlritith Mdlical Journal. 
March 24th, 1928, p. 500.) ' 

„ therapeutics AND PHARMACOLOGY. 

L':"'i'''‘.= '’'’.L.ANOD 0 N llnowN, M.D.. P.K.C.P. (r.ondon). 

V. wu."'''"";; ^^fo'essor W. .1. Dim.ino. 5r.ll., Cli.ll. (Llvcr- 
hilvmi m F.ILC.P. (London); W. 11. 

■Ap LU. Telling, 5I.D.. V.Ii.C.V. (Leeds). 

he GrS r •’I'l J' J>"TKS >r.R.. “Crnnmoor," 

rhnrmnccuticnl 

nry S^gSafe^Lju^don' W.C.L™^”'®'’''®'^' 17. lijooms- 

arranged; 

lie Medicaf'Trei(menri*f‘p'''. ; Recent Adranccs In 

)r. A. P. nnrsT To ho opened by 

KohERTRouAM, 5LD.?LL.D.. F.R.C.P. (Newcastle- 

ylS^AMX'imTi/Tn 'n (Cardiff); 

l-I).,M.P.,c.iULcndouP'’ (I.ondon); Uknuy SkMON, 

honorary Sicrttarhs : n_ rr tc.,.,... „ 

“firmary, Cardiff; , 

‘feel, London, W.l 


•R.C.P. (Lendouj: " (London); Uknuy Skmon, 

JLIl.C.fi., L.n.C.P., Royal 
^ond^rwlL ' >I'1LC.P., 132, 'llarlcy 

looting is D™G General Socrotary of tho Annual 

b Dr. D. I. Stbachan, 20. AVindnnr Pl.noo Enf.HfT 


a.ni. 

p.m. 

ll’x 

^030p.in. 

9-0 a.m, 

^0 p.ra. 


,90 a.ni.- 
jO-0 

^0-0 a.m.. 

S-S: 

i.V'"’ 
10.0 
10.0 
-110 
2 0 

B ^ 


»juv;i;uiary ui fclio Anil 

otbachan, 20, AVindsor Place, Cardiff. 
provisional TIME-TABLE 

-Udics' Dinner. 

— Banco. 

^''"'"’“"'^f^Ro'X.roSitlvcBoar, 

■“voncert. ’ ' 


AY. JtTT.V 91-rtT 


tratlon. 

jy Presldont-Elcct. 


Ttepro- 


‘''In.-cnm. 

scntntlvoxtcclln?'*'’'”' f'>"'"''od by Annual 

-Adjourned Gine^i'yM®?,' Church, Cardiff. 

—Hieeption lu Pre'tuJelit'B Aildrfss. 

'• 1j>’ D ance. . Local Executive, followed 


WlCDNr.HDAY, JOLY 25 t1I. 

9.0 liAii.^^CoutieU 

9.0 iv.in.— Koei'ptlon Kooin open. 

9.0 a.ni.— KxliH»ition oimn. 

9.0 n.iii.— i*iitl)olOf,'Iciil Jliiponm open. 

.10.0 a.m.-rSecliounl AUrttiiQf. 

10.0 o.m.—Latile.s’ Golf Competition. 

10.0 n.iii.— Kxc«»r.s(onR for Ladles. 

).0 p.in.-^IrisL OraduatcH* Lunclicon. 

2.0 P.in.— 'KxctJrslonR and Garden ParUcs. 

2.30 iMii.— SoerctnrieR' Conference. 

CJ^ P.m.— SccretaricR* Dinner. 

8 30p.in.— Jf^C'pffon by Lord Mayor and City Council, City Hall. 
JO.O P.iii.— Drtiicd. 

Tiipilsday, Joly 26Tir, 

-rXttllmial Temperance League Breakfast. 

Mii*.R, St. David’s Catliedrnl, Charles Street. 
-KxliU»itlon upon. 

-Hc«i**lration Olllco open. 


8.30 n.m.' 
9.0 a.m. 
9.0 ft.m. 
9.0 

9.0 n.in. 

9.30 A. Ill,- 
lO.O A.m.- 

10.0 A.m. 

2.0 p.in. 

3.30 p.in. 

7.15 n.m.- 

10.0 


8.30 a.m.- 

9.0 n.m.- 

ID.D n.m.- 
10.0 n.m.- 

2.0 p.in.- 

2. 30 p.m.- 
8.10 p.m.- 

10.0 p.m.- 


Clillde Cups, 


-Honorary Graduation, Unlvorfiity of "Wales. 

-OanUn Party <f» flir Gromulfi of Cardiff Castle, by 
invitation of tho Marauls and Marchioness of Bute. 
-.4ntii/nf of the Association, City Hall. 

“Dance. 

Fjiidat, JrLV 27 tit. 

“Medical Missionary Breakfast. 

• Ilrclstnitlon' Oflico, ExhlbitloHi and Pathological 
.Mimoum open. 

-.SccMorml 3frfttnnff. 

-Dxt'ursIonB for Ladles. 

-I'xriirsIonR and Ga*«;len Parties. 

-Golf Competition for TrcaBUrcr’a Ctip, 

-Jtereption !>>' National Jlnscum of Wales, 

“Dance. 

S^TtTunAY, July 28th, 

E.xcurslons. 


PATH OI.OGl CA L JIU-SEUM. 

Tin; committri' n))|>i)iiilP(l to orPniiiEO tho Pathological 
Mii'-i'um ill nmncxioii witli tlic Annual Jtcoting of tho 
British Mmlical Association at Cardiff next July iiroposcs 
to arrnngo tlio matciial tnidir tlio following heads: (1) 
Kxhihits hi'aniis on tli.cnssions and jiapoi-s in tho various 
.Sections. (2) Specimens ifml illnstrution.s relating to any 
recent researc h woih. (3) Instruments concerned in clinical 
diagnosis and patliologieal investigation. (4) Individual 
.spec imens of special inti>rrst or a seriA's illustrating somo 
spi'c;ial snhjc'ct. (5) J'hxhihits of gcneial interest. TIio 
commitlee apiiiNils for the co-operation of tho profession 
in making the imi.seum a sncce,ss. It ivill ho easy of nccc-ss, 
licing sitnatrsl in tho same hnihling in which tlio Soctions 
will inoc‘t; it is hojied to make arrangements for exhihitors 
to demonstrate their siieeimcns. Every care will ho taken 
of the exhibits, nnd tlio contents of the museum will ho 
insured. TIic honorary seorc-taries (Dr. J. B. Ditgnid and 
Dr. .1. Mills, Department of Pntliology and BactcTiology, ' 
tVclsIi Niitional School of Medicine, Tho Parade, Cardiff) 
ask intending exhibitors to notify them as soon as possible. 

BEDDGl'lD RAILWAY FARES. 

RA'duced fares xvill In' granted to persons travelling to 
ntteiiil the Annual ileetiiig. The railway comiianics in 
Great Britain (cxee|it the Aletropolitan, Metropolitan 
District, and Loudon Electric Railway Companies) have 
aeri'cd to issue return tickets to passengere travelliug to 
Cardiff in this connexion at tho ordinary single fare and 
oiic-third, fractions of 3(1. to he reckoned as 3d., and the 
minimum adult fare to he Is. A vonehor of the usual typo 
must he surrendered when the ticket is bought ; these, 
vom-lier.s, .signed by the Financial Secretary of the Asso- 
ciation, will he ohtniiiahle from Jiim in duo eoiir.se on 
application. 

IRISH 5IEDIC'.\L SCHOOLS’ AND GRADUATES’ 
ASSOCIATION. 

The animal luiiclieon of the Irish 5Iedical Schools’ and 
Graduates’ Associaticiu will he held at tho Royal Hotel. Cardiff, 
on Wcdne.sdny, July 25th, at 1 o’clock shaip. The Pie.sident- 
Elect of the British 5Iedieal -Yssociatioa, Sir Ewen, M.-ieleaii, 
will be the guest of tlie association. Tickets for tlie luaclieon, 
price 4s. 6d. each, r.vciusivc of wines, may he obtained from the 
honorary secretary for the provinces, Dr. Falkland L. Carv, 
67, King’s Road," Harrogate. Alembera of the as.sociation are 
particularly requested tins year to obtain tlieir tickets well in 
.Klvaiicc, owing to the difficulty of catering for an unknown 
iiuniher of guests. 



May- 


5. 1028] 


Mootfngs of Branohea and Dtvtstonsa' 


r uurrr.r.MT:im<i rnr. nni 

LCniTisir siEDicit Joujinai* * 


a dcpiilv rcnii'^i-iitativo for tUo Aumial Iteprcscntntivo Meeting nt 
Canlifl 'in OuU". A papor will bo given bw Jfr. !'• I'- louden 
on =01110 obsorvftlionn on rennl tnbcrcnlosis. l)inncr will be served 
in tlid DiirlinWoii Hotel nt 7.30 p.ni.; members who intend to bo 
present sbonlS notify 0r. JInekintosIi so that (idequnto provision 
may be made. 

ToRKSiiint: Ukanoi; Mewshurv Divisios.— Tlio aiimml meeting 
of tlio ncv.stravv Division will be held nt the Dewsbury Inrumary 
to-day (Friday, May 4tb), at 8.15 p.iii. 


YoBKSimii: ISnAxai ; Sheitiixh Division.— Hie amiiial mccliiig of 
the ShcBicU Division will be held nt the Cliiirch House, St. Janies 
Street Sheirield, on Weebicsdny, May- 16th, at 8.30 p.in. Agenda: 
Itcporl of Executive Coininiltee ; election of oniecvs tor the ensuing 


year. 

YoRKsmiiE Braxcit : WAKEricnn, l’oN-ri:rnACT, AXn CASixEronii 
Divisiox.— The annual meeting of the tVakrlield, ronlcfrncl. and 
CasUefoni ■ Division will be held at the StmtToril Arms Hotel, 
Wakefield, on Jlav lOlli, preceded by a supper at 7.45 Ii.m. Dr. 
k. JIanknell (Bradford) will give an address on the Brilisli Medical 
Asociatioii and its work for the general prartilioiier. 


Yosksiiire BitAScn : York Divisiok.— The aiiniial general meeting 
of the Y'ork Division' will be held to-day (.Saturday, May 5lb>, at 
830 p.m., in the York Jfedical Society’s Room, 17, Slonegate. 
Agenda: Itcporl of honorary secretary for 1927; election of oflirers 
and committee for ensuing year; reports on eases of vanrose iilcera- 
tioii; fees for ambulance lectures; comniiiiiic.rlioii from West Riding 
Local Medic.al and Panel Committees regarding the proposed eslali- 
\khmcni of a medical msUtutc in Leeds; the •* Ideal Benefit 
Society reports by medical practitioners at request of coroners; 
York 'Civic and Health Week — appointment of sidicommittee by 
'Executive Comniillec; fees for medical service lo non-insured 
persons. 


iitretings of llrimclifs nni> Oiinoions. 

BIKMl^*G^AM Br.AKat ; Xuntuton* an*d TAMworTii Divimox, 

A iiEETrxG of tlio Xuncntoii timl T.imwoflh Division held at 
Ximoatou General Hospital on April 
Dr. C. F, Rudd read a paper on oedema of the cyelid«. Ho 
emphasized the preat importance of early oxiiniination of tlie ovo 
itself, and for thh purp^, ho said, retractors might often be 
necc^ty, and in young infants even a general annesilietic. Dr. 
Ruad classified Ihc oedemas as follow^: (1) inflammatory and non* 
inflammatory cases in yhicli the conjunctiva and ovohall were 
nomal; (2) cases in which there were changes in ihe*conjunrtiva 
Q ejnjbau. in the innammatorv group he placed adjacent sep^^i*?, 
rdeolum externum, hordeolum internum, acute dacrocvstUi’'. peri* 
jtis of orbital margin, acute inflammation of lacrvmal gland, 

■ sipelas, herpes zoster ophlhahnicus, and acute eczema. In the 
Q-inflammalorr, group he referred to general oedemas, as in hcati 
ease and nephritis, and to angioneurotic oedema. In group (21 
included acute inflammation of the conjunctiva, aiiv acute 
laramation in the interior of the eyeball, acute glaucoma, acute 
as and widoo-cblis, parophthahnih's oihilal cellulitis, tenonitis, 
3 thrombosis of cavernous sinus. He described two i*arc cases, one 
between the carotid artciy and the cavernous sinus, 
one of chemosis of the lower half of the conjunctiva onlv, 
iiT Die rnaxiliar\' antrum and possibly due 

M plexus. Dr. Rudd dealt verj- prac* 

Aj • ^ diagncKis, and especially the difTercntial diagnosis, 

nf ^ njcntioncd, and gave many helpful liiuts on trcal- 

■RiifTfi followed, in wbicb many memhevs looh part. 

•nrftnEi n replied, on the motion of (he CiiAinaiAK lie was 

per. vote of thanks for. iiis very useful and practical 

v/rillcn, with reference 
oners PT^^DDoners at rcijuest of coioiicrs, to throe 

it verv^fiin !»• districts were in the Division ai-ca, and 

e received from them all. 

incils on n.A ^ secretaries to write to the county 

Dr \y Triwcrtn the draft Ictlor'issued bv headquarters. 

-'d Dr.l Chalw.e,. 

fiicarServ^^ wn= . 1 ™“ of the London Public 

hvin-’ and after full discuision Ihc 

RMo resolution was passed with one dissentient ; 

in sjnipatln-''wit/i Tamwnrlh Division is entirely 

the Public ‘Medir?.! Pnssed by the annual meeting dl 

desires its rcprtSnlatlve 'to i "" ZSth last, and 

eapitalion fee for nubtVe'^'n.^a- npR’nst the acceptance of any 
>« jiiyenilM or adnlf? whieh' "’nd'vine, eitbei 
I. ^ uus, ViUieii lb icjjjj than 13 * 4 . por annum. 

ednesday,^juf^l8th iiunual meeting at Nuneaton on 


socTiT ^'kst Hasts Bbasch : 'West Dorset Divisiosr. 

h, when^'^lj^yft, siitv'^m'^'^i' Division was held on Ap: 

■■kv gatlicrcd at Corfn ^"'(’ 1 ''’^ friends were present. T 

'd a most interesting Drui 

leewards a tour of ifn history and arcliitectur 

'■lor cottaees in the y-in"" "'‘V *'’«’>= of ‘■'>0 ° 

■^0 the pa?tT nLe£d ^1''"®®- of Corfo yvero pointed out, ai 

•!■‘.^•r; the ?e^erilve ^-Iward 11 

dares. Te.i was ornvido?\“^®T?'”''' “.f As history and sped 
■adhall, whidi b *’3-;Pr. and Mrs. Dm Drury at t 

>bicli had been kindly lent by • Mr. Cavend^ 


Bciiliiick, one of tlio governors of the Middlesex Hospital. Ho 
also had throyvn opcii 'hi.s extensivn gardens, and the parly was 
thus aide to take a pleasant stroll after tea. Later a move was 
made lo Clitircli Knowlo, two miles away, yvhen the rector, tho 
Rev. JI. L. Rpssell, described tlic Early English church. Finally 
Harnstoiio was visited | this manor house, containinp a mixture, 
of thiricciilh century aiiH Tudor architecture, was kindly opened 
for inspection by tho lenant, Air. Cooper. Very cor()iu} votes of 
thanks were accorded, at tho suggestion of tlie chairman. Dr. 
Rees, to all wlio liad assisted lo make the meeting so successful, 
and especially to Dr. and Mrs. Dm Drury.' 


MtrmoroLiTA.v Cou.vties Bra.vcii ; Lew-ishaji Division. 

A jiEETiNfi of the Lew'isham Division was held on .April 17tli at the 
Town Hall, Calford, S.E., with Dr. W. E. HAbLi-SAX in .the chair, 
when Dr. William Golusmitii gave .-in addre.ss on tho diagnosis 
and trcalniciit of pruritic skin conditions. 

Dr. Goldsmith defined three groups ; tliose due to external irri- 
tants, those accompanied hy eruptions, and the primary or cs-sen- 
tiai. Ecabiei was. tbc mos't coiiiinoii dermatosis; its distribution 
made diagnosis easy, and Ircatmeiil w-itli sulphur ointment, 
1 drachm lo the ounce, for three or four days was 11 rertain cure. 
Siilpliiir iiiiisl not be used longer or dermatitis followed. Urticaria 
was an idiosyncrasy, similar to serum rash and anaphylaxis; it 
yvas treated hy adrenaline or pilocarpine. Parathyroid extract and 
calcium yverc iiscfiil, also injecUons of pilnilrin. yvhilc externally 
carbolic lolioii and calamine yyere recommended, yvith avoidance 
of baths and changes of temperature. Papular nrticaria of 
oiiildreii might persist till the age of 12; impetigo oticn followed. 
I-> 2 enia yyas a specialized reaction: external causes were more 
iiiiporlaiit than the iiilenial, and Iranina, rough clothing, improper 
drying, and yriiid werc cited. In the treatment of early stages 1 por 
cent, resorcin in water was used first, then lead lotion, followed 
liy cnhiniiiie when the exudate was lessened, and zinc and iclithyo! 
paste. ,V rays were beneficial in persistent cases. Eczema of 
nippits was frequently an aftcr-cticet of scabies. In the axilla 
it yvas due lo hypcridrosis. A lotion of spirit and tannic acid 
was used, and x rara yvould reduce the sweat glands. Primary 
facial ccicnia of infants occurred more often in males and the 
first-born: they were often r.ivcnous feeders, and might fac Iirca-st- 
teil nr Iiottlc-fcd. The condition was often Associated with asllinia. 
Scratching mu.sl he prevented. .\ mask of white lint yva-s used, 
smeared with 3 per cent, coal tar anil zinc jiaste. The skin should 
he cleaned yvith liquid parafiin. 

Di-s. Brackex, Beattie, H. Evaxs, and Bal’xocxah joined in the 
discussion, and Dr. Buciiax proposed a vote of thanks to the 
lecturer. 


METRorOLiTAK CoEXTiES Bra.vcji : Westmixster a.vu Holeorn 

Divisiox. 

Tur. annual general meeting of the Wcslminslev and. Holbovn 
Division was held on Apnl 28tb nt the bottling work.s of tlic 
United Dairies at Scrubbs Lane, Willcsden. The directors of the 
United Dairies had venr kindly invited ineinbei-s and their. friends 
to a short lectuve by Mr. P. B. TusriXi and to an inspection of 
their methods of receiving, pasteurizing, and bottling milk. Tea 
yvas aftonvards provided, and the annual general meeting folloyvcd 
imincdiatolv, at yvhicli the following olficers were cTeclcd for 
1928-29 ; ' 

C/inirmaii. Mr. Cecil Rowiitrec. Vlce-Cliairinan. Mr. D. C. L. Fllzwilliams 
Uuiivratt) Secrclari/ nii(l Treo'.iirrr, Dr. Cedric Hilliard. Rerirr- 
..rntittirrA in the ItriirrArntatirr Jlndy, Dr, K. R. Hav, O.B.E.,'Dr- P. 
llowaid IliimpliTi'i, and Dr, G. E. Ormc. 

This yvas the most successful meeting of the year, and everyone 
yvas interested and pleased yvith tho modern methods used in this 
ihc largest bottling works in tlio world. Tiianks -were accorded to 
Mr. Ben Davies, the managing director, and lo Mr. Tustin tor 
their excellent arrangements and for providing transport- to and 
from the yvorks. - 


Metropolitax Cousties Braxcu : Willesdex Divisiok. 

A CLIXICAL meeting of the IViIlcsden Division was held on April 
18th at tlie AYillcsden General Hospital, when Dr. Bright 
Banister spoke on ante-natal work. 

He yvas strongly of the opinion that ante-natal yvork should be 
tlie province of the medical profession, and sliouhl be undertaken 
by them and not by Hie local municipal officei-s of health or bv 
the midwTves. In a large dislrict there must be some central 
authority for purposes of organization, but other than this the 
work should be done Ira the general practitioner. Tlie cumculum 
for midwives was insuITicient lo quality them, and (lie- local officer 
was not in a position lo cultivate, between doctor and patient the 
personal touch essential to the success of ante-natal work. It’ was 
most important that the doctor should appreciate the problems of 
llie niollicr, and should be her friendly adviser; supervision of the 
general Iicallli was of prime importance, and should involve an 
inclusive medical examination of the patient. Unless there worl' 
definite indications a vaginal examination should not be performed 
during the first half of pregnancy, but should be a routine ahn.,f 
the Uiirty-fourth week. The urine si— 1 -- about 

occasions during the firet • part, and ■ 

pai'l, of pregnancy. The blood pressi 

was not raised as a rule during pregnancy and n. x.i‘ ^5 

pressure above 140 mm. Hg was“not normal ’in a-nreSant yv 
The progress of the child should he watched- SugmSilve^n 
of twins was a uterus higher than normal at mfd^Vwo “I™®® 
early slight oedenia of the legs. A siiiaU patient Sltn Lad rsmall 



MAY 5, -lt)3sl 


Naval arid Military Appointmonts. 


r nvr'rLFiir.ar 70 rnr. 

irr.lTISH MyMCAI* 


■Vtsoointion is lo lie .wild will luit net in 

CTiifonnitv willi its ox|)ri's.sctl vidws, or liy llie nclioiis of 
doctors wlio do not oven liclonp lo llio iVs.socia(ioii or any oilier 
iiH'dical sooicty. . - ,, 

It is useless for Dr. Dain lo say lliat tliu iiroposed foe syoulil 
not in anv iT.spocl. form a .slaiidaril for llio foe lo lie jiaiil in 
national liealtli insnranco.- U’e may not rcRard it as suoli, Irat 
the Minister and the approved soeielics will make it .sncli. 
And Dr. Bone’s argument that the proj.'oseil 6s. 6(1. js ns pood 
. as the insurance 9s., l«y reason of the freedom from cerltHca- 
lion. records, etc., is simply hegging the ipiestion. It as.snmos 
tlmt the profe.ssion is sal'isficd with the 9s. capitation fee, 
whereas, as Dr. Bone knows very well, it never has heen 
satisfied with it or allowed that it constitutes a imiper p.aynient 
for the work done, and only nceepted it under what one may 
term lorrr maji'urr. The action of the Conneil and the Insurance 
Acts Committee in this matter .seems lo me to he the most 
retrograde step that has hcen taken for a long time, and tends 
lo cut from under our feet all ground for future hnrgaiiiiiig 
svith either the Jlinisler or the approved .societies. It is lo 
be hoped that the snhjecl will form matter for discn.ssion at 
tile Hepresentative Meeting, and perhaps also at the Annual 
Conference of Local Medical and I’anel Commiltee.s ; altliongh, 
whatever he the re.snit of such discu.saion, 1 fear that the real 
mischief has already hcen done. — I am, etc., 

Hull, April Ettli. Jos. NtLSON. 


nnb ittiHlarn ^ppointiucnfs. 

ROVAL naval JtnHCAI, SERVICE. 

Sorgism, Command, r F. J. Counns to Hie rfelorii; O. F. Sims to the 
Flora ;E. h, Alarktiam, O.R.E., to tlic Coii,;i,e,t c. V. to tin* 

Kuril Iff, 

Snrpcnn IJcuh'nanls Tl. A. Crafl to the Ilirintii(jhn}ii ; J. Ilnmitton lo 
Chatham: C. 11, Nu'hoUon to the 

, noy\L Xtva VoLi'.vrrrn Ilnsrn*,r. 

D* I.ictilenant Commamler. 

hujTwn Lleutfnnnl n, n. n. Rolwyrti. lo the Cuiirn,feoi„. 

T ?' ha\o cnierfvl n« proliationorv SiirKcon 

Pml 2 Of the IxmOoii I>|^ .-ion. 

In wl MoV "7” "*• ts ronfirmeU 

in uis rank, uiih 8CDlor»t\ o! March IStli, 1377. 


ROYAL ARMY .MEtllCAI, CORPS. 

Captains J.r.W.M«nan and C. J. HeCorty, M.C., to be Majors (prov.). 

nir FORCE MEDICAL SERVICE. 

Witt. ctRci aSa’nJi^m' 6th 'mS'’' 'll i'° '-'.T f-.entenant, 

1S27 (substituted lor notillcat nn 'm’o r InanurT 6th, 
1928). ” nouncation in the (inzfttf of .Jnmmry 10th, 

fo^th^^'yeaM^iI^KcTivo commisf<ion hk n Kh me omcor 

starch 2Eth. 1928 a?d ia ^miJi V n niorily of 

Mmotinl Hospimi, Ewbour^^ ” ^ Princess Alice 

Flight Lieut'enS L cJl Otoiots ; Mmieai, .naixeii. 

Fore?. Came ceases to Iw employe, 1 with the Regular Air 

re„. , .. JIEDICAL SERVICE. 

O.n.ETLieut.-Monel Il^'a SUng^r l'” J. K. S. Fleming. 

Health, Delhi, is anpoiniedto nlT,5?I(^ ‘ llp’ Director ol Public 

-'ledieal Services. ‘ »nicinle as Deputy Director-General. Indian 

is coUrmed'a^' ASi^n^ D?recbj“‘^ Centra? f'search Department, 

with effect Irom April ath.lgS ' Research Institute, Kas.auli, 

Re^amh^und'ASS^i.atfc-'’'?-"--". 'vri'c^ tinder the Indian 

The serrices of Maior ilional irsoarclie?. 

*>"partmcnt, are placed ' 5Ie<l:cal Resi'arcli 

01 Bombay to undeitake a malaria Kurvoc- n i Government 

The 6or\-iccs ot Major J R n \\vi v. n -n city. 

‘he dl^po^al of the ChiVf fS™,!,— ’ ^ placed tcmporarilv at 

fJRciating Assistant Dirw^or apronitment as 

Public Ilcaltli, Delhi, vice Licut. -Colonel 

''P"' 3rd, 1925; 

h?.ithornlhuaile,"w|th'.'Jnife[’ wniority Septemhor Dt, 1924; R, A. 

''ith seniority x’ovcmbor 21^^926 ' -''«“ndcr, 

REGln-.AR ARMV RF.Sr.RVE OF OFFICERS. 

File tollowin- ofUcarf'^T''' ^Irnicn, Cor.rs. 

rrase 'to I.einnh 'to *'“> limit of liability to 

■ ^ 3. -A. Ilowtey and^.A. F. Carlyon"'^™ Officers: I.ieut.-Colonels 

■ territorial ARMY. 

v'^ifiain AY hcslie ‘'J'’'"'. Mimen. Cor.rs. 

1927. ’ ■ 3'?ior, with picccdence as from 

3. A. Kerr to be Lieure'nant •» tbe eslablisbment. 

TERRITORIAL .VRAtv RESERVE OP OFFICERS. 

■ Cipt.a,n G. F. ShepliMd Conrs. 

“cpherd, from tlio Active List, to be Captain. 


COLONIAL MEDICAL SERVICES. . ' ' 

l>r. K. J. Clark, .V.r., appointed M»'«Wcal Officer of Ifcalth, Sanifnfion 
nrntich. Medical nciurtineiit, Gold Conut. Pr. P. P. Marker appoinle<l 
Mt^fHcnl Officer, Wcht African Medical Staff GSIcrra Pconc). Pi-?<. J. Cauchi 
nnil A. proimdiMl Senior Sanitation (HUccr ntul M(‘<lical Officer 

of ilcalth, Nlffcriii, rcapcctivcly. l>r. V. E. IVIiilmnn appointed Medical 
Officer «( IleaKli, Sanitation 'flrancii, .Me<lical Pcjiartmenty Gold Coa.-t. 
I)r. W, MflK^iwiin appointed Afcdic.al n/licer, iMcflical Pcfiartmcnl, GoM 
Coast. 

VACANCIES. 

Acton RoKorcii Ehitation Committh:.— S chool Pcntal Snrpcon. Salary 
1500 per annum, rl«inp to IMO. 

Ano.v Hospital, Gunnerf'luiry hano, 1V.3.— Male Re«idcnf Medical Officer. 
Salary 1150 per nnmim. 

lUH.S.-LKY AND WlKEFinn JOI.NT SlN'WOIUUM CO.MMITTRE.— Ai>«i‘'tartt Tuifcr* 
ciilonfs Officer and Resident Jledical Officer. Salary £450 per annum, 
risliiff lo £COO. 

Ifr.DroRi) IXOROUGii.— Jfctlical Officer of Health. Salary £900 per annum, 
rii^in)' to £1,100. 

IlixrisT. Qi:r.rx‘.s Usivf.n.^m*.— Profcsior of rntholo^ty. Salary £900 with 
Kuppicment ami pension. 

IXlRKEN'iir-il) Union. — T wo Rr-iiicnt .IssiAtant Jlcdicnl Oflicerf'. Salary* £200 
per Aitttiim, riHimr to £300, 

IlOLiNCRROKR lIo-spiTiL, Waiiilsworlli Common, S.W.ll. — Honorary Phjsician. 
Ifni.sTOl. UNi'Tiif I)omon!<lr.ator in I’atholo^jy (part-time). 

Cllfi^Tru Rov\L IsriRMUtv.— House-Surgeon (male). Salary £150 per 
Annum. 

CiiMBnRi.»Nn 4Ni> lVrj?TMORHNn Mental HcKrinL, Carli-lc.— 3fcflicnl Super- 
intendent. Solar\ £850 per annum, risin" to £1,000. 

PtHLiNGTO.N Gi:\miL no.‘‘PJHL. — Sciiiot Honsc-Sur^fcon (male). £150 i>cr 
annum. 

Pr.voN J!r.NHL HO'PiTa, E.xlnin^tc^, near Exeter. — Junior Aj'jjii'tant Jfcdical 
Oflicer (male, iinniarricil). Salary £300 per annum, risirif; to £250. 
PcnitiM (’oirxTV Council.— A r-i-tant Welfare McdicaJ Officer (woman). 

Salary £600 per annum, rlsinp to £650. 

E.vi.ti:r : Roya Pf.von »nii E.xirrrn lin.^riuL.—AMifetunt Hcmfc-Siirfrcon 
(niaie). S.ahiry at tfie rate of £100 per annum. 

Fiji GovrRNMrNT.— District Medical Officer. Salary £590 per annum, 
rixiog to £725. 

HiMi'STmi) GiiNruiL <nii Nortk-West LpNDON Ho.spiTa, H.avcr>fock Hill, 
K.W.3,— Siirpeon to Out-pat leniJ!. 

lIoso-Ko.NG V.MVFRMTy.— I’rofetsur of riiysiolo^y. Salary £800 a year, 
ri^iii" lo £1,000. 

Hoi-PiTtL OP St. John tNn St. Etiztnmi. Grove End Roail, N.W.8.— Resident 
llouyc-l‘)iy*‘ician (male). Salary at the rate of £100 per annum. 

King Euumrd VH Wfl-h XtnONtL .Mnionra AF.'oatTioN.— Two Resident 
Medical Officer?* at tlic Ginn Ely Hospital. Salaries £350 and £200 per 
annum mpcclivcly. 

Lflds Cm*.— Awistant Metllcal Officer for 3ratcrnity and Child Welfare. 
Salary 1600 per annum, 

LtED.s *ruBL!C Dlsrr.NSiRy.— (1) Honorary Physician. (2) • Honorary 
Sur^n. (3) Junior Resident 3Icdical Officer; salary ilM per annum. 
I.mvisH.iy Ror.orcii Counciu— AM istani Sleclicnl Officer of Heallli and 
Jfalcrnily and Child Welfare Mcilical Officer (male) Salary at the' rate 
of per annum, rising to £750. 

EivERrooL iND District Hoyma for Disutfcs or the llEmr.— Rosoarch 
Fellowship. Value tl50 per annum. 

London Jr.^isir Hospitil, Stepney Green, E.L— Resident Medical Officer 
uml Junior Resident Mc<Iical Officer. Salaries at the rate of £150 and 
£100 per annum ri>poetiveh. 

London skin H05PiTa, Fiirroy Square, MM.— Honorary Physician or 
Surjccon, and Surgical Registrar. 

Jlusciir-STER ; A.srom Hospito.— H ou«>-Phy8ician. Salary at the rate of 
£100 per annum. 

Mixcoiirne : Childre.n’s HosriT.a.— Sledical Sunerintendent of Orthopaedic 
Section. Salary £1,000 per annum with emoluments, or £1,250 without 
Xirw Ze\hn» Government.— S enior Assi.stant Medical Officere fmale) in 
the .Mental lIo.«pitals Department. Salary, single men £765, married 
men I'SOO. 

Xor.TncRN IREH.ND.— Medical Referee under the National Ifealth In^tnmnV^ 
Scheme. Salary £t00 a year, rising' to £900, together w’ith bonus 

'J"-*'" Avenue, 
i:-^-r6.v.idan m cbarge 

ROTHtRiiju Hospn^L-Ilouee-Physician (mule). Salnrv £1B0 per anhuni 

ophthalmic Siirgeom 

ROYII. .NoitTnp:.v lIo,sm,h, Holloway, N.7.-Houso-SurRcon. Salary at the 
rate of £/0 per annum. ^ ^ 

Sr. .Ainixs rsD JIid-Herts Hojm.a txD DisraxsiRv —Male ij.».ia„ . 

Jleihcal Omccr. Salary £150 per annum, rising io £200. ' Resident 
St. Johx s IIosPiTiL, Lewisham, S.E.13. — Honorary Anaesthetist. 

SllEFrlllD Royil Ilo-SPITU..— Assistant Pliysiologist. 'Salary £400 per annum 
South oiPTO.v ; Rov.a South Hixts txD South.impio.v Hospital —H oused 
Physician (raak-). Salary £130 per annum. irouse- 

Stockton and Thornabv Hospital. Stockton-on-Tces.— Junior 
Alcdicai Officer (male). Salary £T50. Resident 

Stoke Newt.ngton Ronocoii- Colxcil.— M edical Officer of Health Wsm. 
at the rate ol £700 per annum, rising to £800. Rcai'h. balary 

StoKnox.TRE.NT: North STiproRDsiiiRE Royal I.Nnn3iARY.-(I) Assi.t,„f 

Uouse-Physician; salary fl2o per annum. (2) Honorary .AnaesH eHs? 
®ed”rs”wg?om'*‘ «»"'»■«)■ -Uristant Orth^: 

Walsall County Ronoucii.— Assistant Medical Officer fMatornifv m •, , 
Welfare) (female). Salary £600 per annum, rising^to £7M ' Child 

Walsall General Hospital— S enior House-Surgeon. Salarv AOnn ' 
annum. per 

M’aterloo and District General Hospital, Waterloo near i „ . 

Resilient House-Surgeon. Salary £50 per annum. tLl'Pipool. — 

West Ham Couvn- Borough.— .Assistant Resident 3fedi,.'.i on- 
Dagenham Sanatorium. Salary at the rate of £250 D'^''?nn “I 

3ViitESDp_N Parish.— R esident First Assistant Jlcdieal , . 

- Park -Royal Hospital, Aeton Lane; Salarv £430 ris'ing'ttf^Tain^'"'' 
Woolwich and District AVar SIejioriil Ho'spital ■ 

House-Surgeon. Honorarium £120 per annum Mill, S.E.IB.— 


204 May 5, 1923J 


Assoa'aT on /nte/ifgenco and D/ary. 


r FUPrLT:^Tr.>rr to • 

Lnr.r 


Jocitwr. 


■WoncrsTER GEXFUMi iNKiRAtvRY.— Senior nnd .Tunior Resident Medical 
OfFiccrs. Salaries X180 and X120 per annum respectively. 

Clrtipvjng Factory Surgeons. — The fallov;in«r vacant appointments are 
announced : Brndfurd-on-Avon (W’lUshire), St. Marjratet'a Hope 

(Orkney), Slough (Buckinglmmshiic), Buckhaven (Fifeshire). Applica- 
tions to the Chief Inspector of Factories, Home OfTice, WljjteljalJ, 

S.W.l. 

77iis list of vacancies is compiled from our adrerthement columns, 
where full particulars tcill be found. To ensure notice in this 
column advertisements must he received not later than the first 
post on 'I'xicsday morning. 


APPOINTMENTS. 

Fellows, F. M., M.B., C.M., F.R.C.S.Ed., District Medical OfTiccr and 
Public Vaccinator for the Poynton, etc., District of the Macclesfield 
Union. 

Fowler, W. M., M.B., Ch.B., Medical Referee for the Lochnber District 
(Sheriffdom of Inverness, Elgin, and Nairn), vice A. C. Miller, M.D., 
deceased. 

McGibbon, John E. G.,' M.B., B.S.Lond., D.L.O., Honorary Assistant 
Laryngologist and Aurist, Royal Southern Hospital, Liverpool. 


DIARY OF SOCIETIES AND LECTURES. 

Rov\l Society op JIedicine. 

Social Evening.— ■Q.ZO p.m., Reception by- the President and Laclv 
Berry. 9.15 p.m., Illustrated Address by Jlr. P. B. Tustin : Milk— from 
Cow to Consumer. A number of exhibits, lent by the lecturer, will be 
on view. Music and light refreshments. 

n.. Annual Gcnor.al Meeting. 

‘ ‘ ’ 1.. Annual 

■ * Carcinoma 

' de Courev 

(Surgery), Dr, J3raham J Ciithbert 


Section of 
.Section 0, 
General 
of the 
Wheeler 


Dukes (Pathology). Mr. Ernest Miles will al.^o speak. 

Section of eurofog}/.— Thuvs., 8.30 p.m., Annual General Meeting 

followed by Pathological Meeting. 

Clinical Section. — FiL, 5 p.m., Cases. 

.Section of Balneology.— S slU and Sun., Annual Provincial Meeting at Bath. 

H^rvehn Society, Paddington Infirmary,- Harrow Road, W.— Tluirs 
4.30 p m.. Clinical Meeting. * '* 

^^EST Kent MEDico-CHinuncica Society, Miller General Hospital, Green- 
wich Road, S.E.IO. — Fri., 8.45 p.m.. President’s Address. 

POST-GUADUATE COURSES AND LECTURES. 
FELLou’sriiP OP Medicine and Post-Gradlmte Medical Assocktion.— Mon , 
May 7th, to Sat., May 12th, Cancer Hospital, Fulham Rond, S.\V.3*: 
Tuos., 2 p.m., Operations and Demonstrations; no fee. Hospital for 
Stek Children, Great Ormond Street, "W.C.! : Tues., 2.30 p.m.. Ward 
Round, no fee. Royal London Ophthalwic Hospital, Citv Road, E.C.i : 
Wed., 12 noon, Demonstration; no fee. Central London Throat, x'ose 
and Ear Hospital, Gray’s Inn Road, W.C.l : Intensive Course (Clinical), 
Operative Surgery Class. ilfati<Mc,i/ Hospital, Denmark Hill, S.E.5 : 
Special Post-graduate Course in P^ycho^ogical Medicine, afternoons only; 

loo £5 6s.; continuing for four weeks. Centra' ' ’ 

pitnt, Judd Street, tl'.C.l : Aftor-courso in 
Lecture Demonstrations and Operations p 

Hospital, Vincent Square, S.Sv.l ; Afternoon Course. London Sehoo} of 
Tropical Medicine, End&leigU Gardens, W.C.l : Tues. and Tluir.H., 2 p.m., 
Lecture Demonstrations. Royal Free Hospital, Gray’s Inn Road, W.C.l : 
Wed., A15 p.m., last Lecture Demonstration in Sorfes in Electrotherapy. 
St. .John’s Hospital, Leicester Square, W.C.l : Special Course (Clinical), 
and Series of Lectures throughout the month ; PntJiclogy Course can be 
ananged if desired. Copies of all svllabuscs sent on application, also 
details of geneial course of work.* Apply Sccietary, Fellowship of 
Jledicinc, 1, Wimpole Street, IV.l. 

Delgrave IIospmL for Childrf.n, 1, Clapham Road, S.W.9. — Wed., 
4.30 p.m., Clinical Meeting. 

London School of Derm.^tology, St. John’s Hospital, Leicester Square, 
W.U.2. — Mon., 5 p.m., Drug Eruptions. Tues., 5 p.m.. Alopecia Areata 
and Vitiligo. Thuw., 5 - p.m.,- Mycosis Fungoides. Fri., 5 p.m., Skin 
Diseases due to Protein Sensitization, 

_North-Eist London PosT-GR.\DuiTE College, Prince of Wales’s General 
'Hospital, Tottenham, N.15. — Mon., 2.30 p.m., Demonstration of Surgical 
• Cases; 2.30 to 5 p.m., Medical, Surgical, and Gynaecological Clinics; 
Operations. Tues., 2,30 to 5 p.m.. Medical, Surgical, Throat, Nose, and 
Ear Clinics; Operations. Wed., 2.30 to 5 p.m., Medical, Skin', and -Eve 
Clinics; Operations. Thurs., 11.30 a.m., Dental Clinics; 2.30 to 5 p.m., 
Medical, Surgical, and Ear, Nose, and Throat Clinics; Operations. 
Fri., 10.30 a.m.. Throat, Nose, and Ear Clinic's; 2.30 p.m., Demonsfrafion 
of Medical Cases: 2.30 to 5 p.m., Surgical, Medical, and Childtcil’s 
Discuses Clinics; Operations, 

Roy.il Northern Hospital, Holloway Road, N.7.— Tues., 3.15 p.m,. Treatment 
of Acute Suppuration. 

Wf.st London Hospital Post-Graduate College, Hammersmith, W. — Mon., 
10 a.m. to 1 p.m., Genito-urinary Operations, Surgical Wards, Skin 
• Department; 2 p.‘m. to 5 p.m.. Eye and Gynaecological Departments. 
Tues., 10 a.m. to 1 p.m., Medical Wards, Demonstration of Venereal 
Diseases. Electrical and Dental Departments; 2 p.m. to 5 p.m., Gynaeco- 
logical Operations, Throat, Nose, and Ear Department. Wed., 10 a.m. 
to 1 p.m.. Children’s Medical Department, Medical Wards, Patho- 
logical Demonstration ; 2 p.m. to 5 p.m.. Eye Department, Surgical 
Wards. Thurs., 10 a.m. to 1 p.m., Neuiological and Massage Depart- 
ments; 2 p.m. to 5 p.m.. Eye and Genito-urinary Departments. Fri., 
10 a.m. to 1 p.m.. Skin, Dental, and Electrical Departments, Medical 
Wards, Clinical Demonstration; 2 p.m. to 5 p.m.. Throat, Nose, and 
Ear Department. Sat.. 9 a.m. to 1 p.m., Medical "Wards, Throat, Nose, 
and Ear Operations, Jfedical Children’s Department, Bacterial Therapy 
Department. Daily at 2 p.m.. Operations. Medical and Surgical Out- 
patient Departments. Special Lectures, Tuesdays, May 8fli and 11th, at 
4.30 p.m.; Gastric and Duodenal Ulceration. ^ 

Guiscou* Post-Graduate Medical Assoct.atiox.— At Royal Infirmary; IVed., 
4.15 p.m.', Medical Cases. 

Liverpool University Clinical School Antf.-Natal Clinics. — Roval 
Infinuarv ; Mon. and Thurs., 10.30^ o.m. Jlatcrnity Hospital : Mon., 
Tues., Wed., Thurs., and Fri., 11.30 a.m. (Fee £2 2s. for three months* 
attendance.) 

Manchester Royal iKHRitARV. — Tues., 4.15 p.m., Constipation. Fri., 
4.15 p.ni., Demonstration of Surgical Cases. 


IQrilislj ^cbiral Association. 

OFFICES,' BRITISH MEDICAL ASSOCLITIOS HOUSE, 
TAVISTOCK SQUARE, W.C.l. 


Fri. 

Sat. 


6 Sun. 


Departments. ‘ 

SuBSCuiPTio.NS AND Advf.rtise-Ments (Financial Secretary and Buslnesi 
Manager, Tclrgrams : Articulate Wcstcent, London) 

Medical' Secrctary (Tclegrainj: Medisecra "Westcent, London). 

Editor, British Medical Journal (Telegrams: Aitiologv Weslccnt, 
London). 

Telephone, niiinbers of lirilish’Medicnl Association and British Medical 
Journal, Museum £851, 9862, 9863, and 9864 (internal cxchang* 
four lines) 

Scottish Mf.digal Rfcretary : 6, Drumslieugh Gardens. Edinburgh. (Tele- 
grams; Associate, Edinburgh. TeJ. ; 24361 Edinburgh.) 

Irish Medical Sfa^retarv : 16, South Frederick Street, Dublin. (Tele- 
grams : Bacillus, Dublin. Tel. ; 4737 Dublin.) ’ 

Clary of tho Assocfatlon. 

May. 

London : Consulting Pathologists Group Commiltof'. 2.30 p.m. 
West Suffolk Division : West Suffolk General Hospital. Mr. 
■ T. H. ilust on Acute Infiammatory Condition.^ of the Ear, 
8.45 p.in. 

York Division ; Annual Meeting, York Me<lical Society's Room, 
17, Stonegate, 8.50 p.m. 

Mid'Cheshirc Division : General Hospilal. Altrincham. Ur. 
. Capon on Intracranial Birth Injuries, 3.45 p.m. 

8 Tties. Bourncmoutli Division ; Annual Meeting, St. Peter's Small 

Hall, Bournemouth, 4.15 p.m. 

St. Pnncnis Division;. Annual Meeting, B.M.A. House, 
-- Tavistock * Square, W.C.l, 9 p.m. 

9 Wed. Chichester and Worthing and Horsham Divisions : Annual 

Meeting, Burlington Hot FciUlen on 

Renal Tuberculosis, 6 p.rr I.IO p.m. 

Dorset and West Hants Yeatman 

HospitaJ, Sherborne,' 3 p.m. 

Lanarkshire Division : Annual Meeting, St. Enoch Station 
Hotel, Glasgow, 3 p.Tu. ' ' ' 

Mnrvlebnne Division: II, Chandos Sfreef. Cni'cndish Square, 
W’l. Dr. Hawthorne will open a discu'ssion on Lunacy Lew 
Reform, and Mr. Me.-Vdam Eccl>*s on the General Practi- 
tioner and Paying Beds in Ilo-'pitals. 8.20 p.m. . 
South-Eastern Counlios Dliision: Annual ileeting. Railway 
Hotel, Newtown St. Boswells, 3 p.m. 

10 Tlmrs. London : Charities Committee, 2.20 p.m. 

Hampstead Diidsion : Hampstead General Ilo^pitaJ, 8.30 p.m. 
Wakofiehl,- Pontefract, and Cnstit-ford Division : Annual 
Meeting, Strafford Arms Hotel. Wakefield. Dr. A. JUcknell 
on the Britidi Medical Association and its Work for (ho 
General Practitioner. Meeting nreecded by supper, 7.45 p.m. 
London: Library Subcommittee, 2.20 p.m. . « 

ChoslerfieUl Division : Maternitv Ho‘-pital, CTicMerfield. 

' Lecture In Professor Louise Mcllroy on the Manage- 

ment of Labour, *8.15 p.m. 

Citv Division : Clinical Meeting. c, . 

Southport Division : Annual .Meeting, 52, Houghton ..tract 
Southport, 8.15 p.m. 

London ; Centra) Ethical Committee. 2.15 p.m. 

Lewisham Division: Annual Meeting, Town Hall, L.ot.orci| 

South-West &eN Division; Clnrhtiry Jfcntal Hospital, Wood- 
fold Bridge, 3.20 p.m. 

London : Hospit.al.s Committee, 2.15 pdn. _ 

Sheffield Division : Annual Meeting, Church House, St. James 
Street, Shefneld, 8.20 p.m. ^ ^ , i nr i c 

Sunderland Division ; Royal Infirmary, Sunderlan*!. Dr. J. u 
Spcncc on Hvpcilropluc Pyloric Stenosis, 8.15 p.m. 

Wille.«<len Division; Annuo) Meeting. ii 

London : Insurance Acts Formulorv buhcommittee, ll “-"J- 
London : Insurance Acts Foods and Drugs Conferonco, 2.^ P- 
l,omlon ': Nava\ nnil MiliUvv Cnmmid.n., '2 -0 p.nj. 

Jci>ev Division : General Hospital. Mr. C. H. u- ^ 

iltee, 2.30 p.m. Thnrr'i« 

Suffolk Hospital. Sir Thoma. 
rs in Fibro-^is. 8 30 p.m* 
mmittee. 12 noon. 

Corn \A all Infirmary. 


11 Fri. 


15 Tues. 


10 Wed. 


Fri. 

Sat. 


23 WdL 


24 Thurs, 


births, marriages, deaths. 

ensure insertion in the cunent issue. 


SherrarD,- 


ntllTHS. , „ , - . 

wi|'o“NoJS 

of Eton, a daughter. UARRIAOES; ^ >r . c a 

Riches-Brand.— A t All Sainls’ ciuirclj, Dnmern^ s,(jn(-v 

bv the Rev. Canon Sharrock, M.A., • p r c.S.. f-on of the late 

Barker, Eric M'illinm Riches, -f.t., - ^ 3Iarg!irrt Svlvia, younge-. 

William Riches, E^q., -\liord, -{.V inverv, Driffield, 

daugliler of Dr. A. T. Brand, •» ‘ LitUcover, Derbv, bv^ tliy 

Tuck-Ei>Mitt. — O n April 25(h. at St. r_ • »_ _ snti of 3fr. B. IL 

Rev, ” 

Tuck, 
child 

JiP ^TH ^ 

I.YSK-THOJHS.— On April Wlh. 1928, 

nliirr. Ivan, the hc'“V<'d “7," vLlVr ”, L eclin.l, Card.jan- 

of Sir John anti Lady L.vnn-Thomas, LlMjntljris, 

shire, aged 31. « i, tt«u •Rfimacrc. nar-t.ing, Amy 

Riyxer.— O n April 23rd, 1.9^8, navner, M.D.. of Preston, 

Gertrucle. the belove<l wife of Arthur Erno-t Ha>n. , 

Lancs. — 


laugliler of Dr. A. T. Brand, J-1-* ‘ . T.ftlleover, Derbv, bv the 

[OC-Elmitt.— On April 25(ii. J, jftnrv, .^I'cond sou of Mr. W. H. 

Lev, C. R. Brown, JLA., Vicar V ilfrcd m^r). ^ ^ only 

‘uck. Stoke Ferry. Littleover, Derby, 

hild of Mr. and Mrs. W. Elmitt, Lindum, Litueovf 


Printed and published by the British Medical .Issociation, at their Office. 


Parish of in tl.o County o! London 


STJ PPXjDB3]NCE5 JSTT 


TO TUB 


BRITISH MEDICAL JOURNAL. 


J.OiNlXJN, SATUllDAY, MAY 12th, 1928. 


CONTENTS. 


BRITISH MEDICAIi ASSOCIATION. 

CURRENT NOTES : 

Honx AccosisionjTiOK at nir CAi:nirr MrmNr. 

MiniiLEMonL Rri?.!:, 1929 

Pri?es roK Es'avs uy MrmrAi. pTiT'r.NTS, 1929 
ASSOCIATION NOTICES : 

Electio.t or Ita'.nrr.s or Cooxcil: Nomination's 

Table or Dates 

Br.iNai AND Division Meetings to be held 

MEETINGS OF BRANCHES AND DIVISIONS 

NOTICES OF MOTION FOR THE ANNITAE BEPRESIENTA- 

TIVE MEETING 

ASSOCIATION IKTELEIGENCE AND DIARY 


205 

205 

205 

208 

203 

209 

209 

210 
212 


SJritisIj iHfbiral ^ssocintioii. 

CURRENT NOTES. 


Hotel Accommodation at the Cardiff Meeting. 

The following is n list of flip lioU-ls in CnnlilT and distriol, 
with a stiitcmcnt of flic charges for lied and breakfast : 

d. 


Angel Hotel 

Royal Hotel 

Queen's Hotel 

Grand Hotel 

Barry’s Hotel 

Alcrandra Hotel 

Railway Hotel ... 

Great Western Holel 

Central Hotel 

Sandringham Hotel ... !!! 

«planadc Hotel, Penarth ... 
Washington Hotel, Penarth 
. _ Head Hotel, Newport 


14 

14 

14 

10 

9 

8 

8 

8 

* 7 

7 

*18 

10 

10 

10 


Bings ..u.vi, 

W cstgatc Hotel, Newport 

•Tilts charge ineludes dinner. 

Penarth is only about five miles from Cardiff and so within 
I^'ewjiort (Jlon.) is alKUit twelve inilc.s from 
tardiff, and the new arterial road coiinocling the two 
owns will ho in an advanced stage of comiiletion by July, 
icro IS also an excellent train service, the journey taking' 
ut twenty minutes. Besides' tlie above accommodation 
• number of boarding-liouscs and Iiostels are available, also 
amount of private accommodation. It rvould bo a 
sj ‘V a'aar if those intending to como to the Cardiff 
arnn,,"*^ I'onld write as soon as possible, stating the exact 
who ** . kind of accommodation required ; also those 

come, after trooking accommodation, are 
EperotoJ *'a<iaested to notify the hotels and lodging.s 
if mernf ° * 'A If would he of great assistance 

comninTi:^'''^”'' ^ state if they are coming by car. All 
slioiilrl hn' regarding the rpseiving of accommodation 
CoiDil r“* secretary of the Hotels and 

Cardiff^ -onimittee,- Dr. Abel Evans, 36, Neivport Road, 

The Arm 11 Mlddlemoro Prize, 1929. 
an itIuiD!nnt°'?°'^*^ Trizo consists of a cheque for £50 and 
If’ehard Miin and was founded by the late 

H “J'’"!’ F'R'C'S., of Birmingham, to be 
flic Connell nAi essay or work on any subject rvliich 
time to time 1 *^ British Medical Association may from 
■naclieine or surgei^*" ^ of ophthalmic 

aa award ef +i ° Gonncil is prepared to consider 

fia best pi me ia the year 1929 to the author of 

atudv of tlioL.^J'. following subject: “The clinical 

apacitics and I’O'lyi its swellings, contractions, 

referpiioe to toxic invasion; w'ith special 

^'liimitted in detached retina.” Essays 

eacretarv B M ^tition must reach the Medical 
Becemher’ Sist 1928 "r °’i 'f''"'i®tock Square, tA^.C.! by 
, f^oeli essay must be signed with a 


MoiIUal Certification In Health Insurance. A Eccliiro 
by .1. C. Lath, JI.I!., liJi.Lond 

CORUESPONDENt'E : 

Ricnr or ArratL to the Courts. By Lionel J. Picton, 

M.B., B.Ch 

Nursing IIosies Registtution Act, 1927 : Doctors’ Private 

Houses. By E. Rowland Fothergill, 5I.B 

The Bottle or JlrnicrxE. By Philip R. Kemp, M.B. 

NAVAL AND JIILITARY APPOINTSIENTS 

VACANCIF.S AND APP01NTMENT.S ... 

DIARY OF SOCIETIES AND LECTURES 

POST-GRADUATE COURSES AND LFXTURES 

BIRTHS, JIARRTAGL'S, AND DEATHS 


PAGE 

206 


210 

210 

2U 

211 

211 

212 

212 

212 


motto and accompanied by a scaled envelope, marked on 
the onlsidc with the motto, and containing the name and 
address of the autliov. In the event of no essay being of 
sufiicient merit, the prize will not be awarded in 1929. 

Prlxcs for Essays by Medical Students, 1929. 

Tlio Council of tlic British Medical Association proposes 
to award, in March, 1929, prizes of £25 each for the bc.st 
cs-says by final-year medical students on “ The symptoms 
and" .sequelae of onccplinlitis Ictliargicn, with their appro- 
priate treatment.” One prize will be given in each of the 
following groups of medical schools : 

Group 1.— St. Bnilholonicw;’s Hospital; St. Tliomas’s Hospital; 
Giia'’k no«nilal; London Hospital. 

Group 2. — University College Hospital; St. Mary’s Hospital; 
Middlesex Hospital; ‘Royal Free Hospital (London School of 
Medicine for Women); Charing Cross Hospital; Westminster 
Hospital; King’s College Hospit.Ti; St. George’s Hospit.al. 

Group 3. — Ciiiversily of Birmingham; University of Bristol; 
University of Diirliam’; University of Leeds; University of Liver- 
pool; Victoria University of Manchester; Univeisity of Sheflield; 
Welsh National School of Medicine. 

Group 4. — Universily of Aberdeen; Anderson College of Medicine; 
University of Glasgow \ ” ’ " “ege School of Medicino 

for Women; St. Miing ’ of Edinburgh; School 

of Medicine of Royal St. Andrews. 

Group 5. — Qnccn'K ' , . , Univei-sity of Dublin 

S rinily College); Nalional University of Irel.md (University 
llcgc', Cork; University College. Dublin; University College, 
Galway) ; Royal College of Surgeons in Ireland (.Schools of 
Surgery). 

Group 6. — The Medical Schools in the British Empiie outside the 
Britisli Isles. 

The prize.s will he awarded to the writers of ihe essays 
deemed by the examiners to bo the best sent in, but if no 
essay received from a group is considered by the examiners 
to be de.serving of a prize, no prize will bo awarded. The 
essays, whicli must, not exceed 5,000 words, should be clinical 
in nature, and must include cqnciso notes of three cases per- 
sonally observed by the student. Essays should he plainly 
nvitten or typed on foolscap paper (one side only), and must 
roach the Medical Secretary, British Medicaf Association 
House, Tavistock Square, London, AV.C.l, not later than 
January 12th, 1929. Each essay must he signed by a 
pseudonym only, and ho accompanied by a signed and dated 
statement tliat the essay has been the bona-fido work of tho 
competitor, and that he or she has not yet passed the final 
professional examination, together with the candidate’s 
full name, pseudonym, address, and medical school. Tho 
essays received will he adjudicated on by examiners 
appointed by tho Council from among members of tho 
Association not re.sident in the area of the group. Tho 
decision of the Council will ho filial. 

Subject for Prize. Esxay, 1950. 

The subject for an essay in a competition, on .somewhat 
similar linc.s, the prize for which will be awarded in March 
1930 (essay-s to he received, by mid-Januaiw, 1950) will bo ■ 
“Three cases illustrative of the value of a’iite-natal 
obseivation of pve.gnaut women.” Further particulai-s of 
this competition will he announoed in due course. 

[ 1243 ] 


Medicat CertiHcaiton In Health Insurance. 


r svrvLr.m:i;T to tik 
LD niTisn IIedical Jouhnai. 


206 Mat 12, 19C8] ' 


MEDICAL CERTIFICATION IN HEALTH 
INSURANCE.* 

BY 

J. 0. LYTH, M.B., B.S.Lond., 

lATB HOHOEARY SECRETARY, YORK LOCAL MEDICAL AND PANEL COMIUTTEB. 

We are all human, hut rules and regulations do not ahvays 
make allowances for human nature ; and before proceeding to 
deal with the certification rules individually, I would like to 
stress one aspect of the question which has, I think, sometimes 
been rather lost sight of. It is that medical practitioners as 
a profession are not trained to regard the issuing of medical 
certificates as their main object in life, nor even as an impor- 
tant part of it. The Hippocratic oath, which still forms the 
ideal after which every medical student is trained to strive, 
contains no mention of medical certification. Yet wo must 
recognize the fact that we have come to live in a bureaucratic 
age ; more and more our lives are governed by rules and regula- 
tions. But the practice of medicine is essentially difficult to 
tie up into parcels with red tape; all sorts of unforeseen side 
issues crop up. However good rules may be, if too rigidly 
applied they may become a tyranny. No allowance can bo made 
for times of epidemic, when every moment of a doctor’s life, 
from getting up to going to bed — and often when called out of 
bed — may be occupied with responsible and worrying work. 

It is for these reasons that I shall appeal to you, as princi- 
pally representing approved societies, to make what allowances 
you can for the trials of medical practitioners in this matter 
of medical certification. We cannot but view the question 
from different angles. You are naturally and rightly concerned 
to save your societies’ funds, or at least to see that they are 
properly expended. The doctor is not directly concerned with 
the funds of the societies ; his aim is to get his patient well 
as quickly as possible; and as a doctor lives by his practice, 
and his practice depends on the goodwill of his patients, he 
must also have regard to his patient’s point of view too. It is 
possibly these somewhat opposing points of view which have in 
the past engendered a lack of sympathy — I had almost said 
an antipathy — which it would bo useless to ignore as having 
existed between the medical profession and approved societies 
generally. I can truly say that during the fifteen years or so 
that I have been interested in medical politics it has been my 
aim to improve the relations of doctors and approved societies, 
and it is in the hope that this aim may be furthered that I am 
here to-day. 

I propose now briefly to consider some of the present certifica- 
tion rules, pointing out the difficulties which face medical practi- 
tioners, and offering some suggestions whereby, they may be 
lessened or removed by the oo-operation and goodwill of the 
approved society officials. 

Change of Doctor and Certification. 

The forms under Rule 2 shall not be used for any patient 
other than one whom the practitioner is attending as an insured 
person. This raises the question of the proper procedure to bo 
adopted when an insurance practitioner is attending an insured 
person, not on his list, in a private capacity. Cases are likely 
to crop up more frequently than formerly owing to the recently 
introduced regulation requiring a fortnight’s notice before an 
insured person can change his doctor. If ho refuses to be 
attended during the fortnight by the doctor on whose list he is, 
and requires attention from another' insurance practitioner, this 
■will have to be given privately. Whether a charge is made or 
not, if certificates have to be given. Form Med. 40 cannot be 
used. In such cases a plain private certificate, stating the 
cause of incapacity, can he, and should be, accepted by the 
approved society. I have personally on several occasions had 
such a form refused in the first instance, though after explana- 
tion it has been accepted. I suggest that it should be generally 
made known that such forms will in -these circumstances bo 
accepted. 

Several pitfalls are exposed to the feet of the unwary practi- 
tioner when giving a first certificate under Rule 3. It is to be 
given “ if desired by the insured person.” In actual practice 
I have found that here, as in many other things, it is necessary 
to usurp the place of Providence, and either provide them with 
a certificate without demand, or ask them ■whether they desire 
one; but it is not a duty. 

• A lecture (abridged) given an 'February 20th to the members of the 
Xork and District Centro of the Faculty of Insurance, 


It is in the interpretation and carrying out of the rul 
regarding second certificates and further intermediate certi 
cates that in my experience most of the friction betwc 
doctors and approved societies arises. I have found in a limit 
number of cases that there is an impression that the seco: 
certificate is required three days after the first one. Actual! 
the second certificate must be given not later than the end 
the seventh day after the first certificate. Further intermedia 
certificates are under a different rule — Rule 5 — which stat 
that if incapacity continues beyond tho eight days from t! 
first certificate further intermediate certificates shall bo givi 
by the practitioner (always if so desired by tho insured perso 
week by week during tho continuance of incapacity, and t! 
word “ week ” is specifically defined as meaning midnight i 
one Sunday to midnight on the following Sunday. I belie 
I am justified in saying that this rule really is not proper 
understood by most approved society agents. It means th 
tho length of time which may elapse between two consecuti 
intermediate certificates may be anything from seven to near 
fourteen days ; and it means that the week-dates of inte 
mediate certificates after the first one need not bear any relati( 
either to the previous one, or to the approved society pay-da 
or to tho insured person’s working week, so long as each oi 
is given on a day in tho week, Sunday to Sunday, followii 
the previous one. It is unfortunately true that in the pa 
many approved society officials have instructed insured perso: 
to ask for certificates on certain da 3 -s of the week. No sui 
demand can be justified, and 1 believe an understanding knoi 
ledge of tho rule by approved societj’ agents would do a gre: 
deal to remove the friction which still exists between ageii 
and doctors. 

Problem of Fitness for Work. 

It should bo noted that tho final certificate, given undi 
Rule 6, is tho onlj’ one which a doctor shail issue, whether ( 
not he is asked to do so. Differences of opinion between pract 
tioner and patient ns to the fitness of tho latter for work ai 
bound to exist, and you will be conversant with the necessit 
under which tho Ministry of Health found itself a yes 
or so ago to define the term " incapable of work.” Even tli 
Ministry’s circular leaves it a moot point as to exactly srhe 
the incapacity which prevents an insured person from folloivin, 
his usual employment, but does not prevent him from doin; 
any work at all, ceases to be certifiable under the rules. A 
a profession wo have always objected to this wording, am 
personally I think it would have been much better had thi 
words been ” incapable of following his or her usual emploj' 
ment,” leaving it to be decided by the regional medical officei 
when and whether, and if so what, other emploj-ment could be 
followed. 

The second part of Rule 6 provides for tho giving of a 
delaj'ed final certificate in cases where the doctor is of opinion 
that the insured person, though not fit at the time of examina- 
tion, will be fit on the second day afterwards (or third day m 
rural practice). I would suggest that if this time limit were 
extended to even four days generally it would benefit all con- 
cerned. I think it very unlikely that the funds of approved 
societies- would suffer, as I believe that in actual practice it 
would more often cut short the final week of incapacity to a fc'^ 
days than extend it by a day or two. The issuing of a fina 
certificate when an insured person has started work is, ® 
course, a breach of the regulations, and I have not very ofy"' 
though occasioually, been asked to do so. Almost inyariab y 
when that has occurred I have been informed that it is aske 
for by the society agent — with what truth I cannot alwaj's say. 


Pules that are Too Eigid. a Ha 

Tho particulars to be inserted in the certificate include ^i^ 
ates of examination and of signing, and the specific disease. , n 
irlier form of certificate made it essential that .'uch certi ca^^^^ 
lould be signed on the date of examination; 
irms allow twenty-four hours’ grace only. I suggest fha 
lie is a bad one, particularly when applied to tn 
irtificate. How frequent it is for an Insured person t 
p with a slightly septic finger, or a sore throat, or a “ ‘ ‘ ’j, 
F which may prevent him from working flint day and I ‘ 

le next, but may be better in a couple or days or so,^ ^ 
le other hand, may develop into an incapacity l“sUnS 
eek or more. As he is not fit to work ho is 
irtificate; but if he gets one the chances are that i 
ake a week of it. If we could say, ” I won t put y 
le sick list to-day, and you will probably be all rigl t 



Mat 1 


•2, msl 


A7ot//ca/ Certification in Hoaith insurance. 


r sF/’rr.njnrNT TO Tinr o/>7 
LDnitisu i 


couple or <lnv-u,” anti yet if he got no hotter ronUl Inter give 
Inm a certificate showing that ho was cxaminca ami was unfit 
for irork on the first elate, hnl signeil at the date ot the seemul 
oxamination, and the signature dated aeeordingly. who would 
l,c a penny the worse ottl I am well aware that it is jiovuMo 
to give the first certificate at once, and to insist that the 
insured jicrsoit, under Ride 10, intemital for ronvalescent 
patients, shall come up again for oxaininalion in a period Ie.s.s 
than a week if the doctor thinks fit hy filling in the apiiroiiriate 
siwce on the form instructing the patient to do so. Uut 
I certainly think that it would heiiefit everyone concerned, 
and conserve the fnmls of societies, if this rule weix> altered 
so that the dates of examination nud signing need not coineid-. 
So long as. the facts statrxl on the certificate are true, what 
car. it matter! 

;Ko\v ns to the definition of the " specific ilise.ise or I>odil\- 
or mental dis.ahlcmcnt.” Here is another of the Iione.s of con- 
tention hetween doctors and insurance agents. Non-medical 
opinion sceims to hold that in every case of illiie.ss it should he 
pcEsible for the doctor on the first e.vnminntioii to give a definite 
diagnosis, and there has certainly heeii a gixul deal of friction 
in regard to so-callcd vague wording of rerlificales. The term 
"'debility " is perhaps tlie surest word to raise a hornet's nest 
about the unfortimale doctor's ears, though I have had 
“■gastritis” qaeried, and even “ nnaeiuia,'' though it is 
probably now generally known that there are several forms <-f 
primary anaemia, of which at least one is commonly fatal. If 
yon go round the warik of any of our great hospitals and look 
at the charts of the patients, I guarantee that you will not 
find a diagnosis written up in SO per cent, of the ease.s; and 
yet these are patients who have been niider the skilled observa- 
tion of several doctors and nursir,, often for weeks. 


DIffiaillicJ’ in Dinffiiofle. 

1 am not for one moment defending the practitioner who 
deliberately mislead.^ or fail.s in his diil.v to riakc a diagnosis 
where one is possible. Rut 1 do suggest that the fKipular 
opinion that the doctor is a fool who cannot at once tell what 
13 the matter with a patient, whom he knows is not fit for 
work, is quite irrong. On the other hand, a skilled and pains 
taking eliort to find out may lake wcclci ; whereas the altitude 
wniclt I am afraid is too often adopteil hy approved .societies 
P. premium on the charlatan who calls it a “ chill on the 
liver ' (whatever that m-iy mean), and lets it go at that. Surely 
this is one of the ‘uistances where a little tiaist in the iiitegiuty 
of the medical practitioner would not he nii.splaecd. 

ihe rule that no fresh certificate shall he given without 
further examination is one which was almost hound to he made, 
^d I hold 110 brief for a practitioner wlio attempts to evade it. 
u 1 Would sugge.sl that so fur as possilde the temptation to 
weak this rule should not be placed in Hie w.ay of practitioiiers 
approved society agents. Quite often, we arc informed that 
fe agent has asked for certificates dated so-and-so, quite 
nrespectivc of whether the patients were .seen on those dates or 
I® - At one time this was so prevalent that I felt compelled 
e report one case (a thing I have very rarely done) to the 
mistrj of Health, where an agent had actnally given a list of 
? '''^^red person, who had long since returned to 

rV having seen me, for which he wanted a series 

ihe'" »i™' certificates covering qnite a long period. On 
resne'i'i'^ bund, I finow Uiat there has hocii la.xity in this 
Macd" fi practitioners — so much so that Dr. Peter 

a verv"" r f* of o'*'' Insurance Committee, issued 

I ncCKsary wanting on tlie subject to doctors 
to onr 'S hardly playing the game to suggest 

give a shall ask ib for something we cannot 

and inevitably think we are being obstinate 

(he positin' '■efuse, no matter liow we try to explain 

conva"esCTn”|, Eoveruing arrangements- for examining 


patients, is at present practically a dead letter. 
in"”f- apace provided on the certificate forms 

>0 see tlii.'tl' which, patients should next come 

""bh a little in on 1 in 10,000 of the forms. Yet 

01 savT,,.. mutual goodwill it might be made a useful wav 


1 

for the 
to 


■ saviae fu a Bouu.vui. m mtgnt 

as soon as nos. ^tting (he insured persons back to wort 
iriu Cannot cxn* those instances where 

ovting , ‘^fsintercsted support of a medical man, 

”0 prenaved , of Ms patients verv often, unless you' 

'-.•orrw .1 . S'™ as wen ' • - 


'■'’‘■‘■.r and bothi 


ar you can. 


'as fake, and to sp.ure him all the 


T^IC T'.’c of Sjir.r.in/ CcrliprntcK. 

Rule 11, I suggest, is rather a stupid one; it porniit.s of the 
giving of n special convalescent certificate, to cover a period 
of- not more than fourteen days, only if the insured person has 
been coiitimioiisly ill for tweiily-eiglif d.ays before. Surely the 
arbitrary period of twenty-eight days is too long ; and anyway 
the special iiitcrinediatc certiricnto, while not serving exactly 
Ihe S'amc purpose, might coiiceivalily tie u.sod. It should not be 
beyond the wit of man to produce one form which would cover 
both Rule 11 and Rule. 12 (regarding special iiifcrraediatc certi- 
ficates), and allowing a little more elasticity in their interpre- 
tation. 'Appeal could always he had to the regional medical 
officer in cases of serious doubt. 

I Ihitifc (he maximum period of four weeks for spcci.al inter- 
mediate certificates is hardly long enough. It seems a little 
ridiculous to have to go on -certifying an incurable case such 
a.v hemiplegia or ii blind man every month. Abo 1 suggest that 
pirhaps here approved societies would not suffer any injury 
hy fnisting the insurance pr.vclifioiiers a little more than 
some of them do. C'crlain .societies have actually, as a matter 
of routine, immediately refcrretl to the regional medical officer 
every case in which a special intermediate certificate has been 
given. They may conserve their funds a little by having the 
decisions of the mcdic.al practitioners reversed in a few cases; 
but sucli a practice does not lead to good feeling, and in the 
long run 1 feel sure the funds will suffer more from the hack 
of incentive on the part of practitioners generally to assist in 
eotiseiviiig them than they will gain hy checking the possibly 
faulty judgement of a few. Sloreovcr, even the regional 
medical officer is hiiL homati, and cases are not unknown 
where his judgement has proved less correct than that of the 
praefitioner who knows the patient, with the result that a 
imtienl sent b,ack to work against a practitioner's advice lias 
ill a short time again hceii on the sick list, perhaps for a much 
longer period than would otherwise have been the ea.se. 

Rule 13 allows a statement of cause of incapacity to he given 
.as an alternative to slating the precise diagnosis ou the certificate. 
This alternative operates only in the very exceptional cases where 
the stating of a precise diagnosis would be prejudicial to the 
patient. The procmlure to lx* followed is ctimbersome in the 
extreme, and in any case it docs not, and.-is not intended to; 
provide for the holding up of a diagnosis in donhtful cases. 

I think voluntary certificates might be used more freebr 
than they are. Properly employed, they do something to 
lessen the rigidity of Rules 8 and 9 in regard to the times 
and circHm.stiuiccs in which certificates may be given. It is 
permissible for doctors to charge a fee for these, and ns wliere 
they are used it is implied tliat the mSccssity for them lias 
arisen through the neglect of the insured person to ask for a 
proper certificate at the proper time, no doubt ffiis is tecli- 
iiically justified. But since, as I have mentioned, in my expe- 
rience it is usually necessary for the doctor to give the' certifi- 
cates refjiiiretl without waiting to be asked, nnles,s there is to be 
trouble later on. I do not think most of us actuallv insist on 
a fee unless there has been a flagrant piece of carelessness on 
the part of the insured person. But certificates given under 
this rule will not cover the point I raised under Rules 7 and 8 
iir regard to the holding up of a first certificate for a few daxs 
in cases ol sViglit illness. 


Advice as to Addittonaf Benefifs. 

Tlic ride providing for the insertion of advice as to addi 
lional benefits on the certificate forms is not, 1 think, .alway 
understood. I have in at least one instance had such advice 
given in the appropriate ^ace, at first rejected by an approve 
society, though it "was accepted later on my referring to tbi 
rulix Curiously, this rule seems to- take it for granted tha 
a.n insured person in need of additional benefits (such as denta 
treaHnciit) will be necessarily or usually on the sick list and i 
rc-ceipt of certificates, xvliereas, of course, this is much mor 
nsualiy not the case, 

■The form of certificate for use on the death of a pafieii 
seenB to have been draxvn up with less consideration for tli 
necessities of the occasion than the various other form 
required. It provides for the insertion bv tlie doctor of 
number of quite unnecessary details, such as the date of th 
last certificate and various numerals showing the deceased’ 
society, branch, and nnmber, all of xvhich can readily be fnum 
by referring to the previous certificate issued; and further 
the wording is curiously vague, as it is addressed “ To - ■ 

a blank individual, without any instructions as to what po<^o 


208 Mat 12, 1928] 


Association Notices. ^ 


pnnie or designation is to occupy the blank. In point of fact, 
I Iiave never had the slightest idea to whom the certificate is 
intended to be addressed, and have usually filled in the words 
“ To whom it may concern but if these are intended they 
could have been printed in. 

Now that I have said my say on this vexed question of 
medical certification, I do not pretend to have dealt with all 
the problems involved, but I trust I have said sufficient to show 
that as a profession we have no easy task in fulfilling these 
regulations— regulations which are, perhaps necessarily, so 
complex that I think only a minority of the officials concerned, 
whether medical practitioners or approved society agents, really 
thoroughly understand them; while I am sure that not one in 
a thousand of the insured persons has the slightest working 
knowledge of their intricacies. Like all laws, they are based 
upon the supposition that most people are either fools or 
knaves. Human nature being what it is, I suppose the regula- 
tions are necessary. It therefore behoves us on both sides to 
carry them out in as friendly a spirit and with as little 
unnecessary trouble as we can. 


^S5ociati0n i^otias. 

ELECTION OF 24 MEMBERS OF COUNCIL BY 
GROUPED BRANCHES IN THE BRITISH ISLES. 
The following is a list of the nominations received for 
1928-29: 


■ 

Branches in Group. 

Candidates Nominated. 

A ** 

o 


. 


A 

North of England 

Dr, J. Hudson (Newcastlo-on-Tyno) 

a 

B 

Yorkshire 

Ur. Petek Macdonald (Yorlt) 

a 

c 

Lancashire and 
Cheshire. North 
Lancashiieand South 
Westmorland 

pr, J. 0. Matthews, Af.C, (Liverpool) 
No nomination 

2 

D 


Dr. E. Wallace Henry (Leicester) 

~T 

E 

Cambridge and Hunt- 
ingdou. Essex. 

Norfolk. South Mid- 
land. Suffolk 

Dr. J. F. Walker (Southend-on-Sea) 

~T 

F 

Birmingham 

Staffordshire 

No nomination 

~ 

Or 

North Wales Shrop- 
shire and Mid W'ales 

Dr. E. Lewts-Lloid (Towyn, Merio- 
neth) 

~ 

H 

South Wales and Mon- 
mouthshire 

Dr. W. E. Tqoaias (Ystrad-Rbondda) 

~T 


Metropolitan Counties 

Dr. P. W. OooDBODr(Marylebono) i 

Dr. Christine Murrell (Kensington) 
Dr. W. Paterson (Willesden 

Mr. H. 8 . SoUTTAB, O.B.E. (Marylebone) 

~ 

J 

Bath and Bristol 
Gloucestershire 

West Somerset 
Worcestershire and 
Herefordshire 

Dr. D. E. Finlay (Gloucester) 

~ 

K 

Dorset and West 
Hants. South-West- 
ern. Wiltshire 

Dr. C. E. S, FLEmiiNQ (Bradford-on- 
Avon) 


L 


Mr. N. P. D. Lumb, O.B.E. (Southsea) 

1 

M 1 

Kent. Surrey. Sussex 

Dr. E. R. Fothergill (Hove) 

Dr. 8 . Morton Mackenzie (Dorking) 

1 

N ' 

Aberdeen. Dutidee, 

Northern Counties of 
Scotland. Perth 

Dr. T. Feaser, C.B.E.. D.S.O. (AberdeoD) 
Dr. G. Smith Sowden (Elgin) 

1 

O i 

Edinburgh. Fife 

Dr. John Stevens (Edinburgh) 

T 

i 

Glasgow and West of 
Scotland (4 City 
Divisions) 

Dr. J. G. McCutcheon (Glasgow) 

~ 

Q 

BorderCounties. Glas- 
gow and West of 
Scotland (5 County 
Divisions). Stirling 

; Dr. J. Livingstone Loudon (Hamilton) 

~ 

R 

Conoaoght. Munster. 
South-Eastern of 
Ireland 

Dr. Denis WALSHE(Graiguenamaiiagh) 

1 

S 

Leinster 

Dr. R. 0. Peacocke, O.B.E. (Blackrock, 
Co. Dublin) 

1 

T 

Ulster 

Dr. R. W. Leslie (Belfast) 

1 


Voting papers for Groups M and N will bo posted from the 
Hoad Oinco on Saturday, May 12th ; they are returnable not 
later than Saturday, May 19r.h, to tho Medical Secretary, 
British Medical Association House, Tavistock Square, London. 
W.O.l. 

The Candidates referred to In tho remaining Groups, being 
the only Candidates nominated for those Groups, are hereby 
declared elected Members of the Council for 1928-29, 

ELECTION OF 2 MEMBERS OP COUNCIL BY PUBLIC 
HEALTH SERVICE MEMBERS. 

The following, being tho only candidates nominated tor 
election as Members of Council for 1928-29 by Public Health 
Service members, are hereby declared elected Members of 
tho Council for 1928-29 : 

Dr. G. P. BoonAN, Medical Ofllccr of Health, Willesdoa. 

Dr. E. H. SuEnii, Medical Otllcor of Health , Coventry. 

ELECTION OP 4 REPRESENTATIVES AND 4 DEPUTY 
REPRESENTATIVES IN THE REPRESENTATIVE 
BODY BY PUBLIC HEALTH SERVICE 
MEMBERS. 

The following is a list of the nominations received for tho 
election for 1928-29 of 4 Representatives and 4 Deputy 
Representatives in the Representative Body by Public Health 
Service members: 

Dr. T. Edstaoe Hmi., O.B.E., Medical Oiheor ol Hcallh, County ol 
Durham. 

ProfosTior H. KEim. O.B.E., Medical OOlcer of Health, Newcastle- 
on-Tyno. 

Dr. K. A. Lystf-r. Medical OCflccr of Health, Hampshire, 

Dr. Ernest Ward, Tuberculosis Oilicer. Souto Devon. 

Dr. R. H, IViLSHAW, Medicat Ofllcer or Health, Worthing. 

Voting papers will be posted to all Public Health Service 
members from tho Head Offleo on Saturday, May 12th; 
they are returnable not later than Saturday, May 19th, to 
the Medical Secretary, British Medical Association House, 
Tavistock Square, Loudon, W.C.l. 


May 15, Tues. 
May 19, Sat. 


June 2, Sat. 


June 7, Thurs.- 

June 13, Wed, 
June 21, Thurs. 

June 3U, Sal. 

July 4, W^ed, 

July 20, Frl. 


July 21, Sat. 
July 23, Mon. 

July 24, Tues. 

July 25, Wed. 

July 26, Thurs. 
July 27, Fri. 


TABLE OF DATES. 

Motions by Divisions and Branches for A.R.M. cffcnda on 
matters of which' two months* notice must be given 
• •must be received at Head onicc by this date. 

Last day for receipt ot Head O/Iicc of voting papers for 
election, where tliere are contests, of d) 24 tnem'^ers of 
Council by grouped Branches in British Isles; ana 
(ii) 2 Public Health Service Members of Council, and 
4 lleprcsentatives of Public lleallb Service in Repre* 
ffentativo Body. . 

Publication in Bninsji MRDica Journo Supplemtot of 
motions by Divisions and Brandies for A.R.M, on 
mutters of which two months* notice must be given. 
Representatives and Deputy Representatives must be 
eVcteci by this dote. ^ 

Publication in British MEnica Journal Supplemc,t oj 
result of election of members of Council by < 

Bronclies, and of result of election of mernbers oi 
Council and Itcpresentatlves in Representative Body oy 
Public JJeoJtb Service members. , „ ^ . 

nomination papers availablo (on application at ric 
Onice) for election of 12 members of (jouncil by grouP 
Representatives (British Isles). 
names of Representatives and Deputy Represemaw 
must be received at Head Oflice by this dote. 

Council. j-f. 

Meetings of Constituencies must bo held between iniB o 
and July 20th to instruct Representatives. . 
Supplementary Report of Council appears m r 
MeDIC-IL JOURN.4L SUPPLEMENT. , < o Xf 

Amendments and riders for inclusion in A.k.m. 

must be received at Head Olllce by this date. 

* ■ " . .. w etinff, Cardiff. 10 hr 

of 12 members of Couoca by 

roust bo received (at A.K-W-. 

p.ra. 

■ ’’ceftnp, Cardiff. 

Annual Heprcsentatfve J/ceffnp, Cardifl. . fipnerol 

Annual Jiepi'csptilativo 3/ectin(/, Cardiff. Annual 
Meeting, Cardiff, President's Address. c^iGrptaries. 

Covneff, Cardiff. Conference of Honorary Secret 

Cardiff. 

?/eetinffs of Sections, etc., Coardifl. 

Meetings of Sections, etc., Cardiff. 

Meetings of Sections, etc., Cardiff. 

Alfred Cox, Medical Secrctarif, 


BR.ANCH AND DIVISION MEETINGS TO BE ^ELD^ 

Border Counties Branch: I^umfries ato Gaixot^y jjg 

'ho annual meeting of tho Dumfries and GaHoway iRfh, at 

eld in the Royal Infirmary, Dumfries, on Tuesday, 
p.m. Agenda: Report of executive; election of fnstruc- 
secutive ; consideration of Annual Report of Counc ^ ^ 

ions to representative thereon; Dr. J. IX rases, 

iscussion on the present-day treatment of horderli -t), vision — 

East Yorks and North Linco^ Branch : East Y^ks ^ 

'he annual .general meeting of the E^t at 3-30 

eld in Wilberforco House, Hull, on ' Committee 

genda : To receive the annual report of tho Execu Division . 

nd the treasurer’s financial statemen- ; to consider . first 

Codel Rules of Organization ; to elect officer; to recci 

nk in tho chain of office for the chairman ® a prize 

[ackay, the retiring chairman; to consider tho provision 












































Mvy 12, 19231 


Mootings of Branchos anti Divisions, 


r mii'ri.Kitr.sT to nir orta 

LnillTtHll Sfr.DlOAl* JoUUXAt. 


for medical sHidenfi nt. tlio Univprrily CoIIcrc. After tea tlicro 
Si bo an inspection of local nnlnnities, n'lll, a conunontnry by 
(lie Director of Wiiseimis. 

lAN-ctsmnr. Ciinsnini; HaAXCH : SoimironT pivisioK.-Tbo 
n,mua! mcetinjr of the SonlhporUliA ision n ill bo he d lo-.lay 
Jfav lltli). at 8,15 p.m., at 62, lIoiiRliton Street bontlmort. 
ArJnda- Annual report; election of oHtce-benvera and comimtteo; 
onl.tlialinoscopo demonstrations; ccarlcl fover recovery cortincatcs 
for State-aided schools; •' heart disease ’ certined ns causo of 
death; social function; contract medical ccrvico for juvcnilca; 
Annual Report of Council. 

JrirTr.orotm!i Cocsries RitAKai : Ciiy Di vision-.— A clinie.M 
niccliti^; of tliQ City Division ^vill bo licld to*day (I’ritlayi Siny llth)f 
when Ur. E. Cnutlcy •will show cases. 

Metropoutan Ccukties BnANCir : LtwisiiA^r Divisio?;.— The annual 
meotin*’ of tho Lewisham Division will be held nt the Town Hall, 
Catford, S.E.6, on Tuesday, Jlay 15th, at 8.45 p.tn. 

Metropoutak CouKTiEs CRANai : South-West E*;sex Drvisiox.— 

A meeting of the South-West Essex Division will bo held nt tho 
Clavbury Jlcnlai Hospital, Woodford Bridge, on Tticsda}*, May ISlli, 
at ^.30 p.m. Dr. G. F. Barham, medical superintendent, will give 
a demonstration of cases. 

MmorouTAK Counties Biuxni ; Wii.LE«nr.H Divisiok.— Tho 
annual meeting of Iho Willesdcn Division will bo held on May 
16tli. Agenda: Eicetion of officers and cotnraiKccs, and considera- 
tion of Annual Keiporl of Council. 

Midland Brancti : CiiESTEnriELD Division*. — A meeting of tho 
Clvestcrfield Division will bo held nt the Jfnlentily ICosnilal, 
Chesterfield, to-day (Friday, May IltlOt at 8.15 n.rn, A British 
.Medical Association Lecturo will bo delivered by Frofessor Louiso 
Mcliroy on the management of labour. 

Northern Cod.vties or Scotund Br-ANcn.—Tbo final clinical 
meeting of tho Northern Counties of Scotland Branch for this 
season will bo hold .at tho Latrson Memorial Golspie, on 

Saturday, May 19th, at 12 noon. The programme will includo tho 
demonstration of some surgical eases by Mr. B. S. Simpson, and 
notes on general anac5thcli« by Dr. J. B. Simpson. Go}fins 
members will note that Dr. Simpson lias arranged for tho courtesy 
of tho green at Golspie, Brora, and Dornoch to be extended to 
them for that day. Members desiring to lunch at Gol<;pic should 
notify the honorarj’ secretary by Mav 17th. The annual meeting of 
i’lc Branch IS to bo held nt Kylo of LocIinl<=h on Juno 30tli. This 
mil be Ibo first meeting of the Branch which has been Iicld in tbo 
area of tho Island Dirision, 

Nort^rn Coun'^es of Scotlakt) Brancti : BAKrr, ^[ORAY, ani> 
vi:S annual meeting of tlio Banff, Moray, and 

Arms Hotel, Banft, on ‘ 
5-^ 3 p.m. Apcuila: Aiintml report of tlio 
office-bearers : tlio Annual Report of Council; 
ino iJ.u.A. Chanties Fund. The ennrty-sv „r t).,, T>„rr 


eou°r5 ■hA■^I, courtesy' of tlio b'uir Houso'Boif 
course has been granted for llioso avIio wish to play. 

SuKDrRLAin) DivisioK.— A meeting 
SuaaerUnd „ •'O l''0 Infirmarr, 

° " ednesday, _ May I 6 II 1 , at 8.15 p.m. Dr. J. D. 
.•i- ? ^ "7 ^ lecture entitled ** llvnortronliir nvlrtnV 


iu “ »vviuiu cijuucu * llypcrtropliic pyloric stenosis- 

andsMv°rf V® eiamplfl of the mctliod of diagnosis, treatment, 
ana study of disease in cliildbood.” 

Bp-AKcn : Soern CAnsAnvOK asd JlEnioKtrn Division. 
Dirision Sll n Carnarvon ami Jlcrionctb 

'Tuesday, M3y*atR ** Memorial Hospital on 

the^itord^;!-'^2“'*o .^cANCn : OxTonv Division.— A meoling of 
\v...T_ . ._Msion will bo held at tlio RadclifTo Infirmary on 
I p.m. Dr. F. G. Chandler will read a 
« -v-wis— early diagnosis and trea 

'uu- Mr. C. H. B, 
aloent of gall-stones. 


Vi'cilnesdav Mnv%"’ira’^''i “A Tfuelclilfo Infirmary on 

paper cnl?tiod^n^’,2‘ P-™- D''-. Cbandicr ivill read 
Eroncbiectasis — early diagnosis and treatment." 

-on will Dia-isiox. — A meeting of tbo Jersey 

nth. Mr C B if ^.ocral Hospital on Tliursday, May 

aent'of’gali.^onK"™° ^ paper on tbo diagnosis and 

■‘5 ??'’-’''®aiooTn Division. — Tlio annual dinner of 

™lhsear“rW?n ’5™ T,’” '’O fJa® Queen’s Hotel, 

:• «d. each) can ho “w 2 :. May 16tli. at 8 p.m. Tickets (prici 

luuer address v.-;u ^^^^tained from Dr. H. H. Warren. An aftcr- 

Sourn Ji ™‘‘y- 

»cting of ■■ BuDroiujsinnE Division.— A. general 

Uttuly Hosnita)^ m i'™ P‘’''‘®>on will bo held at tbo Bedford 
■» uket a renrL™i 26tb, at 3 p.m. Agenda: 

‘ Mmmunicat»n”f°n^^', “ deputy representative; to consider 
Annual Renort *'0’ Chanties Committee ; to consider 

Some casM a paper by Mr. W. oi nt„i. 


'' ’:iecL a renrAc««* - uuiy aulu, at o p.m. AgcDua : 

L^QUimumcalmn^frnm^i*^ ?‘^Puty representative; to consider 

Annual Rcnnrt *'r’° Chanties Committee ; to consider 

S'Xne cases P“P<=>- .by Mr. W. G. Nash on 

lad treatnaanl." ^ fnuotion of tbo largo intestine : tbelr diagnosis 

Branch intermediato meeting of tho Soutb- 

.“ Tliursday. Uav oiti Royal Cornwall Infirmary 

'■“"orary secreta„^„l^oo- Members nro asked to inform tho 
■■'■cuneuj^ or niSce. nf'**' possible of any cases, notes, papers, 
that thev Bring forward 

Usable that oanorfoiy I'l P on the agenda paper. It is 
SnrroLK Bean^ . w Po^ib'u- 

ft,l'?‘-.S'odiiate ! J. “.‘y’sioN.- In connexion with 

Suffolk West Suffolk Division at 

May iffh ’«?* Q Horder will give a lecturo 

their^earinp .P*“m on etiological factors in 

^ clinic of Coffee will bo served at 

Vi'Jt D a.m. fjijg cases will bo held sm Sunday, May 

Suffolk and their guesla 1° medical practitioners in 


Sussex Brakcii : Briouto:; Divtsio?.’. — ^I' ho next clinical meeting 
of tho Brighton Division will bo licld nt the Brighton Borough Sana- 
torivina on Thursday, May 17th, at 3.45 p.m. 

West Sosierset Branch.— A meeting of tho West Somerset 
Branch will bo held nt tho Taunton and Somerset Hospital, 
'Aiunton, on Friday, liny 18th, at 3.30 p.m. ‘Agenda : Efcction 
of rcprcscntnlivo and deputies to tlio Annual Rcprcsentativo 
Meeting; consideration of Annual Ueporb of Council. 

Yorkshire Branch : SnErnELO Division. — Tho annual meeting o2 
tho Shcflield Division will bo held at the Church House, St. Jaroc3 
Slreet, SheUloUl, on Wednesday, May 16th, at 8.30 p.m. Agenda: 
report of Executive Committco; election of officers lor tbo ensuing 
year, ' 


^tfrfhigs of JGmncljrs au5 JDibisions. 


McTnoponTAN Counties Beanch: WiNDSwop-nr DmsioS’. 

The Wandsworth Divi-sion held n dinner on May 2nd to eelcbrato 
tlio twenty-fifth .annii'crsary of ita foundation and to> do_ honour to 
Dr. JI. G. Biggs, ono of tho oldest members of the Division and 
still in nelivo pr.icticc. Tho Division ivas inaugurated towards tho 
end of April, l9Q3, and Dr. Biggs was its first cliairman. A letter 
was read from Dr. Cox regretting Ids inability to attend, and 
commending liiglily llio long service rendered to tbo British Medical 
Association by Dr. Biggs, especially in connexion with the work of 
tlio Central Klliical Committco. Dr. SnEKurroN, chairman of tho 
Division, proposed tho toast o{ " The British Medical Asswiation,” 
and Dr. Andebeon, the Deputy Medical Secretary, replied. Dr. 
Ar.Tnun Howeei., proposing tho health of Dr. Biggs, recalled their 
early associations in tho IVandsivorth area. Dr. Bices, rcply-ing, 
said that in a few days lie would be cclehrating his ei"htieth. 
birthday. Not main- doctors were in praclico nt that age, but ho 
might, perhaps, look forward to another ten years yet. Dr. 
IIaavtuokne, Chairman of the Representativo Body, proposing tho 
toast of " The Wandsworth Division," referred to the days when, 
owing to tho energies of a former secretary, the Wandsworth 
Division was particularly well known nt headquarters. After a 
period of quiescence there was renewed activity, and ho wished 
tho Division success in oil its enterprises. Ho also recalled pleasant 
ossociations with Dr. Biggs. Dr. GAnuNait, vice-president of tho 
Division, replied. Dr. Athelstane Nonas, ono of tho representatives 
to tho Representative Body, proposed “ The Guests,” and Dr. 
Bisnop, tho other rcprcsentatii'e, proposed " Tlio Chairman.” Dr. 
SiiEKtETON, replying from the chair, said his duties had been mado 
exsy by tlio work of tho honorary secretary, Dr. G. Pollock, whoso 
health ho then proposed. 


SunnET BnANcn : Ceovdon Division. 

The annual general meeting of tho Croydon Division was held 
at tho Crovdon General Hospital on May 2nd. A- letter was read 
from tho iJnilcd Dairies Company otlcring to convey members' and 
their wives to Streatham to view their plant, and it was resolved 
that tho invitation bo accepted. 

Tlio report of tbo Executive Committco was received and 
adopted. Tho following otficers were elected : 

Chairman, Dr. G. E. E. Brayno-N'ichollg. Vice-Chairman, Dr. R. I*. 

Flnkcrtor " ■ - v --n Dr..C. O. 0. Scudamore. 

.tiAtslanC ■ ' “ Hamond. Auditor, Dr. G. O. 

Genge. . ■ ■ • . Rady, Dr. P. IV. Hamond 

and Dr, 0. G. C. Scudamore. Ucpuly Hepresentative, Mr. E. M. CowcU. 

After the conclusion of tho business Dr. J. Stanley White gave 
an address on somo recent aspecls of biological therapy, illustrated 
by lantern and cincmntograpli. 


SunaEY Br.ANcn : Guildsokd Division. 

An ordinary meeting of the Guildford Division was held at tho 
Royal Surrey County Hospital, Guildford, on April Slh, with Mr. 
H. B. BuLLEit in tho chair. Tho meeting proceeded to elect repre- 
sentatives and deputies to tho Annual Representative Meeting, 
Drs. Arnold Byndon and G. M. Bluett were elected as repre- 
sentatives in the Representativo Body, and Drs. James McGloshan 
end G. A. Clarkson wero norainatod as deputies. After somo 
corrcspondenco with the county medical officer of health and ono 
of tho members had been read and the subject discussed, Dr. 
Bvndon proposed that in the opinion of tlio Guildford Division 
tho mileage fco under tlio Slidwives Act, 1918, in the area of tho 
Division should bo ono shilling each way. This was seconded by 
Dr. Peabsb and carried unanimously. 

Tlio CnAiEMAN exhibited skiagrams of osteomyelitis in children 
of tho femur, tho radius, and the fibula, also one of a cervical rib! 

Mr. E. W. Sheaf showed a woman in the ward who had had 

.. performed in one stage (Crile’s method) 

; • three years’ standing. The pulse fell from 

days, and had remained down. He also 
showed a case of myeloma of tho head of the tibia in a middle- 
aged man discovered during an x-ray examination for a fractura 
which had occurred through it with slight violence. 


Yorkshire Branch ; Harbogate Division, 

At the annual meeting of the Harrogate Division, held on Mav 3rd 
tho following were elected as officers for 1928-29 ; . 

Chairman, Dr. R. T. Morris. Vice-Chairman, Dr. P. A. Stephen Hevr, 
tentative in Repretentative Body, Dr. Solly. Deputy Revresentnti^F'^fZ 
ReprcsentStiro Body, Dr. Milbum. ^ P e e itatice tn 

. Two recommendations were adopted by tho meeting for incliisioii ' 
m tho agenda of tho Annual Representative Meeting It Gardia. ’ 



210 May 12, 1928] 


Co rresp on cten co, 


r RUPPLEimST TO TITE 
kCRlTlSJI 5IE1JIC*1< J0VU<<1L 


JfOTICES OP MOTION BT DIVISIONS POR THE 
ANNUAL REPRESENTATIVE MEETING, 
CARDIPP, 1928. 

lieports hy Medical Practitioners at Itequesl of Coroners. 

By Haheogate: That (wiih reference' to para. 89 of the 
Annual Report of Council), following the cuEtoiu In Scotland, 
the fee lor a report from a praotiiiouer to the coroner ahall 
be £1 Is. 

Scheme oj the Spa Federation for Spa Treatment of Insured 
Persons. 

By Harrogate : That para, (mj of the recommendation 
coniained in para. 128 of the Annual Report of Council bo 
deleted and the following substituted therefor; 

That an initial cer. ifleate as to incapacity for work up to 
one month he given by the home practitioner, any sobscipucnt 
certificates tuat may be necessary being given at the spa. 

Lile Insurance for Members. 

By South-Eastern Ireland Branch; That the Council 
be instructed to aiipoint a committee to inquire into tho 
possibility ol a compulsory BCheino of life insurance for tho 
members being establislied, the premium for such insurance 
to be included in the annual subscription. 

Medical Profession and Motor Spirit. 

By 8 outh-West Wales; That as tho medical profession is 
such a lat e cunsnmer of petrol (and i.s homologues) — used 
for professional purposes — ihe Representativo Body is of the 
opinion that the As'ociatiou should officially approach the 
petrol companies so that the medical profession may obtain 
petrol (and its homologues) at commercial rates. 

Maternal Mortality and Morbidity. 

By South-West Wales ; That in the opinion of the Repre- 
sentative Body general practitioners shonld be adequately 
represented on any oommitieo which may bo appointed by 
the Association to con-ider and formulate sohemes tor tho 
improvement of maternal mortality and morbidity. 

Midtaives Act, I91S. 

By South-West Wales ; That in tho opinion of the Repre- 
sentative Body the Mitlwives Act, 1918, should be amended 
so that adequate payment be made for ante-natal work. 


ffiorrespanDfua. 

Ulyht of Appeal to the Courts. 

Sin, — TIic leading article in the Times of May 3id on 
“ The Courts and the Executive ” must hare recalled to 
anyone wlio attended the Panel Coufereiicc.s of icccilt years 
the claim so often urged in them for a .riglit of appeal by 
jianel doctors from decisions of tho Minister to the Higli 
Court. 

We have not got that appeal. We arc at preseiit working 
on a trial of a departmental system, and there has been 
no recent occasion of protest; but this article iu the Times 
reveals the potential insecurity of the method in wliich 
we have been led to acquiesce. “ These cases,” it says, 
occur at intervals long enough to prei'eut them making 
a^ lasting impression upon general readers. They go about 
tlieir business and grow indifferent or forget.” Tliat is 
exactly what happens to the panel doctors in the intervals 
between, cnti.ses cilebres. Tho echos of “ tlie £1,000 line” 
die away in a year or two, and can hai’dly Ire reawakened. 
It is not so with tho officials. They ” . . go about their 

business, and consider how best they may further augment 
the power of their department by ousting the iurisdiction 
of the courts.” 

, The last words of the article put the whole position in 
a, nutshell. “ Administrative tribunals may be necessary 
for tlic efficient dispatch of tlie mass of business entrusted 
to the (Icpartmcntc by recc'ut legislation. . . But tlie 
sy.'.tom should “ . . save the Executive from all suspicion 
of desiring to iutsrforc with tho indepeudence of the 
courts, and safeguard the subject’s right of access to them 
oil all proper occasions as his necessary protection from the 
exlravagaiice of bureaucratic zeal.’" 

rXlie" Clieobire Panel Ccnimiitoe iias urged, in season and 
out of s-.-ason, that that principle should be accepted and 


established as govoniiiig tlie relation of the jirofc.ssion h 
the Ministry of Health. “ Tliere shonld ho an appeal fi 
tho courts ‘ on the merits.’.” were the words of our spokes 
man, Sir William Hodgson; an appeal, that is, not liiiiitei 
to mere technical iioints as at present. 

There is no objection to administrative tribunals so lonj 
as the tension that may be ciigeiidered in siicli a .systen 
i.s' limited by tlie safety valve of an ajipoal to the Higl 
Court. It is merely stupid to argue that such an appea 
would he distasteful to doctors hecau.se ])ublic and expeii 
sivc. So-nuich the better if it bo, for no one would inaki 
the appeal niiless he had a good case that would couimani 
the hacking of one of tho professional bodies. Appeal 
would be rare, hut decisive ; hut the fact that an appea 
was -possible would he constantly operative in raitigafiiij 
the tone of tho bureaucratic niachiiio. To argue that tin 
right of appeal would be Ijilateral — would cut both wavs— 
is to mislead; for tho other parties-^thc p.aticiits — Iian 
access to tho courts already. 

In the earlier stages of the controversy we were toh 
an appeal was impossible because niicoiistitiitioiial. Evei 
those wlio iiscd that argument now admit that this is no 
so. It is tho denial of the right of a]ipeal that i: 
essentially nneonstitutional. 

It was the timidity engendered by the two other argn 
ments 1 have mentioned that uirstiffcned the will of tin 
Panel Conference and made it pliable enough to accept 
on trial, the present departmental system. Howevc: 
‘‘ successful ” it may be — for a tinfe — it leaves us in i 
wrong relation with’ the Minister — not free contractors 
but dcjicndent for reasonable conditions in the excrcisi 
of our calling on his interi>rotatiou of rcgul.ations whicl 
he is free to make and alter. — I am, etc., 

Holmes Cliapel, Oiwliirc, May Srd. Lionel J.WIES PiCTON. 


Kiirstiig Homes Itegisfralion Act, 10.77: Doctors' Priratc 
Houses. 

gm Buried awav in the Annual Report of Connei 

(Supplement, April ‘28th, pp. 152-53) is a most importani 
report on this Act, with an exiilanation as to tho isositim 
of those doctors— probably many iumdreds, if nol 
thousands— who receive into their privfitc Imnscs pcrsoni 
Iniown ns “ private patients ” or “ p.aying guests, tlm 
I.atf or eiijdiemism being adopted to sokac-c the patients oi 
relatives. Tliis report sliould he carefully read by aU nhoiii 

'The posTtion is thi-s. Before July Ist this year ' 

doctor wlio receives into his private house 
liieutallv or phj-sically iH patient, rriirf inehtdcs in 
meat o.’ condet the prorision of ‘- nursing,’’ 
n nnrse or attendant or otherwise, will have to icgistci tlia 
iiousc which, together with ids domestic staff and 
irr iril! then become subject to inspection by the ocal 
rtWionw nnthorit\' In addition, Jie must display, m n 

ST,r,f. in w. 

*’^There arc only two wavs for him to escape from this 
obSionaWe position; either 

July ;X"Tfo'r“ tCliroi-isipn of_ nursing,” 

IS ^ ‘ ^ . jjonid be an extra beyond lus contract. 

r^Svfas tlJ agenVron. the relatives tbe^ wages,^and, 
SiL obtaC: St fm^be same addressed to tho 

‘"in "the case of those doctora 'l^^^.^^XaSeso 

to inspection or whose houses cannot be remstored, 

suggested lines, and must in consequence become 
one would urge that they get into ’u) and 

with their local aiitiiority county oi '““|.bethcr 

obtain a copy of the draft by-lans, in oi -ble If so, 

they contain anything thought to be ‘b|, 

then the recognized local medical too 

urged to take immediate steps before it is found to 

E.- Bowi.,eND FoTmaiGrr,!.. 

nove» JIiiv 8tlj. 






212 BUT 12, 19281 


Association inteiJigenco and D!ary» . 


r EVPPLT.imKT TO Tn* 
LDniTiBii Medical Jourkal 


'WixcHESTcn : Royal Hampshire County’ Hospital.— H ouse-Pliysician (male). 

Salary il50 per annum. 

Certifying Factory Surgeons.— T he following vacant appointments are 
announced : Kirkwall (Orkney), Halsiead (Esscxl, Lewes (Sussex). 
Applications to the Chief Inspector of Factories, Home Office, Whitcbali, 

S.W.l. 

This list oj vacancies is compiled from our advertisement columns^ 
where full particulars will he found. To ensure notice in this 
column advertisements must he received not later than the first 
post on Tuesday morning. 


APPOINTMENTS. 

Bradlcs, John N., M.B., B.S.Lond., Ophthalmologist, Norwood School 
Chnic. 

IlACinvooD, John Fercday, M.B., B.S., F.R.C.S., F.K.C.S.Ed., Resident ' 
Medical Ofticer, Farnborough Hospital, Kent. 

Roberts, John, M.B., Ch.B., F.R.C.S., Honorarv Assistant Laryngologist, 
Liverpool Stanley Hospital. 

rAUDiNGTON GREEK CuiLDREN’s HOSPITAL. — House-Physictan : John 

McMichael, M.B., Ch.B. House-Surgeon: Geoigc L. Alexander, M.U., 
CJi.B. 

Certifying Factory Surgeon?.— J. L, C, Doyle, M.R.C.S., L.R.C.P., for 
the Fakenham Distiict (Norfolk); R. Dawson, M.B., Ch.B.Aherd., for 
the 5liddleton-in-Tccsdalo District (Durham); K. L. S. Ward. M.B., 
Ch.B.Ed., for tho Westerham District (Kent); IT. M. Roberts, L.R.C.P., 
L.R.C.S.Ed., L.R.F.P.S.Glas., for the Saltcoats District (Ayr); N. II. 
Linzee, M.R.C.S.Eng., L.R.C.P.Lond., D.P.H., for the Kingston District 
(Surrey); F. K.' Beaumont, JLB., Ch.B. Leeds, for the Finedon District 
(Northampton); C. W. Cassell, M.B., Ch.B.Ed., D.T.M.Livcrp., for the 
Chaddesley-Corbett District (Worcester); R, Alderson, M-D.Duth,, for 
the Crowborough and Uckfield Districts (East Sussex). 


DIARY OF SOCIETIES AI^D LECTURES. 

Royal Society of Medicine. 

General Meeting of Fellows.— Tues,, 5.30 p.ni., Ballot for Election to the 
Fellowliip. 

Sections of Dermatology and Surgery.— 8.30 p.m.. Special Dis- 
cussion r Treatment of Varicose ulcers by Intravenous Injection.. 
Openers : Professor Sicord and Mr. Twistington Higgins, to Ihr followed 
by Sir Sidney Alexander, Dr. Goldsmith, and Mr. David Levi. 

Section of Dcrwafolopj/.— Thurs., 4 p.m., Cases. 4.45 p.ra,. Annua! General 
Meeting. Election of Officers and Council for 1928-29. Annual Dinner, 

8 p.m. 

Section of Disease in Children.— Fri., 4.30 p.m., Cases. 5 p.m., Annual 
General Meeting. Election of Officers and Council for 1928-29. 

Section of Obstetrics.— Fti., 8 p.m.. Annual General Meeting. Election of. 
Officers and Council for 1928-29. Short Communication by Dr. Everanl 
Williams : Full-term Pregnancy in a Patient with Grave Myelocvlic 
Leukaemia. 

Section of iUcctro-Thcrapcntics. — Fri,, 6.30 p.m., Annual General Meeting. 
Election of Officers and Council for 1928-29. 7.30 p.m., Annual Dinner 

at the Cafd Verry, Regent Street. 

Royal Society op tropical McDiaNE and Hygiene, 11, Oiandos Street, )V.L 
— Tluirs., 7.45 p.m.. Demonstration and Paper by Dr. G. W. Brav : 
Vitamin B Deficiency in. Infants— its Possibility, Prevalence, and ' 
Prophylaxis. 

London Clinical Society, London Temperance Hospital, Hampstead Road, 
N.W.I.— Tliurs., 8.15 p.m., Clinical Evening. 

St. Cyres Lecture.— J n the Barnes Hall of tho Royal Society of Medicine: 
Wed., 4.30 p.m., Professor K. F. Wenckebach : The Heart and Circulation 
in a Tropical Avitaminosis (Beri-bei'i). 


POST-GKADUATE COURSES AND LECTURES. 

FELLOwsinp OF Medicine and Post-Graduate Medical AssocimoN.— Mon., 
May 14lh, to Saturday, May 19th.—yat?onol HosjiitaJ for Diseases of the 
7/t'arf, Westmoreland Street, W.l. ; Tucs., 2.30 p.ra.. Clinical Demonstra- 
tion ; no fee. SI. Mark's Hospital^ City Road, E.C.1 : Tues,, 5 p.m.. 
Clinical Demonstration of Cases illustrating Diseases of the Rectum; 
no lee. Itoyal London Ophthalmic Hospital, City Road, E.C.l ; Thurs., 
1 p.m,. Clinical Demonstration; no fee. Infants Hospital, Vincent 
Square, S.W.l. ; Course in Diseases of Infants, aftemoons only; second 
week; fee £3 3s. C'enlrof London Throat, h'one and Ear Hosintal, Gray’s 
Inn Road, W.0.1 : Intensive Course— Clinical and Operative; three weeks; 
all day, fee £5 5s. clinical course. Maudsley Hosirilal, Denmark Hill, 
S.E.5 ; Course in Psychological Medicine ; third week. XaCional Hospital, 
Queen Square, W.C.l : Course in Neurology for two months; particulars 
and fees from tho Fellowship of Medicine. Royal Free Hospital, Gray's 
Inn Road, W.C.l : Wed., 5 p.ra,, First of four Lecture Demonstrations 
on Ante-Natal Diagnosis and Treatment; fee for the course, il Is. 
Copies of syllabuses on application to the Fellowship of Medicine, 
1, Wimpolo Street, London, W.L 

Lo.vdon SaiooL OP Dermatology, St. John's Hospital, Leicester Square 
W.C.2.— Mon., 5 p.m., Napkin-area Eruptions in Infants. Tues., 5 p.m.! 
Treatment of Syphilis. Thurs., 5 p.m.. Pathology Demonstration. Fri., 
5 p.m., Alopecia. 

Kortu-Evst London Post-Graduatb College, Prince of Wales’s General 
Hospital, Tottenham, NAS, — BlonC, 2.20 to 5 p.m.. Medical, Surgical and 
Gynaecological Clinics; Operations. 'Tues., a30 p.ra.. Demonstration of 
Surgical Casc^; 2.30 to 5 p.m.. Medical, Surgical, Throat, Nose, and 
Ear Clinics; Operations. W'cd.. 2.30 to 5 p.m., Medical, Skin,, and Ih’e 
Clinics; Operations. Thurs., 11.30 a.in.. Dental Clfnics; 2.30 to 5 p.m.. 
Medical, Surgical, and Ear, Nose, and Throat Clinics; Opcrafions 
Fri., 10.30 a.ni., Throat, Nose, and Ear Clinics; 2,30 p.m,, Demonstration 
of Cases for A’-Rav; 2.30 to 5 p.m., Surgical, Medical, and Children’s 
Disease? Clinics; Operations. 

Royal Northf.rn Hospital, Holloway Road, N.— Tues., 3.15 p.m.. Some 
Reflections on Tumours of the Breast. 

Skefpiixd University Post-Gr.aduate Clinics.— At Royal Hospit.al : Fri., 
3.30 p.m.. Neurological Cases. 

West London IIosfiial PO»t-i;raduatb College, HamroersmHb, W.— Mon., 
10 a m to 1 p.m., Genito-urinary Operations, Surgical Wards. Skin 
Department; 2 p.m. to 5 p.m.. Eye and Gynaecological Departments. 
Tues.’ 10 a.m. to 1 P-m., Medic.al Wards, Demonstration of Venereal 
Di‘'ca«cs Elcctrcal and Dental Departments; 2 p.m. to 5 p.m., GA-naeco- 
locical Operations, Throat, Nose, and Ear pepartiripnt. Wed., 10 a.m. 
to^ 1 pni. Children’s Medical Department, Medical uards, Patho- 
logical Demonstration ; 2 p.m. to 5 p.m., E,ve Department, Surgical 
Wards Thurs ID a,m. to 1 p.ra., Neurological and Massage Depart- 


ments; 2 p.m. to 5 p.m., Eye and Genito-urinarv Departments. Fr 
10 a.m. to 1 p.m., Skin, Dental, and Electrical Hepartmenfs, Medic 
Wards, Clinical Demonstration; 2 p.m. to 5 p.m.. Throat, Nose, ai 
Ear Department. Sat.. 9 a.m. to 1 p.m., Medical Wards, Throat, Nos 
and Ear Operations, Medical Children'.^ Department, Bacterial Therai 
Department. Daily at 2 p.m., Operations. Mcilical anti Surgical On 
patient Departments. Special Lecture, Tiu-sduy, Mav 15Ui, at 4.30 p.m 
Gall-stones. 

Glasgow rost-GRiDUATn JIedical Association.— A t I'ictoria Infirmarj 
Wed., 4.15 p.m., Surgical Case?. 

Liverpool U.s'jversity Clinical School Ante-Natal Cliitjc.?.— R oy 
Infirmary: Mon. and Thurs,, 10.20 a.m. Maternity Hospital: Mor 
Tues., Wed., Thurs., and FrL, 11.30 a.m. (Fee £2 2a. for three montt 
attendance.! 

Manchester Royal Intirmary.— Tucs., 4.15 p.m., Dr. A. Ramsbottorr 
Treatment of Pernicious Anaemia. Fri., 4.15 p.m., Mr. W. IL Hc) 
Demonstration of Surgical Cases. 


50nttslj iHftiirai Assoctatioit. 

OFFICES, DRITISII MEDICAL ASSOCI.iTlON HOVSB, 
TAVISTOCK SQUARE, n\C.2, 


Departments, 

Subscriptions and AdvertiijEmexts (Financial Secretary and Busine 
Manager. Tclegr.ams : Art’"”'''’'' » •'"--n) 

Medical Sr.cnnT^itv (Tclegrar " London). 

Editor, Jiritish Medical Ailiology Weslcen 

London). 

Telephone numbers of Brift«/i Medical Assueiation and British Media 
Journal, Miii^eum 9861, 9862, 9803, and 9854 (internal exchang 
four lines). 

Scottish Medical SrenETAnr : 6, Drumsheugh Gardens, Edinburgh. (Tel 
grains: Associate, Edinburgh. Tel.: 24361 Edinburgh.) 

Irish Medical SfLretarv : 16, South Frederick Street, Dublin. (Tet 
■ grams Bacillus, Dublin. Tel. : 4737 Dublin.) 


Il Fri. 


12 Sat. 
J5 Tues. 


Wed. 


Diary of the Assoeiation, 

Mat. 

London : Library Subcommittee, 2.39 p.m. 

Chesterfield Division : Maternity Hospital, - Chcsterfich 
B.M.A. Lecture b> Professor Louise Mcllroy on the Managi 
ment of Labour, B-15 p.m. 

CilA Division : Clinical Meeting. 

Southport Division : Annual Meeting, 52, Houghton Strec 
Sonlhport, 8.35 p.m. ' 

Bonn, Moray, and Nairn Division: Annual Meeting, Fife Arm 
Hotel, Banff, 3 p.m. 

London: Central Ethical Committee, 2.15 P-ni-,_ .. 

Dumfries and Galloway Division: Annual Mewing, «o;a 
Infiiraary, Dumfries. Dibcussion on Borderline Cases openci 
bv Dr. J. D- Robson, 3 p.m. ^ 

Lewisham Division: Annual Meeting, Town Hall, Catfora 

So^'^AVest ^sex Division: Claybury Mental Hospital,, Wood 
fold Bridge, ,3.30 p.ra. 


London : Hospitals Committee, 2J5 p.m. 
Bedfordshire. Division : pc^fnrd CouMv 


eUfordshirc uivision : ocuioiu vuuutv ^ 

Nasli on ObTtrnction of the Large Inf^sstine, J P.“- 
Portsmouth Division : Annual Dinner, Queen s Hotel, Southse* 

SlfefJield Division; Annual Meeting, Church House, St. Jame 

J'”"','™ ; . ■ 2.30 p.m. 

■ (r. Brighton BorouRh Sana 


toiium, O.HJ p.IU. 

T..... Division : General llospitaJ. 


Mr. C. IL B. Avarne oi 


Fri. 


Sat. 


Thurs. 

Fri.- 

Tues. 

Wed. 

Thurs. 

Wed. 


JcrtcA - 

Hon. 

Wraf’somcrsrt ■ Branch: Taunton and Somerset Hospital 
.,’^?)'"'"'’’rnuntres'"‘of Scotland Branch: Clinical Mcctinfi 

" ^ lUXi. Sir Thoma: 

West snflolk „Dinsip_n ; Fibrosis, 8.30 p.m. 

Infirmary. Dr. F. G. Ohandle] 

val Cornwall -Infirmary, 
rttce, 2.30 p.m.. . w -.„ • 

• oneth Division; Glinical Jlceting 
!• ;pital. 

2 p.m. 

J 3 p.m. 

'oiumittcc, 12 noon. 


London : Conference of 

Hospitals, 2 p.m. ..S SSSS 


BIRTHS, MARRIAGES, AND DEATHS. 

: charge for incertmg forwwied with'thFnotlce 

Deaths is 9s.. which sum fn order to 

not later than the first post on Tuesday morning, 

: ftirrpnt tS. 


not Ulltr wak. /P.*-- I - . 

ensure insci’tion in the current tssu . 

C,«.-On April 30lh, at 'he ‘"S S ?”f’ 

ilary, the wife of Frank A. Bevan, fl » -i • 

laughter. p Korman of “ The Home 

RMAN.-On Mav 4tli, to Dr. and P* ^ 

lead,” Rubery, Birnungham, a daugliter. 

THVE?:.— At Berea, Johannesburg* on Buchanai 


primed and published by the British Medical Association, at their Office, Tavistock Square, in tho Parish ol St. Punerat^. in me counti 


of Lomion. 


ST3‘Pil?IjlSMSNT 

TO Tiin 

BRITISH MEDICAL J OURNAL. 

~~ LONDON, SATUUDAY, MAY 1928. ^ 


CONTENTS. 


BRITISH MEDICAIi ASSOCIATION. 


TACK 


Annual Roprcsontatlvo Tilcotinif, CardirT, 1028 ; 

Eesolctioss hy Divisions and UnANnics ror. mr. Ilrrnr- 
SOTATIVE Body 


213 


CUREENT NOTES : 

Soui WoKK or TDE Week 214 

CoxTEnEsci or Medical Staits or VoLUirrAnY IIosyitals ... 214 

ASSOCIATION NOTICES 216 

MEETINGS OF BRANCHF.S AND DIVISIONS 217 


Medical Services In India: Reorganization Scheiie — 
CoSIMUNlQUfi RY THE GOVERNMENT Or INDIA 

NATIONAL INSURANCE NOTES 

NAVAL AND MILITARY AFFOINTMENTS ... 
VACANCIES AND APPOINTMENTS ... _ ... 
DIARY OF SOCIETIES AND LECTURES ' ... 
ASSOCIATION intelligence AND DIARY ... 
BIRTHS, MARRIAGES, AND DEATHS 


FACE 

.. '215 
.. 218 
.. 219 
.. 219 
.. 220 
.. 220 
.. 220 


SPECIAL NOTICE TO IVIEIVIBERS. 

Every Member is requested to preserve this “Supplement,” which contains matters 
specially referred to Divisions, until the subjects have been discussed by the Division 
to which he or she belong's. 


MATTERS REFERRED TO DIVISIONS. 


JOriitslj iitriiiral Association. 

AXlsUAL RKPRESliJsT.lTIVU AIEETING, 
CaVRDIEE, 


The Amiiial Ropresontative Moctiiif; of tlic llritifli Medical 
Association ivill be held in Cardill on Friday, July 20tli, 
IMS, and tlio following days ns may bo ueco.ssary. 


RESOLUTIONS BY DIVISIONS AND BR.ANCnES FOR 
THE REPRESENTATIVE BODY, TOGETHER 
UTTH RELEVANT RKCOM.MENDA- 
TIONS OF COUNCIL. • 

[Note.— riiis includes onhj those Uccoutmcudalions of the 
Council contained in the Annual jteport to ndiich Amend- 
meiifs or Hiders have been scnl in; also on;/ Motions from 
Vivistons and Branches, of sehich (wo months’ notice snnst 
be ffivcn.] 

PnELISIIN.MlT. 

Jimiial Meetings and Annual Itcprcscntalivc Meetings. 

Motion by SuNnr.nL,AND ; That the Council be instructed 
0 consider the ndris.ibility of restricting tlio business of 
Meeting, wbicli is held at varioMs centres, to 
scien ilic .and social work, and of an Annual Representative 
- eetmg being held on a separate date at tbo Uritisb 
association House in London, to deal with medico- 
political business. 


Fin.ance. 

i. . Insurance for Members. 

instiM . Souxu-Easteiin Ibeund : That the Council bo 
iinssTM t V* appoint a cominittco to inquire into the 
msTvIi ’ ' ^ ® ‘ “ compulsory scheme of life iiisuranco for the 
tn established, the premium for such insurance 

to bo inchided m the annual subscription. 

f. ; Annual Subscription. 

As<inn;^t" 1 Tliat tlie annual subscription to tlu 

Association be reduced to £2 2s. 

. . Medio.w, Ethics. 

embershp and Acceptance of Post ic/iic/i is subject of 
1 ‘ ^‘‘nportant Kotice.” 

tioiier sliall^'lit ,^*^tnDLESEX : Tliat no medical practi 
who 1ms "obtaiiiP for- mombersliip of the Associatioi 

an “ Iinpovtan 


i M , . a position i 

Not; o n ; the subject of 

in tlio British Medical Journal. 


Medico-Political. 

Contract Bate for Juvenile Oddfellows, 

Motion: That the following recommendation of Council 
(Stipplcmc.iii, April 28tb, 1G28, pp. 153-54, para. 104) bo 
ado))tcd : 

That the Roprcsonl.ativc Body approve a standard raic of 
8s. 8d. per be.id per year including drugs for the remuneration 
of medical praclilioiicrs for medical attendance and medicine 
for iuvenilc members of tlio Manebester Unity of the Iiide- 
pciKicnt Order of Oddfellows; that (bo Council bo autborizod 
to approve a sligbllv lower rale than 8s. 8d. per bead per year, 
for a lime lo bo definitely stated, for application in any area in 
wliicli it is satisfied that oiving to economic conditions Die 
standard rate of payment is not feasible; and Hint it bo an 
e.ssential part of this arranrcmctil that Uioro must bo free 
cboice of doctor by patient and of patient by doctor. 

Amendment by M’ands worth : That “ 13s.” be substi- 
tuted for “ 8s. 8d.” in tlio second and eighth lines of the 
recommondat ion . 

Amendment by Tobqd.it : Tliat the Representativo Body - 
docs not approve of tlio recommendation, and strongly 
dcproc.atcs tbo accoptanco of any fee for contract medical 
practice, including medicine, either for juveniles or adults, 
which is lc.5S than 13s. per licad per annum. 

Amendment by Stockton : That any standard rate per 
head per year for tlio remuneration of medical practitioners 
for medical attendance and medicine for juvenile members 
of tbo Manchester Unity of tbo Independent Order of 
Oddfellows bo not less than tbo capitation fco in force for 
persons insured under the National Health Insurance Acts. 

Amendment by Stockton : That the arrangement by 
which the approved society pays tho practitioner for work 
done in individual cases is preferable to an agreed capita- 
tion fee. 

Beports hij Medical Practitioners at Bequest of 
Coroners. 

Motion by H.VBBoCATr. : That (with roforenco to iiara. 89 
of the Aniuml Report of Council, see p. 150 of British 
Medical Journal Supjdcmcnt of April 28th, 1928), following 
I the custom in Scotland, the fco for a report from a 
practitioner to the coroner shall be £1 Is. 

Private Practice. 

Motion by CAnnirF; That (with reference to para. 91 of 
tbo Annual Report of .Council) the Representative Body 
views with anxiety the tendency’ to transfer the treatment 
of many diseases and conditions provioiislv in the hands of 
general practitioners and consultants to departments con- 
trolled by medical officers of iiealth. 

Proprictarij Medicines. 

Motion by Abeiideen: That in view of the very great 
miraber of proprietary medicines which have been puttipon 
the market in recent years steps be taken to sot up at 

[ 1243 ] 


2r4 May 19, 1928] 


Current Notes. 


r BVrrLrMr^'T to tiib 
LT iniTiHH Mkdical Journal 


Head Offico a department to investigate these proprietary 
medicines and to supply information regarding them to 
members, either on request or in the JJrHish Medical 
Journal, or as otheiavise deemed exiiedicnt; or, if this is 
considered impi-acticable, the publication entitled Secret 
licincdics be bi'ought up to date. 

Position of General Practitioners in Pclation to 
Hospitals and Clinics. 

Motion by Aberdeen: That it be remitted to the Council 
to consider and report to the next Annual Representative 
Meeting upon the position of the general practitioner in 
relation to the voluntary and rate-supported hospitals 
and clinics. 

Medical Profession and Motor Spirit. 

Motion by South-West Wales : That as the medical 
profession is such a large consumer of petrol (and its 
homologues) — used for professional- purposes — the Associa- 
tion officially aiiproach the petrol companies so that medical 
l)ractitioners ma}- obtain petrol (and its homologues) at 
commercial rates. 

Midwives Act, tOlS. 

Motion by SouTa-AVEST AAhvLEs : That in the opinion of 
the Representative Bodj’ the Midwives Act, 1918, should bo. 
amended so that adequate 2 iayment be made for ante-natal 
work. 

Amhulancc Zeeturcs. 

Motion by T'ork: That the following resolutions of tho 
Representative Body are herebj' rescinded : 

(A) That ambulance work . . . should be troalcd by the 
profession as a matter of business and not of philanthropy.” 

(Adnptcd hy the A.R.iI., lOOi, Minnie. 107, in approriiiii a 
riport by the M cdico-Volitical C'ommittLC on “ The po.sition 
of medicul men in eonnrxion with ambulance competitions.") 

(B) Minute 2JS, A.R.M., 1910. That members of the medical 
profession should bo suitably remunerated for teaching subjects 
m connexion -with the public health, such as nursing, first aid 

• to the iiiiured, and hygiene, and that tho fee adopted by the 
London County Council of £1 Is. for each lecture is one wliich 
appears suitable for general adoption. 

(C) Minute 263, .4./I.M,, 1010. That a fee should be charged 
for ambulance lectures given to tho British Bed Cro.ss Society, 
and that the fee be not less than £1 Is. for each lecture. 

Slcdical Practitioners and Poad .‘Iccufcnfs. 

Motion by Buckinghamshire: That tho Representative 
Body is of ojiinion that some arraugement should be made , 
for luiymcnt for the emergency services rendered by 
doctors to patients meeting with accidents on the roads. 


turbing to tho lieges ; and (2) that any noise from 11 p.m. 
to 6 a. in. which is capable of being irrevented or mitigated, 
and which is dangerous or injurious to health, shall be a 
nuisance within the meaning of tho Public Health Acts. 

Causation or Puerreral Morbidity and Mortality. 

Maternal Mortality and Morbidity. 

Motion by South-AVe.st AA'ales : That general practi- 
tioners should be adequately represented on' any committee 
which may- bo apjiointed by the Association to consider and 
formulate schemes for the inqirovement of maternal mor- 
tality and morbidity. 

• National Health Insurance. 

Scheme of-the Spa Federation for Spa Treatment 
of Insured Persons. 

Amendment by Hahroc.ate : ■ Tliat snbpara. (ni) of the 
reconimendation of Council (Supplement, April 28tb, 
pp. 168-59, ])ara. 128) be deleted and tlie following sub- 
stituted tberefor : 

That an initial certificalc as to ' mc.ap.acity for work up to 
one inonlli be given by llic home practitioner, any subsequent 
certificates that may be necessary being given at the spa. 

Medical and Dental Examination of Insured Persons. 

Motion bj- AA'indsor; That in the opinion of the Repre- 
sentative Body the establishment of periodical medical and 
dental examinations of all persons insured under the 
National Health Insurance Acts is urgently called for as 
an economic proposition, having regard to the return so to 
bo obtained in licaltb and productive efficiency; that every 
such insured person, when accepted as a jiatient on a 
doctor’s panel, shall be by that doctor medically examined, 
and the result of that examination placed on record; that 
preliminary examination shall ajiply also to dental examina- 
tion when that additional bcnelit is included and available 
under the National Health Insurance Acts. 

Hospitals. 

Indn.drial .Iccidcnfs in Hospitals. 

Motion by Newcastle-on-Ty.ne : That industrial accidents 
should not be a charge on the voluntary hospitals or on the 
services of the visiting staff. 


ittr&iral ^ssariirfion. 

CURRENT NOTES. 


Venereal Disease Schemes. 

Motion by Edinburgh and Leith: I’hat the venereal 
disease schemes which are at present being administered 
are proving inadequate to secure the iiropor control and 
treatment of venere.-il disease, and that it is essential that 
further jiower should be conferred on medical jiractitioiicrs 
and local authorities with a view to .streiigtlieniiig the 
yoluntai-y system by iilacing a “ compulsitor ” on all iiersons 
infected with a venereal disease in order to .secure the 
suhmissioii to treatment, and coiitinuaiice under treatment, 
of such iiersons until discharged hy a registered medical 
jiractitioiier. 

- Case of Tyndall v. Alcoeh. 

Motion by Bath : That the Re]ircseutatiA-o Body regards 
with consternation tho decision of tho Assize Court in the 
case of 'Tyndall r. Alcock and the dismissal of the'aiipcal; 
that tills decision would seem to expose any surgeon who' 
aKlibugh operating in good faith and with due precautions^ 
failed to obtain a perfect .result from his operation to be 
found in damages by a jury of laymen; that while recog- 
nizing that trial by jury is an integral part of the Consti- 
tution the Representative Body desires the Council to 
consider wlictlier means cannot be_ found to ensure that 
expert witnesses appearing on opposite sides. in a case shall 
not so confuse the issue by a divergent representation of 
facts tliat a lay jnrj- cannot assess these facts at their true 
value. 

Public Health. 

Hoisc and Public Health. 

Motion by Edinburgh and Leith: (1) That in the interest 
of the public health the British Medical Association should 
support any measures whicli may bp taken to so alter or 
amend existing legislation as to give gieater power to local 
authorities to suppress unneccssarj' noise which' is dis- 


Some "Work of the Week. ■ . • , 

May 10th the Charities Committee of the Associatioi 
icatcd certain mimevs to the several chanties, discussed 
rious methods of ar'ousing a keener interest in mediea! ■ 
iritics amongst practitioners throughout the couiitij, 
d dealt with a few points of internal administration.- 
iriiiT the week representatives of the Insniance Act- 
11 fttec again discussed with Sir Arthur Robmson at 
Xistry of Health the vexed question of increased 
kness claims. As the outcome of this discussion S 
M blnsnn will iireiiare a memorandum, which will 

by the ripnLnitativ of the Insurance Acts 
nrior to li further discussion with the Ministry s 
mniitt 1 Library Subcommittee also met 

Hng’lhe week and discussed various questions touching 
tlif future of tiio Association s Library. 

conference of Medical Staffs of 
Ae wish to remind the f conference which 

ipitats throughout Association’s House 

to he held at the B g ^ to consider hospital 

Wednesday, June 6t , - ^ jR ; to the medical pro- 

itributory schemes in tlmii re - ^ to lie 

Sion. The Medical. SecreUiy 

vised at the . earliest oppor " -.ij-tcd to attend the 
n-esontatives who have ‘ of representatives 

ifereiice, as if a sufficient number ot rep 

iiifv their intention of being p similar to 

arrange for reduced A.,„"m Meethig- 

ise adopted in connexion veturn journey. 


May 19, 




Medical Services In India, 


r RUPPLLMr.NT TO TUB 
LnnxTisii MKi)icAL Jocix.sxt:i 


21S 


MEDICAL SEimCES IN INDU. 

IIKOIIOAMZATIIIN SflllAln. 

In* tlic of I'clininry lOth wo ivpnKlutod, 

E-l-mtiiiUv in full, a ini'tnoramhun on Iho loniis iiiul cou- 
tUtions of appnintments to porinunont cominiv.sions in the 
Indian Metiical Sorvii-o, i'^^nod from Iho IiuHn OiVwv. Tho 
Secretary of State for Jndiii has now sanctionod a .sohomo 
for tho'rcorganir.alion of the medical f-orviecs in India, 
}>a<;cd on proi)0‘^:ds framed hy tlio Covornmont of Jndia in 
eonsiiUation with the loenrgovornmonls. 'I'lio details of 
this scheme arc omhodied in the eommnnicine hy the 
Cioverninont of India printed helow. Tlie matter is hoing 
considered this week liy the Kaval and Military Committee 
of tlie Uritish ^ledieal Association. 

COMMUKIQXTK BY Tfli: OP INDIA. 

1. In para. 25 of llicir Beport the Ito.val ComniisMon on (he 
Superior Civil Sc^^iccs in India nTomtnended that a Civil Medical 
Seivice should Iks conslhnlcd in each province, piovision heiiip 
made for the nminlcnanrc of a Minicient inmdn'r of British oflicers 
to pro\*idc adequately for medical attcndnnrc on Brtlish memhers 
of All-India Services and their falnilic^, The Go\einment of India 
have since been in correspondemv with the Bocal (io\cnuiients 
and with His Majesty’s SiTrotary of Stale for India on the 
(lueslion of giviii”’ practical cITcct to lhex«* lo'-ommendadoiis and 
the Secretary of State has now f.inclioned the following r^heme, 
^Yhich is based on the proposals fiaincd in consultation with Local 
Govennnents. 

2. The Indian 5!cdical Sorvic**, ronstituted on the hroad 

lines as at present, will ho retained piiinanly to meet, the needs 
of tlie Indian Army. In order to niaintnin (ho necesvury niiniinnin 
war reserve of military medical ofTici'rs and to provide for Ktiropeati 
medical attendance for Kuropean otHcers of the Superior Civil 
Sen ices and their fnmili''s, lx)cal Gom'I iimenls will he n'qnircd 
to employ a Mated number of Indian Medical Service oflicer.*:. 
The Government of India will draw on the saiiie Service to meet 
requirements of tho civil administration for which they are 
re=!poiwihIe. 

has been calculated on as proci«e a liasN ns 
possible that the war ro-sei-vc to ho employed hy tin? civil side 
s lould consist of 131 Brilivh and G6 Intltan ofliccc.^?. The larger 
number of BritLMi officers due to the fact (hat British ofneer-s 
cannot ho iccrnitcd in India in an etnergcncy from the ranks of 
private practUioners. 

^’(irifJicqvircvuiitf . — Tlie other faclor which enters into the 
*!" making adequate anangements foi 

^hendance on Britisli pci'sonncl of (he Superior Civil 
adminw their families, and for tlic requirements of the civil 
^ for which Llic Central Government arc respon.siblc. 

t-hc provision of a number of appointments 
irlainL/ “ rcMduarr,” the incunihcnls of which must be 

co-nin hi civil cmplovinenl, FO as to ensure the 

nuntc a skeleton statT to cope with the medical leqnire- 

troitm^ni Government, whelhor for (he purpo'-e of 

troaifvi adniiinstratioii, and who cannot therefore be 

• of the war reserve. 

S^ervirt»°Afn!!^ th^c data, the total number of Indian Medical 
The AMr,:] ^'^qoircd for civil employment is calculated at 302. 

holow. (1) War icscrvc, 200; (2) For 
and Politir'.i n« ^ 46; (3) Bcqnircments of Foreign 

the Govcrnnient^^f^T^'^'J^' *^POcial posts under 

and Aclon 9 * Ilcaltb OfTiccrs, Bomb.uy 

who would iirtf K of 5 per cent, as allowance for officci-s 

total 302 m ^''*'*hnble on mobilization owing to ilhic.ss, 15; 
represent against (2), (3). (4). (5). and {6} 

E>>ro^ns a^d 90 

i-cmahli'no for 302 ofTiccrB, 237 p05ls arc icquired. 

leave ^e';e^v^ f i i ®®oers will constitute llic leave and study- 
“'•ailable undor li P"" Of Hie 237 posts, 59 arc 

Toreitrn and PnVf ^ i India, including posl.s in the 

^ hie provint^, no ™ provided 

*nents of Cirii ’ q • ^ posts primarily represent require- 

altendance and matter of European medical 

^ the medical Brilisli officers. This cstimato 

^npoiior Civil of the European members of the 

'’‘dll change from their families is based on data which 

'^hl officers nrnd,. to year as proportion of European to Indian 
‘ fiodicaliruu^^ H-»cforo. be 


periodical <rruitr,J °'™\mslics. It will, therefore, be subject 
66 posts will im i necessary, to revision. The remain- 

^PPoinlmonts Europeans or Indians; 28 out of 

open to officers rxf ® Government of India will cimilarly 

Y reserved for the' Tnl' hsls of {a) posts to 

^’^r wlnMi uiaii r, . 


squall 


'^hich Indian Medical Service and (6) reserved posts 

'-H^^Wy -ivitli European nfT service will be eligible, either 

^ommuniqng, - P officers or e.xchisively, arc printed with this 


7. Ihuler regiilalions framed by the Secretary of Stale in Council 
in 1925 under lliile 12 of tlic Devoluiion HuIi^s 268 appointments 
nio at prcMMil reserved for the Indian Medical Service in province.s. 
The new scheme, which rc'^erves only 178 po^U for lliein, will 
giadttnlly reloa'-o 90 posts for ' Provincial Medical Services. It 
represents the innxiinum whicli can at present be sot apail for 
these icrviccs consistently with tlie need for providing economical 
cinployinent in penci; time for llic Medical War Reserve of the 
Indian Army, and willi tbe obligation to provide European doctors 
for European pcr.sonnel of the Superior Services. 

8. The adoption of Ibc new list of reserved posts will leave, 
on tlie civil side, a surplus of Indian Medical Scrv'icc officer.s who 
arc now holding appointments whicli arc at present reserved for 
(be Fcrvicc. Tlie e.Kisting rights of these officers will be fully 
prcsi'rved, and pro-pects equivalent to those affoidcd by the present 
list of reserved posts will lie retained for Ibcm. These prospects 
will be allowed to diminisli only j/ari jmssit with the absorption 
of the surplus which will exist until (he number of Indian Medical 
Service oflicei's now in civil employ is equal to tlic number of posts 
reserved for (hem in the new list. The detailed measures required 
to safeguard the piospects of Indian Medical Service officers 
already in civil employ arc now being worked out. 

9. Ill the imerests of the Army, the Local GovernmenU, and 
of officers themselves, the following rules will come into force, 
foitbwilh as an integral portion of tlie scheme: (i) Liability to 
serve on cither civil or mililaty side will bo a definite condition 
oT scnice for nB fiitnie cntranLs to ibc Indian Medical Service; 

(ii) no offictr will be tran‘-feircd to civil employment without the 
con*:ciit of the Goienunent of India and Local Government; 

(iii) an officer Iran.sferred to civil employment will not ordinarily 
be liable (o lie lecalled to military employment (except on general 
or pariin! mobilization) without the con.scnt of the Local Govern- 
ineiil. but tbe Government of India will retain the power to 
rcc.all an officer ngaiii.st the vvi.shes of a Local Government in very 
exceptional ca«es of abi-olule necessity; (iv) a Local Government 
will not be at liberty, without the consent of Goverament of India, 
to return to military employment an officer transferred to cinl 
employment ; (v) all offirci's in civil employment (including tlio^c 
now ill the Service) about a year before Iho dale on which they 
arc expected to be due for promotion to the rank of Colonel will 
be required to stale whether they wish to return to military 
omployincnl. in order tlial they may be considered for promotion 
to ndmhiistiativc rank; (vi) those officers who elect to return to 
inililary cmployinenl will be recalled and employed in a position 
suitable to their rank willioul, however, any guarantee of 
eventual promotion; (vii) the case of each officer will then be 
considei'cd on its merits when bis name comes up for promotion, 
and (u) tlio<o considered suitable for militnrj* promotion will be 
lotained on (be military side until promoted to administrative 
rank, after whicb they would not normally revert to civil employ- 
ment, while (A) tho^c not considered suitable for promotion will 
normally iTverl to civil employment or, subject to approval of 
military antliorities, be given the option of remaining in militaiw 
employment in ibc rank of Liculenant-Coloncl until ictireraenT; 
(viii) those officei-s wlio do not elect to i*clurii to military employ- 
nieiu will cillicr (o) sever tlicir connexion with the Indian Medical 
Service and beconn* incinbci's of the Provincial Medical Service on 
such Icims as may be mntnally agreed upon between themselves 
and tlio Local Govc*iimcnt, in which case (hoy will cease to belonr' 
to tbe war reserve, or (6) will continue to belong to the Indian 
Medical Service, in which case they v.ill bo eligible for furtlicr 
promotion on the civil side, and will continue to belong to tlic 
wav reserve provided that lliey do not hold residuary appoint- 
mciitb. Also they will be eligible to receive promotion in miliUirv 
rank, as at present, on the basis of the civil administrative posfs 
whicli tlioY hold: (ix) an officer wlio desires permanent civil 
employmciU, but does not succeed, in - obtaining it, will be 
guaranteed employment in the Mililap’ Medical Services unless 
he is unfit for active sciwico, or there is some other cquallv valid 
impediment to his being employed on military duties. 

Civil Appointments Reserved- for Ofideers of the Indian 
Jdodical Service. 

GoVERNMEfTT OF IkDIA. 

Department oj Edneation, HcaUh and Lftmls and Home 

Dipartnn ut. • ■ * 

•1 Dircctor-Gcnornl, I.M.S. 

•1 Deputy Director-General, I.SI.R. 

12 AbTfistant Directors-Genemt, J.M.S. 

*1 Supeiintendent, .V-Ruy Institute. 

1 Imperial Seroiogist. 

*1 Cliict Medical Ofliccr, Dcllii. 

*2 Civil Surgeons, Simla. 

1 Civil Surpeon, Coorg. 

1 llealth OHlcoi, Simla. 

*1 Assistant Director of Public Health, Delhi. 

tl5 MetHcal Research Department appointments. 

‘l.Scnior Medical Officer, Port Blair. 

1 Civil Surgeon, New Delhi. 

♦1 Public Health Commissioner with the Government of India. 

30 

Incumbents of posts marked witli an asterisk 
recallctl on mobilization. Of the posts marked 
Director-General, Indian 3Icdical Service, and 1 
Research Dci)artment are liable to be recalled on 


to bs 

(I) only one Assistant 





May 19, 1923] 


niootlncfs of Branches and DMsfons. [ r.Htriaii 'sii:i>iCAi*^Jou(;SAL 2t7 


BHANcil AKD DIVISION iMEKTlNOS TO HE HELD. 
U\ST Yohks and Noutii EiNcor.N DiuNcir ; East VonicH Division*.— 
Tho nnnun^ pcucral mcoiuv* of (ho Ea‘^t Vorhs Piv^ioii will hi‘ hoM 
in Wilberforco Iloud', Hull, to-flAv {ITiday, Ma;v* ISlh), n(. 3.30 p.tiu 
Af'ciub*. To Tccoivo iUo lumual tvporl of the Executive Conmuttco 
and (ho treasurer’s (iiunieKiI slalcmeiji ; (o consider (he new Division. 
Model Huks of OrgainAalion; to elect oflicei-s; to loeeive Iho fvrst 
link in (ho chain of oflicc for (lie rhnirnmri’s h.idRn from Dr. 
Jrackav, (ho retiring chainn.'in; to consider the provision of n prize 
for medical students at (he University College. After ten there 
will bo an inspection of local antiquities, with n commentary by 
the Director of Museums. 

Glasgow and West or .Scotunt> DnANor.— -Tlie annual ineeliiiff of 
tho Glasgow and West of ?-cotlnnd llranch wiU be \ie\d in (bo 
Pathological Department, Koval Infirmary, Glasgow, on WednoMlny, 
May 30lh, at 2.^ p.m. After tho annua! meeting Ihorr will be a 
clinical demonstration given l>y tho memhers of tho gtaff. 

MErnopoLiTAN* Cor.VTiES llRA.vnf. — Tho annu.al genorni inectinp of 
tho Metropolitan Counties Hranch will bo hold nt tho British 
Medical Association House, Tavistock Square, W.C.l, on Tuesday, 
June 19th, at 4 p.m, Business : (1) Report of scrutineers on election 
of oflicers; {2) Annual Report of Couneil; (3) report of renresenfa* 
lives of the Branch on the Ccnlr.al Council ; (D prA'sidcnlial address 
by Dr. Christine iturrell entitled ** Our changing times,'' 

' MirnopoLm.v Col'ntics Kraxctt : CAMHKitwEix Division. — T he 
annual meeting of the Camberwell Division will ho held at 
St. Giles’s Hospital, Cambenycn, on Tuesday, May 22n(l, at 
9 p.m. An address will bo delivered by 3Ir. Jnme*? U. Ogden on 
Tut-ank-Amen’s tomb, 

: CTtE5Ttr.rin.n Division*.— A meeting of the 
Id at tlie Koy.a) JlrKpitnl, C/iestcr- 
' * at 3 p.ii)., when tlicre uiJI be a 


North Carnarvon AN*n A.vclesev Division’.— T he annual meeting 
Carnarvon and Anglesey Division will be held at Ihe 
Bndgo, to-d.ay (IVidny, .^fnv 18th), at 
) *^8<^Dda : Election of olTicers ami cofnmitti'fs , reception of 
aniuai report niid financial ftalcmciil; con.idcrnlioii of I lie Itcport 
instruction of t)io rcprc'ciilnlivc. Tim cliair- 

^ 1 ■( V' members and ladies to ten at 4 o’clock 

in tlio hotel gardens. 

BnAxcii.-Tiie final clinic.al 
Sa5m,rin hi'] of Scotl.and nmiicli for this 

^atnr<i.iV xrl^. ioM ^ i « Eawson Mcmovinl Ilovjiitnl, Oobpie, on 
dcmonstVni^n^' ^ I'*®”- Tbn programme will iiicltido tlio 

S on s'lrKital cases by Mr, 11. S. Simpson, and 

mcSist^ n 1 liy I2r. J. 1$. Simpson. Golfing 

of llio crcill S“npson baa arranged for the cour(c«.v 

them Ooniocli to be extended to 

Iicid at Kide ,1'’® O'""'®' meeting of tbc Braneh is to bo 

nicetine of ^ Tliis will bo the first 

fsland ilivisfon^ jins been held in tlio area of the 

-A° ’ r °Vi"' CanNAnvoif akp ^r^nIo^-lrr^ Division’. 

Biri'ioa will hi l'’i1 , Carnarvon and Jlcrionctli 

Iwsday, itay 23lb' ^ ^ >r®>norial Ifospital on 

Oxroan Division’.— T he nc.xt 
lofirma'rr Orfowi Division will ho held at tho Radcliffo 
Hcclio7if a May^rd, at 2.30 p.m. Agenda : 

G. GluindlDr^ Division; clinical cases; Dr. 

lantern slidw^ and treatment of bronchiectasis 

meeting of''the™hJn^T*'''^ •‘fiJ’Bi'i'd nnniial .spring 

Ro°yaI X d-\Yalos Branch will be held at 

’^S'lda: EiS S'ny .25ib, nt 3.30 p.m. 

Report of Council for 192^-29 ; consideration of Annual 

*^„3^o™oo™fiiiiiE Bp.AN’cn : Sou-rn-WnsT Wales 
iield on ThursiKv Soutli-3Vcsl Wales Division will be 

jarmarlhen when’ « a' ’’ ® p.m., at tile Ivy Busli Hotel, 

films will bn’ of medical and other cinematograph 


BtSf '"‘oifodiato meeting of the South 

^ruro, on Tliursdiv at ^ ol.i^ Koyal Cornwall InCrmar;^ 

llr.LG P-m. Agenda i-Papem am 

of tho caecum ‘ohsirnn.”;’ "olcs on cases of aplastic kidney, liporo 

findings, death’ from d niJel*; f’J' “ '’®’'d with unusua 

Eric IVordlev • Th^ ir^ ^Khotif pre-operative glycosuria 
ft puzzling abdomin-^i t-^ansfusion problem ; Dr. William King 
Dr. V = Myosarcoma 

ttanci^ ajjjj : Sun and air bathing; Di 


SrrroLK Briy m i » xtt 

he post-graduate Division.— I n connexion wit 


rtancis anri n E 

kbcrculosi^. ‘y Ch^-n ; Tho use of sanocrysin in putmonar 
^toicapula, * Graham: Congenital high clevalion 

fihr«^ (®^tuiday, Slav Wi’h?''^ i^o Herder will give a lectui 
J««'s and their beariim « ’ P'”'-' o" etiological factors : 

Sp-®- a clbic of Coffee will be served i 

bvl J'-if Th„“"^ "dll be held on Sunday, Mi 

and their gu^^ medical practitioners 

tS'* meeting of tho West Somers 

(Friday Somerset Hospiti 

“S: consideration nf ^ ■ **’0 Annual Eepresentati' 

, ‘ucion of Annual Deport of Council. 


^tccUuijs of BrttucljcG anil Oxinsious. 


Don.sET AN’i) West Hants BiiANar : Bodrnejioutii Division'. 

The niimiiil meeting of llio Bonriicmoiilli Dinsion ivas held on 
Jlny 8fh; the nniuial report and fiiiancia! statement were adopted, 
Tho following ofiicers were elected tor the ensuing year : 

Chairman, Dr, Aden, ricc-C'/iairmaii, Dr. JlcCall. Honorary Srcrftnry 
oml Trra/turrr, Dr. C.irti-r. Heyrreentativrs in Hrjirefcntatirr B'nly, 
Dr. 1.0 Plciiitug null Dr. Johnson Smyth. Ucyuty ilcprcfcntalirc, Dr. 
Mitlioiiictl and Dr. Hutton, 

A proposal to hold meetings of tho Division in the evening 
instead of in tho afternoon was referred back to the Executive. 


LAN’CAsiiinn amp CnEsninE Bean'ch : Mid-Chesiiire Division. 

At a meeting of tho Mid-Cheshiro Division at tho Altrincham 
General Hospital on Jfay 7tli Dr. Capo.v, physician to the Doyal 
Southern Hospital, Liverpool, gave a lecture, illustrated hy lantern 
slides, on iiilraeranial birth injuries. The ha.sis of this lecture was 
a Ecries of autopsies and clinie.il observation. Tho causes, patho- 
logy, symptoms, and treatment were fully discussed, and Dr. Capon 
received a cordial vote of thanks for a lucid and instnictivo lecture. 


LAXCAsninu and Ciiesiiire Branch : Warrington Dm:ioN. 

The annual meeting of tho Warrington Division was held at the 
Infirmary on May 4tli. 

Tho following officers were elected for 1928-29 : 

Chairrnnn^ Dr. I.. 3. B. Tasker, rice-Cliairninn, Dr, tV. TI. C. rntr'icU, 
Srrrrtary aiut Trennirfr, Dr. tVilliam Grant. Jleprcrerrtntire on Branch 
Council^ Dr. Donald Ferguson. Hepretentatire in Hepretrnlalire Body, 
Dr, J, B. Jfan.NoM. 

A general discussion on the Annual Report of Council look place, 
.and tho roprescnlalivo received instructions. 

In conne-iion with the proposed contract rate for juvenile Odd- 
fellows, strong opposition was expressed to any contracting with 
insurance tociclies. 


IfETROrOLlTAN CoONTIES BRANCH 1 CamDERWELI, DIVISION. 

A MEETiNO of tho Camberwell Division w.as held at St. Giles's 
Hospital, Camberwell, on April 24th, when Dr. Cox was in tho 
cliair. An address was delivered by Dr. Guy BousYielp, patlio- 
logist to tho bospital, on modern mctliods of combating diplitbcria. 
Tbo lecturer criticiRcd tho methods hitherto used in tho dja-nosis 
of diphtheria; ho did not agree with tho view commonly held of 
tbo infallibilify of the throat swab, but urged more citensivo uso 
of tho Schick test. Dr. Bousficld fully explained the method of 
performing this test, and demonstrated .a number of cases showing 
the positive and negative reactions. After tho lecture an inter- 
esting address was given by Dr. J. G. Forres of the London 
County Council. Public Health Deparlmcnl on tho statistics com- 

E aring the incidence and mortality rato of diphtheria in tbo 
oroiigh of Camberwell during recent years. Several members 
look part in tho general discussion later, and the meeting closed 
with a hearty vote of thanks to Dr. Bousfield and Dr. Forbes. 


MrrRoroLiTAN Counties Branch : Lewishah Division. 

A MECTiN’C. of tho Lewisham Division was held at St. John’s Hos- 
pilnl, Lewisiiam, on May 1st, with Dr. D. J. Miller in tho chair. 
Mr. WiNSDURY White showed a case in which- he had removed 
the left kidney with an oxalate stone. He also exhibited tho 
nozzle from an enema sjTingo which ho had e.xtracted, with tho 
aid of tho cysloscope, from the bladder of a woman who had tried 
to induce abortion. Dr. Golushith showed four cases, tlie fii-st 
being an untreated cpitlielioma of the region of the ej-e and nose. 
The second patient was a man suffering from dermatitis herpeti- 
formis, which was very irritating at night, but bad no constitu- 
tional cRccts; it was treated with arsenic. Tlic third patient was 
a child with systematized naevi on one side; and the fourth was a 
man with black hairy tongue, wliich rr.'isled all forms of treat- 
ment. Dr. OrENHEiM showed four patients, each of whom Iiad had 
the radius plated, tho movements being good; he also exhibited 
a case of fibrocystic disease of the humerus, occurring in a girl. 
Threo eases were shown in which the clinic.-!! symptoms were 
similar, but the diagnoses wero respectively kinked colon, gall- 
stones, and duodenal ulcer. Dr. E, H. Roberts showed a case of 
pleurisy with effusion, which had cleared up, but pyrexia per- 
sisted; the X rays shoxved thickened pleura. Dr. Hallinan moved 
a veto of thanks to tho mcmbci's who had shown cases. 


w.xroRD A.au heauikg lsranch : vviKnsoE UrvisiON. 

A porOLAR lecluvo on “ What sliould wo eat.® ” was given bv Dr 
S. H. Daukes, director of the Welicomo Bureau of Scientific 
Research, in tho Small Town Hall, AVind.sor, on April 20th under 
the auspices of tho Windsor Division. The speaker was’ inirn 
duced by Dr. J. J. Paterson. 

Dr. Daukes dealt first with fads and fancies in connexion with 
food, saying that many ideas called fads were customs or habi^ 
based upon sound reasons, while “ fancies," especiallv thiSo 
children, should bo tenderly dealt with, for there mipbt b^L i 
grounds* for tho preferences'^ and antipathies! He th“n emnhal^T 
the importance of the ■’ aesthetic " side of digestion e“pSL^ ?b^ 
parts played by appearance and service in their mSuSica oif tl 
Sow of tie gastric ju.ee. Ho proceeded to discuss tho question 



srs mat 19, 192Sl 


National Insurance. 


r FurTTjr.imitT to mt 
LIlRiTiaH Mj:dic*l JoueXai. 


of cookin<». Some forms hampered llic digestion, the frying-nan 
bein'' a noted offender; overdone meal was less digestible Uian 
imde°rclone, and Iwice-coohcd food was to ''’‘I'.urt Hii 

and saiiccs led to the eating of more food than was 
vatue was diminished if Ihc food was not properly masticated. 


The "speaker 'then oiiUined the requirements of various types of 
person*^ in Quality and quantity of food in relation to its content 
of vitamins: ho explained the method of measuring values by 
caloritie standards, ‘and described the content of a inmibev m 
common articles of food. An average city worker needed 2,500 
calories daily, and an average woman a little less. Atlcr- onl- 
linin" a model menu that would yield the required propoHions of 
proteids and vitamins. Dr. Daukes referred to the ill effects of 
vitamin deficiency. He considered the hrowii bread agitation 
overdone because with the usual mixed diet white bread would 
suffice. The ordinary English dietary -was generally adequ.alc in 
respect of both calories and vitamins; deficiencies were felt by 
those who lived under abnormal conditions. Variety in diet was 
an essential, but the food must be sufficient as well as varied; 
it should be well balanced and rich in vitamins, but free from all 
chemical additions, Tho plain, simple foods had the highest 
value; they could bo best suited by the instinctive food adopted 
bv people who lived on the land. He was convinced that the 
craze for “ patent ” foods had gone beyond all reason. Answering 
questions, the lecturer said that one of the worst features of the 
present day was the excessive amount of meat consumed; dealing 
with diet in cases of rheumatism, ho rccomniendcd the restricted 
use of meal, and added that there was the greatest value in 
dairy produce and fruit. Dr. Daukes said tho food value of beer 
was low, but the vitamin content was high. He stated later that 
he thought imported meat was an admirable article; the public 
could feel sure at least that it had been well inspected, while 
there was not always the same guarantee of home-killed meat. 
Good tinned fruit ivas an excellent food, and tomatoes kept their 
vitamins well. He believed that frozen foods did not lose their 
vitamins on the way over. 

At the close of the proceedings a vote of thanks to the lecturer 
was passed on the proposition of Dr. Gorr. 


guilty of manslaughter and sentenced to seven years’ pen 

*’'Tho^?cctiire was followed by a di'^cus^ion in wliich Dr. Doka: 
Hall, chairman of tho Divi'^ion, and Mosyi-s. Meai), >\AtLiKC.T 0 
BoRtAisE, I3EnE9For.D, Blabek; SuMAipniiAYEs. John 1 lowers, ura 
Bunker, Bonnalie; Bovle, and Morgan look part. On the* molr 
of Mr. Alderman Cane, seconded hy Mr. Bentiiaji Stevens, a hear 
vote of thanks was accorded to Dr. Parry for Ins inlercsting ai 
instructive lecture. 


South-Eastern of Ireiand Branch. 

The annual meeting of the SouUi-Easicvn of Ireland Brandi was 
held at Kilkenny on May 2nd, with ihc president, Dr. Myles, in 
the chair. Dr. J. Mitchcdl was elected president for 1928-29 on 
the prtiposition of Dr. Walsh, seconded hy Dr. Casstn. A vole of 
thanks to tho outgoing president was proposed by Dr. Grace, 
seconded by Dr. D. Walsh. 

The following officers were ciccicd for (he year 1928-29: 

Honorary Secretary, Dr. Grace. Honorary Treanurer, Dr. Jellclt. Tieprc' 
fentath'e on Irhh Cotmnittec, Dr. Cassin (Jlcntal HospKal, Kilkenny). 
ltel)re(,entaUm in 2iepr€$entatire ilody, Ur. Moore (Fresliford). Deputy 
Heiire^entativcs m licprcscntatii'c Body, Dr. L Mitcirell and Dr. IV. 
Phelan, 

At a meeting of the Branch Council the hai-d case of (he widow 
of a late member of the British Medical Association, who was left 
penniless with eight children, was brought to the notice of tho 
members present by Dr. M. Walsh of New Ross. It was 
unanimously decided that a grant of £25 should bo made out of 
the Benevolent Fund to the widow. The question of organizing 
the Benevolent Fund was fully discussed. 


Sussex Branch ; BmunTON Division. 

The annual joint meeting of the Brighton Divi.sion of Die British 
Medical Association and the Sussex Law Society was Iicld at the 
Dispensary on April 26th; there was a good allendance of medical 
practitioners and lawyers. Dr. L. A. Farry read a paper on 
criminal abortion, with special reference to ihc case of Dr. 
Coliins, and, emphasizing the importance of the subject to botli 
professions, slated that the practice was never more prevalent. 
The law on the, matter, which was quite clear, was comprised in 
Sections 58 and 59 of the Offences against the Pci-son Act, 1861. 
The crime was a felony and was punishable witii imprisonment for 
life. The usual methods employed were mechanical injuries to the 
uterus or its contents, the administration of drugs, and violence 
generally applied. The first was the most frequently used; both 
the othei-s were unreliable. Dr. Parry remarked (hat cases of 
criminal abortion rarely came into court unless the result was 
fatal. Since the woman ^Yas a guilty party she was as anxious to 
hide -the crime, if all went well, as was the operator; in this she 
was usually successful. The reason why a fatal residt ensued in 
so many cases was that generally the operator was an incompetent 
person and very often of intemperate habits; the procedure had 
to be carried out hurriedly and secietly without proper assistance 
or adequate aseptic precautions. Ncarlj* every medical practitioner 
at some time or other was asked by patients lo perfonii the 
operation r there was only one golden rule, and that was to refuse 
definitely and absolutely in cveiy- case. Dr. Parry discussed the 
duty of a medical man called in lo attend a woman who had had 
abortion procured on her, and said there w’as a sharp difference of 
opinion on this matter between the two professions. He held the 
view that, while professional secrecy was a matter of very great 
importance, there were cases in wliich the duty of a doctor as a 
Iq\^ 1 citizen outweighed even this, and in whidi he was bound to 
hein in the punishment of crime, although it might inroK^ a 
breach of nrofcssional secrecy.- Fortunately cases in wluch there 
was such a conflict were rare. Dr. Parry then proceeded to pyo 
r,; or-roiint as a tvpe of what frequently occurred, of the trial 
of d“ Collins for the murder of Mm. Uzielli. He was accused oS 
Siisiug her death by procuring abortion, and as a result was found 


^attottal Unsitrattrc. 

LONDON PANEL COMMITTEE. 

LiHurcs to 3!<<tioat Sfiictciits. / 

£“Sis^n£ S 

students. Tho deans of Channg Cross o ^ ^ 

?^“fonn%°pa-i ‘?f1rct!.rrr’r?:om\ic“ncmho'’rs of the conunitteo 

M a former meet^ £9 
?om^STue‘rhffid UifWe 

mciits being made f'und, but t?iis sanction bad b 

person at the ro|t “ H'o r g appliance in quest 

{vithheld ns t !^. the instruc 

was not a splint. The sec t n Committee and 

MinisC^th a roqucsl'‘u.at tho eommitlec bo informed as 
the definition of a splint. 

Jiuurrd Persons in the mod 

OS'™.;!; £, ““'sS fl”'. 

informed hy'lhe’^Kenl one of Ui'rtute o” t 

admission and of convalescent homes, 

iurisdiclion over Uic conduct oi co mstituii 

therefore, ffinist ry’s letter that the Munster ^ 

It was gathered from the Min t 5 s examined an insuycd per 
of opinion that wljerc \ cntiHcd to acc 

ra's- tS’ie : 

i;F'K^^^^lic S|n^on sej^e P^MOS 

rented from to tL payment of any fee m U' 

that the rommitlco objoclod t^^^ ‘^convalescent .''“'"f.."’? 
cases wlicro insuiod peiso ,yj ^vas appreciated ih‘V 

ro^uest medical .treatment. While it ^ t , 

Minister l>‘«\r.^rc‘w nlei to interfere in the qucslioi) of 
pointed out ’‘^fler'tho National Health Insuraiicc Act. 

paj'ment oi un 

LONDON INSURANCE COMMITTEE. ^ 

AT tho meeting of ^^ 3 X"rma^n Sen 


mmiUee in succession m .... 

SuppUmentaru , 1 ? nctuiry'^hnfl found' t’ 

It was ro^^iccl tlmyhejo^— 

ripeot of services ‘O'fore.lS^nd this amoi 


is lo be distnbutea Mnog if he effect to in® jn“^ 

witli the committee ^niu g sii^htly less than one ha p 
proctitioiier is the P‘‘I“X/or twopence for overv pei^n on 

nor unit of Ci'cdil per quai-lei . v ^ furtliei sum is 

?Gt ttirouehout Hint year. Em , - aetcrraiiintion of 

te^dislribltcd .“"Bcqueiit upon C tlie 

Central Practitioners ‘mount provisionally alloca^ea 

of tho difference between H e amou ^ avails 

the committee and ‘JiSq and will mean an ihc'vi 

is rather more fflf >' quar er, or fourpence for the y< 

one penny per unit of credit pc. qu 

A,,r„tlnnec of Witnesses eit •’""C'l, from the Hasli 
The committee had before ’f “ attendance of 

Insurance CommiUee with r „ Pharmaceutical Servic .- 

-niSr^eS eSef tff'r-S 

f w“' and po£ed out that « subSmmitlee c, 



Naval and Military Appointments. [nr,fTl^"fiKS.”o™5it. 219 


MAY 10, 102sl 


to a decision in llio alisencc of mjcIi cvidouoo, and i]ion, if Un» 
cast' piOAVcdotl lo appenl, if ivn'i >vi(Iu‘n llio powrr of ritlicr party 
to compel tltc nltondniJco of Iho wlien (lie rvidrncr (jivoh 

m};»lil nialcrially alter the whole nsprrt of (Im <*n**r. The liOiidoii 
Coniniitlcc roMilved lo rcilernte tin* view which il. liad placed 
heforv' llic Commissioners ten years a^o (when i( was turned down 
because tlie Commissioners fell tliat more experience was desiralvlc) 
that power sliould !jo conferred upon tfie commiltee to subpoena 
witnesses in couucxiou with iiujuiries, lu reply to a t\ue-<tiau i>y 
Dr. Chase, Mi-s. lUxnn. IKiont, wlio had oron^dil forward (ho 
recoiiimcndalion^ said that the qiics-limi of reqmrinpf evidence to 
be on oath had not been consideixid. 


COLONIAL MEDICAL SEEVICES. 

The fnllnwiii^ nppeintniMiN haic been inaWo bv tbe Rccrctarv of Sfalo 
for the (Monies «Utnjij: tlu* moruU n( April : Dr. V. V. Anderson' As'istant 
.Mcdb'ul OniejT, Ilrjihh IloiidniiK. Dr. V. .McKenna, Meillcal onieer, 
Fttler.ifr#! Mniuy Slatej*. Dr* A. F. Hiown, Medical Onicer, Dtramla. Dr. 
l>. E. Wil-on, >fedicul ofliccr, Taiiirarn il;n Tcrritr»rv. l^r. A. V. Cleniincv, 
Medical Ollieer, TuJi;:an%ika Tin linrv . Lieutenant JL F. CJ. DiclcMih. 
.Ssinitnlloi! Ofneer, Keiun. Dr. K. 'nlaekiiliv, Difln’ct Mcslical OflUer, 
(\piu-*. Dr. \V. Allan, .Surj^ron .SublieiiimaiU A. II, nean, Captain 
H. Dobbin, Lionlrnant C. W. V. Macl.ay, Dr. II. tVeir, ami Dr. 
T. II. I. Pott**, .Mcdic.al Oniecri', We^t Afriran Jlerlical 


l/rt/riif Ciilh, 

'The committee fmthcr considered two cases of complaints apaiwst 
practitioners which, on account of exceptional «linicnlly in nnpor* 
tioning responsibility, hnd been Iwiet' previously ml/ouniod. In 
the one case it wns’aUcgcd that the prnclilionev* failiNl to renlixe 
the seriousness of (he patient’a condition and lo sujiply treatmoni, 
and in the other that lie did not visit when he should have done! 
Both cases were complicated, however, hv the fact that llie pincli- 
lioncr did not appear to have been piopcrly informed ns to tho 
seriousness .and urgency of (ho c.ase. In (he (Ir^l case (lie eoni* 
niillee finally agreed that the practitioner had not failed to 
comply with (ho tonns of senice, Imt on lh<' molioii of Mr. 
Meadjiore, seconded by Dr. CAnn.\Li:, it was further ngromi 
“ that il was to be regretted that tbc insured person did not 
give to the pmclitioncr when he calhd upon him ‘omu better 
indication of the urgency of his need, but it was also regit?t(,able 
that the practitioner should appear to have boon nioic couct'inod 
about tliG hour at whidi the call was made than alioul the. condi- 
tion of the patient.” In (he second case (lie cominittco found that 
the practitioner had been negligent, and atbleil u ndor, again on 
Mr. Meapmore’s proposition, “(hat it is <le>iraldo to emphasise 
the tact that a practitioner's cxpi-css obligaliou under Ids terms 
of scrvK-c IS to visit a p.-itiVnt wbo^o condition leipiin*^. and (hat 

of a sp.vifie i-.'queM 
nnwfn '?/ "‘P Obligation,” Dr. (.'Ar.iuix, in M,p- 

in ‘‘Vi believe Umto was anvone 

rc^ron.Fhnf^ relieve,! from 

rTccTc'k rcq'ucU 

■n,. p . -■ir'-urat;/ in niijtrniinn. 

PlmmwSl .P®,'"' ®" » tiroiislil forward l.v (lie 

r?naur^fn?n It ^ liut, not a monetary 

S-S f in liicarlionatc of soda 

«nort to^ wlif^ ordeted. Tlio rcnienco in (lie 

Iho J V "■>' ol.w>rvcd dial 

drae in l?e miLTirlr’ J.l" ■ " the important and the most potent, 
lliU^o so ™ dispensed ,wth remarkahle accurac?-, and 

tho pLt ot Wc^V ot ihe"er™ '’'® mattef fiom 

not TOch a noiem ‘jf hicarlionate of soda, whirli is 

of “OOTTOV ” thouRhl the qnnhnealion 

suggestion tLt nwomev n 1 r "•''s. nncalled for, and that the 
potent n,iture I * ^ in' jlo.ihng witli drugs wliich were of a 

potent wis whX inwiV “ M?'" 

»m«.ttcc, .agreed^o deleTc (he orm;n|b:”^„,'d'r 


ilftbal fiiitt ^ilitaiTT A-ppuuiimriits. 

Suigwn fns, •''AVAh jrcniCAL SRItVICl:. 

II>riint«rio“taOar'’n"J,'t\^'j_s «"SKTOn la'onl.nant fnr short srn-ice nml 

Surgooi, SnUicutena^f'/t ^.''’'.^'.Jo'T.VTrrn nnsmvi:. 

cnont II. S. Maters rroinoled to .Surgeon Lieutenant. 

Major A. T Fro ''P’*'" AH'mCAI, COIIP.S. 

dn.E.VlLs.O, ’ *° >'icufenant,Colimel, sieo Liciit.-Colonel 


ajor (sub*>t jluted for not'i- 

...... fc.ui, 

P accU On tlio Iialf-pny li^t on account of 


SiuM ticuleMnl'o' S'EDICAL .SERVICE, 

oa i'lili.'-'.'u'onant T si,? P-'.F. Depot, U-shviiloe. 

Fiji'™ Ofr" service,' and ’j’s'o^nnT'\'’'i”' *i'*- ‘«™rorarv commission 

B r “.S'heer p. o’Callaehsn P®Tnille<l to retain liis rant 
(<ir„?:.'Mor6on is his sliort-sen-i 


'oi'unce '» Ri-anted rshort '■'"’’■‘-“fia-icc commission. 

May 1 ? HSS ‘ho Active List commission as a Flying onicer 

b’ci'casMo 19 si’conrl/vii * efTect from, anti with seniority of 

“’"'•upon-Tync, liomih", "'"V "-o Victoria Infirinary; 


Jraptain Av. K Aumy Mrn 


territorial force. 

oI.S.-\?V.''l’hnicmCpni,s, 


- h' rS'?i!^;^:ishes the 

OtP- V"'- ^f“hey I 

h'dsion, OTP 'he Jledicnl lrnit™ris^^'®"'i^®? ®'h. 1927 , supernum 
''•i.C. vipn, tilasgow University Contingent, S 


VaVCAN'CIIi:S. 


llit'.MiNOiiiM .\D Jlim.i'.n Ilrnteroi-uiiic lIo.sfmL ixn Di.srr.ssinY.— 
ltt>i<!*'rit II«u««*-Surgr<in, .Salary il 50 . 

BtuwisciuM Em*eninx CoMurrrrx.— A^istaut Scliool Mcdietil Olficcr 
(iimie). Srtl.ir^ 1600 ju-r annum. 

BtiiVixcifiM TLniox.— C nhiialtv Olllccr (malf) a( (he SdIv Oak Hospital. 
Salary ai the rn(<: nf 1200 per nnnimi. 

nnfKRiT.v ixn £ 15 ^“ L»NTi 5 ni!:E ItnviL I.STinMvnv. — Fourtli }rou««*-Sitrg(’Ou 
(male). Sabary 1120 pi-r aimimi. 

Uct-TOx IXVIP.M.MIY A::n Di'-l’incFmv.— llouFC-Surgenn (male). Solan.- £150 
per nntitiin. 

RniciiTov: New Si'FPrx IlO‘-rinL »op. M'oifr:; ixn CiiiLr)nr_\.— Honorary 
Aitacj'tliflbt. 

Itrr.Mr.Y Corj.rv IIorioi*r.if. — A.«-if>tant Modicid OfTicor of llmllh (lad\). 
S.alary at tlie rate of 1<175 por jinmim. 

Cd.imuiv';!’- — CS totgc Henry Lowik Sttulcnt, 

r»vcTJi Ho-'i-ini. (Fiuj), I'ulhain Ro.nl, S.\V. 3 .^irou'‘o»Siirgcon. fjnlarv at 
tlio rate of LlOO pt'r annum. 

C^nimr Rovn. D;rir.M\r.Y. — ( 1 ) Hmi'so-Surgwn. ( 2 ) Aural llnu'-r-Surgcon. 
( 3 ) y .SmgKM! DHlcor. Salary at the rale of X 50 per annum, 

CmJ_''r.i Ho^p^TU. rou U'onrs', .\THinr S(re«'t, S.IV. 3 .— Junior Ilouse-Surgi on 
(mulol. Salary LIOD i^-r aunura. 

Cnv or J.o\E>o*; lIo«i’ira ron Dr‘n«F.< or rm; llr.mT '..nh Lr.\C‘<. Victoria 
Park, E. 2 . — HAU‘»*.**I’hy>icians (male). Salary .it the rale nf 1100 per 
uutttim. 


Cgtriir.sTiK : n.‘>r..Y CorvTV IIO'^riTiL.— Hou«c-rhy)5ici.an (male). Salary 
£150 per annum. 

Drs'P.icn : NnuTii Cou^^^r« MrxTiL IIo?pitMa. — T hird .\ssUtant Medical 

Otiicor. S.al.ary iiO) per annum. 

DruRY : Ronorcil MrxTa Ho^^pitiL, Rowditcli. — Second .Vfsi'tont Jlcdical 
DfiU'cr. S.alary ‘-350 per annum. 

Drvox ilr-VTiL Ho.«PJTa, Exmin-t»T, near Exeter.— Junior .\.‘=«i‘'tant Medical 
onhvr (male, nmnarriedl). Salary per annum, rising lo £350. 

T>i>wn* Covnty Rr<;U‘NM. EnvcAr.o*; CouMmrx.— School Medical OlHcor 
(male). Salary at llm lutc of X750 iht annum. 

Duiniiit CoY.vtY CocNcti-— Ai'ivtant Meillcal OflTccr (resident) oL (ho 
llolywood Hall Sanatorium, Wobingham. Salary at the rate of 
pcr*aimum, rii'ing to 1500. 

EtsTcocnxn : rnixcr^.? Alice Mr.wonia IIoj-pitu.. — J unior Houie-Surgcon 
(male, unmarried), riMng lo Senior after three mnntb«. Salary at the 
rate of £100 per annum .an Junior, nml £125 }'cr annum as Senior. 

Evfiixi HO'PiT-ti. ron Cintnr.r.v, Southwark, S.E.I.— lIouse‘Ph.v«}ician 
(male). S.al.ary £120 per annum. 

Ho-rnu. ron Sin: CinLnnr-v, (Jieat Ormond Street, AV.C.l.— (1) House- 
Pliyslcian. (2) Hon«4'*Surgeon. (Male‘‘, .•‘Ingle.) Salary £50 for fix 
niontliK. (3) Meilical Registrar (male) in Out-patient Department; 
►.alaiy 1250 por .annum. 

Hi;,’iDr!i-'rir.iD Rova J.NriP.'rir.Y.— Senior llou.cc-Surgcon. Salary £200 per 
annum. 

Hi.O.; Vicronn Hocpjtil ror. Sicv CniLDnEX.— Resident llnu'sc-Plivsicinn 
(lady). Salary 180 per annum. 

KiNC knw.iun vn \vn>u Niriosa MnromiL .\f£ociiTiON*.— Two Resident 
Medical OfTiccr.s at tlio Gian Ely 31o?X’«ta], Sal.aric:* 1350 and 1200 per 
annum rc'peclivcly. 

EDsCTOx RCR-U. DifTRifT CouxciL.— Medical Officer of ITcaKh (male), 

Li.rr» ; Sr. .MMr->‘s Ho-PinL.— Hou^e-Miysicinn and Surgeon. Snlarr £200 
per annum. 

Liviikpooi. iN’D SiMinin.v rop. 3 Vome.v.— H onserSurgeon. Salarv at 

the rate of 1100 p^cr annum. 

LONDON' JrwiFH IIO^PITIL, Slopncv Green, E.3.— Clinical .Vf^i^tnnt^? in 
Actino-thcrapoutic Department. 

I/ 3 XDON* U.NivEP.sm*.— ( 1 ) Prole‘.-or of Palholngv (Sir M'illiam DnnnV 
I'alary approximately 11,330 a year. ( 2 ) Laura* do .Saliceto Student. 

Mu-EnoN'ii.— Health M’orker for the Society of Friend--. Salarv llCo'ncr 
annum. * ‘ 


JIixrHFrTnn : A.xcoas Hospitu..— I lonsc-Surrcon (Oithopacdic). Salarv 
1100 per annum. 

3Dxcni>TFR XonniERX ITospitvl ror. AVoMrj: .axd Childp.e.n-.— S enior an<l 
Junior Ilou^^c-Surgcons. Salary £130 ami £100 per .annum icspcctivelv 
METr.OPOi.mx Hospitil, Kingsland Road, E.8.— Plivsician to the Depart- 
ment for DiEcascs of the Skin. * * 

3tiDDLr.sc.Y HoiMTiL, WJ.— Sufgeon and Assistant Surgeon. 

PoPLtr. Hospital ron Accidents, East India Dock Road, E.14— Second 
Resident Oflicer. Salary at the rate of 1175 per annum. 
tJUEEX Cityrj.oTTE's JliTKRXiTY IIo^PiTa, Jlarvlebonc Road, N’.3V.l.— Ai-sis- 
tant Ro.siUent Medical Otficer (male), for three montlis, and* thwi" n*? 
Senior Resident 31edical Officer for throe months. Salary as -t^sistant 
at the rate of £80 per annum, ami as Senior 1100 per annum. ' 
QUEn,v*s IIospinL for Children, Hackney Road, E.2.— (1) Casualty OfTirnr 
(2) Hou^-Surgeon (male). (3) Physician in charge of tl>e Skiii Dcnartl 
ment. Salary for (1) and (2) 1100 a year each. ^ ^ ” 

ROXIFORD U.niox.— R esident. Second Assistant 3fe<Iieal Officer fm-rMr nf 
(he OKIchurch Hospital, Romtor.L Salary at the rate of 

Hovjh.CtJiiEGr or I-hteicuns of Loxno.s-.-Charles Alorchifon .Scholar in 
Clinical Jleihcine, '-uA^tur in 


Surgeons Casualty Officer (female), and 'obstetric District 
St. Leqxauds-ox-Sea : BuanxAX IIo^tjtal.— H onorary' A-^^istant^.Irl 

SuT^iu Honokry 4hthflm?c 

.Sr. JfmY-s JtosPITU., AV.2.-Surgicol Registrar. Salary £200 per annt.o, 
St. P.vri.-s HosraTsi. ron Dieiuses of the CEYiTO-cRixiny one.vc i 
Enilcll Street, W.C.i— Honorary AnacEthetiat; ‘“‘GjhE vxd Skdj, 



SI3 3?PIjEi:^^43±ljSrT 

TO THE 

BRITISH MEDICAL JQURl^AL. 

LONDON, SATURDAY, MAY 26tii, 1928. 


CONTENTS. 


TACK 

BRITISH MEDICAIi ASSOCIATION. 

CUUUEXT NOTES ; 

Access to the R.M.A. ITohse ... 221 

Some Work at Heahquarters . . 221 

Bv-eaws rsoEP. THE Nfnsixc; Homes Reoistratiox Act . . 221 

Examisatiox or Yac.bakt.s tor SsiAix-rox 221 

Grasts is Am or SciEsrinc Work 221 

NOTICES OF JIOTIONS BY DIYISION.S 222 

ASSOCIATION NOTICE.S 222 

MEETINGS OF BR.INCHES AND DIYISIONS 223 


PAGE 

General Medical Council: 

l’REsinr.[.-r'K Aiiorkss 225 

NATIONAL INSURANCE : 

AYakwickshiri; I’asee asi> Local Medical Committee ... 226 

CORRF-SPONDENCE 227 

NAVAL AND MILITARY AFPOINTAIENTS 227 

VAC.VNCIES AND APPOINTMENTS 227 

DIARY OF SOCIETIES AND LECTURES 228 

ASSOCIATION INTELLIGENCE AND DIARY 228 

BIRTHS, 3IARRTAGES, AND DE^VTHS 228 


Siritislj iltfiiirnl ^nsocintion. 

CURRENT NOTES. 


Access to the B.M.A. House, 
private ro.Tchvay and imvcineiits Ic.odiiip; into tlio 
British llctlical Association House from Tavi^ttn'l: Sfjnarc 
aro nov entirely closed for tinfnc while cxcnvnlions are 
m progress, and the Association can take no ics|ipiisibility 
for accidents occurring to persons who may pass t.ver tlio 
site of the work now proceeding. A covered wooden passage 
las been constructed to form nn ontrnnee to tlio Imilding 
or foot passengers from Tavistock Sijnaro. Members and 
wi " 1 ° covered way, or who 

isu to bring motor cars or other vehicles into tho Associa- 
n s promiios, must proceed southwards down Tavistock 
Tirie**^’ L '’“Horn of tlio Square into 

TRfl 1 ° • turning loft ngain into Marcliinont Street, 

round Cai-tsvriglit-Gardons, thus entering 

widcTthl-’Gilu HaU the archway 


On W' 1 Somo Work at Headquarters, 
armnrrnn, Hospitals Committee completed 

tarv conference of medical staffs of voh 

Hoiwn nn TV British Medical Associati 

Note in In Juno 6tli. As indicated in a Curn 

reDreRoiitnf . ^ sufficient number 
to possihln t' notify their intention to be present it v 
of a sitirtln t for reduced railway fares at tho r; 

schorae to Bo tho preparation of -a model contribute 
Tl.oALooinUn'''^’®‘“^'^ Jiscossion at its next mcetii 
of the eoniifn!! constantly hearing of sclicmos in one pi 
’cquircmentn^-.f'^i f“f* conform to t 
Conimitton nnd' -i f’’®™ time to time by the Hospit 
schetuo is fnrm„i . 'j f nought that if a model contribute 
o"y for memhnnn''*t 1 servo as a useful guide, espe 

sdiemo niav ho h flc^Pital staffs in any area where a n 
duccted the ^^istenco. The committee a 

cottage hosr.itnin^-'^*’!. °f ® memorandum dealing wi 
j'o Association "n * 'at'^ eolation to tho hospital policy 
Siiheommittoe in 24th the National Formula 

file Jlinistrv of 'uu * Retail Pharmacists’ Union a 
®ot to discuss thn J*. • asked to send represehtativ 
lemeinhered tint P* ejected national formulai-v. It will 
o’lt the instruction nf ’“’’''"ftteo was sot up to cai 
“''“Acts Committnfsl''°m‘'‘'‘®‘ f^?"forence that the Insi 
r ■ TilP expedite the production of sxi 

I "no to report to tli "“'"’“‘f'fcc hopes to finish its we 
1 ^ f'“ "ext conference. 


By-laws under tho Nurslntf Homes Registration Act. i927. 

Tho NIinistry of Health is just about to issue draft 
model by-laws under the Nursing Homes Registration 
Act, 1927. By the courtesy of the hlinistry the British 
Medical Association was given nn opportunity of seeing 
tho draft by-laws and making suggestions for their 
amendment. Particnl.ars of theso suggestions will bo 
found in the Annual Report of Council published . in the 
.S'u/ipfcmcnf to our issue of April 28th (p. 152), under the 
heading “ Registration of Nursing Homos.” It is impor- 
tant that Divisions should take an early opportunity of 
approaching their local authorities in order to secure that 
no amendments aro made locally to wliich exception is taken. 
Clause 5 (1) of the Act lays down that there shall be no 
inspection of medical records. In order that this provision 
shall not be lost sight of tho Ministiw of Health has con- 
.sented, at the suggestion of the Association, to recommend 
loc.al autliorities to print this .section at the end of their 
by-laws, and it is very important that Divisions should see 
limt this is done. The Ministry has already circularized 
local authorities (Circular 862 of'jiarch, 1928) calling their 
attention to tho obligations imposed by the Act and tho 
desirability of advertising its requirements to all concerned 
and issuing the necessary forms of aiiplication for registra- 
tion at tho earliest possible date. , 


Examination of Vagrants for Small-pox. 

Tlio SIcdical Secretary has received a number of requests 
for information ns to what remuneration doctors should 
ask from, tho guardians, for tho duty of oxaminino- vaiRranti 
under Order No. 859 off the Ministry of Health to'dete'rmine 
if they show any sign of being affected by small-pox. This 
Order places on Poor Law medical officers the duty of tho 
daily inspection of vagrants for signs of. small-pox before 
they are discharged, and states that ” in view of the ex-tra 
work and responsibility which may be involved the Alinistcr 
will be prepared to consider any 'application which may be 
made by a board of guardians for his sanction to ‘the 
payment of reasonable additional remuneration to the 
medical officer.” The’ Public Health Committee has given 
careful consideration to the matter, and has also been in 
consultation with the vSecretarv of the Poor Law Medical 
Officei-s’ Association, and has decided that the remuneration 
asked for should he Is. a head, with a iiiiniuuim of 10s for 
each attendance. 


Scholarships and Grants in Aid of Scientific Work. 

Scholarships. 

The Council of the British Medical Association is m-o 
pared to receive applications for Research Scholarshins .i^ 
follows: An Ernest Hart Memorial Scholar.ship, of the 
value of poo per aiiiiuni, and three Research ScholarshinT 
each of the value of £150 pot anniun. These Scholai-shfps 

' [1244] 







May 2B, 10281 


iVJoctfngs of Branches and Divisions. 


r BvrPLEm:s'T to Tint 
Limmsii MEoiciz. Jocxtifxi:. 


223 


KI:^'T Bran'cii : DAnTFonn Djviston’.t-A goncrnl incclinp of tl»o 
Biirtford Hivision Avill be lu'ld a( Livinpslono Hospital on Tuesday, 
May 29lh, nl 3 p.m. Apendu : Annual Report of Council: instruct 
representative in Representative Body; elect cliairinan, 1928-29. 

IjAxcasiurf. and CiiEsniKE Rrakcii : Hyde Division. — The annual 
ffcneral mectinp of the Hyde Division ' will be held in the Hyde 
To\\'n HaP on Thm-sday, June 14th, at 8.30 p.m. 

"METROrouTAN Ck)DNTiES BRANCH. — The annual general mcclinp of 
the Motropolilan Counties Branch will bo held at the British 
Medical Association House, Tavistock Square, W.C.l, on Tuesday, 
June 1911), at 4 p.m. Business : (1) Report of scrutineers on election 
of ofTiccrs; (2) Annual Report of Council ; (31 report of representa- 
tives of the Branch on the Central Council; (4) presidential address 
by Dr. Christine ilurrcll entitled “ Our chanping times,** 

McTRoroLiTAN COUNTIES Brancti I CiTT DIVISION, — Tlic annual 
general nicoting of the City Division will be held at ilic Metro- 
politan Hosnilrd, Kingslaiul Road, E., on Tuesday, June 5lh. The 
next cUuicai meeting of the Division will be at' the Mclropolilaii 
Hospital on Priday, June 8lli, at 4.30 p.m.; tea at 4 o’clock. 

Meteopolitan Counties Branch : Heni>on Division.— A meeting 
of the Hendon Division will be held at the Hendon Cottage 
Hospital on Friday, June 29th, at 8.30 p.ni., when member?; are 
innted to sliow c.iscs. The ineoling will subscquontlv discuss the 
Bupplcmcntary Report. 


iltrftiugs af 5£5ranrlj£5 anil Oiijisions. 


BtRMiNOiiAM Branch ; Birminohasi Central Division/ 

The ntiiitial ineotln" of (be Birniinplmm Central Division was held 
on May 8th, with Dr. Beards in Ine chair. Tlic annual report of 
(ho ExeciRive Cornmittce was received and approved. The follow- 
ing ofiicers were elected to serve during the ensuing year : 

Pr. JTnrrix. Vice-C'hainnon, Dr. Beards. Honorary Srere* 
iarie*, Dri. (Jarlmtt arid Ii. A. N. I.iae. llryrcfrnintiief in Hcjirenputatirc 
JJotiy, Mr. \V. StjrJ; Adam'*. .Mr. A. W. Niithnll, Drs. J. A. Brown, lb G. 
Dain, and W. A. Marri*-. JJpjnity ItfprcfeiKative in Hrymcntatirc limhj^ 
Dr. 1>. A. N. bine. 

A letter was rend from tlic medical ofiicor of Iicalth about the 
provision of electrical and medicated baths in connexion with a 
public bath in Birniinghnm. It was decided to reply that thero 
Kccmecl to bo ample provision at m^t of the liospitnls, and that 
the probable demand would not justify (be expense. It was 
derided that expenses, such ns for stationery, incurred by the 
secretaries of tlie ^fcdical Cliarities Fund should be met by (be 
Ceiitial Division. The meeting was subsequently adjourned until 
May 18lli, for further consideration of the roporU 


Metkopoutas Counties Bn*Nai : Hampstead Division.— Tlic . 
aiir.ual mpoling of the Hanipstc.-iiV Division will he held at the 
Hampsicad General Hospital on Tliursday, .Tune IJIIi, at 8.30 p.m., 
for the election of olTicci's and Kxcciilivc Comniitlce. 

Metp-opoeitan Counties Branoi : LAiiairrit and SournwAitK 
Divi.sion.— Tlie annual meeting of the Lambeth and Southwark 
Division will he held nf the British SIcdica! Association House, 
Tavistock Square, W.CJ, on Wedneaday, June Cth. Tea at 4.15 p.m. 

Meteopoutak Canties Branch : Lewisham Division.— A mcctinR 
of tnc Lewisham Division will he held at the Town Hall, Calford. 
on Tuesday. June I9th, at 8.4S p.m. Mr. J. M. Beddine will read 
a paper on some points in the x-ray examination of the alimentary 


Dorset and West Hants BitANai. 

The Dorset and West Hants Branch held its summer meeting at 
the Ycalman Hospital, Sherborne, on May 9tb. The following 
officci's were elected for 1927-28 : 

Vte^iitcnt, Mr, A. Biisil Uookc. yire-Vrefidrnti^ Dr.'*. AVhitaker and 
McCall, Honorary .SVcrcIo; »/, Dr. SlcCiill. Hotiorary Treasurer^ l3r. 
(J rey -Kdwa rd.<. 

The reports from the Bournemouth and West Doi-set Divisions 
were approved. Mr. A. B. Rookc read a paper on some recent 
advances in medicine and surgery. The Sherborne members cntcr- 
(ained the visiting members to liineb and lea. 


Metropoutan Counties Branch: North Middlesex Division. — 
V Id of llio North Middlesex Division will be 

Sncil 1-’^* 2.30 p.m., in the Southgate 

1^- Agenda: Financial statement for 

1^1... I- ni'isioual officers; Annual Report of Council: 

instruction of representatives in Representative, Body. 

Division.— The annual meeting of the 
nenlo^. at tlio Lincoln General Dis- 

Jf “fl-wem- 7 3 p.m. Agenda: Eleclion 

represStivJSTe?^^^ “ 

Tneetffie''ofT» = St. Pancras Division.-A 

6me“v°u B ranch : WiLttsnEN Divisio.v.-A meeting 

FmVii! A- Wednesday, June 20th. Dr. Margaret 

Limhc Will discuss the care of the infant. argartr 

11k or Scotland Branch.— Tlie annual mcetiim of 

LmWsI, Branch is to he held at Kvit- of 

Sell 1 ,'’° V" ‘''n ‘‘■rsl meeting of the 

iJranch which has been held m the area of the Islands Division. 

Carnarvo.v and Merioneth 

corr«pondcnJr rl’n^ ^ of v’ Agenda : Minutc-s and 

report of Executive Committee {members art 


bring \vith^themlhe^u;;r^Ln^“"‘rA^ ^S^rMa" sth 


and May 19th); nemonsirations of x raj 


by Dr. J. A. Davic.s niic 


nice'tirig'Tth^l^J^hh.f "Pd” MM b»4-‘birtl ann.ial spring 

tbe Eo^al Sabp MTntv lo"-daf(Frida? 

prestdont. Jri92^§'; “^sid^S.'oH'of 

-m Sr' sTths"c®a‘’on"r®?“''=^? 

Supper will be smed at 9 If m ' 3'"“= 8lh 

address by Colonel Macarthur' Entitled 
to^Pepys." which will be innst“by 


SuTsef ;;,r IT t'>bercnlosis7fn„r.“‘‘ 

Hastings DivisijSwm*^Sat'lh|,°Hffr''ll T7 '"^^tiiig of 

Road on Tuesday, June 12th, at 3 15 n m Frederic: 

members over the infirmary; and aftT-fea cliPSr' 


Bhown. 


cases will b 


Jbiaf ider Norton, on Mav 31st at 3 ff Collier; 

ricnds. After insnection nf tin:.*#, u* open to members an 

Commercial Hotel by the cLiman, D?. be provided at tl 


Metropolitan Counties Branch: JIarylebone Division. 

The annual meeting of the Slaryicbouo Division was held on 
May 9lh, when tbe ebairman. Dr. Jorson Horne, pi’osided. .Dr. 
Percy Spurcin and Sir William W’illcox were elected ebainnan 
ami vicc-cliniiTnan rc-spcctivcly for 1928-29, The Annual Report of 
C'ouncil was considered. 

Mr, AIcAdam Eccles opened a discussion on the general practi- 
tioner and paying bed.*; in hospitals. Ho described in detail (lie 
variotLs proposals llmt were under discussion in this connexion, 
and laid emphasis on (lie points that were likely to come before 
the Annual Representative Meeting for consideration and decision. 
Mr. Bishop Harsian, Dr. Hawthorne, 3Ir» Walter Spencer, Dr. 
Roxcurgh, Dr. Goullet, and other members took part in the 
disemysion, and accounts were given of the various schemes already 
in openition in London. 


AIetropolitan Counties Branch : Stratford Division. 

The members of the Stratford Division, at the invitdion of their 
chairman. Dr. Garland Collins, visited the West Ham Coiincirs 
sanatorium for adult eases of tuberculosis at D..’*. s.b.-:' > y, 

9lh, and were shown over the institution, f Ik..' ■ ■ ’i ■, 
proceeded to the council’s convalescent ho:*-: .’i;!;.. ' \V, . 

where, after inspecting the wards and grounds, tea was provided 
and the viMlors were welcomed by the chairman of the hospitals 
coniaiiUee of the council, wlio emphasized its desire to elicit the 
co-operation and goodwill of the local medical practitionei*s. 
Dr. CiiALLANS. chairman of the West Ham Insurance Committee 
responding for t))e visitoi-s, congratulated the council on its 
efficient and up-lo-dalt* institutions. On behalf of the Stratford 
Division he reciprocated the desire of tlie council in respect to 
co-operation, and referred to the fact that the clmirman of the 
Division was the medical officer of health for the borough. 


New Soutn Wales Branch. 

A Yruv'fi IPork. 

The annual report of the Council of the New South Wales Branch 
for the year ending ilarch 29th, 1928, has now been issued fo the 
iricmbei's. During tlic period under review the racmbei-ship of llie 
Blanch rose from 1,593 to 1,661. Ten ordinary’ meetings, three 
extraordinary, and seven clinical meotin|s of the Brancfi were 
held, tiie average attendance being fift 3 '-one. Tlie ordinaiy 
meetings were arranged in conjunction with meetings of clinical 
actions, a system whicli has been found to work verv satis- 
factorily. The special clinical meetings were held at various 
hospitals, and the extraordinary meetings "were concerned with 
the passing of the revised articles and bj’-laws. In connexion 
Avilli the holding of the third session of the' Austi-alasian Medical 
Congress (British Medical Association) in Sydney in the sprin" 
of 1929, Sir Alexander MacCormick has been appointed president 
by the Federal Committee, and the organization of the Congress 
is proceeding satUfactorily. Additional land has been acquired for 
the Association’s new premises in Macquarie Street, Sydney and 
the desired frontage of 60 feel has now been secured; competitive 
designs for a building liave been invited from arch!tcct<; tIirou*^h. 
out the CommonweaUh. During the year seven British Medical 
Associalion Lectures were delivered at meetings of local 'associa 
lions outside the motropolilan area, and post-sraduate pnnrco« 
were held in diseases of cliildren and in obstetri;^. courses 





May 2r,, 1928 ] 


Ccncrcif fVfcdicaf CotincIL 


r RTTppr.rMr^rr to thb 

LniUTlSII MlIPlCAli jounsAti 


225 


GENERAL COUNCIL 


MEDICAL EDlICATIOlS" AND IlEGISTRATION.. 


smiMEU SESSION, inas. 


The ono Imntlrcd and twonty-sovcnth session of llio General 
Medical Conncil was opened on Tvicsday, May 22nd, at the 
Connell’s offices at Hnllam Street, under tlio presidency of 
Sir DoXAT.n MAcAi.isrEit, Bt., K.C.B. 

New i\Icmbcrs. 

'Iho followinp; new monil)crs wero introdneed and tonic 
tlioir seats: Alfred IVilliam Slicen, C.B.E., M.S., F.R.C.S., 
as representative of tlic University of AValcs for ono year 
from Becembor 12tli, 1027; John ICny Jamieson, M.B., as 
representative of tlio University of Leeds for threo years 
from Jannavy 1st, 1928; Sir William 'J’liylor, K.B.B., C.B., 
Jf.B., F.R.C.S. I., ns representative of tlio Ro 3 -aI College 
of Surgeons in Ireland for ono year from February 1st, 
1928; Sir Robert Alfred Bolani, O.B.E., M.D., ns repre- 
sentative of the University of Durham for five years from 
March 6th, 1928; and Gcorgo Eenry Edington, M.D., 
as representative of the Royal Faculty of Plij-sicians and 
Surgeons of Glasgow, from M.ay 7th, *1928, to April 6lh, 

1930 . > i > 

Presidk-vt’s Apdress. 

Sir B0.VA1.D M.vcAi.ister then delivered the following 
address from tho chair: 

GEKTiEJtE :!, — 0 have to record witli regret tho loss of no 
fewer than six members of tho Council sineo our last session 
in Xovombor. Dr. James Alexander Sfncdonald of Taunton 
died on April 23rd. Ho was first oloctcd a direct repre- 
seutativo of English practitioners in 1911, and ag.ain and 
again re-elected. His energetic character and his skill in 
practical affairs won him a high place in the regard of 
lus brethren, and enabled him to attain to leadership in 
tboir counsels. His lamented death creates a vacancy on 
tho Council, which must bo filled by an election to bo held 
as soon os conveniently may bo ” during tho summer. 
Sir Arthur Chance has for twelve years been a conspicuous 
ngure among ns; his keen intellect and knowledge of pro- 
fe.'sional conditions gavo value to hi,s frequent contributions 
to our discussions and to our administrative work. I am 
Sony to say that it is not to waning interest but to ill 
health that bis retirement is duo. Our cordial good wishes 
for his recovery go with him. Tho Royal Collogo of 
burgeons m Ireland have honoured us by soiidinc in hi' 
K.B.E., C.B., Regius Professor 
of th ® ^’^“^’’'^hrsity of Dublin, and Past-President 

of tho College. Dr. James Alexander Adams,- for cisht 

from tho Royal FacultyAof 
Withdraw “ teen constrained hy impaired health to 
withdraw from our fellowship. IVo shall miss his sturdv 

tlm? res't'ao“I'‘^ "" goodwill. I am happy to leaw 

his streneth efFecting an iniprovcinont in 

Unfeersity ofTe;^® V f C-M.G., 

sity of Wales and Univor- 

Durham. For* a snrtoo’ Hoa-den, University oi 

familiar friends and fellow “f” 

wo cannot et ti 1 ^ ^ members m this Council, one 

fully their loyaf acknowledging grate- 

University ofXads Cs ^ Th< 

James Kay Ja^ion Dean I’fofessoi 
has appointerprofe’ssor Al?r f ^^hculty; Wale, 

director of tho Sureieal TT Sheen, C.B.E. 

of Medicine at Cardiff- B ^'“tional Schoo 

old friend in a new enUo W / Pfo^ented us a, 

O.B.E., to bear for a rim a Ti””i.® 

«on. By experience in hi representa 

J penence in, his case, by reputation in the cas, 


of his professional collongues, wo ai o well assured that their 
co-operation in the work- of the Council will bo as service- 
able as it is welcome. 

Of niombor.s emeriti three in the fullness of years have 
passed in honour from our veterans’ roll. Those are Sir 
William Selby Church, Bt., K.C.B., from 1889 to 1899 
member for Oxford, and until his death trustee for tho 
English Branch Council; Sir Dyco Duckworth, Bt., who at 
tho end of last coiitui-y represented tho Royal College of 
Physicians of London, and acted as onr treasurer for fifteen 
years; and Dr. Henry William Langley Browne, from 1906 
to 1919 oloctcd and rc-olectod by tho suffrages of his follow 
practitioners in England and IValcs. As one of tho few 
memhers of tho Council who was privileged to servo with 
and to learn from all of these, I offer my memorial tribute 
to tho worthy examples they fnrni.shcd to their successors. 

On Noveiiiher 23rd, 1858, nearly seventy years ago, tho 
Council mot for tho first time pursuant to a summons hy 
tlio Soorclai-y of State. During throescoro years and ten 
many wise and good mcinbcvs of onr profession have been 
inscribed upon its roll of meinbers emeriti. From them we 
have received a heritage which wo are proud to cherish and ' 
emulous to maintain. For more than half of its lifctimo 
I have been privileged to take part in tho Council’s fellow- 
ship, and, recalling memories of nearly forty years, I am 
convinced that at no previous period rvas it more conscious 
tlmn it now is of its responsibilities or moro zealous to 
fulfil them for tho public good. Our inheritance from tho 
“ fathers and brethren ” of past generations has not been 
dissipated, it lias boon enhanced. 

Tivonty-foiir years ago tho Conncil adventurously en- 
I trusted mo, then ono of its junior members, with the 
I onerous task of upholding tho dignity of the President’s 
c-liair. My term of ofiico expires a week hence; but as 
Jtay 27lli may fall outside the limits of tbe present session, 

I propose to consult your convenience in making a fresh 
election of a President by resigning my trust into your 
bands this afternoon, so soon as certain necessary business 
is completed. No President, lot mo s.ay, has ever received 
a fuller mcasnro of loyal support and encouragement than 
has' fallen to mo. For that, and for the opportunity yon 
have thus given mo of rendering service to the public, and 
to Ibo profession as its ministers, I sball ever bo proud 
and grateful. 

Tho Lord President of tho Council, with whoso office we 
stand in s])ecial relation, has informed us that on March 
22nd His Majesty in Council revoked tho Order -in Council 
of 1908, by which tho privilege of practising in this country 
w.as originally afforded to tho practitioners of Quebec. 
That Province, by foi-mal legislation, had already with- 
drawn tho reciprocal privilege of practice within its terri- 
tory hitherto accorded to the registered practitioners of the 
United Kingdom. 

The British Pharmacopoeia. 

In June, 1926, the Conncil, on the recommendation of 
tho Pharmacopoeia Committee, requested the Lord President 
“ to take stops for tbe appointment of a suitable com- 
mittee, including members of the Council, empowered to 
make inquiries, to collect information, to receive evidence, 
and to mako recommendations on tbe question whether it is 
desirable to mako any, and if so what, alterations in tho 
existing law or practice relating to the preparation or 
publication of the British PliarntUcopocia and to its adapta- 
tion to tho requirements of tho British Empire.” The Lord 
President was pleased to grant the Council’s request, and 
a subcommittee of tho Committee of Civil Research -was 
duly appointed in July, 1926, the terms of reference being 
those suggested by the Pharmacopoeia Committee. Tho 
Right Hon. H. P. Macmillan, K.C., was appointed chair- 
man, and j-our President and Dr. Dale were members. Tho 
report of tho subcommittee, which is unanimous, has now 
been submitted for tho Council’s consideration, and will be 
brought before you by the Pharmacopoeia Committee at this 
session. Its conclusions were reached, as I can testify 
after very careful and judicial consideration of the problems 
that have to bo solved in tbe altered circumstances of tho 
times; and I shall have no hesitation in commending to-^ 
you, as worthy of adoption, the proposals for the read} ' 
ment of our practice which have been wrought out ' 


22© May 26, 1928] 


General Medical Council. 


r svrpLEsrEKT to th» 

LIlr.ITISII MEDlCiL JoUBHAb 


Iiarmoiiious deliberation, by the subcommittee. I record 
here with special satisfaction the fir.st conclirsion — “ that 
it is not necessary or desirable to make any alterations in 
the existing Jaw relating to the preparation or publication 
of the British Pharrnncopocin.” For if that view is 
accepted, it irill rest with the Council, witliont waiting for 
legislation, to take immediate action for such alterations 
in our practice as may bo found necessary or desirable in 
view of the current revision of the Brifish Pharmucopocin 
19 li- 1 am but giving expression to the .sentiments of my 
fellow members when I say that wo are all deeply and 
gratofidly sensible of the .singular ability and wisdom of 
our cbairiuan, Mr. Macmillan, and of the eminent service 
which, through him, the Lord President has rendered to 
the Council and to British pharmacopocial science and 
practice. [The report is summarized at p. 915 of this 
week’s Journal.'] 

]\[c(lical I'jclucafion in India. 

Bj' your instructions the important reports on medical 
education in India furnished bj' Sir Norman AValker and 
Colonel Needham, with the conclusions of the Fxecutive 
Committee thereon, have been communicated to the Secre- 
tary of State for India, and through him to the Govern- 
ment of India and to the Indian universities. AVe liaye 
been officially assured that in the course of this year the 
question of the central control of .standards of medical 
qualification in India will be dealt with in connexion with 
the jicnding inquiry on Indian government generally ; and 
further, that proposals are now before the Central Legis- 
lature for the establishment of an All-India Medical 
Council, with which this Council will be able to discuss aiid 
settle questions of rccipi'ocal recognition of i)rofes.sional 
qualifications more conveniently and move satisfactorily 
than is possible in present conditions. 

The University of Calcutta, which has meantime applied, 
for the recognition of its degrees, has brotight into early 
operation its new regulations, revised so as to bring them 
into better accordance with the statutoiy requirements for 
practice in this country, and desired that its final examina- 
tions held under the amended regulations .should . he 
insi)ectcd and reported on by an inspector approved by the 
Council. The Indian Government, notified of this applica- 
tion, has deputed Lieiit.-Colonel J. ^Y. D. Megair, I.M.S., 
to perform this service, in the absence of Colonel Needham 
on leave. His appointment has boon duly approved, and the 
Executive Committee will ])robably liavo to meet in July 
to receive his report and others relating, to India. 

The General Council’s Income Tax. 

Two recent decisions, in the Court of Ajipeal and in the 
High Court, directly affect the Council and call for 
mention. The first has reference to an application for 
exemption from income tax payments on dividends received 
froih investments of surplus income by the General Council 
and its Uranch Councils. The Court appears to have 
decided that, though the Council is conceniecl by statute 
with medical education and registration, its functions are 
not so exclusively “ educational ” as to make, it legally 
a “ charity ” within the meaning of the .law. Our Legal 
Assessor has kindly prepared an opinion bearing on the 
purport of the decision which will be at. our disposal for 
guidance. 

Proceedings for Ulisdemcnnoiir. 

The second decision, obtained at the instance of the 
Dental Board, may be held to dispose finally of the objec- 
tion sometimes raised to the Council’s proceedings in cases 
of conviction in England or Ireland for “ misdemeanour ” 
under Section 29 of the Medical Act, 1858. It has been 
asserted by counsel for. the defence that in that section 
“ misdemeanour ” must be read as if the words were 
“ indictable misdemeanour.” The objection has, under 
legal advice, been again and again overnded from the 
clmir. That ruling is now sustained by the judgement of 
the High Court. 

■ The -Act for ratifying the Agreement on Aledical Begis- 
tration, made on behalf of Great Britain, Northern Ireland, 
and the Irish Free State, has been passed into law, and 
the Agreement is now in force. 

Pegistration of Opticians Bill. 

The Departmental Committee appointed to consider the 


Eegist.iaition of Opticians Bill, before which Mr. Eason 
and 1 gave evidence on your behalf, have reported against 
the Bill, and it will no doubt now bo drop])od. 

1 regret to say that the greater ])art of your time this 
session must be occupied bj- judicial inquiries into allcga- 
tion.s of mi.sconduct or of conviction ag.ainst rogi.stered 
]iraetitioners. Some of them offer features of difficulty, 
which will probably call for pi-olongcd deliberations; all 
of them will certainh- rccei\-e your close and considerate 
attention. It may well be that to do ju.stico to all the 
evidence brought before you the session may be prolonged 
beyond the end of the present week, and so encroach upon 
the AA'hit Monday holiday. Much will depend on the 
])rogross we make in the first two or three days of the 
session. 

The Hfcdual Pcgi.stcr. 

The publication in February of the Hledical llcgistcr 
and of the Students’ Pegistrr shows that the annual 
niimber.s of registered practitioners and of registered 
medical students continues to fall .steadily from those of 
the post-war inflation period. In 1927, 1,941 new practi- 
tioiiers were enrolled, as compared with an average 
number of 2,167 for the preceding seven years. The 
number of medical students entered in the llcgistcr was 
1,214, as compared u'ith the seven years’ average of 1,441 
l>er annum. The decrease in both figures is likely to con- 
tinue for two or three years, more particularly as regards 
practitioners, for the effects of the drop in the number 
of students, which took place in 1923 and 1924 under" the 
influence of the new regulations, arc not yet exhamsted. 

Though the decrease in annual registration is i-eflocted 
in our financial statement, I am glad to say that, owing 
to'prudent anticipation on the part of the Finance Com- 
mittee, it has been discounted in advance. Our surplus 
for the past year is less than it has been, but it still 
reaches the substantial amount of £3,031 ; while the assets 
of the General and Branch Councils have been increased 
J)y .£2,557. Our financial position is, in fact, sound and 
satisfactory. 

Be-ki.ectiok or Pkesident. 

A vote of thanks was accorded to the President on the 
motion of Professor Le,\tiies, seconded by Sir Nohm.\n 


tV.»I,KBIt. ... - 

Sir Donald MacAlister then retired from tlie_ chair, 
ivhich was occupied tem]iornrily by Sir Holbiirt AA ariiyc. 

Sir Nonw.ix AA'aekeh proposed the re-election of Sir 
DoiiahL MacAlister for a period of five years. Sir Jobs 
Moouf seconded, and this was carried unaniniou.sli . 

' Sir DoxamI MacAw-steti, on again taking the chair, was 
leartilv applauded. He said: “I am getting rather od 
For seiVice, but if you think there is anything I c.mi do 
For you still, lUT services arc -heartily at your disposal. 


Rational llnsnranrc. 

WARWICKSHIRE LOCAD MEDICAL 

Com. 

EETIXC ot the May 10th, V.hen Dr. HsKBEirt 

ce was held at ,, attendance. A considerable part 

[HS presided over “ ’'S up with the hearing of a repre- 
he proceedings Health that excess cost had 

rtiow,made bJt bA" Mie nature of a cer am. 

imposed on case of the Minislrj" was laid 

titioner's prpcribing. the case Ministry’s medical 

re the Panel Committee bj - o attended in person. It 

Ms, and the practitioner “ncerned^ f^tee that excess 
subsequently decided by i]’® by rcafeon ot the large 

had been imposed on ^’*e Dra„ 1 ujm^ . charge ot undue 
ilities ot proprietaiw articles ® " tIio sum of £10 

ucncy not being satisfactonlj e ““ ^ months 

asselsed as the amount of the excess 

‘wcd. . f)]p Panel Com- 

le WaiTviclvsliire Insurance Commutce 

CO to meet in conference regarded 

a view to advising h®"' .* •, p«rnmillcG dcciucd that this 

lods could „tter Umy had already expressed 

io\" fpenTcJ^eiwrdo'SS^^ .?ea%s^'r/d were prepared to give 
ler decisions as requested. 

Pronnsed Joint Post-Graduate Hchcmc. _ 

:o question arose of =““^5 ^ *\:®riSng" 
];r.tr'”f.!df'for'roetornn^^¥al a?eas. tL suggestion 



May 2f>, I92s] 


Nava! and Military Appointments. 


Bvmr.ur.HT to the 
. nniTIsn MHOtCAL JOUBNiO 


227 


cmniialctl from (lio Jlinislry of IIoiiUli conBcqticnt tipon llio Ponel 
CominiUce’s previous npplicnlion for a local sclicmo financed from 
(ho Special Milcngo Fiiml. It was intimated tliat tho Ministry 
were prepared to sanction a joint scliemo for doctors in rural 
areas, tlio eircnmsfanccs of whose practices are sncli that it would 
ho necessary to employ locumtcncnts if they proposed to absent 
themselves for purposes of posl-graduato study and could not 
aflord oilier expenses incidental to a course of study. Tho 
chairman was authorized to represent the Panel Comniittco in 
further negotiations and arrangrinents. 

Tho chairman reported that in occqrdanco with tho discretion 
given to him ho had authorized realization of tho Panel Com- 
mittee’s assets accumulated as tho result of voluntary levies, and 
had paid over to tho National Insurance Defence Trust the sum 
of £669, which was tho quota ascertained to ho due. Tho question 
of further methods of raising the Panel Committee’s administrativo 
ineonio was deferred. 

Dr. C. R. Lukk reported in detail with regard to tho recent 
meeting of tho Midland Conjoint Group, and it was decided to 
ta’so advantage of tho oiler to give puhlicity to reporl.s of tho Panel 
Committee’s meetings made hy the Ilirmingham ilcdical Review. 


CcmspanlJEncc. 

Contract Hate for Juvenile OddfeUou's. 

^ Sm, — At A meeting of the Kingston-upon-Hull Panel and 
Local ^Icdical Coinmitlce, held on May lOlh, the recommenda- 
tion of tho Council of tho British ^Icdical Association tliat the 
contract rate for attendance upon juveniles should be 8s. 8d. 
per annum (in sonic eases less), including medicine, was con- 
sidered ; and I was instructed to send to you for publication 
in the Supphnxeni tho following resolution, whicli was passed 
unanimously : 

** That this Committee strongly disapproves of the proposal 
put forward by the ilcdico-Political Committee, endorsed by 
tho Insurance Acts Committee and approved hy the Council 
recommending tho acceptance of a fee of 8s. Bd. per annum 
for attendance upon juvenile members of clubs or societies; 

“ That it is especially disappointed at the apparent attitude 
of tho Insurance Acts Committee, inasmuch as it holds — as the 
Insurance Acts Committee has hitherto held — that any such 
lowering: of the fee for any form of contract practice will 
prejudicially affect the capitation fee under tho National 
Hcallb Insurance Acts. 

“And that it urges all Local Medical Committees to sco 
tyst the matter is brought forward before the Local Divisions 
of the British Medical Association in order that representatives 
• instructed to oppose and vote against the recom- 
mendation of Council when it comes before tho Annual 
Representative Meeting in July.” 

““I am, etc., t xt 

TT „ • J. Jos* Nelson, 

uU, May 12th. Iloaorary Secretary. 

V This matter is of primary interest and importance to 
lose practitioners who have hitherto been rendering services 
of the character indicated at a rate, at tho highest, of 6s. 6d. 
fnl suggestion, of course, that there is 

‘^1 develop tliis cla.ss of work in areas 
effev? nf ’f P™'’’’','! or “re preferred. The general 

for inwirino'^*' ''“if' "S of the contract rate on that adopted 
Sre X -'i” i”. “‘’'f 'vork has Leen 

.Jlodico-Political Committee, the 
tharr/avtuAn "-l-o ore of opinion 

other capitai;X {e«“^ ‘®‘’ i' unfavourable effect on tho 
it appears desirable th?t I" ‘’"=se circumstances 

concerned with contract and areas not primarily 

should not comniiMhelelves ( 1 °". 

enssion at the Eepresentalive Merting fn ^ 


fallal ani ffli ljlKrR Appointments. 

Surgeon CouiiunS 

£ 0. 'l? 

J/oine; j. s. Onvin to the So! »■ Fereiisson 

“• O ' 

a'd'C'S ‘hr Can, Man 

"w 'o 0’= rrfort “‘Oaths’ Posl-Eraduate 

P?«uaVo®tu"X- C ’li "i 0- i-rMdenC tor three 

“i:S“ SsS ss*’ '■■■ — 

vaunts A. B. Enart anti JI. CliBord. 

nf'l'seod hicutenanf DX'F'‘'m'H''''''T“,?r^rnvE. 

Haslar, tor training. ' “ortram to the Victory for R.N. 1 
ourgeon Lieutenant J r. rnr tn *v ^ 

U to.T to tho Emperor of India for trail 


nOYAL ARMY MEDICAL CORPS. 

3IaJor (temporary LIcul. -Colonel) B. lllggnr, from the fccontlcd li?t, is 
restored to the cslahUshmcnt, and relinquishes tlie tempornry rank of 
Lieutenant-Colonel, March 2nd, 1927 (substituted lor notification in the 
London OazHtc of March Uth, 1927). 

Captains to ho Majors: 1). If. Co.its, 0, T. Garraway, and P. G. Russell. 
A. MacMillan, to bo Lieutenant on probation. 


ROYAL AIR FORCE MEDICAL SERVICE. 

Flight Lieutenant G. S. Slrnchan to No. 28 Squadron, India, instead of 
to Headquarters, India, as prcviou^lv notified. 

Flight Lieutenant T. Sheehan relinnulphes his temporary commission 
on completion of service and is permitted to retain his rank, April 29th, 
1920 ( 0 ub«titu(ed for notification in the London Gazette of May 8ih, 1928). 

Tlio following are granted permanent commissions In the ranks stated : 
Flight Lieutenant F. B. C. L. D. Crawford and Flight Lieutenant R. G. 
Freeman. 


REGULAR ARMY RE.SERVE OF OFFICERS. 

Royil Army Medicil Conr.®. 

Llcut.-Coloncl R. McIL Skinner, Jmving attaint'd the age limit of liability 
to recall, cea>c3 to belong to the Reserve of Officers. 

SorPLEMILVlAHY RESERVE 0 ? OmCER-S : ROYAL ARMV JlEDlClL CORPS. 
Lieutenant 0. Marshall to bo Captain. 

D. II. Crossley to bo Lieutenant. 


INDIAN MEDICAL SERVICE. 

Colonel II. if. Cruddas, C.M.O., O.D.E., has retired* from the sendee. 

Lleut.-Coloncl \V. V. Copninger, Professor of Ophthalmic Surgery, 
Medical College, Calcutta, and Ophthalmic Sur^on of the College Hospital, 
is appointed to olficiatc as Surgeon-General, Bengal, during the absence 
of Major-General Tate on leave. 

Tho services of Major M. G. Bhandori arc placed at the disposal of the 
Government of the Punjab for employment as Superintendent of the 
Borstal Institute, Lahore. 

Lieutenants {o. bo Captains : K. M. Bharucha and J. D. O’Neill. 


VACANCIES. 


Belfast: Ulster Hospitil tor Children' and M'oxmf.— (1) Honorary 
Physician. (2) Honorary Asjiifrtnnt Physician. 

BeriLVAL GRix?t Hospital, E.2.— Assistant Medfcal Officer. Salary £<00 per 
annum. 

BlRlUXClIO! AND MIDLAND lIOXlOtOPATinO HOSPITAL AJID DlSPENS-ART.— 
Rc*idcnt House-Surgeon. Salary £150. 

BiRHrNGiiAXi Edltation Co.Ai5nTTEE.--.\ssistant School Medical Officer 
(male). Salary £C00 per annum. 

Dridob of IVeir : Sanatoria of Scotland,— Resident House-Physician’ 
(Protestant, male, unmarried). Salary £200 per annum. 

DoiLNLtY County borough.— .Assistant Medical Officer of Health (lady). 

Salary at the rate of £475 per annum. 

Caxiiiridge Unit'ursitv : PATnoLOCiCAL Labotlaiort.— J ohn Lucas B’alker 
Studentship. Annuo) value £300. 

CA.vcEn Hospital (Free), Fulham Road, S.\V.3.— House-Surgeon. Salary at 
tho rate of £100 per annA>m. 

Cipelmsford; Admlnistrativb Cou.ntv op Essex.— T hree Assistant County 
Medical Officers of Health. Salary X600 per annum each. 

CiiisTtR Union.— ResiAlcnt Assistant Medical Officer at the Institution. 
Salary £203 per annum. 

CiTT 07 London Hospital tor Diseases of the Hlart and Lltncs, Victoria 
Park, E.2. — House-Physicians (male). Salary at the rate of £10D per 
donum. 

CossitAM Mexiorial Hosrn.AL, Kingswood, Bristol. — House-Surgeon (male). 

Salary £150 per annum. >. 

Derby : Borough Mintal Hospital, Rowditch. — Second Assistant Medical 
Officer. Salary £350 per annum, 

Down County Regional Education ComnTTEE, — School Medical Officer 
(male). Salary at the rate of £750 per annum. 

Eastbourne: Princess Alice Memorial Hospital.— Junior House-Surgeon 
(male, unmarried), rising to Senior after three month?. Salarv at the 
rate of £100 per annum as Junior, and £125 per annum as Senior. 

East London Hospital por Children, Shadwell, E.I.— HouscTphysician 
(male). Salary at the rate of £125 per annum. 

IL1RTLEPOOI.S Hospital.— House-Surgeon. Salary £150 per annum, rising to 
£200 after six months. 

Hastikos : Royal East Sussex Hospieal. — Honorary Assistant Surgeon. 
Hospital for Sick Children, Great Ormond Street, tV.C.l.— (1> House- 
Physician. (2) House-Surgeon. (Males, single.) Salary £50 for six 
months. (3) Medical Registrar (male) in Out-patient Department; 
salary £2^ per annum. 

Kensikoton Board of GuardlaKs. — Assistant Sledical Officer (woman) at 
St. Mary Abbott's Hospital. Salary £250 per annum 
Kent County Council. — Locurotenent Assistant Medical Officer at the 
County Sanatorium, Lenham. Salary £8 Bs. a week. 

Ldcester Royal Infiiulary. — Locumtenent House-Surgeon. Four guineas 
weekly. 

IjONDON University.— (1) Professor of Pathology _ (Sir ^VilUam Dunn); 
salary approximately £1,330 a year. (2) University (part-time) Chair of 
Dietetics, tenablo at St. Thomas’s Hospital Medical School; salary £1,000 
ft year, 

Manchester : Ancoats Hospital.— House-Surgeon (Orthopaedic). Salary 
£100 per anniAin. 

Manchester Northern Hospital for Women and Children- — Senior and 
Junior House-Surgeons. Salary £130 and £100 per annum respectively. 
Nsavport, Mon. : Royal Gwent Hospital.— (1) Honorary Surgeon. (2) Two 
Honorary Assistant Surgeons. (3) Honorary Assistant Ophthalmic 
Surgeon. 

Nottinohaxi : City Mental Hospital. — Deputy Medical Superintendent, 
Salary £650 per annum, rising to £700. In addition £50 per annum 
for D.P.M. and £10 for JI.P.C. 


Poplar Hospital for Accidents, East India Dock Road, E.14.— Second 
Resident Officer. Salary at the rate of £175 per annum. 

Queen’s Hospital for Children, H.ickney Road, E.2.— (1) Casualty Officer. 
(2) House-Surgeon (male). (3) Phvsician in charge of the Skin Depart- 
ment. Salary for (1) and (2) £100 a year each- 


S28 mat 2G, 1928] 


Association Intolllgenco and Diary, 


r EVrPJXlWKT TO THE* 
LBniTisn JlEDiciL Joorkal 


Royal College of Physicians of London.— Charles Murchison Scholar in 
Clinical JIcclicine. 

Royal Free Hospital, Gray’s Inn Road, W.C.l. — IIousc*Ph^*sicians, House- 
Surgeon'!, Casualty Officer (female), and Obstetric District Assistant. 

Royal Northern Hospital, Holloway Road, K.7.-~Clinical Assistant in the 
Medical Out-patient Department. 

St. Mary’s Hospital, ■\V.2.--Surgical Registrar. Salary £200 per annum, 

Salford Royal Hospital.— Casunity House-Surgeon (maie). Salary at the 
rate of £125 per annum. 

Staffordshire General Infirmary. — House-Physician (male). Salary at 
the rato of £150 per annum. 

Stockport Infirmary. — Visiting Anaesthetist, 

Surrey County Council. — Medical Superintendent at tho Sanatorium, 
Milford, Surrey. Salary’ £900 per annum. 

Swansea Hospital. — House-Surgeon (male, unmarried). Salary £150 per 
annum. 

Tonbridge Union. — Resident Assistant Medical Officer (male) at i!ic Institu- 
tion. Salary £275 per annum, rising to £350. 

■Warrington Infirmary and Dispensary. — Junior Ilousc-Surgcon (male, 
unmarried). Salary £175 per annum. 

Weir Hospital, Grove Road, Balham, S.W.12, — Junior Resident Medical 
Officer (male, unmarried). Salary per annum. 

West London Hospital. Hammersmith Road, W.6. — (1) House-Physician. 
(2) House-Surgeon. (3) Resident Assistant Casualty Officer and Aural 
and Ophth’almic House-Surgeon. (Males.) Salary at the rate of £100 
per annum. 

WRE.XHAM AND East DENBIGHSHIRE AVar MEMORIAL Ho'=PiTAL.— Two Resident 
House-Surgeons (male). Salary at tho rate of £100 per annum. 


Wards. TJuirs.. 10 a.m. to 1 p.m., Neurological and Massage Deparl 
ments; 2 p.m. to 5 p.m., E^’c and Gcnilo-unnnry Departments. Fri 
10 n.m. to i p.m., Skin, Dental, and Electrical Departments, Medici 
Wards, Clinical Demonstration; 2 p.m. to 5 p.m., lliroat, Nose, an 
Ear Department. Sat., 9 a.m. to 1 p.m., Jtcdical Wards, Throat, Nosi 
and Ear Operations, Medical Children’s Department, Bacterial Therop 
Department. Daily at 2 p.m., Oi»erntinns, Medical and Surgical Ou' 
patient Departments. 

Shepwlxd University Post-Ghadiiate Clinics.— .\t Royal Hospital: Fri 
3.30 p-m., Strabismus. 

Glasgow Post-Graduatb SIedical As^octation.— A t Eye Infirmary: Wed 
4.15 p.m.. Eye Cases. 


58ritislj iRcbiral Assatiaiion. 

OFFICES^ nniTlSU MEDICAL ASSOCIATlOli BOUSE, 
TAVISTOCK SQUARE, ir.C.i. 


Departments, 

BonscuimoNs and Advertisements (Financial Secretary and Bualnet 
Manager. Telegrams: Articulate Wcstccnt, London). 

Medical Secretary (Telegrams : Mcdisccra Wcstccnt, London). 

Editor, British Medical Journal (Telegrams: Ailiology ‘Wcstccnt 
London). 

Telephone tii/mherg of British Medical Association and British Medico 
Journal, Museum 9851, 9S62, 9BM, and 9864 (internal exchange 
four lines). 


Woolwich Union. — ^First Assistant Medical Officer ut the PUimstcad and 
District Hospital. Salary* £400 per annum, rising to £500. 

Certifying Factory Surgeon.— The appointment at Salford and Stretford 
(Lancashire) is vacant. Applications to the Chief Inspector of F’actoric9, 
Homo Office, Whitehall, S.W.l. 

This list of vacancies is compiled from our advertisement columns, 
iihcrc full particulars wilt be found. To ensure notice in this 
column advertisements must be received not later than the first 
post on Tuesday morning. 


APPOINI’MENTS. 

Bolingbroke Hospital, WandsAvorth Common, S.H*. — Honorary Physician: 
W. Ernest Llovd, M.D., M.R.C.P. Out-Patients' Officer, Ophthalmia 
Pepaitmcnt: Alexander Lumsden, M.B., Ch.B. 

Levy, S. I., F.R.C.S., Assistant Surgeon to tho London Jewish Hospital, 
Stepney Green. 

Certifying Factory Surgeons.— T. E. Skinner, M.R.C.S., L.R.C.P., for 
the \l ivenhoe District (Essex), and S. Jackson, M.D.Ed., at Penarth 
(Glamorgan). 

DIAKT OF SOCIETIES AND LECTURES. 

Royal Society of Medicine. 

Sections of Laryngology and Otology, — Summer Meeting. Tliurs., 10 a.m. 
to 12.30 p.m. (Laryngological") — Mr. Rako : Achalasia and Degeneration 
of Auerbach’s Plexus; Mr. A. J. Wright: Silent Tracheotomy, its 
Signification ; Dr. Lowndes Yates : Methods of Estimating the Liability 
to Post-operative Haemorrhage from Unsutured IVouncls; Mr, W. RL 
Mollison : Dysphagia due to Pharyngeal Paralysis. 2.30 to 4.30 p.ra, 
(Laryngological)— Dr. Jobson Horne: Cancer of the Vocal Cords; Dr. 
Watson-lVilliams : Familial Infectlvity of Chronic Sinusitis; Sir StCIair 
Tliomson ; Intrinsic Cancer of tho Larynx operated through a Laryngo- 
fissure (lantern demonstration). Fri,, 10,30 a.m. to 12.30 p.m. 
(Otological) — Professor Dr. Otto Mayer (Vienna) : The Pathology of 
Otosclerosis; Dr. A. Lowndes Yates: A Working Hypothesis for Research 
in Otosclerosis; Mr. Harold Kisch ; Temporal JIuscle Grafts In the 

•■Radical Mastoid Operation; Mr. Douglas Guthrie: Fat Grafting in 
Llastoid Surgery. 4 to 6.30 p.ni. (Laryngological)— Cases and Specimens. 
Dinner at the Hotel Victoria at 7.45 p.m., followed by a dance. Sat., 
Otological Session— 9.30 a.m,. Cases. 10.30 a.m., Professor G. Portmann 
(Bordeaux); Vasomotor Aficctions of tho Internal Ear; Mr. William S. 
Sharpe : Tho Influenza Ear. Cases and Specimens. There will bo a 
display of instruments and apparatus during the Meeting. 

Royal Society of Tropical Medicine and Hygiene, London School of 
Hygiene and Tropical Medicine, Endsleigh Gardens, W.C.l. — Wed., 
5.15 p.m., Dr. Joaquin J. Vallerino, Roentgenologist to the Herrick' CUnio, 
Panama, Lantern Demonstration ; The Value of X-Ray In Intestinal 
Amoebiasis. 

POST-GRADUATE COURSES AND LECTURES. 

Flllou'ship of Medicine and Post-Ghaduatb Medical AssociATion, 
T, Wimpole Street, London, AV.l. — St. Peter’s Hospital, Henrietta Street, 
W.C. : Wed., 2 p.m., Clinical Urological Demonstration; no fee. Itoual 
Km them Hospital, Holloway Road, N.7 : Thurs., 4.30 to 5.30 p.na.. 
Clinical Demonstration ; no fee, St, John’s Hospital, Leicester Square, 
W.C.2 : Post-graduate Course in Dermatology, every afternoon. National 
Hospital, Queen Square, W.0.1 : Course in Neurology for two months: 
particulars and tickets from the Fellowship of Medicine, Copies of 
.*?vllabuses on application to the Secretar 3 ’. 

London School of Def.matology, St. John's Hospital, Leicester Square, 
W.C.2.— Thurs., 5 p.m., Skin Diseases of Animals Transmissible to Man. 
Fri., 5 p.m., Bullous Eruptions. 

North-East London Post-Griduate College, Prince of Wales’s General 
Hospital, Tottenham, N.15. — 51on., 2.30 to 5 p.m., Sfedical, Surgical, and 
Gynaecological Clinics; Operations. Tues., 2.30 to 5 p.m.. Medical, 
Surgical, Throat, Nose, and Ear Clinics; Operations. Wed., 2.30 to 
5 pm.. Medical, Skin, and Eye Clinics; Operations. Thurs., H.30 n.m.. 
Dental Clinics; 2.30 to 5 p.m.. Medical, Surgical, and Ear, Nose, and 
Throat Clinics; Operations. Fri., 10.30 a.m., Throat, Nose, and Ear 
Clinics* 2.30 to 5 p.m., Surgical, Medical, and Children’s Diseases 
Clinics; Operations. 

Wfct London Hospital Post-Gr.aduate College, Hammersmith, W. — Mon., 
10 am to 1 p'm., Genito-urinary Operations, Surgical Wards, Skin 
Di-nartmcnt* 2 p.m. to 5 p.m., Eye and Gynaecological Departments. 
TnU 20 n m. to 1 p.m.. Medical Wards, Demonstration of Venereal 
Di^'aWs Electrical and Dental Departments* 2 p.m. to 5 p.m., Gynacco- 
1 _ mi i. C-o,* r»r.nf»rtmf,Tif cd., 10 tt.m. 

Vards, Patho- 
Eyc Department, Surgical 


wiVnl Operations, Throat, Nose, and Ear Department. 1 
In^'l nm Children's Medical Department, Medical M ards, Datho- 
iSgiLl'^'Semonsti-alion; 2 p.m. to 5 p.m , v.ve D.o.rtm, ■ 


ScOTTisn Medic\l Sfcretary : 6, Drumsbeugh Gardens, Edinburgh. (Tele 
grams: ‘ • *. --'.i • m , . 2436 I Edinburgh.) 

Irish Medic rederick Street, Dublin. • (Tele 

grams: . Dublin.) 

Dfary of tho Aasoclatlon, 

May. 

London : Dominions Committee, 2.30 p.m. 

Bromlcv Division : Town Hall, Ancrley. Mr. Philip Turner 01 
Modern Methods in Surgical Diagnosis, 8.30 p.m. 

Lincoln Division : Annual .Meeting, Lincoln General Dispensary 

Sbro^'biro and Jlid-Walcs Branch : Royal Salop Infirmary 
3.30 p.m. 

Darlford Division: Livingstone Hospital, 3 p.m. , 

South Carnarvon and Merioneth Division: War Memorial llos 
pitnl, Towyn, 2-15 p.m. 

London : Journal Committee, z p.m. 

London : Finance Committee, 3 p.m. , ,, r. « 1 

Cln«gow and West of Scotland Branch ; Annual Meeting. Rojai 
Infirmary, Glasgow, 2.30 p.m. Clinical Demonstration attei 

KorGi^VliSdlrscx Division : Annual Meeting, Southgate Council’B 
Offices, Palmers Green, 3.30 p.m. 

London : Private Practice Committee, ^12 noon. _ . 

Bromley Division : Annual Meeting, llTiitc Hart Hotel, Bromlej, 

Glmiccst^* Branch : Annual .Meeting, General Hospital, Stroud. 

Dr. J. R. Charles on Manganese Toxaemia, 6 p.m. 

Trowbridge Division ; Norton Hill Colliery, Midsomcx Norton, 
3 p.m. _ 

^ June. 

London: Ophthalmic Subcommittee, 5.30 p.m. 

City Division : Annual Meeting, Metropolitan Hospital, 

Representatives of Medical Stalls of 


25 Fri. 


29 Tucs. 

30 Wed. 


31 Thurs. 


5 Tucs. 

6 .Wed. 


8 Fri. 


12 Tucs. 


13 Wed. 

14 Thurs. 


15 Fri. 
19 Tues. 


Division : Annual Meeting, B.M.A 
5 , W.C.l, 4.15 p.m. 
inehousQ Hospital, 3.30 p.m. 

. Meeting, Metropolitan Hospital, 

l^Mceting, Queen’s Ifolel, Southsea. 
.. Some aiedical References to Pepys, 

Hastings Division: llusti^’ss Infirmary. Frederick Hoad. 

3.15 p.m. , • B Tif A House, Tavistock Square, W.C.l. 

® D^“w. Llingdon B'rown on Endocrinology and tho Future, 

, K?s^jad°D”dshn : “An-nnal Meetinff. Hampstead General 
Hospital, 8.30 P-™- , Hyde Town Hall, 8.30 p.m. 

lWntn”ranch: Ann“TMe'eTLfff’AcJ^^^ Hall, Dartford, 2 p.m. 
Bo'-rder'eoSu" e's'S-ranoh : County Bcidins 

Sisham Divlti™ : ^ AhmeSy Tract, 8,45 r ' 


[sham Division : Town . Tract, 8.45 

Tavistock Square, tt.C-l. 4 P-™ 


p.m. 

Hous 


BIRTHS MARRIAGES, AND DEATHS. ■ 

iJliLXJio, i'is.23.3.%,^ Marriages, ana 

The charge for .imertmg j" flrfardcd toith the notice 

Death, is 9s., winch sum ^'S morni.ip, in order to 

not later than the first post on Tuesday mo 
ensure insertion in the current 

Brm.r«.-At Hihside. Heretord,"^ May IBth, to Dr. 3. H. and Mrs. 
• Biilman, a son. ,, „ -g. Gillan (Geraldino 

^fmlTumi. Kenya C'oiooy, a 

tv. B. Ti^n^^^iam i^_3tarimie^ew^^ 

L.R.C.P..(n* wl’iA .. 

Watcrkloof, Pretoria, Soutli Africa Southport, to Dr. and 

mu.o.._On stay .16th, 

MotUock Waller in his 5ith >ear. 


pHated and put)lis^hod by the British Medical Association, at their Office, 


ct r.nnrgj. in tb*^ ‘ London. 

s. Tavistock Square, in the Parish of S - 



SXJ PPLEMENT 


TO TUB 


BRITISH MEDICAL JOURNAL. 


LON’DOX. SATUUDAY, JUNE 2nd, 1928. 


CONTENTS. 


General Medical Council: 

Tm: BniTisii I’KAnMACoroETA 

Disnru.s'Anv Ca'es 

NOTICES OF MOTION BY DIVISIONS 

ASSOCIATION NOTICES : 

Consen, Eurmos 

Table or Dates 

Ebaxoi and Division Meetinos to ce held ... 


PAOE 

. 229 
. 229 
. 232 

. 232 
. 233 
. 233 


MEETINGS OF BLANCHES AND DIVISIONS ... 
NAVAL AND JITIJTARY APPOINTMENTS ... 

VACANCIES AND APPOINTMENTS 

DIARY OF SOCIETIES AND LECTURES 
POST-GRADUATE COURSES AND LECTURES 
, ASSOCIATION INTELLIGENCE AND DIARY ... 
( BIRTHS, ilARRlAGES, AND DEATHS 


PACE 

... 233 
... 235 
... 255 
... 236 
... 236 
... 236 
... 236 


GENERAL COUNCIL 

or 

medical educatiox axd uegistratiox. 


SUMMER SESSION, inS8. 


The British PnARSt.Acoror.iA. 

The President (Sir Donald MncAlistcr) inndo n lengtliy 
Etatement to tlio Council on tlio report of llio subcoinmittco 
appointed by tho Committee of Civil Research at the 
instance of the Council to inquire into tho existing laiv and 
practice relating to the preparation or publication of tho 
unfijA Pharmacopoeia. [This report was suminarizod at 
Lngtb in tho British Medical Journal, M.ay 26tli, p. 915.] 
The Pharmacopoeia Committee of tlio Gcnor.al Medical 
wancil, lio said, found itself fully in accord with tho 
first conclusion of the report — that it Avas not necessary or 
oesirahle to make any alterations in tho existing law, hut 
that tho practice should ho altered in conformity with the 
recommendations set out by tlio suhcommittco. These 
recommend.ations appeared to ho both practicable and 
ihely to promote tho bettor adaptation of tlio Fharma- 
mjwcia to present and future conditions both in Grc.at 
ritain and in tho Dominions. He thought tlio Council 
V- advised to approve genorally of tlio rccom- 
■m?lf to remit to tho Pliarinacopooia Com- 
ing taking immediate stops toivards enrry- 

des! rl*^^ effect. Tho Pharmacopoeia Committee 

nf II Pjooo on record its grateful ncknoHledgcmont 
■Proc''f rendered to tlie Council by tlio Lord 

tinn' t ti,- Council in procuring the formula- 

TBolJ report, and its readiness to give all needful 
imnr Council’s behalf in setting up the 

wn? fnu preparation therein described. It 

varin,, rat the time had come uheii the services of the 
^pivon ^ hitherto obtained individually, should ho 

in T ^ method would he likely to result 

"'HTnocopocia, one more roprosentative of tho 
late I L f j ^ medical practitioners, and embodying tho 
atandlnp w therefore proposed to sot up a 

bower f ^’^''^“popoeia Commission, which ivoiild have 
referenep ''PP“'''t suheommittces ivith special terras of 
A furtlip,.^'*'^ example, as chemical noineuclature. 

PliarTOaconoi’m°»n^''L future the British 

ten veai j which l'’ r stated intervals of 

justify reissue Ever believed to ho sufficiently long to 
Hew dnips new mn+l, there ivould arise 

of old drutrs for PHuparing drugs, and new uses 

■fiuoidod that the BriHsh set. It was 

®uly standard dm PS It, ^^mmincopocia should contain 

iu some parts ;?tha w"’ rf thronghont the Empire. 

mpire tho British Pharmacopoeia 


had been adopted by law ns tho essential standard; there- 
fore it was dcsir.ahlo that tho Dominions should liai'e 
power, where loc.al drugs or alternative preparations 
required to ho sanctioned, to give effect by legislation to 
the use of local supplements. 

Dr. H. n. Dale, as a member of tho subcommittee, 
supported, all that tho President had said, and especially 
praised Air. H. P. Alacmillau’s extremely able cliairman- 
sliip. It iiad been a very hardworking subcommittee, 
taking pains to obtain evidence from every organization 
which was at all in a position to criticize the arrange- 
ments hitherto made by the General Alcdical Council. On 
every one of its cons’trnetive recommendations the suh- 
commiltco iras unanimous. He believed that when this 
work was brought to fruition it would give general satis- 
faction and furnish the machinery which tho Council 
needed to meet tho growing and changing public require- 
ments. 

Tho Council agreed to convey to the Lord President of 
tho PriA'y Council its thanks for the report of the Com- 
mittee of Civil Research ivliich he had caused to he pro- 
duced and submitted to the Council ; approved generally 
of the changes in practice recommended in tho report; and 
"authorized nnd directed tho Pharmacopoeia Committee to 
take, on behalf of the Council, all necessary steps for 
carrying tho conclusions nnd recommendations into effect. 

Discirlinary Cases. 

The number of disciplinary cases on the programme of the 
summer session of the General Aledical Council was iinusuallv 
large. There were thirteen medical inquiries and three dental 
inquiries on the list. The case of Dr. Dorothy Logan excited 
a great amount of public interest, and during the hearing the 
press and public galleries were crowded. 

False Slatutoni Dr'claration. 

Dorothy Cochrane Logan, ■ registered as of Cavendish Place 
London, M.B., B.S.Lond. 1912, M.D. 1915, was summoned on the 
following charge : 

“Thai you nyro on November 7(h. 1927, at the .Mansion House .Tusiice 

Room in the City of London, convicted of the following misdemeanour 

namely, of knowingly nnd wilfully making certain statements false in 
material particulars in a statutory declaration made and declared hv von 
on October 12tli, 1327, under and by virtue of the Stalnlorv Declarations 
Act, 1855, nnd were fined £100 and ordered to pay £10 10s. costs.” 

Dr. Logan conducted her own case, without the aid of counsel 
or solicitor. 

Mr. C. Harper, the Council’s Solicitor, in presenting the facts of 
the ease, said that at the Mansion House Dr. Logan had pleaded 
" Guilty.” He described the nature of a statutory declaration an 
instrument of most solemn affirmation, created or al any rate clearly 
defined by the Statutory Declarations Act, 1835. ’The Co'-nril’s own 
disciplinary procedure was largely based on statutory declarations 
because it had no power to compel the attendance of witnesses or to 
put them oil oath when they appeared. Accordingly every com- 
plaint of infamous conduct must he supported by "one of more 
statutory declarations, unless, indeed, the complainants were a 
Government department, a public bodj-, or a iiniversitv in which 
case statutory declarations might be dispensed with' ’ obviously 
because it was assumed that there could be no complaint made 

[ 1245 ], 




trtfXE 2, 1929] 


•Ccnora! Medical Council. 


[ BVPPzmwsT 70 rm -oof 
Dr.iTisn 1IE01CAI. JounKJit. 


abused his posilion by enter ng 

cxposlHlnliDiis or Iho busliand-persisling Hitoown 0 '> ™. »} 

luainlnining a friendsbip of an unproper cliarnctcr uitt. tlic said 

" mio’complainnnt rvas Ibo husband, v.bo was referred to Itirough- 
ont flic case ns " Jtr. C." The rresidcnl rcquMled -the ° 

refrain from mentioning tiic name Rhonid it bo ncculcnlallj 
divuiecd dnring the hearing. , t- n • j .. 

Dr. Strickland was represented by Mr. ^cllson, instiudcd 

by Messrs. Hempsons, solicitors, on behalf of the Medical Dcfonco 
Union, and the complainant by Mi*. Cnrlhcw, counsel, instructed 
by Messrs. Le llrasseur and Oakley, soucitoi's. 

Mr. Carthow, in opening the complaint, said that his client 
“ Mr C.’' ^Yas a barrister, married in 1914, and residing at 
Ucckcnhara. Tlie medical attendant of Uic family was Dr. liope 
Murray, ‘who, in 1913 or 1914, took Dr. Strickland into nartner- 
ship. -Dr. Hope Muirav liad been in the liabil of allonding Ibo 
■ family personally, but in 1924, wlicn he w;ls away, Dr. Strickland 
attended “ Mrs.* G.” in her confincmeni, nnd from that period. 
Dr. Murray retiring shoiHly afterwards from the practice. Dr. 
Strickland became tlio icgular and pole attendant. In May, 1927, 
an estrangement occurred betrreen Dr. Stnckland and his wife, 
and from that lime onwards Dr. Strickland paid many social visits 
to “ Mr. C.'s house. It was noi unlit Inter, however, that 
“ Mr. C." had any occasion to be suspicious. In the summer of 
1927 Dr. Strickland spent a week-end at the seaside with the 
family, and during that time nltcnde<l “Mrs. C.” for some 
trifling complaint. In the nulunm “ Mr. C.“ was forced to broach 
the matter to the respondent, hut was assured by him Hint there 
was nothing in it. On Christmas Eve Mm, C.” nnd another lady 
went out in their car, and hanng the curiosity to follow on lus 
bicycle, “ Mr. G.“ discovered that Dr. Strickland had also ticen 
in the car. “ Mr. C." then talked over the matter with his wife, 
.and it was anangetl that she should go to Switzerland on lioliday. 
During her absence, looking over some housekeeping papers, 
“Mr, C.” di«covei'ed a letter written by Dr. Strickland containing 
many endearing expressions, such ns “ 1 fc^l our fondest hopes am! 
wishes may one day he realized,*’ and '* 1 am yours, darling, 
absolutely and for ‘over.” ^ a consequence the lui«!band brought 
the complaint to the Council. 

“ Mr. C.,” in the witness-box. said that his recollection was that 
the social rejationship with Dr. Strickland did not amount to 
anything until 1926.. Dr. Strickland was tlicir only family doctor' 
from 1925 onwards. Hh accounts were paid up to the middle of 
1926, after which the witness received no answer to his repeated 
request for the account. 

Dr. Sh'jcklnnd, givhi" cyidcncc on his own behalf, said that 
he had known the farany for many years, had been at numerous 
parties witli both Mr. and Mrs, C.,*’ and as their children went 
to the same schools they met very often, TJic incident of 
Christmas Eve was quite unpremeditated. He met “ Mrs. C.’s ” 
car by accident, stood talking for a few moments in the rain, and 
was inTito<l in by the ladies for the sake of shelter. He denied 
that he had ever met ** Mrs. C.“ clandcsLiuoly, Uiough he agi*ccd 
that they Iwd mot nt the houses of mutual frieiKis, wlio, knowing 
Iheir special friendship, had left them together foe short intervals. 
Asked how he came to write the letter which had been nut in, 
he said that it was because ho loved “ Mrs. C.” He admillcd 
that there was one oilier letter of a similar character. As for 
proicsional relationship, it was true that he attended “Mrs, C.“ 
on her confinement in 1924, but only during the actual dclircry; 
t ho case was then taken oixr by his senior partner. 

^VntcrJlquse gave evidence as to cliaracler. Dr, 
otncklaml had been his dresser and hoasc-suigeon, and 'he had 
seen a great deal of him. He regarded him ns one of tlic kindest 
men he had ever known, as well as straightforward and trust- 
worthy in every respect. He was one of the most brilliant young 
surgeons of the day.^ The President asked whether the letter had 
not altered Ins opnnou, to wliich the Aviluess replied that he had 
been amazed to hear the letter i*ead, and could attribute it only 
to an overwrought mind. ^ 

known of a ease 

ifp ii.i 1 from llie Itrijixlcr because 

mUt b^beeT by bh feelings, and, boweVer fooUsh^ 
™ t “ 4* stopped short of misconduct. In lliis ease 
V>T Strickland^ina'c^'^^ *bal had happened avas that 

^ere was no '‘S ’“''f f'”' "'if'' “"“Iber man. 

proTessro“al";osron“VroHi’\l1b"®'’ bud abused his 

into tlie get into llie confidence, nnd prcsenllv 

‘‘infamour«nducl”^?„/“ E^ber had said U.at 

medical man in the'' aclua?n^^ih’‘ifV''’™'t HS, “ 

and letral cjmivssio,. ?^bis profession. Tins technical 

man 
different 


and ler^al cymv^inn 1*1^ i *' proicssion. Tins tecl 

acting'as such. In this ^ qualified medical 

as to be outside the definition wore so entirely differcm 

began in socin! intp^mTr^i ^ 1 7 association of lliese people 

ih? fa Jl/S boerqu"5Si. 


on 

■was 


only from the argued that it 

that the patient recovered ami Tbrl ’'P ^“ne 

Ids fee, 4at fie ^oTcin^ef .°bbgation by paying 

patient. Unless there was be said to be tlie doctor’s 

tvas sometimes' the case there * continuing appointment, ns 
the mtervais hel4en sickmesseT ’’r 

no ohligalion to return to tt?' " former patient iras undcr 
nns an allcndanee on “ Mm! C i r. case there 
cf any account at all Dr* 

f^onal relationship. All that wi i‘’ nbused a pro- 

that ho had fallen t- said ag ' -- 


pro- 

—...a in Invft against him was 

iliis as sensible citizens P‘ u Council must 

jn their veins would oass mi«:f ^ ^ warm blood 

bon did not proceed trSis^ondu^t ' Bid if the affee- 

n> this case, the wrilin'. of n furllier than, ns 

■"Tmn„ of a foolish letter, he -would ask the 


Council to pause before saying lliat Uie conduct was dishonour- 
able or disgraceful. He added that Dr. Strickland had not Fccn 
tlio lady since site went to Switzerland in January last, and had 
sold his practice at Beckenham. , /. • 1 

Mr. Carthew said that it was by reason of Jus professional 
position that Dr. Strickland had gained entrance into tins house. 
The essence of family practice was trust-; a husband must iiavc 
perfect confidence in the corrccliludc of the practitioner s conduct 
towards his wife. As to infamous conduct-, was it not infamous 
conduct to write such a letter to Uio wife ns had been read, and 
oi the ver 3 * same time to be assuring the husband that there was 
notiiing Tvlinlcvcr in the intimacy? It was asked wlmt Dr. 
Strickland could have done after falling in love with a married 
woman; the Ycrj' least he could have done was to find some 
pretext for breaking off the professional relationship. 

The Council went fa rr/mcm. On the rcadmission of the parties 
and strangers, the Bi*csidcnt announced that Iho Council had found 
the facts proved, had judged Dr. Strickland to have been giiiltj* 
of infamous conduct in a professional respect, and had directed 
tho Itegislrar to erase his name from the Jtcgistcr. 

AlUo^i^ to Aiiriici Vot'icnt^, 

The Council next considered the case of George Howard 
Shanlev. registered ns of Pclaw-on-Tvnc, L.M.S.S.A., who 
appeared on the charge that he had sought to attract to himself 
patients, eUher directly or by an agent. Eight charges relating 
to individual canvassing wci*c set down on tho list, but only one of 
these was. taken. It was understood that statutory declarations 
relating to the others had been distributed among members of 
CounciV,bnt in the atysence of the witnesses Itiey were nol formally 
pill in. It was also charged against Dr. Slianlcy* that in April, 
1927, whilst addressing the Wnrdlcy Lodge of the Diirliam 
Miners* Association, he invited the persons present to become lus 
patients. , ^ -1 • , 

Dr. Shanlcy conducted Iiis own defence. The complainants, 
the London and Counties Medical Protection Society, were repre- 
sented by Mr. Carthew, counsel, insii-ucted by Messrs. Le Brasseur 
and Oakley, solicitors. 

Mr. Carthew said that Dr. Shanlcy came to PeIaw-on-T\'nc and 
commenced practice in 1927. At that time there were two other 
doctors there, Dr. Stich and Dr. Tliomson, practising in partner- 
ship. Sliorllv after Dr. Shanlcy's arrival Dr. Sticli wrote him 
saying lliat he rather expected he Avoiild call upon him and his 
partner, and also drew attention to the fact^ that there had 
l>ccn n canva^«icr or canvassers mnkiug systematic calls at practi- 
cally every liousfc in the district on Dr. Shanlej'*s behalf, nnd 
he could not imndne that Dr. Shanlcy was unaware of what was 
going forward. Dr. Shanlcy itpHcd that the canvassing was 
entireh* without Ills sanction, and that as soon as he hoard . of it 
he ga%c inslnictions that it must cca.«c. Ho added that he valued 
liis professional I'cputation at least as highly as did Dr, Stich, 
nnd that he undcnslood there had been previous unsavoury 
incidents in the medical history of the town, which he honed 
would not be repealed. Dr. Stich replied that if any further 
cause for complaint arose he would place the matter in the hands 
of his protection society. In April, 1927, Dr. Shanley attended a 
lodge mceUng of the ininem at Drardley and gave a ten ininutcs* 
address, during which, it was alleged, he gave them infomialion 
as to how the.v might change their panel doctor, nnd indicated 
how persons ivho wished to become IiLs patients could do so b.v 
leaving their names and addresses nt hU call-house (a name 
used in the North of England foi* n kind of branch surgery). He 
also urged on the same occasion the need for another colliery 
'doctor to de.al ivilh coniponsaliou casas. 

Dr. Stich, in evidence, said that he had been in practice in 
Pclaiv since 1919. He agreed Dial he wrote to the Loudon and 
Counties Medical Protection Soclely about what he liad heard as to 
Dr. Shanley’s canvassing. He would have approached Dr. Shanlev 
privately on the matter had Dr. Shanlcy paid him the usual 
courtesy call. Asked Avhelher he Uiought a practice could be 
built up b.v a man going round and asking people to become his 
paliciils, Dr. Stich_ replied that he did not know; that was not 
tho way ho had built up his own. 

Three miners from Wai'dley llicu testified as to the speecli 
made by Dr. Shanley n year previously. Their* teslimonv was that 
they heard Dr. ^lanley invite the per-sons present to become his 
panel parieuls. On cross-examination by Dr. Shanlev they could 
none of them remember what their wages had been for that 
particular week, and yet their memorv was unshaken said Dr 
Shanley. ns to a much less vital matter to them— the exact words 
spoken in the course of an address. One of them said that he 
could i-emcmbcr a previous lodge meeting addressed by a doctor 
but that was a long time ago. Another, who said' that Dr' 
Shanley s actual Avords Avero, “If you Avant to change vour 
doctor all you have to do is to fill up tho form and hand it to me “ 
admitted that his house was a “call-house ” for Br Stich The 
<inty one of the ei^ht charges relating to individual canvassin«r 
winch -was proceeded Avilh conccnied a man named Joseph Balf 
who gave an a^iuit of street conversations Avhich Avere sharnlv 
challenged by Dr. Shanley, but the Avilness persisted in main- 
taming its cssenlxal tnith. 

rw % evidence on his oaa'ii behalf. He said 

ttet he 'was asked to address the lodge meeliiitr at the invitation 
of tho scCTotary ui pro 9 f whereof he put in a letter from that 
offiaal, who had told him it was a priAulege extended to other 
doctors Avho had ncAvly come to the district. He was told that 
an explanation of the position Arith regard to compensation S 
also as to change of insurance doctor would be AA*eIcomed Tl?o 
wws an impression at the colliery that Dr. Stich and Dr Ihi^i.on 
alono could treat compensation cases. In -wbat he sa’id at the 
meeting he did not for one moment disci-cdit or^Hei^nt^io 
injure any oU.er .lector He cirplained the matters nm-le iSroo , 
ally, and he was careful to say that a elianse ^ S 



232 JUOTl 2, 1928] 


Association Notices, 


r fiurrT.mrr^’T to rm 
LBnxTiHit JounxAL 


bo made from one practitioner to any other, not to himself. Ho 
agreed that when ho first started in practico ono_ person did, 
unknown to him, start canvassing on liis belialf. This person had 
offered himself to him as a collector, but at that time Ihcro was 
nothing to collect, and tho man, with a mistaken sense of doing 
him a 'good turn, went about trying to get hirn patients. He put 
a stop to tlio practice as soon as ho loarned of it. Ho added that, 
unlike tho complainants, ho could not afford to brings witnesses 
from Durham, though many thero wero willing to testify. to tho 
truth of his statements, and ho had certain statutory declarations. 

Mr. Carthew objected to these statutory declarations being put 
in in the absence of tho witnesses, and liis objection was upheld 
by the President. Dr. Shanlcy protested that, as tho statutory 
declarations of absent witnesses for tho complainant, .though not 
formally put in, had been distributed to the members of tho 
Council, and were doubtless in their minds, it was only elementary 
justico that his own declarations should bo in some way produced. 
Ho had had legal advico in Newcastle that such declarations 
would bo received in tho absence of witnesses. Eventually Mr. 
Carthew waived his objections so far as two of tho declarations 
wero concerned, and these wero read ; they were from miners 
who had been at tho meeting in question, not Dr. Shanlcy’s 
patients, and affirmed that it was their^ recollection that 6 r. 
Shanley made no request to tho men to give their cards to him. 
Dr. Shanley also stated that on tho previous Sunday tho miners 
at Wardley had passed a unanimous resolution affirming that when 
he addressed them a year ago ho did not givo any personal 
invitation. Ho reminded tho Council that tho miners wero strong 
trade unionists, they imagined medical men also wero trade 
unionists, and they would not have been likely to tolcrafo any 
infringement of trade union principles. Tho chairman and other 
officials at tho meeting wore patients of different doctors, and had 
ho said anything wrong in his address ho would have been slopped 
at once. Ho alleged that this complaint had been brought out 
of malice, that the witness Ball had spoken demonstrable false- 
hoods, wnich ho would bring to tho attention of tho Public 
Prosecutor, and added that, so far from being unmindful of tho 
ethics of the profession, ho had refused a position worth £500 
a year bccauso it was tho subject of an Important Nolico ’* by 
the British Medical Association. His only ground of self-accusation 
in all thoso circumstances was that when ho first settled in Pelaw 
ho had not called upon Dr. Stich. 


At tho close of his address Dr. Shanley was overcome with 
emotion, and there was a painful interlude during which tho 
proceedings of tho Council wero suspended. 

Mr. Carthew said how much ho regretted that tho accusation 
of malice against Dr. Stich had not been mado when Dr. Stich 
was in tlio witness-box, where ho could have refuted it. 

After a very brief consideration in camera tho Council decided 
that in respect of tho two complaints on which evidence was 
tendered the cliargo had not been proved, Tho caso against Dr. 
Shanley was therefore dismissed 


Conviction for Felony. 

The next case was that of Kenneth Albert Wilson, registered 
as of Wharncliff Street, Newcastle-on-Tyno, L.R.C.P., L.R.C.S.Ed., 
L.R.F.P.S.Glas,, who was summoned on tho charge that in March 
last, at tho Central Criminal Court, he was convicted of a felony 
— namely, of using an instrument to procure miscarriage, and was 
sentenced to eighteen months’ imprisonment in the second division. 

Dr. Wilson attended, accompanied by a warder, and was repre- 
sented by Mr. Magid, counsel, on tho instruction of Messrs. 
Martindalo and Clark, solicitors. 

The certificate of conviction was handed in, and leave was given 
to the Council's solicitor to amend the charge by tho insertion 
of the words “ to wit, a catheter or some other means ” after tho 
word instrument.” 

Mr. Magid made a speech to the .Council on behalf of Dr. Wilson, 
during which he was reminded more than once by tho President 
that the Council could not review tho evidence; alf that it could 
do was to consider any mitigating circumstances. Mr. Ma^^id 
emphasized the disadvantage of his client, who was a man '’of 
colour, in making his caso understood by a British jury, and also 
said that application had been made for leave to appeal to tho 
High Court, but the application had been refused. The President 
said that that must have been because the grounds of appeal were 
not relevant. Counsel added that Dr. Wilson was a most loyal 
subject of His Majesty, and had served under the colours during 
the whole period of the war. ® 

Tho Council, finding tho conviction proved, directed the Registrar 
to eraso from the Medical Uegister the name of Kenneth Albert 
W’ilson. 

Cases Coming vp for Judgement. 

Four cases in which, at previous sessions, tho facts had been 
proved, but judgement had been postponed to givo tho practi- 
tioners concerned an opportunity of considering their position 
wore now brought up to be finally dealt with. Three of the cases 
related to convictions for being, drunk — namelv, thoso of Percy 
Bateman, registered as of New Cross Road, S.E., Robert Moore 
registered as of Mawney Road, Romford, and Duncan Miller* 
registered as of Washington, county Durham. These three practi- 
tioners now attended, and produced testimonials as to their 
sobriety in tho interval, and gave assurances as to their future 
conduct. In all three cases tho Council, having taken account of 
the testimonials and assurances, did not see fit to direct the 
Rc«^istrar to erase the name. 

^he fourth caso was that of Frederick Joseph William Porter, 
D.S.O., registered as of tho Army Medical Service, against whom 
it had been found that ho had sought to obtain patients .and to 
promote his own professional advantage by means of notices 
inserted in the Indian press. 


Major Porter attended and produced nine letters from medical 
colleagues and others testifying to his excellent conduct since tho 
hearing a year ago, and^ undertook that there should bo no 
repetition of the offences with which ho had been charged. 

in this caso also the President announced that the Council did 
not SCO fit to direct tho Registrar to erase 'tho name. 

{To be continued.) 


NOTICES OP MOTION BY DIVISIONS POR TBB 
ANNUAL REPRESENTATIVE MEETING, 
CARDIFF, 1928. 

Pathological Repoits. 

By Bristol: That subpara. (3) of the rccommemlation con- 
talnod in para. 117 of tlio Annual Keport of Connell ba 
nmonileil by tho aildition of the words “ and whero no hos- 
pital facilllios oxlst for tho provision of pathological investi- 
gations for such patients ” after tho words “pay a fee.” 

Schema of the Spa Federation for Spa Treatment of 
Insured Persons. 

By North Glamorqan and Brecknock : That considera- 
tion of tlio rocomniendation contained in para. 128 of tho 
Aiimial Report of Council bo postponed until the position 
of practllloiiois practising In tho town or area has been 
deflnitoly deilued. 

Assistant Medical Officers to Mental Hospitals. 

By York : That (with roferenco to para. 93 of tho Annual 
Report of Council) recoinracndatlons A to B bo referred back 
to tho Council for further consideration. 


^ssoriiiiion 

COUNCIL ELECTION. 

THE names of members already declared elected to tho 
Council for tho session 1928-29 in respect of the groups of 
homo Braiiohos in which there wore no contests wero pub- 
lished in llio Supplement of May 12th (p. 208). 

Contests took place in— 

Group iV, comprising tho Aberdeen, Dnndoe, Northern 
Conn tils of Scotland, and Perth Branches, tbo oandUlates 
oonnt e . , m Eraser of Aberdeen and Dr. G. Smith 

SowdM of Elgin. Of the 641 voting papers issued, 260 valid 
Spclrworo Returned and 4 spoilt ! ^ero n rttvonr o^ 

Hr. Fraser and 112 in i?28-29 

thevebv becomes a member of tho Council foi 192&-^y. 

Crnim M compri.sing tbo Kent, Surrey, luul Sussex 

’ancl 339 In faX o? Dr. Morton Mackenzie. 
g.V|oSGll.“lofoby"hcoomos a member of the Connoil 
for 1928-29. 

nepresentatives and Deputy Representatives of Public 
^ Health Service Members, 

r. ^ c. rnnilidates wero nominated by tho pnblio health 
® nn,hors for “t representatives of 

service '“Representative Body and 4 depi^ty repre- 

that service in ,p Eustace Hill (M.O.H.,oo. Durham), 

sentatives— naiiielj. ■ • Eewcastle-npon-Tyne), Dr. 

Professor Uavold r»r. E. Ward {T.O., South 

•R. A. Lyster (M.O.IL, Ha™P^h ^ _ Worthing). 

Devon), and Dr. B. H. J , 414 ^vero returned, 4 of 

Of tlic 1,214 P®P'ee|f,tiDg ’ot the votes was by the 

these being spoilt, ““"e„,/^tlio quota of votes to be 

single transferable V goenre election being 83. On 

obtained by any rT[,| ^yjth 156 votes, and Professor 

the first count Dr. Eustace Hil, Lystor secured 

Kerr, with 93 votes, seen™ ! MecHon -jyn.i^uw 32. 

61 votes on the first ooniit, Di. Y® 77 votes it was found 
Sii transferring Dr. HRl's surplus of 73 votef . 

that 46 of these went “ 12 to Dr. Wilshaw, 

15 to Dr. Ward, niakiiig bis Er. LVSTER and 

Sr. W^RD^Iong wijbD HiL and Professor KerR. were 

elected representatives. for Dr. Hill. 

Dr. Wilshaw becomes ®, ' ^ ^ 1,^00 remaining 

Under the By-laws the “is o' Cbairman 

deputy representatives rested in tbe . “^^^4 pr, ThoMAS 

of tho Representative Body, rp=fo,. ly Kerr, Dr. R.' M. F. 
EVANS of Swansea deputy ° a Lvste r, and Dr. B. 

Picken of Cardiff deputy for Dr. R. A. Lysia , „ ^ 

SiiIton WILLIAMS ot Glamorgan deputy for Di. E. Ward. 



■ ' Juke 2, 1928] 


Mootings oF Branches and Divisions. 


r BVPPtmrrirr to na ooo 
LDIUTISU MZiJiCAL JOUUHAlt 


Juno 7, Tliura 

Jwuo 13, Weil. 
Juno 21, Thurs. 

Juno 30, Sal. 

July 4, Wed. 

July 20, FtL 


July 21, Snt. 
julv' 23, .Ifon. 


July 24, Tucs. 
Julv 25, Wed. 


July 26. Thurs. 
July 27, Frl. 


TABLT5 OF DATES. 

^*nm<‘5 of Rcprc^rnlathvs and Deputy 7?oprcscntath*ea 
imist bo received ftl Head onice by this date. 

MectfoRs of Constllncncles must bo held between this dafo 
nnd July 20ih to iiu^iruct Rcprcj-entotivcs. 

Snppb'iuohtaTy Ueport ot Council oppeara In HWTisil 
XIfukul Jounx.a Surri.cMR\T. 

Amendments and riders for incbjslon in A.R.M. ftRcnda 
must be received nl Head Olbce by \bla date. 

, -* '•‘ctinrf, CnrdifT, 10 a.ni. 

• of ‘32 members of Council by 

must bo received (at A.U.M.* 
p.m. 

Anrinaf 'Heprf tentative Heettnff, CardIfL 

Cottneif, Cardiff. 

Repretrntatiro Veetinij, Cardiff. 

anuuof Uepretentatire Meeting, Cardifl, Annual General 
.tfcetfnr, Canh’lT, rrc5fdrn(> 'Iddresa. 

Council. Cardin. Contcrenco of Honorary Sccrclatlcs, 
Canlin. ^ 

Mretingt cf Reeltont, etc., Cardiff. 

J/eefinj?* of Sectinnf, etc., Cardiff. 

Jfffftnyi of Section?, etc., Cardiff. 

Alfred Cos, Medical Sccrclxtri/* 


r'uanch and division meetings to be held. 

ConpER Coc^’TrE‘^ Branch. — ^Tho annual prncral mcoUnR of tho 
Border Counties Branch will bo bold nt Ibo County Buildinij.s 
Dumfries, on Friday, Juno 15lb, nt 3 p.ni. Agenda : Brnnch 
Council's report and financial statomcni; report of tUo election 
cf olbco-bcarcrs for 192S-29; Dr. John Kitebio will pivo bis presi- 
dential address cutUlcd '* Somo primilivo conceptions of discaso 
and their bearing on public health.’* 

CAMar.iDGE AND HtiNTixGDOS Brakcii. — O witiR to tbc occasion of 
tho opening of the new theatres at Addenbrooke's Ilospital by 
Sir Berkeley iloynihnn, Bt., B.B.C.S., to-day (^Friday, Juno Isl), 
tbero will not bo a meeting of tho Cambridge Medical Society on 
that date. It is hoped that as many members as possible will 
attend tho opening ceremony. In tho event of nnv member not 
having received duo nolific.ation of this, if he wifi kindlv com- 
iminicato with tho honorary secretary of tho Cambridge Medical 
Society tho omission will bo rccLificd. 

Glasgow akd IVest or Scotland Branch : Lanarkshire Division. 
~A meeting of tho Lanarkshiro Division will he held at tho 
Stonehouso Hospital on Wednesday, Juno 6th, at 3.30 p.m. 

Kent Bran^. — Tho annual meeting of tho Kent Branch will be 
held at Acacia, Hall, Dartford, on Thursday, Juno i4th, at 2 p.m. 
Tho jircsidcntial address will bo delivered by Dr. M, W. Benton on 
tho increasing influcnco of hospital praclico and clinics on privalo 
practice. Dr. Renton invites members and their wives to a 
Inncheon at 1 p.m. Messrs. Burroughs WcDcomo and Co. Imvo 
arranged an exhibition of micrographs of tho commoner parasitcss 
and pathogenio organisms with reference to scro- and vaccino- 
therapy, and will entertain members and their wives at a garden 
parly, Tho Tennyson Smith golf challcngo cup compclUion will 
bo held on tlio same day. 

Lancashire AND CimsHiRE Branch: Hyde Division. — Tho annual 
general meelifm cf tho Hydo Division will bo held in tho Hydo 
Clown Hall on Thursday, Juno 14tb, at 8%30 p.m. 

METRoronTAN Counties Branch.— Tho annual general meeting of 
Counties Branch will bo held at Iho British 
^ociation House, Tavistock Square, W.C.l, on Tuesday, 
JUDyyth, at 4 p.m. Business ; (1) Report of scrutineers on election 
f omcers; (2) Annual Koporb of Council: (3) report of representa- 
h*J n ^ nu • Central Council; (4) presidential address 

y Dr. Chnslmo ilutrcU entitled Our changing times,” 

Cousnrs BnAKcn : City Dtvistos. — Tlie annual 
S Division will bo held at tho Metro- 

nnlt Pi; ’ K'^Sshind Road, E., on Tuesday, Juno Stli. TIio 

Hosndal"nn J^‘''sion will bo at Uio Metropolitan 

H^pital on Friday, Juno 8lh, at 4.30 p.m.; tea at 4 o’clock. 

arnu^l‘“min'‘rf Bas-Voi : H^ipstesd Divisios.— T i.o 

Hamnsteid GoLrfl rr° Division will bo bold at tlio 

for iSs elertin^ f Hospjl.il on Thursday, Juno 14(h, at 8.30 p.m., 
lor tho election of officers and Eiecutivo Committee. ’ 


Supplementary Sepovi. 

Dirmon'^Tho anniS'^'m DAMoEnt awp Sodthwakr 

Division will bo bold a“ ttir^r?rsb‘ a' '"’.''..Southwark 
Tavistock Sauarf* W n y * Medical Association House, 

Avvistock square W.C.l, on Wednesday, Juno 6tli. Tea at 4.15 p.m. 

of tho l,e*wSiam DiSfon^'^ni"? '.'’f Divrsrox-.— A meeting 

on TuesdaY. Juno ISU, atliq^ Cafford, 

a paper on som^pointL’ in thf.^v"'' Rodding will rea<} 

tract. ” 3:-ray examination of tho alimentary 

meetSgYf™a St?'Scras^Divf^ ' Divisioir.— A 

Medical Association House Ta^iUoS w'n Die Brilisli 

Juno 12th, at 9 p.m Dr ' W T , o Tuesday, 

on endocrinology and tho fXri' 


paper 


Tb“"rnruTne?aI^^L®''Si= Dtvtsrox- 

bo bold at tho WeslovaD°qchnH® ®P"bb-Wost Essex Division will 
Tuesday, Juno 5th ar3 3®o„„°’^?°“l,- Rpad. Deyton, on 
paper on some aspects ofim|Wl Ser^ond^! “ 


MsTnofOLiTAH ConsTJES Baxiiaf. WAiniswoaTn Divisiok.— T wo 
meetings of tlio Wandsworth Division will bo held in tho Town Hall, 
Wandsworth to consider tho Kooli diagnosis and treatment of 
tuberculosis by means ot tuberculin, together vyith a proposal for 
a collccUvo investigation into tUo subject. The first mooting will 
bo hold on Friday, Juno 22nd, at 9 p.m., when Dr. Robert Carswell 
will read a paper on “ History and diagnosis.” At tho second 
meeting, on I'riday, Juno 29tb, ot 9 p.m.. Dr. Robert Carswell will 
read another paper entitled “ Treatment, and a proposal for a 
coltectivo investigation.” Tlio meetings will be open to all members 
ot the medical profession. 

MCTr.opoi.iTAS CouKTiBS Branch : Willesdek Division. — A meeting 
of the Willesdcn Division will bo held at the Willcsden Hospital, 
ilarlesdcn Ro,sd, N.W., on Wednesday, Juno 20tli, at 9 p.m. Dr. 
Margaret Emsiio will discuss tho care of tho infant. 

•NoRTnERN Counties or Scotland Branch. — Tho annual meeting of 
tlio Northern Counties of Scotland Branch is to be held at Kyle of 
Eocbalsb on Juno 30Lb. This will bo the first meeting of tho 
Branch which has been held in tho area of tho Islands Division. 

Southern Branch. — Tlio annual meeting of tbc Soulliern Branch 
will bo held nt Queen's Hotel, Soulhsca, on Friday, Juno 8th. 
Supper will bo served nt 9 p.m., and there will then follow an 
address by Colonel Macartbnr entitled " Somo mrdicai references 
to Fepys," which will bo illustrated by lantern slides. 

Southern Branch : JER.vEy Divi.'ion. — meeting of tho Jersey 
Division will bo held at tho General Hospital on Thursday, Juno 
21sl, nt 8.30 p.m. Dr. A. H. Jacob will read a paper on tuber- 
culosis from tlio point of view ot the tuberculosis ofiiccr. 

Sussex Branch : Hastings Division. — Tho next meeting ul tbo 
Hastings Division will bo held at the Hastings Infirmary, Frederick 
Road, on Tuesday, Juno 12tb, at 3.15 p.m. Dr. Bower will conduct 
nictnbcrs over tlio infirmary, and after tea clinical cases will bo 
shown. 

Wiltshire Branch. — Tho annual meeting of tho Wiltshire Branch 
will bo held on Wednesday, Juno 27lh, at 3 p.m., at tho County 
Mental Hospital, Devizes, when a British Medical Association 
LeeVuto ■will bo given by Mr, W. McAdam Ecelcs on the treatment 
of hernia by trusses, illustrated by their actual application. 

Worcestershire and Heresordshiee Branch : Heretorp Division. 
— ^Tlio annual meeting of tbo Hereford Division will bo held at 
20, East Street, Hereford, on Jfondny, Juno 11th, at 3.30 p.m. 
Agenda : Election of officers, etc. ; Annual Report of Council ; 
instructions to reprcsonlativei posl-graduato lectures; corre- 
spondence, 

YoRKsniRE Branch : Hudderspield Division. — Tho annual picnic 
of tho Huddersfield Division will be on Thursday, June 21st. The 
charabanc will leave York Placo at 12.15 p.m. for Dovedsle. After- 
noon tea will bo served at the Peveril of tho Peak Hotel on arrival 
at 3.30 p.m. Tho aflcmoon will be spent in Dovedale, and the 
charabanc will leave Dovedale at 5.45 p.m. for Buxton, where dinner 
will bo served at 6,45 p.m. at the St. Anne’s Hotel. The party will 
leave Buxton at 8 p.m., and should arrive in Huddersfield about 
10 o’clock. Tlio inclusive cliarge for charabanc, ten, dinner (exclusive 
ot beverages), and tips, will be £1 2s. 6d. per head; tor those going 
in their own cars IPs. per head. 


iitcciings xrf ®ranr];fs anil JUljisians. 

Birjhnghaji Branch : West Bromwich Division. 

Thb quarterly ineoling ot the West Bromwich Division was held on 
April 24tli nt tbo West Bromwich General Hospital, The honorary 
secretary was instructed to ask Dr. Sansomo, polico surgeon, if ha 
would approach tho authorities in the matter of tlie suggested 
payment for police calls, and also to communicate with the coroner, 
Mr. Byon Clark, regarding tho suggested scale ot fees for reports to 
coroner. 

At tho conclusion of tho business meeting Mr, Russell Green read 
n paper on tho radiation treatment of cancer of tho cervix uteri 
illustrated fay lantern slides. A vote of thanks, proposed by Dr’ 
Mitchell aud seconded by Dr. Adamson, was accorded to tho 
lecturer. 

Border Counties Branch : Dumfries and Galloway Division, 
The annual meeting of the Dumfries and Gallow,ay Division was 
held m tho Royal Infirmary, Dumfries, on May 15th when Dr 
Georcb R. Livingston, tho chairman, presided. ' ' 

Tho following officers were elected for tho current year i 
Chairman, Dr. J. P ”* - . n,. t? n 

Welts (Kirkoowanl. Diimfr! .v 

Clinical Secretary, mtSHrl 

Itciirarntativc Boiy, 

rentatiTC hodp. Dr. 1 , All. ikLij. ^ ®prc- 

Dr. CROJim, in moving a vote of thanks to Mr. Livingston the 
retiring chairman, emphasized tho amount of work he had Aone 
which had involved both time and money; bo described him ns mi 
ideal chairman. The motion, having been seconded bv Dr Town 
Ritchib, was earned with acclamation. 

Mr. Livingston responded and moved a vote of thanks ■Ht* 
Cromic, expressing regret that ill health was the cause of hU 
retiring. Dr. Easterbrook seconded, and emphasized the diffi- 
culties Dr. Cromie had overcome, especially on the eovial 
Tho motion was duly acknowledged by Dr. Cromie “ ^ 

The Division considered tbo Report of Council ’.and a 

their reprcsenlaHve in the Representative Body especiallTcra^ 
ceraing Clause 104, which was unanimously condemned ^ 

Dr. Robson, from tho chair, initiated a debate on in. » 
method of dealing with borderland causes, ‘and Dr. 








sit]?pxjBm:ent 


TO TnE 

BRITISH MEDICAL JOUR NAL. 

LONDON, SATURDAY, JUNE Orn, 1928^^ ^ 


CONTENTS, 


national Health Insurance ns seen by a Consultant 
Physician. By A. S. WooDWiSK, C.M.G., M.D. 
CURHENT NOTES; 

Some Woke at Headquaeters • 

^ Sir Charles Hastisos Cltkical Prize 

■ NOTICES OF MOTION BY DIVISIONS 

ASSOCIATION NOTICES 

MEETINGS OF BRANCHES AND DIVISIONS 

CORRESPONDENCE 

ASSOCIATION INTELBIGENCE AND DIARY 


237 

240 

240 

241 

241 

242 

247 

248 


General Medical Council; 

Executive Committee ... a.t -.a 

Diploma jh Public Health m. 

The Medical Curriculum ... ... 

Electios op Committees ... ».. ».. 

THE DENTAL BOARD 

NAVAL AND MILITARY APPOINTMENTS 
VACANCIES AND APPOINTMENTS 
DLVRY OF SOCIETIES AND LECTURES 
BIRTHS, MARRIAGES, AND DEATHS ... 


FACE 

. 242 
. 243 
. 244 
. 245 
. 246 
. 247 
. 247 
. 248 
. 248 


NATIONAL HEALTH INSURANCE AS SEEN BY 
A CONSULTANT PHYSICIAN/^ 

A. S. TIVOODWARK, C.M.G., C.B.E., M.D., F.R.C.P.. 

^S'hen I received on invitation from tlie Faculty of Insur- 
ance to give a brief address on a subject related to national 
health insurance, I accepted gladly, for I thought it would 
give me an opportunity of placing before those who are 
spocially interested in the subject my impressions of certain 
phases of the work of approved societies, with which I have 
been associated for a great many years, from the stand- 
point of a doctor who acts as medical adviser to one of 
tliem. Having no responsibility for the administrative 
machinery or finances of an approved society on the one 
hand, nor for the work of the general practitioner on the 
other, I feel I may be able to express views with a degree 
of impartiality which is not always present when either 
one or the other deals with this subject. 

, it would be interesting and, indeed, profitable, if time 
permitted, to follow closely the history of sickness insur- 
ance. I can, however, do no more than briefly touch upon 
it. It had its origin in the voluntary action of workers 
to protect themselves financially against ill health by 
means of mutual aid societies. As this country was the 
first to develop industrially, it was perhaps natural that 
it should have been the pioneer of voluntary sickness 
insurance. The inovement of the workmen was strength- 
ened hy_ the action of many employers in establishing 
welfare ^institutions, prompted, no doubt, to some extent 
by self-interest, but undoubtedly also by humanity and a 
sense of social duty.^ Yet though the need for central 
or Governmental action was certainly present from the 
early ^days of the industrial revolution, no step in this 
^direction tvas taken by • the State. It is not without 
interest,, therefore, to remember that although Britain 
was the pioneer of voluntary sickness insurance, Germany 
.Was tho first country to inaugurate a compulsory scheme. 
,lt IS true that the German scheme- was inspired by the 
politmal motives of Bismarck rather thaii bv the needs of 
the workers, and was regarded with considerable suspicion 
by them ns tending to weaken their .allegianco to t heir 

An naatess aellvered to Uio FacuUr of Insurance on Mari* Jlst, 1928. 


trade unions and attach them to tlie State; but while in 
this country tho introduction of the Insurance Act in 
1911 was a purely social measure, its reception by the 
trade unions and friendly societies could hardly bo called 
enthusiastic. Compulsory insurance, nevertheless, needs 
no champions to-day ; it is its own best advocate. In 
establishing tho scheme we loarnod much from the expe- 
rience of Germany, but we did not copy that country, and 
the Government of tlie day wisely used existing organiza- 
tions for tho purpose of administering health insnr.ance. 

The .approved society system has its critics even 
now, but they are a gradually diminishing body; the 
societies liavo not only survived tlie criticisms of the past, 
but at the International Labour Conference at Geneva last 
year they or their equivalent were accepted by the Govern- 
ment representatives of thirty-seven of the forty-three 
countries represented as the most desirable type of 
organization for administering sickness insur.ance — surely 
a very remarkable tribute to the Britisli system. A scheme 
of sickness insurance administered by- the State is indeed 
a rarity. This is the more remarkable in view of the 
considerable extent of the State’s activity in other foims 
of compulsorj- insurance. The fact that a compulsory scheme 
of sickness insurance should bo allocated to these semi- 
independent bodies can only he explained, T suggest, by 
the nature of the problem itself and the peculiar difficul- 
ties presented in dealing with claims for benefit. Sickness 
is unlike unemployment in that whereas unemployment is 
an ascertainable fact, incapacity for work is a condition 
which varies with the individual and his occupation. 
There is need, therefore, for an individual and, I might 
say, a psychological test, and for tliat personal knowledge 
of the patient which can best be supplied by the family 
physician. Sickness insurance is a many-sided problem 
which calls for methods other than those which can be 
supplied by a State medical service or a public authoritv 
administration. It is not adaptable to formalism, but calls 
for sympathy, understanding, and initiative. To get the 
most out of it there is need for close co-operation between 
the medical and the administrative amis, and in this 
respect my experience teaches me that much ground has 
■yet to he covered and a good many misunderstandinna 
removed. . 

It is hardly a matter for surprise that so few people 
outside those associated with its administration realize 
that the scheme of national health insurance as orio-in- 
ally laid down had a definitely preventive side as welf as 
provision for curative measures. The general iunorance on 

■ L124'5} 


238 June 9, 1928] 


National Health tnsurancOi 


r BXTPPL^lIEliT to IH* 

InriTlSII MKDXCiX JOUSKIK 


tliis subject serves to emi)basize liow few of us really keep 
in touch with the legislative measures passed by Parlia- 
ment unless we are brought into direct personal contact 
with them in some way. I cannot help feeling that 
approved societies themselves are in some measure to 
blame by reason of the strange nomenclature wliich they 
use in connexion with the preventive side. AVhy should 
funds declared at a valuation to bo available' for sjjending 
on ])reventive or treatment benefits be called a surplus:' 
If this term is retained instead of finding a more con- 
venient one, is it not inevitable that the general public, 
and even panel practitioners — not to say a Chancellor of 
the Exchequer — will think that these funds are something 
additional to the scheme, instead of being a fundamental 
part of it? 

I have not a very intimate knowledge of national health 
insurance finance, but as a doctor I can appreciate tho 
practical results of the existence of these surpluses as 
applied to individual sufferers — whether increased cash 
payments are made or they are supplied with surgical belts, 
given optical treatment, sent to convalescent homes, 
supplied with dentures, or nursed when they are sick. 
I read in the press recently that a sum of about £4,000,000 
had been spent-eiuring the past year on treatment benefits 
alone. From the medical standpoint this is, of course, the 
best part of the schome, as it approaches the problem of 
sickness from the right direction;' it is because it is so 
valuable that I would like to sco still further developnicut. 
Insined workers are now entitled as a right to such medical 
advice' and treatment as can reasonably bo expected from 
general practitioners as a class, biit because of the inadc- 
quacy of this I know that, in London at all events, an 
appreciable number are sent to a hospital for ti'catmont. 
In this way they receive specialist treatment, but they get 
it, as it were, by the back door and not ns a right; they 
do not pay for it, and I think it should be paid for. On 
the other hand, there are many insured persons who require 
speoialist treatment much more urgently, but do not 
receive it. I cannot but feel that a schemo which does not 
provide specialist treatment is not only incomplete, but is 
only partially effective, and should be remedied. This is 
impossible at present, I am told, on account of the cost, 

and' that brings me to another phase of my subject 

namol}’, the heavy incidence of sickness claims. 

Among my friends I have a number of actuaries con- 
nected vvith approv'ed societies, and during the past year or 
two their time seems to be mainly occupied in studv-ing 
sickness cuiwes. When I remind them of tho general 
improvement in the health of the community which has 
taken place over tho past few years, they flourish a graph 
and say, “ N'ot among our members.” When they go on 
to say that the treatment and curative benefits of which 
I have just been speaking are in veiy serious jeopardy as 
a consequence of the sustained heavy claims, I must share 
their concern. This matter is also causing apprehension to 
the Ministry of Health, and is the subject of investigation 
between them and^ members of 'my own profession eno'a"ed 
in insurance practice. Happily I am not here to propound 
a solution, but as T see the papers of a groat many 
claimants in the course of a year, in the nature of things 
I cannot help gaining certain impressions. In placing 
some of these before yon I do so not without feelings of 
trepidation, and certainly in no unfriendly spirit. I have 
no desire to make a Roman holiday by offering m 3 -self as 
a sacrifice on the No Man’s Land of improper claims 
but I cannot help thiiikiiig that there may bo many contril 
bntory causes for high claims, the reasons for wdiicll are not 
far to seek and the totality of which must be considerable 
although tho basic causes, whatever they may be, may only 
emerge as the result of prolonged inv'estigation. ’’ 

A doctor, however conscientious ho may bo, is a human 
being, and in the course of his practice he will meet with 
a number of instances that might well make a specialist 
hesitate to saj’ whether the patient is capable or not; tho 
more conscientious he is the more he will hesitate. To 
blame tho average doctor for certifj-ing a patient as 
incapable' where there is so much doubt would not only bo 
unjust, but would be unreasonable. Difficult cases, however, 
are relatively uncommon, and necessarily cannot be tho 


cause of the heavv- sickness claims. It is my considered 
opinion that tho lieavj- claims must aviso from ordinaiy 
common ailments — we have no rare diseases in this country 
to-daj' — and 1 cannot help thinking that a part of the 
difficultj' maj- be not so much in laxitj' in certification, 
hut ill a failure on tho part of the doctor to make propi 
use of the inachinci ij of certification. There is a space c 
the medical certificate upon which tho doctor mav- enti 
the date when tho ])ationt .should next bo examined, bi 
little if any use is made of this space; consequentlj’ man 
claimants may remain on tho funds for a number of da; 
ill excc.s.s of their iiicapaeitv’ for work. If tho patient tale 
tho initiative and prc.sents himself for examination ho wi 
no doubt he given a final certificate, but if ho only prcseiv 
himself for examination at the end of a week, although li 
may have recovered some days previously, he will not 1 
declared “ off ” until tho dav of his examination. Man 


patients must be nciir recovery on, sav-, the date of tho )a‘ 
examination jirior to the date of declaring “ off ” ; on 
would have thought such patients would ho required t 
present themselves for examination before the expiry o 
iinolhor week, say in the mid-week, even though the 
might continue to require treatment. Yet, as I hav 
stated, they arc .seldom so requc.stcd. 

I should be interestml to hear tho view.s of otliers upoi 
this particular point. From inquiries I have made person 
allv, 1 am informed that there aro a great, many coniplct 
weeks of sickness, and 1 can only assumo it is becaiisi 
the patients present themselves for examination at weekh 
intervals. This may be, and no doubt is, a' veiv- .suitabh 
arrangement for pa'ticiit.s who arc seriously ill, but in tin 
case of minor ailments, or whore tho incapacity is drawing 
to a close, it is not sufficient. There is nothing in medicim 
that I know of to indicato that' sickncs.'s should run i[ 
cv'cles of complete weeks, or that so much incapacity shoulc 
come to an end on a Saturday prior to starting work on's 
Monday, or come to an end qn the Thursday, if the week s 
work commences on Friday; yet expcrienco would seem tc 
indicate that this actually happens. As to the coUective 
significance of these additional days in affecting the 
finances of tho .schemo as a whole, it is only neces.sary to 
mention that Sir Walter Kinnear informed the Annua 
Panel Conference in October, 1926, tliat if one additional 
week’s sickness benefit were paid to pch person on the 
sick fund in one year tho additional benefit schemo ot a 
proportion of approved societies must be withdrawn alto- 
gether, and a specialist service would bo no longer possible 

witliiu the schemo. ? 7 „„rnnl 

I gather from the reports in tho TJrifis/t .I/cihriir J™''' « 
that doctors themselves have complained of then uim ^ 
ties in coniiexion with refusing certificates, stating t mv 
they were unable to refuse the application of an iiisuicu 
person for a certificate, as the patient could immedu y 
transfer to some other doctor and, in ndditiou. would take 
tho other members of his family. This may be a rea , 
but it can hardly bo considered a justification toi im- 
properly granting certificates; and, wllilo the , 

doliying the transfer of such a member for' a fortnight 
may do some good, the real remedy must rest lutn - 

profession itself, and with it only. thpre 

Before I leave tho vexed question of certihcaiioii, ti 
is one phase of it which to me has been somewhat surpns 
ing, and that is the tendency amongst some 
to grant monthly certificates to patients ivhcie ■- 
quently the patient is actually found not to bo 
of work. I am speaking from personal 
certain instances, not a few, where the pa ic 
i-eturned to work before tho expiry of the ” .„„g 

obtained a final certificato before the expiry of the P . 
one. It would liavo been thought that, since the P 
is under the doctor’s care for four weeks betore a mo y 

certificate may be granted, tho practitioner ‘ _ 

been familiar ivith his condition, yet too facts poi 
wise and seem to indicate a lack of care on tjie “J 
doctor. In connexion with the question of ^^iiit , 
there is a suggestion that the Ministry of , 

in terms of fixed periods ; it issues four-weekly certilicaies, 
and in the case of parturition appears to standardize 
period of incapacity at four weeks. In a few cases 



June 9,' 1928], 


National Health Insurance. 


r BWPr.r:!tEirr ro nm obo 
LDnixisu MKOICU. JOUeVAL 


niiiy be too long, but in nniny ins,tnnccs the niqthor is not 
iit to return to ivork so soon offer tlic confinenient nnd 
nben slio is still nursing her obilcl. 

iRcgiircling ecrtifieation 1' bnve benrd doctors criticized 
for using vnguo terms in tboir dingnoscs. The ndiuinistrn- 
tivG brnnch ivill not nlloir such terms ns “ debility.” It 
can be argued that this diagno.sis may cover a large 
number of ailments which, if taken separately, would not 
bo sufRciont, but which will, taken together, certainly 
present a picture of incapacity for work due to debility. 
The term is, liowevcr, of no assistance to societies in dis- 
charging their obligation to safeguard the interests of tho 
general body of members. Definitions are, ns the great 
John Hunter said, “of all things tho most dainilable,” 
and even to-day we have no .satisfactory dofinitiou of what 
exactly is meant by the phrase ‘‘ capable of work.” In an 
effort to help the society regional medical officers will 
sometimes state that although a iiinn is not fit for his 
ordinary work, he is lit for light employment, disregarding 
tho fact tli.at no legal authority has' ever been able to 
translato such an e.xprcssion into precise terms. In con- 
sidering certificates 1 am also promiited to suggest that 
regional medical officers might with very slight alterations 
save a great deal of trouble and worry to societies, panel 
doctore, and their patients, if they would inform the 
societies whether a condition causing incapacity is, in their 
opinion, of a chronic character, so that no further refer- 
ence need be made. It certainly would be an ndvanta<'c 
to societies if regional medical officers could advise them 
as to the necessity for additional benefits. 

For my part I am strongly of opinion that all societies 
should have medical advisers at their head offices; if this 
were the case then regional medical officcre, panel practi- 
tioners, and patients would be saved many examinations 
that are irksome and unnecessarv. I woi’ild go further 
and -plead that societies through their medical advisers 
should be given the benefit of making references to 
regional medical officers for consultative iiurposes on the 
undcristandmg that tho result slioiild bo comimiiiicated to 
the panel practitioner and medical adviser direct as a 
pnyiue 5 \iki confidontinl documont. 

The duty of a doctor to his patients will, I feel sure 

s of o particular 

sclicnie, but doctors who have much cxiiericnco of work- 

element which manifests itself in such cases is often very 
remarkable. It is not infreciucnt in cases of severe iniury 
that a surprising ylevelojimciit towards recovery tak4 

n Xr “ofTl' " .f “'‘'"'‘'"t reached. This is not a 
^ * theory— -it is a commonplnco fact. It is of 

plavs"fn tirn'l*'’" l’ 'f ‘‘‘'■S'' "”"'1 

1 do not .suggest that 
t on on Dm ^aggoratioii of symptoms or condi- 

tioii on the part of the patient, but it is a nlnso of 

iFnFre °"ThF exnl "'hdieiue can afford to 

i- ; t explanation may be that so lone- ns +I.o 

mtXts'iu hTe’tli° '*”l and no other 

of necessity leml o"' ?• ‘'’"‘I '"^.t’ertificates. these 

recovery. - ' ° mtiospcclion that is antagonistic to 

crilkal timoiigh a rather 

expenditure on cln'° heavy and increasing 

to grapple ! ? 1 . No attempt 

^Jotween tho anijrovof] ' involve co-operation 

to be successful wW doctors is likely 

tion on their part cannot fa1l‘*to” 

causes of the riresein- sn,.- to find the more immediate 

fi..d a remedy! I Xe thTLFiX V ^ 

tioners can be bro\ieb+ + “dc.st confidence that if practi. 

-of the maeb nei; „ oignificanee 

the part of apSoFed X ip*‘°"’ the desire- on 

bo found willfn- to XXr + “ ^“1’ P'ofession will 
utmost capacity.” a\ a -societies to tboir 


many individual practitioners and representatives of 
approved societies, often to the groat adrant.igo of the 
insured. A doctor can frequently suggest an apjiliaiice or 
convalescent home trcatniqiit wliicli tho approved society 
can supply and thus enable the member to return to work. 
AVhen this is done it not only relieves the doctor of ntteiid- 
iiiico upon tho patient, but is also a relief to the society’s 
funds. This in itself shows the need for a-miitual under- 
.standing and a working seliemo between these medical men 
and societies. 

I have already mentioned convalescent home treatment ; 
this is a subject to which not nearly sufficient attention has 
been given. There are numerous cases, especially among 
women, of debility, iinacmia, neiirnstbonia, etc., for which 
a euro can hardly be oxjioctcd so long as the patient 
remains in her c.xistiiig Iiomo siiiToimdings ; conseqiiently 
a sufferer ivill continue on the funds for long periods. 
Yet if such palients could bo sent away for convalescent 
lioino treatment and given fresh air, good food, and a com- 
))lctc change of surroundings, many of them would recover 
tboir normal liealtb. How 1 am -vvell aware that there arc 
not nearly sufficient convalescent homes in the country — in 
fact, there nro, I understand, only about 130 available for 
general use by approved societies ; further,, some of tlicso 
nro closed in the winter and others will only admit certain 
types of cases, many of thorn rigidly excluding such cases, 
as suspected tuberculosis, neurasthenia, asthma, heart 
coses, etc. — the veiy types which most need this form of 
treatment. Yet many patients whose complaints become 
chronic could have their working capacity restored were 
sucli homos available in the early stages of their con- 
valescence. Apart altogether from the saving in suffering 
to tho mcmbci-s, it would bo a business proposition if these 
lieoplo could be given suitable treatment, and it is a pliaso 
of the preventive side of health insurance the development 
of which I Would commend to your earnest consideration. 

I do not propose to reitergte the complaints regarding the 
present iiosition of tioatmeiit and accommodation for tuber- 
culosis patients. This subject has hocu so much ventilated 
as to render any comments on my jwrt unnecessarv. 

Much heat and not very much’light has been engendered 
by tlio suggestion that malingering mav be taking place 
among claimants for benefit, and 1 am a little puzzled as 
to the cause of so much indignation. 1 am tempted to ask: 

•• Has there been such an improvement in social conditions 
or moral outlook generally since the davs when tho friendly 
societies and trade unions wore the oiilv foi-ms of sickness 
insurance, and iilieii improper claims a'mong mombeis— so 
many of whom were of a better class— were not infrequent » 
Me such societies entirely fi-ee from improper claiiiis on 
their private side to-day? ” It would he interesting to 
Iciiow whether there is also a tendency on the part of the 
more comfoi table sections of the eoinmunitv to undei-state 
their clainrs say, under their fire insurance or burglary 
polices. The answer may he » Yes.” but it would surprisi 
me Yet insured persons many of whom think in making 
a claim foi benefit that they .are siiiipK- getting back what 
they nave paid for, and that their clainris backed hv the 
State, are assumed by some to be incapable of e.xaggcrating 
tber symptoms. Those wlio think so forgot lat tim 
leai lest claims are amongst women, especially married 
iiomeii and that many of tlicm-ieceive very low wa^es and 
have children to care for; indeed, the temVtat on Y tlF^ 
to remain at home to look after their children cS 
drawing benefit must often be severe It rtu: i 5 
suggest that tho amount of benefit ' is inYffirtent'’'"' “ 

vieeUj wages, and sometimes even exceeds them ■ 

Ao consideration of tho .question of sickness benefit Wmihl 

So- i{£erar art 

offioTal latest'avaUabTe 

W and Wales, 

the National Health Insurant Act. Ikknlt 
benefits wore expended tor 28,250,000 weeks’ 

^ the loss of the whole year’s work of equivalent 

figur^ do not include the first t W davf 

benefit is not p.ayab!e. of illness, for which 



r SVPPLTfMr.ST TO thk . 
Lcnixisn liEDicAi. jounKAi. 


24 1 


NOTICES OF JrOTTON Br DIVISIONS EOU THE 
ANNUAL UEPBESENTATIYE MEETING, 
CABDIEF, 1928. 

Contract Hate for Juvenile OitdfcUows. 

By SouTTt C^RNMivonshiue and Meuioneth : Thai jiara. 104 
o£ tlio Aiinnal Eoporb of Coiinr.il bo i-oterretl bade for furthor 
considoratton, and that mc.mivliilo tlio Comidl obtain tho 
views of the Divisions by direct circular, and also that tho 
Local Medical and Panel Couiinittees he eonsnltod before any 
dellnito rocommondation is arrived at. 

Assistant Medical Officers to Mental Hospitals. 

By YORK; That (with reference to jiara. 93 of tho Annual 
Eonort of Connell) Eecoimnendntions B to F ho roferrod back 
to tho Council for further cousldoratiou. (Corrected form.) 


^ssaniduin llotirrs. 

TABLE OF DATES. 

June 13, Wed, Council. ^ . 

Junc21,Tliurs. Meclinrs of Constitticneics musl be bcbl between UiIb dale 

• and JuK* 20lh lo Instruct Hcprcsoatativca. 

Juno 30, Sal. Sanplcmcntnry iteport of Council appears in BniTlsn 
IJEIUCIL JOLT.N^L SlWriEWr.ST. 

July 4, Wed. AmemUnents end riders for Inclusion In A.R.U. n^enda 
must l>o rcccU'od at Head Olilre by this dale. 

Ju1t 20, Frl. Mtmwn/ /leprerrnfofice Cardiff, 10 n.m. 

Nominations for election of li members of Council by 
prouped Representatives miiat be received (at A.R.iI., 
CftrdifTj by tiiis date, 2 p.m. 

July 21, Sat. ^Irinuoi AVpmen/^tirr Meetinff, CardiU 
July 23, Mon. Council, Cardifl. 

Annwflf Rcprcicntaffre Mretinrj, Cardiff. 

Julj21, Tues, Annuol /leprcscnfaftrc Jfcrfiny, Cardiff. Annual General 
Mcelinp, Cardiff, PrcsfdontV AddrcP?. 

July 25, Wed. Conncif, Cardiff. Conference of Ifonornry Secretaries, 

• Cardiff, 

J/fffingii of Sfcliont, etc., Cardiff. 

July 26. Times. J/<eltnyi of SfCthnt, etc., CnrdlC. 

July 27, Frl, • Mettingf of Sections, etc,, Cardiff 

ALFRED Cox, medical Sccrciai*^, 

■BRANCH AND DIVISION MEETINGS TO BE HELD. 

Boniiia Coujrrits Bravcb.^— T iic annual general meeting of Ibo 
Border Counties Brandi will be held at the County Buildings, 
Dumfries, on Friday, Juno 15lh, at 3 p.m. Agenda : Branch 
Counell’s report and financml statement; report of tlic election 
of offico-bcarers for 1923*^29; Dr. John Ritchie will give his presi- 
den(ial_ address entiUed ** Some primitive conceptions of disease 
and their bearing on public hcaUli.*^ 

Dorset ako 'West HA^TS Branch : BouR.vcsrocrrr Division. — T iic 
annual sociaV meeting of the Bournemouth Division will be held 
on Saturday, July 14th, when’ a will bo paid lo.tho Pitt 

Rivens Museum, Famham, Blandford, lo be followed bv tea at 
Larma Treo Grounds, Tollard Royal. 

ic annual meeting of tho Edinburgh Branch 
Ford on Tuesday, Juno 26th. Luncheon 
■ , V . Hall, Pathhead *nt 12415 for 12.30 p.m. 

(cliargc 4s-). Dr. Craig (Pnthlicad) has obtained the courtesy of 
Valley Golf Club for the annual com- 
petition (st^ 0 Ke)^ He has also obtained the courtesy of the Patli- 
nead bowling ffreon. Visits liavc been "arranged for Prcstonlmll 
Gardens, (?richton Castle, and Churcli, and tlic Vogrie Nursing 

Profc.'jsor G. M. Kobevlson. At 
coUrtain the parly lo tea. The business 
mcoiing V ill take place .at 5 o’clock. Agenda : Eeport of Brandi 
and .annual report; election of ofTiccrs; 
noinpctition prwes; report of election of repre- 
thn^ /innrn ^“'Jpail ; election of vacancy on board of 

miiw“ Scottish Corn- 

Meeting ; amondmlT of "p)* 

The presidential address nill bo ddh-cred Iiy’Dr M^W ’RcntoS'on 

fureiVeon s t 1 r, ™ ‘ members nnd llieir ivives to .a 

arranT^ed *nn cvbtbUi^ Wellcome and Go. have 

paSti and XXic commoner 

Taccino-tlierapy. and will entertain memt scro- and 

a garden party. The Tennyson Sm^b'”^'^!r 'i'"*!! wives at 
petition wi’ll be held on the 8<>'f challenge enp com- 

EeXfSinf o?"hc"Hyif/n"- D‘Y,6tOK.-The annual 

iwn HarahX^^^^S^^ ^ “ ‘"0 Hyde 

tho *Mctrop^S?an°Su'nfie^''^'^'T'^'’® annual general meeting of 

Medial KXn Houfe Bnlish 

Juno 19th, ar4 X. B.^sTn’eSl'^^n^ Tuesday. 

n 0.. c.4?Kirjr;a?i. 


SfETRorotmir Coukties BaaNcn : Cm- Divisiok. — A clinical 
meeting of tho City Divi.sion will he held at the Metropolitan 
Hospital, Kingslnnd Road, E., to-day (Friday, June 6lh), at 
4.30 p.m.; (o.a at 4 o’clock. 

METROrOLlTAK COUKTiES BrEKCU ; HeMCSTEAD DIVISION. — ^TllO 
annual meeting of tho Hampstead Division will bo licid at tlio 
Hampstead General Hospital on Tlmrsday, June 14lli, at 8.30 p.m., 
tor the election of oFicors and Executive Committee. 

METROrOEITAN COUNTIES BRANCH I HeNDON DIVISION. — A mcoting 
' of tiie Hendon Division will be held at the Hendon Cottage 
Hospital on Friday, June 29tli, at 8.30 p.m., when members arc 
invited to .shoiv eases. The meeting will subsequently discuss Iho 
Siipplcmoiitary Report, 

Metropomtan Counties Branch : Lewisham Division.-t-A meeting 
of llio Lcwisiiam Division wil! be held at the Town Hall, Gatfdrd, 
on Tuesday, Juno 19th, at 8.45 p.m. Mr. J. M., Redding will read 
a paper on some points in the i-ray examination of the alimentary 
tract. 

Metrofoeitan Counties Bp.ANcn : St. Pancras DivisioN.-yA 
meeting of the St. Pancras Division wii! be licid at tlie Britisli 
Medical Association House, Tavistock Square, IV.C.l, on Tuesday, 
Juno 12lh, at 9 p.m. Dr. \V. Langdon Brown will read a paper 
on cndocVinology and the fiiliiro. 

Metrofoeitan Counties Branch : IVandsworth Division. — ^T wo 
meetings of llio Vi'andsworth Division will be lield in the Town Hall, 
Wandsworth, to consider the Kocli diagnosis and treatment of 
luliercnlosis by means of tuberculin, together with a proposal for 
a colicclivo investigation into tho subject. The first meeting will 
bo held on Friday, June 22nd, at 3 p.m., when Dr. Robert Carswell 
will read a .paper on “ History nnd diagnosis.” At the second 
meeting, on Friday, June 29tii, at 9 p.m.. Dr. Robert Carswell will 
read another paper entitled ” Treatment, and a proposal for a 
collective investigation.” The meetings will be open to all memberr 
of tile medical profession. , . ' , 

Metropolitan Counties Branch : Willesdek Division. — A meetinn 
of tlio Willcsilen Division will be held at tlie Willesden Hospital, 
Hariesden Road, N.W., on Wednesday, Juno 20th, at 9 p.m. . Dr, 
Margaret Emslie will discuss the care of the infant. 

Northern Counties or Scotland Branch. — Tlie annual meeting of 
thc'NorUicrn Counties of Scotland Branch is to bo held at Kyle of 
Loclialsh on June 30lli. This will be iho first meeting of the 
Branch which has been held in the area of the Islands Division. 

North or Enoland Branch ; Sunderland DrvisioN. — A meeting 
of the Division will bo held at the Royal Infirmary, Sunderland, 
on Wednesday, June 20lh, nl 8.15 p.m. Among the matters to 
be con.sidcrcd nl this meeting is the question of the adoption by 
the Division of a 1 x 1501111100 on the scale of miniroum commencing 
salaries for whole-limo cliicf medical officers of health. 

Southern Branch. — A meeting of the Southern Branch will be 
held at the Royal PorUmouth Hospital on Wednesday, Juno 13th, 
at 3 p.m. Sir Arclidall Reid will deliver a lecture on the treaf- 
liicnt of intestinal toxaemia in relation lo artliritis, neuritis, 
mental disorder, and diseases of the skin. Tlie cases upon which 
llio lecture is based will bo shown lo the meeting. 

Southern Branch: Jersey Division. — A meeting of the Jersey 
Division will be lield at the General Hospital on Tliursday, Juno 
21st, at 8.30 p.m. _Dr. A, H. Jacob wil] read a paper on tuber- 
ciitosis from the point of view of the tuberculosis officer. 

South-AVesteRn Branch. — Tiio eiglity-nintli annual meeting of liio 
South-Western Brancli will be lield on AVednesday, June 27tli, at 
3.15 p.m., in Bromley’s Cafe, Barnstaple, when Mr. Pickard will 
resign tlic chair to Dr. Harper, wlio will deliver his inaugural address 
entitled “ Tlie influence of AA'illiam Smellic and Williain Hunter 
on obstetric medicine in the eighteenth centurv.” Tlie report of 
the Branch Council for tlie year 1927-28, and tlie financial slate- 
niciil for the year 1927, will bo presented to the meeting, and tlie 
officers of the Brandi for the year 1928-29 ivill bo elected. 
Luiiclieoii, by invitation of the President-Elect, will be taken at 
1 o’clock at Bromley’s Cafe, and after the meeting has concluded 
lea will be provided. The annual dinner of the Branch, to which 
medical and non-medical guests nnd ladies arc -invited,' will ■ be 
held at 7 o’clock at the cafd. Tickets, 8s. each (exclusive of wines) 
may be obtained from Dr. H. C. Jonas, Boulport Street, BarnI 
staple. Accommodation for tho night could be arranged if notice 
is given <0 Dr. H. C. Jonas, Soutport Street, or Dr. Killard- 
Leavey, Litclidon House, Barnstaple. 

SuBRET Branch.— Tho annual meeting of tlie Surrey Brandi will 
be lield in the Town Hall, Kingston-on-Thames, on AA’cdnesdav 
June 27th, at 2.15 p.m. The Kingston-on-Thames Division invites 
membcis lo lunch at Nuthall’s Restaurant at 1 p.m Colonel 
C. AV. Profeit will addre.ss the meeting on the British Emnire 
Cancer Campaign in Surrey, and the president (Dr. H E Cranl 
will deliver his presidential address. After the meeting members 
will motor to Epsom to visit Epsom College; tea will be taken in 
Big School. Tho annual dinner will bo held at Reid's Restaiinn) 
AsTiloy Road, Epsom, at 6.30 for 6.45 p.m. (tickets 7s. 6d r ose S 
of wines). ’ 

SusSEx Branch; Hastings Division.— The next meeting' of tbo 
Hastings Division will he held at the Hastings Infirmary, Sredcrick 
Road, on auesdny, Juno 12th, at 3.15 p.m. Dr. Bower will conduct 
members over tlie infirmary, and after tea clinical cases will bo 

Wn.TsninE BnAN'Cir. — The annual meclinEr of tho WilfciaJ-ea rt i 
will be held on AA’ednesday, June 27th, ft 3 n m at be r ' 
Mental Hospital, DeviRes, when a British ffiiefi 
Lecture will be given by Mr, AA’. McAdam Ecoles on 
, of hernia by trusses, illustrated by their actuid ai^pUcution.* 






JUNE 9, 1928T 


General Medical Council, 


r TO THB - 

UDbitisu llKDiCAL Jounyit- 


24S 


Eno^lisli, 475 from Scoltisli, and 278 from Irisfi licensing 
bodies), and that tho nverngo length of the curriculum 
was five jears and ten months. 

Some discussion took place on tlio pro-registration 
qualifications of tho student. Sir IIoimuiiT 'W.uiiNO said 
that ho did not tliink tho i>rc-rcgistriitinn examinntion 
had worked out ns ■vvcli ns tho Council would hnvo liked. 

It was agreed to request tho Education Committoo to 
review tho position of pre-registration examinations in their 
bonving on tlio medical curriculum, having in mind^tho 
dilfcrcnt standards of instruction taken. From new regula- 
tions laid down at London University and by the Conjoint 
Hoard in London it appeared tliat in tho first caso a 
student could complcto his curriculum after a maximum of 
fifty-four months — or even of fifty-ono months in certain 
circumstances — and in tho other ease after fifty-seven 
months. Tho Conjoint Board seemed, in effect, to have 
gone back to tho old regulations, under whicli a period of 
not more than six months spent at a secondary school 
or recognized institution could count as part of tho 
curriculum. 

Rrsui.'rs or Ex.\mination.s. 

Sir EoniiAN IVALKHn, chairiiian of the Examination 
Committee, presented tho yearly tablo.s showing tho results 
of examinations held in 1927 for qualifications admitting to 
tho llcgistcr. The highest porcciitago of passes in medicine 
and surgeiy (85 per cent, in each case, witli, respectively, 
74 and 80 students entering) was obtained at Abordeeh 
University-, and next in iiiedicino came Dublin University, 
with 79 per cent, of passes, and in surgery Sheffield Univer- 
sity, with 76 per cent. In the list of exemptions a feature 
was tho number of holders of tho degree of Bachelor of 
Science or of Arts of American universities, who claimed 
and obtained exemption from tho first professional exam- 
ination at the Univci-sity of Edinburgh. Tlio number of 
such was just upon forty. It was iiitcrestiiig, said Sir 
Korman AYalkor, that’ thcro should bo a considerable 
number of young Americans who evidently thought that 
there were advantages in tho study' of medicine in tho Old 
Country. 

Tho committee proposed to present to tho Council a 
report on the various o.xainiiiatioris in materia modica, in 
respect of which there is a good deal of diversity. 

Electjon of Cojijiittee.s. 

During tho session the following committees were elected: 

ficcudrc.-^ir B. Bolam, Sir G. Newman. Sir H. EoUcston, 
|k 3. ^crtah. Sir H. JVanne, Sir H. Young, Sir J. Hodsdon, 
lincUh D*'- Dixon, feir J, Moore, Mr. 

Driifa^ Executive— As above, with Mr. Dolamorc. 

Brackenburj', Sir I’. Buzzard, Mr. 
Newman, Bir H. Rolleslon, Sir J. 
M?rSki\S'’' Dorrain Sraitli, Dr. Dixon, Dr. Kidd, 

Arf Eason, Dr. Fawcett, Mr. Gamgee, 
Dr' Eu^eu sV H. Waring, Da Mackinllsb 

raylw“ ’ ° N., Balter. Dr. CofTcy, Dr. Johnstone, Sir IV. 

Domin, 'ttec.— Dr. Brackenbury, Mr. Eason, Sir 
Edinefno ?'>een, Mr. Thomson, Sir J. Vcrrall, Mr. 

Sir L Moore L. Smith, Dr. Kidd, Dr. Magennis, 

F^lSarT‘Dr’~l?i!® (chairman), Sir R. Bolam, Sir 

IVarinw Va-’ Dale, Mr. Lcathc.s, Sir H. Kolleston, Sir H. 

N. AValker, Dr. Kidd, 

(ebairman). Sir G. Newman, 

IVdS, Dr"cotrer’"'“'"'“®'‘’ 

Committee.— Siv J. Hodsdon 
Sr. sSdaVr. “olamore. Sir H. Waring, Mr. Gu^ 

and Public Health Com- 
CouncL -a nominations of the Branch 

The CouS'’^^donlJd^'"® ” BaACTirioNaa’s Eeqcest. 

Committeo accedini? to ?, ™“mmendation of the Executive 
acceuing to the application of Harold Deatden. 


M.R.C.S.'Eiig., L.U.C.PXon^., for ikft ycmova\ of name from 
tho ilcdicni Register on the eroijnd that he had ceased to practise. 
Tlio Royal Colleges concerned had no vaJid objection to make. 

DisciPLiNATiy Cases. .. 

Complahit xcith Regard to a Stagazinc Article, . 

The Council devoted a whole morninp to the consideration of the 
caso of Reginald Rraneis Edmnncl Austin, registered as of Wimpolo 
Street, London, M.R.C.S., L.R.C.Pt, who was summoned on the 
charge : 

That, being a registered medteal practitioner, you sought to attract to 
yourself paticnl«» nnil to promote your own prolesaionnl aitvanloge by 
means of an article upon Appendicitis written bv you and published in 
tho number for December, 1927, of t!ic magazine llcaltU end Efficiency, in 
whicli you extolled your own methods and depreciated those ot other 
practitioners. ^ . .... 

And that in reialion to the facts so alleged you have been guilty ol 
Infamous conduct in a professional respect. 

Mr. Melville. K.G., appeared for Major Austin, and Mr. Oswald 
Hempson, solicitor, for tho Medical Pefonco Pnion, the coxb- 
piainanls. ^ ^ xt i ' 

. Mr. Hempson put in a statutory declaration by Dr. .Tamos .Keai, 
general secretary of tho Medical Defence Union, stating tliat tho 
Council of that body liad iiad the article under consideration, and 
believing that it constituted a ease of self-advertisoraenfc and dis- 
credited tho profession of medicine, resolved to bring it before the 
General Medical Council. Mr. Hempson said that a man must be 
known to somo extent by his associates, and therefore he first 
called attention to cert.iin advertisements in the publication in 
question, including many “cures'' for various maladies, “gland 
treatment “ for tlio renewal of youth, tho electro-medical clinic of 
J. Slenson Hooker — a name which would be familiar to the Council — 
advertisements of chiropractors, and so rorth. Major Austin must 
have been familiar with the character of this magasine, for he 
had been writing a series of articles for it since April, 1927. An 
editorial note at tho beginning of the scries said that readers 
would recognize the voice of one who spoko with authority. The 
article in question was headed : “ Nature Cure Explained : The 
Truth about Appendix Operations : An Insane Medical Craze 
Exposed,” and this was followed by tho author’s name and 
medical 'qualifications. On tho first page of the, article was a 
portrait of the late Florence Mills, “ yet another victim of opera- 
tion for appendicitis." He understood that with neither the title 
of the article nor the portrait and its caption had. Major Austin 
anything to do. The article stated that, although in ms younger 
days the author used to operate on appendiritis cases, for the’ 
last nineteen years, since reading an article in an American health 
magazine, he had not once advised an operation, and in no case 
had life been lost by his patients, even in gangrenous and pus 
ca^cs. Tho orliclc continued : 

** Operative treatment frequently leaves tho patient in bad health. , , . 
All this unnecessary operating to-day brings to mind a chestnut of mv 
student day?. M\hat did you ‘operate for?’ inquired the medical 
student ‘For 300 guinea?,' replied the eminent surgeon. ‘Yes, hut 
1 mean, what did the patient have?’ rejoined the student, ‘lie had 
100 guineas,' said the eminent surgeon." 

Could anything, Mr. Hempson asked, he imagined more 
insulting to tho profession? Other extracts from the arliclo were: 

*' Operation has become tho accepted procedure, and the average medico 
no more questions its wisdom than he disputes the law of gravity... , . 

"Surgeons when they operotc in these cases work exactly opposite to 
Kalure. And that is why the public so often hears that * the operation 
W’os successful, but the patient died.* 

. all cases which rupture into the abdominal cavity are caused by 
the doctor himself in Ins cflorts to make a diagnosis. lie then often 
'points to the ruptured pus sac as evidence that the operation was' ‘just • 
jij time.* 

" Can there ho any wonder that appendicitis is so fulminating in the 
hands of the orthodox medical man, or can there be any surprise at the 
high death rate? *’ 

Mr. Hempson described the article as self-Iaudafory, full of tim 
pronoun " 1/* and disparaging and insulting to the profession. In 
an editorial note in the same issue as tho “ appendicitis " article 
it was stated that ” There is no denying that this is the ' golden 
age of surgery ’—it is, for surgeons," Tho death of Florence Mills 
was menUoned — “ dead, after being operated upon, at the age 
of 26 : and on the other hand Major Austin^ who never operates 
for appendicitis, has never yet lost a patient’s life under his 
treatment. It is yuch cases as this one which arouse ordinarily 
quiet men to a. kind of fury in reading such pernicious nonsense 
as tliat a patient is * safer on the operating table than in crossing- 
Trafalgar Square.' " - ® 

Major Austin, in evidence, said that he was 61 years of age ahd 
had been in practice for thirty-six years. Until 1921, with tho 
exception of two years, his whole career had been spent in the 
medical service of the army in India, from wii/ch he retired with 
Iho rank of major, and entered private practice. He had been 
interested in “Nature cure " methods for twenty years; it was not 
a new or sudden interest on bis part. Before these present articles 
ho had never published anything in the lay press. Wliat he said 
about “ Nature cure “ was the sincere expression of his view’s He 
was sorry that his article should convey the impression that ho 
depreciated his colleagues; he had not intended to attack the nro 
tession at all. The heading of lli^e article was altered without 
his knowledge; the heading he had given was “ AnnendicpctoniU 
end banity.^’ Tlio portrait of Florence Hills was insert^:! 
without his knoiriedge nor could lie accept responsibilitT for the 
editorial comment. Wilhm a week of the publication of the arficlo 
ho protested to the editor against the wav in whiell ;i 
presented. This was before hi heard from Ihe Brtkh MedYcTl 


246 June 9, 19281 


General Medical Council, 


r BVPPLSUEUT TO TBl - 
LDniTisu Hzoiou. JorairiC 


Association asking tor an explanation. The other articles of tho 
senes, one of which was entitled “ Nature versus the Knife in 
Cancer, had not been altered. He never saw the prbof of the 
article; he was paid a small fee for writing it. but he had no 
iinancial interest in the journal. 

In cross-examination Major Austin said that lie had no inten- 
tion to disparage men : his protest was against methods. Tho 
if-d was a very old one, which ho 

liad heard made by Sir Arbiithnot -Lane two years ago in a lecture 
on health; ho had also seen it m medical journals, and it was 
frequently quoted at medical meetings. The remark, “ The opera- 
hut the patient died,” was also a common 
to iiistify his statement that all cases which 
a • ’ 1 ° « nbdominal canty were caused by the doctor 

tnl n/ Hr!'® “ diagn^is, he said that this was 

case that he had seen. He was aware of the nature 
Idic 1 he contributed to it; he had -seen in it 

nln f Sir Arbiithnot Lane.- Tho fact that a number ' of 

“ dScli ” themselves 

doctoi had not troubled, him. He agreed with the suggestion 
of his counsel, on re-examination, that the magazine contained 
udyertisemcnts, and that the principal 
articles in this particular issue were of a kind to which* no sort 
of objection could be taken. He had expressed tdmself In a w^ 
f rthlt ihW f ,*’“/• soli’-uti'-crtisemcnt was the 

inslea^l^F ^ a'*' wliy he contributed to a lay 

■" Mol * ' llcdtca! Journal an article pointing out the value of 
Nature cure an epitome of a lecture which he nave to a 
1^21 — but it was rejected. 

editor of ffcalth and ^ffictmcu a statutorv 
to th'e''H*' "r® hearing out Major Austin’s statements as 

to the alteiations which he (tlie editor) had made in the title of 

that M!fr' *]'■■** wai sent t^the author and 

the a“pXn^orof"the art?cle!“““*''‘'"“ 

revret that’ he should ^P^^'’,’, ?’^Prcssed his cHenfe great 

fo-tn; ‘t^^l'Ta'nV^^dl frrur^p!:'.!rersi;t’''an7LH‘ Tsfe 

promise on his behalf that ho would never contribute in fnfin-o 

iSpipIMIMl 

to o .lecision 

carefil cm^m'o"r'aLon"to*'the o!iargi“broug1u ngainst“vou ami tf '‘o "‘'ti ' 

your own professional advantage hv meansmPan ariirl« fo hv.*" P™'?®!® 
p!actitio\e'S“ TL^t1a-cS'‘';vStaveteerpm*r^^^ fhosHPiS 
terms of the Council's Warning Notice ^rtic^i stafos that li?!' "'5 
advertising by a registered medical prjetitioner is in the oniH 

?ero°n“’of'“m"edfc?„e“’ The^ «1 “p/ discwdi\lr','J‘'’Sm°^ 

Warning h”Hce?"ahera se?iHs View '>'0 terms of'lhe 

of 1929, when you will be rennirecl to to n.o tlic May session 

some of vour professional bJetbrPn nr Rc-istrar the names of 

written application from the RSstr?r to tesHfv wjUinp, upon 

him for the vise of the Council S to *' ^®^.**’*’* “^dressed to 

to this practice of advertising,’ in tbe^nterval 

You will receive in due course a formal writtpn^'nf^mof * elapse. 

iMmatioo wi Vrthe Tiafe 


meeting to which riiave referr&'wjmniPo" ‘he date of II 

i-hoiiId\.iiderstand llial? in thfwSt ofanv' >e- 
diiring the interval, the Council may forthwith mstni'ct" (he n''®- 
eiase your name from tlie .Vfd/cn/ The 

account of wliat was said on vour behalf bv v^?r taken 

error of judgement and vour 'deiLmSon^^f to'^oSp'®/ ^’^“1 

your assurances will be recorded on the minutes. ^ * of^^nd nfjain, and 

Charpe of Adultery during Professional Metationshw 
She last case considered by the Council was that nf t 

registered as of Norfolk Street, London, MHOS I R r ’ 

was summoned on the charge that he had abused’ h;H!iu'’ v" 
committing adMtery with Alice Mary Braden; a inarei?d woman^ 
with whom and whose husband he stood in professional relaS’ 
® V^i "U-'"'*' .he had been found |uilty by thl decree' 

of the Divorce Division m June, 1927, made absolute ^n Decehiber 
of the .same year, in the case of Braden r. Braden anfl^wls 
Jones, in which he was the co-respondent. -c,ewis 

’There was no complainant in the case, and the facts were laid 
before the Coiincit by the Council’s Solicitor, Mr. Hareer He 
said that Mr. Braden was married in 1918, and Dr Lewis TeSs 
both husband, and. wife from about that time i.ntH 
1926, w-lien he (the h.usband) became suspicious as to the relation- 
filiip. Later the couple went away together. 

Mr. Ronald Braden testified that he lived at Crouch Hill and 
that his marriage was happy until 1926. Dr, Lewis Jones’ who 
w.ns in practice in the Hornsey neighbourhood, attended his ’wife’s 
family before his own marriage. In 1919 the witness was dis- 
charged -from the army and was instructed bv tho Ministry of 
Pensions to place himself under the care of a 'local practitioner 


selreled Dr. Jones. Letters to tho witness from 
.Hr *“ ^ Jo’'®? ."ftcr 11‘cy had gone away together 

1 u medicine with the labels in Dr. Jones's 

!roro"7’^'T-“"i‘l ®^'l‘'®ssed to Mrs. Braden were exhibited; these 
were found in the liouse after Mrs. Braden had left her husband. 
In cross-examiiialion Mr. Braden said that liis wife was ocrnl 
Bionally atlcndcd by Dr. Jeasie Maxwell of Crouch End. biit^ 

i!-e'IfL;‘Vr® ’i'®? attendant. Dr. Jones was actually 

treating hci a week before she left home with liirn. Ho had asked 
Ur. Jones on more than one occasion to send in Ids account, but 

friLd'^f'lImHmiry. “ 

A letter was put in from the Ministry of Pensions slating that 
pcrtodical claims had been made to the Miiiislrv of Pensions for 
attendance on 31r. Bra^n by Dr. Jones up to' 1923. A servant 
maid employed by the Bradens gave evidence as to the doctor’s 
atlcnuanccs at the Jioiisot 

Dr Lewis Jones, examined by bis counsel, Mr. Davies, said 

Horns'r."’r commenced general practice in 

Hornsoj in 1910. Ho had never attended Mrs. Braden as her 
doctor, though on one or two occasions, when slic was suffering 
pain after dmital treatment, he gave her an aspirin. He had 
treated Mr. -Braden under tho pensions cchcme down to 1923. 
Mrs Braden, ho knesv, was attended by Dr. Maxwell. The 
medicines produced, were made up for Mrs. Braden after she had 
come away with him, and were loft inadvertently at the house 
wiicn she rctiirpod to fetch her belongings. 

Mrs. Braden and her sister gave corroborative evidence. 

Mr. Harper commented on the fact that Dr. Maxwell had not 
^cn called, and also on the circumstance that at a time when 
Dr. Jones and Mrs. Braden wore admittedly living together at a 
mottles of medicine should be made up and labelled for 
somebow find their way to Mr. Braden’s house. 
After cleliboration tn camera the Council found that the fads 
alleged against Dr. Lewis Jones in the notice of inquiry had not 
been proved, and the case was accordingly dismissed. 

Convictions for ^fhdcmcanours. 

Tlio Council considered the case of Robert Louis Portwav, regis- 
tered ns of Long Acre, London, M.R.C.S., L.R.C.P., D.P.il,, who 
was summoned on the charge that ho Imd been convicted in 1924 
of being drunk and disorderly, and jn 1927 of being drunk whilst 
m charge of a motor car. Tho Council’s Solicitor, in stating the 
facts, said that after bis conviction in 1924 Dr, Portway was 
warned by the Council. It was staled that ns a result of the 
second conviction Dr. Portway had resigned an appointment worth 
£750 a year. ^ 

Dr. Porlwny made ‘a statement to the Council, saying that he 
knew it was useless to go behind the conviction, but he wished 
to point out that he was brought before a county bench which 
was notoriously hard on inolorists; had the case gone before a 
^ry he had every reason to believe he would have been acquitted. 

Ho was not driving the car at the time; he had pulled it up on 
Eomo common land and gone to sleep, when he w’as roughly 
awakened by. a policeman, and after protest on his part was led 
off to tho police station, ^Yho^e,he lost his temper and his dis- 
cretion. Had ho been left alone he would have been all right. 
Ho^ had been already punished^ out of all proportion, for lie had 
resigned a position in the Civil Service as a consequence of flio 
conviction, and, having applied for and obtained an appointment 
in tho Colonial Medical Service, he was turned down for this, also 
from the same cause^ 

Tho Council found tho facts of tho conviction proved, but post- 
poned judgement until the Hovember session on tho usual con- 
ditions as to the production of testimonials ns to conduct in the 
interval. 


THE DENTAL BOARD. 

A SESSION of the Dental Board, under the. chairmanship of tlie 
Right Hon. Sir Francis Dyke Acland, took place from- May 
8lh to- 11th. *Mr. Michael Heseltine, C.B., Was appointed by 
the Minister of Healtli a member of the Board in place of Mr. 
L,.G, Brock, resigned to take up his duties as chairman of the 
Beard of Contixil. 

In his address from the chair Sir Francis Acland referred to 
a motion before the Board for reducing tlie retention fee to £3; 
Every pound of retention •fee means about £9,500 in income. 
The present income, with a retention fee of £4, was rather 
over £2,000 dn excess of expenditure, arid there did not seem 
to be much margin for reducing the fee’ during even the earlier 
years of practice. He discussed certain alternatives, and 
expressed the hope that tlie Board w'ould be able to find soine 
w'ay of lightening the burden' during the early years. .With . 
regard to clinics he .refrained from any statement, as he under- 
stood that certain aspects of this question might. soon be si/b 
jtidice, except to say that all the members of the Discipline 
Commiftep ivere fully alive to the possibilities, of tlie com- 
mercialization of dentistry which might be involved and to the 
danger to the public interest. Anj' action must be directed, 
not. by the ivishes.of tlie profession or -of the Board, but 
solely by the duty of the. Board to see that the law and tho 
code of conduct proper to dentists %vere maintained. It must 
not be thought that the possibility,- or- indeed the ^desirability, 
of action in certain circumstances had been ruled out. 

After discussion it •was agreed to amend the regulations to 



Jt/A’K.O, 3038] 


Naval and Military. Appplntmonts- .247 


jirovido that tho annual rotcntion fco he kept at £4, that the 
annual registration fee for 1929 and future years ho fixed at £2, 
and that the annual retention fee for the two years immediately 
following original registration ho £2. 

The Board agreed that tho grants in aid of dental teaching 
should bo increased from £21,000 to £24,000. Tho nuniher of 
students avho had been assisted by grants and loans up to tho 
present was 464, of whom 242 had qualified. A report was 
made on tho dental healtli pi-opnganda undertaken by tho 
Board j this has taken tho form of films, posters, transparencies 
in public vehicles, etc. Tho Itc.senrch Committee brought 
forwiird a nuniher of reports on investigations; these w-ero 
"progress” reports from tho committee of the Medical 
Research Council for tho investigation of dental disease and 
the Dental Investigation Committco of tlio Department of 
Scientific and Industrial Research. A si.xth .senes of post- 
registration lectures was arranged for next winter in London, 
Manchester, Bhelfield, and possibly Glasgow. In reply to a 
request from tho British Dental Association the Bo.ird re- 
affirmed a previous resolution that ilia insertion of appointments 
in local directories, even though no payment was made, was 
undesirable. 


Diseiplinnry /?H«inc«». 

The Board had before it no fewer than 14 disciplinary inquiries. 
In -only oiio caso was it found Ihnl the facts sol out in Uio 
complaint had not been proved, but in nine other cases the Board, 
while deciding iliat llio facta bad been proved, did not proceed 
to a * finding,” but gavo a warning to the practitioner or required 
lum to appear with testimonials at a Inter session. Aiiolbcr ease 
was that of Frank Ernest Coe, registered ns of Defoe Rond, 
Tooling, who. had previously appeared on a charge that ho had 
cvrtiDcd tho completion of certain work to a society, and had 
Vs?.’’ P.l’r therefor, whereas no dentures were in fact .supplied. 
When Has case came before the General Jfcdical Council (Supple- 
ment pcccmbcr lOtb, 1927, p. 227) the Council remitted it to tlio 
Roard for further inquiry. TIic Board now, on further considera- 
tion, decided that Sir. Coe's name ought not to lie ornsed from 
the RegMtcr, but added that Sir. Coe, who did not appear before 
tho Board at tho origiiiat inquiry might liavo saved hinisclf a 
good deal of inconvenience, and the Board some trouble, if lie 
had appeared before it when he was called upon to do so in Ibo 
first instance. 

..Jl’ eases tlio ^ Board foitiid that the name ougtit to bo 
Virli 1 ’i? Br<7Mf(r, and mado a recommendation to that 

cfiect to Uio Genord Stcdieal Council. The first was tho case 
n "Tw” fis?”;','"®?' '■ogi.stcred as of IVliitehorB' Road, 
ho°^W?’ • 1”’’° t"'’’''’ summoned on tho charge that 

married 0*1" Position by committing adultery with a 

S"Tl?nSi,' "'bom ho stood in professional relationship, 

the '“’I" ^9'!'''* gu'lty by the decree k 

There .VI?” Dwisioii in a case in winch bo was tho co-respondent. 
den-dnJ (LI Ti”"''’ V®".”’,''' evidence in tlio ca.«o, Sfr. licprimoz 
that had-been any professional relalionsliip, except 

ouestion I'c® ' IS’' ”• denturo tor the woman iii 

when (he ‘ w® -however, found ns slated, and 

S Ibo General Medical Council on May 

Board’s -^nr furlber Mr. Deprimoa’s counsel and the 

gufitv of ‘'“b'o*' ‘bat Jlr. Deprimoa had been 

fSiial vesL^ "V"’','. 'fifn-nous or disgraceful in a pro- 
from the liis name 

wS'lgatrBlvnW ‘ogislcrcd as of 

cIiarKQ th-vt lin f n 1 t>enlist, 1921, who was summoned on the 
namely, that convicted of certain niisdcmcanourfi— 
intmiTto detau^^^^ ‘-VI? Py o certain false pretence and with 
Association two su'ms of' *''® Am.algnnialcd Weavers' 
of dentures Mr Cad^ ' ’” ‘‘cspect to tho alleged remaking 

of his agent tL Rnl T I ‘'cfc"cc was that the faults were those 
and on the’ caso name ought to be erased, 

May 22nd the r„3."^ V.®'®”? '’’.e General Jfedical Council oii 
considering a letter ''’o Board’s sohe-itor, and 

decided tLt, Alfred '"'b® -"V® ficl- present, 

convicted of tire niisdrt?! having been found to have been 
his namo must L er'asclf f?,!®“?i °'' cireiices alleged against liiiii, 
The third c.LrwI! V? ‘.‘®'? 11'® Ben/ii/s Jlcffhtcr. 
of IVoodlesford -^rLi ®.l iV'^’Ty. Patrick Jones, registered ns 
on the charge of havin!l®in Dentist, 1921,” who was summoned 
patients. The cnmnlni”^ canvassed for tho purpose of procuring 
• elation. It annexed iZt^T®®® '''® P«blic DeLal Service Asso- 
tbe Registrar with •'PRcP'lejit iiad been warned by. 

bis practice, and^avr.n \® V®’‘l“',’l ■methods be bad adopted in 
broke the undertaltinff “"'‘ectuking to discontinue them, but 
sufficient— naraelv tliaf roasonB . W'hich seemed to him to be 
him that he was nof a^rovcd society had convinced 

elusion that M, j;®n„ The Board came to the co.i- 

so 111 breach of liig unIcHVt!,! ®^ °?’j' canvassing but was doing 
found that his name Leht (i ? "'defiance of tlio Board, and 
„ On the case eo™L S’ie .V® VT®"®’' ‘‘-oui the Register. 

2cnd a long hcarin ® was Medical Council on May 

plainants and solicifor foi- ^the ,?° ’'’i founsel for the com- 
rire Council, in order to eive (I ^b®’’?-?’-’*' "‘‘dressed the Council, 
his position, adiouniea o?r,,L;„ - P^ctitioiier some time to realize 

year, when’ he 'would be 

profes?ionnl brethren nn/l . produce endciice from hi 

as to his profesSoLriu in his . 


to his professional standing 

regard to his conduct in reUtbi/to'tt?''' ‘”r particutar with 
of making «»Professio„aI. and 


(i$omspfTtt&£nr(!. 

Examination of Vagrants for Small-Pox. 

Sm, — ^Tho Current Hole on page 221 of tho Supplement of 
May 26(h about o.vamiiiatioii of vagrants for smnIl-po.\ come.s 
rather lato in tho day. One qiiarter is past and paid for. 
1 made arrangements with my Board on fair lines, and they 
agreed. 

The arrangement that I have made is that they pay the usual 
fee for a visit in the immediate neighbourhood (under one 
mile) — that is, 5s — and I see any casual or casuals ; they vary 
from one to ciglit. Tiiis seems reasonablo to me, and I am 
satisfied w;itli the remiinerutioii. There are, on an average, 
casuals to bo seen on four or five days a week. The work does 
not lake Ipijg- It certainly tics one up to a slight extent, since 
I try to visit the ca.sual ward ns early as possible. — I am, etc., 

Wcohlcy Jl.S.O., Herefordshire, 3I.vy 27th. John S, ClaeKE. 


Iitalml Bn& ^ppoxitfmcnis. 


ROVAli KAVAL MEDICAL SERVICE. 

Surgeon Lieutenants IL R. Baker to tho Vindictive; W, J). M. .Sim to 
Iho Pcfnbroke for tho R.X. Infirmary, Chatham, temporarv*; B. W. Higgins 
to tlio^ JtospiUI, ilong-Kong; D. R. Campbell to (he 

fer\-]ce) V,\ V. E. McIntyre has transferred 

... . ' _ as Surgeon Lieutenant (short service) hhd 

appointed (0 Ilaslar Hospital for course of instruction. 

Roy-4L NivAt VotTJirrEnR RcsEnyr. 

Surgeon hiciitonants 71. E. Hall and IV. J, Pai’fio to bo Surgeon 
Lieutenant Commanders. 


ROYAI, AKSIY 3IEDICAL CORPS. 

Jfnjor C. R. .Miliar, D.S.O., to be Licutcnont-Colonel, vice Licut.-Colonel 
E. E. Parke*, doceosed. 

Jfajor B. varvill, M.C., retired on retired poy. 

Captain T. H. T«igg to bo Major (prov.) and remains Foconded. 
Temporary CapJain J. I\, Pell rcHnqui&hca his commission and resumes 
Uio rank of Captain. 

Temporary Lieutenant J. D. Cooper relinquishes his commission. 


nvivij/ lunubi MLUHJAh SERVICE. 

Flight LiculenanU P. D. Barling to Headquarters, Middle East; A. F 
Cook to No. 2 Armoured Car Company, Jliddlc East 
The following FlWng .OBicers aro promoted to tho rant ol Flight 
Lieutenant: P. If. Perkins and s. F. Hcatley. 

Rrstavr, or Am FoRCr. Orricr.RB; Mecicil Brikcit 
L ieutenant F. K. Wilson is transferred from Class D !i to 

Lsiass 1-1 1. 


Ma,“to®b’eter'’ 


TACA2fCIES, 

ASHiox-vxntr.-Lv^T. lisiox.— Medical Superintendent of Lake Hosnital 
and Medical omccr of Darnton House, also Second JrVJtmni iimi 
Salary £300 and 1150 per annum respectively. - Othver. 

BcRRiscros HosPiTu—Rcsidcnt Medical Offleer.’ Salary £200 per annum 
UlBULVOInif .IXD MiDUXD IfOMOEOeiTiriC Ifospiru. «D Disecvs.ov n ■' 
dent House-Surgeon. Salary 1160 A.ND uisrzxsiny.—Resi- 

“a^Sm.®”' Surgeon. Honorarium £50 per 

Bniciirox: Hoist, Alex.i,vdiii JjosmiL ran Stnr rirri„,.rx- r,' - 

Surgeon (male). Salary at tho rate of £1M per^annura 
BniSTOI. Gts-EIUL HosPiT.u — ^Honorary Clinical Assistants ' 

CiMap.iDCz U.Nivtnsm' : Pinioiooictt LtBORiroav— .Tntm 
Bludcntslilp. Annual value £300. amoaiioav.-jolm Lucas Walker 

Office' of Hcalti,. Salary ££00 per 
City of London Hospital for Djse.\ses of the ttpirt ivn ■«.. , 

girk. E 2.-(D Radiologist : honmariSm IM gidLas pe^nL.I’®^ 

House-Phjetcian fmalo). Salary at (he rate ft £100 per aimnm' ® 

b-tol.-Housr.Surgeon^Cmale). 

CovEXtay axn WanwiCKsiiijic HosPirit.— (11 Resident TTn„s'» o 
Resident Heuee-Physician. iLHes. Sal?ry at the rate of |l'|“p?®®anniS 

Diauxorqs CexEna IlosPirii.— Honorary Assistant Snf-con 
Devoxport : RoysL Alhert Hospitie axD Eve Ixprauiox-’' if- » . — 

Surgeon (unmarried). Salary at tire Mte of £50 pL ffooco- 

DoxcisrER; Hovsl IxpiaMiRy.— Third House-u„r.-nn.! „ 

the rate of £150 per annum. House Surgeon (male). Salary at 

"“"’""’‘-'’‘■“ior House-Surgeon (male). Salary £i 2 o per 

County Mental ITof'PiTAL TToiiinmi t > 

Medical Officer. Salary £350 ^ler aniiiim, Assistant 

Elizabcth Garef-tt Andf.uron Hospital, Euslon nmu v - tv ■; 

Phynician. (2) Obstetric Asslgtant. (3> Two Houser, H ouse- 
the rate of 150 per annum each. ^ ^ House*Surgcon$. s>Rlary^ at 

HaJIPSTFAD GUNEnAL and MoRTH-Wfct Lovnnv TT^c, 

N.IV.3.— Casualty Surgical Officer at ^hn ^^^''crstock Iliij 

Bayham Street. Salary at the rate of ^ir^'^nnum ®^P*‘****“eat, 


24b June 9,' 1928] 


' Association ' IntcHigerico and' Diary, 


r FurpLnAfruT to Tins 
Lnr.iTiHn MKhicAi. JounNAt. 


Ipswioit; East 'Suffolk- and Ips’n'icrn ITospitai..— Two House-Surgeons | 
(males). Salary at the rate of £100 per annum each. 

IjTVERPOOL SANATOaiun, Delamcre Forest. — Assistant to the Medical 
Superintendent. Salary £250 per annuln. 

IKINDON Homoeopathio HOSPITAL, Great Ormond Street , IV’.C.l. — Physician. 
Eondon School of HroiENii and Tropical Medicine.— Research Studentship 
in the department of Medical Entomology.' Value £250 per annum. 
I/OtATTSTOFT AND NORTH SUFFOLK HOSPITAL.— House-Surgeon (male). Salary 
£120 per annum. 

Manchester Citf. — Assistant Medical Officer at Bagulcy Sanatorium. 

Salary £350 per annum. - _ • 

Manchester Education ComriTTEE.— As.sistant School Medical Ofllccr. 

Salary £600 per annum, rising to £750. 

Manchester Royal Eye Hospital. — Senior and Junior Ilouse-Surgcona. 

Salary £150 and £120 per annum respectively. 

Margate ; Royal Sea-Bathing Hospital.— Male House-Surgeon. Salary at 
tJie rote of £100 per annum. 

Middlesbrough : North Ormesby Hospital. — House-Physician (male, 
unmarried). Salary' £115 per annum. 

KfrwcAsrLE-UPON-TYNE Eye Hospital. — Junior House-Surgeon. Salary £100 
per annum. 

Oldh\m Royal Infirmary.— House-Surgeons in charge of (1) Women^s and 
Cliildien Wards, (2) Male Wards, (3) Out-patients and Special Depart- 
ments. Salary at the rate of £175 per annum each. 

Papworth Viluge Settlement.— Second Assistant Medical Officer. Salary 
£250 pQr annum. 

Poplar Hospital for Accidents, E. — Senior Resident Officer. Salary £200 
per annum, plus fees £75 per annum ns Anaesthetist to Dental Clinic 
for L.O.C. School Children. 

Prestwick, near' Manchester : County Mental Ho.spital.— Assistant 
Medical Officer. Salary £350 per annum, rising to £450. ‘ 

Renfrewshire Education Authority. — School Medical Officer. Salary 
£500 per annum, increasing to £676. 

Royal Chest Hospital, City Road, E.C. — ^Medical Registrar (part-time). 
Honorarium £50 per annum. 

Royal Northern Hospital, Holloway, N.7.— House-Surgeon, Salary' at the 
rate of £70 per annum. 

Royal Waterloo Hospital for Children and Wosien, S.E.l.— House- 
Physician (male). Salary at the rate of £100 per annum. 

87. Mary's Hospital, W.2.— Assistant Director to the Suigical Unit. 
Salary £750 per annum. 

Bt. Peter’s Hospital for Stone, Henrietta Street, W.C.2.— Clinical 
Assistants. 

Salford Royal Hospital.— (1) Housc-Phvsiciar c 

attached to (a) Orthopaedic Department, (6) • 
ment, (c) Ovnaecological, Aural, and Skin . 
the rate of £125 per annum each. 

Salvation Army : The Mothers' Hospital, Loivcr Clapton Road, E.5.— 
Junior Resident Medical Officer, Salary at the rate of £60 per annum. 
Shetland : Parish Council op Tingwall, Whiteness, and Weisdale.— 
Parish Medical Officer and Parochial Vaccinator. Salary from Pariah 
Council £56 per annum, 

Southampton : Royal South Hants and Southampton Hospital.— House- 
Physician (male, unmarried). Salary £130 per annum. 

Stepney Parish,— Resident Deputy Medical Superintendent at (he 
St. Peter's (Whitechapel) Hospital. Salary £600 per annum. 

Victoria Hospital for ' Children, Tite Street, S.W.3.— Senior Resident 
Medical Officer (male). Salary £250 per annum. 

Willesdcn General Hospital.— (1)- Clinical Assistant to the Gynaecological 
Out-patient Department. (2) Two Clinical Assistants to the Surgical 
Out-patient Department. ' — 

Wrexham and Denbighshire War Memorial Hospital.— Two Resident 
House-Surgeons (male). Salary £100 per annum each. - 
Windsor:’ King Edward VII Hospital.— Senior House-Surgeon, Salary 
at the rate of £120 per annum, . ' ' ' 

Certifying Factory Surgeons.— 'The following ' * * • 

announced ; Wishaw (Lanarkshire), Scalloway 
ness-shire). Applications to the Chief Inspw 

Office, Whitehall, S.W.l. . . . 

Medical Referee (Ophthalmic Specialist) for the Lanark District. • .Appli-' 

. cation*? to the Private Secretary, Scottish Office, Whitehall, S.W;1, by 
June 23rd, * -.. 1 — • ' • • 

This list of vacancies is compiled from our advertisement .columns, 
where full particulars will ,be Jound. ^ To ensure notice in this 
column advertisements must be received 'not later than the first 
' post on Tuesday morning. 


APPOINTMENTS. 

St. Mary’s Hospital, London, "SV.— Surgeon in charge of In-patients • 

V. Z. Cope, M.D.; M.S., jF.R.C.S. -Surgeon tn charge of Out-patients: 
. ■ R. M. Handfield-Jones, U.G., M.S., F.B.C.S. 

DIARY OF SOCIETIES AND LECTURES. - 

, Royal Society of Medicine, 

Section of Obstetrics and Vyhaecology.-^YTi., 8 p.m., Professor A. Louise 
Mcllroy : A Case of Dysmenorrhoea due to Calcification of the Ovary 
>ir Clifford White: Vulval Metastases from Pelvic Growths; Professor 

W. Stvoganoff ‘(Leningrad) : Standard of Results in the Treatment of 
Eclampsia— an Experiment in the Treatment of Eclampsia by Telephone 

— r ....... .-Qatefi by tbg Honorary Secretary). 

—At tlie Pharmacological Laboratory, Oxford : 
jneral Meeting. ‘ 

Dftv»L college OF PHYSICIANS OP LONDON, Pall M^l East, S.W.l.— Tues.. 
5 p.m., Croonian Lecture b}' Dr. C. Bolton, C.B.E. : The Interpretation 
of^Gastric Symptoms. 

POST-GUADUATE COURSES AND LECTURES. 
T-mnwsHiP OP Medicine and Post-Gr.aduate Medical Assoclation.— R oyal 

TTosiiital St. George’s Circus. Southwark, S.E. : Mon., 3 p.m., 
5/{l;.S?*^npmnnqtration : no fee. Tioyal horthem Hospital, HoIIowav 


other Hospitals : Second week, Instruction in nil hranchf's of Disease! 
of Children; fro for one week, Xl Is. Syllabus on application to the 
Fellowship of Medicine, 1, Wimpolo Street, W.l. 

Central London Throat, Kosn and Ear Hospital, Cray’s Inn Road, W.C.l. 
— Mon., 1.30 p.m., lilxamination of the Kosc. Wed., 1,30 p.m., Examina’- 
tion of the Ear. 

North-East London Po-ST-nnADUATr. Coi-lece, Prince of Wales’s Genrral 
Hospital, Tottenham, N.15. — Mon.. 2.50 p.m., Demonstration of Medical 
Coses; 2.30 to 6 p.m., Medical, Surgical,' nnd Gynaecological Clinics; 
Operations. Tiies., 2.30 to 6 p.m.. Medical, Surgical; Throat, Nose, and 
Ear Clinics; Operations. Wed., 2.30 to 6 p.m., Medical, Skin, and Eye 
CHnic.s; Operations; Thurs., 11,30 n.m.. Denial Clinics; 2.30 p.m.. 
Demonstration of Surgical Cases; 2.30 to 6 p.m., Medical. Surgical, and 
Ear, Nose, and Throat Clinics; Operations. Frl., 10.30 a.m., Throat, 
Nose, find Ear Clinics; 2.30, to 6 p.m., Surgical, Medical, and 
Children's Dlseasc-s Clinics; Operations. , . 

Roy.al Northern Hospital, Holloway Road, N.— Tucs., 3.15 p.m., Tlie 
Autonomic Nen'ons System, its Form ohd Functl6n?. 

St. Paul's Hospital, Endcll street, W.C.2.— Wed., 4.30 p.m., Trcalmcnl of 
Enlarged Prostate. Ten nt 4 p.m. 

West London Hospital Post-Graduate College, Hammersmith, W.— Jfon., 
10 ft.m. to 1 p m., Ocnito-urlnary. Operations, Surgical Wards, Skin 
Department; 2 p.m. to 6 p.m., Eh-e and Gynaecological Departments. 
Tucs., 10 ft.m. to 1 p.m., Medical Wards, demonstration of Venereal 
Diseases, EiccIrJeal and Dental Departments; 2 p.m. to 5 p.m., Gynaeco- 
logical Operations, Thro.at, Nose, and Ear Department. Wed., 10 a.m. 
to 1 p.m., Children’s ■ Medical Department, Medical Wards, Patho- 
logical Demonstration; 2 p.m. to 6 p.m., Eye Department, Surgical 
l\^rds. Tliurs., 10 a.m. to 1 p.m., Neurological nnd JIassage Depart- 

mcnls; 2 p.m. to 5 p.m.,- Eye .f" * — *— -'^s. Fri.. 

10 a.m to 1 p.m., Skin, Denta Medical 

Wards, Clinical Demonstration . . * ose, and 

Ear Department. Sat., 9 n.m. to 1 p.m., Medical Wards, Throat, hose, 
and Ear Operations, Jledlcal Cliildrcn’s Department, Bacterial The^py 
Deparinlcnl. Dally at 2 p.m,, Operations, Medical and Surgical Out- 
patient Departments. .... 

Liverfool University Clinical School Ante-Xatal Clinics.— Royal 
Infirmary : Mon. nnd Thurs., 30.30 a.m. Maternity Hospital : Jlon., 
Tues., Wed., Tliurs., and Fri,, 11,30 n.m. 

Manchester: Ancoats Hospital.— Thurs., 4.15 p.m., Treatment of Fractures, 
with Demonstrations. Tea nt 3.45 p.m. 

SHEffiELO University Po>t-Gr4DUatb Clinics.— .\t Jrs.«op Hospitol ; Tue?-» 
3.30 p.m., Hints nnd Tips In Midwifery. At Royal Hospital: In., 
3.30 p.m., Clinical Cases. 


58 ritislj iltsbiral Assorifttion. 

Ofl'ICb'S, liRtTISU MEDICAL ASSOOIATIOM 'HOUSE, 
TAVISTOCK SQVAKE, U'.C.I. 


Dopartmonts, . „ , 

BunscmmoN ' - 

‘ ■ ■■ ■' .■ '“’AlSShfgy' Wesloent, 

Of ary of tho Association, 

8 Frl City Division; Clinicj.rVetinB, Metropolitan Hospital, 

' ’ Southern "Branch • AnL'al'’Mceting, .Queen’s Hoiel. Souttse^ 
^Colone" Mncartlmr on Some Medical Hefereucca to Pepys, 

11 Mon. IIeKa^Dil;ision‘;‘’SnuaPi Meeting, 80, East Street, Hereford, 

12 Tues. HnsHngs'"' Division: Hastings Infirmary, Frederick Road, 

r.a^'1? THrislon • B M.A. House, Tavistock Square, W.C.l. 

® Dn“w. Langdon dVow'd on Endocrinology and the Future, 

“ Ro^irPortsmouth Hospi Sir Archdall 

1, Tfiurs.3fed«ol.r=^&.. Hampstead Oenera, 

slfSa ; UnSSari«f '^'“ p-'O- 

Luncheon,'! P-^- ntv Buildings, Dumfries, 3 p.m. 

11 f c|t'r;aMi P- „,,aing 

Lewisham ihP Alimentary Tract, 8.45 p.m. 

MeTrof;]f^anToSn^f aV^^ Me’^ting. B.M.A. House, 

20 Wed. Hondon^i^Private- Practice Commi^itc^^^ 

Sunderland Division . Roj al Inlirro y j[arlesden Road, N.W. 

• : '"i'i?1fa"rg“arerEmdS " “ar?of tUe Infant. 9 p.m. 


BIRTHS, MARRIAGES, AND DEATHS. — 

The charge for T/'/orifur^^^^ KitTih^noUee 

InerhIogfAn orier to 

ensure insertion in the current issue. 

DBATTlS 

}]?rl.l'J'/oT’Me"dJa^ Weft U^’an mSic^ 

o'n?^?nd.’ 

?^;rfi"e,J^‘:."?.uVa]:lf cf"i;ina;jiB^ (u^a Abdy). 


Printed and published by the British Medical Awociation, at their Offioa, S»ilBlock Square, in the Parish of S^ Pancras, in the Couutj 





SXJI']?IjE3Vn±llfTT - 


TO THK 


BEITISH medical JOURlSrAL, 


LONDON, SATUUDAI’, JUNE 16Tn, 1928. 


CONTENTS. 


BRITISH MEDICAI* ASSOCIATION, 

Annual Meotlnff, CardllT; Provisional Profframmo 

The ScinETinc StcrroKs ... 

. pRovisioxAt, Time-Tabs'; ' 

Tathoeobicae Museuji 

Hotel Accommodation 

Annual Dinner . 

Hotices or Motion by Divisions 

Contributory Schemes lor Hospital Benefit. Coneereni 
or Medical IIepresentatives of Yolvstary Hospitals 
CDRUENT NOTES : 

Kepop.ts on Deaths pcenistieo at Request of Coroners 

Help to Individual IIembebs 

■ Medical Appointments Arp.oad 

British MroiCAL Association Libbary 

JIlDDLEMORE TrIZE, 1923 

Access to B.M.A. House 


251 

256 

257 
257 

257 
253 

258 

249 

249 

249 

250 
250 
250 


BRITISH MEDICAIi ASSOCIATION: 

An Open Bettor to Non-Members -. 

Growth of tho Association: Fifty Years’ Progress 

Application for Membership 

Map of tho Environs of tho Association’s House 

ASSOCIATION NOTICES 

MEETINGS OF BRANCHES AND DIVISIONS 

COURESTONDENCE , - 

NATIONAE INSURANCE : 

London Panel Committee 

DilNGEUOUS DRUGS : Withdrawal of Adthorization 
KAVAL AND JIILITAKY APPOINTMENTS 
•VACANCIES AND APPOINTMENTS 
'DIARY OF SOCIETIES AND LECTURES... 
ASSOCIATION INTELLIGENCE AND DIARY 
BIRTHS, MARRIAGES, AND DEATHS ... 


1 

ii 

iii 

iv 
250 
•^51 
262 - 

262 

263 

263 

263 

264 
264 
264 


jJrifisIj ilttbicnl ^ssocirrfioit. 

CURRENT NOTES. 


Reports on Deaths furnished by Doctors at the RCQUOSt ' 
of Coroners. ' 

The Medico-Politicnl ComiHittcc at its last mooting liacl 
.before it a report from the Divisions which had taken 
action to porsuado local authorities to authorizo their 
coroners to pay a feo , 

to doctors for furnish- 
ing, on request, in- 
formation in regard 
to ■ sudden deaths 
which might cnahlo 
them to dispense with 
inquests. The report 
showed that most of 
the Divisions wliich 
had taken action had 
succeeded, hut thero 
aro still many areas' 

■ where no action has 
• heen taken.' Those 
Divisions which havo 
not yet made their 
effort should ho cn- 
.couraged by what has 
been done, and 
remember fliat they 
have a .very good 
argument' on wliicli 
to base tlieir request 
.—namely, that of 
economy. An expen- 
diture of lOs. 6d. is 
well worth while to a ' 



Bnrnsn Medical Associatioi: House: Couet or Hosoue.- 


local autliority if it results in information which obviates the 
cost of an inquest, not to mention the possible additional 
TOSt of a post-mortem examination. Doctors should wait : 
'a Lpoit ^ information before supplying 

can bo shown that more authorities -are 
thF “i-c ?ot, it will .be possible for' 

OfficR witl .f^ilical Association to approach the Home 
to persnading that Department, to brihg 
the altei-n-i+i ' “fcas that.jire not pitying, or in 

wboi:“co?„t;° a general -rule appyu/ to 'thp 


Help to Individual Members. 

Tlio Association is in possession of a very largo amount 
of information on all matters affecting .medical practi- 
tioners in their professional lives. It is thus often able 
to help members individually' in difficulties of a pro- 
fo-ssional' nature, and doing so constitutes a' considerable 
part of its daily work. Tlio Medical Department alone 
has some 5,000 files, dealing with all branches of medical 
activity. Tho Inteliigenco Department, besides assisting 

in the collecting aiid 
recording of informa- 
tion, has . a supply 
of press cuttings on 

- matters concoi-hing 
the profession, and 
this information, to- 
gether with that 
arising in the ernrso 

■ of cofr'osp'ondence, as 
So far as posrible' filed 
in such a way -as, to 
bo readily available 
for the assistauco 
of members tlirough 
the rhediu'm . of tho 
’E d i t o rii a 1 and 
Medical Department’s. • 
Inquiries . by mem- 
bers, whether through 
the honorary . secre- 
taries of ■ Divisions 

- or-Branohes, or other- 
wise, on any matter 

■ of 'doubt or difficulty 
affecting ■ . them in 
.their, professional 
capacity are wel- 






corned; such inquiries should bo addressed to tho 
Medical Secretai-y. Export opinion on income-tax ques- 
tions as affecting the profession is published in tho 
llritish Medical Journal. Tho Solicitors of tho Association 
are consulted when legal matters arise which affect the 
general interests of the profession. 

, Medical Appointments Abroad. 

Tile, liend" office qf tho British Medical Association has 
a good deal of information placed at. it's disposal ‘by ' its 
Branches overseas, which may he very useful to those 'nro- 
posing to ■ accept medical . appointments abroad. Pimcti- 

II247J 


r ,^urpLT:}n:sT to the 
L lIniTIKII MKOIClL JounXAL 


2d6 


June 16, 1928] 


Association Notices, 


tioners are cordially invited to apply to the Medical 
Secretary, B.M.A. House, Tavistock Square, W.C.l, for 
any information that may bo available regarding oversea 
appointments iii which they may ho interested. 

Britisli Medical ilssociation Eibrary. 

The Association’s Library contains moro than 30,000 
volumes, including books in all branches of medical litera- 
ture. It is open on weehda 3 s from 10 a.m. to 6.30 p.ni. 
(Saturdays from 10 a.m. to 2 p.m.). The librarian and his 
assistant are always ready to help memhers to find book.s 
ot references. Besides the facilities afforded to members 
for consulting monographs, periodicals, and works of refer- 
ence in the libraij', books in all branches of medical 
literature and many' in general science can be obtained on 
loan by members resident in tho British Isles, freo of 
charge (other than postage), from the lending department. 
The books issued include latest editions, new books and 
new editions being made available as soon as possible after 
publication. Books can ordinarily be kept for twenty- 
eight days. Inquiries ■ about the library and lending 
department should be addressed to the Librarian, British 
Med.cal Association House, Tavistock Square, London, 
W.C.l. • • 

Mlddlemore Prize, 1923. 

'J’he Middlemore Prize consi.sts of a cheque for £50 
and a certificate, and was founded hy tho Into Richard 
Middlemore, F.R.C.S., of Birmingham, to ho awarded 
for the best o.ssay or work on any subject which 

the Council of the British Medical Association may from 
time to time select in anj’ department of ophthalmic 

niediciuo or surgery, Tho Council is prepared to consider 
an award of the prize in the year 1929 to the author of 
the best eissay on the following subject: “Tho clinic.al 
study of the vitreous body, its swellings, contractions, 
opacities, and reactions to toxic invasion; with special 

reference fo glaucoma and detached retina.’.’ Essays 

submitted in conqietition must roach the Medical 
Secretary, B.M.A. House, T.avistock Square, W.C.l, by 
December 31st, 1928. Each essay must bo signed with a 
motto and accompanied by a sealed envelope, marked on 
the outside with the motto, and containing tho name and 
address of the author. In the event of no essay being of 
sufficient merit, the prize will not be awarded in 1929. 

Access to the B.M.A. House. 

The private roadwaj' and pavements leading into the 
British Medical Association Hou.se from Tavistock Square 
are now entirely closed for traffic while excavations are. in 
progress, and the Association can , take no ro.spoiisibilify for 
accidents occurring to persons ivho in.ay pass through the 
site of the work now pi'oceeding. A covered wooden jtassage 
has been' cbustructed to fonn an entrance’ to the building 
for foot passengers from Tavistock Square, jlembers and 
others v.Iio do not wish to use this covered way, or who 
wish to bring motor cars or other vehicles into tlie As.socia- . 
tion’s premises, must proceed southwards down’ Tavistock 
Square, turning left at the bottom of the Square into 
'•Tavistock Place, turning left again into Marchinoiit Street,' 

■ and again, left round Cartwright Gardens,. thu,s entering 
tho courtyard of th.e B.M.A. House through the arcliway 
under the Great Hall. 


^ssonation l^oiirrs. 


PROPOSED’ AMALGAJfATION OF GLASGOW CENTRAL 
■ GLASGOW EASTERN, GLASGOW NORTH-WESTERN ’ 
AND GLASGOW SOUTHERN DIVISIONS, TO 
FORM A “ GLASGOW DIVISION.” ■ 

NdTiCC is hereby given ol the following i7roi)0,sals made’ by 
the Glasgow and West ol Scotland Branch : ’ . 

' ' ( 1 ) That the existing Glasgovc Central, Glasgow Eastern, 

Gla.sgow North-'Western, and Glasgow Southern Divisions 
ot the Glasgow and West. of Scotland Branch he amal- 
gamated, and their total area c.xtended, to .form a 
'• hldsfjow Division,’!- coterminous with the City ot Glas-. 
"aw the areas of tho Dumbartonshire, Lanarkshire, and 
Renfrewshire and Buteshire Divisions being modified 
Rccordinglj'. 


Or alternatively. In tho event of the foregoing proposal for' 
formation ot a " Glasgow Division ” not being approved : 

( 2 ) That the boundaries of tho Glasgow Central, Glasgow 
Eastern, Glasgow Norlh-Wcstei-n, andlGIa.sgow' Southern 
Divisions be adjusted so ns. to make the total area ot 
these Divisions correspond with that of the City of 
Giasgow, the areas of tho Dumbartonshire, Lanarkshire, 
and Renfrewshire and Bute.shire Divisions being modified 
accordingly. 

■Written notice of tho above proposals has boon given to tho 
existing Divisions above meulioued, and tho matter will be 
dotcrininod in duo course hy tho Council of tho Association. 
Any body, or mouibor, affected b.y the proposed changes or 
cither of them, and objootiug thereto, is requested to write, 
giving reasons, to the Medical 'Secretary, British Medical 
Association House, Tavistock Square, Loudon, W.C.l, not 
later than July Sth, 1928. , 

Alfiied Cox, Medical Secretary. 


Juno 21, TIiur5. 
June 20, Sal. 
July Wed. 
July 20, Fr!. 


July 21, Sflt. 
July 23, Mon. 

July 2-1, Tuca. 

July 25, Wed. 

Julv 26, Thurs. 
July 27. Fri. 


TABLE OF DATES. 

£Icc(ings of Con&tiCucncfcs must be held between thifl date 
and July 20il» lo instruct Itcpresentativcs. 

Snpidemcritttry Jteport of Council appears in British 
Mtuiaa JOURN'At. SUITLEIIENT. 

AinenUnicnts and riders^ for inclusion in A.It.il. agenda 
must be received at Head Olfice by this date. 

Annual Kejircsf.ntattce Meeting, Cardifl, 10 a.m. 

Nominations for election of IZ members of Council by 
grouped Uepre^entatives muut be received (at 
CardilT) by this dale, 2 p.m. 

Annual Reprfgrhlatite Meelint;, C-ardifl. 

Cuuncil, CnidifT. 

Annual Representative Meetinrr, CordifT. 

Annual licjneisciitativc Meetiufj, Cirdill. Annnat Generol 
3Iocting;, CarilifT, President’s Adflres?. 

Coiincif, Cardiff. Conference - of - Honorary Secretaries, 
Cardiff. 

Mceiings of Sections, etc., Cardiff. 

yieeiings of Sections, etc., CartYxO. ^ 

yieetiugs of Sections, cKc.t.CanVx^ . ^ 

AliPitEB Cox; Medical Secretary* 


BRANCH AND DIVISION MEETINGS TO BE HELD. 
Dobsct and West Hants Branwi : Boubnemodth Division.— Tho 
annual social meeting of flic Bourncmoiifh Division lyill bo hold- 
on Saturday, July 14th, wlien a visit - will bo paid to the Pitt 
Rivers Museum, Farnliam, Blandford,- to be followed by tea at 
Laima Tree Gi ouiuls, Tollard Royal. 

DonsCT AND West Hants B^nch : West Dorsct DivisioN.-^The 
annual supper of tlie West Dorset Division will be held at tho 
Autclopo Hotel, Dorchester, on Thuisday, June 21st, at 7.30 p.m. 
Tickets 6s. cacli (exclusive of wines). The ^nual meeting will be 
liold after supper. Agenda : Election of officers, Ihccutivo Com- 
mittee and Sbers of Braneli Council for 1928-29; considcrahon 
M llid Annual Report of tlie Council of the Association and instruc- 
tions lo representative; annual report of honorary secretary. 

■Fr.twMjnrii Bbanoi. — The annual meeting of the Edinburgli Branch 
wiH be heW at Shead Ford on Tdesd-ay, June- 26fli. Luncheon _ 
w be nvovided in the Hall,. Pathliead,- at 12.15 for 12.30 p.m 
/'i" a=°l' Er Crei" (Pathhe.rd) has obtained the. courtesy of 

**'|-|^'i?Tslrokcl He has also obtained tho courtesy of the Path; 
petition (stro )' yijtts gave been arranged for Pre.slonliall 
head bowling gree • „ ^ Church, and tlie Vogrio Nursing 

Gardens Crichton CasUc^^aua g Eobertson. At , 

Ro'"'’. ^ will entertain the party to tc,T. The business 

4.30 P.m. o’clock. Agenda: Report of Branch, 

meeting take place av o report; . election . of officers; 

licasurcrs husme^, prizes; report of election, of repre- 

prescntalion of 6°'^ “'"Pe qu”;). filling 'of Vacaiw^^^ on the board 
scntative to the CenUal ’ proceedings of .Scottish Com- 

of the Queen Mary Nursing Home, Eepresentative 

of Bi-anch to appoint, additioiml members to 
Branch Council under Rule 4 (2) \U)’ • ' , .. e 

llETBOPOEiTim Counties BBANCn.--TI,e annua general 
tho Jlelropoiitan Counties Brandi ^ \V C 1 on 'Tuc<;day, 

by D'r. Cliristine Mu’frell entitled Our clinging times. , , 

Metropolitan Counties Branch : .-H^oon Cottage 

of the Hendon Division will be hold at ‘ho Hendon ^ttage 
Hospital on Friday, June 29Ui, at 8.30 pm. * the 
invited to show cases. The ineeting will subsequently discuss me 
Supplementary Report. , * ‘ 

Metropolitan Counties Branot : Lewisham 
of the Lewisliam Division will he held at *'h® .-ij] read 

0.1 Tuesday, June 19tli, at 8.45 p.m. Mr. J M. ^ 

a paper on some points m the x-ray examination of the alimentary 

track.' - . . ■ . ■ - • 

Metr'ofoutak Counties Branch: ,St: Pancras. Division. --A 
mg ot the St. Paiicvas Division wiU be 'hgld “I ‘“c ^itis 
Medical Association House, Tavistock 

TtiTv inth at 9 Din. Dr. W. Camac Wilkinsbn will lead a paper 
th" heme treatment of tuberculosis by the general practitioner. 



June IG, 1928 ] 


IVIcotings of Branches and Divisions. 


r RUPPLEicnKT TO rnr. 

LBrITISII SIrdICAC JoUBKAt. 


251 


METROrOMTAN COUNTIES BrANCTI : WAHDSWORTn DIVISION. — ^Two 
mccUngs Of Iho WaiuUworUi Division will bo held in the Town Hall, 
\Vandsworili, to consider llio Koch diagnosis nnd Irrntinont of 
tuberculosis by means of tuberculin, together with a proposal for 
a- coilccUvo investigation into tho subject. The first meeting will 
bo'held on Friday, Juno 22nd, at 9 p.ni., when Dr. Kobert Carswell 
will read -a paper on “History and diagnosis." At the second 
meeting, on Friday, .Tune 29th, at 9 -p.m., Dr. Carswell will 
read another paper entitled “ Treatment, and a proposal for a 
collccliyo investigation.” • Tho meetings will be open to all members 
of tho medical profession. 

METRoroErTAN Counties Brancti ; TVielesuen Division. — A meeting 
of tho TYillcsdcn Division will bo held at the ^Yillcsdcn Hospital, 
Ilarlcsdcn Koad, NAY.; on TVednesday, .liino 20Lb, at 9 p.m. Dr, 
Margaret Emslio will discuss tho.caro of Iho infant. 

NoRroLK Branch. — ^T hc annual meeting of tho Norfolk Branch 
will be held 'at tho Town Hall, Alyslmm, on Thursday, July 5th. 
at 5 p.m. Agenda : Report of tlic Branch Council and anmml 
financial slatcmenlj induction of the new president, Dr. R. B, 
Samvell, by the retiring president. Sir Hamilton liallancc, H.B.E., 
C.B.; election of officers; an address by Mr. Vivian Carter, 
British sccrctai'y of Rotary International, on the diagnosis of 
personality. Tea (to which ladies arc invitcdl at 4.30 p.m. at 
tho Grange, Alysham, by invitation of Dr. Sapwcll and Miss 
Sapwcll. 


^ORTl^:nN Counties or Scotland BRANm.—Tho annual mceh'n" of 
the Northern Counties of Scotland Branch is to bo held at Kyle of 
liochalsh on June 30th. This ivill be the first meeting of tho 
Branch which has been held in tho area of the Islands Division. 

- Northern Counties or Scotland Branch : Islands Division.— 
Tho general m»!cling of the Islands Division will bo hold on 
Saturday, June 30th, in the Station Hotel, Kyle of Lochalsh, at 
10.30 a.m., to elect officers and lixeculive Committee. 

North or England Branch: Su.vderland Division.— A meelinn^ 
of the Division unll be held at tho Royal Infinnarv, Sunderland, 
on Wednesday, June 20th, at 8.15 p.m. Among the matters to 
bo considered at this meeting h the .question of the adoption by 
tno Division of a r«olution on the scale of minimum commoncin" 
salaries for whole-time chief medical officers of health. 

North HmsmEE /h'd Sotini Westmorlaot Hrahch.— TIio 
BBnual mrelwg pf the Nerlli lancashirc and South Westmorland 

1 Calgartli (tiy kind permission of Dr. 

•SW.u ^ 1 ? Gowroors of the Ito.sp'itnt). Dr. J. Lang Cochrano 
will deliver Jus presidential address. Ladies are invited, and a 
boat on Lake Windermere will ho placed at tlieir disposal. 

Drannh"wln*lfe X? '‘/’."'I?,' "'celing of the North Wales 

Denhieh''^' t'‘o North Wales Sannloriuin, Llangwvfan, 
NatSl' M ™ ■’“'5’. ®‘’>- The council of the Wcisli 

■ Mnatorium^ndn"'*ii'‘'f""”!i®" >'"<>, tl'O liousc commitlco of the 
the rnjertam the members to lunrli, and a tour of 

win ho ann'eni "a I su'd further particulars 

ZoL ef '“Jer. but members are requested to make a 

note of tho date as a large attendance is hoped for. 

pXTORD AND • RiiADTNO Branch, — A meeting of the Oxford and 

bv aSunner "V'r ^‘"’^i‘"5'’/“"« 21st, at 9.30 p.m.J^.recedel 
miltce- 'Sonorarv x;’*"' Eleclion of ofTicers and com- 

•Nesolution; ^ becrelarj- b report; alteration of BuJe 5; 

I'ropo.cd mrlhods of puhliritv concerning nnWic 

•eeritalives’ Sebeme; report of tl.e Repre- 

'DivSi^vni®bo'l^ld-nfu"' meeting of the Jersey 

21st. at 8.30 n b' Ur a^'h 'ino''1 «’> Thursday, June 

■culosis from tChoinrh^vf^w ^-be 


Thursday, 

he point of view of Die tuberculoses ^'fficer'' 


Thumdav June 21st ft if Vieloria Gardens. Neath, o, 

^S“a|'iafion“of"nr“<Sid '’f f"'® .^"r W^rfbeTtionf 

:c!«s“n“oT?h;^^"eo'’ti?g'’| 1d|f ’■’’f ^Jeton " At th^ c^n 

-;or^.%?-‘‘ein‘o”r 

-purchased as a war^memoriaf*' 

interest to the general urnefitiA^.? cases o. 

■.3-15 p.m., in-BroSey's Caf6 -Rn^n?" W'edncsday June 27f.h, al 
.resign the chair to Dr^Ha^er who witfS P''='=»rd wil 

entitled The influence df Wli?,™ f'’ '“s '"‘'‘'!K«ral address 
medicine in the ciiS^en^n''’ Suntci 

;tIio Branch Council for tho re^r U» 7 *^ 9 r report oi 

“cut for the year 1927, .will state- 

officers of the Branch for to the meeting, and the 

Luncheon, by inflation ^f the PrS'" 

■1 o’clock at Bromley’s Cafd and "it 

■ be provide! -Tho annual concluded 

nicdical ancf non-medical guests Branch, to which 

quests and ladies are invited, _aill he 


held at 7 o'clock at tho cafd. Tickets, 8s, each (exclusive of v,'incs), 
may bo obtained from Dr. H. C. Jonas, Boulport Street, Bam- 
Blaple. Accommodation for tbo night, could be arranged if nclico 
is given to Dr. H. C. Jonas, Boulport Street, or Dr. Killard- 
Leavey, Lilclidon House, Barnstaple. 

Shbrei' Brahch. — The annual mooting of the Surrey Branch will 
bo Iicld in the Town Hall, Kingston-on-Thames, on Wednesday, 
Juno 27th, at 2,15 p.m,- Tlie-Kingston-on-’rharacs- Division invites 
members to lunch at Nuthall’s He.staurant at 1 p.m. Colonel 
C. W. Profeit will address the meeting on the British Empire 
Cancer Campaign in Surrey, and the president (Dr. -H. R. Cran) 
will deliver his presidential address. After the meeting members 
will motor to Epsom to visit Epsom College; lea will he taken in 
Big School. Tho annua! dinner will bo held at Reid's Restaurant, 
Ashley Road, Ep'om, at 6.30 for 6.45 p.m. (tickets 7s. 6d., ciclusis-e 
of winbsl. 


Sussex Brakoi. — The fifteenth annual, meeting of the Sussex 
Branch will be held in the Royal York Hotel, Brighton, on 
Thursday, Juno 21st, at 2 p.m. Agenda: Eleclion of officers; 
induction of president to chair; Annual Report and Financial 
Statement of Council; presidential address. The members of the 
Brighton Division invite ’other members intending to be present to 
luncheon at the Boyal York Hotel, Brighton, at 1 p.m. Xn the 
afternoon cars will leave the hotel about 3 p.m. for Falmer, where 
Dr. Eliot Cura-en will demonstralo a Romano-Brilish Settlement 
at Biickland Bank. Tea will bo provided at Falmer. Members 
are invited to bring their wives to this excursion. 

. Sussex Bp.akch : Baicirrox Drvisiox.— Tho next clinical meeting 
of the Brighton Divi,sion n-ill be held at the Royal Sussex County 
Hospital, Brighton, on Thursday, June 28th, at 3.45 p.m. 

WiLTsninn Braxch.— Tho annual meeting of the Wiltshire Branch 
will bo held on Wednesday, Juno 27Lh, at 3 p.m., at the County 
Mental Hospital, Devizes, when a British Sfcdical Association 
Lecture will be given by Mr, 3V. McAdam Eccles on the treatment 
of herma by trusses, illustrated by their actual application. 

LYest Somerset Branch.— The annual mcelin"- of tbo West 
Somciret Branch will ho held at Deller’s Cafd, Taunton, on 
Saturday, Juno 23rd, at 12.35 noon. Agenda: Induction of 
prcsidcnt-clcM ; annual report; election of officers. Branch Council, 
and Ethical Committee. 


x., 1 , yxitxvuKusnraE ASP.AXcn.— Ahe annual 
meeting of the W orccsterehiro and Herefordshire Branch will be 
held , at the Ifospita^l, Hereford, on Thursday, Juno -filst, at 

Branch Council ;' election of presi- 
dent for 1924-aO; c cclion of honorary treasurer and secreLiry. 
Dr. iSaish will vacate the chair .and iniroduce bis successor. Dr' 
Hincks. A clinical lueetinv will then be held. Dr. Naish invites 
the Branch attending to have lunch with him at 
bo p?ovfd"cd°‘'''° rneeting tea will 

Yorkshire Bra-nch: HuDOERsnELD DrvisioN Tlia annual ntm,-- 

of the Huddep,field Division will bo on Thursday JuneYlst ^ The 
charabanc will leave Lork Place at 12.15 p.m. for' bovedale.- Aflcr- 
noon tea will be served at the Peveril of the Peak Hotel on arrival 
at 3.^ p.m. Tho afternoon will be spent -in Dovednl#» 
charabanc will leave Dovedalo at 5 45 n m for Riirfnn • 
vvill bo served at 6.45 p.m. aflbe St aS 4 XKtd °Ve partv^^^^ 
Icavo Buxton at 8 p.m., and should arrive in Huad?>.r^fi?hf i 
10 o’clock. The inclusive charge for charabanc to? dinner (Ixch^Wu 

of beverages), and tips, wi 1 be £1 2s. Bd tier heirf • fn.- < 1 ,™ - 
in tbeir own -cam lOsr per head. ■ ^ ■ ’ ^9r. ‘tiKe going 


ificriin^s of !6r and;£5 . mb ^msibns': ' 

CloxNAucHT Branch. . . . . . . . • 

The annual general meeting of the Connaimlit ' 

Dm Railway HoteL Galway,' on May TSth. held, at 

’’"n/ .-^ecrrlan/, DA johh jtiHg 
... . Mr. At. G. O’Mallev and 

■ • • ■ ■ . . ■ ‘ 'S'"'-"’ John 'Jlil", 

Tho Report of Council was considerTd ana'dtcL^d.'^- ' ' ' ' 


, . ■ Essex Branch. 

Hoter"so«then1misfa!'’%f^'S,®"“^ the Palace 

The foIloA^ng officers were elected for the ensuinu near • ' 

■ Prestdfntt Dr. T. Brice PooV rt... ^ 3^ear . 

PaH-Pr^ni(ient, Dr. G. T. Ke . ^ " iseynolds Brown. 

Dr, J. F. Walkpr. Ilonorar*/ w’ * i"* Fijlan Fell and 

Dr. Kevetj?, IrHving ind '• 'Y. F. Corfield, 

dcntial chair, passed on t( ’ ' P^^si- 

of office. A unanimous vote ot thanks wte j x ^nd badge 
Presipent and to the Honokary SEraRTARr nf out-going 

replied. Dr. Brice Poole expressed iIS nVxtn.,!j - r briefly 

that had been done him in electing him®^ preBidlnt°f' honour 
.and invited all the members nrespnF tp ® .°o the year. 

The Honorary SEcRrr.ARy^nVSentcd lunch with him. ’ 

the year, which showed that the B^nch P,ind®n ^'o*' 

Dr, WAL^ .drew the attention of the . meeting ' to the, great 




252 June IG," 19281 


MeoVngs of Branches and DfvisionSi 


r BUPPLEiTElfT TO TH> 
iBniTisii nzmCLL JoersvAb 


needs of the B.M.A. Chanties Fund, and proposed that £5 should, 
IIS in the pi'evions :year, be sent to^tbe CbaviUcs Fund fvoin the 
Branch Voumlary Fund. Dr. Haynes seconded this proposal, and 
suggested that the amount should bo increased to the whole of the 
Voluntary Fund, which was unanimously^ ngi'Ccd. 

Lunch followed the meeting, at the invitation of Hr. Brice Poole, 
and aHerwards member and their wives liad a most enjoyable 
cruise in a motor yacht across the mouth of the Tliamcs and up 
the Medway. ______ 


Glasgow and West of Scotland BnxNar. 

The annual meeting of the Glasgow and West of Scotland Branch 
was. held in the Glasgow Royal Infirmary on May 30lh, about 
eighty members attended under the chairmansbip of Hr. II. M. 
Buchanan, president. 

The annual report of the Branch Council was read and 
appiovcd. The following office-bearers were elected for the 
ensuing year : 

l‘r('.->ulcnt. Dr. II. Jf. Buchanan. PrcfidfHt-Rler.t, Dr. G. C. Cr.awford. 
H'nwrnrjj 6Vcrr/cfr//,. Dr. J, G. McCntcheon. • l)r. .latncs 

lUll and Dr. J. P. Brown, llomrarti TreOKurer, Dr. A. S. Riclnnoiui. 
AiifhCois, Dr. J. tPaUace Anderson and Dr. George A. Allan. 

After the annual meeting a clinical demonstration was given 
by the medical and surgical staff of the Glasgow Royal Infirmai-y, 
when many interesting and instructive cases were demonstrated. 

On the motion of the Chairman a vote of thanks to tlic dirccloi-s, 
medical and surgical staffs, and nursing staffs for their hospi- 
tality to the members of the Branch was licaVlily adopted. 

At the clinical meeting a collection was taken for medical 
charities, which amounted to £14 8s. 


Northern Counties of Scotland BnANcn. 

A ^lEETiNG of the Northern Counties of Scotland Branch was hold 
a( the Lawson Memorial Hospital, Golspie, on M«av 19th, under the 
chaumanship of tlio vice-president. Hr. E. K. ’Mackenzie The 
cliairnian referred to the death of Hr. J. W. Mackenzie, and the 
secretary wt^ instructed to send a sympathetic letter to JIrs 
Mae^nzic. The chairman also referred to the serious illness of 
Lr. 1. Macdonald, the president, and the secretary was instructed 
to send him a telegram of sympathy. 

• } ’j-®' Simpson gave a demonstration of surgical cases, 
including iragilitas ossiuni, nuicocclc of the appendix, Paget’s 
disease of the nipple, congenital megacolon, spasmodic torticollis 
and two cases of oxtcnsivo injury of the hand. 

Hr. J. B. Simpson read a paper on general anaesthesia, wJjich 
proved very interesting and instructive. Dr. Simpson said that his 
usual method was to induce anaesthesia by means of ctliyl chloride 
Rdnunistcred in a closed mask, and then to continue tho annes- 
uiesia with a mixture of ether and chloroform by tlie open method. 
He described also the method of anaesthesia bj' nitrous oxide and 
oxygen, and of the administration of carbon dioxide in connexion 
with anaestliesia, emphasizing its value in cases where there was 
difficulty with respiration. 

Northekn Counties of Scotland Branch ; Islands Division. 

A JitEWNG of flic Islands Division was held in the Royal Hotel 
fctornoway, on May 30lh, when members of the Isle of Lewis actc^ 
H i' dinner Mr. Purves, surgeon to the new Lewis 

Hospital, conducted the members on a tour of inspection of llio 
hospital, ■wJiicli was followed by a discussion on various matters. 


North of England Branch : Cleveland Division 
The annual general meeting of the Cleveland Division was held a 

reL^nf th^TVen’ on May 17th. The annua 

Committee was approved. 

19^29* officers were unanimously elected for the yea 

Chairnian, Dr. J^es Brownlee. T’icc-(77n'r/r;/mj#, Dr. If. Jlinnie I^cvieli 
licprcsentativc in licprescntatico Boilu Dr Jo’'- 
John Inkster. Sccretarj/, Dr John 

tho Maternitij and CltiTd )Vclfare C'ommittce of 
Dp. John Ilowen. ' 

Tho Middlesbrough and District Motor Club hospital insurant 
scheme was considered and ^it was resolved that the secrctan 
infoim the club that the Division welcomed the scheme as ai 
attempt, to deal with the problem of the hospital treatmciifc o 
motor accidents, but noted that the insurance covered maiutemne 
only, and that their members would still bo dependent on‘tIi 
charity of the hoTiorar5* medical staff for their trcalment 

Mr, H. D. Lcvick was appointed to represent the Di^sion at ) 
conferoiico called by Sir Thomas Oliver to consider the question o 
file investigation of cancer in the northern counties. Dr Diniylp 
tho medical officer of health for Middlesbrough, nofffied ih 
Division, through Dr. Levick, that he wished to make invesli^a 
tions into cancer in tho town, and requested the help of memb^ 
It was resolved that members should notify Dr. Dingle voluntaril 
of any cases that came to their knowledge. " 


North or England Branch : Hexham Division. 

The annual meeting of the Hexham Division was held in the 
Abbcry Hotel on May 25th, when Dr. Fatrclough was in the chair. 

Tlio annual report of the Executive Committee was received and 
appYOved, and the following officers were elected to serve dorin*» 
tho ensuing year : , . \ ^ “ 

Dr. Lloyd. Vice-Chairman, Dr. Turnbull. 

It was agreed that the election of the representative and deoulv 


rcprescnlativc in the Represenfative Body (by the Consett 
Division) in the Hexham-Confclt constituency be allowed to stand— 
namely, Drs. J. Charles and M. D. McKenzie. 

A resolution tliat a voluntary levy of 5s. per rnomber per annum 
bo rjtiscd to defray cost of refreshments at incefings was carried. 
It u*as agreed to Iiold two summer meetings, one at Wooley Sana- 
torium and the oilier at Prudhoe Hall Colony for Menially Defective 
Children, in June or July. 

Willi regard to tlic inquiry into varicose ulceration treatment, 
five members expressed their willingness to reply. 

The suggestion of the Council of tho Durliam University College 
of Medicine for a united endeavour of the Northern Counties to 
engage in tho cancer campaign w'as approved, and the honorary 
secretary was cloctcil to represent the Division at llie proposed 
j' prcHminary meeting. 


North ^Vales Branch : South Carnarvonshire and BIertoneth ’ 
Division. 

A vert successful meeting of the South Carnarvonshire and 
Merioneth Division was held at the Towyn Cottage Hospital on 
May ^tli, when there was .a good muster of members. 

Previous to llie meeting tlie members were entertained to lunch 
by Drs. H. J*. Rowlani^ and J, A. Davies at the Corbett Hotel. 

*T*bc Report of Council was considered, and "it was rcfolyed to 
ask tho Representative Body not to adopt the recommendation for 
8s. 8d. for attendance on juvenile members of fnendly societies. 

Hr. J. A. Davies showed cases of congenital claAs'-band, paralysis 
of the hypoglos.sal nerve, and extensive ulceration of llic legs. 
Hi'. Davies also gave demonstrations of the T-ray and artificial 
siiaiight apparatus at the hospital, and records of .ca-ses. treated 
were shown. Dr, F. S. Jackson showed a case of pscudo-hj-per- 
trophic paralysis (muscular). 

At the conclusion of tho meeting the members were enlcrlamcu 
(o tea by the matron of tho hospital. 

Altogether tlie meeting was one of the most pleasant functions 
ill connexion with the Division in recent years. 


' Oxford and Reading Branch : Oxford Division. . 

The third meeting of the year of the Oxford Division was hold at 
the RadclilTe Infirmary on Mav 25rd, when Dr. Montgomery was 
in the chair and forty members were present. 

Tlic Secrctarv road a letter from headquarters about a demon- 
stration of the handling of milk, and ho was instructed to write 
and find out when and whero this could be given,* , ^ . 

Dr. A. G. tVallor (Wallingford) was unanimously elccfcd ap - 
associate member of the Division. , 

Mr Bevers showed a woman, aged 59, where R large imroia 
•• • ' • • • ••‘•’•fying the usual symptoms and signs, 

. he best line of treatment. 

• . • , . otes of a male patient, aged 39, wlio 

with symploTn.s referable to the left 
' ' nination was indefinite, but a pyel*>- 

■'ranrrcvenlc.l obslnictioH of Iho left nretor by a sniull stone, the 
remmalof which wns followeil by completo alleviation of the . 

H^CiiANDLsn contribiited a paper on tlie 
and treatment of broncliiect.asis. Ho lii-st discussed ^ ‘®^5ab“Jss^ 
diagnosis between broncbieotasis and 

clironie empyema with a broncho-plenral fistula, foieign body or 
Inmour in the broncluis, pressure on a bronchus, and sjpliihtio 
conditions. In llio earlier stages a diagnosis had to bo oMoe on 
tho symptoms and their history, the physical signs, 
and nalholoirical investigations, radiological examinations, and 
uiiodol i iiee^timis Many‘s illustrative lantern slides ■ were shown, 
■^e lcctu cr pohitcd ont that frequently only an injection of 


SnaorsniRE ako Mid-Wales Brakch. , ' a 

The fifly-tliird annual spring o'n 25tlq 

Wales Blanch i^s heW “t ^be Ropl bMop cTair.- %cfor' 

when tho president. Dr. W. ,icath of Dr. James 

ence was made to tho loss ^ ,.nmitv of Salop, a 

Wheatley, medical oflicer of health for the .“’Wty Branch. 

meSer^Vf tho Branch Council, and a .PasUpresiJent of the Branch 
The Hohobary Secretary havine ’ 1 *'’' 9 '^bed that the 
Shrewsbui-y and district was entirely m .fayoui of r 

10s. 6d. for reports on cases when an inquest- oi ncCTop^ u 
not held, he was instructed to write to tho * 1 gjop 

matter Mr. W. >S. Edmond, senior surgeon to th® irejai saiop 
InBmaiy, was elected to take office in °ber M the n^t^P 

Tlio *;tatement of accounts for 1927 was i _„,’i 

udonted The Annual Report of Council was “ J 

recommendations in regard to the following Odd- 

»#•>» /■/>/> • ID infant hygieno centres; (2) fees for 
feliows- (3) report on puerperal morbidity ; (4) report on Inn cy 

«?rtifieation ; (5) ophthalmic benefit. * nresidenfc 

A- Charities Committee was formed to consist^f the prcsitie c 




June ig, 1028] 


Coffees of Motion foy Divisions, 


r nVTTT^r.^mKT to rm necry 

UBniTISIt MKUtClL JOURS'AL <^£>0 


SoiTTiT Wales anp JfoNMOUTiTsnTrir. BnAKcn. 

The nnniia\ social meeting of iho So\Ul\ Wales' and Monmouthshire 
Branch u’as held at ronlsliciH oh May 51st at the Taf I'ecimn 
Waterworks. The modern plant was examined in dclail, and the 
various processes of water purification and filtering were demon- 
strated, After a motor' run round tlic reservoir two and a half 
miles long, the party proceeded to ’Pohtsarn Sanatorium,' Welsh 
National Mcmor/al Association, wlierc they -were received by tho 
matron and Br.* D. A. Powell, principal medical officer of Iho 
association, and entertained to tea. 


Ulster Bravot. 

The annual meeting of the Ulster Branch was Iiold in the King 
Edward Memorial Hall of the Royal Victoria Hospital, Belfast, 
on May 17th. following a mcoling of the .McKisack Memorial 
Fund; an interesting series of clinical eases and 2)alhologieal 
specimens w'as exhibited. 

Dr. S. Morrow sliowcd a case of pneumothorax, a case of 
aortic incompetence with mifrat lesion, and a rase of disseminated 
sclerosis with acute exacerbations and remissions. Professor 
McIlw'Atnt: oxlnbilcd radiographs of cardiac eases, a ease of 
digitalis heart block, and one of cxophthahnic goitre with auricular 
fibrillation. Dr. Foster Coates (Belfast) brought two patients 
...-jjj tr^jnsverso myelitis, and one with 
abscess of lung. Dr. Bovn Campbell 
. . . of enlarged spmen, ono of subacute 

pulmonarj* jnfcction with obstinate constipation, one showing fits 
associated with congenital syphilis, a specimen and radiograph 
01 a ease of aorlic stenosis, and clcclro-eardiographic records from 
a case of influenzal myocarditis. Dr. R. Marshall (Belfast) 
showed a case of bronchiectasis -witli cerebral abscess, one of per- 
sistent tremor of the thumb, one of splenic anaemia of fifteen 
years’ duration, one of aortic aneurysm, ono of aortic stenosis of 
uncertain origin, one of Hodgkin^s disease with hemiplegia, an 
unusiml ease of general paralysis treated by malaria, and a mother 
and child with hrachydaclyly. Dr. Turkikcton (Belfast) demon- 
strated a case of coai-clalion of the aorta. Dr. Alle?? (Belfast) 
Slowed two cafi's of cretinism, a child aged 10 with acute 
rncnmatic fever, mitral incompetence, and aortitis, n ease of con- 
genital licart (liscaso, and one of djspituilarism. Dr. M. J. Kom.v 
UJ w-npatnek) showed .a case of mimic face paralysis. Dr. IvAtt 
exhibited Rome fine ringworm cultures. Sir TnosiAS 
^USTOK demonstrated some rough and smooth colonies of cnlero- 
reactions of Slaphyheoeevf (Jeformant. Dr. EnsKiirn 
I’.''™"'?, fold disease, a patient willi 
Sf I rt”" A? w-lioopingKiougli, and a ease 

(Ucifast) showed a ease of 
leir of rLiV"? incision, and a ease of 

mofor ^voT o? M P'nniis and fractured clavicle due to a 

motor ejelo accident; there was complete loss of power and of 
sensation ,ii the arm. Mr. T. S. Kick (Belfast) presented a case 

traUoe^no clironic arthritis, and charts illus- 

.trating pneumonia treated by subcutaneous oxvgcn. Professor A 
FtrtLSBTOs exliibilcd a scries of pyclograms, a ciso of liaomr/rhaeic 
pancreatitis with recovery after* operation, ’one of urcteraT calcSfus 

cMopTa veSe'^ Mr®”V “**/ in^P'-antatfon 

cciopia vesiMc, Mr. Howabp Stevessos (Belfast) ' showed two 

surface treated by escisLn, 
lawiv -ectomy for carcinoma. Mr. S. T. 

involv'inl'"tl is^hiu’m, and shdcrThiwing^^’fra^turre 

wo‘’ca“£ S ?• <®'=lfasl) exliS 

root of ^1,0 neuralgia cured by division of tlie sensory 

chro^Tr snnglion, a chart indicating the caus« of 

gastric retention, a patient with an ulcer of the 

fpeoPmen^.' 

oS™ waVper&ed i^July 

"S t^ei™eo 5 SirarS 5 ' 

wound of the abdomen wfu.*’* days duration, and a gnn-shot 

peritonitis, which te™rna'ted^'’rccr^^^^^ 


YoaasitmE BaAKcn : dVAKEviEEn, PonrErnAcr. akh CAsTEEroai, 
m-. , Division. 

H'^Krnmatitc Sodp. D„. T. E lister a?/ G.'' B luK'm * 


TIic annual report of tho Executive Committee was read by the 
SEcacTABY and adopted. . . , 

The Annual Meport -of Council wa.s considered. .Screra) poinis 
of interest were discussed, and it was resolved that the repre- 
sentative 1)0 instructed to vole in f.avour of tho Council’s recom- 
incndntions concerning tho Manchester .Unity , of Oddfellows' 

juveniles . , . . , , . _ 

In tho abseneq of Dr. JIankncll, owing to illness. Ids paper on 
tlio British Medical Association and tho general practitioner was 
read by tho CirAiasiAE". A vote of thanks was passed to the writer 
of (he paper, nnd the lionorarv secretary was in.structcd to c.xprcss 
the regret of the Division to'Dr. MankncU upon his indisposition, 
nnd to wish him a speedy recovery. 

In tho ■subsequent discussion Drs. Hillmak, EimiotDS, Dowwie, 
Walker, Twist, Lyle, and Kax'E took part. 


NOTICES OP arOTION BY DIVISIONS FOR THE 
ANNUAL REPRESENTATIVE MEETING, 
CARDIPF, 1928. 

Remuneration of Non-prof essorial Medical Teachers, 
Laboraiorij and Research Workers. 

Bx Hendon : That tho recommendation contained in para. 80 
of tho Annual Report of Council be amended to read as 
lollotvs : 

That the scale of salaries relative to hon-professorial medical 
leachera, laboratory and research workers, should not apply 
to those academic appointments in universities and medical 
schools which are of a temporary cliaracter and where (he 
duties attached to tho posts are in direct connexion with llie 
advancement of the practitioner’s knowledge and experience 
in the particalar branch of work which he proposes to 
enUivate. 

Assistant Medical Officers to Mental Hospitals. 

By Berth : That Hecommendation C contained in para. 93 
of tho Annual Report of Connell bo amended to read" as 
lollows : 

That those assistant medical ofDcers lo mental Jiospilals who 
had held the position or lionse-snrgeon or house-phvsician for 
ono year or who had lield a hospital appointment lo'r one year 
shonld receive an additional £59 per annum. 

By Perth: Tliat tho Bepresentativo Bodv is of opinion 
that subpara, (iii) of tho last paragraph of para. 93 of the 
Annual Report of Council should be amended by the substitu- 
tion, in the Rftb line, of the tvords “recently admitted ” for 
tho word “ acute.’’ 

Faying Centres for Infant Hygiene. 

By Perth : That (with reference to Recommendation A 
contained in para. 95 of the Annual Report of Council) in the 
opinion of the Representative Body it is undesirable that 
paying centres for infant hygiene be established. 

Protection of Medical Practitioner signing a Certificate under 
the Lnnacy.Act, JS90. 

By Bournemouth : That (with reference to the recom- 
mendation contained in para. 115 of tho Annual Report of 
Connell)— In regard to Section 330 of tho Lunacy Act 1890— 
{a) the onus of proof of want of reasonable care and want of 
good faith should be on the plaintiff; m unless the nlaiiitiff 
can satisfy the judge that he is abl^ to provein a ^ourtol 
law the want of reasonable care and good faith, the case 
shonld not proceed to trial ; and (c) the judge should be able 
to call la expert opinion on the point of reasonable care in 
respect of medical certificates if he himself is in any doubt. 

By Bournemouth: That (with reference to the recom- 
mendation contained in para. 115 of the Annual Rpnoi-f 
Council) If, under Sections 13 and IS of the Lunacy St Iggo' 
a magistrate make an order to one or two medical men as (1.5 
rase may be (two medical men under Section 13 and one 
under Section 16) to examine a person believed to be of 
unsound mind, It should be considered that thrinao i 
should be solely responsible as an instrument of th^lSw^anfl 
the doctors should have the status of a witnesrand eniov'lSf 
immunities of a witness. . ““1°^ '■be 

Method of Voting at Elections in Representative Meet inns 

By Bournemouth : That the method of votimi J iu,. 
elections in the Annual Representative Meetings sbm,li 1 
by the simple majority vote, and not, as at pSt 
of the single transferable vote, ” * ^ueatis 

■ By E. B. Fothergidd (Brighton) • That n i 

^2 (iv). 45 (vii), 46 (Vi), 47 (Hi), and 4S /ii!w/I ^ 

deletion of all reference to the swingle 

mode Of election, and the substitatio^ of the simple mljraily 



254 June 10, 1928] 'Annuai fVIcoting, 1 928 s ^Provisional Programme. 


r nuppLr.iiKUT to rm 
1 J3niTisii ' 2U:dical /oofi»AZ> 


%xiii%\i ^zhittil ^ssnaatton. 

NINETY-SIXTH ANNUAL MEETING, CARDIFF, JULY, 1928. 


Patron: His Majesty the King. 

President : Siu Robert W. Philip, M.D., LL.D., F.R.C.P.Etl., Consnlting Physician, Royal Infirmary, Edinburgh. 
President-Elect : Sin Ewen J. Maclean, M.D., F.R.C.P., Professor of Obstetrics, Welsh National School of Medicine. 
Chairman of Pcjtresentative Body: C. O. Hawthorne, M.D., F.R.C.P. 

Chairman of Council: H. B. Brackeniiory, M.R.C.S., L.R.C.P. 

Treasurer: N. Bishop Harman, M.B., F.R.C.S. 


PEOVISIONAIi PROGRAMME. 


phi 




TOWUll or Si. JUIIM'S CllUltUll, 
Cjnmrr. 


HE incoming President, Sir 
Ewen Maclean,. will deliver 
his address to the Associa- 
tion on Tuesday, July 24th, 
at 8 p.m. 

The Annual Representa- 
tive Meeti.no will begin on 
Friday, July 20th, at 10 a.ra., 
and be continued on the three 
following week-days. TIio 
Representatives' Dinner will 
tako place on Friday evening, 
July 20lh, at 7.30. 

The . statutory Annual 
General SIbeting will bo 
hold on Tuesday, July 24th, 
at 2 p.m., and the adjourned 
general meeting at 8 p.m. 

The Annual Dinner of the 
Association will take place on 
Thursday, July 26th. 

The Conforouco of Honorary 
Scorolarics will bo hold nt 
2.30 p m. on Wednesday, July 
25th, and the Secretaries' Dinner at'6.30 tho same evening. 

The official Religious .Service will bo hold at St, John’s 
Church, Cardiff, on Tuesday, July 24th, at 4.30 p.m, 

Tho Annual Exhibition of surgical appliances, foods, drugs, 
and books will be open for inspection on Monday, July 23rd, 
from 2 till 6 p.m.; tho formal opening by the President 
will take place on July 24tli at 9.30 a.m. Tho exhibition 
will remain open on July 25th, 26th, and 27th from 9 a.m. 
till 6 p.m. 

Saturda.y, July 28th, will bo givou op to excursions to 
places of interest in tho neighbourhood. 


THE SECTIONS. 

The Scientific Sections will meet from 10 a.m. to 1 p.m. for 
papers and discussions on Wednesday, Thursday, and Friday, 
July 25th, 26th, and 27th. 

Tho Tallowing Soctlons will moot on Thrao Days. 
MEDICINE. 

President ; Sir Thomas Lewis, C.B.E., M.D., F.R.C.P., F.R.S. 
(Lonilon). 



r'roiefi^ui ... v...... — . — — (Dublin^, 

n. Lbthp.BY ThiY, M.D., F.R.C.P. (London). 

Jlonortini Secretaries : ABEL Evans. JI.B., M.R.C.P., 36, Newport 
Road, Cardiff; Anthony Feilino, M.D., F.R.C.P., 52, Jlontagn 
Sejuare, London, W.l. 

The following provisional programme has been arranged: 
ii'cdresdav, Jid’l -Jfh,— 10 a-m. niscitssioti: Diseases of the 
Coronary Arlorie's, To be opened by Dr. George A. Allas 
(Glasgow). . T, 

Tliiirsda)/ -Tidi/ SBth. — 10 a.m. Discussion: The Prevention and 
Treatment of Diphtheria. To be opened by Dr. J. D. Rolleston 

10 a.m. Discussion: Acute Nephritis. To be 
opened b’y Professor T. G. Moorhead (Dublin), 


SURGERY. 

President : Professor A. W. Sheen, C.B.E. , M.S., P.R.C.S, 
(Cardiff). 

Ficc-Pr«i(friif«.- n. G. Cook, C.B.E., JI.D., F.R.C.S. (Cardiff); 
C. II. Faooe, M.S., F.R.C.S. (London); Professor Andrew 
Fullerton, C.B,. C.M.G., M.CIi., P.R,C.8.I. (Belfast); .T. W. 
Geary Grant, F,R.C,8. (Cardiff); William Martin, M.B., C.M. 
(Cardiff); ALBERT J, WALTON. M.S., F.R.C.S. (London). 

Ifonorani Secretaries : D. .T. IIarries, D.Sc., F.R.C.S., i05, Lew- 
port Ho.ad. Cardiff; R. St. Leoer Brockman, M.B., M.Ch., 
F.R.C.S., 79, Upper iinnover Street, Shoflicld. 

The following provisional programme bas been arranged : 
V'ednesdaij, July L’Btli.— 10 a.m. Discussion : Tlio Diagnosis and 
Treatment of Spinal Cord 'Tnmours. To bo opened by Mr. 
Donald .j. Armour (London), followed by Dr. George Riddoch 
(London), Sir PERCY Sargent (London), and 3Ir. Geoferey 
Jefferson (Jlanchcster). ^ 

Thursday, -July mU.—lO a.m. to 12 noon. (Joint meoliiig witli 
Section ot'llndiology and Physio-Ther.ipeutics.) Discussion : 1 lo 
Fallacy of A' Rays in Ab lomlnal Dlagnosla. 'To bo opened by 
Mr. IIERIJERT .1. PATEK.SON (London) and Dr. P. HbhNajiaN- 
Johnson (London), followed by Dr. A. F. Hurst (London), 

12 noon. Discussion: Tbo 'Treatment of Gangrene. To bo 
opened by Mr. W. Samp.son Bandley (London), followed by Mr. 
Pilil.ip Turner and Mr. E. G. Si.ksinoer (London). 

i'riday July S'lh.— 10 a.m. Discussion: Pancreatitis. To be 
opened 'by Sir Berkeley Moynihan, Bt. (Leeds), followed by 
Mr. J. W.^GearY GP.ANT (Cardiff) and Dr A. F. IIURST (London). 

12 noon. Discussion : 'Tlio Diagnosis of UrMerlo J?? 

ononed bv Professor ANDREW FULLERTON (Belfast), followed by 
Dr. E. B.^. Mayrs (Belfast), Mr. Kenneth IL Wa^er (Iiondoii), 
Mr. J. Swift JoLY (London), and Mr. HenEY Wade (Edinburgh). 

obbtetbics and gynaecology. 

President; T. Watts Eden, M.D., F.R.C.P., F.R.C.S. Ed. 

n'B?S5;,fwn“S5o»“i'’A 

5, Wimpolo Street, London, AV.l. 
miofollowingprovism^pOT 

Fol’ce’,rs"^:res."To^.eopenedbyPro(^^^^ 

(Manchester), jR^M,',Hnbnrgh). J’aver: Professor R. 

..I 

(London), followed by Dr. Sidney I orsduu. 

Kenneth M. Walker (London). professor W. W. Chipman 

Friday, July 

(Alontreal). Acute (l ondon), The Acute Pelvis; 

Female; Mr. EveRARD Willems ( - Radium Therapy in 

Dr. George Gray Ward iNow (,[ tlio Results 

Carcinoma of the Cervix “)S„~York- Dr.E.FARQUHAn 

ObDiinml nt thoWomcii’s IIoBpita| m NOW YorK, Dr 



§S^SS^diiS:;^S^I^o^ni=Trea=onheA^ 

of Pregnaccy. 

MENTAL DISEASES AND NEUBOLOGY. ' 
President: 

Vice-Presidents; L. D. jj" 0 p'.E,l.(Kdinbnrgh); 

bridge); & H. R. GXRSON.D.S a, 3LD., F.K.O.I p 

Bernard Hart, JLD^, M.D. (Abergavenny). 

(Cacricon, M Eiiwis. F.R.F.P.S., Drymma 

Honorary ^ ',V R'E-KyJTKTjLtM.DM 

Hall, Skfiwc . 

87. Harley S 





June IG, 1028] 


Artnuat tVtcoting, 1928: Tho SoctSons, 


f st7PPZFaf^yr to tct ntr/^ 
LBniTisu Medical Joubxal ^oo 


Tlio following provisional programme lias been arranged : 
Wednesday, July S5ih.— 10 a.m. Diiciission; Antotoxacmia ns a 
Factor in the Causation of the i’a.veluaes. To be oponeil by 
FrofessorW. ■■■ ■' ’ ■ ' illowod by Dr. E. ilAroTiilttt 

(London), Di I (London), Dr. Mahv H. 

Bakkas (Loi ,, ■ BoYbr. (Hove), Dr. D. F. 

EAMn.^uT (Northampton), Dr. F. A. I’lOKWoiiTii (Birmingham), 
and Dr. Iha S. Wilk (Now Yorlc). 

Tlnirsdatj, July 2Ctli.—lO a.m. Dixeu^sion : TJio Differential 
Diaguosis'aud I'reatmcnt of Cerebral States consequent upon 
Head Injuries. To l>o opened by Dr. C. 1’. Sy.Mosns (London), 
followed by Dr. 0. IVonSTKii-DltOPOilT (London), Jlr. WlbritKD 
TnoTxr.R (Loudon), Dr. It. D. Giu.nsnin (London), Df. D. 
JIcAbrJNn (London), and Dr. G. ItipDbcn (Loudon). 

Friday, July 27tU. — 10 a.m. Dhcufshii : The Early Treatment 
of the Tsychoscs and BsychononroscB, To bo opened by Dr. A. 
Uhluk BbYi.K (Hove), followed by Dr. E. M.YroTnKU (London), 
Dr. It. D. Gir.Lcsnn (London), Dr. illAitY It. Haiikas (Loudon), 
Dr. R. G. Goiidon (Bath), Dr. John E. Rees (Ixmdon), and Dr. 
IitA S, IVILE (Now York). 

TTio Tollowina Sections will moot on Two Days. 

. PATHOLOGY AND BACTERIOLOGY. 

Fresidejit: Professor E. 11. Ketti.E, M.D., M.R.G.P. (London). 
rice-Frcsidrnls; Profe.ssor JoH.N CjiuicK-Shank, JM.D. (Aberdeen); 
Sir Thomas Houston, O.B.E., M.D. (Belfast); \V. Panny Moko.ak, 
M.D. (Cardiff); A. F.S. Slauden, M.D. (ttwaneea). 

Honorary Secretnrirs : -J. B. Duoujo, M.D., Do;inrtment of 
Pathology, M'elsh National School of Slcdicine, The Parade, 
Cardiff; Lawuence P. G.auroI), SLB., It.U.U.P., 6S, Gloucester 
Terrace, Hyde Park, London, 1V.2. 

The .following provisional programme has been arranged ; 
ll tduerday, July S5th. — 10 a.m. Dimtirion : The Pathology of 
Euceiihalo-myelitis cccnrring in the conrso of Virus Disease and 
Exanthemata. To be opened- by Professor 11. M. TuUNnuLL 
(London) and Profe.csor J, JIcI.sTosH (Loiidou), followed by 
Professor .7. C. G. Ledi.vgham (London), Dr. diERvvN H. Gordon 
(L ondon), Dr. J. G. Greenkieu) (London). Dr. .1. E. JIcC.yrtnev 
(L ondon), Dr. S. P. Bedso.v (London), and Professor G. UaDFIELD 
(Bristol). 

llluirsday, July SC th. — ^10 a.m. Dircuiiiou : Variations in the 
Intestinal Flora in Health and Chronic Disease, to bo opened by 
Professor J. CltuiCKSii.tNi: (Aberdeen), followed by Sir Tjiojias 
border, Bt. (Loudon), Sir Thomas Hou.ston (Belfast), Professor 
J. H. DlliLE (Cardiff), Dr. A. F. S. Si.adden (Swansea), Dr. L. P. 
Garrod (London), and Dr. 0. E. Dvkks (London). 

ORTHOPAEDICS. 

i-VEN-TnoMAS, K.B.E., C.B., C.M.G., 

Fell.O.b. (Llecbrvd). 

^Vice-Presidfuts; A. Rocyn Jones, M.B.,P.R.C.S. (London); J. J. 

, ■■ '.It. C.S. Ed. (Edinburgh) ; S. Ai.wYN 

. F.lt.C.S.Ed. (Cardiff); P. Jenneu 

■ don). 

ji,, , , ■ RVUaycraft, Jf.G.,M.B.,F.R.C.S., 

St Lloyd, M.B., F.R.C.S., 

33, Wimpole Street, London, W.l. ’ 

The foflowing provisional programme hos been arranged : 

lOn-'H- Dixcuifiim : Low Backacbe and 

MlDDiVTov?Pdi°n^®’i^*^‘ followed by Jlr. STEWART 

f^bAN H. Todd (London). 

Hie ew L Cinematograph Demonstration by tlio Preside.nt of 

ture'^t Femur n^?i (D Colles’s Fracture, (2) Frac- 

ol 1 emur, and (3) Clubfoot, as practised by Sir Robert Jones. 

- .. diseases of children. 

IbVr'prl' M.D.,M.R.C.P. (Cardiff), 


P‘’ogramme has been arranged: 

meualv^in'r’liiiah^ H'launswu : Chronic Spleno- 

Som?^n):\oh;w^rby HDroSsoN 

Df* IjEONwm (London), 

(Maiuihester^ (Glasgow), and Dr. Charles P. Lapage 

Ch^UihS’'To^'bf''Z^n"f’i -^^enssibii : Chronic Nephritis in 
followed br Dr Tt by Dr. J. 0. Spence (Newcastle), 

C.iFON (Liverpool). ’ h^Ianchester) and Dr. Norman B. 

p, .J ophthalmology. 

riZ lZlidJutf: (Cardiff). 

V. Cargill PR CR/Vn ,Gaiger, ii.B.. F.R.c.S. fSheffleld); 
Ch'ewport, Mono- F?Gi'urpfr!?m ’ B.J. Coulter, JI.B.,F.R.C.S.I. 

/honorary Secretaries- T yv’ nC*®-' B.Ch. (.“iwansea), 
ci fton Lodge. 76 C?thedra^nJ°,“°,? M-B.. P.R.C.S., 

F.R.C.S.. 14, Portland Place, Londo’n.^vi'”’ J^bEE, M.D., 


The following provisional programme has been arranged : 
IPednciday, July 25th. — 10 n.m. Tjiscussion : Visual Efficiency 
and Working Ahilily. To bo opened by Dr. A. Freeland FERGUS 
(Rothesay), followed by Sir J. U. Parsons (London) and Mr. N, 
Bishop IfARJfAN (London). 

Palter: Dr. T, II. Whittington (London), The Examination ol 
the Eyes and Eyesight in Y'omig Children. 

Tlitirtday, July 2Cth. — 10 n.m, Diremsion: The Etiology of 
Glaucoma. To bo opened by Mr. W. .S. Duke-Elder (London), 
followed by Mr. Thomson Henderson (Nottingham) and Mr. 
N. Bishop Harman (London). 

Paper: Mr. A. 11. Levy (London), Telescopic Spectacles. ‘ 

LARYNGOLOGY AND OTOLOGY. 

Prefident : Donald E. Paterson, M.D., C.3I., F.B.C.P. (Cardiff). 
Viee-Ptesidenis : Ai.ran Evans, M.R.C.S., L.R.C.P. (Swansea) ; 
E. D. D, Davis, F.R.C.S. (London); Archibald Mason Jones. 
M.D., P.R.C.S.Ed. (Cardiff). 

Honorary Seorelarics: A. A. Prichard, M.D., 14, Windsor Place, 
Cardiff; D. P. A. Neilson, F.R.C.S., dO, Queen Anne Street, 
Loudon, W.l. 

Tho tollowing provisional programme has been arranged : 
ll'eduesday, July 25tU.— 10a.m. Discusiion : Chronic Ethmoiditig. 
To bo opened by Dr. Ross Skillep.n (Philadelphia), followed bv 
Mr. IV. G. Howartii (London). 

Thursday, July 2Gih.— 10 a.m. DiVciission:' Drainage of Brain 
Abscess. To be opened by Sir Percy Sargent (London), loVlowed 
by Mr. Sydney R. Scott (London). 

thbercdlosis. 

President : Hugh Morriston Davies, M.D., M.cii.. F B.G S. 
(Ruthin). , . 

Vice-Presidents; Alf.xakdf.r Brownlee, M.D., P.R.C.S.Ed 
(Fairwatcr, nr. Cardiff); Dan Arthur Poivbll, M.D, (Cardifli; 
Cecil Wall. M.D.,F.R.C.P. (London). ' 

Honorary Secretaries: 3. C. Gilchrist, M.D., Tnbercnlosis 
Institute, It elsb National Memorial. 10, The Parade, Cardiff; J. C 
Hoyle, M.B., B.S., 28, ilalcolm Street, Cambridge. . 

The following provisional pi-ogramme has-been arranged • 

J'l'y ?51Ii.-10 a.m. Discussion: ■The Relation be- 
tween Trauma and Tnbercnlosis, especially from the point bt 
vicw'Of Compensation and Accident Insurance, To be' oneneef bV 
Dr, Norman Tatteusall (Leeds), followed b 3 ’ 3Jr, Robert Milne 

(London) and Dr. Otto May (London). , - 

i^prrs on Factors in the Biochemistry’ of Tnbercnlosis: Dr. 
Metal?- ^r**'.! ^Hoy°f TherapeuHo Vnine' of tlie Hea^ 

Experimental Tnlierculosis ' 'mil“ 

Tnbercnlin-active Fraction ' • 

llednes^y /t/lfniooii^Demonstration of After-results of 
Surgical Treatment of Tuberculous and other Diseases of the 
Lungs. Specimens, lantern slides, anatomical preparations of the 

<C.“mok1ng: Pat^ol^ogi^irSm 

pop.m. There will be an Explanatory Demonstration 
4 p m. Cases vrill be shown in tlio A'-ray Department. Cardiff 
Royal Iiifiraan- |by the courtesy of Dr. Owen L. Rhys) - and Dr 
MraHon*^ (London) will give a PhysiologiLl Demon-’ 

Thursd^j,Jnly 2Glh.—10a.m. Discussions: ( 1 ) After-effects of 
Surgical Procednres on Cnses^of Pulmonary Tnbirculosis To be 
opeiied bj Mr. A. Tudor Edwards (London) followed bv Dr 
F. G Chandler (London). (2) Tnbercnlosis us s»«u i. H, 
General Practitioner. To be opened by Dr. B. CAMERON?C?rdim® 
followed by Dr. Angus E. Kennedy (London). ILaraifl), 

HADIOLOGY AND PHYSIO-THERAPEOTICS 
President : Owen Lewellin Rhys, M.D. (Cardiff) 

T'icc-Pi-fsMoits ; T. Garfield Evvns aid n a/ d - n- , r , ,... 

L.R.C.P.,Sbutt’erne House; fanSffin. 

The following provisional programme has been arranged 

F.U S. (Cambridge), followed by Dr. C. HEALD^(Londou) 

■fsvs\sssz"iA\ “ ' 

followed by Dr. A. F. Hurst (Lonely).” ' (Loudon), 

T/jo following Sections win meet on Ono Day. 

preventive MEDICINE, 

(C??diff,:'“-' ^a.LiAMs. M.D., F.R.C.S.Ed- 

Brigstocke, M.R.C.S. (Haverforciwestif C- A. 

^ Honorary , Seorelarics ; H . Vi . Gsrvn aV D no 

Newport. Mon. ; D. 0. Kirkuopp ’ ar ?(’ Stow Hill 

Tottenbam, London, N.15. ’ Town Hall, South 



25G JUKE 16, 1928] Annuaf Meeting, 1928: Provisional Time-Table, 


r Kxn'rLr.itE}{T to 
Ldritihu Medical joohmal 


The following provisional programme has been arranged: 

Wednesday, July SSth.— 10 a.m. • Discussion : — The Value of the 
Present Methods of Control of Infectious Diseases: (o) The 
Control of Small-pox. To be opened by Dr. D. J. Rajchmann 
(Geneva), followed by Dr. J. Miduleton Mahtik (Gloucester), 
Dr. T. Eustace Hili. (Durham), Dr. R. P. Gap.how (Chesterfield), 
Dr. R. BuUCE Low (Cardiff), and Dr. C. Killick MiLi.AltD 
(Leicester), (fc) Tlie Control of Scarlet Fever and Diphtheria. 
To be opened by Dr. R. A. O'Buien (Beckenham), followed by 
Dr. J. Graham Forbes (London), Dr. B. A. 1. Petehs (Bristol), 
and Dr. B. H. R. Harries (Birmingham). 


FDBIilC HEALTH. 

President ; R. M. F. Picken, M.B., Ch.B. (Cardiff). 

Vice-Presidails : D.T.EocynJones,G.B.B.,M.B., C.M.fRumney, 
nr. Cardiff) ; J. D. Jenkins, _M.D. (Rhondda) ; S. G. Moore, M.D- 
(Huddersfield). 

Honorary Secretaries; Thomas Evans, M.B., Public Health 
Department, Swansea; R. P. GarroW, M.D., Health Office, 
Saltergale, Chesterfield. 

The following provisional programme has been arranged : 
Thursday, July SSth. — 10 a.m. Discussion: The Teaching of 
Hygiene. To be opened by Dr. W. W. Jameson, Professor of 
Public Health, London School of Hygiene, followed by Dr. II. B. 
BrackenbuRY (London). ■ ■ 

MBDICAI. SOCIOLOGY. 

President; William Evans Thomas, M.D., C.M. (Ystrad 
Rhondda). 

Vice-Presiderds ; Professor F. A. E. Crew, M.D., Ph.D. (Edin- 
burgh) ; Letitia Denny Fairfield, C.B.E., M.D. (London) ; 
Evan Lewys-Lloyd, M.R.G.S., L.R.G.P. (Towyn) ; The Rev. Sir 
James Marchant, K.B.E., LL.D., F.R.S.E. (London); Mrs. C. 
Neville Rolfe, O.B.E. (London). 

Honorary Secretaries; F, Y. Pearson, M.R.C.S., L.B.C.P., 
IS, Crwj’s Road, Cardiff; Elizabeth Casson, M.D., D.P.M., 
Holloway Sanatorium, Virginia Water, Surrey. 

The following provisional programme has been arranged : 

Friday, July 27lh. — Discussion: — The Falling Birth Rato in its 
Various Aspects: («) The Biological Aspect. To be opened by 
Professor F. A. E. Grew (Animal Breeding Research Department, 
University of Edinburgh), (h) The Economic Aspect. To be 
opened by Professor W. J. Roberts (Professor of Economics, 
University College of South Wales and Monmouth), (c) The 
Medical Aspect. To . be opened by Sir Thomas Horder, Bt. 
(Loudon), and Lady Barrett (Loudon). 

TROPICAL MKDICINE. 

President; PHILIP H. Manson-Bahr, D.S.O., M.D., F.R.C.P. 
(London). 

Vice-Piesidents ; J. B. Christjpherson, M.D., F.R.C.P., F.R.O.S. 
(London); Lieut.-Colonel A. G. McKendrick, M.B., Ch.B.. 
F.R.O.S.Ed., I.M.S. (ret.) (Edinburgh). 

Honorary Secretaries; ‘ErNEST’ Henry Price, L.R.O.P.I., 153, 
Cathedral Road, Cardiff ; H. McCormick Hanschell, D.S.C., 
M.R.C.S., L.R.C.P., 35, Weymouth Street, London, W.l. 

• The following provisional programme has been arranged ; 
Wednesday, July SSth, — 10 a.m. Discussions : (1) Recent Advances 
in Diagnosis and Treatment of Human Helminthiasis. ■ To be 
opened by Lieut.-Colonel Clayton Lane, I.M.S.(ret.) (London). 
(2) Transmission of Eala-azar. To be opened by Dr. C. M. 
Wenyon (London). 

An exhibition of pathological specimens and preparations 
illustrating tropical diseases will be on view. 

• _ HISTORY OP MEDICINE. 

President ; Walter G. Spencer, O.B.E. , M.S.,F.R.C.S. (London). 
Vice-Presidents: Thomas Wallace, M.D. (Cardiff); (p. P. c 
Ejrkp.atrick, M.D., F.R.C.P.L (Dublin); Professor J. A. Nixon'- 
C.M.G., M.D'., F.R.C.P. .(Clifton) ; Charles Singer, M.A., M.D.’. 
F.R.C.P. (London). - - - 

, Honorary , Secretaries : H. R. Frederick, M.B., Ch.B., 42, Victoria 
Road, Aberavon, Port Talbot, Glam.; Kenneth R. Hay', O.B.E., 
'M.B., 47, Hill Street, Berkeley Square, London, W.l. 

The following provisional programme has been arranged: 
Wednesday, July ZSth. — 10 a.m. Discussion: Historical Aspects 
of Ideas regarding the Nature and Treatment of Dropsy. To be 
opened by Dr. J. D. CoMRIE (Edinburgh).' 

Papers : Dr. E. Roland Williams (Maenclochog), Welsh 
Physicians and the Eetiaissance ; Dr. J. D. Eolleston (London), 
The History of Scarlet Fever; Dr. P. Diy'Erkes (Swansea), The 
Welsh Physician in the Middle Ages; Mr. C. J. S. Thompson ' 
(London), The History and Lore of Cinchona Bark. 

A collection illustrative of tlie theory and practice of folk- 
medicine, human and animal, in Wales will be housed in the 
National Museum of Wa'es, Cardiff. (See British Medical Journal, 
March 24tli, p. 509, and June 2ud, 1923, p. 954.) 


THERAPEUTICS AND PHARMACOLOGY. 

President : W. Langdon Brown, M.D., F.R.C.P. (London). 
-Vice-Presidents: Professor W. J. Billing, M.B., Ch.B. (Liver-. 
nnoB- Philip Hamill, M.D., D.Sc.. F.R.C.P.- (London); W. H. 
Maxwell Telling, M.D., F.R.C.P. (Leeds). 

Honornr'/ Secretaries : J. P. H. Davies, M.B., “Elgin,** 
Llanisli' . ' flardiff ;- J. H. Burn. M.D.. Pharmaceutical Society 
oV Grir ' 'tain. Pharmacological Laboratory, 17, Bloomsbury 
Buuarc, Louuon, W.C.l, 


The following provisional programme has been arranged : 

; IVfdnesday, July 25th. — 10 a.m. - Discussion ; Receiit Adwiiices in 
the Medical Treatment of Gastric Diseases. To bo 0 |>uiie<l by 
Dr. A. F. IIURST (London), followed by Dr. T. IzoD Be.s.nltt 
(L ondon), Treatment by Diet and Drugs. 

DERMATOLOGY. 

• President ; Sir Robert Bolam, M.D., LL.D., F.R.C.P. (Newcastle- 
on-Tyne). 

Vice-Presidents: James Beatty, M.D., M.R.C.P. (Canliff); 
William Griffith, M.D., M.R.C.P. (Londou); Henry SlmuN, 
M.D., M.R.C.P. (London). 

Honorary Secretaries; R. H. Enoch, M.R.C.S., L.R.C.P., Royal 
Infirmary, Cardiff ; J. E. M. Wigley, M.B., M.R.C.P., 132, Har.ey 
Street, London, W.L 

The following provisional programme has been arranged: 
Friday, July 27th. — 10 a.m.' Discussion: Urticaria. To bo opened 
by Dr. A. E. Hallam (Sheffield), followed by Dr. H. W. Barber 
(London). 

Papers ; Dr. H. C. G. Semon (London), Souttar’s Steam Cautery 
in Dermatology; Dr. .1. E. M, ^Wigley (London), Tiialnnm 
Epilation in the Treatment of Ringworm; Dr. W. J. O’Donovan 
(L ondon), Salvarsau Ill-effects and Fatalities. 


Tho Honorary Local General Secretary of llio Annual 
Mooting is Dr. G. I. Sthachan, 20, Windsor Place, Cardiff. - 


. PROVISIONAL TIME-TABLE. 

PniDAT, Jdlv 20X11. 

10.0 a.m . — Jnnueil lleprtsentniive Sieetinp. City Hall. CarJiff. 

7.30 p.m. — Roprcscnttttives’ Dinner. 

7.30 p.m. — Ladies’ Dinner. 

SATUnDAT, July 21st. 

9.30 n.m.— Annual lupresentative X'eettnp. 

8.0 p.m.— Smoking Concert. 

. . Sunday. July 22nd. 

Excursion for tho Keprosentative Body. 

Monday. Jdly 2;nD. 

9 0 u.m.—Cauncil Meeting. City Hall. 

10 0 a.m.— Annual Itepresentaiive Meeting. 

10.0 a.m.— Excursions for Ladies. 

2.0 p.m.— Becoplion Boom open for Reglstmtion. 

2.0 p.m.— Excursions for Ladies. 

8.0 p.m.— Concert. 

. Tuesday, July 2tTH. 

9.0 n.m.— Beeeption Boom open for Begistr^on. 

9.30 a.m.- Official Opening o! Exhibition by President-Elect. 
lo!o n!m.— 4nBw**I ttepresentative Meeting. 
lo!o a.m.— Excursions for Ladies. 

110 a.m. — Opening of Pathological Mu«enm. - 

2.0 p.m. — Annual Qeneral^^Meettug, lollowod by Annual Bepro- 

. hn’s Church, Cardiff. - 

■ • PresitlanVs Address. 

, , • I •' cal Ezecutivc, followed 

by Dane©. 


9.0 a.ro.- 
9.0 a.m.' 
9.0 a.m. 
9.0 

9.0 
10.0 

10.0 am.- 

1.0 p.m.- 

2.0 p.m. 

2.30 p.m.- 
2 30 p.m. 

4.30 p.m.’ 

6.30 p.m.- 

8.30 p.m.- 

10.0 p.m.- 


Wednesdat, Joey 25Tir. 
-Oowioil Meetina, 
-Bccoptionlloom open. 
-Exhibition open. .~ 


-Excursions Jor ijaaiey. 

-Irish Graduates’ Luncheon. 

-E.xcursions and Garden Parties. ... 

'»n°nfial'cmnferenc”of°s’pa Practitioners Group. 
lAnnnal CoMemnee ot Consulting Pathologists Group. 

Sef^'S^Mordilavor and City Council, City Hall. 
-Dance. 


,Tnxmsi>AY,_ 26th. 




' and Child© Cups. 

10.0 a.m.-ExcOTSionslorLauies. , Cardiff Castle, by 

3.30p.m.-G-dr,.PaW^^^ 

7.15 V.m.— Annual Dinner of tho Association. City Han. 

10.0 p.m.— Dane©. ' ‘ . 

FHIPA.Y, July 27 th. 

8.30 a.m.— :\redical Breakfast. Pathological 

9.0 a.m.-Becistration OrQco, JisxniDiiiou. 

1 

^ University of Wales. 

a Parties. 

?-»i’m.-Popnta£ocm^^^^^^ 

Branch. 

Sathhday, July 28Tn. • • 




Annual IVioctCng, 1928: Hotel Accommodat ion. [ nnixmil SlKDICAl. JOUBMAl* 


257 


June 10. 


10281 


PATHOLOGICAL MUSEUM. 

The committco appi-iiitcd to org.inizo tho P.athologica] 
Moscxim vu conuexiou with the Annual Jlccting of tlio, 
British Medical Association at Cardiff next July proposes 
to arrange the material under tho following heads : _ (1) 
Exhibits bearing on discussions and papers in tho various 
Sections. (2) Specimens and illustrations relating to any 
recent research work. (3) Instruments concerned in clinical 
diagnosis and pathological investigation. (4) Individual 
specimens of special interest or a series illustrating somo 
special subject. (S) Exhibits of general interest., Tho 
committeo appeals for tho co-operation of tho profession 
in making tho museum a success. It will bo easy of access, 
being situated in the same building in which tho Sections 
will meet; it is Imped to make arrangements for exhibitors 
t) demonstrato their specimens. ICvery care will bo taken 
of tho exhibits, and tho contents of tho museum will bo 
■insured-, Tim honorary secretaries (Dr. J. B. Duguid and 
Dr. J. Mills, Department of Patliology and Bacteriology, 
IVelsh National School of Modicihe, Tho Parade, Cardiff) 
ask intending exhibitors to notify them as soon as possible. 


REDUCED RAILWAY FARES. 

Reduced fares will bo granted to persons travelling to 
attend the Annual ^Meeting. The railway companies in 
Great Britain (except tho Sfotropolitan, Metropolitan 
District, and Imndon Electric Railway Companies) have 
agreed to issue return tickets to passengers travelling to 
Cardiff in this connexion at tho ordinary single faro and 
one-third, fractions of 3d. to be reckoned as 3d., and the 
minimum adult faro to bo Is. A vouchor of tho usual typo 
must be surrendered when tho ticket is bought; theso 
vouchors, signed by tho Financial Sccrctai'v of tho Asso- 
ciation, will bo obtainable from him in duo course on 
application. 


HOTEL ACCOMMODATION. 

The following is a list of tho hotels in Cardiff and district, 
with a statement of tho charges for bed and breakfast; 


Angel Hotel 
Eoyal Hotel 

Queen's Hotel 

Grand Hotel 

Barry's Hotel ... 

Alexandra Hotel 
Eailway Hotel ... 

Great Western Hotel 
Central Hotel ... 

Sandringham Hotel 

Esplanade Hotel, Penarth 

Washington Hotel, Penarlli 

King's Head Hotel, Newport 

Westgato Hotel, Newport 

charge includes dinner. 


14 

14 

14 

10 

9 

8 

8 

8 

7 

7 

•18 

10 


10 0 
10 0 


Penarth is only about five miles from Cardiff and so within 
easy reacli. A'eu-port (Mon.) is about twelve miles from 
Cardiff, and tho new arterial road connecting tho two 
towns will bo in an advanced stage of completion by July. 
Tlicrwis also an excellent train service, tho journey taking 
about twenty minutes. Besides the above accommodation 
a number of boarding-houses, hostels, and private apart- 
ments are available. A large amount of such accommoda- 
tion has beon secured, and members who intend going 
to Cardiff are requested to write without delay to the 
Hotels and Lodgings Secretary. It would he a groat favour 
also if those members who have made private arrangements 
to stay with friends would inform tho Hotels Secretary 
of tho name and address of the friends ivith whom they 
are staying, as it is tho wish of tho Local Executive that, 
as far as possible, invitations to certain functions should 
M sent to those who aro entertaining members of tlio 
Association. When writing for accommodation it is most 
important that members state clearly (a) wbetber they will 
a accompanied by a lady, (b) whether they avo coining 
\ car, and (c) the exact dates of intended arrival in and 
epartuie from Cardiff, This last point is very important, 
s It is found that many members omit this when 
uii 1 ^, and so cause much unnecessary correspondence. 

Secretary of the Hotels and Lodgings Com- 
iJ n 'communications should be addressed, 

IS Dr. Abel Evans, 36, Nowpoi-t Road, Cardiff. 


ANNUAL DINNER OF THE ASSOCIATION. 

Tho annual dinner of tho Association will be held in the 
Assembly' Rooms, tho City Hall, Cardiff, on Tliursday, 
July26tli, at 7.15 p.in. Tlie dinner will bo open to 
ladies and. lay guests, and it is likely that the number 
present will ho largo. Tho price of tho ticket is 15s. 
(oxclusivo of wines), and, as tho tickets will hear tho 
number of a table and a scat, it is particularly requested 
that those who wish to sit together or make iip parties will 
arrange tliis heforo application, as it will be impossible 
to alter seating at a later date. Application, accompanied 
by remittance, slioiild bo made to the Honoraiy Secretary 
of tho Dinner and Danco Committee, Dr. T. R. Rees, 
1, AValkor Road, Splott, Cardiff. 

WELSH CONCERT AT THE CARDIFF MEETING. 

An important musical event in connexion with the 
Cardiff Meeting will bo a AVclsh concert, which will he held 
in tho Now Theatre, Cardiff, on the evening of Mondaj', 
July 23rd. Tlio Dowlais Mqlo Choir will sing, and the 
other artists taking part . include Mr. Tudor Davies, 
Miss Megan Foster, and Miss Gwendoline Mason tiio ivell- 
known harpist. The love of the Welsh people for -music is 
well known, and this concert will demonstrato to the 
visitors that in AVnles they can not only appreciate good 
music, hut can also produce musicians of tho fust order. 
It is likely that tho concert' will bo broadcast. 


ARRANGEMENTS FOR SPOUTS. 


AVhilo appropriate attention has been paid to the scien- 
tific and medico-political sides of tho Annual Meeting in 
Cardiff, visitors will find that extensive arrangements 
have beon made for social entertainment and for sports. 

Golf. 

In the realm of golf the competition for the Ulster and 
Childo Cups will bo held on Thursday, July 26th, on tho 
links of tho Southerndown Golf Club. Southerndown is 
about an hour’s run from Cardiff, and arrangements have 
been made for tho competitors to go down in two parties, 
ono starting at 9 a.m.,, and the other at 1 p.m. 

The conditions of play are tho same as in previous years, 
and intending entrants should send their names, with tlio 
necessary particulars, to Dr. Garfield Evans, 127, Cathedral 
Road, Cardiff. 

The final stage of the Treasurer’s Cup competition will 
bo played on tho Royal Poithcawl course on Friday, July 
27th. Play will commence at 2 p.m., and the party ■anil 
leave Cardiff at 1 p.m. 

Practically all the golf clubs in the vicinity of Cardiff 
Imvo tlirown their courses open to visiting members for 
tho week of tho Meeting, and a full list of these will he 
published in the JIandhooh of the Meeting.' 

Tho Notts Ladies Ch.illenge Cup, which was presented 
by Airs. Owen Taylor of Nottingham in 1S26, will bo 
played for on the morning of Wednesday, July 25th, oh 
the course of tho Royal Porthcawl Club. “As Porthc.awl is 
about an hour’s run from Cardiff, charabancs will le.ave 
tho Ladies’ Club at 9 o’clock that morning. 

The conditions of play are the same as in previous vears 
and competitors should send their full names, addresses^ 
and L.G.U. handicaps to Mrs. Garfield Evans, 127,’ 
Cathedral Road, Cardiff, as soon as possible, and not later 
than July 16th. 

Tho competition is open to lady members, wives of 
members, and daughters of members; other lady relatives 
accompanying members may be allowed to compete under 
special conditions. 

Laicn Tennis. 


, — ....... uv.-,. uijaiigeu ootn or 

the courts of tho Cardiff Lawn Tennis Club. On Thursday 
July 26th, a ladies’ doubles American tournament ivill he 
held at 10 a.m., and at the same fiour on tho following 
day a mixed doubles tournament will bo held. Intendive 
competitors for either event are asked to send their naniM 
to Mrs. Garfield Evans of 127, Cathedral Road, Cardiff 
without delay, so that tho necessary arrangements can he 
made. Besides the Cardiff Club practically all the Lamn 
tennis clubs in Cardiff and district have offered visiting 


258 June 1G, 1928T 


Contributory Schemes for Hospital Benefit, 


r f^uprixiniNT to tth 
LniiiTisn MRuiciL JoumnAi 


mcmboi’s and tlieii" ladie.s the liospitalilv of tlicir courts, 
and a full list of these n'iU he found in the Ilandhooh of 
the meeting. 

Holds. 

Arrangements have also been made for nicinhers to 
indulge in the games of howls, and a ninnher of excellent 
howling greens in Cardiff and the surrounding area have 
been thrown open to visiting members. It is hoped that 
advantage will he taken of this, and, if a sufficient 
number apply, a bowling competition will be arranged 
between a local green and a B.M.A. team. Any members 
intending to take part in this competition are asked to 
communicate with Dr. E. C. Eobertson, Struan, Llan- 
bradach, near Cardiff. 


IRISH MEDICAL SCHOOLS’ AND GRADUATES’ 
ASSOCIATION. 

The annual luncheon of the Irish Medical Schools’ and 
Graduates’ Association will bo held at (ho Royal Hotel, Cardiff, 
on Wednesday, July 25th, at 1 o’clock .sharp. The President- 
Elect of the British Medical Association, Sir Ewen Maclean, 
will be the guest of the association. ’Tickets for the hinclieon, 
price 4s. 6d. each, exclnsive of wines, may be obtained from the 
honorarj' .secretary for the provinces. Dr. Falkland L. Carj-, 
67, King’s Road, Harrogate. Members of the as.sociaiion are 
particularly requested this year to obtain their tickets well in 
advance, owing to the difficulty of catering for an unknown 
number of guests. 


CONTRIBUTORY SCHEIMES FOR HOSPITAL BENEFIT. 

COJilFEEENCE OF 3IED1CAL EEPRESENTATIYES OF YOLTJNTARY HOSPITALS. 


A coxTERENCE, Summoned by the British Medical Associa- 
tion, and composed of representatives of the medical staffs 
of voluntary hospitals from all jrarts of the kingdom, was 
held in the Great Hall of tho British Medical Association 
House, Tavistock Square, London, on Juno 6th, to discuss 
contributory schemes for hospital benefit (defined in tho 
hospital policy of the British Medical Association as 
schemes “ to which contributions arc made for which there 
is to be a stated or implied return ”). A memorandum 
.setting out the basis of discussion had been circulated, and 
attention was drawn to certain principles which the Asso- 
ciation regards as fundamental and to be insisted upon 
before any contributory scheme is launched — namely: 

ta) That only persons below a definite income limit should bo 
entitled to join a contributory scheme for hospital beuefil. 

(t) That (except in emergency) a contributor to a scheme should 
only lie admitted to hospital upon the recommendation of tho 
at tending practitioner, 

(c) That recognition should be made of tho services of the 
medical .staff. 

The chair was taken by Dr- H. B. Bn.tcKENuuRY (Chair- 
man of Council of the Association), who was supiiortcd by 
Dr. C. 0. Hawthorne (Chairman of the Eepresentativo 
Body), Mr. N. Bisho2) Harman (Treasurer), and Mr. W. 
McAdam Ecclcs (Chairman of the Hosiiitals Committee). 
The attendance was very large, rejiresentatives being 
liresent from some forty hosiiitals in London and about 
one hundred and fiftj' hos^iitals elsewhere in Great Britain 
and Ireland. Every tjpe of voluntary hospital was in- 
cluded — general, special, and cottage hosiiital. Eeiiresenta- 
tives came from as far north as Dundee, as far north-west 
as Belfast, and as far south-west as Plymouth. The pro- 
ceedings lasted little more than two hours, but during that 
time a very useful discussion took place. 

The Ch.mrxian, in opening, said that the subject before this 
large and representative conference was not the whole position 
of voluntary hospitals, their means of support, and their 
methods of management, nor the proposed grouping of hospitals 
and co-ordination of hospital services. The subject was the 
relationship of hospital staffs to contributory schemes, and if 
speakers kept to that subject they would have plenty to occupy 
their time. Tho preponderating support of the voluntary 
hospitals had gradually shifted from charitable subscriptions 
and donations to other contributions not charitable in nature, 
but having the character of insurance payments made with a 
view to an explicit or implied return. The problem was to 
resolve what action should be taken by hospital staffs in this 
new situation — for the prevention of the e.xploitation of their 
services and also for the preservation ef their interests as 
private practitioners. One of the great difficulties was that the 
j)C-isons responsible for contributory schemes were very often 
not the same persons as those' responsible for the management 
of the hospitals; when there were defects in the construction 
or working of the schemes there was apt to be a tossing of the 
responsibility from one body to another. Clearly, then, the 


subject was a complicated one. No doubt all those present 
were conscious of the peculiar circumstances or difficulties of 
their own hospitals or areas, but he begged them in conferring 
not to think too closely of their own localities, and to remember 
that some sacrifice of one’s particular point of view might be 
iiecessarv in arriving at any common policy. 

T/ic Jdistor;/ oj Hospital Polici/. 

Mr. Bishop Harman (Treasurer of the British Medicsil 
Association) presented two documents which had been circu- 
lated, one the memorandum on contributory schemes, already 
mentioned, and the other the British Medical Association’s 
pamphlet entitled " Policy Affecting Hospitals,” the latter 
being a compendium of the policy of the Association 
wliich bad been arrived at in the course oi the last seven or 
eight yctirs. 'This policy, ho said, was based upon resolutions 
passed by the Eepresentativo Body. Such resolutions had to 
be published two months before the meeting, and, further, in 
order to become the policy of tho Association,' they had to 
be agreed to by a majority of at least two-thirds. Ordinarily 
a matter of policy came from some Diinsion which sent up its 
recommendation, but in this matter of hospital policy tho 
Hospitals Committee of the Association set itself to the task 
as far back as 1921." A memorandum was then drafted, sub- 
mitted to the Council, debated very keenly again and again, 
ultimately reaching the Divisions, and then the Representative 
Meeting. This had now grown in subsequent years to - the 
pamphlet which was in the hands of those present. The, policy 
embodied tlierein dealt with many points, such as the co- 
ordination of all sorts of hospitals, the development of volun- 
tary hospitals, the position’of statutory hospitals, and so forth, 
but only one section of it-^that relating to contributory schemes 

concerned the present meeting. The Association (Mr. Bishop 

Harman continued) had never failed to recognize that it had 
a duty to the whole profession, and in this matter the Council 
determined not only to consult the members of the Association, 
hut the staffs of hospitals generally. During the last si.v or 
seven years there had been a series of. such conferences. I ho 
first was held during the Annual Meeting at Cambridge in 1920, 
and was presided over by Sir Cuthbert Wallace, '"'ben the 
principal item discussed was the relation of hospitals to State- 
supported patients. At that conference one rvell-knowir con- 
sultant complained bitterly of the inarticulateness of hospital 
staffs. The next conference was in London in December, 19 , 
under tlic chairmanship of Sir James Galloway, when tie 
principal business was the preparation of evidence to be lai 
by the Association before the Cave Committee. The conference 
wiiicU followed was among London hospital staffs on matteis 
affecting London particularly. Another conference was held in 
1922, when the statement of policy was considered clause by 
clause. During the next year the Labour party brought out 
its hospital policy, and in 1924 there was an interesting ^wo-day 
conference between the .Labour party and the Association s 
lepresentatives ; after that debate the attitude of tlie Labour 
party was considerably modified. The Labour spokesmen had 
come prepared to accept' State hospitals and notliing else, and 
as a result of that conference they went away recognizing that 
the voluntary hospitals had a place in the nation. 




Juke lO, 1928] 


Confr/fewtor'y Scficmos for Hospital Benefit, 


r to titr 

LDRITISU MKDICAI, JOUKSlfc 


25B 


A71 Idi'xiJ Contributory Scheme in Lotulon. 

Mr. \V. 3 IcApak Eccles (Cli^innan of the Hospitals Com- 
mitlcc of the British Medical Association) said that the 
Treasurer of the- BvHish Medical Association had given the 
history of the evolution of the criteria for avhat might he 
desevihed as au Ideal coulrihutory scheme for hospital henefit. 
It ^vas not always the case that ideals could he made to fructify, 
and, further^ it* was obvious that an ideal might he possible in 
one cnvinmuiont and impossible in another. Such an ideal 
scheme (Mr. Ecdc.s coutimicd) had boon inaugurated and 
carried out in London. London was huge, populous, and diffi- 
enU to co-ordinate. The economic stress following the war led 
to the pi'cparation of a scheme for hospital benefit whereby 
tho<;e persons who were wage-earners could voluntarily and 
choerfuny contrihutc towards tlieir inaintcnaiico and treatment 
while at hospital, whcUier as in-patients or out-patients. This 
A\as the scheme of the Hospital Saving Association, and H 
fulfilled all tiie criteria laid down hy the British Medical Asso- 
ciation, although it was found to be somowliat difficult to got 
them actually carried out. -As to income Un\\l, it. vas dehmlely 
laid down tliat the conU'ihutor's income must he within 
hospital income limits, as follows : single man or woman, £4 
per week; married, without dependent children, £5 per week; 
nmvied, with depe.ndeut children, £6 jicr week. Thc?e woi'c 
compacatde to the British Medical Association figures, which 
sol out the yearly income. A definite income limit was 
essential in the interests of the medical staff and the private 
praclitionev. As \o the requirement tliat admission to hospital 
must he, e-veept in emergency, on the recommendation of the 
atteiuling practitioner, the principle was over and over again 
propounded in the literature relating to the scheme and in 
meetiiqjs convened by the Hospital Saving Association, and 
its desirability w’as gradually taking ImJd of hotlj pntient and 
pvaclUionei*, There wore ** snags,’* however, one of which 
arose out of the wish of some patients to visit the hospital 
on their own initiative, presenting the “ green voticher.'* The 
Hospital Saving Association could not absolutely prevent tliis, 
hut the hospital itself could do so by making it a rule that 
uU green voucliers must be accompanied by a doctor’s recom- 
mendation. Upon this rule the medical sta^ should insist. 
Another “ snag ** was discovered when the attending practi- 
tioncr was found not to be desirous of giving a I'cconimen.dation 
to his patient for hospital consultation or treatment or both. 
This refusal might he quite legitimate in some cases, but on 
tile other hand there were mstauecs in which the recommenda- 
tion was withheld pcrliaps without due reason. Such action was 
apt to lend (o trouble, and it w'as difficult to see how it could 
he overcome, except, perhaps, by change of doctor. Tlie third 
principle, that rrcogju’tion should bo made of tlie services of 
the medical staS out of the money received hy the hospital 
from a conti'ibiitorj’ scheme, was perhaps the most debatable. 
-IV. Me Adam Eccles read the paragraphs of the hospital 
pohey of the British Medical Association beanng upon this 
matter ; ^ 


PaynienU raaclo... 
done basetl n- 
hetweeu tlio 


be for work 
time to time 
making full 


r.. * making tui 

anri * pron^ion of hospital accommodation, maintenance 

Payment ot medicaJ staff. 

infft Board of Management of a voluntary hospital enters 

mto a financial arrangement .....under a 

^ or otherwise for the reception of patients, 

ant] *mr r s.iouid be taken to cover the cost of inointcuaucc 

shonbl hn n-. -^^pd a percentage of all such receipts 

honnrarv ^ fuud which is at the disposal of the 

uonorari medical of that hospital. 

The coiitvacl made was for hospital benefit as a whole, con- 
sequcntlj the payment under any financial arrangement was for 
^atment «s well as for accommoila! ion and maintenance. 
'Vhen intmogatca, nine out of ten snbscvibers to the sclicine 
^ou express their belief that they batl contributed towards 
treatment, and it was only fair that this legitimate belief sbouUI 
0 c retrayed. It was, lioweeer, tlic medical staff who shonld 
npress upon the lay authorities of the hospital that a per- 
wntage of the money thus received should pass into a medical 
it^n "" hardly the function of the administrators 

ot the contributory scheme to do so. Where medical staffs had 
aone tins, then- request had not been resented, and where 

m fn f « '“‘I 

to s.™, ^ 8°°^ P«T=oses. Often it had gone 

cximH n equipment of the hospital— for 

example, to install an extra cardiographie apparatus or addi- 


tional at-ray lubes. No amount which might possibly bo 
received could be called adequate for all the service rendered, 
but in these days it was essential that there should be some 
recogitUion of the work done hy llie medical profe.ssion on 
behalf of those who believed they had actually paid for the 
same. (“Hear, hear.”) Hlany ohjections had in the past been 
rahsed against a medical staff fund, but these were gradually 
disappearing, and an increasing mimher of medical staffs saw 
the wisdom of siicli a fund. (Applause.) 

T/ic Position on Mersrysuie. 

J)r. J. C. JiLvtthews (Liverpool) mentioned some of the diffi- 
cuUics which had arisen in applying the Association’s tlivce 
priucijdcs in his own area. The main difference belwcen the 
provinces and London in respect to eontrihutory schemes was 
that in the provinces the contributions were organized through 
the various works or employers, and in most cases tile employers 
added a pcvccnlagc. It was hoped ultimately to include in tlie 
scheme tlie hospitals in the iicighbouriiig townsliips of Mersey- 
side; the population afiectcil would he ahont one million. The 
prolilcm in Liverpool liad been under discussion for several 
years. A scheme was finally launched which was satisf'Actovy 
to the staffs, and operations were started in July of last 3ear. 
For several reasons not concerning the medical profession the 
scheme was undergoing revision at the present time. In tliis 
revision all the points ot professional interest also had como 
under discussion again, and had more or less been re-argued. 
The staffs of the voluntary hospitals ot Liverpool alone 
comprised about one hundred individuals; they had formed 
themselves into a Hospital Staffs Associalioiij and it was 
this body, with the very active and willing co-operation of 
the local Division of the British Medical Association^ whicli 
had so far cairied on the negotiations. As for the three main 
points of the scheme, the first two (income limit and practi- 
tioner’s recommendation) were agreed; on the third (recognition 
of services of medical staff) there were still some differences 
of opinion- The lay authorities of the liospital.s in Liveipool, 
however, had begun to realize the jnstlce of the claim. Tlie 
following paragraph appeared in the original sdieme, and Jiad 
been included in tlie recent report of the Eeversion Committee : 

Tliat the hospitals be asked to gire favourable consideration 
to the request of the doctors for the allocation by the hospital 
to ttio tiospital staff funds of an agreed percentage of grants 
received from the coimcil. 

One stop further was being taken ; the Hospital Staffs Asso- 
ciation hoped to arrange for a conference with nominated 
representatives of the lay committees of the hospitaV-s. Thci'C 
was some nneasine.ss on the part of hospital tieasurers with 
regard to the success of the uonU-lhutory sdresne, and the 
negfitiations were not yet completed. He felt, howcvei-, that 
their lay friends in Liverpool were largely in agreement witli 
(lie request that tlie services wliicli the hospital staffs rendered 
to contvihutors siionld cease to he gratuitous. In consequence 
of the sdieme a number of employers had ceased to give their 
former subscriptions, and for the moment hospital incomes 
appeared to be going down. The rapid growth of the scheme, 
however, rendered it very probable that there would be ample 
funds available for Imspital needs, and that then the request 
of the staffs for recognition would be brought forward with 
a prospect of its favourable reception. 


T/tc Cottage Hospital. 

Dr. C. LiXirtoUGH (Gosport) spoke of the question as Jt 
affected a cottage hospital— namely, the Gosport War Memorial 
hospital, with 26 beds. On the staff of this ho.spital all the 
practices in Gosport were represented, and there were three 
honorary visiting surgeons from Portsmouth. The three funda- 
meirtal principles set out by the Association had been adopted ; 
contributions were obtained by a volunlarj- levj- on eaeii 
employee’s weekly wage; a committee elected annually bv the 
workers themselves oiganized and managed the scheme; persons 
whose income from all sourees was le.ss than £250 per annum 
wei-e eligible, unless they were single persons or persons without 
dependants, in whicli case their income must not exceed .£200 
per annum. The rate of contrihution was one penny per week 
per £1 of wage, but nothing had been contributed hv the 
employers. Of the total sum contributed to the fund, 70 per 
cent, was paid to the hospital for maintenance of patients- 
20 per cent, to the medical staff fund, and 10 per cent, whs used 



-3S0 June 1G, 1928] Contributory Schentos for Hospital Bonofit. - 


for various purposes, including an allocation to the local district 
nursing society, contributions to tho Portsmouth hospitals in 
respect of patients there, and administrative expenses of tho 
scheme, these last amounting only to 1.25 per cent, of the total. 
The contributory scheme brought to the hospital three times 
as much as was received from charitable subscribers and donors. 
The scheme had worked very satisfactorily, but there was a 
tendency for representatives of the scheme to try to increase 
their numerical strength in the management of the hospital, 
and owing to the large proportion of revenue received from this 
source the Hospital Management Committee rather tended to 
sympathize with this attempt. The hospital was immensely 
popular in Gosport, and the annual income was invariably 
larger than the expenditure. Nothing was paid to the medical 
staff fund from receipts other than the contributory scheme. 
(Applause.) 

Genehal Discussion. 

After these three opening statements from different points of 
view, general discussion was invited. 

Mr. H. S. Souttah (London Hospital) said that those of 
them who had studied contributory schemes would realize that 
these were going to have a revolutionary influence on the 
future of the hospitals and of the medical profession. They 
were not a small thing which was going to come in to-day and 
make some trivial difference to the subscriptions. They were 
going to alter entirely the whole basis of the hospital clientele 
and treatment. The subject was a complicated one, and he 
desired to confine himself entirely to one small aspect, placing 
before tho conference some considerations as to the purpose for 
which the contribution was made. The answer to such a ques- 
tion given by the committee of tho hospital would most likely 
be entirely different from the answer given by the patient. 
The committee would assert that tho contribution was to meet, the 
cost of maintaining the patient in hospital, his food and clothing, 
and so forth, and that it had nothing to do with medical 
treatment. The patient, on the other band, would say that lie 
gave his contribution in order that when he wanted medical 
treatment he should be able to get it. , The fact that ho had to 
be fed and maintained, he would claim, was a mere incident; 
the important thing from his point of view was the treatment. 
(“ Hear, hear,’’) The patient did not want to be maintained 
for some weeks in a hospital bed ; what he wanted was to get 
rid of his hernia, or Avhatever the trouble might be. This 
question was extremely important at the present moment. 
Upon the decision of the hospital staffs would depend the whole 
future of the contributory schemes. If hospital staffs allowed 
the idea to take root that all the contributory scheme had to 
do was to provide for the “ keep of the patient in hospital, 
that idea avould be established as a permanent principle. It 
was perfectly obvious that an ordinary working man could mot 
stand the expenditure of a big operation or of a long medical 
illness, but if in times of health and prosperity he subscribed 
a very small amount he would be- able to cover the whole of 
that expense. Actuarially, if a workman paid sixpence a 
week it would cover handsomely the probable cost of any 
hospital maintenance and treatment that he might require. If 
he did not pay for his treatment, what was, in fact, the 
economic position of the hospital staff? A man came into 
hospital, say, for a hernia, for which he was relieved, and he 
paid the hospital £8. Who had earned that £8? The point 
which the speaker wished to make was that as long as the staffs 
were not paid it was the staffs who were paying for the 
hospital. But he did not think . his own chairman would like 
him to send in a little note at the end of his operating session 
and say, “ Kindly add tliirty guineas- as ray donation to-day 
to the hospital fund”! He asked again. For what was this 
contribution paid by the prospective patient? If it was recog- 
nized that the patient really was paying for the treatment he 
received, if the patient Avas greeted in hospital as a man who 
was paying his Avay, instead of it being derogatory for recog- 
nition to be made of the services of the medical staff, it added 
to the dignity of the profession and of the patient as Avell. 
(.Applause.) He begged that it might be recognized that in 
the contributory scheme the patient paid for his treatment. 
Why should anyone be shy or squeamish about admitting it? 
(Loud applause.) 

Mr. Edav.vrd Deanesly (Wolverharnpton and Staffordshire 
• Hospital) said that the staff of bis hospital Avere in entire, 
agreement Avith the principles enunciated for contributory 
schemes. He Avas sure that these schemes Avere going to 


rcA’olutionize the finances and position of tho aaIioIc profession. 
All hospitals Avero looking round for fresh sources of income, 
and flic only source in sight, apart from grants from the 
Government, Avas these contributory payments. At present tho 
employers did not pull their weight; they did not make, as 
employers, the contrihiitions to hospitals Avhich they ought to 
make. It AA-as forgotten by them that it A\-as impossible to 
carry on industry in any toAvn in the kingdom Avithout a aa'cII- 
equipped hospital ; they did not ahvays realize that thc3' Avere 
getting .something for nothing. One great difficultj’ which' AA-as 
already confronting Wolverhampton AA-as the overlapping of 
contributory schemes. It AVas not acceptable to liaA-e a London 
agent coming doAvn and suggesting that the people should make 
their contributions to London hospitals rather than to their 
OAvn. In the Wolverhampton area the local hospital Avas Avell 
supported, largely because of the good management of the 
Hospital Saturday Fund. But Birmingham had launched a 
scheme AA-hich practic.ally promised hospital treatment to iill 
contributors, .although .such a promise could not be fulfilled on 
account of lack of accommodation. Unless something AA-.is'done 
to remedy the overlapping of areas a scheme AA-ould be met by 
insuperable difficulties, and it aa-.as no eas}- matter in a large 
area to bring about co-ordination. 

Dr. W. Collieu (Radcliffe Infirm.arj' and County Hospital, 
Oxford) .said that in connexion AA-ith the CountA’ Hospital one 
of the earliest of the contributory schemes aa-os started and had 
been cxtrcmelj’ succe.ssful ; it had prcA-entcd the hospit.al frqm 
f.alling into a third-rate position. In 1913 the AAorking income 
Avas under £10,000 a year; at the present time it Avas £42,000. 
A large part of the income came from agricultural labourers. 
At the same time those concerned had been out to protect the 
interests of the gener.al practitioner, and, as far as possible, the 
consultant. Tho first tAvo principles in the policy of the 
British Medical Association had been accepted, the third 
principle — recognition of the services of the staff — not yet. If 
the staff AA-ent to the committee to-morroAv and said, " Yon 
must pav up a definite amount from the contributory scheme 
to the medical staff,” he thought the contributory scheme 
AAould bo at once destroj’ed. But ns the result of tho present 
disemssion he thought that the medical staffs in the county 
hospitals Avould take the t]uestion up much more seriously than 
they had done hitherto. With regard to Mr. Souttar’s point 
about sixpence a Aveck from the AA-orker, this Avonld bo impos- 
sible of application to the agricultural labourer, avIio Av.a3 


irning only 30s. a Aveek. 

Mr. R. St. Legeh Bhockjian (Sheffield Roy.al Infirmary) said 
lat from the point of vieAV of finance as seen by the lay boards 
le Sheffield scheme had been a huge success. But thirty, 
irty, or fifty small tradesmen Avho- could afford to run their 
Avn motor cars Avere noAv joining the scheme on the basis of 
aving £1 a year. The unfortunate thing Avas .that Sheffield 
>fused the income limit at the beginning. The scheme had 
een running for some years, and all these people Avere m. 
f now the. staffs insisted on the income limit, these people 
ould have to come out of the scheme, and the staff Avould be 
'Cused of wrecking tactics. The position Av.as unfortunate ; 
mre AV.as a lack of hospital beds, and waiting lists tended to 
ngthen, while continual pressure Avas put on the staffs through 
A^ous large firms Avho claimed to be paying so much .to ho 
■heme— in ^Sheffield the employers gave one-third of AAhat 
on irav6 — ond Wivntcd & Q^iid "pio quo. ^ \ ^ i 

Dr^ A J. Baixantyne (Glasgow Eye Infirmary) 
lat 'in Glasgow there was no such thing as a contributory 
liLe. There the hospital system was as close to voluntarj mm • 

■anything could be. Large contributions certainly were made 

f the Avorkers, but no conditions were laid doAin 
U or specific services in return Although, 
lown, there was no contributory scheme ^ 

Avas felt that such a scheme might be brought f?cAAard at 
ly time; it Avas largely a question of facility '"securing funds. 

considering the principles laid doAvn in the Association s 
emorandum it Avas felt in Glasgow that -there 
ck It might easily happen that in some hospitals 
.tmors would be approached by lay . such as repre- 

ntatives of the AVorkers, Avith a view to Revising some con 
ibntory schemes without the staffs being consulted ndeed, 
AA-as stated that the medical staffs of the hospitals con 
rned in many instances had not been consulted in the netting 
, of the sc^me; Something should be. laid doAVp by the 
= a nrineiole to be observed — namely, that staffs 



JUNE 10, 1928] • 


• . . rx « ^ ( axTTPJ^ixzri'r w ina 

Contributory Schemes for Hospital Benefli. icniTign iigpioM. ;ocii!<ii> 


set 


ill tlipso cases must bo consulted. A contributory schemo 
iiutilicd 0 coutrncl between the contributor and the Iiospilal 
with regard to services, and tlic members of tlio medical and 
surgical°staffs' would' be parties to sucb a contract, and should 
be insulted with regard to the scheme. If a .scheme word 
devised without consultation with the medical staff the staff 
Would he greatly strengthened in its opposition could it point 
to something which had been definitely laid down by tho Asso- 
ciation ill this connexion. He tvislied to move a rc.solution 
on the subject. 

The Cll.MnMAN thought it would be inadvisable in a meeting 
of th.U character to pass any definite resolutions, though ho 
Would not rule out some general proposition which would 
receive practically unanimous assent. It was quite in order, 
luuvover, to mention and speai: to a rosohilion wliich the spealter 
wmiid like to have had brought forward. 

Pr. B.rt-LANTVNK said (hat he would, in deference to the 
chairman, refrain from proposing any resolution, hut he ashed 
mcinher.s of .stalT.s to bo wary lest a cuiitrilnitory .scheme he 
bvougiit forward without, the staff being taken into con- 
sultation. 

Dr. Curroun Et-LraGswowTii, thongli representing the West 
London Hospital, spoke on hchalf of the London Panel Com- 
mittee, _on which lie represented the iiou-iusurancc practitioners 
noitb of the Thames. The Panel Cominillee bad asked him 
to e.xpress its agreement with the prineiplcs laid down by the 
Association in regard to contributoi-y schemes, but to stale that 
Certain liospitais did not confine the benefit to bosiiital treat- 
ment. Ill their out-patient departments they invaded the 
province of the general practitinnor. The Panel Comniiltcc was 
of opinion that general practitioner treatment should not be 
provided by the hospitals under the conlvibntory schemes. 
Jl.-iny volntitaty hospitals, the spealter cotitinued, were run by 
lay secretaries, wiici.se ambition wjis to get as many green 
vonebers a.s possible witltoiif considering the work tiirowii on 
the ho.spit.al staff or the injustice done to 'he general pr.-icti- 
tioners. Mr. Soultar had mentioned (hat patients thought they 
Were paying for their tre.Ttnicnt. Tho speaker declared that 
they did not iu any way pay for their treatment ; was it recog- 
nized th.it at the present time the vuluiitary hospitals had 
become the i-r.iy centres for the whole of their district, 
including the .service of insured p.itients, who. with ilic green 
voucher, deninnded and received x-ray (roafmeiit at the hos- 
pital’. The same was true of drugs for which there was 
Specific provision under the national hvaltli insiirame .system 
without refevenee to Ibc liospital. 

Dr. E. Wjuttin'Gtov (Hove Hospital) asked how far visits 
and consuitations .it the patient’s house should be included in 
Contributory sehcme.s. A113' coiitrilmtoiy sc.[i(.uie which was 
going to be of great use to the patient must include in some 
cases consnltaf ions at the patient's bouse or al the consultant's 
bouse. At the hospital there were a iiuinhcr of patients who 
came up foe coiisulfations, and one would like to know how f.ar 
the com ribn tori- schemes ought to cover the cost of coiisulta- 
tipns in those cases' that could not come up to tiio Iiospitals. 
Such cases Ought to be covered bj- anj- adequate contributory 
scheme. When the scheme in iiis own area wius .started sucii 
service was included, and an .idequate fee of three guineas was 
apiiortioiied to tho coiisuliant who saw (he patient cither at 
Ins own bouse or al the patient’s house. Thi.s provision had 
recently without any consultation with the medical profession, 
ecu cut out of the scheme, .and it .seemed to him that jt must 
01 nece-ssily he so cut out if contributions to the sebeme were 
t- , under most of the schemes now 

•a, f “ coiitrihutory scheme was to be of use it 
sHouiti be on .in actuarial basis so that the contributions were 
adeqn,ifo to the benefits. 


^I-I’-.(n’ember of the Hospitals Coni 
, ), S.iid that this question- had had a long histoiw. Th. 

question arose soon after the w.ir, when it began to be reeog 
II, ! 11 'T-' ‘“' 6 ® ""“'‘’'I’ of members of hospital staff 

at ho mtT" R “me recognition of the work don. 

W1V nf m ■■ .®"\P>^“ot.eally nothing had been done in th, 
necrasim ^^Tt'""® ^ r m ''f°Suilion which was then said to b. 
"a comW f H to see the reason for this long delw 

certain fffi l " ^ "’ambers of staffs felt 1 

mmtev ftv utr. T ’’'"ff. ‘l>e imm'ds of hospitals to asl 

r,i, * ^1 ' f'"^'uSclvcs, and prob.iblj- that Pad been one of lhi 

iMo! rv ‘''S' f‘'oo<3om given to then 

lOluutary workers. But there was no doubt fhat the tim 


had como wiicu it was necessary that the vast amount of ivork 
done in hospitals should receive some remuneration, especially 
in the case of tlio younger members of the staffs.- It this tvas 
not done now it was difficult to see when it would be done. 
Suppose (ho State took over tho hospitals; what could the staffs 
say w-licn the Stale was their master if they had been willing 
to work for notin’iig under tlie prc.scnt system? It was cssonthal 
to be qnepared for such ati event by some sort- of p.ayment. 
There were, alre.idy State hospittils and municipal hospitals the 
staffs of which were getting a certain afnount of remuneration. 
As linic went on tlie.se Iiospitals might grow and come into 
competition with tho voluntary hospitals', and if the staffs of 
one kind of hospital were paid and the staffs of anotlier were 
not (he re.sult might bo to the detriment of tlic voluntary 
hospitals. It seemed to bo the duty of tho conference to make 
a dclerinincd effort (0 arrive at some practical conclusion on this 
.i-spcct of tho question. (Applause.) 

Dr. C. Herbeist Haei, (IVatford and District Peace Memorial 
Ho.spit.al) asked how it had come about that the British Medical 
As,sociatiou schemo had not been accepted more widely. One 
groat reason was tliat it had not received the support of the 
coiisiiltaiit staffs of the big London hospitals. Again, this was' 
primarily a question for the staffs of hospitals. It was thej' 
who must bring forward the case before their committees, and 
it was particularly the seniors who should do it, but it was 
not being dotic. His colleague Dr. Francis Smith and himself 
at Watford were just approaching tho end of their time at the 
hosliital, and they had been sent forwtird by the staff to 
advocate before tlic committee the British Medical Association 
scheme in its entirely. The committee had listened to them 
because it recognized that they had no axe to grind for them- 
selves. One mistake made at Watford was that the British 
Mcdic.1l A.ssocialion scheme was not taken in its entirety at 
first ; it was very desirahle to have a scheme logical from 
beginning to end. The Watford c.tperience was that when it 
came to debating with tlic committee as to the hospital staff 
fund (he Labour element on tho committee proved to be' the 
strongest supporters of the staff, recognizing that the doctor 
should receive his share. The total amount of new money' 
coming to liis hospital as a result of the scheme was £ 4,000 
.1 year at le.ist, .and the medical staff had been offered a fi.xed 
sum of £ 350 , which they had turned down. Ho thought th.it 
stifficieiit emphasis had not been laid at headquarters on the 
desirability of having a percentage arrangement. He and his 
colleagues beliei-ed that the scheme at Watford would presently 
he earning for the hospital from £8,000 to £10,000 a year, and 
the staff should receive an increased .imoiint accordingly, as T't 
would do on .1 percentage basis. He urged support for the 
full British Medical Association policy, with the 'principle of a 
perccnt.ige. 


iliiu XUIUIUIIU XlOSipiia 

for Skin and Uiinary Diseases) begged the conference f< 
remember that (be sick man’s d,iim to service was fuuda 
mentally based on his sickness, not on his membership of i 
pavticiiiar scheme or guild or clique, nor on his position it 
soticly, nor oil his means. He also mentioned the nurses, who 
ill voluntary hospitals, were to a large e.xtent, like the medica 
staff, tloiiovs of their services. They were not p.iid fairly oi 
properly, and lie would suggest that with funds available ii 
was the duty of the medical staff to see ti1.1t some proportiot 
of such funds went to the nurses. 

Mr. A. J. IValtom (London Hospital), referring ' to tht 
veuiavks just made by Dr. Hall, and bis rebuke to the con 
siiltaiits of the London hospitals for not giving full siipporl 
ti the scheme, said tliat he thought the rebuke justified ant 
lie would like to tJirow a- little light on the position. Of tin 
three fundamental propositions set out, the second one (admis 
sioii only on the recommendation of the attending practitioner 
had been iiiiiver.s.illy accepted. His own hospital had becom; 
much more, than fonnerly a consultative centre, and most oi 
the patients admitted were admitted move or less at tin 
request of liimself and his colle-ignes. The difficultv was that 
they had no adequate means of determining what was tin 
patient’s income. It Inippened that certain patients paid'sum^ 
up to £5 per week for their maintenance. On one or tuv 
occasions, on mentioning- to the lay committee that there ivew 
such p,itients, he had been ioM, ” Yes, but the cases w! ■ 
admitted at your own request.” , The staff h.id no memro 
discovering the patient’s ■ economic circumstances B'Jfiv . ! ■ - 
to the third principle (recognition of the service" of 




June ig, 1928] 


Nava! aticf Military Appointments. 


, [e 


Bvrrzr:^}rtrya tsa . 

niTisir iiZDicxx. JawBjfAi. . 


263 , 


committee mifrlit n!fiO refer cases of this nature fo the Insurwicc ^ 
Committee for iiivcsligaliou Tiy the Medical Service SuTicomniittcc. 
In tlio particular case wliich led to tlic- confcreucc the Mmialry 
had informed the Insurance Committee tlmt it v.-as in rrder for j 
the subcommittee to investigate the mailer, and thcrciorc the 
i’ancl Commitlee decided to lake no fnrlllci- action al present. 

■ Drfinitiuu nf a , Splint. 

It was reported tliat tlie Slinistry o( ireattU, in reply lo a 
request by tlio committee, bad ftmiislied a definition of a .splint: , 
. tlio department take the view broadty that Bpiints are 
appliances intended to secure imnioliility of bones or parts of 
bones in relation to one nnollier, in the treatment of fractures, 
dislocations, diseased, or injured bony surfaces or joints, and 
ruptui*cd muscles or tendons.** Tl»c Jfinf'^lry hn<I previously 
excluded a spinal jacVcl from heing dohnetl as a splint, and ihe 
committee requested to informal in what nay a spinal jacket 
was contrary to tlie description of tlic splint laid down in tho 
letter. • • 


DANGEROUS DRUGS r mTHDR.AIVAL OF 

AurnourzATTON. 

•Tju: Home Sccrctai’v gives notice that he lifts' withdrawn from 
Frederick Denis ^Parbury, MJlvG.S.^ Elsliam Road, 

Ivensinglon, the authorizations gnmlod by tho Regulations made 
under tho Dangerotts Dmgs Act, 1920, to duly qualified medical 
practitioners to bo in' pcssossion of and to supply raw opium 
■and the drugs la which Part Ilf of tlie Act allies, and has 
also directed that tho exception in Rogiilalion 4 of the Dangerous 
Drugs Regulations', 1921, which' permits dangerous drugs to he 
supplied on a prescription given by a duly qualified medical 
practitioner, shall ' not' apply in respect of prescription^ given 
■.by Dr. F. Parburv. Any person strpplying Dr. Parhury with raw 
ophnn or an}’ of *’tho drugs lo whidi Part Iff of the- Dangerous 
"Drugs Act, 1920, appTlos., and any person supplying tho drugs 
on a prescription ergnod by him, will be conunitting an ofFciice 
against the Acts. 


Capiainn to b& Ibijors J. H. Aiuslcy, David Clyde, and R. A. 
Irf*enibruggcn. ' 

. Unutcnaul T. A,. Malone to bo. Captain. . . ^ 

Lieutenant J. If. Clapp has re-signed his commission. 


TERRITORIAL ARMY. 

Rovvii Armv SIkdicil. Cap.rs. 

Captain J. K. Ruviiic, .1LC\ (late R.A.if.C., T.A.) to be Captain wiOi 
precedence as from October 2Gth, 1925. 


TERRITORIAL ARMY RESERVE OF OFFICERS. 

Ror.ti. Aiuiy JlcDiciL. Corps . 

Miijar J. IT. Donnell, having: attained the age limit, relinquishes his 
commission am! retains his rank. 

Captain G. F. Hardy, .If.C.,. having .attained the age limit, relinquishes 
Ilia eommtssion and retains his rank. 

dcneral llofpitalg. — Captain IV, Sf*ymotir, haying attained the ago 
hmtf, reiinqnislK^s his enmmis-Hion, and ictains hi-** rank. 

Hyjjirmr CM«rjia«uv.— -Captain D. Smith, having attaine<l the age limit, 
rcliiiqtiishcs Ids commission and retninH his rank. 


COtONTAIi MEDICAL SERVICES. 

Dr. E. P. Jewell appointed Resident .Surgical Officor, Koirobi Hospital. 
Kenya. Dr. H. B. Oweir, Medural Tutor-, Malcercre CoUegt;, promoted 
Medical Superintendent, Midagov. and Principal of the Medical School. 
Pr. C. V. Alien appointed Bacteriologist, Institute for Metlical Research, 
Fedcralcd Malay Slates. Br. W. L. Paterson nppovnteil Medical OflEcer, 
Konya. Drs. N. J. Willans and R. E: Barrett appointed Assistant 
Bacteriologist and Medical OfficeE, Uganda, respectively. Dr. J. J. 
Mitchell, Medical Officer, appointed Slcdical Officer, Hoima, Uganda. 
Slibs C. N. Twining appointeil Lady M^ical Officer, Ken}-a. Captain 
M. Claylon-MilcheM apporntetT Resident Surgeon, Colonial Hospital, 
Grenathr, Windward IslondiJ. Mis I. SL M. Aitken .appornted Lady 
Medical Officer, Gold Coa.'st. Drs.. TI. V. R.. Miller and J. H. Pottinger 
appointed Medical Officers of Health, and A. Herd appointed Medical 
Ofiiccr, Gold Coa-l respectively- Dr. D- M'Tiitboume- appointed Lady 
Mi'dical Offieot (lor one year only') lo Lagoa Toswn. Council, Kigeria. 
Dr. IT. N". irunfer appointed Medical Officer of Ilealtri, Xairobi ilunicipal 
.Area, etc., Ken>ft. . , ... 


ilafrol anil ^tilitaru ^{jpointnuenls. 


RorAb NAVAL WEDICAL SEUVICT. 

, Surgeon CommaiuleT R; J 0. PatneU, ieniontv in present rank ante- 
dated to jMay 3322- 

. Surgeon Commander 1). P. H. Vwvrsun H plar.eil on the retired list. 

Surgeon Commandcr.s C. Roi-g to the f're^ideut for post-graduate 
.coarse; W. F. Beattie to the Kirfory for R.N. Barracks, PortsmoufJi. 

Surgeon Lieutenant Commander J F. Ainley to the for 

/hospital ilii;> Maine, and ai* ophthalmic specialist from date of joining. 

SiTTgeon Licufeuant:! R. R- Baker to tlu» Vindictive; \\\ 1>. M. Sun to 
the 1 ‘einbrni-e for R.M. Difirmarj', Chatham, tanporary (amended 
appointments); T. L. Cleave to the Calfiopr; P. C. M. Bamford to the 
Tmnar. 

Messrs. F. Dolan, S. J. Savage, and R- E. P. Cohen have cntereil as 
Surgeon Lieu^anta for short ren’ice, anti appofntctl to the Victorj/ 
for U,N. Hospital, llaslar, for course ot instruction. 

Rotil XivtL Votu^nriT. Bi:.sEr.vr. 

Surgeon Lieutenant IV. J. Payne to be Burgeon Lieutenant. Commander. 
.. Surceon Lieutenants W- AVinstanley to the iVifciri; to complete foui- 
' teen days' training; J. Ii.-Cox to tlie for eighteen days' train- 

■ appointment to Emprror of hulia cancell^^d'; J. U, OJdhani to the 
Victory -lor R.N. Hospital, Ha*'lar. for training ; R, EttUine-Gray (o the 
.PrinbroKe for.B,N. .Hospital, Chatham, 


ROYAL' ARMY ^lEDTCAL CUTTPE. 

•'^^®,.hotificatian in " the-' Lomlmi Gazette of Norembee 28th, 1917, 
temporary Chptaia Robert B. Jlartiu, J/.f.'., is cnnccHcd, 
Temporary Lieutenant .Robert' B. Martin, 3I.t’ rehunui^llcs his 
.commission, Jiovember Kth, 1917. 

Henry McXHll to fif- temporary Lieiitenont. 

Uieuicnant on pro^tion 0. G. \Ycstou resigns his cominbvjon. 


. ■ RECLX.AR 'ARSn* RESERVE OF OFFICERS. 

* n y . Rovu. .Vr.MY Mnura Cbarv. 

of Ihibim?- 0;n.E.. having attained Hie age !ini 

of liabihtj to recall, ceases to lielon*' to ihe Rei»erro of Uflicers. • 


' boval' atr force .^rmrc.tL ser\tce. 

^ t”- r>oteucc Cron 

qSlrs, AndWw'. ° ’ Bomljiiiff Area Ilea^ 

Lieulenanl (lionor.uv Sqiiailron Leader; If. C. Perkins rclii 
' permed "" onmpletiin n[ serv.cU aad 


.O, , ^JEDICAL SERVICE. 

“ 

Raatle.ol >" Oie Sen 


.«aa le.olbec'HDber "Tranent was notifieil iir Uie Im 

,,'n.e rerriiS.™! JlSor I^’b Lia«t<P>aat.C<.lo, 

. 1 . - _ J 15. Hanna are placed permancnlly at 


disposal of the Go\ernmenl^of^ Pl^ed permanently a 

for employmrat in the Jail DepSmc’nt '*^ ^IlL, 


VACANCIES. 

Btnsstrrv: BECiaTT lI«>*nTi!. int> Dispeksirt.— H ouse-Physician (male). 
• Salary i'l'W per annum. 

B\ii>*5nTtr: Normi Deyo:? I.'CFiiiMiaY- nousa-Sutgeon. (male). Salary at 
the rate nf 1:150 per annum. 

BiRMiriGif.oi CtL'CERiL llo-sriTAL.—Assislant Surgeon. Honorarium £50 per 
annum. 

BOMBIY; Cutk A.\U -AtCLEPS nOSPlTlL POR .WOSIKN A.VD -CHILDnEN'.— 
Medical Officer in Charge (lady). Remuneration Re.800— 50—1,000 per 
mensem for officer ot i'^iatic. domicile, and Rs.OOO— 5<L-800, plua £20 
per mansem ns ovciseas pay for ofilcet of non-Asiatic doraicfle. , 
BnrcnTo.v: X>av Si*sse.y Hospitii. for Women* and Chilpres;—!!) 
llonoTUTy Afcsibtant Ophthalmic. Surgeon. (2) Uonorary Clinical Aasia- 
tanta foe out-palienttf. 

Bristol- £yy llosprr.iL.— Honorary Rbinologist. 

Bury l^nrakLurY,— Senior House-Surgeon (male). Salary at the rate of 
£200 per annum. 

City op LoN'no>i^ Hospitil for Diseises. op Tiir Heirt iiND Ltr^tes, Victoria 
Bark, E.2'.— (1) Radiologist; honorarium 150 guineas per annum.' 
'Eisr Sussex Countt Couxcu.— C oronur for fhe Lewes District. Salary 
JtTSO per aniiunu 

Hist Si'sscc Cou.vrv Mextil Hospital, HelIinglj%-~Junior .^sistant 
Medical Officer. Salary £350 per anaum^ .rising- to i^OO. ■ 

. Britu Una\N District Cocxen..-~Medical Officer of Health. . Salarv X80G 
per annum • ■ 

GLoccr-sTBRSinnc Rovil- JxnR3rmr axd Eye Evstitutton’.— Resident 
Slirgical Officer (male). Salary £175 per annum. 
iriMP5TF.lD GE.NtIl.lL AXl> Ncflrill-IVEST LON’DOM HOSPITAL,- HavC’StOok Hill 
N’\V.3.— Casnalty Surgical Officer af the Out-patient Department’ 
Bajham Street. Salary at the rate of £1C0 per annum. '' ' * 

Have. noaPiT.u..— Resident Medical Officer (male, unmarried). Salarv 
£150 per anniim. ■ • , ^ 

Hull Royal l7»’nRMiRY. — (1) Assistant House-Surgeon (male). (2lCasiialtv 
llousc.-awrguon.. Salary £350 and ^0' per annum reepeotn-eJy ^ 
Ipswich: Ei^ Scfpo^ ixd lPsH;iai Hoepitil—Two House-Sarreons 
(males). Salary at the rale of £100 per annum each. 

I.EHDJ Jewisrr HEiUL-lfosER HosBrr.iL.— Resident Medical Officer Salarv 
£50 per annum. ^-.i***/ 

Losuox Ccp.POPanox— 3r0dical_omcer of IJenlth tor the Tart of London 
Salary £1,500 per annum,, nsing- to jM,000. 

Mixchestfr: A?fca\Ts Hosnr.it.— iroutfe-Surgeon (Orthopaedieb .Sitarv 
at the rate of £100 per anirom. ^ ^ -teaicj. balary 

IIwi^Tun Edccitices t'OMJnna:.— Assistant Ecliool Medical Officer 
Salarj- i600 pet annum, rWns to L7S0. . ’ 

MissriEUJ .txo DlsiiUCT IIosPiriL.— Assistant House-Surgeon (male) 
Salary at the rate- of £150 per annum. i «aj« 7 . 

Marciret Street Hospital for CoxsCMPnoir, 26, Marcaret Strp*>t wi 
Honorary Assistant. Physician. rj^aret. aireet, WX— 

.AIiller Generil Hospitil, Greenwich Road, S.E.IO— (1) iroiicf..Phv«r/.;r,T, 
House-Surgeon. Males. Salary, at the rate or Ak 

KEWCASTL^rPO.V-XTNR : Roy«. ViCTORJI li/PIR3I.tRY.— (l) Jf^tlfcal 
Dep*?;.S^’'''‘'"“'"“ Homnary Asaistant to the 

Nkwuik llosmin BisPEN-s.iiur,— Resident Honse-Siircnn 

, Salary at the rate o( £150 per annum. rion.e-surgeon (male). 

Popun nospmn roit Accroraisv E._Senior Resident Officer. Salarc fom 
per annum, pins few £75 per annom as Anaesthetist to Deni.rtnfi?? 




lor Eac. S^imorChildrenJ’'" i«>nacstUctist to Dental 

Queen CirinLOTTB'® ■>T»-rpo 
fant Resident *’ 
annum, rising 

’<JnEr:ca.nnj, Govi:nnarEST.--ircdicakomcer •for"tti'e“ncm.<m„ . . . 

* Instruction. Salary £60O.fSC0. • ■ opartment of Public 

Ror.li. Wateiu-oo Hospit.il ron CiiiiDRrv .vn it'o..™ o , 
Phisiciait (male). Satary nl llm rate of 


-ftrylebone Road, N.IV.l. .\ssi 3 - 
’■“•o of fBd.per 



S'U'PITjE MB ]sr T 

TO TUB 

BRITISH MED ICAL JOURNAL. 

~ LONDON, SATURDAY, J UNE 23r.D, 1928. ' 

’ contentsT 


WOE 

BRITISH MBDIOAIi ASSOCIATION. 

Proceedings or council 265 

ASSOCIATION NOTICES 271 

MEETINGS OF BRANCHES AND DIVISIONS 272 

NOTICES OF MOTION FOR THE ANNUAL REPRESEN- 
TATIVE MEETING 273 

NATIONAL INSURANCE 

Local Medical akd Panel Committees 275 


WOE 

CORRESPONDENCE : 

Associatios Pkotessioselle Inteukationale des Medeciks 


(A.P.I.M.). By C. E. Douglas, M.D 274 

NAVAL AND MILITARY APPOINTMENTS ... 275 

VACANCIES ANTI APPOINTMENTS 275 

diary OP SOCIETIES AND LECTURES 276 

ASSOCIATION INTELLIGENCE AND DIARY 276 

BIRTHS, MARRIAGES, AND DEATHS 276 


fBnttslj iEcMcjil Assort aitoit. 


PROCEEDINGS OP COUNCIL. 

ircdiicsdny, June ISlh, 10J8. 


A MEETING of the CdbticU of Uip Britisfi Jifcdicol Association 
was held at the Association’s House in Tavistock Square, 
London, on tVodncsdaj-, June 13tli. Dr. H. B. Bilacken- 
Btmv took the chair at 10 n.m. Tlioso present wore; 

Sir Robert Philip (President), Dr. C. O. Hawtiiorno (Chairman 
of Reprcsenlativo Body), Mr, Bishop Harman (Treasurer), Mr. 
R. G. Hogarth (Past President), Sir Ev.on Maclean (President- 
Elect), Dr. A. Lyndon (Deputy Cliairman of Representative Body), 
Sir Robert Bolam (Immediate Past Oiairmaa of Council), Dr. J. 
Barcroft Ahdci'soni Dr. J. Arnislvoiig, Dr. J. BaiUlon, Major- 
General Sir Alfred Blcnkinsop, Dr. J. \V. Bono, Dr. H. C. 
BristoKe, Dr. G. P. Buchan, Dr. if. G. Daiii, Dr. C. K- Douglas, 
T. B. DuuluU, Mr. \V. McAdam Ecclcs, Dr. T, Fraser, Dr. 
F. W, Goodbodj*, Rear-Admiral J. Falconer Hall (ret.), Dr. B. 
Wallace "Henry, Dr.‘ G. B. Hillman, Dr. J. Hudson. Dr. I. W, 
Johnson, Dr. jS. K. Lc Fleming, Dr. R, W. Leslie, Dr. E. Lewys- 
Lloyd, Dr. J. Livingstone Loudon, Sir Richard Luce, M.P,, Ur, 
J. G. McCutcheon, Dr. S. Morton Mackenzie, Dr. O. Marriott, 
Dr. J. G. Matthews, Dr, G. Sv. Miller, Dr. Christine Murrell. 
Lieut.-Colonel F. O'KinValv, Dr. W. Paterson, Dr, R. C, Peacockc, 1 
Dr. J. R. Prytherch," Dr. L. RadcUffe, Dr, E. H, Snell, Mr. H. S. I 
Soutlar, Dr.' E. A. Starling, Dr. Lockhart E. W. Stephens, Dr. j 
John Stevens, Lieut.-Colonel Ashton Street, Dr. W. E. Thomas, ; 
Dr, G. .Clark Trotter, Mr. E. B. Turner, Sir Jenner Verrall, | 
Dr. J. E. Walker, Mr. A. M. Webber, Sir William de Courcy ' 
Wheeler.' ’ . • ' 

Apologies for absence were received from Dr. D. E. Finlay, 
pr. F. J.- Gomez, Dr. R. Langdon-Down, Mr. A. W. Nullmil, 
Mr. J.' Patrick,: Group-Captain K, J. Roche, Dr. D, Walshc, and 
Dr. W. E. A. Worley: 


The Chairman referred at the outset to the death of Dr. 
J. A, Slacdonald. The Council, he said, over which Dr. 
Macdonald had presided for a longer period than any othci 
Chairman, had peculiar opportunities of appreciating hh 
qualities and the great work which lie had done for th* 
profession over many years, though it was a work which, th* 
speaker feared, had not been appreciated by the rank and fib 
of the profession as it should have been. The Council hac 
also to deplore the loss of another valued member. Dr. A. 
Manknell, and of two former members, Dr. G. E. Sliuttlewortl 
and Dr. W. Snodgrass. 

The members stood for a few moments in a silent tribute, 
f u authorized to convey to those member; 

of the Association whose names figured in the recent Honour; 
List the Council’s congratulations. 

A communication was rceoived from the Canadian Medica 
^sociation intimating that in connexion with the Annua 
ee mg to be held at Winnipeg in 1930 it desired to nominati 
President of the British Medical Associa 

tn III agreed to recommend this nominatioi 

m tUa Representative Body,, 


Certain tentative arrangements for the Annual Meeting in 
1930 were discussed. . The suggested date for the opening was 
August 26ih, and a programme ivas sketched following more 
or less closely Hint of the Annual Meeting in this country. 
It was staled" that the Representative Meeting would be hold 
that year in London. Some discussion took place on the 
probable expense of travel to Canada, and the chairman said 
that at the earliest moment — probably at the Cardiff Aleeting — 
an announcement on this subject would • be made. In the 
meantime the greater the number of members who intimated 
the probability of their attendance the more faimurable were 
the terms likely to be. 

A report was received from Sir Robert Philip on the Harvey 
Tercentenary Celebrations, ivliich he attended as President of 
the Association. He wrote that the profession owed a’ debt 
of gratitude especially to Sir John Rose Bradford for the 
reverent dignity with which, as President of the Royal College 
of Physicians of. London, lie conceived and managed the 
numerous functions. 

• The Council approved the action of its cliairman in having 
nominated Dr. J. IV. Bone as representative of the Association 
on the Departmental Committee on the Jlidwives Acts; Air. 
R. G. Hogarth and Sir -Thomas- Border as the Association’s 
delegates to the forthcoming International Congress on Cancer 
in London; and Dr. F.-G. Thomson, Dr. IV. E.’ A. IVo'rley; 
and Dr. J. D. R. Monro as practitioners who might suitably 
be co-opted on the medical committee of the proposed London 
Clinic for Rheumatic Diseases promoted 'by the British' Red- 
Cross Society, 


oir ivouert ir'uiiip,' one President, was appointed to represent 
the -Association at the annual conference of the National 
Association for the Prevention of Tuberculosis, to be held 
in London in October, and Dr. IV. Paterson at the A’ational 
Conference on Maternity and Child IV elf are ' in July. ' Sii 
Humphry Eolleston’s appointment as representative of tlit 
-Association on the advisory committee of tne Pharmaceutical 
Society concerned with the control of therapeutic substance* 
was renewed, as was that of Air. Russell Coombe on the court 
of governors of the University College of the Sonth-IVest ol 
England. 

It was reported that the Brighton Division executive com 
mittee had complained that the section dealing with . th< 
International Union of Aledical Organizations in the Annua 
Report of Council was too meagre in respect to the detai'h 
it furmsbed to permit of the committee advising the Divisior 
as to ’.vhat action it should take, if any, on the Council'; 
decision. (The Council decided, as stated in the Supplcmm 


[I248J 


266 Juke 23, 1928] 


Pt-ocecdings of Council. 


' RVP^LJ:^TT:NT to tub 
InniTisii siBoicAi. Journal 


of April 21st; p. 126, imt to join this intcrnatioiial medical 
movement.) After some discussion it was agreed to send lo 
the Brighton Division, and to any Division mahing similar 
inquiries, any information in the Council’s possession with 
regard to the subject, and to refer them to the reports of the 
discussions in the Council on this subject, as printed in the 
Sv ppliDucnt y but the Council did not see its way to publish, 
in the Supplementary Report the lengthy memorandum by the 
Medical Secretary which was before the Council. 

The Mi'dira! .SVreiee in India. 

Di . Goodbody, chairman of the Naval and Military Com* 
mill/'*, brought forward a report on the reorganization of the 
meJi’.il services in India, which liud been the subject* of a 
ctannniTiique issued l)y the India Oflice. From tliis oommunique 
it ..ppeared to be contemplated tliat the proportion of European 
to Indian officers in the Indian Medical Seivice would greatly 
dinvinish, though the committee had been assured that for the 
present at all events there woxild be a ratio of approximately 
one Indian to two Eiu*opeans iii the service taken as a whole. 
Dr. Goodbody pointed out that one of the chief inducemonls 
lo candidates entering the Indian Medical Service in the qia-st 
wa.s the prospect of civil employment. Under the iiow arrange- 
ments the prospects of such employment were materially 
diminished. An officer might enter the service hclieving that 
he would have opportiniitios for civil employment, but ye! 
bo retained during the whole of his period' of service on the 
military side. It was true that after a period of six or twelve 
yeais’ service an officer miglit retire on a gratuity of £1,000 
or £2,500 respectively, provided he gave notice of 'such inten- 
tion twelve months in advance. The committee believed that 
this safeguard would be still more valuable if the officer were 
ijiturmed at the end of liis fourth or tenth year of service 
uhat his prospects of* civil cmploynieut were; lie would then 
lie able to judge whether or not it was in his interests to 
remain in the service. The committee djd not consider that 
the new proposals would attract an adequate mmibor of 
European medical men to the service, and put forward a 
recommendation that the Socretaiy of State for India be 
informed that the new proposals did not seem likely to have 
this effect so long as tlie posts of chief administrative medical 
ufficer.s of local govcnimenls were not scheduled on the list of 
appointments reserved for I.M.S. officers, and so long n.s definite 
iiifonnation as to the prospects of civil employment as jn.st 
stated were not afforded to the officers. Dr. Goodbody added 
that some later information made him feel that had sucli 
information been before the committee at the time of its 
meeting the recommendation would have been still strongeiv 
The important fact brought out was that the heads of the 
medical services of the provincial governments need not be 
members of the Indian Medical Service at all. The largest 
hospital for Europeans in India, at Calcutta, which was solely 
concerned with Europeans, could be officered under this arrange- ; 
ment by non-European members of the I.iyi.S. 

Lieut. -Colonel O’Kincaly said that since the meeting of 
the Naval and Military Committee he had liad the opportunity 
of seeing and hearing from several brother officers of the 
service, and the general conviction was iJiat the civil side 
of the service under these new conditions was practically 
inorihund. . In- the fii-st place, it was said that on the civil 
side 178 posts would l>e provided in the provinces, and that 
112 of that number must be held by British officers. The 
ineinnranduin went on to say : “ The medical requirements of 
European members of. the Superior Civil Services are based on 
data wliicli will change from year to year as the proportion 
of European to Indian officers gradually diminishes and will 
be subject, therefore, to periodical revision ” — in other words 
the reserved appointments for European officers of the India 
Medical Service would gradually pass away. Of these appoint- 
ments reserved for officci*s of the I.^I.S. a 'number were 
definitely reserved for British officers; othei’s were open to 
Indian officers equally with British. In the Government of 
India, the headquarter's of tJie Government of (he countiy. the 
Department of Education, Health, and Lands, under which the 
medical service worked, had thirty appointments re.servod 
lo officers of the Indian Medical Service, and out of this 
iiumher twenty-five might be held by Indian officers, these 
twenty-five including the director-generalship of the Indian 
]Medical Service, the deputy director-generalship, and the 
two assistantships of the director-genei*al. In the Foreign 
wrd Political Department, A\hich looked after the interests 


of all the native States (tiiat is, the States ruled by Indian 
princes), it was somewhat significant that out of twenty-nine 
posts reserved for officers of the I.JI.S. only three were open 
to Indian officers. With regard to the local governments a vciy 
important matter had to be pointed out. At the present 
moment the presidencies of Madras, Bombay, <and Bengal each 
had a surgeon-general, and each of the provinces, such as the 
United Provinces. Punjab, Bihar and Orissa, and the Central 
Provinces, had an officer of the I.M.S. as inspector-general of 
the civil hospitals. Under this schedule not one of these 
appointments w’as even .mentioned as to be occupied by an 
officer of the I.M.S. He asked the Council to think of the 
feelings of the men in the Indian ^ledical Service at the 
prc.sent time, who went in witli the prospect of rising to 
administrative .grade. It wa.s not too mucli to say that this 
was a death-warrant to their hopes, and he trusted that the 
Council would put up a strong protest. Take Calcutta : there 
the Medical College Hospital and the Gynaecological Hospital 
each had a resident surgeon and the fonner a resident physician. 
These three appointments were all held by officers of the 
I.M.S. at the piescnt moment, but they were excluded from 
this list. In the Presidency General Hospital — the European 
general hospital at Calcutta — ^therc were two resident surgeons, 
botli of them European ofricer.s of the I.SI.S., and the,sc appoiut- 
menls again were excluded from this list. The surgeon- 
superintendent of the European general hospital in Calcutta 
might he an Indian ofTicer of the I.M.S. There were three 
professorships at the Jledical College, Calcutta, which were 
reserved for British officers of the I.JI.S. who were “ .specially 
ijimlificd ” as physician, surgeon, and gynaecologist. But when 
it came to deciding what was meant by “ specially qualified ” 
might it not be urged that men applying were not “ specially 
qualified ” because they had not been resident in these par- 
ticular' hospitals? Colonel O’Kinealy said in making these 
remarks he was not intending' to cjxst any reflection on the 
Indian members of the Seiwice, many of whom were men of 
the highest professional st.anding, but he was now dealing with 
the possibilities. of the service attracting a sufficient niunher of 
the right kind of European officer. He moved ns, an ainend- 
inent to the committee’s recommendation : 

That the Secretary of State for India bo informed (1) that 
the Association has carefully considered the new proposals for 
(he reorganization of the medical services in India and notes 
that the prime object of Ibe proposals is to maintoui a war 
, reserve of military medical ofliccrs and lo provide European 
' medical attendance for European officers of the Superior Civil 
Services and their families; (2) tiiat the Association is con- 
vinced that Iho new proposals will not attract an adequate 
■ mimbcr of European medical men to tho Indian JMical 
Service so long as (o) tho chief administrative medical officoi-s 
of local governments arc not specifically included in the list 
of oppoiiitmeiits of officere of the Indian Medical Service, and 
so long as (t) tho prospect of employment on the civil side, 
which is the chief inducement to enter the I.M.S., is as 
indcliiiitc as it is at present. 

Sir Alfred Blenkin.sop seconded the amendment, and as.so- 
ciated himself with ail that Colonel O’Kinealy had said. 

The amendment was accepted by Dr. Goodbody, and agreed 
to unanimously. 

Colonel O'Kinealy said, in reply to a question by Sir Jeniier 
Verrall, that ,at the present moment European medical officere 
were practically non-procurable from the military side for the 
civil side. The military side declared that it had not got its 
full strength, and therefore he did not think it could he blamed 
for not sparing officers, but the result was that British officers 
were not being obtained as they were required for the civil 
side. . 1 . 

Scale of Salaries for Puhlic Health Ajypoiatme.nis. 

Sir Robert Bolam, as chairman of the conference between 
representatives of the Association and of the Society of Medical 
Officers of Health, brought forward a report with recommenda- 
tions, which had been postponed from the previous meeting of 
Council in order that the public health representatives might 
he present. He said that the conference met on Jlarcli 28th, 
and considered some suggestions from the representatives of tho 
society with a view to the modification of the scale of salaries 
for whole-time public health appointments. Before dealing 
with these, however, it would be well to have regard lo the 
position in ScoGand, where tlie conference recommended that 
the working arrangement agreed to for one year as from June 
last with regard to Gie application of the scale to Scottish 
public health appointments, and approved by- the Representa- 
tive Body in 1^7, should be extended for a further;period of 


Junk 2a, 1928] 


ProccotIfnQS of Councff, 


r svrrLr.VKXT TO riir .ofZT 
Lr.niTisn Mi.TiicAt. Jocn^XL • 


one year on the nn.lor.stnncling that, it hy the eiu) of that 
,.eri 0 (l e.y|>erience .‘•hone.) tliat these ananKemonls liad not 
hioneht ahont tlial measure of success in the apiihcation of the 
scale to Seotlarn! irhich ivonh! jn.stify continuing, the arrange- 
ment. the aclvisahility of reverting to the original .scale .should 

b'.‘ coiisiclored. ^ 

Dr. G. ^V. Miller, clinirmnn of the Scottish Committee, 
movetl that instead of an extension for one year it should he 
for five years. Ho said that after the Council aulhoru.od the 
Scottish ‘Committee to negotiate with the Scottisli Board of 
Health and the local authorities the committee succeeded in 
converting the Board to acquiescence. A circular loiter \yas 
drawn up hy the Board for issue to all health and education 
authorities in Scotland, hut when the Board found that the 
modified scale was authorized for one year only it did not 
issue the letter and would not issue it. Kevertheless, the 
Bo.nrd had advised the payment of .salaries at .scale rates where 
the authorities had cousuHed it dviviiig the past year. He 
wished to impress upon the Council the importance of this 
modified scale for Scotland. The opinion both among medical 
otficers of healtli and general practitioners ^Yas unanimously 
in its favour. Only the other day the medical officer of health 
in his own town expressed to him the hope that the modified 
stale would he adopted, as otherwise all would he confusion. 
The Scottish people had a pretty good hump of common sense, 
and knew that, tlie financial conditions in Scotland hei/ig what 
they were, it was of no use asking the local aulliorilics, who 
were seeking to economize in every possible dirocttori, to give 
what they regarded ns extravagant salaries to tlieir medical 
officers. To limit the extension to one year was to send them 
into the fight with their hands tiwl. 

Dr. Douglas seconded the amendment. He asked whether it 
could he of any use to put forward a scheme for one year 
only. One yearns experience was not sufficient for any 
body of men to estimate the working of such a matter as 
this. The Board of Health was willing, if the period 
were made five years instead of one, to back fliem up. 
The Board was shortly going out of existence: it.s power in 
a year’s time would he mV, and the matter of public health 
would be dealt with by the Secretary for Scotland. Was it not 
common sense to have this matter dealt wdth hy the Board of 
Health while it still had power, and get it ostahlished for 
a term of years? In reply to Dr, Buchan, wlio liad asked 
wliether the terms of the letter of the Board of Health alluded 
to wore .satisfactory'. Dr. Douglas said that the terms were such 
as to make it clearly understood that the grant would be 
awarded in the case of any aulliority which adopted the 
.scale. Dr. Buchan still wanted to know whether the grant 
would bo withheld in the case of any authority whicli did not. 

Dr. McCutcheon said that the members and officials of the 
present Board would do their best to get the scale adopted in 
Scotland, but not if it was to be only for one year. 

The Scottish amendment extending to five veal’s the working 
arrangement agreed to was carried, and the Scottish Com- 
mittee was instructed to obtain full details of all appointments 
made under the arrangcment.s. and of all in wliich the salary 
was below that laid down in the modified scale. 

The Council then returned to the question of the proposals 
made on behalf of the Society of Medical Officers of Health 
with regard to certain points for an improvement in the scale 
uhich might he put up to local autliorities. 

Sir Robert Bolani reminded tlio Council of tlie history' of this 
snoject. He said tliat of late Years the situation in respect to 
tte existing scale in England and Wales had greatly improved, 
so lat at the present time a very large number of appoint- 
mrn s were on that scale. What was proposed in the con- 
levonce from -the side of flie representatives of the society 
uas that the xVssociation should issue a suitable letter to all 
local authorities -asking them to give favourable consideration 
.10 following points in connexion with new and cxistinir 
appointments ; . . ^ 

eigUt (25 per ceut. ou Uic minimum in 


per 


(5) SuiiaWc. grading for snnior 

1 5asc(I on population! 

f officers.’ 

I fm-lbol - 25 (after ten years’ service 

CO pci CCIU. on Uio nmiimiim in five years). 

u- HobtU Bolaiti said tliat Ihe last suggestion -n-ould mean 


llrnt if an omcer nas appointed at a basic salary of £800 tills 
tvoiild rise in rigid years to £1,000, and after itVo further teats 
(lie long service period voiiid Ite reached, and tlien iindei the 
scale proposed there noiild he further emolument, so that in 
fifteen years from the lime of appointment the iiasic salary 
woiild he raised from £800 to £1,200. At the conference in 
jpiestioii he took vltat lie thought to he tlie proper course for 
the chairman of sneli a Itody ; a conference was rather different 
from a committee, and in a conference such as this, consisting 
of representatives of two bodies, matters could not iiscftilly be 
put to the vote and decided liy a majority. He had felt, 
Ihcrcforc, tiiat the best course was to bring the proposals to 
the Council and ict it decide. He was bound to say that the 
iflinistry of Hcaltli was not favonraWe to liic proposals sng- 
go.slcd, and would consider itself compelled to make quite clear 
to the local authorities that it had no part or lot in them, 
thoiigli it could fake no objection to propaganda work on their 
behalf. Sir Robert Bolam added that he considered the matter 
was not helped hy the practice of the Society of Medical 
OfTicer.s of Health in pnWishiiig in its journal particulars of 
these matters before they had been considered by the Council 
of the British Medical Association, which in the end must take, 
or refuse to lake, action. The question for the Council was 
whether it was a politic thing at the present time to send 
this forward to tlie local authorities, not as a policy which svas 
going to the Representative Body, but as the opinion of the 
Council. If the Council set its name as the e.veeiitive of the 
Association to a letter of this kind it must be held. to approve 
the reasonableness of the proposals. 

Dr. Jobn.son pointed out that any proposals of this kind 
would cause other officials of local authorities to appeal for 
similar concessions. 

Dr. Buchan said that the Society of Medical Officers of 
Health svas not asking for any revision of the scale, except 
in two instances — namely, a suitable grading for senior medical 
officers on the range of salaries between £750 and £1,100, and 
that the deputy medical officer of bealfb should receive a salary 
equal to 60 per cent, of that of bis chief. At the present time 
■senior medical officers were all in the grade of £750 to £1,100, 
and as a result of experience it had been found tliat no matter 
liow large the area in which the senior medical officer worked 
liis salary was mticli nearer the lower end of the scale than the 
upper. It wa.s felt, therefore, that a considerable grading of 
that salar.v should be undertaken, blany local authorities 
required guidance in these matters. IVitli regard to the other 
ilcnts all that was being asked for was a rise in salary for 
certain officers in certain localities. He did not think it was 
anything very exceptional to ask for a rise of salary after a 
tiuniber of years’ service. Xow that the minimtim scale had 
in fact been decided upon it liad caused local authorities to 
say, “ Oh, the officer is getting tlie scale salary. MTiat more 
docs lie want?” The Public Health Service representatives 
Were not asking the British Medical Association to depart in 
any wjiy from the terms of agreement which had been reached 
willi the Jliiiistry of Health, nor that these suggestions should 
he made the policy of the Association, hut merely that thev 
should he indicated as a guide to the authorities. IVhat they 
were asked for was chiefly certain increases in salary, and 
it was thought better that these increases should be asked for 
collectively than individually hy members in the different areas 
No attempt was to he made to enforce the points, hut onlv 
to appeal to the sense of justice among local authorities. Save 
in Scotland, the minimum scale operated in something like 
90 per cent, of cases, so that it could not be said that there wjis 
anything ridiculous about the £600 minimum for assistant 
medical officers, 'and all that was ashed for was that steps 
should he taken to get reasonable increments in accordance 
with these various suggestions. 

The Chairman (Dr. Brackenluiry) said that the Council had 
two questions to consider : first, whether tliese propositions 
were reasonable m themselves, and secondlv. whether it was a 
wise thing at present to write round officiallv to the loco! 
authorities commending these propositions. tVith regard to this 
second question, he was hound to sav that in his ; 
it ™i. Aitiioigh 11. W 

been quite gratifying-he was speaking of England and Wales- 
yet there was, he, believed, at the present moment more irrha- 
tipii at the scale among local authorities than there had evTr 
been since it came into, existence. The officers of fh,. vr ■ , 
of Health, who were in the best position To know 'sHt rn^ 


268 June 23, 1928] 


Prooeedings of Council, 


r BXXPPLF.^TEiJT TO TOT 
ICjllTIBn MEDlClb JODBKAL 


protests from — local authorities on' all hands with regard to 
their support of the scale than they had had at any time 
during the past three years or so for which they had given 
it their official support. The Association of Municipal Cor- 
porations had indicated to a number of authorities that its 
support of the scale was not as wholehearted as it had some- 
times been represented — not by the British Medical Association 
— and that all that it had said was that it was willing as an 
Association to have it sent out to local authorities with the 
statement that it was commended to them as a guide whicli 
was not unreasonable in influencing their independent action 
when making appointments. The County Councils Association 
never had approved the scale, in spite of modifications in the 
direction which it desired, and it was being asked at the moment 
to start on a very definite parliamentary campaign against 
recognition of the scale by the Ministry of Health in any way 
whatever. During the previous week he had gone down to the 
annual meeting at Bath of the Association of Education Autho- 
rities ; he had gone, not as a representative of the British 
Medical Association, but of an education authority, and his 
reason for going was because there was on the agenda a 
resolution with regard to the salaries of medical officers, pro- 
testing against the Ministry of Health backing up the British 
Medical Association and the Society of Medical Officers of 
Health. This body was at first inclined to say that there 
should be no scale at all ; it had had to modify that position, 
but it protested against the Ministry of Health in any way 
identifying itself with a scale, and, above all, withholding 
giants — ^as it appeared the Ministry had done in at least one 
case (Lindsey, Lincolnshire) — from the local authority because 
the authority proposed to make an appointment at a figure below 
the scale. In face of this more militant attitude of the local 
authorities and of the fact that the fight for the minimum 
scale might have to he renewed, was it an appropriate moment 
at which to issue a letter which local authorities might regard, 
not as a mere pinprick, but, having great respect for the 
poivers of the British Medical Association, as another attempt 
on the part of the Association — somehow they always spoke of 
the Association and not of the Society of Medical Officers 
of Health — to impose its opinion upon them ? With regard to 
the Association of Education Authorities, whoso idea was that 
there should be no scale at all, but that each authority should 
be master in its own house, he thought he had succeeded the 
previous week in . presenting the view that better men would 
be got into the service if the service under all the various 
authorities were regarded as one whole service, not as a 
number of independent services, so that a man or woman could 
start anywhere in a junior appointment -.with the hope of rising 
to the highest administrative national posts. He had fold the 
meeting at Bath that so far as medical men were concerned 
they were satisfied with the very general application 6f the 
scale in England and Wales, but that if any reasonable modifica- 
tions of detail were proposed, the representatives of the medical 
profession would very carefully consider them, also that if 
it was desired to set up an arbitration committee, which had 
been proposed from the, medical ' side from the first, composed 
of representatives of both sides, with a. representative .of the 
Ministry of Health in the chair, this would be acceptable. He 
thought that the majority .of, representatives of education autho- 
rities were agreeable to such a proposition, but there -was a 
ppwerful section which affirmed that it had no desire to go 
into conference, and, while accepting the desirability of a 
scale, held that its character must be gone into dc novo. As 
to the reasonableness of the propositions, take the one ' which 
asked for suitable grading of senior medical officers. This was 
reasonable enough in itself, but the view of the local autho- 
rities was that the present scale had the advantage of allowing 
a considerable latitude to individual authorities; the more that 
latitude was impaired the more difficult it -u-ould be to persuade 
local authorities to accept the scale. With regard to the applica- 
tion of the scale to e-visting officers he really did not think that 
if . this were pressed it would result in any better position. 
When a request came from an area for help to rrdse the salary 
to a more suitable level, if the Division supported the request, 
the Association- was ready to exert 'whatever pressure it could, 
and, in fact, nothing more could be done in the collective way 
unless all existing medical officers felt the matter so strongly 
that they would resign their appointments and seek reappoint- 
ment under the scale. He had also grave doubts about the 
increments proposed. 


Sir Jenner Verrall considered that certain aspects of the 
proposals might bo regarded as putting a pistol at the head 
of the people concerned. 

Sir Robert Bolam thought that regard ought to be paid to the 
effect which the inevitable letter from the Ministry, of Health 
would have on the c.xisting scale. The Ministry -would send 
down a letter dissociating itself from these proposals, and he 
feared the .effect which this might have on the solid position 
already achieved. 

Dr. Buchan replied that when recently he and others from 
the conference interviewed the officials at the Ministry of 
Health it appeared that the Ministry was at first under the 
impression that these points were to be enforced on local autho, 
ritics, in which case the Ministry said that it would have to 
make it clear that it had no part in them; but it ';vas after- 
wards stated that the Ministry had no objection to pi'opaganda 
in the hope of bettering the position of officers appointed 
previous to the operation of the scale or establishing suitable 
increments. 

The recommendation that the Association ask local autho- 
rities to give favourable consideration to these various points 
in connexion -with new and e.xisting appointments was lost 
by a large majority. It appeared that only the two members 
of Council elected by the public health service members 
supported the rceoramendation. 

It was agreed to recommend to the Representative Body that 
the scale of minimum commencing salaries be made applicable 
to whole-time appointments in Northern Ireland. 

Annual Conference of Ncia Zealand Branch: Delegate’s 
Jlcfort, 

Mr. Victor Bonney, who was the official delegate to the 
annual conference of the New Zealand Branch of the Associa- 
tion in February last, was introduced to the Council at this 
point, and gave some .account of his visit. Before he addressed 
the Council a letter which had been sent to headquarters from 
Dr. Hugh Douglas, President of the New Zealand Branch, was 
read, acknowledging the very kind greetings conveyed by Mr. 
Victor Bonney, whose presence, said Dr. Douglas, had helped to 
cement the bond of affection already existing between the 
Branch and the parent body. The sacrifice which Mr. Bonney 
and others bad made in leaving their work to visit 'this distant 
p.art of the globe was fully appreciated, but the reflection that 
they had performed some very worthy service must be a com- 
pensation. Another letter expressing similar sentiments was 
received from the President of the Victorian Branch, which 
Mr. Bonney had' also visited. 

Mr. Bonney presented to the Association a gift from the New 
Zealand Branch in the - form of an inkstand made of silver, 
greenstone, and New Zealand woods. He said that the ink- 
stand was sent by the Branch as a token of its loyalty and 
affection to the parent body. He was charged to tell them 
that nowhere in the Dominions was there a body of men more 
loyal to the Association or more anxious to keep in touch with 
the old country. The inkstand was of purely New Zealand 
.material. The top of it -was made of New Zealand greenstone 
from the v/est coast of the South Island, the top of the plinth 
was of the magnificent kauri pine so characteristic of New 
Zealand, and other parts, were of the honeysuckle tree and 
other woods. .'In old Latin quotation -ivas inscribed on the 
plinth : “ Coelum non animum mutant gui trans marc curnint.” 

Continuing,' Mr. Bonney described his tour through Austral- 
asia. He started at"TIamitton in the North Island, about 
seventy miles south of Auckland, where the meeting opened ; 
then went to Rotorua, where the second half of the meeting 
was held. After visiting Lake Taupo he went on to Napier, 
where he addressed a meeting of the Association, and then 
crossed to - the South Island, and at Christclmrch, a very 
flourishing and beautiful city, again addressed the local 
members. He lectured and operated also at Dunedin, a 
university town reminiscent of Edinburgh, and Queenstown, 
saw something of the lakes and the wonderful scenery of Mount 
Cook, then returned- for three days to Wellington, on the 
North Island, visiting also Wanganui and New Plymouth, and 
finally getting to -Auckland at the end of five weeks. During 
that time he had the opportunity of meeting the greater 
number of medical men in New Zealand. He lectured or 
addressed meetings at all these places, and operated at most 
of them. In every place he found the most extraordinary 
loyalty and the desire to be one with the old country. 




f miPPI.KMJ'rST TO THE 
LnniTl^.H SIHHICAt. JOCn.VAL 


269 


June 2J, ioi's] 


Proceedings of Council. 


Leaving Js’ev,- Zealand, lie vent (o Sydney, and fiom llieie to 
CanbeiTa. tlie new federal cajiital, where, he waa iirc.sent at 
tlie iimiigura! meeting of tlio CoUegc of Surgeons of Australasia, , 
and lintf tht'- lionour of being made an bonovavy FoUow. He 
next went to Brisbane, wliere iie met tbe local members of the 
Association, meeting many more on reUnuing to Sydney, after 
n-l’icb be went to Hobart and Launceston, and then to 
jMelbourne, wbero lie spoke and op<'rated at liu; four priueipal 
liospitals. He had thus acquired, for tbe time lie was away, 
a very close insight into the conditions oldaining in Austval- 
asiu. He bad conic linck impressed with tlie need for 
maintaining closer relationships with the medical profession 
in tbe southern continent. While there was absolute loyally 
to Britain and things British— indeed, it had made him 
ashamed to sec the earnestness with which these people clung 
to the old country, even people who had never seen it, and 
who belonged to tlie third generation of Auslralnsians — American 
influence and culture were very close, and tliere was some 
tendency for Australians to look to America for their lilerattiiv 
and example. It was very important that frequent visits should 
he .paid to these Dominions, and those who went out were 
really , uiiufncial amhassadoi*s. He also urged the need for 
establishing better facilities for post-graduate study whereby 
fruitful interc*oursc • between Australasians and tlic mother 
country might be promoted, 

. The Cliairman, amid tiio applause of the Council, expressed 
the pleasure with which the inkstand liad been received, the 
latest of a number of prizwl possc-Ssions exJiibiting the loyalty 
of the Branches ovei'seas, and also thanked Mr. Bouney for the 
extraordinarily’ able and energetic manner in wliicli he had 
c.arried out tlic mission eninislrd fu him. He assured him 
that his remarks would have the earnest consideraiion of the 
Council. 

Another overseas matter mentioned was that Dr. Todd, 
honorary secretary of the New Soutli Wales Branch. Iiad 
forwarded a handsomely bound copy of the New South Wales- 
medical roll of honour, compiled by Miss Pnlcie Cohen, a 
nieiiiher of the staff of the Association in Sydney, containing 
the date of appointment to service and lionours of all members 
of the medical profession in New South Wales who had served 
overseas in the great war. The Council accepted the volume 
\yitli thanks, and directed it to be jdaced in tlu* Library of the 
Association. 


j McdicfiJ Services in the Colonics aitd Dcpcndcticics. 

Dr. M, Paterson, chairman of the Dominions Committee, 
hiought forward a report on several interesting matters. One 
n as the position of the Windward Islands Medical Service. 
In December, 1927, the committee had reported that until the 
Ass^iation’s suggestions witii regard to salary. leave, and 
study leave had been adopted,, or at any rate until some 
lyiprovcment had been made, it could not recommend the 
Ml lUi-awM of the “Important Notice” witli regard to this 
seiuce Following this a letter was received from the secre- 
arj of tlie Grenada Brandi pointing out that tlie revenue 
o Je colony showed, a substantial increase per head of a 
giOMing population, and that the annual deficit had been 
i.ined into a surplus, , A letter was thereupon sent to the 
gcio ary of . State expressing the disappointment of the Asso- 
ciation on findihg that, the estimates for 1928 showed no 
proMsion either for an improvement of the scale of salaries of 
e me ical omcers or for an increase in the medical cstablish- 
r- 1 ^^ / ^ statements which indi- 

nn hi the scale of medical salaries and 

^‘stablishment should receive attention at the 
a rim; Colonial OITicf had forwarded 

Anrifli ° * '.'1 **^**'^’' Governor of the Windward Islands. 

*°“cl>ed Upon by Di-. Paterson was the indi- 
aeo ^ mediciu.e in Ceylon, where, a year or two 

G^overmL,!!"!'”’ -i f •“ appointed by the Cej-Ioii 

tnininr f d ^“'’our of financial assistance for the 

of seeking to qualify themselves as practitioners 

the !ncdirinl^'°''^^^^^?’'^ medicine and the investigation of 

systems Th -1 

Lenishtive fo ^ Office had recently reported that the 

estTm.a'tes for l'"lr provision in Its latest 

Es 75 000 t -,1 ' Ayurvedic study to the amount of 

'1'!" State was not 

this sum. ‘ proposed to e.vpcnd 


XtiliotKi! lieuUh In.'iirimri: (A imiulmcui) Bill. 

Dr. Daiii, clniirman of the Insniaiice Actb Committee, 
brought foriyard the fiiiestion of the iSational Health Insurance 
(Ameiidineiit) Bill, now before tlie Hnu.se of Lords, wliicIi, he 
said, made several important altei'.itioiis in tbe relations of the 
niedicid profession to tbe parties concerned in tbe administra-' 
lion of national iiealth insurance, especially in regard- to 
additional treatment benefits. The hill repealed a suhscction 
in the 1SZ4 Act which had been relied upon hy the profe.ssion 
us seenriug 'that any additional medical henefits should not be 
ndniinistcred by approved societies but through Insurance 
Coininiltees. It appeared from the bill that approved societies 
would now be able to establish their own clinics for ophthalmic 
treatment .aiul for an.v other kind of specialist treatment, and 
thus they would be in a yiosition to select and control staffs 
and largely to determine the ebaracter of the treatment. It 
Was true that the societies would be goi-erned by regulations 
made by tbe Minister, which the Minister had promised should 
he .submitted to tbe Association before approvai. but tbe 
Insurance Acts Committee considered that tlie protection which 
the profession had enjoyed under the section of the old Act 
now pioposed to he rep-ealed was better than any jirotcction 
under regulations. The Minister had declined to accept certain 
amendments which, in the committee’s view, would have safe- 
guarded the position. During the Committee stage the Minister 
of Health accepted a projmsal for a further benefit — 
namely, “ The payment of whole or any part of medical or 
.surgical or specialist services.” The In.surancc Acts Committee 
pointed out to the Minister that the word “ specialist ” should 
not he used in any additional benefit clause, as this word did 
not appear to have been employed in the previous Acts, and 
was difficult of definition. The Minister agreed to a revised 
wording, and also to the inclusion of certain other words, 
which the committee had suggested should he inserted in an 
earlier clause, hut which the Minister thought more suitable to 
this, so that the clause was put to, and accepted b.v, the standing 
committee in the following form : “ The payment of the wliole 
or part of the cost of medical or surgical treatment or advice 
hy any registered medical practitioner not being treatment 
within the .scope of any other additional benefit or of medical 
benefit under a speiial .scheme approved by the Minister for 
the purpo.se.” 

Tbe Council agreed at this point to take a reference in the 
riporl of tbe Hospitals Committee to this same subject. 

Mr. McAdam Eccles. chairman of the Hospitals Committee, 
said (hat liis committee had had under review only the 
question of how tliis bill for Die increase of benefits under the 
Act concerned the staffs of hospitals. The committee was of 
opinion that tlie memheis of the staffs of volimtai-y hospitals 
.should not take part in an.v .additional treatment benefit under 
tbe Acts at a hospital or other charitable institution if its 
ndministratioii and control was to he wholly hy approveil 
societies, even though these .should hp governed hy regulations 
iii.ade h.v the Jliiiister of Health. 

Dr. Hawthorne here moved what was in some sense an 
aniendilieiit to this part of the report of the Hospitals 
Committee : 


That in the opinion of the Council it is es.sential if the 
medical profession is to take part in the provision of additional 
tre.almoiit benefits under the National Health Insurance Acts 
that tlie.se, as is the case with statutory medical benefit, sliali 
be ndminislcred in sncli a fasliion that the sen-ices of the 
medical pi-actitionei-s who elect to give advice and treatment 
111 coiinesion therewith shall not be under the direction and 
control of any approved socieiv or societies; and that this 
position shall receive statutoi-j- recognition and definition 


— .....u ..ic lu me riuspitais e-omjnjttee bad 

necessarily to be confined to the position as affecting hospital 
staffs, but it was obvious that when additional benefits became 
established they might be given by consultants who were not 
members of liospital staffs, and thus the Ho.spitats Com- 
mittee’s e.xprcssion of opinion covered only a part of the 
situation. He thought it was the general wisii of the Hospitals 
Committee to have a more inclusive i-e,solutiou. Another 
reason which led him to frame this proposal was that the 
conditions under which additional benefits were to be given 
-ivoald depemi upon regulations by the Minisfrv, and natiirallv 
might vary with tbe Minister’s political complexion aiid out- 
look., Tlie only secure position would be to liave such eon 
■ditions defined in the Act itself. He added tlmt fiist as Dm 
Association years ago fought for the protection of the pr-cti 



270 Jt:ne 23, 1928] 


J^rocecdmgs of Counc/7. 


• FVrPLr.ytF.ST TO Tira 
CnjTISll llKDiCil, JOCBMIL 


tfoner from interference by approved societies in connexion > inspecting vagrants for small-pox. Previous to the meeting 
with ordinary medical benefit, so the Association should fight • of tho Public Health Committee, the Medical Secretary had 

to-day to secure that when the consultants came under the Act advised inquirers that the Association had laid down no rate 

they also should bo protected from similar interference. -- -of remuneration for this service, Imt that if it was on a 

Dr. Goodbody seconded. Mr. Eccles said that Dr. ' sessional basis a fee of £1 11s. fid. per session of not more than 

Hawthorne’s proposal did express the feeling of the members two hours might bo found suitable, or, if on a capitation basis,- 

of the Hospitals Committee, and therefore ho supported it, , Is. per head, with a ma.ximum of one guinea 2 rer hour, and a 

though he was afraid the time was too far gone for the last minimum of 10s. 6d. per attendance. The Public Health 

clause to be effective. Committee had expressed the opinion that suitable remuneration 

Some discussion took place on the meaning of the word’ ‘ for this service would be Is. per head, with a minimum of 10s. 

“ control ” in the resolution. Dr. Wallace Henry asked for any one visit. 

whether the appointment of, say, two representatives of an' ’ Dr. Bono said that this service ■'vas now being carried out ' 
approved society on the board administering the benefit would in practically every workhouse with a casual ward in this 
constitute “control.” Dr. Hawthorne replied that "control” country.. Ho gave ono instance within his own knowledge, 

signified any arrangement which allowed representatives of Tho examinations began on January 23fd, once daily at 

approved societies to be able to overmaster and direct the ■ 7.30 p.m., until February 13th, when they were carried out 
administration of any particular benefit. He consented to the twice daily, at 7.30 p.m. and 8 a.m. The morning examinations 

omission of the last sentence in his resolution, having no wish were discontinued on April Z5th. During the whole -period 

to press anything which was doomed in advance to futilitv- 14, 439 examinations were carried out on 9,686 individuals by one 
Dr. Le Fleming and Mr. Turner were against this dropping doctor up to June 12th. Each session occupied about ono and 
of the reference to statutory recognition, the latter declaring a half hours, so that 432 hours’ service were given. At tho 

his “ profound disrespect for legislation by regulation.” He ’ rate suggested by tho committee of Is. per head the sum 

thought the Council should stick to its guns. The Chairman to bo received by tho. doctor would be £721; at the sessional 
pointed out the difficulty, if any part in the administration ' rate of £1 Hs. 6d. the 288’ sessions would mean £453. Tho 
were allowed to the approved society, of arriving at a form of ' sum which the guardians actually offered, up to June 30th, was' 
words which -would allow of so much voice as was safe without £250, which tho doctor was very pleased to accept, but the 
making its influence preponderant. • Ministry said that this must not be paid, and suggested instead 

Dr. Buchan said that the form of “ control ” to be allowed £5 5s. per week as a maximum, which meant £120. Wliat the 
to approved societies in additional medical benefits should Ministry offered was, of course, far too low, but the figures 

obviously be the same as that e.vercised by them in the case of suggested by the committee seemed to bo unduly high, and 

ordinary medical benefit. The Chairman said that tho approved he suggested that this mailer bo referred bock for further con- 

societies e.vercised no control wliatover over ordinary benefit. sidcration, and that in the meantime tho committee get in 

It was true that in practice officials of approved societies were touch with tlie Poor Law Medical Officers’ Association and 

the representatives of insured persons on Insurance Com- with the men actually carrying out this work. • 
mittees, but the approved societies as such were not repre- Dr. Buchan pointed out that this was an exceptional service; 
sented. There was more than one method whereby control it was not like a constant job for which a salary was paid; 

might be secured. The competent body administering medical it was a duty devolving suddenly upon Poor Law medical 

benefit might contain no representatives of approved societies officers, a responsible one also, for if they missed a case of 

at all, it might consist wholly of representatives of one or more ■ sm.all-pox llicvc. would be a public outcry. What the Ministry 

societies, or it might consist of a miscellaneous group of suggested in tho case "Dr. Bone had mentioned was- equal to 

persons interested, including a certain number of representa- 2d. per head for the examination, which would make medical 

tives of societies, and it would be possible to get preponderant ■ practice purely f.arcical. Anything less than 6d. per head 

control by the societies even though tlieir representaliv6s on seemed unreasonable. • , -n -a 

the administrative body were not in an actual majority. But It w.as agreed that Ibe mailer be left with Dr. Bono 

for practical purposes the rather' vague word “ control ” was {chairman of the Medico-Political Committee), Dr. "I'liman 
perhaps tho best. It was not laid down that there must (.acling-cliairman of tho Public Health Committee), and D'.. 

be no representation of approved societies on these bodies. Buchan to confer as to an appropriate scale of paj-nient, and to 

After further discussion it was agreed that the last’ clause take such steps as seemed desirable, 
of the resolution, calling for statutory recognition and defini- , -i, i 

tion, should not form part of the main resolution, but should Bxj-ehclion oj Direct Representatives to General Medtcal 
bo put subsequently, and Dr. H.awtliorn'e also’ agreed to a Conncil. 

suggestion that, instead of the words " under tho direction Dr. Bone, for the Medico-Political Committee, said t>>.at the 

and control of any approved society,” the phrase should be election of two direct representatives for England .and Males 

“under the control of any approved society.” In this form the on the General Medical Council would take place shortly .to 

resolution was adopted unanimously. The further proposition, fill vacancies arising from tlie death of Dr. J. A. Macdonald 

"-That in the opinion of the Council - this ’ position should .and the appointment of Sir Robert Bolam to represent the 

receive statutory recognition and definition,” was’ put' as’ a' 'University of Durham on the Council. He moved that the 
rider, and also agreed to. The report of the Insurance Acts usual procedure in connexion with these elections, as approved 

Committee was then approved. - by the Annual Representative Sleeting in 1915 for a !>y-elecUoa 

Sir Robert Bolam raised the question of the interpretation in 1916, be followed, 
and interrelation of certain of the clauses in the schedule of After some discussion it was agreed to alter somewhat the 
the new bill, wherein the additional benefits were set out, original procedure. The Divisions would, as usual, bo advised 

and .after some conversation on these points he moved that the by the Medico-Political Committee of tho fact of the election, 
bill should be amended in respect to the clause in the schedule but instead of merely requesting that the matter be taken into 
which -ran: “ P.aj^ents to approved charitable institutions' in consideration by tho Divisions they are to bo asked to c.all a 
respect of any treatment of members required for the prevention meeting of the whole profession in their areas, and to inform 
or cure of disease, not being treatment within the scope of any ’the' committee by a certain date of the names of any person 
other additional benefit or of medical benefit.” His motion or persons legally qu.alified for election whom ' the meeting 
was that- tins’ should not be capable of adoption by an approved might have deemed suitable to be nominated. The rest of the 
society without it being allowable at the same lime to have procedure is to follovf the usual course, including a special 
piiynicnts to private practitioners for similar advice and treat- -meeting of representatives of Divisions, . at the time of the 
ment at places other than clinics or institutions. Annual -Representative Meeting, to make the final choice. 

■ This was agreed to unanimousl}’ in the hope that it would 
still be.possible in the House' of Lords to secure ah amendment' “ Cloehing-in ” by Medical Officers. 

to tliis effect- ... The Sledico-Political Committee had considered a question 

recently raised in Belfast, where the corporation had adopted 
Fees joT Inspection af Vagrants. ^ automatic time-recording machines, whereby its staff, including 

Dr. Hillman, acting-chairm.an of the Poblic ' Health Com- medical officers, recorded their time of arrival on duty, and 

mittco, said that a' number of inquiries had Been received, as- .reported that “ The’ committee sees.no objection to medical, 
to ’ the -fees which tho Association considered 'appropriate for -officers being required to record, in' common with other 





Juke s.'i, in2s] 


AssccJation yVot/ccs. 


T srpr/^KiUK-vr TO rnn 

LUKITISII MEDICAL JOCKNAL ^ / f 


employees o£ tlio corpoi'ntion, (Iicir time of anival on duty 
on nil .lutomalic lime rocordei’, being of opinion tlial tbcrc is 
no diflVicnco in prineiple beUvoen this inetbod and that of 
signing a boob siafing file (iinc of ntfcndancc.” 

•Dr. Leslie strcngly iirotcstod against tliis verdict. Tbo 
principle c£ “ clocking-in ” had hitherto been confined to wage- 
earners. Tlic hour of arrival and departure might well be left 
to the honour of .a professional man. One medic.il officer in 
Beifasd had resigned rather (iian " cioeb-in,” An endorsement 
by the Council of this practice of " clocking-in " would have 
far-reaching consequences. He moved : 

That the Council objects to medical otiicers being reniiireil 
to record tbeir time of arrival or departure from duty on 
a recording macliino ns is cusiomnrv among wa"C-earncrs 
believing .is they do that this custom is derogatory. ’ 

Sir William Wlieclcr seconded. The medie.il officers of 
the Belfast corporation had, ho said, been put in the s.ime 
position as sc.ivcngers. Dr. Buclian spoke in support of the 
resolution, hut- not on any ground of the dignify of the 
professional man. " Clocking-in ” in the case of iho w.ige- 
carncr was for the definite purpose of recording overtime, for 
which the medical officer did not receivo p.iymcnt. As" for 
dignity, no doubt the street-sweeper had his dignity to main- 
tain just as much .is the medical m.in. Sir Robert Bolam asked 
whether this was really a matter of serious importance. What 
real difference was there between a .system of this sort, where 
a man had a key and registered the time he entered the institu- 
Uon, and writing one’s name .ind time of arrival in a book’ 
Dr. Bone s.md that if the Council felt that " clocking- in ” was 
derogatory U would be necessary to have a full discussion of the 
circumstances which }iad arisen in Belfast, where signature in 
an attendance book had proved unsatisfactorv. Dr. Dain said 
tii. 1 t ever since he was a student the honorary staffs of voluntan- 
Hospitals m Birmingham had alw.iys “ clockcd-in.” 

Appeals were m.ide to the chairman of tlio IiIcdico-PoIitic.il 
•n'lthdr.iw the p.iragraph, but ho did not sec his 
way to do so. i,vcntu,illy the motion before the Council being 
lbbn!r®, ‘ ^^'•'I'co-I’oHtical Coramitleo (including 

■r^oSf Leslie, instead of his previons 

• otutwn, moved as an amendment that the report be 

‘ pnragraph, and tWs was 

f. , , . Other Business, 

hio’l of Iho Chiropodists (Registration) Bill, whicJi 

i resoTutir^^^^^^^^ the Cmmcil passed 

Tcco^TiH that chiropodists should be 

to t^nnM- u register,, as such register would convev 

to otiff n' '^'■■repodisfs were competent to undertake-1 

* /r’?- ‘ Preamhlo of the bill_“ the dian-nosis .ind 
treatment of diseases of the feet.” m.,nosis and 

to iVt° Eccles the Council agreed 

st iff- nfTb*” distribution among hospital 

Schtes vhic^'’“’'' - Contributory 

cnemes, which appeared in the last Supplement. 

sion™S HcId^iXs!'" " •'“■'dine exten- 

Council meeting was 
ithi?L Lyndon, chairman of the Central 


Li)in concerned the question of removal 

name had Veen er ‘"'"y medical man whoso 

Colony or Den / ^1,°® ‘ho Register of a Dominion, 

couasA, was TiolZT: 

““y ho terminated in any 

fession^ mi^TOndiict frnm^nnP°ir “'e ground of pro- 
^taWislied for the Irish Fren Register for the time being 

Poffiinion, Colony or nene^rtL ^''^”’ ^Pdia or any BritisS 

mg part thereof ’resnS^i^r n^’f®'’ ^.W^fiee or State form- 

liandalcd Territory.^ "•’ ° Rritish Protectorate or 

“ “ recommendation to the Eepresenfa- 

on the tiVnAld h^ Prepared a simple qneslionan- 

of master marineS^h™^ of disease and injuries for the use 
from a sni-geon nn n^^ti ™<''‘mal advice by wireless 

were due to Mr H S Sn ®hore. Special thanks 

'» tk" P.lval. Praolic, Commilte, 


which had had the advantage of a report by the jMcdtcal 
Secretary on the result of his personal investigations into the 
health services of certain county, county borough, and other 
autlioriticse Tlie report of the cornmittee would be issued' to 
Divisions and Branches probably at the end of 1S28 or the 
beginning of 1929. 

.Dr, Walker, for the Charities Committee, moved, and- it was 
agreed, that a sum of £3S2 standing to the credit of the 
Charities Trust Fund be aflocatcd in certain proportions to the' 
Royal Jtcdical Benevolent Fund, Epsom College, and the Sir 
Charles Hastings Fund. 

The Scotti.sh Committee was authorized to call a conference 
of’ representatives of staffs of voluntary hospitals in Scotland 
to consider hospital policy, and also a conference of secretaries 
of Branches and Divisions for the more effective organization 
and stimulation of interest in the work of the Association in 
Scotland. 

Other reports, which dealt only with routine matters and 
gave rise to no discussion, were submitted by the Journal, 
Finance, Office, and Organization Committees, 

- The Council rose at 6.45 p.m. • 


Juno 30» Sat. 
July 4, T\’cd. 
July 20, Frl. 


July 21, Sat. 
July 23, Mon. 

July 24, Tucs. 

July 25, Wed. 

July 26, Thurs. 
July 27, Friv 


^ssonolion. Jloims. 

TABLE OR DATES. 

Supplementary Report of Council appears in BarriEH 
ttEDlCAL Jounx.u. SUl’PLUIENT. 

Aiijcntlmcnts and riders for inclusion in A.R.il, arcbda 
must bo received at Head OIRce by this date. 

Anuuni 7?e;)refrRfotirc Meetinp, Cardiff, 10 a,m. 
dominations lor election ot 12 members of. Council by 
;:roupt.‘d Representatives must be received (at A.R.M.. 
(’ardiil) by this dale, 2 p.m. 

Annuol Uevretentaiite Slectfnff, CardilT. 

Coi/nerV, Cardifl. . - . 

Annual Hrprcsentatfrc Mtelina, Cordifl. 

Annual Re/Wi>nfattrc 3lcctin>j, CardiiT. Annual General 
Sfccting, Carchff, President’s Address. > •• 

Council, Cardin. Conference of Honorary Secretaries, 
oarutiT. ' 

lleetingt of Sreilont, etc., CnriUg. 

Meetings of Sections, etc., Cardifl. 

Meetings of Sections, etc., Cardifl. 

Adfbed Cos, hleciiceil Sccreteir^, 


BRAKCH AXD DIVISION JiIEETINGS TO BE HELD. 

Bihmiscjmsi Biukoi: West Buoionca Division.— A quarteriv 
meeting, of (he IVest Bromwich Division will be held at the 
Smethwick Committee Booms, 1, South Road, Smethwick ou 
Tuesday, Juno 2Slh, at 3 p.m,, for the consideration of Annual 
Report ot Council and instructions to representative. • 

DottSCT AND West Hakts Bkakch; BonKNEMourn Divrsios— The 
annual social meeting of tho Bournemouth Division will ho held 
on S.itiirday, July 14 th, when a visit will be paid to the PiH 
Rivers Museum, harnliam, Blandford, to bo followed bv tea at 
Larma Tree Grounds, Tollard Royal. ^ ^ 

Edtkbvrgh Br.AKCTi. — The annual moetin? of tho EdinburCTli 
will bo held at P.ithhead Ford on Tuesdfy, Jifno 26t)n heon 
will bo provided in tho Hall, Pathhead, at 1215 for 12 3n „ ™ 
(charge •ts.). Dr. Craig (Pathhead) has obtained tlmcourtesv'^f 
tho green of the Ford V.illey • Gbit ' Club for tho ' 

petition (stroke). Ho has also obtained tbo courtesy of tlie' PathI 
head bowling green. Visits have been arranged for PresfnnheTI 
Gardens. Crichton Castle, and Church, and fhc Vo>»rie ^ 

Home, the latter by invilalion of Professor G M Robertson if 
4.30 p.m. Dr. Craig will entertain the partv to tei Th^ 1 ? j- 
meeting will take place at 5 o'clock. Igeuda : L'p'or^ of BrancT 
treasurers business, and annual report- election of ’ 

presentation of golt competition prizes; report of election of^po?' 
sentativc to the Central Council; filling if vacanct 'orthp “h 
of the Queen Mary Nursing Hoio; proceedings o? Scotch Com 
raittee; Annua! Report of Council and Anifu.il Repre’ent?/^^ 
Meeting: Power of Branch to .appoint additional memW * a 
B ranch Council under Rule 4 (2) (g). members to 

Lakcashire asd Cheshike Brasoi: MiD-CnEsmor riT-n,. ■ 
meeting of the Mid-Cheshire Division w-ill ^ held ih 4 

room of the Altrincham General Hospital on Tuesda-J Tim 
at 8.30 p.m. Agenda: To instruct ieprUeOtativc Ih’ the Ben?* 
scntative Bodj-. .\ddress by Dr, T W IT Repre- 

“ Persona! reminiscences of the profession in entitled 

British Medical Association in iL tet twen^e^Si.’ " ■ 

■ Lascashiee Aim Ciieshiee Beancti : RoainALE DrvrsVov j 
mg of the Rochdale Division will be held in the T '72^ meet- 
Educatioa Committee Offices), Baillie Street (Rochdalo 

day, June 27th, at 8.50 p.m. B^iness Snuai Bpi“’ “^^Vednos- 
and instructions to representatives. * Report of Council 

Meteofoeitas Coukties Branch: Hendov Dtv,c,„, m, 
meeting of tho Hendon Division' will be hplil 
Hospital on Friday, June 23th, at 8 30 n m * Cottago . 

meeting, cases and specimens will be shoiriibT-' Ti Clinical 

■J.'.W.- Easor, E.. Hunt Cooke, and M^ I^ 
members^are , mated to show cases and spec^ew atihfs’mdAi^ ■ 



272 June 23, 1928] 


Meetings of Branches and Divisions, 


r nvvrLEy.rifT io tit * 
LBiirnsii Mkdical JooKMAt 


and to notify Uioir intention io the honorary secretary by June 
27th.- 'Consideration of Supplementary Report. Dr. and Mrs. 
H. R. S. Walford have extended an invitation to members of the 
Division and their friends to view, from Uicir grounds at Hendon 
Grove, the Air Pageant on Saturday, June 30th, at 2.30 p.m. 
Members Y.'i5hing to attend are requested to iiotifj; the honorary 
secretary as early as is convenient, when pei-sonal invitations will 
be issued. 

Metropolitan Counties Branch : Marylebone Division. — A ineol- 
iug of the Marylebone Division will be held at 11, Chandos Street, 
Cavendish Square, "W.!, on Thu^day,^ June 28th, at 8.15 p.m. 
Agenda; Annual Report of Council — -admurned discussion; amend- 
ments will be proposed • by (1) Dr. David Roxburgh, (2) Dr. 
Graham Little, M.P. Discussion on Lunacy Law Rctorm, to be 
opened by. Dr. Hawthorne. Instructions to representatives in 
Representative Body. 

Metropolitan Counties Branch : North Middlesex Division.- — 
A meeting of the North Middlesex Division will be held on 
Thursday, June 28th. This will be a visit to the London factory 
of Messrs. Oxo, Ltd. Members are asked to meet at 16, Soulbwark 
Bridge Road, S.E. (near Southwark Bridge, south side), at 

2.30 p.m. The visit will occupy two hours, and afternoon tea will 
be provided. Arrangements will be made for parking cai*s. The 
nearest stations are Mansion House or Cannon Street (5 minutes), 
Bank or London Bridge. (10 minutes). 

Metropolitan Counties Branch : St. Pancras Division. — A meet- 
ing of the St. Pancras Division will be held at the British 
Medical Association House, Ta\’islock Square, AV.C.l, on Tuesdaj', 
July 10th, at 9 p.m. Dr. W. Camac Wilkinson will read a paper 
on the home treatment of tuberculosis by the general practitioner. 

Metropolitan Counties Branct : Wandsworth Division. — Two 
meetings of the Wandsworth Division will be held in the Town Hall, 
Wandsworth, to consider tbo Koch diagnosis and treatment of 
tubciculosis by means of tuberculin, together with a proposal for 
a collective investigation into the subject. The first niccting will 
be held to- day (Friday, June 22nd)^ at 9 p.m., when Dr. Robert 
Camvell will I'cad a paper on “ History and diagnosis.’* At the 
second meeting, on Friday, June 29th, at 9 p.m., Dr. Carswell will 
read another paper entitled Treatment, and a proposal for a 
collective investigation.” The meetings will be open to all members 
of Uio medical profession. 

Norfolk Branch. — The annual meeting of the Norfolk Branch 
will be held at the Town Hall, Aylsham, on Thursday, July 5th, 
at 3 p.m. Agenda : Report of the Branch Council and aiimml 
financial statement: induction, of the new president, Dr. B. B, 
Sapwcll, by the ictiring president, Sir Hamilton Ballanco, 

C.B.; election of officers; an address by Mr. Vivian Carter, 
British secretary of Rotary International, on’ the diagnosis of 
personality. Tea (to whicli lndie.s arc invited) at 4.39 p.m. at 
the Grange, Aylsham, by invitation of Dr. SapweU and Miss 
Sapwell, 

Northern Counties of Scotland Branch. — The annual meeting of 
the Northern Counties of Scotland Branch will be held at (be 
Station Hotel, Kyle of Lochalsh, on Saturday, Juno 30Ui, at 
2.5 p.m. Business : Report of election of officers of Branch ; report 
of Branch Council and annual financial statement. Before the 
meeting members and their guests will lunch together at the 
hotel at 12.30 p.m. .After the meeting there will be an- opportunity 
for those who wish to play golf, and motor boat cruises arc also 
being arranged. For members coming by road v/ho do not wish 
to take their cai-s across Doimie Ferry, motor transport will be 
arranged from there to Kyleakin, leaving the west side of the 
fen-y at 11.45 a.m. 

Northern Counties or Scotland Branch : Islands Division.— 
The general meeting of the Islands Division will be held on 
Saturday, June 30th, in the Station Hotel, Kyle of Lochalsh, at 

10.30 a.m., to elect officers and Executive Committee. 

.North Lancashire and South Westmorland Branch. — The 
annual meeting of the North Lancashire and South Westmorland 
Branch will bo held on Tuesday, July 3rd, at 5.15 p.m., in the 
Ethel Hedley Hospital, Calgarth (by kind permission of Dr. 
Hough and the Governors of the Hospital). Dr, J. Lang Cochrane 
will deliver his presidential address. Ladies ' are invited, and a 
boat on Lake Windermere will . be placed at their disposal. 

•North Wales Branch. — The annual meeting of the North Wales 
Branch will bo held’ at the North Wales Sanatorium, Llangwyfan, 
Denbigh, on Friday, July 6th. The council of the Welsh 
National Mcmcudal Association and the house committee of tlie 
sanatorium will entertain 'the niembei*s to lunch, and a tour of 
tho institution •'\^^ll be made. Agenda and further particulars 
will be announced later, but members arc requested to make a 
note .of the date as a largo attendance is hoped for. 

Oxford and Reading Branch. — The annual rnceting of the Oxford 
and Reading- Branch will be held, by kind invitation of the 
Governors and Medical Superintendent, at Hollowaj’ Sanatorium, 
.Virginia Water, on Wednesday, June 27tii, at 4.30 p.m. Agenda; 
Election • of officers. A cricket match (St. Thomas’s Hospital r. 
The Sanatorium) will be in progress from 2.30 p.m., and the* 
members mav like to have the opportunity of seeing the hospital 
during the aUenioon. Tea 4.45 p.m. In the forenoon the Collier 
golf cup will be played for at Wentworth. Competitors must play 
from the competition tees at three-quartei*s of their lowcrt 
handicap. Flayers are asked to make their own arrangements for 
partners. 

Oxford and Re.^ding Branch : Oxford Division. — The next mect- 
int' of the Oxford Division will be held at the Radclifie Infirmary, 
Oxford, on Wednesday, June 27tli, at 2.30 p.m. Agenda : Corre- 
spondence, instructions, clinical cases. Mr. Rose-Innes : Surgery, 
and other pursuits in the islands of Scotland. ' 


South Wales and Monmouthshire.Brancti : South-West Wales 
Div'ision. — ^Thc annual meeting of the South-West Wales Division 
will he held at the lyj' Bush Hotel, Carmarthen, on Thursday, Juno 
28tli, at 3 p.tn. Business : Election of officci*s for the coming year. 
Agenda for the Annual Representative Meeting and instructions to 
representative. Nomination from Division of president-elect for 
South Wales Branch. 

South-Western Branch. — TJio eighty-ninth annual meeting of the 
South-Western Branch will bo held on Wedn^^Fday, June 27lh, at 
3.15 p.m., in Bromley’s Caf6, Barnstaple, when Mr.' Pickard will 
resign the chair to Dr. Harper, who will deliver his inaugural address 
eiiiitlcd ” The, influence of William Smcllie and William Hunter 
on obstetric incdicine in the ciglitccnth century.” The report of 
tho Branch Council for tho year 1927-28, and the financial r.tatc- 
mtnl for the year 1927, will \)c presented to the meeting, and Ilia 
officei-s of the Branch for the year 1928-29 will be elected. 
Luncheon, bv invitalion of tho President-Elect, will bo. taken at 
1 o’clock at 'Bromley’s Cafe, and after the mceiing has concluded 
tea will be provideef. The annual dinner of the. Branch, to which 
nicdicui anti iion-incdical guesLs and ladies are invited, will be 
licld at 7 o’clock at tho cafe. Tickets, 8s. each (exclusive of wines), 
may bo obtained from Dr. H. C. .Jonas, Boutport Street. Barn- 
staple. Accommodation for the night could bo arranged if notice 
is given to Dr. H. C. Jonas, Boutport Street, or Dr. Killard- 
Leavey, Litchdon House, Barnstaple, 

Surrey Branch. — The annual meeting of the Surrey Branch will 
1)0 Iicld in tho Town Hall, Kingston-on-Thames, on Wednesday, 
June 27tb, at 2.15 p.m. Tlic Kingston-on-Thames Division invites 
members to Jiinch at Niitball’s Restaurant at 1 p.m. Colonel 
G. W. Profeil will address tlie meeting on the British Empire 
Cancer Campaign in Surrey, and the president (Dr. H. R. Cran) 
will deliver liis presidential address. After the meeting members 
will motor to Epsom to visit Epsom' College; toa will be taken in 
Big School, The annual dinner will bo held at Reid’s Restaurant, 
Ashley Road, Epsom, at 6.30 for 6.45 p.m. (tickets 7s. 6d., exclusive 
of wines). 

Sussex Branch: Brighton Division. — The next clinical meeting 
of the Brighton Division will be hold at the Royal Sussex County 
Hospital, Brighton, on Thursday, June 28fh, at 3.45 p.m. 

Wiltshire Branch.— TIjo annual meeting of tbo Wiltshire Branch' 
will bo held on Wednesday, June 27th, at 3 p.m., at the' County 
Mental Hospital, Devizes, when a British Medical Association 
Lecture will be given by Mr» W. McAdam Eccles on the treatment 
of hernia by trusses, illustrated by their actual application. 

West Somerset Branch.— Tho annual meeting of tho West 
Somerset Branch will be held at Dcllcr’s Cafe, Taunton, on 
Saturday, June 23rd, at 12.15 noon, .^enda : Induchon of 
president-elect; annual report; election of ‘officers, Branch Council,' 
and Ethical Committee. 


^t£tin05 of IJrandjis anb JliinsjoitH. 

Metkopolitak Counties 'BRANai. 

The nresident of tlio Metropolitan Counties Braneh and Mis. E. B. 
Cnci nS “at home at El, Westbonrne Terrace M .. on. 
June 7lli Tiie guests numbered over MO, and includod man} 
mcmbeil of file i!a neb, accompanied tl^^ir w.v^, toge be,' with 
Ladv Bowlbv arid members of , committee of the Eojal Mrdical 
Bcncvcrienl Fund Guild. As Mr. E.'B. Turners term of oflicc as 
president has now drawn to a close it tvas pleasant to see so many 
of bis old friends .and colleagues, and to observe the esteem .ind 
aLc .ion in wlricb be is held. Tlie deliglitful classical smg^ and . 
planofoflf rcciliils of Miss Norab Scott Punier and. Mr. 
were miicli appreciated, and a most enjoyable evening was spent. 


McraorouTAN Counties BaANcn': Cambekwell Division. 

’ ■■ "i’.irtnTbiil— 

afie abfenra ^ the , . ■ ‘he chair was ■taken by 

^*Th?a^nual*report was read and approved. Tlie following officers 
were elected for the ensuing year ^ P 

Proiilenl. Mr. E. tV. G. Jlasterman ■ 

Darkness. Uonorartj Semlari/, ur. J. ... ^ 

Deputjf Representative »» Representative 

^■A'aMi^Wturaddress was then ^iven by Mr. ^AJiK K. Ogden on 
the treasures of Tut-ankh-Amen’s tomb.. Several interesting .ana 
beLJt™des,were shown, i.nelnding many original 
taken by the lecturer during bis recent 1° f 
proposing the vole of thanks, congiatulatcd Mi. pivil ma1 

the most enjoyable address be bad over beard at a Diiisional 

meeting. 

Metropolitan Counties Branch : City Division. ■ 

The annual general meeting of the City Dmsiem was ^ 
Metropolitan Hospital on June 5th, when Dr. Phil After tha 
ill the chair. Thirty-seven members were very 

Secretary had delivered his report for the Kodak 

excellent cincmalograph entertainment was given t 

Ltd., including (1) excision of rib for '=“Py®5;=' per- 
the different parts of the intestinal canal ; (3) ti cphiiiin„ ^ pr 
formed bv Mr. Soiittar; (4) a film demonstrating KoH stroke . 

A lieartv vote of thanks was passed to Jlessrs. Kodak Ltd. and 
their representatives for the exceedingly interesting show. 






274 JUNE 23, 19281 


Correspondence, ' 


r f:vrpiJ:in:sT to nti 
LnniTlRH MKillClL JOV^VIL 


(Knmspon&fita. 

Astiociiition Professionellc hticrnationalc dcs Mcdccins. 

(A.r.I.M.) 

Slit, — An appeal lias been made to tlie British Bledicnl 
Association by tliis young, but active, association, which, 
if we rcineinbcr the early struggles of our own body, might 
bare fallen upon more sympathetic oars. The Association 
Professionelle Internationale des Medecins (A.P.I.M. for 
short) is a societj- which aims at being in medical politics 
for Knvope what we are for the Empire — the body which 
can speak for the united profession. It is a great idea, 
and we may be proud of the fact that its inception was 
the thought of an ordinary country doctor outside Paris. 
That it is meeting a demand seems clear from the fact 
that, though it has only existed for eighteen months, 
tnenty-fonr countries have joined it, while other nine 
are in correspondence with it. Finland and Russia alone 
have definitely icfnsed, the former through liaving no 
official body through which to deal; so if we stay out 
we shall be in good company. Eot only does the majority 
of the profession in Europe see the possibilities; these are 
recognized by others as well. The League of Nations is 
accepting it; its International Labour Office, through 
M. Maurette, the director, has said that the formation 
of a body like the A.P.I.M. was desirable in order timt it 
might be consulted on “ fundamental medical questions.” 
The International Association of Benefit Societies is also 
watching it, and our “ opposite number ” in Britain, the 
Association of Benefit Societies, is represented by Messrs. 
Canter and Rockliff, names not unfamiliar to us. With 
these facts before us it is quite clear that the A.P.I.M. 
may prove to be a necessity for the welfare of the pro- 
fession; it will certainly fulfil a useful function in con- 
nexion with the League, and incidentally will have u)) 
against it the fidl power of the Association of Benefit 
Societies. 

Now such an organization deserves all the help that it 
(an get, and no one is more able to help it than we of 
the British Medical Association. Our Association is in 
a very splendid position. Recognized within the Empire 
as the mouthpiece of the profession, regarded with respect 
not unmixed with envy by the gi-eat trade unions, it is 
the ideal society to which the A.P.I.M. looks, whose 
experience and prestige it invokes, and n'liose comradeship 
it would wish to have. 

How has the Council met its overtures? With the 
caution proper to any breaking of now ground the Council 
was a little timid ' as to having any dealings with the 
infant body; but a more courageous instinct nioved it 
to send over Dr. Cox as an observer to the general meeting 
la.st September. He went quite prepared to be critical. 
He returned with the definite opinion that this is a .sound 
proposition, and said so in the excellent report with which 
he furnished the Council, a report which, in my opinion, 
should have been sent down to Divisions before aiiy decision 
was come to. He, at any rate, has no doubts. 

“I am of, opinion tliat our Association ought to holong to the 
A.P.I.M. ... I felt that Uiere was a good (leal to be said for 
the view (whicli I put forward as plainly as I could at the 
Congress) that it was doubtful whether the hew body could really 
do anytliing which .could uot be done by the usual collaboralioii 
between friendlv bodies and officials. . . . But having been at the 
Congress, and liaving heard what the other represeiitalives had 
to say, and ‘particularly having in view tlie rocoguition which 
is going to be given to the body by tlie International Labour 
Office, and the necessity of having something to act as ‘ opposite 
number ’ to the new international ‘ .approved society ’ organiza- 
tion, I hardly see bow we can afford to remain outside.” 

Such wns the considered opinion of our -Medical Secre- 
t.-iiy: but tlie Council put it aside. The new body was 
too young. Foreigners had a different standpoint' from 
ours. And it was to cost £125 per annum more. For 
those reasons, following an advcr.se opinion of the Finance 
Committee, tliey turned it down. -Tliat is their definite 
opinion, and I think they arc v.-rong. 

For one thing. I do not think tliat so important a 
departure should be settled in rdiiierii. so to speak, by the 
Council. Clearly, in mv .submission, the sanction of the 
Representative Body siionld have been sought. But ajiart 
from that, on the’ merits of the case, , my contention is j 


that this is not a financial matter. It is a matter of tlia 
honour and ])rcstigo of the Association, and, tlirongh it, of 
the nation. Tliorc .stands an ajipcal to ns to hcl]) onr loss 
fortunate hrethren with onr gre.ator experience and skill 
in the management of medical affairs. It i.s an oppor- 
tunity’ we linve never had before, and may never Jiave 
again. Last Septemlior Dr. Cox was ajipealed to by the 
entire Congre.ss, especially by Germany, whose rcprc.senta- 
tivo, if we do not go in, will he tlio dominant power; 
it was a fine gesture on his jiart. Tlie Americans, true 
to their policy of isolation, are not in yet, but arc to he 
guided by Britain. At that moment, in' my view, the 
British IMedical Association stood at a higlier point than 
it lias ever readied in its liistory, with the entire ))rofes.sion 
of Europe turning to it for help and for guidance. Dr. 
Cox came home convinced. He drew up tlie re|)ort, wliich 
left no doubt .as to his views. 

The Council quite properly considered_ ' tlie financi.al 
aspect, and — unfortunately, as I think— gave too ninch 
credence to tlio talo of expense. IVimt, to ns, is £125 
per annum? Lc.ss tlian Id. a head; possibly it might run 
to lid. if the thing cxiiands. But this i.s not a question 
we should decide on the money aspect. We exist for tlio 
welfare of the ))rofession, not in the narrow, but in the 
broado.st, scn.so. But even from the money point of view 
it might not be all loss. • Tliere arc in Europe about ,250 
men on' the British Medical llcghtcr. Practically none of 
these arc our members. If wo take a Jiand in the A.P.I.M. 
wo might pick iqi many of these, and get some to act for 
ns. -Tliat might he considered. 

But history will have to repeat itself one way or the 
other. There are two trends. The one is that of Bright 
and Cobden, the strictly insular position that avoids 
“ entangling nllinncc.s,” the one that has already brought 
on us the scorn of Napoleon ns “ a nation of .shopkeepers ” 
and the cpitlict of ‘‘ perfidious Albion,” a .school of Ihonglit 
that one had hoped wns dead. There is the other wliicii, 
looking beyond these shores and above material interests, 
whicli helped everywhere tlie fight for freedom, destroyed 
the .slave trade, took its part in the liberation of Greece 
and of Itnlv. AVliieh of these lines slmll wo follow, for 
follow one wo must? I appeal oiioe again to the .Conncil 
and to the Association to adopt a policy which shall bo in 
accord with the great traditions of British statosmansliip— 
the succour of the weak wherever they may ho. And 
anyone wlio reads the report will agree that, in comparison 
n-itli oiir.selvos, the medical men abroad are woefully hound 
down, and that onr he!)) would be of gi'eat advantage to 
them. The Brighton Division asked for and received a 
copy of the rcimrt, and I believe that any otlier Division 
may have one on -application. I hope that in some way 
wo mav be able to ventilate this most important subject 
at the *AnnnaI Representative Meeting. I am, etc., 

..... T i7n, - - - G. -E. Doucl.^s. 


.lnfertiou!< Disensca and State /iisiiinnre. • 

Sin— It may be of interest to membors of our profession 
o know that Slate-insured persons are not secured against 
nfcclious diseases. By this I mean that local author! le.s 
Iirougliout the country have the ngljt to determine y hat 
ihould, or should not be, notifiable. An example of this is 

^A few days ago two sisters contracted measles. On the fourth 
laV one developed complications of such a mitme that inime- 
liile removal to a fever hospital was absolutely necessary 
,s well as imperative. On telephoning the autho,'-‘‘y’ / 
nformed that measles was not on tlm notifiable list, hut tliat 
he patient could ' be admitted at a charge, of £3 3,s. a week, 
riiis the p.atieat could not afford to pay, and as a trained nurse 
ras also out of the question the sequel was obvious. One couid 
lot see a patient die without a struggk, so it ended in the 
ees being guaranteed for' a fortnight. On the strength -ot jk 
he patient was admitted. Dnfortmiately the time ex))nes on 
tune 22nd. and, although at the hour of writing, the ease iias 
aken a f.avourable turn, J -cannot imagine the Jiaticiit homg 
Lischarged on that date as convalescent. \\Iio, then, is to Do 
seponsiblc for future cliarges? . , , . , , 

"It is nothing less than a grave scandal that such a state 
if things shhuld exist. When we consider, .too, the tact that 
ie.asles has become a -serious complaint, affecting adults as well 
s children, and .when we consider the various complic.Mmns 
hat mav arise, it is obvious that it should be nouliable 


June !23, 1928l 


Naval and Military Appointments. 


r BorvLEiTEyr to the 

LBRlTlsn JiUDlCJLL JouaHXb 


275 


throughout tlia country. We know that the finances of hos- 
pitals have suffered grievously thi-ougli the Tnsurnneo Act, 
and that contrihiUions from insnred patients arc necessarily 
imperative, hut tiiat this sliould liappen is beyond both reason 
and logic. — I am, etc., 

Cantord Cligs, June 12lli. Fuanos 6. BE-VNETT. 


Exnmimtion of Vngrants for Sntnil-pox. 

Sin, — Br. .T. S. Clarke’s letter in the .^ujiiitcmcn/ of June 9th 
(p. 247) is very muoh to the ])oiiit. Hero, too, one quarter 
was paid for in -Aprii. I arranged with the hoard of giiardians 
in Fohruary to do the inspections for 7s. 6d. per dov. This 
was sanctioned by the Ministry of Health. 

. The daily mun\)or of vagrants hero is anything from 6 30, 

^‘'y? 20. The men arc stripped and lined up in 
lo.yiiness, ^and (lie inspection seldom takes as much as five 
nmmtc.s, 'riic casual waivl is just under half a mile from my 
On font I t.aiic twenty mimites to got there and hack 
and do the inspection, fifteen minutes on .a bicycle, or ten 
minutes hy car. I do the inspection at 7.45 a'.m. In the 
jvinter it makes a welcome oiiject for a sliort walk before 
lircakfast. At tliis time of tlie J'car 1 do it on mv wav hack 
Irom my morning swim, and get up perhap.s* a quarter 
of an hour earlier in order to fit it in. 

I consider 7s. 6d. a sufiicient fee. The remniicratioii sug- 
. on' * *^^nhlic Health Committee would work out at 

.ahout 20s a day here. Anxious though I am to .support the 

II IS 1 aledie.al Association, I liavc not llie courage to appiv 

for tliKs.— I am, etc., “ ' 

Blondford, Dorset, June 12lh. L. BoDLEl' ScOTT. 


Ilniionnl Slftisirrfnicf. 

LOCAL :}JEDICAL AfiD PANEL COMMITTEES. 

. , *. CoUJiTY* or SURHEV. 

March I6th'''‘undef Il.o'" Coiiimiticc on 

iiilci^tiim komt n •'"=>"■‘‘>"1' of lir. Aicvolu Lv.vdo.v, an 

tioncr who Ld ‘ « Suiroy iii,«iiiaiicc pracli- 

that ho should* “ request trom the Insurance Committee 

to n clerical irror in h°e"ornI!o"'r i'*'’ 9'«‘Ti>'d him, owing 

of 3921. Tlic niartiiionor I ^ the committee, since (he cud 

were on li ^ list If snUi "* i^n " ^ '"'"‘os than 

had been made ^iime i ‘ V.° ''7'"'-': 

fliat five other nraciitinniri' ! i '?oeiilly, when it was di.scovcrcd 
of whom hnr? hnnf, n 1“"'* ’“■'■oug data, three 

the Seta?v of i <'>'■<1 /''o underpaid, ifr. Audebsos: 

Medical UMci°tion w^'<.'™r“'‘“ ;''o‘s Committee of the British 
scheme, wliich fo^ed diMributioii 

Insurance Coniiiimco ^he “Srecmetit with the 

coiisideied that the ihJ.M., was clear, but lie 
in not bavin. 1 Imd been verj- negligent 

advised that '’ihe'^enrascntTfit^ examined more frequeiitl.v, and 
raise the matter it ?• * Committee sliould 

been oveiqiaid expHined ^ practitioner who had 

Coinmittei's fimiras accepted the J.isuranee 

end of 1921 wheu^tP^ coricct. Die error occurred at tlic verv 
quarter the 'increase *recp^v?l*“*’°" fi''.-"! 

rcMiviiig previously S ho I'nl ^^..nbove what he had been 
Subsequ.-nt pavmcji’ts worn not uo.iccd that it was higher, 
ot 93. 6d., so that the eh.^ ““r“j oapiution fee 

The Panel Commit tee delecting the error diminished, 

seconded bv Dr. 1’’° footion of Dr. Djtsnx, 

a inotest to be sent to fl* oxecutivc to frame 

neglect to make an carhor Committee at its 

Die Ministry of Health 'OSn-ter, and to request 

Committee for the purnoso of “• ‘’oputatioii from the Panel 
Pnrpose of discussing- tlio question. 

At a recent t* Couijty of Norfolk. 

Committees, u!!dcr Dm °/hsb'.l ^fodical and Panel 

iA;as reported that m dor Iho^n® '‘P Wrigiit, it 

allocated w.rs, for gcneSl fho amonnt 

-3o3 The 'cheme was annmfoa ^1^^’ ®Pooial mileage, 

to the scaling down of ^ question was lai'ed as 

instructed to a.sfc the clerk* of J?' .secretary was 

ou what priuriple the milea.e Ji''' ^orfolk Insurance Committee 
was estimated. 

At 11= -r CoVEXTEY. 

the Coventry” Panel’clmmiUc**' *i''‘ Ay""® Hawley in the chair, 
randnlence with the relatWra'of and 

died recently after a shoH ni? AHhur P.cginald Pittard, who 
nisurance practitioner in the ® leading 

Tanol Committee for o-’or oi.l,t ^;.y'’ t?'* ® member of the 

quent upon the extension of "“‘3 '^Pnrtcd that conse- 

of a scheme for paving mne^le l. ,?*^ boundary the preparation 
area of the countv'borough of CoJen^fT ® “le enlarged 

s-.ic of the old citv and O s-be^, * Hiree lime-s the 

approved. ■ Claims' for special em™?® *“'>>'d!ng'y considered and 
eluded the service of eSration of 

s-ancose veins for variewe «aema " ® “ «^‘'on of 


^abal anlJ iEtlitar^ ^ppoiniiiwnis. 

ROYAL NAVAL MEDICAL SERVICE. 

Surpoon Commanders G. D. ^Val^h to the President for 5fe»IjcaI 
Department, temporary; G. IT. Hayes to the liarhatii on recommirsionjnp ; 
(*. CarliMlc to the r/c/ori/ for R.N. Hospital, Haslar; H. P. Briepa to ilic 
Kent im commissioning: D. H. C. Given to the Tamar for Einpapore 
Naval Base, as Sle/lical Officer in CHiarge of SIcdical Orraniration and as 
Naval Health Officer. 

SiirpHjn Lieutenant Commanders .T. W. Tiffhc to the Fiffjard, trin*' 
porary; W. E. Heath to the Colombo \ A. E. I’hillips to the ritonm on 
relief. 

Surgeon Lietdenants C. H. Eiran to the Barham \ J. Hamilton to the 
r-.. .# - f_. . Fj, lUidd to the Victorij fop R.N. BarracLs, 

\S\ P. E, McIntyre to the Vivid for Plymouth 
» . ■ 'itrpatrick to the Jirr ; “W. W. Darlev "to the 

F.tnperor of India \ T. L. J. Bairy to the Mafiiifilia. 

Surj;e4m Lieutenant (nhort. ser\ice) R. C. May, .V.C., has transferred 
to the permanent list. 

_J. T. Rees and JL J. ifeCann have entered the scr^'ice as Surfreon 
Lieulonanta (short service) ond appointctl to the Vieiory for R.N. 
Hospital, Haslar, for course of instruction. 

RoviL Nivil Voi.u.vteep. ResTRYT. 

Surpeon Lieutenant W. Caithness to be Surgeon Lieutenant Commantler. 

Surgeon Lieutenant W. F, Loscclles to the Viciory for R.N. Hospitoi, 
Haslar, additional, for training. 

Probationary Surgeon Sub-Lieufenant A. Elliott to the Champion for 
(rainini^. 

ROYAL ARMY ilEDICAL CORPS. 

Lieiit.*Colonol R. V. Cowry, D.S.O., having attained the age lifnit for 
compulsory retirement, retires on retiml pay. 

Major L. V. Thurston, D.S.O., to be Lieut. -Colonel vice Lieut.-Colonel 
R. V. Cowey, D.S.O., to j‘etired pay. 


SUPPLEMENTARY RESERVE OF OFFICERS. 
Roval Army JltinciL Corps. 
Lieutenant F. W. Oldcr^haw to be Captain. 


ROYAL AIR FORCE MEDICAL SERVICE. 

Fliglit Lieutenant J. Perdau lYlinquishes his temporary commission 
on cMimplellon of seniee and is permitterl to retain hi» rank. • 

Flying Olficers J. H. Cullman to the Aeroplane and Armament E-vneri- 
mrntal EstablMhmcnt, Martlesham Heath; T. A. Edwards to No 3 
Flying Training School, Grantham: A. R; French to RAF *B 3 '--e 
Gosport; P. J. N\han to No. 2 Flying Training School, Digliv: B 
Porritt to No. 5 Filing Training School, Sealand 


INDIAN MEDICAL SERVICE. 

Major R. L. Vance is appointed to officiate os an .\gencv Surgeon and 
is postefl os Clucf 3Ic<lical Oflicer, M'eslem India State's Agency and 
Residency Surgeon, Rajkot. ^ 

TF.RRITORIAL ARMY. 

Royil Army Mcdic^l Corps. 

Captain .1. D. M Carflell resigns Iiis commission. 

Lieutenant D. T. McDonald (late Northumberland Fusiliers) to lw» 
Lieutenant, / %» 

bViirrot Lientcminl H. Miller to be Captain, «ith prece- 

dence as from June 15th, IS*?. ^ ^ 


TERRITORIAL ARMY RESERVE OF OFFICERS. 

Rovil Arity Medicil Corps. 

Captain F. G, Guinness from Active Lht to be Captain 
Lieutenant J. U*. Munlocli from Active List to be Lieutenant 
f,v..rTO( i/»«t..tat».--Major T, IL W. Alexander, liaving attained the ace 
limit, relinquish 's> his commission and retains his rank. 


TACAJfCIES. 

.\I 1 EF.DCT.>? ROY^L INTIRMAP.Y. — Junior Assistant Ophthalmic Surgeon 
BHIMINGHIM University.— a) Assistant Lecturer in Phvsiolof-v f2) 

SSo annum ?act’ ■" Dopartm™,. S'.ipe';:, 

.ClllL^F.-.- 

mensem for oBicer of Asiatic , 

per mensem ns oversea® pay fo- ■ ■ 

BOURNCJIOUTH , ROVIL ) ICPORIA <KD IVesT HiXTS IIOSPITII — Tliiw.l it 

aS" “ 

®V”/annum”'’' ' Saboal Medical Officer (male). Salary xtoo 

BnioHTOx : Sussex Throit .uxd Eir nosriTFL,— Honorarv Surceou 

surgeon 
to the Ear, 

Edinburgh : Roy'al Edinburgh Hospital fop Stctt r’TnTTXT.r-^- w«- 
Honorary Resident Medical Officers. CinLDRCN.— Five 

GLOCCESTERSHIRE RoYIL I.VnRifIRV .AND Eye -O - . . 

Surgical Officer (male). Salary £175 per annum ^“ident 

Hull IIoy.il I-vriRMARY.—a) -Assistant House-Surgeon fmnlel Fair-,. 

House-Surgeon. Salary £150 and £130 per Sm 
KExstxcrox Boird op Glmrduxs.— Assi-tant Mdieni nm V' . 

St. .Mary Abbotfs Hospital. Salkrj- S m per aSnum ® 

Kenstncsto.x, Fulham, and Chelsra Gfveral tthspita, t ■ w - 
Jletlical Officer. Salary at the rate of Awj per annun/" H''sidenfc 
Ktdderminstkp. and District General Hospitiu — 

Salary 1150 per annum. House-Surgeon (male). 

KirkwiLl : B-iLFOun -IIOseTfAL.— Surgeon and CnnKtiif-mf f tt 
of Orkney and Supciintendent of the BalfSr HospL^*' 
per annum nospitai. Salary X60b 



SXJ PPLEMEISTT 

'XO THE 

BRITISH MEDICAL JOURNAL. 


1.0NDON, SATUUDAY, JUNE 30th. 1923. 

CONTENTS. 


SUPPLEMENTARY ANNUAL REPORT OF COUNCIL, i 927 .: 8 . 

TAOE ' 


(For Coirtciils see hclow.) 


' BRITISH MBDICAL, ASSOCIATION. 

current notes : 

SrA IT.AcrmoxERS Grocp : AxxrAL Coxterexce 
C oxsrLTixa PATnoEOoisTS Gnour or B.II.A. ; 

Coxterexce 

ASSOCIATION NOTICES 

MEETINGS OF BR.ANCHES AND DIVISIONS ... 


.Axxi’al 


286 

286 

286 

287 


NOTICES OF MOTION BT DIVISIONS 

VAC.\NCIES 

DIARY OF SOCIETIES AND LECTURES 

POST-GRADUATE COURSES AND LECTURES 
ASSOCIATION INTELLIGENCE AND DIARY ... 
BIRTHS, MARRIAGES, AND DEATHS ... 


PACE 

287 

288 
288 

■ 

288 

288 


SPECIAL NOTICE TO MEMBERS. 

Every Member is requested to preserve this “Supplement,” which contains matters 
specially referred to Divisions, until the subjects have been discussed by the Division 
to which he or she belonsrs. 


MATTERS REFERRED TO DIVISIONS. 


^ritislj Ifttilital ^ssonaltott. 
SDPPLEMENTARY ANNUAL REPORT OF COUNCIL, 1927 - 28 . 


Preliminnry 

Building " 

Organization ... 

Alcdico-Poiiticai 
PniiUe Heailli and Poor Law 
National Hoallli Insurance 

Hospitals 

Xaval and Military!*.* 

Medical Benevolence 
Over-sca Branches 

Appi^dis^— X ational Insn'rancc Defence Trust Balance 
btieet and Income and Expenditure Account, 1927 ... 


PACE 

277 

278 

279 

280 
281 
282 
205 
284 
264 
284 

286 


Preliminary. 


OniTUAnY. 

deathUL" '■= ? supplementary list of MemLers wliosc 

aeatlis the As=!Dciation deplores 


Name. 

Hr. Ardeshir Koyaji 

Contractor 

Dr. James Will Cook 
Dr. Timothy Corkery 

Dr. Tiiomas Augustus 

TT- T _ Davidson 
Air. Wm. .Tames Foster 


Dr. Alfred 


Charles Edward 
Harris 


Dr. Wna. James Howartli 

C.B.E. 


Offices held in the 
Association. 

Member of Bombay Branch 
Council. 

A Chairmau of the Bury 
Division. 

A Member of the Executive 
Committee of the Chesterfield 
Division. 

A Member of the Ulster 
Branch Council. 

A President of the Oxford and 
Reading Branch. 

A President of tlie Lancashire 
und. -Cheshire Brancli and a 
Chairman and Representative 
of the Birhenhead Division. 

^f.mLcr of the Public 
HeaUh, and Insurance Acts 
Oommittccs. 


Dr. Wm. Robert Tcates 

Ives 

Mr. Archibald Mason Jones 


Dr. James Alexander 

Macdonald 


Dr. Thomas MacDonald 

Dr. James McHardy 

Dr. John Wm. Mackenric 

O.B.E. 

Dr. Arthur Manknell 


Dr. John More 

Dr. Tom Dryden Nicholson 
Dr. Arthur Alfred Pratt ... 


A Vice-President of the South- 
ern Branch and a Chairman 
of the Southampton Division. 
A Bopresentative and Assis- 
Secretary of the Cardiff 
Division. A Vice-President 
of the Section of Laryngol- 
ogy and Otology at 'the 
forthcoming Annual Meeting 
nt Cardiff. ® 

Member of Council, Chairman 
1913 to 1920. Chairman of 
Representative Body, 1907 to 

1909. Chairman of Journal 
Committee. President of 
Section of Medical Sociolo'i'v 

1910. 

A President of the Ncrthe-n 
Counties of Scotland Bianch. 
A President of the Aberdeen 
Branch. 

A Secretary of the Inverness 
^ Yice-President 
« Counties of 

ocotland Branch. 

Member of Council. A Member 
Public Health, 
Medico-Political and Parlia- 
mentary, and Arrangements 
Committees. A Chairman 
and Representative of the 
f President 

of Section of Medical Social, 
owy, 1024. 

A CImirmai, of the Northamp. 

tonshire Division. 

A Member of the Border Coui- 
ties Branch Council. 

A Chairmai, . of ■the 'North 

Lincolnshire Division. ■ 

[1249] 




278 June 30, 1928] 


Supp/emcntat^y Report of Ooundh 


r avpPLK^rF.iJT to td ' 
tRrfiTrsu Ukoicxu Jogrka.0 


Name, 


Oflices lield in the 
Association. 


Dr. George Edward 

Shuttlewoi'th 


Mr. Thomas Waddelow 

Smitli 

Dr. WiHiani Snodgrass 


Dr. John Barclay Stewart ... 
Dr. David Lewis Williams 


Member of Council, I8SD-1903. 
Member of XMrliamentary 
Bills Committee, ri President 
of the Lancashire and Ches- 
hire Branch, a Vice-Chair- 
man of the Hampstead 
Division and a Member of 
the hictropolitau Counties 
Branch Council. Secretary, 
1883, ■ and Vice-President, 
1885 and 1900, of Section of 
Psychology. 

.Secretary of Section of Neurol- 
ogy and Psychology, 1920, 

Member of Council 1919-22. A 
Chairman of the- Glasgow 
North-Western Division, a 
Cliairmim of Scottish and a 
Member of Arrangements 
Committees. 

A Chairman of the Bury ] 
Divi.sion. . 

A Chairman of the South IVest I 
Wales Division. | 


Dr. Allan Huston Adams. Dr. Albert James Bccaley, Dr, John 
Mcara Burke, Dr. Oliver Carlyle, Dr. John Doiial Carroll, 
M C., Dr. Vincent Theodore Carruthers, Dr. Ed-win ClarJr- 
Joues, Dr. Colin Richard Cole, Dr. Egbert John Connell, Dr, 
Henry Charles Morriset Delohcry, Dr. Joseph Hiorns Penn, 
Dr. James Peter Fitzsimmons, Dr. Andrew Gilmour, -Dr. 
Harry Groom, Dr. John Walter Barron Hanuington, Dr. 
David Heard, Dr. Henry Louis Powell Hulbert, Dr. Reginald 
Edward Ingram-Johuson, Dr. Spencer Jackson, Dr. Harry 
Jossop, Dr. Schalk Willem Joubert, Dr. Basil Carlyle 
Kennedy, Dr. John Timothy Kennedy, Dr. Alfred .Tames Lowe, 
Dr. Kenneth Alexander Maclean, M.C., Dr. James Macphcr.son, 
Dr, Albert George Meares, Dr. Wm. Gardner Neill. Dr. John 
Oswald, Lt.-Col. Edward Ernest Parkes, R.A.M.C., Dr. 
Elizabeth Park Toung Paterson, Dr. Reginald Spencer 
Pearson, Dr. Thomas Philip, Dr. Robert Johnson Piric, Dr. 
Robert David Prichard, Dr. .John ■ Lawson Ran kino,’ Dr. 
Herbert Midjfeley Reeve,. Dr. , Harry SautaUe .UobcrlK, Dr. • 
Robert Roger, Dr. Robert Rosie, Dr. Jane Buchanan Houder- 
soii Huthven, Dr. Hubert John Satchwell, Dr. Neill Ca?npbcll 
Seett, Dr. Timothy Francis Sheehan, Dr. Francis Wm. S<juair, 
III. Vytilingam Supramaniam, Dr. Henry Mortlock Waller’ 
Dr. Sidney Winslow' WooRctt, O.B.E., Dr. TS^m. Alc.vaiidor 
Voniig. 


Dn.. J. A. Machonau). 


158. The Council feels that something more than the 
ordinary formal uotice is' due to the memory of Dr. J. A. 
Macdonald, who for many years not only served the Associa- 
tion with all -his strength in many official capacities, hut was 
an outstanding personality who earned the respect and the 
iffection of all who knew him. 


BrHTHDAY HoKotniB. 

159. The Council has pleasure in reporting tliat Honours 
have been conferred upon the following membei-s, to whom the 
congratulations of the Association have been sent: — 

Companion of Honour. 

, Prof. J. Haldane, F.E.S., O.kford. • , 

K.C.M.G. 

Sir Wm. Thomas Pxout, C.M.G., O.B.E., London. 

K.C.V.O. ' 

Prof. John Marnoch, Aberdeen, 

K.B.E. 

Major-Gen. W. H. Ogilvie, C.B., C.M.G.. K.H.P., I.M.S, 
Knighibood. 

Lt.-Col. H. S. Newland, Adelaide. 

Dr. T. Watts, M.P., Manchester. 


SiK Charles Hastings Fund. 

160. Tills Fund was instituted in 1925 by an endowment of 
about £70 a year due to the generosity of the late Lt.-Col. 
J. W. F. Bait, LM.S., and Mrs. Bait. Colonel Rait thought 
there was room for a fund which could be used promptly and 
with less formality than the other medical benevolent funds 
in existence. He particnlaTly wished the Trirstees to' be able 
to give at their entire discretion grants or loans to help 
members of the profession or their deiicudants in emergency. 


Tlio Trustees are the Chairman of the Representative Body, 
the Cliairman of Council .and the Medical Secretary.- Small 
grants liavc been made in a number of cases, mostly in the 
lorm of loans, to meet difficulties not likely to recur and 
which demanded instant action. For c.vample, in several 
instances loans (without interest and to be repaid when the 
i-ccipieiit is in a position to pay) have been made to tlic sous or 
daiiglitcrs of doctors who h.avc died while their children were 
in tho middle of their education. These loans, have enabled 
these very deserving cases to meet class or examination fees. 
A promising young doctor who.se health had broken down wa.s 
advanced money to enable him to complete a sanatorium 
course wliich -was benefiting his health but stood in danger 
of being interrupted for want of funds. Tlic.se arc only a few 
examples of the uses to which the Fund has heeir put and tlic 
Trustees are glad to feel that the Fund is serving the pnrporo 
which its honoured founders had in mind. It is hoped that 
Colonel Halt’s wish may be fulfilled and that other 
memhers of tho profc.ss;on may sec their w.ay to add to the 
capital of the Fund, either by donation or licquest. 


Gift ritoJi the New- Zealand Branch. 

161. Mr. Victor Boimey, the official delegate of the Associa- 
tion at the Annual Meeting of the New Zealand Branch has 
brought back with him n pre.scnt -which ho was asked by the 
Branch to transmit to the Council. It consists of a handsome 
irtkiitand of New Zealand wood, greenstone and silver, -and it 
is inscribed “ Coelum non animum mutant qui trans marc 
currunt.” • 

Tlic Council welcomes this evidence of the loyalty and 
affection of one of its most distant and most successful 
Branebes ami is proud to have tins token of kmship to 
in the House in proximity to the President s Chair winch was 
the gift of the Australian Branches. ^ 

.(VSKUAL Meeting, 1930. 

Ifl” The Council has approved certain arrangements with 
respect to the Animal Meeting at .Winnipeg, in. 1930 and 
hopes to publish details as to travelling facilities, etc., jt 
an early date. 

Tho Council Tccommends.;— _ 

Recommendation : That IV. Harvey Smith, M.D., 
Winnipeg, bo elected President of the Association, 

■ 1D39-31. ' ■ ■ 

Afpointments during Near or Reeresentattves op 
Association on Outside Bdd.es. 

(Continuation of para. 24 of Annual Report-.^ 

163. The following further appointments have ■ Imen -made by 
the Council Departmental Committee on Midwives Act, Dr. 
X W. Bone; Fourteenth Annual ^nference of the Na-tmnal 

Association for tl.e Prevention of Tubcrcul^.s, the Picmd^ 

1928 National Conference on Maternity and Guld "o^re. 
Dr” W. Paterson; Advisory Committee, of lliMroacenticM 
Society re Control of Therapeutic Substance, Sir HuctI^ 
RoRelton - Court of Governor of University -College of South- 
West England, Mr. Bussell Coombe ; British |®gre 
Campaign International Convention, 1928, Mr. E. G. Bo^artn 
and Sir Tliomas Holder, Bart. 


New South "Wales Medicai. B.oll op Honour. 

164. The Council has been pleased to accept a bandsomely 
bound copy of the New South Wales Medical Boll of Hononr, 
containing the date of appointment to service and tno 
Iiononrs if any, of all members of the medical profession in 
New South Wales who served overseas. The Boll oJ DontroT 
may be .-inspected in the . Library of the Association, 

Pstcho-Anal-tsis Committee. - , ; 

163. The Committee appointed by the Council in 1926 to 
conmder, pursuant . to the instruction of - tlic A.E.M., tie 
subject of Psycho-Analysis is still considering its refercaM. 
Although meetings have been held monthly throughout tne 
sessionlthe work of tho Committee is not sufficiently advanccu 
to permit of any report being made at this stage. 


Building. 

166. The Council, in view of tlie great importance of the 
matter and to ensure continuity in the negotiations and the 
control of the building operations, has appointed a special 
Building Committee, to consider all questions of rebuilding 
in connection with the premises of tlie Association, init 
special Committee consists of . Sir Robert Bolam 
Dr. H. B. Hrackenbiirv, Mr. N. Bishop Harman, Dr. 6. JA. 
Hawthorne, and Dr. E. Wallace Henry, together with tua 
chief officials of the Association acting in .an advisory capaciiy. 



Joke so, losol 


Orgttnlxailon. 


T snpprxinntT m rat 

I nniTisn wcdioaz. jouiucit 


S79 


Tavistock Square. 

■ Information was' rocoivca tlmt T.avistock Square, ivlicro 
tlio London Donso of tlin As.soniation stand.s, formed part of a 
Town riannin" Scliemo under wliicli jt was Bciicdulcd ns 
residential nnd°not for commerci.al purpose Assurance w.ss 
tliercupon souulit and obtained tlint llio IJ.M.A. Ilousc was 
outside tbe boundaries of tlio Town rianning Sclicmc and 
that, in nnj- case, the Association’s building proposals wiH 
not be affected. 

• DnsiOLlTIOK, 

Possession wa.s Obtained early in September, 1927, of 
two of tile five lioiises fronting tile main road, .and the work 
of demolition was commenced at the earliest possible moment. 

It was then found that arrangements could conveniently bo 
made for rc-hoiising the two tenants in the other threo 
houses and for proceeding with Blocks A and B together, 
thus reducing the cost of demolition, c.vcavation and 
rebuilding, 'flic demolitions have been comideted, and 
the work of excavation is lieing pushed rapidly forward. It 
has been found necessary to close the private road leading 
-into the Association’s premises, but a covered wooden way has 
■ been erected,. in order to interfere to .as small an extent as j 
passible with the convenience of visitors to the premises. I 

CosrnACT. 

After duo enquiry and consideration, the Council 
. approved the erection of Blocks A and B by means of a 
contract embodying a schedule of agreed prices for work 
carried out, in lieu of a tender with one price for the 
complete building.- Under such a scheme greater latitude 
is allowed for alterations which may- be found to l>c necessary 
or desirable, and no payment is made for work included in 
the original scheme- and subscquentlj' omitted. 

Buildiko Like. 

Very prottaclcd . negotiations were necessary with both 
the Bedford Estate OfSco and the London County Council 
over the questions of the front building line and the party 
walls on the north and south of the proposed extensions. 
The west side of the main road on which the c.vtcnsion of 
the B.M.A. House will front had already been settled, and 
both the Bedford Estate Office and the London County Council, 
together with the loc.al Borough pouncil, desired to sot out 
a general huilding line extending for nearly three-quarters 
of a mile. Sonic difficulty was experienced in adjusting the 
variations in the lines upon, which the dcmoli.slied houses 
stood. Eormai conseiit from tlio London County Council has 
-now heen ohtained to the plan submitted, and Uic p.irtv wall 
awards setting out the necessary underpinning, position of 
stanchions, and lighting nrens to bn left bare been duly 
signed. 

Cloik or Works. 

_ A Clerk of Works of standing and considerable c.v- 
jioricnco lias been appointed. 

HoAnn'iNCs. 

Consideration was given to tiie possibility of letting the 
boardings. fronting the main road to poster advertisers but. 
'It was found desirable to utilise the space for announcements ' 
concerning the extension of the B.M.A. House, flic organisa- 
•tions housed therein, and the prospective tenants. 

ScOTIiAND. 

.. .A scheme for the extension of the Scottish House of the 
Asmciation, by the purchase of Ho. 7, Drumslieugh Gardens, 
Edinburgh, and the reconstruction of portions of Nos. 6 and 
I, Unimsheugli Gardens, has been considered and approved. 

• ’3 being carried through ; details are given 

in this report under the' heading of “ Scotland.” 


; Organisation. 

(Continuation of paras. 47-02 of Annual Eeport.) 

H0NOR.VUY Secretaries 'ycHo have Beuuquished Office- 
1C7. Since the publication of the last Supplementary Bepo: 
Lotincil Supplement, .Tune 2.0th, 19271 the toUowin 

Divisions and Branches have rclii 
^“bcil takes great pleasure in extendin 
ilfip- officers the thanks of the Association, realising as 
1 '”*^ the success of the Association depends very large! 

iimf' the position of 'Secretaries of loc 

units of the .^soeiatiou.- - 


Honorary Secretaries of Divisions. 


Division or Branch. 


Aberdeen 

» ••• 

Assam Talley 

»> _ »» "* *** 

Ayrshire 

Barnstaple 
Binningliam Central 

Blackburn 

Briglitoii 

Cardiff 

Darlford ... 

Dover 

Dumfries 

Eastbourne 

East London 

East Norfolk 

East YorksUirc 

Edinburgh & Lcitli 
Glasgow North Western 
Glasgow Soiitliern ... ' 

IJawkcs Bay 

Hyde 

Inverness 

Kensington 

Lambeth & Southwark... 

Liverpool 

Mid-Clieshire 

Newcastle-on-Tviie 
North East Ulster 
North Glamorgan Sc 

■ Brecknock 
Northamptonshire 
Nuneaton & Tamworlh... 

Otago 

riymontli 

Portadown & West Down 

Hochdale 

Southland 

South Middlesex 

Southport 

Stockport 

Stockton 

Surm.a Valley 

Swansea 

Taran.aki 

Wandsworth 

Wanganui 

Warrington 

Wellington 

West Bromwich 

West Middlesex 
Western Transvaal 
Woolwich 


, Name of Secretary. 

Year o( 
Ajijioint- 
merit. 

F. K. Smith 

191.0 

H. E. Smith 

192-2 

F. W. O’CoTmoT 

1926 

E. A. M. J. Goldie 

1927 

.A. Scott (Asst.) 

19'27 

S. C. Shaw 

192'2 

W. H. Marris 

192.> 

J. Shearer 


L. A. p.arry 

ltt’20 

A. Evans (Jun. Sec.) ■■■ 

]9’27 

W. F. Lace 

1922 

A. E. Jordan 

1920 

J. Cromie 

192.1 

W. Muir Smith (Deed.) 

1907 

P. W. Laidler ... - ... 

-1925 

C. Hurwitz 

19'27 

n. D. Woodroffc 

1!)24 

W. W. Adamson 

19-25 

C. M. Pearson ... 

-1925 

M. White - ... 

19-2.3 

s , . 0 . t'aylor 

1920 

S. Scoular 

1920 ■ 

G. MacQueen 

19.-5 

J. -W. Mackenzie 

1913 

H. M. Stratford 

1922- 

E. L. M. Eusby ... 

1921 

B. Kennon 

1925 

E. Ecid Duncan 

19-2.3 

E. Farquliar Murray ... 

19.2- 

W. porter 

1912 

A. W. Owen ... 

1926 

W. M. Eobson 

1921 

E. J. Cyriax 

1925 

W. B. Carswell 

1925 

S. Not Scotl 

191.5 

J. S. Darling (Deceased) 

1904 

J. Melvin (Deceased) ... 

- 1907 

A. A. Stewart ... 

1927. 

T. Euddock-West 

192-2. 

B. W. Lewis ... ... 

10-2-2 

F. W. Sclioleficld 


(Jt. Sec.) 

192-2 

G. C. M. M'Goniglo ... 

1925 

J. Dunlop 

1927 - 

H. R. Tighe 

1923' 

G. H. Thomson 

1925 

J. Kennisli 

1915 

G. TI. Eobortson . ... 

192-2 

D. Mcikle 

1925 ’■ 

G. F. V. Anson ..; 

1935 

J. M. Mitchell 

1923 

Agnes Dunnett 

1922 

J. C. Tniter 

1927 

W. Eemington 

1927 


Honorary Secretaries of Branches. 


Assam ... 

E. A. jM. J. Goldie 

1927 

Birmingham 

■ p. C. Cloake 

IG2G . 

Border (S.A.) 

Gertrude Neale 

1925 

Border Counties 

R. Connell (Asst.) 

1926 

Edinburgh 

John Stevens 

1914 



P. E. Jardine (Asst.) ... 

1923 

Griqualaiid West 

Comyns Dutliic 

1927 

Hongkong anci China ... 

S. S. Straban 

19-25 

Kenya 

W. H. Kauntze 

1926 

Kent 

E. A. Starling 

1910 

Lancashire & Cheshire... 

A. Corsar Sturrock 

1924 

Mashonalaucl 

J. IV. Hnrworth 

1925 

Metropolitan Cos. 

H. M. Stratford 

1924 

Midland 

C. C. Binns 

1926 

Kew Zealand 

D. E. Fcnwiclc 

1925 

Southern 

Lockhart E. W. 



Stephens 

1920 

South Indian & Madras 

Clive No-wcombe 

1927 

South Midland 

E. Broughton Barnes ... 

1924 

Southern Transvaal 

Max Greenberg 

1024 

’Tanganyika 

S. Mackenyie ... 

1927 

Tasmanian 

E. Brettingham Moore.-,. 

1027 


A..L. Gibliu '... 

1027 

Uganda 

W. L, Webb 

1926 

IVcst Somerset 

IV. G. Parker ...• 

• 

192.5 , 



r BUPi^tnsfEyT to tsi * 
LBRiTisn Meuicaij JottshK 


1280 JUUE 50,- 1928] 


Supp/em'entti'ry 'flefiO'^i of 'Council. 


Medico-Political. 

Assistant Medical Ofitceks to Mental Hospitals. 
(Continuation of para; 93 of . Annual Hojiort >of Council.) 
168. The Council desires that further time should he allowed 
during which negotiations may tahe place with the bodies 
concerned and considers that it would thercforc be appropriate 
if the liepresentative Body at the present time confined itself 
to a general discussion of the pi'oposals contained in Beeom- 
mendations B to E, leaving over until the A.E.M. 1929 any 
question of formulation of policy: — 

The Council recommends 

Recominenslation : That Jlecomiuendalions B, C, I) and E 
contained in para. 93 of the Annual' Beport of Council 
relative to salaries of assistant medical officers to 
mental hospitals be given general approval, but not 
made jiart of the policy of the Association until there 
has been a further opportunity for negotiations between 
the A.ssoeiation and the bodies concerned rvith the 
appointment of assistant medical officers to mental 
liosjiitals'.' 

Encroachments on the Sphere of Pnri'ATE Practice.' 

(Continuation -of para. 91 of Annual Report of Council.) 

109. The. Special Committee has received a report by the 
Medical Secretary on the result of liis observations rvith regard 
to the publicly supplied medical services in several typical 
areas. This repor t will be used as the basis of a report wbicb' 
the Council hopes to be able to present to tlic Bivisious in 
tile autumn. In tbe meantime the Council, desires to CNjiress 
its tlianJm to the Medical Officers of Health in the areas 
visited, for the .^nerons assistance given to the Medical 
Secretary during his visits; and also to those Medical -Officers 
who rejilied so promptly and freely to the requests made to 
them for particulars of the services in their areas. 


Ante-Natal Wohk. 

170. The . following resolution was iiassed 
1927 : - 


by the A.R.M. 


Min.itfc 142. — Beselved : Tliat it be au instruction to 
the Council to consider the Midwives Act, 1918, in the 
interests of all concerned with aut-i-natal work. 

-Is certain of the questions involved in the above 
reference are being discussed by the Private Practice Com- 
miltee, and by the Puerperal Morbidity and Mortality 
Committee, and others will come under the consideration 
of the Departmental Committee referred to in the ne.\t 
paragraph, the Council considers it inadvisable to present to 
the Representative Body at the present time any detailed 
report upon tlie subject matter of above Minute 142. 

-i Dopartmenbal 'Committee ’cansistiog of Sir Robert 
Bolam (Chairman), Dr. J. W. Bone, Dame Janet M. Camiibell 
Eady Cynthia Colville; Dr. W. A. Daley, Mr. J...S. Eairbaiin, 
P.R.C.S., Dr. T. Eustace Hill, Miss Alice Gregory, Mr. A. B. 
MacLnohlan, Dr. P. N. Kay Menz5e.s„ Mrs. Bruce Puchmond 
and Miss Stephenson lias been appointed with the following 
reference : — 

“To .consider the working of . Hie Midwives Acts, 1902 
to 1920, with .particular reference to tlie training of 
midwives (including its relation to the education of 
-medical students in midwifery), and the comlitions under 
-n-hich midwjves -ai-e employed.” . . ■ ' 

and the Council has authorised the' preparation of evidence on 
the lines, of tlie reference to the Departmental Committee and 
the nomination of witnesses to give evidence on .belmlf of the 
Association before tliat Committee. 

Genekal Medicai. Council Bv-Election, 1928. | 

171. In November, 1924, at the election of four Direct Repre- 
sentatives for England and Wales on tlic- General Medical i 
Coiiucil the Association’s candidates, namely. Sir Robert il 
Bolam, H. 13. Brackeubury, J. A. Macdonald, and Sii- Jejmer !l 
Verrall, were returned. The Council regrets to have to reimrt i 
that tlirough the deatli of Dr. J. A. Macdonald a by-election i 
is imminent. Tlici'e is also another -vacancy caused by the | 
election of Sir Robert'Boiam as representative on the General i 
Medical Canucil for the Dniversit-y- of -Durham and hisi ' 
consequent resignation of office as a Direct Representative. I 
The Council has put into ojieratiou the following scheme 1 
in connection- with the two vacancies:- — i 


(1) The - Medico-Political Committee ' Hiall ' cause to be 
circulated as early as possible a notice to every Division 
in England and Wales (i) advising the Divisions of the 
fact that an election of two Direct Rejircsentatives on the 
General Medical Council for England and Wales will in 
the ordinary course take place in October, 1928; (ii) 
requesting 'that the Divisions sliall call meetings of the 
whole ■profession in their areas in order to take this 
matter into consideration; and (Ki) asking to be informed 
not later than July 2nd, 1928, of the names of any pei-son 
or persousj legally qualified for election, whom such 


iiiccliiigs may deem suitable to bo nominated for election 
. as a Direct Rcprosenlative. 

■(2) Tlie Committee shall cause a list to be prepared of 
those porsoiiB, legally qualified for clccliou, who shall 
have been named in the manner prordded in Clause (1). 
The said list shall be circnlated to tlie Diyisions at the 
earliest possible date before the Annual RcjU’esentatiye 
Meeting, 1928, and each constituency shall be requested 
to adopt sucli resolutions 'as may enable its Represciitative 
at the Annual Rc])rc.sentativc Meeting, 1928, to give effect 
to the wishes' of the constituency in a r ote taken in the 
manner licrcinaftcr prescribed. 

f3) At the tiin-A of the Annual Representative Meeting, 
1928, a Special Meeting of Representatives of Divisions in 
England and Wales shall be convened, to select from the 
list of uominec.s two jicrsoiis for nomination as Candidates. 
Toting shall be by ballot. The Candidates who receive 
the greatest number of rotes shall be deemed to be the 
Gandidates selected for support by the Association. 

(4) The hfcdico-Political Committee sliall arrange that 
the persons so selected .shall be duly nominated on belialf 
of the Association as Caudidates for the office -of Direct 
i Representatives on the General Medical CouncR, and 
ovei-y effort slmll bo made by tbe Association to secure tbe 
election of the said Candidates. 

Declaration bt/ Candidate. 

I, the undersigned,’, hereby .consent if duly selected in 
accordance with .the procedure mentioned above, to be 
nominated as a Candidate at tbe electioh in 1928 of two 
Direct Representatives on tlie General Medical Council for 
England end Wales. 

Signed I 

Qualifications -...; 

Address .' 

Tbe scbeine is ■with slight variations the same as that 
approved by the A.R.M. in 1915, the only important e.rception 
being that tho nomination of Candidates from whom the final 
selection is to be made at the A.R.M. is by meetings of the 
whole profession and not by Division meetings. 

Iniernational Medical Sea Code. 

(Coatinuation -of para. 92 of Annual Report of Council.) 

172. The Council has drawn np a simple questionnairo 
on -1110 signs and sj-mptoms of disease and injaries for the use 
of master mariners when ,^secking medical advice by wilder 
from a siii'wcon on nnoUier sliip or on shore, and Ims submittw 

-it to tbe Board of Trade -ttitii a request tlmt -the Board will 
assist Hie Council in its attempt to draw up an international 
medical sea code by having -1310 questiommire set into code 
(or cipher). In order that the code mayJjo of further assist- 
ance to master ranriners the Council proposes to' preface it 
witli -explanatory notes and sample ^messages. 

CniRoroDisTs -(Registeatio.n) Bill. 

173. The Chiropodists (Registration^ Bill, introduced into 

the House of Lords on 2nd May, 1928, by. Viscount Nov.nr and 
•down for second rending on IBtli 1928» Tias for its object 

the recognition by tho State of chiropodists as a -class .of 
special practitioner. A chiropodist is defined as;— * 

** A person who practises chiropody*'; 

'and' “<niiropody.** 

** means and includes iJie diagnosis and medical, 
mechiuiicai or BUJ^gical treatment of foot ailments ^nch 
as aljncrmal niiils, l)unions, corns, warts, aojd callosities, 
but does noC include tho performance of operations for 
which an ancDsthotic is required.** 

Tlie Council recommends: — 

■Recommendation That it is undesirable that cliiropo- 
dists should be reco^ised in a special register as such 
register lyould convey lo the public tliat chiropodists • 
W’ere compertent to undertake tlie diagnosis and treat- 
ment of diseases of the feet. 

- Investigations into Maternal Deaths, Still Births, 
Neo-Natal Deaths and Puerperal Fever. 

174. Arising out of suggestions By the Ministry of Health 
that au investigation should be conducted into all maternal 
deaths, still births, iieo-natal deaths and cases of puerperal 
fever, the Council decided that such investigations would bo 
us^nl if carefully controlled by_ competent experienced 
medical officers and if the results were used -exclusively for 
scientific and public health purposes, and urged th.at it was 
important that, where necessary, such investigation should be 
foUowcid by the offer of expert udvice tind assistance, institu- 
tional or otlunadse. Having received a satisfactory assurance 
on this matter from the Ministry of Healthi tlic Council 
\see paragraph 30 -of Aiiipendix XF. to the .Annual Report of 
Council, page 1G8 of the Supplement of 28th April, 1028) 



jtoe 30.' ms] 


PmMIc Hoatth.and Poor ,Law. ^ 


r sVi'PiJr.MT.KT TO Tire 

LmtlTlim JIKDICAI. JOCT-ITAL 


.281 


nrc-^scs ni.on 'Divisions anrt all members of tlie profession 
jToneraUy. Die necessity of giving all the assiatance tliey ean 
towards making tbc observations under such investigations 
as complete and accurate as possible. In Circular 888 tlie 
Minister of Ilealtli lias stated that it is his intention to set 
ni) a representative Maternal Mortality Cnminittee vhicli will 
consider the investigations in question, ami, with a view to 
securing uniforniify in the nicthod.s of obtaining the informa- 
tion desired, he proposes to invito the Committee to draw lip 
a questionnaire to serve ns a guide to aiithoritie.s in making 
their investigations and hopes that the Coinmittco will com- 
mence its work at an early, date. 

llr.GISTKATION OF NultSINO DoMFS. 


ArpLiCATiox TO NouTnintN lnF.i,.\Ku of Sc.ilk of Mixnitru 
CoMHEKCISO SaLAHIES FOK WhOLE-TIJIE I’UBLIC HfALTSI 
AppoiNritENTS. 

178. So far. the scale of minimum coniiuencing salaries ha.s 
only been applied to England and Wales, and Scotland (in the 
iiioiitied form above-mentioned). At the request of the Dlster 
Branch, the Council now recommends: — 

Recommendation : Tliat the scale of minimum eorii- 
meiiciug salaries for whole-time public health appoint- 
nient.s be made applic-able to whole-time public health 
appointments in Northern Ireland.- 

Dcpil A.ssist.ints to IIedical Officers of He.ilth. 


(Contiuunlion of para. 08 of Annual Rcpoit of Council.) 

375. The Council h.u.s approval the draft by'-laws which the 
Ministry .of Health proposes to issue to local authorities as 
a model for the by-laws which these nuthoritic.s may adopt. 

Manchester CoRPoitATTON’ Act, 1924. 

17G. Under the M.anchester Corjioration Act, 1924, a medical 
practitioner who runs an " establishment for massage or 
special treatment “ (such term including premises used for 
the reception of persons requiring inas-sage, manicure, chiro- 
pody, light, electric, vapour, or other baths, or other similar 
treatment) may be exempted from registering hi.s hou.se if 
lie lodges with the Corporation S certilicalc (ii^ the approved 
fonn) signed by two medical practitioners practising or 
residing in tlie city, not being in partncr.sTiip with the 
practitioner concerned or with each other or not having any 
financial or other interest in the establishment, to the effect 
that the practitioner concerned is a suitable person to c.arry 
on such, an establishment. The same po.sition obtains in 
London under the London County Council General Powers 
Act, lOl.'i. The Conueil, while fully rcengnisins the necessity 
of supcri-ising the activities of persons who arc not registered 
medical practitioners and -who are using the above forms of 
treatment ha.s advised the Manchester Division to point out 
to the Corporation its objections to the oiieration of tliis Act 
ns being a restriction on the legal right of a regi.stercd 
medical practitioner to practise a certain brancli of his profes- 
sion, and to urge that some way lie found to remove the 
restrictions thus placed on medic.al practitioners. 


Public Health and Poor Law. 

Awlication .to Scotland - of Scale of Minisiuh CosniENciNO 
, Salaries Fon AVhole-tisib Piidlic XTcalth iVrpoiNTiioTS. 

177. The Animal Iloprcscntativo Meeting, 1927 (Minute 135(. 
approved the action of the Council in agreeing for one year 
to Die following modilic.ations of the scale in its application 
to Scottisli appointments: — • 

(i) that the commencing^ salarv for resitlout medical 
offircrs be £250 to £400, pimj cmolnmcntj^; 

(ii) tliat the commencing" salary of medical ofneerp 
employed in departments be on a graded scaJo, the avenigc 
salarr over It) years bcing^ not less tlian £C0O, the 
mimmnm commencing- salary' to be not less than. £500; 

(ni) th^ the scale of commencing salaries for chief 
medical officers of health be as follows : — 

Popnlation not exceeding 50,000 ... .£800 to J09OO 

” .. - 100,000 ... £900 to £1,100 

- >- „ 250,000 ... £1,100 to £1.400 

exceeding 250,000 ... £1,-S00 to £1,600 

fliat a minimum commencing salary of nof less than 

±iuu may be recognised in county areas, with a popula- 
011 not exceeding 25,000, where co-ordination with an 
adjoining .area is not feasible. 

a^aia given this matter very careful 
and 'onsultation with the Scottish Committee 

1Tp,hl Branch of the Society of Medical Officers of 

coXnnnt M Conclusion that under present 

conditions the scale, as above quoted, offers the best prospect 

'‘-I?- ^ understood that tlie Scottish 

is^accentpr?ni^'^ no approval of the scale unless it 

tVo rS 4.^ ^ settlement with some assurance of stability 
tue <^xmncii recommends : — 

JiiiiP to for one year as from 16tli 

' of tiii application to Scotland 
whnlp timo * uv couimenciiig salaries foi 

'■ for i appemtments be extended 

tb-if if years on the understanding 

that tbp*^nr.?l® f'^’^'od experience sbowi 

A t the arrangement had not broiir»“ht about that 

“PP'i‘=-''fi°a°of the scale tc 
^vi4b;iit^ it" continuance, the 


170. Duriujr the present session two advertisements were 
tendered for insertion in tho inviting applications for 

pupil assistants to medical oflicora/ of health. In one 
it wa.s staled that the borough council concerned had 
authorised its medical officer of health to receive one pupil 
assistant who would live and be boarded at the isolation 
hospital and that the conditions alTordcd csceptional training 
foi- the D.r.IX. ■ The other stated (1) that tlie Health 
Committee of the Borough was prepared to recei\e 
applications from medical i)raetitiouer.H who desired training 
in public health adiiiinistralion ; (2) that the appointed 
practitioner would receive inetructiou in public health admin- 
istration and be given duties in connection with sanitation, 
infectious diseases, tuberculosis, bacteriology, maternity and 
child welfare and school medical work; (JX) that there would 
be ample time for study, classes, etc., and. if necessary the 
certiticutc in public health administration required for the 
D.P.H. would be given. The appointment was offered for 
six or twelve moiitlis, no preminni being required and no 
salary offered. 

Tlie only declaration by the Association on the subject 
of pupil assistants for medical officers of Itealth is the 
f<»llowing paragraph which appeared in the Supplementary 
Keport of Conncil for 1909-10, and was approved by the Annual 
Beprosentative Meeting in 1910: — 

37. A qu^*^tioll has nrisep ns to the insertion, iii the 
“ British Medical Journal ” of an advertisement for an 
Assistant .Medfcnl Officer of Health (r>tipil), from whom a 
premiuia uns reijUired. The Council is of opinion that it 
is iindt‘^irable that a premium paying pupil of a Medical 
Officer of Health shouM in any eircunistauces be de»Ig- 
iiafed “ Assistant Mediral 'Officer of Health/* and 
fiistrnetions- ha^’e been given to decline advertisements of 
the kind. 


Tile Council rs of opinion that appohitraeuts of thi.s_ 
kind should not be advertised, in the “"British Medical 
Journal as it considers it undesirable that persons who are 
in .'ctefu pupillari should be engaged in duties .which are 
ordinarily performed by salaried officials. 

The Council recommends : — 


Recommendation ; That advertisements, for pupil assist- 
ant.s to act (a) either as residents in infectious 
hospitals, sanatoria or institutions of a similar nature, 
or (b) to do work usually assigned to assistaut medical 
officers of health or assistant school medical officers, 
should not be accepted for publication in the “ British 
Medical Journal wltefTier or not a premium be 
Toquired. 

CojiuiNED ArroixTiiEXTs or IVhole-time MEi>rcAL Officer of 
Health, Poor-L.vw Medical Officer and Public Vaccinator. 
(Continuation of paras. 119-120 of Annual Be^iort of Council.) 

180. In addition to the case I’cferred to in paras. 119-120 of 
the Annual Keport, the Council reports that the Ministry of 
Health has recently approved a combined appointment of a 
Medical Officer of Health, Medical Superintendent of 
Infectious Diseases Hospital, Medical Officer of a Poor Law 
Institution and District Medical Officer for the Union District 
and Public Vaccinator on the ground that it must abide by 
the circular of the Local Government Board of 1910 which 
definitely encourages such appointments in snitable^ cases. 


iiEES for inspection OF \ AGRANTS FOK DIAGNOSIS OF 
' Smallpox. 

181. lu his circular to Boaitls of Guardians in Ernrhand and 
■Wales (No. 859, dated: 23.1.2S) the Ministei' of Health slated 
that, in view of the prcvalciico of snihllpox amongst casuals 
such persons shor-ld be examined by the medical officer with 
a view to detecting cases of small pox. The circuhir also 
stated that in view of the extra work and tesponsibilitv which 
^ V 0«s addition to the mccficJl ofhcers^normal 
duties the Minister will he prepared to consider aiiv annlico 
tion which may he made by a Board of Guirdiais for his 
sanction to the payment ot rca-sonablc additional 
to the medical officer." ' ' /eMncratiou 






.TUNn 30,' 1928] 


'■'fi'aiiondl''HSaltfi''fnsuPanbe,' 


' ' suTPLmtr.^rr to TTse. - oo<» 

.DRITI*?!! MKPXCa^L JOCRKAt; ^OO 


75 (3) of tlio old Act wnH belter timn any protcelion likely 
to ho provided •under reoiilations. 

191. Steps were, therefore, taken dnrintt the Comnnttco 
stage of tlie Bill in the Ilonso ot Coninioiis to have proposed 
amondnienta that the words " the provision of ” in additional 
benefit No. 13 be deleted, that the rcstrieting Snh-Section 
75 (5) of the 1924 Act be allowed to stand, or so amended as 
to maintain the principle that when an additional benefit ia 
of the nature of medical benefit, in wlmtsoover way it may 
be administered, it shall not be administered by approved 
Focietie.s. Dr. A. V. Davie.s, a, moiiiber of the Standing 
Coniniittoc, kindly nndertook to propose tliesc amendments 
but was not succc.sstul, as the Minister declined to accept 
them. 

■ 192. Unsncec.ssfiil effort.s were made to have the same amend- 
ments made to the Bill during the Commiltco Stage of the 
Bouse of Lords. 

The Bill also proposed an entirely new .odditicna) 
benefit, namely. No. 15 : — 

“ 15. I’nymcnts to approved charifable in.stitntions in 
respect ot any treatment of memberR reciuired for the 
prevention or cure of disease, not being treatment within 
the scojic of any other additional benefit or of medical 
, benefit,” 


which it wa.s considered would jircvent a society from making, 
ai range nieiits whereby the servico.s of practitioners in their 
private capacity could be made available in respect ot any 
iic.atnient of its members required for tho prevention or euro 
of disease (c.g., car, no.so or throat spociali.st.s), at privnto 
cor.snitiiig rooms. Consequently, it was suggested to tlio 
Minister that the position foreshadowed might be jirevcntcd 
by the insertion alter tho word " institutions” in additional 
benefit No. 15. flic words “ or to registered medical practi- 
ticners under a siiccial scheme approved by tho Minhstcr for 
thd purpose,” which suggestion tho Minister intimated his 
willingness to accept. During the Committee stage in the 
Bouse of Commons, however, an amcndniont was tabled for 
the inclusion of a further additional benefit, namely: — 

“ The p.nynient of tho whole or any part of medical or 
surgical or specialist services,” 


which the Minister had intimated lo the propo.sers ho was 
prepared to accept, and which ho informed the As.soeiatioii, 
witii the addition of tho words ; ” Under a special scheme 
approved by the Minister for the purpo.se ” would seem bettor 
adapted to meet the ]ioiiit made by the As.sooiatioii in con- 
rcction with additional benefit 15. .The new suggestion, 
however, was not eoiisidcrcd completely to meet tlie point ot 
view put to the Minister and it was pointed out that the 
word specialist ’’ had not been used in any additional -benefit 
Mauso, that it did not appear to have liecn used in any 
Naaonal Health Inairaucc Act, and that it wa.s difficult of 
"■ 1 suggested tliat it would be preferable if 
the new additional benefit read as follow.s : — 


p.aymcnt of the whole or part of tho cost ol 
■ medical. or surgical treatment or advice by any rcgisterec 
medical practitioner not being treatment within the scopi 
any other additional benefit or of medical benefit undei 
piir'^w''" . “PPro-^ed by tho Minister for tin 

benefit accepted, and the additional 

fnra? Standing Committee of tho Bouse it 

•the BP^/n ‘I*® Third Beading ol 

16 mi IS additional benefil 

amended that it should nol 
ments^ ra L®’ ?'’°P^‘°.'? a" approved society without p.ay. 
treatmmit^it™^” medical practitioners for similar advice and 
tfin l e- other than approved cliaritable institu- 

allo’vable^it the same time Nc 
mi’'"'™;'®’'- “ttended these effort.s. 
appear in ‘^ootmpnt heiefits as they now 

fSws- ® Assent we as 


-{ „ ■ payment of the whole or any part of the cos 
s^rgipal advice or treatment hy any regi; 
witin'n pr.actitioner, not being advice or treatmeii 

medhil “"y “dlitional benefit or c 

• ance^anfl^t™®f]i® to. “ospitals in respect of the maintei 
of tlie wlin^ ^ tlicrem of members, and the paymei 
incused bv V- travelling expenst 

and 7rti^fespUall"“^“‘=--°^ travelling t 

P-t of the ?ost of opficaf aphTianles"'' "" 


prevention or cure of disease, hot. being treatment within 
the scope of any other additional benefit or of medical 
benefit. • • . ■ • - 

17. Such other additional benefits, being of a character 
similnr to that of any of those hereinbefore mentioned, 
as may be prescribed. 

104. Tho Council con.siders that the failure to secure the 
retention of Clause 75 (5) of the present Act, or the deletion 
of the' words "the provision of” in additional benefit 13 is 
regrettable notwitlistandiiig the Jlinistry’s'assur.aiice that the 
position -will bo amply safeguarded by regulations. If the 
present or any other Minister should attempt by regulations, 
or the absence of them, to hand over the administration ^01 
benefits of tlic nature of medical benefit to approved societies 
ir, will, of course, bo necessary to organise those members of 
tlic profession concerned in a refusal to give service under 
such conditions in pnrsnanco of the well established policy of 
the Association, and the Council lias no doubt that practical 
niianimity could bo got on a point such as this. 

Tho Council recommends : — 

Recommendation: That it is essential if tho medical 
profession is to take part in the provision of additional 
(medical) treatment benefits under the National 
Health Insurance Acts that these, as in tho case of 
statutory medical benefit, shall bo administered in 
siicli fa.sliioii that the, services of the medical profes- 
sion, who elect to give advice and treatment in 
connection therewith, sh.nll not be under the control 
of any approved society or societies. 
Recommendation: That the jiosition set forth in the above 
resolution should receive statutory recognition and 
definition. ; 

Sickness BEXErir Claims and Medical Cektification. 

fContinnation of paragraph 12G of the Annual Beport.) 

195. Discussions are still proceeding between the Insurance 
Acts Committee and representatives of tbc Ministry 
respect to tho above question. Various data dealing with the 
largo increase in the amount of sickness and disablement 
benefits have been submitted by tlio Ministry to the Insurance 
Acts Committee but so far the Committee is not satisfied that 
the real causes, or at any rate, all of them have ■ been 
discovered. One thing, however, is plain that the suggestion 
that the increase is duo solely or even mainly to a sudden- and 
radical change in the methods of certification adopted by 
insurance practitioners as a whole cannot bo accepted as a 
solution. 

The Council will give any assistance in its power to 
ascertain the causes in co-operation with other parties con- 
cerned. 

National Insurance Defence Trust. • ■ 

196. The Insurance Acts Committee submits herewdth for - 
the information of the Kepresentative Body and Divisions, a 
copy of tbo .audited statement for' the year 1927, and state- 
ment of the income and expenditure accounts for that year, 
in respect of tho National Insurance Defence Trust., , 


Hospitals, . 

Conference re Contributorf Schemes for .Hospital 
Benefit. 


(Continuation of para. 137 of Anniml Beport.) 

197. This Conference was held at the offices of the Association 
on June Gtb, under the Chairmanship of the Chairman of 
Council, and was extremely well attended as is indicated hy 
the following table ; — 


London 

Provincial 

Scotland 

Ireland 


No. of Hospitals. 

36 

117 

5 

1 


No. of Eepre- 
sentatives. 

58 ■ 

161 

7 

1 


A very interesting discussion took place upon the 
Association’s memorandum on contributory schemes, for 
hospitals policy and its pamphlet entitled Policy affecting 
Hospitals.” It was A'ery encouraging to note how the support 
of the Association's hospital policy by the medical practi- 
tioners chiefly concerned has grown siiice the inauguration 
of these Conferences in 1920. A fill] report of the i's'eussion 
will be found in the B.M.J. Supplement of 16th June 1028 
pages 2.5S-2R2, copies of which are being' rircnlarised '’to all 
voluntary hospitals throughout the country. 


IjO-rTAOE HOSPITALS AND HOSPITAL POLICF, 

198. A pamphlet is hoing. prepared dealing with the apnlica 
tion of -the Association’s Hospital Policy to Cottage Hospitals 
ispemal reference being-made to the -method of payment of 
■medical staffs of cottage hospitals for Ireatmbnt therein 


284 June 30, 1928] 


Supplementary, Report of Council. 


f to Tint 

IBRITIHII JlKOICii JoirUTAL 


CoN’EjaDXTTony Schemes. 

. 199. A model contributory sclieme for hospital benefit is iii 
course' of preparation, as it is considered that this will be 
of assistance in securing the adoption of the policy of the 
Association in regard to such schemes. 

Middle-Class Hospital Police. 

(Continuation of para. 134 of Annual Peport of Council.) 

200. Consideration of Minute 219 of the A.P.M. 1927 
has been deferred until the report of the Pay Beds 
Committee ” of King Edward^s Hospital Eund for Loudon 
(referred to in para. 132 of Annual Report of Council) is 
available. 

Na^al and Military. 

Conditions of SEB^^CE of the Eotad Naval Medical 
See VICE. 

(Continuation of para. Idl of Annual Report.) 

201. At the request of a Division, the Council nr"ed upon 
the Admiralty ; — 

(a) That there should be an upper limit in the promo- 
tion zone, that is to say, an officer after having served 
for a period of 18 years shonld be eligible for promotion 
for a period extending for 5 years beyond that date, and 
no longer. 

(b) That the regulations dealing with the question of 
pensions should be amended to provide that in no cir- 
cumstances should the pension of an officer ivlio was in 
the Service when the 1919 changes were made, and ivlio 
was retired with the rank of Surgeon-Commander, be 
reduced below the pre-war figure of i£547. lOs. Od. 

In regard to the first question, tlic Admiralty informed 
the Council that when promotion to Surgeon-Captain by 
strict selection was first introduced, it was laid down that 
there should be no upper limit to the zone of promotion, 
since otherwise the oDect would have boon to debar officer.': 
veiy near the top of the Surgeon-Commander’s list by 
seniority from a chance of being selected for promotion; that 
it considered that the advantages of this system outweighed 
any possible disadvantages, and that there will always be a 
certain number of officers who must be aware that they have 
praolioally no chance of promotion, and such officers arc at 
liberty, under existing regulations, to apply to retire, if they 
wish to start a civilian career before reaching the age of 50. 

As regards the second question, the Admiralty lays 
stress on the facts (i) that the 1910 scheme must be viewed as 
a whole; (ii) that although rank for rank the increase in the 
rate of retired pay to medical officers was relatively small 
compared with other Branches, the effect of the new scalc.s 
was to enable a Surgeon-Commander '(entered at, say, the ago 
of 25) to earn the maximum retired pay of his rank after 
approximately 23 years’ service as compared with 30 years’ 
service imder the old rules; and (iii) that, under a concession 
notified in 1922, officers compnlsorily retired for age under 
the new regulations who were on tne Surgeon-Commander’s 
list on the Ist July, 1919, wili have retired pay of not less 
than £547. 10s. Od. per annum assured to them, whatever 
changes take place in the cost of living. 

On the above grounds the Admiralty does not see its 
way to adopting the Couricil’s suggestions. 

The Council has decided to defer further consideration 
of the 'question of promotion for 12 months, and as regards 
pensions the Council has come to the conclusion that no 
iisefnl purpose will be served by taking any further steps. 

Re-oegakisation of THU Medical Sekvices tn India : the 
Future of the Indian Medical Service. 

(Continuation of para. 139 of Annual Report.) 

202. There has recently been issued by the India Office a 
Communique concerning the re-organisation . of the Medical 
Services in India to the following effect:-^ 

(i) that the I.M.S. constituted on the same broad lines 
. as at present will be retained primarily to meet the needs 

of the Indian Army, the Local tfovernments being 
. required to employ a stated number -of I.M.S. officers in 
order to maintain the necessaiy minimum war reserve and 
to provide for European medical attendance for Euroiiean 
■ •. officers of the I.C.S. and their families;' 

(ii) that the total number of I.M.S, officers required 
for civil employment is calculated at 302, of which 212 
vail he Europeans and 90 Indians; 

(iii) that there will be 237 posts for these officers after 
allbwin"- for leave and study reserve, 178 of wliicli vrill 
be in the provinces and 59 under the Government of 

^”111030 posts wiU be filled as follows:— 

" Under Provincial Governments : 178 posts, of which U2 
innst be held by Eurojiean officers, the remaining GG to be 
open to Europeans or Indians. 


Under Gorernmenl of India: 59 posts, of wliicli 28 
will be open to Europeans or Indians, the remaining 31 
being open to Europeans only; 

(iv) that tlic medical requirements of European mcnibci's 
of the Superior Civil Services are based on data wliicli 
will cliaiigc from year to year as the proportion of 
Euroiican to Indian officers gradually diminishes and 
will be subject, tlicicforc, to jicriodical revision; 

(v) that certain rules will come into force as an integral 
portion of the sclicme. These rules deal with the question 
of cmployiueiit on the military and civil sides, and 
provide inter alia that liability to serve on cither the 
military or civil side will be a definite condition of 
service for all future '011 traiits to the Service. 

The civil appointments. which arc reserved for I-M.S. 
officers are scheduled, but the Council notes-witli deep concern 
that the jioats of Chief Administrative Medical Officers of 
Local Governments are not included in this schedule. In the 
opinion of the Council this is a retrograde step and is against 
the beat ilitcrcsts of the Service. It means that adequate 
op|iortnnities are lacking for reaching high rank in the 
Service, and ibis, rmipled with the fact tlmt employment on 
the civil side is new so indefinite, renders the new proposals 
iiiisaf isfiictory. , 

203. After careful consideration of the whole matter, the 
Council has informed the Secretary of State for India that 
the Association is convinced that the new proposals will not 
attract an adequate number of Eurojican medical men so 
long as : — 

(a) the iiosts of Chief Administrative Medical Officers 
of Local Governments arc noi specifically included lu the 
list of aiipoiiilmciit.s reserved for officers of the Indian 

.Medical Si'rvice; and i - i 

(b) the prosiuct of employment on the civil side.wiiicii 
is the chief indiicenieiit to enter the I.M.S. is as indefinite 
as it is at present. 


Medical Benevolence. 

(Coiif iiiiiation of para. 142 of Annual Report.) 

B.M.A. Chariiies Thust Fund. 

204. From 1st January to 30th April, 1928, the snni of 
£919 11s. 3d. was received for distribution among laeciicai 

cimrjtics at the discretion of the Trustees (ns compared witli 
£809 for the corresponding period last year), and has been 

dishibuted as follows : — , . ■ , 

£ s. d. 

450 0 0 


400 0 0 


Royal Medical Benevolent Fund 
Royal Medical Foundation of Epsom 

College ... ' ••• ••• 

Royal Medical Benevolent Fund 

Guild 

Sir Charles Hastings Fund 

Ill addition, the following .amounts linyc been collect^ 
for and transmitted to the uiidernicntioned Fundb^ the 
amounts for the corresponding period last year being also 
civeii for the jiiiniose of comparison; — 

. 192S. 


50 0 
49 11 


£ 

1,107 


d. 


1927. 
£ s. 
1,074 17 


786 0 0 749 0 3 


.34 10 
*94 6 


22 19 
*5G 16 


Itoyal Medical Benevolent^ Fund 
•Royal 'Medical Foundation ■ of 

Epsom College ■■■ 

Royal Meilical Benevolent Fnntl 
Society of Ireland 

Sir Charles Hastings Fund ... . . _ , 

* Includes contributions from the B.M.A. Chanties Trust 
Fund. 

Oversea Branches. . 

IVindward Islands Medical Service. 

(Continuation of para. 144 of Annual Report of Council.) 

205. The Medical Registration (Amendment) OrdmanM of 
1927 will prevent from practising in the Clo’ony unqualified 
Dersons and neiuons not possessed of qualifications u 
would permit them to be registered in England. This remo^s 
a (rrievance to which the Association 1ms never ceased to call 
attention since the original ordinance was passed. 

The ^cretary of the Grenada Branch having rei>orted 
that the revenue of the Colony showed a substantial increase 
per bead of a growing popnl.ation and that annual deficit 
bad been, transformed iiito n siifplns winch Imd permitted of 
the creation of a reserve fund and of steadily “oiea ,, 
expenditure in public services, the Comicil has informed the 
Secretary of State that the Association is disappointed 4° niid 
that the estimates for the Colony for 1928 make no pcoysm-i 
either for an improvement of the scale of f^^anes o 
medical officer.s or for.an iiicrc.ase in the medical ertablislimeiu. 
In doing so the Council, has called attention to statements bj 
the Secretary of State' and statements contained in reports 
dealing with -the Service, which indicated that improvement 



r fiViTLr,}ir.\T to -rirn ■ 
l British >ikihcai. Journal 


JUSH 30, I 920 J 


Oversea Branches. 


285 


in tlie scale of Kalarios'niid iucrca<-e iji csfnblisluiicut sliould 
receive attention at tlie Kulirsl possible juotiicnt. A copy of 
this letter lias been forwarded by (lie Colouial Office to tlio 
Goveruor of tlio Windward Lslands. 

T)Ei.i:fei!ious Dkugs OiimxwiCE or Stiiaits SiniaEMENTB. 
(Coutimiaiioa of para. IJ.i of Animal llcport of Council.) 
20G. According: to a local aicwspajier it appeam tliat tlic 
regulations tinder the Dflctcrioiis Uriigs Enactiaenl. (Federated 
atalay Statc.s and Strait.s Settlcniciits) have been brouglit into 
lino with the Daiig-eroiis Grng.s ItognlntionR of the' United 
Kingdom, but otlicial coufirniation of tins baa not yet been 
received. 

IxtnoExocs SvsTKMS OF ATedicixi: in Cf.vlon, 

207. The Colonial Office bus reported Ibat tbe Ijcgislative 
Council of Ceylon has made provision in its estimates for 
1027-28 for the sum of l!s.75,()00 as ,a grant for Ayurvedic 
study. 

WOKK OF Tur. OVF.ItSE.V BUANCHEO. 

* 203. The report-s of the .iii.straiian Feder.al Committee, of 
the Federal Council in South Africa, and of jiractiralty tbe 
rvliolc of the Braiiehe.s of the Aasoeiatiou overseas show a 
.splendid iccord of activity. The following points aie of 
special interest. 

Arnic.^. 

The ti'nioii of Smith .Ifricn. 

203. The outstanding event of the year has. of eour-a>, been 
the First Anuual Sciontilic Meeting' of the Medical Associa- 
tion of South Africa (British Medical Association), held in 
Bioemfonteiii. This was attended by the Cliainnan of the 
Council of the sVssociatiou and other home deleg.ates who have 
reported most cuthusiastically ou tbe success of the Conwress 
and the kiuducss that was .sh'own to them. The Council offers 
its hearty congratulations to the I’l-esidciit of the Congress, 
Dr. C. H. Bidwcll, the Honorary Secretaries, Drs. Alice 
Cox, Marion Thomson, and -Ixmisc Tomory, and tlie 
members of the Orange Free State Branch who did 
so mnch to secure the success of tlio Congress. The Federal 
pnmeil under the Chairniamship of Dr. A. J. Oren.stein ha.s 
been engaged during the year in many matters of the greatest 
imjiortance to the profession in South Africa. It has been 
particularly active in placing the organisation of the Branches 
on a sati.sfadory footing. _ many iieiv Divisions iiave heeii 
formed, and the membership 1ms conse<|UCnUy increased coii- 
aulerably. The logical outcome of its action in tliis couucction 
IS a proposal to amend the constitution by creating a House 
of Delegates which would oeciiiiy a position simitar in status 
to that of the Iteprcscntatiye Body in this country. The 
sug'gcsrion has wisely boon postj)oiic(I for the time bciiic* until 
the new Constitution has been further tc.sted. The ouc.slioiis 
of the payment of medical staffs of public licspitais. the 
tiaimng of ji.-itive medical .as.sistaiits and the inopo.sed 
.\atioual Insurance Scheme for South Africa arc ctiwawing the 
a tcntiou of the Federal Council and are of the lir“s^ln^,o^ 

• '2. f •9°'”’;'’ ’S f "ht-e that in addition to tho 
great activity shown by the Federal Committeo .and the 
Brauchra in the ordinary work of the Associatiou. the 

‘V during ihc year increased 

Its Beneiolcnt Fund from TtOO to £1,000. 

010 m c Sovfli-li’esl .4friea. 

- ,.2.10. The .South-West Africa Branch which works under con 

cStrni of , nn-satmfactory position with regard to the 

...» o. X'r'""* 

' 010 -n T- TI'e.tt Africa. 

simcwsM^^w Branche.s report .a year of 

Asra, 

question of ?eS3tratimi^of*2i -If*- ^ report on the 

' Branch has.alfo 00 , 1 . ^ midwiyes ni tiie Fresideiiey. The 

paying treatment qne.stiou of free and 

activity if J., nnf hospitals, and. with its record of 

sl'ip is' rtcadily inerSngf ” Branch member- 

year, 'and tliere^K^^Mcj?'^'’-'!']-. forraod during the 

meet a long felt want 5i7the*2r2*^'”'Vi^’“2i Oody will 

are given to those ''!?“• Tlie tbanks of tbe Council 

in ch-cnir.stavpes of great di^nHy*'*' 


been draini np for the constrnctioii of a tuberculosis sana- 
torium The Branch has mode application to tbe Government 
for a grniit tow.ards the cost of the Institution, and the 
remainder of the money required will he raiseil by voluntaiy 
contributions. 

The need for a medical organisation has long been felt 
ill the I’nnjiib, and to meet this need the Punjab Branch has 
ifcciitly been revived. Foity-livc new members have joined 
tlie llraiich and a fine programme of scientific meetings at 
frequent intervals was carried through. 

The South Indian and Madras Branch also reports d. 
year of succes“{nl activity, 

Ceylon. 

214. The action taken by the Ceylon Branch in connection 
with the ipic-tion of indigenous systems of medicine in Ceylon 
is dealt with in the Council's Annual Report. A record of 
nine nieetiiigs with an increased mcinbership completes a 
satisfactory year’.s work. 

• Song Rang and China. 

215. Notwitlistanilius the nasettled. conditions in China, 
the Hong Kong anil China Branch has been active dtiriiio- the 
year, and a most .successful function was recently liefd at 
which over 100 meilica! practitioners were present. 

Mnlnga. 

2IG. ”1110 Malaya Branch has now its own medical journal 
which IS the official organ of the Branch. The Branch has 
considered questions relating to the Malayan Meilical Service 
and. to the deleterious drugs ordinancc.s of the Straits Settle- 
ments. Its mtanhcrsliip is now nearly 300. wliieh represents a 
considerable increase during the year. • ' 

AtrSTHALAsrA. 

217. The membership of the Association in. Australasia is 

repiescntlug a remarkable increase of over 
* i‘® , ^''® Branches of the Association 

in Mstralasia severally and collectively are in an enviable 
position both as regards numerical strength and influence. 

Australia. 

218. The Australian Federal Committee under the Chairman- 

ship of Sir George .Syme lias again had before- it' many 
mattere of importance to the profession in tho Commonwealth 
The Council is greatly interested to note that Uie Federal 
Committee, after considering the question of medical serrico 
III piibhc hospitals, liag readied the conclusion that in nublic 
hosjMtals 'isduch treat as in-pjitients those 'irho are. able to iVav 
1122 0 “ ?f maintenance aud treatment, \ho 

medical staffs shou d receive payment for their services to 
those wjjo pay while contninincr to treat ffratuitnuoiv 
uuahlc^to pay. The Committee discussed With the Australian 
Ph.nrmacentica Conference points of . mutual interest in con2 
neetion with the proposed nation.-,) health insurance scheZ 
Other matters dealt with include the adoption of 'aiCommon 
For,,, of -weement for the use of the whole of the Branches 
m Australi.a in comicctjon n-Jti Friendly Society re22o 
Practice ; the drafting of model rules governinw protldime^fn 
ethical m.rttcrs; and iho adoption of uniform ^cs f2r 
tiavelhng medical ofiicers of life assurance societies 

The mcmimrsliip of the New South Wales Branch awoin 
shows a ptisfactory increase. No -less than 20 mcetiims wmn 
he d during the ye, nr, the ordinary meetings bei,2g arrani^d 
with meetings of clinical sections, a svstem wl.;2f 
found to work very satisfactorily.' Addition^ land Zl 1 “ 
acquired for the new premises of the Br-S, am H.e 'f?* 
or B.M.A. Lectures delivered at m^tin^Tf Jocal ailFc- 
outside the metropolitan area has been contiiuie'i/ 
tion with the ho/diug of the third l"sXn orthe InstraKln 

KsbiS-’irb.;.- .& ifhA'Ir” 

The organisation of the Queensland Bi-uid, i,»= 1 
improved by the formation of nSie ZeaTmiS Z LoJor^'' 
during the year. Conferences of represenHtZi ^ ^ 

local medical asBoriation'^ and of thf Bush Nursiui 
tmu have been held for the Asrsocia- 

policy of the Branch. Tl.e B^nrif lo^Cpfate 
new premises, and the questions of flri^ "c’^and *2 -f i^^^ 
site are now under consideration. A sncresrtni post 

’ZTJsrimiursr^^ 

TIjc "V Icto'rian Branch renorfs oi -nyoetfi^ v 

creased ■niomheislup. The report of Dm *’nd an in-' 

covc,« a wide fiehi of greatriidoresf III™"®'’ year 

ptcl'ession in Tictori.n. Khmierous etiucal 
been dealt with; the formation of a I '®'^® 

tioners’ Section of the Branch has been .n"'" “®,'^‘®®' 

Ims been t.-iken in connection wiG, action 


286 June 30, 1928] 


Current Notes. 


r BUrpi,T:srT:NT to tot 
Lnnrrisn mkdica.l Joubhil 


officers of public bo^itals, in the majority of cases witli 
eatisfactory results. Owing to the growing importance of the 
hospital policy of the Association a special Hospitals Com- 
mittee has been formed to deal with all matters in connection 
■with hospitals. The Medical Agency under the auspices of 
the Branch continues in a flourishing' condition, as docs also 
Jhe British Medical Insurance Company. 

The work of the Council of the Western Australian 
Branch has been particularly heavy during the vear. the 
new provisions of the Workers’ Compensation Act having 
entailed careful consideration. 

Tasmania. 

219. The Tasmanian Branch reports an improvement in the 
amount of clinical work that 1ms taken place at meetings of 
the Branch. The post-graduate work of the Branch has been 
continued and several important ethical questions have been 
decided. 

New Zealand. 

220. The New Zealand Branch reports an increase of 45 in 
its membership. During the year, the Branch took steps -for 
its Incorporation, and the Council extends to the Branch 
its best wishes for continued success under the new regime 
under which the corporate status of the Branch will lie 
improved. The Branch has now received, from Dr. 
MacEachern, who, in 192G. made a tour of the hospitals in 
New Ze.oland at the request of the Branch, a comprehensive 
report on the whole situation. The report will bo a valuable 
source of reference and the Branch is in communication with 
the Government with a view to publication and circulation of 
the report. 

The Executive Committee of the Branch has been in 
frequent communication with the Government on matters 
bearing on the health of the community ; the newly-formed 
Obstetrical Society, which aims at enrolling all members of 
the Association in New Zealand actively engaged in obstet- 
rical work, has been affiliated to the Branch; the Medical 
Agency, the net profits of which belong to the members of 
the Branch continues to fulfil its useful purpose, and the 
Medical Benevolent Fund has now readied the satisfactory 
total of nearly £7,000. 

West Indies. 

221. The Jamaica Branch, the oldest of the Overseas 
Branches of the Association celebrated its Jubilee in Decem- 
ber. The Council, on behalf of the whole membership of the 
Association, extends to the Branch hearty thanks for past 
good work, congratulations on the jubilee and best wishes for 
Increasing usefulness of the Branch to the profession in 
Jamaica. 

H. B. BRACKENBUBY, Chairman, 


APPENDIX. 

NATIONAL INSURANCE DEFENCE TRUST. 
(A) Balance Sheet, 31st December, 1037. 

LIABILITIES. £ 


To Capital Account : 

Balance 31st December, 1926 

Add Excess of Income over Expenditure 


ASSETS. 

By Investments represented at average cost by 
£2,500 Central London Railway 4i% Debs. 
£5,000 Commonwealth of Australia 5% 1935-45 
£5,000 Commonwealth of Australia 5% 1945-75 
£15,000 Consolidated 2\% Stock ... ... 

£10,000 Consolidated 4% Stock 

£15,500, Conversion Stock 

£10,000 Conversion 4i% Stock 

£12,000 Funding Stock 4% 1950-90 

£10,000 India 5J% Stock 1932 

£5,000 India 3^% Stock 

£5,650 National War Bonds 3rcl Series 1928 
£5,0M New Zealand 5% Stock' 1935-45 ... 

£5,000 New Zealand 4i% Stock 1944 

£5,000 New South Wales 5% Inscribed Stock 

1935-55 

£5,000 New South Wales 4i%. Stock 1935-45 
£5,000 Queensland 5% Inscribed Stock 1940-60.., 

£1,500 Treasury Bonds 5i% 1930 

£11,250 War Loan Bearer Bonds 

' £5,000 Victorian Government 3% Consol. Stock 

1929-49 

(Slarkct Value at 31st December, 1927, £122,245) 
13v Loans— 

'British Medical Association 

. Essex Public Medical Service. ... £400 0 
Less: Repayment £50 


8. d. 


£ 8. 

tl. 

2,325 0 

0 

4,906 5 

0 

5:ooo 0 

0 

8,362 10 

0 • 

8,560 0 

0 

11,603 2 

6 

9,730 0 

0 

10,360 12 

6 

10,125 0 

0 

3,518 15 

0 

5,881 8 

1 

5,106 S 

0 

4,868 15 

0 

4,771 17 

6 

4,690 12 

6 - 

4,662 10 

0 

1,530 0 

0 

9,993 12 

6 

'3,615 12 

6 


•... 104.585 4 11 
... 22,887 6 9 

£127,472 11 8 

6. d. 


• 119,611 18 1 


0 

0 0 


6,500 0 0 


350 0 0 


By Cash at Bank 


6,850 0 0 
1,010 13 7 


£127,472 11 8 


We have examined the above Balance Sheet with the books of the 
’rust, nud find them to be in accordrince therewith. 

' Wr liivf* verified the Investments and Bank Balances, 
wo nave rerineu no (Signed) PRICE. WATERHOUSE & CO. 

3. Frederici’e Place; Old Je^v;r^^ London. E.C.2, 

Jlarch 29th, 1923. 


(B) Income and Expenditure Account for the Tear 
ending Slst December, 1037. 


To Repayment to B.M.A. 
of Expenses in connection 
with 

(a) Annual Conference of 
l.<ocal Medical artd 
Pane. Committees, 
& election of direct 
representatives on 
Insurance Acts Com. 
inittec 

(b) UnUwa 3 ' Fares of In- 
surance Acts Com- 
mittee, SnhCom- 
inittces and Depu- 
tations. and 

(c) Reprinted record 
cards and reply en- 
velopes 

,, Accouiiuints* Fees in 
connection with sUlls- 
tical information suj). 
plicil to the Insurance 
Acts Committee 
,, Preparation of Addresco- 
praph Linksfor montldy 


£ B. d 


. 8i4 17 4 


5 C 0 


practitioners furnisliing 



etntisUcs .. 

1 B 


Income Tax ' on Rank 
Interest and iintnxcd 
I>ividcnds . . . . 

Cl 0 

0 

Mtflcellaneous Frintinga 
and St.ationcrj' 

41 S 

0 

Rank Charges . . 

16 

8 

Railway Fares .. 
Postages 

B T 

8 

70 0 

0 

Audit Fee 

10 10 

0 

Petty Cash 

31 3 

0 

Ralarj* of Plerk .. 

20 B 

0 

Charges incurred in pttr- 
chase of stock .. »» 

fiO 10 

0 

Balance of income over 



Expenditure .. .. 

22,857' 6 

9 


£ 8 d. 

By Subscriptions .. .. 19,170 4 C 

,, Dividends and Interest 

on Investments .. 4,070 0 0 
,, Interest on I/oans .. . . 29il 10 0 

,, Deposit Interest •• 7 9 0 


£2.'I,Br»0 40 


£23.Br>0 4 0 


50 rUislj ^ssonation. 

CURRENT NOTES. 


Spa Practitioners Group: Annual Conference. 

The uttention of incmbcws of tho Spa Practitioners 
Group of tlie Association is drawn to- tlie fact that tlie 
first annual conference of this Group will be hold' during 
the course of Iho Annual Meeting at Cardiff on Wednesday; 
July 25th, at 2.30 p.'ra. . Evei-j- member of tho Association 
who regularly prescribes tlie mineral waters or baths of tlie 
spa in which he resides, or who is on the staff of a hospital 
or clinic wliere tlie use of local mineral waters is part of 
the routine treatment is ipso facto a member of tins 
Group. 

Consulting Pathologists Group of B.M.S.: Annual 
Conference. 

Tlie fii'st annual conference of -the Consulting Patlio- 
legists Group will he licld at Cardiff on Wednesday, 
July 25th, at 4.30 p.m., upon the conclusion of the Spa 
Pradtitibnors Group Conference (referred to above). 
Every meralier ' of tlie Association (not being a' member 
of the Public Health Service) who is working in an institu- 
tion or private patli'ological laboratory engaged in examin- 
ing and reporting on specimens for .clinical purposes is 
ipso facto a member of the Group. 


Association J^otircs. ' 


EAST YOEKS AND NORTH BiNCS BRANCH : EAST 
YORKSHIRE DIVISION. 

Notice is hereby given by tbe Council to all concemecl that 
the East Yoik anti North Lincoln Branch and the East York 
Division ot that Branch, respeotiveiy, propose that their 
nauies be altered to East Yorks and North Lines Branch, and 
East Yorkshire Division. Any body or person affected by 
either of these proposals, and objecting thereto, is requested 
to notify tlic Medical Secretary, slating reasons, by not lalcr 
than July 30th. 



S88 JUNE 30, 1928] 


Assocfatlcn fntc/Ifgonco and D!ary, 


r rrrrr.TTi^rr.vT m rnr 


YACANCIES. 

'AsrrTON’-rNDLn-LYXE : District iNFinjLiny.— Third Ilousc-Surfipon. Salary 
at the lato of ±150 per annum. 

Bomiuy : C\:.iv Axb Albltss Hospital for’ Wohfx and CiiiLORnx. — 
Meiliea! Officer in Chargs (lady). Remunoration Rs.BOO— 50—1,000 per 
iaent>em for officer of Asiatic domicile, and Rs.600— 50— BOO, plus ±20 
per mensem as overseas pay for officer of non*Asiatic domioilc. 
BniOFORD City: Assistant School Jilcdical Officer (male). Salary ±600 
per annum. 

Brightox : Royal Sussex Couxty Hospital.— H ouse-Surgeon (male). 

Salary £159 per annum. _ 

BupvTon-ox-Trext General Ixtirmiry.— S enior Resident Ilonsc-.Surgeon. 

Salary £200 per annum. ' 

Cardiff Royal Intirmary. — Honorary Surgeon fo (he Kar, Ko«e, nncl 
Thioat Department. 

Cfxtral London OpiiTiiALTAnc Hospital, Judd Street, "W.C.!.— (I) I'alhologI':! ; 
honoravinm ±75 per annum. (2) junior House-Surgeon; halary nt the 
rate of £59 jht annum. 

City and Corporation of Kingston-upon-Hull ano Holt, and Goolk Port 
Sanitary Authority. — As'<isfnnt Medical Officer of Health. Sal.ary £600 
per annum, ri.‘<ing to £700. 

Devon Mental Hospital, Exminstcr. — Junior Afslstant Medical Officer 
(male, unmarried). Salary £300 per annum, rising to £350. 

Edinrurgu : Elsie Inglis ^Ie^iortal JIaternity Hospital.— Two nouse- 
Surgeons (women). 

Edinba’rgii Hospital for ^VoMFN and Childritn.— ( 1) lIou<;e-Surgeon. (2) 
House-Physician, (5). Junior House-Surgeon (non-residonf). Women. 
Edinburgh : Royal Edindu.igh Hospital tor Sick Cnii.pnrN. — rive 
Honorary Resident Medical Officers 

Essfx County Hospital, Colchester. — A^'.'istant Hausc-Surgoon and Rcgl*** 
trur (male). Salary £120. 

Grayesf.nd and North Kent Hospital. — Junior House-Surgeon. Salary £100 
per annum fnr nine months, rising to £200 on appointment as Senior. 
Hartlei'ools Hospital. — House-Surgeon (male). Sal.ary £150 per anniitn, 
rising to ±200. 

Hackm:y am.) Stoke Newington TtfREnruLosi.-* DisPiixsAnv. Mi-trimolUnn 
Hospital, Ivingslanrl Road, E.8.— Tuberculosis Officer. S;dar\ £750 per 
annum, ilsmg to £850. 

Hospital for ConajUMption and Dicrases op the Citfst, Brompton, S.W.J.— 
House-Ph\sicuin. Honorarium £50 for si.x months. 
lIOA’c: Lady CHinir..sTER Hospital.— (1) Housc-l’hy.sician. (2) Junior. 

Wompn. SalaiN at the rate of £100 and £50 per annum rc<ipeclively, 
IvENsiNGTON BOKOiGH. — Temporary Tuberculosis Officer at (he Kensington 
Tuberculosis Dispensary, 119, Ladbroho Grove, W.ll. Honmanum 
35 guineas. 

Lancashire County CouxaL — Junior House-Surgeon (woman) nl the 
Biddulph Grange Orthopaedic Hospital. Salary £150 per annum. 

Leeds Public Dispensary. — (1) Honorary Physician. (2) Senior Ri^fident 
Jledical Officer (male); salary £200 per annum. 

Lo.ndon Jewish Hospital, Stepney Green, E.l. — Honor.ary RadiologUl. 
London School op Hygiene and Tropical MEDiaNC.— Ro^carcU Studentship 
in Helminthology, Value £250 per annum. 

LoAvrsTort and North Suffolk IIospital,— H ouse-Surgeon (male). Salarv 
£120 per annum. 

Makxhcster : St. Mary’s Hospitals.— Two House-Surgeons for Whitworth 
Street West Hospital (Maternity) and two for the Whitworth Paik 
Hospital (Children and Gynaecology). Salarv at the rale of £50 per 
annum each. 

Manchester University.— Reader in Materia Mcdica and Thcr.ipeutic<?. 
Stipend £800 per annum. 

National HorPiTAU, Queen Square, W.C.l. — Honorary Surgical Assistant. 
Neavark Hospital and Dispensary.— Resident House-Surgeon (male). 

Salary at (he rate of £150 per annum. 

Nottingham : City Mental Hospital.— Junior Assistant .Mctlicat Officer 
(male). Salary’ £350 per annum, rising to £400, witli an additional 
£50 for D.P.M., and £10 for SI.P.O, 

Plyaiouth : South Devon and East Cornavall Hospital.— Resident Surgical 
Officer (male). Salary at the rate of £100 per annum. 

Rf.adikg : Royal . Berkshire Hospital. — (1) IIoiisf-PhyMcian. (2) House- 
Surgeon. (3) Third House-Surgeon. Salaries £150 per annum, 
Richmond, Surrey : Royal Hospital. — Junior House-Surgeon (male). 
Salary £100 per annum. 

Royal Free Hospital, Gray’s Inn Road, W.C.l. — Junior Clinical At.sistant.s. 
St. Mark’s Ho-spital for Cancer, Fistula, etc,, City Road, E.C.I.— Resident 
Surgical Officer (male). Salary £150 per annum. 

St. Mart’s Hospital, W.2.— Dental Surgeon. 

6t. Vincent’s Orthopaedic Hospital, Eastcote.— Resident Medical Officer 
, (male). . Salary nt the rate of £150 per annum. . ’ . . 

Saltord Royal Hospit.vl. — House-Physician (male). Salary at the rale of 
£125 per annum, 

Skeppield : Jessop Hospital for Women.— (1) Senior Resident Officer 
(male); salary £250 per annum. (2) Three Assistant House-Surgeons 
(male) for Gynaecological and Maternity Departments; salary at the 
rate o( £100 per annum. 

Sheffield Union Hospital.— Resident Assistant Medical Officer. Salary 
£250 for first year, rising to £300 for second year. 

Surrey County Council.— (1) Deputy County Medical Officer of Health. 
(2) Assistant Medical Officer. Salarj' for (1) £1,000 per annum: and 
for (2) £600 rising to £700. 

Taunton and Somerset Hospital.— J unior House Medical Officer (male). 

Salary nt the rate of £10t) per annum. 

Victoria Hospital for Children, Tito Street, S.W.3.— (1) ITouse-Physician, 

■ (2) House-Surgeon. Salary at the rate of £100 per annum each. 

West London Hospital, Hammersmith Road, W,6.— Resident Assistant 
Surgeon. Salary £200 per annum. 

Woking and District Victoria Hospital. — Orthopaedic Surgeon. 

Worthing Hospital.— House-Surgeon (male). Salary at the rate of £150 
per annum. 

Woolwich Union. — Second Assistant Medical Officer at the Plumsiead ond 
District Hospital (male, unmarried). Salary £350, rising to £ilO0. 
Wrexilam and East Denbighshire War Memorial Hospital.— Two Resident 
House-Surgeons (male). Salary at the rate of £100 per annum each. 

TORK : The Retreat.— Temporary Assistant Physician (male). Salary 
six guineas weekly. 


Mrr>ic,AL RuTRrr.<- umku iiii: WorusunV C«TM?iN<^.\T;rN An. i:25. for 
(1) the Invcrno^v (.Wainl.'irnl) Dif-tiirf, :uul (2) the Wirk Dixfrict 
Applications to the Piivato Socrclarv, SvoAtish OlUco, WhilHiah. S.W.l. 

Iiy July IBih. 1 

This thi of rnrnne/fw ».» rovipihfl from our nrlrrrtisrmrpf 

it'hcrc full p(/rfiriif(/rM mill he fouvd. To rvxurr vntirr m this 
column vth'criisnntvts viust hr rccrivrd not later than ihr first 
post on Tuesdup morninii. 


DIAIlY OF SOCIKTIKS AND LECTURES. 

Royal .Society of JJnJiriNr. 

Annual Crnrrnl .Vert/ng.— 4 I'.rn. 

OcnernI Mrctnif; of Tefloirs. — Tuc*.., 5.30 p.ni. 

Harvfia?: Society, Gnv’.s HoopitnJ, .S.E. — ^Thnr«^.. 4.30 p.m,, Prmon'trationf 
in the Cnrdjohjgii-af, B.'iclcnofi'gic.al, and' .V*Ray Department®. 

Mrniro-LfCAL SoniTY, 11, flmtulMs .Strrr‘t, W.I.— Tliur.®., 8.30 p.ni,, Annual 
fJencrai .'freting, followed l)y ordinary meeting. 3Ir. Noel .Middleton: 
TcMainentary Capacity. ’ ' 

POST-GKAnUATK COCnSK-S AN’D DKC'rtJIIES. 

rniow.'fiip or .MiDiriNT a,m> I’o.'^r-fJnAnuATE Mrruru. Af^oumtio.v.— TT rorZ/cy 
Hill Countrf/ OrthopariUr Ilotiiilnl ; Deinensf ration, ’J'tu®., 31.20 p.m., if 
fen pnsf-gradimf r*. notify tfn-ir intrntioti fn !,.• pn-'-'^mt (tr*o-|inorie 
Mayfair 2256); no fee. Jhnrtl lf\->'tnifiit‘frr Ophthotn.ic //o^/oVa/, Bread 
Street, W,f5,2 ; Dcn»nn»iiatif»n. TJuir.®,, 3 p.ni.; no fee. Chnnnp Crntn 
Hospital, W.t‘.2 : Jtennoi'-f ration, I'ri., 2 p.m.; no fee. IJV^f F.uit 
vital for AV/ton* Hhenfi's. Welheek .Street, W, : Special Course of 
I^icfurc^ and Clinical Denion«fraf ions upon hcteetcd caj-es nt 5 p.in. 
daily. Ticket® fioin the IVIJowship of Medicine. 1, W'Impole Street, U.l. 

Koiitii-Ea®t 1.om>(»N rn'T-flRAiurATL C’oii.iGF, I‘rince of VA’ales'p General 
Ilospit.al, Tottenham. .\.15— Mon,, 2.30 to 5 p.m., .Medical, Surgical, 
and IJA'n.accologicn! Clin'ics: Operation®. Tiir®., 2.30 to 5 p.m., .Medical, 
Surgical, Throat, Nc®e, anil Ear Clinics ; ffpeniiioh®. Wed., 2.20 to 5 p.in., 
3!edica!, Skin, and i:ve Climes; Operation®. Thurs., 31.20 a.m.. Dental 
(’linlca; 230 to 5 p.ni.. .Medical, Surgical, and Ear, No»e, .and Throat 
Chnics; Operation®. I'ri., 30.30 a.m., lliroat, N'o-e, and Ear Clinics; 
2.30 ff> 5 p.m., .Surgical, Medical, oiul Children^ -Dif-ca'cs Clinics; 
Operation®. 

.St. r.AUL*-s lIosriTAL, Kndell Street, \V.C.2.— Thurs., 4.30 p.m.. Hydro- 
nephrosi®. 

Joint TuCfmcui.O'l.® Countii..— S pecial Course nt Cambridge. Mon. (n Sat. 

LiVERroC)!, ll.\ivrr..«iTY ri-iNica Sriioni, Antt-Natal fUNirs.— UovHt 
Infirmarv: Mon. and Thnrs., 30.30 u.in. .Maternity Hospital: Mon. 
Tiirs., \\Vd., Thurs., and Fri., 11.30 a.m. . _ 


Jltfbirnl ^550nirtiDn. 
omers, imiTiFU mkihcal dS.«:oc/.ir/o.v uotss, 

TAVISTOCF SQUAJU:, \y.C.2. 


Depart monts» 

SuBSCRimoNs AND ADVERTISEMENTS (Financial Secretary and DusId?sj 
M anager. Telegrams: Articulate Wcslrent, Lantlon). 

Medical Secrctarv (Telegr.'ims : .Medisecra Wcsicent, London). 

Editor, IJritith Hctlieal JvUTual (TelegraAus: Aitiology Wc'tre'U. 

Telephone nnniberji of Rriti*h .Vedtral jAPncinfion nnd Ttritish 
Jotmial, Mnsoum P851, 9862, 9863, and 9864 (internal cxeliang**. 

four lines). , 

Scottish Medical SrcnriAnY : 7, Drumsheugh Carden®, Edinburgh. (Tel^ 
grams: Associate, KdinlmTgh. Teh: 24361 EdinhurghA /t^i*. 

iRi.sir Medical Secretarv : 36, South Fretlenok Street, Dublin. (lete- 
grams : Bacillus, Dublin. Teh: 4737 Dublin.) 

Diary of tho Association. 


Jolt. 

5 Xuc 3 . Croydon Division; CroAtiun General llo®pitnl, 8.30 p.m- . . 

North Lancashire and' .South Westmorlnml Branch ; Annual 
Meeting, Kthci Hedloy Hospital, t'algarth. 3.15 pm 

4 Wed. Bedfordshire Division : Annual Meeting, Swan Hotel, Bedford. 

Sir Maurice Craig on Nerve Exhaustion, 3 p.m. Imnchcon, 
1,35 p.m. Executive Committee. 2.20 p.m. 

Dorset and West Hants Branch : Church House Hall, WimboTne, 
5 p.m. . - . 

Shefiiold l'>ivi®iD7i : TiUnchcon to welcome successful Ktvwlcnts 
at Final M.B., Royal ^'ietoria Hotel, Shcfflold, 1.35 p.m. 

5 Thurs. London: Psycho-Analysis Committee,- 2 to 4 n.m. 

Norfolk Branch: Annual Meeting, Town Hal!, Avlfliam, 3 p.m. 

6 Frl. London : National Formuiary Subcommitlco, 11.30 a.tn. 

North Wale.® Branch : Annual Meeting, North IVale® Sana- 
torium, I.langwyfan, Denhigh. _ 

Sheffield Division ; Church House, St. .Tames Street, Slieffield, 
8.30 p.m. 

10 Tues. St, Pancras Division : B.M.A. House, Tavistock Squnre, 
iVvC.l. Dr. W. Camac Wilkinson on tho Home Treatment 
of Tuberculosis by tho General Practitioner, 9 p.m. 

14 Sat. Bournemouth Division : Social Sleeting, Pitt Rivers Mu.scum, 
Farnhani, Blandford. 


BIRTHS, MARRIAGES, AKD DEATHS. 

The charge for inserting announcement of Itirths, MarriogeSt and 
Deaths is Us., which sum should he foncarded with the pottec 
tiof tefer </inn <Ac first post on T uesday Tnorntnp, tn order to 
ensure insertion in the cui’rcnt i.ssue. 

MARRIAGES. 

Moncrieff-Wedmorb.— On Juno 20th, at All Saints, Clevedon, 

Alan Moncrieff,' RhD., M.R.C.P., to Honor, only child of Mr. and Mrs. 
Cecil Wedmore. 

WALKCR-DArvNTON. — At St. Michacl® and All Angel®, Carlefon. ric.Tr Fonte- 
fract, on Juno 19th, 1928, George Frederick Walker, ShP., M.R.6.P.* 
Resident Medical Officer, the General Infirmarv nt Lccd.®, to Alma, elder 
daughter of Mr. and Mrs. Herbert Darnton of Carleton. 

DEATH. 

WiLLLA^r®. — At VilleTvillc. on June 18fh, Richard Tudor 'William^, 
B.S.Lond., of Llanfairfcchan and of Idas-y-lVnrd, Ruthin, 


Printed and published by the British. Medical Association, at their Office, Tavistock Square, in the Parish of St. Pancras, in the County of London. 



X u.xa 

ritfelt lltedital Jmtmal. 


THE JOTJENAl. OF THE BKITISH MEDICAE ASSOCIATION. 


EPITOME 


OF 


Current Medical Literature. 


a A IJO- XJ AS. R Y TO JUNE, 1028. 


F. W. W. GRIFFIN, M.D., 

STy'B-EDITOIl. 


Exm&mt: 

PSmTEB POTusmB iSSOCUTION 

T^^STOCK square, LONDON, W.C.l. 





INDEX TO THE EPITOME EOE VOLUME I, 1928. 

, , .• I , will finfl if to bear in mind tbnt the references are in several cases distriboted 

Ee,U)ERS in search of a particular subject iustance, as Brain and Cerebral; Heart and 

u^uder two or more segvrate b t Carcinoma; Epithelioma, Malignant Disease, New 

Growth,’ sfrcoma etc. fSd ’and Infant; Bronchocele. Goitre, and Thyroid; Diabetes, Glycosuria, and Sugar; Eye, 
Opbtlialmia, and Visiou, etc. — — 

27ie Figures in this Index refer to the Number- of the Paragraph, NOT the Page. 


A. 


Abdominal adhesions and provoutlon of post- 

operative p0rltonitJB^_4^1 

, nic anaos* 

Abdominal surgery, temporary uaemostaats In, 

412 

Abdominal wall, cystic swellings of. foiiowmg 

AbortS'n’ followed by gonito-peritonoal tuber- 
culosis, 199 , , 

Abortion, induced, lalo 8eanel<i ot.493 
Abscess, amooblc, emotino 
Abscess of liver, treat’^ont of,59 
Abscess, peritoasiUar.57 , _ i? 

Absc^a^, pulmonary, follo'winfi tonslllcctomy.6 
Abscess, pulmonary, and gangreno, surgical 
treatment of, 362 , 

Abscess of spleen in typboid fever, 138 
Accidents followed by oxtrapyramidal syra- 

" a!c?E.’* anaesthetic mUxturc. ainodiOioa falko- 
form), 257 

Acetabulum, fractures of tuo,w7 
Acetone treatment of cancer of the cervix, 127 
Acid-fast bacilli. Srs Bacilli 
Acidosis in athletes 268 

Acidosis, diabetic, 4C6— Chemical changes con* 
cemedin,66l 

Acrodermatitis perstans. 301 , 

Actok, H. W,: Etiology and treatment offporo* 
keratosis. 122 . , , 

Adajijlktiadis. B. : Keratitis due to an infection 
of trachoma. 520 

Adaois. D. K. : Cutaneous spiroebaotosis due to 
frtfpoTima eunienli in British rabbits. 553 
Addison’. W. l. T.; Saline solutions in hyper- 
tension. 490 

Adenomas of rectum, carcinomatous degenera- 
tion in. 60 

Adleb, K.: Fractnro of the clavicle during 
spontaneous labour, 501 
Adrenaline, effects of on respiration, 642 
Agitation, states of. somnifen in, 63 
Air embolism, death from. 457 
Alcohol in acute infectious diseases, 489 
. • ' 622 


• re. 257 

Allen, E. V.: Thrombo-angiitis obliterans, 295 
Aloi. V. : Tuberculosis of the breast. 214 
ALTABEZ, W. C. : Intestinal absorption, 308 
Amato bodies in scarlet fever, 150 
Amaurdtic zoster, 521 

Ambard's constant and the renal functions, 333 
Ameoorrhoea, extensive pigmentation of the 
skin assneiated with. 124— Treatment of, 549 
Amino bases of ergot. 223 
•Amoebic abscess. S'C Abscess 
Anaemia, pernicious : Liver feeding in, 144, 170, 
^.344.353,543— Etiology of. 284— In pregnancy. 

Anaerobic bacteriaemia, 605 
Anaesrhesia. other, carbon dioxide administra- 
tion during. 577 
Anaesthesia, ethylene, 578 
Anaesthesia in gall-bladder surgery, 13 
Anaesthesia.rectal, 12— Ether and gas-oxygen, 255 
Anaesthesia, regional, for operations on the 
spinal column, 14, 452 
Anaesthesia, sacral block, 575. 576 
Anaesthe ia, spinal, in obstetrics, 201 — In 
labour, 375— Ocular complications of 450 
Anaesthesia, splanchnic, in upper abdominal 
Operations, 451 

Anaesthetic mixture, a modified “A.C.E.” 
(alkoforml,257 

Anaesthetic properties of hedonal, 256 
Anaesthetist in certain surgical emergencies, 11 
Analgesic preparation (cibalgine), 25S 
Anaphylaxis, bacterial, the nature of, 456 
EPIT, 2 


ANofinoniAs, J. : Prognosis in abdominal preg- 
nancy, 125 

Ande «fiON. M. 6.: Treatment of pulmonary 

tuborculosls by eanocrj-sin.SlS , , . 

Anderson, W. D.: Eohedrine hydrochloride in 


n, 91— In 
)logy of, 


I , B. aertrvclte 

\ 276 

lotlirax. local immunization against, 263 

Vnllbodiee, typhoid and dysentery. In menial 
patients. 43 

\.ntl-gan«rono serum in treatment of typhoid 
fever, 143 ..... 

^.ntistroptococcal serum In treatment of puer- 
peral sopticaomia, 525 . 

Antitoxic action of yeast extract. 540 
Antitoxin treatment of scarlet fever, 252 
Anuria, post operative, boric glycerin injections 
in. 571 

Aortic syphilis. Syphilis 
Aplasia, bilateral ovarian. 259 
Appendicitis: Simulated by ovarian haemor- 
rhage. 162— Post operative complications of, 
216— Serum treatment of . 574 
Appendicitis. acute,539; and cyclical vomiting 
in children, 464 
AppendlcUU, chronic, 487 

Appendix, spontaneous amputation of. 87 • 

Aqueous humour, transmission of arBonic to the, 

519 , w 

Armstbong, C.: Tetanus caused by skin 
dressings, 339 , 

Arsenic and bismuth therapy m Hodgkin s 
disease, 448 , , . , 

Arsenic, passage of into the cerebro spinal 
fluid. 641 

Arsenic in syphilitic Rneurysms. 275 
Arsenic, transmission of to the aqueous humour, 
519 

Arterial spasm and occlusion of branches of the 
retinal artery, ^ 

Artery, retinal, bilateral pre papillary vascular 
loop of, 69 ^ 

• . ' 3oxy- 

• j. 413 


Asphyxia. localized, due to cold, 559 
Asphyxia neonatorum, 633 

Asthma, intrabronchial medication in, 32 — In 
childhood, 36— Skin affections in, 123. 302— 
Radiotherapy in. 173, 471, 472— Treatment of, 
370— X-ray treatment of,471,472— Bphedrine in, 

517 

Asthma, bronchial, treatment of, 300 
Asthmatic patients.diphtheria prophylaxis in, 289 
Ataxia. Friedreich’s, 280 
Athletes, acidosis in, 268 
Atrophy, optic, hereditary and familial. 67 
Auger. L. : Death from air embolism. 457 
Auricchio ; Value of the Dick reaction, 27 
Auricular fibrillation in an apparently normal 
heart. 133 

Auricular fibrillation, chronic, treatment of, 322 
Autohaemotberapy in spasmodic coryza, 254— In 
conjunctivitis, 494 

Autonomic system, action of ergotamine on the, 
526 

Atman, D. : Bublingual absorption of drugs, 492 
Ayres K. D.: Death in acute intestinal obstruc- 
tion, 446 

Aza, V. : Qenito-peritoneal tuberculosis following 
abortion, 199 


B. 

BAAGOE, K. H. : Skin affections in asthma, 123, 
302 

Bacilli, acid-fast, resistance of to oil emulsion, 
44 

Bacilli isolated from rhinoscleroma, serological 
classification of. 105 

B. aertnjejee infection of animals killed in 
Blaughterhouses, 46 

B.O.O. vaccine, modification of tuberculous 
lesions hr, 79 

Bacillus of diphtheria, virulence of, 262 
B. paratvphosua A isolated from the pig, 104 
B perfriuociis causing puerperal septicaemia, 72 
Bacillus, tubercle: The filterable elements of. 
236— Resistance of to putrefaction, 504 — Bac- 
teriolysis of, 354— Filterable forms of, 480 
SacilluB tvphoana: Precipitable substances de- 
rived from, 179— The H- and O- forms of, 637 
Bacquelainb: Treatment of cholecystitis. 317 
Bacteria, common, culture of filterable forms 
of. 19 

Bacteria in spinal fluids, 584 
Bacteriaemia, anaerobic. 605 
Bacterial anaphylaxis, the nature of, 456 
Bacterial cultivation, the exhaustion of media 
in. 42 

Bacterial flora of periapical infections, 381 
Badous, V. £ : Sero-diagnostlc methods in 
tuberculosis. 555 

Baer. W. : Bilateral ovarian aplasia, 259 
Baermakk, 6. : Splrocbaetosis icterohaemor- 
rb&gica in the Dutch Indies, 239 
Baer, M. A. : The brain in general paresis after 
inoculation malaria. 600 
Bailey, H. : Trial labour, 178 
Baize. P. : Pathogenesis of influenza, 612 
Balard, P.: Spinal anaesthesia in labour, 375— 
Dystocia due to a large foetus, 580 
Baldenwece, li. : Ocular signs ot labyrinthine 
disease. 147 

Balduzzi, a.: Kcbinococcal cyst of the liver 
343 

Balestra, S. : Primary meningeal sarcoma, 165 
Balice, G : The antiseptic property of bile, 23 
Ballin, M. : Menstrual fistulae, 548 
Baltar, C. R. : Large ovarian cyst, 177 
BANCROFT, P. W. : Late treatment of burns, 649 
Bani. M. : Embolectomy. 511 
Bardier: Treatment of infantile paralysis by 
X rays and diathermv. 424 
Barksian, a. : Extraoyramidal Bjuuptoms 
following accidents, 269 

barling, S.: Tannic acid treatment of bums. 
391 

Barlow, D. L.: Protein sensitiveness. 358 
Babnes, H. a. : Malignant tumours of the nasal 
sinuses, 146 

Barnhoorn, j. a. J- : Diabetic psychoses, 533 
B «RRK. J, A. ; Cerebellar localization. 98 
Barringer, B. S. ; Carcinoma of the prostate 
and bladder, 389 

BARTLETT, W. M. I Treatment of anorexia in 
children, 276 

Bartoli, O. : The histology of nasal polypi, 20 
Bauvallet : Prognosis in abdominal pregnancy. 


Beaudtment, B.: Mumps complicated by acute 
nephritis and pancreatic necrosis. 25 
BEOLiJRR, C. : Diagnosis of sterility in women, 
150— Lipiodol in gynaecology. 307 
Bejarano, j. : Gangrene of the genitals, 390 
Belcher, G. W. : Renal distortion, 188 
Benard, R.: Orchitis following mumps, 462 
Benedict, W, L. : Protein therapy in ophthal- 
mology, 596 








coryza, 254 

Benon, R.: Chronic systematized deliriums, 598 
Benso, P.; Kohler’s disease, 414 
Berger, L. : Ulcero-necrotic glossitis in scarlet 
fever, 614 


Bernard, C. : Antistreptococcal serum in treat- 
ment of puerperal septicaemia, 525 



4 JAN.-JUNE, 1928] 


INDEX TO THE EPITOME. 


r .s . r» . ’ ‘.1 V: 1 o' "•’re, 114 
V •. :i ! ■ •■ !,;■ ■■ •..omen, 150 

■ ■.■■■■: , i,’ disease of 

tbe ne-wborn. 546 

BEfERnoLir. O. : Pulse wave velocity, 184 
BiANCHi, L. : The histology of nasal polypi, 20 
BiDOLT, Ii.: Scarlet fever treated by Dick anti- 
toxin, 392 

BiE, V. : Treatment of typhoid and paratyphoid 
fever with a staphylococcal vaccine, 64— Treat- 
ment of pulmonary tuberculosis bysanocrysin, 
518 

Bile, antiseptic property of, 23 
Bii/OON, S. : SyntbaJin in diabelcs, 652 
BiNET. H, : Absorption of oily subcutaneous 
injections, 378 

Bijte'e, L.: Sodium chloride injections in acute 
intestinal obstruction, 190— Absorption of oily 
subcutaneous injections, 378 
Bismuth and arsenic in Hodgkin’s disease, 448 

cerobro-Bpinal 

Bjelke, H. : Late results of treatment by arti- 
ficial pneumothrax, 47 
Black disease. See Hepatitis, necrotic 
Bladder: Closure of following prostatectomy, • 
89— Injuries of during labour, 252— Irritability 
of. of rectal origin, 455— Radiological examina* 
tion of the, 470 —Primary tuberculosis of, 592— 
Cancer of. See Cancer 

Blamontier, P. : Radiotherapy of asthma and 
spasmodic coryza, 173,471 
Blano, H. : Diverticula of tbo duodenum, 364— 
Diagnosis of tuberculous prostate, 650 
BI 2 & 6 I, D.*. Encephalitis in measles, 507 
Blepharospasm, causes of, 69 
Bloch. C. E. : Vitamin deficiency and liability 
to infection, 434 

Blood, bactericidal power of, after ultra-violet 
irradiation, 180 

Blood, glucose in, and spinal fluid, rolaj^ion 
between, 458 

Blood groups of children and infants 556 
Blood plasma in scarlet fever, the surface 
tension of. 107 
Blood in scarlet fever, 587 
Blood serum calcium in urticaria, 45 
Blood traDsfusioninob8tetrios,70— A precaution 
in. 249 

Blood urea in scarlet fever and tonsillitis. 606 
Blvu, h.\ Calcium chloride in hepatic ascites, 
320— Mercurial diuretics in ascites, 467 
Blpm, F. : Charcoal as a medicinal veliiclo, 273 
BoFiZ, L, : Anaerobic bactoriaemia, 605 
BoGDANorp, S. : Superlnfeotion in syphilis. 645 
Boisserie-LaoroiXiJ.: Encephalitis in measles. 
203 

Bonnel, F. : Hemiplegia in cerebro spinal fever, 
2S4 

Bonkin : Prognosis in abdominal pregnancy, 125 
Bony and cartilaginous depositsiin tbe tonsils, 
155 ^ 

BooUs and the transmission of scarlet fever, 406 
Boric glycerin in post>operative anuria, 571 
Boulin, R. : The nature of herpes, 261 
Bourdes, Y. : Spinal anaesthesia in labour, 375 
Bourne, W. : Anaesthesia in gall-bladder 
surgery. 13 

Bowen, B. D. ; The comparative lvalue of renal 
function tests, 105 


Brancati, E. : The histamine test for gastric 
secretion, 334 

Braunbtein, a. P. : Exanthema subitum, 312 
Breast-feeding, four-hourly, 197 
BREHii, \V. : Separation of the syipphysis. 376 
Brem, W. V. : A precaution in blood transfusion 
249 

Bressot, E. : Treatment of liver abscess, 59 
Brestkin, M, P. : Gasbro-entero-anastomosis 
and the activity of the gastric glands, 357 
Brincdjiann, A.: Pirquet test with different 
tuberculins, 157 

Brook. J.: The use of alcohol in puerperal 
' sepsis, 200 

Bronchi, primary carcinoma of the, 55 
Bronchial asthma. See Asthma 
Bronchiectasis, treatment of, 516 
Bronchitis, intrabronchial medication in, 32 
Bbonner. H. : Diagnosis of congenital disloca- 
tion of the hip. 189 

Bbonstein, W. G.: Treatment of ringworm by 
thallium acetate, 169 

Broudin.L.: B.vciratyiiliosus A isolated from a 
pig. 104 

BBOtJHA. M. : Treatment of ovarian cysts during 
pregnancy. 524 

Brotjstet, P.: Mumps complicated by acute 
nephritis and pancreatic necrosis. 25 
Brown; H. P.*. Surgical intervention in extra- 
uterine pregnancy. 523 ^ ' 

Brown, J. H. : Transmissible toxicogenicity of 
■‘Streptococci, 81 

Brown, Muriel J.: The haemoclastic and levu- 
‘ lose tests in childhood, 638 
Bruetsch. 'W. L. : The hrain in general paresis 
* after inoculation malaria, 600 
Bruggeman, H. 0. ; Treatment of acute cbole- 
• -cystitis. 534 . , . ' ’ . . , ’ 

Brushfield, T. : Hemiplegia associated with 
'-extensive naovus and mental defect, 99 
Brutnoghe.-R.: Le^to^ira icteroides and LeptCh 
$pira tcfcro7jaemorr7iffffiac, 401 


Bundesen, H. N.: DiphthorSn in Chicago, 86 

Bunker, H. A. : Malarial therapy in general 
paralysis. 421 

Burnier. B. ; Gold salts in cutaneous tnbor- 
ciilous affections, 393 

Burns: Tannic acid treatment of, 391— Late 
treatment of, 649 

Busbon. B.: Dissociation of toxin-antitoxin 
mixtures, 235 


Cadenhead, a. F. G. : Exophthalmic goitre and 
lead ionization, 532 

CAuv. L. D. : Diagnosis of glandular fever, 509 

Caesarean section, 16, 423 

Caitey. j. P.: Endemic meningococcal mcnin- 
gltls, 481— CerGbro-Bplnal fever in infancy and 
early childhood, 545 

CArriER, P. : Experimental culture of endo- 
metrium, 203 


, ' ins dis- 

orders, 96 

CAMAuhn, A. F. : Syndrome of the corpora 
quadrigemina, 97 

Casirron, J. A. M.: Oosophagectasla In a child, 
137 

CAiirnnLL, J. A. : Accllmatiratlon to low oxygen 
pressure, 436 

Oamorati, M.: Myoloplax tumours of the spine, 
164 

Cancer of the appendix, 293 
Cancer of the bladder, 389 

Cancer of the breast, treatment of. 117— Recur- 
rence after operation for, 217— Statistics of, 
593— Inoperable, treatment of, 319 
Cancer of tbe bronchi, primary. 55 
Cancer of tbo cervix : Acetone tieatmont of, '127 
—Mucous celled, 451— Radium treatment of, 
629 

Cancer, gastric, gastrectomy in, 410 
Cancer, incidence of, 386 

Cancer of the oesophagus, radium Implantation 
in, 172 

Cancer complicating rodlum treatment in preg- 
nancy, 306 

Cancer of the stomach, colloid, 342 
Cancer of the ureter, primary. 213 
Cancer of uterus and radiotherapy, '15— Earlj*. 
230 

Cancer of the vermiform appendix, 293 
Cancer in the young. 90 
Cannon, A.: Diverticulitis, 92 
Capillary dilatation in doop-seated inflamma- 
tion. 508 

Oappii-- - - - * .• -t - 

to T 

Carbo ' 

cont ' * 

—Administration of 
. 577 

Carbuncles, treatment of, 28 
Carcinoma. Sec Cancer 

Cardiac conditions, promotion of diuresis in. 651 
Cardiac insufliciency in pulmonary tuberculosis, 
608 

Cardiac neurosis, 311 

Cardiac nodes, venous drainage of tbo, 438 
Cardiac. See also Heart 

Cardiopathy and vertebral deformity during 
pregnancy, 75 

Cardio vascular diseases, syphilitic, treatment 
of. 222 

Cables, J. : The etiology of localized oedemas, 
78 

Cablirr, P. : Calcium chloride in hepatic 
ascites, 320— Mercurial diuretics in ascites, 
467 

Cabmichael.E.A.: The chlorides of the cerebro- 
spinal fluid in meningitis, 585 
Carol, W. D. L. : Ulcus vulvae acutum, 377 
Carotinaemia. 288 

Cabp.L.: Treatment of carbuncles, 28— Wound 
infection and catgut, 54 
Oabblaw, R. B. : Right-sided visceroptosis, 646 
Oassano, C. *. The mesenteric glands and fat 
absorption, 528 

Casteran, B. : Emetine in amoebic abscess, 570 
Cabtex, M. R. : Sj'ndrome of the corpora quadri- 
gemina, 97— Primary meningeal sarcoma, 165 
Cataract extractions, after-results of. 372 
Catgut and wound infection. 54 
Catheter, retained ureteral, 248 
Cattaneo, L, : Early carcinoma of the uterus, 
230 

Cecil, R. L. : Serum therapy in lobar pneu- 
monia, 572 

Celli, Q.: Renal complications of influenza, 244 
Cellular division, influence of hydrogen-ion con- 1 
centratiou on, 479 I 

Cerebellar localization, 98 
Cerebro-sr’ ' ‘ in, 264— In 

infancy 1 

Cerebro-si: intent of in 

tuberculous 'meningitis, 3£0, 585— In tuber- 
culous meningitis, 477— In cranial injuries 
without fracture. 564— Tlie chlorides of in 
meningitis, 585— Passage of arsenic and bis- 
■ muth into, 641 — Temperature of. 662 
Cerebro-spinal syphilis. See Syphilis 
Cervical ribs, 387 • 

Cervical sympathetic ganglion and pericarotid 
sympathetic, lesions of. 496 


CnAMRERLAiN, W. E. ; The epilation and ery- 
thema dose of X rays, 628 

rv T> . 


Charcoal as a medicinal vehicle. 273 
CnABDoNNi’Au, J. : Osteomyelitis of the scapula, 
316 

CnABRiEB: Ectopic gestation. 352 
CiiATTERji, S. P. : Epbedrino in leprosy, 595 
Chavannaz, j. : Reduction of strangulated 
hernia en manse, 565 

Chemical changes concerned in acidosis, 661 
Chemotherapy in eeptlcaeraia, 63 
Chenilleau. a.: Physiotherapy in the treat- 
ment of salpingo-odpboritis, 176 
Cnr.suT. A.: Transccrvical fractures of tbo 
femoral neck, 411 

CnKVASRu. M. : Technique in prostatectomy, 56 
Chicago, diphtheria in, 86 

CiHorALO, 1.: Diabetes complicating surgical 
urinary conditions, 486 

Chloride content of cerebro-spinal fluid in tuber- 
culous meningitis, 380,585 
Cholecystitis, treatment of, 317— Acuto, treat- 
ment of, 534 

Cholecystography, intravenous and peroral 
methods in, 175— Tolra-iodo-phenolphthalein 
in, 326. 327 

Cholcsterin. thefunctlon of. 504 
“Cibalglne," an analgesic preparation, 253 
Cistema magno. puncture of in eclampsia and 
tbo pre-cclamptic stato, 283 
Claude. F.: Radiotherapy of asthma and spas- 
modic coryza, 173, 471 

CL.VUDE, H. 1 Tho corobro-spinal fluid in cranial 
Injuries without fracture. 564 
Claveltn, C. : Treatment of ostoo-articnlar 
tuberculosis, 3E6 

Olaviclo, fracture of. during spontaneous labour, 
501— Followed by purpura haemorrhagica, 618 
Clefts of palate and lip, surgical treatment of, 
617 

Clebc, a. : Heart block in young subjects, 459 
Climacteric disturbances. 149 
CoDii.S. : Bodinm salicylate in chronic epidemic 
encephaUlis, 369 

Cochin Cb' ■ * ‘ ' 

Coco. V.: 

CoirEK, H ■ . ■ ho 

bladder, 470 

I Cold common, bacteriology of the, 309 
CoLEDitooKT,. L. : Bactericidal power of the 
blood after ultra-violet irradiation, 180 
Coleman, Marion B.; Bacteria in spinal fluids, 
584 

Colct, W. B, : Prognosis and treatment of 
giant-cell sarcoma, 5 * 

Colleks. W. 8 . : Polyneuritis following mumps, 
290. 395 

Collins, L.: Treatment of erysipelas, 224 
CoMOLLi, A- : Plastic surgery for hernia, 617 
Conception, treatment of retained products of, 
103 

Conjunctivitis, autohaemotlierapy in, 494 
CONBTAN 8 , G. M. : Ocular pemphigus, 227 
Corpus, B. C. ; After-histors'Of pyelitis in preg- 
nancy, 18 . . 

Corlktte, 0. E. : Surgical treatment of pruritus 
ani, 88-Calcium deficiency as a cause of 
disease, 478 . 

CORNIL. J.: Leptospira icteroidesand Leptospira 
icterohaemorrhaoiae, AOl 
Corpora quadrigemina, syndrome of the, S7_ 
Corten, M. H. : Bony and cartilaginous 
deposits in the tonsils. 155 
Coryza, spasmodic : Radiotherapy of, 173, 471, 
472 — Auto-lmemotberapy in, 254 — i'-ray treat- 
ment of, 471. 472 . .... 

Cosgrove, B. A.: Use of spinal anaesthesia in 
obstetrics, 201 . , .,1 ^ 

CosTAPiLE, V. : Reticulo-endothelial blockage 
and flocculation, 332 

CosTEDOAT : Resuscitation of the apparently 
drowned. 24 . , . , 

CosTiN, G.: B. aettrycl'e infection of animals 
killed in slaughterhouses, 46 
COYTE. G. : Diagnosis of sterility in women. 150 
— Operation in two stages for large ovarian 
cysts, 198 ... ,,, 

Cottrell, J. E. : Treatment of arthritis with 
salts of ortho-iodoxy-benzoio acid, 33 
Cough, laryngeal, 497 
CouRONNi, P. : Mumps and diabetes, 113 
CoURToiB. R. : Sodium cinnamate in pulmonary 
tuberculoEis, 420 

Court, A.: Prolonged salicylate treatment in 
rheumatic endocarditis, 491 
CouTO. M. : Chronic visceral polysteatosis, 50 
Cranial injuries without fracture, the cerebro- 
spinal fluid in, 564 

Creeping disease, 303 . 

Critchlet, M. : post*encephalitic respiratory 

Crowt:, Elsie : The blood groups of children 
and infants, 556 

Cruohet. R.: Epidemic encephalitis, 337 
Cunningham, T. D. : Asthma in childhood, 36 
CuRSCHMANN, H. : Climacteric disturbances, 149 
CuRTH, W. : Treatment of e.xcessive sweating, 

61 . . , - 
Curtis. A. H. : Surgical intervention in pelvic 
infections, 73 

Cutler, C. W. : Post-operative complications 01 
' appendicitis, 216 
Cyst of liver, echinococcal, 340 
Cyst of ovary, large, 177— Operation in two stages 
for, 198— Treatment of during pregnancy, 524 


JAN.-JUNE, 192S] 


INDEX TO T H E EPITOME. 


-r Tm: UnmiK' 

L ITrcioAi. JoxmKJ* 


Ci'stlc Bwcllines of tbo abdominal wall folIowInR 
trauma. 453 , nt 

Cysts, bydatid, salmonollosiB assocmlou ■vvltb, 
286 

Cysts, palpebral, 225 


D. 

DaiiIi, B.: Insulin poisoninR, 238 
Dxnir-IVF.RSOJJ, K.: Ueouvrcnco alter operation 
lor carcinoma ot U^o breast. 217 
Dxisvmnr., l’\: Malaria therapy In coiobro. 

spinal Bypbllis, 469 
Dalcih':. P.t Genital ncuralRia, 429 
DAKFonTH, W. C. : Aftor-bistory of pyelitis in 
preRnnney, 18 

Daniklopoltj, D.; Sympatbectomy in anfiina 
pectoris, 91— Tho heart in typhus fever. 154— 
Etiology of angina pocloris and abdominalis, 
603 

DANrensoK. R. ^V. : Testicular mumps n’itbout 
parotitis. 242 , , , 

Daudakr : Fatal staph jlococcal puerperal infec- 
tion. 660 

Dausset. H.: Physiotherapy in tbo treatment 
of salpingo-oOpboritls, 176 
DAUinEnANDE, Ii. : The iodino treatment of 
goitre. 346 

DATENPonx, B. C. : Barconm of tbo uveal tract, 
228— After-results of cataract CAtractions. 372 
Davesne, J. : Serum treatment of appendicitis, 
574 

DA\^8, D,: Sublingual absorptlou of drugs, 492 
Dawson, M. IT.; Tho “R** and "S" forms of 
pneumococcus. 503 

Dn Candia, G.: Renal function during preg- 
nancy. 632 

De Capite. a.: Autobaoinotbcrapy In coniunc- 
tivitis, 491 

De CouncT, Q. : Caesarean section, 428 
DECouncT, J, D. : Treatment of gastric and 
duodenal ulcer. 538 

Defbies, R. D.: Laboraton* diagnosis of small- 
pox virus, 202 

Deokwitz, R. : Tbo virus of measles. 128 
Deicber, H. : Filterable forms of tho scarlatinal 
virus, 331 

Df. Jono. 0.: Indications for syntbalin in 
diabetes, 62 

De Ketser, D, : Colloidal blsrautb in syphiUs, 
624 

DELAopEniB. H.7.; An analgesic preparation, 
253 

Delcoprt: Severe cases of raninps. 160 
Delcrois, E.: Late treatment of infantile para- 
U’sis. 221 

Ddlirlnme, chronic systematirodt 595 
Delore, X. : Gastrectomy In ga^^tric cancor. 410 
Dek ZIoeOiD.: Uterinocancorand radiotherapy, 
15 

Denis: Prognosis in abdominal ptegaancy, 125— 
Necrobiosis of uterino fibroids, 601 
Dermatitis, watch-strap, 48 
Dermatology, gentian violet in. 274 
Deschamps, P. N.: Pernicious anaemia in preg- 
nancy, 353 

- .•pjiralyeig 

... . !ral infec- 

tion. 551 

Diabetes: In children, syntbalin in, 95— Insulin 
— Treatment gf, 194 — Giukbormont in, 
2^~IpBUlin treatment of, 192— And mumps, 

• complicated by.lOl— Syntbalin 

10, 62 , 93, 119, 368, 652— Complicating surgical 
468°^^^* conditions, 486— Vitamin B extract in, 

Diabetic acidosis, 405 
Diabetic psychoses. 533 

' Etiology of migraine, 1 
^“.®cute and chronic gonorrhoea, 
•n.ZI ^ paralysis, 424 

dried mirn-; 23?^ 

Dick antitoxin treatment of scarlet fever, 692 
Dick faction, value of the. 27 
Uick teat in scarlet fever, 239 

pelvic haema- 

indications for, 121 

thnlniia”'374°*''*°*‘° sympathetic oph- 

''irnlence of, 262 
Chicago. 86 

• H'owing encophalitia. 267 

Itnnninization against, 310— After 
‘““".nization, 315 — Immunization 
nf.?u virnlent cnitoros. 408 

TmaS “^f.llo 

withont membrane. 183 
^pntneria prophylaxis in asthmatic patients. 

Gangrene lollowiuG. 460 
henri <>'• 135-Severe. the 

n^i .1? 111-Tozic. 361 
rilFii ®°<J°metritis. 603 

^^nfeotion of hands with hydrogen peroxide, 

Diuresis, promotion of in cardiac conditions. 651 
■67 


common 

Dodds, p.: Glucose treatment of eclampsia. 659 


Donald, J.: AnaostboUc properties of bedoual. 
256 

DoNATIEN, / . — 

Dore, S. E. ‘ 

Dott, N. : < ■ i!n 

tbo noso, 348 

Dowling, G. B. : Tbo pitjTosporon of Malassez, 
636 . 

Dragun, B. Q. : Pilocarplno fn gall-bindder 
disease. 3?3 

Drowned, resuscitation of the apparentiv. 24 
Drvfgs: Epidural administration of, 191— Sub- 
lingual absorption of. 492 
DniiAR, G. : Tbo corebro-spinal fluid in cranial 
injuries without fracture. 564 
Ddfoort, a. : Tbo tomporaturo In whooping- 
Gougb, 404 

Dukakis, P. S. : Typhoid moniogitis, 383 
Dukes. C. : Pro-cancorous changes in tbo 
rootum, 615 

Duodenal obstruction, nature of morbid pro- 
cesses following. 356 
Duodenal ulcer. See Ulcer 
Dnodonum. diverticula of tbo. 364 
Durante. G. : Unrecognized mycoses. 156 
Dwukoit, P. P.: Modification of tuberculous 
lesions by tbo B.O.G. vaccino. 79 
Dfas. G. E. : Sodium totra-iodo-phcuolpbtbalein 
in radiology, 627 

Dysentery antibodies in menial patients. 43 
Dystocia duo to a largo foetus. 560 


E. 

Ear, middle, tuberculosi*?©!, 148 
Ererbard. H. a.: Immunization against 
diphtheria with virnlent cultures, 40S 
Ecbtnococcal cystof liver, 340 
Eclampsia, glucose trcatipcot of. 659 
Eclampsia and tlic pro-eclamptlc stato, punc- 


Eczcnia caused by atiinino suppositories, 557 
Erinr.NTiiEiL. O. P. : Arthritis due to foreign 
bodies. 413 

Eidinow, a. : Bactericidal power of the blood 
after ultra-violet irradiation. 180 
Etf ficniTZ, M. : Meningococcus septicaemia, 440 
Eisendraxh, D. N.: Retained ureteral catheter, 
248 

Elet, R. 0.: Antitoxin treatment of scarlet 
fever, 252 

Eliason, E. L. : Fractures'! of tbo ’acetabulum, 
537 

Elliott, C. A.: Liver feeding » in pernicious 
anaemia. 144 

Elliott, J. A. : Hepatitis of early syphilis. 465 
Eraboloctomy. 511 
Embolism, air. death from. 457 
Emergencies, surgical, tbo anaesthetist in 
certain. 11 

Emetine in amoebic abscess, 570 
Emphysema, respiratory, in lRbour,'76 
Empyema in cbiidren, 187 
Emslie. Margaret: Four-bonrly breast-feeding, 
197 

Encephalitis, tbo brain In. 663 
Encephalitis, epidemic, 109. 337— Ocular 'mani- 
fcstatlona of. IS^Sodium salicylate in, 369— 

-Following 

442 

k ^ . salicylate 

' lildren, 610 

Endocardium, primary tumour of the, 565 
Eudocervicltis, chronic, 454 
Endocrine glands, action of on gastric secretion, 
22— In gynaecology. 152 
Endometritis, diphtherial, 603 
Endometrium, experimental culture of, 203 
Endometrium, ectopic, mode of spread of, 40 
Epbodrine hydrochloride : In whooping cough, 
166— In asthma and hey fever. 517— lu leprosy, 
595 

Epidural administration of drugs, 191 
Epilation dose of x rays. 628 
Epilepsy, inhibitory. 611 
Epileptic variants, 589 
Epiphysis. lower femoral, separation of, 219 
Epithelioma following subtotal bystoroctomy. 
602 , 

Epithelioma of urethra, 271 
Epstein, N. : Acute syphilitic phlebitis, 588 
Epstein, S. H. : Sodium salicylate in chronic 
epidemic encephalitis. 369 
Ergot, the amino bases of, 223 
Ergotamine, action of on tho autonomic system. 
526 

Ernberg, H,: Nasopharyngeal infections as a 
cause of varions infantile diseases, 37 
Erysipelas, treatment of. 224, 493 
Erythema dose of x rays, 628 
Erythema nodosum, 385 
Ether anaesthesia. See Anaesthesia 
Ethylene anaesthesia. See Anaesthesia 
EvanG, K : Essential thrombopenia with 
haematomyclia, 338 
Evans. J. H. : Oxygen therapy, 542 
Ewell, G. H. : Treatment of prostatic hyper- 
trophy, 445 

Exanthema subitum, 312 

EsraAQUET, E. : Diagnosis of sterility in women, 


Exlef, E. W. : ProstatIc hypertrophy, 616 
Experimental infection. aScc Infection 
Extrapyramidal symptoms following accidents, 
269 „ 

Extrautorine pregnancy. See Pregnancy 
EysFER. H. : Bladder Irritability of rectal origin, 
455 


F. 

Fabrt, j.: Myosalvarsan in the treatment of 
syphilis, 250 

Feecal fat analyses in children, 132 
Fahr. Q. : The heart in hypertension, 531 
Fairlie. H. P. : Ethylene anaosthesia. 578 
Pansler, W. A. : Rectal fistula in tuhercniosis, 
58 

Farlet, D. D. : Lymphatic leukaemia, 563 
FARNHAii, B. K.: Sodium salicylate in chronic 
epidemic encephalitis, 369 
Farr, 0 . E. : Empyema in children, 187 
Fat absorption and the mesenteric glands, 528 
Fat, faecal, analyses of in children. 132 
Favier. R.: Hereditary and familial optic 
atropbl’, 67 

Favrcau: Prognosis in abdominal pregnancy, 
125 

Fejgin, B.: Transmission of scarlet fever by 
books. 408 

FcldEN, B. P. : Thallium acetate in ringworm, 
449 

Femoral epiphysis. Epiphysis 
Femoral neck, transcervical fractures of the, 411 
Ferguson, E. "W. : Creeping disease, 303 
Feruaud. E.: Boric glycerin in post-operative 
anuria, 571' 

Ferrannini, L. : Localized asphj'xia due to 
cold, 559 

Ferreri, G. : Lanmgeal cough. 497 
Fever, enteric : Abscess of spleen in, 158— Anti- 
gangrene serum treatment of, 143— Gangrene 
of the extremities following,488 -Parkinsonism 
following, 112— Sewer gas and, 161— Staphylo- 
coccal vaccine in treatment of. 64— Vaccine 
treatment of, 653. See also Bacillits titphosus 
Fever, glandular, diagnosis of. 509 
Fever, paratyphoid: Treated with a staphylo- 
coccal vaccine, 64— Chronic psi‘atyphoId septi- 
caemia, 590 

Fever, paratyphoid C, 210 
Fever, sandfly, 3 

Fever, scarlet; Amato bodies in. 130— Antitoxin 
treatment of, 252— Blood in, 587— Blood urea in, 
606*^Dick antitoxin treatment of, 392— Dick 
reaction, value of, 27. 299— Immunization, 
active, against. 205, 206,207— Mumps and second 
attacks of. 243— Serum therapy in, 299— Surface 
tension of the blood plasma in. 107— Trans- 
mission of by books, 406— Ulcero-necrotic 
glossitis in, 614— Virus of, filterable forms of 
the, 331 

Fever, typhus, the heart in, 134 
Fibroids in pregnancy, 305 
Fibroids of uterus, necrobiosis df, 601 
Fibroma and pregnancy, 500 
Fibroma of nterus, radiological treatment of, 
626 

Fibula, osteomyelitis of the. 30 
FiebbInger, N.: Emetine In amoebic abscess, 
570 

Finger, E.: Syphilis and marriage. 53 

Fischer. E. : Sacral hernia of the uterus, 38 

Fibchl, R.: Congenital syphilis, 360 

Fistula in ano, treatment of. 215 

Fistula, rectal, in tuberculosis, 58 

Fiotulae, menstrual, 518 

Fleming, H. W. : Transient hemiplegia, 4 

Flocculation and reticulo-endothelial blockage. 

332 . • 

Foetus, large, dystocia due to a, 580 
Foramitti, C. : Treatment of hypertrophi 
pyloric stenosis, 29 
Foreign bodies causing arthritis, 413 
Foreign bodies in the gastro-intestinal canal 
prognosis in, 443 

Fracture of clavicle ; During spontaneous labour. 

501— Followed by purpura haemorrhagica, 618 
Fracture, metatarsal, 591 
Fractured ribs, treatment of, 648 
Fractures of the acetabulum, 537— Of the femoral 
neck, transcervical, 411— Of the sacrum, 116— Of 
. the semilunar hone, isolated. 341 
Fragomele, a.: The action of the endocrine 
glands on gastric secretion, 22 
Prank. R.: Disinfection of the hands with 
hydrogen peroxide. 466 

Frenckell. G. L. : Purpura haemorrhagica 
following fracture of clavicle, 618 
Fren^l, a.: Diagnostic errors in secondary 
sciatica, 245 

Frbtdow'itch, G. M. ; Infantile paralysis treated 
by X rays and diathermy, 424 
Frideriohsen, C. : Pre-scorbutic myopathy and 
‘ growing pains.'’ 193 j «u 

Fricpjung, K. : The high infantile mortality df 
large families, 265 

Friedman, E.: The spleen in measles. 158 
Friedmann. M. : The radical operation for 
gastric and duodenal ulceration, 115 
^?inal^^us forms of the sca'rla- 

Friedreich's’ataxia. 280 



6 JAN.-JUNE, 1928] 


INDEX TO THE EPITOME, 


r Tirt Cnmsn 

LllEDtClt JOUBKAL 


Fbotez, A.: Pernicious anaemia in pregnancy, 
353 

Frpehwald, R. : Spirochaetosis arthritica. 33S 
Fulmer. S. 0. : Tularaemio peritonitis, 13S 
Fungus poisoning, ttie heart in, 212 
Funk, E. H. : Primary carcinoma of the bronchi, 
55 

Furgason, B. R. ; Primary abdominal preg- 
nancy, 398 

Furth, J. : Precipitable substances derived 
from typhoid bacilli, 179 


a. 


GABRi^iLiDfes, A. : Palpebral cysts, 225 
Gaipami, P. : Accidental haemorrhage. 475 
Gall-bladder disease, pilocarpine in, 323 



Gammeij, J. a.; Amato bodies in scarlet lever. 
130 

Gam:ueltoft, B. A. : The heart in pregnancy. 
427 

Ganglion, cervical sympathetic and pericarotid 
sympathetic, lesions of, 496 
Gangrene of the extremities, symmetrical, fol- 
lowing typhoid fever. 488 
Gangrene of the genitals, 390 
Gangrene and pulmonary abscess, surgical 
treatment of, 362 

Gangrene, pulmonary, following diphtheria. 46Q 
Gardiner-Hill, H. ; Influence of thyroid disease 
on menstruation, 430 

Garreau, Yvonne; The chloride content of the 
cerebro-Bpinal fluid in tuberculous meningitis. 
380 

Garriga.M.: Vaccine treatment in soft chancre 
367 


Gas-oxygen and rectal ether anaesthesia, 255 
Gastrectomy in gastric cancer, 410 
Gastric linitis. 7 

Gastric secretion: Action of endocrine glands 
on. 22— Histamine test for, 334 
Gastric ulcer. See Ulcer 
Gastro-entero-anaetomosis and the activity of 
the gastric glands. 357 

Gastrointestinal canal, prognosis in foreign 
bodies in, 443 

Gastrostomy in the treatment of acute dilatation 
of the stomach, 247 

Gatoh, W, D. : Death in acute intestinal obstruc- 
tion, 446 

Gault, 0. C. ; Calcium therapy in functional 
nervous disorders, 96 

Gauss, 0. J.; Radiological and operative treat- 
ment of uterine conditions, 351 
Gawrilow, R. I. : Purpura haemorrhaglca 
loUowing fracture of clavicle, 618 
Gehrig, U. : Isolated polyposis of the small 
intestine, 139 

Geipel, P.; Ectopic decidual tissue, 552 
Gellborn, G. : Acetone treatment of cancer of 
the cervix, 127 
Genital neuralgia, 429 
Genitals, gangrene of, 390 
Genito-peritooeal tuberculosis. SeeTuberculoais 
Gentian violet in dermatology, 274 
George, P. : The phrenico-pupillary syndrome 
in pleuro-pulmonary affections, 530 
QAraudel, E. : Venous drainage of the cardiac 
node's, 438 

Gestation, ectopic, 352— Ruptured, 260— Decidual 
tissue in, 552 

Gestation. See also Pregnancy 
Gheorghiu, I. : B. aertryche infection of 
animals killed in Blaughterbouses. 46 
Gibert, P. : Radiotherapy of asthma and spas- 
modic coryza. 173, 471, 472 
Giddings, Q. : Friedreich’s ataxia. 280 
Qiemsa staining, the optimum hydrogen-ion 
concentration lor, 664 

Gilbert, Ruth : Bacteria in spinal fluids, *=84 
Gipner. j. F. ; Arterial spasm and occlusion of 
branches of the retinal arteiy, 68 
Gitowitsoh. "W. j.*. Bacteriolysis of the tubercle 
bacillus, 354 

Gland, pineal, tumours of, 318 
Gland, thymus, in Graves's disease. 141 
Gland<i, endocrine, action of on gastric secretion 
22— In gynaecology, 152 * 

Glands, gastric, gsstro-entero-anastomosis and 
the activity of, 357 

Glands, mesenteric, and fat absorDtion.528 
Glandular fever. See Fever 
Glossitis, ulcero-necrotic, in scarlet fever, 614 
Glucose in the blood and spinal fluid, the rela- 
tion between, 458 
Glucose medication. 171 
Glucose treatment of eclampsia, 659 
Glukhorment in diabetes. 297 
Glycerin, boric, injections of in post-operative 
anuria. 571 

Godel, R.: Cardiac insufficiency in pulmonary 
tuberculosis, 608 

Goeckerman, W. H. : Malarial therapy as an 
indirect immunizing process, 402 
Goitre in adolescence, 313 
Goitre in the English school child, 195 
Goitre, exophthalmic, and lead ionization, 532 
Goitre, iodine deficiency in water as an index of, 
560 

Goitre, iodine treatment of, 346 
Gold salts in pulmonary tuberculosis, 8— In 
cutaneous tuberculous affections, 393 


Gold treatment in psoriaBie, 301 
Goldman, M, ; Action of orgotamino on tho 
autonomic system, 526 
Goldman, S. E.; Metatarsal fracture, 591 
Gonorrhoea, acute and chronic, diathermy in, 
325 

Gonorrhoea, rectal, in women, 634 
Goodman, H.; Watch-slrap dermatitis, .48 
Gordon, G. A.; Rosplratory omphysoma in 
labour, 76 

Gordon, O. H. : Ruptured ectopic gestation, 260 
Gordon, M. B. : Stammering produced' by 
thyroid medication, 562 

Gobset. a. : Sodium chloride InjectioDS in acute 
intestinal obstruction, 190 
Goudsmit, j. : Tuberculous infection in schools, 
291 

Gougerot: Tho function of cliolosterin, 204 
Gouoerot, H. r Malaria therapy Jn corobro- 
spinal syphilis, 469 

Qoulltoud : Aneuryf m of the splenic ortori', 388 
Granulomatosis, malignant. 85 
Graves’s disease, tho thymus gland !n. 141 
Grawitz, E. R.: Chronic paratyphoid septic- 
aemia, 590 

Grat, G. M.; Incidence of hernia in children. 
140 

Green, R.: Ephcdrlno in asthma and hay fever, 
517 

Greenbaum, S. 8.: Tho serum calcium In 
urticarla,45 

Greene, T. C.: Obstetrical factors in neo-natal 
intracranial haemorrhage. 281 
Greenwood. M. : The incldcuco of cancer, 386 
Grtbwold, a. S.: Separation of lower femoral 
opiphyala,219 

“ Growing pains ” and pro-Bcorhutlc myopathy, 
196 

Grunert. E.: Pepsin solutions in inoporablo 
prostatic hypertrophy. 

GntJNSTEiN, J. : Prognosis in foreign bodio? in 
the gastro-intcatinal canal, 443 
Guidal. a.: OateomycUtis of thoFcapula, 316 
Gdicciardi, G.: Detachment of tho normally 
situated placenta, 102 

Guldbero, G.: Cancer In the young, 90— 
Primary tumour of the endocardium, 566 
Gunson, E. B. : Hyporpiosis, 382 
Guturie, D, : Occurrence of brain tissue wltbln 
the nose, 348 

Gutot, J. : Treatment of mammary carcinoma, 
117 

Gynaecological conditions, insulin in. 71 
Gynaecology; Tho ©odocrlno glands In, 152— 
Lipiodol ]D, 307 


Hayden, D. II. : Sodium nitrite In sea sickness, 
625 

Heart; Effect of sodium salicylate on, 80— Affec- 
tions of in elderly people, 359— In prognancr. 
427, 630 

Heart block In young subjects. 459 
Heart after severe diphtheria, 111 
Heart dJs' rders in pregnancy, 427, 630 
Heart failure, strophanthin in, 9— DimlniBhod 
secretion of awoat In, 84 
Heart in fungus poisoning. 212 
Heart In hypertension 531 
Heart in typhus fever, 134 
Heart. Sreoiso Cardiac 

Heatlt, C. A. ; Mucocele of tho accessory nasal 
sinuses, 495 

Heckel. E. B. : Diphtheria antitoxin in sym- 
pathetic ophthalmia. 374 
Hedonal, nnaostliotic properties of, 256 
Hoine-Medln’s disease, transvoreo myelitis as a 
form of, 441 

HEiNnicnsBAUER, F.: Tho larynx in whooping- 
cough. 654 

Heliotherapy and renal tuberculosis, 447 
Hellbtadiub, a.: Etiology of congenital torti- 
collis. 186 

Hemiplegia associated with extensive naevus 
and mental defect, 99. 393; in corebro spinal 
^fovor. 264 

. ... . ■ ■ .633 

. . ' Australian 

sheep. 527 

Hepatitis of early syphilis, 463 
Hermann. C •* • “ — *■ 440 

Hkrmann-T. • ■ mt of 

(liihctcs in V.# 

Hermans: Gold suits in pulmonary tuber- 
culosis, 8 

Hernia In children, incidence of, 140 
Hernia, diaphragmatic, 292 


of en masse, 565 

Ilerpcs, virus of, distribution of in the tissues, 
21 

Herpes zoster, ironuinity following, 461 
Hetd, C. G.: The use of iodine in thyroid 
dieoaso, 93 , 

Hiccup controlled by CO 2 inhalations, 35 
HtOGiNS. C. 0.: Malignant tumours of the tes- 
tlclo.415 • 

^ . -f *«-. blood after 

' >sisof. 189 

: ' affections. 


H. 

Haberer, H.: The thymus gland in Graves's 
disease, 141 

Haematology of measlos. 432 
Haematoma. traumatic pelvic, 581 
Haomatomyolia with essential thrombopenla. 
338 

Haf^moclastlo and Icvulose tests in childhood. 
638 

Haemorrhage, accidental, 475 
Haemorihago. intracranial, neo-natal, obstetrical 
factors in. 281 

Haemorrhage, meningeal, at birth, bcquoIb of, 
425 

Haemorrhage, ovarian, simulating appendicitis. 
162 

Haemorrhage, uterine, causes of, 231— Urea in 
the treatment of, 476 

Haemorrhagic disease of the newborn, 546 
Haemorrhoids, prevention of post-operative 
bleeding in. 514 

Haemorrhoids, internal, treated with quinine 
and urea, 568 . 

Gaemostasis, temporary, in abdominal surgery, 
412 

Haeusermann. E. : Extrauterine pregnancy, 604 
Hat.deman, K. O. ; Tumours of the pineal gland, 
318 

Hamilton, B. E. : Heart disorders in pregnancy, 
630 

Hamilton, G. R, : Creeping disease, 303 
Hammack, B. W. : a precaution in blood trans- 
fusion. 249 

Hampton, F. A. : Shyness and schizophrenia, 100 
Hands, disinfection of with hydrogen peroxide, 
466 

Hansen, K. : Eczema caused by quinine sup- 
positories, 557 

H- and O- forms of B. typhosus. 637 
Harbitz, P. ; Pathogenesis of tuberculosis in 
adults. 82 

Harned, C. W. ; a modified “A.G.E.” anaes- 

] ■ ■ 

1 ■■ ■ 

Harrison, G. A. : Faecal fat analyses in 
children. 132 ' 

Hart, T, S.: Diagoocis of chronic myocarditis 
without cardiac failure. 613 
Hartmann. A. F. ; Chemical changes concerned 
in acidosis. 661 

Hashimoto.N.: Sterility and vitamin deficiency, 
607 

Hatzky. K. : IndnPtion of labour by pituitary 
extract, 635 

Hauduroy. P. ; Culture of filterable forms of 
common bacteria. 19 

Hauser, G. H. : The brain in encephalitis, 663 
Hay fever, ephedrine in, 517 


HiRsou, C. : Bony and cartilaginons deposits in 
tho tonsils, 155 

HiRScn-KAUTTMANN. H.: Synthalin treatment 
of diabetes in children, 95 
Histamine te^t for gastric secretion, 334 
Hjort, E. : Tuberculosis of the stomach, 272 
Hodgkin’s disease*, treatment of, 142 — Arsenic 
and bismuth therapy in, 448 
Holm. B.: Multiple ulcers of the stomach and 
duodenum, 31 

Holst J.: Intussusception of Meckel’s diver- 

ticulum, 555 

Homan, C. E. ; Ephedrlno hs'drochloride in 
whooping-cough, 166 

HoMDiiiA, M. : Gangrene of the genitals, 390 
Hosoi. K. : Intestinal absorption, 308 
Huber, J.: Pluriglandular syndrome following 
mumps, 484 

Hugo, H. J,: Hemiplegia associated with ex- 
tensive naevuB and mental defect. 396 
HtlHNE, T. : Vasectomy in prostatic hyiw- 
tropby, 567 

HUMPHRE's, F. B.*. Wound infection and 
catgut. 54 

HttNKRMANN, C. : TransversB myelitis as a form 
of Heine-Medin’s disease, 441 
Hunter, W.K. : Leukaemia in childhood, 423 
Hurxthal, L. M. : Therapeutic uses of carbon 
dioxide, 193 

Hydatid cysts, salmonellosis associated with, 286 
Hydrogen-ion concentration, influence of on 
cellular division, 479— The optimum, for 
Giemsa staining, 664 

Hydrogen peroxide for disinfection of the hands, 
466 

Hyman, A. B.: The heart in fungus poisoning, 
212 

Hyperchlorhydria, x rays in, 473 
Hyperpiesia, 382 

Hypertension, thoracic signs of, 482— Saline 
solutions in. 490 

Hypertrophy, proatatic. See Prostatic 
Hypothyroidism causing oedema, 287 
Hysterectomy, subtotal, epithelioma following, 
602 


• I. 

Immunity following herpes zoster. 461 

Immunization, varieties of, 181— Local, against 
anthrax, 263 

Immunization, active, against scarlet fever. See 
Fever 

Imparato, E.: Leucorrhoea, 550 

Imperiale, C. : Symmetrical gangrene of the 
extremities following typhoid fever, 489 

Incominence, congenital, transplantation of 
ureters for, 619 

Infantile mortality, high, in large families, 265 




JAN.-JONE, 192S] 


Infftntlloraralysis. PairaU'sis 

Infection, cxporJmontal, effect of Bj>lenoctoiny 
on, 234— Treatment bv, 251 
Infection, latent syphiUscarrievB ana llio spread 

IntGcUoUv vitamin deflcicnor and liability to, 
434 

dnfecHous di'seasos, aonte, alcohol in, 488 
Inferior vena cava. Vo»a cava 

Inflammation, doop-aoatod, capillary dilatation 
in, 508 

Influoiica: Renal complications of, 244~In 
lutallt3^422— Pathoflenesis of,612 
iDsanity. inauic-dopresslvo, somatic conuitlons 
in. 279 

lostilin ttealcacnt of diabetes, 192, 191 — In 
children, 191 

. 72 


. ini cliJorldo 

, ' , , f the. 139 

Intrabronchial medication in asthma and 
bronchitis. 32 

Intracranial hiemorrhafie, neo-natali obstetrical 
factors ia>2ai 

Intn^snscoption in cbildron, 621 

Intussusception of Mfckol's diverticulum, 535 

Iodine deficiency in water as an index of eoitro, 
' 560 

Iodine in goitres, 346 

Iodine in thyroid disease, 93. 91 

iRaF.R, J. L’llocarvine in CalbbTaddor 
disease, 323 

Iris, detachment of the anterior layers of the, 
226 

Iron carbonate solutions, saccharated, danger of 
iniecUonB of, 167 

InviKG, F. 0. : Placenta praevia, 126 

ISi:soutusr:T.3t.P,: Bacterlolyelaof the tubercle 
bacillus, 554 


Jacksok, C. 
55 

Jacobakos, 
of lung in 
3AC0UEL1N, 
Infection, 
Jadassohn, 
Jaucho, J. ; 
426 

Jaundice in 

Jeannesex 

125 

jEANSHLilE 


: Primary carcinoma of tho bronebi, 

H. C,: Wa^slro atelectatic collapse 
tnbercnlosis, 644 

A. : Plenro-cardiac streptococcal 
&t3 

.T.*. Syphilis and marriafie, 53 
Delivery of tho adherent placenta, 

theDatch lodie*. 239 
: ProgQosis in abdominal pregnancy. 

j Gold salts in cutaneous tubormlonR 


Johnson, B. D.: Provention of post-operative 
Peritonitis and abdominal adhesions. 41 

^cart after severe diphtheria, 

Jougensen, B, Q.: Bodium salicylate poisoning 
following injections. 182 
JUNO, ti. : Death from air embolism. 457 


Jahn test in primary syphilis. 640 
Mndicu. M ; Paratyphoid C fever, 210 
Kaposi’s disease, 416 

KATZESEt^oGEN, S. \ The relation between 
gJacoM ta the blood and spinal flnld, 456 
Srt secretion of sweat in 

Kehlstadt, A.: ' ' 

Keratitis due to a * 
hrt,BGRT, M. J. : 

Killoran.J. F- 1 
anaesthesia, 25j 

Paratyphoid C fever, 210 
hatatyS^.Wl therapy in general 

^^endiy, f? '■ ^■’''“tancouB atnpntation of 

^?r”i|i;rSlnoy!75'’'°™*‘'' cardiopathy 
KnlSS^r?* • fulminans. 240 

_hancy?naiSonr"3?8''® 

Bevaceination after 
injection, lio 

K0EB5’ n in peritonitis. 623 

diabetes] ef’ ' eynthalin in 

^dHLER’s disease. 414 

of the abdominal 

KogSkt ■ appendicitis. 487 

$70 * m amoebic abscess, 

^"■‘‘''“mar abseeas, 57 ' 


INDEX TO THE EHlTOME. 


KUArr, n.:"” , . . 

ntod iron 

Kramer, P. . ‘ ‘ 

442 

Kraur. 0« : Treatment of erystpolas, 493 

KuAUsr., A. 0.: TransmifiBlon of arsenic to tho 
aoueoua hnmonr, 519 

Kdu. E. J. j intrabronebial medication in asthma 
and bronchitis, 32 

Kphotciikis. T. j. : Tho nature of bacterial 
anaphylaxis, 456 


Dadat, G. : Regional fttiacBlhesia for operations 
on the spinal column, 14, 452 
TiABDf:, M. : Insulin treat"'ont of diabetes, 192— 
SynthaUu la difi botes, 368 

D^iiOKi — “ ' "owing sab- 

total 

Labour —Fracture 

of tho clavicle during sponlanoonB, SOI — 
Induction of by pHuilnry extract, 635— Rain- 
less, jiioduotion of, 319— In contracted pelves. 
258— Ucapiratary omohysoma ia, 76— Spinal 
anaosthesia in, 201, 375— Trial. ITS-Uterine 
muscio during. 328— Uterino rupture during, 
229 • 

Labyrinthine disease, ocular filgna of, 147 
Lacorte. .1. J.: Tho optimum hydrogen-ion con- 
centration for Oiomsastaiofog. 661 
LacoutcRR, J.t Rrogaoais In abdominal preg- 
nancy. 125 

Lacryuial aac, lymphoma of. 371 
Laenkec: Pyotherapy In puerperal infection, 
551 

LatvIN, H- K.'. Carbon dioxide administration 
daring ether anaesthesia, 577 
Lam ache, A . *. Tho cevobto-spiuRl fluid in cranial 
fnjuries without fracture, 564 
Landsteiner. K. ; Precipitable substances 
derived froifl typhoid bacilli, 179 
Landv, a. r Ryntbalm in diobotes. 652 
LangEron.L. : Clinical classification of septic- 
aeiylc states. 569 

Lanovrev'T. a G : Infantile pamlyaia treated by 
X rays and diathermy. 424 
LA<3rry.uRit:Rr.: SUlagraphy In pulmonary 
diseases. 321 

Laquedr. L. : Liver extract In poroicious 
anaemfft. 513 
Larva migvans, 303 
Laryngeal cough, 497 

Laryngeal obstruction. misleading eymptoms of, 
145 

Laryngeal tuberculosis, artificial light baths In, 
573 

Laryn'*^**'* — 

Laryo’' 

LasxO' • ' • , etio 

gang 495 

Laudj . 

Lead i 
Lcllf.' 

Lp. Bouudedlks. B. : Bacteriological examina- 
tion of rboumatic nodes, 529 
L^ Fy.VRV.. L. ' OlphtbeTial cndomaltiMs. 603 
Legueu, F. : Tumours of the renal pelvis, 620 
LF.iTcn, D. B.: Parathyroid extract in infantile 
tetany, 120 

Lemedand ; Fatal staphylococcal puerperal 
infection. 660 

Lemierre, a.* Eoietiae in amoebic abscess, 
570 

Lemoine, G. : Antitoxic action of yeast extract, 
54 j 

LEsroRT : Promotion of diaresis in cardiac con- 
ditions. 652 

Lejiort. A.: Iodine treatment of goitre, 346 
Le Noiu. P. ; Pfeuro-cardiac streptococcal in- 
fection, 543 

Leoni, a.: The blood in scarlet fever, 557 
Leprosy, treatment of, lo — Protein therapy in, 
4i8— Epbedioe in, 595 

Levtospira icteroUles and Leptospira icfero- 
7inemorr7m(7to«,400 401 

Leriche, R. : T1‘ * ’ * *’ ' ' • ■ I 

Lessear, 3. A.; 

Lestoquard, F. * 1 

Lexclue, M. : T 
Leucocyte pictn 
Lencorrhoea, 550 

Leukaemia: In childhood, 423~Lymphati(3, 563 

■ ■ . Iren, 157 

■ . ‘onary thromb- 

osis, 419 

Levulose and baemodastic tests in childhood, 
638 

Lett. D. W.: Treatment of ringworm by 

tlvolHw— -'•p 

young subjects, 4^ 

*' ihloride content of the 

cerebro-spinal fluid in tuberculous meningitis, 
330 

Levy-Bolae : Blood transfusion in obstetrics, 70 
LiiOE, R. : Malicnant granulotnatosic. 85 
Ligature of the - -- »'‘'- 

LruEiE, H, I> ; T 

Limb<j. preserve ' 'tbe 

vessels, 295 

Linder. G. C. : The chlorides of the cerebro- 
spinal fluid in meningitis, 585 
Linitis, gastric. 7 ' 

Lip, cleft, surgical treatment of. 647 
* Lipiodol in gynaecology, 307 


Lifrat, a. : Disinfection of tho hands with 
hydrogen peroxide, 466 ^ 

LiRREuA, G. : Serological diagnosis of the pucr- 
porium. 74 ^ ^ . s« 

LirscH^TZ. B.: Cell changes in the shin m 
measles. 586 

Liver abscess. 3cfAh?cess 
Liver, echinococcal cyst of, 340 , 

Livor feeding in pernicious anaemia, 144. 170, 343, 
314, 353, M5— In nephrosis, 170 
LdamdUb, j. j. : Primary meningeal sarcoma, 
165 

LocjaiART-^IuJDtEny, J. P.: Pre-cancerous 
chaaeeB in tho rectum. 615 
Lombardi. E. : Etiology of pernicious anaemia. 
284 

Lor ; Treatment of fistula in ano, 215 
Lortat Jacob, L.: The treatment of Hodgkin's 
disease, 142 

Lowenstf-in. a.: Local treatment m tabes 
dorsalis. 321 

Lower. W. E.: Closure of bladder following 
prostatectomy. 89 

Ludloff’s phenomenon and injury to the tro- 
chanter minor, 163 

LDNDT. J. S. : S* 'ral !•’ '.h: : . 

Lungabscess. 

Long, massivo :■ < ■ Ss «■ i f si‘. tuber- 

culosis. 614 

Ltn?r, N. : The heart in typhus fever, 134 
Ldrje, a.: Appendicitis simulated by ovarian 
haemoirhage. 162 

Ldxadd: Fibroma and pregnancy, 500 
Lymphatic lenknemia, 563 
Lymphoma of tho faery mal sac, 371 
Lymphomas and leukaemias, 583 
Lynch, Clara J. : Inheritance of susceptibility' 
to malignant tumours, 77 
Lyon, E. C. : Etiology of acUlbittU.l? 


McCarthy, d. : Diabetic acidosis, 405 
McCedrkie, j. a. W. : Cutaneous spirochaetosis 
due to Treponeoia cunfeuli in British rabbits, 
553 

McCrae, T. : Primary carcinoma of the bronchi. 
55 

Macdonnnll, P, M..* Exophthalmic goitre and 
lead ionization, 532 

M'DowARii, R, J. S,: The effects of adrenaline 
on respiration, 612 

McFarland, A. R.: Gentian violet in dermato- 
logy, 274 

McKesson. E. I. : The anaesthetist In certain 
surgical emergencies, II 

McHinnoN, M. E.: Laboratory diagnosle of 
emall-pox virus. 202 

McLean, S.*. Endemic meningococcal mening- 
itis, 481— Cerebro-spinal lever in infancy and 
early childhood, £45 

Macleod, J. M. H. : The pityrosporon of 
Malassez. 636 

MotVHOBTER, G. L. : Torsion of the omentum, 
365 

Maoarey, R. ; Causes of uterine haemorrhage, 
23i 

MaGendie: Ectopic gestation, 352 
MaHnert, a.: Ovarian extract and the men- 
strual cs'cle,474 

MaHon, r. : S pinal anaesthesia in labour, 375 
Malaplate, j. : Encephalitis in measles, 209 
Malarial therapy in gent-ral paraiysis, 421— la 
cerebro-Bpinel syphilis, 469 
Malaria, inocu ation.tho brain in general paresis 
after, 6C0 

Malarial therapy as a direct immunizing 
pioceas, 402 

Malassez. the pityrosporon of, 636 
Mallet-Guy, P.*, Gastrectomy lor gastric 
cancer, 410 

Manic-depressive Insanity, somatic conditions 

JB. 279 

Mann, F. C. : Intestinal absorption, 308 
Maortda, C.; Treatment of amenorrhoea, 549 
Marosak, j. : Thrombo-angiitis obliterans, 294 
Marchal.G.: Malignant granuJoTnatosis, is 
Marchand, L. : Osteomyelitis of the scapula. 316 
Maboaand, R.; Treatment of aypbvUs asso- 
ciated with tuberculosis,515 
MABiANTScaiK, L P.: Treatment of fractured 
nbs, 648 

Marriage and syphilis, 53 

Masvters, a. H, A-; Indications for syntbalin in 
diabetes, 62 

3IABTIN. E. ; Resuscitation of the apparently 
drowned, 24 

• I^iagnosis of sterility in women, 
150 

Uabtin. Xj.: Tetra-iodo-phenolphthaleio in 
nli^^\eftyatograpily, 325 

Martinez, W.: Somnifen in states of agitation, 
6o 

Martini, B. : Levtosvira icteroides and itpio- 
sptrateterohaemorrhagiae, 400 

of radiation of the ovaries, 

O. ; Measles and tnhercalosia, 266 
h- Transplantation of ureiers for 
congenita? incontinence, 619 
Masoobowski, L. P.; Modification of tuber- 
caloasieeionabytheB.C.G.Taccine 79 
^yphhi?,',-i,7^"^“'^“'"^ in acauired 

MASSATOin; Osteomyelitis of the scapnia, 316 


8 JAN.-JUNE, 1928] 


INDEX TO THE EPITOME.' 


r TrbBbitii* ' 
L filEDTCAt. JorTtKAt. 


JlASBi, L.: Prognosis in abdominal pregnancy. 
125 

MASTrn, A. M. : Effect of sodium salicylate on 
tbe heart, 80 
iifastoicl periostitis, 350 

Matebnowska, Z. : Haematology of measles, 432 
Matry: Acute dilatation of the stomach treated 
by gastrostomy, 217 

JilAXWELL, Alice P. : Labour in contracted 
pelves, 258 

Mayer. L. ; - Temporary haemostasis in ab- 
dominal surgery, 412 

Maynard, E. P. : Treatmentof chronic auricular 
fibrillation, 322 

Measles: Cell changes in the shin in. 586— 
Encephalitis in, 209, 507— Encephalitis follow- 
ing, 442— Haematology of, 432— Osteomyelitis 
of the 08 pubis after, 218-— Spleen in, 158— And 
tuberculosis, 266— Virus of, 128 

V.. ‘ '•« <'.535 

■ : ■ • ■ .< '■ ■ : ■ of, 42 

.'*■ ■ . .... I . ...... |j3 553 

V. , •. .. : 

MnisER, H. : Serological classification of bacilli 
isolated from rhinoscleroma. 106 
Melenet, F. L. : ‘Wound infection and calgut, 
54^ 

Melioidosis in Cochin China, 108 
Meningeal haemorrhage at birth, sequels of. 425 
Meningitis, the chlorides of the cerobro-siiinal 
Iluid in, 585 

Meningitis, meningococcal, endemic, 481 
Meningitis, tuberculous, the chloride content 
of the cerebro-spinal fluid in. 389— The cerobro- 
Bpinal fluid in. 477, 585 
Meningitis, typhoid. 383 
Meningococcus septicaemia, 440 
Menopiuse, treatment of, 499 
Meu-trual cycle and ovarian exti'act, 474 
Menatrnal fietulae, 548 

Menstruation, influence of thyroid disease on, 
430 

Mental defect, hemiplegia and extensive naevus, 
99, 393 

Mental patients, typhoid and dysentery anti- 
bodies in, 43 



y • . . I .. ... •• 

r ■ . c 

diptithena.460 

Mcaouterio glands and fat absorption. 528 

in syphilis, 


AIestttz, W. : Mode of spread of octoplc endo- 
metrium, 40 

Metatarsal fracture. 591 

Methyl salicylate poisoning, 335 

MnuLENGRAciiT, E .* Treatment of pernicious 
anaemia with liver, 34 1 

Meter, L. S.L.; Active immunization againsi 
scarlet fever, 206 

METERDiNa, H. W. : Tbrombo-angiltis obli- 
tprans, 295 

and bismuth therapy in 
Hodgkin s disease. 448 

Michel, L L.: Diathermy in acute and chronic 
gonorrhoea, 325 

Migraine, etiology of, 1— Pituitrin in the treat- 
ment of, 541 

MTT-rrr I ri . (i « .... 

lion Ol 


i-spinal 


Milk. . 

l^lilk, 1 . — , . 

Mini E 

MlC.DE . .i ; J - 

ionization, 532 
MiiiDS, C. A. : Vitamin B 
468 

Miles, Katherine C. : 
common cold, 309 


i • ■ • ;4 

' : ■ : : : ‘id load 

extracts in diabetes. 
Bacteriology of the 


MissoRici, A. Piazza; Mastoid periostitis, 350 
MOELLER, A ; Hj'persensitiveness to tuberculin. 

Mode, L, : Influenza in infants, 422 
Moldaret, P. : Glukhorment in diabetes, 297 
Monlcovs, spontaneous epidemic of pneumonia 
m, 355 

MONop, R. : Treatment of inoperable cancer of 
tbe breast. 319 

Mononucleosis. Se# Fever, glandular 
Montel, L. ; Abscess of spleen in typhoid fever, 
138 

Mobetti, P. : The effect of splenectomy on 
experimental infection. 234— Treatment by 
experimental infection. 251 
Mobhardt, P. E. : Treatment of the menopause, 
499 

MobNard, P. : Tumour of pancreas cured by 
operation. 118 

Mobbow, H. : Acute syphilitic phlebitis, 538 
Mortality, high infantile, in large families, 265 
Mobton, D.G. : Transmission of arsenic to the 
aqueous humour, 519 

Moschcowitz, E.: Anglnoid attacks due to 
tobacco, 506 

Motta, R.: Chronic suppurative otitis media 
associated with Vincent’s organisms, 435 
MouzoN, J,: Rectal anaesthesia, 12 
Mucocele of the accessory nasal sinuses, 495 
Muir. E. : Epbedrine in leprosy, 5S5 
MniB, J. : Radium implantation in cancer of the 
oesophagus, 172— Radium treatmentof cervical 
cancer, 629 

MCllerheim, R. : Ovarian tumours in old age. 
582 


Mumps: Compileatod by nento nephritis and 
pancreatic necrosis, 25— And diabotos, 113— 
Otologicnl complicatioiifl of. 159— Sovoro cases 
of, 160— Of tcetriclo, wUhout parotitis. 242— 
Becond attacks of scarlet fever and, 215— 
Followed by polynouritis, 299, 395— Followed 
by orchitis. 462— Followed by pluriglandular 
syndrome, 484 

MflNcn, A. P. W. : Liver extract In pernicious 
anaemia, 543 

MuBPnr, W. W.: Actli’o immunization against 
scarlet fever. 207 

Murray, H. E.t Splanchnic anaesthesia in 
np])or abdominal operations. 451 
Jfneclo, uterine, during pregnancy and labour, 
328 

Muaculo-ppiral paralysis. Paralysis 
Mubber, 3. K. : The brain In oncophalltlR. 663 
Mutebmilch, S. : Passage of arsenic and 
bismuth into the cerebro-spinal fluid, &11 
Myasthenia gravis, 394 
Mycoses, unrecognized, 153 
Myelitis, transverse, ns a forn'i of IlelDC-MoJin’s 
disease. 441 

Myeloplax tumours of the Rplno, 161 
Myers, B. : Composition of human milk, 131 
Myocarditis, chronic, without cardiac failure, 
diagnosis of, 613 

Myopathy, pre-scorbutic, and “growing pains,” 
196 

Myosnlvarsan in the treatment of syphilis, 250 
Myositis osniQcnns.444 


Orchitis following mumps. 462 
Oblandini. O : Cnuses of blopharospasra, 49 
OnoriNo, A.:^Amhard*a constant and the renal 

^ in treatment of 

Outiz-Per'ez, .T. : Symphysiotomy, 151 
Orton, 8. T. : Impediments of speech, 277 
Os piibl.s, tuhorcuiosis of. 216 
Ossiflcntlon. pathology of. 233 
Ostoo-articular tuI>orculo9is. trcafmenfcof, 366 
Onteoinyolitis : Of the flbnla. 30— Of tbo scapula, 
316— Of the os tmbls after measles, 218— 
Suppurative, treatment of. 5 2 
Otitic Bopsls, treatment of, 298 
Otitis media, chronic suppurnllvc, associated 
with Vincent's organisms, 435 
Otologicnl comnlicntions of mumps, 159 
OTTOLENonr, It.: Bacterial flora of periapical 
infections, 381 

Ottow, B. ; injuries of the bladder during 
labour, 232 

OuRT, P. : Gastric linJti<5, 7 
Ovarian aplasia, bilateral, 259 
Ovarian cyst, large, 177— Operation in two stages 
for, 193— Troatmon*. f!l::ri":r 5?1 

Ovarian extract and 1 

Ovarian Imemorrhof ■■ ! 1.: 

162 

Ovarian tumours in old age, 582 
Ovaries, rcquols of rudiation of. 399 
Oxygon presBiiros, low, acclimatization to, 436 
Oxygon therapy, 642 


N. 

Naevus. oxtensivo. associated with hemiplegia 
and mental defect. 99, 396 
N AErzioER, H, C. t Transiotit hemiplegia. 4 
Naolr, N. ; Tbe Kahn tost in primary syphilis, 
640 

Nagtegaad. 0, Q.j Parkinsonism following 
typhoid fever, 112 

Nakahara, W. ; Btorllityand vitamin deficiency, 
607 

Nardel. M. : Soro-dingnosUc methods In tuber- 
culosis, 555 

Nasal polypi, histology of, 20 
Nnsftl sinuses: Malignant tumours of the, 146— 
Mucocele of. 495 

Nasopharyngeal infccUons as a cause of various 
Infantilo diseases. 37 

Nathan, M, : Diphtheria without membrane, 183 
Necrobiosis of uterine fibroids, 601 
Nephrosis, liver diet in, 170 
Nervous disorders. /uDCtiooa}. calcium therapy 
in. 96 

Norvoussystem. sympathetic, surgery of tbo, 513 
Nesbit, W. : Pulmonary abscess following 
tonsillectomy. 6 
Neuralgia, genital, 429 

Neuritis, intorstllial, caused by the virus of 
rabies, 153 

Neuritis, vestibular, in acquired BypliiHs. 347 
Newborn: Haomorrbagic disease of the, 546— 
Sepsis in the. 657 

Neweld, R, R. ; Tbo epilation and erythema 
dose of X rays, 628 

Niosolls, a. G.: Methyl salicj'Iato poisoning, 
335 

NicoiiAtJ. C.: The heart in typhus fever. 134 
NicoLAU, S. : Interstitial Qouritis caused by the 
virus of rabies, 153 

Nielsen, J. M. : Myasthenia gravis. 394 
Nose, occurrence of brain tissue within the, 348 


O. 


Obermater, M. : Immunity following herpes 
zoster, 461 

Obstetrical factors in noo-natal intracranial 
haemorrhage. 281 

Obstetrics; Blood transfusion in, 70 — Spinal 
anaesthesia In, 201, 375 

Obstruction, intestinal, acute: Sodium chloride 
injections in. 190— Death in, 446 
OcHSNER, A,i Pulmonary abscess following 
tonsillectemy. 6 

Ocular complications of spinal anaesthesia, 450 
Ocular manifestations of epidemic encephal- 
itis, J85 : of juvenile tabes. 561 
Ocular pemphigus, 227 • 

Ocular signs of labyrinthine disease, 147 
Odasso. A. : Isolated fractures of the Bomilunar 
bone. 341 


diphtheria, 460 

Oliensis, A. B. : Glucose medication, 171 
Olitzki. L. ; The H- end O- forms of B. tvp7iosits, 
637 

Omentum, toi’sion of, 365 

Ophthalmia, sympathetic, diphtheria antitoxin 
in, 374 

Ophthalmology, protein therapy in, 596 
Opie. E. D.: The leukaemias and lymphomas. 
583 

Optic atrophy, hereditary and familial, 67 


P. 


PACmio.G.: Cervical ribs, 387 
Pagniez, P. : Oedema duo to hypothyroidism, 
2S7 

Palate, cleft, surgical treatment of, G47 
Palazzo. R.: Puerperal septicaemia caused by 
D.pcr/riMpeMS, 72 

Pam'Vici, M. S.: The exhaustion of media in 
bacterial cultivations, 42 
PALMiKni. V. M. : Resfstauco of tubercle bacilli 
to putrefaction, 504 
Palpebral cysts, 225 

Pancreas: Tumour of cured by operation. 118 
Panbini, O.: Misleading symptoms of larj’ngeal 
obstruction, 145 , . , 

Paralysis, general: Malaria therapy in, 402, 421, 
— Tho brain in, after malarial inoculation, 

■ • ' - * ■ ■ ‘of. 221- 

r , ’ ' jection of 


Parameirills and renal disease, i'i 




I 


. A.. - * * ■ • ‘ deep- 

seated inflammation, 508 . . 

Pabise. N. : Synthalin treatment of diabetes, 
119 

Park, W, H.: Modlficalion of the Schick test, 
pimtER. L. B.: Surgical treatment of cleft 






■ ization, 181 

Patel ; Necrobiosis of uterine fibroids. 601 
Patel. M.: Ligature of the inferior vena cava. 
465 

Paterson, D.: Incidence of hernia lu children, 
140 ... 

Peabct, j. F. : Sodium nitrate in sea-sickness 


appendix, 293 


,65 

liform 

381 

•.485 

. al sym- 


en. 547- 

Post operative, prevention ofi and abdominal 
adbe'?ions,41 — Serum treatment of,623— Tular- 
aemic, 136 

Peritonsillar abscess. See Abscess 
Pery: Ectopic gestation, 352 
Petit-Dutaillis, D. : Sodium chloride injec- 
tions in acute intestinal obstruction, 1^0 
Petbesco: Tbe heart in typhus fever, 134 
Petbov, V. P. : Sand-fly fever, 3 . 

Petter, C. K. : Rectal fistula in tuberonlosis, 58 
Peyoelon. R,; Ligature of the inferior vena 
cava, 465 

Peybe, E. L. : Salmonellosis associated with 
hydatid cysts, 286 

Phaneup, L. E, : Low Caesarean section, 16 
Philips, H. B. : Radiological treatment oi 
uterine fibromata and hypertrophied pros- 
tates. 626 

Phlebitis, acute syphilitic, 588 
Phrenico-pupillary syndrome in pleuro-pulmo- 
nary affpetions, 530 

Phthisis. S«6 Tuberculosis , , „ 

Physiotherapy in tbe treatment of salpingo- 
odphoritis. 176 



JAN.-JUNE, 1928] 


INDEX TO THE EPITOME, 


r Th> B*mrt i-k 

LUxdich. Jouxirxi. t7 


noKWORTn, F. A. : Typlioltl nnd aysontory anti- 
bodies la mental patients, 43 
ricot, G.: Snreical troitmont of piumonary 

abscess and flaoKronc. 362 

riKRi.G. : Surgery of tbo Byinpatnotlo nervous 
syslom.SlS 

Pilocarpino In givjl-bladdor disoaso, 325 
Pis-ARD, M.: Arsenio in BypbUitIc aneurysms, 
275 

Pineal gland * 

P 1 NKP 8 . F.: ■ 1 it , 

PiSTO. A. i hputUorla 

bacillus, 262 , ■,« 

PiQorT.J.*. OitcomyoUtisof the fibula, 30 
pirquot to<5t with difforeut tuberculins, 157— 
Puncture molbod, 551 , , ,, , 

Pltnitary extract for tbo induction of labour, 635 
PUnitrln in the treatment of migraine, 5U 
Pityrosporon of Malassos, 635 
Placenta accrota, 579 „ * t 

Placenta : Dotacbmont of the normally situated, 
102— Delivery of the adborent. 425 
Placenta praovia, 126 
Plastic surgery for bornla, 617 
PLATOU, E. S. : Treatment of orysipclaa, 221— 
Treatment of laryngeal dlphtlicria,510 
pleurisy, pulmonary tuberculosis as a sequel to, 
83 .. 

, , rcnico- 

. . . miosis 


Pyolonopbritis in pregnancy, 282 
P ‘ V— entof,29 

r . ' 

r 


Qoain, E. r. : Acute appendicitis, 539 
QprniDo, A.: Encopbalitis followingdipbthoria, 
267 

Quinidino in coronary tbromboais, 419 
Quinlno injection followed by miiscnlo-spiral 
paralysis, 407 

Quinine suppositories causing eczema. S57 
Quinine and urea in treatment of internal 
baemorrhoids, 568 


R. 

Rabies, intersUUal nourUis caused by the virus 
of. 153 

Rabinowitz, IVf. A.: Polyneuritis following 
mumps, 290. 395 

Radiation of the ovaries, sequels of, 399 
— 1 of tbe bladder, 470 

treatment of uterine 


Plntiglanduiat syndrome following mumns, 484 
Pneumococcal peritonitis in cl\lldron.547 
Pneumococci, Typo IV, an epidemic duo to, 129 
Pneumococcus, “R ’* and " S " forms of, 503 
Pneumonia, lobar: Se<Umcnlatvou rato in, 26 — 
Serum therapy in. 572 

Pooumonla in monkeys, spontaneons opidomic 
of, 355 

PneumotUorax, artltlclab late results of treat- 
ment by. 47 

r * * ... 212— Insulio, 

■ ■ Sodium salicylate, 

' ■ regnancr. 305 

Polyneuritis following mumps. 293. 395 

Polypi, nasal. hlstoloHy of, 20 

Polyposis, isolated, of tbo small intestino. 139 

Polysteatosls. chronic visceral. 50 

P0K6, R : The oristence of melioidosis in 

. Cochin China, lOS 

PosTANO. T.: Tuberculous typbobaciUosls in 
adolescents. 2U 

Forges. 0. : Liver diet in nephrosis, 170 
Porokeratosis, etiology and troatment of. 122 
t5«p^ ■»»^ordoT8, 599 

• . t in pregnancy 

d from typhoid 


Pregnancy, abdominal: 
Primary. 398 


Prognosis in. 125— 

'* ’-■ ^ompli- 
. tissue 


• ' inte 

veuiton in. 523 

Pregnancy: Fibroids in, 305, 500— Heart in, 42 
&.^0-^vanan cysts daring, treatment of, 524 
PyelitiB in, after bistoiy' of, 18— Pyoloncphrit 
in, 282— Radium treatment in, complicated I 
carcinoma, 306— Renal function during. 632 
Uterine, following bilateral salpingectomy ft 
T?o muscle durin 

328— vertebral deformity and cardiopatl 
daring, 75— Vomiting of, treatment of. 653 
Pregnancy. See also QestMon 
^■^^^^’Sejitnerio, P. Lo: Erj'thoma nodosui 

• Serum treatment of appendiciti 

Oi4 

Prostate, cancer of. See Cancer 
Prostate, tuberculous, diagnosis of, 650 
Prostatectomy : Technique in. 56— Followed I 
closureof bladder. 89 

Prostatic hypertrophy, inoperable, pepsin sol 

HODS in, DO 

Prostitio hyportroohy: Tteatmont o!.'^45.616 
v^aaootomy in, 567— Radiological treatment c 

Protein sen-iitivenose, 358 
logy^K^'^"^' “ilS— In opUtbalm 

pS?5F' ^ Diagnosis of sterility in women, 1 

f - 

iiititfccai, fatal'.' 660 ’ ' ' '' ' 

Puerperal septicaemia: Caused by B ne 
of alcohol in? 260-An 
P. 

P 

P 

diseases. ekia^plTy in. 324 
Pulmonary tuberculosis. S-f Tuberculosis 
Pu monary ventilation in phthisirsos 
Palse wave velocity. 184 
Pnmnra fnlminanB, 240 

F?no^n“n 363 

PmsslT P ‘he clavicle, 615 

differences in piilmonai 

of, 18 


Radiological troatmont of uterine fibromata and. 

hypertrophied prostates, 626 
Radiology, sodium totra-iodo-phonolphthalein 
in. 627 

Radiolbcrapy : And cancer of the uterus, 15— Of 
asthma and spasmodic coryza, 173, 471, 472. 
See also X rays 

Radium treatment : Of cancorof the oo?ophasuB, 
172— In pregnancy complicated by carcinoma, 
30i— Of cervical cancer, 629 
Raescuke: Osteomyelitis of tho os pubis after 
measles, 218 

Ramon, G. : Immunization against dvphlberia, 
310 

Ratheuv, F. : Glukhoriuentin diabetes. 297 
Uatmond-Hasirt : Tho amino bases of ergot. 223 
Rectal anaesthesia. See Anaeslhoala 
Rectal fistula in tul)orculo6i«, 59 
Rectal gonorrhoea in women, 634 
Rectum, pre-cancerous changes in the, 615 
Red light in treatment of emall-pox. 220 
Redino. a. : Infiuouco of hydrogon-ion con- 
centration on ceiiular division. 479 
RcDLicn, F.: Incidence of visceral spyhills, 
405— Haematology of measles. 452 
Reep, M.: Mucons-collod carcinoma of the 
cervix, 431— Placenta accreta, 579 
Regional anaosthesta. See Anaesthesia 
Regniep: Vromotioaot diuresis ia cardiac con- 
ditions, C51 

Reu, T. : S»»cond attacks of scarlet fever and 
mumps. 243 

nEtD. \Y, D. : Auricular fibrillation in an appar- 
ently normal heart. 133 
Renal complications of influenza. 244 
Renal disease and parametritis. 39 
Renal distortiOD.lSS 
Renal function during pregnancy. 632 
Renal function tests, the comparative value of, 
JOS 

Renal functions, Ambard’s constant and the, 335 
Renal injury and alkalis. 314 
Renal pelvis, tumours of the. 620 
Renal tuberculosis and heliotherapy, 447 
Renard. Claudio : Serum treatment of appondic- 
itis, 574 

Respiration. ofTccts of adrenaline on, 642 
Respiratory disorders, post-encephalitic. 599 
Respiratory emphysema. See Bmphysema 
Respiratory hippus in mediastinal affections. 
558 

Respiratory tract, upper, tuberculosis of the, 349 
Reticulo-endotheliai blockage and flocculation, 
333 

Retinal artery. See Artery 
Retinal vessels, obstruction of branch of, 373 
Retlcuioendoth^^Ual ByBtcm,639 
Revaccination after subcutaneous injection, 110 
Rheumatic endocarditis, prolonged salicylate 
treatment in, 491 

Rheumatic nodes, bacteriological examination 
of. 529 

Rheumatism, acute, treatment of, 315 


'6J9 

RnoADS. P. S. : Diphtheria after active immunh 
zation, 315 

Ribs : Cervical, 387— Fractured, treatment of, 648 
RiETscnuii, H. : Alimentary pyrexia in infants, 
655 

RiGAtJO, A.: Oedematous influenzal larj’ngitis. 
51 

Ringer, A. I. : Synthalin in diabetes, 652 
Ringworm treated by thallium acetate, 168, 169. 
449 

Riviere. M. : Sequels of meningeal haemorrhage 
at birth, 425 

Robinson, G. K.: An epidemic due to Tjtjq IV 
pneumococci, 129 

Rodin, P, H. : Oostruction of branch of retinal 
. vessels, 373 

Rodriguez, P. J. : Sdmnifen in states of agita- 
. tion.es 


RoEonoLT, M. N.: Surgery of the spleen, 594 

Rogers, C. S. : Late troatment of barns, 649 

RohAcek, L. : Mode of action of ingested urea, 
154 

Rodi-'e. W. a.: Treatment of internal haemor- 
rhoids with quinine and urea. 568 

Roeleston, J. D.: Alcohol iu acute infectious 
diseases. 489 

Roleet, E. : Amaurotic zoster, 521 

Rollet, j. : Ocular complications of spinal 
anaesthesia, 450 

Roleier. a. : Heliotherapy and renal tubercu- 
losis, 447 

Romani, A. : Primary tuberculosis of the bladder, 
5S2 

Roques, Alice : Epithelioma following subtotal 
liystercctomy, 602 

Roques, F. : Epidemic encephalitis and preg- 
nancy, 631 

Rosenthae, G. : Treatment of acute rheumatism, 
345 

RosNOBi.r.T, J.: Ocular manifestatlonsof juvenile 
tabes. 561 

Roth, P. : Myasthenia gravis, 394 

Rouques, L. : Oedema dne to hypothyroidism, 
287 

Rovida, G. : Local immunization against 
anthrax. 263 

RuBAsenow, S. ; Results of periarterial sym- 
pathectomy, 485 

RuvB, A. Charlotte: Ulcus vulvae acntum,377— 
Tho filterable form of the tubercle bacillus. 
480 


Sabr^zes, j.: Mumps complicated by acute 
nephritis and pancreatic necrosis;, 25 
Saccharated iron carbonate solutions, danger of 
injections of. 167 

Bacral block anaesthesia. See Anaesthesia 
Sacral hernia. Hernia 
Saernm, fracture of tbo. 116 
Sajdman, M.: Treatment of suppnrativc osteo- 
myelitis. 512 

Baito, S.: Nature of morbid processes following 
duodenal obstiuctlon, 356 
Sakai. K.: Nature of morbid processes follow- 
ing duodenal obstruction, 356 
Saeamon, E.: Passage of arsenic and bismuth 
into the cerebro-splnal fluid. 641 
Salicylate treatment, prolonged, in rheumatic 
endocarditis, 491 

Baline solutions in hypertension, 490 
Salmonellosis associated with hydatid cyst, 286 
Baeotti, a. : Fractures of the saernm, 116 
Salpingectomy, bilateral, for tubal preguancy, 
followed by uterine pregnancy, 397 
Salplngo-oSphoritis, physiotherapy in the treat- 
ment of, 176 

S AEVESEN, H. A. : Acidosis in athletes. 268 ' 
Baezeb. H. : Pneumococcal peritonitis in 
children, 547 
Sand-fly fever, 3 

Sanocrysin in treatment of pulmonary tuber- 
culosis, 518 

Sarcoma : Giant-cell, prognosis and treatment 
of, 5— Primary meningeal, 165 — Of the uveal 
tract. 228 

Sargent, E ; Varieties of immunization, 181 • 
Saupbar: Pyotherapy in puerperal infection, 551 
Scapula, osteomyelitis of the. 316 
Scarlatinal virus, filterable forms of, 331 
Scarlet fever. See Fever 

Schaefer, W. : Distribution of the herpetic 
virus in the tissues, 21 

ScHEEE, O.: Pulmonary tuberculosis as a sequel 
lo pleurisy, 83 

Bcheff. P. : Temperature of the cerebro-spinal 
fluid, 662 

Schick test, modification of, 135 
ScaiM VAN DER LoEFF, H. J. : Diabetic psy- 
choses, 533 

Schizophrenia and shyness. ICO * ‘ 

ScHEESiNGER, B. : Snbaciite infective endo- 
carditis in children. 610 
ScHEUTZ, F. W. ; Treatment of erysipelas, 224 
ScHMiTE. P. : The treatment of Hodgkin’s 
disease. 142 

Schoenberg, M. J. : Detachment of tho anterior 
layers of the iris, 223 

ScHOENFEED, IV. : Epidural administration of 
drugs, 191 

SoHOTTER, H. : Vaccine treatment of typhoid 
fever, 653 

Schrieber. j.: Anaerobic bacteriaemia, 605 
HchArer. Waldheim. F.: Tho use of iodine in 
ths’roid disease. 94 

Schwarz, E. : Local immunization against 
anthrax, 263 

Sciatica, secondary, diagnostic errors in 245 
Scurvy, latent, 437 
Sea-sickness, sodium nitrite in, 625 
Semilunar bone, isolated fractures of the, 341 
Sendtner-Voeldersdorff, T. : Intravenous 
ana peroral methods in cholecystogranhv 17S 
Sepsis in the newborn. 657 • 

Septicaemia: Chemotherapy in, 65— Meninun- 

abortion, 

r 


. 3 



lO JAN.-JUNE, 1928] 


INDEX TO THE EPITOME. 


r Taz Bbitisk 
LUcdical Jorasriz, 


Sergent. E.: The phrenico-pupillary syndrome 
in plenro-pulmonary affections, 530 
Sero-diagnostic methods 10 tuberculosis, 555 
Serological diagnosis of the puerperium, 74 
Serum : Antigangrene. in the treatment of typhoid 
fever. 143— Antistreptococcal, in treatment of 
puerperal septicaemia, 525 
Serum calcium in urticaria, 45 
Serum therapy: In scarlet fever, 299 ~In lobar 
pneumonia, 572— In appendicitis, 574— Of peri- 
tonitis. 623 

Bette, N : Hewer gas and typhoid fever, 151 
Sewer gas and typhoid fever, 161 
Sex differences in pulmonary tuberculosis 
deaths, 52 

Sezart, a.: Treatment of syphilitic cardio- 
vascular diseases, 222 

Sgaettzer. U. : Radiological examination of the 
trachea, 174 

Shannon, W. R. : Intussusception in children, 
621 

Sharp, N. A. Dyco: Protein fchorapj' in leprosy, 
418 

Sheep. Australian, infectious necrotic hepatitis 
in, 527 

Sbelpon, R. F. : Control of hiccup by COj 
inhalations, 35 

Sheldon, W. P. H. : Faecal fat analyses in 
children, 132 

Shiblet G. S. : Bacteriology of the common 
cold, 309 

Shyness and schiznpbrenia, 100 
SiCARD. A : Treatment of osteo-articularituberou- 
losis, 366 

SiEBNER, M : The leucocyte picture in .surgical 
diseases, 379 

Sinai, G. : Vaccine treatment of tj phoid fever, 
653 

Singer, L.: Rectal gonorrhoea in women. 634 
Sinus, nasal. See Nasal 
Skiagraphy in pulmonary diseases, 324 
Skin affections in asthma, 123, 302 
Skin dressings causing tetanus, 339 
Skin in measles, cell changes in the. 586 
Slatman, a F. : Extensive pigmentation of the 
akin associated with amenorrhooa, 124 
Slosse, a. : Influence of hydrogen-ion concentra- 
tion on cellular division 479 
Smail-pox, treated, by red light, 220 
Small-pox virus, laboratory diagnosis of. 202 
fc-aiiLEY, D. F. ; Iodine deficiency in water as ati 
index of goitre. 560 

SMiT, H. P. A. : Pregnancy complicated by 

diabetics, 101 

SUITE. J. F.; Influence of thyroid disease on 
menstruation. 430 

Smits, E. : Spirochaotosis icterohaomorrhagica 
in the Dutch Indies, 239 

Snoece, J. J, : Uterine rupture during labour, 
2i9 

Sodium chloride infections in acute intestinal 
obstruction. 190 

Sodium cinnanlate in pulmonary tuberculosis, 
420 

Sodium nitrite in sea-sickness. 625 
Sodium salicylate: Effect of. on the heart, 80— 
Poisoning by, following injections, 182— In 
chronic epidemic encephalitis, 369 
Sodium tetva-iodo-phenolphthalein in radio- 
logy. 627 

Solomon : X rays in hyperchlorhydria, 473 
SOM3IER, K. : Bacteriology of septicaemia of 
childbirth and abortion, 502 
Somnifen in states of agitation, 66 
SoNDEN. T. : Somatic conditions In manxe- 
depre.'-sive insanity, 279 
Speech, impediments of, 277, 278 
Sfeelman. N. : Active immunization against 
scarlet fever, 203 

Speidel, E. ; Treatment of vomiting of preg- 
nancy. 658 

Spence, A. W. : Splenectomy for pnrpura 
haemorrhagica, 363 

Spence. J. C. : Treatment of pernicious 
anaemia with liver, 343 

Spencer, F. R. : Tuberculosis of the middle 
ear, 148 

Spinal anaesthesia. See Anaesthesia 
Spinal column, recional anaesthesia for opera- 
tions on the, 14, 452 

Spinal fluid; Relation between glucose in the 
blood and, 458— Bacteria in. 584 
Spine, myeloplax tumours of the, 164 
Spirochaetosis arthritica. 336 
Spirochaetosis, cutaneous, in British rabbits, 
due to Treponema cuntculi^ 553 
Spirochaetosis icierohaemorrhagica in the 
Dutch Indies, 239 

Splanchnic anaesthesia. See Anaesthesia 
Spleen, abscess of. See Abscess 
Spleen in measles, 158 
Spleen, surgery of the. 594 

Splenectomy, the effect of on experimental 
infection, 234 

Splenectomy for purpura haemorrhagica, 363 
Splenic artery. See Artery 
SpRUNT, T. P. : Epidemic encephalitis, 109 
Stammering produced by thyroid medication, 
562 

Staphylococcal puerperal infection, fatal. 660 
Staphylococcal vaccine in treatment of typhoid 
and paratyphoid fevers, 64^ 

Stein, D. : Glucose medication, 171 
Steinbrinck, : Toxic diphtheria, 361 
Steiner, P.: Incidence of visceral syphilis. 403 
Stenosis, hypertroiihic pyloric, treatment of, 29 
Sterility and vitamin deficiency, 607 
Sterility in Women, diagnosis of, 150 


Stevens, W. B. : Qufnldlno in coronary Ihrom- 
bosis, 419 

Stewart. C. A.: Treatment of Jaryogoal d/ph« 
thoria.510— The Pirquet tost-puncturo method, 
554 

Stewart, D. : The corobro-spinal fluid in tuber- 
culous meningitis, 477 

Stieqlotz, E. j. : Alkalis and.ronal Injury, 314 
Btillbirth, etiology of, 17 

Stinson, J. W. : Colloid carcinoma of the 
stomach, 312 

Rtookr, a. V. : Goitre In adolo«5concc, 313 
Stocks, P. : Goitre in the English school child, 
195— Goitre In ftdolosconco. 313 
SToxLorp, M.; The relation between glucose In 
the blood and spinal fluid, 458 
Stolkind. E. j. : Angina pectoris in children, 
544 

Stomach, acute dilatation of treated by gastrec- 
tomy, 247 

Stomach. See Cancer, Tuberculosis, ami 
Ulcers 
Ston ■ ^ 

Btra-: • . 416 

Stre' ‘ * * banter minor 

and LiullofT's phnnomcnon, 163 
Streptococcal iofoclion. ideiiro cardiac, 613 
Streptococci. tran‘unlRBibli» toxicogonicitv of. 81 
Striroweu, R. : Trcatniont of bronchiectasis, 
516 

Strophantln In heart failure. 9 
SuhculancouB injccUous, oily, ab'iorptlon of, 
378 

Sulfarsonoi in puernornl fever, 507 
Surgical diseases, the leucocyte picture in, 379 
Surgicfil omerg«*Dciea. See Emergencies 
Sdtherland, C. : Treatment of asthma, 370 
Suzuki. S.: Nature ef morbid proccssoH following 
duodenal obstructlou, 356 
Suzuki, M. : Sterility and vitamin doQcioncy, 
607 

Sweat, diminished cocretlon of in heart failure. 

1 

of, 485 
* irvous 

“ 'the. 376 

for in diabetes, 62 — 

• in clilldron, 55— Treat- 

inent of dinbotos. 119, 368. 652 
Synhilifi: Acquired, vcsUbiilnr neuritis in, 317— 

‘ ' • . . • sod incidence 

sorcad o( in- 
* . irlal therapy 

* — Congenital. 
*. * marriage, 53 

— Myosalvarsan iu treatment of, 250— Prod pi- 
intloD test for, 285— Primary, the Kahn tost in, 
640— SupAvinfectioii In, 615— Aesoclalcd with 
tuhorculosis, treatment of. 515— Visceral, inci- 
dence of, 403 

Syphilitic aneurysms, arsenic in. 275 
Syphilitic cardio-vnscular diseases, treatment 
of, 222 

Syphilitic phlebitis, acute. 588 


T. 

Tabes dorsalis, local treatment in, 321 
Tabes, juvenile, ocular manifestations of, 561 
Tagliavacore, N.: Tuberculosis of the os 
pubis, 246 

Tannic acid treatment of bums, 391 

Tapia, M.: The Bcdimcntatlon rale in lobar 

_ pneumonia, 26 

' •• blood 


Tetanus caused by skin dressings, 339 
Tetany, infantile, pai'athj'roid extract in. 120 
Tetra-iodo-phenoipbtbalein in oholocysto- 
granby, 326— In radiology, 627 
Thallium acetate in the treatment of ringworm, 
168, 169. 449 

Thibault, G.: Treatment of typhoid fever by 
anti-gangrene sernm. 143 
Thirbry j. H.: Treatment of small-pox by red 
light. 220 

Thomas, A. G. : Heart affections in elderly 
people, 359 

Thomas. G J. : Proatatic hypertrophy, 616 


natomyelia, 

338 

Thrombosis, coronary, quinidine in, 419 
Thrush, vnlvo-vaginal, 330 
Thymus gland in Graves’s dispase, 141 
Thyroid disease : Iodine in 93, 94— Influence of 
on menstruation. 430 

Thyroid medication, stammering produced by, 
562 

Titus, P. : Glucose treatment of eclampsia, 659 
Tobacco, anginoxd attacks due to. 506 
Toda, T. : Resistance of acid-fast bacilli to oil 
emulsion. 44 

Todd, D. C. ; Hepatitis of early syphilis, 463 
Tomcsik. j.: The nature of bacterial anaphy- 
laxis, 456 

Toniettx. F.; Respiratory hippus in medias- 
tinal affections. 558 

Tonsillectomy followed by pulmonary abscess, 6 


Tonsillitis, blood urea In, 605 
Tonsils, bony and cartilaginous deposits in, 155 
Toomey. J. A.: Amato bodies in, scarlet fever, 
130 

Toomey, N. ; Gold treatment In psoriasis, 301 
ToiiRES. J. : The sodimontation rate in lobnr 
pnoutnonia, 26 

TortlcolUs, congenital, etiology of, 186 
Toverud, K. U. ; Treatment of diabetes in 
children. 191 

Toxin-nntitoxin mixtures, dissociation of, 235 
Trachea, radiological examination of the. 174 
Trachoma, korntltis duo to an infection of, 620 
Tiiauba. N. C. : Treatment of arthritis with 

suits of ■ • 

Trauma ' of the 

abdomt..... .>.*>«, 

Travih, D. E.: Impediments of speech, 278 
'Tret}onema cunicuU causing cutaneous spiro- 
ebaetosis in Hriti-h rabbits, 553 
Trial labour. See Labour 
Trochanter minor and Ludloff's phenomenon, 
injury to the. 163 

Trubler. H. M.: Death in aente intestinal 
obstruction, 446 

Tubercle bacilli: The filterable cleraonta of. 236 
— Bacteriolysis of the, 351— The filterable 
form of. 480— Resistance of to putrefaction; 501 
Tuberculin, hyporscnsltivonosB to, 433 
Toborcullns, Pirqnet’s tests with different. 157 
Tuberculosis; In adults, pathogt-nosis of, 82— 
Of the bladder, primary, 552— Of the breast. 

bortion.199 

• ■ . 'rectum in, 

f * iathsin.573 

— Massive atelectatic collapse of the lung in, 
$14— A-Tid measles, 266— Of the os pabie,246 — 

T 


T 


salts in. 392— Of tlie stomach. 272— .Associated 
with syphilis, treatment of, 515 
TuborculoUB infection in Fchools. 231 
Tuborculons legions modified by the B C.G. 

vaccine, 79 ^ , 

Tuberculous ineningitis : Chloride content of 
the cerolwo spl' al fluid in, 380— The cerebro- 
spinal fluid in. 477 

Tuberculous prostate, diagnosis of, 660 
Tuberculous typbobacillosis in adoIesceutSi 241 
Tularaemia, 211 
Tularaeniic peritonitis, 136 
Tumour of the endocardium, primarj’. 566 
Tumour of pancreas cured by operation, 118 
Tumours, malignant: Inheritance of ausceptf* 
bility to. ’77— Of the nasal sinuses, 146— -Of the 
testicle, 415 , , . 

Tumours, myeloplax, of the spine, 164 
Tumours of ovary in old age, 582 
Tumours of ihe pineal gland, 318 
Tumours of the renal pelvis, 620 ^ 

Turner, A. W. : Infectious necrotic hepatitis m 
Australian sheep. 527 

TuRNEn, 3V. A.; Post-oncephalitic respiratory 
di‘;ordorfl. 599 , , . 

Typbobacillosis, tuberculous, in adolescents, 
241 

Typhoid antibodies in mental patients. 43 
Typhoid bacillus, precipitable substances de- 
rived fi'om, 179 

Typhoid fever. See Fever, enteric 
Typhoid meningitis. 383 
Typhus fever. Nee Fever . 

Tzanck, A.; Blood transfusion m obstetrics, 70 


U. 

UHRiG.MHe: Chemotherapy in septicaemia, 63 
Ulcer: Duodenal, treatment of, 533 — Gastric, 
treatment of, 538 s j- 1 

Ulceration, gastric and duodenal, the radical 
operation for, 115 

Ulcero-necrotic glossitis in scarlet fever. 614 . 

Ulcers of stomach and duodenum, multiple, 31 
Ulcus vulvao acutnm, 377 . 

Ultra-violet irradiation, bactericidal power 01 
the blood after, 180 . . , 

Urbatn, A. : Distribution of the herpetic virus 
in the tissues. 21 

Urea in the treatment of uterine bleeding. 476 
In treatment of internal haemorrhoids 568 
Urea, blood, in tonsillitia and scarlet fever, 60b 
Urea ingested, mode of action of, 154 
Ureter, cancer or. See Cancer 
Ureteral catheter, retained, 248 . , . 

Ureters, transplantation of for congenital in- 
continence. 619 
Urethra, epithelioma of, 271 
Urinary conditions, surgical, complicated oj 
diabetes. 466 

Urticaria, the serum calcium in, 45 
Uterine bleeding, urea in treatment of, 476 
Uterine conditions, radiological and operativ 
treatment of 351 

Uterine fibroids, necrobiosis of, 601 --e 

Uierine fibromata, radiological treatment 01,0 
Uterine pregnancy. Sec Pregnancy 
Uterus, cancer of. See Cancer 



'92S] 


INDEX TO THE EPITOME. 


r Tnr Baixisn 
L Medical JornvAL 


II 


Uterus, Cftuscs of haemon*l)B«o of, 231. Set also | 
HBomorrhneo ' 

Utonis: KuMuro of duriuf? labour, 229— Sacral \ 

bomia of the, 3S s 

Uveal tract. Barconm of, 228 I 


Vaccinations, subcutaneous, rovacciuation after, i 

ilO , , 

Vftcclno treatment In soft cliancre, 3C7— Of 
typboUl fever, 653 

Vaolio, It.: Bersis in Die newborn. 657 
VALven. L. : Totra-lodo.pbenolphtbaloln in . 
cbolccystocraphy, 327 

ValleuT'Rapot. r.: Itntliotherapy of nsthnm , 
and spa^^uiodic coryr.a. 173. 471 
Yai.tis..!.: The filterable olomcnls of tubercle 
bacilli, 23G 

. . ''estaiions of 

• ■ ■ of (liurc'^ia 

in cardiac condilions. 651 
Van* pun Loo, .1. C. : Tuberculous infection in 
scbool?, 291 

Van DoRr-bnucunu Anpupak, D.: Active im* 
lunnization against scarlet fever. 205 
Vaiicoso veins. SfC Veins 

Vascuhr loop, bilateral prcpaiiillary. of ibo 
retinal artery. 69 

Vasootoniy in prnslatlc hs pertropby. 557 
VAUCHEn. E. : Chouiotbcrai*y in septicaemia. 63 
Veins: Injection of in arDintis defonnan^, 2— 
Varicose, treatment of by injections. 556 
Vena cava, inferior. liRatnre of Die. 465 
Venous drainafie of Die cardiac nodes. 433 
Veroely. J. : Sulfarsenol in puerperal fever. 597 
Vertebral deformity and cardiopatby dnrinn 
proRnancy.TS 

ViLi,AT,v, G.: Cancer of the breast, 593 
Vincent. G. : Infantile pjelocystitie. 655 
Vincont‘B organisms associated with chronic 
suppurative otitis media. 435 
Virus of herpes in the tissues, distribution of. 21 
Visceral polj steatosis, cbionic, 50 
Visceral syphilis, incidence of. 403 
Visceroptosis. riRbt-sided, G4G 
VISKOYSKT, B, V.: Baud tly fever, 3 ' 

Vitamin 11 extracts in dlahotos. 468 
Vitamin deficiency and liability to infection. 434 
^—And aterilUy, 607 

Vogt. E.: Insxdinin Bynaecological condition*, 
71— The production of painless labour, 3W , 
'OLtNTE. F,: Primary carcinoma of Die ureter, 
213 

Vomiting, cyclical, and acute api>en:licitis in ' 
^^children. 4&4 , 


W. 

AYaoenbr. U, P, : Arterial spasm and occlusion 
of branches of the retinal artery, 68 

WAntiio, F. : Blood iiron in scarlet fever and 
tonaillitiR. COS 

Waldbott. G. L : Diphtheria propbyla.Nis in 
nstbiuatic patients. 289 


WoLrr.RTn, C. C. : Indications for digitalis, 121 
■WoErr. K. : Injuries and deatlis from boxing. 417 
■Wood. G. B. : Tuberculosis of the tipper respira- 
tory tract, 349 

WoopBORY, F. V.: Melbyl salicylate poisoning, 
335 

Wound infection and catgut, 54 
Wright, B. E. : Mikulicz’s disease treated by 
X rays, 522 

Wbigiit. V. W .01. : Fractures of the acetabulum. 


_^537 


irethra, 271 
with exten- 


Wkbf.r. D. A, : Tuberculosis of the os pubis, 246 
WEiNiiERn, Bl. : Treatment of typhoid fever by 
anti-gangrene serum. 143 — Serum treatment 
of appendicitis. 574 

Weinstein. S. : Thoracic signs of hypertension. 
482 


Wr iRAtTK. H. V.: Separation of the symphysis, 
376 

Weisz. U. F. : StropUanthln in heart failure, 9 
Wenckbach, K. F.: Angina i>cctoris. 208 
Wmsirn, P. : Urea in the treatment of uterine 
blocding, 476 

WcssLEit, J. A.: Prevention of ipo«t-opcrative 
bleeding in haemorrhoids. 514 
Wnvn, n. : Eymphoma of the lacryonal sac, 371 j 
White, J. C. : Therapeutic uses of carbon di- I 
oxide, 193— Treatment of angina pectoris by j 
alcohol iojcctiODS. 622 I 

White. P.D : Thobeartaftevseverediphtboria, ] 
111— Clinical significance of gallop rhythm, 5 
40?— Treatment of angina pectoris by alcohol ; 
injections, 622 ! 

Whooping-cough: Ephedrino hydrochloride in, 
165— The temperature In, 404— The larynx in. 
651 

Wielock: Puncture of the cisterna magna in 
eclampsia and the pre-eclamptlc state, 283 
WiLiiF.TT. .1- O : The Kahn test in primary 
syphilis. 640 i 

WiLLE.TTS, H. W. ; Glucose treatment of eclamp- ' 
sia. 659 ' 

WrrxTASfSON, FI. C. : Trial labour, 178 
WiLiiAjfSON. H. • Pulmonary venDJation in 
phthisis. 505 j 

ll iLUNs. F. A. : Cardiac neurosis, 311 l 

WiLMEU, n. B. : Treatment of bronchial 
asthma. 300 

Wilson, S. A.Kionier: Epileptic variants, 589— 
Inhibitory epilepsy. 611 

WiNDHOLZ. F. : The use of iodine in thyroid , 
disease. 94 ; 

Wisnhr, B. : Spontaneous epidemic of pucu* j 

moiiia ID monkeys. 355 ) 

WonoN, .1. L : Treatment of retained products | 
of coucoplion. 103 

WoLimicii. A. : The increased incidence of 
aortic and cerobro-'^pinal eyobilis, 354 
Wolf. W. : Treatment of varicose veins by i 

injections, 536 I 


X. 

AT.ray examination of the trachea, 174 
X rays, the epilation and erythema dose of, 628_ 
A'-ray treatment: Of asthma and spasmodic 
coryza. 173. 471, 472— Of infantile paralysis, 424 
Of Jlikulicz’s disease. 522 
-V rays in bypevchlorliydria, 473 
A' rays. hZro Radiology 


Y. 

Yeast extract, antitoxic action of. 540 

Yeomans, F. C.: Carcinomatous degeneration 
in rectal adenomas, 60 

Yudkik, a. M. t Bilateral pre- papillary vascular 
loop, 69— Transmission of arsenic to the 
aqueous humour, 519 


/. 

Zak. E.: Diminished secretion of sweat in heart 
failure, 84 

ZANGEMriSTER. W. ; UtoHue pregnancy fol ow- 
ing bilateral salpingectomy for tubal preg- 
nancy, 397 

ZniLEB. A. H.: A precaution in blood trans- 
fusions, 249 

Zeiser-Henrjksen, K. : Pituitrin in the treat- 
ment of migraine. 541 

Zimmer, a.: lojection of veins in arthritis 
deformans, 2 

ZorLLER. O. : DiphDicria of the larynx in the 
adult, 439 

Zoster, amaurotic. 521 , 


ponied and published by the Bnt.sh Medical AssoeintiouTIt their m the Pae.sh'^ St. 




1 


JAN..7I I92*J 


[ The DninsB 
ICxpiCiXi JovstniXt 


EPITOME OF CURRENT MEDICAL LITERATURE, 


Medicine. 

1 . Etlolofy of Migraine. 

J. S. Diamond (Amcr. Jom-n.Med. Sci., Novoinbor, 1927, p. G95) 
onnmeratos tho various views tlmt Iiavc been lield as to tlio 
causatiou of niigniino, and states tiiat no scientlflc data have 
ever been collected to Indicate a definite lesion or cause. Tbo 
boliof that tlie liver Is responsible for this ailment baa been 
long bold, and tho introducllon and ostablisbcd utility ol 
liver function tests have enabled tho testing of its validity. 
Diamond porformod a series of tests on 35 carefnlly chosen 
patients, cases in which other pathological processes wero 
found and cases of symptotnatic migraine being excluded. 
Of these patients 21 wore female and 14 male ; their ages 
ranged from 19 to 46. In over two-thirds thoro was a history 
of onset in the first and second decade, tlio rornaindor being 
in tho third. Nearly all gave a familial history, the trans- 
mission being usually through tho mother. Tiie frequency of 
attacks varied from fonr to six wcelts to once or twice a week. 
Headache of heuiicrauial type was present in all the cases, 
wliich wero placed in tlireo groups : in Group A (12 cases) 
the Iioadncbo was of purely cephalic typo witliont' digestion 
upset; in Group B (15 cases) it was associated with nausea 
and vomiting, tho so-called bilions attaci:; and in Group C 
(8 cases) the gastric and abdoininal symptoms predominated. 
Ciompletc examinations were jiiado in each case, tho tests 
including the estimation of bilirubin in tlie serum and of 
nrobilinogen in tbo urine. The rcsnlts indicated n definite 
liver disturbance ; in 91 per cent, of tho cases there was a 
bilirubin retention of 1 to 5 units (normal 0.4 to 0.8 unit). 
The urobilinogen was also increased from 1 to 35 up to 1 to 200 
(normal about 1 to 20). Tho reactions wore lowest in Group A 
and highest in Gronp C. Constipation of tlio spastic tj’pc, 
fatigue, strain, emotional factors, and sexual excesses wero 
found to precipitate an attack. Tlie development of an attack 
following tho ingestion of animal protein during a period of 
constipation loads to a theory of intestinal toxaemia, and 
Diamond advances tbo iiypotbosls that migraine is due to tlie 
Inability of the liver to detoxicate putrefactive substaucos 
derived from animal protein in the intestinal canal. Weight 
is added to this view by tho marltcd bonofloial results 
tollowing the addition to tbo intestinal flora of fJ. aciclophilus, 
and avoiding Intestinal putrefaction. This was accomplished 
by witlidrawlng all forms of animal protein from tho food, by 
placing the patient on a. strict lacto-vogotarlan diet, and by 
overcoining the spastic constipation so as to secure copious 
daily evacuations. 


^ Injection of Yolna in Arthritis Deformans. 

5,000 joint lesions of various kinds A. Zimmer 
{Med Welt, October 1st, 1927, p. 1310) found that a large 
number of patients suffered from arthritis deformans of the 
Kuee-joint with crepitaiion on movement, and marginal pro- 
joint surfaces shown in tho skiagram ; 
e insion, however, was rare. AVIieu this condition was 
associated with varicose veins in the neighbourhood of the 
ucctea joint marked relief of such symptoms as difficulty in 
infnf standing up after sitting, rapid fatigue in the 

increased pain at night and during changeable 
eainer, was obtained when the varicose veins were treated 
though other forms of treatment had 
without effect. One of the larger veins 
toee and as near as possible to it was chosen for 
V •*' . ^®ins draining away from it were compressed, 
nf on 'fijcciion frozen with ethyl chloride, and 3 to 4 c.cm. 

alnwi cent, saline solution (varicophtin) were injected 
tlio vein from a record syringe. The pressure on 

•ms central to the site of injection was then released 
minutes in the reonmbont position the 
in to return home. When jiain developed 

foniwi flunng the first few days wet compresses wgj-e 

TIib -n-i'-. necessary other veins wero injected later. 

etiological connexion between the 
annts^n the joint lesion is being investigated. In 

bnH, i-r, cases, in which a chronic arthritis of one or 

tliB associated with obesity in women at about 

ttipni . 2i>hmer found that considerable improve- 

H symptoms was produced by pluri-glandniar 
beforn dieting without local treatment even 

Estiinnt!**^ appreciable reduction in weight had occurred. 
reif-Mnnl,°n.® C“docrine activity on thelinesof Abderhalden’s 
trealmpi^f^nf, on these patients before and- after 

independently ol the clinical findings, and the 


curves compared with tho ’‘normal” deduced from a series 
of 1,400 observations. Tbo relative value obtained for the 
various endocrine glands was considered of more importance 
than tlio absolute value of each. Tho majority of the carves 
wero abnormal at tho beginning of treatment and approached 
tho normal as tbo joint symptoms snbsided nnder endocrine 
treatment. Tliongh tho value of the estimations of endocrine 
activity is disputed by some workers Zimmer considers that 
they are distinctly nscfnl, it dne precautions are taken, and 
his observations domoustrate that endocrine disturbance may 
bo an important etiological factor in one typo ol arthritis. 

3. Sandfly Fever. 

According to S. V. Viskovskv and V. P. Petrov {llcdici/n- 
skaya Myal Uahehistana, Soptehibcr, 1927, p. 5), plilebotomus, 
or suiidily fever, which assnmes epidemic form in Central 
Asia in tho snrainer months, is duo to a virus which is nenro- 
tropical and affects mainly tlio sympatholio nervous system. 
At first it circulates freely in tho blood and is only subse- 
quently fixed in the nen’ous ti.s.sne. The fever is transmitted 
by mosquitos of the genus pUlebotomus (P. •papafasaii, per- 
aticioans, caucasicus, li, ininntua). Systematic investigations 
of the cercbro-spinal fluid and ol the blood pressure, as well 
as clinical observations, show that the actual duration of the 
fever is not less tliau two to three weeks, but the disease 
presents two periods — a short one characterized by an acute 
febrile attack, and a long afebrile period accompanied by 
general weakness, bradycardia, disorders of the vegetative 
nervous system, and increase of the intracranial pressure. 

9. Transient Hemiplegia. 

H. W. Pi.r.OTNG and H. C. Naffziger (Joiirn. Atncr. Med. 
Asaoc., October 29tb, 1927, p. 1484) state that transient hemi- 
plegia is most often encountered in the aged who.so vessels 
are sciorosed, and is tare in younger individuals whose 
vascular system lias retained its maximum elasticity. The 
usual explanation, therefore, of transient hemiplegia by a 
vascular spasm causing a temporary localized cerebral 
anaemia is improbable, since spasm is unlikely to oocnr in 
thickened and hard vessels. A more probable explanation 
of transitory hemiplegia is cerebral anaemia dne to a fall 
of tho general blood pressure or of the venous pressure below 
tho patient’s optimum. This view is supported by the fre- 
quency of transient hemiplegia or aphasia during a meal 
when splanchnic dilatation with a drop of venous pressure 
causes a cerebral anaemia. Lowering of the blood pressure, 
• therefore, in cases' of transient hemiplegia is a dangerous 
measure, and should be avoided. 


Surgery. 

5. Prognosis and Treatment of Giant-cell Sarcoma. 

"W. B. COLBY {Annala of Surgery, November, 1927, p. 641) 
considers that giant-cell sarcomas are usually benign and only 
locally malignant, but in a few cases they have the clinical 
features of a malignant tumour, causing death by metastases, 
and so should be classed as ordinary’ sarcomata. In the 
majority of cases the clinical and x-ray evidence permits a 
correct diagnosis to he made, but this is not always possible. 
Most of these tumours can be cured bj’ curetting and carbolic 
acid or zinc chloride. If the disease recurs repeated curetting 
may be necessary. When a pathological fracture develops 
amputation is often obligatory. Giant-cell sarcoma can defi- 
nitely bo destroyed by radiation ; the time required, however, 
is longer than in the case of operation, and so the period of 
disability is prolonged. It is possible to cure benign giant-cell 
sarcoma, and even advanced borderline cases, by injection of 
the mixed toxins of erysipelas and B. pjodigioaus without 
other treatment ; also it is possible to cure these cases by 
a combination of toxins and radiations or toxins and curetting. 
The most rapid and certain method is by curetting, followed 
by toxins ; this requires a much shorter time, is not associated 
witli greater risk, and so is the method of choice, 

6. Pulmonary Abscess following Tonsillectomy. 

A. OCHSNER and W. Nesbit {Arch, of Otolaryngol., October 
1927, p. 330) discuss the mode of infection of the inngs wlien 
tonsillectomy is followed by pulmonary abscess. Moore had 
collected over 200 cases, and it was found that in nearly 
one-fifth the operation had been performed under local 
anaesthesia. The transfer of the infection must be by the 

38 a 



2 JAN. 7, 19 j 8 ] 


EPITOME OF CUEKENT MEDIOAE LITEBATUEB. 


t TiiKlJarnni'. 

UXDICAZ, JOCnSTAl. 


lymphatics, the cardio-vasoular system, or by the tracheo- 
brouchial tree. Since the lymphatic drainage ot the tonalllai' 
region passes directly into the venous stream at the junction 
ol the subclavian and internal jugular veins, infcctiou could 
not travel from the tonsil by the lymph stream to the lungs. 
It has been shown that if infected emboli are placed in iho 
internal jugular vein a pulmonary abscess inevitably results ; 
attempts to produce the same result by deliberately iutocting 
the tonsillectomy wounds in dogs have been uusuocossful. 
Those experiments have indicated that the oardio-vascular 
system is not the line of infection of the lung. The aspira- 
tion theory ot transference ot septic material by the tracheo- 
bronchial tree is supported by the fact that every abscess 
following tonsillectomy is in open communication with a 
bronchus, and the cavity is lined with eiiitbolium in part at 
least. The problem how the infected material passes the 
defences of the lung at the glottis appears to be elucidated by 
the fact that when the anterior piilars of the fauces or the 
peritonsillar region is anaesthetized by cocaine the act of 
deglutition is so deranged that the larynx is not raised up 
behind the back ol the tongue, and material tends to pass 
through the larynx into the trachea. This has been watched 
in the human subject by anaesthetizing this region and using 
iodized oil. The authors are convinced that post-operative 
pulmonary abscesses are duo to aspiration ol septic particles. 

7. Gastric Iilnltls. 

P. OuRY (Joum. dc Med, ct de Glilr. Frat,, November 10th, 
1927, p. 772) reports three oases ot this rare form ot gastric 
carcinoma and discusses Its etiology and development. Tho 
sj'mptoms as a rule are alow In appearing and at first do not 
suggest any serious gastric condition^ later wasting, pain, or 
vomiting may arouse suspicion ot malignant disease. As a 
rule no lump is felt and there is never any ha'omatomosls or 
melaena. The diagnosis is made by radiology, when it is seen 
that the stomach is small and retracted, shows no peristalsis, 
has rigid walls, and empties itself with great rapldltj', often 
in ton minutes. It contains little or no residual fluid, so that 
teat meal examinations are difllcult ; anachlorhj’dria Is con- 
stant. The stomach walls become almost cartilaginous, but 
the mucous layer is not affected. The disease may affect tho 
whole stomach or part of it, and It sometimes attacks tho 
intestines. Metastases seldom occur in the liver, Irnt may 
appear in the rectum, especially ou tho anterior wall; the 
peritoneum may be affected by the disease spreading along 
the lymphatics. The metastases may bo nodular or annular, 
ooustricting the bowel, and ascites is not uncommon. Since 
these metastatic growths do not always conform histologically 
to the primary growth they may be mistaken for primary 
multiple cancers. Diagnosis, as a rule, can only be made by 
radiology, and the prognosis is uniformly hopeless. 


[Therapeutics. 

8. Gold Salts In Pulmonary Tuberculosis. 

Hermans {Jotirn. de Med. de Bordeaux ct du Sud-Oucst, 
November loth, 1927, p. 812) describes the use in tuberculosis 
of a combination of the salts ot gold, iodine, and cadmium, 
the two latter adding an antibacillary action to that of 
the gold. In the preparation used (crysiodal) the action 
of each ^ its elements is said to be increased by the 
others. Hubl has shown that the fixation ot iodine bv 
the uou-saturated fatty acids Is much accelerated bv 
a mercury salt, and Margosches and Himmer and other 
investigators have stated that many metals, inoludim- 
cadmium, possess this same property. Since tubercle bacilli’ 
at least at their periphery, contain non-saturated acids it is 
reasonable to believe that a salt composed ot gold iodine 
and cadmium would be efficacious in the treatment of tuber’ 
culosis. For some two years Hermans has used crysiodal in 
thirty cases ot pulmonary tuberculosis,' and reports five of' 
these in detail, the drug having been administered either 
intravenously or intramuscularly. Some ot these patients 
appear to have been cured, the others showing very marked 
improvement; only one failed to respond to the treatment. 
No serious ill effects followed any of the injections, and any 
slight symptoms that did arise occurred only during the same 
evening; after the sixth injection the patients declared that 
they felt much better. Under treatment the appetite im- 
proved, sleep was more regular and tranquil, and oppression 
and breathlessness diminished. The temperature progres- 
sively dropped to normal, night sweats lessened by degrees, 
and the weight slowly but 'steadily increased. Radiograms 
showed a diminished opacity, the shadows finally disappear- 
ing. The thorax became more mobile with increased pul- 
monary ventilation; the duliness gradualiy iessened, vocal 
vibrations lost their intensity, and the rales decreased. The 
cough improved very rapidly, and the sputum, increased at 
38 B 


first and after each injection, lessoned ns treatment pro- 
gressed, became loss purulent, and finally ceased. Hermans 
has also used crysiodal with marked benefit in cases of 
adenitis, and also in one of tlbio-tarsal osteitis with peritonitis 
and dlsoroto pulmonary lesions. ' 


O. Strophanthin in Heart Failure. 


E. F. IVeisz (Med. Il'clt; October 22nd, 1927, p. WW) states 
that tho strophauthins prepared from different species of 
strophanthus differ considerably in their action: crystalllrio 
strophauthin-g (ouabain), prepared from Slrophanthua grains, 
la much more powerful in its action on tho human heart 
than amorphous stropbantbin-k, prepared from Sti‘ophanthns 
homhi ; with tho former tho tbcrapoutlc and toxic doses aro 
very close together and the risk of overdose Is considerable. 
It is therefore Important to distinguish between the two 
when estimating tho effect of a given dose. The best results 
are obtained by intravenous Injection, but special precautions 
are necessary; thus tho author considers It advisable to use 
a fresh needle for injecting tho solution after removing tho 
one through which it was withdrawn from tho aniponlo into 
tho syringe, so that the irritant action ou the tissues of traces 
of tho drug adhering to tho outside of tho needle may bo 
avoided. ■Strophanthin closely resembles digitalis in its 
effect on tho heart, but its action is much more rapid. It is 
also much more rapidly excreted, hut, though tho risk of 
a cumulative effect is negligible, injections should In general 
not bo given more frequently than once in twenty-four liour.s, 
and they should not bo started until two to three days after 
cessation ot a course of digitalis. In sensitive persons vomit- 
ing from central irritation may bo produced. The usual dose 
ot strophanthln-g is 0.5 mg. ; sometimes 0.3 to 0.4 mg. is 
Bufllciont, though it is considered advisable to start with an 
adequate doso, whlio O.8 to 1.2 mg. should bo tho maximum. 
The doso maj' have to bo increased gradually during a course 
of treatment, bocauso increasing weakness of tho cardiac 
muscle can only bo postponed but not prevented. Though 
tho blood pressure rises after the Injections a moderate 
dogroo ot hypertonia is eousldored no contraindication to 
their UBO. The main indications are myocardial weakness, 
especially if acute or associated with pulmonary, hepatic, or 
poriphoral congestion, pulmonary oedema, or cardiac asthma, 
and disturbances of rhythm when these aro due to myocardial 
degeneration. For these one or a small number of injections 
generally sullloo. In more chronic cases a course of injections 
is required, starting dally or ou alternate days and with a 
gradually increasing interval, until tho desired effect on 
oedema or congestion is produced ; these are followed by a 
course ol oral or rectal dosos ot digitalis. In tho worst cases 
tho injections may have to be continued indefinite y. Aonto 
circulatory failure in infective diseases, duo largely to toxic 
dauiago of tho peripheral vessels, is hardly affected bj 
stroi>hanthin. 


10, Treatment of Leprosy. 

E. G. Medina- (Arc7i. dc med., cir. y cap., November 26tb, 
1927, p. 610) remarks that though leprosy is not so prevalent 
in Spain as in some other countries it occurs in most oi 
tho Spanish provinces, the foci ot greatest intensity being 
Galicia, Hevante, Andalusia, Extremadura, and the Canary 
I.slaiids. Murillo reckons that tho number of lepers m Spain 
is 800, but this figure is too low au ostlmato. Medina, who 
records tourfccon illustrative cases in patients aj^eci from io 
to 52, has obtained the best results from treatment wtii 
antUeprol, a preparation consisting of a mixture of ethyuc 
esters of all the non-saturated fatty acids contained m 
cbaulraoogra oil. Intravenous injections ^vere given twice 
a week in doses of 0.2 c.cm. at first, which wore gradnaliy 
increased up to 2 c.cm. Apart from slight attacks of coughing 
no bad effects were observed. After a hundred injections on 
an average the Wassermann reaction, which is con.stantly 
positive in leprosy, as well as the Hecht and Meiuicko 
reactions, became negative. A clinical cure was obtained in 
many cases as well, as disappearance of IS, leprae from the 
nasal mucus, a result which Medina had been unable to 
obtain \Yith any other drug. ^ 


'Anaesthetics. 


11. The Anaesthetist In Certain Surgical Emergencies. 

E. I. McKesson (Canadian Med. Jaaoc. Joum., Novemb^er, 
1927, p. 1314) dosorlbos certain emergencies in which the 
anaesthetist may render exceptional assistance to the 
surgeon. After the relief of strangulation ot the bowel tho 
doubt whether the mysentery and gut should be returnea to 
the abdomen or be resected may be resolved by. the adminis- 
tration of pure oxygen to the patient for two or three ,4 

If the colour of the gut definitely changes to a lighter red anu 


Jan. 7, igzS] 


EPITOME OF CURRENT. JilBDICAE. LITER ATURE. 


no ovcds retain a black or (‘reyish-purpio nppoarauco tho 
circulation- is present and recovery of the bowel may bo 
expected. jrcKosson gives osauiples of tlic value of raising 
for a short time tho pressure tinder which tlio anaesthetic is 
• given. In such cases ns tlio locating of a small broncho- 
pleural llstula nud collapse or npnoea in n patient when pns 
is rclensod from the pleural cavity by rib resection, if tho 
anaosthotio is continued under sutneiont pressure so as to. 
■obliterate the pleural cavity and force loose masses of oxndato 
inio tho incision, tho surgeon can clean tho cavity' more 
olToctivoly' and reduce tho period of couvnloscenoe. McKqsson 
eraphnsiaes the iinportauco of nrtilloinl respiration with pure 
oxygen under pressure in certain emergencies, and describes 
a method of distinguishing between the lowering of blood 
pressure duo to the auacsthetic and that caused by surgical 
conditions. 

12. Bcctal Anaesthesia. 

J. MbuzoN (Presse Med., Novoinbor 16th, 1927, p. 1396) de- 
scribes the ouiploymcnt ol a rcolnl anacstbctlo termed 
“avcrtinc," which has the formula CCr-CH-jOH, and was 
origiually prepared by tho fcrmcntatlvo reduction of bromai, 
but is now made by a siuiplo sj'iithotlo proces". It is a white 
crystalline powder rooltiug at 79’ to 80’ G., soluble in water 
up to 2.5 per cent, at 20’ C. and 3.5 per cent, at “10’ C. ; at higher 
temiicr.atnres it is decomposed with liberation of IlBr, which 
has a highly irritant effect on mucous mombrancs. After ox- 
perlmcnls on mice and rabbits, tlio Urst clinical trial was 
made by Butzougeiger in March, 1926, and tho first publication 
of cases treated by Unger and Heusz to the Medical Society 
of Berlin in March, 1927. Tiio clilof advantages claimed for 
avcrtinc over ether tor rectal adinluistration are that it can 
be administered with loss risk of toxic couccutratlou in tho 
Wood ; that It Is tion.irrjtant to the raspimtory passages, being 
excreted in tho urine; that theio aro no disagreeable post- 
anaesthetic effects; and that, properly adnilnistcrod, it docs 
not give rise to irritation of tho rectal mucous luembrano. 
Eater reports have been less favourable, and doubts have 
been thrown on its supposed non-toxicitj' as regards hepatic, 
reual, and cardiac tissno ; it is stated that only in 40 to 50 per 
cent, of subjects can fail anncstlicslu ho assured by its tiso 
alone. Liquid diet only’ is given the niglit lioforo operation ; 
some surgeons administer morpbiuo or pantopon one to two 
hours before the operation. A solullou of about 1 in 40 of 
freshly prepared avertino in distilled water or normal saline 
nt 40’ C. is run in tlirough a rectal tube slowly’, about 
0.08 to 0.15 gram being given for each kilo of body weight, 
ihe patient sliould go into quiet sleep In about seven minutes, ' 
If bo attained in p. quarter 

to half an lionr. Tailor and shallow respir.ation. with a slight 
pressure, supervene. Pupil and comoai 
oS u somewhat variable, but may be entirely 

polished without being a sign of danger. Narcosis lasts 
wo to four hour."!, after wlilcli time a state resembling normal 
s eep often ensues, with peraislenoo of tho pallor aud super- 
nciai respirations. In spite of gouio unfavonrablo reports, 
Mimzon considers the drug worthy' of a more oxtensivo trial, 
i value in operations on tho tliorax and 

upper respiratory tract, aud In cranial surgery, 

XV^'rtnn - In Gall-Bladder Surgery. 

n 10311 Jonm., September, 1927, 

snrr'prv- ohoico of auaostUetics In gall-bladder 
least lia’rmfm'f^ M <>« H'O ground ol its being tho 

® . to the liver, while lung complications are less 

_ ’■ ent, is not increased. He advises 

luiimini f.'f ft,., . . ’ Infiltration under the peri- , 

been odpupO^^ anterior wall of the abdomen after this has 
the mo^nrl^’ interior splanchnic injection. He thinks 
gasers anpppf?“» =°“bined with the use of one of the 
required tn 'nuob oxygen being added as is 

he\dds doM danger of anoxaemia. Nitrous oxide, 

case anil n,pvpm^'^°^“®° suffloicut relaxation in this type of 
Ethvlenp hnwp.®''® requires the addition of a little ether, 
hot ^as a rnlp'^plf ^'’°'‘s^es rigidity more readily’ and does 
that if tho cIoltfni^K ether. The author adds 

it should bo ehnri- i® known to be increased 

venous inwtious o^^c 

redistilled water forVnvp'‘^“‘ 10 Per cent, solution in 
Hon. Glucosp wifh snocessive days prior to the opera- 

injected siiipR quantity of water should also be 

anaesthetics cause the damage which some 

scopolamine mav atropine or 

should be so given m smtable doses, which 

hypcrglycaomia ii effects are produced, such as 

staltiO^activiWa’nd ml^p®'^ acidosis, and depression of peri- 
the.sia the state otihJ^F respiratory centre. During anaes- 
ivith an incveapptl requires watching, so that 

lasting more than blood pressure 

intravenous iulectinno*^ shock can be prevented by 

injections. For the remedy of acidosis, sodium 


and potassium iihosphatcs in alkaline form should be adminis- 
tered in approximately tlie same proportions aud quantities 
as those in wliich they aro being excreted ; tliey' are given by 
tho rectum iu dilute solution. Care must bo taken to avoid 
cy'auosis, in view of the severe damage to the liver which 
follows anoxaemia. 

H. Regional Anaesthesia for Operations on the Spinal 
Column. 

G. LftBAT (Brif. Journ. Anaesthetics, October, 1927,. jT. 81) 
states that tlie principles involved iu regional anaesthesia for 
ortJiopacdlc operations upon tho sjiinal colawn differ some- 
what from those for other operations, since the normal land- 
marks have become altered by trauma or disease. Ho gives 
notes of six cases to illustrate the technique, aud remarks 
that the anaesthetist must have a thorough anatomical 
knowledge In order that his procedure may be modified to 
suit individual distortions. Labat considers that the follow- 
-Ing practical inferences are jnstifled. The supine position of 
tho patient is tho best because It facilitates paravertebral 
injection technique, affords the greatest relaxation of the 
back muscles, and avoids lateral distortions. In advanced 
tuberculous conditions tho use of a 0.5 per cent, neooaine 
Eolation is advisable, even in paravertebral block, with a 
limit of 250 c.cm.; it should be Introduced very slowly, and 
with tho addition of 5 drops of 1 in 1,000 adrenaline solution 
to each 100 c.cm. of anaesthetic solution injected. A modified 
technique of paravertebral block is advocated by which the 
nerves aro approached from a point overlying tho transverse 
process, tho same wheals being used for the field-block ; 'the 
resulting ischaemia of the operative field facilitates dis- 
section. This method of regional anaesthesia renders decom- 
pression of the cord at the level of the first and second 
cervical vorlebrao less difilcnlt and hazardous, and its use at 
lower levels of the spine is greatly’ to the advantage of both 
surgeon and patient. By its means extensive spinal fnsiohs 
aro possible with but little post anaesthetio disturbance and 
with considerably improved prognosis, especially jn tho 
presence of active pulmonary’ tuberculosis. The method was 
not attempted in operations on children. 


Obstetrics and Gynaecology. 

is. Dterlne Cancer and KadJotherapy. 

U. Ben Hoed [Nedci-l. Tljdschr. V. Gencesh., November 196U, 
1927, p. 2132) remarks that cancer ol the uterus is very often 
infected, especially in an advanced stage. This complication 
may assume various forms, such as infection of the tumour, 
pyoroetra, salpingitis, parametritis, and pelvic peritonitis. 
Any gynaecological operation or radiotherapeutic application 
may aggravate this condition or rouse a dormant infection 
into activity. Tbe complication may’ occur during treatment 
and assume any of the following types ; fever without localiza- 
tion, infection of tho pelvic connective tissue, pelvic peri- 
tonitis, general peritonitis, pyaemia, or septicaemia. The 
infection may be one ol the reasons for a failure of treat- 
ment. Tbe author concludes, therefore, that a careful clinical 

examination should be made of every patient with cancer of 
the uterus before radiotherapy ; a bacteriological examination 
of the vaginal flora is also said to be of valne, \vhen haemoly tie 
streptococci are present an attempt should be made to destroy 
them or at least to reduce their virulence, ns the author suc- 
ceeded In doing in some of bis cases. Special care must be 
taken in the use of radium therapy in such patients. In every 
infected case local disinfectants, such as Dakin’s fluid, and 
specific vaccine and serum treatment should be used before 
radiotherapy is commenced. 

16. Low Caesarean Section. 

L. E. PhANEUF (-Boston Med. and Bury. Joui-n., November 10th 
1927, p. 825) claims that when the transverse ceiwical incision 
is used in the low Caesarean section, dividing only non- 
contracUle tissue, tho percentage of rupture oi the cicatri.x 
Is reduced, convalesceuce is better, and post-operative coni- 
pllcationa are lessened. His technique differs from that 
usually adopted In that the bladder is completely’ separated 
from the cervix down to the vagina and as far as possible 
laterally, tbe incision being placed at a lower level and 
entirely in the cervix, so that it is retrovesical or snbperi- 
toneal at the completion of the operation. With tho patient 
in the Trendelenburg position a six-inch median abdominal 
incision, starting at the symphysis, is made and the lower 
uterine segment walled off witli a long strip of gauze Tbs 
uterine peritoneum is incised tiansversoiy, and -the ‘lower 
flap, together with the bladder, is pushed downward ami 
protected by a Doyen retractor. A transverse incision with ' 
its concavity towards the symphysis is made as low as 
possible m the cervix and the child is delivered tbrou-’h 


4 Jas. 7, 1928] EPITOME or CUBEENT MEDIGAE LITEEATITBE. 


it. Tho placenta and membranes are removed through the 
incision unless the os is fully dilated, when they are expressed 
through the vagina after closure of the ecrvical incision and 
suture of tho peritoneal flaps.' 'Pliaueuf lias performed 
36 operations by this method, with"ohiy one maternal death 
and a foetal mortality of 8 per cent. He adds thafwhllo' 
there is but little bleeding. the curved incision with tho con-; 
cavity towards the symphysis affords plenty of room, and' 
the procedure can be used for patients in .whom a classical 
Caesarean section is contraindicated!' - • 

17. Etiology of Stlllblpth. 

B. C. Eton [Amer.Journ. of Obstet. and Qi/nccol.,Oct6bcv,X927, 
p. 548) has examined the statistics. of stillbirth in 4,000 
consecutive ward deliveries at the Women’s Hospital, New 
York. He finds that 104 patients had 105 stillborn infants 
(25 stillbirths per 1,000 deliveries) ; 85 of these patients had 
been attending tho pre-natal clinic (21 stillbirths per 1,000 
deliveries); 25 patients showed evidence of toxaemia, and' 
4 of these had convulsions. Of ,79. patients on whom tho 
IVassermann test was performed -9 ,wero “four plus,” but 
only two infants wore bom with evidence of syphiils. There 
were 61 abnormal deliveries,. 22 being-.by forceps and 39 by 
breech presentations; 90 patients had normal pelvic measure- 
ments. 'There were 37 premature infants and .44 ,w.oro 
macerated; 11 cases of prolapsed cord occurred, an.l in 10 of 
tliese it was a contributory or actual cause of stillbirth. Of 
53 infants on whom an autopsy was performed lO'showod' 
cerebral iniury. In 55 patients no foetal lienrt was hoard on 
admission to hospital, and in 41 of these ,lt was inandiblo 
subsequently during labour. Eyon thinks that 20 of theso 
41 stillbirths might have been avoided if a different method’ 
of delivery had been chosen in 8 cases, and earlier oporatlvo . 
intervention had occurred in 12. ■ ' 

i 

18. After-History of Pyelitis In Pregnancy. 

B. 0. COBBUS and Vf. C. Danforth {Amer. Jotirit. of Ohslct. 
and Gynecol,, October, 1927, p. 544) report pyolographic studios 
in thirteen consecutive patients who, during pregnancy, had 
suffered from “ pyelitis ” accompanied by pyrexia. Except 
in two instances the observation's-wCre'hnado from four to 
lorty-elght months after termination of pregnancy by labour 
(usually) or abortion ; tho average time was ten months. In 
every instance abnormality of the urinary tract was detected; ' 
all the patients had a stricture of the ureter, ten had hydro- 
nephrosis, twelve a dilated ureter, and seven a ureteral kink, 
Ihe authors’ studies were occasioned by their finding that 
whereas oases of pyelitis in 'pregnancy usually yielded to 
treatment by posture, tree ingestion' of water, urinary anti- 
septics, and, occasionally, catheterization of. .the ureter, tho 
patients wore frequently found to b'o not entirely well after ‘ 
delivery. They conclude that it is'masouable to infer that ■ 
patients suffering from pyelitis during, pregnancy have had, ■ 
before conception, some morbid condition In tho ureter ; and 
lliey point to Hunner's reports of the frequency of ureteral 
stricture as a cause of upper urinary tract infections. The 
practical conclusion'drawn is that since termination of preg- 
nancy does not cure urinary infection patients ' should bo 
treated subsequently in order to restore adequate urinary 
drainage. If possible, . • 1 j 


Pathology, 


19. Culture of Filterable Forme of Common Bacteria. 

P. Haudubot (G.-B: Soc. de IHologie, November 25th, 1927, 
]). 1392) iias devised a method of cultivating bacteria from 
filtrates which by ordinary methods appear sterile. A culture 
of a given organism— typhoid, dysentery, colon bacilli, diph- 
theria bacilli, staphylococci, or streptococci— is filtered rapidly 
under a low pressure.' The filtrate is transferred to a sterile 
tube and' incubated. After'about a aveek, though sometimes 
not for several months, a small granular sediment appears or 
less often a very slight opalescence, which may later^be 
replaced by a granular sediment. ■ No further change' occurs, 
even after prolonged incubation. Subculture into ordinary 
media is followed after a long time by a reproduction of the 
same appearances as in the original filtrate. After numerous 
trials Haudnroy has succeeded iu' cultivating bacteria from 
these apparently sterile filtrates. A few cubic centimetres 
of a granular or opalescent filtrate are planted on the surface 
of a litmus lactose agar plate. After twenty-four or forty- 
eight hours iu the incubator the surface appears slightly dull 
aifd as though covered with a very thin depo.sit. The surface 
is scraped carefully, the material suspended in broth, and 
planted again on to another plate. This operation is repeated 
halt a dozen times or so, when very tiny colonies appear just 
visible with a magnifying glass ; these gradually increase 

aS Ti 


in size, and finally resemble tho ordinary colonics of tho 
organism from avhich one started. ’The.so colonic.s can bo 
mibcnlturod in tho usual media. By no other method has 
Haudnroy been able to reproduce the ordinary forms of 
bacteria from filtrates. 


20 . Tho Histology of Kasai Polypi, 

O. Babtolt and E. Bianciii (Arch. Hal. dl Olol., October, 
1927, p, G09) have made an oxtonsivo study of polypi from 
twenty patients. They have found that tho covering cpi- 
thollum varies from columnar through cuboidal to squamous 
oplthollum. In polypi of recent formation, and especially 
in single polypi, tho epithelium retained tlio typical nasal 
columnar formation, but ns tho polypi increased in iigo these 
colls bocaino flatter until in very old polypi a single layer of 
flattened colls covered tho polypus. 'The connective tissue 
appeared normal except that plasmocytcs wore found near 
'the periphery and especially near tho glands. Tho vessels 
■ often showed thickening of tho walls with hyaline degenera- 
tion. Glands were certainly present in young polypi, but 
tended to degonernto in polypi of older stan.ilng. Elastio 
fibres were limited to tho tvnlls of tho vessels. 'The pedicles 
of tho polypi consisted of b'undlos of fibres with vessels which 
did not show any hynlliio degeneration ; there were no traces 
of glands in the pedicles.- 'Tho authors found no excess of 
leucocytes in tho polypi, hut considered that a number of 
them passed' through tho covering epithelium to enter the 
mucus which covers tho polypi and bathes tho interior of the 
noso. 'Tlioy do not consider that there is any evidence that 
' those polypi are neoplastic, but aro convinced that they are 
o'htlroly inflammatory. Eocnrrencos aro holioved to ho duo 
to liicomplb’.o treatment originally, and tho absonco of 
• motastnsos or of cachexia confirms this opinion. Tho authors 
think that tlio bleeding polypus of tho septum, tho naso- 
pharyngeal fibroma, and choanal cystic polypus maj’ be 
neoplastic', but that all other nasal polypi aro inflammatory. 


21. Distribution of tho Horpotlo 'Virus in tho Tissues. 

A. TJnnAlN and W. ScnAEFBB (C. B. Soc. itc Biologic, November 
lltli, 1927, p. 1279j..liavo studied, the distribution of tho virus 
in tho tissues of rabbits suffering from oxporlinontal herpes. 
They removed tho tissues from tho affected animal at or 
immediately., before death, make a thick suspension in saline 
solution, and Inoeulatod this cither by tho cutaneous or tho 
cerebral route info fresh animals. Tho brain of each animal 
which died after inoculation with those tissue suspensions 
was tested for vlrnlonco. Tho authors found that tho virus 
was always iirosdnt in the brain and spinal cord, frequently 
in tlio corobro-spinal fluid, occasionally in tho saliva and tho 
suprarenal glands, an.l never in tho lungs, kidneys, spleen, 
liver salivary glands, or .striated muscles, it was detected 
in one specimen of urino.ex.amined immediately after passage, 
but not in anothor Bpoclmeu collected twenty-four hours 
previously. It was also demonstrated twice out of live times 
in rabbits which had boon Inoculated with 5 o.om. of a faecal 
suspension. 

22. The Action of Endocrine Glands on Gastric 

Secretion. 

A. EbAGOJIBLE (H Morgagni, October 30th, 1927, p. 1721) 
reviews tho lltoratnro And comos.to tho following conclusions 
as tho result of experiments on a dog in which he had made 
a small Pavlov stomach : (1) Adrenaline, thyroidin, and pitu- 
glandol, injected subcutaneously, have a well marked inhibi- 
tory action on the gastric secretion,’ causing n diminution la 
tho amount of secretion of hydrochloric acid. (2) The inhibi- 
tory action is most intense after injection of pitnglanflol. 
(3) Adrenaline, even when given in the dose of 1 mg., as was 
done by Lobper, does not. stimulate the secretion pt hydro- 
chloric acid, as that author maintained. Fragomelo adds 
that the investigations not only show the remarkable Influence 
on tho gastric secretion of the active principles of the supra- 
renals,1^hyroId, and hypophysis, but also help to explain the 
causes of gastric dyspepsia found in various affections of the 
endocrine glands according as they are in a condition 01 
excessive or recluceo 


23. The Antiseptic Property of the Bile. 

G. Bai^ICE (II Policlinico, Sez. Cbir.» Novembor 15fcb, 1927, 
p. 501) has performed a series of experiments on dogs lo 
ascertain the effect of cholecystectomy on the nntiscptio 
property of the bile. He finds that the portion contained m 
the gall bladder plays a very important part the anti- 
Bcptic property of the total bile, and that \Yhen this is n 
poured into the intestine there is a notable increase 
intestinal bacterial flora. The enhanced antibacterial 
of the biie in the gall bladder as compared 'with the ° 
bile is attributed to the greater content in the former o 
sodium glycocholate and taurocholate. 


[ r»r Bjuww 

UePIOU. Jox;X3lA^ 


5 


JAN, 14. igjsj 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 


si, Bcsusoltatlon of tho Apparently Dronmed. 

E. Martin and Costedoat {Journ. dc Med. do Lyon, ' 
Novombor 20tb, 1927, p. S89) agroo that in cases of accidental , 
drotriilng or snloldo death can bo caused (1) hy syncopo, ! 
when tho aspect of tho person Is pallid, or (2) by asphyxia 
dno-to tho ponotratlon of tho lungs by water, when tho 
aspect is blue. If restorative efforts arc started early tho 
pallid typo of drowned person can nsnnlly bo revived without 
difQcalcy, bnt in tho second typo the imlnionary lesions are 
such that In many cases treatment is without effect. Tho 
respiratory syncopo is produced with a complete loss of 
consciousness at tho moment of tho fall into the water, by 
terror, emotion, snddon chilling of tho body, and tho inhala- 
tion of vomited matter in tho case of those who batho too 
sooh after meals. Tho snddon cessation of respiration Is of 
benefit In' that water is not drawn into tho longs, which 
therefore remain • uninjured. Tho authors deal fully with 
tho second or oyanosod typo, and show that submorsion is 
really a traumatic asphyxia, tho water acting not only as an 
inert medium hy suffocation but also by destroying tho 
pulmonary parenchyma. Experimental cvldcuco is given 
and tho pathology of animals dro-wned is detailed. In the 
microscopic examination special attention is drawn to tho 
vegetable and mineral plankton, nlgao, diatoms, coal dust, 
and 'sHlceons shells found scattered tlironghout tha lungs. 
Tho authors raise tho Important question whether simple 
post-mortem immersion, of a corpso caii cause these same 
changes in tho lung. The most valuable sign is hypor- 
aeratioh (or dry ballooning), or oven cuiphyscmatous hydro- 
aeration. Tho value of this sign is unfortunately destroyed 
by pntrotaotivo changes. Whou tho lining membranes of tho 
alveoli aro destroyed water containing crystalline particles 
can enter tho lolt aurVolo by tho pulmonary veins. The 
microscopic examination, thorofqro, with chemical cloanli- 
of ^ho fluid from tho left auricle is of groat value, and 
^hthors ddscrlbo tho technique of this investigation ns 
themselves, using antiformin and a microscopo 
,with lateral Illumination. Tho siliceous particles after 
Mlcination can be weighed for comparison. The practical 
conclusions aro that syncopo is a means of preservation of 
Jt.®' on 'apparently drowned person who is pallid may 
nns i. , 1 '’5^ persevering with artlilclal respiration 
ana rhythmic traction on the tongue oven after submersion 
wni ° person who is cyauosod recovery 

lu not follow if tho lungs have been Invaded by water for 
treatment bleeding and artificial 
ftnav ^ORftal decubitus should be tried, 

dlagnos’ methods should bo used in cases of doubtful 


, 25. Mi^ps CoinpUcated by Acute Nephritis and 
’v _ . Pancreatic Necrosis. 

. SABRAZES, P. Beoustbt, nud R. Peaudimekt (Gat:, hebd, 
roLr. L' Bordeaux, November. 6th, 1927, p. 705) 

death almost certainly due to necrosis of the 
snfrori,?™ ■ by- the virus of mumps. A. lad, aged 19, 

niuht mumps, escaped from hospital daring the fifth 

ln'’nn walked about four miles and returned 

days i„f the following morning. Ho died two 

pulmonm-l’ “ I'" vndrome of acute nephritis, 

Was nn f ■ ' pains, and vomiting. There 

clhiimi ■ . ' '■as rapid and feeble. The 

the pancreas in mumps is said by 

At thn Oemonstrablo in one in every 250 cases, 

increasorl Pancreas was found to be greatly 

necrn«i« 1 , ', 1 . > there was generalized coagulative 

Was nounl? . aytoplasmio and nuclear. The necrosed tissue 
and ''■ll'hout lencooytlo inflltratlou. Here 

to flufl occasional signs ol thickening. It was difficult 

onlv mm i® “^.^^angerhans ; in one segment there was 

blasts wbioh was necrosed and compressed. Fibro- 

luusoular flhv parenchyma and the smooth 

uo thrombnoi hO haemorihagic offusion and 

evident tArtfJn hecrosis in and around the organ was 
minute hvnernt^’’ small collections of fotty acid crystals ; 

round tlm avaP SS'CHUn, of lymphatic material were seen 
■were no m.o « ■ , ^o^ootlve organisms were found. There 

■ . dnets calf V? stomach. Intestine, bile and pancreatic 
gland’ ‘“'rim'll soP'^a-renals, lacrymals, and thyroid 

nephritis tim condition of • the liveiv the acute 

■ congestion of the lungs, and the slight menin- 


geal lymphocytosis led the anthers to conclude that mumps 
was tho solo causative agent in this case, aggravated by con- 
ditions operating at the onset. The necrotic condition of 
tho pancreas showed that it was definitely attributable to 
tho vims -of mumps. Death dno to pancreatitis cansed by 
mnmps Is rare. Records of sneh cases show that there have 
nsnally been other complications, which have made it difficult 
to attributo death to tho condition of tho pancreas. 

26. Tho Scdlmontatlon Bate In lebar Pneumonia. 

M. Tapia and J. Torres (.Ireli. de sued., dr. y esp., November 
12th, 1927, p. 569) had previously shown that the sedimenta- 
tion rate of tho red corpuscles did not possess any prognostic 
valno in pnenmonia, as there was an absence of any relation 
between tho acceloratton rate,- which was constantly in- 
creased, and tho pnonmqnio process. In the present paper, 
however, they maintain that the sedimentation rate has an 
undoubted diagnostic value, at least in the first few days of 
tlio disease, especially in conjunction with ' morphological 
examination of the blood in cases of pnenmonia in whicli 
physical signs aro Insnfllcient or completely absent. They 
record a case of a slow sedimontatiou rate in which lobar 
pnonmonia conld be excluded, while the clinical and bacterio- 
logical ovldenco indicated the presence of a pn'enmo-typhoitl 
infection. 

27. ■ Value of the Dick Beactlon. 

AuricchiO (II Morgagni, November 6th, 1927, p. 1787), as the 
result of observations carried out on 66 children, a large 
number of whom were living in a community in which scarlet 
fever was prevalent, came to the following conclnsiona. 

(1) Tho Dick I'eaction is positive in a much larger percentage 
of children than that usually affected by scarlet fever. 

(2) Children who have recovered from scarlet fever may show 
a positive Dick reaction. (3) Children •with a negative 
reaction may contract scarlet fever, and, vice versa, children 
with a positive reaction, althongh exposed to infection, may 
remain immune. (4) The Dick reaction is specially liable to 
bo positive in children in whom tho tnhercnlin reaction is 
positive. Aurlcohio, therefore, does not regard the Dick 

, reaction as a specific indication of susceptibility to scarlet 
I fever. 


Surgery. 

28. Treatment of Carbuncles, 

L. Carp (Annals of Snrgenj, November, 1927, p. 702) discusses 
tho various methods of treating carbuncles, and conoludes 
that, while each case is a piohlem in itself and requires 
special treatment, yet certain, main generalizations are 
possible. In large carbuncles, whether diabetic or not, the 
treatment oi choice is said' to be radical surgery. In small 
superficial carbuncles and some large ones, iuclDding those 
of tho face, x-ray therapy, as an aid to ponltioes and carboliza- 
tion, lias given good results; if improvement does not ocenr 
in throe or four days other measures, such as surgery and 
tho circnminjection of antogenons blood, are indicated. In 
diabetic carbuncles the prompt establishment of free drainage 
is essential to prevent spread of infection; x-ray therapy 
withont surgery is contraindicated. Carp advises the circum- 
injeclion of autogenous blood in selected cases, and thinks it 
.is also a valuable procedure in accessible spreading infections 
even though they are receiving other treatment. In his 
series of 153 carbuncle cases treated during the last ten years 
no evidence was obtained that x-ray therapy alone could 
bring about cure. 


29 . Treatment of Hypertrophic Pyloric Stenoslsl 

Since several autopsies after the Weber-Bammstedt opera- 
tion lor pyloric stenosis in infants have shown that death 
was due to haemorrhage from tho pyloric incision or peri- 


„ - . — Revised 

by Doreta and first performed by Nicoll in 1900. His techniono 
is as follows: a longitudinal incision barely 1 cm lone is 
made, in the anterior wall of tho stomach through a small 
incision above the umbUicus ; through this carved forcens 
are inserted into the pylorus, and tho blades are slowlv 
.and carefnlly separated until a small Hegar’s dilator can hn 
passed, followed by two or three larger LelTsaccTsLn 
The gastrostomy incision is sutured in .three layers, and u 




JAN. 14, 1928] 


EPITOME OF OURKBNT MBDICAIi EITERAXUBE. 


[ Thb Brixisii 
JIeOICXL JOtTEXlt. 


7 


owing lo tbo (llscoiufort cnuso;1, oral aucl rcctnl administra- 
tiou was tried. 'SVheii given by tbo mouth 0.5 gram caiisules 
of the salt, coated witli phenyl salicylate, wore used, one 
cansnlo being given tbo llrst day and two on each ot the ' 
Bviccceding tblrtcon days ; in rectal administration 1 gram ot 
tho salt dissolved in water was given tlirico weekly after 
preliminary cloansiug onoiuata. Smarting of tbo tongue, 
nose, cbnjnnotivao, and forehead, an epigastric burning 
sensation, and nausea followed tho Intravenous iujoctibns, 
while oral administrations caused only slight epigastric dis- 
comfort and nausea. Tlio rectal method proved as boarablo 
as tho ora), and is said to bo tbo method of choico when 
intravenous injection is Impossible. Other forms ot therapy, 
such ns diathermy, poptouo injocllons, and orthopaedic 
manipulatiohs, wore used coucurroiuly in all the cases. 
A tabulated summary of thirty-one ebrouio arthritic patients 
treated with salts of ortho-iodosy-bouzoic acid is given, and 
this shows that IG per cent, were inarkodly improved, IG per 
cout. moderately, and 32 por cent, slightly so; 20 pot cent, 
were no bcttor,'whiIo in 7 por cent, the bonollt was duo to 
other thorapeutio measures. ^YhlIo these results aro not so 
favourahlo as those obtained by oilier investigators, Traiiba 
considers them encouraging. Ue adds that further study is 
necessary to dotermino tho most offlcaolous form of tho drug, 
tho best method otadrolnlstraUon, the size and Ircqucncy ot 
dosage, and tho modo' ot action. 

35 . Control of Hiccup by COj Inhalations. 

It. P. SH13LDON (Joimi. Aincr. ited. Assoc., October 1st, 1927, 
p. 1118) believes that hiccup ns a rule is merely a symptom of 
some nnderlj-ing condition, tliongh it may bo a disease itself. 
It is often part of a vicious circle wblcb, without control, may 
directly lead to death. Tbo .spasmodic contraction of tiio 
diaphragm Isdne toanabnormal stimulation of tho respiratory 
centre. It is known that carbon dio.vido in tho strength of 
5 to 5.G per cent., with oltlicr oxygon or air, increases tho 
activity of this centre, and overcomes the lesser stimulation 
ol hicenp, restoring normal respiration. Sheldon records 
eleven cases of hiccup effectively troalcd in tills way, and 
believes that tho results justify tho statoiucut that carbon 
dioxide, in proper slrenglli, will control hiccup during its 
administration and for a varying period tlicrcaftcr ; in some 
cases there will he no recurronco. Sinco it increases tho blood 
pressure and entails muscular ctloct it is oxliausting, and 
should, thcrotoro, not ho employed for prolonged periods in 
tho extremely debilitated or in those to whom tho marked 
respiratory effort would he more dotrlmoutnl than tho con- 
tinuing hiccup. Tlioro is said to bo no more danger of 
haemorrhage In post-opcratlvo cases or ot tho dissemination 
ot infection following tho uso ot tlic gas than from tho sudden 
convulsive hlccnp. In most cases the carbon dioxide adminis- 
tration has produced no discomfort, and has stopped tho 
hiccnp at tho second to tho eighth breath. 


Disease in Cliildliood. 


.38. 


,p Asthma In Children, 

that : {Hadiolorjij, October, 1927, p. 280) state! 

chilUrarf^ii? generally accepted belief that in smal! 

mdimonf accessory nasal sinuses aro non-existent oi 
®nveral competent ohsorvers have proved th£ 
histeriao°..?^ sinusitis in children. Tho study of clinical 
fpefinn majority of cases of broncliial in- 

childhnni* ^didts started w'ith nasal trouble and cough in 
cure i ®°*^Sical intervention is far more. likely tc 

In thn a 1 produce greater relief, in childhood than 

attacho fcrsistont nocturnal cough and asthmatic 

astiimn 1 ?, always suggest ginns infection. In 

a lame sensitization has been a groat help, but 

foods .rii. asthmatics aro not relieved by changing 

case is "7, “‘’^J^^'l'S^ation, and tho bronchial asthmatic 
value of Cunningham thinks that the 

that exaggerated. Ho adds 

have disr.P^^*^?'^^ asthma and sensitization in childhooci 
ebauee of .smnsitis. The cause ot Improvement by 

at a hinhor Most patients require to live 

must havp ■» they remove to a lower altitude ii 

valesoont oon,r!i'°'^ warmer atmosphere. Milieu con- 
majoritv their original climate, but the 

Cases of bronebfaTas^hf ^ ‘■®>«;tively high, dry atmosphere, 
usually Khoxvo,s^* asthma or clironio bronchitis in children 
graphi'Lllv and jufectiou when examined radio- 

maitina and hilum infection, with diffuse 

nnlosi.s. butloosi that of tuber- 

and general uusuro drainage is essential 

violet i-avs snnmv'^cp measures aro very important. Ultra 
diet rich in vltsmin^'^i ^ much-needed sunshine, i 

“ is beneficial, and autogenous vaccinei 


aro somotimes useful. The only drug which assists recovery 
is lodino, given in small doses for a long period. Asthmatic 
bronoliitis cannot be cured during an acute attack of asthma ; 
tho greatest rellot follows treatment between attacks. 'When 
this fails, a change to a bigli, warm, dry climate benefits a 
child much more than an adult. 

37. Nasopharyngeal Infections as a Cause of Various 
Infantile Diseases. 

In earlier Investigations H. Biinberg [Acta Paediatrica, 
November Uth, 1927, p. 87) observed that hospital epidemics 
among infants weio more severe in winter than in summer, 
that this increased sicicoess in winter was chiefly drio to an 
increased number of dyspepsias, nutritive disturbances, and 
otbor nliied conditions, and that these conditions were mainly 
caused by pharyngeal Infections. Investigations have since 
been continued in Stockholm, and a summary is given of 
all cases of acato dyspepsia, cholera infantum, and septi- 
caemia admitted to hospital during the period 1922-24. This 
shows that in far the greatest number of these cases pharyn- 
geal infection, perhaps with aural and sinus complications, 
was one of the primary causes in tbo pathogenesis. Ernberg 
cimphnsizes tbo importance of obtaining a inll historj' and 
ot making a carcfnl examination in each cash ; information 
as to antecedent colds or similar conditions in the home 
immediately before or when the child was taken ill should 
bo elicited. As good and rapid a view of the pharynx, and 
particnlarly of tho posterior fauces and retrophavynx, as is 
practicable shonld be obtained, the sides ot the neck should 
bo examined for possible lymphadenitis, and attention paid 
to any aural symptoms that might indicate a previous or 
present nasopharyngeal infection. The author suggests that 
pharyngeal Infection with ils complications is far the most 
important cause of hospital epidemics among infants as well 
as ot similar conditions in homes, such as dyspepsias, other 
acuto nutritive disturbances, and septicaemias, and empha- 
sizes the Importance of advising mothers as to hygienic and 
alimentary measures. 


Obstetrics and Gynaecology, 

38. Sacral Hernia of the Uterus. 

E. Fischer (Zentralhl. /. Gynak., November 19tb, 1927, 
p. 298G) records the case of a woman who, at the age of 3G, was 
lonnd to have carcinoma of the rectum and to be five months 
pregnant. Tbo pregnancy was stopped, and after left Iliac 
colostomy the rectum was excised by the sacral route, -with 
removal of the coccyx and tho second to fifth sacral vertebrae. 
There was no recurrence ; the patient declined further opera- 
tion for closure of the artificial iliac anus, and controlled by 
a belt and pad a hornia which developed at the site of the 
sacral incision. A year later abortion -was induced tor a four 
months’ pregnancy. Five years after this she again became 
pregnant; no subjective symptoms accompanied the first 
three months’ amenorrhoea, but from tho beginning of the 
fourth month she was unable to replace the sacral hernia, 
which progressively increased in size. On these accounts^ 
and because also of irregular vaginal bleeding and a protrusion 
of the colostomy opening, admission was sought to hospitai. 
A living child was found in the six months’ pregnant uterusi 
which was acutely retrofloxed and incarcerated within the 
hernial sac ; the cervix was tightly pressed against the back 
of the pubic symphysis. The pregnancy was terminated and 
the empty uterus was still irreplaceable; destruction ot 
ovarian function by x rays, to avoid the danger of subse'quont 
pregnancy, was advised, but was refused. 


£9. Parametritis and Bcnal Disease. 

H. Wahner (Deut. Zeit. f. Gliir., November, 1927, p. 350 \ 
illnstrates the close association betw-eeu renal disease and 
affections of the connective tissue in the female pelvis by the 
following figures. Dannrenther found well marked lesions of 
the urinary tract in 15 per cent, of bis gynaecological cases 
and Schmieden noted the occurrence of surgical disease of 
the kidneys in 62.9 per cent, in women as compared with 
37.1 per cent, in men. Similarly, in a study of the records of 
the University Surgical Clinic ot the Charity Hospital at Berlin 
during the last five years 'Warner found that 55.8 per cent of 
the renal cases occurred in women, as compared with 44 2 tier 
cent, in men. He records eight illustrative cases in -ivouipn 
aged from 25 to 51, in whom renal disease in the form of 
pyonephrosis, hydronephrosis, calculns, or wandering kidnev 
was .-issooiated with parametritis. In advanced cases 
meut consists only in unilateral nephrectomy, which 
performed in seven ofWarner’s cases, and with one exception 
was successful. c^i-cpcion 

Sz o 



JAKi ail 1938] 


I TneBamat Q 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 


«7. Lnto HcsiiUs of Treatment by Artiflclal 

Pneumothorax. 

n. Bjet.kE {Tidsskri/l f. d, NorsJ;c Lacgcfov., Novombor Ist, 
1927, p. 1278) has investigated the nttcr-hiatorics of the 
111 patients given artlfloial pnouniothorax troatinont at the 
Vensmoon publlo sanatorium during tbo imst ton years. In 
'll cases the disease was mainly ot an exudative, progressive 
cbarnctor, 5 of tbo patients belonging to tbo second and 3S to 
tbo third stage ot tbo disease as classified by tbo Turban- 
Gerbardt system. Cavities were demonstrable in 31 ot these 
<11 cases, and whoroas ‘10 wore .sputnm-iiositive on admission, 
only 29 were so on discharge. As many as 23 of tlioso 'll 
wero discharged as improved. On investigation, however, 
3G were found to bo dead, and among the 5 survivors thoro 
was only one who could claim as long an interval as three 
years between the treatment and tbo prosout investigation, 
Tbo results wore very dlfToront in tlio ease of the remaining 
70 patients, whoso disease was mainly of a productive, chronic 
character. There wero 3S in the second and 39 in the third 
stage ot tbo disease. Cavities were dcmoustrablo in 56, and 
tnberclo bacilil were found in tlio sputum in 69 ot those 70 
cases. On disebargo, only 18 of those 70 patients wore still 
sputum-positive, and 65 wore discharged as improved. The 
investigation of their aftcr-bistorios showed that 58 were 
still alive, only 12 having died. During tbo ton ycai'S under 
review tbo choice ot patients for this treatment underwent 
considerable modifications. During tlio first five yoar.s — that 
is, up to 1922— most ot the patients sufTered from sovcrc 
dlsoasoof tbo cxndatlvcr, progressive type. During tbo last 
five years tbo p.ationts solcctod for treatment suffered ns a 
class rather from the productive tlian from tlio exudative 
type of the disease ; and ot tbo 63 patients treated during 
this last five-year period as many ns 53 wore found to bo fit 
for work when tbo present investigation was made, only' one 
patient being unfit for woric, and 9 having died. Tbo author 
.cmplmsizcs tbo importanco to tlieir surroundings of patients 
being discharged from tlio sanatorium sputum-negative, and 
in this connexion ho notes that, though as many ns 109 of the 
111 patients had tuberclo bacilli in the sputum boforo a 
pnoumolliorax was Induced, 62 loft tbo sanatorium sputum- 
negative. There was no case ot gas embolism in this series. 


^8. Watch-strap Dormatltls. 

n. GooDM.ts (Vrol. and Citlan. llcv,, October, 1927, p. 648), 
who records an illustrative case, suggests tliat tiiis condition 
is commoner than his experience or tlio reports ho has 
seen would indicate, since cases ot dermatitis among leather 
writers and tanners have been freeiucut. His patient was a 
woman, aged 24, who complained tliat for ten days she had 
been annoyed by a reddened area about the left wrist where 
she carried her watch. Altliough she had worn the strap for 
several inontlis sbo had never been troubled before, and 
thought that the perspiration of n recent hot siiell had caused 
the eruption. She removed tho strap to the right wrist, on 
which she noted a similar redness and itching forty-eight 
hours later. On examination it was found that the lesions 
Were limited to tho forearm. Surrounding the left WTlst was 
an area of erytliema surmounted by closely crowded small 
vesicles. The part of the surface npon which tho watch rested 
was least affected. Although tho strap was only half an inch 
W'ide, tho left forearm was erythematous half-way up to tho 
elbow. Tbo more recently exposed right wrist showed an 
area ot erythema and vesicles more nearly that ot the strap. 


Causes of Blepharospasm. 

O. OUEASDixi [G-iorn. med, d. Osp. Civ. di Venezia, Septembor- 
uetober,' 1927, p. 140), who records two illustrative cases In 
^ states that the causes ot blepharo- 

?• direct or reflex irritation or stimulation ot 
iin.i . nerve in its poriplieral portion, in its passage to its 
i-pfin ' or, lastly, in its cortical motor centre. Tho 

frin blepharospasm aro chiefly irritation of the 

n nerve, and consist in oonlar or periocular trauma 
rnnin tho oyehall and its adnexa (Ireratitis, 

so i'®’ '^'oors, iritis, blepharitis, dacryocystitis, and 

. . Pathological excitability ot the sensory tracts, 

ilepharospasm is found 
. ' ■' diates to the trigeminal 

' ; ■ duo to disturbance of 

errors of refraction. Lastly, the irritation 
snffovi^S' . ° distant region, as in the case of children 
g from intestinal worms and In uterine disease. 


Blopharospasm may be due to a direct cause, such as trauma 
in tbo region of tbo fascial nerve, compression by tumours, 
caries of tho petrous bono from otitis, and parotid abscess. 
Infections diseases and intoxications, snob as syphilis, alco- 
holism, and malaria, may also give rise to motor disturbances 
in tho orbicularis. Tho etiological factor may be found in 
tnberentons meningitis and diseases of tho brain with irrita- 
tion of the facial norvo by compression or a meningeal 
exudate. In other cases the origin ot tho blepharospasm 
cannot be determined, and therefore^ the motor disturbance is 
regarded ns functional or dj'namio. Blepharospasm is, in 
fact, ranlccd among the motor anomalies ot nenroses and 
psychoses, such as epilepsy, chorea, and especially hysteria. 
In which it is usnally fonnd on both sides. 


so. Chronic Visceral Polysteatosis. 

JI. COUTO (.inn. de Med., November, 1927, p. 449) describes 
n clinical complex, at first sight seemingly due to arterio- 
sclerosis, but differing from it in that it is not a sclerosis bnt 
a steatosis of the affected viscei-a. The condition is com- 
pai'able witli that found in yellow fever, which is an acnio 
infectious polystcatosis; and in which the colls of all the 
organs aro llllod with fat droplets, their unclei also being 
more or less attacked. Tho sole etiological factor in cliromc 
polystcatosis is alcohol. The differential diagnosis between 
arlcrio-sclerosis and steatosis can bo made by a careful 
examination. In both the heart is enlarged, but in the 
former the loft side is chiefly Involved, the precordial shock 
is strong and diffuse, the bruits are accentuated and the 
gallop bruit Is frequently present, hypertension occurs, and 
tbo pulso is bard. In steatosis the right side is principally 
affected, tho prccordial shock is weak or absent, the cardiac 
sounds progressively lessen even to the extinction of one or 
the other, hypotension is present, and tho pnlse is soft. At 
tho end of tho disease the precordial shook becomes strong 
and diffnso and the bruits clearly perceptible, uraemic sym- 
ptoms develop, and death occurs from cardiac insnfiiclency. 
In steatosis, emaciation due to pancreatic insufifioiency and 
other enusos, asthenia resulting from suprarenal insnffli- 
ciency, delirium, vertigo, vomiting, oliguria, albtimiunria, 
and cylindruria are present. The liver is always enlarged 
and palpable, and icterus is seen. An ophthalmic complex, 
the batraohopbthalmus of Leltao, always occurs ; this con- 
sists of a slight oedema ot the eyelids, dull yellow solerotics, 
and the arcus senilis. The lesions and symptoms may he 
more marlted in some organs only; they aro sometimes 
isolated, and occasionally combined, forming the various 
clinical types— cardiac, renal, and cardio-renal. While death 
usually ensues, recovery may occur, as in a case noted hy 
Couto. Opinions differ as to whether the condition is a fatty 
Infiltration or degeneration of the cells. 


SI. Oedematous Influenzal Iiaryngitis. 

A. Big.vud (These de Paris, 1927, No. 107), who records five 
cases in patients aged from 23 to 36, inclndlug three hitherto 
unpublished, states that acute oedematous laryngitis in 
influenza, wliich was first described by Wolfoiideu (.lounNAE, 
1890, vol. i, p. 541), may present all degrees of severity, it.s 
intensity ranging from a slight interference with respii-ation 
to asphyxia requiring tracheotomy. Tho general symptoms 
are very variable, the sole constant one being a high tem- 
perature. The diagnosis can only be made by exclusion ot 
all other causes ot laryngeal dyspnoea. Thus, in children 
cases of acute dyspnoea must be excluded, such as laryngcai 
diphtheria, laryngismus stridulus, foreign bodies, and causes 
ot chronic dyspnoea, such as congenital laryngeal stridor 
papilloma ot the larynx, cicatricial laryngeal stenosis and 
hereditary syphilis of the larynx. In the adult it is 
necessary to eliminate acute causes such as Bright’s 
disease, angioneurotic oedema, iodine inflammation acute 
infections diseases, cancer, gont, laryngeal paralysis and 
crico-arytenoid arthritis, and chronic causes such as tumours 
and scleroma. There is no specific treatment, but palliative 
measures and intubation or tracheotomy must be emploved 
as required. ; 


52. Sox Siflerences In Bulmonary Tuberculosis Deaths. 

P. PUTlTiM (.inter. -Tourn. 0 / Hyg., November, 1927, p 6631 ha' 
made a statistical analysis ot the mortalitv and nomilntinl 
data of the D.S. Eegistratiou States of 1900 and the DiS 
of Columbia during the period 1870-1920, in order to determim 
the influence of sex on the death rate from pulmonar^ 
tuberculosis. For.the first five years ot life he fin^a sBeS 
excess of male over female deaths. This is reversed at th( 

ISO A 


10 JAN, 2 I,^ 928 ] 


EPITOME OF CUBRENT MEDICAL LITERATURE. - f „ t... 

I MKDfClL^Ot/BUJfc 


ages of 5 to 24 by a female excess, ^v^th the maximum 
between 10 and 14, when the proportion of fcmalo to male 
deaths Is 100 to 39l The ratios swing bade bctwoon the ngos 
of 25 and 44, after wliicli there is a marked excess in male 
deaths, reaching its maximum at the ages 45 to 54. Tlio 
male prevalence persists till the age group 75 and over is 
reached, when the male and female death rates are approxi- 
mately equal. The two most striking observations are Iho 
constant excess of female deaths during the 5 to 24 ago groups 
throughout the firty years examined, and the excess of malo 
deaths during the 35 to 75 ago groui)S. Tills cxco.ss has 
become far more evident during the last thirty years; for 
example, in 1880 the ratio of male to female deaths at ages 
45 to 54 was 110 to 100, but in 1920 it had risen to 230 to 100. 
From a critical analysis of his data the author comes to the 
conclusion that sox differences at ages under 25 are eluo 
primarily to biological causes, related chieily to phyRiological 
changes occurring during puberty and adolOHConoo. The 
differences at ages 35 to 75, on the other hand, ho ascrlhos to 
environmental causes, related to the greater wear and tear 
on the physiological resistance of men. 


53. Syphilis and Marriage. 

P. PiNKUS (Ued. Ifimi/.-., November 18th, 1927, p. 1767) reports 
the case of a man infecting his young wife six years after ho 
had contracted syphilis ; he had no symptoms, nor had ho 
received treatment, hut nineteen years later he died from 
aortic and cardiac syphilis. Syphilis may remain dormant 
for years and then suddenly become active. I’inltus also 
reports tlie case of a man who was apparently cured by 
treatment but yet infected his wife, and subsequently, when 
actually cured, was reinfected by her. The author believes 
that these patients should not marry within five or six years 
after the date of infection, and in the meanwhile should havo 
frequent Wassermann tests of both the blood and llio cerebro- 
spinal fluid. Organic disease of the central nervous system 
IS said to occur most frequently within six years of tlio date 
of infection. He adds tliat an untreated syphilitic woman 
may give birth to a oougonitally syphilitic cliild twenty years 
after she was infected, and that it is probable that there is 
a larger percentage of untreated oases among women. When 
a woman has received adequate treatment she slionld not 
marry for seven years, and be kept under observation diiriii" 
that period. E. Finger (ibid., p. 1769) states that oven after 
ten or twenty years a syphilitic patient may still bo Infectious 
but he Llimks that these patients may marry when four or 
five years have elapsed since infection, provided that thov 
have had prolonged and energetic treatment every six months 
and that they have been entirely free from symptoms for 
two or three years. In women the period of observation 
should be extended to six or seven years. J. Jadassohn 
(I bid., p. 1770) thinks that a syphilitic man, in selected cases 
may marry four years after infection, provided that lie lias 
been treated on the most modern lines, and that repeated 
examinations of the blood and cerobro-spinal fluid have been 
invariably negative for at least two years. 


Surgery. 

65. Wound Infection and Catgut. 

F. L. Melenev, F. B. Humphreys, and L. Carp (Sura 
Gynecol, and Obstet., December, 1927, p. 775) report mi lin- 
usual fatal operative wound infection yielding a nathogeuic 
anaerobe of the gas gangrene group not hitherto described 
and referable to catgut. A Clostridium was obtained which 
differed culturally from the other known species associated 
with human gas gangrene— such as C. wetchii, C. oedematis 
maligni, G. novyi, and C. histolyticum- it produced a true 
exotoxin not ueutralizable by the antitoxins for anv of tlie 
others, and the specifle antitoxin was ineffective against anv 
of their toxins. The occurrence within four days of four 
other fatal wound infections of the gas gangrene type in the 
same hospital led to an investigation of the theatre technique 
and it was found that the chromic catgut in use at the time 
yielded on culture C. novyi, two strains of this newly 
described species, two different strains of haemolytic 

G. welcJiii, and two other non-patliogenio spore-forming 
organisms. Clinically the organism recovered, produced a 
painful, brawny, red, oedematous swelling around the wound 
with fever, leucocytosis, feeble rapid pulse, nausea,- and pro- 
fuse perspiration. and terminating in somnolence, prostration, 
and circulatory failure ; it was highly pathogenic for the eight 
different species of lalioratory animals tested. The authors 
point out that these flndings call tor the establishment by 
manutacturers of adequate aerobic and anaerobic methods 
for the absolute demonstration of sterility' of all catgut put 
upon the market. 

X20 B 


55. Primary Carcinoma of tho Bronchi. 

T. MoCrah, E; II. Funk, and-C. 3 ackbos- {J ourn, Amcr, Med, 
Assoc., October 1st, 1927,. p. 1140). state. Uiat statistics show 
that iiiallgiiniit disease of tlio lung is increasing in frequency, 
though nooplasiiis originating in tlio lung iiaroncliyma coni- 
pilso only 10 to 15 per cent, of all lung tumours. The great 
majority start in tho bronchi and' subsequently inv.ade tho 
lung tl.ssuc. From an analysis of 90 cases reported by Weller, 
128 cases colloctod from tlio litoraturo, ami 14 observed by 
thoinsolvcs, tho authors deduce certain clinical features of 
inimary broncliial carelnoma. Apiiroxlmately 91 per cent, of 
the patients wore past the ago of 35, and males predominated 
in the proportion of 4 to 1. , In 40 per cent, tho right side was 
involved, In 47 por cent, tlio loft. In 9 per cent, both sides, 
while in 4 por cent, tho site was uiidetermliiablo. Tho onset, 
usually insidious, may bo Biuldou, with pulmonary haemor- 
rhage, pain in tho chest, or symptoms of acute bronchitis. 

‘ Cough, presenting no special characteristic, was present in all 
tho cases, Tho expectoration varied from a scanty mucoid 
' fluid to a iH'ofiiso, muco-piinilont, fetid discharge. In somo 
instances tlio sputum rovoaled fragments of tumour tissue, 
but tho “currant jolly’’ sputum, said to bo characteristic, 
was rarely oncoiintcrod. 'Tubercle bacilli were never foiiml 
unless tuberculosis was also present, and tho absence of the.so 
■ has somo diagnostic Iniportauco. Ilaomoptysis, a frequent 
and im|)ortnut symptom, usually appeared early in tho 
disease, and varied from a mere streaking of tho sputum to 
dcfliiito haomorrhngo. Dyspnoea was common, and pain in 
tho chest occurred frcqiiontly. In general, the early physical 
signs wore thoso of bronchial obstruction ; they became more 
iutciiso ns tho obstruction increased. Weakness, loss of 
weight, and pyrexia were usually present, though the fever 
was largely dopoudont -on tho presence of an associated in- 
fection. Tho blood showed eltlier a normal count or varying 
degrees of anaomla and leucocytosis. Motastases were found 
after death in about 66 por cent, of tho cases, and tho authors 
I bollovo that bronchial carcinoma metastasis occurs late in the 
couaso of tho disease. The malady must ho distinguished 
from tuberculosis, foreign body in a broiiohus, abscess, 
pressure on a bronchus from without, cbaiigos peripheral to 
tho now growth, and caiiccr of tlio traolioa. 'The surest and 
ino.st essential inothod of diagnosis is bronchoscopy. These 
bronchial tumours appear to havoarolalivoly low lualignaiioy, 
and early diagnosis, followed by Intousive x-ray therapy, may 
nt least prolong life. 'The authors maintain that by broncho- 
scopy a i) 0 .sitlvo diagnosis can almost .always bo made 
promptly, and that patients with obscure pulmonary and 
bronchial symptoms have a right to tho boueflts of this 
procedure. 

56 . Tccbnlquo in Prostatoctomy. 

M. Chevassu (Bull, ct Mem. Soc. B'at. dc Cliir., November 26th, 
1927, p. 1256) describes tho, methods ho has adopted with 
coiisldorablo success in tho operation of suprapubic prostat- 
ectomy ; in a sbrios of 27 ciisos bo had uniformly successful 
results. Ho performs the operation in one stage whenever 
possible, and only Uses tho two-stage method in oxooptiouql 
clrcutustancoBi for ho considers ib unnecessary to inUlcfc ^o 
.operations on any patient who is not in very poor condition. 
Moreover, removal of tho prostate is much more difncnic 
when the operation is iiorformed In two stages. Chevassu ^ 

' states that tho operation can bo extremely rapidly performed, 
often in less than a minute, 'He uses ethyl chloride anaes- 
thesia on a mask, which lasts for three minutes aud is devoid 
of any risk. Ho liovor packs the cavity loft after removal o 
tho gland. Haemorrhage is controlled by flushing with hot 
water, but it is important that the cavity itself should no 
actually flushed ; for this purpose he uses a special type oi 
irrigator, 'The absence of packing is said to give tho pationi 
a better and more comfortable convalescence. 

67. Peritonsillar Abscess. 

Kowler [Rev. dc Lari/nyol., d’Otol. et de Rhinol., Novembel 
15th, 1927, p. 662) considers tliat the collection of pus known 
as a peritonsillar abscess is wrongly named. Ho says that 
tbe abscess that occurs is always in the palate above the 
supratonsiilar fossa. It forms in the space between the 
palatal ends of the palato glossus and the palato-pharyngona 
muscles which is normally filled with loose areolar tissue. 
The reason why the abscess is sometimes not discovered is 
that the knife is caused to enter tho anterior piha'’ 
explore the region behind. Although the anterior pillar is 
often red and bulging tho iius is rarely found behind It, and 
it is significant that a collection of pus between tho tonsil 
and the iiosterior pillar is of the rarest occurrence, in 
support of this the author cites two cases of Meuzel wheic 
an abscess occurred more than a year after the complete 
removal of the tonsil, aud on incision revealed no trace of 
tonsillar tissue. In another -case an abscess , of. the palate 
occurred in two successive years, and after the second attack 



JAN. ai, 192S] 


r tnz Dnmsn 
L UcdICjU. JonUTAL 


EPITOME OE CUERENT MEDIOAL LETEBATUKE. 


u 


tho tonsils wcro coniplotcly removed. In the following year 
nnotbor abscess appeared and was inolsod ; in tho fourth year 
this was repeated. Tho author states that In oases of abscess 
in association with tho tonsil tho pus is always in tho thick- 
ness of tho palate, no matter where tho swelling appears 
most proiiiinout, and ho advises that it should always ho 
sought there. 

58. Hcctal Flstnla In Tuberculosis. 

E’. A. EA-N-sleb and C. K. PnTTEn (Minnesota Med., Novombor, 
1927, p. 699)hollovo that tuborculons paiionts have a tendency 
to rectal Dstnbio, which occur in 3 per cent, of all cases of 
this Infoctiou. Clinical c.'cainiimtlon alono will often bo 
snfllcient to establish tho tuberculous nature of a fistula, but 
annmbor of apparently slniplo lesions aro on closer study 
found to bo tuberculous. Tho finding of tnborclo bacilli in 
smears of pus from an unrnpturcd abscess, or as tho result 
of animal inoculation, and in sections of tho diseased tissue, 
will confirm a dhoguosis made on clinical grounds, but 
retMatcd sections may have to bo cut in order to demonstrate 
tho cliaractcr of tho lesions. The anthors doubt whether 
a Tstnla is over primarily tuberculous. Tho form of operative 
treatment recommended is tho cautery alone or combined 
with dissection, depending on tho needs of the case. The 
anthors considor that operative intervention should bo 
seriously considered In all cases of tnbcrcnious Ustulac. 


59- Treatment of I-Ivcf Abscess, 

f {Bull, ct Mem. Soc. Chir. etc Bans, October 21st, 

1K7, p. G20) records his oxpcriouce.s in treating amoebic 
abscess of the liver by evacuation witiioiit drainage in a scries 
of five cases. Loe-al auacstlicshi was used in four cases. Tho 
liver was exposed by one of the ordinary incisions and the 
abscess 0]icued under full vision. Tho pus was examined at 
iODce, and during this time the abscess w.as evacuated by 
' aspirator. Tlie cavity, when emptied by the 

aspliator, was freely opened and swabbed ; the walls were 
never curotloa. The liver opening was thou oblitoratcd by 
lavnro '■ ■ ■' ibul Iticiaion was closed in 

;V,„ !?• , . ■ ■ ■ " ■ , iu tho pus did not influonco 

treatment, hnt emetine was given suhseqaently. 
nni P'’®'^'°P°tativo course In all cases was straightforward 
quickly to normal ; sometimes the 
‘*>0 tlay after operatieu. but this was 
the wound was 
favourably with tho fifty to 120 days 
tliat wore drained. The rapidity of tL 
obtained aro thought to 
employed ibothoa superior to auy other that may bo 

60. Carcinomatous Degeneration of HectaJ Adenomas. 

‘ p’m (Jotirn. Amer. Med.^Assac., September, 1927, 

.'which rectal adenomata, in si.x of 

developed. Ho cenclndes that 
withtmt h^rnmi adcnoma may exist for many years 
Bulerea^ni-p^^*“® malignant, yet that It ought to'bo^con- 

The more sessile is 

“orfhos^. and 


more set; bo snared at _ 

requires wide excision or'thVbaso" an 
SoUtarTld°i,„°i coagnlauon of the site of attachmenl 
Beared: ■r^„P®“™‘=matca growths may sometimes be safe! 
alreadv bn ° la sessEe but removable it ma 

plantation stonte^; coagulation or radon in 

tion. Hinb ItuSIt “ safegnard against dissemlna 

tl>rongh^abanmfnnf’° ““y be remove, 

e'flng to the ‘pelsmn— a more dangerous prooedur 

a lisix 01 pecitoneaX infection# 


Therapeutics. 


61. 


Curth Excessive Sweating. 

treatmLfo't cen’e^l discus: 

lypo occurs in ‘be gene 

Ibcg, Basedow’s ‘ypb°s fever, tuberculosis of t 

Atropine, thoue-h brain tumours, and oachex 

mg the salivary seormin?*^.^!^' disadvantage of arre 

Inciting congt in causing dryness of the mouth, a 

?"rth\hini|'‘ It distressing to the patie: 

gram, in pig fom^’evo ®mP'°y agaric 

bydrastis. 25 to 30 d^ evening, or flntd extract 
tops three times a day. Arsenic giv 


for a long time in small doses is strongly recommended ; 
an infusion of sage leaves, or a tincture of sage leaves, 20 
drops throe or four times a diaj’, is also useful. Al! these 
roiiiedics, with the exception of sage, seem to iuflnence tho 
sweat glands througli their nerve supply. Daily’ baths at 
a tomporaturo of gO’F. are advised, and friction with some 
alcoholic Eolation, eau-de-Cologne, lavender or thyme or 
menthol solutions 1/2 per cent. Adipose persons require 
sonic dusting powder ; but a powder containing salicylic 
acid is contraindicated in inng diseases, since it irritates 
tho organs of breathing. The powder most employed is 
salicylic acid 2 per cent., iris root 10 per cent., zinc oxide 
and bismuth snbnitrato each 20 per cent., with talc 
powder to 100. For sweating and malodorous feet Cnrth 
recommends horsehair or straw movable inner soles to tho 
shoes dnsted with a 30 per cent, sodium biborate powder, as 
arc the stoclclngs or socks. The toes should be separated 
with cotton-wool, and the feet washed each evening with 
spirits of wine, eau-de-Cologne, or 2 per cent.' salicylic 
acid in alcohol; afterwards they should be dusted with 
3 per cent, salicylic acid mixed with equal parts of bismuth 
subnitralc and talc pow'dor to 100. Painfnl fissures on the 
feet should be painted with 1 to 2 per cent, of silver nitrate 
before applying an nngnent. For sweating in the axilla 
Garth recommends concentrated acetic acid - 60 per cent., 
spirits of lavender and spirits of rosemary each' 1 per 
cent., spirits of cloves 1/2 per cent., camphor 8 per cent., 
aromatic spirits of vinegar to 100. For clammy hands he 
also recommends a spirit solntion, either 5 per cent, salicylic 
acid or the following: formic acid and chloral hydrate each 
5 percent., Pemvinn balsam 1 per cent., dilnte spirit ,to ICO. 
For sweating of the head ho recommends cold water douches 
and subsequent friction with spirits of ether 50 per cent.; 
tinctnro of benzoin per cent., and a few drops of vanilla, 
heliotrope, or oil of geranium ; at night a salicylic powder 
may he used. ' ■ 


62. Indications for Synthalin in Diabetes. 

A. H. A. Mabtess, C. H. EoEns, and C. db Joxg (Kcclerl. 
Tijdschr. v. Geneesk., November 5tU, 1927, p. 1918), who record 
11 cases of diabetes iu patients, aged from 14 to 71, treated' 
with synthalin, summarize their conclusions as follows : 
(1) Synthalin reduces tho amount of sugar in the blood as well 
as in tho urine. (2) Tho use of synthalin may be of service 
not only in mild and moderate cases of diabetes but also in 
acidosis after or in association with a course of insulin treat- 
ment. (3j It is desirable to test the hepatic fnuotion beiore 
commencing synthalin treatment. (4) Increase of urobilin or 
nrobilinogeu hardly ever occurs after administration ot syn- 
thalin. It cannot, therefore, be regarded as a contraindication 
for synthalin treatment. (5) A sequel ot synthalin treatment 
to which no attention has been drawn is the frequent occur- 
rence of loss of flesh. (6) The complications of synthalin 
treatment aro usually ot short duration and are no indication 
for tho suspension ot the treatment. The administration ot 
fractional doses usually canses the symptoms to disappear. 
(1) Any cholagogne has a good effect In causing disappearance 
ot tho symptoms. This supports the view that an efficiently 
functioning liver is the principal requisite for synthalin treat- 
ment. (8) The success ot synthalin is not dependent on good 
gastric function, since synthalin treatment bad a favourable 
effect in several patients with achlorhydria. (9) Treatment 
with synthalin requires special attention to each individual 
liatieut even moie than insulin, does. 


63. Chemotherapy In Septicaemias. 

E. Vaucher and Mile Uhrig (Paris mill., December 3rd 
1927, p. 454) assert that some chemical products have given 
very good results In the treatment of Infections, and 
they describe four iu particular— trypaflavine. merenre- 
chromo, septicemine, and optochine— and the conditions in 
which they have proved of benefit. Tri’paflavine is a 
brownish-red powder, solnble in water, formin"- a teHow 
solution. This shonld ho sterilized for one hour'at 70’ and 
as it is sensitive to light, shonld be kept in dark bottle's or 
ampoules. It possesses a marked bactericidal action and 
acts, as a powerful disinfectant in the blood, sernm’ not 
modifying its action. Trypaflavine is said to be only sliahtlv 
toxic, and is usually administered in 2 per cent. solnHons 
Slight reactions, including a yellow coloration of the skin’ 
without shock, follow the injections. Normally it is exci-eted 
in the urine in thirty-six to forty-eight hours. Indications 
for Its use are septicaemias in general, septic endocarditis 
aU infections, and typhoid fever; it is contraindicated In 
acute haemon-hagic or chronic nepliritis. Metcurechrome 
tho sodmm salt of dibromoxy-mercorv-finoresceiu conts!n= 
26 per cent, of meremy, and is soluble in wa?er’ forin^na 
a cherry-red solution. It posse.sses great ponetrattag and 
bactericidal powers, and canses only slight rritation of 
tissues. A 1 per cent, solution is' usoluy 


120 C 



EPITOME OF OUEEENT MEDICAL DITERATtlEB. 


12 Jan. it, 1928] 


venously, the dose being 5 mg. for each kilo of body -weight ; 
It causes rather marked reactions. The drug is eliminated 
In the urine and faeces. Merourochrome has been used with 
benefit in many infections, as septicaemia, pneumonia, and 
scarlet fever, and as a wet dressing in cutaneous infections. 
Optoohlne or'ethylhydrccupreine, a' quinine derivative, is 
liable to cause aural and ophthalmic troubles, and Its use 
needs careful supervision, but it has given good results In 
pneumococcal infections owing to its selective action on the 
pneumococcus. Septloemine contains 33 per cent, of iodine 
and 45 percent, of formine ; It is extremely diffusible, non- 
toxic, and strongly germicidal. The drug causes no reactions, 
and is eliminated by the kidneys. It la said to bo indicated 
in all general infections, particularly the puerperal, in 
septicaemias, and in pyaemias. The authors discuss the 
combining of these drugs with vaccines and serums in the 
septicaemias due to streptococci, staphylococci, colon bacilli, 
pneumococci, and gonococci. 

B5. Treatment of Typhoid and Paratyphoid Fever 
with a Staphylococcal Vaccine. 

V. Bib [UcfesTcrlft for Laeger, November 24th, 1927, p. 1072) 
has, since 1921, been treating typhoid and paratyphoid fever 
with vaccines. During tlio first two years a typhoid vaccine 
was given. Later a staphylococcal vaccine was used, ns its 
action was equally effective and the treatment could bo 
started at once on the strength of a clinical diagnosis without 
the subsequent serological diagnosis being rendered dilllcult 
by artificial changes in the Widal reaction. On five successive 
days intramuscular injections were given, the doses being 
100, 200, 400, 700, and 1,000 million organisms. In the few 
cases in which this series of injections proved Ineffective it 
was repeated after an interval of a low days. There was no 
more than a sliglit rise of temperature, and a rigor was 
observed in only one case. No patient collapsed under this 
treatment. The result was usually a fall of temperature by 
lysis during or directly after the injections. All the 51 
oases of paratyphoid fever thus treated wore severe. In 39 
the result was good, the temperature falling during or 
directly after the injections; in 4 cases the fall of the 
temperature was slow, or the effect of the Injections was 
doubtful, aud in 8 cases the treatment seemed to have no 
effect. None of those 51 patients died. Of the 54 patients 
suffering from moderately severe, or severe, typhoid fever 
35 responded satisfactorily to the treatment; its action was 
doubtful in 3 oases, and ineffective in 9 ; 7 of the patients 
died. Among the 47 who recovered tliore were as many as 
13 who suffered from pneumonia. The author concludes that 
the pneumonia complicating typlioid fever is seldom affected 
by vaccine treatment, and that when this treatment fails to 
benefit a case of typhoid fever it is usually because the 
patient is also suffering from pneumonia. Dncomiilicated 
typhoid fever usually reacts satisfactorily to intramuscular 
injections of a staphylococcal vaccine, and tho disappointing 
results obtained by other workers may in many cases be 
traced to the fact that tlioy gave the vaccine by the intra- 
venous, and not by the intramuscular route. 


es. Pepsin Solutions In Inoperable Frostatlc Hypertrophy. 
E. Gruneet (Ze7iiralbl, f. Chir., December 3rd, 1927, p. 3088) 
confirms Bayr’s observations on the efficacy of injections of 
pepsin solutions in this condition, and he describes tho case 
of a man in whom the pelvic floor was occupied by a non- 
inflammatory apparently malignant tumour. He gave three 
injections into the prostate of 10 c.om. of a 2 per cent, pepsin 
solution, employing Payr’s technique and allowing an Interval 
of live days between each dose. The tumour coutraoted 
and urination became normal. The patient, however, lost 
weight and died two years later. No necropsy was performed. 
Grunert suggests that this treatment might be of great value 
in affording relief in inoperable cases of prostatio hypertrophy 
or of malignant prostatio tumours. ^ 

OS. Somnifen In States of Agitation. 

W. Martinez and F. J. Rodriguez {liev. de neural., 
•psiguiat., y mcd. leg. de Uruguay, September, 1927, p. 2), 
who record ten illustrative oases of various forms of motor 
agitation treated by tho soluble hypnotic somnifen (diethyl- 
diallyl-barbiturate of diethylamine, came to the following 
conclusions. This drug, given intravenously in doses of 
2J to 4 c.cm., proved a powerful hypnotic in all cases of 
insomnia; it was also an effective sedative in motor irrita- 
bility of alcoholic origin. It had absolutely no action on 
restlessness due to other causes such as manic-depressive 
psychosis, and it did not soothe post-onelrlc states of de- 
pression or delirium even in alcoholic subjects. When given 
la the ordinary doses it -tvas harmless provided that the 
blood urea did not exceed 50 eg. per litre and the cardio- 
vascular system was healthy. 


r Tw B*rrmi 
L UxDzoiL JorsviA 


Ophthalmology. 

67. Hereditary and Familial Optic Atrophy. 

R. Fa-VIER {These de Paris ', 1927, No. 439), who records two 
: illustrative cases in brothers, maintains that this condition — 
first described in 1871 by Leber, who collected 55 cases— is 
not so rare ns is supposed. Hormuth in 1900 obtained 
information about 74 families, which included 300 patients, 
of whom 131 submitted to medical examination. Other cases 
have slucb been reported by Klopfer, Buisson, Muthien, and 
Ilolnsbergor. In tho great majority of cases the condition 
develops ns rotrobiilbar neuritis, and appears to have no other 
causo bat a familial and hereditary predisposition, being 
characterized not by its symptoms or ophthalmoscopic 
appearance, which resemble those of toxic amblyopia, but 
by its peculiar course. It rarely appears before tlio age of 
12 or 13, nor after 30, except in women, in whom it develops 
between 41 and 49, about tho time of tho menopause. The 
youngest patient hitherto soon was a child aged 6 j'cars, and 
tho oldest wore aged 52 and 67. Prodromal symptoms are 
exceptional. Visual disturbance occurs suddenly and develops 
rapidly in tho course of tlie following four or five weeks, 
when It becomes more or loss stationary. Sometimes the 
course Cf tho disease is slower, lasting six to, twelve 
months, or it may bo rapid, producing almost complete 
blindness in a few days. Such cases, however, are excep- 
tional. Tho affection is always bilateral, although both eyes 
are not always affected to the same extent or at tho same 
limo. Tho results of ophthalmoscopic examination vary 
according to tho stage of tho disease when it is made. During 
tho progressive period comparatively little is to be seen ; 
later, however, signs of partial atrophy develop. General 
disturbance may occur in tlie form of migraine, vertigo, 
vomiting, and sometimes epileptic attacks. The prognosis 
should bo guarded, tliough it is not invariably hopeless. All 
treatment has hitherto proved Ineffective. 

68. Arterial Spasm and Occlusion of Branches of 

the Botlnal Artery. 

H. P. Waoener and J. F. Gipner (diner. Joum. Ophthalmol., 
September, 1927, p. 650) describe five cases of spasm of a 
branch of tho retinal artery. In two of tho cases tlic affected 
branch was completely obliterated beyond a certain point 
and quite invisible. While under observation the artery 
opened up, refilled with three progressive pulses, aud became 
normal, vision being completely restored. In both patients 
early signs of hypertension were noted, and in one symptoms 
of tho Raynaud typo had boon detected. This patient com- 
plained of occasional short periods of blindness on various 
occasions over a period of years and involving part of tho 
visual field. In tho other cases there was permanent loss of 
vision, and on examination the affected artery appeared as 
a white cord. The authors consider that in these cases 
thrombosis of tlie blood occurred at the time of the arterial 
spasm or immediately following it. ■ 

69. Bilateral Pre-paplllary Yasoulnr Loop. 

A. M. XODKIN (Arch. Ophthalmol., September, 1927, p. 474) 
describes a case of bilateral pro-papillary loop of the retinal 
artery. In both eyes the central artery of the retina divided 
on the disc into two main branches. From the lower a spiral 
loop protruded into the vitreous, took a sharp turn, and 
returned to the upper temporal edge of the disc after maffing 
three spiral 'coils. Tho other vessels were normal. The 
slit-lamp examination revealed no remnants of the hyaloid 
arterial system. These phenomena have been reported from 
time to time, but it is very rare for the condition to ho iden- 
tical or oven presentin both eyes. With regard to the etiology, 
it is now held that the condition has nothing to do with cither 
an inflammatory process or with the embryonic remains of 
the hyaloid artery, but is rather an excessive development 
with exaggerated tortuosity of the normal arterial system. 


Obstetrics and Gynaecology. 

70. Blood Transfusion In Obstetrics. 

In order to obviate tlie use of stabilized blood in bulk ■with its 
contained anticoagulants fsucb as sodium citrate), which are 
toxic in largo doses, Ii6vt-SolaIi and A. Tzanck {Presse Mccl.t 
December 10th, 1927, p. 1505) have designed a sitnplo apparatus, 
by means of which a number of donors may be successively 
utilized at the one operation. The authors report twenty-sia 
obstetrical aud gynaecological cases in which this procedure 
was most beneficial and no fatalities occurred. These cases 
included post-partum haemorrhages, abortions complicated 
with haemorrhage, obstetrical shock, placenta pr'aevia, acute 



EPITOME OF CUEKENT MBPICAL PITEEATOEE. . 


[ T:t* CJwnsTl 
Hrmcu. JocEjfAti 


13 


JAM. ar, lOaSJ 


nimcmlas of tlio pernicious typo, and oxtiauloviuo p^'sS- 
naucicB ; in BO\no ot llicm artlllclal Horum tuul been oniployod 
wUliont beiiclll. The iiutlioia cinpliasizo llio imporlanco ot 
cliooslnp the right moment for transfusion, and state that in 
all varieties ol severe hacmorrlmgu thoro are three distinct 
phases : (1) the. stage of tolerance, in which the symptoms 
are not very apparent; (2) the plmso ot orltical thrcsltold, 
niarlvcd Ijy an alnnjit or progressive falling of tlio ftonoral 
state ; and |5) the phase of astlicnia or collapse, cliaraotorized 
by an imjicrcoptihlo pulse and an absonco of arterial tension. 
Preparations tor tbo transfusion slionld bo made on the first 
appearaiico ot disquieting .symptoms, and tlio operatlou ho 
performed wlicn progressive acceleration ot tlio pulse and 
respiration occur. A desoiiplloii of the technique Is given, 
whereby largo amounts ot pure blood can bo transfused -with 
the maximum of control and salcly. As much ns two litres 
may bo necessary, and tlio authors' ruio is to inject as much 
blood ns bas boon lost. Tbclr twonty-slxcaaos inclndod six of 
protuso bleeding during labour, seven of liaomorrhago after 
aboriion, three of shocU following loss of a moderate amount 
ol blood, Ibrco ot placenta pracvln, two of .severe anaemia In 
pregnancy, and five of oxtrauterinc gestation. 


11. Insulin In Gynnocotoglcnl Conditions. 

Accoudino to E;' Vogt (^en/ru/Af. /. Oyiiul;., November 25tli, 
1927, p. 5034) insulin oxcrci.sos important intlncucc.s on the 
activity ot tbo endocHue glands, especially the ovaries. In- 
jections ot Insnlin have l)ecn found by Vogt to ho effective in 
Iroatnieut ot certain ca.ses of “ ovariogcnoii.s bleeding" — that 
is, cases of inoiiorrhngla or metroirbagia attributable, in tlio 
absence ot morbid uterine conditions, to ovarian dysfunction. 
Moderate do-es given twice daily before tbo nioruiug and 
ovoiiing meals are recommended, and are said to be effective 
usually wlthlu two or tlirco clay.s. In two eases ot wasting 
without discoTcralilo organic disease a eoursc of iosuiln In- 
jections in small doses led not only to a large gain in weight 
but also to a return of tlin mon.ses. Tlio first (lalicnt, a nulli- 
para aged 35, bad lost 40 lli. in weight and Iiad Iiad aiucuor- 
rhoctt during six moutiis; she rogainod tier lost weight with 
seventy-two days’ Insulin ti oalmcut and began to menstruate 
roguiacly. The second patient, an unmarried woman aged 23, 
hi Kovon weeks regained 11 lb. in wolglit and menstruated for 
tbo first time (or two ycara. Furtlicr evidence pointing to a 
connexion between insulin and tlio ovary is pcrliaps found in 
Buccosslul Insulin tboraiiy of liyporcmcsis gravidarum, wliich 
n 1 , ''®'4ttided ns a consequence of ov.arinii liypotuuction, 
and wWeu in tbo expcricuco ot certain ob.scrvots has been 
Snin ‘“*^"o«ced by Injection of ovarian extract, 
oioriiizalion of female animals by injections ot insulin has 
^°tui>lhlicd by Vogt and others; iujcclious oriin- 
piauiatious ot ovailau extract or snbstaiico from gravid 
fno*?! - “ same ciTcct. Vogt finds tliat tho efifeet of 
uon-dlabelic (omalos shows a con.staut 
tlto luoustruai cycle. The maximum diininu- 
blooCl sugar was obtained duriug tlio last eight 
™ menstruation and during menstruation; after 
effect of insulin became rapidly less, and 
minimum level tlirougbont the first halt of the 
findings, which have an obvious 
hv la the treatment of female non-diabetics 

whnUot * 1 '’ '■^*1** those of Franlt and of Fels, 
in (ho m concentration of ov.arJaii hormone 
and its highc.st ton days before menstruation 

tin during tbo first ten days ot 

ot tho tippnrently tho ovarian hormone content 

the ,,,0.1°?° *"snlin sensibility take par.allel courses in 
Voot Lo pycle. During the latter half ot pregnancy 
coDstonf . sensibility remains liigh but 

from t*'at the ovarian hormouo in the blood 

tnanenti,, *u pregnancy onwards remained per- 

mensirnot! * of twice tho amount present before 

the aofi^, oil'- .. tliat with increasing knowledge of 
is not srvoom*°‘\° *? .**' i’°comos more evident tliat its action 
that of ^ complex, pinripotenfc, and related to 

‘ ductless glands other than the pancreas. 

Septlcaemta caused by B. perfrlngens. 
S'limioter ,^"d-dn;er. ile eiulocrhwl., iminunol. y 

*^aso Iollowini°^ol^-°^i !’• '"'i'o records au illustrative 
Septicaemia bao ''■’’“''tion, states that though puerperal 
tioiis, esneoinu? ! suhjoet of numerous commniiica- 

thc attention i, and Germany, it has not received 

’t de-serves, as It 


8uppose(l" ^3 much more frequent tlmn is 

thenterinsn.oii , , mfeolion with develomueut ot gas in 

hetoretbea ior-o, - ''to was do.scribed by Dohru in 1872 
process remaino,i°*°, Irnown, but the nature of the 


Halbann in ““t until 1900 that 

fi^Pgreno of thn n,il. ° first ^bacteriological study of 

daring lUo a,,,] which ho found FraeiikoTs baclllns 

nterua” to thB”nnni?r!° “ septic emphysema ot the 

the condition. The most important studies have 


since been made by Schottmiiller (1910), FraeuUei (1924), 
Nfirnbergor (1925), and IjOhmanu (192G) in Germany, Brindeaii 
and Mac6 (1900), Balard (1918), and Teissier, Itivalier, and 
Thciral (1926) in France, and H. Thorn in England. According 
to Nnrabovger tViis infection is commonest in cases of criminal 
abortion. The cliaractoristio symptomatic triad due to an 
intense destruction ot tlio red corpuscles consist.s in a 
yollowi.sli-greou coloration ot the skin and solorobics, changes 
in colour ot tho urine, whicii is at first yellowish red, tlien 
darlc, and llnnily black, and dark red coloration of the blood 
scrum. Spectroscopic examination shows the presence of 
lucthacmoglobin. 'The prognosis is bad, death being due to 
destruction of haemoglobin and endogenous asphyxia. The 
absorption ot toxic products duo to disintegration ot the 
tissues may hasten the fatal termination. 

T3. Surgical Intervention In Pelvic Infections. 

A. H. CDliTls (Journ. Amcr, Meet. Assoc., October 8th, 1927, 
p. 1191) discusses gynaecological problems and their treat- 
ment. Ho fiud.s that in chronic lencorrhoea Skene’s duct is as 
important a source of discharge as the uterine cervix and 
needs as mucli treatment. Iii chronic endocervicitls the 
establishment ot tliorougb drainage Is ot great importance. 
Ho stresses the danger ot repeated instrumentation of the 
nterns and also inaiutaius that supravaginal hysterectomy 
performed oven several days after diagnostic curetting is not 
an aseptic surgical procedure. In acute inflammation of tho 
tubes operative treatment should be avoided. Curtis holds 
that a quiescent tubal inteotion is a self-Bmited disease, and 
that an operation is to bo avoided except in tlie case ot 
sequels. Witli regard to diseased ovaries he thinks that less 
radical surgery is required in gonococcal cases than in those 
of tuberculous or streptococcal origin. 

74. Serological Diagnosis of Iho Puerperium. 

C. DlPPEltA (11 Toiiflmico, Sez. Prat., November 14tb, 1927,- 
p. 1G55) 1ms tested tiio medico legal value of serological 
examination in a number of puerperal women. It has been 
suggested that iu the puorporium some milk passes into the 
blood aud. acting as a hotorogeneons protein, excites tho 
formation ot agglutinins, which in their turn will cause 
agglutination wlien mixed with prepared serum. Tho author 
found that witli two c.xceplions the test was positive up to 
eleven months after parturition. It was found positive in 
a woman who brought forth a macerated foetus at seven 
months and in a woman eight months pregnant. 

75. Yertebral Deformity and Cardiopathy during 

Pregnancy. 

P. Kdein {Arch./. Gyniik., September 1st, 1927, p. 653) draws 
attention to tlio need ol surveillance during pregnancy ot 
women with severe liyphosis and scoliosis; in addition to 
pelvic deformity morbid conditions of the heart are present 
■which may have serious or even (as in two cases here 
described) fatal consequences. Tho cor kyplioscolioticnm ’’ 
is associated with typical post-mortem findings ot mnscnlat 
degeneration, well marked hypertrophj' ot the right ventrioie, 
and little or no alteration ol the valves. Strain is thrown 
on tho heart by (1) tlio compression ot one lung by vertebral 
deformity and compeusatorj' emphysema of the other,' 
(2) impediment of thoracic breathing 'by ankylosis ot the 
ribs, (3) difficulty" of cardiac expansion owing to narrowing 
of the thorax. Women with advanced kyphosis and scoliosis 
are subjected to increased cardio-vascnlar strain from the 
earliest month.s of pregnancy and during each of the stages 
ot labour. Klein describes sixteen cases and alindes to 103 
others, iu the majority of which grave signs of cardiac em- 
barrassment occurred iu tbo earliest stages of pregnancy". 
He tliiuks that when signs of decompensation have appeared 
belove pregnancy, or when medical treatment is not speedily 
elTectivc in cases iu which cardiopathy is noted during the 
early mouths, induction of abortion is indicated. When the 
patient is first seen with marked signs of cardiac trouble 
dating labour it is probably wisest to perform Caesarean 
section ; this is the best means of eliminating the inuscnlar 
labour of parturition, and has the advantage that by a simul- 
taneous Porto’s operation the patient may be spared the 
dangers of the puerperium aud protected from the risks of 
subsequent conception, 

7G. Respiratory Emphysema in Dabonr. 

G. A. Gordon (Jvier. Journ. ObsUt. and Gynecol., November 
1927, p. 633) reports two cases of respiratory emphysema as 
an unusual complication ot labour, and reviews 130 previously 
recorded. Both hia patients were healthy young primiparae 
in -whom labour was somewhat prolonged, but the paius and 
straining -were no wor.se than usual. In the first air crepiia- 
tlon with slight tenderness developed subcutaneously over 
the face, neck, and cliest to the nipple level, eventually 
spreading to the parietal scalp, with entire disappearance by 

izo B 


14 Tan. si; 1928] . EPITOME OP CUPEENT MEDICAL LiTEEATUEE. ' Tii«” ^ 


tlie fifth flay. la the second an area of emphysema extended 
from the infraolavicnlar space to the zygomatic arch on the 
right and to the lower jaw and trapezius on the left ; by the 
fifth day it was present only just above the riglit clavicle, and 
had entirely disappeared by the tenth day. No predisposing 
cause could bo discovered in the first case, wliilo In the 
second the fact that the patient had had resection of two 
ribs for empyema in childhood may have boon a determining 
factor. The clinical course of both was uneventful. The 
condition usnally occurs during the second stage, but may 
arise in the first; frequently it is not noticed until after 
delivery, and may originate in any part of the air passages. 
Its etiology and pathology are not known. The prognosis 
is good and treatment is expectant, rapid delivery being 
indicated for steadily increasing emphysema or for symptoms 
of respiratory distress. 


Pathology. 


77 . Inheritance of Susceptibility to Malignant Tumours. 
Claea J. Lynch (Journ. Exper. Med., December, 1927, p. 917) 
has already adduced evidence that susceptibility to spon- 
taneous tumours in mice is inherited. She has now per- 
formed a series of experiments to determine whether suscep- 
tibility to tumours Induced by tar is also inherited. Two 
strains of mice were chosen : (1) an agouti strain having an 
incidence of spontaneous lung tumours of G.73 per cent., and 
(2) an albino strain having an incidence of spontaneous lung 
tumours of 37.01 per cent. Thirty mice of each group were 
painted on twelve different regions of the body with tar 
extract ; each region was painted four times, the total treat- 
ment lasting four months. The incidence of lung tumours 
in the agoutis was 22 per cent., in the albinos 85 per cent. 
The effect of the tarring had therefore been to raise the inci- 
dence of lung tumours considerably in both groups of mice. 
The agoutis had been crossed with the albinos, and 35 of the 
El generation were tarred ; after sl.x months, .when the 
surviving animals were killed, the incidence of lung tumours 
was 79 per cent.— that is, nearly as high as in the pure albino’ 
mice. Males of the FI generation were then back-crossed 
with females of the albino strain, and the offspring tarred';’ 
the incidence of lung tumours in these mice was 81 per' cent.-, 
or about the same as In the pure albinos. The same males of 
the FI generation were also mated with females of the agouti 
group; 39 offspring, all agoutis, resulted and wore tarred, the 

incidence of lung tumours being 39 per cant that is; greater 

than in the pure agoutis, but considerably loss than in tho 
albinos. Tho author concludes that there Is little doubt that 
susceptibility to tumours induced by tar is inherited. It 
would appear that at least one factor governing susceptibllitj' 
is dominant, lor the FI generation when back-crossed with 
the albinos gave approximately tho same rate of tumour 
incidence as the pure albinos ; on the other hand, the back- 
cross with the agoutis gave an intermediate result, indicating 
that probably more than one factor is involved. 

78. The Ktiolo^y of liocalized Oedemas. 

J. Cables (Journ. de Mid. de Bordeaux, November 25th 1927 
p. 847) draws attention to the fact that a localized oedema of 
cardiac or nephritic origin is usually related to a previous 
trauma. He mentions one case in which a previous fracture 
determined tho site of oedema in a nephritic. In another 
case erysipelas was the factor which started an oedema of 
the face only. In cases of unilateral hydrothorax a previous' 
pulmonary lesion, such as pleurisy or tuberculosis, is nearly . 
always to be found. As an explanation the author sunnosts 
that in accordance with a general law by which microbes 
and poisons are attracted to the seat of a lesion a special 
aptitude is conferred on the tissues to detain locally such 
substances as chlorides and sodium. Or it may be that 
trauma has the effect of damaging the osmotic power of tho 
capillaries or modifying their vasomotor functions. 

79. Modification of Tabaronlons'Leslons by the 

B.C.G. Vaccine. 

P. P. Dwijkofp and L. P. Masoueowski (Ann. de I’Inst 
Pasteur, November, 1927, p. 1194) vaccinated 17 gniuea-pjos 
with the B.C.G. vaccine. The doses used were very small 
and were administered by the mouth, subcutaneously, or by 
intraperitoneal injection. The animals ware subsequently 
inoculated with a very small dose of virulent tubercle bacilli 
apparently by the same route as that used for vaccination! 
All the guinea-pigs except four 'died in from three weeks to 
three months ; the four exceptions lived from four to seven 
and a half months. At necropsy the lesions in the guinea- 
pigs were found to be distributed throughout tho usual organs, 
120 P ' 


but histological examination revealed that tho tuberculous 
proco.ss was often advancing only slowly or was actually 
retrogressing. Fibrous tissue was abundant, caseation w.ih 
not very marked, and in some animals actual calcification 
was 'Been. Tho guinea-pigs that survived for some months 
showed actual c.avitics In tho lungs, together with calcareous 
masses. The authors conclude that in animals vaccinated 
with tho B.C.G. strain and subsequently infected with 
virulent tuborclo bacilli the lesions tend to bo sclerotic, 
particularly' those in tho lymphatic glands and liver. Tho 
altbratlou in tho ' course of tho disease, however, is not 
Bufilclout to prevent death. 

80. Effect of Eodlum Salicylate on tho Heart. 

A. M. Mastee [American Heart Journal, December, 1927, 
p. 180) has studied tho effect of sodium salicylate on normal 
individuals in order to dotorralno whether tho use of this 
drug in rlionmatic fever produces some of tho electro-cai'dio- 
graphlc changes observed In that disease. Those luclnda 
prolongation of tho P-E interval, from an almost imperceptible 
doprossion of conduction to dropped boats ; partial or com- 
plete lie.art-bloclc; alteration in rhythm (sinus arrhythmia, 
sluo-nurlcular block, nodal rhythm, premature beats, 
paroxysmal tachycardia, auricular fibrillation, and flutter);- 
nnd changes in tho QES group and ST transition interval. 
Master ghvo full medicinal doses (that is, 60 to 120 grains 
of sodiiiin salicylate in the twenty-four hours) to thirteen 
patients in hospital, until toxic symptoms occurred. The 
patients' hearts and lungs and blood pressures wore pre- 
viously' normal. Electro-cardiograms were taken before and 
after tho salicylate administration. Tlio drug liad no 'effect 
on the pulse rate, tho elcotro-cardiographic tracing showed 
no abnormality, and no evidence was obtained that tho drug 
affected normal heart muscle. The author concludes that 
since in rheumatic fovor olectro-cardiographic changes are 
almost invariably present, and sodium salicylate has been 
shown to bo incapable of causing such alterations, they must 
bo duo to tho disease alone. 

81. Transmissible Toxlcogonlclty of Streptococci. • 

M. Frobisher, jun., and J. H. Bro'W'n (Bull. Johns Ilophins 
Jlosn.; Sep’tciiibor, 1927, p. 167) cultivated uon-toxicogonio, 
non-scarlatinal streptococci, and strains of B. colt, B, 1^'°' 
digios'us] It. subtitis, and S. albus in mixed culture' with 
to.xlcdgonlc’' Bcarlallnal streptococci, and recovered them in 
pure ciilthro'.' ■ Two non-scarlatinal streptococci wero'tlien 
found' to' have acquired temporarily a definite toxioogehioity 
giving rlsd'to a toxin which was neutralized by antiscarlatinal 
serum. Tlio bthcr organisms did not acquire any toxlco- 
gcniclty'. Tho authors also found that non-toxicogenio strepto- 
cocci might acquire a toxicogonicity from sterile Berkefcld 
flltratos of tho scarlatinal typo, although the toxicogenic 
powers so acquired wore in general loss marked than those 
acquired from tho mixed cultures. This Is taken to suggest 
the oxistehco of a filterable second factor associated with 
the scarlatinal streptococci. 


82. Pathogenesis of Tuberculosis In Adults. 

P. Harbitz (Nore/c Mag. /. Laegevidettsh., Noyemher- 
lecembor,T927, p. 892) publishes post-mortem findings during 
be ton-year period (1916-25) at the Eikshospital in Oslo, 
vhere 1,882 completo examinations were made of persons 
)ver the age of 15, Among them there wore 239 cases 
vhich death was duo to tuberculosis, pulmonary tuberculosis 
leing responsible for 141 deaths, and other forms oI this 
lisease for 98 deaths. Among the 141 cases of fatm 
mlm'onary tuberculosis there wore 35 in which tho necrop y 
Indings proved,-or suggested, that the disease was cab'’® ? 
nfection in childhood. Among the 98 cases of other forms 
nbercnlosis there were as many as 65 m 
50tild be traced to infection iu chilcihoocl. Thus 100 of ft 
►f 239 fatal cases of tuberculosis could be regarded as 
tuto-reinfections. This proportion (42 per cent.) of ^ * 

einfections was probably an underestimate, as some c • 

►f old infectious in .childhood may have been 
Yhen tho persons dying between the ages of 16 and ou n 
lonsidered by themselves it was found that among the 
lecropsies made on per.sons of this age there were as ^ 
iS 143 (30 per cent.) whose deaths were caused by 
ulosls. At the necropsies of these 143 cases signs w 
ound of an old infection in childhood in as many ^ , 

55 per cent.). The author concludes that with 
uberculosis in structures other than the lungs the 
n adult life is usually the result of spread of 
rom a focus which developed in childhood. Ho JS m 
autious in his judgement with regard to fatal cases 
mlraonary tuberculosis in adults, as it is comparativ y 
ifficult to judge from the clinical history and the posi- 
'lorteni findings between tho possibilities of a 
xogenons, and an endogenous infection from an old focus. 


JA^T.'iSj.rsaS]! 


.’WoKA (IV* 


rori 


t TnzBnmiH , 
Sltsici^ JOVIMAA 


15 


epitome of current medical literature. 


Medicine. 


83. Pulmonary Tuboroulosls na a Sequel to Pleurisy. 
O.ScnnKii(iVor«/; Mag.f, Ltugcvidaisl:., Novombor-Decouihcr, 
l?d7, p. 913| lull iuvc.stigatod tlio subsequont fato of patients 
snfferlDg from pleurisj', uitli spcoi.nl rcforonco to the develop- 
Bent of tuberculosis. For the sake of comparison ho quotes 
the Swedish statistics of KOstcr and Allard, whoso 514 eases 
of primary pleuristy, were observed for one to twenty-eight 
years after the pleurisy. They found that 47.7 per cent, 
subsequently developed tuhoroulosis, and that 22.4 per cent, 
died of it, most of tlio cases of tuberculosis dovoloping within 
the first Dvo years after tho pleurisy. Schcol’s eases of 
pleurisy were treated at the TTlIovaal Hospital in Oslo in tho 
tea-year period (1916-25). srorothan two-tbirds of tlio total 
ot 956 patients were between the ages of 11 and .10, tho period 
between 16 and 25 being tliat at which the pleurisy was most 
common. In tho spring of 1927 iutomiatlon was obtained as 
to tho subsequent fate ot 812 ot those 956 patients, and It was 
found that ZZA per eent. hail developed tuberculosis, mostly 
of the pulmonary form, and tho mortality was 9.9 per cent. 
Commenting on tho fact that the proportion of post-plcnrlay 
cases of tuberculosis was mncli lower in liis own material 
th.an iir K0stcr’.s, Scbocl suggests that the after-treatment 
which his patients received was bettev. lie found that the 
most daiigerons years after an attach of pleurisy were tho 
first Ibrcc or lour. 

84. Diminished Secretion of Sweat In Heart Failure. 


It has been obsorvcil that when cardiac patients with oedema 
are confined to bcdniul given appropriate treatment increases 
in the Eccrotiou of sweat and ot uriuo otteu run parallel ; tho 
fact that these patients stand beat, wbetber climatic or in 
tto fonu ot physical treatment, badly has also been ascribed 
to inujcrieoi wgulatlon ot body temperature due to defective 
sweat secretion. E. Kauf and E. Zak. (Il'ieii. fcitii. IKoeft., 
AOTemberlOtb, 1927, p. 1405) found Iiy microscopic obsevva- 
uon tbnl in normal persons perceptible droplet secretion ot 
sweat is confined dnring mental and physical rest to a few 
areas, Inclnding tho finger-pads of the terminal phalanges, 

I ^ continuous. In tho other mctliod employed in 
slndjflug the accretion ol sweat tho fingers were pressed for 
two uiinntcs on to filter paper which had previously been 
nnpregnated with 1 per cent, silver nitrate solution and 
uned; the sodium chloride in the sweat droplets couvorted 
lilu ^^0 chloride and showed on exiiosuto to 

nj,iit as a series of blaci; spots. Kepoated observations on a 
°T with canliac disease gave the following 

Muits. In 15 ont of 17 cases witli compensated valvular 
n^* secretion at sweat was normal, while in all 
* valvular lesions with failnro ol comtjensation, 

degeneration, and enlargement of tho liver the 
sweat was much diminlsbtsd or absent; in most 
^ ® persisted even when other symptoms had improved. 
iuiti«t 1 consider that the failnro ot secretion is 

peripheral conditions, sncli as lack ot 
carbon dioxide, or local anaemia, 
heart eh "'“u normal In tbreo cases of congenital 

under *“u'^'red cyanosis, and sweating occurs 

EsuiarMi’ treatment in an arm made anaemic by 
ot Tl'uy conclude that tbo phenomenon 

dosplv sweat secretion in cases ol the type described is 
bv stagnation ol finids in the tissues 

® ^uechanlsm which, has not yet been explained. 


8S. 


C Lirm Malignant Granulomatosis, 

k'o. 6 n (Feu. He 2Iia., 2327, 

lor this “ Hodgkin’s disease ” is a misnomer 

Who -P^uy report the case of a man, aged 23, 

Cachexia “ ^^uciation, extreme pallor, profound 

both ’ n^ii ®“P*>^FaImos, Multiple adenitis was noted 
tupracIaTiriio sides of the neck, in the left 

•uediastimi ^®8'un, and in the groins. Ho exhibited a 
Wlatetal nhiSn'*”"”° prestemal and intercostal pain and 
cud esDeeiait^ puronssion over the entire thorax, 
spleen and* liver'Xl sternum, being very painful. The 

Uonaal. Diffnon other organs were 

the BUDraorhitoi S" , *®“clnating headache, most marked in 
» Jencoevtosii ^ present. The blood showed 

pleural and cornpleto absence ot eosinophils, tbo 

Second of three a lymphocytosis, while the 

syphiutip tests was positive. Prnritns 

yrmuuo stigmata were absent. In spite of treatment 


tho patient died tv/ 0 ‘ months later, and at the necropsy 
a soft white mass, which had eroded the first cartilage and 
the second rib, was found at tho first right intercostal space. 
Thelivor, spleen, and ganglia were enlarged. Microscopically 
the ganglia showed a marked development of fibrous con- 
nective tissue in which were nnmerons new blood ves'-els. 
Eosinophils wore very rave, but many giant ceils ot Sternberg, 
a histological characteristic 01 this disease, were seen, some 
showing karyokinesis. Tho liver revealed a cirrhosis marked 
by a very rich vascnlarizatioh, and a lymphocytic granulo- 
matons infiltration. The new blood vessels were gorged with 
red cells, cansing minute haemorrhages. In an ahdomiual 
metastatic nodnio many colls of Sternberg were seen. The 
authors remark that the absence of pruritus, and of eosino- 
phils in the blood, two symptom.s of great diagnastio value, 
Is not exceptional, and that variations in the Wassermann 
reaction are found also in other diseases. They believe that 
inflammation plays an important part in the genesis of this 
malady, bnt that its malignant character is necessarily due 
to tho development of malignancy of the sarcouiatons order. 
Tho oroaSon of the sternniu, the great lotination ot new biood 
vessels, tlio karyokinesis in the Sternberg’s cells, and the 
microscopic embolisms, arestrong arguments in favonrof this 
theory, which is widely held. 

86. Diphthepfa. in Chicago. 

H. N. BtJNDESEM (Public Health lleports, October 7th, 1927, 
p. 2447) states that during the first seven months of 1927 the 
nnmhcr of cases ot diphtheria in Chicago was greater by 50 
percent, than that recorded fertile corresponding months of 
1926; the death rata also was nearly doubled, partly in con- 
sequence of a corresponding increase in morbidity, but the 
major factor was a marked rise In the case fatality rate of 
•the disctisc— namely, 12.8 per cent, dnring the first seven 
nionlhs, ns compared with 7.4 tier cent, in 1926 and 8 per cent, 
in 1925. Clinically the type of diphtheria in Chicago, as in 
Germany, was more iiialiguant than for several years past. 
j?ho .severe toxic and septic cases often failed to respond to 
treatment, oven when antitoxin was given early and in 
nsually adequate doses. The greater prevalence of diph- 
theria in Chicago dnring 1927 was not due to infection by 
milk, food, or epidemic loci, but represented a generalized 
increase in the endemic rise. 


Surgery, 


87. Spontaneous Amputation of Appendix. 

B. d. Kibkwood (JSosion iled. ami Surg, Jonm,, November 
24tb, 1927, p. 982) descilbes a case of spontaneons amputa- 
tion of the appendix in a woman, aged 58, who was 
admitted to hospital with. a diagnosis of chronic appendicitis. 
For some years she had had pain in the right iliac region of 
a mild character, with some nausea; abont fonr weeks before 
admission there had been a more severe attack. Deep 
palpation showed some tenderness bnt no spasm; and the 
patient was constipated ; while under observation for four 
days the temperature never rose above 99.5’, and thfe blood 
and mine showed no abnormality. At the patient’s request 
an operation was nndertaken. The caecnm was found free 
and there were no adhesions.- The appendix, which was 
2 cm. long, was found lying entirely free from any connexion 
with the caecum. It was slightly injected, closed at both 
ends, and attached by a mesentery. The pathological report 
showed a ebrouio and healing appendicitis. Convalescence 
was rapid and without incident. 

88. Surgical Treatment of Pruritus Ani. 

C. B. CORLETTE (Med. Journ. Of Australia, October 22nd, 1927, 
p. 580), reasoning from the success following division of the 
nerve sniiply in faTitable nicer of the leg, adopted a similar 
procedure in cases ol pruritus ani, -with resulting cure of 
the condition. Under local anaesthesia by infiltration with 
novocain and adrenaline of the anns and surrounding skin 
for two and a half inches a straight bistoury is inserted pain- 
lessly at fonr spots far enough from the anus to avoid 
'infection ; two of these are lateral, one is behind, and one in 
front of the anns ; the point of the knife is directed np to and 
beneath the anal margin, underoatting without perforating 
tho skin around the anns so as to sever the nerve filaments 
passing towards the skin from the subentaneons tissue. By 
inserting the knife at all four points it is possible by a 

164 A 



16 JAS. 28, 1928] EPITOME OP CUKEENT MEDiqAE EITEEATUEE.’ 


Tms finmn 
Medical JontxAL 


8^Yeel)iu^ movement to separate completely the skin near the 
nnus from the underlying fat. It is not necessary or advisable 
to separate the skin out to the circumference In which the 
points of insertion lie; all that is needed is that the anal margin 
shall be undercut, the punctures boing effectively sealed with 
collodionized gauze. Corlette claims that this method is less 
severe tlian the other open operations described and which 
are more liable to infection. Where the area of pruritus is 
extensive lio advises a series of opei-ations so that the field 
should be undercut piecemeal, area after area being treated 
at intervals of about a fortnight. He emphasizes the Impor- 
tance of getting the knife beneath the area at the orifice of 
(he anus, and advocates a second attempt If the first Is not 
completely successful. 

89. Closure of Bladder following Prostatectomy. 

W. E. Lower [Joui-n. Amer. Med. Assoc., September 3rd, 1927, 
p. 749) gives a preliminary report of his experience of fifty 
prostatectomies, in most of which the bladder was closed 
at the time of operation, a rubber tube being inserted 
Buprapubically for a few days in the remainder. With a 
catheter in the urethra a dot-and-dash catgut (No, 0) suture 
is passed from the bottom of the cavity from which the 
prostate has been removed and along its walls on each side 
up througli and including a small margin of mucous mem- 
brane, bringing the walls into apposition, the suture being 
inserted above and below the catheter. The catgut is cut 
short and the mucous membrane trimmed to facilitate healing. 
A good sized catheter wilh two eyes should be used, aud any 
spurting vessels are tied before the sutures are closed. By 
this means, it is claimed, haemorrhage can be absolutely 
controlled. The cut edges of the bladder are sutured, care 
being taken that there is no protrusion of the mucous mem- 
brane, and a rubber cigarette drain is placed in the space of 
Betzius. The danger of stricture at the vesical nock may bo 
obviated by dilatations for a short time, and the use of too 
heavj' catgut, especially chromic, should be avoided, since 
the knots may form a nucleus for the formation of stones. 
Lower claims that with this technique convalescence is 
shortened and the incidence of fistula reduced to a minimum, 

00. Cancer in the Young. 

G. Guldberg {Norsk Mag, f, Laegevidensk., November- 
December, 1927, ji. 1131) states that during' (he period of 
twelve years specimens of 4,612 oases of cancer have been 
collected at the patiiologioal institute attached to Oslo 
University ; 157 of these specimens were taken from persons 
between birth and the age of 30, 112 being female aud 
45 male, and 11 children under 15 years of ago. The disease 
occurred most frequently in the female genitalia, which 
supplied 53 oases ; next came the digestive organs (24 cases), 
the skin (19;, testis (9), nose and its accessory sinuses, larynx, 
and ear (9), buccal cavity (6), appendix (10), and other situa- 
tions, as well as recurrences aud me'tastases (25 cases)) There 
were two cases of carcinoma of the oesophagus, in men aged 
20 and 28 respectively ; as the second patient had drunk lye 
at the age of 5 or 6 his case was probably one of cancer 
developiug in soar tissue caused by the lye twenty-two years 
previously. The ten cases of gastric cancer included one of 
adenocarcinoma in a man, aged 21, in whom the disease had 
a rapid course terminating fatally in twelve weeks. The 
necropsy showed cancer of the pylorus with extensive meta- 
. Stases in peritonenin and liver. The eleven cases of intes- 
tinal cancer included one of carcinoma of the ileum In a 
• girl aged. 18, and three cases of carcinoma of the caecum 
associated with caecal tuberculosis. The cutaneous cases, 
.which included one of carcinoma of the leg in a boy aged 12, 
following, neurodermatilis of many years’ duration, showed 
that the skin in childhood and youth does not remain 
unaffected by irritants which have a caroinogenous effect in 
later life. 

ai. Sympathectomy In Angina Pectoris, 

D. DaniElopolu (Bnixelles-Medical, November 13th, 1927, 
p. 33) asks why permanent lesions such as disease of the 
coronary arteries should give rise at times, though not 
invariably, to spasmodic anginal attacks, which may occur 
in the absence of coronary disease. Huchard collected no 
fewer than eighty hypotheses to account for the pain which 
Dauifilopolu attributes to myocardial fatigue and pressor 
reflex. Elimination of the pressor reflex by section of the 
sympatliotio cures the angina. The operation recommended 
by Danielopolu has now been employed several times success- 
fully, and, unlike other surgical procedures for the cure of 
this complaint, is not fatal. Usually it is performed on the' 
left side of the neck, and in two stages If required,' but 
often a further operation is not necessary. Under the term 
“pressor reflex” the author includes raised blood pressure, 
increased cardiac force and pulse rate, aud probable vaso- 
constriction of the coronary arteries. The aim of the opera- 
I6^ B 


tlon is not so much the relief of the pain as the prevention 
of the conduction of the pressor reflexes along the cardlo- 
aortic nerve fibres ; the centrifugal nerve fibres of the heart 
are untouched. In the -first operation the • cervical sym- 
pathetic is cut above the Interior cervical ganglion, the 
vertebral nerve, and the branches of the cervical vagus 
entering the thorax. After the operation the attacks cease, 
recur a little later owing to cicatricial irritation, and then 
gradually diminish. So far death has not .followed this 
operation. 


BZ. Diverticulitis.' 

A. Cannon (The Cadueeiis, July, 1927) cites a reference to 
Telling’s disease (Journal, 1927, vol. i, p. 344) and suggests 
a scheme to link - the anatomy of the condition with the 
pathology and clinical manifestations. He describes four 
clinical groups— uamelj', inflammatory, obstructive, fistulous, 
and pelvic — and emphasizes the importance.of a radiological 
examination to distinguish it from suoli conditions as car- 
cinoma, sigmoiditis, hyperplastic tuberculosis, syphilis, and 
pelvic conditions, particularly, in the female. Ho appends 
notes on twelve clinical cases collected from the literature 
and supplies a bibliography of 349 reforonces. 


iTherapeutics. 


93 . r The Use of Iodine In Thyroid Disease. 

C. G. Hetd (Boston Med. and Surg. Joitrn., December 8th, 
1927, p. 1075) dlstingnlshes three typos of thyroid disease : 
one characterized by an increase of secretion with varying 
clinical reactions, the so-called toxic adenoma ; one by a 
change in the character of the secretion and representing 
a dystunotlon with hyperthyroidism, the so-called Graves’s 
disease; and the third by a decrease of secretion, the so- 
called colloid goitre or myxoedema. Thyroxine, discovered 
and isolated by Kendall, contains 65 per cent, of iodine, and 
every cell In the body requires it In order to function properly. 
'The thyroid gland must obtain 22/100 mg. of iodine per day, 
and all thyroid activity is dependent upon the amount ,oI 
Iodine present in the gland, the bloo.l stream, and in the bodji 
fisstics. Thyroxine is manufactured In the cells of the acini, 
and any excess over the physiological requirement is stored 
in the colloid material. If the colls fall to elaborate this 
substance in snfflolent amount, the colloid begins to lose its 
thyroxinoand to contain less and less iodine. If more thyroxine 
is elaborated than is necessary, the excess passes into the 
blood stream and the colloid material is partially or wholly 
unable to storo iodine. After discussing the various condi- 
tions of hyper- and hypo-thyroidism, Heyd asserts that 
iodine is pre-eminently useful in goitre prophylaxis, and that 
it is immaterial how it is administered or in what form, pro- 
viding that the dose is small and the treatment Intermittent. 
It is useful in stabilizing function in colloid goitre, but care 
should be taken to eliminate adenoma', which is infrequent 
before the age of 20. It is distinctly indicated as a preventive 
measure, either in or out of regions of high goitre incidence, 
during pregnancy and lactation, and the menopause ; for a 
short period of time, but without n gap, as a pro-operative 
measure in Graves’s disease ; and ns a postroperative measure 
after all types of goitre operations) Its value in adenomata 
is variable, biit there is the deflhite danger of causing hype^ 
thyroidism in non-toxic adenomatous goitres. lYhen used 
outside of these restricted indications, there is a risk of pro- 
"ducirig ah iodine hyperthyroidism which is fixed, progressive, 
and dangerous) 


94. F. SCHtJRBR-'WAiiDHElM and F. WiNDHOLZ (Beut. Zeit, 
f. Cliir., December, 1927, p. HI) record their observations on 
18 cases of Graves’s disease, 17 of which wore in women and 
one la a man, who were treated with iodine in the Inrm ol 
Lugol’s solution in doses of 10 drops two or three times a day. 
In every case a remission of the symptoms occurred, as shown 
by disappearance of palpitation, restlessness, . sweating. 

tremors, and diarrhoea. The goitre became harder and .the 
pulse Blower. Operation, which consisted in extensive 
bilateral resection of the thyroid, was well borne, and there 
was no post-operative shock when administration of ? 

solution was continued for six or seven days. Histological 
examination also showed that the morphological 
of the thyroid was affected by administration of iodine, -i-ne 
state of the goitre after iodine treatment was found to depenn 
principally on its original condition ; the change was msc 
shown by hyperplastic forms being replaced by an inaocivo 
parenchymatous or colloid goitre.- Atrophy and sev 
degenerative changes in the epithelium also 
place of the watery colloid a thick colloid aPPe^’‘®^^'‘",‘“ * 
a drying up of secretion. Infiltration of lymphocytes was 



iS, ig as]- 


of c&ikekt MEmdAL litefatuee. . 


r The UniTisa 
L ilEtrcAi. Jocb:cai, 


17 


mot wllU iu councxiou wUli.Uio alroiiliic and tlogoucmtcfl 
colls. No illrect vcUitioii, howcvcf, couW bo touml bcUvceu 
tUo iiogi'co ol inorphological changes ami the clinical condition 
iu tho glands treated nith Iodine. 

■ 95. Synthalln Treatment of Diabetes inXhlldrcn. 

B. IIlItSCH-lCAUrF.MANN and a. IlEnM.tXX-Tl!OSIBN (Jahrll. f. 
KimtohcUl;., November, 1927, p. ^7), ns the result of their 
observations on diabetes in children treated with syu- 
tbalin, come to the following conclusions. (1) A course of 
synthalin most bo started with tho smallest doses pos- 
sible; cholagogno drugs should ho given at tho same time as 
synthalin so as to prevent occurrence of unpleasant symptoms 
such as abdominal pain, vomiting, and diarrhoea. (2) Tho 
interval of twenty-four to thirty-six hours between the dosos 
regnired by Frnnl: mav be reduced to sixteen hours without 
any bad cticots. (3) Xlicrc is no hard-and-fast lino between 
an cttcctive and a toxic dose, but not moro than 1.5 mg. of 
synthalin per liilo of body weight should.be given. (4) Tho 
etlcct ot synthalin treatment is much slower in children 
than in adults. The omission of insulin treatment, thore- 
fore, should not begin until the second course. (5) Glycosuria 
and glycaomia arc distinctly diminished by tho treatment. 
(B) A combination ot insu.in and synthalin treatment leads to 
a considerable reduction in the amount of insulin required. 
(7) Syntlialin treatment Is contraindicated in coma and tho 
precomntosc stage, as well as In very young children and 
those cousidcrahly midcr weight. 

9S. Calcium Therapy In Functional Nervous Disorders. 

C. C. Gault (.liinnrso/fi ited., Docomher, 1927, p. 759), 
' recognizing the. shnllarity betrveen animals during calcium 
Starvation and patients s'uftering from the less severe func- 
tional nervous disorders, and arguing timt such symptoms 
might bo. tho expression ot a disturbed hationie ratio 
resulting in general cellular Irritability, and a lowered 
calcium retention, treated eighteen patients witli calcium 
' tor Irom threo to six' months.- After a thorough iiliysicnl 
oxamiuation to cxclndo tho presence ot organic disease 
each patient was given orally the equivalent of 20 grains 
of calcium lactate four limes daily, nu intravenous injec- 
tion ot calcium chloride to ono patient being disoontJuucu as 
being no moro boncllcial than when tho calcium was given 
by the mouth. Tho results were quite uniform, as within 
twenty-four to forty-oiglit hours a sonsatiou of mental 
and physical well-being was exporionced, and all feelings 
of fatigue, nervonsness, and apprcUcusion disappeared. 
Appetite and sloop also improved, and fonr p.atleuts had 
no rcciuTcncc ot tho dull occipital lieadaclios Irom which 
they had frequently snffored. Gault considers that this 
senes of cases shows the probability of a direct relationship 
between fimotionalncrvousdiaordors and calcium metabolism, 
"“i®h may be of value in dealing with the milder ncnrose.s. 


Neurology and Psychology. 


of ono of these centres will result in the limb performing 
the .opposite action. Tims in tho case of irritation ot tho 
adductor Centro of tlio forearm, the forefinger will he brought 
hack abducted from tlie elbow ; if tho lesion is a pai’alytic 
one — for example, ot tlio adductor centre — llic iiaticnt is 
unable voluntarily to adduct his forearm, evenwheu electrical 
stimulation is applied to tlio muscles. Barre, without iui- 
piignitig these results, nevertheless considers the test un- 
TelSablo. lie states that it is often fonudposiUve in vestibular 
disease, and, ns many cerebellar affoctious exhibit only 
vestibular symptoms, the test may fail just wlien it Is most 
needed. In cases, therefore, wlieii the labyrinthine syndrome 
(nystagmus towards the side opposite to lliat iu which 
deviation of the trunk and limb.s is observed) is altered in 
any way — as, for cxamide, by the direction of deviation of 
the limbs — cerebellar disease may be at once snspected, but 
a positive Biirauy’s sign should not be alio-wed to excludo 
the possibility of a irare vestibular condition. 

M. Hemiplegia Associated -with Extensive Naevus • ■ 
and Mental Defect. 

T.' BnUSIiriCLD and W. Wfatt {Hrit. Jouiti. Child. Bis., 
.Tnly-Soptcmbcr, 1927, p. 209), who had previonsly reported 
three cases of a syndrome comprising hemiplegia, extensive 
cutaneous naovns, and mental defect (see Epitome, August 
27th, 1927, para. 178), report a fonrth case in a male patient 
aged 17 years 8 montlis. The patient -was a low-grade 
imbecile who from birth bad presented naevus markings 
involving tho right side of the face, right arm, chest and back, 
both legs and penis, leaving tho abdomen free. The bnccal 
mneons membrane was also involved. He could -walk and 
vnn, but tho loft leg had a tendency to drag, and the right- 
arm was paralysed and spastic. Only three similar cases, 
reported by E. A. Coclca-yne, F. Parkes Weber, and D. H. 
Greig respectively, are on record. 

too. Shyness and Schizophrenia. 

F. .A. Hampton [Jouru. Seuiol. and'Fsychopat'n., October, 
1927, p. 124) discusses the similarities and differences between 
shyness and scltizopbrcnin, and suggests that in the former 
a normal instinct of self-assertion is inhibited by an abnor- 
mally active instinct of submission. In the schizophrenic 
tho morbidly active instinct ot self-assertion dominates the 
personality," but is iuliibitcd, except in tho later stages, by 
a normal instinct of snbmi.ssion. Hampton regards tho shy 
person in gonerni as suffering from a conflict between an urge 
to voacli upwards to tlie normal ievel from the position of 
imagined inforioiity and a deterrent fear of failnre. He 
discusses this feeling of inferiority and also the general 
phenomena of shyness, and adds that here, as in other 
neuroses, the symptoms may represent tho deformed fnlfll- 
ment of a repressed wish. He agrees that .suggestion, if care- 
fully used, may benefit a shy patient, bnb insists that a 
moro satisfactory method of treatment is to help him to 
recognize the source of the feeling of inferiority^, and so to 
deal witli it effectively. 


Syndrome of the Corpora Quadri^emlna. 

' • li. Castex and A. F. CAMAUiiB {Rev. oto-nciiro-o/lalmol, ti 
September, 1927, p. 121), who record four 
Mses — in a man aged 53, a girl aged 12, a woman 
nnl , aged 24 respectively— state that this is 

onlv eondition, as 3’aiobra in 1909 could find 

mroi record. The symptoms arc as follows; 

, epward movement of tho eyes; amblyopia; 
nen.^y Pf .“e-5, which are usually symmetrical hut may be 
’ Pepil'ary changes, of which absolute lack ol 
tnrhpn stimuli is tho most frequent ; auditory dis- 
e >. cerebellar clianges, shown by disturbanco ol 
and t^'^^ftyPbasia ; and, lastly, headache, vomiting, 

the « ^y'eptonis due to cranial hypertension. In 

of cpi-Pi ^ I autiiors' cases the necropsy sliowed an area 
and ern ^ softening in the region ot the corpora quadrigemina 
iu tlip on substance siirioimding tlie aqueduct of Sylvius, and 
found third cases a small round-celled glioma was 

necropsy situation. The fourth case did not come tc 

93. 

j , . Cerebellar Localization, 

the valnr;rf\-^"’‘"' October 8th, 1927, p. 265) discusses 
disease index-finger test in suspected cerebellai 

hisanuand L oRr,!® performed by placing the patient with 
bis on a level with his shoulder: 

>s then against that ot the observer, and he 

Mm to tWo" oye.s closed, to raise and lower his 

the original times, coming back each time tc 

observpd^° cerebellar lesions certain effects 

has, for eapi,‘c„i„ that the cerebellar cortex 

the four chipt^ ''“•b, four centres, representing 

threcnons ot movement, an irrit-Mve lesion 


Obstetrics and Gynaecology. 

101. Pregnancy Complicated by Diabetes, 

ACCOUDING to H. P. A. Sjut {Nedcrl. I'ijdschr. v. Geneesh., 
November 26th, 1927, p. 2226) the association of diabetes 
mellilus with pregnancy is so rare tlint the earlier writers 
thought that conception could not occur in women suffering 
from diabetes mellitus.. This view was subsequently shown 
to be incorrect, as about 5 per cent, ot diabetic women 
become pregnant. The chance ot fertilization is only .slight, 
iuasmnch as diabetes does not usually occur in yonng persons 
and women with diabetes nsnally suffer Irom genital atrophy 
and inflammatory processes, such as vulvitis; vaginitis 
cervical catarrh, and endometritis. There is only a com- 
paratively small number ot cases ot pregnancy in diabetes 
on record. Offevgeld, iu 1908, -was able to collect only litty- 
eight examples, some of which did not have true diabetes. 
Veil Noorden saw 9 cases ot pregnancy among 240 women 
between 20 and 40, and Rosenberg had 7 cases among 111 
patients. According to Offergeld, 50 per cent, of diabetic 
women who become pregnant die wlthm two years of 
delivery. It is important, however, in the case of pregnant 
women with glycosuria to determine whether diabetes is 
really the cause, and an estimation of the blood sugar content 
is indispensable for this purpose. Smit regards it as reason- 
able to suppose that the proguo.sis is not so unfavourable 
under an appropriate treatment including insulin. Induc- 
tion ot abortion, therefore, is not justified, especially as the 
dangers of this procedure are much greater in a diabetic than 
in a normal woman. It is also possible that the current 
views regarding the prohibition of breast-feeding for diabetic' 
women should be changed. 


164 0 



18 tan . 28, 1928] 


EPITOME OE CEKKENT MEDIoSi ‘rilTERATUEE.' 


. -S-f. TnxUnmrt 
LltrufCALJocayir 


102. Detachment of the Normally Situated Placenta. 

G. Guicciaedi {lliv. d’Osiet. e Ginecol. Prat., November, 1927, 
p. 421) aesoribes a series of 22 cases of aelachmont of tho 
normally situated placenta (accidental Iiaemorrhage), in all 
but three of ■wbicli tho urine contained albumin. Of the 
three exceptional cases, in one there tvas a clear history of 
accident preceding the haemorrhage, and in one grave bleed- 
ing followed immediately spontaneous rupture of a hydram- 
niotic membrane-sac. The series contained two primiparao 
only, and no more than live patients were leas than 30 years 
old. There were four maternal deaths, one before and three 
within a few hours after delivery ; in all the necropsy showed 
unusual softness of the uterine wall and an inllltration of 
the myometrium with blood, which extended as far as the 
peritoneum, and was most marked in tho none of placental 
attachment. Seven foetuses survived. Labour was com- 
pleted eight times by accouchement forefi, twice by forceps 
delivery, eight times by podalic version and extraction, and 
three times by craniotomy of a dead foetus ; one patient died 
undelivered, Gnlcoiardi thinks, nevertheless, that in the 
grave cases coellotomy with subtotal hystereotoray or Porro’s 
operation Is the only means of saving tho raoihor's life; 
careful routine examination of the urine during pregnancy, 
early diagnosis, and early admission to hospital will improve 
the prognosis. The loss of life is ultimately caused loss by 
the haemorrhage than by the underlying pregnancy toxicosis. 
In treatment it is wrong, except where the os is fully dilated, 
to rupture the membranes, rvhich, by diminishing the Intra- 
amnlotic pressure, may increase the tendency to bleeding. 
Injections of pituitary extract or ergot, or gauze plugging 
before delivery, also favour haemorrhage, and are contra- 
indicated ; morphine and chloral hydrate, on tho contrary, 
aie called for in some cases. It Is recommended that the 
uterus and vagina be plugged with gauze after delivery, 
however effected. 

103. Treatment of Retained Products of Conception. 

J. L. WODON (lirtixelles- Medical, November 27th, 1927, p. 103) 
bases bis treatment of retention of placental or membranous 
fragments on the three following assumptions, which he 
regards as proved. (1) From the fifth day of tlie puerporium 
the uterine cavity is invaded by vaginal organisms, including, 
in 38 per cent, of oases, strepto.ocoi. (2) The presence of 
placental remains is, even in intro, an encouragement to 
bacterial growth. (3) So long as any part of the utero- 
placental circulation remains behind, direct invasion of the 
maternal blood by intrauterine organisms is possible. Having 
emphasized the Importance of careful examination of the 
placenta after delivery, the author recommends tho following 
procedures. When fragments of momhranes are retained 
immediate Injections of eigotine or pituitrin (preferably the 
latter) should in most cases cause expulsion in two or throe 
days. It they are not extruded, curetting should bo per- 
formed before the fifth day in afebrile cases, but in febrile 
oases intrauterine douches should be begun early and con- 
linued till the sixth day. With retention of a cotyledon after 
instrumental delivery, manual removal should be pertormed- 
at once under strict conditions of asepsis. If the delivery 
has been natural, the uterus should be curetted between the 
third aud fifth day if expulsion has not occurred. It there is 
Elevation of temperature or pulse, curetting should bo per- 
formed at once. The author recommends the use of a cutting 
curette of large dlatneter, always gently manipulated so that 
no intrauterine grating sound is produced. Ho considers that 
the blunt curette commonly used cannot be relied on for the 
removal of small fragments, especially if there has been any 
endometrial infiammation. 


Pathology. 

104. B. paratyphosns A Isolated from a FI^. 

L. Broudin (C. B. Soc. de Biologie, December 16th,’ 1927, 
p. 1589) examined a pig that had died after an Illness lasting 
one week and characterized by haemorrhagic diarrhoea. The 
main features at necropsy were broncho-pneumonia, necrosis 
of the liver, congestion of the intestine, and small ulcers in 
the caecum. Cultures from the bone marrow produced a 
coliforra organism which gave the cultural, biochemical, and 
serological reactions of B. paratt/phosus A. Injected sub- 
cutaneously in a dose of 4 c.cm. of a twenty-four-hours' broth 
culture it killed a wild boar in six days, after an illness 
marked by severe fever. In a dose of 1 c.cm. it killed a 
young pig in eleven days ; this animal likewise developed 
hi"h fever. From the bone marrow of both animals an 
or“anism was recovered similar to that injected, except that 
the agglutination titre was lower. Six months after its 
isolation it had become avirulent for. young pigs, except in a 
dose of 20 c.cm., and its agglutination titre with a specific 
J5, parati/phosus A serum had sunk even lower. 


105. Tho Comparative Value of Renal Function Tests. 

To dotormino tho most roliable of tho renal function tests in 
common use B. D. Bowen (Amer. Journ. Med. Set,, December, 
1927, p. 769) made a study of fifty-two mild or suspected 
nophritlcs, employing in cachTbo following determinations: 
.the relation of tho day and night urino volume aud specific 
gravity, the blood urea nitrogen content, the phonolsulphone- 
phthaloin excretion, the urea concentration tost (Maclean), 
tho urea .concentration index (J. F. McIntosh), and a modifica- 
tion of tho urea concentration factor (Harrison). Patients 
having albumiunrln, with or without c.asts, arterial hyper- 
tension, or oedema, were chosen ; many suffered from diabetes 
also. Cases of renal lesions with functional impairment were 
purposely avoided. Bowen discusses tho work and conclu- 
sions of many experiraontors, and describes his own tech- 
nique. His experiments showed that all tests were satis- 
factory, thongli some wore more delicate and uniformly 
reliable than others. He believes that tests to determine 
tho concentrating power of tho kidney should be employed in 
all routine worlt. 'The urea tests corresponded bettor with 
the day-night urine volume ratio and specific gravity than 
.with the phenolsulphoncphtbalcin tost or determination of 
tho blood urea-nitrogen, though tho last two are useful for 
rapid diagnosis. Pheuolsulphonophthalein tests are 'seem- 
ingly normal in about 50 per cent., and too low in 40 per cent. 
The urea concentration index (McIntosh) is a fairly depend- 
able criterion. 'The author agrees with Maclean that any 
concentration of urea in the urine (second hour) that is below 
2 per cent, is evidence of kidney Insulllcloucy, and if the 
concentration exceeds 2.5 per cent, renal fniictlon is fairly 
efficient. 'The day-night urino volume ratio and the urea 
concentration tost (Maclean) give a satisfactor'y estimation 
of renal function, but tho blood uric acid test is valueless. 

106. Berological Classlflcatlon of Bacilli Isolated from 

Rhlnoscleroma. 

H. MeiseIj nml E. Mikulaszbk {€/ 72. Soc, He Biologie^ 
December 2ml, 1927, p. 1495) Imvo isolated bacilli of the 
Fdodluudor tj'po from 77 per cent, of patients suffering from 
rhlnoscleroma. Hlgh-titro agglntlnating serums Avere pre- 
pared by tlie injection of rabbits wiih strains Avhlch hnd lost 
tholr capsules as the result of prolonged cultivation. Cross- 
agglutination nnd absorption tests were made, using non- 
capsulated bacilli as aniigeus. B3’ this means it was found 
2>o.sslb}o to cJas.sif}^ the organisms into three types; other 
strains of Friedhiuder's bacillus isolated from jioii-rhino- 
sclcroraatous conditions provided four further types. Those 
results were conllrracd by tho complement fixation test 
(Ibid., p. 1498), ^7Ilich apparently cau be used with both 
capsulatcd and nou-cap^iulated strains. Of the strains 
isolated from patients with rhlnoscleroma 64 per cent, fell 
into T^'pe A, and gave similar biochemical reactions. 

107. Tho Surface Tension of the Blood Plasma In 

Scarlet Paver. 

AccoRDiNa to P. v. Kiss {JahrJ}, f. Kind^rh^Ulc., January, 
1928, p. 381), Traube and his collaborators, followed by 
Ehrlich and Bechold and Berezelier aud Het§uyi, have shown 
that an increase in the activity of toxins and bactericidal 
substances was usually accompanied by a diminution in the 
surface tension of their solutions. These results prompted 
the present author to investigate whether and in what degree 
the surface tension of the blood plasma was affected m scarlet 
fever. As tho result of tho examination of fifteen cases of 
scarlet fever in children, ton of which were uncompHcated 
while five had various complications, he came to the follow- 
ing conclusions t (1) In childhood the surface tension of tii 
plasma shows more or less of a fall in the first week of 
fever. (2) lu cises in which there is an uucompheatea 
recovery this fall of tension gradually disappears, and m 
a large percentago of the cases the normal value is rostor 
on complete recovery from the attack. (3) If a complication 

occurs, and often before it has actually 
a fresh fall in the surface tension. (4) The fall of tension 
occurs at the same time as the rise in the fibrinogen value. 

108. The Existence of Tlelioidosis In Cochin China. 

B. PONS (Ann. de VInst Pasteur, December, 1927, P- 1338) 
records two cases of melioidosis in Cochin China. _ 

first case he succeeded in obtaining a positive blood out • 
The causative organism of tho disease, first describe y 
'Whitmore, nnd later named B. whitmori by Stanton anu 

Fletcher, is a slightly motile bacillus closely resembUn^. am 

glanders bacillus. lu man it gives rise to a disease 
may simulate either cholera or typhoid fever, ov may 
a chronic suppurating type. It is probable that the disea 
is endemic in rats, and that man contracts infection by o 
or cutaneous contamination with tho faeces of these aniraa . 
The author draws attention to the resemblance of „ 

to n.pgocgaueus, and suggests that it is intermediate between 
this organism and B, malleu 


PEB. 4, I9*SJ 


1. Uxst^ Jecsuii 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

Epidemic Encephalitis. 

T. 1’. Sprunt (.Inter. Joiirn. Med. .'tci., November, 1927, p. 660) 
ili'seusses a series ot 50 cases ot opiclfiiilc encephalitis. There 
■was lie ilellnlio evlOenco ot n constitutional predisposition to 
nervous disease, os In only seven cases was tliere a history 
ot nervous taint in the tamily. Tlio ados ot tlio patients 
ranged irom 12 to 69, the great majority falling within the 
third, fourth, and lltth decades. In the early stage the 
diagnosis was often dilTlcuit or impossible. The symptoms 
ot onset -wero, In oidcr of frequency, fever, diplopia, aotuuo- 
lonce, insomnia, delirium, and ptoai.s. There was a great 
predominnueb of motor over sensory Bymptoms, ns aho'wn by 
the fact that “18 had KOtiie form of motor disiurhaiice, as com- 
pared with only 15 with any ovidonco of sousbry disturbance. 
Exaniination of the corobro-spinal fluid was useful In ex- 
clndlng other dlsenso of the nervous Kystem. Tho pressure 
was normal in 18, increased in 6, and diminished in 5. There 
was a pleocytosis of ten cells or more per cubic millimetre 
in only 4 cases. Tho ninoimt of globulin was more or less 
increased in 13. and in 10 out of 11 cases examined tho sugar 
values were 70 mg. or more per 100 c.cm. Thoro were few 
marked disturbances of tho autonomic nervous system. 
Mydiiasis was noted in 19 and sinlocriioe.a in 10. Tho basal 
metabolic rate was not sigmllcautly changed, and tho blood 
as a rule was normal. As regards prognosis, the probability 
ot the dcvelopinctit of Pnrkiusonism varies with the severity 
ot tho syinpioms ot onset; in tho case of those with a severe 
onset 77 percent, developed this syudronio, with a moderate 
onset 57 per cent., and with a mild onset only 28 per cent. 
Of 35 patients who .wore followed up 12 were able to work, 
22 became chronlo. Invalids, nud one committed suicide. 
Treatment consisted in rest, freedom from too much 
respouslhllity, psychotherapy, dietetic and hygienic regimen, 
mechanotherapy and hydrotherapy, and sedative drugs, 
capeoially hyoaotua hydrobcomido In tho Parklnsouian cases. 

110,' Bevaeclnatlon after Subcutaneous Injection. 

■W. KNOEPFj;h.M.\Ci!ER (Il'fctj. Min. IVoch., December 8tb, 
1927, p. 1541) records his observatlous on tho rovaccination of 
six children who had boon vaccinated subcutaneously against 
small-pox from two to live years previously. Two cblldren 
who had been given a 1 in 1,000 dilution ot lymph two and 
three years previously showed typical vaccine lesions after 
entaneons revacclnation. Another three who bad bad the 
characteristic inflltiutlon afrer subcutaneous iujeotlon of 
1 c.ciu. of 1 in 100 dilution did not show any pustule forma- 
““o .oo cutaneous revacclnation tour years later. Tho sixth 
1 • was given a subcutaneous injection of 1 c.om. of 

.1 in 200 dilation of vaccine lymph lu 1919, alsoprovcd immune 
to entaneons Inoculation in 1924. The author concludes, 
tnerefore, tliat subcutaneous Inoculation ot diluted virulent 
^‘''“‘“o'ymphindilntionsotlinlOO, 1 in 200, but not 1 In 
iiwu, confers Immunity on children for some years. 


Heart after Severe Diphtheria. 

1 Q 07 White (Amer. Heart Jonm., December, 

I P" “P) report tho onso of a woman, aged 22, who had 
nns heart-block for uinetetn years after diphtheria, 

itlicd 22, wlio, three weeks after pharyngeal 
nniin I ” complete heart-block, followed by 

In periisted for at least si.x months. 
f)in contradictory concinsions as regards 

1(10 . ‘Ifp'iiheria on the heart the authors investigated 

vp'i.-o severe diphtheria at least five 

‘‘ ^ ’ '^0 were classiiied as “severe,” and 30 as 
’’ ‘f'phthoiia. All had been baclerio- 
the info live to eight years had elapsed since 

recpiro/sc nk/i great majority ot tho severe cases had 
dlnnimoo,, more units of antitoxin. They had been 

a a as bavine <‘ myocarditis,” somo cardiac ab- 


nornnlit.. having lujuuiiLutvis, sumu u.iLaiiae au- 
lnvpoiirt..M„°'^ severe toxic diiihtheria. In the subsequent 
Bkia«rania were taken in all cases, and 

appeared to bo enlarged. No 
disease '"^‘^rvul history suggestive ot organic heart 

aiuinan’p,.°'^ tlierc any symptoms at the time ot ex- 
patients cardiac enlargement was found; only two 

had sliciit ventricular premature beats, but 52 patients 
other tvnr. arrhythmia. No heart-block or 

and no f'lan tlio above was detected, 

heard. The. ml® >m>icative of organic valvular disease were 
mood pressures were within the normal limits. 


One electro-cardiogram showed a doubtful A-'V nodal prema- 
tnro beat and veutrlcnlar escape. Two records showed 
slight (postural) rigiit axis deviation. The authors conclude 
that there Is no evidence that diphtheria has any appreciable 
and lasting effect on the heart. 


112. Parkinsonism Follomlne Typhoid Fever. 

C. G. NagteGAAE (Nedcrl. Tija. v. uenetsfr., November 12th, 
1927, p. 2079,, who records an illustrative case, remarks that, 
with the cxcopiion-Qt encephalitis, all farms ot nervous 
sequels have been described in typhoid fever, including 
nicuingilis and neuritis. On the other hand, most inieCtious 
diseases have been mnutioned in the etiology of encephalitis, 
though typhoid fever has not. Nagtegaal now records the 
case ot a girl, aged 15, who, directly after an attack of 
typhoid rover, the clinical diagnosis of which was coutirmed 
by Iho IVIdal test, developed symptoms of Parkinsonism, 
including tho mask-liko facies, rigidity of the muscles, and 
change of character such as Is met with after lethargica 
encephalitis. 

113. Mumps and Diabetes. 

P. COURONNI (These tie Paris, 1927, No. 313), who records nine 
cases, fonr ot which were fatal, in patients aged from 6 to 42, 
Including those reported by Gilhespy and Holden {-louERAli, 
1917, ii, 115) and Patrick libid., 1924, ii, 802), states that 
mumps is the only infectious disease besides syphilis which 
can give rise to a diabetic syndrome. Moreover, an attack 
ot mumps in a diabolic subject may ca'use grave symptoms 
ot acidosis. It is therefore indispensable, during the course 
ot mumps and in convalescence from the disease, especially 
when there arm signs ot involvement of the pancreas, to 
make a careful examinaiion ot tho urine, so as to employ an 
appropriate diet and insulin treatment at the very onset ot 
the attack of diabetes. 


113, Intra-uretbral Chancre. 

B. Bebhstein (Urol, and Uutan. Hev., November, 1927, p. 715) 
states that this term is applied to chancres whether occurring 
in whole or iu part lu the last half to three-quarters of an 
incli of the lumen of the nretbra. The chancres may involve 
the whole orifice or only a portion of it; they are rarely met 
with below the fossa navicnlaris. They may be seen in full, 
in part, or be entirely bidden from external view. The 
features of an intra-nretbral chancre are as tollows : (1) a 
dirty white slongblng or necrotic centre bordered by the red 
ring seen iu external chancres ; (2) ioduration occurs early 
and is characteristic; i3) a sanions nrethrai discharge in 
which Treponema pallidtim is found; (4) the urethroscope, 
when it can be passed — a matter of difficulty as a rale. on 
account of the pain and obstruction — assists iu the diagnosis ; 
(5) inguinal lymphangitis aud lymphadenitis. ,A pure trepo- 
nemal inlectiou is rare, andjn all Bernstein’s cases infection 
with the gonococcus was present also. The nsnal remedies 
are employed— namely, derivatives ot arsenic, mercury, and 
bismuth. Healing of the chancre may be facilitated by in- 
jecting and washing the sore with a little ot the salvarsan 
solution used for intravenous injection. Dilatation of the 
nretbra sbonld be started early to pi event strictnre. Bern- 
stein adds that many patients with tabes or general paralysis, 
who deny having had syphilis bat admit gonorrhoea, have in 
all probability bad an intra-nretbral chancre. 


Surgery. 

115. The Radical Operation for Gastric and Duodenal 
Ulceration. 

According to M. Feiedemann iZentralbl.f. Chir., Novembei 
26tb, 1927, p. 3015) extensive gastro-duodeual resection foi 
ulceration is less popular now owing to the pain the 
diminished capacity ot the stomacli, and the larger per 
centage ot post-operative complications than was antici 
pated. Friedemaiin finds that the number of definite recur 
rcuces is not excessive. Taking the slatistics ot varion< 
authorities who have kept their patients under observatior 
for three years, the number of patients who were cured com 
pletely varies from 94 to 98 per cent. After short-circuit ins 
the number ot successes was onlv 83.8 per cent Auothei 
author reports that among over 300 patients who' were snh 
mitted to the Billroth I operation thece were only twt 


204 X 



20 TEB. 4 ~, 1928] EPITOME OE CUEEEHT MEDICAL LITEEATDBE. 


[ 


Tni P:arniTi 
McDiciX Jotrsvii 


relapses, possibly due to old ulcers, undetected at the opera- 
tion. In 70 oases o£ the Billroth II- operation, only one 
doubtful jejunal peptic ulcer occurred Bubsequently. Another 
writer records one case of jejnnal peptic ulcer among nearly 
400 cases of Billroth II operation, although those patients 
were under observation for a shorter period. Eriedemann 
received 374 replies from 450 patients, and found that 95.2 per 
cent, -were either entirely or partially relieved, although 1G.3 
per cent, still complained of pain ; 4.8 per cent, of the patients 
were unrelieved. Five patients had large or moderately 
large scar-herniae, and sixteen had small herniae. Friedo- 
mann concludes that after three to six years’ observation of 
a large number of gastro-duodonal resections for ulcorntion 
the results are generally satisfactory and superior to those 
following any other operation. He dismisses the adverse 
criticisms as not justified by the results. 

116. Fractures of the Saernm. 

A. Salotti (Arch, Ital. di Ckir,, October, 1927, p. G33), who 
states that fractures of the sacrum were first described by 
Paul Barbette of Amsterdam in 1680, records two personal 
cases, and lias collected twenty-three eases from the litera- 
ture since 182G In which there was an isolated fracture of the 
sacrum. His conclusions are as follows : Isolated fractures 
of the sacrum are most frequently horizontal, loss frequently 
oblique as in the author's two cases, rarely vortical, and only 
exceptionally comminuted. Horizontal fraotnros aro duo 
either to direct trauma, such as the kick of a horse or a fail 
on the sacrum, or, more frequently. Indirect trauma trans- 
mitted from the coccyx from below upwards. Oblique frac- 
tures may be due to the same causes as horizoutal, and It la 
only the direction of the trauma transmitted from tho coccyx 
that Is to a certain extent oblique. Isolated vertical frac- 
tures are caused only by traction in the combined action of 
a fall on the feet or knees and the pull exorcised by tho 
trunk through the lumbar vertebrae, and are usually situated 
on one wing of the sacrum near the saoro-lliad joint. In 
some cases lateral trauma applied to the pelvis may give rise 
to subluxatlon of the lumbo-sacral joint, thus canslng an 
increase of the lumbo-saotal angle, the dlagtioslB of which 
can be demonstrated radlologicaliy, 

117. Treatment of Mammary Carcinoma. 

In mammary carcinoma, J. GuroT (Gynecol, ct OMtit,, 
November, 1927, p. 401) strongly advocates radiotherapy as a 
sequel to the surgical treatment of cancer of the breast. 
Following the Willy Mayer-Halsted method, ho makes an 
extensive excision of tho breast, aponeuroses, and axillary 
contents. Both pectoral muscles aro removed, tho removal 
of the peotoralis minor being particularly useful, as this dis- 
closes a subclavicular cellular space which coutaius the last 
axillary ganglion. The wound is closed with three silk 
sutures according to Mayo’s technique. When tho wound has 
cicatrized, tr-ray treatment is started, doses of 3 to 5 Holz- 
knecht units per field under a filtration of 3 to 6 mm. of 
aluminium, a spark equivalent of 25 cm.,’ and a skin anti- 
cathode distance of 25 cm. being repeated once a week for 
the first month, twice at fifteen days’ interval during the 
second month, and then once a mouth tor a year. At the end 
of this time further irradiation may be given every three 
months. Cases -which do not benefit from tliis treatment, and 
In which recurrences and metastases are frequent, are those 
of advanced growths, and cancers in young and in syphilitio 
women. Guyot has obtained remarkable results by this 
method, many of his patients surviving for years (two for 
seventeen) after the operation. He adds that the irradiations 
must be non-penetrating and repeated at intervals ; they will 
then cause no ill effects even if the treatment Is continued 
for a long period. Pre-operative irradiation la said to he 
naeless and to aggravate the comlitious ; post-operative high 
tension treatment should also be absolutely rejected. 

US. Tumour of tbe Pancreas Cured by Operation. 

P, Mobna'RD (Bnll, et Mem, Soc. Chir, de Paris, November 4th, 
1927, p. G61) records two cases showing identical conditions 
and diagnosed as tumours of the pancreas at the operation, 
but both of which were cured by a simple cholecyst- 
enterostomy. Twenty-two months had elapsed since opera- 
tion in one case and thirteen months in the other. In these 
cases the symptoms prior to operation were typical of car- 
cinoma, and during several months in which the patients 
were under observation they showed very marked cachexia. 
The nsnal course in cases of caucer of the pancreas is very 
rapid, and after laparotomy death follows in two -or three 
months. In Mornard’s cases the exact nature of the growth 
is unknown, since it was not possible to remove a portion for 
examination owing to the difficulty of dealing with baeinor- 
rha e. It is probable that the tumour was an adenoma or 
a flbro-adenoma. It is unlikely that it was a chronic pan- 
creatitis, since this disease affects the whole glaiid, -while la 

•204 B 

-;,r — 


those oases tho morbid process was localized. It therefora 
appears justifiable, as these canes sliow, to perform cholecyst- 
oiitcrostomy in cases of pancreatic tumour in tlio absenco 
of enlarged glands and molastnscs when tho iialnro of tho 
growth is not Itnown. Even If tlio growth should prove to 
bo malignant tho patient tvould bo benefited and relieved oi 
tho jaundlco. 


Therapeutics. 


110 . Bynthalln Treatment of Diabetes, 

K. Pabise (If Morgagni, Dccombor 4th, 1927, p. 1921) records 
his observations on sixteen cases of diahetos in out-patient 
practice treated by syntUailn ; ton of tliem were mild and 
six of moderate sovority, ■ Two of the latter had previously 
boon treated with Insulin. 'The results of treatment were as 
follows. All tho patients showed a considerable diminution 
of polyuria, but no outstanding cliangcs wore .found in tho 
chemical composition of tho urlno. Thirst was iiinch reduced 
and in some patients entirely disappeared ; hunger -\vas also 
considorably modified by tho syntlialin treatment, and the 
gouoral symptoms. Including a souse of fatigne, underwent 
improvomont. Symptoms of intoleranco wore noliufroqnontly 
observed, especially at tho commcucemcnt of treatment, in 
tlio form of loss of nppotito, n fooling of oppression in tho 
epigastrium, dlarrliooa, and vomiting. I’nriso, like most 
writers, thinks that synthalin cau ho of benefit only in mild 
forms of dinhotes, and only cxcoptionally in cases of moderats 
sovority. It is contraindicated In severe cases becanso the 
largo doses required cannot bo tolerated. In moderate cases 
It can only bo given rvlion tlio patient can take sufflcleutly 
largo doses. Pnriso has obtained good resnlts by tho alternate 
use of synthalin and insulin, tho lattor being substituted 
for a period of ton to fifteen days every thirty to forty days. 
Synthalin is chiefiy indicated in mild cases, as It allows tho 
patient to tako a more liberal diet. Lastly, ho regards it as 
specially suited for out-patient practice, becanso It does not 
require modical supervision, except at tho start. ■ ■ 

120. Parathyroid Extract In Infontllo Tetany. 

D. B. Leitch (Canadian Med. Assoc, .'onrn., November, 1927, 
p. 1321) discusses tlio uso of para-thor-mono (a standardized 
parathyroid extract) in tho treatment of infautile tetany aa 
a moans of raising tho sorum colciiiiii content, which in snon 
cases ranges from 5 to 8 mg. per 100 c.cm., as compared ititu 
10 to 11 mg. per 100 c.cm. in normal blood. The potency of 
this preparation is Indicated in units ns 1/100 of tho ninouno 
of extract which will prodneo an average increase of 5 mg. in 
tho blood sorum calcium of normal dogs of approximately 
20 kg. weight over a period of fifteen hours. Notes of eight 
cases show tliat para-thor-mono, given subcntnueonsly at 
daily intervals, increases the scrum calcium and acts bene- 
floially in iufantilo tetauy. As these wore amhulaut patients 
they were given 2 c.cm. or 40 units snhoiitaueonsly each clay 
instead of tho more rapid method of 5 units every two or four 
hours. Four injections ns a rulo sufficed to cause cossalion 
of symptoms, although tlio serum calcium Iiad not quite 
reached tho normal by that time. In ouly one case was any 
other medication used, tho para-thor-mono being given alone 
in order to demonstrato its valuo in increasing tho scrnin 
calcium, though probably tho improvomont in symptoms ana 
return of serum calcium to normal levels would hayo been 
further hastened it some form of calcium and cod-liver on 
had been simultaneously administered from the beginning- 
In all tho oases the diet was modified, tho total quantity 0 
milk being reduced, and more cereals, vegetables, and meac 
juices being added. 


121. Indications for Digitalis. 

C. C. 'WoiiFBRTH (Amer, Jonrn, Med, Sci., December, 1927, 
p. 760) believes that success in tho digitalis treatment 0l 
cardiac affections depends on the correct recognition ol 
indications for Its administration and on proper dosogo ; he 
discusses its uses in the treatment of abnormal rates anu 
rhythms, and in heart failure with normal cardiac mechanism. 
In adults digitalis only slightly slows the normal heart, but 
in children and adolescents the effect may bo miicli more 
marked. The drug usuall.v fails to control simple tachycardia 
in adnlts with compensation, but in decompensated hearts 
It sometimes lessens the rapidity coincident on restoied com- 
pensation. Digitalis can cause various forms of arrhythmia, 
may convert auricular flatter to fibrillation, and may even 
precipitate fibrillation in normal hearts. In sinns arrhythmia, 
ventricular escape, anricnio-ventricular rhythm, and sino- 
anricnlnr block its nso is contraindicated. 
recommended it is not contraindicated in extra-systo e • 
The most useful field for digitalis therapy is -1“ 
fibrillation, duo to a depressing rather than a stimnu g 
action bn the transmission of impulses through the juuc 


FED. 4, 1923] 


EPITOME OF CURRENT MEDICAE EITERATURE. 


[ rcrz B&msB 

SIZDICJIZ/ JOU11K4.& ■ 


tissno.s. G!von accoriUng to EyRlcstou’s principles rathor 
than In small flosos cllgitixlis may holltc-Hnvinj;. Tho optimum 
ventricular rate at rest sIiouUl ho maintained, and it com- 
pensation lias not been rcstoictl by this measure, or If it falls 
\vhilo tho rate Is maintained, tho cardiac work should bo 
lessened by rest in hod ratlior than by larger doses of digitalis. 
If treated vigorousiy with digitalis auricular flutter will bo 
converted into flbrillatlon ; if treatment bo then abruptly 
stopped many cases will rovort to normal rhythm. Tho drug 
is useless In paro.vysmal flutter, and It should also ho avoided 
in lucompleto hcart-hlook, but pormauont coraploto block is 
not a contraindication to its cinployment. It is useful also in 
preventing tho Adams-Stokes .syndrome. In sovero congestlvo 
heart failure, and in. elderly patients xvlth myocardial weak- 
ness. Digitalis is more vnluablo in mitral than in aortic 
• lesions, though not contraindicated in tho latter, nor In 
coron.ary disease. Its action on tho blood pressure depends 
on tho presence or absence of heart failuto,aud blood prossuro 
levels are not important indications ns to its uso. Its 
administration is somotimes necessary in tho cardiac falluro 
■ of hyperthyroidism lu order to support or stimulate tho 
circulation, but its value in infectious such as pneumonia la 
still donbtinl. Tho principles of digitalis therapy aro tho 
samo in snrgicat as in medical cases. 


Dermatology. 

122. Etlotcgy and Treatment of Porokeratosis. 

H. IV. Acton (hidian Jonm. iird, lies., October. 1927, p. 349) 
dfllnes porokeratosis as a typo of hyperkeratosis, which 
spreads lu an Ivrrgnlar, coiitrilugal manner. This rare skin 
condition was tlrst described in 1893 by Jilhelll, who named 
it porokcraldsls, since he considered that it occurred es3cn- 
■ tlally round tho sweat pores. During the past few years 
Acton has seen eight cases of tills disease, and he gives short 
notes on cacli. Tho lesions nio eommonc.st on the hands, 
especially on tho dorsal aspect, and may bo present on the 
feet a.s well. Theynppear first ns small, liorny elevations 
resomhling corns, which slowly oulargo, taking months or 
years to reach any conspicuous size, and may occur at any 
penod ot life. Etiologically the discaso appears to ho asso- 
ciated with some hereditary factor closely related to ondo- 
Mine Innction. In two of tho cases tho basal motabollc rate 
w^as very low, indicating some deficiency lu the action ot tho 
tnjTOld gland. Clinically tho coudUlon is characterized by 
“ pdro-like lesions ; ns tlioy oulargo they form an 
which surrounds an atrophic depressed 

; , ■ ' ■ ■■ • 

endothelial cells and fibroblasts 
atrnnw 1 coustrlct thc vcssols by pressure, and 

’°><^“dshig tho depressed, depigmeuted, wrinlded 
association of a familial tendency and the 
suggests a partial correlation 
cnrivt of tho thyroid gland. Tlio lesions can bo 

dospnf three weeks by thyroid medication. Tho 

of thn mnfo'iP regulated by tbc degree of deflclencj' 

20 net diminisbed botween 15 and 

twice a flnl' n ^ grains ot the dried glands Is given 

3 grains ^ diminution is moro than 20 per cent., 

as to keen rsn 'hcreascd or diminished so 

thatporokpJt^'s between 90 and 100. Acton considers 

(mor^ocal nn'u fi “ '°®s’*zcd keratosis with central atrophy 
skin*^aisp.!'“„ 't into tho largo group of so-callcd 
fflorplioea-J^i.7'^®'^°^“™’'‘> so'orodenna, folliculitis, and 
tiypofanctioD.”*'^” associated with thyroid 

123. 

Accordint t Affections In Asthma. 

22nd, 1927 „ {itcia Med. Scnxuf., November 

asthma ihavh^k °®9“™”®® ot ®utaneous symptoms In 
attack has^hPoT.® ouological signillcanco. The asthmatic 
tnneous Infection ot the 

an examinatioiww'ioi'”^ observed In tho sidn. In 

the author notpu^ °^thmatics (92 children and 32 adnlts) 
adnits). IrnHifn t“ 74 (57 children and 17 

24,.prnritnslu?4 in -36, .strophulus or urticaria in 

other skin disease oedemas in 6, and 

^patients. In snmf *'^0 faco, herpes, bnllae) in 

. in others two affection was present, 

With feathers Im!!? r “i ‘■’“o- Cutaneous tests 

on 70 ot these mHpi? and pollen were performed 
. donbtful or ‘ gi^mg positive reactions and IJ 

Palientsrm ^vhnm asserts that In the 

With the asthjnadc attach?) ^ broke out in connexion 
. the relationshin hptTOp? ® reasonable doubt as tc 
asthma. He emnhlyat « ® oataneons affection and tht 
emphasizes the facts that the skin losiom 


occurred In paroxysms, were characterized by hyperaemia, 
ocdoina, and itching, and were frequently, if not always, duo 
to idiosyncrasy. Ho agrees with the American authors that 
these skin diseases should bo included in a common group 
under tho name of allergic or idiosyncratic diseases of thc 
skin. 

124 . Extensive Pigmentation of tho Skin Associated 
with Amenorrhoea. 

Accoudino to A. P. StiATMANN (Dermatol. Woch., December 
10th, 1927, p. 1703) tho female sexual organs, from pubort3' to 
tho monopau.so, produce very Oellnite metabolic abd patho- 
logical chauges in tho skin, chiefly through the ovarian 
hormone; any derangemeut of this endocrine sj'stem may 
produce changes in tlie pigmentation ot the skin. He describes 
tho case ot a girl, aged 19, witli amenorrhoea and a skin 
eruption, both ot a j’car’s duration; the eruption had com- 
menced on thc limbs and spread over the entire trunk. Sho 
had had typhus fever at the age ot 13. Menstruation com- 
menced norumlly at 17, bnt a year later it becamo irregular 
and scanty, and it ceased entirely four months before 
admission to hospital. As tho menstruaticn became irregular 
a red papular eruption appeared ; tho papules were as large 
as peas ami caused no di.scomfort, but became more numerous 
and pigmented when meustrnation ceased entirely. The 
nose, hands, feet, and legs were cyanosed and cold, but there 
was no Ollier abnorinalitj'. Arsenic and other drugs, with 
local applications of Lassar’s paste, antohaemotherapy, and 
terpene treatment, had no effect. On the limbs, especiallj' on 
tlic exteusor surfaces, there was a papular, coffee-brown 
eruption below tho skin surface, which persisted on pressure. 
Between the papules the skin was normal. Histological 
examinatiou ot a papule showed piling up of the superficial 
opithcliiiiu, au atrophic stratum lucidnm, and many fresh 
hacniorrlingcs into tlio stratum cornenm. The papillary 
layer was relatively thinned; tlie capillaries were dilated 
and ongovged, and there was much subcpithelial small-ceiled 
infiltration. Tho sweat glands and roots of the hair were 
normal. An ovarian extract was admiui.stered, and in sixteen 
days defluitc iiuprovcmcut followed with free desquamation ; 
tho pigmented areas became smaller and paler. In three 
weeks normal menstruation was restored. There was no 
recurtcnco of the eruption, although, a year later, very pale 
isolated areas of pigmentation persisted, and the hands, feet, 
and logs wore distinctly red and slightly cyanosed. 


Obstetrics and Gynaecology. 

125. Prognosis In Abdominal Pregnancy. 

Jeannenev, DONNIN, Favdeae, and B.AXrVAiff,ET {BttU. Soc. 
d’Obstet. ct tic Gynecol, de Paris, November, 1927, p. 664) 
advocate speedy operation when the diagnosis of abdominal 
pregnancy is made before term. Tho luatemal mortality 
after operation, according to Guermer, is 6 per cent, in 
patients operated on at the fifth to seventh month, 22 per cent, 
at term, and 32 per cent, afterwards. The majority ot the 
foetuses are raalfornied and non-viable, and, according to 
Baronnet, who summarized 300 cases, the foetal mortality is 
83 per cent., wtiile one-third of the surviving foetuses are 
maltorincd. The chdnee ot securing- a healthy infant is 
therefore so slight tliat it is unjustifiable to increase tho 
maternal risk by deferring operation. J. Lacoutere and 
L. MASsfi (ibid., p. 666) found that an infant born after 
abdominal pregnancy showed at the age ot 2J years normal 
mentality and no morbid physical characters except .slight 
cranial and facial nsymmetrj% J. Anderodias and Denis 
(ibid., p. 675) operated fifteen days before term for secondary 
abdominal pregnancy'; a living, well formed infant was 
delivered, but died within a fexv days, and the liiother died 
from embolus on the twenty-third daj\ 

12s. Placenta Praevla. 

F. C. Irving {Surg., Gynecol, and Obstet., December, 1927, 
p. 834) discusses some of the problems of placenta praeria, 
based upon his own experience in 57 consecutive case.s. 
There were no deaths from haemorrhage, but two mothers 
died from sepsis — a maternal mortality of 3.5 per cent. ; the 
infantile mortality among viable infants was '45 per cent. 
The morbidity rate was 21 per cent. Delivery was effected 
mostly by dilatation of the cervix by a bag and Braxton 
Hicks version, and forcible dilatation ot the cervix eillier 
manually or by traction on the foetus was never adopted. 
Two Caesarean sections were performed, one being followed 
by hysterectomy, .and the placenta -n-as generally removed 
by expression. Since sepsis is responsible for a considerable 
number of deaths Caesarean section, followed by hysterec- 
tomy, regardless of the state ot the child, is Indicated if there 
Is a possibility that the patient has been infected, blood 

■ 204 O 


22 ■ I’EB. 4, 192S] 


EPITOME OF OUEEENT MEDIOAE EITERATUEB.' 


f Tmt Bimw 
Medicii. JorsEU 


transfusion being porforinecl prior to operation. Irving 
snramarizos the ideal treatment as : (1) ah uninfeeted patient 
in poor condition from loss of blood should bo given a pro- 
llminary blood transfusion, followed immediately, regardless 
of the infant, by a Braxton Hicks version as being tho 
quickest way to stop tho haemorrhage ; (2) .an uninfected 
patient in good condition, with tlio foetus dead, non-viablo, 
or a monster, should have a Braxton Hicks version as afford- 
ing the lowest maternal mortality ; and (3) in an uninfected 
patient in good oondition with a normal live child of sulHciont 
size to warrant the assurance of survival Caesarean section 
affords the best means of saving tho infant without unduly 
jeopardizing the life of the mother. In marginal placenta 
praevia simple rupture of. the membranes is safe for tho 
mother, but has no advantages over metreurysis for tho child. 

127. ficetone Treatment of Cancer of tho Cervix. 

G. GelIjHORN (Zentralbl. /. Gijnalc., Docorabor 3rd, 1927, 
p. 3114) views with satisfaetion his twenty years’ experience 
with acetone in treatment of cancer of tho cervix uteri, and 
believes that this substance is in certain respects superior to 
radium in both inoperable and operable cases. Tho indica- 
tions for acetone applications in inoperable cases are : 
(1) where radium is not procurable ; (2) in patients whoso 
general oondition is so bad that absorption of tho products of 
tissue degeneration due to radium application is likely to 
accelerate death — such oases account for tho greater part of 
the 1 to 3 per cent, mortality associated with radium therapy 
in these cases : (3) where there is deep ulceration near tho 
bowel or bladder, and radium would cause fistula formation ; 
and (4) where the vaginal wall is tho site of innltlplo 
or superficial nodules of neoplasm. IVlth regard to pro- 
operative preparation in operable oases, Gollhorn remarks 
that cauterization quickly arrests tho bleeding, but Is 
followed by a prolonged and copious watery discharge which 
weakens tho patient. Radium applications before hyster- 
ectomy are said to be of doubtful value in tho prevention of 
reourronoes, and in the author's experience of operations 
performed from throe days to three months later have been 
found to cause the pelvic cellular tissue to bo congested and 
oedematous or densely cicatricial; in either case the operation 
is rendered diiHouIt. Acetone stops the bleeding at once and 
causes the discharge to cease within a few days. Gollhorn’s 
technique is as follows : One hour after an injection of scopol- 
amine and morphine, without general anaesthesia ns a rule, 
or after a few drops of ether have been given, projecting 
ulcerated parts of the tumour aro removed witli a largo sharp 
spoon ; subsequently, with tho pelvis elevated, a well greased 
cylindrical speculum is plaped in the vagina, and filled with 
one or two teaspoonfuls of pure acetone, which is allowed to 
remain for ten minutes. Tho pelvis is lowered nitd tho vagina 
emptied, and more acetone is now similarly applied for twenty 
minutes. This is repeated daily for one or two weeks, and 
then on every other day ; after tho first application morphino 
or an anaesthetic is unnecessary. Care must bo taken that 
the vulva is not burnt by contact with the acetone. In certain 
cases acetone bisulphide is applied in powder form. 


Pathology. 


123* The Virus of Measles. 

R. DegicWITZ {Journ. Infec. Dis., October, 1927, p. 304) has 
found that the virus causing measles can be kept alive for 
several weeks outside the human body it the blood is taken 
from the patient just at the beginning of the eruption and 
diluted in the proportion of 1 In 7 to 1 in 10 with buffered salt 
solution containing the same number of anions and kations 
and showing the same pH as blood. The mixture must be 
kept at a temperature of 0’ 0. Measles produced by sub- 
cutaueons inoculation begins earlier than when it starts 
naturally or follows artificial inoculation of the respiratory 
mucous membrane ; the symptoms are milder and of shorter 
duration. There seems thus to bo an analogy between 
morbillization against measles and variolation against small- 
pox. Measles can be produced in human beings with the 
sterile blood of a measles patient or with dilutions of such 
blood which has passed through a Borkefeld filter. Sterile 
filtrates of nasal secretions collected in the pre-ernptivo 
stage and diluted with normal saline are’ also capable of pro- 
ducing the disease. Measles virus can bo grown in cnlture 
media containing plasma derived from susceptible or immune 
persons' and dilated in a proportion of 1 in 6 or 1 in 7 with 
buffered normal saline.' To keep the virns alive it must bo 
associated with living cells such as the slowly growing 
bacteria regularly found in measles. Injection of sterile 
filtrates of cultures into human beings can produce reactions 
similar to measles, the specificity of which can be proved by 
the fact that sucli persons are later immune against large 
amounts of inteotious blood. Monkeys {Macactis rhesus) can 


■bo infected by injections of such material, and the specificity 
of tlio reactions can bo proved by tlio fact tliat tboir serum 
collootcd after tho reaction can protoot infected Jiuman beings 
against measles, wlillo the serum of normal measles has no 
such protective power, 

12D. An EpIdotnlo'Duo to Typo lY Pneumococci. 

G. H. Robinson (Journ. Infect'. Dis., December, 1927, p, 417) 
do.scrlbcs an cpideinlo of pneumonia dnring tho first six 
months of 1927 in Pittsburgh, Pa., duo apparently to Typo I'V 
pneumococci. ' Tlio 'organisms were recovered from the 
sputum by tho usual mouse teebniquo, tested for blle- 
solublllty and Innlln fermentation, and used to prepare 
agglutinating serums In rabbits. Altogetlior 65 strains of 
'Type IV pnonmococci were studied; tlieso foil into eight 
serological groups, though it is stated that not all strains 
were grouped. Twonty-oiglit of tho strains fell into four 
groups, lahollod K to D. Tlicso fonr groups woro provalont 
during tho first threo or fonr mouths of tho epidemic; dnring 
tho later .stages members of tho other groups appsarod, 
possessing far greater hoterogouoity. A study of tho mor- 
tality of tho dlllorcnfc groups sliowcd that 56 per cent, of 
patients infected with Group 0 died, whereas tho mortality 
duo to Groups A, B, and D varied from 14 to 33 per cent. 
Tho mortnllty in the whole epidemic was 37.3 per cent. ; this 
was considerably higher than la tho previous year, when tho 
mortality duo to Typo IV strains was only 18.5 per cent.; 
tho Increaso in death rate conid bo ascribed very largely to 
tho liigh vlnilcnco of tho Group 0 strains. It would appear, 
therefore, that in this opiilouilo a few dominant types of tho 
usnaliy hotcrogoncous Typo IV pneumococci emerged, and 
that one of those assumed a much higher pathogenicity than 
tisnnl. As tho epidemic died away, tho inoro homogoneons 
strains woro roplacod by moro hetorogonoons strains, similar 
to those encountered in non-epidemic times. . 

130. Amato Bodies In Scarlet Fever. 

J. A. TooMET and J. A. GAMMEt, (Amcr.Jonrn.iyis. Child., 
November, 1927, p. 841) state that Amato In 1913 described 
small bodies — roimdisu, oval, elliptical, triangular, quad- 
rangular, or crcscent-sbapcd-^in tho cytoplasm of the un- 
granulatod polymorphonuclear leucocytes of scarlet 
cases. As they woro i>rosout from the first day of the 
invasion to tlio second and third day of desquamation be 
ascribed to tliom a difforoutlal value in tho diagnosis of scarlet 
fever. The present authors, who regard tlio Amato bodies os 
nothing else than tlio inclusion bodies dosoribod by Dohle, 
examined 100 cases, consisting of 50 senrlot fever patients 
and 50 controls, and found tliat tbeso bodies were not always 
present in scailot fever, but occurred in other diseases, 
although they woro prosoub moro frequently In scarlet fever 
than in any otlier aouto Infcotiou. 

131 . Composition of Human Milk. 

B. Mtebs (Brit. Journ. Child. Dis., Octobor-Docemher, 1927, 
p. 249) reports on 184 soparato analyses made, of the 1?"'' 

84 nursing mothers, whose ages ranged from 16 to 
average ago' being 22. The results were as follows, ino 
average analysis showed protein 1.5S per cent.) fat 3.85 pc 
cent., lactose 6 per cent., and tho calorie value per ounce 
18.95. Tho last tliird of tho milk contained tho highest per- 
centage of fat. Although a large number of analyses showed 
fairlysimilarresults, there was in many instances a distmcc 
variation, ospeolally as regards the fat content and the pro- 
tein, whicli within certain moderately wide limits romalnen 
normal. The milk of a nursing mother was apt to vary to 
some extent even from day to day, but unless this variation 
was excessive it did not affect the Infant. In conclusion, 
Myers maintains that for the purpose of an analysis or caloric 
va’lne concentration the middle third or tho whole of tho milk 
In the breast should be used. 

132 . Faecal Fat Analyses In Children. 

G. A. HabRIBON and TV. B. H. Sheedon (Arch. Dis. in CJuld., 
December, 1927, p. 338) recommend that the method of Holt, 
Courtney, and Fales should be used for the routine clinical 
examination of fat in the faeces of children. ' They state that 
normally not more than one-third of the dried faeces should 
be fat, and that of that fat not moro than one-third should be 
unsplit, it being borne in mind that in infants as ranch as 
one-balf of tho dried faeces may consist of fat. They add 
that faecal fat percentages give a rongh indication of the , 
efiloienoy of tho digestion and absorption of fat, though, by 
themselves, such estimations aro seldom, if ever, patho- 
gnomonic of any one disease. The total fat gives a measure 
of the effleienoy of absorption, while the ratio of nusplit to 
split fat indicates the efilciency of fat digestion. Separate 
estimations of free fatty acids and soaps are said to aflora 
little or no useful clinical information. . The ratio of free to 
combined fatty acids depends largely on the reaction of tue 
Intestinal contents. 


Fi:b. Ill igiS] 


[ 


TireB»mra 

IfzCICJLZ. 


23 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

133. Auricular Fibrillation In an Apparently Normal 
Heart. 

■\V. D. Reid (Boston Mctl. and Sunj. Joimi., Dccoinlier 29tli, 
1927, 11 . 1213) describes a case ot auricular Ilbrillatiou in an 
aiiparently normal heart to show tho importance ot recogniz- 
ing this condition, since normal rhythm and pertect heaitli 
may bo restored by appropriato troatmont. Irregularity liad 
first been noticed by the patient four years previously, follow- 
ing ovor-cxertiou on ouo occasion ; no further symptoms 
were noticed until cloven mouths later, when, after an attack 
ot influenza, the patient became unable to work for more 
tlian two hours a day on account ot dyspnoea and palpitation. 
There was nothing in tho history to snggest rheumatic 
infection, and with tho oxception of a completely irregular 
rhythm at a rate of about 100 no abnormality was discovered 
on clinical examination. A diagnosis ot auricular fibrillation 
was coiillrmed by tho olcotro-cardiogram. Two doses of 
digitalis loaf <6 grains each) wero given, and ou tho next day 
tho patient discovered that ho had loss breathlessness on 
exertion than at any time since tho onset of his illness. Two 
days later qninidiuo sulphate was administered (36 grains 
spaced over eight hours), and four liours afterwards tho 
rhythm was observed to be normal, this being demonstrated 
by tho electro-cardiogram. -V-ray examination before and 
after treatment showed that some dilatation of the right side 
ot the heart, which had been present during tho illness, 
had disappeared on the restoration of normal rhythm. Tho 
authoremphasizos tho futility ot inadequate digitalis therapy'. 
During the illness tincture ot digitalis, halt a drachm daily, 
bad been given without benefit, but it was found that con- 
siderable increase in the dose tor ouo day' produced marked 
amelioration ot symptoms. Since tlio case was considered 
to he suitable for treatment with quiuidine sulphate it was 
decided to make, if nocessai'y, vigorous use of this drug in 
tho attempt to restore normal rhythm, contiuuiug its admini- 
stration either until regularity was established or toxic 
symptoms made their appearance. As it happened, tho effort 
was successful before this limit was reached. No recurrence 
ot irregularity lias beou noticed during the ton mouths 
following its disappearance. 


134. The Heart In Typhus. 

D. DASiiux)Poi.u, N. Dcpu, C. Nicolau, and Pethesco 
(Presse Med., October 15th, 1927, p. 1257) state that typhus 
fever is one of the infections in which the heart is most 
frequently affected. The lesions are localized exclusively in 
the myocardium. The cardiac phenomena which occur in 
tho course ot tho disease, nanally during the second week, 
are more Intense in the hy'pertoxio than in the mild forms, 
and in old persons than In the young. In tho hypertoxic 
forms they become progres.sively worse and coutiuue until 
death, oven after the temperature has reached normal. The 
cardiac symptoms, therefore, follow the same course as tho 
other symptoms of typhus. In the bypertoxio forms the low 
arterial tension, morphological chauges in the blood and 
cerebro-spinal fluid, and the nervous symptoms disappear iu 
the mild forms as soon as defervescence occurs, but become 
progressively more pronounced until death in ajiyrexia iu the 
hypertoxic forms. Hyocardial insufliciency in typhus is 
usually manifested by a pulse rate of over 120, sometimes 
exceeding MO to 150, aud occasionally accompanied by extra- 
systoles. As in all acute infections It is favourably affected 
by Etrophanthin in fractional doses. On histological e'xamina- 
tion tho myocardium shows Inflammatory and degenerative 
lesions. The stellate ganglion presents an intense diffuse or 
nodular infiltration of lymphocytes, polymorphonuclear and 
plasma cells, with often intense degenerative lesions iu the 
nerve cells. Similar lesions are found in the vagus nucleus. 


135. Modification of the Schick Test. 

W. H. P.ARK (IVie nation's Health, November, 1927, n. 5 
states that he found in 1922 that it toxin-antitoxin of tl 
standard degree of incomplete neutralization was giv< 
immediately under the slriu it acted both as au immnnizit 
arent and as a method of determining immunity. At tl 
present time, ho says, ail the first injections of toxiu-antitox 
y the New York City Health Department medical inspecto 
Ic.cm. being injected directly nudi 
end ^ H lower part of the arm just above tl 

incn-fii- ® Ou the sixth or seventh day the arms a' 

inspected and those patients who show no skm reactii 


arc given no further injections. Those with a very slight 
reaction aro given a second injection, and those wlio have 
definite reactions receive two more injections. Tlie time and 
labour ot tlie extra Schick injection are thus saved and only 
tbo susceptible children receive the three injections. In 
chiltlvcn under six yoars old the reactions are practically the 
same as with tho Schick test. In older children tlio reactions 
are somewhat increased owing to a few peisisliug psendo- 
reactlons. This immunizing injection has How been n^d 
as a modified Schick test in inoi-e than 100,000 children. 
Park thinks tliat the nse ot the Schick test aiter iujectloils 
ot toxin-antitoxin, thougli of great value to individual 
children, is not necessary as a general public health procedure. 

138. Tularaemic Peritonitis. 

S. C. Folmer and M. J. ICiDBUnr (Jonrn. Amor. Med. Assoc., 
November 12th, 1927, jr. 1661), who report an Illustrative case, 
state that there liave been no previous o.xainples on record 
ot abdominal complications in tnlaraemla. Their case, 
which occurred in a man aged 90, was apparently au ordinary 
attack of tnlaraomia until abdominal symptoms developed 
three months after the initial Infection. The abdominal 
condition resembled a low-grade peritonitis with ascites 
and gaseous distension. About 20 c.cm. ot greenish-tinged, 
clondy ascitic fluid was withdrawn. Cultures on ordinary 
media and smears from the ascitic fluid failed to show the 
presence ot organisms. The fluid was then centritngallzod, 
tho sediuientwas mixed with 5 c.cm. of normal saline, and 
Injected Into a guinea-pig, which died of tularaemia in four 
days. The organism was isolated from the spleen and grown 
on glucose cystine meat intireion agar of pH 7.3, as recom- 
mended by Francis, who first described tularaemia. 

137. Oesopha^ectasia In a Child. 

J. A. 31. Cameron (Arch. Dis. in Child., December, 1927i 
p. 358) reports tlie case of a male child who suffered from 
dilatation of tho oesophagus due to cardiospasm, and died 
when 6 years old. He discusses the pathological findings la 
a scries of eight cases of recurrent attacks of vomiting, 
chronic in uatnre ; in ail an infiltration in tbo iuteruiuscniar 
layer was found wliioh had invaded Auerbach’s plexus in 
tbo lower end ot the oesophagus. The present case afforded 
evidence of bacterial invasion and supports the theory ot 
a toxic basis of the condition. The ganglionic chauges result 
in the stimulus of food being followed by contraction only ; 
tho retention of the food causes tho stomach to dilate, and 
the circular muscle hypertrophies. 


Surgery. 

138. Abscess of the Spleen In Typhoid Fever, 

D. JIOXTEE (Ann. de Med., November, 1927, p. 489), who 
reports a case of abscess of the spleen in typhoid fever, 
alludes to the one reported by Jlorel, Dambrin, and Ta))io 
(Epitome, April 24tb, 1926, para. 447), arid remarlrs that the 
abscess is usually single and situated at the upper pole of the 
organ, .as in thirteen of the fourteen cases where the localiza- 
tion was noted. Occasionally multiple abscesses have beeu 
observed, ranging in number from two to eight. The pus is 
greyish or yellowish in colour and often haemorrhagic. The 
organism most frequently present is the typhoid baoillns. 
Tho symptoms are unobtrusive, being usually disguised by 
the other manifestations ot typhoid fever ; pain is the moat 
constant one. No definite Information is provided by palpa- 
tion, perousslon generally shows a definite splenomegaly 
and the fever varies in character. The general condition is 
grave and tlie face is pinched. In view of these vague signs 
Hoatel thinks it is not surprising that the conflition is as a 
rule not discovered until the necropsy. If left to itself 
splenic abscess either causes death at once or gives rise to a 
series of complications in the abdomen, such as peritonitis 
and perforation of the colon ; or more often in the thorax 
such as adhesive, serous, haemorrhagic, or purulent pleurisy! 
Moutel’s case, which occurred in a man who had been twice 
inoculated against typhoid with a heated polyvalent vaccine 
five months and seventeen months previously, was remark! 
able in that abscess ot the spleen was complicated by pnm- 
lent pleurisyon the loft sideand perforation of the diaphragm' 
The organism isolated from the blood was probably of a 
typho-paratypboid nature, but distinctly atypical."^ The 

Widal reaction did not give any definite result withy?, ivvhosvs 

01 B.jparafyphosns A or E, ° 


A 



EPITOME OP CUERENT MEDIOAE LITERATURE, 


24 Pbb, II, ip 28 ] 


139. Isolated Polyposis of tlio Small Intestine. 

R. Gehrig [Deut. Zeit.f. Chir., Deoeuibor, 1927, p. 286), tvbo 
records au illustrative case, remarks that in comparison with 
polypus formation in the large intestine polyposis in the small 
Intestine, especially the duodenum, is rare. Many observers 
have drawn attention to the hereditary factor in intcsliual 
polyposis, but opinion differs considerably as to the inipor- 
tance of age. While Staemmler regards intestinal polyposis 
mainly as a disease of advanced life Roering states that It is 
chiefly found in youth and middle ago. The condition is 
essentially chronic. Attacks of intestinal obstruction which 
recur frequently for years and subside spontaneously should 
suggest intestinal polyposis. Treatment, which was formerly 
limited merely to extirpation of the polypi, should consist 
of resection of the affected intestinal segment. Gehrig’s 
patient was a girl, whoso mother had died at the ago of 34 
from ileo-oaecal Intussusception, probably connected with 
polyposis, but no autopsy was performed. 'Tho daughter bad 
her first attack of intestinal obstruction at tho ago of 7, 
Operation revealed intussusception of tho small iiitcstino 
associated with four polypi, which were excised. Tho palieiit 
subsequently had attacks of colicky pain almost every year 
in the autumn, when the diagnosis of duodenal ulcer was 
often made. At the age of 18, .when she had au unusually 
violent attack, laparotomy was performed, when au oiiterio 
intussusception was found associated with numerous largo 
and small polypi of the duodenum and upper part of tho 
small intestine. Resection of tho affected part was performed, 
but death followed fourteen hours after the operation. At 
the necropsy the lower part of tho small intestine and the 
Whole of the large intestine were found to bo normal. 

150. Incidence of Hernia In Children. 

R. Paterson and G. M. Gray {Arch. Dia. in Child., Rocomber 
1927, p. 328) investigated 1,018 cases of hernia in children and 
noted that among patients attending the out-patient depart- 
ment of a children’s hospital the incidence of hernia was less 
than 1 per cent. The sex incidence of hernia in children was 
found to be four males to each female. 'The authors report 
that inguinal hernia is about four times as common as 
umbilical hernia, and that the sox incidence In this variety 
was nine males to each female. Spontaneous cures of hernia 
have been claimed by some writers, though others hold that 
such do not exist. Paterson and Gray state that there was 
an apparently spontaneous cure of inguinal hernia in one- 
fourth of all their oases, the tendency being higher in females 
than in males. A right inguinal hernia was present in 62 per 
cent, of their oases, a left in 20 per cent, only, and a double 
hernia in 18 per cent. In umbilical hernia the sex inoidouce 
was equal, and in half tho patients under tho ago of 12 an 
apparently spontaneous cure occurred. Tho routine treat- 
ment of inguinal hernia at the hospital where those observa- 
tions were made Is to postpone the operation until after the 
first year, except in special circumstances. Tho authors 
mention that there is a wide discrepancy iu the statistics ou 
a number of the above-mentioned details, and quote those of 
various English and American authorities to illustrate this 
point. 

151. The Thymus Gland In Graves’s Disease. 

As a result of his own observations and those of other workers 
H. Habbuer {Wien, hlin. Woch,, Recehiber 1st, 1927, p. 1501) 
concludes that the thymus, like the thyroid gland, pl.ays an 
Important part in the endocrine dysfunction associated with 
Graves’s disease, especially in the more severe cases. A laree 
thymus has been found in nearly 100 per cent, of patients 
dying of heart failure after thyrqjdectomy operations while 
this was present in only 82 per cent, of those who succumbed 
to the disease without operation, and iu 44 per cent, of those 
dying of intercurrent affections. When performing thyroid- 
eetomy for this disease he has, therefore, in a series of 61 
cases, of which 45 were classified as severe or very severe 
removed as much as possible of the thymus as well, geuerallv 
at the same time. Occasionally, though only a small thymus 
was found, microscopic examination showed delayed involu- 
tion of the glandular tissue. The results in the majority of 
the cases were very satisfactory ; many of the patients were 
operated on more than seven years ago and some more than 
fourteen, and, in spite of considerable emotional' stress and 
worry', iu some instances there was'no recurrence of sym- 
ptoms, though in a few the thyroid gland enlarged again 
subsequently. In three out of the four'deaths which occurred 
in the. series there was marked post-operative restlessness 
and tachycardia, and largo residual portions of the thymus 
were found at necropsy. Haberer thinks that failure in 
these cases was probably due to the technical diflicalties of 
removing sufficient of the thymus. 'The fourth fatal case 
was that of a patient five months pregnant, with advanced 
Graves’s disease, aortic stenosis', and hypertrophy of the 
right ventricle and dilatation of the left. lie concludes that 

244 ^ ^ 


t TniBtma • 
UcDiciX Joruifc 


for tho successful surgical treatment of a largo proportion of 
cases of Graves’s disease reduction of tho activity of llio 
thymus is necessary ; until this can bo accomplished inedi. 
cally, operative removal of ns largo a portion of this gland as 
possible is advisable. 


Therapeutics. 

152. 'The Treatment of Hodgkin’s Disease. 

R. RORT AT- Jacob and P. BOII.MITB {Paris Med., Recembor 
3rd, 1927, p. 452) draw attonllou to the bonollts produced by 
tho combined use of c-ray and biological therapy in Hodgkin's 
disease, and report a caso In which this method proved most 
clllcucioiis. Carefully tlltcrcd rays wore used two or three 
times a week, and always caused great amelioration of the 
symptoms; tho ganglibnio masses dlsapiieared, function. 1 
signs IcHscuod, tho pruritus became less intense, and tlio 
general state improved. At tho same time tho leucocytes 
'diminished in number and tho erythrocytes rapidly Increased. 
Tho authors agrob that this Improvement is only transitory, 
and sooner or later tho symptoms recur with a fatal termina- 
tion. In biological treatment, Llndstroom, having obtained 
only inconstant results with injections of iminnno rabbit's 
and sheep’s serums, tho autliors advocate the use of homo'- 
logons serums. In tho present case the serum employed win 
obtained from another patient snftorlng from Hodgkin’s 
disease who had been treated with x rays. 'This was given 
in two courses, 9^ c.cm. being injected subcutaneously in ten 
days during the first, and 11 c.cm, in tlio same time during 
tho second course. 'The first injection caused a slight febrile 
reaction, but no general disturbances. Rurlng this stage of 
tho treatment tho red cells increased from 2,800,000 to 
4,300.000 per c.mm. and tho white cells decreased from 22,800 
to 7,800. Following theso Injections x rays were adminis- 
tered, and in twonty-oight days tho patient was apparently 
cured. Tho result of tho blood examination showed that tho 
.serum treatment was an undoubted factor iu the apparent 
cure; its action may bo duo to protein shock, a vcritablo 
vncolnallou reaction, or to tho liberation in tho blood of 
loucolytic products of dlsiutogralion. Tho authors are 
inclined to favour tho last theory, since many experimenters 
have shown that tho sorum of irradiated leuUaemio patients 
causes in vitro a partial loucolysls in normal or other leuk- 
aomio blood. Roep, radiotherapy and radium have given no 
bettor results than superficial irradiation. 

153. Treatment of Typhoid Fever by Anti-gangrene 
Serum. 

M, tVEiNBERG and G. THIBAULT (C.' It. Soc. de Biologic, 
Recembor 2ud, 1927, p. 1476) record a severe case of typhoid 
fever troaled successlully with a serum prepared against the 
causative organisms of gas gangrene. Ruring the first three 
weeks of Illness antityphoid and nnti-coii vaccine ' hy the 
mouth, Eodot’s antityphoid sorum, and, later, the antityphoid 
bacteriophage, were all tried, but without avail. The patlout 
had a severe Intestinal haoniorrhage; and his red colls sank 
to 2 900 000 per c.mm. As his stools were very fetid and 
showed microscopically a mixture of typhoid bacilli and 
B. per/riiigens, it was decided to administer nntl-gangreua 
serum. Grassot and Gory’s antityphoid serum was given 
subcutaneously and a mixture of. anti-per/rtnyrns and poly- 
valent auti-gnngrene sorum by the rectum. The patient s 
condition rapidly improved-; a second injection was given 
therefore on tho next day; and an Injection. of antityphoid 
serum alone on the third day. After the second injection 
the temperature commenced to fall, and the stools becanie 
Inodorous ; the red cells rapidly rose to 4,200,000. 'The. 
patient apparently recovered quickly. The authors conclude 
that the anti-gangrene serum was largely responsible for 
this result, and recommend its administration in all severe 
cases of typhoid fever. 

155. Diver Feeding in Pernicious Anaemia. ' 

From the results obtained in fourteen cases of pernicious 
anaemia 0. A. Elliott {Med. Joum. of Australia-, November 
12th, 1927, p. 672) concludes that the addition of sufficient 
liver daily to an adequate well balanced diet will produce 
a prompt remission in most cases of pernicious anaemia, the 
response by the reticulocytes apparently being characteristic 
of this disease. He finds that the liver may be cooked or 
raw, while some patients prefer to take it weli ground and 
diluted with orange juice. In some cases administration by 
means of a stomach tube is advisabie. and hydrochloric acid 
may be given aiso. Under the liver diet, the red blood cell 
count and haemoglobin increased, the colour index fell bolow 
one,' and the megalooytes and irregular forms diminished. 
General improvement occurred, the bilirubinaomia becanie 
normal, and the glossitis and gastro-lntestinaT symptoms 


FEif. II, I92§J 


EPITOME OP. CURRENT. MEDICAE.EITEnATUKE. 


[ Tbt Bamstt 
MroicAi. JocTtxxXi 


25 


quickly olcareil up. ■ Gastric anaoiclity, .however, and syni- 
ptbtus rotcrableto the spinal eord persisted, although numb- 
ness and tingling decreased or disappeared. Of the tourtcon 
patients, eleven had coiiipleto rotnissioiis of their anaemia 
aud a corresponding gouoral clinical improvement. One of 
the remaining throe received the liver for only ouo nionlh, 
and the two others, elderly aud extremely debilitated, who 
wore given raw liver pnrC'o by the stomach tube, developed 
suppurative broncho-pneumoMia and died, this being possibly 
attributable to the nn-tliod of administration. In other types 
of Bovero anaemia tliero was no such marked response to 
liver feeding as was seen in tho pernicious form. 


Laryngology and Otology, 


135. Misleading Symptoms of Laryngeal Obstruction. 

6. Pakstni (ficB. do Larijvgol,, a’Olol. ct dc fffu'no?., October 
31st, p. Gill describes two cases whore tho nnsaspected 
inhalation of a foreign body gave rise to symptoms of croup 
aud for which antidiphthcrlal serum was given. The first 
p.atient was a child aged 6 mouths, who was brought to 
hospital with signs of larviigcal obstruction. It liad had 
dyspnoea, congb, and lo“s of voice for three days with some 
fever, and antidiplithorial serum had been administered 
without improvement. Eespiratlon continued difllcult, with 
iiituruiittent periods of noiTual breathing. Tho pharynx aud 
liirynx were reddened and Rwolten, without any exudate. 
After two days in hospital llio child had a violcut attack of 
coughing and expelled a melon seed, with a cousidorablo 
aruounr of mucons secretion. It was tlien ascertained that 
tho child had liad a fall wlillo Gating a slice of melon and had 
cried lendly for a fow moments; the symptoms had uot 
appeared for .several hours afterwards. In tho second case 
a similar series of symptoms was related. Tills child was 
10 months old, aud liad signs of laryngeal obstruction, with 
cough and loss of voice, hut there wore no intermittent periods 
Qt normal breathing. Trnoheotomy was performed and the 
vertebra of a llsh was found in tho subglottic space. The 
child had been present at a meal several hours before the 
sj’iuptoms appeared, and must have secreted and swallowed 
3. morsel of fish then. These oases demonstrate how in 
a small child a foreign body may bo present In tUo most 
unsuspected case.s, and may give rise to symptoms which do 
not suggest a foreign tiodv, but rather an acute infection or 
spnsm ; tho 'foreign body may have been inhaled some 
consiaerable time before any. symptoms are noticed. 


136. Malignant Tumours of the Kasai Sinuses. 

H. A. .Barkes {Arch. 01 Otolaryngol., August, 1927, p. 1231 
reports a series of twenty-flvo cases of malignant dlseaso ol 
sinuses of tho nose. 'He considers that the 
^>^ 1 ? cases begin in either tho maxillaiy antrum 

ethmoid cells. In those cases where the first symptom 
Is pam around Uio molar teeth, the site of origin is usually in 
the earlier symptoms are nasal haemor. 
obstruction the growth probably began in the 
■ labyrinth. The sphenoidal sinus rarely appears 

to be the_ primary site, although affected by exteusion.s. The 

bn'fllv! liy growth, thougb usually 

badly mteo„ed and full of granulation tissne. Tbe majorltv 
carcinomata, usually epithelial in. type. 
Jhe author s method of treatment consists iu a very Iree 
tuiiionr, with a margin of healthy tissue. His 
brow ‘ ‘'‘® eyabrcw, follows till 

“'^y®“tnre, and then makes a wide 
It the l-mt' "“'Sliiog up just below the outer angll 

the S^es a very wide approacii to the area of 

.-^^oure s lateral rliinotomy is then practised, 
“’® n>allgnant tissne is reuioved! 
covltv wid?nnln°r ® are removed so as to leave the 
of the mspeetiou and treatment. At the end 

are incornovatBi^i cavity is plugged with gauze with which 
stronln? TOi ^ tubes of radium of from 100 to 200 mg. 
houlf Thi ‘^"■euty-four to forty-eight 

and'ariv examined carefully once a Week 

with ra^linm^ g' anniatioa tissne at once treated 

cavU^flTho cheek" T? by means of the opeS 

gradually increasii^inrvall.t;ie\Tli°“ 

of Labyrinthine Disease. 

October. September- 

- ’ “arefully investigated the ocular 


reaction of di Jeases of iub t investigated the oculai 

nystagmus has Spontaneous vestibulai 

nlly When unilatera*! u, characteristics, aud, especl 

Horizontal nvstagmnB'toM^^! ^ distinguished from central 
mai nystagmus to the healthy side indicates completi 


loss of, function of the labyrinth. Past-pointing aud failing 
aro always to the saiiio side as tho slow component of the 
nystagmus. If this rale is uot followed an extra-labyrinthine 
lesion, usnally a cerebellar abscess or tumour, is indicated. 
Nystagmus duo to movement of the head varies as to whether 
the movement is rapid or slow. In the former the semi- 
clrcnlar canal system and in the latter the otolith appara ns 
is brought into action, Hypor-oxcitability of tbe labjrinlh 
docs not indicate a patliological process, but is' part of a 
general nervous Iriitaiillity ; hypo-excitability in itself Is 
insufllclcnt to indicate tbe site of the lesion. Caloric tests 
have tho advantage that only one side is examine J at a time. 
The technique of Bilraiiy Is said to he rather more reliable 
than tho minimal stimulation of Kobrak. In the caloric tests 
the l.atoncy of the nystagmus iadicates tbe state of (he laby- 
rinth, tho duration Indicates the condition of the central 
uicchauisni. Tho electrical reaction is not very conclusive, 
but it it gives results different from the hormal a ceulral 
lesiou fa to be su-peoted. If other tests show tho central 
region to be normal the lesion must be iu tho vestibular nerve. 


138. Tuberculosis of the Middle Ear, 

E. B, Spencer {Arch, of Otolaryngol., September, 1927, p. 242) 
thinks that tuberculosis of tho middle ear in adults is more 
common than is generally supposed, though it is difScuIC to 
isolate tho bacillus from the discharge. In the child it is 
a very serious disease and extends to all parts or the temporal 
bone : it is acutg, and causes widespread necrosis. In adults 
tho disease Is more chronic and tends to be restricted to the 
middle cat. Iu Ipbcrcnlona oUtis there is frequent caries of 
tho ossicles, and paralysis of the facial nerve is a common 
complication, especially in children. As in the lungs, the 
blood vessels aro eroded and haemorrhages ocenr. but they 
are very small and aro often unnoticed. The auditory meatus 
contains mucus and pus, and there are usually multiple per- 
forations of the tympanic membrane which tend to coalesce 
in time until aliuost the .whole membrane has disappeared 
aud tho middle ear becomes filled with pale, flabby granula- 
tions. Sfastoiditis is frequent in children, but rare in adults,' 
though in some chronic cases an attack of infl.uenza may 
light up the whole condition. Intracranial complications 
consist maiiiiy of meningitis, which is rapidly fatal. In 
chronic adult cases the prognosis is good, but in children the 
course of the disease is likely to end in meningitis. Helio- 
therapy is the best conservatWe form ot treatment, hut 
operation is necessary in cases of necrosis. 


Obstetrics and Gynaecology. 

339. . Climacteric Disturbances. 

H. CURSCHMANN {Med.-Klmih, November 18th, 1927, p. 1759) 
believes that the differential diagnosis of climacteric patho- 
logy is an important subject for study- Ho finds that the 
symptoms vary greatly according to the racial type and the 
psycho-physical constitution. The “pyknic” (thick-set' 
muscular) woman Is said to suffer much less at the meno-’- 
pause than the patient ol the “ asthenic-prosic ” tvne ■ 
Tbe intelligent, sensible, bu>.y woman seldom becomes 
tho depressed, unhappy nenrasthenio at the menopause 
Curschmann doubts the wisdom of regarding these climacteric 
disturbances as largely tnnctional and relatively unimportant 
While menopausal hot flnshes, morbid blushing, and dermato- 
graphia are common, yet migraine, acroasphyxia, and ana- 
pbylactic asfchiDa dizniDi.sh or disappear. Obesity verv 
commonly folloiys the menopause; jess frequently the patient 
becomes thin. Barer forms of endocrine disturbance are 

late osteomalacia, psychoses ot the depressive, hielan-' 
cholic, or manic-depressive type, changes of character, sexual 
excitement, unreasoning jealousy, hy.stei la, and nenrasihenia 

Again, hyperaemia and swelling of the thyroid, thymus and 
adrenal cortex, analogous to those comlUious oocurrin.- i„ 
pregnancy, are common All these symptoms indicate pro- 
found disturbances of the hormonic and endoorine balance 
The author thinks that the absence of the ovarian* hormone - 

alone wiH not account for this, and he advi.ees that (he 
patient s general health should be investigated thoronghlv^ 
rather from Hie phy-sioian’s than from the gynaecologist's 
standpoint. Eor nstance, emaciation, debility^nd pmi^tnl 
arc sometimes attributed to the climacteric, when an exa 
mination ot the nriue shows that the patient has 

He adds that there may be conimeneiSg or defilfte artlrto 
sclerotic changes in tbe heart, kidneys, brain, and abdominal 
viscera or carcinoma may appear; careful dian|o“l fs 
required to exclade these and to determine th,> 
lines of treatment, which include organotherapy'^ sna and 

ll"Sives!*“"”'’ the adm^nis^Jmliln 


243 0 


26 TEB. ii| i9j3] 


EPITOME OE CTTIIBENT MEDICAE EITEEATUEE. 


t TitEORm« 
Meoicxi. 


150. . Diagnosis of Sterility in Women. 

blsoussiNa the diagnosis and treatment of uterine and tubal 
eterility, G. CottB and F. J. Martin (GynicoU ct ObsUt., 
October, 1927, p. 299) state that when liplodol Is introduced 
Into the uterus and the Fallopian tubes are patent the fluid 
escapes into the peritoneal cavity, where, in normal cases, it 
disappears without there being any ovidenceof injury. 'When, 
however, the tube is occluded or otherwise unhealthy, the 
liplodol cannot be evacuated, but is taken up by macrophages. 
Or an interstitial rupture of the tube may occur. ' The authors 
have never seen any serious consequence following injection 
of lipiodol when the apparatus is fitted with a jiressuro 
gauge. E. Ekohaquet (ibid., p. 3051 recommends insufilatlon 
at low manometrio pressure (22 cm.). He has employed this 
method fourteen times in 10 cases of sterility without any 
ill effects. In cervical stenosis, with or without ondo- 
cervicitis, he recommends diathermy in preference to Pozzi’s 
operation. He agrees that endooervioltis is an important 
cause of sterility, and that either of these operations secures 
free drainage, often curing the endocervioltis and obviating . 
subsequent treatment. R. Proust and 0. BfiouflRE (ibid., 
p. 317) claim that radiological examination after the injection' 
of lipiodol gives more valuable information regarding the 
condition of the uterus ami Fallopian tubes than simple 
Insufflation. Tliey do not think that intrauterine Injection 
of lipiodol prevents subsequent pregnancy, and cite four cases 
reported by. Henser in which tubal permeability was restorbd 
after repeated injections of lipiodol, and two patients sub- 
sequently became pregnant. For those reasons Proust and 
Bdclere hold that lipiodol injections are not only harmless, 
but may have a definite .therapeutic action, and are thoroforo 
the best procedure in the diagnosis' of sterility.' Beotner 
(ibid., p. 327) confirms Douay’s enumeration of the dangers 
of insufflation — namely, rupture, infection, embolism, and 
syncope. He reports a case in whloh_tho patient, shortly , 
after insufflation with Douay's apparatus, had a tribal 
pregnancy. ' • • ' ' ; ; . 

151. Symphysiotomy. 

<1. Ortiz-Perez ( Bull. Soc, d’Obatit. ct de Gynlcol, do Paris, 
November, 1927, p. 623) describes the experience of a Ouban 
obstetrical clinic with regard to labour in moderately con- 
tracted pelves, with a conjugate of nofless than 8 cm. Ho 
states that 60 per cent, of patients with such contraction 
are delivered spontaneously, and that during five years 
approximately fifty-four symphysiotomies to each Caesarean 
section have been performed. Tho routine practice is to 
allow labour to proceed and to employ symphysiotomy when 
it has been proved that normal delivery is impossible. The 
series included only two foetal deaths, and the last forty-one 
cases were without foetal mortality ; there was no maternal 
death. In cases in which the foetus la already dead not only 
is symphysiotomy leas dangerous than Caesarean section, 
but, on account of the pelvic enlargement which ia produced, 
the mother is left in a more favourable position for subse- 
quent confinements. At the same time as the symphysis is 
divided from above downwards by a tenotome, separation of 
the pubes by two or three flngerbreadths is effected slowly. 
Careful observation of the uterine tonicity Is necessary, and 
valuable assistauce is derived from the administration of 
morphine in some cases, and in others of pituitary extract. 
Application of forceps is occasionally required. It is admitted 
that in cases of symphysiotomy, perineal tears. are frequent, 
especially in .the first and second labours, and that extensive 
eplsiotomies are not Infrequently necessary. ■ ■ ' ' 

152. The Endocrine Glands In Gynaecology, 

According to Serdjukopp (La GynCcol,, September, 1927, 
p. 513) a certain amount of physiological enlargement of tho 
thyroid glands commonly occurs at puberty, and perfodical 
changes in its size are often associated with menstruation. 
Graves's disease also frequently manifests Itself at or soon 
after puberty, when it is due to pronounced modiflo'ation of 
the functions of this gland. Either deficiency of the menses 
or excess may be produced by hyperthyroidism. At puberty 
the parathyroid and the suprarenal glands also become more 
active, while the development of the mammary glands is also 
closely correlated with that of the ovaries. The Influence of 
gestation and lactation on the endocrine glands is established 
both clinically and experimentally. During pregnancy there is 
a progressively increasing hyperactivity of the thyroid, and 
it has been suggested that eclampsia and the chorea of preg- 
nanej’ may be due to, or associated with, parathyroid dis- 
orders. During this time also the anterior pituitary lobe 
undergoes hyperplasia, and may be indicated by a change in 
the facial aspect of the patient. No morphological changes 
can be found in the posterior pituitary lobe, notwithstanding 
the marked action of its secretion on the parturient uterus. 
SerdjukoEI concludes that hormones produced by the foetus 

244 D 


and tho placenta stlmniato the development of tho mammary 
glands, though tlioro is as yet no satisfactory'oxplanation of 
tho onset of lactation after delivery. Since tho work of the 
liver in tho detoxication of poisonous substances is greatly 
increased during pregnancy, hepatic disorders are likely to 
occur. At and after tlio menopause there ia atrophy of the 
cndocrino glands and of the uterus, ovaries,' and glandular 
tissue of the mammary glands; tho whole endocrine system 
becomes reorganized, and 111 balanced action often results, 
leading to such manifestations as goitre, myxoedenia, 
Graves’s disease, acromegaly, and obesity. 


Pathology. 

i53. Intoratltial Neuritis Caused by tho Virus of Babies. 
According to S. Nicolau and I. A. Galdowat (G. P. Soc. de 
JHologic, January I3th, 1928, p. 31) tho virus of rabies is able 
to spread along tho nerves In both a centripetal and a centri- 
fugal 'direction. .Roux demonstrated tho presence of the', 
virus in tho nerves of tho healthy arm of a man who'had 
been bitten bn tho opposite arm'. Roux'aud Nocard brought 
evidence to show. that after intracerebral infection of dogs 
tlio virus reached the saliva by passing down the nerves. 
Tho present ontho’rs have performed a series of experiments, 
to determine whether the virus is demonstrable in the. peri- 
pheral nerves of rabbits after intracerebral injection with the 
rabies virus, A street virus was used, itroduoing death in ten 
to thirteen days after inocnlation', and giving rise to very' 
obvious Negri bodies, which rendered diagnosis very simple. 
Tho brachial or .sciatic nerves , of rabbits inoculated intra- 
co'robrally were themselves inoculated into the brains of 
fresh'ririimals. Altogether these nerves were injected flftfeen 
times into the brain of nineteen rabbits) and each time the 
inoculated animal developed rabies. Histological examina- 
tion of tho peripheral , nerves of animals inocrilated.by the. 
cerebral route showed a mild degree of Interstitial neuritis. 
The sheaths of the nerves wore intact, but in between them 
was an Infiltration with mononuclear cells. Perivascular 
cuffing was observable, tho ohiof colls being lymphocytes, 
plasma cells, arid large mononuclears. No degenerative 
leslons'woro found in the nerves.. Tlio' authors conclude that 
tho street virus'of rabies, when Introduced into tho brain, is 
able to travel centrlfugally .and to reach the peripheral 
notyes, in which it sets up a' mild degree of ■ interstitial 
riourltis. ' ... . ... 


155. Mofle of Action of Ingested 'Orea, . . 

Ij RohAcek [IJratislavslie Lcharelii histy, December, 1927,- 
p.’598) states that although urea is no more considered a toxic 
wbstanco, it may still in certain oircumstanoes bring about 
a condition which, by .its symptoms,' resembles nephritic 
uraemia. Thus symptoms of intoxication were observed after 
the ingestion of small quantities of urea in two patients with 
oedema and ca'rdio-hepalic oliguria: Ho adds that the varia^ 
tionof tho diuretic actiori.of urea is most remarkable.. In an 
advanced case of oirrhosis of.tho liver, urea therapy “ot 
prevented tho renewal of.the ascites; butarresfed the further 
advance of the disease. ’.Many other successes in cirrhotic 
conditions are reported, but failures haye.been met with jnst 
ns frequently. After the’ ingestion of ureaAln.the s.upcessfnl 
cases) there results not only, an incre.ased elimination of urea, 
but also of writer. In refractory cases the concentration ot, 
urea in the urine becomes unusually high, this disturbance 
being caused not by disease of the. renal epithelium, but by 
failure ot the ingested urea to release tlie water assemb.etl in 
the tissues. The diuretic qualities' of urea depend upon tne 
liver function in two ways. (1) The production Of urea has 
its chief site in the. liver. An inadequate production may 
cause disturbances In the elimination ot water and salt, anu 
in the same way lead to the. apiiearanoe of oedenia anu 
ascites. (2) The' liver influences the water and salt meta- 
bolism, possibly .through the hormones or diastases, and 
preserves the balance between tho concentration of sodium 
chloride in the blood and iri the urine. 

155. Bony and Cartllaglnous'DeposIts in the Tonsils. 

□. Hirsch and M. H. Corten (Zeit. f. Jigls- 'Posen- und 
Ohrenheilh., December 22nd, 1927, p. 397) record tb.e case ot 
a diphtheria carrier, a woman aged 22, on whom tonsillectomy 
was performed without any difficulty, with the result tliat 
no more diphtheria bacilli were found in the swabs, uu 
examination of the'capsule of the excised tonsils islands of 
cartilage and bone'were discovered, a rare condition ot which 
mlv about thirty cases have been recorded, the llr-t "aviUi 
men reported by Orth in 1893.. There did not appear to be 
iny connexion between the carrier state and the carti aginous 
tnd bony deposits. 


FEB. i8, igaS] 


t Tn Bsmn 
Uzszcu. Jocmxi* 


27 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 


15 G. Unrocognlzotl Mycoses. 

According to G. DIJR.^NTII {Hull, ct Mem. Soe. Med. dcs Hop. 
dc rnris, November 17tli, 1927, p. 1513), mycoses in tlio 
tissues ot mnn uro c.^ceptiounl, apait' Irom well marked 
intcctioiis siicli ns nctinomycosis, oidinm, and aspcrgillus. 
Ilo recorils tlic csso ot a woman wlio died Irom eclampsia. 
Near the vessels in the stroma ot llio kidney were long 
mycelial lllanicnts tvliicli had not caused any reaction in the 
snvromullU); tissues. This voprcscuted a tyiio ot saprophytic 
mycosis peitectly tolerated. A second caso was that of a 
young woman who had had attacks ot appendicitis sulTlclnutly 
abnormal to obscure the diagnosis. Histological examination 
ot llie appondi.x revealed several supcrllcial nlcorations of 
tlio mneous membrane with numerous ramifying mycclia. 
The region ot the operation remained tender for two mouths, 
bnl si.K months afterwards tlio iialient liad put on weight and 
was in portcot health. Durante also encountered a ease of 
true mycelial soiitlcacmla in a woman wlio, before parturi- 
tion, was slightly jiyrcxial ; the fever poi -isted for five days 
after labour and then disappeared liy lysis, and the patient 
was discharged. Twelve days later she became comatose 
and died. At the necropsy were found numerous mycclia in 
the ntcrinn and pulmonary vessels. Threads 4 to 5/t in 
diameter were found lying between the red cells in the 
vessels, hut had not caused thrombosis. On several occasions 
during the Jiast ilftoen years the author has found that 
ncopl.asms which had been diagnosed ns sarcomata were 
really duo to mycoses. Tlio fungi had a very low virulence, 
as evidcEcod by the fact that there was no reaction in the 
surrounding tissues. He thinks that these infections are 
probably frequent In their latent form. The septicaemlc 
type in which the mycelium invaded the general circulation 
appeared to detonnlno accidents rather by tbolr presence 
Iban by their virulence. The fact that certain liaomophilic 
niycoics appeared to develop in the gonoral circulation 
rendered it advisable to malcc blood cultures on media 
suitable foriuycolia iu doubtful eases. 


1S7. Plrquct Tests with DlfToront Tuberculins. 

A. Brikciimasn (A'or.it; Map, f. Lacgevidcml.-., .Tamiarj', 1928, 
p. 36) has perfonned comparative Pirqnct tests slmnUaucously 
with four different kinds of tuberqalin— tlio official Norwegian 
preparation, a tuberculin from the Scrum luslituto in Copon- 
bagen, a German . tuberculin (lloechst’s', and a French 
tuberculin from tlic Pasteur Institute. Each cliild examined 
received tlvo scratches, one serving as a control, and the 
remainder being used tor ono each ot tlio four tuberculins. 
Altogether 89 children wero examined, and 342 tests were 
performed, the re.action being repeated several times in somo 
cases. Variations in tlie intensity ot tlio reaction provoked 
by the different lubcrcnlins were ohsorved in several eases, 
but tbei'o were no uniform differences enabling the author to 
decide that any one tubei'cnlin w'as superior to tho otliers. 
ibero were 68 children who gave a negative or doubtfnl 
respome, only- 21 giving a positive ono. Witli but two 
excephons, the.se21 childicu gave a positive reaction to all 
our tuberculins. But there wore only 5 cliildren who.se 
espouse to the four tuliorculins was identical; all the other 
rirquet posiiivo children showed reactions ot different 
severity to the various tuberculins, this dilTcrouce being in 
'"dry marked. . The aullior note.s that while in 
, l”'ddtice it is tho custom to observe the reaction 
is ^"d (ortj'-eigbt boms after the inoculation, there 

'^d'd-y df two days in general practice before 
° inoculation is examined. In two ot his cases a 
nernV°" "'y'dch was positive after twenty-four bonrs was 
d'itdr torty-eighl hours, and it would therefore seem 
is test should be controlled earlier than 

to the case iu general practice. The author has failed 
osvr,.!*,, that any one tnbcrculin is better than others for 
dairying out the Pirquet test. 


158 

p * The Spleen in Measles, 

p' {-imer. Journ. Dis. Child., November, 192' 

’1‘ ,® to tho paper on this subiect by A. 131eyt 
cidar<icn’iA°i ^ para. 4), who found tho splee 

■lie roenr.io tuajority ot 400 cases ot measles at all ages 
observations, on 116 case.s. In- Snl 
fonua Tn 'Vof °t' 12 per cent., was any . cnlargomei 
have 'easiiir cases tho enlargement was so slight as I 
y -soaped detection under normal circumstance 


It was noteworthy that not a single example ot enlarged 
spleen was found iu tho severest attacks cr in patients with 
tho ordinary complications ot measles. Tlie culargeuient 
was most pronounced in the younger children, its degree 
was independent ot the stage ot eruption, and the frequency 
ot splenomegaly’ was almost as great during tho early stage 
as at tho height of the eruption. Friedman conclndos that 
an enlarged spleen is not a prominent or frequent occurrence 
in measles at any stage of its development. 

159. Otological Complications of Mnmps. 

O. V03S (Dcut. med. IVoch., November 25th, p. 2023, December 
2ud, 1927, p. 2074) reviews the literature relating to impair- 
ment ot liearing or aeiual deafness on one or both sides and 
disturbances of equilibrinm which occur chiedy iu children 
after the ago of 11, hut principally’ in adults suffering from 
mumps, and records eight cases which came nuder his own 
observation iu patients aged from 6 to 32. Unlike other 
writers, who attribute tho sy’mptoms to a metastatic laby- 
rinthitis or neuritis, Voss regards these symptoms as due to 
a .seroflbriuons meningitis which not infrequently' ocems iu 
mumps. Support for this view is to be found in Ibe sne- 
cfissful experiments by Kerinorgant in producing parotitis iu 
iiioiikeys. In view of tbe discovery’ by Kermorgaut of spiro- 
chactes, treatment ot these complications should consist in 
injection of arsenical salts. 

160. Severe Cases of Mumps. 

DeLCOUHT {Mnixelles-Medical, November 20th, 1927, p. 89) 
reports a serins ot three remarkably severe cases of lunmps, 
one ot which terminated fatally’. Tbe first was in a boy, 
aged 13, who developed orchitis; the second was iu a woman, 
aged 22, in whom the attack was complicated by bilateral 
oophoritis or pancreatitis, as indicated by generalized 
abdominal pain. Recovery ensued, though the hardness 
ot the parotid persisted. The third case was that of a girl, 
aged 17, iu whom per-iisteut hardness ot the parotid was 
accompanied by high fever. Incision of the gland gave issue 
to a sanions llnid ; gangrene of the parotid followed, and 
finally myocarditis and death. 

161. Sewer Gas and Typhoid Fever. 

N. Sette (if Policlinico, Sez. Frat., December 12tli, 1927, 
p. 1813) reports the case ot a man, aged 29, who as mechanic 
In thfe pneumatic post service was much exposed to inhala- 
tion of sewer gas. In tbe period Juue-October ho had four 
attacks ot continued fever. In the first two attacks the 
serum tests for typhoid, paratyphoid, and nndnlaiit fever, 
and tlio blood culture for the malarial parasite were negative, 
and the only’ evidence ot typhoid was a dicrotic pulse and 
enlarged spleen. In the third attack rose spots appeared and 
tho fever subsided after injection of Bruschettiui’s tyifiioid 
vaccine. In tbe fourth attack the typhoid bacillns was 
recovered from tbe blood and the infection was apparently’ 
cared by’ an anto-vaccine. Sette maintains that inhalation 
ot sewer gas simuitaucously irritates the respiratory and 
Intestinal system, thereby causing a change iu the tissue 
fluids, and so inhibiting the serological reactions. 


Surgery. 

162. Appendicitis Simulated try Ovarian Haemorrhage. 

A. LURJE (Zcntralbl. f. Chir., January 7tb, 1928, p. 22) rotors 
to several recorded instances ot ovarian baeinorrbago slmn- 
latiug acute appendicitis, and reports the case ot an anaemic 
unmarried woman, aged 23, wlio jiad suffered for a year from 
moderate pain in tbe right iliac fossa. She had typical 
pressure pain at McBnrney’s point, and dysmenorriioea. 
Chronic appendicitis was diagnosed and append icectomy 
was performed. Tbe appendix was over four and a lialt 
inches long, and the middle third was loosely adlicrent; 
no macroscopic changes were seen. Although a little blood 
was oozing from the lower end ot the wound, its source was 
not evident, and, after removal ot the appendix, the abdomen 
was closed. Tbe patient’s temperature fluctuated and her 
condition caused considerable anxiety for four days, when 
on account of symptoms of localized' peritonitis in the left 
flank, the abdomen was reopened. A dirty green exudate 
was found beneath the caecum and covering the uterus and 
right tube ; tbe right ovary was normal. The left ovary was 
ns large as a plum ; it was dark blue and nodular,- and blood 

292 A 



28 Feb. i8, 1928] EPITOME OF CUEEENT 


oozed from a pin-lioad orifice. This ovary vras removed, 
many foul-smelling blood-clots in tlie pelvis were swabbed 
put, and the abdomen was closed. Convale.sccnoo was tardy, 
but the patient was discharged eventually in good health. 
Lurje remarks that the operation for chronic appendicitis 
coincided accidentally with the rupture of a Graafian follicle. 
The usual intra-abdominal haemorrhage followed, hut ap- 
peared so slight that it was disregarded. He adds tliat the 
incision was lengthened in order to find the bleeding point, 
and advi.s“s that tho incision in appondioectomy shonld bo 
long enough to permit of the examination of adjacent organs, 
especially of the adnexa. 

163. Injury to the Trochanter Minor and IiudlofTs 

Phenomenon. 

17. Strebeb (Klin. TTocfi., January 15th, 1928, p. 123) finds 
this sign valuable in diagnosis. It is found with avulsion of 
the small trochanter, and consists in loss of function of the 
psoas and iliacus. If the affected log cannot bo raf.sed when 
the patient is in the sitting position, and at the same time 
the two muscles remain lax, a diagnosis of avulsion of the 
small trochanter is certain. In one of tho author’s cases, 
a boy aged 12, this sign was absent, and tho ir-ray examina- 
tion revealed no avulsion but a tear in tho small trochanter. 
In two other patients, aged 15 and 11 respectively, Lndloft’s 
sign was present, and a;- ray examinations proved tlio correct- 
ness of the diagnosis. Treatment consists in rest In bed 
with the leg flexed and rotated outwards, 'i'ho patients 
were cured in nineteen days and there wore no aftor-offocts. 

164. Myeloplax Tumours of tho Spino. 

M. Camubati (La Chirvrrjin degli Organi di Movimenfo, 
November, 1927, p. 581) reports a case 0/ myclopla.x tumour 
of the cervical spino, and gives brief details of 18 cases 
collected by him. In tlio autlior’s case tlio tumour con- 
tained the usual giant cells. Of the 18 cases tlio youngest 
patient was 7 years of age and tlio oldest 40. lu 2 cases the 
cervical verteltrao wore affected, in 6 tlio dorsal, in 7 tho 
lumbar, iu 1 the sacrum, and in 2 the site was not given. 
Metastases were never noted, but local roenrronoo was not 
uncommon. Ossification occurred in 4 oases, and in 3 cases 
paraplegia persisted in spite of operation. In 14 cases Im- 
provement or cure followed removal of tlio growlli. Camuratl 
adds tliat the exact etiology of these tumours is uncertain ; 
they may represent irregular attempts at repair after injury 
and correspond with the granular tissue containing giant 
cells which is sometimes seen in psoudarthrosls. 

^S5. Primary Menlnffeaf Sarsoma. 

M. B. Castex, J, J. I/LAMBiAS and S. Balestra (Kcv. oto- 
ncuro-ojtalmol. y de cir. neural., October, 1927, p. 235), who 
record an illustrative case witli a review of the literature, 
state that in tho immense majority of reported cases of 
meningeal sarcoma the growth is secondary to a central 
lesion. They have been able to find only fivo cases, reported 
by Fox (1883), Hudden (1835), Schrader (1899), and Cassiror- 
Levy (two oases, 1920), in which, as in their own case, the 
sarcomatosis was confined to the pia mater. Tho present 
case is that of a man, aged 24, who died after an illness 
of five months’ duration, characterized by symptoms of 
meningitis and terminating with a condition of status 
epileptious. The necropsy showed a diffuse thickening of 
the pia mater of the spinal cord, especially iu the dorsal 
region, and base of the brain. Histologically the condition 
was found to be a .sarcomatous process which had developed 
in the perivascular connective tissue of the pia. The under- 
lying cord and brain tissue were not affected. 


Therapeutics. 

166. Ephelrlns Hydroclilor do In Whooplng-oonSh. 
H.AvrxG noted the relief obtained in five cases of asthma fu 
the young following the adpiiiiistration of ephedriiie hydro- 
chloride, 17. D. ANDERSON and C. B. Homan, jun. (Amer. 
Joui-n. Med. Scl., December, 1927, p. 733), concluded that this 
drug might also give relief in whooping-cough, and they 
report twenty cases in which it was tried. No cultural or 
agnintination tests were made, and the cases were diagnosed 
from the symptoms and general history. Vaccine treatment 
had been tried without effect in eiglit of the cases, and five 
children had received reetal injections of other in olive oil, 
with but slight improvement iu only two. The ephedriue 
salt was given or.ally in a watery solution, the doses being 
1/4 gr.ain for children one year old, and 1/8 grain for those 
younger. In six cases the ineJic.atiou w.as given at bedtime 
only.'tbe remaining patients receiving it night and morning 
and occ.asionallv three times a day. No other treatment was 
used. Tlie following slightly toxic symptoms were noted in 


MEDICAL LITEBATUBE, r Tm-.nrim™ 

L U.Dici, Jorn.n 


some of tho cases following tho administration of tho drng: 
marked abdominal diston.slou, apparent suppression of urine 
for twelve Ijoiirs, nljdominal pain and discomfort, marked 
sweating, prolnso nasal discharge, cpi.staxis, and subconjuno- 
tlvnl haoniorihago. Tlio aiitlior.s found that tho cplieurioe 
hydrochloride {{live relief from spasmodic cougli and vomiting 
in eighteen oases ; they attrlhuto it citlior to tlio abolition of 
Inryngospasm by tlio inliibition of a pathological reflex or to 
direct action on tiio sympathetic. Homo cougli porsisfed, 
blit It was mild and witlioiit tlie clmractcristlcs of whooping- 
cough. No Bcrions toxic symptoms or complications were 
noted. 'The anthers believe that tho drug is most useful 
during the second stage, and that siiiallcr doses would give 
relict without any toxic symptoms, 'Tiio lilood pressure 
showed a sliglit rise in six out of nine healthy children after 
ophcdrlno administration, 

167. Tho Danger of InJcotlonB of Saccharated Iron 
Carbonate Solutions, 

n. Kraft (Zcntralhl. f. C/itr., 110001111)01 3rd, 1927, p. 3092) has 
found that colloidal saccliaratod iron earbonato solutions, 
ndiniuistornd intravononsly, are of dofinito value in tho treat- 
ment of various infections and soiitic conditions. Tho injec- 
tions are often followed by a rapid snbsidonco of pathological 
syniptoms and a distinct iinproveinont lu liaomatopoiesis. 
Seventy patients so treated recovered, wliile in 250 other 
cases no untoward effects followed the injections. Tho only 
adverse signs wore siiilden transient rigors and pj-roxia. 
Boccntly, however, Kr,art lias had two fatal cases, sliowing 
that this trcalineiit is not free from danger. Tiio first patient, 
aged 18, liad appendix p^foratlon, followed by peritonitis 
and phlcgranioiis clianges ill tlio caecum. Abscesses followed 
in tho nbilomliial and pelvic cavities, and, as bronebo- 
pncnraonla ensued, 80 c.cm. of, saccharated iron carbonate 
solution was Injected. Tills was followed l>y a severe rigor and 
slgnsot circniatory falliiro; and four lioiirs later tlio patientdied 
from heart failure. Tlio second patient, a man aged 56, liad 
nndcrgouo gastro-jojiinostoiiiy for gastric cnrcinoina ; ibis 
was followed by symptoms of commencing pneumonia. An 
Injection of 100 c.cm. of saccliaratod Iron carbonate soJntlon 
was given, and fifteen minutes later tliero was a sovoro rigor 
lasting twelve mlnutos. Two lionr.s inter tlio patient lost 
consciousness, became dyspnooio, tho circulation gradually 
failed, and lie died lu ton lioiirs. Kraft states that the 
Baccliaratod iron solution onglit to bo perfectly clear reddish 
brown iu colour, and lio rocoinmeuds a 4 per cent, colloidal 
solntlon In twlco-distillcd water. 

163, Treatment of Ringworm by ThnlHum Aceta‘e. 

D, M. Lbvt (Ncdcrl. Tijdschr. v. Genecsl:., December 17tb, 
1927, p. 26111 .states that tills motliod was flr.st introduced by 
Cicero, and later employed by Busclike, Peter (354 cases), and 
Trokao (104 cases) with invariable success. The present 
author records his own experiences of this method in twenty- 
six cases of ringworm in patients aged from 3 to 16 years. 
Tho drug was given by tlio moutli, according to Buschke’s 
recommendation, in doses of 8 mg. for eacli kilo of body 
weight, 'riio lia’rs began to fall out in from two to three 
weeks; in a montli’s time tlie wlioio scalp becarne bald, and 
after anotlier four weeks a fresli growth of hair appeared. 
Tho lialr of tho scalp only was affected. No complications 
ocenrred except Iu one cliild who developed a generalized 
eruption of largo and small macules accompanied by nephritis; 
recovery followed in three weeks’ time, 

1G9, 17. G. Bronstein (Med. Klinili., December 2nd, 1927, 
p. 1854) reports 94 cases of ringworm treated in one year by 
tliallinm acetate, and describes experiments on animals. 
Ho finds tliat young ohildren stand the treatment better tlian 
older ones, and that severe albuminuria only occurs tbrougU 
a miscaloniation of dosage. He states that no departure 
from tho normal is discernible in children a year^lator. llis 
motliod is the administration of 0.008 gram of thallium acetate 
for each kilo of body weight in water before foo.1 in the 
morning; lie only treats children between the ages of 1 ana 
14. Tho hair comes out fourteen to sixteen days later, and 
growth begins again in four to six weeks. Comparing tins 
treatment with a: rays the author finds it to be more often 
successful, sliorter, less unpleasant, and followed by fewer 
complications. 

170. Iilver Diet In Nephrosis. 

O. Forces (Wien. Idin. IVoch., December 29th, 1927, p. 1640) 
reports a case of pernicions anaemia with extensive oed^a 
which demonstrates tho diuretic action of liver diet, ine 
patient, who had had a course of arsenic a month previously, 
had a severe relapse ; she was very anaemic and had exten- 
sive oedema. Arsenic injections produced an improvement 
in the blood state and also in tho general health, but wibliont 
reduction of tho oedema. Enphyllin and tbeooin produced 


FEB. iS, tgaSJ 


EPITOME OF CURRENT MEDICATi IiITERATURB.’ ' 


[ rmBBtiiF* 
UzOICiX 


29 


ilistlnct diuresis, Iho weight being reduced by 41b., when It 
became stationary. Liver diet tvns then coiniiioncod, and 
attor three days considornblo diuresis occurred, tlio ainouufc 
of urine passed daily rising to 4 litres. At the end of a fort- 
night the patient’s weight bad been reduced by IJst., whiio 
the erythrocyte count and the haoinoglobln Index Improved 
but slowly, so that the diuresis could not bo attributed 
to blood regeneration. When tho oedema bad disappeared 
onllroly a rapid rostltnttou of tho blood occurred. Theso 
observations suggest that tlio diuretic nation of liver diet In 
dropsy might liavo otlicr origins. In two cases of heart 
failure with hepatic cirrhosis, generalixod oedema, and sovoro 
ascites, tho liver diet prevented rocurronco of ascites after 
paracoutcsls, wlion all diuretics lind failed. In a caso of 
inodotato cacheotlo oedema, nssoclntcd with secondary 
anaomla following ulcoratlvo colitis, tlio weight was reduced 
by 61 lb. in eight days, oedema disappeared, and continuous 
impfoveinent in tlio blood condition followed. A case of 
dlnbotcs complicating alcoliolic liojiatic oirrliosis with slight 
ascites was cured by liver diet. In four days tlio weight was 
reduced by 6jlb. ; after llvo days' treatment tlio liver diet 
was discoutluncd, and sl.x days later tho patient’s weight 
had increased by GJlb. 'Tho patient’s general condition im- 
proved rapidly ; appetite returned and tho glycosuria was 
inhibited. Porgos agrees that tlio liver produces a hormone 
that regulates tho oxcrotion of water ; tills substance is’ not 
destroyed by cooking, and is active when administered orally. 

171. GIncoBo Medication. 

Admittixq the great value of intravenous glucose Injections 
in uraemia and toxaemia In conscqiiouco of tho supply of 
calories, tho relief of nausea, tho economizing of proteins, and 
tho completing of tho combustion of fats, W. E. Robertson, 
A. B. OLIEN-Slff, and D. Stein (3Jed. Journ. anil llecord, 
December 7(h, 1927, p. 654) have tried to doterinluo tho 
factors responsible tor tho untoward reactions and deaths 
which occasionally follow this treatment. They find that 
a concontiated solution alTords greater safety and freedom 
from reactions than weaker concetilratlons with larger 
volumes I tho rate of Injoctiou and tho tomperaturo of tho 
Bolullon aro also Important factors. They advocate tho 
injection by gravity at body' toniporatnro of 108 grams of 
doxtrosotn 180 c.cm. of freshly preiiarod sterile salt soUitlou, 
tho llmo taken holug never less than tlilrty in/nutos. tVlth 
this toolmtqno no rvaollous occurred in fourtoou consocutivo 
cases, although tlio patients wore sorlonsly ill, and it was 
found that a severely damaged cardio-vasculnr system was 
no contraindication. 'Tlio autliors conclude that untoward 
results aro duo to too rapid a rato of Injection, too largo 
a volume of fluid, and an improper tomporatiirc of tlio solu- 
non. Tlio uso ol distilled water is deprecated, since It has 
been shown to produce liaomolysis and occlusion of tho 
coronary arteries and poripUorul vessels. 


to have given approximately 82 per cent, of cases cured or 
Improved and 16 per cent. of. failures. Reference is made 
to tho paper by S, Gilbert Scott (British Medicai, Jouenae, 
Jnno 5th, 1926, p. 939), who, in 21 cases treated by combined 
thoracic and sjjlonlo irradiation, obtained very good results 
In all but ono. Tho present authors treated 64 patients of 
both soxos, of whom 31 had asthma only, 8 spasmodic coryza 
alone, and 25 had both affections. Almost ail the patients 
were adnits, and the cases were not selected. They report 
30 per cent, cured, 25 percent, improved, and 45 percent, 
were failnres, or showed only temporary improvement ; 
26.5 per cent, of these were total failures. Borne patients 
remained cured or greatly improved lor fifteen or eighteen 
months. Tho authors believe that their best results followed 
combined thoracic and splenic irradiation. Twelve treat- 
ments may be necessary before a case can be regarded as 
a success or a failure, and many patients have improved only 
after 6, 8, or 10 Irradiations. In apparently similar cases tho 
treatment succeeded in one patient and failed In another, 

174. Radiological Bxamlnatlon of tho Trachea. 

M. SaAlilTZER (Jl'ten. klin. iroch., Soiitember 15th, 1927, 
p. 1181) states that acciirato infoimation regarding altera- 
tions In the position of the trachea may be obtained 
radiographically if tho patient is examined in the lateial 
position, with tho shooldors thrown well back, as wed 
as in tho antero-posterior position. The information thus 
obtained is very nsotul In cases of enlarged thyroid when 
surgical treatment is under consideration; it will assist in 
differentiating dyspnoea directly dne to pressure on the 
trachea from that due lo cardiac weakness, so that operation 
on nn enlarged thyroid which Is not really afiecling tho 
trachea may bo avoided when the heart is embarrassed from 
toxic or other cannon. In some cases goitres of very slow 
growth m.ay compress the trachea to a considerable extent 
wlthont producing resi>ir!itory symptoms; in these an x-ray 
examination will demonstrate the need for an operation it 
tho risk Is to be elimlna'ed of sudden acute dyspnoea or even 
suffocation from obliteration ol the lumen of tho trachea, 
which such conditions os mild tracheitis might produce. 
Sg.alitzcr adds that screening will also show the sizo and 
position of a substernal goitre, ns well as the range of 
mobility of the U'aoliea on coughing and deglutition ; this 
information is valuahio, since the presence ol extensive 
adhesions considerably increases the difilcalty of thyroid- 
ocloniy. The extent to wliich pressure has produced atropliy 
of tho rings ol the trachea, with consequent weakness of tlio 
tracheal wall, may bo seen from the amount of bulging or 
rotrnction of the tracheal wall produced when forcible expira- 
tion or Inspiration is atlempled while the external respiratory 
passages are closed. This atrophy is an Important Indication 
for surgical treatment, 

179, IntravenoQS and Peroral Metliods In 

Cholecystography. 


Radiology. 


Radium Implantation In Oasophngcal Cancer. 

Soptomhor, 1927, p. 660) recognizes 
radium lu oosonliageal cancer: 
placing it accurately ; (’2) tlio practical 
eflpi-tn 1 maintaining It iu position long enough to bo 

?''^d (3) tho great danger of biirniiig the tissues, 
Invariisi fistula iuto the mediastinum, 

ot raiiin, accident. He has elaborated a locliaique 

‘‘nplantation through n specially de.signed oeso- 
imiil’-intf^^" operation is Illuminated and an 

emnlnvifi through tho tube. The radio-active souice 

tho*^ platiuum radon seed, which offers 

Indnen advantage of being so screened (hat it will not 
an possibility of removal by menus of 

the nsn •J’fead. 'The entire procedure is facilitated by 
The rpsnifo « ° fluoroscopo, though tliis i.s not essential, 
laethoil h,.,, small series of cases so far treated by this 
“““ have been gratifying. 

p_ Asthma and Spasmodic Coryza. 

Cmude ®ibert, P. Blamoutieb, and F, 

ployed JraTtretf"'’ 5th, 1927, p. 1201) have em- 

ooryza with c.-!, naAos of asthma and spasmodic 

from the literamvo‘’°°m ‘'ssults, and cite suiiporting evidence 
thorax and . ,e methods include irradiation of the 

heen iitadn to combined, and apjilications have 

ophthaliuio asthma associated with ex- 

tliere is olten -> results have been very variable; 

authors onotn trausient iuiproveuieut. 'The 

irradiation • thoo,. iuvestigator» who used thoracic 

“tS per cent.' ol nnooo approximately 30 per cent, of cures, 
failures, On tho relieved, and 27 percent, of 

other hand, splenic x ray treatment appears 


T. Sendtner-Voeldeknliorpp (Jled. Klinik, September 9tli, 
1927, p. 1374) contrasts the two methods of filling the gall 
bladder in cholecystography, and emphasizes tho value of 
tho peroral method. In this be maintains there Is less 
danger to tlio patient ; it is easier, and gives equally good, 
results. He uses a preparation called “ videofel,” either in 
the form of pills or of c.v'psules containing 0.5 gram each, tho 
dose being one pill per 10 Icilograms of body weight. Theso 
pills, in common with all tetraiodio preparations, do not keep 
well. The patient should have a light meal and an enema in 
the evening, alter which the pills should be given with cream. 
Tliis not only disguises the pills, but, as an emulsion of fat, 
assists in -emptying the gall bladder. The patient then fasts 
for twelve hours, after which the x-ray examination takes 
place. The author adds that he has never observed any ill 
effects to the patient result from this method, and iu 36 out of 
50 cases the gall bladder was made distinctly visible. 


Obstetrics and Gynaecology. 

170. physiotherapy in the Treatment of Salpin^o- 
ocphoritls, 

H. Dausset and A. Chgnilleau {Paris Med., December 17tli, 
1927, p. 499) describe the treatment of salpingo-oopboritis in 
the pbysiotberapeutic department of the Hotel-Dieu iu Paris. 
The treatment of clioice in tuberculous cases is beliotborapy 
and ultra-violet irradiation. Hyilrotberapy', diathermy, and 
vaccines are recommended for all other cases, irrespective of 
etiology', though vaccines are said to be particularly valnablo 
In the gonococcal group, which is otherwise very resistant to 
treatment. The bydrotherapeutic procedures include vaglual 
irrigation at minimal pressure with 100 litres of water aft 
104'’ to 112'’ F., continued for at least half an hour, spraying of 
the abdomen and loins with water at a temperature of 112’F 


29. O 


30 FEB. i8, igaS] 


EPITOME OF CUREENT MEDICAL LITERATURE. 


r TttKDiimMt 

L UXDICAL JovzxiC 


a quick sliower lasting half a ininuto to a minute, commencing 
■with a temperatnro of 100’ F. and cooling clown to 8G'’. 
Auothof method is theadmiuistiatiou of a hot vaginal donche, 
104’ to 108’ F., under water in a batli at blood heat; about 
100 litres of water are given in ton minutes, and a shower h.ith 
couc'udes the treatment. For diathermy an apparatus yield- 
ing 3.5 to 4 amperes is used. The electrodes aro placed over the 
abdomen and lambo-sacral regions, with or without another 
in the vagina, or one may be introduced into the rectum and 
tlie other placed over the abdominal wall. Bipolar electro- 
coagulation w'ith Walter's apparatus and a current of 200 to 
401 milliamperes is said to bo of particular value in subacute 
ciso=<. Heliotherapy may bo general or localized over the 
abdomen. Ultra-violet irradiation is applied by means of a 
mercury vapour or an arc lamp ; for local treatment alone 
a 20-ampcre BGnard lamp is used, while intravaginal applica- 
tion is effected by an arc lamp and a vaginal speculum. 
Local irradiation with infra-red raj'S is also used, and with 
the total rays of a metal filament lamp of 2,000 to 3,000 candle 
power. Gynaecological massage, direct or indirect, and 
active movements, such as abduction and adduction at the 
hips, complete the course. 

177. Iiar^e Ovarian Cyst. 

C. E. Baltar {Revista Clinica de /lilbao, Soptoraher, 1927, 
p. 419) records the case of a woman, aged 42, ivho had passed 
tlio menopause nine months previously. For a year she had 
had pain in the lower abdomen and a fooling of weight in the 
gastric region. Gradual increase in the size of the abdomen 
occurred, and later became rapid. 'The circumfcrenco of the 
ab lomon was 44 inches ; it was wholly occupied by a tumour, 
wliich also invaded tlie base of tlio chest, pushing forward 
the xiphisternum. Through the iiosterior vaginal fornix a 
cystic swelling could bo felt. The diagnosis of ovarian cyst 
was made. In order to reduce the pro-isurc ofTects para- 
centesis of the cyst was peifonned under local anaesthesia 
and a large quantity of blackish iiseudo-mucinous fluid, 
typical of ovarian cyst, was evacuated. Tlio pa'ient ex- 
perienced much relief from the ovacuation.of this fluid. The 
abdomen w'as later opened through a median subumbilical 
incision, which had to be lengthened to deliver the tumour, 
the pedicle being ligatured with catgut. Tlio po 3 t-o|)crativo 
course was uneventful. The weight of the extirpated 
tumour was 48 lb., wliich with that of the 25 pints of fluid 
evacuated made a total weight of 92 lb. 

178. Trial Labour. 

H. Bailey and H. C. Williamson {-loimi. Avicr. Med. Assoc., 
December 17th, 1927, p. 2085) recall that the primary indica- 
tion lor Caesarean section is pelvic contraction, or dispropor- 
tion between the size of the child and the mother’s pelvis. 
The mortality from Caesarean section performed after 
protracted labour has been from 10 to 15 per cent., so that 
a trial labour in cases of pelvic contraction has not been 
justified; with the recent development of the low cervical 
Caesarean section, which decreases the danger to the mother, 
a primary test of labour is, however, permissible. As regards 
contraction, they recognize three types : (1) The normal 
pelvis, AVith an estimated true conjugate of more than 9.5 cm. 
or with a bisischiatic diameter of more than 7 cm. (2) The 
relatively contracted pelvis, with a true conjugate of from 
7.5 to 9.5 cm. in the generally contracted pelvis, from 
7 to 9 cm. in the fiat pelvis, and from 6 to 7 cm. as an outlet 
measurement in the funnel-shaped pelvis. (3) The absolutely 
contracted pelvis, where there is a true conjugate of under 
7.5 cm.' in the generally contracted, under 7 cm. in the flat, 
and under 6 cm. for the bisischiatic diameter in the funnel- 
shaped pelvis. 'Of 11,491 deliveries under their control daring 
a period of five years there were only five cases of absolute 
contraction and 671 cases of relative contraction, as estimated 
by these measurements. With the exception of the live cases 
of absolute contraction and twenty-four elective Caesarean- 
sections, the ■\vomen w'ere given a trial labour. In 65 per 
cent, of these deliyerj’ was spontaneous. The remainder 
were delivered by operation, and of these 9.9 per cent, 
required Caesarean section. No maternal deaths followed 
the sections, and in the entire series there were onlj^ three 
deaths. The authors conclude, therefore, that it is advisable 
to give all patients with relatively contracted pelves a trial 
labour. The unknown factor in every labour is the mallea- 
bility and compressibility of the foetal head and the force of 
the labour pains. Many foetal heads which are unengaged 
before labour rapidly monld and enter the pelvis at the onset 
of good contractions. The patient .should he permitted to 
have a trial labour of at least twelve hours of bard pains, and 
this should be conducted without vaginal or rectal examina- 
tions, in order that the vaginal tract may be free from infection 
should operative delivery become necessary. It, at the end 
of this time, the foetal head has not entered the pelvic canal, 
as can be ascertained by means of the Pawlik grip, a low 
Caesarean section should be performed : if the head has 
- ■ 


entered the canal tho patient wilb cither deliver herself 
spontaneously or should bo delivered by forceps. Tho 
authors believe that a trial labour is more complete if it is 
porinlttod to continue after tho rupture of the membranes. 
Even it tho foetal head becomes engaged after strong pains 
labour is not allowed to continue until tho patient is ex- 
hausted or until harmful pressure on the soft parts may occur. 
Spontaneous clolivory, they add. In relatively contracted 
pelves can be accomplished in a labour that is no longer 
than normal. Trial labour reduced the incidence of Caesarean 
section in their 676 cases to 14 per cent., and there were no 
deaths; tho gross foetal mortality was 6.2 per cent. 


Pathology. 

179. Prccipitable Substances derlyed from Typhoid 
Bacilli. 

J. FOUTH and K. Landsteinep. (Joiirn. Exper. Med., January, 
1928, p. 171) have isolated two serologicalli’ active protein 
substances from 11. typhosus, and another substance, chiefly 
of carbohydrate nature, that reacts as a speoific iirecipitablo 
body. The first protein substance was extracted from the 
bacilli with 75 per cent, alcohol ; the second protein substance 
was obtained by saline extraction of tho bacilli remaining 
over from the first process. The carbohydrate substance was 
obtained by digesting with trypsin bacilli which had been 
extracted with alcohol ; the material resulting from digestion 
was made strongly alkaline and precipitated with alcohol. 
Tho protein substances were destroyed by tryptic digestion 
and by treatment with antiformin ; tho carbohydrate sub- 
stance, on the other hand, resisted both these methods of 
digestion. Serologleally, it appears tliat tho carbohydrate 
substance is rosponsiblolor the specific precipitation obtained 
with an immune typhoid scrum. Similar specific precipi- 
tablc substances wore obtained from IS. paratyphosus B, 
IS. cuteritidis, and JS. protens. ' 

■ 180. Bactericidal Power of the Blood after Ultra-violet 
Irradiation. 

L. Colebp.ook, a. Eidi.sow, and L. Hill concluded from 
exporiihents tliat tlic blood of animals submitted to irradia- 
tion with ultra-violet light has an increased bactericidal 
power, the increase reaching a maximum one hour after 
exposure and being followed by, a return to normal in throe 
hours. I. TataRAMU (C. R. Hoc. de JSioloyie, January 4th, 
1928, p. 1737) has repeated these experiments. Rabbits were 
exposed to rays from a quartz lamp (4 amperes, 110 volts) for 
thirty minutes at a dislanco of 40 cm.; the part of the body 
exposed was shaved twenty-four hours previously. Blood 
was withdrawn from the auricular or saphenous vein before 
ever}^ exposure, and half an hour, three-quarters of an hour, 
one, two, six, and twenty-four hours after it. The blood was 
detlbiinatcd, and tested’ immediately for its bactericidal 
action on Staph i/lococcJis aureus. The technique employed 
differed from Wright's only in that tho organisms wore sus- 
pended in Ringer’s solution instead of in saline, tho latter 
having, ns has beea shown by numerous workers, a disinfec- 
tant action on bacteria. Tataranu made experiments on ten 
rabbits, but failed to detect any difference in the bactericidal 
power of the blood after exposure to the ultra-violet rays. 

IBl. Ifarletles of Immunization. 

E. Sarg.ent, L. Parrot, A. Donatien, and F. Lestoquarp 
{Arch. Inst. Pasteur d'Algeric,vo\. y. No. 4,1927, p.469) observe 
that from tho standpoint of immunity infectious diseases 
cau be divided iuto two groups, lu one, acute and cyclic, 
a true immunity is conferred on tho organism ; this is chaise- 
tcrized by a complete disappearance of tho causal microbes 
and by a resistanco of the cured subjects to all reinfection. 
Such diseases in::lude small-poi:, scarlet fever, and measles. 
In the other group, after an initial period of invasion marked by 
reactions, an equULbrinm is established between the organic 
defence and the microbic attack, the patient becoming to all 
appearance cured, though tho aggressive micro-organisms 
still persist. Sj'philis, tubercnlosis, and malaria are examples 
of such infections. The authors assert that the terms 
“relative immunity and “immunity tolerance” are really 
incorrect, as they express a part only of the phenomenon of 
immunity — uaineljstho inuring of the organism to infection — 
and omit the other essential characteristic of resistance to 
reinfection. The term “ premunition ” is suggested as being 
more appropriate, its definition indicating “guarding by 
precaution.** Premuuitive vaccination would be descriptive 
of such measures as antituberculous vaccination with bacillus 
Calraette-Gu§rin vaccine. Five methods of preraunizing are 
described. The authors maintain that, though still theoretical, 
premunition can bo a useful therapeutic measure, and that 
further work is necessary to perfect the present methods and 
to discover now ones. 


I Tit* UiiJTira 
UiDicxs, Jor*«*i> 


FEB. 25t J^S] 



EPITOME OF CURRENT MEDICAL LITERATURE. 

- _____ • / 


Medicine. 

162. Sodlnm Salicylate Poisoning following Injections. 

E. G. JOUGENSRS (Uffcskrift tor Lacr/rr, Jnuimry 12th, 1928, 
!p. 31) rcconls tho case of n wotnnn, ngoil '55, wlio rocolvotl 
tbreo Intravenous injections of Kodlimi sniicyinto (5 o.cm. of 
a 20 percent, solution nt cnoli Injection, without any abnormal 
local or fionoral roaoiiou. A weel: utter the third Injection 
the fourth and last Injection of 5 c.cin. of a 20 per cent, 
solution w.as given one morning without any dlfllculty, hnt 
two or tUrco hours later tho patient complained of headache, 
tinnitus, shivering, and severe perspiration. Ifer face, hands, 
and feet rapidly became oedomatons; she was hardly recog- 
nizable, and her hands wero bloated and shapeless. During 
the afternoon of tho samo day an urticarial erythema brolto 
ont, being most marked on tho face and lower limbR; somo 
petechlao api>carcd on tho inner side of both thighs. In the 
evening she suffered from nausea and repeated vomiting, 
hot there was no diarrhoea or disturbance ot micturition. 
Jtespiration was somewhat lahoured nud rapid, but there was 
no hoarseness or congli. She was very frightened nud rest- 
less, and complained ot ficvcro palpitation of tho heart; the 
pnlto was quick, soft, and regular; the tompernture was 
normal and tho iiriuo contaliiod noaihumln, blood, or sugar. 
The oedema, rash, ami headache disappeared after about 
twentj’-fotir hours. Tho patient had imeviously taken largo 
doses ot aspirin without ill effects, nud tho llrst three injec- 
tions of so.litun salicylate had heoii well tolerated. So far as 
the treatment of the varicose veins was concerned, tho four 
injections were sncccssfut. Discussing the possibility of this 
form of poisoning, tho author romarks that his is proh.ably 
the llrst c,ase to bo recorded in Denmark, and ho notes that 
Sicard nud Gangicr have observed only tavo cases among 
several thousands of patients given Intravenous Injections 
of sodium salloylato. In one case urticaria developed 
directly alter the injection. In tho other twenty-four hours 
sahicqnently. 


Diphtheria Without Iilcmbrane. 

Uocemher 3rd, 1927, p. 1476) states 
luatuiphtberia without dellnito momhrano i.s most frequently 
I below tho ago ot G months, wlion It 

‘ otitis, inflammation ot tho nmhilicns, 

the ears, imt chiefly as rhinorriiocn. 
hvn,.^. nasal localization ot diphtheria was recognized 
fnrm *'*” unuio to tho disease, the only 

thnt n. vccojnized for a long period was 

ft li'ombstalucd mcinhranous discharge; 

Hutliiel drew attention to tho 
°* diphtheria bacilli in the purulent nasal dlscliargo 
^dter JIarfnn, Kibadeau-Dumas, and 
nVrt,.' , I 1 even tbo mildest form ot nasal 

civoo 1 " contain diphtheria bacilli. Tho apparently 
io*ri> iddy develop croup, hroncho-puenmonia, 

? 8d'’dro form of infantilo diarrhoea, the 
itesnAm 7 * °^ may escape recognition. Tho clinical 
the , 11 , ®^°,'^“'°^ nasal diphtheria are not distinctive, 
uination ® made by bacteriological 


ErEPUnr Wave Velocity. 

>sscs the December 12th, 1927. p. 32’ 

itiouR anri”ivf° ypiodity in certain patliologicr 

pulse velocitv Bhe’^o'i ,i>°*'b ! f be blood pressure an 

rds age individual variations, particularly a 

g aormarvah°^-, l>ds been experienced i 

3ns showed these, bnt a study ot 90 health 

er than lift , normal blood pressnre should not h 

3dl pulse than 80 mm., tb 

"■itis and artpr^^J^i”" ® a second. Chroni 

irtonia. Testo “’'d principal causes c 

iritis with men and 1 woman) of chroni 

2 velocity is In^rop*? showed that in this condition th 
dot proportionatJ'^'^T* *'*''**' pressure and velocit 

rterio-aclerosis wl'n. , fidse.s i9 male and 11- femah 

3dsed, and as s ^ bypnrionia the pulse velocity wa 
sure. In ps indium dorrospomled to a high bloo 

rioscletosis withonV ® 8 

greater th,an in ?yP°rtonia the pulse velocity wa 
rlQ-sclerosis. In samo ago class wlthoi 

penaated valvular dfr 7 disease, neurosis cordis, an 
d Showed nd urano inn^?''® rrelooity of the puls 

pronounced pathological -changes/ 


roanlts In arrhythmias were inoonclnsive, ns many of the 
patients had other complications. Beyerholm asserts that 
tho clinician may be assisted by ascertaining the pnl.se -wave 
volocily, wiiou, after oixlinary blood pressure measurement, 
there is a doubt ns to tho presence ot hjpertouia. li, for 
instance, in chronic nephritis or supposed nrterio-solerosis 
n systolic blood prossme is found which varies between 
130 nml 150 mm. of mercury, n pulse Wave velocity ot 
9J to 10 metres a second, or more, will practically be 
evidence of tho presence ot hypertonia, and at any rate 
provide certainty that tbo circuiation conditions are patho- 
logically altered. In over a thousand examinations ot 
about 200 cases such a velocity occurred only in patients 
with liypcrtonia. 

185. The Ocular Manifestations of Epidemic 
Encephalitis. 

AccoiiDING to G. W. 'V'A.VDEORIFT {.Ved. Journ. and Jtccord, 
December 21st, 1927, p. 729) paralysis of convergence is a 
very common prouromal symptom ol epidemic encepiialitis ; 
tho patient complains of donblo vision, especially on reading. 
Instead of paralj’sis ot convergence there may be a paralysis 
of a lateral ninsc!e,'u8nally tho external rectus, willi homo- 
nymous diplopia, or a paralysis of divergence with the same 
diplopia without paralysis of cither external rectus. While 
ptosis may accompany any of theso paralj’ses it is more 
likely to be a later development. Fundus examination 
roveals marked fnlluess ot tho central vein and its branches. 
Optic neuritis is rare and choked disc develops only as a 
result of very high Intracranial pressure. As thesevediyof 
tho disease increases, photophobia and visual irritauility 
appear. Tho usual ocular paralysis is of the tiiird and sixth 
nerves, soparatcly or in various combinations; abducens aud 
iovator palsies are common. Fourth nerve paralysis is rare, 
.'tssoci.atcd with the ocni.ar palsies may bo disturbance ot 
other cranial nerves, especially the fifth, seventli, ninth, and 
tenth, and any or all of those may bo accompanied by sym- 
pathetic disturbance. The pupillary reactions show a great 
vaiicty; one or both eyes may ho involved, and, when 
binocular, the plicnotncua may bo similar or dissimilar. In 
35 per cent, tliero wa-s defoctivo pupillary linht react on with 
irregularity nud inequality. The Argyll Robertson pnpil may 
•bo present, though more frequently tlie convergence is absent 
las well ns the light reaction. As the acute encephalitis 
subsides the ocular symptom may disappear or persist, or 
Ithcro may be a recurrence of ocular symptoms after periods 
of absonce or quiescence. The value of treatment is doubtfnl, 
,but bismuth salicylate intramuscularly and sodium iodide 
•iuternally maybe ot beuollt in some cases. In the later 
stage a bosmetlc operation may be needed. 


Surgery. 

186. Etiology of Congenital Torticollis. 

A. HELIjSTADIUS (Jefrt Chir. Scand., December 24th, 1927, 
p. 586) has collected tho 23 cases of congenital torticollis 
observed In the period 1915-25 in a children’s hospital in 
Gothenburg. Among these there were two with a family 
history of torticollis, the younger sister of one patient and 
.the uncle ot another having also suffered from it. It was 
signillcant that in as many as 15 of these cases the confine- 
ments had been abnormal’; there had been a breech presenta- 
tion in 13 cases, and forceps had been required in 2 other 
cases. With tho exception of 2 ont of the 23 cases, fairly 
accurate data were obtainable as to the time at which the 
torticollis had begun to develop. Only in 5 cases was this 
condition present at birth ; in 5 other oases it appeared 
during the first year of life, and in tho remaining cases after 
an interval ranging from one to twelve years. The facts that 
in several oases the disease appeared many years after birth 
and developed gradually are, in the author's opinion, opposed 
to the theory that torticollis is of i-chaemio origin. There 
were 16 cases in which the torticollis was associated with 
BAiymmetry ot the face, but the degree of the one con- 
dition -was not proportional to that of the other, aud the 
author adds that tho type of asymmetry ot the face most 
often found in association with torticollis’ may also exist in 
the absence ot this condition. He concludes that, although 
the frequency ot abnormal conlluements (notably breech 
presentations! is exceptionally high in association with torti- 
collis, the most favoured theory as tb its origin hinges on 
hereditary factors. - ... - • . 

434 A 



32 Feb. ss , 1928] EPITOME OF CUEBENX MEDICAL LITEEATUEE.' [ii/mcij"".! 


187, Empyema in Children. 

C. E. Farr and M. I. Levine {Surg., Gynecol, and Obstet,, 
tfannary, 1928, p. 79) review n series of 371 cases of erapj’otaa 
In children especially with regard to age, incidence, and 
organisms. All were treated surgically, and definitely 
diagnosed by aspiration and a rays. At least 92 per cent, 
were secondary to an attack of pneumonia, tho highest 
Incidence occurring In the second year of life. Tho death 
rate reached Its highest point during the first year of life, and 
steadily declined after tho second year until tho ago of 6; 
after this death seldom occurred save as tho result of some 
complication, and it was not directly duo to tho empyema 
Itself. In the first year the pneumococcus was rosiionsiblo 
for 22 per cent, of the cases, whereas it subsequently averaged 
about GO per cent. During the first year stroptococcal and 
mixed infections showed a higher percentage. Treatment 
consisted chiefly in a primary aspiration to ascertain tho 
nature of the pus, followed by open draining by resection 
or intercostal incision with open tube. Tho best tiino for 
operation depends entirely upon tho general condition of each 
Individual case, since tho gravity of tho prognosis is increased 
if an operation is undertaken before tho pus has becomo thick 
and the cavity well walled off. Bccurronco seldom results 
it free drainage is established and maintained until tho 
wound closes. 

188, Henal Distortion. 

G. W. Beecher {Joum. Amsr. Med, Assoe., Deoombor Slth, 
1927, p. 2166) considers tho relation of renal distortion to 
nephralgia, a distorted kidney being one in which a part or 
the whole of the pelvis is twisted, tilted, or bent from tho 
normal position. When such a condition, as shown by the 
pyelogram, is associated with nephralgia and tho pain la 
jndneed by distension of tho renal pelvis or ureter tho dis- 
tortion of the kidney has to bo considered as a possible factor 
in its production unless some other pathological condition of 
the urinary tract is present. Renal distortion may only bo 
discovered by chance, since it does not usually cause any 
symptoms; in some oases nephralgia results, which maybe 
intermittent and postural or be caused by the cneroaohment 
of neighbouring viscera, commencing hydronephrosis, post- 
operative oioatrlzatlon, or arterio-solorosis. Belcher states 
that care must be exercised In interpreting tho pyelograms, 
especially if there has been previous nephrotomy or nephro- 
pexy ; if there are any other associated dlsturblng'conditlons 
they should be treated before operating for tho relief of tUo 
pain. In any event the patient should bo undpr obaorvatlon 
for a considerable time and other measures tried. . If an 
operation is to be performed the author advises decapsulation 
and section of the nerves of the renal pedicle should tho 
kidney function be fairly normal; but in the' presence of 
severe symptoms and marked atrophy nephrectomy with 
removal of the capsule is recommended. 

189, Diagnosis of Congenital Dislocation of the Rip, 

In a number of cases of congenital dislocation of tho hip- 
joint Lorenz’s bloodless method of treatment fails to effect 
a cure because of a constriction in the capsule, which may 
be hour-glass in shape or due to bands or the llio-psoas 
muscle, and which it may be impossible to diagnose clinically 
or by ordinary radiological -methods. - H. Bronneb [Zcntrglbl. 
f. -Ghir,, December 10th, 1927, p. 3237) has found the injection 
of air into the capsule of considerable diagnostic value, 
especially in older patients. Tho position of the acetabulum 
is ascertained by an a- ray examination and the thigh anaes- 
thetized locally with novocain at this level at the border of 
the tensor fasciae femorls and sartorlns. A 15 cm. needle is 
introduced at an angle of about <15 degrees to the vertical, 
pointing towards the centre of the acetabulum, the direction 
being, If necesoary, controlled by screening. . When the 
resistance of the floor of the ace^bulum Is reached. the' 
needle is pvesseu firmly home to ensure piercing the anterior 
part of the capsule, and then withdrawn' Blightly, before 
filtered air is slowly and carefully injected; the quantity 
and pressure are controlled by the subjective sensations of 
the patient as in pyelography. A series of skiagrams is 
taken at different stages of the injection and with the pelvis 
and leg in various positions, so as to obtain even distribution 
of the air and the best image of the acetabulum. Bronner 
maintains that by tin's method, found to be freo from danger, 
it is possible to estimate the extensibility of the capsule and 
the relations of the surrounding soft parts to it, which is of 
considerable prognostic value. The results oompiire favour- 
ably with those obtained by the iodipih injection method 
recently advocated by Slevers, certain disadvantages of the 
latter method being avoided — such as the need for using a 
wide-boro needle or cannula, the risk of obscuring the skia- 
grams bj- spilling an opaque fluid into the surrounding 
tissues, and the slow absorption of the injected fluid which 
may interfere with subsequent skiagrams. 


Therapeutics. 

IDO. Bodlum Chloride Injections In Acute Intestinal 
Obstruction. 

A. GOSSET, L. BINET, and D. PetIT-Dutaileis {Pressc Med., 
January 7tli, 1928, p. 17) ooncindo, from a study of tbo 
cvidouco obtained by Froncli, Britisli, and American rescaroli 
wovkotn, that tho Incrcanlug toxaemia from the moment 
when obstruction occurs is duo to the using up of tho sodium 
chloride in tho blood in tho course of tho converslou of toxins 
Into Bomo innocuous compound. They give experimental 
flguros to show tho decrease of sodium chloride iu tho blood 
after cxporimontal tying of. tho intestine in dogs, and record 
how, In other cxporimontal cases tvhero tho intravenous 
administration of liyportonlc salino solution has kept tho 
Bodinm clilorido content of tho blood at tlio normal love!, the 
life or tho animal has boon prolonged beyond the nsu.al three 
or four days after operation to ns nuioli ns twenty-eight to 
fcliirty days. Tlio authors tliiulc tliat tho diminution of tlio 
sodium clilorido content of tlio blood is a far more important 
factor in eases of intestinal obstruction than the mere loss of 
fluid by vomiting ; moreover, tliey show Iiow tho urea and 
residual nitrogen content of tlio blood constantly rises ns tliat 
of tho RO'.ilum clilorido falls. They describe cases ol acute 
intestinal obstruction in Iiumnu beings whore severo toxic 
symptoms had supervened in spito of surgical relief of tlie 
condition, and In yliioli tiio admluistration of liyportonic 
sodium chlorldo intravenously had brought tho patients from 
a moribund to a convalescent state. In one series of cases 
reported in America tlioio was an operative mortality of only 
11.1 per cent., ns compared with 50 per cent', in liiiotlier series 
not troatod by this method. Tho authors consider that intra- 
venous medication should bo hogiin immediately niter opera-, 
tlon ; tho longer the delay the loss is the likelihood of success. 

Tho maximum doso is given ns 1 grain per kilo of body weight • 
during forty-eight hours (that is, about 70 grams for a man of 
nvorago weight), but a total quantity of about 20 grams is 
said to bo sufilclcnt to make good tho loss of body fluid. 
Subcutaneous administration of 1 litre of physiological serum 
should bo given during tlio same forty-eight hours. Although 
stronger. concentrations have been used without mishap it is 
reoommondod tliat a 10 per cont. hyportonlo saline solution 
should bo employed, and that not more than 30 o.cin. should 
be given nt a time, ■ ■ 

191. Epidural Administration of Drh^s. 

W. SonOENFEED [Urol, and Cut. Beu., November, 1927, p. 710) 
states that tho epidural method of injecting drugs was Intro- 
dneod into medical practice by Cnthelin more than twenty- 
five years ago, since when it has been used extensively lor 
tho Introduction of nuaostlietics, especially cocaine and novo- 
cain, of normal salino solution in the treatment of nocturnal 
enuresis, and of yohlrabino in tho tveatmant of impotouce. 
Schoenfeld now dlscussos tho question whothor tho epidural ; 
administration of bromidos, iodidos, and salvarsan is useful 
in practice, and comes to tho following conclusions. Solutions 
of 3 to To per pent, of sodium bromide or iodide when intro- 
duced opidhrally in doses of 30 c.cm. pass into tlie spinal 
fluid. Therapeutic results, therotora may bo expected, in 
those, diseases in which large quantities of bromides or. 
Iodides .are Tequirod. .Little, is to be expected , from the . 
epidural administration of salvarsan, since the passage of- 
this drug into the spinal fluid cannot bo detected after 
epidural injection; . ... - ' . . ' 

193. Insulin Treatment of Diabetes. 

M. LABbE [Ann. de Med,, December, 1927,- p. 563 ) .discusses 
tho insulin treatment of diabetes.as regards the Indications, 
technique, and results. In grave diabetes -with nitrqgenons . 
denutrition and acidosis two methods of procedure • may be ■; 

followed. By a oilculation of the weight and height of the 
patient a diet is instituted which provides the necessary 
calories, and insnlin is given in doses approximately ,caIon- - 
lated on the tolerance for carbohydrates and on the hypothesis 
that one clinical unit of insulin utilizes about 1 gram of 
carbohydrate. LabbS prefers to follow another niethod. :■ 
Commencing with a diet of green vegetables, insulin is given 
in small doses of 10 to 20 units a day. At the end of three 
or four days the diet is gradually augmented, and, if the . 
glycosuria reappears or increases, the insnlin dosage is 
progressively increased from 30 to even 100 units fiuily. 

IVhen tho nutritive equiilbrinm has been established this 
^should be maintained and the patient kept without hyper- 
.glycaemia and acidosis by a suitable diet and insnlin dosage. 

In diabetic coma, which is preventable by a careful ad^ierence • 
to treatment, heroic measures are necessary, and 20 units 
.of Insnlin should bo injected every half-hour. IVlien iniprove- 
ment results the time Interval is gradually increased until ■ 
only 60 units a day are given. In order to ensure rapidity ol 


FEU. 251I928] 


EPITOME OP CURRENT MECIGAIi LITERATURE.- 


[ TjiEBRmnx 

MEDICAt, JOtmSAI. 


33 


Diction tlio llc.st Injoctioim kIiouIcI bo IntnivonoUH, and the 
subseqtiout ones Inti'iimnsonlai- or stibculaneoiiH. Owing to 
tho excess of iusulliv iiyuoglycnyuilo ooiiin may suiiorveno, 
inwliioh case injections of 5 pur cent, glncoso are recpiirod. 
As a rnio, iusniiu is not necessary in diabetes without do- 
nutrition, and should oidy bo given in .severe cases in modcrato 
doses of 10 to 20 unlt.s daily; lliero aro no apocillc contra- 
imlicatious to its use. Tiio injections aro nsiially given 
subcntauconsly ns a slow ab.sorptiou is desirable, or intrn- 
uiuscularly ; tlio intravenous route is employed only in urgent 
cases. Other methods, as by tlio mouth or nnres, in sup- 
positories, enemas, or luuuctlouH, aro inelllcnoious. Abscess 
fonnatiou and dermatitis may occur during treatment, but 
tho serious complications aro the conscquonco of hypo- 
glycaeinln due to too strong a do.sagc. Though tho favournblo 
results following a persevering and energetic treatment aro 
oaconraging no autlicutlc case of euro lias yot been reported. 
Labbe boliuve.s that no case of true diabetes is refractory to 
insulin treatment. 


193. Therapeutic Uses of C.-irbon Dioxide. 

J. C. WUITE and L. AI. Huiixthai. {Iloston end Siitg. 
Jouni., December 15tb, 1927, p. 1117) roviow the present 
tberapentlc status ol carbon dioxide, c.specially with legard 
to research during the past seven years in ils usoas a respira- 
tory Btimulanl. In conccnlrallons varying from 5 to 7 per cent, 
its uso is recommended lor all purposes wliero a respiratory 
stimulant is needed, but in cases of carbon monoxido poisoning 
it sbonld bo given in oxygon ratlier Ilian in atmosplioric air, 
since by tids means tlio dtssociatiou of carbon itiaiioxldc bactuo- 
globin is more rapidly brougtit about. Tlio autliors iiicntlon 
its value In tho elimination ol volatllo drngs — as, lor oxamgilo, 
in ilc-ctliorir.ation after aimcstliosia by tiio dosed motliod 
and in alcoholic Inioxicatioii— and ns a iiicaiis of producing 
smooth and rapid imluctlou ill a struggliug patient or in ono 
who pci-sistcntly holds Ids hrcalli. In oomliatiiig respiratory 
failure .alter overdoses of deiircssaiit drugs — for example, - 
niorpliinc or veronal— it lias boon used with success, as also 
in the trcatinoutof prolonged blccu])S and in tlio rosnsoitation 
of the newborn. Owing to its action in lucrcasliig rcsplrntorj' 
cnort it aids expansion of tlio atoloctatlo lung, and its uso in 
the obliteration of largo ciiiiiycma cavities is recommended 
as an acoossovy to llio usual breathing exorcises. The authors 
con'.idev that tlicro Is iiraotically 110 coutraiiidication to its 
use in snlhcicul quanlitios to produce modorato degrees of 
uyiierimoca and to suppleiucut witliout roplaolug other 
tborapeufic nicasnros. 


Disease in Cliildtiood. 


Treatment of Diabetes In Children. 

' 10 !: (Hril. ■Jotirn. Cliihi. Din., .July-Soptoiubor, 

Octob0'--Deccuibor, 1927, p. 157) records his 
wim lino i'^ cliildrcii suIToriiig from diabetes mollitus, 
ot tlin Cf,, ih'd'lin ut the pediatric cliuio 

ISa I^'orway during tlio period April, 

ever under observation 

•lid not etiology the lioroditarj' factor 

only R iuiportaiicc, since It was pre.soiit iu 

iliatelv !• wberciis acute infectious imme- 

P!>rcent l'^°a?mP ‘hahetes wore present lii 12 cases (26 
Quilo no, -I,, Ml* ^‘•'ulfon undcrinsullu treatmontdovolo|)cd 
"■ere Itont auH physically, provided tiioy 

toicranco Woo ct '=°'R‘'oI. In 7 cases tlic carboliydrato 
i'll thesn . 1 increased with insulin. In 
strict and control ol tho did was iuvariahly very 

the other recurrent infectious. In 

decreased onSm'j'f ’i t>'0 carboliydrato toloraucc 

recurrent inror.V ° of. control over tho diet and acute 
"hichweronr factors in tho series 

carljohvdritn I'eportauce in (Iccrcasing the child's 

died, 5 iu coma pW c'rildron, 17 (36 per cent.) 

coma iust 1' ‘^“"“Gcted.wjth au infection, and ono 

children rotnspd fc'uur. Iu 4 cases tlio 

Remaining ^ casns’um ** treatment at lioiiie, and iu tho 
in-snlin treatniom attention was paid to tlio diet, and 

‘catmont was never given regularly. 


195. 


r given regularly. 
Goitre In the English School Child. 


P. Stocks **rQ EngUs 

critical' d^erf., January, 1928, p. 223) makes 


, •,'re incidencp of survey iu 1924 

^Sed 11 to 13 V Guiargemenfc among children 

directly from tlieae coiiolusioiis could be drawn 

Personal equationrnf^t'u of the varying 

Ispi *'‘^^P“-rtof malting returns. 

Actor by means of iFaFm fl>o comimtation ot tliis 

‘Ire author In coiAm^wm ^’°°° oliildren made 

u company with twenty of the observers con- 


cerned. Study of tho corrected returns shows that all degrees 
of thyroid oulargement arc proportionately more frequent 
in goitrous tliau iu noii-goitrous districts, a finding which 
suggests that endemic goitre differs from “ physiological 
goitre ” merely in degree. Sox distribntion is found to 
depend upon general pvovaleuce ; where this is low girls 
arc affected live times as often as boys, wliile if the incidence 
In a district is higli the sexes are affected equally. In regions 
whore goitre is prevalent towns arc less affected than rural 
districts, ami coast towns generally are less affected than 
those Inland. Incidence was found to bo high principally in 
tho West of England, and more especially in Cornwall, Devon, 
and Somerset, whence the belt ot greatest prevalence passes 
northward into Nortliamptoushire, and Derbyshire, and up the 
TcuuluoChaiu. Areas of moderate prevalence include Cheshire 
uud Herefordshire and parts of North and South IVales. 
Geological formation is shown to influence goitre incidence, 
this being highest in country areas underlain by the trias, 
carboniferous limestone, and old red sandstone ; evidence is 
submitted that this Is the result ot poor iodine content in 
these formations. Iu view of this probability it is thought 
that bcuellcial results might follow tho administration of 
iodine to girls in those districts where goitre is most 
prevalent. 

196. Prc-acorbutlc MyopatUy and. " Growing Pains.” 

C. I’niDElucuaCN [UgesUriJt /'or Lncjer, November 24th, 1927, 
p. 1069) gives evidence iu support of his hypothesis that in 
early childhood pain in, and flabbiness of, certain muscles 
may be due to latent .scurvy. In the records of two hospitals 
during tlio past fifteen years he has found 30 cases of infantile 
scurvy, in all of wlilcb, with only ono exception, a rapid 
recovery was effected under an antiscorbntio diet. Though 
all these children suffered from pain iu the limbs, and many 
of them from swelling ot the limbs, there were only 16 in 
whom x-ray changes in the bones were demonstrable with 
cerlainty. In 4 cases tliero were doubtful changes and in 
10 there were no cliangos in the hones demonstrable by the 
X rays. In 12 cases there was no bleeding from the gums, 
and In 11 no haemorrhages into the skin ; haematnria was 
found in 19 eases. Only in 7 cases were periosteal changes 
detected. It was thus sliown that in a largo proportion ot 
cases tho i-rav examination ot tho bones and periosteum 
failed to explain why the pains wore found iu the limbs. 
In further support ot bis hypothesis that pain in the muscles 
occurs early iu infantile scurvy, at a stage when other well- 
known signs bavirnot yot developed, the author records the 
efise of a child aged 3, admitted with tho diagnosis of myelitis. 
After an attack of measles throe months earlier he had lost 
his appetite and liad become irritable. Poins in the mnsoles 
of the calf and thigh were regarded as growing pains. He 
began to limp and to develop flat-foot. Rickets was diagnosed, 
but antirachitic treatment proved ineffective. He became 
uiiahic to stand or walk. The skin over the tender muse'es 
was shiny and slightly oedematons, but showed no haemor- 
rhages or bruises. Tho gums wove slightly swollen, but did 
not bleed until pressed on with a spatula. Infantile scurvy 
being suspected an antiscorbntio diet, which included lemons, 
was prescribed, and after ten days the pain iu tho muscles 
bad vanished, the child could walk, and bis appearance bad 
completely changed. The food at home had to be overcooked 
as the father’s teeth were defective, and as tlie child never 
ate fruit or drank unboiled milk the attack of measles had 
ovidcutly precipitated the scurvy. 

197. Four-hourly Breast-feeding. 

JIARG-MIET Emswe {Arch. Dis. Child., October, 1927, p. 302) 
advocates that infants be breast-fed at four-honrly intervals — 
nanielj’, at 8 a.in., 12 noon, 4 p.m., and 8 p.m. She thinks that 
these times interfere least with the many duties of a mother 
who has a baby, school children, and a husband to look after. 
The author stresses the importance ot breast-feeding being 
made as easy as possible for a mother within the limits of 
'a lactatory zone ot efllciency.” Too often it is the intelli- 
gent, conscientious, and eager mother who becomes inhibited 
tlirougli overcrowding ot bor daily tinie-toble, and bas to fail 
back on supplementary feeds. A report is given of a series 
of 103 infants fed on this plan from early infancy, frequently 
from ono month onwards, never later than from the sixth 
month. Tlic transition from more frequent feeds to • four 
feeds a day is now made iu from four to six wdeks. One 
breast only is used at each feed, which does not last more 
than twenty minutes. Tlie average weight curve of the 
cases reported is slightly above and approximately parallel 
with the normal. Judged on the following points — a regular 
weekly gain of 6 to 8 oz., normal development, and comfort 
of mother and child — this method of feeding has, the anther 
believes, been entirely satisfactory. A further series of ten 
cases is reported wliore, for reasons as a rule maternal, only 
three feeds a day were given— at 8 a.m., 1 p.m., and 6 p.m. 
The progress made by these children ivas also satisfactory. 

334 G 



34 Teb. 25, 1928] 


EPITOME OE CtTREENT MEDICAL LITERATTOE. 


f 7nt BsTTT'nr 
ilcDicAL JocaniX 


Obstetrics and Gynaecology. 

193. Operation In two Stages for I/arge Ovarian Cysts. 
Though excision cn masse ol ovarian cysts without prellmt- 
nary puncture constitutes tho beat procecluro G. COTTE {La 
Gtjnscol., November, 1927, p. 681) states that this is impossible 
in very large cysts. The danger ot punoturo lies in a too 
rapid and abrupt decompression or tho abdomen, causing 
cardiac arrhythmia and intestinal paresis with abdominal 
distension, the latter being due neither to infection nor to 
peritonitis. The autlior excises tho cyst a day or two after 
puncturing it, and advises that. tho puncture should bo open 
to the surface rather than, ns formerly, made blindly across 
the soft parts. He reports a case in which lie incised tlio 
skin under novocain, punctured tho cyst without opening tho 
peritoneal cavity, and withdrew 10 litres of mnco-purulont 
fluid; the abdominal wall was closed with throe sutures. 
Next day the cyst (ot the vegetating type witliont any signs 
of malignancy) was excised under spinal anaostliosla.' Ootto 
insists upon the advantages ot preliminary puncture and 
complementary appendicectomy in all cases of very largo 
ovarian cysts. 

199. Cenlto-perltoneal iTuberouIosIs-followlng Abortion. 

T. Aza (La Med. Ibera, October. 22nd,, 1927, p. 338) reports 
the case ot a married woman',, aged .23, wlio began to 
menstruate regularly at the ago of 12; she had had no 
children, but two miscarriages had occurred, tlio flrst, at four 
months, a year previously, being attributed to a fall, while 
tho second had no apparent cause. She was emaciated and 
slender with pallor of skin and raucous membranes and 
raised temperature and pulse rate ; she presented symptoms 
suggesting an acute inflammatory process in the polvio 
cellular tissue and uterine appendages. A blood count 
however, showed a relative lymphocytosis suggesting a 
tuberculous affection. Anterior colnotomy was "performed 
and a large amount ot foul faeculcnt fiiatcrial was. evacuated, 
Tho patient's condition became gradually worse and death 
ensued. The necropsy revealed a stercoral peritonitis in tho 
loft flank, with perforation ot tlie ascending colon from three 
tuberculous tilcers. 'There was also generalized miliary 
tuberculosis ot tho peritoneum with tho intestinal loons 
universally adherent. . ^ 

200 . The Use of Alcohol In Puerperal Sepsis. 

3, Brock (Uonats. /. Oeburt. und Gi/niili., August, 1927, p 3) 
recommends uterine irrigation with'alcohol as soon as sym- 
ptoms of puerperal sepsis appear. He uses for this purpose 
about 1 litre ot a table brandy containing about 40 per cent, 
of alcohol. Ho claims to have obtained very good results in 
tins way, which he attributes partly to the local action ot the 
alcohol and partly to its absorption into tho system. Brock 
recalls Kiistner’s advocacy, in cases of puerperal sepsis ot 
alcohol given by tlie mouth in quantitios.sufllciontly large 
to bring about a condition of deep intoxication at tho time 
ot the expected rigor; no bad results were noticed. It was 
suggested by Kiistner that alcohol might produce its good 
effects by slowing the rate of metabolism and so conserving 
tlio strength ot patients with lowered nutrition, ' but ho 
believed rather that the inhibitory action ot the alcohol on 
'the bacteria was the prime factor. 

201. Spinal Anaesthesia in Obstetrics. 

S. A. Cosgrove (Amcr. Jonrn. Obstet. and Gj/neeoZ., December 
1927,- p. 751); as the result ot- an experience of 54 cases 
cbuclndes that spinal anaesthesia -has an important-place in • 
obstetrics, since theoretically it appears to bo ideal for use ' 

ill pre-eclamptic or eclamptic, operative prooednres. • In prac- ’ 

tice ha has found it free from danger, except in hypotension 
the safe, systolic minimum being 110 mm. Hg ; it is unfitted 
for flrst-stage analgesia on account , ot its short duration 
Working with a dosage ot 50 mg. in the fourth lumbar inter- 
space for vaginal and perineal operations and 75 mg, at the 
third interspace for laparotomies, ho uses needles o't small 
calibre, 22 to 20 gange, dissolving weighed quantities ot 
sterilized novocain crystals from sealed ampoules in 2 to 
21 c.cra. ot spinal fluid, and injecting as slowly as possible 
■with the patient on her side. At tho end ot the secqiid stage 
there is entire soft-tissue relaxation which maj"^ obviate 
lacerations or the necessity for episiotomy. Its chief useful- 
ness should be in conditions for which a general anaesthetic 
is contraindicated, and it appears to be directly conservative 
of both maternal and foetal life. Cosgrove claims that in 
obstetric l.aparotomies it has the same advantages as in 
general surgery, giving complete anaesthesia and ranscnlar 
and visceral relaxation, with relatively slight bleeding, 
minimal post-operative discomfort, and a smooth conva- 
lescence. For operative procedures, in pregnancy toxaemia 
and eclampsia this method is especially indicated." 

334 D 


Pathology. 


203. Laboratory Diagnosis of Smnll-pox Virus. 

R. D. Defries and N. E. McKinnon (Ainer.Jown. o f Hygiene, 
January, 1928, p. 107) have devised a laboratory test for tlie 
recognition ot small-pox vims. Hitherto uso lias been made 
ot tho allergic reaction observed in tho skin ot a rabbit 
provlou.sly Immunized with vaccinia virus and tho corneal 
reaction which follows tlio application of small-pox vlrns to 
tho eye of a normal rabbit. 'Tho autliors find neither of 
theso tests to be reliable. Tiio former reaction is so variable, 
both in qocurronco and character, that accurate interpretation 
is often impossible ; tho latter reaction occurs in only about 
50 per cent, of cases. They now draw attention to tho reaction 
that follows tho intradermal injection of small-pox material 
into tho normal rabbit. In tbo course of fifty injections 
they obtained a definite reaction each time. A red palpable 
lesion, varying from about 10 to 20 mm. in diameter, appears 
on tho flrst or second day, and reaches its maximum develop- 
ment about tho fourth day, when it resembles a firm elevated, 
plateau; subsequently tho central-'redncss gives place to 
n straw colour, and desquamation or crust formation often 
occurs ; tho lesion disappears by tho twelfth day and leaves 
no scar. Chicken-pox material gives no skin reaction in tho.. 
normal rabbit. For laboratory diagnosis the auihors recom- 
mend that tho suspected material should bo inoculated intra- 
dcrmnlly into normal rabbits and into vaccinated rabbits;, 
a typical, lesion In tho norrnal contrasted with a modified 
lesion in tho vaccinated animals is diagnostic of small-pox. 

,203. Experimental Culture of Endometrium; . 

P. CafFIER [/'.cntralbl. f. GynaU., January 7tli, 1928, p. 63) 
has tried to cultivate fragments ot human endometrium 
I in vitro. Using human or animal plasma as a medium, to 
I which in some cases ovarian or other organ extracts had 
j been added, ho found that in many cases a voil-liko mcm- 
1 brano grow out from an implanted endometrial fragment, 
whatever itsbyclical phase. Decidnal tissue" up to, but not 
beyond, tho third month ot proguanoy gave similar results,' 
but no growth occurred in the case ot spontaneously dis- 
charged menstrual fragments. 'These experiments, like those 
ot Holm, wore inconclusive ns a test of tho validity ot 
Sampson's theory ot production ot “cndomotriomata,” tor 
microscopical examination of tho veil-like outgrowths failed 
to show whothor the cells which they contained originated 
from epithelial cells or from stroma cells, which in tho 
ondometrlum aro known to possess special characters. 

204. The Function of Cholesterin. 

As illnstrating various properties of cbolostorin, GOCGF.nOT 
(I’aris Med., January gist, 1928, p. 64) reports a case of Inber- 
cnlidcs which was apparently cured by n subsequent attack 
ot xanthoma. Following two attacks ot soro-llbrinous pleurisy 
those tnbercnlldes appeared in a young man with latent 
tuberculosis, and persisted without any change tor about ten 
months. At this date xanthomatous deposits conimonced to. 
infiltrate tho tuberculides, and were confirmed by histological 
and chemical examination. 'The xanthoma slowly increased 
I in size, at tho same tinio the tuberculous lesions gradually 
regressed. Finally, five years later, both conditions cleared 
.up, only a slightly red, lino cicatricial atrophy persisting.' 
The patient had no antecedents ot hereditary or acquired ■ 
syphilis, and repented 'iVassermann tests -were negative. 
■Daring tho xanthomatous- period he ' developed signs of' 
aortic InsulBolency, and, as ho presented no cardiac lesions 
Iwhen flrst seen, Gougorot attributes this to aortic xanthoma. . • 
■Gougerot adds that xanthomata are characterized by the ' 
•presence in tho skin of masses ot large lymphoid connective 
.tissue cells with- a reticular vacuolnted-protoplasm. These. - 
vacuoles contain theethereal saltsof cholesterin or lipoids, and- 
'those ot glycerin or neutral- fats; The author maintains 
ithat. xanthoma is a hypercholesterinaemia, and fixes- tho' 
qiiolesterin in tho tissues, especially the skin, just as gout 
fixes uric acid in the form ot tophi. The process is an active, 
not a passive, one, and is therefoi'e a defensive reaction. 
Many workers have demonstrated that the lipoids, of which 
cholesterin is the type, possess antihaemolytic, antito.xic, 
and bacteriolytic powers. Gerard and Iiemoine have stated 
that the amount ot blood cholesterin is below normal in 
tuberculosis, and that the low resistance noted in this disease 
is due to a lack of cholesterin reserve. They insist on tho 
auto-protection conferred by the lipoids in tuberculosis, and 
advise tho treatment of this infection by biliary lipoids. 
Gougerot believes that tho appearance ot xanthoma in tuber- 
culosis is a favourable sign, and that an endeavour should ha 
made to create such a condition by a suitable diet, with the 
ingestion and injection ot cholesterin and other lipoids. Caro 
should be taken in pursuing this ti'eatraont, as iu many cases 
tho action ot cholesterin may become injurious if tho sub- 
stance is present in excessive amounts. 


35 


MARCH 3. 19*8] 


t Tnn Csmsa: 
tfrx>icix. 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 


205. Xctlvc Immunisation nUalnst Bcarict Fever. 

1), VAS Donr-BROCKBlt-iVNunTiAK nml N. SPiintMAN- (Xcderl. 
Tijdsclir. V. Oenretk., Uecembof 2411!, 1927, {). 2692) record 
tlirlr obserraUeDs on 235 jicrsons n-bo ivero ncHrely 
ittiianiifred against scarlet fover nt tlio Jtarinc Hospital at 
Kntivijlr. Uo severe reactions wore soon cxcopt In a nnrse, 
wlio had a high tomporaUito and nansen for a tow days after 
tbo first injection. Tl.i-eo injootioiis were given, with a weeU 
between cadi, tho doses bolug ns follows : Up to 6 years of 
ago Inclnsivo, 200, 300, and 400 sUln tost doses ; for cblldron 
aged from G to 12 years, 300, 450, and 950 akin test doses ; and 
for persons over 12 years, 400, GOO, and 1,200 sldii test dose?. 
The anthers find tho Dick tost less reliable limn might bo 
expected, A reaction which is at first nogativo may become 
positive becauso the first test was not performed properly, 
or It may hapimn that after an attach of scarlet fever or active 
immnnizatlon the reaction slowly becomes positive again. 
It is probnblo that in n largo nniiibcr of these eases which 
! t!io imuinnity Is only lost in the body 

. i; I;:'.-. b-ou converted into a latent collnlar 
i'!i" sr.ily ; there I'l Ihus no longer any free antitoxin present 
in tho body flalds, but a small quantity of toxin is snillcient 
fo sflmnlato tbo allergic colls to tho rapid production of 
antitoxin, so that the Dick reaction becomes negative again. 


2C6. If. S. U. 3rEVKU (.Yederf. Tijdsdir, v. GrC7!<r«?f., January 
7tb, 1928, p. 26) records tlio results of active immunization 
against scarlet fever among tho scliool citiidren at Vclsen in 
Hoiiand. The Dick tost was performed on 3,159 ont of a 
population of 6,234 school children, wUU the following roaults. 

“6 d'o reaction was negative, In 1,901 poittivc, and in 
it proportion of 27, and 13 (icr cent, rcspec- 

*™'y’ 91boro was little difference iti tho rosnits in boys and 
guls. Of 39 children who had previously had scarlet fever 
^ gave a negative, G a positive, and G a doubtful reaction. 

was also performed on 63 children in wlioso families 
tuorobad been aeaso of scarfei fever, tho rosnits befog as 
imiows: positlvo 25 eases (45 per cent.), negative 17 oases 
And doul.tfut 13 eases (24 per cent,). All the 
Mfwrcn with a positive reaction wore fuooulatod, 3 injeettons 
girea of 3/4 clem., 5/4 o.cm., and 1 o.om. respeetivety. 
'tontroi examinations which were carried, out 
luootUs after the luocnlatioo 
I!?,!, . 3Vhoro.as on control oxauiluation after 
cpiilf-l” against diphtheria all tho inoculated 
. many of Ihoso Inoculated against 
" ■ j siUve Dick reaction, many gavo 

. ■ ■■ the rest wove negative. The success 

■ ■ ■ was thus not so great in scarlet fever 

is suggc.sted lliat a larger quantity 
<dscaria(mal to.xin ahould bo Inoculated. 


(Jrcii. of red., IJovcmbcr, 1927, p. 727) 
ns ^ school cUildreii, of whom 304 

PosUlvo And 100 were ucgallvc. Of tho 304 
(Qvin vrviSr ' who wore inoculated with scarlatinal 
ccnt.l bccaiuo Dlck-nogative, 31 flO per cent.) 
There w(nn°M "■‘^re lost sight of. 

fever ^hobt n per cent., immune to scarlet 

to the inin sciiool popiilofion of 1,927. The reaction 

of marl-,,,! 1 toxin was moderately severe, consisting 
accouiuanL! fi'velling, redness, tenderness, and pain, 
aobe ver ?.?■ “• .temperature of 103= to 105=, violent hcad- 

who’hfl/} '“'"‘t'Rg, and prostration. All the patients 
followed !ii ^VRPtoms showed a mild scarlatinal rash 
Pormauenr “^-“tisquamation. In no case was there any 
fiSOO, 5,000 is^nnn”''* ‘>°sage consisted ol 500, 

relation WTO 20,000 skin tost do.scs. Ko definite 

snscenHj,ii, 7 v°^^ dlfferont age groups and either 

fhhuunity fever or tho degree of active 

2oa. 

K. r Wp,.,,,, A-uglna Fectorls. 

P- 1) draws January 5th, 1922, 

‘’^angina pectoris Uio symptomatology 
prevailinn tliporin?" . . adequately explained by the 

rases the atbir!r'^?„'^^ pathology. Though in arabnlatory 
more vlogtny ““ induced by quite slight exertion, 

pain: merely produce dj'spnoca witb- 

scvecal titaps , °?Gh tho patient way have to stop 
roatinuE wttlitinrr Goes out, after, a while ho can 

ng Without discomfort. YVenckebach considevs 


that the symptoms of angina, ore closely related physio- 
logically to the distress experienced by normal persons 
dating severe exercise (especially rnnning and rowing) before 
they get their ‘‘second wind.” The physiological process is 
explained by an increased supply ot blood from the viscera 
to the heart and larger arteries, an acceieration. ot the pulse 
rate producing a rise in blood pressure, and congestion in the 
aorta betore this head ot pressure finds relief in the dilatation 
ot peripheral arteries and veins. In the anginal attack ot 
the ambulatory type (the status anginosus differs in many 
respects) the ‘‘second wind” stage is not reached, though 
the dilatation produced by nitrites is said to be somewhat 
analogous. 'Wenckebach believes that, just as the pain in 
Uaynand’s disease occurs as the circulation is restored, and 
tho femoral artery is often very tender to pressure just below 
Poupart's ligament during an attack ot intermittent claudlca- 
tioB, so the pain of an anginal attack is due not to ischaemia 
ol tho peripheral, but to distension ot the proximal, parts of 
diseased coronary arteries, which are somehow more sensitive 
to alteration la tension. Since the coronary arteries are 
developed from the proximal section of the aorta their motor 
and sensory innervations ate the same; therefore either or 
both together can piodnco the typical anginal syndroine, and 
there is no need to attempt todistinguish aortic from coronary 
angina. Contraction of vessels at any part ot the periphery, 
or severa! parts simuitanemisly, may initiate an anginal 
attack by increasing the pressure in the aorta and coronary 
vessels, and may bo relieved or prevented by such medica- 
ments as nitrites, which produce peripheral dilatation. It 
toltows from this that when the left side of the heart fails 
there will be insufficient pressure to produce the necessary 
tension, and the painful anginal attacks will often diminisli 
as tho signs ot heart failnre increase. It has been observed 
also that digitalis, hy restorieg the powers of the heart, 
may produce a recurrence of anginal attacks, which had 
temporarily ceased. Wenckebach, disputes the originator’s 
explanation ot the rationale ot Jonnesco's sympathectomy 
(and liericho’s operation on the femoral artery) on anatomical 
gronuds, and cQusiders that the beneficial effects are due to 
Interruption ot afferent sensory pafb.v, whereby a break is 
made in a vicious circle of pain and raised pressure, 

209. lEnctphaUtls In Measles. 

J. BoissEIUE-Lacbois and 3. Madapeate (Jbttm. de 3ted. de 
Uordcaus et dii SuU-OuesI, December 25th, 1927, p. 946), who 
record an illustrative case, remark that, -apart from con- 
vulsions at the onset, nervous complications in measles are 
very rare. The age at wSiich they are most frequently 
observed is from 2 to 7, but Bourne has reported a case 
in an infant of 14 months, and Dienlafoy, Lagare, and 
Lemidro have seen cases in adnlts. It is chieKy in severe 
attacks of tho haemorrhagic form that nervous complications 
occur; they are frequently accompanied by pnlmonajy con- 
gestions or broncbo-pucumonia, and maj' develop in the 
eroptivo stage or later in convalescence. The present case 
is said to be the first example on record ot nieningo-cucephal- 
itis occurring during the period of invasion. The anthors 
adopt the following classification of the nervoos complica- 
tions ol measles. (1) Tho upper or cerebral form, which 
chiefly occurs in severe measles and is characterized by 
stnpor, coma, and convnisions, which are bilateral or pre- 
dominant on one side ot the body. (2) The iutermediafe 
form, in which there is a predomraanco of ocular disturbance, 
ataxia, and bnlbo-pontine symptoms. (3) The low or spinal 
form. A mental and meningeal form may also be described. 
The encephalitis of measles in cases which have come to 
necropsy does not differ from acute encephalitis due to other 
causes. 

210. Paratyphoid! C Fever. 

. A. N. KisGSBURT, J. a. DessgaR, and JI. KAItDicH Qlala^an 
Sled. Journ., December, 1927, p. 127], who record two ilfustra- 
[ live cases, sfate that in paratyphoid O fever the onset is 
usually sudden ; the duration depends on the severity of the 
infection and tho degree ot involvement of the respiratory 
system. Bronchitis and patches ot bronebo-pnenmonia are 
not nnciammon, and the cansat organism may sometimes ho 
isolated from the sputum. The course does not exceed five 
to six days in mild cases, and since the mortality rate is low, 
few descriptions of post-morlem findings have been published. 
Usually some congestion ot the upper part ot the small 
Intestiue has been noted as well as congestion, and small 
snpcrfioinl erosions ot the -mucous membrane of the colon. 
The authors’ first ease occurred in a Chinese male, in whom 
tho only symptoms were lever, loose stools, and an icteric 

3S24, 



B6 MAHCH 3, 192S] 


EPITOME OF CtJKEENT 


tint of the shin ; death followed a twelve days' illness. At 
the necropsy no abnormality of the heart, iungs, or kidneys 
•was noted. 'The spleen was enlairged ‘and the liver con- 
gested, but no uicoration or inflammation- was noted in the 
Intestinai canal. The sernm failed to agglutinate emulsions 
of JJ. tiiphosua or of the paratyphoids B and C, but it aggln- 
tinatad'the paratyphoid 0 strain to a titre of 1 in 6,400. 'The 
second case occurred in a Tamil woman, aged 26, who had a 
remittent fever for twelve days, which was not affected by 
quinine, although malignant tertian parasites were found in 
the blood. B. paratyphosus C was isolated from the urine 
and was agglutinated by the specifle serum in high dilutions. 
Owing to the concurrent malarial infection the characteristio 
slow pulse of enteric fever was not present. Subcutaneous 
inoculation of the strain into a guinea-pig caused death in 
thirty hours, and the necropsy showed extensive subcutaneous 
haemorrhage, splenic enlargement, and a blood-stained peri- 
toneal exudate. The bacillus w'as recovered from the heart, 
blood, spleen, and peritoneal fluid in pure culture. 

Qll, Tularaemia. 

L. L. MebeiMAN (Minnesota Med., December, 1927, p. 719), 
who records four cases originating in Minnesota, remarks 
that tularaemia, which in nature'occurs in wild rats, ground 
squirrels, and wild rabbits, may be transmitted to man by 
(Ij handling diseased animals ; (2j contamination of the hands 
or coujunctiva with the tissues or body fluids of diseased 
animals; (3) the bite of diseased animals; (4) contamination 
of the hands or bites of flies, ticks, bed-bugs, or lice which 
have bitten diseased animals; (5) the bite of any animal 
that has eaten diseased rodents. The causal organism, 
Jl. tularcnse, can penetrate the unbroken skin or conjunctiva, 
but a frequent portal of entry is a wound. Laboratory 
workers are very prone to contract the disease. The organism 
is Gram-negative, non-motile, and non-spore-bearing; It 
occurs in both bacillary and coccoidai forms, and appears 
early in the blood of the lower animals as well as in man. 
It grows well on coagulated egg yolk and blood glucose, and 
on cystine agar, but not on ordinary media. Four types 
of the disease are described : the ulcero-glandular, ooulo- 
glaudular, glandular, and typhoidal. The period of disability 
Is rarely less than a month. The mortality is nothigh, but 
occasionally a fatal case occurs. Tularaemia must be dis- 
tinguished from typhoid fever, septicaemia, tuberculosis, and 
Malta fever. The following points are of diagnostic value : 
a history of contact with rabbits or rodents. or of bites; 
0 primary papule or wound; persistent local glandular 
enlargement; fever of two to four weeks’ duration ; a nega- 
tive Widal reaction ; and a relatively low leucocyte count. 
The diagnosis is proved by agglutination of li. fularense 
With the patient’s serum. The treatment is entirely 
symptomatic. 

212. The Heart In Fungus Poisoning. 

A. S. Hyman (Bali. Johns Hopkins IIosp., Januarj', 1928, p. 8) 
describes an investigation of the cai dio-vascular disturbances 
in a case of mushroom (Amanita phailoides) poisoning. This 
fungus was consumed in error by a party of four persons, ' 
three of whom recovered completely after gastric lavage. 
The fourth patient complained ot severe headache and giddi- 
ness, and ten hours after the ingestion of the poison there 
was observed some irregularity ot the pulse, which became 
more marked on the following day. Two days after the onset 
all symptoms except weakness had disappeared, while exam- 
ination showed the rhytlim ot the heart to be mainly regular 
■with frequent irregularities. There was no lo^s ot couduc- 
tivity to the radial pulse; apart from a soft systolic murmur 
at the apex and a trace of albumin in the urine no further 
signs ot disease were found. Electro-cardiograms taken at 
this time showed delay in conduction ot the normal stimulus 
through the heart, the F-E. interval being slightly prolonged 
and the QES complex split and grossly delayed. Diphasic 
T- waves in 0 injunction with the above signs led to a dia»uosis 
ot right bundle-branch block, while the electrical record 
further showed the irregularity to be due to right ventricular 
extra-systoles. Eighteen days alter the onset the electro- 
cardiogram showed improvement in the condition ot the 
heart, but there were still signs of severe myocardial damage. 
Four mouths from the beginning of the illness a third ex- 
amination was made, this showing almost unimpaired con- 
duction, while five months later the electro-cardiogram was 
normal. The author reviews the literature on the [lathoiogy 
of mushroom (muscarine) poisoning, the changes generally 
found being fatty or lipoid degeneration of the myocardium, 
sometimes with fragmentation. In the case described such 
damage probably occurred in the neighbourhood of the 
anterior papillary, muscle ot the right ventricle, the close 
anatomical relation ot this region to the right branch ot the 
bundle ot His explaining the abnormalities found in the 
electrical changes ot the heart. 

■3S2 B 


MEDICAL LXTEEATUEE. , 


Surgery. 


213. ■ Primary Carcinoma of the Ureter. 

F. VOIiANTE (Areh. Hal. di Urol., December, 1927, p. 105) has 
collected and discusses 38 cases, including a personal one in 
a man aged 49, of primary carcinoma ot the ureter, the flrst 
ot which was reported by Wising and Blin in 1878. Volanto 
comes to the following conclusions : (1) The ureter may be 
the primary site ot various malignant epithelial tumours. 
(2) Not all the recorded cases are to be regarded as genuine ■ 
primary tumours of the ureter ; the large number ot organs 
affected and the development of the tumour in persons who 
had already been operated on lor tumours elsewhere throw - 
a doubt on the diagnosis. (3) Papillary carcinomata are by 
far the most frequent, and aro usually to be regarded as the ' 
malignant transformation ot honign papillomata. (4) Lithiasis 
has been regarded as responsible for the condition, and' has ■ 
actually been found in a certain number of cases, the chronic 
irritation produced by the concretion and the concomitant ' 
irritation being an explanation of the origin of the tumour. 
(5) Lcucoplakia and the coll nests ot von Brunn, both of 
which are the result ot chronic inflammation, are of consider- 
able importance in the pathogenesis of epithelial tumours ot 
the ureter. (6) Embryonic malformations and trauma aro ■ 
also of importance in the pathogenesis. (7) 'The site of pre- 
dilection tor the tumour is immediately below the normally 
constricted parts ot the ureter. (8) 'The tumour may develop • 
concentrically or eccentrically, or both forms may be com- 
bined. (9) Hydroueplirosis is the most frequent result and 
often the flrst obvious sign of ureteral tumour; other sym- . 
ptoms which aro inconstant are liaemnturia and pain. 'The 
latter is most frequent in the papillomatous growths. (10) 'The 
presence ot tumour elements in the urine Is a good diagnostic 
sign, but is rarely found. 

215 . Tnberiulosls of the Breast, 

V. ALOI (Itif. mod., January 9th, 1928, p. 33), who records an 
illustrative case, remarks that tuberculosis ot the breast is a 
rare condition, ot which only 200 oases have hitherto been • 
reported in women and 11 in men. The earliest cases in . 
which the diagnosis was based on the naked-eye appearances 
were reported by Cooper (1829), Nglaton, Velpeau, and Bill- 
roth. Dubar, in 1881, was the first to describe the morbid 
anatomy, and the following year Ohnacker demonstrated tlie 
etiology experimentally. It is probable that many oases have 
been mistaken for cancer ot the breast. Very few cases 
have developed during lactation (Habermass, PlsEacek, and 
Plujette). Aloi’s case was in a woman, aged 27, who had 
noticed a swelling on the outer side ot her right breast three . 
years previously during the sixth month ot lactation. Since 
then it had gradually increased in size. The Pirquet reaction 
was positive, and a-ray examination showed caries ot the 
sixth rib. The upper and outer quadrant of the breast was 
removed, leaving the nipple and areola. Complete recovery , 
followed. . Examination , ot the excised, tissue showed 
numerous cavities filled with caseous .tissue, giaut cells, 
and a few tubercle bacilli. 

215. Treatment of -Fistula In Ano. 

Lop (Bull. Soc. de Ther.; December 14th, 1927, p. 276) states 
that he is now leas inclined than formerly to operate on 
fistula in auo. It often happens that a primary localization 
of tuberculosis may simulate an ordinary acute abscess of the 
margin ot the anus, giving rise to violent pain, interference 
with defaecationV and a high temperature; in such cases an , 
operation is inevitable. In at least six-tenths of the patients 
a blind external or complete fistula communicating with the 
rectum is left, and in such 'cases Lop considers it advisable 
not to interfere, even when clinical examination, radioscopy, 
and laboratory tests show that the lungs are normal. He has 
fonnd that a localization ot anal tuberculosis due to passage 
through the bowel ot iutected broncho pulmonary secretion 
is much less frequent than a primary^ localization, if, indeed, 
it really exists. Lop -therefore only operates on cases ot anal 
fistula after carefully examining the lungs and sputum, and 
investigating the discharge from the wound for the tubercle • 
bacillus. He refuses to operate whenever the bacillus is - 
found in the discharge, even when it is absent in the sputum 
and nothing abnormal is found in the lungs, nor does ho 
operate on any individual in good health in whom the fistula 
has been in existence lor some time and has-not been painful. ‘ 
He has recently seen ton cases in which a radical operation 
was .successfully performed ; six of the patients subse- 
quently died ot pulmonary tuberculosis. Abstention from 
operation applies only to the so-called spoutiuieous iistnlae, • 
since it is required- lor those which result from trauma of 
any kind. 


MAhcn 3i'i92Sl 


tlPITOJVK OV CuilUENT MEDIOAIi LITEEATURE, 


[ 


Tnr. Bmttw • - 

ilEDJCAI. JOCBXAti 


37 


216. post-opcrntlvo ComplIontlonR of Appondlcltlr. 
AoCOnoiNi’t to C. W. CcriiKU, jun. (.tiiic)-. .Initni. Stirg., 
December, 1927, ]>• 602), kiiccoss or fjiiliiro in tlio Ircalinent of 
bUPpnmtivo.iltlxMnVicilisdi'iicmls lnr(>oly on I ho po.st-opcratlvo 
events. In n series ot 391 o.ascs -U patients dleil, Riving a 
mortality of 10.5 per cent. It becomes aiiparcnt that In tho 
vast majority ot cases procmsllnatlon is wore, ilangcrons than 
operation. I’crilonitis was the most sorions complication, 
and in these cases tho injection of saline solutions and 
morphine with the Fowler position was the chiot lino of 
treatment. Oastric lavage and pitnitrin woie also employed. 
lliCh cnlci'cstomy was performed for paratytic ileus in live 
c.ascs, and one patient recovered. Cutler insists tliat cntcro- 
Btomv to be ot any uso must be performed eai ly. Secondary 
abscess was also a serious complication in 18 eases; 5 
patients died, including 2 avitli suliphrcuic abscesses. In 
tlieso eases drainage was employed ns soon as tho abscess, 
had become localized. Tliero were 5 eases ot faecal llstnla 
and2 required fnrllior operation to close tliem. 'I'o iircvent 
tills Gutlor advises tliat tlio drains slionid bo moved daily. 
JIcchanic.sl lions occurred in 5 cases and necessitated opera- 
tion. I’ost-opcrnlivo liornia was found in G cases (1.5 per 
cent.); to prevent tills tbo weaving ot a licit is advised for 
six montlis after operation. Pulmonary comiilications were 
not frequent, but ono patient died from embolism on tlio 
fitthday. 

2t7. Recurrence after Operation for Carcinoma of 
tho Breast. 

E. D.tiilrlVKKSl'.K {Lynn Cliir., Movcinlicr -Dcccmlicr. 1927, 
p. Gi8) refers to tlio'numcrons attempts to detcnnlnc tbo 
trcqucncy of recurrence ot carcinoma, of tlio lircast after 
operation, aud adds that tlio relation betucen tlio liistoIogic.al 
appearances ot tho growth and tlio (iiognosis after opeiation 
lia's not been settled. .Statistics sliow that after tlie radical 
operation 15 per cent, of tlio patients remain for three yc.ars 
without sign of recurrence. In a .series of 12G cases lie Ilnds 
that 33 per cent, .showed no sign of rcapiiearaiice of tlie con- 
dition at tho end ol tbreo years, lie conoliides tliat a point 
on wliicli aproguo.sls can bo given Is tlie size of tlio tumour; 
when this was small, the alze ot a plum, only 17 per cent, 
showed recurrence, Imt in large growths, tlio size of an ogg, 
87 per cent, showed reourrcnco williin tlirco years. C.ascsof 
medullary carciuoiua all recurrod within tliis period, as did 
57 per cent, ot cases of sciriluis. Wlieu tlio axillary glands 
were involved Ihcro wa.s iccnrrento in 80 per cent., Imt if 
the glands wcio not affected only in 41 ]ior cent, williin tlirco 
J'^rs. luvolvewcnl ot these glands was found in G5 per cent, 
of the cases. Tho clavionlar glands appear to lio alTectod in 
rfper cent, of cases. As cxpeiieuco sliows tliat tlio clavicular 
glands may he affected, even wlica tlio a.xillary glands are 
clear, they should, according to the author, liii rcinoved in 
all cases. 


218. OstcomvctlUs of tho Os Pubis after Measles. 
jlAESCUKr. (A'fiii. Il'or/i., January 8lli, 1928, ji. 72) describes 
uio c.aso ot tt hoy, aged 7, who sntlercd from measles four 
ecus previously. After the rash liad disappeared the fever 
nil remained, aud tho patient did not improve. Suddenly 
liiglier and severe pain was felt in 
ami f could not he moved; 

Aiiniit inter removed some serous fluid, wliicli was sterile, 
bnl „ afterwards tlio liip-jolnt was free from pain, 

sweliim hccamo swollen; after removal of tho 

tlw !ic,£ 1.'’°''*^''^'^® painfnl infiltration remained on 

lion pnhis, and an x-ray cxainimi- 

incroa<.-n,i P ' . porio.stcal tliickcning. Tlio inflltratloii 

bv 1)11111-1 " hccamo soft; sterile fluid was removed 

of -i^’iot'icr x-ray cxamiiiation showed softening 

On onni-nt: ot tlic ascoiiding ramus ot tho pubis, 

conieiiit. cit-a walnut was fomul; its 

ivas iinove tf cavity was di-aiucd. Recovery 


■A S* of liowcp Femoral Epiphysis. 

1528 n 0/ Rone aiu! Joint Sitrij., January, 
cpii)'livsis--i? I separation of the lower femoral 

Olten assoeia^cf.yfM^’ ‘■J’Po of foiiioral fracture, hut 
•cave.s thp * ocevo or vessel injury. It frcqiiently 

tiou. Aentn ^'‘*'** considerable impairment ot func- 

meut of thncp p “snally been adopted in tlie treat- 
uiaiutaiu n,i„ I'laster-ot-Paris lias been used to 

nged 8. Xhe fr^ t .*’■ ®'^*^"'ohl’s case occurred in a boy 
ncuto tlcxini, " A’* reduced under anaesthesia, ami 

»‘c In.ee was day. Each day 

increasGcI. Twonfv -i ^ degrees and extension 

iKJS'ible aiifi fim m ? later <iomplcto extension was 

?' one yew it '"’ith a sticic. At tlie end 

ininred. ‘ ® ‘Uipossible to toll which log had been 


Therapeutics. 

220. Treatment of Small-pox by Red Light. ■ • ' 

J. H. TlllERiiY (Uyeskriftfor Lneger, January 12th, 1928, p. 29) 
refers to Niels Fiiiseu’s earliest work on tho action ot liglit 
on the human body, in wliicli bo suggested that suppuration 
in small-po.x vesicles was caused by the action ot tlie liglit 
rays ot tho sun on tlio skin. It snob rays could be exclnded 
before suppuration liad bognn it could be preventcil, the 
danger of death from suppuration fever would be eliminated, 
and disflgnring scars avoided. Tliierry remarks that in' 
Denmark lliei'C has been but little o|)portunity to test the 
accuracy of this tlieory, the small epidemic in 1891, during 
wliicli a “ rod ward ” was provided for some cases, yielding 
lusufticlcnt evidence. In tlio HGpital del Salvador in Valpar- 
aiso, in the beginning of 1921, lie was able to obtain a 16-bed 
l>avlI!on witli only red liglit. Tbo one doorway was provided 
with three door.s, only one of wliich could be opened at a time, 
and tlie double windows provided with red glass were screwed 
fast so tliat they could not bo opened. Ventilation and liglit 
were supplied by tlirco petrolonni lamps protected with red 
glass, having chimneys wliich passed up thTOUgU the voof ; 
liolcs in tho floor were connected with bent tubes tbrougli 
whlcli plenty ot air, but no light, could pass. The lamps 
were kept burning day and niglit, and the ventilation tlicy 
provided was as effectivo ns Ihat ot the pavilions with o;>eu 
doors and windows. Tho complctonoss with which daylight 
was excluded may ho gaugcil from the fact tliat pbotogra|ihic 
paper exposed in tlio pavilion lor three mouths was scarcely 
discoloured. Only patients in the first stage of the disease 
wero admitted to this pavilion, and none in whom pustules 
had already formed. While the deatli rate was 11.66 per cent. 
(192 patients, 80 deaths) among these “red-light” patients. 
It was 11.96 per cent. (1,582 patients, 664 deatlis) among all 
the patients admitted to Jiospital. It shonld ho noted tliat 
tho 23 p.atienls wlio died in tlie primary stage of the disease 
were in the red room. When thc.se cases wore subtracted, as 
well ns those in wliicli haemorrhages into tho vesicles ohscuted 
the diagnosis of suppuration, there remained 159 “red-light ” 
patients, of wliom only 9, or 5.66 percent., showed no siippiuti- 
tiou. Tliero wore 10 who snirorcd from very .severe suppura- 
tion and .scarring. Though exact data were not available as 
to the proportion of patients who wore treated in dayliglit, 
anti wliosc vesicles did not suppurate, tho author thinks tliat 
the percentage ot “ daylight ” patients free from suppuration 
was no loss tliau that ot tho “red-light” patients. But 
altliougli the death rate, aud the frequency and severity ot 
.suppuration aud scarring sconietl to be nninfiuenced by red 
light, it evidently liad a bencllcial eifect so far as the eyes 
were concerned, for, with only ono exception, the “red-light” 
patients were free from any serious complaints of the ej-cs, 
wliile about 10 per cent, of tbo “ daylight” patients doveloped 
pnstules of tho cornea, about 3 per cent, losing one eye, aud 
about 1 pec cent, both eyes. Witli regard to tlie frequency ot 
hacinorrlingic cases, and of abscesses in or under tlie sitiu, no 
distinctions could ho drawn between the "red-light” and the 
“daylight” patients. 

221. Late Treatment of Infantile Paralysis. 

E. Df.lcroix {Bnixellcs-Mcclical, January 15th, 1928, p.360) 
describes his method ot dealing with limbs affected bj' 
infaiitilo paralysis.- Hitherto the treatment of poliomyelitis 
at the stage when tho paralyses ore determined has chiefly 
consisted in endeavouring to correct muscular weakness aud 
deformities. Attention is. now being directed primarily 
towards the nutrition of tlie affected part. Delcroix bathes 
the paralysed limbs in warm sea-water irradiated by ultra- 
violet rays ; the name he gives to this type ot bath is “ actino- 
marine.” It is found that the combined action ot the thermic 
element ami tiio variations in tho difference of potential in 
the osmotic o.xchangcs increases tho nutrition of the tissues. 
Encouraging results had previously been obtained from hot 
sea- water baths. Sea- water, containing as it does a large 
number ot electrolytes, constitutes a highly ionized medium, 
and when it is reinforced by ultra-violet radiation the resuKs 
h.avc been very promising. Tlie study of tho osoillometric 
index, wliich is the •visible expression of tho total pulse of 
, a limb, gives a direct indication ot tlio peripheral circulation. 
In order to gauge tho possible variations ot this index llie 
same children wero submitted to the following tests : (1) warm 
water bath, (2) irradiated warm water, (3) warm sea-walcr 
and (4) Irradiated warm sea-water. The otlier factors of the 
different tests were identical in all. IVhen the rate ot circula- 
tion attor each test was observed it was found that the 
maximum osoillatorjf amplitude occurred after the touith 
test, the actiuo-marine bath. Delcroix reports eleven cases 
in which the attaclc ot poliomyelitis preceded the initial 
treatment at periods ranging from si.x weeks to nine years 
All except two of these patients had been submitted, to the 

382 0 



33 March 3, 192S] 


EPITOME OF CEPBENT MEDICAE LITEBATtTEE; ' 


r XffE learns* - • 
M£t>rcAi. JoxjusUt 


nsnal tlierapeufcic procotlurcs Avitbout success. Before com- 
j)leto recovery wiis . obtained tbe nuiuberol treatments needed 
varied, but in the series quoted the previously paralysed 
cliild was able, alter twelve to twenty-four baths, to stand 
alone, to rvalk, and to ascend and to. descend stairs. Tlio 
results have beeu constant and were maintained. ■ Tbo 
patients treated in 1926 were seen in 1927, and .wore found 
to bo as well as, and in some cases l)otter than, at.tbo end 
of tbe course. llelcroi.N. adds that this method synthesizes 
two important elements in tiierapontics— tbo electric and tbo 
ibermic; to tbe judicious association of these two are attri- 
buted tbe encouragin'! results which have been obtained. 

222 . Treatment of Syphilitic Cardio-vascular Diseases. 

A. SfiZARr (Bull, ct Mem. Soc. Med: ‘Acs Hop., do Paris,- 
December 1st, 1927, p. 1547) agrees that antisypbilitic treat-' 
ment should bo modilied in tbe case ot patients suiferlng.froih: 
any grave cardiac, hepatic, or renal complications wliich are' 
iiot of syphilitic origin. Advancing age is not a contraindica- 
tion to tbe use of the arsenobeuzols,'but only necessitates: 
their careful administration. He doubts whether there is 
any real danger of aggravating the arterial liypertension in 
the case ot aged syphilitic patients by speclile medicaments, 
even when the hypertension is non-syphilitic, and thinks that 
tlie treatment of cases of cardiac syphilis, as of syphilitic 
sldn diseases, should be governed by 'the individuahcircura-' 
stances. In ordinary cases bismuth and mercury are most 
often employed, but neosalvarsan remains the most powerful 
agent, and occasionally mixed arsenical and bismuth treat- 
ment is indicated. Patients under tlie ago of 50 bear the 
treatment better and the clinical diagnosis ot cardio-vascular 
syphilis IS easier in such cases, since atheroma and arterio- 
scleroses are seldom present. Syphilis may play an important 
put in cardio vascular disease in much older patients ; 
a igina pectoris ami aortitis may yield to antisypbilitic treat- 
ment even though the clinical diagnosis ot syphilis- is not 
fiillv established. Such treatment should bo neither brief 
nor insufHcient, and atsenio, bismuth, or mercury should be 
u.ed, as indicated clinically. Unsatisfactory results maybe 
duo to the iresenoo ot atheroma or to degeneration of the 
tHsues. Thrte cases of aortic aneurysm treated with bismuth 
arc reported. One patient was relieved, aud skiagrams 
showed that the aneurysm had not increased in size. In tbo 
two other cases, however, the symptoms became worse, and 
ill one of tliese, in spite ot three courses ot bisraulh, tlie 
aneurysm increased ti ilouble its size in a few mouths. The 
results of specillc tri atmenb ot angina pectoris are, however, 
so encouraging that it should be given in all cases where 
s\ philis is suspected. Sezary quotes seven cases, in four ot 
which the results were very good. One man, aged 61, con- 
tacted syphilis when 23; tho slightest exertion caused an 
anginal attack. He was treated with bismutli for two years ; 
the attacks gradually decreased aud finally disappeared, and 
the patient was able to lead an active life. In throe other 
cases, however, the patients weic not relieved. Tlio average 
age of those who were relieved was 56.5 years, while that of 
those who were not relieved was 51 years. Of the former 
two were treated with novarsenoheuzol ..and two with- 
bismuth ; of the latter, one was treated with novarsenobenzoi 
and tho other two rvilh bismuth. In aortitis the disappear- 
auce ot bruits canuot be expected, but symptomatic improve- 
ment may follow specific treatmentalthough the Wassormaun 
reaction remains positive. Of twelve cases of .aortitis live 
were greatly benefited. Sezary believes it possible to cure 
completely syphilitic cerebral arteritis; aud advises that' 
intensive treatniont should be started immediatel3' in all 
cases ot hemiplegia in young subjects,' unless contraindicated 
by grave visceral disease. 

223. Tho Amino Bases of Ergot. 

Batmond-Hamet (Presss Mid., January 11th, 1328, p. 35) 
discribes three amino bases ot ergot, tyramine, histamine, 
and acetylcholine, and discusses tlie action ot each on the 
uterus, circulation, heart, respiration, intestine, aud sym- 
pathetic system. In a short note lio states tli.at the four 
alltaloids of ergot — ergotiuiuo, ergotaminiue, ergotamine, aud 
hydro-eigotinine— possess a .long, excitant uterine action, 

.a profound vaso constrictive effect, aud a sympathicolytic 
action, and that tho last two are markedlj- powerfnl .agents. 
The amino bases are present, merely in.minute qnantit?es.in 
fresh ergot, and are .appreciable only after decomposition ; 
wlicn required, therefore, they slionid he prepared ssmthctic- 
.ally, since ergot is not administered for the effect prodneed' 
1)V tho amino bases. They have the same action on the 
n'.crns as tho alkaloids, but this is very transitory, and even- 
ill therapeutic doses they possess highlj' injurious properties. 
Tlie bases are devoid ot ail -sympatliicolytic power, and the 
action of tj-ramiue is partly explained by its stimulation of- 
the sympatliotic nervous system. This base is a vaso- 
constdetor, but histamine aud -acetylcholine are so power- 

a.S2 D 


fully vaso-dilatatiVo and hypotonsivo tlmt their action is first 
mauife.stod when injected with tyramine or even with the 
alkaloids. It has been shown both chemically and physio- 
. logically that the galenic preparations of ergot contain little 
or none ot tho alkaloids, hut are rich in the amino bases.. 
Houco they alraost.ahvays produce vaso-dilatation and hypo-, 
tension, and tlioir use is contraindicated, vaso-coustriccioa 
being tbo desired end for which ergot is administered. 

224. Treatment of Erysipelas. ■ 

E. S. PbATOU, F. W. SCHLUTZ, and D. CobLlNS {Amcr. Journ. 
Vis. Child., Doconiber, 1927, p. 1030) report a series of 155. 
cases of or.vsipelas, of which 80 were treated with- ar-ray 
irradiation, 30 tvitlr the antitoxin,- add 35 AVith magnesium, 

, and glycerin pacics, Tho return to normal temperature 
.averaged 1.5, 2.2, and 3.4 daj's respectively , in the. threo- 
. groups, while tho svtbsidcnco of symptoms- such as -paiu, 
toxaemia, aud general, malaise took2, 5-8, and 8 days. The 
. mortality was .6, 6, and 23 per cent.. respectively. E.xtension, 
■of tho disease occurred, in 21, 46, ond-68 per cent, of the, 
cases in tho threo groups. In a further scries of ten espc-. 
daily grave cases a combination ot ic-ray and antitoxin 
treatment was particularly successful, the erj'sipolas .dis-, 

, appearlug invariably, though, one infant aged 3 -, mont.hs. 
developed bronclio-pucnuionia and meningitis later and died. : 


Ophthalmology. 

225. Palpcsbral Cysts. 

A. GABniiiiLiDES {Ann, (i'ocnlistiqne, December, 1927, p. 92S) 
states chat wliafc-woro doscribetl as b5’(3atid C3^Rt.s of the 
eyelids by the early Greek writers, such as Galen and Paulus 
Aegincta, were cysts with watciy. contents formed behind 
the shspensdry ligatnent of*tI)C tarsus aud' below tho anterior 
extremity of 'I'enon’s capsule. These cj^sts occur both in 
children and in adults.' ‘Gabriehdes distinguished them from 
chalazion for tho following reasons. (1) A chalazion is not 
contained in a membranous sac which can be seized by the 
fingers and extirpated. (2) A chalazion doesjiot contain 
a clear fluid, bub an amorphous matorlal. (3) A chalazion is 
nob situated at the upper part of tho Jid below tho ej’obrow, 
bub on Iho tar.sus itself. (4) A chalazion does. not possess 
deep roots. Tho hydatid cysts of tho Jlds described by the 
ancient Greeks are really the only cysts of modern ophthal; 
inolo<*ists. They may be congenital like dermoids, occur iu 
early* life, ami gradually increase in size so as to interfere 
with vision. They contain a llald, which is cither clear like 
glycerin or vollowish liko ascitic fluid,’ and fats (stearates, 
"lycerO'Oleatos, and i)almitabcsl. Treatment cousists in their 
total extirpation or in removal of tlie most prominent part, 
followed bv scraping out the bottom of tho cyst. Gabri§lides 
describes flyc pcr.sonal cases in patients aged from 49 to 60. 

226. Detac'nment of the Anterior Layers of the Iris. 

HI. J. Schoenberg {Arch, of Ophtlinhnol,^ November, 1927* 

■ p. 538) describes a case of this couditiou. . The patient.had 
lost his right eye from iridocyclitis many years previously. 
He was a Jiigli diver at a circus, aud on oue occasion, after 
his dive, as lio came to the surface of tho water ho fonucl 
. thathe had.hecome blind. After a week, however, his vision 
I had returned to normal; for some time previous to the 
:= accident, Ijowever, it had- not been good, and he -presented * 
liimsclf at hospital on this account. On examination ho was 
' found to have advanced ‘olirouic ^lancorna iii the- left cye»- 
the cornea, pupil, and media wore clear, hut the optic disc 
was atrophic and deeply cupped- The anterior layers of the 
iris were stripped off and were floating as threads in the 
j anterior chamber. There wore cracks in the deeper layers 
! aud iu tlie pignient layer. The sphincter papillae was intact 
and the angle of the chamber was not obvionslj^ obstructed. 
The most probable explanation was that the force of the 
high dive had driven the aqueous into the iris tissue, teariiig 
the strands apart. The author adds that cases of a similar 
nature have been .described, but iu very old people and 
without a traumatic jiistor5\ 

, 227. ■ - Osular Pemphigus. 

G. HI. doNSTANS {Am*n\ Journ. of Ophthalmol. ^ November, 1927, 

• p.810) describes ihreo cases of ocular pemphigus aud discus-ses 
'tliiS' rare* disease, which may occur. in. the eyes alone or 
associated'Witli generalized skin pemphigus. The etiology is 
quite uiilcnowii ; it has been attributed to toxic action upou 
the nerve centres. The condition in the eye starts with 
swelling ami congestion of the coniuuctiva and the formation 
of bullae which rupture. Later shrinking of the conjunctiva 
with tlic formation of adiiosions occur.s — the conditionals 
sometimes called “essential shrinking of the conjunctiva ' 



. KPia:o:\IJ3 OF.CUHRENT.MEPICAI^.I/irERATUPB. 


r ToKlinms* QO 


M.lKCil. j, rgjS] 


niiii,K«bsC(]iici)tly,tliocovnc'al)OCoincs(U'y, dull, and atrophic. 
Treatment con.slats In reinovliifj all causes of sepsis, and 
hcopliijt tlio oyo ns clean and moist as possililo, rcpoatdd 
boric acid IrrlHailons, a mild ooiijnnotlva! antisoplio, Bitch ns 
•zinc sulphato I/'t (train to tho oiinco or 1 per eont. niovcuro- 
, chrome, and tlio -iustillation of liquid paraltlu at frequent 
intervals, rroynosis is ultimately bad. 

22S. . . .SaTcomn of tho Uveal Tract, 

B. C. Daven’pout (/inf. •>oiini. o/ Ophthnlmol., Dccomhor, 
1927, p. 609) reviews all eases (35 in nunihor) of sarcoma of 
the choroid seen at ISIoorllelds Uyo Hospital during Iho period 
1918-23, tho avcrano being 7 a year. I’rovious records 
of past HOiies (1871-19^5) show almost exactly tho same 
ycnrlj- occiirronco. Davenport thlnhs tho ease incldciico at 
Jtoorllolds nowadays is about 2 In 10,000. IIo has been able 
to trace 22 patients out of tho 35; of these, 10 arc Ituowu to 
bo alive and well. Out of tho ivholo series 28.5 per cent, nro 
hnown to have lived irco from recurrence for more than three 
years after excision. Twolvo p.aticnts (3‘1.28 per cent, of tho 
whole series) are known to have died, and 7 of thoso (20 per 
cent, of tho whole series) died from rccurronco of tho 
sarcoma. Of tho untraced cases, two were seen alive three 
years after operation. 


svas absent, ilficroscoplcal o.xamination after biopsy showed 
regular im[)illary foriuatioDS consisting of a vascular core 
covered by regular squamona epitholinm. In two places, 
liowovcr, coll nests wero present and the epithelium in the 
iioighhonrhood showed a tendency lo multiple stratiilcatioa 
■and the presence of mitosis. Darly nmligoant disease of tho 
cervix Iiclug tlioreforo suspected vaginal hysterectomy was 
porforniod. Microscopical examination of tlio cervix in tho 
region subjacent to. tlio papilloma now showed invasions by 
squamous epithelium witliln the lumen of tho glands of the 
cervix and peuetralioii into tho adjacent connective tissue 
and inyouiotrium. 

231. Causes of Uterine Haemorrhage. 

It. Maoahey (Mcii. Joiirn. of AuHritlin, October 8tl), 1927, 
p. 50'!) agrees witli Wliiteliouso’s classiiicatiou of excessive 
uterine bleeding into (1) cplnicnorrhoen, or too frequent mon- 
stniatioii ; (2) nienostaxis, or too prolonged menslrnatiou ; 
(3) true mcnorrlingia, or too great a loss at a period other- 
wise normal; and (■!) ructrostaxis, or irregular ulerino bleed- 
ing, Under extra-genital can.scs of hatmmriiago lie refers 
lUst to excessive tliyrold action, and attributes menorrhagia 
at llic end of laclntiou to a coiitiim.aucc of' the .incica.scd 
tlis'ioid activity of (ireguaticy ; tlio approiuiate treatment is 
i-adiation of the thyroid and tho exhibilion of calcium salts. 


Obstetrics and Gynaecology. 

£29. Uterine Rupture during Labour. 

V, COCQ and J. J. Snoeck {tlrnxcHcs-Midicat, January 1st, 
1928, p. 269) record llirco eases of uterine rupture during 
labour, and describe in detail a fourtli personal one. In one 
case the rnptnro was evidently caused liy maminl ov Instru- 
mental Intervention, doatb ensning dming the conllnemcut. 
In another case the rupture was ajiparcntly Rpoutaiieous, and 
a subtotal hysterectomy was portormed. Tlio patient, a 
mnltipara aged 35, progressed favourahly after the operation, 
but broucho-pnoumouin supevvcniiig on the llftU day sho- 
succumbed in six weeks. Thoantliors classify uterine rupture 
as incomplete, complete, and complicated with involvement 

• of neighbouring organs; it may bo ot traumatic origlu or occur 
spoutaueousiy, Tiicy agree witli Band! tliat certain spon- 
taueous ruptures in muitiparae are duo to an exaggerated 
development ot tho uterus, tlic result ot fonuor picguaucies, 

. which by too stroug and too frequent contractions can cause. 
i a tear ot tiio lower. segment. .'l*'actor3'prcdlsposiug to mpturo. 
arc mnltiparity (only 6 to 12 per cent, occur in priniipatao), 
neoplasms, oicatricos (the result of previous opeiatious , 
degeuemtioii ot tho uterine muscular llhros, and any factors 
causing abnormal resistance to tlio uterine contractions, such 
as retracted pelvis and liydroccpbalus. Two important 
traumatic causes are version and iH-juclgcd forceps applica- 
tion. The prognosis is bad, the maicruai mortality beiu.' 
60 per cent, and tlie foetal 96. Tho treatment in these cases” 
as soQU as a diagnosis is made, is abdominal seclion foiloweii 
most frequently by subtotal bysterectomv, tliougU in excep- 
tional cases snturiug ot the aterhio tear is suOIciaat. 
Extraction ot tlio- cUild tbrougii the natural passage is 
indicated only when the presenting part is decplv engaged 
in tho pelvis. The autliors strongly deprecate ve'i-sioii and 
' forceps to a uou-eugaged liead, or before 

dilalation is complete. Internal podalio version in a uterus 
e.specially if preceded by forcible 
hifant^ with grave risks to both mother and 

230. Early Carcinoma of tho Uterus. 

AcconmxG to D. Cattaxeo (.jtih. dt OsUt. c Ginecol 

• r ■’ P- cavcinoma mavXde 

makfvhln symptoms, tlio neglect to 

wni) o opsy. o- to insnmcieiit care to e.xamiue the deep as 
\\cll as the supctlicial, portions of the suspect tuinonr- tlm 

mvesligatiou should e.xteud laterally hitrtt.o apprrm^^^^^ 
Letmi'p alludes to a case recently described by 

fram a *'^“S-ucnt.s, removed by curetting 

uom a patient witli menopausal bleeding, wero rennripd 
si ow Iimgoas ondoiuetritis with no sign of malignant disease 
ulernra&rf’"""^^ ^^y^terecton^ a few days 

the fundns of carcinomatous inllltration of 

ssiaSP— 

norma^eLent that PHysieal signs were 

- coS 


Ho next mentions Inllneuv.a, when tlio menorrhagia is only 
(emporaiy. As regards (lie ntcrino can.ses, (lie rotciitioii of 
tlio products ot coucc))liou iscoinmou even wbon tlio coiiliiie- 
ment lias been normal ; in inevitable abortion the autliordoes 
not advise immcdialo curettage, hut advocates packiug'tliJ 
vagina tiglitly for twenty-four to thirty-six liour.o, dilating 
the cervix andstimnlatlng uterine contraction ; this facilitalcs 
tho siibseqnent curettage and lessens liaemorrbage. Under 
malignant causes of liaemoribngo eiidoeervicnl carcinoma is 
important, bccauso it may bo easily missed before (be tiimoui 
has reached, tho vaginal surface ; even a diagnostic curettage 
may fall to detect it, tlio only indication of ils existence 
being tho fusiform shape of the cervix from (ho external lo 
tho internal os. Non-miilignnnt causes most commonly over- 
looked aro: (1) small sessile cervical polypi, which are easiest 
fonud by insjiootlon ; (2) Intrautorino polypi, often nssociiiled 
witli small llbroids, and frequently missed at a curetlage-i- 
tboso may cause temporary aincuotiiicea, followed by proliiso 
loss; (3) enlarged, tliickcncd, and possibly Jnceraled cervix; 
(4) previous operations on tubes or ovaries, because tlio 
infeotiou wliich necessitated oporatibn has caused a librosis 
uteri; in sneh caso.s compjeto. hysterectomy is nece.s.saiy. 
The. author Jins foniitV treatment hy. 'radiation-: p.afticularlv 
useful for menopansal hneuionhago, espooialiy if duo to suli- 
invoiutiou and to illiroids. Ho ndd.s tliat it sliouid ho remeiii- 
bered tliat the full effect of radiation is frequently delayed 
for several moiulis, during which lime iiieustniation may ho 
quite irrcgnlnr, and tliat for six weeks or so tho palicul may 
have a rather profuse ioucorrhoea. 


xujunes-oi tne joiauaer auring Uabour. 

B. Ottow {Zcntralhl.f. Gi/inik., Noveiuhor 12th, 1927 u 2924) 
clnssilles vesical injuries during labour .as coutusious, pressnro 
erosions, and lacerations. Contusions may c.anso oedema 
wTiicli may bo conliued to the spliincior or extend to the 
tiigouo; they may bo accompauied by multiple haenior- 
lunges iiilo tUo lijucons luciiibrciuc. ogcIguio. vjirics 

ill extent, and is usually iulUtrative, but may be bullous 
in patclics. Haemorrhages aro coiumwiest at the tri«ono 
and fundus. SncU coutusious are caused more l>v delav 
iu the pelvic canal than at the pelvic inlet, nhd alteraliou 
In the tissues due to pregn.auoy uiust not be overlooked 
as a contributory factor. As the head descends the bladder 
13 pusuctl upwards and the trigone and sphincter region aro 
compressed between the liead and symphysis ; they are also 
piislied lip over tho advancing part, tlius squeezing tlie‘ s6ft 
parts between two hard resistances. Similar contusion^ mav 
arise from, or bo iacteaseil by, operative measures Sueli 
contusions nro apparent shortly after birth ; tliev cause no 
constant symptoms, although haematuria is common The 
rate of r-ecovery varies greatly, but this bruising ‘raielv 
causes fistala formation. Pressure erosions arise diuirigthe 
overcoming ot discrepancy between the foetal liead and the 
pelvis; the critical moment is at the pelvic inlet Tho 
characteristic sites aro fn the fimdu-s-trigone region and on 
the anterior wall; these are seen in flat pelves.® In ^Muslo 
minor, crises the above pressure points are joined by bauds 
Cystoscopically pressure erosions of the trigone and fund ..; 
show an degrees from oedema to deep necrolis of the bladder 
flo-,;. ° H ° anterior aspect they are usually more supo” 
flcial m splimcter area necrosis and fissures mav® he 

tpiind. Tlie.Re pressure erosions frequently lead to MstLap 

but in tbeir absence tlio erosions heal durim- - 

It they aro superficinl iio-scar is ieft but if 

extensive then sloughing and a secondai'i fistula may® resu“tl 

322 B 


-40 March 3 , igzS] 


EPITOME OF CDERENT MEDICAIi EITERATUEE. 


r TnX DBITTtK 

Mcoiciz. JOCTIBJA 


bGconiing manifest a lyeek after clolivery. Fistulae appear- 
ing immetliately after operative cleliverj' are due to rupture 
of parts already weakened by pressure. Lacerations may 
occur during operative procedures, and are ebaractcrizcd by 
their ragged outline and absence of oedema. Cystoscopy is 
the only accurate means of investigating any suspicions case, 
and the risk of infection is lessened if it is performed at once 
before the lochia have started. A permanent .catheter is 
Iho best means of preventing fistula formation and other 
sequels; it should bo left, in for ten to twelve days. Should 
a fistula develop the catheter.should be retained and in many 
cases the fistula will heal. No urinary antiseptics arc given 
by the mouth, but once daily a small quantity of a silver 
preparation is instilled and left for some time in the bladder 
to prevent an ascending infection. 


Pathology. 

233, The Pathology of Ossification. 

R. Leriche (Bruxelles-Medical, January 29th, 1928, p. 439) . 
inferring to a paper by A- Policard on osseous physiolo^^y 
(ibid., p. 433), shows that an increased knowledge of the laws 
governing ossification have added to the pathology and treat- 
ment of many bone conditions. Two now ideas have been 
evolved. ^ The first is that pathological bone formation a 
metaplasic, humoral, uon-cellular phenomenon, involves two 
processes— congestion with oedema of the soft peri- and para- 
osseous tissues, and rarefaction of the bone. The calcareous 
reparative material does not come from the blood stream but 
from the Injured boue itself by the action of the congested 
and oodematous surrounding connective tissue. Dry tissues 
will not cause ossification, but only those modified by hyner- 
aemia and oedema. The second idea is that all increased 
circulatory activity and all hyporaemia round a bone cause 
absorption. Congestion of the periosteum and reabsorption 
or the bone are the physiological conditions necessary for 
boue formation. Leriche illustrates these points by describing 
the repair of fractures in long bones, and the conditions 
existing after injury. All traumatism produces an active 
1 aso-dllatation which is usually of short duration, but may be 
prolonged by various causes lor several weeks; the author 

a ml ‘^‘^2 *>0116 with 

tiimcuity of articular movement is oxperleuccd after ini'uri’ 
without any apparent bone lesion, radiograms will reveal n 
considerable decalcificatiou. This has been caused by the' 
vino-dllatatlou, but will not bo followed by repair uuloss the' 
circulation be modified. Osteogenesis and osseous rare- 
faction are, therefore, vasomotor phenomena, and those can' 
treated. Leriche maintains that in certain 
conditions the formatiou of lime and the subsequent healinx- 
can be much accelerated by sympathectomy. In slow com 
solidation, as in the pseudo-arlhro.ses', where osteb-synthesis : 
and grafts have failed, peri-arterial sympathectomy produces! 
a great transformation and ossification iu ten to twenty days 
In osteo-poroses, where the bone is being absorbed, symnath- 
ectomy (pen-aiderial if the trouble is very peripheral, rami- 
soction If It is diffuse) after a phase of increased rarefaction 
\\ill cause speedy repair. Two cases are reported wlilch 
show the benellts from these methods. 

2;4. The E£fe:rt; of Splenectomy on Experimental 
Infection. 

(Giorn. di Baticriol. e Immunol., December, 1927 ' 
p. 80 d) has investigated the effect of splenectomy on thoi 
course of bacterial and spirochaetal infections in animals ' 
In one experiment he injected subcutaneously two mice, one' 
of which had had its spleen removed thirty days previouslv 
with 0.5c.cm. of blood from a patient with staph, loSi 
septicaemia. The spleUectomized mouse became ill and was ' 
killed on the sixth day, a pure culture of staphylococci bein«' 
recovered from the heart blOod and liver.' tAc - con Uol moose' 
remained well ; it was killed on the twelfth day audcnltm'ns' 
Of the blood and spleen were negative. ' In a s^boiid AypeS/ 
ment three pairs of mice, one of each pair h ivin-' been 
splenectomized, were injected with blood from three natieuts 
in different stages of uudnlant fever. . One of the spleuecto • 
imzed mice died on the fourth day, and Ji. melilcnsii waa- 
recovered from the blood and liver iu pure culture. Theother 
mice remained well. In a third experiment two spleuec- 
tomized and two normal mice were injected with blood from- 
a patient suffering from spirochaetosis (S'pirocliacta dutloni) 1 
It was found that iu the splenectomized animals the spiro- 
chaetes appeared on the fifth day) and were present in the' 
blood in fairly large numbers, whereas in the controls they 
did not appear in the blood till the eighth day, and were then 
present in only small numbers. Moreover, the intermissions 
were short and incomplete in the experimental, but clear-cut 
382 r- 


and complete in the control animals. Finally, two white 
•rats, ono splenectomized and ono normal, were injected with 
blood from a mouse infected with Spirochaeta dutloni. In the 
iblood of the splenectomized nuimal a very few spirochaetes • 
-were found oil the seventh day ; the animal died two days 
later. In the blood of tho control rat spirochaetes were never 
found microscopically, oven thoughthe blood proved infective 
to mice ; tho animal survived. From these experiments tho 
author concludes that tho effect of splenectomy’ is to diminish 
the resistnuco of the aiiiiiial to experimental infection. In 
his opinion ono of the actlvilios of the spleen is to prevent 
bacteria which have gained access to the circulation from 
giving rise to a g'eneral Infection. 

235 . Dissociation of Toxin-antitoxin Mixtures. 

B. Bnssdsf (Ccntralhl. f. Bald., January 16th, 1928, p. 183) 
criticizes a recent article by Gorochownikowa of Moscow, 
who maintains that dissociation of a neutral diphtheria toxin, 
antitoxin mixture cannot be brought about either by physical 
or chemical iiiiluoncos, and who explains tho fatalities that 
have occurred after its administration by’ assuming tliat pure 
toxin was given by’ mistako. Busson points out that several 
workers have no,v shown that' such a mixture may undergo 
dissociation, and that n cousiderablo excess of free toxui may 
result. Working with old batches of toxin, ho has found that 
tho colloidal solution may .scpai'ato into different lay’crs, and 
ho believes that the same may occur in a toxin-antitoxin 
mixture. Normally' tho union of toxinaud antitoxin is rever- 
sible, but tho author draws attention to the change that would 
occur it n certain amount of dissociated toxin or antitoxin was 
removed fromailask containing an originally neutral mixture; 
instead of the remaining substances combining again to form 
a neutral ml.xture they would give rise to a quite different 
end-produet. Busson has observed similar alterations in 
toxin-antitoxin ml.xtnres as the result of change of tempera- 
ture. In practice it is known that the injection of toxin- 
antitoxin mixtures may prove fatal in children; such fatalities 
have been reported iu America, Austria, and Germany. Tho 
author describes tho case of a man who was severely ill with 
a high toinporatnrc and severe local distiirbanco after injec- 
tion of a supposedly neutral luixtnro. Ho concludes that there 
is no doubt about the dissooiability of toxin-antitoxin mixture; 
this couclnsion is supported both by laboratory work and by 
practical experience iu tho field. 

236. The Filterable Elements of Tubercle Bacilli. 

J. Valtis (Bresse Mid., January 28th, 1928, p. 113) describes 
exporimonts on the fllLcrablc viruses of tubercle bacilli with 
reference to their pathogenicity, culturable properties, tho 
sensitivity to tuberculin, tho immunity conferred by their 
inoculation, and their transplacental infection of the foetus. 
AVorking with gniiiea-pigs, and using filtrates of bacilli 
obtained from tuberculous sputa, pus, and cultures, ho fonnd 
that, ill addition to the tyiiioal acid-resisting Koch’s bacilli, 
there undoubtedly existed an ultra-microscopic form cap.ablo 
of passing through L- and L., Chamberlaud filters. In the 
filtrates, even after. long contrifugiiig, no visible elements 
were detected, and cultures on special media remained 
constantly sterile. lutraperitoneal and subcutaneous in- 
oculations of the filtrates caused an infection, sometimes 
transitory’, of a special typo and of very’ slow evolution, 
characterized by the presence of very marked sclerosed 
ganglionic lesions, and discrete visceral nodules, which con- 
tained ty'pical tuberclo bacilli. Their virulence, however, 
was so slight that it could not bo increased by succes- 
sive. jiassages through animals. A^altis believes that with 
the exception of A^audromcr and Mile Togouroff no ex- 
perimenter has succeeded in cultivating these filterable 
elements. The filtrates caused sensitiveness to intradermic 
inoculations of tuberculin, and produced a certain amoimt 
of immunity against an infection of average intensity. 
A'altis also demonstrated that tuhorcnlons infection could 
be- carried through the placenta to tho offspring by these 
filtrates, typical tubercle bacilli being recovered from the 
foetal lesions.- - , . 

237. Bacteriology of Dried Milk. 

G. F. Dick and Gr..,iX)YS H. Dick (Amcr. Journ. Bis. Child., 
December, 1927, p. 1040) investigated the bacterial content 
of two samples of preparations of dried milk, following on 
an epidemic of enteritis in an institution in which infant." 
received artifleiai feeds composed largely of dried protein 
milk. Cultures were made from broth suspensions plated on 
sheep's blood agar- A feed’ prepared with ono Sample was 
fonnd to contain 22,000 living bacteria per c.cin., of which 
11,000 were • -green-producing streptococci. _AV’ith another 
sample a feed contained 9,000 living bacteria in 1 c.cm. with 
7,000 green-prodneiug .streptococci. The authors emphasize 
the necessity for the pasteurization or boiling of powdered 
milk feeds. 



[ TiiK Bninsii 
Medicai. JounxAi* 


41 


MAiiCn lo.'^oaS] 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

239, InBtilln Poisoning. 

B. D.Mlt. (lYorsTc Mag. f. Lacgcvid., .Tamiarj’, 1928, p. 40) 
records Iho first ratal case of fiisiiHn poisoning to bo reported 
in Bcandinavin— a woman, aged 52, who was admitted to 
hospital lor sovoro diabetes, in a state of incipient coma. 
"Under trcatinout by insniin tho glycosuria and acidosis dla- 
appcarod and considerable general improvement followed. 
On the ninth day of treatment, however, slio neglected to eat 
tho regulation amount of bread at lunch ; half an hour 
previously sho liad been given 15 nnits of Insulin. After 
lunch sho wont to sleep as usual, so tliat tho luciplcut hypo- 
glycacinic reaction escaped notice ; threo hours after tho 
injection sho was found in deep coma with a blood sugar of 
0.(K5 per cent. In spite of tlio administration of adrenaline 
and glucose, whereby hyiicrglycaorala was produced (seven 
hours alter onset of coma 0.380 per cent, and two hours before 
death 0.089 per cent.), death ensued in nineteen hours with- 
out a return of consciousness. No convulsions wore observed. 
No special pathological condition was found at tho necropsy, 
so that an ovirdoso of insulin must bo regarded ns tho 
cause of death. 

23?. Spirochnctosls Ictcrohaomorrhaglca In tho 
Putcli Indies. 

Accohding to G. B.vt’.nsi.tNN and E. Smits {Scdcrl. Tijdsclir, 
V. Geucesl:.), December lOlh, 1927, p. 2478) special attention 
has boon paid during the last live years In tho Central 
Hospital at Sumatra to febrile diseases caused by spiro- 
chaetes, with tho result that they have collected about 
300 oases, all duo to tho same organism and mostly of a mild 
oharaotor; there wore, however, some moderate and some 
very sovoro forms presenting typical symptoms of spiro- 
ohaetosis ictorohaemorrhagica. Almost all the patients were 
Javanese workmen employed in tho rubber works, and only 
a few women were roprosontod. Tho incubation period 
ranged from four to tcu days. Neatly all oomplalued of 
feeling tired, and very many of paius in various muscles. 
Apart from tho sovoro cases tho average duration of the 
disease was ten days. Jaundice, which developed on tho 
third and fourth day, and usuaily not later than tho sixth, 
was found in only 17 per ceut. In 33 per cent, there wero no 
renal symptoms; 42 per cent, had ouly slight albuminuria, 
and 25 per cent, had casts or red colls in tho sediment. 
Haemorrhages, to which tho disease owes Its name, rvero 
limited to a slight conjnnctival haemorrhage, potechiae, and 
bleeding under the gums. Deflulto jaundice was not always 
present in these cases. Iiitec iou was always traced to water, 
without rats t.ikiug part in tho dissemination of the disease. 
The prognosis was remarkably good, as only four deaths 
occurred among 340 oases. Treatment was mainly sympto- 
matic, but a polyvalent sernm was used in tho severe cases. 

Z50. Purpura Fulminans. 

H. Knacer {Jahib. f. Kinderlitiill;., November, 1927, p. 1), 
who records an illustrative case, states that this condition 
was first given Its name in 1887 by Henoch, who defined 
its characteristic features as tho absence of haemorrhage 
from the mucous inembruue, the occurrence of extensive 
ecohymoses, an e.xtremely rapid course, ahsence of complica- 
tions, aud lack of post-mortem Dndiug.s, apart from general 
anaemia. Knaner’s patient was a previously healthy girl, 
aged 6, who on tho eiglith day ot a mild attack of chickon-po.x 
developed the lesions of purpura fulminans on the lower 
limbs, and shortly aiterwards passed bright red blood from 
the urogeniial tract and rectum. Recovery followed repeated 
large transfusions. Scurvy could ho excluded as well as 
thtiiubopenia, since the numher of blood platelets was 
normal. Kuaner attributes the extensive Jiaemorrhage in 
hiS case to very marked diminution ot fibrinogen. There 
was complete absence of coagulation in vitro with a normal 
bleeding time. 


2«. Tuberculous TyphobaoIUosis In Adolescents. 

foliclinico, Sez. Med., January 1st, 1928, p. 
records three cases, in patients aged 14, 17, aud 20 respe 
V . Pyosented a special form of tuberculosis corr 
sjoaamg to tho tynhobacillosls ot Liindouzy. Tho clinic 
withn,?f constitutioual distnrbam 

enlarfiemenfc P'^‘’‘°“Sed irregular fever with sligl 

argement ot tho spleen, absence of signs in the chest < 


clinical examination, aud late development of iileurisy with 
ofloslon, followed by recovery. Radiological examination, 
however, in such "cases showed considerable enlargement of 
tho lymphatic glands at tho hilum similar to that met with 
In childhood. Tlio condition, tberofore, does not represent 
a gouoraUzed infection, hut rather au infection of the pm"'" 
inonary hiluui, in which tho lymplioid tissue has retained 
tho characteristics of tho lymphoid tissue of early life. 

242. Testicular Mumps without Parotitis, 

R. W. DanieLSOX [Jonm. Amer. Med. Assoc., December 10th, 
1927, p. 2041), who records an illustrativo case, remarks that 
very few examples of tho condition have been reported, the 
most complete account of It being fonnd in Bathait’s Paris 
thesis of 1918. Dauiolson’s case was that of a man, aged 44, 
who had recently been engaged in riding bronchos and wood- 
hauling, but had not to his knowledge injured his testes in 
the slightest degree. Ho had bilateral uncomplicated mumps 
at tho ago of 9. Thirty- threo years later ho developed 
bilateral orcbltis, six weeks after liis wife and six children - 
bad bad mild uncomplicated mumps. The diagnosis was 
mado by oliminaiion of other causes, sneb as syphilis, 
gonorrhoea, tuberculosis, and trauma, and the history of 
exposure to mumps. 

243. Second Attacks of Scarlet Fever and Mumps. 

T. Run {Arch, de .Vcd. des Enf., December, 1927, p. 724) 
reports a second attack of scarlet fever in a girl, aged 10, who 
had had a previous attack threo years before. On both 
occasions Infection occurred during an epidemic and was 
followed by typical desquamation. In the recurrent attack, 
however, the temperature was hardly at all raised. -A second 
attack of mumps occurred in n boy, aged 8J, who bad had 
I a previous attack seven years bolore at the same time as his 
sister. On the aoooud occasion, however, his sister escaped, 
altliougU sho had to live in the same room as her brother. 
Tho case is of interest both on account of tho early ago of the 
boy at tho time of his first attack and tho immunity enjoyed 
by the sister. 

244. Penal Complications of Influenza. 

Q. Celli (11 Morgagni, .lannary 9th, 1928, p. 41), who records 
an Illustrative case, believes that tho occarrence of slight 
albumiuaria in iuflueuza is the rule aud its absence is 
exceptional. Severe renal lesions, on the other baud, though 
they do exist, are not at all frequent. The prognosis is 
generally good, and the lesions rarely become chrouio in pre- 
viously healthy subjects. As regards the pathogenesis of 
theso renal changes Gelli considers tho toxic factor the most 
important, though in certain cases tho microbial factor 
caunot be excluded. Influenzal nephritis and nephrosis do 
not present any special characteristics to distinguish them 
from renal lesions due to other causes. 


Surgery. 

245. Diagnostic Errors In Secondary Sciatica. 

A. Frexkbe (ZenCralbl. f. Chir., February 4th, 1928, p. 274) 
reports lour cases of tho lairly common condition ot sciatica 
secondary to other disea'-es. One, a man, after being treated 
for threo months for left sciatica and then discharged as 
a chronic invalid, developed shortly afterwards a phlegmonous 
inflammation ot tho left bnttook. The history and clinical 
appearance suggested that there was a necrotic tniueur in 
the sacral region. This was confirmed by an operation, which 
relieved the pain and saved the patient’s life. A lad, aged 18 
was treated in the neurological department of a ho’spftal for 
sciatica apparently duo to some spinal deformity thon«h 
oxtensiou of the vertebral column was easy and painless ' 
There was a tender spot over the spinous process of the third 
lumbar vertebra. Spondylitis posttyphosa was diagnosed 
aud confirmed by radiography. After two months’ ortho- 
paedic treatment the patient was cured and fit for work 
A woman, aged 45, with uterine carcinoma was treated bv 
radiotherapy ; three mouths later she developed sciatica and 
vaginal examination showed an extensive secondarv growth 
involving tbo lelt sciatic nerve. The fourth patient had 
been treated for sciatica for two years, was snbsequentlv 
thought to have tuberculous bip disease or malignant disenee • 
an exploratpry operation revealed an inoperable sarcoma ’ 


430 A 



42 JUncH 10, T928] EPITOME OF CUEBENT -MEDICAL LITERATURE. ’ ' = [ "SSSIu 


293. Tuberculosis of the Os Pubis. 

N. Tagli.WACCHE anil L. A. WBBBtt (Roll, y Trah. Soc. de Gir. 
de Jhienos Aires, Deconiber 7th, 1927, p. 9^7), who record nn 
Illnstrative case ot twelve yoar.s’ duration In a man aged 31, 
assert that tuberculosis of the pubic bone is an uncouimon 
affection, only one example being found among every 
thousand cases of surgical tuberculosis (Peoromaus). The 
onset generally occurs before the age of 30, rarely later. It 
is not more common in one sex than in the other; trauma 
does not appear to be ot much sigulflcanoo, but pregnancy 
and iiarturition are more important since they are liable to 
reactivate a dormant tuberculous process. The localization 
depends on whether the osteitis develops before or after 
puberty. In.the former case the body and rami ot the pubis 
arc affected, and in the latter the angle, spine, or symphysis. 
The lesion may assume a circumscribed or cavernous form, 
which may give rise to sequestra and is comparatively 
frequent and diffuse, or, more r.irely, it may be ot a peri- 
osteal type; the former is manifested by a rarefying osteitis 
and the latter by an enlargemout and caseous transformation 
ot the periosteum. Abscesses usually develop, with the 
same characteristics as those of other tuberculous processes ; 
they spread to neighbouring regions, giving rise to ffstulao, 
which may open in the labia rnajora, adductors of the thigh, 
or Scarpa’s triangle. The onset is usually insidious. The 
pain varies in degree, but is usually not intense, and may be 
situated either in the pubis itself or in adjacent regions; such 
as the groin, hips, or inner side ot the thigh. Tlie patient 
may show a certain degree of flexion and adduction of the 
thigh. The movements of the limb are usually preserved, 
apart from adduction, which is occasionally limited. Limping 
is rare and is most frequently found in children. A'oold 
abscess, which often occurs and may be found In various 
situations, may be the only manifestation of the disease. 
The most important complications are involvement ot the 
symphysis, hip-joint, and bladde'r. The. diagnosis must bo' 
made from neuralgia, simple or traumatic periostitis, in- 
guinal or crural adenitis,' and osteomyelitis of the pubis. 
Treatment does not differ from that of other osseous localiza- 
tions of tuberculosis. 

297. Acute Dilatation of the Stomach treated by 

Gastrostomy. , 

Matkt {Sull, ct MSm, Soc. Nat, Ue Chfr.,- January 2l3t, 1923, 
p. 10) records a case of acute gastric dilatation in a lad 
aged 15. After a large meal his abdomen became enormously 
distended, and he was brought to hospital in a serious 
condition. Under spinal anaesthesia gastrostomy was per- 
formed, but the patient died shortly afterwards. At the 
necropsy the duodeno-pyloric flexure was found fixed high 
up in contact with the liver, and the cause ot the condition 
probably lay in this congenital anomaly. The condition of 
acute dilatation of the stomach has been scon in varying 
circurastanoes. It is best known as a complication following 
operation, or associated with acute febrile conditions such as 
typhoid fever, or following accidents. Eating a large meal 
too quickly is also given as a cause. An interesting feature 
In some ot these cases is the absence of vomiting, which is 
difflcult to explain unless it is due to atony ot the stomach. 
The diagnosis is easily made by the enormous distension 
ot the upper part .of the abdomen. Treatment by surgical 
operation, or by the stomach tube, or by posture, has not 
given good results as a rule. 

298. Detained Ureteral Catheter. 

D. N. EisENDRATH (Joiirn. Amer. Med. Assoc., December 24th, 
1927, p. 2170) advocates a more widespread use of the retained 
nreterai catheter in tlie treatment of acute and chronic 
(nqn-tnberculous) pyelonephritis ; for the relief of obstruc- 
tive anuria and the severe pain in acute ureteral block by 
calculus or itinkiug ; in cases of ureteral injury following 
operations; and as a method ot dr.ainage ot the kidney after 
the repair ot a vesico vaginal fistula. Illustrative oases arc 
given from a relatively large number treated. during the past 
four years. The author uses small (5 F.) opaque catheters, 
only one being inserted, since the use of two lying side by 
Bide or one largo occluding catheter was not fouud to pos.sess 
any advantage. Irrigation of the reual pelvis was seldom 
necessary because ample drainage was provided through the 
lumen or alougside the catheter. Such catheters have been 
left in position as long as two weeks, there being no time 
limit other than until the temperature has been normal and 
the urine clear for five days. Eiseiidrath adds that any 
tendency for the catheters to be expelled when the bladder 
becomes distended can be overcome by the insertion of a 
urethral catheter in order to avoid the accumulation of urine 
in tlie bladder. Results liavo been most gratifying, and tlie 
antlior considers that the method deserves to be better 
known. , _ . , • - - . . 

430 B 


Therapeutics. 

299. A Precaution In Blood Transfusions. 

W, V. Brem, a. II. ZisiLER, and R. W. Hamjiack (AniM, 
Joum, Med. .Set., January, 1928, p. 96), from their c.xporicnce 
with over 4,000 blood transfusions, recognize tliroe types ot 
reactions: tlio febrile, with or witlioiit clillls; those duo to 
use of a wrong group ; and iho auaplij'lactoid. Tlio last two 
are rare, the common one lioing the first, but current theories 
as to its causatlou are Btill speculative and Iiavo no prophy- 
lactic value. A recent base, wliich is fully described, led the 
authors to bollovo tliat the nso of Lasting donors might help 
to provont.tlieso febrile reactions, 'i'ho patient suffered from 
rocurroiit haemorrhages due to duodenal ulcer, for the effects 
ot whicli blood traimfusions wore administered. When these 
were given from non-fasting donors severe febrile reactions 
occurred, but when fnsUiig donors were used there were no 
reactions in tour transfusions and only a mild 0110 in a flith. 
On one occasion, when n transfusion was being given two 
hours after tlio donor lia'd oaten a hearty protein meal, includ- 
ing boot steak, the patient had a severe chill and fever 
I'oactlon, beginning two hours after the transfusion, and 
haeinogloblnuria was noted tlireo Imurs later. No grouping 
error could bo discovered. 'Tlio antliors sugge.st, tliereroro, 
that somo ot those fohrllo reactions may bo duo to toxio 

roducts in the donor's blood, and that tliey may bo avoided 

y requiring the donors to fnst-for a certain time before the 
transfusion. In the case recorded an overnight fast seemed 
to bo sufilclont. i-''' • “ . - ' 

250. Myoaalvarsan In the Treatment of Syphilis. 

J. Fabry (il/cd. Il'cli, January 7th, 1928, p. 20) prefers myo- 
salvarsan -to the. older arsenoboiizol preparations for the 
reason that in many cases, especially among women and 
children, the, veins are difflcult to locate, and tiiat intra- 
'mnscnlar Injections ot, the ntsonobenzols are ' frequently 
palnfnl and In a considerable number of cases Iiavo produced 
extensive necrosis of muscle and fascia. Myosalyarsan is, 
however, equally snttablo for. intravonous, intvainnsoular, 
and subfascial Injection, but intraiiiusonlar or subcutaneous 
injections are less potent than are Intravenous iujootlons. 
Fabry has seen no case ot necrosis of muscle or fibrous tissno 
after the' Injection of myosalvarsan, and he regards it, as an 
important addition lo tlie list of avallablo drugs. The best 
site for intramuscular iujootlons Is in the glnteal region, as 
far ns possible away from the sciatic nerve. He recommends 
its administration in distilled water or in lactose solutions. 
Intrainnsciilar iujeotion is contraindicated in recent Inien- 
tions, but iiitravouous injections offer a rapid cure. Intra- 
muscular injections arc said to be suitable for all cases of para- 
syphilis, aortic anonrysin, and cerebral or visceral syphilis, 
especially in the specifle cacliexia and the arsenic-resistant 
forms of tile disease. lu opifascial injections tlicre^is some 
cumulative action, since tlie deposit at tlie site ot injection 
is but slowly absorbed ; tiio injections sliould not, be given* 
therefore, at shorter intervals than eight to ten days. A 
cannula of at least 3 cm. in length should he em’ployed. 

251. Treatment by Experimental Infection. 

F. MORETTI (Tftf. mod., January 2iid, 1928, p. 2) remarks that 
the therapeutic action ot experimental infection lias not yet 
been satisfactorily explained. It is at present impossible to 
say whether the'beneticial effects are duo' to the fever, shock, 
focal reaction, or a special liypotlietical antagonism betivoen 
clifferout viruses. He records a case of myeloid leukaemia in 
a woman aged 50, and of chronic articular i-henraatism in 
a man aged 23, botli treated by subcutaneous injections ot 
Spirochneta duttoni, the micro-organism ot African relapsing 
fever. Transient iraproveiuenc occurred in the flr.st case and 
a complete cure in the second, after other methods of treat- 
ment had failed. Moretti empliasizes the importance o| 
keeping in stock a strain of Spirochacta duttoni or tlie special 
virulent mosquitos which, under suitable conditions, retain 
tboir Infectivity for a considerable period. Experimental 
relapsing faver is a much milder disease than malaria, does 
not give rise to complications or changes in the blood picture, 
and is readily cured by the oral administration of stovarsol. 

252. Antitoxin Treatment of Scarlet Fever. 

E. -G. Bley [Amer. Jonrn. Dis. Child., January, 1928, p. 14) 
reports a series of 465 consecutive and unselectod cases ol 
scarlet fever; of these, 215 received either antitoxin or a 
combined antitoxin and bactericidal sernin, the I.attor giving 
the better results. Moderately slight cases did not receive 
the treatment for fear of a serum rasli, which would be worse 
than the disease. Adrenaline, opliedrine, and in some case.s 
morphine, were given when- a rash developed. Tlie value of 
the treatment is said to be definite. The toinperatuve falls 
to lOQ’F. o-l below within twenty-four to forty-eight hours, and 



MAIiOII 10, IQlS] 


EPITOJfK 01-' CURRENT MEDICAL LITERATURE. 


r Ti/E Bfimyn • 
\ Medical Jocbnai< 


43 


tl'o entire clinical plclnro is strlliinuly clmnjica for tlio bolter. 
AVlioro no improvoinont is niipiironc nfter forty-oifjlit hours 
it is ndviseil tliat a socona doso lie Riven, Cases that do 
not respond to treatment are possibly duo to strains of 
streptococci not ropresented in tlio preparation used. Eloy 
recomnieuds that sovoro cases sliould bo Riven tlio antitoxin 
cillior intravononaly, or intravenously and intramnacnlarly 
conibluod. The dose depends on tlio severity of the case and 
the ago and slr.o of the patient. In tlio cases detailed in this 
scries the dose ranged from 2,500 to 10,000 units. 

253. An Analtfcsio Preparation. 

II. Y. Dr. L.VQUEnn: (.l/cd. .lonni. itiul IlcconJ, December 7th, 
1927, p. 667) calls attention to. the analgesic advantages of 
cibalgino, a comliination of dial and amidopyrine, and refers 
toils' tolerability, duration of action, and ease of ndmlnlslra- 
tioii. lie states that it can bo given eillior orally in tablet 
fonii, each consisting of dial 0.03 gram and amidopyrine 
0.22 gram, or in 2 c.cm. ampoules for hypodermic use, con- 
taining dial O.OG gram and amidopyrino 0.'14 gram. Expori- 
iiientally it has been shown to bo of distinct advantage iu 
cases whore it is desired to relievo pain by calming a peri- 
pheral nervous excitation without disturbing sensibility or 
consciousness. In many cases it is said to bo proforablo to 
morphine, since there is no risi: of addiction or craving, and 
it may be administered fici\ucutly for an almost Indotlnito 
period. No nausea, licadaehc, or stupor on .awaltcning was 
observed, and constipation and otiicr after-effects of luorpliluo 
wore avoided. Its caliuing effect upon morphine addicts 
ciiahles the period of deprivation to bo passed without 
suffering. The aiitlior recommends its use for tlio relict of 
p.iin iu c.ases of tuberculosis with cavities and liaeiuoptysi.s, 
in astlmialio attacks, hepatic and renal coliCj .and for the 
relief of opiloplio attacks or the treatment of morphine 
addiction. 

251. Auto-haomotKerapy In Spasmodic Coryza. 

A. h. Benito (dro/i. do mod., cir. y esy., .lamiary 14th, 1928, 
p. 58), who records two illustralivo cases iu patients aged 29 
and 35, considers spasmodic corysa to bo a local manifesta- 
tion of a general distnrlianco duo to one or more various 
external irritants acting on tlio hypersensitive ocular, nasal, 
and bronoliial mucous niombranos of Individuals who directly 
or by heredity are neuropatliic or gouty. The predominant 
sjmptoms are nasal obstruction, snoozing, and liydrorrhooa, 
which are accompanied by photophobia, epiphora, and 
asthmatic attacks, and are followed by tlio expectoration of 
frothy sputnni. Benito’s method of treatment consists iu 
withdrawing 10 c.cm. of biood from the vein of the elbow 
ami Injecting it without any further mauipulatlon into the 
external aspect of tho thigh. Tlie Injections are given every 
two or three days, from Uirce to five usually being snflioient 
to produce a cure. The treatment was combined with resec- 
tion of tho nasal spurs, not only to re-establish permeability 
of tlio nostrils, but also to modify the liypersonsitivoness of 
the nasal inncons membrane. It was found that better 
results were obtained by this combined treatment than by 
resection or cauterization alone. 


Anaesthetics, 


1 drachm of paraldcliydo is , made up and given in tho 
qiiautity pre.soribed an lioiir or so'hcforo tlie ojicration with 
a hypodermic injection of morphine, tlio latter bciugTcpeatcd 
half an hour later if desirable. By tbis molhod deep or light 
nnae.slhcsia can bn obtained, a greater percentage of oxygen 
■can bo given, and tlioro are no dangerous periods of pro- 
tracted cyanosis. It can bn used wliorevcr gas and oxygen is 
indicated, except in diseases of tlio lower bowel sucb as 
colitis. 

250. Anaesthetic Properties of Hcdonal. 

J. Dosaed {Vril. Joitvri. Anacsihesia,' January, 1928, p. 112) 
discusses llio advantages, disadvantagos, and physiological - 
action in animals of licdonal, wliicli is iiietliyl-propyl- 
carbinol-urctiiano. It.s advantages arc as follows : (1) Tlicre 
Is littio or no oxcltcinent during the induction of narcosis 
by intravenous injection. (2) Great muscnlar relaxation is 
obtained. (3) It 1ms a diuretic octlon without albumin, 
haemoglobin, or casts appearing in tho urine, (4) Fatty 
dogeucratiou does not occur iu the liver, kidneys, or heart 
after its use. (5) Tlicro is no irritation of tho respiratory 
tract liccanso hodonnl is not excreted by the Imigs. ^6) It 
iias special advantages iu cases of low tension or haemor- 
rhage. (7) Wlicn used as a precursor to chloroform tho 
quantity of tlio latter can bo greatly reduced. The disadvan- 
tages, on tlio otiior hand, nro that the apparatus for intra- 
venous anaesthesia is cumbersome, tho drug is unsuitable for 
I conditions of liigli tension and for plethoric patients, arid its 
use in very long operations is sometimes followed by oedema 
in iieudulous parts. 

257. A Modified “ A.C.E.” Anaesthetic Mixture. 

C. 3V. IlAnNED (Ajiesl/icsin and Analgesia, December, 1927, 
p. 285) dcscrilies under tlio name of “ alkofovm” a mixture of 
one part of alcoliol, two parts chloroform, and three parts 
other, to wliieU snlllcicnt ether is added to make the spocifle 
gravity exactly tlie same as distilled water at 70’ F. Tliis 
dellnito proportion of other is .said to give better clinical 
results than is tho case when either more or less ether is 
present in the .solution; anaesthesia is produced more quickly 
and tho sleep is more natural. There is also less mental and 
physical cxeitcmcnt.less perspiration, less bronchial irritation, 
and recovery is more rapid and mucU freer from nausea and 
vomiting. The destructive changes in tho blood, kidneys, 
and liver by ether alone are markedly reduced, almost to a 
minimum, by tho action of alkoform when given as a wann 
dry nebulized vapour. The alcohol seems to dilute the chloro- 
form vapour, modifying its action. Tho average amount of 
alkoform required per hour is about IJ ounces, and this small 
amonnt of anaesthetic, coupled with the masicing of the 
objectionable ether odour, largely accounts for tho lessened 
nausea and vomiting. The time of recovery ranges from 
throe to twenty-five minutes, depending npon'the depth and 
length of time of the anaesthesia. Alkoform is said also to 
possess greater analgesic properties than either chloroform or 
ether, and to be valnable therefore iu obstetrics. Giving to 
tho difference of volatility of the three agents iu tho solnlion, 
ID is necessary that some means, other than evaporation, be 
devised to ensure tliat the gas or vapour will contain each 
in exactly tlie same proportions as iu tho liquid, and Harned 
recommends tlie Hiukie anaesthetic machine as being excellent 
lor tbis purpose, owing to its ncbnlizing action. 


- -Gas-Oxygen and Hcctal Ether Anaesthesia. 

J- D. Kiedoran (SI. Idichacl’s Hasp. Sled. Bull. (Toronto), 
Deceniber, 1927, p. 76) recapitulates briefly Gwnthmoy’s 
technique for rectal ether anaesthesia. In this technique 
preliminary cleansing enemata are given iu tho evening 
preceding and the morning of tho operation, and premedica- 
tiou with morphine, cUloretone, or paraldehyde one hour 
beforo^ the operation is advised. A 65 per cent, solution of 
ether m olive oil is administered one hour before tho opera- 
tion m a ratio of 1 oz. per 20 lb. of body weight. As iu 
respiiatory administration, tho reactions to this drug vary 
greatly , the danger signs being cyanosis, diminution of reflex 
activity, and embarrassed respiration. The amount of detail 
in the method has rendered it unpopular. The employment 
oxygen for surgical anaesthesia has 
during recent years, and tho improved 
ppiiances permit tho synohronons administration of ether, 
fvuiv vapours. In a number of cases, particularly 

nco inflammation is present in tho respiratory tract, the 
oxtrln', desirable. By the addition of nitrons 

hn nrn 1 anaesthesia with muscular relaxation can 
eth« operation with a smaller rectal dose of 

oil has been somewhat changed. Mineral 

solutron "sod, and a 50 per cent, 

per so lb Ji V’ paraffin is given in a ratio of 1 oz. 

{ffixtui-n S''- Jlioliael’s Hospital a 

taming 1 oz. each of ether and paraffin with 


Obstetrics and Gynaecology. 

258. I^abour In Contracted Pelves. 

AIjICkF. MAXWEtiL (JoT(?vi, Aiiier, Mecl„ Decenaber 171 h 

1927, p. 2088) classifies n pelvis as flat if the diagonal conjimate 
measures Jess than 10.9 cm., as generally contracted lAhe 
diagonal conjugate measures less than 11.4 cm., and as 
funnel-shaped if the distance between the tuberosities of 
the is-ohia nieasnres less than 7.9 cm. Judged by these 
standards pelvic contractions ocenrred in 252 out of 6 500 
deliveries under her control. She found that women ilith 
a generally contracted or funnel-shaped pelvis had smaller 
babies than women with flat pelves. Her experience taught 
her that one out of every two women with a small pelvis was 
a potential candidate for operative deliveiy, and witli tin's 
possibility iu view she considered it imperative that everv 
patient should be given detailed instructions as to nroner 
hygiene ol the birth canal during the last month of preonanev 
She emphasizes tlie point that trial lahonv has vapiiclx' 
defined time limits, the real test commencing only when 
cervix is completely dilated; it should not be pi-olonneu 
beyond the limits of the patient’s endnrance CemVal 
rigidity, feeble infrequent uterine contractions, aid occVnitn 
posterior presentations prolong labonr, wealren tho wo3,°s 
power of resistance, and cause exhaustion before th^alue 

43° C 



44 MaeCH lo, 1928] EPITOME OF CUBBENT, M EDIOAE LITER ATEBE, ■ 


of KAal labour can be determined. In view of the seriona 
foetal and maternal mortality hbe is of opinion that high 
forceps deiivcry should be discarded; although until recently 
this was trequentiy the only method of delivery available 
when maternal e.vhaustion compelled delivery, licr present 
policy in the management of contracted pelvis is conservative. 
The patient is allowed to go into natural labour: the progress 
is determined by rectal examination only, and in the event 
jot it being unsatisfactory the child is delivered by, a low 
cervical section. 

259. Bilateral Ovarian Aplasia. 

W. Baer (Zcntralbl. f. Gynal:., December 17th, 1927, p. 3241) 
describes the case of a single woman, aged 23, who sought 
treatment for purulent vaginal discharge and abdominal 
pain. The body showed distinctly male characteristics : the 
shoulder girdle was broader than the pelvic girdle, tha 
breasts were entirely undeveloped, hair was absent from the 
axillae and sparse on the pubes, the labia majora were small 
and the iabia minora almost undeveloped. The hymen was 
intact and the vagina was narrow, but tlio infantile utorus 
admitted the sound for 3.3 cm. The symptoms wore proved 
to be dne to cervical gonorrhoea, probably contracted from 
a sister with whom she slept; the patient, who was sexually 
Indifferent, bad not had intercourse. On account of tho 
difflculty experienced in dilating the infantile cervix the 
infection proved to bo very re.sistant to local treatment. It 
was thought that abdominal operation was justified and the 
uterus and adnexa were extirpated. The specimen showed 
a uterus of the same size as that of a full-term foetus, and 
two nodules the size of peas occupied tlie position of the 
ovaries. Microscopically it was found that these nodules 
did not resemble ovarian tissue, bub consisted of largo cells 
like those of the glomerular zone of tlie suprarenal cortex. 
The endometrium showed only rudimentary gland formation, 
as well as an intense inflammatory infiltration. 

250. Raptured Bctopic Gestation. 

0. H. Gordon [Amer. Jonrn. Stirg., November, 1927, p. 456) 
states tliat neither the etiology nor the pathology of ruptured 
ectopic gestation is understood, and that treatiuont depends 
upon noourate diagnosis, which seems to present considerable 
difflonlty. Most cases require operation, though a few 
patients recover witliout it. In a series of 120 cohseentivo 
oases collected by tlie author at two hospitals, 62 occurred on 
the right side and 58 on tlie left. In nearly all the oases 
there was va.giual bleeding; the average period of amenor- 
rhoea was six weeks. Pain is constant, and with blooding is 
the most important factor in diagnosis. A dofluite mass was 
palpable in 78 per cent, of the cases, while pain on moving the 
cervix was reported by nearly all the patients. Drawing the 
cervix forward caused intense pain and is a positive sign in 
diagnosis. Breast signs are occasionally present and Iielp in 
the diagnosis of pregnancy. Pre-operative treatment consists 
in rest, the admini-stiation of morphine, and, in some cases, 
in transfusion of blood. The operative treatment consisted 
in removal of tlie tube alone in 75 cases, and of tho tube and 
ovary in 36 cases. In 6 cases double salpiugeotoray was 
performed, and in 2 cases of Interstitial rupture tlie' uterns 
was removed, Gordon thinks that the mortality will be still 
further- reduced by care before operation ; in' the present 
series there were two deathsv - • i------ 


Pathology, 


261. The Nature of Herpes, 

Eemarking that the theory of Bokay and Nettar as to the 
identity of the virus of varicella and herpes is still undeter- 
mined, K. Boudin {Ilev. de lied., No. 8, 1927, p. 1029) reports 
a case of generalized herpes in illustration of his views. ■ 
Between tj'pioal herpes, unilaterally confined to certain' 
lierve areas, and these atypical types, many Intermediate 
forms exist, from the hemiplegic herpes of Fournier to the 
aberrant ones described by Miiiet and Leclercq. Generalized- 
herpes, of which 45 cases h.ave been reported, including the' 
present one, is characterized by two distinct eruptions: the; 
one, atypical herpes, consisting of reddish, anaesthetic, 
painful patclies with one or more nerve distributions, and 
studded with gioups of vesicles; tho other comprising isolated 
vesicles or p.apnles.ou the normal skin- and not on the. 
crytheinatons pa'clies, devoid of all pain and anaestlie.sia, 
and diffused over tlic whole body independently of any neural 
localization. 'J'lie Iierpes patches always appear first, and 
the general eruption four to twelve days later. Tho latter 
may present various forms, .sncli as erythematous macules, 
papnlos vesicles, or bnllae, hut they always lie on the 
healthy skin, and dry up without any trace remaining, while 


the herpetic areas become haemorrhagic and necrotic, and 
leave an anaesthetic cicatrix ; nervous complications are, 
however, exceptional. Throe theories are held as to the 
pathogenesis of this affection. According to tho first ono the 
iierpes Indicates a virulent infection of .soiiio ganglia by the 
virus, wliilo the generalized eruption ropresenls its dis- 
semination along all tho ganglionic cliains and tho infection 
of distant isolated colls. Tho ordinary theory, which Boulin 
supports, attributes to tho herpes a gaiiglionio localization of 
tho virus, and to tlie general eruption its dissemination by 
tho blood stream. Herpes, then, is a trophic trouble due to 
tho presonco of the virus, and this theory explains its first 
appearance ns vesicles and tho absence of neural distribution 
and sensory complications in the general eruption. Netter 
holds that botli eruptions are caused by tlio same virus, 
acting In tlio ono case by ganglionic localization and in the 
other bj' sopticaomio .diffusion, that this common virus is 
varlcollous, and that tho geuoial eruption is true varicella. 


262. • Vlrulerico of tho Diphtheria Bacillus. 

A. A. PINTO (C. 71. Soc. de Tiiologie, January 20tli, 1928, p. 159) 
gives an account of two diphtlieria-liko bacilli the virnlenca 
of which was altered by passage through the guinea-pig. 
■The first camo-froin tho throat of a woman who was not 
suffering from, and who had not beoti in contact with, diph- 
theria; tho second catno from tlie throat of a woman who 
likewise was not suffering from diphtheria. Both strains on 
isolation appeared to bo diphtheroids; they were arranged 
in palisades; they did not give Neisser’s stain; they fer- 
mented no sugars ; and they were avirnlent to guinea-pigs in 
a dose of 3.5 n.cm. of a twenty-four-hour broth culture. 
Attempts were made to exalt tho virnleiicc of these streins. 
Growth from a serum cniture was washed off in a little saline 
solution, ml.xbd with 10 c.oin. of 35 per cent, gelatin, and 
injected iiUra|)oritoneally into guinea-pigs. Cultures were 
made from tlio heart blood or peritoneal exudate of the 
animals which died, and injected into fresli animals. At the 
commoncomontof tho passage experiments the lethal dose 
of those organisms was 16 sornm slopes. After the first 
Strain had been passed throngli twenty guinea-pigs it proved 
fatal lii twenty-tonr to thirty-six liours wlioii injected intra- 
perltoneally with gelatin in n dose of oiio-tontli o' a sornm 
slope; injected’ without gelatin it was not virulent, ine 
second strain, after being passed through eighteen gnmoa- 
nii's likewise proved fatal in a dose of one-tenth of a serum 
slope; but it was also fatal when injected siibontanooiisly 
wlthont gelatin. Examination sliowed that the first strain 
had not altered morphologically ; it .still fermented no sngars, 
was not agglutinated by an antidiphtherial serum, and was 
not neutralized by an antitoxic sernui. The second strain, 
on' tho contrary, had beoomo morphologioally like the diph- 
thei-ia bacillus; it fermented 

glvcerin.was agglutinated to a litre of over 1 in 10,000. and 
was neutralized partly by an antitoxic serum. The a,ntlmr 
considers that his second strain was an avirnlent diphtheria 
bacilius, and tliat its virulence was restored to normal by 
passage through the guinea-pig. 

263. Bocal Immunization against Anthrax. 

G BOVIDA and B. Schwarz (Lo Sperimentale, January, 
Ifi'gS, p. 569) have investigated- the truth of Besrodka’s views 
on local immunity to- anthrax. -The anthrax bacillus was 
grown for five to eight days in broth, filtered tlirongh , a 
Ghamberlahd candle, and tested for bactericidal 
experlmentB condneted in-viifo and in vivo showed that such 
filtrates had only a slight inhibitory influence on the growth 
of thh anthrax bLillus, and little or no effect on its 
for guinea-pigs.: A series of guinea-pigs was then vacomated 
with filtrates- of anthrax cultures. One group '“-I®?'®? 
aiihriifcanGouslv. another group lutracutaneoosly, and atnim 
greup was tolterby rubbing the filtrate on to the shaved 
Ld Larifled skin of the abdomen three vaocmations being 
made .at. intervals of Ave.days. All animals, togethc With 
nninocnlated controls,- were nnjected 'with -a ^ 

f-nrniif-v-f. ■ . ^f -B-' anthy'acis five days alter 

tliB last ■ Gie Injections being made by 

rnhbinn ' icarifled abdomen. The seven 

control animals died in 35 to G2 '.ours; t’j® 
vaccinated subcutaneously died m 36 to 60 hours, 
fourteen animals vaccinated mtracntanequsly ten dffd m 
36 to 72 hours and of. -the six animals vaccinated per 
cntaLons“ died in 48'to 62 hours Thus the amu;^s 
died except four of tho.se- vaccinated ana 

one of those vaccinated .percutaneousb'. 

these survivors were immune. they were inooniatea iUc iaja 
later In tho same way as before with a living ‘ .2 

culture; all of them died in three days. It ’ 

therefore, that if there is any immunity conferred bj moonia 
tion of the skin with broth filtrates it Is very slight ana 
transitory. 


D 430 



MAliOn 17, 19^8] 


[ Tirr. UrjTisB • 
Mectcu. JocBXiL 


45 


EPITOME OF CURRENT MEDICAL LITERATURE, 


Medicine. 


2M. Hemiplegia In Cerobro-splnal Fever, 

r. IIOUNKL {Jouiii. tic Med. dc Itordraur ct dtt Siid-Oucst, 
I’obnmry 10th, 1928, p. 99), who records nn illustrative ease, 
romntlis that central paralyses are not very frequout in 
lueninstococcal Infection. . They generally appear at the com- 
nieiicoiucnt of the disease in the course of the llrst six days, 
and occasionally after convulsions or .Tacicsonian epilepsy. 
As a rule the paralysis talios the form of liciuiplcgia which 
closely rosoniblos a hoinli'lcgia of vascular origin. The 
licinlplcgia, wliicli generally affects tiie whole of one side, 
is flaccid at first, but soon boconies converted into a spastic 
form with Bablnslti’s sign, exaggeration of tlic tendon 
refloxes, and anklo clonus. Tho facial paralysis Involves 
oUiotty the muscles supplied by tho lower branch of tho 
facial nerve, with comparative immunity of the orbicniarls 
palpebrarum and frontalis musclos. Treatment, which is 
tliat of nioningoooccal sopticaomia, should consist of injec- 
tion of autimcningococcal sornm by the intrathecal, intra- 
venous, and subculaucouB routes. Bound's ease occurred in 
a soldier, aged 21, wlio developed complete loft homiplogia 
on the fourth day of lucningococcnl nicnlugitis which had 
been treated by antimenlngococcal serum. The paralysis, 
which was at first flaccid, became spastic, but terminated in 
almost complete recovery, 

2B5. TThc High Infantile Mortality of I*argo FamlUea. 

K. l''ntl'.DJUKG (Wien, lilin. V'oeh., Dccombor 15th, 1927, 
p. 1578) reviews the lUomtuvo illustrating the high infantile 
mortality eharactcristio of largo families, and records his 
own observations, which are based on the study of 100 work- 
ing-class women in Vienna, each of whom had given birth to 
six or more children In tho course of the last fonr years. 
'Tho fertility of many of them was o.xtraordinarily high; five 
had been pregnant twenty to twenty-five times, and seven 
sixteen to nhietoou times, and another twelve had had more 
than llftoeu pregnancies each, Tho whole aeries had had 
1,033 iiregnaucies, ending In the birth ot 885 living childrcu 
and WB misearringes, So that each motiinr had an average 
of 10-33 birtlis- Of the 885 living ohildrou, however, 330 had 
died by September 30th, I927, so tliat, including tho 148 
miscarriages, 46-27 per cent, of the pregnancies had been 
a dead loss to the State, Of tho 100 mothers only 11 had not 
lost a child and 89 had lost one or move, as is shown by tho 
foUowing examples. One mother lost 16 out ot 24 children born 
alive, and others lost 12 ont ot 19, 10 out ot 13, 9 ont ot 11, 
7 ont ot 9, 6 ont of 8, 6 out ot 7, and 3 ont ot 6. Ot 115 living 
children born to nine mothers 81 died and only 34 survived. 
The causes ot this high mortality are to be found in over- 
crowding, lack of cieanliuess and ventilation, and greater 
liability of infection, especially tuberculosis. In a consider- 
able proportion ot cases tlio death of a child was due to an 
accident owing to lack ot proper supervision. 


year in tho period under review, but the incidence both of 
new cases of tuberculosis and of deatlis from tuberculous 
moningitis during periods immediately following severe out- 
breaks of uicaslos was not unusually high. In fact, while tho 
incidence ot measles showed wide llnotuatious, ranging from 
4 cases in 1918 to 2,650 cases in 1902, tliat of inberculosis was 
highest about tho end of last cetftnry, since when it has 
shown a tendency to decline. Tho author adds that IVilhelm 
Bolsken (Xeil. f, KinderheiVc., Bd. xl, .1926, p._352), after 
reviewing 162 cases observed in his liospiial in Dusseldorf in 
tho period 1908-24, concludes that though measles, like other 
dl.soasos, may weaken tho body it does not.stir tuberculosis 
into activity wholesale. 

267. Fnccphalltls Following Diphtheria, 

A. Qderido [Nederl. Tijdschr, v. Ucncesh., January ■14th, 1928, 
p. 181), who records an Illustrative case, remarks that the 
nervous ftistnrbances following diphtheria are ot fonv kinds ; 
(1) paralysis of the peripheral nerves, (2) haemorrhages in tho 
CQtttral nervous sy.stom owing to changes in the walls of tho 
fossels, (3) emboli in tho cerebral vessels, and (4) pava- 
chymatons Inflammation of the central nervous system. The 
last variety, according to the literature, appears to be tho 
rarest. Quorido’s case occurred in a nurse, aged 20, who, on 
the eighth day of an attack ot diphtheria, complained ot 
severe licadachc, showed an inclination to vomit, and had 
slight twitching ot tho right hand. Tho knee and anide jerks 
were brisk, and Bahinski’s sign was present in the right foot. 
Tiuinbar puncture gave issue to a clear and sterile cerebro- 
spinal fluid. The symptoms gradually subsided in the course 
of the next few days and complete recovery followed. 
Haemorrhage and embolism could bo excludod”by tlie short 
duration of the symptoms. Meningitis was put but ot court 
by the absence of pain and Kemlg’s sign, and tho condition 
ot tho cerebro-spinal fluid. Encephalitis tUerotoro appeared, 
to bo tho most likely explanation, the lesions being situated 
in tho front part of the left internal capsule.' 

2B8, Acidosis in Athletes. 

H. A. S.tr.VESnS (Sois/: Sdinj. f. Lnegevid., February, 1928, 
p. 121) mado studies ot tho acidosis in young athletes after 
running various distances — namely, 100 metres, 400 metres, 

I, 500 metres, and 10,000 meiros; it was found to be most 
pronounced after a 1,500 metre race. There was no relation 
between the degree ot acidosis and previous training or the 
tiioo taken by tho race. From the body weight and lowering 
of tho alkali reserve it w.ss calculated that large amounts of 
organic acid (lactic acid) circulated in the organism after the 
race. Only a small ))art of this acid was excreted in tho 
nrlnc during and after tho race ; attcr a 10,000 metro race 
even less acid was excreted than during the control period. 


' Surgery. 


^6. Measles and Tuberculosis. 

O.^SlARVEti /. d, Koraf:c Laegeforcniiiff, February 

Ist, 1928, If. 105) has checked the old clinical dogma that 
measles is a frequent activator of tnberculosij?, by means of 
certain statistical observations which do not bear out this 
teaching. lie iuvestit'atcd I ho records of 208 children treated 
during the past ten years at tho Uikshospital in Oslo. In 
all of them- tubcrcnio.sis was diagnosed with more or less 
certainty. Tn 75 cases (36 per cent.) there was a history of 
measles, and in 12 there had been an interval of about a year 
between the outbreak of tho measles and the admission to 
hospital. In 7 cases this interval w’as only two to four months, 
aud m 4 tho measles had broken out just befoi-e aduiis.siou. 
In two cases there had been signs of tuberculosis before tho 
outbreak of the measles. Thus, altogether there were only 
y out of the 208 (4.3 per cent.) in wdiom tuberculosis would 
com to have been stirred into activity by the measles, 
whereas there were 66 children (31.7 per cent.) who contracted 
without immediate ill effects. The author has also 
notilicatious of measles and tuberculosis in 
^Mo With a View to ascertaining whether severe epidemics 
nni!?»?« ^ were or were not followed by an increase in the 
mnninr!;f?i of. fatal tuberculosis, notably tuberculous 

comiin?c:n^* • notification of opou tuberculosis was not 
helQve 1900, bub for the past thirfcy-one 
Lkowmnnf Ot tho incidence ot measles and 

Shows P^'opai'Cd by tho anthoi 

s ows, the incidence ot measles varied greatly from year tc 


269. Extrapyramidal Symptoms Tollowlng Accidents. 

A. Barkman (Acta Jfert.-.S'cand., January 30th, 1928, p. S3) has 
observed that, iu many cases ot accidents a most careful 
cxaminaliou may bo uecessai-y in order to diagnose correctly 
tbo resulting lesion, and reports an instance ot an incorreet 
diagnosis. The patient was a miner who, four years pre- 
viously, bad fallen down a mine shaft. When found he was 
seiuiconsciona, but completely recovered his senses soon 
afterwards. Hni'ing a three weeks’ confinement to bed be 
complained only of soreness and stiffness of the back and 
upper extremities and of pain in the right knee. Later, on 
leaving bed, weakness iu the left leg and sharp pains and 
trembling in tho right arm were felt ; pareses in both arms 
and tlie left leg, and trembling— most marked in the right 
arm but present over the entire body on exertion — were also 
noted. ’The patellar reflex, present on both sides, was 
exaggerated on the right. Since there was no evidence ot 
any organic origin ot this syndrome a diagnosis was made 
ot traumatic uenvosis. The patient coutiuned incapable of 
heavy work, and on examination fonr years later showed 
trembling of Ibc right arm, tonic contraction ot the right 
hand on movement, stiffness ot the arms and right leg and 
pains iu the right flank, along the inner sides of the thighs 
and in the left halt ot the head. These symptoms wore in- 
creased by exertion, and the mnscuJar rigiditj-, myotony and 
trembling indicated an extrapyramidal lesion. Further ex- 
amination revealed that, on walking, the left leg remained 
stiff, causing a peculiar limping, and the left arm moved 

4S0 A 



4G March 17, 192S] EVITOME OF CUEEENT MEDICAL LITERATTJBE. 


[ Tni Uritisw 
M eDtClL JoOBViA 


normally, while tbe right was abcluctecl at the shoultlor and 
flexed at the elbow. The plantar reflex was normal on the 
left .side but absent on tlie right. Many muscles ot the right 
arm and lower extremities gave myotouic or iiiyodyfitonio 
electrical reactions. Atter treatment by electricity and sug- 
gestion these symptoms abated, but they soon returned 
•in an exaggerated form, thus showing that the condition 
was not, as in hys eria, of psychogenic origin, but was due to 
a lesion ot the extrapyramidal motor area, possibly a tear ot 
the cerebral substance or haemorrhago. Barkinan discusses 
the parodoxal kinesla ot Souquos and Jarkowski, and con- 
cludes that the position ot the extrapyramidal area, in' 
equilibrium between the pyramidal tracts and the higher 
neurons, easily explains the tact that lesions ot this area 
give rise to functional troubles ot both organic and psycho- 
genic origin. 

270. Abdominal Incisions^ 

According to I. M. Boykin (Annals of Surgery, January, 
1928, p. 74) the observation ot a few simple rules renders It 
possible to leave the abdominal wall as strong and tree from 
deteets after an operation as It was previously. Tlie incisions 
usuaily employed in the upper abdomen and in the pelvis are 
through the right or left rectus muscle or through tlie linca- 
alba. An incision which splits the muscles produces a per- 
manent detect. Mid-line incisions are said to be defective 
also, as they provide only one fascial plane to suture, which is 
not sufficient to ensure security. The paramedian incision is 
considered the most satisfactory. In gall-bladder operations 
a right paramedian oblique incision is useful ; this begins 
across the mid-line and extends to beyond the liiioa semi- 
lunaris below the umbilicus. The muscle is reflected out- 
wards and gives ample exposure. For the appendix a 
transverse incision is made at the level ot the anterior superior 
spine of the ilium; the aponeuroses ot tho oblique muscles 
are split in the direction ot tho skin incision, tlie rectus 
drawn inwards, and the peritoneum is opened tor tlie whole 
length ot this incision. It is beat to drain near tho llnea 
semilunaris. Secure and accurate suturing is necessary to 
leave the abdominal w'all free.from detects. 

271. Epithelioma of tho Urethra. 

According to E. Wurmser (Joum. d'Urol., December, 1927, 
p. 497) cancer ot tho urethra is a rare condition, and cases 
occurring in the posterior urethra are usually only recognized 
too late for treatment to bo effective. It appears in patients 
between 50 and 60 years ot age, and frequently follows some 
previous inflammatory conditiou of the urethra. The first 
sign may be a urethral discharge which is followed by a 
perineal fistula even before a swelling has been recognized. 
There may bo dillioulty ot micturition and "all the symptoms 
met with in a case ot stricture. Later a periueal tumour 
may be detected, and also pain and haeraaturla, atter which 
a fistula develops. Wurmser thinks that to diagnose the 
condition all painful strictures of the urethra should be 
examined with the urethroscope. He adds that tho effective 
treatment ot the condition depends on early diagnosis. In 
caheer ot tho penile urethra the urethra may be excised in 
early cases, or the_ penis be amputated. .When the growth 
involves the perineal urethra extensive excision may be tried; 
whore this is not possible locahremoval and cautery or radium 
applications should be employed. lu some cases a cystotomy 
may be the best treatment to relieve pain and retention. 

272 . ^ ■' Tuberculosis of the Etomach. 

E. HjoRT (Norslc Mag./. Laegevid., January, 1928, p. 20), who 
■ records a personal case', illustrates the rarity ot tuberculosis 
ot the stomach by the following statistics. Ot 568 cases ot 
gastric ulcers in Eiselsberg's clinic at Vienna in the course of 
twenty-three years only 3 were, of a tuberculous nature. 
Bicrnak found only 4 cases ot gastric tuberculosis among 
12,528 necropsies, and Simmonds only 8 cases among. 2,000 
nocro|)sies. Hjort's case was that of a women, aged 47, who 
suffered from dyspepsia for a year, with occult haemorrhago ■ 
and normal acid values ; resection of the stomach (Moynlhan) ■ 
was pertoruied . No ulcer or tumour was found in the resected 
portion, but tubercles visible only on microscopic examina- 
tion were found in the mucosa. The patient had otherwise 
no clinical symptoms ot tuberculosis ; the case was therefore 
an example ot primary gastric infection. The incident was 
ot special interest not only as presenting an early form of 
gastric tuberculosis', but also because this early stage was 
associated with pronounced dyspepsia wiihout any obvious 
anatomical basis. Tho author adds that it is open to question 
whether the gastric tuberonlosis in this case should be re- 
garded ns the cause ot the dyspepsia, which in the absence 
of ulcer formation is doubt ul, or wiiether the cause should 
bo .sought in an overlooked peptic ulcer in the duodenum or 
in an ulcer situated nigli up in the intestine. The presence 
of perijejunal adliosions and the a: ray picture ot a dilated 


Therapeutics. 


273, Charcoal a's a ficdlclnal Vehicle.' 

P. BDUM (Bull. Acad, de J/rd., January 24lh, 1928, p. 119) 
states that the high adsorptive powers ot charcoal, due to 
Its poro'sitj' or tho iirosonce of impurities, such as traces of 
iron, lime, or nitrogen, vary so widely, according to its origin 
and manufacture, that it cannot bo employed therapeutically 
without sonio degree ot selection. It has been widely used, 
with favourahio results, in cases of poisoning. Experiments, 
however, have shown that in certain conditions charcoal can 
give up tho substances previously adsorbed and thus bo 
utilized as a medicinal vehicle. Using animal charcoal, Blum 
obtained a preparation of iodineby trituratingit withcliarcoal. 
Cachets eontalning 0.01 gram of iodine and O.Sgramof charcoal 
were administered at first, but later tho amount ot iodine was 
Increased to 0.08 gram. These were well tolerated and proved 
oUlcaoloas, tho iodine being slowly liberated and- exercising, 
thorotoro, a more prolougcd action on the body. The mixture 
Is now prepared by slightly heating 10 grama ot iodine with 
30 grams ot animal charcoal. After soino mlnutes no trace ot 
free Iodine remains; .70 grams ot chatcoal are then added and 
Intimately mixed, tho resulting mixture-containing 0.1 gram 
ot lodino per gram. Mercurial preparailou's can be similarly 
made, aud experiments are being; conducted with -bromine, 
sulphuretted hydrogen, and other substances. Hydro'chlorio 
charcoal can easily bo- prepared by bubbling hydrochloric 
acid gas through charcoal lor ten minutes, stopping the opera-- 
tion lor ten minutes, and then renewing it slowly lor twenty- 
five minutes. Tho charcoal thus prepared sliould be kept 
In woll-stoppored bottles and its acidity tested from time 
to time. Tho charcoal loses a great part ot the adsorbed 
gas during the first five minutes, hut then the de-adsorption 
becomes very slow and lasts for several days. Blum bolioves 
that this is a conveuiont method ot administering many 
gaseous aud solid medicaments ; that it permits ot a mole- 
cular therapy by substituting salts for metalloids and metals, 
and solutions for gases; and that it utilizes tho catalysing 
properties ot oertain drugs usually given in inHuitosimal 
doses. It is also of advantage iu the administration ot galenic 
liroparatious. 


274 , Gentian Violet In Dermatology. 

A. E. McFarland [ Arch . Derm, and Syph., January, 1928, 
p 16) records his experience of tho clinical use ot gentian 
violet locally in certain pyogenic skin infectipns and as 
a nroventl.vo. Using an approximately 5 per cent, solution 
in distilled water, with 20 per cent, ethyl alcohol ns a solvent 
and to render tho dye more penetrating, rapid improvemeut 
resulted in a child sultoring from a severe pustular lufection 
of the head and chest, and in au obstinate case ot iutecuoiis 
eczemaloid dermatitis which had failed to respond to otiier 
treatment. In folliculitis and bolls improvement followed 
n.aintlng twice daily, but McFarland found tho solution of 
most value in the post-operailve treatment ot lesions, which 
had been fulgurated or treated by diathermy, by painting 
tho denuded areas after removal of the burned tissue with 
a curette.- It the skin is kept dry for about twelve hours the 
dve becomes set and does not wash off; a dry* emst forms,- 
which drops off in about a week, the patient suffering but 
little disoomtort or inconvenience. Similar results were 
obtained in the ' post-opera'tivo' treatment ot molluseiun 
contagios'um, and one ot mycotic infection ot the mouth 
cleared up bv its use. For opitheliomata which have been 
destroyed by diathermy the use of gentian violet is adv sable 
until the granulations begin to form, when a mild stimulntjng 
ointment will hasten epithelial proliteration. EesuUs were 
negative in‘ patients with coccigenlc sycosis barbae and 
epidermophytosis ot the feet.' The denuded surface to be 
treated should be as dry as possible, and this may be hastened 
by swabbing -tvith 1 in 1,000 adrenaline solution. All cru.sts 
must first be removed, and no surface should be treated m 
the presence ot an albuminous or mucoid deposit or it there 
is haemorrhage or oozing. The application should be made 
wlth a small applicator wrapped in cotton--tvool, since a brush 
tends to splash the surrounding tissues. The only drawbacks 
are the colour and the liability to staining after frequent use. 


275. Arsenic In Syphilitic Aneurysms. 

II. PINARD (Dull, ct Mem. Soc. Med. dcs Hop. de Paris, 
fanunry 5th, 1928, p. 1711) agrees that specific treatment is 
tseless in cases ot nou-syphilitid aneury.sm, but since it is 
ioractimcB difficult to dotermine the etiology ot the lesion ho 
relieves that a test treatment is otteu successful, and tliac 
ntensive arsenical treatment is always jnstiflabloin dcfliiitely 
ivnhllitlc cardio-vascnlar disease. He describes tlie ca'io of 
i man aied 53, who had a large retrosternal aneurysm hmo""' 
ng syphilis acquired at tlio age ot 18 and untreated. Piimi-d 
.sro without much benefit four subcutaneous injections of 


JHAHCII 17, 1928] 


EPIIOJIE OF CUIU5ENX JMEDICAIi EITEBATUEE. 


r TnHamd 

i VzDzcAZ. Jovnzii 


4:7 


tropoquinol tiud twelve of ncetylarsan, the patient roumiu- 
iiiq ilysipuoclo Mid osliausled, and Biiflcclut; fi’oiu severe 
Uysplmfjin. The tiucurysm waa ns larHO ns nu orauiio and 
had eaiised oxtonslvo absorption o( tbo stornuiu. In six 
weeks 6.3 t'ranis or novar=enobenr.ol were Injected Intrn- 
vouously, and tbo patient Improved rapidly. After an Interval 
ol tbrcQ weeks It was decided to glvo a turtber seilos of two 
daily bijcetlous, each of 0.3 {'ram of uovnrscuobeuzol, at 
lutorval.s or four days. A second palicnt bad on aneurysm of 
tbo rl{;ht oxlcrual carotid ns Iar('o ns a pl{>eon’8 ogq ; bo bad 
been under the Intcnsivo treatment, with Intervals, tor nearly 
six years. Over 130 grams ot novarsenobcnzol bad been 
given. This was well tolerated, and innintniued tbo patient 
in good bealtb. Wbon tbo intervals between tbo scries of 
iujectlous were prolonged, or wbon tbo doses wore diminiabod, 
tbo serum roaotiou bccauio po-sltivo. Pluard coneludcs tba’t 
a loss intcnsivo trc.atment would bavo been useless. IlALlifi 
(ibid., p. 1715) doubts, liowevcr, wboibor Ibis intcnsivo treat- 
ment with nrsonobenzol is nccossary to obtain good results. 
Ho finds that all troatmeut often falls, but sometimes tbo 
long-continued admiulstratiou of small doses ot mcrcuiy and 
potassium lodlilo has produced nstonishiug roaulis in aortic 
aueurysms. Ho describes tbo caso of a woman, aged 65, wbo 
was treated thus and who survived for several years, dying 
eventually from heart disease.' Xbo aneurysm and jicrl- 
aortitis wore cured by a very moderato mercurial and todido 
treatment. Slcnrd recommouda repeated small aubcutaucous 
or Intramuscular injbetious ot novarsonobenzol ; bo considers 
niassivo doses daugoious. G. Caussndo memiona a caso 
treated in 1898 by injections of “I mg. of mercuric iodide in 
oily Busponsiou. Afior two scries, each consisting of ton 
injections, tbo symptoms were greatly relieved, but tbo 
tumour did not diminish. 

27G. Treatment of Anorexia In Children, 

TV. 31. Bartlett Jonrn. Uis, Child., January, 1928, 

p. 25j lias analysed tbo cousccutlvo records ot 1,471 children 
presenting tbomselvca during a period of eight mouibs at tbo 
out-patient department ot a hospital; 349 of them, 24 per cent., 
had loss of appetite, togetlier with signs ot maluutriiion. No 
organic cause could bo found in 121 cases ; septic tonsils and 
adenoids were tbo commouost pathological conditions asso- 
ciated with auoro.xla aud malnuirltiou, being present in 
77 cases. Patients with tuuotloual anorexia wero treated by 
one ot three mctliods; (1) the admiulstratiou ot 5 grains of 
sacobaratod iron tbreo times a day ; (2) ball au ouuco of 
ood-llvcr oil given two or tlirco times a day ; (3) trosb calf’s 
liver, broiled beef-steak, and lamb's kidneys ns part ot tbo 
diet at ledst three times a week. General Improvement was 
noted in each ot tiioso groups, but tbo rohults wero cousider- 
ably better in tbo third tliaii in tlio first and second groups. 
'I'bo author suggests that in fresh liver there la a specific 
Btimulaut to tbo appetite. 


Neurology and Psychology. 


lug characteristics : (1) a fairly close correspondence between 
thoracic aud abdominal breathing; (2) a relatively greater 
number ot laryngeal than breathing movements ; (3j a rela- 
tively complete Independence between vertical movements 
of tbo larynx and movements of breathing ; (4) an evident 
rhythm ot breathing, of tbo vertical movements ot the larynx, 
aud ot tbo obaugos in breath pressure ; (5) a disproportionato 
lucreaso In tbo duration ot expiration during speech ; and 
(6) tbo praseutation by the abdomen of small in-and-out 
movements ranging from five to seven a second. The 
stutterers showed a disintegration ot certain motor speech 
units which was apparent in the following ways : a completo 
antagonism botweeu tbo actions of the thorax and abdomen ; 
a imirkod synchronism between the movements of the larynx 
and of tbo various units ot tbo breathing apparatus ; a marked 
prolongation of inspiration ; largo vertical movements of the 
larynx during iiiK(iiratiou ; tonic and clonic spasms ot tbo 
muscles of speech ; and a now abdominal tremor rate. 

270. Somatic Conditions In Manlc-Depresslvo Insanity. 

T. SONdSn {Upsula Liiharejdmenings Fdihnnd., September 
20th, 19..7, p. 25) gives an extensive review ot work done in 
tbo attempt to discover correlotivo physical and psycliical 
factors in cases of mania and molaucbolia. He describes in 
detail a group ot eleven cases of manic-depressive menial 
disease under bis care, and elaborates the numerous clinical 
investigations performed liy him ; these included observations 
of tbo temporaluro, pulse rate, blood pressure, re.spiraiory 
rate, erythrocytes, baemoglobiu, leucocytes, albmuiu content 
of the scrum, blood sugar, non-jirotein and uiea nitrogen, 
prefornied and total creatluiu in tbo blood, tbo response of 
tbo vago-syiopalbctlc nervous system to adrenaline injections, 
tbo oculo-cardiac reflex, and Loewi’s conjunctival reaction. 
No parallelism was found between the psychic and somatio 
conditions, and no definitely abnoimal physical factors were 
discovered ; as regards the respiratory rate and uon-iirotein 
nitrogen tbo results were' completely negative. No clear 
connexion was found botweeu blood sugar and the psyebio 
condition, but tbo author states that this result does nob 
contradict tbo hypothesis of au association between manic- 
dopressivo psychosis aud diabetes. There seemed to l e some 
numerical increaso in the leucocytes, especially neutvophlles, 
during mania as compared with the quiet periods,' but tbo 
daily variations were cousiderablo and the result ot doubtful 
value. In some cases ot mania a rise in the pulse rate waa 
noted during manic periods, especially in tlie early stages. 
Tbo blood pressure seemed at times to be definitely higlier 
during periods of both mauia aud depression than duiing tbo 
quiet periods. 'Two patients showed increases In the uumbae 
of rod colls during transition stages from quiet to mania and 
from quiet to depression, but in the other cases no such 
parallelism was found. The author discusses bypoiheses 
concerning the Interrelationship ot the endoctlne and nervous 
systems in the psychoses, aud suggests that some means of 
prevention moy bo found by the employment of tberapentio 
measures iullneucing these systems. Numerous cliarts, 
tables, and graphs aro appended, and a list of references ia 
given at the end of the paper. 


ImpedlTn*\n*s of Speech* 

During a study of fifteen cases ot strophosymbolia, oi 
reading disability. S. T. OuTON {.irch, Neurol, and Fsijchiat. 
November, 1927, p. 671) noted that tbreo patients stuttercc 
and four others bad a peculiar laboured hesitancy In speech 
Numerous instances also arc recorded of the onset of stutter 
mg when a normally left-handed child is coerced into nsiD( 
the right hand for writing, and of recovery when the use 01 
tue left hand 13 permitted. 'I'beso cases seem to support the 
tneory that stuttering anil strophosymbolia are expressions 
in cerebral eloniinauce, and that therefore 
stattering would bo more closely related to tbo aprti.xiaa tbar 
to the ataxias. Jbe act of stnttciiug is not unlike an ataxia, 
wuieli has led to the .suggestion tliat the cerebellum may be 
at i.-iult. No deimonstrable cerebellar lesions, however, have 
.1! nh stutterers, and both speech and writing are 

piohab y essentially integrative functions of the highei 
v'sriwl dominant hemisphere. Emotional 

weirP ohserved in many stutterers, and furthei 

integrative solidarity— 0 

elismtegralion— in the stutterer’s attempt at speech, 

P- suggests that the complex 
fanc Sp®‘ three main 

Normal sDPPeh^’ms 1'°®® breathing, voice, aud articulation 
aed thoir p I I ‘^*?.P's-ys a harmony in the separate groups 
?n the.; ^‘"'t^'-ing sbow.s a dlsbaTmon^j 

iuvestiVnfip'®^ within each group. In the 

s^vemPnoi persons with severe forms of stuttering anc 
the and the technique oi 

tieord^oTnormalsn^ff^'i"’®^-. ^*'.® that tbs 

Units of tlip Prppti ,P®^^h showed an integration of tbo variom 
of the breathing mechanism, which exhibited the lollow 


280, Friedreich’s Ataxia. 

G. GIDDINGS {Journ, Amor. Med. Aseoc., October 22nd, 1927, 
p. 1395) reports ten cases of Friedreich’s ataxia in one family. 
Direct Inheritance is unusual, but the percentage of cases in a 
family appoavs to increaso with each generation. In the first 
generation of this series 4 cases occurred, while in the second 
generation 6 have developed. Gowers recorded 65 cases in 
19 families — au average of 3.42 in each family. In Giddings’s 
series there wero six males and four females ; their ages 
ranged from 5 to 42 years. One patient died at the age ot 40, 
another at 50, while 8 are still aiive. Ail developed definite 
symptoms at Ibe aawo age — namely, 12. Certain prodromal 
symptoms, undescribed hitherto, wero observed by the 
parents ; in almost every case, from late infancy to the age 
ot 12, a nervous instability, indicated by infantile convulsions, 
be.Tdacbo, lassitude, or e.xcessive nervousness, preceded the 
definite onset. Blood and cerebro-spinal fluid IVassetmann 
tests of the patients, parents, and blood relations were 
invariably negative. 'There was no familial history of epilepsy 
or of psychosis in relatives, but some oi the parents were 
closely related. The urine was always normal; two patients 
had hookworms, and ouo had a Taenia nana infestation, but 
without secondary anaemia or definite oosiuopbilia. In some 
cases severe scoliosis prevented lumbar pnuci ure. Pes cavus 
with or without hyperexteiision of the great toe, was generally 
present; there was ataxia in 9 cases. The eldest patient 
a man aged 42, had been imbecile for six or seven years and 
confined to a chair for tw-enty-flve yeais. Giddin^s gives 
det.sils of all the cases, and records the following conclusions 
(1) Friedreich’s ataxia is not connected with any of tlie acuto 
exanthemata. (2) Wbeu first noted as following these the 
pre-existent ataxia ia aggravated by the patient’s weakened 


480 a ' 


EPITOME OF CDRHENT MEDICAL LITERATDKE. 


- '48 March 17, 1928] 


condition. (3) Definite prodromal symptoms may be present 
for five , to' seven years betoro ataxia ' appears, while dis- 
appearance of deep reflexes was an early and constant sign 
in all but one case. (4) Ocular changes had occurred in 
G cftsos, but nystagmus was absent. (5) Ataxia developed 
in 7 patients between 11 and 12 years old; (Gj'Otlier congenital 
defects or stigmata of degeneration occurred, including inal- 
lormed ears, cardiac abnormalities, and hernia. (7) Scoliosis 
was constantly present, and appeared to be duo to an un- 
conscious effort to control' the ataxia; (8) Mental changes 
were not constant." (3) Laboratory findings 'were negative. 
(10) The rate of progress is variable, but all these patients 
were confined to a chair within five to eleven j'ears after the 
onset. Treatment is useless. 


Obstetrics and Gynaecology. 

281. Obstetrical Factors in Neo-natal Intracranial 
Haemorrhage. 

T. C. Greene {Boslon 3Icd. and Siirr/. Jonni., January 12th, 
1928, p. 1302) records a study of the incidence, causes, relation 
to breech extractions, and diagnosis of intracranial haemor- 
rliaga in the newly born, based upon 177 consecutive necropsy 
findings in infants dying before or shortly after birth. Greene 
concludes that such haemorrhage is the most frequent cause 
of neo-natal death, since it was present in 55 of the 177 cases- 
injury to the child’s liead, especially by sudden trauma, was 
tlio most important factor, but disease associated with haemor- 
r lages in tho body was sometimes detected. An analysis of 
the methods of delivery in these 55 cases indicated that intra- 
cranial haemorrhage occurs most often in primiparous and 
op rative deliveries, especially breech extractions, thounh 
only s X cases occurred in 258 cousGcutive breech extractions 
no preceded by version, and in five of tlicse there was no 
dilfiouUy in delivery. Since sucli haemorrhage occurs in a 
numbor of simple uncomplicated breech deliveries, and since 
breech extractions appear to be its commonest cause, tho 
routine use of version and breech extraction is condemned. 
The author adds that though intracranial haeuiorrliage is a 
serious complication, it is not necessarily fatal, and minor 
breeches of the tentorium and falx can liardly be regarded ns 
a cause of deatli, thougli they way be evidence of fatal Intra- 
cranial pressure transmitted to tho medulla. Diagnosis is 
usually easy, tho infants being drowsy and cyanotic, and 
tliere may be deviation-, of the eyes, ptosis, or convulsions. 
Opisthotonos and a hydrocephalic cry may be present, and 
the spinal fluid be increased in pressure and blood-stained. 

212 , Pyelonephritis In Pregnnn'cy. 

W. S. Pugh {.Vcd. Jonni. and Fecord, January 4th, 1928, p. 27) 
discusses the occurrenco and treatment of pyelonephritis in 
pregnancy. Of 100 apparently normal pregnant women 
examined from the seventh to the ninth month 80 per cent, 
showed evidence of ureteral retention, mostly right-sided, 
and it would appear that obstruction witli retention is the 
primary factor in the causation of the disease, bacterial 
implantation being secondary. A striking feature of tho 
condition, especially when there is marked renal retention, 
is the liigh pulse rate, out of proportion to tho temperature. 
Drug treatment was found to avail but little, and continuous 
drainage through tho ureter with as large a catheter as 
possible is essential. No smaller size than a No. 8 a-ray 
catheter with several large eyes should be used, since tho 
larger the calibre the better the drainage, with material 
shortening of the attack. 'The catheter is left in position in 
tho pelvis of the kidney with its external end draining into 
a bottle attached to the thigh ; if it does not drain properly 
it should be aspirated and irrigated with normal saline 
solution. Any initial discomfort can be relieved by mild 
sedatives or a 1-grain opium suppository. After .about three 
da3-s tlic smaller catheter may be withdrawn, when it will be 
found that the patient will take a No. 11 or 13, or even up to 
No. 18 ; it is important to use as large a catheter as possible, 
even performing ureteral meatomy or dilatation if necessary. 
Goncurrentlj- with this treatment copious draughts of water 
at frequent intervals should be taken. In a series of fifteen 
cases thus treated fourteen cleared up permanently without 
the use of anj^ urinary antiseptics. • : 

233. Puncture of the Cisterna lUa^na In Eclampsia 
and the Pre-eclamptlc State. 

■W1EI.OCH { Arch . f . GynSk ., November 28th, 1928, p. 296) 
recoi-ds his experience of aspiration of cerebro-spinal fluid by 
suboccipital puncture of the cisterna magna in 10 cases of 
eclampsia and 45 of the pre-eclamptio condition. The purpose 
of the procedure is to bring about a diminution in intracranial 
and intracerebral pressure; as much as 58 cubic centimetres 
of fluid was abstracted. In 3 onlj- of the 45 pre-eclamptic 




cases did a convulsion follow. Two-thirds of the patients 
showed after the puncture a fall of blood pressure (20 mm. of 
mercury on tho average) and in about one-third of the series 
a marked diuresis ensued. The pressure of the cerebro- 
spinal fluid, was measured in 12 patients, and on an average 
was found to bo 250 mm. of water, as compared with a normal 
average value of 150 mm. 


Patliology. 

284. ■ ■ Etiology of Pernicious Anaemia. 

E. Lombardi (Rif. 3Icd., January 30th, 1928, p. 98) records 
experiments on dogs in which lie produced an artificial 
stenosis of the ileum with tho following results. In five out 
of six cases a varying degree of stenosis of the last part of 
tho iieum was produced, and above it a dilatation of the 
Inmen, which in one case reached tho size of a second 
stomach. After tho operation' the animals showed a charac- 
teristic syndrome consisting in progressive emaciation, 
voracious hunger, and ulceration of tlie limbs, while the 
blood showed considerable diminution of the haemoglobin, 
progressive reduction in the nnmbcrof the red cells, poikilo- 
cytosis, auisooj’tosis, and somotimes metncliromatophiliaand 
loucocj’tosis. Death followed in eight to nine weeks. In 
some cases tho necropsj- showed a reversion of tho bone 
marrow to its embryonic state. ' These experiments clearly 
indicate tho delolorious action of enterogenous to.xins on the 
blood and general nutrition. 

285. A Precipitation Test for Syphilis. 

Remarking that one of tho chief difilcultios of the Kahn 
precipitation tost is in the reading of doubtful and slightly 
positive reactions, F. B. JOHNSON {Jonni. Lab. and Clin. Med., 
Jannarjq 1928, p. 334) describes an adaptation of this test, . 
introdneed by Kline and Tonng, in which the readings are 
made with a microscope. In this method twelve paraffin 
rings are made on thoroughly cleansed slides (2 by 3 inches) 
by dipping a wire loop of 12.5 to 13 mm. diameter into 
smoking paraffin and touebing tho slide with it. All the 
app.aratus should bo kept at a temperature of betiyeon 
22'= and 2'?= C., and tho air bo fairlj’ moist. The serums are 
heated for half an hour at 56’ C., and 0.05 to 0.06 o.om. of 
each scrum is pipetted into tho centre of a paraffin ring, 
positive, negative, and salt controls being also prepared. The 
antigen, titrated and diluted according to Kahn’s method, 

is most salisfactorj' when used after the lapse of 10 to 30 
minutes. One drop of the antigen dilution is added to each 
scrum with a capillary pipette drop|)iug 0.0075 to 0.0085 o.cm. 
to the drop. Tho sornms and antigen are brought together 
by a wooden toothpick, furlhor mixing being offected by 
a rocking circulatory movement of the slide for two or three 
minutes. The readin-cs are determined in dim light with 
a microscope. A clear fluid is negative ; fine granular clump- 
ing is recorded ns + , fine flocculation as -f-p, marked floccula- 
tion as -f -f -t-, and coarse flocculation as -t--f -f -p. Johnson 
claims that this method is more simple than the Kahn test, 
requires less material and time, and gives more easily read 
results. It is slightly more sensitive than either the Kahn 
or Wassermann test, and no loss adaptable to the globulin 
concentrated cerebro-spinal fluids. 

2S6, Salmonellosis Associated witb'Hydatid Cysts. 

E. L. Feyrb {Presse Med., Jannarj- 21st, 1928, p. 85) adds to 
the bacteriology of hydatid cysts bj- describing the case of 
a colonial soldier who went to Indo-China in, a transport 
containing a consignment of parrots, many of which died 
during the voyage. The patient entered hospital for pleurisy. 
After much investigation numerous bipolar staining Gram- 
negative cocco-bacilli were found in pus drawn from the 
region of the base of the left lung ; thej’ were shown to bo 
closely related to /(, paratyphosnsB, but were not agglutinated 
by the corresponding nor by a human serum, though ngglnti- 
nated bj' 1 in 100 serum of the patient himself. Tho patient’s 
serious condition forbade intervention, but much improvement 
followed injection of an autogenous vaccine and resection of 
the eighth rib. The titre of agglutination rose to 1 in 300. 
About a mouth later during defaecation a very thick whitish 
membrane escaped through the wound and suggested a 
hj'^datid cyst; this was confirmed by finding ccchinococcus 
booklets. Exploration of the wound localized the trouble in 
the region of tho spleen. The patient improved considerably 
and returned to France. Feyre discusses the diagnosis and 
localization of hydatid cj'sts, calling attention to the un- 
reliability of eosiuophilia as a diagnostic sign, but emphasizing 
the value of serum tests. He suggests that the amelioration 
of the suppuration can be largely attributed to the vaccine 
treatment. Tho infection was evidently one of J!. psittacosis 
following a hydatid cyst, apparently contracted in Morocco 
at some previous date. 




MAi’.cn 2^, igaS] 


[ mBsmtB 
UxoicAx. jov»]ri& 


49 


EPITOME OF CURRENT MEDICAL LITERATURE. 


^Medicine. 

287. Oc Ionia duo to Hypotliyroldlsm. 

r. PaONIF.J; ana I<. ltOUQUf;s {finll. ctMem. Soti. Mrd. desUop. 
dc I’iirh, ITolinmrj’ 23id, 1928, p. 2G8) lllusU-atc the oeourronco 
or oeilumn In liyiiolliyroUlism by aosoribiiii; n caso of this 
Uftturo. A woiuaii, ajitul 32, liud iioiiceil tov six >Ycoks j^raAUtv' 
sivolling ot lUo IcMB and avins wliicli Intei-fei'oil with tlio 
movements ot tbo limbs. When llrst observed the oedoina, 
vvldcU was bard, tender, and pittlni* only on linn jircssnrc, 
readied to tbo clbow.s and almost np to tlio Ituees. I’ain was 
present, not onlv on niovonicnt, but at rest also, and tliovo 
was insomnia fro'in tbis canso, but a--ray cxainluatlou vovcalcd 
no lesion or cnlartJoincnL ot tbo bones. Tbero bad been no 
remissions sinco tbo onset, and no sldnitlcant history ot 
previous illness was obtained. Tlio cxticniilios wore cold and 
cyanosed, tbevc was no cvldouco ot on.ioorino disturbance, 
and coniploto oxaniiuation revealed no sign ot niyxocdeina 
or Gr.avcs’s discaso, nor any tnrtlior abnorinallty except 
a regular tacbycardia of 120, which did not yield to rest. 
Treated by diuretics and calcinin cblorldo tbo patient niado 
no progress, but on administration ot tliyroid extract in doses 
iuercasing from 0.05 to 0.1 gram dally tbo swelling and 
cyanosis gradually disappeared, the oedema resolved, and 
movements ot tbo limbs became uurcstrlotcd. Some months 
were needed for restoration to tbo normal, but nine months 
after starting treatment withdrawal ot tbo drug occasioned 
relapse. After a year’s treatment only slight non-progressive 
oedema appeared on disconllnuanco. During this period tbo 
pnlso rate fell steadily to 80. A siudy of tbo literatnro shows 
that oedema ot tbis nature occurs principally in thyroid 
lesions — for oxamplo, in Graves’s disease — and In certain 
allied conditions showing pornianont tacbycardia and. tremor 
without goitre or oxopUtUalmos. 

288. Carotlnacmla. 

C. SsTONBIl (/tiller. Joiirn. Med. Set., January, 1928, p. 31), who 
reports on illustrativo caso with a review ot tbo literature, 
states that immediately alter the groat war Gotinau writers 
described a number ot cases by the name ot oarotiiiacniin 
wblcb wore obviously duo to tbo high vegetable diet ot 
that period. Tbo eases a-ero most frequently lound In 
children who bad been exclusively tod on diets rich In 
carrots aud green vegetables. Tbo cbiot interest ot tbo 
condition, which is not necompanied by any symptoms 
ot constitutional disturbance, lies in iho tact that It may bo 
confused with true jaundice, tbo priucipal ditTorcnco being 
the absence ot pigmeutatiou ot tbo scleiotics in carotinaeraia. 
Tbo discoloration ot tbo skin, resembling that caused bj’ 
jaundice, has been shown to bo duo to so-called carotiuold 
colouring matters designated lipocbroracs contained in yolk 
of egg, fats, and certain vegetables such as carrots, green 
vegetables, and oranges. Occasionally the colour ot tbo 
mine is altered. Stoner's case was unusual in that it 
occurred in a woman, aged 65, who bad been living tor 
several nioutlis almost oxclnsively on a diet ot vegetables, 
which included carrots. Tlie skin showed a slight generalized 
yellowish pigmentation, which was most iutenso on the 
palms ot the hands aud soles ot the feet. There was no 
pruritus, as is the rule in jaundice, and tlie sclerotics were 
not icteric. Tbo temperature was normal, and apart from 
flatulence and constipation, which bad been present for 
years, sbo bad no other symptoms. Examination of the nrino 
was negative, but the test tor carotin in the blood was dis- 
tinctly positive. The issue ot the caso is not recorded. 


289. Diphtheria Prophylaxis In Asthmatic Patients, 

G. Ij. "Waudbott iJourn. Ainer. Med. Wssoc., -January 28tl 
1928, p. 290) states that six astliniatic cliildreii who bad bee 
tree from astlimatio symptoms for several mouths bad recui 
ronces ot attacks coincidentally with the ndrainistration ( 
mxm-aiuitoxin. In two other children with an allergic famil 
mstory the first attacks were brought on by administrntio 
o[ toxm-autitoxln. Tbo attacks were of very severe typo an 
not yipid as well to adrenaline as is usually the case i 
astimia. .The skm tests for Iiorso serum were found positivi 
ru an cases eosiuopbilia was present, and in seven was bight 

till '“’‘Is that sine 

ue beiients of diphtheria immunization are too great t 

persons it is advisable to U 5 
?rlquenM^te“vS'sf desensitizing doses t 


290. Polyneuritis following Wumps. 

^V. COLBBNS and M. A. Eabinowitz (Jrc7i. Intern. Med., 
January, 1928, p. 61), who record an illustrativo caso, classify 
the neurological complications of innmps into (1) meningitis, 
i2) encephaiilis, and (3) neuritis — (n) ot the second, sixth, 
sevenlli, cightli, clcvontb, and twelfth cranial nerves, 
(h) difTiiso imlynonritls, and (c) localized nenriti-s. Only lent 
cases ot diftuso polyiicuritis have been dcscribod, all by 
Ercnch writers— namely, Joffroy (1886), Bevilliod (1896), 
Gallavardin (1898), and Pitres and Marcband (1922). AH tbo 
cases ot polyneuritis on record presented tbo quadriplegio 
syiidrcine, but they varied in tbo nature ot tho cerebral 
involvement. 'Tbo motor phcuoineua always predominated, 
wliilo tlio sensory symptoms and signs played a minor part. 
The common fcatuios ot all the patients were flaccid para- 
lysis of all tbo oxtremities, lo-s ot siiporficinl and deep 
reflexes, slight or no sensory disorders, aud disturbance ot 
the joint and vibratory sonse.s. No deaths followed, and all 
the patients recovered completely wilbin a month to a year. 
Tbo present ease, which occurred in a man aged 29, after a 
mild attack ot mumps complicated by left orchitis, was 
niiiquo in that quadrijilogla was associated witli bilateral 
facial parnly.sis and meningitis.' Complete recovery ensued 
within four mouths. 

231. Tuberculous Infection In Schools. 

J. GoUDSMIT and J. C. van der Loo (Nederl. Tijdsehr. V . 
Geneesk., February 4tli, 1928, p. 520), as tbo re.sult of a study 
of tbo literatnro and their own investigalious, have come to 
tho conclusion that in classes which have been exposed for 
a varying period to intociion by a teacher suffering from open 
tuberculosis a larger number ot children develop signs ot 
tuberculosis than might bo expected from’ examination ot 
other groups ot children. Tho nulhors ciupha.slze this lorm 
ot infection as being probably of cousiderablo imporlauce, and 
advocate careful physical examination of school teachers. 


Surgery. 

• 292. Diaphragmatic Hernia. 

S. \V. H.ARRINGTON (Archives of Siirqenj, January, 1928, 
Part IT, p. 386) reports thot au incroasitig unmber of cases 
of diaphragmatic hernia aro being detected and that the 
condition is probably more common than is at present 
rpcoguized. The embryonic formation of tho diaphragm 
predisposes to herniation at certain sites, and there is a great 
preponderance of cases on tho left side. Tlie types may bo 
classified into the wain groups — namely, tbo traumatic, and 
the uou-trauinatic or congenital in origin. -The symptoms 
are often obscure, and indefinite upper abdominal signs 
dcuiaud sr-ray examination ot the diaphragm. IVhen the 
syniptonis arc mild without incarceration of viscera medical 
treatment may be adopted. Definite attacks ot obstruction 
duo to incarcerntiou demauci operation. The abdominal 
approach is usually proterred, and closure ot the hernial 
opening is e.>sential to relieve the symptoms. Paralysis ot 
tbo diaphragm by phrenic neurectomy assists in closing largo 
apertures. Eight cases are recorded', with no mortality bat 
with recurrence in one case. ’Pho best results are said to bo 
obtained in the traumatic variety ot heruia. 

293, Cancer of the 'Yermlform Appendix. 

M.P&RAlRE(Btili.«t ilftim. Soc.de Chir.de Paris, Decerobei'IBth 
1927, p. 833) remarks that caucer ot the appeudi.x is only 
discovered either at a necropsy or during the course of an 
operation. He reports a caso in which it was found wUilo 
operating to remove a parovaiian cyst in a patient aged 30. 
This condition has been found at all ages, but more frequently 
in feuiales. The growth in tho appendix is nsnally small, and 
large tumours aro exceptional ; its consistence is hard, and it 
is usually found at the tip ot the organ. The glands are not 
as a rule involved, and metastases do not appear to occur. 
The condition gives rise to no special symptoms, apart from 
those ot clironic appendicitis. 'it is not unlikely that the 
carcinomatous condition may follow on or be secondary to au 
old attack ot acute appendicitis where the lumen o' 1 he organ 
has bccomo obliterated. Contrary to what is found in other 
cases ot cancer, the prognosis is good, aud appeudltcctomv 
removes all danger ot any recuneuce. 'Pho treatment is 
removal ot the appendix and Its mesoappendix. The disease 

is histologically serious, but clinically benign. 

_ 53^ A , 



50 march 24,-1928] EPITOME 'OF CUBEEiST’MEDIOAri- LITERATURE;'^-' 


J ?rO*Tni! BnmsK "M 
L MkDICXL JOUBKiL 


2S4, Thromlio-aii^iitia Obliterans, 

M. Lbtulle, J. Marchak, aud G. Rover (Prase Mcd.t 
Febrnary ISfib, 1928, p. 193) base their acconut ot this disoaso 
upon a seribstiJ twenty-eight patients under their observation 
in Paris. Gliiiicaily they recognize three periods. fl)~The 
insidious beginning is often found in the superficial veins ot 
the limbs ; the-arteries are sometimes not alleeted for several, 
years. Phlebitis always precedes true gangrenous changes. 
Sometimes veins, even when varicose, are completely bloched, 
and absorbed. The hair of the limbs comes' oiit, and in slight 
cases swelling and heaviness of the feet are observed. Thera! 
are also small tender inflammatory .nodules in or below the' 
skin. This stage ot the disease may pass' almost unnoticed 
by the patient. (2) After .a period.varying from two to sovcu' 
years the second stage begins by the patient being seized one 
day when walking by a sudden pain, which feels like a sprain 
of the plantar arch or toe-joint. After a time his legs get 
weaker and tlm distance he can walk diminishes. His feet 
cannot bear tlie heat ot the bedclothes and a slight jar brings 
on intolerable pain. He cannot sleep lying down and generally 
consults a doctor at this stage. The feet are rather dry, 
and pain is increased by warmth. Exercise produces vaso- 
constriction. Arterial examination by oscillometry is usually 
positive. The leucocyte count was 10,000 to 15,000 per c.nim. 
in halt the cases, and the blood cholesterin figure was raised. 
The condition is easily mistaken for gout, rlieumatism, or gono- 
coccal arthritis. (3) The third period often begins during cold 
weather. The former symptoms are aggravated. The painful 
attacks are more frequent, the limb is blanched, and a little 
vesicle forms bn the toe. It ulcerates, docs not heal, and 
multiplies, becoming acutely painful. Morphine is necessary, 
and finally in most cases amputation. As regards treatment, 
sodium citrate, insulin, and sodium nitrite iiavo been tried, 
the latter being successful in five cases. Out ot 21 cases' 13 
thus treated were able to resume their work. 'Amputation 
wlien necessary shonl'' - ■ - ’ ; ' v the lower 

tliird ot the limb. T (Buerger’s 

disease) is oharaoterizeu oy a tioumte lesion ot Uirombo- 
angiitiis— the lumen ot the vessel being almost entirely 
obliterated by an organized thrombus containing many giant 
cell systems. Seven plates drawn from sections ot vessels 
in amputation material show in detail the characteristic 
lesions found iu the disease. The authors conclude by stating 
that on both clinical and histo-pathological grounds it is an 
entity duo to some specifiebut undetermined cause resembing 
leprosy, tuberculosis, and syphilis. 

29;. E. ALLEN and H. IV. Mbverding (Surg., Gynecol, 
and Obstet., February, 1928, p. 260) discuss tiie surgical 
procedure in thrombo-augiitis obliterans witli a report ot 
45 oases. Fatigue or claudication pain after exercise, relieved 
by rest, are early symptoms, followed by burning or aching 
in the digits unrelated to exercise and later becoming un- 
bearable and only relieved by amputation. Tlie earliest oiijec- 
tive sigu is a bluish-red discoloration with cold extremities, 
diminished pulsation, and followed by gangrene, A study ot 
the cases showed that iuois'iou of toes or removal ol uails 
should not be performed, and that amputation of toes is 
successful only in selected cases. In approximately 80 per 
cent, amputation below the knee is successful provided that 
medical post-operative measures, such as radiant heat, can 
be employed to Increase the blood supply to tiio stump. 
Amputation above the knee should only be undeit.aken in 
cases in which infection or trophic changes are vdy exten- 
sive, and for those patients who are unwilling to risk a. 20 per 
cent, cliance of failure ot amputation at a lower level. 
Procedure iu each case has to be decided on its merits, it 
being remembered that function iu many cases can be 
re-establisliod by medical treatment. Cases of gangrene of 
the toes only should be treated medically provided ih-at tho 
pain can bo relieved and economic conditions do not call for 
surgical intervention. 

29S. Preservation of the Iiimbs after High Ligature 
of the Vessels* 

O. Frisch (Zentralhl. f. CJiir., January 21st, 1928, p. 141) does 
not agree with H. Hartloib that the continued vitality of 
a limb after ligature of tlie main blood vessels is very 
doubtful. In 1916 Frisch' had two cases of ligature of tho 
femoral artery; these indicated that, as a rule, tlie limb is 
not endangered by ligature. He mentions that in tlio Russo- 
Japanese war ligature of tiie great vessels yielded very 
good results. In the Balltan war Frisch ligatured fifteen 
aneurysms: of these, five were of the femoral artei-y, one of 
tlie axillary artery, and one of the subclaviau, and iu no 
instance was tliere any interference witli tho nutrition of the 
limb. Frisch adds that many other surgeons h.ave had 
similar successes; usually the collateral circulation was 
established quickly, and the continued vitalitj' of- the limb 
was not endangered. 


.Therapeutics, 

297. Clukhorment In Diabetes. 

F. RATHERY and P. Mollaret ef nicm . Soc . Sled, det 

Hop. tie Paris, February 16th, 1928, p. 203) have investigated 
the therapeutic action ot glukhorinout iu diabetes. Two 
methods ot administration have been tried, each ot tliom on 
two cases of diabetes -mellitus- with wasting. To the first 
two patients glulthormout was given in doses increasing from 
one t6 two tablets (30 grams. each) after, food three times 
. a day; .Thorp followed at once slight rednctlon of glycosuria, 
acetonuria, and the blood, sugar, \Ylth a marked failing, oft 
of bota-oxybutyric acid in the urine. In the second group of 
cases ginkhorinent was given in conjunction with, insulin. 
With a constant dose ot insulin there resulted a decided fall 
of sugar iu tho blood and urine and in tho acetone bodies, bnt 
there was increased excretion ot beta-oxybut.vric acid. On 
tho other hand, it was found that if tho usual do.se of insulin 
was reduced during tho administration severe acidosis and 
coma resulted. The authors conclude that neither synthalin 
nor glukhorment can compare iu ■ efficacy with insulin. 
Glukhormcnt is found to have tho power of decreasing 
gij'cosurla nnd'hyporglycaomia, but pronounced individual 
variations occur precinding tbo determination of sugar and 
I glukhorment equivalence. A marked action in reducing 
' ketosis is observed, but this and tlio other properties ot the 
. drug usually become apparent after a certain delay. Some 
patients show groat intolerance to both synthalin and gink- 
hormeut. It is considered, that equilibration by diet should 
always bo attempted, and that it. this fails synthalin or 
glukhorment may replace insulin by virtue of its easy 
ndminiatratiou, but only under close supervision; injections 
ot insulin should be renewed it the blood sugar or acetone 
bodies tend to increase. Tho authors add that there is 
evidence to suggest that synthalin and glukhorment are 
identical in composition. (See Dale and Dudley, British 
Sledical Journal, December 3rd, 1927, p. 1027). 

298. Treatment of Otitio Sepsis. 

H. I. Lillie (Arch, of Otolaryngol., January, 1928, p. 30) 
record’s his results in twelve cases of septicaemia following 
mastoiditis and lateral sinus infection. Good results having 
followed transfusion in septicaemia, he resolved to use it in 
lateral sinus sepsis, and particularly in tho case ot patients 
tvlio were iu a serious physical condition before operation, or 
who did not appear to bo recovering subsequently. In many 
cases he transfused blood before the operation with very 
good results. When a blood, culture showed an actual blood 
infection a solution ot germicidal dye was added to the blood 
at the transfusion or was given separately. Merourochrome- 
220 was tho dye used ; this has been reported ns having high 
bactericidal properties, esoeoinlly for Jtacillns coli, while 
gentian-violet i.s said to bo' specific for Gram-positive cocci, 
but is more difficult to prepare and to standardize than 
mercurochrome. The optimum dose of the dye was found to 
be 5 mg. for each kilogram of body weight, and the best 
results were obtained by adding it to tlio -transfused blood. 
Tho combined transfusion, whether pre-operative or pos^ 
operative, had tlie cffoct of reducing the temperature and 
pulse rate considerably and lessened tho operative shook. 
•Blood transfusion was found also to shorten convalescenco 
and add to tho recuperative powers, the dye being entirely 
a curative measure. Lillie insists that transfusion and in- 
jection of the dye cannot iu any way supplant operative 
measures, but are auxiliary. 

299. Scrum Therapy in Scarlet Fever. 

B. Johan (Slonats. f. Kinderheilh., December, 1927, p. 536) 
has observed 25,000 children on wliom the Dick test was 
made. He finds that on repeating tho test conflicting results 
appear in some cases, which he thinks may be duo to faulty 
technique or may mean a real change iu immunity. Ini' 
majority ot Dick-positive patients were between 2 and 4 years 
old. while most cases of scarlatina occur between 5 and 
9 years ot age ; Joliaii attributes this to the greater risks of 
infection at the later period. In .spite of. such v.-iriatiou ho 

considers the Dick test sulfioiently reliable to justify furtliM 

investigation. Ho states that in Hungary more than 25,000 
cliildren were iiiimmiized by tho Dick method ; ot these, no , 
child who was Dick-iiegative at the time ot exposure has 
become infected by sc.arlet fever. In a few cases children 
who were very strongly positive but who received a small 
injection remained negative fori only a short time, and 
eventually bec.sme infected. In his opinion more work is 
needed to settle t lie dosage necessary for acquiring permanent 
immunity. Theraponliciilly two varieties ot serum are nsoa,^ 
one ot which is propared from convalescebts and tlie other 
from Iiorsos treated with haemolytic streptococci “Om 
scarlatina cases. Johan has found the Dick unit nnsatis- 
lactory and has elaborated another method, taking the size 


SS4 B 


JUnciI 24 , ipsS] EPlTO^ilK Or.pTOHENT imDlOAE LITEHATUEB. 


r TiTE nnmsn 
ilEDiCAL Jocr::ii, 


51 


oftlio ronclion asstamlord and dcUnliif; a scarlatina antitoxin 
nnit. Ho 1ms treated ■ 14*1 patients vltli iiorso scrum and 
148 with convalescent sornni ; lio compaved tlio resnltawSth 
llioso in 1,838 cases treated without scfiim, wlilcli was j^lven 
only when Iho infection was sovevo. Convalescent Eorum 
liijcoted Intravenously proved tlio most elTcottvo, with a 
mortality ot 4.5 per cent.; intravenous Injections of horso 
Fcriiin gave 6.9 per cent. ; and untreated cases 20.2 per cent, 
intravenous Injection was found to ho inoro offcctlvo than 
Intraninscnlar. The earlier tlio scrum tvas given tlio better 
the result; if Injected after tlio lUili day tlio luortallly was 
doiihled. 'Xlio host slrenglh for a niodovately sevcio case was 
4,000 units, tlio luortallly holiig thrro limes less than If tho 
doso was only 1,500 nnlts. I’ailcnts reacting well to serum 
were found to bo less subject to ncplirilla and olUls. 

303. Treatment of Bronchial Itsthma. 

n. B. 'WlT.Mr.Tt (.iroh. rh;/». Ihciapu, Sanniiry, 1928, p, 18) 
niahitaiiis that Iho infra-red and ultra-violet rays should bo 
used In all cases ot bacterial sensitivity ns an adjunct to 
b.actcrlotbcrnpy. Tho trentmont is Indicated in nil children 
Enfferlug from astliiiin, no matter what the cause, who nro 
dcflnltcly anaemic and show cvidcnco of ricltets; in all 
paticnts'who^c living conditlon.s are p.oor with Inadequacy of 
Bunlleht; and In ndnlls with a dry cough and very toimcious 
spnfimi. Of 20 children aged from 2 to 10 years, 14 wero 
relieved, 3 Improved, and 3 sliowcd no benefit from this 
trentmont; of 12 patients aged from 10 to 21, 6 were relieved, 
2 were improved, and 4 wero not beno/ltcd ; and of 50 between 
21 and 72 years ot ago, 30 were relieved, 8 Improved, and 12 
wero not Iioncfltcd. Itlost ot them bad been uusnccessfully 
treated by various molliods' before radiation was employed. 


Dermatology. 

aOt, Gold Treatment In Psortasts. 

N. ToosfET (Urol, niul Ciitdn. Jlcu., December, 1927, p. 747), 
who records five illustrative cases In adults, states that for 
the last seven years he has treated selected cases of psoriasis 
by colloidal gold, wliicli may ho given by tho monlli or, in 
obstinate casc.s. Intravenously. • No untoward effects wero 
observed. The preparation originally employed for intra- 
venous injection and most cases ot or.al medication was made 
from gold olilorido according to tlio method used for inalcing 
the Dango spinal fluid test reagent. Eoccntly Tooniey has 
used for oral adininfstratfon a stronger snspension made from 
cliomlc.ally pure motalllo gold treated with bromides and 
from gold (ribroinido. Tho doso varies from 1 drachm 
(4 c.ctn.i tliroo times a day to a tablcspooiifnl (16 c.cm.) two 
or three times a day. Tlio antlior reports that tlio drug 
should ho administered on an empty storaacli, and a glass ot 
water .should bo falcon immediately afterwards. Iiitr.avcnoos 
injeclloiis arc given twice a weelr, beginning with 5 c.cm. and 
Increasing tho dose to 10 c.cm. Improvement, tho rate of 
which varies greatly, Is generally noted in tho following 
scqiicnco: lo.ss of sensations ot tenseness and burning, 
cessation ot itching, loss congestion of the lesions, and 
diminution in acanthosis and scaling. There nro said to bo 
no coutraindications to the treatment apart from albuminuria. 
Tooincj' adds that rolloidnl gold Is not expensive, or un- 
pleasant to take. Though not an indlsponsablo or specific 
roiiiody, he finds that, it taken for a aiifflcicnt time, it will 
Usually produce as lasting a cure as can bo effected by any 
ouvev moUioil ot treatment, 


302. Diseases of the Skin In Asthma. 

t^irta Med. Scand., vol. Ixvii, Base. Ill, p. 189, 
19271 has performed, cutancons tests in 120 out of 124 cases ol 
asthma (92 children, 32 adults). Among these 124 patients 
inevo were as many as 74 who had had some disease of thf 
Skill or wero still .sutloring from It, Prurigo occurred Jn 3C 
c.ases, urticaria in 34, pruritus in 14, par.aesthesia in 2, local 
edema In 6, and certain other .skin dlsea.ses in 4. The 
entaueons tests involved the nso ot such snb.stanoos as 
wui uhtl pollen, and among 70 patients 

57 giving a positive 
Snrtm ■ Among 50 asthmatics with no skin 

a nno H s«l>mitted to skin tests there were 30 who gave 
inatcrisnvso'i'^' '’"r'l author .admits that as no control 
Staiml thnf h'®® 5o made with 

commoL^ n „cf\® «5ovc-mont oned skin diseases wero more 

to (loubt tlZ Zi hardly any reason 

afleerion and ft » relationship between the skin 

coZiHons flniii tlioso cases in which tho two 

okarketer ot tbe sSZ Z regard to the 

er 01 the skin diseases observed, be notes tho exist- 


ence ot several cliaracteristics common to them all. Thug 
tlioy appeared In paroxysms and were associated with byper- 
acrnla, oedema, and ilcbing. For this reason, and becanso 
most, perbapsall, of tlic.so cases of skin disease wero due to 
an idiosyncrasy’, Baagoo follows the suggestion of certain 
American antliors in including tliese diseases in a common 
group, with tbo titlo " Idiosyncratic or allergic diseases of tho 
skin,’’ 


303. Creeping Disease. 

G. R. HAsni-TON end 14. W, PBnGUSON (Med. Joiim. of 
Avstraiia, Docember 24lb, 1927, p. 875; record a case ot larva 
migrans In a girl, aged 3, wlio bad lived for two and a halt 
months in Now Gninca, She spent a week at Samarai, 
wlicro it rained all tho tlmo and sho went barefooted, and 
then sailed for Sydney'. On tbo second day at sea a small 
spot Ilko a flea-bite was noticed on the iiiiddio toe of the right 
toot, and two days later similar spots appeared on the left 
solo. K-icli day’ following a ridge formed along the line ot 
small blisters until; eight days later, it bad travelled across 
tbo left sole, and tbo ridge on the right too bad extended 
down ono sido ot the too and up tlio other. The trade was 
nlway’s most red at its advancing end, while tho other end 
slowly faded ; there was Intense itcliing at both sites. Both 
areas were excised widely and Thiersch grafts applied, which 
took well ; from tlio time of operation all itching ceased. No 
parasite could bo found. Creeping myiasis has been attri- 
bnted to (1) tho larvao of oostrid flies, (2) nematode larvae, 
(3) mites, and (4) inanimate objects such as horsehair. Of 
these It ts posslhlo that a uomatoUe tutection by ancylostoma 
and strongyloldes larvae may have been responsible for this 
infection, sinco New Gninea is heavily infested with hook- 
woim. Previons rofercuces to creeping disease have appeared 
in our Epitome columns (1926, vol. II, paras. 18 and 19, and 
1927, vol. 1, para. 529j. 

30?. Acroacrmatltis PevEtans. . 

S. E. DORE (Brit. Jonm. Derm, and Stjph., January, 1928, 
p. 12) records live cases ot acrodermatCtls porstan.s— a rate, 
chronic, vesicular, and pnstnlar eruption of mild, localized, 
bnt persistent cbavacter, affecting tlio palms of Iho hands, tha 
fingers, and the solos ot the feet. The condition Is dlstln'ct 
from. and not related to dysidrosis, eczema, dermatitis, or 
ringworm, and the nails are not necessarily affected.' In the 
cases reported tho eruption was limited almost entirely’ to the 
tlieuar and hypotlienar eminences and palms, and the soleg 
were lately affooted. The diagnosis from dysidrosis depends 
mainly upon its distribution, chronicity, resistance to treat- 
ment, and tbo destrncflvo character of the lesions, which 
first appear as phlyctennlnr pnstnlcs rcssmbllng “small lakes 
of pus,” with but little surrounding inflammatory r'eaelion. 
RIngw'orm was exclnded by microscopical examination and 
cultures. There was no history ol wliitlow or of any septic 
infection, and no evidence of a neurosis or vascular causation ; 
tho condition may remain localized and persistent without 
giving rise to any more serious sequels. Various methods ot 
treatment wero adopted. In ono caso crude coal-tar' in 
Das‘ar’s paste was henellcial and prevented tho druptlon ot 
fresh pustules for several months after 3; ray, ultra-violet 
light, and ionization, and tho Dvacnaliou of tbo pus, with 
insertion of pure carbolic acid, had failed. In another case 
affecting the soles ot the feet treatment with iodine oil and 
a; rays caused some Improvement, hnt fresh pustules deve- 
loped when tho x rays wero discontinued. Another patient 
wn.s benefited by repeated ionization, but in some ot the cases 
no treatment was permanently successful. 


Obstetrics and Gynaecology. 

305. Fibroids in Pregnancy. 

J. O. POIiAK (Surg., Gynecol, and Obstet., January, 1928, p. 21) 
discusses tbo iniluence ol fibroids on preguaiicy’ and iabour. 
Not only is tho development ot tho pregnant uterus inllnenced 
by fibroids, but the prognaucy affects tlio fibroids by increas- 
ing their nutrition so that they tend to enlarge In the lines 
ot least resistance. Their effect upon any particular' preg- 
nancy will bo determined by their site. Treatment resolvea 
Itself into determining whether the patient’s Jite will bo 
endangered by allowing the growth to remain, and estimating 
tbo effect ot its removal upon the continuation of the preg- 
nancy, but experience goes to show that women with uterine 
myomata nsnally go through pregnancies with bnt little diffi. 
cnlty, so that tho necessity for therapeutic abortion rarelv 
ocenrs. In the majority ot cases there will be no necessity 
for surgical intervention unless tho tunionr by Its position or 
degeneration seriously endangers the patient. Polak advises 
delaying any operative intervention until the child is viable 
'While endeavouring to prevent abortion by rest' at the 

534 a ' 


52 march 24 . 1923] EPITOME OF CURIIENT‘MEpiCAr.'r.ITERATOBE. [w'rS 


/xpected menstrual periods, and b 3 ’ tlic dally adoption of llio 
knee-chest postnro in order to prevent impaction of Iho 
tumonr mass and uterus in the pelvis and to relieve engorge- 
ment. When the tumour l.locks tlio birth pas.sngo Polak 
thinks that no attempt should bo made to displace it inannalij' 
-because of tlio risk of injnr.v to the motlier, child, and 
tumonr; if the Icneo-chest position docs not lift the tumour 
out, section followed by cnueloation or liy.storoctomj’ sliould 
ho performed. Many fibroids, especially iutraraurnl growtlis, 
diminish in size and disappear during involution, but an 
emergency operation during tlio puerporium may become 
necessary should injury to the tumour in the course of 
labour be followed by necrosis or infection. Polak adds that 
during the pnerperium surgical intervention is only indic.atcd 
in the pedunculate, subserous, and intrauterine polypoid 
growths, while radium and x rays have no place in the treat- 
ment of haemorrhages from them during this period. 


SOS. Badium Treatment in Pregnancy complicated by 
Carcinoma. 

H. PouEY (Hull. Hoc. d'Ohstet. cl de Gtjn^col., December, 1927, 
p. 702) reports a case of cervical ca'roinoma in a pregnant 
woman ; radium treatment was followed bj' a normal 
a-couchement. A multipara, aged 34, and six and a half 
months pregnant, had on the po.sterior cervical lip an 
ulcerating haemorrhagic tumour, which proved to bo a 
spino-cellnlar epithelioma. Eadiiim was applied on tlirco 
consecutive days, followed by a day’s rest. Treatment was 
then continued in smaller dose.s, and finally stopped in about 
SIX weeks. A month later the tumour had disappeared. The 
pregnancy pursued a normal course, and eightcoii days before 
the supposed full term the patient was delivered of a healthy 
ucll-clevelopecl child. Six weeks after confinomonfc a final 
application of radium w.as made. Two mouths later the 
patient showed signs of a rectal radium-necrosis, which 
however, yielded to treatment with alkaline enemas. Nearlv 
lour years later both mother and child were well, and the 
cure seemed to bo permanent, no trace of cancer being found, 
irouej’ draws attention to tho perfect tolerance of tho pregnant 
uterus to the radlnm, to the natural delivery without lacern- 

normal post-partum period. 
He behoves that the rectal necrosis could havo been avoided 
by the use of a supplementary lead filter covered with rubber. 

, Llplodol In Gynaecology. 

C. BECLfcRE {Bruxelles-Medical, January 8th, 1928, n. 3191 
comments on tho valuable results obtained in gynaecological 
ri Means of injections of li[.iodol into the utS-lno 

cavitj aiid tubes ; the ouly contraindication is prc'mancvor 
acute febrile conditions. Ho thinics it better to inject \ho 
solution through soft catheters and at a pressure not morn 
thnn 30 cm. Hg, taking caro that the fluid does not Leape 
•imo the vagina. No had results have been observed aftnr 
this practice, and by its means it is possible to see tho size 
and shape of the uterine cavity, ascertain tlio permoabUitv 
detect wliero any obstruction is 
situated, determine the shape and position of the uterus and 
gather useful information as to the site of nhm.noo 
n cases of metrorrhagia iudfertious o? irreguTarltio^ 

pictures when-possible. The author bases Ws 
an experience of over a hunXd cases for 
verified by operation. Part 


Pathology. 

Intestinal Absorption. 

treatment of diarrhoea or after rectal or anal operSj" 
an cnd-to-oiid anastomosis of tho ileum and rectum a fict,^^ 
of tho terminal lieuiii was practically obtained ve?retofn“ “ 
a normal anus and sphincter, rendering it easier for ^ 

faeces and the care of the animal. FastlaTfesUloos 
characteristics with different diets, and the Ite of ™s’sMe‘'o} 
protein, carbohydrates, fats, fruits, liquids simsr’^nd ® .S' 
wore studied, as also the influence of milk unoa"thp "f’-‘ 
of other foods, the amount of residue with different^r^I?" 
and tlie influence of the quantity given From theso 
tio.is it is concluded that the best basis for a low residue S 
is lean meat, with possibly rice, hard-boiled eg-fs minarJ 
(except lactose), and .small amounts of fruit juices ten “npo 
^olTee; the highest degree of absorption wal 
giving .small quantities often and keeping the diet fairly 


'J'he fact that milk loaves a large ro-idiio in tim terinl 
iloiiin sliow.s that this food Hhonid not ho given wlien it 
desired to prevent bowel movoiiioiits. Tho authors einplia'. 
tho fact that milk should ho avoided when it is dosireil 
allow tho (llgostlvo tract to rest. They think that it slioi 
ho forhlddcii In diarrhoea, since thelroxperienco Is that itl 
.a h.id cITcct In. many such patients, who promptly iiiiprc 
when given moat alone or with a little ptirc starch ami sag, 
Thoir rosnlts agree closely with lliose ohtaliiod in aaiiii; 
and man witli the colon Intact, thus showing that tho col 
absorbs little besides water. Contradicting tho general bel 
In tlic noiirisliing properties of a raw egg, attention is ctill 
to tho IndigOHtlliillty of raw egg allmmen and the resnlll 
large moist rosldtio, Tlio highest percentage of moist resid 
was found wltli raw h, annua, wliicli somcilmcs gave rise 
stools larger than tlic original meal, ns was also tlio case irl 
prunes and h.akod potato. Dargc. moist residues were al 
ohlalnod after giving lard, butler, Swiss cheese, apple, mil 
and bread. 


309. Bacteriology of the Common Cold, 

KATiir.itr.N-i; C. Mfhi.s. O. S. Sifim.EV, ami A. R. Doan 
{■lourtt. Krper. Med., February, 1928, p. 193) have .studied tl 
iiicldonoo of Grnm-iicgntive flllcr-passliig niinerohic bacicri 
in tlio nasopliaryiix of heallhy persons nud of patieiii 
with coId.s. Tho general procedure was towasli out the nasi 
pharynx with broth, llltcr tho wasliliigs tliroiigh aliurbefclil 
candle, and inoculate Siiiltli-Xogiiclii medium, fresh rabbit 
hlood-ngar plates, and rahlilt’s lilood hrotli whh Ihcflitrati 
These were tlicn liiculiated anaerobically, and ibe llol 
cultures plated after a week. During tlie winter of 192>-2 
live hcaltlij’ normal persons were watched overaperiedt 
five months; timing tho winter of 192S-27 threo iiorinal 
were studied. Frcsli oxaniinnlioiis were made when the.- 
persons dovolopod colds. In luldillon, otlicr p.atienls ivill 
colds wore examined on sliiglo occasions oiilj'. Tlio ineidcuci 
of tho Gram-nogatIve flltcr-passiiig nmicrohes in tlionoinial 
svas 78. G por cent, dnrlng the winter of 1925 - 25 , and 70 pci 
cent, during that of 192G-27. In p.aticmts witli c-old.s, on lb) 
otlicr hand, tlio incidence of tlicso orgaiiisiiis during thi'Si 
two winters was 48.5 and 44.4 per cent. re.“pcctively. TiiKinj 
into consideration the difllcultics encountered in ^boemh'"*' 
Hon of tlicso orgnnism.s, thennlhors rcgaidlt as probable tna 
they arc uoarlj' always present in tlio iipiior respiratory traoi 
of healthy persons, but that there is a dollnUo decrease m 
thoir hicldonco during colds. Cnrcftil oxamlnalion ol twemy 
nino strains showed that thoj’ could bo di>trlliiiled rongnij 
iiilotlircogroupsoii aiuorpliological, ciillural.andbiocliemiw 
basis ; serologically tho strains exhibited considerable betew 
gonoity, and dis|)lnyed no rolntlou to their source of orlU 
The nnthors conclude tliat tlieso orgnuisms eousliiutepart 

the normal flora of Ihe upper respiratory tract, and prooao j 

bear no relation otiologically to tho coiiiraou cold. 


310. Immunization against Diphtheria. 

G. E.ASION (C. n. Hoc. de Biologic, February 10th, 1928. p. 351 
has investigated diilercut methods of producing experiineii 
iiiimunitj’ to diphtheria in guinea-pigs and horses, eonip-ari t 
an anatoxin-antitoxin llocculato with tlio simple •''“bto. • 
The flocculate, which was tho result of mixing 9 . 

tity of anatoxin with less than tlie full neutralizing uos 
antitoxin, was dissolved in distilled water or suspendc 
saline; it svas nsod either iinlicated or heated to 70 , 

rort}--Uvo minute.s. In tho first scries of 
groups of six guinea-pigs were nsed ; each received b'''0 
of tho antigen at an interval of three weeks; the deg 


second 


quite Clear: m® 

received flocculate, heated or unhoated, dissolved m ® , jj 
water or suspended in saline, resisted from 20 to 50 mi j 
lethal doses of toxin ; tho two wlilcli received an com 
amount of anatoxin, heated or iiiilioated, resisted (j 

1,000 doses of toxin. In tho second ■‘’®tde 3 _ of expo j 
three groups of guinoa-pigs wore used ; a siuglo 
tho antigen was given, corresponding to 10 c cm. ®, ^ ‘ ^ 

(five times tho dose nsod in the first series), and tliog 
pigs were to.sted five weeks later. The aniniais 
received tho flocculate resisted only 5 minimal 1®^®*" j'ji 
of toxin, whereas those injeeted with the pure i ^ 
resisted 200. A final experiment was made on , „„goI 
groups of five horses wore u.scd ; each received b"''®® . of 
the antigen at weekly intervals; the antitoxin r|q,oso 
their serum was tested a week after the last joJ®®‘ .And .and 
treated with a saline suspension of flocculate, i tliose 
unheated, had a titre of 26 and 30 units e®'’!’®®*’ , « t’itro of 
Injected with anatoxin, heated, and o®beatod, na 
125 and 140 units respectively. The authors c 
anatoxin is undoubtedly much superior to a u^kosIo 
antitoxin ■ flooonlate in producing oxporimen 
immunity in animals. 



aiAiicn Ji, igaS] 


[ TirEjJninsif- 
MEtJiCAI. JocitK*!. 


.53 


EPITOME OF CURRENT MEDICARE LITERATURE. 


Medicine. 

ail. Cardiac Neurosis. 

F. A. IVILUCS (jrilincfotii jua., February, 1928, p. 102) di.q- 
cusses llio problciu oC fuucUojial iliaturbaucca ot tUo heart, 
luaJuly ti'oiu the ncurof'ciiio atauclpolut. KnowicdKo of tlio 
vilal importauco ot tlic cardiac actlvUj', auil the Ireqnciib 
rctcceucea iu literature and the draiua, direct the attciition 
ot the ludividiial to the Iieart from cUlldliood onward.. Tills 
Is one ot the factors which play a part in the prodiicUon 
of cardiac uoutosis; others uro Iicrcdilary disposition to ' 
emotional instability, and a condition of depleted notrous 
reserve in whicli llncncss ot iudKoiuont is blunted. Some 
event such ns abnormal phy.sical ellort produces, auftmented 
cardiac action and a sense of palpllntlon which maltcs an 
undue improssiou upon tlic distorted perceptive faculty.. The 
patient worries and becomes sieoplchs ; the tlircshold of 
tachycardia and palpitation Is lowered so tiiat a vicious 
circle is e.stablished. Tlie occurrence of extra-systoles or 
ot paroxysmal nodal .tachycardia mav ptoduco the same 
neuroses by the same meclianism. IViillus ur^cs thq Im- 
portance iu every case of soltlUif* raphlly tlic question, ot the 
presence or abscuco ot ornanic disease iu order to avoid 
cardiac ucucqrLs- lie tUinies there Is no stood lirouud for tho 
belief that functlounl disturbances depend upon nnxecognized 
palholoylcal couditious ; c.ardinc ncuro.sis is therefore a 
dcllulte clinical entity. The possibility of uenrosis snper- 
Iniposed on cardiac disease is considered, and a tree dis- 
cussion with tho patient and relatives Is advised; explana- 
tion ot the necessity for certain restiictious wili oliiuinate 
fear and introspection. The judicious u.so of bromide is 
hclpiul in many of these casc.s, audqulnidiue often dUuiuishes 
the Ctc<iacucy and severity of attaeUs ot Cuuelloual paroxyauial 
tachycardia. 

312. Exanthema Subitum. 

A. P. Bn.iUsSTElX (Jtihib. /. Kindeihcil!;., January, 1928i 
p. S85) reviews tho lileraturo (see Fpifoir.c, Uccombor 19tli, 
1925, para. 558; February 27ib, 1926, paia. 229; December 
18th, 1926, para. 562; November 12th, 1927, para. 431) and 
records ids ob-iervations on live caso-s wliicli lie liad recently 
soon at Chavkov, thus uiviU',; the lirst description ot tho 
occurrence ot tills disease iu Russia. The patients were 
ahod from 7 to 19 luoutlis ; llitcc ot them were boys and two 
fiirls. In ail but one tlio tomperaturo kojit liiijh foe tliree to 
three and a hall days, reaching a niaxluium ot 103.G'’. Tho 
cruptioo, which Was morhilliform, appeared on tho fourth 
day sliualtauoously witli tlic fall ot tcmpeiaturo, and dis- 
appeared in two days without leaving any irace. It extended 
over the whole bodj-, but was most pronounced on the trunk, 
especially the back. No complications or sequels were 
ob.served. Tlio blood picture was characterized by a Icuoo- 
penia, relative lyiiipbocytosis, and diminution ot the poly- 
morphonuclear leucocytes. In short, the clinical picture of 
Biauii.stoiu’s ca.ses closely corresponded with the description 
of tile Aincricau writers such as ZaUorsIcy, Veedor, and 
Hempeliiiann, as well .as with that of GlauzmaUn. and von 
Bokay. Further invcsligatious are needed to determine 
whetlier exanthema subitum is an independent nosological 
entity or not. 


Goitre In Adolescence. 

P. Stocks and A. Y. Stocks {Diovietri7;a, December, 1927 
P- 292) have made au authropouietrical study ot the relatioi 
between the size of the thyroid gland and the physical am 
mental .development iu adolescence. They find that th< 
measurement of tho ina.xininm breadth ot tlio gland is tin 
mo.st reliable index to its actual size. The authors repor 
the statistical re.snlts ot clinical examinations couductedii 
various parts of this country, and thoj- fiud that the pte 
goitre increases- with agetoa maximum in hoys o 
about 13 to 14 years old, and in girls .of about 17 to 18, when 1 
oecimes. Where goitre is not endemic the gland lianib 
Changes between, the ages ot IQh and 13.1, this flattening d 
hurve ju.st before puberty beiug unique aiiioni 
measurements so far. undertaken. In girls a rapii 
dev elopmont of tUegland occurs between the ages of 131 andlS 
Tl.nr “dhbtles.s associated with the onset ot menstruation 
h-ppears to bo, hi boys no. evidence of any relatioi 
she n? '‘“‘1 the. physical developmenl 

aiin growth, or tlie strength ofth 

tion’witli s‘griincant.po.sitlve assach 
e height and weight, the rate of growth, the grij 


and tho systolic and diaslollo pressures, but none with the 
pulsQ pressure and rate, the colour of the bain and eyes, or 
proflciency in scliool woric. Tlio authors attach importance 
to tbo corrcspoudence between growth curves ot the thyroid 
and of tho diastolic, pressure, and add that long-continued 
general development la excess of tlio average rate seems to 
favour the nppearanco ot huge goitres ;, while slow develop- 
ment, followed by temporary rapid growtli, Is associated with 
small enlargements. They think that tlicse.complox relations 
in gfris arc capable ot being, explained on the theory ol 
iodino deprivation, for wliich thborythey afford indirectly an 
additioual proof- Tliey arc opposed to the lufectivc tlieory 
’nul'oss it is'assnmed that the agent ot inicetion acts by 
preventing tlio. proper absorption of iodine. 

314 . Alkalis and Renal Injury. 

E. J. Stieglotz (Arch. Intern. Med., January, 1928, p. 10) 
remarks tliat alkalinizatioa ot the urine by administration 
of alkalis greatly iucrcases the renal cellular acidity. This 
roversal ot iiitracelluiar reaction is undoubtedly physio- 
logically irritatilii, and thereby nften causes a renal diuresis. 
Tho aUtalosia wliicii may bo- produced by long-continued 
or excessive adiuinistratiou ot allcalis causes distinct renal 
irritation and' occasionally a trno nephrosis; This probably 
docs not occur more: frequently because ot the tremendous 
reserve of renal, structure, and physiological efforts at com- 
pensation. In tlie nuLhor’s view the administration, ot. largo 
doses of alkalis is therefore contraindicated,, especially in 
tho presence ot pre-existing renal: disease. 

315. Diphtheria after Active Immunization. 

P. S. EnO.UJS (Journ. Amcr. Med. Assoc., Jauuary'28tli, 1928, 
p. 254), who records fourteen cases ot climoal diphtheria in 
nnrscs who hail received three dosos of toxlu-antitoxiu, 
atates-.that tlio persistence of positive ischiclc tests in 67.2 per 
cent, of case-s and tho occnrronco of clinical’ diphtheria in 
cases wJiich had been given toxiu-autitoxln is a not infrequent 
occurrence.- Tlie- explanation ot this, disappointing result 
Is that. the. commercial preparation used is not snflloiontiy 
potent. It is tliovefore necessary that Schicic tests should 
be repeated three montlis after the last dose of toxiu-auti- 
toxin, and tliat moi-e immunizing dosos shonld ho given wlien 
they are indicated. Moreover, when large numbers ot toxin- 
antitoxin: imintraizntlous are required it is advisable to make 
tests tor potency on the particular toxin-antitoxin to be used 
before the 'worlr is undertaken. 


Surg^ery. 

316 . Osteomyelitis of the Scapula. 

■JjASSABUiU, A. Gthbai., J. Chxrdonnexc, and Ii. Maiichand 
(Arch. Soc. dcs k'ci. Med. et JHol.. de Montpellier, February, 
1928, p. 55) describe a case of acute osteomyeliti.s of the 
sciipnla, and point ont that the shape and position of this 
bone maiie tho diagnosis a difficult problem. Tho patient 
■was a boy aged 14. When lirst seen the shoulder on the 
affected side was kept iinmobilb and the respiratory' move- 
ments were diminished. Palpation pcodnoed pain nil over 
tiie scapniar regibu, but there were no evident signs of In- 
flammation. The next day a swelling appeared between the 
scapula and the spine, and an exploratory puncture showed 
the presence of. pus.. A. diagnosis, of empyema was made. 
An operation disclosed that the pus was coming from tho 
scapnla.itself; the periosteum of which was stopped up. The 
bone was drained and tho patient made a satisfactory 
recovery'. The authors add that the chief diagnostic sign in 
this condition is localized pain along, the axillary border of 
tbe scapula. Tlio best incision is one. along the vertebral 
border, which gives access to all the bone. The condition, is 
rare and caUBoa.muoh difficnlty in diagnosis. 

317. Treatment of Cholecystitis.. 

Bacquei^aine (he Scalpel, February. 25th, 1928, p..l97) states 
that iu cholecystitis, in addition to cliolecystotomy, often 
insnOlcient, and cholecystectomy, often too radical, there is 
another possible procedure, wbich. be terms “ biliary devia- 
tion ”;. he reports thirteen- cases in which this operation was 
performed, in twelve. by a cbolocysto-gastrostoniy, and- in one 
by a cholecysto-colostoniy, the. result^ iu.all being oxcollent 
In seven ot'tliese cases tlie gall-biadders were' enlarged' witli 
healthy, tense walls ; the thickened contents showed no’ signs 

sSa 


'54 MAECH 3I| ^ 928 ] EPITOME OF CURBENT MEDICAL LITERATURE. * ^ f Tnriinmw 

•* *■ Wkdicil JotrsHj* 


oE Infection, and no adhesions were present. The affection 
seemed essentially mechanical, the vesicular retention follow- 
ing a diminished permeability of the common bile duct and 
the bile reaching the duodenum by- a sort of overflowing, 
in four of the cases lithiasis was present; one was com- 
])licated by a neoplasm and one by gastric ulcer. In the latter 
the excess of hydrochloric acid was neutralized by conveying 
the alkaline bile directly into the stomach. Bacquelaine 
contends that if the bile cannot reach the intestine freely it 
is logical to conduct it there by deviation, and ho maintains 
that from a technical point of view these operations are 
simple and benign. Local anaesthesia suffices in the majority 
of cases. The organs involved lie immediately under the 
peritoneum in contact with one another ; there is no pulling 
of the organs, no deep manipulation, no shock; tamponntng 
and drainage is unnecessary, and' the operative procedures 
are simple. The operation .is ini^icated in cases of chronic 
cholecystitis without calculi, and of cfiblellthiasis where the 
walls are sufficiently healthy to permit suturing. The advan- 
tages over cholecystfectomy are its greater benignity and the 
absence of subsequent adhesions.- Moreover, in -cases where 
cholecystectomy fails, no further surgical Intervention is 
possible, while after failure in choleeySto-gastVostbmy the 
organs can be replaced in their original position and such 
other operation performed as is deemed advisable.' 


318. iTamonrs of the Pineal Gland. 

K. O. Haldeman {Arch, Neurol, and Psychiat,, November, 
1927, p. 724) describes two oases of tumour of tho pineal 
gland, and also gives a' tabulated summary of the microscopic 
Undings, symptoms, and sex and age incidence of 113 addl- 
tional recorded cases. In each of the two present cases, both 
females, the tumour proved to be a glioma, and in one a 
syringomyelic cavity was found. The association of such 
cavities with intracranial tumpurs is rare, and is due 
according to Danghans and ICrouthal, to a venous stasis 
in the cord, tho tumour forcing the' cerebellum 'irito 
the foramen magnum with compression of tho vertebral 
veins, the resulting oedema and stasis, favouring distension 
of the central canal, hydromjielia, and disintegration, of the 
grey matter of the cord. The symptoms observed in oases of 
tumours of the pineal gland may be grouped as follows: 
(1) General symptoms of intracranial -pressure: headache 
(especially occipital), vomiting, choked disc, mental apathy, 
somnolence, clonic spasms, and incontinence of urine and 
faeces. (2) Localizing symptoms : ocular palsies, rigid 
dilated pupils, nystagmus, blindness, deafness, cerebellar 
symptoms (ataxia, adiadokokinesis), peduncular symptoms 
(monoplegia, oculomotor paralysis), pontobulbar symptoms 
(disturbances of speech and swallowing), and disturbances 
of hypothalamic sympathetic nerve centres (exophthalmos, 
tachycardia, etc.). (3) Symptoms referable to the gland: 
many young patients show a precocious sexual develop, 
ment and adiposity or general overgrowth, which with 
symptoms of internal hydrocephalus constitute the syn- 
drome designated by Pellizzi as macrogenitosomia praecox. 
An analysis of all the reported cases shows that the eye 
symptoms are important in lopallzing pineal tumours, the 
most significant being paralysis of upward movement, 
diplopia, abducens paralysis, nystagmus, ptosis, and absence 
of the pupillary light reflex. Of 102 cases in which the sex 
was reported 78 were males, and the greatest age incidence 
was during the second decade. Surgical removal of these 
tumours, while difficult and resulting fatally in most cases, 
has been advocated by Dandy. The contradictory results 
from experiments .on pineal gland feeding of animals and 
defective children, and the destruction of the gland in 
animals, prevent any conclusions being formed regarding the 
function and significance of this gland. 

■ 319. Treatment of Inoperable Cancer of the Breast. 

E. Monod (Bull, et Idem, Soc', Nat, <le Ghir,, February 4th 
.1928, p. 92) records the case of a woman, aged 49, with cancer 
of file left breast and enlargement of the axillary glands. 
The tumour when first seen’wasthe size of an egg; it was 
hard and adherent to surrounding structures. The glands 
were fixed and hard, and there was much pain in the arm 
from pressure on the brachial plexus. Eemoval by operation 
appeared impossible owing to the extent of the disease, and 
ar-ray treatment was advised. Ten applications were given ; 
three months later the tumour and glands showed marked 
diminution in size, and there was freedom from pain. 
Kadical amputation was then considered possible, and this 
was performed satisfactorily. E.xamination of the tumour 
showed it to be a tyiiical soirrhus with great increase of the 
fibrous tissue, probably produced by the x rays. The patient 
was well more than throe years alter the operation. The 
case illustrates the good results of the use of x rays combined 
irith surgery. 


; Therapeutics. 

320. Calcium Chloride in Hepatic Ascites. 

Despite unfavourable opinions as to the value of calcium 
chloride in the treatment of ascites duo to hepatic cirrhosis, 
L. Blum and P. CarIiIER (Presse Med,, February 25th, 1928, 
p. 241) strongly advocate its use in these conditions, and 
report -throe cases illustrating its benollcial action. Large 
doses of tho salt were administered, Jn one case 3G0 grama 
being given in twelve consecutive days; during treatment 
common -salt and substances containing it wore rigorously 
excluded from tho diet. Tho drug is said to bo harmless 
oven'ln these largo doses, and in two of tho oases tho only ill 
effect was a slight diarrhoea lasting a day. Tho third patient, 
however, suffered from loss of appetite, acid regurgitations, 
constipation’, and a sense of weakness, these symptoms 
disappearing on cessation of tho medication. Tho absorption 
of the nsoltlc fluid and the resulting reduction of weight- 
caused by calcium chloride are duo to its diuretic action. 
Dlfllcultlos arising out of tho unpleasant taste of this salt and 
its occasional gastric and intestinal reactions can bob-vercomo 
by supervision of tho patient. Large doses are very dangerous, 
however, in cases with only slight aqueous retention. Calcium 
exists only in small quantities in tho secretions and tissues, 
and it Is'nccossary, therefore, that all given in excess of the 
requirement should bo eliminated or rendered inactive. 
Chlorine can bo retained by tho body in greater amounts, and 
largo doses of calcium chloride cause an accnmulatiou of 
chlorine without a proportional increase of tho basic element, 
a chloro-acidosis rosnltlng. In eliminating this excess of 
chlorine tho kidneys combine tho latter with the sodinra (the 
principal base of tho body), and, in the blood, tho increase of 
calcium causes a decrease of tho sodium ; thus a chloro- 
acidosis with natropenials prodnced-7-a condition analogous 
to that of nephritis with chlorine retention. Ascitic- or 
bedematou's liquids form an alkalino resorve which provides 
'the ' necessary base for' the neutralization of tho chlorine 
excess; in hepatic t oedema where 

the quantity of liqui . complications 

need not bo feared. • iso of tliis drng 

are renal conditions where there exists a circulatory instim- 
cienoy, as in asystolia, or a secretory Insufllcioiicy, ks-m 
nephritis -with oodeina or chlorine retention. Tho authors 
believe that other caloinm salts are useless in those conditions, 
since the chlorine is the essential factor; they emphasize the 
necessity of adralnistoring large doses of tho drug over a long 
period, and of excluding salt from the diet meanwhile. • 

321, Local Treatment In Tabes Dorsalis. 

A. LOwexstein (IVicn,' Ulih, ll'och,, January 26th, 1928, P- 120) 
describes a method of injecting air into the spinal canal ; this 
acts as a form of irritation therapy on a tabetic lesion in 
the central nervous system. Tho technique is as follows: 

10 c.cm. of cerebro-spinal fluid are replaced by 5 c.cni. of 
air. The process of withdrawing 5 c.cm. of fluid and replacing 

it by air is then ropo.ated four or five times, resulting m the 

substitution of 20 to 30 c.cm. of fluid by about 10 to 20 c.cm. 
of air. Tho patient is now slowly placed in tho recnmboni 
position and an hour later is given an intravenous dose ot 
neosalvarsan. The process is repeated five to seven-times 
at three-day intervals. Tho object- ot this treatment is to 
produce an aseptic localized irritation of the meninges o 
short duration. The author has found that only under sneu 
conditions -were drugs able to pass from the blood to the 
cerebro-spinal fluid. The same principle ot treatment is saui 
to hold good in syphilitic affections of the eye, where siin- 
conjnnctival injections ot hypertonic salt solution oj" P''S' 
parations ot iodine cause an increased quantity ot a h'ooa- 
borne drug to reach the lesion. ■ This form of treatment was 
found to bo of most use in tho early stages ot tabes before 
neural atrophy sets in. 

322 . Treatment of Chronic Auricular Fibrillation. 

B. P. MATNard, Jun. (/finer. Join-n. il/cd. Sci., January, 1928, 
p. 55), reports that, by the use of quinidine sulphate, auricular 
fibrillation can be abolished in at least 50 per cent, of cases, 
and that, even with persistence of the irregular action, tlio 
patients are undoubtedly relieved and exercise tolerance is 
increased. In order to determine if this effect was sufficiently 
lasting to counterbalance the discomfort and danger of this 
drug, Maynard studied 53 cases ot chronic auricular fibrilla- 
tion treated -with quinidine, and followed them for periods 01 
one to five years. The drug was administered as follows. 
Two test doses ot 0.2 gram each were given the first day m 
order to eliminate all possibility ot hypersensitivity 
drug; it no symptoms appeared, the dose was increased to 
0.4 gram every two hours lor five doses. In the case of a few 

I 'patients who failed to respond to this treatment the dose was 

I cautiously Increased to 0.6 or 0,7 gram every two honrs. 


Mahou 31 , 192S] EPITOME OF CUltKENT MEDICAL LITEKATUBB. 55 


Later, In ouo ease, followlnf* .tbo siigficatlon of Bleolcor, 
0.4 Rrani was ridmiiiistorcd ovory four hours iiiRht anil ilny in 
orOcr to-Tiroihico an* ovcn’noMon Ihronglionttlio •trcatuiOnt.' 
It was toiuul that In 38 of -tho eases iionnnl BlnusThytliin 
i-cturnea, 25 roiiialnin" rcRiilar for ouo month or luoro, and 
15 for at least six inontlis. - Various toxic rhythms wero 
detooted, inoliidliig aiiilciilar flutter and paroxysmal Toiitri- 
cular tachycardia ; ouo caso of collapse and auddoii death 
occurred followin'; the admlulstrallou of tho quinidiiio. Short 
duration of llbrlllatlon was found to bo a good itrognostlc sign, 
but tbero was a ddiiiito tondoiioj’forit to hecomo pertnanont. 
Maynard conclndcs that in this form of treatment of chronic 
anriciiiar llbrlllation a caroful selection of tho cases must bo 
practised, the two dcllnito criteria for this purpose being, 
lli-st, a- relatlvclv short duration of tho tlbrillatlon, and, 
secondly, a woll-coinpeuBatod heart wilhout tho signs of 
congestive heart failure. 

;323. Pilocarpine In Gnll-blndCor DUease. 

j; M. Iltoun and B. G. Dhagun (ll'ien. I.lin. iroc7i., January 
2Gth, 1928, p. 127) conllrm tho observation that lu non- 
obstructive cases pilocnv|)ino, by siimnlaiing tho emptying 
ot tho gall-bladder, increases tho excretion of bile. Tho 
action is similar to that of ma'<ncsla in that it Is an Irritant, 
but It also appears to paralvso the unstriped muscle ot tho 
gall-bladder and to Inhibit tiio so-called gall bladder reflex, 
thus permitting an Unobstructed flow ot bile. Given sub- 
cutaneously in small doses of 0.2 to 1 c.cm. ot a 1 per cent, 
solution, it Is said to he very beuellcial lu many loruis ot 
cholocyslilis and cholelithiasis. 


Radiology. 

32t. Sk'agraphy in Pulmonary DUcasea. 

L.AQUEnnifiRK t.tolirti. tie -Ved. cl tie Cliir. I'rat., January 10th, 
1928, p. 34) insists on tlio importance of obtaining a scries ot 
shiagrams in ovory caso ot pulmonary disease examined by 
means ot the fluorescent screen. While formerly it was 
impossible to obtain satisfactory fliins ot tlio tlioraoio viscera 
bn aoooniit of tho respiratory movetnonts, tlio modern rapid 
exposure.s (while the patient liolds ids brealli), however, give 
sharply deflned skiagrams. Although tho fluorescent sorcou 
frequently furnishes important inrormatloii, the imago is 
indetlnito and badly illimiinatcd. Fluor details are iuvlsible 
to tho observer and can bo obtained only by iiistautaueous 
sldagrapby. Laquorriuro condenms tlio too common de- 
peiidouco of specialists and general practitioners on repeated 
radioscoplcal examinations, wliicli are misleading and do cot 
provide a permauout record. A series ot skiagrams takou at 
intervals is of great value in watching tho progress ot tho 
disease. 

325 . Diathermy In Acute and Chronic Gonorrhoea. 

L. L. Michel (.l/cd. Jonrii. anti JteconI, January 18th, 1928, 
p. 87) rejiorts that in a series of two liiindred cases of acute 
anterior gonococcal infections tho results ot diathermy treat- 
ment alone were not encouraging. Tho patients came for 
treatment from twelve hours to ten days after tho infection, 
and were treated daily and thoroughly. After four weeks it 
was found that the diathermy had had no effect on tho dis- 
charge or upon the destruction ot the gouococcus in the 
secretions. Inclirouic anterior infections, however, diathermy 
proved vei-y u.soful. Galv.anism, applied by special eicotrodo 
tlirougb tbe endoscope, gave excellent results in strictures, 
however impassable they had appeared. In involvement of 
the posterior urethra, prostate, and seminal vesicles dia- 
thermy had given its best re.sults, surpassing any other Jorm 
ot treatment known ; since using it Michel has rarely 
employed surgical intervention in posterior gonorrhoea, and 
has found that acute pus formation -within the prostate Avas 
not a contraindication to diathermy. Gonorrhoea in the 
female yielded more qnickly to this treatment than to any 
other form, chronic endocorvicitis being controlled by one or 
two applications. The author decries limitation of treatment 
to diiithormj’, and thinks all available methods should be 
used in tho treatment of gonorrhoea. 

320, - Tetra-lodo-phonolplitbalcln In Cholecystography, 

To elucidate the results obtained by the use of tetra-iodo- 
phenolpbthalein in the diagnosis ot gall-bladder disease, 
J . H. King and D. Martin {Hull. Johns Hopkins Hosp,^ October, 
1927, p. 219) studied a series of 407 cases of various clinical 
conditions in which this dj'e had been administered orally. 
The method employed was as follows. Twelve 5-grain cap- 
sules ot the fresh chemical were given, four at 4 p.m., four 
at 4.30 p.m., and four at 5 p.m. Supper was given at G p.m., 
but no breakfast in tho morning. Plates were taken at 
Sixteen, uiuetceu, and twenty-two hours, and betiveen the 


last two a meal containing fats was .-given. > "Very -few dis-' 
ngroeabloisymptoms resulted' from taking tho dyo by the 
luoutli, and in only one c.ase wore plates unobtainable owing 
to porslsteutivomiting. The- patients were divided into two 
groups — namely, tlioso who liad undergone operations and 
those Avlio had not; the latter tvero further subdivided into 
patients not suspected of having any gall-bladder disease and 
those with definite signs of such a condition. Tho former 
wore grouped, ns a result of the te.st, into those having a 
normally functioning gall-bladder, those with an ahnonnally 
functioning one, and those which did not show the faintest 
trace of the dyo in the gall-bladder. From their observations 
tlio authors draw tho following conclusions. This method 
will not give positive assurance that a normally functioning 
gall-bladder Is organically sound, and may give misleading 
Inforinntion, In normally functioning gall-bladders tho re- 
snltaiit picture does not depend on the method of administer- 
ing tho dyo, and there is a probability ot error whether it be 
given Intraveuou-sly or orally. In .non-lllling gall-biaddcis 
tho test will not indicate definitely tlio preseuce-of disease, 
though tho possibility of error is less (20 percent.). A so-called 
delayed Ulling of the gall-bladder cannot be taken as evidence 
of early gall-bladder or any other disease. The nninber ot 
stones demonstrated by a: rays after dye adrainistratiou is 
decidedly giealcr than without it. Tho evidence afforded by 
this dye te.st is helpful but not absolnte, and must be conipai eil 
with the clinical symptoms of tho cases under consideration. 

327 . Op the two ractliods of administering tetra-iodo- 
phcnolplithalciu Dr. L. Valach (Jlratislnvske Lekarske Listif, 
Februavy, 1928, p. 49) favours the intravonons rente. It is 
said to be. quite havuiless it fresh preparations are used. The 
anthor dl'sliugiiishcs three types of galLbladder (1) tho 
hypertonic ororthotoiilc bladder, (2) tlie atonic-ptotio bladder, 
and (3) tho pathological bladder. The gall-bladder empties 
ill two ways — first, actively thiongh contraction ot its mus- 
cular wall, and secondly, passively through relaxation of iis 
sphincter. Active emptying has been observed only after 
inti-avoiious administration ot hypophysiu, but in cases ot 
atony and cholecystoptosis the effect ot hypophysiu was 
only slight and set in very late. Substances given by tlia 
month cause only passive evacnatiou ot the galj-bladdor, the 
most active in this respect being fats, yolk of egg, peptone, 
and magnesium sulphate. The atonic or hypotonic gall- 
bladder does not diminish in size after a fatty meal, hut 
tbo Intensity of tho j-ray shadow diminishes greatly. The 
author considers that his experiments proved further the 
mechanical influence of the pregnant uterus upon the gnll- 
bladder, favouring staguation, which tends to gall-stone 
formation and infection. Whenever possible stereoscopic 
skiagrams should he taken. 


Obstetrics and Gynaecology. 

328. The Uterine Muscle during Pregnancy and Labour. 

H. KNAUS (Wien. kiin. ll'och., January 12th, 1928, p. 45) has 
found in a series of observations on animal uteri (mainly 
rabbits) that spontaneous contractions occur .in the non- 
pregnant organ which are comparatively iufreoirent and 
feeble before Sexual maturity is reached, but become much 
more poweriul ahd frequent subsequently,- attaining a'uiaxi- 
mnm at the rut period of the sexual cycle ; it, however, the 
ovaries arc removed this uterine activity ceases and atiopliy 
supervenes. In order to study the activity ot the uterine 
muscle at the different stages of gestation one horn of the 
uterus ot a number of rabbits was rendered sterile by division 
ot the tube under anaesthesia fourteen days before coitns was 
allowed. Thus only one horn in each animal became prc"- 
nant, while the consecutive changes in the muscalature coiiUl 
be studied either in situ or by excising the sterile horns at 
successive stages ot pregnancy— which in rabbits lasts thirty- 
two days — and plotting illustrative curves. Knaus reports 
that by tho second day after coitus tho spontaneous con- 
tractility and tone ot the uterus is considerably reduced and 
this condition persists till about the eighth day; this corre- 
sponds to the phase of gestation befoie the ovum is firmly 
embedded. On the tenth day irregular muscular contractions 
occur again, and the tone increases until by the fourteenth 
day the activity closely resembles that of the non-pre''naut 
adult uterus. On the eighteenth day regular contractions 
somewhat like feeble labour pains, begin ; the.se contractions 
are arranged in groups separated by rest intervals ot fairly 
constant duration, and gradually increase in power reachiu-' 
a maximum on the twenty-ninth day ot ge.station. Jilean 
while the tone ot tho m-uscle lias been 'increasing slowly and 
from the thirtieth day onwards tho increase In tone is mneh 
more rapid until the onset of labour. As a result ot his 
ob.servations Knaus came to the conclusion that there is no 
sudden change in the tone and activity of the uterus at the 

5S.1 0 


56 MadCH 3T, jrpaS] 


EPITOME OE COKEENT MEDICAL LITEBATCEE. 


r Tit* UBITIf* 

iSfencAL Jartait 


onsut o£ labonv, but that, so tar as these two fanolloiia ol tbo 
uteriuo mnsole are coneeniotl,:the. latter part .o£ pregnancy, 
passes into the beginning ot labour by orderly stages. ■Gaaoa 
of precipitate labour -are ascribed to ailaclc-.of perception of 
tUe dilatation o£ the birth cauaU Tlie increase 6t tone 
occurring in the human uterus during the last four "weeks 
(the last tenth) of pregnancy corresponds to the last two-days 
(also the last tonthjdu the rabbit, and accounts for tho diminn- 
tiou in size ot the uterus observed to occur about this time. 


329 . The Production -of Painless Iiabaur. 

E. YQGT (Med, .Klinik, January '6tb, 1928, p; 24) has nscd 
pernocton— a 10 per cent, solution, of a barbituric ••acid 
derivative, also employed by surgeons .and! psychiatrists— tor 
the production. ot “ twilight isleep ” ia-a series of over sixty, 
cases without ill ietfectslto. inotbcr or intant. An average 
dose of 1 c.cm. per 121 Jtilos of body weight is injected very 
slowly intraveuonsly/when .good .pains aire '.present. and the 
os is dilated about '5 cm. in primiparae aucl 2 lingers in 
multiparac. If the correct -dose !has been administered the 
patient falls asleep immediately, bat rousea .snlllciently 
during the pains to use voluntary muscles it .-encouraged to 
do so, though the analgesic -oftect is almost complete -and 
lasts for two or three hours. Tho preparation -did -not inter- 
fere in any way with the -nterine contractions, -it iind .no 
deleterious effect on .the -irilant, it produced a sullficiont 
anaesthesia for. .-minor "urgent .m'anipulatious such ras .the 
treatment ol prolapsed cord, and was besides a usefulprc- 
liminary, espeoiallyin 'nervous patients, lor full aiiaestlicsia 
when this was 'subsequently 'fonn’d to be necessary. Vogt 
adds that the vomiting which sometimes ocenrs may bo 
prevented by a preliminary injection of atropine bait an honr 
before the pernocton is administered. 


330. "yulvo-vaginal'Thrusb. 

Accoeding to M. E. -Lb 'BTyAYB.(G//tii’coi: el OhsUt., January, 
1928, p. 40) vulvo- vaginal 'thrush is much -more eonimon than 
is usually supposed, and its 'alleg"ed especial frecfuency in 
association with pregmancy and diabetes .is duo to the greater 
sevoritj' of tho lesions ..in these two conditions. It" occurs at 
all ages, but is more common in ailult' life, bein'g about equally 
frequent befci'e and after the menopause. "In .'smears and 
mlt-nrflo Hio ' l/icdhs' IS 'sl!tltla,V lo 


' y.'tho aspbefot -the 
em'ely rariablo, and 
eslous— some or aU 
■je caset— a!re recog- 
(nsually vaginal), 
reddened, sensitive, 
(2) Intertriginoua or 


cultures the ' 
that found 
Infected are 
the followin 
of Avhioh m 
nizable. (r ■ 
which are d^ 

but usually non-ulcdrated mucosa" 
eczematous patches, most common at the vulva, "especially 
over the internal surfaces-of the-labiamajora or the external 
surfaces of tho labia minora. (3) Vesiculo-pustular lesions, 
rarely larger'than -a pinhead, and most common mu the skin 
near tho vulva. Diagnosis can .bo made with certainty by 
microscopical examination ot .smears or -cultures, and with 

cons''’ ' ipenlioal testing of the 

effec . leptic remedies are .nsc- 

*<5ss, ■■ e.xample, ot a 1 or 2 per 

cent, sodinm'bicarbonate solution, made at least twice daily 

are quickly effectual. Such treatment must be xirolonged for 
sometime afterthe pruritus has disappeared. 


Pathology^ 


331. Ptlterable Forms -of the Scarlatinal Trlrus. 

U. Euiedem.a.5:n - and H. Deioher (Z«£t./. Jiijg. u. InJcHions- ' 
krATiklu, Januai-y 30th, 1928, p. 354) have ‘endeavoured to ^ 
prove the existence of a filterable form of -the scarlatinal ' 
virus, but witbout success. Throat washings from a patient ' 
with a severe attack of scav'let lever were taken on the • 
second -day of the disease, ■filtered through Bcrkefeld "lY ' 
candles, and the filtrate rubbed on to the throat -or'liivb ' 
persons with a strongly positive Dick reaction^ both persons • 
remained well. It was thought that perhaps tbo filterable 
virus acted 'ohly in the presence of streptococci, so -in the ■ 
next experin7ent the 'filtrate was rubbed on to the throat ot • 
four patients -who '-■■ ■ -■ ■' ' ' angina and -who ■ 

showed numdrons ' ' ■ iii throat smears. 

All those patients . ■ eaction, but -none 

of 'them contracted scarlet levee; one of them, however, 
developed scarlet fever, four weeks later through intection 
at home. The authors conclude from the.so experiments 
and from other e'videuce "tliac the existence of a filterable • 
virus acting'albue'or -in symbiosis with streptococci in the 
produetion -of hcariatina is iinprobable. A •different question 
is whetber filterable "forms of streptococci exist. Eamsine 
observed in certain batches of streptococcal toxin a fioccnlent 
582 n 


I precipitate; on culture this -proved sterile, but "when injected 
into, mice it infected -them, and streptococci were later 
demonstrated in their -organ.s.. Tho present autlior.s .have 
endeavoured -to .repeat Ilaipsinp’-'J obsorvatjon.s. One batch 
out of -six -of toxin in which lldccnlation had appeared was 
found by .them to be infootivo for iiiice; haemolytic strepto- 
cocci rvere recovered in small numbers from tbo spleen and 
kidney. They have also examined the -uriuo ot patients 
with scarlatinal, nopbritis ; - ono mouse out of sovouty-Ionr 
injected with such Urine died, and haemolytic streptococci 
were isolated in -largo numbers from tho blood, spleen, and 
kidneys. . TUeso successes-nro so uncommon that the author 
regards them ns practically devoid ot slgniflcauco. 

- 332 . .Rotlcnlo-cndothelialjBlockaffe and Flocculation. 

V; GOSTABlbE {II ii/orqnpni,- January 22nd, 1928, p. 121) bus 
studied tho olTect of blookliig the rcticnio-ohdothblial sy-stem 
on certain diagnostic reactions which depend oh disturb- 
ance of tho colloidal ■eqnillbrinm of Tlio" senim’. Sneb aro: 
(1) Costa’s Toactioh— positive in intoxications,' Infectious, ' 
pregnancy, and malignant disease; (2) Brossn’s reaction — 
duo to -a rolativo jnereaso of .the less bydrophilo . colloids 
(fibrinogen, globulin) in the sernm, and positive in maliguant 
disease ; -(3) Botcllro’s reaction — doponding -on the easier 
floocnlntion of tho loss bydrophilo -colloids in an acid medium 
by -means of a -solution of iodine .in -potassinm iodide, and 
UkewiSD positive in malignant disease; (4) Matefy’s reaction — 
caused by tbo action ot trivalcnt nlnminium on iglobniiu, and 
positive in tuberculosis and all disoasas iu which there "is 
active destrnctiou of globulin.. In -addition to these reactions 
ho studied tire sedimentation rate of ttic red blood corpuscles, 
using Linzonmeier's metb'od oh yonng' malo dogs. Tho 
blocking ot the reticulo-ondotholial system was effected by 
intravenous injection otal, per cent, solution of trypau-blue 
in saline, 3 c.em. being given per kilo ot dog. Tbo reactions 
wore practised on tlio two days preceding the blockage, and 
on each flay following it, up to Iho fourth. It -was found 
that -after blocicago all tho reactions were rendered more 
positive than -before; the time at whicb ilocoulatiqu appeared 
was earlier, and tho degree of iloooulalion was' iuoreasod. 
With -the sodiiuontation test tho time taken for the blood 
cells to settle wa.s oonsidcrably decreased. That tho altera- 
tionintliG roaotious was due to a blocking of the retloulo- 
ondotbeUal system, nud not to the tvypan-hluo itself, was 
shown -by control teats in whleh the dye was added to the 
serum in vitro- The author concludes that as a result ot the 
blockage of the roticnlo-endotbelial system there is an in- 
crease ot floconlatiug substances — albumins and globulins — 
which i'endci'.s the reactions more intense. It is clear, there- 
fore, that those reactions cannot have-any specific y.aluo in 
diagnosis; they merely indicate a disturbance in the colloidal 
equilibrium of the body fluids. 

333. Ambard's Constant and tho Kenal Functions. 

A. Oropino {Jtassegna intenias. vli -clin. e ter., December, 
1927 ,".d. 818 ), as tho result ot his investigations, comes to the 
following conclusions. (1) -As regards the two functions ot 
the kidney, excretion ot wafer and-the excretion of substances 
in solution, the chief ot which is urea, Ambard’s formula for 
denoting tho oirca index in terras of tho body weight can 
determi-nelhe latter but not the former. (2) -Azotaemia may 
bo a sign of uraemia, but is no means ot showing slight renal 
changes. (3) The concentration ot urea in the urine, as 
determined .by use of the ureteral catheter, may serve for 
tcsti"ng "the -comparaUve value :o£ the t-wo .kidneys, but it is. 
no indication of theh' -functional valne, since. the excretion 
ot urea depends on Iho albuminoid content .of . the diet.,; 

- (4) Ambard’sfoi'mula shows riot only thestate ot the kidneys, 
but also their lunolional value. (5) Iu tuberculous lesions; 
a-norraal Ambard’s constant is an undoubted sign of a healthy 
kidney, while a high fignre points 'to bilateral renal lesions.., 

(G) In urinary surgery it, is.or-";.very.-;great value, " .sirioe U 
indicates whether an operation. sbould-be performed or .not. 
Itlhe figure exceeds certain.'litnitsit is dangerous tQ "i>erform 
:a -■nephrcctom.v or prostalectomy, whereas .n good • constant 
.justifies-any operation. , ' 

j - . . > - 

.’ 339. The Histamine Test for Castrlc Secretion.- 

it. BraNCATI (II 1‘oliclinico, Sez. Cliir., January 15th, 1928, 

\p. 18) reports a series ot observations on sixty patients divided 
Hnto three g'roap.5 — those without gastro-duodena’l Jesions, 
ithose with gastric or duodenal ulcer, and those .suffering from 
new growths. He injected I mg. of liis'tamit'ie subeuta'rreoasly 
'and'fitteen minutes later extracted and, exaniined tbe gastric 
juice; ho repeated this iwOoess six or seven times. - Com- 
0>arison with fractional test meals showed thattliisbistaiiiina 
lest gave a constantly-higher acidity curve. By tlio histamino 
imetUod a pure juice is obtained which can bo .estimated 
rwltbont filtration, and is suitable for cytological or bacterio- 
■Jogical "investigations. 



Ariiiii 7 i iga*] 


67 




Thz Bbitwb 
Uxoicix JounxA£> 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

335. Methyl Salicylate PoIsonlniJ. 

Though cases of methyl salicylate poisouiug appear to bo 
very rare, only thirteen cases with six tloaths having beou 
rccottloil, r. V. Wooiniunv ami A. G. Nicholls (Canadian 
Med. Assoc. Jottm., i'obruarj', 1928, p. 167) point out that oil 
of wlntorgrccn Is a drug In rathor common use and may bo 
extremely dangerous. Accidents from its therapeutic ad- 
ministration seem to bo unknown, due doubtless to its being 
prescribed for external uso only, but it has beou taUcu 
accidentally, tor suicidal purposes, and ns an aboctifaclcnt. 
The authors describe two fatal eases of poisoning with this 
drug, and review n case reported by Pincus and Ilandiey last 
year. One ouuco Is usually regarded as a fatal dose, 
though recovery has followed tho ingestion of this amount ; 
on tho other hand, less than 15 c.cm. has caused more than 
one fatality in infanta. 'Where recovery has ensued tho 
following symptoms and physical signs have been noted: 
vomiting, purging, vertigo, general weakness, excessive 
appetite and thirst, rapid pulse, alow and laboured respira- 
tion, drowsiness, and air hunger; the appearance of acotouo 
and diacctlc acid in tho urine ; fever ; contracted pupils and 
amblyopia; with tremors, homiparosis, and mania. In fatal 
eases, convulsions, tonic spasms, and opisthotonos may 
develop, followed by cyanosis and collapse. Tho varions 
authors emphasize epileptiform convulsions as tlic clinical 
cardinal feature in these eases. Tho outstanding patho- 
logical appearances are acute degenerative parenchymatous 
nephritis, acute gastritis, intense congestion and oedema of 
tho lungs, and multiple small haemorrhages iu tho peri- 
cardium, pleurae, and beneath tho dura. The convulsions 
and paretic manifestations are possibly duo to vascular 
disturbances in the cerebral cortex. 

33S. Spiroebactosis Arthrltlca. 

11. Fiiueuw.ALD (Urol, and Ciitan. liev., January, 1928, p. 7), 
who reports two personal cases, states that Iteiter in 1916 
described a peculiar form of artliritis associated with con- 
junctivitis and urethritis and a constant absence of gonococci; 
Hitliorto only twelve cases, including tho author's, have been 
recorded. The disease always begins with urethritis, which 
is followed by conjunctivitis and tlien arthritis. Tlio InOam- 
mation of tho urethra is usually severe, both tlic anterior and 
posterior urethra being affected, and in some cases pro- 
nounced cystitis develops. Involvement of tho testes or 
vosiculae seminales has not been observed. The ocular con- 
dition commences with inflammation of the conjunctivae, 
which are greatly reddened, swollen, and discharge abundant 
pus. Tlierc may also be keratitis, corneal ulceration, and 
iritis. The arthritis always attacks several joints, especially 
those of the lower extremities. Tho flrst cases recorded by 
Keiter were very severe and were not affected by treatment, 
but their llnal issue was not recorded ; subsequent cases have 
been mucli milder. Treatment is entirely symptomatic. 
Heiter isolated a spirochaete from tho blood which he called 
Spirochaeta foi'ans, but his findings have not been corro- 
borated. 


337. Epidemic Encephalitis. 

B. CRUCHET {JoiLini. dc Med. de Bordeaux ft du Sud-Ouest 
November 25th and December 10th, 1927, pp. S'lfl and 895 
records iu full tho histories of 64 cases observed by him ii 
1917, when ho gave the flrst description of the disease am 
adopted tho following classiflcatiou, which still holds good 
(1) a ment.al form in whicli the cerebral torpor, amnesia 
lack of orientation, changes in the pupils, tremor, dysarthria 
paraphasia, and changes in the oerebro-spinal fluid at firs 
suggested gener.al paralysis ; (2) a convulsive form iu whicl 
there was a succession of fits which constituted a transien 
status opilepticus ; (3) a choreic form with all the features o 
infective clioroa in the adult ; (4) a meningeal form in whicl 
the meninge.al symptoms such ns rigidity, Kernig's sign, paii 
m tho back, somnolence, and vasomotor phenomena whicl 
"i^re alWivy s associated witli profound and persistent cerebra 
changes were not explained by any hitherto known factor 
(0) a homiplogic, or, rather, a hcmiparetic form, which 
owing to its rapid subsidence and arrest at a certain stage o 
Its development, was quite different from the ordinary hemi 
p egia in tho adult ; (6) a pouto-cerebeilar form with ptosis 
deviation of the eyes, titubatiou, and a simpli 
°'°sely resembling cerebellar tumour; (7) i 
bulbo-pontine form with varions nuclear lesions affecting th 


nerves in this region, such as the fifth and seventh cranial 
nerves, vagns, and spinal accessory ; (8) an acute ataxic form, 
resembling in some respects toxi-infective polyneuritis ; and 
(9) an anterior iioliomyclitio form, resembling infantile 
paralysis. 

338. Essential Thrombopenia with Haeraatomyelia. 

IC. Evasg (XorsJi Mae/, f. Laegevid., February, 1928, p. 163) 
records a case iu a man, aged 30, who had shown slight 
symptoms of tho haemorrhagic diafhesis from the age of 
12 years, and suddenly developed, apart from any accident, 
symptoms of a complete transverse lesion of the spinal cord 
at about tho level of tho .second dorsal nerve. During the 
course of seven months tho disease iiassed through the stages 
of llaecid parajilcgia, spastic paraplegia, and spastic para- 
Xilegia with extension contracture. Examination of the blood 
sliowod socoud.T.ry anaemia, relative neutropenia and relative 
lymphoe3'tosis, slight eosinophilla, blood platelets about 
20,000 per. C.mni., no retraction of the clot, considerably 
prolonged bleeding time, almost normal coagulation time, 
positive stasis test^, and extravasation of blood on contusion 
and puncture. Evang regards the case as an example 
of chronic nou-reenrrent essential thrombopenia (Frank, 
Breslau) complicated by haematomyelia. 

339. Tetanus Caused by Skin Dressings. 

C. Armstrong (Public IlealOi Reports, December 16th, 1927,- 
p. 3061) brings forward evidence to show that post -vaccination 
tetanus tends to follow severe primary vaccinations performed 
with large insertions and dressed with some type of shield or 
covering sti-apped to the site. Moreover, shields or dressings 
mavkedlj’ predispose to the development of post-vaccina- 
tion tetanus in monkeys or rabbits vaccinated with virna 
arllflclally contaminated with B. ietani. Armstrong defines 
a proper vaccination as one in which the insertion is not over 
an eighth of an inch in its greatest diameter, and is made by 
some method which does notdestroj' or remove the epidermis. 
Such Insertions treated withont shields or dressings strapped 
to tho site have never been followed by tetanus. Itis probable 
that such simple procedures on the part of vaccinators, 
coupled with a warning to tho vaccinated individual concern- 
ing the dangers of home-applied shields and dressings, would 
eliminate tetanus as a sequel of vaccination. 


Surgery. 

330. Echinococcal Cyst of the Etvor. 

A. BalduZZI (11 Policlinico, Sez. Prat., January 30th, 1928, 
p. 129) discusses the differential diagnosis of echinococcal 
cyst of the liver. Contrary to the usual view he has found 
pain in the hypochondrium a prominent symptom. He fully 
discusses tho symptomatology and comments on the dis- 
agreement in this respect. In his experience pain of a heavy 
character was the most dependable symptom ; it was present 
in the right hypochondrinm, and radiated in front to the 
epigastrium and behind to the shoulder and angle of tho 
right scapula. Sometimes it was felt along the right side of 
the vertebral column behind and ns far down as the groin 
in front. Such pain is not, however, pathognomonic. He 
reports three cases, in all of which pain was the predominant 
symptom, and in varying degree had persisted for years. 
The first patient, while under observation, for two days 
passed with tho faeces fluid containing daughter cysts. No 
treatment was given, and the patient made a good recovery. 
In the second ease the diagnosis was based entirely on the 
character and looalitj’ of the pain accompanied by fever. An 
exploratory puncture was negative, as also was the sero- 
logical tost. Pus and daughter cysts were evacuated by an 
operation, and the patient made a good recovery. The third 
case was diagnosed by pain and the position and hardness 
of a palpable tumour. At the operation the cyst was found 
to bo caloilied, as was expected. 

341. Isolated Fractures of the Semilunar Bone. 

A. OdASSO (C/cir. d. org. di movimenlo, Januarj-, 1928, p. 1) 
,wbo records two illustrative cases in men aged 53 and 39 
'respectively, states that isolated fracture of the semilunar 
bone is rare, only about thirty examples of the kind having 
been published. As a rule it is associated with fracture eff 
tho radius or other carpal hones. The etiology is the same 
as that of Colles’s fracture, but semilunar fracture is peculiar 

6iS A 



68 April 7 , 1928 ] EPITOME OP CUKEENT MEDIOAE LITEEATUKE. „ 


In that it only occurs during ulnar flexion of the hand, and is 
essontialiy due to one of two causes — namely, compression 
or tension exercised by the anterior radiocarpal ligament. 
The softening or so-called lacunae of the semilunar bone 
whicli have been described may in some cases predispose 
to fracture, but are usually the remote result of previous 
injuries or fractures which have escaped detection. Clinical 
diagnosis, though feasible lu some cases, is often very 
dilBciilt or impossible, and the most frequent error is to 
mistake it for a simple sprain of the wrist. To avoid this 
error systematic a ray examination is advisable whenever 
the wrist is injured. The prognosis varies according to the 
case, and depends on the greater or less degree of severity 
of tlie initial lesion, the stage at which treatment Avas 
instituted, and the general condition of the patient. 'While 
in some cases the functional result is good, in others com- 
plications develop, such as pseitdarthrosis, cliroulc arthritis, 
more or less complete aukylosis, considerable Avasting of the 
muscles of the forearm, and Aveakness of the Avrist. Treab- 
mout should consist of immobilization of the Avrist-joint for 
eight to ten days, followed by hot baths, massage, ' and 
mechanotherapy. If these bloodless methods fail, and the 
fracture shoAvs no tendency to unite, the semilunar bone 
should be removed as soon as possible. 

392. Colloid Carcinoma of the Stomach. 

Accokdisg to J. W. Stinson (.Surg., Gynecol., anil Obstet., 
T’obruiuy, 1928, p. 180) the first statistical studies of gastric 
carcinoma were published in the British and Foreign Medical 
Jtcviein iu 1857 by Brintou, Avho, in a series of 135 cases, found 
that 9.4 per cent. Avere of the colloid type. In a series of 
2,516 pathologically proved cases of carcinoma of the stomach 
oxamuiod at the Mayo Clinic from March 1st, 1913, to May 1st, 
1925, colloid changes Avere found iu 121, or 5.09 per cent. ; 
25 of these pa’ionts Avero Avomon and 95 men, the aA-erago ago 
of the Avomoii being 50.5 years, of the men 53.3 years, and the 
general age being 52.7 years. The oldest patient Avas aged 79 
and the youngest 31. As regards the symptoms, thero AA’as 
nothing to distinguish colloid carciuomala from other types 
of gastric cancer. The only sure method of distiucUon con- 
sisted in exploratory operation and microscopical examina- 
tion of the tissue. In struoturo colloid carcinoma resembles 
the ordinary adeno-caroinoraa of the stomach, except that 
a great deal of thin mucus is present. In typical oases the 
Avliole wall of the stomach is almost completely changed by 
the presence of colloid material, so that the cub surface is 
clear and gelatinous and of a soft consistency. Colloid 
changes may bo noted in the earliest stages of the carcino- 
matous process, and are frequently found on microscopical 
c.xamiuatiou when not visible to the naked eye, especially iu 
cases of small ulceration, AVheu the diagnosis lies betwoon 
benign ulcer and carcinoma. In the present series 97 of 
the cases (80 per cent.) Avere operable aiid the groAVth AA’as 
removed, 19 were inoperable, and 5 Avere suitable forpalliatiA'e 
measures. The percentage of patients living three and live 
years after operation is about the same as in the non-colloid 
types of carcinoma, but the incidence of early recurrence is 
high in the colloid variety. The post-operative mortality 
rate is about the same as in the non-colloid types, the x) 03 t- 
operative life expectancy being less iu young patients. 


Therapeutics. 

343 . Treatment of Pernicious Anaemia Awlth Liver. 

J. C. Spence (Newcastle Med. Journ., January, 1928, p.71) 
recalls that Cohn, working on the liver treatment of pernicious 
anaemia, divided the liver into. fractions, and, -.discarding- 
those which proved inactive, has shown that the .essential 
curative factor is probably a liver extract. This is a non- 
protcin fraction representing about 1 per cent. of . the liver, 
a fcAv grams of which, taken daily by the mouth, act Avith 
apparent specificity. Spence reports the results in twenty 
cases . of pernicious anaemia treated Avith U\-er and subse- 
quently followed np. In nineteen of these the improvement 
Avas striking and rapid, some of the most severely ill patients, 
being able to resume full activities in three mouths. The 
rapid disappearance of the glossitis Avas particularly striking. ; 
Treatment consisted lu the daily addition of 1/2 to 1 Ib. of 
lightly cooked ox-liver to the .ordinary hospital diet. Later, 
the .amoiiut was slightly reduced in some cases. Prolonged 
cooking of the liver is said to be very .inadvisable, since .this 
may destroy or decrease the potency of the active cnratlve- 
principle. Only one case shOAved no improvement, and it is 
suggested that this may not haA-e been true pernicious 
anaemia. As a concentrated preparation could ho mote 
easily glA'en than the liver itself, certain proprietary com- 
pres.sed liver tablets Avero tried in two cases bnt Avith little' 
resjinn.so. Later a concentration prepared by Cohn’s method 

6ifi R 


was used, AvitU boneflclal results in two other cases. Tlio 
number of reticulocytes rises during treatment, the climax 
being reached Avitbin seven days, and this may be considered 
as n rapid method of estimating the ollloacy of treatment. 
Once the process of erythrocytic regeneration is established, 
the reticulocytes return to a steady level of 3 to 5 per cent, 
of the rod cells. During treatment two patients had acute 
attacks of gout, and another had marked oedema of the legs 
duo to venous thrombosis. These patients had oaten liver 
very freely, Avhich suggests that the response to the diet is 
a quantitative one. Spence has found that Avhon the red colls 
liaA’O roaoliod 4J to 5 millions per c.inm., no more liver should 
bo taken than is necessary to maintain that loA'el, 1/2 ib. four 
times a Aveok probably proving sufllcient. Ho believes that 
the discovery of an oCfeetlA'o liver fraction indicates that 
pernicious anaemia is'a’ disordo'rof an internal liA’or seorotion, 
and that the Avork of Peabody disposes of the theory that the 
disease is the result of a primarily haemolytic process, the 
bacmolyslu being probably a secondary factor. 

394. E. MeuLENGRACHT (TJgcshrift for Larger, February 
9tli, 1928, p. 123) has treated 21 cases of pernicious anaemia 
with a liver diet during the past year. At first be thought 
that raw liver must bo more potent than cooked liver, and 
that doses, siiico.found to bo totally inadequate, AA’ould suflloe. 
Hence the disappointing results obtained in his earliest cases. 
The first three patients, all of Avhom AA’ero very ill, obtained 
no benefit from 10 to 20 grams of raAvlivor a day (even this 
timid dosage Avas not maintained consistently), and died. Of 
the remaining 18 patients 2 died, the necropsy iu one of these 
cases 'shoAving malignant disease of a kidney and the Inngs. 
In the other fatal case the cause of death Avas obscure, but it 
is possible that the fever and persistent diarrhoea may have 
been duo to some intestinal infection Avhicli Avas aggravated 
by the constant prosouco of liver in the intestines. In all the 
remaining 16 cases the treatment proved most satisfactory. 
The blood picture sboAA-cd marked improvoinont, and in those 
cases in Avhicli the tongue sliowcd morbid changes they dis- 
appeared. In 2 cases thero wore severe spinal .symptoms 
with paralyses and ataxia of the logs. The iinprovomenti 
effected in ' those patients Avas tlio more striking as, under 
otiicr mctliods of treatment, such cases have liitherto been 
notorious for their progressive character. But aa'Iiou achylia 
AA’as found, it appeared to bo uninfluenced by tlie liver diet. 
Mostsbrikiug of ail Avas the Improvement in ilio general con- 
dition, patients AVlio liad been debilitated finding thomsolA’es 
quite fit for Avotk. The author was impressed by the, fact 
tliat some of his patients preferred to take tlieir liver in the 
raAV state, citlior made up in a fluid form Avith oranges, or iu, 
lumps of 5 to 10 grams, wrapped up in paper, SAA’allowed 
AVhoIe, and washed down AVltii a little water. Others ate the 
necessary quantity (200 to 250 grams a day) in the raAV state, 
minced and eaten Avitli a spoon. Calf'.s liver Avas usually 
oinplbyed, for it was found that pig’s liver had a more un- 
pleasant taste. AVltli regard to substitutes and extracts of 
liver, tiie author prefers to recommend Avliolo liver until^raoro 
is knoAvn of tho actiA’o principles. He suggests that experi- 
ence Avitli this treatment may alter the existing views as to 
tho pathogenesis of pernicious anaemia, and that.^instead of 
being regarded as a condition caused by oortaiu poisons intro- 
dneed into tho body, it may bo proved to be a deficiency 
disease, in the same class as scurvy and bori-berl. : 

39 s| Treatment of Acute Kheumatlsm. 

G. Kosenthal (linll. Soc. de Tliir., January 11th, 1928, p. 29) 
states that in acute artiouhar rheumatism and allied affeo- 
tious such as chorea immediate and vigorous treatment is 
indicated in the form of intravenous injection of salicylates, 
as recoranJGnded by Lesn^* However mild, the case may bQ 
the intravenous route should bo emploj^ecl whenever there is 
a possibility oF.au endocardial localization. ThoniPthodis 
also indicated in cases where there is gastric intolerance For 
salicylates. In. tho case of adolescents during tlie acute 
stage of acuto rheumatism an intravenous injection of 1 grain 
of salicylate should be given morning and evening, combined 
with 6 grams by the mouth. As the symptoms subside 
a single intravenous injection should be given, combined 
with 3 grams by tlie mouth morning and evening, for a few 
days, when the intravenous injections may be stopped, while 
the treatment by mouth is continued. 


316. The Iodine Treatment of Goitres. 

Ij. Dautrebande and A.LEmort (Zin{.xelieS'.l/<^cficaZ,Fcbruary 
12th, 1958, p. 528) describe a modified iodine treatment oI 
exophthalmic goitre and thyrotoxic adenomas. They have 
obtained good results by admiuisteriiig a solution containing 
10 grams of iodine and 20 grams of potassium iodido dissolved 
in 100 c.cm. of distilled water. In Graves’s disease at first 
5 to "30 drops are given daily in two to four doses *, then the 
dose is increased to 60, 100, or even 150 drops daily, tho 


Arnir. y, loaSJ 


EPITOME OF OUEBENT MEDIOAE IiITEKATimE. 


L UesiCAi. JoxnntjiL 


ilosnpo being rognlatcil by frcqnont examinations ol the basal 
tnotabollam. In ndonomaa a dally doso ot 60 drops bna novor 
boon cxooeded. Xlio authors bcliovo that, In tlioso con- 
ditions, the iodlno acts by lowering tho gonoral motabolisra, 
by rodnoing tho activity of nil tho tisanos and thus arresting 
tho abnormal oscitation ot tho thyroid gland, and by restoring 
to normal tho disordorod functioning ot its internal soorolion. 
They claim that, ndmlnistorcd in this form, iodlno is a 
vnlu’ablo adjunct to tho modloal and surgical measures usually 
oinploycd in these conditions. 


Laryngology and Otology. 

3 t 7 , Vestibular Ncurltla In Acquired Syphilis. 

D. MASSA (jifu. oto-ncnro-oftalm. y tie ciriir/iu nenroJoff., 
November, 1927, p. 312) describes two cases ot lesion of tho 
vestibular norvo somo fluio after syphilitic infection. The 
first patient was n man, aged 20, who had been infected five 
years previously, ho had attacks ot vertigo, nausea, and 
vomiting, with unsteadiness and nystagmus, which continued 
and rendered him unable to walk. Examination showed 
tho middle car to bo' normal, thoro was a spontaneous 
horizontal nystagmus, and Darany’s calorie tests indicated 
very reduced irritability. Tito fistula sign was absent and 
neither vestibule reacted to tho galvanic test. Tho Wassor- 
mann reaction was positive. Hearing was good and tho 
cochlea did not appear to ho involved. Tho patient was 
given injections ot mercuric cyanide and of pllooarpino 
hydrochloride on aUernato days for a month, with an interval 
of six days in tho middle on account of vomiting and 
diarrhoea. Tho second case was similar, but tho vestibular 
symptoms occurred four mouths after Intectlon', tho cochlea 
was not involved, tho labyrinth did not respond to caloric 
tests, and tho rotatory tests gavo_dimIuislied reactions. Tho 
patient ■was given mercuric cyanide and ucosalvarsau on 
alternate days for three weeks, and became very much better, 
losing ail tho vertigo. Massa finds that vcsttbular neuritis in 
syphilitic oases comes ou suddenly and that its symptoms are 
sovoro. The reactions of tho labyrinth to stimuli are very 
much reduced, it not entirely aliollshod. The diagnosis Is 
made on tho sudden and severe nature ot tlio labyrintUiue 
symptoms and tho history ot acquired syphilis. Ho believes 
that with energetic treatment those oases can be cured. 


3$8. Occurranco of Brain Tissue within tho Noso. 

D. GUTHniE- and E. Dott {lourn. LanjngoU and Olol., 
November, 1927, p. 733) romarlc that while tho upward 
passage ot a malignant growth from the nose to tho brain is 
notpartionlarly rare tho downward extension from tho brain 
to tho nose <7ocs not appear to have been provionsiy recorded. 
Tliey describe two cases 'u-horo brain tissue was present In 
the nasal cavity. Tho first patient was a roan with symptoms 
of a rapidly growing frontal lobe glioma, which, in spite ot a 
decompression operation, rapidly attacked tho basal ganglia 
and caused death. Tho necropsy revealed a large glioma 
which had taken on malignant characteristics, had pene- 
trated tho dnra mater at tho olfactory sulcus, and bad per- 
forated tho cribriform plate. A. small tumour ot neuroglial 
tissue was- found in tho nasal cavity, and on examination 
was found to consist ot the same malignant tissue ns the 
cranial growth. In addition, in one microscopical field, there 
were one or two thrombosed veins and a slight polymorpho- 
nuclear infiltration showing the earliest stages of a cerebral 
abscess. Tho second patient was a man who had had a blow 
on tho head in 1911, since when ho had snffered first from 
hemiplegia and inter trom-paraplegia. Glioma of tho frontal 
lobe ot the brain liad been diagnosed, but apparently incor- 
rectly. In 1920 nasal obstruction had occurred, and in that 
year and iu 1921 nasal polypi ot the usual appearance wore 
removed. In 1925 ohstrnction recurred and a further polypus 
was removed. This appeared to be more solid and flesby 
tlian usual, and was therefore examined microscopically, and 
proved to contain glial cells and fibres. It was covered by n 
ciliated epithelium under which was a fibrous layer resem- 
the meninges. Tlie recovery of this case was, from a 
rhlnological.poiiit of view, complete. The authors consider 
that the first case was an example of a malignant growth 
lorcmg its way by pressure atropliy througli the base ot the 
Skull into the nose, and the second to liave been an en- 
ceiuialocelc, tlio stalk of which bad been nipped oB by 
Closure ot (he aporture of the base ot tho skull. 


of tbe Upper Respiratory Tract. 
revW» or Otolaryngol., December, 1927, p. 572 

mastmn *'*^0 upper respirator 
bpiiPl^n= ’. 1 ,““^ 'nrection ot the larynx. H 
small invasion of this organ always occurs throng; 

sions ot tho mneous membrane and not through th 


lymph system. Tho connexion between the tonsils and 
cervical glands and tho interior of the larynx is of the 
slfgbtost, and shows no. signs of the transmission of tuber- 
culosis. Tlio four stages ot laryngeal tuberculosis, according 
to Manessa following Asoboff, are as follows. (1) Infiltration ; 
tho mucosa is tblokenod, red, and studded with miliary 
tubercles, with a certain amount of round-celled infiltration, 
and possibly oedema. Tho oedema may bo ouo of two types ; 
in one there aro largo lyiiiph-fllled spaces In the connective 
tissuo crossed by lino tibrils, while In the other there are 
miiltlplo miiiuto spaces between tho bundles ot conuectiye 
tissno. (2) Ulceration ; it has been shown that the ulcers in 
tho larynx are not due to caseatiug tubercles, but to the 
extension of intact grannlation tissue. (3) Perichondritis ; 
when this is present there Is usnally very advanced destruc- 
tion of tho superficial tissues and some degenerative clianges, 
at least in the cartilage. (4) Tumour formation ; this may 
represent cither a true tuberculoma or a pachydermia. The 
tuberculomata are rounded smooth swellings, only very rarely 
ulcerated, and are of two types — thoflbro-tuberculonia, which 
is pedunculated, and contains a largo proportion of fibrous 
tissue round the tubercles, and the granule-tuberculoma, 
which is rarely pedunculated, and contains tubercles em- 
bedded in granulation tissuo. Pachydermia only occurs 
whore sqnnmons epithelium is present. It is found in chronic 
simple laryngitis, but the tnmonr formation is much more 
marked in tuberculosis. Pachydermia may be tho only 
evidence of tuberculosis, and must always bo, viewed with 
suspicion. In some cases of paralysis of the recurrent nerve 
iu tuberculosis it is found that tlic nerve is not merely com- 
pressed by a mass of tnberculons glands, but is actually 
infiltrated and destroyed by a mass of tnberculons tissue. 

350. Mastoid Periostitis. 

A. Piazza MiSSOP.ici (Arch. Ital. ui Olol., December, 1927, 
p. 750), who records 110 cases of mastoid periostitis, has found 
that swelling occurs over tho mastoid process, tho temporal 
region, or both. The periostitis 'u-as unassocialed with any 
nudorlying mastoiditis In over 50 per cent, of cases under tho 
ago ot 5;- in 45 per cent, between the ages of 6 and 10; iu 
44 per cent, bot'weeu 11 and 18; and in 42 per cent, between 
19 and 30. Above tho age ot 30 only 24 per cent, of swellings 
behind tho car were duo to periostitis only, while tho 
remaining 76 per cent, were caused by mastoiditis and peri- 
ostitis. The site ol the swelling gave no indication of the 
nature of tho inflammation. Mastoiditis, ns a rnle, was 
accompanied by swelling over the mastoid alone, while, in 
simple periostitis, the swelling tended to spread to the tem- 
poral region or occurred in that area alone. Investigation of 
the nature ot the microbic infection did not show any dis- 
tinctive feature in tho infection of each type of inflammation.' 


Obstetrics and Gynaecology. 


351. Radiological and Operative Treatment of 
Uterine Conditions. 

C. J. Gauss (ilfed. Klinik, Febrnary 3rd, 1928, p. 183) reviews 
the results of his own experience and various summaries In 
the literature of the radiological and operaiive treatment of 
haemorrhagic metropatbies and fibromyoniata of the nterhs. 
He compares the two methods ot treatment under the follow- 
ing headings : curative effect ; mortality risk ; complications; 
and social considerations, such as cost aud loss of time. He’ 
mentions also the subjective preference of the patienffor the 
more conservative method ot treatment. He conolndes that 
flbromyomata aud haemorrhagic metropathies require active 
treatment if they do not react to medicinal or tho .simpler 
gynaecological measures. He considers irradiation of the 
ovaries to be the method of choice, and denies from his own 
experience of over twenty years that the symptoms of the 
artificial menopause are more severe when prodneed in this 
way than by surgical treatment. Dperatiou is indicated 
when the fibroid growths are pedunculated — either sub- 
mucous or BUbserouB — aud torsion is likely or has already 
occurred. It is also advisable when it is desirable and 
possible to avoid amenorihoea' and sterility by a myom- 
ectomy, when there is evidence ot degeneration or suppura- 
tion of a fibroid tnmonr which might lead to a spread of 
sepsis, and -when the possibility of an ovarian tnmonr being 
present cannot be excluded. In all other cases of this typo 
he considers operation unjustifiable. Gauss adds that the 
method of temporary sterilization to control haemorrliage 
and tumour growth In young Individuals is still in its infancy. 
Because of the theoretical risk ot damaging the ova of 
which, however, he has no evidence, he limits the method ot 
temporary or partial sterilization to those cases in wh’cU 
subsequent pregnancy is unlikely, or in which the condition 


6i8 0 


60 Arnir, 7, 192S] 


EPITOME OF CEPEENT MEDICAL LITERATE itK 


f Tms WBtns* 
MeoxcAL JoouiiS 


or the iiaticnt in other respects malces the risks associated 
with tlie foriri of irradiation the lesser ot two evils. Ho 
approves diagiioitic curettage as a preliminary to a:-ray 
treatment. 

352. Ectopic Gestation. 

Peny, Charrier, and Magendib (Journ.'de Mid. do Bordeaux, 
January 10th, 1928, p. 1) report the case ot a Woman, agcd-37, 
who had a miscarriage ten years ago, followed by slight 
menorrliagla. In November, 1926, she had'a normal period, 
followed in January and February, 1927, by slightly coloured 
discharge. At the end ot February she had severe colicky 
piins but without any vaginal discharge; the attack passed 
oH in two or three days, but the abdomen continued to 
increase in size, and at the end ot April the patient felt 
foetal movements. At tlie end ot September she had 
labour pains but no delivery. In October she snITered 
from tachycardia, hypertension, and albuminuria. The 
foetal parts could be clearly made out. Lipiodol was 
injected into the uterus and its cavity was found to be 
enlarged but empty. On October 14th the abdomen was 
opened and a dead fully formed child was removed with the 
jilucenta. The authors believe that this was an abdominal 
and not a tubal gestation, for the walls of the foetal cyst 
Were formed of a thin inorabrane suggesting the amnion, and 
there was nothing to implicate the tube. They lay stress on 
the necessity in these cases ot finding suitable lines of 
cleavage in the removal of the mass. In addition to the 
above condition tlie woman had a small fibroid, which perhaps 
accounted for her history of menorrhagia, but it is doubted 
whether it had anything to do with the ectopic gestation. 

353. Pernicious Anaemia in Pregnancy. 

P. N. Deschamps and A. Frovez [Ball, ct Mini. Soc. Med. des 
Hop. de Pans, February 9th, 1928, p. 143) report a case ot 
tlie above disease snccessfully treated by liver. A primipara, 
aged 27, and six months pregnant, was admitted into hospital 
in July suffering from extreme pernicious anaemia. The 
periods were regular up to five months; there was marked 
albuminuria and oedema, but the liver and spleen were not 
enlarged. The red corpuscles numbered only 1,800,000 per 
c.mm. She was given 250 grams ot halt-cooked liver for a 
period ot twenty-six days, and tliree blood transfusions were 
performed. About a fortnight after the liver treatment was 
instituted a remarkable change for the better occurred. By 
August the red corpuscles had risen to 5 million and they 
remained between 4 and 5 million up to November, when the 
patient was in good health. lu October she gave birth to a 
healthy full-term child and a mummified foetus. The sur- 
prising feature was the improvement in the blood while the 
foetus was still in the uterus ; as a rule there is no improve-' 
ment until delivery. The persistence of the periods for tho 
first five months was also unusual. The authors do not think 
that the blood transfusion had nearly as much to do with the 
good result as tho liver treatmeut. 


Pathology. 


354. Bacteriolysis of the Tubercle Bacillus. 

M. T. ISABOMNSKY and W. J. Gitowitsch {Hcit.f. Iminunitals. 
u. exper. Pherapie, January 16th, 1928, p. 285) find that certain 
oils are able to dissolve the tubercle bacillus, aud that the 
Ij'sates have a protective action against tuberculosis when 
injected into guinea-pigs. In their experiments tubercle 
bacilli were mixed in test tubes with cod-liver oil and with 
olive oil, and incubated at 38'= C. for six months and at room 
temperature for four and a halt months. Ender these con- 
ditions the bacilli were largely dissolved ; a few acid-fast 
bacilli could still be demonstrated, however, in films. Ly.sis 
was more active in the olive oil mixture, and was more 
complete when freshly isolated strains ot bacilli were 
employed than when old laboratory cultures were used. Not 
all the bacilli were dead, for cultures of tho deposit on c"g 
medium- sometimes gave a slight growth ; this the autho"rs 
think is due to tlie presence ot lipoid-resistant strains, which 
are able to multiply in tho oil. A number ot other oils were 
tested — animal oils, vegetable oils, and ethereal oihr^biit 
none was so active as olive oil. The authors consiaer it 
probable that the substances responsible for lysis are lecithin, 
olive oil, and oleic acid, and that their action is specific. 
Guinea-pigs were injected subcutaneously with some of the 
oil that had covered tho tubercle bacilli and contained their 
disintegrated iiroduots; two injections were made at intervals 
of a week. The animals remained perfectly well, A month 
later they were injected subcutaneously with 5 nig. of a 
virulent culture ot tubercle bacilli. The two animals used 
were killed after a month; oao was corapletelj' free from 
tuberculosis, the other showed a local lesion only. The 
61 8 JJ 


experiment was repeated, but the virulent bacilli wore 
Injected intraperltoneally, ns was also tho olive oil. Two 
guinea-pigs died in three and n half months with slight 
tuberculous lesions; two others wore perfectly well after 
that time, and when killed showed localized tuberculosis ot 
tho lungs; control guinea-pigs died of miliary tuberculosis 
in twelve to nineteen days. • The authors conclude that tho 
action of the olive oil in the test tube mixtures was so to 
weaken the- virulence of tho bacilli that they served as a 
vaccine to protect animals against subsequont Inoculation ot 
virnicnt bacilli. 

355. A Spontaneous Epidemic of Pneumonia in 

. ' liTonkcys, 

B. Wisher (C. If. Soc. dc Ilioloijie, February 17th, 1928, p. 458) 
records the outbreak ot a spontaneous epidemic ot pneumonia 
in tho monkeys at the' Cantacuzene serological institute, 
Rumania. During tho fortnight October 26th to November 
10th, 1927, eight monkeys out ot n stock of seventy-six con- 
tracted tho disease aud died. Necropsy showed in six cases 
a lobar pneumonia, in two cases a broncho-pneumonia;' in 
all cases but one tho lesions were bilateral. Tho pleura and 
poritouenm woro each attacked once, and tho pericardium 
twice; false membranes wore found deposited on those 
.serous membranes. In all cases the spleen was swollen. 
Microscopically a Gram-positive capsulatod diplocoocus was 
found in the lungs, spleen, and false membranes ; it was 
I'ccovered in culture from tbo heart's blood. Serologically 
tho organism proved to be a Typo II pneumococcus. A vaccine 
was made from some of the strains recovered ; these wore 
grown in a liquid medium for eighteen hours, centritu,gcd, 
and tho deposit suspended in saliuo solution. Three doses 
were given ot 0.1, 0.2, and 0.5 c.cm. subcutaneously on 
November 12th, 14Lh, aud 17th respectively ; no further cases 
of pneumonia occurred. Tho anllior draws attention to the 
points of similarity between this epidemic and those al tack- 
ing human beings, particularly tho morbid anatomy ot the 
lesions and the presence ot a Type' II jmenmococens. He 
suggests that tho vaccination was responsible for bringing . 
the epidemic to an end. 

356. Nature of Morbid Processes following Duodenal 

Obstruction. 

S. Saito, K. Sakai, and S. Suzuki [Japan Jonrn. Med. Sci.t 
Juno 27th, 1927, p. 43) have investigated acute intestinal 
obstruction experimentally to ascertain the cause of deatli in 
animals with duodenal obstruction, the factors influencirig 
the occurrence ot acute poisoning, and conditions which 
lougtbon tho life of animals; special attention was paid to 
the probable processes taking place in tho intestine below 
tho obstruction. Tho authors found that tho incidence ot 
rapid intoxication in duodenal obstruction is prevonled and 
life is much prolonged wlien tho bile duct, or tho ureter, is 
transplanted into tho duodenum just below tho obstruction, 
tbus allowing the bile, or the urine, to flow through tho 
intestine, and that the -Rauie result followed irrigation of 
tho intestine below tlie obstruction with normal snliiie. By 
anastomosing tlie duodenum with the colon, so that the 
duodenal contents llowod directly, into the colon without 
passing through tho small intestine, tlio animals sliowed 
signs ot duodenal iiitoxiciition witli extensive bleedings from 
the mucous niemlinnio of the excluded intestine, but when 
the excluded intestine was daily irrigated witli iioriual 
saline no signs of intoxication or lileedings ocourred. It was 
further found that when tho duorlniial iiigesta flowed through 
tho whole course ot the ileum without pa.ssing. through tho 
jejunum, or tlirough about 30 to 50 cm. of tho lowest ileuiu 
without passing iliiougli most of tbo small iiitcstuie. Ihe 
animals survived without develo|)ing any signs of dumleunl 
intoxication. These results point to the fact tliat I he oau“0 
ot rapid death in animals witli duodenal obstruction lies in 
tho altered couditioii ot tlio small intestine mainly below tlie 
obstruction. 

357. Gastro-eutoro'-anastomosls and the Activity of 

the Gastric G-auds. 

M. P. Brbstkin (.-Ircli. des sci-nres biologiqncs [Russian], . 
vol. xxvii, fasc.'4-5, p. 211), reports tlie results of his itiye.sii- 
gaiions on dogs after gastro-eutoio-auastoinosis. Tlie activity 
of the gastric glands is intimately connected with tliatofthe 
jiyioric part of tho stomach, and gastro-entoro-annstoinosis 
interferes couaider.-ibly with their normal function ; it c.nuses 
acoutiuual flow of gastric juice. Tho reflex gastric seerntiou 
observed .under normal conditions is not inanilest in anima ls 
with gastro-entcro anastomosis, and in ni.any cases there is 
even a diminution ot tlie secretion durhnt meals. Chemiea 
stimulants cause an increase of the se-retion as under 1101 n'a 
condirion.s. Fat docs not iniiibit, tiie secretion as it norma v 
does, but the .soaps foritied in tlic duodenum stimulate me 
gastric secretion as usual. 



Arnit- 14, 1918] 


[ Tue IJnmsn 
Hedical JoTmJTAi;. 


61 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

353. Protein Sensitiveness, 

n. L. B.VT 1 T.OW (.Bfi?. Jonriu Of Ausiralia, Jnnnary 2811) , 1928, 
1). 112), rccofjnlzlni; tlio importniioo ot seiisltivoncss to foreign 
proteins In tho causntiou of various pathoiogleal coiulitious, 
oinphaslzos the diagnostic valuo ot testing tho skin for 
sensitiveness and tlio employment ot speciflo treatment. In 
hay fever and asllinm protein sensitization is liic underlying 
mcclinuism in their production, nnd it is Important that 
patients should bo tested early in order that tho protein 
concerned may be avoided, or that dosensitizatiou may bo 
effected before tho condition has bccomo chronic or com- 
plicated. Scratch testing is said to bo bettor than intra- 
dermal injection os a rontiuo for pollen and epidermal 
proteins, though it may often bo necessary to resort to tho 
latter method in order to dcuioustrato sonsltiveuoss to food 
nnd bacterial proteins. IVliilo spoolflo desonsitlzation treat- 
ment is indicated ivhou it is impossible to avoid contact with 
the offending protein, it must not bo regarded ns the whole 
treatment ot the alTection. Tlio general management of an 
asthmatic condition and tho elimination ot contributory 
causes, sncli as sinus disease or infected foci elsewhere, arc 
most important in treatment. lYhilo mifuy hay-fever patients 
obtain temporary relict by local treatment, dcsousltization 
by inoculation witli the offending proteins should bo per- 
formed also. In pollen asthma prcseasoual treatment should 
bo adopted with dcsoiisltizatiou treatment as early ns pos- 
sible, and not bo postponed until other measures have failed. 
Kpldermal asthma generally responds well to treatment, but 
further inoculation may bo needed later. Barlow considers 
that vaccines prepared from sputum or nasopharyngeal 
swabs are frequently valuable in astlima which is not due to 
pollens, food, or epidermal proteins, but tor this purpose only 
those organisms causing reactions should bo incorporated in 
the vaccine alter tho patient lias boon tested with pure 
Btovilizcd cultures lutradermicnlly. 

359. Heart AfTcctlons In Elderly People. 

A. G. Thomas (Jonrn. Med. Atsoc. South Africa, February 11th, 
1928. p. 56) has analysed 46 cases ot heart disease, excluding 
valvular lesions, in patients over 50 years ot ago. These 
patients, half ot whom were men, showed myocardial damage 
due either to toxaemia or to artorio-sclerosis. The commonest 
symptoms in order of frequency were found to bo dyspnoea 
on exertion or oven at rest, pain or discomfort in tho cardiac 
region, insomnia, sometimes due to dyspnoea, and slight 
swelling of tho ankles. Little was generally discovered on 
physical examination ; tliorc were no murmurs and no 
enlargement of the heart; occasionally dropped beats were 
detected and a slight increase in tho blood pressure. Several 
patients complained of epigastric pain and breathlessness, 
and it was found that an increased risk ot sudden death was 
associated with this syndrome. Tlie conditions giving rise 
to uon-valvular heart disease in this group ot patients were 
high blood pressure, senile degenerative changes, and 
toxaemias from acute infections such as influenza and pneu- 
monia, but chronic interstitial nephritis was not prominently 
an etiological factor. Acute digestive distnrbaiicos were apt 
to produce changes ot rhythm and sudden collapse in this 
type of case. The author regards general regimen and relief 
of symptoms as the most important lines of treatment; ho 
recommends ample rest, a congenial environment, and 
moderation in diet witli restriction ot meat. Tho response 
to digitalis is said to be often disappointing, but a mixture 
of nux vomica, potassium iodide, and bromide was found to 
benefit the majority ot patients. 


Congenital Syphilis. 

B. Fischd {Med. Welt, February 18tb, 1928, p. 243) believe 
iiac the greafc majority oC cases of coui’eultal syphilis ar 
ane to infection through the placental circulation, and nc 
oy contact 'vvith maternal lesions at the time of hirtU. H 
has observed 164 cases in the last ten years. Among these 
lirff • symptoms during tho first week afte 

fK* 1?. 1 symptoms appeared in the second weel 
linn- only 17 showed signs of cougeuital iufec 
pnri ^®^6^opetl symptoms between the third wee 

month. Tims the great majority of case 

dav? T. symptoms between the tenth and twelft 

‘J - u I’lschl S' personal experieuca the percentage t 


cases of congonital syphilis is now very small, approxi- 
mately 0.25 per cent. Ho reports a remarkable decline in 
tho number of cases during the last two years, coincidcutly 
with a moro intensive treatment of parental syphilis. 
Ho has obtained no evidence that the intensive treatment 
of congonital sj’phiils Induces visceral lesions instead ot 
Buperfloial manifestations. Ho finds that a negative 
Wassormann reaction occurs relatively frequently (nearly 
22 per cent.) in infants presenting symptoms of florid 
syphilis, and concludes, theretore, that this test is ot little 
value in doubtful cases ; examination ot the conjunctival 
and nasal secretions lor tho presence ot spirochaetes is said 
to bo a mucli moro reliable method ot diagnosis. Fiscbl 
maintains that tho passage of spirochaetes from mother to 
child docs nob depdnd directly on the condition ot tlie 
mother’s lesions, for in some cases these were found to lio 
definitely regressive or healed. Ho thinks that the possi- 
bility of direct paternal infection has not been disproved, 
and bo believes in the existence of the '‘Colles’s mother,” 
with a negative lYasscrmann reaction. 

361. - Toxic Diphtheria. 

Vf. Steinbrinck {Med. Welt, March 3rd, 1928, p. 327) reports 
that In Breslau there has been during the last two years an 
incrcaso in severity in cases of diplitberia, as also in Berlin 
and several other German towns. The cases were charac- 
terized less by increased frequency of laryngeal obstruction 
nnd its complications than by diffuse foul-smelling pharyngeal 
deposits, glandular onlargement, periglandular oedema, and 
severe toxaemia, which frequently led to vasomotor para- 
lysis, cardiac dilatation, and death in the first or'secdud" weeic 
of the disease. An attempt to prevent the occurrence of toxic 
symptoms by early and large doses of antldiphtherial serum 
failed to reduce the mortality. It has recently been suggested 
in Berlin that tlie severity of the toxaemia is due to a mixed 
infection witli streptococci, and combined injections ot autl- 
diphtbcrial nnd antistreptococcal serum have been nsofl. 
Steinbrinck also found autistreiJtococcal serum of great value 
in bis toxic cases. 


Surgery, 

362, Surgical Treatment of Pulmonary Abscess and 
Gangrene. 

G. PiCOT [Arch, vied.-chtr. dc I’appareil respiratoire, 1927, 
Tomo II, No. 4, p. 355) comments on the dilfloulty in 
pulmonary suppuration ol determining the site or size of the 
abscess, its depth, multiplicity, and even its very existence; 
moreover, septic lesions may exist near the abscess and 
may so modity tho symptoms as completely to mask it. 
Pulmonary abscesses may be classified as non-fetid, caused 
by specific organisms (streptococci and pneumococci); fetid, 
due to specilic bacteria ; and putrid or gangrenous, in which 
a multiplicity ot organisms, particularly anaerobes and 
spitochaeles, are found. Non-fetid abscesses can heal 
spontaneously, Co not cause a marked failing ot the general 
health, and, being encapsulated, are circumscribed. Putrid 
abscesses are of graver prognosis, and, becoming subacute 
or chronic, usually end fatally in about two years. These 
abscesses exist as cavities in the parenchyma, are non- 
capsulated, and the walls are broken, torn, and covered p-itli 
gangrenous debris. Marked pulmonary sclerosis, especially 
lonud the bronchi, accompanies these lesions. Spontaneous 
cure is very rare, and medical treatment is often insufficient, 
since tho cavity cannot be completely obliterated, thus 
causing danger ot a recurrence. Surgical intervention aims 
at draining the abscess and producing its obliteration and 
cicatrization ; it necessitates precise diagnosis ot tho lesions. 
Repeated radiographs should be made, and an exploratory 
puncture is an excellent aid to diagnosis. Picot does not 
favour bronchoscopy, which ho considers dangerons and 
almost useless. Pneumotomy, by which the abscess can bo 
drained to the exterior, should be performed only when tho 
infected area is limited and the ims has already collected ; 
it should be practised under local rather than general anaes- 
thesia, since the latter favours septic complications ot tho 
opposite side. Other abscesses should bo drained into tlie 
bronchi by one ot tho collapse procedures, such as artificial 
pneumothorax, phrenicotomy, or thoracic plastic operations. 
Phtenicotomy does not give conclusively good results nn l 

one ot the other operations is preferred by Picot; ■ ’ * ' 


650 A 



EPITOME OF CUEBENT MEDICAL LITEEATUBE. 


r Tnr. Bam« 

L UZDICIX. JouftsiS 


62 APBIIi 14, 1928] 


363. Splenectomy for Purpura Haemorrha^ica. 

A. W. Spence (Brit. Journ. Surg., January, 1928, p. 4G6) 
remarks that splenectomy was perlormetl for purpura haomor- 
rliagioa on the- assumption that tho haemorrhages were the 
result of the reduction in tho number of blood jilatolets caused 
by the destructive action of a diseased spleen. It is tliought 
that the prolongation of the bleeding time is duo to a detective 
quality of the platelets rather than to diminished numbers. 
Tho transfusion of citrated blood in these cases results in a 
fall in bleeding time to normal and a temporary rise in the 
platelet count. Purpura haemorrhagioa may bo divided into 
acute and chronic cases ; splenectomy is benoflcial in 80 per 
cent, of the chronic and IG per cent, of tho acute cases. 
IVhen splenectomy is sncoe,ssfiil there is a decrease iii tho 
bleeding time to normal and an increase in the platelet count. 
Two cases are described which show the value of splenectomy 
as a therapeutic measure. In chronic cases its effects ard 
said to be so beneficial ns, to warrant its performnnoo when 
the diagnosis is made. 

J ' 

364. Diverticula of the Duodenum. ''I 

n. Blanc (Bull, et Mem. Soc. Nat. clcs Cliir. dc Paris, 
February 17th, 1928, 13. IIG) discusses tho subject of diver- 
ticula of the duodenum. The false or secondary diverticula 
are usually the result of some inflammatory condition or due 
to an ulcer. True diverticula arc congenital in origin, and the 
name should really be confined to this group. Those diver- 
ticula are usually found in the second part of the duodenum, 
and there maybe two or three present in the same case. Tho 
symptoms are not typical, and are usually similar to those of 
other gastro-intestinal lesions ; there are generally indefinite 
dyspeptic troubles aggravated by food, but vomiting does not 
occur as a rule. In some cases, however, vomiting has been 
marked, suggesting pyloric stenosis, while jaundice and 
symptoms of chronic pancreatitis have also been noted. Tho 
diagnosis is always made by radiography. The treatment of 
choice is resection of the diverticulum and closure of its 
mouth in two layers. Invagination has also been practised. 
It these procedures cause narrowing of the duodenum it may 
be advisable to perform a gastro-jejunostomy also, 

335. Horslon of the Omentum. 

G. L. McWhorter (Arch, of Snrg., February, 1928, p. 569) 
finds that pure torsion of the omentum, unassociated with 
hernia, adhesions, or tumour, is rare, and records two oases. 
This condition may arise without any pre-existing abdominal 
symptoms. There appears to be in all oases evidence of 
a pre-existing pedicle which may be congenital in origin. 
Obesity of the omentum is usually present, and is a frequent 
predisposing factor in thet condition. Hyperaemia may be 
the exciting factor in torsion, although trauma or unusual 
exertion may initiate it. Early operative resection of the 
strangulated omentum should be performed. Prophylactic 
treatment consists in resection of a pednnoulated omentum 
and the freeing of adhesions when found at an operation. 


-Therapeutics. 


36S. Treatment of Osteo-articular Tuberculosis. 

C. Clavelin and A. Sicard (Presse Med., February 22nd, 
1928, p. 227) have combined intravenous injections of calcium 
chloride with ultra-violet irradiation in a large number of 
severe cases of osteo-articular tuberculosis. They always 
iTse freshly prepared weak solutions (never more than 1.5 per 
cent. CaCh) of the chemically pure .salt in distilled water. 
The solution is repeatedly filtered, then sterilized in an auto- 
clave. They give two series, each of ten injections, adminis- 
tered on alternate days. An interval of twenty days’ rest is 
permitted before the second series of injections' is com- 
menced. In the first series five injections of a 1 per cent, 
solution are given in progressive doses of 50 to ^0 c.cm. and 
then five injections of a 1.25 per cent, solution in similar 
dosage. After the twenty days’ interval, five injections ot a 
1.25 per cent, solution in doses graduallj- increasing from 50 
to 250 c.cm. are followed by live more injections of a 1.5 per 
cent, solution in similar dosage. In two months the patient 
receives a total quantity ot 30.5 grams of the salt, of which 
50 per cent, is absorbed (Delore). The flask ot solution is first 
heated in a water-bath to 40’ C. ; its contents are then poured 
into a graduated funnel with a rubber tube, to which the 
needle is attached. If the vein is not entered a blister will 
be seen and the injection is stopped at once. When an intra- 
venous injection is given, the patient-feels a sensation of heat 
in the head, sometimes through the whole body; occasionally 
there is a “chalky taste” in the mouth,prevon slight nausea, 
when it is better to stop the injection lest vomiting should 
occur, though this seldom happens if the solution is -injected 
very slowly. At least five minutes should be allowed for the 
650 B 


injection of 100 c.cm., and immediately afterwards tho ultra- 
violet treatment is given. Irradiations are repeated every 
second day during tho injections and tho interval between 
tho aeries. 'The patient receives in all thirty general irradia- 
tions. The first irradiation lasts for one minute with the lamp 
at a distance of one metro. Every subsequent irradiation is 
Increased by one minute, and the patient is brought nearer 
the lamp. 'The final irradiation lasts for thirty minutes with 
tho lamp at a distance of' 0.5 metre. Usually the injections 
are well borne ; the pulse is not changed nor does tho tem- 
perature rise. Tho injections should not bo given Imme- 
diatcl3’ after food, and the tolerance ot the patient should bo 
observed closelj'. Onlj- one case ot intolerance was seen ; the 
patient tainted, but was restored qnicklj' bj’ an injection ot 
ndroualino. In some advanced cases with pulmonary tuber- 
culosis, rigors and profuse sweating followed tho injections ; 
in such cases it is advised that the dosage should bo increased 
more gradnallj'. 'Tlio results have been generally satis- 
factory. Of 28 patients, 4 lost weight slightly, but 17 others 
gained from 5 to 20 Ib. Manj' fistuiae grow smaller and then 
healed. 'The authors consider that tho combined treatment 
enables the patient to fight bettor against tho disease. 

367. Yncclne Treatment In Soft Chancre. 

M. GarRIGA (La Med. Ibcra, March 10th, 1928, p. 261) records 
65 cases ot soft chancre treated by Nicollo’s vaccine, his 
conclusions being ns follows. (1) Tho vaccine can bo given 
intravenouslj’ aud intraoutnneonslj'. Tho intravenous method 
is undoubtedly tho most elllcaoious, although it gives rise to 
certain reactions, especially a high and continued fever. The 
intracutanoons method is less ellloaoions and slower in its 
action, but has the advantage of notgiving rise to any general 
reaction. (2) The therapeutic effect ot tho vaccine, whether 
given intravenously or iutracutaneously, is very slight in the 
case of ordinary chancroid. It is when tho soft chancre and 
tho secondary ulcers become abnormal by their extent and 
depth that vaccine therapy is valuable. (3) Vaccine treat- 
ment bj' tho Intraoutaucous route is indicated, therefore, as 
a prophylactic against complications in the case ot ordinary 
chancroid, and as a curative treatment in abnormal chancroid 
and secondary ulcers. In such cases tho vaoolne should 
be given intravenously if possible. (4) Intravenous vaccine 
therapy is oontratudicatod in old and weakly patients, in 
subjects of cardiac, renal, and hepatic disease, aud in latent 
or active tnborculo.sis. In such cases, however, Intra- 
cutaneous injection involves no risk. 

308. Synthalln In Diabetes. 

M. LABB^; (La Vie Medicate, February lOch, 1928, p. IGl) 
discusses . tho value ot synthalln in diabetes, and refers 
to tho copious literature. Ho agrees that the dose 
should be 20 mg. twice a day with meals, with a po-isiblo 
increase to 25 or 30 mg., but as its action is cumulative,' tho 
administration should bo discontinued for one day in every 
three, if the drug is well tolerated aud no gastric symptoms 
such as anorexia, epigastric oppression, diarrhoea, or voudt- 
ing occur. 'Those disturbances aud tho possible partial or 
complete anuria are seldom sufficiently serious to necessitate 
stopping the treatment ; they are said to bo duo to a direct 
action on the sympathetic nervous system, and may occur 
when the drug is injected hypodermically. Calcium carbonate, 
belladonna, bromides, and bile extracts have been given as 
antidotes. Glycosuria is not diminished immediately, bub 
the action of the drug is very definite after three days. The 
reduction is proportional to the dose administered, 1 mg. 
usually reduces glycosuria to the extent of 1.2 grams. While 
insulin can be administered safely, for a long time in large 
doses, synthalln 'is dangerous in larger doses than 50 mg. 
daily. It cannot replace insulin in the treatment of acidosis, 
while its action in hyperglycaemia' is slower. In young 
patients synthalln does not arrest emaciation, and toxic 
symptoms may occur. It cannot replace insulin ' in those 
cases in which the latter has failed. ■ LabbG’s personal 
experiences of syuthalin accords witli that ot other authors — 
that its toxicity is a serious obstacle to its general use. He 
adds that it will never replace insulin in severe diabetes, 
especially wheu emaciation and acidosis are present; it is 
ineffective in 'diabetic coma, aud its utility is restricted to 
mild cases in which insulin is unnecessarj', 

369. Sodium Salicylate In Chronic Epidemic 
Encephalitis. 

S. H. Epstein,' E. K. Farnham, and S. Cobb (Bostou Med. 
and Surg. Journ., February 16th, 1928, p. 1552) state that 
the favourable influence of salicjdates on certains forms ot 
encephalitis was not recognized until 1923, when Carnot 
and Blamoutier treated two patients with acute epideniio 
encephalitis bj- intravenous injections ot sodium salicj'late. 
Since then numerous cases have been reported of acute 
epidemic encephalitis treated by intravenous injection of 



ArniL 14,. 1928] 


EPIT05IE -or CUREENT MEDICAE LITERATURE. 


[ XflrBninss 
UeOICAX. JOUBXlIi 


63 


soillnm Balioylnto with nioro or toss success. Onlj> a few 
eases, Iiowovcr, of iiost-oncophalitio rnrltinsoiiiani have been 
trcatccl in this way, but tlio results wore loss successful. 
The present authors rccoril twelve oases of Parkinsouism in 
patients aged from 15 to <14, who were given intravenous 
injections of 2 grams of sodium salicylate in 20 per cent, 
solution at weekly intervals. Although subjective improve- 
ment was noted in nearly ovorj’ instance, little or no real 
benellt resulted. The improvement was only transitory, and 
the progress of the disease was not arrested. Local venous 
thrombosis occurred in every case. To prevent this tho 
authors suggest that oral administration should bo tried in 
future, and that It might bo more olleotivo than intravenous 
doses owing to tho continuity of adiuiulstratlon. 

370. Treatment of Asthma. 

According to C. Sutiierdand ( Aral . Jotirn. of Australia, 
•January 7th, 1928, p. 2) rather more than half the cases of 
asthma are duo to speoltlc hypersonsltlvcness ; in many of 
the remainder some focal sepsis can often bo found. The 
exciting substance in tho first gronp Is probably allied to 
histamine, and treatment should bo directed to provouting 
its formation or combating tho spasm. By skin tests tho 
exciting cause may bo detected, when the patient may be 
desensitized by injections of tho substance to which ho is 
sensitive. For those who do not react to these tests such 
vaccines ns tho nnti-inflnonzal may be tried, or intravenous 
peptone, tuberculin, autohnomotherapy, shook protein 
therapy, x rays, and diathermy. Adrenaline, in small doses 
given early and repeated every ton minutes, is still the most 
useful, aud pttultrin is efllcaclous ; epbedriue given by the 
mouth is slower in notion, but its effect is more lasting. 
Morphine and atropine, or light chloroform annesthosin, may 
be useful in severe cases. Between tlie attacks sodium 
iodide is better than tho potassimii salt, and in children 
arsenic is often bcnctlci.al. Authorities differ ns to tho 
advisability of special diet unless there is definite dyspepsia; 
in children it is best to cut down tho carbohydrates. Atten- 
tion to tho general hygiene is n necessary part of any course 
of treatment. Sutherland adds that tho results of removing 
nasal polypi in these oases are often disappointing. 


Ophthalmology. 

37f. Aymphoma of tho Aacrymal Sac. 

H. JVeve (A’cderi. Tijdsclir. v. Geneesh., February 11th, 1928, 
p. 69S), who records an illustrative case, states that tumours 
of tho lacrymal sac are very rare, so that many ophthal- 
mologists of extensive experience may not have soon a single 
case. Schirmer, in the first edition of Grnofo-Saemisch's 
System, docs not mention the subject. In a later edition 
Stock, in addition to carcinoma aud sarcoma of the lacrymal 
sac, alludes to a case reported in 1881 by Creutz, who found 
a lymphoma of the lacrymal sac In a patient sufferiug from 
leukaemia. Wove's case occurred in a woman, aged 59, who 
had suffered from lacrymation for a year, but had only had 
a swelling of tho lacrymal sac for six mouths. The blood 
picture was normal, but tho patient had had an enlarged 
cervical gland for six mouths. Toti’s operation was per- 
formed and a yellowish-grey nodular tumour was extir- 
pated. On microscopical examination it was difficult to 
determine whether the growth was a round-celled sarcoma 
or a lymphoma. The last diagnosis, however, appeared the 
more probable, since the wall of the sac and tho lacrymal 
duct had a lymphatic structure, and lymphoid growths 
show a predilection for snob situations. Comparison of the 
sections with lymphomata of the lacrymal gland and con- 
junctiva, and celloidin preparations of tho tumour of the 
lacrymal sac, confirmed the view that the growth was a 
lymphoma. The only similar case was one recorded in 
1927 by Pascheff at tlio forty-sixth congress of the German 
Ophtbalmological Society, in a man, aged 70, who had a 
bilateral lymphoma of the lacrymal sac. The blood picture 
was normal. There was recurrence one year after removal 
of the growths, but this was successfully treated by x rays. 

^72. After-results of Cataract Bxtractlons. 

tq'-jo'" (llrit. Journ. of Ophthalmol., February, 

1928, p. 85) analyses all the cataract extractions performed at 
Moorflelds Eye Hospital during the years 1919-25, aud com- 
pares them with a similar analysis made at this hospital by 
Devereux Marshall for tlie years 1889-93. By far tho most 
popular technique employed in the recent series is extraction 
with peripheral iridectomy. Tho losses from acute infection 
appear to bo considerably lower in recent years. With regard 
with simple extractions and those 
vitn peripheral iridectomies are bettor than those with com- 
plete iridectomy, but against this must be remembered the 


fact that at tho present time compilote iridectomy is often 
performed In complicated cases. Compared with the earlier 
series prolapse of tho iris is more common in all forms of 
technique. This may bo explained by the more frequent 
extraction of immature cataracts. The visual results after 
iris prolapse are, however, better in the recent series. 
Vitreous loss is about the same in both series, and was 
considerably more common after complete iridectomy. 
Only four cases of sympathetic ophthalmia occurred in 
tlie recent series, as compared with eight in the earlier 
series. There were a great many more necdlings nece.s.-^ary 
in the recent series, probably again owing to tho greater 
number of Immature cataracts operated upon nowadays. 
Tho total number of cases in tho 1889-93 series was 1,519, 
and in the 1919-25 scries 2,368. 

373. Obstruction of Branch of Retinal Vessels. 

F. H. Rodin (Amer. .Jotim. Ophthalmol., October, 1927, p. 753) 
describes a case of obstruction of a branch of the superior 
temporal artery of the left eye which supplied the macula. 
Tho patient had complained of headache for some months. 
On examination a partial central scotoma and a small relative 
inferior paracentral scotoma were found. He remarks that 
tho interest of the case lies in the fact that from the lower 
temporal border of the disc a cilio-retinal vessel extended 
towards the macula, and in consequence a portion of macular 
vision w.as retained. In cases of embolism of the central 
artery of the retina it is stated that the presence of a cilio- 
retinal artery, which occurs in 16 per cent., sometimes saves 
central vision. 

379 . Diphtheria Antitoxin in Sympathetic Ophthalmia. 

E. B. HeCKEL (Arch, of Ophthalmol., January, 1928, p. 54) 
describes this method of treatment in four cases of this, 
condition. The result was favourable in all four cases.. In 
the first case five doses of diphtheria antitoxin, each of 
3,000 units, wore given. In the second case, after an initial 
dose of 1,500 units, four doses of 3,000 units were injected at 
intervals of a week. Only slight improvement occurred, so 
tho dose was increased to 20,000 units, which was repeated 
dally for four days, when very considerable improvement 
ensued. Tho third case was a child, aged 6 years ; 5,000,uuits 
were given daily for ten days with very good result. The 
fourth patient was given 20,000 units daily for seven days, 
with the result that the sympathizing eye regained full 
vision, after being reduced to 2/200. Heckel emphasizes the 
need fbr large doses of tho antitoxin. . . 


Obstetrics and Gynaecology. 


375 . spinal Anaesthesia In Bahour. 

F. Badard and R. Mahon (Fresse Med., March 7th, 1928, 
p. 291), discussing the advantages gained by spinal anaes- 
thesia in labours complicated by, spasmodic rigidity of tha 
cervix, state that this rigidity is really on arrest of dilatation 
duo to a state of uterine contraction, Demelln showed that 
tho Intrncervical mucosa is lined with fine transvei-se mns- 
culav fibres, and the present authors agree with Keiffer that 
tho cervix is a veritable sphincter. Cases are rare in which 
tho mnscnlar bed is so developed that Its contraction alone 
can bo dystooic, and most frequently the arrested dilatation 
is due to a generalized uterine contraction, of which the 
cervical rigidity is only a local manifestation. In the 
majority of cases of arrested dilatation due to cervical con- 
traction time, rest, and opiates produce very good results 
but often the maternal and foetal interests demand a more 
rapid termination of labour. The irritation caused by 
mechanical dilators is liable to increase contraction without 
accelerating dilatation. Two methods come np for con- 
sideration— namely, manual dilatation and incision of tho 
cervix. The former, very efficient in the supple cervices of 
mnltiparae, is painful and liable to cause cervical tears in 
priiniparae ; in these oases the anthers strongly advocate 
spinal aiiaestliesia. By producing a physiological section of 
the posterior roots of tho cord, this method suppresses the 
pathological hypovtony, and even the normal tonicity, of the 
cervix, and permits an easy and sometimes spontaneous 
dilatation. The contraction of the body remains nnohanoed 
as tho autonomous uterine nervous system, freed from the 
moderating control of the medullary centres, produces a 
hypertony. Balard and Mahon inject 5 to 7 eg. of svncaine 
and use manual dilatation, it necessary, when the flaccidityot 
the vulva aud anus indicates an atony of the soft parts. No 
risk to mother or child is involved by this method, and the 
puerperinm romnius unaffected. Spin.al anaesthesia is use- 
less iu pathological or primarily infective rigidity, bnt iii 
normal contraction or in cases of secondary infection it is 
a most efficient method of producing speedy dilatation. 

650 o 


64 APBIIi 14 ~, 1928] 


EPITOME OF CUEEBNT MEDICAE EITEKATTJBE. ■ 


[ Tht IlRmnt, . 
'hlr.DtCAL JoVSHiL 


Y. BourPES (ibid., March 10th, 1928, p. 31G) draws attention 
to the dangers attending spinal anaesthesia In total or sub- 
total abdominal hysterectomy, and reports an illustrative 
case. The great atony of the anal sphincter occurring during 
this anaesthesia constitutes a serious risk, since it permits 
soiling of the operative field by the faeces. In these cases 
Bourdes strongly advises that an enema be given on the 
morning of the operation, and that, after the pudendal toilet, 
the vaginal entrance should be closed by well-packed sterile 
gauze. 

376. Separation of the Symphysis. 

W. Bbehm and H. V. Weieaiik {Amer. Jotirn. Obstet. anil 
Gynecol., February, 1928, p. 187), as the result of a systematic 
aj-ray study of pelves before and after delivery, were surprised 
at the amount of separation of the symphysis pubis which 
occurs in apparently normal labours. In their last series 
of 54 cases 25 were normal without any separation, slight 
separation (0.5 to 0.9 cm.) was noted in 15, moderate separa- 
tion (0.9 to 2 cm.) in 13, aud severe separation (more than 
2 cm.) in one case. Slight separation gave rise to no sym- 
ptoms, but moderate separation caused pain over the pubes 
on turning, and fear of moving because of the unpleasant 
sensation occasioned there. The authors state that crepita- 
tion may be felt; there is usually retention or Incontinence 
of urine, with possibly prolapse of the urethra aud bladder; 
there may be sudden pain due to the soft parts getting 
between the separated bones, and cystitis is common. Similar, 
symptoms, but more pronounced, occur in severe separation. 
It is recommended that slow labours should be treated with 
scopolamine and morphine, and that tho entire pelvis should 
be strapped aud bandaged alter delivery. The bladder should 
not be allowed to become distended, aud after catheterization 
one ounce of 5 per cent, argyrol solution should bo introduced. 
The patient should be kept in bed for from three to four 
weeks, and a bandage he worn for three months after getting 
up. It symptoms persist surgical apposition may be neces- 
sary. An ic-ray e.vamination should bo made if there is any 
suspicion of disproportion between tho foetus and tho pelvis. 

377. Ulcus Yulvae Aoutum. 

W. L. L. Carol and A. Charlotte Ruvs {Nederl. Tydschr. 
V. Geneesli., January 28th, 1928, p. 396), who record three 
illustrative cases, state that Lipsohutz, in 1912, described 
under the name of “ ulcus vulvae aoutum ” a specific form 
of genital ulceration associated with the presence of an 
organism which he called B. crassus, aud which wak first 
obtained in pure culture by Soherber in 1913. Between 1913 
and 1923 Lipsohutz and Scherber recorded about twenty cases, 
and altogether about sixty oases have been desoribod in 
various couulries, including Austria, Germany, Boland, Den- 
mark, England, Italy, and the IJulted States. The first case 
in France was recorded by Eoederer and Slo'imovici of 
Strasbourg in 1927. The localization of the ulcers is the 
inner aspect of the labia minora, the free margin of the 
labia majora and minora, the introitus vaginae, perineum, 
anterior and posterior commissure, aud preputium elltoridis. 
Three forms have been described — namely, a gangrenous 
form of sudden onset, causing more or less destruction of the 
labia minora ; a venereal form consisting of multiple ulcers 
resembling soft chancres ; and a miliary form characterized 
by the presence of ulcers the size of a pin's head. Dicers, 
resembling ulcus vulvae acutum in which J3. crassus was 
jiresent have been found in men at the root of the penis, 
perineum, and round the anus. Ulcers have also been found 
on the vulva similar in appearance to those described, but 
in which B. crassus was not present. B. crassus has been 
found, apart from ulcus vulvae aoutum, in vulvitis, cervicitis, 
salpingitis, aud non-gonorrhoeal urethritis in women, espe- 
cially in prostitutes. In some oases ulcus vulvae aoutum has 
been associated with aphthous stomatitis, as in one of tho 
authors’ cases, in a woman, aged 24, in which B. crassus was 
found both in the buccal and vulvar lesions. The authors 
emphasize the forensic importance of ulcus vulvae acutum, 
since the patients may wrongly be suspected of venereal 
disease. 


Pathology. 

378. Absorption of Oily Subcutaneous Injections. 

L. Binet and H. BINET (Bev. ae Med., No. 9, 1927, p. 1143) 
relate tho results of their experiments in the subcutaneous 
injection of certain oils and oily combiuatious into various 
animals, both vegetable aud animal oils and oils with different 
substances in solution, in combination, and in suspension, 
being used. Tiiese workers found that the absorption of oil 
occurs very .slowly, and is complete only after several months, 
the absorption being slower with vegetable than with animal 
650 D 


oils. Tho injection of oil causes a very marked histological 
reaction in the hypodermic connective tissue, an eucystment 
of each oil droplet occurring, and tho cyst walls contain 
numerous mononucleatedfcells, which seem to play an active 
part. This reaction is nccompauled by chemical changes in 
the oil, which becomes acidified, a local digestion of tho oil 
occurring with tho liberation of fatty acids. Tho absorption 
of substances in solution varies with the substance, sudan 
and chlorophyll persisting in situ after tho disappearance of 
the oil, while camphor was absorbed in some hours and 
iodoform in a few days. In the case of substances in com- 
bination with oil, such as iodine, there was n slow destruction 
of the oil and a tardy resolution of the substance itself, this 
depending, not on the quantity of oil or drug injected, but on 
the activity of tlie tissues, which varied with the individual. 
As regards, substances such as mercury and bismuth in 
suspension, L. Binet and Fieury have found that the oil 
undergoes saponification, and Picon has suggested that such 
saponification is the basis of the accidents following bismuth 
injections. Experiments in vitro have proved that a mixture 
of a neutral oil and fatty acids in the presence of certain 
bismuth salts, such ns the hydroxide, results in saponifica- 
tion, while other salts, such as the carbonate, cause no such 
reaction. 'The present authors confirm those findings, aud 
assert that only such salts should .be used for oily injections 
as are incapable of combining with the fatty adds formed la 
the course of the absorption of tho oil. .... 

379. The Leucocyte Picture in Surgical Diseases. 

M. SlEBNER (Bcuf. Zeit. f, Chir., February, 1928, p. 318) 
states that examination of tho blood picture may yield 
valuable information, especially in the following groups of 
diseases. (1) Acute osteomyelitis aud acute abdominal 
disease, such as appendicitis, pancreatitis, cholecystitis, aud 
cholangitis, u-hich show loucooytosis, noutropbilip, eosino- 
philia, aud a disjfiacement to the loft. (2) Localized sup- 
puration, such as cerebral, diaphragmatic, or porinophritio 
abscesses, aud especially. circumscribed peritoneal ab.scessos, 
after diseases of the stomoch, gall-bladder, aud appendix, 
infected wounds, fractures, and baematomata. Such oases 
show hyporleucocytosis, absence of eosinophllia, and neutro- 
philia at the expense of tho lymphocytes. Chronic sup- 
puration, ns a rule, shows only moderate or slight leuco- 
cytosis, and a characteristic feature in such oases is tho 
presence of degenerated neutrophils. (3) Simple catarrhal 
infiauimatiou of the appendix, chronic cholecystitis, chronic 
peritonitis or pleurisy, extensive thrombophlebitis, recent ■ 
fractures, and baematomata. In such oases there 5s only a 
slight loucooytosis with a normal or only slightly diminished 
number of lympliooytes. 

380. The Chloride Content of the Cerebro-splnal 

Fluid in Tuberculous meningitis. 

M. LSvy-Bruhl and Yvonne Garreau [G. R. Soc. dc Biologic, 
February 24th, 1928, p. 487) draw attontion to the importance 
of estimating the chloride content of the cerebro-spinal 
fluid in the diagnosis of tuberculous meningitis. Following 
Mestrezat, they consider that the normal content is 0.73 to 
0.74 per cent. ; that in tuberculous meningitis it falls below 
0.63 per cent, and is generally between 0.5 and 0.6 per cent., 
while in other meningeal affections it is generally between 
0.65 and 0.7 l)er cent. In cases of subacute tuberculous 
meningitis, in which the chloride content may be. 0.6 to 0.65 
per cent., the differential diagnosis from other meningeal 
infections is best made by a oytologloal examination ; in 
tuberculous meningitis nearly all the cells are lymphocytes, 
while in other infections most are polymorphouuolears. The 
authors record eleven cases of meningitis or meningismus, 
in which the value of the chloride test in picking out the 
tuberculous from the non-tuberculous cases is exemplified. 


381. Bacterial Flora of Periapical Infections.' . 

E. Ottolenghi [Gioni. di Batteriol. e Immunol., February, 
1928, p. 114) has examined the pulp of 100 dead teeth. Pre- 
vious workers have obtained positive cultures from 50 per 
cent, or more of such. teeth, the predominant organism being 
a streptococcus, not Infrequently accompanied by a staphylo- 
coccus. The author’s procedure was to remove the tooth as 
aseptically Us possible, to cut off the ape.x, aud to drop it into 
broth. Subsequently cultures were made on different media, 
and were incubated aerobically and auaerobically. Positive 
cultures were obtained in 43 per cent, of cases. The organisms 
recovered -were non-haemolj'tic streptococci in 15 per cent., 
Strcplococcus viridans in 8 per cent., haemolytic streptococci 
in 2 per cent., staphylococci in 6 per cent., the enterocbccns 
in 2 per cent., unclassified spore-bearing bacilli in 4 per cent., 
and pneumococcus Types I, II, III, and IV, B. acidophilus, 
and B. coli each in 1 per cent. Bacilli of the obligatory 
anaerobic typo were never encountered. 



•Ai’ini. 21, 1928] 


[ The n»rnsH 
Usmcu. 



EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

382. Hyporpicsis. 

E. B. Gunron {Xcir P:calan(l Med. Jonrti., Fobniary. 1928, p. 1) 
emphasixos Uio Tact that hyporplosis is now widely rccoa-' 
uized as a separate clinical entity which may or may not bo 
associated with eardio-vnscniar or rouni disease. lie finds 
that, on nnaly.'-is of 500 consociitivo medical cases, 113 have 
systolic blood pressure readings of 170 mm. ot mercury or 
over, in the abseuco ot renal or valvular heart disease, and 
ho considers these cases from the standpoint ot systolic blood 
pressure rcadinys in relation to symptoms and clinical 
findings. More or less equal numbers ot both sexes are 
inclndcd in the total ot 113, the agc.s averaging 52. Etic-. 
logical factors are: hereditary tendency, worry, septic foci, 
excessive and faulty di( t, and inlostlnal toxaemia. Altbougli 
hyporpicsis occurs without symptoms, the most diverse 
, manifestations may appear from impairment of tho various' 
bodily Innetious. Ten eases are dc'eribcd to demonstrate 
the common symiitoms and tho pressure ciinngcs resulting 
from treatment. General wcaicncss, brcalhlesMicss, palpita- 
tion, and' tightness in the client on exertion, tinnitus, 
he.adacbe, giddiness after effort, llatnlcncc, and epigastric 
discomfort are among the .syinptums most frequently noted. 
The .author regards I'cst as the first essential In treatment ; 
worry and au.xicty must he eliminated as far as possible. 
•Any benefit i-esnltiug from dieting is moio often due to 
general moderation titan to restrict ion ot meat or salt- 
containing foods. Digestive dislnrbauocs may bo largely ■ 
avoided by rodnoliou ot the carbohydrates and the avoidance t 
of llnid at meal times. It is romarlced that a too prolonged : 
reduotion in diet somotiincs results in anaemia. Bromides, 
nitrites, and digit.alis are rccommeudcd, tho latter especially 
where elevation ot blood pressnro and return ot symptoms 
have followed initial improvement. In most patients the 
greatest subjective improvoiuout follows inodorato blood 
pressure rednetion, the level still remaining rather above 
normal. • 

383. Typhoid Meningitis. , , 

■p. S. Dukakis (Jotmi. Amer, Med, Assoc., December 31st, 
1927, p. 2257) concludes that meningitis is a rare complication 
of typhoid, since only 33 oases have been reported. Among 
2,768 cases ot typhoid fever at tlic Johns Ilopkias Hospital 
there were only 5 cases ot meningitis. A study ot tlie litcra- 
tnro shows that only 30 cases of meningitis dne to various 
canses have been reported in infants under 3 months old, tho 
great majority being due in order of frequency to If. coli, 
streptococci, meningococci, pnouiuooocci, and the tubercle 
bacillus. There was only one case of paratyphoid meningitis 
in children under 1 year, the patient being aged 7 months. 
DnliaUis reports the ca'-e of a male Infant, aged 2 months, 
breast ted, whose symptoms were regurgitation ot its feeds, 
fever, bulging fontauelle, and slight nucbal rigidity; 5 c.cm. 
ot opalescent fluid was obtained by Innibar puncture, and 
25 c.cm. by cisterua puncture. Autimeniugococcus serum 
Was given intrathecally and intracisternally. Death, pre- 
ceded by optic neuritis, convulsions, and head retraction, 
occurred on tho seveiiteontU day of disease. Tliero W'as 110 
necropsy. S. typhosus was recovered from Iho corobro-spiual 
finiO. The Widal test was positive in the mother and typhoid 
bacilli were found in the stools. 


38?, The Increased Incl-^ence of Aortic and Cerebro- 
spinal Syphilis. 

A. WoLDRicii llVicti. Arch. f. iuiure Med., February 3rd, 1928, 
p. I'll) states that there has been a recent increase in cerebro- 
spinal sj-jihilis and syphilitic aortitis, though most ot tho 
smaller European States show a general decline in primary 
syphilis since 1924.- Occasional decreases in the numbers of 
cases have been observed in recent times. After the Franco- 
Prnsslau Avar-it-was noted tl\nt the. number of Infected persons 
declined this . was .attributed to a large increase in the 
marriage .rate and more stringent .control of prostitntion. 
In contrast with tho decrease in [U'imary sj'philis, parasj'philis 
- has shown a continuous increase. It is . generally admitted 
tJiat among the less civilized races tabes dorsalis and general 
pavalysis_ seldom. ooonr, while tertiary sypbilides and gnm- 
mata of the bones are more frequent; in the more civilized 
communities parasypluHs is always more prevalent. This 
anieronco has been variously attributed to strains of apiro- 
cUMles having special .affinity for tho nervous .system, to 
degeneration of the civilized-races, to a IiigUer power of resist- 


ance ot native races, and to tlio evil inflnences of civilization 
and w’ar injuries. Woldrich traces a parallelism between the 
incidence of corebro-spinal sypliilis and aortic syphilis; and 
stales that after the year 1918-19 there was a great rise in 
tho ineidoiico of both until 1924. Since that date there has 
. been a cousidorablo fall in the curve of cerebro spinal sypliilis 
incidence, while that of aortic disease has remained almost 
stationary. Tables show also that cases of cerebio-spinal 
syphlli.s were threo times as nnmerous in 1924 as in 1904, 
while tho'-.o ot syphilitic aortitis were fifteen times as 
numerous in 1924 ns in 1904. Woldrich finds tliat in 
Cz.eclioslovnkia tho increase of aortic and cerebro-spinal 
parasyphilis during receut years is undeniable. It com- 
menced in the years 1918-19, but, assuming that the 
average incubation period of parasyphilis is fliteeu -years, 
the present remnrltable increase is due to infection occur- 
ring in tile quinquennium 1910-15, and is contempe- 
raueous with the comiiienoement of salvarsau trcatiiient. 
Tlic nullior adds that tho prevention of parasyphilis can be 
secured only by systematic efllcient treatment of all cases ot 
syphilis in the early stages of the disease. 

385. Erythema Nodosum, 

F. Do PnESTl-SEAllNEnio {.stndiui/i, January 20th, 1928, p. 12) 
reports threo cases of crytlicma nodosum in young chiklrcu, 
and discusses its etiology. In the first two patieuts, a brother 
and sister, the Pirqnot reaction was .strongly positive, .and in 
one tlicro was some evidence of Iiilns disease. Tho third 
patient gave no evidence of any other disease. The author 
.believes that erythema nodosum is a Kpeoific-infectiou, pro-- 
.bably duo to some- filterable vims,- and’ often having, some 
orclatiou to tuberculosis. In each of his cases tbedonsHs were 
hypertrophied, bnt no mention is made of any rlicumatio 
Infection. 


Surgery. 


386. The Incidence ot Cancer, 

.Eeviewisg the prc.scnt. position, of certain cancer, problems, 
M. Greenwood (Caucer lleviciu, March, 1928, p. 97) slates 
that the incomplete method of rccortliug statislios followed 
in many countries renders dilBonlt the obtaining of reliable 
information on this subject, hut certain facts have emerged 
from this study'. There has ceriainiy been no decrease, and 
probably an increase, in tho real mortality rate, but there is 
an indication that this increase is slowing down. Improved 
diagnosis is partly responsible for this apparent increase. 
The mortality rate is no longer considered to bo higher in 
women than in men. The greater liability' to a fatal termina- 
tion of uterine cancer depends on injury to the cervix during 
the first labour, and the rislis do not increase with the number 
of children born. Mammary carcinoma appears to be more 
frequent among unmarried women, and women who develop 
cancer seem to be less fertile ; tlierefore. the non-specific 
factor involved may be the absence of a normal stimnhis. 
Tlie most prosperous class socially has the lowest mortality 
rate, and this differentiation has been found to be confined to 
certain sites, including the alimentary tract, skin, and larynx ; 
this suggests that tho poorer members ot the population are 
exposed to some irritant or irritants the action of which does 
not reach tho internal organs and cannot pa^s down the 
digestive tract below the stomach. The belief that a meat 
diet predisposes to cancer has not been confirmed. The 
results ot treatment, especially as regards tho breast and 
ntcrus, show that early radical operation is a much more 
hopeful procedure than is generally realized, and may give 
an average prolongation ot life of more than ten years. There 
is also satisfactory evidence that radiology can compete 
satisfactorily with the knife in the tvcatmeut.ot cancer, and 
Grccuwoocl believestUat sufficient advantage of this metlioil 
is not yct'takcn in this country. Adequate inloVihalibn is hot' 
y'et available as to the influence of race, civilization, localUy, 
and occupation on the incidence of cancer. 

387. Cervical Elbs. 

G. Pacetto i-frcfi. Ital. di Chir., Jamiary, 1828, p. 375) 
reports five cases of the above condition and discusses the 
subject generally. Ho states that the supe'rhnmerai-y rib 
may be associated ivitii hypertrophy' .of .the transverse pro-- 
cess, or this hypertrophy may be tile sole anomaly, as was 

the case in 5fi out ot 70 cases of, cervical anomalies collected 

by Crouzon. Cervical ribs are nsually bilateral; but, owing ' 



66 Apeii, 21, 1928] - EPITOME OF CUEEENT 


to tlio fact that the conclitiou is senerally much more marlcecl 
oil one side, so far as signs and symptoms are concerned they 
appear to be unilateral; they occur more often in, young 
■women than in men. ' They may give rise to local physical 
signs and to distnrbances of the circulation or of the nerves, 
due to pressure; motor disturbances are more rare than 
changes in sensation. Probably aSebtions of the sympathetic 
system due' to' pressure are more common' than is usually 
believed. When symptoms arise the 5 '.do not necessarily 
persist, but may cease when the immediately exciting cause 
di'appears ; Pacetto remarks that, bearing this in mind, 
surgical intervention should not be hurried. He adds that it 
is said that cervical ribs or hypertrophy of the transverse 
])rocess may be seen in 10 per cent, of the population, but the 
number of persons in whom this condition produces symptoms 
is very much less, and still smaller is the number of those 
who require surgical treatment for it. The possibility of 
anomalies in the first rib 'or transverse iirocess of the first 
dorsal vertebra should also be borne in mind. The author 
appends an extensive bibliography of recent literature on the 
subject. 

388. Ane'rrysm of the Splenic Artery. 

Goullioud (Bull, el ]\Icm. Soc. Nat. de GUir., March 17th, 
1928, p. 402) records an uiiusnal case of aneurysm of the 
splenic artery treated by removal of the sac. In this case 
the condition wai diagnosed as a cyst of the pancreas, and 
its real nature was only discovered at operation. Tho 
aneurysm was successfully removed after ligature of the 
splenic artery, and tho patient made a satisfactory recovery. 
A leurysms of this vessel are said to occur about equally in 
inoii and in women. Syphilis ds not regarded as of any 
importance in the etiology, and in no ease docs tlie diagnosis 
appear to have been made before operation. Trauma as a 
cause has been noted in a number of cases, either duo to a 
guusixot wound or abdominal injury. . Tho treatment of those 
cases is entirely surgical, and cure is not possible by any 
other means. Simple removal of tho sac should be per- 
formed, bub if this is impossible tlie aneurysm, together with 
the spleen, should be excised.- This latter procedure will be 
necessary whore tho aneurysm is situated in a- terminal 
braucli of the splenic artery. Ligature of tlie artery alone 
should be performed it no other procedure appears iiossiblo. 

383. Carcinoma of Prostate and Bladder. 

31. S. Bareinger (New England Journ. Med., March 8tb, 1928, 
)). 117) considers that cases of extensive prostatio carcinoma 
sliould not be subjected to major operations if it is possible 
to cope with the disease by radium, x rays, or a modified 
inmob operation uudor local or spinal anaesthesia. It is 
shown by classifying tho duration of life of 202 consecutive 
c.ases that iu ouly 15 jier cent, was there any Icugtii of life 
after tlie first examination, and ouly a few were benefited 
by any treatment. The operation should bo followed by 
jicrsistent radiation of the prostatio bed and of the lymphatics 
arouud tlie seminal vesicles; for tlioso advanced cases with 
urinary retention some minor procedure should be adopted, 
since at least half of tho ijatients will not survive for a year. 
In considering carcinoma of the bladder, of 20 cases of 
))apillary carcinoma 75 per cent., and of 51 eases of iaflltr.ating 
carcinoma 35 per cent., were caucor-freo as long as observed. 
Tlieso included all cases in which tlie growth was small 
enough to be controlled intravesically and all those with 
radium implanted snprapabically. In 94 suprapubic implanta- 
tions of radium the mortality was slightly over 3 per cent.', 
compared with a mortality of between 10 and 20 percent; 
for the operative removal of carcinoma of the bladder ; this 
in licated that even it radium iuiplautaliou was not more 
cffjctlv'e than operative removal a number of lives c'onld be 
saved by its use. In Barringer’s ' experience a .large and 
increasing number of such cases are being controlled by' the 
cystoscopic applications of radium, but the suprapabic opera- 
tion is advised for practitioners who are not experienced in 
file use of radium, or when for any reason there is doubt as 
10 Iho control of a tumour. 

3:0. Gangrene of ths Genitals. 

J. Bejarano and M. IIoiibiua (Arch, dc mccl., cir. y cap., 
February 25th, 1928, p. 279) record a case iu a man, aged 43, 
who, shortly after tho crisis of lobar pneumonia, developed 
gangrene of the scrotum. Rapid recoverj- followed injection 
of 20 c.om. of a polyvalent autigaugreuo soriim consisting of 
a iiii.xturo of nuli-vibrio, anti-jwr/ringens, nwli-ocdemalitna, 
and nuti-ltistolylicns serums. B. pro'lcna and B.. sporogehes 
were grown from tho lesions, and tlie patient’s serum 
aggliiiiuated IS. prolcns iu 1 in 150 and Jl. spo?-ogenes in 
1 in 100 dilutions. Inoculation of guinea-pigs witli //. piclnis 
and B. sporogenca produced do-tnicti ve lesions of a gangrenous, 
typo, which did not follow inoculation of either of those' 
organisms separately, 
vco B 


MEDICAL LITERATURE. 


Therapeutics. 


391 . Tannic Acid Treatment for Burns. 

S. B.arlin'G (Birmingham Med. Jlcv., March, 1928, p. 58) 
observes lliat in many cases of burns patients who survive 
tho initial shook succumb later in consequence of absorption 
of toxins produced by tiis breaking down of tlie stable pro- 
teins of the damaged tissues. Tiiis absorption commences 
within a few hours after tho burn, roaches its maximum 
after the second or tliird day, and dcatli nsuallj’ occurs at 
the end of tho first week. Furthermore, burns, as generally 
treated, almost always become septic, such sojisis .being 
inevitablo while dead or damaged tissue is present to provide 
a soil for tho growth of bactoria. 'The chief clinical sym- 
ptoms of sovoro burns aro elevation of temperature and pulse 
I’ate, rcstlessiioss, cyanosis, coma or convulsions, rapid 
respirations, and cold extremities. Treatment should be 
both local and general. Locally, to.xic absorption and septic 
infection must bo prevented, or at least limited, so far as 
possible. Since excision of tlie wliole of tho injured tissues 
is, as a rule, iiiipracticablo, tliese aims aro best attained by 
applying coagulants, wliicli fix tho tissues and render the 
broken-down elements insoluble. Absolulo alcohol and solu- 
tions of picric and tannic acids Iiavo been tried, the least 
objectionable being taiiiiio acid. It is non-toxic. and rapidly 
transforms llio damaged tissues into a brown, leathery 
coagulum, wliicli is insensitive, iirotects the underlying 
tissues, resists absorption, and is an unsuitable nidus for 
bactoria. Riioclc, it severe, sliould bo first treated, local 
treatment being postpouod for a.fow Iiours. • Light ctlier 
anacsthosia may advantageously bo used duriug tlie first 
dressing. ’The sltln sliould be oloaused witli soa)i and water, 
then with a 10 per cent, solution of sodium bioarbonato, 
■followed by swabbing witli oilier, the opening of blisters, anil 
the removal of loose cuticle. 'Tlie liurnt area is tlicn sprayed 
with a 22 per cent, aqueous solutiou of .tannic acid, dried by 
a stream of warm air, and protoclcd from iiressure. The 
spraying is repeated iiourly for tlio flr.st eiglit or twelve 
hours, wlion the coagulum will , bo formed. Any frosli 
blisters sliould bo opened and sprayed, ns sliould also any 
moist areas. To avoid injury to tiie oyos, nose, and mouth 
in face burns, a 5 per cent, taoiiio acid ointment may be used 
instead of tho spray. As tho solution deteriorato.s with 
keeping, it should be tre.slily made every twenty-tour hours. 
Gonornl treatment must provide for .tlio noutralizatiou or 
removal of toxins and tlio re placement of losi sal ts and fluids. 
Liquids sliould lie given ftcely by tlio moutli and normal 
saline solution by proctocTj'sis or subcntaiioously. Alkalis 
should bo admiuisterod to increase the alkaline reserve, and 
in very severe cases exsaugniuatiou transfusion may be 
desirable, the blood of tlio douor being introduced into one 
vein while the patient’s blood is withdrawn from another. 

392. Scarlet Fever treated by the Dick Antitoxin. 

L. BiDOWfSfurliiiiit, January 20tli, 1928, p. 6) gave to 51 patients 
witii scarlet fever intramuscular injeotious of Dick antitoxin ; 
as controls be treated 54 cases ou ordinary lines. ' Iu selecting 
the cases for injections preforenoo was given to tlio more 
severe cases, which made the good results of the injections 
ail the more striking. Tho usual dose of the serum was 
25 c.cm. eacli day for the first tbreo daj’s. Improveiueut 
in all tlio main symptoms soon followed, and no serious 
anaphylactic complications were noted. The duration of the 
rasli was not appreciably affected, but patients treated by 
ioiections ■wore able to leave the hospital five or six daj’S 
before the controls, altliougli'the latter were the milder cases. 
As regards complications,' rhinitis was present m 14 iier cent, 
of the controls, as against 4.5 per cent, in tho serum cases, 
and otitis in 9 per cent., against 20 .per cent. ; the inculence 
of mastoid trouble was aliout the .same in both series, but 
there were no suppurative glands in the serum cases, as 
contrasted with 10 per cent, in the controls. ’I’lie neimiitis 
cases were about equal, but albumiuuria occurred in 27 per ■ 
cent, of the sermu'easos, as compared with 15 per ooiit. in 
the controls. 'There wore three deaths among the control 
cases and uouo iu tho serum group. 

S93. Gold Salts In Cutaneous Tuberculous AfTeotions. 
JE.ANSEGJIE and R. Burnier (Journ. de Med. ct dc Chir. 
Febraary lOtli, 1928, p. 77) give an account of the treatment 
of cutaneous tiiheroulosis by gold salts, using a FieiicU 
preparation, crisalbiiio, closely resembling sauociysin. Ou 
tho whole -the iiiiprovcment was very marked, and tlie best 
results were obtained with cases of ciytlicmatoiis lupus. 
Grisalbiiie is described as a white crystalline sa’t readily 
soluble in water. It is supplied in ampoules allowing a 
dosage of 0.05 to 1 gram. If, is dissolved in distilled waiet 
immediately before use and iujooted iuliavciiously. luo 



ArKir. 21. 1928) 


EPITOSIK OF CUKRENT MEDIOAIi LITERATURE. 


r Tn* DnmsB 

UCDICAL JOOTI7.‘Ai; 


67 


ilrsl iiijcclloii cousistsof 0.10 fjniiii, followetl foiu- days lator 
by one ol 0.25 I'yaui. Aftei- lUlH t.\vo iiijcclloiis ot 0.25 Kraui 
aro (jlvoii each wcoli np to twenty injections. Govtain 
Vhcuomcna ot iiitolci-anco may bo o.xliibltcd — namely, 
albmnimiiia, nausea and vomiting, rlso of temperatnro, 
coiigl), neuralgic pitins, loss of wciglifc, and stomatitis. 
Cntaneons complications arc said to bo tiio most freqncnt 
and tiio most seclons. Ot 32 c.ascs ot oryllicmatons lupus 
localized on tiio face tlicro were 20 complotocures, 7 Improved, 
and 5 rallurc.s. Ry complolo euro Is meant tiio total dls- 
appcatanco ot inllltration, redness, and Itcrallnization. In 
some cases the skin became quite normal, and it was im- 
possible to say wlioro tiio lupus bad been. In otliers a 
brownish pigmentation or slight scarring remained, but thc.so 
were far less dlsllguring than the original lupus. In obdurato 
c.ascs after twenty Injocllons the patients wore given n 
mouth’s rest before nnolbor scric.s of injections tyas .started. 
In four cases rccurrcnco was noted, but this rapidly yielded 
to a second course ot treatincut. 


Neurology and Psychology. 

33?. ■ Myasthenia Gravis. 

J. M. XlEr 2 ;E>t and P. Roth (Jonrn. Xciv. am! Moil. Dis., 
January, 1928, p. 32) euumorato tbo Iiypotboses of various 
writers ns to tbo pathology ot this relatively rare disease. 
Jolly has demonstrated bis niyastbcnio reaction (rapid 
fatigue ot faradio Irritability wltli uuimpaircd galvanic 
irritability), whicli proves tlie prcsonco ot organic changes. 
Among Ollier observers, Weigert has described cell Inflltra- 
tions ot tiio imisolcs, wliicli bo regarded ns mctastascs from 
tbyniiolymplio.sarcomn, Starr lia.s noted patliological clianges 
•in tbo tliymus In 28 per cent, ot 250 necropsies, and JclIllTo 
hcliovcs that the, cause lies in the vogotallvo nervous system. 
The present authors report three cases ot myasthenia gravis, 
which, sliowlug many dilTorcDoos, present a few salient 
points for comparison. Quo paliont was a woman, aged 34, 
who presented a poorly developed muscnlaturo in general, 
-witli ovidcnco ot luvolvomcnt of tiio bowels, a history ot 
sexual excesses, and sevoro psychic trauma. Tiio second 
patient, a married woman, aged 25, bad given birth to a 
healthy child five moutlis previously ; slio liad a very low 
basal metabolic rate witli ovidonco of myxoodema aud ot 
ondocrlno dysfunction witli involvcniciit ot tbo bowel. Tiio 
third patient, a man auod 36, liad a poor muscnlaturo, and 
tlioro wore signs ot sypliilis ot llio central nervous system. 
Tiio throe patients bad tbo typical onset and development 
ot myastlionia gravis, and nil sliowod Jolly’s reaction. ’X’bo 
authors maintain that the sexual excesses, my.xoodema, 
sypliilis, and psychic trauma are coincidences and not 
causatlvo factors. Tlioy assort tliat myasthenia gravis 
seems to occur in persons with small or flabby muscles in 
general, and that tbo iutestiual walls aro impaired as is tiio 
voluntary mnscnlatviro. Jolly’s roaclion is not necessarily 
present in all tbo muscles at any time. It was absent during 
remissions in two ot tbo cases (the third was not tested), 
.nnil was present only in tbo weakest muscles in one case. 
Stryclmino seems to have littlo or no influence on the course 
ot the (liseaso. The basal metabolic rate is normal, and tbo 
exhaustion is iirobably ot neuro-muscular origin. 


395. Polyneuritis duo to TJumps. 

IV. S. COLT.ENS and M. A. Rabikowitz {Arch. Intern. .I/cd., 
January 15th, 1928, p. 61) report a ease of polyiicuvitic quadri- 
plegia with bilateral facial paralysis and meningitis com- 
plicating epidemic parotitis. A review ot tbo literature 
showed that tiio cliaractcristics ot parotitic quadrlplogia 
Were flaccid paralysis of tiio extroraities witli loss ot deep 
and snperficial reflexes, slight son'^ory disorder.^, and deep 
disturbances such .as those ot tbo joint and vibratory 
senses. Complete recovery was the rule. Tbo absence ol 
abaominal reflexes, tiio presence ot meningeal signs, and 
the tew sensory manifestations with predominatingly motor 
puenomeua point to there being somo involvement of the 
cord in addition to tbo polyneuritis. The authors’ patient 
Was a man, aged 29, who, after a mild attack ot epidemic 
parotitis, developed, one week from- tbo onset, a left orcUitfs 
wutcli resulted in atrophy. A fortnight later lie complained 
ot weakness in his legs, and was unablo to stand ; within two 
mni^ T? to sit up or roll over in bed, and had 

owing to complete bilateral upper aud 
paralysis, all the other cranial nervel being 

lioad in slight 
uuablo to move his head or extremities. 
■ hiiatm-Mir’’ paretic qnadriplegia and a marked 

'• Si* ®«PorfloiaI, deep, and plantar 
elloxes were absent. Twenty-four hours later paraestiiesia 


of the tcot developed, with tingliug and burning sensations 
and liyperaestlicsla ot the arms, legs, bauds, and teet, arid 
loss ot joint and vibratory sense. A week later tho sym- 
ptoms began to improve, tlie progress being more rapid after 
treatment with stryclmino sulphate, 1/30 grain, tlirco times 
a day; tho motor signs improved more rapidly than lha 
sensory. Four weeks after tiio onset ot tlio paralysis he was 
able to stand witli assist.aucc and maintain quadriceps exten- 
sion for thirty seconds, and bis right facial power was return- 
ing to normal, tliougli tbo deep reflexes and joint sense were 
still absent. Eleven weeks later all sensory, motor, and 
reflex pliouomcna were normal and bo was discharged cured. 
All tiio reported eases sliowed quadriplegic manifestations, 
but varied in tiio nature ot cerebral nerve involvement. Tliis 
type ot polyneuritis is said to bo nsually ot intcclious origin, 
reseiubliug that complicating other Infectious diseases. 

393 . Homiplogla Associated with Extensive Naevus 
and Mental Defect, 

n. .T. Hugo (•tonrn. illnl. Assoc. South fl/ricn, October 22ud, 
1927, p. 534) refers to Brnsiifteld aud Wyatt's case ot hemi- 
plegia associated willi naevus aud mental defect {liyiiomc, 
August 27tli, 1927, para. 178), and reports 'an additional caso 
of tho same condition in a fomalo idiot, aged 7, who was 
destrnctivo, and nnablo to walk, speal:, teed, or tend licrselt 
in any way. Slie was well noorisiied plis'sically, but very 
undersized; she liad epileptic seizures, tlie paroxysms being 
very sovero. There was an extensive cavernous naevu.s 
haoninngioma over tho right side of the neck from about tiio 
upper border ot tho mandible to tho upper margin ot tbo 
clavicle, which involved tbo upper ami lower lips. Tiio 
tumour increased in size during two years, and almost com- 
pletely occluded tiio nostrils, but tiiero was no haemorrliago 
from it. Thu left arm and both legs were paralysed, witli 
a slight degree of atrophy of the mu.scles. The ciiild died 
from status cpilopticus, and at the necropsy vascular tumours, 
ranging in size Irom a pin’s head to a pea, were found in all 
tho brain ventricles, aud siinUar growtlis were found in the 
kidneys and tho liver; tbo brain showed scattered patches ot 
sclerosis. It was concluded tliab tbo vascular tumours in 
Iho brain and internal organs were eiidotlielioinata, probably 
secondary to tlio skin tumour. (Reterouco 'U'as made lo 
another case ot tliis condition, recorded by Brushlleld aud 
Wyatt, in tbo itpitomc ol J'annary 28tb, 1928, para. 99). 


Obstetrics and Gynaecology. 

397. Uterine Prcfnancy following Bilateral Salpingectomy 
for Tubal Pregnancy. 

W. ZAKGE-MGrsTER {iicntralbt. f. Gyuiih., February 18tli, 1928, 
p. 411) describes the caso of a woman, aged 24, who in 1927 
complained ot weakness, sickuo.ss, and pains fn the back, 
and expressed fear ot pieniaturc cessation of tho mouses. 
In 1925 the gravid left tube Iiad been removed, but not tho 
loft ovavy; in 1926 the rlglit adnexa bad been e.xcised for 
rigiit tubal gestation, and ventral fixation done. Bubse- 
qiieutl,y tiio periods iiad becoino less, and the last two liad 
been missed altogctlier. Examination showed a two nionllis’ 
iitcriiio pregnancy; three days later abortion occurred and 
placoiUai rcmuaiits were demonstrated iiiicroscopically in 
tbo fragments removed by cuiolting. About 200 cases have 
been published of riglit tubal pregnancies after operation foe 
left, or vice versa ; tnbal gestation on tlio other side, it i.s 
said, may be expected to occur in about 5 per cent, ot those 
operated on for tubal pregnancy— that is, in about one-sixth 
of tboso who become pregnant after such an operation. 
About 21 cases liave been described in which tnbal pregnancy, 
has been repeated on tho same side, occurring in fragments 
ot tuho left laterally or mesially, or in the iutevstitial part; 
to prevent sucli occurrences a wedge-shaped severance of 
tube and uterus has been recommended, but that this pro- 
cedure is not necessarily eSeotivo is shown by Knstner’s 
two observations ot uterine pregnancy following -wedge 
excision of both tubes for the purpose of sterilization. 

338. Primary Abdominal Pregnancy. 

B. R. Forgason {Journ. Ainer. tiled. Assoc., February llih 
1928, p. 436) reports a caso of what he considers to have been 
definitely a primary abdominal pregnancy in which the foetus 
■was carried for ten months after the date of confinement. 
Caesarean section was performed, and the foetus was found 
In a large sac, completely filling the abdominal cavity, and 
adherent to the abdominal wall in front, to the transverse 
colon above a-nd behind to the posterior abdominal wall and 
to tho small intestine below. So completely was the trans- 
verse colon adherent that it could not have been separated 
Irom tho sac ■without destroying tho intestinal blood supply. 

700 a 



68 AphiIi 21, 1928 ] EPITOME OF GEPEENT MEDIOAIj LITEEATUEB. 


t -Irn: D»rai« 
Uepjcax. Jocnuft 


Tlie placenta had undergone oalcifloation and -was still 
adherent to the wall of the sac, the thickness of which was 
■ almost that of a normal .uterus-; there wore no adhesions to. 
the uterus. Only a small portion of the sac could be removed, ■ 
but the patient made, a good recover}' and was able to leave . 
the hospital throe weeks after the • operation. . .Enrgasoni 
.comments on the confusion caused in this -case by the re-: 
establishment of normal menstruation :at Idll .term,- andi 
-coucludes that it is advisable to open.the abdomen whenever 
thero is such a history. The final diagnosis depended onj 
vaginal examinations, confirmed by the use of x rays, and it. 
is suggested that both these, procedures should be utilized, 
moie frequently .when. there is any doubt.about the. condition | 
of the pregnancy. t 


393 ., Seuuels- of. Hadlation- of the 'Ovaries. . 


H. Martius (/.cntralbl. f. Gytifilc., October 8th, 1927, p. 2801) ! 
discusses the liossibility of the ovum being- damaged - in • 
radiation of tbe ovaries. Weak radiation, in which the dosoj 
is iu-,ufricient to prevent ovulation, has been used in pelvic \ 
inflammations and with varying result's, the best occurring 
in gonococcal infection of the adnexa, in puerperal para- 
metritis, and in tuberculosis of the female genital tract. 
Martius uses it only when future pregnancy is already 
unlikely, as in two-sided infectious and tuborcuiosis, since it' 
is impossible to regulate the dose so as to he sure of avoiding . 
interference with ovulation. "Weak radiation of the ovary is 
used in disorders of menstruation and sterility ; its action is 
on tlic follicles, and if the dose is to be effective it risks ' 
damaging them. The clinical results are uncertain, and ' 
similar benefit follows radiation of the endocrine glands and 
diathermy. Martius thinks that It is only justiflablo in 
polymeuorrhoea and amenorrhoea of ovarian origin after 
medical treatment has been exhausted and surgical inter- 
voution is not possible. Stronger radiation doses prevent 
ripening of tbe follicles either permanently or temporarily • 
pregnancy may occur before the onset of the radiation ' 
ainonorrhoea, and it so the oliild is usually damaged. It Is 
advi.sed that patients should avoid pregnancy for four months 
after radiation, and tbe author does not advise these larger 
doses while there is any prospect of pregnancy. When 
r.idiation is applied in order to promote temporary steriliza- 
tion the usefulness in youug'womeu depends on the possibility 
0' future pregnaucy being preserved ; there is always a risk 
of the induced sterility being permanent, or, if conception 
occurs subsequently, of tlie offspring being damaged. It 
should therefore only bo used whore there is no likelihood 
of future pregnancy, or where the radiation is confined to 'one 
side only, jilavtlus deprecates the prevailing idea that radia- 
tion of the ovaries has no bad, effects on the offspring, but 
he thinks that in some cases it-maybe worth while to dis- 
regard the progeny for the sake of the immediate benefit to 
the mother. 


Pathology. 


400. 


Leptospira icteroldes ard Leptospira ictero- 
haemorrhaglae. 

E. Martini (CentralU. f. liaJct., 'Eebru’ary 15th. 1928, u. 4021 
has made some comparative observations on the spirochaetes 
of yc low fever and of Weil’s disease. Erom experimentalfy 
mtected guinea-pigs cultures of the heartts blood, liver and 

Engermann's medium, which 
consists of ralibit s serum inactivated by heating to GO’C for 
half an hour, and covered witii a layer of parafUn. The 
pthor found It very important iu tlie cultivation of LeptospiZ 
mfrroides to make cultures from tho animal at the height of 
y the temperature reaches its maxfmum 
at 40 to 41 C. between the fourth ami seventh days’ some- 
times It IS maintained at a high level for only a few liom-s 
so that It IS necessary to observe the animal carefullv A 
high temperature does not necessarily betoken a particul'arlv 
severe attack of tho disease; some of his autaals have 
rocovereii, even after exhibiting a temperature of 41° C and 
Qvor, and after suffering from typical jaundice. On the other 
hand, the animals may die, with all the usual symptoms of 
jaundice, skin haemorrhages, epistaxls, necroses in the liver 
and calcium cylinders in tho kidneys without ever showing 
a rise of tomperatnre to 40’ C. Guinea-pigs were inoculated 
every weelc with cultures of L. icicroidcs; the virus was 
recovered from the heart’s blood and introduced afre.sh into 
other gninea-pigs. The effect of this passage w.ts to reduce 
tho viiTiIonco of the strain. After about throe mo iths animals 
ceased to die after inoculation; infection till ooenrred and 
cnltures were obtainable from the blood, but death did not 
result. During the succeeding months the virulence became 
even less, so that icterus was no longer produced^ a hi«h 
temperature, however, continued to follow inoculation, and 
the organisms Icould still be recovered at tho height of the 
fev'er.' The resistance broUe strain of -I,.' I'cfefoidcs'and brie’ 


700 D 


strain of L. ictcrohacmorrliagicic was tested in various media. 
In Engermaiiu’s medium tho former lived up to three yca.va, 
.the latter up to two years and, ouo month; in a medium 
.consisting of one part of rabbit’s serum (inactivated; and 
three parts of saline the former Jived up to three aud a half 
. ycar.s, the latter up to six mouths. It would appear, therefore, 
.that tho life ol.L. icteroides in culture isivery much greater 
.than that of L. ictcrohacmorrhagiac. The author suggests 
.this very. high resistance of J-. icteroidcs may explain Ihe 
-rccriidesccnco of disease in. human beings after, a long inter- 
lepidemic.period 

.. 401 . E. UnuyNOGHK and J. Cor.xil [C. Tt. Soc. dc Biologic 
March 2nd, 1928, p, 598) have endeavoured to tind out whether 
Leptospira icicroidcs -iVitCors from L. icieroltacmorrhagiae, 

• A comparison was made between two strains of i; icfei'ofdcs, 
ono strain of L. iclcroliacmorrliagiac, and ono strain of a 
saprophytic spirocliaete isolated from water. Thc.so organisms 
wero cultivated in a inedlura-consistiug of ono part of rabbit’s 
serum, ono part of broth, and four parts of saline solution,- 
covered with a layer of vaseline ; tlioy all grew well at 28’ C., 
and morphologically appeared identical. Throe immune 
serums were prepared by injecting rabbits with L. iclcro- 
haeinorrltagiac, saprophytic siiiiochaotcs, and ono strain of 
h. icteroidcs. Two scries of tests wore made with these 
soruins. In tho first series mixtures of serum aud autigen'ln 
varying dilutions wore incubated at. room teniperatuie aud 
examined under the ultraraicro.scope after three or four hours 
and again after fifteen lioiirs. ’The nnU-icteioIiacmoniiagiae 
serum was strongly lytic and weakly agglutinating ; it acted 
equally well on its homologous strain and on the two strains 
of L. icicroidcs. Moreover, its action was not inhibited by 
heating to 5S°C., which suggests that complement was not 
essential to tlio lysis. 'Tlio anti-icferoirfes serum was more 
strongly agglutinating than lytic ; It acted equally woll 011 its 
two homologous straius aud on tho strain of L. iclcroitaanor- 
rliagiac. Neither of these two serums had any effect on the 
saprophytic spirocliaete. On tho other hand, the serum 
prepared against tho sapropliytic strain agglutinated aud 
lysed Its own cultures, . but had no effect on the cnltures of 
L. icicroidcs or L. ictcrofiaemorrhagidc.- In the second scries 
culture media wore made up with the different serums. 
Media containiug; anti-ictcrofrtcs or D.Titi-icierohaemorrliagiae 
semm inliibited the growth of both L. icteroidcs and L. iclcro- 
haemorrhagiae, but permitted a normal development of the 
saprophytic sptrochaeto ; whereas media containing sernm 
prepared against tho saprophytic strain had no inhibitory 
effect on L. icteroidcs or L. icterohaeinon-hagiae, though 
inhibiting, tho growth of tho saprophytic strain. From these 
experiments tho authors couclndo :that ,i. icteroidcs and 
L. iclcroUgcmonitagiac aro biologically identical, and that, 
considering the clinical differences between yellow fever 
and WoiTs disease, the oansativc agent of yellow fever is still 
unknown. 

402. Malarial Therapy as an Indirect Immunizing 
Process. 

W. H. Goeckerman (.Iiucr. ■Jom-u.'iiferf. .Sci.,Fobrnary, 1928, 
p. 261) remarks that although thovaluo of malarial inocula^ 
tions in general paralysis has been fully established, no 
explanation of their action has boon afforded by the various 
hypotheses propounded ; he reports a case suggestiug nil • 
unusual factor, A woman, aged 35, presented all the mental 
symptoms of goueial paresis, and such physical o.xanii nation 
as was po.ssi ile,. -together with the -IVassermann aud other 
tests, confirmed this" diagnosis. A malarial inoculation was" 
given, rind after p.assing through the usual coarse tbep-siient 
was discharged. Si.x wools later she showed definite iiieutal 
improveineut, aud 110 cutaneous lesions wero noted. Quinine, 
but no antisyphilitic treatmeut, was continued at home. 
Five months after inoculation- the mental and iiliysical 
progress was remarkable, hut, despite, this, typical uodulo- 
ulcerative syphilides liad appeared on. the lelt thigh and 
right buttock, these having been noticed by. the patient about 
two weeks previously. ;Bloch believes that- tho. appearance 
of a late sypliilidels evidenoe.of an allergic.state, or at least 
of partial immunity',, aud the work .of iBrown and Pearce 
indicates that the tissue defence reaction is caused.-hy the 
Treponema paitidiiHi. No. cutaneons test is known that will 
demonstrate specific allergy in syphilis, aud it is .possible 
that the entire defence reaction, , including tliat of the skin, 
is non-speciflo in this disease. - Goeckerman .believes that 
the late appearance, of the sy'philides, coupled with the 
striking mental and physical improvement, suggests that the 
malarial treatment reestablished a . partial immunity in 
which the skin play'cd a definite part. The gradual rattier 
than rapid iinpiovemeut of the spinal fluid in this case, as in 
many' others, further supports the theory that the mechanism 
of malarial treatment is, at least in part, explainable on the 
basis, of a tissue, reaction .rather than. .of a direct spiro- 
chaeticidal effect. ’ ' 



Araiii aS, igaS] 


[ Tire BRm« 
UxDXCiX. JOCBHUb 


69 


EPITOME OP CURRENT MEDICAL LITERATURE. 


Medicine. 


403. The Incldonco of Visceral Syphilis, 

F. EnDLICII and F. Stkineu (ir/cn. Arch. /. injure Med., 
February 3ri1, 1928, p. 163) coiuniout on iho fact that tThnc 
there is an nndouhtccl extension of syphiiis ns a result of the 
late war, the former predominance of syphilitic lesions of 
the shin, tnneons membranes, and hones has been oxchanged 
for a prcpoiidornnco of syphilitic diseases of the nervous and 
circnhitory systems. Jloroovcr, during the last decade visceral 
syphilis has been much inoro common, coiucidcntly with the 
adoption of energetic mercurial and arsonohcuzol treatment. 
The authors cite Gorman and American statistics In support 
of this observation. They have observed 3,000 patients (1,‘100 
men and 1,600 women) dnrlng the period 1923-26. Of the 
1,‘100 males, 212 wore syphilitic ; of these, 82 admitted infec- 
tion (5.8 per cent, of tboso under observation, and 38 per cent, 
of the syphilitic case.s) ; 13 males who had been treated 
recently in the dermatological department liad no symptoms 
of syphilis, although 6.1 per cent, had a positive 'Wassormann 
reaction. Among tho 1,600 females only 194 wore definitely 
syphilitic. Of these, 33 patients admitted infection (2 per 
cent, of tho observed oases and 17 per cent, of tho syphilitics) ; 
3 patients showed no signs of syphilis, but liad positive 
Wassormann reactions (1.55 per cent, of all patients). Tho 
authors draw the following conclusions. (1) Among 3,000 
patients 406 (13.6 per cent.) wore definitely syiihllitic. Out of 
1,400 males there vvero 212 cases (15.14 per cent.) and among 
1,600 women there were 194 (12.2 per cent.) syphilitics. 
(2) Between tho ages of 31 and 60 years 19.4 per cent, males 
and 15.1 per cent, females wore syphilitic — that is. approxi- 
mately e'very fifth man and every seventh woman had been 
Infected. (3) ThoWassermann reaction was positive in 10.23 per 
cent, of all patients under observation and a positive reaction 
without clinical symptoms occurred in 27 per cent. — that is, 
every tenth patient had a positive reaction, but 3 of these 
had no clinical evidence of sypliilis. (4) Diseases of the 
central nervous system were present in 135 patients (4 per 
cent.). (5) Diseases of the circulatory system were found in 
88 patients (2.9 per cent.) ; excluding patients under 40 years 
old, the peroeutage was raised to 5.4. -Among tho 3,000 
cases 3 per cent, had syphilitic aortitis (21 per cen(. of 
all syphilitic pationt.s). These observations show the pre- 
ponderance of syphilis of the circulatory and ceutral nervous 
sy.stoms. The authors add that tills great frequency of 
visceral sypliilis necessitates tlio greatest attention being 
paid to the patient’s previous history and to the Wasser- 
manu reaction. The authors agree that syphilis haslostits 
character ns a skin disease and h.as become largely a disease 
of the circulatory and central nervous systems which demands 
most careful study. 


50?. The Temperature In Whooping-cough. 

A. DOFOnitT {Joum. de Med, dc Lyon, February 20th, 1928, 
p. 109) disputes the view of Cadet de Gassicourt that any 
considerable rise of temperature in whooping-cough indicates 
a pulmonary complication. Daring tho catarrhal stage, as 
Bonchnt, West, and Trousseau, among others, h.ave pointed 
out, the temperature may be fairly high and irregular 
or simulate intermittent fever; with the advent of the 
paroxysmal stage a fall of temperature may occur. Occa- 
sionally, however, tho temperature keeps up, or rises still 
higher. In the course of the paroxysmal stage sudden febrile 
attacks may develop without any obvious cause and of long 
or short duration. Dufourt records five cases in children 
aged from 6 months to 8 years, in which the temperature was 
of an inverted type and presented wide oscillations between 
the morning and evening record. In none of the cases was 
there a definite pulmonary lesion, Tnbercnlin teats were 
negative, and the subsequent favourable course in each case 
Showed that tuberculosis was not responsible for the fever. 


Diabetic Acidosis, 

McCarthy (iftnnesofrt Med., March, 1928, p. 158) analyse 
nf o . ^ oases of diabetic acidosis and coma from the standpoin 
bn 5 thplomatology. Apartfromtheabnormalitlesin the urine 
1 1 signs ns important : flushing of th 

llir-rnnen .® mentality ; odour of acetone in the breath 

and depth and frequency of respiration — this sign 

common being always present. Othe 

"■r® pain in the upper abdomen an^ 
abBonr-^’-,»*M*'- ‘^f^^ohse in the intraocular tension. Th 
ol this latter sign in a comatose patient who i 


known to bo a diabetic may prompt search for, and discovei'y 
of, a vascular lesion such as cerebral thrombosis, and so avert 
tho danger of an unnecessary injection ot insulin. Aleuco- 
cytosis of 13,000 to 20,000 per c.mm. is a constant flnding, but 
tho numbers always return to normal on recovery from 
coma. Tho presence of such leucocj’tosis in association with 
abdominal pain and vomiting may lead to a mistaken 
diagnosis of an acute abdominal condition. For the general 
management of severe acidosis or coma the author considers 
roassnrauco, warmth, normal saline enemata, and the ad- 
ministration ot fluids ns tho most important measures. 
Fluids should be given by the month if possible, or, failing 
this, by tho rectum or subcutaneously. Gastric lavage is 
necessary it there is vomiting, and hypodermic injections of 
digifolin are recommended until the patient is out ot danger. 
The method ot administration of insulin depends upon the 
degree ot acidosis ; if this is not severe the patient is given 
8 oz. ol milk and 10 to 20 units ot insulin every tour hours, 
tho later doses of insulin being controlled by urine examina- 
tion. In tho more severe cases an initial dose ot 30 units is 
given intravenously and repeated every two hours until the 
urine is sugar-free ; tho dose is then decreased and the 
patient begins to take milk or orange juice. 

50S. Transmission of Scarlet Fever by Books, 

B. Fejoih (C. li. Soc. de SMogie, January 20th, 1928, p. 118) 
examined cultures ot the pages of the books used by children 
suffering from scarlet fever, especially the corners of tho 
pages, which were mest likely to bo contaminated by tho 
patients’ saliva, and isolated haemolytic streptococci either 
in pure culture or in association with saprophytic organisms, 
especially Staphylococevs albiis. Further tests showed that 
tho streptococci were identical with the causal organism ot 
scarlet fever. The following two control tests were per- 
formed. Six books ot healthy children who had never had 
scarlet fever were examined, and in none ot them were 
scarlatinal streptococci found. A new book was contaminated 
with a broth culture ot a scarlatinal streptococcus, with the 
result that cultures ol the book taken at different intervals 
were positive for four to si.x weeks. Fejgin adds that the 
practical outcome of these Investigations is that books handled 
by scarlet fever patients may harbour the causal organism 
and bo responsible lor the spread of tho disease. Such books, 
therefore, should not be used for at least six weeks, and even 
alter that period it would be best to disinfect them. 

507. Musculo-splral Paralysis following Injection of 
Quinine. 

J. M. De Villaverde (La Med. Ibera, February I8th, 1928, 
p. 173) records the case of a man, aged 33, who developed 
right musculo-splral par.alysis directly alter subcutaneous 
injection of a solution ot quinine for malaria in the outer 
aspect of the upper arm 5 or 6 cm. obove the elbow. Three 
hypotheses may be suggested to explain the paralysis : 
(1) the neuritis was due to an Infection ; (2) it was caused by 
a direct lesion of the nerve by the point ot the needle ; (3) it 
was due to direct irritation ot the nerve by the quinine. 
Infection could be excluded by the fact that the loss ot 
power occurred immediately after the injection ; moreover, 
there was no evidence ol any local infection. It was hardly 
conceivable that the neuritis was of traumatic origin, since 
it was almost impossible for a lesion of such magnitude 
to be produced by tho mere prick ot a needle. In lumbar 
puncture one ot the nerve cords of the cauda equina may be 
pricked by the point of the trocar, but the only effect is” the 
occurrence ol severe pain radiating to the foot, and no para- 
lysis results. The most likely explanation is that the lesion 
ot the musculo-spiral was produced by direct action ol the 
drug on the fibres of the nerve. The prognosis in cases ot 
local toxic neuritis is always very favourable, and rapid re- 
establishment of function follows. The possibility ot pro- 
liferation ol the connective tissue round tho nerve roust, 
however, be taken into account, since the fibrous tissue 
which is formed may cause compression ol the nerve. 

50S. Immnnlzation against Diphtheria with Virulent 
Cultures. 

H. A. Eberhard (Dent. mcd. Wocli., Febrnai-y 3rd, 1928, 
p. 181) states that Bohme in 1924 published a paper on active 
Immunization against diphtheria by a vaccine composed ot 
cultures ot living virulent diphtheria bacilli. Since then 
Eberhard has also used the same method, with the following 
results. Inoculation was performed on 82 subjects, 37 ot 
whom were small children, 13 school children, and 32 adults 

742 A ' 



70 Aphil 28, 1928] - EPITOME OF CUEEENT MEDICAL LITEllATUEE.' 


[ Tut Cnrnw' 

UCDICAL JoOffXAX> 


between the ages ol 20 and 40. Tbe Inoculations were niaao 
on the skin on the front of the tbighr the .contenbs-o£ a 
capillary tube being rubbed in without drawing much blood. 
Local reaction was usually slight, and constitutional disturb- 
ance was rare, or at most there was a slight rise of tempera- 
ture. Healing occurred in most cases without redness of the 
skin or scab formation. In 54 cases the antitoxin content of 
the blood was determined before inoculation, and once or 
more afterwards. In 20 cases there was no change in litre in 
the first fortnight after inoculation. Although some patients 
showed an increase in the titre following inoonlation, a con- 
siderable number of them showed no such rise. In any case, 
the method proved very inferior to that of toxin-antitoxin 
mixtures as regards the formation of antitoxin. Eborliard 
adds that the question mast remain open as to how far 1 
formation of antitoxin is an indication of immunity. j 

909. Clinical Significance of Gallop Hhythm. 

P. D. White (girfi. Intern. Med., danuarj', 1928, p. 1) records 
Ins observations on 100 patients with gallop rhythm, his 
couclnsions being as follows. Gallop rhytlim, which he 
defines as a rapid sequence of three heart soimds with each 
cardiac cycle, may be divided iuto four types — presy.stolic, 
systolic, protodiastolic, aud mesodiastolic. The protodiastolic, 
which is the commonest, is probably duo to tlio marked 
accentuation of the usually faint normal tliird heart sound. 
Gallop rhythm is almost invariably evidence of severe heart 
disoaso. No fewer than 45 ol White’s patients died within 
two years of the discovery of llie sign, and 32 within six 
inontlis. When last heard of a considerable number of the 
remainder rvore dead or seriously ill. Males were more often 
alfeoted than females, in the proportion of 3 to 1. Gallop 
rhythm occurred in both young aud old, hut the average ago 
was between 50 and 60, and 48 per cent, wore between 60 and 
70. In 16 patients under 30 it was more often associated 
with nephritis or mitral stenosis, and in tlio older patients 
with coronary aortitis. Congestive failure was the most 
omstandiug feature, being present in at least 60 per cent. 
Angina pectoris was common (25 per cent.); cardiac asthma 
ooourred In 14 cases. The heart rate was usually rapid, 
averaging about 100. The blood pressure varied, the sj'stolic 
being between 100 aud 150 mm. of mercury in 43 oases, 
between 150 and 200 In 35, ovor 200 in 19, aud under 100 in 3. 
Pulsus alternans was found in 21 per cent. The heart was 
considerably enlar'ged in 60 per cent., definitely normal in 
only 6, aud doubtful lu 18. Valvular disease was uncommon. 
Eieetro-cardiograms were obtained in 64 cases, and only 2 
were normal. Intraventricular block was the most common 
abnormality found (24 cases, or 38 per cent.), but auriculo- 
ventricular block was surprisingly infrequent, being recorded 
lu only 11 cases. Of the 17 cases tested, renal function was 
normal in 8 and abnormal in 9, Digitalis as a possible 
factor in the production of gallop rhythm could be eliminated, 
as in at least 32 oases none had been given, aud in only 12 
had a considerable amount been administered. Moreover, 
in some cases the gallop rhythm disappeared coincident 
with the improvement follou’ing rest and administration of 
digitalis. 


Surgery. 

310. Gastrectomy In Gastric. Cancer. 

X. Deloub and P. Maheet-Gcy {Paria Med., March 17th, 
1928, p. 254) emphasize the importance of early diagnosis it 
operation for gastric cancer is to he successful, and, while 
not denying tlie aids furnished by the laboratory and radio- 
logy, assert that clinical symptoms and the clinical sense are 
of eqnal, it not greater, importance in this respect. An 
exploratory operation is strongly advocated whenever carci- 
noma is suspected. After the age of 50 loss of appetite and 
emaciation are almost definite indications of cancer, and 
when enfeebling chronic affections, snob as tubercnlosis aud 
nephritis, can be excluded, anorexia for fats and meats, with 
a progressive loss of weight and energy, is often the first 
sign of gastric cancer. Gastric symptoms are often limited 
to simple sensations of heaviness, gastric cramps, and dis- 
comfort offer food. Except in stenosis, vomiting and baenia- 
temesis rarely occur early, though the vomit and stools 
should always be te.sted for occult blood. A slight, anaemic, 
yellowi.sh tint of the skin often .appears at an, early stage, 
and blood counts and gastric intubation will afford valuable 
information. The authors believe that the classic hypothesis 
tliat an orifloial seat of the tumour is of better prognosis 
is unrounded. Early diagnosis may ho more difilcnlt when 
the acuteness of the pain resembles tliat of .nicer. In the 
latter, though great emaciation is present, loss of energy is 
not so marked and the complexion remains clear. Change in 
the pains, their unusnal persistence, and the disappearance 

- . •.■•rvi-ir.rl I'in Hnnc nnin h r>lAnr7v #o flift 


in-cscuce of a tumour. Tlescction of chronic gastric ulcers is 
strongly advised ns.n prophylaxis against cancer. In gastric 
carcinoma gastrectomy should be performed in preference 
lo palliative operations, sucli as gastro-enterostomy. The 
anDhor.s do not attach much iniportauco to the four factors 
usually considered as Iniluonoiug prognosis— namely, stono.sis 
of the pylorus, extension to the lymphatic sy.stem and neigh- 
bouring organ.s, and tho microscopic and macroscopic anatom}' 
of tho cancer, though tliey consider colloid cancers to ho par- 
ticularly malignant. In many cases marked improvement ■ 
audeven temporary arrest have been noted after gastrectomy, 
life being prolonged from one to two years. The authors 
believe that a patient who has passed the third year in good 
health is almo.st certainly cured, and give six years as the 
extreme limit for the appearance of reciiirencos. 

311. Transcervlcnl Fractures of the Femoral Neck. 

*\. GUENUT {.toiini. dc Med. dc Itordcanx ct du .Sud-Oucaf, 
February 25tli, 1928, p. 145) remarks that it is indisputable 
that o.xcollcnt results arc obtained by bloodless treatment 
in cervico-Uooliaiitcric fractures of tho neck of the femnr, 
but that this is cortaiuly not so in trauscervical ones, and 
a case is reported in .support of this viciv. The patient, a 
man aged 74, was admitted to hospital with such a fracture 
of tho riglit femur. Eloodlcss treatment was institnted by 
means first of the IVliitmauu apparatus, and later of the 
piaster hoot of Parcclior, and after live mouths tho patient 
was discharged apparently cured. About two months later, 
on flexing the limb, intense qiaiu was felt. in the hip; after 
thi.s walking hccamo impossible, and the weight of the body 
could not he homo by the frnctuicd limb. Clicnnt believes 
that tho callus formed had not been ossified, oven at the cud 
of seven moiitbs, though it had heeome siifiicicntly solid to 
permit of walking for more than three months, and that m 
these traiisoervioal fractures spontaneous o.ssiflcation is very 
rarely realized. In sucli o.asos bloodless treatment should be 
employed only whore other operative measures nro contra- 
indicated owing to the ngo, or tlie cardiac, renal, or 
condition of iho patient. Operation should bo performed as 
soon tis possible after tho fracture m order to prevent tlio 
formation of pseudo-arthrosos. IVliere bloodless treatment 
is deemed advisable Cliouut strongly recommends lb? wso of 
Farcelier’s plaster boot with Katorai wings. It is said to bo 
tolerated much bettor than ■\Vliltmann’s apparatus, is very 
simple and easy to apply, and keeps the limb m tlio desiiod 
position of forced internal rotation and abduction. 

31s. Tempo- ary Haemostasis In Abdominal Surgery. 

L. Maver {llrnxcllca-Mcdical, Fobruary 2Gtli, 1928, V- ^ ) 
believes that drainage after 

oxceutioual, aud that many operators have abandoned 
tamponing aitor clioleoystectomy ; be emphasizes the diffl- 
cultv in certain conditions' of tying a deep vessel or oxcietoi} 
SucG Ho inaintaiiis that as satisfactory a haemostasis can 
be obtained bv leaving clamps in position for a certain IcDoth 
of rime, ami threxeefient r^ults^btained technique 

in vaoiiial hysterectomy have encouraged him to t*.} it m 
certain abdominal operations. Fourteen cases of such opera- 
tions including cholecystectomy, nephrectomy, and splcncq- 
iomy. are repofted in which this procedure ^ s adoifled w H 
satisfactory results, secondary c" 

untoward accident never occurring. litis method ooenpte^ 
less time than tying, and is especially advantageous in cases 
where the poor general condition of rendera 

advisable a minimum duration of operation; it is also sa 
to be expeilient in cases, such, as acute ^‘‘“Srono*?® 
cystitis, -^-here the friability of tho tissues f ’J, ■ 

tinn of Butnres doubtful. Mayer uses a long, curved, mouse ^ 
toothed forceps clamp, seizes the vessels 

and leaves tiro clamp in position for forty-eight hours. He 
adds that tho clamp should be ^ 

injury to the surrounding tissues, and should be withdrau n 

carefully aud jiaralloi with the axis of the incision. 

513. ArtbritiB due to Foreign Bodies. 

O. f’ EhrenTHEIE {Dent. Zeil. f. C7iir., February, ^.928, P- ). 
.states that this condition was first ? tto 

Ec-mitzler, who distinguished two forms of arthritis of this 
kind, according as the foreign was ol metal or oi vootb 

In tho first form tho symptoms are inteiornttent f,,®' 

the joint, with pain and disturbance of function. 3\ hen tne 
joint is immobilized by a bandage the 

but recur when the joint is used again. The d agnows in 
sneh cases is easily made by z rays. In tne '5 

symptoms are tho same as in a fungatmg 
with discharge of thin serous pus and flstnloirs 
bluish-violet undermined edges. In such cases^^ir la} s do no^ 
help and the diagnosis can he made only -jind 

sideration ot the history, inspect!^ of ®cavs, palpation, 
finallv exnloratory arthrofoiiiy. ■Elifonthcil reports a 



ArKiii 28, 192S] 


EriTOME OF CURRENT MEDICAIi LITERATURE. 


r The BniTinf 
L Medical Journal 


71 


In !i }jivl ngcd 12 ycnra, In whom the comlltion wns llrst 
nilstakcn for tuboicnloua nrtlirilis and troatcil accordingly by 
extension for threo months. Tho correct diagnosis was thou 
inado" by .r-ray examination, which showed a ucodlo in tho 
left liuco-joiut. Comitlote recovery followed its removal. 

, Kohlor’B Disease. 

F. llllNSO (Hif. .Vccl., February 20th, 1928, p. 179), who records 
two Illustrative cases in a girl aged 5 and a boy agedG years 
respectively, states that Kohler In 1908 was tho llrst to describe 
n painful condition of tho tarsal scaphoid, usually unilateral 
and occurring between tho llfth and ninth years, and charac- 
terised by delay in' tho development of tho bone. Tho 
condition is rather rare, and not more than one hundred eases 
have been rccoixled. Boys between tho ages of 5 and 10 years 
aro chiefly alTcctcd. There is no example of hereditary trans- 
mission of tho dlscaso or of tho occurreueo of more than ono 
case in a family. Tho symptoms arc spontaneous pain in tlio 
dorsum of the foot, aggravated by wnllcing and pressure on 
tho tarsal region, which Is slightly swollen, red, aud hot. 
Tlio.o Is a slight degree of limping; passive movements of 
tho foot aro not restricted. There is somotlmos atrophy of 
the calf. .V rays show that tho lesions aro localized to tho 
scaphoid, which .is smaller than normal, especially in its 
autcro-itosterlor diameter. Tho architecture is impossiblo 
to recognize, tho cortex and spongj- portion running together 
aud tho density being increased two- to four-fold. Tho courso 
of tho dlscaso varies, but as a rule recovery ensues in a few 
nioulhs. Not infrequently tho symptoms disappear after a 
few days’ rest, aud recovery of function la obtained in one or 
two mouths. 'Troatmoiit, which is essentially conservative, 
should consist in immobilizing tho foot by a suitable apparatus 
for a time ranging from ono to six or sovon months according 
to tho severity of tho case. As regards pathogenesis, Kohler’s 
disease has been variously attributed to trauma, infections 
(esiiccially tuberculosis and syphilis), cudocrinc disturbances, 
aud late rickets. 


4.S. Malignant Tumours of the Testicle. 

C. C. Higgins {Anuals oj ttvrgen/, February, 1928, p. 263) 
roiiiarks that most malignant tumours of the testis may bo 
classified ns teratomas, or mixed tumours, aud spheroidal- 
cell tumours. Sarcoma of tho testis is'qullo rare. Teratomas 
conipriso over halt tho malignant conditions of tho testis; 
they are very ipalignant aud rapid In growth. 'These tumours 
ate usually fouud between tho ages of 20 and 50 years, but 
no ago is exempt. There is often n history of trauma. Many 
casus are only seen after mctastascs aro present ; these may 
be found in tho abdominal glands and also in tho inguinal 
glands. Treatment has been tried by a rays, radium, Coley's 
llui.f, orohideetomy, and radical operation. Higgins thinks 
that a radical operation should not be performed if en- 
largement of tho glands can bo recognized clinically. The 
pro^uosis after all forms of treatment is grave; it la most 
sor.ous in tho mixed tumours. Carcinomatous growths are 
tho least malignant type. Higgins records twenty-three 
cases ; six of tho patients aro still alive at varying periods 
after operation. 


5IS. Kaposi’s Disease* 

E. K. Stiiatton (Urol, and Cutan. Rev., February, 1928, p. 71) 
records a case, in a man aged GO, which clinically and mlcro- 
sco;iically corresponded to the rare disease known ns Kaposi’s 
multiple haemorrhagic sarcomata. The interesting features 
were (1) tho development of a primary tumour on the scrotum 
at a spot where there had been severe pruritus ten years 
previously; (2) the appearance of similar tumours on the 
extremities — namely, tho hands, feet, and ears after exposure 
to extreme cold ; (3) the involvement of the right inguinal 
lymph glands; (4) no evidence of tumour formation in the 
viscera. 'The history of a primary lesion beginning at tho 
sue of n severe pruritus is suggestive of a specific mloro- 
org.inism acting as tho irritant. Winternitz and Noggs in 
mo reported a case associated with cirrhosis of the liver, 
pw , metabolic products constituted the stimuli, 

tjuculatory disturbances, such as exposure to severe cold, 
. hate been frepently recorded as a cause of Kaposi’s disease, 

escaping blood provides the 
irritant substances causing endothelial proliferation. 

Injuries and Deaths from Boxing. 

1928, p, 379) states 

Itactnm the*? n in boxing is metacarpal 

queuov ■’ m 1 , r'’ affected in order of fre- 

fomlh^and metacarpal; (2) bodies of second, 

case of the ; (3) Bennett’s fracture of the 

Bccond and f tA. m 7 W '■^“turo of the neck of the 

thoTirS memcarn^f 

occurred “““V fatalities must have 

ourrett in the brutal lights of past centuries, relatively few 


cases have been recorded in recent years. In a series of 
22 bases which have been reported since 1920 in Germany,' 
where boxing was first introduced after tho war by men who 
had been interned in England, evidence as the cause of death 
was available in only 13, and in only 9 for tvhich boxing was 
responsible, subdural haemorrhage on ono or both sides being 
tho cause in 6, cerebral haemorrhage in 1, and fracture of the 
skull in 2. In view of tho largo number of boxing matches 
which have been held a total of 9 fatal cases is regarded as 
extremely small. 


Therapeutics. 

418. Protein Therapy in Leprosy. 

N. A. DYCE SlLVRP (Trans. Roy. Soc. Trop. Mecl. and Jlyy., 
January, 1928, p. 305) believes that the essential feature in 
tho treatment of advanced cases of leprosy is the degree of 
initial reaction. Any substance, therefore, which will result 
in a smart reaction in a leprous individual will probably 
achieve a beneficial result apart from any specific action. 
The most suitable protein body to produce a shock is tinned 
milk prepared under the most hygienic circumstances and 
free from preservatives of any sort. The. technique is as 
follows. Tho top of the tin is cleaned and a small hole made 
in It by a sterile nail ; 2 or 3 c.cm. of milk are then slowly 
drawn up into a 10 c.cm. syringe and diluted with distilled 
water In a tost tube, so that tho strength of the dilution is , 
1 in 10. The standard dose of 0.5 c.cm. of tinned milk is 
therefore contained in 5 c.cm. of diluted milk. The reaction 
consists in a feeling of giddiness, which comes on within half 
a minute, followed in threo or four minutes hy marked respira- 
tory distress and more or less severe precordial pain. Within- 
five minutes of the injection there was always sharp pain in 
all tho joints with severe frontal headache. General improve- 
ment followed in another five minutes, and usually within 
half an hour tho patient was able to go home. A secondary 
reaction, shown by a vise of temperature to 103“ to 104“ F., 
would set in at night, and might recur for several nights. 
In every case complete relief from pains in the joints and 
bones and from formication ■ occurred within twenty-four 
hours. At tho end of forty-eight hours the temperature was 
usually normal, and there was almost complete Irecdom frotn 
pain, e.xcept in tho septic ulcers. In the course of a week 
the skin lesions, including the perforating ulcers in the soles, 
showed a marked Improvement. Relapses aro apt to occur, 
when benefit may be derived from a second injection. In two 
of tho twelve cases treated the injection was given into the 
buttocks. There was little, if any, immediate reaction, but 
when there was a smart febrile reaction a few hours later the 
end-results seemed to be the same. The author concludes 
that the treatment, though admittedly drastic and undoubtedly 
dangerous, seems to be specially applicable to the late and 
less hopeful forms of the disease. 

419, Quinidine In Coronary Thrombosis. 

S. A. Levine and W. B. Stevens (Amer. Heart Joitrn., 
February, 1928, p. 253) describe the use of quinidine sulphate 
in coronary thrombosis complicated by ventricular tachy- 
cardia. This abnormal rhythm is not uncommon, and is in 
most cases the sequel of coronary occlusion. In many cases 
the tachycardia is transient, but, if it persists, the condition 
of the patient soon becomes extremely grave, ns in a case 
reported. A man, aged 53, was admitted to hospital suffering 
from typical coronary thrombosis with persistent retrosternal 
pain, gallop rhythm, pyrexia, lencoeytosis, and falling blood 
pressure. He continued to have some cardiac failure, but no 
other complication, until the fliteenth day in hospital, when 
the pulse rate was foulid to be 198, and an electro-cardiogram 
proved the presence of ventricular tachycardia. An intra- 
venous injection of 5 grains of quinidine sulphate was given’ 
without effect. Four hours later 6 grains was given b 3 ' the 
mouth, and on the next day 8 grains. Since the condition of 
tho patient was deteriorating these daily doses were increased 
progressively to 18 grains, and then, four days from the 
Inception of abnormal rhythm, it was shown by electro- 
cardiography that occasional normal cardiac cycles were • 
appearing. After two more doses of quinidine, each of 
23 grains, tho rhythm had become normal, apart from occa- 
sional ventricular extra-systoles. For the next six days 
doses of 15 grains were given four or five times a day, and 
then on withdrawal of tho drug the pulse was slow and no 
irregularity recurred. Great improvement in the general 
condition of the patient coincided with the restoration of 
normal rhythm. Tho authors concur with the general 
hesitancy to use quinidine, but believe that its use is justified 
where the continuance of ventricular tachycardia is hastening 
a fatal issue. They comment also on the very Iar"e doses 
which were required in this case to produce the '’desired 
effect. 


*’42 0 



72 Apeil 28, 192S] 


EPITOME OE CURRENT MEEIOAE EITERATURB; 


• r Tnr.Ciivn« 

‘ LKedical JoUBNlt 


420. Sodium Cinnamate In Pulmonary Tuberculosis. 

R. COUKTOIB [Le Scalpcli February 11th, 1928, p. 141) clis- 
cusses the treatment ol pulmonary tuberculosis by sotlium 
cinnamate, tYhich has been used for more than twenty years 
at the sanatorium of La- Hulpe- Waterloo, from which the 
author has drawn his cases. Total statistics taken from a 
series of 200 unselected cases indicate that less than half of 
those treated were benefited at all, and that only some 12 per 
cent, were greatly improved. By arranging, however, all the 
cases in classes according to their lesions It is shown that 
the cinnamate treatment has had well-marked influence in 
certain types of oases, including the so-called uloero-fibrons 
type, usually associated with normal or raised blood pressure, 
and tuberculous pleurisy which is not becoming quiescent 
under sanatorium, treatment. The author has found that in 
cases of the ulcero-caseous type, cinnamate treatment does 
not give much hope, especially where the temperature is 
persistently high, nor is it useful in bronchitic cases. In 
early stages with a tendency to the ulcero-casebus tj'pe, ns 
indicated by low blood pressure, cinnamate treatment may 
check the disease. Courtols has not used sodium cinnamate 
in any case .unless sanatorium treatment alone had effected 
no Improvement in two months. He gives a series of forty 
intravenous injections, ten with 1 per cent, solutions, ten 
with 2 per cent. and twenty with 5 lier cent. 'Jh i total 
amount of the drug used is not stated. In conclusion, the 
author claims -that sodium cinnamate is the most important 
drug that can be used as an adjuvant in the treatment of 
pulmonary tuberculosis; he recommends it strongly for 
eases seen in general practice where there Is no great 
elevation of temperature and whore sanatorium treatment 
is Impracticable. 

421, Malarial Therapy in General Paralysis^ 

II. A. Bunkee, Juq., and 6. II. Kihby (jfed. Joiirn, and 
Record, February 15th, 1928, p. 173) describe their experience 
daring four and a half years of the treatment of general 
paralysis by malaria, comprising .observations on 15S nn- 
selecled males in all stages of the disease with definite 
mental symptoms necessitating commitment to a mental 
hospital. At least 50 per cent, gave a definitely favourable 
response, even though in a third of them residual signs of 
previous cerebral tissue destruction precluded full clinical 
recovery. Discussing the permanence of the remission of 
mental symptoms obtained in those responding favourably to 
treatment the authors call attention to the fact that not only 
did complete remission occur in about one-third of the cases, 
but that in fourteen out of sixteen cases the remission has 
been maintained unaltered for at least three and a half to 
four and a half years. With reference to the type most 
likely to respond to treatment it was found that'remission 
was good in 14 per eent. of the simple dementia tj’pe, whereas 
in the manic or hyperactive type 75 per cent, were definitely 
improved. The authors remark that by earlier tre.atment, 
before marked mental symptoms have appeared, much irre- 
parable cerebral damage might be avoided, and they urge 
that advantage should be taken of a form of treatment'which 
IS remarkably effective against a disease which has Largely 
resisted older methods of treatment. In just over one-fifth 
of the cases the Wassermann reaction in the spinal fluid 
became completely negative after treatment with malaria 
alone. ‘ 


Disease iu Childhood. 

422, Influenza in Infants. 

L. Monij {Wien, Idin. Woch.^ November 24th, 1927, p -1486V 
states that the organisms generally found in influenza in 
infants are the pneumococcus of Fraenkel. Micrococcus 
catai-rhalis, Streptococcus pyoqcnes, and, much more r-arelv 
Pfeiffer’s influenza bacillns. In some epidemics a haemolytic 
streptococcus predominates. Two main forms of inflnenza 
occur in infants — the severe and the mild. In the sevel-e or 
vasomotor type, commonest during the first' three jiioutUs 
of life, death may occur after, only -a couple of days' illness 
with symptoms of severe general mnscular weakness, pallor’ 
rapid respiration, and general cyanosis, with occasionai 
meningeal signs, such as ■ vomiting, squint, and rigiditv. 
Large areas of the lung are dull to pei-cnssion and a feV 
crepitations may be audible, the liver is enlarged and soft, 
the heart may be- dilated to the right, and the pulse small 
and accelerated ; the temperature varies, and may be high 
or subnormal. Post-mortc7n examination frequently shows 
congestion of the liver, spleen, and the whole portal' system, 
and the author ascribes this to vasomotor paralysis inainly 
affecting the splanchnic area ; he thereby accounts for a part 
of the symptomatology of the . disease in older children .and 
adults as well. Ho also found, in co-operation with Luksch, 
that the suprarenal glands are congested and only contain 


minimal amounts of advenaliuo, but whether this is the cause 
ol the paralysis or is a concurront phenomenon is undecided. 
'These pathological obaorvation.s ofror an explanation for the 
proved value of such vasomotor stimnlants ns adrenaline 
'.(1/2 c.om. of 1 in 1,000 solution, snboutaueonsly) and caffeine 
(0.5 gram spread over two days orally, or 0.5 to 1 c.cm. of 
a 10 per cent, solution subcutaneously). In the nilldor form 
catarrhal sj-mptoms predominate, often beginning in the 
nasopharynx and spreading to the larynx, trachea, and 
bronchi ; If the lungs ore affected it is generally the upper 
lobes. For tho nasopharyngitis Moll advocates sweating 
treatment: 0.1 to 0.2 gram of aspirin may be given with 
comparatively largo quantities of toa; sweating is also 
enconrnged (though it must be carefully watched as it is not 
without risk) by a steam-tent constrnctod from an open 
umbrella covered wltli a sheet under which tho mother sits 
holding tho Infant with a vessel of hot water at her feet. 
Locally one or two drops of adrenaline or 1 per cent, coliargol 
solution are applied to each nostril. In cases with caplUarj' 
bronchitis tho condition of the gastro-Intestlnal tract is of 
particular importance, so that the absorption of nonrishment 
may be adequate ; in both breast- and bottle-fed infants 
a mixed diet of breast and cow’s milk. was found useful, 

423. Iieukaemla In Childhood. 

W. K. Hunter {Glasgow Med. Joui-n., January, 1928, p. 1) 
classifies In five groups a series of twenty-two cases of leuk- 
aemia in childhood, observed over a period of. twenty years. ' 
(1) One case of chronic lymphatic lonliaemia witli tho white 
cell count rarely above normal, although the lymphocytes 
were absolutely and relatively increased ; the glands all over 
the bodyi ns well as the spleen, were enlarged; 'The case 
terminated fatally In two years. (2) Two cases of a more 
acute type of lymphatic leukaemia, with a dur.ation of six 
weeks and fourteen weeks respectively. 'They each had a 
largo mediastinal tumour with the histological characters of 
a lymphosarcoma. (3) Six cases of the most charaotorlstic 
. typo of the disease, with a duration of from one to live and 
'a' half montlis. • In most of -tliem there was a pronounced 
anaemia, and in all a lenoocytosls of from 13,000 to 300,000, 
inainly of a mononuclear, non-granular, primitive type of 
cell, now more generally regarded as a myeloblast rather 
than as a lymphoblast. (4) lUvo cases of loukanaomia, or 
perhaps more correctly orythro-Ienkaeinia, associated with 
liemiclous anaemia. 'The difference between these cases 
and those in tho third group is itainly one -of degree, for 
several cases in the earlier group had also a number of 
nucleated red cells in the blood. (5) Eight cases of alenk- 
aemia ; indeed, there was an actual leucopenia in almost all. 
In two cases the mononuclear cells seemed to-be mainly 
myeloblasts, while In tho other six It was regarded as a 
lymphocyte. Another feature of the group was the profound 
anaemia. Some haematologists would place tho latter six 
cases among the aplastic anaemias : the author, however, 
inclines to tho view that they are loukaomias. The patho- 
genosis of lonkaomia iu childhood is ohsenre. Several of the 
cases in the series' presented many features of an acute 
infection, such ns tho sudden onset, often with (ever, and the 
rapid course of tho illness. The author suggests that the 
disease is not necessarily the same as in the adult, .and that 
the v.arions types he has described are possibly not all due to 
the same cause. • ■ 

424. -Treatment of Infantile Paraiysls by X Kays 

and Diatliermy. 

INSPIREB by the work -of Bardier, A. G. Lanovskv .and 
G. M. ■ Freydowitch {Mcdiciinshaya Mysl Vshcldsliitia 
[Eussian], 'October, 1927, p. 37) report tUo treatmeiit by 
S' rays and diathermy of- 39 cases of infantile paralysis duriUCT 
the first six- montlis of the 'disease. A complete cure vas 
achieved iu 21 per cent., excellent results were obtained in 
50 per cent., and iu the remainder, with the exception oi 
two cases of diffuse ' poliomyelitis, the' therapentio resiiits 
were good. The treatment began with irradiation of tue 
spine. lyhen the lower limbs were affected, the raj’S_weio 
directed to the ninth, tenth, eleventh, and twelfth 
verlebrae ; in- paralysis affecting the upper limbs. the iiltn, 
sixth, and seventh .cervical and the first dorsal 
were irradiated. In cases of combined paralysis, both tu 
upper and lower segments of the spine were treated. Lac 
field was Irradiated with 30 to 50 per cent, of the sa 
erythema dose with a filter of. 0.3 mm. zinc and 1 
aluminium. The treatment was repeated at intervals 
two to three weeks, and twice or three times altogetuc . 
Diathermy was employed everj’ second or third day ”/ * i 
intervals between the- x-ray treatments. A small electrouc 
was applied to the affected segment of tho spine, “ 
indifferent electrode opposite in front, arid a.cuircnt of buu i 
1.000 milliamperes was passed for ten to fifteen Kimut • 
The course of treatment usually lasted from one to two 
months. 


i 



Al-HlL 28, ipTjS] EPITOHK OF CDRUENX.MEDICAti LITERATTOE. T u«S . 73 ; 


425. Sonuolo of MonlnUoal HnomorrhnUo at Birth. 

!\I. RlVlfclll', {Hull. Soc. (VObsl^.l. ct dc Gi/urcol. ■ de Paris, 
Novoiiibor, ■ 1927, ]). 043) reports Uio .subsequent history ot 
six lutnnts, n',;oC from 1 to 2 years, who at birth hatl bail , 
meningeal- haeinorrhngo, which was proved by lumbar 
pnueture. Four appeared to be iiornml, mentally and 
piiysically, aiul these included (1) a child delivered by toreops 
in n condition ot asphyxia, whoso apparoully moribund 
condition, attended-, by Inclpleut couvulsloiis, improved 
pari .passu with lumbar punctuvo repented t\vo or three 
times daily ; (2) n child delivered by brcecli. In whom lumbar 
puncturo was performed repeatedly, Kaugulneous lluld being 
replaced eventually by one which to the naUed oyo appeared 
inirnlent, but whicli was nolnnlly storllo. A firth child had not 
wnlUed at the ago ot 13 moiitlis and aiipoarcd to bo lacking in 
facial expression ; a sixth walked at 22 months. Inn seventh 
case nieuhigoal lincmorriiage was diagnosed clinically, but 
not proved by puncturo; this child was dellciont nioutally 
and parotic at 4 years oi age, but there was a history ol 
lecent paternal syphilis. • 


Obstetrics and Gynaecology. 

A3G, Delivery of the Adherent Placenta. 

.I.-JAIICHO ISurff., Gynecol, and Obslct. ,l'ol)rimry, 1928, p. 2G5) 
reports three eases iu which the Mojon-Gnbaston method ot 
removing tlie. placenta wn.s employed, wltli resulting delivery 
in Irom ten to forty mInntCB and uuovontful recovery. Ry 
I ho Injection of. warm sterile saline solution Into tho umbilical 
corrbvcin the placcutal vc.ssols become distended and rnp-. 
lured, with tho formation of a rctroplacental liydroraa; which 
inechanically'causcs separation of tho placoulu, tlms avoid- 
ing lutrantcrino o.xploratloiii with its attendant dangers. 
1' com 100 -to 300 c.cui;- ot warm stccllo salt solution are 
hijeeted slowiy. with n-Rccord or Luor syriugo Into tho vein 
ot the niubilicat .cord, the nccdlo being lield in po.sltlou by 
an artery clamp, which can bo tightened to prevent any 
rotucu flow ot saline slioutd a second puncturo bo found 
nccessarj-. It required a rectal o.xnmination will determine 
whotUor the placoula after dotaclnncnt is remaining in the 
cervl.x and vagina. Jarcbo advocates tlio luoco general use ot 
i.ectal exaniinntiODS in ob.stotric pr.aotlco ns being easily and 
is’n ^ glovo, ami aHordlng all 

progress ot the labour, 
before injection, the 
^ Pti'utod with iodine or 

luiectca patients, Its pcrformanco is simple. reanire<t nn 

nortio^ot^ being made into the unsoilca 

portion ot tho protrndiug cord close to tho external genitals 
there is no danger of carrying infection. bcmcais, 

. The Heart In Pregnancy. 

« iSurrf., Gijnscal. ami Obs/cl., iravch 1928 

records tho results of studies undertaken to ascertain 
iJio condition of tlio heart Itj precnanov Tin»»nini* r,' i 

lious throughout the ^ ^ I^egular examina- 

afterwards were made. “-'“I lor a time 

could not bo completed m more than 239. Only tbosS of nor^ 
physique between 20 and 35 years of ago, and cither mln.f 
frmn'ff* ^-parae, lyere selected, and during the whole period 
from the second or third month onwards tlilv were 
every two or three weeks by the usual methods of aus^iibn^ 
tion, pulse, and blood pressure readings before and after 

HHm. , I'jasrualler.sones the amount of blood circu 

nf^+he ‘**'^°“11** the heart in one mhmto (the minute volume 
Tiiidf determined by the inotbod ot KrogU and' 

ureensnr; majority of patients went tbroSoU 

sStomS 39 O??hro'?o"‘' "'““put ““F unirsnal circulatory 
during S ‘rcalthy women present^ 

tlip tno^ latter halt of ge.station symptoms wh/cii during 
o g-r„?r pronounced as to suggest "n 

pam bead^rhn*^^'°i ’ o'liet complaint, being caydiac 

extr-i dyspnoea accompanied by rapid pufse 

lahniir Pulmonary and tncusi)i(l valves •Durinf* 

murnmrsriisaZ\r"edrf'’77‘'"^r^ sj-mptoms, a^rthl 

liad subsided ^befni o^mLI '^" symptoms 

and those of discharge. From tbe.so investigations 

apparontlyhealtbv'wompn^oy^^^i eoncludes that 

during preenanev which functional symptoms 

live ot I’odo considered as ihdica- 

not conclntively prove oardfaTlivn'T"^'i^'®."‘''‘^®‘‘*5ations do 

IS increased as a n Portropliy, tho lieart’s notion 

and the increased Imonm amount of blood 

one minute, thus explaining rife the heart in 
and possibly dilatation. ® development of hypertrophy 


428. Caesarean Section. 

G. DECoUnoi- (Amcr. Jonm. Surf/., Jaunary, 1928, p. 30) 
vevtows some recent inodiflcatious iu tho technique ot 
Cnesnrenn scotioii, and dc.scribos ids own oiioratioii dovi.scd 
to avoid that contamination of the peritoneal cavity and 
iitcrlno incision which occurs when tho aniiilou is ruptured 
within tho uterus. Xo tlii.s end tlio entiro gestation sne is 
doUvered iiitact nnd is opened away from the Hold of opera- 
tion. After dollv'ery lof tlio uterus tliroiigli a rectus incision 
sllghliy to tho loffot tho median lino the intestines and 
abdominal .cavity arc walled oft with salino gauze and the' 
ntorusis opened by a low Incision corntnoncing at tlic bladder' 
and extending BUlllclently high for easy delivery but not 
longer than is necessary, the resulting ‘scar from snchlo-iv' 
llicislon being more seenre. Xho entire gestation sac Is then’ 
■ carefully stripped from tlic uterine wall and delivered- en 
masse, an assistant removing it from tlio vicinity of the 
wound and niptni-liig tho membranes, extracting tlie- child, 
and lying and severing the cord. So long as the placental' 
circniation is innintaiiicd tlici-c i.s no danger to the cliild ; the' 
separation from tho uterine wall occupies about a niiiintc. ' 
In eight consceiitlve dellvcrlc.s witbont mortality to -mother' 
or child no dlibculty has arisen in it.s performance. Tho 
author states that llndlng the placenta hcue.ath the uterine 
Incision need not occasion concern, and there is Icss'dnnoer 
of riiiitiirlng tlic sac if tbosopnraiiou starts with the placenta. 
By this method tho risk of infection is reduced to a ininimuTn, 

. and tho aullior contends that on ncconnt of its greater safety 
( totlio motbcrandcblld itslionld, In the majority of instances, 

: bo given preference to tlic uso ot high forcep.s, since by its’ 

I nso lacerations of tho birtlr canal and -the dangers of com- ' 
' prcsslon of the Infant’s skull are avoided.' - 

429. Ccnital Neuralgia. 

)r. Balchi; (ha GijjtceolOgic, January, 1928, p. 5) discusses 
. >< habit ” ueura.gias of the female genital organs, and records 
I eases in which tlio pain was of great intensity and was 
- accompamod by a persistent burning sensation which' did 
1 not yield to any treatmeut. This kind' of pain was always 
I intcuslflcd by tho slightest touch, and by any ■ volnutarv 
inovemcut such as walking. After a long period of uiiserv 
the patients became anxious and Irritablo from lo.ss of sleep 
and appetite. Xho nntbor compares this typo ot pain with 
that occasionally noticed after iranma of nervo.s; particularlv 
I tho median ami Bciatic. This similarity has led some 
observers to attribute tho neuralgia' to a sympathetic svn 
drome following a lesion ot tho periarterial plexuses. TVhat- 
i ever tho cause, thero is no doubt that no organic lesion conld 
bo found even after tho most minute examination' The 
patients wore not hysterical or psychasthenic. The theory 
that a particnlar nervo may develop a habit ot re«isterinn 
pain Is considered by the author. Ho -argues that, presum° 
ably, some initial cause starts the pain and tho nerve 
continues linbitnally to record pain even attei- the can-^e 
has ceased to operate. Dalclie suggests that this may be 
posslblo Without auy accompauying mental derangement 
Ho remarks that such patients often explain their ills badlv"' 
and tho prc.sent me.'ins of investigation aro too incomplete to 
allow an accurate diagnosis to be made. Further investi"-! 
tion of the cause of the pain Is required. Treatment ti-Ted 
Includes psychotherapy, drugs, thermal waters, light dia 
tbermy, ionization, and surgical treatment. In one woman 
relief was obtained by section of the internal pudendal nerve ' 


430 , innuence or TJiyroia Disease on Menstruation. 

H. Gaudiner-Hill and J. F. Smith (Joum. Obst'et. and 
Gynaecol, of the llritish Ihupirc, 'Winter, 1927, p. 701) discuss 
tho typo ot menstruation occurring in cases ot thyroid disease ' 
based upon 300 cases, including 9 creiius, 100 instances of 
adoloscent goitro with varying degrees of disturbed function ’ 
96 cases ot exophthalmic goitre and hyperthyroidism 41 6f 
myxoedema, 24 of parenchymatous goitre, and 22 of thx-roid 
adenoma, the basal metabolism being estimated to confirm 
the degree ot thyroid activity. It is shown that, while such 
coniHtions do not always allect menstruation, any alteration 
tends to be iu a uniform direction, the type of menstruation 
Varying inversely with the degree ot thyroid aetivitv • thus 
hypothyroidism may be associated with excessive haemor- 
rhage, and liyporthyroidism with amenorrlioea. In cretins 
menstruation was usually found to be delayed or absent unless 
tho patients were adequately treated, when normal regnlarit-ir 
was obtained. In adolescent goitre without other signs of 
thyroid dtatui-bance menstruation was geuevally normal but 
in the presence of liypertbyroidisni the periods were apt to 
be delayed and scanty , or excessive if hypothyroidism existed. 

In exmrhthalmm goitre there may be i;o menstrual disturb- 
ance, but in severe cases the periods tend to become scanty 
or absent. B hen myxoedema ocems before the menopause 
menorrhagia is generally present, but since this condUtan 
frequently does not develop till after the menopause the 
impression has arisen that it is sometimes accompanild by ' ' 

742 E 


74 Apnir, 28, 192S] 


EPITOME OE CEBEENT 


amenorrhoea. Pavenchyinatous goitre aucl simple nclenoma 
are usually unacoompaniea by auy menstrual tllsturbance, 
unless, as was found , in a small proportion of the patients, 
hypothyroidism is present, when menorrhagia inas' occur. 

931. IHucous'Celled Carcinoma of the Cervix. 
Accohding to M. Beeb (Gynecol, cl Obstet., January, 1928, 
p. 1), whereas carcinomatous growths of the intestinal mucosa 
not infrequently contain mucous cells, it is extremely rare 
to meet such cells in malignant tumours of the lining of the 
cervix uteri ; nevertheless in both situations cells having 
a physiological mucigenous function are present. Mucons- 
cellei; carcinoma of the cervix has been recorded in eight 
cases only, to which Beeb adds a ninth. A 2-para, aged 36, 
sought treatment for debility, loss of weight, and a sticUy 
colourless vaginal discharge ; she added that recently slight 
bleeding had occurred after coitus. There was a softened 
and moist vagina ; the anterior lip of the cervix was enlarged 
to the size of a hen’s egg, with a soft, smooth, and’ very 
sticky surface which was not ulcerated, but bled after being, 
touched. This lip after excision ;showed a cylindrical-celled 
adenocarcinoma which, near the internal os, had typical 
microscopical characters, but In the middle, and especially 
in the lowest third, there was extensive mucous transforma- 
tion. Large quantities of mucin wore preient, distending 
and finally bursting the intraglandular cavities and infiltrating 
the stroma in large collections to which degenerated remnants 
of gland ceils were attached. In contrast u-itli the corre- 
sponding neoplasms in the rectum there appcai-s to be no 
evidence that mucons-celled cervical carcinomas are speciallj’ 
mxllguant. 


Pathology. 


532. Haematolo^ of Measles. 

F. Eedlich and Z. Maternowska (Monatsscli.f. KiiulcrheiV! 
January-Februaiy, 1928, p. 178), during an outbreak of 
measles at Lemberg, examined the blood of twent}--two 
cases and came to the following conclusions. During the 
incubation period there is often a rise in the number of. 
leuooo 3 'tes accompanied bj' an increase of the eosinophils* 
in the prodromal stage the number of white cells falls, and 
there is at the same time an increase in the monocytes. 
During the eruptive period the diminution in the number of 
leucocytes persists and the percentage of the monocytes 
falls to normal. At the beginning of convalescence the 
leucocytes are normal in number or slightly increased, and 
there is a rise In tlie number of the eosinophils, plasma cells, 
and monocytes. There are also not infrequently cases in 
which the blood picture differs- from the type described 
owing to such factors as constitutional peculiarities, age, 
recent diseases, intestinal parasites, and, last but not least, 
the character of the particular epidemic. The authors con- 
clude that examination of the blood in measles maj'^ be of 
value, hut that in doubtful cases the diagnosis must be 
guided mainly by clinical considerations. , . ’ 

933. Hvpersensltlveness to Tuberculin. 

A. MOEliUER, studying.the phenomena of hj-persensitiveness 
to various tuberculins, has come to the conclusion (Med IVelt ' 
February 25th, 1928, p. 281) that some of the interpretations 
of this, reaction are untenable. He compare.s the hyper- 
sensitive reaction with the rashes of the exanthemata and 
believes that a period of hypersensitivenoss of variable dura- 
tion appears at some time in all tuberculous infections • tiiis 
is attributed to by-products of the contest between the 
organism and the invading bacilli, varying wltli tlie ago and 
constitution of individuals; ft is not due ,to antigens. and 
should not be regarded as a measure of immunity. These 
b}--m-odncts may at times be prc.sent in minimal quantities 
only, and, since in young guinea-pigs giving a negative tuber- 
cnlin reaction tuberculous lesions maj- often be found’ when 
the animals are killed and dissected, he considers the 
assumption unjustifiable that j-oung infants who give a 
negative tiibercnlin reaction are free from tuberoulotis infec- 
tion. He lias also found that on the thin arm of an under- 
nourished child a negative reaction may* he obtained, although 
when tho child becomes fatter again tlie reaction becomes 
positive. He adds that it has also been demonstrated in 
cattle that cutaneous hj'persensitivoness maj* disappear for 
a time, and yet the auimais may be very resistant to 
infection. - - 

934 . yitamln Deficiency and Iiiabllity to Infection.' 

C. E. Bloch (Vgeslcrltt for Lacgcr, February- 23rd, 1928, 
p. 185) notes tliat while he and various other observers have 
found vitamin A deficiency give rise to defective immunity, 
as demonstrated by the existence of varions infections' 


MEDICAL LITEBATEBE. • 


processc.s, no clinical or experimental investigations liave 
hitherto been made with regard to tho possibility of vita- 
min C deficiency having tho same effect. He aslts if vitamin C 
.doflcicuey provokes the same, degree of .defective immunity 
as docs vitamin A doiloiency% and whether patients sHlTeriiig 
from scurvy are apprecialily more susooptiblo to Inteotions, 
benign and otherwise, than other patients. To answer these 
questions ho grouped liis cllulcnl material into'two elasse.s. 
In tho first thoro wore 32 cases of scurvy* (vitamin G 
deficiency), and in tho second tlicrc wore 86 cases of 
xerophthalmia (vitamin A dolloiency). Among the oases of 
scurvy thoro were 18 Intauts whose ages were between 6 and 
12 mouths, and 14 children whoso ages were over 1 year, 

, Among the cases of xcrophtlialuila there were 20 infants 
ilnder tho ago of 6 months, 27 botwcon the ages of 6 and 12 
months, and 39 clilUlren whoso ages were over 1 year. 
Among tho cases of scurvy tliero were 9 showing evidence of 
some Infection on admission or during residence In hospital, 
but with tlie exception of one case of pneumonia and one 
case of pyuria and congenital syphilis coui)>lloated by 
’vitamin A defloiency, these infections were of a slight 
catarrhal character and rapidly* cleared up. Tlie incidence 
and severity* of the infectious in this class were not greater 
than in other hospital patients whose principal ailment was 
not an infectious dlsoaso. On the other hand, among the 
86 patients snlTerlng from xero[)hthaImla there were 68 also 
snfferlng from some infection, whicli in 15 cases consisted of 
pnenmonia, in 12 of bronchitis, in 13 of otitis media, in 27 ot 
pyuria, and in 14 of purulent conditions ot the skin. Those 
severe infections did not disappear till the vitamin A 
deficiency lind been overcome. The author concludes from 
these observations tiiat, in Denmarlt at any rate, it is only 
vitamin A deficiency*, among all tho varions vitamin fle- 
flciencios, wliich causes a marlced fall In tlie state ot 
■ iinmnnity. He notes in this connexion that while in chronic 
tuberculosis tho increasing ot the supply of vitamin A is most 
beneficial, tho increasing of vitamin 0 has little efteot except 
in tho rare cases in which tho tuberculosis is complicated by 
Bcur.-y. 

935. Chronic Suppurative Otitis Media Associated 
with Vincent's Organisms. 

B. Motta (Tl PolicUnico, Boz. Prat., January* 23rd, 1928, p. 83) 
describes the cases of two children with discharging oars; 
tho slight discharge tended to be fetid, and the children were 
often noticed to mb their ears with their fingers. At a later 
date tho discharge increased in volume and in fetor; it tvas 
found to contain largo numbers of fusiform haoilli and the 
spirilla of 'Vincent. The first case was a chronic condition 
ot nearly two years’ standing ; tho second was of . mucli 
shorter duration. In both ca.ses there was painful enlarge- 
ment of the uppor deep cervical glands, and in the first case 
there was an ulcer in tho external auditory* meatus, about 
halt a centimetre across. Both cases had been treated 'u’lth 
hy*drogon peroxide drops, but neither had improved. A 
solution of 10 per cent, salioylio acid in alcohol was tried 
bnt without success. Finally a 15 per cent, sblntion of 
hoosalvarsan was applied locally and a very* considerable 
degree of improvement was obtained. It was found that tlie 
spirilla of Vincent and fusiform bacilli gradually* disappeared 
from the . discharge, and many* pseudo-diphtheria bacilli 
remained. The author thiuks that the infection with 
Vincent's organisms may have been added by tho flngcr.s of 
the children. 


• 93B. . Acclimatization to Low Oxygen Pressures. 

J. A. Campbell. '(. loKj’n. of Physiol., September 9tli, 1927, 
p. 325), cohtlhulug his investigation ot acclimatization to low 
oxygen pres.sure equivalent to that ot the top ot Mount 
Everest; confirms the general rule that the haomoglohm 
percentage decreases as the oxygen pressure in the air rises, 
and vice versa. The changes produced by* altering the oxygen 
pressure pass off again after a few weeirs’ exposure to the 
normal. Changes in the haemoglobin percentage are, how- 
ever, not essential to acclimatization to alterations in the 
oxygen pressure, and should be regarded only as possible 
consequences ; tliey* are of some assistance to the heart wlien 
tliey* do occur. Campbell adds tliat, coutrary* to the prevailing 
views, aoclimatlzatiou to lowered oxygen pressure in the air 
is not due fo improvement in the tissue oxygon tension, but 
to the fact that the tissne.s accustom themselves to the lower 
figure. Bapld acclimatization is due to the ability of the 
vital organs — particularly the heart — to continue to function 
under a iow oxygen tension. In all animals experimentally* 
exposed to low pressures heart failure was the most constant 
phenomenon. Acclimatization to increased oxygen luessiuo 
in the air.wns similarly* found to be dne to the tissues accoin- 
Tuodating themselves to it. Hypertrophy* of the’muscnlar 
coat of the branches of the pulmonary* arteiy was observed 
to follow exposure to low oxygen pressures- 



.MAY 5, 1938 ] 


t -TneCnrmH 

Mn»lCAJL JomXAr. 


75 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 


■ 437. / ■ Latent Scurvy. 

Tilduon scurvy is oonsldcrctl ol rare occurrence, 11. OhselIj 
(Ada iled. Scaiid., Jlarch 15th, 1928, p. 176) believes that it 
is not so iutrequont in Sweden ns is thought, and that the 
syiuptoms nro often so luild ns to load to nn erroneons dia- 
gnosis. He has had twenty-two such cases under his care, 
and Jilonlcngrncht lias this year reported eight cases in 
Dcuninrlc. Of the twenty-two patients, six (aged 21 to 61) 
were males and sixteen (aged 21 to 53) were fcniales; all the 
cases seemed to ho duo to a lack of vitamin C in the diet, 
which had .been modilled in conaequenco of the existence of 
intestinal disease. The predominant feature in moat of those 
cases was n gingivitis, localized to the jiroximity of the teeth 
and accomiianicd by intensively swollen iutcrdoutal papillae, 
though rarely by marked bleeding. Cutaneous haemorrhages, 
almost c.KcIusivcly coutlucd to the lower extremities, were 
noted in most cases; these were usu.ally isolated, but in a few 
cases wore continent. Ilacmorrliagcs in other organs were 
rarely observed, haoniaturia occurring only in one and slight 
haemoptysis in two patients. Tests for occult liiclaona were 
always negative. In two cases there was marked oedema of 
the lower limbs, llhcumalic pains and slight anaemia wero 
often present, and nervous disturbances wero very frequent, 
(ibncll adds that the presence of gingivitis and cutaneous 
haemorrhages, combined with n history of vitamin G defi- 
ciency, arc the chief factors in diagnosis, wliich may be aided 
by a radiological examination ol the teeth for the typical 
scorbutic changes which aro often scon. Prophylaxis, difll- 
cult in Intestinal diseases, consists in supplementing the diet 
as soon as possible with frnit and vegetable juices rich in 
vitamin C, the juice of oranges, lemons, tomatoes, or carrots 
being given daily in teaspoontul doses. In treatment Ohnoll 
■.glvcs.thoso juices in larger doses — namely, the juice of one or 
several oranges or lemons or 50 to 200 grams of tomato or 
carrot juice dally ; since the vitamin content varies consider- 
ably In the same kind of fruit or vegetable, several different 
varieties aro prescribed lor each patient. 


438, Venous Drainage of the Cardiac Nodes. 

E. GfiUAUDEt, (/Irch. des Mai. dii Cmiir, Jlarch, 1928, p. 148) 
lias established the fact tliat the cardiac rhythm depends 
upon the arterial supply of the nodes, and he now gives an 
account of the venous drainage of these structures. The 
bundle of His and'the auriculo-ventricular node arc drained 
by n -vessel -which closely follows the artery supplying them. 
This vein Is joined by one flowing from the Interventricular 
septum, and the main trunlc then opens into the right auricle 
immediately above the valve of Thebesins. No vein is found 
corresponding to the principal artery of the slno-aurlcular 
node, but many small veunles are present in this region, and 
tlicy open into the posterior portion of the right anricle on 
tlie medial aspect of the crista terminalis. The author has 
previously shown that arterial ischaemia results in impaired 
cardiac action Corresponding to the nodes involved, and he 
considers that comparable alterations of rhythm may follow 
passive byperaemla of the nodes due to faulty drainage. 
Thus, since arterial hyporaemia augments the action of the 
heart, so hyperaeinia of venous origin should exert the same 
influence. Support for this hypothesis is found iu clinical 
medicine, for it is particularly in those cases of raitiol disease 
.associated with right-sided dilatation tliat tachycardia is 
most common. Passive hyperaemla of the nodes may, there- 
fore, be the link connecting auricular distension with rapid 
cardiac rhythm. 


939. Diphtheria of the Larynx In the Adult. 

C. ZOELLER (Hull, ct 31cm. Sdc. 3!M. des flop, dc Paris, March 
Etb, 1928, p. 426), who records a personal case, illnsbrates the 
rarity of diphtheria of the larynx iu the adult by the fact 
that Collet hdd-secn only eight examples. Megias rej)orted 
three cases, none of which was recoguizod at the onset, 
while one --was mistaken for tuborcnions laryngitis. It is 
noteworthy that Bretonneau made a retrospective diagnosis 
of diphtherial laryngitis in the case of George Washington, 
who died at tlie age of 67. ZooHer’s case was that of a 
colonel, aged 60, who had an attack of purely laryngeal diph- 
tUevia. followed by . paralysis of tbo palate aiid constrictors 
rb'' -Pbarynx, but ultimately recovered. It was remarkable 
that, living as he did in a community whore diphtheria was 
ubiquitons,.he had not becomeimmuutzed. ■ 


) 


440. Meningococcus Septicaemia. 

O. Hermans .and M. EiFscinTZ(Penf. mcd. ll'ocTi., March 2nd, 
1928, p. 355) state that moiJingococens septicaemia is not an 
infrequent occurrence. In all oases of suspected malaria, 
influenza, or enteric fever in which the diagnosis is not 
dcllnitely established a repeated bacteriological examination 
of the blood sbonld be made. According to Eriedeu'ann 
and Ucichor, tbo characteristic features of meningococcus 
septicaemia are (1) catarrli of the nasal mneous membrane, 
tliroat, or bronchi ; (2) fever, at first remittent and then 
irregular, from one to several months’ duration ; (3) erythema 
cxndativuiu or nodosum ; (4) protracted coarse witliout 
pliysical signs ; (5) a relatively good general condition. The 
author.s record a case in a man, aged 30, who presented all 
these symptoms and showed a pure culture of meningococci 
in the blood. Spontaneous recovery’ followed, the, disease 
being app.areiitly not atlectsd by quinine, arsenic, or iron. . 

44t. Trausverfie Myelitis as a Form of Hcine-Medln’s 
Disease. 

C. IIBsermann {.Irrii. /. KinderheiVk., March Hrd, i928,'p.25I) 
records the case of a previously healthy boy, aged 14, in 
whom, during an epidemic of poliomyelitis, there developed 
paralysis of both lower limbs and retention ol urine. There 
had been no trauma to cause haematomyelia, which might 
have given rise to these symptoms. Syphilis, tuberculous 
spondylitis, or a tumour w.bich could have produced a trans- 
verse lesion conld be excluded, as well as lead or anscnical 
poisoning. Tlie di.agnosis was therefore made of acute polio- 
myelitis in the form of transverse myelitis, of which several 
examples have been recorded in recent years,- so that the 
description of a transverse myelitis form of Heine-Medin's 
disease appears jusliflable. Since no normal -horse serum or 
convaic.sccnt serum was available, antimeningocoocal serum 
was injected intraspinally and intramusonlarly, and in the 
course of three months recovery ensued, 

442. Encephalitis following Measles. 

P. H. KR-AMER (Sederl. Tijdschr. v, Oeneesk., February 25th, 
1928, p. 937), who records five illustrative cases, regards it as 
probable that encephalitis following measles is not due 
directly to the virus of measles, but results from the invasion 
of a iieurqtropio virus which is already present in the patient 
or has attacked him after the onset of measles. Kramer 
draws attention to the greater frequency of the occurrence 
of encephalitis in connexion with other infeotrous diseases 
in recent years in various countries, such as vaccinia, 
varicella, scarlet fever, and whooping-cough, and- suggests 
that it may be connected with, epidemic or sporadic cases of 
encephalitis lethargica. 


Surgery. 


443 , Prognosis In Foreign Bodies In the Gastro-lntestlnal 
Canal. 

J. GRUNSTBIN (Zentralbl. f. Cftir., March 10th, 1928, p. 585) 
states that the majority of elongated foreign bodies that 
enter the alimentary canal are passed naturally pet anum. 
Some, however, are retained,, either on account of their 
size or because they become impacted in tbe region of an 
anatomical or patbologieal narrowing of tlie canal. Perfora- 
tion of the large intestine by foreign bodies is verv rare, bnt 
Bruniug reported a perforation of the transverse colon by 
a fish-bone, which was found in an omental abscess; tbe 
perforation in the iute.stlnal wall had healed completely. 
Theinflammatory omental swelling was removed successtullv. 
Griinsteiu now reports two other cases. A woman, aged 38,' 
observed a hard mass in the left side of her abdominal wail 
below the umbilicus. She ban occasional severe- painTn thi.s 
region, and her general health wa,s failing. At the operation 
a hard, tender omental tmiionr, as large as the fist, was found 
firmly- attached to the peritoneal surface of the abdominal 
■wall. The adherent transverse colon was definitely thickened 
over an area two inches iu diameter. With the probability 
of this being a carcinoma with omental nietastases, the bowel 
was resected and an end-to-end anastomosis performed. The 
omental tumour contained a flsli-bone and several abscesses 
-In the resected portion of the bowel .there was a, perforation 
which easily admitted a .sound. Tho patient did well until 
the fourth day, when a sudden fatal liacmatemesis occurred 
A man, aged 36, was said to have -had recently a severe 

788 A 


76 5 i 1928] EPITOME ,OE CURRENT 


attack of typlius with melaena. A skiagram showeii a tleop 
sliailow, three flogers in breadth, below the iiver margin, 
and a diagnosis of metallic foreign bodies was made. On 
opening the abdomen, .a .hollow viscus presented, densely, 
adherent to the parietal porltonoum over an area as largo as 
a five-shilling piece. Thin proved to bo the stomach, and 
immediately beneath the pylorus a irrotrusion as largo as a 
small apple was found. On opening this sac two coins and 
fifty-six straight and bent nails, some as long as 5 inches, 
were found. The patient made a rapid' recovery. The 
author adds that reports of such cases, followed by successful 
operation, are very frequent, and prognosis is favourable it 
operation is not delayed. 

4^9, Myositis Ossificans. 

T. E. Chambers (Arch, of Stirg., March, 1928, p. 755) reports 
an uuusual case of myositis ossificans occurring in a man, 
aged 28, who, while helping to lift a motor car, felt a sudden 
sharp pain in the upper part of his right arm and .shoulder,’ 
which was followed by swelling and slight pain and tender- 
ness. A month later an K-ray examination showed a definite 
bone forming tumour of the outer side of the right humerus, 
which was thought to be due to the stripping of the peri- 
osteum at the insertion of the deltoid, the result, of the 
indirect violence a month previously. Six months later the 
bony mass was larger and appeared to be extending round 
the shaft as a pedunculated bony tumour attached to the 
humerus at one point. It was at first thought advisable to 
defer operation until the mass had ceased growing, but a 
sudden rapid incraase in size led to a decision to. operatej 
aud twenty months after the injurj' the mass was curetted 
down to the shaft and a considerable amount of periosteum 
with some cortex was curetted and chiselled off. The wound 
liealed without any complication and tiie patient was freed 
from |)ain. Two months later recurrence took place; and 
steadily increased, threatening the blood and nerve supply 
to the arm. Amputation at the shoulder-joint was performed, 
and one and a halt years later there was no evidence of 
any further involvement. Sections showed typical myositis 
ossificans without any sign of malignancy. Chambers com- 
ments on the possibility that the condition was duo to 
indirect violence by muscular exertion, recurrence follow- 
ing removal before a stationary or receding stage had arrived, 
liad it not been that the earlier x rays showed the cortex 
to bs intiot without eros'on or irregularity, a diagnosis of 
lieriosteal sarcoma would undoubtedly have been made after 
the first operation in view of the recurrence, and because 
the films then more closely resembled sarcoma, the mass 
being more irregular, and the cortex being irregular aud 
eroded as the result of curetting. 

Treatment of Prostatlc Hypertrophy. 

G. H. Ewele (Amer. Journ. Snrg., February, 1928, p. 201) 
states that the mortality after operations on the prostate 
during recent years has fallen to about 3 per cent, as the 
result of careful pre-operative and post operative preparation 
and treatment. The Institution of bladder drainage and the 
forcing of Uuids before operation is important. Acrillavine 
is usually administered together with urotropine, and if 
cystitis is present bladder-irrigation is performed twice daily. 
The suprapubic operation gives excellent results, and the 
mortality is low witli this method. Nitrous oxide or ethylene 
gas are the anaesthetics of choice. Complete baeinokasis 
after operation is the second most important factor in the 
management of these cases; this. is secured by gentleness 
and care in the enucleation, and by the use of some 
mechanical pressure. The Pilcher bag is useful, but the 
gauze pack is to bo proferred. . This is soaked in glycerin and 
packed tightly into the gland cavity. Bladder Irrigation is 
started about the fourth day. • Epididj’mitis is a frequent 
complication and may retard convalescence. Double ligature 
and division of thovas prevents this and should be performed. 

9?3. Death In Acute Intestinal Obstruction. 

W. D. GATCH, H. M. Trusler, and K. D. Atres (Siirg., 
Gynecol, and Obstet., March, 1928,. p. 332), discussing the 
cause of death in acute intestinal obstruction, conclude that 
in .simple obstruction without gangrene death is not due to 
absorption of toxins, but results from dehydration and the 
loss of chlorides through vomiting and starvation; in acute 
strangulation, however, death is due primarily to toxin 
absorption from bacterial action in the distended and gan- 
grenous bowel, which quite overshadows the dehydration and 
hypochloracmia. In simple pyloric or duodenal obstruction 
operation.should be postponed until the dehydration, hypo- 
chloraemia, aud starvation have been overcome by the intra- 
venous administration of sodium chloride, glucose, and water; 
in early stages of intestinal obstruction the operation .should 
be performed as soon as the blood chlorides have reached 
■ 78 S E 


MEDICAE LITERATURE. [ 


a normal level. The authors think that, unless the patient is 
moribund, the prognosis of acute simple obstruction should 
be favourable, provided that tho metabolic disturbances 
respiting from dehydration and loss of. chlorides can bo 
relieved by the administration of sodium chloride solution. 
In obstruction cora[)llcatod by gangrene, such treatment, 
while it supplies fluids and chlorides and increases kidney 
elimination, does not relievo tho to-xaeinia, which is clOi;cly 
allied to that of surgical shock ; such patients stand anaes- 
thosia badly, and the operation should always bo preceded by 
tho intravenous administration of a considerable quantity of 
sodium chloride solution. Tho gangrenous loop should bo 
excised and enterostomy performed, an intestinal anasto- 
mosis being postponed until tho patient has recovered, and 
not being undertaken in tho presence of groat distension of 
tho bowel. 


iTherapeutics. 

441. Heliotherapy and Bonal Tuberculosis. 

A. BOLLIER (Hrit. Jonm. of T/iiercufosis, .Tanuary, 1928, p. 9) 
outlines tho important position v;hich heliotherapy occupies 
in tho treatment of renal tuberculosis as a most valuable 
subsidiary agent. He • considers nephrectomy ' essential as 
soon as tho diagnosis of noi/atcral rooni tuberculosis is bstab- 
lished because of tho risk of bladder infection. In such cases 
heliotherapy is of use, and is especially indicated in tho pre- 
operative stage for those patients whoso general condition is 
precarious and- who aredikely to-be poor operative risks or to 
suffer from post-operative complications. It is claimed that 
helio'therapy induces repair of tuberculous lesions, improves 
tho circulation. Increases tho general powers of .resislauco, 
and, by. developing local cdllular' resistance in tiio area' of 
tho operation, it iqs'sens tiie Visit of wound infection. Post- 
opo'ratively heliotherapy gives excellent results by assisting 
healing, destroying germs,' aud stimulating the cellular 
defence. In bilateral disease it is tho trcatniont of choice 
in helping the organism to light against extension of tho 
tuberculous lesions and exerting an aualgesio actioil upon 
ulcerations of tho bladder. To bo oillcacious its administr.a- 
tion demands strict adherence to proper dosage lor each 
individual case, so that tlie local and general reactions never 
become so intense as to be dangerous. Application to tlio 
whole surface of tho skin, commencing wltli tiie lower 
o.xtromities, is of importance, the different regions of tho 
body being exposed In short sessions at intervals of five 
minutes, repeated three times. Local treatment should 
I’arely exceed thii'tj' niinutcs for the kidney or bladder. 
Rollier advises patients to talco up somo.form of work wliich, 
combined with the sun cure, exercises a valuable psycho- 
therapeutic Influence. 

548. Arsenic and Bismuth Therapy In Hodgkin's Disease. 
Although certain chemical x’roparations exercise a rapid 
aud r.adical effect at first ou tho glands in Hodgkin’s disease 
Michaelis (lirnxelles-Mcdical, March 18th, 1928, p. 677) gives 
the warning tliat the prognosis should bo guarded, since m 
tho final stages tlieir action is Inefficacious. He reports an 
illustrative case of a woman,- aged 52, who when first seen 
had an enlarged gland behind the right ear. Treatment with 
an iodine ointment aud hot moist dressings caused no ini- 
provoiuent, and, three weeks later, furtherenlarged indurated 
ganglia were found in tho neck aud arms. Cytological 
examination of the blood revealed no .special features; tho 
"U'assermann reaction .Avas negative, and the family history 
was inconclusive ns regards syphilis. At this time the right 
parotid gland commenced to enlarge, and a diagnosis of epi- 
demic parotitis Avas tentatively made. Three intramuscular 
injections of eparseno (12 eg.) were given, Avhich were folloAved 
by decrease in the parotid aud in the subjacent and sub-^ 
raaxillai-y glands, though other enlarged glands appeared. 
Tavo further injections of eparseno AA-ere not AA-ell tolerated, 
and three injections of mercury cyanide Avere given. The 
parotitis completely subsided, but an attack of general 
pruritus supervened. ' Owing to. the persistence of the 
adenitis, which proved that the parotitis Avas secondary and 
not primary, and the continued negative character of the 
blood reaction, a diagnosis of Hodgkin’s disease was now 
made. Fearing the action of arsenic on the liver Michaelis 
now employed injections of Millet’s beuzo-bismuth (20 eg.) 
tAvice weekly. This at first had a rapid action on the ganglia, 
but later another ganglion appeared in the right axilla, and 
tho right breast became enlarged and congested. X rays 
Avere tried, but without effect. The patient became emaciated : 
cough, dullness over the intero-lateral and posterior region 
of the right lung, and enlargement of the liver occurred. The 
blood still shOAved no changes, and now a diagnosis of lympho- 
sarcoma terminating the Hodgkin’s disease Avas' made. At 
the end of the seventh month the patient died, iracumonia 



May Si jgjSj 


EPITOME or CURRENT MEDICAL LITERATURE. 


[ The Uninsii 

UZDICAX. JOUHXAX. 


77 


not supcrvciiiuH, since the pulmonary tumoui- did not undergo 
niccialion or suppuration. MlcUaolis draws attention to tho 
initial Ijoncllclal action ol tho arsenic and bismuth in this 
case, and siiURCsts that this was possibly duo to tho prcseuco 
ot a syphilitic terrain upon which tho llodgltlu’s disease 
developed. 

449. triinlllum Acotato In nintfworm. 

11. 1'. Fki.uen (Arch. Derm, nnil .Si/ph., Fohruary, 1928, p. 182) 
records his cxperlcnco ot troating forty-seven children- 
with riiiywoiui of tho scalp by oral administrations of 
thallium acetate; of those, thlrly-sl.': wore cured by one 
dose. Tho doso Avas 8 ui;t. of tho drii(> for each kilogram of 
body wcifiht; it was dissolved in half a fjlass of water 
sweetened with suHar, and given on an empty stomach in 
tho morning. Epilatiou usually occurred on tho elgliteenth 
day, but was only entirely complete in a])proxiinatoly 50 per 
cent, of tho cases, tho remaining loose lialrs being painlessly 
extracted by strips ot adhesivo jilastor ; in somo cases only 
partially successful results wore obtained. In from three 
to four weeks the hair began to grow again and during 
tho whole period daily local treatment with 5 per cent, 
tincture ot iodine and 10 per cent, sulpiiur ointment 
was coutiuoed ; It was found that this did not canso 
irritation, thus constituting an advantage ns compared 
with x-ray ti-Qatmont. Patients with a marked discrepancy 
between weight and ago are said to bo unsuitable for pure 
thallium treatment, hut a modillcation consisting ot one- 
half or two-thirds ot tho doses ot both x rays and thallium 
combined gives good results. On account ot its toxicity full 
dosage must bo avoided in adults and adolescents ; repetition 
ot tho doso in loss than two months is dangerous, and acute 
infections nud kidney diseases arc contraindications for its 
use. Symptoms of poisoning are : muscle and joint pains, 
choreiform convulsions, albumlnnrla, gastro-intostiual dis- 
turbances, achlorhydria, secondary anaemia, and tachy- 
cardia.- Foldon regards tho drug ns ot value in piodneing 
epilation in children, but warns against its judiscrimlnato 
use by those who are not familiar with its grave toxic 
qualities nud contraindications. 


Anaesthetics. 


450. Ocular Complications of Spinal Anaesthesia. 

J. Rollet (Aourn. clc Med. do Lyon, March 20th, 1928, ]). 167) 
states that ocular complications following spinal anaesthesia, 
which wore first described by C. Adam and then by Looser 
and Roe.ler in 1906, are rare, tlioir frequonoy being about 
1 in every 300 cases of spinal auacstliesia. Paralyses of the 
external rectus are far the commonest, occurring in more 
than 90 per cent, ot tho cases. Involvement of the oculo- 
motor nerve is much rarer. Paralysis of the external rectus 
is generally unilateral. Other ocular palsies are exceptional. 
In spite of tho toxicity ot cocaine, most ot tho paralyses have 
followed the use ot stovaine or novocain, and in only one or 
two cases has cocaine been incriminated. As regards the 
size ot tlio dose, altliougli at Urst paralyses occurred even 
after small doses, at present they have mainly followed large 
doses. The ocular paralyses may bo sometimes accompanied 
by affection of other cranial nerves, while signs ot a meningeal 
reaction are constant. Tho paralyses usually appear a week 
after the operation, and subside in the course of si.x or seven 
weeks. Ot tlie numerous theories suggested to explain their 
occurrence, the most likely appears to be localization ot an 
attenuated meningeal process follotving spinal anaesthesia. 
It is possible that a previous taint, sucli as syphilis, may 
cause a special disposition. Recovery is usually spontaneous, 
but may be. hastened by treatment with strychnine or 
urotropiue combined with antisyphilitic drugs. 


,451. Splanchnic Anaesthesia In Upper Abdominal 
Operations. 

H. E. Murray (Indian Med. Gao., March, 1928, p. 117) men 
tions the ditUcuIties and annoyances encountered in surger- 
of tho upper abdotnen AvhicU can be obviated by anaesthesh 
of the splanchnic area ; ho has adopted this method in twelvi 
cases with striking results. AVithin two or throe minutes o 
Induction tho patient is breathing without distress; there i: 
no protrusion of tho iutestines into the operation area or on 
of the abdomen, and the amount of general anaestheti* 
required is considerably lessoned. Two strengths ot novocain 
/z and 1 per cent., and a 50 c.cm. and 30 c.cm. syringe an 
employed, 100 c.cm. ot tlio 1/2 per cent, solution being use< 
tor the first stei) and 30 c.cm. ol tho 1 per cent, for the second 
general anaesthesia having been started in tho usual manner 
w” , “ into the skin and deeper tissues at tin 

cArtlli. arches. AVlieu the rib o 
cauuaoO is felt the needle point is doiu-essed,’ passed' fo 


a short distance under tho arch, and some ot the 1/2 per cent, 
solution is injected into tho tissues surrounding the inter- 
costal nerve. Tho ueodio is then withdrawn, inserted a little" 
higher up, and more .solution is injected. This is repeated 
until tho eusiform cartilage is reached, and the opposite 
costal arch is similarly treated. After opening the abdomen 
tho lessor gastric curvaUiro is defined and tho fingers of tho 
left hand are introduco'd above It until tho body of the first 
lumbar vertebra is felt just above and to tho right of the 
origin ot tho coeliac axis. The index and middle fingers are 
then slightly .separated, thus pushing the aorta to the left 
and leaving an area devoid of blood vessels on the vertebral 
body. Tho needle is passed into this space and on to the 
body ol tho vertebra ; tho 1 per cent, solution is then slowly 
injected. Caro must be taken not to puncture a blood vessel, 
but,- If this should happen, the needle must be withdrawn 
and Inserted in anotlier place. No adverse sequels have been 
noted In any ol tho case.s'. 

952, Regional Anaesthesia for Operations upon the 
Spinal Column. 

G. Lab.at (.Anesthesia and Analgesia, .Tanuary-February,' 
1928, p. 38) points out that tho principles involved in the 
induction ot regional anaesthesia for orthopaedic operations 
upon tho spinal column differ to some extent from those 
underlying tho technique lor other operations, since they 
have usuallj' to bo made in regions where the landmarks 
have been distorted by trannia or disease, and that therefore 
tho anaesthetist must have a Ihorough anatomical know- 
ledge. Tho best posture for the patient is lying prone; this 
facilitates the paravertebral injection technique and keeps 
tho back muscles ns relaxed as possible. Induction of para^ 
vertebral block by approaching the nerves from a iioint over- 
lying tho transverse processes is advised, since tho same 
■wheals are used for tho field-block. By producing tho 
“ barrage” as near tho middle ns possible- forcible retraction 
does not cause any discomfort, part ol tlie injection finds- its 
way through tho wound, and the resulting ischaemia of tlio 
operative field facilitates dissection. A 0.5 per cent, solution 
ot novocain with tho addition ot five di-op-i ot adrenaline 
solution (1 in 1,000) to each 100 c.cm. injected is advised to 
delay absorption and increase the duration ot the anaes- 
thesia. Not more tlian 250 c.cm. should bo -very slowly 
injected, it being borne in mind that perfect anaesthesia 
should not be sacrificed to the possibility of sliglit circulatory 
reactions which have no clinical significance. 'Under regional 
anaesthesia decompression ot the cord is rendeied- less 
difilcnlt and hazardous: extensive spinal fusions can be 
performed witli but little post-aiiae.sthetio disturbance and 
greatly improved prognosis, especially in the presence ot 
active imlmouaiy tuberculosis. 


Obstetrics and. Gynaecology. . , 

953. Cystic Swellings of the Abdominal Wall 
Following Trauma. 

AV. KOLDE (Xentralhl. f. Gyniilc., March 3rd, 1928, p.'553) 
describes two cases to illustrate the diagnostic difiiculties 
which may be caused by large subcutaneous collections ot 
fluid in tho abdominnl wall. The first patient, a woman 
aged 46, reported abdominal swelling and general wastiu<> ot 
flftceu mouths’ duration ; the appearance ot tiio abdomen 
(its girth was 4 tt. 5 in.) together with tho emaciation sug^ 
gested a giant ovarian cyst, bat tho iudeflniteness ot'the 
Jimitatiou ot the tumour above and below led to a diagnosis' 
ot ascites Irom intra-abdominal carcinoma (primary'tocus 
unknown) or ot peritoneal tubevonlosis. Incision ot the 
skin as a preliminary to laparotomy gave issue to nearly 
nine gallons ot greouisli-brown fluid containing necrotic 
shreds, and the tumour was emptied without incision ot 
the abdominal cavity; microscopical examination of the 
cyst wall pointed to its having a lynipliatio origin. The 
patient’s hoalth and weight were subsequently tully restored ■ 
Questioning elicited tlio .statement that tho abdominal swell- 
ing liad been preceded by a fall with direct violence to the 
abdomen. In the second case a fall iuto a pit at work was 
followed by tho admission ot the patient, a l-para aged 22 
to hospital ; fracture of two ribs was noted, as well as morbid 
physical signs in both lungs, and a diagnosis ot miliai-y 
tubercio was made. A collection ot pus iu tlio poneb of 
Douglas was evacuated by the posterior foruixf but an 
abdominal swelling, thought to be duo to abdominal tuber- 
culosis, did not regress. At operation a largo abscess was 
evacuated from the, space between tlie abdominal w->Il 
muscles aud tlio poritoneura. ’The tall was tliou«lit to have 
caused tho formatiou iu’tliis region of a baematoma wliicli 
bad bccoiiio infected by the blood stream from the iielvic 
abscess. Kolde adds that to arrive at a correct pre-operative 


7S8 c 


78 may 5, 1928] 


EPITOME OF. CUEEENT- MEDICAL LITEHATUEE- 


[ The Britiw 
MxDiCiU. JetrsffAft* 


aUiynosis ill cases of collections ot, lliiUl in the abdominal i 
-ivall aijpears, Irom the cases recorded in the literature, to bo ■ 
exceptional ; among the diagnoses ■ made, have- been- ilens, 1 
twisted ovarian tumour, ' choielithiasis, and Strangulated 
hernia. Treatment, except in the, case of small haeiiiato: ; 
mata, is surgical ; if it is .too long delayed there' is danger of . 
secondary infections and of grave cachexia. ' ' ' 

45?. Chronic' EndocerYlcitls.'.', ‘ < 

C. J. MlliLBR (Sitrg., 'ihoi' 

p. 337 ), discussing the , ■ ■ 

considers that the un 

treatment arise from ■ ■ , . 

manifestation of the 
cause. Since the cor . 

to spontaneous cure, and gives rise tp-seguels which may bo 
very serious, prompt treatment is fnecessary ; any surgical 
procedure should be preceded by a Course ot treatmout with 
a view to reducing hypertrophy and.inflammatory rbaction and 
to restoring thenormal relation ol thoimrts. Local treatment 
has been found very unsatisfactory, and diathermy, ib'uiza- 
tion, alcoholic injections, and vaccines are onlj'- moderately' 
effective, while radium is too dangerous^ for routine employ- 
ment. lu a large number of cases cudocervicitis may ho 
averted by prophylaxis^, 'especially soon after 'parturition. 
Cauterization, trachelorrhaiihy, or removal of the gland- 
bearing area of the cervix b'y 'thp -Stui'nidoif o'peratiou may 
be needed, 'but amputation ot 'the' c'er.vix should bo avoided 
whenever possible. If there should be the slightest evidence 
of stenosis after the use ot the cautery' graduated dilatation 
must be promptly instituted. Miller agrees with the siig-' 
gestion ot Mattliows that the iudications lor cauterization 
may be widened if it isj performed unilaterally so that one 
lip is allowed to heal before the other is treated. 

95 s. Bladder Irritability 'of Rectal Origin. . 

H. Eymer (Zentralbl. f, Gyniik., February 25th, 1928, p. 498) 
reports a case in which irritability ot the bladder was Kept 
np by an abnormal rectal condition after tbe original cause 
had been removed. The patient, a .married nullipara, aged 
40 years, had complained of frequency of micturition for fiyo 
years. The urine showed no abnormality. Directly behind 
the bladder in the anterior wall of the uterus lay a fibroid 
as large as a fist aud fixed in the pelvis. The yagina was 
double, with two external orifices, and the uterus -was septate. 
After hysterectomy the bladder conditiou improved- but did 
not disappear, and tbe patient then stated that she fiad had 
anal tenesmus and painful aud diffloult defaecationnince the 
beginning of the frequent micturition. On examination .the 
external sphincter was found to be greatly hypertrophied,' 
the mucous membrane was tlirown into folds tightly pressed 
together with tiny faecal masses and rhagades between them, 
aud the levatores ani were also very strongly' developed. 
About a year after the hysterectomy the sphincter and 
levatores ani were thoroughly stretched and the bladder 
trouble ceased entirely. 'The condition was thought to be 
due to the strenuous efforts of the patient to control the 
frequent and precipitate micturition. She contracted- the 
whole iielvic floor, causing-it to hypertrophy; the eufolding 
of the mucous membrane, with faecal retention and forma-; 
tioii of rhagades,- led to the tenesmus of the external, 
sphincter ani. 


Pathology. ' 

45G. The Nature ot Bacterial Anaphylaxis. 

J. TomcsiK and T. J. Kukotchkin {Jo'tii-n. Exner Hied ■ 
March 1st, 1928, p. 379) remark that the main difficulty in 
studying bacterial anaphylaxis is' the primary toxicity of the 
bacterial protein ; Doerr showed that tbe amount ot bacterial 
antigen which produces shock in sensitized animals is 
negligibly smaller than the lethal dose for normal animals. 
Zinsser and Mallory reported-, -that act'vo — .i-c., . 

rendered very difficult Because the bacte 

little coag’ulahle protein, and that' in - . . ■ 

there is an apparently' slowni- -unibh- ot 
animal tissues than in the Case of protein antibodies. The 
present authors think, however, that the prlniary toxic sub- 
stance of the bacteria is not' necessarily identical with-the 
specific antigenic part and that it might be possible to isolate 
an atoxic spaciflc constituent responsible for anaphylactic 
shock. The discovery of speoiflcally acting polysaccharides- 
led them to; investigate -ivhether animals' -could be sensitised 
to carbohydrate haptines, either actively by the Injection of 
bnctoria, -or passively by immune serum. Using guinea-pigs, 
experiments were made with B. laefis acroycnes, pnenino- 
bacilH; and a'yoast. 'No inaction -was, noted 'in'aSy'ot these' 
testsMu actively sensitized 'ahiuia,ls', 'b'tit in the passi>-'ely; 
sensitized ones bacterial anaphylaxisnvas produced; in vivo ' 
7SS D 


aud in vitro, with haptines from .each . ot the tost micro- 
orgaulsms. The smallest amount of haptino-giving riso-to 
fatal anaphylaxis was loss than the .•uilnlraal .'quantityjof 
dirotoln "Which caused doatii- in jiropcrly, sensitized: animals. 
The haptines used -wore largely nnrbphydfates, .^16^ since 
they contained a small amount of -nitrogen, H- could 'not be 
positively assorted tliat carbphyd rate alone will -prodifce 
shook. Since liaptincs .will not sonsitizq'animalsi'thoso in- 
vestigator.s conclude that 'tfic- nnapliylactdgonic and shock- 
producing parts of the antigen aro-not ulentlcali-and-that the 
experiments' provided further evillonco of the' close rolatio'n 
b'btwecn prccipitins and anaphylaxis'; '■ ■■ 

to 1 . . .- ■ ' ' 

.j 457. Aleath from Air Embolism. 

L, juNG and L< AUGUn {C. It. Sac. de^Bioioijie, March '9th, 
1928, p. GIO) recall lliat many explanations liavc been given 
of death from air embolism — such as iiuimonary enibolism, 
nervous disturbances, and distension of the right ventricle 
leading to paralysis of tho hoart.. Thpir. own experiments 
suggest n different pnthogo'iicsis,'.. To .kill a dog it is noces- 
sary to inject at least 50 c,om. of air into the right ventricle 
or at least ..100 c.ciu. into the jugular vein ; moreover, this 
amount nnist.bo lujectedin-tlio opurso_ of a fow seconds. It 
the nlr Is; Injected sufficiently ,slbwly„.aO; almost indoflnite 
amount cun Vio used. Immediately niter Injection there is a 
sudden fall of pieBsnro, in the carotid artery to 30 to 40 mm. 
ot -mercury. The right auricle and ventricle dilate rapidly, 
and. a peculiar sound.is heard during systole. After a short 
timotnumerons bubbles of gas are seen in the coronary veins 
passing in n retrograde direction till they reach the finest 
branches, whore tli.oy stop. Shortly afterwards both ventricles 
enter into fibrillation, while the auricles continne to beat. At 
this moment the right lieart, the great veins, and often veins 
at a considerable distance are filled, with a foaming mass of 
blood. -If the air is introdncod into, the left ventricle, only 
20 c.oni; is required to cause death ; almost immediately 
gas bubbles enter tlio coronary' arteries, whore they come to 
a standstill, and the two vontriclos pass, into fibrillation very 
rapidly... In neitlior instance wore any appreciable lesions 
found in the lungs, nor did section ot tbe.modnlia or vagus 
nerves' alter .'t'lio cardiac manifestations. In interpreting 
these findings the authors consider that ventricular distension 
is by'itsolf insnfiloieut to cause death, partly because it does 
not occur when tlie injection is mode into tlio left heart, and 
pa'rtly bocansd it cannot explain the slmiiltanoons arrest of 
both ventricles. They believe rather that death occurs from 
embolism of the coronary arteries- when the air is injected 
Into the left ventricle, and from retrograde embolism of the 
coronary veins when -it'. is injected into the right ventricle; 
in c'ach case thocoronary'embolism is followed by ventricular- 
fibriilation and death. ' ' '• • ■ . 

458 ; The 'Relation .Bet-ween aiucose In the Blood and 
"1 ' :i; > ., 1 -' Spinal Fluid, ■ 

' Accobd'ing to 'S.' KatzEnelboge'n" and Mile M. StoIloff 
i (Ann. rlc'Mcd;, Fcbriiaty, 1928, p. 160) no significance can bo 
; atfache'd tP the amounts of glucose in the spinal fluid whffiii 
: some nnthors consider excessive, because such quantities 
have been noted both in different pathological conditions and 
j ill normal subjects ; they conclude that tbe hypothesis that 
I Byperglycorrhachia is due to a local trouble in the cerebro;- 
spinal axis favouring tbe passage ot glncoso from the 
Blood to the 'spinal fluid must be abandoned. The inter- 
dependence of the blood and cerebro-spinal glucose in 
diabetics has been long known, but in non-diabetics the- 
flgures vary greatly. Derrien estimates the spinal fliiid 
glncoso content as half that of tbe blood content, while 
Folonowsky and Duhot think these amounts aro equal, and 
other workers report figures between these extremes. In 
order to ascertain if a “haemo-meningeal ” relation exists— 
a relation depending not only on the amount of glycaemla 
but aI.so on modifications - of the- cerebro-spinal axis-^hc' 
authors .examined forty.-two cases of different maladies— 

) namely. -meningltls,, nervous and . mental troubles, and dls- 
I. '■ '• . .1 -- i'--"- — IS (gastric, respiratory, 

[ , .... , . , . . ' meningitis and one of 

; ; • ' ■ ■ -to be lower than the 

1 figure of Derrien, and in thb other -cases the ratios varied 
I from 0.41 to 0.83. It -'has Been shown that experimental 
' aseptic 'iiiflammation'-of the meninges increases their perme- 
ability for nitrates, but that the amounts of these salts 
which pass into the spinal fluid are not proportional to tho 
Intensity of the inflammation. This variation in permeability 
I is Still' greater for glucose. The authors believe that the 
amount ot glycorrhaohia is dependent in a certain measnro 
on the degree of glycaemia, hut more so on tho ineningoal 
permeability, which, favoured by meningeal congestion, is 
snbject to important phj'siologTcal variations. They' maintain 
that nh'increas'ed ratio’ BeDweeU-tiie' blood and Cerebro-spinal 
glucose has no'semeiolbgicalsigniffc^nc''eV-''- ''^''i " 



JIAY II, igaS] 


[ TiTzHBrnsn 
RTgnrgAT. JoxniXiL 


79 


EPITOME OF CURRENT MEDICAL LITERATURE, 


Medicine. 

55^. Hcnrt-blooH in Vonni! SuWocts. 

JL Cf-UI!C nml .11. Jjtrv {/lull, el Mem. Hoc. Med. Ih'ip. dc Paris, 
Slnrch 22n(i, p! -ISO), In an Investigation or hoart-bloclc, touuil 
tlmt tills condition niiglit occur in children and young adults 
ns well as in jiiiddlo-agcd patients, .althongli Adams-Stokos 
attacks wove less liable to cotupllcate the juvenile gronj,. 
lltey describe four cases In wliicli lieart-bloclc was either 
constantly or -usually complete in patients between 20 and 28 
years of age. Such cases may he classlllcd into those which 
aro nncotniilicated and those in which there is a coexisting 
congenital- cardiac detect; cases in the latter .group arc 
Tisuallj diagnosed hefore 'the ago ot 10 on account ot the 
accompanying cyanosis, avhilc those without conyillcatioiis 
remain nnrccognixcd often until 20. Diphtheria Is an hu- 
portant etiological factor, but rhouuiatisin is not; the 
inllnenco of syphilis and congenital heart disease la not 
Iniown, The development of the .condition is .slow, and 
tbongli syncopal or convulsive attacks may supervene 
whether the bloclc is complete or not, they occur only in 
one-third ot all cases. Since congcnitid malformations aro 
themselves of grave import, prognosis as regards lifo is bettor 
in the nncomplicatcd cases; these withstand intercurrent 
infections, opernfJons, mid even pregnancy very well, and 
trcgnently the patient snITers no ill effects from strenuous 
exercise, althongli there Is a tendency for syncopal attacks to 
foilow -violent exertion. Itestoration ot normal rhythm never 
occurs. For treatment, the authors advise soluhaino in 
small doses, alternating with helladoiiun; sports should bo 
forbidden and the uvoldauco ot pregnancy is recommended 
iUTiow ol the danger ot Adams-Stokos attacks. 

9EO. Pulmonary Gangrene fotlowlngJllphUicrla. 

C- X. Olcott and J. G. jilEiisltLTS {.^mcr. Journ. Pis. Child., 
February, 1928, p. ^OJ record n. case ot pulmonary gangrene 
following , a severe attaok.ot faucial diphtliorin, which proved 
fatal on the twelfth day at disease. .-V diagnosis of .pulmonary 
Sangreuo was made only forty-eight .hours beloro death 
owing to the signs ot pulmonary consolidation and the foul 
odour ot the breath, ilici-o was practically no sputum. An 
tc-ray examination showed irregular .patchy cousolidation 
scattered throughout both lungs, with areas of cavitation in 
the right lung. At the necropsy the lower two-thirds of the 
right lung were found to be eoniplotoly gangrenous. Smears 
from the lung showed Vincent’s organisms, and cultures 
yielded abundant diplitheriaiaoiUi, non-bacmolysiug strepto- 
cocci, and stapliylococci. Tlio authors bclicvo that no 
similar case ot pulmonary gangrene following diphtheria has 
been recorded. 

4SI. Immunity following Herpes Zoster. 

31. OBEim.tTEn {Derm. M’oeh., March 3rd, 1928, p. 297) remarks 
that -until recently most aTitliorities inarataiued that one 
attack of herpes aostci- oonterred a lifelong iinmnnity, and 
only a few examples of second attaelts of sostev have boon 
rcTOi-ded. Obermayer reports tlic oase of r. man, aged 32, 
w-hoiu the course of a few yoor.s had eleven ToourrenoeB of 
typical left Jnmbo-‘-acral zoster, accompanied by the cliarac- 
teri'-iio constitnlional dis-tnrbance in the protironial stage, 
inguinal ademtls,aud neuralgic pain. Tliopatient had liadan 
altackof TOiicella in cbildliood. lu-contrart with previously 
rcpnrtod cases -U jo latest attacks were iriore severe than the 
previous ones. .Sexual excesses appeared to be causally 
connected -with the eruption, -which nsnally Qovclopod after 
an. “inenhation period” of .two to four da3's. A somewhat 
anuiiar^ cose ot recurrent zoster is i-eportod hj' ilichtor in 
connoxiem -witli menstruation. 

Orchitis -rotlowlnff Tilnnips. 

(l.a -Vnrfecinr, December, 1927, p. 184) -gives the 
Statistics ot -orchitis in mum,p.s based on personal 
mnB-or-403 cases of mumps and studvot the olllcial 
jL^tcnch army during the pcrioil 1832-1913 
Frotiio? ™ 373,197 cases. ’Plic freqnency of mnmps in the 
■'’aries considerably from one year to another, 
esti'mn? ’wi' ^ 3,000 ot the total streiigtli. Laveran 

60 t of orchitis at 33 percent., Huilelo at 

38 niid 1705801110611 and Benard hirn.self at 

to he •T.tv 1 , tormer times, -n-lien soldier.s were not admitted 
Wa-vnnnB '"mnipsaiid were often kept on dnty% orchitis 
1 075 than at present. Daveran collected 

> 03 ot mumps, complicated by orchitis in 184, ol -which 


21, or almost 1 in '9, wore hilaleral. In Benard’s Keries iin 15 
ot Oio cases of mntnjis orchitis was bilateral. AsTegardstho 
frcgncncy ot testicniar atrophy following mumps orchitis 
-only kwo ot ‘BenanVa patients had any atrophy, und -tins -was 

a-cry slight and nnilatora'l on disoliargo from hospilal-; eight 

others showed a dimlimtion in tlio size ot the testis -from 
one-tliird to onc-gnartcr some months later. Benard -con- 
siders cases of bilateral orchitis -with atrophy, impotence, 
and feminism a.s mythical, both on statistical and anatonio- 
■cliuical grounds. 

503 . Hepatitis of Early SypTinis. 

J. A. EL.U0IT and B. C. XODD (Arch. Verm, and ISj/ph., 
■March, 1928, p. '299) report a case ot eady sj-pliilltie hepatitis 
In which the blood bilirubin determinations afforded an aid 
to diagnosis and a guide to treatment. 'They adapted the 
ictems index ns a quantitative estimate ot the bHirnbin In 
the blood, using the van .den Borgh test qualitatively to dotei- 
minc the typo of janudice : in the earlier stages ol the case 
this latter test indicated that the jaundice Wnsdne to injnry 
ot tho hepatic cells. The patient, a man, aged S5, snUeriug 
from severe janudice, gave a strongly positive IVassennann 
reaction tw-o -months after the deVelopment .oT a sore on ‘the 
penis. Beenuso ot tho severity ot The liver disturbance 
0.1 gram ut bismuth was injected at w-c(Skly intervals, and 
aftertbo third injection improvement, both -subjectively and 
ol^ectivciy, was rapid, tho index having become normal, and 
Iho patient feeling well aftei- having received twenty injec- 
tions. In -twonty-ilvc control cases hotli tests were nsed to 
determino the effects of early syphilis and of treatment on 
the -liver fimctlcnij as sho-mi ’by the bilirubin content of "the 
blood. IVitU throe exceptions the blood was normal lor blli- 
mbin thronghont treatment, with, in some cases, asmanyas 
twenty neoarsphenamine and from Dtty to sixty bismuth 
injections. All tho reactions in these three indicated only a 
slight increase of blood bilii-nbin content at one time during 
treatment. In the case of early syphilitic hepatitis recorded 

treatment with bismuth proved to ho ot great value. 


Snrgery. 

564. Jicnte appendicitis and Cyclical iromitinC in 
Children. 

M. Kkabbel (Zcntrail. f. Chir., March 31st, 1928, p. 781) 
roTers to the difficulty In the differential diagnosis of acuto 
appendicitis and cyclical vomiting in children. .Althongh 
nniuerons articles on acute appendicitis in children have 
appeared in recent years scant attention has been paid to tho 
symptoms ot acotonaemia, although -these often simulate 
those ot acute appendicitis. Krabbel records the case ot a 
delicate boy, aged 6, who bad hod severe indefinite abdominal 
liaiu lor thirty-six hours, accompanied by violent vomiting, 
which was becoming wprse. Although there was no definite 
tenderness over ■McBrirney’s spot gangrenous appendicitis 
was suspected. There was profound collapse, dry tongue, 
and asiimll and rapid pulse, ’Irat tbe rectal temperature was 
normal. He was qnite conscious, -and complained of pain -in 
the right side of the abdomen, but there was no mnscniar 
rigidity. -A distinct odour ot acetone was detected in the 
bveatb; sugar -and a trace ot allramm were found in the 
urine. During the examination thechfld vomited spasmodi- 
cally and frequently. The operation revealed u completely 
normal aiipsncTix and perUoneum. Twelve hours later the 
chiUrs condition was nncliauged and the vomiting persisted 
■withadistlnctodonrof acetone. Theurinecontainedtracesot 
acetone, ■diacetic acid, and sugar. Two 'S-unit-do.scs of insulin 
were given; -the vomiting ceased and the child’s condition 
-improved rapidly. In two -days the acetounria disappeared 
and recovery was uninterrupted. Krabbel state.s that cyclical 
•'(acetonaemic) vomiting is rat e in that disti-ict fAachen Forst). 
ItlBcharacterizedby the sudden -onset of intractable vomit- 
ing, with sudden -collapse, acetonaemia, and possibly aceton- 
uria. The -etiology is obscure; constitutional diathesis may 

be afactor, as this patient’s elder brother had had a similar 
though less serlons, attack. The iiroduction of ketono bodies 
is not tbe canse ol tbe vomiting, but is a concomitant 
symptom. Free -administration of carbotiydrates and ot 
insalin is indicated, and the possibility ot recurrence mnst 
he remembered. Kiahbel hopes tliat this report may prevent 
other snrgeons from performing unnecessary appendicmctoiiiv 
in-such cases. - • 

83: A 



80 May 12 , igaS] 


EPITOME OP CUEEENT MEDICAL LITEEATUBE. 


965. Ligature of the Inferior Yena Cava. 

M. PateIj and B. Pbycblon \Lyon C/u'r., Jauuary-Pobrunry, 
1928, p. 22) report a case of lijlaturo of the inferior veua cava 
after uephrectomy for a large tuberculous ItUlnoy. A woman, 
aged 37, complaiued of acute pain iu the right lumbar region, 
pus in the urine, and a swelling in the right flnuk, which had 
increased in size during the previous three mouths. This swell- 
ing, which was painless aud about the size of au adult bend, 
was found at the operation to he a very hard aud pedunculated 
tumour. Along the big vessels there were nuinorona largo 
glands ; the' renal artery was normal, but the roual vein was 
much dilated and obscured by a fatty mass atthehilumot 
the kidney. This was freed and ligatured, and the tumour 
removed. A few seconds later a largo jet of venous blood 
sprang Irom thebottomof the wound near the vertebral column, 
and obviously from a tear in the inferior vena cava, which 
was sutured by a catgut ligature above and below the rent. 
The tumour weighed 1,500 grams, aud was composed oi many 
pockets filled with caseous material and containing also 
many calculi. The patient suffered only slightly Irom shock, 
the urine soon became normal, and the to raperature scarcely 
rose. There was a slight swelling in the legs at the cud of 
eight days, but this only lasted lor two days. The patient 
got up on the fifteenth day aud has had no further trouble, 
there being no outward indication that the inferior vena cava 
had been ligatured. 

966. Disinfection of the Hands 'with Hydrogen Peroxide. 

E. Phank (Zevtralbl, f. Chir., March 3rd, 1928, p. 519) has 
found that when hydrogen peroxide is mixed w'ith soap a 
copious loamy lather is formed and the nascent oxygen 
penetrates deeply into the pores and fissures of the slcin, 
destroying any bacteria without injury to tho opldorniis. 
Prank recommends the following procedure for sterilizing tho 
hands before au operation. After thoroughly washing them 
wilh soap tho hydrogen peroxide is allowed to fall iu drops 
on tho hands, which are constantly rubbed together, and the 
nails aud subungual spaces are scrubbed thorouglily. This 
process is repeated three times aud the foamy lather washed 
off in a stream of hot water for one minute. The bauds are 
then rinsed with 30 to 40 o.cm. of tho hydrogen peroxide 
solution and dried with a sterile swab; this is said to bo 
most important, as the swab will remove any bacteria 
remaining on tbe skin surface. Prank finds that this renders 
tlie hands praotlcally sterile, and that subsequent washing 
with alcohol does not materially increase the freedom from 
bacteria. A. Lippay (ibid., p. 519) mentions that ho has 
employed Prank’s method with yery good results in over 
800 operations, and fopnd hydrogen peroxide mucli more 
satisfactory than merourio, chloride solutions. Lippay uses 
au elevated Irrigator with a .tap- adjusted to deliver 100 to 
150 drops of hydrogen peroxide solution per minute. Among 
his 800 operations were 180 laparotomies, as well as thyroid- 
ectomies, and operations on boiies and joints. Ho thinks 
that the primary healing without reaction obtained in all 
tlieso cases is a proof of the practical value of hydrogen 
peroxide-soap sterilization. 


.Therapeutics. 

567% Mercurial Diuretics iu Ascites* 

L. Blum and P. Caulieb {Presse Med., March 21st, 1928, 
p. 353) find that although mercurial diuretics are often of 
great value and that their toxicity is relatively low, they 
may fail to give relief and produce serious toxic symptoms, 
including pyrexia, rigors, stomatitis, and colitis. They 
report the case of a man, aged 56, who had hepatic cirrhosis 
. with severe ascites, anasarca, and oholaemia. Transient 
relief followed the administration of large doses of calcium 
chloride, but tho quantity of urine diminished, aud the 
oedema increased when the calcium chloride was dis- 
conlinued. An intramuscnlar injection of novasurol (0.22 
gram) produced copious diuresis and a loss of 7i lb. iu weight ; 
on tho following day tlie patient became worse, and died 
eight days' later from oholaemia. A further danger men- 
tioned is that a single injection of one of these diuretics 
does not always suffice. The authors recommend the ad- 
ministration of large doses of caleiura or ammonium chloride 
iu solut in with raspberry syrup to disguise the taste before 
.or after tho injection of tho mercurial preparation. They 
describe a case of atrophic cirrhosis with severe ascites in 
which this treatiiieut was successful. Injections of mercurial 
compounds were tried without permanent benefit and the 
patient was then given 150 grains of calcium chiorido daily, 
for .four days, followed by an intramuscular injection of 
ncptal, a inercurial preparation. This produced marked 
diuresis (8 pints iu twenty-four hours), with a loss of 61 lb. 
in weight. 'Thus three mercurial diuretics failed, iu 'the 

Kav B 


absence of n preliminary course of calcium chloride. Tho 
authors dcscribo a similar result In tho case of a man agod 42, 
who had cardiac dilatation aud hepatic cirrhosis. They add 
that ammonium clilorido.has certain advantages; it does not, 
like calcium chloride, cause constipation, and has a leas 
unpleasant taste. 'They recoiuuiond that when an iutra- 
iiiuscnlar iujcclion of a mercurial diuretic has failed, ouo or 
other of these chlorides shoilld bo given for three or four 
days. In chronic noph'rilis with hypertension and ahundaut 
albumin, either calcium or aramonium chloride may bo 
dangerous, by increasing the retention of chlorides. In such 
cases tho authors consider that mercurial diuretics are 
contraindicated. 


968. Yltamln B Extract In Diabetes. 

' As tho result of four j’cars’ clinical experience of Us action, 
C. A. Mills (Ainer. Juitni. Med, Sei., March, 1928, j). 376) 
bellcvcB that vitamin B stimulates tho .utilization of glucose 
in the body. Ho has found it very offecllvo iu increasing tho 
appetite aud rate of growth both iu cliildren aud adults, and, 
since increased food utilization, growth, and resistance to 
infection aro attained iu diabetes by tho use of insulin, ho 
assnmed that tlio vitamin might be exerting a similar action. 
Mills, tlioreforo, tried the addition of vitamin B to tho treat- 
ment of dialtotIcH, and reports seven cases in which a delluito 
effect scorns to have been obtained. In five of those thero 
was indispntahio ovidonco of vitamin effect on sugar ex- 
.cretion ; in another tho clinical .improvement tvas very 
marked ; and tho remaining patient Jett hospital when 
delluito results wore commencing to nppoar. Eunk, Corbitt, 
and Collip, among others, have jiroviously performed animal 
. cxiiorimeiits iu this connexion. Mills gives an aoid-alcoliol 
extract of plants rich iu vitamin B, such ns alfalfa, onions, 
aud spinach. In diabetics tho alooliolie cxiract was adminis- 
tered, but iu tho case of children tlio alcohol %vas evaporated 
and glycerin to 40 per cent, added as a preservative. Tho 
rosults in those cases, indicate that vitamin B doss' possess 
the power of lowering sugar oxcrotioii, and 30 c.om. of tho 
extract were found to bo roughly equivalent to 30 units of 
insnliu. Without indicating diabetes ns a doUoieucy disease, 
Mills holioves tliat this therapy affords tho injured pancreas 
an opporluiilty for fiiuctioual recovery, and might in comhlua- 
tion with insulin give better resnlls than cltljor wonltl alone. 
It has tho added ndvaulago that oral administration is effec- 
tive, and tho treatment may therefore ho carried on safely in 
the homes of patients to whom insulin could not be entrusted. 

■ In further experiments on dogs aud rabbits ns to tho physio- 
logic propcrlies of this extract, Millsjibid., p. 384) found that 
it did not produce hypoglycnomln, and had no effect on tho 
normal fasting blood sugar. -It increases glycogen storage in 
tho liver, but it has no iusulin-like action on depnnoreatized 
dogs, nor does it enhanco insulin action in such dogs. . Tho 
author concliidos that its. effect, is exerted directly, on the 
pancreas, and tliat its action in inducing glycogen storage is 

■ secondary to its pancreatic effect. 

969. Malaria Therapy In Corcbro-splnal Syphilis. 

H GoUGEROT {Paris Med., March 3rd, 1928, p. 198), discussing 
the malarial treatment of oerebro-spi'nal syphilis, remarks 
that patients who have contracted malaria after syphilis 
have nevertheless developed iieuro-syphilis, Including general 
iinralysis of tho insane aud tabes dorsalis. Eoutino malaria 
therapy cannot be recommoiided in all oases as it is stin 
under trial, and also a fatal caso after inoculation wltn 
Plasmodium vivax has been recorded. He describes tho caso 
of a man aged 39 who contracted syphilis in 1916. In 
he coutracled malaria and had many severe attacks until 
1919. In spite of these he developed definite symptoms o 
early general paralysis. After luteriiiitteiit antisypmlltm 
treatment the patient was Inoculated with malaria in Marcn, 
1927, and during the following month he had eleven 
attacks; rapid and definite improvement followed, and nvo 
months later he returned to business. Gougerot thinks tua 
this case shows tliat while previous malaria cannot prevem 
tho development of neuro-syphilis, malarial inoculation uaa 
tho power of arrosting tho progress of general paraljsisi 
though this anomaly is difficult to explain. P- ^s'nvn 
described the caso of a man who contracted malaria lu 
syphilis in 1916; ho is now suffering from 
dorsalis, Milian (ibid., p. 200) doubts whether malaiia pro 
vents the development of neuro-syphilis ; if it 
effect is not attributable to shock, nor to production « “yPyJ 
pyrexia, but evidently to tbo production of .antibodies, “o 
cites the case of a man who contracted syphilis as a i>tude . 
When approaching the age of 40 he develO)iea so"®"® 
symptoms. A prolonged but irregular course of antisyphihtio 
treatment produced some improvement. Subscqueidly, 
bad a severe attack of enteric fever, and the cardiac sy P 
disappeared completely; for three years he has been ncu 
from both heart disease and syphilis. 



May 12, IC2S] 


EPITOME OF COKRENT MEDIOAIi ETTERATURB. 


t TnEUniTTSH 
MeOICAI, JotmiTAX, 


81 


Radiology* 

170. RndIoIoi;lcal Examination of the Bladder. 

H. Cohen (.iff*?. Jotmi, and Uecord, February 1st, 1928, p. 121) 
omphnsizos tbo value, ns n dlngnostlc inotliocl in blntltlcr con- 
ditions, of Introducing nir in conjunction with w rays, by 
irhich means lesions arc rendered demonstrable ^Yblcb rvonid 
otberwisc bo ovorlooltcd ; In many it Is the only means of 
pre-operative diagnosis. Tbo technique is said to bo Blmplo 
and free from danger under ordinary sterile precautions. 
After an ordinary skiagram of tbo bladder has been taken 
for comparison a soft rubber catbetor is introduced and the 
nrlno drawn off ; tbo bladder is then gently inflated with air 
by moans of a baud bulb attaobod to tbo catbetor, and tbo 
patient is then i-niycd again. Coiion does not use any dcvico 
for measuring tbo amount of nir introduced, but relics on 
tbo patient’s feelings, tbougb the Rubin apparatus used by 
gjuiaecologlsts can bo employed. While foreign bodies aro 
readily shown by tbo ordinary film this method, by making 
tbo proper contrast, assists in localizing the foreign body in 
tbo bladder and away from tbo rectum. Tbo dilTlculty in 
visualizing tumours by an ordinary film owing to tbo want 
of comparison is overcome by this moans, the nir atfordlng 
a contrast with solid tissuo. Except in diverticulum of the 
bladder this method is said to give better results than those 
obtained by tbo use of sodium bromide or iodide sointious 
which, besides being expensive, tend to disguise pathological 
conditions in tbo bladder. In tbo case of a diverticulum, if 
the bladder is first distended with solution and ar-r.ayed, the 
solution drained off, air Introduced, and another £c-ray photo- 
graph taken, the diagnosis will be easy — tbo dlvcrtlculnm 
showing a white negative shadow, since, being devoid of 
muscular tissuo, it retains the solution while tbo bladder 
shows n black air shadow. In tbo diagnosis of tumours 
washing out the bladder with bromide solution will leave 
a coating on the tumour. 

4171. X-ray Treatment of Asthma and Spasmodic 
Coryza. 

P. VALLEItr-RADOT, P. GiDERT, P. BLAMOUTIER, aud F. 
Claude {Ann. dc Med., Slarcli, 1928, p. 214) believe that 
radical treatments, acting on tbo body generally, give more 
lasting results in asthma, and state that they have obtained 
excellent results from the empioyment of a" rays. They 
recall that Soliilling in 1906 was the first to ufeo this metbod 
of treating asthma. Irradiations can bo applied over the 
pnlmonary bila, tbo spleen, or over both sites, either on the 
same occasion or alternately iu successive treatments. The 
authors employ an induction-coil apparatus with a standard 
Coolidge ampoule, alocal distance of 30 cm., and an aluminium 
Alter of 5 to 10 inm,, aud a dosage of 500 R. For both the 
lung and the spleen two ports of entry are used, anterior and 
posterior, in order to save the skin. Ten to twelve successive 
^ irradiations are given at the rate of two wceldy. If no 
' success follows, a second and even a third similar series may 
ho tried. A summarized table showing the diagnosis, treat- 
ment, and results of sixty- four cases treated by this method is 
given. After a single prolonged Irradiation nausea, vomiting, 
and sometimes a recrudescence of the aflectiou have occurred, 
but these sj'mptoms last only a low hours aud aro usually 
followed. 'by marked amelioration. No other untoward 
symptoms were noted, and eosinophilia, a fall in tbo Icnco- 
cytic percentage, and a lowering of arterial tension were 
never seen. BcncAcial results have been reported following 
irradiation ot several pulmonary areas and of other organs 
such as the thyroid, the corvico-thoraoic ganglia, and the 
long bones. Many hypotheses as to the mode ot action of 
the rays in these affections have been suggested. As Widal 
and others have proved that an aslbmatic is a coiloidoclasic, 
the authors believe tliat tho rays cause a change in the 
humoral state which prevents the production of oolloidoclasic 
shock. 

472. P. Gibert {Paris Med., February 4tb, 1928, p. 126) 
notes that the statistics ot other workers show 30 per cent, 
of very good results, 35 per cent, ot improvements, and 35 per 
cent, of f.ailures iu the treatment of asthma with x rays. In 
his own series of 64 cases of asthma aud of spasmodic coryza 
either separately or in combination 19 patients scorned' to 
recover completely, 16 were much' improved, while the treat- 
ment failed in 29 cases. Ho advocates a dosage of 500 R 
"''me a weelc, over a Aeld of 12 by 12 cm. at a focal distance 
of 30 cm. with moderately penetrant rays. When there is 
spasmodic coryza alone he irradiates the spleen ; in cases of 
■asthma, with or witliont coryza, he irradiates the spleen aud 
the hilar region. lie docs not conclude that the treatment 
las failed until ho has given twelve irradiations. No un- 
toward results have followed. 


473, X Bays In Hyperchlorhydrla. 

SowfMON {Paris Mdd,, February 4th, 1928, p. 123) advocates 
irradiation with x rays for functional hyperchlorhydria, 
gastric or dnodcnal nicer, and after gastro-enterostomy. Ho 
reports n representative case in each series in which he had 
obtained satlsfactm-y results — namely, disappearance of pain 
and neurosis, fall in tho acidity, absence of occnlt blood 
when previously present, increase ot weight, and return of 
tbo capacity for work. Ho irradiates an abdomioal Aeld ot 
12 by 12 cm. or 16 by 16 cm. over the gastric area, at a focal 
distance of 30 to 40 cm. He uses penetrant rays (120 and 
200 kilovolts) Altered throngli 0.5 mm. of copper and 1 mm. of 
alnmlniniu. Tlie dose at each Irradiation is 500 R, repeated 
at Intervals ot three to eight days, until a total dosage of 
5,000 R is attained. A second series of irradiations is given 
eight weeks later if the Arst has not been suAlcient. 


Obstetrics and Gynaecology. 

474. Ovarian Extract and the Menstrual Cycle. 
Following np Zondek’s observation that the activity of 
ovarian extracts could be tested by their effect on the cyclical 
eban^cs in tho vaginal epltbelinm of tho mouse, Mahnert and 
Siegmund concluded that tho same hormone was produced iu 
the ripe or ripening corpus Interim and in the corpns luteum 
ot pregnancy, the dillorenco being quantitative and not quali- 
tatlvof Having found from animal experiments that folllcnllu 
was a satisfactory preparation, A. Mahnert {Wten. Min. ll'ocii., 
March 8tb, 1928, p. 329) tested its effects on the human 
meusti-nal cycle. 'I’cn normal women, aged 21 to 33, were 
given Ave to ten snbontaneons injections of follicnlin during 
tho Arst two days of menstrnatlon, six starting on the Arst 
day with 12 to 20c.cm. in all and four on the second day 
receiving a total of 8 to 10 c.om. ot a preparation standardized 
in mouse units ; in seven of these women menstruation was 
curtailed from tho usual font or Ave days to two days or less. 
Mahnert considers that these results conArm the hypothesis 
that tho period ot repair ot the endometrinm during the 
mcnstrnal cycle oocnrs when the ovarian follionlar hormone 
secretion is at Its maximum, and that the disintegration ot 
the endometrinm associated with the Aow oconrs when the 
homoDO secretion is at its minimum. If the ovum from 
a ripened follicle dies early in the cycle, the follicle rapidly 
breal 3 down and the mcnstrhal Aow recommences after a 
shortened interval— that is, menstruation occurs with ab^ 
normal frequency. The Inhibitory effect of injections of 
follicnlin on the Aow is ascribed partly to the regenei-ation ot 
endometrium induced and partly to an effect on the' uterine 
vessels. Similar injections were given to sixteen patients 
with functional abnormalities ot menstruation, tho Aow being 
either excessive in quantity or duration, or there being dis- 
turbances of rhythm ; satisfactory results were obtained in 
all but one. Mahnert concludes that an abnormal menstrual 
cycle due to delayed or inadequate ovarian secretion or early 
death of tbo ovum can be iiiAuenced by injections of the 
speciAc hormone present in follionlin,- 

375 , Accidental Haemorrhage. 

P. GaifaMI {Ann. di Ostei. e Ginccol., February 29tb, 1928, 
p. 253) bases his account ot premature detachment (before 
labour) of the normally situated placenta — so called accidental 
haemorrhage — on 400 unpublished cases collected from Italian 
and other sources. Of these 125 were at the author’s clinic. 
Ho distinguishes between (1) asymptomatic cases, recognized 
by examination of the placenta; |2) severe cases with clamant 
clinical signs and accompanied by diffuse haemorrhagic 
lesions of the myometrium and adnexa (ntero-placental 
apoplexy), and (3) cases of an intermediate degree of gravity ; 
these last form the majority. Tlie apparent incidence of the 
morbid condition varies with the sharpness of the watch 
which is kept for it : the mean Agnre is roughly 0.22 per 
qent. Albuminuria was noted in 80 per cent, of the cases; 
eclampsia was present in 6 per cent, ot Gaifaml’s cases. 
Only about one patient in Ave is a primipara. Several clinics 
have reported an increasing frequency of accidental haemor- 
rhage during recent years. The foetal mortality is given as 
80 per cent., and cadaveric rigidity is stated to be frequently 
noted when the foetus is delivered. Diagnosis by the prac- 
titioner or midwife is said to be infrequent, most cases being 
confused with placenta praevia ; it is nevertheless important 
that detachment of the normally- situated placenta should 
be recognized before external bleeding, combined with a 
state of shock, has rendered the patient’s condition desperate. 
The chief signs are (1) progressive increase in size of the 
utems, which is tense and tender, (2) acute pain localized In 
one portion of the uterus, (3) loss of blood-stained serous 

83a C . 



EPITOME OP CUEEENT MEDIOA.E LITEEA.TERE. 


82 MiY 12, 1928] 


[ The aniviMt - 
tlZVlCXL JotnuTAft 


aiscliai-fie, (4) touseness oj the bag of membraucs, anti (5) 
iireguiaiity of the- uterus in. the neighbourhootl o£ a retro- 
placeutal haeinatoma.’ Etero-placeutal apoplexy njay be 
jjteseut iu cases in which hardness and tenderness of the 
uterus are slight or absent, but is aiways accompanied by 
grave general signs. About one-half of cases require no 
vperative intervention, but there is always considerable, 
j'angor that post-partum haemorrhage may follow. In hyper-' 
iioute cases iu which the patient is too ill to be taken to 
hospital stimulants should be given, au abdominal binder 
applied, and perhaps pituitary or adrenal extract injected. 
Vaginal tampouuage is not to be recommended, but rupture 
of the membranes may sometimes be justillable. Acconche- 
luent forefi with metallic dilators is now superseded by 
vaginal or abdominal Caesareau section, which oilers the 
only hope of cure in grave cases. The author reports a' 
mortality of 14 per cent, in the abdominal and 22 pcr cent, 
iu the vaginal operation. Pro-Caesarean hysterectomy has 
been largely adopted for these cases in Italy, chiefly on 
account of fear of grave post-partum haemorrhage it the 
uterus bo left behind, but Eritish statistics are taken to bo 
reassuring in this respect. The decision whether hyster-. 
ectomy shouid be performed calls tor careful judgement, 
which shouid take into account the patient’s general con- 
dition, the contractility of the uterus and its degree of 
morbidity as revealed during the operation, the patient’s 
prospects of maternity, and the nature of the therapeutic 
essays to which she has been previously subjected. 

576. Xfrea In the Treatment of Uterine Bleeding. 

P. WBaMEB {Zcntralbl.' j. Gynalc., March 17 Ih, 1928', p.'693) 
reports the treatment of 46 women, aged from 16 to 50, 
suffering from excessive uterine bleeding, by administration 
twice daily of 20 giams of urea dissolved in water.' Myoma 
and other gross morbid coudiUous of the uterus were absent 
from' the senes, which consisted mostly of patients with 
ovariogenous bleeding, bub contained some cases of bleeding 
due to acute or ohrouio adnexal inflammation aiid one or two 
of climacteric haemorrhage. In 27 cases the bleeding was 
arrested, in 6 diminished : as a rule, five doses — that Is, two 
days’ treatment— were required, but' a tiausitofy fayourabld 
effect was noted after the first powder had been taken. 
According to Wermer , the effeot, of the urea is duo iudirqotly 
to its diuretic ■aotion';'the organisui responds to the increased 
elimination of water by increased production of the hormone 
of the posterior iobe of the pituitary gland ; the pituitary 
hormone, secreted to counteract diuresis, exercises iucidout- 
ally a utero-haemostatio 'luucUon. Wermer has had similar 
results from intravenous iujeotious of certain other diuretics, 
some'of which, however, are kuown to increase the coagula- 
bility of the blood, a fuuctiou which urea iloes uot appear to 
I'ossess. Uterine bleeding has been reported by Vogt and 
others to be inllueuced favourably by injections of insulin, 
and in this connexion "Wermer refers to Dixon’s discussion of 
the action of pituitary extract {liritish Medical Journal, 1927. 
YOl. ii, p. 1070j. . • , , ’ ’ 


Pathology. 


577 . The Cerehvo-splnal Fluid in Tuberculous Menlnffltls. 
D. STEWART [Ellin. Ued. Journ., March, 1928, p. 141); referring 
to the diffloiilty of early diagnosis of tuberculous meningitis 
in children, points out that examination of the cerbbro-spinaf 
fluid affords the most accurate means which we at present 
possess of distinguishing between this condition, the menin»- 
ism of acute infections, and other types of meningitis an'd 
encephalitis. The value; of early examination of the cerebro- 
spinal fluid is borne out by a case In which a diagnosis of 
tuberculous meningitis and a hopeless pro mosis had been 
based upon adequate symptomatic data, though the cerebro- 
spinal findings showed no inore.nse in cell count or protein 
and no organisms ; at the end of a fortnight, however com- 
plete recovery resulted. The fluid may be withdrawn either 
by lumbar or cistern puncture, the latter route being as safe 
and as easily performed as the' former, except in the very 
late stages of the disease when acute hydrocephalns causes 
brain displacement. In a series of thirty cases the cell count 
was increased in all, and the differential count showed a 
lymphocytosis of from 80 to 93 per cent. the' total protein 
was dellnitely increased in twenty'-flve. The estimation of 
the chlorides and sugar gave .such variable results as to 
render it of no diagnostic importance, the, significant data 
being furnished by qualitative and quantitative protein 
examination and enumeration of the^ .cell.s, inclnding the 
valuable differential count. Tubercle 'bacilli were found in 
the cistern fluid in all cases, and in the lumbar fluid in 57 
per cent. Stewart conclndes that in every' case of doubtful 
tuberculous meningitis the cerebro-spiiial fluid shqnld bo 
examined qualitatively and'quautltatively for' increased 'pro-' 


toin as early as possible ; any iiicieaso In the cell count 
should bo noted, and a seafoh bo made for tubercle bacilli in 
the cistern and lumbar fluids. 


578, Calcium Bellclcncy as a Cause of Disease. 

Citing au important experiment performed by Stccnbock 
and Hart ou tbo calcium metabolism of a goat, C. E. Corlette 
(Med, Joum. of Australia, Eebruary 18th, 1928, p. 198) dis- 
cusses fully the pathology of various diseases of animals and 
birds which are caused ovldoully by a calcium deilcieuoy. 
Ho concludes tliat In calcium deficiency there is a general 
disorder involving nil tbo functioning cells and important 
organs of secretion. Disonsbs such. as rickets, gastro-imes- 
tiual catarrh, broncliitis, and diarrhoea, ropresout a proce.ss 
going on in tlic liver, pancreas, kidneys, thyroid, para- 
thyroids, and otlier organs, the functions of wliicli become 
disordered and depressed. ,TJio glyc,6gcnio function of the 
liver is disturbed, its detoxicating function la more or leas 
suspended, and metabolic poisons unay not be properly 
nentalizod. .'These organs and also iiie nervous system do 
not always recover completely' when the original doDciency 
is removed, and some permnnout damage often remains. 
'Thus coellac disease iu children and cinhovia of the liver iu 
adults may bo the result of a deflciency no longer existing iu 
the diet. Corlette believes that calcium aiid/or pliosphorus 
deflciency can cause nervous disorder • closely resembling 
that produced by deflciency of vitamin B, and that it is, or 
may bo, implicated in many niotbid conditions of man and 
animals in which nervous syruptoms often occur. 

579. influence of Hydrofen-lon Concentration on 

. Cellular Division. 

E. Eeding and A. Seosse [C. Jt. Soc. da Biologic, March 23rd, 
1928, p. 878) have porfoi nmd some- experiments on the effect 
of peptone shook in allorlng the hydrogou-ion conoeutratioii 
of the blood and in stimnlnling cell division, Dnstin fouud 
in the mouse that under tlio iiillucncc of peptone shook tlioro 
was evident nnclear destruction on the first day, followed on 
the third or fourth day by a very active wave of UaryoUinesis; 
the mitoses wore observable not only in those organs such 
as the lymphatic glands, intestinal lunoosa, and thymus iu 
which they can normally ho found, _hut also in olkers in 
which itb'oy' are' soldom’ seou'i '- Tlio'autlidrs!. experimonls 
wore performed on six dogs; iu eiglit oxporimonts peptone 
shock was produced and in ono exporlment nnapliylaotlo 
shook was cau’se'd'b'y'me'ans of horse 'serum. 'The hydrogen- 
ion concentration of tbo blood was measured by Hasting and 
Saudroy’s method. In cases of ))eptouo shock the hydrogen- 
ion concentration, fell from pH 7.42 to pH 7.20 1 tho return to 
normal ocenrrod rapidly, generally in' a few honrs. ■•But 
forty-eight lioiirs after tlie sbook tho liydrogou-ion coiiociitra- 
tiou commenced to dncroase, so tliat on tho tliird and fourth 
days it was about pH 7.48; after this it again returiicd to 
normal. Histological- obsorvatlous showed that tho primary 
fail of pH was accompanied by iiucicar destriiotiou ; and that 
the wave of alkalinity on the third and fourth days was 
accompanied by a prolonged wave Itaryokinesis. 'Tlio autbors 
therefore consider tliat tlie activity of tlie ocllnlar division is 
determined by tlie alteration in tlie hydrogen-ion concentra- 
tion of the blood. Even when no actiml sliock was apparent 
after tho intravenous injection of peptone marked alterations 
in the bydrogon-iou concentration occurred. • , 


580. The Filterable Form of the Tubercle Bacillus. 

A. Charlotte Buys (Neitcrl. Tijdschr. v. ueheesh., February 
18tb, 1928, p. 795), in a review of the literature dealing witli 
the existence of a filterable form of the tubercle bacillus, 
states that the opinions of tlie French investigators cannot 
be regarded as couclu'iive. Two views may be held on tins 
subject. The first is that the 'pathogenic tubercle bacillus 
may produce a filterable form which m ly bo transformeii 
again into the typical bacillus. The second is that tut 
pathogenio tubercle bacillus can prodnee a virus wmeu 
differs from tho original tubercle bacillus as regards patuo- 
genicity, form, and other properties, and is a filler passoi. 
A number' of French observers have based tbo existence 01 
snob a virus on the following considerations. (1) The pre.sence 
of acid-fast bacilli in the tracheo-bronohial glands of 
pigs inoculated with filtrates containing tubercle bacii 
witliont typical inoculable tuberculosis developing; i ' 
positive tuberculin reaction in these animals ; (3) the t 
from cachexia of a number of these animals. Buys, 
brings forward tlie following objections. A ...j 

investigators have been unable to find acid-fast_ f.-rti.q 
reserabliug tubercle bacilli, and no control exainmatioua 
were made on normal animals. A po.sitive 
reaction can bo explained ns a reaction ‘o, " 

tubercle bacilli which were iiitroducc-d with tho 
The death from cachexia may have been due to the lafoO 
quantity of the filtrates iutro'duced. 


May i9i igaS] 


[ The Bnmsii 
UeDICH^ J0CE51I. 


83 


EPltOAlE OF CURRENT MEDICAL LITERATURE. 


Medicine. 

4S1, Endemic Meningococcal Meningitis. 

S. jrcLKAS and .T. P. CAri'KY {Ama\ Joimu Dis. Child., 
March, 1928, p. 357) doscrlbo tho protean nature ot the clinical 
manifestations In 136 eases adnilttcil to hospital from 1914 to 
1926; 17.6 per cent, of tho patients tvero not over 3 months old 
and 67.6 per cent, were In tho first year ot life. Crowding, 
poverty, and poor hygleno are predisposing causes. Muscular 
rlsldity, cspoolally at tho level of tho node, with or without 
retraction of tho head, was present in 84.5 per cent, of tho 
eases, and is tho most frequent and important slnglo clinical 
sign. Increase ot tendon retlexes— Kcrnlg’s and Brndziusltl's 
signs— though often present, arc unreliable diagnostically In 
infants. Unexplained Irritability (62.5 per cent.) and drowsi- 
ness, stupor, or coma (46.2 per cent.) arc of value In focusing 
attention on tho central nervous system. Kxnminatiou of 
tlio cercbro-spinnl iluid Is essential when there is a bulging 
fontancllc. Convulsions were present in 29.4 per cent, of tho 
patients, generally at tho onset of tho disease ; 11 per cent, 
had a haemorrhagic eruption, mcnlngooooei being domon- 
strablo in blood films made from tho purpuric areas. The 
most frequent ocular manifestation was strabismus, which 
was present in 20.5 per cent, ot tlio eases. The tciuporaturo, 
vomiting, and tacho cerebralo are not characteristic. The 
need for lumbar puncture in suspected eases is emphasized. 
The presence of a purulent fluid nearly always indicates 
uieningococcal meningitis ; tho discovery ot meningococci 
makes tho diagnosis certain. Blood cultures should bo made 
in all cases, hut particularly iu the fulminating ones, when 
organisms can be recovered from tho blood, though they are 
not demonstrable in tho cerebro-spiual iluid. 

482. Thoracic Signs ot Hypertension. 

S. Wei.n-STEIx Qleil, lain., Jrarcli 16tli, 1928, p. 418) conOrms 
tho observations ot Dolherm and Chaperon that hypertension 
is frequently associated with dilatation of tho aorta. Among 
100 patients (42 mou and 58 women) 18 (4 men aud 14 women) 
had hypertension and 23 (10 men and 13 women) had aortic 
dilatation. Further analysis showed that 50 per cent, of 
those 18 patients who had hypectension had also aortic 
dilatation, ns compared with 17 per cent, iu whom this con- 
dition was associated with a normal or slightly lucroased 
blood pressnro ; 39 per cent, of patients having aortic dilata- 
tion had hypertension, while only 12 per cent, of those in 
whom the aorta appeared to be normal had hypertension. 
YVeinstein states also that there is a direct relation between 
the size ot the longs and the blood pressure. In collabora- 
tion with AV. Liutz he has investigated clinically a number of 
cases by means ot skiagrams ; it was found that a subnormal 
development of tho lungs was very often associated with 
hypertension. Tho two authors also investigated tho pnl- 
monary development of 100 patients ; ot those, 31 (8 men and 
23 women) had small lungs. Among these, of 18 patients 
having hypertension 13 had small lungs, while among 82 
patients who had normal or slightly raised blood pressure 
only 18 had small lungs. Among 31 patients who had small 
lungs 13 had hypertension, while among 69 patients who had 
lungs of normal size only 5 had hypertension. Among 116 
women over 50 years old 52 per cent, with small lungs had 
hypertension, in contrast with only 6 per cent, ot ‘‘control” 
cases ; 86 per cent, ot women having hypertension had small 
lungs, as compared with 25 per cent, of women who had 
normal or slightly raised blood pressure. AVeinstein draws 
the following conclasions. (1) Tho aortic dilatation described 
by Delherm and Chaperon and its coimexion with hyper- 
tension has been proved in a considerable number ot cases. 
(2) The size ot the lungs should be estimated systematically, 
as hitherto this question has not been considered. Small 
lungs, especially in women, stand in close relation with 
hypertension. (3) One or both Symptoms (aortic dilatation 
and small lungs) were present in all cases ot hypertension ; 
when both symptoms were absent there was no hypertension. 

483. l/atent Syphilis Carriers and the Spread of 
Infection. 

(Ccntralftl. /. Baht., 1928, vol. 106, Festschrift, 
p. 154) asks why it is that with tho widcspreacl emploj^raent 
ot salvarsan in every country syphilis has not been practically 
stamped out. For it is Icnowii tliat salvarsan rapidly causes 
every symptom ot tho disease to disappear, and that it leads 
m a high proportion ot c.ases treated early to a lasting cure. 

IS autnitted, on the other hand, that the majority of patients 

> 

V. 


treated with salvarsan, although they show an immediate 
apparent cure, yet relapse and again become infeotiye, but 
it is dlllUcnU to boliovo that all cases ot syphilis originate 
from contact with cases of o))on infection. Many patients 
aro found to ho syphilitic during the course of routine 
examination who never suspected it themselves ; this applies 
cs))ocialIy to patients with disease of tho nervous or arterial 
system. Tho author tliinks that these patients have become 
infected with sypihills Avithont ever'developing primary mani- 
festations. His suggestion is that a large number of persons 
with latont syphilis aro in reality chronic carriers of the 
disease, and that they may prove infective in much the same 
way as an apparently healthy person may excrete typhoid 
bacilli. lie thinks it possible that these persons are carrying 
liA’lng spirochactes on their mucosae Avithout shoAving any 
evidence of disease. Animal experiments tend to siippovt 
this view. Albrecht has shoAvn Avith rabbits that a primary 
chancre ot tho vulva undergoes spontaueons cure ; but Avhen 
does that have recovered completely from snch a chancre 
arc brought to a buck, the buck develops syphilis Avithout, 
liOAVCver, showing any primary manifestations ; the infection 
can bo demonstrated by extirpation ot the regional glands 
and injection of them into fresh animals. A symptomless 
infection can also be produced in the mouse, as the author 
lias shoAA’D. Alter infection, tho sinrochaetes live in the 
glands, s))locn, and brain for seA'cral months; they can easily 
be demonstrated by inoculation into fresh mice. The author 
doubts Avhether there is any Immnnily iu syphilis other than 
an infection immunity. If this is so, and if syphilis can be 
imparted by apparently liealthy persons Avho are carriers of 
the disease, the only hope in the cure ot syphilis is the 
earliest possible treatment so as to obtain a chemical 
sterilization and thus prcA'ent the development ot the carrier 
condition. 

484. Pluriglandular Syndrome following Mumps. 

J. Hubeia {Bull, el Him. Hoc. Med. Hop. dc Paris, March 8th, 
1928, p. 368) records tlio case ot a man, aged 26, who, after a 
severe attack of mumps complicated .by unilateral orchitis 
follOAved by atrophy of tho left testis, deA'eloped a pluri- 
glandular syndrome consisting in sexual frigidity, hyper- 
trichosis, and upper dorsal kyphosis indicating ovoraction 
of the suprarenals aud hypophysis respectively, together 
AVith general Aveakness and diftnse pain most marked In tho 
lumbar region and sacrum, suggesting nn involvement ot the 
sympathetic system. No beueflt Avas derived from opotherapy. 


Surgery. 


485. Results of Periarterial Sympathectomy. 

S. Rubaschoav (ZeniralU. f. Chir., March 24th, 1928, p. -727), 
who reports 46 cases of periarterial sympathectomy, believes 
that this iirocedure should not be abandoned ; it may give 
good i-esnlts in certain diseases. The operation affects 
chiefly the trophic nerve fibres and not the vasomotor fibres. 
He has had very good clinical results in three cases of 
causaigia, and in two cases of amputation the stumps re- 
mained entirely free from trophic changes. In Raynaud’s 
disease three out of four patients with injuries of the sciatic 
nerve remained free from nlceration. In twelve cases of 
ulcers due to various causes cure was obtained in six. Among 
ten cases ot spontaneous gangrene tAVO patients improved ; in 
six cases the operation had no effect and tAVo patients beca'mo 
AA'orse. In two cases of nnunited fracture some improvement 
resulted iu one case. The operation failed in a case of 
syringomyelia, in five cases of tuberculous arthritis, and one 
case of elephantiasis. The author states that moist gangreuo 
occurred in two ot the cases which did not improA’e. He 
considers that periarterial sympathectomy is advisable only 
incases shoAVing “dry” gangrene. One patient Avith causaigia 
remained cured after three and a half years, another with a 
gunshot wound of the sciatic nerve relapsed after three years. 
In a case ot early gangrene of the little toe improA-ement has 
persisted tor more than two years. In a typical case of 
Raynaud’s disease of the hand there Avas no immediate 
result, but after two or three months considerable improve- 
ment resulted. No case became septic. In femoral sym- 
pathectomy the author operates on the middle third of the 
artery belOAV the origin ot the profunda artery and tlie lymiih 
glands. In one case the brachial artery was injured aud 
required ligature, but the ultimate result was satisfactory. 

884 A 



‘ 8'4 iriT .ip, 1528] EPITOME OF CUEEENT kEDIOAL-LITEEATUEE. 


Occasionally post-operative arterial hyperaomia persisted, In 
one case (incipient spontaneous gangrene) for two years with 
good result; in two other cases (Causalgia and trophic ulcer) 
it lasted for three years. Eubaschow does not think that 
hyperaemia Is the preponderant factor in the healing process ; 
in a case of ulcer of the foot to lowing a gunshot wound of 
the sciatic nerve, the operation was tollow.ed’for two weeks 
hy anaemia and coldness of the foot, possibly arterial spasm, 
yet during this period the ulcer healed. In the cour.so ot the 
following two years there was intense hyperaemia and no 
recurrence. In another case an ulcer reappeared after three 
years, in spite of persistent hyperaoniia. In one case ot 
digital ulceration (thrombo-angiitis obliterans) the whole 
right arm was pulseless.- Brachial syinpatheotomy with 
resection of 2 cm. ot the artery was performed ; this was 
■followed hy hyperaemia and uninterrupted healing ot the 
ulcers ot the fingers. 

5Se. Diabetes Complicating Surgical Urinary Conditions. 

1. CHlOFAliO {Journ, d'Uvol., January, 1928, p. 11) discusses 
the pre-operative treatment of surgical uririary disease asso- 
ciated with diabetes. 171160 Ihe 'case is not urgent; as, for 
example, in prostatectomy, it is usually sufllciout to redneo 
tile carbohydrates, thus iiroduoing a condition ot'tolerauco 
so that the glycosuria disappears. Jn such cases liisulin is of 
no use and patients can be satisfactorily prepared for opera- 
tion without its employment. 'When there is marked acidosis 
it is necessary to employ a strict diet combined with' insulin. 
The results in these cases are said to' be oxcelleut.'aud the 
operation can he performed with little or no risk. It will bo 
necessary to inject 15 to 20 units of insulin one and a half 
hours before operation, followed In half ah hour' by a stiiall 
quantity ot sugar. Morphine may also bo given with advau-' 
tage. Ohloroform is absolutely contraindicated, and local 
anaesthesia, ether, or spinal auaesthesia should ' be' used. 
In urgent cases a dose of 40 to 50 units of Insulin should bo 
given an hour before the operation, followed hy 50 grams ot 
sugar. Insulin is given lu all cases after the operation; the 
results so obtained ate said to be excellent and frequently to 
result in cure. 


337. Chronic Appendloftls. 

H. Koster (Archives of Surgery, January, 1928, Part I, p. 44) 
argues that while dull aching pain or intermittent andoolickv 
))ain in the right iower quadrant of the abdomen may 
ho referable to organic or. functional, disturbances .in the 
appendix, it is not correct to, group all the .conditions of the 
appendix under the heading, “chronlo. appendicitis.’.’ In 
many ot these cases the pathologist may .not find . any 
evidence of cbroulc. inflammation, the symptoms havlu" 
resulted from kinks, adhesions, and strictures. He sufx'ests 
that the term chronic. appendicitis ’’.should be replaced as 
a pre-operative diagnosis by “appendicular colic.’’ This 
will have a deflnite meaning and a, distinct application 
as a working basis. "No two pathologists 'agree as to the 
criteria for the diagnosis, of chronic iuflammation, and the 
result has been confusion and controversy. " Koster (liluks 
that with the acceptance of definite criteria such confusion 
will be avoided. .... 


538. Symmetrical Gangrene ot the Extremities following 

TyphoJd Fever, • * • 

IVTarcJi 5tli, 1928, p, 242)^-'\vlio recordi 
au illustratiYG_caso, statos tbat of all tlio uuiucrous infectiou' 
diseases followed by gangrene of the extremities tviiUou 
fever occupies the first place. Of 102 cases of post-infectivi 
gangrene collected by Barrand, 44 were due' to this cause 
Predisposing causes include cold and damp, excessive phvslca 
exertiou, and pre-existing diseases such as syphilis, nephritis 
diabetes, nrterio-sclerosis, alcoholism, and . indulgence li 
tobacco. As a rule the lower extremities are affected thi 
right as often as the left, bub the simultaneous appearanci 
of gangrene in both is rare. 'The upper limbs ale seldon 
affected. Post-infective symmetrical gangrene presents t 
characteristic clinical picture in that the onset is suddei 
and the progress rapid and extensive. The condition cai 
readily he distiugnished from Eaynaud’s disease, In whicl 
there is a long prodromal period and a certain periolicity o 
the symptoms. As regards the pathogenesis, post-typiioic 
gaugreue is usually due to arterial thrombosis, with whicl 
may be associated vascular spasm of sj-mpathetic orimn 
’The prognosis is grave, the mortality being about 50 per cent 
'The present case was that of a soldier, aged 20, who developei 
gangrene, first lu the right leg and sliortly afterwards in thi 
left leg, about a month after the onset of an ordinary attael 
ot typlioid fever. Amputation on the right side was per 
formed in the middle halt of the thigh, and'on the left Ic 
at the upper third of the leg. Eecovery followed. Examina 
tiou of the arteries in the amputated limbs showed thickcuin( 
of the iutima and the formation of a thrombus. 


iTlierapeutics. 

589. Alcohol In Acute Infectious Diseases. 

J. D. EoLLESTON (lirit, Journ, of Inebriety, April, 1928, p. 201), 
contiuuiug his observations on llil.s subject iseo Kyitomc, 
April 23rd, 1927, imra. 451), states tliat during tlio year 1927, 
when the annual consumption of brandy at liis liospital wtis 
only 25h oz., ns compared with 991J oz. in 192G and 2,539 oz. 
in 1925, "no brandy wlialovcr was. used in the trcatmo.ut of 
diphtheria, the case mortality from which was the lowest 
recorded nt his hospital (3.01 per coiit.) though Uio type of 
disease roinalucd the same. He iuaiutaius that the u.-io of 
brandy, in spite of tlio ovldouce ot its iuolflcacy or harmful- 
nesa, is doubtloss often due to tlic prossuto exercised upou 
the' doctor hy the patients’ . frioiids, ulid are iiucler the 
mistaken impression that in tlio absence of'such troatmbut 
everything "is not being done that can bo to save lile or 
iiastou roedvery, Suoli iiilliicnee,' tliongli' much' nijro likely 
to be brought to boar succossfully iiiiprivato j)radlico lliaii in 
institutions, Is not witliout its effect' oven in hosiiilall la 
addition to tho' reduction in tlio administration of alcohol 
in the wards' Eollestou ii'as exercised ii strict cdntrul over its 
use iu tho ambulance service coniiectcd with' iii.s hospital, 
the nurses on amhiilauco duly having received ordcis to/iiruish 
a report of every case in wliicli lliey considered hucli admiiii- 
.straliou. necessary, together uilli the' aiuoiiiit given. 'The 
result ot this measure was that during the whole o: 1127 only 
1 ounce and 7 drachms of brandy' was used hy the amhiilauco 
nurses. This figure n|)plicd not only to Ihd 3,233 'iia.iuuts 
admitted to tlio hospital iu tho course ot the year, but to all 
the other cases removed by tlio amhulauco'niir.sds, amouuting 
to a total of over 12,000 iiersous couveyed aud a mileage of 
over 68,000. • • 

590. Bnllno Eotutlons in Hypertension, 

"W. L. T. Addison (Canadtan Olcd. Assoe. Journ., March, 1923, 
p. 281) summarizes iirovlous rescarcli in arterial hypertension 
as showing that calcium chloride proJucos au inorganic 
acidosis, with increased excretion of ammonia and soda; 
potassium chloride, without change of tho acid-alkali ratio, 
gives an increase of soda sooreliou; potassium citrate pro- 
duces an alkalosis .with an increased soda o.scrotlou ; and all 
three drugs with proper dosage reduce arterial iire^suro in 
the iarge majority of ca.sos. Consoquoutly Addisou luvosti.- 
gated tho reaotiou of potassium and sodium choridos in. tho 
same person, and tho exporimeuts wore ropontoj with tho 
respective hromldos.lost tlio chloriuo should he tliouglit to ho 
a jia'rty to the action. . 'Tests wore, madp upou five iirtlents, 
nil of wliom wero oil a salt-poor diet with fish once daily and 
vegetables, fruits, cereals, aud uiillc freely, but Irom which, 
meat, poultry', eggs, cliccso, beaus, peas, aud nuts woio 
excluded. Addisou prescribes a mi.xturo of i)Ota.sh saits^ 
namely, potassium broiiiido 10 grains, potassium chloride 
20 graius, potassium citrate 30 grain.'-’, witli syrnji to lialfaa 
ounce, to bo taken in water after food. 'Tliis loriiinla actea 
well in certain 'Cases wlieu tho chloride acted iu.iiffereutly, 
the potassium bromide aud citrate being niiioug the 
efficient of tho potash, salts iu.roduciughyiierleusioii, while 
tho inclusion of potassium cliiorido assists the stomach and 
kidney' lauotious. Tho investigation showed that the giviqg 
of all three potassium salts causes a fall in blood pressure 
with au aiiielloratiou ot symptoms of liypertousion, while the 
aiiiiiiiiistratiou pf.sodinui chloride aud. bromido is associated 
with a rise iii blood pressure 'and an iiicreaso of tho symptouiH 
of hypertension. 

591. Prolonged Salicylate Treatment In Rheumatic 

Endocarditis. 

A. Court (Dull. Soc. de Thor., February 8th, 1928, p. 51), who 
records two illustralivo cases in children aged 13 and 7 y'ears 
respectively, protests against the view that salicylate treat- 
meut is needed in acute rheumatism only so long as the joint 
affection lasts, and that it has no effect, in cardiac complica- 
tions. Numerous writers in France and other countries have 
shown that acute articular rheumatism is a disease with 
a very prolonged course, and in essence cardiac ratlier thau 
articular. During the last fen y'ears Coury has contipned to 
treat his rheumatic patients for at least a year after ail the 
joint manifestations liad disappoarccl. 'This treatment com- 
prises the administration ot -salicylates for from fifteen to 
twenty' day's a month with ten to fifteen day's' rest, aud iu 
much smaller doses than are required for the acute attack of 
rhemiiatism. Coury’s two cases show that rheumatic endo- 
carditis can clear up entirely oveu a long time a. ter it has 
been established. 'The large doses of Iho acute stage were 
not needed, no more than from 2 to 5 grams daily' being 
required. In prolonged salioy'late treatiiiout two factors must 
be considered. Gastric intolerance is more likely' to occur 
when the treatment is prolonged thau when the drug is given 


t in* Unmsa 
MeDicxt. Jotmirix. 


85 


MAY 10, igaS] EPITOMK OF CURRENT 


ill Itirjjo (loses for n (ow days only. Tlio second factor is 
Imliitimtion, ivhioli rapidly ovoltea resistance of tlic rheum- 
atic virus to specific treatinont. Coiiry recoinnicnds Intra- 
Tonous Injections of ?. or 3 prams of salicylates in (jiucoso 
solution two or three times a week. 


MEDICAE LITERATURE. 


but in tiio majority of casco an external operation is neees- 
sary. In addition, a larpo drainapo tube is passed from the 
sinus into the nose and left in position for several days. 
Prompt subsidence of orbital synijitoms usually follows 
operation. 


432 . Subllnituat Absorption of Drufs. 

1). DAVlR and 1). AymaN {.IrrJi. Jnlrrtt. Mcil., February 15tb, 
19 ^, p. 231) comluoted Investigations In order to detennino 
the nbsor|)tlon c.spaclty of llio siiljlinpnal mucoiiH inoinbraiio 
tor drops. A known (juaniity of morphine sulpiiato was 
placed beneath the tonpne, and aftera plvon time the contents 
of the snhiinpnal space wore washed out and the exact ainonnt 
ot nnabsorhed drnp was detorinincd. The authors found that 
no appreomblo absorption occurred in seven experiments in 
fflilcli 10 to 15 nip. of powdered morplilne sulpiiato wcio 
Dlncod mulcr tbo tonpno for from live to ten minutes, C5 to 
90 per cent, of tlio driip belnp recovered. Allowing for toss 
In recovery less tlnin 10 per cent., it any at all, ot tho total 
drug was absorbed. Tliero is no evidence from tlio literature 
in support of any caii.aeity for nbsorplloii liy tlio sublinpuai 
imicons ine.mbrnno at ail comparablo witli tlio rapid absorp- 
tion c.ai abilities of tlio pastro-iiitostlna! and rectal mucous 
incml)r.",ncs, and tlic aullior.s consider that this method of 
administering morpliino should bo discontinued. 

493. Treatment of Erysipelas. 

0. KnAUS (Mcih Kliv., Folirnary 2Itli, 1928, p, 291) records 
45 cases ol erysipelas in ndnils, 15 of wliom were treated witli 
inlraplntcal iiijccttons of milk, 15 willi dlplitluna'autitoxlii, 
and 15 witli local applications sncli as Icbtliyol ointment, 
burow’s solution, or tliiclnrc of iodine. The vesnlts were as 
follows : Itapld recovery occurred after the injection ot 
5 c.ciu. ot milk wlilcb bad been sterilized for ten ininntes in 
a water batli. .\n cipml dose ot diplitbcria amitoxin was not 
nearly so elllcaclous. bocal Ircatniciit did not cssciitlally 
shorten tiio cause of tlie disease. Tlic only contraindication 
for milk injections is tlio )iresenro of pulmouavy luhcrculoals 
or chronic recurrent liacinatcmcsia. 

494. Autohaemotherapy In Conjunctivitis. 

A. DECAPirn ll<i I'atialrui, .Afarcli 1st, 1928, p. 225) publishes 
brief details ot tliirly-ono cases of conjunctival and corneal 
affections in cliildrcn, Ircalcd liy injections of 5 c.ciii. of 
W’holo blood into tho gluteal innsolcH. Tho Injections were’ 
given every other day or 'twice a wcelt, and the results were 
oxcollcnt, fpr in 78 per cent, ot the cases cure was obtained, 
altliongh most of tho inllainiimtions woro clironic in type, 
improvonicnt sliowcd It.self in tlic ropld disappearance ot 
Iivltalion, photophobia, bicpliarospasm, and corneal iullltra- 
noii. No general reactions woro observed after tho injections, 
ilioauthof tliiiiks that tlicy imty net like uon-spcclllc proteins, 
or produce their cITcots hy stimulating tlic sympathetic 


Laryngology and Otology. 

495. Mucocolo of tho Acecarory Nnaal Sinuses. . 

^IIATEY (/I ref/, of Olohn-ijogal.., February 
P’, r™) imicocole ot tlio accessory nasal sinuses is no 
(liflnn I. fre/jiicntly boon considered. IT* 

a retention williin a sinus o 

"of I, owing to contiiiuoiis or periodic closnri 

or resulting in gradual thinning, distension 

diepaen • of one of its walls. Tiio ouset ot tin 

loss niiil tlio course so slow and pain 

liavp bon etiology is dilllcult to ostablisli, tlioiigli en'e; 
innmrini ‘''^'^°‘dcd ill wliicb catarrh, triiunin, or ostcomr 
Bicn is ut' '’^eiliug cause. As a rule tlio llrsi 
the armnn 1 . region.' Tliis usiiallj' occurs it 

Is (liiii^nn angle ot tho orhit, aud as a result the cychal 
diiilonia ‘'°"'""ards and outwards. Jilxoplitlialinos am 
ICiUliiin eiiipliora may bo an early and mis- 

wall nniin f swelling may involve tlio antorioi 

ohsUneim,, ‘’“"•s, and in etiinioidai nuicocclos nasn' 

Iisiially no ioe-Tl ‘lerorinity, may be iirosent. Tliero i; 

hone Of n,n„ • T ™ay be as liard a/ 

crodon nr fi.n ‘ .'’•.Parcliincnl-likc crepitation. If actua 
tniuour mav^bn'^'f sinus lias talcen place a lluctualin{ 

The absmmo of nn 

the duct is nnf I oharactcristic, altiiongi 

all cases. Tlic content! 

ICeiO VnrinQ f -i . . 


*ho 'uiicocelo varies grc.nUy’ in colour 


and coiisi<:tciici 


UsnaUv u ;. gfoatly : 

a Jamo Bhonld aim at cslablishi*: 

cases, csiieeinU?*'^ communication witli tho nose. In son: 
ctinjioignl iniivrT. f^^o mucocele is contliiod to tl 

J iiith, a simple Intranasal opening will sufllc 


400. Eoslons of the Cervical Sympathetic Ganglion and 
the Perlcarotld Sympathetic. 

IiASAONA {Arch. Ital. ili Olol., January, 1928, p. 1) has per- 
formed a .series of experiments on the cervical sympathetic 
apparatus in rabbits, emiiloyiug three types ot operation. 
In tlio llrst lie removed tlie sympathetic trunk with the three 
cervical ganglia of one side ; in the second, in addition to 
this, he also excised the pericarotid plexus ot the same side ; 
and In tlio tliird case he merely removed the carotid plexus. 
Tlio nniiiials were killed at pieriods of a few hours, a few 
days, a mouth, two months, and so on, and examinations 
wore made of the turbinate hodlos and their mucosa, the 
laryngeal inneosa, and tlie wall ot the carotid vessel. It was 
found Hint tlio nasal aud laryngeal luuco.sa were congested 
with diluted vessels, and tliat the glands became engorged 
and secreted a copions tiiiicoiis fluid with which the ducts 
were diluted. In tho cases where tlie pericarotid sympathetic 
was removed there was an oedenmtous inilltration of the 
submucous layer, hut not wlierc tlic gauglionatcd tihnk only 
was removed. These clianges were found only in those 
aiiiinals wliich were killed soon after the experiment. The 
longer tho period between the experiment and the micro- 
scopic examination tho more nearly had the tissues returned 
to normal, until at tho end ot a month there were practi- 
cally no pathological changes to be seen. Removal of the 
gaiiglionalcd trniik and the poi icarotid plexus had a greater 
effect, wliich lasted longer than that produced by removal of 
the triml: aioiio. Removal ot the plexns alone had about the 
samo effect as tlie removal of both systems. Examination ot 
tho carotid revealed a reduction ot the Inmeu, an overgrowth 
of the muscnl.ir coat, and a copious formatiou ot couneotive 
tissue in place ot tlio oxtir|)ated tunica adventitia, which 
sliowcd that now syinpatliotic fibrils appear. The conclusion 
is that extirpation ot tho cervical sympathetic system pro- 
diicos an engorgement of the nasal and pharyngeal mneosa, 
but that its dmation is too sliort to he’ of any thcrapentio 
value in such cases as atrophic rhinitis aud ozaena. 

4D7, Laryngeal Cough. 

G. FEnnEUl {.Irch. Itnl. lii Laringol., December, 1927, p. 5) 
discusser, the causes and siguillcance ot the various types of 
cough. From an etiological point of view lie classifies cough 
according as it is duo to a laryngeal lesion or secondary to 
conditions of tlic central norvons system, the air passages, 
iucliuiing the upper aud lower respiratory tract, the alimen- 
tary tract, and general body diseases, 'such as diabetes and 
nlhuminurin. Tlio type of cough is often a useful diagnostic 
sign in cliildrcn, especially in the harsh raucous cough ot 
mcasics and scarlatina and iu whooping-cough. In some 
cases of Iraclico-lnonehial adenopathy there are frequent 
attack.s of couvulslvc cough, but these two types can be dis- 
tinguished by symptoms of pressure on the bronchi — an 
nstlimatic wheeze in many cases. In cases of laryngeal 
papilloma there is some alteration in the voice besides the 
cough. In adults tho persistence of a raucous cough may be 
of coiisidorahio gravity in the exanthemata, since it may 
signitj- the onset ot ulceration ot the mucosa. In influenzal 
larvngitls tiio superficial ulceration ot tlie cords is accom- 
panied by a violent metallic cough. Benign growths ot the 
lai'vux cause short attacks ot violent cough, but (he cough iu 
malignant disease has no diagnostic value. In tuberculous 
laryngitis tlie cougli is more noticealile in the pachj-derinatons 
type tlian in tho ulcerative or the oedematous. The brassy 
coiigli of laryngeal paralysis is very typical, and each of the 
various affections of the larynx aud trachea has a particular 
variety ot congli which gives indications as to its origin. . 


Obstetrics and Gynaecology. 

^gg_ Late Sequels of Induced Abortion. 

SeuduivOFI-' [GijoGcol. ct Obslct,. lilarcli, 1928, p. 196), in the 
linUt of his experience iu Russia, whore abortion for social 
reasons 1ms liccn authorized since 1920, describes tho liavmrnl 
effects which are produced in women wlio have undergone 
one or several artificial interruptions of pregnancy during (he 
early moutlis. He is satisfied that iu young women aged 
17 or 18 artificial ahortiou, even when unaccompanied by 
inflammatory phenomena, is followed hy intractable sterility. 
In older subjects a morbid involution of the genital organs 
ensues, wliich takes three main forms— infantile fibro-atrophic 
uterus, small atrophic uterus,' and flbro-metropatbic uterus, 

S84O. 



■'86 Mat ig, 1028 ] epitome of current medical literature. 


TmtllRmsi 
MrotCAL JoCBIfXt 


wliicli may be associated with llbio-cystic ovarian clegonera- 
tioii. In certain instances psycliic instability, liypo-ovaria, 
obesity, frigidity, dysparennia, .and various bystero-ncuroscs 
arc also noted; these, together ydth, tbo ntropliic uterine 
changes, may be attributed to the sudden distuvbarico by 
arliflcial abortions of tlio endocrine activity of corpus 
inteum, placenta, ovum, uterus, etc. In tliree eases out of 
four artificial abortions are followed by oiigomenorrhoea, 
in one out of ten by 'amenorrbooa. SerduUoft quotes tho 
ol)servatious of his oo-worlcer' Lanlcovitz, who, comparing 
tlio confinements of 1,700 women wiio had not undergouo 
abortion with those of 6G0 who had had from, two to four 
or more artificial abortions, found that in the latter series 
pyrexia was three times as frequent as in the former, dura- 
tion of labour was' three times as great, low placental Insertion 
w.as throe times as common, difficulty in placental detach- 
ment was twice as frequeut, and retarded involution of tho 
uterus was four times as common. , • 

999. Treatment of the IlenopauEe. 

P. E. Mouhaudt {La vie M6d., April 10th, 1928, p. '527). dis- 
cusses recent views on tho causation and treatment of tlm 
various disturbances associated with the menopause. It is 
supposed that the leas normal the sexual life of a woman has 
been the more tronblos sho lias at tho nietiopauso. • It is 
stated that the more primitive women aro less disturbed tlian 
civilized women. The hot -flushes felt when tho blood of tho 
splanchnic area arrives rapidly at the periphery aro attributed 
to the loss of tlie vagotonic action of tlie ovniios. Tliei-o is 
a profound moJifloation in the relations hetweeu tlio two 
amagonistio systems, vagotonic and sympatlilcotouic, due to 
tlie functional disappearance of tho ovaries. Tlie question 
wlietlier the obesity so frequently noticed at tills time is 
associated with a modification of the basal mofaliolism lias 
not been satistaotovily settled, as hypo- or liyper-thyroldism 
m i.y be simultaneously present. Tlio autlior tliinics it reason- 
able to suppose that the removal of tlm gvatian secretion will 
upset tho endocrine equilibrium, and many of tlio syinploras 
may be due to this. The psyoliic phenomena arc said to bo 
more marked in flie unmarried and in widows. Notliing lias 
yet been found which replaces tho effects .wldoli tlie ovarian 
secretion exorcises on tlie nutrition, of tlio articular cartilages 
and capsules. Tho author places psyoliotlierapy first in liis 
coniideration of tieatinent, then the various ovarian prepara- 
tions. As a sedative he rcootnnionds two (ablespoonfuls a day 
of potassium bromide 30 to 40gratns, codeine pliospliate <10cg., 
ON tract of valerian 6 grama, syrup of bitter orange pool 
200 grams, water q.s, to 300 o.cm. Local symptoms such 
as borbovygmi lio treats with cliarcoal, and pruritus with 
doi niatol 50 eg., boric acid 1.5 grams, tuni6iiol 1 gram, vasolino 
30 grains. For aeue rosacea cold cream, with the addition of 
adieualino (2 per cent, of the 1 in 1,000 solution), has proved 
useful. 

500. Fibroma anl Pregnancy. 

L'JTAud (Ball, et Mem. Soc. Cliir. de Paris, March 2ad, 
19.18, p. 168) reports a case of a three months' abortion in 
a multipaia who had previously given birth to two bealtliy 
chililren. . On curettage being attempted a fibroma,’ the size 
or a large orange, was discovered, attached to tlie posterior 
uiciine, wall, this being evidently the cause of the abortion. 
Myomeptomy was advised but refused, and on examination 
some time later it was found that the tnraour liad undergone 
marked regression. A subsequent pregnancy terminated 
noi iiially at full term. T'vo years later, after strong pains 
simulating labour pains, a hard tnraour as large as a foetal 
bead was passed into tho vagina and was easily removed. 
Dining the following three years the patient lias enjoyed 
cxcelleut health, and montlily examinations have revealed 
no abnormalitie.s. Lutaud observes that other similar cases 
b.ave been reported iu which an increase in size, during 
pregnancy, of a fibroma by oedomatous infiltration has been 
followed after labour by a regression or pseudo-regression of 
tile tumour. 

501. Fracture of tho Clavicle during Spontaneous ' 

Labour. - - -- 

K. AbhEIt (Zenfralbl. f. Gynalc., April 7th, 1928, p. 879) 
examined a series of '2,000 infants (1) at the' time of their 
spontaneous delivery by vertex presentation, (2) at the date 
of tlieir discharge from an obstetric clinic. One case only 
of fracture of the clavicle was found ; the mother was a 
d-para. aged 33, and the child weighed “1.3 kilograms. A irao- 
tnre of the anterior clavicle was audible as the perinenm was 
boiiig supported for passage of the slioulders : subsequently 
the usual physical signs ivero readily recognizable. Of tlie 
infants lu tliis series 603 were examined radiologically for 
missed clavicular fracture. According to reports in Ibo older 
iiter.atnre fracture of the clavicle after sponfanoons vertex 
delivery appears to have been at one time ratlier frequeut. 

SSi D 


Riotber in 1902 reported 65 cases during one year at a Vienna 
clinic; Mints a year later reported an Inclilouco of 1.3 per 
cent, among 1,600 easos at Go])onliagon, and Hauch (1905) an 
Incidenco of 0.67 per cent.' among 2,500 spontaneous vertex 
deliveries. (Jortaiu of the older writers believe tliat tho frac- 
ture oco'urrcd during birth of tlic shoulders, others ascribed 
It to ah liitrapclvic injury. It was agreed tliat diagnosis was 
dllllcult for tlie 'roasou -tliat .crepitation, unusual mobility, 
and impaired function were ficqucntly absent. It was- 
invariably' noted, tliat the anterior clavicle was the more 
frequently fractured. 


Pathology. 


502. - Bacteriology of Scptlcaomla of Childbirth and 
Abortion. 

k. SOMMER [Zentralhl. f. liiiniiU., April I4th, 1928, p. 942) 
adduces ovidcnco tliat of ia'to yoars. in industrial areas at 
any rate, liaomolytic streptococci no longer play the, cliiet 
part in causation of septicaomic conditions following child- 
birth or abortion. Ills material comprises 58 cases of normal 
birth or proniatiiro hirtli and 186 cases of septic abortion, 
of which uoaily all were artificially induced. 'The deaths 
numbered 44 and 164 rospectivoly in tlio two groups. A 
haemolytic Slaphi/lococcus nnrciis was found in tho blood in 
71 cases, with 86 per cent, mortality; the uext place was 
shared by a lianinolytic Rtroptoooccns and tlie anaerobic 
Slrcptococciis pittridns, c.icli witli 46 cases and 81 per cent, 
mortalitv. 'i'liere were sterile blood cultures in 42 cases, 
with 89' per cent, niortality. Further aualy.sis sliowert 
staphylococcal' Rcpticaomia to lie much more frequent m 
tho cases of infected aliorliohs, which appear to Iio induced 
most usually by irregular practitioners wlio imdcrtako iii 
addition a consider.rhio amount of unqualified treatment of 
skin disease. Tlio figures aro from a Berlin clinic. 


503. Th c " R ” and “ S " Forms of Pneumococcus. 

M. H. DAWgOK (.fotirit. Exper. Sled., April 1st, 1928, p. 577) 
inontions that, following tho ' 1 i;‘covory by Arkwri^^^ two 
variants of tho .same baclorlal species, “R (tough) and 
“S" (smootli), Grimth was tlio first to recogmze two corre- 
sponding varianls of tho imciimococcns._ 'The 
features of these are as follows. “S forms ^ ’ 

produce tho spocifle solnblo substance upon wliioh type 
snccifioltv depends, and form colonies which bavb a smooth 
surface when examined by roflectod light. “R 
avlrulont, do not produce the specific soluble substance, and 
form cXnicB which have a rough surface. The question of 
their intorcliangcabllily 1ms considerable slgmfloauce In the 
uroble W epTi einiology and iu the interpretation of bacterial 
mutation Dautton Ims undo a series of experiments on ti o 
intorconvcrtibility of tlie two forma, and ospeem ly e“ ‘'‘U 
l“lSon from ■' R ” to '■ S." He has pfcvious T 
virulence and type specificity could bo 

by growth in anti-'-R'.' .?“^Pr'^mmuno serul^ 

tn'fl.^ 1 ? ZVirT'Tay be obtained Horn -S" aud^S'' 

from “R” forms respectively.^ In those 

in vitro -by growth in anti-‘'R’’ " n of 

by animal passages, both mass and single Dawson 

Tvnes I II and III pnonniooocoi were craplojed. 

found that ‘'R” pnouiuoeocci may revert 

the -S" type, and that in all i’mtunccs-m whieb imorsmn 

ocouvroa the “B” forms invariably ‘P, “^Vived! 

specific tyiie from wliioh tliey wore >’?<=«• 

Reversion from "R” to “S” was always accompanied y 

the acquisition of maximal virulouce. ; • i 

505. ReslstaucB of Tubercle Bacilli to Putrefaction. 
ACCORDING to V. M. 

1928, p. 205) it is generally agreed that ® eternal 

is one -of- the most resistant ater but 

agencies, such as liigh temperature, -axv 

excluding simlight. This peculiarity u t® 

covering anci lugh fat and hpoid ]t,oth 

regarding its capacity of resistance to putrefaction mo b t 

scanty and contradictory. Palinieri records ‘1^® 
man, aged 21, who was exliurned ufter four raoutlis b 
his death being duo to pulmonary tuborculosis, wine i t 
. alleged to be tlie result of a wound m the '”°ition' 

lireviously. In spite of tlio advanced stage of (.gg 

naked-eye aiipearauoes of tuberculosis -lyero toTnd m t^ 
•lungs, in wliioh numerous tubercle bacilli were fonnl uy 
Zielil-Neelsen’s stain, as well as with Gram s and Hoa 
methods. Animal inoonlation W'as not employcct. 

■ tho lungs had been immer.sed in formalin; at me tmm 
exhumation. . 



MAY s6, igsS] 


[ TireBnmsB 
UXCICAX. JocbmaA 


87 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

505. Pulmonary Ventilation in Phthisis. 

R. WILWAMSOX ((^iiart. Jourit. Meil., April, 1928, p. 371) ha<i 
made observations on tlio pulmonary ventilation, oxygen 
consumption, and rcsplratorj' quotient or patients Buttering 
Itom pulmonary tuborculosls and ot normal Individuals. 
Experiments wore perlormcd in three groups ; in the llrst, a 
series of observations wore niodo on tho samo patient, who 
had been tasting and at rest tor lonrteen hours ; in tho second 
group the records were made three times during tho day on 
tho samo patient, tho Initial readings being taken under tho 
basal conditions present In tho first group ; In tho third series 
determinations were made on healthy subjocts at varying 
times during tho day. Tho results ot these Investigations 
Bbovred that tlio pnlmonnry ventilation and consumption of 
oxygen varied I roni time to 'time in tho same tiatleiit under 
the same basal conditions ot rest and fasting; by plotting 
these values against each other it was found tliat each was 
directly proportional to tho other. Tho same direct ratio was 
found to hold in tho second group of experiments, whero tho 
variables fluctuated with the taking of exercise or food. In 
the normal subject tho corrospondeuco between ventilation 
and oxygen consumption was loss marlicd owing to tlio varia- 
bility of tho respiratory quo, lent. The author considers that 
for practical purposes tho pulmonary veutilatlon is a measure 
of oxygen utilization, and thcretoi o of metabolic rate, and ho 
suggests that dctermiiiatiou ot pulmonary ventilation modo 
under constant conditions may be a nsotul means ot cstl- 
mating the progress of a ])aticut. With a given oxygen 
consumption the tnboiculous patient is found to have a 
grea'er ventilation than a normal subject, and this observa- 
tion is adduced to explain tho fact that dyspnoea Is more 
readily produced by work in tbo tiiborculous than lu tho 
healthy individual. 


S03. Capillary Dilatation In Deep-seated Inflammation. 

A. I’AllAVlciNl (llev. ucl Itistiinte Ih-dico "iiHcre," -Taunary- 
February, 1928, p. ^9) has observed that mauy patien.s with 
deep-seated inllammatory processes present fllifonu sub- 
cpidcriiiic striae of a bright red colour and of a iiermant nt 
character, localized on the skin ot the trunk, especially that 
of tho supraspinous fossae at the site corresponding to the 
pnlmonarj' apices, tho extent ot this striation varying wilh 
the severity of tho sulijacent lesion. Tbo striae may also he 
found on distinct parts ot tho shoulder and breast, corre- 
sponding with lesions in the mediastinum, perieaidiuiu, or 
pleura. They rcseiiiblo those met with on the nostrils of 
alcoholic subjects, but differ from them in their greater 
delicacy'. In all the cases in which the author observed the 
sign it was constantly associated with deep-seated lesions, 
usually of n tuberculous nature. Tbo condition is thought to 
bo a dilatation of the superficial cutaneous capillarie-s, which 
Is at first transient and subsequently becomes permanent. 
The only other changes in tho skin observed are dryness, 
slight increase of thickness, occasional branny desquamation, 
and adhesions. Most of the author’s observatiuns were 
made in mining centres, where the sign was frequently met 
with, especially among subjects of pneumonocouiosis and dry 
pleurisy'. 

S09. Diagnosis of Glandular Fever. 

Ii. D. Cady [Avtcr. Jouni. Meet. Sci., April, 1928, p. 527) dis- 
cusses tho diagnosis ot sporadic infectious mononucleosis 
(glandular fever), and reports nine cases. Ho concludes 
that the diagnosis from such conditions as syphilis, tuber- 
culosis, and Hodgkin’s disease can only be established by 
careful study of the differential white cell count in associa- 
tion wilh tbo clinical features. The clinical symptoms may 
persist for a few mouths, but the abnormal blood picture 
contiunes for montbs or years after the initial attack. 
Patients may be affected in the fonrtb or fifth decades, as 
well as during childhood and early adult life. 


SOB. Anginold Attacks Duo to Tobacco. 

E. SIoBcncowiTZ (./oiini. snirr. Sled. Assoc., March 10tli,1928, 
p. 733| records four illustrative cases, in persons aged from 
35 to 62, lu whom tobacco smoking caused anginold pains, 
which ceased when they no longer smoked. One of tho fonr 
was a woman. 'They had all smoked for many years previous 
to tbo Boizuros. Two smoked only Turkish cigarettes, aud 
two strong Havana cigars with occasional pipes, so that tbo 
variety of tobacco used apparoutly made no difference. The 
pain ot tobacco heart differs from that ot coronary or aortic 
disease in being more intense, ot longer duration, aud usually 
accompanied by little or no disturbance of heart function. 
A iiromiucnt feature is the apparent sensitization which 
ocenrs. In some cases more or less pain was caused by 
merely puffing a cigarette or sitting in an atmosphere 
of tobacco smolie. MoscUcowitz describes two varieties of 
tobacco lieart : (1) those in which evidence of cardiac iujui'y' 
is not present, aud |2) those in wliioh the signs are suggestive 
of the intraventricular condnetiou disturbance associated 
with coronary or aortic disease. In the latter tobacco is 
probably the exciting cause ot the anginoid paiii. Treatment 
consists in complete withdraw'ai ot tobacco, as mere limita- 
tion of its use is not enough, Tbo pains do not cease imme- 
diately after withdrawal, but they continue for many weeks 
or even montbs. Altliongli the meobaiiism of tobacco angina 
IS not definitely known, tbo most probable explanation is 
that it is due to the constrictive action of tobacco on the 
blood vessels. 


507 . Encephalitis In Efeasles. 

.^E rarity ot nei-voas coiuplicatioiis in the course ot measles 
(Bouliciiii in 5,910 cases only noted their jireseuce in 0-4 per 
cent.) induces D. Bdasi (Ca Pediatria, April 1st, 1928, p. 362) 
to record a case in a child aged 3. Four days after the 
appearance Ota typical measles rash generalized convulsions 
developed ; they were rather more marked on the left side, 
between the attacks tho child was in a stnporose state, 
n f refused food for two days, 

ont bad no vomiting, .and there were no pulmonary or cardiac 
ciiangos. There was slight .strabismus and neck rigiditj’. 

exaggerated. Kernig’s sign was absent, 
auci lumbar puncture gave no evideuce ot meningitis. The 
yiiiptoms lasted abont .six days and then slowly disappeared; 

the child completely recovered. The 
eucfjphaUtis iu this case was probably 
aae to tbo measles toxia • 


510. Treatment of Daryngeal Diphtheria. 

E. S. Platou and C. A. Stew.art {Ulimtesoia Med., March, 
1928, p. 170) have found two mcasuros ot value in the treat- 
ment of laryngeal diphtheria. ’The first of these Is laryngeal 
suction for removing laryngeal membrane. Through a 
laryngoscope a plain seiiii-sott or metal catheter is intro- 
duced, the distal part of which is atiached to a suction 
iiiacliiiie. Over n two-year period the incidence ot intubation 
was reduced approximately one-haif by this method, which 
is comparatively simple after practice with the laryngoscope. 
Tho second measuie is intraperitoueal injection of antitoxin. 
Tests showed that this method was second only to the intra- 
venous, and that Bulfioieut antitoxin was present in the blood 
one hour niter intraperitoueal injection to neutralize all the 
circulating toxin in the very worst case of diphtheria. 


Surgery, 

£mbolectomy. 

H. Bam {II Policlinico, Sez. Chir., March 15th, 1928, p. 117 ) 
reports the case of a woman, aged 39, admitted into hospital 
with a history of sudden pain iu tho right leg, followed by 
coldness and deadness of the limb, and gangrene^ evidently 
due to ail embolus iu tbe femoral artery. The lea was 
amputated iu tbe middle third of the thigh. A wcel^ater 
the patient was seized with a similar sndden attack oTpaln 
iu the left leg, aud there was evidence ot an embolus in tbe 
left femoral artery. Tho leg was cold and insensible the 
reflexes were absent, aud no pulse could be felt below 
Scarpa’s triangle. In spii e of lier grave geuerai condition tbe 
clotiu tbe femoral artery was removed about six hours after 
the onset of the symptoms. Local anae.sthesia was used aud 
an embolus about 4 cm. long was extracted from the artery 
Tbe ai-teriai wound was sewn up with catgut without involvinfi 
the intima; silk threads were left on the artery and were 
brought out of tbe external wound in case secondary liaemor- 
rliage should occur. The immediate result of the operalioa 
was excellent, the leg became warm, sensation returned and 
pulsation could be felt iu tbe arteries. The leg continued to 
do well for tbo next seventeen days, when, after sudden 
emotion, tbe heart, whicli was affected with advanced mitral 
stenosis ,md fibrillation, failed, aud death occurred from 
embolism. No necropsy was allowed. 


930 A 



88 mat 26, 1928] 


EPITOME OF CTIBEENT MEDICAIi EITERATTJBE. 


r Tnt IJRmt* 
LMiDtcii. Jova»4i 


512. Treatment of Suppurative Osteomyelitis. 

M. Satdman (Zentralbl. f. Cliir., April 7th,' 1928, p. 844) 
recomiiionds ■irdf'atioii of tlie modnlliiry canal in all oases 
of nouto or subaciito osteomyelitis of long bones. Alter 
opening the meclullary canal 'with a small trephine, tvithin 
a short distance ofthe upper and lower epiphyses, he removes 
tlic marrow through these-bpenings by means of a curette 
or spoon. The medullary cavity is tlicn irrigated witli dilute 
iiietbylene blue solution, or other antiseptic by iheans of a 
syringe and cannula, the latter having a lateral oriiice. In 
tlio case of very long bones, suoli as the femur, tibia, and 
humerus, it is sometimes advisable to trephine tlie diaphysis 
at three or even four equidistant points; it may also bo 
necessary to introduce a curved sound through the . trephine 
openings before the medullary canal can bo irrijjatcd 
llioroughly. Saidman describes the case of a man, aged 53, 
wlio had a typical attack of subacute osteomyelitis in the 
upper lialt of the left tibia. The operation was performed 
muier local anaesthesia. Two small incisions wore made at 
tlic upper and lower borders of the painful area. Through 
these tlie medullary canal was opened by means of a small 
trephine, the outlet being made larger than tlic Inlet, and Ibo 
uiairorv in the vicinity of the tropliino openings was removed 
with a spoon. Pus flowed from both orifices. The wounds 
were lightly plugged and the limb was fixed in a Volkuiann’s 
splint in the position of rest. The temperature rose at fir.st 
and then fell sliglitly, otherwi.se tliorc was hut little clmugc 
ill the clinical condition. Two days laier the medullary canal 
■was irrigated witli a weak antiseptic solutiou under very low 
Iirdssure. From tlio exit orifice a mixture of the solution, 
pus, and masses of marrow containing largo drops of tat 
escaped, and the irrigation was continued until the solution 
was clear. Tlie procedure was performed six times ; only 
after the first treatment was there a rise of temperature and 
increased pain in the inflamed area, which necessitated tlio 
administration of a hypodermic injection of morpliiue. On 
tho next day tlio patient was free from pain and slept sounclly. 
The rapid improvement that followed tho first irrigation was 
evidently due to the -treatment. Saidman claims that tills 
treatniout is scientitlo, and so simple that it can be performed 
under local anaesthesia. 

513. Surgery of the Sympathetls Nervous System. 

G. Fieri (Arch. Ital. di Chir., February, 1928, p. 487) publlslics 
a series of cases illustrating the effect of section of the rami 
eommunicantes in conditions where pain is the predominant 
syiiiptoin, and wlioro after abdominal section no sufUoiont 
oauso is found to explain the symptoms. Ee reports tlireo 
oases of gastralgia which oould not be explained by the 
ordinary suppositious, whore lamlseclion caused complete 
cessation of Uio pain. Three cases of persistent pain in the 
riglit iliac fossa not apparently doe to the appendix or 
paeoum were also relieved by ramiseciion. In these cases he 
also removes tlio appendix ns a prophylactic measure Tlie 
next throe ca.scs refer to biliary psoudo-lithiasis, oco’urrin" 
111 young subjects suffering from pain in the riglit hypo” 
chondrium especially over the gall-bladder, and radiating to 
tlie back wilhout fever or jaundice. One case of doubtful 
slight psucroatitis was relieved of piin by ramisection Tlie 
author also reports cases of roual, vesical; testicular, or’pelvic 
pain treated similarly with success. He only resorts to tliis 
symptomatic Iroatmeiit .after excluding any removable cause 
As to the duration of the enre, none of the cases are very 
old— tlie oldest goes hack only two year.s~bnt in every case 
tho relief has been maintained to date. Fieri adds that avhen 
operating on tho dorsal roots care mnst be taken to avoid 
.injuring tlie pleura, and in every case the nerve trunks must 
be disturbed ns little as possible. Altogether tlie author 
lias performed tliirty-oue ramiseotions, with one'death from 
• broncho-pucninonia. 

. 515. Prevention of Post-operative Bleeding in 
Haemorrhoids. 

J. A. "Wesslick and Ilecord^ March 21st 1928 

■p. 310) considers quinine,-nrea hydroohlofide, arid coagulen 
to be an ideal combination for tlio prevention’ of post-opera- 
tive haemorriiage in haemorrlioidectomy. He prefers local 

■ to general anaesthesia, using a 1 per cent, solution of quinine 

■ and urea hydroclilorido with tho addition of 3 per cent 
congulon, a combination whicli afforded a nearlj- bloodless 
field during operation in fifty cases without any post-opera- 
tivo bleeding. After dilatation of tlio sphincters under a 

■ 1 per cent, solution of novocain the most dependent haemor- 
rlioid is injected witli the solution from base to apex to the 
]iointof distension and blanching. After it has been drawn 
down the skin and pile tissue are divided at the mnoo- 

■ cutaneous junction and a No. 30 liucn thread is passed round 
-tlie pedicle, the entire liaemorrhoid being tied and out off, 

h aving siillicient stnmp to preventslipping of the ligature. 
Each 'individual haemorrhoid is similarly treated. 'The 
930 B 


advantages claimed are that the quinine and urea hydro- 
chlorldo produce a prolonged anaesthetic effect, wliiic llio 
coagulen prevents sccond.ary liaernorrhagc and provides a 
nearly bloodless field. Wessler advocates coagulen ns being 
a solution of thrombokinaso isolated from blood platelets; it 
is free from protein and tliore is no danger of nnnphyl.-iciic 
shock. It is a stable preparation wjiich roraains nuitonii in 
potency; if neecssavy, the ainponlo.s can bo sterilized by 
boiling, without affecting tlio coagulating qualities. 


Therapeutics. 

SIS. Treatment of Syphilis Associatccl xvlth TubcrcniOEls, 
R. MATlCbAND [Hull, cl J\lhn. Soc. Med. Hop. dc Paris, 
Marcli 29tli, 1928, p. 548) illnstratos the liannful iuiluenco 
of novar.sonobenzol on tnbercnlons syphilitic patients liy 
describing two cases in wliicli tlio first few Injections wero 
followed by uncontrollable activity in iirovionsly quiescent 
lesions. Arsoiiicnl couipotiiids as a whole have, during tlio 
last fifteen years or so, fallen into disuse in pulmonary 
tuberculosis on account of tlio' visit of aggravation of the 
disease. Snob activation is bronglit aliout by tlio pulmonary 
congestion wliich follows tlic administration of arsenic, and 
tills drug is tliorefore sjicclally contraindicated wlieu tliero 
is fever, haomoptysis, or progressive loss of w'oiglic. Con- 
siderablo elevations of tompevaturo in febrile tuhercnlous 
patients Iiavo been shown to follow five or six injections of 
cacodylato of soda. Marcland romarlts tliat syphilis and 
tuberculosis arc such common diseases tliat they innst fre- ■ 
queiiUy coexist) and it Is therefore important to uialro a 
tliorongh search for a tuhsrciilons lo.slon whenever a febrile : 
reaction or a' loss of weiglit occurs during treatment with 
novarscnobensol. Patienis suffering from hotli ■ diseases 
should not ho treated with tliis drug unless the temperature • 
and pliysloal signs are carefully watched so that the 
administration may ho immediately stopped shonld' signs 
of tuborculo'ns activity appear. If withdrawal of: arsenic 
becomes necessary troatiiioiit sliould be continued with 
bismuth and mercury. Those drugs are. well tolerated by 
tuhorciilous patients, and although cure of tho syphilitic 
condition may be delayed; it may ultimately bd effooted.- On 
the other hand, it may bo dillloult or oven- impossible to 
arrest a pulmonary tuberculous lesion whicli lias been lit up 
by the ill-advised and uncontrolled use of novarsenobenzol. , 


5je. The Treatment ot Bronchiectasis. 

AccORDiNa to It. Strisower (irfcn. }din. irocn., AptU 5fcb, 

1928, p. 495) the tbreo most important indlcatious to prevoQC 
the extension of bronoliiectasis ai-eto doorcase the expectora- 
tion, to assist in its expulsion, and to prevent gangreiie. 
One of the moat important measures in dimmiMlno om 
oxpootoration'is' to decrease the amount of fluid imnmea, 
Ifsliould amount to about 600 o.cm. per diem for three ciajs, 
and on tho fourth day, which may be called a “ „ J,} 

tlio ordinary amount is taken; To avoid thirst a slice of 
orange or loition may ho given and. the mouth may bo T “shea 
out with soda-water. Tlic following remedies can also oe 
employed : atropine, turpentine; eucalyptus, “f 
and camphor in solntioni-’and- eucalyptus and menthol ois 
solved in oil; To assist in its expnlsion the expectoiati^ 
should be made thinner by alkaline waters ■ and potassmm 
iodide. -The -'most important moans for getting rm oi im 
expector.-ition is ' the adoption- of Quincke’s Pps'hp” 
respiratory gymnastics. Adoption of the 
is often effloaoious— the patient should be in theteorsa 
position with the pelvis raised, and shonld then take cieci 
breaths; "He'shoulfl'theu bend the hips'and knees and press 
them firmly into the abdomen. Salicylates diatnermy ■ 
have also proved nsotul. It there are signs of ganoVe 
neosalvavsan injections should be given; should there 
ho result after six or eight they must be abandonetl. a 
operation is' indicated it tho sputum is excessive and pntrm, 
nr if t.lin fii.(ien.so hrnaresses in suite of treatment. 


517. Ephedrine In Asthma and Hay Fever. 

■R. Green [Malayan Med. ffoimi., March, 1928, p. dO) teoor s , 

his observations upon the symptomatic treatment of 

and hay fever with ephedrin'e. The hydrochloride was gw 

orally in doses varying from 1/2 to IJ grains in ten astn 
cases, while in two cases of hay fever’a 3 per cent, epheurm 
sulphate solution was applied locally to the nasal mucous 
membrane. Each asthma patient was kept under 
tion for from two to six lionrs, and in some cases tho 
pressure was recorded every lialt-houi-. Complete wa 

obtained in six of the ten cases, while five developed tox 
symptoms, including mental contusion, urticaria, palpitatio , 
tremor, sweating,- tachycardia,' or collapse. Green turn 


MAT 25, ig2Sl 


■■EPITOl^rE OP OURRENT MEDIOAE EITERATURB. 


r Tnt JfTj- ns n 

STs OICAX. JotTHSXL 


89 


that oplicilHno Is ot toiicU Iho Riinio valiio In nslhmntlo 
at taolu IIS aaronalliio, lint Ims Hio nilvntitnHo Of l)ciii(? (ilvcn by 
mouth liistcnd ot by Injection. In view ot tho toxic symptoms 
so.iictiim’M acisliiK KiiiiUt itoscs shonhl bo employed nntll 
toler.meo Is ostablisboil.. Whon tlio ilriiU' was nsoil dnrlnfi an 
attack tho hlooil picssnro was unatTcctcd or loworod, bub 
when given durinH a qtilcscoiit period the blood prossnro was I 
temporarllv raised, so tlial it avould appear to liavo tlio samo ] 
contmlndlcivtlons ns otlior blood-pressnro-raislng drugs in 
diseases ot tlio cardlo-vascniar systoin. In tho two eases ot 
bay tever treated by local applications ot ophedrino snlpiiato 
to tho swollen nasal mneons nieinbrnno marked temporary 
relict tor three hours was obtained; 1 grain of epbedrino 
hydiochlmido had no ertect upon the symptoms, but prodneed 
atoxic cIToct ot faintness, palpitation, ami sweating siniiiac 
to that noticed in some ot the asthma cates. 

518. Treatment of Pulmonary Tube -eul.-Bla by 
Snnccrysin. 

V. CtR and Jf. S. AxDntiSRN {.tcUi Tubci cnloseti Scandinavicit, 
1927, vol. 3, Paso. 2, p. Glj pubUsU details ot a scrlos.ot 35 
Cii'-cs ot pulmonary tuhorculosis Ircato.l by satiocry.sin. 
lujeclions were mado Intravenously as a rule, occasionally 
Imrainnsculaily, ot .a 5 tier cent, solution, and In general tlio 
do,s.igQ was- regulated accoiding to Moellgaard'a directions. 
Ta-o stilts ot Injections were glvrn, sometimes three. In 
tho caily stages ot tho Invostlgatioii au aiititubcrculosis 
sornm was given dmliig tho first soiies of hijcctious, hut 
later this pracllco was discontinued, ilfost ot tlio palionts 
atter Ire.atuicut with sanocryslu were dlsprdchod to a snna- 
torinin. Ot 12 acute eases with tubercle hacllll in their 
Rpiitmii 6 patients died, 4 were .apparently cured {1 relapsed 
later), 1 remnined- sfiilioiinry, and 1 nas improved.. Of 
12 acute cases, and 2 chronic enscs with acute exacerbations. 
Without tuhcrcio li.aci'.lt in , their simltim, 1 patleut died, 
9 were apparcutly cured (hut 2 rolaiiscd later), 3 wero 
pro! ably curo.i (but were not examiued later), and 1 was 
improved. Of 8 clii'Oiiio cases with tubercle bacilli in tboir 
Bpulum 3 patients died, 1 was apiarcntly cured, 2 wore 
Improved, aud 2 romaiued statiouary. Two patients wUb 
eliioiiic disease but witliont luborcio bacilli in tbeir sputum 
were npjiareutly cured. Agalust lUaso may bo set 19 eases 
Hint wero not treated by satioorysln. Hoveutoen ot these 
Were acute g.ases, or chroiiio oases with nettle exacerhations, 
with luhcvdio bacilli lu the sputum; ot thoto, 9 patients died, 
4 were Improved, and 4 wero worse. Of 2 acute ca'-os with- 
out tubercle bacUll 1 patient died, the other was liuprovcd. 
I'lio nutliors consider that these dgurcs deuioustrato tho 
Value ot sanocryslu treatnuut. 


Ophthalmology. 

519. TraUBmlsaton of RrEcnls to the Aqueous Humour. 

A. 3t. YUDkin, a. C. Kn.tusB, aud D. G. MonTOX {Arch, of 
Ophlhahnol,, March, 1928, p. 147) descriho four experiments 
oil dogs with rcyanl to the transniisslou ot arseuio to the 
aqueous humour. They found that, whereas after intra- 
venous Intecllon ot largo doses of ai-seuical compounds 
practically no arsenic could be found in tho aqueous, yot if 
paracentesis ot the anterior cliamher was pcitorincd shortly 
before or after the Intravenous injection arsenic was foand 
in the aqueous Uuid, and, furtlier, that Ibis presence of arsenic 
in the aqueous could be increased by further paracentesis. 
The arsenic present in the aqueous lUiid after these pro- 
cedures leaves Iho anteiior chamber in a few hours. Tlio 
JnslJJJaliwi ot p'docarpiue aud eaccino iiel[is to iiicrca-.c the 
quantity ot arsenic in the aqueous. In view ot their experi- 
ments tho authors suggest that iu eases ot syphilitic affections 
of the eye, and iu particular in cases ot iuterstitial keratitis, 
paiaceute-.ia of Iho auteiior chamber shoul.l be performed 
near the tiiiio of the intravenous injection of au arsenical 
compound, and that the paracentesis might with advantage 
be repeated -dgaln within a few hours, and- that concurreutly 
pilocarpine or eseriuo drops should ba instilled into the eye. 

-S29. . Keratitis .Due to an, lafcctlon ot Trachoma. 

DuiUKG .tJio , course, ot aunual.autuinual epidemics of acuto 
conjunctivitis iu AtUeus, due ottcu to the bacillus of Weeks, 

B. Adasiaktlvdis (dun. d'Oauliaii, Eebrnary,d928, p.T19) has 
noticed tliat iu certain patients, particularly infants, a latent 
lr.i<;hom.a becomes apparent during tlio decliuo of an acuto 
Cl nj'.mctivjtls ; the coiicse ot tliis acute conditiou was much 
lou“er in .tracbouiatqus- subjects}, and' favoured complications 
ot tlio cornea or .aggravated existing ones. This ulcerative 
keraUtis, .caased by . a suporinfectiou ot tho trachoma by 
Week -Id baellll, diffard from other forms ot keratitis iu tho 
o lowing ciiaractcristioR. , Tiio .iilceraliou, always duo -to 

tins bactllis,' occurs lu debllitatod cases, aud is liuuted to 


tho middle ot Ibo cornea on tho horizon'al meridhan. It i.s 
In tho form ot a furrow, very deep In tho centre cn.1 le.vq 
so on tho two sides, perforation alway.s occnrrlng in Iho 
centre. Tho edges np(icar polished, shiny, an.l witliont any 
greyish Intlltratlon. Tho ulceration is uncomplicated by 
suppuration, and lias a vciy rapid conrso. Two or tlireo 
days after tho onset of tho oplilbalmia the cornea is affected 
and speedily lieconios eroded in its depth. Aliundaut lacryrua- 
tlon and Intense periorbital pains accompany Ihe coriical 
Involvement. The prognosis is very grave, though with coii- 
tlnnous and systemalic troatnicnt it is not hopeless. The 
author i-ccotniricU(’s daily cantetlzallons witli a 1 per cent, 
solution ot silver nitrate after careful eveisiou ot the lid, 
InsliHallons ot pilocarpine or argyrol, and compress dressings. 
At llrst, owing to tlio lacrymation, tliese dre’-sings tlionld bo 
changed four or live limes daily, tlio iustillalions being then 
made, and au antiseptic oiiitnient applied. In obstinate cases 
BUbconjnnctlval injections ot mercury cyanide may bo given 
combined with parenteral injections ot milk, 

521. Amaurotic Zoster. 

E. BOLr.T;T {Jouru. de Mi-d. de Lyon, JCarcIi 20tli, 1928, p. 1491, 
who records an illn'-trativo case In a woman aged 70, states 
that lu addition to tlio ordinary oplithalmic herpes obarac- 
tcrized by pain, eruption, .and various distuibances of Iho 
anterior segment ot tho eye, sneU as keratitis or iritis, tlicro 
Is a form of ophtlialmio zoster in wliich tho poaterior segnirnt 
Is Involved owing to affoclion ot the optic nerve. Tlio 
innammatlou ot tlio nerve ap; ears to be secondary to herpetic 
mcuingills, tho oxistenco ot which is proved by lumbar 
puHClurc, w'liicli shows a distinct lymphocytosis. Whereas 
optic’ atropliy occurring in general diseases and intracranial 
atfoctlons Is symmetrical, unilateral atrophy will often bo 
found to be duo to a previous attack of ophthalmic zoster. 

522. Mikulicz's Disease Treated by X Bays, 

R. E. 'Wright {Amcr. Journ. of OplUUaimol., 'Deeemher, 1927, 
p. S03) describes a case ot this di.seaso in which tho lacrymal 
and silbmaxillary glands were involved. The swelling ot lha 
iacrynmi glands was so groat that corneal ulceration ensue.! 
and tho lids liad to bo suture.!. .Y-ray applications wero 
given over a period of six weeks, two' being given to the left 
eye, which was the one least involved, and six to ihe riglit 
eyo. At the end ot tho six weeks the swelling of the laciyTna! 
giauds had disappeared. 


Obstetrics and Gynaecology. 

523. Surgical Intervention in Extrauterlne Pregnancy* 

H. P. Bnow.v, Jun. {.innats of Sttr/jertj, April, 1928, pi SSI) 
records the experiences gathered from 109 cases ot cotopio 
gestation treated at the Pennsylvania Hospital. Regarding 
tho cfology and pathology ot lids condition, Robinson has 
stated that it is due rather to a functional dislmbauce ot the 
tnbo than to an Inflammatory and meobsnical condi ion of 
tho tube itself, and numerons authors have shown that the 
canse ot rnptnre and haemorrhage, oonditiens chiefly respen- 
slblo lor tlie symptoms, are dependent not only on the ill . 
tension of tho lube by the growing embryo, hut also on iho 
degree of penetration of its Avails aud blood vessels by the 
foolal elciiieuts. In the present series a combination of 
vaginal bleeding and abdominal pain was the most Irequeutly 
seen — namely, in 55 per cent.- ot tho cases — while iowi r 
abdominal pain without haemorrhage occurred in 36 per cent. 
Salpingitis was noted as havlng'bceu present i.n only 10 p<r 
cent., while a high leucocyte count was net obse'ived fre- 
quently enough to bo ot diagnostic value. In no iustauce 
was the temperature on admis.siou above 101“ P. The onset 
of the symptoms was fonud to be often insidious, depeudii.-g 
largely ou the degree and rapidity ot rupture o’ the tuLo or 
embryonic sac. The diffeieutial' diagnosis between ectopic 
pregnancy and conditions simalatiiig if, especially f alpiiigitis 
and appendicitis, is trcqueutly difflcnlr. In the pieseut cases 
the right side tvas involved in 53 |ier cent, and the le.t in 
38 per cent., 'ivbilo on operation tho tube alone was lemovcd 
Ju 81 per ceut.and both tnbe and Ovary- in 15 per cent, lu two 
cases both tubes wero excised, -and in one ovarian pregnancy 
only tUo ovary. The mortality was 6.3 per cent; %rowu 
conclndes ' that, diagnosis is difllcnlt in' atypioa.Vcas-..S‘, and 
that much reliance cannot be placed in the menstinal history 
or tho absence of previous preguauole.s. -■ In doubtfnl cases 
whole an acnlo surgical emergency is not present reasouablo 
delay.is permissible in order to arrive -at- a coirecfdi.-igliossi- 
bnt in those presenting symptoms of active llee;iin« Immei 
diate operation is necessary without -waiting for a reaction 
from shock, since there is aln-ays a chance of recovery despite 
extensive intra-abdominaL haemorrhage or shook. lYhere 
indicated an aatotranslusloninay bo beneficial. 


930 0 


90 Mat 26, 1928] 


EPITOME OE OTERENT MEDICAE EITERATUBE. 


I TnT?attn» 
Uemcix. Jovat4S 


524. Treatment of Ovarian Cysts during pregnancy. 

M. BROTJHA (Bnixelles-Medical, April 15th, 1928, p. 803) states 
that, while the systoraatic operaiive treatment of ovarian 
cysts during the first months ol pregnancy is generally 
approved, opinions cliHer as to its advisability during tho 
latter months. Despite the dangers of torsion, rupture, and 
suppuration of the cyst, surgical intervention, practised by 
certain authorities, is not reconi mended by' Bronha owing to 
the risk of causing a premature accouchement and eventra- 
tion due to rupture of the abdominal cicatrix; a case of this 
nature is cited. When tiie cyst lies in the abdominal cavity 
spontaneous natural delivery is possible, and tho cyst can bo 
treated at the end of the puerperal period. Pelvic cysts causo 
a mechanical obstruction, and other measures arc necessary. 
Manipulation of the cyst into the abdomen is tedious and 
risky; puncture, formerly much practised, and vaginal in- 
cision of the tumour have :been abandoned. Ovariotomy is 
the motliod of choice, and Brouha advocates the combining 
of this operation with natural delivery'. When dilatation of 
the os is almost complete,, and not before, he opens tho 
abdomen, 'removes the cyst; temporarily closes tho abdomen, 
and terminates labour per vaglnum by forceps or version. 
Two cases treated with complete success in this manner arc 
reported. This method is not applicable when the cyst lies 
Intraligamentally, or when strong adhesions are present. 
There is also risk in cases wlioro the foetal vitality has 
already suffered, as the exteriorization and luxation of tho 
uterus may cause disturbances of tho placental circulation 
capable of producing foetal asphyxia. Those aro said to bo 
the two only contraindications, and tlio method possesses 
the immense advantage of conserving the utorlno integrity', 
which Is BO advisable tor future pregnancies and labours. 
Bronha recommends a definite closing ol the abdomen only 
at the end of the accouchement, as then the reduced size of 
the uterus renders suturing much easier. Moreover, It is 
thus possible to verify a haemostasis of the pedicle, which is 
liable to be interfered with during delivery, 

523. Antlstregtocoseal Serum fn Treatment of Puerperal 
Septicaemia. 

C. Behnabd {Gynecol, et Obstet,, March, 1928, p, 216) reviews 
the results given by treatment by autistreptoooocal serum in 
puerperal septicaemia. Thirty-five cases wore treated: in 
all the diagnosis was confirmed by blood culture, baoterio- ' 
logical examination of pus from metastatic abscesses, or 
necropsy. Streptococci were found in tlio blood in eighteen 
cases. The proportion of cures was 57.1 per cent. ; if the 
cases are deducted in which death occurred within a few 
Iiours of the serum being injected, as well as those in 
which the pathological agent was otlior tliau a streptococcus, 
the cures numbered 47.3 per cent. Tiio doses advocated aro 
high: from 80 to 100 o.cm. in two injections during the first’ 
day and on succeeding days from 60 to 80 c.cm. Two or three 
days are requited in which to judge of tho efficacy of the 
treatment. The conclusion is di'awn tliat llio serum may act 
(1) in about 20 per cent, of cases, rapidly and periiaps spcci- 
fioally, the temperature falling and tlie general condition 
improving as from introduction of antibodies is appropriato 
to the Infecting agent; t2) move slowly and indirectly', its 
efficacy being non-specific and equal or inferior to that of 
colloidal metallic preparations given intravenously. 


Pathology. 


52 s. The Action of Ergotamine on the Autonomic 
System. 

M. Goldman {Arch, des Mai. du Cccur, April, 1928, p. 204) 
has observed the effect of ergotamine, the principal active 
constituent of ergot, on normal individuals and on those 
suffering from various diseases. This substance was injected 
into and under the skin and intravenously in doses of 0.25 m". 
upwards of the tartrate. A diminution of pulse rate varying 
between 6 and 60 beats a minute was found ; this was due 
citlier to excitation of the cardio-in'hibitory mechanism or to 
predominance of the latter as a result of paralysis of the 
sympathetic terminations. When ati-opine had been pre- 
vionsly administered the redaction of the pulse rate was even 
more marked. In relation to adrenaline it was found that 
this drng would abolish the ergotamine effect, whereas ergot- 
amine did not influence the effect of adrenaline. The fact 
that ergotamine has a variable effect depending upon the 
bodily state at the time of administration was shown by the 
aceoleratlng influence on the pulse rate in a patient suffering 
from hyperthyroidism. The effect of tliis substance on the 
blood pressure was always to increase the diastolic pressure. 
Generally the pulse pressure rose, but in a few cases there 
was a fall, so that tho systolic pressure dropped below the 
930 D 


original level. This alteration of diastoiic pressure by ergot- 
amino is comparablo with tlio effect of ndrcnalino, but tlio 
change is more prolonged. It is conclndod from those investi- 
gations tliat crgolamino excites the synipaliictio Imiorvation 
and tlio muscles of tlio peilplicral vessels, while in tlio heart 
it activaics tho parasyiupathctic nnd pcrlmps parnlysos the 
sy’mpathotic. Tlic sympathetic supply to tlic stomach is 
stimulated so tliat secretion and motility arc dlnilnislied, 
Tho therapeutic indications for ergotamine arc iholollowing; 
circulatory' dlsoydorswitli a tendency to tachycardia, whether 
paroxy'smal, toxic, or glandular; cases of irausieiit or per- 
manent hy'potonsion, ospeolnlly in circulatory failure; ami 
digestive troubles associated with excessive secretion and 
motility. 

627. Infections Necrotic Hopitltts In Australian Sheep, 

A. W, TunNER (Ann. dc VInst. J'asleur, Fchrnary, 1928, 
p. 211) has provlonsly' submitted cvldenco'to' sliow that the 
black disease {Inloctio'us necrotic hepatitis) of Australian 

. sheep Is essentially a localized Infection of tho liver duo to 
Cl. oedcmalicns. He now gives an account of tho experi- 
mental reproduction of the disease in animals, and the 
preparation of a protective vaccine. By cnitivating the 
organism for sevornl goncrntlons in a glucose nitrate agar 
medium ho obtained a typo which was liighly virulent but 
only slightly toxic to guinea-pigs. Injected in a dose of 
0.25 c.cm. it’ gave rise to local oedema, and to a pleural and 
peritoneal effusion ; hnt instead of tho organisms being con- 
fined to tho local losloir they' were found in the serous 
effusions, in tho viscera, and in tlio blood. In ono ont of ten 
gnlncii-pigs injected witli tills dose necrotic areas were found 
in tho liver containing largo Gram-positive bacilli which 
proved to bo Cl. oedemntiens.- , Similar areas of necrosis in 
tho liver wore found in a sUeop injected with tho bacillus. 
Experiments socni to indicate, howovor, that the appcnrance 
of tlioso necrotic areas, botli in guinea-pigs and in sheep, is 
tho exception rnilior than tlio rule, Vaccin.ition experiments 
woro 'ntterapted is both niiJinal,s, hnt with ratlicranibignous 
results. A fonnolizod wliolo culture of Cl. oedcianticns.ia- 
■jeeted on one, two, oc three occastous lulo guincn-plgs g-ivo 
rise to no definite imraimlty'. In sheep tho results appeared 
to bo more liopoful, but unfortunately so few animals were 
available for iiso ns controls that tho interpretation of the 
oxporlmonts was difficult. Tlio author thinks, however, 
tliat animals can bo protected with a Biiilabto vaccine, 
hnt tliat an cxperiinoiit in tho field on a large scale is 
necessary' before tho value of prophylaoilo vaociuaiiou can 
be ascertained. 

628. The hlcsenterfc Glands and Fat Absorption. 

C. CASSANO (II Policlinico, Soz. Mod., February 1st, 1928, p. 93) 
reports a bistological investigation of tlio function of the 
mesenteric glands in dogs during tlie digestion of fats. The 
stains used for the microscopic sootiona wore Sudan III and 
haomotoxylin, nnd tbo method of Ciaccio for lipoids. Cas'-ano 
found that the fatty substances in the niesentoric glands dm 
not exist only' ns neutral fats, but also ns soaps and fatty 
acids. Two liours after the ingestion of a fat-containing 
meal tho glands sliowed conspicuous activity' in building up 
the largo fat molecules nt tbo expense of the soaps and other 
lipoids. After twelve hours’ digestion the neutral fats pre- 
vailed in greater quantity' than the soaps. At this period also 
he noted deposits of neutral fats inside the blood vessels. It 
thus appeared that there was a gradual passage of these fats 
into the blood, oircnlatlon, this being contrary to tbo opinion 
formerly held that the fats pass wholly by the receptacnlmn 
chyli into tho thoracic duct. From twenty-four to forty- 
eight hours after the last meal there was always to be seen 
a large quantity' of fat In the glands, indicating that they acted 
as a storehouse to economize the fats. During protracted 
'fasting (seven to fifteen day's) tlio mesenteric glands still 
conserved part of the deposited fats, and at the same time it 
was noted that a certain amount of separation bad occurred, 
liberating the fatty acids and augmenting the soaps. 

529. Bacteriological Examination of Rhenmattc Nodes- 

B. DE BOURDELLES (C. It. Soc. de Diologie, Mnrch 9tli, iS2S, 
)r. 691) examined baoteriologically two" small subcntanpoiis 
nodes removed during life from the scalp of a young man 
suffering from cardiac rheumatism. Tho nodes, which were 
taken out under strict aseptic precautions, were dropped, u’® 
one into glncoso peptone broth, the other into a modiued 
Noguchi medium. On the fourth day' a streptococcus deve- 
loped in the glucose broth, and on the tenth day' in u'® 
Noguchi medium. Subcultures made from these primary 
cultures remained sterile. The organism did not haeiiiolyss 
the patient's blood. The author considers this finding of a 
streptococcus as of interest in relation to the etiology Of 
acute rheumatism. 


JUSE *D»8] 


t TnE Bnmsn 

UeDICIL JOUBKAZf 


91 ' 

EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 


530. Tlio Phrcnlco-Puplllary Synaromc in Plcnro- 
pulmonary AITcclionn. 

E. Sergekt and T. Gi;onc.r. {I’nssc Mild., April 28tli, 1928, 
p.529) concUido that in niiaitiou to tho Intonnation given by 
tho direct investigation ol tho respiratory apparatus (clinical 
and radiological examinations) tho indirect signs of locailza- 
tiou based on anatomical and pliyslologioal considerations 
arc to bo roincmbcroil, since they can in many eases iirovido 
diagnostic help of great value. Among tho most valuablo of 
tboscludlrcct ' and diaphragmatic 

responses to ' o irido-dllator and 

phrenic ners'es. ilieso signs may exisb singly or in asso- 
ciation 'witli each other, producing a phrcnico-pupillary 
syndrome of variablo type. Tliero may thus occur a 
spasmodic mydriasis, or a paralytic _ myosls, or tho 
syndrome of Clando Bemard-Horner, associated with phrenic 
paralysis, and completed by other signs of tlie mediastinal 
series — such as, for example, paralysis of tlio recurrent 
laryngeal nerve. Tho anthers state that tho phrcnico- 
pnplllary syndrome, which is obsorvablo in ail plenre- 
pnlmonary nffcctions, bnt principally In tubercnlosis, 
acquires in many cases a diagnostic value where tlic physical 
signs are indistinct or still latent. It Is always scrviceablo 
in making more precise tho exact topography aud knowledge 
of observed or snspeoted lesions. A summary of two ease 
reports exemplifying tho phtcnico-impniary syndrome, illus- 
trated by radiograms, is given. 


531. The Heart In Hypertension. 

G. F.Uin (diner. Jour. Med. Set,, April, 1928, p. 453) believes 
that, though tiio general length of life has increased during 
tho last century, yot tho adult who survives to-day nuUl 
tho ago of 45 caunot expect to live much lougor tlian his 
eighteenth century ancestorH. He adds that the greatest 
obstacle to longevity is hyperplesio, hy this term being 
meant a condition of high blood pressure not associated with 
nephritis. Heart tailuro associated with high blood pressure 
is tho most common form of cardiac impairment and tho 
most Important result of high blood pressure coutinuod for 
many years. Of approximately 140,000 annual deaths in the 
United States from tho consequences of liypertonsiou, about 
one-half were duo to cardiac failure. Fabr discusses this 
condition and describes fonr wcll-followod cases. The most 
cliaracteristicpliysical sign of the heart in liypcrteusion is 
left ventricular dilatation, which canscs an increase in its 
weight. Tho symptoms develop about twelve to flttcon years 
after the onset of hypertension if only a very moderate 
coronary arterio-scleiosis is present and no other com- 
plication has meanwhile occurred. Tho symptoms do not 
differ essentially from those found in heart failure duo to 
other types of cardiac impairment, though pulsus alternaus 
is more frequently found In hypertension hearts. The blood 
liressnre may remain high oven to within twenty-four hours 
of death, though it may fall, especially it auricular flbrillation 
or marked coronary sclerosis be present. Treatment should 
ho directed towards lowering the blood pressure and redneing 
the physical activities of the patient, thus lessening the work 
of the exhausted lieart mnsclo. Digitalis, diuretics, and 
sedatives have tho same indications as in other forms of 
heart disease witli failure, aud loug-continuod rest in bed is 
probably the most eflective mcasm-o in treatment. Yenc- 
section helps in eraorgoucics where the venous pressure has 
risen above 20 cm. of water. 


532. Exophthalmic Goitre and Eead Ionization. 

J. SIiLIiEn, P. 31. ^IacdonNEIjE,, and A. F. G. CadenhbaD 
(Canadiau Med. Jssoc. Joicm., April, 1928, p. 400) record a 
case of exophtliaimic goitre complicated with toxic adenoma 
and treated hy lead ionization. A woman, aged 46, was 
admitted to ho-pilal with symptoms of advanced exoph- 
tliaimic goitre and sjnnmetrical enlargement of the thyroid 
gland, which for the previons year had rendered swallowing 
lucrcasingl}- diflicult. Failure in treatment led to the sup- 
position that the enlargement was possibly malignant. Dead 
ionization was performed twice a week for live months; 

10 electrolyte was lead nitrate, and each administration 
lasted tor fitteeu to twenty minutes, represeuting a dose of 
m °’ii . treatment. Mariced improvement 

n an symptoms resulted, though surgical intervention was 


contraindicated on acoonnt of the cardiac condition. The 
patient loft hospital much better, bnt returned two months 
later very much worse, anti died in spite of active treatment. 
Post-mortem examination revealed an encapsuleci foetal 
adenoma of tho thyroid gland buried in a colloid goitre 
whicli showed marlicd degenerative changes. On chemical 
analysis tho load content of the thyroid proper apiproximatecl 
G to 8 mg., but there was no trace of lead in the foetal 
adenoma. Tho authors conclude that the case was primarily 
ono of exoplithalmio goitre, and that the degenerative 
cliangcs and relatively large lead content found after death 
pointed to the lead ionization being an Important factor in 
tho diminution in the size of the gland and in tho improve- 
ment in symptoms. The rapidity with which the patient 
became worse is attributed mainly to tho growth of tho toxic 
adenoma developing in the last tew months; this was 
probably not present during tho time the lead ionization was 
being performed, since lead \vas absent from the growth. 
Tile tact that lead Ionization appears to cause degenerative 
cliangcs in tho cells of a parenchymatous goitre, with marked 
diminntion iu its size and general improvement in health, 
suggests tho practical utility of sncli treatment, followed, as 
soon as tho swelling has been reduced, by surgical inter- 
vention in tlioso cases in which there is no cardiac or other 
contraindication. 


533. Diabetic Psychoses. 

H. J. SCIIIM VAX DER LoEPP and J. A. J. Barshoorn {Nederl, 
'I'ijdschr, v. Gcnecale., Siarch 24th, 1928, p. 1465) state tliat 
diabetic psychoses — that is, psychoses caus-ally connecied 
with diabetes mellitus— occupy only a small place in the 
group of symptomatic psychoses and are rarely observed. 
Tho anthers record four Illustrative cases in women, their 
conclusions being ns follows. (1) Diabetic psychoses may 
appear in tho form of amentia, haiinciuations, and delirium, 
(2) The term “ diabetic psychosis ” should he nsefl when 
symptoms develop in a diabetic patient iu association with 
an aggrav-atiou of tho primary illness and disappear as the 
diabetes improves oi- coma ensues. (3) The development ot 
paranoid or manic-depressive symptoms must be regarded 
as mere coincidences which originated before the attack of 
diabetes. (4) In spite ot the rarity of diabetic psychoses tho 
possibility of their occurrence should always be considered 
in cases of mental disorder, as their timely recognition and 
antidiabetic treatment may be of great benefit. 


Surgery. 

531 , Treatment of IKcnte Cholecystitis. 

H. O. BruGGEMAN (Annals of Surgerij, Slarcb, 1928, p. 423) 
compares acute cliolecystitis with acute salpingitis as being 
rarely fatal if treated conservatively. It is not comparablo 
witli acute appendicitis, wblch is a lethal disease, since it so 
frequently results in diffuse peritonitis. Acute cholecystitis 
rarely causes widespread peritonitis because when the gaU- 
hladder becomes inflamed it is soon walled off from the 
peritoneal cavity. The author thinks that an operation 
dnriug the acute stage of cholecystitis is seldom required and 
should bo avoided niitil the active inflammation has subsided. 
Best, morphine, and fluids suffice in most instances to limit 
the iuBammatory process. The gravest danger in conserva- 
tive treatment is a mistaken diagnosis. There is a wide 
difference ot opinion about the indications for operation in 
these cases and as to the bostprocedure to adopt. Bcuggeinan 
thinks tliat cholecystectomy is nsually preferable, tbon<>h 
cliolecystostomy may be wiser as the more simple ojieration. 
Ho insists that in acute cholecystitis an operation is very 
rarely indicated. In mild cases any form ot treatment trill 
make but little difference to tho result. 


535. Intussusception of Keekers Diverticulum. 

J, IIOLST (YorsA- Mag. f. Laegev'id., March, 1928, p. 279) reports 
tho case of a boy, aged 12. wlio was admitted to hospital with 
the diagnosis ot acute appendicitis. Ho had been ill for 
twenty-six liours with acute abdominal symptoms. On lapar- 
otomy an intussusception ot the ileum 20 cm. iu length was 
seen aud was found to be duo to Jleckel’s diverticulum” which 
had become invaginaled into the lumen of the small intestine 
and had given rise to intussusception in a similar manner to 

966 a 


> 



,92 Juke s, igas] 


EPITOME OF CUBEENI MEDICAE LITERATUBE, 


t TmcBamn 
HzDicii. JonwAft 


that cansecl by a peiianculated polypus. The bllnfl cud ot 
the aivertionlam showea a polypus the sizo ot a pea. The 
iatussnsception 'was refluced and the divertlouluni was 
resected ; recovery £oUo^Yed. ; 

536, tlrsatmsnt of Yavlcoss Yelns by Injeottona. 

In view of tlie bother and poor results attending the use of 
elastic stockings and bandages in the treatuiout of varicoso 
veins, 'W. WouF (,1/cd. doiim. and Record, April 18th, 1928, 
p. 416) concludes that the only satisfactory local luelhod is to 
obliterate those veins, thereby iiroveiitlng their rupture or 
the production of varicoso ulcers. Surgical extirpation ot tlio 
affected vessel or the tying of the trunk vein at a higher 
point is not recoiniuended because the circulation is seriously 
interrupted, the patient is laid up for some time, and the log 
never looks or feels normal afterwards. Another method is' 
to inject the vein with a solution which is not injurious, docs 
not cause coagulation of Iho blood with the consequent^ 
danger of embolism, and which will produce such inflanima- 
lion of the vessel walls as will cause obliteration ot its lumen. 
Substances such as iodine or sodium bicarbonate should not 
be employed ow'ing to the coagulation and violent inflamma- 
tion they cause. Those, in the order of their importance, 
which may be used are: a 60 per cent, dextrose solution; 
a 20 to 25 per esnt. sodium chloride solution containing a 
small amount ot local anaesthetic ; a 1 to 3 per cent, mercury 
bichloride solution ; 5 to 20 per cent, phenol lu glycerin and 
water ; 5 to 10 per cent, quinine urea hydrochloride ; and a 20 
per cent, salicylate solution with a small amount of local 
anaesthetic added to preveut painful cramping of the veins. 
IVoIt describes his method ot iujection, and emphasizes that 
a particular and carefully executed technique is ot greater 
Importanee than the substance used. A reaction usually 
occurs iu from twelve to seventy-two horns, and consists in a 
swelling and tenderness arouud the ojieratiou area, but this 
Is rarely severe enough to Incapaoitate the patient or to 
require treatment. With correct technique no untoward 
results or failures need occur, the patient is not laid up in 
bed, the symptoms commouly associated with varicoso veins 
(eczema, ulcer, cold feet, and a teeliug ot heaviness in the 
legs) are rapidly relieved aud disappear, and the desired 
obliteration of the vein is produced. 

537, Fractures of the Acetabulum, 

E. h. Euason and V, W. M. 'SVivight (Siiry., Gynecol, and 
Ohsict., April, 1928, p, 509) define three groups ot central 
dislocation fractures ot the acetabulum ; (1) fractures of the : 
rim ; (2) radiating, including fractures aud epiphyseal separn- 
tlou of the floor ; aud (3) penetrating, with or witliout iutia- 
pelvic displacement ot the femoral head. Over 50 per cent, 
ot the cases are complicated by other pelvic fractures with 
varying manifestations from associated pelvic and abdominal i 
injuries. Diagnosis of the nature aud degree rests principally i 
upon a;-ray examination, but symptomatically there may bo 
flattening of the trochanter, shortouingi flexion, abduction, 
and external rotation. Obturator 2iain from injury to or 
liressuro upon the nerve, crepitus, and symptoms arising 
from injury to blood vessms and bladder may also be present^ ■ 
while there is always tenderness on lateral pressure over the 
trochanter. All movements ot the thigh are restricted, but 
jiatients have been able to walk immediatelj' after the injury, 
which may have been unrecognized at the time. Eesions of 
the Eoiatlo nerve may result in varying degrees ot paralysis 
and pain. Direct violenoe over the great troohautor is the 
cause iu the majority of cases (60 per cent, of the authors’ 
oases and 97.5 per cent, of those reported In tlie' llteroture). 
Associated complications require jirorajit treatment, and 
reduction is best performed by closed methods under ether 
anaesthosia with conudete muscular relaxation, open opera- 
tion being contraindicated, lleduotion should be maintained 
by the application of a plastei-spioa with the thigh in abduc- 
tion, sliglit flexion, and external rotation. 

633. Treatment of Gastric and Duodenal Ulcer. 

J. L. DeCourcy (Annals of Surgery, April, 1928, p. 5S6) i 
remarks that the treatment of gastric or duodenal nicer * 
varies according to the patboiogioal coudition found in each 
individual case. While focal infection is a deflnito etiological 
factor iu these ulcers, daily misuse of the stomach function 
is also an important cause. The lesions always coexist with i 
a gastric liyperacidity, and treatment is based on the ailevia- i 
tion of this symptom and the iiroteotion of the ulcer from 
its ill ollects. DeConrey classilles peptic ulcers as follows: 
ulcer of the ninoosa, ot the submucosa, indurated ulcer, i 
and delamiuatiug ulcer with or without induration. Dicers 
extondiug uo deeper than the mucosa usually yield to proper 
medical tieatmeut, aud, especially iu patients under 30, this 
should he giveu a t'uorough trial before an operation is 
advised. For .subrauco.sal ulcers DeConrey advocates, iiar- j 
ticularly in c rses under 40, gastro-enterostomy with cauteriza- 
tion of the ulcer or ulcers from within the stomach. Careful ' 


search should be made for multiple ulcers, since it is possible 
that gastro- jejunal ulcers following posterior gastro-ontcro- 
-stomy are duo to. contact lufoction. from the original ulcer, 
.ns in the “ kissing ulcers ot Moynihau. For indurated 
ulcers, in particular in patients over the ago of 40, partial 
gn.strcctomy should bo performed in preference to gastro- 
entero.storay. The author advises this drastic measure as a 
prophylaxis against sub,scqunnt carcinoma, aud, while grant- 
ing tho high inortalily in such oiiorations, holiovos that with 
Improved tochniquo tlioir safety will bo much increased, ns 
lias ocGurrcd In oliolocystoctomy and tliyroidoctomy, opera- 
tions formerly very dangerous. Ho empiiasizos the need of 
a careful closure of the duodenum, since this is au important 
factor In the mortality, 

, 539. Acute Appandlcltls, 

E. P. Quain and B. H, Waldschjiidt (Arch, of Sary., April, 
1928, p. 868) record a study of 1,000 consecutive cases operated 
on for acute appendicitis. A trial or tho treatment rocoin- 
monded by Ochsnor was nhaudonod after several unfortunate 
exporioncos, and all patients are now oiieratod on without 
.preliminary treatment. Tho authors belie.ve that the best 
cliaiico ot recovery lies in immediate operation with cfilcient 
drainage of tho poritonoum. The split muscle incision was 
employed, and can be enlarged by cutting across the linoa 
senillunarls. Po-t-operative hernia was found in 1.5 per cent, 
ot cases. In cases of Intostiual distonsiou a small rubber 
tube is passed into the caocuin through tho stump ot the 
.appoudlx ; theso fistulas soon lical and are.serviceablo while 
they last. 'WhDro thoio is widespread- peritouitis and great 
disloiision enterostomy should be porformod at once through 
a separate incision. Tho majority of the patients seen had 
rocoivod a ijnrgativo soon after tho onset of the disease; 
tho aulhors think tliat this prootico is strongly to be con- 
doninod in cases ot acute appendicitis. The mortality in the 
1,000 recorded cases was 2.5 per cent. 


.Therapeutics. 

540. Antitoxic Action of Yeast Extract. 

.6. LEMOINE (Bull. Soc, tie TMr., March 14th, 1921, p. 90! 
suggests an otboroal extract of yeast for the treatment of 
.iuteotlons diseases. In bis previous investigations ho had 
employed pyocyanaso, which is an alcoholic extract of dry 
cultures of It. jjyoci/nnciis, and thou an ethereal extract of 
these cnlturoB. With the last product he had obtalucd 
oxcollcnt results lu tho treatment ot diseases due to strepto- 
cocci. The work of B. Gfirard and tho more recent investiga- 
tions ot Beuoit, which had shown the resemblance between 
the extraots ot cultures and yeast extracts, induced Lomoiuo 
to employ the latter In tho treatment of Infectious diseases, 
such as streptococcal intoctions, erysipelas, tnierpcral^ fover, 
scarlatina, aud scpticaomia, as well as in other affections m 
which tlio streptococcus la an associated organism. In 
scarlet fover In particular and in measles Hie ve-mlts were 
remarliahly strilting, tho fover and constitutional dislurbance 
subsiding iu less than forty-eiglit hours. The yeast extract 
employed by Ijemoine Is essentially composed of lipoids, 
orgosterin, and undetermined nitrogenous compounds, and 
it is- to' the combinaliou of these products that the author 
attributes the good results obtained. 

5M. Pltultrin In the Treatment of Migraine. 

K. Zeikpr-Hekuiksen (Tidsslcrifl f. cl. Norshe Laegeforening, 
March 15tli, and April 1st, 1928, pp. 250 and 312) has treated 
-forty-two cases of migraine with ))ituitrin during a period m 
two years aud. nine months, and has achieved iirolonged 
improvement in twenty cases. An iatramnscular Injection 
of 0.5 c.cm. was given once a week. In one case, that ol 
a woman who had been subject to regular attacks of migraine 
since she was 7 years old, the treatment was started at tlie 
age of 23. After tliree injections no further attacks occurred. 
She received altogetiier twelve injections, aud was free from 
attacks during an observation period of more than a year. 
Many ot .the patients complained ot feeling very tired during 
the trealinent, but they were still able to attend to their 
daily routine of duties. Discussing the rationale of tins 
treatment, the author suggests that it may break a vicious 
circle, the e.xistence of which depends on faulty functioning 
of tho irituitary body, which at times does not produce an 
adequate secretion on account ot some iisycliic disturbance 
or otlier cause. In this connexion it is jioiuted out that, of 
all the theories put forward to account for the genesis of 
migraine, the most plausible is that which Quincke advanced, 
aud which de)ieuds on the assump'.ioii tliat an acute serous 
hydrocephalus develops on certain occasions. Whatever the 
explanation may ha of the beneficial action of intuitrin, the 
author holds that it is more effective than other symptomatic 
remedies, even including luminal. 


c 


JUME 2, I9»8] 


EPlTOliB OP OUBRENX MEDIOAIi EIXERATURE. 


t TiiK iJr.mnn QC> 

Mroicii. JocnsAX. * jO 


552 . Oxyifon Tlionipy. 

J. II. Evans {Mai, Jouru, atul Record, April 'Itli, 1928, p. 349) 
suggests that nnacstlicsia aud iiihaliUiou thorapy Bhould bo 
regui'ilotl ns combluocl Hpoclnlilos, slueo tlio Inttcf Is tUo 
naiurnl outgrowth ot tho former. While Inlinlntlou therapy 
may cveutually liicludo tho namliilstratlon of otlior gnsos or 
combiuatloiis ot gases, Evnua illacussos tho tiso ot o.'tygcii 
ouly, mainly from his oxporlcnco hi fourteen cases of 
puoimioula lu which from 60 to 100 per cent, oxygen was 
given coutinuousiy for periods of four to ilttoon days. In no 
iust.auco did such liigli coucoiitmtlons act as au irritant or 
produce any harmful results, hecauso pueumotila patients 
require more than tho usual amount ot oxygen lu tlio Inhnlcil 
air to bring the blood oxygen up to normal, and even a slight 
lack of oxygen for several days is serious, since tho harmful 
effects of anoxaemia aro consideralile. To bo effective It 
sbonld bo commenced early aud In aunlclcutly high concen- 
trations to abolish any dcllclency lu tho arterial blood. In 
anoxaemia of tho intestinal tract causing distension and 
suspending the digestive processes oxygen administratlou in 
high conconlratlons by removing tlio anoxaemia improves 
the prognosis. Tlio cases sliow Hint a conllntions GO to 100 
per cent, oxygen administration can bo safely given over 
a period ot several days to abolish cyanosis, and in tlio 
absence of cyanosis puro oxygon, administered for twenty 
minutes every hour, apparently exerts a thcrapeulic action. 
Its bcneflcial use is indicated in various oilier diseases— such 
as asthma, broucliltis, arthritis, burns, and cardiac c.ascs. 
Evans points out that whilo its administration to relievo 
anoxaemia is logical, its application to diseases in whicli tho 
blood oxygon la normal is illogical unless they aro caused by 
an anaerobe which might bo combated by oxygon therapy'. 

543, lilYcr Extract In Pornlcioua Anaemia. 

E. LAQUEUn and A. R. W. MOncii {Sedcrl. Tijdschr. v. Geneesli., 
April 7tli, 1928, p. 1G64) record tliolr obaervatious on fourteen 
cases ot pernicious auaeinla treated wltli liver extract. All 
the patients improved, some within a week, and tho majority 
wilbln a inoiilh. This was partloulaily noticeable in tho 
severe cases, In most ot wliicii tliero had provlonsly been 
relapses. At first a syrupy extract was used, and later a 
powder. The doses consisted ot 300 grams ot fresh liver 
daily, in some cases 400 to 500 grams. Tho treatment was 
continued lor four weeks. Tho authors remark that their 
cases wero not very' numerous, aud odd that oven inEugland, 
where the treatment was used before it was introduced into 
Eoliand, ouly about thiity-two eases have been recorded 
in which this treatment had been tried, the results being 
favonrable in ali except two. 


valiiablo signs, was present in 62.5 per ennt. ; a bulging 
fontanollo was found in 5G.G percent.; convulsions occurred 
in 29.4 per cent., nearly always at the onset ; 11 per cent, had 
a lincniorrlmgio eruption. Herpes occurred in only two 
patients, both over 1 your old. Tliero was no characteristic 
tomporatnro curve, and fever was frequently absent in the 
notivo stages of tlio dlsea.so. Vomiting occurred in 56.6 per 
cent, and diarrhoea In ouly 2 per cent. ; tacbe edrebrale was 
noted In 20.5 per cent. Btrabisinus, present lu 20.5 per cent., 
was the most frequent ocular manifestation of the disease. 

590. Haemorrhagic Disease of the Newborn. 

Rudy S, Beveiudob [Arch. Vis. in ChiUihood, February, 1928, 
p. 39) reports twenty-four eases of neo-uatal haemorrhagic 
dlseaso treated in tho Royal Hospital for Sick Children, 
Glasgow. Silo fonnd tliat tlio .sex incidence of tho children 
affected was practically equal, aud she remarks that it is in 
tho first week ot life, espcomlly witliin the first four days, 
that bleeding is prone to ocenr. In only a small minority ot 
cases was tliero any question of trauma at birth. She sug- 
gests that a deteriiiination ot the coagulation and bleeding 
times would assist in the diagnosis between haemorrhage 
duo to trauma and tho true liaeiiiorrbagic disease. The most 
effleient aud satisfactory treatment is said to be the injection 
ot whole iiiiiuan blood, and transfusion is especially’ neces- 
sary where tho constitutional symptoms are severe. 

547. Pneumococcal Peritonitis In Children. 

H. SAliZEP. (Dent, y.cit. f. Chir., February', 1928, p. 226) 
records his observations on 31 cUses of pneumococcal peri- 
tonitis which have occurred at tho Mautbner-JIarkhof 
Children’s Hospital at Vienna in the last twenty years ; 
twenty-eight were girls and only three were boys, the iiincli 
greater frequency of the disease in tho female being probably 
due to an ascending infection from the vagina. In twenty-one 
cases the correct diagnosis was made before operation. In 
the tlirco boys the disease originated in pneumococcal 
appendicitis, but in none of the girls w’as a pneumococcal 
appondicitis present. One girl, however, showed a simple 
appendicitis duo to H. coli, while a pnre culture ot pneumo- 
cocci was obtained from the peritoneal pus. Salzer remarks 
that in the enso of boys, therefore, it is not necessary to make 
a differential diagnosis between appendicitis and pneumo- 
coccal appendicllis, and an operation sbonld be performed at 
once. In girls, however, an early operation should be avolded, 
ns sl.x out ot eight girls so treated died, and a tonic treatment 
Bboiild bo adopted. Alter the severe initial symptoms have 
subsided incision and drainage should be employed. By 
such treatment Salzer was able to save fifteen patients.' 


Disease in Childhood. 


544. Angina Fcotorls In Children, 

E. J. Stolkind (llrit. Jotirn. Child. Die., January-March, 
1928, p. 1) records four personal cases and has collected 
twenty-five examples from tho literature ot angina pectoris 
in children aged from 7 to 14 years. After a hlstoric.al note 
lu which he vindicates Heberden’s priority over Rougnon, he 
describes the symptoms, etiology, and pathology, which ho 
maintains are tho same In children as lu adults. Ho Is ot 
opinion that the attack ot angina is brought about by a com- 
bination of factors— namely, tho chemical and toxic sub- 
stances circnlating in tho blood, tho state ot tho nervous 
system, especi.dly the autonomic system, aud the condition 
of the heart and aorta. 


545. Cerebro-spinal Fever In Infancy and Early 
Childhood. 

S. SIcLean and J. P. Cappey [Amer. Joiini. Bis. Child., 
Aiavcli, 1928, p. 357) record their observations on 136 cases of 
endemic nioiiinjjococcns paeningitis in patients aged from 
days to 7 years ; 50 per cent, were admitted to hospital 
more ihan one week after the onset. The age was not over 
3 months m 17.6 per cent., and 67.6 i^er cent. wer*e in tho 
nrst year of lire. The disease occurred almost unfailinglv in 
districts in which crowding, poverty, and poor hygiene were 
prevalent. Maternal nursing did not tend to produce im- 
munity, as ot 22 infants not more than 3 months ot age 
of exolnsively up to the onset of tlio disease, 

6 months 21 had been nursed exolnsively, 
and of 28 aged from 6 to 9 moutlis 15 were still being nursed 
Musem'a; w'; rf " symptoms wore noted. 

retrsoMon Of" of "oclc and with or without 

S?cn wn^fo,! 1 present in 84.5 per cent., Kernig’s 

cent TTnov^f “ Brndzinski’s sign in 36 per 

Unexplained Irritability', which was one ot tho moat 


Obstetrics and Gynaecology. 

598. Menstrual Flstulae. 

M. Ballin (Stirff., Gynecol, and Obstet., April, 1928, p. 525), 
who records two personal cases with a review of the litei.> 
tnre, applies this term to fistnlae in laparotomy scars charac- 
terized by periodic discharge of blood, more or less coincident 
witb normal menstruation. Although a few menstrual fistnlae 
have been caused by a suppurating tube or tubal pregnancy 
spoutaneonsly rupturing through tho abdominal wall, most 
aro ot post-operative origin, being caused either by direct 
communication witb the uterine or tnbal cavity, (1) following 
Caesarean section ; (2) after operations for pelvic inflam- 
matory diseases, salpingectomy, or' partial byslerectomy ; 
(3j after ventrofixation of the uterus, or by post-operative 
enclosure of endometrial tissue in the abdominal wall in the 
course ot snob operations ns hysterectomy, ovariotomy, and 
ventrofixation. While there are on record at least 32 cases 
ot menstrual fistnlae following Cao-areaii section, examples 
of spontaneonsiy formed fistnlae from inflammatory con- 
ditions and tubal pregnancy are much rarer. Frequent com- 
plications with extensive intestinal adhesions and faecal 
fistnlae occur; they render operation difflcnlt and sometimes 
fatal, as in one ot Ballln’s cases. 

598. Treatment of Amenorrhoea. 

G. Maortua (Arch, de med., cir. y esp., April 7tb, 1928, p. 489) 
records three illustrative cases, in women aged 20, 22, and 40 
suffering from ameuorrboea, -n-ho were treated by injection 
of tho serum of a pregnant woman. The results were found 
to bo far superior to those hitherto obtained by the nsnal 
method, including rolliculin. Maortna is of opinion that the 
sernm in pregnancy, in addition to an exogenous hormone 
contains internal secretions, principally ot the anterior lobe 
ot tho hypophysis, wnich explains tho excellent resnlls 
obtained. It the good results are confirmed by snbsequenb 
investigations he suggests that a sernm might be prepared 
from pregnaut animals which would be of value in practice. 

966 0 


94 JUNE 2, 1928] 


EPITOME OE CUKBENT MEDICAL DITERATUEE. 


r Tm Bnmni . 

MeDICAL J0ITBXA& 


550. licucoprhooa. 

E. Impaumo (La Gynecol., Pobruarj^ 1928, p. 65) doos not 
ngroe with the five groups of vaginal organisms which 
Wegolins formulated. As a result of examining the vaginal 
flora in over 200 women the author finds that evGr5f case falls 
into one of three groups : (1) containing Gram-positive 
organisms with .flat epithelial cells. and. scarcely. any leuco- 
cytes ; (2) containing cocco-bacilli, Gram-positive and Gram- 
negative staphylococci, and Gram-positive diplococci; and 
(3) largo masses of cocci both Gram-positive and Gram- 
negative, together with flat epithelial cells. This last group 
never contains Diiderloin’s bacillus. ’ Trahsition forms from 
puo group to another were noted. Imparato remarks that the 
vaginal secretion is notably different in infancy, puberty, and 
old age. In the newborn there is a minimal secretion, which 
is acid and destitute of germs, but rich in glycogen, on which 
the acidity seems to depend. The glycogen diminishes 
slowly as the secretion becomes alkaline. At gexual maturity'' 
the secretion again becomes acid and contains numerous 
bacilli of Doderlein. The acidity is a natural protection 
against germs, and attains its maximum at. the cud of preg- 
nancy. During the menopause the glands begin to atrophy 
and the reaction is feebly acid. Pathologically the vaginal 
secretion may increase and give iflaco to an abundant 
Jeucorrhoea, milky, mnco-purnlent, or sero-sanguinoous. . As 
regards treatment, the outstanding cause must be treated, 
wliether it be constipation, anaemia, lack of sexual hyfgicno, 
gout, or arthritis.,- The author enumerates .the various kinds 
,of local treatment which are in use, and for tho typical 
leuoorrhoea in -which no appreciable cause is found ho 
suggests douching with two small spoonfuls in a Iltro of 
water of a solution of zinc chloride 10 grams, distilled 
water 100 grams. 


SSI. Pyotherapy in Puerperal Infection, 

L. DEVnAlQNB, Sauphab, and Eaennec (Itev. Sldd. Francaisc, 
March, 1928, p. 195) remark that lencocytothorapy now 
oooupios an important place in the treatment of certain 
infections, and many authorities, particularly Netter, aro 
cited as having employed this procedure, the results obtained 
being due to the leucocytic diastases. There are-two foms 
of this method of treatment : autoleuoooytotherapy, in which 
a hyporleuoooytosiR is produced by excitation of the haemato- 
poietic centres ; and hetoroleuoooytothevapy, in which foreign 
leucocytes are introduced into tho organism. The pus is 
obtained ironi an equine abscess of lixation caused bv a 
turpentine injection. After repeated bactoriological controls 
and sterilizing in an oven a solution of uroformiue (12 eg 
per o.cm.) in pby.siological saline is added to tho pus to con- 
serve its sterility when ampouled. The authors report two 
series of cases of puerperal infection treated with excellent 
results by this method. In one scries of fifteen cases tho pus 
was given in curative, and in the other of live cases in pro- 
pbyl.actlc, doses. The dose employed -by . the'authors Was 
d o.cm. daily, given subcutaneously in two injections, one 
into each thigh. In only one case, owing to -the grovitv of 
^e patient’s condition, was the intravenous route adopted 
These doses were well tolerated and no ill after-effects were 
noted. The authors compare this' treatment with that of 
abscess of fixation. Both aro based on similar biological 
principles. In the one the introduction into the organism of 
Irritant substances causes an abscess of fixation- the other 
Involves the direct introduction of the pus. Tho advanta«e3 
of pyotherapy are Us easy administration, its harmlossne'’ss, 
and Its being well tolerated. ’ 


652. . Ectopic Decidual Tissue. 

P. Geipel (/lrc7i./. Gynal!., January 2nd, 1928, p. 6501 who 
in 1921 described the finding of decidual tissue in the pXwo 
lymph glands during pregnancy, reports to the present date 
forty such findings in women dying during pregnancy and 
shortly after delivery ; one case was that of a tubll gestation 
at the eighth week. About one-half the patients -were nrlmi- 
parae ; fourteen patients died from eclampsia and six from 
sepsis. Decidual deiiosit was not more common in vonng 
than -in old subjects, , and- was found in about two of five 
necropsies on pregnant or lately pregnant persons. As a rule 
one or two glands, usually on one side of the body only were 
affected. The deposits were found in the reticular tissue of 
tho follicles, in the capsule and trabeculae, and in tho 
afferent lymph vessels outside tho glands ; true lymph.atic 
tissue was destroyed indirectly by pressure, but endothelial 
tissnb seemed insusceptible of decidual metaplasia or depo.sit 
From the distribution of the decidual cells and for other 
reasons Geipel is inclined to believe that decidual transforma- 
tion is duo to tho influence of a hormone diffusing from (he 
peritoneal cavity; such an inflaeuco is comparable to that 
producing fat necroses in cases of pancreatic apoplexy. 
Decidu.al llssnc was also found in the pouch of Douglas, in 
both omenta, on or in. the diaphragm (fourteen cases),- and in 
one instance in the spleen. 


Pathology. 

553. Cutaneous Splrochactosls duo to Troponema 

cunlculi In British Rabbits. - • • • ■ ■ 

D. K. Adams, D. F. Cappeed, and J. A. W. McCedskib 
(J oitra. Path, and Fact., April, 1928, p. 157) drawattontiou' to_ 
a disease In rabbits whicli is liable to bo confa’-ecl with 
cxpcriniontal syphilis. According to some observers as many 
as 20 to 40 per cent, of wild rabbits in this country arc 
affected, though it would appear Hint in hiUch rahbits'tlio 
disease is inu'ch 'les's c'o'ininou. Tlie anthors during the past 
four or five years Iiavc examined 228 rabbits, belonging to 
the laboratory stool: ; of tliese 14 were affected. Tho lesions 
consist of small scaly patches, often slightly eroded aiid 
coi-ered with a browuisli crust, situated on tlio genitals or in 
tlic perineal region. In males tlio pori-anni region was chiolly 
affected; in foinalos tho vagina and nelglibouringskin. In two 
aulnials tho nostrils ■were nttaclred ; they shoiyed deep erosions 
with raw, blooding edges. In two others tlie 'diseaso attacked 
tlio' dyelids', which wore thickened and scaly. In all le-'ions 
splroclinotes wore rondils' found, sometimes in euormou.s 
ninnbcrs. Tho organisms closely resembled Treponema 
pallidum, and, except for their being apparently rather 
longer, tlioy wore inorphologlcnlly indistingiushable from it. 
Like Tr. pallidwn tho organism took bn a ro.so-red colour 
with Giomsa’s stain ; in sncli preparations the two organisms 
were IndistingulBhablo. Histologically the lesions were found 
lo bo superficial ; no Splrocliaotos were demonstrated in the 
deeper tlssu'es. Tlio dlsoalsd was readily transmitted from 
rabbit to rabbit by inoenlatlon of an infective tissue sns- 
ponslon on to tbe' scarified slcin of tlie genital region. Tiie 
iucnb.atlon period varied from tWo to'ciglit weeks. Once 
estabilsbcd Infection persisted, often for inou'lis; in males 
spontaneous enro usually ' occurred, bnt in fciiinles, even 
though the largo coudyloinalous lesions tended to heal, stnall 
scaly patches remained for a long time. Transmission by 
mating was offoctod, tliougli not with constancy. The disease 
is readily cured by nngnontiim hydrargyrl. or by tbe intra- 
venous injeotlon of uovarsouobillon. 


651. The Plrquot Test— Pnnetare Method, 

C. A. Stewart (Amcr. Journ. Dts. Child,, March, 1928, p. 338) 
found, on applylng tho Plrquot tost at the Lymanhiirst sol'ool 
for tuberculous cbildicn, tliat the children preferred a single 
puncture tUrough tlio skin to 'tlio usual soaviflcatiou. A 
comparison of tlio efllcaoy of tbe two motliods w.as therefore 
carried out on 281 cliildren. The ''esubs in all ^ 

cases, the same 223 children giving po.sitivo tions both 
by the soarlfication and the puncture methods, wbi'o ‘no 
rcmaiulng 58 wbro uniformly negative. 
simple : tho forearm is cleansed with other, a n' ' 
culln is placed on tlio skin and a single lUirture maclc 
through the drop Avith an ordinary sowing 
■.tuberculin may bo wiped off iinniediatoly aftci without 
a'nnreoiablv aitcring the effectiveness of the test. 


555 . Sero-dloi^nostlc Methods In Tuberculosis. . ^ 

ri E. Badoux and Milo M. Nabbed (Ilcv. Med. J", “ 
llomandc, January 251h, 1928, p. 21, and lehruarj' 25th, 
p. 103) compare two metliods and attempt to assess tiie 
value botli from a diagnostic and a progno^ic point o' ' n?' ; 
They describe in 'dotail tho method of Femes in 
0.6 c.cm. of clear serum’ is mixed with an equal nmonnt 0 
a r.25 per cent, solution of pure resorcin. The optical densi i 
of this mixture is measured by means of a photometei. 
authors have compared their results by this niothon 
those obtained by Besredica’s complement fixation test 11 
conjunction with sputum and clinical examinations in a s ■ 
of over 300 oases. They find that in 94 per cent, of 
Vbrnes test is iiositive, as compared with 96 per cent, w 
the Besredka, and that therefore both methods are use , 
although neither is infallible. They find that 
test is of more value in prognosis than the other. 
simpler, but the apparatus is expensive. In 
Ts diagnostio value is 81 tier cent, as compared with faJ. pc 
and its accuracy in prognosis is said to be even mo 


cent , 


556. Tiie Blood Groups of Children and Infants. 

Eesib.Cbowb (Arch. Dis. in Childhood, April, 1928, p. IM) 
records the investigation of tbe blood groups of 200 children. 
The first 100 were under, the age of 12 and were normal boys 
and girls. Tbe second 100 were infants under 1 year, many 
of whom were suffering from pneumonia, diarrhoea, and 
vomiting. The results show that infants as well as children 
have a. definite blood group. In infants Group I contain.s 
a smaller and Group ll' a larger proportion of case's than 
in children. This suggests tliat the blood groups may not 
.be established . during , (lie. carl j' montlis of Jifo., Sex and 
V*nT»/a T»n ninifirnTif; I'oInffnJi Irt flio HTrinrl f?rf)tinS. 



. June 9, jgas] 


[ 


ItaBantfa 
Uxczcix. Jo;nuu& 


93 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 


557 . Eczema caused by Quinine SupposiCorIcs. 

K. IlANSBS {TidssK-riJt f, (?. Sorshc T.neijeforciiiufi, jrarcli Inl 
1928, p. 215) recalls that, accordliii; to Moltzcr’s Invcstlya- 
tions, 0.12 per cent. o£ all hinuan boliios arc liable to sliow 
■some idiosyncrasy to qnlnlno in the form of ranbes aiul the 
like. This idiosyncrasy’ may’ appear not only’ when qniulno 
is taken by tbo moutb.bnt also Avbeii it is used in hair iotlons 
and suppositories. Ho records three eases of eczema pro- 
Yoked by qnlnlno suppositories. Tbo llrst patient rvas a 
■vrouian, aged 23, suffering from an aiuto sveoping eczema of 
tbo genitals and surrounding structnres. She know that she 
BUtlorcd from idlosy’ncrasy’ to quinine, wbicb, wbeu taken by’ 
tbo month, bad several times provoked a rash, but she bad 
not realized that tbo vaginal suppositories she bad used con- 
tained quinine. Tbo second patient was a man, aged “15, who 
bad never bad eczema provionsly’, and who bad suffered from 
acute eczema of tbo genitals, tbo Inner side of tbo tbigbs, 
and the face. It transpired that bis wife used vaginal sup- 
positories containing quinine. Some time later, before the 
eczema had completely’ disappeared, tbo experiment was 
made of giving him 0.1 gram of quinine sulphate by' tbo 
month. A few bom's later an almost universal, violently’ 
itching crytbonia broke out, and the eczema in the inguinal 
regions flared up afresh. The third patient was a woman, 

I 'aged 40, suffering from an acute weeping eczema of the 
genitals. She did not know that she was sousitivo to 
quinine, but tbo eczema broke out after she bad begun to use 
quinine suppositories. Tbo author remarks that, considering 
how often qnlnluc suppositories are used as contraceptives, 
and how common is an idiosyncrasy to quinine, it Is strange 
that oases such as his have so seldom been recorded. He 
can, in fact, find only one such ease, that of Zacharias 
■{Hied, KUnik, 1926). It Is probable that tbo rarity of such 
records does not imply that this condition itself is rare; 
more probably it is fairly common, but often overlooked. It is 
characteristic of this condition that it begins ou tbo genitals, 
that the husband or tbo wife suffers, but not both of them, 
that its severity depends ou tbo degree of idiosyncrasy’, that 
it extends to many other parts of tlio body' If tlio use of 
the suppositories is continued, and that it is difllcult to cure 
unless its cause is discovered. 


558. Respiratory HIppus In lAcdiastlnal Affections. 

F. Tonietti {II J’olicHnico, Scz. Pr.at., March 5tb, 1928, p. 307) 
reports tlireo cases of alternate pupillary’ dilatation and con- 
traction during inspiration and expiration. Roeb, in 1903, 
reported a case of aneurysm of tbo arch of the aorta com- 
plicated with mediastinal, pleural, and pericardial adiiesions 
in which this ocular phenomenon was continuous and 
bilateral, and gave it the name “ respiratory hippus." 
Tonietti remarks that the interpretation of the phonomonon 
is not.quito clear. . Tbo first of his throe patients had suffered 
for live months from difiloulty of breathing, profuse sweating, 
violent cough, and scanty expectoration. He had a feeling 
of weight in the head with giddiness and persistent coryza. 
The neck then increased in volume, and his face and the 
upper part of the trunk were red and swollen. At night he 
often had severe attacks of dyspnoea. The jugular veins 
were markedly distended, and reticular veins were evident 
over the upper part of the thorax ; the lymphatic glands of 
the nock were hard and fixed. The dyspnoea was Intense, 
as was also tlie cough, owing to compression. The pupils 
were of normal size, symmetrical and of regular outline: 
^eir reactions to light and accommodation were sluggish. 
Both pupils presented continuous and rhy’thmical oscillations 
in size synchronous with the respiratory act, dilating with 
inspiration and contracting during expiration. The pheno- 
menon was not influenced by the size of the pupil in relation 
to light or accommodation; it occurred without jerks or 
interruptions. In Tonietti’s second case a hard indolent 
appeared at the base of the neck in the region of the 
right carotid; and jugular distension followed with sensations 
of hea-vmess, heat, and giddiness in the head. An after- 
noon rise of temperature was followed by an evening fall 
accompanied by sweating. The pupillary movements were 
continuous and bilateral. Tonietti’s third patient had similar 
nut less severe symptoms. The author considers that the 
° had undoubtedly mediastinal lympho- 

'ineurysm of the aortic arch. In the first 
presence of a mediastinal 
aiiection its exact nature was not quite clear. Tonietti agrees 


with Bocli that the movements present no irregularity, and are 
not nervous affections. Kussmaul has reported a very slight 
dilatation of the pupil in normal man during the act of 
inspiration. The movements appear to be due to alterationu 
In vascular pressure alone which affect the volume of tho 
circulation in the iris. 

659. Eocallzod Asphyxia Due to Cold, 

Tj. Fr.nnANNiNi (SludUim, February 20tb, 1928) reports an 
Investigation into tho etiology and pathology of a case in 
which local asphyxia was produced by cold. A woman, 
aged 30, with tbreo healthy children, stated that w’hen sho 
was several months pregnant with her last child a fleeting 
cj’aiiosls of tbo tip of tlio nose bad been noticed. • This 
coincided with n period of worry and anxiety. At Ibo- 
beginning of 1925, on n cold and windy day in tho country, 
sho had noticed a nnmbing of the exposed parts— hands, legs, 
face — which became first pale, then red, and finally bine. 
Sho was obliged to return to the house to restore warmth 
and fooling. This affection increased to the extent of pre- 
venting her carrying ou her work ns a domestic servant. At 
the end of 1927 sho was admitted to hospital, and a blood 
examination revealed a diminution of red cells with a 
lymphocytosis ; the Wassermann reaction was negative. 
When tho patient’s hands, which otherwise appeared normal, 
wore submitted to cold air or cold water the skin became 
palo and tho circnlntlon ce.ascd locally in a few minutes. 
When the cooling ngout was removed tho jinllor remainccl 
for some minutes, after which blueness supervened. During 
tbo Iscbaenilc stage tho patient did not have any abnormal 
sensation, but thero was diminution of tactile sensibility and 
aifllcnlty in flexing the fingers was experienced. When 
warmth was applied tbo normal appearance was regained in 
gradual stages. Tho pulse and respiration rates diminished 
somewhat at tho boginulng of the local syncopal attack, bat 
the amplitude and character of the pnise were not appreciably 
altered. The lower extremities, nose, and ears behaved 
similarly ou exposure to cold. The question at issue was 
whether tho condition was duo to functional or oi^aulo 
alterations in the vessels. The caplllariscope did not reveal 
any marked changes from tho normal, bnt investigation of 
tbo action of the vagus and of the sympathetic by means of 
injections of pilocarpine and atropine brought to light in- 
stability of the sympathetic. Tho possibility of endocrlno 
disturbance was explored with Raynaud’s “uterine cyanosis” 
in mind. Ferraunlnl concludes that this case represents a 
variety of Raynaud’s syndrome, but adds that neither the 
etiology nor the pathogenesis of the condition is clear and 
no effective treatment has been fonnd. 

560. Iodine Deficiency in Water as an Index of Goitre. 

D. F. S.MIL,EY {Aiiicr. Jonrn. of Hygiene, March, 1928, p. 297) 
has endeavoured to correlate the existence of slight degrees 
of goitre with iodine deflcieucy of tho water supply. Ho 
oxarained two groups of students sitting for their eutranca 
examination at Cornell University. One group showed 
enlargement of the tliyroid gland ; the other group did not. 
During the last seven years 967 male students In each group 
have been studied. It was found that of the first group 654, 
or 67.6 per cent., came from regions whose waters contain 
less than 23 parts of iodine per 100,000,000,000, whereas of the 
second group 555, or 57.3 per cent., came from such regions. 
•This difference, in tho author’s opinion, is too small to be’ of 
significance. Since McClendon and Hathaway have shown 
that coarse cereals, green vegetables, and milk contain from 
1 to 29 grams of iodine per ton of dehydrated food, even in 
regions wliere the waters are deficient in iodine, tho author 
argues that iodine may frequently be ingested in snffloient 
quantity in foodstuffs to balance any effect of the iodine 
deficiency in the water. He therefore conolndes that the 
iodine content of the water in a given region is not an 
accurate index of the frequency with which thyroid enlarge- 
ment is to he expected in male students who come from that 
region. 


561. Ocular Wanlfestatfens of Juvenile Tabes. 

J. ROSNOBLET (Jonrn. da Had. da Lyon, March 20th, 1928, 
p. 163} states that one of the principal features of juvenile 
tabes is the frequency of ocular manifestations such as 
changes in the pupils, oculomotor palsies, and especially 
optic atrophy. These ocular signs usually form the first 
evidence of the disease, juvenile tabes being first and fore- 
most an amaurotic form, in which the cerebral symptoms 
.predominate, whereas motor ataxy is ill marked or absent 

ioo8 A 


96 JUNE -9,- 1928] 


EPITOMfl' OF CUKEENX. MEDIOAIj rilTEUATUHE. ■ 


IfEDlCAL JOVMV'ii 


and the general condition remains satisfactory. In 73 per 
cent, the pupils are unequal and often irregular in outllno 
quite ap.irt from tho irregularity associated with the 
synochiae resulting Irom old iritis. In other oases tho 
pupils are dilated and do not react to light or accom- 
modation. The oculomotor palsies may he early or - late. 
In the first group the levator palpebrae, rectus externus, 
rectus iuternus, and more rarely the rebtus Interior and, 
obliques are affected. The onset of these paralyses Is 
rapid and recovery is quick and spontaneous, whereas the 
late paralyses, which are often bilateral and chiefly affect 
the third nerve, have a slow course and show no tendency to 
clear up. Optic atrophy has been noted in 53 per cent, of tho 
published cases of juvenile tabes, and is thus twice ns fre- 
quent aa in the tabes of the. adult. The atrophy, whether 
grey or white, primary or secondary to neuritis, invariably 
ends in complete blindness after an. Interval varying from'a 
few months to a few years. < .• . 

SB2. Stammering Producoa. by Thyroid Medication. 

M. B. Gordon {Amer. Journ, Med, Sci,, March, 1928, p. 360) 
asserts that tolerance to thyroid medication varies greatly, 
and depends on the autogenous thyroid content and suscoptl- , 
billty of the individual and not on. his ago or weight. .The, 
untoward symptoms produced by .thyroid administration are 
essentially those of an acute .thyroiditis, and are generally 
disturbances ol the central nervous, gastro-intestinal, and- 
cardio-vascular systems. Stammering may be produced by 
thyroid extract, and should ..be considered as a general 
nervous excitation following disturbance of tho central 
nervous system.. Five cases of .infantile myxoedoma and 
hypothyroidism are reported in which stammering occurred 
during tho course of the thyroid treatment. The relationship 
between the stammering and the medication was emphasized 
by the subsidence and cassation of the affection following 
discontinuance of treatment. Alter a quiescent period of 
variable length, thj;roid tolerance was later brought back by 
a gradual Increase in the dosage. Gordon affirms that when 
stammering Is noted during thyroid treatment, it should be 
treated as any other toxic symptom by Immediately suspend-. 
Ing the medication, which should not be resumed until some 
time has elapsed after the disappearance of the trouble and 
then only with small doses. 


SB3. I/ymphatlc fjeukaemla. 

D. L. Farlee (Medicine, February, 1928, p. 65) reviews the 
classifleation of lymphatic leukaemias, their relations to 
other lymphatic diseases, and their treatment, especially by 
irradiation. In chronic lymphatic leukaemia the.two oharao- 
teristio features are the blood picture, with its Increase of' 
lymphocytes, and the histological structure of an excised 
lymph node, an unorganized hyperplasia of lymphatic cells 
of nuiform size and appearance. Xu aleukaemlc lymphoma ' 
or leukaemia, regarded by some observers as only a phase in 
either chronio or acute lymphatic leukaemia, Ihe blood 
picture is lacking, while the lymph node presents the histo- 
logical features described. In acute, lymphatio leukaemia 
the lymph tissue may vary from normal to the chronic type, 
while the blood picture is marked. Most of these acute 
cases probably belong to the myeloid group. ' A true mixed 
lenkaomia has never been, definitely demonstrated in man. 
The author' further draws a' distinotlbn between the lymph- 'I 
atio leukaemias and lymphosarcoma, leucosarcoma, mycosis 
fungoldes, and Hodgkin’s disease. ' Irradiation Inleukaemia 
has been accomplished by the use of radium, a rays, meso- 
thorium, thorium-x, and various radium salts. 'The last 
three have been injected intravenously. The results obtained 
with radium in .the past decade have been very promising 
B§clere reported excellent results from using concentrated 
n: rays over the spleen iu myelogenou.s ienkaemia and over 
the lymphatio masses in the lymphatic type. Attempted 
irradiation ol the bone marrow failed to produce auy effects. 

A' rays or radium do not shorten the course of acute leukaemia 
of either type and may definitely accelerate the ‘disease. 
Minot and Isaacs and Wood agree that chronic cases are' 
benefited by irradiation; the improvement, though temporary, 
is often striking) The patient does not live longer, but he 
gains greater comfort and freedom from symptoms. Many 
other observers, however, consider that irradiation does 
prolong life in Individual cases. A change to a different form 
of irradiation might be successful in resistant cases. Increase 
in the patient’s sense of well-being and decrease in the size 
of the lymphoid masses or spleen appeared to be proportional. 
Generally . myelogenous cases reacted very much better to 
irradiation than lymphatic ones. The in'traveuons injection 
of mesothorium, thorium, or thorium-x is still in the'experU 
mental stage; control over this form of therapy is tod 
indefinite. The technique employed in different clinics' is 
described in an addendum to the'revlew. ' ' - 


Surgery. 

569. ' Tho Cerobro-splnal Flulc- In Cranial Injuries 

without Fracturs. 

H. Claude, A. liAMACHE, and G. Duhar (Paris Mid., March 
24th, 1928, p. 271) review tho facts knowu at tho present time 
ns to modifications in tho physical an.l chemical state of the 
corcbro-splnal fluid luduced by Injurios to the skull in- 
salllclcnt to causo fracture, and record their own observations 
in twenty-two recent cases. Tho suhjeotivo sj’mptoms most 
commonly noted by thorn in subjects of such injuries are, 
in order of frequency; headache, vertigo, asthenia, insomnia, 
tinnitus aurlum, and visual fatigue. Chemical examination 
of tho oerebro-splnal fluid included estimation of albumin, 
globulin, and sugar, Exco.s.s of a'bumlu was found in nine 
cases and a fkll In the albumin porcoutago was observed to 
) tako place gradually ns tbo symptoms improved. Globulin 
was not detected In any case, and variations in the sugar 
content, always variable in normal subjects, did not yield 
any information of clinical value. Variation in tension was 
'tho most striking feature; In five cases only was the tension 
ifoiind to bo normal; in tho remainder tension was found 
.either (1) raised (tho greatest number), (2) lowered, or 
(3) unstable, varying considerably even in the course of a 
single observation ; the authors note that sach du stability 
.has boon found by otiior observers previously inopileptics. 
AVboro hypertension is found lumbar puncture usually gives 
good rosulLs, tbougli several punctures and the withdrawal of 
largo quantities of fluid may bo necessary. Whore lumbar 
puncture Is refused tbo ingestion of hypertonic saline and 
glncoso solullons may bo tried, though its efficacy Is doubtful. 
In hypotension intravenous injection of distilled water has 
been tried, but the authors record one case of success following- 
tbo apparently paradoxical withdrawal of fluid, 'posslb.y- 
owing to stimulation of tho mechanism of sooretlon. 'Treat- 
ment of Instability of pressure has proved most difficult, but 
the trial of ergotamlno tartrate is recommended. Variations 
In tbo corebro-splnal tension are attributed to the liberation 
of toxins acting upon tho secretory mechanism as the , result 
of brain injury. Leakage ’of cerdbro-'spinal fluid into the 
surrounding tissues has been suggested ns a possible cause of 
hypotoUBlon, but is not considered likely where no fracture 
can bo demonstrated. It has boon shown that the retinal 
pressure, as read by Bailliart’s ophthalmo-dynamometer, 
gives a close approximation to the cerebro-spinal tension, 
a uspful alternative whore lumbar puncture is refused,. 

565., .Reduction of Strangulated Hernia en lua'sse. 

J. Chavannaz (ncv. de Chir:, No. 1, 1928, p. 33) records observa- 
tions made In a series of cases of strangulated hernia reduced 
en masse. He concludes that roduotion in this way is rare 
but not unknown, and that it. occurs usually in adults and old 
people, men being affected more olten than women. IVhou 
reduction en Uoc occurs It is nearly always the result of taxis 
■by the patient hlm.self or bis doctor. It is most frequent in 
cases of inguinal hernia of long standing, particularly when 
on the right side and containing small intestine. The- deatli 
of the patlent'ls tho usual result of a case which is neglected. 
Diagnosis is difficult, being often confused with intestinal 
obstruction. Tne. chief charaoterlstics on which It is made 
are. the persistence of symptoms after reduction of the 
strangulated hernia en masse and the presence of a swelling 
in. the. region of the hernial orifice. Immediate operation is 
necessary, and 'the abdomen , must be opened ; in cases of 
•gangrenous iutestiue there must be resection. Early opera- 
tion, is essential to success. In 1908 the death rate was 48 
per. cent, and Is estimated now at 25 per cent., but It is 
probably lower since surgical intervention is more often 
undertaken. . 

556, Primary Tumour of the .Endocardium, 

6 . GulDBBRG (Norsh Mag. f. Laegevidensli., March, 1928, 
p. 272) records the case of a woman, aged 76, who had suffered 
for six months Irom symptoms resembling angina pectoris. 
At the necropsy a roundish tumour the size of a plum was' 
found in the left auricle, as well as extensive artoiio-sclerosis 
in the aorta and coronary arteries, fibrous m.voeardicis, and 
multiple pulmonary emboli. As neither the li'i.story nor the 
post-morte?n' Umiiags gave any support’ to the view- that the 
tumour could have been the cause of death its presence, was 
regarded as'a mere coincidence. It was situated on the lower , 
margin of the closed foramen ovale, was brownish-red in , 
colour, and of soft elastic consistence. On uiicr’oscopioal 
examination it was found to be a ' vascular fibroma inter- ■ 
spersed 'with haemorrhages. There were no signs of any , 
remains of thrombi In its formation, and Guldberg therefore 
had no doubt that it was a real tumour, confirming tjio view , 
that the endocardium may be the seat of new growths. 


JUNE 0, igsS] 


EPITO'ME 'OF CUllriENi ‘ilElilOAri MTEKA/r^EB^ ' 


'f THEBRinan -• 
■ LMrcicii. Jon»:r*ii 


97 


B67. Ynscotomy In ProBtntlo Hyportropliy. 

T. lIOllNE (Hcntralbl. /. Chir'., Jrnrch 17tli, 1928, p. G'12) 
rcuiarlts that the more sorlous sequels of prostatlc Jiyi)or- 
trophy nro tesliliwl urine, septic cystitis, niul nscom1in(* 
Eccoiulary pyclo-ncpliritls. Itonnl bnclt pressure may enuso 
irreparable dauiat’o niul uUininfely unicmia. lie considers 
that vrbile prostatectomy is tlio i)roferabIo operation it tho 
patient’s condition permits, tlio post-opcrntivo mortality may 
bodlmlnlsbcd fnrtber by more rifJorouR selection of cases. As 
a preliminary or nlternatlvo to the major opci-atiou ho recom- 
mends ligature or resection of tho vasa deferentin, which he 
has employed in thirty-si.K cases. As n preliminary operation 
vasectomy or ligature permits tho use of a self-retaining 
c.athoter, before and after prostatectomy, without danger of 
secondary septic cpididyinitlB or orchitis. Tho author found 
in his oldest patient, aged over 80, that tho vas was patent. 
Ho recommends that one vns should bo ligatured or resected, 
and then, after an interval, tho other should bo treated ; this 
will lessen tho danger of post-oporallvo psychoses occurring, 
nuhno has performed vasectomy in fourteen patients aged 
between 6G and 85 without subsequent prostatectomy, which 
was contraindicated by renal InsuIMclency or advanced ago. 
Shv of these patients were treated subsequently by injection 
of the hypertrophied iirostato with pepsin-novocain solution, 
as recommended by Payr. In four cases rapid improvement 
followed, and nine mouths later tho patients were able to ! 
micturate normally. One patient had 20 c.cni. residual urine, 
tho remaining patients had none. In tlio tour patients tho 
sire of tho gland was reduced from that of an egg or an apple 
to that of a chestnut. These results of tlio comhination of 
vasectomy and pepsin treatment correspond witli those of 
simple pepsin treatment. Two patients were not relieved 
by vasectomy and died from intcrcurrcnt diseases. Ilfiline 
concludes that vasectomy is a safe and simple operation 
which will prevent serious septic infection and may obviate 
tho necessity for subsequent prostatectomy. 

SBS. Treatment of Internal Hacmbrrholds wrlth 
Quinine and Urea. 

W. A. Eolfe (AV»i EiKjlaiid Jouiiu .Ifcrf., March 15th, 1928, 
P..187) describes tho use of iujootious of quinine and urea 
hy'drocblorido in tho trontment of iuterunl hnomorrhoids. 
As the method is painless and ambulatory it Is well adapted 
to out-patient clinics, but care is needed in tho selection of 
cases., Straugnlatod, sloughing, or external haemorrhoids 
should not bo treated by this iiiothod, and sphinctcrio spasm, ■ 
denoting infection in tho ano-rectal region, is also a contra- 
indication. Treatment should consist in six to ciglit Injec- 
tions at five or six days’ interval, and tho full course should 
bo given oven though bleeding is arrested by tbo llrst 
injection. Atrophy and ullliunto disappearance of tho pile 
follow Successful treatment. There is no danger of com- 
plications, except that very rarely a patient may show 
symptonis of Idlosjuicrasy with vomiting and some collapse, 
but these quiclcly yield to suitahlo troathiont. Tho injections 
should bo given With tho patient in the right or left Sims 
position; a Brinkerhof or Otis reotal Speculnm is used to' 
expose tho haemorrhoid, which is swabbed with a 3 per cent, 
solution of mercurochroinc/ or, failing this, tincture of Iodine. 
Some 5 per cent, solution of quinine and nrb.'i hydrochloride 
is drawn into a 5 c.cni. -syringe,- to which is attached a ' 
four-inch 26 gauge needle. Into' tho centre of eacli haemor- 
rhoid. 5 ’to 15 minims -.of the' sdluliou are Slowly injected. 
Sneh -rinjectious Bhonld^be mftdo well- above the recto-anal 
line, otherwise painful oodbnin’ uiay''r'csnIt. If rectal aching 
follows the operation it may b'e' snbsdqiverttly prevented by 
tile addition of a-drop of "saturated sbdiUin hicarbouato solu- 
tion to the contents of the syringe. ' During tho treatment' 
constipation must bo corre'eted by liquid paraffin.- 


SS9. Clinical Classiflcatlon of Septlcaemlc States. 

C>iV.,Prnf.,'i?ebruary 25IIi 
1928, p. 130) dispusses..tho possibility, of :maUing. a., clinlca' 
(uaj'uo.sis ol tho'causal or^'anisinju septicaeniifl, of -which he 
recognizes four nmiii groUps. His first group includes thqst 
cases in which the organisms give rise to the typhoid state; 
111 ms second grpiqi the septicaemia is tho sequel of an 
Obvious local sepsis such as puerperal fever. In his' tbird 
wwi!, ’°i domlnaut .symptom, or group of symptoms, 
nlilphiHc°r suggest a particular organism'— as, for example, 
I Ju*)itis cansilig a streptococcal septicaemia, or' osteomyelitis 
whibn fourth group comprises cases in 

let, . no obvious or definite character- 

thom’if “ir • .tbo causal agent oau frequently be snspected, 
obfmu ^ S V • .auflnitely established. In brder to 
p.atliolonmr^ appeal must rest with the 

mr'the \ always helpful 

iuqnmy flToWd ^rocbld?- directibn\he 


Therapeutics. 


570. Bnictinc In Amoebic Abscess. 

Tub value of oiuotiiio hydrochloride in niiioehic hepatic or 
pulinouary abscess lias uot been generally recognized, 
although Iiconard Eogers, more than ton years ago, advised 
nspiratiou of a “ tropical ” abscess and injection of the cavity 
through tlio cannula, with an aqueous solution of emetino 
hydvochlorldo (2 grains to the ounce). N. Fiessinger and 
11. CasteraN (Hull, el 3l6m. Soc. Hid. dcs Uop. dc Paris, 
January 5th, 1928, p. 1746) record two cases of imlmqnary 
abscess in which tho symptoms disappeared rapidly after 
iiypodcrmio administration of tliis drug. They comment on 
tho great dlfllculty of diagnosing iiopatic abscess when the 
picuro-pnlinonary syndrome simulates pulmonary congestion, 
pleural eftuBiou, or ompyema. ’Their first patient was an 
ox-soldicr, aged 53, who was tlionght to have chronic diabetes 
with plouro-pulmonary congestion at the right base. There 
was no albuminnrio, but tho sugar content was 33.3 grama 
per litre. Thopatlcnt subsequently developed pyelonephritis, 
followed by violent pain in tho uiuch enlarged liver, .and 
pyrexia. There was no Iilstory of dysentery, bnt he had 
served wltli dyscntcry-infectcd troops. Hypodermic Injec- 
tions of 0.08 gram of emotino liydrochloride were given daily 
for four days, and tho dose was doubled on each of the four 
following days. Tho pain and fever ceased at once, and ten 
days later the polyuria and glycosuria had di.sappca'red.- He 
returned to work in three weeks, and four months later he 
had gained 111b. Tho liver was enlarged but not hard, the 
pulmonary signs had disappeared, and the urine was normal. 
The second patient, a man aged 33, was admitted with 
pleuro-pulmonary congestion at tho left b.ase. An amoebic 
absce.ss in tho left lobe of the liver was mapped out by 
lipiodol ; it contained 1.5 litres ot pus and was cured by 
aspiration and emetino without incision. In two months the 
paticut gained 221b. ond resnmed work. A. Lemibbre and 
B. KourILSKV (ibid., January 26Lh, 1928, p. 37) report tho 
case of a man, aged 46, who was admitted to hospital with 
slight fever and pain at the right base. At first he had no 
cough, but after a violent attack of coughing, with inodorous 
greenish sputum, excavation occurred, and tho sputum 
became fetid and septic. Aspiration of the right lower lobe 
prodneed abundant greenish-yellow odourless pus. A daily 
hypodormio injection ot emetine hydrochloride (0.08 gram) 
was given, and six days alter tho commencement of tliis 
treatment tho patient’s sallow, earthy colour disappeared. 
He gained weight rapidly and the teniperaturo beeamo 
normal. From the second day of treatment all fetor'of the 
sputum disappeared. 

571. Boric Glycerin Injections in Post-operatlye Anuria. 

Ip urinary retention persists for about twelve hours after 
operation, E. Febjiaud [Rev, 3Ied. de la Suisse Romande, 
March 25th, 1928, p'. 212) pursues the following treatment. 

A few drops of urine are withdrawn by catheterization, and 
then lOc.cra. of a '20 per cent, solution of boric glycerin are 
Injected into the bladder still full ot urine ; this dosage and 
concentration have been found to prodno'e the best results. 
Twenty-eight cases are reported, in 24 ot which the desired 
effect was produced in halt an hour or less. In 15 cases only 
one injection was necessary, in 8 two, in 3 (in -wliich spinal 
anaestliesia had been emiiloyed) three were given, and in 
only 2 cases wore no results obtained and catheteriza- 
tion became necessary. Previously existing oj'stitis is said 
to bo the only contraindication to this tieatmeut, which is 
described ns a simple, painless, and safe procedure, tolerated 
perfectly by patients. Fermaud insists that ft is essential 
not to empty the bladder before making the injection.?, since 
injections into a void bladder are liable .to cause haematnria 
or even nephritis. 

57?. _ Serum Therapy In Lobar 'Pneumonia. 

K. Tj,' Q^Ui.:{-irch. Intern. 3Ied., March 15th, 1928, p. 295) 
discussing the specific treatment of lobar pneumonia, submits 
evidence from 'his own work and that of others which clearly 
shows that antipneumococcal .serum and its derivatives 
properly administered exert a definile influence on the course ‘ 
of pneumonia 'Types I and II. In pnonmococcus infection in 
man tlie result depends upon whether tho pneumococci or 
the leucocytes gain the supremacy, the infection remaining 
localized and recovery ensuing it the host produces suffleieut 
immune bodies, whereas death from pneumonic sepsis results 
it the pnenmococci prodneo sufficient soluble substauce to 
overcome the mimune bodies so that phagocytosis is in- 
hibited, the infection spreads, and the pnenmococci gain ' 
access to the blood stream. From a study of the Type laud II 
antipnenniocqccal sermn of Gole.Hnutoon’sautibodysotution 
and Felton’s concentrated , antipneumococcal serum it is eon- 
eluded that the principle involved is the same in all. In a 

ioc8 c 


98 June 9 , igz"!] 


EPITOME OE CEBEENT MEDTCAE ETTEBATEBE.' 


[ Trr ^^TlTTm 


Kories of 195 patients with Type I pnouraonin Colo lonntl tlio 
mortality rate reflncea- two-thirds by treatment as compared 
with those untreated. Eariy.and adequate treatment with 
large doses of serum is essential since tbe sernrn is bacterio- 
tropic, producing an opsonization of the bacteria prior to 
tfieir destruction by the leucocytes; thus by early and 
siilHoiently continuous administration the solnble substance 
of the pneumococcus uiay become neutralized and a balance 
of iinoTune bodies established with prevention of bacteraemin. 
The present diflidnlty in speeffle treatment Is due to detects 
in the serum or its derivatives, so that purification and con- 
centration are important factors in its practical application, 
Huntoon’s antibody solution, though free' from horse protein,' 
lacking suiilcient concentration, while Felton’s extract, 
though concentrated, is not entirely free fromliorse protein ; 
both products mayproducechills in large intravenous dosage. 
It is in Typos I and II that tho' outlook for success with 
specific therapy is most promising. ■ In' <Typo III efforts 
to sterilize the blood by specific therapy have failed, tho' 
death rate being almost identical with that of untreated 
patients, and in Type IV spscifleity of- tho protective sub- 
stance is impossible because a number of different types-aro 
concerned, so that a suitable serum cannot bo made from 
a single strain of Type IV pneumococcus, though it might 
be possible to prepare a polyv.alent Typo IV serum by 
immunizing a horse against a number of strains. 

573. Artificial Eight Baths In Taborcniosis of the 

Larynx, 

A. Blum [TJgcsUrifl for haeger, March 15th and 22nd, 1928, 
pp. 241 and 259) gives a statistical analysis of the rosnits of 
the treatment of tuberculosis of tho larynx -with carbon arc 
light baths at the Finsen Institute in Copenhagen. His 
material consists of 163 patients whose treatment was started 
l)eforo January Ist, 1926, their records being completed up to 
January Ist, 1927. Practically all tho patients had to bo 
treated under ambulatory conditions, and many of them had 
to come to the Institute from unhealthy homos, and had to 
make their way to tho institute e'von .though they were febrile 
and debilitated. The exposures lasted only fifteen minntos 
at first, being increased by fifteen minutes each time till the 
full exposure of two hours and a halt was reached. As a 
rule, a light bath was given every otlier day, but women 
were often given dally light baths in order to make good tho 
time lost during menstruation. For the most debilitated 
patients the Initial exposure was only tor ten minutes, and 
tiie increase of the exposures was Comparatively slow. 
Among the 163 there wore as many as 90) or 55 per cent.] 
who were cured; 'InTl other cases marked iraproveraenti 
and in 20 cases some improvement, was effected. Tlioro 
remained 42 patients whose disease was unaffected or became 
worse. Eelapses were infrequent, only ' eiglit relapses 
occurring among the 90 cases of recovery. The author 
points out, however, that the term “recovery” refers only- 
to -the disease' of the larynx, and not to tuberonlosis elso- 
where, and in this connexion .he admits'that at least 14 of 
the 90 patients who recovered so far as their throats' were 
concerned died subsequently of pulmonary tuberonlosis. 
Also, among the 163 patients with tuberonlosis of the larynx 
there were as many as 49 who died. A olassiUoation of the 
material according to sox showed that there were 99 men to 
64 women. ' The recovery rate was considerably better for 
the latter, being 67.2 per cent., whereas in the case of tho 
men it was only 47.5 per cent. The author suggests that, 
this difference may depend chiefly on -the fact that men 
come to treatment comparatively late because they are 
breadwinners with families to support, and because they 
often have to continue at work during treatment. ^ 

574. Serum Treatment of Appendicitis, 

"With a view to establishing specific serum treatment 
M. "Weinberg, A. E.- PrEvot, J. Davesne, and Claudie 
Eenard {C. n. Soc. de Biologic, Marcli IGtii, 1928, pp. 749 and 
752) have made a study of tbe microbic -flora in 150 cases of 
acute appendicitis, of which a great number were of tlie 
gangrenous type. Tho nitramicroscope showed that, in 
• contrast with pulmonary gangrene, spirochaetes are rarely 
present in appendicitis ; they were found in only three cases. 
Of the aerobic bacteria the frequency in the 150 cases was; 
Jt. coli 123, the enterococcus 41, M. proteus 14, staphylococcns 
12, streptococens 10; a few other species of organisms wore 
found less frequently. Of the anaerobic bacteria the fre- 
quency was ; B. pcrjringcns 49. Gram-negative organisms 60, 
cocci and streptococci 40, S. ramosns 16, B.fallax 5, B. hifldus 
2, r. septiguc 2, B. Jiistolgticus 2, and other organisms in 
Email nnmbors.. Tlie flora, of the inflamed - appendix is 
generally mixed, and consists of both aerobic- and anaerobic 
organisms. ..Tho authors think That the flora varies in 


tciani has boon found very froqnontl 5 ', ,wIiorons in Franco it 
is uncommon. It appears that tho two most important 
organism's are B. coli, whioli -was present in 85 per cent., and 
JJ. peffringens, wlilcli was present in 30 per cent, of cases. 
As a'rosnlb of tills study tho' authors have roplanod anti- 
ocdcviatieris sorum by antl-cofi sornm, and they have prepared 
Bornms, for use in special cases, against B'. ramoms and the 
enterococcus. Tlio polyvalent serum is employed as a 
routine both for' prophylactic purposes and to comhat'pbst- 
operatlvo accidents. It is specially recommended fornso in 
ca'cs of acute appendicitis in order to lower tlie tbinpenithro 
and abate tlio .symptoms, tlins allowing tho operation to bo 
performed in a relatively quiescent stage. 


Anaesthetics. 

5751 Sacral Block Anaesthesia. 

J. S. EuNDV (Amcr. Aourn. Snrg., March, 1923, p. 252) finds 
that for many operations, sncii ns tiioso on tlio rectum, 
bladder, and perineum, sncrnl ncrve-bloolc anaesthesia is 
generally satisfactory. Tlio patient during tlie injection is 
placed in tlio prone position, tlie Iiips being elevated. The 
skin over tlio sncnim is carefully prepared and a solution of 
procaine-adrenal ino is lisod to produce tiie anneslliesia. A 
small fikin-wiioal is then made with a fine needle through 
which tho cnndal needle is to bo tiirust. Tills needle is then 
introduced throngli tlio saoro-coccygoni membrane into tlie 
caudal canal'. Tlio needle is'ndvancod until it reaches tlio 
level of tho second sacral foramen and ns near tlio c'-ntro of the 
canal as possible. It spinal fluid appears tho needle must be 
partly wltlidrawn till it lies below tlio dural s-'C. Twenty 
cubic centimetres of solution arc Injected Into the canal, and , 
while this is being done tbo respiration increases in depth. 
Anaostlicsia ocenrS in tliirty to forty-five minutes. If anaes- 
thesia is incomplete it may be necessary to inject tlio first 
four sacral foramina postoriorlly. -. In cases where the caudal 
canal cannot bo located good anaosthosln can lie prodneed by 
injecting twjoo the amount into tho sacral foramina without 
a caudal injection. , .... 

576. s! A.. .Wallace (Canndfnn.il/'cd. Assoc, .fom-n., April, 
1928,- p. 405) compares sacral witli spinal anaesrlicsfa and 
surveys its anatomy, tooliniqnc, and clinical application. 
BeiD" a .combination of caudal, and trans-sacrai block lb 
affects tlie coccygeal and porlnoal regions, and tiie anus, 
rectum, urethra, and bladder. It is especially nacful in 
cystoscopic work, li.bliolapaxics,-and stricture dilatation, as 
well as in rectal op'or.ations and prostatectomies. Tliongh 
more dllTicult to perform it is said to bo mneli safer than 
spinal anaesthesia; an accurate anatomical knowledge is 
essential. In .caudal Vfloclt 20 c.om. of a 2 per cent, novocain 
sointlon in normal" saline with 10 minims of adrenaline 
per 100 c.cm. is injected very slowly at body te-iiperatnre 
through the sacral hiatus, and in trans-sacrai block througli 
tlie sacral foramina. Mild reactions aro common, lint severe 
ones can bo avoided by slow injection, taking caro tliat tho 
needle is not in a vein or in the subarachnoid space. Wallace 
describes tho tochniqno for each procedure in detail, and 
points out tliat caudal block nsnally suffices for ordinary 
cystoscopic and urethral work, with the additional injection 
of tho second and tiiivd sacral foramina in cases in wliicli 
the bladder is inflamed and contracted. He adds that for 
Iiacmorrhoidectomies and anal oper.atioiis oxcollent anae.s- 
thesia results from caudal lilock witli tho additional injection 
of tlie lower foramina'.*' For the more extensive operations of 
rectal resection and prostatectomies caudal block with injec- 
tion of all the sacral foramina is required. In suprapubic 
prostatectomy an additional' abdominal field block is neces- 
sary, and pre-operativo narcosis by “ twilight sleep ’ is 
indicated in apprehensive patients. . . - 

5T7. Carbon Dioxide Administration during Ether 
Anaesthesia. 

H. A. IiAKIN [Anesthesia and Analgesia, Marcli-April, 1928, p. 85) 
relates his experience of using carbon dioxide. in anaesthesia 
at over two thousand operations, and reviews the opinions 
of several other a'naesthetiats. For administering the anaes- 
thetic Iiakin employ.s a McKesson Model G apparatus, tliongh 
ho states that any ether inhaler which has a robreathing bag 
with stopcock attachment is snitable. Tho patient is first 
given pure oxygen or air, and the cai-hon dioxide is gradually 
added until it rises to 30 per cent. The other administration is 
then commenced wliile tho patient is getting this amount of 
carbon, dioxide. Two methods iiave been tried with tho 
same results : in tiie first, after tlio patient lias taken eight 
to ten breaths of carbon dioxide, the etlier indicator is turned 

r cent. 


Jl’NE C, 1928] 


EPITOME OP cuhrent sieeical liteuature. 


' TnEHRm^' 
Mr.DtCAL J0UR»AIr 


99 


cavboii (lioxido is'rcaclicil, tpo cllici- !>? tnriiea 011 slowly to 
tUcoc iiuailcis or full, iind tht> carbon (lloxlilo How is Btoppcd. 
■Xlic rosnirallon rate lii an liultcation as to tlio suniclciicy of 
the carbon (lioxlilo Hiron. ilfany nilvantaiJCH nro claimed for 
this method. Tho induction to the ether anaosthc'-la is said 
to bo smooth and pleasant, avrd tho period Is shortened, 
many patients boin^ HnRlclentty relaxctl at ttio end of three 
minntesof ether inhalation. There l.s practio.ally no strnfifjllng, 
excitement, cliohinKT or hreatlile.ssncsa, and no cyanosis, 
patients always inalntaiiilnj; a fjood colour. Post-operative 
thirst is rcdnc'od, and nansca and voinltliif; iiavo rarely been 
noted, even in Rail-bladder operations. Tho depth of anacs- 
thcsiacan bcc.a.sllycontrollcti, and de-ctlicrizatlon procedures 
can be trsed to hasten tho return of cousclonsucss and tho 
elimination of ether. 


178. Kthylcno Anaesthesia. 

11. 1’. P.MUl.iE {It)il. Journ. Aiiitcsili., April, 1928, p. IS-l) 
records bis experience of ctliyicnc nnacslhcsla in 200 cases, 
lie considers that tho daiiRcr of explosion when mixed with 
either oxyRcn or air is no Rrcalcr tliau willi certain nimliar 
mixtures of etlicr If the same precautions aro taken ; 
moisteuiuR the apparatus tlirouRh wiilcU tlio mixture passes 
prevents .such ri.sir. The obnoxious .smell, more obvious to 
those In attendance (lian to tlic patient, can be modillcd by 
tlio addition of encalyptns oil or by securin'; Rrc.ater purity 
cl the gas.' In administration a lilRlier percentage (about 
16 per cent.) of oxygen Is reijnired tlian with nitrons oxide, 
and McKcssou’s api>ar.atus is iircfcrrcd bcc.ause it allows foe 
rapidity of ebango in tlioproporticn of the- two gases and tor 
lIiG immcdialo nclivecy otpnrc oxygen if necessary. Faitlic 
regards-eliiylcno ns a safe amicslbetic provided tliere is not 
too strict a limitation of oxygen ; lie considers it superior to 
K hiixtuf'c of nitrons oxide and o.xygcu, owing to tlie freedom 
from cyanosis and venous liaeinorrhago resulting from its 
higher ’oxygen content. Fewer patients require snpprc- 
iDcutary ether administration and a .smaller amount Is 
needed. It Is an advanlago to give a prcirmftiarj' dose of 
morphine' or 'of liyoscinc-morphinc. As "to the depth of 
anaesthesia for producing satisfactory relaxation in abdo- 
minal operntfons, ethylono is said to bo superior to nitrons 
o.xide, and it 1ms been frequently possible to anaesthetize 
with ctliyicno alone In c.ascs where otlier wonid Iiavo been 
necessary had nitrons oxide been tlic initial anaesthetic. 
The ’oldest patient was S? and seven wore fnfanis a’fcw 
weeks old : tho series incindod •M alKlonifnal oporaffonk, 
14 appendectomies, 7 gall-bladder operations, 5 gaatro-. 
jeJnnosTomics, and 4 hysterectomies. T'"'' 


Obstetrics and Gynaecology. 

S79, Placenta Accrcta. 

Accqudixg to ir. Rreb ^(lijnfcol. ct dbstcl., February, 1928 
p. 81) the gravity ot placenta, accrcta (•* true atUierence of thi 
placenta”) is inteusifled by tho fact tliat this conditioi 
cannot be diagnosed until thc..iupuient of intervention, whei 
an attempt is made to remove inaunally a retained afterbirth 
Its occnrrenca lu.ay perhaps be thought likely in the case o 
tliosq w,ho have liad many ehildren and liaye been siibjectei 
to repeated manual removals of Uio placenta or to rcpeatei 
cniotting.s (especially in tlie pnerperiiini), iu’cas6s of myoma 
teas or urnffornred uterus,. and. in tliose patients in whoii 
jitognancy has supervened after along period of amcnorrlioea 
At any rate the history of many ca.se.s has pointed (osncli etio 
logical factors, which may be talien to indicate tliat cnsulni 
pregnancies should be. terminated in hospital. Of the 21 
ca.scs collected by Rceb from the literatfire, in G only did thi 
patients survive the condition of placenta accrcta and it! 
canscqnence.s— haemorrhage, shock, and sepsis. Of the sur 
viving patients two were treated by subtotal Iiystorcctonn' 
nqitnrc ot the nterus having been diagnosed in one; one bt 
hysterectomy after laparotomy for placenta praevia; oin 
by tamponage after laparotomy for placenta praevia ; ant 
one by tamponage after cnietliiig following a live months 
abortion. 1 lie sixth c.asewitii survival is now described bv 
Keeb; delivci-y. wa.s by Caesare.m section. Tlie patient 
a 't-para aged 24, suffered from violent abdominal pain 
'‘"’""I’hhrin, and sliglit vaginal bleediiu 
dajs before term; tlie nterns was distended ani 
xTi ' ' iind tlic os admitted tiio tip-ot the Cngei 

^tL as one of partial dctachmeni 

Thi o ^ piacenta. laparotomy was performed 

iho aento symptoms were touiKl to be due to left purnleni 
Sol it peritonitfs. . After the cSe« 

“V"*’ impoBsibic to determine a plane o: 
maiiv cnivi, of tlfb placenta, whicli tore and lefi 

aiij cotjltdons intimately adherent to the myometrium. 


Subtotal liystcrcotoiiiy was perforinetT and Ih'c patient re- 
covered. E.xamiuation ot the specimen showed that in seine 
areas the placental aCtaclimont was' practically noriiiai ; 
otiicrs showed varying degrees ot accretion, and the niyq- 
uiclriuni was greatly thinned towards tho fundps.^ Micro- 
scopically in the areas of adhesion the iiracontai villi .were 
Inextricably tangled with tlie ninscnlar bundles; thedeoidria 
apougipsa was comiilctely absent, arid tho ccimpacta w'as for 
the most part lacking. Inflammatory reaction in the deeidna 
hasalls was absent. 

BSO. Dystocia due to a Large Foetus. 

T, Bataud (G'IC. IMhI. tics Sci. Metl.dc lloi tlcntitr, March 11th, 
1928, p. 165) discn.sso.s dystocia duo to disproportion ot the 
foetus .and polvi.s. Uc concludes tliatdy.stocia maybe saidto 
begin with a foetal weight ot 9 lb. 14 oz., though tho head is 
not always iiropoitiouatc to the weight. Dystocia depends less 
on the absolute volnmcot the head than on its degree ot ossifi- 
cation, or its failure to reduce .salisfactorily, but excessive 
size ot the slioiildors creates tho chief obstacle in delivery. 
Tlic diagnosis of dystocia can he made in the later niontlis ot 
pregnancy when tho uterus is found to be bigger than tho 
time of prcgmiucy would suggest, twins and hydramiiios 
being excluded. As regards tlie etiology, dystocia seems do 
occnronly in mnitiparae, and generally at the optimum ago, 
bnt heredity jilays some part, and the author quotes from hi.s 
own records tlio cases of a mother and daughter, both of 
whom had disproportionately large children. The breadth ot 
Shonlder Is said to bo inherited from, tho fatlier. Best on the 
part ot tlic expectant mother is likely to predispose to a large 
child ; syphilis, diabetes, and endocrine deficiency have been 
snggosted as canses. Labour In those cases is very prolonged 
and fraught with danger to mother and child. True dystocia 
of the sliouldcrs docs not appear until after the head is born. 
Traction must tlicu he avoided, and an attempt should be 
made to substitute the cervico-acroiuial diameter for the’ bis- 
acromial one. The posterior arm sliould be bronglit dow'n, 
the head rotated, and tlio same mancenvre performed with 
the other arm, now posterior— all with great rapidity, A. fre- 
quent coiuplicatlou is post-partnm haemorrhage. The pro- 
gnosis of an undiagnosed case is had. Mlien the diagnosis is 
made in tlio later months ot pregnancy the choice of treat- 
ment lies between induction and Caesarean section. 

581. Tra iuii atlc Pelvic Kacmatoma. 

I S. Di FrAXCESco (.4)177. ili Ostet. c Ginccol., February 29th, 
1928, p. 183) believes that trauma tie haematomas in the 
’■pelvis are mote common during than apart from the puer- 
perium, and arc more often encountered below' than above 
the muscnlo-Iasoinl iiclvlc floor. The majority ot haema- 
tomas nncounecled with labonr arc of small size, and with 
conservative treat ment'are, as a rnle,.spontaneonslyabsorbe J. 
Largo liaeiiiatomas nsualiy cause considerable difftcnlty Jn 
diagnosis ; operative treatment is required because of their 
slow absorption and the considerable danger which exists of 
tlicir becoming iDfccfed. The case is ttescribed of a singl’e, 
poorly developed girl, aged 16, with rachitic stigmata, who 
while labouring in a factory snstained a blow on the right 
buttock; in spite otpain and faintness she continued to wpirk 
for eight days. The pain was felt from time to time in the 
abdomen, b.ack, right buttock, and right groin ; . walking 
became difllault, and rectal and vesical tenesmus were noted. 
During three weeks’ rest in bed under medical supervision 
slight eveuiug pyrexia ivas noted, bnt no gross pelvic. lesion 
was suspected until the iutrodnetion ot a syringe into the 
rectum was found to be difflcrilt and painful. On admission 
to hospital three months after the accident a mvelling -was 
found extending upwards to three flngerbreadths below' the 
navel and presenting below in the perinonrn, cansing the 
posterior and right walls ot the vagina to protrude. The 
hymen was intact; Uie nterns .wnsdi.splaced upwards and to 
the left.' Puncture from below gave issue to blood clot, from 
wbicli staphylococci and streptococci were cnItivatecT. Six 
hundred .c.ciu. of, odoran.s contents were evacuated from the 
haoma’foma by a 2 c.m. incision in the right anterior vaginal 
wall. It is suggested that the bleeding came from a branch 
of the right gluteal artery. 

582. . Ovarian Tumours in Old Age. 

R. 75rat.Lr.unEIM {Zentralbl. f: Gtjnah., ilarcli ITUi, 1928 
p. 689) records tho case of a woman, aged 72, wlio complained 
ot swelling and pain in both breasts, from which tumour 
formation was absent. Severe uterine bleeding was noted 
a fow' days later. The uterus, previously known to be 
atrophic, was found to be ot double the normai size hut 
enrettiugs showed only benignant endometrial hypertvophV ' 
a tumour the size ot-aii apple -was felt in the left ovarv'’ 
Microscopically this was fonnd to be acolumnar-celled earei- 
noina, partially cystic.-' ' A'sccoud caSe 'is .recorded in whicli’ 
a woman, aged 69, had bilateral mammary enlargement ' 



100 June g, 192SJ 


EPITOME OP CEBKENT MEDICAD EITERATUBE. 


r TjTX IlnTTnts 

MCDfCiL Jocnxib 


ufcorino blecdin", and a solid columnar-collod carcinoma of 
one ovary; she survived opoi-abioii for eigtit years. Clinically 
tUoso cases confirm tlio importance, in cases of poafc-meno- 
pnusal bleeding, of paying attention to tbo ovaries as well as 
to the uterus ; ■.Similar' cases' were reported' byMoulougliot^ 
Dol6ris In 1924, but in his patients tUo tumours were mostly 
boiiign — solid or cystic and sometimes intraligamontary. 
Mammary hypertrophy, it is said, has not previously been 
described as an accompauimciit of ovarian tumour causing 
metrostaxis in old women ; it may bo regarded as confirming 
tlio view that the renewed uterine activity i.s duo to hormoiiic 
ovariogenous influences. Myomotrial and endometrial ac- 
tivity in aged subjects .suffering from ovarian tumours' lias 
been held to be correlated with the fact that .such tumours 
either contain primordial ova or are of granulosa-coli origin. 
The ca.ses described in this = paper do not conform- to those 
characters. 


Pathology. 


5&3. The Leukaemias and Lymphomas. 

E. L. Opie {Medicine, February,' 1928, p. 31) surveys thd 
literature on leukaemia and aleukaemiclymphomain animals. 
Leukaemias conforming with the types found lii man aro 
found in many, if not in all, domestic animals, and in small 
animals available for experimental studies. Aleukaomic 
lymphocytosis apparently occurs much more freguently. 
Experimental study of leukaemias, resembling those of man 
has been as yet unfruitful. There has been almost unanimous 
agreement that none of these diseases can' be conveyed from 
one species to another. Evidence is wanting that leukaemia 
in mammals can be transferred to other animals of tlio same 
spooios, and the same can perhaps, he said of aleukaomic 
lymphoma. The “infectious lyiiipfiosarcoma of dogs” is 
readdy transmitted by natural means, like a contagious 
disease, 'or artificially, with material preserved in glycerin. 
No micro-organism has been found in constant association 
witli them. Eesistance which appears in animals witih the 
tumour has some resemblance to that caused by bactorial 
infection. The nature of the disease is as yet undetermined. 
Multiplication of blood cells and their precursors mav bo 
stimulated more readily in birds than in mammals; Dise’itsos 
occur in fowls which closely resemble human leukaomlas 
but are easily transmitted to other fowls. Alenkaom'lo' 
lymphomata arc not unoomraon with transitions to mvelo- 
gonous lenkaomia on the one hand, and to anaemia with 
hyperiilasia of the precursors of erythrocytes on .tlio other 
though it is doubtful it lymphatic leukaemia occurs. Tlieso 
various changes aro transmitted by a single virus,' Svhich 
is ultrarai-jroscopic and fl'lterablo. In this respect these 
leukaemias differ from mammaliau ones and resemble certain 
malignant tumours of fowls (sarcoma of Itous). 


Bacteria In Spinal Fluids. • 

Butii Gilbert and Marion B. Coleman {Tonrh. -Iiah and 
Gltn Hied., March, 1928, p. 547) report the bacterial ffndings 
in the spinal fluids of 284 cases ot meningitis, the- examina- 
tions covering a period ot over seven years. The number of 
tuberculous fluids was relatively high, being IG7, duotperhaps 
to the fact that 89 ot the patients were under 10 years -of age.' 
In thirty-one instances ten strains proved to bo ot-bdviho'and 
twenty-qno of liutnaQ origin. Meningococci wer(rjKokited iri^- 
only eighteen cases, .and these corresponded serologlcallv 
with the various type organisms. In aocordanco with the 
Undings ot other workers it was noted that meiifngococoi 
isolated from sporadic cases wore less uniform .sorolo° icallv 
than tliose found in epidemics. Pfeifferls bacillus was^found' 
in twenty-three instances, ot which seventeen were children 
2 years of ago or under, and no history ot previous respiratorv 
disorders was given. This type of infection is said to be 
indicated by tile presence of large numbers ot polymornlio- 
nuclear: leucocytes .and very, pleomorphic Gramfiifixative 
bacilli, and a tentative diagnosis may be made' on °tlieso 
flndmgs. The mort.ality from influenzal meningitis is high 
bnt experiments on monkeys appear, to indicate tliat, with 
early diagnosis, vaccine or serum treatment may bo of value 
riieiimococci were found in thirty-three and streptococci in 
tbirty-flve cases. In only three of tbo former was a historv 

ot pneumonia given ; and of sp — ‘ — ■ ■ noiytic 

streptococci, two were froir bead 

injuries, 3 followed mastoid , ot 

the variety producing metli-Iiacmoglobin. Jl. ti/pJwms was 
found in one case. M. caiarrltalis In two, and Jl. pyocijancns 
in ono case following a sl:uU fracture. In four instances 
hnidentilled organisms, due possibly to contamination, wero 
found. Tim authors draw attention to the relatively low 
incidence of meningococci in this series. 


SB5. The Chlorides of the Cerobro-splnal Fluid In 
IVTcningltls. 

G. C. Linder and E. A. Carmic!Iaf.l {THocUcm. Jonrn., 1928, 
„vol.,xxil. No. .1, ,)>.., .46) .liavo. made, an .o.xaiiilnation ot the 
chloride coiiicnt of the cerobro-.siiinal llnid in four cases ol 
meningitis— two tnborciilous, one meningococcal, ami one 
streptococcal. In lieallli the concentration ot clilorido in 
the serum is 0.58 per cent, and in the corobro-spinal fluid 
0.73 per cent., tbo ratio ot tbo two being 0.79. Tbo reason 
for tills difforonco Ls not clear, and attempts to o.xplain it on 
physical grounds have not beoii altogollier convincing. The 
lall in tlio chlorides ot. the cerobro-splnal fluid in meningitis 
has been attributed to an increase in pormeabllity.of the 
choroid iiloxuscs, tlins allowing tbo chloride concentration 
.to npproacli tbali in tlio sernm. In favour ot this explanation 
Is tlio fact that in 'iiioiiiiigitls ccrtiiiu substances such as 
flbrlnogeii, bile pigments, and coniploinont appear in. .the 
cerobro-splnal fluid.' Against it, however, is tlio fact that 
the decre'aso'in clilbrldoslii tuberculous iiionliigitis from 0.72 
to 0.55 jior cent., for oxaiiiplo, is iinassoclatcd with a great 
increase in protein in tlio corcbro-spiiial fluid. Tim aiilhor.s 
bring evidence to sliow tliat tlio fail ot chlorides is net-duo to 
increased periuoaliillty ot tbo moninges. They find that tbo 
-fail in chloridos occurs almost equally in tlio corebro-.spitinl 
fluid and in the soriim. In tlio four cases the chloride coiitoiit 
of tlio seniiii varied from 0,56 to 0.45 per cent., of tlio cerebro- 
spinal fluid friiiii O.Gl to 0.52 per cent. Tlio ratio' between 
tlio two was 0.86 to 0.90. (According to -tbo tablo given this 
ratio is tlio saiiio as in licaltli; but in tbo text tlio iioriiial 
ratio is given as 0.79.). Tbo autliors concliido, tlicrefore, that 
tbo fall ill tlio clilorido coiitont ot tbo corobro-spliml 'fluid is 
dependent on a similar tall in the chloride of tbo sormu, 

586. Cell Changes in the Skin in Measles. 

B. LirscnOrz (ll’icii. /din. iVoch., March 15tli, 1928, p. 365) 
has found that tlio liltcrablo virus ot measles .produces 
definite changes in tlio colls ot tbo .skin during tbo rasli. It 
affects nrimarily tim suporllcial capillaries ot the snbiiaplllary 
layer, loading to proliforation ot tlio colls roniid tbo vessels. 
There is also an jnllamnintory ronotlon in the superficial 
parts of tlio corliim, and tlio boundary botwooii the corinra 
and opiderniis is obliterated at certain points. Swelling and 
pocaslohal vnciiolatlon of tho opitliolial colls and soinotinios 
dl.apedeslR.bf leucocytes occur. The cliangcs in the epidermis 
depend largely on tlio stage tho rash lias reached and tho 
.severity- of liio case. Tim most important and constant 
changes Lipschfltz found, ]iowovcr,'to bo intraoollnlar and to 
affect tlie nucleoli of the cells; one ot those is saiff to be 
normally presont in each coll and to bo qnito distinct from 
the nuclons. In a nmiibcr ot the skin cells in measles the 
two to four con trooyfes wbicli ordinarily constitute a luiclcolns 
aro increased in nnmhcr, and alter in staining re.-iction, sliow- 
ing an'increasod aillnity for liacmatoxylin, Siiiiilnr ciiaiigcs 
have been found in monkeys, in whom typical symptoms of 
measles occurred eight to fourteen d.a3'S after an Injection of 
me.asIoB virns. Lipsclintx considers tlmse intracollar changes 
ot particiilar importance, since otlmr worlcers li.avo iohhd 
other cli'Aractcristin iiitracollnlar changes associated with 
such filterable virii.ios as variola nnd varicella. He suggests 
thnt.tlidjvsbonld bo ot value In identifying possible ciiltiires, 
and 'iU'-Rtu(lviD" tho nature and mode of action of those 
nitrates to wiileh other motliods aro inapplicable. ^ 

. 

•.ysST.- - ♦ The Blood In Scarlet Fever. 

A'. liTJONl {Spcrhn*‘nfalr, January 12th, 1928, p. 641), from a 
study of 90 -cases of scarlet fovor and 55 other idiscascs, 
incliidlni:’. mcaslos, diphtheria, tj’phoid fever, varicella, and 
serum aicknes^, comes to the following conclusions, (f) 
Pohle's inclusion bodies occur in all diseases in wlilch there 
■ is a slight lencocytosis, whereas in .typhoid fever, which is 
characterized by ieucopenia, they arc absent. According to 
• Leoni these inclusion bodies indicatciminaturity and perhaps 
also degeneration of tho leucocytes. (2) Aniato's' bodies 
(ronnd-or oval .bodies in the neutropliil leucocytes), on tho 
otiicrhand, are found exclusively in scarlet fever and in no 
other -infectiohB or diseases whatever; their presence is 
. closely connected with the acute stage of the disease. They 
arc of considerable diagnostic value owing to tlio readiness 
with which they can bo found, and to tho fact that they are 
present in scarlet fever and in no otlier disease, (3) Eosino- 
pliilia docs not appear to occur in scarlet fever, in which in 
the great majority of caso.s tho number of eosinopliils is 
almost normp.l. They are, however, diminished in number 
or entirely absent in severe toxic attacks, cspeciall}^ those 
•which end* fatally. (4) Tho leucocyte picture in scarlet fever 
•coiistantl)' show.s a neutrophil polynucleosis (80 to 90 per 
cent.) with relative lymphopenia (1 to 10 per cent.). In 
severe attacks immature forms, such as Tn5’cIoc3'tcs and 
metamyelocytes, may bo found in large numhers- 


I 


Jl'.NK JO, 19*8] 


[ Tnt DnmBB 
Uzoicjo^ JocBMifi* 


101 


EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

S£S. Acuta Syphilitic Phlebitis. 

11. Jlonnow null N. nrsTr.iN {Arch. Derm. .%;)7i., March, 
192S, p. 309), who report au illustrativo case, state that 
phlebitis is Olio ot tho x-arcr luaultcstatlous ot syphilis, tho 
vcliis, ill strikiiii; contrast with tho artcrios, appearing to 
enjoy a comparative imniiinity. In aihlltion to Iho llrst ease 
rcporlcil by Girwooil in 18G0, tho antliors havo collected 
forty-llvo observations of various forms of syphilitic phlebitis, 
which they havo classillcd in tho following three groups: 
early superficial phlebitis; nodular throiubo-phlobitls; and 
lato phlebitis. Early Byphilltlo phlchlils, to wliich they 
coniine their attention, may appear as an lullaiuniatory 
process of ono or more soginonts of a vein. It lias a tendency 
to bo luuUlpIc, involving tho veins ot inoro than ono limb, 
and frequently progressing from ono vein to anotlicr, Tho 
lower limbs aro more froquontly affected, tho internal 
saphenous usually being attaclccd. Tho phlebitis develops 
within a tow months of the chancre, and may accompany ot 
oven precede the early secondary rash. The local and general 
sj'niptoras aro nsnally so slight that the condition is readily 
overlooked ; they may, however, be severe, giving rise to 
nocturnal pains and constitutional dlstnrbanco. The skin 
over the affected vein is usually reddened, and occasionally 
there Is slight oedema. Tho limb may bo swollen, but doc.s 
not pit on pressure. Early syphilitic phlebitis has a romarU- 
ablo tendeney to recur, either in the original vein affected or 
in another vein in tho same or opposite limb. Under specific 
treatment complete involution occurs in two or three weeks. 
Complications aro rare, and only ono case of embolism has 
been recorded. Early syphilitic phlebitis is much commoner 
in males than in foninlos. Of 31 eases in which the sex was 
stated 27 were in males and only 4 in females. Strain and 
alcoholism are contributory factors. Tlio oblof pathological 
change is a proliferation ot connective tissue in the sub- 
ondothollal layer which causes protrusion ot the ondothoHutu 
into tho lumen. Tho Sjnrochacta palluhi has never been 
found in tho lesions. Early syphilitic phlebitis Is distin- 
guished from tho phlebitis duo to other iufcctivo processes 
by tho lack ot constitutional and local symptoms, tho multi- 
plicity ot tho veins Involved, tho tendonoy to recurrence, the 
rarity ot omhollsm, and the prompt response to specific 
therapy. Tho authors’ case occurred in an alcoholic black- 
smith, aged 30, 'Who developed phlebitis in the loft calt in the 
fourth month ot infection, tho right calf being subsequently 
involved. Much Improvement took place under arsphenamine, 
but tho condition recurred when he resumed liis work ; a 
second though milder recnrrcnce develoiicd later, but com- 
plete recovery followed. 


58U. Bptleptlc Variants. 

puRKJG the course ot twenty years' practice S. A. KixsiEU 
Neurol, and Psychopath., January, 1928; 
p. ^3) has noted a large nnmhev ot cases which proseuj 
similantlos to epilepsy, but which noverthcloss do not seem 
superficially to resemble each other. Close study ot these, 
which ho terms epileptic variants, dispels the idea th.al 
epilepsy is a self-contained and sharply delimited cliuica' 
entity, and indicates that their clinical signs must bo con- 
sidered physiologically. Epileptic phenomena grade easilj 
from the motor convulsive seizure to iisyohical, sensory, oi 
visceral symptoms of a highly disparate nature, and 'Wilson 
classifies epileptic variants into tho motor, sensory, psychical 
and visceral, illustrating each group with clinical examples! 
The motor group includes mj'oclonic or regional epilepsy, 
epilepsia :ated, and inldbitorj 

or akinotl ■ ■ ■ which is by far Hit 

coiiimonost variant, consists In irregular twitches of a limb 
in inuUiiiuiscuIar groups. Epilepsia partialis coiitlnna, some- 
differs from the former typo in that the t'witohini: 
IS limited to one, generally a peripheral, segment of the body: 
twitchings continue between the fits, and are not so iiiuch 
movements as irregular individual muscular contractions, 
ionic opuepsy is characterized by tonic contractions only, tc 
the exclasiou of the, clonic element; in these ca,se.s it is 
suspect an organic and localizable basis for the 
n.* . *^°'°'^‘Ilnaled epilepsy includes those cases where 
co-ordinated and seemingly purposive, 
nrp ni.pc? leatuies of voluntary movements. But they 
^ repeated and never attain an objective. Ic 
y or akinetic epilepsy immobility forms a promineni 


feature of tho fit ; an illustrative case is reported in whiob 
there was a clear transition from convulsive to inhibitory 
epilepsy, the former being classifiable as epileptic and tho 
latter as cataplcctic. Sensory variants are grouped as reflex, 
sensory, and aficctivc. In the reflex typo the seizure develops 
after au extrinsic sensory oxcitatiou, and the sensory sensa- 
tion may represent tho whole of the disturbance. Affective 
epilepsy is characterized by its development following 
extrinsic or Intrinsic affective stimuli, and differs from reflex 
opilopsj' In tho dofliiitoly affective element ot the excitants. 
Discussing psychical variants Wilson states that much Ot an 
ordinary fit may consist ot phenomena in conscioushess, Md 
refers to tho ocentrenoo ot had temper in epileptic famiUcs. 
Visceral variants arc possibly the outcome of physiological 
disorder localized largely in syinpatliotic centres to tho 
exclusion ot sensorl motor phenomena of somatic typo. One 
varlotj', vaso-vngal attacks, can be clearly distinguished, and 
the symptoms are referable to transient functional disturb- 
ance in tho organs supplied by the pneumogastrlo nerve, and 
probably develop from disorder ot the dorsal vagal nucleus 
in the medulla and ot tho juxtaposed vasomotor centre. In 
other types ot recurring seizure tho symptoms may represent 
some disturbance of third ventricle visceral centres with 
spread to similar centres in the floor of the fourth ventricle. 

590. Chronic Paratyphoid Septicaemia. 

E. R. Ghawitz (.Ifiincii. Died. H'ock., March 30th, 1928, p. 5G0) 
reports the case ot a woman, aged 53, who had had attacks 
of severe pain in the splenic region fora month, was diagnosed 
as suffering from primary tuberculosis ot the spleen, and had 
tlic organ removed. After tho splenectomy general sep- 
ticaemia developed with metastatic abscesses in the pleura 
and siibcutaucons tissue, bnt recovery ultimately followed 
intravenous injections ot solganol, au organic gold prepara- 
tion. Examination of the spleen showed two large abscesses 
from which a pure growth ot paratyphoid bacilli was grown. 
Tlio strain isolated was a transitional form between the 
so-called Breslau and the Sohottmuller types. The remark- 
able variability of all paratyphoid bacilli, which has been 
constantly, emphasized by bacteriologists, is considered to 
explain the nnnsnal clinical course iu this case. 


Surgery. 


591. Metatarsal Fracture. 

S. E. Goldman (-/oiii'd. of Done and Joint Siiry., April, 1928, 
p. 228) remarks that Iiactures ot the metatarsal bones, duo 
iu part to indirect violence, aro not aucomuion and are often 
overlooked. Lesions of this type are met with in strenuous 
athletic activities and where violent muscular effort involving 
the feet is required. As the initial trauma may be very 
slight, those fractures may pass unnoticed unless a:-ray photo- 
graphs are taken. " March foot,” as it is called, is commonly 
met with in tho army, where long forced marches with 
heavy kit aro underlakeii ; hence it is well known to military 
surgeons. Its incidence in civilian practice appears to be 
nncomiuon. The condition is the result of over-fatigue in 
weak feet, resulting in spasm of the muscles, which can.ses 
blood and lymph stasis in the tissues. As a result of this 
there is swelling of the soft parts and brittleness of the bone 
tissno. leading eventually to fracture. It may be noted that 
“ march foot ” may occur wilbont fracture ot the metatarsals, 
which is usually a later development. Goiamaii records a 
case in a civilian where the *-ray examination showed 
fracture of the second metatarsal bone. The treatment 
should be rest and massage. 

590. Primary Tuberculosis of tho Bladder. 

A. Bojiani {.Arch. Ital. di Urol., February, 1928, p. 201), who 
records a personal case, illustrates the rarity of the occur- 
rence of primary tuberculosis ot the bladder by the fact that 
Leguen in bis textbook states that tuheroalosis of tho bladder 
is always seoondaiy, almost always following renal tuberen- 
losis and much more rarely tuberculosis of the genitals, 

.Jungano in 1920 collected all the cases hitherto published 

namely, five in numher — but none ot them could withstand 
criticism. Romani’s case was that of a man, aged 38, who 
tor the last six years had suffered from difficult inictnrition 
which had gradually been getting worse. Forty days before 
admission to hospital he had profuse haematuria. Nothing 
abnormalwas found on examination of the lungs and genifals 

^°54 A 



102 Jure i6, 1928] 


EPITOME OF CUERENT MEDICAL LITERATUEE. 


Tni ISftmm 
Mcdicu. J0SSIA& 


bnfc cystoscopy showed typical tuberculous ulceration ot the 
bladder. Exploratory operations, first on tho lett kidnoj' and 
a month later on tlio right, showed that those organs wero 
normal. Examination of the urine from the bladder for 
tiiberolo bacilli was negative, but inoculation of a gninea-plg 
caused death from generalized tuberculosis in llfty-throo 
days. On the other hand, the liririe' obtained by nrotcr.al 
catheterization was normal and sterile. Improvement 
followed local treatment ot the, bladder, but .death from 
anuria occurred four days after cystoscopy. There was no 
necropsy. Romani concludes that primary tuborculo'-is ot 
the bladder is a clinical entity which may exist as an isolated 
condition lor several years, and, under suitable treatment, 
may end in recovery. 

593. Cancer of the Breast, 

G. VlIibATA [Arch. Itiil. di Cliir., Eebrnary, 1S28, p. 585) 
gives a statistical account of 231 oases of cancer ot tho breast 
operated upon in the Tnrin hospital. In 81 cases tlio subse- 
quent career of the patients could not bo traced’; in the 
remaining 150 cases the percentage of survivors beyond three 
years was 45.7 and after live years 27.4. The right Itrcast 
was affected i-n 57.8 per ce.nt. an against 42 per cent, in the 
left ; growths which had ulcftratod gave a high post-operative 
mortality, and those adherent to the skin soon i-clapsed. 
Yillata considers it advisable to examine tho thorax vadio- 
logically in late cases to avoid operating when iiitrathoracic 
growths are present. Relapses usually appear in tho scar. 
Tlie chief mortality occurs between tlic first and second year, 
nnd diminishes by more than a half between the second and 
third year. He adds tliat malignant growths of the breast in 
tlioir earliest stage may be considered a local diseaRc'.and 
that bony metastases are considerably beneftted by radiation 
treatment. 

S95. Surgery of the Spleen. 

M. N. BoEGHOIiT [Nederl, Tijdsclir. v. Genccs7c., March 31st, 
1928, p. 1582) reviews the litecamre, and records his observa- 
tions on 55 oases ot splenic disease scon by him in the Dutch 
indies in tho course ot six years. He classidos them as 
follows : 34 oases ot trauma (30 ruptures and 4 stab wounds), 
1 rupture without known cause with death in fltioen minutes, 
10 cases where splenectomy was necessary owing to the 
largo size of the organ, 2 dysiopio spleens with chronic 
tocsion ot the pedicle, one of which showed an infarct, 

1 dystopic spleen in which operation was performed in tlio 
a"ute stage, 3 splenic abscesses, 1 Hanot's cirrhosis, 1 .splen- 
ectomy for liaemolytio anaemia, 1 operation for myeloid 
leukaemia, and 1 case ot regenerated spleen two years after 
splenectomy, RoeghoIt'.s conclusions are as lollows : (1) A 
very slight trauma is snffleient to. cause rupture ot a spleen 
culargcd by malaria. (2) Splenectomy is tlio most .suitable 
operation for rupture or wounds ot the spleen. (3) In-tbo 
presence ot acute conditions splenectomy should be per- • 
lormed under a general anaesthetic. (4) In tlie quiescent 
stage splenectomy siioiiid bo performed under local anaes- 
thesia, provided there are no adhesions with tlio diaphragm. 
(5) An enlarged malarial spleen which is giving rise to 
symptoms should be removed it medical- treatment does not 
canse any diminution in size. (6) Care siiould he taken not 
io rnptnre the tail ot the pancreas in the coarse ot splen- 
ectomy. (7) A search should be made for accessory spleens. 
18) A healHiy life is pos.sible without a spleen. Nouo ot 
Ruegbolt’s .splenectomized patients showed a haemorrhagic 
diathesis, increased ' snsceptihility for infection including 
malaria, or delayed healing ot fractures. ■ 


.Therapeutics. 

533. Bphedrine In Leprosy. 

While using adrenaline in tebriio and. asthenic leprosy 
]i.stioufs_E. Mum and .S. P, •Chatteoji [Indian Med. Gazi, 
April, 1928, p. 193) found that in most cases the nerve pains 
were romarltably relieved, and as o’phedrino has a very 
similar action to adrenaline tlio effect ot the former was tried. 
Tlie results were excellent, and ephedrine proved to be more 
ciHcicnt and lasting in its action, at the same time having tho 
ad.litioual advantage ot producing its effects when adminis- 
tered or.ally. 'The pains are duo to the presence of the 
Mijcohacterinm leprae in tlio nerve tranks, especially those 
of tho limbs, tho ulnar and peroneal nerves beingparticnlarly 
affected. Tliis organism causes a proliteration ot the con- 
nccUvo tissue surrounding the axis oyliuders. Considerable 
cell proliferation may gradually, occur during the^quiescent 


is .sudden vascular engorgement of tho granulation ti.ssiro 
nnd tho pressure on tlio axis C3’linder.s is increased, tlio nerve 
often becoming very swollen.' Ejilicdrine relievos this con- 
dition, probably by causing contraction ot tho arterioles ot 
tlio iiervo trunlrs, tliiis lodiicing tho ongorgcmciit ; it also 
appears to raise tho rcaclion level ot the patient, wliiJc not 
. iiiterfeting with tlio honcflcial effects ot Ircatiiient. The 
. snipliato, given iii liaid gelatin' ca'psnlcs in a single dose ot 
! 0.05 to 0.1 gram, is sufficient in most cases to cause relief in 

■ fortj'-ffvo to sixty minutes, a'nd'tlie action lasts for twenty- 
four to Royenty-two lioiirs or longer. Norvo ro.actious' .arO 
often caused during treatment witli potassium iodide, and it 
eplicdrino is given at tli'e beginning ot tho pain tho patient 
is enabled to oontinuo treatment in comfort until the granulo- 
matous condition Is cleared -up and tho iodide causes no 
furtlior reactions.' As vertigo' appears, in some cases the 
smaller dose mentioned sliontd bo Tlr.st given to test tho 
patient’s tolerance, and tlie second after forty-five, raiiintes- 
it tiicro is no Toaction ; it pain reenrs on the following <lay 
repetition ot the smaller dose may suffloo to produce' the 
desired effect. Tiio action of .ephedrine is in contrast to 
that of opium and its preparations, wliicli give onlj- a sUglit, 
.short relief, and also liavc a harmful effect on tlie 'general 
condition of tlio patients.' Hliort notes on tliirteen cases 

' henefieinlly treatotV by ibis' metlioil are apponilcil to this 
communication. '. . ■ - - 

£93. Protein Therapy In Ophthalm'oloify- 

■W. E. Bexedtct (,}U^neso^a Med., April, 1928, p. 203) observes 
tliat in tlio trcaliiiont ot iuffaiiiiiiatory diseases ot tho ej'o 
the goncrnllj' accepted indications for the use ot proiein 
injections aro (1) aento or snhacuto local infections aliout tlio 
ej'o, (2) clironic constitntioiial or systemic diseases willi 
SDCondarj’ iullammation in tho cyo or adnexa, and (3) pro- 
pliylaxls. Rroliminai-y tests for protein sensitization can 
usn.allj’ bo perfonnod. Tlio best results are obtained wlien 
a moderate rise ot tomporatmo (101° to 103’) nnd mild louco- 
cj-tusis (12,000 to 18,000 coll.s) follow six to twelve hours after 
an injection and disappear betoro twoiity-fonV lionrs. Tho 
specific proteins used include diplitlieria antitoxin, tetanns 
antiloxin, nntogonons vaccines, nnd tnborciilin. ■ Sties, 
chalazions, and corneal ulcers respond most favourably to 
autogenous vaccines. Milk, diplitiioria antitoxin, and * 
typhoid vaccines ore tlio non-speclllo proteins gonorally 
used. Acute serpiginous ulcers ot tho cornea react to any 
of those proteins, wliilo chrouio infections of tho lids, cornea, 
.or uveal tract respond more readilj^ and more_ satisfactorily 
to milk. Tli'o total benefit ot. wlik injections is usnally , 
obtained if four injections of from 5 to 10 c.cm. are given 

■ at intervals of from forty-cigiit to sixtj' lionrs ; two injections 

'of tjqilioid vaccine .ai)0 usually sufiloicnt for good results, and 
diphtheria antitoxins sliouId- bo given in moderate doses 
: (2,000 to 5,000 units) daily for as long ns desired. After one 
firotein lias ceased to be effective a satisfactory reaction can 
often be obtained witli anotiier. -Local treatment ot^iiifected 
ej'csis not to bo supplanted by protein therapy, but is rather 
aided by it.' , . . ■ . 

597. Bulfarsenol In Puerperal Fever. , - 

J. t'^ERGEl.r (Journ. de Med. de Jiordcaux ct ,du Sud-Ouest, 
April loth, 1928, p. 265) reports a method ot treating puerperal 
.fever with snifarsonol. In a'series of 2,223 accoucheiiients 
there were 500 cases ot fever, the mortality was 0.089 pec 
cent., and the morbidity (which remained unchanged) 22.04 
percent. An axillary temperature ot 99.5° tor, twelve hours,, 
•if of genital origin, was arbitrarily looked upon as “fever. 

As the result ot experience it was found that the.prophylaotio 
use ot Bultarscnol was not required so long as there.was no 
sepsis, bnt as soon as there arose a doubt about asepsis — as, , 
for example, when the membranes had been. long ruptured, . 
or when several digital' examinations had bceii made, pr in 
forceps eases, manual dilatations, or digital curetting — then 
a dose of sulfarsenol should be given. In the author’s cases 
a dose ot 12 og. was always administered immediately after 
any intervention, and the result was ■ . ' '' -y ; 

•if pyrexia ensued it 'was generally o ' 

cases in which tho temperature rose in. spite ot ant imwal 
dose, a second injection ot 12 or 18 eg. was given eacli time 
there was a notable rise, and conUl, it necessary, bo repeated 
(daily. ' Vergely states thafsulfarseriol has the advantages 

■ of being a superior bactericide; it is the least toxic of the., 
arseno-benzenes, can bo given hj'podermicallj', and is not 
painful when proporlj’ .diluted, A possible disadvantage is 
a toxic erj-thema. A few oases showed a morbilliforra 
eruption with a sharp rise ot temperature, both of which 
disappeared . in forty-eiglit hours. Contraindications aro 
grave hepatic troubles and uraemia. It can bo .used -in 

■ eclampsia it the albuminuria is carefully watched. '-Che 


t 


Ju.N’i: i6i JSsSj 


EriTOMB OF OUBllEN® MEDIOiOi OITEU/tTUllB. 


f Tjt* Hntnsn 
Vkvic^i^ JOCVttAt, 


103 




NcuroloiJy and Psychology. 

■ SSS. Clironlo Systomnflioil Dcllrlumn. 

]J. 3ii:,VO.\' (Kc(?. fie .Fcfl., 1928, Ko. 1, p. 33) UutocR n. AcUtUiM, 
ivliicli in soiiiotlmoH iliniciillr to cIIhIIiihuIhIi clliiloftlly from 
luwila ami doincniln, ns a Hyslcm of Woas, colioruut ov con- 
XusoJ, sinfiJcor;uii)tl))]o, loiiixloil on ))nHiicl)mllo))H, IIIuhIoijb, 
or iiuinerons oxltnviVRnnl SnleviituVnVioiitt, and nccouipnnlcd 
iy varied omotlonnl nianUcstailonH wtiicU involve lUo Roncrnl 
boHef or full conviction. Dolirivunn, tUoai;U of oxtrcino 
diversity, present four points in common: tlioy arc chronic 
psyclioscs, and almost Invariably Incurable ; llioy nro Bya- 
tonmllzcd, this being Komollmos perfect, somoliinoH more or 
less olisctiro, sometimes more or lesalncolioroni; they never 
ferrainnto in deinoutia or loss of memory ttnd Ideas, and tho 
delirious symlromo is often dilllcnlt to follow, though tho 
intelligence may ho cutcobled or diminished ; and all appear 
to linvo nn emotional or passional origin, oven when they 
follow aento or subaente, toxic, or Infections doUrlnms — Uinl 
is, the troubles engendered by the emotions always precede 
tho appearance ot Ibo Insane Ideas. In tlio great majority ot 
tboso cases ideas of poi.secutiou nro tbo csscnllnl tbciiie, 
tliongU these may ho veiled by Ideas, as, for example, ot 
grandeur, or may oven totally dhappear; Ihoy arc ROuioUnics 
accompanied by inotaucholla. Beuou places tiicac dellrlutus 
In five groups. (1) llaUnoluatory delirium, tho conmionest 
form and tho true persecution delirium ot Iinstguo. Its 
evolution is marltod by threo potio<ts : a period ot Incubation 
or cryatalliT'.aUon, ouo of lintlncinatloiis, and one of ideas 
of grandeur. (2| Delirium with psyclio-motor hallucina- 
lions, a rare form, tii which tho patient only hears 
inner voices to which ho submits and which direct his 
jenora! actlvitio.s, sometimes (langerously. (3) Parngnoslc 
delirium, also rate, Is based solely on false recognitions ot 
porsons, itlacc.s, and sounds. This paragiiosis is wot an 
illusion; tho ohjeots that cause tho sensations aro not 
altered or dl.stortcd by tho souses, tho patient merely cow- 
Insing them with others which ho rometubors. (Ai Inlot- 
ptetativo delirium, which is constltutod by delirious 
paroxysm.s bn.sod on an.vioty, Ilallticinntions aro always 
absent, and tboro aro incessant ropotllions ot awxions 
manttostatlons. (S) xV delirium, styled rcucuilicaii/, with 
paro.vysms based ou joy. xVs in the preceding form, emo- 
tional dov/affon plays nn essential part In the absurd beliefs 
ot the patlnuts, and halliicinatlons are never prosout. Donon 
consider-s tliat chronic systematized deliriums are os varied 
as men thomselvos; that pure forms aro rare; and that 
tho greatest number aro atypical, corresponding to tho 
systematized deliriums ot 3Iagnau's degenerates, and nro 
caused by individnal degcncrativo elements which nro at 
once of a sensorial, emotional, and dystbcnlc order. Sncli 
nn atypical case Is fully described. 


599. Post-cnccphalltic Respiratory Risordors. 

"W. A. Tubnbb and M. CniTCHI,Ei- {.lount. Neurol, au, 
Psycjiopalh,, January, 1928, p, 191; roujarlc that, though fh 
respiratory disorders associated with epidemic cuccphaliti 
have been frequently described, no oCfort has hitlicrto heoi 
made to trace their Bcquols. A sliort review is given ot th 
relating to a lew cases which have been followe 
OQ „ i aome time, ami tho anthers report tho oud-reaults i 
“9?*^ which were treated at tbo National Ho; 
'h t 1 noted were tachypiioeo (tlic coiiimoucE 

vawnmlj *?9®'‘''|* *'0ltling (tlio next in order of frequency 
Tn 9f)°nf suilllng, coughing, and br.adypuocs 

Jn 2U of the case.s on association ot varying degrees o 
Parlduaomsm was observed, but in only 8 were psSli 
changes seen. Age seemed to be a factor, flitcen patient 
bemg in the second decade of life and only one in tho^l^th 
The outnumbered females in the proportion ot 21 to S 

mi ®P'^®‘“‘'=^PPcared to bo responsible for the majorit 
^°®*‘'?““‘=P>ia.litio respiratory disorders at 
usually paroxysmal ; diurnal variability is tho rule, and n 
norf tracoH. Emotional stress i 
potent aggravating. factor; conceutralei 
effort may cause a diminution in the paro.vysmS, aud inter 

TheteVor’^H°^ »my divert tii’o disorders 

eating has exerted an unfavonrablo influenco ii 
ew case.s; but severe pbysiCal e.vertion as a rale has litth 
and rim n ‘ “PP‘^‘'''aPce or the respiratory trouWos 

an ariackYs ^ <=uTsl,or 

stiumH mav rnmnn™ Pby.sical and psychicn 

te'uporailly inffHence tliosoyorityot thodtsorder 

Of the pq ra no ' 1*^ 0 ^ seoms to be spontaneous 

Jn In thr r. ?'''y ^ patients showed complete recovorv 


(ory disorder improved, otJior waulfcetatlonn bocaino worse 
or remaliiud uuchaugod; in 13 tlio ros))'ratory disorder 
remained imclianged ; and deatli occurred in 2 caso.s. Jt, G. 
OOBDON (ibid., xVpril, 1928, p. 3A0) reports in sonie detail 
a case ot post-oncopli/iiuic rcaiiiriUory Oinordcr in nhicb 
there was au apparent coniplcto recovery. xV young wotimu 
who had been under observation for twenty-one nionibs bad 
h. dcllnlto history of dorangoment of sleep and iuterferenco 
with co-ordluatlon of oyo miiscle.s; Ibi.s, with Iho subsequent 
sequels ot rosplratory (pautlng) and violent conduct dis- 
oviiers, left no doubt that thero had been a mild attack ot 
cncoiilialltls lothargicn. No trentmont, e.vcopting tho, mildest 
form of psychothorniiy, was given, and recovery was almost 
Bpontancous, 

600. The Drain In Coneral Paresis after Inoculation 
Malaria, 

W. Jj. Blitirvrsctt and M. A. Baiib (Journ. Nerv. and 3Ient, 
Tii-i; Jrnrcli, 1928, p. 209j report a ciiso of general paralysis in 
a man, aged 5G, who died seven days alter the intravenous 
injection of 1.5 c.cm. of malarial blood during a paroxysm. 
Tlio authors' conclusions aro as follows. (1) Tiio treatment 
ot general paresis with inoculation malaria produces during 
tho paroxysm hlalopathological changes in tho brain,. con- 
sisting In proliferation ot tlio capillary ondothclinm. (2) This 
reaction of tho rcticnlo-ciidothclial system is ns intense as 
in lyiihold fever, which has otten been followed by good 
remissions In goiioral paralytic.s. (3) The absence ot the 
perivn.souIar iiillltratlons in tbo present cose suggests the 
disappoaraucQ of tho iiitlltrnting cells during the acute 
malaria. (A) 'Tho perivascular iuUHrations persisted in the 
temporal lobes and tho corpus striatum. These flndiugs 
accord with tho ob.sorvatlon of other authors on the modiJled 
distribution ot tho inllatnmalory phenomena following 
lunlacia. (,5) During malaria, and particularly at the time 
ot tho tobrilo attacks, plasma cells probably immigrate into 
tbo brain vessels aud take part in tbo phagocytosis of. tbo 
liberated young plasmodia. |6) After retrogression of tbo 
porivascutar iDliltrntions normal conditions are ro-ostablished 
in tbo porivnsonlar lymph spaces, resulting in a partial 
recovery of tho ectodermal tissue (ganglion and glia ceils). 


Obstetrics and Gynaecology. 

601 . Necrobiosis of tJterino Fibroids. 

ACCQBDING to Patea and Denis {Gynicol. et Obslet., Jfarch, 
1928, p. 161), necrobiosis of a uteriue hbroid occurs most com- 
uionly in women aged from 30 to 50, and is relatively.frequeut 
during pro.gnancy ; tbo initial acute stage of tho aseptic 
nccrosfs Is known as rod degeucratfon. Clinically there are 
two different symptomatic pictures, according as uccrobioais 
Is slow or rapid, but intermediate cases are not rare. Slow 
necrohiosis is characterized by (1) an almost complete 
absence of local signs or symptoms and (2) vague general 
symptoms due to resorptiou of toxic material— malaise 
digestive troubles, slight pyrexia (100.5“), and loss of wei«ht.’ 
Kapld necrobiosis is associated with an acute pain in the 
lower abdomen which simulates torsion of an ovarian cyst or 
nn attack ot pelvic peritonitis, and confines the patient to 
bed for a few days, tbereatter gradually disappearing. _There 
Is also increase ot volnme ot the.fibroma, and alterations ot tho 
general condition are.nolioed, such- as. pyrexia, and thinning 
and ycllou'uess of the face. Tiic sequels ot necrobiosis mav 
. bo (1) calcification : (2) a continued condition of malaise and 
wasting which, if attention is not drawn to the pelvic organs 
may bo attributed to anaemia or tuberculosis ; (3t an opening 
of the necrotic focus into the cavum uteri, with socondarv 
infection and intermittent vaginal discharge— cancer of the 
body of the uterus may therefore be suspected ■ or (A) an 
infection by contiguity or the lymphatic rouic— the infected 
iiccrobiotio focus may secondarily open into the uterus or the 
peritoneal cavity. Necrobiosis of a uteriue fibroid can be 
diagnosed with a considerablo degree of oortaiutv when i 
patient known to have a fibroid has abdominal pain accom'- 
panied byincreased size and softening of the tumour which 
becomes more render. It maybe suspected when' a patient 
known to have a fibroid has slight pyrexia, wasting, and 
digestive disturbances, even m the absence of local &l"ns 
Gangrene or septic necrosis of a fibroid may be distinguished 
from necrobiosis m that tho former i.s rarer, and ocMrl as 
a rule, afwr a coopnemenc or abortion or operation oh ’the 
uterus; it is associated with high /ever rigors, well-marked 
poritoneal reaction, and a fetid vaginal dischargh, A siu4o 
llbraid in a young woman may be removed by n.yom'ectomv 
but otherwise hysterectomy is usually called Ior“ana the 
prognosis IS not worse than that of uncomplicated fibroids! 

1054 0 



104 June iG, 1928] 


EPITOME OF CTJKEENT l^DICAE EITERATUEE.' 


[ Tin: Dsinwi 
Mjcdical Jovutt 


A sabserons infeetel neorobiotic fibroid requires vaginal 
drainage after hysterectomy. When pregnancy is present 
with a necrohiotic fibroid expectant treatment will frequently 
enable the iratient to go to term. When the syrnptoms do not 
abate it is necessary, according to the situation of the tumour . 
and the duration of the gestation, to perform myomectomy; 
supravaginal hysterectomy, or Caesarean section ■followed_ ' 
by myomectomy or hysterectomy. ' " -■ •' '■ < 

602. Epithelioma following Subtotal Hysterectomy. 

Simone Labordb and Auce. Roques {Pull. Soc: d'ObsUt cldc 
Gynecol., February, 1928, p. 123) remark tliat the development 
of epithelioriia in the cervix uteri following subtotal hyster- 
ectomy is generally considered to be somewhat exceptional. 
Nevertheless, among 379 uterine cancers they have met with 
this condition in 11 cases, the details of which arogivon. Tillting 
as a basis the condition for which tho subtotal hysterectomy 
was performed, they group these cases as follows. In tho 
first class the cancer of tho cervix developed after subtdt.al 
hysterectomy for an affection of the adhoxB. In these cases 
tlie cancer w'as a Malpighian epithelioma', and .developed at 
long intervals (from five to sixteen years) after tlio hyster- 
ectomy. In the second class tho cancer' developed after 
subtotal hysterectomy for fibromyoma of the uterus, and the 
neoplasms were again Malpighian epithelio'mata. Here the 
interval between the hj’Stereotomy'and the development of 
the cervical cancer was much shorter, ranging ' from one 
month to three years. The third category comprised two 
cases of glandular epithelioma, one appearing a'month after 
subtotal hysterectomy, performed on account of epithelioma; 
of the body of the uterus, the other developing two y'ears 
after subtotal hysterectomy' for fibromyoma of the uterus. 
In this case the cancer may have been'- due to a malignant 
transformation in a tumour of the cervix already existing. 
The authors add that in general it may bo said that tho 
cancer in tho cervix tends to show rapid development and 
an early spread to the vaginal. walls. • On- account 'bf th'eir 
anatomical relations and the absence of the uterus,' treatment' 
by radium is said to be very effective. The' obcurronee of 
these cancers might be attributfed to'tlieTabl thdfsurgical 
intervention suppresses vascular and ' nervo'ns, ■ especially 
sympathetic, connexions and thus favours the development 
or cancer in an organ, the nutrition of which thereby becomes 
profoundly modified. The authors, however, consider its 
jiresenoo a pure coincidence in view of tho frequency of 
cancer of the cervix, which should be’ taken, into account 
in considering the relative advantages of total and subtotal 
hysterectomy. . . . 

U 03 . Diphtherial Endometritis. 

L. LeFEVRE (Journ. Amer. Med. Assoc., March Slst, 1928, 
p. 1015), who records an illustrative case, has collected three 
oxaruples of diphtherial endometritis from the literature of 
the last twenty years. Two were reported by Hash and one 
by Beek. All presented great tenderness in the lower part of 
the abdomen, cramps or other abdominal pain, and in one 
case haemorrhage— symptoms which' are absentin diphtherial 
vaginitis. LeFevre’s patient was an unmarried woman, 
.".god 21, who, on the sixth day of recovery from an ill 0 '’al 
abortion, had a discharge of about a pint of bright red bliTod 
from the vagina, followed by a second severe haemorrhage 
a few hours later, accompanied by severe abdominal pain 
and tenderness. The pulse and temperature were normal. 

A largo piece of placenta was removed from the uterus' 
which was packed with iodoform gauze. The following day 
the temperature rose to lOCP and the pulse to 120. During 
tho next four weeks the uterus and vagina' were packed 
repeatedly, haemorrhage occurring every time the packing ' 
was removed. Finally, after a very alarming haemorrhage' 
the uterus' was removed under gas anaesthesia, and the 
specimen showed post-abortive infection and non-resolution 
of the decidua. A culture of the uterine cavity after the 
organ had been removed ' produced a luxuriant growth of 
diphtheria bacilli and streptococci ; 20,000 units of anti- 
toxin were given, and rapid recovery followed without any 
paralysis. LeFevre recommends that culture of the uterine 
cavity should bo made in cases of puerperal infection showing 
low fever and a markedly disproiiortionate increase in the 
pulse rate. 

60f. Extrauterlne Pregnancy. 

ACCOUDING to B. Haeusermann '{Zentralhl. f. GynUl:., 
Jlnrch 31st, 1928, p. 822) a greatly increased post-war in- 
cidence of ectopic pregnancy has been reported from several 
German districts. At . the Stadjtischen Frauenklinik at 
Dortmund tho incidence rose from between 10 and 20 
annually from 1911 to 1918 to between dO and 55 annually 
from 1919 to 192G. Tho increase is ascribed to tho greater 
frequency of inflammatory disease in the Fallopian tubes as 
a consennence of increased commonness of criminal and 


other abortions. In almost every case in tho author’s clinio 
diagnostic puncture of tho pouch of Douglas is performed ; 
tho aspiration of dark-Colonrcd non-'clottcd blood is regarded 
ns characteristic of ruptured or aborted ectopic pregnancy. 
Tho prognosis is; largely dependent on tho carliiiess with 
which the patients coirib to operation; since 1921 tlicro have 
boon 259 recent' non-'infcctod cases with a mortality of 0.7 
per' ceht., and 21 late infected cases with a 25 per cent, 
■mortality. In tho latter group of cases it is recommended 
that whenovor possible tlio abdomen should not bo opened 
until tho pyrexia has disappeared, dr.aining through a colpo-. 
tomj'dponfhg being performed in.thc meanwhile if nobcssary. 


Pathology. 


605. Anaerobic Bacterlaomla. ' 

L. BOEZ, a; Keiipstadt; and J. ScHnElBBU (dim. de Med., 
April, 1928, p. 310) recxill tiint, while P. ramosns, described 
hy'V^oillon and Zubor, has' often been noted in gangrenous 
pus, it has oiily been isolated from tlio blood by Gilbert and 
Dippmann. Tlio present aotlior.sVbowevor, in 1921 recorded 
a case of bactcrlacinia duo' to this iiiic'ro-organi.sm, and now 
report seven further cases of a similar infcclion. In all these 
instances P. ramosns was isolated from the blood; in four 
innumernblo colonies appeared In the ciiltiiros, and in three 
only ton to twenty colonics per 10 c.cm. of blood were found. 
This bacillus Is very ulelicato, aiid requires the stricte.st 
nnacrohlc coiiditions tor its growth.' It is a small, iion-motile, 
non-liacth'oI'ytic..and Grain-positive bacillus, growing with 
difilcully on, A’cillon’s' agar, and iii'oro rcadiij-'bn 'hi's ascitic 
agar, but not at all oh 'gelatin.- lt doos nob'ccagnlnte milk, 
but it fernionts gliicp.sq and lacvrilqse tliougli not maltose or 
saccharose. ' A soriiiii prepared from a rabbit agglutinated 
the seven strains isolated in a titrb of 1 in 500. The colonies 

■ arb very sin.ail, round, and often piinctiform.’ Of the seven 
patio'iits, two dic'd.- On'o ot these suffered from tuborenibus 
meningitis complicated by a .maxillary sinusitis from which 
a streptococcus and a Staphylococcus nnrciis wore isolated; 
tho other from a mastoiditis with thrombophlobitis of the 
sinus duo to' infection with an annorobio staphy'ocooous. 
Tlio authors remark that tho part plaj'od by P. ramosns is 
not groat; that its prosonco in the circulation does not 
markedly modify the clinical evolution of tlio disease ; and 
that the prognosis In baotorlaomlns dim to tliis microbe, ns also 
in tho majority of ann'brohio blood Infections, is governed by 
the initial infectious focus had its motnstases. 

606. The Blood Urea In Scarlet Fever and Tonsillitis. 

F. AVahMG , (lain, .ll’orfi., March 18th, 1928, p. 512) used 
Ambard’s bromine and caustic soda method of estimation of 
the blood urea in forty cases of scarlet fever and live of ' 
tonsillitis, tho blood being token wlien the patient was in the 
fasting condition. Most of tlm scarlet fever patiqnts .were 
children aged from 3 years and upwards, and the adults wore 
in tho second or third doceimium. The examination was 
usually made on tlio first to flftli day of tlie ra.sh. Most of 
tlie cases -wero mild and only a few sovero, Tho average 
blood urea value was 30.7 mg. per cent. In- only four cases 
were liigli values found — namely, 78 mg. and 119 mg. per cent, 
in two cases of nephritis and 96 mg. per cent, in two cases 
without any abnormal findings iirtlio urine. In view, there- 
fore, of the 'fact that the physiological average blood urea 
i-anges,froin is to lObiig. 'per cent., It is lield to bo- obvious 
that starlet fever' as such does not tend to increase tho blood 
urea in tlie majority of cases wliicli are not sdvere. Most of 
the cases of tonsillitis occurred in adults in tlie second, -third, 
or fourth ^deceriniure.'- Their average blood urea value was 
found to be'lSIS mg. per cent.— that is; the lowest of all acuta 
iutectlous diseases. 

607. Sterility and TItamln Deficiency. 

TJ. Suzuki, W. Nakahara, and N. Hashimoto (Japan Med, 
World, February ISth, 1928, p. 31) refer to previous work on 
the factors governing reprodnetion in animals, and describe 
a series of experiments on -white rats in which tho effect of 
diet on reprodnetion was studied. The animals wero fed on 
a diet practically free from fat and lipoid, but adequate for 
growth. Prolonged observations proved that no reprodnetion 
took place among the test rats, though their general nutrition 
was good. The sex glands of the. males became markedly 
degenerated, and on microscopical examination no sperma- 
tozoa were found. Small amounts of cholesterol or of syn- 
thetic triolein and daily exposures to ultra-violet light did not 
affect these results, the rats remaining sterile. As these diets 
are not deficient in any other known factor than vitamin E, 
these workers attribute the reproductive failure to the absence 
of this vitamin. 



Jusn aji.ijjs] 


f Tni! IlRinun 


105 




EPITOME OF CURRENT MEDICAL LITERATURE. 


Medicine. 

608. C.'xrdlac Insultlclonoy >n Pulmonary Tubcrculoala. 

R. Gom-J. {I'resse MM., May 1928, p. 596) filvos an 

ncconnt ot Uw synclrotno iircacnlcd by carilino UisulUclcncy 
snjierreiiing In paticals Kofforliig from pnlinoiiftry tuber- 
colosis, Dj'spuoca Is the principal symptom ot siiclt an 
event, aud varies from a slight degree ot breathlessness ■with 
orertion to gravo paroxysmal nttncUs in which the patient 
awakes during the night in great respiratory distress and 
expectorates abundant blood-stained sputuni. 'i'acbycardla, 
hypotension, and increasing nonibcrs ot rales ate nstially 
observed In sneh attacks; oliguria, tinnitus, and subjective 
visual phoiioiucna limy be experienced. XIio ai-r.ay appear- 
ances ot the heart arc trcqnently obsenred by abnormal liing 
BbadowR and by’ c.snllac displacement, but a marked con- 
vexity ot the left ventricular border is not uncommonly 
tonud. Despite tbo dllllcnlty of making elcctro-cardlogtapldc 
rcconls during attacks ot this nature, tracings have been 
obtained sbowing left vciitrlcnlnr extra-systoles, isolated or 
In groupSw The extent of tbo pulmonary lesion bears no 
relation to the onset orgrmloot cardiac Insulhclency, uUhongb 
dy.spnocicattiicks may mark the incipient stage ot tbediseaso 
oraccompany the lighting up of an old lesion. X’hi.s syndrome 
may .also precede or accompany haemoptysis. I’atliological 
ciaiiiination ot tbo heart reveals the left ventricle as being 
globnlar in shape and relatively largo Ironi hypertrophy In 
the majority ot eases; the lungs show acdotna, congestion, 
nod soniotinies haemorrhage surrounding cascating areas. 
Even severe dyspuoolo attacks arc amcnahlo to Immcdiato 
treatment; onabuiii should bo given intravcuonsly in daily 
doses ot l/>? mg. for three or four days. In the less severo 
oases it Is protorablo to give ouabain by the mouth in doso-s 
of “iO inlnims of a 1 In 1,000 solution twice dail}’ for llvo or 
six days; siuoo the oCIcet ot the drug Is transient, this treat- 
ment should bo supplcinontcd by digitalis In luodorato doses. 
Camphor Is sometimos bcncllcial. 'iVllh regard to tbo induc- 
tion ot attifleial pneumothorax, all signs of cardiac liisufll- 
cieucy must disappear before this Is coutomplatcd, and a 
look-out should bo kept tor such signs after each rclUI. 

603. Etiology of Angina Poctorla and Abdomlanlls. 

D. DASlfiLOrOhU (Zcil. J. Itlin. Med., 1928, Band 107, Hcrto 3 
and 4, p. 397) considers that the term “angina pectoris” is 
still too iudcUuUo, bIucc many authors Include incorrectly in 
this category eases ot dyspnoea and acute puluiouary oedema. 
Danifelopoln divides all coses ot angina pectoris into the 
Bimplo aud tbo complicated, the former being subdivided 
Into organic and non-organic types. Ho cannot accept either 
ot tho current Uicorics of tho etiology ot this syudromc, 
wbiob, in his opinion, Is an indication uf myocardial ex- 
haustion due to Intoxication rendering tho sensory and motor 
elements unable to eliminate their waste products. This 
condition produces a transient myocardial circulatory faiinro, 
due to a series of reflexes which he terms “ pressor reflexes.” 

this severe circuJatocy failure tliero are secondary factors : 
(1) coronary' arterio sclerosis ; (2) coronary aphasia ; (3) aortic 
dilatation or other dotonnUios obstructing the coronary 
orifices and so diminishing the myocardial blood .supply; 
(4) pathological changes in tlie cardiac plexus and aortic 
wall. Dauieiopolu has seen many cases presenting evidence 
ot inflammatory aortic aud coronary arterio-sclerotic de- 
generation, extensive peri- and inlra-nouritic inflltratioo ot 
the small scattered ganglia of tho cardiac plexus, with 
changes in their nerve cells. A fifth predisposing factor'is 
the generalized hyperexcitability^ of tho vegetative nervous 
system amt ot the sensory visceral system, which predispose 
the cardio-vasenlar reflexes to tho production ot anginal 
aUacks. The determining taotors are as follows. The anginal 
attack is the i-esnit of sorions myocardial cirenintory tailare ; 
the special predisposing factors are constant, while angina 
pectoris is paroxysmal. There must be a critical moment 
"Which determines the attack — in other words, the attack is 
dno to direct myocardial circulatory fnilnro, caused by some 
“°‘i'*'.'vhich imposes too great a strain nponthe myocardi.al cir- 
culation, Tills condition may be induced by increased cardiac 
actiritj- or diminisiiod myocardial circulation, or by both, 
hfiort js tho nsnal cause ot the former, especially when the 
patient lias hypertension, wliicli may evoke attacks when 
be patient is at rest.- The increased cardiac activity may 
ctminale in paroxysmal tacliycardia. Some patients who 
arterio-sclero’sis iliay have a typical anginal 
an.actdnrmg an attack of paroxysmal tachycardia; this may 


ccaso suddenly, while the tachycardia persists. Emotion or 
healed argniuont m'ay determine an attack through siiuni- 
taucouH spasm ot tliu coronary arlcrics and increase of tlio 
cardiac action. Tlio aiitlior holieves tliat llicro is a “faliguo 
phenomenon” in these eases analogous to tliat of the volun- 
tttty iiuisclcs» *rhc ujyocjirtUuiii is ilioni^Ut to bo tbo feito of 
tho anginal attack, wlicrc tlio accumulated toxic substances 
Irritate the sensory uerve-endings aud tlio motor elements ot 
tho myoc.ardlum. Tliis stimiiintos the heart to furtiier effort 
and a‘“ vicious circle ” supervenes. DauifOopoIu suggests a 
similar etiology torabdoniinal angina ; the circulatory halanco 
is dlsUithcd aud severe abdominal pain follows. Tlio pain is 
usually sltnatcd in tlie epigastrium, and radiates to tho 
spine or tlie right liypociiondrium ; it is caused by increased 
peristalsis and tympanites. Attacks are frequent after meals 
and after strenuous exertion ; they are occasionally coni- 
plCcated by luclacna. In many cases tlie alidominal nrtcrioics 
have uudcrgoiio degenerative changes similar to iho.so of 
coronary arlcrio-Rclerosis. This hypothesis is supported by 
the tact tliat iinglua pectoris and angina abdominalis may 
occur in tho same patient ; occasionally the two syndromes 
occur nllcruatcly. 

GIO. Subacute Infective Endocarditis in Children. 

B. ficni,K.6lXGHli (iJrif. Jours. Child. Dis., January-March, 
1928, p. 33) illustrates tlio extreme rarity ot snbaente infective 
endoc.ardllia in children by the following statistics. During 
the last si.xty-Hvo years ot tlic Hospital for Sick Children, 
Great Onuoml Street, only 10 cx.ample.s were found after 
dcalii as compared w ith 349 necropsies on undoubted cases of 
rhcnmalic carditis witli endocarditis over tlio same period. 

1 At lluivcrsity College Hospital only 4 out ot 60 coses of .snb- 
: acutg inlcotivo endocarditis were in persons under the ago 
ot 15, the average ago at dcatli being 33. Hordor, in a series 
ot 26 cases with positive blood cniluro, bod only 2 in children. 
Among Blnmcr’s 317 oases there was only one under 10 years 
aud 54 in the second decade. Snbaente iuieotivo endocarditis 
and rhcnniatic endocarditis often show a close resemblance 
in tholr onset, while signs wiiich are specially attributed to 
subacute infective endocarditis occasionally appear in certain 
rhevrmatio cases such as enlargement of the spleen, pnrpnra, 
and clubbing ot tho lingers. Tho characteristic signs of 
sahacutc infective endocarditis in children are prolonged high 
irregular pyrexia aud embolic manilestations, both of which 
arc rare ia rheumatism. Tlie pathology of splenic ehlargc- 
ment dillers ia the two diseases. Enlargement in rheumatism 
is caused olUicr by a severe primary infection or by secondary 
infection. Splenic infarction, although rare in rhenmatism, 
is ihv.ariably present in subacute infective endocarditis. On 
tljo other hand, acute pericarditis, so common in rhenmatism, 
is exceptional in suhaente infective endocarditis, although 
signs oiold pericardial inflammation are often present. 

611. Inhibitory Epilepsy, 

S. A. KrXNiER WlbSOS (Jottru. Neurol, and Psychopath., 
April, 1928, p. 332) maintains that many epUeptie phenomena 
aro inhibitory and not exeitomotor in ciiaractcr ; ho discusses 
a case in which tho restraint or inhibition of motor centx-es 
by epileptic sensory discharges was shoxvn, .and refers to two 
analogous cases. In the first case the sensoi'y aura followed 
the nsnal course of cortical excitation—nnmeij-, from the 
lingers up the arm to the shoulders and necl:, thence doivn 
the trnnk to the leg and toes, and at the same time to the 
tongne and face. Motor function varied during the seiznre, 
tlio affected limbs being flaccid at the outset and passing 
tlirough a poriod of relative rigidity to recox-exj-. ■n’'hen the 
limbs were flaccid the)' were also powerless, aud volitional 
innervation returned W'ith the tone. In three fits it was 
noted that during recovery from tlie absolute flaccid akinesia 
the limbs for a time exhibited a striking defective inhibition 
of tho aniagonists. This distnrbanee of the normal inter- 
action or synergists and antergists supports the view that 
such interference witli reciprocal innervation is commonly ot 
cortical site, and is not obsorr.able, or only exceptionally so, 
at lower pliysiological levels. Actual loss or diminntion of 
the deep reflexes was not noted tinring the attack. Their 
exaggeration, the presence ot ankle clonus, aud, on one 
occasion, of a probable extensor response, clearly point to 
iutracortical release synclironons with cortical inhibition. 
The development ot temporarj' motor paralysis xvithont 
spasmodic dNcharge must be assigned to lower activity of 
the motor centres involved— -that is, to their iuhihiiiDn. The 
author remarks that tlie- recent elaborate investigations of 
Pavlov have eondusively proved how readily inli'ibitioa 

1098 A 


3 



106 JUNE 23, 1928] EPITOME OF CURRENT MEDICAr. LITERATURE, 


follows stimulation, and how, in respect of cortical function ' 
the two processes are constantly and continuously interaclinf* 
and superimposed the one on the other. ' Epilepsy cannot 
create physiological processes that do not exist ; at the most 
it can only distort the processes of the individual concerned 
and an epileptic, development, may be a sudden inhibition of 
the man’s own movements. Wilson emphasizes tho parallels 
and^ resemblances between inhibitory epilepsy and other 
clinical states in which akinesia Is a prominent feature In 
a recent paper on narcolepsy and cataplexy he stressed the 
fact that “sleep is a misnomer, and that the clinical 
.syndromes are constituted rather by a state of immobility 
without loss of consciousness, and are only allied to catalepsy 
on the one hand and to epilepsy on the other. ^ 

Pathogenesis of Influenza. 

P. Baize {Gaz. des Hop., March 24th, 1928, p. 4211 discusses 

the views held on t' - • ■ ^ 

discovery of Pfeiffer’ 

the pandemic of 191u-j.j, one puasiuiiity of luflnenza*^be1m’ 
due to a lllterabie virus, Hact. p,iaimioai„“" 
organisms met with in the disease, such as varietiefot 
streptococci, pneumococci, spirochaetes, and special dinlo- 
cocci. He distinguishes two varieties of influenza— namolv 
(1) true or essential influenza caused by a filterable viriiV 
possibly JIact. pnenmosintes of Olitsky and Gates and renrn 
sentmg an excessively contagions diseaseroccurrlng^Tu 
pandemics at more or less distant intervals- bX®M,n 
pulmonary complications are extremely -frequent and severe 
and convalescence is protracted ; (2) various seasonXi^l’ 
leterinined affections, such as rhino-pharyumtis lTv„en 
tracheitis, ordinary colds and catarrhal sore throats whiH.' 
are improperly called Influenza, and should bo more snitnldll 
denominated para-influenzal states. This group d'fflrffrom ' 
mfluenza in not having an epidemic dharactL and 
much less contagious. Complications -ife vnra being 

U usually rapid. These c™udiMons are sakf to 
non-speoiUo organisms localized in the respiratory traot.'^° ° 


Tintramim ' 

alSDICiL JOUSKAL 


Surgery. 


G13. Diagnosis of Chronic Myocarditis mlthont 
Cardiac Failure. 

I. S. Haht (Amar, Heart Journ., April, 1928 n 4ini 
the term “chronic myocarditis 

and inflammatory processes which nro flegeneratlve 

gostiug cardiac insufficiency, but in a certeffi mon'lfrif 

"rgnl ol* fadu?e “'That'^^such"^^® « 

hlqumit finding of ‘sL'“ mrocard?a“rie 

where no cardiac defect had been suspected fri iHe 

Iliiee cases are described as examples of this group lu two 
fibrillation, and in the ■ third rffiht branch 
of ?frdlni°“ ’ ''m*'® P^-esent without any evidence 

u ; m all three, however, such evidince 

sivn? *1 ^ appeared. Many patients give a history or present 
'liagnosis of chronic myocartiitl^-^o^ 
example, some etiological factor may be discovered or there 
may be precordial pain, cardiac enlargemenra n?uiSnr 
abnormal or very unstable heart rate, or alteratio^ i™ he 
heart sounds such as reduplication or gallop rhythm The 
emphasizes the fact that these cases are not c“miW 
damagm "dually accompanies myooarf°al 

GW. Dlcero-necrotlc Glossitis In Scarlet Fever. 

L. Bergeu (Mona/sscfir. /. Kinderlieini., April, 1928 n PRur 
whh nv illustrative case, remarks that, in c^ptmit 
tor^"u?anrw.l‘“^^ i“^ulyement of the 

Berger’s case was a girl, aged lU,'’who in the conrse of^a 
Bevero attack of scarlatina an£tinnc;n V^nTfol,^.i«;^ T course or a 
the sides and then on the bacTorthe ton^®^ and bVh r 
No diphtheria bacilli were fpnnd, and no benefit was derived 
from the intramuscular injection of flini.ti.ovio - 


ei5. Pre-canoerous Changes In the Rectum. 

J- LpCKHAUT-MUMMEiry aiid.C. Dukes tsiirk, Gynccoi 
and Obstet.,- May, 1928, p, 591) -record their observations npdii 
the premancorous changes in the rectum and colon, and show 
from pathological and clinical data that cancer of the rectum 
is frequently preceded by chronic hyperplastic epithelial 
proliferations similar to those described by Lonthal Cheatlo 
as preceding mammary cancer. Adenomata of the mucous 
membrane of tho largo intestine are known to be peouliarlv 
V?. undergo malignant changes, and an irrognlarlv 
distributed hyperplasia, often only microscopic, has been 
shown to represent tho first stage of such tumour formation 
Ihe authors regard tho sequence of events in the develop- 
ment of cancer in the majority of cases as being ; (1) localized 
microscopical patches of hyperplasia affecting an extensive 
area of tho bowel ; (2) the appearance of sessile adenomata 
scattered over tho same area; (3) cancer development either 
ill one of such pre-existing adenomata or in the iieighbourinn 
epithelium ; and (4) tho progressive enlargement and di&° 
semination of tho malignant tumour accompanied by retro- 
gression of tho hyperplastic changes and benign tumours 
surrounding tho malignant growth. In the rectum such a 
pre-caiicerons condition is distlugui.shed by irregular patches 
of hyperplasia of the mucous membrane and adenomatosis. 
Every such hyperplastic patch, however, does'not uedessarily 
develop into an adenoma, nor every adenoma into a cancer, 
since tho former may disappear and tho latter may become 
pedunculated and be shod ; nevertheless, a patient in whom 
such a condition of multiple adenjimata is found on sigmoido- 
scopic examination should bo kept under strict observation. 
Tho authors state that this pre-cancerous stage may exist for 
many years or may abruptly assume tho invasive properties • 
of cancer; with tho development of the malignant tumour 
the neighbouring epithelial proliferations and benign tumours 
tend to retrogress and disappear, so that they are leas evident 
in association with largo malignant ulcers. 

eie. , Prostatlc Hypertrophy. 

G. J. Thomas and E. W. E.xuey {Minnesota Hcd., May, 1928. 
p. 297) discuss tho technique of pro-operative and post- 
operative treatment of nou-malignant hypertrophy of tlio 
prostate. 'Their experience suggests that conditions contra- 
indicating operation or indicating a definite method of 
procedure may be discovered by a careful examination of 
tho past history and physical condition of the patient, and 
they have been in tho habit of co-operating with tho other 
members of tho hospital staff in an intonsive study of every 
patient requiring prostatectomy. Not only should particular 
attention be paid to the heart and kidneys, but foci of liifec- 
lion should bo searched for and renal function investigated, 
with complete blood, a-ray, and cystoscopio examinations. > 
Gradual decompression of the bladder with an indwelling 
urethral catheter ns a one-stage operation is performed, 
a suprapubic drain being only, needed if decompression is 
not accomplished within a reasonable time, and double vaso- 
tomy under a local anaesthetic is recommended ns soon as 
decompression is completed. The Importance of protecting 
the patient from chill during an operation, so that pneumonia 
may beprevented, is emphasized. Eorobviatingpost-operativo 
haemorrhage the authors advocate infiltration of the prostate 
before enucleation with novooaip, stitching the mucosa edge, 
tying all visible bleeding points, and using in addition tho 
Pilcher bag. Vasotomy and the control of infection with 
mercurochrome have in their series reduced the number of 
cases of post-operative epididymitis. 

617. Flastlc Surgery for Hernia. 

A. COMOLLI {Arch, di Cliir., April, 1928, p. 109) reports ten 
cases of relapsing hernia cured by transplantation of part of 
the sartorius muscle. The . author .has made a special 
anatomical study of the nerve and vascular supply of tho 
sartorius, and gives a long detailed account of his researches.' 

He then describes in detail ten cases of relapsing hernia 
where ho used part of the sartorius muscle to fill tho gap. 

In every case tho result was completely satisfactory and has 
remained so for three and a half years. The position and 
shape of the sartorius muscle make it very suitable for 
plastic purposes in tho lower abdomen, and the direction of 
its fibres and good blood and nerve supply render transplanta- 
tion likely to be successful. The success of a graft depends 
largely on an accurate knowledge of the nerve supply, hence 
tho av ■ or’s careful description of this in the case of the 
particular muscle in question. He believes that some of the 
failures reported are due more to lack of knowledge in this 
respect than to sepsis. The paper is freely illustrated and 
a bibliography is appended. 



JUNR =3, 192S] EPITOMK OF CUERENT MEDICAE LITERATURE, 107 


CIS. Pxirpura HacmorrharClca foUowfntf rro-cturo 
of Claviclo. 

G. L. FuKXCicr.r.r, ana K. I. GAWUii,0\v (Zcnlvalhl. f. Cliir., 
May 5tli, 1928, p. 1037) doacrilio the caso ot a. inau, nficd 43, 
who .sustained a conimlnuled fraoUuo of the iuncr third ot 
hi.s loft clavicle. SUiaKiaius showed timt tho bouo was badly 
Bplbitercd ; tho uiodullary canal was opened and tho dia- 
physis was impacted In I bo splintered epiphysis and also 
probably in tho triaufjnlar carlilajte ot tho aterno-clavicular 
joint. Four days after tho accident the patient exhibited 
inultiplo Bubculancons haomorrhaftes over the lolt this’ll and 
icy. On the next d.ay pctechiao appeared on various itarts 
of tho body, varylnj; In siao from that ot a pea to areas 
15cm. in dhuueler. The potechlae beynu to fade In ton days 
and they had disappoared entirely In a mouth. The Wn.s3er- 
maim, reaction w.as uoitatlro. Tlicro were no symptoms nor 
history suj’ye.stlvo of haomophllla, inirpura, or scvu'vy. Tho 
erythrocyte count and haomoylobln content woro allRbtly 
below normal; on the flr.st day there was Icucopcnia (3,600), 
inonopculn, and sllylit coslnop.hilia. Snbacquontly tho 
wyvhiooylo count became normal, the mouopeuta Increased, 
and eosinophilla disappeared. Thrombocytes woro very 
nnmerons (132,000) at llrsl, but later they returned to normal. 
Many small nucleated erythrocytes (0.5 to 1 per cent.) were 
present; tho congnlability was snhnonnal. Tho urine and 
f.iecos were free from blood. Tho anlhor.s refer to Yerzar’a 
recent discovery that extract of hone marrow has dellnitcly 
h.aemolytic properties. They believe that whcn,fn this case, 
tho incdnllary canal ot tho clavicle was opened and the hone 
forcibly com|ircsscd sonic of the marrow was forced into tho 
circniaciou and thu.s produced haemolytic phenomena. 

ei9. Transplantation of Orcters for Congenital 
Incontinence. 

G. A. JlASOX [Arch. Di.'>. in ChiUthooil, April, 1928, p), 103) 
reports the case of a hoy, a"cd 10, wlio snffered from in- 
coulincnce of urino and complete cjnsiiadla.s. The ureters 
were trauspl.antcd fnto tho sigmoid colon, one at a time. 
After each operation there was renal react Ion and coutinenco 
Was established, the child passing his nriuo by the rectum 
four liinos daily, lloscomod in perfect health. Throe years 
later ho developed ohslruction from a baud associated with 
tuberculous hicseuleric glands, and died after the operation. 
At the necropsy tho rectum showed a catarrhal inflammation 
of the raucous membrane below tho cntrauco ot tho ureters. 
The right Icidiicy was in a ooudition of advanced pyo- 
nephrosis, tho left kidney was normal. Mason remarks that 
It is clear that after transplantation ot tho ureters a life may 
ho lived which is to ail intents and purposes normal. Tho 
reotnm is able to tolor.ato tho passing of urine, control is 
soon ostahlishcd, and voluntary evacuations are obtained nt 
convenient inteiTals. 

. G20. Tumotirs of the Konal Pelvis, 

r. LEGunti [Vrol. and Cnt. Itev., Jlarcli, 1928, p. 140), who 
records four illustrative ca-scs in patient.s aged 56, 64, 50, and 
59, states that three varieties of tnmour of the renal pelvis 
m.ay ba described — namely, non-papillomatons cancer, 
papillomatons cpltlieliomn, and simple papillomtu Sessile 
non-papillomatons tumours are rare; siiiiplo papilloma is 
rarer in tlic renal pelvis than in the bladder, and degenerates 
rapidly into a malignant tnmonr. A characteristic feature 
of all tumonrsof the renal pelvis is their extension through 
a part or whole lengtli of the ureter, so that tlicj'have often 
been revealed on cystoscopy by a tnmonr appearing in the 
maiuier at the ureteral orifice. Tho iircdoniioant clinical 
mature of these tumours f.s hacniatnria, which, instead ot 
ooiiig spontaneous as i.s nsnal with new growths, is often 
cansed by examination and is nsuallj' accompanied by renal 
retention. Nephrectomy alono is not suflicicut, but complete 
or partial excision ot the ureter is also required to prevent 
recurrences, which take place in most of these tumours. 

Intussusception in Children. 

W. 11. Sii.vKxo.\' Olinnesaia 3lcd., April, 1928, p. 221) 
euiphasizes the importance of o-arly diaguosis. The cardinal 
poiiit.s arcr (1) pain, sudden and severe, llrst constant, later 
mtenniltcnt ; (2) early nausea and vomiting (in lEG cases 
out of 170, according to Hess) ; (3) prostration, snddon and' 
out of proportion to other symptoms ; (4) tumour, the most 

(Hess), present in over One-half the cases; 
to) stools which contain blood in "varying amounts after one 
or more normal evacuations ; (6) temperature, which, is 
r ^ bot raised or subnormal in early stages. But any 
° symptoms may be absent in a particnlar case. The 
. * , bt holds that blood in the stools is the most important 
anl"'' sign, though many conditions other than iutns- 
*> ' gri’e rise to it. The treatment is surgical, with 
, s^teption of an Involvement frankly in the 
reduct' tr-ray studies could reliably indicate 


Tlierapeutics. 


622, Treatment of Angina Pectoris by Alcohol Injections'. 
J. G. liUllTE 'and P. D, WiiiTe {Jonrri. Jnicr. il/erf. Assoc., 
April 7th, 1928, p. 1099) describe the nse ot paravertebral 
injections ot alcohol in (Ive cases ot angina pectori.s, the 
upper live left dorsal nerves being blocked ; they have 
watclicd these cases for pcriod.s varying from fonr to thirteen 
months after tho troatniont. Tliis is administered as follows. 
A 10 c.cm. .syringe witli thin sharp needles 8 to 10 era. long 
is used, with a pteco of rnbbcr transfixed by it to indicate 
the' depth to which it 1ms been inserted, and the patient’s 
position is as for lumbar puncture. Alcohol and iodine are 
used to disinfect tlic area, and a sniaii cotton-wool pledget 
dipped in acrillavine i.s nsed to p.alpatc and to mark the npper 
five dor.sal vertebrae, acriflavine with iodine giving a black 
colour. A second series ot marks is made 4 cm. to the left of 
tlie spinons processes, and a wheal is raised at each ot the.se 
points by injecting 1 per cent, procaine. Through the wheal 
tho needle is advanced pcrpcndicnlarlj' to the plane at the 
h.ack niilil, nt 3 to 5 cm. depth, the underlying i-ib i.s felt; 
the needle is then- .shifted nntil its tip i.s felt to slip by the 
lower edge ot tlie rib. It is tlion rotated so that it (loints 
caudnlly and medially 45 degrees, niid it is then advanced 
forward a distance ot exactly- 2 cm. If one of the iutcr- 
cost.al vessels is injured the needle must he withdrawn aiid 
reinserted. Five needles are tliiis put into position and 
aspirated to see if any blood or cerebro-spinnt fluid is present. 
If the needle h.as penetrated the plenral cavity- the imtient 
will coiigli : .a manometer can bo nsed and the needle re- 
adjusted. An injection i.s now given ot 5 c.cm. of 1 per cent, 
procaine ; this should ho followed by anaesthesia froni tho 
middle of tho hack to the sternum in front,' and from the fifth 
Intercostal space np to the region where the descending 
branches of the cervical plexus overlap the upper three ribs. 
If the first and second dorsal nerves iiave been properly 
blocked there shonld be good anaesthesia of the axilla extend- 
lnga few centimetres down the arm, with Horner's syndrome 
— a contracted left pupil and narrowed palpebral fissure. 
When anaesthesia is complete 5 c.cm. of 85 per cent, alcohol 
is injected and the needles witlidrawn. Font- ont of the 
authors’ five patients were definitely bonoflted, but one In 
wiiom Horner’s syndrome did nOt appear at the time of 
injection was unimproved. 

623. Scrum Treatment of Peritonitis. 

J. KsopP [Zcutralbt. f. Clnr., April 14th, 1928, p. 923) has 
roceutiy employed a B. coU serum in tho post-operative treat- 
ment ot ton cases of diffuse peritonitis and other kindred 
conditions. In two cases therre were perorations of the 
gastro-iutcstinal canal, with severe diffuse B. coli peritonitis 
occurring twelve to fourteen hours after operation. Follow- 
ing the injection there was a rapid return of peristalsis with 
improvement in the general condition and tlie circulation. 
The scrum, was administered, in four cases of difftise peri- 
tonitis following, appendicitis with, perforation, with good 
results. In two ot tlmsc cases the serum was given at a late 
period, after drainage bad faGed to arrest the progress of tlie 
peritonitis. In a subsequent case of B. coti peritonitis after 
appendicitis, the injection of scrum produced severe ana- 
phylactic shock; the treatment was not repeated, and the 
patient died next day-. In the remaining three cases the 
admiiiistraLion of the serum failed. One patient had a B. coU 
luctastntic pnlmonary abscess, following perforated gastric 
ulcer, and another severe -septic cholangitis. The third case 
was one of strangulated hernia, and the serum was given after 
operation. Tlie infection had traversed tlie strangulated 
intestinal wall and possibly had cansed slight peritonitis 
Tho resalt ot serum treatment was doabtful. Peristalsis 
was restored, but subsequently the patient developed severe 
hypostatic pnemnouia. Tho autbor adds that the last three' 
cases suggest that this treatment has limitations althou-h 
for diffuse JA. coli perlbonttis, its employment seems to be 
clearly iadicatecl- 


^-oiioiaoL BismutK in Syphilis^ 

E.DnrKEn:BEn [BrnrelTes-AIctTical, May 6th, 1928, n. 886)renort 
the results of treattng 66 cases of syphilis at various sta-p 
with colloidal bismuth. He place.s the cases in three cate 
gories for the purpose of- comparing the effects of treatment 
(1) In twenty-two patients who had not had any proviou 
treatincnt tne action of colloidal bismuth in prfman- am 
secondary- syphilis very slow and generallv insufllcien 

bub It was parTicularly efficacious in nerve lesions and mpc 
mally lu headache. Sixteen ot this gronp of cases weiM 
ta-bnry, and m 4 of these the symptoms were amelioratei 
although the blood reaction remained unaffected (21 nr t 
j^Uents who had had previous, treatment 8 had ’a nigafiv 
Wassermann reaction, which remained negative even afte 

logS a 


O 


3 


■108 23 , xgaS] EPITOIiffi OF'CUKBENT MEDICAIj LITERATT7BE; 


c 


Tnr nsms* 

U cmcAj. 3 0VB11A& 


a course o£ bismuth. In 16 cases the previous treatment had 
not modilled the blood reaction, and in 9 ot these the bismuth 
did not appear to have any influence on the Wassermann 
reaction. In the others the results were {jood. (.1) There 
irere'd cases ol congenital syphilis, two ot which had. never 
been treated ; in only one ot these did the 'SVasaerraann 
reaction become negative. . In another, although the reaction 
remained positive, a large ulceration ot tho leg cicatrized and 
albumin disappeared. The author concludes that there’ is no 
doubt that colloidal bismuth has a curative action on syphilis 
at all stages, but its action on recent primary or secondary 
lesions is generally slow. In two. cases secondary lesions 
actually developed while the patient was under treatment. 
In the treatment ot tertiary lesions ulcers and gummata are 
seen to disappear rapidly, and the action on the nervous 
inanilestations at all stages is most marlted, but cspoeially in 
tabes. In two cases there was retrogression of optic neuritis 
after the second course of treat'me'nt. In about 50 per cent, 
ot the cases a resistant positive 'Wassermann reaction was 
made (negative. In certain cases in which this reaction had 
become negative under previous treatment it did not become 
positive during the cure with bismuth. The author comments . 
on the freedom from danger in this treatment ; only once was 
gingivitis observed after daily Injeqtibn's. ■ ' 

625. Sodium Nitrite in Sea-sickness. 

J. F. Pearct and D. B. HaYDEN {Joui~n. Amcr. Med. Assoc., 
April I4th,T928, p. 1193) report 'that during research on tho 
labyrinthine function in relation to blood iiressure it was 
found that- by lowering the normal blood pressure to between 
95 and 105 mm. ot mercury the nystagmus after rotation 
was greatly diminished.' Believing that sea-sickness is due 
mostly, it not entirely, to over-stimulation ot the vestibule, 
they concluded that the nitrites offered a direct lino of attack 
on the morbid process in sea-sickness. Sixteen persons 
suffered from sea- sickness on a return trip across tho Atlantic, 
and all had suhoutanooua injections ot adcenallno hydro- 
chloride. For the test by sodium nitrite they were divided 
into two groups ot eight. The controls wore prostrated for 
the average two days, and there was not much variation from 
that period. The other group received 3 to 5 grains of sodium 
nitrite over.y two hours until'relief. The average time before 
members ot this second group were tree from ocular 
nystagmus, vertigo, nausea, etc., and were - comfortable on 
deck and could eat a meal, was four hours, and there was 
no recurrence. The authors agree that tho series is a small 
one and think that there may be oases that cannot be dealt 
with sncoessfully in this way. 


I^adiology. 

G2B. Badlological Treatment of Uterine Fibromata 
and Hypertrophied Prostates. 

H. B. Philips {Med. Jonrn. andjlecord, March 7th, 1928, p. 238), 
discussing the a:- ray and radium treatment ot uterine fibroids 
and hypertrophied, prostates, suggests that the similar histo- 
patholqgy ot the two conditions affords a logical basis for 
expecting success from radiotherapy in both. In nterino 
fibroids his experience in two; cases points to the fact that 
large size need not be considered a contraindication for 
treatment, since complete resolution without any disturbing 
symptoms resulted when the fibroids .were larger than a six 
months and a full-term pregnancy respectively. , A'-ray treat- 
ment, in small doses ot 20 or 30 minutes’ duration on alternate 
days, is recommended until a suberytheiua dbsfe is given on 
the anterior and posterior aspects ; in very large tumours the 
sides are used for additional portals of entry in cross-firing. 
Persistent bleeding can be- promptly codtroiliad by supple- 
mentary radiation of the spleen and pituitary gland. An 
analysis of 65 oases shows that the earlier the treatment is 
commenced the .quicker and more' suooesstnl -will be the 
cure, since failure Js nsually due to the. supervention ot such 
secondary changes ■ as chronic cystitis mnd bladder atony. 
Large boggy prostates' react favourably in all instances and 
are more easy to relievo than small hard fibrous ones ; several 
prostates ot the'size ot a small grape-fruit have completely 
involuted to normal size. Philips concludes that radium or 
a:-ray therapy I’s the treatment ot choice, the former being 
used either exclusively or to supplement the latter; surgery 
should only be employed it these fail. ^ 

627- Soaium Tetra-loao-phenolphthaleln In HadlologTy, 

G. E. Eyas {Brit. Jonrn. Itadiol., March, 1928, p. 97) reports 
a death associated with the oral administration ot this drug. 
A man, aged 52, previously diagnosed as suffering from gall- 
stone colic, was admitted into hospital in 'November, 1927. 
Tho liver was greatly enlarged and reached to the umbilicns; 
>t was smooth and not tender, and the sclerotios were slightly' 
logS D . 


yellow. Tho only other abnormality was a high blood 
pressure (200/110). The. patient had been a total abstainer 
for nearly tho whole of his life. It was decided to have tho 
gall-bladder a;-ray'od, and tho patient was given sodium totr.v 
lodo-phonolphthalein by tho mouth tho night before ; though 
apparently quite well a few minutes earlier, ho suddenly 
collapsed and died after returning to tho ward from tho ar-ray 
department. At the necropsy a linear tear about one inch in 
length was found at tho most dependent part of tho right 
lobe. Further examination showed ovidoiice ot advanced 
portal cirrhosis ot both lobes, with, in addition. In tho right 
lobo, acute degeneration ot tho hepatic colls and rupture ot 
tho walls ot sinuses, as a result ot tho removal of tho support 
normally afforded by those cells. 'Tho tear in the capsule 
presumably occurred as a result of tho Increased pressure 
■within the liver brought about by tho haemorrhage from tho 
sinuses. The portal cirrhosis obviously played some part in 
the onset of tho acute degeneration, but Eyas agrees that the 
relation ot tho totra salt to tho degeneration can only bo 
conjectured. 

628. Tho HpIIatlon and Hrythoma Dose of X Rays. 

"W. E. Chamdeulain and E.' E. Newell (Eddioioyy, April, 
1928, p. 280) havo made a Borles ot experiments on the rela- 
tion betsveen tho hardness ot x rays and their biological 
effect. Frloko and 'Foterson have shown that radiation 
A=0.75 Angstrom has within 2 por cent, the same effect as 
radiation '^=0.248 Angstroihi but Glas-sor and Moyer found 
tho erythema dose' to bo markodly'dependbnt on tho wave- 
length. In tho present studjr opilatibn was chosen as being 
a precisely mcasurablo offect,'and erythema readings, largely 
a matter of personal judgement, were made for complete- 
ness. X rays ot two qualities, filtered and unflltered, -vyero 
employed, and dosage was measured in the E units described 
by Bohnkon. 'The experiments wore performed on tho 
anterior surfaces of tho thighs of five young men. tho Ibit 
being treated with tiio unflltered and the' right with tho 
filtered bbam. Tho degree ot both' epilation and erythema 
■was found to be practically tho sumo for each kind^ of ray, - 
and' tho dose dolivored to a surfaco was augmented in every 

" ’■ from tho mass ot material irradiated. 

or hard than for soft rays,"riud, wWle 

oas, becomes important when large 
masses aro treated. Tho authors found that neither epilation 
nor skin erythema snlllcos to define ®-ray dosage with satis- 
factory precision, and that tho maximum safe dose is several 
times the minimum erythema dose. 

629. Radium Treatment of Cervical Cancer. 

Following a previous paper on tho general technical prin- 
ciples underlying radium- treatment of tho carcinomatous 
uterine cervix, J, Muir {Med. Jonrn. and liecord, May 2u(l, 
1928, p. 472) now describes his own technique. Ho emphasizes 
that in this method precautions as to pre-operative prepara- 
tion, rigid, asepsis, and measures to avoid shock are as 
important ns in surgical operations. Since this therapy is 
based on giving the highest possible dosage compatible wit 1 
immunity of tho surrounding unaffected tissues, proper appli: 
cators:and suitable instruments , for every stop of the pro- 
,'cedure are. essential ; protection for the rectum; bladder, am 
adjacent -vaginal .mucosa must, be provided; and necrosis in 
the malignant tissue itself avoided. Pre-operative prepara- 
tion includes the complete emptying of the bladder. .anu 
rectum; just before the rtidium' is applied .the patient -is 
given a , thorough douching with normal -saline' (W. weak .per- 
manganate solution, and, it necessary, thercanal JS dilateu. 
After the applicators have been ploced in position the -vagina 
is packed' with gauze (on each side of the applicator) un i 
the.uterus and radium are well above' and beyond the rectum 
and bladder. A catheter may be left in the bladder, or tiie 
urine drawn off every six hours. A firm T-bandage.is appbea 
and absolute rest Js prescribed for forty-eight hours. At tne 
end of the second day’ the applicators are withdrawn ana 
sterilized, the vagin'a-is douched, the rectum is emptied, anu 
the applicators .'are'-re-introduced. This is repeated at tne 
end ot each fbrty -'eight hours for six days and twenty hours 
that is, for 164 hours in all — and thus is given a slow, intensive 
radiation so '. disseminated as to reach both ' the uterine 
periphery and the diStal parts. Muir employs a much 
dosage; rendered possible by proper filtration, than is habit- 
ually used, the total irradiation being 7,900 millionrle hours, 
divided as follows: 2,200 millicnrie hours from the intra- 
uterine tube, 3,800 from the ' pessary, and 1,900 from tne 
cervical applicator. Muir maintains that tho Bucces.s attend- 
ing this mode of treatment depends entirely upon the 0®°®' 
trating radiation made possible by tho construction of the 
applicators, that the segregation of the hard gamma ray ot- 
the shortest wave length (the true therapeutic ray) is effected 
by the extraordinarily heavy filtration employed, and that 

i slow intensive radiationigives the best results.' , 


c 



EPITOME or CUKKENT MEDIOAE LlTEllATURE. 


r TnBPnmfTi 
I Ukdtcaz. JoritxiX. 


109 


JUNE I3i *02S] 


Obstetrics and Gynaecology. 

kIo. Heart Dlaordors In Projfnanoy. 

u 1’ HAMILTON {Kcw Ettohiiul Joiint, ^Ttircli 29(.h, 

1928 "p 292) roporia tliat In the Obatotrlcal Clinic of tlio 
aofton r.yh.fi-ln Hospital 7.5 por cent, ot the patlpnta uro 
rcfcrrcil to the cnrillao clinic for Jnvcsllfiallon. riioy aro 
classlllca into tlirco uroiips. Tlio least iniportant ot 
consists ot patients complaluln)! ot brcatlilossncBS, palpita- 
tion, faiutintt, ot heart pain. NotlilnR boyoiul tachycartlla or 
cxtra-systolcs is fouml on oxanilnatlon, and they arc inostly 
cases ot cardiac neurosis. Tbo second class contains inHlpnls 
wllli possible or slight cardiac damage ; rhouinatic and slignt 
congenital heart dlscaso and mild Jntrcipient paroxysinat 
tachycardias make up the majorltyot thlsgroup. Among s21 
patients of this and tbo next class watched through pregnancy 
there was wo occuiTciico of carillac failure, anti only two 
maternal tleatliB. Tho rcinainlnf* class consists of patients 
sho\Yhij5 such oviilcncc of severe cardiac damage as gross 
cardiac culargouicnt, a diastolic iniirniur, signillcant disorder 
ot the heart beat, and signs or history ot congestive fatUiro. 
01201 patients holonglug to this group, thoro was a maternal 
mortality of 8.5 per cent, and au infant mortality of 22 per 
cent. The prcsonco of any ot tho following comiillcatlons Is 
held toeonstltuto an uusafoprognancy risk : congestive failure 
past or present, recent or actlvo rheumatic fever, active endo* 
carditis, auricular llhrillatlon, nephrites, and liypertcuslou ; 
nuder any ot Ihoso clronmstancca tho early Intcrcuptlou ot 
pregnancy Is advised. Tho avoidance ot pregnancy, and 
stcrlliaallon it practlc.ahlo, Is suggested. As a result ot 
iuiprovcniout in tho treatment of these patients the maternal 
and Intautilo dcatli rates at tho Heston Lying-In Hospital 
have been considerably reduced during tho last tour or tlvo 
years. Tho following linos of treatment arc recommended 
toe patients lu the last-mentioned class who are able to 
conliuuo to term ; during pregnancy ten hours in bed each 
night; much rest, particularly after meals; tho avoidance of 
any but tho lightest oxertiou, and it possible tbo prevention 
ot any intcctlou. Labour should bo coiidtioted lu hospital, 
and it cardiac falluro occurs tho patient should remain In 
bed at least threo weeks atter all signs have disappeared, 

631. epidemic Encophalltls and Prettnancy. 

E. Eoques (Joiini. Ohsict. and Gynaccoi. of the British 
Empire, Spring, 1928, p. 1) discusses tlio reciprocal relations 
ot opideinlo cncophaUtls and pregnancy, using tho notes ot 
eighteen eases from tho Shelllcld epidemic (1920-29) and 
three London cases, as well as rovlowlng 200 cases collcolcd 
from the literature of various Continental countries and 
America and from Scotland. In tho largest scrios of eases 
tlio incideuco among pregnant women did not exceed 
2.7 per cent., and there is no cvidouco that ]ucgiiancy 
increases Busccptibilltj'. Tho mortality' in Itoqnes's English 
cases (18) was 5 per cent., hut lu larger series in France, 
Italy, and Great Britain It was from 44 to 60 por cent. ; 
probably it Is not as a rule greater on tho average than that 
of all persons attacked under similar conditions of ago, sox, 
time, and place. . Prlmlparao aro rather more commonly 
attacked than mnUipara'o, probably because they are on the 
whole younger. In Itoqnes’s series alt tho infants were bore 
healthy, and 85 pec cent, survived tbo early months ol 
infancy, Encephalitis in tho newly born ot mothers artcctcil 
with.the disease has been reported, but Is very rare; trans 
placental transmission ot tho virus Is proved by Marinesco’i 
case, In which post-mortem examination showed signs ol 
epidemic encephalitis in tho brain of both mother and foctoi 
(the motheg was infected during the fifth month and diet 
establish a diagnosis ot epldomio on 
cephalitis , in tho pregnant woman Is easy, provided the sign' 
are not too obsenre and that an epidomio Is isnowu to hi 
existent at tho time. Mild cases, however, may bo dlaguosei 
as inflaenza, aud the early stages may bd confused witl 
pregnancy toxaemia, eclampsia, or hyperemosis. Occasion 
ally epidemic oncophalitis mimics very closely tho chorea 6 
pregnancy, but in the latter condition the- facial musclei 
ever escape, and an onset later than tho third oi 
termination of-pregminc-l 
fheraponsis of acute epidemic eri 
cephalitis, for miscarriage or labour rarely alters tho coursi 

Labour^ is® f affect the mortality 

a iargot while pregZ 

acute ^ become Parliiusoniaii than w'hen thi 

acute attack oeeurs without pregnancy. Whether this attacl 


occurs with or wlthont pregnancy, Parkinsonism may mako 
its llrst appoaranco during nu cnsnlug pregnancy. Pregnancy 
in II I’nrkiUKonlau subject may bo attended by nn nccontno- 
tlon of tho I’nrltlusoiilan symptoms. Thoro Is no ovldonco 
that PaiUlnsonIsm lins an liijurlouB effect on pregnancy, 
labour, or tho piiorporluiii, and llttlo ovldonco tlmt tho child 
is morbidly affocted. llcgardlng treatment ot pregnancy in 
Parklusoijlau subjects, Iloqucs concludes that (1) prophyiactlc- 
nlly, those wlio liavo rucovored from aculo encophalltls 
should ho advised not to hccomo pregnant until four years 
Imvo ohipscd since recovery— tho sniiio advice applies to 
those first seen ns Parkinsonians ; (2) wlicn Parkinsonian 
sym)itoms appear for tho llrst tliiio with jircguancy. Induction 
ot labour Is justified aud advisable; (5) in those who aro 
I’arliiiisonlnii before coucclvlug, and in women wlio becoiiio 
pregnant ntlcr an acute attack hut have not so far exhibited 
Parkinsonian inniilfestatloiis, c.aretiil observation is called 
for, and dutcrlorntion or aiipcarauco ot tho signs ot chronic 
oncophalUls calls for termination of pregnancy. 


032, Tlenal Function during Pregnancy, 

ACCOltniNO to G. Di: Candia {Ann. di Osict. c Ginccol., March 
3l8t, 1928, p. 293), It is wrong to reject tho old concept of a 
“preguaucy kUliioy ” with Impaired function. Estimatiiic 
tho renal tuiiclioii by tho phenolsulplioiicphtlialcin test and 
comparing llio conloiit in dlastaso of blood scrum and nrliic, 
ho finds tlmt tho variations shown by tho two methods aro 
without exception parallel. In normal pregnancy the renal 
sufilclcncy does not differ during tlic early months from that 
of nou-gravid subjects. As pregnancy (lersists, however, 
both tests show a diminution ot renal function, wliich is most 
marked at term aud increases dclliiltoly during labour, 
returning to normal within tho first days of tho puorperium. 
Examination of iciinl function during pregnancy complicated 
by various iiinladics, including hyperomesis, tubeicTlloBis, 
syphilis, nophrllls, and renal calculus, showed In some cases 
nu Impairment wlilcli persisted after labour and was taken to 
point to permanent kidney damage. 


C33. Asphyxia Neonatorum, 

M. HENKEL (^ciifrrtikl. /. Gynctlt., March 24th, 1928, p. 720) 
protests agnlnst tlilj npiillcaliou ot forceps ns routine troal- 
incnt for nspliyxia uooiiatoruiii. Since thoro aro ninny causes 
ot asphyxia, it is difilcull 10 cstimato its degree, and a linsiy 
forceps delivery may mean unnecessary damage to the 
mother and injury or death to tho child. Utoiiuo contr.aollon 
iutoricrea with tho supply of oxygon to tho child ; hence the 
accolcratiou of tho lieart, a process which is normal and 
shows the cfilclenoy of tho heart's response. Should tho 
contractions hccomo too strong or frequent asphyxia will 
siiporvcnc, aud should bo treated by lessening tho uterine 
activity by morphine or cliloroforui. During expulsion tho 
head limy bo unduly compressed and the brain injured, tho 
corebrul centre may ho upset oitlier from lack ot oxygen or 
irritation of tho vagus, or from direct pressure, lu any 
enso the foetal heart is slowed, preventing tho acceleration 
necessary to procuro sunicleiit oxygon. Further, stimulation 
ot the rcsplralory ceiitro may lead to establishment of lung 
breathing, and. It tho foetal clro'ulatiou' cannot bo restored, 
the child dies. Honliol o.x'amiucs tho foetal lieart at frequent 
intervals and regards as danger signals slowing, and Irregu- 
larity lu time and pace; to estliimto tho' latter careful 
oxaiulnallou early in labour is necessary for comparative 
purposes. Ho adds that tho appearance ot meconium is of- 
less Blgnificauco than is 'usually supposed. Treatment con^ 
slsts of frequent observation ot tho foetal heart, administra- 
tion of morphiuo or' chloroform; or both,' to control very 
strong contractions, and cpislotomy of rigid porineuui. In 
severe asphyxias no rnlo can bo laid down ;, each case rimst 
bo dealt with on its own merits, bearing in mind that tho 
delivery of an asphyxiated child by high forceps defeats its 
own object and risks injury to tbo mother. 


uunurrooca, lu Xxomon., 

L. SlNOEH {Dermatol, ll’oc/i., April 14th, 1928, p. 506) com- 
ments on tho dlvergenco in tho reported incitlenco of rectal 
gonorrhoea, and coiicUides that this coudltioii is more common 
in womon than is generally bolioved. It is often caused by 
urethral or vaglual disohargo passing backwards towards the 
anus aud, when established, seldom gives much dlsconirort 
In recent InfeoUoiis thoro is pain and sometimes teiiosmus 
during defaecntion, anal pruritus, aud tho discharco ol 
yellowish or occasionally ot blood-stained mucus. In sub- 
acute of- chronic cases pain Is seldom present, and para- 
pioctitic abscess is n rare complication. On account of tlic 
comparatively painless character of this condition its frenucut 
occiuTonco has escaped recognition until recent years Sin.'ei 
recommends that it sliould bo treated by irrigation w7tli 
silver salts in a viscid or gelatinous medium, twioo aailv • 
10 per cent, protargol suppositories are also said to bt 

1098 B 



EPITOME OF OEBRENT MBDIGAE ETTEHATUBB, 


t TrrK nnirrf* 
Mkpicil JorsMUi 


110 JUNE 23> 19*8] 


vei-y effieaclons, usually curing tlie palient in two or tliree 
weeks, tliough, exceptionally, the treatinont may have to be 
conlinueil lor six weeks. The author believcs that in women 
the r-cccurii is infected in approximately 38 por oout. ■oEall 
cases of gonorrhoea. As a method of diagnosis and observa- 
tion, irrigation is snpei'mr to swabbing, but .the best JcesiUts, 
are obtained by alternating these procedures. 

635. Induction of I/abonr by Pituitary -Extract; 

K. Hatzki [Zcniralbl. f. Gyniiti., April 28th, 1928, p. 105S) 
reports seventeen selected cases in which ho indneed labour 
with pituitary extract. The patients were all at -term with 
the inembranes intact, and the pains had -not begun. If 
priiniparae were concerned the os was closed ; It multiparac, 
it admitted one Anger. The dose of the extract was 1 c.cm. 
given in three stages at intervals of -an hour — ^0.2e.cm. twice 
and 0.6 c.cm. once. The resnlts were : (1) Sncoesstul in 30 
per cent., the patients being in labour within two hours of 
the last iniectlon and the child having been horn within' 
twenty hours in the case of primiparae, and within twelve' 
hours in the case of mnltiparae. (2) Doubtful in 11 per cent., 
labour having started hut being prolonge'di - (3) -Failure ih"59 
per cent., Jabour not having become established A wentj’-foar. 
hours after the lastdnjection. The course of labour was.not 
inlluencod by the injeotions, and serious complications wore' 
met with only among the failures. The puerperinm was 
normal except for one case of mastitis and one of thrombosis 
of the pelvic veins. As regards the duration of labour, tu 
the successful cases it was shortened to. two-thirds of the 
normal ; no further injections were given when labour bad- 
started, and this happened in some before the full dose had- 
been given.. The points in favour of the method are said- 
to he its simplicity, the avoidance of risk of iriloction or. 
oompiieations, and the shortening of labourg .the -maiu.dis-i 
advantage is its great unreliability. It is .suited dor patients . 
who have reached full term.rtbe child being fully ide-i'clopeil. 
and there being no immediate hurry, so that in the ovcntlof. 
failure there is time for other measures. It is of no value in. 
the induction of premature labour or where lime is important.. 


Pathology, 

638. The Pityrosporon of Hlalassez. 

J. M. H. MaoIiEod and -G. B. Doivling {Brit.J'ouni. Dermatol, 
and Sijph., April, 1928, p. 139), from an experimental study 
of the morphology, cultivation, and pathogenicity, of the 
pitju-osporon of Malassez, conclude that schbirhooic dermat- 
itis is a pure infection, and that, as is the case with other 
related fungi, the pityrosporon grows best lu subjects with 
moist, greasy skins, and in such warm moist sitnationsas 
the axillae, interdigital folds, scalp, and presternal and intor- 
scapular regions. Conditions of clothing or environment 
tending to provoke perspiration and sebaceous activity also 
favour its growth. Itappears to he a frequout cause of anal 
pruritus and of scrotal and ingaino-crural dermatitis. Experi- 
mental inoculations varied in their effects upon the already- 
existing disease, i-n some cases rapidly clearing up tlio' 
lesions, in some causing fresh'foci, while in others tliero was 
no response or reaction. The organism Is pleomorphic,' 
usually in the form of a gourd or flask with a largo spherical 
portion surmounted -hy a small roundish process, or it may be 
honr-glass, ovoid, or sansage-shaped. 

637. The -3cl- and O- Eorms of B. tyrihosus. 

L. Or.TTZKi [Zcit.f. Imniimitats., April 12th, 1328, p. ‘1‘15) has 
studied the different antigens contained in the- bacilli ro- 
covered from patients with typhoid lever and from con- 
valescents. Of 23 strains of J3. typhosus cultivated fro n the 
blood, 17 were of the E- or heat-labile form, and 6 of the D- or 
heat-stable form. Of IS strains cultivated from the stools of 
patients, most of whom were in a -fate stage of the disease 
only 3 were of the H- form, the remaining 12 being of -the O- 
loria. Likewise of 19 strains recovered from the stools of 
typhoid oouvaleseents only 4 were of the H- form, the 
remainiuglS being of the 0- form. Though, no examination 
of the stools appears to have been made in the early stn«B of 
the disease, the author considers that during the staoe of 
i-ecovoiy from the disease there is a progressive change in the 
tj'peof the infecting organism from theH- to theO- form. This 
wouid-explain -why in cultures taken from the blood in the 
early stages of the disease the predominating type is the 
H- form, whereas in stool onltnres from convalescents the 
predominating type is the O- form. There is evidence that 
in certain clironic carriers the change in the organism may 
be even greater, and that some other antigen is elaborated, 
different both from the H- and the O- forms, Jn the actual 
logS E 


diagnosis of chronic carriers and of convalescents the .author 
considers it advisable to put up suspicious organisms against 
both an H- and an 0- agglutinating .scrum. 

638. The Haemoclastlc and Ecvulosc Tests In Childhood. 
M-URIEL J.. BROivn (.Irc7j. 'o/'jjfis, in, Childhood, April, 1928, 
p. 81) reports the result^’ gf JhyesTigating the value of tho 
haemoclastic crisis and thclovuidsb .'te.st.s f n childhood. Tho 
first tost depends on the .phy.siologic'al .fligqs.tipn Icnoocytosis. 
The author coucliulos that'jt'gTve.s iiiost ^ucousistent resnlts, 
both in normal yan’d abnormal .Bubjecls.-' ifegarding the 
Icviiloso tost, coil.sidbrahlq yanatioii w'as'.'Ioiiud lii normal 
individuals, apart. from tliq'agq jot ' the child. ' _Tt_i.s cousidered 
that a ri.se of 30 per, cent.'Jiii 'th'c hlbo3 sugar pon'teut', after tho 
administration of .lovulbsp. should' coubtiluto 'evifleuco of 
hepatic disease. Tlio' pnttty of the 1eval6,sd was of great 
importance. In most cxfiVuplQ's'.df..dcflulto hepatic, disease 
the test was positive, h'lit' in Icotdsia. and coeliao disease the 
liver appoans to bp normal, "a’q indicated by the to.st. On tho 
whplo, whqi'O tlio'clinic'al pvldcncc left tho diagnosis in doubt, 
tho lovuld.sb tost was of dcllnite help', . ' ' 

.689, . The Hctieulo-EndotheVlal System. 

C. P. UnOAPS {Ncta Dngtdnd Journ, of-Mcd,, March 1st, 1928, 
p. 76) descrlboB'tho TOticnlO-endotUolial system' as an organiza- 
tion of -colls grouped logbthor bocauso of the common function 
of phagocytosis.-- Ifjs iiiado up of cells of .somewhat similar 
morphology, and possibly of conuuon origin;' found in lymphoid 
tissue, spleen, Qlvcr, boho niacrow, and counoctivo tissno. The 
function of this cell -group as very important loir Iho following 
reasons. (l)'It-hns.to do with blood fonnation aind destruc- 
tion and with tho formation of bile pigments. {2)Xt is active 
in combating infection, locally by phagocytosis andigonorally 
by tho fdrmntidu.'btAntibodios. '(3)'lt.-jccacts'iSpOGillcaUy to 
certain itifcctioh.s, sucliastnhcrcnlosisjIeproBy.-tj'pi'oid fever, 
typhus, .-rlionmatic lever, trench fever, and kala-nzar, and 
tnkos'pnrt in proocsse-i of inflammation and repair. (4) It has 
atflll-dofonhlncd 'relation :to di-sordorod Jipoid inotaboHsm. 
p) -It probably forms a certain group of rare tnmonrs variously 
tenhed'fotioulum' cell-sarcoma and onaothclloma. 

640.' Tho Kahn Test In Primary Syphilis. 

J. C. ’WlEEETT aniTN. Nagle (lonm. .finer. Jlcd. -fssoc., April 
I4th, 1928, p. 1189) remark that only a smalj .percentage of 
cases of syphilis show a positive IVassormann reaction during 
of beloro' tho sfecond or third week following the appearance 
of tho chancre. They claim for the Kahn test a marked 
increase In tlio positive' reactions during the early primary 
stage, and they compare this test -with the result of dntk- 
ground examinations. In a series of T87 patients exhibiting 
venereal .lesion.s, 105 were found hy dark-ground and clinical 
examination to be cases of primary syphilis.' Of tliese 105 
cases, 84 gave a positi'to ICabu reaction, and in 64 the clark- 
gronnd was positive, lu 39 cases the 'Kahn test was positive 
while the darlr-groimd was negative,', tho Kahn test was 
negative in 19 cases in which the dark-ground illnniinntion 
test was positive. During the first week after the chancre 
appeared the dark-gi-ound was most reliable, bnt in the 
second and snhseqnont weeks the Kahn test was the more 
reliable. The authoi's conolndo that the Kahn test is a 
valnabie diaghoslic procedure in persons having a chancre of 
less -than one week’s duration. It gave 80 per oent.'positive 
as compared witli 60 per cent, in the case of the davk-gronnd 
test. Til© primary lesions were of loss- than twcut 3 '-eight 
days’ duration -in all bnt four cases. The Kahn test failed 
in 20 per cent, of cases and dark-field examination failed in 
59 per cent, of cases. . . 

631. Eassage of Arsenic and Bismuth into -the Cerebro- 
spinal Eluld. 

S. Mutermiloh and Mile E. Sadamon /C. Jf. Soo. dc Biologic, 
April 27th, 1928, p. 1113), working with general paralj'tios, And 
that tho injection hy lumbar puncture of 1 to 2 c.cm. of a 
sterile 10 pep cent, emulsion .of Aour in saline gives rise to 
an aseptic meningitis,, -evidenced -by a rise of temperature, 
headache, retraction of the nebkj and Kernig’s sign. IVhon 
arsenic or bismuth compounds are injected iutavonously 
into such patients the metals can be dotected ip the cerebro- 
spinal iinld an hour Qr;twb later; in patients- without an 
aseptic meningitis this floes not occur. In practice tho flour 
emulsion was injected the previous day. The cerehro-spinal 
fluid withdra-wn the following, day was more or less tnrlna 
and contained, jU considerable number of polymorphonuclear 
cells. The quantity of metal that passed into the cerebro- 
spinal fluid was very small; two hours after injection.it was 
never greater than 1 mg. per cubic centimetre of fluid, 
and generall}' verj'^ much less. The therapontio results 
of this method of treatment are reserved for a further 
communication. 



JUNE iOi «93S] 


[ Tun nRITI«iK 

Mtoicux. Jotmyil. 


Ill 


epitome of current medical literature. 


Medicine. 

64S. The Effects of Adronnllno on Rosplratlon< 

H. J. S. M'DoW'AI.Tj [fjiiart. Jouni, Erjjcr. I’hysiol., May 5Ui, 
1928, p. 325) rL'innrlts that Oliver anti Soliator fouml tliat 
ndrcualiuo causes « iliiulnulion iu iho rate and depth ot 
re'pitntion, aiiiountint; at times to a cessation, tvlilcli has 
been termed adrenal liionpnoea; and liohmisolf has previously 
noted that tho elTccta on rosplnitlon of section ot tho vagi 
depend on tho state of tho animal. It was suggested that 
the condition of tUo nnUual affects the rcapouslvoueas of the 
centre to iicrvons stimulation, nod tho jircscut author has 
reinvestigated tho cUccts on resplmllon ot ndtcnnlino troni 
a similar point ot view. Tho osporluicuts divided thoiiiBOlvcs 
Into two main classes : those In which there was ovidetico of 
sympathetic stimulation, ns indicated by a rapid heart and 
dUatrttiOM of tho pupil, nod those iti trhlch sitch sthiiiilattea 
was absent. The action ot crgotoxlno and crgotaniluo and 
the interaction of crgotoxlnc and adronnllno tvero also 
investigated. As n rcsnlt of theso oxporlnicnfs IH'Uowall 
concludes that if stops aro l.aiccn othcrwlso to avoid atlninln- 
tion or lospirntion, tho classical reduction of respiration by 
adronnllno la followed by an incrcaso, and that adrctmlluo 
apuoea is piodnced slinilatly to and colucldoutalty with the 
vagal iniiibltion of tlie heart cansed by adronnllno. Ergo- 
toxino or crgotamlno causes a rapid, shallow respiration, which 
may bo prccodorl by an evanescent reduction. Eventually 
a stage la renebod when respiration depends wholly on tho 
• itnputscs which pass up the vagi, section ot which causes 
a complolQ cessation of respiration. After orgotoxino, 
a<lrcunliuo apnoon Is not only abolished, but ndrcnallno iiiay 
canso an incrcaso In respiration. It repeated, adrenaline 
may cause complete respiratory failure. 

043, Plouro.cnrdtao Streptococcal Infection. 

WiilLi: Streptococcus viridaus has long been recognized as 
aluiosl the specifle agent iu malignant cndoc.arditls, tho part 
it plays in plonml or pleuro-pulmonary affections has received 
little attention. P. LE Koiiiaud A. JACQUr.biN (Bh». ct Mim. 
Soc. lied, dcs Hop. do Paris, May 10th, 1928, p. 701) report a 
case in which tho pleura, poricnialium, and oudocardium wero 
successively attacked by this organism. The authors contro- 
vert the classic theoi'j' that streptococcal endocarditis is 
necessarily malignant and fatal, and agroo with Llbniann 
that streptococci can progressively attain an attounated 
viinlenco, leaving In their passage only valvular lesions 
analogons with those found In rheumatic endocarditis. 
A youth, 15 years old, first suffered from a virulent, 
purulent right plcnrlsy, which profoundly affected his 
general health and necessitated an operation for empyema, 
streptococci, culturally proved to bo of tho virida7is type, 
were isolated from the pleural fluid. About a month later 
the opposite pleura was affected; though tho same. organism 
was again found, this attack was less severe and was cured 
by simple puncture. Alter tho lapse of another month an 
attack of pericarditis with effusion supervened. The viru- 
lence of tho streptococci had apparently hecomo farther 
attenuated, cither spontaneously or by autovaccino therapy 
and, beyond the application ot cupping glosses to tho pro- 
cordia! region, no treatment was given, the patient maitinc 
an uninterrupted recovery'. Finally, endocarditis marked by 
two successive recrudescences of pyrexia, palpitations, and 
tacli y-art hy thmia developed , and subsided without treatment. 
This patient has been followed up for some flvo or six years 
and at tho present timo exhibits only a typical aortic 
insufficiency. Other similar cases of streptococcal Infection 
aro cited. 


645. Massive Atelectatic Collapse o£ the Iiuntf In 
Tuberculosis, 

J^'- 0 ®AEns (Acta. Med. Scandiaavica, April 18th, 1,92 
p. 361) remarks that this is an unusual condition, appearii 
m two more or loss distinct forms ; in ono the respiratoi 
symiitoms proriominate, and in the other the associated avi 
ptoms completely overshadow the chest condition, the ni 
monary collapse being discovered incidentally during physic 
examination. In the flrst type the onset is nsually sudd* 
and signalized by pain in the chest, dyspnoea, tachycardi 
cyanosis within tweuty-fonr hours aft, 
operation m trauma. Tlie temperature may rise to It^j 
^ at first scanty, but later bocomi 

more profuse and „,uco- paeaioiit, though never biood-stain< 
or of the prnne-juioe typo. There is usually leucocytosi 


which may reach 20,000 per c.ctn. In tho second typo there 
may ho llttlo, If any, dyspnoea, tncliycardia, or lover. In 
either typo tho duration is usually Irom ono to three wcolcs. 
Tho lung may bo siiddoiily or gr.adually relnllatcd. In a few 
instances tho condition teriiiliiates latnily.or some coexistent 
lesion limy cause death. In no case iias there been a re ord 
ot bronchial obstruction, pleural effusion, or other lesions 
interfering with aeration. Tho lung exhibits massive aiol- 
cctasls. Skiagrams show a small consolidated long ; the 
heart and mcdiaBiInnm aro drawn over to the involved side 
with depression ot tho chest wall, and raising of the dia- 
phragm on that side. Hitherto this condition has only been 
described as a post-operativo coiiiplicntloii eras due to trauma. 
Ill two of tho author’s cases it complicated pulmonary luber- 
culosls. Jacobacus thinks that massive pulmonary collajisc 
probably occurs quite trequently In pulmonary tuberculosis 
after hacmoiitysis or after pneumonia, but that, owing to tho 
patient’s serious condUion, jiTiyslcal and skiagrapbic exam- 
inations aro not very thorough. In ono case reported by him, 
tho paiiout rccovcicd after artificial pncnniolliorax bad been 
performed. It was impossible to determine bow long a timo 
was required for the coiilraotcd lung to expand, as ibo opera- 
tion aUcred the conditions. In two cases the condition was 
misiuterproted at first, pneumonia being mistnk. n for a 
chronic shrinking process of pulmonary tuberculosis, 

Q>5. Supcrlnfi ctlon In Syphilis. 

G. Mestchetisky and S. BoodakoiT {Viol, and Cut. Rev. 
April, 1928, p. 230), who portoi-mod thirty-eight experiments 
on twenty-six patients in v.arious stages of syphilis in tho 
dermatological clinic of the .Sinlo University ot Moscow, have 
coiiio to tlio following conclusions. (1) Superinfection is 
possible iu all stages of syphilis, including latent secondary 
sypliilis; this indicates that no absolute immunity e.xists in 
syphilis. (2) The syphilitic nature ot the lesious in snper- 
Infection Is douionstrated by tlio fact that the lesions are 
exactly idonllcal with those of spontaucous syphilis, that 
they yield rapidly to specifle iveatmeut, aud lhat they do not 
develop during the course of specific treatment. (3) Unlike 
Tarnowslty, who found that tbo results oi inocnialion wore 
most successful in tho early stages, tho present authors 
found that cutaneous and other lesions could be produced 
most easily during the later stages aud in persons who did 
not show any cutaneous lesions. (4) The clinical character 
of tho lesions depends on the stage ot the disease at which 
the patient is inocnlatcd and the virulence of tho inoculated 
material. (5) There is no reason to suppose that tho reaction 
of a syphilitic patient to a foreign virus would be different 
from tho reaction to his own. 


Surgery. 

696. Right-slded Visceroptosis. 

R. B. Cakseaw (Ifrff. Jouru. Sniff., April, 1928, p. 545) in an 
ondeavour-to estimato the iuiportauce of abnormal mobility 
aud prolapse of the asceudiug colon in the causation of 
various abdominal couditions, maintains that many dilfioult 
cases can be cured by a right colopexy it performed at an 
early stage ot visceroptosis. He states that persistent stasis 
in tho ascending colon aud caecum is a factor in the pro- 
duction of gall-stones and iu the etiology of gastric and 
duodenal nicoration. Right-sided ptosis is also responsible 
for chronic duodenal ileus ; mucous coll: Is may follow colonic 
stasis, and faecal stagnation or suppuration in a wide- 
moulbetl appendix is usually secondary to caecal stasis. 
Operative treatment must con-ect the ptosis, and the stasis 
will then cure itself it taken in time. Gastric and duodenal 
stasis may be cured by a r-' ■'-* ’■ . on of the 

ascending colon and caecum ' . ' , meiliod ; 

it will bo followed by improve ■ ■ activities 

ot the colon, duodenum, and stomach, and in the position of 
the right kidney and stomach. One of the chief obstacles to 
recovery may be the abnormal mentality of the patient 
which is associated with visceropto.sis. 

647. Surgical Treatment of Clefts of the Palate and EIp, 

D. B. Barker (Anler. Joum. Sur({., April, 1928, p. 385), writing 
on thcsurgical treatment of clefts of the palate aud lip, states 
that the prevalence of these conditions in families which 
have intermarried for generations shows that the influence 
ot heredity is an important factor. He adds lhat statistics 
available give the number of congenital lip and palate clefts as 

JISA A 



112 JUNE 30, 1928] EPITOME OF CUBBEMT MEDICAE EITEBATUBE. 


0 " 0 uiL'iu» in ono out of 2,200 births. He considers Uio best 
time to operate, when the elett of the palate is coinplelo and 
iuvolvos ibe'premaxilla and Jiard and' soft palate, is between 
(he fust and third months. Eepair of the soft palate stionld 
1)0 niidertalcen between the ages of 18 and 24 mouths, before 
(ha child has learned to talk. Clefts of the lip should be dealt 
with between the ages of 3 weeks and 3 mouths. In pro- 
iiiaxillary clefts a wire is passed through the innxilla above 
the alveolus and through the bone from the palatal sido to 
the labial surface, the bones being moulded towards each 
other. The u’ire is removed in four to six tvoeks' time. The 
O'lei ation advised lor clefts of the lip is a modilicatioii of that 
of Thompson, as described by Now of the Mayo clinics, and 
for closur j of the soft tissue in palatal clefts a modilicatioii of 
the Laugenbeok operation is said to give good results. Post- 
o'leraiive care is necessary to ksep the child quiet, and 
roap’ation sutures .should he removed, beginning after tlio 
fourth day following the operation. 

i 

6?8. Treatment of Fractured Ribs, 

L. P. MAMANTSCiiiK'(ffftifrn/tl. /. Chir., May 12tli, 1928, 
p. 1171) recommends for Iraetnrod ribs the application of a 
tliin i iihher hamlage as' being ineforable to the ordinary 
method of fixing tlie chejit wall by means of strips of plaster; 
he lias employed this iiictliod in nine cases, one iiatient being 
n woman and the otlie'r.s males wlioso ages ranged tioiii 
40 to 71 years. In three cases tlie patients liad fractured four 
to six nils, in four cases two vilis were fractured, and in two 
cases only one rib was involved. In, all cases tlie result was 
entirely satisfactory. The antlior’s method is as follow.s. 
Tlie patient’s skin is disliircctcd and smeared with ointiiient 
or dll le I with talc ; he Is tlien told to breatlio out as coiii- 
fl Icly as iiossihle. A rubber bandage, tliree inches bio.id, 
is then applied spirally to tlie cliest wall, commencing over 
file nil lieiow the site of tlie Iraotnre; each turn of the 
bandage is overlapped for lialt its breadth by tlie suoccoding 
dun ami tlie bandage is continued spirally to tlie level of Ibe 
rib aliovo the site of the fracture, when it is secured by 
covoi'iiig it with a gauze haudage, tlie applicntiou being 
a'lowed to remain in position lor'a period of from 'two to four 
wecits. It is recommended tliat skiagrams should be taken 
after the applioatiou of (lie rnlilior bandage and before its 
rmiovil, anil tliat tlie chest w.ill sliould ho siiltscqncutly 
massaged. A ganze ban.iago will give any support tliat may 
ho ro.inlrod during couv.ilescouce. 

6i9. Eate Treatment of Burns. 

F. W. Bancroft and C. S. Boouits (/fiv/i. ofSnr^., May, 1928, 
p. 97 ji describe the successlnl treatment of severe, burns by 
jiioans of tanuic acid. Tin's ireatinent diminishes p.ain, 
provosts fluid depletion, docreaso.s toxaemia, and,- in first 
and second degree burns, permits, cpitlielial growth while 
Die mombiane Is in place. Among 114 patients treated with 
tannic acid tlie mortality from all causes was 20 per cent., 
■a bile other methods sliowed a 40 per cent., or even 57 per 
cent., mortality. The treatment is as follows: morpliiiie is 
g.voii as soon as possible and combined with saline injections 
or transfusion. The sltin is cleansed and that covering the 
blisters removed. After this, loose gauze dressings are applied 
tvhicli bayo been soaiced in .a S per cent. aTqueous soliitioii of 
tannic acid; they are kept in place for- twenty-four hours, 
no bandages being used. TVlien the burned area is tanned 
a inabogany Itrown tlie dressings are removed and a tent' is 
erected, with electric Jiglits to. warm the air.' ) Hypertonic 
saline^ injections help to relieve to.xaemia and prevent 
vomiting. Care must be talcon to prevent infection under 
the tanned membrane, wliiclt after one or two weelcs* should 
curl at the edges and separate, leaving newly formed epitlie- 
Itnm nuderneatli. If, as is possible in -a third degree typo 
of burn, infection occurs, and the patient lias an elevated 
tomporainre with gastro-intestinal disturbances, the meiu-' 
branc must be excised and hot boric acid dressings applied 
to the granulating area ; this will become red and clean, after 
wliicli epithelial growth slionid )iroceed rapidly. In deep 
burns skin grafts should be applied after the sloughs separate. 
For granulating areas which Jiave been pnfocted the scar 
tissue must be excised to the fascia beneath. Finch grafts 
arc usually snccessfnl if applied immediately. 

630. Diagnosis of Tuberculous Prostate. 

H. BbANC (Journ. de Med. dc Bordeaux, March 25tb, 1928, 
p. 226) tbiults that the apparent -raritv' of-tbis condition may 
be in part due to difficulties of diagnosis. He believes that 
it is often thought to be renal tuberculosis. It does not follow 
that tnborcle bacilli in.tbe urine are duo to renal disease, and 
lie quotes two cases of baoillnria in which the lesion was 
traced to the prostate by the use of appropriate methods. 
These metliods are to wash out the Bladder several times 
with, a weak antiseptic, .leaving it full. - The' patient then 
micturates, after which the prostate is vigorously massaged. 

2 1.1 4 'b 


The patient then micturates again. TJic second sample alone 
will bo found to contain tuberclo bacilli. On cysiosoopic 
examination lirsucb cases there will be found a more or lo.ss 
iibriiuvl bladder, with- possibly an Inflamed trigone. The 
prostate is not usually enlarged. 


Therapeutics. 


B51. Promotion of Diuresis In Cardiac Conditions. 
BnoNinu, and j\IiIo VAK den BeKHOUDT 

(i.c Scalpel, jMarcIi 24tli, 1928, p. 309) linve tried mercuric 
acetate of BHiicylallylaiimlo-O-acotatc (salyrj»aii) in ten ca^cs 
of licavt disease,’ in v ew of^ llic fact ilmt many of these 
patients liavo anasarca and other sijiiis of Iluid reientioii 
Avhich })rove icriactory to all treatment, u'hcthor cardiac or 
diuretic. Novasiiml yields satisfactory l esults in some cases, 
hnt Its action is incoiisiant, while several casc.s of nephritis 
foHowinf* its use have heon recorded. The aiitlior.s state that 
salyri*a», whicli contains 35 per cent, of niereury, seemed to 
ho ii reliable and r.ipicl diuretic. They administered it both 
intravenously an i inlramiisciilarly, eiiher pmc or diluted 
Willi physiolo^^ical scrum.- The iiiiravcnons injections were 
u.sually well lolerateil, hut it was found that even a small 
quantity of salyi{«an injected snhciunneously mi«ht proiluce 
scars, e.spcciallj' In old patients. No shock fodowetl iiitravenous 
lnjv*clions‘, bntiho vein mlj^lit bo oblitcrnicd. liitramuscular 
injections occasionallj' ]>‘.'Oiiucod extensive aseptic inllltraLion, 
and, very rarely, lavj’c ubsccs-cs developed, ainco iiiipiciisnnt 
sequels occnrx'ed more freqncntJj' after ititravcnon.s injccliouH, 
the autlior i have omp'oyed only llic liilramtisciihir romc in 
their more recent ca-es, J>iurcsis lasted for twcnty-lour 
hour.s only when salyiKaii was j»iven intravenously, Imt for 
two days when injected intramuscularly. The quantity of 
urino is increased very rapidly — for example, from 40 c. cm. 
to 400 or 500 c.cm. cvci’y hour, in two or three liouis after the 
Injection; the avera^tc daily quantity wns 3 to 4 litres, the 
maximum boiu'4 7.25 litres in twtmty-four hours. .One patmiit 
passed 700 c.cm. in. an hour. IMio authors ad.Mhnt in a 
heallhy man salyryan does not ]>roduce diuresis. In all 
ca'^cs the dvu't increased the How of urine without prov.olcint, 
alhuminnria or the jxassat^c of casts. If iircviou'Iy pres-ent, 
altmiuiu and casts were not increased hy salyr^aii, oven when 
twentv injections had been on altcrnnio da\ s, hnt Jn a i 

cases of nepluitis in which this dnij4 Is used the mine slionld 
he c.x.amined daily for Ihoir presence. - Cardiac ooilomn 
arnl ascites duo to licpatic cirrhosis are -both by 

salyr*»an. After a year’s experience they rena’d 1'“®^ 
Dio hc.st diuretic in refractory cases of cardiac oedema, anti 
they limit its use to tbese oases. 


652, Synthalln Jn Diabetes. 

A. I. niN-GF.it, S. Biloon, M. M. IlARnis, and A. f; 

lulcn,. Med., April, 19z8, p. 453) (liscusR "j 

ill llic treatment of diabelc.x: it is admini.stored J ■ _ 
from 20 to 25 mg. twice on tbo llrst and third dajs, 
the second, and oiiiitted entirely on the fourth 
dose causes anorexia, epigastric pressure 
vomiting, and diarrhoea. The authors 
reiirescnting all stages of uncomplicated ‘’"'•I’f 
concinde that the drug -has a flecided .advantage li ora the 
patient’s point of view since it can be 

form, thus obviating the nooessitj'. for 1 5 1 ^ 

injections as required in the case of losnlin , c i 
clearing up glycosuria and ketonuria. Tboiigb instil n is con^ 
Bidered ideal In clearing up liyperglycaeinia, k'J 
ketonuria, iu alleviating sy'‘n>to™s> •''•’’t* 

and .well-being, it has the one iBsad van tage of possible Jio 
Riycaemio reaction. Synthalin .occasionally causes gastr e 
distress, which .Adler claims can bo Pole 

aduihiistration of 0.5 gram of a so?', 
acid which, actiuH as a bile stimulant, eliminates an> 
pleasant effects. ' It is unsnitablo for j®'” vbicb ' 

action is Blow, bnt it may be found useful in cases m 




653. Vaccine Treatment of Typhoid Fever. 

r. SCHOTTER, S. BrodskAJA, and G. SINAI ('Uien. W'”- " 

larch 1st, 1928, p. 297) state that ^’^^ougli moio tl 
ears have elapsed since Fraenkel, is still 

i-eatmentin typhoid fever, the question of tl>at 

nsettled. Stolkind, in 1916, collected only 3.416 oas^ tn 
ad been so treated up till ‘''oo- so 
aratively few papers on the s"hjoct have ^oeu P ^ 
hat there is barely a total of 4,000 cases of tPo 

I'hich vaccine therapy has been employed. fronted 

eriod November,- 1926, to July, 1927. , vg were 

ritU vaccines 41 cases of enteric fever, K J® q 

yphoid aua-5 paratyphoid, while 30 cases, of which 2fa 


t 







Jcun 30, 1918] EPITOME OP CUEKENX MEDIOAE LITERATOEE. [aif,"gJ!jSg ii, 11 3 


typlioiil ftuil 4 imratyphoid, wore given syiuptoniatic front- 
moiit only and soivecl as controls. Tlio rc.snUs woro ns 
tollovR. (1) Eo onconraghig tesults 'wcio obtained Irotn tUo 
intrauuiscuiar ncliniuistration ot vaccine. (2) Tho intra- 
venous injection ot antovacciiios caused only a slight general 
reaction and rendered relatively largo doses posaiblo, but 
owing to tUo time required tor thn \)rcparation ot those 
vaccines and tho consoquout dolas' in their application they 
were ot little praotical nse. (3) Tho Inlravoiioas injection ot 
a tonnaiiv.od vnecino coiuposod ot several strains was tried 
in 31 cases and produced a soinowhnt shorter duration ot tho 
disease than in 30 cases which had symptomatic treatment 
only. Systematic ropotitiou ot smail doses did not cause any 
alarming si’mptoms, but it had no Influence on tho occurrence 
or character of complications, sequelae, or relapses. (4) Tho 
vaccino treatment ot enteric fever is not to bo coniiomnod 
a priori, hut needs lurthcr study. 


Disease in Cliildhood. 

654. Tjjo Larynx In Wiiooplnf-cou^li. 

P. HElKniCIISDAUKn i-Jaliflj. J. ICincierheilk., November, 1927, 
p. 104) records his observations on the post-mortem appear- 
ances of the lavyux in thirteen cases ot wliooping-cougli in 
children aged from 8 weeks to 3 j-cars. Pour showed typical 
ulcers, which in three were on the vocal cord and iu one in 
the internrytenoid space. In another three eases Ihcro was 
considerablo intlamuiatory inflltiatiou of tho mucous mcm- 
brauc, which in tho intcraryicnoid region had led to a peri- 
chondritis ot tho subjacent cartilage. In all tho cases the 
capillaries were greatly dilated and the mucous membrauo 
in tho region ot tho .sinus of Morgagni .showed infiltrations 
which mosllj' consisted ot round cells of the lymphocj'to typo, 
in several eases there wore accumulations ot lyiuiihocytes, 
partly iu a dilTnso arrangement aud partly in nodular form, 
often grouped around the openings ot tho ducts ot tho glands. 
Another change present iu one ease consisted in complete 
necrosis of the inucons mombrano ot considerablo extent. 
In four oases tho li'-stio ot the vocal cord or its vicinity was 
loosened, and in another four eases rouod coll infiltrations 
were fonnd round tho lobnles ot tho glands. Tho origin ot 
fho nlcors wliieh showed a typical localization in tho vocal 
cord was undonbtedly duo to mechanical factors, especially 
tho knocking of the vocal cords against oacli other during tho 
violent attacks of coughing. As the slightest irritation of tho 
thro.at and larynx was sufficient to produce an attack ot 
coughing, the anther thinks that considerablo itnportance 
must bo attributed to the inflammatory lesions, cspeciallj’ 
tho ulcerative changes. A vicious circle is thus termed by 
tho attacks ot coughing favouring the development of intlam- 
matoiy changes in the vocal cords, and bj' tho latter in turn 
provoking a paroxysm. Ho adds that tho changes are not 
confined to whoopiug-cough, similar though isolated lesions 
being fonnd in measles. The practicai signiflcauco ot tho 
findings i.s that thej’ furnish anatomical evidence ot the dura- 
tion and trcquency ot the individual paroxysms and of the 
duration of the disease as a whole. 


655. Infantile Pyelocystitfs. 

G. VrxcEXT (Arch, drs Mnl. ties Jlnns ct ties Ortjaiics Genilo- 
Urinaires, February Ist, 1928, p. 239) describes 'two cases ot 
pyelocystitis occurriug in male infants aged 10 and 2 months 
respectivelja The older child was admitted for a rhino- 
pharyngeal infection complicated by intestinal disturbance. 
Tho iiriuo contained albumin, and the mother stated that the 
child frequently cried when inictDratiug. Tho temperaturo 
rose to 104= F. ; there was cervical rigidity, Kernig’s sign 
tvas positive, and tho general condition suggested meningitfs. 
Tho urine had a faecal odour, and contained numerous J!. coif, 
polymorphonuclear cells, and granular casts. In spite ot 
hyiJodoimio injection of urotropine tlie temperature did not 
begin to fall for nine days, but four days later it was normal 
aud the general condition bad improved greatlj’. A week 
later tho urine was apparently normal. Pn spite of repeated 
tobfilc attacks (apparently due to tonsillar or ph.aryn^eal 
infection, relieved by ablalion ot tonsils and adenoids) there 
was no reeurrenco of pyelitis. Tho younger child, who was 
reyensii and had persistent vomiting, had been suckred for 
hfteou days, and afterwards was led on coudeusod milk, 
riiroo days beforo adniis.'-ion he vomited ail food, was con- 
sctp.ated, and the temperature rose to 102.6°. There was 
optsthotonos.and dohnito ontaneons hyperaosthesia. Kernifi’s 

mhnhic® spleen, and kidneys -wore 

1 urine contained albumin, numerous, polv- 

leucocytes, graunlar leasts, 11. coti, and 
buVwno ^'ehvo-spinal fluid-escaped under pressure, 

but was sterile. Under autogenous vaccine treatment there 


was temporary iinprovemeut, but the vomiting and diarrhoea 
returned and tho child died from exhaustion at the end ot 
four montUa’ illucss. The necropsy revealed no sign of 
tnboronlosls, bnt slight glomoruloncphritis with pyelocystitis 
Was present. The author remarks that in infancy' hoys aiiil 
girls arc equally suscoptiblo to pyelocystitis, but in later 
childhood it is far more connnon among girls than among 
hoys. Vincent adds that pyelocystitis results most frequently 
from aento gastro-intestinal infections, and to a loss extent 
from aciito or chronic bronchial aud pulmonary infections. 
Other causes are nasopharyngeal infections, otitis media, 
and, occasionally', suppurative dermatitis. 

656. Alimentary Pyrexia tn Infants, 

H. IllETSCllEL (Med. Klin., December 9tb, 1927, p. 1904) quotes 
experiments which show that deprivation of water in adults 
produces a rise ct temperature during rest aud an increased 
rise after physical exercise. Hyperthermia can also be pro- 
duced In infants and others by the siibcutnneous and oral 
administration of hypertonic saline solution. The following 
phj'sico-dyiiamical explanation ot the process is given. For 
every 10 grams of a 4 per cent, sodium chloride solution 
administered approximately 57 grams of water have to be 
withdrawn from tlio tissues In order to make the solutiou 
isotonic (0.6 per cent.) with tho body' fluids. By this “woik ” 
heat is generated, wliilc tho lack or water interferes with tho 
loss ot heat ; the thirst produces restlessness and crying iu 
the infant, thereby increasing the generation of heat, and 
py'i-cxia tlins ensues. A. similar result may' be produced by 
insufficient water in young infants, and Kietscliel thus 
accounts for the temporary pyrexia of breast-fed- infants, 
frequently observed to reach its highest point about llio 
second or tliird day after birth betore the secretion of milk 
is fully eatablisbod. This occurred iu a larger proportion ot 
one series iu snmmer tlian in winter, aud may be prevented 
by' tho administration ot water. Loss of water is also prob- 
ably an imiiortaut factor in the production ot pyrexia aud 
the general toxic state associated with the more severe cases 
of infantile diarrlioea, wliich helps to account for the in- 
creased mortality from this condition dnring the -warmer 
month.s. Eletschol also ascribes tho fall in temperatnio 
which has been observed when bottle-fed babies -ivith nn- 
explaiucd pyrexia are given breast milk partly to the lower 
salt content of the latter. The pyrexia ot some infective 
conditions, especially in infants, is dne to tho cnmulativo 
effect of thirst and the inteoting organi.sm, and a rapid thera- 
peutic effect is therefore often produced by tho administration 
of water — as, for cxainplo, iu pyelitis, influenza, and pyuria. 
Though water is very valuable in the treatment ot pyrexia, 
especially lu infants with poor appetites, tho optimum amount 
must not be exceeded, ns an excess of water also has dele- 
terious effects and may produce digestive disturbances. 

657. Sepsis in the Newborn. 

H. VAgLIO (La Pediatria, Jannary' 1st, 1928, p. 1) deals with 
newborn infants who, after starting well, begin to lose weight, 
become pallid and bluish, are nnwilling to feed, develop 
vomiting or diarrhoea, have a dry inelastic skin, sunken eyes, 
and occasional sudden rises ot temperature, and often die 
suddenly. He believes that many' of these cases are due to 
sepsis, and since greatercare has been taken to avoid possible ' 
sources of it the results have been much better. He has 
abandoned the practice ot early vaccination iu these cases, 
as. he considers it to be a possible sonree ot infection; the 
same applies to mouth cleansing. Any skin lesion, especially 
abont tile buttock, heels, and malleoli, should be carefully 
aUended to. By careful prophylaxis on these lines the 
author obtained far better results than by measures directed 
to the cure of the sepsis itself, such as vaccinotherapy. - 


Obstetrics and Gynaecology. 

658. Treatment ot Vomiting of Pregnancy. 

For the treatment ot vomiting ot early pregnancy and the 
prophylaxis of hy’pereme.s-is E. Speidel (Amer. Jotn-ii. Ohttet 
and Gynecol., Slaich, 1928, p. 411) recommends (1) prohibition 
of coitus, the patieut occupying a separate room and resting 
during the morning; (2j a change ot scene ; (3) light meals of 
rusks,- lemonade, iced tea, and sweetened fruit juice- aiid 
(4) intravenous injections of corpus luteum extract, exhibition 
or luminal sodium IJ grains thrice dailv, tablespoon doses of 
milk of magnesia at bedtime, and in some cases (to combat 
hypochiorhydria) administration of ten drops ot dilute hydro- 
chloric acid iu water before meals. An enema of a halt 
gallon ot warm water containing a tablespoontnl of sodiuiu 
bicarbonate will empty the colon and to some extent relieve 
the acidosis. If these simple measures are not successful 


114 June 30, igiS] 


EPITOME OE CUIIBENT MEDICAE EITERATEEE. 


r Tfn: IJRtTtnr 
SfrMCAL JoCSNi£ 


tlio condition takes tlie aspect oE hyporemcsis and doinands 
eneifjetic measures. Tlie patient should , bo . isolated from 
tiicnds and relations, preEerably in a hospital, and kept In 
a .somnolent condition by rectal administration oE G 07 .. ot 
10 par cent, glucose solution containing 60 grain.s ol sodinw 
bromide and 15 grains ot chloral hydrate throe times a day. 
To combat the dehydration one quart o£ decinormal saline solu- 
tion should be injected daily under the breasts. Intravenous 
injections ot glucose are most valuable : the solution must be 
pieparcd with pure glucose and Ereshiy distilled water, and 
mrrsO be given warm. Half a litre daily In 10 pet cent, 
solution is reoointnohded; double the amount has been given 
to very dehydrated patients, but there is some danger ot 
acute dilatation ot the heart. Stronger solutions in smaller 
hulk have been advocated by .Titus and others, hut diuresis 
is to be avoided. Admixture with separately dissolved sodium 
bicarbonate solution (200 o.cm. ot 3 per cent.) will, help to 
diminish acidosis. In very severe eases a tube should be 
passed through the nose into the duodenum, whore it c.an 
be lett tor several days, serving for the introduction ot water, 
glucose solutions, liquid food, and laxatives. If intensive 
iutraveuous glucose treatment continued for four days is not 
snocesstul duodenal treatment should be performed for a 
similar period. If at the end of that time decided imptovoment 
is not evident interruption ot the pregnancy is jnstiftable. 

659. Clacose Treatment of Ectamvsla. 

P. Titus, P. Dodds, and E. W. IViDfiETTs {Amer. Joiim. 
Obstet, and Gynecol., March, 1928, p. 303) have found that 
wliereas in normal pregnant women tlie blood sugar maintains 
a constant level for each person, an eclamptic patient shows 
repeated and rapid fluctuations. In the majority the blood 
sugar level is normal or reduced, except after tlie muscular 
c.xer'tion of a convulsion, and a convulsion Is preceded by 
relative hypoglycaemla— that is, a rapid fall in blood sugar 
by from 15 to 80 mg. per 100 o.cm. within a tew minutes, A 
causative connexion is traced between the onset of relative 
liypoglyoaomia and of a convulsion ; It is admitted, Iiowovor, 
tliat an eclamptic convulsion may ooour when the recently 
reduced blood sugar content is still at or even above the 
normal level, just as In certain circumstances diabetics may 
suffer from hypoglyoaemic crises at average tliough recently 
and rapidly diminished blood sugar levels. According to the 
views ot Titus and bis co.workers, pregnancy is associated 
with diminution ot hepatic glycogen by reason ot foetal 
demands, hypertrophy of the uterus, and vomiting with 
insuffleient diet during the early months' of gestation. 
Piognanoy toxicoses, such as hyparemosis and eclampsia, are 
attributable to disorganized carbohydrate metabolism ; tho 
associated nephropathy is incidental or contributory only, 
and the same may bo said of the disturbances iii nitrogen 
metabolism. Insulin treatment, which has reoentl3’ been 
recommended for eclampsia — eitlier alone or combined with 
iuiections ot glucose — is coutraindioated. Applying their 
conclusions to treatment, the authors recommend in pre- 
eclampsia restriction ot salt and protein intake, but increased 
ingestion ot carbohj’drate, especiallyglucose with fruit juices. 
For eclampsia thej' advocate the injection ot morphine hypo- 
dermically, magnesium sulphate hypodermically or iutra- 
venousljT and chloral hydrate bj' the reotmn. Thej' also 
commend the intravenous administration ot large single 
doses of hypertonic glucose BOlution^75 grams dissolved in 
300 o.cm. of distilled water, the injection lasting from 60 to 
75 minutes and being repeated at Intervals ot four to flvo 
Iionrs during the attack and throe or tour times during the 
day following cessation ot tlie convulsions. TTie immediate 
effects are diuresis, lowering of blood pressure, cessation of 
convulsions, and prompt regaining of consciousness, 

660 . ■ Fatal Staphylococcal Puerperal Infection. 

Lemedand and Dakdane {JJnll. Soc. d'Obstct. et de Gynicol., 
Febrnar3% 1928, p. 152) record a case of labour at seven 
-mouths, following a^ fall, in which a slightly macerated 
leinale foetus weighing 3jlb. was spontaneously delivered. 
The same night the pulse and temperature rose, and all 
tiie signs and S3’mptoms ot acute puerperal infection wore 
present. Fi£t3’-eight hours after the delivery the abdomen 
was opened and total h5’stereotom3- was performed. The 
reins in the ^utero. ovarian pedicles, being tlie scat of a i 
llicombo-phlebifcis, were ligatured. The patient’s condition 
liecame worse, and she died on the twelfth day after delivery. 
On two occasions during the illness blood cultures revealed 
a pure cultnre ot staph3.1ooocci. T'be authors .^um 
points ot intei-est in Ibis case as follow.s : (1) IBtfe''rapifU§?oIj j 
fiio onset ot phlebitis; (2) the irapossibilifa^^if O^.! 

condition; (3) the dlfflcully in llxiug t)% 1- on . f,.- 

liyslerectomy in acnle puerperal infecti«i 5 (4) rhe,. Jaclc^f 
.success ot surgical intervention ; (5) the utoffinpl sereiitjjiwft 
a stapbsTococcal intection. 'i x 


Pathology. 


661. Chemical Changes'concornocl In Kcldosls, - 

A. F. HAHTMANN (/Imer. Jonrn. Vis. Child., April, 1928, p. 557) 
has studied the chonilcal'cliangcsin the blood of twenty-seven 
infants with mastoiditis who Buffered from diarrlioea, vomit- 
ing, dehydration, and aoldosi.s, presenting n clinical picture 
simriar to that ot alimentary iuto.xicatlon. lie found that tho 
chemical changes were duo to tlie chief symptoms of the 
infection — namely, vomiting, diarrhoea, dehydration, and 
oliguria. As a result ot vomiting, hydrocbloric acid and base 
chloride are lo.st from tlie body. Base bicarbonate is mucli 
reduced b3' loss in tho Intestinal secretion and diarrhoeal 

■ stool. Doh3'dration accounts for the occasional increase of 
lactic acid and protein, and ollgnria for tho increase of 
phosphoric acid and non-protolu nitrogen in tho blood. In 
a largo number ot tho cases the blood was not examined 
chemically until after a considerable quantity of common 
salt, in tho lorm ot Eingor’s solution, bad boon given intra- 
perltoncally. In these cases tho serum base bicarbonate and 
pH wore much reduced, while tlie base chloride content was • 
frequently greatly Increa.sed. Whore tlio blood was examined 
before signlllcant anionuts'of fluid were adminlkcrcd par- 
ontcrally tho base bicarbonate, althougli reduced, was not 
usually ns low, while tho base clilorido was also" reduced. 
Tho administration of largo amounts of snlino solution when 
diarrhoea and oliguria persist Is thorofore contraindicated, 
for it may prodiico extreme, persistent, and often fatal 
acidosis. Water in largo quantity must bo given' orally as 
such, or intravenously as dextrose solution. Becanse of the 
frequent marked loss of base bicarbonate from the botl3' 
intravenous administration of sodium bicarbonate is oltcn 
indicated, and may at times be a life-saving measure. 

662. Temperature of the Cerebro-splnal Fluid. 

B. SCHEFF (/Ivck. rtc wctl., cir. p.csp-, Mavob 2‘lth, 1928, p. 4221 

found that the average tomporatnre ot tho cerobro-spinal 
fluid, as estimated by a tiiormo-elcotrical apparatus, was 
37.68“C. in fifty patients with a normal rectal tomporatnre. 
This result indicates that the temperature of tho cerobro- 
spinal fluid Is approximately half a degree higher than that 
ot tho rectum. Tlio spinal temperature to a great extent 
appears to he independent ot extornal agencies, sueh as 
analgesic or antitlierniio drugs or motor oxoitenicnt. It floes 
not appear to have n direct relation to tho general tompera- 
turo of tho iudiviflnal nor to tlin fonsiou of tho cerobro-spinal 
fluid. Ton patients showed an abnorninlly groat difference, 
ranging Irom 0.9^ to 1.5“ C., between tlie tomporature in . 
tlio rectum and tliat in tlio spinal canal. Most of tlie.so 
patients were suffering from senile pss'choses. The antiior 
thinks that it would bo proniatiiro to draw an3' dcfliiito con- 
clusions from tliGSG facts, as patients suffering from tb® same 
affections presonted normal spinal temperatures. Eigid 
patients wlio were suffering from nn anxiety syndromo 
showed spinal temperatures wliich wore tho same ns or 
lower than the rectal temperatures. 'Those ro.siilts were 
obtained under rigorously controlled conditions. The appa- 
ratus is dellcalo, costly, and takes up considerable space, 
and is not suitable for clinical use. , 

663. The Brain in Encephalitis. 

J. H. Musser and G. H. Uavseu {Jonrn. Amer. Med. Assoe., 
April 21st, 1928, p. 1267) describe tho post-mortem appearances 
ot the brain in ten cases of encephalitis in measles, me 
gross changes consisted in extensive injection of the pm- 
'arachnoid vessels and cerebral vessels gonorall3'. In u"® 
case thrombi were noted in, tlio vessels of tlie pia-avaclinoiu. 
None showed inflammatory exudate over the siirlace of tne 
brain, but there was considerable clear fluid in the ..sun- 
arachnoid spaces. The convolutions were flattened and the 
snici shallow. On section the brain showed discrete punctate 
haemorrhages, with some areas of diffuse haeroorrliage. 
Microscopical examination revealed perlvasonlar liaeuioi- 
rhages round the small vessels, which appeared to be peculiar 
to this type of encephalitis. Notio ot the cases showed any 
clinical or post-mortem evidence ot tuberculosis or s3'philis. 

661. The Optimum Rydrogen-Ion Concentration Tor 

Glemsa Staining • ir7ni 

J. G. IiACOBTE (C. V. Soc, de Biolooie, May 25th, 1928, p. 1579 
fiucls that the best method of differGntlating 
j^ff^Kbiense in fjninea-pig’s blood is to add one dropof Gjo» • ‘ • 

1 cubic centimetre of a buffer solution at ^>11 ^ 

in contact ."with it for hour.’ . 

‘ jtl{ti,OT<d^nadc bv adding acid sodium phosphate I 

wateri-0'3f-;b))b,/7H is below 7.4 the organisms ami the moon 
fel.4 appfeatHfiddisb ; it it is above 7.4 they become bliuBii. 
Tho beslffi'uoiifintiation was obtained at pH 7.4.